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Conservative Approach to Treating American Football Players With Medial Collateral Ligament Grade 2 Sprain During the Season

Lucas Bianco, Eden Jahn, and Shannon Renninger

Context: The medial collateral ligament is the most commonly injured ligament in the knee. The high-speed pivoting and agility movements that are common in the sport of American Football put participants at an increased risk for a valgus force stress from contact or noncontact injuries. Positional release therapy (PRT) also considered strain/counterstrain focuses on releasing the tension in a tissue through unloading the involved body part. Case Presentation: Two male student-athletes participating in football with a mean age of 20.5 years were diagnosed by a physician with medial collateral ligament grade 2 sprain. Both patients sustained their injuries in a regular season game with a contact valgus force from an opposing player. Management and Outcomes: After the initial 72 hours of compression, elevation, and cryotherapy, the patients were both treated with PRT followed by progressive loading exercises. Following 4 treatment sessions of PRT over the next 6 days, the patients started with quadriceps engagement exercises, single-leg squats to 60° knee flexion, side steps, triceps dips, slow controlled lunges, and toe walk. The patients progressed to full body weight squats, single-leg landing, step-up tri-extension, and sidekicks with a leg on table. Then, the patients completed function movements and sports-specific exercises. Conclusions: In this case series, 2 patients competing in intercollege American Football were treated with PRT and progressive loading exercises to facilitate return to unrestricted activities and improve outcome measures. Commonly, a grade 2 medial collateral ligament sprain is conservatively treated with return to sport taking 20 days on average. In this type 2 case series, the clinician found success utilizing PRT early in the recovery process, which in these 2 cases lead to restoration of function, outcome measure improvement, and an expedited return to sport. The expedited return to sport occurred at an average of 18 days for these patients.

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Effect of Low-Load Blood Flow Restriction Training on Patients With Functional Ankle Instability: A Randomized Controlled Trial

Ziliang Wen, Jiang Zhu, Xuelian Wu, Bing Zheng, Li Zhao, Xin Luo, and Zonghui Wu

Context: Decreased muscle strength and balance in patients with functional ankle instability (FAI) can be effectively improved by ankle strength training. Low-load blood flow restriction (LL-BFR) training increases muscle size and strength, but there is limited evidence from studies on muscle strength and balance in FAI patients. Objective: To study the effects of LL-BFR training versus high-load training (HLT) on muscle strength and balance in FAI patients. Design: Randomized controlled trial. Participants: Forty-six young adults with a history of FAI. Interventions: Participants in the LL-BFR and HLT groups performed 4 sets (30 × 15 × 15 × 15) of ankle training at 20% to 40% of the one-repetition maximum and 70% to 85% one-repetition maximum, respectively, twice a week for 6 weeks. Main Outcome Measure(s): Plantar flexion, dorsiflexion, inversion, and eversion muscle strength, and the Y-balance test scores were assessed at baseline and after 3 and 6 weeks; the thickness of the tibialis anterior, triceps surae, and peroneus longus muscles were assessed at baseline and after 6 weeks. Results: Inversion, eversion, dorsiflexion, and plantar flexion muscle strength; tibialis anterior, triceps surae, and peroneus longus thickness; and Y-balance test scores were significantly increased in the LL-BFR group after 3 and 6 weeks compared with baseline (P < .05), with no significant difference between the LL-BFR and HLT groups after 6 weeks (P > .05). However, at the end of 3 weeks, eversion muscle strength and Y-balance test scores were significantly higher in the LL-BFR group than in the HLT group (P < .05). Conclusions: Over 6 weeks, LL-BFR training was as effective as HLT in improving ankle muscle strength, muscle thickness, and balance in FAI patients, but LL-BFR training improved the ankle eversion muscle strength and dynamic balance more than HLT did in the early stages of the intervention. This finding will provide a new intervention strategy for the clinical rehabilitation of FAI patients.

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Effects of A Single Balance Training Session on Neural Excitability in Individuals With Chronic Ankle Instability

Sunghoon Chung, Avery Rodriguez, Elham Alijanpour, and Ryan S. McCann

Context: Individuals with chronic ankle instability (CAI) demonstrate reduced spinal reflex modulation and corticospinal excitability of the soleus, which may contribute to decreased balance performance. Objective: To determine the effects of a single session of balance training on Spinal-reflexive excitability modulation and corticospinal excitability in those with CAI. Design: Randomized controlled trials. Setting: Research laboratory. Participants: Thirty participants with CAI were randomly assigned to the balance training (BAL) or control (CON) group. Main Outcome Measures: Modulation of soleus spinal-reflexive excitability was measured by calculating relative change in normalized Hoffmann reflexes (ratio of the H-reflex to the M-wave) from prone to single-leg standing. Corticospinal excitability was assessed during single-leg stance using transcranial magnetic stimulation, outcomes of which included active motor threshold (AMT), motor evoked potential, and cortical silent period (CSP). Balance performance was measured with center of pressure velocity in anterior to posterior and medial to lateral directions. Separate 2 × 2 repeated-measures analyses of variance were employed to determine the effect of group (BAL and CON) and time (baseline and posttraining) on each dependent variable. Results: There were significant group by time interactions in the modulation of soleus spinal-reflexive excitability (F 1,27 = 4.763, P = .04); CSP at 100% AMT (F 1,27 = 4.727, P = .04); and CSP at 120% AMT (F 1,27 = 16.057, P < .01). A large effect size suggests increased modulation of spinal-reflexive excitability (d = 0.81 [0.03 to 1.54]) of the soleus in BAL compared with CON at posttest, while CSP at 100% (d = 0.95 [0.17 to 1.70]) and 120% AMT (d = 1.10 [0.29 to 1.84]) was reduced in BAL when compared with CON at posttest. Conclusion: After a single session of balance training, individuals with CAI initiated increases in spinal reflex modulation and corticospinal excitability of the soleus. Thus, individuals with CAI who undergo balance training exhibit positive neural adaptations that are linked to improvements in balance performance.

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Return to Sport and Clinical Outcomes Following Osteochondral Autograft Transplantation in Baseball Players and Gymnasts With Unstable Osteochondritis Dissecans: A Critically Appraised Topic

Natalie L. Myers, Sean M. Kennedy, Luke D. Thorburn, John E. Conway, and J. Craig Garrison

Clinical Scenario: Osteochondritis dissecans (OCD) of the capitellum is a condition occurring at the elbow and often seen in both baseball players and gymnasts due to the repetitive loading of the radiocapitellar joint. Treatment options for OCD vary and are dependent on lesion presentation, elbow motion, and growth plate maturity. OCD lesions categorized as unstable can be treated with an osteochondral autograft transplantation surgery (OATS). Focused Clinical Question : In an adolescent population, what are the return to sport rates and clinical outcomes following OATS in baseball players and gymnasts with unstable OCD lesions? Summary of Key Findings : Three articles met the inclusion criteria for this appraisal, and all indicate an OATS procedure should be considered in the management of unstable OCD lesions. Return to play outcomes were favorable for both baseball players and gymnasts. Self-reported patient function and elbow extension all improved following an OATS. Clinical Bottom Line : An OATS procedure is a favorable option for the management of OCD lesions of the elbow in baseball players and gymnasts. Strength of Recommendation : There is level B evidence to support return to sport and clinical outcomes in baseball players and gymnasts following an OATS procedure. This score is directly related to the quality of evidence that currently exists on the topic.

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Sport Specialization’s Impact on Female Adolescent Athletes’ Lower-Extremity Neuromuscular Control: A Critically Appraised Topic

Sierra Reich, Jeremy Hawkins, Alli Powell, and Michael Reeder

Clinical Scenario: Nearly 60 million youth ages 6–18 participate in athletics within the United States. Over the last 30 years, the outlook on youth sport participation has drastically changed, resulting in an increased emphasis on performance and college sport participation. These evolving expectations have created a sense of perfectionism, demanding more time and energy to be placed into a single sport, resulting in an increased prevalence of sport specialization, and consequently, an increased rate of injury. Clinical Question: What is the impact of sport specialization on lower-extremity neuromuscular control in female adolescent athletes? Summary of Key Findings: Four studies were included, all comparing movement efficiency and movement patterns among multisport and sport-specialized female adolescent athletes. Three studies showed that sport specialization is associated with lower-extremity biomechanical alterations that are indicative of altered levels of neuromuscular control, which can predispose an individual to an increased risk of injury. One study concluded that no differences in neuromuscular control exist when comparing sport-specialized to multisport adolescent female athletes. Clinical Bottom Line: Sport specialization has the potential to create negative alterations in a female adolescent athletes’ lower-extremity biomechanics, leading to the creation of altered levels of neuromuscular control and a possible increased risk for injury. Strength of Recommendation: Level B evidence exists to support the conclusion that sport specialization negatively affects a female adolescent athlete’s lower-extremity neuromuscular control.

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Volume 32 (2023): Issue 6 (Aug 2023)

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Low-Intensity Resistance Exercise Based on Myofascial Chains Alters the Lower-Limb Tension and Improves Health Status in Female Individuals With Knee Osteoarthritis

Yao Lu, Jie Chen, and Xue-lin Zhang

Background: Low-intensity resistance exercise therapy (LIRET) based on myofascial chains, applied to both affected and nonlocal joints, is an effective method for knee osteoarthritis (OA) rehabilitation. This study applied LIRET in a comparison of prevalues and postvalues of lower-limb tension in female patients with knee OA and asymptomatic participants. Methods: Twenty-four female participants with knee OA and 20 asymptomatic women took part in a 3-month long application of LIRET. Participants’ ankle passive torque and ankle range of motion in the sagittal plane were assessed with an isokinetic dynamometer. The collected values were used to estimate the sagittal-plane lower-limb tension. Results: Compared with the asymptomatic group, participants with knee OA presented decreased maximum ankle dorsiflexion (P < .001), decreased ankle plantar flexion range (P = .023), ankle resting position more inclined to dorsiflexion (P = .017), increased ankle dorsiflexion stiffness (P = .005), and lower ankle plantar flexion stiffness (P = .034). After exercise intervention, the knee OA group self-reported less knee pain (P < .001), improved physical function (P < .001), increased maximum dorsiflexion (P = .021), and increased plantar flexion range (P < .001). While plantar flexion stiffness increased (P = .037), dorsiflexion stiffness decreased (P = .015) and ankle resting position moved toward dorsiflexion (P = .002). Results suggest possible decreased anterior leg tension and possible increased posterior leg tension in patients with knee OA. Conclusions: The results supported that knee OA patients present imbalanced myofascial tension of lower limbs. LIRET based on myofascial chains appears to decrease pain, and stiffness, and improve physical function of patients with knee OA and change their lower-limb tension.

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Comparing the Effect of Exercises With Different Gluteal-to-Tensor Fasciae Latae Activation Index in Patients With Chronic Low Back Pain

Leila Jahandideh, Amir Letafatkar, Reza Khanzadeh, and Farzad Omidi Kashani

Context: Hip muscle imbalance, especially between gluteal muscles and tensor fasciae latae (TFL), is one of the risk factors for developing low back pain which should be considered in rehabilitation programs. This study compared the effect of exercises with gluteal-to-TFL muscle activation index above and below 50 on pain intensity, disability, and lower limbs’ range of motion (ROM) in patients with nonspecific chronic low back pain. Design: A semiexperimental intervention study with a pretest and posttest. Methods: A total of 45 patients with nonspecific chronic low back pain were randomly divided into 2 experimental groups of gluteal-to-TFL muscle activation index above 50 (n = 15), below 50 (n = 15), and a control group (n = 15). Pain intensity (visual analog scale), disability (Roland–Morris Disability Questionnaire), and lower limbs’ ROM including hip extension, hip abduction, hip external rotation, and knee extension (goniometer) were assessed at pretest and after 8 weeks of intervention. Results: Within-group comparison showed significant improvement of pain, disability, and ROMs in both experimental groups. No significant changes were observed in the control group. In between-group analysis, significant differences were observed in group of gluteal-to-TFL muscle activation index above 50 for only pain (P = .03) and disability (P = .01). For ROMs, although clinical improvement of lower limbs’ ROMs was higher in group of gluteal-to-TFL muscle activation index above 50, no statistically significant differences were found between 2 experimental groups. Both experimental groups were superior to the control group for all outcomes. Conclusions: Findings indicate the statistically and clinically superior effectiveness of exercises with a gluteal-to-TFL muscle activation index above 50 in the reduction of pain and disability. Based on the clinical significance of exercises with a gluteal-to-TFL muscle activation index above 50 for improving ROMs, utilizing specific exercises that more activated gluteal muscle compared to TFL is recommended for patient with restricted lower limbs’ ROMs.

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Infrared Thermography—A Novel Tool for Monitoring Fracture Healing: A Critically Appraised Topic With Evidence-Based Recommendations for Clinical Practice

Tristan Castonguay and Geoff Dover

Clinical Scenario: Stress fractures are one of the most common injuries in athletes. Unfortunately, they are hard to diagnose, require multiple radiology exams and follow-up which leads to more exposure to radiation and an increase in cost. Stress fractures that are mismanaged can lead to serious complications and poorer outcomes for the athlete. During the rehabilitation process, it would be beneficial to be able to monitor the healing of fractures to know when it is safe to gradually allow a patient to a return to sport because the return to activity is not usually objective and based on pain level. Clinical Question: Can infrared thermography (IRT) be a useful tool to measure the pathophysiological state of the fracture healing? The aim of this critically appraised topic is to analyze the current evidence of IRT for measuring the temperature change in fractures to provide recommendations for medical practitioners. Summary of Key Findings: For this critically appraised topic, we examined 3 articles that compared medical imaging and IRT over multiple time points during the follow-up. The 3 articles concluded that a 1 °C asymmetry in temperature followed by a return to normal (less than 0.3 °C) temperature during the healing process of fractures can be monitored using IRT. Clinical Bottom Line: Once the patient has been diagnosed with a fracture, IRT can safely be used to monitor the evolution of a fracture. When the thermogram progresses from a hot thermogram to a cold thermogram, the healing is considered good enough to return to sport. Strength of Recommendation: Grade 2 evidence exists to support IRT being used by clinicians to monitor fracture healing. Due to the limited research and novelty of the technology, the current recommendations are for following the treatment of the fracture once the initial diagnosis is made.

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The Effects of High-Load Slow-Velocity Resistance Exercise Training in Athletes With Tendinopathy: A Critically Appraised Topic

J. David Taylor, Annemieke Corbitt, and Ruth Ann Mathis

Clinical Scenario: Tendinopathy is a musculoskeletal pathological condition experienced by athletes that can result in pain, impaired muscle performance, and loss of physical function and can hinder return to sports. Various types of resistance exercise training are effective for treating tendinopathy, including isometric, concentric, eccentric, and high-load slow-velocity resistance exercise. Clinical Question: What are the effects of high-load slow-velocity resistance exercise training, compared with other forms of resistance exercise, on tendon morphology and patient-reported outcomes in athletes with tendinopathy? Summary of Key Findings: The findings of 4 randomized clinical trials were included. One study compared high-load slow-velocity resistance exercise with moderate-load slow-velocity resistance exercise. Two studies investigated the effects of high-load slow-velocity resistance exercise versus eccentric resistance exercise. The fourth study compared high-load slow-velocity resistance exercise with inertia-based resistance exercise. In all of the studies, high-load slow-velocity resistance exercise was as effective as the other forms of resistance exercise for improving patient-reported outcomes and pain. Three studies found no significant differences in changes in tendon morphology between patients who received high-load slow-velocity resistance exercise versus those who received the other forms of resistance exercise. One study showed that high-load slow-velocity resistance exercise was more effective than eccentric exercise for improving tendon morphology outcomes. Clinical Bottom Line: Current evidence supports the use of high-load slow-velocity resistance exercise as a treatment option for patellar and Achilles tendinopathy in athletes. Strength of Recommendation: Results from level 2 studies suggest grade B evidence in support of high-load slow-velocity resistance exercise for treating athletes with tendinopathy.