Level of Evidence: 5 Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Diagnostic Study This paper describes a case of a 20-year-old collegiate football player who sustained a direct elbow contusion during play, leading to lateral elbow pain radiating into the right hand with an 8/10 Numeric Pain Rating Scale (NPRS). Initial imaging included radiographs, which were normal. Subsequent magnetic resonance imaging (MRI) is show below. What is it?

ZO14431 Does the internet provide accurate information about foregoing treatment for common musculoskeletal conditions. Simpson, et al. (2025) Level of Evidence: 5 Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Diagnostic/Therapeutic Topic : Hand MSK conditions - Misinformation The study assessed the quality of internet-based health information for musculoskeletal conditions such as carpal tunnel syndrome, de Quervain tendinopathy, and lateral epicondylitis. The authors found that many websites inaccurately suggest that surgery may become necessary for these conditions, misrepresenting the fact that it is often optional unless explicitly required for specific reasons (e.g., preventing permanent nerve damage in carpal tunnel syndrome). Similarly, the portrayal of symptom severity as a justification for surgery or further intervention is misleading, as discomfort and incapacity often correlate more with mindset and circumstances than pathophysiological severity. These misrepresentations can harm individuals by validating worst-case thinking and negative pain beliefs, which exacerbate discomfort and disability. The authors emphasise the need for clearer communication to avoid misinformation. 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 information available through internet on carpal tunnel syndrome, de Quervain tendinopathy, and lateral epicondylitis is largely incorrect. Websites provide misinformation by often exaggerating the necessity for surgery (e.g. surgery for tennis elbow ) and misrepresent symptom severity. Little information is provided on how mindset can affect symptoms rather than them being solely dependent on physical severity. Thus, anxiety and fear can often heighten the pain response . Limited evidence is available on the importance of trialing conservative treatments before considering surgery. It is therefore important for clinicians to discuss the information that patients have been gathering and helping them navigate their symptoms management by calling out what is misinformation. URL : https://doi.org/10.1177/23743735251323390 Abstract We studied how websites address the consequences of leaving common musculoskeletal conditions untreated, two that have a benign, self-limiting course without treatment (de Quervain tendinopathy, lateral epicondylitis) and one that is expected to have progressive nerve deterioration without treatment (carpal tunnel syndrome). Using a common search engine, the first 120 websites addressing each diagnosis were rated for statements regarding disease progression and need for surgery without treatment. Most sites stated that disease would worsen without treatment: carpal tunnel syndrome (99%), lateral epicondylitis (91%), and de Quervain tendinopathy (72%). For each condition, approximately a third of the websites stated surgery might become necessary. The observation of inadequate distinction between conditions that deteriorate with treatment from those that resolve without treatment emphasizes the potential for harm by reinforcing common misconceptions such as “this is taking too long” or “this will not resolve without treatment” and by jeopardizing personal health agency. Producers of online medical information can add an item to their quality checklist that ensures that people are accurately informed about a choice to not seek treatment. 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

Cognitive behavioral therapy reduces unhelpful thinking among people with musculoskeletal symptoms: A meta-analysis. Patel, et al. (2024) Level of Evidence: 1a Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Therapeutic Topic : CBT - Musculoskeletal pain This systematic review and meta-analysis of randomised trials, explored the role of Cognitive Behavioral Therapy (CBT) in managing musculoskeletal conditions by addressing unhelpful mindsets related to pain. The results showed that CBT effectively reduces catastrophic thinking, kinesiophobia, and negative pain-related thoughts, with larger effects observed among individuals with higher baseline levels of these unhelpful mindsets. While CBT delivered by mental health providers showed greater effectiveness in reducing such mindsets compared to physical therapists, the study highlights the potential benefits of integrating psychologically informed physical therapy. Additionally, both group and individual CBT sessions, as well as online versus in-person delivery, were found to be equally effective, emphasising flexibility in treatment strategies. The research underscores the importance of early initiation of CBT to support recovery and suggests that combining CBT with exercises could enhance effectiveness, particularly for patients who may avoid mental health referrals due to stigma. 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, CBT appears helpful in managing musculoskeletal conditions by targeting negative thought patterns related to pain, such as catastrophic thinking and kinesiophobia. If your patients have higher baseline levels of these thoughts, CBT is more likely to help. It also appears that initiating CBT early can prevent escalation of negative thought patterns. Reducing the level of fear avoidance may also reduce disability as they appear to be associated . URL : https://doi.org/10.1177/24705470241304252 Abstract Background: Greater unhelpful thinking is associated with greater musculoskeletal discomfort and incapability. Cognitive-behavioral therapy (CBT) fosters healthy thinking to help alleviate symptoms. Questions: In a meta-analysis of randomized control trials (RCT) of CBT for unhelpful thinking among people with musculoskeletal symptoms, we asked: 1) Does CBT reduce unhelpful thinking and feelings of distress, and improve capability, in individuals with musculoskeletal symptoms? 2) Are outcomes affected by CBT delivery methods? Methods: Following QUOROM guidelines, we searched databases using keywords of pain catastrophizing, kinesiophobia, cognitive-behavioral therapy, musculoskeletal and variations. Inclusion criteria were RCT's testing CBT among people with musculoskeletal symptoms. Study quality was assessed with Cochrane Review of Bias 2. Meta-analysis of means and standard deviations was performed. Results: CBT led to modest reductions in catastrophic thinking (−0.44 CI: −0.76 to −0.12; P = .01, kinesiophobia (−0.60 CI: −1.07 to −0.14; P = .01) and anxiety symptoms (−0.23 CI: −0.36 to −0.09; P < .01) over six months compared to usual care. There were no improvements in levels capability (−0.28 CI: −0.56 to 0.01; P = .05). CBT led by mental health professionals reduced catastrophic thinking more than CBT led by other clinicians (QB Test = 4.73 P = .03). There were no differences between online and in-person sessions, group versus individual therapy, or surgical versus non-surgical interventions. Conclusion: The evidence that CBT delivered by various clinicians in various settings fosters healthier thinking in people presenting for care of musculoskeletal symptoms, supports comprehensive care of musculoskeletal illness. More research is needed to develop indications and interventions that also improve levels of capability. 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: 👍 👍 (2/4 Thumbs up) Type of study: Diagnostic This study describes the case of a 42-year-old right-handed male writer who injured their right little finger whilst lifting gardening tools. They reported immediate pain in the forearm and little finger. Objectively, they could not flex their little finger, especially at the dipj. Carpal tunnel view x-rays were normal. What is it?

The natural history of paediatric trigger thumbs. A prospective cohort study. Chew, et al. (2025) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Therapeutic/Prognostic Topic : Paediatric trigger thumb - Prognosis This study assessed the rate of spontaneous resolution of paediatric trigger thumb over time and identified factors influencing its treatment. It found that approximately 37% of children resolved spontaneously within five years, with a higher rate observed by eight years. The interphalangeal joint (ipj) angle was identified as a significant predictor, with thumbs presenting at less than 30 degrees more likely to resolve conservatively. Economic analysis highlighted cost savings associated with conservative management compared to surgery. However, the study’s findings are limited to a cohort of children whose parents opted for non-surgical treatment initially, potentially skewing results. 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, pediatric trigger thumb resolves spontaneously in 40% of cases within five years. This number increases to 50% by eight years. A key predictor is the interphalangeal joint (ipj) angle: thumbs with an angle below 30 degrees are more likely to improve without surgery. This suggests that conservative management, such as observation and therapy, is a viable option for many children. Monitoring and conservative care are recommended for mild cases with low ipj angles. If there's no improvement after four years or if symptoms worsen, surgical intervention may be necessary. URL : https://doi.org/10.1177/17531934241295903 Abstract The aim of this study was to report the natural history of paediatric trigger thumbs, determining the rate and factors predictive of spontaneous resolution. A total of 62 patients presenting with 79 thumbs locked in flexion were observed for a mean of 4.2 years. The median age at presentation was 20.5 months. The spontaneous resolution rate was 37% at 5 years and 50% at 8 years of follow-up. Of the thumbs, 27% had undergone surgery at 5 years and 48% at 8 years. Thumbs that spontaneously resolved did so at a mean of 3.4 years. Thumbs presenting with an interphalangeal joint angle of less than 30° were likely to resolve spontaneously, with a sensitivity of 0.50 and specificity of 0.82. It is reasonable to offer observation alone for 4 to 5 years as the first line of management for paediatric trigger thumb. 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

Measurement of the cross-sectional area of the median and ulnar nerves by hand surgeons without ultrasound training: A prospective study. Portney, et al. (2025) Level of Evidence: 4 Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Diagnostic Topic : US imaging - Median nerve The study investigates whether orthopedic surgeons without ultrasound training can accurately measure the cross-sectional area (CSA) of the median and ulnar nerves using US machines. The study compared measurements taken by an expert sonographers, a hand surgeon, and an orthopedic resident in 15 healthy volunteers. Non-inferiority margins were <2 mm². For the median nerve, both the hand surgeon and the resident achieve non-inferiority, with mean differences of 1.2 mm² each, indicating accurate measurements comparable to those of experts. However, for the ulnar nerve, neither clinicians met the criteria non-inferiority criteria. This suggests that measuring the ulnar nerve is more challenging due to factors such as transducer positioning and elbow anatomy. A limitation noted is the small sample size of healthy volunteers, which may not fully reflect real-world scenarios with symptomatic patients. 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, untrained orthopedic surgeons can measure the cross-sectional area (CSA) of the median nerve using ultrasound similarly to experts. However, their ability to measure the CSA of the ulnar nerve is less reliable, likely due to technical challenges such as transducer positioning and anatomical complexity. Keep in mind that whilst changes in CSA of the median nerve could be useful to make a diagnosis ( US changes are proxy for NCS ) of carpal tunnel syndrome, these are not predictive of response to treatment . URL : https://doi.org/10.1177/17531934251329264 Abstract Fifteen healthy subjects underwent ultrasound of their median and ulnar nerves by three examiners: an expert ultrasonographer and two surgeons without formal ultrasound training. The surgeons accurately measured the cross-sectional area of the median nerve, but not the ulnar nerve. 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

Investigating a no-cost, noninvasive, patient-driven approach to pain reduction for trigger finger injections: A randomized controlled trial. Crislip, et al. (2025) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 (/4 Thumbs up) Type of study: Therapeutic Topic : Trigger finger injections - Tactile stimulation This study investigates the effectiveness of tactile stimulation and distraction techniques, in reducing pain during corticosteroid injections for trigger finger. A randomised controlled trial with 105 participants compared tactile stimulation proximal to the injection site, distraction, or no intervention during the corticosteroid injection for trigger finger. The distraction group was asked to self scratch the shoulder on the unaffected side whilst the tactile stimulation group was asked to scratch the forearm on the affected side. The results showed that both forearm tactile stimulation and distraction had a clinical and significant reduction in pain during injection compared to no intervention. The difference between tactile stimulation and distraction was significant as well as clinically relevant. 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, tactile stimulation or distraction methods effectively reduce pain during corticosteroid injections for trigger finger. These non-invasive techniques may be useful to implement with our anxious patients . The first line of treatment for trigger finger should however be splinting as it has been shown to be as effective as injections . If you are interested in the topic, have a look at the whole database . URL : https://doi.org/10.1016/j.jhsa.2025.03.012 Abstract Purpose: To evaluate whether patient-controlled scratching of the skin proximal to the injection site in the relevant cervical dermatome is associated with a reduction in pain caused by corticosteroid injection for trigger finger compared to no scratching or scratching of the contralateral limb. Methods: A total of 105 patients presenting with trigger finger were enrolled in this prospective, single-blind, randomized controlled study. Patients were randomly assigned to one of three groups: control (no intervention), distraction (cognitive/motor distraction task with patient-controlled scratching of the shoulder contralateral to the injected digit), and experimental (patient-controlled scratching of the ipsilateral upper extremity within the cervical spinal dermatome corresponding to the injected digit). Before injection was performed, anticipated pain was measured with a visual analog scale (VAS), and pain catastrophizing scale (PCS) surveys were completed. Postinjection, experienced pain was measured with a second VAS score. Results: The experimental condition resulted in a statistically and clinically significant reduction in experienced pain compared to the control condition (means = 59 vs 28 on VAS, respectively). There were also clinically significant differences in mean VAS scores between control and distraction groups (59 vs 43) and between distraction and experimental groups (43 vs 28). Only the experimental condition resulted in a significant reduction in experienced pain compared with anticipated pain. Conclusions: Patient-controlled scratching of the skin of the forearm within the same cervical dermatome as the injection site results in clinically significant pain reduction during injection administration. Although purely cognitive distraction may exert nonspecific effects to attenuate the conscious experience of pain, tactile stimulation in the relevant dermatome appears to be more effective. 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 in patients with posttraumatic elbow stiffness: 3d analysis of regional distribution features and associated risk factors. Hua, et al. (2025) Level of Evidence: 4 Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Aetiologic/Prognostic Topic : Heterotopic ossification - Presentations This study investigates the development of heterotopic ossification (HO) following elbow injuries in 170 patients, analysing various clinical factors influencing its occurrence across different anatomical regions. The most common injuries included distal humerus fractures (34%), olecranon fractures (32%), and radial head fractures (31%). High-energy trauma was more prevalent (52%) than low-energy mechanisms, and operative treatment was the primary intervention in 85% of cases. Key findings from logistic regression analyses revealed that HO development varied significantly by region. HO in the anteromedial region was more common after elbow dislocation and longer time intervals (≥1 year). HO in the anterolateral region showed higher odds with high-energy trauma. HO in the posterior region was influenced by prolonged immobilisation (>2 weeks). Radial head fractures were strongly associated with proximal radioulnar joint (PRUJ) HO. 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 (HO) after elbow injuries varies across different anatomical regions. Notably, high-energy trauma elevates HO risk in specific areas. Prolonged immobilisation beyond two weeks significantly increases HO risk, particularly posteriorly. Additionally, radial head fractures are strong indicators of HO, especially affecting the proximal radioulnar regions. These findings are in line with previous evidence , and they highlight the importance of getting the elbow to move as soon as possible after injury. URL : https://doi.org/10.1016/j.jse.2025.03.020 Abstract Background: The development of heterotopic ossification (HO) is a common yet debilitating complication after elbow injuries and related surgical procedures. We intend to evaluate the regional distribution features of HO around the elbow joint in patients with posttraumatic elbow stiffness (PTES), and explore the independent risk factors for HO development in different regions. Materials and Methods: Patients who presented with PTES attributed to HO from January 2018 to December 2019 were consecutively enrolled. The pattern of HO distribution was analyzed using Mimics software and classified into 8 distinct regions: anteromedial (AM), anterolateral (AL), posteromedial (PM), posterolateral (PL), posterior (P), medial (M), lateral (L), and proximal radioulnar (PRU) regions. The initial injuries were further categorized based on the presence or absence of 5 fundamental injury types: distal humerus fracture, olecranon fracture, radial head fracture, coronoid fracture, and elbow dislocation. With the occurrence of HO in a specific region as the dependent variable and the initial injury patterns and baseline clinical data as independent variables, logistic regression analyses were conducted to identify the associated independent risk factors for HO development in different regions. Results: A total of 170 patients were included. We identified PM HO in 166 patients (97.6%), P HO in 135 patients (79.4%), PL HO in 128 patients (75.3%), AM HO in 92 patients (54.1%), AL HO in 57 patients (33.5%), PRU HO in 32 patients (18.2%), M HO in 12 patients (7.1%), and L HO in 11 patients (6.5%). The results of logistic regression analyses: (1) AM HO: time interval between the initial injury and this admission ≥1 year (OR=2.338), the presence of elbow dislocation (OR=3.193) and olecranon fracture (OR=0.305); (2) AL HO: high energy trauma (OR=2.073) and the presence of olecranon fracture (OR=0.367); (3) P HO: immobilization for more than 2 weeks after the initial injury or subsequent surgical procedures (OR=2.466); (4) PL HO: the presence of radial head fracture (OR=2.805); (5) PRU HO: the presence of radial head fracture (OR=8.186); (6) PM+P+PL HO: the presence of radial head fracture (OR=2.235). Conclusion: The regional distribution of HO in patients with PTES exhibits distinct features, and PM HO is observed in almost all patients. The type of initial injury and its subsequent management are closely related to the occurrence and development of HO in different regions. Our findings provide valuable insights and serve as a useful reference for the clinical assessment of HO in patients with PTES. 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

Incidence of extensor carpi ulnaris pathology in patients with triangular fibrocartilage complex foveal repairs. Jung, et al. (2025) Level of Evidence: 2b Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Diagnostic/Symptom prevalence Topic : ECU pathology - TFCC injury The study investigated the relationship between extensor carpi ulnaris (ECU) tenosynovitis and distal radioulnar joint (DRUJ) subluxation in patients with TFCC foveal tears compared to controls without ulnar wrist pain. Using MRI, researchers measured variables like ulnar groove dimensions and DRUJ subluxation ratios, but found no significant differences between groups. ECU tenosynovitis and subluxation grades were identified as significant factors in multivariate analysis, with tenosynovitis strongly associated with TFCC foveal tears. The study highlights that ECU tenosynovitis is more prevalent in patients and likely linked to DRUJ instability caused by TFCC tears. Limitations included underpowering for some analyses, static MRI assessment, and the several univariate analyses, which increase the odds of returning significant findings. 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, there is a significant association between ECU tenosynovitis and TFCC foveal tears. This may suggest that ECU inflammation could be the result of DRUJ instability or is a common pathology alongside these presentations. Keep in mind that despite people with TFCC injuries have a higher likelihood of ECU tenosynovitis, there are many asymptomatic people with MRI changes in the wrists . Have a look at the whole database on ulnar wrist pain if you are interested in the topic. URL : https://doi.org/10.1177/17531934251335104 Abstract We analysed the association between extensor carpi ulnaris pathology and triangular fibrocartilage complex foveal tears. In total, 178 patients (58 patients and 120 controls) were retrospectively recruited. The patient group comprised individuals with foveal tears. Extensor carpi ulnaris pathology was defined as the presence of tenosynovitis, tendinosis and high-grade tendon subluxation in magnetic resonance images. Tenosynovitis and a high grade of subluxation were more prevalent in patients than in controls (43 vs. 23% and 26 vs. 14%, respectively) whereas the incidence of tendinosis did not significantly differ. In a multivariate regression model, only tenosynovitis was associated with foveal tears (odds ratio 2.56; 95% CI 1.29 to 5.08; p =  0.007). Overall, the prevalence of tenosynovitis was higher in the patient group than that in the control group. Extensor carpi ulnaris tenosynovitis detected on magnetic resonance images is highly associated with triangular fibrocartilage complex foveal tears. 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

Clinical irrelevance of the Martin–Gruber communication: A study in proximal ulnar and median nerve lesions. Sporer, et al. (2025) Level of Evidence: 3b Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Diagnostic Topic : Median-ulnar anastomosis - Martin-Gruber The study examined the clinical relevance of the median-to-ulnar nerve motor fibre communication (Martin-Gruber communication - MGC) in individuals with ulnar or median nerve injuries. Researchers assessed patients to determine if this anatomical connection could compensate for lost thumb adduction or little finger abduction functions, particularly in cases where one nerve is affected. Through clinical testing and intraoperative electrical stimulation, the study found no evidence of a significant motor fibre exchange between the two nerves. Patients with ulnar nerve injuries exhibited severely reduced key-pinch strength, indicating that the MGC does not effectively compensate for lost function. Conversely, those with median nerve injuries retained full thumb adduction and related functions. The researchers concluded that the clinical significance of the MGC has been overstated, suggesting it may be more relevant anatomically than functionally. 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, Martin-Gruber communication (MGC) is not sufficient to compensated for isolated nerve lesions of the ulnar/median nerve. This shift emphasises the need for early surgical options in cases where nerve injuries are severe or incomplete. There is now clinical evidence confuting the previously held notion that Martin-Grouber anastomosis could help in proximal ulnar or median nerve lesions . URL : https://doi.org/10.1177/17531934251330989 Abstract The Martin–Gruber communication is a median-to-ulnar motor fibre exchange. However, no clinical evidence of its potential compensatory function was found in 54 patients with complete proximal lesions of either the ulnar or median nerves, suggesting that its significance is largely anecdotal. 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

Results of a 6-week treatment with 10 mg prednisolone in patients with hand osteoarthritis (HOPE): A double-blind, randomised, placebo-controlled trial Kroon, et al. (2019) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Therapeutic Topic : Hand OA - Prednisone This double blind placebo trial evaluated the efficacy of a six-week course of 10 mg prednisolone daily compared to placebo in 92 patients with painful hand osteoarthritis and synovial inflammation. Results showed significant improvements in pain, functional limitation, and joint tenderness favoring prednisolone. Around 70% of people in the experimental and 30% of people in the placebo group obtained clinically relevant changes. While short-term use was effective, prolonged prednisolone use was discouraged due to risks like glucocorticoid-induced osteoporosis. 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 six-week course of prednisone is likely to reduce pain hand osteoarthritis by reducing synovial inflammation. This seems to be in line with another study looking at topical NSAIDs, which reduced synovitis within two weeks of application . URL : https://doi.org/10.1016/S0140-6736(19)32489-4 Abstract Background: Hand osteoarthritis is a prevalent joint condition that has a high burden of disease and an unmet medical need for effective therapeutic options. Since local inflammation is recognised as contributing to osteoarthritic complaints, the Hand Osteoarthritis Prednisolone Efficacy (HOPE) study aimed to investigate the efficacy and safety of short-term prednisolone in patients with painful hand osteoarthritis and synovial inflammation. Methods: The HOPE study is a double-blind, randomised, placebo-controlled trial. We recruited eligible adults from rheumatology outpatient clinics at two sites in the Netherlands. Patients were considered eligible if they had symptomatic hand osteoarthritis and signs of inflammation in their distal and proximal interphalangeal (DIP/PIP) joints. For inclusion, patients were required to have four or more DIP/PIP joints with osteoarthritic nodes; at least one DIP/PIP joint with soft swelling or erythema; at least one DIP/PIP joint with a positive power Doppler signal or synovial thickening of at least grade 2 on ultrasound; and finger pain of at least 30 mm on a 100-mm visual analogue scale (VAS) that flared up during a 48-h non-steroidal anti-inflammatory drug (NSAID) washout (defined as worsening of finger pain by at least 20 mm on the VAS). Eligible patients were randomly assigned (1:1) to receive 10 mg prednisolone or placebo orally once daily for 6 weeks, followed by a 2-week tapering scheme, and a 6-week follow-up without study medication. The patients and study team were masked to treatment assignment. The primary endpoint was finger pain, assessed on a VAS, at 6 weeks in participants who had been randomly assigned to groups and attended the baseline visit. This study is registered with the Netherlands Trial Registry, number NTR5263. Findings: We screened patients for enrolment between Dec 3, 2015, and May 31, 2018. Patients completed baseline visits and started treatment between Dec 14, 2015, and July 2, 2018, and the last study visit of the last patient was Oct 4, 2018. Of 149 patients assessed for eligibility, 57 (38%) patients were excluded (predominantly because they did not meet one or several inclusion criteria, most often because of an absence of synovial inflammation or of flare-ups after NSAID washout) and 92 (62%) patients were eligible for inclusion. We randomly assigned 46 (50%) patients to receive prednisolone and 46 (50%) patients to receive placebo, all of whom were included in the modified intention-to-treat analysis of the primary endpoint. 42 (91%) patients in the prednisolone group and 42 (91%) in the placebo group completed the 14-week study. The mean change between baseline and week 6 on VAS-reported finger pain was −21·5 (SD 21·7) in the prednisolone group and −5·2 (24·3) in the placebo group, with a mean between-group difference (of prednisolone vs placebo) of −16·5 (95% CI −26·1 to −6·9; p=0·0007). The number of non-serious adverse events was similar between the groups. Five serious adverse events were reported during our study: one serious adverse event in the prednisolone group (a myocardial infarction) and four serious adverse events in the placebo group (an infected traumatic leg haematoma that required surgery, bowel surgery, atrial fibrillation that required a pacemaker implantation, and symptomatic uterine myomas that required a hysterectomy). Four (4%) patients discontinued the study because of an adverse event: one (2%) patient receiving prednisolone (for a myocardial infarction) and three (7%) patients receiving placebo (for surgery of the bowel and for an infected leg haematoma and for Lyme disease arthritis of the knee). Interpretation: Treatment with 10 mg prednisolone for 6 weeks is efficacious and safe for the treatment of patients with painful hand osteoarthritis and signs of inflammation. The results of our study provide clinicians with a new short-term treatment option for patients with hand osteoarthritis who report a flare-up of their disease. 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

Topical diclofenac reduces joint synovitis in hand osteoarthritis: A pilot investigation using fluorescent optical imaging. Mantantzis, et al. (2024) Level of Evidence: 2b Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Therapeutic Topic : Hand OA - Topical NSAIDs This pilot study investigated the effectiveness of topical diclofenac in reducing synovitis, a marker of inflammation in hand osteoarthritis (OA), using fluorescence optical imaging (FOI). The research employed a quantitative approach to analyse FOI images, demonstrating a 42.4% reduction in synovitis after two weeks of treatment compared to baseline. This reduction was consistent with semi-quantitative analyses and subjective improvements in pain perception. While the study highlights the potential of topical diclofenac to alleviate inflammation in HOA, it is limited by its small sample size (10 patients) and open-label design without a placebo control. It is possible that improvements in synovitis could be part of a larger cycle of synovitis and remission independent of the NSAIDs. 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, this pilot study explores the potential benefits of topical diclofenac in managing inflammation in hand osteoarthritis through its ability to reduce synovitis. The reduction in synovitis after two weeks of treatment aligned with subjective improvements in pain perception. The findings from this paper seem to be in line with previous evidence suggesting that in presence of synovitis, prednisone had a clinically relevant improvement in pain . Since we cannot prescribe prednisone, topical NSAIDs may be a useful alternative. URL : https://doi.org/10.2147/JPR.S463633 Abstract Purpose: Synovitis, the inflammation of joint synovia, is a prominent feature of osteoarthritis (OA) manifested by enhanced synovial vascularity, endothelial leakage, and perivascular oedema. In this pilot study, we assessed the effect of topical diclofenac in hand OA (HOA) using the established semi-quantitative methods Magnetic Resonance Imaging (MRI) and Ultrasonography (US), and compared them with Fluorescent Optical Imaging (FOI), an emerging imaging modality. Patients and Methods: Ten patients with symptomatic and diagnosed HOA used topical diclofenac for 14 days, with FOI, MRI, US, and subjective pain assessed at Baseline and after 7 (Day 8), and 14 (Day 15) days of treatment. Changes in synovitis were assessed for all 10 joints of the hand (via sum scores), and separately for the two joints most affected by synovitis. A new, fully quantitative approach for objective synovitis assessment based on the FOI images was also developed and applied. Results: The semi-quantitative analysis of the sum scores showed a small decrease in synovitis throughout the treatment duration across the different imaging modalities. The effect of the treatment was more prominent on the two most affected joints, with a synovitis reduction vs Baseline of 21.1% and 34.2% on Day 8 and Day 15, respectively, in the FOI. The quantitative FOI pixel analysis further strengthened the evidence for this effect, with observed reduction of 17.8% and 42.4% for Days 8 and 15, respectively. A similar trend was observed for subjective pain perception, with a reduction of 7.2 and 13.3 mm on Days 8 and 15. Conclusion: This pilot study evidenced the effect of topical diclofenac on reducing synovitis in hand OA in semi- and fully quantitative analyses, with the effect being stronger in the most affected joints. Further, supporting studies are needed to probe the accuracy of the quantitative pixel analysis of FOI images. 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