Comparative Analysis of Patient-Reported Outcome Measures for Proximal Hamstring Injuries: A Systematic Review.

Background: There is controversy regarding which patient-reported outcome measures (PROMs) should be used for proximal hamstring tendon injuries. Hypothesis: It was hypothesized that (1) most (>50%) of the questions on the 13 most common PROMs for proximal hamstring injuries would demonstrate extensive overlap in the health domains and question categories and (2) each of the PROMs would contain a variable distribution of questions within each health domain. Study Design: Systematic review. Methods: We conducted a literature review through PubMed, Scopus, and CINAHL and identified the 13 most common PROMs for proximal hamstring injuries: Lower Extremity Functional Scale (LEFS), Marx activity rating scale (MARS), 12-item Short Form Survey (SF-12), Tegner activity scale (TAS), Single Assessment Numeric Evaluation (SANE), Perth Hamstring Assessment Tool (PHAT), Proximal Hamstring Injury Questionnaire (PHIQ), modified Harris Hip Score (mHHS), University of California, Los Angeles activity score (UCLA), International Hip Outcome Tool (iHOT-12), Hip Outcome Score (HOS), Sydney Hamstring Origin Rupture Evaluation (SHORE), and Non-Arthritic Hip Score (NAHS). All PROM questions were sorted into 5 health domains (pain, symptoms, activities of daily living, sports, and mindset) and further divided into question categories if they referred to similar tasks or aspects of health. Questions in the same health domain and question category were considered overlapping, and those within a health domain that did not fit into a question category were considered unique. For each PROM, we analyzed the distribution of questions within particular health domains and question categories as well as the amount of overlapping and unique questions. Results: Of the 165 questions evaluated, 116 (70.3%) were overlapping, and 49 (29.7%) were unique. The SF-12 contained the most unique questions (9/12 [75.0%]). The MARS, TAS, SANE, and UCLA had 0 unique questions. The PHIQ and iHOT-12 contained questions in all 5 health domains. The PHAT, SHORE, and NAHS contained questions in every health domain except mindset. The LEFS, MARS, SF-12, TAS, mHHS, SANE, UCLA, and HOS contained questions in ≤3 health domains. Conclusion: The evaluated PROMs had a high degree of overlapping questions (≥50%) and demonstrated a statistically significant variance in the distribution of questions within each health domain.

Comparison of trunk proprioception between patients with low back pain and healthy controls.

OBJECTIVE: To determine whether proprioceptive impairments exist in patients with low back pain (LBP). We hypothesized that patients with LBP would exhibit larger trunk proprioception errors than healthy controls. DESIGN: Case-control study. SETTING: University laboratory. PARTICIPANTS: 24 patients with nonspecific LBP and 24 age-matched healthy controls. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We measured trunk proprioception in all 3 anatomical planes using motion perception threshold, active repositioning, and passive repositioning tests. RESULTS: LBP patients had significantly greater motion perception threshold than controls (P<.001) (1.3+/-0.9 degrees vs 0.8+/-0.6 degrees ). Furthermore, all subjects had the largest motion perception threshold in the transverse plane (P<.001) (1.2+/-0.7 degrees vs 1.0+/-0.8 degrees for all other planes averaged). There was no significant difference between LBP and healthy control groups in the repositioning tasks. Errors in the active repositioning test were significantly smaller than in the passive repositioning test (P=.032) (1.9+/-1.2 degrees vs 2.3+/-1.4 degrees ). CONCLUSIONS: These findings suggest that impairments in proprioception may be detected in patients with LBP when assessed with a motion perception threshold measure.

Telerehabilitation for Total Hip and Knee Arthroplasty Patients: A Pilot Series with High Patient Satisfaction.

BACKGROUND: The demand for total hip and total knee arthroplasty in the USA is projected to increase significantly. Traditionally, face-to-face physical therapy has been an essential component of recovery in patients after total joint arthroplasty. Emerging technology allows telerehabilitation, or virtual physical therapy, which may reduce costs and increase standardization, but its effects on outcomes are not known. QUESTIONS/PURPOSE: We sought to review our initial experience using a telerehabilitation protocol for patients after primary total hip or total knee arthroplasty. METHODS: In this pilot study, we retrospectively compared our first 40 telerehabilitation patients after a primary total hip or knee arthroplasty with a historical cohort or literature referenced values and evaluated (1) readmission rates at 90 days, (2) emergency department visits, (3) patient-reported outcome scores, (4) incidence of closed knee manipulation within 90 days of primary total knee arthroplasty, and (5) patient satisfaction surveys. RESULTS: We observed no increase in the telerehabilitation group at 90 days in readmissions, emergency department visits, or closed knee manipulations. Accuracy of telerehabilitation exercises performed was 92%. Patient-reported outcome scores showed improvements comparable with traditional therapy. Extremely high patient satisfaction scores were reported with the telerehabilitation protocol. CONCLUSION: Our early experience demonstrates the feasibility of implementing a telerehabilitation program following primary total hip or knee arthroplasty without compromising clinical quality and with high patient satisfaction.

Neuromuscular control of trunk stability: clinical implications for sports injury prevention.

Recent prospective evidence supports the hypothesis that impaired trunk control is a contributing factor to sports injuries of the spine as well as to segments of the kinetic chain. The current concepts regarding neuromuscular control of trunk stability are best described from a systems engineering perspective. In the analysis of current neuromuscular training protocols for sports injury prevention, these principles are applied to identify components that optimize neuromuscular control of trunk stability. Current perspectives of neuromuscular learning can be applied clinically to aid in the formulation of injury prevention strategies.

Hamstrings to quadriceps peak torque ratios diverge between sexes with increasing isokinetic angular velocity.

Our purpose was to determine if females demonstrate decreased hamstrings to quadriceps peak torque (H/Q) ratios compared to males and if H/Q ratios increase with increased isokinetic velocity in both sexes. Maturation disproportionately increases hamstrings peak torque at high velocity in males, but not females. Therefore, we hypothesised that mature females would demonstrate decreased H/Q ratios compared to males and the difference in H/Q ratio between sexes would increase as isokinetic velocity increased. Studies that analysed the H/Q ratio with gravity corrected isokinetic strength testing reported between 1967 and 2004 were included in our review and analysis. Keywords were hamstrings/quadriceps, isokinetics, peak torque and gravity corrected. Medline and Smart databases were searched combined with cross-checked bibliographic reference lists of the publications to determine studies to be included. Twenty-two studies were included with a total of 1568 subjects (1145 male, 423 female). Males demonstrated a significant correlation between H/Q ratio and isokinetic velocity (R=0.634, p<0.0001), and a significant difference in the isokinetic H/Q ratio at the lowest angular velocity (47.8+/-2.2% at 30 degrees /s) compared to the highest velocity (81.4+/-1.1% at 360 degrees /s, p<0.001). In contrast, females did not demonstrate a significant relationship between H/Q ratio and isokinetic velocity (R=0.065, p=0.77) or a change in relative hamstrings strength as the speed increased (49.5+/-8.8% at 30 degrees /s; 51.0+/-5.7% at 360 degrees /s, p=0.84). Gender differences in isokinetic H/Q ratios were not observed at slower angular velocities. However, at high knee flexion/extension angular velocities, approaching those that occur during sports activities, significant gender differences were observed in the H/Q ratio. Females, unlike males, do not increase hamstrings to quadriceps torque ratios at velocities that approach those of functional activities.

A multidisciplinary approach to the evaluation, reconstruction and rehabilitation of the multi-ligament injured athlete.

Knee dislocations with multi-ligamentous involvement are potentially limb-threatening injuries that require extensive surgical and rehabilitative intervention. These knee injuries, such as combined anterior cruciate ligament, posterior cruciate ligament, medial collateral ligament and/or lateral collateral ligament injuries, are devastating injuries with results that vary from total disability to nearly full recovery of function. Recent surgical advances, including the use of allograft tissues, have increased the efficacy of these procedures while posing new challenges. By combining scientifically based surgical and rehabilitative approaches, improved outcomes in these difficult cases are being reported in the orthopaedic literature. This review details the epidemiology and biomechanics of these serious knee ligament injuries. In addition, state-of-the-art surgical and rehabilitative techniques will be outlined. Clinical and diagnostic imaging evaluation of these knee injuries is reviewed in order to plan and execute the surgical and rehabilitative practices. We review the basic science, surgical and rehabilitative theories and practices associated with bringing patients with these serious knee injury injuries to full recovery, and detail the development of strategies for developing protocols to address these complicated cases.

Effects of the menstrual cycle on anterior cruciate ligament injury risk: a systematic review.

Several theories have been proposed to explain the 3- to 6-fold gender difference in the incidence of anterior cruciate ligament injuries. One potential theory for the increased incidence is based on gender-related hormonal differences between men and women, especially after puberty and the onset of menses in the female athlete. The purpose of this systematic review was to compile and systematically analyze the published literature to determine if the menstrual cycle is associated with anterior cruciate ligament injury risk and to provide an objective comparison of the published results. Investigations were included in the systematic review if the report included associations between the menstrual cycle and noncontact anterior cruciate ligament injuries in female athletes. Abstracts and unpublished studies were excluded. Seven articles were identified that met the systematic review inclusion criteria. The 7 reviewed studies favored an effect of the first half, or preovulatory phase, of the menstrual cycle for increased anterior cruciate ligament injuries. The 6 studies that separated the non-oral contraceptive and oral contraceptive data also favored an effect of the first half of the menstrual cycle for increased anterior cruciate ligament injuries. The clinical relevance of this finding is that female athletes may be more predisposed to anterior cruciate ligament injuries during the preovulatory phase of the menstrual cycle. These findings may lead to potential interventions targeted toward this phase of the menstrual cycle to reduce the incidence of anterior cruciate ligament injury.

Deficits in neuromuscular control of the trunk predict knee injury risk: a prospective biomechanical-epidemiologic study.

BACKGROUND: Female athletes are at significantly greater risk of anterior cruciate ligament (ACL) injury than male athletes in the same high-risk sports. Decreased trunk (core) neuromuscular control may compromise dynamic knee stability. HYPOTHESES: (1) Increased trunk displacement after sudden force release would be associated with increased knee injury risk; (2) coronal (lateral), not sagittal, plane displacement would be the strongest predictor of knee ligament injury; (3) logistic regression of factors related to core stability would accurately predict knee, ligament, and ACL injury risk; and (4) the predictive value of these models would differ between genders. STUDY DESIGN: Cohort study (prognosis); Level of evidence, 2. METHODS: In this study, 277 collegiate athletes (140 female and 137 male) were prospectively tested for trunk displacement after a sudden force release. Analysis of variance and multivariate logistic regression identified predictors of risk in athletes who sustained knee injury. RESULTS: Twenty-five athletes (11 female and 14 male) sustained knee injuries over a 3-year period. Trunk displacement was greater in athletes with knee, ligament, and ACL injuries than in uninjured athletes (P < .05). Lateral displacement was the strongest predictor of ligament injury (P = .009). A logistic regression model, consisting of trunk displacements, proprioception, and history of low back pain, predicted knee ligament injury with 91% sensitivity and 68% specificity (P = .001). This model predicted knee, ligament, and ACL injury risk in female athletes with 84%, 89%, and 91% accuracy, but only history of low back pain was a significant predictor of knee ligament injury risk in male athletes. CONCLUSIONS: Factors related to core stability predicted risk of athletic knee, ligament, and ACL injuries with high sensitivity and moderate specificity in female, but not male, athletes.

The effects of core proprioception on knee injury: a prospective biomechanical-epidemiological study.

BACKGROUND: In sports involving pivoting and landing, female athletes suffer knee injury at a greater rate than male athletes. HYPOTHESES: Proprioceptive deficits in control of the body's core may affect dynamic stability of the knee. Female, but not male, athletes who suffered a knee injury during a 3-year follow-up period would demonstrate decreased core proprioception at baseline testing as compared with uninjured athletes. STUDY DESIGN: Cohort study (prognosis); Level of evidence, 2. METHODS: Study subjects were 277 collegiate athletes (140 female, 137 male) who were prospectively tested for core proprioception by active and passive proprioceptive repositioning. Athletes were monitored for injury for 3 years. An ANOVA and multivariate logistic regression were used to test whether core proprioception was related to knee injuries in athletes. RESULTS: Twenty-five athletes sustained knee injuries (11 women, 14 men). Deficits in active proprioceptive repositioning were observed in women with knee injuries (2.2 degrees ) and ligament/meniscal injuries (2.4 degrees ) compared with uninjured women (1.5 degrees , P or= .05). Uninjured women demonstrated significantly less average error in active proprioceptive repositioning than uninjured men (1.5 degrees vs 1.7 degrees , P

The effects of the menstrual cycle on anterior knee laxity: a systematic review.

Female athletes are at a 4- to 6-fold increased risk of anterior cruciate ligament (ACL) injury compared with male athletes. There are several medical, emotional and financial burdens associated with these injuries. Sex hormones may be involved in the ACL injury disparity, with potential associations reported between phases of the menstrual cycle and ACL injury rates. The reported relationships between ACL injury and menstrual status may be related to associated changes in ligament mechanical properties from cyclic fluctuations of female sex hormones. A PubMed electronic database literature search, including MEDLINE (1966-2005) and CINAHL (1982-2005), with the search terms 'menstrual cycle' and 'knee laxity' was used for this systematic review. Studies were included in this systematic review if they were prospective cohort studies and investigated the association between the menstrual cycle and anterior knee laxity in females. Nine prospective cohort studies, published as 11 articles, were included in the systematic review. Six of nine studies reported no significant effect of the menstrual cycle on anterior knee laxity in women. Three studies observed significant associations between the menstrual cycle and anterior knee laxity. These studies all reported the finding that laxity increased during the ovulatory or post-ovulatory phases of the cycle. A meta-analysis, which included data from all nine reviewed studies, corroborated this significant effect of cycle phase on knee laxity (F-value = 56.59, p = 0.0001). In the analyses, the knee laxity data measured at 10-14 days was >15-28 days which was >1-9 days. Future studies testing the relationship between the menstrual cycle and potentially associated parameters should consider the limitations outlined in this article and control for potential biases and confounders. Power analyses should be utilised. Subjects should be randomly entered into the studies at alternate points in the cycle, and standard and consistent data acquisition and reporting methods should be utilised. Future studies should clearly define what constitutes a 'normal' cycle and appropriate control subjects should be utilised. Furthermore, there is a need to define cycle phase (and timing within cycle phase) with actual hormone levels rather than a day of the cycle. Although hormone confirmations were provided in many of the studies that selected specific days to depict a particular cycle for all women, it is unknown from these data if they truly captured times of peak hormone values in all women. A combined systematic review and meta-analysis of the literature indicate that the menstrual cycle may have an effect on anterior-posterior laxity of the knee; however, further investigation is needed to confirm or reject this hypothesis.

Gender comparison of hip muscle activity during single-leg landing.

STUDY DESIGN: Controlled laboratory study. OBJECTIVES: To determine whether gender differences in electromyographic (EMG) activity of hip-stabilizing muscles are present during single-leg landing. BACKGROUND: Numerous factors may explain the greater rate of anterior cruciate ligament (ACL) injuries in female athletes. However, gender differences in hip muscle activity during dynamic events have not been well characterized. METHODS AND MEASURES: Twenty-two Division I collegiate athletes (13 female, 9 male) performed drop landings from 30.5- and 45.8-cm heights. Surface EMG was used to examine relative muscle activity from 200 milliseconds prior to initial contact to 250 milliseconds postcontact. Peak and mean values for each muscle (gluteus maximus, gluteus medius, rectus femoris) in each time epoch were analyzed using 2 x 2 (group by height) analyses of variance (ANOVAs) to determine significance. RESULTS: Females demonstrated lower gluteus maximus peak (mean +/- SD, 69.5 +/- 30.2 versus 98.0 +/- 33.4 percent maximum voluntary contraction [%MVIC]; P= .019) and mean (mean +/- SD, 37.5 +/- 15.6 versus 53.9 +/- 18.0 %MVIC; P = .018) muscle activation during the postcontact phase of landing than males. Furthermore, females demonstrated greater peak rectus femoris activity during the precontact phase (mean +/- SD, 33.6 +/- 18.5 versus 18.7 +/- 8.2 %MVIC; P = .029). A positive effect of drop height on relative activity of all muscles was observed during both phases (P<.05). CONCLUSIONS: Females utilize different muscular activation patterns compared to males (ie, decreased gluteus maximus and increased rectus femoris muscle activity) during landing maneuvers. Decreased hip muscle activity and increased quadriceps activity may be important contributors to the increased susceptibility of female athletes to noncontact ACL injuries.

The Epidemiology of Pediatric Basketball Injuries Presenting to US Emergency Departments: 2000-2006.

BACKGROUND: There is limited published research on the epidemiology of basketball injuries treated in US emergency departments (EDs). HYPOTHESIS: Age and sex patterns exist for the most common pediatric basketball injuries treated in EDs. STUDY DESIGN: Descriptive epidemiology study. METHODS: Data from the National Electronic Injury Surveillance System and the National Sporting Goods Association were used to calculate national injury incidence rates and 95% confidence intervals of pediatric basketball injuries. RESULTS: An estimated 325 465 annual visits were made to US EDs for pediatric basketball-related injuries from 2000 to 2006. The 5 most common injuries were ankle sprains (21.7%), finger sprains (8.0%), finger fractures (7.8%), knee sprains (3.9%), and facial lacerations (3.9%). Among persons aged 12 to 17 years, girls had a higher rate of knee sprains than boys (P < 0.001), but this association did not exist among those aged 7 to 11 years (P = 0.27). Boys had a higher rate of facial lacerations than girls (P < 0.01). Among persons aged 12 to 17 years, girls had a higher rate of finger sprains (P < 0.01). For both boys and girls, the rate of the 5 most common basketball injuries was higher among those aged 12 to 17 years compared with those aged 7 to 11 years (P < 0.01). CONCLUSIONS: The annual number of basketball-related pediatric ED visits approaches a third of a million and demonstrates the extent of the public health problem that injuries in this sport pose. Distinct sex and age patterns were observed. CLINICAL RELEVANCE: The study findings provide important information on basketball injury rates that may be used for targeting prevention interventions by sex and age group.

Viscosupplementation for knee osteoarthritis: a systematic review.

Due to the rising number of patients affected by osteoarthritis (OA), appropriate management decisions for minimizing pain and improving physical function for patients with OA are important. Hyaluronic acid (HA) knee injections have become a common tool for the management of OA of the knee, and the number of randomized controlled trials on the efficacy and safety of this treatment is growing. We performed a systematic review of the five published meta-analyses, which include single- or double-blinded randomized trials performed at one center or multiple centers (Level I evidence). Within each meta-analysis, a quality assessment tool for each trial was used based on outcome measures of OA-related pain, disease severity, trial period, and mean efficacy. We analyzed and compared the data collection and qualitative analysis methods, outcomes, and conclusions presented for each meta-analysis. Although they used different strategies, each used scientifically sound methods for analysis of many of the same trials; however, each used a different measure of trial quality and heterogeneity. Despite these differences, all come to a similar conclusion that when the strictest quality tools and interpretation of heterogeneity are used, Level I evidence demonstrates that the use of HA in patients with OA results in modest improvement in validated outcomes.