Catherine Logan

Systematic Review of the Effect of Taping Techniques on Patellofemoral Pain Syndrome

Context: Taping is commonly used in the management of several musculoskeletal conditions, including patellofemoral pain syndrome (PFPS). Specific guidelines for taping are unknown. Objective: To investigate the efficacy of knee taping in the management of PFPS. Our hypothesis was that tension taping and exercise would be superior to placebo taping and exercise as well as to exercise or taping alone. Data Sources: The PubMed/MEDLINE, Cochrane, Rehabilitation and Sports Medicine Source, and CINAHL databases were reviewed for English-language randomized controlled trials (RCTs) evaluating the efficacy of various taping techniques that were published between 1995 and April 2015. Keywords utilized included taping, McConnell, kinesio-taping, kinesiotaping, patellofemoral pain, and knee. Study Selection: Studies included consisted of RCTs (level 1 or 2) with participants of all ages who had anterior knee or patellofemoral pain symptoms and had received nonsurgical management using any taping technique. Study Design: Systematic review. Level of Evidence: Level 2. Data Extraction: A checklist method was used to determine selection, performance, detection, and attrition bias for each article. A quality of evidence grading was then referenced using the validated PEDro database for RCTs. Three difference comparison groups were compared: tension taping and exercise versus placebo taping and exercise (group 1), placebo taping and exercise versus exercise alone (group 2), and tension taping and exercise versus taping alone (group 3). Results: Five RCTs with 235 total patients with multiple intervention arms were included. Taping strategies included McConnell and Kinesiotaping. Visual analog scale (VAS) scores indicated improvement in all 3 comparison groups (group 1: 91 patients, 39% of total, mean VAS improvement 44.9 [tension taping + exercise] vs 66 [placebo taping + exercise]; group 2: 56 patients, 24% of total, mean VAS improvement 66 [placebo taping + exercise] vs 47.6 [exercise alone]; and group 3: 112 patients, 48% of total, mean VAS improvement 44.9 [tension taping + exercise] vs 14.1 [taping alone]). Conclusion: This systematic review supports knee taping only as an adjunct to traditional exercise therapy for PFPS; however, it does not support taping in isolation.

Epidemiology of Navicular Injury at the NFL Combine and Their Impact on an Athlete’s Prospective NFL Career

Background: Navicular injuries can result in persistent pain, posttraumatic osteoarthritis, and diminished performance and function. Purpose: To determine the epidemiology of navicular fracture in players participating in the National Football League (NFL) Scouting Combine and evaluate the impact of a navicular injury on the NFL draft position and NFL game play compared with matched controls. Study Design: Cohort study; Level of evidence, 3. Methods: Data were collected on players who previously sustained a navicular injury and participated in the NFL Combine between 2009 and 2015. The epidemiology of navicular injury was determined through an evaluation of the number of injuries, surgeries, and collegiate games missed as well as the position played, a physical examination, the surgical technique, and imaging findings. Players with a previous navicular injury (2009-2013) were compared with a set of matched controls. NFL performance outcomes included the draft position, career length ≥2 years, and number of games played and started within the first 2 years. Results: Between 2009 and 2015, 14 of 2285 (0.6%) players were identified as having sustained a navicular injury. A total of 11 of 14 (79%) athletes had sustained an overt navicular fracture, while 3 of 14 (21%) were diagnosed with stress reactions on magnetic resonance imaging. Eight patients who sustained a navicular fracture underwent surgery. There was evidence of ipsilateral talonavicular arthritis in 75% of players with a navicular fracture versus only 60% in the uninjured foot (odds ratio, 1.3; P = .04). Fifty-seven percent of players with navicular injury (72.7% of fractures) were undrafted versus 30.9% in the control group (P = .001). Overall, 28.6% of players with navicular fracture played ≥2 years in the NFL compared with 69.6% in the control group (P = .02). Conclusion: A previous navicular fracture results in a greater risk of developing posttraumatic osteoarthritis. Although only a low prevalence of navicular injury in prospective NFL players was noted, players with these injuries had a greater probability of not being drafted and not competing in at least 2 NFL seasons when compared with matched controls without an injury history to the NFL Combine.

The Role of Therapeutic Modalities in Surgical and Nonsurgical Management of Orthopaedic Injuries

Rehabilitation professionals often use therapeutic modalities as a component of the surgical and nonsurgical management of orthopaedic injuries. Myriad therapeutic modalities, including cryotherapy, thermotherapy, ultrasonography, electrical stimulation, iontophoresis, and laser therapy, are available. Knowledge of the scientific basis of each modality and the principles of implementation for specific injuries enables musculoskeletal treatment providers to prescribe these modalities effectively. The selection of specific therapeutic modalities is based on their efficacy during a particular phase of rehabilitation. Therapeutic modalities are an adjunct to standard exercise and manual therapy techniques and should not be used in isolation.

Posterior Cruciate Ligament Injuries of the Knee at the National Football League Combine: An Imaging and Epidemiology Study

PURPOSE To determine the epidemiology by player position, examination, imaging findings, and associated injuries of posterior cruciate ligament (PCL) injuries in players participating in the National Football League (NFL) Combine. METHODS All PCL injuries identified at the NFL Combine (2009-2015) were reviewed. Data were obtained from the database organized by the NFL medical personnel for the compilation of the medical and physical performance examination results of NFL Draftees participating in the NFL Combine from 2009 to 2015. Inclusion criteria were any player with clinical findings or a previous surgery consistent with a PCL injury who participated in the NFL Combine. RESULTS Of the 2,285 players who participated in the NFL Combine between 2009 and 2015, 69 (3%) had evidence of a PCL injury, of which 11 players (15.9%) were managed surgically. On physical examination, 35 players (52%) had a grade II or III posterior drawer. Concomitant injuries were present frequently and included medial collateral ligament (MCL; 42%), anterior cruciate ligament (ACL; 11.6%), and chondral injuries (31.8%), especially in the lateral tibiofemoral compartment. CONCLUSIONS Three percent of the players at the NFL Combine presented with a PCL injury, with a significant amount being either running backs (14/69, 20.2%) or offensive linemen (14/69, 20.2%). Approximately half of the players with a PCL tear had a residual grade II or III posterior drawer after sustaining a PCL injury. Concomitant injuries were present frequently and included MCL (42%), ACL (11.6%), and chondral injuries (31.8%), especially in the lateral tibiofemoral compartment. For those players with clinical concern for PCL ligamentous laxity, there should be a complete comprehensive workup that includes plain and PCL stress view radiographs, and magnetic resonance imaging. LEVEL OF EVIDENCE Level IV, case series.

Medial Collateral Ligament Injuries Identified at the National Football League Scouting Combine: Assessment of Epidemiological Characteristics, Imaging Findings, and Initial Career Performance

Background: The medial collateral ligament (MCL) is one of the most commonly injured structures in the knee, especially in young athletes. The impact of MCL injury on National Football League (NFL) performance in elite collegiate athletes has not yet been described in the literature. Purpose: We aim to (1) describe the prevalence and severity of MCL injuries in NFL Combine participants, (2) detail injury management, and (3) analyze the impact of MCL injury on NFL performance in terms of draft position, games played, games started, and snap percentage. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of all NFL Combine participants from 2009 to 2015 was performed by reviewing medical records and imaging reports from the combine to identify all players with MCL injuries. A control group was developed from the players evaluated at the combine without MCL injury. For each affected knee, the MCL injury was classified by location and severity based on results of magnetic resonance imaging (MRI). Each player’s respective NFL draft position, number of NFL games played, number of NFL games started, and NFL snap percentage for the first 2 seasons in the league were collected through the use of NFL.com and Pro-Football-Focus, which are web-based, publicly accessible, comprehensive sports statistics databases. Results: A total of 2285 players participated in the NFL Combine between 2009 and 2015. Three hundred one athletes (13.2%) were identified as having MCL injuries; 36 (12%) of the athletes with MCL injury presented with bilateral injuries, for a total of 337 MCL injuries. Additional soft tissue injury was identified on 187 of 337 (55%) MRIs. Players with a history of MCL injury were more likely to play at least 2 years in the NFL compared with those in the control group (P = .003). Players who had isolated MCL injury performed significantly better compared with athletes who had combined injuries with regard to draft position (P = .034), proportion playing at least 2 seasons in the NFL (P = .022), games played (P = .014), and games started (P = .020) in the first 2 years. No significant difference was found between players who underwent operative versus nonoperative management of their MCL injury. Conclusion: A relatively high percentage of players at the NFL Combine had evidence of MCL injury (13%). A prior history of MCL tear had no negative impact on an athlete’s NFL performance. Players who had isolated MCL injury performed significantly better compared with athletes who had combined injuries with regard to draft position, proportion playing 2 seasons or more in the NFL, and games played and started in the first 2 years.

The Epidemiology of Injuries Identified at the National Football League Scouting Combine and their Impact on Professional Sport Performance: 2203 athletes, 2009-2015

Objectives: Normal At the annual National Football League (NFL) Scouting Combine, the medical staff of each NFL franchise performs a comprehensive medical evaluation of all athletes potentially entering the NFL. Currently, little is known regarding the overall epidemiology of injuries identified at the Combine and their impact on NFL performance. The purpose of this study is to determine the epidemiology of injuries identified at the Combine and their impact on future NFL performance. Methods: All previous musculoskeletal injuries identified at the NFL combine (2009-2015) were retrospectively reviewed. Medical records and imaging reports were examined. Game statistics for the first two seasons of NFL play were obtained for all players from 2009 to 2013. Analysis of injury prevalence and overall impact on draft status and position-specific performance metrics of each injury was performed and compared versus a position-matched control group with no history of injury and surgery. Results: A total of 2,203 athletes over seven years were evaluated, including 1,490 (67.6%) drafted athletes and 1,040 (47.2%) who ultimately played at least two years in the NFL. The most common sites of injury were the ankle (1160, 52.7%), shoulder (1143, 51.9%), knee (1128, 51.2%), spine (785, 35.6%), and hand (739, 33.5%). Odds ratios (OR) demonstrated quarterbacks were most at risk of shoulder injury (OR 2.78, p=0.001) while running backs most commonly sustained ankle (OR 1.49, p=0.038) and shoulder injuries (OR 1.55, p=0.022). Ultimately, defensive players demonstrated a more negative impact than offensive players following injury with multiple performance metrics impacted for each defensive position analyzed whereas skilled offensive players (i.e. quarterbacks, running backs) demonstrated only one metric affected at each position. Conclusion: The most common sites of injury identified at the Combine were: (1) ankle, (2) shoulder, (3) knee, (4) spine, and (5) hand. Overall, performance in the NFL was significantly impacted by previous injuries. NFL performance was directly dependent on position played as well as anatomic location of injury. Defensive players were more negatively impacted than offensive players. Additional work is necessary to determine longer-term impact of these injuries on NFL career and post-NFL quality of life.

The Epidemiology of Lisfranc Injuries at the National Football League Combine and its Impact on an Athlete’s National Football League Career

Objectives: Lisfranc injuries may have a detrimental effect on athletic performance and an athlete’s career. Understanding the epidemiology of these injuries in collegiate football players and their impact on future performance may assist team physicians in counseling injured athletes and determining optimal treatment. The purposes of this study are to 1) determine the epidemiology of navicular fractures in players participating in the NFL Combine, 2) define positions and demographics that might be at higher risk for sustaining this injury, and 3) evaluate the radiographic healing and eventual impact the injury and radiographic findings has on Lisfranc injuries on NFL draft position and NFL game play compared to matched controls. Methods: All players who sustained a Lisfranc injury prior to Combine evaluation between 2009 and 2015 were evaluated. The prevalence, positions affected, treatment methods, and number of missed collegiate games were recorded. Radiographic outcomes were analyzed via Combine radiograph findings, while NFL performance outcomes were assessed for all Lisfranc injuries (2009-13) compared to matched controls in first two years of play. Results: A total of 41/2162 (1.8%) Combine participants were identified with Lisfranc injuries, of which 26/41 (63.4%) were managed operatively. When compared to players managed nonoperatively, those who underwent surgery were more likely to go undrafted (38.5% vs. 13.3%, p=0.04) and featured a worse NFL draft pick position (155.6 vs. 109, p=0.03). Lisfranc-injured players were noted to have a worse NFL draft position (142 vs. 111.3, p=0.04), NFL career length ≥2 years (62.5% vs. 69.6%, p=0.23) and fewer games played (16.9 vs. 23.3, p=0.001) and started (6.8 vs. 10.5, p=0.08) within the first two years of NFL career versus controls. Radiographs demonstrated 17/41 (41.5%) athletes with residual Lisfranc joint displacement >2mm compared to the contralateral foot. Lisfranc-injured athletes with >2mm residual displacement had lower draft position (111.2 vs. 156.9, p=0.009), and fewer games played (23.3 vs. 14.4, p=0.001) and started (10.5 vs. 3,1, p=0.03) versus matched controls. Moreover, athletes with >2mm residual displacement featured worse outcomes across all assessed NFL variables versus athletes with ≤2mm residual displacement. Conclusion: Lisfranc injuries identified at the NFL Combine have an adverse effect on an NFL athlete’s draft status, draft position and overall play during initial NFL seasons. In particular, residual displacement of the Lisfranc joint has a detrimental impact on the first two seasons of NFL play and may lead to long lasting negative effects on career.

The Epidemiology of Navicular Injuries at the NFL Combine

Category: Sports Introduction/Purpose: Navicular injuries are documented to have the potential for significant impairment of foot function. Regardless of treatment choice, these injuries can result in persistent pain, advanced osteoarthritis, and chronic dysfunction. A clearer understanding of their prevalence in collegiate athletes as well as their impact on their NFL career would help team physicians better counsel players and their teams, and perhaps also aid in defining optimal treatment. The purpose of this study was to 1) determine the epidemiology of navicular fractures in players participating in the NFL combine, 2) define positions that might be at higher risk for sustaining this injury, and 3) evaluate the impact of navicular injuries on NFL draft position and NFL game play compared to matched controls. Methods: Data was collected from the NFL combine website on all participating players who had sustained a navicular injury before entering the NFL between 2009 and 2015. Medical records, imaging, and treatments were reviewed on all individuals who met these criteria. The epidemiology of navicular injuries was determined by evaluating the number of injuries, surgeries, games missed, position played and draft position of each player. Available exam and imaging findings were reviewed for each player. Players from 2009 to 2013 with a navicular injury were compared to matched controls. Control groups consisted of players who missed less than 2 games in college, played the same position, and did not have a previous surgery. NFL performance outcomes were evaluated through analysis of draft position, career length ≥2 years, and number of games played and games started within their first 2 years. All NFL performance data was obtained from STATS.com. Odds ratios were calculated using logistic regression to assess the risk of sustaining a navicular injury by position. Two-sample, two-tailed T-tests were computed to assess games missed in college and draft position in players with a navicular injury and NFL career consisting of games played, and started in the NFL in the first 2 years of their career versus control players. Results: A total of 2285 foot players participated in the NFL combine between 2009 – 2015. There were 15 navicular injuries (14 players) with an incidence of 0.6% of NFL football players participating in the combine during this time frame. Defensive backs had a statistically significant increased odds ratio (Odds ratio = 3.0, p=0.03) of sustaining a navicular injury, however only 3 defensive backs had a navicular injury. Three players had nonunions or a refracture and 2 players required a revision surgery. Fifty-seven percent of players with navicular injuries (72.7% of fractures) were undrafted versus 30.9% in the control group (P< 0.001). Twenty-nine percent of players with navicular fractures played 2 years in the NFL compared to 69.6% in the control group (P< 0.01). Conclusion: While only a small percentage of players at the NFL combine had a navicular injury, there was a significant increase in percentage of players undrafted and a decreased percent of players who played two years in the NFL when compared to controls. This demonstrates the detrimental effect this injury may have to a player’s career.

The Epidemiology of Lisfranc Injuries at the NFL Combine

Category: Sports Introduction/Purpose: Lisfranc injuries can have detrimental consequences to an athlete’s career. If left inadequately treated, these injuries can result in persistent pain and lead to advanced osteoarthritis. Understanding the prevalence of these injuries in collegiate athletes and their effect on NFL draft position can help team physicians counsel future players and determine optimal treatment. The purpose of this study was to determine the epidemiology of Lisfranc injuries in players participating in the NFL combine and to determine the positions that are at higher risk for sustaining these injuries. Methods: Data was collected from the NFL combine website on all players who participated in the combine and had sustained a Lisfranc injury before entering the NFL from 2009 to 2015. Medical records, imaging, and treatments were reviewed on players who were identified with these injuries. The epidemiology of Lisfranc injuries was determined by evaluating the number of injuries, surgeries, games missed, position played and draft position of each player. Odds ratios were calculated using logistic regression to assess the risk of sustaining each injury by position. Two-sample, two-tailed T-tests were computed to assess games missed and draft position in players with operative versus non-operative management. Players with a Lisfranc injury as well a second primary midfoot injury (n=3) were excluded from analysis. Results: Thirty-nine(1.7%) players at the NFL combine had an isolated Lisfranc injury during their collegiate football career. Of these players, 27(69.2%) required surgical intervention. The average number of collegiate football games missed for this injury was 3.0±5.0. The average number of games missed for players requiring operative fixation was statistically greater(4.2±5.7) than those in the non-operative group (0.3 ±0.9, p=0.02). The average NFL draft position was 141.7±69.4, and 13(33.3%) went undrafted. There was no statistical difference in the average draft position(p=0.84) and number of undrafted players(p=0.15) between the operative and non-operative groups. No position was found to be at increased risk for Lisfranc injury; however, as a whole, offensive players had a significantly increased risk(Odds ratio=2.7, p = 0.01) of having a Lisfranc injury when compared to all other players. Overall, 24(61.5%) of the players with a Lisfranc injury played on offense. Conclusion: The majority of players who reported a Lisfranc injury required operative intervention, and offensive players were at a higher risk for this injury. Lisfranc requiring operative management did not significantly change a player’s draft position or chance of being drafted.

Rotator Interval and Stiffness

The rotator interval is a triangular space located between the subscapularis and supraspinatus tendons in the anterosuperior region of the shoulder. Within its borders lie the superior glenohumeral and coracohumeral ligaments, the long head of biceps tendon, and capsule. From a biomechanical standpoint, the rotator interval contributes to shoulder stability and maintains normal glenohumeral translation, and helps maintain stability of the long head of the biceps. Multiple studies have described various surgical closure techniques and the associated outcomes on overall function; still the optimal surgical technique is a source of debate. The primary objectives of this chapter are to review the anatomy and biomechanics of the rotator interval, its components and their function, and surgical treatment of the rotator interval as related to stiffness.