Context:

Prolonged symptoms after concussion are called post-concussion syndrome (PCS), which is a controversial disorder with a wide differential diagnosis.

Evidence Acquisition:

MEDLINE and PubMed searches were conducted for the years 1966 to 2011 using the search terms brain concussion/complications OR brain concussion/diagnosis OR brain concussion/therapy AND sports OR athletic injuries. Secondary search terms included post-concussion syndrome, trauma, symptoms, metabolic, sports medicine, cognitive behavioral therapy, treatment and rehabilitation. Additional articles were identified from the bibliographies of recent reviews.

Results:

Of 564 studies that fulfilled preliminary search criteria, 119 focused on the diagnosis, pathophysiology, and treatment/rehabilitation of concussion and PCS and formed the basis of this review. Rest is the primary treatment for the acute symptoms of concussion. Ongoing symptoms are either a prolonged version of the concussion pathophysiology or a manifestation of other processes, such as cervical injury, migraine headaches, depression, chronic pain, vestibular dysfunction, visual dysfunction, or some combination of conditions. The pathophysiology of ongoing symptoms from the original concussion injury may reflect multiple causes: anatomic, neurometabolic, and physiologic.

Conclusions:

Treatment approaches depend on the clinician’s ability to differentiate among the various conditions associated with PCS. Early education, cognitive behavioral therapy, and aerobic exercise therapy have shown efficacy in certain patients but have limitations of study design. An algorithm is presented to aid clinicians in the evaluation and treatment of concussion and PCS and in the return-to-activity decision.

Background:

With increasing frequency, platelet-rich plasma (PRP) preparations have been used to treat cartilage lesions to regenerate tissue homeostasis and retard the progression of knee osteoarthritis (OA).

Purpose:

To determine the effectiveness of intra-articular PRP injections in active patients with knee OA and to evaluate clinical outcomes in patients with and without previous surgical treatment for cartilage lesions.

Study Design:

Case series.

Materials and Methods:

Fifty patients with knee OA were followed for a minimum of 12 months. All were treated with 2 intra-articular injections of autologous PRP. Twenty-five patients had undergone a previous operative intervention for cartilage lesions, whereas 25 had not. Operated patients had undergone either cartilage shaving or microfracture. Multiple evaluative scores were collected at pretreatment and at 6 and 12 months posttreatment. The required sample of patients was determined beforehand by using statistical power analysis; International Knee Documentation Committee (subjective) score was defined as the primary parameter. A P value of less than 0.05 was considered statistically significant. General linear model–repeated measure test evaluated within-time improvement for each variable for all patients. Post hoc test with Bonferroni adjustment for multiple comparisons was performed to investigate the significance in improvement within time evaluations for each variable for the total sample. The differences in improvement between operated and nonoperated patients were also investigated, as were those between sexes.

Results:

All patients showed significant improvement in all scores at 6 and 12 months (P < 0.01) and returned to previous activities. No significant difference in improvement was found between the evaluated subgroups (P < 0.01).

Conclusions:

The PRP treatment showed positive effects in patients with knee OA. Operated and nonoperated patients showed significant improvement by means of diminishing pain and improved symptoms and quality of life.

Clinical Relevance:

There are only a few studies of PRP treatment for cartilage on osteoarthritic knees. Different PRP products might be more or less appropriate to treat different types of tissues and pathologies. The clinical efficacy of PRP remains under debate, and a standardized protocol has not yet been established.

Context:

Nutritional supplements advertised as ergogenic are commonly used by athletes at all levels. Health care professionals have an opportunity and responsibility to counsel athletes concerning the safety and efficacy of supplements on the market.

Evidence Acquisition:

An Internet search of common fitness and bodybuilding sites was performed to identify supplement promotions. A search of MEDLINE (2000–August, 2011) was performed using the most commonly identified supplements, including glutamine, choline, methoxyisoflavone, quercetin, zinc/magnesium aspartate, and nitric oxide. The search terms supplement, ergogenic aid, and performance were also used.

Results:

Six common and newer supplements were identified, including glutamine, choline, methoxyisoflavone, quercetin, zinc/magnesium aspartate, and nitric oxide.

Conclusions:

Controlled studies have not determined the effects of these supplements on performance in athletes. Scientific evidence is not available to support the use of these supplements for performance enhancement.

Background:

Conservative treatment protocols to effectively treat knee flexion motion restrictions are dependent in part on the torque applied to the joint.

Hypotheses:

Clinicians apply greater torque with the test leg in a simulated prone position than in a seated position. Clinicians also apply greater torque than a dynamic splint or a static progressive stretch brace. Finally, clinicians apply a torque equal to the high-intensity stretch device.

Study Design:

bservational study.

Methods:

An instrumented test leg was used to record peak torque applied by 14 licensed clinicians (7 women, 7 men; age, 44.3 ± 10.2 years; height, 172.9 ± 13.2 cm; weight, 72.6 ± 13.0 kg) during knee flexion mobilizations and 3 types of mechanical therapy (dynamic splint, static progressive stretch, and high-intensity stretch).

Results:

The dynamic splint applied 5.1 ± 0.1 N·m, while the static progressive stretch brace applied 20.8 ± 2.2 N·m. Clinicians applied 49.5 ± 22.4 N·m with the test leg in a seated position and 55.8 ± 22.0 N·m with the leg in a prone position. The high-intensity stretch device applied up to 214.7 ± 29.2 N·m. All comparisons were statistically significant (P ≤ 0.02) with the exception of the 2 testing positions (P = 0.94).

Conclusions:

The results demonstrate that the torques applied to the knee differ between passive stretching therapies. Clinicians should be cognizant of these torque differences when constructing treatment protocols for patients with limited knee flexion range of motion.

A 24-year-old female swimmer presented to a sports medicine clinic with complaints of frequent urination and increased thirst. The patient admitted to progressive worsening of her symptoms over a 4-year period since suffering a concussion. A water deprivation test, antidiuretic hormone level, and diamino-8-D-arginine vasopressin challenge were completed, and the patient was diagnosed with persistent central diabetes insipidus. As concussion awareness increases, health care professionals will be faced with treatment of post-concussive patients more often. The aim of this case report is to increase awareness of possible pituitary dysfunction—specifically, central diabetes insipidus—following a concussion.

Context:

There is a wide spectrum of hamstring-related injuries that can occur in the athlete. Accurate diagnosis is imperative to prevent delayed return to sport, injury recurrence, and accurate clinical decision making regarding the most efficacious treatment.

Evidence Acquisition:

This review highlights current evidence related to the diagnosis and treatment of hamstring-related injuries in athletes. Data sources were limited to peer-reviewed publications indexed in MEDLINE from 1988 through May 2011.

Results:

An accurate diagnostic process for athletes with posterior thigh–related complaints should include a detailed and discriminative history, followed by a thorough clinical examination. Diagnostic imaging should be utilized when considering hamstring avulsion or ischial apophyseal avulsion. Diagnostic imaging may also be needed to further define the cause of referred posterior thigh pain.

Conclusions:

Differentiating acute hamstring strains, hamstring tendon avulsions, ischial apophyseal avulsions, proximal hamstring tendinopathies, and referred posterior thigh pain is critical in determining the most appropriate treatment and expediting safe return to play.

Context:

Injuries to the anterior cruciate ligament (ACL) are immediately disabling and are associated with long-term consequences, such as posttraumatic osteoarthritis. It is important to have a comprehensive understanding of all possible risk factors for ACL injury to identify individuals who are at risk for future injuries and to provide an appropriate level of counseling and programs for prevention.

Objective:

This review, part 2 of a 2-part series, highlights what is known and still unknown regarding hormonal, genetic, cognitive function, previous injury, and extrinsic risk factors for ACL injury.

Data Sources:

Studies were identified from MEDLINE (1951–March 2011) using the MeSH terms anterior cruciate ligament, knee injury, and risk factors. The bibliographies of relevant articles and reviews were cross-referenced to complete the search.

Study Selection:

Prognostic case-control and prospective cohort study designs to evaluate risk factors for ACL injury were included in this review.

Results:

A total of 50 case-control and prospective cohort articles were included in parts 1 and 2. Twenty-one focused on hormonal, genetic, cognitive function, previous injury, and extrinsic risk factors.

Conclusions:

Several risk factors are associated with increased risk of suffering ACL injury—such as female sex, prior reconstruction of the ACL, and familial predisposition. These risk factors most likely act in combination with the anatomic factors reviewed in part 1 of this series to influence the risk of suffering ACL injury.

Context:

Fatigue and underperformance are common in athletes. Understanding overtraining syndrome (OTS) is helpful in the evaluation, management, and education of athletes.

Evidence Acquisition:

Relevant articles in English were searched with OVID (1948-2011) and PubMed using the following keywords: overtraining syndrome, overtraining, overreaching, unexplained underperformance, staleness, pathophysiology, management, treatment, evaluation. Bibliographies were reviewed for additional resources.

Results:

OTS appears to be a maladapted response to excessive exercise without adequate rest, resulting in perturbations of multiple body systems (neurologic, endocrinologic, immunologic) coupled with mood changes. Many hypotheses of OTS pathogenesis are reviewed, and a clinical approach to athletes with possible OTS (including history, testing, and prevention) is presented.

Conclusions:

OTS remains a clinical diagnosis with arbitrary definitions per the European College of Sports Science’s position statement. History and, in most situations, limited serologies are helpful. However, much remains to be learned given that most past research has been on athletes with overreaching rather than OTS.

Context:

Patellofemoral pain syndrome (PFPS) is one of the most common overuse injuries.

Objective:

To assess the collective evidence of predisposing factors to PFPS.

Data Sources:

MEDLINE (1960–June 2010), EMBASE (1980–June 2010), and CINAHL (1982–June 2010).

Study Selection:

Studies were included if patients were asymptomatic at baseline testing (free of PFPS) and were prospectively followed for the development of the disorder. Only studies that assessed at least 1 variable that can be measured at a typical clinic were included. After duplicates were removed, 973 studies were assessed from their titles or abstracts, 20 from the full text, and from these, 7 met the inclusion criteria.

Data Extraction:

Data were extracted for age, weight, height, sample size, patient type (military vs civilian), follow-up periods, diagnostic methods, and diagnostic criteria. Means and standard deviations were extracted for all outcome variables.

Results:

Meta-analyses were performed for height, weight, leanness, Q angle, number of sit-ups, knee extension strength, and peak knee valgus angle during landing. Lower knee extension strength was the only variable that was predictive of PFPS (P < 0.01). Other variables that were identified as predictive of PFPS by single studies were vertical jump, push-ups, knee flexion and hip abduction strength, thumb-to-forearm flexibility, quadriceps and gastrocnemius flexibility, genu varum, navicular drop, knee valgus moment at initial contact during landing, social support, and palliative reaction.

Conclusions:

It appears that anthropometric variables are not associated with PFPS, while knee extension strength deficits appear to be predictors of PFPS.

Context:

Chronic lower leg pain in athletes can be a frustrating problem for patients and a difficult diagnosis for clinicians. Myriad approaches have been suggested to evaluate these conditions. With the continued evolution of diagnostic studies, evidence-based guidance for a standard approach is unfortunately sparse.

Evidence Acquisition:

PubMed was searched from January 1980 to May 2011 to identify publications regarding chronic lower leg pain in athletes (excluding conditions related to the foot), including differential diagnosis, clinical presentation, physical examination, history, diagnostic workup, and treatment.

Results:

Leg pain in athletes can be caused by many conditions, with the most frequent being medial tibial stress syndrome; chronic exertional compartment syndrome, stress fracture, nerve entrapment, and popliteal artery entrapment syndrome are also considerations. Conservative management is the mainstay of care for the majority of causes of chronic lower leg pain; however, surgical intervention may be necessary.

Conclusion:

Chronic lower extremity pain in athletes includes a wide differential and can pose diagnostic dilemmas for clinicians.

Background:

The throwing motion results in unilateral increases in dominant arm external rotation (ER) range of motion (ROM). Trunk forward tilt at ball release is related to ball velocity. The relationship between lower quarter flexibility and dominant arm ROM is not known.

Hypothesis:

There is a relationship between lower extremity flexibility and dominant arm ER ROM and total rotation ROM.

Study Design:

Prospective cohort study.

Methods:

Forty-two collegiate baseball pitchers were studied. Demographics, dominant arm, and bilateral glenohumeral ER and internal rotation (IR) ROM were measured. Lower quarter flexibility was assessed via sit-and-reach test. Total rotation motion (TRM) was calculated as ER + IR = TRM. Paired t tests examined differences between the dominant and nondominant arms for ER, IR, and TRM; Pearson product-moment correlation coefficients, shoulder ROM and lower extremity flexibility variables (α = 0.05).

Results:

ER mean value was significantly greater, and IR mean value significantly less, in the dominant arm. TRM mean values were not significantly different bilaterally. Sit-and-reach results were strongly correlated with TRM and ER of the dominant arm.

Conclusions:

There was a significant shift in TRM toward ER in collegiate baseball players. Lower quarter flexibility was strongly correlated with dominant arm ER and total rotation ROM but not in the nondominant arm.

Clinical Relevance:

The sit-and-reach test may be useful to identify a pitcher’s potential to achieve an appropriate amount of trunk forward tilt. This may maximize the lag effect necessary to achieve maximum ER of the dominant arm and increased ball velocity.

Background:

Rehabilitation of soccer players after anterior cruciate ligament reconstruction is usually performed without sport-specific guidelines, and the final phases are often left to the team coaches. The possibility of changing this approach has not yet been investigated.

Study Design:

Case series.

Hypothesis:

A specific rehabilitation protocol for soccer players, with direct control of the last on-field rehabilitation phases, may lead to complete functional recovery.

Methods:

Fifty competitive soccer players who followed a sport-specific rehabilitation protocol for soccer were evaluated during the recovery period until their return to competition. The assessment of the functional outcomes was performed using the Knee Outcome Survey–Sports Activity Scale and isokinetic and aerobic fitness tests.

Results:

The average start of on-field rehabilitation was 90 ± 26 days after surgery; the average time to return to the competitions was 185 ± 52 days. The improvement in the Knee Outcome Survey–Sports Activity Scale during on-field rehabilitation was significant (P < 0.01; from 79 ± 15% to 96 ± 7%). The isokinetic and aerobic fitness tests showed a significant improvement of muscle strength (knee extensors, +55%, P < 0.01; knee flexors, +86%, P < 0.01) and aerobic threshold (+23%, P < 0.01) from the beginning to the end of on-field rehabilitation.

Conclusions:

Adding on-field rehabilitation to the traditional protocols after anterior cruciate ligament reconstruction may safely lead to complete functional recovery in soccer players.

Context:

Several factors have been associated with the development of osteoarthritis after anterior cruciate ligament (ACL) reconstruction, yet little attention has been given to the association between range of motion (ROM) and osteoarthritis after ACL reconstruction. Several studies have shown a link between ROM loss and a higher incidence of osteoarthritis.

Evidence Acquisition:

A search was performed with PubMed (MEDLINE) for English-language level I-IV studies involving the long-term evaluation of ROM and osteoarthritis after ACL reconstruction. Keywords were osteoarthritis, anterior cruciate ligament, and range of motion.

Results:

Six studies considered whether ROM was a factor in association with osteoarthritis after ACL reconstruction: In 3 of these studies, an association was found between loss of knee motion and the development of osteoarthritis, while the other 3 studies failed to identify a significant association. Two studies identified an association between ROM loss and decreased subjective outcomes after ACL reconstruction.

Conclusions:

Previous studies have shown an association between loss of knee ROM and osteoarthritic changes on radiographs in the long term after ACL reconstruction. Loss of ROM and osteoarthritis are also associated with lower subjective scores. Other factors related to osteoarthritis, such as meniscal and articular cartilage status, cannot be modified, but through implementation of a directed rehabilitation program before and after ACL surgery, the achievement of full symmetric ROM can be promoted. More emphasis needs to be placed on careful and precise examination of knee ROM, as well as rehabilitation to achieve and maintain full symmetric ROM in the long term after ACL reconstruction.

Background:

Neuromuscular alterations are common following lower extremity joint injury and often lead to decreased function and disability. These neuromuscular alterations manifest in inhibition or abnormal facilitation of the uninjured musculature surrounding an injured joint. Unfortunately, these neural alterations are poorly understood, which may affect clinical recognition and treatment of these injuries. Understanding how these neural alterations affect physical function may be important for proper clinical management of lower extremity joint injuries.

Methods:

Pertinent articles focusing on neuromuscular consequences and treatment of knee and ankle injuries were collected from peer-reviewed sources available on the Web of Science and Medline databases from 1975 through 2010. A theoretical model to illustrate potential relationships between neural alterations and clinical impairments was constructed from the current literature.

Results:

Lower extremity joint injury affects upstream cortical and spinal reflexive excitability pathways as well as downstream muscle function and overall physical performance. Treatment targeting the central nervous system provides an alternate means of treating joint injury that may be effective for patients with neuromuscular alterations.

Conclusions:

Disability is common following joint injury. There is mounting evidence that alterations in the central nervous system may relate to clinical changes in biomechanics that may predispose patients to further injury, and novel clinical interventions that target neural alterations may improve therapeutic outcomes.

Context:

Injuries to the anterior cruciate ligament (ACL) of the knee are immediately debilitating and can cause long-term consequences, including the early onset of osteoarthritis. It is important to have a comprehensive understanding of all possible risk factors for ACL injury to identify individuals who are at risk for future injuries and to provide an appropriate level of counseling and programs for prevention.

Objective:

This review, part 1 of a 2-part series, highlights what is known and still unknown regarding anatomic and neuromuscular risk factors for injury to the ACL from the current peer-reviewed literature.

Data Sources:

Studies were identified from MEDLINE (1951–March 2011) using the MeSH terms anterior cruciate ligament, knee injury, and risk factors. The bibliographies of relevant articles and reviews were cross-referenced to complete the search.

Study Selection:

Prognostic studies that utilized the case-control and prospective cohort study designs to evaluate risk factors for ACL injury were included in this review.

Results:

A total of 50 case-control and prospective cohort articles were included in the review, and 30 of these studies focused on neuromuscular and anatomic risk factors.

Conclusions:

Several anatomic and neuromuscular risk factors are associated with increased risk of suffering ACL injury—such as female sex and specific measures of bony geometry of the knee joint, including decreased intercondylar femoral notch size, decreased depth of concavity of the medial tibial plateau, increased slope of the tibial plateaus, and increased anterior-posterior knee laxity. These risk factors most likely act in combination to influence the risk of ACL injury; however, multivariate risk models that consider all the aforementioned risk factors in combination have not been established to explore this interaction.

Background:

Acute exertional rhabdomyolysis has been infrequently reported among adolescents. In August 2010, several high school football players from one team developed rhabdomyolysis and triceps compartment syndrome following an upper arm exercise held in a non-air-conditioned wrestling room.

Purpose:

To confirm the diagnoses, characterize the spectrum of illnesses, and determine the factors contributing to rhabdomyolysis and triceps compartment syndromes.

Study Design:

Descriptive epidemiology study.

Methods:

The authors reviewed hospital medical records and interviewed players, coaches, school administrators, and hospital staff, using a standardized questionnaire that assessed symptoms, exposures, and activities.

Results:

Among 43 players, 22 (51%) experienced rhabdomyolysis (peak creatine kinase range, 2434-42 000 U/L): 22 patients had upper arm myalgia; 12 were hospitalized; 3 experienced triceps compartment syndrome; none experienced renal failure. Illnesses started 1 to 3 days after the triceps exercise. Forty players (93%) completed questionnaires. Among 19 players receiving at least 1 vote from a teammate as 1 of the 3 hardest working players, 13 (68%) experienced rhabdomyolysis versus 7 (33%) of 21 not considered hardest working (relative risk, 2.1; 95% confidence interval, 1.04-4.0). Of 40 players, 10 (25%) reported creatine supplement use, which was not associated with rhabdomyolysis. No player acknowledged use of alcohol, illicit drugs, or performance-enhancing drugs; results of performance-enhancing drug tests on the 4 players tested were negative. Environmental investigation did not identify additional factors contributing to illness.

Conclusions:

The upper arm exercise, possibly exacerbated by heat, led to rhabdomyolysis and compartment syndrome. Greater awareness of specific exercise hazards and prevention strategies can minimize risk for clinically significant muscle injury.

Context:

Reconstruction of the anterior cruciate ligament (ACL) is a common surgical procedure; however, there is no consensus to what the best graft option is to replace the injured ACL. The main options available consist of allografts and autografts, which include patellar tendon, hamstring tendon, and quadriceps tendon autografts.

Evidence Acquisition:

The PubMed database was searched in August 2010 for English-language articles pertaining to ACL grafts.

Results:

Postoperative outcome variables were analyzed to determine similarities and differences among the different graft options. These variables include stability, strength, function, return to sports, patient satisfaction, complications, and cost.

Conclusions:

Both allografts and the 3 main options for autografts can provide excellent results in ACL reconstruction and lead to a high percentage of satisfied patients. However, differences exist among the graft choices. Both the similarities and the differences are important to discuss with a patient who will be undergoing ACL reconstruction so that he or she has the best information available when making a choice of graft.

Hyoid fractures in athletes are rare injuries that can be difficult to diagnose. Typically resulting from a direct blow to the anterior neck, hyoid fractures can lead to subcutaneous edema and subsequent airway compromise. The treatment of this fracture depends largely on the severity of the presenting symptoms. Generally, these fractures do not require surgical intervention but warrant close observation for delayed onset of airway obstruction. To raise awareness of this potentially dangerous fracture, the authors present 2 cases of isolated hyoid fractures in collegiate football players at our institution.

Context:

Many anterior cruciate ligament (ACL) injury prevention training programs have been published, but few have assessed the effects of training on both ACL injury rates and athletic performance tests.

Objective:

To determine if ACL injury prevention programs have a positive influence on both injury rates and athletic performance tests in female athletes.

Data sources:

In August 2011, a search was conducted (1995–August 2011) of the PubMed, Science Direct, and CINAHL databases.

Study selection:

Selected studies determined the effect of ACL intervention training programs on ACL incidence rates (determined by athlete-exposures) and athletic performance tests, such as isokinetic strength, vertical jump height, speed, agility, and dynamic balance. Because no single article contained both criteria, investigations were cross-referenced to obtain data on both factors from the same training programs.

Data extraction:

The authors reviewed the selected studies for cohort population numbers, age, sports, duration of study, program components, duration of training, number of athlete-exposures, ACL injury incidence rates, and results of athletic performance tests.

Results:

Initially, 57 studies were identified that described 42 ACL injury prevention training programs. Of these, 17 studies that investigated 5 programs met the inclusion criteria. Two programs significantly reduced ACL injury rates and improved athletic performance tests: Sportsmetrics and the Prevent Injury and Enhance Performance program (PEP). Sportsmetrics produced significant increases in lower extremity and abdominal strength, vertical jump height, estimated maximal aerobic power, speed, and agility. Prevent Injury and Enhance Performance significantly improved isokinetic knee flexion strength but did not improve vertical jump height, speed, or agility. The other 3 programs (Myklebust, the “11,” and Knee Ligament Injury Prevention) did not improve both ACL injury rates and athletic performance tests.

Conclusions:

Only the Sportsmetrics and PEP ACL intervention training programs had a positive influence on injury reduction and athletic performance tests.

Background:

Meniscal tears have been associated with meniscal cysts and fullness of the knee joint line on physical examination.

Hypothesis:

Joint line fullness is an accurate, sensitive, and specific test to detect meniscal tears.

Study Design:

Prospective cohort study.

Methods:

One hundred consecutive patients undergoing knee arthroscopy were included. All had physical examinations documenting the presence of joint line fullness, joint line tenderness, and the McMurray sign. Arthroscopy was the gold standard for tears. Accuracy, sensitivity, and specificity were calculated and correlated with type of tear. Sixty-one patients had a magnetic resonance imaging preoperatively (the gold standard for determining the presence of a cyst).

Results:

Meniscal tears were found in 67 patients at arthroscopy. The accuracy, sensitivity, and specificity of joint line fullness were, respectively, 73%, 70%, and 82% in detecting meniscal tears; 68%, 87%, and 30% for joint line tenderness; and 47%, 32%, and 78% for the McMurray sign. The highest positive predictive value for detecting a tear was 88% for joint line fullness, compared with 77% for joint line tenderness and 76% for the McMurray sign. However, joint line fullness did not correlate well with the presence of a cyst, with a low positive predictive value (29%). Of those patients with joint line fullness on physical examination, 89% had a horizontal cleavage component of their tear at arthroscopy.

Conclusion:

Joint line fullness is an accurate, sensitive, and specific test to detect meniscal tears.

Clinical Relevance:

The findings support the routine use of joint line fullness during physical examination along with other common tests to improve the accuracy of clinically diagnosing meniscal tears.

Background:

Effective treatments for chronic lateral epicondylosis have not been studied adequately. Eccentric overload exercises have been used with success for other chronic tendinopathy, mainly Achilles and patellar.

Hypothesis/Purpose:

To compare a wrist extensor eccentric strengthening exercise program with a wrist extensor stretching/modality program for the treatment of chronic lateral epicondylosis. The authors hypothesized that the eccentric strengthening program would produce more favorable results than a stretching/modality program.

Study Design:

Prospective randomized controlled trial.

Methods:

Twenty-eight adults with lateral epicondylosis of greater than 4 weeks’ duration were randomized to an eccentric strengthening group or a stretching group. Exercises were taught by a physical therapist, and participants performed most of the exercises on their own at home. Pain scores with visual analog scale from 0 to 100 were obtained at baseline and then at 4, 8, 12, 16, and 20 weeks after the start of the exercise program.

Results:

Both groups improved their pain scores from baseline to the 4-week time point, followed by nonsignificant further decreases in pain scores thereafter. No statistically significant differences were found between the eccentric strengthening group and stretching groups at any follow-up time point.

Conclusions:

Despite previous reports documenting favorable results with eccentric exercises for other tendinopathy, the authors were unable to show any statistical advantage to eccentric exercises for lateral epicondylosis during these periods compared with local modalities and stretching exercises.

Background:

Specific guidelines for therapeutic exercises following an Achilles tendon repair are lacking.

Hypothesis:

A hierarchical progression of triceps surae exercises can be determined on the basis of electromyographic (EMG) activity.

Study Design:

Randomized laboratory trial.

Methods:

Bipolar surface electrodes were applied over the medial and lateral heads of the gastrocnemius as well as the soleus on 20 healthy lower extremities (10 participants, 27 ± 5 years old). Muscle activity was recorded during 8 therapeutic exercises commonly used following an Achilles repair. Maximal voluntary isometric contractions (MVICs) were also performed on an isokinetic device. The effect of exercise on EMG activity (% MVIC) was assessed using repeated measures analysis of variance with Bonferroni corrections for planned pairwise comparisons.

Results:

Seated toe raises (11% MVIC) had the least amount of activity compared with all other exercises (P < 0.01), followed by single-leg balance on wobble board (25% MVIC), prone ankle pumps (38% MVIC), supine plantarflexion with red elastic resistance (45% MVIC), normal gait (47% MVIC), lateral step-ups (60% MVIC), single-leg heel raises (112% MVIC), and single-leg jumping (129% MVIC).

Conclusion:

There is an increasing progression of EMG activity for exercises that target the triceps surae muscle complex during common exercises prescribed in an Achilles tendon rehabilitation program. Seated toe raises offer relatively low EMG activity and can be utilized as an early rehabilitative exercise. In contrast, the single-leg heel raise and single-leg jumping should be utilized only during later-stage rehabilitation.

Clinical Relevance:

EMG activity in the triceps surae is variable with common rehab exercises.