Chronic Conditions

Chronic ankle & foot conditions: arthritis, malalignment, tendon pathology – diagnosis, conservative & surgical management options.

Overview

Management of chronic conditions requires a multifaceted approach that extends beyond acute intervention. Strategies effective across chronic illnesses benefit high-cost patients with low back pain [3]. Patients must be counseled on the increased risk of adverse events presented by medical comorbidities and optimized regarding these chronic conditions [10]. Individuals with chronic, incurable disorders require more than average support from their physician, necessitating a comprehensive program of care stressing continuity [118].

Surgical indications are increasingly defined by functional status and disability rather than rigid demographic or historical metrics. For ankle fractures resulting from rotational injuries, conditions such as diabetes or advanced age are no longer contraindications to usual management recommendations [12]. Surgical indication for gluteus medius tears is reserved for symptomatic patients who have failed a primary nonoperative protocol [84]. Surgical indications for anterior shoulder instability should focus primarily on the degree of demonstrable chronic disability rather than the number of documented dislocations [91]. Strict patient selection for surgery in recurrent posterior shoulder instability is advised, reserving it for those with significant pain and functional disability, as most patients function well with conservative management [115].

In joint arthroplasty and trauma reconstruction, evidence-based patient selection is becoming more inclusive. BMI should not be used as an exclusion criterion for primary total joint arthroplasty at ambulatory surgical centers, as BMI greater than 40 is not correlated with early complications in this setting [107]. Focusing on management of preoperative comorbidities and custom surgical planning can achieve outcomes comparable to those of patients with normal BMIs in ambulatory surgical centers [107]. For medial unicompartmental knee arthroplasty, short-term patient-reported outcomes and survivorship are similar between groups based on indications, though stricter indications potentially lead to underutilization [74]. Future studies on sustained compression for tibiotalocalcaneal arthrodesis should focus on cost-effectiveness, long-term outcomes, and patient-specific optimization [15]. The appropriate indications and long-term outcomes of biologic enhancement options for stress fracture healing in athletes are yet to be determined [85]. Indications, contraindications, and best practices for three-dimensional metallic implants for reconstruction of critical bone defects after trauma will continue to be refined as more outcomes data become available [92].

Anatomy & Pathophysiology

Osseous & Articular Mechanics

The fibula serves as a dynamic bone critical for the kinematics and kinetics of both the knee and ankle joints [24], with its dynamic role being equally vital for the knee as it is for the ankle [55]. Restoration of normal fibular length is crucial to restore the biomechanics of the ankle [60]. Within the ankle, cartilage properties vary significantly across topographic locations, with opposing articulating surfaces exhibiting distinct biomechanical and biochemical properties [56]. Defects in the ankle talus cartilage significantly affect ankle biomechanics, particularly during midstance and push-off phases [44]. When blood-induced cartilage damage alters ankle joint load during walking, no compensatory biomechanical function is observed in other foot joints [40].

Ligamentous & Syndesmotic Integrity

Dynamic congruency of the joint, influenced by ligamentous integrity, remains the main anatomical component in mechanical ankle instability, whereas three-dimensional talar shape is not a factor [46]. Syndesmosis repair results in greater syndesmosis length and altered kinematics compared to the healthy side during all tested activities [49]. The anatomy, biomechanics, diagnosis, and treatment of high ankle sprains share striking similarities with ACL knee injuries [36]. Accurate diagnosis of anatomy, biomechanics, and soft tissue structures is fundamental to correctly identify patients requiring conservative or surgical treatment to prevent chronic ankle instability [39]. Careful clinical and radiographic evaluation, coupled with a thorough understanding of the anatomy and biomechanics of the foot, allows accurate evaluation and appropriate treatment [52].

Kinematics & Neuromuscular Control

It is important to include the kinematics and kinetics of the hip and ankle joint in all 3-dimensional planes [25]. The existence of the Achilles tendon and ankle position have a great influence on the kinematic coupling relationship between tarsal bones, whereas increased stiffness of the Achilles tendon has no influence on this relationship [28]. Subjects with functional instability exhibit altered neuromuscular control and kinematics of their ankle joints [30]. Ankle functional impairments exist in patients with diabetes, with or without neuropathy, suggesting mechanisms besides neuropathy contribute to altered foot-ankle biomechanics [34]. The injured and uninjured sides of individuals with chronic ankle instability (CAI) demonstrate biomechanical characteristics associated with an increased risk of ankle sprain during unanticipated jumps [59]. Increased subtalar rotational motion occurs in patients with symptomatic ankle instability under load and stress conditions, and differences in kinematics between symptomatic and asymptomatic hindfeet are demonstrated when both feet are compared [64]. Ankle position from 0° to 30° of plantarflexion does not change axial CT measurements of the syndesmosis in a cadaveric model [65].

Alignment & Systemic Biomechanics

Functional alignment in knee arthroplasty is associated with smaller changes in ankle alignment parameters, indicating better preservation of native joint positioning [37].

Classification

Symptom-Based Subgroups: Common symptoms such as pain intensity and depressive and anxiety symptoms in chronic pain conditions carry important information that can be used to identify clinically relevant subgroups [4].

Platelet-Rich Plasma (PRP): Classification systems and identification of differences among products are needed to understand the implications of variability in platelet-rich plasma applications [66].

Reflex Sympathetic Dystrophy (RSD): Use of each type of classification provides more precise clinical information to describe analyzed groups of reflex sympathetic dystrophy (RSD) patients [83].

Chronic Skeletal Disorders of the Forearm: There is a lack of a generally accepted classification system for chronic skeletal disorders of the forearm in adults [101].

Femoral Bone Defects in Revision Total Hip Arthroplasty: A consensus on a comprehensive and reliable classification system and management algorithm for femoral bone defects in revision total hip arthroplasty is still lacking [108].

Gait Disruption in Cerebral Palsy: The current gait disruption classification system uses the concept of primary versus compensatory deviations to identify common patterns and common causes for these patterns in children with cerebral palsy [111].

Primary Knee Arthroplasty Risk: A simple 4-part classification system based on local and systemic factors demonstrates significant differences between complex groups and standard patients in terms of complication rates and length of stay for primary knee arthroplasty [112].

Ehlers-Danlos Syndromes (EDS): The International EDS Consortium proposes a revised classification recognizing 13 subtypes of Ehlers-Danlos syndromes [119].

Tibial Plateau Fractures: Employing individualized classification systems remains the most logical approach for tibial plateau fractures [120].

TKA with Kinematic Alignment: The proposed classification system for TKA with the Kinematic Alignment technique describes six specific issues to consider, with specific recommendations for each situation type to improve the reliability of prosthetic implantation [122].

Chronic Achilles Disorder: There is no clear consensus on what defines a chronic Achilles disorder or a uniform classification and treatment scheme [123].

Non-Prosthetic Peri-Implant Fractures: A novel classification system for non-prosthetic peri-implant fractures has been proposed to aid further research [124].

Alternative Payment Models (APMs): The framework for alternative payment models includes a 4-part classification scheme for alternative payment models (APMs) and establishes 8 principles to guide their development [125].

Human Tendinopathy Pathophysiology: The identified inflammatory cell types in human tendinopathy favour a chronic inflammatory process, but the heterogeneity of data and lack of comparable studies means a common pathophysiology cannot be concluded from the systematic review [126].

ACL Tears in Pediatric and Adolescent Populations: A classification system for ACL tears in the pediatric and adolescent population provides a step to achieve specific goals [127].

Clinical Presentation

Accurate diagnosis of complex chronic conditions relies on precise knowledge of pathophysiological relationships [2]. In chronic pain, symptoms such as pain intensity and depressive or anxiety states identify clinically relevant subgroups [4]. Management strategies effective across chronic illnesses benefit high-cost low back pain patients due to comorbidity associations [3]. Recognition of pain dysfunction requires clinical experience and sensitivity to interpret patient history [26].

Inspection and history-taking are paramount for specific syndromes. Iliotibial band syndrome diagnosis depends on characteristic history and physical examination, with imaging reserved for recalcitrant cases [6]. Subacromial pain syndrome patients frequently present with conflicting or concomitant diagnoses [53]. Orchitis and infertility lack reliable epidemiological data, and noninvasive diagnostic techniques for chronic asymptomatic inflammation are unavailable [54].

Palpation and physical examination distinguish upper extremity pain sources via neurologic, musculoskeletal, vascular, and other etiologies [29]. For total hip arthroplasty, awareness of ilio-psoas tendon rupture signs aids diagnosis and management [35]. In chronic renal failure, aluminum intoxication osteomalacia should be considered in patients with bone pain [45]. Rheumatoid arthritis patients seek help for persistent, unmanageable symptoms, though some delay care [47].

Range-of-motion and stability assessments reveal acute-on-chronic risks. Subtalar subluxation recurs and becomes chronic if neglected [5]. Delayed diagnosis of posterior malleolar fractures impairs functional prognosis, causing longer incapacity and sequelae like cracking, pain, and stiffness [33]. Delayed acute osteomyelitis following closed fractures is common, indicated by persistent pain, fever, and increased local tissue reaction weeks post-injury [38].

Red-flag patterns and systemic presentations require urgent attention. Early, correct diagnosis of synovial sarcoma is critical, as misdiagnosis or delay has devastating consequences [31]. Acute medical conditions present in approximately one in ten elderly drivers involved in motor vehicle collisions [27]. Exercise testing remains the mainstay for diagnosing and treating pulmonary disorders in athletes [48]. Early coping strategies do not influence whiplash prognosis, and the CSQ is inappropriate for predicting chronic symptoms [50].

Orthopedic sports surgeons face complaints regarding complications, misdiagnoses, and uncontrolled pain [43].

Investigations

Plain radiography: Radiographs serve as the initial diagnostic test for femoral neck bone stress injuries in children and adolescents [96]. Key radiographic findings and a lowered threshold for additional imaging studies are essential for proper diagnosis of commonly missed peritalar injuries [63].

MRI: Noninvasive imaging technologies, particularly MRI, provide objective measures to better understand the natural history and mechanisms of diseases, optimize treatment, and assess the integrity of joint tissues [1]. MRI serves as a noninvasive tool that overcomes the shortcomings of radiography by detecting preclinical disease and subtle early abnormalities [76]. MRI is evolving as a complete answer to cartilage-imaging requirements for lesion description, treatment planning, and outcome measurement [76].

MRI shows the proper diagnosis and therapeutic approach for knee injuries in rock climbing and bouldering [58]. High-field magnetic-resonance imaging may provide a useful diagnostic adjunct in evaluating persistent symptoms in the ankle after trauma [93]. Assessment using MRI substantially modified treatment recommendations in one third of cases following anterior cruciate ligament reconstruction [99]. Assessment using MRI substantially modified treatment recommendations in one third of cases for tibial eminence fractures in pediatric patients [100].

For distal triceps tendon injury, MRI is valuable but is not always accurate, and false-positive results are not uncommon [81]. Treatment strategies for bone marrow edema vary based on symptom severity and MRI evidence [86]. Pathologic MRI findings in elite overhead athletes can be present but are often asymptomatic [95].

MRI did not confirm any significant cartilage condition improvement in patients with tibiofemoral cartilage degeneration treated with platelet-rich plasma [80]. In isolated patellofemoral joint arthroplasty, using only MRI for preoperative assessment resulted in a 31% failure rate due to progression of the disease [67]. MRI is time consuming, expensive, and can lead to treatment delays in diagnosing acute Achilles tendon ruptures [89].

CT: Diagnosis of retroperitoneal fibrosis relies on imaging (CT/MRI) and histology [62].

Other Considerations: Long-term follow-up studies are required to validate the predictive validity of noninvasive imaging technologies for clinical outcomes [1]. Longer-term clinical follow-up is needed to understand the clinical impact of radiological findings regarding arthroscopic capsulodesis combined with transtibial repair of posteromedial root lesions [70]. Longer-term clinical follow-up is needed to understand the clinical impact of radiological findings regarding medial meniscus posterior root repair delaying but not avoiding histological progression of osteoarthritis [71]. MRI-based imaging results for osteochondral lesion repair using MaioRegen® allograft need further clarification by mid-term studies [94].

Further imaging is usually necessary to establish the diagnosis and determine a treatment plan for femoral neck bone stress injuries in children and adolescents [96]. Adjunctive studies such as radiographs, magnetic resonance images, and electrodiagnostic studies aid in diagnosing radicular and nonradicular etiologies of cervical radiculopathy mimickers [72]. Clinical examination should be combined with imaging for accurate diagnosis and treatment planning of distal triceps tendon injury [81]. Clinicians should rely on history and physical examination rather than MRI for diagnosing acute Achilles tendon ruptures [89]. The sensitivity and specificity of imaging procedures for detecting recurrence of renal cell carcinoma remain unclear due to a lack of standardized follow-up protocols [87].

Treatment

Non-Operative Management

Conservative management serves as the primary intervention for a wide spectrum of chronic orthopaedic conditions. For chronic non-specific low back pain, multidisciplinary group videoconferencing is feasible and may shift patients from surgical to non-surgical candidacy [78], while general management approaches for chronic illnesses benefit high-cost patients with low back pain [3]. In the extremities, nonoperative treatment is almost always initiated for primary and posttraumatic elbow arthritis [41], anterior ankle impingement [61], and posterior ankle impingement with flexor hallucis longus pathology [68]. Non-insertional Achilles tendinopathy often yields excellent clinical results with conservative care [73], and high-volume injection (HVI) may outperform platelet-rich plasma (PRP) for chronic midportion Achilles tendinopathy in the short term [90].

For foot and ankle pathologies, conservative treatment is first-line for Morton’s interdigital neuroma [75] and is successful in approximately 90% of plantar fasciitis cases [79]. Prolonged non-operative treatment is recommended for mucoid degeneration of the patellar ligament in athletes [82]. Rib-tip syndrome generally responds effectively to conservative measures [69]. For chronic whiplash, comprehensive exercise programs [113] and combined dry needling with exercise [98] are effective management strategies. However, current non-surgical managements for osteoarthritis do not alter the clinical course or arrest disease progression [42].

Operative Management

Indications: Surgery is indicated when conservative measures fail or for end-stage disease. For primary and posttraumatic elbow arthritis [41], anterior ankle impingement [61], posterior ankle impingement with flexor hallucis longus pathology [68], Morton’s interdigital neuroma [75], and rib-tip syndrome [69], operative intervention is reserved for cases refractory to non-operative management. Joint replacement is indicated for end-stage osteoarthritis [42]. Surgery for lateral ankle injuries is reserved for chronic instability or failed non-operative management [57]. For plantar fasciitis, surgery is reserved for patients with persistent, severe symptoms refractory to nonsurgical intervention for at least 6 to 12 months [79]. Operative excision relieves mucoid degeneration of the patellar ligament in athletes if non-operative treatment is unsuccessful [82]. Surgery for iliotibial band syndrome is reserved for recalcitrant disease [6].

Surgical Approach / Technique: Insertional Achilles tendinopathy management is improved by evolving surgical approaches [73]. The minimally invasive approach to the subtalar joint is restricted to cases without the need for correction [77]. For coccidioidal spondylitis, amphotericin B remains the mainstay of treatment [104]. The treatment approach for chronic osteomyelitis resulted in a 98.4% cure rate while significantly reducing the need for long-term intravenous antibiotics [114].

Patient Optimization and Comorbidities

Patients must be counseled on the increased risk of adverse events associated with medical comorbidities and optimized regarding chronic conditions [10]. Conditions such as diabetes or advanced age are no longer contraindications to usual management recommendations for ankle fractures resulting from rotational injuries [12]. Exceptions to usual management for partial tears of the gastro-soleus complex include patients with general contraindications for operation, rheumatoid diseases, or low activity levels [103]. Future studies on sustained compression for tibiotalocalcaneal arthrodesis should focus on patient-specific optimization to further refine treatment protocols [15].

Technology and Adjuncts

Smartphone applications and wearable devices for postoperative rehabilitation after total knee arthroplasty have improved adherence to care plans and medication schedules [97]. Novel technologies for periprosthetic joint infections require validation of efficacy and safety through large-scale clinical trials and integration into existing treatment protocols [109].

Patient Expectations and Context

Treatment credibility for meniscal tears varies by race, and treatment outcome expectancies differ significantly by pain duration (acute vs chronic) [106]. Long-term efficacy expectations for benign prostatic syndrome vary culturally between the US and Germany [121].

Complications

Imaging and Diagnostic Limitations: Noninvasive imaging technologies, particularly MRI, provide objective measures to assess the integrity of joint tissues, though long-term follow-up studies are required to validate their predictive validity for clinical outcomes [1]. Only a precise knowledge of pathophysiological relationships can help to adequately diagnose and treat complex disease pictures in the long term [2].

Chronic Recurrence and Natural History: Subtalar subluxation can recur and eventually become chronic if neglected [5]. The natural history of chronic recurrent multifocal osteomyelitis appears to be slow, spontaneous resolution of osseous lesions without specific treatment [18]. The natural history of Achilles tendinopathy is typically a long protracted course where management focuses on physiotherapy; while exercises improve function in the majority, 40% of patients report ongoing pain even after five years of therapy [19]. The natural life history of nodules in pigmented villonovular synovitis of the glenohumeral joint and biceps tendon sheath speaks against a neoplastic origin [128]. Despite recent advances in understanding the epidemiology, biomechanics, pathophysiology, long-term effects, associated risks, and natural history of concussive brain injury, no proven effective therapies or preventative measures exist [130].

Other Considerations: Longitudinal studies are warranted to determine if head impacts in youth football influence long-term health [8]. Long-term follow-up is necessary to evaluate differences in long-term durability between gap balancing and measured resection techniques in simultaneous bilateral total knee arthroplasty [9]. Future focus on outcome quality requires attention to medium- and long-term patient-reported outcomes [11]. There is an increase in the benign squeaking rate at five-year follow-up with large diameter ceramic-on-ceramic bearings in total hip arthroplasty, and long-term follow-up is recommended [13]. Long-term clinical follow-up is warranted for novel porous titanium metaphyseal cones used in revision total knee arthroplasty [14]. Long-term follow-up is required to determine if differences in outcomes between traditional awl and drilling for marrow stimulation are sustained [16]. Mid-term and long-term outcomes for modular bicompartmental knee arthroplasty still need to be established [17]. Only long-term analysis (when the patient is an adult) and comparison with established natural history studies can provide answers for evaluating pediatric orthopaedic results [20]. A large-scale, prospective, observational cohort of polymyalgia rheumatica patients in primary care allows for a full investigation of the natural history and prognosis of this condition [21]. Studies of natural history and retrospective studies of treatment should adopt a 10-degree difference as an indication of a true change in scoliosis and kyphosis radiographs [22]. Data from the largest cohort and longest follow-up time ever reported provides information to accurately advise patients about the natural history of their disease in other joints after primary TKA or THA [23]. While short-term outcomes for endoscopic-assisted ACDF for C2-C3 disc herniation are promising, multicenter studies with long-term follow-up are needed to validate durability and complication profiles [105]. Long-term follow-up studies are needed to obtain more accurate data on the number of complications associated with deltoid ligament injuries [117].

Recovery

Light activity (weeks): Evidence does not specify a precise week range for light activity or return to desk work. However, assessment of post-injury job satisfaction combined with satisfactory private life activities is recommended to evaluate long-term rehabilitation outcomes [7]. For pediatric orthopaedic results, evaluation requires long-term analysis in adulthood compared with established natural history studies [20].

Full activity (months): Specific month ranges for full activity or return to sport are not defined in the available evidence. Long-term follow-up is necessary to determine if differences in outcomes between traditional awl and drilling for marrow stimulation are sustained [16]. Additionally, long-term follow-up is required to evaluate differences in long-term durability between gap balancing and measured resection techniques in simultaneous bilateral total knee arthroplasty [9].

Complete recovery / outcome plateau (months): The evidence does not provide specific month ranges for outcome plateaus. Long-term follow-up is recommended for large diameter ceramic-on-ceramic bearings in total hip arthroplasty due to an increase in benign squeaking rate at five-year follow-up [13]. Long-term clinical follow-up is warranted for novel porous titanium metaphyseal cones used in revision total knee arthroplasty [14]. Mid-term and long-term outcomes for modular bicompartmental knee arthroplasty still need to be established [17]. Longer follow-up is necessary to determine long-term durability for low-dose irradiation and constrained revision for severe, idiopathic, arthrofibrosis following total knee arthroplasty [110].

Rehabilitation protocol: Specific rehabilitation protocols, including PT phasing or immobilisation duration, are not detailed. However, exercises improve function in the majority of Achilles tendinopathy patients, but 40% report ongoing pain even after five years of therapy [19]. Management of Achilles tendinopathy typically focuses on physiotherapy due to its long protracted course [19]. Long-term randomized studies remain necessary to confirm the reliability of posterior arthroscopic subtalar arthrodesis and the type of bone graft to favour [88].

Functional milestones: Validated PROM trajectories are not specified. Future focus should be placed on medium- and long-term outcome quality, particularly patient-reported outcomes, for prostate cancer care [11]. Three natural courses of health-related quality of life recovery were identified following hip arthroscopy for femoroacetabular impingement syndrome: early progressors, late regressors, and late progressors [134].

Other Considerations: Noninvasive imaging technologies, particularly MRI, provide objective measures to better understand the natural history and mechanisms of diseases, optimize treatment, and assess the integrity of joint tissues [1]. Long-term follow-up studies are required to validate the predictive validity of noninvasive imaging technologies for clinical outcomes [1]. Precise knowledge of pathophysiological relationships is necessary to adequately diagnose and treat overactive bladder in the long term [2]. Longitudinal studies are warranted to determine if head impacts in youth football influence long-term health [8]. The natural history of chronic recurrent multifocal osteomyelitis appears to be slow, spontaneous resolution of osseous lesions without specific treatment [18]. The natural history of Achilles tendinopathy is typically a long protracted course where management focuses on physiotherapy [19]. Only long-term analysis when the patient is an adult, and comparison with established natural history studies, can provide answers for evaluating pediatric orthopaedic results [20]. A large-scale, prospective, observational cohort of polymyalgia rheumatica patients in primary care allows for a full investigation of the natural history and prognosis of this condition [21]. Studies of natural history and retrospective studies of treatment should adopt a 10-degree difference as an indication of a true change in scoliosis and kyphosis radiographs [22]. Data from the largest cohort and longest follow-up time ever reported can accurately advise patients about the natural history of their disease in other joints when undergoing primary TKA or THA [23]. A larger prospective randomized study is required for low-dose irradiation and constrained revision for severe, idiopathic, arthrofibrosis following total knee arthroplasty [110]. Internet search analysis on rheumatoid arthritis treatment shows that questions are most frequently related to the timeline of treatment and clinical course [131]. Long-term clinical and radiographic follow-up is necessary to determine the natural history of asymptomatic talar bone marrow edema in professional ballet dancers [132]. The natural course of melorheostosis progresses in both childhood and adult life, often causing contractures, deformities, and pain that may require surgical treatment but frequently progress despite intervention [133].

Key Evidence

• [L5] Noninvasive imaging technologies, particularly MRI, provide objective measures to better understand the natural history and mechanisms of diseases, optimize treatment, and assess the integrity of joint tissues, though long-term follow-up studies are required to validate their predictive validity for clinical outcomes. (10.1177/0363546518817315)
• [Paper] Only a precise knowledge of pathophysiological relationships can help to adequately diagnose and treat this complex disease picture in the long term. (10.1007/s00120-006-1076-9)
• [L3] Given the association of comorbidities and cost for patients with LBP, management approaches that are effective across chronic illnesses may prove to be beneficial for high cost patients identified with LBP. (10.1186/1471-2474-7-72)
• [L3] Common symptoms (such as pain intensity and depressive and anxiety symptoms) in chronic pain conditions carry important information that can be used to identify clinically relevant subgroups. (10.1371/journal.pone.0065483)
• [L4] The condition can recur and eventually become chronic if neglected. (10.1177/03635465990270020501)
• [L5] The diagnosis of iliotibial band syndrome is typically made based on a characteristic patient history and physical examination, with imaging studies reserved for cases of recalcitrant disease. (10.5435/00124635-201112000-00003)
• [L3] To assess the long-term outcome of rehabilitation programmes, we recommend a measure that combines patient's satisfaction in their post-injury jobs with a satisfactory level of activities in their private lives. (10.1016/j.injury.2013.10.019)
• [L2] Longitudinal studies are warranted to determine if these impacts influence long-term health. (10.1177/2325967119s00001)
• [L1] Long-term follow-up will be necessary to evaluate any differences in long-term durability. (10.1016/j.arth.2019.10.002)
• [L3] Patients should be counseled on the increased risk of adverse events presented by medical comorbidities and should be optimized in regards to chronic conditions. (10.1177/2325967123s00263)
• [Paper] Future years will need to focus more on medium- and long-term outcome quality, particularly patient-reported outcomes. (10.1007/s00120-015-3855-7)
• [L5] Conditions such as diabetes or advanced age are no longer contraindications to usual management recommendations. (10.5435/00124635-200311000-00004)
• [L3] Long-term follow-up is recommended. (10.1016/j.arth.2017.11.044)
• [L5] Long-term clinical follow-up is warranted. (10.1016/j.arth.2017.01.013)
• [L3] Future studies should focus on cost-effectiveness, long-term outcomes, and patient-specific optimization to further refine treatment protocols. (10.5435/jaaos-d-25-00011)
• [L3] Long-term follow up is required to determine if these differences are sustained. (10.1016/j.arthro.2020.12.136)
• [L4] Mid-term and long-term outcomes still need to be established. (10.1016/j.arth.2013.04.044)
• [L4] The natural history of chronic recurrent multifocal osteomyelitis appears to be slow, spontaneous resolution of the osseous lesions without specific treatment. (10.2106/00004623-199072020-00025)
• [L5] For the evaluation of such results, only long-term analysis (when the patient is an adult) and comparison with established natural history studies can give us the answers that we want. (10.2106/00004623-199910000-00014)
• [L4] This protocol outlines the first large-scale, prospective, observational cohort of PMR patients in primary care, which will allow for a full investigation of the natural history and prognosis of this condition in the primary care setting. (10.1186/1471-2474-13-102)
• [L4] Studies of natural history and retrospective studies of treatment should adopt a 10-degree difference as an indication of a true change. (10.2106/00004623-199072030-00003)
• [L3] This study includes the largest cohort and longest follow-up time ever reported, providing data to accurately advise patients about the natural history of their disease in other joints. (10.1016/j.arth.2012.10.008)
• [L5] The study concludes that the fibula is a dynamic bone important for the kinematics and kinetics of the knee and ankle joints. (10.1007/s00402-005-0054-9)
• [L3] It seems more important to include the kinematics and kinetics of the hip and ankle joint in all 3-dimensional planes. (10.1016/j.arth.2016.07.035)
• [L5] Recognition of pain dysfunction requires clinical experience and sensitivity to listen to and properly interpret a patient's history, while treatment involves addressing acute anatomical problems, combined rehabilitation for psychological and physical issues, and reassessment of chronic problems. (10.2106/00004623-198971010-00025)
• [L3] Acute medical conditions are a moderately common diagnosis among elderly drivers, presenting in about one in ten patients. (10.1016/j.injury.2015.04.012)
• [L5] The existence of the Achilles tendon and ankle position have a great influence on the kinematic coupling relationship between tarsal bones, while increased stiffness of the Achilles tendon has no influence. (10.1186/s13018-020-01728-0)
• [L5] Knowledge of the characteristic clinical presentation and physical examination findings of neurologic, musculoskeletal, vascular, and other etiologies can help distinguish the source of upper extremity pain quickly to facilitate appropriate diagnostic measures and treatment. (10.5435/jaaos-d-11-00086)
• [L3] Subjects with functional instability exhibit altered neuromuscular control and kinematics of their ankle joints, providing direct in vivo evidence to support the biomechanical model of ankle sprain in subjects with ankle instability. (10.1177/0363546506290989)
• [L5] Early and correct diagnosis and treatment are critical for clinical outcomes, as misdiagnosis or delayed diagnosis can have devastating consequences for the patient. (10.1530/eor-23-0193)
• [Paper] Delayed diagnosis impairs functional prognosis, leading to longer incapacity and more severe sequelae such as cracking, pain, and stiffness. (10.1016/j.otsr.2014.02.008)
• [L3] The investigation revealed ankle functional impairments in patients with diabetes, with or without neuropathy, thus suggesting that other mechanisms besides neuropathy might contribute to alter foot-ankle biomechanics. (10.1186/1471-2474-9-99)
• [L4] Awareness and earlier recognition of signs and symptoms will aid in diagnosis and direct appropriate management. (10.1186/1749-799x-5-6)
• [L5] The authors identify striking similarities between the anatomy, biomechanics, diagnosis, and treatment of high ankle sprains and ACL knee injuries, suggesting a potential continuum or identical entities that warrants future biomechanical research on the pivot-shift injury link. (10.1007/s00167-020-06008-2)
• [L3] Functional alignment was associated with smaller changes in ankle alignment parameters, indicating its ability to better preserve native joint positioning. (10.1002/ksa.12615)
• [L4] Delayed diagnosis is common, with clinical clues including persistent pain, fever, and increased local tissue reaction weeks after injury. (10.2106/00004623-197557030-00024)
• [L5] Accurate diagnosis of anatomy, biomechanics, and soft tissue structures is fundamental to correctly identify patients requiring conservative or surgical treatment to prevent chronic ankle instability. (10.1177/23259671211021352)
• [L3] No compensatory biomechanical function was observed in other foot joints. (10.1002/jor.24715)
• [L5] Nonoperative treatment is almost always initiated although surgical treatment may be indicated in cases refractory to conservative management. (10.1155/2013/473259)
• [L5] Current non-surgical managements for osteoarthritis do not change the clinical course or arrest disease progression, while joint replacement is indicated for end-stage disease. (10.1530/eor-2025-0050)
• [L4] The most common clinical complaints were complications, misdiagnoses and uncontrolled pain. (10.1016/j.asmr.2021.07.008)
• [L5] The effect of the defect area of the ankle talus cartilage on the ankle biomechanics is evident in the midstance and push-off phases. (10.1186/s12891-022-05450-2)
• [Case_report] The authors recommend that this diagnosis be considered in patients with chronic renal failure presenting with bone pain. (10.2106/00004623-198365060-00020)
• [L3] This supports the interpretation that the dynamic congruency of the joint, which is influenced by ligamentous integrity remains the main anatomical component in mechanical ankle instability. (10.1186/s12891-025-09458-2)
• [L4] Whilst all patients are prompted to seek help by persistent, unmanageable symptoms, some delay help-seeking. (10.1186/1471-2474-15-364)
• [Paper] Exercise testing remains the mainstay for the diagnosis and treatment of these disorders. (10.1016/j.csm.2011.03.010)
• [L4] The operative ankle exhibited greater syndesmosis length and altered kinematics compared to the healthy side during all tested activities. (10.2106/jbjs.20.01787)
• [Paper] The CSQ does not appear to be appropriate for predicting chronic symptoms. (10.1016/j.injury.2004.09.038)
• [L5] Careful clinical and radiographic evaluation, coupled with a thorough understanding of the anatomy and biomechanics of the foot, will allow accurate evaluation and appropriate treatment. (10.5435/00124635-199509000-00005)
• [L3] Patients presenting with signs and symptoms of subacromial pain syndrome have a high prevalence of conflicting and concomitant diagnoses. (10.1177/23259671251332942)
• [L5] However, reliable epidemiological data are lacking, and noninvasive diagnostic techniques for chronic asymptomatic inflammation are not yet available. (10.1007/s00120-010-2256-1)
• [Case_report] The dynamic feature of the fibula is as important for the knee joint as it is for the ankle. (10.1007/s00167-003-0375-6)
• [Paper] The cartilage properties of the various topographic locations within the ankle are significantly different, with opposing articulating surfaces exhibiting significantly different biomechanical and biochemical properties. (10.1016/j.arthro.2014.05.025)
• [L5] The article concludes that most acute lateral ankle injuries recover with conservative treatment, while surgery is reserved for chronic instability or failed non-operative management. (10.1302/0301-620x.98b7.36588)
• [L4] MRI shows the proper diagnosis and the proper therapeutic approach is conservative treatment. (10.1177/2325967118s00019)
• [L3] The study showed that the injured and uninjured sides of CAI demonstrate biomechanical characteristics associated with increased risk of ankle sprain, suggesting that management strategies should target both ankles. (10.1177/23259671251394031)
• [L5] Restoration of normal fibular length is crucial to restore the biomechanics of the ankle. (10.1016/j.injury.2018.09.010)
• [L5] Conservative treatment is the first-line treatment, with surgery indicated only when conservative measures are unsuccessful. (10.1136/jisakos-2019-000282)
• [L5] Diagnosis relies on imaging (CT/MRI) and histology, while treatment involves corticosteroids for active disease and surgical decompression (stents/nephrostomy) for obstruction. (10.1007/s00120-016-0081-x)
• [L5] Key radiographic findings and a lowered threshold for additional imaging studies are essential for proper diagnosis. (10.5435/00124635-200912000-00006)
• [L3] Furthermore, differences in kinematics between symptomatic and asymptomatic hindfeet was demonstrated when both feet were compared. (10.1007/s00167-023-07553-2)
• [L4] Ankle position from 0° to 30° of plantarflexion did not change the measurements obtained. (10.1007/s00402-019-03209-4)
• [L4] Classification systems and identification of differences among products are needed to understand the implications of variability. (10.5435/jaaos-21-12-739)
• [L3] In the group where only an MRI was used, there was a 31% failure due to progression of the disease. (10.1016/j.arth.2019.08.021)
• [L5] Nonsurgical treatment should include injections, physical therapy, and activity modification, while surgical approaches must be thoughtfully contemplated when conservative treatment fails. (10.1016/j.csm.2020.06.001)
• [L4] Treatment is relatively easy and generally effective, with surgery indicated if symptoms persist or recur after conservative management. (10.2106/00004623-197557060-00012)
• [L2] Longer-term clinical follow-up is needed to understand the clinical impact of this radiological finding. (10.1016/j.jisako.2023.03.251)
• [L2] Longer-term clinical follow-up is needed to understand the clinical impact of this radiological finding. (10.1016/j.jisako.2023.03.253)
• [L4] Adjunctive studies such as radiographs, magnetic resonance images, and electrodiagnostic studies aid in diagnosing radicular and nonradicular etiologies. (10.2106/jbjs.rvw.m.00080)
• [L5] Non-insertional Achilles tendinopathy is often managed conservatively with excellent clinical results, while insertional Achilles tendinopathy management is improved by recognizing coexisting pathologies and evolving surgical approaches. (10.1302/0301-620x.95b10.31881)
• [L3] Stricter indications potentially lead to underutilization of UKA, as demonstrated by similar short-term patient-reported outcomes and survivorship between groups. (10.1016/j.arth.2025.05.070)
• [L5] Nonoperative management is recommended initially, while operative treatment is indicated after nonoperative management has failed. (10.1302/2058-5241.4.180025)
• [L5] MRI is evolving as a complete answer to cartilage-imaging requirements for lesion description, treatment planning, and outcome measurement, serving as a noninvasive tool that overcomes the shortcomings of radiography by detecting preclinical disease and subtle early abnormalities. (10.2106/jbjs.rvw.15.00093)
• [L5] The indication for the use of this access, however, has to be restricted to cases without the need of correction. (10.1007/s00402-003-0627-4)
• [L2] The multidisciplinary group videoconferencing approach to managing chronic non-specific low back pain was feasible, suggesting overall beneficial effects on patients' health and could play a role in changing a patient's status from candidate to non-candidate for surgery. (10.1186/s12891-023-06763-6)
• [L5] Nonsurgical management is successful in approximately 90% of patients, with surgical treatment reserved for a small subset of patients with persistent, severe symptoms refractory to nonsurgical intervention for at least 6 to 12 months. (10.5435/00124635-200806000-00006)
• [L1] Magnetic resonance imaging did not confirm any significant cartilage condition improvement. (10.1007/s00402-013-1782-x)
• [L4] MRI is valuable in diagnosis but not always accurate, and false-positive results are not uncommon; therefore, it is crucial to combine clinical examination with imaging for accurate diagnosis and treatment planning. (10.1177/2325967124s00388)
• [L4] Prolonged non-operative treatment should be pursued, but if unsuccessful, operative excision will relieve the condition. (10.2106/00004623-199274030-00016)
• [L4] The author believes that use of each type of classification provides more precise clinical information to describe analyzed groups of RSD patients. (10.1016/s0749-0712(02)00131-2)
• [L5] The article highlights the importance of patient selection, noting surgical indication in symptomatic patients having failed a primary nonoperative protocol, and identifies the need for randomized controlled trials to develop a nonoperative strategy. (10.1016/j.arthro.2017.08.238)
• [L5] However, the appropriate indications and long-term outcomes of these treatment options are yet to be determined. (10.5435/jaaos-d-19-00112)
• [L5] Treatment strategies vary based on symptom severity and MRI evidence, including physical modalities, pharmacological options, and surgical therapy. (10.2106/jbjs.21.00300)
• [L4] It highlights that the sensitivity and specificity of imaging procedures for detecting recurrence remain unclear due to a lack of standardized follow-up protocols. (10.1007/s00120-005-0880-y)
• [L4] Long-term randomized studies remain necessary to confirm the reliability of the procedure in these different indications, and the type of bone graft to favour, if really needed. (10.1016/j.otsr.2011.02.005)
• [L2] MRI is time consuming, expensive, and can lead to treatment delays, so clinicians should rely on history and physical examination. (10.1007/s11999-012-2355-y)
• [L1] HVI may be more effective in improving outcomes of chronic AT than PRP in the short term. (10.1177/0363546517702862)
• [L4] Surgical indications should focus primarily on the degree of demonstrable chronic disability rather than the number of documented dislocations. (10.2106/00004623-198062060-00005)
• [L5] With increased use and as more outcomes data become available, indications and contraindications will continue to be refined and best practices established. (10.5435/jaaos-d-22-00676)
• [Case_report] High-field magnetic-resonance imaging may provide a useful diagnostic adjunct in evaluating persistent symptoms in the ankle after trauma. (10.2106/00004623-198668060-00017)
• [L4] MRI based imaging results need further clarification by mid term studies. (10.1177/2325967116s00046)
• [L4] Pathologic MRI findings in elite overhead athletes can be present; however, they are often asymptomatic. (10.1016/j.arthro.2017.08.035)
• [L1] Radiographs should be the initial diagnostic test, but further imaging is usually necessary to establish the diagnosis and determine a treatment plan. (10.1177/2325967121s00088)
• [L1] Randomized trials validate their accuracy, effectiveness, and utility in this context, with improved adherence to care plans and medication schedules emerging as recurrent findings. (10.1016/j.arth.2025.01.034)
• [L1] The successful completion of this trial will provide evidence of the effectiveness and cost-effectiveness of a combined treatment approach for the management of chronic whiplash. (10.1186/1471-2474-10-160)
• [L3] In one third of the cases, assessment using MRI substantially modified the treatment recommendations. (10.1016/j.arthro.2017.08.147)
• [L4] In one third of the cases, assessment using MRI substantially modified the treatment recommendations. (10.1016/j.arthro.2017.08.148)
• [L5] Exceptions include patients with general contraindications for operation, rheumatoid diseases, or low activity levels. (10.1016/j.csm.2007.10.005)
• [L4] The authors prefer the term 'arrested' over 'cure' for chronic disease and note that amphotericin B remains the mainstay of treatment. (10.2106/00004623-197860020-00018)
• [Case_report] While short-term outcomes are promising, multicenter studies with long-term follow-up are needed to validate durability and complication profiles. (10.1186/s12891-025-09302-7)
• [L4] Treatment credibility varied by race and treatment outcome expectancies differed significantly by pain duration (acute vs chronic). (10.1177/2325967123s00217)
• [L3] Focusing on management of preoperative comorbidities and custom surgical planning can achieve outcomes comparable to those of patients who have normal BMIs at ASCs, questioning BMI as an exclusion criterion and advocating for more inclusive, evidence-based patient selection. (10.1016/j.arth.2025.08.065)
• [L4] A consensus on a comprehensive and reliable classification system and management algorithm is still lacking. (10.1530/eor-21-0088)
• [L5] Future research should focus on validating their efficacy and safety through large-scale clinical trials and integrating them into existing treatment protocols. (10.1016/j.arth.2025.06.086)
• [L4] However, longer follow-up is necessary to determine long-term durability, and a larger prospective randomized study is required. (10.1016/j.arth.2012.11.009)
• [L5] The current gait disruption classification system uses the concept of primary versus compensatory deviations to identify common patterns and common causes for these patterns. (10.5435/jaaos-22-12-782)
• [L3] A simple 4-part classification system based on local and systemic factors demonstrates significant differences between complex groups and standard patients in terms of complication rates and length of stay. (10.1016/j.arth.2008.02.010)
• [L2] The successful completion of this trial will provide evidence on the effectiveness and cost-effectiveness of a simple treatment for the management of chronic whiplash. (10.1186/1471-2474-10-149)
• [L4] The treatment approach resulted in a 98.4% cure rate for chronic osteomyelitis while significantly reducing the need for long-term intravenous antibiotics, offering benefits to patient care and society. (10.1016/j.injury.2019.04.016)
• [L4] The authors advise strict patient selection for surgery, reserving it for those with significant pain and functional disability, as most patients function well with conservative management. (10.2106/00004623-198466020-00002)
• [L4] Long-term follow-up studies are needed to obtain more accurate data on the number of complications. (10.1002/ksa.12274)
• [L5] Individuals with chronic, incurable disorders require more than average support from their physician, and a comprehensive program of care stressing continuity is absolutely essential. (10.2106/00004623-196749060-00022)
• [L5] The International EDS Consortium proposes a revised classification recognizing 13 subtypes. (10.1002/ajmg.c.31552)
• [L2] Therefore, employing individualized classification systems remains the most logical approach at present. (10.1530/eor-2024-0184)
• [L5] While guidelines have improved, randomized controlled trials often fail to reflect clinical reality due to exclusion criteria, and long-term efficacy expectations vary culturally between the US and Germany. (10.1007/s00120-016-0254-7)
• [L5] The proposed classification system describes six specific issues to consider, with specific recommendations for each situation type to improve the reliability of prosthetic implantation. (10.1302/2058-5241.6.210042)
• [L5] There is no clear consensus on what defines a chronic Achilles disorder or a uniform classification and treatment scheme. (10.5435/00124635-200901000-00002)
• [L4] The authors propose a novel classification system to aid further research. (10.1007/s00402-018-2905-1)
• [Paper] The framework includes a 4-part classification scheme for alternative payment models (APMs) and establishes 8 principles to guide their development. (10.1001/jama.2017.20226)
• [L1] The identified inflammatory cell types favour a chronic inflammatory process, but the heterogeneity of data and lack of comparable studies means we cannot conclude a common pathophysiology from this systematic review. (10.1186/s12891-020-3094-y)
• [L4] Our classification system provides a step to achieve this goal. (10.1177/2325967120s00255)
• [L5] Despite recent advances in understanding the epidemiology, biomechanics, pathophysiology, long-term effects, associated risks, and natural history of concussive brain injury, no proven effective therapies or preventative measures exist. (10.1016/j.csm.2010.09.008)
• [L4] The questions were most frequently related to the timeline of treatment and clinical course. (10.1371/journal.pone.0285869)
• [L4] Long-term clinical and radiographic follow-up is necessary to determine the natural history of these lesions. (10.1177/23259671231159910)
• [L3] Three natural courses of health-related quality of life recovery were identified: early progressors, late regressors, and late progressors. (10.1177/2325967121s00562)

See Also

• Arthritis

References

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