Despite the high level achieved in the field of shoulder surgery, a global consensus on rotator cuff tears management is lacking. This work is divided into two main sessions: in the first, we set questions about hot topics involved in the rotator cuff tears, from the etiopathogenesis to the surgical treatment. In the second, we answered these questions by mentioning Evidence Based Medicine. The aim of the present work is to provide easily accessible guidelines: they could be considered as recommendations for a good clinical practice developed through a process of sys- © C I C E d i z i o n i I n t e r n a z i o n a l i tematic review of the literature and expert opinion, in order to improve the quality of care and rationalize the use of resources. KEY WORDS: rotator cuff tears, Guidelines. IntroductionThe pathologies of the rotator cuff are common and they can be considered as a natural decline of the muscletendon unit in aging with statistically significant increase in frequency after 50 years. The painful shoulder is related in 30-70% of cases to disorders of the rotator cuff. The incidence of rotator cuff tears varies between 5 and 40%, although it is very difficult to establish the real incidence of these lesions, which are often asymptomatic. Currently, the pathology of the rotator cuff is considered to be multifactorial, because extrinsic and intrinsic factors play important roles, although it remains unclear the specific weight of each of these factors (Tab. 1). and often increased in number. staining eosinophilic There is a loss of orientation of homogeneous preparation the cores in relation to the bundles with hematoxylin/eosin. of collagen fibers. Chromatin has a dark color. Muscles, Ligaments and Tendons Grade 4 SevereComplete loss of orientation of The cores are reduced in number, Hyalinization with a homogeneous degeneration the collagen fiber bundles.small, dark and round. appearance. I.S.Mu.L.T -Rotator Cuff Tears Guidelines Grade 1The nuclei become more Colorable mucin between Decreased polarization Occasional clusters oval or round in shape fiber bundles but still fibers: separation of the of capillaries, less than without large cytoplasm. discrete number. individual fibers with one per 10 fields at high maintenance of the magnification. demarcation of the beams. Grade 2The nuclei are circular, Colorable mucin between Separation of the fibers 1-2 cluster of capillaries slightly widened and the fibers with loss with loss of demarcation for 10 fields at high a small amount of demarcation and a clear loss of normal magnification. of cytoplasm becomes of the beams. polarization. visible. Grade 3The nuclei are round, Abundant mucin among Demarcated separation More than two clusters wide with abundant poor colorable collagen. of fibers with complete to 10 fields at high cytoplasm and loss of architecture. magnification. the formation of a gap (chondroid change). © C I C E d i z i o n i I n t e r n a z i o n a l i MethodologyThe Authors were divided into four groups: -Coordinator: he conce...

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Osteoarthritis (OA) is the most common form of arthritis clinically characterized by joint pain, functional limitation, and reduced quality of life. Several studies have shown a clear link between obesity and higher risk of knee OA. According to the multifactorial OA pathogenesis, the management of this condition requires a multidisciplinary approach. The objective of this study is to evaluate hydrokinesitherapy effects in thermal setting in obese patients with knee OA. Fifty-three patients were assessed for eligibility, of which 33 refused the treatment, while 10 patients dropped out after the enrollment for personal reasons or inability to adhere to the program. Ten patients (8 females, 2 males, mean age of 59.4 years) with obesity (range BMI 30-45 kg/m2) and knee OA (II-III grade of Kellgren-Lawrence scale) treated with hydrokinetic therapy in thermal water (two sessions per week for 8 consecutive weeks) completed the study. Primary outcome measure was pain (VAS). Secondary outcomes were clinical knee evaluation (range of motion-ROM, lower-limb muscle strength), WOMAC, and Lequesne Algofunctional Index. Patellar tendon and peri-articular soft tissue ultrasound evaluation and gait analysis at baseline (T0), at the end of treatment (T1), and at 6 months of follow-up (T2) were performed. Significant decrease on VAS pain during walking on a flat surface and going up/down stairs was reached from baseline at T1 (p = 0.0039; p = 0.0098) and was maintained at T2 (p = 0.00954) exclusively for VAS pain during walking on a flat surface. WOMAC score showed a significant reduction between T0 and T1 (p = 0.0137) and between T0 and T2 (p = 0.006438), as ROM evaluations. Kinematic path assessment did not show significant results in individual gait steps, except for the space-time variables of the average speed and the values of ground reaction force (GRF) obtained with force platforms. Hydrokinesitherapy in thermal environment in obese patients with knee OA may determine pain relief, joint function improvement, and walking speed increase until 6 months of follow-up.

Introduction: Several conditions such as training, aging, estrogen deficiency and drugs could affect the biological and anatomo-physiological characteristics of the tendon. Additionally, recent preclinical and clinical studies examined the effect of detraining on tendon, showing alterations in its structure and morphology and in tenocyte mechanobiology. However, few data evaluated the importance that cessation of training might have on tendon. Basically, we do not fully understand how tendons react to a phase of training followed by sudden detraining. Therefore, within this review, we summarize the studies where tendon detraining was examined.Materials and Methods: A descriptive systematic literature review was carried out by searching three databases (PubMed, Scopus and Web of Knowledge) on tendon detraining. Original articles in English from 2000 to 2015 were included. In addition, the search was extended to the reference lists of the selected articles. A public reference manager (www.mendeley.com) was adopted to remove duplicate articles.Results: An initial literature search yielded 134 references (www.pubmed.org: 53; www.scopus.com: 11; www.webofknowledge.com: 70). Fifteen publications were extracted based on the title for further analysis by two independent reviewers. Abstracts and complete articles were after that reviewed to evaluate if they met inclusion criteria.Conclusions: The revised literature comprised four clinical studies and an in vitro and three in vivo reports. Overall, the results showed that tendon structure and properties after detraining are compromised, with an alteration in the tissue structural organization and mechanical properties. Clinical studies usually showed a lesser extent of tendon alterations, probably because preclinical studies permit an in-depth evaluation of tendon modifications, which is hard to perform in human subjects. In conclusion, after a period of sudden detraining (e.g., after an injury), physical activity should be taken with caution, following a targeted rehabilitation program. However, further research should be performed to fully understand the effect of sudden detraining on tendons.

SummaryPrimary traumatic patellar dislocation is common, particularly in young active individuals. A consensus on its management is still lacking. The present work provides easily accessible guidelines to be considered as recommendations for a good clinical practice developed through a process of systematic review of the literature and expert opinion, to improve the quality of care and rationalize the use of resources. Level of evidence: Ia.

Background. Achilles and patellar tendinopathies are common causes of chronic pain and functional impairment. Conservative management can be effective, but it is time-consuming and it requires intensive patient compliance. Hyaluronic acid (HA) is a key component of the extracellular matrix and its anti-inflammatory, lubricant and analgesic properties are well documented in osteoarthritis. Growing pre-clinical studies indicate a possible role of HA in tendon pathology, while clinical evidences are still lacking. Objectives. The primary objective was to assess the efficacy of a new formulation of HA obtained from biofermentation (Hyalotend ® Fidia Farmaceutici, Italy) to improve the clinical symptoms assessed by the VISA-A and VISA-P questionnaires at 90 Days of follow-up. Secondary objectives were to evaluate improvement in pain (NRS-11), US parameters (tendon appearance and neovascularization), and quality of life (EQ-5D). Safety was also evaluated. Methods. This was a prospective, open-label, multicenter clinical trial. Thirty-five patients (26 in AT group; 9 patients in PT group), who satisfied inclusion and exclusion criteria, were recruited during a 4-month period. Each patient received 1 injection weekly for 3 weeks under US-guidance at the painful site, and was evaluated at 14, 45 and 90 days after the procedure. Subjects were instructed to record on a diary any intakes of the permitted rescue medication for pain relief oral paracetamol, up to the "rescue dose" of 3 g/Day (i.e. 6 tablets/Day) throughout the study period and to interrupt treatment at least 24 hours prior to each visit. Results. Significant improvement occurred in both VISA-A (23.22±23.17; 95% CI: 13.20; 33.24; p<.0001) and VISA-P (19.25±11.61; 95% CI: 9.54; 28.96; p=0.0022). NRS-11 score significantly decreased in subjects with AT or PT during the study (p<0.0001 and p=0.0040 respectively). Significant improvement of swelling and tenderness evaluated with US in the AT group was revealed (McNemar's test; p=0.0016 and p=0.0114, respectively), while in the PT group the presence of these clinical symptoms showed only a non-significant tendency to decrease (p=0.3173 for both). The EQ-5D-5L total score increased in both the AT and PT groups (mean change vs. baseline at day 90 equal to 15.96±18.95 (range: -50; 45) and 15.50±32.42 (range: -40; 71), respectively. Seven patients (20.59%) experienced at least one adverse event (AE), all AEs had mild severity. No serious AE or other significant AE leading to study treatment discontinuation or temporary interruption was reported. Conclusions. Three US-guided HA injections may induce prompt improvement in pain and function in mid-portion Achilles and patellar tendinopathies that last until 90 days of followup. Amelioration in tendon structure, neovascolarization and clinical parameters may also be achieved. The treatment is also safe and well-tolerated.

SummaryBackground: The anatomy of hip is widely complex and several anatomical structures interact and contribute to its functioning. For position and role, hip and the surrounding tendons, which have their insertion around, are overstressed and often overloaded, especially in athletes. This could lead to the developing of several tendinopathies, among which the differential diagnosis is often complicated. Many conservative treatments are used in clinical practice, while actually, no defined conservative protocol is recommended. Methods: This is a review article. The aim of this manuscript is to evaluate the current evidences about the effectiveness of conservative management in hip tendinopathies. Conclusion: Conservative treatment is effective in the management of hip tendinopathies and may be considered the first-line approach for patients affected. However, there is lack of evidences about which is the most effective treatment. Exercise therapy seems to provide long-term pain relief, but the literature is still lacking about the correct type, dose, posology, intensity of exercise prescribed. Further studies about different local approaches, as PRP or hyaluronic acid injections, may be encouraged. Level of evidence: I.

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