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Todd A. Evans and Kenneth C. Lam

Evidence-based practice is an established guiding principle in most medical and health care disciplines. Central to establishing evidence-based practice is the assessment of clinical outcomes. Clinical outcomes represent a form of evidence on which to base medical decisions, as well as providing the mechanism for assessing the effectiveness of evidence-based interventions. However, clinical outcomes are not routinely assessed in sport rehabilitation. If sport rehabilitation clinicians fail to incorporate clinical outcomes assessment and, as a result, evidence into daily practice, they may be missing an opportunity to improve patient care and putting their professional reputation at risk within the medical community. The purposes of the article are to highlight the emergence of clinical outcomes assessment in the medical community and the current health care system, illustrate the role of clinical outcomes assessment as it pertains to providing the best patient care, and identify challenges that could potentially impede the implementation of outcomes assessment in sport rehabilitation.

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Kenneth C. Lam and Jessica G. Markbreiter

Context: Current evidence suggests that, despite returning to full participation, physically active adults with a previous knee injury experience lower health-related quality of life (HRQOL) than those with no knee injury history. It is unknown if this relationship is present in adolescent athletes. Objective: To determine the impact of knee injury history on HRQOL in adolescent athletes who were medically cleared for full participation. Design: Cross-sectional. Setting: Athletic training clinics. Participants: A convenience sample of 183 adolescent athletes, who were medically cleared for full participation, were grouped by self-report of a previous knee injury: positive knee injury history (HIS; n = 36, age = 15.7 [1.4] y, height = 168.0 [11.9] cm, and weight = 71.8 [11.9] kg) and no knee injury history (NO-HIS; n = 147, age = 15.5 [1.4] y, height = 166.0 [10.5] cm, and weight = 67.6 [14.6] kg). Interventions: Participants completed the Pediatric International Knee Documentation Committee form and Pediatric Quality of Life Inventory during their preparticipation examination. Main Outcome Measures: Generalized linear models were used to compare group differences for the total and subscale scores of the Pediatric International Knee Documentation Committee and Pediatric Quality of Life Inventory. Results: Main effects of injury group indicated that the HIS group reported significantly lower scores than the NO-HIS group for the Pediatric International Knee Documentation Committee total score (P < .001; HIS = 79.2 [21.7], NO-HIS = 95.8 [8.6]) and for the Pediatric Quality of Life Inventory total (P = .001; HIS = 85.7 [10.9], NO-HIS = 90.9 [7.3]), physical functioning (P = .002; HIS = 86.7 [13.6], NO-HIS = 92.1 [8.2]), school functioning (P = .01; HIS = 80.6 [12.4], NO-HIS = 86.8 [12.2]), and social functioning (P = .01; HIS = 89.3 [12.4], NO-HIS = 94.6 [8.9]) scores. No group differences were reported for the emotional functioning subscale (P = .13; HIS = 85.7 [17.7], NO-HIS = 89.7 [13.1]). No interactions or main effects of sex were reported (P > .05). Conclusions: Our findings suggest that, despite returning to full sport participation, adolescent athletes with a previous knee injury generally experience lower HRQOL than their peers with no knee injury history, specifically for knee-specific HRQOL, physical functioning, school functioning, and social functioning. Our results are similar to previous findings reported in college athletes and military cadets.

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Alison R. Snyder and Kenneth C. Lam

Edited by John Parsons

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Alison R. Snyder, April L. Perotti, Kenneth C. Lam and R. Curtis Bay


Electrical stimulation is often used to control edema formation after acute injury. However, it is unknown whether its theoretical benefits translate to benefits in clinical practice.


To systematically review the basic-science literature regarding the effects of high-voltage pulsed stimulation (HVPS) for edema control.

Evidence Acquisition:

CINAHL (1982 to February 2010), PubMed (1966 to February 2010), Medline (1966 to February 2010), and SPORTDiscus (1980 to February 2010) databases were searched for relevant studies using the following keywords: edema, electrical stimulation, high-volt electrical stimulation, and combinations of these terms. Reference sections of relevant studies were hand-searched. Included studies investigated HVPS and its effect on acute edema formation and included outcome measures specific to edema. Eleven studies met the inclusion criteria. Methodological quality and level of evidence were assessed for each included study. Effect sizes were calculated for primary edema outcomes.

Evidence Synthesis:

Studies were critiqued by electrical stimulation treatment parameters: mode of stimulation, polarity, frequency, duration of treatment, voltage, intensity, number of treatments, and overall time of treatments. The available evidence indicates that HVPS administered using negative polarity, pulse frequency of 120 pulses/s, and intensity of 90% visual motor contraction may be effective at curbing edema formation. In addition, the evidence suggests that treatment should be administered in either four 30-min treatment sessions (30-min treatment, 30-min rest cycle for 4 h) or a single, continuous180-min session to achieve the edemasuppressing effects.


These findings suggest that the basic-science literature provides a general list of treatment parameters that have been shown to successfully manage the formation of edema after acute injury in animal subjects. These treatment parameters may facilitate future research related to the effects of HVPS on edema formation in humans and guide practical clinical use.

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Ashley N. Marshall, Alison R. Snyder Valier, Aubrey Yanda and Kenneth C. Lam

Context: There has been an increased interest in understanding how ankle injuries impact patient outcomes; however, it is unknown how the severity of a previous ankle injury influences health-related quality of life (HRQOL). Objective: To determine the impact of a previous ankle injury on current HRQOL in college athletes. Design: Cross-sectional study. Setting: Athletic training clinics. Participants: A total of 270 participants were grouped by the severity of a previous ankle injury (severe = 62, mild = 65, and no injury = 143). Main Outcome Measures: Participants completed the Foot and Ankle Ability Measure (FAAM) and the Short Form 12 (SF-12). Methods: A 2-way analysis of variance with 2 factors (injury group and sex) was used to identify interaction and main effects for the FAAM and SF-12. Results: No interactions were identified between injury group and sex. Significant main effects were observed for injury group, where the severe injury group scored lower than athletes with mild and no injuries on the FAAM activities of daily living, FAAM Global, and SF-12 mental health subscale scores. In addition, a main effect was present for sex in the SF-12 general health, social functioning, and mental health subscales in which females reported significantly lower scores than males. Conclusions: Our findings suggest that a severe ankle injury impacts HRQOL, even after returning back to full participation. In addition, females tended to report lower scores than males for aspects of the SF-12, suggesting that sex should be considered when evaluating HRQOL postinjury. As a result, clinicians should consider asking athletes about their previous injury history, including how much time was lost due to the injury, and should mindful of returning athletes to play before they are physiologically and psychologically ready, as there could be long-term negative effects on the patients’ region-specific function as well as aspects of their HRQOL.

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Michelle L. Weber, Kenneth C. Lam and Tamara C. Valovich McLeod

Clinical Question:

In youth and adolescent athletes, are jumping/plyometric exercises more effective than balance exercises in preventing sport-related injuries?


The aim of this article is to examine the meta-analysis by Rössler et al.1 as it relates to the clinical question.


Evidence in this meta-analysis suggests that injury prevention programs provide beneficial effects in injury reduction for youth and adolescent athletes. Prevention programs that contained jumping or plyometric exercises and were targeted toward females appeared to be especially beneficial for decreasing injury risk.

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Alison R. Snyder Valier, Elizabeth M. Swank, Kenneth C. Lam, Matthew L. Hansen and Tamara C. Valovich McLeod


Accurate assessment of health-related quality of life (HRQoL) is important for quality patient care. Evaluation of HRQoL typically occurs with patient self-report, but some instruments, such as the Pediatric Quality of Life Inventory (PedsQL), allow for proxy reporting. Limited information exists comparing patient and proxy reports of HRQoL after sport-related injury in adolescent athletes.


To compare patient ratings and parent-proxy ratings of HRQoL in adolescent athletes who suffer musculoskeletal injuries requiring orthopedic consultation. The authors hypothesized poor agreement between patient and parent-proxy ratings of HRQoL.


Cross-sectional study.


Orthopedic practice.


Thirteen adolescent patients with a sport-related musculoskeletal injury requiring orthopedic consultation and 1 of their parents participated.


During the initial visit to the physician’s office, each patient was asked to complete the PedsQL, and the patient’s parent was asked to complete the parent-proxy version of the PedsQL.

Main Outcome Measurements:

The PedsQL is a pediatric generic outcome measure that consists of a total score and 4 subscale scores: physical, emotional, social, and school functioning. Means and standard deviations were calculated for all scores, and comparisons between patient-self report and parent-proxy ratings of HRQoL were made for the PedsQL total score and subscale scores using Pearson product–moment correlations (r).


Pearson product–moment correlations showed little to fair insignificant relationships between patient self-report and parent-proxy report of the PedsQL for the total score (r = −.1) and all subscales (range r = .1 to .4).


Our results suggest a lack of agreement between patient and parent-proxy ratings of HRQoL, with patients rating their HRQoL lower than their parent. Patient perception of HRQoL may be more accurate than proxy report, which supports the use of patient-rated HRQoL in patient evaluation. Assessments of HRQoL made by proxies, even those close to the patient, may not represent patient health status.

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Richelle M. Williams, Matthew A. Corvo, Kenneth C. Lam, Travis A. Williams, Lesley K. Gilmer and Tamara C. Valovich McLeod

Context: Postural control plays an essential role in concussion evaluation. The Stability Evaluation Test (SET) aims to objectively analyze postural control by measuring sway velocity on the NeuroCom VSR portable force platform (Natus, San Carlos, CA). Objective: To assess the test-retest reliability and practice effects of the SET protocol. Design: Cohort. Setting: Research laboratory. Patients or Other Participants: 50 healthy adults (20 men, 30 women, age 25.30 ± 3.60 y, height 166.60± 12.80 cm, mass 68.80 ± 13.90 kg). Interventions: All participants completed 4 trials of the SET. Each trial consisted of six 20-s balance tests with eyes closed, under the following conditions: double-leg firm (DFi), single-leg firm (SFi), tandem firm (TFi), double-leg foam (DFo), single-leg foam (SFo), and tandem foam (TFo). Each trial was separated by a 5-min seated rest period. Main Outcome Measures: The dependent variable was sway velocity (deg/s), with lower values indicating better balance. Sway velocity was recorded for each of the 6 conditions as well as a composite score for each trial. Test-retest reliability was analyzed across 4 trials with intraclass correlation coefficients (ICCs). Practice effects analyzed with repeated measures analysis of variance, followed by Tukey post hoc comparisons for any significant main effects (P < .05). Results: Sway-velocity reliability values were good to excellent: DFi (ICC = .88; 95%CI: .81, .92), SFi (ICC = .75; 95%CI: .61, .85), TFi (ICC = .84; 95%CI: .75, .90), DFo (ICC = .83; 95%CI: .74, .90), SFo (ICC = .82; 95%CI: .72, .89), TFo (ICC = .81; 95%CI: .69, .88), and composite score (ICC = .93; 95%CI: .88, .95). Significant practice effects (P < .05) were noted on the SFi, DFo, SFo, TFo conditions and composite scores. Conclusions: Our results suggest the SET has good to excellent reliability for the assessment of postural control in healthy adults. Due to the practice effects noted, a familiarization session is recommended (ie, all 6 conditions) before data are recorded. Future studies should evaluate injured patients to determine meaningful change scores during various injuries.

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Brandon C. Platt, Sue Falsone and Kenneth C. Lam,

A 21-year-old male baseball catcher sustained an injury to the right testicle from a foul ball that ricocheted from the ground to his groin. The athlete was removed from competition when testicular pain began to increase. Ice was applied to the affected area and nonsteroidal anti-inflammatory drugs (NSAIDs) were utilized through the evening. Further diagnosis and treatment were warranted the following morning. Diagnostic ultrasound revealed a fracture to the right testicle, necessitating surgical repair. The athlete followed a return-to-play progression and returned to play 20 days postinjury. This case describes evaluation and treatment of a rare acute condition and the need for early recognition and diagnosis.