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Clinical Scenario: Anterior cruciate ligament (ACL) ruptures are one of the most common injuries in young athletic populations. The leading treatment for these injuries is ACL reconstruction (ACL-r); however, nonoperative treatments are also utilized. Following ACL-r, patients experience prolonged muscle weakness and atrophy of the quadriceps muscle group, regardless of rehabilitation. Nonoperative treatment plans following ACL injury exist, but their outcomes are less familiar, in spite of providing insight as a nonsurgical “control” for postsurgical rehabilitation outcomes. Therefore, the purpose of this critically appraised topic was to evaluate quadriceps strength and function following nonoperative ACL rehabilitation using objective and subjective measures including isokinetic dynamometry, the single-leg hop test, and the International Knee Documentation Committee (IKDC) subjective knee form. Focused Clinical Question: What are the effects of nonoperative treatment on peak isokinetic knee-extensor torque, the single-leg hop tests, and the IKDC in patients who have sustained an ACL rupture? Summary of Key Findings: Patients who underwent nonsurgical ACL treatment produced limb symmetry index, with the side-to-side torque difference expressed as a percentage, and values at or above 90% for all 4 single-leg hop tests and strength tests similar to ACL-r patients. All studies showed individuals had higher IKDC scores at baseline collection when compared with patients who underwent ACL-r but showed lower IKDC scores at long-term follow-up compared with ACL-r patients. Clinical Bottom Line: Nonoperative treatments of ACL injuries yield similar long-term results in quadriceps strength as ACL-r. Due to the quality of evidence and the absence of randomized controlled trials on this topic, these outcomes should be considered with caution. Strength of Recommendation: The Oxford Centre for Evidence-Based Medicine taxonomy recommends a grade of B for level 2 evidence with consistent findings.

Clinical Scenario: Joint instability is a common condition that often stems from inadequate muscle activation and results in precarious movement patterns. When clinicians attempt to mechanically treat the unstable joint rather than attending to the underlying cause of the instability, patient outcomes may suffer. The use of kinesiology tape (KT) on an unstable joint has been proposed to aid in improving lower-extremity neuromuscular control. Clinical Question: Does KT improve factors of neuromuscular control in an athletic population when compared with no-tape or nonelastic taping techniques? Summary of Key Findings: The current literature was searched, and 5 randomized controlled studies were selected comparing the effects of KT with no-tape or nonelastic taping techniques on lower-extremity neuromuscular control in an athletic population. Primary findings suggest KT is not more effective than no-tape or nonelastic tape conditions at improving lower-extremity neuromuscular control in a healthy population. Clinical Bottom Line: The current evidence suggests that KT is ineffective for improving neuromuscular control at the ankle compared with nonelastic tape or no-tape conditions. KT was also found to be ineffective at improving hip and knee kinematics in healthy runners and cyclists. However, preliminary research has demonstrated improved neuromuscular control in a population displaying excessive knee valgus during a drop jump landing, after the application of KT. Clinicians should be cautious of these conflicting results and apply the best available evidence to their evaluation of the patient’s status. Strength of Recommendation : There is grade B evidence that the use of KT on an athletic population does not improve biomechanical measures of ankle stability. There is inconclusive, grade B evidence that KT improves neuromuscular control at the knee in symptomatic populations.

Context: Infrared thermography has been used to detect skeletal muscle overload and fatigue in athletes, but its use in injury prevention in professional soccer has not been studied to date. Objectives: To establish a novel injury prevention program based on infrared thermography and to determine its influence on the injury incidence in professional soccer players in the preseason. Design: A cross-sectional, prospective study design was used to compare a conventional injury prevention program (CPP) applied over the first preseason and an infrared thermography injury prevention program (IRTPP) carried out in the following preseason. Setting: Soccer training ground. Participants: Twenty-four players belonging to a first division soccer team from Spain. Main Outcome Measures: Injury incidences of each player were recorded according to the Orchard Sports Injury Classification System (version 10.0) convention to determine the injury classification, location, and type. Results: The incidence of injuries decreased from 15 injuries in the CPP preseason (0.63 [0.77] injuries per player) to 6 injuries in the second preseason when the IRTPP was applied (0.25 [0.53] injuries per player). The days of absence due to injuries also decreased from the CPP preseason (156 d, 10.4 [11.0] d per injury) to the IRTPP preseason (14 d, 2.3 [2.8] d per injury). The injury severity also decreased from the first preseason to the second preseason, and fewer musculoskeletal injuries in the thigh, hip, and groin were reported. Conclusions: The implementation of an IRTPP can reduce the presence of injuries by identifying players potentially at risk and as a result, reducing the injury severity and days lost as a consequence.

Context: Convergence dysfunction following concussion is common. Near point of convergence (NPC) is a quick and easy assessment that may detect oculomotor dysfunction such as convergence insufficiency (CI), but NPC measurements are rarely reported. Convergence dysfunction is treatable in otherwise healthy patients; the effectiveness of oculomotor therapy following concussion is unclear. Objectives: The purpose of this article was to systematically review the literature and answer the following clinical questions: (1) Is performance on NPC negatively affected in patients diagnosed with a concussion compared with pre-injury levels or healthy controls? (2) In patients diagnosed with concussion, what is the effect of oculomotor/vision therapy on NPC break measurements? Evidence Acquisition: The search was conducted in CINAHL, SPORTDiscus, MEDLINE, and PubMed using terms related to concussion, mild traumatic brain injury, convergence, vision, and rehabilitation. Literature considered for review included original research publications that collected measures of NPC break in concussion patients, with a pretest–posttest comparison or comparison with a healthy control group. A literature review was completed; 242 relevant articles were reviewed, with 18 articles meeting criteria for inclusion in the review. Evidence Synthesis: Articles were categorized according to the clinical question they addressed. The patient or participant sample (number, sex, age, and health status), study design, instrumentation, or intervention used, and main results were extracted from each article. Conclusions: The authors' main findings suggest that there is a moderate level of evidence that patients have impaired NPC up to several months postconcussion, and a low level of evidence that impairments can be successfully treated with oculomotor therapy. These findings should be cautiously evaluated; the studies are limited by weak/moderate quality, small sample sizes, varied methodology, and nonrandomized treatment groups. Future research should explore factors affecting convergence postconcussion and include randomized, controlled studies to determine if performing vision therapy improves visual measures and promotes recovery.

Clinical Scenario: Concussions are severely underreported, with only 47.3% of high school athletes reporting their concussion. The belief was that athletes who were better educated on the signs and symptoms and potential dangers of concussion would be more likely to report. However, literature has shown inconsistent evidence on the efficacy of concussion education, improving reporting behaviors. Factors such as an athlete’s attitude, subjective norms, and perceived behavioral control have shown promise in predicting intention to report concussions in athletes. Focused Clinical Question: Do attitudes, subjective norms, and perceived behavioral control influence adolescent athletes’ intention to report? Summary of Key Findings: Three studies (1 randomized control and 2 cross-sectional surveys) were included. Across the 3 studies, attitudes, subjective norms, and perceived behavioral control positively influenced athletes’ reporting intention. The studies found that attitude toward concussion reporting and perceived behavioral control were the most influential predictors of reporting intention. Clinical Bottom Line: There is moderate evidence to suggest that positive attitudes, supportive subjective norms, and increased perceived behavioral control influence reporting intention in secondary school athletes. Strength of Recommendation: Grade B evidence exists that positive attitudes, supportive subjective norms, and increased perceived behavioral control positively influence concussion reporting intention in secondary school athletes.

Clinical Scenario: Low back pain is widely prevalent in the general population as well as in athletes. Therapeutic exercise is a low-risk and effective treatment option for chronic pain that can be utilized by all rehabilitation clinicians. However, therapeutic exercise alone does not address the psychosocial aspects that are associated with chronic low back pain. Pain education is the umbrella term utilized to encompass any type of education to the patient about their chronic pain. Therapeutic exercise in combination with pain education may allow for more well-rounded and effective treatment for patients with chronic nonspecific low back pain (NS-LBP). Clinical Question: Does pain education combined with therapeutic exercise, compared with therapeutic exercise alone, improve patient pain in adults with chronic NS-LBP over a 2- to 3-month treatment period? Summary of Key Findings: A thorough literature review yielded 8 studies potentially relevant to the clinical question, and 3 studies that met the inclusion criteria were included. The 3 studies included reports that exercise therapy reduced symptoms. Two of the 3 included studies support the claim that exercise therapy reduces the symptoms of chronic NS-LBP when combined with pain education, whereas one study found no difference between pain education with therapeutic exercise. Clinical Bottom Line: There is moderate evidence to support the use of pain education along with therapeutic exercise when attempting to reduce symptoms of pain and disability in patients with chronic NS-LBP. Educational interventions should be created to educate patients about the foundation of pain, and pain education should be implemented as a part of the clinician’s strategy for the rehabilitation of patients with chronic NS-LBP. Strength of Recommendation: Grade B evidence exists to support the use of patient education with therapeutic exercise for decreasing pain in patients with chronic NS-LBP.

Context: Sensorimotor, proprioceptive, and neuromuscular programs are critical for the successful rehabilitation of injured athletes, and these decrease reinjury rates. Objective: To investigate the effects of an unexpected disturbance program (UDP) on balance and unilateral strength metrics in athletes with unilateral knee ligament injury. Design: A 3-week parallel-group experimental design consisting of 9 rehabilitation sessions. Setting: National Sports Institute. Participants: Twenty-one national-level athletes (age 21.4 [4.4] y, body mass 63.9 [10.8] kg, height 169.0 [10.2] cm) who had sustained a unilateral knee ligament injury. Intervention: An UDP program designed to evoke rapid sensorimotor responses was compared with traditional training and a nonexercise control group. Main Outcome Measures: Unilateral total, anteroposterior, and mediolateral sway with eyes open and closed and unilateral isometric strength. Results: Traditional exercises tended to outperform the UDP when unilateral balance testing was performed with eyes open; however, balance improvement following UDP tended to be greater in the eyes-closed condition. Significant strength gains in both the injured and uninjured legs were only observed following the UDP. This increase in unilateral isometric strength was 23.4 and 35.1 kg greater than the strength improvements seen in the traditional rehabilitation and control groups (P < .05). Conclusions: UDP could improve neural aspects of rehabilitation to improve rehabilitation outcomes by improving strength, sensorimotor function, and proprioception. Given the complementary adaptations, an UDP could provide an effective adjunct to traditional rehabilitation protocols and improve return-to-play outcomes.

Context: The influence of playing surface on injury risk in soccer is contentious, and contemporary technologies permit an in vivo assessment of mechanical loading on the player. Objective: To quantify the influence of playing surface on the PlayerLoad elicited during soccer-specific activity. Design: Repeated measures, field-based design. Setting: Regulation soccer pitches. Participants: Fifteen amateur soccer players (22.1 [2.4] y), injury free with ≥6 years competitive experience. Interventions: Each player completed randomized order trials of a soccer-specific field test on natural turf, astroturf, and third-generation artificial turf. GPS units were located at C7 and the mid-tibia of each leg to measure triaxial acceleration (100 Hz). Main Outcome Measures: Total accumulated PlayerLoad in each movement plane was calculated for each trial. Ratings of perceived exertion and visual analog scales assessing lower-limb muscle soreness were measured as markers of fatigue. Results: Analysis of variance revealed no significant main effect for playing surface on total PlayerLoad (P = .55), distance covered (P = .75), or postexercise measures of ratings of perceived exertion (P = .98) and visual analog scales (P = .61). There was a significant main effect for GPS location (P < .001), with lower total loading elicited at C7 than mid-tibia (P < .001), but with no difference between limbs (P = .70). There was no unit placement × surface interaction (P = .98). There was also a significant main effect for GPS location on the relative planar contributions to loading (P < .001). Relative planar contributions to loading in the anterioposterior:mediolateral:vertical planes was 25:27:48 at C7 and 34:32:34 at mid-tibia. Conclusions: PlayerLoad metrics suggest that playing surface does not influence mechanical loading during soccer-specific activity (not including tackling). Clinical reasoning should consider that PlayerLoad magnitude and axial contributions were sensitive to unit placement, highlighting opportunities in the objective monitoring of load during rehabilitation.

Context: The latissimus dorsi plays a major role in generating the propulsive force during swimming. In addition, stiffness of this muscle may result in altered stroke biomechanics and predispose swimmers to shoulder pain. Measuring the flexibility of the latissimus dorsi can be of interest to reduce injury. However, the reliability of such measurement has not yet been investigated in competitive swimmers. Objective: To assess the within-session intrarater and interrater reliability of a passive shoulder flexion range of motion measurement for latissimus dorsi flexibility in competitive swimmers. Design: Within-session intrarater and interrater reliability. Setting: Competitive swimming clubs in Flanders, Belgium. Participants: Twenty-six competitive swimmers (15.46 [2.98] y; 16 men and 10 women). Intervention: Each rater performed 2 alternating (eg, left-right-left-right) measurements of passive shoulder flexion range of motion twice, with a 30-second rest period in between. Main Outcome Measures: The intraclass correlation coefficients were calculated to assess intrarater and interrater reliability. Results: Interrater intraclass correlation coefficient ranged from .54 (95% confidence interval [CI], −.16 to .81) to .57 (95% CI, −.24 to .85). Results for the intrarater reliability ranged from .91 (95% CI, .81 to .96) to .94 (95% CI, .87 to .97). Conclusion: Results of this study suggest that shoulder flexion range of motion in young competitive swimmers can be measured reliably by a single rater within the same session.

Trunk-flexor muscle strength plays a fundamental role in athletic performance, but objective measurements are usually obtained using expensive and nonportable equipment, such as isokinetic dynamometers. The aim of this study was to assess the concurrent validity of a portable, one-dimensional, trunk-flexor muscle strength measurement system (Measurement System) that uses calibrated barbells and the reliability of the measurements obtained using the Measurement System, by conducting test–retests. As a complementary assessment, the measurements obtained during a maximum contraction test performed by a group of 15 subjects were also recorded. Four conditions were assessed: repeatability, time reproducibility, position reproducibility, and subject reproducibility. The results demonstrate that both the concurrent validity and the measured reliability (intraclass correlation coefficient > .98) of the Measurement System are acceptable. The Measurement System provides valid and reliable measures of trunk-flexor muscle strength.