Clinical Scenario: Anterior cruciate ligament (ACL) tear is a devastating knee injury with negative long-term consequences, such as early-onset knee osteoarthritis, biomechanical compensations, and reduced physical activity. Significant reduction in physical activity is a powerful indicator of cardiovascular (CV) disease; therefore, those with a history of ACL injury may be at increased risk for CV disease compared with noninjured individuals. Focused Clinical Question: Do individuals with a history of ACL injury demonstrate negative CV changes compared with those without a history of ACL injury? Summary of Key Findings: Three articles met the inclusion criteria and investigated CV changes after ACL injury. Both cross-sectional studies compared participants with ACL injury with matched controls. Bell et al compared time spent in moderate to vigorous physical activity and step count, whereas Almeida et al compared maximum rate of oxygen consumption, ventilatory thresholds, isokinetic quadriceps strength, and body composition. Collectively, both quantitative studies found that individuals with a history of ACL injury had less efficient CV systems compared with matched controls and/or preoperative data. Finally, a qualitative study of 3506 retired National Football League athletes showed an increased rate of arthritis and knee replacement surgery after an ACL injury when compared with other retired National Football League members, in addition to a >50% increased rate of myocardial infarction. Clinical Bottom Line: A history of ACL injury is a source of impaired physical activity. Preliminary data indicate that these physical activity limitations negatively impair the CV system, and individuals with a history of ACL injury demonstrate lower maximum oxygen consumption, self-reported disability, and daily step count compared with noninjured peers. These complications support the need for greater emphasis on CV wellness. Strength of Recommendation: Consistent findings from 2 cross-sectional studies and 1 survey study suggest level IIB evidence to support that ACL injury is associated with negative CV health.
Cody R. Butler, Kirsten Allen, Lindsay J. DiStefano and Lindsey K. Lepley
Marcie Fyock, Nelson Cortes, Alex Hulse and Joel Martin
Clinical Scenario: Patellofemoral pain (PFP) is a common knee injury in recreational adult runners, possibly caused by faulty mechanics. One possible approach to reduce this pain is to retrain the runner’s gait. Current research suggests that no definitive gold standard treatment for PFP exists. Gait retraining utilizing visual feedback may reduce PFP in both the short and long term. Clinical Question: In adult runners diagnosed with PFP, does gait retraining with real-time visual feedback lead to a decrease in pain? Summary of Key Findings: A literature search was performed; 3 relevant studies utilizing gait retraining with visual feedback, pain level as an outcome measure, and follow-up measures of at least 1 month after the intervention were included. All the included studies reported a decrease in short- and long-term pain for participants following visual feedback gait retraining. In addition, biomechanical measures related to PFP, including peak hip adduction angle and the angle of contralateral pelvic drop, improved after the completion of the intervention. Clinical Bottom Line: There is level 2 evidence supporting the implementation of 8 sessions over 2 weeks of visual feedback gait retraining as a means of treating patients diagnosed with PFP. Based on current available evidence, clinicians should identify faulty mechanics of patients and implement a protocol of increasing real-time visual feedback over the first 4 sessions and decreasing visual feedback over the final 4 sessions. Strength of Recommendation: Level 2.
Lauren Anne Lipker, Caitlyn Rae Persinger, Bradley Steven Michalko and Christopher J. Durall
Clinical Scenario: Quadriceps atrophy and weakness are common after anterior cruciate ligament reconstruction (ACLR). Blood flow restriction (BFR) therapy, alone or in combination with exercise, has shown some promise in promoting muscular hypertrophy. This review was conducted to ascertain the extent to which current evidence supports the use of BFR for reducing quadriceps atrophy following ACLR in comparison with standard care. Clinical Question: Is BFR more effective than standard care for reducing quadriceps atrophy after ACLR? Summary of Key Findings: The literature was searched for studies that directly compared BFR treatment to standard care in patients with ACLR. Three level I randomized control trial studies retrieved from the literature search met the inclusion criteria. Clinical Bottom Line: Reviewed data suggest that a short duration (13 d) of moderate-pressure BFR combined with low-resistance muscular training does not appear to measurably affect quadriceps cross-sectional area. However, a relatively long duration (15 wk) of moderate-pressure BFR combined with low-resistance muscular training may increase quadriceps cross-sectional area to a greater extent than low-resistance muscular training alone. The results of the third randomized control trial suggest that employing BFR while immobilized in the early postoperative period may reduce quadriceps atrophy following ACLR. Additional data are needed to establish if the benefits of BFR on quadriceps atrophy after ACLR outweigh the inherent risks and costs. Strength of Recommendation: All evidence for this review was level 1 (randomized control trial) based on the Centre for Evidence-Based Medicine criteria. However, the findings were inconsistent across the 3 studies regarding the effects of BFR on quadriceps atrophy resulting in a grade “B” strength of recommendation.
Matt Hausmann, Jacob Ober and Adam S. Lepley
Clinical Scenario: Ankle sprains are the most prevalent athletic-related musculoskeletal injury treated by athletic trainers, often affecting activities of daily living and delaying return to play. Most of these cases present with pain and swelling in the ankle, resulting in decreased range of motion and strength deficits. Due to these impairments, proper treatment is necessary to avoid additional loss of play and prevent future injuries. Recently, there has been an increased use of deep oscillation therapy by clinicians to manage pain and swelling following a variety of injuries, including ankle sprains. However, very little evidence has been produced regarding the clinical effectiveness of deep oscillation therapy, limiting its application in therapeutic rehabilitation of acute lateral ankle sprains. Clinical Question: Is deep oscillation therapy effective in reducing pain and swelling in patients with acute lateral ankle sprains compared with the current standard of care protection, rest, ice, compression, and elevation? Summary of Key Findings: The literature was searched for studies of level 2 evidence or higher that investigated deep oscillation therapy on pain and inflammation in patients with lateral ankle sprains. Three randomized control trials were located and appraised. One of the 3 studies demonstrate a reduction in pain following 6 weeks of deep oscillation therapy compared with the standard of care or placebo interventions. The 2 other studies, 1 utilizing a 5-day treatment and the other a 1 time immediate application, found no differences in deep oscillation therapy compared with the standard of care. Clinical Bottom Line: There is inconclusive evidence to support the therapeutic use of deep oscillation therapy in reducing pain and swelling in patients with acute lateral ankle sprains above and beyond the current standard of care. In addition, the method of treatment application and parameters used may influence the effectiveness of deep oscillation therapy. Strength of Recommendation: Level B.
Heidi A. Wayment, Ann H. Huffman, Monica Lininger and Patrick C. Doyle
Social network analysis (SNA) is a uniquely situated methodology to examine the social connections between players on a team, and how team structure may be related to self-reported team cohesion and perceived support for reporting concussion symptoms. Team belonging was positively associated with number of friendship ties (degree; r = .23, p < .05), intermediate ties between teammates (betweenness; r = .21, p < .05), and support from both teammates (r = .21, p < .05) and important others (r = .21, p < .05) for reporting concussion symptoms. Additionally, an SNA-derived measure of social influence, eigenvector centrality, was associated with football identity (r = .34, p < .01), and less support from important others (r = –.24, p < .05) regarding symptom reporting. Discussion focuses on why consideration of social influence dynamics may help improve concussion-related education efforts.
Jonathan M. Williams, Michael Gara and Carol Clark
Context: Balance is important for injury prediction, prevention, and rehabilitation. Clinical measurement of higher level balance function such as hop landing is necessary. Currently, no method exists to quantify balance performance following hopping in the clinic. Objective: To quantify the sacral acceleration profile and test–retest reliability during hop landing. Participants: A total of 17 university undergraduates (age 27.6 [5.7] y, height 1.73 [0.11] m, weight 74.1 [13.9] kg). Main Outcome Measure: A trunk-mounted accelerometer captured the acceleration profile following landing from hopping forward, medially, and laterally. The path length of the acceleration traces were computed to quantify balance following landing. Results: Moderate to excellent reliability (intraclass correlation coefficient .67–.93) for hop landing was established with low to moderate SEM (4%–16%) and minimal detectable change values (13%–44%) for each of the hop directions. Significant differences were determined in balance following hop landing from the different directions. Conclusion: The results suggest that hop landing balance can be quantified by trunk-mounted accelerometry.
Damien Moore, Tania Pizzari, Jodie McClelland and Adam I. Semciw
Context: Many different rehabilitation exercises have been recommended in the literature to target the gluteus medius (GMed) muscle based mainly on single-electrode, surface electromyography (EMG) measures. With the GMed consisting of 3 structurally and functionally independent segments, there is uncertainty on whether these exercises will target the individual segments effectively. Objective: To measure individual GMed segmental activity during 6 common, lower-limb rehabilitation exercises in healthy young adults, and determine if there are significant differences between the exercises for each segment. Method: With fine-wire EMG electrodes inserted into the anterior, middle, and posterior segments of the GMed muscle, 10 healthy young adults performed 6 common, lower-limb rehabilitation exercises. Main Outcome Measures: Recorded EMG activity was normalized, then reported and compared with median activity for each of the GMed segments across the 6 exercises. Results: For the anterior GMed segment, high activity was recorded for the single-leg squat (48% maximum voluntary isometric contraction [MVIC]), the single-leg bridge (44% MVIC), and the resisted hip abduction–extension exercise (41% MVIC). No exercises recorded high activity for the middle GMed segment, but for the posterior GMed segment very high activity was recorded by the resisted hip abduction–extension exercise (69% MVIC), and high activity was generated by the single-leg squat (48% MVIC) and side-lie hip abduction (43% MVIC). For each of the GMed segments, there were significant differences (P < .05) in the median EMG activity levels between some of the exercises and the side-lie clam with large effect sizes favoring these exercises over the side-lie clam. Conclusions: Open-chain hip abduction and single-limb support exercises appear to be effective options for recruiting the individual GMed segments with selection dependent on individual requirements. However, the side-lie clam does not appear to be effective at recruiting the GMed segments, particularly the anterior and middle segments.
Victoria Fauntroy, Marcie Fyock, Jena Hansen-Honeycutt, Esther Nolton and Jatin P. Ambegaonkar
Clinical Scenario: Dancers participate in a functionally demanding activity. Athletic participation typically requires the completion of a preparticipation examination, which involves a functional movement screen offering insight into potential injury recognition. The Selective Functional Movement Assessment (SFMA) was created to measure the status of movement–pattern-related pain and dysfunction using regionally interdependent movement to aggravate symptoms and exhibit limitations and dysfunctions. Still, a functional assessment has not been identified to recognize potential dysfunctions or limitations in this population. Clinical Question: Does the use of the SFMA improve overall evaluation of dancers by providing more information on a dancer’s overall functional ability and limitations? Summary of Key Findings: The literature search discovered 12 studies and 3 books in which 4 studies were included (2 case reviews, 1 case report, and 1 original research study) based on the inclusion and exclusion criteria. Three of the studies provided clinical case studies utilizing the SFMA to improve the patient’s dysfunctions, whereas 1 study examined the intrarater and interrater reliability of the SFMA. In 3 studies, participants displayed less movement dysfunction. The authors from 3 of the studies agreed the SFMA was a valuable tool for clinicians to use during evaluations, as it provided a more holistic view of the patient, discovering dysfunctional movement patterns that may better identify the source of injury. Clinical Bottom Line: Low-quality evidence, defined as poorly designed case studies, case series, and cohort studies, exist that supports improvement of overall evaluations when utilizing the SFMA. Although the studies were considered low-quality evidence, each included study displayed an effective use of the SFMA as an overall evaluation that correctly identified dysfunctional movement patterns. Strength of Recommendation: Grade C evidence exists that the SFMA contributes to the functional evaluation used in dancers.
Bradley J. Conant, Nicole A. German and Shannon L. David
Clinical Scenario: Rates of ulnar collateral ligament (UCL) injuries continue to rise in overhead athletes of all ages. Surgical interventions require minimally 6 months and up to 2 years of rehabilitation. Younger athletes and those with partial tears have seen positive results with conservative treatment approaches. Platelet-rich plasma (PRP) continues to be studied with various orthopedic injuries, and its use has the potential to improve return-to-sport rates and reduce recovery time. Focused Clinical Question: Do PRP injections improve conservative treatment outcomes in overhead athletes with partial tears of the UCL compared with conservative treatment alone regarding return to participation? Summary of Search, Best Evidence Appraised, and Key Findings: A literature search was performed to locate all studies investigating outcomes when PRP is included in a conservative treatment program for overhead athletes with partial UCL tears. Three case series qualified and were reviewed. Clinical Bottom Line: Current evidence suggests that including PRP in a conservative treatment program can improve outcomes in overhead athletes with partial UCL tears. Athletes whose treatment included PRP show higher return-to-competition rates and shorter recovery times compared with athletes who used rehabilitation alone. Athletes with grade-1 and proximal-based grade-2 injuries returned to competition at rates comparable with athletes undergoing surgical intervention. For optimal conservative management outcomes, PRP injections should be recommended for treatment of partial UCL tears. Strength of Recommendation: The studies qualifying for inclusion are level 4 evidence based on the 2011 Oxford Centre for Evidence-Based Medicine levels of evidence. The studies are well designed and show consistent results, but higher level studies need to demonstrate similar results to improve the body of evidence. The strength of recommendation is C.
Natália Barros Beltrão, Camila Ximenes Santos, Valéria Mayaly Alves de Oliveira, André Luiz Torres Pirauá, David Behm, Ana Carolina Rodarti Pitangui and Rodrigo Cappato de Araújo
Context: Stretching intensity is an important variable that can be manipulated with flexibility training. However, there is a lack of evidence regarding this variable and its prescription in stretching programs. Objective: To investigate the effects of 12 weeks of knee flexor static stretching at different intensities on joint and muscle mechanical properties. Design: A randomized clinical trial. Setting: Laboratory. Participants: A total of 14 untrained men were allocated into the low- or high-intensity group. Main Outcome Measures: Assessments were performed before, at 6 week, and after intervention (12 wk) for biceps femoris long head architecture (resting fascicle length and angle), knee maximal range of motion (ROM) at the beginning and maximal discomfort angle, knee maximal tolerated passive torque, joint passive stiffness, viscoelastic stress relaxation, knee passive torque at a given angle, and affective responses to training. Results: No significant differences were observed between groups for any variable. ROM at the beginning and maximal discomfort angle increased at 6 and 12 weeks, respectively. ROM significantly increased with the initial angle of discomfort (P < .001, effect size = 1.38) over the pretest measures by 13.4% and 14.6% at the 6- and 12-week assessments, respectively, and significantly improved with the maximal discomfort angle (P < .001, effect size = 1.25) by 15.6% and 18.8% from the pretest to the 6- and 12-week assessments, respectively. No significant effects were seen for muscle architecture and affective responses. Initial viscoelastic relaxation for the low-intensity group was lower than ending viscoelastic relaxation. Conclusion: These results suggest that stretching with either low or high discomfort intensities are effective in increasing joint maximal ROM, and that does not impact on ROM, stiffness, fascicle angle and length, or affective response differences.