The value of provocative tests for the wrist and elbow: a literature review

Assessment of Balance During a Single-Limb Stance Task in Healthy Adults: A Cross-Sectional Study

Single-limb stance (SLS) is a demanding postural task, widely used for balance assessment in both research and clinical practice. Despite extensive data on elderly and clinical populations, less is known about younger and healthier adults. Our aim in this study was to assess balance during a SLS task among a cohort of healthy adults to determine whether there are age or sex group or testing condition differences in performances. In this cross-sectional study, we involved 120 participants aged 30-65 years and divided them into four age sub-groups with equal numbers of males and females in each. We assessed balance during a 45-s SLS task on a] the Delos Postural Proprioceptive System for both lower limbs in two conditions - open eyes (OE) and closed eyes (CE). We calculated stability (SI) and autonomy (AU) indices and used analysis of variance to determine that there was no significant effect of limb dominance or sex on balance parameters. However, there was a significant interaction effect between age group and testing condition for both SI and AU (p < .001 for both), with balance worsening as age increased only in the CE condition. These results highlight a pattern of balance decline with age when vision is eliminated from balance performance, underscoring the critical relationship between sensory input and postural control as people age.

Scapholunate Ligament Injuries

Injuries to the scapholunate interosseous ligament (SLIL) complex can result in a predictable cascade of incongruous motion in the carpus that leads to radiocarpal degeneration. Both acute traumatic impact and repetitive motion can render the SLIL insufficient. A thorough understanding of SLIL anatomy is required for appropriate diagnosis and treatment. Here, we review scapholunate ligament anatomy, prevention strategies, methods of diagnosis, nonoperative and operative treatments, and outcomes. A myriad of treatment options exist for each stage of the SLIL injury, and management should be an open discussion between the patient and physician.

Effectiveness of Active Release Technique With Conventional Therapy in the Management of Lateral Epicondylitis: A Case Report

The condition known as tendonitis, tennis elbow, lateral epicondylalgia, or lateral epicondylitis affects the radiohumeral joint and causes persistent, severe discomfort in the elbow. It commonly affects those who work in professions that need repetitive forearm motions, like athletes who play on courts, computer operators, and woodworkers. It tends to originate from additional rapid, tiresome, recurring eccentric contractions and activities that grab gliding joints. It commonly affects the dominant hand. This case report describes the author's seven years of experience living with lateral epicondylitis, including functional disability in day-to-day life, and then physiotherapy management was started. Mill's and Cozen's tests were performed, and lateral epicondylitis was confirmed. From 2023, the physiotherapy session, including active release technique and conventional therapy, was taken regularly for four weeks. The outcome measure score of the Visual Analog Scale (VAS) was 7/10 pre-treatment and 2/10 post-treatment, and for the Patient-Rated Tennis Elbow Evaluation (PRTEE) scale, it was 50/100 pre-treatment and 25/100 post-treatment. The results that are reported from this particular case study suggest that physiotherapy has a significant effect in improving muscle strength, increasing range of motion, improving activities of daily living, and enhancing the overall quality of life. The study concludes a physiotherapist is crucial in treating these overuse injuries and returning the patient to their daily activities.

The "Selfie Test": A Novel Test for the Diagnosis of Lateral Epicondylitis

Background: Lateral epicondylitis (LE) is one of the most diagnosed elbow pathologies. The purpose of this study was to determine the diagnostic test accuracy of a new test (selfie test) for the diagnosis of LE. Methods: Medical data were collected from adult patients who presented with LE symptoms and ultrasound findings that supported the diagnosis. Patients underwent a physical examination, including provocative tests for diagnosis as well as the selfie test, and were asked to fill out the Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaire and subjectively rate the activity of their affected elbow. Results: Thirty patients were included in this study (seventeen females, 57%). The mean age was 50.1 years old (range of 35 to 68 years). The average duration of symptoms was 7 ± 3.1 months (range of 2 to 14 months). The mean PRTEE score was 61.5 ± 16.1 (range of 35 to 98), and the mean subjective elbow score was 63 ± 14.2 (range of 30 to 80). Mill's, Maudsley's, Cozen's, and the selfie tests had sensitivities of 0.867, 0.833, 0.967, and 0.933, respectively, with corresponding positive predictive values of 0.867, 0.833, 0.967, and 0.933. Conclusions: The selfie test's active nature, which allows patients to perform the assessment themselves, could be a valuable addition to the diagnostic process, potentially improving the accuracy of the diagnosis of LE (levels of evidence: IV).

Differences in Clinical Tests for Assessing Lateral Epicondylitis Elbow in Adults Concerning Their Physical Activity Level: Test Reliability, Accuracy of Ultrasound Imaging, and Relationship with Energy Expenditure

BACKGROUND

Physical activity (PA) can generate physical stress on the musculoskeletal system. Thus, the aim of the current study was to assess the influence of the level of physical activity on clinical tests used in the diagnosis of lateral epicondylitis in adults, intertest reliability and accuracy based on ultrasound imaging, and relationship with energy expenditure.

METHODS

102 adults with lateral epicondylitis were assessed via an International Physical Activity Questionnaire and divided according to PA level: low (n = 19) moderate (n = 42) or high (n = 41). Pain (visual analog scale), Cozen's and Mill's clinical tests and ultrasound exams were performed.

RESULTS

The Cozen's and Mill's tests differed among PA levels. Excellent reliability was found for Mill's test for PA levels and the ultrasound exam (low ICC = 1.0, moderate ICC = 0.82 and high ICC = 0.99). Good reliability was found for Cozen's test (low ICC = 0.80, moderate ICC = 0.74 and high ICC = 0.73), but with significant differences between the ultrasound exams. The Cozen's and Mill's clinical tests had no relationship to the level of energy expenditure for PA levels.

CONCLUSION

Mill's test was reliable and accurate for the PA levels. Intertest reliability was poor for the PA levels. Mill's test proved to be accurate based on the ultrasound exam. The pain caused by the tests was not related to the level of energy expenditure.

Effect of dog-related parameters on the flexion test outcome: A large cohort retrospective study on physiological and orthopedic pathological-related factors

Objectives

This retrospective study evaluates the dog-related factors of variation influencing the outcome of the flexion test (FT), when performed to localize pain to a joint area, on a large group of canine orthopedic patients.

Materials and methods

The selection criteria for this retrospective study were dogs undergoing a FT in a referral orthopedic clinic between 2009 and 2020 with a complete medical record. The canine FT, described in a previously published protocol, was performed on dogs presented with an orthopedic problem. In summary, a dog's joint, identified as suspected of an orthopedic problem according to the clinical examination, was flexed for 1 min before walking 15 m on a hard and even surface. The FT was considered positive if the lameness increased after the application of the FT and negative when it remained unchanged. Statistical analysis was performed to determine which of the following criteria could influence the outcome of the flexion test: age, gender, neutered status, weight category, tested joint and initial lameness score.

Results

Over 1,161 patients' files were collected and analyzed for this research. The FT showed 82.8% (95%IC: 80.5-84.9) of true positives and 17.2% of false negatives. None of the patient's intrinsic characteristics influenced the outcome of the test (age, gender, neutered status, and weight category). The orthopedic parameters, such as the initial lameness score and the tested joint, showed to have a statistically significant influence on the outcome of the test.

Clinical relevance

The FT is an easy-to-perform technique presenting reliable results on most joints. This test presents an interest when performed in addition to a complete orthopedic examination to localize pain to a joint area. Only the orthopedic pathological-related parameters such as the lameness score and the tested joint seem to influence the outcome of the FT. The FT is not influenced by the physiological-related characteristic of the patient (age, weight category, sex, and neutered status).

Lateral Elbow Pain and Muscle Function Impairments

Although often described as a self-limiting condition and likely to resolve on its own, high recurrence rates and extended sick leave frame a need for effective non-surgical treatment for people with lateral elbow tendinopathy. The interrelationship of histological and structural changes to the tendon, the associated impairments in motor control, and potential changes in pain processing may all drive symptoms. This clinical practice guideline covers the epidemiology, functional anatomy and pathophysiology, risk factors, clinical course, prognosis, differential diagnosis, tests and measures, and interventions for managing lateral elbow tendinopathy in the physical therapy clinic. J Orthop Sports Phys Ther 2022;52(12):CPG1-CPG111. doi:10.2519/jospt.2022.0302.

Wrist weight-bearing tolerance in healthy adults

STUDY DESIGN

Cross-sectional.

INTRODUCTION

No information is available in the literature regarding the amount of weight-bearing tolerance in a normal human wrist.

PURPOSE OF THE STUDY

To establish the normal limits of human wrist weight-bearing tolerance and to determine if gender, age and height are predictors of this weight-bearing tolerance.

METHODS

A sample (N = 465) of healthy adults ages 18-64 completed a questionnaire indicating their gender, age range and height. Subjects were instructed in performing a wrist weight-bearing tolerance test using a calibrated analog scale. The amount of pressure that the subject was able to apply to the scale in 3 independent trials was recorded and analyzed.

RESULTS

A strong positive correlation was found between average weight- bearing values achieved through the right and left hands for the subjects of this study, r(463)= .97, P < .001. A 2-way analysis of covariance revealed main effects for both gender (20.9, 95% CI [15.7, 26.0] pounds, P < .001) and age (F(4, 454) = 6.143, P < .001, partial η² = .051). The highest weight-bearing tolerance was observed in males and individuals 25-34 years of age. Multiple regression analysis affirmed that gender, height and age categories of 45-54 and 55 to 64 were all statistically significant predictors of wrist weight-bearing tolerance, P < .01.

DISCUSSION

These results establish normal wrist weight-bearing tolerance values and demonstrate that gender, age and height are predictors of this weight-bearing tolerance.

CONCLUSION

These results could allow identification of pathologies associated with wrist instability.

Diagnostic accuracy of history taking, physical examination and imaging for non-chronic finger, hand and wrist ligament and tendon injuries: a systematic review update

OBJECTIVE

The diagnostic work-up for ligament and tendon injuries of the finger, hand and wrist consists of history taking, physical examination and imaging if needed, but the supporting evidence is limited. The main purpose of this study was to systematically update the literature for studies on the diagnostic accuracy of tests for detecting non-chronic ligament and tendon injuries of the finger, hand and wrist.

METHODS

Medline, Embase, Cochrane Library, Web of Science, Google Scholar ProQuest and Cinahl were searched from 2000 up to 6 February 2019 for identifying studies. Methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 checklist, and sensitivity (Se), specificity (Sp), accuracy, positive predictive value (PPV) and negative predictive value (NPV) were extracted.

RESULTS

None of the studies involved history taking. Physical examination, for diagnosing lesions of the triangular fibrocartilage complex (TFCC), showed Se, Sp, accuracy, PPV and NPV ranging from 58% to 90%, 20% to 69%, 56% to 73%, 53% to 71% and 55% to 65%, respectively. Physical examination in hand and finger injuries the Se, Sp, accuracy, PPV and NPV ranged from 88% to 99%, 75% to 100%, 34% to 88%, 91% to 100% and 75% to 95%, respectively. The accuracy of MRI with high-resolution (3 T) techniques for TFCC and interosseous ligaments of the proximal carpal row ranged from 89% to 91% and 75% to 100%, respectively. The accuracy of MRI with low-resolution (1.5 T) techniques for TFCC and interosseous ligaments of the proximal carpal row ranged from 81% to 100% and 67% to 95%, respectively.

CONCLUSIONS

There is limited evidence on the diagnostic accuracy of history taking and physical examination for non-chronic finger, hand and wrist ligament and tendon injuries. Although some imaging modalities seemed to be acceptable for the diagnosis of ligament and tendon injuries in the wrist in patients presenting to secondary care, there is no evidence-based advise possible for the diagnosis of non-chronic finger, hand or wrist ligament and tendon injuries in primary care.

Upper limb neurodynamic test 1 in patients with clinical diagnosis of carpal tunnel syndrome: A diagnostic accuracy study

STUDY DESIGN

Diagnostic accuracy.

INTRODUCTION

Upper limb neurodynamic test 1 (ULNT1) is used to evaluate the mechanical sensitivity especially in the peripheral nerves of the upper limbs. The reproduction of typical symptoms in the affected hand improves the estimation of the probability of carpal tunnel syndrome (CTS). However the test has not been evaluated sufficiently to determine its real usefulness. In the present study the diagnostic accuracy of ULNT1 as a clinical test for CTS was determined.

METHODS

We used the ULNT1 as the index test and nerve conduction as the reference standard. 120 subjects, (240 hands), with a medical diagnosis of CTS were evaluated. The study population was a consecutive series of participants. Sensitivity, specificity, positive and negative predictive values, accuracy, and positive likelihood ratio were calculated.

RESULTS

ULNT1 was found to have a sensitivity of 93 % and a specificity of 6.67 %. The positive likelihood ratio was 1.04 and the negative likelihood ratio was 1.00. The positive predictive value was 86.9 % and the negative predictive value was 12.5%.

DISCUSSION

Acute or relatively mild CTS cases may not be accurately identified through nerve conduction tests. The findings of this study coincide with other studies in the finding that ULNT1 has a significant diagnostic and clinical screening value for CTS in people at-risk, or with upper limb symptoms.

CONCLUSION(S)

This research suggests the use of ULNT1 as a screening test for CTS, followed by tests that are more specific.

LEVEL OF EVIDENCE

III-2.

Cumulative incidence of carpal instability 12-24 months after fall onto outstretched hand

STUDY DESIGN

Descriptive Epidemiological Study.

INTRODUCTION

Ligament tears between carpal bones are easily missed on initial presentation, but can have potentially debilitating effects on the patient if they progress to an instability. They are usually the result of a fall onto an outstretched hand with the wrist in hyperextension. Current incidence of carpal instability after these falls is unknown.

PURPOSE OF THE STUDY

Using established clinical and radiological measures, we sought to establish the cumulative incidence of carpal instability in people who have fallen onto an outstretched hand in the second year after injury. We also sought to describe its relationship with functional impairment.

METHODS

We used emergency department records of an inner-urban tertiary hospital to contact all patients who presented with wrist pain following fall onto outstretched hand who were between one and two years after injury. Carpal instability was defined by blinded radiological evaluations and provocative clinical tests, including Scaphoid Shift (Watson's) test, Ballottement, and mid-carpal shift test. Wrist-related pain and disability was measured using the Patient-Rated Wrist and Hand Evaluation.

RESULTS

Of the 279 potentially eligible cases, only 146 were contactable, and fifty (28 male, 22 female; mean age of 48 years) attended for assessment. We found a cumulative incidence of 44% of carpal instability within the second year after injury. Of these, 12 (24%) cases had scapho-lunate instability, 12 (24%) had luno-triquetral instability and 7 (14%) had mid-carpal instability. There were no significant correlations between clinically confirmed carpal instability and pain, function, or work participation.

DISCUSSION AND CONCLUSION

This study found a higher than anticipated cumulative incidence of carpal instability in the second year after injury, which may reflect volunteer bias. Patients should be advised to monitor symptoms in the year after injury and seek a review if symptoms of pain, clicking or clunking arise.

LEVEL OF EVIDENCE

II.

Prognostic value of clinical and radiological findings for conservative treatment of idiopathic ulnar impaction syndrome

Ulnar impaction syndrome (UIS) is a common source of ulnar-sided wrist pain, yet not all cases of radiographic ulnar impaction are symptomatic. We retrospectively analyze clinical or radiologic factors that affect prognoses of conservative treatment for idiopathic UIS. A total of 114 patients who had been diagnosed with UIS were treated with 6 weeks of short arm orthosis followed by formal physiotherapy for 6 weeks, with lifestyle modification to limit aggravating movements. The response to treatment, including pain numeric rating scale on an ulnar provocation test, grip strength, Disability of the Arm, Shoulder, and Hand score (DASH), was assessed at 24-week follow-up. For the 24-week follow-up, 29 patients (25%) underwent ulnar shortening osteotomy due to persistent symptoms after conservative treatment, and 18 (16%) patients had pain scores of greater than 5, but they had not undergone surgery. After controlling for confounding variables, female gender (odds ratio (OR) 1.39), duration of symptom (OR 1.27), high pain NRS score on provocation test (OR 1.45), and enhanced carpal or distal ulna bone on MRI (OR 1.82) were associated with a higher likelihood of treatment failure. Knowledge of the factors offers physicians insight into predicting prognoses and helps patients set realistic expectations.

Assessment of dexterity and diagnostic accuracy of the Functional Dexterity Test in patients with carpal tunnel syndrome

BACKGROUND

The diagnosis of carpal tunnel syndrome (STC) is centered on the symptoms. However, patients also show an impairment of sensorimotor functions, but the relationship between STC and manual dexterity has never been investigated.

OBJECTIVES

To analyze the correlation between manual dexterity and severity of the STC. Another objective was the diagnostic accuracy of the clinical battery including provocative tests (Phalen, Tinel) and Functional Dexterity Test (FDT).

METHODS

A sample of 80 subjects with suspected STC was subdivided into 4 groups based on EMG (severe/extreme-GrA, moderate-GrB, mild/minimal-GrC, negative-GrD) and evaluated in blind by Phalen, Tinel and FDT. The relationship between the FDT and the allocation of subjects was investigated by Spearman's rho, while the groups were compared with univariate ANOVA and Tukey's post hoc analysis. Diagnostic accuracy of the clinical battery was expressed by sensitivity, specificity, and likelihood ratios (LR).

RESULTS

A moderate (r=0.48, p minor of 0.001) correlation was found between FDT and the 4 groups. ANOVA has returned a significant difference between GrA vs. all others and between GrB vs. GrD. The battery showed a sensitivity, specificity, positive likelihood ratio (LR+) and negative likelihood ratio (LR-) of 70%, 94%, 11.98 and 0.31 respectively.

CONCLUSIONS

The results of this study supported the hypothesis that STC patients also have a dexterity impairment. The FDT was able to discriminate between three levels of severity (negative, mild to moderate, severe to extreme), maintaining a good level of diagnostic accuracy in addition to provocative tests.

It's time to change perspective! New diagnostic tools for lateral elbow pain

PURPOSE

The presence of intra-articular findings that may complement the extra-articular pathology in lateral epicondilytis has been suggested, and a role for minor instability of the elbow as part of the causative process of this disease has been postulated. This study was designed to describe two new clinical tests, aimed at detecting intra-articular pathology in patients affected by recalcitrant lateral epicondylitis and investigate their diagnostic performance.

METHODS

Ten patients suffering of atraumatic lateral elbow pain unresponsive to conservative treatment were considered in this study. Two clinical tests were developed and administrated prior to arthroscopy: Supination and Antero-Lateral pain Test (SALT); Posterior Elbow Pain by Palpation-Extension of the Radiocapitellar joint (PEPPER). Sensitivity, specificity, predictive values and accuracy of SALT and PEPPER as diagnostic tests for seven intra-articular findings were calculated.

RESULTS

In 90% of the patients, at least one test was positive. All patients with signs of lateral ligamentous patholaxity or intra-articular abnormal findings had a positive response to at least one of the two tests. SALT proved to have a high sensitivity but a low specificity and is accurate in detecting the presence of intra-articular abnormal findings, especially synovitis. PEPPER test was sensible, specific and accurate in the detection of radial head chondropathy.

CONCLUSIONS

Two new diagnostic tests (SALT and PEPPER) were specifically designed to evoke pain from intra-articular structures. These tests could be a valid support in the diagnostic algorithm of recalcitrant lateral elbow pain. Positive findings may be indicative of a minor instability of the lateral elbow condition.

LEVEL OF EVIDENCE

Diagnostic study, development of diagnostic criteria on basis of consecutive patients, level II.

Peripheral Nerve Nanoimaging: Monitoring Treatment and Regeneration

Accidental and iatrogenic trauma are major causes of peripheral nerve injury. Healing after nerve injury is complex and often incomplete, which can lead to acute or chronic pain and functional impairment. Current assessment methods for nerve regeneration lack sensitivity and objectivity. There is a need for reliable and reproducible, noninvasive strategies with adequate spatial and temporal resolution for longitudinal evaluation of degeneration or regeneration after injury/treatment. Methods for noninvasive monitoring of the efficacy and effectiveness of neurotherapeutics in nerve regeneration or of neuropathic pain are needed to ensure adequacy and responsiveness to management, especially given the large variability in the patient populations, etiologies, and complexity of nerve injuries. Surrogate biomarkers are needed with positive predictive correlation for the dynamics and kinetics of neuroregeneration. They can provide direct real-time insight into the efficacy and mechanisms of individualized therapeutic intervention. Here, we review the state-of-the-art tools, technologies, and therapies in peripheral nerve injury and regeneration as well as provide perspectives for the future. We present compelling evidence that advancements in nanomedicine and innovation in nanotechnology such as nanotheranostics hold groundbreaking potential as paradigm shifts in noninvasive peripheral nerve imaging and drug delivery. Nanotechnology, which revolutionized molecular imaging in cancer and inflammatory disease, can be used to delineate dynamic molecular imaging signatures of neuroinflammation and neuroregeneration while simultaneously monitoring cellular or tissue response to drug therapy. We believe that current clinical successes of nanotechnology can and should be adopted and adapted to the science of peripheral nerve injury and regeneration.

Proprioception retraining for a patient with chronic wrist pain secondary to ligament injury with no structural instability

STUDY DESIGN

Case report.

INTRODUCTION

Previously published studies demonstrate the importance of the sensory innervation of the carpal ligaments and the implication for the sensorimotor control of the wrist. In addition, this case considers key rehabilitation concepts to include the dart-throwing motion and the stabilizing effect of the forearm muscles.

PURPOSE OF THE STUDY

To describe the rehabilitation program for a patient with chronic wrist pain, diagnosed with a partial tear of the dorsal intercarpal ligament and a sprain of the scapholunate ligament of the right wrist.

METHODS

The patient participated in a staged treatment plan over a 3-month period (20 sessions), which began with a focus on proprioceptive awareness and joint position sense retraining. The treatment progressed to strengthening of specific muscles to enhance stability of the wrist joint. The patient completed the Quick Disabilities of the Arm, Shoulder and Hand and the patient-rated wrist evaluation on initial evaluation, re-evaluation at ninth session, and discharge at 20th session.

RESULTS

Raw scores in the Quick Disabilities of the Arm, Shoulder and Hand and the patient-rated wrist evaluation improved from 33 and 61.5 on initial evaluation to 18 and 17.5 on discharge, respectively.

CONCLUSIONS

Sensorimotor techniques including proprioceptive retraining may improve pain, neuromuscular control, and functional outcomes in patients with chronic wrist pain due to ligament injury. The effectiveness of proprioceptive retraining needs to be evaluated in a well-designed randomized controlled trial recruiting this patient population.

LEVEL OF EVIDENCE

5.

Clinical manual assessment of the wrist

Although hand therapists often evaluate patients with wrist pain, novice and experienced clinicians alike would benefit from a systematic assessment to efficiently identify the source of dysfunction and initiate an appropriate treatment plan. This article proposes a systematic approach for clinical evaluation of the wrist by describing the basic clinical examination (BCE) process and interpreting the findings in terms of common pathology. The BCE will enable the hand therapist to identify conditions that are contraindicated for conservative care and require further physician intervention, determine a working diagnosis for most musculoskeletal problems, and determine the appropriate extra tests to confirm the working diagnosis and/or rule out differential diagnoses. By combining findings from the patient's history, BCE, and special testing, hand therapists can efficiently determine the underlying pathology and provide appropriate treatment that can optimize clinical outcomes.

Physical examination of the elbow, what is the evidence? A systematic literature review

OBJECTIVE

Primary to provide an overview of diagnostic accuracy for clinical tests for common elbow (sport) injuries, secondary accompanied by reproducible instructions to perform these tests.

DESIGN

A systematic literature review according to the PRISMA statement.

DATA SOURCES

A comprehensive literature search was performed in MEDLINE via PubMed and EMBASE.

ELIGIBILITY CRITERIA

We included studies reporting diagnostic accuracy and a description on the performance for elbow tests, targeting the following conditions: distal biceps rupture, triceps rupture, posteromedial impingement, medial collateral ligament (MCL) insufficiency, posterolateral rotatory instability (PLRI), lateral epicondylitis and medial epicondylitis. After identifying the articles, the methodological quality was assessed using the QUADAS-2 checklist.

RESULTS

Our primary literature search yielded 1144 hits. After assessment 10 articles were included: six for distal biceps rupture, one for MCL insufficiency, two for PLRI and one for lateral epicondylitis. No articles were selected for triceps rupture, posteromedial impingement and medial epicondylitis. Quality assessment showed high or unclear risk of bias in nine studies. We described 24 test procedures of which 14 tests contained data on diagnostic accuracy.

CONCLUSIONS

Numerous clinical tests for the elbow were described in literature, seldom accompanied with data on diagnostic accuracy. None of the described tests can provide adequate certainty to rule in or rule out a disease based on sufficient diagnostic accuracy.

Comparison of Wrist Motion and Grip Strength in a Normal Chinese and Caucasian Population

BACKGROUND

Anatomical and functional differences between Asian and Caucasian populations have been described and are important in treatment of wrist pathology. The purpose of this study was to establish and compare normal values in an Asian and Caucasian population. We hypothesized that a normal Asian population will have greater wrist ROM and reduced grip- strength when compared to a normal Caucasian population.

METHODS

One hundred and-seventy-one normal Asian and 156 normal Caucasian wrists were evaluated. We excluded wrists with current or a history of wrist pathology including past surgery, injury or congenital malformation. We collected demographic information regarding occupation, body mass index (BMI), and previous wrist pathology. The wrist measurements included: wrist extension, flexion, radial, ulnar deviation, and grip strength. Wrists were also evaluated for a mid-carpal clunk, and scaphoid shift test. Mixed models accounted for evaluation of both hands in the same individual and for the relative contribution of different factors to the outcome measures of ROM and grip- strength.

RESULTS

The two groups differed in height, BMI and the distribution of occupation. The Asian group had more flexion, less extension and similar radial/ulnar wrist deviation when compared to the Caucasian group. Ethnicity was a significant predictor of wrist joint flexion and extension significantly predicting grip- strength. Age was associated with ROM while occupation, hand side and gender were not significant factors in the mixed model.

CONCLUSIONS

We found discrete differences between values in the two populations. More study of anatomical morphological patterns may explain the reason for variations in motion and grip- strength. The differences identified in this study between Asian and Caucasian populations should be taken into account when evaluating outcomes of wrist therapeutic procedures and rehabilitation in different communities.

Electroacupuncture and splinting versus splinting alone to treat carpal tunnel syndrome: a randomized controlled trial

BACKGROUND

The effectiveness of acupuncture for managing carpal tunnel syndrome is uncertain, particularly in patients already receiving conventional treatments (e.g., splinting). We aimed to assess the effects of electroacupuncture combined with splinting.

METHODS

We conducted a randomized parallel-group assessor-blinded 2-arm trial on patients with clinically diagnosed primary carpal tunnel syndrome. The treatment group was offered 13 sessions of electroacupuncture over 17 weeks. The treatment and control groups both received continuous nocturnal wrist splinting.

RESULTS

Of 181 participants randomly assigned to electroacupuncture combined with splinting (n = 90) or splinting alone (n = 91), 174 (96.1%) completed all follow-up. The electroacupuncture group showed greater improvements at 17 weeks in symptoms (primary outcome of Symptom Severity Scale score mean difference [MD] -0.20, 95% confidence interval [CI] -0.36 to -0.03), disability (Disability of Arm, Shoulder and Hand Questionnaire score MD -6.72, 95% CI -10.9 to -2.57), function (Functional Status Scale score MD -0.22, 95% CI -0.38 to -0.05), dexterity (time to complete blinded pick-up test MD -6.13 seconds, 95% CI -10.6 to -1.63) and maximal tip pinch strength (MD 1.17 lb, 95% CI 0.48 to 1.86). Differences between groups were small and clinically unimportant for reduction in pain (numerical rating scale -0.70, 95% CI -1.34 to -0.06), and not significant for sensation (first finger monofilament test -0.08 mm, 95% CI -0.22 to 0.06).

INTERPRETATION

For patients with primary carpal tunnel syndrome, chronic mild to moderate symptoms and no indication for surgery, electroacupuncture produces small changes in symptoms, disability, function, dexterity and pinch strength when added to nocturnal splinting.

TRIAL REGISTRATION

Chinese Clinical Trial Register no. ChiCTR-TRC-11001655 (www.chictr.org.cn/showprojen.aspx?proj=7890); subsequently deposited in the World Health Organization International Clinical Trials Registry Platform (apps.who.int/trialsearch/Trial2.aspx?TrialID=ChiCTR-TRC-11001655).

The diagnostic accuracy of five tests for diagnosing partial-thickness tears of the supraspinatus tendon: A cohort study

STUDY DESIGN

A cohort study.

INTRODUCTION

The causes of the pain can be difficult for clinicians to diagnose due to the complexity of the shoulder anatomy and the wide spectrum of shoulder conditions.

PURPOSE OF THE STUDY

The aim of this study was to investigate the clinical usefulness of provocative diagnostic tests, in patients with partial-thickness tears of the supraspinatus (SST) tendon.

METHODS

The partial-thickness tears SST tendon group consisted of 50 patients and 50 subjects with shoulder pain. Sensitivity, specificity, positive and negative predictive values, and likelihood ratios of five physical examination tests were calculated using a 2 × 2 table.

RESULTS

All the tests exhibited clinical useful positive LR greater than 2 (all, >7.0). The Yocum, Jobe, and Hawkinse-Kennedy exhibited clinically useful negative LR of less than 0.5.

CONCLUSIONS

The provocative tests examined were clinically useful in determining the presence or absence of pathology of the supraspinatus tendon.

LEVEL OF EVIDENCE

2b.

De Quervain’s syndrome: It may not be an isolated pathology

Introduction

This paper details a retrospective review of patients’ records diagnosed with de Quervain’s syndrome following a traumatic event but no history of repetitive strain.

Methods

Data analysis of 41 patients was performed. The inclusion criteria were pain over first dorsal compartment, pain on resisted extensor pollicis brevis and/or abductor pollicis longus, and a positive Finkelstein’s test. The assessment included a subjective history to establish a repetitive activity or a traumatic incident and diagnostic tests to establish possible instability or osteoarthritis.

Results

There were 13 men and 28 women with an age range from 20 to 72 years. Statistical analysis was undertaken using Fisher’s Exact tests. 46.3% ( n = 19) of 41 patients had a ligament injury diagnosed after the de Quervain’s. 94.7% ( n = 18) of 19 patients with ligament instability had a history of trauma, and this was statistically significant. Clinically significant was that 82.9% ( n = 34) of 41 patients demonstrated extensor carpi ulnaris (ECU) muscle weakness, but there was no statistical significant correlation between ECU weakness and ligament instability. Patients could have ECU weakness without ligament instability; however, patients with ligament instability appeared more likely to have ECU weakness.

Conclusions

The results would suggest that de Quervain’s syndrome, in a proportion of patients, could be secondary to underlying wrist pathology due to previous trauma. If the patient does not report a true repetitive strain history, a more thorough assessment may need to be undertaken to establish if there is any underlying pathology.

Intraobserver and interobserver variability in diagnosing scapholunate dissociation by cineradiography

PURPOSE

To evaluate the intraobserver and interobserver variability in diagnosing scapholunate dissociation (SLD) by wrist cineradiography.

METHODS

A musculoskeletal radiologist, hand surgeon, and trauma surgeon assessed the records of 50 consecutive wrist cineradiographies performed in 25 patients. Fluoroscopy was performed on the unaffected and affected wrist and consisted of radiographer-controlled passive flexion-extension and passive radial-ulnar deviation in both posteroanterior and lateral projections. To determine the intraobserver variability, the 3 reviewers reassessed all wrist cineradiographies 6 months after their first assessment. The kappa coefficient for interobserver agreement was calculated using the jackknife method. The Cohen kappa was used to assess intraobserver variability.

RESULTS

The interobserver variability for diagnosing SLD by cineradiography was excellent (κ = 0.84). The intraobserver variability for the hand surgeon was excellent (κ = 0.80), and was good for the radiologist (κ = 0.72) and the trauma surgeon (κ = 0.76).

CONCLUSIONS

Cineradiography is a promising and helpful, noninvasive tool for diagnosing SLD. It is widely available and has relatively low costs. Conventional radiographs remain essential in the primary workup for suspected SLD. However, we recommend cineradiography when an SLD is clinically suspected.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.