Implementation of an Injury Prevention Program in NCAA Division I Athletics Reduces Injury-Related Health Care Costs.

BACKGROUND: The estimated cost per year of injuries in collegiate athletics has been reported to be billions of dollars in the United States. Injury prevention programs are often assessed only by their ability to reduce injuries, and there is little evidence of any potential reduction in associated health care costs. PURPOSE: To investigate changes in injury-related health care costs at a National Collegiate Athletic Association (NCAA) Division I university after the implementation of an injury prevention program. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Included were 12 sports teams that used the injury prevention program (user group) and 16 teams that did not implement the program (nonuser group). The injury surveillance and prevention system (Sparta Science) utilized a commercially available force-plate system to assess kinematic variables, flag high-risk athletes, and guide individual conditioning programs. Data were obtained from 3 academic years before (2012-2014) and 2 academic years after (2015-2016) implementation of the Sparta Science system. The number of injuries and associated health care costs (surgery, clinic visits, imaging, and physical therapy) were compared between users and nonusers. RESULTS: Total average annual injuries did not change significantly between users and nonusers after implementation of the program; however, users demonstrated a 23% reduction in clinic visits as compared with a 14% increase for nonusers (P = .049). Users demonstrated a 13% reduction in associated health care encounters, compared with a 13% increase for nonusers (P = .032). Overall health care costs changed significantly for both groups, with an observed 19% decrease ($2,456,154 to $1,978,799) for users and an 8% increase ($1,177,542 to $1,270,846) for nonusers (P < .01 for both). Costs related to associated health care encounters also decreased by 20% for users as compared with a 39% increase for nonusers (P = .027). CONCLUSION: This study demonstrated the ability to significantly reduce injury-related health care costs in NCAA Division I athletes via a comprehensive injury surveillance and prevention program utilizing force-plate technology. Given the substantial and appropriate focus on value of care delivery across the US health care system, we recommend the continued study of sports injury surveillance and prevention programs for reducing injury-related health care costs.

Arthroscopic Diagnosis of Occult Posterolateral Meniscocapsular Separations: Another Hidden Lesion.

PURPOSE: The purpose of this study was to describe the surgical findings and clinical outcomes in a series of patients with occult posterolateral meniscocapsular separations diagnosed arthroscopically after a negative magnetic resonance imaging (MRI) scan. METHODS: A retrospective analysis of prospectively collected data of consecutive patients who underwent surgical arthroscopy with repair of an occult posterolateral meniscocapsular separation by 2 fellowship-trained orthopaedic sports medicine surgeons at a single institution was performed. All lesions were identified arthroscopically in the posterolateral aspect of the lateral compartment as a distinct pathologic separation between the posterolateral capsule and adjacent meniscal tissue with increased excursion on probing. Clinical examination notes, MRI scans, and operative reports were reviewed. Patient-reported outcome measures were assessed via patient questionnaire. RESULTS: A total of 6 patients were included for analysis. MRI evaluation of the lateral meniscus was unrevealing in 4 patients, suggesting a possible tear of the body of the lateral meniscus in one patient and demonstrating a parameniscal cyst abutting the anterior root of the lateral meniscus in another patient. Arthroscopic examination revealed meniscocapsular separations of the posterolateral meniscus in all 6 knees, with 2 knees demonstrating concomitant bucket-handle meniscus tears. Patient-reported outcomes were determined for 67% of study patients. The average reported International Knee Documentation Committee score was 63.8, the average Knee Outcome Survey Activities of Daily Living Scale score was reported as 63, the 12-Item Short Form Survey (SF-12) Physical score averaged 46.8 with an average SF-12 Mental score of 59.9. CONCLUSIONS: The diagnosis of occult posterolateral meniscocapsular separations (MCS) could be missed on advanced imaging, such as MRI, so arthroscopic diagnosis may be required. This study indicates that arthroscopic diagnosis and repair of occult posterolateral MCS results in good functional and clinical outcomes. LEVEL OF EVIDENCE: IV, therapeutic case series.

A Rare Incident of Intraarticular Fibromatosis of the Knee: A Case Report.

CASE: Our patient is a 34-year-old male aHthlete who presented for consultation after left knee discomfort and pressure for greater than 2 years. Advanced imaging revealed a nonspecific intraarticular suprapatellar lesion with subsequent ultrasound-guided core biopsy demonstrating a spindle cell proliferation consistent with superficial fibromatosis. Thus, the patient underwent an open en bloc surgical resection by a fellowship-trained orthopaedic oncologist. CONCLUSION: As the first reported case of intraarticular fibromatosis of the knee, this case highlights the importance of a thoughtful approach to the management of nonspecific intraarticular lesions through a comprehensive and collaborative strategy to decrease patient morbidity and optimize outcomes.

Descriptive Epidemiology of the MOON Shoulder Instability Cohort.

BACKGROUND: Shoulder instability is a common diagnosis among patients undergoing shoulder surgery. PURPOSE: To perform a descriptive analysis of patients undergoing surgery for shoulder instability through a large multicenter consortium. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: All patients undergoing surgery for shoulder instability who were enrolled in the MOON Shoulder Instability Study were included. Baseline demographics included age, sex, body mass index, and race. Baseline patient-reported outcomes (PROs) included the American Shoulder and Elbow Surgeons (ASES) score, Shoulder Activity Score, Western Ontario Shoulder Instability Index (WOSI), 36-Item Health Survey (RAND-36), and Single Assessment Numeric Evaluation (SANE). The preoperative physician examination included active range of motion (ROM) and strength testing. Preoperative imaging assessments with plain radiography, magnetic resonance imaging (MRI), and computed tomography were also included and analyzed. RESULTS: Twenty-six surgeons had enrolled 863 patients (709 male, 154 female) across 10 clinical sites. The mean age for the cohort was 24 years (range, 12-63 years). Male patients represented 82% of the cohort. The primary direction of instability was anterior for both male (74%) and female (73%) patients. Football (24%) and basketball (13%) were the most common sports in which the primary shoulder injury occurred. No clinically significant differences were found in preoperative ROM between the affected and unaffected sides for any measurement taken. Preoperative MRI scans were obtained in 798 patients (92%). An anterior labral tear was the most common injury found on preoperative MRI, seen in 66% of patients, followed by a Hill-Sachs lesion in 41%. Poor PRO scores were recorded preoperatively (mean: ASES, 72.4; WOSI, 43.3; SANE, 46.6). CONCLUSION: The MOON Shoulder Instability Study has enrolled the largest cohort of patients undergoing shoulder stabilization to date. Anterior instability is most common among shoulder instability patients, and most patients undergoing shoulder stabilization are in their early 20s or younger. The results of this study provide important epidemiological information for patients undergoing shoulder stabilization surgery.

Does arthroscopic knee surgery work?

A recent randomized trial from the Finnish Degenerative Meniscal Lesion Study Group was published in the New England Journal of Medicine and attempted to determine the efficacy of partial meniscectomy without osteoarthritis. Patients were randomized to either arthroscopic partial meniscectomy or sham surgery. The authors concluded that the clinical outcomes after arthroscopic partial meniscectomy were no better than those after the sham surgical procedure. However, there are several important limitations of this trial that make it difficult to generalize to the 700,000 arthroscopic partial meniscectomies performed in the United States each year. In this small sample of 146 patients, patients with traumatic meniscal tears and locking symptoms-those most likely to benefit from a partial meniscectomy-were excluded. In addition, although patients with radiographic arthritis were excluded, most of the patients in the study had degenerative changes at the time of arthroscopy. Therefore it is difficult to determine whether the patients were symptomatic from their chondral degeneration or their degenerative meniscal tear. In our opinion this study does not change the role of surgery in current clinical practice. The primary indication for arthroscopic partial meniscectomy remains symptoms of well-localized joint line pain with acute onset and mechanical symptoms such as catching or locking that have failed comprehensive nonoperative management.

Anterior cruciate ligament reconstruction in patients aged > 40 years: a case-control study.

PURPOSE: To determine the outcomes of isolated anterior cruciate ligament (ACL) reconstruction in physically active patients aged > 40 years, and to compare these results with those of a younger patient cohort who underwent the same procedure. METHODS: A retrospective review was performed on all patients aged > 40 years who underwent ACL reconstruction between 2000 and 2008. A consecutive series of patients aged ≤ 25 years who underwent the same procedure during this same time period were selected as a control group. Age, sex, graft type, concomitant injuries, complications, and a validated outcome measure (Lysholm Knee Scoring Scale) were assessed at final follow-up. RESULTS: Forty-six patients (average age, 44.9 years; 28 men, 18 women) in the older group were identified and compared with 48 patients (average age, 21 years; 23 men, 25 women) in the younger group, with an average follow-up period of 5.4 and 5.1 years, respectively. There was no statistically significant difference between the groups in terms of associated injuries. The older group had a higher degree of cartilage degeneration (P = 0.0001). Lysholm scores averaged 90.3 in the older cohort compared with 88.7 in the younger cohort, with no statistical difference between groups. CONCLUSION: The older patients had outcomes comparable with the younger patients. Age alone should not exclude ACL-deficient patients from undergoing reconstructive surgery.

Complications in brief: Anterior cruciate ligament reconstruction.

When performing reconstruction of the ACL, the major complications that can arise include missed concomitant injuries, tunnel malposition, patellar fracture, knee stiffness, and infection. We review the complications that can occur as a result of errors made before, during, and after surgery.

Poly-L/D-lactic acid anchors are associated with reoperation and failure of SLAP repairs.

PURPOSE: This study investigates factors associated with failure and reoperation after glenoid labrum repair. METHODS: We studied a nonconcurrent cohort of consecutive patients undergoing arthroscopic superior labrum repair at a single institution by 2 fellowship-trained surgeons over a 10-year period. RESULTS: There were 348 patients included in this study with a mean age of 33.4 years (95% confidence interval [CI], 32.1 to 35.9) and a mean clinical follow-up of 12.3 months (95% CI, 10.9 to 13.8). The overall reoperation rate was 6.3%, with a revision labrum repair rate of 4.3%. Subsequent surgery and failure after arthroscopic labrum repair were significantly correlated with Workers' Compensation claims (odds ratio [OR], 4.6; P < .001; 95% CI, 1.8 to 11.7), the use of tobacco (OR, 12.0; P = .03; 95% CI, 1.2 to 114.9), and the use of absorbable poly-L/D-lactic acid (PLDLA) anchors (100% correlation, P < .001). The OR for having repeat surgery was 12.7 (95% CI, 4.9 to 32.9; P < .001) with poly-96L/4D-lactic acid (Mini-Revo; Linvatec, Largo, FL) and also increased with the use of poly-70L/30D-lactic acid (Bio-Fastak and Bio-Suturetak; Arthrex, Naples, FL) anchor material (P = .04) after removal of the patients exposed to poly-96L/4D-lactic acid anchors. The rates of repeat surgery with PLDLA anchors from Linvatec and PLDLA anchors from Arthrex were 24% and 4%, respectively. None of the patients treated with nonabsorbable suture anchors (polyether ether ketone or metallic) returned to the operating room (P < .001). After we controlled for associated factors in a multivariate analysis, the use of absorbable anchors, in particular poly-96L/4D-lactic acid anchors (OR, 14.7; P < .001), and having a work-related injury (OR, 8.1; P < .001) remained independent factors associated with both repeat surgery and revision superior labrum repair. CONCLUSIONS: Bioabsorbable PLDLA anchor material led to significantly more SLAP repair failures and reoperations compared with nonabsorbable suture anchors. Our recommendation is that glenoid labrum repairs be performed with nondegradable material and, specifically, that the use of anchors composed of PLDLA material should be avoided.

Performance after rotator cuff tear and operative treatment: a case-control study of major league baseball pitchers.

CONTEXT: Little is known about pitching performance or lack of it among Major League Baseball (MLB) pitchers who undergo operative treatment of rotator cuff tears. OBJECTIVE: To assess pitching performance outcomes in MLB players who needed operative treatment of rotator cuff tears and to compare performance in these athletes with that in a control group of MLB players. DESIGN: Case-control study. SETTING: Publicly available player profiles, press releases, and team injury reports. PATIENTS OR OTHER PARTICIPANTS: Thirty-three MLB pitchers with documented surgery to treat rotator cuff tears and 117 control pitchers who did not have documented rotator cuff tears were identified. MAIN OUTCOME MEASURE(S): Major League Baseball pitching attrition and performance variables. RESULTS: Players who underwent rotator cuff surgery were no more likely not to play than control players. Performance variables of players who underwent surgery improved after surgery but never returned to baseline preoperative status. Players who needed rotator cuff surgery typically were more experienced and had better earned run averages than control players. CONCLUSIONS: Pitchers who had symptomatic rotator cuff tears that necessitated operative treatment tended to decline gradually in performance leading up to their operations and to improve gradually over the next 3 seasons. In contrast to what we expected, they did not have a greater attrition rate than their control counterparts; however, their performances did not return to preoperative levels over the course of the study.

Eminence-based medicine versus evidence-based medicine: level V evidence in sports medicine.

Through extensive survey analysis, we investigated expert opinion in sports medicine. The study had 3 purposes: to provide clinical guidance for cases in which the correct action is not necessarily apparent, to examine expert opinion itself, and to delineate areas of future study. A total of 500 members of the American Medical Society for Sports Medicine and the American Orthopaedic Society for Sports Medicine evaluated a set of 25 statements on unresolved issues in sports medicine. The following 10 statements were deemed false: "It's okay for 12-year-old pitchers to throw curve balls; it's the pitch count that matters"; "Resistance training ('weight lifting') should be avoided until physeal closure"; "Jogging during pregnancy is to be avoided"; "At an athletic event, if sideline coverage is offered by an emergency medical technician and athletic trainer, there is little additional benefit from having a physician present"; "Contact sport athletes who sustain a second concussion should be excluded from contact sports permanently"; "The utility of pre-season medical screening is derived from the history; as such, student-athletes should complete a questionnaire, with physical examination reserved for only those with a positive relevant history"; "Femoroacetabular impingement is a myth-the designation of anatomic variation as disease"; "An AC (acromioclavicular) separation in a contact athlete should not be treated surgically if the athlete won't give up the sport; it will fail"; "Ankle taping induces weakness and atrophy of the dynamic stabilizers of the ankle"; "Only autografts should be used in ACL (anterior cruciate ligament) surgery, as allografts have an unnecessary high failure rate in clinical practice." One statement was accepted as true: "Surgery to treat anterior (patello-femoral) knee pain in a patient with normal patellar mechanics and stability is contraindicated." In short, expert opinion may be a helpful adjunct to clinical practice. Expert opinion cannot replace individual judgment and certainly does not trump the primary medical literature. Yet when better evidence is lacking, expert opinion is valuable for even the staunchest practitioner of evidence-based medicine.

The Disabilities of the Arm, Shoulder, and Hand questionnaire in intercollegiate athletes: validity limited by ceiling effect.

HYPOTHESIS: The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire has been validated as an effective upper extremity specific outcome measure. Normative scores have not been established for young athletes. This study was conducted to establish normative DASH scores for intercollegiate athletes. We hypothesized that DASH scores in intercollegiate athletes differ from published values obtained from the general population. MATERIALS AND METHODS: The DASH questionnaire was administered to 321 athletes cleared for full participation in intercollegiate sports. Their scores were compared with normative values in the general population and 2 other age-matched cohorts. RESULTS: Intercollegiate athletes had significantly better upper extremity function compared with the general population (1.37 +/- 2.96 vs 10.10 +/- 14.68, P < .001) and an age-matched cohort of employed adults (1.37 +/- 2.96 vs 5.40 +/- 7.57, P < .0001). The DASH was 0 for 65.1%. Within this cohort, men reported better upper extremity function than women (0.98 vs 1.82, P = .010). Athletes participating in overhead sports reported worse upper extremity function than nonoverhead athletes (1.81 vs 0.98, P = .042). DISCUSSION: We report normative DASH values for a group of intercollegiate athletes and show a significant difference between the scores of these athletes and the general population. Within our cohort of competitive athletes, overhead sports and female gender are associated with significantly lower DASH scores and sports module scores. The utility of using these results are limited by a substantial ceiling effect in this population of competitive athletes. Differences within our cohort and differences between our cohort and other populations are minimized by this ceiling effect. Various upper extremity outcome measures may be similarly limited by a ceiling effect and should be examined for appropriateness before use. CONCLUSION: Intercollegiate athletes report significantly greater upper extremity function than the general population; however, validity of the DASH in these athletes is limited and population differences may be minimized by a substantial ceiling effect.

Athletic performance outcomes following lumbar discectomy in professional basketball players.

STUDY DESIGN: Retrospective case-control study. OBJECTIVE: To quantify the athletic performance profiles after lumbar discectomy (LD) in a cohort of National Basketball Association (NBA) players in comparison with a control group of matched NBA players who did not undergo LD during the same study period. SUMMARY OF BACKGROUND DATA: LD provides symptomatic relief and improved functional outcomes in the majority of patients as assessed by validated measures such as Oswestry Disability Index, Visual Analog Scale, and Short Form-36 (SF-36). Among professional athletes, however, the goal of lumbar HNP treated by discectomy is not only to improve functional status but also, ultimately, to return the player to preinjury athletic performance levels. No study to date has compared the athletic performance profiles before and after discectomy in professional athletes. METHODS: An analysis of NBA games summaries, weekly injury reports, player profiles, and press releases was performed to identify 24 NBA players who underwent LD for symptomatic lumbar HNP between 1991 and 2007. A 1:2 case: control study was performed using players without history of lumbar HNP who were matched for age, position, experience, and body mass index as control subjects (n = 48). Paired t tests were conducted on the following parameters: games played, minutes per game, points per 40 minutes, rebounds per 40 minutes, assists per 40 minutes, steals per 40 minutes, blocks per 40 minutes, and shooting percentage. For each athletic performance outcome, between-group comparisons evaluating preindex to postindex season performance were done (index season = season of surgery). RESULTS: In the LD group, 18 of 24 players (75%) returned to play again in the NBA, compared with 42 of 48 players (88%, P = 0.31) in the control group. One year after surgery, between-group comparisons revealed statistically significant increase in blocked shots per 40 minutes in the LD (0.18) versus control group (-0.33; P = 0.008) and a smaller decrease in rebounds per 40 minutes in the LD (-0.25) versus control group (-1.42; P = 0.049). No other performance variable was found to be significantly different between the study and control group. CONCLUSION: Compared with a closely matched control cohort, we found that 75% of surgical patients returned to play again in the NBA, compared with 88% in control subjects who did not undergo surgery. For those players who returned, overall athletic performance was slightly improved or no worse than control subjects.

Results and performance after microfracture in National Basketball Association athletes.

BACKGROUND: Microfracture technique is commonly used to treat symptomatic chondral lesions of the knee. Performance outcomes and attrition rates associated with this injury/surgery in National Basketball Association athletes are unclear. HYPOTHESIS: National Basketball Association players undergoing microfracture for symptomatic chondral lesions of the knee will have demonstrable differences in performance compared with preinjury and with matched controls. STUDY DESIGN: Case control study; Level of evidence, 3. METHODS: We evaluated 24 National Basketball Association players who underwent microfracture between 1997 and 2006. Descriptive data and performance data for the first full season preceding and following the index surgery were collected. Data were obtained from 48 matched controls. Univariate/multivariate statistical methods were used to assess change in performance and return to play. RESULTS: Thirty-three percent (8 of 24) of National Basketball Association athletes who underwent microfracture surgery never returned to play in the National Basketball Association. Fourteen players returned to play in the National Basketball Association for >1 season. Within-group comparisons revealed that points scored (P = .008) and minutes played (P = .045) were reduced postoperatively. No performance variables were significantly different when averaged over 40 minutes of play. When compared with controls, cases experienced a significant decline in points per game (P = .013). Multiple regression analysis revealed that cases were 8.15 times less likely to remain in the National Basketball Association than controls (P = .005) after the index year. CONCLUSION: Players undergoing microfracture for knee chondral injuries are at risk for not returning to the National Basketball Association postoperatively. With the exception of points per game, athletes returning exhibited similar performance postoperatively compared with matched controls.

Meniscus tissue engineering on the nanoscale: from basic principles to clinical application.

The meniscus is a fibrocartilaginous tissue uniquely adapted to enable load transmission in the knee. Although the meniscus was once considered a useless remnant of joint formation, removal of all or part of the meniscus initiates osteoarthritis. Surgical repair methods focus on fragment stabilization or biologic enhancement of healing. An alternative approach based on tissue-engineering principles involves the development of new materials for implantation. Our meniscus tissue-engineering efforts aim to recapitulate the architectural features and mechanical anisotropies essential to native tissue function. We use a novel scaffold production technology called electrospinning, in which organized three-dimensional arrays of ultrafine biodegradable fibers are generated. Using these scaffolds as micropatterns for directed growth, we have generated constructs with mechanical properties and architectural features comparable to native meniscus. This review details our progress and outlines the remaining hurdles that must be addressed to translate this work into clinical implementation.

MRI of HAGL lesions: four arthroscopically confirmed cases of false-positive diagnosis.

OBJECTIVE: The purpose of this article is to present the cases of four consecutive patients with preoperative MR diagnosis of humeral avulsion of the glenohumeral ligament (HAGL) who had no evidence of HAGL at arthroscopy. CONCLUSION: These four cases suggest that the diagnosis of HAGL should be reserved for arthroscopy and illustrate the difficulty in distinguishing HAGL from other abnormalities of the inferior glenohumeral ligament complex with MRI. Thus, MRI findings classically associated with HAGL should be more broadly described as defects of the inferior glenohumeral ligament complex. This terminology more accurately describes the abnormalities of the inferior glenohumeral ligament complex that may be depicted by MRI.

Acute and chronic management of posterolateral corner injuries of the knee.

Isolated injury to the PLC of the knee is rare. More commonly seen is injury to the PLC combined with other ligamentous and bony knee injuries, such as ACL and PCL tears and tibial plateau fractures. Prompt recognition and treatment of PLC injuries is important as failure to do so can compromise the success of PLC repair or reconstruction, as well as the success of associated ACL or PCL reconstructions. Clinical management of the PLC is dictated by the severity of injury and timing of diagnosis. A general treatment algorithm can be followed based on grade of injury, but individualized treatment is necessary for each patient and must be based on an understanding of the biomechanics of the injury and of surgical principles.

Normative SF-36 values in competing NCAA intercollegiate athletes differ from values in the general population.

BACKGROUND: The Short Form-36 (SF-36) is a valid and reliable generic indicator of health status. The scoring distributions for the general and specific populations have been extensively reported in the literature and vary according to age, gender, the type and severity of a medical condition, and socioeconomic status. However, normative data pertaining specifically to athletic populations are limited. The purpose of the present study was to establish SF-36 reference norms for athletes cleared for participation in intercollegiate sports. METHODS: Six hundred and ninety-six United States National Collegiate Athletic Association Division-I and II student athletes who had been cleared for participation in intercollegiate sports completed the self-administered form of the SF-36 at the time of pre-participation evaluations. Demographic information and history of injuries were also recorded. RESULTS: Compared with the general population and an age-matched sample of the general population, the athletes scored significantly higher in all health domains (p < 0.01) except for bodily pain (p = 0.05). Among the athletes, men scored significantly higher than women in the general health domain only (p = 0.0006). Athletes with no reported history of injury scored significantly higher than those with previous injuries in all health domains, except in role limitations due to emotional problems. CONCLUSIONS: Intercollegiate athletes cleared for participation reported significantly higher SF-36 scores in comparison with a similarly aged sample of the general population. These normative values are important in the evaluation of health status of intercollegiate athletes before and after intervention.

Case series utilizing drop-out casting for the treatment of knee joint extension motion loss following anterior cruciate ligament reconstruction.

STUDY DESIGN: Case series. CASE DESCRIPTION: Four patients who had developed knee extension motion loss following anterior cruciate ligament reconstruction were referred to physical therapy for treatment. They were treated with drop-out casting and completed a Lower Extremity Functional Scale at baseline, at the time of application of the drop-out casting, and at discharge. OUTCOMES: Three males and 1 female with a mean age of 20.5 years (range, 18-22 years) were referred to physical therapy a mean of 31 days (range, 19-49 days) following bone-patella tendon-bone autograft anterior cruciate ligament reconstruction. The mean number of physical therapy sessions attended was 29.5 visits (range, 20-47 visits). The mean improvement in knee extension range of motion (ROM) and knee flexion ROM prior to the application of drop-out casting was 4.3 degrees (range, -1 degree to 10 degrees) and 24.3 degrees (range, 0 degree to 40 degrees), respectively. The mean improvement on the Lower Extremity Functional Scale was 10.3 points prior to drop-out casting. At time of discharge, the total mean improvement in knee extension ROM loss was 11.0 degrees (range, 4 degrees to 15 degrees), knee flexion ROM was 30.8 degrees (range, 22 degrees to 35 degrees), and Lower Extremity Functional Scale was 12 points (range, -5 to 21 points). Two of the patients were able to complete a running program without difficulty, while the other 2 patients had difficulty with higher-level activities. DISCUSSION: Despite the low incidence of knee extension ROM loss following surgery, the inability to achieve full knee extension does occur and can have debilitating consequences. When early emphasis of full passive knee extension has been inadequate, these results suggest that improving knee extension motion without inhibiting knee flexion motion is possible with the use of a drop-out cast. Future research should focus on comparison of drop-out casting to dynamic splinting, as well as the optimal frequency and duration of low-load long-duration stretching using a drop-out cast.