Diercks R, Bron C, Dorrestijn O, Meskers C, Naber R, de Ruiter T, Willems J, Winters J, van der Woude HJ [Netherlands Orthopedic Society, Koninklijk Nederlands Genootschap voor Fysiotherapie, Netherlands Association of General Practitioners, Netherlands Society of Rehabilitation Medicine, Netherlands Association of Occupational Medicine, Netherlands Society of Radiology]
Acta Orthopaedica 2014;85(3):314-322
Treatment of "subacromial impingement syndrome" of the shoulder has changed drastically in the past decade. The anatomical explanation as "impingement" of the rotator cuff is not sufficient to cover the pathology. "Subacromial pain syndrome", SAPS, describes the condition better. A working group formed from a number of Dutch specialist societies, joined by the Dutch Orthopedic Association, has produced a guideline based on the available scientific evidence. This resulted in a new outlook for the treatment of subacromial pain syndrome. The important conclusions and advice from this work are as follows:
(1) the diagnosis SAPS can only be made using a combination of clinical tests.
(2) SAPS should preferably be treated non-operatively.
(3) Acute pain should be treated with analgetics if necessary.
(4) Subacromial injection with corticosteroids is indicated for persistent or recurrent symptoms.
(5) Diagnostic imaging is useful after 6 weeks of symptoms. Ultrasound examination is the recommended imaging, to exclude a rotator cuff rupture.
(6) Occupational interventions are useful when complaints persist for longer than 6 weeks.
(7) Exercise therapy should be specific and should be of low intensity and high frequency, combining eccentric training, attention to relaxation and posture, and treatment of myofascial trigger points (including stretching of the muscles) may be considered.
8) Strict immobilization and mobilization techniques are not recommended.
(9) Tendinosis calcarea can be treated by shockwave (ESWT) or needling under ultrasound guidance (barbotage).
(10) Rehabilitation in a specialized unit can be considered in chronic, treatment resistant SAPS, with pain perpetuating behavior.
(11) There is no convincing evidence that surgical treatment for SAPS is more effective than conservature management.
(12) There is no indication for the surgical treatment of asymptomatic rotator cuff tears.
de Vries JS, Krips R, Sierevelt IN, Blankevoort L, van Dijk CN
Cochrane Database of Systematic Reviews 2011;Issue 8
Chronic lateral ankle instability occurs in 10% to 20% of people after an acute ankle sprain. Initial treatment is conservative but if this fails and ligament laxity is present, surgical intervention is considered.
To compare different treatments, conservative or surgical, for chronic lateral ankle instability.
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, Medline, Embase, CINAHL and reference lists of articles, all to February 2010.
All identified randomised and quasi-randomised controlled trials of interventions for chronic lateral ankle instability were included.
DATA COLLECTION AND ANALYSIS:
Two review authors independently assessed risk of bias and extracted data from each study. Where appropriate, results of comparable studies were pooled.
Ten randomised controlled trials were included. Limitations in the design, conduct and reporting of these trials resulted in unclear or high risk of bias assessments relating to allocation concealment, assessor blinding, incomplete and selective outcome reporting. Only limited pooling of the data was possible. Neuromuscular training was the basis of conservative treatment evaluated in four trials. Neuromuscular training compared with no training resulted in better ankle function scores at the end of four weeks training (Ankle Joint Functional Assessment Tool (AJFAT): mean difference (MD) 3.00, 95% CI 0.3 to 5.70; 1 trial, 19 participants; Foot and Ankle Disability Index (FADI) data: MD 8.83, 95% CI 4.46 to 13.20; 2 trials, 56 participants). The fourth trial (19 participants) found no significant difference in the functional outcome after six weeks training programme on a cyclo-ergometer with a bi-directional compared with a traditional uni-directional pedal. Longer-term follow-up data were not available for these four trials. Four studies compared surgical procedures for chronic ankle instability. One trial (40 participants) found more nerve injuries after tenodesis than anatomical reconstruction (risk ratio (RR) 5.50, 95% CI 1.39 to 21.71). One trial (99 participants) comparing dynamic versus static tenodesis excluded 17 patients allocated dynamic tenodesis because their tendons were too thin. The same trial found that dynamic tenodesis resulted in higher numbers of people with unsatisfactory function (RR 8.62, 95% CI 1.97 to 37.77, 82 participants). One trial comparing techniques of lateral ankle ligament reconstruction (60 participants) found that operating time was shorter using the reinsertion technique than the imbrication method (MD -9.00 minutes, 95% CI -13.48 to -4.52). Two trials (70 participants) compared functional mobilisation with immobilisation after surgery. These found early mobilisation led to earlier return to work (MD -2.00 weeks, 95% CI -3.06 to -0.94; 1 trial) and to sports (MD -3.00 weeks, 95% CI -4.49 to -1.51; 1 trial).
Neuromuscular training alone appears effective in the short term but whether this advantage would persist on longer-term follow-up is not known. While there is insufficient evidence to support any one surgical intervention over another surgical intervention for chronic ankle instability, it is likely that there are limitations to the use of dynamic tenodesis. After surgical reconstruction, early functional rehabilitation appears to be superior to six weeks immobilisation in restoring early function.
Carcia CR, Martin RL, Houck J, Wukich DK [Orthopaedic Section of the American Physical Therapy Association]
The Journal of Orthopaedic and Sports Physical Therapy 2010 Sep;40(9):A1-A26
RISK FACTORS: For specific groups of individuals, clinicians should consider abnormal ankle dorsiflexion range of motion, abnormal subtalar joint range of motion, decreased ankle plantar flexion strength,increased foot pronation, and abnormal tendon structure as intrinsic risk factors associated with Achilles tendinopathy. Obesity, hypertension, hyperlipidemia, and diabetes are medical conditions associated with Achilles tendinopathy. Clinicians should also consider training errors, environmental factors, and faulty equipment as extrinsic risk factors associated with Achilles tendinopathy. (Recommendation based on moderate evidence).
DIAGNOSIS/CLASSIFICATION: Self-reported localized pain and perceived stiffness in the Achilles tendon following a period of inactivity (ie, sleep, prolonged sitting), lessens with an acute bout of activity and may increase after the activity. Symptoms are frequently accompanied with Achilles tendon tenderness, a positive arc sign, and positive findings on the Royal London Hospital test. These signs and symptoms are useful clinical findings for classifying a patient with ankle pain into the ICD category of Achilles bursitis or tendinitis and the associated ICF impairment-based category of Achilles pain (b28015 Pain in lower limb), stiffness (b7800 Sensation of muscle stiffness), and muscle power deficits (b7301 Power of muscles of lower limb). (Recommendation based on weak evidence).
DIFFERENTIAL DIAGNOSIS: Clinicians should consider diagnostic classifications other than Achilles tendinopathy when the patient's reported activity limitations or impairments of body function and structure are not consistent with those presented in the diagnosis/classification section of this guideline, or,when the patient's symptoms are not resolving with interventions aimed at normalization of the patient's impairments of body function. (Recommendation based on expert opinion).
EXAMINATION -- OUTCOME MEASURES: Clinicians should incorporate validated functional outcome measures, such as the Victorian Institute of Sport Assessment and the Foot and Ankle Ability Measure. These should be utilized before and after interventions intended to alleviate the impairments of body function and structure, activity limitations, and participation restrictions associated with Achilles tendinopathy. (Recommendation based on strong evidence).
EXAMINATION -- ACTIVITY LIMITATION AND PARTICIPATION RESTRICTION MEASURES: When evaluating functional limitations over an episode of care for those with Achilles tendinopathy, measures of activity limitation and participation restriction can include objective and reproducible assessment of the ability to walk, descend stairs, perform unilateral heel raises and single-limb hop, and participate in recreational activity. (Recommendation based on moderate evidence).
EXAMINATION -- PHYSICAL IMPAIRMENT MEASURES: When evaluating physical impairment over an episode of care for those with Achilles tendinopathy, one should consider measuring dorsiflexion range of motion, subtalar joint range of motion, plantar flexion strength and endurance, static arch height, forefoot alignment, and pain with palpation. (Recommendations based on moderate evidence).
INTERVENTIONS -- ECCENTRIC LOADING: Clinicians should consider implementing an eccentric loading program to decrease pain and improve function in patients with midportion Achilles tendinopathy. (Recommendation based on strong evidence).
INTERVENTIONS -- LOW-LEVEL LASER THERAPY: Clinicians should consider the use of low-level laser therapy to decrease pain and stiffness in patients with Achilles tendinopathy. (Recommendation based on moderate evidence).
INTERVENTIONS -- IONTOPHORESIS: Clinicians should consider the use of iontophoresis with dexamethasone to decrease pain and improve function in patients with Achilles tendinopathy. (Recommendation based on moderate evidence).
INTERVENTIONS -- STRETCHING: Stretching exercises can be used to reduce pain and improve function in patients who exhibit limited dorsiflexion range of motion with Achilles tendinopathy. (Recommendation based on weak evidence).
INTERVENTIONS -- FOOT ORTHOSES: A foot orthosis can be used to reduce pain and alter ankle and foot kinematics while running in patients with Achilles tendinopathy. (Recommendation based on weak evidence).
INTERVENTIONS -- MANUAL THERAPY: Soft tissue mobilization can be used to reduce pain and improve mobility and function in patients with Achilles tendinopathy. (Recommendation based on expert opinion).
INTERVENTIONS -- TAPING: Taping may be used in an attempt to decrease strain on the Achilles tendon in patients with Achilles tendinopathy. (Recommendation based on expert opinion).
INTERVENTIONS -- HEEL LIFT: Contradictory evidence exists for the use of heel lifts in patients with Achilles tendinopathy. (Recommendation based on conflicting evidence).
INTERVENTIONS -- NIGHT SPLINT: Night splints are not beneficial in reducing pain when compared to eccentric exercise for patients with Achilles tendinopathy. (Recommendation based on weak evidence).