Age-, Sex-, and Graft-Specific Reference Values From 783 Adolescent Patients at 5 to 7 Months After ACL Reconstruction: IKDC, Pedi-IKDC, KOOS, ACL-RSI, Single-Leg Hop, and Thigh Strength.

OBJECTIVE: To describe age-, sex-, and graft source-specific reference values for patient-reported, physical function, and strength outcome measures in adolescents at 5 to 7 months after anterior cruciate ligament reconstruction. DESIGN: Cross-sectional study. METHODS: Data were collected at 3 universities and 2 children's hospitals. The participants completed at least one of the International Knee Documentation Committee (IKDC) Subjective Evaluation Form, Pediatric IKDC (Pedi-IKDC), Knee Injury and Osteoarthritis Outcomes Score (KOOS), and Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) Scale. Participants also completed single-leg hop tests and/or isokinetic quadriceps and hamstrings strength assessments (at 60°/s). Reference values were summarized using descriptive statistics and stratified for age, sex, and graft source. RESULTS: Reference values were reported for common patient-reported outcomes and measures of physical function and strength from 783 participants (56% females, age = 16. 4 ± 2.0 years) who were in early adolescence (12-14 years, N = 183, 52% females), middle adolescence (15-17 years, N = 456, 58% females), or late adolescence (18-20 years, N = 144, 55% females). Three hundred seventy-nine participants (48.4%) received a bone-patellar tendon-bone autograft, 292 participants (37.3%) received hamstring tendon autograft, and 112 participants (14.3%) received autograft or allograft from an alternative source. CONCLUSION: Reference values for common patient-reported outcomes and measures of physical function and strength differed depending on a patient's age, sex, and graft source. Using patient-specific reference values, in addition to previously described age-appropriate cutoff values, may help clinicians monitor and progress patients through rehabilitation and return to physical activity after anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 2023;53(4):1-8. Epub: 23 January 2023. doi:10.2519/jospt.2023.11389.

A Displaced Double-Layered Meniscus in a Caucasian Patient: A Case Report.

CASE: Double-layered menisci are a rare anatomical variant, with cases identified predominantly in Asian populations. We present a case of Caucasian woman with a double-layered lateral meniscus, in which the accessory lateral meniscus had displaced into the intercondylar notch causing feelings of instability within the right knee. The accessory lateral meniscus was removed through arthroscopic surgery, and the patient had complete resolution of her symptoms postoperatively. CONCLUSION: Double-layered menisci can present similar to bucket-handled meniscus tears if the accessory meniscus displaces into the intercondylar notch. Arthroscopic debridement can be effective at improving clinical symptoms for these patients.

Shoulder Range of Motion Deficits in Youth Throwers Presenting With Elbow Pain.

BACKGROUND: Glenohumeral internal rotation deficit (GIRD) and total arc of motion difference (TAMD) have been associated with elbow injuries in throwing athletes. HYPOTHESIS: Youth pitchers with elbow pain will have greater GIRD and TAMD compared with youth pitchers without elbow pain. STUDY DESIGN: Cross-sectional study. LEVEL OF EVIDENCE: Level 3. METHODS: Glenohumeral range of motion of 25 consecutive throwing athletes presenting with elbow pain and that of a matched control group of 18 asymptomatic throwing athletes were compared. Bilateral glenohumeral internal rotation, external rotation, and horizontal adduction at 90° were measured and GIRD and TAMD were then calculated. An analysis of variance was performed to compare range of motion between throwers with and without elbow pain. RESULTS: The average GIRD of the elbow pain group was 32.7° compared with 14.5° in the control group (P < 0.05). The average TAMD in the elbow pain group was 28.3° compared with 6.7° in the control group (P < 0.05). GIRD and TAMD were present in 88% (22 of 25) and 96% (24 of 25) of the elbow pain group versus 33.3% (6 of 18) and 55.6% (10 of 18) of the control group, respectively. CONCLUSION: Compared with asymptomatic youth pitchers, those presenting with elbow pain have a statistically significant GIRD and TAMD. CLINICAL RELEVANCE: This study suggests that a GIRD and TAMD may predispose youth pitchers to present with symptomatic elbow pain.

Comparison of Glenohumeral Range of Motion Deficits in Youth, Collegiate, and Professional Baseball Players.

BACKGROUND: Examining range of motion deficits across levels of baseball competition can result in a better understanding of the extent of altered range of motion patterns and identify competition levels that may require preventative interventions that target the deficits. PURPOSE: The purpose of this study was to compare shoulder range of motion in baseball players across levels of competition and compare the prevalence of glenohumeral internal rotaton deficit (GIRD) and total arc of motion differences (TAMD) between competition levels in pitchers and position players. STUDY DESIGN: Prospective descriptive cohort. METHODS: Passive internal and external rotation range of motion was measured bilaterally. Individuals with current pain in the arm, shoulder, elbow or shoulder surgery within the prior two years were excluded. Measurements were taken during pre-season physical examinations. Players were divided into seven groups: 12u (11-12 years; n=30), 14u (13-14 years; n=30), High School 1 (HS 1; 15-16 year; n=42), High School 2 (HS 2; 17-18 years; n=25), College (n=22), Professional 1 (Pro1; 17-22 years; n=37) and Professional 2 (Pro2; 23 and older; n=37). Multiple one-way analyses of variance were performed to determine differences between groups. Tukey test for post-hoc analysis was employed to determine which competition levels were significantly different. RESULTS: Two-hundred and twenty-three male baseball players ages 11-26 participated. The 12u (53.7°) and 14u (54.2°) groups had significantly less internal rotation than HS1 (65.2°), HS2 (63.9°), College (62.3°), Pro1 (64.9°), and Pro2 (64.5°) players (p<0.0001). The 12u, 14u, HS1, college, and Pro2 groups had greater than 50% of players with total arc of motion differences >5°. Conclusions: Range of motion alterations exist across ages and levels of competition with 12u and 14u players having less internal rotation than the older groups and youth pitchers having less total range of motion than HS1. LEVEL OF EVIDENCE: 2.

Blumensaat Line as a Prediction of Native Anterior Cruciate Ligament Length.

BACKGROUND: Graft-tunnel mismatch (GTM) is a condition in which the anterior cruciate ligament (ACL) graft is either too long or too short. GTM is particularly problematic when bone-patellar tendon-bone grafts are used because of a potential compromise in fixation of the bone plug on the tibia. HYPOTHESIS: The Blumensaat line (BL), a radiographic landmark representing the roof of the intercondylar fossa, will accurately approximate the native ACL (nACL) length and may aid in the prevention of GTM. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: A total of 130 patients (66 males, 64 females) underwent direct measurement of the nACL during knee arthroscopy. The lengths of the nACL and patellar ligament (PL) were measured intraoperatively, and BL length was measured on lateral knee radiographs. The nACL length was compared with PL and BL lengths to calculate the absolute difference (AD). Mean AD was calculated and used to determine mean percentage difference (MPD). Pearson correlation coefficients (CC) between BL, PL, and nACL length were calculated, along with inter- and intraobserver reliability coefficients for the measurement of BL. RESULTS: For male patients, the mean length of the nACL was 32.5 mm, BL was 30.4 mm, and PL was 49.2 mm. The AD between the BL and nACL was 2.4 ± 1.3 mm, MPD was 2.6% ± 1.9%, and CC was 0.88. The CC between the PL and nACL was 0.08. For female patients, the mean length of the nACL was 30.2 mm, BL was 27.5 mm, and PL was 44.4 mm. The AD between the BL and nACL was 2.7 ± 1.7 mm, MPD was 4.5% ± 2.4%, and CC was 0.93. The CC between the PL and nACL was 0.1. The inter- and intraobserver reliability coefficients for the measurement of BL were 0.86 and 0.83, respectively. CONCLUSION: A strong correlation was found between BL and nACL with a high inter- and intraobserver reliability. This correlation provides a simple and reliable method to closely approximate nACL length before reconstruction and may aid in the prevention of graft-tunnel mismatch.

Decision making in the throwing athlete.

The throwing athlete represents a very interesting and challenging patient population to treat. Few other athletes require the unique combination of stability combined with inherent laxity to allow them to achieve peak performance. Treatment of them and their injuries necessitates an understanding of this phenomenon, recognition of common pathologies encountered, and experience in the process. In this section, we will review several of the most common entities that we encounter in the care of throwing athletes and the current literature on these topics as well as describing our approach to the decision-making process with regards to their treatment. We will also review our surgical techniques for each of these when nonoperative care has failed or acute intervention is deemed necessary.