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Background We investigated clinical equipoise across surgical members of the British Elbow and Shoulder Society (BESS) in relation to rehabilitation following rotator cuff repair. Method An online survey explored clinical equipoise regarding early patient-directed versus standard rehabilitation after rotator cuff repair to inform the design of a national randomised controlled trial (RCT). It described different clinical scenarios relating to patient age, tear size, location and whether other patient-related and intra-operative factors would influence equipoise. Results 76 surgeons completed the survey. 81% agreed/ strongly agreed that early mobilisation might benefit recovery; 57% were neutral/ disagreed that this approach risks re-tear. 87% agreed/ strongly agreed that there is clinical uncertainty about the effectiveness of different approaches to rehabilitation. As age of the patient and tear size increased, the proportion of respondents who would agree to recruit and accept the outcome of randomisation reduced, and this was compounded if subscapularis was torn. Other factors that influenced equipoise were diabetes and non-secure repair. Conclusion Surgical members of BESS recognise uncertainty about the effectiveness of different approaches to rehabilitation following rotator cuff repair. We identified a range of factors that influence clinical equipoise that will be considered in the design of a new RCT.

Background Lateral elbow tendinopathy (LET) is a common condition that can cause significant disability and associated socioeconomic cost. Although it has been widely researched, outcome measures are highly variable which restricts evidence synthesis across studies. In 2019, a working group of international experts, health care professionals and patients, in the field of tendinopathy (International Scientific Tendinopathy Symposium Consensus (ICON) Group), published the results of a consensus exercise defining the nine core domains that should be measured in tendinopathy research. The aim of this study is to develop a core outcome set (COS) for LET mapping to these core domains. The primary output will provide a template for future outcome evaluation of LET. In this protocol, we detail the methodological approach to the COS-LET development. Methods This study will employ a three-phase approach. (1) A systematic review of studies investigating LET will produce a comprehensive list of all instruments currently employed to quantify the treatment effect or outcome. (2) Instruments will be matched to the list of nine core tendinopathy outcome domains by a Steering Committee of clinicians and researchers with a specialist interest in LET resulting in a set of candidate instruments. (3) An international three-stage Delphi study will be conducted involving experienced clinicians, researchers and patients. Within this Delphi study, candidate instruments will be selected based upon screening using the Outcome Measures in Rheumatology (OMERACT) truth, feasibility and discrimination filters with a threshold of 70% agreement set for consensus. Conclusions There is currently no COS for the measurement or monitoring of LET in trials or clinical practice. The output from this project will be a minimum COS recommended for use in all future English language studies related to LET. The findings will be published in a high-quality journal and disseminated widely using professional networks, social media and via presentation at international conferences. Trial registration Registered with the Core Outcome Measures in Effectiveness Trials (COMET) database, November 2019. https://www.comet-initiative.org/Studies/Details/1497.

Objective: To evaluate the feasibility of a multi-centre randomised controlled trial to compare the clinical and cost-effectiveness of early patient-directed rehabilitation versus standard rehabilitation following surgical repair of the rotator cuff of the shoulder. Design: Two-arm, multi-centre pilot and feasibility randomised controlled trial. Setting: Five National Health Service hospitals in England. Participants: Adults ( n = 73) with non-traumatic rotator cuff tears scheduled for repair were recruited and randomly allocated remotely prior to surgery. Interventions: Early patient-directed rehabilitation ( n = 37); advised to remove their sling as soon as able and move as symptoms allow. Standard rehabilitation ( n = 36); sling immobilisation for four weeks. Measures: (1) Randomisation of 20% or more eligible patients. (2) Difference in time out of sling of 40% or more between groups. (3) Follow-up greater than 70%. Results: 73/185 (39%) potentially eligible patients were randomised. Twenty participants were withdrawn, 11 due to not receiving rotator cuff repair. The between-group difference in proportions of participants who exceeded the cut-off of 222.6 hours out of the sling was 50% (80% CI = 29%, 72%), with the early patient-directed rehabilitation group reporting greater time out of sling. 52/73 (71%) and 52/53 (98%) participants were followed-up at 12 weeks when withdrawals were included and excluded respectively. Eighteen full-thickness re-tears were reported (early patient-directed rehabilitation = 7, standard rehabilitation = 11). Five serious adverse events were reported. Conclusion: A main randomised controlled trial is feasible but would require allocation of participants following surgery to counter the issue of withdrawal due to not receiving surgery.

Introduction Approaches to rehabilitation following rotator cuff repair are variable but typically include 4-6 weeks of immobilisation followed by a gradual introduction of movement and activity. However, research has questioned whether such an approach is optimal. The aim of this study was to undertake an updated survey to understand whether practice has evolved in line with contemporary research. Methods An electronic survey was developed describing three case scenarios (medium-sized rotator cuff repair [2 cm], large-sized rotator cuff repair [4 cm] and large-sized rotator cuff repair with biceps tenodesis). Clinicians involved with rehabilitation following rotator cuff repair were invited to participate. Results 129 responses were received (United Kingdom = 87, other regions [ORs] = 42). Respondents would most commonly recommend four to six weeks of immobilisation for all case scenarios. Passive movement would commence during this period, with active movement recommended from four to six weeks. Resisted exercise would commence between seven to 12 weeks along with return to driving. There were some minor differences in recommendations between respondents from the United Kingdom and ORs, including a greater proportion from the United Kingdom recommending sling immobilisation rather than abduction brace immobilisation. Conclusion For many respondents to this survey, rehabilitation for the three case scenarios was similar and has not evolved in line with contemporary research evidence. The reasons behind this need to be explored and incorporated into the design of future research evaluating rehabilitation following rotator cuff repair.

Background There are few studies reporting the outcomes from arthroscopic shoulder stabilisation using all-suture soft anchors. The aim of this study was to assess the clinical outcomes and failure rate for arthroscopic shoulder stabilisation using these anchors. Methods A retrospective cohort analysis of a consecutive series of patients in a single unit undergoing arthroscopic shoulder stabilisation using JuggerKnot all-suture soft anchors by four consultant shoulder surgeons was performed. Exclusion criteria were revision procedures, engaging Hill-Sachs lesions and glenoid bone loss greater than 20%. The primary outcome measure was failure (dislocation or subluxation as perceived by the patient with subsequent revision surgery). The secondary outcome measure was function as assessed by the Oxford Shoulder Instability Score (OSIS). Results 67 patients with a mean age at the time of surgery of 32.6 years (range 15–55 years) met the inclusion criteria. Median follow up was 34.5 months (minimum 13 months). No patient experienced a postoperative dislocation. However, three patients experienced painful subluxations; two underwent revision arthroscopic stabilisation and one required open stabilisation due to glenoid bone loss. Consequently, failure rate was 4.5%. Mean post-operative OSIS was 39/48 (n = 49). Conclusion This series supports the use of all-suture soft anchors in arthroscopic shoulder stabilisation. The failure rate compares favourably with that previously reported in literature for conventional anchors. Level of evidence Level IV: Case series with no comparison group.

Background Physiotherapy is recommended for people with tennis elbow, but whilst a wide array of treatments is available, the optimal approach remains uncertain. We have therefore recently developed an optimised physiotherapy treatment package for tennis elbow based on a synthesis of the evidence, patient input and clinical consensus. It consists of detailed advice and education, a structured progressive exercise programme and provision of a counter-force elbow brace. Here, we report the protocol for our multicentre pilot and feasibility randomised controlled trial (RCT) designed to (a) examine the feasibility of our optimised physiotherapy treatment package and (b) to pilot trial processes for a future fully powered RCT to test clinical and cost-effectiveness compared with usual physiotherapy treatment. Methods A multicentre pilot and feasibility RCT will be conducted across three sites in England, recruiting up to 50 patients (or for a maximum of 12 months). Participants with tennis elbow, identified from physiotherapy clinic waiting lists and general practice surgeries, will be randomly allocated to receive the optimised physiotherapy treatment package or usual physiotherapy care. Analysis will focus on feasibility measures including consent rate, intervention fidelity, follow-up rate and outcome completion rate. A nested qualitative study will explore the acceptability of the study processes and patient and physiotherapist experiences of the new optimised intervention. Discussion This study will determine the feasibility of a new optimised physiotherapy treatment package for people with tennis elbow and pilot the processes for a future fully powered RCT. In the longer term, this treatment package may provide superior clinical outcomes for patients, in terms of pain and quality of life, and be more cost-effective for the health service. Trial registration Registered with the ISRCTN database 19/7/2021, https://www.isrctn.com/ISRCTN64444585

Background There is limited evidence to guide therapists in the management of patients with atraumatic shoulder instability however physiotherapy remains the recommended course of treatment. In this paper we report the updated results of a rehabilitation programme designed for this patient group. Method A service evaluation was conducted at a large university teaching hospital in the UK between August 2013 and September 2018 including patients with atraumatic Stanmore type 2 or 3 instability. Western Ontario Shoulder Index (WOSI) and Oxford Instability Shoulder Scores (OISS) were measured at baseline and final follow-up. OISS was also repeated at every clinic visit. Patients were treated using the Derby Shoulder Instability Rehabilitation Programme until a point of agreed discharge. Results 66 patients were included but 15 were lost to follow-up. Patients attended for a mean of 6.9 sessions over 30 weeks. The mean OISS (n = 51) improved from 38.00 to 21.96 (p Conclusion For patients with atraumatic shoulder instability the Derby Shoulder Instability Rehabilitation Programme provides significant benefit to patients in terms of pain, stability and function. Further study is required to assess whether such improvements can be sustained in the medium and long terms.

Background Corticosteroid injections and physiotherapy exercise programmes are commonly used to treat rotator cuff disorders but the treatments' effectiveness is uncertain. We aimed to compare the clinical effectiveness and cost-effectiveness of a progressive exercise programme with a single session of best practice physiotherapy advice, with or without corticosteroid injection, in adults with a rotator cuff disorder. Methods In this pragmatic, multicentre, superiority, randomised controlled trial (2 × 2 factorial), we recruited patients from 20 UK National Health Service trusts. We included patients aged 18 years or older with a rotator cuff disorder (new episode within the past 6 months). Patients were excluded if they had a history of significant shoulder trauma (eg, dislocation, fracture, or full-thickness tear requiring surgery), neurological disease affecting the shoulder, other shoulder conditions (eg, inflammatory arthritis, frozen shoulder, or glenohumeral joint instability), received corticosteroid injection or physiotherapy for shoulder pain in the past 6 months, or were being considered for surgery. Patients were randomly assigned (centralised computer-generated system, 1:1:1:1) to progressive exercise (≤6 sessions), best practice advice (one session), corticosteroid injection then progressive exercise, or corticosteroid injection then best practice advice. The primary outcome was the Shoulder Pain and Disability Index (SPADI) score over 12 months, analysed on an intention-to-treat basis (statistical significance set at 1%). The trial was registered with the International Standard Randomised Controlled Trial Register, ISRCTN16539266, and EuDRACT, 2016-002991-28. Findings Between March 10, 2017, and May 2, 2019, we screened 2287 patients. 708 patients were randomly assigned to progressive exercise (n=174), best practice advice (n=174), corticosteroid injection then progressive exercise (n=182), or corticosteroid injection then best practice advice (n=178). Over 12 months, SPADI data were available for 166 (95%) patients in the progressive exercise group, 164 (94%) in the best practice advice group, 177 (97%) in the corticosteroid injection then progressive exercise group, and 175 (98%) in the corticosteroid injection then best practice advice group. We found no evidence of a difference in SPADI score between progressive exercise and best practice advice when analysed over 12 months (adjusted mean difference −0·66 [99% CI −4·52 to 3·20]). We also found no evidence of a difference between corticosteroid injection compared with no injection when analysed over 12 months (−1·11 [–4·47 to 2·26]). No serious adverse events were reported. Interpretation Progressive exercise was not superior to a best practice advice session with a physiotherapist in improving shoulder pain and function. Subacromial corticosteroid injection provided no long-term benefit in patients with rotator cuff disorders. Funding UK National Institute for Health Research Technology Assessment Programme.

Evidence on which to base decision-making in the management of atraumatic shoulder instability is limited. This is due to the lack of a universal definition for the condition, small cohort studies and multiple outcome scores being used to evaluate treatment. Despite these limitations it is evident that the vast majority of patients with atraumatic shoulder instability (with or without structural pathology) seem to improve with physiotherapy. Physiotherapy should always be the first line (and second line) of management for such patients. Patients that do not improve should be referred to a specialist orthopaedic shoulder surgeon and shoulder physiotherapist for careful assessment. If necessary, patients with certain indications may be referred directly to tertiary centres early ○ Frequent attendance at A&E for relocation ○ Persistent displacement or shoulder dislocation/subluxation ○ Absence from school (>20%) or work (>3 months) A multidisciplinary team approach is essential in complex cases. Evidence for operative intervention is poor and inconsistently reported in the literature. If surgery is to be undertaken then arthroscopic capsulorrhaphy is not recommended for the treatment of atraumatic shoulder instability. Inappropriate or incorrect surgery is to be avoided as this has been shown to be associated with poor outcomes. We propose a treatment algorithm as shown in Figure 3 to guide the management of patients with atraumatic shoulder instability based on the limited available evidence and expert consensus opinion. Open in a separate window Figure 3. Proposed algorithm for the management of atraumatic shoulder dislocation. EMG: electromyography; MDT: multidisciplinary team.

Shoulder dislocation is usually as a result of trauma, although some individuals experience episodes of instability in the absence of injury. In this paper we highlight the classification of shoulder instability and describe clinical assessment before discussing the evidence behind managing this often complex problem both from a conservative and surgical perspective.

BackgroundEnhanced recovery (ER) programmes are well established in hip and knee arthroplasty, but are not yet commonplace for total shoulder arthroplasty (TSA). This study analyses the effect of implementing an ER programme with TSA, on length of stay (LOS), functional outcome and patient satisfaction.Local problemNo established programme applying ER to the specifics of upper-limb arthroplasty existed at our unit.MethodsA three-cycle plan–do–study–act quality improvement methodology was applied, involving development of our multifactorial programme, a pilot phase and wider roll-out. A consecutive series of patients who underwent TSA and were enrolled in an ER programme were compared with a matched control group of consecutive patients who underwent TSA in the year before the programme started. For all patients, LOS as well as mean Oxford Shoulder Score (OSS) and Constant Score (CS) were quantified and patient satisfaction assessed.InterventionsA dedicated multidisciplinary team led preoperative class involving patient education, advice and occupational therapy assessment. A standardised perioperative anaesthetic regime based on regional anaesthetic techniques with preoperative analgesic and nutritional loading was introduced. Postoperative rehabilitation was also standardised with slings for comfort only and early safe-zone mobilisation. New patient information was developed.Results71 patients were included in matched cohorts. Mean LOS was reduced from 2.4 nights to 1.9 nights. The single night stay rate improved from 40% to 49%. Across the ER cohort, 15 less nights were required to complete same volume of surgeries as in the non-ER cohort.Parity in OSS and CS measured at 3 and 12 months after surgery were observed in both cohorts.Satisfaction was already high before ER but scores stayed the same or improved across all areas surveyed.Absolute complication rates of 9.9% in the non-ER group and 7% in the ER group were recorded.ConclusionOur ER programme benefited patients and the Trust by reducing time in hospital and improving patient satisfaction without an adverse effect on complication rate.

© 2019 - IOS Press and the authors. All rights reserved. BACKGROUND: Disorders associated with the rotator cuff are regarded as the most common shoulder pain presentation. The range of diagnostic terms used to explain this problem reflect uncertainty in relation to causative mechanisms, diagnosis, prognosis, and the most effective treatments. The aim of this consensus exercise was to facilitate a shared understanding as a means of reducing mixed messages, informing clinical practice and providing a foundation for future research. METHODS: Nine physiotherapists with clinical and academic expertise in shoulder pain participated in an online and face-to-face consensus exercise. RESULTS: This consensus exercise suggests specific factors in the history and physical examination that might raise the index of suspicion of Rotator Cuff Related Shoulder Pain. The suggestions for non-surgical management include a minimal number of exercises prescribed to challenge the functional deficit of the patient over a minimum 12-week period. Apart from aiding exclusion of red flag pathology, imaging is not regarded as useful unless the patient does not respond as expected. Steroid injections wouldn't be considered a first-line intervention unless pain was severe and preventing engagement with exercise. CONCLUSION: This consensus exercise provides a benchmark for clinical reflection while highlighting areas of uncertainty that still exist and require further research.

Traditional pain models that describe tissue pathology as a source of nocioceptive input directly linked with pain expression, have been insufficient for assessing and treating musculoskeletal pain. The need for pain to be avoided or alleviated as much as possible during physical activity has recently been challenged, with a paradigm shift from traditional biomedical models of pain towards a biopsychosocial model of pain. The aim of the review is to provide an understanding on the potential mechanisms behind exercise, and to build on this into discussing the additional theoretical mechanisms of painful exercises. Central and peripheral pain mechanisms, the immune system and affective aspects of pain are described. This review focuses on these three mechanisms as these systems appear to respond differently to painful stimulus, compared with necessitating pain-free exercises. They are discussed in relation to the biological effect of exercise for people with chronic pain, with a broader overview of possible mechanisms behind the potentially additional beneficial effect of allowing painful exercises for individuals with chronic musculoskeletal pain. This additional mechanistic consideration could be used to help clinicians in the prescription of therapeutic exercise and for researchers to advance knowledge for such a globally burdensome condition.

ObjectivesThere is an emergent body of evidence supporting exercise therapy and physical activity in the management of musculoskeletal pain. The purpose of this study was to explore potential barriers and facilitators with patients and physiotherapists with patellofemoral pain involved in a feasibility randomised controlled trial (RCT) study. The trial investigated a loaded self-managed exercise intervention, which included education and advice on physical activity versus usual physiotherapy as the control.DesignQualitative study, embedded within a mixed-methods design, using semi-structured interviews.SettingA UK National Health Service physiotherapy clinic in a large teaching hospital.ParticipantsPurposively sampled 20 participants within a feasibility RCT study; 10 patients with a diagnosis of patellofemoral pain, aged between 18 and 40 years, and 10 physiotherapists delivering the interventions.ResultsIn respect to barriers and facilitators, the five overlapping themes that emerged from the data were: (1) locus of control; (2) belief and attitude to pain; (3) treatment expectations and preference; (4) participants’ engagement with the loaded self-managed exercises and (5) physiotherapists’ clinical development. Locus of control was one overarching theme that was evident throughout. Contrary to popular concerns relating to painful exercises, all participants in the intervention group reported positive engagement. Both physiotherapists and patients, in the intervention group, viewed the single exercise approach in a positive manner. Participants within the intervention group described narratives demonstrating self-efficacy, with greater internal locus of control compared with those who received usual physiotherapy, particularly in relation to physical activity.ConclusionsImplementation, delivery and evaluation of the intervention in clinical settings may be challenging, but feasible with the appropriate training for physiotherapists. Participants’ improvements in pain and function may have been mediated, in some part, by greater self-efficacy and locus of control.Trial registration numberISRCTN35272486; Pre-results.

BACKGROUND: A novel loaded self-managed exercise programme that includes pain education and self-management strategies may result in better outcomes for people with patellofemoral pain (PFP). However, establishing program feasibility is an essential first step before testing efficacy. The purpose of this study was to evaluate the feasibility and acceptability of conducting a definitive RCT which will evaluate the clinical and cost-effectiveness of a loaded self-managed exercise programme for people with PFP compared with usual physiotherapy.METHODS: In a mixed methods, pragmatic, randomised controlled feasibility study, 60 participants with PFP (57% female; mean age 29 years) were recruited from a physiotherapy clinic within a large UK teaching hospital. They were randomly allocated to receive either a loaded self-managed exercise programme (n = 30) or usual physiotherapy (n = 30). Feasibility indicators of process, resources, and management were collected through follow-up of standardised questionnaires six months after recruitment and semi-structured interviews with 20 participants and physiotherapists.RESULTS: Recruitment rate was 5 participants per month; consent rate was 99%; adherence to intervention appointments was 87%; completeness of questionnaire data was 100%; and adherence to intervention delivery was 95%. Three exercise diaries were returned at six months (5%). At six months, 25 questionnaire booklets were returned (9 in the loaded self-managed group, 16 in the usual physiotherapy group), with a total retention rate of 42%. At six months, 56% (5/9) of respondents in the loaded self-managed group and 56% (9/16) in the usual physiotherapy group were classified as 'recovered'. Both groups demonstrated improvements in average pain (VAS), kinesiophobia, pain catastrophizing, general self-efficacy and EQ-5D-5 L from baseline to six months.CONCLUSION: The results of this feasibility study confirm that it is feasible and acceptable to deliver a loaded self-managed exercise programme to adults with PFP in an NHS physiotherapy outpatient setting. However, between group differences in lost to follow up and poor exercise diary completion mean we are uncertain on some feasibility aspects. These methodological issues need addressing prior to conducting a definitive RCT.TRIAL REGISTRATION: ISRCTN 35272486 . Registered 19th December 2016.

Background Tennis elbow is a common painful condition that may affect daily function and ability to work. Physiotherapy is the most commonly used primary intervention but there is a wide range of treatment options within the umbrella of physiotherapy. Our aim was to report on the treatments that are currently used by physiotherapists in a UK National Health Service (NHS) setting. Methods A retrospective service evaluation was conducted at two NHS hospital trusts by reviewing patient attendance records over a 1-year period. All patients with tennis elbow were included, except those referred for postoperative rehabilitation. Patient notes were analysed using a predefined assessment template. Results A total of 65 patient records were identified, with patients having a mean age 48 years and mean symptom duration of 5.4 months. The mean treatment duration was 64 days, over 3.7 sessions. The most commonly used treatments were education and exercise, although the type and dosing of exercise varied greatly. Passive modalities such as ice, taping, manual therapy, acupuncture and electrotherapy were still used. Conclusions Wide variations in treatment approaches were identified. There was no consistency in the choice of modality used, the type of exercise or the dose of exercise prescribed. The use of passive modalities and corticosteroid injections was found to remain commonplace, despite a lack of supporting research evidence. There is a clear need for evidence-based guidance for physiotherapists treating patients with tennis elbow.

BACKGROUND: Chronic musculoskeletal disorders are a prevalent and costly global health issue. A new form of exercise therapy focused on loading and resistance programmes that temporarily aggravates a patient's pain has been proposed. The object of this review was to compare the effect of exercises where pain is allowed/encouraged compared with non-painful exercises on pain, function or disability in patients with chronic musculoskeletal pain within randomised controlled trials.METHODS: Two authors independently selected studies and appraised risk of bias. Methodological quality was evaluated using the Cochrane risk of bias tool, and the Grading of Recommendations Assessment system was used to evaluate the quality of evidence.RESULTS: The literature search identified 9081 potentially eligible studies. Nine papers (from seven trials) with 385 participants met the inclusion criteria. There was short- term significant difference in pain, with moderate quality evidence for a small effect size of -0.27 (-0.54 to -0.05) in favour of painful exercises. For pain in the medium and long term, and function and disability in the short, medium and long term, there was no significant difference.CONCLUSION: Protocols using painful exercises offer a small but significant benefit over pain-free exercises in the short term, with moderate quality of evidence. In the medium and long term there is no clear superiority of one treatment over another. Pain during therapeutic exercise for chronic musculoskeletal pain need not be a barrier to successful outcomes. Further research is warranted to fully evaluate the effectiveness of loading and resistance programmes into pain for chronic musculoskeletal disorders.PROSPERO REGISTRATION: CRD42016038882.

Background There is no consensus on the most suitable treatment for tennis elbow but, in the USA, surgical intervention is increasing despite a lack of supportive research evidence. The aim of this systematic review was to provide a balanced update based on all relevant published randomized controlled trials conducted to date. Methods An electronic search of MEDLINE, EMBASE, CINAHL, BNI, AMED, PsycINFO, HBE, HMIC, PubMed, TRIP, Dynamed Plus and The Cochrane Library was complemented by hand searching. Risk of bias was assessed using the Cochrane Risk of Bias Tool and data were synthesized narratively, based on levels of evidence, as a result of heterogeneity. Results Twelve studies of poor methodological quality were included. The available data suggest that surgical interventions for tennis elbow are no more effective than nonsurgical and sham interventions. Surgical technique modifications may enhance effectiveness compared to traditional methods but have not been tested against a placebo. Conclusions Current research evidence suggests that surgery for tennis elbow is no more effective than nonsurgical treatment based on evidence with significant methodological limitations. Given the recalcitrant nature of tennis elbow for some patients, further research in the form of a high-quality placebo-controlled surgical trial with an additional conservative arm is required to usefully inform clinical practice.

Background Patellofemoral pain (PFP) is considered one of the commonest forms of knee pain. This study aimed to identify how physiotherapists in the United Kingdom (UK) currently manage patellofemoral pain (PFP), particularly in relation to exercise prescription, and response to pain. Methods An anonymous survey was designed with reference to previous surveys and recent systematic reviews. Practising UK physiotherapists who treat patients with PFP were invited to take part via an invitation email sent through professional networks, the ‘interactive Chartered Society of Physiotherapy (iCSP)’ message board, and social media (Twitter). Descriptive statistics were used to analyse the data. Results A total of 99 surveys were completed. Responders reported a wide range of management strategies, including a broad selection of type and dose of exercise prescription. The five most common management strategies chosen were: closed chain strengthening exercises (98%); education and advice (96%); open chain strengthening exercises (76%); taping (70%) and stretches (65%). Physiotherapists with a special interest in treating PFP were statistically more likely to manage patients with orthotics (P = 0.02) and bracing (P = 0.01) compared to physiotherapists without a special interest. Approximately 55% would not prescribe an exercise if it was painful. Thirty-one percent of physiotherapists would advise patients not to continue with leisure and/or sporting activity if they experienced any pain. Conclusion Current UK practice in the management strategies of PFP is variable. Further high quality research on which to inform physiotherapy practice is warranted for this troublesome musculoskeletal condition. Electronic supplementary material The online version of this article (doi:10.1186/s12891-017-1539-8) contains supplementary material, which is available to authorized users.

Background Tennis elbow is a common condition in the UK but there are no guidelines on how best to manage the condition. The purpose of the present study was to establish the current UK practice in managing patients with chronic tennis elbow. Methods A cross-sectional online survey of UK surgeons and therapists was conducted in June 2017. Results In total, 275 responses were received, the majority from consultant surgeons and experienced physiotherapists. In total, 81% recommended exercise-based physiotherapy as the first-line intervention. Second-line treatments varied widely, with corticosteroid injections being the most popular (27%), followed by shockwave therapy, platelet-rich plasma injection, surgery, acupuncture and a wait-and-see policy. Conclusions There is wide variability of treatments offered when physiotherapy fails patients with tennis elbow. The majority of second-line interventions lack evidence to support their use and, in the case of corticosteroid injections, may even be harmful in the long term. There is a clear need for national guidance based on best evidence to aid clinicians in their treatment approach.

Shoulder problems account for 2.4% of GP consultations in the United Kingdom and of those 70% are related to the rotator cuff. Many rotator cuff tears are of a degenerate nature but they can occur as a result of trauma in 8% of cases. Evidence suggests that patients with traumatic rotator cuff tears gain a better outcome in terms of pain and function if the tear is repaired early after injury. A specialist shoulder soft tissue injury clinic was set up in a large UK NHS teaching hospital with the primary purpose in the first year to halve the length of time patients with traumatic rotator cuff tears had to wait to consult a specialist and double the number of patients undergoing surgical repair within three months. The secondary purpose was to ensure that the new clinic was utilised to capacity by the end of the first year. The clinic was later expanded to manage patients with acute glenohumeral joint (GHJ) or acromioclavicular joint (ACJ) dislocations and identify those patients requiring surgical stabilisation. The new service involved referral of all patients presenting to the Accident & Emergency department with recent shoulder trauma and either an inability to raise the arm over shoulder height with a normal set of radiographs, or a confirmed GHJ or ACJ dislocation; to a specialist clinic run by an experienced upper limb physiotherapist. Patients were reassessed and referred for further imaging if required. Those patients found to have traumatic rotator cuff tears or structural instability lesions were listed for expedited surgery. The clinic ran alongside a consultant-led fracture clinic giving fast access to surgical decision-making. The service was reviewed after 3, 6, and 12 months and findings compared to a sample of 30 consecutive patients having undergone rotator cuff repair surgery via the previous pathway. 144 patients were referred to the clinic in the first year: 62 with rotator cuff symptoms, 38 with GHJ instability, 13 with ACJ instability, and 33 others. 7 missed fractures were identified. 12 patients subsequently underwent rotator cuff repair surgery, 10 GHJ stabilisation, and 1 ACJ stabilisation. Mean referral time to first clinical assessment improved from 37 days to 8 days. For rotator cuff repair: mean referral to surgery time was 86 days compared with 115 days on the old pathway. 58% of patients underwent surgery within 90 days of injury compared with 20% previously. Our new service resulted in surgical repair of traumatic rotator cuff tears 29 days faster than the traditional system with an extra 38% of patients having surgery within 90 days of injury - a benchmark thought to improve outcome. Future work will aim to improve this percentage further and include long term patient follow up of outcome measures after surgery.

Missed hospital appointments (DNA: did not attend) are a large problem for the NHS, costing up to £745 million a year. The national rate is 9.1% and the aim of this audit was to compare traditional appointment booking methods in a physiotherapy outpatient setting with two new methods. DNAs were analysed over a six-month period using traditional methods vs choice booking for follow-up appointments, and vs choose and book for new appointments.

Leg pain and weakness can often be seen in a musculoskeletal physiotherapy outpatient setting. While the differential diagnoses for neuropathic pain and weakness is often spine related, this unusual cause for polyradiculopathy is less commonly seen. Shingles is not something routinely seen in a physiotherapy department but is usually associated with skin eruptions and pain but less so with motor loss. The purpose of this case report is to therefore raise awareness that this presentation can occur and should not be mistaken for spinal radiculopathy.

AimWe present the medium-term clinical results of a reverse total shoulder arthroplasty with a trabecular metal glenoid base plate.Patients and MethodsWe reviewed 125 consecutive primary reverse total shoulder arthroplasties (RTSA) implanted in 124 patients for rotator cuff arthropathy. There were 100 women and 24 men in the study group with a mean age of 76 years (58 to 89). The mean follow-up was 32 months (24 to 60). No patient was lost to follow-up.There were statistically significant improvements in the mean range of movement and Oxford Shoulder Score (p < 0.001). Kaplan-Meier survivorship at five years was 96.7% (95% confidence interval 91.5 to 98.7) with aseptic glenoid failure as the end point. Radiologically, 63 shoulders (50.4%) showed no evidence of notching, 51 (40.8%) had grade 1 notching, ten (8.0%) had grade 2 notching and one (0.8%) had grade 4 notching. Radiolucency around the glenoid base plate was found in one patient (0.8%) and around the humeral stem in five (4.0%). In all, three RTSA (2.4%) underwent revision surgery for aseptic mechanical failure of the glenoid within 11 months of surgery due to malseating of the glenosphere.ConclusionThe clinical results of this large independent single unit series are comparable to those from previous series of RTSA reported in the literature. A trabecular metal base plate is safe and effective in the medium-term. Cite this article: Bone Joint J 2016;98-B:969–75.

Objectives: To evaluate the clinical effectiveness of a self-managed single exercise programme versus usual physiotherapy treatment for rotator cuff tendinopathy. Design: Multi-centre pragmatic unblinded parallel group randomised controlled trial. Setting: UK National Health Service. Participants: Patients with a clinical diagnosis of rotator cuff tendinopathy. Interventions: The intervention was a programme of self-managed exercise prescribed by a physiotherapist in relation to the most symptomatic shoulder movement. The control group received usual physiotherapy treatment. Main outcome measures: The primary outcome measure was the Shoulder Pain & Disability Index (SPADI) at three months. Secondary outcomes included the SPADI at six and twelve months. Results: A total of 86 patients (self-managed loaded exercise n=42; usual physiotherapy n=44) were randomised. Twenty-six patients were excluded from the analysis because of lack of primary outcome data at the 3 months follow-up, leaving 60 ( n=27; n=33) patients for intention to treat analysis. For the primary outcome, the mean SPADI score at three months was 32.4 (SD 20.2) for the self-managed group, and 30.7 (SD 19.7) for the usual physiotherapy treatment group; mean difference adjusted for baseline score: 3.2 (95% Confidence interval -6.0 to +12.4 P = 0.49). By six and twelve months there remained no significant difference between the groups. Conclusions: This study does not provide sufficient evidence of superiority of one intervention over the other in the short-, mid- or long-term and hence a self-management programme based around a single exercise appears comparable to usual physiotherapy treatment.

Background The aim of this systematic review was to evaluate the effectiveness of rehabilitation programmes following surgical repair of the rotator cuff with emphasis upon length of immobilisation and timing of introduction of load. Methods An electronic search of CENTRAL, MEDLINE and PEDro was undertaken to August 2014 and supplemented by hand searching. Randomised controlled trials were included, quality appraised using the PEDro scale and synthesised via meta-analysis or narrative synthesis, based upon levels of evidence, where appropriate. Results Twelve studies were included. There is strong evidence that early initiation of rehabilitation does not adversely affect clinical outcome but there is a marginally higher, statistically non-significant, incidence of tendon re-tear (OR 1.3; 95% CI 0.72 to 2.2). There is strong evidence that initiation of functional loading early in the rehabilitation programme does not adversely affect clinical outcome. Discussion Concern about early initiation of rehabilitation and introduction of gradual functional load does not appear warranted but this should be considered in a context of potential for Type II error. There is further need to evaluate approaches that foster early initiation of rehabilitation and gradual introduction of functional load as well as considering key outcomes such as return to work.

BackgroundRecurrent shoulder instability is usually caused by a traumatic event resulting in structural pathology, although a small subgroup of patients experience symptomatic recurrent shoulder instability without trauma. These patients are usually treated non-operatively but limited evidence exists regarding effective conservative management. In particular, there is a lack of reproducible exercise regimes and none that have been tested with condition-specific outcome measures.MethodsA service evaluation was conducted over a 15-month period to assess our current treatment protocol used in the management of patients with atraumatic recurrent shoulder instability. The regime is reproducible with target-led progression milestones. Oxford Instability Shoulder Scores (OISS) and Western Ontario Shoulder Index (WOSI) scores were compared between baseline and final follow-up.ResultsEighteen consecutive patients were included with mean follow-up of 4.5 months (range 1.35 months to 11.77 months). A statistically significant improvement was seen in both outcome measures. Mean OISS improved by 16.67 points (confidence interval: 12.34 to 20.99; p ConclusionsFor this small group of patients with recurrent atraumatic shoulder instability, the Derby Shoulder Instability Programme produced significant improvements over the short term, with a high level of patient compliance. This is the first study to include pathology-specific patient-reported outcome measures to assess outcomes from a specific and reproducible exercise regime in this group of patients. The findings support further research to evaluate the exercise protocol in a larger group of patients over the longer term.

Background Rotator cuff disorders, including rotator cuff tears, are common and can be treated conservatively or surgically. Data suggest that the incidence of surgery to repair the rotator cuff is rising. Despite this rise, the most effective approach to postoperative rehabilitation, a critical component of the recovery process, is not well developed. The present study aimed to describe current practice in the UK in relation to rehabilitation following rotator cuff repair. Methods An electronic survey was developed and disseminated to UK based physiotherapists and surgeons involved with rotator cuff repair. Results One hundred valid responses were received. Although there is a degree of variation, current practice for the majority of respondents consists of sling immobilization for 4 weeks to 6 weeks. During this time, passive movement would be commenced before active movement is introduced towards the end of this phase. Resisted exercise begins 7 weeks to 12 weeks postoperatively, alongside return to light work. A progressive resumption of function, including manual work and sport, is advised from approximately 13 weeks. Conclusions In the context of the current literature, it might be suggested that the current approach to rehabilitation following rotator cuff repair for the majority of respondents is somewhat cautious and has not progressed for over a decade.

Frozen shoulder is a common condition resulting in pain, stiffness and functional impairment. Symptoms can persist for months or even years if left untreated. Various treatments are available, but a standard care package does not exist and the most cost-effective treatment has not been established. The objective of this study was to conduct a service evaluation of current practice to establish the effectiveness of corticosteroid injection and physiotherapy intervention and the costs associated. A review of all patients with a diagnosis of frozen shoulder who had received a corticosteroid injection and physiotherapy was undertaken for a 12-month period at a single NHS hospital in the UK. Patient-reported outcome measures were analysed and the costs for treatment calculated. Out of the 55 patients, 43 were happy to be discharged following treatment. Ten were referred for a surgical opinion and two were lost to follow-up. The median pain rating significantly reduced from 8 (interquartile range (IQR) 7, 9) to 2 (IQR 0, 3.75) (p

Objectives: To conduct a feasibility study to compare concentric and eccentric rotator cuff strengthening exercises for rotator cuff tendinopathy. Methods: A total of 11 patients with rotator cuff tendinopathy who were on the waiting list for arthroscopic subacromial decompression surgery were randomised to perform eccentric rotator cuff strengthening exercises, concentric strengthening exercises or no exercises. Patients were evaluated in terms of levels of pain and function using the Oxford Shoulder Score and a Visual Analogue Scale initially, at 4 weeks and at 8 weeks. Results: The study design was found to be acceptable to patients and achieved a high level of 86% compliance. The drop-out rate was 0%. Two patients performing eccentric strengthening exercises improved sufficiently to cancel their planned surgery. Conclusion: Further research in this area is recommended. The study design was feasible and power calculations have been conducted to aid future research planning.

Tendinopathy is a term used to describe a painful tendon disorder but despite being a well-recognised clinical presentation, a definitive understanding of the pathoaetiology of rotator cuff tendinopathy remains elusive. Current explanatory models, which relate to peripherally driven nocioceptive mechanisms secondary to structural abnormality, or failed healing, appear inadequate on their own in the context of current literature. In light of these limitations this paper presents an extension to current models that incorporates the integral role of the central nervous system in the pain experience. The role of the central nervous system (CNS) is described and justified along with a potential rationale to explain the favourable response to loaded therapeutic exercises demonstrated by previous studies. This additional consideration has the potential to offer a useful way to explain pain to patients, for clinicians to prescribe appropriate therapeutic management strategies and for researchers to advance knowledge in relation to this clinically challenging problem.