Adult-onset hypophosphatemic osteomalacia as a cause of widespread musculoskeletal pain:A retrospective case series of single center experience

BACKGROUND Osteomalacia(OM)is frequently confused with various musculoskeletal or other rheumatic diseases,especially in patients with adult-onset widespread musculoskeletal pain because of its low prevalence and non-specific manifestations.AIM To facilitate the early diagnosis and etiology-specific treatment of adult-onset hypophosphatemic OM.METHODS A retrospective review of medical records was performed to screen adult patients who visited a physiatry locomotive medicine clinic(spine and musculoskeletal pain clinic)primarily presenting with widespread musculoskeletal pain at a single tertiary hospital between January 2011 and December 2019.We enrolled patients with hypophosphatemia,high serum bone-specific alkaline phosphatase levels,and at least one imaging finding suggestive of OM.RESULTS Eight patients with adult-onset hypophosphatemic OM were included.The back was the most common site of pain.Proximal dominant symmetric muscle weakness was observed in more than half of the patients.Bone scintigraphy was the most useful imaging modality for diagnosing OM because radiotracer uptake in OM showed characteristic patterns.Six patients were diagnosed with adefovir(ADV)-induced Fanconi syndrome,and the other two patients were diagnosed with tumor-induced OM and light-chain nephropathy,respectively.After phosphorus and vitamin D supplementation and treatment for the underlying etiologies,improvements in pain,muscle strength,and gait were observed in all patients.CONCLUSION Mechanical pain characteristics,hypophosphatemia,and distinctive bone scintigraphy patterns are the initial diagnostic indicators of adult-onset hypophosphatemic OM.ADV-induced Fanconi syndrome is the most common etiology of hypophosphatemic OM in hepatitis B virus-endemic countries.

Orthotic approach to prevention and management of diabetic foot:A narrative review

Diabetic foot is a common complication affecting more than one-fifth of patients with diabetes.If not treated in time,it may lead to diabetic foot ulcers or Charcot arthropathy.For the management of diabetic foot,shoe modifications and orthoses can be used to reduce pressure on the affected foot or provide the foot with increased stability.In addition,the shoe modifications and orthotic devices can relieve patient discomfort during walking.Appropriate shoe modifications include changing the insole material,modifying the heel height,adding a steel shank or rocker sole,and using in-depth shoes.Alternatively,a walking brace or ankle-foot orthosis can be used to reduce the pressure on the affected foot.The purpose of this narrative review was to provide a reference guide to support clinicians in prescribing shoe modifications and foot orthoses to treat diabetic foot ulcers and Charcot arthropathy.

Intraneural ganglion cyst of the lumbosacral plexus mimicking L5 radiculopathy:A case report

BACKGROUND Intraneural ganglion cysts are benign gelatinous masses that form within the epineurium of a peripheral nerve.Only few cases of intraneural ganglion cyst arising from the hip joint have been reported.CASE SUMMARY A previously healthy 65-year-old woman who had been experiencing left buttock pain radiating to the dorsum of the foot for 2 years visited our clinic.Prior to visiting the clinic,she underwent lumbar spine magnetic resonance imaging and received physiotherapy,pain killers,and epidural injections based on a presumptive diagnosis of spinal stenosis for 2 years in other hospitals.Repeat magnetic resonance imaging revealed joint connection of the articular branch of the hip joint and rostral extension of the cyst along the L5 spinal nerve near the L5-S1 neural foramen.The patient was diagnosed with intraneural ganglion cyst arising from the articular branch of the hip joint based on high-resolution magnetic resonance neurography.Using the arthroscopic approach,a cystic opening within the intra-articular space was detected,and cyst decompression was then performed.The pain in the left leg was significantly relieved during the 6-mo follow-up.CONCLUSION Although intraneural ganglion cysts arising from the hip joint are rare,they can cause typical radicular pain and mimic common L5 radiculopathy.Typical cyst ascent phenomenon starting from the termination of the articular branch on magnetic resonance imaging is a crucial finding indicative of intraneural ganglion cysts arising from the hip joint.

Amputation stump management:A narrative review

In this review intended for medical staff involved in patient rehabilitation,we provided an overview of the basic methods for managing amputation stumps.After the amputation surgery,it is imperative to optimize the remaining physical abilities of the amputee through rehabilitation processes,including postoperative rehabilitation,desensitization,and continuous application of soft or rigid dressings for pain reduction and shaping of the stump.Depending on the situation,a prosthesis may be worn in the early stage of recovery or an immediate postoperative prosthesis may be applied to promote stump maturation.Subsequently,to maintain the range of motion of the stump and to prevent deformation,the remaining portion of the limb should be positioned to prevent contracture.Continuous exercises should also be performed to improve muscle strength to ensure that the amputee is able to perform activities of daily living,independently.Additionally,clean wound or edema management of the stump is necessary to prevent problems associated with wearing the prosthesis.Our review is expected to contribute to the establishment of basic protocols that will be useful for stump management from the time of completion of amputation surgery to the fitting of a prosthesis to optimize patient recovery.

Essentials of thoracic outlet syndrome:A narrative review

Thoracic outlet syndrome(TOS)is a group of diverse disorders involving compression of the nerves and/or blood vessels in the thoracic outlet region.TOS results in pain,numbness,paresthesia,and motor weakness in the affected upper limb.We reviewed the pathophysiology,clinical evaluation,differential diagnoses,and treatment of TOS.TOS is usually classified into three types,neurogenic,venous,and arterial,according to the primarily affected structure.Both true neurogenic and disputed TOS are considered neurogenic TOS.Since identifying the causative lesions is complex,detailed history taking and thorough clinical investigation are needed.Electrodiagnostic and imaging studies are helpful for excluding other possible disorders and confirming the diagnosis of true neurogenic TOS.The existence of a disputed TOS remains controversial.Neuromuscular physicians tend to be skeptical about the existence of disputed TOS,but thoracic surgeons argue that disputed TOS is under-diagnosed.Clinicians who encounter patients with TOS need to understand its key features to avoid misdiagnosis and provide appropriate treatment.