Medial tibial stress syndrome can be diagnosed reliably using history and physical examination.

BACKGROUND: The majority of sporting injuries are clinically diagnosed using history and physical examination as the cornerstone. There are no studies supporting the reliability of making a clinical diagnosis of medial tibial stress syndrome (MTSS). AIM: Our aim was to assess if MTSS can be diagnosed reliably, using history and physical examination. We also investigated if clinicians were able to reliably identify concurrent lower leg injuries. METHODS: A clinical reliability study was performed at multiple sports medicine sites in The Netherlands. Athletes with non-traumatic lower leg pain were assessed for having MTSS by two clinicians, who were blinded to each others' diagnoses. We calculated the prevalence, percentage of agreement, observed percentage of positive agreement (Ppos), observed percentage of negative agreement (Pneg) and Kappa-statistic with 95%CI. RESULTS: Forty-nine athletes participated in this study, of whom 46 completed both assessments. The prevalence of MTSS was 74%. The percentage of agreement was 96%, with Ppos and Pneg of 97% and 92%, respectively. The inter-rater reliability was almost perfect; k=0.89 (95% CI 0.74 to 1.00), p<0.000001. Of the 34 athletes with MTSS, 11 (32%) had a concurrent lower leg injury, which was reliably noted by our clinicians, k=0.73, 95% CI 0.48 to 0.98, p<0.0001. CONCLUSION: Our findings show that MTSS can be reliably diagnosed clinically using history and physical examination, in clinical practice and research settings. We also found that concurrent lower leg injuries are common in athletes with MTSS.

Chlorhexidine mouthwash and sodium lauryl sulphate dentifrice: do they mix effectively or interfere?

FOCUSED QUESTION: What is the effectiveness of a chlorhexidine (CHX) mouthwash used in combination with a sodium lauryl sulphate (SLS) dentifrice on the parameters of plaque and gingivitis? MATERIAL AND METHODS: MEDLINE-PubMed, Cochrane-CENTRAL, EMBASE and other electronic databases were searched up to July 2014. The inclusion criteria were (randomized) controlled clinical trials, subjects ≥18 years of age with good general health. Papers evaluating the effect of CHX mouthwash used in combination with SLS dentifrice or a dentifrice slurry compared with CHX mouthwash as a single oral hygiene intervention or in combination with an SLS-free dentifrice were included. From the eligible studies, data were extracted, and a meta-analysis was performed when feasible. RESULTS: Independent screening of 83 unique papers resulted in four eligible publications, with nine comparisons. The meta-analysis showed that when an SLS dentifrice was used as a slurry rinse, the interference on the plaque-inhibiting effect of a CHX mouthwash was significantly decreased (MD 0.33; P ≤ 0.00001; 95% CI: <0.24; 0.42>). No significant difference was observed when SLS dentifrice was applied as a paste in combination with CHX mouthwash (MD 0.08; P = 0.42; 95% CI: <-0.26; 0.11>). Descriptive and subgroup analyses support these findings. Moreover, the observed effect for the dentifrice paste occurred regardless of the order of use. CONCLUSION: This review demonstrates that when CHX mouthwash is recommended, it can be used in combination with an SLS dentifrice without any interference regarding its inhibiting effect on dental plaque, regardless of the order of use. Consequently, the collective evidence indicates that the combined use of dentifrice and CHX mouthwash is not contraindicated. However, this recommendation has been graded as moderate taking into account a potential publication bias because three of the four included studies emerged from the same research group.

The effect of water on morning bad breath: a randomized clinical trial.

OBJECTIVES: To assess the effects of water on the parameters of 'morning bad breath' (MBB) and to evaluate whether there is a difference between rinsing with water and drinking a glass of water. MATERIALS AND METHODS: A total of 50 participants were recruited and were randomly divided into two equal groups. One group rinsed with 15 ml of water for 30 s, and another group drank 200 ml of water within 30 s. Clinical assessments were carried out during one visit between 7:30 am and 12:00 pm. Pre- and post-intervention measures were assessed organoleptically as primary outcome parameters, and a secondary outcome parameter was assessed using both the Halimeter(®) and OralChroma(™) apparatuses to evaluate volatile sulphur compounds (VSCs), hydrogen sulphide (H2 S), methyl mercaptan (CH3 SH) and dimethyl sulphide ((CH3 )2 S). In addition, the presence of tongue coating (discoloration/thickness) and tongue fissures was assessed. RESULTS: All 50 participants completed the study. In both groups, a significant reduction in the organoleptic score and the OralChroma(™) H2 S and CH3 SH readings was obtained after the intervention. Both regimens resulted in a CH3 SH reduction of approximately 60%, whereas the reduction in H2 S was between 30% and 50%. The acceptable change between pre- and post-assessments of the clinical parameters was not significantly different between the drinking and rinsing groups. CONCLUSION: Rinsing with water or drinking a glass of water had a statistically significant effect on the MBB parameters. No significant difference was obtained between the two regimens.

Victorian Institute of Sport Assessment-Achilles thresholds for minimal important change and return to presymptom activity level in active soldiers with mid-portion Achilles tendinopathy.

INTRODUCTION: Mid-portion Achilles tendinopathy (mid-AT) is common in soldiers, significantly impacting activity levels and operational readiness. Currently, Victorian Institute of Sport Assessment-Achilles (VISA-A) represents the gold standard to evaluate pain and function in mid-AT. Our objective was to estimate VISA-A thresholds for minimal important change (MIC) and patient-acceptable symptom state for return to the presymptom activity level (PASS-RTA), in soldiers treated with a conservative programme for mid-AT. METHODS: A total of 40 soldiers (40 unilateral symptomatic Achilles tendons) were included in this prospective cohort study. Pain and function were evaluated using VISA-A. Self-perceived recovery was assessed with the Global Perceived Effect scale. The predictive modelling method (MIC-predict) was used to estimate MIC VISA-A post-treatment (after 26 weeks) and after 1 year of follow-up. The post-treatment PASS-RTA VISA-A was estimated using receiver operating characteristic statistics. The PASS-RTA was determined by calculating Youden's index value closest to 1. RESULTS: The adjusted MIC-predict was 6.97 points (95% CI 4.18 to 9.76) after 26 weeks and 7.37 points (95% CI 4.58 to 10.2) after 1 year of follow-up post-treatment.The post-treatment PASS-RTA was 95.5 points (95% CI 92.2 to 97.8). CONCLUSIONS: A VISA-A change score of 7 points, post-treatment and at 1 year of follow-up, can be considered a minimal within-person change over time, above which soldiers with mid-AT perceive themselves importantly changed. Soldiers consider their symptoms to be acceptable for return to their presymptom activity level at a post-treatment VISA-A score of 96 points or higher. TRIAL REGISTRATION NUMBER: NL69527.028.19.

Prognostic value of ultrasound tissue characterisation for a recurrence of mid-portion Achilles tendinopathy in military service members: a prospective cohort study.

INTRODUCTION: Tendon structure in mid-portion Achilles tendinopathy (mid-AT) appears poorly associated with symptoms. Yet, degenerative tendon changes on imaging have been associated with an increased risk of mid-AT. We aimed to investigate the prognostic value of ultrasound tissue characterisation (UTC) for a mid-AT recurrence in service members reporting to be recovered following standard care. METHODS: Mid-portion aligned fibrillar structure was quantified post-treatment in 37 participants. Recurrences were determined after 1 year of follow-up, based on self-perceived recurrence (yes/no) combined with a decrease in post-treatment Victorian Institute of Sports Assessment-Achilles score of at least the minimal important change of 7 points. Receiver operating characteristic curve analyses were used to determine a threshold for dichotomisation of outcomes for aligned fibrillar structure (normal representation/under-representation). Using multivariable logistic regression, the association between a mid-AT recurrence (yes/no) and the dichotomised aligned fibrillar structure was determined. RESULTS: Eight participants (22%) experienced a recurrence. The threshold for aligned fibrillar structure was set at 73.2% (95% CI: 69.4% to 77.8%) according to Youden's index. Values below this threshold were significantly associated with a mid-AT recurrence (odds ratio (OR) 9.7, 95% CI: 1.007 to 93.185). The OR for a mid-AT recurrence was 1.1 (95% CI: 1.002 to 1.150) for each additional month of symptom duration. The explained variance of our multivariable logistic regression model was 0.423; symptom duration appeared to be a better predictor than aligned fibrillar structure. CONCLUSIONS: This study identified mid-portion aligned fibrillar structure and symptom duration as potential prognostic factors for a mid-AT recurrence in military service members. The threshold for aligned fibrillar structure of 73.2% can guide preventative interventions (eg, training load adjustments or additional tendon load programmes) aiming to improve tendon structure to minimise the future recurrence risk. TRIAL REGISTRATION NUMBER: https://www.toetsingonline.nl/to/ccmo_search.nsf/Searchform?OpenForm, file number ToetsingOnline NL69527.028.19.

The effect of an oxygenating agent on chlorhexidine-induced extrinsic tooth staining: a systematic review.

BACKGROUND: Although chlorhexidine digluconate (CHX) is currently the most effective mouthwash for reducing plaque and gingivitis, one of its side effects is extrinsic tooth staining. Interestingly, oxygenating agents may reduce this staining. OBJECTIVE: The aim of this review was to systematically search the literature for data concerning the inhibiting effect of an oxygenating agent (OA) on CHX-induced tooth staining. METHODS: MEDLINE-PubMed, Cochrane-CENTRAL, EMBASE and other relevant electronic databases were searched for articles that were published up to November 2011. Articles were included if they were randomized controlled trials or controlled clinical trials conducted with healthy subjects ≥ 16 years of age that compared the effects of CHX mouthrinse combined with an OA with the effects of CHX alone. RESULTS: An independent screening of 1183 titles and abstracts resulted in 4 publications that met the inclusion criteria. The extracted data allowed meta-analyses of intermediate length studies and showed that combining an OA with CHX mouthrinses led to a significant reduction in tooth staining (mean difference: 0.27; P = 0.02) and plaque scores (mean difference: 0.10; P = 0.003) when compared with CHX alone. One of the included studies reported a side effect for one participant. The present review was limited by the availability of data, and the included studies were methodologically and clinically heterogeneous, which affected the quality and interpretation of the evidence. CONCLUSION: There is moderate evidence that a combination of CHX and an OA reduces tooth staining without interfering with plaque growth inhibition.

Measuring intracompartmental pressures for the chronic exertional compartment syndrome: Challenging commercially available devices and their respective accuracy.

The aim of this study was to compare commercially available manometers and needles used for intracompartmental pressure measurements for accuracy. An experimental compartment simulation model was developed in order to compare four different terminal devices (Compass manometer, Stryker device, Meritrans transducer, and arterial line) and 22 types of needles. First, all possible device/needle combinations were introduced in rubber ports at the bottom of a water column. The water column was gradually drained three times for each device/needle combination and pressures were recorded by two researchers. This procedure was repeated after placement of a sample of homogenous porcine gluteal muscle tissue. When measuring the fluid column only, all Intraclass Correlation Coefficients were found to be ≥0.980, indicating good resemblance to the reference pressure. After addition of the muscle tissue to the experimental set up, accuracy of the Stryker device and arterial line remained the same. The accuracy of the Compass manometer and Meritrans transducer became less. Excellent reliability was found for 7 out of 22 needles when combined with the Stryker device and for 2 out of 22 needles when combined with the arterial line. The four terminal devices tested were all accurate when measuring pressure in a water column, whereas only the Stryker device and arterial line accurately represented the water column pressure in a porcine gluteal muscle model. Future research will have to verify whether these results can be repeated in human cadaver models and in vivo.

Measuring Intracompartmental Pressures in the Lower Leg: Assessing the Use of Unilateral Measurements in Patients with Bilateral Symptoms.

The purpose of the present study was to evaluate whether unilateral intracompartmental pressure (ICP) measurements correctly represent the contralateral ICP value in patients suspected to have bilateral chronic exertional compartment syndrome (CECS) in the anterior compartment of the leg. Methods: A retrospective cohort study was performed that included military service members who had been referred to a secondary care department for bilateral anterolateral exercise-related leg pain. The obtained ICP values were utilized to assess 2 possible measurement strategies to perform unilateral ICP measurements: the right-leg strategy (i.e., always testing the right leg) and the most-symptomatic-leg strategy (i.e., always testing the most symptomatic). The diagnostic cutoff value for CECS in this cohort was 35 mmHg in the first minute after provocation. Four outcome categories were created to describe the pressure classification of the second leg if only 1 leg would have been measured: correct (category 1: both values ≥35 mmHg; category 2: both values <35 mmHg) or incorrect (category 3: measured leg, ≥35 mmHg and contralateral leg, <35 mmHg; category 4: measured leg, <35 mmHg and contralateral leg, ≥35 mmHg). Results: A total of 442 patients (884 legs) were included. In 88% of patients, the unilateral value would have correctly diagnosed the other symptomatic leg, whereas in 12% of patients, the contralateral leg would have been diagnosed incorrectly. The right-leg strategy had a slightly smaller proportion of cases in which the contralateral leg would have been incorrectly diagnosed (7% compared with 8% for the most symptomatic leg strategy). In 89% of the 390 patients in categories 1 and 2, the ICP values deviated by >5 mmHg from the 35-mmHg cutoff value compared with 40% of the 52 patients in categories 3 and 4. Conclusions: In military service members with bilateral chronic anterolateral exertional pain, a unilateral ICP measurement seems to be justified, especially among those with pressure values >5 mmHg above or below the diagnostic cutoff value. When a unilateral pressure measurement is within 5 mmHg above or below the cutoff value, a bilateral ICP measurement may be warranted. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Poor association between tendon structure and self-reported symptoms following conservative management in active soldiers with mid-portion Achilles tendinopathy.

INTRODUCTION: Mid-portion Achilles tendinopathy (mid-AT) is currently the preferred term for persistent Achilles tendon pain, defined as located 2-7 cm proximal to the calcaneus, and with loss of function related to mechanical loading. Histologically, mid-AT is considered to represent a degenerative condition. Therefore, monitoring of tendon structure additional to pain and function may be warranted, to prevent progression of degeneration or even tendon rupture. The aim of this study was to determine the association between pain and function, relative to the Achilles tendon structure, in soldiers treated with a conservative programme for mid-AT. METHODS: A total of 40 soldiers (40 unilateral symptomatic tendons) were included in this study. Pain and function were evaluated with the Victorian Institute of Sports Assessment -Achilles (VISA-A) questionnaire. Tendon structure was quantified using ultrasound tissue characterisation (UTC). We quantified both the Achilles tendon mid-portion (2-7 cm) and the area of maximum degeneration (AoMD) within the tendon mid-portion. VISA-A and UTC measurements were taken at baseline and after 26 weeks of follow-up. Spearman's rho was used to determine the correlation between VISA-A and UTC. Correlations were calculated for baseline, follow-up and change score values. RESULTS: Negligible correlations were found for all analyses, ranging from -0.173 to 0.166 between mid-portion tendon structure and VISA-A, and from -0.137 to 0.150 between AoMD and VISA-A. While VISA-A scores improved, on average, from 59.4 points at baseline to 93.5 points at follow-up, no detectable improvement in aligned fibrillar structure was observed in our population. CONCLUSION: Pain and function are poorly associated with Achilles tendon structure in soldiers treated with a conservative programme for mid-AT. Therefore, we advise clinicians to use great caution in communicating relationships between both clinical entities. TRIAL REGISTRATION NUMBER: NL69527.028.19.

The additional value of a pneumatic leg brace in the treatment of recruits with medial tibial stress syndrome; a randomized study.

OBJECTIVE: To study the additional effect of a pneumatic leg brace with standard rehabilitation for the treatment of medial tibial stress syndrome (MTSS) in recruits. METHODS: In a single blinded randomized study, 15 recruits (age 17-22) followed a rehabilitation programme consisting of leg exercises and a graded running programme. Recruits performed daily exercises and ran three times a week. The running programme consisted of 6 consecutive phases. One group was, after randomization, additionally provided with a pneumatic leg brace. Follow-up was provided every other week. Days to completing the running programme was the primary outcome measure, the Sports Activity Rating Scale (SARS) score and satisfaction with the treatment were secondary outcome measures. RESULTS: In total 14 recruits completed the rehabilitation programme. No differences were found in the number of days until phase six of the running schedule was finished between the brace and the control group (Brace 58.8 +/- 27.7 (mean +/- SD) vs Non-Brace 57.9 +/- 26.2 (mean +/- SD, p = 0.57). Also no differences were found in the SARS scores between the groups. Overall satisfaction with the treatment was 6.4 +/- 1.1 (mean +/- SD) on a 1-10 scale for the brace group and 7.1 +/- 0.7 (mean +/- SD) for the control group (p = 0.06). Comfort of the brace was assessed as 4.8 +/- 1.3 (mean +/- SD) on a 1-10 scale. CONCLUSIONS: No additional large effect of the pneumatic leg brace could be found in recruits and wearing of the brace was not feasible, since the wearing comfort was low.

A manual therapy technique for chronic adductor-related groin pain in athletes: a case series.

The objective was to retrospectively examine whether a manual therapy technique is effective in the treatment of chronic adductor-related groin pain in athletes. Thirty-three athletes with chronic adductor-related groin pain were approached. Thirty patients gave their consent to participate in the study. Patient satisfaction, return to activity and numeric pain score were recorded. Patients were treated after prewarming of the muscles; one hand is used to control the tension in the adductor muscles and the other hand is used to move the hip into abduction and external rotation. This flowing, circular motion stretches the adductor muscle group. The movement is repeated three times in one treatment session. Twenty-five out of 30 (83%) athletes reported a good or excellent satisfaction. Twenty-seven out of 30 (90%) athletes had resumed sport at (15/30) or below (12/30) their previous level of activity. The pain score for during or after activity decreased significantly from 8.7 to 2.2 after the treatment (P<0.01). This study shows that the manual therapy treatment might be a promising treatment for chronic adductor-related groin pain in athletes.

Reducing vertical ground reaction forces: The relative importance of three gait retraining cues.

BACKGROUND: Previous studies in our department demonstrated that gait retraining as part of a conservative treatment program for service members with exercise-related leg pain can lead to persistent changes in vertical ground reaction forces while running in shoes and boots. It is not known which gait retraining cue has the largest effect and whether a combination of cues is advantageous. METHODS: During a single gait retraining session, 12 male heel striking patients were given three cues in isolation: Cue 1. Change to a ball-of-foot strike; Cue 2. Increase cadence to 180 steps per minute; Cue 3. Stand up taller; and finally, all three cues combined. Runs were performed on an instrumented treadmill at 10 km/h, 1% incline and in running shoes. The three cues were randomly introduced. Measurements, taken during 30-second episodes, were stride length, cadence, and six force variables: maximum force (N) and maximum pressure (N/cm2) on the heel, mid-foot and fore-foot. FINDINGS: Each cue, i.e., each change in running technique, caused a different pattern of changes among the six force variables, mostly reductions. In isolation, cue 1 produced the largest reduction of force and pressure on the heel, resulting percentages 45.8 and 67.2 respectively (p = 0.00, p = 0.00). Overall, the combination of cues 1 + 2 + 3 ranked first in reducing forces for four of the six force variables. INTERPRETATION: Three commonly used gait retraining cues, when applied in isolation, all resulted in a reduction of most vertical ground reaction forces. The combination of the three cues is advantageous.