Clinical Scenario: Ankle fractures are a frequent occurrence, and they carry the potential for syndesmosis injury. The syndesmosis is important to the structural integrity of the ankle joint by maintaining the proximity of the tibia, fibula, and talus. Presently, the gold standard for treating an ankle syndesmosis injury is to insert a metallic screw through the fibula and into the tibia. This technique requires a second intervention to remove the hardware, but also carries an inherent risk of breaking the screw during rehabilitation. Another fixation technique, the Tightrope™, has gained popularity in treating ankle syndesmosis injuries. The TightRope™ involves inserting Fiberwire® through the tibia and fibula, which allows for stabilization of the ankle mortise and normal range of motion. Clinical Question: In patients suffering from ankle syndesmosis injuries, is the Tightrope™ ankle syndesmosis fixation system more effective than conventional screw fixation at improving return to work, pain, and patient-reported outcome measures? Summary of Key Findings: Five studies were selected to be critically appraised. The PEDro checklist was used to score 2 randomized control trials, and the Downs & Black checklist was used to score the cohort study on methodology and consistency. Two systematic reviews were also appraised. All 5 articles demonstrated support for using the TightRope™ fixation. Clinical Bottom Line: There is moderate evidence to support the use of the TightRope™ syndesmosis fixation system, as it provides both clinician- and patient-reported outcomes that are similar to those using the conventional metallic screw, with a shortened time to recover and return to activity. Strength of Recommendation: Grade A evidence exists in support of using the TightRope™ fixation system in place of the metallic screw following ankle syndesmosis injury.
Scott Benson Street, Matthew Rawlins, and Jason Miller
Alexandre Nehring, Thiago Teixeira Serafim, Elisa Raulino Silva, Fábio Sprada de Menezes, Nicola Maffulli, Luciana Sayuri Sanada, and Rodrigo Okubo
Context: Myofascial self-release is performed using a roller to exert pressure on the soft tissues and to promote effects similar to those of traditional massage. However, there is no standardization regarding its application, mainly in relation to time. Objective: To evaluate the effects of myofascial self-release with a rigid roller on range of motion (ROM), pressure pain threshold (PPT), and hamstring strength in asymptomatic individuals following 2 different times of intervention. Design: Randomized, controlled, blind, clinical trial comparing preintervention and immediately postintervention within 2 groups. Setting: Institutional physiotherapy clinic. Participants: A total of 40 university students (18–30 y), who had no symptoms, participated. Intervention: Foam roller for 30 seconds and 2 minutes for group 2. Main Outcome Measures: Hamstring PPT, knee-extension ROM, and peak knee-flexion torque measured before and immediately after the intervention. Results: Both groups experienced a statistically significant increase in ROM compared with baseline (30 s and 2 min for group 2 P < .024). There were no statistically significant differences comparing peak knee-flexion torque or PPT. Conclusions: Hamstring myofascial self-release using a roller for 30 seconds or 2 minutes produced an increase in ROM in healthy individuals. PPT and peak knee-flexion isometric torque showed no effects.
Dhinu J. Jayaseelan, Cesar Fernandez-de-las-Penas, Taylor Blattenberger, and Dean Bonneau
Clinical Scenario: Plantar heel pain is a common condition frequently associated with persistent symptoms and functional limitations affecting both the athletic and nonathletic populations. Common interventions target impairments at the foot and ankle and local drivers of symptoms. If symptoms are predominantly perpetuated by alterations in central pain processing, addressing peripheral impairments alone may not be sufficient. Clinical Question: Do individuals with chronic plantar heel pain demonstrate signs potentially associated with altered central pain processing? Summary of Key Findings: After searching 6 electronic databases (PubMed, CINAHL, Scopus, SportDiscus, Cochrane, and PEDro) and filtering titles based on predetermined inclusion and exclusion criteria, 4 case-control studies were included. All studies scored highly on the Newcastle-Ottawa Scale for quality assessment. Using pressure pain thresholds, each study found decreased pressure pain hypersensitivity locally and at a remote site compared to control groups, suggesting the presence, to some extent, of altered nociceptive pain processing. Clinical Bottom Line: In the studies reviewed, reported results suggest a possible presence of centrally mediated symptoms in persons with plantar heel pain. However, despite findings from these studies, limitations in appropriate matching based on body mass index and measures used suggest additional investigation is warranted. Strength of Recommendation: According to the Oxford Centre for Evidence-Based Medicine, there is evidence level C to suggest chronic plantar heel pain is associated with alterations in central pain processing.
Matthew K. Seeley, Seong Jun Son, Hyunsoo Kim, and J. Ty Hopkins
Context: Patellofemoral pain (PFP) is often categorized by researchers and clinicians using subjective self-reported PFP characteristics; however, this practice might mask important differences in movement biomechanics between PFP patients. Objective: To determine whether biomechanical differences exist during a high-demand multiplanar movement task for PFP patients with similar self-reported PFP characteristics but different quadriceps activation levels. Design: Cross-sectional design. Setting: Biomechanics laboratory. Participants: A total of 15 quadriceps deficient and 15 quadriceps functional (QF) PFP patients with similar self-reported PFP characteristics. Intervention: In total, 5 trials of a high-demand multiplanar land, cut, and jump movement task were performed. Main Outcome Measures: Biomechanics were compared at each percentile of the ground contact phase of the movement task (α = .05) between the quadriceps deficient and QF groups. Biomechanical variables included (1) whole-body center of mass, trunk, hip, knee, and ankle kinematics; (2) hip, knee, and ankle kinetics; and (3) ground reaction forces. Results: The QF patients exhibited increased ground reaction force, joint torque, and movement, relative to the quadriceps deficient patients. The QF patients exhibited: (1) up to 90, 60, and 35 N more vertical, posterior, and medial ground reaction force at various times of the ground contact phase; (2) up to 4° more knee flexion during ground contact and up to 4° more plantarflexion and hip extension during the latter parts of ground contact; and (3) up to 26, 21, and 48 N·m more plantarflexion, knee extension, and hip extension torque, respectively, at various times of ground contact. Conclusions: PFP patients with similar self-reported PFP characteristics exhibit different movement biomechanics, and these differences depend upon quadriceps activation levels. These differences are important because movement biomechanics affect injury risk and athletic performance. In addition, these biomechanical differences indicate that different therapeutic interventions may be needed for PFP patients with similar self-reported PFP characteristics.
Adesola C. Odole, Olawale T. Agbomeji, Ogochukwu K.K. Onyeso, Joshua O. Ojo, and Nse A. Odunaiya
Background: Athletes’ perceptions toward physiotherapy services have an impact on their general attitude toward these services and their willingness to work together with physiotherapists for rehabilitation. The study investigated athletes’ perspectives of physiotherapy services in sports injury management. Methods: A mixed-study design of a cross-sectional survey that involved 178 conveniently sampled athletes and an explanatory qualitative study (8 purposively-selected athletes) was used. The authors assessed the participants’ knowledge and perception of physiotherapy services using the modified versions of the Athletes’ Level of Knowledge Questionnaire, Matsuno Athletes Perception Scale, and focus group discussion. The data were analyzed using chi-square, Spearman correlation at P ≤ .05, and deductive reasoning thematic analysis. Results: The age of the participants for the cross-sectional survey (131 men and 47 women) was 22.50 (7.51) years. Our results showed that the majority (91.6%) of them had adequate knowledge and (78.7%) positive perception about the role physiotherapists play in sports injury management. The participants’ knowledge of physiotherapy services had a significantly positive correlation with age (ρ = .12; P = .01), sporting years (ρ = .17; P = .02), and duration in sports council (ρ = .19; P = .01), while their perception showed a negative correlation with age (ρ = −.15; P = .05), sporting years (ρ = −.16; P = .03), and duration in sports council (ρ = −.08; P = .02). However, no significant correlation existed between the participants’ knowledge; perception and level of education; level of competition; type of sport; and type, nature, and severity of sport injury. Seven themes were generated from the focus group discussion. Conclusion: The participants reported adequate knowledge and a positive perception of physiotherapy services. The correlates of participants’ knowledge and perception of physiotherapy services are age, sporting years, and duration in the sports council. From the qualitative component of the study, the authors identified the need to provide more physiotherapy services to athletes and more facilities for physiotherapy services.
Louis Howe, Jamie S. North, Mark Waldron, and Theodoros M. Bampouras
Context: Ankle dorsiflexion range of motion (DF ROM) has been associated with a number of kinematic and kinetic variables associated with landing performance that increase injury risk. However, whether exercise-induced fatigue exacerbates compensatory strategies has not yet been established. Objectives: (1) Explore differences in landing performance between individuals with restricted and normal ankle DF ROM and (2) identify the effect of fatigue on compensations in landing strategies for individuals with restricted and normal ankle DF ROM. Design: Cross-sectional. Setting: University research laboratory. Patients or Other Participants: Twelve recreational athletes with restricted ankle DF ROM (restricted group) and 12 recreational athletes with normal ankle DF ROM (normal group). Main Outcome Measure(s): The participants performed 5 bilateral drop-landings, before and following a fatiguing protocol. Normalized peak vertical ground reaction force, time to peak vertical ground reaction force, and loading rate were calculated, alongside sagittal plane initial contact angles, peak angles, and joint displacement for the ankle, knee, and hip. Frontal plane projection angles were also calculated. Results: At the baseline, the restricted group landed with significantly less knee flexion (P = .005, effect size [ES] = 1.27) at initial contact and reduced peak ankle dorsiflexion (P < .001, ES = 1.67), knee flexion (P < .001, ES = 2.18), and hip-flexion (P = .033, ES = 0.93) angles. Sagittal plane joint displacement was also significantly less for the restricted group for the ankle (P < .001, ES = 1.78), knee (P < .001, ES = 1.78), and hip (P = .028, ES = 0.96) joints. Conclusions: These findings suggest that individuals with restricted ankle DF ROM should adopt different landing strategies than those with normal ankle DF ROM. This is exacerbated when fatigued, although the functional consequences of fatigue on landing mechanics in individuals with ankle DF ROM restriction are unclear.
Karin Weman Josefsson
Sweden has adopted a somewhat different approach to handle the corona pandemic, which has been widely debated both on national and international levels. The Swedish model involves more individual responsibility and reliance on voluntary civic liability than law enforcement, while common measures in other countries are based on more controlling strategies, such as restrictive lockdowns, quarantines, closed borders, and mandatory behavior constraints. This commentary aims to give a brief overview of the foundations of the Swedish model as well as a discussion on how and why it has been adopted in the Swedish society based on Swedish legislations, culture, and traditions. Finally, perspectives on how the Swedish model could be connected to the tenets of self-determination theory will be discussed.
Zachary Y. Kerr, Julianna Prim, J.D. DeFreese, Leah C. Thomas, Janet E. Simon, Kevin A. Carneiro, Stephen W. Marshall, and Kevin M. Guskiewicz
Context: Little research has examined health-related quality of life in former National Football League (NFL) players. Objective: Examine the association of musculoskeletal injury history and current self-reported physical and mental health in former NFL players. Setting: Cross-sectional questionnaire. Patients or Other Participants: Historical cohort of 2,103 former NFL players that played at least one season between 1940 and 2001. Intervention: Players were grouped by self-reported professional career musculoskeletal injury history and whether injuries affected current health: (1) no musculoskeletal injury history; (2) musculoskeletal injury history, currently affected by injuries; and (3) musculoskeletal injury history, not currently affected by injuries. Main Outcome Measure: The Short Form 36 Measurement Model for Functional Assessment of Health and Well-Being (SF-36) yielded physical and mental health composite scores (PCS and MCS, respectively); higher scores indicated better health. Multivariable linear regression computed mean differences (MD) among injury groups. Covariates included demographics, playing history characteristics, surgical intervention for musculoskeletal injuries, and whether injury resulted in premature end to career. MD with 95% CI excluding 0.00 were deemed significant. Results: Overall, 90.3% reported at least one musculoskeletal injury during their professional football careers, of which 74.8% reported being affected by their injuries at time of survey completion. Adjusting for covariates, mean PCS in the “injury and affected” group was lower than the “no injury” (MD = −3.2; 95% CI: −4.8, −1.7) and “injury and not affected” groups (MD = −4.3; 95% CI: −5.4, −3.3); mean MCS did not differ. Conclusion: Many players reported musculoskeletal injuries, highlighting the need for developing and evaluating injury management interventions.
Landon B. Lempke, Jeonghoon Oh, Rachel S. Johnson, Julianne D. Schmidt, and Robert C. Lynall
Context: Laboratory-based movement assessments are commonly performed without cognitive stimuli (ie, single-task) despite the simultaneous cognitive processing and movement (ie, dual task) demands required during sport. Cognitive loading may critically alter human movement and be an important consideration for truly assessing functional movement and understanding injury risk in the laboratory, but limited investigations exist. Objective: To comprehensively examine and compare kinematics and kinetics between single- and dual-task functional movement among healthy participants while controlling for sex. Design: Cross-sectional study. Setting: Laboratory. Patients (or Other Participants): Forty-one healthy, physically active participants (49% female; 22.5 ± 2.1 y; 172.5 ± 11.9 cm; 71.0 ± 13.7 kg) enrolled in and completed the study. Intervention(s): All participants completed the functional movement protocol under single- and dual-task (subtracting by 6s or 7s) conditions in a randomized order. Participants jumped forward from a 30-cm tall box and performed (1) maximum vertical jump landings and (2) dominant and (3) nondominant leg, single-leg 45° cuts after landing. Main Outcome Measures: The authors used mixed-model analysis of variances (α = .05) to compare peak hip, knee, and ankle joint angles (degrees) and moments (N·m/BW) in the sagittal and frontal planes, and peak vertical ground reaction force (N/BW) and vertical impulse (Ns/BW) between cognitive conditions and sex. Results: Dual-task resulted in greater peak vertical ground reaction force compared with single-task during jump landing (mean difference = 0.06 N/BW; 95% confidence interval [CI], 0.01 to 0.12; P = .025) but less force during dominant leg cutting (mean difference = −0.08 N/BW; 95% CI, −0.14 to −0.02; P = .015). Less hip-flexion torque occurred during dual task than single task (mean difference = −0.09 N/BW; 95% CI, −0.17 to −0.02). No other outcomes were different between single and dual task (P ≥ .053). Conclusions: Slight, but potentially important, kinematic and kinetic differences were observed between single- and dual-task that may have implications for functional movement assessments and injury risk research. More research examining how various cognitive and movement tasks interact to alter functional movement among pathological populations is warranted before clinical implementation.