Objective To compare arthroscopic hip surgery with physiotherapy and activity modification for improving patient reported outcome measures in patients with symptomatic femoroacetabular impingement (FAI). Design Two group parallel, assessor blinded, pragmatic randomised controlled trial. Setting Secondary and tertiary care centres across seven NHS England sites. Participants 222 participants aged 18 to 60 years with symptomatic FAI confirmed clinically and with imaging (radiography or magnetic resonance imaging) were randomised (1:1) to receive arthroscopic hip surgery (n=112) or a programme of physiotherapy and activity modification (n=110). Exclusion criteria included previous surgery, completion of a physiotherapy programme targeting FAI within the preceding 12 months, established osteoarthritis (Kellgren-Lawrence grade ≥2), and hip dysplasia (centre-edge angle Interventions Participants in the physiotherapy group received a goal based programme tailored to individual patient needs, with emphasis on improving core stability and movement control. A maximum of eight physiotherapy sessions were delivered over five months. Participants in the arthroscopic surgery group received surgery to excise the bone that impinged during hip movements, followed by routine postoperative care. Main outcome measures The primary outcome measure was the hip outcome score activities of daily living subscale (HOS ADL) at eight months post-randomisation, with a minimum clinically important difference between groups of 9 points. Secondary outcome measures included additional patient reported outcome measures and clinical assessment. Results At eight months post-randomisation, data were available for 100 patients in the arthroscopic hip surgery group (89%) and 88 patients in the physiotherapy programme group (80%). Mean HOS ADL was 78.4 (95% confidence interval 74.4 to 82.3) for patients randomised to arthroscopic hip surgery and 69.2 (65.2 to 73.3) for patients randomised to the physiotherapy programme. After adjusting for baseline HOS ADL, age, sex, and study site, the mean HOS ADL was 10.0 points higher (6.4 to 13.6) in the arthroscopic hip surgery group compared with the physiotherapy programme group (P Conclusions Patients with symptomatic FAI referred to secondary or tertiary care achieve superior outcomes with arthroscopic hip surgery than with physiotherapy and activity modification. Trial registration ClinicalTrials.gov NCT01893034.

https://www.bmj.com/content/bmj/364/bmj.l185.full.pdf

Arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of symptomatic femoroacetabular impingement: multicentre randomised controlled trial.

Diabetic foot disease greatly impacts both affected patients and society, but remains the "Cinderella" of diabetes-related complications. However, recent progress in research and guideline development have led to increased awareness of the problem and improved clinical outcomes. Thus, it is time for a shift in global perception of this increasingly prevalent problem. In this special issue, we present 7 up-to-date clinical guidelines and 10 systematic reviews developed by the International Working Group on the Diabetic Foot, together with 17 informative and stimulating related papers. These guidelines offer new recommendations on ulcer classification, diagnosis of infection severity, and vascular assessment, to assist in ulcer risk stratification, diagnosis and interdisciplinary communication. Key developments include providing guidance on methodological assessment of research papers; expanding the evidence base for ulcer treatment by the use of wound products and offloading treatment and suggestions for improving ulcer prevention through technological advances in patient monitoring of risk factors and footwear. The 17 invited papers discuss related topics ranging from stem cell research to patient psychology and describe the way forward in diabetic foot care. While there is much more to learn, the new knowledge of underlying pathways, advancements in diagnosis, treatment and prevention presented in this supplement should help improve outcomes and reduce the great and growing burden of diabetic foot disease.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/dmrr.3249

Diabetic foot disease: "The Times They are A Changin' ".

Should weight-bearing activity be reduced during healing of plantar diabetic foot ulcers, even when using appropriate offloading devices?

Objective The purpose of this review was to compare the efficacy of motor control exercises (MCE) to strengthening exercises for adults with upper or lower extremity musculoskeletal disorders (MSKDs). Methods Electronic searches were conducted up to April 2020 in Medline, Embase, Cochrane CENTRAL and CINAHL. Randomized controlled trials (RCTs) were identified on the efficacy of MCE compared to strengthening exercises for adults with upper or lower extremity MSKDs. Data were extracted with a standardized form that documented the study characteristics and results. For pain and disability outcomes, pooled mean differences (MD) and standardized mean differences (SMD) were calculated using random-effects inverse variance models. Results Twenty-one RCTs (n = 1244 participants) were included. Based on moderate quality evidence, MCE leads to greater pain (MD = -0.41 out of 10 points; 95% CI = -0.72 to -0.10; n = 626) and disability reductions (SMD = -0.28; 95% CI = -0.43 to -0.13; n = 713) when compared to strengthening exercises in the short term; these differences are not clinically important. When excluding trials on osteoarthritis (OA) participants and evaluating only the trials involving participants with rotator cuff-related shoulder pain, shoulder instability, hip-related groin pain or patellofemoral pain syndrome, there is moderate quality evidence that MCE leads to greater pain (MD = -0.74 out of 10 points; 95% CI = -1.22 to -0.26; n = 293) and disability reductions (SMD = -0.40; 95% CI = -0.61 to -0.19; n = 354) than strengthening exercises in the short term; these differences might be clinically important. Conclusions MCE leads to statistically greater pain and disability reductions when compared to strengthening exercises among adults with MSKDs in the short term, but these effects might be clinically important only in conditions that do not involve osteoarthritis. Inclusion of new trials might modify these conclusions. Impact These results suggest that MCE could be prioritized over strengthening exercises for adults with the included non-osteoarthritis MSKDs; however, results are unclear for OA disorders.

Motor Control Exercises Compared to Strengthening Exercises for Upper- and Lower-Extremity Musculoskeletal Disorders: A Systematic Review With Meta-Analyses of Randomized Controlled Trials.

The Biomechanical Disadvantage of Dysplastic Hips

Objective To compare 3-D hip kinematics during the single-leg squat and step-down in patients with hip-related groin pain to those in asymptomatic participants, and to assess relationships among hi...

Hip Kinematics During Single-Leg Tasks in People With and Without Hip-Related Groin Pain and the Association Among Kinematics, Hip Muscle Strength, and Bony Morphology.

Study design Pilot, multicentre randomised clinical trial (RCT). Objectives Assess viability of performing a definitive RCT and compare preliminary effects of movement pattern training (MoveTrain) and strengthening/flexibility (Standard) to improve function in people with chronic hip-related groin pain (HRGP). Background To determine the best physical therapist-led intervention for patients with HRGP, we must understand treatment effects of different treatment modes. Methods Forty-six patients (17M:29F; 29±5.3 years; body mass index 25.6±6.3 kg/m2) with HRGP were randomised. MoveTrain included task-specific training to optimise biomechanics during daily tasks. Standard included strengthening/flexibility. Treatment included 10 visits/12 weeks and home exercise programme (HEP). Primary outcomes for feasibility were recruitment, retention, treatment adherence and treatment fidelity. Secondary outcomes were patient-reported function (Hip disability and Osteoarthritis Outcome Score (HOOS)), lower extremity kinematics and hip muscle strength. Results We achieved target recruitment, and retention was excellent (91%). Patient session attendance was high (93%); however, reported HEP adherence (62%) was lower than expected. Physical therapists’ adherence to treatment protocols was high (90%). Patients demonstrated high treatment receipt; 91% of exercises performed were rated independent. Both groups demonstrated clinically important improvements in function (HOOS) and muscle strength; however, there were no between-group differences (HOOS subscales, p≥0.13, strength, p≥0.34). Compared with Standard, MoveTrain demonstrated greater reductions in hip adduction (p=0.016) and pelvic drop (p=0.026) during a single leg squat. No adverse events were noted. Conclusion Our experience in completing this RCT confirmed that a larger, multicentre RCT is feasible and highlighted modifications we will implement to optimise the future RCT. Trial registration number NCT02913222.

https://bmjopensem.bmj.com/content/bmjosem/6/1/e000707.full.pdf

Movement pattern training compared with standard strengthening and flexibility among patients with hip-related groin pain: Results of a pilot multicentre randomised clinical trial

Clinicians and patients face a dilemma in understanding how best to resume walking after a healed diabetic neuropathic ulcer. The objectives of this brief review are to: provide context for the patient's health and mobility status; propose 5 suggestions to safely and effectively progress mobility following a healed foot ulcer; and to consider topics for future research to improve care in this area. Rates of ulcer recurrence and mortality are high, and activity is low following a diabetic foot wound. Medical and rehabilitation approaches have emphasized protection of the insensitive, fragile foot with the hope to prevent subsequent harm to the foot and person. In particular, the 1-2 months following wound unloading and "healing" have the greatest risk for ulcer recurrence. While early protection should be emphasized, a growing body of evidence suggests that over-protection of the foot and limited walking can be harmful, presumably because of the negative effects of prolonged immobility and stress protection. Multiple recent studies report the ability of exercise and walking to have a positive effect on various diabetic foot outcomes without additional harm. Much less is known about how an ulcerated foot can resume walking after the wound is healed. This review integrates available guidelines, evidence, and precautions to suggest advice on how best to resume and progress walking in this population at high risk for ulcer recurrence.

https://onlinelibrary.wiley.com/doi/epdf/10.1002/dmrr.3259

Michael J. Mueller

Papers

Hip Kinematics During Single-Leg Tasks in People With and Without Hip-Related Groin Pain and the Association Among Kinematics, Hip Muscle Strength, and Bony Morphology.

Movement pattern training compared with standard strengthening and flexibility among patients with hip-related groin pain: Results of a pilot multicentre randomised clinical trial

Mobility advice to help prevent re-ulceration in diabetes.

Midfoot and ankle motion during heel rise and gait are related in people with diabetes and peripheral neuropathy.

Relationships within and between lower and upper extremity dysfunction in people with diabetes.