Clinical Scenario: A variety of training approaches have been adopted in anterior cruciate ligament (ACL) prevention programs, including neuromuscular control training, core stability training, balance training, and plyometric exercise. This review was conducted to determine if current evidence supports one of these training approaches over the others for reducing noncontact ACL injuries in adolescent female athletes. Focused Clinical Question: What is the most effective training approach for preventing noncontact ACL injuries in adolescent and/or high school–aged female athletes? Summary of Key Findings: A literature search generated 2 level 1b randomized control trials and 1 level 2b cohort study. Plyometric training resulted in decreased knee valgus during landing in 3 studies and increased knee flexion at landing in 2 studies. Balance training or neuromuscular training led to decreased knee valgus and increased knee-flexion angles with landing in 2 studies. Core stability training had conflicting effects on knee valgus and knee-flexion angles at landing, with 1 study reporting no effect and another reporting an undesirable decrease in knee joint flexion angle at landing. Clinical Bottom Line: Based on this review, plyometric training, balance training, and neuromuscular training approaches appear sensible to include in ACL prevention programs for female athletes to help decrease knee valgus and knee flexion during landing. Core stability training may be somewhat beneficial for decreasing knee valgus angles at landing, although may have nominal or even deleterious effects on knee-flexion angle at landing, and thus should be implemented with caution. Strength of Recommendation: Our recommendations were derived from the results of 2 level 1b randomized control trials and 1 level 2b cohort study.
Erica M. Willadsen, Andrea B. Zahn, and Chris J. Durall
Jenny H. Conviser, Amanda Schlitzer Tierney, and Riley Nickols
It is estimated that 1.6 million people in the United States are currently diagnosed with an eating disorder. Eating disorders (EDs) have high rates of morbidity and mortality and remain the most severe mental illness. Unfortunately, rates of EDs and disordered eating behaviors (DEBs) among athletes appear to be increasing. In this study, authors summarize ED-related risks that pose compromises in psychological and social functioning, medical health, and overall quality of life. The importance of early detection and formal evaluation in preserving the athlete’s health, well-being and sustaining successful sport participation, and performance are highlighted. Athlete-specific factors, which challenge the ease and accuracy of ED detection and assessment, are noted. The recommended components of effective ED assessment are identified, including use of self-report measures and clinical interviews conducted by ED certified and licensed professionals. The importance of being well informed in tenets of ED awareness, prevention and supporting early detection, and referral for formal ED assessment are noted. Conclusions reflect the vital roles that both the multidisciplinary sport personnel and the sport environment/culture play in reducing the serious health risks of DEBs and EDs. Each is needed to protect an athlete’s well-being while fostering safe and successful sport participation.
Laura K. Fewell, Riley Nickols, Amanda Schlitzer Tierney, and Cheri A. Levinson
The current study tested if athlete patients differed from non-athlete patients in measures of eating disorder (ED) and related pathology. Athlete (n = 91 in Study 1; n = 39 in Study 2) and non-athlete (n = 76 in Study 1; n = 26 in Study 2) patients completed self-report measures, and body mass index (BMI) was calculated. Athlete patients had significantly lower ED symptomatology and depression than non-athlete patients (ps < .05). ED impairment, worry, psychosocial functioning, BMI, obsessive-compulsiveness, and compulsive exercise did not significantly differ between groups (ps > .08). Greater ED symptomatology was associated with higher psychosocial functioning among athlete patients and higher obsessive-compulsive symptoms and compulsive exercise among non-athlete patients. This is a novel study comparing ED symptomatology and related measures of mental health in athlete and non-athlete patients engaged in residential or partial hospitalization ED treatment. Future research should further investigate how participation in high-level sport impacts the presentation, treatment, and outcome of individuals with EDs.
Jenny H. Conviser, Amanda Schlitzer Tierney, and Riley Nickols
Eating disorders (EDs) and disordered-eating behaviors (DEBs), pose a high risk of morbidity and mortality, threatening physical health, emotional health, and overall quality of life. Unfortunately, among athletes, prevalence rates continue to increase. This document summarizes the challenges of establishing and navigating the multidisciplinary care needed to effectively treat EDs and DEBs among athletes. The benefits of timely and frequent communication within the multidisciplinary treatment team (MDTT) are emphasized and discussed. Authors advise who should be selected as members of the MDTT and suggest that all personnel, including athletic coaches, athletic trainers, physical therapists, and certified fitness professionals be ED-informed and ED-sensitive. Vital components of care are noted including use of a variety of evidence-based psychotherapeutic modalities, interventions which target emotional regulation, and prioritize values based compassionate care. Authors caution that performance decrements and medical/physiological changes are not always easily observable in individuals with EDs and DEBs and therefore, attuned, consistent, and ongoing monitoring is needed. Consensus regarding previously established parameters for return to play and careful titration of physical activity throughout the ED recovery process are suggested as important for preserving health, preventing re-injury, or relapse and facilitating successful return to sport participation.
Laura K. Fewell, Riley Nickols, Amanda Schlitzer Tierney, and Cheri A. Levinson
Understanding the unique needs of athletes who undergo eating disorder (ED) treatment is sorely needed. This study explores changes of strength and power in athlete (n = 21) and non-athlete (n = 36) patients from intake to discharge. Maximal oxygen consumption, vertical jump, push-ups, hand grip strength, and body mass index (in anorexia nervosa; AN) were measured among treatment center patients. The number of push-ups and hand grip strength were significantly improved upon discharge in the full sample (ps < .005) and in AN only (ps < .001). Body mass index was also significantly higher in AN (p < .001). Maximal oxygen consumption and vertical jump did not significantly improve between admission and discharge in either group (ps > .40). This study is the first to investigate measures of strength in athletes engaged in intensive eating disorder treatment and indicates the need to address the psychological mindset around physical activity using exercise education as part of a comprehensive program. Recommendations for incorporating exercise into an intensive ED treatment center are also provided.
Aaron Nelson, Nathan Koslakiewicz, and Thomas Gus Almonroeder
Context: Athletes who have undergone an anterior cruciate ligament reconstruction often demonstrate more pronounced interlimb knee kinetic symmetry in comparison with uninjured athletes, even after they have completed rehabilitation. Part of the reason for the persistent asymmetry may be that sports medicine professionals are typically not able to assess knee joint kinetics within the clinic setting. Developing measures to assess knee joint kinetic symmetry could help to augment current rehabilitation practices. Objective: The purpose of this study was to explore the extent to which interlimb vertical ground reaction force (GRF) symmetry can predict knee kinetic symmetry during a drop landing task. Design: Cross-sectional study. Setting: Motion analysis laboratory. Participants: A total of 21 uninjured subjects (9 males and 12 females). Protocol: Three-dimensional kinematic data were collected using a multicamera system while subjects performed double-leg drop landings. GRF data were collected synchronously using 2 adjacent force plates. Main Outcome Measures: Knee joint moments and power were calculated for both limbs during the landing trials. An interlimb symmetry index (dominant/nondominant limb) was calculated for both the peak knee joint moment and power variables, as well as for the peak vertical GRFs. Linear regression analyses were performed to determine if the degree of symmetry in the peak vertical GRFs predicted the degree of symmetry for the kinetic variables. Results: The symmetry index for the vertical GRFs was a significant predictor of the symmetry indices for the knee joint moments (r = .81; P < .001) and power (r = .88; P < .001). Conclusion: Interlimb symmetry in the peak vertical GRFs can be used to predict knee joint kinetic symmetry during a double-leg drop landing task.
Megan P. Brady and Windee Weiss
Clinical Scenario : The anterior cruciate ligament (ACL) injury is a common knee injury within varying athletic levels. Clinical diagnostic tests and magnetic resonance imaging (MRI) are two methods of evaluating ACL injuries. Clinical Question : Are clinical diagnostic tests as accurate as MRI when diagnosing ACL tears? Summary of Key Findings: Three cross-sectional design studies were included. One study found that clinical diagnostic tests were superior to MRI when diagnosing an ACL tear. Another study found that clinical diagnostic tests were equal to MRI when measuring sensitivity, but scored higher in specificity, positive predictive value, negative predictive value, and diagnostic accuracy. The last study found that clinical diagnostic tests scored higher than MRI on specificity and positive predictive value, were equal when measuring accuracy, and scored lower when measuring sensitivity and negative predictive value. Clinical Bottom Line: The evidence supports the use of clinical diagnostic tests when diagnosing an ACL tear. Strength of Recommendation: Level 2–3.
Objectives : The efficacy of eccentric cycling has been proved in research, clinical, and sport training activities. However, several constraints make it difficult to use commercially available eccentric cycle ergometers. This study will stimulate the application of eccentric cycling as an exercise modality. Study Design: University research laboratory. Methods : In this study, the multiple-input single-output (MISO) Wiener nonlinear model was applied to the design of the eccentric training system. Particle Swarm Optimization (PSO) algorithm was then applied to identify the parameters of the MISO Wiener nonlinear model. The computer software embedded with MISO model was programmed for not only controlling and monitoring the running status of the eccentric training system, but also collecting data in a flexible and convenient manner. Results : The correlation coefficient of 0.9985 and root mean square error of 3.3264 between the collected power value and the estimated power value from the model shows the good performance of the model. Conclusion : The proposed method for the design of the eccentric training system using MISO Wiener nonlinear model provides a new way for eccentric research and training.
Christie Powell, Jody Jensen, and Samantha Johnson
Context : As sport participation increases globally, so will injury-related risks. The process used to determine return-to-sport following injury is vital to future sport participation and injury prevention. Early specialization along with poor management of sport participation causes an increase in injury risk and potential long-term health consequences for youth athletes. Objectives : Previous injury is a common intrinsic risk factor for new injuries. Identifying functional performance deficits, defined by return-to-sport criteria, minimizes these risk factors and provides athletes with guidelines to return safely to sport. The purposes of this clinical commentary and literature review are to provide a summary of current concepts and clinical practices and to identify functional performance measures as clinical assessment tools for return-to-play criteria in the youth population. Evidence : A literature review was completed using numerous databases, where 154 relevant articles were reviewed and 22 articles were included in this commentary. Of the 22 articles using functional performance measures for return-to-sport criteria, 6 were specific to youth, 12 had mixed populations of adults and youth, and 4 were normative samples for specific youth populations. Acquisition : The gaps in the literature pertaining to functional performance measures in the youth population are addressed, and future research needs for return-to-sport criteria are identified. Evidence Synthesis : This descriptive literature review identifies 22 articles that meet the search criteria for the youth population discussing the use of clinical functional performance measures in order to identify return-to-sport criteria for lower-extremity injuries. Conclusions: Due to the inconsistencies in terminology, definitions, and standardization of clinical assessment tools, it seems necessary to create a comprehensive functional performance test battery for the lower extremity that can be used as return-to-sport criteria.
Julie A. Fuller, Heidi L. Hammil, Kelly J. Pronschinske, and Chris J. Durall
Clinical Scenario: Acute patellar dislocations during adolescence often lead to future patellar instability. Two common treatment options include nonoperative treatment or operative repair of injured structures. Focused Clinical Question: In adolescents with acute patellar dislocation, how does operative stabilization compare with nonoperative treatment for reducing dislocation recurrence? Summary of Key Findings: Three studies were included: 2 randomized controlled trials and 1 nonrandomized study. All studies compared operative and nonoperative treatment outcomes in adolescents who experienced an acute patellar dislocation. Each study included nonoperative treatment such as patellar bracing and quadriceps strengthening. The operative treatments utilized in each study included lateral retinacular release and medial retinacular repair. All 3 of the studies included a follow-up of at least 6 years. Two of the studies concluded there to be no significant difference between treatment groups regarding redislocation rate, pain, and function. The third study reported a lower redislocation rate following operative treatment. Clinical Bottom Line: Reviewed evidence suggests that outcomes are similar when comparing operative and nonoperative treatment approaches with little agreement as to which is the optimal plan of action. Strength of Recommendation: One level II randomized controlled trial and a level III nonrandomized study suggest that patellar dislocation recurrence rates are similar among operative and nonoperative treatment approaches, while another level II randomized controlled trial suggests that an operative approach is superior.