Évaluation de la gravité des lésions du ligament collatéral latéral de cheville : étude de corrélation clinique-échographie

The clinical examination is sometimes insufficient to assess the severity of lateral collateral ligament (LCL) sprain of the ankle, making it difficult to choose the most appropriate treatment. The purpose of this study was to compare retrospectively the observed or reported clinical signs assessed two days after the trauma and ultrasound findings in patients who experienced a recent ankle inversion trauma. Between 1st May and 1st November 2004, 34 patients referred in the sports medicine service were clinically examined in a standardized way two days after the injury, and underwent an ultrasound by the same operator. No isolated clinical sign was correlated with the severity of ligamentous lesions revealed by ultrasound. Taking in account the whole set of the clinical signs appear to better guide for diagnosing the presence or absence of a ligament rupture: positive predictive value if the presence of all the signs equal to 75% for the anterior talofibular ligament (LTFA) and 88% for fibular ligament (CFL), negative predictive value if all the signs of lack of gravity equal to 80% for LTFA and 62% for the CFL. These results confirm the lack of correlation between clinical signs and Imaging findings in ankle sprains. They raise questions about the adequacy of clinical classifications and suggest an expansion of indications for ultrasound in ambiguous situations, especially for athletes showing little signs of severity, to ensure optimal treatment and faster recovery.     

Prise en charge des fractures récentes de la clavicule

Fractures of the clavicle are extremely frequent (2,6 to 5% of all the fractures). They typically occur in male children or young adults before 25 years. Because of anatomical particularity of the bone, these fractures are involving the middle third of the bone in 69% to 82% of cases. Satisfactory results are often achieved with an orthopedic treatment. However, in some cases, increasing risks of poor functional outcomes, higher risk of pseudarthrosis, ungraceful results or delayed work resumption lead to choose a surgical treatment. Many surgical procedures are described by authors to treat these fractures, but actually, there is no common consensus for surgical indication. The admitted shortening value for a surgical treatment is 20 mm. However, Altamini has shown the superiority of a surgical treatment in terms of functional results and decreasing cases of nonunion and pseudarthrosis in cases of fractures involving the middle third part of the bone.     

Évaluations prédictives de l’entorse de cheville. À propos de 58 cas

When an injury comes out, it is seen like a fatality for a sportsman and the medical staff. The ankle sprain is from far the most common pathology. Preventions programs proved their efficiency in many fields. However, it is very hard to put them into practice because there is few or no tools to these persons. The goal of this work is to provide assessments reliable, reproducible and non-dependent operator that will identify potential topics victim of a sprain ankle in the medium term. We tested 58 youngs healthy athletes whose sport practice was up to 2 hours a week. We have made assessments on a motor coordination machine, on a posturography platform and we analysed the muscular benefits of each lower limbs thanks to a accelerometer. These analyses have been done in November 2007, January 2008 and March 2008. We sorted out five articulars instability. Topics victims of the ankle sprain during the study got a 13% coordination deficiency. The difference is statisticly significant. All the tests which have been done on the postuography plateform were not accepted because the evaluation results were not comparables with the 1985 norms of the French Association of Posturology. We were able to see a curve problem with wounded patients during the ground absorbtion phase and had a stabilisation time shorter than the one for the healthy subjects. This significative difference was up to 110 ms. Pope et al. find out on patients hit by a talocrural sprain, a significative diminution of the dorsiflexion during the previous traumatism report. Willems et al. find these facts and describe others intrinsic factors of predisposition which match our results. Our work proved that it is possible to warn, in a mid term, the sprain of the ankle. These warnings reports must be done in the beginning of the sporting season and will allow to determine the athletes weakness thanks to reliable and reproducible evaluations.     

Coalitions du tarse ou « fausses entorses » de l’enfant et de l’adolescent. À propos d’un cas

Tarsal coalitions, also called synostoses, are a cause of pain and gait disturbance in children and adolescents. They are often diagnosed as tarsal sprains, leading to an inappropriate functional prognosis. This is the case of an 8-year-old child with talo-calcaneum synostosis, presenting pain, hind-foot stiffness and marked disability in daily life activities and sports.     

Contrôle de l’équilibre et port unilatéral d’une orthèse rigide de cheville. Partie II : effets sur des sujets sains évalués debout en bipédie

In order to compare the effects induced by the unilateral wearing of a rigid orthosis (Thuasne, Ligacast Immo^®) in comparison to a reference model consisting of an elastic stocking, balance control strategies of 14 healthy subjects have been evaluated in two-legged standing. To this aim, 10 trials lasting 32 s have been recorded through a device made of two separate force platform allowing the separate measurement of the reaction forces intervening under each foot. Balance strategies have been assessed from the centre of pressure trajectories issued from the left (CP_G) and right feet (CP_D) and, through a calculation, from the resultant CP (CP_Res). These various trajectories, projected along mediolateral (ML) and anteroposterior (AP) axes, have been then analysed in the frequency domain. If no difference has been observed for the CP_Res trajectories, the separate analysis of each support has furnished statistically significant results for the CP trajectories measured under the foot wearing the orthosis since the amplitudes decrease along both ML and AP axes. Contrary to what was observed in the previous study conducted in one-legged standing, with effects occurring only along the AP axis, these results appear thus in better accordance with the objectives of an orthosis since diminishing the involvement of the lateral ligaments. This kind of protocol appears thus more relevant for characterising in situ the effects of an orthosis made of two rigid shells.     

Contrôle de l’équilibre et port unilatéral d’une orthèse rigide de cheville. Partie I : effets sur des sujets sains évalués debout en unipédie

In order to assess the effects induced by wearing a rigid ankle orthosis, 14 healthy adults, without traumatic previous injuries at this level, were tested in a one-legged postural task. The subjects stood upright on a force platform and were required to remain still, eyes open. Ten trials lasting 32 s were recorded in a random order in two conditions: with a rigid orthosis model worn at the ankle level of the supporting leg (Thuasne, Ligastrap Immo^®) and with an elastic stocking. Balance strategies have been quantified by studying the centre of pressure (CP) trajectories, that is, the successive positions of the resultant reaction forces, and processed through a frequency analysis. The results indicate that slight decreases occur for the CP displacements intervening along the medio-lateral axis whereas statistically significant trends were found for those intervening along the anteroposterior one. This finding a priori suggests that wearing a rigid orthosis affects one-legged standing in healthy individuals but mainly along an axis not usually weakened by sprained ankles.     

Prise en charge thérapeutique des pubalgies de l’adulte sportif

Groin pain is a very complex pathology in sports. We described our experience in therapeutic management of male athletes in each specific clinical form of groin pain and for each step of treatment and rehabilitation.     

La prise en charge rééducative globale de patients présentant un syndrome fémoro-patellaire : la lutte contre l’effondrement du membre inférieur par le renforcement du moyen fessier

The patellofemoral pain syndrome (PPS) is characterized by anterior knee pain and poor patellar kinetics. In this review, we focus on primary PPS. Several local factors are known to provoke knee pain (subchondral bony disorders, retraction of the lateral retinaculum, inflammation of the infrapatellar adipose pad). Furthermore, proximal factors involving the hip and pelvis as well as distal factors involving the ankle and foot explain the impact on lower limb mechanics, for instance on single-stance squat. In the 1980s, the gold standard management strategy for PPS was to strengthen the vastus medialis in order to counter lateral subluxation of the patella during knee flexion. More recently, with improved techniques for neuromuscular biomechanical investigations, several publications propose reinforcing the hip abductor muscles for PPS. This offers a more global approach by correcting the posture of the entire lower limb to provide relief from this difficult-to-treat complex syndrome. Strengthening the hip abductors (gluteus medius) appears to be the best way to eliminate the single-stance lower limb postural failure leading to several musculoskeletal disorders. This new approach to rehabilitation is a validated evidence-based therapeutic strategy.     

Apport de l’exercice physique et du régime dans la prise en charge de la gonarthrose chez l’obèse

Objective

Our objective was to determine whether exercise and weight loss are more effective either separately or in combination, in improving pain and physical function in obese adults with moderate knee osteoarthritis (OA).

Patients and methods

Forty-five obese adults, with a body mass index greater than 35 kg/m² or 30 ≤ BMI < 35 associated to at least one cardiovascular risk factor, suffering from knee pain with evident radiographic signs of knee OA, were involved in our study. All patients were evaluated at baseline and at the end of the study. The assessment parameters were weight loss, the bioelectric impedance analysis, pain, six-minute walk distance, cardiovascular parameters, and muscular strength. The physical function was measured with the Womac and the Lequesne indexes. Patients were randomized into four groups, a control group (G1), exercise only group (G2), diet plus exercise group (G3) and diet only group (G4).

Results

There was no difference between the four groups at baseline. Significant improvement of function (Womac) was noticed in groups performing exercise only (G2) (26 %), diet plus exercise (G3) (37,89 %) and diet only (G4) (18,34 %). We also noticed an improvement in pain in G2 (p = 0.04), G3 (p < 0.001) and G4 (p = 0.02). The improvement of quadriceps strength was noted only in G2 (p = 0.01) et G3 (p = 0.001) without any change in control group and diet only group (G4). The improvement of cardiovascular parameters was observed only in G2 and G3. Weight loss, decreased BMI and waist circumference was more important in diet plus exercise group (G3).

Conclusion

The combination of weight loss and exercise provide better improvements in physical function and pain in obese adults with knee OA compared with either intervention alone. Exercise used alone or associated to dietary provides better improvements in physical capacity and muscle strength.     

Instabilité d’épaule et isocinétisme : apport de l’isocinétisme dans une situation clinique complexe

Introduction

The treatment of shoulder instability is codified. In case of a resistant instability to a well-conducted rehabilitation, the surgery can be proposed with good results. Sometimes, the situation can be more complex, and the case report presents the interest of isokinetics as an alternative therapeutic.

Case report

A man of 36 years, operated of Latarjet for recurrent anterior dislocation of the shoulder, presented in postoperation an infectious osteoarthritis. After recovery of the infectious episode, in a painful and stiffness shoulder, shoulder instability repeated with a clinical examination agreeing and an evocative context: failure of the surgical treatment, osseous postinfectious rehandlings. The surgery having been excluded and traditional rehabilitation having shown its limits. A rehabilitation oriented by the research of a muscular imbalance in isokinetic evaluation permitted a functional improvement with disappearance of the instability feeling.

Discussion

In complex clinical situations, isokinetic evaluation showed an interest to adapt and to optimize rehabilitation. A practical application of isokinetics is in the pathologies of articular instability and in particular the shoulder instability. The positions of evaluation will be adapted to the patients. That opens new prospects in rehabilitation.

Conclusion

This case report illustrates isokinetic interest for an objective and rigorous assessment of muscular strength and so an adaptation and optimization of the rehabilitation.     

Influence du type d’orthèse de genou sur l’évolution clinique postopératoire d’une chirurgie du ligament croisé antérieur chez le sportif

Objectives

To establish the influence of the type of brace on the postoperative clinical evolution after anterior cruciate ligament (ACL) surgery in competitive sportspeople.

Methods

The authors prospectively followed the evolution of three populations of ACL reconstruction: one who received a functional brace, the other a rigid brace and last no brace. The three groups followed the same rehabilitation program. The clinical parameters of evaluation were pain, perimeter patellar joint, range of motion, muscular atrophy, locking the quadriceps, and the quality of walking. We also used the IKDC subjective Knee Evaluation Form and PPLP scoring scale.

Results

There is no clinically significant difference at about a month of surgery between the three groups (407 patients). There is no difference with the PPLP scoring scale. No repeat rupture is occurred postoperatively. There is a significant difference in the IKDC subjective (P = 0.03) between the group with functional brace and rigid brace.

Conclusion

With the same active rehabilitation program, the clinical evolution is identical with or without brace. The only difference is subjective (IKDC subjective Knee Evaluation Form).     

Traitement de la laxité latérale de cheville par ligamentoplastie à l’hémitendon du court fibulaire avec remise en tension capsuloligamentaire

The authors developed an original method, using tenodesis and anatomical repair, for the treatment of lateral chronic instability of the ankle in young military people. In this medium-term retrospective study, 32 patients were rewieved for functional and radiological evaluation. With a mean follow-up period of 20 months (range from six to 64 months), 90.6% (n = 29) of the patients were “satisfied” or “very satisfied”, 78.1% (n = 25) were painfree, but 15,6% (n = 5) complained about stiffness. Ninety-seven percent of them (n = 31) returned to athletic activity and no instability occured. The mean score for the Olerud and Molander Ankle Score was 91.5 (range from 70 to 100). On postoperative stress radiographs the mean side-to-side talar tilt difference was 0.6 ± 2.9°. The mean loosening of eversion isometric strength on the ankle operated was 5.4%. The present study demonstrates that this mixed procedure give excellent results in terms of stability, despite of a well-tolerated stiffness.     

Évaluation des orthèses de genou et de cheville en pathologie de l’appareil locomoteur. Avis d’experts

A french committee of experts worked to create an assessment methodology for knee and ankle orthoses in order to evaluate the beneficial effects of these devices in current pathologies. It lead to the establishment of a simple evaluation tool for knee and ankle orthoses.     

Épidémiologie du syndrome de surentraînement chez le sportif : étude pilote sur 176 sportifs amateurs et professionnels

Overtraining syndrome is classically seen among athletes. It is characterized by a decrease in performance despite training, mood changes, and a chronic fatigue. With the aim to determine its prevalence, a validated questionnaire (French Society of Sport Medicine) completed with a panel of subsidiary questions was given to 176 Swiss athletes between May and June 2009. The results showed a prevalence of 13% (± 5%) in this sample of athletes. We found a statistically significant relationship between overtraining and existence of menstrual disturbances, antecedents of overtraining or illness in the last six months. This very high prevalence has to encourage all the medical staff around athlete to increase their knowledge for this pathology. The prevention has to become the key-element. In fact, when overtraining is installed, its management includes over all a prolonged interruption of physical and sport activities.     

Incidence des ruptures du LCA chez le jeune rugbyman et intérêt de la prévention

We followed two teams of young rugby players for two seasons to determine the incidence of anterior cruciate ligament (ACL) tears in these young athletes (2.45/1000 playing hours). Risk factors were quality of the playing field and insufficient physical training. In light of the data in the literature, we consider that prevention based on awareness of the risk factors can and should play a crucial role in decreasing the incidence of these serious sports accidents.     

Plaidoyer pour une mobilisation précoce dans les ruptures du tendon calcanéen opérées

This work puts forward a quick program of rehabilitation for operated Achilles’ tendons. From a review of the literature, we call back the following in the rehabilitation of tendinous ruptures over a period of 25 years. We insist on the interest of such a method in order to improve the overall care of the patients. There are many theoretical benefits such as a better scar on biomechanical aspects, quicker articular amplitudes, less complication due to immobilization, less physical therapy sessions, a quick return to physical and professional activities. To train such mobilizations, different devices are used either articulated splints close to the instep, or anterior/posterior plastered splints of the leg. Whatever device has been chosen, it allows gentle mobilizations of the ankle while protecting the surgical act by locking the dorsal flexion of the foot. This kind of therapy must be appropriate to the patient and be especially supervised by PMR doctors in order to avoid a repeated rupture which is the main complication.     

Test isocinétique précoce après ligamentoplastie antérieure de genou : résultats et conclusions

Objectives

To compare 4-months isokinetic results after anterior cruciate ligament reconstruction with patellar tendon or hamstring tendons.

Material and methods

A retrospective study during 5 years concerning isokinetic records from patients who went to our rehabilitation center after anterior cruciate ligament reconstruction, and who did an isokinetic test 4 months after surgery. There was 146 patients, 116 males and 30 females, 69 with hamstring reconstruction and 77 with patellar tendon reconstruction.

Results

In Kenneth-Jones surgery, there is more deficience on leg extensors, while hamstrings are more deficient after hamstrings reconstruction surgery. This deficience concerns peak torque and work, whatever speed.

Conclusion

Leg flexion deficience in hamstring reconstruction surgery is due to late work during reeducation, because of pain and injuries localized on sample area. There is also loose of biomechanical properties due to muscular fibrosis. For the two reconstruction surgeries, leg extension deficience is due to pain and edema.     

Rupture du LCA : cas de l’athlète féminine

Female athletes have 2–3 times more risks of ACL injury than male. Hormonal, anatomical and neuromuscular factors would explain this female predisposition. Prevention training, aimed to avoid “dynamic” valgus, leads to a reduction of ACL injury risks. These programs, including a neuromuscular training, improve knee dynamic control in female athletes and decrease the loadings on the ACL. The aim of this review is to make an inventory of the knowledge on this subject by analyzing theses predispositions and most specially the influence of the neuromuscular factors. Therefore, the purpose is to make a comparative assessment of the various prevention programs to determine the essential elements for an effective intervention of the physiotherapist.