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Test the muscles of the ankle by first having the patient dorsiflex the foot against resistance (Photo 4) cheap protonix 40mg with amex chronic gastritis weight loss. This tests the tibialis anterior muscle purchase protonix 20 mg with visa gastritis diet treatment inflammation, which is innervated by the deep peroneal nerve (L4). Next, have the patient plantarflex the foot against resistance (Photo 5). This tests the patient’s gastrocneumius and soleus muscles, which are innervated by the tibial nerve (primarily S1). The anterior talofibular ligament (ATFL) attaches from the anterior por- tion of the lateral malleolus to the lateral aspect of the talar neck in the Ankle Pain 115 Photo 4. The ATFL is the most commonly sprained ankle ligament in part because it is the first to be stressed during inversion and plantar flex- ion. To perform this test, with the patient’s foot in a few degrees of plantar flexion, take hold of the patient’s lower tibia with one hand and grip the patient’s calcaneus with the palm of the other hand. Pull the patient’s calcaneus (and talus) anteriorly toward you while you simultaneously push the patient’s tibia posteriorly away from you (Photo 6). The ATFL is the only ligament resisting this ante- rior talar subluxation. Increased subluxation and/or a clunking sensa- tion with subluxation reflect a torn ATFL. The calcaneofibular ligament (CFL) attaches the fibula to the lateral wall of the calcaneus. To test for the integrity of the CFL and ATFL, invert the patient’s calcaneus and assess for gapping of the talar joint (Photo 7). Increased gapping (compared with the unaffected limb) indicates a torn ATFL and CFL and reflects ankle instability. The posterior talofibular ligament (PTFL) is the third ligament in the lateral ankle to be sprained. The PTFL attaches from the posterior edge of the lateral malleolus to the posterior aspect of the talus. Because of its position and strength, the PTFL is rarely torn except in severe ankle injuries, such as dislocation. Having assessed the integrity of the lateral ligaments, next assess the integrity of the MCL. Stabilize the patient’s leg by holding the patient’s tibia and calcaneus and evert the foot (Photo 8). Increased gapping at the medial ankle reflects a tear in the medial collateral ligament. Finally, if you are concerned about a possible stress fracture in the lower leg or foot, place a tuning fork onto the painful area or area of local- ized tenderness over the bone. Plan Having completed your history and physical examination, you have a good idea of what is wrong with your patient’s ankle. Here is what to do next: Suspected ankle sprain Additional diagnostic evaluation: The Ottawa ankle rules were designed to offer an evidence-based approach to determine which patients with a suspected ankle sprain require X-rays and which do not. All patients with a suspected ankle sprain require radiographs except patients who are younger than 55 years old, able to walk four steps at Ankle Pain 119 the time of injury and at the time of evaluation, and who do not have tenderness over the posterior edge of the medial malleolus. If the diag- nosis is in doubt, or concomitant injury to the soft tissues is suspected, magnetic resonance imaging (MRI) may also be very helpful. Treatment: most ankle sprains may be managed conservatively with rest, ice, compression, and protective devices, such as an air cast (or other brace). Physical therapy that emphasizes range of motion, pro- prioceptive, and strengthening exercises is also helpful. In general, once a patient can run, jump 10 times on the injured foot, stand for 1 min with eyes closed on the injured foot, and pivot quickly without significant pain, the patient is ready to return to sport. Treatment: Conservative care is first-line therapy and includes rest, orthotics, ice, and physical therapy. Treatment: Conservative care is first-line therapy with ice, rest, non- steroidal anti-inflammatory drugs (NSAIDs), and physical therapy. Treatment: Rest, ice, NSAIDs, lidocaine patch, and/or a steroid and anesthetic injection are helpful. Surgical release is reserved for severe cases that are not responsive to conservative care. Treatment: Conservative care, including weight loss, rest, activity modification, nonweight-bearing exercises, acetaminophen, and NSAIDs, may be used.

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Depression in spouses of chronic pain patients: The role of patient pain and anger generic protonix 40mg fast delivery definition akute gastritis, and marital satisfaction buy protonix 40mg low cost gastritis keeps coming back. The problems of pain and its detection among geriatric nursing home residents. Semantic and pragmatic aspects of context effects in social and psychological research. Effects of marital interaction on chronic pain and disability: Examining the down side of social support. Social and pain behavior in the first three minutes of a pain clinic medi- cal interview. Consequences of nonverbal expres- sion of pain: Patient distress and observer concern. Prediction of facial displays from knowl- edge of norms of emotional expressiveness. The evolution of research on recurrent abdominal pain: History, assumptions, and a conceptual model. From a cognitive-behavioral perspective an examination of pain-relevant marital communication in chronic pain patients. Dissertation Abstracts International: Section B: Sciences & Engineering, 56, 4596. CHAPTER 5 Pain ver the Life Span: A Developmental Perspective Stephen J. Gibson National Ageing Research Institute, Parkville, and Department of Medicine, University of Melbourne Christine T. Chambers Department of Pediatrics, University of British Columbia, and Centre for Community Child Health Research, Vancouver Pain is a complex phenomenon that consists of interacting biological, psy- chological, and social components (Merskey & Bogduk, 1994). For many years, the study of pain was focused primarily on young and middle-aged adult populations; however, as research in the area of pain expanded, so did consideration of the importance of developmental factors in pain expe- rience and expression, including pain in infants, children, and seniors. Life- span developmental psychology involves the study of constancy and change in behavior through the life course (Baltes, 1987). This approach can be helpful in gaining knowledge about the pain experience across the life span and furthering understanding about interindividual differences and similarity in pain responses. The present chapter provides a broad overview of developmental per- spectives in pain across various life stages, including infancy, childhood, adolescence, adulthood, and seniors. Research pertaining to age differ- ences in pain experience and report and psychosocial and physiological factors that impact on pain for each of these developmental periods are re- viewed. Further, developmental factors that relate to pain assessment and management are discussed. An appreciation of the unique challenges faced by individuals at various stages of life is critical to furthering understanding about the developmental progression of pain across the life span. This period is charac- terized by dramatic changes to the body and brain and the emergence of a wide array of cognitive capacities, including language and the ca- pability to engage in social relationships with others. These years are character- ized by further refinements in motor skills and cognitive functioning. Advances in understanding of the self and others are evident during this phase. Cognitive abilities become more ab- stract and puberty leads to physical and sexual maturity. A broad spectrum of pain experiences is evident across these developmen- tal periods. Throughout the sections that follow, the terms children or child- hood are used to refer to the entire range from 0 to 18 years and particular developmental periods are specified as appropriate. Age Differences in Pain Experience and Report During Childhood In comparison to the extensive literature among adult populations, little is known about the epidemiology of pain in children and adolescents (Good- man & McGrath, 1991). Investigations of pain prevalence have traditionally focused on specific pain conditions restricted to particular developmental periods, rather than providing a more comprehensive description of pain problems across childhood. Headache is the pain condition among children that has been most broadly explored (Goodman & McGrath, 1991), with prevalence rates ranging anywhere from 2% (Bille, 1962) to 27% (Abu-Arefeh & Russell, 1994), depending on the type of diagnostic criteria used and the age and gender of the child.

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Monostotic fibrous dysplasia in the area of the right tibia a bulge may be palpable proven protonix 20mg gastritis attack. Bowing or axial deviation of of a 2-year old boy the bone may also be visible (⊡ Fig generic 20mg protonix with mastercard gastritis diet . A very typical finding is bowing of the proximal femur in the shape of a shepherd’s crook (⊡ Fig. Pain oc- curs only if fractures are present, or occasionally during taken if the diagnosis is clear. Since it can be difficult to obtain sufficient distended and the cortex thinner than normal. In the autologous cancellous bone to fill the gap, homologous medullary cavity there is a large osteolytic area inter- cancellous bone or hydroxyapatite can also be used. Rein- woven with bone trabeculae (under magnification), forcement with an intramedullary load-bearing implant, producing a characteristic ground-glass opacity. For the proximal casionally pronounced sclerosis is visible around the femur, an intertrochanteric valgus osteotomy and stabili- focus. On the MRI scans the tissue signal is low in all zation with a gamma-nail is appropriate. The shaped fibrous trabeculae embedded in a moderately sleeve and the nail are inserted from the greater trochan- cell-rich fibrous stroma. The trabeculae show flat- ter and the nail can be transfixed at the distal epiphysis tened cells on the surface rather than cuboid osteo- with a screw. In a In the initial stages (particularly in relation to the sample of approx. However, the frosted-glass opacity and Osteofibrous dysplasia (according to Campanacci) bowing are both absent. On the lower leg monostotic fibrous dysplasia can be Definition confused with an osteofibrous dysplasia (see below), Congenital, probably hamartomatous, predominantly although the latter almost always affects the tibia intracortical lesion consisting of osteofibrous tissue, alone and shows osteolytic-sclerotic changes in the almost invariably located in the tibia, rarely in the fibula cortical bone. The condition was described in 1976 by Cam- Treatment, prognosis panacci. Provided no major deformation is present, surgical treat- Synonyms: Congenital fibrous defect of the tibia, ment is not usually required. Nor does a biopsy need to be Campanacci’s disease, ossifying fibroma 608 4. The lesion is rarer than fibrous dysplasia and does not Fractures should be treated conservatively. The male sex is more fre- possible only after the completion of growth) is indicated quently affected. The disease usually manifests itself if the bone is greatly weakened, or if substantial bowing within the first five years of life and occurs almost or pseudarthrosis are present. If the x-rays raise doubts exclusively in the tibia, and only rarely in the fibula. It about the possibility of an adamantinoma (intramedullary tends to start in mid-shaft and then spread distally or involvement! Not infre- Clonal, possibly neoplastic, proliferation of Langerhans quently, a pathological – possibly incomplete – fracture cells with activation of lymphocytes, eosinophils, mac- can occur. Recovery can sometimes be problematic, and rophages, multinuclear giant cells and Langerhans cells. The foci are ▬ Synonyms: Histiocytosis X, eosinophilic granuloma located not in the medullary cavity of the bone but in the cortex, which gradually bends and may show mi- crofractures. The picture is also characterized by re- Occurrence, site modeling processes and callus formation (⊡ Fig. Boys are ▬ Histology: In contrast with fibrous dysplasia, the im- twice as frequently affected as girls. The disease can be mature bone trabeculae, which are likewise embedded found in all bones. It is especially common in the man- in a fibrous stroma, are occupied by cuboid osteo- dible and skull, but can also affect all long bones, the ribs, blasts. The lesions are structured in zones with a cen- the spine and the flat bones.

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