Effects of Eccentric Versus Concentric Strengthening in Patients With Subacromial Pain Syndrome: A Randomized Controlled Trial.

BACKGROUND: Subacromial pain syndrome (SPS) is the most common cause of shoulder pain. Therapeutic exercise is the first-line treatment for SPS; however, the ideal exercise type remains unclear. Here, we compared the effects of eccentric and concentric strengthening in patients with SPS. HYPOTHESIS: Adding isolated eccentric strengthening to a multimodal physiotherapy program (MPP) would lead to greater improvements in outcomes compared with either MPP alone or adding isolated concentric strengthening to the MPP. STUDY DESIGN: Randomized controlled trial. LEVEL OF EVIDENCE: Level 2. METHODS: A total of 45 patients were randomized to eccentric strengthening (ESG), concentric strengthening (CSG), and control (CG) groups; all groups received the MPP. The strengthening groups also performed group-specific strengthening. Shoulder pain, abduction and external rotation (ER) strength, joint position sense (JPS), the Constant-Murley Score (CMS), and the Disabilities of the Arm, Shoulder and Hand score were collected at baseline, after 12 weeks of treatment, and at week 24. RESULTS: For CMS, ESG exhibited a greater, but not clinically meaningful, improvement than CSG and CG (P < 0.05). Eccentric abduction strength increased in ESG compared with CG. From baseline to follow-up, abduction strength increased in ESG compared with CSG and CG. Eccentric abduction strength increased in CSG compared with CG. JPS at abduction improved in the ESG compared with CG. Other between-group comparisons were not significant (P > 0.05). CONCLUSION: In SPS, eccentric strengthening provided added benefits, improving shoulder abduction strength and JPS at abduction, and was superior to concentric strengthening for improving shoulder abduction strength. Neither strengthening approach had an additional effect on shoulder function, pain, ER strength, or rotational JPS. CLINICAL RELEVANCE: Clinicians could implement eccentric strengthening as a motor control retraining for strength and proprioception gain rather than for pain relief and reducing disability.

Novel Posterior Shoulder Stretching With Rapid Eccentric Contraction and Static Stretching in Patients With Subacromial Pain Syndrome: A Randomized Trial.

BACKGROUND: In subacromial pain syndrome (SPS), it is unknown whether posterior shoulder stretching exercises (PSSE) with rapid eccentric contraction, a muscle energy technique, improve clinical and ultrasonographic outcomes more than no stretching or static PSSE. HYPOTHESIS: PSSE with rapid eccentric contraction is superior to no stretching and static PSSE in improving clinical and ultrasonographic outcomes in SPS. STUDY DESIGN: Randomized controlled trial. LEVEL OF EVIDENCE: Level 1. METHODS: Seventy patients with SPS and glenohumeral internal rotation deficit were randomized into the modified cross-body stretching with rapid eccentric contraction group (EMCBS; n = 24), static MCBS group (SMCBS; n = 23), or control group (CG; n = 23). In addition to 4-week physical therapy, EMCBS received PSSE with rapid eccentric contraction, SMCBS static PSSE, and CG no PSSE. The primary outcome was internal rotation range of motion (ROM). Secondary outcomes were posterior shoulder tightness, external rotation ROM (ERROM), pain, modified Constant-Murley score, short form of the disabilities of the arm, shoulder, and hand questionnaire (QuickDASH), rotator cuff strength, acromiohumeral distance (AHD), supraspinatus tendon thickness, and supraspinatus tendon occupation ratio (STOR). RESULTS: Shoulder mobility, pain, function and disability, strength, AHD, and STOR improved in all groups (P < 0.05). CONCLUSION: In patients with SPS, PSSE with rapid eccentric contraction and static PSSE were superior to no stretching in improving clinical and ultrasonographic outcomes. Stretching with rapid eccentric contraction was not superior to static stretching, but improved ERROM compared with no stretching. CLINICAL RELEVANCE: In SPS, both PSSE with rapid eccentric contraction and static PSSE included in physical therapy program are beneficial to improve posterior shoulder mobility and other clinical and ultrasonographic outcomes. In the case of ERROM deficiency, rapid eccentric contraction might be preferred.

Relationship Between Vitamin D Levels and ß Cell Function and Insulin Resistance.

Background This study aimed to determine the relationship between vitamin D levels and ß cell function and insulin resistance in patients with diabetes, glucose tolerance disorder, or impaired fasting glucose. Methodology A total of 75 outpatients (55 females and 20 males) between the ages of 30 and 65 years were included in the study. There were 25 healthy individuals, 25 individuals with prediabetes, and 25 individuals with diabetes. The Homeostasis Model Assessment (HOMA) score was used to evaluate insulin resistance. Results The mean levels of vitamin 25(OH)D among the groups included in the study were 35 ± 16.9 nmol/L in the control group, 44.5 ± 34.5 nmol/L in the prediabetes group, and 35.7 ± 13.1 nmol/L in the diabetes group. There were no significant differences. The mean level of vitamin 1.25(OH)2D3 was 15.95 ± 8 pg/mL in the control group, 18.4 ± 7.5 pg/mL in the prediabetes group, and 21.5 ± 7.9 pg/mL in the diabetes group. While the levels of vitamin 25(OH)D were similar between the groups, the levels of vitamin 1,25(OH)2D3  were significantly higher in the diabetes group. Considering all individuals, no significant difference was found between the vitamin 25(OH)D and glucose levels at minutes 0, 30, 60, 90, and 120. While there was a significant positive relationship between the 1,25(OH)2D3 vitamin and glucose levels at minutes 0, 30, 60, and 90, there was no significant relationship between the levels at minute 120. When the 1,25(OH)2D3 vitamin and HOMA insulin resistance and HOMA ß scores were compared, a significant positive relationship was found between the 1,25(OH)2D3 vitamin and HOMA ß levels. Conclusions In our study, there was no significant difference between the groups (control, prediabetes, and diabetes) in 25(OH)D levels. Similarly, there was no significant relationship between the 25(OH)D levels and insulin sensitivity and resistance between the groups. The positive relationship identified between the 1,25(OH)2D3 vitamin levels and the glucose concentration at minutes 0, 30, 60, and 90 and the higher 1,25(OH)2D3 vitamin levels in the diabetes group compared to the control group in our study can be interpreted as the effort of the organism to prevent glucose-induced ß-cell apoptosis.

Cast immobilization versus volar locking plate fixation of AO type C distal radial fractures in patients aged 60 years and older.

OBJECTIVE: The aim of this study was to evaluate the efficacy of conservative treatment (cast immobilization) for complex intra-articular distal radius fractures (AO type C) in elderly patients and to determine whether or not the application of a volar locking plate (VLP) is necessary. METHODS: A retrospective study on patients treated at two different clinics was conducted between 2014 and 2016. A total of 49 elderly patients ≥60 years old were treated either operatively with volar locking plate fixation (n = 25; 7 males and 18 females; mean age: 66.6 ± 7.4 years) or conservatively with cast immobilisation (n = 24; 7 males and 17 females; mean age: 68.9 ± 8.7 years) for complex intra-articular distal fractures. Clinical, functional and radiological evaluations were conducted at the final follow-up examinations of the patients. RESULTS: There was no statistically significant difference between the two groups of patients with respect to the follow-up periods, gender, age and fracture type (p > 0.05). At the end of mean follow-up time of 16 months the grip strength (p = 0.03), radial tilt (p = 0.06), radial inclination (p = 0.01), radial height (p = 0.01) and articular step-off (p = 0.02) were significantly better in the volar locking plate group, while there was no significant difference between the functional results (based on the Quick Disabilities of the Arm, Shoulder and Hand score) (p = 0.8) and range of motion. The grip strength was significantly higher in the VLP group when compared to the cast group (p = 0.03). CONCLUSION: The results of this study suggest that the locking plate fixation for the complex intra-articular distal radius fractures provides better results for the grip strength and radiographic parameters than cast immobilization in patients ≥60 years old, while no difference was found between the clinical and functional results. LEVEL OF EVIDENCE: Level III, Therapeutic Study.

Sanders type 3-4 calcaneal fractures fixed with locking plate: does tri-cortical iliac bone autograft provide extra benefit for stabilization?

OBJECTIVE: The aim of this study was to determine whether tri-cortical iliac bone autografting provided extra benefit for the stabilization in Sanders Type 3-4 calcaneal fractures fixed with locking plate. MATERIALS AND METHODS: The study included 29 calcaneal fractures (Sanders Type 3/4=15/14). All fractures were fixed with locking plate using the extended lateral approach. Bone grafts were used in 16 (Group A; Sanders Type 3/4=7/9) and not used in 13 (Group B; Sanders Type 3/4=8/5) calcaneal fractures. As a grafting material, only tri-cortical iliac crest bone autograft was used. All operations were performed by the same surgeon. The same locking plate was used in all fractures. Calcaneal height and angle of Bohler and Gissane were measured in early postoperative and final control radiographs in both groups. Clinical evaluations were performed using the American Orthopedic Foot and Ankle Society ankle hind foot scale. RESULTS: There was no difference between the groups in terms of clinical results. Radiologically, the degree of change in Bohler's angle, Gissane's angle, and calcaneal height was not different between the groups. CONCLUSION: Bone grafting does not affect the clinical and radiologic outcomes in Sanders Type 3-4 calcaneal fractures fixed with locking plate, and they provide no extra benefit to the stabilization. We think that fixation using locking plate is adequate and there is no need for bone grafting.

Fixed-bearing unicompartmental knee arthroplasty tolerates higher variance in tibial implant rotation than mobile-bearing designs.

BACKGROUND: UKA necessitates a learning period. From this point of view, it would be logical to prefer the design that tolerates suboptimal tibial rotations better, especially for inexperienced surgeons. The aim of this study was to evaluate and compare the clinical and radiological results of mobile-bearing and fix-bearing UKA designs in case of suboptimal tibial rotations. METHODS: A retrospective case-control evaluation was made of all the patients with medial compartment osteoarthritis, treated between January 2011 and January 2015. 324 patients ideal femoral rotation were enrolled in the study. 153 patients (Group 1) were treated with fix-bearing design with a mean 28.8 ± 11.3 month follow-up and 171 patients (Group 2) were treated with mobile-bearing design with a 31 ± 14.3 month follow-up. Each patient in groups was subdivided into (A): optimal tibial rotation, (B): external rotation of tibial component > 5°, (C): internal rotation of tibial component > 5° subgroups. WOMAC and KSS scores of each patient at preoperative and postoperative final control were compared between groups and subgroups. RESULTS: No significant differences were determined between the groups in terms of mean follow-up time (p = 0.0612), preoperative WOMAC, and KSS scores (p = 0.754 and p = 0.832, respectively). No significant differences were determined between subgroups 1A and 2A in terms of WOMAC and KSS scores at the final evaluation (p = 0.314 and p = 0.546, respectively). A significant difference was determined between subgroups 1B and 2B in terms of WOMAC and KSS scores (p = 0.021 and p = 0.012, respectively). In addition, the difference between subgroups 1C and 2C was significant (p = 0.047 and p = 0.034, respectively) at the final evaluation. CONCLUSION: Both mobile- and fix-bearing designs are beneficial in the treatment of medial compartment osteoarthritis of the knee. However, in case of both tibial internal or external suboptimal tibial rotations, fix-bearing design have better results compared to mobile-bearing design. STUDY DESIGN: Level III retrospective comparative clinical study.

Lunate excision with capitohamate fusion in the treatment of stage IIIB and IIIC Kienböck's disease.

OBJECTIVE: The aim of this study was to report our results of lunate excision combined with capitohamate fusion in the treatment of Kienböck's stage IIIB/IIIC disease. METHODS: A total of 7 patients with a mean age 35.2 (SD 11.5) years were enrolled in the study. Pain was the principal reason for surgery. All operations were carried out by the same senior surgeon. Patients were evaluated in terms of range of motion, DASH and VAS scores, satisfaction, and grip/tip/palmar/key pinch strength compared with contralateral sides. Preoperative carpal height indexes and findings of osteoarthritis were determined radiographically and compared with postoperative evaluations. RESULTS: Mean duration of follow up was 15.2 months. Mean DASH and VAS scores were 13.8 2.7 and 2 1.1 respectively. The mean patient satisfaction score was 3.2 0.4 over 4 points. The mean grip strength in the operated hands was 66.4%, palmar pinch was 75.1%, tip pinch was 71.8% and key pinch was 70.4% when compared to the contralateral unaffected sides. The mean flexion range in the operated hands was 58.8%, extension range was 60.3%, radial deviation range was 65.2% and ulnar deviation range was 65.7% when compared to the contralateral sides. There was no significant difference between preoperative and postoperative carpal height ratios (p = 0.086). CONCLUSIONS: Our early term results indicate that lunate excision combined with capitohamate fusion may be an alternative treatment option in patients with stage IIIB and IIIC Kienböck's disease. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

Linburg-Comstock: Is Overuse an Etiological Factor?

BACKGROUND: Linburg-Comstock anomaly is typically defined as a tenosynovial interconnection between flexor pollicis longus and flexor digitorum profundus tendon of the second finger. There are several studies stating that the current anomaly is congenital or acquired. The aim of this study is to reveal whether overuse, which is mostly reported as an acquired etiologic factor, effective in development of the current anomaly. METHODS: Three hundred thirteen medical secretaries who work with computer keyboard at least 6 hours a day were defined as study group. Three hundred twenty-three volunteers without jobs who necessitate continuous and repetitive hand and finger activities were defined as control group. All individuals were examined by an orthopaedic surgeon. Additionally, cases with Linburg-Comstock anomaly were evaluated in respect of forearm pain and subjective findings of carpal tunnel syndrome. RESULTS: Linburg-Comstock anomaly was determined in 27.8% cases of medical secretary group and in 32.2% of healthy control group. In medical secretaries with Linburg-Comstock anomaly, 25.3% had forearm pain and 5.7% had findings of carpal tunnel syndrome. In control group with Linburg-Comstock anomaly, 21.2% had forearm pain and 13.5% had findings of carpal tunnel syndrome. No relationship was found between overuse of the hand and Linburg-Comstock anomaly and the symptoms accompanying the anomaly. CONCLUSIONS: The current study reveals that overuse is not an etiologic factor in Linburg-Comstock anomaly existence and related symptoms. We think that the current anomaly develops on congenital basis rather than acquired factors.

HISTORIQUE: En général, le syndrome de Linburg-Comstock désigne une interconnexion ténosynoviale entre le tendon long fléchisseur et le tendon fléchisseur profond de l'index. Selon plusieurs études, cette anomalie est congénitale ou acquise. La présente étude visait à déterminer si la surutilisation, surtout considérée comme un facteur étiologique acquis, contribue à l'apparition de cette anomalie. MÉTHODOLOGIE: Les chercheurs ont sélectionné un groupe d'étude composé de 313 secrétaires médicales qui saisissaient des données au moins six heures par jour. Le groupe témoin était formé de 323 volontaires n'occupant pas un emploi exigeant des activités répétitives et continues des mains et des doigts. Un chirurgien orthopédique les a tous examinés. De plus, les chercheurs ont évalué les syndromes de Linburg-Comstock en fonction de la douleur de l'avant-bras et des observations subjectives de syndrome du canal carpien. RÉSULTATS: Les chercheurs ont constaté la présence d'un syndrome de Linburg-Comstock chez 27,8 % des secrétaires médicales et 32,2 % des sujets du groupe témoin. Chez les secrétaires médicales atteintes de ce syndrome, 25,3 % souffraient de douleurs à l'avant-bras et 5,7 % présentaient des constatations de syndrome du canal carpien. Quant aux sujets du groupe témoin ayant l'anomalie, 21,2 % souffraient de douleurs à l'avant-bras et 13,5 % présentaient des constatations de syndrome du canal carpien. Les chercheurs n'ont remarqué aucun lien entre la surutilisation de la main, le syndrome de Linburg-Comstock et les symptômes connexes. CONCLUSIONS: La présente étude révèle que la surutilisation n'est pas un facteur étiologique du syndrome de Linburg-Comstock et des symptômes connexes. Les auteurs croient qu'il s'agit d'une anomalie congénitale et d'un problème non acquis.

DISCORDANCE BETWEEN GH AND IGF-1 LEVELS IN TURKISH ACROMEGALIC PATIENTS.

OBJECTIVE: Discordance between insulin-like growth factor-1 (IGF-1) and growth hormone (GH) levels is an important problem in the follow-up of patients diagnosed with acromegaly. Our aims were to evaluate the discordance between IGF-1 and GH levels and compare the performance of different cut-off levels for the nadir in GH (GHn) in acromegalic patients. METHODS: The study included 63 acromegalic patients in a follow-up at a tertiary care university hospital facility. Levels of IGF-1, IGF binding protein-3 (IGFBP-3), and GH were investigated. The baseline GH and GHn levels were evaluated after an oral glucose tolerance test (cut-offs of 0.4 and 1 ng/mL, respectively). The discordance rates between GHn and IGF-1 levels, and IGF-1/IGFBP-3 ratios were determined. RESULTS: We first adopted a GHn cut-off value of 1 ng/mL and found that 27 patients (42.9%) exhibited biochemical remission (BR) (IGF-1 <95th percentile, GH <1), and 25 patients (39.7%) had no BR (NBR) (IGF-1 ≥95th percentile, GH >1). Discordance in the presence of normal IGF-1 and nonsuppressed GH (DC1) occurred in 2 of 63 (3.2%) patients; discordance in the presence of high IGF-1 and suppressed GH (DC2) occurred in 9 of 63 (14.3%) patients. If the GHn cut-off value adopted was 0.4 ng/mL, the distributions were 17 of 63 (27.0%) patients in BR, 29 of 63 (46.0%) patients in NBR, 12 of 63 (19.0%) in DC1, and 5 of 63 (7.9%) patients in DC2. If only the baseline GH values were considered, the distributions were very similar to those with a GHn cut-off value of 0.4 ng/mL. The IGF-1/IGFBP-3 ratio was lowest in the BR group. CONCLUSION: Adopting a GHn cut-off value of 0.4 ng/mL did not increase the test performance compared with baseline GH only. In contrast, in the follow-up of acromegalic patients, the IGF-1/IGFBP-3 ratio might be a useful measurement when discordance between IGF-1 and GH levels occurs. We propose that these values be considered in clinical practice. ABBREVIATIONS: BR = biochemical remission DC1 = discordance group 1 DC2 = discordance group 2 DM = diabetes mellitus GH = growth hormone GHn = nadir in GH IGF-1 = insulin-like growth factor-1 IGFBP-3 = IGF binding protein-3 LAR = long-acting release NBR = not in biochemical remission OGTT = oral glucose tolerance test.

[Massive rotator cuff tears: diagnosis and treatment techniques]. / Masif rotator manset yirtiklarinin tani ve tedavi yöntemleri.

The treatment of massive rotator cuff tears presents challenging difficulties. Re-rupture after treatment may be frequently seen, along with it muscular degeneration, leading to insufficient clinical results. There is still controversy as to whether conservative or surgical treatment methods will be more appropriate for massive and partial tears. This article aimed to provide an update on the diagnosis and treatment of massive rotator cuff tears.

Congenital anterior dislocation of the radial head: a case with radiographic findings identical to traumatic dislocation.

Differentiation of congenital unilateral dislocation of the radial head from a traumatic dislocation depends mainly on the radiographic findings. Here, we report a case of congenital unilateral anterior radial head dislocation with radiographic findings identical to traumatic dislocation.

Osteochondrosis of the primary ossification center of the patella (Köhler's disease of the patella) report of three cases.

Radiography of three boys 5-6 years old with anterior knee pain revealed increased density and irregularity of the patellar ossification centers. A search of the literature suggested that it was osteochondrosis of the primary ossification center of the patella, named after Köhler. Continuing search also revealed that it might be a normal variant instead of an osteochondrosis. A short course of activity modification led to marked improvement in all. The patients were either asymptomatic or experienced minor symptoms 18-34 months after presentation. It was concluded that the process, either physiological or pathological, has a benign course and favorable prognosis.