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Production of Consistent Pain by Intermittent Infusion of Sterile 5% Hypertonic Saline, Followed by Decrease of Pain With Cryotherapy

Blaine C. Long, Kenneth L. Knight, Ty Hopkins, Allen C. Parcell, and J. Brent Feland


It is suggested that postinjury pain is difficult to examine; thus, investigators have developed experimental pain models. To minimize pain, cryotherapy (cryo) is applied, but reports on its effectiveness are limited.


To investigate a pain model for the anterior knee and examine cryo in reducing the pain.


Controlled laboratory study.


Therapeutic modality laboratory.


30 physically active healthy male subjects who were free from any lower extremity orthopedic, neurological, cardiovascular, or endocrine pathologies.

Main Outcome Measures:

Perceived pain was measured every minute. Surface temperature was also assessed in the center of the patella and the popliteal fossa.


There was a significant interaction between group and time (F68,864 = 3.0, P = .0001). At the first minute, there was no difference in pain between the 3 groups (saline/cryo = 4.80 ± 4.87 mm, saline/sham = 2.80 ± 3.55 mm, no saline/cryo = 4.00 ± 3.33 mm). During the first 5 min, pain increased from 4.80 ± 4.87 to 45.90 ± 21.17 mm in the saline/cryo group and from 2.80 ± 3.55 to 31.10 ± 20.25 mm in the saline/sham group. Pain did not change within the no-saline/cryo group, 4.00 ± 3.33 to 1.70 ± 1.70 mm. Pain for the saline/sham group remained constant for 17 min. Cryo decreased pain for 16 min in the saline/cryo group. There was no difference in preapplication surface temperature between or within each group. No change in temperature occurred within the saline/sham. Cooling and rewarming were similar in both cryo groups. Ambient temperature fluctuated less than 1°C during data collection.


Intermittent infusion of sterile 5% hypertonic saline may be a useful experimental pain model in establishing a constant level of pain in a controlled laboratory setting. Cryotherapy decreased the induced anterior knee pain for 16 min.

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Case Study: Symptomatic Exercise-Associated Hyponatremia in an Endurance Runner Despite Sodium Supplementation

Martin D. Hoffman and Thomas M. Myers

Symptomatic exercise-associated hyponatremia (EAH) is known to be a potential complication from overhydration during exercise, but there remains a general belief that sodium supplementation will prevent EAH. We present a case in which a runner with a prior history of EAH consulted a sports nutritionist who advised him to consume considerable supplemental sodium, which did not prevent him from developing symptomatic EAH during a subsequent long run. Emergency medical services were requested for this runner shortly after he finished a 17-hr, 72-km run and hike in Grand Canyon National Park during which he reported having consumed 9.2–10.6 L of water and >6,500 mg of sodium. First responders determined his serum sodium concentration with point-of-care testing was 122 mEq/L. His hyponatremia was documented to have improved from field treatment with an oral hypertonic solution of 800 mg of sodium in 200 ml of water, and it improved further after significant aquaresis despite in-hospital treatment with isotonic fluids (lactated Ringer’s). He was discharged about 5 hr after admission in good condition. This case demonstrates that while oral sodium supplementation does not necessarily prevent symptomatic EAH associated with overhydration, early recognition and field management with oral hypertonic saline in combination with fluid restriction can be effective treatment for mild EAH. There continues to be a lack of universal understanding of the underlying pathophysiology and appropriate hospital management of EAH.

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Experimentally Induced Pain Results in Reduced Activity of the Rotator Cuff Muscles in Healthy Subjects

Jennifer L. Cooper and Andrew R. Karduna

for observation of the pain’s effects. 2 Injection of hypertonic saline into soft tissues is one method of inducing acute pain, stimulating local receptors to a nociceptive level and causing localized, temporary pain. 3 This experimental technique has been used to determine effects of acute pain in

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Effects of Experimental Anterior Knee Pain on Muscle Activation During Landing and Jumping Performed at Various Intensities

Jihong Park, W. Matt Denning, Jordan D. Pitt, Devin Francom, J. Ty Hopkins, and Matthew K. Seeley


Although knee pain is common, some facets of this pain are unclear. The independent effects (ie, independent from other knee injury or pathology) of knee pain on neural activation of lower-extremity muscles during landing and jumping have not been observed.


To investigate the independent effects of knee pain on lower-extremity muscle (gastrocnemius, vastus medialis, medial hamstrings, gluteus medius, and gluteus maximus) activation amplitude during landing and jumping, performed at 2 different intensities.


Laboratory-based, pretest, posttest, repeated-measures design, where all subjects performed both data-collection sessions.


Thirteen able-bodied subjects performed 2 different land and jump tasks (forward and lateral) under 2 different conditions (control and pain), at 2 different intensities (high and low). For the pain condition, experimental knee pain was induced via a hypertonic saline injection into the right infrapatellar fat pad. Functional linear models were used to evaluate the influence of experimental knee pain on muscle-activation amplitude throughout the 2 land and jump tasks.


Experimental knee pain independently altered activation for all of the observed muscles during various parts of the 2 different land and jump tasks. These activation alterations were not consistently influenced by task intensity.


Experimental knee pain alters activation amplitude of various lower-extremity muscles during landing and jumping. The nature of the alteration varies between muscles, intensities, and phases of the movement (ie, landing and jumping). Generally, experimental knee pain inhibits the gastrocnemius, medial hamstring, and gluteus medius during landing while independently increasing activation of the same muscles during jumping.

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A Review of the Relationships Between Knee Pain and Movement Neuromechanics

Matthew K. Seeley, Hyunwook Lee, S. Jun Son, Mattie Timmerman, Mariah Lindsay, and J. Ty Hopkins

upon an EKP model introduced by Bennell et al 3 or methods adapted from this model. This EKP model involves hypertonic saline placed in the infrapatellar fat pad to stimulate fat pad nociceptors. Hypertonic saline is believed to stimulate the same neural pathways as clinical musculoskeletal pain. 4

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Hip Musculoskeletal Conditions and Associated Factors That Influence Squat Performance: A Systematic Review

Scott W. Cheatham, Kyle R. Stull, Mike Fantigrassi, and Ian Montel

induced hip muscle pain. Hatton et al 27 examined 3 single-leg movements after injecting the gluteus medius with a hypertonic saline solution in a group of 12 younger adult subjects (8 men and 4 women; mean age = 27.1 (3) y). The movements included single-leg standing (eyes closed), single-leg squat

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Effectiveness of Salted Ice Bag Versus Cryocompression on Decreasing Intramuscular and Skin Temperature

Jennifer Ostrowski, Angelina Purchio, Maria Beck, and JoLynn Leisinger

infusion of sterile 5% hypertonic saline, followed by decrease of pain with cryotherapy. J Sport Rehabil . 2012 ; 21 ( 3 ): 225 – 230 . PubMed ID: 22894975 doi:10.1123/jsr.21.3.225 10.1123/jsr.21.3.225 22894975 15. Dykstra J , Hill H , Miller M , Cheatham C , Michael T , Baker R

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A 3-Dimensional Gait Analysis of the Effects of Fatigue-Induced Reduced Foot Adductor Muscle Strength on the Walking of Healthy Subjects

Rogerio Pessoto Hirata, Alexander W. Erbs, Erik Gadsbøll, Rannvá Winther, Sanne H. Christensen, and Morten Bilde Simonsen

the reduced maximum voluntary contraction force capacity from the adductor muscles to maintain their preferred walking speed, similar to baseline conditions. Comparable results were reported while experimental pain was induced via intramuscular injection of hypertonic saline solution in the tibialis

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Muscle Activity Before and After Subacromial Injection

Lucas Ettinger, Matthew Shaprio, and Andrew Karduna

musculature (agonists), which helps to maintain the subacromial space and glenohumeral mechanics during arm elevation. 2 Induced subacromial pain through hypertonic saline injections has been shown to reduce rotator cuff muscle activation and strength, indicating a reduction in humeral centering during arm

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Arthrogenic Muscle Inhibition: Best Evidence, Mechanisms, and Theory for Treating the Unseen in Clinical Rehabilitation

Grant Norte, Justin Rush, and David Sherman

– 93 . PubMed ID: 27632828 doi:10.1123/jsr.2015-0119 10.1123/jsr.2015-0119 38. Hodges PW , Mellor R , Crossley K , Bennell K . Pain induced by injection of hypertonic saline into the infrapatellar fat pad and effect on coordination of the quadriceps muscles . Arthritis Rheum . 2009 ; 61