Context: Conventional ankle prophylactics restrict harmful ankle inversion motions that lead to injury. But these existing prophylactics also limit other ankle motions, potentially leading to detriments in functional joint capacity. The ankle roll guard (ARG) may alleviate the prevailing issues of existing ankle prophylactics and prevent harmful ankle inversion, while allowing other joint motions. Objective: This technical report sought to compare the ARG’s ability to prevent ankle inversion, but not restrict other ankle motions with existing prophylactics. Design: Repeated-measures study. Setting: Motion capture laboratory. Participants: Thirty participants. Intervention: Each participant had dominant limb ankle kinematics recorded during 5 successful trials of a sudden inversion event and 30-cm drop landing task with each of 4 conditions (ARG, ASO ankle stabilizer [brace], closed-basket weave athletic tape [tape], and unbraced [control]). Main Outcome Measures: Peak ankle inversion angle, range of inversion motion (ROM), and time to peak inversion during the sudden inversion event, and ankle plantar- and dorsiflexion ROM during the drop landing were submitted to a 1-way repeated-measures analysis of variance to test the main effect of prophylaxis. Results: Participants exhibited greater inversion ROM with control compared with tape (P = .001), and greater plantar- and dorsiflexion ROM with ARG and control compared with brace (P = .02, P = .001) and tape (P = .02, P < .001). It took significantly longer to reach peak ankle inversion with brace and tape compared with ARG (P < .001, P = .001) and control (P = .01, P = .01). No significant difference in peak ankle inversion was observed between any condition (P > .05). Conclusion: The ARG may prevent ankle inversion angles where injury is thought to occur (reportedly >41°), but is less restrictive than existing prophylactics. The less restrictive ARG may make its use ideal during rehabilitation as it allows ankle plantar- and dorsiflexion motions, while preventing inversion related to injury.
Wyatt D. Ihmels, Kayla D. Seymore, and Tyler N. Brown
Kenneth Färnqvist, Stephen Pearson, and Peter Malliaras
Context: Exercise is seen as the most evidence-based treatment for managing tendinopathy and although the type of exercise used to manage tendinopathy may induce adaptation in healthy tendons, it is not clear whether these adaptations occur in tendinopathy and if so whether they are associated with improved clinical outcomes. Objective: The aim of the study was to synthesize available evidence for adaptation of the Achilles tendon to eccentric exercise and the relationship between adaptation (change in tendon thickness) and clinical outcomes among people with Achilles tendinopathy. Evidence Acquisition: The search was performed in September 2018 in several databases. Studies investigating the response (clinical outcome and imaging on ultrasound/magnetic resonance imaging) of pathological tendons (tendinopathy, tendinosis, and partial rupture) to at least 12 weeks of eccentric exercise were included. Multiple studies that investigated the same interventions and outcome were pooled and presented in effect size estimates, mean difference, and 95% confidence intervals if measurement scales were the same, or standard mean difference and 95% confidence intervals if measurements scales were different. Where data could not be pooled the studies were qualitatively synthesized based on van Tulder et al. Evidence Synthesis: Eight studies met the inclusion and exclusion criteria and were included in the review. There was strong evidence that Achilles tendon thickness does not decrease in parallel with improved clinical outcomes. Conclusions: Whether a longer time to follow-up is more important than the intervention (ie, just the time per se) for a change in tendon thickness remains unknown. Future studies should investigate whether exercise (or other treatments) can be tailored to optimize tendon adaptation and function, and whether this relates to clinical outcomes.
Natalie L. Myers, Guadalupe Mexicano, and Kristin V. Aguilar
Clinical Scenario: Workload monitoring and management of an athlete is viewed by many as an essential training component to determine if an athlete is adapting to a training program and to minimize injury risk. Although training workload may be measured a variety of different ways, session rate of perceived exertion (sRPE) is often used in the literature due to its clinical ease. In recent years, sports scientists have been investigating sRPE as a measure of internal workload and its relationship to injury in elite-level athletes using a metric known as the acute:chronic workload ratio (ACWR). This critically appraised topic was conducted to determine if internal workload using the ACWR is associated with injury. Focused Clinical Question: In elite-level athletes, is there an association between the ACWR for sRPE and noncontact injuries? Summary of Search, Best Evidence Appraised, and Key Findings: The literature was searched for studies investigating the association between noncontact injuries and the sRPE ACWR in elite athletes. Three prospective cohort studies were included. Two studies found that high ACWR led to 2.0 to 4.5 times greater injury risk compared with a more balanced ACWR. One study found that low chronic workloads coupled with a low ACWR were associated with injury. Clinical Bottom Line: The majority of evidence suggests that when the acute workload exceeds the chronic workload, there is an increase in injury risk. The evidence also supports that a low chronic workload with a low ACWR should be considered as an injury risk factor. Strength of Recommendation: Based on the American Family Physician’s Strength of Recommendation Taxonomy, there is level A evidence to support the sRPE ACWR as a risk factor for noncontract injuries in elite athletes.
Clinical Scenario: Ice hockey and soccer are both dynamic sports that involve continuous, unpredictable play. These athletes consistently demonstrate higher rates of groin strains compared with other contact sports. Measuring the hip adductor/abductor ratio has the potential to expose at-risk players, reduce injury rates, and preserve groin health in players with chronic strains. Focused Clinical Question: What is the clinical utility of measuring the hip adductor/abductor ratio for preseason and in-season ice hockey and soccer players? Summary of Key Findings: Three studies, all of which were prospective cohort designs, were included. One study involved assessing preseason strength and flexibility as a risk factor for adductor strains in professional ice hockey players. Another study performed with the same professional hockey team used preseason hip adductor/abductor strength ratios to screen for those players who would benefit from a strengthening intervention aimed at reducing the incidence of adductor strains. The final study, which was performed in elite U17 soccer players, assessed the effectiveness of monthly in-season strength monitoring as a guide to trigger in-season interventions to decrease injury incidence. Clinical Bottom Line: Measuring the hip adductor/abductor strength ratio in hockey and soccer players can be a beneficial preseason and in-season tool to predict future groin strain risk and screen for athletes who might benefit from a strengthening intervention. Strength of Recommendation: Level 3 evidence exists to support monitoring the hip adductor/abductor strength ratio to assess and reduce the risk of adductor strains in ice hockey and soccer players.
Caroline Westwood, Carolyn Killelea, Mallory Faherty, and Timothy Sell
Context: Concussions are consequence of sports participation. Recent reports indicate there is an increased risk of lower-extremity musculoskeletal injury when returning to sport after concussion suggesting that achieving “normal” balance may not fully indicate the athlete is ready for competition. The increased risk of injury may indicate the need to refine a screening tool for clearance. Objective: Assess the between-session reliability and the effects of adding a cognitive task to static and dynamic postural stability testing in a healthy population. Setting: Clinical laboratory. Participants: Twelve healthy subjects (6 women; age 22.3 [2.9] y, height 174.4 [7.5] cm, weight 70.1 [12.7] kg) participated in this study. Design: Subjects underwent static and dynamic postural stability testing with and without the addition of a cognitive task (Stroop test). Test battery was repeated 10 days later. Dynamic postural stability testing consisted of a forward jump over a hurdle with a 1-legged landing. A stability index was calculated. Static postural stability was also assessed with and without the cognitive task during single-leg balance. Variability of each ground reaction force component was averaged. Main Outcome Measures: Interclass correlation coefficients (ICC2,1) were computed to determine the reliability. Standard error of measure, mean standard error, mean detectable change, and 95% confidence interval were all calculated. Results: Mean differences between sessions were low, with the majority of variables having moderate to excellent reliability (static .583–.877, dynamic .581–.939). The addition of the dual task did not have any significant effect on reliability of the task; however, generally, the ICC values improved (eyes open .583–.770, dual task .741–.808). Conclusions: The addition of a cognitive load to postural stability assessments had moderate to excellent reliability in a healthy population. These results provide initial evidence on the feasibility of dual-task postural stability testing when examining risk of lower-extremity musculoskeletal injury following return to sport in a concussed population.
Ryan Morrison, Kyle M. Petit, Chris Kuenze, Ryan N. Moran, and Tracey Covassin
Context: Balance testing is a vital component in the evaluation and management of sport-related concussion. Few studies have examined the use of objective, low-cost, force-plate balance systems and changes in balance after a competitive season. Objective: To examine the extent of preseason versus postseason static balance changes using the Balance Tracking System (BTrackS) force plate in college athletes. Design: Pretest, posttest design. Setting: Athletic training facility. Participants: A total of 47 healthy, Division-I student-athletes (33 males and 14 females; age 18.4 [0.5] y, height 71.8 [10.8] cm, weight 85.6 [21.7] kg) participated in this study. Main Outcome Measures: Total center of pressure path length was measured preseason and postseason using the BTrackS force plate. A Wilcoxon signed-rank test was conducted to examine preseason and postseason changes. SEM and minimal detectable change were also calculated. Results: There was a significant difference in center of pressure path length differed between preseason (24.6 [6.8] cm) and postseason (22.7 [5.4] cm) intervals (P = .03), with an SEM of 3.8 cm and minimal detectable change of 10.5 cm. Conclusions: Significant improvements occurred for center of pressure path length after a competitive season, when assessed using the BTrackS in a sample of college athletes. Further research is warranted to determine the effectiveness of the BTrackS as a reliable, low-cost alternative to force-plate balance systems. In addition, clinicians may need to update baseline balance assessments more frequently to account for improvements.
Janelle Prince, Eric Schussler, and Ryan McCann
Clinical Scenario: A sport-related concussion is a common injury to the brain that may cause a variety of symptoms ranging in duration and severity. The mainstay of treatment for concussion has been rest, followed by a stepwise return to activity. This recovery process may be lengthy when symptoms persist. Aerobic exercise conducted at subsymptom and submaximal intensities has been proposed as a potential intervention for symptoms following a concussion. Therefore, the purpose of this critically appraised topic is to examine the safety of varying aerobic exercise intensities in patients with a concussion. Focused Clinical Question: Are subsymptom and submaximal exercise programs safe when implemented in a population with a symptomatic sports-related concussion when compared with traditional rest? Summary of Key Findings: Four randomized controlled trials were included for critical appraisal. The 4 studies investigated supervised and controlled aerobic exercise as early as within 1 week of with a concussion; all studies conclude that exercise is safe and may be of benefit to individuals with a concussion. Two studies support the use of submaximal exercise as a therapeutic intervention for adolescents with persistent concussion symptoms. Clinical Bottom Line: The authors conclude that controlled exercise performed within the symptom or exertion threshold of patients with concussion is safe compared with rest. It was noted that symptom changes may occur; however, the changes did not have a negative impact on long-term recovery. This research should ease concerns about prescribing physical activity when an athlete with concussion is still experiencing lingering symptoms. While specific parameters of the activity performed have not been described in detail, the individualization of each exercise program was stressed. Strength of Recommendation: Grade A.
Yuko Kuramatsu, Yuji Yamamoto, and Shin-Ichi Izumi
This study investigated the sensorimotor strategies for dynamic balance control in individuals with stroke by restricting sensory input that might influence task accomplishment. Sit-to-stand movements were performed with restricted vision by participants with hemiparesis and healthy controls. The authors evaluated the variability in the position of participants’ center of mass and velocity, and the center-of-pressure position, in each orthogonal direction at the lift-off point. When vision was restricted, the variability in the mediolateral center-of-pressure position decreased significantly in individuals with hemiparesis, but not in healthy controls. Participants with hemiparesis adopted strategies that explicitly differed from those used by healthy individuals. Variability may be decreased in the direction that most requires accuracy. Individuals with hemiparesis have been reported to have asymmetrical balance deficits, and that meant they had to prioritize mediolateral motion control to prevent falling. This study suggests that individuals with hemiparesis adopt strategies appropriate to their characteristics.
Patrick O. McKeon and Jennifer M. Medina McKeon
Sergio Jiménez-Rubio, Archit Navandar, Jesús Rivilla-García, Víctor Paredes-Hernández, and Miguel-Ángel Gómez-Ruano
Context: Although there are multiple, validated return-to-play programs following hamstring strain injuries, no studies have evaluated their changes in match performance parameters. Objectives: The aim of this study was twofold as follows: (1) to determine the changes in match-based physical performance parameters in professional soccer players before and after sustaining a hamstring strain injury and undergoing a soccer-specific rehabilitation program and (2) to observe the progress of these performance parameters 6 to 10 weeks after the player returned from injury. Design: Prospective, quasi-experimental longitudinal study. Setting: Soccer playing and training grounds. Participants: Nineteen players suffering a hamstring strain injury from 2 male professional teams playing in the Spanish professional football league (La Liga) were followed during the 2015–2016, 2016–2017, and 2017–2018 seasons. Intervention: Participation in on-field training program following a hamstring injury. Main Outcome Measures: Match global positioning system data were collected in the following stages: prior to injury (PRE), after return to play (RTP), program, and 6 to 10 weeks following RTP (C2). Peak velocities and distances ran at sprint velocities showed most likely improvements in C2 versus PRE, and very likely improvements in RTP versus PRE. Results: The distances ran at high and very high intensities, the average velocity, and work-to-rest ratio showed very likely improvements in C2 versus RTP and likely improvements in RTP versus PRE. Likely improvements were observed for all variables in C2 versus RTP. The authors’ results showed an improvement of physical performance during competitive match after RTP, compared with PRE. There was a steady progression in the progress, and in 8 months following RTP, there was no injury reported in the players. Conclusions: The current findings may indicate that the hamstring muscle complex not only recovered completely from the injury but could also withstand a greater training and match load reducing the risk of reinjury.