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Brian Anderson and Ashley Par

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Timothy Neal

Athletic health care professionals, team physicians, and athletic trainers have an ethical obligation to safeguard the short- and long-term well-being of the athlete they care for. The potential long-term negative consequences to the student-athlete’s physical, cognitive, and mental health as a result of concussions and their mismanagement is a reality. How the athletic health care professional attends to this top priority of providing optimal health care to the concussed athlete while navigating the mitigating circumstances and influences of nonmedical entities found in competitive athletics is one of the great ethical challenges of present day sports medicine. Effectively navigating the complex challenges faced by athletic health care professionals is as important as the care delivered. Understanding the ethical challenges faced by athletic health care decision makers should be a central focus in providing the optimal care the patient deserves.

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Matt Hausmann, Jacob Ober and Adam S. Lepley

patients with acute lateral ankle sprains compared with the current standard of care protection, rest, ice, compression, and elevation? Summary of Key Findings • The literature was searched for studies of level 2 evidence or higher that investigated deep oscillation therapy on pain and inflammation in

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Katrina G. Ritter, Matthew J. Hussey and Tamara C. Valovich McLeod

aerobic exercise protocol was more effective than the current standard of care for recovery from PCS. • The literature search returned 17 possible studies related to the clinical question, of which 4 studies 10 – 13 met the inclusion criteria and were included. • The 4 studies 10 – 13 included reported

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

use of goal setting–enhanced rehabilitation to improve self-efficacy in patients undergoing rehabilitation for sports-related injury compared with the standard of care group. Strength of recommendation: The grade of A is recommended by the Strength of Recommendation Taxonomy for consistent, good

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Frank Cerny

In 1989 we knew that exercise, including regular prescribed physical activity, could be safely performed and described some of the physiological responses to exercise in patients with cystic fibrosis (CF). Also in 1989, the genetic defect causing cystic fibrosis (CF) was identified leading to improvements in treatment that greatly extended the life span for these patients. Increased understanding of the factors limiting exercise capacity and of the important role of regular exercise in slowing the progression of CF and in modulating some of the effects of the genetic defect on airway function has led to the consensus that regular exercise should be part of the standard of care for this disease.

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Raymond Chronister, George C. Balazs, Adam Pickett, John-Paul H. Rue and David J. Keblish

Context:

Acute lateral patellar dislocation is a common injury sustained by athletes, and often requires several months to recover and return to play.

Objective:

To describe a novel protocol for the treatment of acute lateral patellar dislocation that returns patients to play far sooner than traditional treatment protocols.

Design:

Case series and review of the literature.

Setting:

Division I NCAA institution.

Patients:

Two collegiate athletes who sustained first-time acute lateral patellar dislocations.

Interventions:

Traditional standard of care for acute lateral patellar dislocation after reduction involves 1–7 weeks of immobilization in full extension. Knee stiffness commonly results from this method, and return to full activity typically takes 2–4 months. We used a protocol involving immobilization in maximal flexion for 24 hr, with early aggressive range of motion and quadriceps strengthening in the first week after injury.

Main Outcome Measures:

Time to return to play.

Results:

Immediate on-site reduction of the patella followed by 24 hr of immobilization in maximal knee flexion was performed. Following an accelerated rehabilitation regimen, patients were able to return to sport an average of 3 days postinjury. Neither patient has experienced a recurrent dislocation.

Conclusions:

Our protocol is based on anatomic studies demonstrating reduced tension on the medial patellofemoral ligament, reduced hemarthrosis, and reduced soft tissue swelling in maximal knee flexion. This method apparently bypasses the knee stiffness and deconditioning commonly seen with traditional nonoperative regimens, allowing return to sport weeks or months sooner.

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Harold King, Stephen Campbell, Makenzie Herzog, David Popoli, Andrew Reisner and John Polikandriotis

Background:

More than 1 million US high school students play football. Our objective was to compare the high school football injury profiles by school enrollment size during the 2013–2014 season.

Methods:

Injury data were prospectively gathered on 1806 student athletes while participating in football practice or games by certified athletic trainers as standard of care for 20 high schools in the Atlanta Metropolitan area divided into small (<1600 students enrolled) or large (≥1600 students enrolled) over the 2013–2014 football season.

Results:

Smaller schools had a higher overall injury rate (79.9 injuries per 10,000 athletic exposures vs. 46.4 injuries per 10,000 athletic exposures; P < .001). In addition, smaller schools have a higher frequency of shoulder and elbow injuries (14.3% vs. 10.3%; P = .009 and 3.5% vs. 1.5%; P = .006, respectively) while larger schools have more hip/upper leg injuries (13.3% vs. 9.9%; P = .021). Lastly, smaller schools had a higher concussion distribution for offensive lineman (30.6% vs. 13.4%; P = .006) and a lower rate for defensive backs/safeties (9.2% vs. 25.4%; P = .008).

Conclusions:

This study is the first to compare and show unique injury profiles for different high school sizes. An understanding of school specific injury patterns can help drive targeted preventative measures.

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Mason D. Smith and David R. Bell

Context:

Anterior cruciate ligament (ACL) reconstruction is the standard of care for individuals with ACL rupture. Balance deficits have been observed in patients with ACL reconstruction (ACLR) using advanced posturography, which is the current gold standard. It is unclear if postural-control deficits exist when assessed by the Balance Error Scoring System (BESS), which is a clinical assessment of balance.

Objective:

The purpose of this study is to determine if postural-control deficits are present in individuals with ACLR as measured by the BESS.

Participants:

Thirty participants were included in this study. Fifteen had a history of unilateral ACLR and were compared with 15 matched controls.

Interventions:

The BESS consists of 3 stances (double-limb, single-limb, and tandem) on 2 surfaces (firm and foam). Participants begin in each stance with hands on their hips and eyes closed while trying to stand as still as possible for 20 s.

Main Outcome Measures:

Each participant performed 3 trials of each stance (18 total), and errors were assessed during each trial and summed to create a total score.

Results:

We observed a significant group × stance interaction (P = .004) and a significant main effect for stance (P < .001). Post hoc analysis revealed that the ACLR group had worse balance on the single-leg foam stance than did controls. Finally, the reconstructed group had more errors when total BESS score was examined (P = .02).

Conclusions:

Balance deficits exist in individuals with ACLR as measured by the BESS. Total BESS score was different between groups. The only condition that differed between groups was the single-leg stance on the unstable foam surface.

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Dai Sugimoto, Benton E. Heyworth, Jeff J. Brodeur, Dennis E. Kramer, Mininder S. Kocher and Lyle J. Micheli

Context: Recent epidemiology studies indicated a steady increase of anterior cruciate ligament (ACL) injury in young athletes. ACL reconstruction (ACLR) is currently a standard of care, but the effect of ACLR graft including bone patellar tendon bone (BTB), hamstring tendon (HT), or iliotibial band (ITB) on balance and hop performance is understudied. Objective: To compare balance and hop deficits between uninvolved and reconstructed limbs in each autograft type (aim 1) and among the 3 autograft groups (aim 2). Setting: Biomechanical laboratory. Participants: Male ACLR patients who are younger than 22 years (total N = 160; BTB: N = 19, HT: N = 108, ITB: N = 33). Intervention: Approximately 6 to 9 months following ACLR, Y-balance and 4 types of hop tests were measured bilaterally. Main Outcome Measures: Limb symmetry index of balance and hop tests within each graft type and between the 3 graft types. Results: In the BTB group, significant anterior reach, single hop, triple hops, and cross-over hops deficits were observed on the ACLR limb compared with the uninvolved limb. The HT group showed significant deficits in single hop, triple hops, and cross-over hops on the ACLR limb relative to the uninvolved limb. Compared with the uninvolved limb, significantly decreased triple hops and 6-m timed hop deficits in the ACLR limb were recorded in the ITB group. When controlling for confounders and comparing among the 3 autograft types, the only significant difference was anterior reach, in which the BTB group showed significant deficits. Conclusion: Compared with the uninvolved limb, significant hop deficits in ACLR limb were prevalent among adolescent ACLR at ∼6 to 9 months postoperatively. After controlling covariates, significantly reduced anterior reach balance was found in the BTB group compared with the HT and ITB groups.