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The mechanistic response of rotator cuff tendons to exercises within the context of rotator cuff-related shoulder pain (RCRSP) remains a significant gap in current research. A greater understanding of this response can shed light on why individuals exhibit varying responses to exercise interventions. It can also provide information on the influence of certain types of exercise on tendons. The primary aim of this article is to explore if changes in supraspinatus tendon thickness (SSTT) ratio differ between exercise interventions (high load vs. low load). The secondary aims are to explore if changes in SSTT ratio differ between ultrasonographic tendinopathy subgroups (reactive vs. degenerative) and if there are associations between tendinopathy subgroups, changes in tendon thickness ratio, and clinical outcomes (disability). This study comprises secondary analyses of the combined dataset from two randomized controlled trials that compared high and low-load exercises in patients with RCRSP. In those trials, different exercise interventions were compared: 1) progressive high-load strengthening exercises and 2) low-load strengthening with or without motor control exercises. In 1 trial, there was also a third group that was not allocated to exercises (education only). Ultrasound-assessed SSTT ratio, derived from comparing symptomatic and asymptomatic sides, served as the primary measure in categorizing participants into tendinopathy subgroups (reactive, normal and degenerative) at baseline. Data from 159 participants were analyzed. Two-way repeated measures ANOVAs revealed significant Group (P <.001) and Group × Time interaction (P <.001) effects for the SSTT ratio in different tendinopathy subgroups, but no Time effect (P =.63). Following the interventions, SSTT ratio increased in the "Degenerative" subgroup (0.14 [95% confidence interval {CI}: 0.09-0.19]), decreased in the "Reactive" subgroup (−0.11 [95% CI: −0.16 to −0.06]), and remained unchanged in the "Normal" subgroup (−0.01 [95% CI: −0.04 to 0.02]). There was no Time (P =.21), Group (P =.61), or Group × Time interaction (P =.66) effect for the SSTT ratio based on intervention allocation. Results of the linear regression did not highlight any significant association between the tendinopathy subgroup (P =.25) or change in SSTT ratio (P =.40) and change in disability score. Findings from this study suggest that, over time, SSTT in individuals with RCRSP tends to normalize, compared to the contralateral side, regardless of the exercise intervention. Different subgroups of symptomatic tendons behave differently, emphasizing the need to potentially consider tendinopathy subtypes in RCRSP research. Future adequately powered studies should investigate how those different tendinopathy subgroups may predict long-term clinical outcomes. [ABSTRACT FROM AUTHOR]

To perform a systematic review of clinical practice guidelines (CPGs) covering the management of common shoulder disorders. A systematic search of CPGs on specific shoulder disorders was conducted up to August 2022 in relevant databases. Twenty-six CPGs on rotator cuff (RC) tendinopathy, RC tear, calcific tendinitis, adhesive capsulitis, glenohumeral (GH) instability, GH osteoarthritis, or acromioclavicular disorders published from January 2008 onward were screened and included. CPGs methodological quality was assessed with the AGREE II checklist. All recommendations from CPGs were extracted and categorized by shoulder disorder and care components (evaluation, diagnostic imaging, medical, rehabilitation, and surgical treatments). After semantic analysis of the terminology, recommendations for each shoulder disorders were classified by 2 reviewers into "recommended," "may be recommended," or "not recommended." Disagreements were resolved by discussion until reviewers reached consensus. Only 12 CPGs (46%) were of high quality with major limitations related to the applicability and editorial independence of the guidelines. The initial evaluation of shoulder pain should include patient's history, subjective evaluation focused on red flags, and clinical examination. Magnetic resonance imaging is usually not recommended to manage early shoulder pain, and recommendations for X-rays are conflicting. Acetaminophen, oral non-steroidal anti-inflammatory drugs, and rehabilitation including exercises were recommended or may be recommended to treat all shoulder pain disorders. Guidelines on surgical management recommendations differed; for example, 6 CPGs reported that acromioplasty was recommended or may be recommended in chronic RC tendinopathy, whereas 4 CPGs did not recommend it. Recommendations vary for diagnostic imaging, conservative vs surgical treatment to manage shoulder pain, although several care components are consensual. The development of evidence-based, rigorous CPGs with a valid methodology and transparent reporting is warranted to improve overall shoulder pain care. [ABSTRACT FROM AUTHOR]

To compare the efficacy of region-specific exercises to general exercises approaches for adults with spinal or peripheral musculoskeletal disorders (MSKDs). Electronic searches were conducted up to April 2020 in Medline, Embase, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health. Randomized control trials (RCTs) on the efficacy of region-specific exercises compared to general exercises approaches for adults with various MSKDs. Mean differences and standardized mean differences were calculated using random-effects inverse variance modeling. Eighteen RCTs (n=1719) were included. Cohorts were composed of participants with chronic neck (n=313) or low back disorders (n=1096) and knee osteoarthritis (OA) (n=310). Based on low-quality evidence in the short-term and very low-quality in the mid- and long-term, there were no statistically significant differences between region-specific and general exercises in terms of pain and disability reductions for adults with spinal disorders or knee OA. Secondary analyses for pain reduction in the short-term for neck or low back disorders did not report any statistically significant differences according to very low- to low-quality of evidence. The difference in treatment effect remains uncertain between region-specific and general exercises approaches. Based on very low- to low-quality evidence, there appear to have no differences between both types of exercise approaches for pain reduction or disability for adults with spinal disorders. Future trials may change the current conclusions. More evidence is needed for region-specific exercises compared to general exercises for other peripheral MSKDs including knee OA. [ABSTRACT FROM AUTHOR]

Advanced practice physiotherapy has emerged as a promising solution to improve health care access because access to orthopedic care is limited in several countries. However, evidence supporting advanced practice physiotherapy models for the management of shoulder pain remains scarce. The purpose of this study was to establish diagnostic, surgical triage, and medical imaging agreement between advanced practice physiotherapists (APPs) and orthopedic surgeons (OSs) for the management of patients with shoulder disorders in an outpatient orthopedic clinic. Patients referred to an OS for shoulder complaints were recruited and independently assessed by an OS and an APP. Each provider completed a standardized form indicating diagnosis, imaging test requests, and triage of surgical candidates. Patient satisfaction with care was recorded with the 9-item Visit-Specific Satisfaction Questionnaire (VSQ-9). Inter-rater concordance was calculated with the Cohen κ, prevalence-adjusted bias-adjusted κ, and associated 95% confidence interval (CI). We used χ2 tests to compare differences between providers in terms of treatment plan options and Student t tests to compare patient satisfaction between providers. Fifty participants were evaluated. Good diagnostic agreement was observed between providers (κ, 0.80; 95% CI, 0.67-0.93). Agreement for triage of surgical candidates was moderate (κ, 0.46; 95% CI, 0.21-0.71) as APPs tended to refer patients more often to OSs for further evaluation. Imaging test request agreement was moderate as well (κ, 0.42; 95% CI, 0.19-0.66). Patient satisfaction with care was high, with no significant differences found between providers (P =.70). APPs could improve access to orthopedic care for shoulder disorders by safely initiating patient care without compromising satisfaction. These results support further development and evaluation of APP care for orthopedic patients presenting with shoulder disorders. [ABSTRACT FROM AUTHOR]

To perform a systematic review of clinical practice guidelines (CPGs) and semantic analysis of specific clinical recommendations for the management of rotator cuff disorders in adults. A systematic bibliographic search was conducted up until May 2018 in Medline, Embase, and Physiotherapy Evidence Database, or PEDro, databases, in addition to 12 clinical guidelines search engines listed on the Appraisal of Guidelines for Research and Evaluation (AGREE) website. Nine CPGs on the management of rotator cuff disorders in adults or workers, available in English or French, and published from January 2008 onward, were included and screened by 2 independent reviewers. CPG methodology was assessed with the AGREE II checklist. A semantic analysis was performed to compare the strength of similar recommendations based on their formulation. The recommendations were categorized in a standardized manner considering the following 4 levels: "essential," "recommended," "may be recommended," and "not recommended." Methodological quality was considered high for 3 CPGs and low for 6. All CPGs recommended active treatment modalities, such as an exercise program in the management of rotator cuff disorders. Acetaminophen or nonsteroidal anti-inflammatory drug prescriptions and corticosteroid injections were presented as modalities that may be recommended to decrease pain. Recommendations related to medical imagery and surgical opinion varied among the guidelines. The most commonly recommended return-to-work strategies included intervening early, use of a multidisciplinary approach, and adaptation of work organization. Only 3 CPGs were of high quality. The development of more rigorous CPGs is warranted. [ABSTRACT FROM AUTHOR]

Study Design Clinical commentary. Introduction Proximal humeral fractures (PHF) are the third most common fracture in the elderly with an increased incidence expected in the coming years with the aging population, causing an important burden to the healthcare system. The management of PHF is challenging due to its complexity and the wide variety of fractures and treatment options. Purpose The objective of this clinical commentary is to update the available evidence on clinical presentation, classification, imaging, medical treatment, and rehabilitation of acute PHF. Methods/Results/Discussion N/A for clinical commentary. Conclusions The first step to a successful management of PHF is the clinical and radiographic examination of the shoulder, which enables the physician to classify the fracture and choose the appropriate treatment option. The Neer and OA classifications are commonly used and are based on the identification of the fractured parts of the humerus, as well as the displacement of the fragments. In case of non-displaced or minimally displaced fractures, a conservative treatment, consisting of initial immobilization and a rehabilitation program will be chosen. Displaced or unstable fractures will be managed operatively. Different surgical options exist and will vary according to the fracture type, patient's age, and functional needs, followed by rehabilitation. Level of Evidence 5. [ABSTRACT FROM AUTHOR]

Clinicians often rely on physical examination tests to guide them in the diagnostic process of knee disorders. However, reliability of these tests is often overlooked and may influence the consistency of results and overall diagnostic validity. Therefore, the objective of this study was to systematically review evidence on the reliability of physical examination tests for the diagnosis of knee disorders. A structured literature search was conducted in databases up to January 2016. Included studies needed to report reliability measures of at least one physical test for any knee disorder. Methodological quality was evaluated using the QAREL checklist. A qualitative synthesis of the evidence was performed. Thirty-three studies were included with a mean QAREL score of 5.5 ± 0.5. Based on low to moderate quality evidence, the Thessaly test for meniscal injuries reached moderate inter-rater reliability (k = 0.54). Based on moderate to excellent quality evidence, the Lachman for anterior cruciate ligament injuries reached moderate to excellent inter-rater reliability (k = 0.42 to 0.81). Based on low to moderate quality evidence, the Tibiofemoral Crepitus, Joint Line and Patellofemoral Pain/Tenderness, Bony Enlargement and Joint Pain on Movement tests for knee osteoarthritis reached fair to excellent inter-rater reliability (k = 0.29 to 0.93). Based on low to moderate quality evidence, the Lateral Glide, Lateral Tilt, Lateral Pull and Quality of Movement tests for patellofemoral pain reached moderate to good inter-rater reliability (k = 0.49 to 0.73). Many physical tests appear to reach good inter-rater reliability, but this is based on low-quality and conflicting evidence. High-quality research is required to evaluate the reliability of knee physical examination tests. [ABSTRACT FROM AUTHOR]

Background Multiple factors have been associated with the presence of a subacromial pain syndrome (SPS), including deficits in performance of scapular and glenohumeral muscles. Such deficits can lead to inadequate kinematics and decreased acromiohumeral distance (AHD). Exercises that aim at correcting these deficits, such as movement training, were suggested to improve symptoms and functional limitations. To date, few studies have assessed outcomes following an intervention focused on movement training. Objectives Evaluate the effects of a rehabilitation program based on movement training on symptoms, functional limitations and AHD in individuals with SPS. Design Prospective single group pre-post design. Methods Twenty-five participants with SPS (SPS group) participated in a 6-week program. Twenty asymptomatic volunteers were recruited for normative AHD values (control group). Outcomes of both groups were evaluated at baseline and 6 weeks, i.e. immediately following intervention for the SPS group. Changes in symptoms and functional limitations for SPS group were assessed using the Western Ontario Rotator Cuff (WORC) index and Disability of the Arm Shoulder and Hand (DASH) questionnaire. Changes in AHD for both groups were assessed using ultrasonographic measures. Results Following the rehabilitation program, the scores on WORC and DASH were significantly improved (p < 0.001). AHD increased significantly in the SPS group (p = 0.019), especially in a subgroup with initial deficits (p < 0.001). Conclusion The rehabilitation program yielded improvements in symptoms and functional limitations in participants with SPS. Moreover, it led to an increase of the AHD – thus potentially decreasing subacromial compression, particularly in participants with an initially smaller AHD. The trial was registered at ClinicalTrials.gov: identifier – NCT02395770 . [ABSTRACT FROM AUTHOR]

A systematic review and meta-analysis on the efficacy of therapeutic ultrasound (US) in adults suffering from rotator cuff tendinopathy. A literature search was conducted in four databases for randomized controlled trials (RCT) published until 12/2013, comparing the efficacy of US to any other interventions in adults suffering from rotator cuff tendinopathy. The Cochrane Risk of Bias tool was used to evaluate the risk of bias of included studies. Data were summarized qualitatively or quantitatively. Eleven RCTs with a low mean methodological score (50.0% ± 15.6%) were included. Therapeutic US did not provide greater benefits than a placebo intervention or advice in terms of pain reduction and functional improvement. When provided in conjunction with exercise, US therapy is not superior to exercise alone in terms of pain reduction and functional improvement (pooled mean difference of the Constant-Murley score: -0.26 with 95% confidence interval of -3.84 to 3.32). Laser therapy was found superior to therapeutic US in terms of pain reduction. Based on low to moderate level evidence, therapeutic US does not provide any benefit compared to a placebo or advice, to laser therapy or when combined to exercise. More methodologically sound studies on the efficacy of therapeutic US are warranted. [ABSTRACT FROM AUTHOR]

Study design: Clinical measurement. Purpose: Several questionnaires assess symptoms and functional limitations following shoulder disorders, but few are available in French. The purposes were to translate and culturally adapt the Western Ontario Rotator Cuff (WORC) index into Canadian French and to evaluate its validity, reliability and responsiveness. Methods: In accordance with standard procedure, the WORC original version was translated and crossculturally adapted into Canadian French (WORC-CF). Then, 87 patients with rotator cuff (RC) disorders completed the WORC-CF on three occasions: baseline, two days later to evaluate reliability, and four weeks later to evaluate responsiveness. Results: Cross-cultural adaptation was performed without problems with content or language. WORC-CF was found to be reliable (Intraclass Correlation Coefficient = 0.96), valid (high correlation with Disability of the Arm, Shoulder and Hand [DASH]) and responsive (Standardized Response Mean = 1.54). Conclusion: WORC-CF can now be used to assess functional impairment in patients with RC disorders. Level of evidence: Not applicable. [ABSTRACT FROM AUTHOR]

Objective To assess the validity of diagnostic clusters combining history elements and physical examination tests to diagnose or exclude patellofemoral pain (PFP). Design Prospective diagnostic study. Settings Orthopedic outpatient clinics, family medicine clinics, and community-dwelling. Participants Consecutive patients (N=279) consulting one of the participating orthopedic surgeons (n=3) or sport medicine physicians (n=2) for any knee complaint. Interventions Not applicable. Main Outcome Measures History elements and physical examination tests were obtained by a trained physiotherapist blinded to the reference standard: a composite diagnosis including both physical examination tests and imaging results interpretation performed by an expert physician. Penalized logistic regression (least absolute shrinkage and selection operator) was used to identify history elements and physical examination tests associated with the diagnosis of PFP, and recursive partitioning was used to develop diagnostic clusters. Diagnostic accuracy measures including sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios with associated 95% confidence intervals (CIs) were calculated. Results Two hundred seventy-nine participants were evaluated, and 75 had a diagnosis of PFP (26.9%). Different combinations of history elements and physical examination tests including the age of participants, knee pain location, difficulty descending stairs, patellar facet palpation, and passive knee extension range of motion were associated with a diagnosis of PFP and used in clusters to accurately discriminate between individuals with PFP and individuals without PFP. Two diagnostic clusters developed to confirm the presence of PFP yielded a positive likelihood ratio of 8.7 (95% CI, 5.2–14.6) and 3 clusters to exclude PFP yielded a negative likelihood ratio of .12 (95% CI, .06–.27). Conclusions Diagnostic clusters combining common history elements and physical examination tests that can accurately diagnose or exclude PFP compared to various knee disorders were developed. External validation is required before clinical use. [ABSTRACT FROM AUTHOR]

Tendon integrity can be described using a wide range of biomarkers via specialized analysis software for images recorded by musculoskeletal ultrasonography. This study proposes a minimal biomarker data set to characterize Achilles tendon ultrasound images and to differentiate between symptomatic and asymptomatic Achilles tendon images. Forty-one individuals with unilateral Achilles tendinopathy and 35 healthy controls had their Achilles tendon images recorded bilaterally by ultrasonography in the longitudinal and transverse planes. A set of 22 biomarkers, organized around three dimensions (geometric, composition and texture), were computed in each plane. A symmetry index, reflecting relative side differences, was compared between groups and analyzed through principal component analysis to isolate biomarkers that best explained data variance. A specific minimal data set was identified by linear regression in the longitudinal (mean thickness, echogenicity, variance and homogeneity at 90°) and transverse (mean thickness, echogenicity and mean homogeneity) planes to characterize and differentiate Achilles tendon integrity. [ABSTRACT FROM AUTHOR]

Background: Achieving a neutral static Hip-Knee-Ankle angle (sHKA) measured on radiographs has been considered a factor of success for total knee arthroplasty (TKA). However, recent studies have shown that sHKA seems to have no effect on TKA survivorship. sHKA is not representative of the dynamic loading occurring during gait, unlike the dynamic HKA (dHKA).Research Question: The primary objective was to see if the sHKA is predictive of the dynamic HKA (dHKA). A secondary objective was to document to what degree the dHKA changes during gait.Methods: We analysed 3D knee kinematics during gait of a cohort of 90 healthy individuals with the KneeKG™ system. dHKA was calculated and compared with sHKA. Knees were considered "Stable" if the dHKA remained in valgus or varus for greater than 95% of the corresponding phase, and "Changer" otherwise. Patient characteristics of the Stable and Changer knees were compared to find associated factors.Results: Absolute variation of dHKA during gait was 10.9 ± 5.3° for the whole cohort. The variation was less for the varus knees (10.3 ± 4.8°), than for the valgus knees (12.8 ± 6.1°, p = 0.008). We found low to moderate correlations (r = 0.266 to 0.553, p < 0.001) between sHKA and dHKA values for varus knees and no significant correlation for valgus knees. Twenty two percent (36/165) of the knees were considered Changers. The proportion of knees that were Changers was 15% of the varus versus 39% of the valgus (p < 0.001).Significance: Lower limb radiographic measures of coronal alignment have limited value for predicting dynamic measures of alignment during gait. [ABSTRACT FROM AUTHOR]

Background: Normal 3D knee kinematics during gait is still not well understood, especially regarding differences between women and men.Research Question: The objective of the present study was to characterize 3D knee kinematics during gait in healthy women and men with a validated tool.Methods: Knee kinematics was analysed with the KneeKG™ system in 90 healthy subjects (49 females and 41 males). 3D knee rotations were compared between women and men, and between right and left knees. Each subject underwent full-length weight-bearing x-rays. Correlations between abduction-adduction angles and lower-limb alignment measures on x-rays were assessed.Results: In the frontal plane, 2.0-5.0° more abduction occurred in women compared to men (0.000 ≤ p ≤ 0.015) throughout the entire gait cycle. In the transverse plane, 2.4-3.7° more external tibial rotation was seen in women than in men (0.002 ≤ p ≤ 0.041) during the initial and mid-swing phases. No difference was found between the right and left knees. Low correlations (-0.52 ≤ r≤-0.41, p < 0.001) were observed between radiographic hip-knee-ankle angle (HKA) and abduction-adduction angles throughout the stance phase.Significance: Kinematic differences between women and men in the frontal plane can be partly explained by their anatomical differences: women were less in varus than men (HKA of -0.8° vs. -2.6°, p < 0.001). Our study contributes to a better understanding of healthy 3D knee kinematics during gait and highlights the need for accounting of gender differences in future investigations. Better knowledge of natural knee kinematics will be helpful in assessing pathological gait patterns or determining the efficiency of conservative and surgical treatments to restore normal kinematics. [ABSTRACT FROM AUTHOR]

Introduction Gait analysis has been extensively studied by many different disciplines using various methods. Despite numerous attempts to understand the “normal” gait cycle, our current body of knowledge is insufficient to allow us to model normal locomotion in a clinically relevant manner. The primary objective of our study was to characterize normal knee3D kinematics during treadmill gait using the KneeKG™ apparatus. Materials and methods Ninety-five patients, 52 females and 43 males, were recruited to participate in our study. Each patient completed the KOOS and SF-12 questionnaires, underwent a KneeKG™ examination, and had full-length weightbearing (FLWB) x-rays. We analyzed the results of the questionnaires, generated gait cycle 3D kinematics (sagittal, transverse, and frontal plane), and measured clinically relevant angles on the FLWB x-rays. Furthermore, we compared knee kinematics between men and women and between the right and left knees of the same patient. We also attempted to find a correlation, using Pearson correlation statistics, between the hip-knee-ankle angle (HKA) and the frontal plane kinematic. Results Average age of our cohort was 36.1 years (SD: 13.3). Our cohort had scores superior to 98 in all five subsections of the KOOS questionnaire. Knee gait cycle kinematics in all planes was similar to what has been reported in the literature. When comparing men and women, significant differences were found in the sagittal motion and transverse rotation planes and in the entirety of the gait cycle in the frontal plane. When comparing the right and left knees, significant differences were only found in the frontal plane. No meaningful correlations could be made between the HKA angle and abduction. Discussion – conclusion As three-dimensional analysis of human gait progressively becomes a clinically useful tool in musculoskeletal diseases, an understanding of normal gait as well as a creation of a normal gait data bank is essential. We believe the results of our study contribute to understanding the kinematics of the gait cycle and foster the notion that cohorts should be divided for gender to account for gait differences in the frontal plane. [ABSTRACT FROM AUTHOR]