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The effect of scapular muscle strengthening on functional recovery in patients with lateral elbow tendinopathy: A pilot randomized controlled trial. Day, J. M., et al. (2021). Level of Evidence : 2b Follow recommendation : 👍 👍 Type of study : Therapeutic Topic : Lateral epicondylalgia - Scapular strengthening This is a pilot randomised controlled trial assessing the effectiveness of local interventions (elbow) vs local interventions plus scapular strengthening for lateral epicondylalgia (LE). A total of 21 participants were included in the study. To be included, participants had to be experiencing symptoms at the lateral elbow during the following test: gripping with the elbow in extension, resisted middle finger or wrist extension, palpation at the lateral epicondyle, or stretching of the wrist extensors. Participants also had to present with a grip strength deficit of at least 8% in elbow extension compared to flexion and pain measured through the patient related tennis elbow evaluation questionnaire (PRTEE) had to be at least 3/50. Participants were excluded if they presented with neck or arm symptoms, if they presented with neurological symptoms, or had received a cortisone injection in the previous three months. Participant were randomised to local interventions (n = 14), or local interventions plus scapular strengthening exercises (n = 7). Local interventions included activity modification, the use of a counterforce brace, manual therapy (mobilisation with movement - see this previous synopsis on their effectiveness ), physical modalities (e.g. icing), stretching and wrist extensors strengthening exercises. The group that performed additional scapular strengthening performed serratus anterior exercises (push up position), and an isometric triceps hold in supine while holding light weights (see picture below). Efficacy of intervention was assessed through the PRTEE questionnaire at baseline, after 4-6 weeks of treatment, 6 months, and 12 months. Treatment frequency was not standardised. Compliance with the home exercise program was not reported. The results showed that the average number of treatment provided within 4-6 weeks was 8. No difference between the two treatment groups (local vs local plus shoulder strengthening) was reported on the PRTEE. Both groups improved to the same extent. 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 adjunct of general upper limb exercises provides no additional benefits compared to local elbow treatments in clients with lateral epicondylalgia. During the acute phase of LE, tendon unloading may be more appropriate through rest/activity modification or the use of a counterforce splint (see previous synopses on splint effectiveness and biomechanics ). During the disrepair/degenerative phase of LE (sub acute/chronic - see previous synopsis on tendinopathy grading and treatment ), graded resistance training of the wrist extensors alone may be enough to improve function and reduce pain. Open access URL : https://doi.org/10.1123/jsr.2020-0203 Abstract CONTEXT: There is a lack of consensus on the best management approach for lateral elbow tendinopathy (LET). Recently, scapular stabilizer strength impairments have been found in individuals with LET. OBJECTIVE: The purpose of this study was to compare the effectiveness of local therapy (LT) treatment to LT treatment plus a scapular muscle-strengthening (LT + SMS) program in patients diagnosed with LET. DESIGN: Prospective randomized clinical trial. SETTING: Multisite outpatient physical therapy. PATIENTS: Thirty-two individuals with LET who met the criteria were randomized to LT or LT + SMS. INTERVENTIONS: Both groups received education, a nonarticulating forearm orthosis, therapeutic exercise, manual therapy, and thermal modalities as needed. Additionally, the LT + SMS group received SMS exercises. MAIN OUTCOME MEASURE: The primary outcome measure was the patient-rated tennis elbow evaluation; secondary outcomes included global rating of change (GROC), grip strength, and periscapular muscle strength. Outcomes were reassessed at discharge, 6, and 12 months from discharge. Linear mixed-effect models were used to analyze the differences between groups over time for each outcome measure. RESULTS: The average duration of symptoms was 10.2 (16.1) months, and the average total number of visits was 8.0 (2.2) for both groups. There were no significant differences in gender, age, average visits, weight, or height between groups at baseline (P > .05). No statistical between-group differences were found for any of the outcome measures. There were significant within-group improvements in all outcome measures from baseline to all follow-up points (P < .05). CONCLUSION: The results of this pilot study suggest that both treatment approaches were equally effective in reducing pain, improving function, and increasing grip strength at discharge as well as the 6- and 12-month follow-ups. Our multimodal treatment programs were effective at reducing pain and improving function up to 1 year after treatment in a general population of individuals with LET.

The effects of taping combined with wrist stabilization exercise on pain, disability, and quality of life in postpartum women with wrist pain: A randomized controlled pilot study. Jung, K. S., et al. (2021) Level of Evidence : 2b Follow recommendation : 👍 👍 👍 Type of study : Therapeutic Topic : De Quervain tenosynovitis - Resistance training This is a pilot randomised controlled trial assessing the effectiveness of taping and exercises in participants with De Quervain tenosynovitis. Participants (N = 45) were diagnosed with De Quervain if they had pain on the radial side of the wrist, pain greater than 3/10 (VAS), and if they had given birth within the past year. Participants were excluded if they were undergoing any other treatments or if they were taking painkillers. Effectiveness of treatment was assessed through the VAS for pain and the DASH score for function. These outcomes were assessed before treatment and at the end of treatment (8 weeks). Participants were not blinded to treatment allocation. Participants were randomised to a resisted isometric exercises plus taping group (n = 15), resisted isometric exercises alone (n = 15), or a control group performing passive range of movement exercise (n = 15). The resisted isometric exercises included wrist extensors, flexors, radial deviators, ulnar deviators (with therabands) as well as shoulder isometric exercises while holding a dumbbell (0.5 to 2 kg) in shoulder flexion, extension, abduction, and adduction (see picture below). All the exercises were performed for three sets of 10 repetitions. Each isometric repetition was held for 10 seconds. Participants in the passive range of movement exercises performed the same movements without any resistance and held the positions for the same length of time. The exercises were performed once per day, 5 days/week for 8 weeks. Participants were reviewed once per week by a physiotherapist. For the exercises plus tape group, kinesiotape was applied to the radial side of the wrist on the volar and ulnar aspect of the forearm and wrist. The results showed that both resisted isometric exercises plus taping and resisted isometric exercises alone significantly improved pain or function from baseline to 8 weeks after treatment. However, only pain improved to a level that would be deemed clinically relevant. In addition, resisted isometric exercises plus taping provided greater pain relief (statistically and clinically significant) compared to isometric exercises alone. No improvements were noted with passive range of movement exercise. 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, resisted exercises of the wrist and shoulder plus wrist taping provide greater pain relief than resistance exercises alone for De Quervain tenosynovitis in postpartum clients. In addition, resistance exercises with or without taping provide greater pain relief than passive ROM exercises. It is possible that taping or splinting would have a similar effect and we could therefore choose whichever modality we prefer. It appears however clear that loading the wrist's tendon with resisted exercises (in this case isometric) is an important aspect of treatment of these clients. This is in line with previous research showing that graded resistance exercises appear to be effective in the treatment of tendinopathies , once the reactive stage (acute phase) has settled. Open access URL : https://www.mdpi.com/1660-4601/18/7/3564 Abstract The purpose of this study was to evaluate the effects of wrist stabilization exercise combined with taping on wrist pain, disability, and quality of life in postpartum women with wrist pain. Forty-five patients with wrist pain were recruited and randomly divided into three groups: wrist stabilization exercise + taping therapy (WSE + TT) group (n = 15), wrist stabilization exercise (WSE) group (n = 15), and control group (n = 15). The WSE + TT and WSE groups performed wrist stabilization exercises for 40 min (once a day, five times a week for eight weeks), and the control group performed passive range of motion (P-ROM) exercise for the same amount of time. Additionally, the WSE + TT group attached taping to the wrist and forearm during the training period. The visual analogue scale (VAS) was used to assess pain level of the wrist. The Disabilities of the Arm, Shoulder and Hand (DASH) and the Short Form-36 (SF-36) were used to evaluate the degree of wrist disability and quality of life, respectively. The WSE + TT group showed a significant decrease in wrist pain and functional disability compared to two groups (p < 0.05). Significant improvement in the SF-36 score was observed in the WSE + TT and WSE groups compared to that in the control group (p < 0.05). However, there was no significant difference between the WSE + TT and WSE groups in the SF-36. Our findings indicate that wrist stabilization exercise combined with taping is beneficial and effective in managing wrist pain and disability in postpartum women with wrist pain.

Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: A randomized controlled trial. Coombes, B. K., L. Bisset, P. Brooks, A. Khan and B. Vicenzino (2013). Level of Evidence : 1b Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Lateral epicondylalgia - cortisone injections This is a randomised placebo controlled trial assessing the effectiveness of cortisone injections for lateral epicondylalgia (LE). A total of 165 participants were included in the study. To be included, participants had to been experiencing symptoms for at least six weeks. Pain had to be unilateral, intensity of at least 3/10, had to be located at the lateral epicondyle of the elbow and participants had to present with at least two of the following: pain on gripping, resisted middle finger or wrist extension, palpation at the lateral epicondyle, or stretching of the wrist extensors. Participants were excluded if they presented with neck or arm symptoms, if they presented with neurological symptoms, had receive cortisone injections or physiotherapy in the previous six and three months respectively for LE. Participant were randomised to cortisone injection alone (n = 43), saline injection alone (placebo) (n = 41), physiotherapy with cortisone injection (n = 40), or physiotherapy with saline injection (n = 41). Physiotherapy included 8 sessions of thirty minutes each over the course of 8 weeks. These included manual therapy (mobilisation with movement - see this previous synopsis on their effectiveness ) or graded progression of concentric and eccentric exercises for the wrist extensors. Efficacy of intervention was assessed by self reported complete recovery and recurrence at one year. The results showed that 93% of participants had recovered in the placebo group compared to 83% in the corticosteroid injection group. In addition, participants undergoing corticosteroid injections had a significant improvement at 4-8 weeks followed by a greater recurrence of symptoms at one year (55% recurrence) compared to the placebo injection group (20%). Both these results were statistically significant. There was no difference between the physiotherapy vs no physiotherapy groups at one year follow up. 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, corticosteroid injections for lateral epicondylalgia hinder our clients' recovery and increase the recurrence rate in the long term (one year). It may be better to provide our clients with a course of physiotherapy, which does not hinder recovery and may facilitate return to function in clients with severe pain . Graded resistance training may be appropriate in the disrepair/degenerative phase of LE (sub acute/chronic - see previous synopsis on tendinopathy grading and treatment ). During the acute phase, tendon unloading may be more appropriate through rest or the use of a counterforce splint (see previous synopses on splint effectiveness and biomechanics ). Open access URL : https://jamanetwork.com/journals/jama/fullarticle/1568252 Abstract Importance: Corticosteroid injection and physiotherapy, common treatments for lateral epicondylalgia, are frequently combined in clinical practice. However, evidence on their combined efficacy is lacking. Objective: To investigate the effectiveness of corticosteroid injection, multimodal physiotherapy, or both in patients with unilateral lateral epicondylalgia. Design, setting, and patients: A 2 × 2 factorial, randomized, injection-blinded, placebo-controlled trial was conducted at a single university research center and 16 primary care settings in Brisbane, Australia. A total of 165 patients aged 18 years or older with unilateral lateral epicondylalgia of longer than 6 weeks' duration were enrolled between July 2008 and May 2010; 1-year follow-up was completed in May 2011. Interventions: Corticosteroid injection (n = 43), placebo injection (n = 41), corticosteroid injection plus physiotherapy (n = 40), or placebo injection plus physiotherapy (n = 41). Main outcome measures: The 2 primary outcomes were 1-year global rating of change scores for complete recovery or much improvement and 1-year recurrence (defined as complete recovery or much improvement at 4 or 8 weeks, but not later) analyzed on an intention-to-treat basis (P < .01). Secondary outcomes included complete recovery or much improvement at 4 and 26 weeks. Results: Corticosteroid injection resulted in lower complete recovery or much improvement at 1 year vs placebo injection (83% vs 96%, respectively; relative risk [RR], 0.86 [99% CI, 0.75-0.99]; P = .01) and greater 1-year recurrence (54% vs 12%; RR, 0.23 [99% CI, 0.10-0.51]; P < .001). The physiotherapy and no physiotherapy groups did not differ on 1-year ratings of complete recovery or much improvement (91% vs 88%, respectively; RR, 1.04 [99% CI, 0.90-1.19]; P = .56) or recurrence (29% vs 38%; RR, 1.31 [99% CI, 0.73-2.35]; P = .25). Similar patterns were found at 26 weeks, with lower complete recovery or much improvement after corticosteroid injection vs placebo injection (55% vs 85%, respectively; RR, 0.79 [99% CI, 0.62-0.99]; P < .001) and no difference between the physiotherapy and no physiotherapy groups (71% vs 69%, respectively; RR, 1.22 [99% CI, 0.97-1.53]; P = .84). At 4 weeks, there was a significant interaction between corticosteroid injection and physiotherapy (P = .01), whereby patients receiving the placebo injection plus physiotherapy had greater complete recovery or much improvement vs no physiotherapy (39% vs 10%, respectively; RR, 4.00 [99% CI, 1.07-15.00]; P = .004). However, there was no difference between patients receiving the corticosteroid injection plus physiotherapy vs corticosteroid alone (68% vs 71%, respectively; RR, 0.95 [99% CI, 0.65-1.38]; P = .57). Conclusion and relevance: Among patients with chronic unilateral lateral epicondylalgia, the use of corticosteroid injection vs placebo injection resulted in worse clinical outcomes after 1 year, and physiotherapy did not result in any significant differences.

Diagnostic accuracy of examination tests for lateral elbow tendinopathy (LET) – A systematic review. Karanasios, S., et al. (2021) Level of Evidence : 3a Follow recommendation : 👍 👍 Type of study : Diagnostic Topic : Tennis elbow - Physical test This is a systematic review on the specificity and sensitivity of tennis elbow tests. If a test is very sensitive and its result is negative, you can be more certain that the patient does not have the condition. If the test is specific and its result is positive, you can be more certain that the patient has the condition. Twenty-four diagnostic studies were included in the systematic review, for a total of 7,454 participants. These studies were assessed through the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) criteria. The overall strength of evidence was not assessed. The two studies assessing the usefulness of the physical tests were compared against the "gold standard" of tenderness on palpation of the lateral epicondyle. The results showed that the Cozen't test had the highest sensitivity (91%; 95%CI : 81-96%) whilst a 10% reduction in grip strength from elbow flexion to extension had a reasonable sensitivity (83%) and specificity (93%). The limitation of this study is the lack of an appropriate gold standard. At the moment, we only know the specificity and sensitivity of these tests when compared to tenderness on palpation at the lateral epicondyle. We don't know whether they are able to discriminate against other pathologies of the elbow. 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 10% reduction in grip strength from elbow flexion to extension may be useful in identifying clients with tennis elbow. Unfortunately, no studies have assessed this or other tests against a gold standard. The problem with "gold standard" for painful tendinopathies is that there is not such a thing. As a matter of fact, findings from US or MRI showing tissue changes within the common extensor tendon do not necessary correlate with symptoms. If you would like more information on staging and treatment of tendinopathies, have a look at this synopsis . URL : https://doi.org/10.1016/j.jht.2021.02.002 Available through The Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Background: Reviews on the diagnostic performance of the examination tests for lateral elbow tendinopathy (LET) based on updated context-specific tools and guidelines are missing. Purpose: To review the diagnostic accuracy of examination tests used in LET. Design: Systematic review following PRISMA-DTA guidelines. Methods: We searched MEDLINE, PubMed, CINAHL, EMBASE, PEDro, ScienceDirect, and Cochrane Library databases. The QUADAS-2 checklist was used to assess the methodological quality of the eligible studies. We included diagnostic studies reporting the accuracy of physical examination tests or imaging modalities used in patients with LET. Results: Twenty-four studies with 1370 participants were identified reporting the diagnostic performance of Ultrasound Imaging (USI) (18 studies), physical examination tests (2 studies) and Magnetic Resonance Imaging (MRI) (4 studies). Most studies (97%) were assessed with “unclear” or “high risk” of bias. Sonoelastography showed the highest sensitivity (75- 100%) and specificity (85- 96%). Grayscale with or without Doppler USI presented poor to excellent values (sensitivity: 53%-100%, specificity: 42%-90%). MRI performed better in the diagnosis of tendon thickening and enthesopathy (sensitivity and specificity: 81%-100%). The Cozen's test reported high sensitivity (91%) while a grip strength difference of 5%-10% between elbow flexion and extension showed high sensitivity (78%-83%) and specificity (80%-90%). Conclusions: Cozen's test and grip strength measurement present high accuracy in the diagnosis of LET but are poorly investigated. USI and MRI provide variable diagnostic accuracy depending on the entities reported and should be recommended with caution when differential diagnosis is necessary. Substantial heterogeneity was found in inclusion criteria, operator/ examiner, mode of application, type of equipment and reference standards across the studies.

Patients with higher treatment outcome expectations are more satisfied with the results of nonoperative treatment for thumb base osteoarthritis: A cohort study. Hoogendam, L., et al. (2021) Level of Evidence : 2b Follow recommendation : 👍 👍 👍 Type of study : Therapeutic Topic : Thumb osteoarthritis - Expectations and treatment outcomes This is a prospective, multi-centre study assessing the effect of psychological variables on conservative treatment satisfaction of participants with thumb osteoarthritis (OA). Participants (N = 308) were diagnosed with thumb OA by a hand surgeon based on a clinical and radiological assessment. Psychological variables were assessed at baseline and 3 months after initiation of conservative treatment. Participants' treatment expectations were measured at baseline through the Credibility and Expectancy Questionnaire (CEQ - see figure below from the paper by Devilly et al., 2000 ). Each item in this questionnaire was scored between 1 and 9, with greater scores representing greater credibility/positive expectation from treatment. Participants' treatment satisfaction was measured by asking them how satisfied they were with the intervention provided (this was scored as excellent, good, fair, moderate or poor). All participants received a splint for immobilisation of the thumb and were provided exercises to maintain range of movement and improve strength of the thumb muscles. However, treatment was not standardised and hand therapist could deviate from the treatment protocol if they deemed it necessary during the three months of conservative intervention. The results showed that treatment expectations (not credibility) increased the likelihood of treatment satisfaction while controlling for other confounding variables (e.g. pain catastrophising). 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, clients' expectation significantly contribute to the conservative treatment satisfaction in thumb OA. This is probably why multimodal interventions for thumb OA perform slightly better than unimodal interventions in these clients. Thus, a larger number of interventions may increase clients' expectation and therefore treatment outcomes. Considering that a recent large multi-crentred RCT found splinting to have no greater effect than a placebo splint in thumb OA, it is possible that the type of conservative treatment is irrelevant for treatment satisfaction. We may however indulge our clients with a splint if they strongly believe that a splint will help them, as trying to convince them otherwise may be counterproductive (despite the evidence). Independently of whatever conservative approach we choose, we could encourage joint motion for lotion , promote joint movement for amusement , and suggest meditation for elation . Supplements for osteoarthritis have shown some small but statistically significant effects compared to placebo on pain and they may be an alternative if clients do not want to perform exercises. Also remember: keep smiling , your clients' pain will decrease! Open access URL : https://doi.org/10.1016/j.apmr.2021.01.080 Available through EBSCO Health Databases for PNZ members. Abstract Objective: To investigate how satisfaction with treatment outcome is associated with patient mindset and Michigan Hand Outcome Questionnaire (MHQ) scores at baseline and 3 months in patients receiving nonoperative treatment for first carpometacarpal joint (CMC-1) osteoarthritis (OA). Design: Cohort study Setting: A total of 20 outpatient locations of a clinic for hand surgery and hand therapy in the Netherlands. Participants: Patients (N=308) receiving nonoperative treatment for CMC-1 OA, including exercise therapy, an orthosis, or both, between September 2017 and February 2019. Interventions: Nonoperative treatment (ie, exercise therapy, an orthosis, or both) Main Outcome Measures: Satisfaction with treatment outcomes was measured after 3 months of treatment. We measured total MHQ score at baseline and at 3 months. As baseline mindset factors, patients completed questionnaires on treatment outcome expectations, illness perceptions, pain catastrophizing, and psychological distress. We used multivariable logistic regression analysis and mediation analysis to identify factors associated with satisfaction with treatment outcomes. Results: More positive pretreatment outcome expectations were associated with a higher probability of being satisfied with treatment outcomes at 3 months (odds ratio, 1.15; 95% confidence interval, 1.07-1.25). Only a relatively small part (33%) of this association was because of a higher total MHQ score at 3 months. None of the other mindset and hand function variables at baseline were associated with satisfaction with treatment outcomes. Conclusions: This study demonstrates that patients with higher pretreatment outcome expectations are more likely to be satisfied with treatment outcomes after 3 months of nonoperative treatment for CMC-1 OA. This association could only partially be explained by a better functional outcome at 3 months for patients who were satisfied. Health care providers treating patients nonoperatively for CMC-1 OA should be aware of the importance of expectations and may take this into account in pretreatment counseling.

Neuritis ossificans of the ulnar nerve at the elbow: A case report. Sammons, M., I. Tami and T. Giesen (2021) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic/Therapeutic This is the answer for last week Sherlock Handy. The patient was a 76 years old female who had been experiencing cubital tunnel syndrome in the last 3 years. Objectively, the client reported allodynia at light touch of the elbow. In addition, Tinel's sign at the cubital tunnel was positive, and elbow flexion immediately caused numbness in the ulnar hand. Nerve conduction test were positive for a cubital tunnel syndrome. During surgery for cubital tunnel release, a 5x5x5 mm mass was identified and removed (see picture below). Histological examination of the mass revealed it to be a calcified nodule of hyaline tissue. The patient was neurovascularly intact post surgery and no recurrence occurred at the 6 months follow up. 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, space occupying lesions may be responsible for cubital tunnel syndrome. The prevalence of a space occupying lesion causing cubital tunnel syndrome has been suggested to be relatively uncommon (7% of all cases). US imaging may be a useful tool in helping identifying them . URL : https://doi.org/10.1177/1753193421999777 Available through EBSCO Health Databases for PNZ members. No abstract available

Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic/Therapeutic Have a think about this case study. Leave a diagnostic comment if you like. I will publish the diagnosis reported by the paper next week. The patient was a 76 years old female who had been experiencing cubital tunnel syndrome in the last 3 years. Objectively, the client reported allodynia at light touch of the elbow. In addition, Tinel's sign at the cubital tunnel was positive and elbow flexion immediately caused numbness in the ulnar hand. Nerve conduction test were positive for a cubital tunnel syndrome. During surgery for cubital tunnel release, a 5x5x5 mm mass was identified and removed (see picture below). What was it?

Distal biceps provocation test. Caekebeke, P., E. Schenkels, S. N. Bell and R. van Riet (2021) Level of Evidence : 2b Follow recommendation : 👍 👍 Type of study : Diagnostic Topic : Biceps tendon pathology - Physical test This is a cross sectional study on the specificity and sensitivity of the distal Biceps Provocation Test (BPT). If a test is very sensitive and its result is negative, you can be more certain that the patient does not have the condition. If the test is specific and its result is positive, you can be more certain that the patient has the condition. A total of 60 participants were included in the present study. Of these, 30 presented with a clinical picture suggestive of distal biceps tendon pathology whilst the remaining 30 with a suspect of other elbow pathologies (e.g. tennis elbow). The BPT consisted in resisted elbow flexion in supination and pronation (see picture below). The BPT was deemed positive when it caused more pain in pronation compared to supination. MRI or arthroscopic were utilised as the gold standard against which the physical tests were assessed. The results showed that the BPT was 100% specific and sensitive to include or exclude the presence of a distal biceps tendon pathology, which included tendinopathies and partial tendon tears. There is however a limitation in the study. In particular, tests are never 100% sensitive and specific. It is therefore possible that when applied in clinical practice, in a more heterogeous group of clients, this test will present with a certain degree of false positive and negative. 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 biceps provocation test may be a useful test in the identification of distal biceps tendon pathology (e.g. tendinopathy). This test is unlikely to be useful when we suspect a full distal biceps tendon rupture where a hook test may be more appropriate. If the clinical picture and the biceps provocation test suggest the presence of a Tendinopathy, reduction in loading may be appropriate, followed by graded loading . URL : https://doi.org/10.1016/j.jhsa.2020.12.012 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Purpose: To describe and study a test for distal biceps tendon pathology other than complete tears. Methods: In this prospective study, the biceps provocation test (BPT) was performed in a cohort of 30 patients with suspected distal biceps tendon pathology and 30 patients with another elbow pathology. Patients with a complete tear were excluded. Diagnosis was confirmed on magnetic resonance imaging or from surgical findings. The BPT is a 2-part test. The elbow is flexed to 70° with the forearm supinated. The examiner’s hands are placed on the patient’s forearm and the patient is asked to flex the elbow against resistance (BPTs). The forearm is then pronated and the test is repeated (BPTp). Pain is documented for both supination and pronation using a visual analog scale from 0 to 10. The test is positive when the patient indicates an increase in pain with BPTp compared with BPTs. Results: The BPT was positive in all patients with distal biceps tendon pathology. The average visual analog scale score in this group was 1 (range, 0–7) for the supinated part of the test (BPTs) and 7 (range, 4–10) with the forearm in pronation (BPTp), with an average increase of 5 points (range, 2–8). This difference was significant. No significant difference was found in the control group. Among the controls, BPTp and BPTs were rated as equally painful by 27 patients, and BPTp was less painful than BPTs in 3. Sensitivity and specificity were both 100% in this small group of 60 patients, with a high prevalence of distal biceps tendon pathology. Conclusions: The BPT appears to be highly sensitive and specific for distal biceps partial injury or tendinitis.

Applying evidence to inform carpal tunnel syndrome care. Giladi, A. M., I. C. Lin, K. R. Means, Jr. and S. A. Kennedy (2021) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic Topic : Carpal tunnel syndrome - Physical tests This is a viewpoint on the specificity and sensitivity of symptoms and physical tests for carpal tunnel syndrome (CTS). If a test is very sensitive and its result is negative, you can be more certain that the patient does not have the condition. If the test is specific and its result is positive, you can be more certain that the patient has the condition. The symptoms and diagnostic tests discussed were the ones included in the CTS-6 diagnostic tool and included: numbness in median nerve distribution, night numbness, thenar atrophy/weakness, positive Phalen's test, loss of 2-points discrimination, positive Tinel's test (see figure below). Nerve conduction studies were utilised in a previous study as a gold standard to validate the diagnostic accuracy of the CTS-6. It has be suggested that the use of the CTS-6 is useful in screening or making a diagnosis of moderate/severe CTS. In particular, a score on the CTS-6 equal or greater to 12 suggests the presence of CTS (probability greater than 80%). A score equal or lower than 5 suggests the absence of CTS (less than 25% probability). 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 use of CTS-6 may be useful to exclude or make a diagnosis of a moderate to severe CTS. It is important to remember that the CTS-6 is useful to suggest or exclude the presence of a moderate/severe CTS only. It is very possible that clients with a mild CTS will score very low on the CTS-6. People with a mild CTS can still present with severe pain but low sensory and/or motor loss. The sparing of motor function in CTS may also be due to the presence of a Martin-Gruber or Riche‐Cannieu anastomosis , which provide motor innervation of the thenar muscles bypassing the carpal tunnel. If you are interested in better understanding the repercussions of mild vs severe entrapment neuropathies have a look at these synopses on clinical presentation and a recent update on the diagnostic tools available . URL : https://www.jhandsurg.org/article/S0363-5023(20)30534-7/fulltext Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Carpal tunnel syndrome (CTS) is one of the most common problems treated by hand surgeons. As our understanding of the condition has improved and focus on quality and evidence-based care has evolved, management of CTS has shifted as well. Although for many patients the diagnosis and treatment plan are relatively straightforward, understanding how to decide what diagnostics are appropriate, how to avoid complications especially in high-risk patients, and even which surgical option to offer remains a challenge. As CTS research efforts broaden and available evidence grows, understanding the different research findings in order to implement the evidence into practice is critical for all surgeons. In this article, we approach commonly encountered challenges in CTS management and take a methodological viewpoint to guide evidence-based practice.

The non-operative management of bony mallet injuries. Trickett, R. W., J. Brock and D. J. Shewring (2021) Level of Evidence : 2c Follow recommendation : 👍 👍 👍 Type of study : Therapeutic, Prognostic Topic : Bony mallet - Conservative vs surgical treatment This is a retrospective study assessing the outcomes of splinting in participants with and without bony mallet fragments greater than 1/3 of the articular surface and joint subluxation. A total of 211 participants were included in the present study. Of these, 168 fingers presented with joint congruency and 50 with joint subluxation (11 participants had two fingers affected by bony mallets). The bony fragment was 1/3 of the joint surface or larger in 60% of the participants (n = 126). Participants with bony mallet of the thumb were included. Treatment outcome was assessed by extension lag of the dipj and pain (0 to 10 VAS). Extension lag was assessed at baseline and at discharge. After inclusion in the study, all participants were provided with a custom made splint. The results showed that there were no differences in dipj lag and pain between participants with dipj joint subluxation (Median: 9°; Interquartile range: 3° to 14°) and without dipj joint subluxation (Median: 19°; Interquartile range: 7° to 21°). I also ran a chi-square on the prevalence of lag at discharge between participants who presented with and without joint subluxation and there was no difference between the two (in both subgroups, the prevalence of a dipj lag at discharge was 20%). One of the limitation of the study was that "dipj lag" was not defined in the methods section. However, considering the interquartile range reported for people with a lag, they might have classified a lag as any loss of extension beyond 0°. 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, joint subluxation and fragment size of bony mallet injuries may not be as useful in determining the need for surgical intervention. Thus, the outcomes of conservatively treated bony mallet do not appear to differ significantly based on these features. The prevalence of dipj lag at discharge is similar between the two subgroups and is around 20%. We can therefore advise our clients that 1 out of 5 people with a bony mallet will present with a dipj lag at discharge. Among those who develop it, the lag may be larger in those who initially present with a joint subluxation, however, due to the large variability in outcomes, this does not appear to be significant. These results are supported by previous evidence , although if you are uncertain, you can always refer your clients for a follow up x-ray with the finger splint in place. If you are interested in hand fractures and want to read a synopsis on the topic, here is the link . URL : https://doi.org/10.1177/1753193421992986 Available through EBSCO Health Databases for PNZ members. Abstract Over a 4-year period, 218 mallet fractures in 211 adult patients were treated using a custom-made thermoplastic splint. Clinical results were collected prospectively, including the visual analogue score for pain, the range of motion and extensor lag, and the Patient Evaluation Measure (PEM). The joints were congruent in 168 and subluxed in 50. There were no differences in range of movement, extensor lag or PEM associated with articular subluxation or the size of the articular fragment. Pre-existing joint degeneration did not influence outcome. Non-surgical treatment demonstrates predictably good outcomes regardless of fragment size or subluxation in most patients and should be considered when discussing treatment for patients with bony mallet fractures.

Somatosensory and psychological phenotypes associated with neuropathic pain in entrapment neuropathy. Matesanz, L., A. C. Hausheer, G. Baskozos, D. L. H. Bennett and A. B. Schmid (2021). Level of Evidence : 2a Follow recommendation : 👍 👍 Type of study : Symptoms prevalence Topic : Neuropathic pain in CTS - Symptoms severity and psychological phenotypes This cross-sectional cohort study assessed whether there was a difference in clinical and emotional characteristics of participants with neuropathic pain and non-neuropathic pain (diagnosed through the Douleur Neuropathique 4 - DN4) associated with carpal tunnel syndrome (CTS). Peripheral neuropathic pain is a clinical description (not a diagnosis), which has been defined by the International Association for the Study of Pain (IASP) as pain associated with pathology of the peripheral somatosensory nervous system (e.g. objective impairment in nerve conduction in CTS). A total of 108 participants with objective evidence of CTS nerve conduction impairments were included. A group of age and sex matched healthy controls (n = 32) were included. The CTS group was subdivided in participants presenting with neuropathic pain features (DN4 score greater or equal to 4) and non-neuropathic pain features (DN4 score lower than 4 - pain more likely to be nociceptive in nature). The clinical tests and signs assessed in the study included the Tinel's test at the carpal tunnel, Phalen's test, Carpal compression test, thenar muscle atrophy, and abductor pollicis brevis strength (manual muscle test). Participants' depression, anxiety, pain catastrophising and sleep quality were assessed through questionnaires. The results showed that most participants with CTS presented with neuropathic pain (positive on DN4 questionnaire) (80%). A smaller proportion of participants with CTS (20%) presented with a clinical presentation more indicative of nociceptive pain (negative on DN4 questionnaire). There were no differences between participants with or without neuropathic pain on the clinical tests analysed. Anxiety and pain catastrophising were higher in the CTS group compared to healthy controls (see picture below). Of interest, participants with neuropathic pain features had a wider spread of pain compared to participants with nociceptive pain features. 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, clinical tests for CTS cannot discriminate between nociceptive and neuropathic pain features in our clients with objective evidence of CTS . The DN4 appears to be the best tool to identify clients with neuropathic pain characteristics and it only takes 5 minutes to complete. Once we identify clients presenting with neuropathic pain, we may be able to implement interventions such as splinting and wrist exercises in addition to mild to moderate aerobic exercise as a potentially effective treatment. Clients presenting with a more nociceptive pain phenotype, may benefit more from a biomechanical approach which limits the extremes of wrist movement . At this point in time, it does not appear that neuropathic pain medications (e.g. gabapentin) should be suggested for clients with CTS . However, this advice may change in the future if further research suggests their usefulness in clients with severe neuropathic pain associated with CTS. Open Access URL : https://journals.lww.com/pain/Abstract/9000/Somatosensory_and_psychological_phenotypes.98228.aspx Abstract It currently remains unclear why some patients with entrapment neuropathies develop neuropathic pain (neuP), whereas others have non-neuP, presumably of nociceptive character. Studying patients with carpal tunnel syndrome (CTS), this cross-sectional cohort study investigated changes in somatosensory structure and function as well as emotional well-being specific to the presence and severity of neuP. Patients with CTS (n = 108) were subgrouped by the DN4 questionnaire into those without and with neuP. The latter group was further subdivided into mild and moderate/severe neuP using a pain visual analogue scale. N = 32 participants served as healthy controls. All participants underwent a clinical examination, quantitative sensory testing, electrodiagnostic testing (EDT), and skin biopsy to determine the structural integrity of dermal and intraepidermal nerve fibres. Patients also completed questionnaires evaluating symptom severity and functional deficits, pain distribution, sleep quality, and emotional well-being. The overall prevalence of neuP in patients with CTS was 80%, of which 63% had mild neuP. Symptom severity and functional deficits as well as somatosensory dysfunction was more pronounced with the presence and increasing severity of neuP. No difference was identified among patient groups for EDT and nerve fibre integrity on biopsies. The severity of neuP was accompanied by more pronounced deficits in emotional well-being and sleep quality. Intriguingly, extraterritorial spread of symptoms was more prevalent in patients with moderate/severe neuP, indicating the presence of central mechanisms. NeuP is common in patients with CTS, and its severity is related to the extent of somatosensory dysfunction and a compromise of emotional well-being.

Diagnostic accuracy of ultrasound and magnetic resonance imaging in detecting Stener lesions of the thumb: Systematic review and meta-analysis. Qamhawi, Z., et al. (2021) Level of Evidence : 2a Follow recommendation : 👍 👍 Type of study : Diagnostic Topic : Thumb Stener lesion – Ultrasound and MRI diagnostic This is a systematic review and meta-analysis assessing the usefulness of MRI and Ultrasound (US) in identifying Stener lesions of the thumb. Fifteen longitudinal studies were included in the review for a total of 423 participants. The quality of the studies included was assessed through the Quality Assessment of Diagnostic Accuracy Studies tool . Studies were included if participants had undergone US or MRI of their thumb following a thumb injury. The sensitivity and specificity of US and MRI was compared to surgical assessment of the lesion (gold standard) or clinical follow up. If a test is very sensitive and its result is negative, you can be more certain that the patient does not have the condition. If the test is specific and its result is positive, you can be more certain that the patient has the condition. The results showed that median time from injury to MRI and US was 6 and 9 days respectively (range 1-20). The time between in injury and surgery or clinical follow up varied greatly with a range from less than 2 weeks to 5 years. The sensitivity and specificity of MRI and US was beyond 90% suggesting that both investigations are useful for screening and diagnostic purposes. Unfortunately, not all participants from the studies underwent open surgery (gold standard) to assess the presence of a Stener lesion. This is therefore a limitation of the review as the pooled sensitivity and specificity are not drawn on true positive or negative. Clinical Take Home Message : Based on what we know today, US and MRI investigations may be useful for screening against, or making a diagnosis of Stener lesion in the thumb. The sensitivity and specificity of these imaging procedures have however been calculated against a mix of surgical (gold standard) and clinical assessment procedures rather than surgical findings alone. It is therefore possible that in the future, the real utility of these investigations may change. A previous non peer-reviewed study showed that the sensitivity of US imaging to identify Stener lesions of the thumb is quite low in a group of participants who all underwent surgery. Open Access URL : https://doi.org/10.1177/1753193421993015 Abstract This study assesses the diagnostic accuracy of ultrasound and magnetic resonance imaging (MRI) in diagnosing Stener lesions of the thumb. MEDLINE, PubMed, Embase and Cochrane CENTRAL were searched for studies using ultrasound or MRI to detect Stener lesions following suspected thumb ulnar collateral ligament injuries. The reference standard was surgical exploration or clinical joint stability. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies tool. A random-effects bivariate meta-analysis was used to estimate pooled sensitivity and specificity. Forest plots were generated. Nine ultrasound (315 thumbs) and six MRI (107 thumbs) studies were included in meta-analysis (all high risk of bias). Pooled sensitivity and specificity for ultrasound were 95% and 94%, and for MRI were 93% and 98%. Both ultrasound and MRI demonstrate high diagnostic accuracy in detecting Stener lesions. Ultrasound is an appropriate first-line imaging modality.