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

’s perspective. HRQOL is estimated through the use of patient-reported outcome measures, instruments that allow patients to provide feedback on the effect of their injury or health condition on their overall health status 26 through generic or region-specific questionnaires. Although ankle injuries are thought

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Johanna M. Hoch, Cori W. Sinnott, Kendall P. Robinson, William O. Perkins and Jonathan W. Hartman

-oriented outcomes are used to subjectively assess a patient’s well-being and function and are often categorized into generic, region, and dimension-specific patient-reported outcome measures (PROMs). 3 Clinician-oriented outcomes (CBOs) can be utilized to assess the effects of the health condition at the body

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Krista M. Hixson, Alex N. Allen, Andrew S. Williams and Tamara C. Valovich McLeod

Clinical Scenario:

Mild traumatic brain injury, or concussion, has been associated with physical, cognitive, and emotional sequelae. Little is understood in regard to many characteristics, such as anxiety, and their effect on post-concussion symptoms.

Clinical Question:

Is state anxiety, trait anxiety, or anxiety sensitivity a clinical predictor of symptoms in those presenting with mild traumatic brain injury or concussion?

Summary of Key Findings:

A literature search returned 3 possible studies; 3 studies met inclusion criteria and included. One study reported in athletes that greater social support was associated with decreased state-anxiety, lower state anxiety post-concussion was associated with increased social support, and that those with greater social support may experience reduced anxiety, regardless of injury type sustained. One study reported baseline trait anxiety in athletes was not significantly associated with post-concussion state anxiety, but that symptoms of depression at baseline was the strongest predictor for post-concussion state anxiety. Three studies reported that state and trait anxiety are not related to increased post-concussion symptom scores. One study reported that greater anxiety sensitivity is related to higher reported post-concussion symptom scores, which may manifest as somatic symptoms following concussion, and revealed that anxiety sensitivity may be a risk factor symptom development.

Clinical Bottom Line:

There is low-level to moderate evidence to support that anxiety sensitivity is linked to post-concussion symptoms. State and trait anxiety do not appear to be related to post-concussion symptoms alone. Post-concussion state anxiety may occur if post-concussion symptoms of depression are present or if baseline symptoms of depression are present. Better social support may improve state anxiety post-concussion.

Strength of Recommendation:

There is grade B evidence to support that state and trait anxiety are not risk factors for post-concussion symptom development. There is grade C evidence to support anxiety sensitivity as a risk factor for developing post-concussion symptoms.

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Revay O. Corbett, Tyler R. Keith and Jay Hertel

Context: Patient-reported outcome measures (PROs) and functional performance tests are recommended in the National Athletic Trainers’ Association’s position statement on the prevention and management of ankle sprains during the return-to-play process. Evaluating perceived confidence may be another valuable method to evaluate an athlete’s readiness to return-to-play following an ankle sprain. Objective: To evaluate the relationship between PROs and perceived confidence when performing functional performance tasks in high school athletes with a history of ankle sprain. Design: Descriptive study. Setting: Public high school. Patients or Other Participants: A total of 25 high school student-athletes (6 males and 19 females, age 16.2 [1.1] y, height 169.3 [7.7] cm, mass 63.2 [9.8] kg). Intervention(s): None. Main Outcome Measures: The Cumberland Ankle Instability Tool, visual analog scale (VAS) for pain, Identification of Functional Ankle Instability, and Tampa Scale of Kinesiophobia-11 were completed by all participants. Participants then completed the weight-bearing lunge test; star excursion balance test; lateral, up–down, and triple hop tests; the single-leg vertical jump; and Southeast Missouri agility test and were asked to report their confidence in completing each task using a VAS with anchors of “no confidence” and “complete confidence.” Pearson r correlations were calculated between the PROs and the confidence VAS scores of the functional tests. Results: Moderate to strong negative correlations were identified between pain VAS measures and confidence VAS measures for all functional tests except the star excursion balance test and vertical jump. Moderate negative correlations were found between Tampa Scale of Kinesiophobia-11 scores and perceived confidence during the star excursion balance test and vertical jump. Finally, a moderate positive correlation was identified between Cumberland Ankle Instability Tool scores and perceived confidence measures during the Southeast Missouri agility test. Conclusions: High school athletes with a history of ankle sprain demonstrated significant correlations between several PROs and perceived confidence during various functional performance tests. The value of perceived confidence measures when making return-to-play decisions after ankle sprains warrants further investigation.

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Jennifer S. Howard, Carl G. Mattacola, David R. Mullineaux, Robert A. English and Christian Lattermann


It is well established that autologous chondrocyte implantation (ACI) can require extended recovery postoperatively; however, little information exists to provide clinicians and patients with a timeline for anticipated function during the first year after ACI.


To document the recovery of functional performance of activities of daily living after ACI.


ACI patients (n = 48, 29 male; 35.1 ± 8.0 y).


All patients completed functional tests (weight-bearing squat, walk-across, sit-to-stand, step-up/over, and forward lunge) using the NeuroCom long force plate (Clackamas, OR) and completed patient-reported outcome measures (International Knee Documentation Committee Subjective Knee Evaluation Form, Lysholm, Western Ontario and McMaster Osteoarthritis Index [WOMAC], and 36-Item Short-Form Health Survey) preoperatively and 3, 6, and 12 mo postoperatively.

Main Outcome Measures:

A covariance pattern model was used to compare performance and self-reported outcome across time and provide a timeline for functional recovery after ACI.


Participants demonstrated significant improvement in walk-across stride length from baseline (42.0% ± 8.9% height) at 6 (46.8% ± 8.1%) and 12 mo (46.6% ± 7.6%). Weight bearing on the involved limb during squatting at 30°, 60°, and 90° was significantly less at 3 mo than presurgery. Step-up/over time was significantly slower at 3 mo (1.67 ± 0.69 s) than at baseline (1.49 ± 0.33 s), 6 mo (1.51 ± 0.36 s), and 12 mo (1.40 ± 0.26 s). Step-up/over lift-up index was increased from baseline (41.0% ± 11.3% body weight [BW]) at 3 (45.0% ± 11.7% BW), 6 (47.0% ± 11.3% BW), and 12 mo (47.3% ± 11.6% BW). Forward-lunge time was decreased at 3 mo (1.51 ± 0.44 s) compared with baseline (1.39 ± 0.43 s), 6 mo (1.32 ± 0.05 s), and 12 mo (1.27 ± 0.06). Similarly, forward-lunge impact force was decreased at 3 mo (22.2% ± 1.4% BW) compared with baseline (25.4% ± 1.5% BW). The WOMAC demonstrated significant improvements at 3 mo. All patient-reported outcomes were improved from baseline at 6 and 12 mo postsurgery.


Patients' perceptions of improvements may outpace physical changes in function. Decreased function for at least the first 3 mo after ACI should be anticipated, and improvement in performance of tasks requiring weight-bearing knee flexion, such as squatting, going down stairs, or lunging, may not occur for a year or more after surgery.

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Kenneth C. Lam and Jessica G. Markbreiter

-IKDC Form The Pedi-IKDC is a valid, reliable, and responsive knee-specific patient-reported outcome measure that evaluates symptoms, function, and sports activity across 15 items using Likert-type or binary scales. 17 The total score on the Pedi-IKDC ranges from 0 to 100, with higher scores indicating

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Jennifer S. Howard, Aaron Sciascia and Johanna M. Hoch

, combined with the nuances of patient individuality, have made a complex topic much more challenging. One critical component to patient-centered care is the use of patient-reported outcome measures (PROs). PROs (also known as patient-rated outcomes) are any report of a patient’s health condition that comes

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Caitlin Brinkman, Shelby E. Baez, Francesca Genoese and Johanna M. Hoch

that included participants who sustained sports-related injury; • studies that assessed self-efficacy using a patient-reported outcome measure (eg, Sports Injury Rehabilitation Beliefs Survey [SIRBS]); and • studies published in English. The exclusion criteria for the study were as follows: • studies

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Kellie C. Huxel Bliven and Kelsey J. Picha

studies presented in this issue is apparent by the integration of laboratory, clinical, and patient-reported outcome measures used to answer the research questions. As you read the articles in this special issue, not only do we hope you learn from each study individually, but are also able to appreciate

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Robert Vallandingham, Zachary Winkelmann, Lindsey Eberman and Kenneth Games

recommendations, clinicians should deploy a myriad of tasks, as outlined in Table  1 . 6 Table 1 Recommendations Set Forth in the Position Statement Treatment Recommendations Other Interventions Return-to-Play Considerations Cryotherapy Range of motion Patient-reported outcome measures (PROMs) Compression