Patient specific instrumentation in ACL reconstruction: a proof-of-concept cadaver experiment assessing drilling accuracy when using 3D printed guides.

INTRODUCTION: Accurate positioning of the femoral tunnel in ACL reconstruction is of the utmost importance to reduce the risk of graft failure. Limited visibility during arthroscopy and a wide anatomical variance attribute to femoral tunnel malposition using conventional surgical techniques. The purpose of this study was to determine whether a patient specific 3D printed surgical guide allows for in vitro femoral tunnel positioning within 2 mm of the planned tunnel position. MATERIALS AND METHODS: A patient specific guide for femoral tunnel positioning in ACL reconstruction was created for four human cadaveric knee specimens based on routine clinical MRI data. Fitting properties were judged by two orthopedic surgeons. MRI scanning was performed both pre- and post-procedure. The planned tunnel endpoint was compared to the actual drilled femoral tunnel. RESULTS: This patient specific 3D printed guide showed a mean deviation of 5.0 mm from the center of the planned femoral ACL origin. CONCLUSION: In search to improve accuracy and consistency of femoral tunnel positioning in ACL reconstruction, the use of a patient specific 3D printed surgical guide is a viable option to explore further. The results are comparable to those of conventional techniques; however, further design improvements are necessary to improve accuracy and enhance reproducibility.

Compensatory Movement Patterns Are Based on Abnormal Activity of the Biceps Brachii and Posterior Deltoid Muscles in Patients with Symptomatic Rotator Cuff Tears.

BACKGROUND: Abnormal movement patterns due to compensatory mechanisms have been reported in patients with rotator cuff tears. The long head of the biceps tendon may especially be overactive and a source of pain and could induce abnormal muscle activation in these patients. It is still unknown why some patients with a rotator cuff tear develop complaints and others do not. QUESTIONS/PURPOSES: (1) Which shoulder muscles show a different activation pattern on electromyography (EMG) while performing the Functional Impairment Test-Hand and Neck/Shoulder/Arm (FIT-HaNSA) in patients with a symptomatic rotator cuff tear compared with age-matched controls with an intact rotator cuff? (2) Which shoulder muscles are coactivated on EMG while performing the FIT-HaNSA? METHODS: This comparative study included two groups of people aged 50 years and older: a group of patients with chronic symptomatic rotator cuff tears (confirmed by MRI or ultrasound with the exclusion of Patte stage 3 and massive rotator cuff tears) and a control group of volunteers without shoulder conditions. Starting January 2019, 12 patients with a chronic rotator cuff tear were consecutively recruited at the outpatient orthopaedic clinic. Eleven age-matched controls (randomly recruited by posters in the hospital) were included after assuring the absence of shoulder complaints and an intact rotator cuff on ultrasound imaging. The upper limb was examined using the FIT-HaNSA (score: 0 [worst] to 300 seconds [best]), shoulder-specific instruments, health-related quality of life, and EMG recordings of 10 shoulder girdle muscles while performing a tailored FIT-HaNSA. RESULTS: EMG (normalized root mean square amplitudes) revealed hyperactivity of the posterior deltoid and biceps brachii muscles during the upward phase in patients with rotator cuff tears compared with controls (posterior deltoid: 111% ± 6% versus 102% ± 10%, mean difference -9 [95% confidence interval -17 to -1]; p = 0.03; biceps brachii: 118% ± 7% versus 111% ± 6%, mean difference -7 [95% CI -13 to 0]; p = 0.04), and there was decreased activity during the downward phase in patients with rotator cuff tears compared with controls (posterior deltoid: 89% ± 6% versus 98% ± 10%, mean difference 9 [95% CI 1 to 17]; p = 0.03; biceps brachii: 82% ± 7% versus 89% ± 6%, mean difference 7 [95% CI 0 to 14]; p = 0.03). The posterior deltoid functioned less in conjunction with the other deltoid muscles, and lower coactivation was seen in the remaining intact rotator cuff muscles in the rotator cuff tear group than in the control group. CONCLUSION: Patients with a symptomatic rotator cuff tear show compensatory movement patterns based on abnormal activity of the biceps brachii and posterior deltoid muscles when compared with age-matched controls. The posterior deltoid functions less in conjunction with the other deltoid muscles, and lower coactivation was seen in the remaining intact rotator cuff muscles in the rotator cuff tear group than the control group. CLINICAL RELEVANCE: This study supports the potential benefit of addressing the long head biceps tendon in the treatment of patients with a symptomatic rotator cuff tear. Moreover, clinicians might use these findings for conservative treatment; the posterior deltoid can be specifically trained to help compensate for the deficient rotator cuff.

Arthroscopic isolated long head of biceps tenotomy in patients with degenerative rotator cuff tears: mid-term clinical results and prognostic factors.

INTRODUCTION: The long head of biceps tendon is frequently involved in degenerative rotator cuff tears. Therefore, this study explored the clinical results of an isolated biceps tenotomy and identified prognostic factors for improvement in pain and function. MATERIALS AND METHODS: Between 2008 and 2017, an arthroscopic isolated biceps tenotomy was performed on 64 patients with a degenerative rotator cuff tear (> 65 years). Primary outcome was patient-perceived improvement in pain and function. Potential prognostic factors for improvement in pain and function were identified. RESULTS: A perceived improvement in pain was reported in 78% of the patients at three months after surgery and in 75% at a mean follow-up of 4.2 years (1-7 years; n = 55). A perceived improvement in function was observed in 49% of patients at three months and in 76% of patients at follow-up. Patients with a preoperatively normal acromiohumeral distance (> 10 mm) reported an improvement in pain and function significantly more often. Retraction of the supraspinatus tendon Patte 3 was significantly associated with worse functional outcome. CONCLUSIONS: A biceps tenotomy can be a reliable treatment option for patients with symptomatic degenerative cuff tears who fail conservative treatment and have a normal acromiohumeral distance (> 10 mm).

The Achilles tendon Total Rupture Score is a responsive primary outcome measure: an evaluation of the Dutch version including minimally important change.

PURPOSE: Aim of this study was to evaluate the responsiveness of the Dutch version of the Achilles tendon Total Rupture Score (ATRS-NL). METHODS: Patients (N = 47) completed the ATRS-NL at 3 and 6 months after Achilles tendon rupture (ATR). Additionally, they filled out the Euroqol-5D-5L (EQ-5D-5L) and Global Rating of Change Score (GRoC). Effect sizes (ES) and standardized response means (SRM) were calculated. The anchor-based method for determining the minimally important change (MIC) was used. GRoC and improvement on the items mobility and usual activities on the EQ-5D-5L served as external criteria. The scores on these anchors were used to categorize patients' physical functioning as improved or unchanged between 3 and 6 months after ATR. Receiver operating curve (ROC) analysis was performed, with the calculation of the area under the ROC curve (AUC) and the estimation of MIC values using the optimal cut-off points. RESULTS: There was a large change (ES: 1.58) and good responsiveness (SRM: 1.19) of the ATRS-NL between 3 and 6 months after ATR. Using ROC analysis, the MIC values ranged from 13.5 to 28.5 for reporting improvement on EQ-5D-5L mobility and GRoC, respectively. The AUC of improvement on mobility and improvement on GRoC were > 0.70. CONCLUSION: The ATRS-NL showed good responsiveness in ATR patients between 3 and 6 months after injury. Use of this questionnaire is recommended in clinical follow-up and longitudinal research of ATR patients. MIC values of 13.5 and 28.5 are recommended to consider ATR patients as improved and greatly improved between 3 and 6 months after ATR. LEVEL OF EVIDENCE: II.

Biceps Autograft Augmentation for Rotator Cuff Repair: A Systematic Review.

PURPOSE: To improve surgical outcomes in patients with massive cuff defects, different techniques and augmentations are proposed. The biceps tendon is easily available as an autograft. Our aim was to conduct a qualitative systematic review of various methods and surgical techniques that use a biceps autograft (BAG) for rotator cuff repair. Functional outcomes are also reported. We hypothesized that by using a BAG to treat massive rotator cuff tears, a more anatomic and biomechanical reconstruction could be achieved compared with other techniques. METHODS: A qualitative systematic review was conducted (MEDLINE and Embase databases) to inventory surgical techniques for use of a BAG for rotator cuff repair. The following search terms were used for MEDLINE: biceps AND (augment* OR autograft* OR transplantation* OR (cuff AND graft*) OR biceps-incorporat*). Studies were included if the following criteria were fulfilled: description of surgical technique, only human subjects, functional outcomes noted, all study designs except technical notes, and no restrictions on study date. The quality of the studies was assessed in a standardized manner using a tool based on the Cochrane handbook. RESULTS: We identified 981 studies; among these, 8 case series met the inclusion criteria. We identified 6 studies as high quality and 2 as medium quality. Different techniques for harvest and augmentation were used. Some studies left the proximal or distal portion intact, whereas others used it as a free graft. The clinical results of these studies showed significantly improved function, pain relief, and range of motion at follow-up, although this was not compared with a control group. The constructs were intact on magnetic resonance imaging in most patients (82%) within 2 years. CONCLUSIONS: It can be concluded that use of a BAG is an option for augmentation in massive rotator cuff tears, although no definitive recommendations can be given. This is based on Level IV medium- and high-quality studies. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

Shoulder Stiffness: Current Concepts and Concerns.

UNLABELLED: Shoulder stiffness can be caused by various etiologies such as immobilization, trauma, or surgical interventions. The Upper Extremity Committee of ISAKOS defined the term "frozen shoulder" as idiopathic stiff shoulder, that is, without a known cause. Secondary stiff shoulder is a term that should be used to describe shoulder stiffness with a known cause. The pathophysiology of frozen shoulder is capsular fibrosis and inflammation with chondrogenesis, but the cause is still unknown. Conservative treatment is the primary choice. Pain control by oral medication, intra-articular injections with or without joint distension, and physical therapy are commonly used. In cases with refractory stiffness, manipulation under anesthesia or arthroscopic capsular release may be indicated. Because of various potential risks of complications with manipulations, arthroscopic capsular release is preferred. After the capsular release, stepwise rehabilitation is mandatory to achieve satisfactory outcome. LEVEL OF EVIDENCE: Level V, evidence-based review.

Comparing surgical repair with conservative treatment for degenerative rotator cuff tears: a randomized controlled trial.

BACKGROUND: Good clinical results have been reported for both surgical and conservative treatment of rotator cuff tears. The primary aim of this randomized controlled trial was to compare functional and radiologic improvement after surgical and conservative treatment of degenerative rotator cuff tears. METHODS: We conducted a randomized controlled trial that included 56 patients with a degenerative full-thickness rotator cuff tear between January 2009 and December 2012; 31 patients were treated conservatively, and rotator cuff repair was performed in 25 patients. Outcome measures, including the Constant-Murley score (CMS), visual analog scale (VAS) pain and VAS disability scores, were assessed preoperatively and after 6 weeks and 3, 6, and 12 months. Magnetic resonance imaging was performed preoperatively and at 12 months postoperatively. RESULTS: At 12 months postoperatively, the mean CMS was 81.9 (standard deviation [SD], 15.6) in the surgery group vs 73.7 (SD, 18.4) in the conservative group (P = .08). VAS pain (P = .04) and VAS disability (P = .02) were significantly lower in the surgery group at the 12-month follow-up. A subgroup analysis showed postoperative CMS results were significantly better in surgically treated patients without a retear compared with conservatively treated patients (88.5 [SD, 6.2] vs 73.7 [SD, 18.4]). CONCLUSION: In our population of patients with degenerative rotator cuff tears who were randomly treated by surgery or conservative protocol, we did not observe differences in functional outcome as measured with the CMS 1 year after treatment. However, significant differences in pain and disabilities were observed in favor of surgical treatment. The best outcomes in function and pain were seen in patients with an intact rotator cuff postoperatively.

Cross-cultural adaptation and reliability and validity of the Dutch Patient-Rated Tennis Elbow Evaluation (PRTEE-D).

BACKGROUND: Lateral Epicondylalgia (LE) is a common injury for which no reliable and valid measure exists to determine severity in the Dutch language. The Patient-Rated Tennis Elbow Evaluation (PRTEE) is the first questionnaire specifically designed for LE but in English. The aim of this study was to translate into Dutch and cross-culturally adapt the PRTEE and determine reliability and validity of the PRTEE-D (Dutch version). METHODS: The PRTEE was cross-culturally adapted according to international guidelines. Participants (n = 122) were asked to fill out the PRTEE-D twice with a one week interval to assess test-retest reliability. Internal consistency of the PRTEE-D was determined by calculating Crohnbach's alphas for the questionnaire and subscales. Intraclass Correlation Coefficients (ICC) were calculated for the overall PRTEE-D score, pain and function subscale and individual questions to determine test-retest reliability. Additionally, the Disabilities for the Arm, Shoulder and Hand questionnaire (DASH) and Visual Analogue Scale (VAS) pain scores were obtained from 30 patients to assess construct validity; Spearman's correlation coefficients were calculated between the PRTEE-D (subscales) and DASH and VAS-pain scores. RESULTS: The PRTEE was successfully cross-culturally adapted into Dutch (PRTEE-D). Crohnbach's alpha for the first assessment of the PRTEE-D was 0.98; Crohnbach's alpha was 0.93 for the pain subscale and 0.97 for the function subscale. ICC for the PRTEE-D was 0.98; subscales also showed excellent ICC values (pain scale 0.97 and function scale 0.97). A significant moderate correlation exists between PRTEE-D and DASH (0.65) and PRTEE-D and VAS pain (0.68). CONCLUSION: The PRTEE was successfully cross-culturally adapted and this study showed that the PRTEE-D is reliable and valid to obtain an indication of severity of LE. An easy-to-use instrument for practitioners is now available and this facilitates comparing Dutch and international research data.

A comprehensive multidisciplinary care pathway for hip fractures better outcome than usual care?

INTRODUCTION: Hip fracture surgery is among the most performed surgical procedures in elderly patients. Mortality rates are high, however, and patients often fail to live independently following a hip fracture. To improve outcome, multidisciplinary care pathways have been initiated, but longer-term results are lacking. Aim of this study was to compare functional outcome and living situation six months after hip fracture treatment with and without a care pathway. PATIENTS AND METHODS: A multicentre prospective controlled trial was conducted with three hospitals: in one hospital patients were treated with a care pathway, in the other hospitals patients received usual care. All patients aged ≥ 60 years with a hip fracture were asked to participate. Besides basic characteristics, health-related quality of life (EQ-5D) and performance scores of activities of daily living (Katz Index and Lawton IADL) were assessed. Differences in scores were analysed using linear regression. Propensity score adjustment was used to correct for differences between the care pathway and the usual care group. Missing data were imputed. RESULTS: No differences in rate of return to prefracture ADL level were found between patients in the care pathway group and the usual care group. The percentage of participants in the same situation as before the fracture was the same in both treatment groups (81%). There were no significant differences in quality of life, activities of daily living or mortality (15% vs 10%, p = 0.17), but hospital stay in the care pathway group was significantly shorter (median 7 vs 10 days). DISCUSSION: Treatment of elderly patients with a hip fracture is commonly organised in care pathways. Although short-term advantages are reported, positive effects on longer-term functional results could not be proven in our study. This study confirmed a shorter hospital stay in the care pathway group, which potentially may lead to a reduction in costs. CONCLUSIONS: Functional outcome and living situation six months after a hip fracture is the same for patients treated with or without a care pathway.

The results of using a tendon autograft as a new rotator cable for patients with a massive rotator cuff tear: a technical note and comparative outcome analysis.

BACKGROUND: Several surgical reconstructive options are available to treat massive rotator cuff tears (MRCTs). The rotator cable has an important function and we evaluated the clinical result after arthroscopic reconstruction of the rotator cable with an autograft tendon. METHODS: A prospective pilot study was performed with inclusion of four patients, average age of 64 years, with an irreparable MRCT. The patients underwent an arthroscopic reconstruction of the rotator cable with the use of the long head of biceps tendon autograft, except for one which was reconstructed with a hamstring tendon. Pre- and postsurgically, the Constant-Murley Score (CMS), Western Ontario Rotator Cuff Index (WORC), Simple Shoulder Test (SST), visual analog scale (VAS) scores, and an MRI was performed. Clinical results of the study group were compared with clinical results of comparable cohort of patients with a MRCT, treated non-operatively with physiotherapy. RESULTS: The CMS score increased after surgery in three of the four patients. The improvement of CMS score was comparable to the improvement of the CMS score encountered in a comparable cohort. The MRI at 12 months follow-up showed that the reconstructed rotator cable was disintegrated in all patients and the rotator cuff was detached and retracted. CONCLUSIONS: In our pilot study, arthroscopic reconstruction of the rotator cable using a tendon autograft failed over time and showed no clinical benefit in comparison to the non-operative treatment with physiotherapy. TRIAL REGISTRATION: The regional Medical Ethical Committee (Zwolle) gave approval at 14th of October 2016 and assigned no. 16.06100.

Effect of ACL Reconstruction on Range of Tibial Rotation: A Systematic Review of Current Literature and a Recommendation for a Standard Measuring Protocol.

BACKGROUND: Tibial rotation is an important topic in anterior cruciate ligament (ACL) surgery, and many efforts are being made to address rotational stability. The exact role of the ACL in controlling tibial rotation in clinical studies is unknown. PURPOSE: To quantify the effect of ACL reconstruction on the amount of tibial rotation based on the current available literature. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A literature search of the PubMed and EMBASE databases was performed in August 2019. Two independent reviewers reviewed titles and abstracts as well as full-text articles. A total of 2383 studies were screened for eligibility. After screening of titles and abstracts, 178 articles remained for full-text assessment. Ultimately, 13 studies were included for analysis. A quality assessment was performed by means of the RoB 2.0 (revised tool for Risk of Bias in randomized trials) and the ROBINS-I (Risk Of Bias In Non-randomized Studies-of Interventions) tools. RESULTS: According to the studies using computer-assisted surgery that were included in this review, ACL reconstruction resulted in an average reduction in tibial rotation of 17% to 32% compared with preoperatively; whether the range of tibial rotation returned to preinjury levels remained unclear. In the current literature, a gold standard for measuring tibial rotation is lacking. Major differences between the study protocols were found. Several techniques for measuring tibial rotation were used, each with its own limitations. Most studies lacked proper description of accompanying injuries. CONCLUSION: ACL reconstruction reduced the range of tibial rotation by 17% to 32%. Normal values for the range of tibial rotation in patients with ACL deficiency and those who undergo ACL reconstruction could not be provided based on the current available literature owing to a lack of uniform measuring techniques and protocols. Therefore, we advocate uniformity in measuring tibial rotation.

Implementing Individually Tailored Prescription of Physical Activity in Routine Clinical Care: Protocol of the Physicians Implement Exercise = Medicine (PIE=M) Development and Implementation Project.

BACKGROUND: The prescription of physical activity (PA) in clinical care has been advocated worldwide. This "exercise is medicine" (E=M) concept can be used to prevent, manage, and cure various lifestyle-related chronic diseases. Due to several challenges, E=M is not yet routinely implemented in clinical care. OBJECTIVE: This paper describes the rationale and design of the Physicians Implement Exercise = Medicine (PIE=M) study, which aims to facilitate the implementation of E=M in hospital care. METHODS: PIE=M consists of 3 interrelated work packages. First, levels and determinants of PA in different patient and healthy populations will be investigated using existing cohort data. The current implementation status, facilitators, and barriers of E=M will also be investigated using a mixed-methods approach among clinicians of participating departments from 2 diverse university medical centers (both located in a city, but one serving an urban population and one serving a more rural population). Implementation strategies will be connected to these barriers and facilitators using a systematic implementation mapping approach. Second, a generic E=M tool will be developed that will provide tailored PA prescription and referral. Requirements for this tool will be investigated among clinicians and department managers. The tool will be developed using an iterative design process in which all stakeholders reflect on the design of the E=M tool. Third, we will pilot-implement the set of implementation strategies, including the E=M tool, to test its feasibility in routine care of clinicians in these 2 university medical centers. An extensive learning process evaluation will be performed among clinicians, department managers, lifestyle coaches, and patients using a mixed-methods design based on the RE-AIM framework. RESULTS: This project was approved and funded by the Dutch grant provider ZonMW in April 2018. The project started in September 2018 and continues until December 2020 (depending on the course of the COVID-19 crisis). All data from the first work package have been collected and analyzed and are expected to be published in 2021. Results of the second work package are described. The manuscript is expected to be published in 2021. The third work package is currently being conducted in clinical practice in 4 departments of 2 university medical hospitals among clinicians, lifestyle coaches, hospital managers, and patients. Results are expected to be published in 2021. CONCLUSIONS: The PIE=M project addresses the potential of providing patients with PA advice to prevent and manage chronic disease, improve recovery, and enable healthy ageing by developing E=M implementation strategies, including an E=M tool, in routine clinical care. The PIE=M project will result in a blueprint of implementation strategies, including an E=M screening and referral tool, which aims to improve E=M referral by clinicians to improve patients' health, while minimizing the burden on clinicians.

Strict adherence to evidence-based protocol in choice of implants and surgical technique leads to fewer hip fracture reoperations.

BACKGROUND AND PURPOSE: Surgery for hip fractures is frequently followed by complications that hinder the rehabilitation. Only part of the complications are surgery-related, however these, including reoperation may have the highest impact. Operative protocols are designed to treat all patients equally, according to evidence based guidelines. Aim of this study was to investigate the association between strict adherence to an operative protocol and postoperative complications, especially reoperations. MATERIALS AND METHODS: A retrospective analyses of a prospective cohort. The cohort included all patients aged ≥60 treated for a hip fracture at University Medical Center Groningen between July 2009 and June 2013. The files of the patients were searched for complications, including reoperations. To evaluate adherence to the operative protocol all X-rays were retrospectively reviewed and the fracture type was reclassified. This retrospective fracture classification was compared with the treatment method used. Logistic regression analyses were used to assess whether patients that were not treated strictly according to the operative protocol have higher odds of developing a complication or of undergoing a reoperation. RESULTS: The study population consisted of 479 patients with a mean age of 78.4 (SD 9.5) years. Reoperation was performed in 11% of the patients during the follow-up period. The operative protocol was not followed strictly in 12% of the patients. When the operative protocol was not followed, the odds of having a reoperation was 2.41 times higher (p = 0.02). The overall complication rate was 75% and did not differ in both groups. CONCLUSION: Strict adherence to an evidence-based operative protocol is of major importance toward preventing implant-related problems and reoperations.

Using the Long Head of Biceps Tendon Autograft as an Anatomical Reconstruction of the Rotator Cable: An Arthroscopic Technique for Patients With Massive Rotator Cuff Tears.

The treatment of massive rotator cuff tears (MRCT) is challenging. Insufficient tissue quality, size, and retraction of the cuff often lead to failures of repair. Different techniques like direct repair, partial repair, and graft applications have been developed, but results are not yet predictable. In this arthroscopic technique the objective is not to reconstruct the rotator cuff as a tissue layer but to restore the biomechanical function of the rotator cable with an autograft of the long head of the biceps tendon. After glenohumeral inspection, the long head of the biceps tendon is harvested and the retracted cuff is released and, if possible, closed partially side-to-side. The biceps graft is positioned from the posterior aspect of the greater tubercle to the superior part of the lesser tubercle and fixed with 2 biotenodesis anchors. Finally, the cuff remnants are securely sutured to the biceps graft with standard cuff repair sutures. This arthroscopic technique has several advantages because the biceps autograft is easily harvested, autologous, and rich in collagen. Previous studies show use of the biceps tendon differently for reconstruction of the rotator cuff, with promising results. Future studies are needed to evaluate clinical outcomes.

Preventive interventions for tendinopathy: A systematic review.

OBJECTIVES: Tendinopathy, the most prevalent tendon disorder which is considered as the clinical diagnosis of pain and dysfunction, is common in sports and its prevalence is ever-increasing. Despite the lack of clarity about risk factors, various preventive interventions for tendinopathy have been investigated. The main objective of this study is to review current preventive interventions for tendinopathy in the major regions: ankle, knee, hip, groin, shoulder and elbow. DESIGN: A systematic literature search was conducted. METHODS: The PubMed and Embase databases were explored to identify articles that met the inclusion criteria. The included studies were assessed on methodological quality and data was summarized. RESULTS: Ten articles were included that describe a wide variety of preventive interventions. These were divided into three categories: stretch and exercise interventions, shoe adaptations and other interventions. The methodological quality of the studies was moderate to high. Three out of ten studies showed a significant beneficial result. CONCLUSIONS: There is limited evidence that a long-term intervention including balance training is effective in the prevention of patellar and Achilles tendinopathy. Shoe adaptations in the form of shock absorbing insoles could have a preventive effect on Achilles tendinopathy. Hormone replacement therapy seems to reduce the risk for structural Achilles tendon changes in active post-menopausal women. No evidence was found for a positive effect of stretching exercises. Prophylactic eccentric training and stretching can increase the risk of injury in asymptomatic players with patellar tendon abnormalities. A limited amount of studies was available and more research is needed on (multifactorial) etiology, risk factors and preventive interventions.

Gentle thawing of the frozen shoulder: a prospective study of supervised neglect versus intensive physical therapy in seventy-seven patients with frozen shoulder syndrome followed up for two years.

Seventy-seven patients with idiopathic frozen shoulder syndrome were included in a prospective study to compare the effect of intensive physical rehabilitation treatment, including passive stretching and manual mobilization (stretching group) versus supportive therapy and exercises within the pain limits (supervised neglect group). There were no significant differences in age, sex, time elapsed since onset, and disease severity at inclusion. All patients were followed up for 24 months after the start of treatment. In the patients treated with supervised neglect, 89% had normal or near-normal painless shoulder function (Constant score > or =80) at the end of the observation period. This end result was reached by 64% within 12 months. In contrast, of the group receiving intensive physical therapy treatment, only 63% reached a Constant score of 80 or higher after 24 months. Both the level of the Constant score at the end of the study and the moment a Constant score of 80 or higher was reached confirm that supervised neglect yields better outcomes than intensive physical therapy and passive stretching in patients with frozen shoulder.