Acute clinical evaluation for the diagnosis of lateral ankle ligament injuries is useful: A comparison between the acute and delayed settings.

PURPOSE: To determine the diagnostic value of seven injury history variables, nine clinical tests (including the combination thereof) and overall clinical suspicion for complete discontinuity of the lateral ankle ligaments in the acute (0-2 days post-injury) and delayed setting (5-8 days post-injury). METHODS: All acute ankle injuries in adult athletes (≥18 years) presenting up to 2 days post-injury were assessed for eligibility. Athletes were excluded if imaging studies demonstrated a frank fracture or 3 T MRI could not be acquired within 10 days post-injury. Using standardized history variables and clinical tests, acute clinical evaluation was performed within 2 days post-injury. Delayed clinical evaluation was performed 5-8 days post-injury. Overall, clinical suspicion was recorded after clinical evaluation. MRI was used as the reference standard. RESULTS: Between February 2018 and February 2020, a total of 117 acute ankle injuries were screened for eligibility, of which 43 were included in this study. Complete discontinuity of lateral ankle ligaments was observed in 23 (53%) acute ankle injuries. In the acute setting, lateral swelling had 100% (95% confidence interval [CI]: 82-100) sensitivity, haematoma had 85% (95% CI: 61-96) specificity and the anterior drawer test had 100% (95% CI: 77-100) specificity. In the delayed setting, sensitivity for the presence of haematoma improved from 43% (95% CI: 24-65) to 91% (95% CI: 70-98; p < 0.01) and the sensitivity of the anterior drawer test improved from 21% (95% CI: 7-46) to 61% (95% CI: 39-80; p = 0.02). Clinical suspicion had a positive likelihood ratio (LR) of 4.35 (95% CI: 0.55-34.17) in the acute setting and a positive LR of 6.09 (95% CI: 1.57-23.60) in the delayed setting. CONCLUSIONS: In the acute setting, clinical evaluation can exclude complete discontinuity (e.g., absent lateral swelling) and identify athletes with a high probability of complete discontinuity (e.g., positive anterior drawer test) of the lateral ankle ligaments. In the delayed setting, the sensitivity of common clinical findings increases resulting in an improved diagnostic accuracy. In clinical practice, this study underlines the importance of meticulous clinical evaluation in the acute setting. LEVEL OF EVIDENCE: Level III.

The MyJump App is a Valid Method of Assessing and Classifying Limb Symmetry During Recovery from Anterior Cruciate Ligament Reconstruction.

Background: Jump testing performance and limb symmetry measures are important metrics for clinicians to monitor during rehabilitation after Anterior Cruciate Ligament (ACL) reconstruction, however they require hardware and software which is not commonly available in clinical practice. Video-based solutions may present a feasible alternative, but their veracity in classifying patients using limb-symmetry of 90% has not been established, nor have the clinimetric values for the performance measures been reported in this population. Purpose: To describe the diagnostic accuracy (pass/fail using 90% LSI) and clinimetrics of an iPad-based app ("MyJump") compared to reference force plate analyses for limb symmetry, jump/hop height, contact time, flight time, and reactive strength index. Study design: Prospective cohort, diagnostic accuracy. Methods: Fifty-one consecutive patients recovering from ACL reconstruction undertaking routine independent clinical evaluation of their hop and jump performance were concurrently and independently examined using force plates and the MyJump app. Diagnostic accuracy of MyJump was compared to reference force plate analyses using a criterion of 90% limb symmetry. Results: Diagnostic accuracy of the MyJump app was very good: positive predictive value for jump height was 0.83 and 1.0 for reactive strength index, and negative predictive value was 0.95 and 1.0 for the same metrics, respectively. Of the 131 classifications made using the MyJump app, there were five false positives and three false negatives - all of these were in classification of jump height with no misclassifications of RSI. Irrespective of jump type, the MyJump app displayed excellent reliability (ICC>0.95) for both height and reactive strength index. Minimum detectable changes were approximately 1cm for height, 0.1 for reactive strength index, 0.02s for contact time, and 0.3s for flight time. Conclusion: Where force plates are unavailable, the MyJump app is a valid and reliable substitute for criteria assessment of jump/hop height and reactive strength index in those recovering from ACL surgery using a 90% limb symmetry threshold. The minimum detectable changes vary by metric but are likely sufficiently accurate to detect clinical changes. Level Of Evidence: Level 3.

Evaluating lower limb tendinopathy with Victorian Institute of Sport Assessment (VISA) questionnaires: a systematic review shows very-low-quality evidence for their content and structural validity-part I.

PURPOSE: The Victorian Institute of Sport Assessment (Achilles tendon-VISA-A, greater trochanteric pain syndrome-VISA-G, proximal hamstring tendinopathy-VISA-H, patellar tendon-VISA-P) questionnaires are widely used in research and clinical practice; however, no systematic reviews have formally evaluated their content, structural, and cross-cultural validity evidence. The measurement properties referring to content, structural and cross-cultural validity of the VISA questionnaires were appraised and synthesized. METHODS: The systematic review was conducted according to Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) methodology. PubMed, Cochrane, CINAHL, EMBASE, Web of Science, SportsDiscus, grey literature, and reference lists were searched. Development studies and cross-cultural adaptations (12 languages) assessing content or structural validity of the VISA questionnaires were included and two reviewers assessed their methodological quality. Evidence for content (relevance, comprehensiveness, and comprehensibility), structural, and cross-cultural validity was synthesized. A modified Grading of Recommendations Assessment Development and Evaluation (GRADE) approach was applied to evidence synthesis. RESULTS: The VISA-A presented very-low-quality evidence of sufficient relevance, insufficient comprehensiveness, and inconsistent comprehensibility. VISA-G displayed moderate-quality evidence for sufficient comprehensibility and very-low-quality evidence of sufficient relevance and comprehensiveness. The VISA-P presented very-low-quality evidence of sufficient relevance, insufficient comprehensiveness, and inconsistent comprehensibility, while VISA-H presented very-low evidence of insufficient content validity. VISA-A displayed low-quality evidence for structural validity concerning unidimensionality and internal structure, while VISA-H presented low-quality evidence of insufficient unidimensionality. The structural validity of VISA-G and VISA-P were indeterminate and inconsistent, respectively. Internal consistency for VISA-G, VISA-H, and VISA-P was indeterminate. No studies evaluated cross-cultural validity, while measurement invariance across sexes was assessed in one study. CONCLUSIONS: Only very-low-quality evidence exists for the content and structural validity of VISA questionnaires when assessing the severity of symptoms and disability in patients with lower limb tendinopathies. LEVEL OF EVIDENCE: IV. REGISTRATION: PROSPERO reference-CRD42019126595.

A systematic review evaluating the clinimetric properties of the Victorian Institute of Sport Assessment (VISA) questionnaires for lower limb tendinopathy shows moderate to high-quality evidence for sufficient reliability, validity and responsiveness-part II.

PURPOSE: The evaluation of measurement properties such as reliability, measurement error, construct validity, and responsiveness provides information on the quality of the scale as a whole, rather than on an item level. We aimed to synthesize the measurement properties referring to reliability, measurement error, construct validity, and responsiveness of the Victorian Institute of Sport Assessment questionnaires (Achilles tendon-VISA-A, greater trochanteric pain syndrome-VISA-G, proximal hamstring tendinopathy-VISA-H, patellar tendon-VISA-P). METHODS: A systematic review was conducted according to Consensus-based Standards for the Selection of Health Measurement Instruments methodology (COSMIN). PubMed, Cochrane, CINAHL, EMBASE, Web of Science, SportsDiscus, grey literature, and reference lists were searched. Studies assessing the measurement properties concerning reliability, validity, and responsiveness of the VISA questionnaires in patients with lower limb tendinopathies were included. Two reviewers assessed the methodological quality of studies assessing reliability, validity, and responsiveness using the COSMIN guidelines and the evidence for these measurement properties. A modified Grading of Recommendations Assessment Development and Evaluation (GRADE) approach was applied to the evidence synthesis. RESULTS: There is moderate-quality evidence for sufficient VISA-A, VISA-G, and VISA-P reliability. There is moderate-quality evidence for sufficient VISA-G and VISA-P measurement error, and high-quality evidence for sufficient construct validity for all the VISA questionnaires. Furthermore, high-quality evidence exists with regard to VISA-A for sufficient responsiveness in patients with insertional Achilles tendinopathy following conservative interventions. CONCLUSIONS: Sufficient reliability, measurement error, construct validity and responsiveness were found for the VISA questionnaires with variable quality of evidence except for VISA-A which displayed insufficient measurement error. LEVEL OF EVIDENCE: IV. REGISTRATION DETAILS: Prospero (CRD42018107671); PROSPERO reference-CRD42019126595.

Measuring only hop distance during single leg hop testing is insufficient to detect deficits in knee function after ACL reconstruction: a systematic review and meta-analysis.

OBJECTIVE: To systematically review the biomechanical deficits after ACL reconstruction (ACLR) during single leg hop for distance (SLHD) testing and report these differences compared with the contralateral leg and with healthy controls. DESIGN: Systematic review with meta-analysis. DATA SOURCES: A systematic search in Pubmed (Ovid), EMBASE, CINAHL, Scopus, Web of Science, PEDro, SPORTDiscus, Cochrane Library, grey literature and trial registries, was conducted from inception to 1 April 2018. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Studies reporting kinematic, kinetic and/or electromyographic data of the ACLR limb during SLHD with no language limits. RESULTS: The literature review yielded 1551 articles and 19 studies met the inclusion criteria. Meta-analysis revealed strong evidence of lower peak knee flexion angle and knee flexion moments during landing compared with the uninjured leg and with controls. Also, moderate evidence (with large effect size) of lower knee power absorption during landing compared with the uninjured leg. No difference was found in peak vertical ground reaction force during landing. Subgroup analyses revealed that some kinematic variables do not restore with time and may even worsen. CONCLUSION: During SLHD several kinematic and kinetic deficits were detected between limbs after ACLR, despite adequate SLHD performance. Measuring only hop distance, even using the healthy leg as a reference, is insufficient to fully assess knee function after ACLR. PROSPERO trial registration number CRD42018087779.

Musculoskeletal Screening Tests and Bony Hip Morphology Cannot Identify Male Professional Soccer Players at Risk of Groin Injuries: A 2-Year Prospective Cohort Study.

BACKGROUND: Musculoskeletal hip/groin screening tests are commonly performed to detect at-risk individuals. Bony hip morphology is considered a potential intrinsic risk factor but has not been examined prospectively. PURPOSE: To evaluate the association between intrinsic risk factors identified from musculoskeletal and radiographic screening tests and hip/groin injuries leading to time loss from training and/or match play in professional male soccer players. STUDY DESIGN: Prospective cohort study; Level of evidence, 2. METHODS: Male professional soccer players, aged ≥18 years, underwent screening specific for hip/groin pain during 2 consecutive seasons of the Qatar Stars League. The screening battery included pain provocation, range of motion, and strength tests as well as a hip radiographic examination. The radiographic examination included an anteroposterior pelvic view and 45° Dunn view, with bony hip morphology determined using quantitative methods. Time-loss (≥1 day) hip/groin injuries and individual player exposure (training and match play) were recorded prospectively, and injuries were categorized as adductor-related, inguinal-related, iliopsoas-related, pubic-related, or hip-related groin pain, or "other," as recommended in the Doha agreement. We calculated hazard ratios (HRs) from univariate and multivariate Cox regression models to assess the relationship between potential risk factors and hip/groin injuries. RESULTS: There were 438 players, completing 609 player seasons, and 113 hip/groin injuries that met the criteria for inclusion, with 85 injuries categorized as adductor-related. The proportion of players with bony morphological variants was the following: cam, 71%; pincer, 5%; and acetabular dysplasia, 13%. Previous hip/groin injuries (HR, 1.8; 95% CI, 1.2-2.7) and eccentric adduction strength were associated with the risk of hip/groin injuries. Higher (>1 SD above the mean) than normal eccentric adduction strength was associated with an increased risk for all hip/groin injuries (HR, 1.6; 95% CI, 1.0-2.5). Lower (<1 SD below the mean) than normal eccentric adduction strength was associated with an increased risk for adductor-related injuries (HR, 1.7; 95% CI, 1.0-3.0). No other musculoskeletal screening test or bony hip morphology variables were associated with the injury risk. CONCLUSION: Previous groin injuries and eccentric adduction strength were associated with the risk of groin injuries. However, these associations were not strong enough to identify an "at-risk" individual, and therefore, musculoskeletal screening tests were not useful to dictate individualized prevention strategies. Bony hip morphology was not associated with the risk of groin injuries.

Is Bony Hip Morphology Associated With Range of Motion and Strength in Asymptomatic Male Soccer Players?

Study Design Cross-sectional cohort study. Objectives To investigate the relationship between musculoskeletal screening findings and bony hip morphology in asymptomatic male soccer players. Background Athletes with femoroacetabular impingement (FAI) syndrome have cam and/or pincer morphology, pain on orthopaedic testing, and often reduced hip range of motion (ROM) and strength. However, cam and pincer morphology is also common in asymptomatic hips. Therefore, it is currently unknown whether the ROM and strength deficits observed in athletes with FAI syndrome result from the variance in their bony hip morphology or from their hip condition. Methods Male professional soccer players in Qatar were screened specifically for hip/groin pain in 2 consecutive seasons. The screening battery included pain provocation, ROM and strength tests, and hip radiographs. Univariate and multivariate regression analyses, using generalized estimating equations, evaluated the relationship between musculoskeletal screening findings and each bony hip morphological variant (cam, large cam, pincer, and acetabular dysplasia). Results Asymptomatic hips with cam and large cam morphology were associated with lower internal rotation ROM and bent-knee fall-out, and with a higher likelihood of pain on provocation testing. Pincer morphology was associated with lower abduction ROM and higher abduction strength. Acetabular dysplasia was associated with higher abduction ROM. Each association was weak and demonstrated poor or failed discriminatory power. Conclusion Bony hip morphology is associated with hip joint ROM and abduction strength, but musculoskeletal screening tests have a poor ability to discriminate between the different morphologies. J Orthop Sports Phys Ther 2018;48(4):250-259. doi:10.2519/jospt.2018.7848.

Marked asymmetry in vertical force (but not contact times) during running in ACL reconstructed athletes <9 months post-surgery despite meeting functional criteria for return to sport.

OBJECTIVES: Compare maximum plantar force (Fmax) during running in soccer players following anterior cruciate ligament reconstruction (ACLR) as they pass return to sport (RTS) criteria. DESIGN: Case control study. METHODS: Soccer players after ACLR (n=16) and matched healthy controls (n=16) ran on a treadmill at 12, 14 and 16km/h while plantar loading data was measured using an in-shoe pressure system (Pedar-X, Novel). Fmax and contact time of the injured and uninjured limbs in athletes <9months post-ACLR and those ≥9months ACLR were compared to healthy players (no ACLR). RESULTS: Significant differences with large effect sizes in Fmax asymmetry were seen at all running speeds for the athletes <9months ACLR compared to those ≥9months, and the healthy subjects. Fmax difference peaked at 16km/h; 32±11%BW in <9months ACLR group compared to 6±5%BW in ≥9months group; ES=1.67, p<0.01. There was a non-significant trend for increasing asymmetry with increasing speed for subjects who were <9months after ACLR while the reverse was true for those ≥9 months and the healthy subjects. CONCLUSIONS: Relatively large unloading of the ACLR limb (but not differences in contact times) are seen during running for athletes <9months post-ACLR despite having completed functional criteria required to permit RTS training. These asymmetries appear to slightly increase with increasing speed, and the reverse is true for healthy controls and those ≥9months after ACLR surgery.

Cohen's MRI scoring system has limited value in predicting return to play.

PURPOSE: Numerous authors have hypothesised that MRI scoring systems provide a valid means of predicting return to play duration following an acute hamstring muscle strain. The purpose is to prospectively investigate the predictive value of the MRI scoring system of Cohen for return to sport (RTS), following an acute hamstring injury. METHODS: Male football (soccer) players (n = 139) with acute onset posterior thigh pain underwent standardised clinical and MRI examinations within 5 days after injury. All players underwent a standardised physiotherapy regimen with RTS documented. The MRI scoring was statistically evaluated against RTS. RESULTS: One hundred and ten MRI-positive hamstring injuries were evaluated with RTS duration ranging from 1 to 66 days. Total Cohen's MRI score accounted for approximately 4% of the variance in RTS duration. When comparing those with an MRI score of 10 or more took on average 9.8 days longer to RTS than those with an MRI score less than 10 (effect size: 0.85, p < 0.01). CONCLUSIONS: Utilising the Cohen's MRI scoring system previously described, we were unable to provide a clinically useful prognosis for RTS in male soccer players. This may reflect the broader challenges of attempting to accurately determine RTS duration from imaging performed at a single point in time. LEVEL OF EVIDENCE: Prospective case series, IV.

Pubic apophysitis: a previously undescribed clinical entity of groin pain in athletes.

BACKGROUND: Sport-related pubalgia is often a diagnostic challenge in elite athletes. While scientific attention has focused on adults, there is little data on adolescents. Cadaveric and imaging studies identify a secondary ossification centre located along the anteromedial corner of pubis beneath the insertions of symphysial joint capsule and adductor longus tendon. Little is known about this apophysis and its response to chronic stress. AIM: We report pubic apophysitis as a clinically relevant entity in adolescent athletes. METHODS: The clinical and imaging findings in 26 highly trained adolescent football players (15.6 years ± 1.3) who complained of adductor-related groin pain were reviewed. The imaging features (X-ray 26/26, US 9/26, MRI 11/26, CT 7/26) of the pubic apophyses in this symptomatic group were compared against those of a comparison group of 31 male patients (age range 9-30 years) with no known history of groin pain or pelvic trauma, who underwent pelvic CT scans for unrelated medical reasons. RESULTS: All symptomatic subjects presented with similar history and physical findings. The CT scans of these patients demonstrated open pubic apophyses with stress-related physeal changes (widening, asymmetry and small rounded cyst-like expansions) that were not observed in the comparison group. No comparison subject demonstrated apophyseal maturity before 21 years of age, and immaturity was seen up to the age of 26 years. CONCLUSIONS: This retrospective case series identifies pubic apophyseal stress (or 'apophysitis') as an important differential consideration in the adolescent athlete who presents with groin pain.