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Is My Neck Getting More Stiff Every Year? An Analysis of Cervical Spine Range of Motion Changes Over Forty Years.

One’s neck mobility seems to gradually get worse as we celebrate birthdays and suffer our share of accidents and uncomfortable hotel pillows. The garden variety pain or achy stiffness in the neck, categorized in the healthcare world as ‘nonspecific neck pain’ sends a lot of people to their care providers for some sort of treatment and medical relief. In order to best assess neck complaints, providers perform an examination of the spine. The physical therapist (or other provider of choice) will measure their range of motion (ROM), as in many cases one of the goals for patients with nonspecific neck pain is to improve the neck’s mobility. Normative values for the neck’s mobility are memorized by clinicians during their respective education, so relative stiffness measured in degrees, documented and treated for hopeful improvements. For example, we learned in PT school that the “normal” neck flexes and extends about 60 degrees, rotates 90 degrees and side bends 45 degrees. But, “normal range of motion” changes with age, and thus ‘normal’ for a 20 year old is quite a bit more generous than the age-reduced ‘normal’ for a 60 year old.

Enter the work of Dr. Swinkels and his team of researchers from the Zuyd University’s Department of Physiotherapy in the Netherlands. They recently published a paper on their investigation on the range of motion differences in the cervical spine as we age. They studied four hundred people without neck issues and quartered the data set with 100 for each decade of age from 20 years to 60 years and in each quarter subgroup. Each subgroup also had an even balance of genders with 50 males and 50 females. The mobility of the neck was measured with a special cervical range of motion device called the ‘CROM’. Swinkels’s team crunched the nitty-gritty analyses of variance, linear regressions and even further dredged the data with Scheffé post hoc tests to investigate the differences in neck mobility between the decades of age and any possible relationships of age and/or gender.

As one may expect, they found that age does have a significant effect on active ROM of the neck. Recall the “normal” ROM for neck flexion we committed to memory was 60 degrees. This normal mobility of 60 degrees in Swinkels’s study was assessed as typical for 20-somethings, but each decade men and women evenly lose a degree or two, until the 50-something decade. 50 years and older, active ROM declines greatly in all directions except neck extension and side bending. Neck flexion on average is reduced 12 percent (seven degrees) to 53 degrees. Clinically this is relevant, as we in the physical therapy profession tend to council a lot of people on improving their stiff neck’s mobility. In all due fairness, the “new normal” should be on an age-adjusted sliding scale when goal setting for target neck mobility.

Results of MOBILITY Ankle Replacement

Total ankle surgery is becoming a valid alternative to an ankle fusion for people with severe ankle arthritis. Changes have been made in the implant designs in the past several years, which are showing encouraging results. The benefit for replacement over fusion is preservation of some ankle mobility and thus improved ankle function for all kinds of life activities. This study looks at clinical outcomes as well as patient reported outcomes following ankle replacement with the MOBILITY Total Ankle System. These outcomes were measured with several questionnaires pre and post operatively. There was a clinical outcome measure called the American Orthopaedic Foot and Ankle Society score (AOFAS) and a patient reported, quality of life survey called the 36-item Short-Form Health Survey. They also collected overall patient satisfaction, height, weight, age and details of other medical conditions.

There were 106 participants in this study with a mean age of 61.9 ranging from thirty-three to eighty-nine years. In this group there were fifty-six with a preoperative diagnosis of osteoarthritis, twenty-eight with posttraumatic arthritis, and twenty-two with rheumatoid arthritis. The group of patients with posttraumatic arthritis was significantly younger at 54.8 compared to the other two groups.

The results indicate that there was not much difference between the groups for most of scores at both the one and two year follow-ups, and that all groups showed improvement in the outcome scores. The AOFAS score increased by an average of fifty-three points, which is comparable to some other similar studies, indicating consistency in this score improvement. The Short-Form Health Survey was used to get a feel for the patients’ perception of their general health and improvement related to their ankle replacement surgery. The results here also showed improvement from pre to post surgery. The rheumatoid arthritis group did have slightly lower scores in this questionnaire, indicating possibly the impact of this disease process on overall quality of life.

There were a few complications as a result of the MOBILITY ankle replacement surgery in this study. The most common was a medial malleolar fracture at six patients. Other less common complications included persistent medial ankle pain, infection and distal tibial fracture. There was one revision, however this was following a trauma. In all groups only one patient had a fusion following the total ankle procedure. Two patients had unresolved medial ankle pain and were later diagnosed with medial impingement, and following surgery this pain was resolved.

Common Causes and Treatment of Heel Pain

Heel pain is a common ailment that is frequently misdiagnosed because of a lot going on in a small space. A review article recently looked at the most common diagnoses and their causes. Authors challenge that a thorough exam should result in a correct diagnosis, which usually can be treated conservatively with over the counter anti-inflammatory medication (NSAIDs), rest, shoe modification, or physical therapy. Corticosteroid injections should be used with caution because of the multiple side effects and brief relief of symptoms. Surgery should only be considered when all other options have been completely explored.

Plantar fasciitis (PF) is the most frequently diagnosed cause of heel pain. The plantar fascia is a stiff piece of tissue that originates at the inner heel and is responsible for helping with maintaining an arch during push off while walking or running. PF is a slow degeneration of this tissue and is often caused by micro-trauma or strain. The telltale symptom is the dreaded first step in the morning that is painfully sharp but does not radiate. Pulling the big toe up or pushing on the PF itself recreates this pain. Effective treatment includes physical therapy, rest, stretches, store bought orthothoses, ice, NSAIDs, and weight loss. Evidence is mixed on long-term outcomes for night splints, prescription orthoses and the use of walking boots. Corticosteroid injections improve pain initially but can increase risk of PF rupture, along with facial flushing, skin and fat pad shrinking, or increase in pain following the injection.

“Heel pad atrophy” occurs when the fat pad under your heel bone, usually responsible for shock absorbance begins to break down. Pain is deep and localized in the center of the heel and is often mistaken for PF. Treatment should include NSAIDs, padded shoes, silicone heel cups, and low impact activities. Corticosteroid injections should not be performed as this can shrink the fat pad further and surgery should be avoided as there are no existing techniques that effectively address this problem.

The Baxter nerve travels down the inner side of the heel and can be squished, or entrapped, between a foot muscle or at the level of the heel bone. Burning pain is felt on the inside of the heel bone, or calcaneus, toward the arch in the foot. About half of patients with Baxter nerve entrapment usually also have PF. Conservative treatment includes physical therapy, rest, NSAIDs, and orthotics for proper heel alignment. Surgery is only considered if conservative measures have not worked and symptoms have lasted greater than three months. The most common surgical technique is to cut the fibrous tissue of the main foot muscle that is crushing the nerve, the abductor hallicus. Other surgical techniques include removing bone spurs and cutting other muscle fascia involved.

Calcaneal stress fractures, or tiny breaks in the heel bone, are often caused by a sudden increase in intensity of exercise. Pain is felt on the inside of the heel about one to two centimeters up from the pad of the foot and is a deep ache that increases with bearing weight but can become bad enough to feel even at rest. Stress fractures show up on an x-ray about two to eight weeks following injury. Treatment includes rest and wearing a walking boot or cast for four to eight weeks.

Tarsal tunnel syndrome happens when the tibial nerve, which normally travels through a tunnel created by fibrous tissue and the heel (calcaneal) bone, becomes trapped. This most commonly affects people with flat feet. The pain is not well pinpointed but is often behind the inside ankle bone and is tingling or burning and can radiate to the foot. Conservative treatment includes NSAIDs, immobilization, or custom orthoses. Surgery is an option when conservative treatment fails and involves careful release (cutting) of the fibrous tissue making up the roof of the tunnel. Good outcomes for surgical intervention, however, are around 50 per cent.

Percutaneous Drilling for Osteonecrosis of the Ankle

Osteonecrosis is a degenerative joint condition caused by decreased blood flow to a bone to the point that the bone begins to break down. A potentially life altering condition, osteonecrosis most commonly affects the femoral head, knee, shoulder and ankle. Risk of developing osteonecrosis has been associated with increased corticosteroid use, alcohol abuse, sickle cell disease, human immunodeficiency virus, and other immunosuppressive diseases.

The most common site for an osteonecrotic lesion in the ankle is in the talus or distal tibia, with a high prevalence in younger patients. Osteonecrosis can be stratified into four Stages according to the Ficat and Arlet classification system:

Stage 1: no apparent evidence of the disease on radiographs, however changes can be seen on MRI
Stage 2: cystic and/or osteosclerotic lesions on radiograph with a normal contour of the talus AND no evidence of subchondral fractures
Stage 3: crescent sign or sunchondral collapse
Stage 4: end stage disease with a narrowing of the joint space and secondary changes in the distal tibia

The treatment options can be non-joint preserving procedures, such as arthrodesis, talectomy, and arthroplasty, or joint preserving techniques, such as core decompression or bone grafting, which are typically preferred for younger populations. One variation of core decompression, described as percutaneous drilling, has been the subject of recent attention as it has been successful in treating osteonecrosis in the femoral head, knee, shoulder, and ankle.

Researchers recently looked at a total of 101 subjects, eighty-one of which had no previous surgical procedure and twenty of which had unsuccessful prior ankle core decompression. All patients underwent 12 weeks of nonoperative management, including analgesics, partial weight bearing exercise, bone stimulators and orthosis, but continued to have pain and thus elected to undergo percutaneous drilling as an outpatient procedure. This technique differs slightly from other core decompression techniques in that it uses smaller drill bits and is thus less invasive and removes less bone.

Post-operatively, the patients followed the same protocols beginning with partial weight bearing for four weeks, full weight bearing thereafter, and no high impact activities for ten months. At the most recent follow up of these patients, there were significant improvements in the patient reported outcome measures and pain scores and 83 per cent of the ankles demonstrated no further progression of osteonecrotic lesions. Seventeen of the ankles had progressed to a more advanced stage, four of which were at joint collapse, however the presence of sickle cell disease and HIV was associated with this progression.

An Overview of the Complications of Shoulder Arthroscopy

Shoulder arthroscopic surgery has become more utilized than open shoulder surgery over the past 20 years, with many citing fewer complications as a reason for the shift in treatment. However, after a review of the available evidence, Dr. Moen and his colleagues found that complications of arthroscopic surgery are not less devastating or prevalent than those of open joint surgery, they are simply different.

Arthroscopic surgery is performed by inserting instruments into a joint through small portals. Surgeons use small video cameras and tiny instruments to minimize joint disruption while they are repairing the joint. Prior to this technology, surgery was always open, with the skin, being cut back, muscles pulled aside, and the joint exposed for repair.

Surgical complications exist in three stages: prior to the surgery, during the surgery, and after the surgery. Prior to the surgery several things must be considered. The underlying patient pathology should be first taken into account. Certain procedures are best repaired with an open technique and others with an arthroscopic technique and if the wrong technique is used it can further subject the patient to problems down the road. Surgeon’s skill level and history with performing the indicated repair with an open or arthroscopic technique is another careful consideration. But, the highest probability for complication with arthroscopic surgery is choice of patient position during the surgery.

There are two main positions used for shoulder surgery. Bench position resembles sitting up in a recliner. Lateral decubitis position is the patient laying on their side with their injured shoulder facing up with the arm held away from the body by a special sling. Precautions for both of these positions include the standard ones for any surgery. The longer a body is held in a certain position, the greater the chance for skin breakdown and joint injury so the patient is carefully positioned and padded. If an extremity is wrongly positioned or held down too tightly nerves and blood supply can be negatively affected. Specifically, the head and neck must be carefully positioned and held in a neutral alignment to avoid risk of stroke or brachial plexus. This is especially true for the bench position as the patient is vertical and the neck could easily fall to the side. In the lateral decubitis position there is an increased risk for lower leg nerve injury because of the pressure on the side of the leg, and brachial plexus injury because the patient’s shoulder is under a certain amount of traction. Studies reviewed found the best arm placement for visualization to be 25-30 degrees of abduction (away from the patient’s side) and 30 degrees of forward flexion (in front of the body), with a decreased risk of brachial plexus injury with the arm positioned at either zero or 90 degrees of abduction and 45 degrees forward flexion with the least amount of traction required to complete the procedure. Authors strongly suggest that the surgeon be involved in the positioning of the patient to avoid foreseeable complications.

During the operation many nerves are vulnerable to injury. The portal site placement, or the holes through which the instruments pass, is crucial in that the nerves are avoided. The three main nerves at risk to direct injury are the axillary, musculocutaneous, and subscapular nerves. Certain surgical procedures present a greater risk to certain nerves, however each procedure follows specific precautions to decrease chance of injury. Another intraoperational complication, though rare, is a neurological event. These very serious events can include damage to nerves in the neck or eye nerves as well as venous air embolisms (an air bubble is introduced into the venous system and often results in death).

The most looked at serious complications of arthroscopic surgery are ischemic events where blood fails to flow where it should resulting in stroke, central nervous system cell death, and vision loss. Typically these events occur when the patient is placed in the seated “bench” position during surgery. When a person is awake, the nervous system regulates blood pressure, assuring blood is flowing to where it should. General anesthesia depresses this blood pressure regulation and the system can fail. Surgeons and anesthesiologists can mitigate the ischemic events by carefully monitoring blood pressure, applying regional or intravenous anesthesia, or performing the surgery in the less risky side-lying position.

Postoperative complications include joint infections and thromboembolic events (when a blood clot forms, breaks away, and moves to another area to block a blood vessels). Arthroscopy itself has a very low rate of infection, however the infection risk increases significantly with a transition to an open procedure during an arthroscopy. This infection risk is lowered by proper sanitization of surgical instruments, proper preparation of the patient’s skin and glove changing prior to conversion to an open surgery, and the patient taking antibiotics prior to the surgery. Thromboembolic events are rare for arthroscopic surgery and therefore have little evidence to investigate procedures for their prevention.

Even though arthroscopic surgery is rapidly becoming the method of choice for shoulder patients, there are surgical complications that must be considered. These complications can be minimized by careful patient selection, proper choice of surgical technique (open versus arthroscopic), the patient’s position during surgery, thorough knowledge of shoulder anatomy, and careful use of anesthesia.

What Is Femoral Head Osteonecrosis and What Are the Treatment Options?

Osteonecrosis of the femoral head most frequently affects 30 to 50 years old, with 20,000-30,000 new cases diagnosed annually. Although the actual pathology behind femoral osteonecrosis is not yet understood, the disease typically follows a progression to eventual femoral collapse, which results in the need for a total hip replacement.

Osteonecrosis literally translates to bone death. There are several reasons why this can occur. Ischemia, or lack of blood flow, is one. This can happen from trauma (like a hip dislocation or fracture), a blood clot blocking blood flow, or high blood pressure at the level of the bone tissue from excessive alcohol or corticosteroid use. Some genetic blood clot formation mutations have also been linked to femoral osteonecrosis. Disruption to the bone cells themselves by irradiation, chemotherapy, or the presence of excessive free radicals, also causes osteonecrosis. Primary risk factors include corticosteroid use, alcoholism, trauma, and coagulation disorders. They have found, however that a risk factor alone does not determine the onset of osteonecrosis, but that there must also be a genetic factor present.

The earlier the disease is diagnosed, the better the outcome. The most frequent symptom is deep groin pain that can radiate to the buttock or knee on the same side. The gold standard for femoral osteonecrosis detection is an MRI, which can give insight into the amount of bone death present, its location, and the amount of swelling in the bone. All of this information can help physicians treat the problem and predict whether or not the femoral head will “collapse,” which then means a need for a total hip replacement.

Nonsurgical treatment of femoral osteonecrosis is limited to smaller, symptom free lesions for a period of no weight bearing to see if symptoms do occur. Little evidence exists backing shockwaves and electromagnetic field treatment. Pharmacologic agents are also not strongly backed in the literature for prevention and treatment of femoral osteonecrosis.

Surgery is the primary treatment option for femoral head osteonecrosis and consists of femoral head preserving procedures or total hip replacement. The type of femoral head preserving procedure is subject to debate and dependent on the extent and location of the bone death. Femoral head sparing procedures are also indicated for the younger patient.

Knee Joint Cartilage Repair Options

Articular Cartilage is a cushing agent in your joints and overtime it can degenerate for a host of reasons and it has limited inherent ability for repair. There are many options for surgical treatment of knee pain that is caused by cartilage degeneration. A lot of research is being done on the different surgeries available and this article will give a brief overview of what is availble in the medical community for restoration of articular (joint) cartilage.

Cartilage imaging is common and you will most like have a specific type magnetic resonance imaging (MRI) performed on your knee. This is a noninvasive method used to visualize your knee’s cartilage status and health. The mechanical alignment of your knee (how you are built) will also influence what are available options or combinations of options for you.

There are some prescription and over-the-counter (OTC) drugs available that are being studied to examine their ability to protect cartilage and prevent or delay cartilage degeneration. A couple common OTC drugs are glucosamine and chondroitin sulfate. Studies on the drugs out there have been mixed in reporting benefit, so there is not a clear benefit of taking one of these medications yet. Prescription medications and OTCs effectiveness also depend on your mechanical alignment. If there is overloading on one side of your knee it is not likely that a medication will be of significant help alone.

Bone Marrow Stimulation and Microfracture

These techniques encourage the formation of new cartilage cells by stimulating underlying bone. Very simply put, in these procedures little divots are made in the bone and they bleed stimulating new cartilage growth. A systematic review (summary) of studies with greater than 3000 patients found that knee function was improved two years after microfracture. After two years, function declined but was still above pre-operative levels. Some shortcomings of microfracture are: unpredictable repair cartilage volume and higher failure rates for cell transplantation surgery (this well be described later). At the present time procedures that stimulate bone marrow are best for a first choice if the defect is isolated to the femoral condyle and smaller than 2.5cm^2.

Cell-Based options

These types of surgeries attempt to repair cartilage in the joint by injecting stem cells or your own chondrocytes (a cell found in cartilage). Implanting chondrocytes requires two separate surgeries with a period of growing the cells in-between. This can create a high cost and a substantial amount of time to finish the procedure. One study found superior results with chondrocyte implantation vs. microfracture when surgery was performed within three years of symptom onset. A study of 100 patients with 10-year follow up reported autologous chondrocyte implantation for lesions greater than 2cm^2 had a low failure rate (17 per cent). There is limited information on success rates with stem cell implantation but clinical trials to validate the technique are underway.

Chondral and Osteochondral Grafts

Cartilage autografts (your own body tissue) and cartilage allografts (donor tissue) have demonstrated growth of new tissue at the cartilage lesions. Operative procedures are fairly straightforward and require just one operation. Osteochondral (bone/cartilage) plugs have properties of both tissues so they provide a complete unit of graft tissue. Research has shown them to be a good option for lesions less than 3cm^2.

Rehabilitation

Non-weight bearing and partial weight bearing are used for a time during rehabilitation times frames range from eight to twelve weeks. Rehabilitation programs will depend on surgery, health status, cartilage lesion size, structural joint factors and age.

Restoration of Mechanical Environment and Summary.

If there is a structural deformity in the knee a surgery may need to be performed to improve success of of cartiage repair procedure.Techniques are used to cut away bone to make an equal loading surface. Cartilage surgery must focus on restoration of joint mechanics, address the defect-specific variables (location, size, numbers, bone health). Patient characteristics are also considered such as age, body mass, symptoms, lifestyle and surgical history. These procedures are fairly new and the quality of research is limited.

Stabilization for an Unstable Shoulder.

The operative management for traumatic anterior shoulder instability has changed from open to arthroscopic techniques. Even though the surgical procedure has evolved there is still controversy over the results of open or arthroscopic shoulder stabilization. Advantages of arthroscopy are faster recovery, less postoperative pain, decreased operative time. improved cosmetic appearance, improved shoulder range of motion and more accurate identification of problems within the joint. Those that favor open procedures cite superior long-term results with fewer recurrences. This study wanted to find out the quality of life at two years, as measured by the Western Ontario Shoulder Instability Index (WOSI).(The WOSI is a tool form designed for self-assessment of shoulder function for people with instability).

In this study, dominant and non-dominant shoulders were operated on depending on the injured side. The time from injury to repair went up to 75 months. The average age of the patient was about 20 years old to 36 years old and both males and females underwent surgery.

In the post-operative findings, the WOSI scores improved significantly in both groups form baseline to two years after the either operation. On average there were slightly higher scores in the arthroscopic group but they were not significantly higher. Range of motion between the two procedures was similar between groups, with the arthroscopic repair group having slightly less outward rotation of the shoulder. An important finding was in the rate of recurrent instability was significantly lower in the open group than the arthroscopic group. At two years the difference in quality of life between the patients in the two groups was similar.

In the study a higher complication rate was found in the open surgery, but all patients recovered from the complications (transient nerve dysfunction and infections). Data in this study suggests a patient profile that is more likely to experience recurrent instability after surgery: male, twenty-five years old or younger, has a Hills-Sachs lesion ( an injury to the head of the bone of the arm). The study recommends considering an open repair for this group.

There was no significant difference that was found in quality of life between the patients who were operated on, as measured by the WOSI. The information in this study suggests that open repair may be recommended to reduce recurrent instability in younger male patients with a Hills-Sachs lesion.

Comparing Open to Percutaneous A1 Trigger Finger Release

Trigger finger occurs when a finger gets stuck in a flexed or bent position then releases into a straight position with a snap-like motion. Caused by the narrowing of the sheath that surrounds the tendon in the affected finger, the treatment often ends up being surgical. An open trigger release is considered the gold standard as it has a high success rate with little complications. It involves creating an incision to openly release the affected tendon.

Percutaneous trigger release is another option that is becoming increasingly more popular in recent years with proponents claiming that it is a much simpler procedure that often results in a less painful and faster recovery. It involves using a hypodermic needle or specially designed scalpel to release the affected tendon without an open incision. Percutaneous release can be done in an office setting, thus minimizing cost.

The research investigating effectiveness and complications associated with open A1 pulley release surgery treating trigger finger indicates success rates varying from a 60 per cent to 100 per cent rate of symptom resolution. Adverse effects with open trigger finger release may include infection, nerve injury, slow range of motion recovery or bowstringing. Research has looked at the rate of adverse effects with findings ranging from less than one per cent to five per cent. One study identified adverse effects occurring in 30 per cent of patients, but this particular study included swelling and pain as adverse effects.

Percutaneous A1 pulley release has also been the subject of research investigating effectiveness and rate of complication, though the research is not as strong as with A1 pulley release. Excluding the research of percutaneous release on thumbs, which is a procedure much more difficult to perform, and excluding cadaver studies, the success rates vary from 91 per cent 100 per cent. Complications of percutaneous release may include risk of incomplete release, superficial tendon abrasions, and neurovascular damage. Risk of these complications ranged from zero percent to 60 per cent, with the 60 per cent being primarily superficial tendon abrasions.

Comparing outcomes of open versus percutaneous A1 pulley release surgery shows that those undergoing percutaneous repair reported post-operative pain lasting only three days compared to almost six days for open repair. Return to work was four days for the percutaneous repair compared to seven and a half days for the open repair. According to these comparative studies, there was no difference between the two groups with regards to failure or complication rate.

Overall, percutaneous repair for trigger finger is promising in being both highly effective and economical, though strong research is lacking. As new techniques, such as ultrasound guided releases, and new equipment, such as specially designed scalpels, are introduced, randomized trials comparing these methods are warranted.

ACL injury prevention programs outweigh the benefits of ACL injury screening

Anterior cruciate ligament injuries are one of the more common injuries impacting young athletes. The impacts are not only physical in nature but have psychological components and add financial stress as well. As the prevalence of youth participating in sports has increased, ACL injuries have also increased. Some research estimates that return to sport after ACL rupture and repair is as low as fifty per cent in young athletes, while epidemiological studies estimate that females are four to six times more likely to suffer and ACL injury compared to their male counterparts. For these reasons, a considerable amount of attention has been paid to programs aimed to decrease ACL injury rate, particularly in the female athlete.

Research supports the effectiveness of many ACL injury prevention programs that have been developed in the past decade. These programs typically involve an altered warm up and inclusion of certain fitness drills in practice that include core work, stretches, plyometrics, strengthening and sport-specific agility drills. The end goal is to optimize muscle balance and improve the athletes biomechanics, particularly with jumping and cutting type movements that typically stress the ACL. Aside from these ACL injury prevention programs, more recently certain researchers have recommended screening programs to identify the young athletes that may be at higher risk for ACL injury. Medical screening tools ideally are designed to be sensitive enough to identify only the high risk individuals so that interventions can target this population rather than those who do not need the intervention, thus saving money. With an effective ACL injury screening tool, the athletes that are at highest risk can then participate in an injury prevention program, rather than having all of the athletes in the program, again with a goal of saving time and money.

As finances for youth and college sports can be limited and injury rates continue to rise with increased sport participation, it is important to find the most cost-effective program to implement that also provides the best results. It necessary to take into consideration the cost and accuracy of a screening tool, as the purpose of the screen is to identify those at risk. Similarly it is important to make sure that the intervention is targeting the correct population and is effective in making the modifications desired. Though research supports the sensitivity of screening tools as being effective in predicting ACL injury risk, these screening tests require extensive set-up, expensive motion analysis video equipment, and a skilled tester. Typically the athlete will run through a battery of jump and landing tests to determine the knee abduction moment. Even if a coach is educated on what to look for with a screening test and is able to use a simple camera, the time and cost required to conduct the testing exceeds the benefit.

The incidence of ACL injuries in youth is high enough that a screening tool is just not warranted. The high incidence rate equates to the fact that most athletes will benefit from an ACL injury prevention program, which are very inexpensive and highly effective as supported by research. On average, such programs decrease the incidence of ACL injury from three per cent to one per cent in a single season, saving on average $100 per player per season in expenses related to such injuries. Universal ACL injury prevention programs for young athletes, male and female, are a cost effective strategy for reducing the physical, psychological and financial burden of ACL pathology.

Effectiveness of Surgery For The Middle-Aged Patient With Hip Pain

A recent review of current evidence found that surgical treatment for hip pain in the middle-aged, active patient population is highly dependent on the type of underlying pathology and condition of the joint. Decisions regarding type of surgery should be made based on the amount of degeneration, bony deformities present, and the ability to repair the labrum and cartilage damage.

The hip joint is a ball and socket joint that has a labrum, or firm piece of tissue that extends out over the socket and makes a deeper pocket to hug the head of the leg bone (femur). In addition to the suctioning of the labrum, the joint is surrounded by ligaments, which hold the bones together, and muscles on top of the ligaments, which are responsible for moving the bones. All of these tissues work in conjunction to allow you to move your leg through space in a controlled manner. If any of these tissues are disrupted, the direction of forces change across the joint and wear and tear can happen at a faster rate. Wear and tear, or arthritis, can also occur from repetitive activities and from bony anomalies that occur either on the ball of the femur or on the socket of the hip joint.

Femoralacetabular impingement (FAI), hip pain due to a torn labrum or disrupted articular cartilage, can be caused by a “cam-lesion”, “pincer-lesion”, or combination of the two. A cam-like lesion is a “speed bump” on the ball of the femur. A pincer-like lesion is a speed bump of bone deposit on the edge of the socket of the hip joint. Either of these lesions results in hip pain and early wearing away of the cartilage protecting the joint which ultimately leads to further break down of the hip joint.

Young, active patients with cam or pincer lesions or labral tears are very successfully treated with arthroscopic surgery. Surgeons are able to make a small incision and remove the extra bone and repair the labrum without disrupting much of the joint. Older, active patients (30 to 50-somethings) with hip pain also have the same lesions or labral tears but additionally often have joint arthritis. When hip joints become so arthritic that it interferes with daily life a total hip joint replacement is indicated. However, a middle-aged active person’s joint arthritis typically does not merit total hip replacement but still requires surgical help.

The surgery that results in very good outcomes for the younger population does not give the same results to the middle-aged population. As many as 25 per cent of the middle-aged hip pain person undergoing the same surgery continue to have hip pain with an increased risk of quick progression to a total hip replacement.

After reviewing the available evidence, authors found people undergoing hip arthroscopic surgery with a decent amount of cartilage damage did not have good pain relief and actually seemed to have an accelerated road towards total hip replacement. Additionally, x-rays do not seem to be a good indicator for estimating how much cartilage damage there is. Authors do point out, however, that the studies reviewed are not ranked highly on the hierarchy of evidence, are a little old in that they mostly only address labral issues, and are not focused on long term outcomes.

Studies that compared labral repairs versus debridement (or removing the extra bony deposits) found that fixing the labrum, even with coexisting cartilage damage (or early arthritis), could possibly prevent or slow down the arthritis. Furthermore, by fixing the labrum the normal joint mobility and tracking is maintained which can also help slow down the joint degeneration by keeping the joint surfaces rolling and gliding as they should and the labral suction seal intact.

Even though the evidence is lacking for the middle age, active patient with hip pain, the general consensus is that the joint is treated in its entirety by repairing the torn tissues and removing the extra bony deposits that potentially caused the tear in the first place. Given time, the research should reflect the current surgical practices that are proving to be effective in this population.

A Summary of Treatment Guidelines for Knee Osteoarthritis

Every five years or so the American Academy of Orthopedic Surgeons (AAOS), along with a cohort of other professions (like physicians and physical therapists) publish a guideline to treat certain conditions based on the latest and greatest evidence. These guidelines offer a quick look into what’s proven to work, what does not work, and what still needs to be further investigated.

Below are the items that the AAOS recommends for the most up to date treatment of knee arthritis.

People with knee arthritis should:
1. Routinely take part in a strengthening program, neuromuscular education (or using techniques to restore balance, improve coordination and fine tune awareness of where your leg is in space), perform low-impact aerobic exercises, and keep physically fit to national standards in regards to heart health and body weight.
2. Maintain a body mass index (BMI) of less than 25.
3. Use nonsteroidal anti-inflammatory drugs (oral or topical) or tramadol to help with symptom management.

The following are NOT recommended for treatment of knee arthritis:
1. Acupuncture
2. Lateral wedge insoles are not supported in the literature. This being said, however the recommendation is moderate and patient preference should be kept in mind.
3. The use of glucosamine and chondroitin.
4. The injection of hyaluronic acid into the knee joint.
5. Performing an arthroscopy with lavage and/or debridement in which the fluid of the knee joint is removed, the joint is washed, and any loose bodies or debris are removed.
6. The use of needle lavage where saline is injected into the joint and then removed in attempts to wash the joint and remove inflammatory factors and debris.
7. The use of free-floating (not cemented or screwed into place) interpositional devices in the inner knee compartment to alleviate pain and mimic meniscus function. (This was a general consensus recommendation due to the lack of research available for these devices.)

Evidence is inconclusive for the following due to either lack of available evidence or inconsistencies in the studies that have occurred.
Practitioners should be on the lookout for future evidence, but in the meantime decisions regarding their use should be influenced by their clinical judgment and patient preference.
1. The use of physical agents, such as electrical stimulation and ultrasound.
2. Manual therapy.
3. Valgus knee brace (to unload the inner knee compartment).
4. The use of acetaminophen, opioids, or pain patches.
5. The use of injections into the knee joint of corticosteroid.
6. The use of growth factor injections and/or platelet rich plasma.
7. A valgus-producing proximal tibial osteotomy, or bone shaving that changes the direction of forces across the knee joint to relieve pressure at the inner knee.

As the evidence changes and our knowledge evolves, it is good to keep the AAOS standards in mind and to be on the look out for future recommendations.

What is the deal with Platelet-Rich Plasma?

Recent treatments for joint pain due to cartilage damage are focusing in the area of less invasive solutions, and platelet-rich-plasma (PRP) is of interest to many clinicians and researchers alike. Platelets are particles in the human bloodstream that contain biological building blocks for tissues such as cartilage. The building blocks in platelets that are theorized to assist in healing include various growth factors and cytokines. The benefit of PRP are that it is a low cost and minimally invasive technique using the client’s own blood, however there is little known about the optimal method for preparing the PRP for the specific purpose of cartilage repair. It is important to find the most beneficial mixture because the growth factors and cytokines that will be released onto the client’s tissue could have very different and potentially detrimental results with only small changes in the concentrations. This particular study was conducted to investigate two different formulas, which have previously been shown to be beneficial, on human cartilage cells and the effects these different formulas will have on these cells.

In this study, blood from ten healthy male subjects was used to prepare two PRP solutions as well as a platelet poor solution (PPP) as a third comparison. The first platelet preparation (P-PRP) had a relatively low concentration of platelets and very few leukocytes. The second preparation (L-PRP) had high concentration of both platelets and leukocytes. The researchers tested these three preparations on cartilage taken from four male subjects all over the age of sixty-two with grade II osteoarthritis who were undergoing major knee surgery, meaning that they had pretty worn cartilage. The cartilage samples were broken down to extract the actual chondrocytes, which are the cells in charge of building new cartilage. Then the samples of chondrocytes were placed in the PRP formula for seven days. There were three preparations of each of the formulas; five, ten and twenty percent concentration of each PRP in order to assess various dose possibilities. Seven days was chosen because the clinical protocol includes a follow up injection at that time.

The growth of the chondrocytes was measured at one hour, three and seven days; genetic markers were measured at seven days; and hyaluronan and lubricin protein levels were also checked at the seven-day marker.

All three preparations increased growth of the chondrocytes, at all three times, but the P-PRP had a significantly increased cell growth on the seventh day. The genetic expressions tested also seemed to favor the P-PRP formula for stimulus of chondrocyte growth, however it appears that the L-PRP also promoted this growth, but through different pathways involving the leukocytes present in this formula. Surprisingly the PPP formula was also able to change the genetic expression similarly to the P-PRP samples, and it is theorized that simply having the plasma proteins and growth factors present in blood plasma will also positively affect cartilage repair. The L-PRP chondrocytes tended to secrete more hyaluronan, but both the L-PRP and the P-PRP caused similar secretion of lubricin. Both hyaluronan and lubricin are involved in joint lubrication.

The findings of this study suggest that more research is needed in this area, and there needs to be consideration taken into account as to the actual biological process that you want to be happening. This study has shown that different formulas of PRP and even PPP all seemed to provide positive effects on the cartilage, but through different pathways, indicating that some formulas could be more useful for different patients depending on their history.

The Effectiveness of Therapist-Delivered Treatments for Low Back Pain

It is widely accepted that low back pain is one of the most common orthopedic pains we will experience in a given year. It is also a highly scrutinized and researched health condition, as it is a very costly public health problem that affects a third of all adults. Treatments for low back pain range from medication, to surgery, to therapist-delivered care. Recently, Dipesh Mistry and a team of health scientists from the UK’s Warwick Medical School, performed a systematic review of the research on the quality and effectiveness of low back pain treatments performed by therapists. Acceptable therapies for low back pain included a lot of treatments from psychological interventions to intensive rehabilitation programs, from laser acupuncture in Australia to high velocity thrust manipulation in Sweden. The targeted types of low back pain were classified as ‘nonspecific’, meaning they do not come from a likely cause such as a fracture, tumor, infection or inflammatory disease. Nonspecific back pain is generally known as the common back ache or strain.

Mistry’s team combed through the research to select only high-quality, randomized controlled trial-based articles on subjects older than 18 with a history of nonspecific low back pain. Their results largely followed the prior literature reviews consensus small, rather than the conventionally-accepted moderate positive effective gains from therapeutic treatments. They were able to use a total of 39 articles from various search engines (i.e., Medline and Cochrane Controlled Trial Register) completed between the years of 1948 to 2013. They divided the articles into two sub-classifications as either a confirmatory finding or an exploratory finding. Confirmatory are more rigorous, follow-up research that strides to confirm or test the hypothesis. Exploratory are more preliminary research that aims to generate future hypotheses or build a base for future research. Of the accepted, high-quality studies, only three studies (8 per cent) tested hypotheses and were classified as confirmatory. Eighteen studies (46 per cent) were classified as exploratory findings. The remaining 18 (46 per cent), fell short of a substantive conclusion and were given the ‘insufficient findings’ status. The researchers further tweezed each articles’ respective study methods for appropriate statistical testing for each interaction between studied variables. Fortunately, appropriate stats were employed in 27 of the 39 of the articles. The remaining articles had sub-classification reporting deficiencies or other areas deemed too weak to qualify for this paper’s systematic review.

They concluded that the sub-classified (either the confirmatory or exploratory findings) therapies for treating nonspecific low back pain have been ‘severely underpowered’ in their analysis. In other words, over the past 65 years, the 39 acceptable high-quality articles were only able to provide exploratory class research with insufficient evidence to boot. Moreover, they had poor quality data in their reported findings. Misty’s team also generalized that if we hope to better identify which form of low back pain treatment will be the most economical and effective, then we need to better classify which subgroup of persons with back pain are appropriate for each treatment. Future research was suggested here to develop new methods to effectively identify subgroups in back pain research. Furthermore, they recommended that the low back pain research community needs to collectively revise their current approach to subgrouping the back pain studies. Continued perpetuations of exploratory class research won’t help improve the care for our substantial population of persons with back aches looking for effective therapies.

Options for Splinting as Treatment for Post-traumatic Elbow Contracture

Loss of range of motion due to capsular contracture of the elbow is not uncommon following traumatic injury to the joint. Nonsurgical options for treatment of the contracture include splinting and stretching exercises supervised by an occupational or physical therapist. Splinting can either be done statically or dynamically and may or may not include a turnbuckle feature.

Static progressive splinting does not allow the elbow to move and is typically used for short periods of time in a position that forces the elbow in one direction. The patient can control the force with guidance from their doctor and physiotherapist. Dynamic splints have a hinge at the elbow and a mechanism that allows some movement of the elbow while being stretched the rest of the time. These splints are worn for longer periods of time as they work by applying a low load prolonged stretch that typically causes little discomfort to the patient. The turnbuckle splint can be static or dynamic and allows the hand to pronate and supinate, or twist up and down.

The protocols for splinting vary greatly, but result in similar outcomes. Though static splints are typically worn for shorter periods of time, often in 30 minute increments several times a day, some protocols have the patient wearing the splint all day in varying positions. The range of motion gained with static splinting can vary, with reported results ranging from 26 degrees to 50 degrees. There is less research reporting protocols and results with dynamic splinting, but typically these splints are worn for at least six hours/day and often 24 hours a day. Range of motion gains vary from 20 to 47 degrees as reported in the literature.

Range of motion can continue to improve for up to a year after injury, with the greatest gains being made in the first three months. It is important that the patient understands this and prepares mentally to allow the stretching to take place in the early months. There is evidence that patients who have a protective attitude toward stretching in the first month of recovery gain less range of motion.

Recontracture Following Surgical Correction of Dupuytren Disease

Dupuytren Disease is a flexion deformity of the proximal interphalangeal joints of the hand. It involves a gradual thickening of the tissue under the skin on the palm of the hand into a cord-like structure. The flexion deformity makes it very difficult to fully straighten the fingers. Though it typically affects the ring and pinky finger, all fingers can be affected. Surgical correction of the flexion contracture is a common procedure that can have varying results, short and long term.

The PIP joint can recontract following surgery either due to post-operative scarring, post-operative joint contracture, or a recurrent Dupuytren Disease. In order to better understand the recurrence rate of contracture, a group of 82 patients exhibiting contracture greater than 30 degrees were recruited to participate in a longitudinal study that followed their progress up periodically over a course of five years after surgery.

The surgical procedure involves excision of the fibrous bands and nodules and a ligament release if necessary, followed by z-plasty. Of the initial 82 patients, a total of 62 showed for follow-up. Of these 62, 49 per cent showed good improvement after surgery that was maintained five years, 32 per cent showed good initial improvement that worsened less than 20 degrees in three months then remained at this level for the five year follow up. Seven per cent of the patients showed immediate severe worsening greater than 20 degrees in the first three months then remained stable after this for the five year follow up. The final group of 12 per cent showed immediate worsening that progressed over the next five years. Four patterns of recontracture following surgical correction were thus identified.

In looking at patient demographics and surgical procedure, a few trends were identified. The progressive recontracture group constituting 12 per cent of the patients had higher disability scores, longer duration of disease and required longer surgical time. These characteristics can be used to help determine success rates of surgical correction for Dupuytren Disease.

The basics about intrinsic contractures of the hand.

The hand is a very intricate and complicated feature of the human body. There are many small structures, including tendons, ligaments and muscles that run through the hand and fingers. When these structures don’t move properly the result can be mild to severe disability from weakness of grip strength, inability to grasp objects and difficulty with general hygiene.

Intrinsic contracture is a diagnosis that specifically refers to small muscles with origin and insertion in the hand called interossei and lumbricals. There are seven interossei muscles, four on the dorsal or backside of the hand and three on the volar or palm side. There are four lumbricals, which originate from one of the long finger flexor tendons. These muscles course through the fingers to act as flexors of the MCP and extensors of the PIP. With this case these muscles become stiff and contracted causing imbalance in the forces that help us open and close our fingers. This results in stiffness, deformity and even dislocation of the fingers. In severe cases the resultant deformity is where the base of the finger (metacarpophalangeal or MCP joint) is flexed or bent while the middle finger joint (proximal interphalangeal or PIP joint) is extended or straight.

Intrinsic contractures can result from several causes. This can include trauma, spasticity, loss of blood supply, rheumatoid arthritis or even as a result of a medical procedure.

With a traumatic injury, such as a fracture, the primary problem is edema and immobilization, which can lead to adhesions and stiffening of the tendons and muscle bellies over the course of the recovery. Other injuries causing a fibrotic muscle can result from a loss of blood flow as with compartment syndrome or a vascular injury. Blood loss can also result from bandages or casts that are too tight, however this is less common today.

Spasticity is a condition where the neuron controlling the muscle is injured as with a stroke, traumatic brain injury or cerebral palsy. In this case there may be other contractures present as well.

Rheumatoid Arthritis is another common cause of intrinsic contracture. In these such cases the impaired muscle function can be the result of adhesions, muscle spasm from inflammation, or contraction due to decreased movement. Often in this population there are several factors including joint instability, and drifting of the fingers in the ulnar direction (towards the pinky finger).

Assessment and evaluation of these cases is based on the history of the injury as well as measurements for both active movements and passive movements of all the joints in the hand. This is important to distinguish between joint or muscle contracture. Often there will be testing of multi-joint motion to further evaluate the complicated balance of the many structures in the fingers and hand. There may also be radiographs to evaluate bony deformity, fracture, or joint instability. Testing for joint instability may also include laboratory testing for signs in the blood stream for rheumatic signals in cases with no obvious cause.

The most conservative and first line of management is nonsurgical. This will include proper care following trauma to reduce effects of swelling and immobilization. Quite often hand therapy protocols will be utilized to assist in reducing these effects and will usually include stretching and progressive splinting. With spastic patients, often optimizing their medications can improve on intrinsic function.

Surgeries are also common to treat intrinsic contractures, and there are many types that are chosen based on the specific case. Some of the many surgical options are to release tendons, release or partial release of the passive structures of the joints; or the procedures can be more complicated and include tendon repositioning, lengthening of the muscles, moving the location of the muscles, or even cutting off the nerve supply.

A Closer Look at Management Following Shoulder Dislocation in Children

A recent review of the literature found that immobilization followed by physical therapy remains the standard treatment following shoulder dislocation in young children. The review did find a paucity of evidence regarding the appropriate treatment, possibly due to the fact that shoulder dislocation in the younger population is rare with about 20 per cent of all dislocations occurring in the less than 20 year old population and .92 per vent of those occurring in less than nine year olds.

Your upper arm bone, known as the humerus, continues to form after birth. The end of the bone that makes up part of your shoulder joint has two bone-forming centers called ossification centers. One of these centers stops laying down bone when a child is between five and seven years old and the other stops between 14 and 17 years old. This is significant because if these centers are disrupted prior to them finishing their job trouble can result. Once these centers, along with others located in other parts of the skeleton are closed, a person is considered “skeletally mature.”

The shoulder joint relies heavily on a joint capsule, shoulder rotator cuff muscles and ligaments to hold it together. The combining motion of these structures allow for us to have a great range of motion at our shoulder joint. If any of these structures fail, due to trauma or laxity, the shoulder joint can dislocate. A true dislocation involves the humeral head slipping outside of the capsule and it requires someone to “reduce” it or put it back in place. Sometimes the humeral slips out of the capsule slightly, or jumps its normal track, and this is called a subluxation. A subluxation does not normally require a reduction and the person can usually move their arm around to get it “back into place.” The direction of the location is also important to note, with the most common being the humeral head slipping out towards the front of the armpit.

In a child, tissues tend to be more elastic which can be more forgiving during an injury. If an injury does occur, it is typically a fracture as children’s ligaments are often stronger than their bones. The anatomical shoulder capsular attachment site also adds for more stability than in an adult. These factors make shoulder dislocation difficult to happen in children and less likely to re-occur once it does happen. That being said, however, when a traumatic dislocation does happen part of the front of the capsule can tear, called a Bankart lesion.

The evidence is very inconsistent regarding redislocation rates for skeletally immature children, with studies siting anywhere from 0-100 per cent. One study delved further into the dislocation recurrence rate and looked at the differences in age when the dislocation occurred. They found that the younger the child was at the time of dislocation, the less likely they were to re-dislocate in the future and that they had less actual damage to their capsule, which was probably due to the elasticity of their tissues.

Following reduction, patients are put in a sling to allow for the stretched joint structures to rest. The length of time in the sling is still debated, but often ranges from one to six weeks. This length of time has not been investigated in relation to re-dislocation rates. The direction that the arm is held in the sling is also controversial, the most common direction being palm towards the stomach with the elbow away from the side of the trunk. However, a recent study found better results for dislocations that happen to the front to be placed in a sling in the opposite direction, or external rotation.

Physical therapy is the gold standard treatment following the immobilization period and includes strength progression. A study following shoulder dislocation treatments in children less than 16 years old found that physical therapy was effective for six per cent of first time dislocations, with the remainder requiring surgical intervention.

Surgery is considered when more conservative treatments fail to prevent future instability incidences. Any tears in the tissue are repaired and the surgery is the same as repairs in the adult population. Outcomes of these repairs are excellent in the two studies cited in this article, however the studies conducted were only on a small sampling of patients.

Central to the debate of preventing recurrent shoulder instability in the non-skeletally mature patient is to have surgery or not. Results are favorable for preventing recurrent dislocations for adult patients, but are mixed with the younger populations. Immobilization followed by physical therapy remains the gold standard treatment in populations less than 14 years old without a Bankart lesion who have only dislocated one time. Surgery becomes an option with recurring incidences of instability or with a coinciding Bankart lesion.

A Review of Factors Affecting Rotator Cuff Healing

A review of current literature identified positive and negative factors regarding rotator cuff repair healing. Negative healing factors include larger tears, excessive fatty tissue in the repair, muscle atrophy (or lack of muscle mass), and older age due to a poor healing environment. Factors that do not affect healing outcomes are the type of surgical technique used or the use of platelet-rich plasma. Evidence is conflicting for the type of rehabilitative postoperative protocol used.

The shoulder joint is a complex joint, which consists of your arm bone (humerus), collarbone, and shoulder blade. These three bones are linked together via ligaments, tendons, and a thick fibrous capsule. The amount of boney congruency is likened to a golf ball (the head of the humerus) on a tee (the scapula). This lack of bony contact allows us to move our arms in a circle but at the same time sacrifices joint stability. Instead of relying on bone to help hold the joint together, the shoulder joint must rely on six “rotator cuff” muscles and tendons as well as a capsule surrounding the joint made up of thick fibrous tissue.

Authors point out that rotator cuff repair studies often focus on patient functional outcomes versus actual healing and that these two factors do not always go hand in hand. Functional outcomes, or the return to doing what you want to do, are often measured by questionnaires. Pain, motion, and strength are also considered in gauging effectiveness of surgery. The actual tendon healing, however, is often overlooked. The amount of tendon healing can be seen with imaging, such as an MRI.

The extent of the tendon healing depends on numerous factors. The proper surgical technique is debated among surgeons. Incision type can be either open (large incision) or arthroscopic (small incision). Because this review simply looked at the tendon healing, it found that there was no difference between the two. Surgeons have the option to perform either a single row stitch or a double row stitch on the tendon for the repair, depending on the type and size of the tear. The failure rate for a single row stitch is slightly higher than that of a double row stitch, but the data is considered “not statistically significant,” meaning that there might be some factors unaccounted for that may make these numbers misleading. Tying knots or not tying knots in the stitch is yet another technique controversy that goes unanswered with regard to tendon healing. Another review did find unknotted sutures to be slightly more beneficial from a shoulder movement standpoint. Suture anchors, or the piece of material that holds the suture to the bone, have yet to be examined for their contribution to tendon healing. The preparation of the bone for the anchor attachment is also a factor and some worry that it can interfere with the anchor integrity in bones that are osteoporotic, or brittle. Studies show that there is slightly better healing with a microfracture technique (tiny holes are poked in the bone to encourage healing), than the standard procedure. Platelet-rich plasma (PRP), or blood components thought to speed up healing, is sometimes injected at the site of the repair. Multiple studies show no benefit of this towards healing and that it can actually increase the chance of infection.

Often in a shoulder that has difficulty with stability, an extra piece of bone builds up on part of the shoulder blade, called an acromial bone spur. Sometimes this spur is removed during the rotator cuff repair. Authors found that whether or not the spur is removed during the rotator cuff surgery healing of the rotator cuff is not affected. Likewise, a person’s anatomy can predispose them to a rotator cuff problem and surgeons can “fix” these by changing the direction of the pull of the tendons with an “augmentation patch.” However, at this time evidence is controversial whether or not they help with the healing process for rotator cuff repair, with the bulk of the evidence suggesting not using them.

Surgical techniques aside, there have varying opinions on what rehabilitative protocol, or recipe, to use following surgery. Two common camps are early movement after surgery versus delayed movement but there is no great evidence to support faster healing times with either. There are several patient factors that significantly effect healing time, including increase in age, the size and location of the tear, the quality of the tissue, how long prior to surgery the tear occurred, and the presence of osteoporosis and diabetes.

Overall, rotator cuff healing is affected by a number of variables. The exact combination of factors has yet to be determined. Authors point out as well that readers should keep in mind that there factors that are unaccounted for in this review such as pain levels, outcomes, speed and ease of procedure and postoperative complications.

The Relationship Between Low Back Pain, Obesity and Physical Activity

Obesity and LBP combined make up for about 30 per cent of U.S. health care costs. More evidence is supporting an association between obesity and low back pain (LBP) but, not much is known about the relationship between the two. Obesity is listed as a impacting factor in LBP mostly described through the body mass index (BMI). Body mass index is categorized as: normal weight <25, overweight 25-30, obese 31-35, and ultraobese 36+. Physical activity is a logical suspect to connect obestiy and lower back pain, but no study has demonstrated the role of physical activity. Exercise and weight loss is know to benefit some with back pain, yet the role that physical activity plays is unclear. This study looked into the relationships between LBP, obesity and physical activity.

To collect data on the relationships between obesity, LBP and physical activity information was obtained through participant surveys, physical examinations, and for 7 days the participants wore accelerometers. (Accelerometers can measure in real-time, duration and intensity of motion). Participants wore the accelerometer while they were awake and every minute of that time was used to calculate activity level.

Once the data was collected the findings were very interesting. First, the baseline risk of LBP increased with increased BMI. Smoking was consistently a strong predictor of LBP across any BMI level. WIth overweight subjects it was found that time spent doing sustained activity in a moderate range reduced the odds of having LBP and was even protective from getting LBP. For the average overweight American increasing time doing moderate activity by 17.6 minutes a day, decreases the risk of getting LBP by 32 per cent! In obese subjects, time spent in sedentary activity states had positive relationship with increased LBP. In the morbidly obese category more time spent in moderate activity reduced odds of getting LBP. A small increase in moderate activity level for the morbidly obese by 2.1 minutes reduces back pain risk by 38 per cent!

This study shows that there is a relationship for increased BMI being a risk factor for LBP. Reduced physical activity is also a risk factor for getting LBP, lots of sedentary time and reduced moderate activity have a greater impact on increased LBP risk in overweight Americans. In the overweight population physical activity can be a dimishing factor in lower back risk and it does not take great increases in physical activity to for exercise to have a protective effects.