Assessment and management of shoulder pain at primary care level.

Most patients with shoulder pain will initially visit their community health centre, private general practitioner or family physician, with various levels of experience in the assessment and management of shoulder conditions. Shoulder conditions will range from early, simple ailments that can be treated in the primary care setting, to post-traumatic injuries and complex pathologies requiring the expertise of an orthopaedic surgeon or a fellowship-trained shoulder surgeon. Correct assessment of the patient's shoulder condition at the index consultation is a prerequisite for appropriate management. This article sets out straightforward guidelines to help general practitioners confidently identify the patient's source of shoulder pain and initiate an appropriate management plan at primary care level. Criteria for urgent and elective referral for specialist care are also outlined.

Hamstring stretch reflex: could it be a reproducible objective measure of functional knee stability?".

BACKGROUND: The anterior cruciate ligament (ACL) plays an important role in anterior knee stability by preventing anterior translation of the tibia on the femur. Rapid translation of the tibia with respect to the femur produces an ACL-hamstring stretch reflex which may provide an object measure of neuromuscular function following ACL injury or reconstruction. The aim of this study was to determine if the ACL-hamstring stretch reflex could be reliably and consistently obtained using the KT-2000 arthrometer. METHODS: A KT-2000 arthrometer was used to translate the tibia on the femur while recording the electromyography over the biceps femoris muscle in 20 participants, all with intact ACLs. In addition, a sub-group comprising 4 patients undergoing a knee arthroscopy for meniscal pathology, were tested before and after anaesthetic and with direct traction on the ACL during arthroscopy. The remaining 16 participants underwent testing to elicit the reflex using the KT-2000 only. RESULTS: A total number of 182 trials were performed from which 70 trials elicited stretch reflex (38.5 %). The mean onset latency of the hamstring stretch reflexes was 58.9 ± 17.9 ms. The average pull force was 195 ± 47 N, stretch velocity 48 ± 35 mm/s and rate of force 19.7 ± 6.4 N/s. CONCLUSIONS: Based on these results, we concluded that the response rate of the anterior cruciate ligament-hamstring reflex is too low for it to be reliably used in a clinical setting, and thus would have limited value in assessing the return of neuromuscular function following ACL injuries.

An analysis of the biomechanics of interference screw fixation and sheathed devices for biceps tenodesis.

BACKGROUND: This study aimed to evaluate the differences in biomechanical properties of biceps tenodesis when performed with sheathed versus unsheathed screws and also to investigate the effect of altering the pre-tension. METHODS: Tenodesis was performed in an in vitro model using biomechanical test blocks and ovine tendons. Blocks were allocated to 1 of 5 groups which varied by method of tenodesis and cyclical loading protocol: Group A, Biosure PK screw (10-100 N), Group B: 7-8 mm Biosure Sync and Biosure PK screw (10-100 N), Group C: Biosure PK screw (10-70 N), Group D: Biosure PK (20-100 N), and Group E: custom sheath and Biosure PK screw (10-100 N). If tenodeses remained intact after 500 cycles maximum load to failure testing was performed. FINDINGS: 30% of tenodeses in Group A failed prior to 500 cycles whereas none failed in the sheathed device groups (P=0.02). Using a sheathed device prevented mal-rotation. However, tenodeses in Group B were more likely to fail immediately distal to the tenodesis at a load below the anticipated maximum load to failure suggesting tendon damage during fixation. Using the custom sheath, which did not have sharp edges, resulted in a statistically significant increased maximum load to failure in Group E (348 N) when compared to Group A (228 N, mean difference 120 N, P=0.01) and Group B (253N, mean difference 95 N, P=0.0007). INTERPRETATION: Sheathed devices prevent mal-rotation and increase stiffness and maximum load to failure. This is further improved by reducing tendon damage at the time of tenodesis.

Defining the Role of the Tibial Tubercle-Trochlear Groove and Tibial Tubercle-Posterior Cruciate Ligament Distances in the Work-up of Patients With Patellofemoral Disorders.

BACKGROUND: The radiological work-up of patients with patellofemoral disorders continues to be debated. The interchangeability of the tibial tubercle-trochlear groove (TT-TG) distance between computed tomography (CT) and magnetic resonance imaging (MRI) has recently been questioned. In addition, a new measurement-the tibial tubercle-posterior cruciate ligament (TT-PCL) distance-has shown that not all patients with a pathological TT-TG distance (>20 mm) have lateralization of the tibial tubercle. Another factor to consider when looking at the position of the tibial tubercle is the knee joint rotation, defined as the angle between the femoral dorsal condylar line and the tibial dorsal condylar line. PURPOSE: To determine, with a larger population, if the TT-TG measurements can be used interchangeably between CT and MRI and to confirm the correlation between the TT-PCL and TT-TG distances in determining tibial tubercle lateralization. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: Patients with patellofemoral disorders and MRI and CT scans of the same knee (n = 141) were identified. The TT-PCL, the knee joint rotation, and TT-TG were measured independently by 2 fellowship-trained orthopaedic surgeons. Thirty measurements were repeated on a separate occasion to allow for an assessment of the intrarater reliability. The intraclass correlation coefficient (ICC) was used to assess reliability of the measurements. RESULTS: The mean TT-TG was 4.16 mm less on MRI (P < .05), with the mean TT-TG ± SD being 17.72 ± 5.15 mm on CT (range, 6.97-31.33 mm) and 13.56 ± 6.07 mm on MRI (range, 2-30.04 mm). The ICC for each rater comparing the 2 imaging modalities was only fair (0.54 and 0.48). The mean TT-PCL measurement was 20.32 ± 3.45 mm (range, 10.11-32.01 mm) with excellent interobserver and intraobserver reliability (>0.75). Based on the TT-TG and TT-PCL measurements, 4 groups of patients can be established. When knee joint rotation is compared among groups, an increased TT-TG may result from true lateralization of the tibial tubercle, an increased knee joint rotation, or both. CONCLUSION: Based on a statistically significant mean difference (4.11 mm) and only a fair ICC (0.54 and 0.48) for raters comparing the 2 modalities, the measurements for the TT-TG cannot be used interchangeably between CT and MRI. Therefore, currently accepted values for TT-TG based on CT scans should not be applied to an MRI scan. The TT-PCL measurement is a measure of true lateralization of the tibial tubercle, while the TT-TG is an amalgamated measure of true lateralization and knee joint rotation.

Arthroscopic treatment options for irreparable rotator cuff tears of the shoulder.

The management of patients with irreparable rotator cuff tears remains a challenge for orthopaedic surgeons with the final treatment option in many algorithms being either a reverse shoulder arthroplasty or a tendon transfer. The long term results of these procedures are however still widely debated, especially in younger patients. A variety of arthroscopic treatment options have been proposed for patients with an irreparable rotator cuff tear without the presence of arthritis of the glenohumeral joint. These include a simple debridement with or without a biceps tenotomy, partial rotator cuff repair with or without an interval slide, tuberplasty, graft interposition of the rotator cuff, suprascapular nerve ablation, superior capsule reconstruction and insertion of a biodegradable spacer (Inspace) to depress the humeral head. These options should be considered as part of the treatment algorithm in patients with an irreparable rotator cuff and could be used as either as an interim procedure, delaying the need for more invasive surgery in the physiologically young and active, or as potential definitive procedures in the medically unfit. The aim of this review is to highlight and summarise arthroscopic procedures and the results thereof currently utilised in the management of these challenging patients.

A Glomus Tumour of the Elbow: A Case Report and Review of the Literature.

Extradigital glomus tumours are relatively uncommon. We present a case report of a glomus tumour of the elbow and review of the literature with regards to the clinical features, work-up and management of these tumours, to highlight the importance of considering a glomus tumour as part of the differential diagnosis in patient with atypical pain around the elbow.

Magnetic resonance imaging findings in spinal tuberculosis: Comparison of HIV positive and negative patients.

BACKGROUND: There is an increasing incidence of Human immunodeficiency virus (HIV) and tuberculosis (TB) co-infection. This has led to an increasing number of atypical features on magnetic resonance imaging (MRI). We postulated that the type 4 hypersensitivity response causing granulomatous inflammation may be disrupted by the HIV resulting in less vertebral body destruction. This study compares the MRI features of spinal tuberculosis in HIV positive and negative patients. MATERIALS AND METHODS: Fifty patients with confirmed spinal tuberculosis, HIV status and available MRI scans at a single institution from 2003-2009 were identified. HIV status was positive in 20 and negative in 30. Females were predominant (34:16). The HIV positive group was younger at 32.4 versus 46 years (P=0.008). Blood parameters (WCC, ESR, Hb, Lymphocyte count) were not significantly different between the HIV groups. MRI scans were reviewed by a radiologist who was blinded to the HIV status. Site, extent of disease, body collapse, abscess location and volume, kyphotic deformity and cord signal were reported. RESULTS: There was no difference between the number of vertebral bodies affection with TB involvement, presence of cord signal or incidence of non-contiguous lesions. The HIV negative group had significantly more total vertebral collapse (P=0.036) and greater kyphosis (P=0.002). The HIV positive group had a trend to larger anterior epidural pus collection (P=0.2). CONCLUSION: HIV negative patients demonstrate greater tuberculous destruction in terms of total percentage body collapse and resultant kyphosis. There is no difference in the incidence of cord signal or presence of non-contiguous lesions. HIV positive patients show a trend to a greater epidural abscess volume. This difference may be explained by the reduced autoimmune response of the type 4 hypersensitivity reaction caused by the HIV infection.

A comparison of two treatment protocols in the management of exercise-associated postural hypotension: a randomised clinical trial.

OBJECTIVE: To investigate which of two commonly used treatment protocols for exercise-associated postural hypotension (EAPH) resulted in earlier discharge from the medical facility. METHODS: This randomised clinical field trial was undertaken at two Ironman Triathlon competitions and one ultra-distance footrace. All collapsed athletes admitted to the medical facilities were considered for the trial. Following clinical assessment and special investigations to confirm the diagnosis of EAPH, 28 athletes were randomly assigned to an oral fluid and Trendelenburg position (OT=14) or an intravenous fluid (IV=14) treatment group. Following admission fluid intake was recorded, and all athletes were assessed clinically (blood pressure, heart rate, level of consciousness) every 15 min until discharge criteria were met. The main measure of outcome was the time to discharge (min). RESULTS: On admission, subjects in the OT and IV groups were similar with respect to age, systolic blood pressure, heart rate and serum sodium concentration. There were no significant differences in heart rate, systolic and diastolic blood pressure between groups and over time until discharge. The fluid intake during the treatment period was significantly greater in the IV group (IV 1045 ± 185 ml, OT 204 ± 149 ml; p<0.001). The average time to discharge for the OT group (58 ± 23 min) was similar to that of the IV group (52.5 ± 18 min; p=0.47). CONCLUSION: Endurance athletes with EAPH can be treated effectively using the Trendelenburg position and oral fluids and the administration of intravenous fluids does not reduce the time to discharge. The findings of this study support the hypothesis that EAPH is a result of venous pooling due to peripheral vasodilatation, rather than dehydration.