Observation of New Isotopes in the Fragmentation of ^{198}Pt at FRIB

Five previously unknown isotopes (^{182,183}Tm, ^{186,187}Yb, ^{190}Lu) were produced, separated, and identified for the first time at the Facility for Rare Isotope Beams (FRIB) using the Advanced Rare Isotope Separator (ARIS). The new isotopes were formed through the interaction of a ^{198}Pt beam with a carbon target at an energy of 186  MeV/u and with a primary beam power of 1.5 kW. Event-by-event particle identification of A, Z, and q for the reaction products was performed by combining measurements of the energy loss, time of flight, magnetic rigidity Bρ, and total kinetic energy. The ARIS separator has a novel two-stage design with high resolving power to strongly suppress contaminant beams. This successful new isotope search was performed less than one year after FRIB operations began and demonstrates the discovery potential of the facility which will ultimately provide 400 kW of primary beam power.

Patient ratings in exercise therapy for the management of tendinopathy: a systematic review with meta-analysis

OBJECTIVE

To synthesise exercise therapy intervention data investigating patient rating outcomes for the management of tendinopathy.

DESIGN

A systematic review and meta-analysis of randomized controlled trials investigating exercise therapy interventions and reporting patient rating outcomes.

SETTING

Any setting in any country listed as very high on the human development index.

PARTICIPANTS

People with a diagnosis of any tendinopathy of any severity or duration.

INTERVENTIONS

Exercise therapy for the management of tendinopathy comprising five different therapy classes: 1) resistance; 2) plyometric; 3) vibration; 4) flexibility, and 5) movement pattern retraining modalities, were considered for inclusion.

MAIN OUTCOME MEASURES

Outcomes measuring patient rating of condition, including patient satisfaction and Global Rating of Change (GROC).

RESULTS

From a total of 124 exercise therapy studies, 34 (Achilles: 41%, rotator cuff: 32%, patellar: 15%, elbow: 9% and gluteal: 3%) provided sufficient information to be meta-analysed. The data were obtained across 48 treatment arms and 1246 participants. The pooled estimate for proportion of satisfaction was 0.63 [95%CrI: 0.53-0.73], and the pooled estimate for percentage of maximum GROC was 53 [95%CrI: 38-69%]. The proportion of patients reporting positive satisfaction and perception of change increased with longer follow-up periods from treatment onset.

CONCLUSION

Patient satisfaction and GROC appear similar and are ranked moderately high demonstrating that patients generally perceive exercise therapies positively. Further research including greater consistency in measurement tools is required to explore and where possible, identify patient- and exercise-related moderating factors that can be used to improve person-centred care.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO ID=CRD42020168187 CONTRIBUTION OF PAPER.

Production and separation of positron emitters for hadron therapy at FRS-Cave M

The FRagment Separator FRS at GSI is a versatile spectrometer and separator for experiments with relativistic in-flight separated short-lived exotic beams. One branch of the FRS is connected to the target hall where the bio-medical cave (Cave M) is located. Recently a joint activity between the experimental groups of the FRS and the biophysics at the GSI and Department of physics at LMU was started to perform biomedical experiments relevant for hadron therapy with positron emitting carbon and oxygen beams. This paper presents the new ion-optical mode and commissioning results of the FRS-Cave M branch where positron emitting ¹⁵O-ions were provided to the medical cave for the first time. An overall conversion efficiency of 2.9±0.2×10^{-4 15}O fragments per primary ¹⁶O ion accelerated in the synchrotron SIS18 was reached.

Discovery of ^{39}Na

The new isotope ^{39}Na, the most neutron-rich sodium nucleus observed so far, was discovered at the RIKEN Nishina Center Radioactive Isotope Beam Factory using the projectile fragmentation of an intense ^{48}Ca beam at 345  MeV/nucleon on a beryllium target. Projectile fragments were separated and identified in flight with the large-acceptance two-stage separator BigRIPS. Nine ^{39}Na events have been unambiguously observed in this work and clearly establish the particle stability of ^{39}Na. Furthermore, the lack of observation of ^{35,36}Ne isotopes in this experiment significantly improves the overall confidence that ^{34}Ne is the neutron dripline nucleus of neon. These results provide new key information to understand nuclear binding and nuclear structure under extremely neutron-rich conditions. The newly established stability of ^{39}Na has a significant impact on nuclear models and theories predicting the neutron dripline and also provides a key to understanding the nuclear shell property of ^{39}Na at the neutron number N=28, which is normally a magic number.

Local neuromuscular characteristics associated with patellofemoral pain: A systematic review and meta-analysis

BACKGROUND

Local neuromuscular deficits have been reported in people with patellofemoral pain. We synthesised the neuromuscular characteristics associated with patellofemoral pain to help identify interventional targets and potential mechanisms.

METHODS

Five databases were searched for local neuromuscular characteristics in case-control studies. Electromyography, flexibility, muscle performance and cross-sectional area data were derived from functional or isolated task investigations and synthesised accordingly. An evidence gap map was constructed.

FINDINGS

Sixty-seven studies were included. In functional tasks, electromyographic investigations showed moderate evidence of small effect for vastus medialis onset-delays relative to vastus lateralis (0.44 [0.03, 0.85]) during stepping/stair negotiation tasks, and higher biceps femoris mean excitation amplitudes (0.55 [0.06, 1.04]) in single-leg triple-hop test. In isolated tasks, we found moderate evidence of medium effect for lower Hoffman-reflex amplitude of vastus medialis (-1.12 [-1.56, -0.67]). Muscle performance investigations showed; strong evidence with medium and small effects for lower extensors concentric (-0.61 [-0.81, -0.40]) and eccentric (-0.56 [-0.79, -0.33]) strength, and moderate evidence of medium effect of lower isometric (-0.64 [-0.87, -0.41]) strength, moderate evidence with small effect for rate of force development to 30% (-0.55[-0.89, -0.21]), 60% (-0.57[-0.90, -0.25]) and medium effect to 90% (-0.76[-1.43, -0.10]) of maximum voluntary contraction, and small effect for lower flexors concentric strength (-0.46 [-0.74, -0.19]) and extensors total work (-0.48 [-0.90, -0.07]). Flexibility investigations showed tighter hamstrings (-0.57 [-0.99, -0.14]).

INTERPRETATION

Differences within quadriceps and hamstrings motor-control, hamstrings tightness, and quadriceps and hamstrings weakness are associated with patellofemoral pain, and can be used to guide investigations of treatment effects.

Patellar tendinopathy outcome predictors in jumping athletes: feasibility of measures for a cohort study

OBJECTIVES

The main aim was to assess feasibility by testing data collection procedures for a cohort study. Measurements validity and reliability were secondary objectives.

DESIGN

Feasibility study.

SETTING

Combination of remote contact, assessment in clinic and biomechanical evaluation.

PARTICIPANTS

36 jumping athletes (female:17, male:19) equally spread between those with patellar tendinopathy, other knee problems and controls.

MAIN OUTCOME MEASURES

Measurements validity, reliability and feasibility.

RESULTS

There was no systematic difference between administration methods for patient reported outcome measures and miscellaneous questions (range of d = -0.32 to 0.26) without any order effect (all p > 0.05) except KOOS-PF (p = 0.02). Questionnaires' inter-session reliability was moderate to excellent (ICCs = 0.68-0.93). Pain maps were 94% matched between methods. Training load recall percentage decreased until week-3 with only 20% maintaining a training diary completing the full 6 weeks. The graded loaded challenge was clinically applicable, biomechanically valid with increasing load through progression and reliable (ICCs = 0.63-0.98).

CONCLUSION

The tested questionnaires were valid and reliable for online use, therefore being suitable for clinical and research purposes. A shorter survey to reduce burden and collecting training load using shorter recall duration should improve feasibility. Biomechanical measures were valid and reliable, and a graded loaded challenge, suitable for further testing, has been defined.

Location of the Neutron Dripline at Fluorine and Neon

A search for the heaviest isotopes of fluorine, neon, and sodium was conducted by fragmentation of an intense ^{48}Ca beam at 345  MeV/nucleon with a 20-mm-thick beryllium target and identification of isotopes in the large-acceptance separator BigRIPS at the RIKEN Radioactive Isotope Beam Factory. No events were observed for ^{32,33}F, ^{35,36}Ne, and ^{38}Na and only one event for ^{39}Na after extensive running. Comparison with predicted yields excludes the existence of bound states of these unobserved isotopes with high confidence levels. The present work indicates that ^{31}F and ^{34}Ne are the heaviest bound isotopes of fluorine and neon, respectively. The neutron dripline has thus been experimentally confirmed up to neon for the first time since ^{24}O was confirmed to be the dripline nucleus nearly 20 years ago. These data provide new keys to understanding the nuclear stability at extremely neutron-rich conditions.

Discovery of ^{60}Ca and Implications For the Stability of ^{70}Ca

The discovery of the important neutron-rich nucleus _{20}^{60}Ca_{40} and seven others near the limits of nuclear stability is reported from the fragmentation of a 345  MeV/u ^{70}Zn projectile beam on ^{9}Be targets at the radioactive ion-beam factory of the RIKEN Nishina Center. The produced fragments were analyzed and unambiguously identified using the BigRIPS two-stage in-flight separator. The eight new neutron-rich nuclei discovered, ^{47}P, ^{49}S, ^{52}Cl, ^{54}Ar, ^{57}K, ^{59,60}Ca, and ^{62}Sc, are the most neutron-rich isotopes of the respective elements. In addition, one event consistent with ^{59}K was registered. The results are compared with the drip lines predicted by a variety of mass models and it is found that the models in best agreement with the observed limits of existence in the explored region tend to predict the even-mass Ca isotopes to be bound out to at least ^{70}Ca.

Effect of a specific exercise strategy on strength and proprioception in volleyball players with infraspinatus muscle atrophy

Infraspinatus muscle atrophy is common in professional volleyball players, but it is unclear whether commonly observed strength and proprioception deficits can be reversed with training. Fifty-four participants were recruited into an infraspinatus atrophy group (IAG, n = 18) and a non-atrophy group (NAG, n = 18) of elite volleyballers plus a healthy non-athletic control group (CG, n = 18). IAG were trained with a progressive, specific shoulder external rotator strengthening routine for 32 sessions over 8 weeks. Shoulder external rotation peak torque (SERPT) and threshold to detect passive movement (TTDPM) and joint position sense (JPS) were measured before and after the intervention. At baseline, no significant difference was detected in strength or proprioception between the injured and control groups, but the normal athletes were stronger and had better proprioception than either IAG or CG (P < .001). IAG (d = 2.78) and NAG (d = 0.442) improved strength significantly after training. IAG improved TTDM and JPS (P < .001, d = -0.719 and -2.942, respectively) but were still worse than NAG (P < .001). Elite volleyball players with Infraspinatus muscle atrophy have strength and proprioception deficits which can be improved by a specific exercise program to normal but not elite athlete control levels.

Exercise training as a novel primary treatment for localised prostate cancer: a multi-site randomised controlled phase II study

Alternative management strategies for localised prostate cancer are required to reduce morbidity and overtreatment. The aim of this study was to evaluate the feasibility, safety and acceptability of exercise training (ET) with behavioural support as a primary therapy for low/intermediate risk localised prostate cancer. Men with low/intermediate-risk prostate cancer were randomised to 12 months of ET or usual care with physical activity advice (UCwA) in a multi-site open label RCT. Feasibility included acceptability, recruitment, retention, adherence, adverse events and disease progression. Secondary outcomes included quality of life and cardiovascular health indices. Of the 50 men randomised to ET (n = 25) or UCwA (n = 25), 92% (n = 46) completed 12 month assessments. Three men progressed to invasive therapy (two in UCwA). In the ET group, men completed mean: 140 mins per week for 12 months (95% CI 129,152 mins) (94% of target dose) at 75% Hrmax. Men in the ET group demonstrated improved body mass (mean reduction: 2.0 kg; 95% CI -2.9,-1.1), reduced systolic (mean: 13 mmHg; 95%CI 7,19) and diastolic blood pressure (mean:8 mmHg; 95% CI 5,12) and improved quality of life (EQ.5D mean:13 points; 95% CI 7,18). There were no serious adverse events. ET in men with low/intermediate risk prostate cancer is feasible and acceptable with a low progression rate to radical treatment. Early signals on clinically relevant markers were found which warrant further investigation.

Tendinopathic supraspinatus tenocytes may have a neuroendocrine-like function, secreting CGRP, SP and VEGF: a pilot immunohistochemistry study

We wanted to observe and compare the appearance of neurovascular tissue from tendon ex vivo, in patients with and without painful rotator cuff tendinopathy. Supraspinatus tendons were biopsied from 5 participants with painful tendinopathy and normal tendon from a young male. Slides were stained with haematoxylin and eosin and toluidine blue for histological assessment. Immunohistochemical markers for general nerves (protein gene-product 9.5 and synaptophysin), sensory nerves (calcitonin gene-related peptide; substance-P) and vascularisation (vascular endothelial growth factor) were used. PGP9.5 and CGRP-immunoreactive fibres were associated with vessels in cases and control. Synaptophysinlabelled fibres were observed in close relation to vessels in tendinopathy. PGP9.5, CGRP, SP and VEGF-immunoreaction also labelled tenocyte-like cells in degenerative areas and fibres in regions of fat and collagen. Sensory innervation and vascularity are increased in tendinopathy. The evidence for innervation and vascularity of symptomatic rotator cuff tendon may aid the development of novel investigations and therapies in the management of patients with this ailment.

High Precision Determination of the β Decay Q(EC) Value of (11)C and Implications on the Tests of the Standard Model

We report the determination of the Q(EC) value of the mirror transition of (11)C by measuring the atomic masses of (11)C and (11)B using Penning trap mass spectrometry. More than an order of magnitude improvement in precision is achieved as compared to the 2012 Atomic Mass Evaluation (Ame2012) [Chin. Phys. C 36, 1603 (2012)]. This leads to a factor of 3 improvement in the calculated Ft value. Using the new value, Q(EC)=1981.690(61)  keV, the uncertainty on Ft is no longer dominated by the uncertainty on the Q(EC) value. Based on this measurement, we provide an updated estimate of the Gamow-Teller to Fermi mixing ratio and standard model values of the correlation coefficients.

Mass Measurement of 56Sc Reveals a Small A = 56 Odd-Even Mass Staggering, Implying a Cooler Accreted Neutron Star Crust

We present the mass excesses of (52-57)Sc, obtained from recent time-of-flight nuclear mass measurements at the National Superconducting Cyclotron Laboratory at Michigan State University. The masses of 56Sc and 57Sc were determined for the first time with atomic mass excesses of -24.85(59)((-54)(+0))  MeV and -21.0(1.3)  MeV, respectively, where the asymmetric uncertainty for 56Sc was included due to possible contamination from a long-lived isomer. The 56Sc mass indicates a small odd-even mass staggering in the A = 56 mass chain towards the neutron drip line, significantly deviating from trends predicted by the global FRDM mass model and favoring trends predicted by the UNEDF0 and UNEDF1 density functional calculations. Together with new shell-model calculations of the electron-capture strength function of 56Sc, our results strongly reduce uncertainties in model calculations of the heating and cooling at the 56Ti electron-capture layer in the outer crust of accreting neutron stars. We find that, in contrast to previous studies, neither strong neutrino cooling nor strong heating occurs in this layer. We conclude that Urca cooling in the outer crusts of accreting neutron stars that exhibit superbursts or high temperature steady-state burning, which are predicted to be rich in A≈56 nuclei, is considerably weaker than predicted. Urca cooling must instead be dominated by electron capture on the small amounts of adjacent odd-A nuclei contained in the superburst and high temperature steady-state burning ashes. This may explain the absence of strong crust Urca cooling inferred from the observed cooling light curve of the transiently accreting x-ray source MAXI J0556-332.

In vivo biological response to extracorporeal shockwave therapy in human tendinopathy

Extracorporeal shock wave therapy (ESWT) is a non-invasive treatment for chronic tendinopathies, however little is known about the in-vivo biological mechanisms of ESWT. Using microdialysis, we examined the real-time biological response of healthy and pathological tendons to ESWT. A single session of ESWT was administered to the mid-portion of the Achilles tendon in thirteen healthy individuals (aged 25.7 ± 7.0 years) and patellar or Achilles tendon of six patients with tendinopathies (aged 39.0 ± 14.9 years). Dialysate samples from the surrounding peri-tendon were collected before and immediately after ESWT. Interleukins (IL)-1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-17A, vascular endothelial growth factor and interferon-γ were quantified using a cytometric bead array while gelatinase activity (MMP-2 and -9) was examined using zymography. There were no statistical differences between the biological tissue response to ESWT in healthy and pathological tendons. IL-1β, IL-2, IL-6 and IL-8 were the cytokines predominantly detected in the tendon dialysate. IL-1β and IL-2 did not change significantly with ESWT. IL-6 and IL-8 concentrations were elevated immediately after ESWT and remained significantly elevated for four hours post-ESWT (p < 0.001). Pro-forms of MMP-2 and -9 also increased after ESWT (p < 0.003), whereas there were no significant changes in active MMP forms. In addition, the biological response to ESWT treatment could be differentiated between possible responders and non-responders based on a minimum 5-fold increase in any inflammatory marker or MMP from pre- to post-ESWT. Our findings provide novel evidence of the biological mechanisms underpinning ESWT in humans in vivo. They suggest that the mechanical stimulus provided by ESWT might aid tendon remodelling in tendinopathy by promoting the inflammatory and catabolic processes that are associated with removing damaged matrix constituents. The non-response of some individuals may help to explain why ESWT does not improve symptoms in all patients and provides a potential focus for future research.

Mass measurements demonstrate a strong N=28 shell gap in argon

We present results from recent time-of-flight nuclear mass measurements at the National Superconducting Cyclotron Laboratory at Michigan State University. We report the first mass measurements of ^{48}Ar and ^{49}Ar and find atomic mass excesses of -22.28(31)  MeV and -17.8(1.1)  MeV, respectively. These masses provide strong evidence for the closed shell nature of neutron number N=28 in argon, which is therefore the lowest even-Z element exhibiting the N=28 closed shell. The resulting trend in binding-energy differences, which probes the strength of the N=28 shell, compares favorably with shell-model calculations in the sd-pf shell using SDPF-U and SDPF-MU Hamiltonians.

Novel technique for constraining r-process (n, γ) reaction rates

A novel technique has been developed, which will open exciting new opportunities for studying the very neutron-rich nuclei involved in the r process. As a proof of principle, the γ spectra from the β decay of ^{76}Ga have been measured with the SuN detector at the National Superconducting Cyclotron Laboratory. The nuclear level density and γ-ray strength function are extracted and used as input to Hauser-Feshbach calculations. The present technique is shown to strongly constrain the ^{75}Ge(n,γ)^{76}Ge cross section and reaction rate.

Musculoskeletal triage: a mixed methods study, integrating systematic review with expert and patient perspectives

BACKGROUND

Triage is implemented in healthcare settings to optimise access to appropriate care and manage waiting times.

OBJECTIVES

To determine the optimum features of triage systems for patients with musculoskeletal conditions.

DATA SOURCES

AMED, BNI, CINAHL, EMBASE, Health Business Elite, HMIC, MEDLINE, Cochrane Library, Web of Science and Google Scholar.

STUDY SELECTION OR ELIGIBILITY CRITERIA

Studies that included non-musculoskeletal conditions, concerned patients aged <18 years or were set in emergency departments were excluded.

STUDY APPRAISAL AND SYNTHESIS METHODS

Study quality was graded using the Downs and Black quality index. Qualitative methods were used to further inform the findings of the literature review.

RESULTS

Thirty-four studies met the inclusion criteria, with study quality ranging from eight to 24 out of a possible 27. Musculoskeletal triage is conducted via face-to-face consultation, paper referral letter or telephone consultation. Triage performed by physiotherapists, general practitioners, multidisciplinary teams, nurses, occupational therapists and speech therapists has been shown to be effective using a range of outcomes. Qualitative data revealed the value of supportive interdisciplinary teams, and suggested that this support is more important than choice of clinician. Patients trusted, and expressed preferences for, experienced clinicians to perform triage.

CONCLUSION

Triage can be performed effectively via a number of methods and by a range of clinicians. Satisfaction, cost, diagnostic agreement, appropriateness of referral and waiting list time have been improved though triage. Multidisciplinary support mechanisms are critical elements of successful triage systems. Patients are more concerned with access issues than professional boundaries.

Intermediate care pathways for musculoskeletal conditions--are they working? A systematic review

BACKGROUND

Musculoskeletal condition assessment and management is increasingly delivered at the primary to secondary care interface, by inter-disciplinary triage and treat services.

OBJECTIVES

This review aimed to describe Intermediate Care pathways, evaluate effectiveness, describe outcomes and identify gaps in the evidence.

DATA SOURCES

PubMed, ISI Web of Science, EMBASE, Ovid Medline, PEDro, Google Scholar to October 2013.

STUDY SELECTION/ELIGIBILITY CRITERIA

Studies in English that evaluated relevant services were considered for inclusion. Studies evaluating paediatric or emergency medicine and self-referral were excluded.

RESULTS

Twenty-three studies were identified. Between 72% and 97% of patients could be managed entirely within Intermediate Care with a 20% to 60% resultant reduction in orthopaedic referral rate. Patient reported outcome measures typically showed significant symptom improvements. Knee conditions were most commonly referred on to secondary care (35% to 56%), with plain films (5% to 23%) and MRI (10% to 18%) the commonest investigations. Physiotherapists' clinical decision making and referral accuracy were comparable to medical doctors in 68% to 96% of cases. Intermediate Care consistently leads to significantly reduced orthopaedic waiting times and high patient satisfaction.

LIMITATIONS

These findings are not based on strong evidence and there is an urgent need for high-quality, prospective, comprehensive evaluation of Intermediate Care provision, including cost-effectiveness and impact on other services.

FUNDING

Part funded by EPSRC and AXA-PPP.

CONCLUSION

Intermediate Care consistently improves patient outcome, typically results in appropriate referral and management, reduces waiting times and increases patient satisfaction. There is a case for wider provision of Intermediate Care services to effectively manage non-surgical musculoskeletal patients.

General practitioners' attitude to sport and exercise medicine services: a questionnaire-based survey

AIM

Sport and exercise medicine (SEM) aims to manage sporting injuries and promote physical activity. This study explores general practitioners' (GPs) awareness, understanding and utilisation of their local SEM services.

DESIGN

A questionnaire survey, including patient case scenarios, was administered between February and May 2011.

PARTICIPANTS AND SETTING

693 GPs working in Cardiff and Vale, Leicester and Tower Hamlets were invited to participate.

RESULTS

244 GPs responded to the questionnaire (35.2% response rate). Less than half (46%; 112/244) were aware of their nearest SEM service and only 38% (92/244) had a clear understanding on referral indications. The majority (82%; 199/244) felt confident advising less active patients about exercise. There were divergent management opinions about the case scenarios of patients who were SEM referral candidates. Overall, GPs were significantly more likely to refer younger patients and patients with sport-related problems rather than patients who would benefit from increasing their activity levels in order to prevent or manage chronic conditions (p<0.01). GPs with previous SEM training were significantly more likely to refer (p<0.01). The majority (62%; 151/244) had never referred patients to their local SEM clinics but of those who had 75% (70/93) rated the service as good.

CONCLUSIONS

There is a lack of awareness and understanding among GPs on the role of SEM within the National Health Service which may be resulting in suboptimal utilisation especially for patients who could benefit from increasing their activity levels.

A field programmable gate array-based time-resolved scaler for collinear laser spectroscopy with bunched radioactive potassium beams

A new data acquisition system including a Field Programmable Gate Array (FPGA) based time-resolved scaler was developed for laser-induced fluorescence and beam bunch coincidence measurements. The FPGA scaler was tested in a collinear laser-spectroscopy experiment on radioactive (37)K at the BEam COoler and LAser spectroscopy (BECOLA) facility at the National Superconducting Cyclotron Laboratory at Michigan State University. A 1.29 μs bunch width from the buncher and a bunch repetition rate of 2.5 Hz led to a background suppression factor of 3.1 × 10(5) in resonant photon detection measurements. The hyperfine structure of (37)K and its isotope shift relative to the stable (39)K were determined using 5 × 10(4) s(-1) (37)K ions injected into the BECOLA beam line. The obtained hyperfine coupling constants A((2)S(1/2)) = 120.3(1.4) MHz, A((2)P(1/2)) = 15.2(1.1) MHz, and A((2)P(3/2)) = 1.4(8) MHz, and the isotope shift δν(39, 37) = -264(3) MHz are consistent with the previously determined values, where available.

High-volume image-guided injection for recalcitrant medial collateral ligament injuries of the knee

AIM

To evaluate the effectiveness of a novel injection technique in the management of recalcitrant medial collateral ligament (MCL) injuries of the knee.

MATERIALS AND METHODS

The injection, comprising 10 ml local anaesthetic with 25-50 mg hydrocortisone, is directed beneath the periosteal attachment of the MCL. Twenty-eight patients who received the intervention were asked to complete a questionnaire, a visual analogue scale (VAS) and the International Knee Documentation Committee (IKDC) subjective knee form to quantify symptoms pre-injection and at follow-up. Data were assessed using descriptive statistics. Further analysis was conducted using the Wilcoxon signed-rank test and Fisher's exact test.

RESULTS

Sixty-eight percent (n = 19) of patients responded. Three patients were excluded according to the exclusion criteria. Of those studied, 37.5% (n = 6) were professional athletes. At follow-up, patients reported a mean improvement on the VAS of 75.5% (SD = 23.6). There was a significant improvement in IKDC scores (mean difference 42%, SD = 14.2) pre- and post-injection (Wilcoxon signed-rank test, p < 0.001). No residual symptoms were reported by 50% (n = 8) of patients, and a further 37.5% (n = 6) of patients had improved. Of those patients who played sport, two-thirds (n = 10) had returned to their previous level of sport at follow-up, including all of the professional athletes.

CONCLUSION

Periosteal high-volume image-guided injection is a useful treatment for recalcitrant MCL injury. Results are encouraging, particularly amongst the professional athletes studied.

Doppler ultrasound signal in Achilles tendinopathy reduces immediately after activity

BACKGROUND

A relationship has been identified between vascularization on Doppler ultrasound (Doppler signal) and Achilles tendon pain. Doppler signal may increase minutes after prolonged activity, but the immediate effect is unknown. The aim of the study was to investigate the immediate effect of short term activity on Achilles tendon Doppler signal. Achilles tendinopathy patients (7 patients, 10 tendons) and asymptomatic controls (6 controls, 12 tendons) performed 2 activity tasks; a 2 minute continuous step task and one minute continuous calf raise task. Doppler signal was measured at rest and within a minute after each activity. The presence of Doppler signal was quantified using both semi quantitative (modified Ohberg scale; 0=no signal, 5 = > 90% of pathological area contains Doppler signal) and quantitative methods (pixel number). Doppler signal was present in 90% of symptomatic individuals and in none of the asymptomatic controls. The modified Ohberg scale and pixel number reduced significantly after both activity tasks and heart rate increased significantly (p < 0.05). Doppler signal in Achilles tendinopathy may decrease immediately after activities that load the calf muscle and increase heart rate, suggesting that this activity should be avoided prior to imaging to avoid false negative results.

Achilles tendinopathy in club runners

Ultrasound (US) changes within the Achilles tendon are present in asymptomatic Achilles individuals. We assessed the association of US signs with symptoms of Achilles tendinopathy in a study group of club level running athletes and in a control group of athletes training at least 2 times per week. The Achilles tendon was assessed in its entirety on longitudinal US scans, at the musculotendinous junction (MTJ), the calcaneal insertion site, and at a midtendon point. 25 middle distance runners, 19 males and 6 females, aged from 18 to 58, were enrolled in each group. When compared to control athletes, club level runners presented significantly increased tendon thickness (p=0.046) at the musculo-tendinous junction, and increased tendon thickness, with no statistical significance, at the other landmarks points. Although club level runners were significantly more symptomatic and predisposed to develop signs of tendinopathy than control athletes (p=<0.001), ultrasound abnormalities were not significantly associated with local symptoms complained at the US investigation time. Prospective studies on asymptomatic athletes are needed to define the predictive value of US signs of Achilles tendinopathy in the development of symptoms in the long-term.