Showing papers by "Nicola Maffulli published in 2002"

Time to abandon the “tendinitis” myth

Abstract: Tendinitis such as that of the Achilles, lateral elbow, and rotator cuff tendons is a common presentation to family practitioners and various medical specialists.1 Most currently practising general practitioners were taught, and many still believe, that patients who present with overuse tendinitis have a largely inflammatory condition and will benefit from anti-inflammatory medication. Unfortunately this dogma is deeply entrenched. Ten of 11 readily available sports medicine texts specifically recommend non-steroidal anti-inflammatory drugs for treating painful conditions like Achilles and patellar tendinitis despite the lack of a biological rationale or clinical evidence for this approach. 2 3 Instead of adhering to the myths above, physicians should acknowledge that painful overuse tendon conditions have a non-inflammatory pathology. Light …

Quantitative Review of Operative and Nonoperative Management of Achilles Tendon Ruptures

Abstract: Background: There is no consensus on the best method for management of acute Achilles tendon ruptures. Individual preferences, drawn from experience and study, determine whether treatment is operative or nonoperative.Purpose: Our goal was to review the literature to try to determine what management method was the most popular and effective. We wanted to ascertain the best results in terms of complication rates and patient outcomes.Study Design: Retrospective review of retrospectively and prospectively collected data.Methods: We analyzed 125 articles in peer-reviewed journals for year of publication, patient numbers, sex, management method, follow-up complications, and patient satisfaction. Each article was graded using a validated methods score. Methods, patient satisfaction, and complication rates were correlated with the year each article was published.Results: Skin-healing complications were lowest in conservatively managed patients (3 of 578, 0.5%) and highest in open repair and immobilized patients (...

Tendinopathy of tendo achillis.

Abstract: study, however, 31% of 58 patients with this condition did not participate in vigorous physical activity. 3 In this article, we have concentrated on tendinopathy of the main body of tendo Achillis. We have not dealt with Haglund's condition, insertional tendinopathy, or with lesions of the myotendinous junction. Anatomy. The gastrocnemius muscle merges with the soleus to form tendo Achillis. 4 It has a round upper part and is relatively flat in its distal 4 cm. Its fibres spiral through 90°, increasing the release of stored energy during locomotion. 5 Tendo Achillis is enveloped by a paratenon, originating from the deep fascia of the leg, the fascia cruris. Blood flow in the tendon increases considerably with exercise, probably due to the marked rise in the negative tissue pressure

Management of Achilles tendinopathy by ultrasound-guided percutaneous tenotomy.

Abstract: TESTA, V., G. CAPASSO, F. BENAZZO, and N. MAFFULLI. Management of Achilles tendinopathy by ultrasound-guided percutaneous tenotomy. Med. Sci. Sports Exerc., Vol. 34, No. 4, pp. 573–580, 2002.PurposeTo report the middle to long-term results of ultrasound-guided percutaneous longitudinal tenotomy of t

Tendon healing: can it be optimised?

Abstract: Growth factors may be useful in tendon healing, possibly introduced using gene therapy Tendon disorders are a major problem in sports and occupational medicine. Tendons have the highest tensile strength of all connective tissue because of a high proportion of collagen in the fibres and their closely packed parallel arrangement in the direction of force. The individual collagen fibrils are arranged into fascicles which contain blood vessels and nerve fibres. Specialised fibroblasts, tenocytes, lie within these fascicles and exhibit high structural organisation.1 Histologically, they appear as star shaped cells in cross sections. In longitudinal sections, they are arranged in rows following the direction of the tendon fibres. This specialised arrangement is related to their function, as tenocytes synthesise both fibrillar and non-fibrillar components of the extracellular matrix, and are able to reabsorb collagen fibrils.2 The fascicles themselves are enclosed by epitenon. This is surrounded by the paratenon, and the potential space between them is filled by a thin, lubricating film of fluid which allows gliding of the tendon during motion. Tendon healing is classically considered to occur through extrinsic and intrinsic healing. The intrinsic model produces obliteration of the tendon and its tendon sheath. Healing of the defect involves an exudative and a formative phase which, on the whole, are very similar to those associated with wound healing.3 Extrinsic healing occurs through the chemotaxis of the specialised fibroblasts into the defect from the ends of the tendon sheath.4 The process can be divided into three phases: inflammation, repair, and organisation or remodelling. In the inflammatory phase, occurring three to seven days after the injury, cells migrate from the extrinsic peritendinous tissue such as the tendon sheath, periosteum, subcutaneous tissue, and fascicles, as well as from the epitenon and endotenon.5 Initially, the extrinsic response far …

Long-term ultrasonographic features of the Achilles tendon after rupture.

Abstract: PURPOSE: To assess the long-term ultrasonographic appearance of rupture of the Achilles tendon. SUBJECTS AND METHODS: We examined 70 patients at an average of 63 months (range 10-120 months) after rupture of the Achilles tendon. We assessed the patient's contralateral tendon and also performed ultrasonography on the Achilles tendon of 70 age- and sex-matched controls. We recorded the maximum transverse anteroposterior diameter, the presence of intratendinous alterations, and the presence of intratendinous calcification. RESULTS: The average maximum anteroposterior diameter of the ruptured tendon was 11.7 mm (SD = 2.10). The patients' normal tendons measured an average of 5.4 mm (SD = 0.9), and there was an average measure of 4.9 mm (SD = 0.5) (p = 0.0001) in the controls. There was no difference in the maximum anteroposterior diameter of the ruptured tendon depending on the method of treatment (conservative, open repair, percutaneous repair). Seventeen patients exhibited areas of hypoechogenicity in their ruptured tendon, two patients had areas of hypoechogenicity in their unruptured contralateral tendon, and 10 patients had calcification in their ruptured tendon. CONCLUSION: The anteroposterior diameter of the ruptured tendon was significantly greater than the nonruptured contralateral. However, when compared with a group of individually age- and sex-matched controls, the patients' contralateral tendons had significantly greater maximum anteroposterior diameter and had a greater prevalence of intratendinous alterations. This difference may represent a background of subclinical tendinopathy that may predispose to rupture.

Ultrasound changes to intramuscular architecture of the quadriceps following intramedullary nailing.

Abstract: Background. Disuse atrophy is the basis for profound physiological changes of the muscles of immobilised limbs. The aim of this study was to use high resolution real-time ultrasonography (HRRTU) to assess the quadriceps musculature and to try and measure atrophy. Methods. We monitored the effects of enforced reduction of mobility due to trauma on the intramuscular architecture of the quadriceps using HRRTU in 13 skeletally mature male patients (43.2 years, range 16 to 82 years), with an isolated unilateral diaphyseal fracture of the femur or of the tibia. All patients had undergone interlocked intramedullary nailing (IIN). Using HRRTU, the pennation angles and muscle fibre lengths of vastus lateralis, the cross sectional area (CSA) of the rectus femoris, and the quadriceps muscle layer thickness (MLT) were measured in the injured and the normal contralateral limb. Results. Repeated measurements showed the technique of measurement of the variables used in this study to be highly reproducible. There was a significant difference in the angle of pennation of the vastus lateralis in the nailed (15.4°) and the unnailed limb (21.2°), documenting that muscle atrophy causes a change to muscle architecture that results in a significant decrease in pennation angle (p=0.0002). The muscle fibre length was significantly different (p=0.002) and there was a significant correlation between pennation angle and muscle fibre length (r=-0.51, p=0.001). There was also a significant difference in the quadriceps MLT (p=0.001) and CSA of the rectus femoris (p=0.0004) implying that the whole of the quadriceps muscle is affected. Conclusions. These simple, reproducible, non-invasive ultrasound measurements can easily demonstrate differences in the quadriceps morphology in the nailed and unnailed limb, which could allow individual exercise programme prescription.

Percutaneous repair of ruptured Achilles tendon

Abstract: Percutaneous repair of a ruptured Achilles tendon is a safe and reliable method of treating such injuries in patients with low sporting requirements. It has a lower incidence of wound complications compared with open techniques but a slightly higher incidence of re-rupture. Sural nerve injury is avoidable by careful placement of the incisions.

Adjusting Bone Mass for Differences in Projected Bone Area and Other Confounding Variables: An Allometric Perspective

Abstract: The traditional method of assessing bone mineral density (BMD; given by bone mineral content [BMC] divided by projected bone area [Ap], BMD = BMC/Ap) has come under strong criticism by various authors. Their criticism being that the projected bone "area" (Ap) will systematically underestimate the skeletal bone "volume" of taller subjects. To reduce the confounding effects of bone size, an alternative ratio has been proposed called bone mineral apparent density [BMAD = BMC/(Ap)3/2]. However, bone size is not the only confounding variable associated with BMC. Others include age, sex, body size, and maturation. To assess the dimensional relationship between BMC and projected bone area, independent of other confounding variables, we proposed and fitted a proportional allometric model to the BMC data of the L2-L4 vertebrae from a previously published study. The projected bone area exponents were greater than unity for both boys (1.43) and girls (1.02), but only the boy's fitted exponent was not different from that predicted by geometric similarity (1.5). Based on these exponents, it is not clear whether bone mass acquisition increases in proportion to the projected bone area (Ap) or an estimate of projected bone volume (Ap)3/2. However, by adopting the proposed methods, the analysis will automatically adjust BMC for differences in projected bone size and other confounding variables for the particular population being studied. Hence, the necessity to speculate as to the theoretical value of the exponent of Ap, although interesting, becomes redundant.

Patellofemoral Pain in Female Athletes

Abstract: SUMMARYPatellofemoral pain syndrome (PFPS) is the most common complaint in female athletes. There are clear structural, biomechanical, sociological, and hormonal differences between women and men that contribute to an increased incidence of PFPS in women. Unfortunately, the etiology of PFPS is still

Surgical release of de Quervain's stenosing tenosynovitis postpartum: can it wait?

Abstract: We compared the efficacy of conservative management of de Quervain's disease in 30 women postpartum (group 1) and 30 nonpregnant women (group 2). All patients underwent conservative management consisting of 2 weeks of splinting of the affected wrist, followed by physiotherapy and antiinflammatory drugs (NSAIDs). Clinical evaluation was performed using a functional score and the visual analogue scale (VAS) of Scott-Huskinson at entry to the study, 1 month later, and at a follow-up of 6 months. Conservative management gave good results in patients in group 1. At the 6-month follow-up a significant difference between the two groups on pain and function was evident. Only one patient in group 1 versus 25 patients in group 2 underwent surgery because of failure of conservative management.

Temporal trends in femoral curvature and length in medieval and modern Scotland.

Abstract: We measured how much the radius of the anterior curvature and the length of the femoral shaft of cadaveric bones have changed from medieval to recent times Around 20 (x, y) coordinates of a virtual coordinate system were measured at intervals of 15 cm along the shaft of the femur to calculate one single radius of a virtual circle in the (x, y) plane The median radii of curvature were 119, 141, and 158 cm for medieval, early, and late 20th century femora, respectively Early and late 20th century femora were of similar length (45 cm), but medieval femora were shorter (435 cm) Femora have become not only longer but also straighter since the Middle Ages These findings account in part for the increase in height of modern generations Size and shape changes may have significant implications for the biomechanical response of the femur to the forces to which it is subjected in everyday life, in trauma, and following surgical intervention

Exercise in Pregnancy: How Safe Is It?

Abstract: SUMMARY The role of exercise in pregnancy (EIP) is widely debated. Pregnancy produces marked changes of several physiologic variables of the mother. Regular EIP limits the increase in O2 requirement and produces an increase in the absolute anaerobic threshold, which persists for up to 36 weeks. Exercise in pregnancy reduces the incidence of muscle cramps, lower limb edema, fatigue, and shortness of breath. Increased knee cruciate ligament laxity does not normally produce any instability. Exercise in pregnancy reduces the increase in baseline maternal heart rate that occurs in pregnancy. Heart rate and stroke volume increase more markedly with exercise in pregnant women than in nonpregnant controls. Noradrenalin response to EIP is lower than in nonpregnant controls. Blood glucose levels decrease more promptly and to lower values with exercise in pregnant women than in nonpregnant controls. Glucose tolerance normally decreases in pregnancy, but increases during EIP. Regular EIP improves glucose tolerance in diabetic mothers and reduces total maternal weight gain and subcutaneous fat deposition toward the lower end of the normal range. Regular EIP produces higher plasma endorphin levels during labor and better pain tolerance than in sedentary controls. Women who undertake regular EIP have a lower incidence of 3rd- and 4th-degree vaginal tears. Children of exercising mothers have similar birth-weights as children of sedentary mothers, and mental performance at age 5 is higher. If there are no specific obstetric or medical contraindications, fit pregnant women can safely maintain the same level of fitness during pregnancy, although exercise schedules may have to be reduced.

Seasonal variation of slipped capital femoral epiphysis.

Abstract: During the 18-year period 1980-1997, 1103 patients were treated as in-patients for slipped capital femoral epiphysis (SCFE) in Scottish hospitals. This paper reports a significant seasonal variation, especially in male patients, with an excess admitted in the autumn. Examining the physiological seasonality of the monthly increment of growth in height and weight in childhood, we hypothesised that these physiological rhythms, while not pathogenetic, may be responsible for the timing of the seasonal features of SCFE. Previously published studies suggest that the average time between first symptoms and diagnosis is 3 to 5 months. The condition may start with the spring peak in growth and become more symptomatic with the autumn peak in weight. In conclusion, we report a new epidemiological finding, but, in accordance with other studies, we cannot provide a certain aetiological explanation. The timing, but not the pathogenesis, of admission to hospital for a SCFE might be related to the timing in the year of seasonal increments of height in spring and weight in autumn. It is tempting to draw attention to associations with environmental features. For example, in autumn there is the most rapid annual fall in temperature, and the hours of darkness are increasing from the autumn equinox to the winter solstice. However, there is no reason to conclude that these associations have anything to do with aetiology.

The treatment of open tibial fractures and of tibial non-union with a novel external fixator

Abstract: We report the results of external fixation in 29 patients treated for tibial fractures and tibial non-union using a novel multi axial external fixator (MAXX) followed prospectively until bony union. The results of treatment were classified according to the Association for the Study and Application of the Method of Ilizarov (ASAMI). Overall, 13 patients had excellent bone results; 13 had good bone results; two had fair bone results, and 1 patient had poor bone results. Regarding functional results, 21 patients had excellent results; 6 obtained good results; none had fair results, and two had poor results. Acute patients did better functionally than chronic patients. This fixator is safe and versatile, although the indications for its use are very specific.

Clinical and functional results of open operative repair for Achilles tendon rupture in a non-specialist surgical unit.

Abstract: We followed up 25 patients (average age 47.9 years, range 22 to 77) after open repair of their Achilles tendon rupture. All had been operated on by a single general surgeon using an end-to-end reabsorbable suture, and immobilised in a plaster of Paris cast for six weeks. All patients had been discharged from follow up by 18 weeks from the operation. At an average of 3.4 years (range six months to 9.25 years), 18 had "excellent", six (24%) "good" and one (4%) "satisfactory" results. All but one patient were able to walk on tiptoes, and 20 of the 22 patients examined directly walked without a limp. Ultrasonography showed the injured tendons to be on average 2.3 times thicker in the antero-posterior diameter and 1.7 times thicker in the transverse diameter. In the hands of a single non-specialist but fully trained general surgeon, this management regimen produced full return to pre-operative activities in the majority of patients, and a low rate of local complications. The macroscopic and ultrasonographic appearance of the operated tendon remained abnormal, but this was not associated with any overt clinical disturbance

Ruptured Achilles tendons show increased lectin stainability

Abstract: MAFFULLI, N, S W WATERSTON, and S W B EWEN Ruptured Achilles tendons show increased lectin stainability Med Sci Sports Exerc, Vol 34, No 7, pp 1057–1064, 2002PurposeTo ascertain whether lectins could be a useful tool for investigation of the extracellular matrix of degenerated and nor

A study of the mechanical stability of scoliosis constructs using variable numbers of sublaminar wires

Abstract: Sublaminar wiring with posterior instrumentation is one of the methods used when long fusions involving 10–12 thoracolumbar levels are required. Classically, wires are used at every consecutive level to make the construct as rigid as possible, although complications like dural tears, cerebrospinal fluid leak, and neurological deficit have been reported during their passage. We compared the mechanical stability under torsional strain of five specimens of each of three construct designs, by static and fatigue testing, using an electro-servo-hydraulic testing machine. In construct A, a contoured Hartshill rectangle was used from T2 to L2, with sublaminar wires passed at every level. In construct B, the Hartshill rectangle was wired to the spine at every alternate level. In construct C, every alternate level was wired except at the proximal end, where two consecutive levels were wired. Industrially fabricated spine models were used to prepare these constructs. The intervertebral motion within the construct was measured using the Fastrak magnetic field sensor device. On static testing, no statistically significant difference was found in the rotational displacement of the three construct designs. On fatigue testing, all samples of construct B consistently failed, with breakage of the wire at the most proximal level on the left side. But on adding additional wires to the next level (construct C), all five samples withstood fatigue testing at 300 N load to three million cycles. We conclude that wiring alternate levels instead of every level does not compromise the stability of the construct, provided that the most proximal two levels are consecutively wired. This practice would minimise the risk of dural tears and cord damage during wire passage and reduce surgical time, not to mention the economic benefits.

Isolated avulsion fracture of the coronoid process requiring open reduction in a paediatric patient: a case report.

Abstract: Coronoid process fractures are reported to occur from avulsion by the brachialis muscle or to be associated with elbow dislocations. We report a rare case of coronoid process fracture due to avulsion by the anterior bundle of the medial collateral ligament rendering the elbow unstable. In children, small fracture fragments of the coronoid process (types 1 & 2) are in reality often much larger but the actual size is not appreciated radiographically, as the coronoid process contains considerable amounts of cartilage. If the fragment is seen to be significantly displaced it may have resulted from avulsion by important structures such as the medial collateral ligament and open reduction is required to stabilise the elbow.

Endocrinologic Changes in Exercising Women

Abstract: Exercise produces hormonal changes. The more intensive and prolonged the exercise is, the more pronounced the changes are. In postpubertal female athletes, these changes are generally transient (for example, anovulation and menstrual cycle irregularity), with no long-term effects. In younger athletes, however, the hormonal changes produced by prolonged and strenuous exercise, particularly when competition is involved, require careful monitoring for their potential effects on the time of onset of puberty and the delay in menarche. Stress, anxiety, recurrent increase in body core temperature produced by strenuous physical activity, and an inadequate diet are among the most important factors that can enhance these hormonal alterations. We review the recent literature on hormonal changes in exercising women, focusing on the effects of exercise on gonadotrophins, sex steroid hormones, cortisol, prolactin, melatonin, growth hormone, endorphins, and parathyroid hormone.

Trauma and orthopaedic training in the United Kingdom.

Abstract: The United Kingdom has a free health-care system, the National Health Service, which was started in 1947 by Clement Attlee, the Prime Minister at the time. Many changes have occurred since then: the population has increased from around forty-six million to almost sixty million (according to government figures), and medicine has evolved dramatically so that many more conditions can now be prevented, diagnosed, investigated, and treated both medically and surgically. These developments have been paralleled by an increase in people’s expectations. As the population has increased, so has the number of doctors. Although the United Kingdom has increased its doctor-to-population ratio over the last ten years, the increase is less than that in mainland Europe and North America. Currently, there are 1453 consultant trauma and orthopaedic surgeons and 700 orthopaedic trainees in the United Kingdom. Following graduation from medical school, all doctors complete two six-month preregistration house jobs: one in surgery (occasionally within a broad surgical specialty, such as orthopaedics and trauma or cardiothoracic surgery) and one in medicine. These jobs are the broad equivalent of internships in the United States. The trainee will then apply for a basic surgical training rotation, which involves several six-month posts in different surgical specialties, such as general surgery, trauma and orthopaedic surgery, urology, cardiothoracic surgery, neurosurgery, etc. Most often, basic surgical training lasts between two and three years, during which time the trainee is expected to gain Membership in one of the Royal Colleges of Surgeons (MRCS). The MRCS examination, which has replaced the old fellowship examinations (FRCS), comprises multiple-choice questions, essays, oral examinations, and clinical examinations in aspects of surgery in general. Following successful completion of basic surgical training, the trainee can then apply for a specialist surgical training post. Specialist surgical training has become more structured over the past eight years. …

Movement analysis of scoliotic subjects using Fastrak.

Abstract: An attempt has been made to simplify the measurement of composite movement involving abnormal rotation in scoliosis, which is considered to have an important role in the diagnosis and treatment of the condition. Analysis of three-dimensional movement provides pertinent information concerning the morphological description of scoliotic deformities. The description of this movement is of clinical interest for aiding diagnosis and/or prognosis of spinal deformity evolution. Previous studies have indicated that idiopathic scoliosis is a three-dimensional deformity accompanied by a generalised torsion phenomenon and attempts have been made to associate the geometric torsion index with the curvi-linear shape of idiopathic scoliosis. Although previous investigations have documented the three-dimensional reconstruction of scoliotic spine, most methods either expose the subject to a high level of radiation, as in stereo-radiographs, or demand a high degree of technical input and time, as in video based gait analysis systems. This study employs an electro magnetic field capturing system (FASTRAK) to estimate the spinal movements. This simple system is inexpensive and highly portable. Furthermore, it can give instant graphic and numerical values of the composite movement. The results of this study indicate the usefulness this system in the diagnosis of scoliosis and highlights the possibility of its uses in screening school children and other surveys.

Achilles tendinopathy during pregnancy.

Abstract: Pregnancy can alter cell metabolism in the synovium, ligaments, and tendons. There are many reports of increased incidence of carpal tunnel syndrome and of De Quervain’s tenosynovitis, and of remission of rheumatoid arthritis during pregnancy. Also, there have been reports of transient greater ligamentous laxity even in reconstructed ligaments. However, a literature search has not revealed any information on resolution of ongoing tendinopathy during pregnancy.

Seasonal variation of slipped capital femoral epiphysis.

Abstract: During the 18-year period 1980-1997, 1103 patients were treated as in-patients for slipped capital femoral epiphysis (SCFE) in Scottish hospitals. This paper reports a significant seasonal variation, especially in male patients, with an excess admitted in the autumn. Examining the physiological seasonality of the monthly increment of growth in height and weight in childhood, we hypothesised that these physiological rhythms, while not pathogenetic, may be responsible for the timing of the seasonal features of SCFE. Previously published studies suggest that the average time between first symptoms and diagnosis is 3 to 5 months. The condition may start with the spring peak in growth and become more symptomatic with the autumn peak in weight. In conclusion, we report a new epidemiological finding, but, in accordance with other studies, we cannot provide a certain aetiological explanation. The timing, but not the pathogenesis, of admission to hospital for a SCFE might be related to the timing in the year of seasonal increments of height in spring and weight in autumn. It is tempting to draw attention to associations with environmental features. For example, in autumn there is the most rapid annual fall in temperature, and the hours of darkness are increasing from the autumn equinox to the winter solstice. However, there is no reason to conclude that these associations have anything to do with aetiology.