Clinical Scenario: Ulnar collateral ligament (UCL) injuries are highly prevalent in professional baseball players with the success of operative management being well known in the literature. Return to play (RTP) rates following nonoperative management of partial UCL injuries in professional baseball players are not well established in the literature. With a UCL tear being a potential career-ending injury, it is imperative that the best treatment option is provided to these throwing athletes. There is an increase in the incidence of UCL surgical rates and a lack of general agreement on nonoperative treatment of partial UCL injuries as reported by the American Shoulder and Elbow Surgeons in 2017. There is also a lack of clarity on when to initiate rehabilitation, which may be due to the limited amount of studies reporting success of RTP rates and time to RTP following conservative interventions of partial UCL injuries. Evidence on the RTP rates seen following conservative management of partial UCL tears injuries can help guide health care providers in deciding on the best treatment option for professional baseball athletes who desire to return to their athletic careers. These rates of RTP will add valuable objective input when determining if conservative management is the best choice. To determine the current evidence, inclusion criteria for the literature search consisted of RTP rates following conservative treatment in professional baseball players between inception and 2018. Clinical Question: Is there evidence for successful RTP rates in professional baseball players following conservative treatment of a UCL injury? Summary of Key Findings: Three retrospective studies met the inclusion criteria and were included. Of those, 2 reported RTP rates following a nonoperative rehabilitation program of a UCL injury, whereas 1 reported RTP rates after injection therapy in subjects who attempted a trial of conservative treatment. All 3 studies considered location and grade of UCL tear. Successful RTP rates (66%–100%) were reported in professional baseball players following nonoperative treatment of partial UCL injuries. Clinical Bottom Line: Current evidence supports high success with RTP rates up to 100% after nonoperative treatment of grade 1 UCL injuries in professional baseball players and between 66% and 94% for a grade 2 and above. Strength of Recommendation: There is level C evidence for high RTP rates following nonoperative treatment of partial UCL injuries in professional baseball players.
Nicole Cascia, Tim L. Uhl and Carolyn M. Hettrich
Sergio Jiménez-Rubio, Archit Navandar, Jesús Rivilla-García and Victor Paredes-Hernández
Context: Despite the presence of various injury prevention programs, the rate of hamstring injuries and reinjuries is increasing in soccer, warranting the need for a soccer-specific rehabilitation program. Objective: To develop and validate a new, functional on-field program for the rehabilitation and readaptation of soccer players after a hamstring strain injury through a panel of experts; and determine the usefulness of the program through its application in professional soccer players. Design: A 13-item program was developed, which was validated by a panel of experts and later applied to professional soccer players. Setting: Soccer training ground. Participants: Fifteen strength and conditioning and rehabilitation fitness coaches with a professional experience of 15.40 (1.57) years in elite clubs and national teams in Europe validated the program. The program was later applied to 19 professional soccer players of the Spanish First Division (La Liga). Interventions: Once a player sustained a clinically diagnosed injury, the player would first be subject to mobilization and strengthening exercises in the gym after undergoing treatment by percutaneous needle electrolysis. The player would then complete an on-field readaptation program consisting of 13 drills arranged in a progressive manner in terms of complexity. The drills integrated various aspects of repeated sprint abilities, retraining and reeducation of biomechanical patterns, and neuromuscular control of the core and lower limbs. Main Outcome Measures: Aiken’s V for each item of the program and number of days taken by the players to return to play. Results: The experts evaluated all items of the program very highly, as seen from Aiken’s V values between 0.78 and 0.98 (0.63–0.99) for all drills, while the return to play was in 22.42 (2.32) days. Conclusion: This program has the potential to help a player suffering from a hamstring strain injury to adapt to real-match conditions in the readaptation phase through the application of sports-specific drills that were very similar to the different injury mechanisms.
Rafael Squillantini, Brielle Ringle and Julie Cavallario
Clinical Question: In patients with acute knee injuries, is there evidence to support that the lever sign test is more accurate in diagnosing an anterior cruciate ligament sprain than the Lachman test? Clinical Bottom Line: The evidence does not indicate that the lever sign test can be used in isolation in lieu of the Lachman test, but there is sufficient evidence to support adding the lever sign test to the examination of potential anterior cruciate ligament sprains.
Marcos de Noronha, Eleisha K. Lay, Madelyn R. Mcphee, George Mnatzaganian and Guilherme S. Nunes
Context: Ankle sprains are common injuries in sports, but it is unclear whether they are more likely to occur in a specific period of a sporting game. Objective: To systematically review the literature investigating when in a match ankle sprains most likely occurred. Evidence Acquisition: The databases CINAHL, EMBASE, MEDLINE, and SPORTDiscus were searched up to August 2016, with no restriction of date or language. The search targeted studies that presented data on the time of occurrence of ankle sprains during sports matches. Data from included studies were analyzed as a percentage of ankle sprain occurrence by halftime and by quarters. Meta-analyses were run using a random effects model. The quality assessment tool for quantitative studies was used to assess the article’s quality. Evidence Synthesis: The searches identified 1142 studies, and 8 were included in this review. A total of 500 ankle sprains were reported during follow-up time, which ranged from 1 to 15 years, in 5 different sports (soccer, rugby, futsal, American football, and Gaelic football). The meta-analyses, including all 8 studies, showed that the proportion of ankle sprains during the first half (0.44; 95% confidence interval [CI], 0.38–0.50) was smaller than the second half (0.56; 95% CI, 0.50–0.62). For the analyses by quarters, the proportion of ankle sprains in the first quarter (0.14; 95% CI, 0.09–0.19) was considerably smaller than the second (0.28; 95% CI, 0.24–0.32), third (0.25; 95% CI, 0.17–0.34), and fourth (0.29; 95% CI, 0.22–0.36) quarters. Conclusion: The results of this review indicate that ankle sprains are more likely to occur later in the game during the second half or during the latter minutes of the first half.
Erica S. Albertin, Emilie N. Miley, James May, Russell T. Baker and Don Reordan
Clinical Scenario: Hip osteoarthritis currently affects up to 28% of the population, and the number of affected Americans is expected to rise as the American population increases and ages. Limited hip range of motion (ROM) has been identified as a predisposing factor to hip osteoarthritis and limited patient function. Clinicians often apply therapy techniques, such as stretching and strengthening exercises, to improve hip ROM. Although traditional therapy has been recommended to improve hip ROM, the efficiency of the treatments within the literature is questionable due to lack of high-quality studies. More recently, clinicians have begun to utilize joint mobilization and the Mulligan Concept mobilization with movement techniques to increase ROM at the hip; however, there is a paucity of research on the lasting effects of mobilizations. Given the difficulties in improving ROM immediately (within a single treatment) and with long-lasting results (over the course of months), it is imperative to examine the evidence for the effectiveness of traditional therapy techniques and more novel manual therapy techniques. Focused Clinical Question: Is there evidence to suggest manual mobilizations techniques at the hip are effective at treating hip ROM limitations? Summary of Clinical Findings: 5 Randomized Controlled Studies, improved patient function and ROM with the Mulligan concept, high velocity low amplitude improved. Clinical Bottom Line: We found moderate evidence to suggest favorable outcomes following the use of hip mobilizations aimed at improving hip ROM and patient function. Strength of Recommendation: Strength of the studies identified are 1B.
Kellie C. Huxel Bliven
Genki Hatano, Shigeyuki Suzuki, Shingo Matsuo, Satoshi Kataura, Kazuaki Yokoi, Taizan Fukaya, Mitsuhiro Fujiwara, Yuji Asai and Masahiro Iwata
Context: Hamstring injuries are common, and lack of hamstring flexibility may predispose to injury. Static stretching not only increases range of motion (ROM) but also results in reduced muscle strength after stretching. The effects of stretching on the hamstring muscles and the duration of these effects remain unclear. Objective: To determine the effects of static stretching on the hamstrings and the duration of these effects. Design: Randomized crossover study. Setting: University laboratory. Participants: A total of 24 healthy volunteers. Interventions: The torque–angle relationship (ROM, passive torque [PT] at the onset of pain, and passive stiffness) and isometric muscle force using an isokinetic dynamometer were measured. After a 60-minute rest, the ROM of the dynamometer was set at the maximum tolerable intensity; this position was maintained for 300 seconds, while static PT was measured continuously. The torque–angle relationship and isometric muscle force after rest periods of 10, 20, and 30 minutes were remeasured. Main Outcome Measures: Change in static PT during stretching and changes in ROM, PT at the onset of pain, passive stiffness, and isometric muscle force before stretching were compared with 10, 20, and 30 minutes after stretching. Results: Static PT decreased significantly during stretching. Passive stiffness decreased significantly 10 and 20 minutes after stretching, but there was no significant prestretching versus poststretching difference after 30 minutes. PT at the onset of pain and ROM increased significantly after stretching at all rest intervals, while isometric muscle force decreased significantly after all rest intervals. Conclusions: The effect of static stretching on passive stiffness of the hamstrings was not maintained as long as the changes in ROM, stretch tolerance, and isometric muscle force. Therefore, frequent stretching is necessary to improve the viscoelasticity of the muscle–tendon unit. Muscle force decreased for 30 minutes after stretching; this should be considered prior to activities requiring maximal muscle strength.
David M. Werner and Joaquin A. Barrios
Context: Core stability is considered critical for the successful execution of rehabilitative and athletic tasks. Although no consensus definition exists, different components related to core stability have been identified. An important component is the domain of motor control. There are few clinical tests assessing the motor control component of core stability (MCCS). Objective: To evaluate the interrater reliability and known-groups validity of a novel test of MCCS, the in-line half-kneeling test. The test is aimed at assessing MCCS by challenging the ability to maintain a static position with minimized contributions from the distal extremities over a minimized base of support. Design: Cross-sectional group comparison study. Setting: Laboratory. Patients or Other Participants: A total of 75 participants (25 individuals with a history of anterior cruciate ligament reconstruction, 25 uninjured Division 1 collegiate athletes, and 25 uninjured controls) were recruited from a university community. Intervention: Participants were video recorded while performing the in-line half-kneeling test for 120 seconds bilaterally. Three observers independently viewed each video to determine if individuals broke form during each test using 2 dichotomous criteria. Main Outcome Measures: Cohen’s kappa was used to assess interrater reliability, and chi-square tests of independence were used to compare break rates between groups. Results: Good-to-excellent interrater reliability (.732–.973) was seen between the 3 observers. Chi-square tests of independence revealed different break rates between all 3 groups. Compared to break rate for the reference control group (11/25—44%), those with a history of anterior cruciate ligament reconstruction broke at a higher rate (18/25—72%), whereas the uninjured collegiate athletes broke at a lower rate (4/25—16%). Conclusions: The in-line half-kneeling test is a reliable test between raters that can differentiate between groups expected to differ in MCCS.
Rosa M. Rodriguez, Ashley Marroquin and Nicole Cosby
Clinical Scenario: The anterior cruciate ligament is one of the major stabilizing ligaments of the knee joint by preventing anterior translation of the femur in the closed kinetic chain. A ruptured anterior cruciate ligament may require reconstructive surgery for patients who wish to return to physical activity. For the most part, surgeries are successful at repairing the ruptured ligament and restoring ligamentous function; the percentage of athletes that return to a competitive level of physical activity is only 44%, and 24% of patients report a main factor of preventing their return is fear of reinjury and pain. Most physiotherapy and rehabilitation research has focused on the physical treatment and is limited on the psychological aspects of recovery. Imagery has been suggested to be effective at reducing anxiety, tension, and pain, while promoting and encouraging healing after an injury. Imagery is defined as a process of performing a skill in one’s mind using the senses (touch, feel, smell, vision, etc) without any overt actions. Clinical Question: In athletes who are first-time anterior cruciate ligament reconstruction patients, does imagery training in combination with standard physical therapy reduce the fear of reinjury and pain perception? Summary of Key Findings: Previous research has primarily looked at the physical treatment aspect, and few studies have focused on the psychological factors affecting recovery. Researchers concluded that fear of reinjury was the unique predictor of return to sport even in a sample of participants that reported very little or almost no pain at all. Imagery as a therapy is an effective intervention in reducing fear of reinjury and confidence building. Furthermore, mental imagery is suggested to assist with a reduction in anxiety, pain, and tension, while promoting healing. Clinical Bottom Line: Based on the strength of recommendation taxonomy, there is a combination of level A and B evidence proposing that imagery, in combination with traditional physical therapy, can be effective at reducing psychological distress such as fear of reinjury and pain perception in first-time anterior cruciate ligament reconstruction patients.