Diapositiva 1

Greater Trochanter Pain Syndrome
Antoni Morral
Greater trochanteric pain syndrome
Trochanteric pain syndrome or trochanteric bursitis is a
common regional pain syndrome. The incidence of GTPS: 1.8
patients per 1000 per year. The prevalence is higher in
females than males (rate 4:1)
Segal NA, Felson DT, Torner JC, Zhu Y, Curtis JR, Niu J, Nevitt MC;
Multicenter Osteoarthritis Study Group. Greater trochanteric pain syndrome:
epidemiology and associated factors. Arch Phys Med Rehabil. 2007 Aug;88(8):988-92..
Greater trochanteric pain syndrome has an incidence
of 5.6 per 1,000 adults per year,
and affects up to 25%
of patients with knee osteoarthritis
and low back pain in industrialized nations.
Genth B, Von Düring M, Von Engelhardt LV, Ludwig J, Teske W, Von
Schulze-Pellengahr C. Analysis of the sensory innervations of the greater
trochanter for improving the treatment of greater trochanteric pain syndrome.
Clin Anat. 2012 Nov;25(8):1080-6.
Williams BS, Cohen SP. Greater trochanteric pain syndrome: a review of
anatomy, diagnosis and treatment. Anesth Analg. 2009 May;108(5):1662-70. Review.
Symptoms of GTPS consist of persistent pain in the lateral hip radiating along the lateral aspect of
the thigh to the knee. Physical examination reveals point tenderness in the posterolateral area of
the greater trochanter.
Williams BS, Cohen SP. Greater trochanteric pain syndrome: a review of
anatomy, diagnosis and treatment. Anesth Analg. 2009 May;108(5):1662-70. Review.
DIAGNÓSTICO CLÍNICO:
Los pacientes con dolor lateral de cadera (LHP) y
en ausencia de dificultades con
la manipulación de los zapatos y calcetines,
junto con dolor a la palpación del trocánter mayor
y LHP con una prueba de FABER
(flexion abduction external rotation)
es probable que tengan GTPS.
Fearon AM, Scarvell JM, Neeman T, Cook JL, Cormick W, Smith PN. Greater
trochanteric pain syndrome: defining the clinical syndrome. Br J Sports Med. 2012 Sep 14.
Lequesne et al. 2008; Arthritis & Rheumatism 59:241
Segal et al. 2007; Arch Phys Med Rehabil 88:988
Segal et al. 2008; Arthritis Res Ther 10: R62
CONCLUSION:
The effectiveness of the various treatment modalities
needs to be tested in carefully
conducted randomized controlled trials.
Del Buono A, Papalia R, Khanduja V, Denaro V, Maffulli N. Management of the
greater trochanteric pain syndrome: a systematic review. Br Med Bull. 2012
Jun;102:115-31.
CONCLUSION:
The effectiveness of the various treatment modalities
needs to be tested in carefully
conducted randomized controlled trials.
Repetitive low-energy radial shock wave therapy and home
training approach provide beneficial effect over months,
with almost 80% success rate at 15 months.
Del Buono A, Papalia R, Khanduja V, Denaro V, Maffulli N. Management of the
greater trochanteric pain syndrome: a systematic review. Br Med Bull. 2012
Jun;102:115-31.
Each patient received 1 low-energy treatment. N= 66
Conclusion: Shock wave therapy is an effective treatment for
greater trochanteric pain syndrome.
Study Design: Case control study; Level of evidence, 3.
Furia JP, Rompe JD, Maffulli N. Low-energy extracorporeal shock wave therapy
as a treatment for greater trochanteric pain syndrome. Am J Sports Med. 2009
Sep;37(9):1806-13.
Hypothesis:
The null hypothesis was that local corticosteroid injection,
home training, and repetitive low-energy shock wave
therapy produce equivalent outcomes 4 months from baseline.
Study Design:
Quasi-randomized clinical trial; Level of evidence, 2.
Methods:
229 patients with unilateral greater trochanter pain syndrome were
assigned to:
1.- A home training program,
77 patients.
2.- A single local corticosteroid injection (25 mg prednisolone),
76 patients.
3.- A repetitive low-energy radial shock wave treatment.
76 patients.
INCLUSION CRITERIA
• Local tenderness on palpation of the area of the greater trochanter
• Pain located anterior, lateral, or posterior to the greater trochanter
for more than 6 months
• Pain while lying on the affected site
• Positive resisted rotation test
Lequesne et al. 2008;
Arthritis & Rheumatism 59:241
Lequesne et al. 2008; Arthritis & Rheumatism 59:241
Segal et al. 2007; Arch Phys Med Rehabil 88:988
Segal et al. 2008; Arthritis Res Ther 10: R62
EXCLUSION CRITERIA
• History of acute trauma. Acute low back pain.
• Presence of signs and symptoms of another cause
of regional hip pain, such as dysplasia, deformities,
sciatica. Bilateral GTPS.
• Previous injection of the trochanteric area during the
preceding 6 months.
• Previous spinal or hip surgery.Local infection to the hip joint region.
• Blood coagulation disorders or use of anticoagulant
Medication
.
• Any known kind of vascular, neurologic, or neoplastic
comorbidity.
Eligible
Patients
(n= 229)
Home Training
Program
(n= 76)
Corticosteroid
Injection
(n= 75)
Shock Wave
Therapy
(n= 78)
Follow-Up
4 Months
(n= 71)
Follow-Up
4 Months
(n= 69)
Follow-Up
4 Months
(n=73)
Subjects from the various groups did not differ
clinically significantly regarding their baseline characteristics
(all P > .05).
Home training program
All exercises were to be performed
twice a day,
7 days a week, for 12 weeks.
GROUP 2: CORTICOSTEROID INJECTION
Position of Patient. The patient should be in the lateral recumbent position with the affected side
up. For the patient’s comfort and stabilization, the hip is flexed 30 to 50 degrees and the knee is
flexed 60 to 90 degrees.
Palpation of Landmarks. The greater trochanter is identified by palpating the femur from the
mid-shaft proximally until the area of bony protrusion is reached. The injection site is the point
of maximal tenderness or swelling.
Approach and Needle Entry. At the area most tender or swollen to palpation in the region of the
greater trochanter, a 22- or 25-gauge, one and one-half–inch needle is inserted perpendicular to
the skin. In very obese patients, a longer needle may be required. The needle should be inserted
directly down to bone and then withdrawn two to three millimeters before injecting.
Cardone and Tallia 2003; Am Fam Physician 67:2147
5 mL Mepivacain 0.5% (= Meaverin
0.5%) +
1 mL Prednisolone 25 mg (= Predni 25
Kristallsusp.)
www.painmngt.com
All patients were invited to see the physician after 2 and 4 weeks to secure the
same number of physician-subject contacts as in the other groups.
Group 3: Radial Shock Wave Therapy
The patients were treated in 3 sessions
(at interval of one week)
with 2000 impulses per session.
Energy flux density: 0.12 mJ/mm2.(3 bar)
Frequency: 8 Hz
Device used: Swiss Dolor Clast (EMS)
Subjects underwent outcome
assessments at baseline and at 1,
4, and 15 months.
Primary outcome measures were degree of
recovery, measured on a 6-point Likert scale
(subjects with rating completely recovered or much
improved were rated as treatment success), and
severity of pain over the past week (VAS 0-10
points)
Likert scale
1. “completely recovered”
2. “much improved”
3. “somewhat improved”,
4. “same”
5. “worse”
6. “much worse”
“completely recovered”
or “much improved”
were counted as successes.
RESULTS:
RESULTS: LIKERT SCALE
Main Outcome
Measure
SUCCESS RATE (%)
DEGREE OF RECOVERY
100
N.S.
90
<.01.
<.001
N.S.
<.001
80
N.S.
<.001
<.001
<.001
80
75
70
74
68
60
50
51
40
48
41
30
Home Tr.
Corticoid Inj.
Shock Wave
20
10
0
13
7
0
1 Mo
4 Mo
15 Mo
from baseline
RESULTS: NUMERIC RATING SCALE
Main Outcome
Measure
10
9
N.S.
8
7
VAS
6
5
N.S.
N.S.
N.S.
6.2
5.8
<.001
<.001.
6.3
5.9
N.S.
<.001.
<.01.
N.S.
5.6
<.001
<.001
Home Tr.
Corticoid Inj.
Shock Wave
5.3
5.2
4.5
4
3
3.2
2.7
2
2.2
2.4
1
0
0
1 Mo
4 Mo
15 Mo
from baseline
These side effects were observed:
petechiae (32 %)
CONCLUSIONS:
The significant short-term superiority of a single corticosteroid injection
over home training and shock wave therapy declined after 1 month.
Corticosteroid injection was significantly less successful than was home
training or shock wave therapy at 15-month follow-up.
Both corticosteroid injection and home training were significantly less
successful than was shock wave therapy at 4-month follow-up.
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Brinks A, van Rijn RM, Willemsen SP, Bohnen AM, Verhaar JA, Koes BW,
Bierma-Zeinstra SM. Corticosteroid injections for greater trochanteric pain
syndrome: a randomized controlled trial in primary care. Ann Fam Med. 2011
May-Jun;9(3):226-34.
Patellar tendinopathy
Antoni Morral
Etiology
Tendinopathy is a failed healing response of the tendon.
Maffulli N, Longo UG, Denaro V.
Novel approaches for the management of tendinopathy.
J Bone Joint Surg Am. 2010 Nov 3;92(15):2604-13. Review.
Tendinopathy cycle
Increased demand on tendon
Adequate repair
(Adaptation)
Increased vulnerability
to further injury
Inadequate repair
Decreased collagen
& matrix production
Further decrease in
collagen & matrix
Tenocyte death
Mechanical theory
•Overload
•Overuse
•Repeated and/or prolonged stressing
•Repetitive microtrauma
•Chronic repetitive damage
Ker RF. The implications of the adaptable
fatigue quality of tendons for their
construction, repair, and function.
Comp Biochem Physiol A Mol Integr Physiol.
2002;133:987-1000.
Vascular theory
Knobloch K. The role of tendon microcirculation in Achilles and patellar
tendinopathy. J Orthop Surg Res. 2008 Apr 30;3:18.
Oxygen-to-see probe, a combined laser Doppler and spectrophotometry
system to determine Achilles microcirculation non-invasively. (Tendon
capillary blood flow, tendon oxygen saturation, and tendon
postcapillary venous filling pressures)
Neural theory
Björklund E, Forsgren S, Alfredson H, Fowler CJ. Increased expression of
cannabinoid CB₁ receptors in Achilles tendinosis. PLoS One. 2011;6(9):e24731.
Epub 2011 Sep 8.
The origin (or cause) of pain in the body of a tendon or at the enthesis is
presently unknown.
Maffulli N, Longo UG, Maffulli GD, Khanna A. Achilles tendon ruptures in elite athletes.
Foot Ankle Int. 2011 Jan;32(1):9-15.
FACTORES DE RIESGO
The evidence for the identified risk factors was only limited:
•weight
•body mass index
•leg-length difference
•quadriceps flexibility
•hamstring flexibility
•quadriceps strength
•vertical jump performance
van der Worp H, van Ark M, Roerink S, Pepping GJ, van den Akker-Scheek I,
Zwerver J. Risk factors for patellar tendinopathy: a systematic review of the
literature. Br J Sports Med. 2011 Apr;45(5):446-52.
78 Volleyball players competing in the Victorian State League, Australia.
48 men and 30 women.
CONCLUSIONES:
Los hombres (pero no las mujeres) con una postura de pie normal eran más
propensos a tener PT en comparación con los hombres con un tipo de pie pronado.
de Groot R, Malliaras P, Munteanu S, Payne C, Morrissey D, Maffulli N. Foot
posture and patellar tendon pain among adult volleyball players. Clin J Sport
Med. 2012 Mar;22(2):157-9.
Q-Angle
The Q-angle is the angle formed
by a line from the anterior
superior spine of the ilium to
the middle of the patella and a
line from the middle of the
patella to the tibial tuberosity.
Males typically have Q-angles
between 10 to 14o, females
between 15-17o.
90 junior elite basketball players.
Ankle dorsiflexion range is a risk factor for developing PT in basketball players.
Players with dorsiflexion range less than 36.5° had a risk of 18.5% to 29.4% of
developing PT within a year, as compared with 1.8% to 2.1% for players
with dorsiflexion range greater than 36.5°.
Limbs with a history of 2 or more ankle sprains
had a slightly less mean ankle
dorsiflexion range compared to those
with 0 or 1 sprain (mean difference, -1.5° to -2.5°),
although this was only statistically significant for
nondominant legs.
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Backman LJ, Danielson P. Low range of ankle dorsiflexion predisposes for
patellar tendinopathy in junior elite basketball players: a 1-year prospective
study. Am J Sports Med. 2011 Dec;39(12):2626-33.
2001 -2009, the authors followed 51 European elite soccer clubs (2229 players)
1.5% of all injuries and corresponding to an incidence of 0.12 injuries/1000 hours.
Exposure to did not increase the prevalence or incidence of injury.
High total amount of exposure was identified as a risk factor for patellar tendinopathy
Hägglund M, Zwerver J, Ekstrand J. Epidemiology of patellar tendinopathy in
elite male soccer players. Am J Sports Med. 2011 Sep;39(9):1906-11.
102 volleyball players
Engrosamiento AP del tendón patelar leve
(> 4,2 mm entre los hombres, > 4 mm entre las mujeres)
pueden indicar patología entre los deportistas activos. Normal: 7 mm
Malliaras P, Cook J. Changes in anteroposterior patellar tendon diameter
support a continuum of pathological changes. Br J Sports Med. 2011
Oct;45(13):1048-51.
1505 Basketball and volleyball players between 18 and 35 years.
Heavy physically demanding work
seem to have an increased risk for
developing patellar tendinopathy.
van der Worp H, Zwerver J, Kuijer PP, Frings-Dresen MH, van den Akker-Scheek
I. The impact of physically demanding work of basketball and volleyball players
on the risk for patellar tendinopathy and on work limitations. J Back
Musculoskelet Rehabil. 2011;24(1):49-55.
Estudio en proyecto. Tendón rotuliano en ratas
Abboud JA, Beason DP, Soslowsky LJ. Emerging ideas: the effect of
hypercholesterolemia on tendons. Clin Orthop Relat Res. 2012 Jan;470(1):317-20.
Campeonato Europeo de atletismo de veteranos en Poznań en julio de 2006,
174 atletas (103 hombres y 71 mujeres; edad media: 53,8 años (35-82)
En atletas veteranos de atletismo el perfil de impacto, el peso, la altura, la edad
y el sexo no ejercen ninguna influencia en el desarrollo de Tendinopatía patelar.
Longo UG, Rittweger J, Garau G, Radonic B, Gutwasser C, Gilliver SF, Kusy K,
Zieliński J, Felsenberg D, Maffulli N. Patellar tendinopathy in master track and
field athletes: influence of impact profile, weight, height, age and gender. Knee
Surg Sports Traumatol Arthrosc. 2011 Mar;19(3):508-12.
20 junior pre-elite male basketball athletes.
•Hip joint range of motion (ROM),
•Quadriceps flexibility
•Knee joint angle at initial foot-ground contact during stop-jump
(talonamiento)
This enables identification of asymptomatic athletes at higher risk of developing
patellar tendinopathy, which allows the development of effective preventative
measures to aid in the reduction of patellar tendinopathy injury prevalence.
Mann KJ, Edwards S, Drinkwater EJ, Bird SP. A lower limb assessment tool for
athletes at risk of developing patellar tendinopathy. Med Sci Sports Exerc. 2012
Oct 10.
La PT no se debe a la magnitud de la carga del tendón rotuliano,
sino a los patrones de carga en la fase de “aterrizaje horizontal”
Una alta flexión de rodilla
y una baja flexión de
cadera.
Edwards S, Steele JR, McGhee DE, Beattie S, Purdam C, Cook JL. Landing
strategies of athletes with an asymptomatic patellar tendon abnormality. Med Sci
Sports Exerc. 2010 Nov;42(11):2072-80.
Evidencia científica
Rees JD, Maffulli N, Cook J. Management of tendinopathy. Am J Sports Med. 2009 Sep;37(9):1855-67
Levels of evidence:
1.- Strong: Consistent findings among multiple
hight-quality RCTs.
2.- Moderate: Consistent findings among multiple
low-quality RCTs and/or CCTs and/or one hight-quality RCT.
3.- Limited: One low-quality RCT and/or CCT.
4.- Conflicting: Inconsistents findings among multiple trials
(RCTs and/or CCTs).
5.- No evidence from trials: No RCTs or CCTs.
van Tulder M, Furlan A, Bombardier C, Bouter L. Updated method guidelines for systematic
reviews in the Cochrane Collaboration Back Review Group. Spine 2003; 28: 1290–1299.
2003
STUDY DESIGN:
Cross-section with control group; Level of evidence, 3
2003
STUDY DESIGN:
Cross-section with control group; Level of evidence, 3
STUDY DESIGN:
RCT; Level of evidence, 2
2007
The American Journal of Sports Medicine, Vol. 35, No. 6, Mar, 2007
SW as a solitary treatment during the competitive season has no benefit over
placebo treatment in the management of actively competing jumping athletes with
patellar tendinopathy who have symptoms for less than 12 months.
STUDY DESIGN:
RCT; Level of evidence, 1
2011
Zwerver J, Hartgens F, Verhagen E, van der Worp H, Diercks RL. No Effect of Extracorporeal Shockwave
Therapy on Patellar Tendinopathy in Jumping Athletes During the Competitive Season:
A Randomized Clinical Trial. Am J Sports Med. 2011 Feb 1.
Furia JP, Rompe JD, Cacchio A, Del Buono A, Maffulli N. A single application
of low-energy radial extracorporeal shock wave therapy is effective for the
management of chronic patellar tendinopathy. Knee Surg Sports Traumatol Arthrosc.
2013 Feb;21(2):346-50.
STUDY DESIGN:
CT; Level of evidence, 3
CONCLUSION: A single application of radial SWT is an
effective treatment for chronic patellar tendinopathy.
Larsson ME, Käll I, Nilsson-Helander K. Treatment of patellar tendinopathy--a
systematic review of randomized controlled trials. Knee Surg Sports Traumatol
Arthrosc. 2012 Aug;20(8):1632-46.
Strong evidence was found for the use of
eccentric training to treat patellar tendinopathy.
25 grados
Larsson ME, Käll I, Nilsson-Helander K. Treatment of patellar tendinopathy--a
systematic review of randomized controlled trials. Knee Surg Sports Traumatol
Arthrosc. 2012 Aug;20(8):1632-46.
Protocolo
•
•
•
•
•
•
3 series de 15 repeticiones, 2 por día
Lentas, con control del movimiento
Retorno pasivo a la posición inicial
Leve sensación de dolor
Incremento de la carga en relación al dolor
6 a 12 semanas
PROBLEMAS DE ADHERENCIA AL TRATAMIENTO !!!!!
Moderate evidence was found for conservative treatment
(heavy slow resistance training) as an alternative to eccentric training
Larsson ME, Käll I, Nilsson-Helander K. Treatment of patellar tendinopathy--a
systematic review of randomized controlled trials. Knee Surg Sports Traumatol
Arthrosc. 2012 Aug;20(8):1632-46.
Protocolo
NO
The program lasts a total of 12 weeks.
15 repetitions maximum (RM) during week one
12 RM weeks 2-3
10 RM weeks 4-5
8 RM weeks 6-8
6 RM weeks 9-12
You should complete four sets of each exercise
with 2-3 minutes rest between sets.
3 sessions per week
During each exercise you should not go below
90 degrees of knee flexion at any time.
It is also suggested that you count 3 seconds
for both the lower (eccentric) and raise (concentric)
phase of each exercise. Total: 6 seconds.
You can continue to play your normal sport as long as your pain does not exceed 3/10 in severity
Limited evidence
Moderate evidence
Limited evidence
Limited evidence
sclerosing injections
Larsson ME, Käll I, Nilsson-Helander K. Treatment of patellar tendinopathy--a
systematic review of randomized controlled trials. Knee Surg Sports Traumatol
Arthrosc. 2012 Aug;20(8):1632-46.
CONCLUSIONS:
The current literature is complicated by a lack of standardization of study protocols,
platelet-separation techniques, and outcome measures.
As a result, there is uncertainty about the evidence to support the increasing clinical use of
platelet-rich plasma and autologous blood concentrates as a treatment modality for
orthopaedic bone and soft-tissue injuries.
Sheth U, Simunovic N, Klein G, Fu F, Einhorn TA, Schemitsch E, Ayeni OR,
Bhandari M. Efficacy of autologous platelet-rich plasma use for orthopaedic
indications: a meta-analysis. J Bone Joint Surg Am. 2012 Feb 15;94(4):298-307.
Intensidad,
frecuencia,
volumen,velocidad.
tiempo
Injury
Charles Robert Darwin (1809-1882)
Adaptation theory, is an organism's ability to adapt to
changes in its environment and adjust accordingly over time.
Medicus curat, natura sanat
The physician treats, nature cures
Honestidad: SWT 2ª línea
Paciencia: 3-4 meses