A 21-year-old female NCAA Division III soccer player presented with an insidious onset of posterior ankle pain. Lateral radiographs revealed a Stieda process, leading to a physician diagnosis of posterior ankle impingement (PAI). Mulligan Concept mobilizations with movement (MWM) were used to ameliorate patient complaints. The MWM glide was maintained during activity using a tape application. Return to play and patient improvement occurred dramatically faster while utilizing the MWM technique than other traditional methods used to treat this condition. This case report demonstrates a novel approach to treating Stieda process-related PAI that warrants further clinical inquiry.
Alex J. Rhinehart and Caroline C. Guindon
James W.G. Thompson and David Hagedorn
Sports-related concussions are complex injuries with biomechanical and biochemical etiology that present with central and autonomic nervous system dysfunction. Current methods for assessing concussions and basing return-to-play decisions rely on symptom resolution, rating scales, and neuropsychological testing, all of which are indirect measures of injury severity and detect functional capabilities but do not directly measure injury location or severity. In addition, these downstream measures are susceptible to false negatives because compensatory mechanism, such as unmasking and redundancies in brain circuitry can return functional capabilities before injury resolution. The multifactorial nature of concussion necessitates rapid, inexpensive, and easily applied multimodal analysis methods that can offer greater sensitivity and specificity. This article discusses how new approaches utilizing electrophysiology (e.g., QEEG, ERP, ECG, HRV), quantified balance measures, and biochemistry are necessary to advance the science of concussion assessment, treatment, recovery projections, and return-to-play decisions. These additional assessment tools offer a more direct window into the severity and location of the injury, real-time measures of brain function, and the ability to measure the multiple body systems negatively affected by concussion.
Fiona McVeigh and Stephen M. Pack
Research involving long-term follow-up of patients after successful anterior cruciate ligament reconstruction (ACLR) has shown that return-to-sport rates are not as good as would be expected despite many patients’ having normal knee-function scores. The psychological component, specifically fear of reinjury, plays a critical role in determining patients’ return to play and is frequently underestimated. Little is known about the recognition and intervention from the therapist’s perspective.
To gain a greater understanding of the views of sports rehabilitators and athletic rehabilitation therapists on recognition of fear of reinjury in clients after ACLR.
Method and Design:
A qualitative approach, consisting of semistructured interviews with a purposive sample of 8 participants, sports rehabilitators, or athletic rehabilitation therapists. This population has been largely unexamined in this context in previous research.
Thematic analysis yielded 2 main themes: communication and education. Participants discussed the importance of communication in the client–therapist relationship and how it is used in addressing misinformation and fear of reinjury. All participants used education in outlining the rehabilitation pathway and dealing with those providing social support around the client. Issues emerged relating to therapists’ recognition of observable signs of fear of reinjury in the clinical setting. Overall, participants thought that fear of reinjury was not a barrier to return to play after ACLR.
There is a need for more education of therapists on recognizing fear of reinjury and the appropriate use of psychological intervention skills as a method for dealing with this throughout the rehabilitation process.
Hyung Rock Lee, Jacob E. Resch, Tae Kyung Han, Jessica D. Miles and Michael S. Ferrara
Few studies have been conducted on individuals’ knowledge of sport-related concussions (SRCs) in South Korea. The purpose of this study was to examine South Korean athletes’ knowledge and recognition of SRC. A cross-sectional survey assessing (a) the recognition of specific signs and symptoms associated with SRC; (b) history of SRC; and (c) knowledge of the return-to-play decision (RTP) process after SRC was distributed to 410 high school and collegiate student-athletes from a variety of sports. No participants correctly identified all 9 items on the checklist of SRC signs and symptoms. While 8.9% reported a history of SRC, approximately 50% of those never reported their postconcussion signs and symptoms. Furthermore, 63.9% of the athletes who reported SRC made RTP decisions on their own. These results reflect the lack of knowledge in South Korean athletics of common signs, symptoms, and appropriate RTP decisions following concussion.
Bryan L. Riemann and Kevin M. Guskiewicz
Mild head injury (MHI) represents one of the most challenging neurological pathologies occurring during athletic participation. Athletic trainers and sports medicine personnel are often faced with decisions about the severity of head injury and the timing of an athlete's return to play following MHI. Returning an athlete to competition following MHI too early can be a catastrophic mistake. This case study involves a 20-year-old collegiate football player who sustained three mild head injuries during one season. The case study demonstrates how objective measures of balance and cognition can be used when making decisions about returning an athlete to play following MHI. These measures can be used to supplement the subjective guidelines proposed by many physicians.
Andrea Cripps and Scott C. Livingston
Sport-related concussions are a significant health issue due to the high incidence of concussions sustained each sports season. Current approaches to the evaluation of acutely concussed athletes include the use of balance assessments to identify and monitor underlying postural instability arising from concussion. Balance assessment has been recommended as a primary measurement tool for monitoring recovery and for making return-to-play decisions. Balance impairments have been shown to occur in the initial postconcussion period (ie, 1–10 d). Numerous clinical and laboratory measures have been used in the assessment of balance immediately after concussion, and clinicians are faced with deciding which measures to use.
Focused Clinical Question:
How do clinical or field-based balance-assessment tools compare to laboratory-based balance measures in identifying deficits in postural stability among acutely concussed athletes?
The two articles in the area of cardiovascular physiology and disease in youth were chosen for commentary because of their exploration of new approaches to the diagnosis and management of cardiovascular derangements in young persons. The first, by Hinds et al., describes the potential clinical importance of detection of cardiovascular changes during exercise testing in adolescent athletes following concussions. This approach might prove useful in establishing safe return-to-play guidelines. The second, a review article by Van De Schoor et al, evaluates the frequency of myocardial scarring in athletes, some of adolescent age, which is a recognized risk factor for sudden cardiac death. These findings support other evidence indicating that sports participation per se might rarely increase the risk of such tragedies. Clearly more research is indicated by the information raised in both of these articles, but their importance to clinical medicine is obvious.
Lara Mitchinson, Amity Campbell, Damian Oldmeadow, Will Gibson and Diana Hopper
Volleyball players are at high risk of overuse shoulder injuries, with spike biomechanics a perceived risk factor. This study compared spike kinematics between elite male volleyball players with and without a history of shoulder injuries. Height, mass, maximum jump height, passive shoulder rotation range of motion (ROM), and active trunk ROM were collected on elite players with (13) and without (11) shoulder injury history and were compared using independent samples t tests (P < .05). The average of spike kinematics at impact and range 0.1 s before and after impact during down-the-line and cross-court spike types were compared using linear mixed models in SPSS (P < .01). No differences were detected between the injured and uninjured groups. Thoracic rotation and shoulder abduction at impact and range of shoulder rotation velocity differed between spike types. The ability to tolerate the differing demands of the spike types could be used as return-to-play criteria for injured athletes.
Lynda M. Mainwaring, Sean M. Bisschop, Robin E.A. Green, Mark Antoniazzi, Paul Comper, Vicki Kristman, Christine Provvidenza and Doug W. Richards
Despite suggestions that emotions influence recovery from injury, there is little research into the emotional sequelae of mild traumatic brain injury (MTBI), or “concussion,” in sport. This examination compares emotional functioning of college athletes with MTBI to that of uninjured teammates and undergraduates. A short version of the Profile of Mood States (POMS; Grove & Prapavessis, 1992) assessed baseline emotions in all groups, and serial emotional functioning in the MTBI and undergraduate groups. Whereas preinjury profiles were similar across groups, the MTBI group showed a significant postinjury spike in depression, confusion, and total mood disturbance that was not seen for the other groups. The elevated mood disturbances subsided within 3 weeks postinjury. Given that concussed athletes were highly motivated to return to play, these data could be used as a benchmark of normal emotional recovery from MTBI. Findings are discussed in relation to current literature on emotional reaction to injury and directions for future research.
Michelle Cleary, Daniel Ruiz, Lindsey Eberman, Israel Mitchell and Helen Binkley
We present a case of severe dehydration, muscle cramping, and rhabdomyolysis in a high school football player followed by a suggested program for gradual return to play.
A 16-year-old male football player (body mass = 69.1 kg, height = 175.3 cm) reported to the ATC after the morning session on the second day of two-a-days complaining of severe muscle cramping.
The initial assessment included severe dehydration and exercise-induced muscle cramps. The differential diagnosis was severe dehydration, exertional rhabdomyolysis, or myositis. CK testing revealed elevated levels indicating mild rhabdomyolysis.
The emergency department administered 8 L of intravenous (IV) fluid within the 48-hr hospitalization period, followed by gradual return to activity.
To our knowledge, no reports of exertional rhabdomyolysis in an adolescent football player exist. In this case, a high school quarterback with a previous history of heat-related cramping succumbed to severe dehydration and exertional rhabdomyolysis during noncontact preseason practice. We provide suggestions for return to activity following exertional rhabdomyolysis.