Artroscopia y reconstrucción articular

viernes, 31 de enero de 2014

Patellofemoral Update

  • Patellofemoral Update focuses on the causes, prevention and treatment of patellofemoral disorders. The blog is sponsored by The Patellofemoral Foundation whose mission is to improve the care of individuals with anterior knee pain through targeted education and research.
Wednesday, January 29, 2014

Variability in tibial tubercle to trochlear groove distance and measurements of malalignment

Patellofemoral Update
In the assessment of patellar instability, malalignment is an important factor to consider in determining the appropriate surgical treatment. Mechanical variations, such as excessive femoral anterversion, genu valgum or external tibial torsion, can increase the lateralization of the tibial tubercle and contribute to patellar instability. Identifying such factors can aid in determining the optimal surgical options for a patient, particularly with respect to tibial tubercle osteotomy. Realigning t...
Wednesday, January 8, 2014

Anteromedial tibial tubercle transfer is a powerful procedure to control patellofemoral pain, instability

Patellofemoral Update
Anteromedial tibial tubercle transfer, originally described in 1983, effectively moves the patella from tracking laterally and thus unloads the lateral patella while making the patellofemoral joint more congruous and stable. Additionally, because the tibial tubercle is also moved anteriorly, the distal pole of the patella is lifted up thereby unloading distally located patella articular lesions that may be a source of pain. Such lesions are fairly common in association with a lateral tracking, painful patella.
Monday, December 23, 2013

Is there any indication for trochleoplasty?

Patellofemoral Update
Trochleoplasty for patients with recurrent patellar instability has been debated the past few years. The procedure is becoming more common in Europe, while orthopedic surgeons in the United States have a more cautious approach, although a few surgeons are doing the procedure. One can ask if there is a need for trochleoplasties when there are other well-established procedures.
Many surgeons are excited about medial patellofemoral ligament (MPFL) reconstructions. Some studies with long-term follow-up seem to have good results; however, it is not a solution for all patients with patellar instabilities. We have to be aware of the underlying pathomorphology. In a recent meta analysis, Shah and colleagues found a complication rate of 26% after MPFL reconstruction. A major complication was postoperative instability with recurrent apprehension, which was 32% of all complications. Howells and colleagues found that 15 of 25 patients with persistent recurrent symptoms after reconstruction of the MPFL had moderate trochlear dysplasia. Patients with severe trochlear dysplasia already had been excluded.
Thursday, December 5, 2013

Catastrophic thinking is a new puzzle piece in understanding anterior knee pain

Patellofemoral Update
Anterior knee pain is one of the most common reasons to consult an orthopedic surgeon who specializes in the knee. Despite the high frequency of anterior knee pain, its etiopathogeny is not well known and myths about the condition are widespread. One myth is the patient with anterior knee pain as a patient with peculiar psychological traits responsible for the genesis of pain.
Many patients with anterior knee pain (AKP) have insubstantial clinical and radiologic findings. However, their pain and disability are important. If we add in the allodynia and hyperalgesia that many patients have, then we could be led to believe that the problem is psychological. This is not true. Patients with AKP have a high incidence of anxiety, depression, kinesophobia (the belief that movement will create additional injury or re-injury and pain) and catastrophizing (the belief that pain will get worse and one is helpless to deal with it). However, it is also true that these psychological disorders are the result of the pain severity but not the cause of the pain and disability.
Tuesday, November 19, 2013

Is anatomic femoral tunnel position important in medial patellofemoral ligament reconstruction?

Patellofemoral Update
Biomechanical studies have shown increased medial patellofemoral force and pressure with a malpositioned femoral tunnel. Clinical reports describe knee pain, medial patella overload, medial patella subluxation and knee stiffness in select cases with femoral tunnel malposition. However, larger clinical studies have not shown any correlation with tunnel position and clinical outcome at short-term follow-up.
Servien and colleagues had 10 of 29 femoral tunnels malpositioned on MRI but no difference in outcomes when comparing groups. McCarthy and colleagues evaluated postoperative radiographs in 60 patients and found 65% of femoral tunnels were malpositioned. However, there was no difference in clinical outcomes.
Monday, November 11, 2013

Lateral facetectomy can improve symptoms of patellofemoral osteoarthritis

Patellofemoral Update
Isolate patellofemoral osteoarthritis is a relatively common condition. In a radiographic study of patients older than 40 years who had painful knees, Davies and colleagues noted that the prevalence of patellofemoral osteoarthritis (PFO) was 9% (19 of 206 knees).
McAlindon and colleagues found the presence of isolated patellofemoral degeneration in 12% of men and 26% of women in patients with knee pain who were older than 55 years. In patients older than 55 years without knee pain, the prevalence was 5% in both men and women. They concluded from this study that PFO is common, associated with disability, occurs in the absence of tibiofemoral disease, and can no longer be omitted from future studies of the osteoarthritis of the knee joint.
Wednesday, October 16, 2013

Patellar alta: More precise measurements are needed for operative management

Patellofemoral Update
Patella alta has been a known associated factor of recurrent lateral patella dislocations for decades. The Lyon group recognized patella alta as and one of four main “objective” patella instability risk factors, and suggested distalization of the tibial tubercle as a surgical solution for the problem.
The biomechanical result of patella alta is decreased bony constraint secondary to the delayed entry of the patella into the trochlear groove, thus there is a greater arc of knee motion in early flexion in which the patella is potentially subjected to lateral forces leading to a patella dislocation. This delayed entry into the groove is magnified in the face of trochlear dysplasia when there is a shortened or shallower groove as well. This delayed entry also alters the patellofemoral contact area, which in conjunction with known forces at early flexion angles, results in an increase in patellofemoral (PF) stress. This increased stress could lead to pain and chondral wear.
With the historical backdrop of patellar infra contraction syndrome (PICS), many U.S. surgeons have been hesitant to treat patellar alta. Surgeons now realize that optimizing patellar height can be performed without causing patella infra. However, distalization of the tuberosity with poor surgical technique or wrong indications can lead to disastrous results.
Tuesday, October 1, 2013

Is there a role for medial-sided repair in patellar instability?

Patellofemoral Update
Historically, combinations of proximal and distal realignment procedures have been used to address patellar instability.
The proximal realignment procedures include medial retinacular repair, medial imbrication, VMO advancement, medial patellofemoral ligament (MPFL) repair or medial capsular reefing, with or without lateral retinacular release. Although several level 4 case series have shown satisfactory results with these proximal realignment procedures, there are at least four level 1 studies which have failed to show a difference between these medial-sided repairs and nonoperative treatment.
Wednesday, September 18, 2013

Arthroplasty vs. joint preservation in young adults

Patellofemoral Update
Treatment of full-thickness patellofemoral chondral lesions in young patients remains a challenge. The goal of restoring hyaline cartilage that possesses normal structural and mechanical properties has been particularly difficult to achieve in the patellofemoral joint. Treatment options include marrow stimulation techniques, osteochondral autograft or allograft transfer and various autologous chondrocyte implantation (ACI) techniques. Concomitant correction of anatomic abnormalities, such as tibiofemoral or patellofemoral malalignment, appears to improve the results of such restoration procedures.
Wednesday, September 4, 2013

Recognize the unique characteristics of the patellofemoral compartment

Patellofemoral Update
Unfortunately, the general treatment options for cartilage restoration in the United States have remained somewhat stagnant for more than 15 years. Fortunately, within this static group of specific cartilage treatments, orthopedic surgeons have expanded treatment options in the knee and other joints.
Initially, the technique was primarily used for femoral lesions. With relative success in those areas, surgeons gradually expanded the techniques to the patellofemoral (PF) compartment. While the compartment obviously has the same type of articular cartilage as the tibiofemoral (TF) compartments, certain factors are essential to optimize outcomes.
First and foremost, cartilage is aneural. Therefore, it must be appreciated that the cartilage lesion is secondarily contributing to the patient’s pain. The source of the pain must be exhaustively investigated. Cartilage treatment only should be contemplated after failure of thorough physical therapy (with up-to-date patellofemoral specific techniques) and adherence to the “envelope of function” principles by Scott Dye, MD.

Thursday, August 15, 2013

Develop functional approach to exercise for patients with patellofemoral pain

Patellofemoral Update
While many advocate a functional approach to exercise for patients with patellofemoral pain, isolated muscle weakness can lead to bad compensation patterns in weight-bearing exercise if the strength impairment is not addressed first. The eternal open chain vs. closed chain, isolated versus multi-joint exercise argument is derivative. Why set up an either-or unnecessary forced choice?
Wednesday, August 7, 2013

Arthroscopic patella realignment: Don’t forget minimally invasive stabilization

Patellofemoral Update
There has been great emphasis recently on invasive methods of medial patellofemoral ligament reconstruction for patella instability. Although these techniques can be effective and appropriate for severe cases of instability caused by medial patellofemoral ligament insufficiency, it is important to keep perspective on the appropriate indications for these techniques.
Medial patellofemoral ligament (MPFL) reconstruction with a graft is indicated when the native MPFL is incompetent, and the remaining native tissue is inadequate to be repaired or reefed primarily. However, in many cases of mild or moderate instability, a simple reefing of the MPFL is a highly successful procedure, whether done arthroscopically or by mini-open techniques, and is a much less invasive procedure.
Numerous studies have been published documenting the effectiveness of arthroscopic realignment for patella instability, with success rates of more than 90% and no or minimal complications. Although effective, MPFL reconstruction is an open invasive procedure fraught with potential complications including patella fracture, over-tightening, and non-isometric placement of the graft resulting in pain stiffness and medial tracking.
Wednesday, July 17, 2013

Distalization of the patella to correct patella alta in patients with patella instability

Patellofemoral Update
The review of the available literature by Robert A. Magnussen, MD, on this topic is timely as orthopedic surgeons are increasingly interested in the correction of patella alta to control patella instability. Distalization of the tibial tuberosity brings the patella into the deeper part of the trochlear groove sooner in knee flexion, thereby affording improved stability and diminished likelihood of dislocation. When the trochlea is shallow, distalization makes sense.
As pointed out by Magnussen et al, the question remains as to when other procedures such as medial tubercle transfer or reconstruction of the medial capsular structures, including the medial patellofemoral ligament (MPFL), might be warranted in addition to, or instead of, patella distalization. Many surgeons have achieved patella stability for years by assuring proper alignment/tracking of the patella in the trochlear groove and then restoring, by reconstruction, the medial support structures that support the patella as it slides along the trochlea with flexion and extension of the knee.
Tuesday, July 2, 2013

Avoid overtreatment of patellofemoral chondrosis/arthrosis in the athlete

Patellofemoral Update
Patellofemoral chondrosis/arthrosis is extremely common. It is often an incidental finding and has been reported in almost 50% of MRIs in asymptomatic players of the National Basketball Association.
The articular cartilage is aneural and most pain originates in the soft tissues. The treating orthopedic surgeon must be careful in attributing a patient’s anterior knee pain to the presence of a patellofemoral articular cartilage lesion. Often times, they are incidental findings and it is imperative to search for other causes. Most patellofemoral pain will go away if treated conservatively despite the presence of a significant articular cartilage lesion. Always look at the soft tissues closely as a source of pain.
Tuesday, June 18, 2013

Paper underlines importance of patient counseling in maintenance of ideal body weight

Patellofemoral Update
Anterior knee pain is one of the most common complaints in an orthopedist's office. Some patients have pain due to abnormalities of the patella tracking over the trochlea, but a significant number of patients have normal X-ray parameters indicating normal alignment and no clinical evidence of maltracking. Many of these patients are significantly, if not severely overweight presenting with a body mass index of 40 and higher. These patients likely overload the patellofemoral joint. It is important to understand that, while all lower extremity joints suffer from high body mass, the patellofemoral joint sees the highest loads (7 to 10 times body weight) with every step the patient takes.
Monday, June 3, 2013

Primum non nocere: MPFL reconstruction complications

Patellofemoral Update
This case series by Panikh and colleagues reviews the authors’ experience with complications after medial patellofemoral ligament reconstruction. I greatly appreciate their honestly and willingness to publish and emphasize complications related to this procedure. Much too often authors emphasize and readers remember only the success rates of surgical procedures.
The patient population included 179 patients with recurrent patellar instability. They determined by retrospective record review with more than 3-year follow-up that 16% of their patients developed complications including recurrent instability, stiffness, pain and patella fractures. Their medial patellofemoral ligament (MPFL) technique evolved somewhat away from more aggressive patellar tunnels (to avoid fracture), but for the sake of consistency it did not include lateral release in any patients. According to the Materials and Methods section, the preoperative evaluation included tibial tuberosity-trochlear groove (TTTG) analysis although those results were not reported. It would be interesting to know if the patients who had recurrent instability had increased TTTG measurements compared to the more successfully treated patients.
Thursday, May 16, 2013

Diagnosis and treatment of patellofemoral disorders must be individualized

Patellofemoral Update
After reading an article from Pagenstert and colleagues on lateral retinacular release vs. lengthening, I was compelled to respond with a letter to the editor. I was surprised and disappointed that an orthopedic surgeon would design a study using a 22-year-old technique that was said to assure an “adequate” release (the “90° turn-up” test), even cutting the vastus lateralis tendon if necessary to achieve this goal, and leave it unrepaired. Severing the vastus lateralis tendon is known to cause iatrogenic medial patellar subluxation and permanent disability in a high proportion of patients. Indeed, about one third of their release-only patients have this totally predictable fate.
Wednesday, May 1, 2013

Patellofemoral pain: Where does it originate and how to get rid of it

Patellofemoral Update
Pain in the front of the knee is usually called patellofemoral pain, but may originate in any of innervated structure around this part of the knee, or be referred from the hip or back. Anterior knee pain walking down stairs or running is a fairly common cause of time lost from sports and vigorous activity. Irritation of structures around the patella – retinaculum and synovium – from overuse or imbalances also can cause pain. Such anterior knee pain will usually get better with rest ...

miércoles, 29 de enero de 2014

El Hospital San Juan de Dios de Santurtzi organiza una Jornada de Evaluación Integral de la Gonalgia dirigida a médicos de familia

Blog de la Condroprotección has posted a new item:
 'El Hospital San Juan de Dios de Santurtzi organiza una Jornada de Evaluación Integral de la Gonalgia
dirigida a médicos de familia'

Durante la jornada celebrada el pasado 24 de enero se trataron aspectos ligados
al diagnóstico diferencial del dolor de rodilla, tratamientos conservadores y
quirúrgicos, y métodos de rehabilitación. Fue la primera jornada científica
de un ciclo de tres (rodilla, hombro y columna) que se impartirán en el “Aula
de San Juan de Dios” organizada por [...]

El Hospital San Juan de Dios de Santurtzi organiza una Jornada de Evaluación Integral de la Gonalgia dirigida a médicos de familia 

Durante la jornada celebrada el pasado 24 de enero se trataron aspectos ligados al diagnóstico diferencial del dolor de rodilla, tratamientos conservadores y quirúrgicos, y métodos de rehabilitación. Fue la primera jornada científica de un ciclo de tres (rodilla, hombro y columna) que se impartirán en el “Aula de San Juan de Dios” organizada por el hospital.
60 médicos de la Margen Izquierda y el Gran Bilbao asistieron a la jornada impartida por especialistas reumatólogos, traumatólogos y rehabilitadores del hospital de Santurtzi. La inauguración corrió a cargo del subdirector médico del centro, Ramón Izquierdo, al que siguió el reumatólogo Javier Aróstegui, que planteó los principios básicos de la exploración funcional ante un dolor de rodilla y cómo plantear su diagnóstico diferencial.
A continuación, el doctor Ander Álava, especialista en Medicina Física y Rehabilitación expuso el enfoque del tratamiento conservador, analizando las posibilidades que actualmente ofrecen la ortesis, la ergonomía articular y el tratamiento rehabilitador como elemento fundamental para mejorar la función.
Tras él intervinieron los traumatólogos Martín Montes, Aransáez, Elorriaga y González Iglesias, que hablaron sobre los aspectos básicos de la patología del menisco y las causas fundamentales que provocan inestabilidad en la rodilla, las condropatías y la utilización de los test genéticos.
jornada científica
Fotografía de Doctor Comunicación en Flickr
Entre estos el doctor Martín Montes destacó un test genético que ayuda a pronosticar la evolución de la artrosis de rodilla, a partir de una muestra de saliva. Señaló que según algunos estudios epidemiológicos, la artrosis de rodilla es hereditaria en un 40%.

Servicios en 'la nube' para la rehabilitación motriz de los miembros superiores del cuerpo

Servicios en 'la nube' para la rehabilitación motriz de los miembros superiores del cuerpo 

Esta herramienta, que está siendo utilizada desde 2011 con excelentes resultados en el centro hospitalario, permite la ejecución de ejercicios terapéuticos de forma interactiva, aumenta la motivación del individuo hacia su tratamiento y posibilita la medición objetiva y conocimiento del estado real del paciente y su avance.

La versión de Toyra en 'la nube' se ofrece en modo SaaS (Software as a Service) y está especialmente orientada a las necesidades y características de las clínicas y centros de rehabilitación que no tengan capacidad, tanto por volumen de pacientes como por costes de infraestructura tecnológica, para acceder a una versión instalada ad-hoc para ellos en sus servidores. El modelo de prestación del servicio de Toyra es totalmente flexible, en modalidad on-premise (el software está instalado en los servidores del cliente) o cloud, por lo que se establecerá el esquema de relación comercial que mejor se adapte a las necesidades del cliente y de sus pacientes.
Los centros y usuarios también tendrán a su disposición las actualizaciones del software de manera inmediata y sin coste adicional, ya que al tratarse de un despliegue en 'la nube' todos los clientes se benefician de las mejoras. Otro punto a destacar es la mejora de la trazabilidad y de la seguridad de la información de la compañía. Indra aporta los mecanismos necesarios para garantizar la seguridad de la red, la identidad del usuario y gestionar el acceso a los recursos de las aplicaciones. Además, este modelo de prestación de servicios permite la creación de una base de datos de referencia compartida y actualizada por los centros en cloud para, por ejemplo, contrastar si la evolución del paciente transcurre de acuerdo a lo esperado para su tipo de lesión.

Mayor motivación del paciente
Toyra se apoya en la captura de movimiento, bien a través de sensores inerciales o mediante el uso del dispositivo Kinect de Microsoft. Estos dispositivos de captura se conectan a la estación de terapia interactiva, que envía al sistema su localización y posición para recrear en la pantalla, a través de un avatar, los ejercicios que realiza el paciente. Con la información recibida y almacenada en un servidor central, Toyra evalúa, registra y analiza los resultados obtenidos por un paciente durante la sesión de terapia. El sistema consigue también aumentar la motivación gracias al uso de visión especular (imagen de espejo), recreación de movimientos en el mundo virtual y una dinámica lúdica de ejercicios.

Además, Toyra proporciona una plataforma electrónica de gestión de la historia terapéutica y de rehabilitación que permite el análisis de los resultados de la terapia de forma individualizada. Esa información ayuda a la realización de estudios y protocolos clínicos, e incluso podría ser integrada en la historia clínica electrónica del paciente.

En el caso de la prestación del servicio en modo cloud, el usuario accederá a través de una clave personalizada al sistema instalado en el equipo de terapia interactiva. Toda la información quedará almacenada en Flex-IT, la nube híbrida de Indra, y será accesible en todo momento para el profesional o incluso para el paciente. Por otro lado, la multinacional tecnológica suministrará las estaciones de terapia interactiva utilizando la modalidad más adecuada al uso que hará el cliente.

Hacia la deslocalización de los tratamientos
La adaptación a 'la nube' supone además un nuevo impulso a uno de los principales objetivos de Toyra, que es el de constituirse como base para la futura deslocalización de tratamientos que permita la telerehabilitación tras el alta. Es decir, para la continuación del tratamiento en el domicilio con un seguimiento remoto del clínico.

Indra y el Hospital Nacional de Parapléjicos, con la colaboración de la Fundación Rafael del Pino, ya han desarrollado una versión autónoma de Toyra orientada a aquellos pacientes que han logrado un cierto grado de autonomía y son capaces de ejecutar las terapias por sí mismos. Esta versión es de fácil manejo para el paciente y resulta más económica, ya que funciona con el dispositivo Kinect de Microsoft, y permite el seguimiento a distancia de la rehabilitación por parte de los profesionales, que dirigen y monitorizan todo el proceso de rehabilitación. Tanto Toyra Autónomo como Toyra Asistido (orientado a la fase inicial de rehabilitación en entornos hospitalarios) están disponibles en modo cloud.

Resultados contrastados 
El sistema de Realidad Objetiva y Terapia Audiovisula (TOYRA) es fruto de un proyecto de I+D iniciado en 2008 por Indra y la Unidad de Biomecánica y Ayudas Técnicas del Hospital Nacional de Parapléjicos, con el apoyo de la Fundación Rafael del Pino. En un principio, esta herramienta fue creada específicamente para personas con lesión medular con afectación de la movilidad de miembros superiores. Sin embargo, al tratarse de un proyecto en continua evolución, se vio la necesidad de dirigirlo a otros sectores de la población, creándose ejercicios específicos para personas que han sufrido un ictus y con cualquier dificultad de movimiento y lesiones traumáticas también en miembros superiores. Actualmente se está trabajando en su ampliación a pacientes con problemas en las extremidades inferiores, tronco y cuello.

Desde 2011, casi 50 pacientes, de entre 16 y 80 años, han comprobado las ventajas de este avanzado sistema de rehabilitación. En este contexto, se ha realizado un estudio piloto con diez pacientes con lesión medular cervical completa en el que se obtuvieron resultados positivos en aquellos que utilizaron Toyra como complemento a las terapias tradicionales en relación a la movilidad, funcionalidad y coordinación de movimientos precisos. Asimismo uno de los estudios que se han llevado a cabo sobre 20 usuarios para valorar su satisfacción general con Toyra arrojó un resultado de 90,5 puntos sobre 100.

A la vanguardia en servicios Cloud 
La versión de Toyra 'en la nube' forma parte del nuevo portfolio Saas de la multinacional de consultoría y tecnología, integrado en la actualidad por más de 35 soluciones que ofrecen una respuesta concreta a necesidades de negocio específicas con la idea de ir añadiendo nuevos productos de manera incremental.

Indra se encuentra a la vanguardia de los servicios y soluciones de Cloud Computing gracias a una oferta integral, denominada Indra InCloud, que cubre toda la cadena de valor de los servicios de Tecnologías de la Información: desde la consultoría, (para ayudar en la optimización de las capacidades y los costes de los clientes), hasta el desarrollo de nuevas soluciones pasando por la externalización de servicios de TI.

InCloud tiene entre sus principales objetivos el desarrollo de soluciones Software as a Service (SaaS) que ofrezcan una respuesta concreta a necesidades de negocio específicas. Indra pone así a disposición de sus clientes un amplio catálogo de soluciones end to end, diferencial y especializado por sectores (administraciones públicas, sanidad, energía, servicios financieros, industria…) que buscan aumentar la funcionalidad de su TI.

Esta oferta forma parte del nuevo modelo propio de Cloud Computing de Indra, denominado Flex-IT, para dar servicios bajo demanda a sus clientes. Flex-IT parte de la premisa que la gestión de las Tecnologías de la Información requiere una combinación de modelos tanto tradicionales como virtuales soportados en nubes privadas y/o públicas manteniendo una visión única mediante una gestión híbrida. Este modelo de entrega, más evolucionado respecto al tradicional, supone un cambio importante en la forma de ofrecer servicios de outsourcing, ya que hace posible el acceso en tiempo record, desde cualquier ubicación y pagando solamente por lo que se utiliza.

martes, 28 de enero de 2014

The shoulders of giants

Br J Sports Med 47:873 doi:10.1136/bjsports-2013-092852
  • Warm up

The shoulders of giants

  1. Johannes Zwerver2
+Author Affiliations
  1. 1Department of Sports Medicine, Aspetar, Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
  2. 2University of Groningen, University Medical Center Groningen, Center for Sports Medicine, Groningen, the Netherlands
  1. Correspondence toDr Adam Weir, Department of Sports Medicine, Aspetar, Qatar Orthopaedic and Sports Medicine Hospital, Doha 29222, Qatar;
  • Accepted 5 July 2013
As far back as 1159 John of Salisbury realised, and later Newton acknowledged that advances in science were made by building on previous knowledge. They likened themselves to dwarves who were only able to discover distant wonders because they sat on the shoulders of giants. Although we have moved on nearly an entire millennium since this phrase was coined, the principle still holds up. Kentucky, while famous for fried chicken, also has some more healthy exports to its credit. The Second Scapular Summit, held in Lexington, lead to this month's consensus paper ( which summarises the current state of affairs, allows us to elevate our knowledge and broadens our vision on this subject.
In his editorial, Dr Ben Kibler (, who is recognised as one of the giants in the field, glances back over his own shoulder and explains the origins of the article. Dr Babette Pluim reflects on the practical application of some of the recommendations made during the scapular summit in her editorial on page 875. There is also a podcast with Dr Kibler (
As we wing our way through this Dutch Association of Sports Medicine issue of the BJSM, we encounter a wealth of great publications. A thorough clinical examination, an art as old as medicine itself, remains the corner stone of diagnostics in sports medicine. The shoulder and hip are all areas commonly injured in athletes presenting for advice and treatment. This issue contains a series of articles that give insight and help us refine our evidence-based physical examination techniques (, Our honed examination skills will enable us to diagnose injuries in patients more accurately and hopefully lead to improved treatment.

Some exercises are more equal than others

We once again rub shoulders with the BMJ in our highlighted paper on the treatment of subacromial impingement syndrome. In many studies exercise programmes are not well reported or not specified for the condition being studied. Holmgren et al's study on page 908which includes a clear description of the physical tests used and of the programme followed, demonstrates that some exercises are more equal than others. The use of a scapula and cuff-specific programme gave significantly better outcomes than unspecific movement exercises for the neck and shoulder, and was successful in decreasing the need for surgery. We hope that future studies on exercise programmes as interventions will continue to include an accurate description of the intervention used. The PEDro for this month also covers the topic of exercise therapy for shoulder impingement syndrome and gives us a great summary of the literature on this subject (see page 927).

Falling this fall

As we approach the cooling down of this fall warm up we include a Dutch paper on falling. While falling itself could not be easier, landing is the hard part. This study examined whether school children could be taught to land more safely and with improved technique in order to prevent getting themselves injured. If you are curious about whether it worked check out the paper on page ( To finish off on a Dutch note we also have a podcast with Professor Ron Dierks from the University of Groningen on the latest sports medical news from Holland (


  • Competing interests None.
  • Provenance and peer review Not commissioned; internally peer reviewed.