Aims. Rotator cuff tendinopathy has a multifactorial origin. Rejecting the mechanistic theory has also led to abandoning operative treatment at initial presentation in the first line. Physiotherapy exercise programmes are the accepted first line treatment. The aim of this study was to assess the long-term additional benefits of subacromial decompression in the treatment of rotator cuff tendinopathy. Patients and Methods. This randomised controlled trial of 140 patients (52 men, 88 women, mean age 47.1 years; 18 to 60) with rotator cuff tendinopathy extended previous work up to a maximum of 13 years. The patients were randomised into two treatment groups: arthroscopic acromioplasty and a supervised exercise treatment and a similar supervised exercise treatment alone. Self-reported pain on a visual analogue scale (VAS) was the primary outcome measure. Secondary measures were disability, working ability, pain at night, Shoulder Disability Questionnaire score and the number of painful days during the three months preceding the final assessment. Results. A total of 90 patients (64%) returned questionnaires at a mean 12 years after randomisation. On an intention-to-treat basis, both treatment groups reached statistically significant improvement compared with the initial VAS for pain, but there was no significant difference between groups. The same was true in the secondary outcome measures. Due to group changes, the results were also analysed per protocol: operated or not. No significant differences between the groups were found. Conclusion. The natural history of rotator cuff tendinopathy probably plays a significant role in the results in the long-term. Even though the patients who underwent operative treatment had a stronger belief in recovery, which is likely to be surgical and the effect of placebo, the exercise group obtained similar results. In the future, an optimum exercise regime should be searched for, as the most clinically and cost-effective conservative treatment for rotator cuff tendinopathy. Cite this article: Bone Joint J 2017;99-B:799–805

As high incidences of tendinopathies are observed particularly in those who intensively use their tendons, we assume that pathological changes are caused, at least partially, by mechanical overload. This has led to the so-called overload hypothesis, explaining the development of tendinopathies by structural failure resulting from excessive load. At the same time, tendon loading is an important part in tendon rehabilitation. Currently, exercise treatment approaches such as eccentric training or heavy load resistance training are widely applied in tendinopathy rehabilitation, with good clinical results such as an improvement in function and a reduction in pain. Particularly those rehabilitative approaches which impose high strains on the tendon may induce an adaptation of the tendon's mechanical properties such as increased tendon stiffness. An increased tendon stiffness is often interpreted as desirable, as it may protect the tendon from overloading and thus prevent future strain injuries. However, the tendinopathic tendon is not necessarily less stiff than the tendon in the contralateral leg and an improvement in tendon stiffness is not necessarily accompanied by an improvement in tendon pain or function. In addition, metabolic factors, resulting e.g. in low-level systemic inflammation, may contribute to pathological tendon tissue changes and are not necessarily affected by an exercise program, while nutritional interventions or dietary supplements may potentially affect tendon cell metabolism. Indeed, dietary supplements have been introduced as an additional therapeutic approach in the treatment of tendinopathies in recent years, and their positive curative effects have been reported for both the general population and athletes. In the management of tendinopathies, it may thus be advisable if therapeutic approaches aim to address both tendon mechanics and tendon metabolism for better treatment effectiveness and a sustainable improvement in pain and function

Background and Aim of Study. Despite several hundred RCTs of exercise for persistent non-specific low back pain (NSLBP), the treatment targets of exercise are unclear. In a systematic review we observed 30 direct and indirect treatment targets of exercise described across 23 RCTs for persistent NSLBP. Since not all treatment targets and outcomes can be assessed in all RCTs, it is therefore important to prioritise these treatment targets through consensus from key stakeholders. These consensus workshops aimed to agree treatment targets for the use of exercise interventions in randomised controlled trials (RCTs) in persistent NSLBP using nominal group workshop (NGW) methodology. Methods and Results. The first UK workshop included people who had experience of exercise to manage their persistent NSLBP, clinicians who prescribe exercise for persistent NSLBP, and researchers who design exercise interventions tested in RCTs. The second workshop included participants attending an international back and neck pain research workshop. Twelve participants took part in the UK NGW and fifteen took part in the final ranking of the exercise treatment targets. In addition to the original list of 30 treatment targets, a further 26 ideas were generated. After grouping and voting, 18 treatment targets were prioritised. The top five ranked targets of exercise interventions for persistent NSLBP were: pain reduction, improvement in function, reduction of fear of movement, encouragement of normal movement and improvement of mobility. The results of the international NGW will also be presented. Conclusion. Future RCTs of exercise should consider more consistent assessment of these treatment targets. Sources of Funding: This PhD is funded by the Research Institute for Primary Care and Health Sciences, Keele University. Prof NE Foster is a UK National Institute for Health Research Senior Investigator, and was supported by a UK National Institute for Health Research Professorship (NIHR-RP-011-015). The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. Conflicts of Interest: No conflicts of interest

Background. Complex interventions, such as exercise for LBP, often have many treatment targets. Matching a primary outcome to the target(s) of exercise interventions may provide greater standardized mean differences (SMDs) than using an unmatched primary outcome. We aimed to explore whether the conclusions of exercise trials for LBP might differ with i) improved matching of outcomes to treatment targets and ii) the use of composite outcome measures. Methods and Results. We investigated i) matching in five trials (n=1033) that used an unmatched primary outcome but included some of their matched outcomes as secondary outcomes; ii) composite outcomes in four trials (n=864). The composite consisted of standardised averaged matched outcomes. All analyses replicated the primary outcome analysis, applied to the matched or composite outcome in each dataset. When not possible, SMDs were calculated for the primary and matched outcomes. i) Of five trials, three had greater SMDs and increased statistical significance with matched outcomes (pooled effect SMD 0.35 (95% CI 0.16, 0.54), p=0.0003) compared to an unmatched primary outcome (pooled effect SMD 0.13 (95% CI 0.04, 0.23) p=0.007). ii) Of four composite outcomes: two matched trials had greater SMDs and improved statistical precision in the primary outcome than the composite outcome; two unmatched trials had greater SMDs and improved statistical precision in the composite compared to the primary outcome. Conclusion. Using an outcome that matches exercise targets in LBP trials appears to produce greater SMDs than an unmatched primary outcome. Future trials should consider primary outcome selection aligned with exercise treatment targets. Sources of Funding: L Wood's PhD is funded by the Research Institute for Primary Care and Health Sciences, Keele University. Prof NE Foster is a UK National Institute for Health Research Senior Investigator, and was supported by a UK National Institute for Health Research Professorship (NIHR-RP-011-015). The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. Conflicts of interest: No conflicts of interest

We report a randomised controlled trial to examine the effectiveness and cost-effectiveness of arthroscopic acromioplasty in the treatment of stage II shoulder impingement syndrome. A total of 140 patients were randomly divided into two treatment groups: supervised exercise programme (n = 70, exercise group) and arthroscopic acromioplasty followed by a similar exercise programme (n = 70, combined treatment group). The main outcome measure was self-reported pain on a visual analogue scale of 0 to 10 at 24 months, measured on the 134 patients (66 in the exercise group and 68 in the combined treatment group) for whom endpoint data were available. An intention-to-treat analysis disclosed an improvement in both groups but without statistically significant difference in outcome between the groups (p = 0.65). The combined treatment was considerably more costly. Arthroscopic acromioplasty provides no clinically important effects over a structured and supervised exercise programme alone in terms of subjective outcome or cost-effectiveness when measured at 24 months. Structured exercise treatment should be the basis for treatment of shoulder impingement syndrome, with operative treatment offered judiciously until its true merit is proven

Background: The purpose of this study was to investigate the relationship between neck pain and upper limb disability. Methodology: This was a secondary analysis of neck pain patients participating in an RCT comparing usual physiotherapy with graded exercise treatment, to investigate the correlation between baseline neck pain and baseline upper limb disability. 151 neck pain patients from High Wycombe, Nottingham, Grimsby and Hull participated in the study. The measure used to assess baseline neck pain/disability was the Northwick Park Neck Pain Questionnaire (NPQ). The measure of baseline upper limb disability was the Disabilities of Arm, Shoulder, Hand (DASH). A range of variables were also measured at baseline as potential confounding variables. These included pain self efficacy, anxiety, depression, fear avoidance beliefs, coping strategies, age, gender, current smoking status, material and social deprivation and activity level. The measures were validated self administered questionnaires. Results: Pair wise analysis revealed a strong positive correlation between NPQ score and DASH score (Pearsons’ r=0.799, p< 0.001 (2 tailed), n=142). Stepwise linear regression indicated that increased severity of upper limb disability was predicted by two baseline variables: higher NPQ scores (B=0.743) and lower pain self efficacy scores (B= – 0.489) {Adjusted R2=0.708; n=100, p< 0.001}. After adjusting for potential confounding variables there remains a strong positive association between NPQ score and DASH score. Conclusions: Patients presenting with high levels of neck pain may also have high levels of upper limb disability. Upper limb disability may need to be assessed and addressed as part of the neck management process

AIM: The purpose of this retrospective study was to assess the results of a novel surgical technique for chronic lateral ankle instability using dynamic extensor digitorum brevis (EDB) muscle transfer. METHODS: 15 patients underwent dynamic EDB muscle transfer for symptomatic chronic lateral ankle instability. All patients were quite fit and physically very active. 9 male and 6 female patients, mean age 27 (range, 22–32) were operated by single surgeon (ALP) between March 2003 and August 2005. All patients had standard procedure involving proximal transfer of the origin of EDB muscle whilst preserving its neuro-vascular pedicle. All patients went through a standard post-operative physiotherapy protocol including pro-prioceptive training. Mean follow-up was 24 months (range, 12–36 months). The mean functional Karlsson scores improved from 26.5 before surgery to 86.5 at 12 months after surgery. At follow-up, all patients had normal range of ankle movements and were functionally stable. All patients regained their pre-injury activity level at 12 months after surgery. There were no early or late complications in our series. DISCUSSION: Ankle sprains are the most common injuries sustained during sports and physical exercise. Treatment is usually conservative because most of these injuries heal without consequence. However, symptomatic chronic lateral ankle instability is a difficult problem to treat and several surgical techniques have been described. EDB muscle not only acts as a dynamic substitute for the deficient ligament but also overcomes the problem of over-tightening of the ligament leading to restricted supination. CONCLUSION: Dynamic EDB muscle transfer is a safe, clinically effective and reliable surgical option for symptomatic chronic lateral ankle instability

Given the growing prevalence of obesity around the world and its association with osteoarthritis of the knee, orthopaedic surgeons need to be familiar with the management of the obese patient with degenerative knee pain. The precise mechanism by which obesity leads to osteoarthritis remains unknown, but is likely to be due to a combination of mechanical, humoral and genetic factors. . Weight loss has clear medical benefits for the obese patient and seems to be a logical way of relieving joint pain associated with degenerative arthritis. There are a variety of ways in which this may be done including diet and exercise, and treatment with drugs and bariatric surgery. Whether substantial weight loss can delay or even reverse the symptoms associated with osteoarthritis remains to be seen. . Surgery for osteoarthritis in the obese patient can be technically more challenging and carries a risk of additional complications. Substantial weight loss before undertaking total knee replacement is advisable. More prospective studies that evaluate the effect of significant weight loss on the evolution of symptomatic osteoarthritis of the knee are needed so that orthopaedic surgeons can treat this patient group appropriately.

1. Three cases are reported of ischaemic necrosis of the anterior tibial muscles which were not due to injury. In two, ischaemia was the result of strenuous or unaccustomed exercise in young adults; in the third it was an incident in a systemic disturbance. All three cases were probably the result of spasm of a large segment of the anterior tibial artery. 2. The clinical features during the first few hours resemble those of tenosynovitis of the tibialis anterior; and after twelve to twenty-four hours those of cellulitis of the leg. Later there is "drop foot" due to muscle weakness, contracture limiting plantar-flexion movement, and woody hardness of the muscles in the middle third. 3. The morbid histology is similar to that of Volkmann's ischaemic contracture. 4. The possible explanations—primary arterial disease, arterial occlusion by pressure of the interosseous membrane, occlusion by tension within the fascial space, intraluminary occlusion by embolism or thrombosis, and fatigue arterial spasm, are discussed. 5. The vascular pattern of the anterior tibial muscles has been studied by experimental injections in cadavers. 6. It is concluded that the most likely cause is spasm of the anterior tibial artery due to muscle fatigue, aggravated by increased tension within the anterior fascial compartment due to reaction after strenuous exercise. 7. Treatment is outlined. Exploration of the anterior tibial artery within the first twelve hours is warranted, but late exploration may be dangerous. 8. Although not previously recognised, evidence is shown that regeneration of necrotic muscle is possible in the human being

i Background and purpose Although there are now many trials of the effectiveness of back pain treatments, there are few robust cost effectiveness analyses of these treatments. ii Methods and Results: We analysed the cost-effectiveness of adding to ‘best care’ in general practice for patients consulting with low back pain: spinal manipulation; exercise classes; or manipulation followed by exercise (‘combined treatment’) alongside the UK BEAM trial. We collected health care resource use and health-related quality of life data at baseline, 3 and 12 months from 1334 trial participants. We estimated participant-specific quality-adjusted life-years (QALYs) and costs over the 12 months study period. Over one year mean treatment costs relative to ‘best care’ were: £195 (95% credibility interval £85 to £308) for manipulation; £140 (£3 to £278) for exercise; and £125 (£21 to £228) for combined treatment. All three active treatments increased participants’ average QALYs compared with ‘best care’ alone. For each extra QALY that combined treatment yielded relative to ‘best care’, it cost £3,800; in economic terms it had an ‘incremental cost-effectiveness ratio’ (ICER) of £3,800. Manipulation alone had an ICER of £8,700 relative to combined treatment. If the NHS were prepared to pay at least £10,000 for each extra QALY (lower than previous recommendations in the UK), manipulation alone would probably be the best strategy. If manipulation were not available, exercise would have an ICER of £8,300 relative to ‘best care’. iii Conclusions The UK BEAM spinal manipulation package is a cost-effective addition to ‘best care’ for back pain in general practice

Introduction: The piriformis syndrome is known as an entrapment of the sciatic nerve, in which the pain is felt over the upper part of the buttock and radiates down the leg. However, the pain in the buttock may also be located in the area of the ischial tuberosity, accompanied by referred pain to the back of the thigh and this is called the hamstring syndrome. The reason for the piriformis syndrome is quite often hypertrophy or inßammation of the muscle and that condition can be caused by sport or other strain even straight injury to the piriformis muscle. The hamstring syndrome is very often a disease of athletes, especially of sprinters, but may also occur in non-athletes. The pain begins mostly without trauma. The symptoms of the hamstring syndrome are caused by the tense tendinous structures of the hamstring muscles. This tendinous structure presses the sciatic nerve when sitting or exercising. The treatment of these syndromes is always at þrst conservative but if the pain lasts long enough you must consider the operative treatment. Patients and methods: There were 75 patients in the years 1975–95 who were operated because of piriformis or hamstring syndrome (40 hamstring and 35 piriformis). We sent the questionnaire to the operated patients and 45 patients answered (23 hamstring and 22 piriformis). Our retrospective study group consists of 45 patients. There were 13 female and 9 male in the piri-formis group and 6 female and 17 male in the hamstring group. The average age was 45 years (ranged 28–66 y) in the piriformis group and 28 years (ranged 15–43) in the hamstring group. Results: The mean follow-up was 8 years (ranged 2–18 y). The most common symptoms before operation were radiating pain in thigh 20 in the piriformis and 18 in the hamstring sdr, pain in the buttock 17 and 21, pain in sitting 15 and 21. Typically many of the hamstring patients complained pain when stretching the leg. The patients had suffered the symptoms 5,6 years in the piriformis sdr and 1,6 years in the hamstring sdr average. The result of the operation was excellent or good according to patientsñ opinion in the18 (82%) piriformis and in the 18 (87%) hamstring syndromes. The common þndings in the operation in the piriformis sdr were tight and tendinous structure in piriformis muscle, n. ischiadicus and piri-formis muscle adhered to each other and thick piriformis muscle. In the hamstring sdr the þndings were one or more distinct tense tendinous structure like a violin string, n. ischiadicus adhered to m. biceps and adhesions to n. ischiadicus. Conclusions: We prefer conservative treatment at þrst, but if symptoms are difþcult and last many months so operative treatment is a good choice. The results were better in the hamstring sdr. A modiþed Kocher incision was mostly used. Of course the preoperative diagnosis must be correct and you must use all modern possibilities for good diagnosis for example MRI

Objectives

To report the five-year results of a randomised controlled trial examining the effectiveness of arthroscopic acromioplasty in the treatment of stage II shoulder impingement syndrome.

The December 2013 Hip & Pelvis Roundup³⁶⁰ looks at: Enhanced recovery works; Acetabular placement; Exercise better than rest in osteoarthritis patients; if Birmingham hip resurfacing is immune from pseudotumour; HIV and arthroplasty; Labral tears revisited; Prophylactic surgery for FAI; and Ceramics and impaction grafting