Malanga Talks

Thank you for joining us on another episode of Malanga Talks. Today, we will be discussing the Lyftogt procedure also known as perineural injection therapy. This technique was developed by Dr. John Lyftogt in order to treat chronic neuropathic pain. This therapy option consists of a series of small injections immediately under the skin targeting painful areas where the nerves are sensitive. Originally, this treatment was named subcutaneous prolotherapy and eventually later named neural prolotherapy; however, a more descriptive term was utilized and this procedure is known as Lyftogt Perineural Injection Therapy. Throughout the episode, we will take a deeper dive into everything you need to know about this safe procedure. We hope you enjoy this learning experience. 

Time Stamp

· Intro (0:00)

· Dr. Josh Martin Introduction (0:28)

·What is the Lyftogt procedure, and what is the goal of the procedure? (0:53)

· Patient scenarios that can utilize this procedure (3:00)

· Defining the terms hyperalgesia and allodynia (3:30)

· Discussing the research behind the Lyftogt procedure (5:00)

· History behind the Lyftogt procedure (8:00)

· Recap on the Lyftogt procedure (10:50)

· Closing statements (12:50)

Welcome back to another episode of Malanga Talks. Today, we will discuss the three most common causes of axial low back pain and how to differential between the various etiologies. Also, we will discuss the true meaning of the Waddell sign and how to interrupt these clinical findings. Waddell sign was first described by an orthopedic surgeon named Dr. Gordon Waddell, who identified patients likely to have a poor prognosis following back pain surgery. However, this sign has been misinterpreted by clinicians and insurance companies to detect malingering. These Waddell signs include overreaction, distraction, regional sensory disturbance and weakness, axial loading, superficial or non-anatomic tenderness. A score of 3 or more out of the five categories is considered a positive test. This significant finding should prompt clinicians to utilize psychological and behavioral management for low back pain. We hope you enjoy this learning experience, and this episode makes you a better future physician.

Introduction (0:00)

· Overview on axial low back pain and clinical patient presentation (0:30)

· Discogenic back pain symptoms and presentation (3:00)

· Understanding the pathophysiology of a straight leg test (6:55)

· An overview of Waddell sign (8:30)

· What are the 5 Waddell signs? (9:20)

· Non-organic pain (11:20)

· Facet vs. sacroiliac joint mediated pain symptoms (19:18)

· Discussing a positive diagnostic branch block (20:00)

· How to treat and approach a patient that exhibits Waddell’s sign (23:50)

· How to approach a patient that does not meet Waddell’s sign criteria (28:50)

· Clinical patient presentation following a motor vehicle accident (31:30)

· What is a maximal medical improvement? (38:00)

In today’s episode, Dr. Martin and Dr. Malanga will be discussing the etiology, epidemiology, pathophysiology, evaluation, and treatment options for a medical condition called piriformis syndrome. Unfortunately, this musculoskeletal condition is improperly diagnosed and relatively uncommon to have a true piriformis syndrome. We want to educate our audience and future physicians about the misconceptions of piriformis syndrome. So, what is this medical condition? Piriformis syndrome is a form of sciatica caused by compression of the sciatic nerve by the piriformis muscle. This condition most commonly presents as unilateral gluteal region pain characterized by shooting, burning, and aching down the back of the leg. The piriformis muscle can be stressed due to poor body mechanics from prolonged sitting activities or acute trauma to the gluteal region. When the piriformis is overused, irritated, or inflamed, it leads to irritation of the adjacent sciatic nerve causing sciatic-like symptoms. This medical condition's outcome is often excellent, and patients will become symptom-free within 2-4 weeks of proper management. We hope you enjoy this educational talk on piriformis syndrome, and for more information, the research article is listed below. 

References:

Piriformis Syndrome: A Narrative Review of the Anatomy, Diagnosis, and Treatment   https://pubmed.ncbi.nlm.nih.gov/31102324/

Time Stamp

· Intro (0:00)

· Dr. Martin opening remarks about piriformis syndrome (0:29)

· What is the Malanga Triad? (1:59)

· Initial thoughts by Dr. Malanga on piriformis syndrome (4:25)

· The history of piriformis syndrome (9:00)

· Understanding sensitivity vs. specificity (11:40)

· What is the Lasegue sign? (14:20)

· What is the H-reflex for electrodiagnostic testing? (16:25)

· Anatomy of the piriformis muscle and variations of its’ structure (19:40)

· Is palpating the piriformis muscle for reproducible pain a good test? (25:00)

· Differential diagnosis to think about in regard to posterior gluteal pain (29:30)

· Physical exam maneuvers for this musculoskeletal condition: FAIR test, Beatty test, active piriformis test, PACE test (31:38)

· Imaging modalities MRI vs. CT vs. ultrasound (36:20)

· Treatment options for piriformis pain (38:39)

· Thoughts on botulism toxin as a treatment option (44:19)

· Comprehensive physical exam for identifying piriformis pathology (47:00)

· Closing remarks (48:00)

Thank you for joining us on another episode of Malanga Talks. Today, we will be discussing the topic of greater trochanteric pain syndrome. This pain process is a regional pain disorder in which patients experience lateral hip tenderness and pain. These symptoms may be caused by damaged tendons, muscles, bursas, or other structures surrounding the greater trochanter of the femur. In the past, this condition was often referred to as “trochanteric bursitis” due to the inflammation of the trochanteric bursa. Recently, imaging studies and research suggest that lateral hip pain is more often caused by other etiology such as gluteal muscle tendons, head of the femur, or other soft tissue structures. Thus, the appropriate terminology for lateral hip pain is now called greater trochanteric pain syndrome. We hope you enjoy!

· Intro (0:00)

· Dr. Josh Martin Introduction to greater trochanteric pain syndrome (0:28)

· Is it really greater trochanteric bursitis? (1:10)

· Discussing the characteristics of a bursa and pathophysiology of bursitis (3:51)

· Describing a Trendelenburg gait pattern (7:25)

· How to utilize a cane and understand the importance of using a cane with a Trendelenburg gait pattern  (9:00)

· What is the association between Trendelenburg sign and chronic low back pain? (10:42)

· Malanga Triad (13:55)

· Dr. Monica Rho’s research literature review paper (15:36)

· Ober Test (18:27)

· Continued discussion on the patient presentation from the literature review article (21:00)

· Provider education to the patient on their needs vs. wants (25:00)

· Captain crunch cereal analogy (28:11)

· Concluding thoughts on the research article (31:34)

During today's episode, we will cover the evaluation process for various traumatic knee injuries and how these types of injuries occur in the athletic population. We will focus on understanding each of the ligamentous injury grading scale components and how to grade a patient's injury. What is the O'Donoghue triad, also known as the unhappy triad? What is the dial knee test? Why is the posterior lateral knee compartment important? Our great physicians will answer all these questions to help each listener grow as a medical provider. We hope you enjoy this great educational talk on traumatic knee injuries. 

Time Stamp

· Intro (0:00)

· Dr. Josh Martin Introduction (0:25)

· What is the most injured ligament of the knee? (1:40)

· Understanding grade one ligamentous injury (2:00)

· Testing the Medial Collateral Ligament with valgus force (4:35)

· Understanding grade two ligamentous injuries (5:05)

· Understanding grade three ligamentous injuries (7:20)

· Anterior cruciate ligament mechanism of injury (8:50)

· The Unhappy Triad (11:38)

· Posterior cruciate ligament injury (12:27)

· Isolated PCL treatment options (13:50)

· Structures located in the posterior lateral compartment of the knee (16:50)

· Dial Knee Test (17:40)

· Varus thrust during gait (20:00)

During today's episode, we will discuss the characteristics of the Lisfranc injury. This will include the history, physical examination, pathophysiology,  diagnostic criteria, and management options. What is a Lisfranc injury? A Lisfranc injury is when a tarsometatarsal dislocation occurs by traumatic disruption between the articulation of the medial cuneiform and the second metatarsal bone. This usually occurs through some traumatic event where an individual provides an excessive axial load through a hyperplantar flexed forefoot. The force exerted on the forefoot is transmitted to the tarsometatarsal joint causing the metatarsals to be displaced in a dorsal and lateral direction. The diagnostic criteria include midfoot pain and a widening interval between the 1st and 2nd metatarsal bone on AP view x-ray. Depending on the severity of the injury and x-ray findings, nonoperative or operative management should be discussed with the patient to receive the best outcome. We hope you enjoy this educational discussion on Lisfranc injuries. 

Time Stamp

· Intro (0:00)

· Dr. Josh Martin Introduction (0:25)

· The history and anatomy of the Lisfranc joint complex (0:50)

· Mechanism of injury behind Lisfranc injuries (1:45)

· Acquiring an orthopedic medical history (3:05)

· Physical examination (4:45)

· Pathology that occurs with excessive eversion (7:55)

· What is a Lisfranc fracture? (10:00)

· X-ray findings associated with Lisfranc injuries (10:30)

· Determining non-operative vs. operative management based on X-ray findings (11:20)

· Non-operative treatment options (11:50)

· Operative treatment options and post-operative recommendations (12:40)

· Is there a role for cortisone injections for Lisfranc injuries? (14:20)

· Physician’s obligation to the patient/athlete in his/her health (16:00)

· Closing remarks (17:40)

During this episode, Dr. Malanga will discuss an important randomized trial called the Spine Patient Outcomes Research Trial (SPORT) published in JAMA (2006). This research study enrolled 743 patients, of which 528 patients received surgery and 191 received nonoperative care for lumbar disk herniation at the 2-year mark. Also, we will be discussing an important topic on non-operative treatment options in particular epidural injections.  We will compare the efficacy and safety profile for transforaminal and interlaminar injections to help our future providers give their patients the best treatment option.  

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2562254/

Time Stamp:

· Opening remarks (0:29)

· Introduction to the Spine Patient Outcomes Research Trial (SPORT) by Dr. James Weinstein (1:55)

· Defining non-operative treatment for the SPORT research study (4:00)

· How could this study be improved? (6:15)

· Thoughts on non-operative treatment options like epidural injections (7:20)

· Comparing transforaminal vs. interlaminar epidural injections (8:15)

· Why are interlaminar injections not as popular? (10:10)

· Understanding how paralysis can occur with epidural injections (11:30)

· Is the transforaminal approach superior to the interlaminar approach? (12:35)

· Cervical versus lumbar interlaminar approach (16:15)

· Closing remarks (17:10)

During today's episode, Dr. Martin and Dr. Malanga will discuss the specialty of Physical Medicine and Rehabilitation (PM&R), also called physiatry as well as its' historical origins in the early 20th century. We will also talk about some of the earliest leaders who helped establish the specialty of PM&R and how these great influencers changed medicine. 

Time Stamp

· Intro (0:00)

· Why is the importance of knowing our history? (0:35)

· Dr. Frank H. Krusen (Grandfather of Physical Medicine and Rehabilitation) (3:05)

· Dr. John Coulter (First Professor of Physical Medicine) (8:00)

· Beginnings of the American Society of Physical Therapy Physicians (13:00)

· Dr. Howard Rusk (Founder of Rehabilitation Medicine) (15:00)

· Organizing the Board of Physical Medicine and Rehabilitation (18:00)

· Dr. Malanga’s input on the history of physical medicine and rehabilitation (21:00)

· Dr. Henry Kessler (Kessler Institute) (25:00)

· Closing thoughts with Dr. Martin and Dr. Malanga (28:15)

During today's episode, Dr. Malanga and Dr. Martin will discuss an excellent sports medicine case. One that provides medical students, residents, and fellows an opportunity to be reminded to never forget about the serious conditions even when at face value may present as a straightforward diagnosis. We hope you enjoy this learning opportunity. 

Time Stamp

· Intro (0:00)

· Dr. Martin’s opening remarks about our first clinical case discussion (0:30)

· Patient History (1:05)

· Physical Examination (5:00)

· Ultrasound Findings (6:05)

· Dr. Malanga’s thoughts on the patient presentation (7:30)

· Doppler evaluation confirming DVT diagnosis (10:30)

· Possible pulmonary embolism? (11:00)

· Learning lessons from Dr. Malanga about this case (12:30)

· Dr. Martin reviews Virchow’s Triad, deep vein thrombosis, and pulmonary embolism (15:30)

· Closing remarks (18:25)

In today's episode, Dr. Malanga will discuss with his residents the underlying pathophysiology of stress fractures that occurs in the athletic population. After discussing the mechanism behind stress fractures, he will focus on the best course of action in regards to imaging modalities, treatment plans, and prognosis for athletes with underlying stress fractures. 

Time Stamp

· Intro (0:00)

· How to describe stress fractures (0:29)

· Pathophysiology of stress fractures: Bone abnormality vs. force overload (1:41)

· Wolff’s Law: Bones will adapt based on the stress or demands placed on them (2:33)

· Stress fractures in adolescent and young athlete population (5:40)

· Common stress fracture presentations and provocation maneuvers (9:00)

· Imaging modalities for suspected stress fractures (11:40)

· What use does ultrasound have in stress fractures? (14:24)

· Management and care for stress fractures (15:08)

· Does vitamin D play a role in stress fracture management? (15:38)

· Maintaining cardiorespiratory fitness levels with a stress fracture (19:20)

· Return to sport timeline (20:41)

· Closing remarks (23:35)