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Michael Sanders, Anton E. Bowden, Spencer Baker, Ryan Jensen, McKenzie Nichols and Matthew K. Seeley

Context: Foot and ankle injuries are common and often require a nonweight-bearing period of immobilization for the involved leg. This nonweight-bearing period usually results in muscle atrophy for the involved leg. There is a dearth of objective data describing muscle activation for different ambulatory aids that are used during the aforementioned nonweight-bearing period. Objective: To compare activation amplitudes for 4 leg muscles during (1) able-bodied gait and (2) ambulation involving 3 different ambulatory aids that can be used during the acute phase of foot and ankle injury care. Design: Within-subject, repeated measures. Setting: University biomechanics laboratory. Participants: Sixteen able-bodied individuals (7 females and 9 males). Intervention: Each participant performed able-bodied gait and ambulation using 3 different ambulatory aids (traditional axillary crutches, knee scooter, and a novel lower-leg prosthesis). Main Outcome Measure: Muscle activation amplitude quantified via mean surface electromyography amplitude throughout the stance phase of ambulation. Results: Numerous statistical differences (P < .05) existed for muscle activation amplitude between the 4 observed muscles, 3 ambulatory aids, and able-bodied gait. For the involved leg, comparing the 3 ambulatory aids: (1) knee scooter ambulation resulted in the greatest vastus lateralis activation, (2) ambulation using the novel prosthesis and traditional crutches resulted in greater biceps femoris activation than knee scooter ambulation, and (3) ambulation using the novel prosthesis resulted in the greatest gastrocnemius activation (P < .05). Generally speaking, muscle activation amplitudes were most similar to able-bodied gait when subjects were ambulating using the knee scooter or novel prosthesis. Conclusions: Type of ambulatory aid influences muscle activation amplitude. Traditional axillary crutches appear to be less likely to mitigate muscle atrophy during the nonweighting, immobilization period that often follows foot or ankle injuries. Researchers and clinicians should consider these results when recommending ambulatory aids for foot or ankle injuries.

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Matt Greig, Hannah Emmerson and John McCreadie

Context: Contemporary developments in Global Positioning System (GPS) technology present a means of quantifying mechanical loading in a clinical environment with high ecological validity. However, applications to date have typically focused on performance rather than rehabilitation. Objective: To examine the efficacy of GPS microtechnology in quantifying the progression of loading during functional rehabilitation from ankle sprain injury, given the prevalence of reinjury and need for quantifiable monitoring. Furthermore, to examine the influence of unit placement on the clinical interpretation of loading during specific functional rehabilitation drills. Design: Repeated measures. Setting: University athletic facilities. Participants: Twenty-two female intermittent team sports players. Intervention: All players completed a battery of 5 drills (anterior hop, inversion hop, eversion hop, diagonal hop, and diagonal hurdle hop) designed to reflect the mechanism of ankle sprain injury, and progress functional challenge and loading. Main Outcome Measures: GPS-mounted accelerometers quantified uniaxial PlayerLoad for each drill, with units placed at C7 and the tibia. Main effects for drill type and GPS location were investigated. Results: There was a significant main effect for drill type (P < .001) in the mediolateral (η 2 = .436), anteroposterior (η 2 = .480), and vertical planes (η 2 = .516). The diagonal hurdle hop elicited significantly greater load than all other drills, highlighting a nonlinear progression of load. Only the mediolateral load showed evidence of progressive increase in loading. PlayerLoad was significantly greater at the tibia than at C7 for all drills, and in all planes (P < .001, η 2 ≥ .662). Furthermore, the tibia placement was more sensitive to between-drill changes in mediolateral load than the C7 placement. Conclusions: The placement of the GPS unit is imperative to clinical interpretation, with both magnitude and sensitivity influenced by the unit location. GPS does provide efficacy in quantifying multiplanar loading during (p)rehabilitation, in a field or clinical setting, with potential in extending GPS analyses (beyond performance metrics) to functional injury rehabilitation and prevention.

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Matthew Booth, Jacob Powell, Patrick O. McKeon and Jennifer M. Medina McKeon

Focused Clinical Question: In patients who have sustained a concussion, does vestibular rehabilitation therapy improve clinical symptoms of dizziness and self-reported balance deficits and/or influence return-to-participation timelines beyond that of preintervention scores or standard care? Clinical Bottom Line: The evidence supported the use of VRT to attenuate clinical symptoms of dizziness and self-reported balance deficits.

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Leilani Madrigal, Jamie Robbins, Diane L. Gill and Katherine Wurst

Collegiate rugby is a competitive, collision sport, yet insufficient empirical evidence exists regarding participants’ perspectives on pain and injury. This study addressed male and female rugby players’ experiences with injury, and their views about playing through pain and injury. Eleven rugby players (five male; six female) competing in USA Rugby’s National College 7’s tournament participated in semistructured interviews, which were recorded, transcribed, and content-analyzed. Two major themes emerged: passion for sport and sport ethic. Passion for sport was composed of (a) love of the sport, (b) meaning of the sport, and (c) desire to be on the field. Sport ethic included: (a) helping the team, (b) game time sacrifice, (c) personality, (d) minimize, and (e) accepted behavior. The researchers explain these findings and propose strategies for increasing future athletes’ understanding of the dangers associated with playing through pain, and confronting the currently accepted culture of risk.

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Gil Rodas, Lourdes Osaba, David Arteta, Ricard Pruna, Dolors Fernández and Alejandro Lucia

Purpose: The authors investigated the association between risk of tendinopathies and genetic markers in professional team sports. Methods: The authors studied 363 (mean [SD]; 25 [6] y, 89% male) elite players (soccer, futsal, basketball, handball, and roller hockey) from a top-level European team (FC Barcelona, Spain). Of 363, 55% (cases) had experienced 1+ episodes of tendinopathy during 2008–2018 and 45% (controls) remained injury free. The authors first examined the association between single-nucleotide polymorphisms (SNPs) and tendinopathy risk in a hypothesis-free case-control genome-wide association study (495,837 SNPs) with additional target analysis of 58 SNPs that are potential candidates to influence tendinopathy risk based on the literature. Thereafter, the authors augmented the SNP set by performing synthetic variant imputation (1,419,369 SNPs) and then used machine learning-based multivariate modeling (support vector machine and random forest) to build a reliable predictive model. Results: Suggestive association (P < 10−5) was found for rs11154027 (gap junction alpha 1), rs4362400 (vesicle amine transport 1-like), and rs10263021 (contactin-associated protein-like 2). Carriage of 1+ variant alleles for rs11154027 (odds ratio = 2.11; 95% confidence interval, 1.07–4.19, P = 1.01 × 10−6) or rs4362400 (odds ratio = 1.98; 95% confidence interval, 1.05–3.73, P = 9.6 × 10−6) was associated with a higher risk of tendinopathy, whereas an opposite effect was found for rs10263021 (odds ratio = 0.42; 95% confidence interval, 0.20–0.91], P = 4.5 × 10−6). In the modeling approach, one of the most robust SNPs was rs10477683 in the fibrillin 2 gene encoding fibrillin 2, a component of connective tissue microfibrils involved in elastic fiber assembly. Conclusions : The authors have identified previously undescribed genetic predictors of tendinopathy in elite team sports athletes, notably rs11154027, rs4362400, and rs10263021.

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Kristin M. Mills, Scott Sadler, Karen Peterson and Lorrin Pang

Background: Falls in the elderly represent a public health crisis. Effective prevention programs need to conduct economic analyses. The Move With Balance program showed a 65% reduction in falls in institutionalized elderly. Methods: We evaluated the return on investment (ROI) of Move With Balance. We calculated the ROI for 2 situations: first, using data from the current study (N = 27); second, extrapolating the data to an “intended” annual program (N = 45) where training costs can be spread over 6 years. Results: The program costs for the current study was $11,143. Based on an efficacy rate of 65%, we estimated that 13 falls were averted among the 21 participants in the treatment group. At a cost of $1440/fall, total averted cost of falls was $18,720. The ROI was 1.7:1 for a 10-week period. Program effects persisted for at least 6 months. Extrapolating the current program costs and fall rates to include classes for 45 people twice a year, the annual program costs would be $27,217. Total annual averted cost of falls would be $208,594. The annual ROI in this group would be 7.6:1. Conclusions: Move With Balance not only is efficacious in reducing falls in institutionalized elderly but also has a positive ROI.

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Michael S. Guss, John P. Begly, Austin J. Ramme, David P. Taormina, Michael E. Rettig and John T. Capo

Context: Major League Baseball (MLB) players are at risk of hook of hamate fractures. There is a paucity of data assessing the effect of a hook of hamate fracture on MLB players’ future athletic performance. Objective: To determine if MLB players who sustain hook of hamate fractures demonstrate decreased performance upon return to competition when compared with their performance before injury and that of their control-matched peers. Design: Retrospective case-control design. Setting: Retrospective database study. Participants: 18 MLB players who sustained hook of hamate fractures. Methods: Data for 18 MLB players with hook of hamate fractures incurred over 26 seasons (1989–2014) were obtained from injury reports, press releases, and player profiles ( and Player age, position, number of years in the league, mechanism of injury, and treatment were recorded. Individual season statistics for the 2 seasons immediately prior to injury and the 2 seasons after injury for the main performance variable—Wins Above Replacement—were obtained. Eighteen controls matched by player position, age, and performance statistics were identified. A performance comparison of the cohorts was performed. Main Outcome Measures: Postinjury performance compared with preinjury performance and matched-controls. Results: Mean age at the time of injury was 25.1 years with a mean of 4.4 seasons of MLB experience prior to injury. All injuries were sustained to their nondominant batting hand. All players underwent operative intervention. There was no significant change in Wins Above Replacement or isolated power when preinjury and postinjury performance were compared. When compared with matched-controls, no significant decline in performance in Wins Above Replacement the first season and second season after injury was found. Conclusion: MLB players sustaining hook of hamate fractures can reasonably expect to return to their preinjury performance levels following operative treatment.

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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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Gakuto Kitamura, Hiroshige Tateuchi and Noriaki Ichihashi

Context: In competitive swimming, many swimmers experience low back pain (LBP). Lumbar hyperextension may cause LBP, and tight hip-flexor muscle may cause lumbar extension during swimming. Objective: The purpose of this study was to clarify the features of the elastic moduli of the muscles and the lumbar extension when swimmers with LBP perform a dolphin kick (DK). Design: Cross-sectional study. Setting: Single center. Other Participants: Eleven male college swimmers were enrolled as the LBP group (who have LBP when swimming and during a lumbar extension), and 21 male college swimmers were recruited as the control group (no LBP). Interventions: The elastic moduli of the psoas major, iliacus, teres major, latissimus dorsi, pectoralis major, and pectoralis minor were measured through ultrasonic shear wave elastography. The lumbar and hip extension angles during a DK were measured using a video camera. The passive hip extension and shoulder-flexion range of motion (ROM) were measured using a goniometer. Main Outcome Measures: Muscle elastic moduli and lumbar extension angles during DK. Results: The characteristics, muscle elastic moduli, DK motion, and ROM were compared between the 2 groups. LBP group demonstrated significantly higher elastic modulus of the psoas major and lower modulus of pectoralis minor compared with the control group. Also, LBP group showed greater lumbar extension during a DK and less hip extension ROM than the control group. Conclusions: The higher elastic modulus of the psoas major and greater lumbar extension during a DK may be related to the LBP in swimmers.

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Brett Krueger, Laura Becker, Greta Leemkuil and Christopher Durall

Clinical Scenario:

Ankle sprains account for roughly 10% of sport-related injuries in the active population. The majority of these injuries occur from excessive ankle inversion, leading to lateral ligamentous injury. In addition to pain and swelling, limitations in ankle range of motion (ROM) and self-reported function are common findings. These limitations are thought to be due in part to loss of mobility in the talocrural joint. Accordingly, some investigators have reported using high-velocity, low-amplitude thrust-manipulation techniques directed at the talocrural joint to address deficits in dorsiflexion (Df) ROM and function. This review was conducted to ascertain the impact of talocrural joint-thrust manipulation (TJM) on DF ROM, selfreported function, and pain in patients with a history of ankle sprain.

Focused Clinical Question:

In patients with a history of inversion ankle sprain, does TJM improve outcomes in DF ROM, self-reported function, and/or pain?