Knee stability and movement coordination impairments: knee ligament sprain

Current concepts for injury prevention in athletes after anterior cruciate ligament reconstruction

Ligament reconstruction is the current standard of care for active patients with an anterior cruciate ligament (ACL) rupture. Although the majority of ACL reconstruction (ACLR) surgeries successfully restore the mechanical stability of the injured knee, postsurgical outcomes remain widely varied. Less than half of athletes who undergo ACLR return to sport within the first year after surgery, and it is estimated that approximately 1 in 4 to 1 in 5 young, active athletes who undergo ACLR will go on to a second knee injury. The outcomes after a second knee injury and surgery are significantly less favorable than outcomes after primary injuries. As advances in graft reconstruction and fixation techniques have improved to consistently restore passive joint stability to the preinjury level, successful return to sport after ACLR appears to be predicated on numerous postsurgical factors. Importantly, a secondary ACL injury is most strongly related to modifiable postsurgical risk factors. Biomechanical abnormalities and movement asymmetries, which are more prevalent in this cohort than previously hypothesized, can persist despite high levels of functional performance, and also represent biomechanical and neuromuscular control deficits and imbalances that are strongly associated with secondary injury incidence. Decreased neuromuscular control and high-risk movement biomechanics, which appear to be heavily influenced by abnormal trunk and lower extremity movement patterns, not only predict first knee injury risk but also reinjury risk. These seminal findings indicate that abnormal movement biomechanics and neuromuscular control profiles are likely both residual to, and exacerbated by, the initial injury. Evidence-based medicine (EBM) strategies should be used to develop effective, efficacious interventions targeted to these impairments to optimize the safe return to high-risk activity. In this Current Concepts article, the authors present the latest evidence related to risk factors associated with ligament failure or a secondary (contralateral) injury in athletes who return to sport after ACLR. From these data, they propose an EBM paradigm shift in postoperative rehabilitation and return-to-sport training after ACLR that is focused on the resolution of neuromuscular deficits that commonly persist after surgical reconstruction and standard rehabilitation of athletes.

The effects of neuromuscular training on the gait patterns of ACL-deficient men and women

BACKGROUND

Anterior cruciate ligament rupture is the most common knee ligament injury sustained by active individuals, and the relative injury risk is sex-specific. Women not only demonstrate an increased risk for injury, but also a poorer response following ligament rupture. Perturbation training has shown positive results in healthy females, but gender-specific responses to training after injury have not been evaluated. The purpose of this investigation was to describe the effects of perturbation training on the gait characteristics of male and female non-copers.

METHODS

Biomechanical data were collected before and after training on 12 male and nine female non-copers using standard motion analysis techniques. Subjects walked at a consistent, self-selected speed over an embedded force plate. Data from both limbs were post-processed and analyzed using a mixed model analysis of variance and minimal clinically important differences to compare the limb behaviors of men and women.

FINDINGS

Prior to training, only women demonstrated significant hip joint excursion asymmetry (ES=1.03; P=0.009). Minimal clinically important difference values showed that the involved limb of the women had reduced hip and knee flexion angles and moments, truncated knee excursions, and increased hip excursions when compared to their own uninvolved limb and the limbs of the male non-copers. Following training, only knee extensor moment values exceeded the minimal clinically important differences in women.

INTERPRETATION

Female non-copers demonstrated unique movement strategies following injury and perturbation training. Women may be a meaningful subgroup of non-copers, and future investigations should consider the effects of gender in the outcomes of non-copers.

Rehabilitation considerations for all epiphyseal acl reconstruction

BACKGROUND

The management of the pediatric patient with an Anterior Cruciate Ligament (ACL) rupture is evolving towards earlier reconstruction. The rehabilitation progression and outcomes for skeletally immature individuals undergoing ACL reconstruction (ACL-R) are not well described in the literature. Differences in surgical procedure, age related physiology, and emotional maturity may have a significant impact on recovery and return to sports. The purpose of this case report is to present the rehabilitation and outcome of a skeletally immature patient that underwent an all-epiphyseal ACL-R, highlight important considerations in the rehabilitation process and present topics for future research.

CASE DESCRIPTION

Single subject case report of an 8 year-old boy who underwent all epiphyseal ACL-R after complete ACL rupture.

OUTCOMES

The patient was able to achieve at least 90% strength symmetry and pass all necessary functional criteria to return to sports by 9 months post surgery. Two year follow up data indicated that the patient was able to make a full return to previous level of athletic activity, as well as maintain lower extremity strength and power over time.

DISCUSSION

Objective outcome measures, rehabilitation protocols and time frame for return to sports for skeletally immature patients following physeal sparing or all epiphyseal ACL-R are not well described in the literature. This case report outlines objective measures of strength and functional recovery in a patient from this unique population. As ACL-R in the skeletally immature patient is studied more, new information on rehabilitation progression and outcomes may alter the rehabilitation program and timeline for return to unrestricted activity.

LEVEL OF EVIDENCE

4, Case Report.

Utilization of Vascular Restriction Training in post-surgical knee rehabilitation: a case report and introduction to an under-reported training technique

INTRODUCTION

The objective of this paper is to introduce a new and reportedly safe training technique, utilizing a vascular restriction stimulus during low intensity rehabilitative exercise and provide a case example within a post-surgical rehabilitation scenario. A brief review of the most commonly reported mechanisms of action behind the purported success of the training stimulus is included.

METHODS

19-year-old athlete presented for an accelerated post-operative knee rehabilitation program. She received a commonly utilized rehabilitation program that was supplemented with vascular restriction stimulus.

RESULTS

The patient maintained muscle cross-sectional area and had improved function at a 12-week follow-up.

CONCLUSION

Low intensity exercise supplemented with vascular restriction may prove to be an efficient and effective means of maintaining post-surgical muscle size and subjective knee function.

Depressive symptoms, anatomical region, and clinical outcomes for patients seeking outpatient physical therapy for musculoskeletal pain

BACKGROUND

Clinical guidelines advocate the routine identification of depressive symptoms for patients with pain in the lumbar or cervical spine, but not for other anatomical regions.

OBJECTIVE

The purpose of this study was to investigate the prevalence and impact of depressive symptoms for patients with musculoskeletal pain across different anatomical regions. Design This was a prospective, associational study.

METHODS

Demographic, clinical, depressive symptom (Symptom Checklist 90-Revised), and outcome data were collected by self-report from a convenience sample of 8,304 patients. Frequency of severe depressive symptoms was assessed by chi-square analysis for demographic and clinical variables. An analysis of variance examined the influence of depressive symptoms and anatomical region on intake pain intensity and functional status. Separate hierarchical multiple regression models by anatomical region examined the influence of depressive symptoms on clinical outcomes.

RESULTS

Prevalence of severe depression was higher in women, in industrial and pain clinics, and in patients who reported chronic pain or prior surgery. Lower prevalence rates were found in patients older than 65 years and those who had upper- or lower-extremity pain. Depressive symptoms had a moderate to large effect on pain ratings (Cohen d=0.55-0.87) and a small to large effect on functional status (Cohen d=0.28-0.95). In multivariate analysis, depressive symptoms contributed additional variance to pain intensity and functional status for all anatomical locations, except for discharge values for the cervical region.

CONCLUSIONS

Rates of depressive symptoms varied slightly based on anatomical region of musculoskeletal pain. Depressive symptoms had a consistent detrimental influence on outcomes, except on discharge scores for the cervical anatomical region. Expanding screening recommendations for depressive symptoms to include more anatomical regions may be indicated in physical therapy settings.