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Exploratory Examination of Knee Self-Efficacy in Individuals With a History of ACL Reconstruction and Sport-Related Concussion

Francesca M. Genoese, Aaron J. Zynda, Kayla Ford, Matthew C. Hoch, Johanna M. Hoch, Tracey Covassin, and Shelby E. Baez

Context: Knee self-efficacy and injury-related fear are associated with poor self-reported knee function and decreased physical activity (PA) after ACL reconstruction (ACLR). Limited research has explored contextual factors that may influence psychological responses in this population, such as history of sport-related concussion (SRC). After SRC, individuals may experience increased negative emotions, such as sadness and nervousness. However, it is unknown how SRC history may influence knee-self efficacy and injury-related fear in individuals with ACLR. The purpose of this study was to compare knee self-efficacy and injury-related fear in individuals after ACLR who present with and without history of SRC. Design: Cross-sectional study. Methods: Forty participants ≥1 year postunilateral ACLR were separated by history of SRC (no SRC = 29, SRC = 11). The Knee Self-Efficacy Scale (KSES) and subscales measured certainty regarding performance of daily activities (KSES-ADL), sports/leisure activities (KSES-Sport), physical activities (KSES-PA), and future knee function (KSES-Future). The Tampa Scale of Kinesiophobia-11 measured injury-related fear. Mann–Whitney U tests were used to examine between-group differences. Hedges g effect sizes and 95% confidence interval were used to examine clinically meaningful group differences. Results: Individuals with a history of ACLR and SRC demonstrated worse KSES-PA (7.5 [5.3]) compared with those without a history of SRC (8.1 [6.1], P = .03). No other statistically significant differences were observed. A medium effect size was present for the KSES-PA (0.62), KSES-ADL (0.42), KSES-Present (ADL + PA + Sport) (0.48), KSES-Total (0.53), and Tampa Scale of Kinesiophobia-11 (0.61) but must be interpreted with caution as 95% confidence interval crossed 0. Conclusions: This exploratory study indicated that individuals with a history of ACLR and SRC had worse knee self-efficacy for PA compared with those without history of SRC. Rehabilitation specialists should monitor knee self-efficacy deficits in the post-ACLR population and recognize the potential influence of cumulative injury history on rehabilitative outcomes.

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Participant-Level Analysis of the Effects of Interventions on Patient-Reported Outcomes in Patients With Chronic Ankle Instability

Cameron J. Powden, Rachel M. Koldenhoven, Janet E. Simon, John J. Fraser, Adam B. Rosen, Abbis Jaffri, Andrew B. Mitchell, and Christopher J. Burcal

Context: Intervention studies for chronic ankle instability (CAI) often focus on improving physical impairments of the ankle complex. However, using an impairments-focused approach may miss psychological factors that may mediate function and recovery. Patient-reported outcome (PRO) measures can be used to assess several dimensions of the health-related quality of life (HRQoL) and deliver enhanced patient-centered care. Therefore, the purpose of this investigation was to evaluate group-level improvements in HRQoL and treatment response rates following various interventions in patients with CAI. Design: Cross-sectional. Methods: Data from 7 previous studies were pooled by the chronic ankle instability outcomes network for participant-level analysis, resulting in 136 patients with CAI. Several interventions were assessed including balance training, gait biofeedback, joint mobilizations, stretching, and strengthening, with treatment volume ranging from 1 to 4 weeks. Outcome measures were PROs that assessed ankle-specific function (Foot and Ankle Ability Measure), injury-related fear (Tampa Scale of Kinesiophobia and Fear Avoidance Belief Questionnaire), and global well-being (Disablement in the Physically Active); the PROs assessed varied between studies. Preintervention to postintervention changes were evaluated using separate Wilcoxon signed-rank tests and effect sizes, and a responder analysis was conducted for each PRO. Results: Significant, moderate to large improvements were observed in PROs that assessed ankle-specific function, injury-related fear, and global well-being following intervention (P < .001). Responder rates ranged from 39.0% to 53.3%, 12.8% to 51.4%, and 37.8% for ankle specific function, injury-related fear, and global well-being, respectively. Conclusions: Various interventions can lead to positive improvements in HRQoL in patients with CAI. Treatment response rates at improving HRQoL are similar to response rates at improving impairments such as balance, further reinforcing the need for individualized treatment approaches when treating a patient with CAI.

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Acute and Overuse, Time-Loss and Non-Time-Loss Lateral Ankle Sprains and Health Care Utilization in Collegiate Student-Athletes

Cathleen N. Brown, Viktor E. Bovbjerg, Michael T. Soucy, SeokJae Choe, Michael Fredericson, and Janet E. Simon

Context: Health care utilization and the occurrence of non-time-loss (NTL) lateral ankle sprains is not well documented in collegiate athletes but could provide better estimates of injury burden and inform clinician workload. Design: Descriptive epidemiologic study. Methods: Lateral ankle sprain injury occurrence for Division I collegiate student-athletes in a conference with 32 sports representing 732 team seasons was collected during the 2018–2019 through 2020–2021 academic years. Injuries were designated as acute or overuse, and time-loss (TL) or NTL. Associated health care utilization, including athletic training services (AT services), and physician encounters were reported along with anatomical structures involved and season of occurrence. Results: A total of 1242 lateral ankle sprains were reported over the 3 years from 732 team seasons and 17,431 player seasons, resulting in 12,728 AT services and 370 physician encounters. Most lateral ankle sprains were acute-TL (59.7%), which were associated with the majority of AT services (74.1%) and physician encounters (70.0%). Acute-NTL sprains represented 37.8% of lateral ankle sprains and were associated with 22.3% of AT services and 27.0% of physician encounters. On average, there were 12.7 (5.8) AT services per acute-TL sprain and 6.0 (3.6) per acute-NTL sprain. Most sprains involved “ankle lateral ligaments” (45.6%), and very few were attributed to overuse mechanisms (2.4%). Conclusions: Lateral ligament sprains are a common injury across many sports and result in substantial health care utilization from ATs and physicians, including NTL lateral ankle sprains. Although TL injuries were the majority of sprains, a substantial proportion of sprains were NTL and accounted for a considerable proportion of health care utilization.

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Association of Proximal and Distal Factors With Lower Limb Kinematics During a Classical Ballet Jump

Anelise Moreti Cabral, Adalberto Felipe Martinez, Vitor Leme, Bruna Calazans Luz, and Fábio Viadanna Serrão

Context: Excessive dynamic lower limb misalignment may predispose ballet dancers to jump-related injuries. However, it is unknown whether proximal and distal factors influence this movement pattern. The aim of this study was to investigate whether hip abduction strength, foot alignment, and ankle dorsiflexion range of motion (ROM) are associated with peak angles of hip adduction and internal rotation and knee abduction during the preparation and landing phases of a classical ballet jump. Design: Cross-sectional study. Methods: Forty-one healthy amateur ballet dancers were included. Hip abduction strength was evaluated isometrically using a handheld dynamometer, foot alignment was determined by the shank-forefoot alignment, and weight-bearing ankle dorsiflexion ROM was measured by performing the lunge test. Peak hip and knee angles were analyzed 3-dimensionally during the preparation and landing phases of a single-leg jump. A Pearson correlation matrix was used to investigate the association of hip abduction strength, shank-forefoot alignment, and ankle dorsiflexion ROM with peak angles of hip adduction and internal rotation and knee abduction during the preparation and landing phases of the jump. Results: Greater hip abduction strength was associated with greater peak hip internal rotation angle (r = .43, P < .05), but not with peak hip adduction and knee abduction angles during the preparation phase of the jump. There were no associations of shank-forefoot alignment and ankle dorsiflexion ROM with peak hip and knee angles during the preparation (r = −.23 to .36, P > .05) and landing (r = −.20 to .24, P > .05) phases of the jump. There was no association of hip abduction strength with peak hip and knee angles during the landing phase of the jump (r = −.28 to .16, P > .05). Conclusion: Hip abductors strengthening, correction of foot misalignments, and increasing ankle dorsiflexion ROM may not prevent excessive hip and knee movements during a classical ballet single-leg jump in amateur dancers.

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Volume 31 (2022): Issue 7 (Sep 2022)

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Kinesiophobia Is Related to Acute Musculoskeletal Injury Incidence Following Concussion

Xavier D. Thompson, Thomas M. Newman, Catherine C. Donahue, Nicholas K. Erdman, Siobhan M. Statuta, and Jacob E. Resch

Context: Athletes with a history of sport concussion (SC) have an increased risk of musculoskeletal injury (MSK); however, the underlying mechanisms have yet to be determined. The purpose of our study was to evaluate kinesiophobia in college athletes with or without a time-loss MSK within 180 days of unrestricted return to play following a SC. Design: This was a retrospective cohort study within a sports medicine facility. Methods: Participants were eligible if they were diagnosed with a SC, completed the Tampa Scale of Kinesiophobia (TSK), and completed an unrestricted return to play. Fifty-six college athletes (40 men and 16 women) with an average age of 19.5 (1.25) years, height of 183.5 (10.45) cm, and mass of 94.72 (24.65) kg, were included in the study. MSK participants were matched to non-MSK participants 1:1. Demographic and TSK outcome scores were compared using independent t tests. The proportion of participants in each group who scored above the clinical threshold (TSK ≥ 37) was compared using a chi-square analysis. Alpha was set at α = .05. Results: The MSK group (31.2 [6.30]) reported similar TSK scores to the matched group (28.9 [3.34]; t 54 = 1.70, P = .10, d = 0.45 [ 0.08 to 0.97]). A greater proportion of athletes who were diagnosed with an MSK-reported scores above the cutoff (χ 2[1] = 6.49, P = .01). Conclusions: Athletes diagnosed with SC had similar kinesiophobia values regardless of MSK status. However, a higher proportion of athletes with a time-loss MSK injury reported a TSK score greater than the clinical cutoff. Our results suggest that factors such as kinesiophobia should be considered following a SC.

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Neurodynamic Exercises in College Athletes With Musculoskeletal Pain: A Critically Appraised Topic

Nicholas Hattrup, Kacey Ohlemeyer, Zachary Schmidt, Emily Gibb, and Nicholas Pfeifer

Clinical Scenario: Pain is a common complaint following an orthopedic injury; however, the exact cause of nociception can be complex. Multiple tissues can generate a patient’s complaint of pain, such as the skin, muscle, ligaments, tendon, nerves, and bones. Regarding the somatosensory system, inflammation around the nerve can create pain and alter movement coordination; this information has resulted in increased awareness of neurodynamic assessments and exercises. Neurodynamic assessments and exercises provide a unique paradigm to effectively assess and treat neural tissue, which may not commonly be considered within the traditional orthopedic examination. Clinical Question: In college athletes with musculoskeletal pain and activity impairments, does the use of neurodynamic exercises improve pain or function? Summary of Key Findings: Of the 5 studies, all consisted of chronic injuries with 3 involving upper-extremity pathologies and 2 focusing on lower-extremity pathologies. All 5 studies noted short- and long-term improvement following the incorporation of neurodynamic sliders or tensioners into the treatment plan. Four of the studies had follow-up periods greater than 30 days with sustained improvement on patient outcomes. Only 2 studies described a progression of neurodynamic exercises through sliders and tensioners. Three studies utilized a set/repetition format for exercise prescription, whereas a fourth used a time-based format, and a fifth article utilized both. Finally, 4 studies utilized neurodynamic assessments to identify whether there was a neural component to the patient’s presentation (eg, peripheral nerve mechanosensitivity). Clinical Bottom Line: In individuals with musculoskeletal impairments, evidence exists to support the use of neurodynamic exercises, such as sliders and tensioners, to improve pain and pain-related disability when neural sensitivity exists. Strength of Recommendation: Grade C evidence exists to support the use of neurodynamic exercises in college athletes with a musculoskeletal impairment.

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Concurrent Validity of Lower Limb Muscle Strength by Handheld Dynamometry in Children 7 to 11 Years Old

Ryan Mahaffey, Megan Le Warne, Stewart C. Morrison, Wendy I. Drechsler, and Nicola Theis

Context: The assessment of pediatric muscle strength is necessary in a range of applications, including rehabilitation programs. Handheld dynamometry (HHD) is considered easy to use, portable, and low cost, but validity to measure lower limb muscle strength in children has not been assessed. Objective: To determine the concurrent validity of lower limb torque from HHD compared with isokinetic dynamometry (ID) in children aged from 7 to 11 years old. Design: A descriptive assessment of concurrent validity of lower limb joint torques from HHD compared with ID. Methods: Sixty-one typically developing children underwent assessment of maximal hip, knee, and ankle isometric torque by HHD and ID using standardized protocols. Joint positions were selected to represent maximal strength and were replicated between devices. Concurrent validity was determined by Pearson correlation, limits of agreement, and Bland–Altman plots. Results: Correlations between HHD and ID were moderate to large for knee extension (r 95% CI, .39 to .73), small to large for plantar flexion (r 95% CI, .29 to .67), knee flexion (r 95% CI, .16 to .59), hip flexion (r 95% CI, .21 to .57), hip extension (r 95% CI, .18 to .54), and hip adduction (r 95% CI, .12 to .56), and small to moderate for dorsiflexion (r 95% CI, −.11 to .39) and hip abduction (r 95% CI, −.02 to .46). Limits of agreement for all joint torques were greater than 10% indicating large error in HHD measured torque compared with ID. A positive proportional bias was detected for plantarflexion, indicating that HHD underestimated torque to a greater extent in participants with higher torque values. Conclusions: Maximal torque values from HHD and ID are consistent with those previously reported in the literature. Poor concurrent validity of HHD may have arisen from issues around joint position, joint stabilization, and the experience of the tester to prevent an isokinetic contraction. Pediatric lower limb muscle strength assessed by HHD should be interpreted with caution.

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Variability in Normalization Methods of Surface Electromyography Signals in Eccentric Hamstring Contraction

Juan Guerrero-Henriquez, Claudio Tapia, and Martin Vargas-Matamala

Context: In human movement analysis, normalization of a surface electromyography signal is a crucial step; therefore, parameter selection for this procedure must be adequately justified. The aim of this research was to determine the variability of electromyography signals in eccentric hamstring contraction under different normalization parameters. Design: Cross-sectional study. Methods: Nine university rugby players (age 21.50 [3.61] y; body mass index 21.50 [4.95]) and no history of recent hamstring injury. Values from maximum voluntary isometric contraction protocol and task related (ie, Nordic hamstring exercise) were used for surface electromyography signal normalization. Intersubject and intrasubject variation coefficients were used for normalization method variability and for signal reproducibility, respectively. Results: Intrasubject variation coefficient value indicates acceptable reproducibility of surface electromyography (less than 12%) for all normalization procedures. Lower values of intersubject variation coefficient value were achieved for normalization procedures using task-related values. Conclusion: Parameters extracted from task execution provided less variability for surface electromyography amplitude normalization in eccentric hamstring muscle contractions.

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Association Between Nondominant Leg-Side Hip Internal Rotation Restriction and Low Back Pain in Male Elite High School Soft Tennis Players

Toru Tanabe, Takumi Watabu, Hiroichi Miaki, Naoyuki Kubo, Tiharu Inaoka Pleiades, Tomonari Sugano, and Katsunori Mizuno

Context: The incidence of low back pain (LBP) is high among high school male soft tennis players. In some sports for which the rotational component of the body is important, an association between restricted hip internal rotation of the nondominant leg and LBP has been reported; however, whether this association holds in soft tennis is unknown. Therefore, this study aimed to evaluate the association between hip internal rotation, hip external rotation, hamstring flexibility, iliopsoas flexibility, and LBP incidence. Design: This study was designed as a cross-sectional study, conducted at a sports training center. Methods: Participants comprised 113 male elite high school soft tennis players (age: 16.1 [0.7] y) from 9 elite-level teams. The main outcome measures were the hip internal and external rotation range of motion, hamstring flexibility on the straight leg raise test, and iliopsoas flexibility on the Thomas test. Multiple logistic regression analysis was performed to examine the influence of main outcomes on LBP incidence in the past 1 year. Results: A total of 35 participants had LBP (LBP group); 78 participants did not have LBP (non-LBP group). Multiple logistic regression analysis revealed that the odds ratio for height was 1.08 (95% confidence interval, 1.00–1.16; P = .043) and for the hip internal rotation range of motion in the nondominant leg was 0.90 (95% confidence interval, 0.85–0.95; P < .001), indicating significant associations with LBP. Conclusion: Hip internal rotation range of motion in the nondominant leg and height were crucial factors related to LBP in male elite high school soft tennis players.