Sports Med Research Articles

Cooling during exercise enhances performances, but the cooled body areas matter: A systematic review with meta-analyses.

Hyperthermia during exercise induces central and peripheral fatigue and impairs physical performance. To facilitate heat loss and optimize performance, athletes can hasten body cooling prior (pre-cooling) or during (per-cooling) exercise. However, it is unclear whether per-cooling effect is the same on 'aerobic' and 'anaerobic' types of exercise (duration <75 and >76seconds, respectively, according to Gastin [Sports Med 2001;31:725-741]) and whether the body area that is cooled makes a difference. A literature search led to the identification of 1582 potential studies. Included studies had to include physical exercise with sufficient details on the type, duration, intensity, and provide valid performance measures and a cooling intervention administered during exercise with sufficient details on the type and site of application. Forty-five studies were included. Per-cooling provides a performance benefit during 'aerobic' (standardized mean difference (SMD) of0.60, P<.001)and 'anaerobic' exercises (SMD=0.27, P<.02).The effects were greater during aerobic compared to anaerobic exercises (P<.01). Internal cooling (cold fluid ingestion such as cold water and ice slurry/menthol beverage) and external cooling (face, neck, and torso) provide the greatest performance benefit for 'aerobic' performance with a moderate to large effect (0.46<SMD<1.24). For 'anaerobic' exercises, wearing a whole-body cooling garment is the best way to enhance exercise performance (SMD=0.39, P<.01). Per-cooling improves 'aerobic' and 'anaerobic' exercise performance with a greater benefit for 'aerobic' exercise. The magnitude of the effect depends on the type and site of the cooling application.

RETRACTED ARTICLE: Determining the Sites of Neural Adaptations to Resistance Training: A Systematic Review and Meta-Analysis.

The authors have retracted this article [1] because after publication it was brought to their attention that the statistical approach is not appropriate. The authors are re-analysing their data and intend to submit a new manuscript for peer review in due course. All authors agree to this retraction. [1] Siddique U, Rahman S, Frazer AK, Howatson G, Kidgell D. Sports Med (2019). https://doi.org/10.1007/s40279-019-01152-3.

Increased Female Athlete Triad Knowledge Following a Brief Video Educational Intervention

To assess female high school athletes’ changes in Female Athlete Triad (Triad) knowledge following a brief educational intervention.Triad knowledge questionnaires were completed by female high school athletes before and after either an educational video intervention or control group activities.Four high schools in the Pacific Northwest.Ninety-three female high school athletes (15.9±1.2 years) participating in basketball, cheerleading, track & field, softball, soccer, golf, tennis, and volleyball.The 10-minute Social Cognitive Theory-based educational video highlighted Triad etiology, progression, impact on sports performance, and fueling strategies to decrease Triad risk.Triad knowledge score out of 7; proportion of participants who correctly answered each question.Mann-Whitney U tests assessed differences in pre and post intervention Triad knowledge scores between the control and intervention group. The McNemar test compared the proportion of participants (intervention group) who correctly answered individual Triad knowledge questions pre vs. post-intervention.Participants in the intervention group achieved greater increases in Triad knowledge following the intervention, than did control participants (P<0.001). For each Triad question, improvements in the proportion of participants (intervention group) who answered correctly was observed (P<0.05).The Triad educational video was an effective and timeefficient method for increasing Triad knowledge among female high school athletes.

The new LassoLoop360° technique for biomechanically superior tissue grip.

Suprapectoral tenodesis is a frequently used technique for treating pathologies of the long head of the biceps brachii (LHBB) tendon. However, so far, no Gold Standard treatment exist. Hence, the arthroscopic LassoLoop360 (LL360) technique is introduced aiming to provide secure fixation and improved biomechanical properties. It was hypothesized, that the LL360 technique would show superior biomechanical response to cyclic loading and ultimate load-to-failure testing compared to the commonly used simple Lasso Loop (SLL). Twenty-two porcine superficial flexor digitorum tendons were prepared using a No. 2 suture according to either the SLL or the LL360 technique. Displacement after cyclic loading (1.000 cycles) between 5 and 30N, ultimate load-to-failure (ULTF), mode of failure as well as the construct stiffness were tested. Significantly less displacement was found in the LL360 group (SLL 2.25 ± 0.51mm; LL360 1.67 ± 0.37mm; p = 0.01). Ultimate Load to Failure was significantly higher in the LL360 (168.6 ± 29.6N) as compared to the SLL (124.1 ± 25.8N, p = 0.02). The LL360 also revealed a significant higher stiffness compared to the SLL (SLL 13.1 ± 0.9N/mm vs. LL360 19.1 ± 1.0N/mm, p < 0.001). The most common mode of failure was the suture cutting through the tendon, with a significantly less suture cutting through for the LL360 compared with the SLL (p < 0.05). The LassoLoop360-technique offers superior biomechanical characteristics regarding the tendon-suture-interface compared to the SLL. In the initial healing phase, the suture-tendon-interface is the most vulnerable part of the tendon-suture-anchor construct, the aim of this new technique is to reduce this weakest part of the chain (Ponce et al., Am J Sports Med 39:188-194, 2011). This technique may therefore be beneficial for arthroscopic suprapectoral biceps tenodesis at the entrance of the bicipital groove.

Insights from outside BJOG

Insights from outside BJOG

Retraction Notice to: &lt;I&gt;DRD2/ANKK1&lt;/I&gt; gene polymorphism rs1800497 is associated with exercise habit in the period from childhood to adolescence in Japanese [J Phys Fitness Sports Med, 6 (2): 95-102 (2017)

Retraction Notice to: &lt;I&gt;DRD2/ANKK1&lt;/I&gt; gene polymorphism rs1800497 is associated with exercise habit in the period from childhood to adolescence in Japanese [J Phys Fitness Sports Med, 6 (2): 95-102 (2017)

Impact of a regular exercise program on amount of exercise and QOL metrics in patients on immune therapy.

TPS11636 Background: Studies show physical activity has a positive impact on fatigue and quality of life both during cancer treatment with chemotherapy and radiation and post-treatment (1, 2). There may also be a survival benefit to increasing physical activity both during and after treatment (3). To date there is no published research on the role of exercise in ameliorating the fatigue patients can experience during treatment with immune therapy. Our study proposes to use the existing framework of the LIVESTRONG at the YMCA program to objectively measure improvement in activity level and objective quality of life measurements. Methods: Randomized controlled prospective study evaluating patient participation in LIVESTRONG at YMCA program during active cancer treatment to assess change in minutes per week of self-reported physical activity over 12 weeks. Assessments will be done based on attendance of 12 week program, activity log, functional assessments of physical activity pre- and post- program (6 min walk test, % change in weight, % change in max weight lifted and flexibility), and questionnaires evaluating fatigue (PROMIS 13a FACIT-F), pain (PROMIS pain intensity scale, ASCQ-Me short form), quality of life (FACT-G), Godin Leisure Time Activity Questionnaire, and inflammatory markers (ESR, CRP). Data will be analyzed on an intention-to-treat analysis. A sample size of 100 participants per group will achieve 80% power to detect a 60 minute difference with a standard deviation of 150 minutes 1 and with a significance level (alpha) of 0.050 using a two-sided two-sample t-test. Enrollment is targeted at 108 participants per arm to allow for 8% attrition, 216 total. Secondary endpoints will be assessed at a baseline functional assessment session for all participants and a follow up session after 12 weeks, including administration of questionnaires at both sessions. For physical activity measurements and survey completions, percent change in baseline and completion measurements will be calculated for each patient, then comparison using a chi-square test will be done to determine statistical significance.(Tomlinson et al. Effect of exercise on cancer-related fatigue: a meta-analysis. Am J Phys Med Rehabil. 2014;93:675-686; Irwin et al. Effect of the LIVESTRONG at the YMCA Exercise Program on Physical Activity, Fitness, Quality of Life, and Fatigue in Cancer Survivors. 2016 (published online October 28, 2016); Li T et al. The dose–response effect of physical activity on cancer mortality: findings from 71 prospective cohort studies . Br J Sports Med. 2016;50:339-345).

Author Correction: Effect of bright-light exposure before sleep on human urine metabolome [J Phys Fitness Sports Med, 8 (2): 89-96 (2019)

Author Correction: Effect of bright-light exposure before sleep on human urine metabolome [J Phys Fitness Sports Med, 8 (2): 89-96 (2019)

Insights from outside BJOG

Insights from outside BJOG

CHRONIC LACK OF SLEEP IS ASSOCIATED WITH INCREASED SPORTS INJURY IN ADOLESCENTS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background:Although sleep has been identified as an important modifiable risk factor for sports injury, the effect of decreased sleep on sports injuries in adolescents is poorly studied.Purpose:To ...

ACL GROWTH WITH AGE IN PEDIATRIC PATIENTS: AN MRI STUDY

BackgroundThe incidence of anterior cruciate ligament (ACL) injury is steadily increasing in skeletally immature patients [1-7]. As a result, surgical approaches to reconstruction of the ACL withou...

TUCK JUMP ASSESSMENT AS AN INDICATOR OF PREVIOUS UPPER EXTREMITY INJURY

Background: When using the tuck jump as a dynamic movement assessment, clinicians note movement flaws to determine injury potential and provide further training in attempt to improve movement technique deficits. The Tuck Jump Assessment has been identified as a dynamic assessment for lower extremity injury susceptibility.[3-6] The purpose of the Tuck Jump Assessment is to identify postural neuromuscular imbalances, throughout the dynamic movement, that could potentially result in greater injury susceptibility.[5] With the focus of neuromuscular imbalances on Tuck Jump Assessment performance, as well as the common notion of the body acting as a kinetic chain functions most efficient when there is proximal stability for distal mobility,[1] it was our purpose to determine if the Tuck Jump Assessment can be used as a dynamic movement assessment to ascertain a previous history of upper extremity injury in overhead throwing sports such as baseball and softball. We hypothesized that a more flexed trunk and less elevated upper leg in the peak of the tuck jump would correlate with previous history of upper extremity injury for the overhead athlete. Methods: Seventy-one youth baseball and softball athletes (28 baseball/43 softball; 12.41 ± 2.22 yrs.; 161.98 ± 13.65 cm; 59.17 ± 14.90 kg) were recruited to participate. All participants were in good physical condition and had no injuries within the last six months. A health history form was completed by the participants prior to participation. If a participant indicated that they have had an upper extremity injury in the past year that had kept them from competition, then they were placed in the previous injury group (N = 18). All other participants were placed into the no previous injury group (N = 53). Participants that indicated they had a previous lower extremity injury were excluded from of the study. The University’s Institutional Review Board approved all testing protocols. Informed written consent was obtained from each participant and participant’s parents before testing.[2] Kinematic data were collected at 100 Hz using an electromagnetic tracking system (trakSTARTM, Ascension Technologies, Inc., Burlington, VT, USA) synced with the MotionMonitor® (Innovative Sports Training, Chicago, IL. USA). Participants were instructed to start with their feet shoulder width apart and initiate the jump with a slight downward crouch while holding their arms in front of their chest. As they jumped, they were instructed to pull their knees as high as possible during the jump aiming to reach a position where their thighs were parallel to the ground and to immediately begin the next tuck jump once landing.[5] A trial of 10 tuck jumps was collected. Analysis included jumps 4 through 8 to mitigate the Hawthorne effect. Values for trunk flexion and upper leg elevation were taken from peak leg elevation and averaged and a priori was set at a level of p = 0.05 to determine significance. Results: A logistic regression showed no significance in trunk flexion or upper leg elevation being able to determine upper extremity injury (&amp;[Chi] &amp;[sup]2 (&amp;[sub]1, N = 71) = 3.55, p = .315). The model explained 7.2% of the variance in upper extremity injury and correctly classified 73.2% of all cases. Conclusion/Significance: While a direct link was not found between the Tuck Jump Assessment and upper extremity injury, further investigation into injury precursors should be performed. During our Tuck Jump Assessment, we only examined trunk flexion and upper leg elevation, which are two variables that make up the proximal control factor indicated by Lininger and colleagues. [3] In their exploratory factor analysis, it was concluded that three factors defined as fatigue, distal landing pattern, and proximal control should be examined to get the most benefit of the Tuck Jump Assessment in injury assessments.[3] Our results agree with their conclusion, that a simplified unidimensional construct of the Tuck Jump Assessment may not be the best way to use this dynamic movement assessment to identify previous upper extremity injury. In conclusion, examining only trunk flexion and upper leg elevation during the Tuck Jump Assessment is not enough for clinicians to recognize previous upper extremity injury. Even though the body behaves as a kinetic chain, simplifying the dynamic movement assessment while not specifying the type of upper extremity injury is not favorable for the clinician to identify previous injury. References Chu SK et al. PM R. 2016;8(3 Suppl): S69-77. Harris D et al. Int J Sports Med. 2017;38:1126-1131. Lininger MR et al. J Strength Cond Res. 2017;31(3):653-659. Myer GD et al. Strength and Conditioning Journal. 2011;33(3):21-35. Myer GD et al. Athl Ther Today. 2008;13(5):39-44. Myer GD et al. Am J Sports Med. 2010;38(19):2025-2033.

OUTCOMES OF DISCOID MENISCUS REPAIRS IN CHILDREN AND ADOLESCENTS

Background: Discoid meniscus tear patterns vary, but typically involve horizontal cleavage tears of the central discoid component with or without anterior or posterior meniscocapsular tears. Classically, the central discoid component is saucerized and meniscocapsular tears are repaired. Recent data suggests that meniscal preservation provides long-term benefits over resection1-2. However, many meniscal transplants are performed secondary to unsalvaged or unsalvageable discoid meniscus tears3. Reoperation rates after meniscus repairs vary greatly4-6, with some series reporting high rates of reinjury and reoperation, but there are no large series of pediatric discoid meniscus repairs in the literature. The purpose of this study is to describe the outcomes of meniscus repair and saucerization in pediatric patients with symptomatic discoid menisci. Methods: A single-institution retrospective review was performed of consecutive pediatric patients with surgical treatment of a discoid meniscus tear over a five-year period. Inclusion criteria were age less than 18 years, a symptomatic torn discoid meniscus treated with knee arthroscopy with meniscus repair, and minimum 4-month follow-up. A chart review was performed to describe tear location, tear pattern, and repair type (inside-out, outside-in, all-inside, and hybrid). Hybrid repair constructs were defined as those that used 2 or more repair types. The primary outcome was revision meniscus surgery. Results: Forty-four patients were identified to meet inclusion criteria. There were 23 males and 21 females with a mean age of 12.4 years (range 5 – 17 years). The right knee was affected in 61% of patients. The lateral meniscus was involved in all patients. Tear patterns included anterior meniscocapsular (19 patients, 43%), posterior meniscocapsular (14 patients, 30%), radial (7 patients, 16%), and bucket-handle (5 patients, 11%). Tears most commonly involved the posterior horn and body (21 patients, 48%) or posterior horn (16 patients, 36%) Arthroscopic meniscus repair was performed in all patients. Forty-three patients (98%) also underwent saucerization. Marrow stimulation, as a biological approach to improve repair healing, was performed in 14 patients (32%). The distribution of repair types and number of sutures for each type is listed in the table below. Mean follow-up was 19 months (range 4 – 70 months). Four patients (9%) underwent revision meniscus surgery following the primary repair, including 2 all-inside repairs and 2 partial meniscectomies. There were no statistically significant differences between patients who did or did not require a secondary surgery with respect to sex, age, tear location, tear pattern, repair type, or number of sutures. During follow-up, 9 patients (20%) had surgery for a symptomatic discoid meniscus in the contralateral knee. Conclusions: Saucerization and repair of discoid lateral meniscus tears in the pediatric population have good outcomes with low rates of reoperation. Appropriate saucerization, followed by an arthroscopic assessment of stability and tear patterns is critical to successful treatment of symptomatic discoid menisci. If tissue quality permits, meniscal preservation should be considered in all patients to avoid the consequences of subtotal meniscectomy. [Table: see text] Manzione M, Pizzutillo PD, Peoples AB, et al. Meniscectomy in children: a long-term follow-up study. Am J Sports Med 1983;11:111-115. Ahn JH, Kim KI, Wang JH, et al. Long-term results of arthroscopic reshaping for symptomatic discoid lateral meniscus in children. Arthroscopy 2015;31(5):867-873. Kocher MS, Tepolt FA, Vavken P. Meniscus transplantation in skeletally immature patients. J Pediatr Orthop B 2016;25(4)343-348. Steadman JR, Matheny LM, Singleton SB, et al. Meniscus suture repair: minimum 10-year outcomes in patients younger than 40 years compared with patients 40 and older. Am J Sports Med 2015;43(9):2222-2227. Paxton ES, Stock MV, Brophy RH. Meniscal repair versus partial meniscectomy: a systematic review comparing reoperation rates and clinical outcomes. Arthroscopy 2011;27(9):1275-1288. Shieh AK, Edmonds EW, Pennock AT. Revision meniscal surgery in children and adolescents: risk factors and mechanisms for failure and subsequent management. Am J Sports Med 2016;44(4):838-843.

FUNCTIONAL POPLITEAL ARTERY ENTRAPMENT SYNDROME: INVESTIGATION WITH DYNAMIC AND DOPPLER ULTRASOUND

A. Background Functional popliteal artery entrapment syndrome (fPAES), a cause of exertional leg pain, has a clinical presentation and clinical findings that are often indistinguishable from those of other leg pain causes (1). This condition may also coexist and overlap in symptomatology with other leg pain causes, further complicating the diagnosis (2). Although fPAES is usually considered a rare cause of leg pain (3), the true incidence of this condition is unknown, and fPAES is likely underdiagnosed and underreported (4). A missed diagnosis may result in disease progression and the use of unnecessary invasive procedures (3), and untreated fPAES may lead to popliteal artery damage, embolization, and limb ischemia (5). Although a diagnostic method using a combination of dynamic ultrasound and MR imaging/MR angiography has been described for fPAES (5), to our knowledge, no investigational studies have been performed to assess the dynamic ultrasound findings in this entity. This study sought to evaluate the usefulness of dynamic plantar flexion and dorsiflexion of the calf and the effect on the popliteal artery Doppler waveform in patients with clinically suspected fPAES and no structural abnormality. B. Methods We performed a retrospective review of ultrasound studies in patients who presented with clinically suspected PAES over a 3-year period. The ultrasound studies consisted of an anatomic survey of the popliteal. Dynamic nonresistant dorsiflexion and plantar flexion evaluations of the popliteal artery plus spectral Doppler evaluations of the popliteal artery obtained in neutral, plantar flexion, and dorsiflexion positions were performed before and after patients exercised. Patients with anatomic abnormalities were excluded. The following parameters were assessed: The proportion of symptomatic knees versus asymptomatic knees in which plantar flexion and/or dorsiflexion of the foot resulted in popliteal artery compression. The peak systolic velocity (PSV) of the popliteal artery in all positions for knees with and knees without dynamic popliteal artery compression. The absolute value change in PSV of the popliteal artery from neutral to plantar flexion and from neutral to dorsiflexion in the pre- and postexercise state for knees with and knees without dynamic popliteal artery compression. ROC analysis for clustered data was used to assess the ability of PSV to distinguish between knees with and knees without arterial compression. C. Results A total of 88 knees (77 symptomatic, 11 asymptomatic) in 45 patients were included in the study. Dynamic arterial compression was observed in 38% (29/77) of symptomatic knees. No compression seen in asymptomatic knees. Both pre-exercise and postexercise knees with arterial compression had significantly higher absolute changes in PSV from neutral to plantar flexion versus knees without arterial compression (Table). There was a smaller significant change in PSV from neutral to dorsiflexion in the pre-exercise state. There was no significant change in PSV in the postexercise state from neutral to dorsiflexion or with respect to PSV values at any position between knees with and knees without arterial compression. D. Conclusions/Significance In patients with clinically suspected PAES without anatomic abnormality, dynamic ultrasound demonstrated compression of the popliteal artery in 38% of knees. No dynamic arterial compression was seen in asymptomatic knees. There was a significant elevation in PSV from neutral to plantar flexion in pre- and postexercise states and from pre-exercise neutral to dorsiflexion positions in knees with arterial compression versus knees without arterial compression. Tables [Table: see text] References Joy SM, Raudales R. Popliteal artery entrapment syndrome. Curr Sports Med Rep. 2015;14(5):364-367. Hislop M, Kennedy D, Cramp B, Dhupelia S. Functional popliteal artery entrapment syndrome: poorly understood and frequently missed? A review of clinical features, appropriate investigations, and treatment options. J Sports Med (Hindawi Publ Corp). 2014;2014:105953. Gaunder C, McKinney B, Rivera J. Popliteal artery entrapment or chronic exertional compartment syndrome? Case Rep Med. 2017;2017:6981047 Hislop M, Brideaux A, Dhupelia S. Functional popliteal artery entrapment syndrome: use of ultrasound guided Botox injection as a non-surgical treatment option. Skeletal Radiol. 2017;46(9):1241-1248. Williams C, Kennedy D, Bastian-Jordan M, Hislop M, Cramp B, Dhupelia S. A new diagnostic approach to popliteal artery entrapment syndrome. J Med Radiat Sci. 2015;62(3):226-229.

THE RATE OF MENISCUS TEARS IN ASSOCIATION WITH ANTERIOR CRUCIATE LIGAMENT INJURIES INCREASES WITH AGE

Background: Anterior cruciate ligament (ACL) tears are frequently associated with meniscal injury. Numerous authors have described associations between the presence of a meniscal tear at the time of ACL reconstruction and time to surgery and number of instability episodes1-3. The purpose of this study was to evaluate the relationship between age and the presence of a meniscal tear at the time of ACL reconstruction in children and adolescents. Methods: A single-institution retrospective review was performed of consecutive pediatric and adolescent patients who underwent ACL reconstruction over a 3.5-year period at a single institution. Inclusion criteria were age less than 20 years and an ACL injury treated with knee arthroscopy and ACL reconstruction. Patients with multiligament knee injuries were excluded. A chart review was performed to obtain demographic information and intra-operative findings. Meniscus tears were defined as tears documented during diagnostic arthroscopy. Results: Four hundred sixty-one patients met inclusion criteria, including 226 males (49%) and 235 females (51%) with a mean age of 15 years (range 7 – 20 years). The right and left knees were affected equally. Two hundred seventy patients (80%) had intra-operative evidence of a meniscal tear, including 215 lateral meniscus tears (56%) and 119 medial meniscus tears (44%). Sixty-four patients (14%) had both medial and lateral meniscus tears. Age at surgery was found to be a statistically significant independent predictor of the presence of a meniscus tear, odds ratio=1.14, 95% CI (1.05 – 1.25), p=0.003. For every 1-year increase in age, there is a 14% increase in the odds of having a meniscus tear and this is depicted in the figure below. Among patients 13 years of age and younger (n = 89), 47% had a meniscus tear. In contrast, 62% of patients 14 – 19 years of age (n = 301) had a meniscus tear, which was significantly greater (p = 0.01). Age was also a statistically significant independent predictor following subgroup analysis of medial and lateral meniscus tears. For every one year increase in age at surgery, there was a 21% increase in the odds of having a medial meniscus tear (odds ratio = 1.21, 95% CI: (1.08 – 1.35), p&lt;0.001) and a 13% increase in the odds of having a lateral meniscus tear (odds ratio = 1.13, 95% CI: (1.04 – 1.24), p=0.01. Conclusions: Among children and adolescents with anterior cruciate ligament tears, for every 1-year increase in age, there is a 14% increase in the odds of having a meniscus tear. Adolescents over the age of 13 years had a significantly greater rate of meniscus tears than did those 13 years of age and younger. A complete arthroscopic examination with close attention to the menisci is required to diagnose and treat meniscal tears. Surgeons should be comfortable with all meniscus repair techniques, including inside-out, outside-in, all-inside, radial, and transosseous root repairs as the majority of children and adolescent patients with ACL tears also have an associated meniscus tear. Anderson AF, Anderson CN. Correlation of meniscal and articular cartilage injuries in children and adolescents with timing of anterior cruciate ligament reconstruction. Am J Sports Med 2015;43(2):275-281. Millett PJ, Willis AA, Warren RF. Associated injuries in pediatric and adolescent anterior cruciate ligament tears: does a delay in treatment increase the risk of meniscal tear? Arthroscopy 2002;18(9):955-959. Shieh A, Bastrom T, Roocroft J, et al. Meniscus tear patterns in relation to skeletal immaturity: children versus adolescents. Am J Sports Med 2013;41(12):2779-2783.

BIOMECHANICAL COMPARISON OF ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION TECHNIQUES USING A NOVEL ROBOTICALLY SIMULATED PIVOT SHIFT: A CADAVERIC STUDY

INTRODUCTION: The robotically simulated clinical pivot shift (PS), a dynamic loading profile based on measurement of loads applied by a surgeon, was developed as a more robust test for detecting kinematic changes for evaluating ACL reconstructions [2]. Two ACL reconstruction techniques were evaluated in this study: the all-epiphyseal (AE) and over-the-top (OTT). These techniques are used exclusively in the pediatric population in lieu of traditional techniques so as not to disrupt the epiphyseal in growing patients. Both techniques’ effectiveness in restoring intact knee kinematics has been examined previously in a cadaveric study, concluding that both techniques provide anterior and rotational stability, but no conclusions were made as to which technique provided more stability [1]. This study aimed to use the simulated clinical PS to assess anterior and rotational stability provided by the AE and OTT surgical techniques. METHODS: Six fresh-frozen, cadaveric legs were transected mid-femur and mid-tibia and mounted to the Universal Musculoskeletal Simulator capable of real-time force feedback using simVITROTM software. Four surgical conditions were tested: Intact knee, deficient ACL, AE reconstruction and OTT reconstruction. The AE and OTT reconstruction order was randomized. For each surgical condition, three tests were performed: Anterior drawer (134 N anterior, 20 N compression) at 0, 15, 30, 60, and 90° of flexion Rotary loads (5 Nm internal rotation torque, 10 Nm valgus torque, 20 N compression) at 5, 15, and 30° of flexion Simulated clinical PS test [2] For each specimen, the kinematics from the intact knee for each respective test was subtracted from the kinematics of the three remaining surgical conditions to acquire kinematic response relative to the intact knee. Relative anterior tibial translation (ATT) and internal tibial rotation (ITR) were reported at each tested flexion angle for the Anterior Drawer and Rotary Loads tests and for the flexion angle initiating the shift in the simulated clinical PS test. This angle was at the peak ATT and corresponded to the start of the shift. Paired t-tests were used to determine significance (p&lt;0.05). In one specimen the simulated clinical PS could not induce a shift, even in the deficient state, and thus was excluded from the analysis. RESULTS: Figure 1A displays the ATT and ITR for the simulated clinical PS at the flexion angle initiating the shift. Neither surgery restored intact knee kinematics. OTT exhibited 4.2 mm more ATT compared to AE (p=0.021) and 7.2° more ITR (p=0.015). OTT had no significant kinematic difference compared to the deficient ACL. Figure 1B displays the ATT for the Anterior Drawer test. The AE surgery significantly reduced ATT compared to deficient at flexion angles of 0, 15 and 30°. No significant difference between OTT and deficient was established. Figure 1C and 1D display the ATT and ITR (respectively) for the Rotary Loads test. Neither surgery restored intact knee kinematics nor significantly reduced ATT or ITR compared to the other surgery, agreeing with previous work with similar loading conditions[1]. DISCUSSION: The all-epiphyseal technique, though unable to restore native kinematics, showed significantly improved stability (4.2 mm ATT, 7.2° ITR) compared to the over-the-top technique when tested with a robotically simulated clinical pivot shift. Analysis of the Anterior Drawer and Rotary Loads tests did not detect significant differences in these surgical techniques, and are in agreement with a previous study which utilized similar loading conditions [1]. Limitations of our study include the small sample size, and the removal of one of the specimens. More work is needed on refining the loading profile to ensure it is able to induce a pivot shift in all specimens. While there is still room for improvement, it is currently still more effective than Rotary Loads, especially in its ability to detect rotational instabilities. The results from our study agree with previous studies [1, 2] in that the Rotary Loads test does not induce large rotational changes amongst ACL surgical states. It also does not provide additional information compared to the Anterior Drawer test for measuring anterior laxity. It is our recommendation that the Rotary Loads test be replaced by the simulated clinical PS when comparing biomechanical advantages of ACL reconstruction techniques in in vitro testing. SIGNIFICANCE: This study provides evidence that the novel robotically simulated clinical pivot shift is a more robust test for detecting kinematic changes when evaluating ACL reconstructions compared to the traditional Anterior Drawer and Rotary Loads tests. It also provides evidence that the All-Epiphyseal technique for reconstructing the ACL restores native kinematics better than the Over-the-Top technique. REFERENCES: [1] McCarthy et al., Am J Sports Med. 41,6: 1330-1339,2013 [2] Colbrunn et al., Pro ASME SBC, SCC2013-14288, 2013

Erratum

[This corrects the article DOI: 10.1177/2325967118786960.].

Static patellofemoral alignment in anterior cruciate ligament deficient knees; a retrospective analysis with magnetic resonance imaging

Static patellofemoral alignment in anterior cruciate ligament deficient knees; a retrospective analysis with magnetic resonance imaging

Return to sport after acute acromioclavicular stabilization: a randomized control of double-suture-button system versus clavicular hook plate compared to uninjured shoulder sport athletes.

Traumatic high-grade acromioclavicular joint (ACJ) separations can be surgically stabilized by numerous anatomic and non-anatomic procedures. The return to sport (Maffe et al. in Am J Sports Med 23:93-98, 1995] and remaining sport-associated impairments after acute ACJ stabilization has not yet been investigated. 73 consecutive athletes with acute high-grade ACJ separation were prospectively assigned into two groups (64.4% randomized, 35.6% intention-to-treat): open clavicular hook plate (cHP) implantation (GI) or arthroscopically assisted double double-suture-button (dDSB) implantation (GII). Patients were analyzed using shoulder sport-specific measurement tools for sport ability (ASOSS), sport activity (SSAS), and numerical analog scales: NASpain during sport, NASshoulder function in sport, and NASre-achievement of sport level. Four points of examination were established: preoperative evaluation (FU0) and first postoperative follow-up (FU1) at 6months; FU2 at 12months; and FU3 at 24months after surgery. The control group (GIII) consisted of 140 healthy athletes without anamnesis of prior macro-injury or surgery. After surgical stabilization, 29 of 35 athletes in GI (82.9%; 38.6 ± 9.9years) and 32 of 38 in GII (82.9%; 38.6 ± 9.9years) were followed up for 24 months (FU3) (loss 17.8%). All operated athletes showed significantly increased scores compared to FU0 (p < 0.05). Compared to GI, GII showed significantly superior outcome data for sporting ability as well as for NASre-achievement of sport level (p < 0.05). While GII re-achieved GIII-comparable SSAS and ASOSS levels, GI remained at a significantly inferior level. Athletes after ACJ injury of Rockwood grade IV/V and overhead athletes benefited significantly from the dDSB procedure. The dDSB procedure enabled significantly superior sport-specific outcomes compared to the cHP procedure. Athletes after dDSB surgeries re-achieved the sporting ability and the sport activity levels of healthy athletes, whereas athletes after cHP implantation remained at significantly inferior levels. The more extensive dDSB procedure and the more restrictive rehabilitation are recommended for treatment of acute high-grade ACJ separations of functionally high-demanding athletes. I.

PROPOSAL FOR “RETURN TO SPORT” TESTS AFTER INJURY, SPECIFIC TO FOOTBALL

The decision to return to sport (RTS) after an injury is one of the most complicated in sports medicine, due to the posibility of reinjury.1 The return to sport tests allow one to set goals to assess the condition of the patient and establish certain criteria before returning to competition.2 These tests include: strength tests, jumping tests and stability tests, and are based on the “Limb Symetry Indexes” (LSI).3 Nevertheless, there are studies which indicate that this method of evaluation could overestimate knee function values, 4 and the need to include specific sport movements in the tests.5 OBJECTIVES: To design a specific RTS protocol for football which is objetivable, adaptable and easily-reproduced. A survey was conducted among 22 professional players (6 defenders, 8 midfielders and 8 forwards) of a second-division Spanish team, which compiled 24 basic football movements based on technique (individual, collective and defensive) and their key actions, according to the Royal Spanish Football Association (RFEF: Real Federación Española de Fútbol) 6, and in which they were asked: - the frequency of executing the action. - the perception of risk associated with the action. - the injuries suffered that were associated with the action. - the conditioning of their mode of play due to the perception of risk of injury. Dependant on the frequency of the action and according to the player’s position, it has been established: 12 common plays, 3 specific plays for defenders, 2 for midfielders and 3 for forwards. A play was identified with a high index of risk perception by the players: jumping off-balance due to contact from a rival. The study outlined the actions suffered by players with a greater injury index, which were confirmed by experts in sports medicine, who completed the protocol The injuries suffered by players did not condicionate significantly their play. An RTS protocol was created, based on the general and specific actions determined in this study, which will be objetived through video analysis among others and through 2 measurements, previously taken during pre-season. Sanders TL, Maradit Kremers H, Bryan AJ, Larson DR, Dahm DL, Levy BA, Stuart MJ, Krych AJ. Incidence of Anterior Cruciate Ligament Tears and Reconstruction: A 21-Year Population-Based Study. Am J Sports Med. 2016 Jun; 44(6):1502-7. Ardern CL, Glasgow P, Schneiders A, Witvrouw E, Clarsen B, Cools A, Gojanovic B, Griffin S, Khan KM, Moksnes H, Mutch SA, Phillips N, Reurink G, Sadler R, Silbernagel KG, Thorborg K, Wangensteen A, Wilk KE, Bizzini M. 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. Br J Sports Med. 2016 Jul; 50(14):853-64. van Melick N, van Cingel RE, Brooijmans F, Neeter C, van Tienen T, Hullegie W, Nijhuis-van der Sanden MW. Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus. Br J Sports Med. 2016 Dec; 50(24):1506-1515. Wellsandt E, Failla MJ, Snyder-Mackler L. Limb Symmetry Indexes Can Overestimate Knee Function After Anterior Cruciate Ligament Injury. J Orthop Sports Phys Ther. 2017 Mar 29:1-18. Hoog P, Warren M, Smith CA, Chimera NJ. FUNCTIONAL HOP TESTS AND TUCK JUMP ASSESSMENT SCORES BETWEEN FEMALE DIVISION I COLLEGIATE ATHLETES PARTICIPATING IN HIGH VERSUS LOW ACL INJURY PRONE SPORTS: A CROSS SECTIONAL ANALYSIS. Int J Sports Phys Ther. 2016 Dec; 11(6):945-953. Moreno, M. La técnica aplicada al alto rendimiento. Curso nivel-3 entrenador nacional de fútbol, técnico deportivo superior. 3ª ed. España: Real Federación Española de Fútbol, Escuela Nacional; 2003.