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J. Allen Hardin, John A. Guido and Christopher J. Hughes

Due to the likelihood of hamstring dysfunction associated with anterior cruciate ligament (ACL) injury, it is clinically significant to determine if a hamstring weakness exists preoperatively. The purpose of this study was to determine if a hamstring muscle deficit existed at the time of surgery and to determine the time necessary to achieve hamstring strength equal to preoperative measures of the uninvolved extremity during postoperative rehabilitation. Twelve patients who underwent ACL reconstruction using a patellar tendon autograft participated. Each subject underwent a preoperative isometric knee strength evaluation at 60° of knee flexion. Each subject underwent postoperative rehabilitation including hamstring muscle strengthening. Repeat isometric testing was performed on each subject at 21 and 42 days postoperative. There was no statistical difference in hamstring muscle strength, as measured by isometric peak torque, either preoperatively or postoperatively. Therefore, maintaining rather than increasing hamstring strength postoperatively should be emphasized as an integral part of rehabilitation.

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Michael R. McCarthy, Barton P. Buxton and Carlan K. Yates

Continuous passive motion (CPM) is a modality used in the treatment, management, and rehabilitation of a variety of orthopedic problems. Recently, CPM devices have been therapeutically employed immediately after autogenous patellar tendon reconstruction of the anterior cruciate ligament (ACL). Whereas the concept of early motion is indicated, there is a concomitant concern that the implementation of immediate passive motion may stretch or rupture the graft. Twenty subjects scheduled to undergo ACL reconstruction were randomized into two groups (10 CPM and 10 non-CPM). All subjects performed the same postoperative rehabilitation with the exception of the CPM. Objective anterior tibial translation measurements were recorded with a KT-1000 for a 30-1b (133.5-N) Lachman test at 1 year postreconstruction. The results of this study indicated that the implementation of immediate continuous passive motion did not have any deleterious effects on the stability of the ligament reconstruction.

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Robert J. de Vos, Marinus P. Heijboer, Harrie Weinans, Jan A.N. Verhaar and Hans T.M. van Schie


Chronic midportion Achilles tendinopathy is a common and hard-to-treat disorder characterized by degenerative changes of the tendon matrix. Ultrasonographic tissue characterization (UTC) was successfully used to quantify structural human Achilles tendon changes. This novel and reliable technique could be used in follow-up studies to relate tendon structure to symptoms.


To quantify structural tendon changes and assess clinical change in patients with tendinopathy.


Prospective observational study.


Orthopedic department in a university medical center.


23 patients with chronic midportion Achilles tendinopathy.


The patients performed a 16-wk home-based eccentric exercise program. An experienced researcher performed the ultrasonographic data collection with the UTC procedure. These data were assessed by a blinded observer. The severity of symptoms was established with the validated Victorian Institute of Sport Assessment–Achilles (VISA-A) questionnaire.

Main Outcome Measures:

UTC was performed to quantify tendon structure through measuring the proportion of 4 echo types. Echo types I and II represent more or less organized tendon bundles, and echo types III and IV represent disintegrated tendon structure. On the VISA-A, the total possible score is divided by 100 for a percentage score, with a perfect score of 100. Follow-up was at 2, 8, 16, and 24 wk.


The mean percentage of echo types I and II changed by 0.3% after 24 wk (P = .92, 95% CI −5.8 to 5.3). The mean VISA-A score increased slightly but significantly by 11.3 points after 24 wk (P = .01, 95% CI 2.6–20.0). An increased VISA-A score was not correlated with an increased percentage of echo types I and II (P = .94, r = −.02), and the baseline percentage of echo types I and II did not correlate with an increased VISA-A score (P = .74, r = .07).


There is no short-term increase in organized tendon structure after eccentric exercises. Tendon structure is not related to symptom severity and cannot be used as a predictor of clinical outcome.

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Carlan K. Yates, Michael R. McCarthy, Howard S. Hirsch and Mark S. Pascale

This study examined the benefits and possible risks of immediate continuous passive motion after autogenous patellar tendon reconstruction of the anterior cruciate ligament. Thirty patients scheduled to undergo ACL reconstruction were prospectively randomized into two groups, CPM and non-CPM. Postoperatively, those in the non-CPM group wore a hinged knee brace. Those in the CPM group were kept on a CPM machine 16 hrs a day while in the hospital and they used it 6 hrs a day for the first 2 weeks postoperatively. After surgery the patients were assessed for hemovac drainage, range of motion, swelling, effusion, subjective pain, and use of pain medication. The CPM group had significantly less swelling and effusion, required less pain medication, and had greater knee flexion. No differences were found in hemovac drainage, passive knee extension, or subjective pain reports despite a significantly greater use of pain medication in the non-CPM group. The results suggest that immediate CPM after ACL reconstruction is safe and facilitates early range of motion by decreasing the amount of pain medication, effusion, and soft tissue swelling.

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Dominic James Farris, Erica Buckeridge, Grant Trewartha and Miranda Polly McGuigan

This study assessed the effects of orthotic heel lifts on Achilles tendon (AT) force and strain during running. Ten females ran barefoot over a force plate in three conditions: no heel lifts (NHL), with 12 mm heel lifts (12HL) and with 18 mm heel lifts (18HL). Kinematics for the right lower limb were collected (200 Hz). AT force was calculated from inverse dynamics. AT strain was determined from kinematics and ultrasound images of medial gastrocnemius (50 Hz). Peak AT strain was less for 18HL (5.5 ± 4.4%) than for NHL (7.4 ± 4.2%) (p = .029, effect size [ES] = 0.44) but not for 12HL (5.8 ± 4.8%) versus NHL (ES = 0.35). Peak AT force was significantly (p = .024, ES = 0.42) less for 18HL (2382 ± 717 N) than for NHL (2710 ± 830 N) but not for 12HL (2538 ± 823 N, ES = 0.21). The 18HL reduced ankle dorsiflexion but not flexion-extension ankle moments and increased the AT moment arm compared with NHL. Thus, 18HL reduced force and strain on the AT during running via a reduction in dorsiflexion, which lengthened the AT moment arm. Therefore, heel lifts could be used to reduce AT loading and strain during the rehabilitation of AT injuries.

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Michael Lyght, Matthew Nockerts, Thomas W. Kernozek and Robert Ragan

Achilles tendon (AT) injuries are common in runners. The AT withstands high magnitudes of stress during running which may contribute to injury. Our purpose was to examine the effects of foot strike pattern and step frequency on AT stress and strain during running utilizing muscle forces based on a musculoskeletal model and subject-specific ultrasound-derived AT crosssectional area. Nineteen female runners performed running trials under 6 conditions, including rearfoot strike and forefoot strike patterns at their preferred cadence, +5%, and –5% preferred cadence. Rearfoot strike patterns had less peak AT stress (P < .001), strain (P < .001), and strain rate (P < .001) compared with the forefoot strike pattern. A reduction in peak AT stress and strain were exhibited with a +5% preferred step frequency relative to the preferred condition using a rearfoot (P < .001) and forefoot (P=.005) strike pattern. Strain rate was not different (P > .05) between step frequencies within each foot strike condition. Our results suggest that a rearfoot pattern may reduce AT stress, strain, and strain rate. Increases in step frequency of 5% above preferred frequency, regardless of foot strike pattern, may also lower peak AT stress and strain.

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Keitaro Kubo, Teruaki Komuro, Noriko Ishiguro, Naoya Tsunoda, Yoshiaki Sato, Naokata Ishii, Hiroaki Kanehisa and and Tetsuo Fukunaga

The present study aimed to investigate the effects of low-load resistance training with vascular occlusion on the specific tension and tendon properties by comparing with those of high-load training. Nine participants completed 12 weeks (3 days/week) of a unilateral isotonic training program on knee extensors. One leg was trained using low load (20% of 1 RM) with vascular occlusion (LLO) and other leg using high load (80% of 1 RM) without vascular occlusion (HL). Before and after training, maximal isometric knee extension torque (MVC) and muscle volume were measured. Specific tension of vastus lateralis muscle (VL) was calculated from MVC, muscle volume, and muscle architecture measurements. Stiffness of tendon-aponeurosis complex in VL was measured using ultrasonography during isometric knee extension. Both protocols significantly increased MVC and muscle volume of quadriceps femoris muscle. Specific tension of VL increased significantly 5.5% for HL, but not for LLO. The LLO protocol did not alter the stiffness of tendon-aponeurosis complex in knee extensors, while the HL protocol increased it significantly. The present study demonstrated that the specific tension and tendon properties were found to remain following low-load resistance training with vascular occlusion, whereas they increased significantly after high-load training.

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Robert A. Weinert-Aplin, Anthony M.J. Bull and Alison H. McGregor

Conservative treatments such as in-shoe orthotic heel wedges to treat musculoskeletal injuries are not new. However, weak evidence supporting their use in the management of Achilles tendonitis suggests the mechanism by which these heel wedges works remains poorly understood. It was the aim of this study to test the underlying hypothesis that heel wedges can reduce Achilles tendon load. A musculoskeletal modeling approach was used to quantify changes in lower limb mechanics when walking due to the introduction of 12-mm orthotic heel wedges. Nineteen healthy volunteers walked on an inclinable walkway while optical motion, force plate, and plantar pressure data were recorded. Walking with heel wedges increased ankle dorsiflexion moments and reduced plantar flexion moments; this resulted in increased peak ankle dorsiflexor muscle forces during early stance and reduced tibialis posterior and toe flexor muscle forces during late stance. Heel wedges did not reduce overall Achilles tendon force during any walking condition, but did redistribute load from the medial to lateral triceps surae during inclined walking. These results add to the body of clinical evidence confirming that heel wedges do not reduce Achilles tendon load and our findings provide an explanation as to why this may be the case.

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Akinori Nagano, Taku Komura and Senshi Fukashiro

The two goals of this study were (a) to evaluate the effects of the series elasticity of the muscle tendon complex on an explosive performance that allows a counter movement, and (b) to determine whether or not a counter movement is automatically generated in the optimal explosive activity, using computer simulation. A computer simulation model of the Hill-type muscle tendon complex, which is composed of a contractile element (CE) and a series elastic element (SEE), was constructed. The proximal end of the CE was affixed to a point in the gravitational field, and a massless supporting object was affixed to the distal end of the SEE. An inertia was held on the supporting object. The goal of the explosive activity was to maximize the height reached by the inertia. A variation of the SEE elasticity was examined within the natural range. The optimal pattern of neural activation input was sought through numerical optimization for each value of the SEE elasticity. Two major findings were obtained: (a) As the SEE elasticity increased, the maximal height reached by the inertia increased. This was primarily due to the enhanced force development of the CE. (b) A counter movement was automatically generated for all values of the SEE elasticity through the numerical optimization. It is suggested that it is beneficial to make a counter movement in order to reach a greater jump height, and the effect of making a counter movement increases as the elasticity of the muscle tendon complex increases.

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Marge Taylor