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Context: After completing rehabilitation, patients face a high risk of subsequent injury following anterior cruciate ligament reconstruction. It is important to identify potential barriers to patient success including clinician knowledge. The purpose of this study was to assess clinician knowledge of research related to anterior cruciate ligament reconstruction rehabilitation. Design: This was a survey study using snowball sampling. Methods: Survey development began with the creation of a construct map and contained varying levels of advanced concepts, level I indicating the most basic and level V the most complex. The survey was distributed to advertise to target population. A total of 60 participants (24 athletic trainers, 33 physical therapists, and 3 dual credentialed) completed the study. Results: Overall, participants displayed moderate to high levels of knowledge (79.7%–93.5% correct), apart from the implementation of motor learning principles. Conclusions: Clinician knowledge may not be the primary barrier to patient success, but the implementation of this knowledge should be explored in relation to patient outcomes. Future research should examine a larger cohort to examine differences between clinician types.

Context: In line with emerging research, an interprofessional specialty concussion clinic instituted a policy change permitting earlier physiotherapy-based treatment entry. Our objective was to determine the effect of this policy change on concussion recovery outcomes. Design: Secondary analysis of prospectively collected clinical data. Methods: 600 youth with concussion were included. Active rehabilitation was initiated ≥4 weeks (prepolicy) or ≥2 weeks (postpolicy) postconcussion based on institutional policy. Cox proportional hazard models, linear mixed models, and chi-square analyses were conducted. Results: The postpolicy group (median = 22 d [interquartile range: 17–27]) started treatment earlier than the prepolicy group (median = 26 d [interquartile range: 24–30], P < .001). Length of episode of care (χ ²(1) = 11.55, P < .001, odds ratios = 1.49; 95% confidence interval, 1.19–1.88); rehabilitation (χ ²(1) = 9.47, P = .002, odds ratios = 1.73, 95% confidence interval, 1.22–2.45]); and total recovery (χ ²(1) = 11.53, P < .001, odds ratios = 1.49; 95% confidence interval, 1.18–1.88) were reduced in patients postpolicy change. A significant interaction effect was found for total postinjury symptom (F _2,320 = 3.59, P = .03) and symptom change scores (F _2,315 = 5.17, P = .006), with the postpolicy group having faster symptom resolution over time. No group differences were observed for persisting symptoms. Conclusions: Earlier rehabilitation initiation occurred as intended following an institutional policy change, which had small, but significant, effects on recovery outcomes in youth with concussion. Health care providers should adopt policies to encourage early active rehabilitation services after concussion.

Context: Limited information exists regarding the immediate and short-term effects of scapula retraction exercises (SREs) on acromiohumeral distance (AHD) in subacromial pain syndrome (SPS). This study’s 2 main objectives were to investigate (1) the immediate effect of the SRE on AHD at varying shoulder abduction angles in patients with SPS and healthy controls and (2) the effect of the 8-week SRE program on AHD in patients with SPS. Design: Cross-sectional and pre–post intervention designs were utilized on this study. Methods: Twenty-one patients with SPS and age-matched healthy controls were included. First, AHD at 0°, 30°, 45°, 60°, and 90° of active shoulder abductions were recorded during (1) resting upper quadrant posture and (2) while participants were performing SREs. Patients then underwent an 8-week progressive SRE program. AHD measures, pain intensity (visual analog scale), and disability (Shoulder Pain and Disability Index) were recorded at baseline and 8 weeks. AHD were analyzed using mixed-model analyses of variance. Pain and disability were analyzed using paired samples t test. Results: The immediate effect of the SREs revealed a significant angle-by-exercise-by-group interaction for the AHD values (F _3,155 = 3.956, P = .009, ${\eta }_{\mathrm{p}}^2=.175$ ). Pairwise comparisons yielded that the SRE increased AHD values in patients with SPS (P < .05), yet it did not affect healthy controls (P > .05). Besides, the SRE program revealed a significant angle-by-time interaction for the AHD values (F _3,054 = 9.476, P < .001, ${\eta }_{\mathrm{p}}^2=.195$ ). AHD increased at all elevation angles, and pain and disability improved over time (P < .05). Conclusion: SREs immediately affect AHD in patients with SPS but not in healthy populations. Moreover, SREs applied in progressive abduction angles improve pain, functionality, and AHD values in patients with SPS.

Context: To further improve rehabilitation programs while preventing overstretching the anterior cruciate ligament (ACL), a thorough understanding of the knee kinematics and ACL length change during closed kinetic chain and open kinetic chain (OKC) exercises is essential. The measurement of ACL graft length relates to the changes in strain experienced by the ACL graft during different types of exercises rather than simple physical length. Objective: This study aimed to determine the effects of closed kinetic chain and OKC exercises on tibiofemoral kinematics and ACL graft length changes following double-bundle ACL reconstruction. Design: Cohort study (diagnosis); level of evidence, 3. Setting: Laboratory. Patients: Fifteen patients who underwent double-bundle ACL reconstruction were asked to perform 10-kg loaded seated knee extension (OKC-10) and single-leg lunge. During the seated knee extension, patients were instructed to extend and flex the knee within a range of 0° to 90° of flexion, with a 10-kg load applied to the ankle. For the lunge, patients began in a natural standing position and were instructed to flex the ACL-reconstructed knee to approximately 90°. Interventions: The 3-dimensional tibiofemoral kinematics under different weight-bearing conditions were determined using a dual-fluoroscopic imaging system. Main Outcome Measures: The tibiofemoral kinematics in 6 degrees-of-freedom were measured. And 3-dimensional ligament simulation technique was used to quantify length changes of the anteromedial bundle and posterolateral bundle. Results: The tibia exhibited significantly more external rotation during the OKC-10 motion than during the single-leg lunge from 35° to 70° of knee flexion (P ≤ .028). Beyond 30° of knee flexion, the tibia exhibited significantly more varus during the OKC-10 motion than during the single-leg lunge (P ≤ .028). And a significantly more anterior tibial translation was observed during the OKC-10 motion than during the lunge from 0° to 15° of flexion (P ≤ .018). The anteromedial bundle length was significantly longer during the OKC-10 motion than during the lunge between 0° and 25° of knee flexion (P ≤ .028). Conclusions: The effects of OKC exercises with loads on knee rotational stability should be considered in making rehabilitation programs for patients after ACL reconstruction. Since some degree of anterior tibial translation is physiological, it is important to note that increased translation alone does not necessarily indicate danger or instability.

Context: Athletes with a history of concussion (CON) have been demonstrated to have heightened levels of anxiety and depression that may continue well beyond the resolution of concussion symptoms. The global events of 2020 resulted in elevated levels of anxiety and depression in the general population, which may have unequally presented in collegiate athletes with (CON) than those without a history of concussion (NoCON). Using a deception design, our survey-based study compared levels of anxiety and depression in CON and NoCON collegiate athletes in response to the pandemic and social injustices. We hypothesized that the CON group would have significantly elevated anxiety and depression as compared to the NoCON group in response to events of 2020. Design and Methods: Collegiate athletes (N = 106) during the academic 2020–2021 academic year were divided into CON and NoCON groups based on their preinjury (baseline) concussion assessment. Participants completed the Social Readjustment Rating Scale (SSRS), Center for Epidemiologic Studies Depression Scale (CES-D), and Generalized Anxiety Disorder Scale-7 (GAD-7) via an electronic survey pertaining to the events of 2020. The term “concussion” was not used in any study materials which was the basis for our deception-based design. An analysis of covariance was used to compare group CES-D and GAD-7 outcome scores while controlling for the SSRS outcome score. Results: Our survey response rate was 14.2% (48/337 [77.1% female]) and 10.1% (58/580 [67.2% female]), for the NoCON and CON groups, respectively. The NoCON group had significantly (F ₁ = 5.82, P = .018, ${\eta }_{\mathrm{p}}^2=.06$ ) higher anxiety (8.3 [5.89]) as compared to the CON group (5.5 [2.85]). The NoCON group also had significantly (F ₁ = 13.7, P < .001, ${\eta }_{\mathrm{p}}^2=.12$ ) higher levels of depression (21.0 [12.52]) as compared to the CON group (16.07 [9.10]). Discussion: Our deception-based study revealed NoCON participants had elevated and clinically relevant mood states as compared to CON participants in response to the events of 2020.

Context: Targeted and directed rehabilitation with a healthcare provider can be an effective approach in the treatment of concussion, particularly for patients with protracted recovery, high symptom reporting, cervicogenic dysfunction, musculoskeletal involvement, and/or vestibular/oculomotor dysfunction. While many environmental and intrinsic medical history factors may influence concussion recovery, little is known about whether an individual’s recovery trajectory can be influenced by the amount of time taken to receive rehabilitation. The purpose of this study was to evaluate recovery trajectories of concussion patients requiring targeted multimodal rehabilitation after a specialty concussion clinic visit within ≤3 days, 4 to 7 days, and >7 days. We also sought to evaluate risk factors for protracted recovery. Design and Methods: The study involved a retrospective chart review of 103 patients (mean age = 13.78 [2.89]; 55% female) who, after their initial specialty concussion clinic visit, received rehabilitation in ≤3 days, 4 to 7 days, and >7 days. Patients were evaluated at a pediatric specialty concussion clinic between April 2021 and December 2023, and diagnosed with concussion by a specialist (primary care sports medicine physician, nurse practitioner, and/or neuropsychologist), referred for rehabilitation via physical therapy services, completed more than one rehabilitation session, and received medical clearance to initiate the return-to-sport protocol. Groups were compared based on relevant clinical factors, Vestibular Ocular Motor Screening, neurocognitive testing (Trails B-A), Post-Concussion Symptom Scale, days from injury to concussion evaluation, days from concussion evaluation to rehabilitation, number of rehabilitation sessions, recovery days after rehabilitation, and total recovery days (ie, days from injury to medical clearance to initiate return-to-sport protocol). Data analysis included chi-square, correlations, 1-way analysis of variance, and general linear regression. Adjusted odds ratios for protracted recovery were derived from a logistic regression model. Discussion: Days from injury to concussion evaluation (P < .001), days from concussion evaluation to rehabilitation (P = .006), and Trails B-A (P = .009), were significant predictors of total recovery time among pediatric concussion patients who required multimodal rehabilitation. Risk of protracted recovery increased by 34% each day from injury to concussion evaluation a patient did not receive treatment (Nagelkerke Pseudo R ² = .45; P < .001). Previous studies have also shown that time to concussion evaluation is an important prognostic indicator of recovery. Correspondingly, prompt referral to concussion care and rehabilitation for patients with a need for multimodal rehabilitation can improve recovery outcomes.

Clinical Scenario: Individuals with patellofemoral pain (PFP) present with a variety of neuromuscular and psychological deficits, with the “gold-standard” for treatment being rehabilitation programs with strengthening-based exercises. While such interventions primarily target pain and function measures, it is unknown whether psychological measures such as fear-avoidance beliefs (FABs) are also affected. Clinical Question: Is rehabilitation including strengthening exercises effective in improving FABs in individuals with PFP? Summary of Key Findings: Three studies met the inclusion criteria and were included in the appraisal. All studies found that rehabilitation including strengthening exercises was effective in improving FABs for physical activity, though such improvements were modest. One study found that supplementing a one-time psychological intervention to rehabilitation including strengthening exercises resulted in greater improvements in FABs than with rehabilitation including strengthening exercises alone. Two studies found associations between changes in FABs and changes in pain and/or function outcomes. Clinical Bottom Line: There is consistent evidence that the incorporation of rehabilitation with strengthening exercises is effective in improving FABs in individuals with PFP, though such improvements are modest. Furthermore, supplementation with psychological interventions to rehabilitation including strengthening exercises may produce larger improvements in FABs, particularly in patients with an elevated FABs phenotype. As a result of improving FABs, patient outcomes of pain and function may be improved, though future research is needed. Therefore, at this time, we recommend that rehabilitation, including strengthening exercises with supplemental psychological interventions be prescribed for the treatment of PFP particularly in subgroups with elevated FABs, to improve patient outcomes. Strength of Recommendation: Collectively, the body of evidence included to answer the clinical question aligns with the strength of recommendation of A based on the Strength of Recommendation Taxonomy.

Context: Functional movement screen (FMS) and Y-balance test (YBT) are used to predict the risk of musculoskeletal injuries. FMS and YBT tools in relation to injury in elite female softball athletes have not been examined. Objectives: This study aims to (1) compare the differences in FMS, Y-Balance upper quarter (YBT-UQ), and lower quarter (YBT-LQ) scores between injured and noninjured group and (2) determine the ability of FMS and YBT scores to predict the odds of musculoskeletal injury in elite fast-pitch female softball athletes. Design: Prospective cohort study. Methods: Thirty-eight athletes (age = 22.9 [2.6] y, height = 170.2 [5.2] cm, mass = 65.5 [7.2] kg) completed preseason FMS and YBT assessments. Injury data were collected throughout one full season, categorized based on the location of the injury, and then recorded as a binary variable (ie, injured and noninjured groups). FMS, YBT-UQ, and YBT-LQ scores were compared between injured and noninjured groups. Binary logistic regression was used to predict the occurrence of injury among softball athletes. Results: FMS scores were significantly lower for the injured group compared with the FMS scores belonging to the noninjured group (P ≤ .001; d = 1.52). Lower FMS composite scores predicted injury (Wald_(df = 1) = 6.755; odds ratio = 0.231; P = .009; 95% confidence interval, 0.076–0.697). No between-group differences existed in YBT-UQ (P = .67; d = 0.14) and YBT-LQ (P = .16; d = 0.50) composite scores between the injured and the noninjured groups. YBT-UQ (Wald_(df = 1) = 2.300; odds ratio = 0.893; P = .129; 95% confidence interval, 0.772–1.033) and YBT-LQ (Wald_(df = 1) = 0.145; odds ratio = 1.024; P = .703; 95% confidence interval, 0.906–1.157) were not significant predictors of injury. Conclusions: FMS appears to be a valuable screening tool for assessing musculoskeletal injury risk in elite fast-pitch female softball athletes.