Although stress injuries are a common occurrence in sports medicine clinics, a distal femur stress fracture is less so. Early detection can result in a favorable prognosis and may prevent the need for surgical intervention. A misdiagnosis resulting in delay of care can result in significant complications. This case report documents a rare distal femur stress fracture in a long-distance hiker. A 35-y-old male presented to an orthopedic clinic in Pennsylvania with left knee pain after completing 1423 km (884 mi) of the Appalachian trail over a 4-mo period. He was attempting a thru-hike, a specialized type of backpacking focused on completing a trail from end-to-end. Thru-hiking of this trail involves backpacking between Georgia and Maine, covering about 3540 km (2200 mi) with approximately 141,580 m (464,500 ft) of gain/ loss in elevation. His pain began 2 mo into his hike when he noted medial sided left knee discomfort. Over the following 2 mo he sought treatment at 2 different locations along the trail with etiology undetermined. Upon evaluation in Pennsylvania, history and physical exam were suggestive of a stress fracture. Radiologic studies confirmed a closed nondisplaced nonangulated grade 4 transverse fracture of the shaft of the distal left femur. The patient was instructed to terminate his hike immediately and he was placed on nonweight bearing status. This case illustrates the importance of considering a distal femur stress fracture for the differential diagnosis of persistent knee pain in a long-distance hiker.
SUMMARYObjective. To assess the association between BMI, fitness, and mortality in men with type 2 diabetes and to explore racial differences in this association.Design and methods. This was a prospective, observational cohort study of veterans (n = 4,156) from 1986 to 2010. The cohort consisted of 2,000 Caucasian men, 2,013 AfricanAmerican men, and 143 men of unknown or undetermined race.Information was accessed via patients' electronic medical records. Vital statistics assessed included BMI, cardiac risk factors, medications, and peak exercise capacity in metabolic equivalents (METs), evaluated by a standardized treadmill protocol.All-cause mortality was accessed across BMI, race, and fitness categories. BMI ranges were 18.5-24.9 kg/ m 2 (normal weight, n = 668), 25-29.9 kg/m 2 (overweight, n = 1,610), 30-34.9 kg/m 2 (obese, n = 1,160), and ≥ 35 kg/m 2 (obese II and III, n = 718). The fitness levels were divided into four categories based on the peak MET level attained before volitional failure: ≤ 5 METs (least fit, n = 1,162), 5.1-7.0 METs (moderately fit, n = 1,163), 7.1-8.7 METs (fit, n = 995), and > 8.7 METs (highly fit, n = 836).Results. A total of 1,074 deaths occurred over a median time period of 7.5 years. An association was seen individually among age, hypertension, smoking, BMI, exercise capacity, and mortality. Mortality was reduced by 12% for every 1-MET increase in exercise capacity across the entire cohort.There was an even greater reduction in mortality (18% per 1-MET increase) in the two highest BMI groups (BMI 30-34.9 and > 35 kg/m 2 ) with increasing fitness. The reduction in risk with increased fitness was such that the group with risk factors in addition to diabetes who had a high fitness level had a lower risk of mortality than the group with no additional risk factors and a low fitness level (Figure 1).When looking at the mortality rates compared to the BMI classes, there was a significantly higher mortality rate in the lowest BMI category. No significant difference in mortality was seen among the three highest BMI categories. The researchers attempted to correct for reverse-causation by removing those patients who died within 2 years and had an exercise tolerance of ≤ 5 METs. However, the inverse association between mortality rate and BMI remained.Conclusion. This study supports the association between increased activity and decreased mortality regardless of race or BMI in patients with diabetes. This study also supports the previously described and consistently surprising finding of a low BMI being associated with increased mortality. COMMENTARYThe rate of obesity in the United States and worldwide is increasing and is associated with an increase in type 2 diabetes. Six of the top 10 leading causes of death are directly associated with obesity. 1 BMI-Mortality ParadoxSeveral studies have documented what has been called the "BMImortality paradox," an observation that low BMI is associated with increased mortality. This is considered a paradox because most of the risk factors, including h...
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