AFP Journal Review

1. AFP Journal Review Volume 76, Number 2, July 15, 2007 Sarah A. Bailey PGY3

2. Outline • Common Problems in Endurance Athletes • Fibromyalgia • Home Monitoring of Glucose and Blood Pressure • Screening and Treating for Sexually Transmitted Disease in Pregnancy

3. Common Problems in Endurance Athletes • Endurance athletes who do intensive physical training with inadequate periods of recovery are at risk for overuse injuries. • Largest age group is 35 to 50 yoa. • Tendinopathy are degenerative process and not inflammatory like a tendinitis. • Rest is main component of treatment. May not respond to NSAID’s or steroid injections.

4. Running • Evaluation of how, when, where, aggrevating and alleviating factors. • Weekly running mileage, changes in duration or intensity of training, change in running surface or surface grade, age of footwear, recent changes in gait, shoes, or orthotics. • Physical examination of injured area, gait, patellar alignment, leg length, foot morphology, and foot biomechanics.

5. Cycling • Evaluate recent changes inequipment, position on the bicylce, or saddle height, and in training habits or terrain. • May also observe patient on bicycle.

6. Patellofemoral Pain Syndrome History – • Anterior knee pain exacerbated by running, jumping, or cycling • Pain on climbing or descending stairs or hills • Pain with prolonged sitting with knees flexed (i.e., "theater sign") Physical examination • Patellofemoral malalignment • "J" sign (i.e., curvilinear lateral tracking of the patella with contraction of quadriceps) • Tenderness along patellofemoral facets and pain with patellar compression • Crepitus with active extension Diagnostic Imaging: • Radiography (sunrise or merchant view) often normal but may show lateral tilt or subluxation of patella • Computed tomography and MRI usually not indicated but may reveal patellar malalignment or chondromalacia

7. Iliotibial band friction History : • Lateral knee pain exacerbated by running, cycling, or hiking • May be aggravated by prolonged hill running, running on a slanted road shoulder, or too much unidirectional running around a track Physical Examination: • Tenderness along lateral femoral condyle or approximately 2 cm above lateral joint line. • Tight iliotibial band with Ober's test (i.e., passive adduction of hip and leg, with patient lying on unaffected side and knee slightly flexed) Diagnostic Imaging: • Imaging usually not indicated when diagnosis is strongly suspected on clinical examination • Radiography typically normal • MRI may show thickened iliotibial band and associated edema

8. Medial tibial stress syndrome (i.e., shin splints) History: • Activity-associated shin pain described as dull ache along mid- to distal tibia Physical Examination: • Tenderness along posteromedial border of the mid- to distal tibia for several centimeters • Focal tenderness over anterior tibia suggests stress fracture Diagnostic Imaging: • Radiography typically normal • MRI or bone scan may determine nature of injury if stress fracture is suspected or patient has poor response to rest and treatment

9. Achilles tendinopathy History: • Gradual onset of pain in Achilles tendon • More common in middle-aged athletes • Acute injury with sensation of being struck in back of heel suggests rupture Physical Examination: • Tenderness along Achilles tendon 2 to 6 cm proximal to attachment, often with thickened, tender nodules • Crepitus suggests acute tenosynovitis • Perform Thompson's test if rupture is suspected (i.e., assess passive ankle plantarflexion with calf squeeze; no response indicates tear) Diagnostic Imaging: • Radiography usually not indicated but may show thickening of Achilles tendon or calcification at the insertion • MRI helpful if rupture is suspected and clinical evaluation is equivocal, although careful examination is usually diagnostic • Ultrasonography may be useful

10. Plantar Fasciitis History: • Pain in plantar heel or arch that is worse with first few steps in the morning • Pain may subside with warm-up and activity, only to become stiff and sore after activity Physical Examination: • Tenderness at medial plantar calcaneal tuberosity and along medial arch • Pain with passive dorsiflexion of the toes • Pes planus or pes cavus Diagnostic Imaging: • Radiography usually not necessary but may show calcaneal spurring or calcifications within the plantar soft tissue • Presence or absence of heel spur does not change management

11. Stress Fracture History: • Progressive pain over a bony structure that is worse with weight-bearing activity • Pain at rest in some cases • Physicians should maintain high suspicion of stress fracture in long distance runners with musculoskeletal pain Physical Examination: • Focal tenderness over bony structure • Overlying edema may be present • In femoral neck stress fracture, pain with passive hip range of motion Radiography often negative early in course of injury (less than two to four weeks) Diagnostic Imaging: • May show cortical thickening, periosteal reaction, or fracture line • MRI and bone scan are more sensitive and should be performed if high-risk stress fracture (e.g., femoral neck or navicular fracture) is suspected • Dual energy x-ray absorptiometry may be indicated if osteoporosis is suspected

14. Recommendations

15. Question #1 Which one of the following treatments is recommended for most patients with plantar fasciitis? A. Extracorporeal shock wave therapy. B. Corticosteroid injections. C. Silicone shoe inserts. D. Surgery to remove the bone spur.

16. Question #2 Which one of the following statements about exercise-associated collapse is correct? A. It is caused by inadequate hydration. B. The most common cause is hyponatremia. C. Hyponatremic athletes are typically hyperthermic. D. Hyponatremia can be prevented by avoiding overhydration during exertion.

17. Fibromyalgia • Fibromyalgia is an idiopathic, chronic, nonarticualr pain syndome with generalized tender points. • Initially called fibrositis, but when it became evident that it was not an inflammatory condition, then changed to fibromyalgia.

18. Fibromyalgia: Epidemiology • 3.4 percent prevalence in women and 0.5 percent in men. • Women 20 to 50 years of age • Both genetic and environmental factors • Factors associated with this disorder include female sex, being divorced, less than high school degree, low income, somatization disorder, anxiety, personal and family history of depression.

19. Fibromyalgia: Clinical Features • c/o pain at multiple sites, fatigue, and poor sleep. Common pain sites low back and neck. Pain described as “burning, gnawing soreness, stiffness, or aching.” • Stiffness worse in morning and improves throughout day. • Exhaustion in the morning and frequently awakening at night. • Subjective swollen joint and/or parasthesia without object findings on exam.

20. Fibromyalgia: Clinical Features • c/o cognitive difficulty, headaches, dizziness, anxiety, or depression. • Aggrevating factors: cold and humid weather, poor sleep, and stress. • Allevating factors: warm and dry weather, moderate physical activity, adequate sleep, and relaxation.

21. Fibromyalgia: Assesment • Fibromylagia Impact Questionnaire http://www.myalgia.com/FIQ/fiq.pdf • Relevant social, personal, and familiy history including h/o trauma, childhood abuse, anxiety, depression, or sleep disorder.

22. Fibromyalgia: Diagnosis • ACR criteria involve two components: • Widespread pain involving both sides of the body above and below the waist, as well as the axial skeletal system, for atleast 3 months. • Presence of 11 tender pints among 9 pairs or 18 specific sites.

23. Fibromyalgia: Diagnosis

24. Differential Diagnosis Myofascial pain syndrome which arises from trigger points in individual muscles. Chronic fatigue syndrome is an inflammatory process with low grade fever, lymph gland enlargement, and acute onset of illness. Also hypothyroidism, inflammatory myopathies (statins), polymyalgia rheumatica, and other rheumatologic diseases.

25. Fibromyalgia: Treatment

26. Fibromyalgia: Treatment

28. Question #3 • According to the American College of Rheumatology, which one of the following is a diagnostic criterion for fibromyalgia? A. Excessive daytime sleepiness. B. Pain involving both sides of the body, above and below the waist, for at least three months. C. History of depression treated with medication. D. Chronic abdominal pain and disturbed bowel function

29. Question #4 • Which one of the following pharmacologic treatments has been shown to be effective in decreasing sleep disturbances associated with fibromyalgia? A. Tramadol (Ultram). B. Ibuprofen (Motrin). C. Amitriptyline. D. Venlafaxine (Effexor).

30. Glucose monitoring • FDA requirements for glucose monitors to produce results within 20 percent of reference measurement. • FDA recommends within 15 percent. • ADA recommends within 5 percent of laboratory values. • Common errors include expired strip use, inadequate sample size, and not calibrating meter.

31. Clinical Utility • SMBG improves glycemic control when used to adjust therapy. • ADA recommends SMBG atleast 3x per day with Type I diabetes. • Type II diabetes benefit from periodic monitoring.

32. Meter Selection • Smaller sample size requirement may be less painful and permits alternate site testing. • Alternate site testing allow less discomfort. • Meters giving results in less than 15 seconds increase convenience.

33. Blood Pressure Monitoring • Arm monitors are preferred over wrist or finger monitors. • Office-based BP measurements usually higher than at home readings. • JNC 7 defines home BP over 135/85 as hypertension, and is better at predicitng target organ damage and CV mortality.

34. Blood Pressure Monitoring • Measure BP 4x/day (twice in morning and twice in evening) for three consecutive days to obtain accurate assesment. • Medication adjustments should incorporate values from home and office monitoring. • Electronic BP reading correlate well with the auscultatory method.

35. Recommendations

36. Question #5 • A patient recently diagnosed with type 2 diabetes asks for advice on purchasing and using a home glucose meter. Which one of the following would be appropriate guidance? A. A glucose meter does not meet the standards of the U.S. Food and Drug Administration if its values vary by 10 percent from laboratory glucose values. B. Obtaining a smaller-than-required sample size will not significantly affect the meter's accuracy. C. Self-monitoring of blood glucose readings should not be the only basis for treatment decisions. D. The American Diabetes Association recommends that patients with type 2 diabetes monitor their blood glucose at least three times daily.

37. Question #6 In which one of the following patient groups do differences between home and office blood pressure measurements tend to be greater? A. Younger patients. B. Female patients. C. Patients taking antihypertensive medication. D. Anxious patients

38. Question #7 A 38-year-old woman previously diagnosed in the office with high-normal blood pressure has been checking her blood pressure at home with an arm monitor twice a day for the past several weeks. The readings are consistently between 135/85 mm Hg and 140/90 mm Hg. Which of the following actions should be recommended? A. Confirming these readings before and immediately after exercise once a day. B. Confirming these readings with a wrist monitor device. C. Adjusting medications based solely on home blood pressure readings. D. Confirming these readings by checking her blood pressure twice in the morning and twice in the evening for three consecutive days.

39. Screening • All pregnant women should be screened for HIV, hepatitis B, syphillis, and Chlamydia trachomatis. • At risk women (younger than 25 yoa and/or multiple sex partners) should be screened for Neisseria gonorrhea early in pregnancy and rescreened in their third trimester.

41. Chlamydia • 5 to 15 percent of pregnant women infected with C. trachomatis. • Mother to child transmission at birth may result in opthalmia neonatorum or pneumonitis in the newborn. Also, post partum endometritis in the mother. • Some reports of low birth weight and preterm birth.

42. Gonorrhea • Mother to newborn transmission risk is 30 to 47percent and may cause opthalmia neonatorum, systemic neonatal infection, maternal endometritits, or pelvic infection. • NAAT most sensitive and specific method of testing. • Nucleic acid hybridization tests and Thayer-Martin culture also used.

43. Hepatitis B • Presence of IgM Ab to hepatitis B core antigen is diagnostic of acute or recently acquired infection. • Pregnant women seeking STI treatment should be vaccinated. • Infants of HBsAg positive mothers should receive hep B Ig at birth and hep B vaccine.

44. Hepatitis C • Screen pregnant women with known risk factor (h/o IV drug use, blood transfusion/ organ transplant before 1992). • 5 percent of infants whose mothers have Hep C will become infected. • Breastfeeding is not a known way of transmission.

45. Herpes Simplex Virus • Risk of transmission is 30 to 50 percent higher among women who acquire genital HSV near time of delivery. • Screening by physical exam and history. • Diagnose by PCR assay of active lesion. • Routine serological testing is not recommended. • Acyclovir or valacyclovir suppressive therapy starting at 36 weeks EGA.

46. HIV • USPSTF all pregnant women be screened early in pregnancy. • Retesting in third trimester for women at high risk (h/o STI, exchange sex for money or drugs, multiple sexual partners during pregnancy, use illicit drugs, or sexual partner with HIV) • Testing done with an enzyme immunoassay for Ab to HIV.

47. HIV • HAART used except efavirenz (Sustiva) to suppress viral load. • Elective c-section at 38 weeks EGA for women not on anti-retrovirals or taking only zidovudine (Retrovir). • AIDSinfo website at http://www.adsinfor.nih.gov/guidelines/default.aspx

48. Human Papillomavirus • Testing normally done with ASCUS on pap smear, but treatment is not recommended for women with no cervical squamous intraepithelial lesions or genital warts. • Podofilox (Condylox), imiquimod (Aldara), and podophyllin are not recommended during pregnancy. • Trichloracetic acid 80-90% applied by health care professional weekly safe in pregnancy.

49. Syphillis • Complications may include hydramnios, spontaneous abortion, preterm delivery, fetal syphilis, fetal hydrops, prematurity, congential syphilis, neonatal death, and late sequelae. • Screening with RPR or VDRL and confirmed with flourescent treponemal antipbody serology and T. pallidum particle agglutination. • If dx after 20 weeks EGA then ultrasonography should be performed to evaluate for fetal syphilis signs inlcuding hepatomegaly, ascites, hydrops, polyhydramnios, and placental thickening. • Tx is PCN G 2.4 million units IM.

50. Vaginal Infections • Trichomonas vaginals screening in asymptomatic women is not recommended. • Treatment is metronidazole (Flagyl) 2 gram x 1 or 500 mg po BID x 7 days. • Treatment has not shown to decrease the incidence of preterm birth.