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Thoracic outlet syndrome: A comprehensive review. Simpson, et al. (2025) Level of Evidence: 5 Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Diagnostic Topic : Thoraci outlet syndrome - Upper limb entrapment mimicker This is an expert opinion on Thoracic Outlet Syndrome (TOS) and their clinical presentation. TOS is a multifactorial disorder caused by compression of the brachial plexus, subclavian artery, or subclavian vein within the thoracic outlet, a space bounded by the clavicle, first rib, and scalene muscles. The most common presentation is neurogenic TOS (≈90 % of cases), followed by venous, and arterial subtypes, each presenting with distinct neurologic, ischemic, or thrombotic symptoms that can mimic cervical radiculopathy, carpal tunnel syndrome, or cardiac embolic disease. Clinical diagnosis is difficult, and currently available tests include Adson, Roos, and Wright test. In terms of imaging, MRI, CT angiography (CTA), and dynamic ultrasound can be helpful, however, they have limitation under dynamic or subtle compressions. Anterior scalen blocks can be a useful diagnostic and short‑term therapeutic tool, with response rates predicting surgical benefit, especially in older patients. Management approaches include conservative physical‑therapy regimens to first‑rib resection with or without scalenectomy, depending on subtype. Venous TOS decompression yields 94 % clinical improvement, while arterial procedures achieve 85 % long‑term relief, though restenosis can occur. 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, thoracic outlet syndrome (TOS) is best approached as a multidisciplinary problem. Neurogenic TOS, which is the most common, often mimics cervical radiculopathy or carpal tunnel syndrome. This seems to be in line with previous research on upper limb entrapment neuropathies . A high index of suspicion and provocative tests (Adson, Roos, Wright) are first steps in making a diagnosis. If you are concerned about an arterial TOS, the use of a pulsoximeter during these tests may be useful. Keep in mind that a cervical/upper thoracic x-ray may be useful in excluding a cervical rib or long transverse processes that may contribute to the compression of these structures. Similarly, US imaging could be utilised to assess whether there is dynamic compression of the neurovascular bundles. Treatment wise, resection of the anterior and middle scalene seem to have a similar effect to 1st rib removal with lower complications . Unfortunately for younger athletes, surgery for neurogenic TOS does not seem to be as effective as for older and possibly less active individuals . URL : https://doi.org/10.1097/CRD.0000000000001023 Abstract Thoracic outlet syndrome (TOS) comprises a range of conditions characterized by compression of the brachial plexus, subclavian artery, or subclavian vein as these structures traverse the thoracic outlet. Although TOS was first documented in 1860 by Willshire, it remains a diagnostic and therapeutic challenge—particularly for cardiologists evaluating upper-extremity ischemia, suspected arm emboli, or unexplained swelling. This article provides a cardiology-focused overview of TOS, emphasizing the condition’s subtypes (neurogenic, venous, and arterial), key diagnostic approaches, comparative surgical outcomes, and considerations relevant to cardiovascular specialists. Literature pertaining to TOS pathophysiology, clinical diagnosis, imaging, and surgical management was reviewed. Where available, quantitative outcome data and success rates are highlighted to guide evidence-based decision-making. TOS is commonly categorized into neurogenic, venous, and arterial forms. Each subtype necessitates a distinct approach. Developments in imaging (magnetic resonance imaging, computed tomography angiography, and dynamic ultrasound) and refined surgical techniques have improved diagnostic accuracy and therapeutic success: yet questions remain regarding long-term efficacy and optimal procedural approaches. Prompt differentiation between TOS and intrinsic cardiac or major vascular etiologies is essential for preventing severe complications such as limb ischemia and permanent nerve damage. A multidisciplinary model integrating cardiologists, vascular surgeons, neurologists, and physical therapists offers the best outcomes. Further studies, particularly large-scale comparative trials, are needed to standardize diagnostic protocols and evaluate emerging surgical approaches. 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

Relative metacarpal shortening as a radiographic measure of fourth and fifth carpometacarpal fracture dislocation. Fones, et al. (2025) Level of Evidence: 2b Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Diagnostic Topic : Cmcj fracture dislocations - Relative metacarpal length This retrospective study assessed whether an easily calculable radiographic metric called Relative Metacarpal Shortening, could improve detection of fourth and fifth carpometacarpal joints (cmcj) fracture‑dislocations hand x-rays. A total of 41 patients with confirmed cmcj injuries and 42 matched controls were included in the study. Three independent reviewers measured the perpendicular distance from each affected metacarpal head to a line tangent to the third metacarpal, dividing by the third metacarpal length to obtain RMS values (postero-anterior x-ray). Injured digits exhibited significantly greater shortening compared to the healthy controls. Inter‑observer agreement was excellent. Cut‑off thresholds to detect fracture-dislocations was 0.13 and 0.28 for the fourth and fifth digit respectively. Keep in mind that these thresholds were selected based on the best diagnostic accuracy of the sample available, however, they have not been validated on a separate sample. Have a look at the pictures below to get an understanding of these measurements. 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, relative metacarpal shortening (RMS) is a practical and simple measurement that can be added to the routine review of posteroanterior hand films in patients with 4th and/or 5th cmcj pain. It appears that if the fourth and/or fifth metacarpals are shortened by more than 1/10 and 1/3 of the third metacarpal, this may increase the probability of our patients having a cmcj fracture-dislocation. If you are interested in other cool ways to utilise x-ray for clinical decision making, have a look at this synopsis on bony mallets . URL : https://doi.org/10.1016/j.jhsa.2025.08.011 Abstract Purpose: Fourth and fifth carpometacarpal fracture dislocations may be missed on plain x-ray. The purpose of this study was to describe a radiographic measurement, the relative metacarpal shortening (RMS), to evaluate for fourth and fifth carpometacarpal fracture dislocations on posteroanterior radiographs. We hypothesize that the RMS will increase in patients with fourth and fifth carpometacarpal fracture dislocations relative to controls. Methods: A retrospective review identified posteroanterior hand radiographs of skeletally mature patients with fourth and/or fifth carpometacarpal fracture dislocations. Comparisons were made of normal radiographs identified from patients presenting to the outpatient orthopedic hand clinic for complaints other than fracture or dislocation. Three independent reviewers performed measurements, with two of these reviewers measuring the RMS for each patient radiograph. The fourth and fifth RMS were calculated by dividing the length from the fourth/fifth distal metacarpal head to a tangential line to the third metacarpal head by the third metacarpal length. Measures were compared between the two cohorts. Agreement was assessed by intraclass correlation coefficients between reviewers. Results: In total, 42 controls and 41 fractures were included. The fracture group included 18 patients (43.9%) with isolated fifth metacarpal involvement and 23 patients (56.1%) with both fourth and fifth metacarpal involvement. Fractures were more commonly right-sided, younger, and men relative to controls. The fourth and fifth RMS were higher for fractures (0.16 and 0.31) than for controls (0.12 and 0.26), respectively. The intraclass correlation coefficient agreement test was almost perfect for all measurements (range: 0.82–0.94). Conclusions: The RMS is a radiographic measurement with almost perfect agreement between reviewers and is increased in fourth and fifth carpometacarpal fracture dislocations. Fourth RMS >0.13 and fifth RMS >0.28 should increase the index of suspicion for carpometacarpal fracture dislocation in a patient with corresponding ulnar hand pain. 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

Cubital tunnel syndrome: Does a consensus exist for diagnosis?. Collins, et al. (2025) Level of Evidence: 5 Follow recommendation: 👍 (1/4 Thumbs up) Type of study: Diagnostic Topic : Cubital tunnel syndrome - Physical tests This is a Delphi study that attemped to establish consensus on diagnostic criteria for cubital tunnel syndrome (CuTS) among 12 hand and upper limb surgeons. A 55‑item questionnaire covering history, physical exam, and provocative tests was distributed, and panelists ranked each item’s importance on a 1–10 scale. Internal consistency was assessed through Cronbach’s α. Items which were identified as very similar amongst each other were combined. The results showed that there was a high level of agreement amongst surgeons on what subjective and objective aspects were useful in making a diagnosis of cubital tunnel syndrome. The top three were: Paresthesias localised to the ulnar nerve distribution of the forearm/hand. Symptoms worsening with elbow flexion. A positive Tinel sign at the medial elbow. Other objective findings/history that they deemed important included atrophy/weakness of intrinsic hand muscles, loss of two‑point discrimination within the ulnar hand, and successful treatment of the contralateral limb with cubital tunnel release. 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, paraesthesia in the ulnar hand/forearm that worsen with sustained elbow flexion, and a positive Tinel's at the cubital tunnel seem to be useful in making a cubital tunnel diagnosis. In addition, a good neurological assessment including sensory and motor tests are useful in differentiating between a peripheral entrapment vs a more proximal compression. Don't forget to screen the rest of the upper limb, including the neck , as some presentations like thoracic outlet or cervical radiculopathy can mimic peripheral entrapment neuropathies. URL : https://doi.org/10.1016/j.jhsa.2023.05.014 Abstract Purpose: Cubital tunnel syndrome (CuTS) is the second most common compressive neuropathy of the upper extremity. We aimed to determine a consensus among experts using the Delphi method for clinical criteria that could be validated further for the diagnosis of CuTS. Methods: The Delphi method was used for establishing a consensus among a group of expert panelists, comprising 12 hand and upper-extremity surgeons, who ranked the diagnostic clinical importance of 55 items related to CuTS on a scale from 1 (least important) to 10 (most important). The average and SDs of each item were calculated, and Cronbach α was used to assess homogeneity among the panelist-ranked items. Results: All panelists answered the 55-item questionnaire. A Cronbach α value of 0.963 was obtained on the first iteration. The top criteria that were considered most clinically relevant to the diagnosis of CuTS among the group were determined based on the most highly ranked and correlated items among the expert panelist group. The criteria based on which there was agreement were as follows: (1) paresthesias in ulnar nerve distribution, (2) symptoms precipitated by increased elbow flexion/positive elbow flexion tests, (3) positive Tinel sign at the medial elbow, (4) atrophy/weakness/ late findings (eg, claw hand of the ring/small finger and Wartenberg or Froment sign) of ulnar nerve-innervated muscles of the hand, (5) loss of two-point discrimination in ulnar nerve distribution, and (6) similar symptoms on the involved side after successful treatment on the contralateral side. Conclusions: Our study demonstrated a consensus among an expert panelist group of hand and upper-extremity surgeons on potential diagnostic criteria for CuTS. This consensus on diagnostic criteria may help clinicians readily diagnose CuTS in a standardized form; however, further weighting and validation are necessary prior to the development of a formal diagnostic scale. Clinical relevance: This study is the first step in producing a consensus on how to diagnose CuTS. 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

Mental and physical health disparities in patients with carpal tunnel syndrome living with high levels of social deprivation. Wright, et al. (2019) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Prognostic Topic : Social deprivation - Carpa tunnel outcomes This retrospective study assessed how neighborhood socioeconomic deprivation influences health outcomes in patients with carpal tunnel syndrome (CTS). A total of 367 patients with CTS were included in the present study. Area Deprivation Index, which ranks U.S. census tracts from most to least deprived, was included as a variable amongst patient‑reported outcomes were measuring physical function, pain interference, depression, and anxiety. Comorbidity burden and tobacco use were quantified by the Charlson Comorbidity Index and self‑report. The resultsh showed that patients residing in the most deprived areas reported significantly lower physical function and higher pain interference, depression, and anxiety compared with those in the least deprived areas. These results were maintained after adjusting for age, sex, employment type, and other covariates. 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, living in a highly deprived neighborhood is independently associated with worse physical function, greater pain interference, and higher depression and anxiety in patients with carpal tunnel syndrome. Even after controlling for age, sex, employment, comorbidities, and tobacco use, social deprivation remaines a significant predictor of poorer outcomes. These findings are in line with previous research showing that social deprivation is an importand social determinant of health in upper limb conditions . Clinicians should routinely assess patients’ socioeconomic context and integrate multidisciplinary resources (social work, mental‑health support, smoking‑cessation programs ) into treatment plans to address the broader determinants of health that hinder recovery and satisfaction. URL : https://doi.org/10.1016/j.jhsa.2018.05.019 Abstract Purpose: Social, mental, and physical health have a complex interrelationship with each influencing individuals’ overall health experience. Social circumstances have been shown to influence symptom intensity and magnitude of disability for a variety of medical conditions. We tested the null hypothesis that social deprivation would not impact Patient-Reported Outcomes: Measurement Information System (PROMIS) scores or objective health factors in patients presenting for treatment of carpal tunnel syndrome (CTS). Methods: This cross-sectional study analyzed data from 367 patients who presented for evaluation of CTS to 1 of 6 hand surgeons at a tertiary academic center between August 1, 2016, and June 30, 2017. Patients completed PROMIS Physical Function—v1.2, Pain Interference—v1.1, Depression—v1.0, and Anxiety—v1.0 Computer Adaptive Tests. The Area Deprivation Index was used to quantify social deprivation. Medical record review determined duration of symptoms, tobacco and opioid use, and the Charlson Comorbidity Index (CCI) for each patient. Sample demographics, PROMIS scores, and objective health measures were compared in groups defined by national quartiles of social deprivation. Results: Patients with CTS living in the most deprived quartile had worse mean scores across all 4 PROMIS domains compared with those living in the least deprived quartile. A higher proportion of individuals from the most deprived quartile had a heightened level of anxiety than those in the least deprived quartile (37.3% vs 12.6%). The mean CCI was higher in the most deprived quartile, as was the proportion of individuals using tobacco. There were no differences in opioid use or symptom duration between patients from each deprivation quartile. Conclusions: Social deprivation is associated with worse patient-reported health measures in patients with CTS. Compared with those from the least deprived areas, patients from the most deprived areas also have a greater comorbidity burden and higher rates of tobacco use at presentation to a hand surgeon. 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

Surgical management of double crush syndrome: Outcomes of cervical decompression with and without peripheral nerve release. Gullborg, et al. (2025) Level of Evidence: 2c Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Therapeutic Topic : Double crush syndrome - Cervical and peripheral nerve release This retrospective study assessed the surgical management of double crush syndrome by comparing outcomes between patients undergoing anterior cervical discectomy and fusion (ACDF) alone versus those receiving both ACDF and subsequent peripheral nerve decompression. A total of130 patients were included, with 66 in the ACDF-alone group and 64 in the bimodal decompression group. The results showed that the bimodal decompression group experienced significant improvements in physical examination metrics, including recovery of two-point discrimination, which was not observed in the ACDF-alone group. The bimodal group also presented with greater reductions in neck and arm pain scores compared to those receiving only ACDF. 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, double crush syndromes appear to benefit the most from release of all compression sites. This appears to improve both neurological findings and subjective symptoms compared to a cervical discectomy alone. These findings appear to be in line with other conservative treatment approaches that not only include management of the area of peripheral entrapment but also more proximal areas of potential compression . URL : https://doi.org/10.1016/j.jhsg.2025.100770 Abstract Purpose: Double crush syndrome involves two distinct compressive lesions along a single peripheral nerve. Patients with compressive neuropathies at the wrist and elbow may experience exacerbated symptoms from cooccurring cervical radiculopathy. Surgical management aims to decompress at either or both proximal and distal sites. This study compares outcomes of anterior cervical discectomy and fusion (ACDF) alone versus ACDF with subsequent peripheral nerve decompression. Methods: This retrospective study evaluated patients with double crush lesions, diagnosed with magnetic resonance imaging-confirmed cervical radiculopathy and carpal or cubital tunnel syndrome via electrodiagnostic confirmation. Two cohorts were matched and analyzed: (1) ACDF alone and (2) those with ACDF with subsequent peripheral nerve decompression. All procedures were performed at a single institution between 2004 and 2020, with a minimum 1-year follow-up. Postoperative symptoms, examination findings, patient-reported outcomes, and reoperations were compared. Results: Among 130 patients (66 receiving ACDF alone, 64 with additional peripheral nerve decompression), those with both procedures had a significantly longer duration of preoperative radicular/peripheral symptoms (29.2 months vs 18.3 months). At the latest follow-up, patients receiving ACDF alone had significantly more persistent numbness (42.4% vs 17.2%), nerve irritability (21.2% vs 4.7%), and reduced 2-point discrimination (20.3% vs 12.1%) when compared with those who had bimodal decompression. Patients receiving both procedures reported significantly greater improvements in visual analog scale neck pain (−5.62 vs −3.63), visual analog scale arm pain (−4.73 vs −3.54), and neck disability index scores (−17.50 vs −6.80). Conclusions: Isolated cervical decompression may be insufficient for double crush neuropathies. Treatment of both proximal and distal sites can provide superior pain and symptom relief. Management of compressive pathology at both sites should be strongly considered by treating surgeons. 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 local tenderness at the lacertus fibrosus in healthy people. Fang, et al. (2025) Level of Evidence: 4 Follow recommendation : 👍 👍 (2/4 Thumbs up) Type of study: Diagnostic/Symptoms Prevalence Study Topic : Lacertus fibrosus - Palpation This study assessed the incidence of tenderness over the lacertus fibrosus in healthy individuals and its implications for diagnosing lacertus syndrome. A total of 36 healthy adults (72 limbs) were included in the present study. Age ranged from 20 to 75 years old. Palpation of the lacertous fibrosus was defined as thumb pressure applied to this anatomical landmark for 5 seconds. The results showed that 14 limbs exhibited tenderness, with bilateral tenderness observed in two participants. There was also a higher incidence of tenderness among individuals over 60 years old compared to younger participants, though the small sample size limited definitive conclusions about age-related effects. 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 incidence of tenderness over the lacertus fibrosus in healthy individuals is 20%. In addition, utilising the contralateral limb as a comparison may not be particularly useful. There is some evidence that these pathologies exist ( Lacertus fibrosus and pronator teres ), as well as a cadaver studies looking at how this structure can cause higher levels of compression . However, it appears that palpation of the median nerve at these areas can be tender in asymptomatic subjects. URL : https://doi.org/10.1177/17531934251346595 Abstract In 36 healthy adults (72 arms), we found tenderness at the lacertus fibrosus in 14 limbs. Local tenderness in the area of the lacertus fibrosus alone may have no diagnostic value, and using the contralateral arm for comparison may not be reliable. 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

Anatomical reconstruction of the terminal tendon and lateral band for severe chronic tendon mallet injury. Suzuki, et al. (2025) Level of Evidence: 4 Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Therapeutic Topic : Chronic mallet finger - Surgical intervention This case series discusses various surgical treatments for chronic tendon mallet injuries. Thes surgical interventions were considered after conservative management, such as splinting or pinning, proved ineffective. The article reviews several techniques, including central slip tenotomy and tendon reconstructions. Central slip tenotomy involves releasing the central slip of the extensor tendon to allow dipj extension. Reconstruction of the terminal tendon is often performed with the palmaris longus and a bone anchor can be placed at the distal phalanx. Overall, eight out of eleven patients recovered with excellent to good dipj extension (less than 10deg of extension lag and less than 20deg of flexion loss. 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, surgery for chronic tendon mallet injuries may be valuable option when conservative management fails. Central slip tenotomy or terminal extensor tendon reconstruction with palmaris longus appear to be common surgical approaches . Remember to screen your patients with bony mallet, as not all of them appear to be amenable to conservative treatment. The concentric circle method appears to be feasible to assess these patients . URL : https://doi.org/10.1016/j.jhsa.2025.04.025 Abstract Purpose: This study aimed to evaluate the clinical outcomes of surgical treatment for chronic mallet injury with severe extension lag using an anatomic reconstruction of the terminal tendon and lateral band with a palmaris longus (PL) tendon graft. Methods: Eleven patients with a mean age of 52 years (range, 24–82 years) who underwent surgical reconstruction for chronic tendon mallet injuries using the PL tendon were included. The harvested PL tendon was either folded longitudinally or divided into two slips. The graft was secured to the distal phalanx using a bone anchor and sutured to the soft tissues and remnants of the original terminal tendon distal to the distal interphalangeal (DIP) joint. Each half-slip tendon was passed under the transverse retinacular ligament and sutured side-to-side to the lateral band at approximately the midpoint of the proximal phalanx. The active range of motion of the affected finger was evaluated before and after surgery, and any complications were recorded. Results: Before surgery, the extension of the DIP joint averaged −49.5° (range, −40° to −60°). The postoperative mean lag of the DIP joint improved to −7.8° (range, −20° to +20°). According to the Miller classification, four patients had excellent results, four had good results, and three had fair results. Two patients who underwent folded-PL tendon grafting developed superficial dorsal skin infections on the little finger that resolved with oral antibiotics or removal of the sutures. Conclusions: Anatomical reconstruction of the terminal tendon and lateral bands using a PL tendon graft yielded satisfactory outcomes in chronic tendon mallet injuries. Dividing the PL tendon into two slips is recommended to reduce the risk of postoperative infection. 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

Neck or shoulder? Establishing consensus for spine screening in patients with shoulder pain: An international modified delphi study. Requejo-Salinas, et al. (2025) Level of Evidence: 5 Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Diagnostic Topic : Cervical vs shoulder pain - Differentiating This expert opinion study utilised a three‑round modified Delphi process with a panel of 25 experienced clinicians to establish a consensus on a comprehensive, multifactorial screening protocol for shoulder and cervical spine disorders. Drawing on contemporary evidence, biomechanical, and neurophysiological concepts, the authors integrated patient history, pain distribution, and physical tests in a potential screening approach. In particular, previous history of neck pain, the presence of numbness in the upper limb, limitations in range of movement of the cervical spine, a positive Spurling test, and modification of upper limb symptoms with cervical positions or mobilisations increases the probability of the presentation being originating from the cervical spine. 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 positive Spurling test, limitations in cervical range of movement, modification and/or reproduction of upper limb pain with palpation, sustained position, or symptom modification procedure at the cervical spine help in the differentiation between cervical and peripheral origin of symptoms. All these suggestions seem to be in line with previous papers suggesting that sustained end range positions of the neck should be trialed to differentiate between cervical and peripheral origin of symptoms . Remember that if people present upper limb pain alongside numbness or neuropathic pain features, you should probably complete a neurological exam, which would include myotome testing , light touch assessment , deep tendon reflexes, and pinprick assessment . URL : https://doi.org/10.1093/ptj/pzae133 Abstract Objective: There is no established consensus for screening the spine in patients with shoulder pain. The aim of this study was to explore the role of the spine in shoulder pain and generate a set of recommendations for assessing the potential involvement of the spine in patients with shoulder pain. Methods: A modified Delphi study was conducted through use of an international shoulder physical therapist’s expert panel. Three domains (clinical reasoning, history, and physical examination) were evaluated using a Likert scale, with consensus defined as Aiken Validity Index ≥0.7. Results: Twenty-two physical therapists participated. Consensus was reached on a total of 30 items: clinical reasoning ( n  = 9), history ( n  = 13), and physical examination ( n  = 8). The statement that spinal and shoulder disorders can coexist, sometimes influencing each other and at other times remaining independent issues, along with the concept of radiating pain as an explanatory phenomenon for the spine contribution to shoulder pain, achieved the highest degree of consensus. Conclusion: International physical therapists shoulder experts reached consensus on key aspects when screening the spine in people with shoulder pain, including consideration of the distal location of symptoms relative to the shoulder, the presence or previous history of neck pain, the changes in symptoms related to neck movements, and the presence of neuropathic-like symptoms. They also acknowledged the importance of assessing active cervical or cervicothoracic movements and the usefulness of the Spurling test and symptom modification techniques applied to the spine. Impact: This consensus holds implications for both clinical practice and research. In research, applying these considerations may ensure more homogenous samples, thereby enhancing the investigation of outcomes in shoulder pain populations. In clinical practice, determining the need for spine screening and its potential impact on prognosis and management could significantly influence patient care. 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

Changes in hand function and health state utility after cubital tunnel release using the united kingdom hand registry. Teunissen, et al. (2025) Level of Evidence: 2c Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Therapeutic Topic : Cubital tunnel surgery - Symptomatic relief This prospective study assessed outcomes following cubital tunnel surgery using data from the UK Hand Registry. The researchers focused on improvements in quality of life and hand symptoms. More than 500 participants were included and the surgery performed involved either decompression alone or decompression plus transposition of the ulnar nerve. The results showed that symptom relief was significant at two months, however, after this, no significant changes were noted. In terms of health related quality of life, the surgery did not appear to provide significant benefits and based on these criteria, it would not be justified from a health economics point of view. 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, cubital tunnel surgery appear to provide some immediate improvements in hand symptoms (2 months) after which no major changes are obvious (6 months). It is important to remember that this surgery may be completed to avoid long term intrinsic strength impairments. Thus, people who wait for surgery for longer periods of time tend to present with worse outcomes . Pre-surgical consultations may be beneficial in these people to set their expectations . URL : https://doi.org/10.1177/17531934241275487 Abstract This study aimed to analyse and contrast changes in health-related quality of life (HR-QoL) and hand symptoms in the first 6 months after surgical treatment for primary cubital tunnel syndrome. Data originated from the United Kingdom Hand Registry. HR-QoL was assessed using the generic EuroQol five-dimensional assessment tool (EQ-5D-5L) and hand symptoms using the Patient Evaluation Measure (PEM). In total, 281 patients were included in the statistical analysis. Cubital tunnel release resulted in clinically relevant relief of hand symptoms. However, no improvement in HR-QoL was detected by the EQ-5D-5L. As a result, current health economic models, such as those used by the National Institute for Health Care Excellence (NICE) in the UK, might conclude that cubital tunnel release is not cost-effective. This discrepancy requires exploration, and hand-specific preference-based measures might be needed for value-based healthcare in hand surgery. 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

Postoperative management of total elbow arthroplasty: Results of a European survey among orthopedic surgeons. Dam, et al. (2025) Level of Evidence: 4 Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study : Therapeutic Topic : Total elbow replacements - Loading This survey assessed the postoperative management of Total Elbow Arthroplasty (TEA) among 54 orthopedic surgeons across 17 countries. Key findings revealed differences in immobilisation duration, activity restrictions, and protocols for primary versus revision surgeries. Nearly half of the respondents noted variations between primary and revision TEAs, with more restrictive measures often applied post-revision surgery. The research underscores the lack of consensus among surgeons, potentially contributing to low TEA survival rates due to complications like loosening, possibly linked to overloading. Seventy percent of the surgeons suggested a maximum elbow loading of 1-5 kgs and 10% deemed 1 to 10 kg loading being acceptable. 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 significant variability in terms of recommendations for Total Elbow Arthroplasty (TEA) loading. The large majority of surgeon suggest a maximum loading of 1-5 kg with the most adventurous suggesting that loading can reach 10 kg. Overall the survival rate of a TEA is 90% at 10 years . However, for males, it appears that TEA survival is significant lower, with a 50% chance of needing a revision after 10 years . As for the majority of upper limb presentations, those patients with a TEA and lower social determinants of health, tend to have worse outcomes . URL : https://doi.org/10.1371/journal.pone.0277662 Abstract Background: The number of complications after total elbow arthroplasty (TEA) is high and survival rates are low compared to hip and knee arthroplasties. The most common reason for revision is aseptic loosening, which might be caused by overloading of the elbow. In an attempt to lower failure rates, current clinical practice is to restrict activities for patients with a TEA. However, postoperative management of TEA is a poorly investigated topic, as no evidence-based clinical guidelines exist and the aftercare is often surgeon-based. In this study we evaluated the current postoperative management of TEA among orthopedic surgeons. Methods: An online survey of 30 questions was sent to 635 members of the European Society for Surgery of the Shoulder and the Elbow (SECEC/ESSSE), about 10% (n = ± 64) of whom are considered dedicated elbow specialists. The questions were on characteristics of the surgeon and on the surgeon’s preferred postoperative management, including items to be assessed on length of immobilization, amount of weight bearing and axial loading, instructions on lifelong activities, physiotherapy, and postoperative evaluation of the elbow. Results: The survey was completed by 54 dedicated elbow specialists from 17 different countries. Postoperative immobilization of the elbow was advised by half of respondents when using the triceps-sparing approach (52%), and even more with the triceps-detaching approach (65%). Postoperative passive movement of the elbow was allowed in the triceps-sparing approach (91%) and in the triceps-detaching approach (87%). Most respondents gave recommendations on weight bearing (91%) or axial loading (76%) by the affected elbow, but the specification shows significant variation. Conclusion: The results from this survey demonstrate a wide variation in postoperative care of TEA. The lack of consensus in combination with low survival rates stresses the need for clinical guidelines. Further research should focus on creating these guidelines to improve follow-up care for TEA. 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

Zone-specific pitfalls in flexor tendon rehabilitation: Management and prevention. Chinchalkar, et al. (2025) Level of Evidence: 5 Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Therapeutic Topic : Flexors repair - How to avoid adhesions This is an expert opinion on flexor tendon repair and rehabilitation. The authors highlight the complexity of these injuries and potential for functional impairment due to their intricate anatomy. Adhesions are one of the primary complications, which can hinder tendon gliding and lead to limited finger mobility. Early mobilisation, selective motion blocking splints, and specialised exercises (see figures and ideas below) are critical for restoring function and minimising these issues. Additionally, the article highlights specific complications like the Quadriga phenomenon (gapping of the tendon repair with lag of affected, or adhesion of affect side limiting finger flexion across affected and unaffected fingers), where excessive shortening or adhesions in one digit restricts movement in adjacent fingers, and Lumbrical plus (FDP avulsion/repair failure distal to lumbricals leading to pipj extension during finger flexion) causing paradoxical joint extension during flexion. Once established, this issues can necessitate surgical intervention, however, rehab has the potential to prevent them. ZONE I AND II - SCRATCH YOUR INDEX FINGER! ZONE III - GET THAT HOOK FIST GOING! ZONE IV and V - I AM AN INDEPENDENT FINGER! 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, early mobilisation, splinting, and exercises have all got strong evidence in their support following flexors repair. Early mobilisation (Level 1-2) is supported by numerous studies, including randomised controlled trials, showing effectiveness in preventing adhesion and promoting recovery. Motion-blocking splints (Level 1-2) have also large evidence from clinical studies supporting their protective role in tendon healing. Exercises as well (Level 1-2) are supported by strong evidence from both clinical and experimental studies. Zone-specific rehab protocols have varying level of evidence and there are no specific protocol for all zones. Remember that flexor tendon outcomes tend to be worse in people with lower social determinants of health and that Zone I and II tend to be at greater risk . Hence, we should monitor these people more closely. If you are interested in the topic, have a look at the entire dataset, we have lots of synopses and case reports! URL : https://doi.org/10.1177/17531934241265579 Abstract Despite significant advancements in flexor tendon repair techniques and rehabilitation strategies, achieving complete restoration of digital motion remains a formidable challenge. The most prevalent complications associated with tendon repair are the development of tendon adhesions and joint contractures. Left unaddressed, these complications can further lead to secondary pathomechanical changes, resulting in fixed deformities significantly affecting hand function. This review of zone-specific considerations in flexor tendon rehabilitation provides an in-depth analysis of the dynamics of tendon motion after repair and strategies to minimize common secondary complications. 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

Surgical treatments of post-traumatic elbow stiffness: A systematic review and meta-analysis. Khorram, et al. (2025) Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Therapeutic Topic : Post-traumatic elbow stiffness - Surgery This systematic review assessed the impact of surgical interventions have on elbow range of movement, pain, function, and complications for people with post-traumatic elbow stiffness. A total of 99 studies were included, with the majority being retrospective studies. The interventions analysed included arthroscopy, open arthrolysis with or without external fixation. The results showed that all interventions provided with statistically and clinically relevant improvement in range of movement, pain, and function. Complications were around 3%, however, open arthrolysis with external fixation had a much greater risk of nerve injury (9%) compared to open arthrolysis alone or arthroscopy. Figure 2. Forest plot of Range of Motion (ROM) improvement 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 interventions such as arthroscopy or open arthrolysis seem to have a large statistically significant and clinically relevant effect on improving pain, range of movement, and function in people with post-traumatic elbow stiffness . Those people undergoing external fixation seem to have a much greater risk of having a nerve lesion and should therefore be followed more closely. If you would like to determine which of your patients are more likely to benefit from this surgery, have a look at this prediction model . Have a look at the entire database on the topic! URL : https://doi.org/10.1016/j.jse.2025.05.004 Abstract Background: Surgeons may choose between open vs. arthroscopic arthrolysis to address a post-traumatic elbow stiffness (PTES) based on their proficiency in elbow arthroscopy, the ulnar nerve condition, the presence and location of heterotopic ossification, the degree of contracture, and the extent of articular surface damage. This systematic review and meta-analysis aims to compare the effectiveness, range of motion (ROM), and complication rates between open and arthroscopic release in patients with PTES. Methods: The Preferred Reporting Item for Systematic Reviews and Meta-Analyses guidelines were utilized to conduct a systematic review and meta-analysis on surgical treatment for PTES. Comprehensive search was conducted in PubMed, Web of Sciences, Medline, and Scopus from their inception to January 2024. A total of 3,278 records were screened, of which 99 studies on the adult population were included. Outcome variables were changes in the ROM, visual analog scale score, Mayo Elbow Performance Index, and complication rate. Surgical techniques were grouped as arthroscopic, open arthrolysis, and open arthrolysis with external fixator. Results: ROM, visual analog scale, and Mayo Elbow Performance Index improved in patients with PTES after all surgical techniques. Open arthrolysis with external fixation had the highest ROM improvement but also the highest rate of nerve injury. Other variables did not show statistically significant differences among the modalities. Conclusion: Since the overall results of open and arthroscopic arthrolysis for PTES are comparable, the surgeon's expertise and the patient's condition are more important factors to consider when choosing a surgical technique over another. 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