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John J. Nicholas, Margaret Reidy and Denise M. Oleske

In order to supplement the literature that describes individual injuries of the shoulder, carpal tunnel, and back in golfers, we administered a survey to demonstrate the incidence of golfers' injuries and describe the most frequent types. A questionnaire was administered to 1,790 members of the New York State Golf Association (amateur) under age 21. Three hundred sixty-eight players responded. Half of those responding had been struck by a golf ball at least on one occasion (47.6%), and 23% of the injuries were to the head or neck. Male golfers were 2.66 times more likely to be struck by a golf ball than females. Women and golfers with a higher handicap were at an increased risk for upper extremity problems, whereas younger and overweight golfers were more likely to have golf-related back problems. We concluded that golf is associated with a significant morbidity. Repetitious trunk and upper limb motions probably contribute to musculoskeletal disorders. However, an unexpectedly high incidence of trauma from projectile golf balls leads to the conclusion that no amount of stretching or muscular exercise is as important as increased alertness by golfers to decrease this hazard.

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Tricia Majewski-Schrage and Kelli Snyder

Clinical Scenario:

Managing edema after trauma or injury is a primary concern for health care professionals, as it is theorized that delaying the removal of edema will increase secondary injury and result in a longer recovery period. The inflammatory process generates a series of events, starting with bleeding and ultimately leading to fluid accumulation in intercellular spaces and the formation of edema. Once edema is formed, the lymphatic system plays a tremendous role in removing excess interstitial fluid and returning the fluid to the circulatory system. Therefore, rehabilitation specialists ought to use therapies that enhance the uptake of edema via the lymphatic system to manage edema; however, the modalities commonly used are ice, compression, and elevation. Modalities such as these may be effective at preventing swelling but present limited evidence to suggest that the function of the lymphatic system is enhanced. Manual lymphatic drainage (MLD) is a manual therapy technique that assists the lymphatic system function by promoting variations in interstitial pressures by applying light pressure using different hand movements.

Focused Clinical Question:

Does MLD improve patient- and disease-oriented outcomes for patients with orthopedic injuries?

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Kyle Southall, Matt Price and Courtney Wisler

A 20-year-old male collegiate football athlete reported a remarkably swollen elbow after direct contact with the ground. Initial radiographs and magnetic resonance imaging were negative for a fracture and soft tissue structural damage. After 2 weeks of conservative treatment, the athlete had no decrease in swelling and associated symptoms. He was diagnosed with a Morel-Lavallée lesion, later confirmed by diagnostic ultrasound imaging. The lesion was initially treated with compression therapy and cryotherapy to reduce swelling. Upon the final diagnosis the lesion was eventually incised, drained, and packed with iodoform sterile strips. It is hypothesized that many minor Morel-Lavallée cases are under- or misdiagnosed due to overlapping of signs and symptoms with other soft tissue traumas common in athletic populations. The procedures of this case can be utilized to optimize outcomes in future cases. While rare, Morel-Lavallée lesions can occur in athletic activities involving the upper extremity, and not solely crush injuries or traumatic and high-intensity accidents. This knowledge, along with the presented signs and symptoms, can give future healthcare professionals knowledge to include this diagnosis in their working differential diagnosis of injuries with similar presentations.

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Gerald A. Larson, Chad Starkey and Leonard D. Zaichkowsky

This study investigated the perceptions of certified athletic trainers concerning their attitudes, beliefs, and application of a variety of psychological strategies and techniques used in the treatment and rehabilitation of athletic injuries. The Athletic Training and Sport Psychology Questionnaire (ATSPQ) was adapted from instruments developed by Wiese, Weiss, and Yukelson (1991) and Brewer, Van Raalte, and Linder (1991). The ATSPQ, a letter of introduction, and a self-addressed stamped envelope were distributed to 1,000 certified athletic trainers randomly selected from the membership database maintained by the National Athletic Trainers’ Association (NATA). Only 482 (48.2%) of these questionnaires returned were usable. 47% of athletic trainers who responded believe that every injured athlete suffers psychological trauma. 24% reported that they have referred an athlete for counseling for situations related to their injury, and 25% reported that they have a sport psychologist as a member of their sports medicine team. This study concludes that future education of athletic trainers should address the psychological aspects of injury treatment as well as the development of a sport psychology referral network.

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Jeffrey B. Driban, Nicole Cattano, Easwaran Balasubramanian, Michael R. Sitler, Mamta Amin, Joseph Glutting and Mary F. Barbe

Context: To better understand why a knee develops osteoarthritis after joint trauma we need to assess the local biochemical changes. Unfortunately, it is challenging to obtain synovial fluid from a knee with no effusion. Objective: To describe the authors' protocol for aspirating synovial fluid from noneffused knees. Second, they demonstrate the validity of this method by evaluating the relationships between normalized and raw biomarker concentrations among knees with effusion (undergoing a traditional aspiration) and without effusion (requiring a saline-assisted aspiration). Design: Validation study based on secondary analyses from 2 cohort studies. Setting: Outpatient orthopedic clinic and basic-science laboratory. Participants: Participants had moderate to severe radiographic knee osteoarthritis (n = 15 with and 11 without effusion) and no osteoarthritis or effusion (n = 4). Interventions: The same orthopedic surgeon performed all synovial-fluid joint aspirations, including saline-assisted aspirations. Main Outcome Measures: The authors used multiplex enzyme-linked immunosorbent assays to determine 7 synovial-fluid biomarker concentrations. They then calculated correlations between raw and normalized (to total synovial-fluid protein content) biomarker concentrations. Results: The authors excluded 1 sample collected with a saline-assisted aspiration because it contained blood. Normalized biomarker concentrations had positive associations with raw biomarker concentrations (r = .77-99), with the exception of interleukin-13 and interleukin-1Β among knees that underwent a saline-assisted aspiration. Excluding interleukin-1Β, associations between normalized and raw biomarker concentrations were consistent between knees that had a saline-assisted or traditional aspiration. Conclusions:Saline-assisted aspiration is a valid technique for assessing the local biochemical changes in knees without effusion.

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Jeffrey B. Driban, Easwaran Balasubramanian, Mamta Amin, Michael R. Sitler, Marvin C. Ziskin and Mary F. Barbe

Context:

Joint trauma is a risk factor for osteoarthritis (OA), which is becoming an increasingly important orthopedic concern for athletes and nonathletes alike. For advances in OA prevention, diagnosis, and treatment to occur, a greater understanding of the biochemical environment of the affected joint is needed.

Objective:

To demonstrate the potential of a biochemical technique to enhance our understanding of and diagnostic capabilities for osteoarthritis.

Design:

Cross-sectional.

Setting:

Outpatient orthopedic practice.

Participants:

8 subjects: 4 OA-knee participants (65 ± 6 y of age) and 4 normal-knee participants (54 ± 10 y) with no history of knee OA based on bilateral standing radiographs.

Intervention:

The independent variable was group (OA knee, normal knee).

Main Outcome Measures:

16 knee synovial-protein concentrations categorized as follows: 4 as pro-inflammatory, or catabolic, cytokines; 5 as anti-inflammatory, or protective, cytokines; 3 as catabolic enzymes; 2 as tissue inhibitors of metalloproteinases [TIMPs]; and 2 as adipokines.

Results:

Two anti-inflammatory cytokines (interleukin [IL]-13 and osteoprotegerin) and a pro-inflammatory cytokine (IL-1β) were significantly lower in the OA knees. Two catabolic enzymes (matrix metalloproteinase [MMP]-2 and MMP-3) were significantly elevated in OA knees. TIMP-2, an inhibitor of MMPs, was significantly elevated in OA knees.

Conclusions:

Six of the 16 synovial-fluid proteins were significantly different between OA knees and normal knees in this study. Future research using a similar multiplex ELISA approach or other proteomic techniques may enable researchers and clinicians to develop more accurate biochemical profiles of synovial fluid to help diagnose OA, identify subsets of OA or individual characteristics, guide clinical decisions, and identify patients at risk for OA after knee injury.

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Marie A. Johanson, Megan Armstrong, Chris Hopkins, Meghan L. Keen, Michael Robinson and Scott Stephenson

Context:

Stretching exercises are commonly prescribed for patients and healthy individuals with limited extensibility of the gastrocnemius muscle.

Objective:

To determine if individuals demonstrate more dorsiflexion at the ankle/rear foot and less at the midfoot after a gastrocnemius-stretching program with the subtalar joint (STJ) positioned in supination compared with pronation.

Design:

Randomized controlled trial.

Setting:

Biomechanical laboratory.

Participants:

22 volunteers with current or recent history of lower-extremity cumulative trauma and gastrocnemius tightness (10 women and 4 men, mean age 28 y) randomly assigned to stretching groups with the STJ positioned in either pronation (n = 11) or supination (n = 11).

Intervention:

3-wk home gastrocnemius-stretching program using a template to place the subtalar joint in either a pronated or a supinated position.

Main Outcome Measures:

A 7-camera Vicon motion-analysis system measured ankle/rear-foot dorsiflexion and midfoot dorsiflexion of all participants during stretching with the STJ positioned in both pronation and supination before and after the 3-wk gastrocnemius-stretching program.

Results:

A 2-way mixed-model ANOVA revealed a significant interaction (P = .019). At posttest, the group who performed the 3-week stretching program with the STJ positioned in pronation demonstrated more increased ankle/rear-foot dorsiflexion when measured with the STJ in pronation than the group who performed the 3-wk stretching program with the STJ positioned in supination. No significant main effect of stretching group or interaction for dorsiflexion at the midfoot was detected (P = .755 and P = .820, respectively).

Conclusion:

After a 3-wk gastrocnemius-stretching program, when measuring dorsiflexion with the STJ positioned in supination, the participants who completed a 3-wk gastrocnemius stretching program with the STJ positioned in pronation showed more increased dorsiflexion at the ankle/rear foot than participants who completed the stretching program with the STJ positioned in supination.

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Aditi Mankad, Sandy Gordon and Karen Wallman

Psychological trauma associated with long-term injury can cause athletes to experience intense stress-like symptoms and considerable negative affect (e.g., Tracey, 2003; Udry, 1997). Due to the nature of competitive sport, however, it is thought that injured athletes inhibit these emotions to the detriment of their physical health. The present study examined Pennebaker’s (1989) emotional disclosure paradigm within a sporting context. It was hypothesized that writing about a traumatic injury would reduce athletes’ mood disturbance and stress during rehabilitation. Further, it was believed that these changes would correspond with an increase in immune expression from pre- to postintervention. Elite injured athletes (N = 9) rehabilitating from anterior cruciate ligament surgery participated in the 3-day writing intervention, consisting of 3 X 20 min writing sessions, during which athletes disclosed negative emotions associated with their injury and rehabilitation experiences. Measures were taken at six time-points (T1-T6), with pre- and postintervention phases lasting for 4 weeks each. Measures consisted of psychological stress (intrusion and avoidance), total mood disturbance, and relative cell-counts/µL for circulating T-cells (CD4/8) and NK cells (CD16/56). Repeated-measures ANOVAs showed a signifcant main effect of time for intrusion, F(5, 70) = 5.83, p =.001, η2 = .29 and avoidance, F(5, 70) = 5.73, p =.002, η2 = 0.29 subscales; mood disturbance, F(5, 70) = 3.71, p= 0.005, η2 = 0.21; and CD4+, F(5, 65) = 2.39, p= 0.048, η2 = .16. Subsequent linear contrasts provided further evidence of significant prepost differences among the stress, mood state, and immune variables. These results suggest that the written disclosure intervention has potential psycho-immunological benefits for athletes rehabilitating from long-term injury.

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Thomas Koesterer, Aaron Blanchard and Patrick Donnelly

Objective:

To present a unique case of meralgia paresthetica.

Background:

A 21-year-old male collegiate lacrosse player fell, twisted his right leg, and felt a “pop” in his hip. Objective fndings included: antalgic gait, mild palpable swelling, and tenderness to touch with limited range of motion due to pain. Joint stability tests were negative.

Differential Diagnosis:

Right hip abductor strain, hip sprain, trochanteric bursitis, or labral tear.

Treatment:

The physician’s findings included deep hip pain that increased with hip scouring and pain with active and passive motion. The physician’s diagnosis was hip sprain; treatment was to continue with ice and begin active progression for return to play. The athlete was treated over the next several days with warm whirlpools, stretching, and a hip fexor wrap. Ten days postinjury, the athlete played in a game, but in the fourth quarter came off the field stating he couldn’t feel his thigh. The orthopedic physician evaluated the athlete and provided a differential diagnosis of right hip fexor strain and hip capsule sprain with numbness, possibly due to meralgia paresthetica. The physician ordered treatment to continue and began a regimen of 600 mg of ibuprofen three times per day and noted the athlete could continue to play.

Uniqueness:

The athlete did not show any symptoms of meralgia paresthetica for 10 days post initial injury. The meralgia paresthetica was most likely caused by swelling resulting from the hip sprain, in which the swelling compressed the lateral femoral cutaneous nerve (LFCN) against the inguinal ligament.

Conclusions:

Meralgia paresthetica may occur as a result of trauma and subsequent swelling of the inguinal region. A thorough evaluation of the hip must be conducted to ensure no motor neuron involvement is associated with the paresthesia symptoms.

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Randon Hall, Kim Barber Foss, Timothy E. Hewett and Gregory D. Myer

Objectives:

To determine if sport specialization increases the risk of anterior knee pain in adolescent female athletes.

Design:

Retrospective cohort epidemiology study.

Methods:

Female basketball, soccer, and volleyball players (N = 546) were recruited from a single county public school district in Kentucky consisting of 5 middle schools and 4 high schools. A total of 357 multisport and 189 single-sport (66 basketball, 57 soccer, and 66 volleyball) athlete subjects were included due to their diagnosis of patellofemoral pain (PFP) on physical exam. Testing consisted of a standardized history and physician-administered physical examination to determine the presence of PFP. This study compared self-reported multisport athletes with sport-specialized athletes participating in only 1 sport. The sports-participation data were normalized by sport season, with each sport accounting for 1 season of exposure. Incidence rate ratios and 95% confidence intervals (CI) were calculated and used to determine significant differences between athletes who specialized in sport in early youth and multisport athletes.

Results:

Specialization in a single sport increased the relative risk of PFP incidence 1.5-fold (95% CI 1.0−2.2, P = .038) for cumulative PFP diagnoses. Specific diagnoses such as Sinding Larsen Johansson/patellar tendinopathy (95% CI 1.5−10.1, P = .005) and Osgood Schlatter disease (95% CI 1.5−10.1, P = .005) demonstrated a 4-fold greater relative risk in single-sport compared with multisport athletes. Incidence of other specific PFP diagnoses such as fat pad, plica, trauma, pes anserine bursitis, and iliotibial-band tendonitis was not different between single-sport and multisport participants (P > .05).

Conclusion:

Early sport specialization in female adolescents is associated with increased risk of anterior knee-pain disorders including PFP, Osgood Schlatter, Sinding Larsen-Johansson compared with multisport athletes.