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The Effectiveness of Open Repair Versus Percutaneous Repair for an Acute Achilles Tendon Rupture

Heidi Krueger and Shannon David

Clinical Scenario:

There are 2 approaches available for surgical repair of the Achilles tendon: open or percutaneous. However, there is controversy over which repair is superior.

Focused Clinical Question:

Which type of surgery is better in providing the best overall patient outcome, open or percutaneous repair, in physically active men and women with acute Achilles tendon ruptures?

Summary of Search, “Best Evidence” Appraised, and Key Findings:

The literature was searched for studies of level 3 evidence or higher that investigated the effectiveness of open repair versus percutaneous repair on acute Achilles tendon ruptures in physically active men and women. The literature search resulted in 3 studies for possible inclusion. All 3 good-quality studies were included.

Clinical Bottom Line:

There is supporting evidence to indicate that percutaneous repair is the best option for Achilles tendon surgery when it comes to the physically active population. Percutaneous repair has faster surgery times, less risk of complications, and faster recovery times over having an open repair, although it is acknowledged that every patient has a different situation and best individual option may vary patient to patient.

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Athletes’ Perception of Athletic Trainer Empathy: How Important Is It?

Shannon David and Mary Larson

Context: Health care practitioners face increasing expectations to provide patient-centered care. Communication skills, specifically empathy, are critical in the provision of patient-centered care. Past work correlates empathy with improved patient satisfaction, compliance, and treatment outcomes. In particular, a predictive relationship exists between clients’ ratings of their clinician’s empathy and treatment outcomes. There is a dearth of studies examining empathy using qualitative methodology and factors of empathy in athletic training. Objective: To gain an understanding of athletes’ perceptions of empathy in the patient–clinician relationship. Design: Qualitative interviews were completed using grounded-theory techniques. Setting: A quiet office. Participants: A typical, purposeful sample of 15 college-age Division I student-athletes (8 female, 7 male; 19.3 ± 1.2 y) from a variety of sports (football, wrestling, volleyball, baseball, etc) participated. Data Collection and Analysis: Researchers utilized an interview protocol designed to understand the factors of empathy related to athletic training. The interview protocol established a concept of empathy to help facilitate discussion of ideas. Data were transcribed, coded, and analyzed for themes and patterns using grounded-theory techniques. Trustworthiness of the data was ensured using an external auditor, member checks, and methods triangulation. Results: Five themes described empathy: advocacy, communication, approachability, access, and competence. Advocacy was described as the athletic trainer (AT) representing the patient. Communication was the ability to listen reflectively; approachability emerged as the comfort and personal connection the patient felt with the AT. Access and technical competence were bridges required for the development of empathy. Conclusions: Providing patient-centered care facilitated by developing good patient–clinician relationships is critical in enabling the best treatment outcomes. ATs portray empathy through advocacy, communication, and approachability. Empathy improves the patient–clinician relationship and is critical for patient-centered care delivered by ATs.

Open access

Nonsurgical Treatment of Acetabular Labral Tears

Melissa Theige and Shannon David

Clinical Scenario: Surgical treatment of acetabular labral tears has been explored in multiple studies, while there is a lack of research on the effectiveness of conservative methods. Focused Clinical Question: To what extent can nonsurgical treatment produce symptomatic or functional improvements in athletes with an acetabular labral tear? Summary of Search, Best Evidence Appraised, and Key Findings: The literature was searched for studies of patients with confirmed acetabular labral tears who participated in any level of sport. Four studies were located, all of which were included. Clinical Bottom Line: The research discussed in this review agreed that conservative management of acetabular labral tears produced measurable improvements in pain and function among the athletes studied, including their ability to participate in sport activities. Based on these findings, it appears that conservative management is effective at rehabilitating athletes with acetabular labral tears. However, this method should not be applied to every athlete based on the low strength of current research. Treatment plans should be decided upon on a case-by-case basis. Strength of Recommendation: The studies located were of low quality. The highest Oxford Center for Evidence-Based Medicine Level of Evidence achieved was 4. Higher level studies must be conducted before the conclusions of this research can be applied clinically with assertion. Strength of recommendation is level 3.

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A Rare Case of Lemierre’s Syndrome in a Male Division I Collegiate Football Player

Heather Fahsl and Shannon David

During the fall preseason of 2013, a 19-year-old Division I linebacker (body mass = 104 kg; height = 189 cm) attending a college football camp developed severe throat pain, quickly followed by night sweats, fever, nausea, vomiting, shortness of breath, and generalized body weakness. The athletic trainer believed that the athlete had a cold. Because symptoms did not improve, the athlete was referred to several physicians with different specialties and underwent standard testing. The ears, nose, and throat (ENT) physician recognized the signs and symptoms of Lemierre’s syndrome based on a previous case seen only once in his career. A computed tomography (CT) scan confirmed the presence of a peritonsillar abscess and thrombosis of the left internal jugular vein, which justified further investigation for this rare syndrome. A positive blood culture for Fusobacterium necrophorum confirmed the diagnosis of Lemierre’s syndrome. Several antibiotics and anticoagulation medications were prescribed and the athlete was closely monitored. After two months, he was cleared to play football.

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A Case of Morel-Lavallée Lesion of the Lower Leg: A Case Report

Erin Macaronas, Shannon David, and Nicole German

A healthy, 21-year-old football player presented to the athletic trainer with pain and swelling over anteromedial aspect of his lower right leg after being “cleated”. Physical examination revealed a hematoma, ecchymosis, and no unusual sensations. The physician’s physical examination revealed a superficial fluid filled collection, ecchymosis, minimal discomfort with palpation and no muscular deficiencies. MRI results revealed an organized collection of fluid in the subcutaneous tissue, confirming a Morel Lavallée lesion. The fluid collection resolved, without aspiration, and the athlete finished the season without further complications due the interprofessional collaboration between medical staff.

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Examining Impulse-Variability in Overarm Throwing

M.A. Urbin, David Stodden, Rhonda Boros, and David Shannon

The purpose of this study was to examine variability in overarm throwing velocity and spatial output error at various percentages of maximum to test the prediction of an inverted-U function as predicted by impulse-variability theory and a speed-accuracy trade-off as predicted by Fitts’ Law Thirty subjects (16 skilled, 14 unskilled) were instructed to throw a tennis ball at seven percentages of their maximum velocity (40–100%) in random order (9 trials per condition) at a target 30 feet away. Throwing velocity was measured with a radar gun and interpreted as an index of overall systemic power output. Within-subject throwing velocity variability was examined using within-subjects repeated-measures ANOVAs (7 repeated conditions) with built-in polynomial contrasts. Spatial error was analyzed using mixed model regression. Results indicated a quadratic fit with variability in throwing velocity increasing from 40% up to 60%, where it peaked, and then decreasing at each subsequent interval to maximum (p < .001, η2 = .555). There was no linear relationship between speed and accuracy. Overall, these data support the notion of an inverted-U function in overarm throwing velocity variability as both skilled and unskilled subjects approach maximum effort. However, these data do not support the notion of a speed-accuracy trade-off. The consistent demonstration of an inverted-U function associated with systemic power output variability indicates an enhanced capability to regulate aspects of force production and relative timing between segments as individuals approach maximum effort, even in a complex ballistic skill.

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Music and On-task Behaviors in Preschool Children With Autism Spectrum Disorder

Shannon Titus Dieringer, David L. Porretta, and Diane Sainato

The purpose of our study was to determine the effect of music (music with lyrics versus music with lyrics plus instruction) relative to on-task behaviors in preschool children with autism spectrum disorder (ASD) in a gross motor setting. Five preschool children (4 boys, 1 girl) diagnosed with ASD served as participants. A multiple baseline across participants in conjunction with an alternating-treatment design was used. For all participants, music with lyrics plus instruction increased on-task behaviors to a greater extent than did music with lyrics. The results of our study provide a better understanding of the role of music with regard to the behaviors of young children with ASD.

Open access

The Use of Platelet-Rich Plasma for Conservative Treatment of Partial Ulnar Collateral Ligament Tears in Overhead Athletes: A Critically Appraised Topic

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.

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Validation of the Ottawa Ankle Rules for Acute Foot and Ankle Injuries

Shannon David, Kim Gray, Jeffrey A. Russell, and Chad Starkey

The original and modified Ottawa Ankle Rules (OARs) were developed as clinical decision rules for use in emergency departments. However, the OARs have not been evaluated as an acute clinical evaluation tool.


To evaluate the measures of diagnostic accuracy of the OARs in the acute setting.


The OARs were applied to all appropriate ankle injuries at 2 colleges (athletics and club sports) and 21 high schools. The outcomes of OARs, diagnosis, and decision for referral were collected by the athletic trainers (ATs) at each of the locations. Contingency tables were created for evaluations completed within 1 h for which radiographs were obtained. From these data the sensitivity, specificity, positive and negative likelihood ratios, and positive and negative predictive values were calculated.


The OARs met the criteria for radiographs in 100 of the 124 cases, of which 38 were actually referred for imaging. Based on radiographic findings in an acute setting, the OARs (n = 38) had a high sensitivity (.88) and are good predictors to rule out the presence of a fracture. Low specificity (0.00) results led to a high number of false positives and low positive predictive values (.18).


When applied during the first hour after injury the OARs significantly overestimate the need for radiographs. However, a negative finding rules out the need to obtain radiographs. It appears the AT’s decision making based on the totality of the examination findings is the best filter in determining referral for radiographs.

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Internal Bracing Augmentation of the Ulnar Collateral Ligament on a Level 10 Competitive Gymnast: A Case Study

Dana Vander Wal, Brenda Potter, Shannon L. David, and Nicole German

Ulnar collateral ligament (UCL) injuries have become increasingly more common over the years. Reconstruction and nonoperative treatment have been the conventional treatment for athletes, especially for overhead athletes. This case study presents a 16-year-old female, competitive Level 10 gymnast, with a complete distal tear of her UCL with a full thickness, Grade 3, ulnar sided avulsion off of the sublime tubercle. She underwent medial UCL repair with internal brace augmentation with the goal of faster return to gymnastics. To the author’s knowledge, this is the second gymnast reported in the literature to have an internal brace augmentation completed on the UCL.