Three Sessions of Radial Extracorporeal Shockwave Therapy Gives No Additional Benefit Over "Minimal-Dose" Radial Extracorporeal Shockwave Therapy for Patients With Chronic Greater Trochanteric Pain Syndrome: A Double-Blinded, Randomized, Controlled Trial.

OBJECTIVE: To investigate the outcomes following 3 weekly sessions of radial extracorporeal shockwave therapy (rESWT) in patients with chronic greater trochanteric pain syndrome (GTPS) presenting to an NHS Sports Medicine Clinic in the United Kingdom. DESIGN: Double-blinded randomized controlled trial. SETTING: A single NHS Sports Medicine Clinic, in the United Kingdom. PATIENTS: One hundred twenty patients in an NHS Sports Medicine clinic presenting with symptoms of GTPS who had failed to improve with a minimum of 3 months of rehabilitation were enrolled in the study and randomized equally to the intervention and treatment groups. Mean age was 60.6 ± 11.5 years; 82% were female, and the mean duration of symptoms was 45.4 ± 33.4 months (range, 6 months to 30 years). INTERVENTIONS: Participants were randomized to receive either 3 sessions of ESWT at either the "recommended"/"maximally comfortably tolerated" dose or at "minimal dose." All patients received a structured home exercise program involving flexibility, strength, and balance exercises. MAIN OUTCOME MEASURES: Follow-up was at 6 weeks, 3 months, and 6 months. Outcome measures included local hip pain, validated hip PROMs (Oxford hip score, non-arthritic hip score, Victorian Institute of Sport assessment questionnaire), and wider measures of function including sleep (Pittsburgh sleep quality index) and mood (hospital anxiety and depression scale). RESULTS: Results were available for 98% of patients at the 6-month period. There were statistically significant within-group improvements in pain, local function, and sleep seen in both groups. However, fewer benefits were seen in other outcome measures, including activity or mood. CONCLUSION: There were no time × group interaction effects seen between the groups at any time point, indicating that in the 3 sessions, the "recommended-dose" rESWT had no measurable benefit compared with "minimal dose" rESWT in this group of patients with GTPS. The underlying reason remains unclear; it may be that rESWT is ineffective in the treatment of patients with chronic GTPS, that "minimal dose" rESWT is sufficient for a therapeutic effect, or that a greater number of treatment sessions are required for maximal benefit. These issues need to be considered in further research.

Nutrition for swimming.

Swimming is a sport that requires considerable training commitment to reach individual performance goals. Nutrition requirements are specific to the macrocycle, microcycle, and individual session. Swimmers should ensure suitable energy availability to support training while maintaining long term health. Carbohydrate intake, both over the day and in relation to a workout, should be manipulated (3-10 g/kg of body mass/day) according to the fuel demands of training and the varying importance of undertaking these sessions with high carbohydrate availability. Swimmers should aim to consume 0.3 g of high-biological-value protein per kilogram of body mass immediately after key sessions and at regular intervals throughout the day to promote tissue adaptation. A mixed diet consisting of a variety of nutrient-dense food choices should be sufficient to meet the micronutrient requirements of most swimmers. Specific dietary supplements may prove beneficial to swimmers in unique situations, but should be tried only with the support of trained professionals. All swimmers, particularly adolescent and youth swimmers, are encouraged to focus on a well-planned diet to maximize training performance, which ensures sufficient energy availability especially during periods of growth and development. Swimmers are encouraged to avoid rapid weight fluctuations; rather, optimal body composition should be achieved over longer periods by modest dietary modifications that improve their food choices. During periods of reduced energy expenditure (taper, injury, off season) swimmers are encouraged to match energy intake to requirement. Swimmers undertaking demanding competition programs should ensure suitable recovery practices are used to maintain adequate glycogen stores over the entirety of the competition period.

Autologous Blood Injection With Dry-Needling vs Dry-Needling Alone Treatment for Chronic Plantar Fasciitis: A Randomized Controlled Trial.

BACKGROUND: Autologous blood injection (ABI) for patients with chronic plantar fasciitis has been promoted as an approach to improve outcomes over standard dry-needling approaches. The purpose of this trial was to investigate if there are improved outcomes following an ultrasonography-guided ABI compared to dry needling alone for patients with chronic plantar fasciitis. METHODS: A double-blinded (participant-blinded and observer-blinded) RCT within a single clinic enrolled 90 patients with symptoms of plantar fasciitis that had failed to improve with a minimum of 3 months of rehabilitation. The mean age was 49.5±8.9 years, 67% were female, and the mean symptom duration was 40.0±28.2 months (range: 8 months-10 years). Participants were randomized to receive ABI or an identical dry-needle fenestration-procedure without coadministration of autologous blood. All participants received identical structured rehabilitation and were followed up at 2, 6, 12, and 26 weeks. Outcome measures included local foot pain, validated foot patient-reported outcome measures (Foot Function Index-revised, Manchester-Oxford Foot Questionnaire, Foot and Ankle Ability Measure), measures of general function and "ability" (EuroQol [EQ]-5D-5L, Oswestry Disability Index), specific measures of activity (International Physical Activity Questionnaire), sleep (Pittsburgh Sleep Quality Index), and mood (Hospital Anxiety and Depression Scale). RESULTS: There were no significant between-group differences seen at any time-point studied. There were a number of statistically significant within-group improvements for local foot pain and function in both groups comparing baseline/follow-up data. Overall, levels of pain improved by 25% by 6 weeks and by 50% at 6 months. There were improvements in some generalized function markers. Activity rates did not change, demonstrating that improvements in pain did not necessarily influence physical activity. CONCLUSION: Coadministration of 3 mL of autologous blood had no additional effect compared to a dry-needling procedure alone for patients with chronic plantar fasciitis. LEVEL OF EVIDENCE: Level I, double-blinded randomized controlled trial.

Meniscus preservation; rationale, repair techniques and results.

It is inescapable that loss of part or all of the structure of the meniscus of the knee alters the biomechanics of knee function leading to a gradual deterioration of the chondral surface, which ultimately will result in osteoarthritis. The goal of the knee surgeon should therefore be to preserve as much as possible the function of the meniscus. Classic teaching is that many meniscal tears, which are peripheral and longtitudinal, will heal if sutured and protected during a slow healing process. However it is clear that other tear configurations can heal if given the opportunity by adequate preparation of the meniscus rim, careful suturing and delayed rehabilitation. Thus some radial tears, horn avulsions, double longtitudinal tears and retears, previously thought to be irreparable, can be sutured with good results. Over 12 years, 288 meniscus repairs were undertaken in 265 patients ranging in age from 12 to 70 years. Most were repaired at the time of anterior cruciate ligament reconstruction, although 55 were isolated repairs. While the average time from injury to surgery was 11.7 months (1 - 72), one third of patient's already had chondral damage of at least Outerbridge Grade 2. The purpose of this paper is to report on the more difficult meniscus repair techniques and as such formal follow up was not undertaken to determine the final outcome of these patients. Never the less it is estimated from known data that there was a retear rate in the order of less than 10%. There have been three complications, 2 infections and one temporary neuropraxia of the common peroneal nerve; all of these healed completely with appropriate treatment. Therefore we recommend that meniscus repair should be undertaken if a clinical case for meniscal preservation exists, even if the appearances are not those classically recommended.

Concomitant talar neck fracture and Achilles tendon rupture.

A 56-year-old man fell down 1 m from a ladder and sustained a forced dorsiflexion injury to his right ankle when his foot contacted a lower rung, which resulted in the rare combination of a Hawkins II fracture of the neck of the talus and a concomitant rupture of the Achilles tendon. Clinical examination and diagnostic imaging confirmed the injuries, and surgical fixation of the fracture and repair of the Achilles tendon were achieved by means of a posterior approach. Healing proceeded unremarkably, and, at 18 months postoperatively, the patient had regained full function despite a 5 degrees limitation of subtalar joint range of motion.