Medical employment standards (MES) are used to identify and quantify the effects of pathology on a person's ability to carry out their duties. Any person requiring a change in their MES for longer than 28 days should have their permanent MES altered accordingly. In the Royal Air Force this is undertaken by Medical Boards.

A retrospective review was performed of all personnel attending RAF Medical Boards for a change in their PMES between 15/1/12 and 31/10/13. The primary reason for downgrade was recorded using ICD-10 code.

There were 1,583 PMES downgrades, approximately 800/year. This is approximately 2% of all regular RAF personnel. Musculoskeletal disease accounted for 58% of all cases (923 cases, 500/year). Other causes included medicine and general surgery (23%), mental health (10%), obstetrics and gynaecology (5%) and other causes (4%). The majority of the musculoskeletal cases were arthropathy (42%) or back pain (31%).

Musculoskeletal disease is the most common cause for medical downgrade in the RAF. More data are required to ascertain the precise nature of these cases and the level of the imposed limitations. This will allow targeted use of increasingly limited resources to ensure that our personnel are as fit as possible to execute their duties.

The aim of this study was determine if the detection of pathology in children with a limp can be optimised by screening with blood tests for raised inflammatory markers.

The entry criteria for the study were children (0–15 years) presenting to our hospital Emergency Department from 2012–2015 with a non-traumatic limp or pseudoparalysis of a limb, and no sign of fracture or malignancy on plain radiographs. ESR and CRP blood tests were performed along with other standard investigations. Children with ESR or CRP over 10 underwent MRI scan of their area of pain or tendernesss, with those under 7 years old having general anaesthetic. MRI provided the diagnosis in cases of osteomyelitis, pyomyositis, fasciitis, cellulitis, discitis, as well as non-infective conditions such as malignancy and fracture not visible on plain radiographs. Where a joint effusion was present, the diagnosis of septic arthritis was made from organisms cultured following surgical drainage, or high white cell count in joint fluid if no organisms were cultured. The study was completed once data from 100 consecutive children was available.

64% of children had an infective cause for their symptoms (osteomyelitis, septic arthritis, pyomyositis, fasciitis, cellulitis or discitis). A further 11% had positive findings on MRI from non-infective causes (juvenile idiopathic arthritis, cancer, or occult fracture). The remaining 25% had either a normal scan, or transient synovitis. ESR was a more sensitive marker than CRP, since ESR was raised in 97% of those with abnormal scans, but CRP in only 70%. There were no complications from any of the GA MRI scans. Conclusion: This shows that MRI imaging of all children with a limp and either raised ESR or CRP is a sensitive method to minimise the chance of missing important pathology in this group, and is not wasteful of MRI resources.

Evaluating musculoskeletal conditions of the lower limb and understanding the pathophysiology of complex bone kinematics is challenging. Static images do not take into account the dynamic component of relative bone motion and muscle activation. Fluoroscopy and dynamic MRI have important limitations. Dynamic CT (4D-CT) is an emerging alternative that combines high spatial and temporal resolution, with an increased availability in clinical practice. 4D-CT allows simultaneous visualization of bone morphology and joint kinematics. This unique combination makes it an ideal tool to evaluate functional disorders of the musculoskeletal system. In the lower limb, 4D-CT has been used to diagnose femoroacetabular impingement, patellofemoral, ankle and subtalar joint instability, or reduced range of motion. 4D-CT has also been used to demonstrate the effect of surgery, mainly on patellar instability. 4D-CT will need further research and validation before it can be widely used in clinical practice. We believe, however, it is here to stay, and will become a reference in the diagnosis of lower limb conditions and the evaluation of treatment options.

Cite this article: Bone Joint J 2021;103-B(5):822–827.

The use of routine sampling for histological analysis during revision hip replacement has been standard practice in our unit for many years. It is used to identify the presence of inflammatory processes that may represent peri-prosthetic infection. This study follows up on a smaller study in the same unit in 2019 where an initial 152 cases were scrutinised. In this follow up study we examined 1,361 consecutive patients over a 16-year period whom had undergone revision hip replacement in a tertiary orthopaedic centre for any reason excluding primary bone tumour or malignant metastasis. All patients had tissue sampling for histopathological analysis performed by consultant histopathologists with a specialist interest in musculoskeletal pathology. The presence of bacteria in greater than 50% of samples sent for microbiological analysis in each patient was used as the gold standard diagnostic comparator for infection. This was then compared with the histology report for each patient. After excluding 219 patients with incomplete data and 1 sample rejection, 1,141 cases were examined. Microbiology confirmed infection in 132 cases (prevalence of infection 11.04%) and histopathology analysis suggested infection in 171 cases. Only 64 cases with confirmed infection in more than 50% of microbiology samples had concurrent diagnosis of infection on histological analysis (5.60% of total; PPV 51.20%). Furthermore, microbiology analysis confirmed infection in 62 cases where histological analysis failed to identify infection (5.43% of total; False negative rate 49.21%). Overall, histopathology analysis was seen to have a good specificity of 93.99% but poor sensitivity of 50.79%. We believe that this is the largest series in the literature and is somewhat unique in that all histology analysis was performed by consultant histopathologists with specialist interest in musculoskeletal pathology. Based on the costs incurred by this additional investigation our experience does not support routine sampling for histological analysis in revision hip arthroplasty. This is a substantial paradigm shift from current practice among revision arthroplasty surgeons in the United Kingdom but would equate to a substantial cost saving

The purpose of this study was to assess the knowledge acquired from completing online case-based e-learning modules. A secondary objective was to identify how students use these independent resources and gauge their level of support for this novel instructional strategy. Fourth year medical students were randomized to either a module or control group. Both groups received the standard musculoskeletal medical school curriculum, while the students in the module group were also given access to case-based online modules created to illustrate and teach important orthopaedic concepts related to unique clinical presentations. The first module depicted an athlete with an acute knee dislocation while the second module portrayed a patient with hip pain secondary to femoral acetabular impingement (FAI). All participating students completed a knowledge quiz designed to evaluate the material presented in the module topics, as well as general musculoskeletal concepts taught in the standard curriculum. Following the quiz, the students were invited to share their thoughts on the learning process in a focus- group setting, as well as an individual survey. Demographic data was also collected to gauge student's exposure to and interest in orthopaedics, emergency medicine, anatomy and any prior relevant experience outside of medicine. Twenty-five fourth year medical students participated in the study with 12 randomized to the module group and 13 to the control group. The regression revealed students in the module group did on average 18.5 and 31.4 percentage points better on the knee and hip quizzes respectively, compared to the control group, which were both significant with a p-value < 0.01. Additionally, students who had completed an orthopaedics elective did 20 percentage points better than those who had not, while there was no significant improvement in students who had just completed their core orthopaedics rotation. The feedback collected from the survey and small group discussion was positive with students wishing more modules were available prior to musculoskeletal clinical skills sessions and their orthopaedics rotations. Medical students given access to online case-based e-learning modules enjoyed the innovative teaching strategy and performed significantly better on knowledge quizzes than their classmates who only received the standard musculoskeletal curriculum

Biomedical imaging is essential in the diagnosis of musculoskeletal pathologies and postoperative evaluations. In this context, Cone-Beam technology-based Computed Tomography (CBCT) can make important contributions in orthopaedics. CBCT relies on divergent cone X-rays on the whole field of view and a rotating source-detector element to generate three-dimensional (3D) volumes. For the lower limb, they can allow acquisitions under real loading conditions, taking the name Weight-Bearing CBCT (WB-CBCT). Assessments at the foot, ankle, knee, and at the upper limb, can benefit from it in situations where loading is critical to understanding the interactions between anatomical structures. The present study reports 4 recent applications using WB-CBCT in an orthopaedic centre. Patient scans by WB-CBCT were collected for examinations of the lower limb in monopodal standing position. An initial volumetric reconstruction is obtained, and the DICOM file is segmented to obtain 3D bone models. A reference frame is then established on each bone model by virtual landmark palpation or principal component analysis. Based on the variance of the model point cloud, this analysis automatically calculates longitudinal, vertical and mid-lateral axes. Using the defined references, absolute or relative orientations of the bones can be calculated in 3D. In 19 diabetic patients, 3D reconstructed bone models of the foot under load were combined with plantar pressure measurement. Significant correlations were found between bone orientations, heights above the ground, and pressure values, revealing anatomic areas potentially prone to ulceration. In 4 patients enrolled for total ankle arthroplasty, preoperative 3D reconstructions were used for prosthetic design customization, allowing prosthesis-bone mismatch to be minimized. 20 knees with femoral ligament reconstruction were acquired with WB-CBCT and standard CT (in unloading). Bone reconstructions were used to assess congruency angle and patellar tilt and TT-TG. The values obtained show differences between loading and unloading, questioning what has been observed so far. Twenty flat feet were scanned before and after Grice surgery. WB-CBCT allowed characterization of the deformity and bone realignment after surgery, demonstrating the complexity and multi-planarity of the pathology. These applications show how a more complete and realistic 3D geometric characterization of the of lower limb bones is now possible in loading using WB-CBCT. This allows for more accurate diagnoses, surgical planning, and postoperative evaluations, even by automatisms. Other applications are in progress

In the context of regenerative medicine for the treatment of musculoskeletal pathologies mesenchymal stromal cells (MSCs) have shown good results thanks to secretion of therapeutic factors, both free and conveyed within the extracellular vesicles (EV), which in their totality constitute the “secretome”. The portfolio and biological activity of these molecules can be modulated by both in vitro and in vivo conditions, thus making the analysis of these activities very complex. A deep knowledge of the targets regulated by the secretome has become a matter of fundamental importance and a homogeneous and complete molecular characterization is still lacking in the field of applications for the musculoskeletal system. Therefore, the aim of this work was to characterize the secretome obtained from adipose-derived MSCs (ASCs), and its modulation after pre-conditioning of the ASCs. Pre-conditioning was done by culturing cells in the presence of i) high levels of IFNγ, as proposed for the production of clinical grade secretome with enhanced regenerative potential, ii) low levels of inflammatory stimuli, mimicking conditions found in the osteoarthritis (OA) synovial fluid. Furthermore, EVs ability to migrate within cartilage, chondrocyte and synoviocytes obtained from OA patients was evaluated. The data showed that more than 50 cytokines / chemokines and more than 200 EV-microRNAs are detectable at various intensity levels in ASCs secretomes. The majority of the most abundantly present molecules are involved in the remodelling of the extracellular matrix and in the homeostasis and chemotaxis of inflammatory cells including macrophages, which in OA are often characterized by an M1 inflammatory polarization, promoting their transition to an M2 anti-inflammatory phenotype. Inflammatory priming with IFNγ and synovial fluid-like conditions were able to further increase the ability of the secretome to interact with inflammatory cells and modulate their migration. Finally, the penetration of the EVs in the cartilage explants resulted a rapid process, which begins a few minutes after administration of the EVs that are able to reach a depth of 30-40 μm in 5 hours. The same capacity for interaction was also verified in chondrocytes and synoviocytes isolated from the cartilage and synovial membrane of OA patients. Thanks to the soluble factors and EV-microRNAs, the ASCs secretome has shown a strong propensity to modulate the inflammatory and degenerative processes that characterize OA. The inflammatory pre-conditioning through high concentrations of inflammatory molecules or in conditions similar to the synovial fluid of OA patients was able to increase this capacity by increasing their chemotactic power. The microscopy data also support the hypothesis of the ability of MSC-EVs to influence the chondrocytes residing in the ECM of the cartilage and the synovial cells of the synovial membrane through active interaction and the release of their therapeutic content

Virtual encounters have experienced an exponential rise amid the current COVID-19 crisis. This abrupt change, seen in response to unprecedented medical and environmental challenges, has been forced upon the orthopaedic community. However, such changes to adopting virtual care and technology were already in the evolution forecast, albeit in an unpredictable timetable impeded by regulatory and financial barriers. This adoption is not meant to replace, but rather augment established, traditional models of care while ensuring patient/provider safety, especially during the pandemic. While our department, like those of other institutions, has performed virtual care for several years, it represented a small fraction of daily care. The pandemic required an accelerated and comprehensive approach to the new reality. Contemporary literature has already shown equivalent safety and patient satisfaction, as well as superior efficiency and reduced expenses with musculoskeletal virtual care (MSKVC) versus traditional models. Nevertheless, current literature detailing operational models of MSKVC is scarce. The current review describes our pre-pandemic MSKVC model and the shift to a MSKVC pandemic workflow that enumerates the conceptual workflow organization (patient triage, from timely care provision based on symptom acuity/severity to a continuum that includes future follow-up). Furthermore, specific setup requirements (both resource/personnel requirements such as hardware, software, and network connectivity requirements, and patient/provider characteristics respectively), and professional expectations are outlined. MSKVC has already become a pivotal element of musculoskeletal care, due to COVID-19, and these changes are confidently here to stay. Readiness to adapt and evolve will be required of individual musculoskeletal clinical teams as well as organizations, as established paradigms evolve. Cite this article: Bone Joint Open 2020;1-6:272–280

Introduction. Although multiple studies have consistently demonstrated that orthopaedic surgeons receive greater transfers of value than other specialties, the industry payments of providers involved in practice guideline formation have not been explored. Therefore, the purpose of our analysis was to evaluate the industry payments among authors of the Appropriate Use Criteria (AUC) from the American Academy of Orthopaedic Surgeons (AAOS). Methods. The publicly available web portal (. OrthoGuidelines.org. ) from the AAOS was queried for all AUCs released over the past decade for the management of musculoskeletal pathologies. For each AUC available through this portal, information related to the AUC and its respective voting members were recorded. We used this information to conduct a retrospective cross-sectional analysis of the CMS Open Payments Database. This information was utilized to determine the number of total value of industry payments to AUC voting committee members during the year of voting for AUC criteria. The total amount of industry payment to AUC voting members was calculated, per each AUC, annually, as well as per orthopaedic subspecialty. The average total industry payment per voting member was calculated for each AUC and compared with the average total industry payment per orthopaedic surgeon nationally, in the same year. All descriptive data analyses were performed in Microsoft Excel 2016 (MicrosoftCorp). Results. A total of 18 different AUCs were included in our analysis. Among the 214 voting members of these AUCs, there was a mean (± standard deviation) of 16.23 (± 39.80) payments totaling USD$20,886.30 (± $123,268.95). Combined industry payments for the voting authors of each guideline ranged from $1,432.53 (Carpal Tunnel Syndrome guideline) to $2,757,444.88 (Surgery for Degenerative Lumbar Scoliosis guideline) (Table 1). Notably, the average payment per voting member was less than the average for all orthopaedic providers in the respective year for a majority (16/18) of AUCs (Table 1). Only average payments of voting members for the Non-Surgical Management Knee Osteoarthritis guideline (13,089.38 vs. $8,183.93) and Surgery for Degenerative Lumbar Scoliosis ($250,676.81 vs. $16,477.55) exceeded yearly averages among all orthopaedic surgeons with payment disclosures. Although authors for AUCs related to osteoarthritis management received the largest quantity of payments (n=491; Figure 1), the AUCs for spine related pathologies received the largest amount of industry payments ($2,757,444.88; Figure 2). Discussion and Conclusion. Our analysis demonstrated that authors on current AAOS appropriate use criteria voting panels collectively received low amounts of industry payments. Specifically, a majority of authors declared industry payments lower than the average value reported among all orthopadic providers per respective year. Therefore, our analysis suggests that there has been limited industry influence in the formation of these practice guidelines. This information should provide peace of mind for invested parties and encourage providers engaged in the formation of future guidelines to limit and fully disclose relationships with industry. Future analyses are needed to evaluate if and how industry relationships among individual providers and the boards of orthopaedic societies shape practice decisions. For any figures or tables, please contact the authors directly

This study used the lunge test to measure the difference between ankle dorsiflexion with the knee flexed and extended in persons with and without foot and ankle pathology. This may help us devise a weight bearing test for GT. Rationale. There is little credible research comparing GT in people with and without foot and ankle pathology. There is no normative data for ankle dorsiflexion range measured using a Lunge test and prevalence of GT in the normal population. Methodology. 97 ankles with foot and ankle (FA) pathology and 89 ankles of healthy volunteers (HV) without FA pathology were recruited from the royal national orthopaedic hospital (RNOH). Degrees of ankle dorsiflexion range were measured using an inclinometer and a version of the lunge test with the knee flexed and extended. These findings were then compared between groups. Results. The difference between FA vs HV for knee flexed: Ankle dorsiflexion with the knee flexed was lower in the FA group (mean=27.56 degrees, SD=8.10) than the HV group (mean=29.95 degrees, SD=6.37) however, the mean difference (2.39 degrees) between the groups was not statistically significant (p=0.30 [CI 2.40–4.54]). The difference between FA vs HV for knee extended: Ankle dorsiflexion was lower in the FA group (mean=22.02 degrees, SD=8.27) than the HV group (mean = 26.25 degrees, SD=6.04) with the knee extended. The mean difference (4.23 degrees) between the groups was statistically significant (p=< 0.001 [CI 2.11–6.34]); Cohens d=0.58. The difference in ankle dorsiflexion between knee positions in FA vs HV: The difference in ankle dorsiflexion between knee positions was higher in the FA group (mean=5.62 degrees, SD=4.41) than the HV group (mean=3.62 degrees, SD=3.12). The mean difference (1.996 degrees) between the groups was statistically significant (p=0.001 [CI 0.88–3.11]); Cohens d=0.52. Conclusion. FA patients have significantly lower ranges of ankle dorsiflexion with the knee extended when compared to controls using the lunge test. The difference in ankle dorsiflexion between knee positions is significantly higher in FA patients when compared to controls; this may be attributable to GT. We aim to continue recruiting healthy controls, patients with FA pathology and patients with other musculoskeletal pathology to show the prevalence of GT in the general population. These findings could improve both conservative and surgical management of GT in associated musculoskeletal pathology

A good understanding of musculoskeletal pathologies not only requires a good knowledge of normal human anatomy but also an insight in human evolution and development. Biomechanical studies of the musculoskeletal system have greatly improved our understanding of the human musculoskeletal system via medical imaging, modeling and simulation techniques. The same techniques are, however, also used in the study of nonhuman species and a comparison of human and nonhuman data can yield interesting insight in form-function relationships and mechanical constraints on motion. Anatomical and biomechanical studies on dogs and rabbits have already yielded valuable insight in disease mechanisms and development of musculoskeletal pathologies such as osteoarthritis (OA). Nonhuman primates have, however, rarely been studied in this context, though they may prove particularly valuable as they can provide us with an evolutionary context of modern human anatomy and pathology. The high prevalence of osteoarthritis in modern humans and its rare occurrence in wild primates has previously been explained as due to human joints being ‘underutilized’ or ‘underdesigned’. Modern humans are highly specialized for bipedalism, while nonhuman primates typically use a wide range of locomotor modes and joint postures to travel through the three-dimensionally complex forest canopy. These hypotheses can, however, be challenged, as it seems more likely that the low occurrence of OA in wild primates is due to a combination of underreporting of the disease and absence of the ageing effect in these species. Our understanding of musculoskeletal function and disease in modern humans would clearly benefit from more studies investigating the occurrence and characteristics of OA in nonhuman primates

Aims

The COVID-19 pandemic has caused unprecedented disruption to elective orthopaedic services. The primary objective of this study was to examine changes in functional scores in patients awaiting total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty (UKA). Secondary objectives were to investigate differences between these groups and identify those in a health state ‘worse than death’ (WTD).

Aims

This study aimed to analyze kinematics and kinetics of the tibiofemoral joint in healthy subjects with valgus, neutral, and varus limb alignment throughout multiple gait activities using dynamic videofluoroscopy.

Purpose:. To explore clinicians' perceptions of empathy during musculoskeletal clinical consultations. Background:. Empathy is considered essential to creating a positive experience within healthcare for both the patient and clinician, improving adherence, creating trust and improving patient experience. However, little is known about how clinicians acquire and display empathic communication skills during musculoskeletal consultations. Methods:. In this qualitative study, 11 physiotherapists and 6 students participated in three focus groups, separated by clinical grade. The definition of empathy, its acquisition and impact on clinical practice were discussed, audio-recorded, transcribed verbatim and analysed. Data were managed using a Framework approach, and key themes identified. Results:. The data from 17 participants comprised 149 minutes of audio recording. Six key themes and 48 sub-themes were identified. Empathy was considered a key component of communication and similarly defined in all three focus groups; however divergence surrounded how it is acquired, the extent it can be taught and whether a clinician's personality influences their career pathway. Experienced clinicians highlighted greater importance and impact of empathic communication in practice than novices, whilst novices considered a lack of time a key barrier in preventing empathic communication. Discussion:. There is a mismatch between the importance attributed to empathic communication in the literature and by clinicians, compared with the time and energy spent acquiring and developing these skills. Conclusion:. Displaying genuine empathy is considered essential to building rapport and optimising non-specific treatment effects in clinical practice, however clinicians need greater awareness and engagement to further these skills for patient benefit

Ancient Egypt was a highly developed agrarian society with a massive civil engineering capability. Trauma and skeletal disease were common and vestiges of the evidence for that survive, largely in the form of hieratic images and papyri dedicated to the practice of medicine. The earliest treatise on trauma is the Edwin Smith papyrus, possibly the work of Imhotep. This study details some remarkable examples of musculoskeletal pathology including fatal open fractures, foot deformity of Tutankhamun, and the earliest recorded instances of child abuse

Diagnosing musculoskeletal pathology from radiographs is an important skill in orthopaedics and emergency medicine. Knowing which fractures are more likely to be missed allows a high index of suspicion when looking at certain radiographs. Likewise, knowing which fractures will be rigorously followed up if they are missed helps to increase index of suspicion for those fractures. Therefore we used a prospectively gathered database of missed radiographic diagnoses to determine which injuries are missed most commonly and how these injuries are followed up. Four hundred and thirty two missed radiographic diagnoses were recorded from a total of thirty seven thousand, two hundred and seventy nine radiographs (37,279) in an emergency medicine department over three years. The most common area in which fractures were missed was the foot (22%), followed by hand (19%) and wrist (15%). The most common diagnosis to be missed was fracture of a proximal phalanx, followed by fracture of a distal radius and fracture of a metatarsal. The hip, knee, cervical spine and wrist were the areas most likely to be followed up, each with 32–35% of missed diagnoses being followed up in this way. The areas most likely to be further imaged with CT or MRI were the knee and hip. Two of the missed fractured femurs were managed operatively. Our results show that missed radiographic diagnosis are most commonly of the foot and hand, and that missed diagnosis of knee and femur fractures are followed up most rigorously. By showing which radiographs are most likely to contain missed fractures, and what these fractures are, we allow orthopaedic trainees to increase their level of diagnostic suspicion when reviewing these radiographs

Purpose: Gait analysis has become an innovative approach to assess the biomechanical adaptations due to an ACL injury. However, interpreting the large amount of data collected often requires an expert. Therefore, there is a need to develop an automatic method capable to distinguish kinetic pattern of an ACL deficient patients from an asymptomatic population. Method: 26 ACL deficient patients and 30 asymptomatic participants took part in a treadmill gait analysis. 3D ground reaction forces (vertical, medio-lateral and anterior-posterior) were collected using the ADAL 3D treadmill. Features were extracted from the 3D ground reaction forces as a function of time and then classified by the nearest neighbour rule using a wavelet decomposition method. The classification method was tested on our data base of 56 participants. Results: The proposed classification method obtained an accuracy of 90%. The classification accuracy per class was higher for the ACL deficient group allowing classifying correctly 25 out of 26 ACL deficient patient. 25 out of the 30 asymptomatic participants were properly classified. Conclusion: This study shows that an automatic objective computer method could be used in a clinical setting to help diagnose an anterior cruciate ligament injury during a gait analysis evaluation. Future studies should apply this method on a larger database including data from patients with other musculoskeletal pathologies to help diagnose other injuries

Elbow contracture is a well recognised sequel of neuromuscular disorders and can be a rather debilitating condition. Non operative treatment, such as physiotherapy and splinting, results in an improved range of motion, but since musculoskeletal pathology in neuromuscular diseases is progressive, an open surgical release of the elbow is often required. Therefore, the purpose of the present study was to assess the results of surgical treatment of elbow stiffness in patients suffering from neuromuscular disorders. Between January 2000 and October 2008, 11 patients with neuromuscular diseases underwent surgical treatment of elbow contracture. The mean age of the patients was 21 years. Eight patients had cerebral palsy, 2 arthrogryposis and 1 brachial plexus palsy. Pre-operatively the lag of elbow flexion and extension was 45° and 38° respectively. In 6 patients releases were performed through a lateral approach, while 3 required an additional medial incision. In 2 patients the pathology was addressed through a posterior approach. The mean follow up was 26 months. Postoperatively one patient developed skin necrosis which was treated conservatively. Furthermore, another patient developed transient ulnar neuritis, and finally one more presented with medial collateral ligament insufficiency. All patients had an improved functional arc of motion. Namely, the lag of elbow flexion and extension was reduced to 22° and 10° respectively. At the final follow up the patients maintained 90% of the range of motion that was achieved immediately postoperatively. Open release of the elbow contracture in neuromuscular diseases yield satisfactory results. Therefore, it can be expected that patients will obtain a functional range of motion

Background: The aim of this study is to evaluate the efficacy of extracorpereal shock wave therapy (ESWT) in some of most frequent muscularskeletal pathologies. Material and methods: From July to October 2004 310 patients were treated with ESWT, suffering from the following pathologies: 96 symptomatic calcific tendonitis of the shoulder, 53 symptomatic sub-acromial impingement, 48 humeral epichondylitis, 52 plantar fasciitis, 24 pertrochanteric bursitis, 15 Achilleous tendinopathy and 22 patellar tendinopathy. Patients were evaluated clinically and instrumentally before the first application and at one and three months of follow-up. Three disability scales we utilized (NRS, Mcgill Pain Questionnaire e Chronic Pain Grade Questionnaire). Results: We observed a reduction of the pain and an increase of the articular functionality in 83% of calcific tendonitis of the shoulder, in 55% of sub-acromial impingement, in 76% of epichondylitis, in 74% of palantar fasciitis, in 90% of pertrochanteric bursitis, in 82% of Achilleous tendinopathy and in 86% of patellar tendinopaty. Discussion: The data confirm the therapy with ESWT is efficient in some of most frequent musculoskeletal pathologies, with variable outcome in the various pathologies under investigation