Topical nitroglycerin decreases pain intensity in daily activities: a review.

OBJECTIVE: To review the evidence for the effectiveness of topical nitroglycerin in treating acute and chronic tendinopathies among adults. DATA SOURCES: The investigators searched 27 databases for experimental studies, published from January 1990 to March 2009 in any language, on nitroglycerin application for tendon injuries. Further studies were sought from the reference lists of relevant articles. STUDY SELECTION: Selection criteria were randomized controlled trials (RCTs) and other clinical controlled trials that compared topical nitroglycerin with placebo, an alternative intervention, or a standard treatment for acute (<2 weeks), subacute (2-6 weeks), or chronic (>6 weeks) tendinopathy; adult participants; and reduction of pain as an outcome measure. The search identified 163 published articles, of which 7 RCTs were included. DATA EXTRACTION: Details of the study design, participants, interventions, and outcomes (primarily pain, and secondarily range of motion and strength of the involved musculotendinous units) were extracted. Quality was evaluated by the Standard Quality Assessment Criteria for Evaluating Research Papers (14 points, scored 2 for "yes" and 1 for "partial"). Data assessment was done by 2 independent reviewers. MAIN RESULTS: Glyceryl trinitrate was compared with placebo in 5 studies, 1 study compared nitroglycerin with local corticosteroid/anesthetic solution, and 1 study compared nitroglycerin and tendon rehabilitation with tendon rehabilitation alone. Dosage of transdermal nitroglycerin varied from 0.72 to 5 mg per day for a period of 3 days to 24 weeks. In the acute phase of tendinopathy, 2 studies reported conflicting evidence for pain relief, with the comparison between nitroglycerin and corticosteroid infiltration favoring the latter. In 2 studies, there was limited evidence for the effectiveness of nitroglycerin in improving joint mobility. In the chronic phase, 5 studies assessed pain intensity at rest, with activity, and/or at night. Meta-analysis of the results of 3 of the studies favored nitroglycerin over control for decreasing pain on activities of daily living [odds ratio (OR) 4.44; 95% confidence interval (CI) 2.34-8.40]. When results from the acute studies were included, the positive effects of nitroglycerin on pain intensity remained (OR, 4.86; 95% CI, 2.62-9.02). In chronic tendinopathies, evidence for decreasing pain at rest and during the night was conflicting. Pain duration and sleep-hour duration were not improved. There was limited evidence of improvement effected by transdermal nitroglycerin in range of motion and in local tenderness. Evidence from 3 studies showed an increase in peak muscle force after 24 weeks. All 7 studies reported headache as an adverse event, which resulted in 1 to 9 discontinuations of the intervention. Data from 4 studies found an increase in the incidence of headache with nitroglycerin (OR, 1.73; 95% CI, 1.01-2.97). Data from 3 studies showed no difference in the occurrence of contact dermatitis between nitroglycerin and placebo. Study quality was good (mean score, 23.71/28 points). Most of the studies passed the criteria pertaining to randomization, comparison of baseline characteristics, and appropriate methods of outcome evaluation and analysis. Blinding was infrequent or inadequate. CONCLUSIONS: Topical nitroglycerin relieved pain intensity in activities of daily living among patients with chronic or acute tendinopathies. There was little evidence for effectiveness on other outcomes. The incidence of headache was increased by nitroglycerin.

Quadriceps contusions: clinical results of immediate immobilization in 120 degrees of knee flexion.

OBJECTIVE: Quadriceps contusions often result in significant time loss and the possibility of myositis ossificans. The objective of this descriptive case series was to document the results of an initial treatment regimen instituted within 10 minutes from the time of the injury. DESIGN: This study was a prospective case series of 47 midshipmen who sustained quadriceps contusions between August 1987 and December 2005 and who were treated identically and followed by serial examinations until the return to unrestricted full athletic activities. SETTING: United States Naval Academy (USNA), Annapolis, Maryland. PARTICIPANTS: USNA midshipmen who sustained quadriceps contusions while participating in sports activities. Inclusion criteria were (1) stated inability at the time of the injury to continue participation and (2) the inability to perform a pain-free, isometric quadriceps contraction and maintain the knee in full extension with a straight leg lift. INTERVENTIONS: On diagnosis the knee was passively flexed painlessly to 120 degrees and held continuously in that position for 24 hours. Use of the brace was discontinued at 24 hours and the midshipman was instructed to perform active, pain-free quadriceps stretching several times a day and to perform pain-free isometric quadriceps strengthening exercises as soon as possible. Goals included pain-free knee flexion and quadriceps size and firmness equal to the uninjured side. MAIN OUTCOME MEASUREMENTS: Average time from the day of the injury to return to unrestricted full athletic activities with no disability. RESULTS: The average time to return to unrestricted full athletic activities with no disability was 3.5 days (range of 2 to 5 days). Radiographic examination of the first 23 midshipmen at 3 and 6 months following the injury revealed 1 case of myositis ossificans. CONCLUSIONS: Placing and holding the knee in 120 degrees of flexion immediately following a quadriceps contusion appears to shorten the time to return to unrestricted full athletic activities compared with reports in other studies.

Structured exercises to prevent lower limb injuries in young handball players.

OBJECTIVE: To investigate the effect of a structured warm-up program in reducing the occurrence of knee and ankle injuries in teenage handball players. DESIGN: Block randomized controlled trial with a sample size designed to achieve 90% power with [alpha] = 5% to detect a relative risk (RR) reduction of 50%. Clubs within the randomization blocks were matched by region, playing level, and number and sex of players. SETTING: Norwegian Handball Federation clubs in the 16-year and 17-year divisions during the 2002 to 2003 season. PARTICIPANTS: Clubs in the division were invited to participate in the study before the season (n = 123 clubs recruited; 85% of the 145 invited clubs). After 3 clubs were excluded or dropped out, 1837 eligible players (uninjured at baseline) aged 15 to 17 years (86% young women) were included in the analysis. INTERVENTION: Coaches of the intervention group clubs (958 players) were instructed in exercises to improve awareness and control of knees and ankles during standing, running, cutting, jumping, and landing. The program comprised exercises with the ball, including the use of the wobble board and balance mat, for warm-up, technique, balance, and strength. Players were to spend 4 to 5 minutes on each group of exercises for a total of 15 to 20 minutes at the first 15 training sessions and thereafter once per week. Coaches recorded attendance and details of the sessions on standard forms. Coaches of the control group clubs (879 players) were asked to continue with their usual training methods and to record types and volume of exercises used. MAIN OUTCOME MEASURES: The primary outcome measure was an acute injury to the knee or ankle during a match or training session that required the player to have medical attention or miss part of the next session. Secondary outcomes were any injury to the lower limbs, injuries overall, and injuries to the upper limb. Injuries were recorded by physiotherapists blinded to group assignment who were in contact with the coaches at least every month. The physiotherapists interviewed injured players in person or by telephone as soon as possible (range, 1 day to 4 months). MAIN RESULTS: During the season 262 players (14%) were injured at least once (241 acute and 57 overuse injuries). In intention-to-treat analysis, the intervention group had lower risks than the control group of acute knee or ankle injuries (RR, 0.53; 95% CI, 0.35-0.81), lower limb injuries (RR, 0.51; CI, 0.36-0.73), any injury (RR, 0.49; CI, 0.36-0.68), and upper limb injuries (RR, 0.37; CI, 0.20-0.69). Rate ratios for moderate and major injuries (absence from play for 8 to > or =21 days) were lower for the intervention group for all injuries (P < 0.001) and for acute knee or ankle injuries (P < or = 0.03). Fewer players in the intervention group had > or =2 injuries. Risk of injury did not differ for young men and women. Crossovers to the other intervention occurred in 13% of the intervention clubs (noncompliance with the training program) and 22% of the control clubs (use of similar preventive exercises to the intervention group). CONCLUSIONS: The rate of acute knee and ankle injuries and all injuries to young handball players was reduced by half by a structured program designed to improve knee and ankle control during play.

Preparticipation orthopedic screening evaluation.

OBJECTIVE: To review evidence-based support for the preparticipation orthopedic evaluation. DATA SOURCES/METHODS: Articles were reviewed that dealt with the sensitivity, specificity, and predictive value of the components of the standardized preparticipation orthopedic evaluation. In addition, studies describing musculoskeletal conditions/findings predictive of future injuries were sought through a PubMed search. RESULTS: The sensitivity of the evaluation questionnaire appears to be adequate, exceeding 90% in some studies. There is little or no published information documenting that the physical examination (1) approaches the questionnaire in either sensitivity or specificity or (2) identifies elements of value based on their association with future injuries or reinjuries. There are no readily discernible elements even in an expanded examination that are documented as being predictive of future problems. CONCLUSIONS: The current questionnaire and examination appear to fulfill adequately both legal and institutional requirements. Practitioners should be aware of the absence of data linking virtually any of the findings on the examination to either an increase or a decrease in the likelihood of future injuries. There is no evidence that increasing the scope of the examination would enhance its predictive value.

Sports and fitness activities: the negative consequences.

Participation in sports and fitness activities offers potential health benefits for individuals of all ages, such as combating obesity and osteoporosis, as well as enhancing cardiovascular fitness. Negative consequences of musculoskeletal injuries sustained during sports participation in childhood and adolescence may compromise function in later life, limiting the ability to experience pain-free mobility and engage in fitness-enhancing activity. Increasingly successful management of sports-related injuries has allowed more athletes to return to participation. However, even effective early management of meniscal or anterior cruciate ligament injury does not minimize or preclude the increased likelihood of developing subsequent osteoarthritis. In addition, even in the absence of injury, vigorous participation in sports and fitness activities during childhood and adolescence increases the likelihood of developing osteoarthritis. It is ironic that return to vigorous sports participation has been adopted as an important measure of success of treatment, yet few efforts have been made to document long-term consequences of continued participation. Awareness of the long-term consequences of intensive sport and fitness activities allows the physician to help patients make informed decisions about the types and levels of activity they choose.

Tennis Leg.

Gastrocnemius strain can be extremely painful and requires immediate medical attention. With proper splinting of the injured leg, nonsteroidal anti-inflammatory medications, and an appropriate rehabilitation program, physicians can help tennis leg patients successfully recover.

The Role of Instruction in Preventing Ski Injuries.

Even though ski instruction may mean transiently increased risks for the skier, lessons can ultimately mean safer, more enjoyable skiing.