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Apophyseal Injury

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101. Cervical Facet Syndrome (Diagnosis)

, , and , and . Next: Epidemiology Frequency United States Aprill and Bogduk estimated the prevalence of cervical facet joint pain by reviewing the records of patients who had presented with neck pain for at least 6 months secondary to some type of injury. [ ] These patients underwent discography, facet joint nerve blocks, or both at the request of the referring physicians. A total of 318 patients were investigated, and 26% of the patients had at least one symptomatic facet joint. However, only 126 patients (...) , but there was often a painful disc at the same level. This finding is not surprising when one considers how the facet joints and discs are intimately involved in motion of the cervical spine. Cervical facet joint pain is a common sequela of whiplash injury. Barnsley and Lord et al studied the prevalence of chronic cervical facet joint pain after whiplash injury using double-blind, controlled, diagnostic blocks of the facet joints. [ ] The joints were blocked randomly with either a short-acting or long-acting

2014 eMedicine.com

102. Ankylosing Spondylitis and Undifferentiated Spondyloarthropathy (Diagnosis)

) and transforming growth factor-β (TGF-β), are also important in the inflammatory process by leading to fibrosis and ossification at sites of enthesitis. [ , , ] The initial presentation of AS generally relates to the SI joints; involvement of the SI joints is required to establish the diagnosis. SI joint involvement is followed by involvement of the discovertebral, apophyseal, costovertebral, and costotransverse joints and the paravertebral ligaments. Early lesions include subchondral granulation tissue (...) spondylitis. J Rheumatol . 1999 Apr. 26(4):971-4. . Anwar F, Al-Khayer A, Joseph G, Fraser MH, Jigajinni MV, Allan DB. Delayed presentation and diagnosis of cervical spine injuries in long-standing ankylosing spondylitis. Eur Spine J . 2011 Mar. 20(3):403-7. . . Baraliakos X, Hermann KG, Landewé R, Listing J, Golder W, Brandt J, et al. Assessment of acute spinal inflammation in patients with ankylosing spondylitis by magnetic resonance imaging: a comparison between contrast enhanced T1 and short tau

2014 eMedicine.com

103. Ankylosing Spondylitis (Diagnosis)

) and transforming growth factor-β (TGF-β), are also important in the inflammatory process by leading to fibrosis and ossification at sites of enthesitis. [ , , ] The initial presentation of AS generally relates to the SI joints; involvement of the SI joints is required to establish the diagnosis. SI joint involvement is followed by involvement of the discovertebral, apophyseal, costovertebral, and costotransverse joints and the paravertebral ligaments. Early lesions include subchondral granulation tissue (...) spondylitis. J Rheumatol . 1999 Apr. 26(4):971-4. . Anwar F, Al-Khayer A, Joseph G, Fraser MH, Jigajinni MV, Allan DB. Delayed presentation and diagnosis of cervical spine injuries in long-standing ankylosing spondylitis. Eur Spine J . 2011 Mar. 20(3):403-7. . . Baraliakos X, Hermann KG, Landewé R, Listing J, Golder W, Brandt J, et al. Assessment of acute spinal inflammation in patients with ankylosing spondylitis by magnetic resonance imaging: a comparison between contrast enhanced T1 and short tau

2014 eMedicine.com

104. The Approach to the Painful Joint (Treatment)

spine, ask the patient to touch the chin to the chest (flexion) and then look up at the ceiling (extension). For lateral flexion, ask the patient to touch an ear to the shoulder. For lateral rotation, ask the patient to touch the chin to a shoulder. During lateral rotation and flexion, pain that occurs on the ipsilateral side of the neck is bony in origin (eg, from apophyseal joint disease), whereas pain on the contralateral side is muscular or ligamentous in origin. With the thoracic spine (...) polyarthritis include the following: Traumatic osteoarthritis (see ) Hypertrophic pulmonary osteoarthropathy Amyloidosis (see ) Differential diagnoses for regional musculoskeletal pain Shoulder Referred pain may derive from cervical disorders, Pancoast tumor of the lung, subphrenic pathology, or entrapment neuropathies and brachial neuritis (see ). Rotator cuff tendinitis (see ) [ ] is inflammation of the rotator cuff tendons, arising acutely as a result of a recognizable injury (throwing) or insidiously

2014 eMedicine.com

105. Osgood-Schlatter Disease (Treatment)

however both groups reported symptom relief with no adverse outcomes. [ ] Long-term immobilization is typically contraindicated, because it may result in increased knee stiffness in mild cases, thus predisposing the athlete to additional sports-related injuries. However, if a patient is noncompliant, the clinician may recommend immobilization in a knee brace for a minimum of 6 weeks. The brace should be removed daily, but only for stretching and strengthening exercises. Inform the patient to avoid (...) of the extensor mechanism. Open reduction and internal fixation (ORIF) usually is recommended, depending on the size and displacement of the fragment as well as the phase of apophyseal closure. Indications for surgery Occasionally, adults have a large ossicle and an overlying bursa, which may cause pain with kneeling. If so, treatment consists of excision of the bursa, ossicle, and any prominence. [ ] Contraindications for surgery The real question is whether or not surgery is ever indicated in the growing

2014 eMedicine.com

106. Cervical Facet Syndrome (Treatment)

> Cervical Facet Syndrome Treatment & Management Updated: Aug 28, 2018 Author: Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM; Chief Editor: Craig C Young, MD Share Email Print Feedback Close Sections Sections Cervical Facet Syndrome Treatment Acute Phase Rehabilitation Program Physical Therapy Kibler et al defined 3 phases of rehabilitation of soft-tissue injuries. [ ] The goals of the first phase are to reduce pain and inflammation, and increase the pain-free ROM. Ice is indicated during the acute phase (...) for the treatment of chronic cervical facet pain after whiplash injury. [ ] Patients enrolled in the study had been diagnosed with a painful cervical facet joint by responding to different facet joint nerve blocks on 2 separate occasions with Xylocaine and bupivacaine and receiving a longer period of relief with bupivacaine. After allowing time for their usual pain to return, the patients underwent random intra-articular facet joint injections with either bupivacaine or betamethasone. Fluoroscopy was used

2014 eMedicine.com

107. Cervical Facet Syndrome (Overview)

, , and , and . Next: Epidemiology Frequency United States Aprill and Bogduk estimated the prevalence of cervical facet joint pain by reviewing the records of patients who had presented with neck pain for at least 6 months secondary to some type of injury. [ ] These patients underwent discography, facet joint nerve blocks, or both at the request of the referring physicians. A total of 318 patients were investigated, and 26% of the patients had at least one symptomatic facet joint. However, only 126 patients (...) , but there was often a painful disc at the same level. This finding is not surprising when one considers how the facet joints and discs are intimately involved in motion of the cervical spine. Cervical facet joint pain is a common sequela of whiplash injury. Barnsley and Lord et al studied the prevalence of chronic cervical facet joint pain after whiplash injury using double-blind, controlled, diagnostic blocks of the facet joints. [ ] The joints were blocked randomly with either a short-acting or long-acting

2014 eMedicine.com

108. Cervical Disc Disease (Overview)

Updated: Mar 21, 2018 Author: Michael B Furman, MD, MS; Chief Editor: Dean H Hommer, MD Share Email Print Feedback Close Sections Sections Cervical Disc Disease Overview Practice Essentials Cervical disc disorders encountered in physiatric practice include (HNP), (DDD), and internal disc disruption (IDD). HNP (seen in the image below) is defined as localized displacement of nucleus, cartilage, fragmented apophyseal bone, or fragmented anular tissue beyond the intervertebral disc space. [ ] Most (...) of the herniation is made up of the annulus fibrosus. DDD involves degenerative annular tears, loss of disc height, and nuclear degradation. IDD describes annular fissuring of the disc without external disc deformation. can result from nerve root injury in the presence of disc herniation or stenosis, most commonly foraminal stenosis, leading to sensory, motor, or reflex abnormalities in the affected nerve root distribution. [ , ] Sagittal magnetic resonance imaging (MRI) scan demonstrating cervical

2014 eMedicine.com

109. Sickle Cell Anemia (Overview)

by a spinal artery branch) results in the characteristic H vertebrae of sickle cell disease. The outer portions of the plates are spared because of the numerous apophyseal arteries. Osteonecrosis of the epiphysis of the femoral head is often bilateral and eventually progresses to collapse of the femoral heads. This same phenomenon is also seen in the humeral head, distal femur, and tibial condyles. Infarction of bone and bone marrow in patients with sickle cell disease can lead to the following changes (...) and an inability to deal with infective encapsulated microorganisms, particularly Streptococcus pneumoniae, ensue, leading to an increased risk of sepsis in the future. Chronic hemolytic anemia SCD is a form of hemolytic anemia, with red cell survival of around 10-20 days. Approximately one third of the hemolysis occurs intravascularly, releasing free hemoglobin (plasma free hemoglobin [PFH]) and arginase into plasma. PFH has been associated with endothelial injury including scavenging nitric oxide

2014 eMedicine.com

110. The Approach to the Painful Joint (Overview)

spine, ask the patient to touch the chin to the chest (flexion) and then look up at the ceiling (extension). For lateral flexion, ask the patient to touch an ear to the shoulder. For lateral rotation, ask the patient to touch the chin to a shoulder. During lateral rotation and flexion, pain that occurs on the ipsilateral side of the neck is bony in origin (eg, from apophyseal joint disease), whereas pain on the contralateral side is muscular or ligamentous in origin. With the thoracic spine (...) polyarthritis include the following: Traumatic osteoarthritis (see ) Hypertrophic pulmonary osteoarthropathy Amyloidosis (see ) Differential diagnoses for regional musculoskeletal pain Shoulder Referred pain may derive from cervical disorders, Pancoast tumor of the lung, subphrenic pathology, or entrapment neuropathies and brachial neuritis (see ). Rotator cuff tendinitis (see ) [ ] is inflammation of the rotator cuff tendons, arising acutely as a result of a recognizable injury (throwing) or insidiously

2014 eMedicine.com

111. Lumbosacral Spondylolysis (Overview)

):487-99, ix. . Dubousset J. Treatment of spondylolysis and spondylolisthesis in children and adolescents. Clin Orthop Relat Res . 1997 Apr. 337:77-85. . Albanese M, Pizzutillo PD. Family study of spondylolysis and spondylolisthesis. J Pediatr Orthop . 1982. 2(5):496-9. . Stinson JT. Spondylolysis and spondylolisthesis in the athlete. Clin Sports Med . 1993 Jul. 12(3):517-28. . Patel DR, Nelson TL. Sports injuries in adolescents. Med Clin North Am . 2000 Jul. 84(4):983-1007, viii. . Sakai T, Goda Y (...) , Saifuddin A, Wolman RL. The radiological investigation of lumbar spondylolysis. Clin Radiol . 1998 Oct. 53(10):723-8. . Lowe J, Schachner E, Hirschberg E, Shapiro Y, Libson E. Significance of bone scintigraphy in symptomatic spondylolysis. Spine . 1984 Sep. 9(6):653-5. . Bellah RD, Summerville DA, Treves ST, Micheli LJ. Low-back pain in adolescent athletes: detection of stress injury to the pars interarticularis with SPECT. Radiology . 1991 Aug. 180(2):509-12. . . Collier BD, Johnson RP, Carrera GF, et

2014 eMedicine.com

112. Lumbosacral Radiculopathy (Overview)

, and from the opposite side. The sinuvertebral nerve supplies the posterior longitudinal ligament, superficial annulus fibrosus, epidural blood vessels, anterior dura mater, dural sleeve, and posterior vertebral periosteum. The 2 structures capable of transmitting neuronal impulses that result in the experience of pain are the sinuvertebral nerve and the nerve root. The posterior rami of the spinal nerves supply the apophyseal joints above and below the nerve as well as the paraspinous muscles (...) at multiple levels. Herniation of the intervertebral disc can cause impingement of the above neuronal structures, thus causing pain. The presence of disc material in the epidural space is thought to initially result in direct toxic injury to the nerve root by chemical mediation and then exacerbation of the ensuing intraneural and extraneural swelling, which results in venous congestion and conduction block. Notably, the size of the disc herniation has not been found to be related to the severity

2014 eMedicine.com

113. Lumbosacral Facet Syndrome (Overview)

zygos , meaning yoke or bridge, and physis , meaning outgrowth. This “bridging of outgrowths” is most easily seen from a lateral view, where the Z-joint bridges adjoin the vertebrae. The term facet joint is a misnomer because the joint occurs between adjoining zygapophyseal processes, rather than facets, which are the articular cartilage lining small joints in the body (eg, phalanges, costotransverse and costovertebral joints). This joint is also sometimes referred to as the apophyseal joint (...) surgeons or neurosurgeons is not surprising. As the primary cause of work-related injuries, LBP is the most costly of all medical diagnoses when time off from work, long-term disability, and medical and legal expenses are taken into account. [ ] The lumbosacral Z-joint is reported to be the source of pain in 15-40% of patients with chronic LBP. Ray believed that Z-joint–mediated pain is the etiology for most cases of , [ ] whereas other authors have argued that it may contribute to nearly 80% of cases

2014 eMedicine.com

114. Hip Tendonitis and Bursitis (Overview)

pain, such as a hamstring tendinopathy from repetitive activities such as running. Training errors, biomechanical issues, and sudden increases in activity levels are also risk factors. In the adolescent age group, traction injuries such as avulsion fracture and apophysitis can occur and cause difficulties with training and performance. [ , ] The investigation into the cause and treatment of hip overuse injuries can often be frustrating for clinicians and patients alike. Many musculoskeletal (...) . Sports Med . 1998 Apr. 25(4):271-83. . Garrick JG, Webb DR. Sports Injuries: Diagnosis and Management . 2nd ed. Philadelphia, Pa: WB Saunders; 1999. Shbeeb MI, Matteson EL. Trochanteric bursitis (greater trochanter pain syndrome). Mayo Clin Proc . 1996 Jun. 71(6):565-9. . Kujala UM, Orava S, Karpakka J, Leppävuori J, Mattila K. Ischial tuberosity apophysitis and avulsion among athletes. Int J Sports Med . Feb 1997. 18(2):149-55. . Kivlan BR, Martin RL. Functional performance testing of the hip

2014 eMedicine.com

115. Little League Elbow Syndrome (Overview)

year. This increase in participation has been paralleled by an increase in sports-related injuries in the pediatric population. [ , , , , , , , , , , , ] Increased single-sport participation with year-round training, higher intensities at young ages, and longer competitive seasons are contributing factors to the increased injury rates seen in pediatric athletes. [ ] Conditioning and training errors also contribute significantly to the risk and frequency of injury. Although briefly discussed below (...) , injuries to the lateral, posterior, and anterior elbow are separate entities and should not be confused with the medial injuries referred to as little league elbow syndrome. During the throwing motion, valgus stress is placed on the elbow. This valgus stress results in tension on the medial structures (ie, medial epicondyle, medial epicondylar apophysis, medial collateral ligament complex) and compression of the lateral structures (ie, radial head, capitellum). Repeated stress results in overuse injury

2014 eMedicine.com

116. Osgood-Schlatter Disease (Overview)

traction (traction apophysitis) on the anterior portion of the developing ossification center leads to multiple subacute microavulsion fractures and/or tendinous inflammation, resulting in a benign, self-limited disturbance manifested as pain, swelling, and tenderness. The most common long-term ramifications of OSD are pain on kneeling as an adult and the cosmesis of a bony prominence on the anterior knee. Less common complications are the persistence of a painful ossicle requiring surgical excision (...) persist for 2-3 years until the tibial growth plate closes. Previous Next: Patient Education Inform patients about activities that aggravate Osgood-Schlatter disease and about the self-limiting nature of the condition. For patient education information, see the , the , and the , as well as . Previous References Pommering TL, Kluchurosky L. Overuse injuries in adolescents. Adolesc Med State Art Rev . 2007 May. 18(1):95-120, ix. . Smith JM, Varacallo M. Osgood Schlatter Disease. StatPearls [Internet

2014 eMedicine.com

117. Medial Epicondylitis (Overview)

has also been reported in bowlers, archers, and weight lifters. [ , , , ] Little leaguer's elbow is sometimes considered a variant of medial epicondylitis, but this condition is technically a traction apophysitis of the medial epicondyle, which requires a different treatment course. For patient education resources, see the , as well as . Next: Epidemiology Frequency United States Medial epicondylitis accounts for only 10-20% of all epicondylitis diagnoses [ ] ; the annual incidence is between 3-4 (...) NS, Schickendantz MS. Medial epicondylitis: evaluation and management. J Am Acad Orthop Surg . 2015 Jun. 23 (6):348-55. . Kiel J, Kaiser K. Golfers Elbow. StatPearls [Internet] . 2018 Jan. . . Kohn HS. Prevention and treatment of elbow injuries in golf. Clin Sports Med . 1996 Jan. 15(1):65-83. . Nirschl RP. Prevention and treatment of elbow and shoulder injuries in the tennis player. Clin Sports Med . 1988 Apr. 7(2):289-308. . Nirshal RP. Muscle and tendon trauma: tennis elbow. The Elbow and Its

2014 eMedicine.com

118. Lumbosacral Facet Syndrome (Treatment)

on proper posture and body mechanics in activities of daily living that protect the injured joints, reduce symptoms, and prevent further injury. Positions that cause pain (eg, extension, oblique extension) should be avoided. Bed rest beyond 2 days is not recommended because this can have detrimental effects on bone, connective tissue, muscle, and the cardiovascular system. Thus, activity modification, rather than bed rest, is strongly recommended. Modalities such as may also help relax the muscles (...) (2):129-38. . Adams MA, Hutton WC. The mechanical function of the lumbar apophyseal joints. Spine . 1983 Apr. 8(3):327-30. . Anderson R, Meeker WC, Wirick BE, et al. A meta-analysis of clinical trials of spinal manipulation. J Manipulative Physiol Ther . 1992 Mar-Apr. 15(3):181-94. . Bogduk N. International Spinal Injection Society guidelines for the performance of spinal injection procedures. Part 1: Zygapophysial joint blocks. Clin J Pain . 1997 Dec. 13(4):285-302. . Bogduk N. Management

2014 eMedicine.com

119. Lumbosacral Spondylolysis (Treatment)

in a brace as symptoms resolve. Consultations Consult neurosurgeons, orthopedic surgeons, neurologists, and physiatrists as indicated. Other Treatment (Injection, manipulation, etc.) Electromagnetic field therapy for persistent nonunion may be used in this phase. Previous Next: Maintenance Phase Rehabilitation Program Physical Therapy Maintenance phase The single best predictor for a new injury during athletic activity is a history of a previous injury. Patients showing a spondylolytic defect on plain (...) . 2(5):496-9. . Stinson JT. Spondylolysis and spondylolisthesis in the athlete. Clin Sports Med . 1993 Jul. 12(3):517-28. . Patel DR, Nelson TL. Sports injuries in adolescents. Med Clin North Am . 2000 Jul. 84(4):983-1007, viii. . Sakai T, Goda Y, Tezuka F, Takata Y, Higashino K, Sato M, et al. Characteristics of lumbar spondylolysis in elementary school age children. Eur Spine J . 2016 Feb. 25 (2):602-6. . Weiker GG. Evaluation and treatment of common spine and trunk problems. Clin Sports Med

2014 eMedicine.com

120. Hip Tendonitis and Bursitis (Treatment)

Physician . 2000 Apr 1. 61(7):2109-18. . . Johnston CA, Wiley JP, Lindsay DM, Wiseman DA. Iliopsoas bursitis and tendinitis. A review. Sports Med . 1998 Apr. 25(4):271-83. . Garrick JG, Webb DR. Sports Injuries: Diagnosis and Management . 2nd ed. Philadelphia, Pa: WB Saunders; 1999. Shbeeb MI, Matteson EL. Trochanteric bursitis (greater trochanter pain syndrome). Mayo Clin Proc . 1996 Jun. 71(6):565-9. . Kujala UM, Orava S, Karpakka J, Leppävuori J, Mattila K. Ischial tuberosity apophysitis and avulsion (...) Tendonitis and Bursitis Treatment & Management Updated: Oct 12, 2018 Author: Jeffrey Rosenberg, MD; Chief Editor: Sherwin SW Ho, MD Share Email Print Feedback Close Sections Sections Hip Tendonitis and Bursitis Treatment Acute Phase Rehabilitation Program Physical Therapy The initial treatment for all chronic hip overuse injuries is similar, and this can be taught to patients in the office or via formal physical therapy. The initial alleviation of overuse pain is accomplished with relative rest

2014 eMedicine.com

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