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Conservative treatment for stable osteochondritis dissecans of the elbow before epiphyseal closure: Effectiveness of elbow immobilization for healing. Takahara, M., et al. (2022) Level of Evidence : 4 Follow recommendation : 👍 (1/4 thumbs up) Type of study : Therapeutic Topic : Osteochondritis dissecans - Treatment This is a retrospective study of a case series assessing the effectiveness of immobilisation vs no immobilisation on the healing of stable osteochondritis dissecans in preteenagers/teenagers. A total of 43 participants with an average age of 12 were included. To be included in the present study, participants had to present with osteochondritis dissecans of the capitellum. Potential participants were excluded if they presented with persistent pain, locking of the elbow, irregularity in the joint contour, fragment displacement, or severe elbow AROM limitations. Potential participants were included if the lesion was stable and if they had an open epiphysis at the elbow. All participants included were provided with activity limitation advice. In particular, they were advised against any heavy use of the affected limb (e.g. using a racket, throwing). Aerobic exercise without upper limb involvement was encouraged. Participants then received either elbow casting (n = 12) or splint immobilisation (n = 9). The control group did not receive anything in addition to advice (n = 22). The casting group had a cast on for 4 weeks followed by 7 weeks of elbow splint. The splint group wore the splint for 9 weeks. The effectiveness of the intervention was measured by the number of months prior to return to sport and radiographic evidence of healing. Return to sport was allowed if there was no pain while playing sport and normalisation of the lateral aspect of capitellum. Radiographic evidence of healing was defined as ossification of the central aspect of the lesion or complete resolution of the lesion on x-ray. The results showed that healing occurred more quickly with casting (see graphs). In addition, in the casting group, 80% of participants were able to return to sport on average at 4 months post-injury compared to 6 and 8 for the splinting and advice only groups. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, casting followed by splinting appears to be the most effective approach to the management of osteochondritis dissecans in preteenagers/teenagers. On average, clients treated with this approach can return to sport between 4 to 5 months from injury and 80% of them will be fully healed (radiographically) by 12 months. If you are interested in the management of more severe elbow osteochondritis dissecans, have a look at this synopsis . URL : https://doi.org/10.1016/j.jse.2022.01.148 Abstract Background: Stable lesions of osteochondritis dissecans (OCD) of the capitellum have been treated with activity restriction (AR) and the complete healing requires one or two years. Little is known about the effectiveness of elbow immobilization. Hypothesis: Elbow immobilization has positive effects on healing of stable OCD. Methods: The study subjects were 43 patients (mean age, 12.2 years) with 43 stable OCD lesions of the pre-matured elbow (mean skeletal age score, 17.1 points of 0-27 points system). The subjects were divided into three: Group A, AR without elbow immobilization, 22 cases; Group B, splint (mean, 8.8 weeks) followed by AR, 9 cases; and Group C: cast (mean, 3.7 weeks) followed by splint (mean, 7.3 weeks) and AR, 12 cases. The mean nonoperative observation period was 17.5 months (minimum three months). On anteroposterior radiographs of the elbow at 45 degrees of flexion, five observers independently assessed the healing of the capitellum, and the inter- and intra-observer reliabilities were examined. The differences in outcomes among three groups were also examined. Results: The inter- and intra-observer reliabilities of the radiographic assessment were almost perfect (Cohen kappa value: 0.82 and 0.91). There were no significant differences in age, sports played, or stage of the lesion before the treatment. The proportion of patients returning to sports and the mean period required were 77% and 8.2 months in Group A, 78% and 5.7 months in Group B, and 83% and 4.4 months in Group C. The proportion of patients showing ossification in the central aspect of the capitellum and the mean period required were 67% and 8.2 months in Group A, 63% and 4.9 months in Group B, and 91% and 1.9 months in Group C. The proportion of patients showing complete healing and the mean period required were 41% and 16.4 months in Group A, 67% and 7.0 months in Group B, and 92% and 5.5 months in Group C. Compared to Group A, Group C showed a significantly earlier return to sports (P = .034), a significantly shorter period required for ossification (P < .001), and significantly higher proportion of patients with complete healing (P = .012) within a significantly shorter period (P = .009). Conclusion: Elbow immobilization had positive effects on healing and enabled both an early return to sports and complete healing. Cast immobilization is recommended as a first choice of nonoperative treatment for stable OCD lesions of the elbow before epiphyseal closure. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

A case of an elderly patient with rubber band syndrome. Amemiya, E., et al. (2021) Level of Evidence : 5 Follow recommendation : 👍 (1/4 thumbs up) Type of study : Diagnostic/Therapeutic This is the answer to last week's Sherlock Handy. The patient was a 71 years old man presenting with numbness tingling, swelling, and limited finger mobility in the left hand. They visited a hospital where they were given antibiotics to treat what they believed to be cellulitis. This treatment led to no resolution of the presentation and they were referred for a second opinion. Objectively, they presented with 0 deg of wrist flexion, 60 deg of wrist extension and a circumferential scar at the proximal wrist. Blood tests revealed no signs of infection. X-rays identified some indentations on the radius. MRI was also completed and identified compression of the median nerve by a cord-like structure. Surgery was performed and it identified and removed a rubber band from the wrist. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical take home message : Based on what we know today, rubber band syndrome is a rare presentation. This syndrome is more common in babies, people with cognitive disabilities, and older adults with cognitive/memory impairment. This syndrome may be misdiagnosed and we should therefore remain vigilant in clients who are at higher risk. URL : https://doi.org/10.1016/j.jhsg.2021.07.005 Abstract Rubber band syndrome is a relatively rare disease in which a rubber band around a limb becomes embedded under the skin, resulting in tissue damage. Most reported cases are in children, and its occurrence in adults is considered extremely rare. We present a case of a 71-year-old patient with cognitive impairment, in whom a rubber band around the wrist became embedded under the skin. The examination of the distinctive circumferential scar, ultrasonography, x-ray, and magnetic resonance imaging led to the diagnosis of rubber band syndrome. To avoid further damage to the tissue, surgical removal of the band was conducted. When elderly patients with cognitive impairment present with chief complaints of swelling and contracture in the limbs due to an unknown cause, accompanied by a circumferential scar on the affected limb, rubber band syndrome should be considered. Due to risk of deep tissue necrosis, prompt band removal is necessary. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

A high rate of children and adolescents return to sport after surgical treatment of osteochondritis dissecans of the elbow: A systematic review and meta-analysis. Cohen, D., et al. (2021) Level of Evidence : 1a- Follow recommendation : 👍 👍 Type of study : Therapeutic Topic : Osteochondritis dissecans - Treatment This is a systematic review and meta-analysis assessing return to sport following surgery for osteochondritis dissecans in adolescents (10 to 19 years old). A total of 31 case series for a total of 548 participants were included in the present study. Eighty per cent of participants played baseball, 10% were involved in gymnastics, and the remaining 10% were involved in other sports. All studies underwent quality assessment through the Methodological Index for Non-Randomised Studies (MINORS). Amongst the many outcomes, return to sport (at the pre-injury level) and post-operative rehabilitation protocols were reported. The results showed that between 70% and 90% of participants returned to sport at the pre-injury level (see Forest plot). The most commonly adopted post-operative rehabilitation protocol involved immobilisation of the elbow in neutral forearm rotation for 2 weeks post-surgery and return to sport at the 6 months mark. In the early phase of rehabilitation, rehabilitation focused on regaining elbow range of movement on the affected side, as well as general conditioning and strength training of unaffected body segments. This was followed by graded resistance training for the affected side and sport-specific exercises. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, a moderate to large proportion (70-90%) of adolescents undergoing surgical treatment for osteochondritis dissecans of the elbow, return to sports at pre-injury levels. The average time to return to sport is 6 months. A surgical approach is often undertaken for unstable or extensive lesions. Post-surgical rehabilitation often focuses on maintaining conditioning and gradually regaining range of movement and strength of the affected limb. If you are interested in the conservative management of less severe elbow osteochondritis dissecans, have a look at this synopsis . URL : https://doi.org/10.1007/s00167-021-06489-9 Abstract Purpose: The purpose of this systematic review was to determine the return to sport rates following surgical management of ostechondritis dissecans of the elbow. Methods: The databases EMBASE, PubMed, and MEDLINE were searched for relevant literature from database inception until August 2020 and studies were screened by two reviewers independently and in duplicate for studies reporting rates of return to sport following surgical management of posterior shoulder instability. A meta-analysis of proportions was used to combine the rates of return to sport using a random effects model. A risk of bias assessment was performed for all included studies using the MINORS score. Results: Overall, 31 studies met inclusion criteria and comprised of 548 patients (553 elbows) with a median age of 14 (range 10–18.5) and a median follow-up of 39 months (range 5–156). Of the 31 studies included, 14 studies (267 patients) had patients who underwent open stabilization, 11 studies (152 patients) had patients who underwent arthroscopic stabilization, and 6 studies (129 patients) had patients who underwent arthroscopic–assisted stabilization. The pooled rate of return to any level of sport was 97.6% (95% CI 94.8–99.5%, I2 = 32%). In addition, the pooled rate of return to the preinjury level was 79.1% (95% CI 70–87.1%, I2 = 78%). Moreover, the pooled rate of return to sport rate at the competitive level was 86.9% (95% CI 77.3–94.5%, I2 = 64.3%), and the return to sport for overhead athletes was 89.4% (95% CI 82.5–95.1%, I2 = 59%). The overall return to sport after an arthroscopic procedure was 96.4% (95% CI 91.3–99.6%, I2 = 1%) and for an open procedure was 97.8% (95% CI 93.7–99.9%, I2 = 46%). All functional outcome scores showed improvement postoperatively and the most common complication was revision surgery for loose body removal (19 patients). Conclusion: Surgical management of osteochondritis dissecans of the elbow resulted in a high rate of return to sport, including in competitive and overhead athletes. Similar rates of return to sport were noted across both open and arthroscopic procedures. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Level of Evidence : 5 Follow recommendation : 👍 (1/4 thumbs up) Type of study : Diagnostic/Therapeutic Have a think about this case study. Leave a diagnostic comment if you like. I will publish the diagnosis reported by the paper next week. The patient was a 71 years old man presenting with numbness tingling, swelling, and limited finger mobility in the left hand. They visited a hospital where they were given antibiotics to treat what they believed to be cellulitis. This treatment led to no resolution of the presentation and they were referred for a second opinion. Objectively, they presented with 0 deg of wrist flexion, 60 deg of wrist extension and a circumferential scar at the proximal wrist. Blood tests revealed no signs of infection. X-rays identified some indentations on the radius. What is it?

Eccentric exercise improves joint flexibility in adults: A systematic review update and meta-analysis. Diong, J., P. C. Carden, K. O'Sullivan, C. Sherrington and D. S. Reed (2022) Level of Evidence : 1a- Follow recommendation : 👍 👍 👍 👍 (4/4 thumbs up) Type of study : Therapeutic Topic : Eccentric training - Range of movement improvements This is a systematic review and meta-analysis assessing the effectiveness of eccentric exercises on joint range of movement. Thirty-two RCTs were included in the systematic review, for a total of 1,122 participants. Participants' average age ranged from 20 to 70 years old. Only healthy participants were recruited. Twenty-seven studies were included in the meta-analysis. All studies were assessed through the PEDro risk of bias criteria. The overall strength of evidence was assessed through the GRADE approach ("low", "very low", "moderate", "high"), which has also been suggested by the Cochrane group for systematic reviews. Eccentric exercises were compared to no intervention, concentric or general exercises. Efficacy of intervention was assessed through active or passive range of movement of lower and upper limb joints, or fascicle length (measured through ultrasound). Intervention duration ranged between 5 and 16 weeks, with a maximum training frequency of 3 times per day and a minimum of 2 times per week. The assessment time points varied significantly, and they ranged from 5 to 16 weeks. High-quality evidence showed that eccentric exercises improve range of movement compared to a control group. Low-quality evidence showed that eccentric exercises improved fascicle lenght compared to a control group. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, eccentric exercises may provide better range of movement compared to other forms of exercise. Low load eccentric exercises may therefore be a good option if the goal of our treatment is to regain range of movement and there is moderate to high irritability. A useful progression would then be performing resistance training, which has been shown to be as effective as stretching to improve range of movement . URL : https://doi.org/10.1016/j.msksp.2022.102556 Abstract Background: Eccentric exercise is thought to improve joint flexibility, but the size of the effect is not known. We aimed to quantify the overall effect of eccentric exercise on joint flexibility in adults. Design: Systematic review, meta-analysis. Data sources: AMED, CINAHL, MEDLINE, EMBASE, SportDiscus. Participants: Adults. Intervention: Eccentric exercise compared to no intervention or to a different intervention. Outcome measures: Joint range of motion or muscle fascicle length. Data extraction and synthesis: Descriptive data of included trials and estimates of effect sizes were extracted. Standardised mean differences (SMD) of range of motion or fascicle length outcomes were meta-analysed using random effects models. Overall quality of evidence was assessed using the GRADE scale. Results: 32 trials (1122 participants, 108 lost to follow-up) were included in the systematic review. The mean (SD) PEDro score was 5.2 (1.3). Four trials reported insufficient data for meta-analysis. Data from 27 trials (911 participants, 82 lost to follow-up) were meta-analysed. Eccentric exercise improved joint flexibility in adults (pooled random effects Hedges' g SMD = 0.54, 95% CI 0.34 to 0.74). The true effect size is different across studies and 50% of the variance in observed effects is estimated to reflect variance in true effects rather than sampling error (I2 = 50%, Q = 67.6, d.f. = 34, p = 0.001). Overall quality of evidence ranged from ‘low’ to ‘high’. Conclusion: Eccentric exercise improves joint flexibility in adults. The overall standardised mean effect of eccentric exercise was moderately large, and the narrow width of the 95% confidence interval indicates the effect was estimated with good precision. Registration: Open Science Foundation (https://osf.io/mkdqr); PROSPERO registration CRD42020151303. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Normal values of the second interosseous pinch: A measurement of pure ulnar-innervated intrinsic muscles of the hand. Shackleford, T., et al. (2021) Level of Evidence : 3b Follow recommendation : 👍 (1/4 thumbs up) Type of study : Diagnostic test Topic : Second interosseous pinch – Normative values This is a cross-sectional study assessing the normative values for the second interosseous pinch (2IP) test. A total of 238 participants (130 females, 108 males) older than 18 years old, were included in the study. During the 2IP test, a pinchmeter was placed between the index and middle finger. People are then asked to squeeze the pinchmeter as hard as possible (see figure). Care was taken to avoid the contribution of the thumb in this test. This test may be a good indicator of the ulnar nerve function as this innervates all the intrinsic muscles of the hand. The results from this test were repeated three times. The results showed that the average strength in the 2IP test was 2.9 kg in the dominant hand and 2.8 kg in the non-dominant hand. The results also showed that with ageing, strength in the 2IP test reduced. Normative values for the 2IP test based on age/sex, are reported in the table. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, the second interosseous pinch (2IP) test may be utilised to assess ulnar nerve function. This test may be a useful addition to the use of pinch and grip strength to identify ulnar nerve impairments . We need to keep in mind, however, that nerve variations such as Martin‐Gruber anastomosis (MGA) may partially mask a severe ulnar nerve motor involvement. Another test that we can perform to gather overall upper limb strength is the push-off test . URL : https://doi.org/10.1016/j.jhsa.2021.09.024 Abstract Purpose: The second palmar interosseous muscle is innervated solely by the ulnar nerve, and second palmar interosseous pinch (2IP) strength may be a good indicator of ulnar nerve motor function. The goal of this study was to describe the 2IP test and establish its normative values, stratified by age, sex, and dominance. Methods: Volunteers were recruited to participate in this study at various community locations. Patients over the age of 18 years were eligible for this study. Demographic information on all subjects was collected. The volunteers were asked to pinch a hydraulic pinch gauge between the index and middle finger proximal phalanges with the proximal and distal interphalangeal joints flexed and without recruiting the thumb. Three 2IP measurements were taken for each hand. Descriptive statistics and analysis of covariance were performed to determine the effect of age, sex, dominance, and side on 2IP. We analyzed the 2IP strength using the 2IP test across 3 trials to determine whether it was affected by repeated testing. Results: Two hundred thirty-eight patients met the inclusion criteria (45 ± 21 years, 55% women, 87% right-hand dominant). There was no statistically significant difference between dominant and nondominant hands or among the 3 trials. There was a statistically significant correlation between age and 2IP strength ranging between 0.32 and 0.44 kg. Age and sex showed a statistically significant association with 2IP strength, with patients of older age and women having weaker 2IP. Conclusions: We determined normative values for 2IP strength using a sample from a normal population. More studies are needed to validate these results. Clinical relevance Second interosseous pinch strength may be a useful tool to assess ulnar nerve function. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Neuropathic pain in hand osteoarthritis: A cross-sectional study. Magni, N., J. Collier, P. McNair and D. A. Rice (2021) Level of Evidence : 2c Follow recommendation : 👍 👍 👍 Type of study : Symptoms prevalence Topic : Neuropathic pain - Hand osteoarthritis This is a cross-sectional study assessing the presence of neuropathic pain in people with hand OA and its association with other symptoms. A total of 105 participants were included in the study. Hand OA was diagnosed through the American College of Rheumatology (ACR) criteria and confirmed through x-ray. The presence of neuropathic pain was assessed through the douleur neuropathique 4 (DN4) . Other clinical outcomes such as worst pain in the last 24 hrs, number of pain medications, and neglect-like symptoms were assessed. Neglect-like symptoms relate to body schema alterations and the questionnaire includes five statements (see picture). The results showed that 40% of participants with hand OA presented with neuropathic pain. In addition, participants with neuropathic pain presented with higher levels of pain. This suggests that those people who presented with tingling, burning pain, and pins and needles suffered to a larger extent. Moreover, people with these symptoms also reported taking a greater number of pain medications and reported more neglect-like symptoms. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, a large proportion of clients with hand OA present with neuropathic pain characteristics. In addition, these people have greater levels of pain, take more pain killers, and have foreign feelings of their affected hand (see neglect-like questionnaire above). It is possible that this subgroup of people may benefit from neuropathic pain medications or aerobic exercise, which appears to be effective in neuropathic pain conditions . Currently, however, a multidisciplinary approach to symptomatic hand OA is supported by higher quality evidence, and may be implemented first. Open access URL : Abstract Symptomatic hand osteoarthritis (OA) is a severely debilitating condition. Neuropathic pain (NP) has been shown to be a factor affecting pain severity, hand function, psychological wellbeing, body schema, and the number of pain medications in people with OA of other joints. The aim of this study was to assess the prevalence of NP in symptomatic hand OA and assess its association with pain, hand function, measures of psychological wellbeing, sleep, body schema disturbances, and number of pain medications. Participants with symptomatic hand OA diagnosed through the American College of Rheumatology criteria, were recruited and completed a series of online questionnaires. These included the Douleur Neuropathique 4 interview (DN4-interview), Short Form Brief Pain Inventory (SF-BPI), Neglect-like Symptoms questionnaire, Functional Index of Hand Osteoarthritis (FIHOA), Centre for Epidemiologic Studies Depression Scale (CES-D), Pain Catastrophising Scale (PCS), and the Pittsburgh Sleep Quality Index (PSQI). Logistic regression with age, body mass index, and sex as covariates were utilised to assess differences between participants with and without NP as identified through the DN4-interview. Correlation analysis assessed the relationship between pain intensity, body schema alterations, and number of pain medications. A total of 121 participants were included in the present study. Forty-two percent of participants presented with NP. Participants with NP reported higher levels of worst pain (OR: 10.2 95% CI: 2.2 to 48.5; p = 0.007). Worst pain intensity correlated with the number of pain medications (rho = 0.2; p = 0.04), and neglect-like symptoms (rho = 0.4; p < 0.0001). No difference between phenotypes was shown for catastrophising, function, depression, neglect-like symptoms, pain interference, or sleep. A large proportion of people with symptomatic hand OA present with NP. This phenotype is characterised by greater levels of pain intensity. Pain intensity is associated with number of pain relief medications and body schema alteration. Psychological factors, hand function, and sleep do not appear to be affected by the presence of NP. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Baseline pain intensity is a predictor of chronic pain in individuals with distal radius fracture. Mehta, S. P., J. C. MacDermid, J. Richardson, N. J. MacIntyre and R. Grewal (2015) Level of Evidence : 2b Follow recommendation : 👍 👍 👍 (3/4 thumbs) Type of study : Prognostic Topic : Persistent pain - Distal radius fracture This is a secondary analysis of a prospective cohort study with the aim of identifying risk factors for the development of persistent pain following distal radius fracture. A total of 386 participants were included. Potential participants were included if they presented with a distal radius fracture. The pain subscale of the Patient Rated Wrist Evaluation (PRWE) was utilised to predict the presence of persistent pain or functional limitations at 12 months. This outcome was measured at 7-14 days from injury. Persistent pain at 12 months was defined as a score of 12.5/50 on both the pain and function subscales of the PRWE. The results showed that 30% of the sample presented with persistent pain at 12 months. In addition, the findings suggest that a PRWE pain subscale score of 35/50 or greater, predicts the presence of persistent pain at 12 months with an accuracy of 87%. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, in our clients with a distal radius fracture, a pain level of 35/50, as measured through the PRWE pain subscale, indicates a high probability of presenting with persistent pain at 12 months from injury. High levels of baseline pain following distal radius fracture have also been shown to increase the odds of developing complex regional pain syndrome . Similar findings have been shown for hand fractures . Interestingly, pain intensity following upper limb fractures is not entirely determined by fracture severity but also depression and pain catastrophising . URL : https://doi.org/10.2519/jospt.2015.5129 Abstract STUDY DESIGN: Secondary analysis of cohort study. OBJECTIVE: This study examined whether baseline pain intensity is a predictor of chronic pain and wrist/hand functions at 1 year following distal radius fracture (DRF). The study also examined the cutoff level for baseline pain intensity that best predicted chronic pain. BACKGROUND: Many individuals experience wrist/hand pain and functional impairments for as long as 1 year after DRF. Early identification of individuals at risk of these adverse outcomes can facilitate the delivery of required interventions to mitigate the risk. METHODS: Data for the Patient-Rated Wrist Evaluation (PRWE) pain and function subscales at baseline and 1 year after DRF, age, sex, injury to the dominant side, presence of comorbidity, education level, mechanism of fracture, smoking status, fall history, and energy of fracture were extracted from an existing data set. Multivariate regression analysis examined the utility of baseline pain intensity and the above variables in predicting pain and functional status at 1 year in individuals with DRF. Receiver operating characteristic curves examined the sensitivity/specificity of baseline pain intensity in predicting chronic pain and functional impairment. RESULTS: Required data were available for 386 individuals. Baseline pain intensity was found to be a strong predictor of chronic pain, explaining 22% of the variance. A baseline score of 35 out of 50 on the pain subscale of the PRWE had the best sensitivity (85%) and specificity (79%) cutoff values for predicting chronic pain at 1 year after DRF. CONCLUSION: Rehabilitation practitioners may be able to use a score of greater than 35/50 on the PRWE pain subscale to screen individuals at risk of chronic pain following DRF. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

The implications of chronic pain models for rehabilitation of distal radius fracture. Mehta, S., J. MacDermid and M. Tremblay (2010) Level of Evidence : 5 Follow recommendation : 👍 👍 (2/4 thumbs) Type of study : Prognostic Topic : Preventing persistent pain - Distal radius fracture This is a narrative review of risk factors for the development of persistent pain following distal radius fracture and the potential therapeutic strategies to reduce this risk. Learned helplessness, negative expectations about recovery, and fear of movement have been suggested to contribute to the development of persistent pain. In addition, the presence of comorbidities, lower levels of physical activity, smoking, lower socioeconomic status and educational level have been linked to worse outcomes following distal radius fracture. All this suggests that a biopsychosocial approach to the assessment and rehabilitation of patients with distal radius fracture can be useful. In terms of treatment, a positive approach to clients' recovery, identifying activities that can be done, rather than what can't, may help reduce helplessness and fear of movement. Assessment of catastrophising attitudes and the discussion of their pain beliefs may also help reducing fear avoidance. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, in our clients with a distal radius fracture, a biopsychosocial approach may be useful in reducing the likelihood of developing persistent pain. This approach may be particularly appropriate for those clients presenting with higher levels of pain post distal radius fractures . It is important to remember that kinesiophobia is associated with greater upper limb disability and that considering this aspect during our treatment may be useful. In addition, an active approach to rehabilitation involving the use of occupational activities rather than solely exercises has shown to have large potential . URL : https://doi.org/10.1258/ht.2010.010022 Abstract Distal radius fracture (DRF) is the most common fracture and usually occurs as a result of a fall. Most patients recover following DRF with minimal residual pain or disability; however, a small subset of patients continue to experience pain and disability even one year after the injury. Currently, there are no practice guidelines for early identification and treatment of patients who are potentially at greater risk of developing these adverse outcomes. As a result, hand therapy management of patients following DRF does not incorporate screening of these at-risk patients. The objective of this paper is to apply constructs from learned helplessness and cognitive-behavioural models of chronic pain in assessing the psychosocial risk profile of patients following DRF. We have also integrated key findings derived from studies addressing personal and life-style factors in assessing this risk profile. This framework is proposed as a basis to categorize patients as higher or lower psychosocial risk for developing chronic pain and disability following DRF. We outline a model depicting the RACE approach (Reducing pain, Activating, Cognitive reshaping, Empowering) towards the management of patients following DRF. The model suggests that patients with minimal psychosocial risk factors are managed based on their injury profile and those with higher psychosocial risk are treated with the risk-based RACE approach. Using a biopsychosocial RACE approach to prognosis and treatment, hand therapy intervention can be customized for patients recovering from DRF. In future, researchers can conduct clinical trials to compare the RACE-based treatment approach to routine hand therapy in mitigating the risk of chronic pain and disability in patients with elevated risk profile for adverse outcomes following DRF. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Distal triceps tendinopathies. Lappen, S., et al. (2020) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic/Therapeutic Topic : Triceps tendinopathy - Diagnosis and treatment This is a narrative review about distal tricep tendinopathies and distal triceps tendon ruptures. Distal triceps tendinopathies usually present with pain in the posterior aspect of the elbow during resited elbow extension. In contrast, the presence of posterior elbow pain in combination with bruising, swelling, and loss of strength of elbow extension suggests a tendon rupture instead. A couple of objective tests can be performed to exclude the presence of a distal triceps tendon rupture and they include "extension test" and "modified Thompson test" (see images). Lack of elbow extension in both tests would suggest the presence of total distal triceps rupture. Nevertheless, the sensitivity and specificity of these test has not been assessed. X-rays should always be completed to detect bony avulsion injuries. If an olecranon flake is visible on x-ray, it is highly likely that the patient had a tendon rupture (see picture). The conservative management of distal triceps tendinopathies and partial ruptures involves the immobilisation of the elbow in 30 deg of flexion for 4 weeks. This is followed by the use of a removable splint in combination with range of movement exercises, with recovery of full AROM by 12 weeks. This should be followed by resistance training exercises to restore full strength by 6-9 months. Full distal triceps rupture are candidates for surgery and the repair should be done within 3 weeks from injury. Following surgery, clients are immobilised for 1 week in 90 deg of flexion and range of movement should be limited to 90deg of elbow flexion for the first 6 weeks. No active elbow extension should be performed for the first 6 weeks. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, triceps tendinopathy can be evoked by overhead active resisted elbow extension. If the client is unable to generate elbow extension force and this is associated with bruising and swelling at the time of injury, a distal triceps rupture may be the cause . X-ray imaging and US may be useful in the differential diagnosis. Treatment of distal triceps tendinopathy or partial distal triceps tear involves initial immobilisation of the elbow in 30deg of flexion, followed by graded resistance training. Full distal triceps ruptures are candidates for surgical repair and the recovery time has been previously described . URL : https://doi.org/10.1007/s11678-020-00601-0 Abstract Tendinopathy of the distal triceps represents a rare pathology in the upper extremity. Although there is scant scientific evidence published to date, the association with risk factors such as internal diseases or steroid use is commonly described in various reports. Due to traumatic incidents or sporting overuse, partial or complete ruptures can occur. Clinically, stress-related posterior elbow pain, swelling, ecchymosis, loss of strength in extension, and a palpable gap in the tendon can be seen. Physical examination shows reduced extension force and increasing pain with forced extension against resistance. Tendinopathies and resulting partial or complete ruptures can be detected by ultrasound and magnetic resonance imaging. Conservative therapy with temporary immobilization is recommended for tendinopathies or minor ruptures of the triceps tendon. Complete ruptures or larger partial ruptures should be treated surgically with anatomical refixation of the tendon. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Return to work following a distal biceps repair: A systematic review of the literature. Rubinger, L., Solow, M., Johal, H., & Al-Asiri, J. (2020) Level of Evidence : 2a Follow recommendation : 👍 👍 👍 Type of study : Prognostic Topic : Distal biceps repair - Return to work This systematic review reports on return to work outcomes following a distal biceps repair surgery. Forty articles were included for a total of 1270 patients with distal biceps ruptures. Patients' average age was 45 (range 38 to 63) years old. Return to work outcomes included time to return to work and the number of work modifications required. The results showed that the average time for return to work was 13-15 weeks. One per cent of patients had to modify their working environment and 6% did not return to work (this group did not include retired patients). One limitation of this study was the lack of details regarding the type of work patients returned to (e.g. manual, sedentary). Complications were reported following 56 surgeries (4.4%) and lateral antebrachial cutaneous neuropraxia was the most common one. Have a look at the table for the other complications reported. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, it usually takes 3 to 4 months for clients to return to work following distal biceps repair. Most of the patients appear to be able to go back to their normal job, however, heavy manual labour may require longer timeframes for proper conditioning of the repaired tendon. Numbness or dysaesthesia in the lateral forearm is the most common complication reported for this surgery. Additional complications include motor nerve impairments (e.g. Posterior interosseous nerve ), however, they are rare. Considering all these potential complications, surgical repair of a distal biceps rupture may be appropriate in a subgroup of clients only . URL : https://doi.org/10.1016/j.jse.2019.12.006 Abstract Background: Among an active aging population, distal biceps tendon ruptures are becoming increasingly common. Typically, they are the result of an acute heavy eccentric load being placed on an already contracted muscle, and surgery is the gold standard treatment for optimal clinical and functional outcomes. Although improved strength has been shown after operative repair, there is little evidence available regarding a timeframe for return to work-related activity. The purpose of this study was to conduct a systematic review of the literature to provide guidance for return to work after a distal biceps repair. Methods: The authors searched online databases (EMBASE, MEDLINE) from inception until October 11, 2018, for literature pertaining to functional outcomes after distal biceps repair. Study inclusion and exclusion criteria were established a priori and applied in duplicate independently by 2 reviewers. Results: Of the 480 initial studies, 40 papers satisfied full text inclusion criteria (19 case control studies, 12 retrospective reviews, 9 prospective reviews). A total of 1270 patients with 1280 distal bicep ruptures were included in the study. The mean age of patients was 45.38 years, and 97% (n = 1067) of reported patients were male. The mean follow-up time was 30 months (range, 6-84 months). After distal biceps repair, 1128 (89%) of patients were able to fully return to work without any modification of duties. Time to return to work was reported in 17 of the included studies with a mean of 14.37 ± 0.52 weeks. Discussion: The average time to return to work after distal biceps repair in the literature was just beyond 14 weeks. Patients and employers may be given a range between 3 and 4 months, with variation dependent on job demands. Further studies are needed to establish whether the surgical approach or repair technique has any impact on time to return to work. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Diagnosis, etiology and outcomes of revision distal biceps tendon reattachment Prokuski, V., Leung, N., & Leslie, B. (2020) Level of Evidence : 4 Follow recommendation : 👍 👍 (2/4 thumbs up) Type of study : Therapeutic Topic : Distal biceps tendon re-rupture - Patient presentation and characteristics. This retrospective study assessed the clinical presentation and characteristics of patients ( n = 10) who underwent revision surgery for a previously repaired distal biceps tendon rupture. The reason for revision surgery was the presence of persistent pain since primary repair (40% of patients) or acute pain following a specific traumatic event (60% of patients up to two years post-surgery). Hook test and MRI were unhelpful in screening or diagnosing re-rupture due to tethering around the surgical site. Three of the 10 patients had a previous re-rupture in the contralateral arm. It has been suggested that if re-rupture occurs without biceps tendon retraction, the repair is not urgent and can be performed up to two years post-injury. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, we should immediately refer patients with a previous primary biceps tendon repair who report sudden onset of antecubital pain due to trauma. Delays in repair of re-rupture may lead to tendon retractions. On the other hand, if pain has been on-going, referral may not be as urgent. If you are wondering whether surgical repair of a distal bicep tendon rupture is worth it, have a look at this synopsis . Also, if you are interested on how to gradually load the bicep post surgery, have at the low and moderate-high level exercises. URL : https://doi.org/10.1016/j.jhsa.2019.05.006 Abstract Purpose: To evaluate the incidence, etiology, and clinical outcomes after revision distal biceps tendon repair. We hypothesized that re-ruptures are rare and can be reattached with satisfactory results. Methods: Cases were identified from the case log of the senior author. Demographic information, details regarding the primary repair and subsequent injury, time between reinjury and reattachment, and operative findings were recorded. Clinical outcomes were assessed using the Disabilities of the Arm, Shoulder, and Hand (DASH) and American Shoulder and Elbow Surgeons-Elbow (ASES-E) functional outcome scoring systems. Range of motion, strength, and ability to return to work were recorded. Results: We identified 10 patients with re-rupture, all of whom were men. Average age was 46 years (range, 35-57 years). Four ruptures occurred in the dominant arm. Three patients had a history of bilateral ruptures. Incidence of primary failure was 1.1%. In 6 patients, re-rupture occurred 6 days to 11 months after the primary surgery. Three patients described a sense of ripping or tearing after a specific traumatic event. Four others had persistent pain after the primary reattachment. Re-rupture resulted from the loss of fixation owing to technical error, the suture pulling out from the tendon, or suture breakage. Two patients required an allograft. The hook test was abnormal in 3 patients. Magnetic resonance imaging results did not affect the operative plan. Nine patients returned to their former occupation. Five returned for follow-up evaluation and completion of the DASH and ASES-E self-assessment examinations. Average DASH score was 4.4 (range, 0-19) and average ASES-E was 93.2 (range, 74-100). Postoperative average elbow flexion was 141° (range, 135° to 145°), elbow extension was -12° (range, -5° to -30°), pronation was 70°, and supination was 80°. Postoperative average supination strength was 87.8% of the nonsurgical arm (range, 79% to 106%); average pronation strength was 79.2% of the nonsurgical arm (range, 50% to 110%). Conclusions: Revision reattachment resulted in acceptable functional outcomes. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings