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Non-pharmacological interventions in osteosarcopenia: A systematic review. Atlihan, R., B. Kirk and G. Duque (2020). Level of Evidence : 1a- Follow recommendation : 👍 👍 👍 👍 Type of study : Prognostic, Preventative, Therapeutic Topic : Musculoskeletal and bone health – Resistance training This is a systematic review of randomised controlled studies assessing the effect of resistance training on muscle and bone health in older participants with sarcopenia (loss of muscle mass) and osteopenia/osteoporosis (loss of bone density). Two studies were included for a total of 106 participants (average age range: 64-79 years old). The overall strength of evidence was assessed through the GRADE approach ("low", "very low", "moderate", "high"), which has also been suggested by the Cochrane group for systematic reviews. Participants took part in upper and lower limb resistance training 2-3/week for 3 to 18 months. There was moderate quality evidence that resistance training improved muscle strength and muscle mass. Low quality evidence suggests that by the 6 months mark, bony density improved. Clinical Take Home Message : Based on what we know today, resistance training improves our clients' muscle strength and mass in the short and long term. Furthermore, if performed for at least 6 months, resistance training has the potential to maintain if not improve bone density in our older clients. As hand therapist we are privileged to see several older patients after a distal radius fracture. These clients are often fragile and would definitely benefit from resistance training. We may also invite our clients to take at least 8,000 steps/day as a greater number of daily steps has been shown to reduce mortality in previous studies. In addition, general resistance training may increase grip strength , which is another predictor of mortality. URL : https://link.springer.com/article/10.1007/s12603-020-1537-7 Available through EBSCO Health Databases for PNZ members. Abstract BACKGROUND: Osteosarcopenia is a geriatric syndrome defined by the concomitant presence of osteopenia/osteoporosis (loss of bone mineral density (BMD)) and sarcopenia (loss of muscle mass and/or function), which increases the risk of falls, fractures, and premature mortality. OBJECTIVE: To examine the efficacy of non-pharmacological (exercise and/or nutritional) interventions on musculoskeletal measures and outcomes in osteosarcopenic adults by reviewing findings from randomized controlled trials (RCTs). METHODS: This review was registered at PROSPERO (registration number: CRD42020179292) and conducted in accordance with the PRISMA guidelines. Electronic databases were searched for RCTs assessing the effect of at least one non-pharmacological intervention (any form of exercise and/or supplementation with protein, vitamin D, calcium or creatine) on any musculoskeletal measure/outcome of interest (BMD, bone strength/turnover, muscle mass and strength, physical performance, falls/fractures) in adults with osteosarcopenia as defined by any proposed criteria. RESULTS: Two RCTs (of n=106 older osteosarcopenic adults (≥65 years)) assessing the effects of progressive resistance training (RT) (via resistance bands or machines; 2-3 times/week; ~60 minutes in duration) were eligible for inclusion. The two RCTs demonstrated moderate quality evidence that RT increases muscle mass, strength, and quality, with changes in strength and quality occurring before muscle mass (12 vs 28 weeks). There was low quality evidence that RT increases lumbar spine BMD and maintains total hip BMD when performed for 12 and 18 months, respectively, and moderate quality evidence that RT has no effect on markers of bone turnover or physical performance. No major adverse effects were recorded in either of the RCTs. There were no eligible RCTs examining the impact of nutritional interventions. CONCLUSION: Chronic RT is safe and effective at potentiating gains in muscle mass, strength, and quality, and increasing or maintaining BMD in older osteosarcopenic adults. No RCT has examined the effects of protein, vitamin D, calcium, or creatine against a control/placebo in this high-risk population.

Extensive Tumoral Calcinosis of the Hand. Gonzalez, M., M. Rettig and O. Ayalon (2020) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic Topic : What is the differential diagnosis? – Case study This is the answer for the case study from last week. The patient was a 34 years old female with a six months history of atraumatic painless mass on the volar aspect of the right little finger (especially at the middle phalanx). The mass had grown significantly in the last few weeks and it was now associated with pain and blanching of the skin. Objectively, they were unable to bend the right little finger. The patient reported a history of hypothiroidisn and Sjogren's syndrome. The x-ray image is shown below. The results suggested the presence of a tumoral calcinosis on the volar aspect of the right little finger. Surgery was performed to remove the mass which had a chalk like consistency. Six weeks post surgery, the pain had resolved and the range of movement had significantly improved. URL : https://doi.org/10.1016/j.jhsa.2020.10.030 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Tumoral calcinosis is a rare and benign subtype of calcinosis cutis, a group of disorders involving soft tissue calcium deposition. Only 250 cases have been described since 1898; hand involvement is exceedingly rare. We report a case of extensive calcinosis within the flexor sheath of the little finger. Presentation included a painful mass over the volar aspect of the little finger, restricted digit motion, and skin compromise at the site of the mass. Surgical debulking was performed resulting in restoration of finger function.

Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic Topic : What is the differential diagnosis? – Case study Have a think about this case study. Leave a diagnostic comment if you like. I will publish the diagnosis and treatment reported by the paper next week. The patient was a 34 years old female with a six months history of atraumatic painless mass on the volar aspect of the right little finger (especially at the middle phalanx). The mass had grown significantly in the last few weeks and it was now associated with pain and blanching of the skin. Objectively, they were unable to bend the right little finger. The patient reported a history of hypothyroidism and Sjogren's syndrome. The x-ray image is shown below. What is it?

Exercise interventions in lateral elbow tendinopathy have better outcomes than passive interventions, but the effects are small: A systematic review and meta-analysis of 2123 subjects in 30 trials. Karanasios, S., et al. (2020). Level of Evidence : 1a- Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Lateral epicondylalgia - Eccentric resistance training This is a systematic review and meta-analysis of randomised controlled trials assessing the effectiveness of active vs passive interventions for lateral epicondylalgia. Thirty randomised controlled trials were included for a total of 2,123 participants (21 studies were included in the meta-analysis). The results from this systematic review and meta-analysis were assessed through the GRADE approach (suggested by the Cochrane Group), which scores the evidence as "very low", "low", "moderate", or "high" quality. Efficacy of intervention was assessed through changes in pain, pain-free grip strength (PFG), and elbow disability. Pain was assessed through the visual analogue scale (VAS) or the numerical rating scale (NRS), pain-free grip strength (PFG), and elbow disability through the Patient-Rated Tennis Elbow Evaluation (PRTEE) and the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire. Follow-up times ranged between very short term (less than 2 months), short term (2-3 months), mid-term (3-12 months), and long term (more than 12 months). The results showed that there was low to very low quality evidence suggesting that exercise provided clinically and statistically significant greater improvements in PFG compared to cortisone injections at all time points. No difference was noted between exercise or wait and see. Eccentric exercises were not superior to concentric exercises. Clinical Take Home Message : Based on what we know today, exercises are more effective than cortisone injections in both the short and long term for clients with lateral epicondylalgia. This is not surprising considering the results from previous trials showing that people undergoing cortisone injection for lateral epicondylalgia are twice as likely to present with a recurrence at one year compared to somebody receiving a saline (placebo) injection. Any form of resistance exercise appears to be useful and eccentric exercises do not appear to be superior to concentric exercises, although they may provide with greater analgesia once the acute reactive tendinopathy has subsided. If clients are happy to wait and see, they may improve without the need of any intervention. URL : http://bjsm.bmj.com/content/early/2020/11/04/bjsports-2020-102525.abstract Available through EBSCO Health Databases for PNZ members. Abstract Objective: To evaluate the effectiveness of exercise compared with other conservative interventions in the management of lateral elbow tendinopathy (LET) on pain and function.Design Systematic review and meta-analysis. Methods: We used the Cochrane risk-of-bias tool 2 for randomised controlled trials (RCTs) to assess risk of bias and the Grading of Recommendations Assessment, Development and Evaluation methodology to grade the certainty of evidence. Self-perceived improvement, pain intensity, pain-free grip strength (PFGS) and elbow disability were used as primary outcome measures.Eligibility criteria RCTs assessing the effectiveness of exercise alone or as an additive intervention compared with passive interventions, wait-and-see or injections in patients with LET. Results: 30 RCTs (2123 participants, 5 comparator interventions) were identified. Exercise outperformed (low certainty) corticosteroid injections in all outcomes at all time points except short-term pain reduction. Clinically significant differences were found in PFGS at short-term (mean difference (MD): 12.15, (95% CI) 1.69 to 22.6), mid-term (MD: 22.45, 95% CI 3.63 to 41.3) and long-term follow-up (MD: 18, 95% CI 11.17 to 24.84). Statistically significant differences (very low certainty) for exercise compared with wait-and-see were found only in self-perceived improvement at short-term, pain reduction and elbow disability at short-term and long-term follow-up. Substantial heterogeneity in descriptions of equipment, load, duration and frequency of exercise programmes were evident. Conclusions: Low and very low certainty evidence suggests exercise is effective compared with passive interventions with or without invasive treatment in LET, but the effect is small. PROSPERO registration number CRD42018082703.

Nerve compression syndromes of the shoulder. Patetta, M. J., E. Naami, B. M. Sullivan and M. H. Gonzalez (2020) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic, Therapeutic Topic : Thoracic outlet - Symptoms and treatment This is a narrative review on entrapment neuropathies of the shoulder. I selected to cover the neurogenic thoracic outlet syndrome as this is the one that may present with symptoms in forearm and hand. In addition, neurogenic thoracic outlet syndrome constitute 90% of all the thoracic outlet syndromes. In term of diagnostic tests, there is not one single test that present with high specificity (ability to confirm the diagnosis) or sensitivity (ability to exclude the diagnosis). Nerve conduction studies rarely show any objective impairments, making the diagnosis even more challenging. Conservative treatment is always advocated before any surgical approach. The positive news is that if surgery is required, 56% to 89% of clients report improvements in their symptoms following the surgical procedure. Clinical Take Home Message : Based on what we know today, thoracic outlet syndrome may be in part responsible for vague upper limb symptoms reported by clients. Unfortunately, there is not one single test that is useful to confirm or exclude the diagnosis. It may be useful to utilised tests such as the arm squeeze test, Spurling's, Cx distraction, and neurodynamic tests to confirm or exclude the presence of a cervical radiculopathy . Dermatomal patterns are not always consistent in presence of a cervical radiculopathy and the presence of vague symptoms alone does not increase the likelihood of a thoracic outlet syndrome. In clients with a potential thoracic outlet syndrome it is worth remembering that psychological factors (e.g. anxiety, depression, pain catastrophising) have been shown to mediate pain/recovery. Light aerobic exercise (e.g. walking, cycling) may be a helpful intervention to reduce symptoms in clients with neurogenic thoracic outlet syndrome. URL : https://doi.org/10.1016/j.jhsa.2020.09.022 Available through EBSCO Health Databases for PNZ members. Abstract Nerve compression syndromes of the shoulder contribute to pain, paresthesia, and weakness of the upper extremity. This review examines the recent literature regarding thoracic outlet syndrome, suprascapular neuropathy, long thoracic nerve palsy, and quadrilateral space syndrome. Overlapping features are common among shoulder pathologies, and thus, key anatomical features, pathophysiology, clinical manifestations, diagnostic techniques, and treatments are highlighted for all aforementioned conditions.

Lumbrical muscle tear: Clinical presentation, imaging findings and outcome. Lutter, C., A. Schweizer, V. Schöffl, F. Römer and T. Bayer (2018). Level of Evidence : 4 Follow recommendation : 👍 👍 Type of study : Diagnostic, Therapeutic Topic : Lumbricals' tear - Imaging and treatment This is case series on lumbrical muscle tear's diagnosis and treatment. A total of 60 clients with a positive lumbrical stress test (see figure below) were included in the study. This type of injury occurs when a finger (middle/ring finger) is forcefully extended while the other fingers are actively flexed. Rock climbers are at greatest risk for lumbricals muscles tears. The diagnostic recommendation is to request an US investigation to determine the lesion grade: Grade I (microtear - non visible on US), a Grade II or III (both visible on US). In case of a grade I tear, gentle intrinsic minus pain-free stretching is performed for 4-6 weeks followed by graded lumbricals loading. For grade II, buddy taping is recommended for a max of 8 weeks, followed by a similar treatment as per grade I. For a grade III, immobilisation with an ulnar gutter including MF, RF, and LF to the proximal phalanx is recommended for 2 weeks. This is followed by the same treatment as per grade II lesion. Clinical Take Home Message : Based on what we know today, the lumbrical stress test is a quick way to assess the involvement of the 3rd or 4th lumbricals. An US has been indicated as the most appropriate way to confirm a clinical diagnosis, especially if there is a grade II or III, which is visible through this investigation. Considering the potential role of lumbrical in finger proprioception ( see previous synopsis ), the inclusion of dexterity exercises may be appropriate in this subgroup of clients. URL : https://doi.org/10.1177/1753193418765716 Available through EBSCO Health Databases for PNZ members. Abstract The incidence of lumbrical muscle tear is increasing due to the popularity of climbing sport. We reviewed data from 60 consecutive patients with a positive lumbrical stress test, including clinical examination, ultrasound and clinical outcomes in all patients, and magnetic resonance imaging in 12 patients. Fifty-seven patients were climbers. Lumbrical muscle tears were graded according to the severity of clinical and imaging findings as Grade I-III injuries. Eighteen patients had Grade I injuries (microtrauma), 32 had Grade II injuries (muscle fibre disruption) and 10 had Grade III injuries (musculotendinous disruption). The treatment consisted of adapted functional therapy. All patients completely recovered and were able to return to climbing. The healing period in Grade III injuries was significantly longer than in the patients with Grade I or II injuries (p < 0.001). We recommend evaluation of specific clinical and imaging findings to grade the injuries and to determine suitable therapy.

Osteosarcoma of the Trapezium. Ferrando, E., Navarro, J., Rojas, R., Mata, D., & Silvestre, A. (2020) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic Topic : What is the differential diagnosis? – Case study This is the answer for the last week case study. The patient was a 51 years old female with a three years history of painless palpable firm mass on the dorsal and radial aspect of the wrist. Subjectively, they reported swelling and pain in the last two months. The patient reported a history of hypertension. The x-ray that you see below revealed a calcification on the radial aspect of the wrist. An MRI was completed, which revealed a soft tissue mass. Surgery was performed to remove the mass and histological studies revealed that it was a low grade osteosarcoma. URL : https://www.jhandsurg.org/action/showPdf?pii=S0363-5023%2820%2930607-9 Available through EBSCO Health Databases for PNZ members. Abstract Osteogenic sarcoma is a malignant tumor that rarely affects the hand. When it does, it most often involves the phalanges or metacarpal heads. We present the case of a 51-year-old woman with a low-grade osteosarcoma affecting the trapezium bone of her left hand. A total trapeziectomy with partial removal of the first metatarsal, scaphoid, trapezoid, and capitate bones was performed, and no adjuvant therapy was administered. Six years after the intervention, the patient is disease-free, with excellent functionality and yearly imaging tests showing no signs of recurrence.

Functional outcomes of trigger finger release in non-diabetic and diabetic patients. Stirling, P. H. C., P. J. Jenkins, A. D. Duckworth, N. D. Clement and J. E. McEachan (2020) Level of Evidence : 2b Follow recommendation : 👍 👍 Type of study : Prognostic Topic : Trigger finger surgery - diabetes and functional recovery This retrospective study assessed the effect of diabetes on functional recovery following surgery for trigger finger (A1 pulley release). Functional recovery was measured through the QuickDASH questionnaire, and the presence of diabetes was self-reported by participants. A total of 192 participants were recruited at baseline and they were assessed pre-surgery and one year post-surgery. The results showed that 25% (n = 49) of the participants reported diabetes (no information was provided on number of participants with Type 1 or Type 2 diabetes). Participants' function at baseline was significantly worst in diabetic subjects (16 points worse). However, improvements in functional outcome following surgery were similar in both the diabetic (13 points improvement) and non-diabetic participants (9 points improvement). Clinical Take Home Message : Based on what we know today, clients affected by trigger finger and diabetes may have greater disability than clients without diabetes. It may be worth checking with the client if they are compliant with their diabetes medications (e.g. metformin) and if they have had a check up with their GP recently. The functional outcomes of A1 pulley release are similar between clients with and without diabetes. This synopsis is a nice addition to the one written on the effect of diabetes on functional recovery following distal radius fracture . URL : https://doi.org/10.1177/1753193420925027 Available through EBSCO Health Databases for PNZ members. Abstract We compared the functional outcomes, health-related quality of life, and satisfaction in diabetic and non-diabetic patients undergoing A1 pulley release for trigger finger in 192 patients. Preoperative and postoperative Quick Disabilities of the Arm, Shoulder and Hand questionnaire (Quick DASH), EuroQol-5 dimensions, and satisfaction scores were collected prospectively over a 6-year period. These patients had a mean follow-up of 14 months (range 11?40) after surgery. There were 143 patients (143 trigger fingers) without diabetes and 49 patients (49 trigger fingers) with diabetes. We found overall QuickDASH improvement was the same in both groups (-4.5 points). Patient satisfaction rates were comparable in both groups (90% versus 96%), and no significant difference in postoperative health-related quality of life was observed. No complications were reported in either group. We conclude from this study that A1 pulley release leads to similar functional improvement and high patient satisfaction at one year postoperatively in diabetic and non-diabetic patients.

Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic Topic : What is the differential diagnosis? – Case study Have a think about this case study. Leave a diagnostic comment if you like. I will publish the diagnosis and treatment reported by the paper next week. The patient was a 51 years old female with a three years history of painless palpable firm mass on the dorsal and radial aspect of the wrist. Subjectively, they reported swelling and pain in the last two months. The patient reported a history of hypertension. X-ray images are shown below. What is it?

Trapeziometacarpal joint arthritis: A personal approach to its treatment. Davis, T. R. C. (2020) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Therapeutic Topic : Thumb OA - Surgeon's point of view This is a surgeon's opinion on treatment of thumb osteoarthritis (OA). I particularly enjoyed the open minded approach that this surgeon has about thumb OA. They recognise the limitations of their own approach and they are ready to change their practice in light of new evidence, which will inevitably arise in the future. The approach suggested is to delay surgery (e.g. trapeziotomy) as much as possible. This is based on evidence suggesting that a limited proportion of the pain is correlated with radiographic findings and that a flare in pain may resolve within 6 months to a year. Furthermore, conservative treatments may help in the resolution or reduction of pain. More importantly, they recognise the significant impact of psychological factors in the exacerbation of pain (which is the driver for surgery) and the potential effect of other conservative interventions in the management of thumb OA. Cortisone injections are suggested as an additional treatment option. They report being happy to provide more than 3 injections if the benefits last for more than 6 months. A final point was made on the lack of evidence suggesting greater effectiveness of trapeziotomy alone vs trapeziotomy plus suspension arthroplasty. No differences have been identified between these approaches at short and long term in randomised controlled trials. 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, thumb OA should be initially treated conservatively. Conservative treatments should last between 6 to 12 months and consider other factors contributing to pain other than radiographic evidence of thumb OA. Psychological factors (e.g. anxiety, depression, pain catastrophising) have been shown to mediate pain/recovery and should be taken into account more than the degree of "degeneration" of the joint ( up to 75% of people with radiographic evidence of thumb OA do not have pain ). Have a look at conservative treatments for hand OA (e.g. manual therapy/exercise , illusory resizing , mental health component ) , we can make a difference! URL : https://journals.sagepub.com/doi/abs/10.1177/1753193420970343?journalCode=jhsc Available through EBSCO Health Databases for PNZ members. Abstract Many hand surgeons have fixed beliefs on how trapeziometcarpal (TMC) osteoarthritis should be treated. However, not all hand surgeons share the same fixed beliefs, so different factions of hand surgeons can hold contradictory beliefs. Many retain their fixed beliefs, rather than reconsidering them, when the best available evidence challenges them. The problem causing this heterogeneity of fixed beliefs is the lack of high-quality evidence that can withstand critical appraisal and cannot be ignored or simply dismissed by those with rigid contradictory beliefs. This article examines some of the dogmas surrounding the treatment of TMC osteoarthritis.

Factors affecting suboptimal outcomes in hand infections. Botma, N., McGuire, D., Koller, I., & Solomons, M. (2020) Level of Evidence : 4 Follow recommendation : 👍 👍 Type of study : Prognostic Topic : Revision surgery following infection – Diabetes This is a non-peer reviewed prospective study assessing the risk factors for the development of complications following a hand washout procedure. A total of 674 participants diagnosed with a hand infection were included in the study. The results showed that being diabetic increased the risk of a second infection by at least twofold. In people with diabetes, delayed presentation to ED (i.e. more than 1 week) increased the odds of amputation due to sepsis by 6 times. 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, diabetes is a risk factor for the development of a secondary infection following a washout procedure. A prompt referral to ED is warranted given the substantial risk of sepsis and potential amputation in clients with diabetes. This synopsis is a nice addition to a previous synopsis on risk factors for hand infection . URL : https://journals.sagepub.com/doi/full/10.1177/1753193420977791 Available through EBSCO Health Databases if you have access ( PNZ ) No abstract available.

The impact of type 2 diabetes on the development of tendinopathy. Cannata, F., Vadalà, G., Ambrosio, L., Napoli, N., Papalia, R., Denaro, V., & Pozzilli, P. (2020) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Prognostic Topic : Lateral epicondylalgia – Risk factors This is a narrative review assessing the connection between type 2 diabetes and tendinopathy, and exploring the potential treatment pathways. Type 2 diabetes is associated with chronic hyperglycemia (high levels and significant fluctuations of glucose in the bloodstream - especially if not treated) and poses several risks for tendons. In particular, it reduces the loading threshold at which tendons enter a degenerative phase, and it reduces the ability of tendon to heal due to tenocytes oxidative stress and impairment of stem cells activity. This is not to mention the effect that hyperglycemia has on connective and vascular tissue. Thus, glycation of connective tissue makes it more stiff and less resilient to loading. Vascular impairments lead to a reduction of neoangiogenesis (formation of new vessels), which is fundamental for tendon healing. Management of people presenting with type 2 diabetes and tendinopathy includes both local treatment ( reduction in loading during the acute phase and gradual resistance training ) and other interventions aiming at weight-loss (i.e. exercise, diet, and pharmacological, +/- surgical). Interventions aiming at weight loss have shown to reduce symptoms in both weight-bearing and non-weight-bearing tissues. Finally, resistance training and aerobic exercises are fundamental interventions in the management of type 2 diabetes and should be undertaken under the supervision of a health professional. Clinical Take Home Message : Based on what we know today, clients with type 2 diabetes may be predisposed to develop lateral epicondylalgia. When assessing clients with Type 2 diabetes, hand therapists should investigate whether they are compliant with medications (e.g. metformin) and encourage clients to take part in supervised resistance and/or aerobic training exercises (as per international guidelines ) . This article is a nice addition to what we already know on the risk factors for lateral epicondylalgia . URL : https://doi.org/10.1002/dmrr.3417 Available through EBSCO Health Databases for PNZ members. Abstract Tendinopathy is a chronic and often painful condition affecting both professional athletes and sedentary subjects. It is a multi‐etiological disorder caused by the interplay among overload, ageing, smoking, obesity (OB) and type 2 diabetes (T2D). Several studies have identified a strong association between tendinopathy and T2D, with increased risk of tendon pain, rupture and worse outcomes after tendon repair in patients with T2D. Moreover, consequent immobilization due to tendon disorder has a strong impact on diabetes management by reducing physical activity and worsening the quality of life. Multiple investigations have been performed to analyse the causal role of the individual metabolic factors occurring in T2D on the development of tendinopathy. Chronic hyperglycaemia, advanced glycation end‐products, OB and insulin resistance have been shown to contribute to the development of diabetic tendinopathy. This review aims to explore the relationship between tendinopathy and T2D, in order to define the contribution of metabolic factors involved in the degenerative process and to discuss possible strategies for the clinical management of diabetic tendinopathy.