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Purpose The incidence of groin pain in athletes is steadily increasing. Symptomatic pubic overload with groin pain and aseptic osteitis pubis represent well-known and frequently misdiagnosed overuse injuries in athletes. This study investigated the benefits of standardised non-surgical treatment for swift return-to-football. Methods In a prospective double-blinded controlled study, 143 amateur football players with groin pain as well as radiological signs and clinical symptoms of pubic overload were analysed for 1 year. Two randomised study groups participated in an intensive physical rehabilitation programme, either with or without shock wave therapy. The control group did not participate in any standardised rehabilitation programme but only stopped participating in sports activity. Follow-up examinations took place 1, 3 months and 1 year after the beginning of therapy. Endpoints were visual analogue scale (VAS), functional tests, the time of return-to-football, recurrent complaints and changes in the MR image. Results Forty-four football players with groin pain and aseptic osteitis pubis were randomised into two study groups; 26 received shock wave therapy, 18 did not. Clinical examination showed pubic overload as a multi-located disease. Players receiving shock wave therapy showed earlier pain relief in the VAS ( p  < 0.001) and returned to football significantly earlier ( p  = 0.048) than players without this therapy. Forty-two of 44 players of both study groups returned to football within 4 months after the beginning of therapy and had no recurrent groin pain within 1 year after trauma. Fifty-one players of the control group returned to football after 240 days ( p  < 0.001), of whom 26 (51%) experienced recurrent groin pain. Follow-up MRI scans did not show any effect of shock wave therapy. Conclusion Non-surgical therapy is successful in treating pubic overload and osteitis pubis in athletes. Shock wave therapy as a local treatment significantly reduced pain, thus enabling return-to-football within 3 months after trauma. Early and correct diagnosis is essential for successful intensive physiotherapy. Level of evidence I.

Background and objectives Treatment of chronic running-related overuse injuries by orthopaedic shoe orthoses is very common but not evidence-based to date. Hypothesis Polyurethane foam orthoses adapted to a participant's barefoot plantar pressure distribution are an effective treatment option for chronic overuse injuries in runners. Design Prospective, randomised, controlled clinical trial. Intervention 51 patients with running injuries were treated with custom-made, semirigid running shoe orthoses for 8 weeks. 48 served as a randomised control group that continued regular training activity without any treatment. Main outcome measures Evaluation was made by the validated pain questionnaire Subjective Pain Experience Scale, the pain disability index and a comfort index in the orthoses group (ICI). Results There were statistically significant differences between the orthoses and control groups at 8 weeks for the pain disability index (mean difference 3.2; 95% CI 0.9 to 5.5) and the Subjective Pain Experience Scale (6.6; 2.6 to 10.6). The patients with orthoses reported a rising wearing comfort (pre-treatment ICI 69/100; post-treatment ICI 83/100) that was most pronounced in the first 4 weeks (ICI 80.4/100). Conclusion Customised polyurethane running shoe orthoses are an effective conservative therapy strategy for chronic running injuries with high comfort and acceptance of injured runners.

Repetitive behaviors are a core symptom domain in autism that has been linked to alterations in the serotonin system. While the selective serotonin-receptive inhibitor fluvoxamine has been shown to be effective in adults with autism, as yet no published placebo controlled trials with these agents document safety and efficacy in children with autism. This study examines the selective serotonin reuptake inhibitor liquid fluoxetine in the treatment of repetitive behaviors in childhood and adolescent autism spectrum disorders (ASDs). In total, 45 child or adolescent patients with ASD were randomized into two acute 8-week phases in a double-blind placebo-controlled crossover study of liquid fluoxetine. Study design included two randomized 8-week fluoxetine and placebo phases separated by a 4-week washout phase. Outcome measures included measures of repetitive behaviors and global improvement. Low-dose liquid fluoxetine (mean final dose: 9.9+/-4.35 mg/day) was superior to placebo in the treatment of repetitive behaviors by CY-BOCS compulsion scale. The effect size was in the moderate to large range, and the doses used were low. Liquid fluoxetine was only slightly, and not significantly, superior to placebo on CGI autism score partially due to a phase order effect. However, fluoxetine was marginally superior to placebo on a composite measure of global effectiveness. Liquid fluoxetine did not significantly differ from placebo on treatment emergent side effects. Liquid fluoxetine in low doses is more effective than placebo in the treatment of repetitive behaviors in childhood autism. Limitations include small sample size and the crossover design of the study. Further replication and long-term maintenance trials are needed.

Groin pain is common among athletes. A major cause of long-standing problems is adductor-related groin pain. The purpose of this randomised clinical trial was to compare an active training programme (AT) with a physiotherapy treatment without active training (PT) in the treatment of adductor-related groin pain in athletes. 68 athletes with long-standing (median 40 weeks) adductor-related groin pain—after examination according to a standardised protocol—were randomly assigned to AT or PT. The treatment period was 8–12 weeks. 4 months after the end of treatment a standardised examination was done. The examining physician was unaware of the treatment allocation. The ultimate outcome measure was full return to sports at the same level without groin pain. Analyses were by intention to treat. 23 patients in the AT group and four in the PT group returned to sports without groin pain (odds ratio, multiple-logistic-regression analysis, 12·7 [95% CI 3·4–47·2]). The subjective global assessments of the effect of the treatments showed a significant (p=0·006) linear trend towards a better effect in the AT group. A per-protocol analysis did not show appreciably different results. AT with a programme aimed at improving strength and coordination of the muscles acting on the pelvis, in particular the adductor muscles, is very effective in the treatment of athletes with long-standing adductor-related groin pain. The potential preventive value of a short programme based upon the principles of AT should be assessed in future, randomised, clinical trials.

Achilles tendinopathy is a painful overuse injury that is extremely common in athletes, especially those who participate in running and jumping sports. In addition to pain, Achilles tendinopathy is accompanied by alterations in the tendon's structure and mechanical properties, altered lower extremity function, and fear of movement. Cumulatively, these impairments limit sport participation and performance. A thorough evaluation and comprehensive treatment plan, centered on progressive tendon loading, is required to ensure full recovery of tendon health and to minimize the risk of reinjury. In this review, we will provide an update on the evidence-based evaluation, outcome assessment, treatment, and return-to-sport planning for Achilles tendinopathy. Furthermore, we will provide the strength of evidence for these recommendations using the Strength of Recommendation Taxonomy system.

Objectives The aim of this study was to investigate the effectiveness of an ergonomic intervention on productivity loss at work caused by upper-extremity disorders (UED). Methods Workers with medically verified UED were invited to participate. The intervention consisted of a physician contacting the worker's supervisor and an occupational physiotherapist conducting an ergonomie assessment at the worksite. Before and after the intervention, the employees self-assessed UED-related productivity loss (ie, decreased quality and quantity of the daily work output). We tested for differences between groups at 8 and subsequently 12 weeks. We also applied generalized estimating equation (GEE) to analyze repeated measures data. Results Altogether 177 employees were randomized. The overall participation rate was 88%. At baseline, 54% of the intervention group and 58% of the control group reported productivity loss. The magnitude of productivity loss was 17% and 20%, respectively. At 8 weeks, both the proportion and magnitude of productivity loss were lower in the intervention than the control group, but the differences were statistically significant only at 12 weeks (proportion 25% versus 51%, magnitude 7% versus 18%, P=0.001 for both). Using GEE analyses, we also found the differences to be statistically significant (proportion 38% versus 52%, magnitude 12% versus 18%). The intervention only benefitted employees with 0-20% loss of productivity at baseline, not those with a higher initial productivity loss. Conclusions Early ergonomic intervention, in addition to adequate medical care, is effective in preventing and restoring self-reported productivity loss associated with UED.

Background Fifth metatarsal (MT-V) stress fractures often exhibit delayed union and are high-risk fractures for non-union. Surgical treatment, currently considered as the gold standard, does not give optimal results, with a mean time to fracture union of 12-18 weeks. In recent studies, the use of bone marrow cells has been introduced to accelerate healing of fractures with union problems. The aim of this randomized trial is to determine if operative treatment of MT-V stress fractures with use of concentrated blood and bone marrow aspirate (cB + cBMA) is more effective than surgery alone. We hypothesize that using cB + cBMA in the operative treatment of MT-V stress fractures will lead to an earlier fracture union. Methods/Design A prospective, double-blind, randomized controlled trial (RCT) will be conducted in an academic medical center in the Netherlands. Ethics approval is received. 50 patients will be randomized to either operative treatment with cB + cBMA, harvested from the iliac crest, or operative treatment without cB + cBMA but with a sham-treatment of the iliac crest. The fracture fixation is the same in both groups, as is the post-operative care.. Follow up will be one year. The primary outcome measure is time to union in weeks on X-ray. Secondary outcome measures are time to resumption of work and sports, functional outcomes (SF-36, FAOS, FAAM), complication rate, composition of osteoprogenitors in cB + cBMA and cost-effectiveness. Furthermore, a bone biopsy is taken from every stress fracture and analysed histologically to determine the stage of the stress fracture. The difference in primary endpoint between the two groups is analysed using student’s t -test or equivalent. Discussion This trial will likely provide level-I evidence on the effectiveness of cB + cBMA in the operative treatment of MT-V stress fractures. Trial registration Netherlands Trial Register (reg.nr NTR4377 )

Bone stress injuries (BSIs) are a spectrum of overuse injuries caused by an accumulation of microdamage, from high physical demands on normal bone or normal physiologic loads on structurally compromised bone. They typically result from overuse in younger patients but are also caused by pathologic bone conditions, including relative energy deficiency in sport, which features decreased bone mineral density. Stress fractures, representing 20% of BSIs, are the most severe type and feature discernable sclerosis or fracture lines on imaging. Without treatment, they can progress to complete fractures. BSIs present as localized pain and loss of function, most often in the setting of sudden load volume changes. Palpatory bony tenderness is the most significant examination finding. Prevention focuses on recognition and optimization of modifiable risk factors, which include nutritional, lifestyle, and physical activity habits. Despite low sensitivity, radiography should be the initial imaging modality for suspected BSI. Magnetic resonance imaging is the preferred definitive study. Point-of-care ultrasonography is gaining popularity, but training and availability are barriers in primary care. Once a BSI is diagnosed, early intervention is imperative to reduce pain and promote healing. Severity of BSI (grade) and location (low- vs high-risk of complications) guide the management approach. Injuries in low-risk sites are treated conservatively, whereas fractures in high-risk sites warrant consultation with sports medicine or orthopedics. Femoral neck BSIs, especially when tension-sided, require urgent surgical consultation.

This study aimed to determine the role of DHEA-S in coping against the exercise training mixing aerobic and resistance components. During 5-day successive exercise training, 16 young male participants (19.2 ± 1.2 years) received either a placebo (flour capsule) or DHEA (100 mg/day) in a double-blinded and placebo-controlled design. Oral DHEA supplementation significantly increased circulating DHEA-S by 2.5-fold, but a protracted drop (~35 %) was observed from Day 3 during training. In the Placebo group, only a minimal DHEA-S reduction (~17 %) was observed. Changes in testosterone followed a similar pattern as DHEA-S. Muscle soreness was elevated significantly on Day 2 for both groups to a similar extent. Lower muscle soreness was observed in the DHEA-supplemented group on Day 3 and Day 6. In the Placebo group, training increased circulating creatine kinase (CK) levels by approximately ninefold, while only a threefold increase was observed in the DHEA-supplemented group. This mix-type exercise training improved glucose tolerance in both groups, while lowering the insulin response to the glucose challenge, but no difference between treatments was observed. Our results suggest that DHEA-S may play a role in protecting skeletal muscle from exercise training-induced muscle damage.

Family physicians play a valuable role in the diagnosis, management, and treatment of musculoskeletal disorders that result from occupational exposures, including overexertion, repetitive motion, and vibration. Carpal tunnel syndrome is a common peripheral nerve entrapment syndrome often identified in workers whose jobs require repetitive hand motion. Treatment of carpal tunnel syndrome includes splinting, rehabilitation exercises, and oral or injected corticosteroids; surgical release is considered in patients for whom conservative treatment has failed or who have severe symptoms. Lateral epicondylitis is an elbow disorder resulting from overuse; it is diagnosed clinically and managed with bracing, nonsteroidal anti-inflammatory drugs, corticosteroid injections, and physical therapy. Rotator cuff tendinopathy is a degenerative disorder of the rotator cuff musculature and tendons and is often identified in people who perform repetitive work overhead. Rotator cuff tendinopathy is diagnosed clinically and generally managed nonoperatively with nonsteroidal anti-inflammatory drugs, physical therapy, and corticosteroid injections; imaging may be considered to confirm the diagnosis after initial conservative treatment. Trigger finger is a stenosing tenosynovitis of the flexor ten-dons of the hand and occurs among people whose jobs require repetitive gripping. Corticosteroid injection is a first-line treatment for trigger finger. A careful history can assist the clinician in determining whether an injury is work related. Providing appropriate work restrictions for injured workers to allow a safe return to work may expedite recovery.