Wendy J. Hurd

A 10-Year Prospective Trial of a Patient Management Algorithm and Screening Examination for Highly Active Individuals With Anterior Cruciate Ligament Injury Part 1, Outcomes

Background A treatment algorithm and screening examination have been developed to guide patient management and prospectively determine potential for highly active individuals to succeed with nonoperative care after anterior cruciate ligament rupture. Objective To prospectively characterize and classify the entire population of highly active individuals over a 10-year period and provide final outcomes for individuals who elected nonoperative care. Methods Inclusion criteria included presentation within 7 months of the index injury and an International Knee Documentation Committee level I or II activity level before injury. Concomitant injury, unresolved impairments, and a screening examination were used as criteria to guide management and classify individuals as noncopers (poor potential) or potential copers (good potential) for nonoperative care. Results A total of 832 highly active patients with subacute anterior cruciate ligament tears were seen over the 10-year period; 315 had concomitant injuries, 87 had unresolved impairments, and 85 did not participate in the classification algorithm. The remaining 345 patients (216 men, 129 women) participated in the screening examination a mean of 6 weeks after the index injury. There were 199 subjects classified as noncopers and 146 as potential copers. Sixty-three of 88 potential copers successfully returned to preinjury activities without surgery, with 25 of these patients not undergoing anterior cruciate ligament reconstruction at the time of follow-up. Conclusion The classification algorithm is an effective tool for prospectively identifying individuals early after anterior cruciate ligament injury who want to pursue nonoperative care or must delay surgical intervention and have good potential to do so.

Perturbation-enhanced neuromuscular training alters muscle activity in female athletes

Female athletes involved in jumping and cutting sports injure their anterior cruciate ligaments (ACL) 4–6 times more frequently than their male counterparts in comparable sports. Neuromuscular factors, including quadriceps dominance, has been incriminated as contributing to the higher rates of injury in women. Currently, the most effective form of intervention developed to reduce female ACL injury rates has been neuromuscular training. The purpose of this study was to (1) identify gender based muscle activity patterns during disturbed walking that may contribute to ACL injury, and (2) determine if a novel training program could positively influence patterns among healthy female athletes utilizing a disturbed gait paradigm. Twenty healthy athletes (female=10, male=10) were tested. All subjects participated in five trials during which a platform translated horizontally in a lateral direction at heel contact before and after completing ten sessions of a perturbation training program. Electromyographic (EMG) data from the vastus lateralis, medial and lateral hamstrings, and medial gastrocnemius were collected. Trials were analyzed for the muscle onset, termination of activity, peak amplitude, time to peak amplitude, and integrated EMG activity. Muscle cocontraction, the simultaneous activation of antagonistic muscles (lateral hamstrings-vastus lateralis, and medial gastrocnemius-vastus lateralis), was calculated as indicators of active knee stiffness in preparation for heel strike, during weight acceptance and midstance. Prior to training, women had significantly higher peak quadriceps activity and higher integrated quadriceps activity during midstance than men. Both medial and lateral hamstring integrals during midstance increased from pre to posttraining. Onset times to peak activities for hamstrings and quadriceps were similar before training except for medial hamstring time to peak which occurred after heel strike in most women. Time to peak medial hamstring activity moved from after to just before heel strike after training. Women had higher medial gastrocnemius-vastus lateralis cocontraction indices in the preparatory and weight acceptance phases of gait than men after training. Prior to training, the athletic women in our sample demonstrated characteristic quadriceps dominance and decreased active knee stiffness when compared to male athletes. Modulation of activity and timing of ACL agonist musculature (hamstrings and gastrocnemius) from before to after training resulted in normal quadriceps-hamstring balance and increased active stiffness. These alterations in ACL agonist muscle activation patterns may reduce the risk of biomechanical strain injury among a high risk population.

A 10-Year Prospective Trial of a Patient Management Algorithm and Screening Examination for Highly Active Individuals with Anterior Cruciate Ligament Injury

Background A treatment algorithm and screening examination have been developed to guide patient management and prospectively determine potential for highly active individuals to succeed with nonoperative care after anterior cruciate ligament rupture. Objective To prospectively characterize and classify the entire population of highly active individuals over a 10-year period and provide final outcomes for individuals who elected nonoperative care. Methods Inclusion criteria included presentation within 7 months of the index injury and an International Knee Documentation Committee level I or II activity level before injury. Concomitant injury, unresolved impairments, and a screening examination were used as criteria to guide management and classify individuals as noncopers (poor potential) or potential copers (good potential) for nonoperative care. Results A total of 832 highly active patients with subacute anterior cruciate ligament tears were seen over the 10-year period; 315 had concomitant injuries, 87 had unresolved impairments, and 85 did not participate in the classification algorithm. The remaining 345 patients (216 men, 129 women) participated in the screening examination a mean of 6 weeks after the index injury. There were 199 subjects classified as noncopers and 146 as potential copers. Sixty-three of 88 potential copers successfully returned to preinjury activities without surgery, with 25 of these patients not undergoing anterior cruciate ligament reconstruction at the time of follow-up. Conclusion The classification algorithm is an effective tool for prospectively identifying individuals early after anterior cruciate ligament injury who want to pursue nonoperative care or must delay surgical intervention and have good potential to do so.

A 10-Year Prospective Trial of a Patient Management Algorithm and Screening Examination for Highly Active Individuals With Anterior Cruciate Ligament Injury Part 2, Determinants of Dynamic Knee Stability

Objective To clarify the determinants of dynamic knee stability early after anterior cruciate ligament injury. Study Design Cohort study (diagnosis); Level of evidence, 1. Methods Three hundred forty-five consecutive patients who were regular participants in International Knee Documentation Committee level I/II sports before injury and had an acute isolated anterior cruciate ligament injury from the practice of a single orthopaedic surgeon underwent a screening examination including clinical measures, knee laxity, quadriceps strength, hop testing, and patient self-reported knee function a mean of 6 weeks after injury when impairments were resolved. Independent t tests were performed to evaluate differences in quadriceps strength and anterior knee laxity between potential copers and noncopers. Hierarchical regression was performed to determine the influence of quadriceps strength, preinjury activity level, and anterior knee laxity on hop test performance, as well as the influence of timed hop, crossover hop, quadriceps strength, preinjury activity level, and anterior knee laxity on self-assessed global function. Results Neither anterior knee laxity nor quadriceps strength differed between potential copers and noncopers. Quadriceps strength influenced hop test performance more significantly than did preinjury activity level or anterior knee laxity, but the variance accounted for by quadriceps strength was low (range, 4%–8%). Timed hop performance was the only variable that affected self-assessed global function. Conclusion Traditional surgical decision making based on passive anterior knee laxity and preinjury activity level is not supported by the results, as neither is a good predictor of dynamic knee stability. A battery of clinical tests that capture neuromuscular adaptations, including the timed hop test, may be useful in predicting function and guiding individualized patient management after anterior cruciate ligament injury.

Influence of Age, Gender, and Injury Mechanism on the Development of Dynamic Knee Stability After Acute ACL Rupture

STUDY DESIGN Cross-sectional study. OBJECTIVES To determine whether the distribution of those with and without dynamic knee stability after anterior cruciate ligament (ACL) rupture differs by age, gender, and contact versus non-contact injury mechanisms. BACKGROUND There is a differential return to preinjury activities after ACL rupture. It is unknown if there are specific patient groups who are more or less likely to experience good dynamic knee stability after ACL rupture. METHODS AND MEASURES The study sample consisted of 345 consecutive, highly active patients with complete, isolated ACL insufficiency. Based on the results of a screening examination, patients were categorized as having either good (potential coper) or poor (noncoper) dynamic knee stability. Descriptive and chi-square statistics were calculated to describe patient characteristics and identify the proportion of potential copers and noncopers based on age, gender, and injury mechanism. RESULTS The groups with the greatest proportion of noncopers were women (P=0.002), mid-aged adults (35-44 years old) (P<0.001), and individuals who sustained a noncontact ACL injury (P=0.011). CONCLUSIONS Women who sustain an ACL rupture, and those who sustain an ACL rupture via a noncontact mechanism frequently experience dynamic knee instability. A profile of demographic characteristics of those most likely to experience knee instability after ACL rupture may facilitate improved patient outcomes.

Data-Based Interval Throwing Programs for Baseball Players

Context: Baseball throwing injuries are common. Emphasis on injury prevention and rehabilitation is made in an attempt to keep athletes on the field of competition. Interval throwing programs are an integral part of training, conditioning, and returning an injured baseball player to the game. Evidence Acquisition: Development of data-driven programs was based on the number, type, distance, and intensity of throws during games, across the spectrum of ages and positions for baseball athletes at all levels of play. Statistical analysis by age, position, and level of play determined the need for separate throwing programs. Means, the high range, game rules, and practical considerations were used to develop each data-based interval throwing program. Results: Data-based age and level-of-play interval throwing programs for pitchers, catchers, infielders, and outfielders have been developed, tested, and implemented for more than 10 years. Progression is based on type and location of injury, symptoms in response to throwing, and preinjury performance profile. Although the throwing programs are highly structured, there is ample opportunity to modify them to meet the needs of individual athletes. Conclusion: Data-based interval throwing programs for baseball athletes are an integral training and conditioning element for both injured and uninjured athletes who are preparing for sports participation. Medical team members should equip themselves with an understanding of how to use the programs for safe training, conditioning, and return to play.

Management of the Athlete With Acute Anterior Cruciate Ligament Deficiency

Background: Identification of highly active individuals early after acute anterior cruciate ligament deficiency who are good candidates for nonoperative management is a clinical challenge. The University of Delaware has developed and validated a treatment algorithm and screening examination to distinguish between nonoperative and surgical candidates. Study Design: Review. Evidence Acquisition: A description of the decision-making rules and rehabilitation protocol for highly active individuals with anterior cruciate ligament deficiency is provided. Results from clinical trials, outcome studies, and biomechanical investigations conducted using the treatment algorithm and screening examination are also reviewed. Results: Patients identified as nonoperative rehabilitation candidates using these clinical guidelines have a far greater success rate than what has been reported when patients self-select nonoperative management. Furthermore, nonoperative outcomes are improved when patients participate in a perturbation-enhanced rehabilitation protocol. Divergent lower extremity movement patterns are consistent with the different functional abilities of the dichotomous patient groups identified with the screening examination. Conclusion: Given the differential patient response to anterior cruciate ligament injury, implementation of the decision-making guidelines discussed in this review offers clinicians the opportunity to provide individualized patient care rather than continuing with a blanket surgical treatment strategy.

Data-Based Interval Hitting Program for Female College Volleyball Players

Context: Interval sports programs are a critical rehabilitation element when preparing the injured athlete for a return to preinjury activities. There is currently no published interval hitting program to guide a return to unrestricted play for the volleyball athlete. Therefore, data-based, position-specific overhead hitting programs that control for intensity, time, and number of ball strikes were developed for female college volleyball players. Evidence Acquisition: Records from a single Division I varsity women’s volleyball team were examined for all matches during 7 consecutive years of team play. Data were collected for number of hitting and service attempts per game for each position and the number of games per match. Results: Per game, middle hitters averaged 4.51 attacks and 2.77 service attempts; right-side hitters, 3.58 attacks and 1.26 service attempts; outside hitters, 6.37 attacks and 3.44 service attempts; and setters and defensive specialists, 0.17 attacks and 1.78 service attempts. Conclusion: The interval hitting program can provide rehabilitation specialists with a data-based approach that may facilitate a return to play and minimize the risk of reinjury for volleyball athletes.

Refractory Ulnar Nerve Symptoms in an Adolescent Pitcher With Medial Apophysitis

A 16-year-old high school baseball pitcher with a 3-week history of acute-onset pain in his medial elbow during throwing presented to physical therapy. Following examination, physical therapy was initiated and the patient was referred for imaging, with suspicion of ulnar collateral ligament (UCL) injury. Radiographs were noncontributory. Ultrasound imaging, however, was performed by a physiatrist and was suggestive of a partial-thickness tear of the UCL and ulnar nerve enlargement. The physiatrist ordered magnetic resonance imaging, which confirmed a medial apophyseal stress reaction, a mild UCL sprain, and reactive ulnar nerve edema. J Orthop Sports Phys Ther 2018;48(5):419. doi:10.2519/jospt.2018.7359.