Effect of Compression Therapy in the Treatment of Tibial Stress Syndrome in Military Service Members.

CONTEXT: Tibial stress syndrome (TSS) is an overuse injury of the lower extremities. There is a high incidence rate of TSS among military recruits. Compression therapy is used to treat a wide array of musculoskeletal injuries. The purpose of this study was to investigate the use of compression therapy as a treatment for TSS in military service members. DESIGN: A parallel randomized study design was utilized. METHODS: Military members diagnosed with TSS were assigned to either a relative rest group or compression garment group. Both groups started the study with 2 weeks of lower extremity rest followed by a graduated running program during the next 6 weeks. The compression garment group additionally wore a shin splints compression wrap during the waking hours of the first 2 weeks and during activity only for the next 6 weeks. Feelings of pain, TSS symptoms, and the ability to run 2 miles pain free were assessed at baseline, 4 weeks, and 8 weeks into the study. RESULTS: Feelings of pain and TSS symptoms decreased during the 8-week study in both groups (P < .05), but these changes were not significantly different between groups (P > .05). The proportion of participants who were able to run 2 miles pain free was significantly different (P < .05) between the 2 groups at the 8-week time point with the compression garment group having a significantly increased ability to complete the run without pain. CONCLUSIONS: Although perceptions of pain at rest were not different between groups, the functional ability of running 2 miles pain free was significantly improved in the compression garment group. These findings suggest that there is a moderate benefit to using compression therapy as an adjunct treatment for TSS, promoting a return to training for military service members.

Elite athletes' experiences of musculoskeletal pain management using neuroanatomical dry needling: A qualitative study in Swedish track and field.

OBJECTIVES: To investigate how elite track and field athletes with a history of musculoskeletal pain (MSKP) describe their perceptions of clinical treatments based on dry needling guided by a neurological map (neuroanatomical dry needling (naDN)). DESIGN: Qualitative study. METHODS: In-depth interviews were conducted with eight elite Swedish track and field athletes (6 males, 2 females, median age 28.5) treated at a clinic specialised in MSKP management. All interviews were audio recorded and transcribed verbatim. The data were structured and analysed using a thematic method. RESULTS: The athletes approached clinical MSKP treatment from a performance-orientated perspective. They explained that they inevitably suffered MSKP episodes due to the intense physical demands of their sport. The use of naDN was considered an integral part of their sports practice and the study clinic's services were readily utilised when MSKP caused minor reductions in physical capacity. The athletes appreciated an unambiguous anatomical diagnosis, preferably supported by imaging scans, as this increased their confidence in clinical services. They valued the naDN treatment as it was perceived to provide fast-acting analgesia that enabled rapid return-to-play. These factors combined to reduce performance-related stress. CONCLUSIONS: Elite track and field athletes with a history of MSKP sought and appreciated clinical treatment with naDN largely because it provided fast-acting analgesia that enabled rapid return-to-play at a high-performance level. These athletes' expectations of MSKP diagnosis and management appear incongruent with current research indicating that MSKP sensitivity within the nervous system does not accurately reflect musculoskeletal tissue state or recovery following tissue damage.

Conservative Treatment of Tendon Injuries.

Tendon injuries or tendinopathy is a common painful and disabling conditions resulting from overuse and aging. Tendinopathy remains a challenging clinical problem because response to different treatment modalities is usually unsatisfactory and recovery is slow. We performed an extensive literature review focusing on nonsurgical treatment options for tendinopathies, including nonsteroidal anti-inflammatory drugs, corticosteroid, eccentric exercise, extracorporeal shock wave therapy, therapeutic ultrasound, hyaluronic acid, platelet-rich plasma, prolotherapy, polydeoxyribonucleotide, and stem cells, aimed at providing the most updated evidence as a guideline for caregivers.

Reflexoterapia podal para lombalgia aguda ocupacional: ensaio clínico randomizado duplo cego / Foot reflexology for acute occupational low back pain: a double-blind randomized clinical trial / Reflexoterapia podal para lumbago agudo ocupacional: ensayo clínico aleatorizado doble-ciego

OBJETIVO: Comparar os efeitos da reflexoterapia podal no alívio da lombalgia aguda ocupacional da equipe de enfermagem. MÉTODO: ensaio clínico randomizado, controlado, duplo-cego. Participaram 36 profissionais efetivos, randomicamente alocados. A coleta de dados foi realizada com a Escala Visual e Analógica de intensidade da dor, antes e depois das aplicações do protocolo de reflexoterapia e Questionário para Lombalgia, aplicado no início e fim da pesquisa. Para normalidade da amostra utilizou-se o teste Shapiro Wilk; teste Qui-quadrado ou Exato de Fisher para verificar a significância da associação entre variáveis categóricas; teste de Wilcoxon (dados não paramétricos) e teste t (dados paramétricos). RESULTADO: reflexoterapia podal apresentou efeito significativo (p=0,000) nas etapas de intervenção para alívio da intensidade da dor lombar aguda, tanto no escore do EVA, quanto no Questionário para Lombalgia (p=0,0002). CONCLUSÕES: a reflexoterapia apresentou efeitos estatisticamente significativos na redução da lombalgia aguda dos profissionais da Enfermagem

AIM: To compare the effects of foot reflexology in relieving acute occupational low back pain in the nursing team. METHOD: randomized, controlled, double-blind clinical trial. Participants included 36 randomly allocated, effective professionals. Data collection was performed with the Visual and Analogue Scale of pain intensity, before and after the applications of the reflexotherapy protocol and Questionnaire for Low Back Pain, applied at the beginning and end of the research. For normality of the sample the Shapiro Wilk test, Chi-square test or Fisher's exact test was used to verify the significance of the association between categorical variables; Wilcoxon test (non-parametric data) and t-test (parametric data). RESULT: reflexotherapy showed significant effect (p=0.000) in the intervention stages to alleviate the intensity of acute low back pain, both in the VAS score and in the Low Back Pain Questionnaire (p=0.0002). CONCLUSIONS: reflexotherapy showed statistically significant effects on the reduction of acute low back pain in Nursing professionals.

OBJETIVO: Comparar los efectos de la reflexoterapia podal en el alivio del lumbago agudo ocupacional del equipo de enfermería. MÉTODO: ensayo clínico aleatorizado, controlado, doble-ciego. Participaron 36 profesionales efectivos, asignados aleatoriamente. El muestreo se realizó con la Escala Visual y Analógica de intensidad del dolor, antes y después de las aplicaciones del protocolo de reflexoterapia y con el Cuestionario para Lumbago, aplicado al inicio y fin de la investigación. Para normalizar la muestra se utilizó el test Shapiro Wilk; test Chi-cuadrado o Exacto de Fisher para verificar la significancia de la asociación entre las variables categóricas; test de Wilcoxon (datos no paramétricos) y test t (datos paramétricos). RESULTADO: La reflexoterapia podal presentó efecto significativo (p=0,000) en las etapas de intervención para aliviar la intensidad del dolor lumbar agudo, tanto en el escore del EVA, como en el Cuestionario para Lumbago (p=0,0002). CONCLUSIONES: La reflexoterapia presentó efectos estadísticamente significativos en la reducción del lumbago agudo de los profesionales de Enfermería.

Prevention and treatment of exercise related leg pain in young soldiers; a review of the literature and current practice in the Dutch Armed Forces.

Overuse injuries of the leg are a common problem for young soldiers. This article reviews the literature concerning the prevention and treatment of exercise related leg pain in military settings and presents the latest developments in proposed mechanisms and treatments. Current practice and treatment protocols from the Dutch Armed Forces are reviewed, with an emphasis on the most prevalent conditions of medial tibial stress syndrome and chronic exertional compartment syndrome. The conclusion is that exercise related leg pain in the military is an occupational problem that deserves further study.

Nonoperative Management of Chronic Exertional Compartment Syndrome: A Systematic Review.

Although nonoperative treatment options for chronic exertional compartment syndrome (CECS) are often used in clinical practice, supporting evidence is limited. The objective of this study was to systematically review the literature for nonsurgical treatment options for CECS of the lower leg. The literature search identified seven articles describing in total four different treatment options: massage, gait changes, chemodenervation, and ultrasound-guided (USG) fascial fenestration. Pertinent studies were in the form of case series and one case report, which limited the robustness of the data. Nevertheless, all four treatment options have little to no reported adverse effect profiles and can be considered in clinical practice. In addition, gait changes and USG fascial fenestration were found to have continued effect at 1 and 1.5 years, respectively.

Manual therapy as an effective treatment for fibrosis in a rat model of upper extremity overuse injury.

Key clinical features of carpal tunnel syndrome and other types of cumulative trauma disorders of the hand and wrist include pain and functional disabilities. Mechanistic details remain under investigation but may involve tissue inflammation and/or fibrosis. We examined the effectiveness of modeled manual therapy (MMT) as a treatment for sensorimotor behavior declines and increased fibrogenic processes occurring in forearm tissues of rats performing a high repetition high force (HRHF) reaching and grasping task for 12 weeks. Young adult, female rats were examined: food restricted control rats (FRC, n=12); rats that were trained for 6 weeks before performing the HRHF task for 12 weeks with no treatment (HRHF-CON, n=11); and HRHF task rats received modeled manual therapy (HRHF-MMT, n=5) for 5 days/week for the duration of the 12-week of task. Rats receiving the MMT expressed fewer discomfort-related behaviors, and performed progressively better in the HRHF task. Grip strength, while decreased after training, improved following MMT. Fibrotic nerve and connective tissue changes (increased collagen and TGF-ß1 deposition) present in 12-week HRHF-CON rats were significantly decreased in 12-week HRHF-MMT rats. These observations support the investigation of manual therapy as a preventative for repetitive motion disorders.

The Application of Tensegrity Massage in a Professionally Active Musician - Case Report.

PURPOSE: The purpose of our study was to present options for the application of tensegrity massage to manage pain caused by the overload of soft tissues in musicians. DESIGN: Tensegrity massage was applied to a 34-year-old male violinist. METHODS: The methodology included a correct positioning and tensegrity massage with individually designed procedure. FINDINGS: After therapy, the patient achieved complete pain relief, and relaxation of muscles in the shoulder girdle and free part of the upper arm. The analgesic effect lasted for 6 months after the end of therapy. CONCLUSIONS: Massage is an effective method in eliminating pain caused by the overload of soft tissues. If used regularly before physical effort, it can prevent muscle overload. CLINICAL RELEVANCE: The presented massage procedure is an effective therapy in pain caused by the overload of soft tissues in musicians and it can be one of the elements of complex physiotherapy in active musicians.

The Acute Effects of Hold-Relax Proprioceptive Neuromuscular Facilitation With Vibration Therapy on Glenohumeral Internal-Rotation Deficit.

CONTEXT: Clinicians use various stretching techniques to prevent the onset of and treat glenohumeral internal-rotation deficit (GIRD). It is unknown which stretching technique is the most effective. OBJECTIVE: To investigate the acute effects of hold-relax proprioceptive neuromuscular facilitation (PNF) with and without vibration therapy on internal rotation in individuals with GIRD. DESIGN: 2-within (stretch × time) comparison with repeated measures. SETTING: Controlled laboratory. PARTICIPANTS: 11 male current and former overhead athletes (19.8 ± 1.4 y, 184.5 ± 4.5 cm, 91.8 ± 11.6 kg) who presented with GIRD. INTERVENTIONS: At 3 separate sessions, participants performed 1 of 3 randomly assigned stretches: hold-relax PNF (PNF), hold-relax PNF in combination with a whole-body-vibration unit set at 30 Hz (PNF-V), and static stretch (SS). Pretest and posttest maximum passive glenohumeral internal-rotation measurements were taken with a digital protractor. MAIN OUTCOME MEASURES: The dependent variables were the mean glenohumeral internal-rotation measurements taken at the pretest and posttest. The influence of stretch (PNF, PNF-V, and SS) and time (pretest and posttest) on mean glenohumeral internal rotation was compared using a 3 × 2 factorial ANOVA with repeated measures on both variables (P ≤ .05). RESULTS: There was a stretch-by-time interaction (F2,20 = 34.697, P < .001). Post hoc testing revealed that the PNF posttest (73.0° ± 10.4°) was greater than the PNF pretest (60.0° ± 11.8°), the PNF-V posttest (74.7° ± 10.0°) was greater than the PNF-V pretest (57.4° ± 10.4°), and the SS posttest (67.0° ± 10.7°) was greater than the SS pretest (60.1° ± 9.4°). When comparing the posttest values, the PNF-V posttest was greater than the SS posttest. CONCLUSIONS: All 3 stretches (PNF, PNF-V, and SS) resulted in acute increases in glenohumeral internal rotation in individuals presenting with GIRD. The PNF-V stretch resulted in the greatest increase and would be the most clinically beneficial for patients with GIRD.

Conservative interventions for treating work-related complaints of the arm, neck or shoulder in adults.

BACKGROUND: Work-related upper limb disorder (WRULD), repetitive strain injury (RSI), occupational overuse syndrome (OOS) and work-related complaints of the arm, neck or shoulder (CANS) are the most frequently used umbrella terms for disorders that develop as a result of repetitive movements, awkward postures and impact of external forces such as those associated with operating vibrating tools. Work-related CANS, which is the term we use in this review, severely hampers the working population. OBJECTIVES: To assess the effects of conservative interventions for work-related complaints of the arm, neck or shoulder (CANS) in adults on pain, function and work-related outcomes. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, 31 May 2013), MEDLINE (1950 to 31 May 2013), EMBASE (1988 to 31 May 2013), CINAHL (1982 to 31 May 2013), AMED (1985 to 31 May 2013), PsycINFO (1806 to 31 May 2013), the Physiotherapy Evidence Database (PEDro; inception to 31 May 2013) and the Occupational Therapy Systematic Evaluation of Evidence Database (OTseeker; inception to 31 May 2013). We did not apply any language restrictions. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi-randomised controlled trials evaluating conservative interventions for work-related complaints of the arm, neck or shoulder in adults. We excluded trials undertaken to test injections and surgery. We included studies that evaluated effects on pain, functional status or work ability. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials for inclusion, extracted data and assessed risk of bias of the included studies. When studies were sufficiently similar, we performed statistical pooling of reported results. MAIN RESULTS: We included 44 studies (62 publications) with 6,580 participants that evaluated 25 different interventions. We categorised these interventions according to their working mechanisms into exercises, ergonomics, behavioural and other interventions.Overall, we judged 35 studies as having a high risk of bias mainly because of an unknown randomisation procedure, lack of a concealed allocation procedure, unblinded trial participants or lack of an intention-to-treat analysis.We found very low-quality evidence showing that exercises did not improve pain in comparison with no treatment (five studies, standardised mean difference (SMD) -0.52, 95% confidence interval (CI) -1.08 to 0.03), or minor intervention controls (three studies, SMD -0.25, 95% CI -0.87 to 0.37) or when provided as additional treatment (two studies, inconsistent results) at short-term follow-up or at long-term follow-up. Results were similar for recovery, disability and sick leave. Specific exercises led to increased pain at short-term follow-up when compared with general exercises (four studies, SMD 0.45, 95% CI 0.14 to 0.75)We found very low-quality evidence indicating that ergonomic interventions did not lead to a decrease in pain when compared with no intervention at short-term follow-up (three studies, SMD -0.07, 95% CI -0.36 to 0.22) but did decrease pain at long-term follow-up (four studies, SMD -0.76, 95% CI -1.35 to -0.16). There was no effect on disability but sick leave decreased in two studies (risk ratio (RR) 0.48, 95% CI 0.32 to 0.76). None of the ergonomic interventions was more beneficial for any outcome measures when compared with another treatment or with no treatment or with placebo.Behavioural interventions had inconsistent effects on pain and disability, with some subgroups showing benefit and others showing no significant improvement when compared with no treatment, minor intervention controls or other behavioural interventions.In the eight studies that evaluated various other interventions, there was no evidence of a clear beneficial effect of any of the interventions provided. AUTHORS' CONCLUSIONS: We found very low-quality evidence indicating that pain, recovery, disability and sick leave are similar after exercises when compared with no treatment, with minor intervention controls or with exercises provided as additional treatment to people with work-related complaints of the arm, neck or shoulder. Low-quality evidence also showed that ergonomic interventions did not decrease pain at short-term follow-up but did decrease pain at long-term follow-up. There was no evidence of an effect on other outcomes. For behavioural and other interventions, there was no evidence of a consistent effect on any of the outcomes.Studies are needed that include more participants, that are clear about the diagnosis of work-relatedness and that report findings according to current guidelines.

Management of chronic tendon injuries.

Chronic tendon injuries present unique management challenges. The assumption that these injuries result from ongoing inflammation has caused physicians to rely on treatments demonstrated to be ineffective in the long term. Nonsteroidal anti-inflammatory drugs should be limited in the treatment of these injuries. Corticosteroid injections should be considered for temporizing pain relief only for rotator cuff tendinopathy. For chronic Achilles tendinopathy (symptoms lasting longer than six weeks), an intense eccentric strengthening program of the gastrocnemius/ soleus complex improved pain and function between 60 and 90 percent in randomized trials. Evidence also supports eccentric exercise as a first-line option for chronic patellar tendon injuries. Other modalities such as prolotherapy, topical nitroglycerin, iontophoresis, phonophoresis, therapeutic ultrasound, extracorporeal shock wave therapy, and low-level laser therapy have less evidence of effectiveness but are reasonable second-line alternatives to surgery for patients who have persistent pain despite appropriate rehabilitative exercise.

Approach to the patient with noninflammatory musculoskeletal pain.

Musculoskeletal pain is one of the most common presenting symptoms at the pediatrician's office. Etiology ranges from benign conditions to serious ones requiring prompt attention. This article addresses entities that present as musculoskeletal pain but are not associated with arthritis. The most common nonarthritic conditions are benign limb pain of childhood (growing pains), hypermobility, overuse syndromes with or without skeletal abnormalities, malignancies, and pain amplification syndromes. The| initial decision process, diagnosis, and treatment options for each of these conditions are discussed.

Athletic osteitis pubis.

Athletic osteitis pubis is a painful and chronic condition affecting the pubic symphysis and/or parasymphyseal bone that develops after athletic activity. Athletes with osteitis pubis commonly present with anterior and medial groin pain and, in some cases, may have pain centred directly over the pubic symphysis. Pain may also be felt in the adductor region, lower abdominal muscles, perineal region, inguinal region or scrotum. The pain is usually aggravated by running, cutting, hip adduction and flexion against resistance, and loading of the rectus abdominis. The pain can progress such that athletes are unable to sustain athletic activity at high levels. It is postulated that osteitis pubis is an overuse injury caused by biomechanical overloading of the pubic symphysis and adjacent parasymphyseal bone with subsequent bony stress reaction. The differential diagnosis for osteitis pubis is extensive and includes many other syndromes resulting in groin pain. Imaging, particularly in the form of MRI, may be helpful in making the diagnosis. Treatment is variable, but typically begins with conservative measures and may include injections and/or surgical procedures. Prolotherapy injections of dextrose, anti-inflammatory corticosteroids and a variety of surgical procedures have been reported in the literature with varying efficacies. Future studies of athletic osteitis pubis should attempt to define specific and reliable criteria to make the diagnosis of athletic osteitis pubis, empirically define standards of care and reduce the variability of proposed treatment regimens.

Proper body mechanics from an engineering perspective.

The economic viability of the manual therapy practitioner depends on the number of massages/treatments that can be given in a day or week. Fatigue or injuries can have a major impact on the income potential and could ultimately reach the point which causes the practitioner to quit the profession, and seek other, less physically demanding, employment. Manual therapy practitioners in general, and massage therapists in particular, can utilize a large variety of body postures while giving treatment to a client. The hypothesis of this paper is that there is an optimal method for applying force to the client, which maximizes the benefit to the client, and at the same time minimizes the strain and effort required by the practitioner. Two methods were used to quantifiably determine the effect of using "poor" body mechanics (Improper method) and "best" body mechanics (Proper/correct method). The first approach uses computer modeling to compare the two methods. Both postures were modeled, such that the biomechanical effects on the practitioner's elbow, shoulder, hip, knee and ankle joints could be calculated. The force applied to the client, along with the height and angle of application of the force, was held constant for the comparison. The second approach was a field study of massage practitioners (n=18) to determine their maximal force capability, again comparing methods using "Improper and Proper body mechanics". Five application methods were tested at three different application heights, using a digital palm force gauge. Results showed that there was a definite difference between the two methods, and that the use of correct body mechanics can have a large impact on the health and well being of the massage practitioner over both the short and long term.

Performing arts medicine - instrumentalist musicians part I - general considerations.

Performing arts medicine is a relatively new specialty addressing the medical needs of dancers, musicians, ice skaters, and gymnasts. This paper focuses on the role of healthcare providers in the diagnosis and therapeutic management of instrumentalist musicians. Musicians are at high risk for developing painful musculoskeletal problems, including pain and overuse injuries, entrapment and peripheral neuropathies, and focal dystonias. Musicians' careers are threatened, when they are no longer able to play their instrument because of pain and dysfunction. To appreciate music-related injuries, it is important that clinicians are familiar with the context of musicians' injuries and disorders. This is the first paper in a series of three. This paper discusses the importance of taking an extended history. The typical history procedures need to be broadened when interviewing musicians, and should include instrument-specific questions, and questions regarding practice habits, education, repertoire, and employment. The second article addresses the physical examination, while the third article provides three case reports of musicians with hand problems, which serve to illustrate the points made in the first two articles. The articles are illustrated with several tables and photographs of musicians to assist the reader in assessing instrumentalist musicians and determining the most appropriate course of action.

In vitro modeling of repetitive motion strain and manual medicine treatments: potential roles for pro- and anti-inflammatory cytokines.

Despite positive clinical outcomes documented post-treatment with a variety of manual medicine treatments (MMT), the underlying cellular mechanisms responsible remain elusive. We have developed an in vitro human fibroblast cell system used to model various biomechanical strains that human fibroblasts might undergo in response to repetitive motion strain (RMS) and MMT. Our data utilizing this system suggest that RMS induces disruption of cell-cell and cell-matrix contacts, which appear are reversed when a modeled MMT is also added to the treatment protocol. Similarly, while RMS induces secretion of several inflammatory cytokines, modeled MMT attenuates this secretory response. In terms of strain direction, fibroblasts strained equiradially exhibit unique cytokine secretory profiles vs. those strained heterobiaxially. Taken together, these data suggest that this cell model may prove useful in identifying the cellular mechanisms by which various fascial strains used clinically to treat somatic dysfunctions yield positive clinical outcomes such as reduced pain, reduced analgesic use and improved range of motion.

Long-term follow-up of hypothenar hammer syndrome: a series of 47 patients.

Hypothenar hammer syndrome (HHS) is an uncommon form of secondary Raynaud phenomenon, occurring mainly in subjects who use the hypothenar part of the hand as a hammer; the hook of the hamate strikes the superficial palmar branch of the ulnar artery in the Guyon space, leading to occlusion and/or aneurysm of the ulnar artery. In patients with HHS, such injuries of the palmar ulnar artery may lead to severe vascular insufficiency in the hand with occlusion of digital artery. To date, only a few series have analyzed the long-term outcome of patients with HHS. This prompted us to conduct the current retrospective study to 1) evaluate the prevalence of HHS in patients with Raynaud phenomenon and 2) assess the short-term and long-term outcome in patients with HHS. From 1990 to 2006, 4148 consecutive patients were referred to the Department of Internal Medicine at the University of Rouen medical center for evaluation of Raynaud phenomenon using nailfold capillaroscopy. HHS was diagnosed in 47 of these 4148 patients (1.13% of cases).Forty-three patients (91.5%) had occupational exposure to repetitive palmar trauma. The more common occupations were factory worker (21.3%), mason (12.8%), carpenter (10.6%), and metal worker (10.6%); the mean duration of occupational exposure to repetitive palmar trauma at HHS diagnosis was 21 years. One patient (2.1%) had recreational exposure (aikido training) to repetitive trauma of the palmar ulnar artery, and 3 other patients (6.4%) developed HHS related to a single direct injury to the hypothenar area. Clinical manifestations were more often unilateral (87.2%) involving the dominant hand (93%). HHS complications included digital ischemic symptoms (ischemia: n = 21, necrosis: n = 20) and irritation of the sensory branch of the ulnar nerve (n = 11). In HHS patients, angiography demonstrated occlusion of the ulnar artery in the area of the Guyon space (59.6%), aneurysm of the ulnar artery in the area of the Guyon space (40.4%), and embolic multiple occlusions of the digital arteries (57.4%). All patients were advised to change their occupational exposure. They were given vasodilators, including calcium channel blocker (n = 37) and buflomedil (n = 12); 36 patients (76.6%) also received oral platelet aggregation inhibitors. Twenty-one patients with digital ischemia/necrosis were further given hemodilution therapy to reduce the hematocrit level to 35%. In 3 patients with HHS-related digital necrosis who exhibited partial improvement with vasodilators, prostacyclin analog therapy (a 5-day regimen of intravenous prostacyclin analog) was instituted, resulting in complete healing of digital ulcer in these 3 patients. Other conservative treatment options included controlling risk factors (smoking cessation, low-lipid diet, therapy for arterial hypertension) and careful local wound care of fingers in the 20 patients with digital necrosis. Only 2 patients, exhibiting digital necrosis and multiple digital artery occlusions, with nonthrombotic ulnar artery aneurysm underwent reconstructive surgery, that is, resection of the aneurysm with end-to-end anastomosis of the ulnar artery. The median length of follow-up in patients with HHS was 15.9 months. Thirteen patients (27.7%) exhibited clinical recurrences of HHS; the median time of HHS recurrence onset was 11 months. Outcome of HHS relapse was favorable with conservative measures in all cases. Awareness of HHS is required to increase suspicion of the disorder so that further exposure to risk factors like repetitive hypothenar trauma can be avoided for these patients; this is of great importance for their overall prognosis. We found favorable outcomes in most patients after conservative measures were initiated; therefore we suggest that surgery may be undertaken in the subgroup of patients who exhibit partial improvement while receiving conservative therapy. Finally, because we observed recurrence of HHS in 27.7% of patients, we note that HHS patients require close follow-up, including both regular and systematic physical vascular examination.

Iliotibial band friction syndrome--a systematic review.

Iliotibial band friction syndrome (ITBFS) is a common injury of the lateral aspect of the knee particularly in runners, cyclists and endurance sports. A number of authors suggest that ITBFS responds well to conservative treatment, however, much of this opinion appears anecdotal and not supported by evidence within the literature. The purpose of this paper is to provide a systematic review of the literature pertaining to the conservative treatment of ITBFS. A search to identify clinical papers referring to the iliotibial band (ITB) and ITBFS was conducted in a number of electronic databases using the keyword: iliotibial. The titles and abstracts of these papers were reviewed to identify papers specifically detailing conservative treatments of ITBFS. The PEDro Scale, a systematic tool used to critique randomized controlled trials (RCTs), was employed to investigate both the therapeutic effect of conservative treatment of ITBFS and also to critique the methodological quality of available RCTs examining the conservative treatment of ITBFS. With respect to the management of ITBFS, four RCTs were identified. The interventions examined included the use of non-steroidal anti-inflammatory drugs (NSAIDs), deep friction massage, phonophoresis versus immobilization and corticosteroid injection. This review highlights both the paucity in quantity and quality of research regarding the conservative treatment of ITBFS. There seems limited evidence to suggest that the conservative treatments that have been studied offer any significant benefit in the management of ITBFS. Future research will need to re-examine those conservative therapies, which have already been examined, along with others, and will need to be of sufficient quality to enable accurate clinical judgements to be made regarding their use.