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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

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

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

Risk factors of lateral epicondylitis: A meta-analysis. Sayampanathan, A. A., Basha, M., & Mitra, A. K. (2020) Level of Evidence: 2a- Follow recommendation: 👍 👍 👍 (3/4 thumbs up) Type of study: Prognostic Topic: Lateral epicondylalgia – Risk factors This is a systematic review and meta-analysis assessing risk factors for the development of lateral epicondylalgia (LE). Fourteen studies, most of which were retrospective, were included in the meta-analysis, for a total of 24,526 participants. A diagnosis of LE was confirmed in all studies by pain localised at the lateral epicondyle and pain reproduction on palpation of the lateral epicondyle and resisted wrist extension. The results showed that females had 1.12 to 1.5 greater odds of presenting with LE compared to males. In addition, a current or past history of smoking increased the odds of having LE by 1.2 to 1.9 times. The results showed that smoke cessation did not reduce the likelihood of presenting with LE, suggesting that a past history of smoking has an ongoing effect on tendons' health. A high body mass index (BMI) did not increase the odds of presenting with LE (OR: 1.12; 95%CI: 0.7 to 1.3). Other factors that increased the odds of presenting with LE were metabolic conditions including diabetes mellitus and elevated blood pressure. However, a limited number of studies investigated these risk factors. The results of this study need to be considered in the context of a few limitations. Due to the retrospective nature of the studies included, causation between these risk factors and LE cannot be proven. A third variable not measured in the studies may be the causative factor for the development of LE. 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, LE is more common among female clients or clients with a present or past history of smoking. A high BMI does not appear to increase the likelihood of presenting with LE, although metabolic diseases may increase the odds of presenting with the condition. It is possible that an improvement in the metabolic profile of our patients, may reduce the likelihood of presenting with LE. Smoking cessation does not appear to reduce the risk of developing LE, however, this should clearly be encouraged due to other health benefits. URL: https://doi.org/10.1016/j.surge.2019.08.003 Abstract Introduction Lateral Epicondylitis is commonly associated with numerous anatomical and mechanical risk factors. Thus far, there have been no reviews synthesising the risk factors of lateral epicondylitis. We hence aimed to perform a meta-analysis of factors associated with lateral epicondylitis. Methodology We searched MEDLINE, Scopus and Web of Science for 1032 articles. Eventually, based on our exclusion criteria, we had 33 articles remaining for our systematic review. 15 of these articles were used for our meta-analysis. Data was analysed using Mantel-Haenszel statistics and random effect models where appropriate. Results Females had a 1.29 times higher odds of sustaining lateral epicondylitis (OR Males: Females = 0.77, 95% CI = 0.67–0.89, Z = 3.52, I2 = 33%, p < 0.001). The odds of an individual with a current or past tobacco smoking history sustaining lateral epicondylitis was 1.49 times that of an individual with no tobacco smoking history (95% CI = 1.18–1.87, Z = 3.40, I2 = 0%, p < 0.001). There was no statistical difference in sustaining lateral epicondylitis when comparing individuals with a current tobacco smoking history to individuals with a past or no tobacco smoking history (OR = 1.18, 95% CI = 0.91–1.51, Z = 1.26, I2 = 0%, p = 0.21). Neither was there a statistical difference in sustaining lateral epicondylitis when comparing individuals with a BM ≥ 25 to those with a BMI<25 (OR = 1.12, 95% CI = 0.69–1.83, Z = 0.46, I2 = 62%, p = 0.65). Conclusion Female gender and a positive and past smoking history were associated with lateral epicondylitis. Further studies should focus on identifying other associations with lateral epicondylitis and the pathophysiological explanation of such associations. 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

Rehabilitation exercises for athletes with biceps disorders and slap lesions: A continuum of exercises with increasing loads on the biceps. Cools, A. M., et al. (2014). Level of Evidence: 2c Follow recommendation: 👍 👍 (2/4 thumbs up) Type of study: Therapeutic Topic: Biceps tendon - Low-level loading This is a cross-sectional study assessing the activation of biceps brachii during several different exercises. The aim was to identify which exercises should be included in the very early phase rehabilitation of clients presenting with a biceps brachii pathology. A total of 32 healthy participants were included in the present study. Of these, 50% were females. Participants were excluded if they performed resistance training of their upper limb for more than 5 hours a week and if they were competitive overhead athletes. Sixteen different exercises were assessed. However, only eleven exercises were included in this synopsis. The reason being that the other exercises assessed, closely overlapped with the exercises described in another synopsis. The weight utilised in the exercises was based on participants' body weight. The percentage of biceps brachii activation was based on a maximum isometric voluntary contraction (MVC) of the biceps (EMG). In the exercises described, biceps activation ranged from a minimum of 2% of MVC to 13% of MVC. I have created the table below so you can easily determine what exercise is appropriate for your clients, Enjoy! 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 exercises described above can be utilised in the very early stages of biceps brachii rehabilitation. These exercises may be appropriate in the very early phase of a biceps brachii tendinopathy or distal biceps repair where an initial rest is required. Once clients can start loading their bicep more, the exercises described in this other synopsis provide a worthy loading progression. URL: https://doi.org/10.1177/0363546514526692 Abstract BACKGROUND: Although rehabilitation exercises are recommended in the nonoperative and postoperative treatment of biceps-related disorders and superior labrum anterior-posterior (SLAP) lesions in overhead athletes, a progressive exercise protocol with controlled low to moderate loads on the biceps has not yet been described. PURPOSE: To describe a continuum of exercises with progressive low to moderate loads on the biceps based on electromyographic (EMG) analysis. STUDY DESIGN: Descriptive laboratory study. METHODS: Using surface electromyography, the EMG activity of 8 muscles (upper [UT], middle [MT], and lower [LT] trapezius; serratus anterior [SA]; anterior [AD] and posterior [PD] portions of the deltoid; and biceps [BB] and triceps [TB] brachii) was measured in 32 healthy participants performing 16 commonly described shoulder rehabilitation exercises. RESULTS: Of the 16 exercises, 13 (side-lying shoulder forward flexion, prone extension, seated rowing, serratus punch, knee push-up plus, internal and external rotation both in 20° and 90° of abduction, forearm supination, uppercut, and internal and external rotation diagonal) showed low (<20% maximal voluntary isometric contraction [MVIC]) EMG activity in the BB, and 3 (forward flexion in supination, full can, and elbow flexion in forearm supination) showed moderate (20%-50% MVIC) activity. None of the exercises elicited high (>50% MVIC) EMG activity. Based on the results, a ranking was calculated of the exercises, with mean EMG levels between 2.2% ± 1.24% (during internal rotation against resistance in 90° of shoulder abduction) and 35.9% ± 18.82% (during forward flexion in external rotation and supination) of MVIC. CONCLUSION: This study describes a continuum of exercises with an increasing level of EMG activity in the BB. Exercises targeting the trapezius resulted in less loads on the biceps compared with exercises for the SA. In addition, exercises with an internal rotation component showed low activity in the BB. In general, the exercises meant to target the BB showed the highest levels of activity in the BB. CLINICAL RELEVANCE: These results may assist the clinician in the appropriate choice of exercises in a graded rehabilitation program of biceps-related injuries. 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

Biceps disorder rehabilitation for the athlete: A continuum of moderate- to high-load exercises. Borms, D., I. Ackerman, P. Smets, G. Van den Berge and A. M. Cools (2017). Level of Evidence: 2c Follow recommendation: 👍 👍 (2/4 thumbs up) Type of study: Therapeutic Topic: Biceps tendon - Gradual loading This is a cross-sectional study assessing the activation of biceps brachii during several different exercises. The aim was to identify which exercises should be included in the early/middle phase vs later phase rehabilitation of clients presenting with a biceps brachii pathology. A total of 30 healthy participants were included in the present study. Of these, 50% were females. Participants were excluded if they were performing resistance training of their upper limb for more than 5 hours a week and if they were competitive overhead athletes. Eleven different exercises were assessed. The weight utilised in the exercises was based on the participants' body weight. The percentage of biceps brachii activation was based on a maximum isometric voluntary contraction (MVC) of the biceps (EMG). In the exercises described, biceps activation ranged from a minimum of 15% of MVC to 70% of MVC. For your ease of use, I have created the table below. 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 exercises described above can be utilised to gradually load biceps brachii during the early/middle and later phases of rehabilitation. These exercises may be appropriate for distal biceps brachii tendinopathies (after an initial rest has been provided), which could be detected through the distal Biceps Provocation Test (BPT). This test is, however, unlikely to be useful when we suspect a full distal biceps tendon rupture where a hook test may be more appropriate. URL: https://doi.org/10.1177/0363546516674190 Abstract BACKGROUND: Progressive biceps loading is recommended in the nonoperative and operative rehabilitation of biceps-related disorders. Previous researchers have proposed a continuum of exercises with low to moderate biceps loads to be used in the early and intermediate phases of rehabilitation. A progression of exercises with moderate to high biceps loads to be used in the more advanced phases of rehabilitation is lacking. PURPOSE: To describe a progression of exercises with progressive moderate to high loads on the biceps brachii (BB) based on electromyographic (EMG) analysis. STUDY DESIGN: Controlled laboratory study. METHODS: The EMG activity of BB and triceps brachii; upper trapezius, middle trapezius, and lower trapezius; and serratus anterior was determined with surface electromyography in 30 asymptomatic participants during 11 exercises. RESULTS: Of the 11 exercises, 4 (arm shake with an Xco-trainer, lateral pull-down in pronation, chest shake with an Xco-trainer, lateral pull-down in supination) showed low (<20% maximal voluntary isometric contraction [MVIC]), 5 (pull-up in pronation with Redcord, air punch, forward flexion in supination, pull-up in supination with Redcord, inclined biceps curl) showed moderate (between 20%-50% MVIC), and 2 (throwing forward flexion, reverse punch) showed high (>50% MVIC) EMG activity in the BB. These exercises were ranked with an increasing level of activity in the BB. CONCLUSION: The continuum of exercises with moderate to high biceps activity may be applied in the more advanced phases of treatment for biceps disorders. In addition, biceps muscle activity may be targeted by (1) sagittal plane elevation; (2) elbow flexion with supination, without upper arm support; (3) biceps contraction from an elongated position; or (4) high-velocity, explosive exercises. CLINICAL RELEVANCE: These findings may assist clinicians to select appropriate exercises to be used in the more advanced phases of nonoperative or postoperative rehabilitation of overhead athletes with biceps-related injuries. 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

Operative versus non-operative treatment of distal biceps ruptures: A systematic review and meta-analysis. Looney, A. M., et al. (2022) Level of Evidence: 1a Follow recommendation: 👍 👍 👍 👍 (4/4 thumb up) Type of study: Therapeutic Topic: Distal biceps rupture - Conservative vs surgical treatment This systematic review and meta-analysis assessed the effect of surgical repair vs conservative treatment of distal biceps rupture. Sixty-two articles were included for a total of 2,481 patients with a distal biceps rupture. Of these, 2,302 underwent operative management whilst 79 underwent conservative management. Patients' average age was 47-50 years old. The effectiveness of interventions was assessed through elbow range of movement (flexion/extension, supination/pronation), strength/endurance of elbow flexion/supination, self-reported function (DASH), and complication rate. The results showed that elbow range of movement was similar between the surgical and conservatively managed patients. Elbow flexion and supination strength were 19% to 34% greater in the surgically managed compared to the conservatively managed group. Endurance was 1% to 44% greater in the surgically managed group. Functional improvements measured through the DASH were greater in the surgical group, however, they did not achieve the clinical relevance threshold. Complication rates ranged between 10% to 25% following surgical repair with the most common being heterotopic ossification (7% to 18%) and sensory nerve injury (7% to 15%). 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, surgical repair of distal biceps ruptures leads to better elbow flexion/supination strength and endurance outcomes. However, the risk of complications associated with surgery is much greater. In particular, heterotopic ossification is very common. In addition, injury to the lateral antebrachial cutaneous nerve is common and may lead to numbness/dysaesthesia in the lateral aspect of the forearm. Overall, surgery may be appropriate for those people who require to recover high levels of elbow flexion and supination strength. URL: https://doi.org/10.1016/j.jse.2021.12.001 Abstract Background: Ruptures of the distal biceps tendon are most commonly due to traumatic eccentric loading in the middle-aged male population and can result in functional deficits. While surgical repair has been demonstrated to result in excellent outcomes, there are few comparative studies that show clear functional benefits over nonoperative management. Purpose/Hypothesis: The aim of this systematic review and meta-analysis is to compare the functional outcomes of operative and nonoperative management for these injuries. We hypothesized that operative treatment would be associated with significantly superior outcomes. Methods: According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review of the literature was performed using MEDLINE, SPORTDiscus, CINAHL (Cumulative Index to Nursing and Allied Health Literature), CENTRAL (Cochrane Central Registry of Controlled Trials), Embase, and Web of Science databases. Outcomes of interest included range of motion (ROM), strength, endurance, and patient-reported outcomes including Disabilities of the Arm, Shoulder and Hand (DASH), Mayo Elbow Performance Score (MEPS), and Visual Analog Scale (VAS) for pain scores. Summary effect estimates of the mean difference between operative and nonoperative management for each outcome were estimated in mixed effects models. Results: Of an initially identified 6478 studies, 62 reported outcomes for a total of 2481 cases (2402 operative, 79 nonoperative), with an overall average age of 47.4 years (47.3 for operative, 50.3 for nonoperative). There were 2273 (98.5%) males and 35 (1.5%) females among operative cases, while all 79 (100%) nonoperative cases were males. Operative management was associated with a significantly higher flexion strength (mean difference, 25.67%; P < .0001), supination strength (mean difference, 27.56%; P < .0001), flexion endurance (mean difference, 11.12%; P = .0268), and supination endurance (mean difference, 33.86%; P < .0001). Patient-reported DASH and MEPS were also significantly superior in patients who underwent surgical repair, with mean differences of -7.81 (P < .0001) and 7.41 (P = .0224), respectively. Comparative analyses for ROM and pain VAS were not performed due to limited reporting in the literature for nonoperative management. Conclusion: This study represents the first systematic review and meta-analysis to compare functional and clinical outcomes following operative and nonoperative treatment of distal biceps tendon ruptures. Operative treatment resulted in superior elbow and forearm strength and endurance, as well as superior DASH and MEPS. 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

Fluoroquinolone-associated tendinopathy of the hand and wrist: A systematic review and case report. Berger, I., I. Goodwin and G. M. Buncke (2017) Level of Evidence: 1a- Follow recommendation: 👍 👍 (2/4 thumbs up) Type of study: Therapeutic/Preventative Topic: Medications - hand and wrist tendinopathy This is a systematic review investigating antibiotics-induced tendinopathies in the hand and wrist. The review identified 7 case studies on fluoroquinolone (antibiotic) induced hand and wrist tendinopathy. Several types of fluoroquinolones were suggested to cause hand/wrist tendinopathy (see table). Tendinopathies occured one to four weeks since the start of antibiotic therapy. Antibiotic care was initiated to treat a suspected or confirmed hand infection. Most cases of tendinopathy or rupture (finger flexors/extensors) presented with unilateral symptoms. Due to nature of the studies involved in the review (case studies) it is hard to identify causality between the antibiotics use and tendinopathy/tendon rupture. There are, however, basic science studies showing that fluoroquinolone antibiotics lead to connective tissue matrix degradation and the formation of weaker collagen fibres. 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, fluoroquinolone used to treat hand infections may contribute to the development of tendinopathies or tendon rupture. It is therefore important to ask our clients what medications they take and be particularly alert when they are taking these antibiotics (see table). In particular, if they start reporting pain which is not in line with the expected recovery trajectory, fluoroquinolones should be interrupted. URL: https://doi.org/10.1177/1558944717701237 Abstract Background: Fluoroquinolone use has been known to be associated with tendinopathy and tendon rupture for over 30 years. Hand and wrist involvement has been reported rarely, yet without early recognition and withdrawal of the fluoroquinolone, there is potential for significant morbidity. Methods: We searched Medline using a comprehensive search strategy for fluoroquinolones and tendinopathy of the hand and wrist, and provide a case report of a possible levofloxacin-related tendon rupture in a patient with a previous mutilating hand injury. Results: We located 10 previously reported cases of fluoroquinolone-associated tendinopathy in the hand or wrist ranging from 1983 to 2015. Unlike Achilles tendinopathy, women were no more likely than men to have tendon rupture affecting the hands or wrists. Our patient was a 59-year-old man with prior tendon repair but otherwise noncontributory medical history who experienced spontaneous tendon rupture on an extended course of levofloxacin and required extensive pulley and boutonnière repair. Conclusions: Given the extensive damage that may be caused to weakened tissue, clinicians should maintain a high index of suspicion of tendinopathy in patients taking fluoroquinolones who have had previous tendon repairs, particularly in the setting of unexplained changes in recovery trajectory. 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

Heterotopic ossification after revision carpal tunnel release causing mixed ulnar and median compression neuropathy. Maheshwari, A. V., et al. (2022) 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 46 years old right-handed woman. They reported previous surgery for carpal tunnel syndrome 6 years prior. This was followed by a second surgery for ongoing symptoms where additional fibrotic tissue was removed from the volar aspect of the wrist. After the second surgery, a mass on the volar aspect of the wrist slowly developed. Subjectively, the patient presented with numbness in all fingers. Objectively, there was a hard, non-mobile mass in the volar aspect of the distal forearm. They also presented with limited wrist range of movement, a positive Allen's test, and reduced 2-points discrimination ability in all fingers. An x-ray was taken and is shown below. Surgery was performed to remove the mass and diagnose the lesion. The median and ulnar neurovascular bundles were found to be stretched by the mass. Following surgery, the patient underwent hand therapy and within four months they had regained full strength and sensation in the hand. The pathology report indicated that this was a heterotopic ossification with no evidence of malignancy. 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, heterotopic ossification is a rare space invading lesion following carpal tunnel surgery. In contrast, the elbow is a more common site for heterotopic ossification and it can be a significant contributing factor to post-traumatic elbow stiffness. URL: https://doi.org/10.1016/j.jhsa.2020.12.009 Abstract We report a case of heterotopic ossification formation 6 years after a revision carpal tunnel release in a 46-year-old woman, causing new-onset mixed ulnar and median nerve compression symptoms. The patient underwent excision of the heterotopic ossification mass along with decompression of the median and ulnar nerves, and postoperative radiation. Four years after treatment, the patient was completely asymptomatic with full range of motion in her hand and wrist. 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

Soft-tissue injuries simply need PEACE and LOVE. Dubois, B. and J.-F. Esculier (2020) Level of Evidence: 5 Follow recommendation: 👍 (1/4 thumbs) Type of study: Therapeutic Topic: Acute non-traumatic pain – Biopsychosocial approach This is an editorial from the British Journal of Sports Medicine. A new PEACE and LOVE era has started for soft tissue injuries. This era comes after the RICE era and aims at updating it. The PEACE and LOVE acronyms stands for several steps that we can follow to rehabilitate soft tissue injuries. Protection is the first pillars which aims at allow tissue healing following an injury. This is followed by Elevation which allows for reduction of swelling. Avoidance of anti-inflammatories is also suggested as they inhibit the remodelling of injured tissue, which is a necessary step in the healing process. Compression goes alongside elevation and it aims at reducing swelling. Education clearly follows these steps as it is important to provide clients with a timeframe and get them to buy into the rehabilitation process. Gradual Loading favours tissue healing and can modulate pain. Optimism is also fundamental as a positive attitude can make a significant difference. Getting clients to take part in aerobic exercise has also been shown to improve Vascularisation and healing. Regaining strength, local tissue capacity, and proprioception is then achieved through active Exercises. Overall this article summarises nicely a large body of literature, which encompasses not only biological but also psychosocial aspects of rehabilitation. 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 provide PEACE and LOVE to our clients with soft tissue injuries. A large amount of evidence supports this approach. Thus it has been shown that education in combination with exercise can reduce pain, and that gradual loading can build up local tissue capacity. In addition, there is a growing amount of evidence showing that aerobic exercise may favour soft tissue healing, including wounds healing. Finally, several research studies have shown a correlation between upper limb disability and mental health (e.g. kinesiophobia, pain catastrophising, depression). URL: http://dx.doi.org/10.1136/bjsports-2019-101253 Abstract Rehabilitation of soft-tissue injuries can be complex. Over the years, acronyms guiding their management have evolved from ICE to RICE, then on to PRICE and POLICE.1 Although widely known, these previous acronyms focus on acute management, unfortunately ignoring subacute and chronic stages of tissue healing. Our contemporary acronyms encompass the rehabilitation continuum from immediate care (PEACE) to subsequent management (LOVE). PEACE and LOVE (figure 1) outline the importance of educating patients and addressing psychosocial factors to enhance recovery. While anti-inflammatories show benefits on pain and function, our acronyms flag their potential harmful effects on optimal tissue repair. We suggest that they may not be included in the standard management of soft-tissue injuries. 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