Pattern of strength recovery differences Exist in Adolescent athletes after anterior cruciate ligament reconstruction when using quadriceps versus Hamstring tendon autograft.

OBJECTIVES: To compare the timeline for post-operative quadriceps and hamstrings strength recovery following anterior cruciate ligament reconstruction (ACLR) using either a quadriceps tendon (QT) or hamstring tendon (HT) autograft. METHODS: Patients (≤18 years) who underwent ACLR using autograft QT or HT were included. Isokinetic strength was extracted at 3, 6, and 12 months post-operatively. Effects of time and graft type on quadriceps or hamstring limb symmetry index (qLSI/hLSI) was assessed with two-way repeated measures ANOVA. Between group differences at each time point were assessed with unpaired t-tests. Chi-square and Kaplan-Meir analysis analyzed the proportions of subjects able to achieve ≥90% LSI. RESULTS: A total of 75 subjects (QT n = 38 HT n = 37,15.8 years) were included. There were significant differences in qLSI, with greater symmetry within the HT group at all time points. A higher proportion of subjects with HT grafts were able to achieve ≥90% qLSI within 12 months of surgery (81% vs 45%, p = 0.001). CONCLUSION: Compared to those with HT autografts, adolescents with QT autografts demonstrate a prolonged timeline for quadriceps recovery. While mean strength values above 90% are achieved, a significantly lower percentage of QT patients are able to achieve 90% qLSI by 12 months post-op.

Anterior Cruciate Ligament Rehabilitation for the 10- to 18-Year-Old Adolescent Athlete: Practice Guidelines Based on International Delphi Consensus.

Background: There are 2 treatment options for adolescent athletes with anterior cruciate ligament (ACL) injuries-rehabilitation alone (nonsurgical treatment) or ACL reconstruction plus rehabilitation. However, there is no clear consensus on how to include strength and neuromuscular training during each phase of rehabilitation. Purpose: To develop a practical consensus for adolescent ACL rehabilitation to help provide care to this age group using an international Delphi panel. Study Design: Consensus statement. Methods: A 3-round online international Delphi consensus study was conducted. A mix of open and closed literature-based statements were formulated and sent out to an international panel of 20 ACL rehabilitation experts. Statements were divided into 3 domains as follows: (1) nonsurgical rehabilitation; (2) prehabilitation; and (3) postoperative rehabilitation. Consensus was defined as 70% agreement between panel members. Results: Panel members agreed that rehabilitation should consist of 3 criterion-based phases, with continued injury prevention serving as a fourth phase. They also reached a consensus on rehabilitation being different for 10- to 16-year-olds compared with 17- and 18-year-olds, with a need to distinguish between prepubertal (Tanner stage 1) and mid- to postpubertal (Tanner stages 2-5) athletes. The panel members reached a consensus on the following topics: educational topics during rehabilitation; psychological interventions during rehabilitation; additional consultation of the orthopaedic surgeon; duration of postoperative rehabilitation; exercises during phase 1 of nonsurgical and postoperative rehabilitation; criteria for progression from phase 1 to phase 2; resistance training during phase 2; jumping exercises during phase 2; criteria for progression from phase 2 to phase 3; and criteria for return to sports (RTS). The most notable differences in recommendations for prepubertal compared with mid- to postpubertal athletes were described for resistance training and RTS criteria. Conclusion: Together with available evidence, this international Delphi statement provides a framework based on expert consensus and describes a practice guideline for adolescent ACL rehabilitation, which can be used in day-to-day practice. This is an important step toward reducing practice inconsistencies, improving the quality of rehabilitation after adolescent ACL injuries, and closing the evidence-practice gap while waiting for further studies to provide clarity.

Rehabilitation After Pediatric and Adolescent Knee Injuries.

According to epidemiology studies, the majority of youth sports injuries presenting to primary care, athletic trainers, and emergency departments impact the musculoskeletal system. Both acute and overuse knee injuries can contribute to sports attrition before high school. Effective rehabilitation of knee injuries ensures a timely return to sports participation and minimizes the negative physical, psychological, and social consequences of becoming injured. The following article provides rehabilitation and returns to play strategies for postsurgical and nonsurgical injuries of the young athlete's knee.

THE EFFECT OF HUMERAL RETROTORSION ON PITCH VELOCITY IN YOUTH BASEBALL PLAYERS.

BACKGROUND: Pitching velocity is a critical measure of performance, but it may also play a role in the development of injury. It has been proposed that increased humeral retrotorsion (HRT) may be an advantageous adaptation among throwers, resulting in increased throwing velocity. However, there is limited published data directly investigating this relationship. PURPOSE / HYPOTHESIS: The purpose of this study was to examine the effects of HRT on pitching velocity in a group of youth baseball players. We hypothesized that there would be a positive association between pitching velocity and increased humeral retrotorsion. STUDY DESIGN: Cross-sectional cohort study. METHODS: Demographic and physical variables that may correlate to pitching velocity (age, height, weight, glenohumeral external rotation (ER) range of motion, dominant arm humeral retrotorsion and shoulder internal rotation (IR) strength) were assessed. Univariate analysis using Pearson correlation coefficients examined the relationship of each variable to pitching velocity. Significant variables were retained and entered into a multivariable regression analysis. RESULTS: All variables significantly correlated with pitching velocity (p<0.05) with the exception of ER (r = -0.169,p = 0.145). Multivariable regression model was significant and accounted for 81.7% of pitching velocity (R2 = 0.817 F(5,70) = 62.59,p<0.001). Player age (B = 1.7,p < 0.001), height (B = 0.225,p = 0.001) and shoulder IR strength (B = 0.622, p < 0.001) significantly contributed to the model. After accounting for all other variables, HRT had a non-significant (B = 0.005,p = 0.884) and very small contribution to pitching velocity adding only .005mph per degree of HRT. CONCLUSIONS: Pitching velocity in youth baseball players is strongly influenced by age, height and IR strength. In opposition to the hypothesis, the degree of humeral retrotorsion did not have a significant effect on pitching velocity. LEVEL OF EVIDENCE: Level 3.

Uninjured Youth Athlete Performance on Single-Leg Hop Testing: How Many Can Achieve Recommended Return-to-Sport Criterion?

BACKGROUND: Current anterior cruciate ligament reconstruction (ACLR) guidelines utilize single-leg hop tests (SLHTs) to assist in return-to-sport decision making. A limb symmetry index (LSI) of ≥90% is often required; however, after ACLR, most youth athletes cannot achieve this standard. Reporting the performance of age-matched normative controls will allow clinicians to compare post-ACLR performance with noninjured peers, improving the utility of SLHTs. The purpose of this study was to report hop test LSI within healthy youth athletes and determine whether athlete performance surpasses post-ACLR requirements. HYPOTHESIS: The LSI for the majority of healthy youth athletes will be ≥90%. STUDY DESIGN: Cross-sectional cohort study. LEVEL OF EVIDENCE: Level 3. METHODS: Each participant performed a single hop (SH), triple hop (TrH), crossover hop (CrH), and timed hop (TiH). A 3-trial mean was utilized to calculate an LSI (nondominant/dominant leg [self-reported kicking leg]) for each hop. The frequency of pass/fail at ≥90% LSI was calculated. Pearson correlation coefficients analyzed the relationship between the different hops, and a 2-way analysis of variance determined the effects of age and sex on LSI. RESULTS: A total of 340 participants (54% male; mean age, 10.9 ± 1.5 years; range, 8-14 years) were included. The mean LSI was >95% for each SLHT (SH, 97.9% [SD, 0.7]; TrH, 96.6% [SD, 0.6]; CrH, 96.8% [SD, 0.8]; TiH, 96.5% [SD, 0.6]). When analyzed as a test battery, only 45% of participants achieved this standard. Significantly weak to moderate correlations existed among hop tests (P < 0.01; r = 0.342-0.520). Age and sex had no effect on LSI (P < 0.05). CONCLUSION: While the mean LSI in our sample was >95% for each individual hop test, participant performance across all SLHT components varied, such that less than half of healthy athletes could achieve ≥90% LSI across all hops. CLINICAL RELEVANCE: Current guidelines require ≥90% LSI on SLHTs. The majority of healthy youth athletes could not achieve this standard, which questions the validity of this LSI threshold in youth athletes after ACLR.

Anterior Cruciate Ligament Reconstruction Rehabilitation Clinical Practice Patterns: A Survey of the PRiSM Society.

BACKGROUND: Recovery after anterior cruciate ligament (ACL) reconstruction (ACLR) requires extensive postoperative rehabilitation. Although no ideal rehabilitation procedure exists, most experts recommend a fusion of time and strength and functional measures to guide decision making for activity progression during rehabilitation. This process is often directed by surgeon protocols; however, the adoption of contemporary rehabilitation recommendations among surgeons is unknown. PURPOSE: To understand the current landscape of surgeon practice as it relates to ACLR rehabilitation recommendations in adolescent athletes. STUDY DESIGN: Cross-sectional study. METHODS: An online survey was distributed among members of the Pediatric Research in Sports Medicine (PRiSM) Society in January 2017. The survey was designed to identify clinical practice patterns during 3 key transitional points of rehabilitation after ACLR: progression to jogging, modified sports activity, and unrestricted return to sports. RESULTS: Responses from 60 orthopaedic surgeons were analyzed. While 80% of surgeons agreed upon initiating jogging within a 1-month range (3-4 months postoperatively), similar levels of agreement were only captured when including a wider 4-month (4-8 months) and 6-month range (6-12 months) for modified sports activity and unrestricted return to sports, respectively. All respondents (100%) reported using knee strength as a determinant to progress to modified sports activity; however, the mode of testing varied, with most using manual muscle testing (60%), followed by isokinetic (28%) or isometric (12%) testing. Most surgeons (68%) reported using some form of functional testing to return to modified sports activity, but the mode of testing and required progression criteria varied considerably among all reported testing procedures. The use of patient-reported outcome measures was limited to 20% of the sample, and no respondents reported using fear or self-efficacy questionnaires. Upon completion of rehabilitation, 73% recommended injury prevention programs, and 50% recommended the use of a functional ACL brace. CONCLUSION: Rehabilitation progression practices in adolescent athletes are variable and become more inconsistent as the time from surgery increases. While the majority of the sample considered strength and functional testing important, the mode of testing and criteria thresholds for activity advancement varied considerably.

Changes in humeral retrotorsion and the development of little league shoulder: A case study.

OBJECTIVE: To present the case of a 15 year-old baseball player with Little League Shoulder (LLS) and describe how developmental changes in the angle of humeral retrotorsion (HRT) may contribute to the underlying pathology of this condition. DESIGN: Case report. SETTING: Two years earlier, the patient had participated in a healthy player screening program at which time measurements of height, weight, shoulder motion, and HRT were obtained. These same measures were obtained during the initial evaluation after injury. Between measurements, the patient grew more than 12 cm in height and demonstrated a large shift in proximal humeral torsional alignment with a change of 13° and 19° of HRT in the dominant and non-dominant sides respectively. PARTICIPANT: 15 year-old male (1.88 m, 79.8 kg), right hand dominant baseball pitcher and 3rd baseman diagnosed with right LLS. CONCLUSION: The pathoanatomical factors contributing to LLS are not well understood. The degree of HRT is a developmental characteristic that changes over the course of physiological maturation. The large changes in HRT seen in this case, may implicate rapid changes in HRT angle create a window of increased susceptibility to physeal damage, and contribute to the development of LLS.

Differential Diagnosis of a Pathological Spine Fracture.

A 71-year-old woman with a 10-month history of atraumatic low back pain was referred to physical therapy after an insidious exacerbation of symptoms. Red flags raised suspicions for spinal compression fracture, necessitating the physical therapist to contact her physician and recommend imaging. Radiographs and magnetic resonance imaging were ordered, the latter of which showed an acute fracture at T10, with lesions at T9 and in the liver suggesting metastasis. Following bone scintigraphy and an ultrasound-guided biopsy of a liver lesion, she was diagnosed with metastatic breast cancer. J Orthop Sports Phys Ther 2018;48(7):595. doi:10.2519/jospt.2018.7768.

Rehabilitation Practice Patterns Following Anterior Cruciate Ligament Reconstruction: A Survey of Physical Therapists.

BACKGROUND: Recovery from anterior cruciate ligament reconstruction (ACLR) requires an intensive course of postoperative rehabilitation. Although guidelines outlining evidence-based rehabilitation recommendations have been published, actual practice patterns of physical therapists are unknown. OBJECTIVES: To analyze the current landscape of clinical practice as it pertains to rehabilitation progression and the use of time and objective criteria in rehabilitation following ACLR. METHODS: In this cross-sectional study, an online survey was distributed to members of the Academy of Orthopaedic Physical Therapy, the American Academy of Sports Physical Therapy, and the Private Practice Section of the American Physical Therapy Association between January and March 2017. RESULTS: The study analyzed a sample of 1074 responses. Supervised physical therapy was reported to last 5 months or less by 56% of survey respondents. The most frequent time frames for activity progression were 3 to 4 months (58%) for jogging, 4 to 5 months (50%) for modified sports activity, and 9 to 12 months (40%) for unrestricted sports participation. More than 80% of respondents reported using strength and functional measures during rehabilitation. Of those physical therapists who assessed strength, 56% used manual muscle testing as their only means of strength testing. Single-limb hop testing (89%) was the most frequently reported measure used to allow patients to begin modified sports activity following ACLR. Performance criteria for strength and functional tests varied significantly across all phases of rehabilitation. The 45% of respondents who reported using patient-reported outcome measures indicated that just under 10% of those measures involved fear or athletic confidence scales. CONCLUSION: Considerable variation in practice exists among American Physical Therapy Association members regarding rehabilitation following ACLR. This variability in practice may contribute to suboptimal outcomes and confusion among practitioners and patients. J Orthop Sports Phys Ther 2018;48(10):801-811. Epub 22 May 2018. doi:10.2519/jospt.2018.8264.

Physical and Functional Differences in Youth Baseball Players With and Without Throwing-Related Pain.

BACKGROUND: Identifying risk factors that contribute to shoulder and elbow pain within youth baseball players is important for improving injury prevention and rehabilitation strategies. HYPOTHESIS: Differences will exist between youth baseball players with and without a history of upper extremity pain on measures related to growth, shoulder performance, and baseball exposure. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A total of 84 youth baseball players were divided into 2 groups based on self-reported history of throwing-related arm pain. Group differences for growth-related, shoulder performance, and baseball exposure variables were analyzed by use of parametric and nonparametric tests, as appropriate. Multivariate logistic regression was used to assess variables most predictive of pain. RESULTS: The group of athletes with pain (n = 16) were taller and heavier, played more baseball per year, and had greater pitching velocity. Athletes with pain also had greater loss of internal rotation range of motion and greater side-to-side asymmetry in humeral retrotorsion (HRT), attributable to lower degrees of HRT within the nondominant humerus. Multivariate analysis revealed that player height was most predictive of pain, with a 1-inch increase in height resulting in a 77% increased risk of pain. CONCLUSION: Vertical growth that accompanies adolescence increases the risk of experiencing throwing-related pain in youth baseball players. Players who are taller, particularly those with faster pitching velocities, are at the greatest risk for developing pain and should be more carefully monitored for resultant injury. The degree of nondominant HRT may have a relationship to the development of pain, but further research is required to better understand the implications of this observation.

Humeral Retrotorsion and Glenohumeral Motion in Youth Baseball Players Compared With Age-Matched Nonthrowing Athletes.

BACKGROUND: Baseball players exhibit a more posteriorly oriented humeral head in their throwing arm. This is termed humeral retrotorsion (HRT) and likely represents a response to the stress of throwing. This adaptation is thought to occur while the athlete is skeletally immature, however currently there is limited research detailing how throwing activity in younger players influences the development of HRT. In addition, it is presently unclear how this changing osseous orientation may influence shoulder motion within young athletes. PURPOSE: To determine the influence of throwing activity and age on the development of side-to-side asymmetry in HRT and shoulder range of motion (ROM). STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Healthy athletes (age range, 8-14 years) were categorized into 2 groups based upon sports participation; throwers (n = 85) and nonthrowers (n = 68). Bilateral measurements of HRT, shoulder external rotation (ER), internal rotation (IR), and total range of motion (TROM) at 90° were performed using diagnostic ultrasound and a digital inclinometer. Side-to-side asymmetry (dominant minus nondominant side) in HRT and in shoulder ER, IR, and TROM were assessed. Statistical analysis was performed with 2-way analysis of variance and Pearson correlation coefficients. RESULTS: Throwers demonstrated a larger degree of HRT on the dominant side, resulting in greater asymmetry compared with nonthrowers (8.7° vs 4.8°). Throwers demonstrated a gain of ER (5.1°), a loss of IR (6.0°), and no change in TROM when compared with the nondominant shoulder. Pairwise comparisons identified altered HRT and shoulder ROM in all age groups, including the youngest throwers (age range, 8-10.5 years). A positive correlation existed between HRT and ER ROM that was stronger in nonthrowers ( r = 0.63) than in throwers ( r = 0.23), while a negative correlation existed with IR that was stronger in throwers ( r = -0.40) than in nonthrowers ( r = -0.27). CONCLUSION: Throwing activity causes adaptive changes in HRT and shoulder ROM in youth baseball players at an early age. Other factors in addition to HRT influence shoulder motion within this population.

Rehabilitation Following Anterior Cruciate Ligament Tears in Children: A Systematic Review.

BACKGROUND: Anterior cruciate ligament (ACL) tears are increasingly prevalent in the pediatric population. ACL rehabilitation is an essential component of recovery following injury and reconstruction, yet there are few explicit descriptions of pediatric-specific ACL rehabilitation protocols in the literature, especially in the context of varying treatment interventions. Our aim was to systematically review the literature on rehabilitation following ACL tears in children in order to describe common principles among different treatment options and areas of future research. METHODS: Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we performed a systematic review of the PubMed, EMBASE, and Cochrane databases (for the past five years) to identify detailed rehabilitation protocols described in the pediatric population following ACL rupture. When available, the following aspects of rehabilitation were extracted: "prehabilitation" (exercises prior to surgery), bracing, weight-bearing status, range of motion, strength, modalities (ice, heat, electrical stimulation, etc.), plyometrics/proprioceptive exercises, return-to-sport criteria, and suggested ACL injury-prevention programs. RESULTS: Two hundred and two unique articles were identified. Twenty-seven articles meeting inclusion criteria with extractible rehabilitation data were included. A table, categorized by differing orthopaedic intervention, was designed to detail the components and duration of the different aspects of rehabilitation. While there are substantial differences across protocols, several trends emerged, particularly regarding weight-bearing, bracing, range of motion, and strength training. Interestingly, we found that many current protocols are based on time frame alone rather than on functional milestones; of the fourteen unique articles that addressed return-to-sport criteria by specific orthopaedic intervention, seven were based on temporal progression whereas seven also involved achievement of physical milestones. In addition, only three of the eight articles that mentioned a future ACL injury-prevention plan described a formal prevention program. CONCLUSION: We systematically identified, and subsequently outlined and compared, the current trends of the various components of pediatric-specific ACL rehabilitation protocols, categorized by orthopaedic intervention. Several protocols are based on time frames rather than milestones achieved, with newer protocols involving milestone-based progression. Newer protocols are also incorporating formal prevention programs. Just as skeletally immature patients require unique methods of operative fixation, so too do they require catered rehabilitation protocols. To effectively prevent re-rupture or contralateral injury, future research should focus on prospectively evaluating each component of the rehabilitation protocols described and return-to-sport criteria for young patients.

The Development of Humeral Retrotorsion and Its Relationship to Throwing Sports.

CONTEXT: Several investigations have noted that throwing athletes exhibit a more posteriorly oriented humeral head (humeral retrotorsion) in the dominant arm. This asymmetry is believed to represent an adaptive response to the stress of throwing that occurs during childhood. The significance of this alteration and factors that affect its development are currently not clear. EVIDENCE ACQUISITION: Basic science, research studies, and review articles were searched through PubMed with search terms including humeral torsion, humeral retrotorsion, and with 1 of the following: pediatric, adult, baseball, pitching, shoulder, and range of motion. The references from each article were reviewed for further inclusion. This review included articles through March 2015. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 4. RESULTS: The throwing motion creates stressors that result in bony adaptations that occur while skeletally immature. These osseous changes likely contribute to the observed shift in the arc of rotational range of motion noted in throwing athletes and may play a protective role against injury. However, too much or too little retrotorsion may predispose the shoulder to injury. The degree of "optimal" humeral retrotorsion and factors that influence its development are not fully understood. CONCLUSION: Evidence supports the assertion that the throwing motion creates stressors that alter bony anatomy while young. It is important to determine what specific factors affect this adaptation and its relationship to injury.

Strength and functional performance recovery after anterior cruciate ligament reconstruction in preadolescent athletes.

BACKGROUND: In the skeletally immature population, the incidence of anterior cruciate ligament (ACL) injuries and ACL reconstructions appears to be increasing. Differences in surgical techniques, physiology, and emotional maturity may alter the rehabilitation progression and impact the outcomes when compared with adults. Reports of objective strength recovery and performance-based outcome measures after pediatric ACL reconstruction (ACLR) are limited. STUDY DESIGN: Retrospective case series. LEVEL OF EVIDENCE: Level 4. METHODS: All patients that underwent all-epiphyseal ACLR from January 2008 to August 2010 were identified. Isokinetic peak quadriceps/hamstring torque values and functional performance measures in unilateral hopping tasks were extracted and compared with the noninjured limb. A limb symmetry index (LSI) of ≥90% was considered satisfactory. RESULTS: Complete data were available for 16 patients (mean age, 12.28 years; range, 8.51-14.88 years). By a mean 7 months (range, 3.02-12.56 years) postoperatively, only 9 of 16 (56%) were able to achieve a satisfactory LSI for quadriceps strength. For hamstring strength, 15 of 16 (94%) were able to achieve satisfactory LSI. By a mean of 12 months (range, 5.39-24.39 months) postoperatively, only 6 of 16 subjects (38%) were able to achieve satisfactory performance on all functional hop tests. At a mean 15.42 months (range, 8.58-24.39 months) postsurgery, only 4 of 16 (25%) subjects were able to achieve an LSI of ≥90% on all testing parameters. CONCLUSION: For some pediatric patients, significant strength and functional deficits may be present at greater than 1 year after ACLR. This population may require more prolonged rehabilitation programs to allow for adequate recovery of strength and function because of unique characteristics of normal growth and development.

Fibular stress fracture in a high school athlete.

The patient was a 15-year-old adolescent male who was referred to a physical therapist for a chief complaint of bilateral posterolateral lower-leg pain, which was worse in the right lower extremity than in the left. Due to findings that were concerning for a stress fracture, the patient was referred to a pediatric sports medicine physician. Subsequent radiographs revealed findings that were concerning for a stress fracture along the medial aspect of the midshaft of the right fibula.

Rehabilitation considerations for all epiphyseal acl reconstruction.

BACKGROUND: The management of the pediatric patient with an Anterior Cruciate Ligament (ACL) rupture is evolving towards earlier reconstruction. The rehabilitation progression and outcomes for skeletally immature individuals undergoing ACL reconstruction (ACL-R) are not well described in the literature. Differences in surgical procedure, age related physiology, and emotional maturity may have a significant impact on recovery and return to sports. The purpose of this case report is to present the rehabilitation and outcome of a skeletally immature patient that underwent an all-epiphyseal ACL-R, highlight important considerations in the rehabilitation process and present topics for future research. CASE DESCRIPTION: Single subject case report of an 8 year-old boy who underwent all epiphyseal ACL-R after complete ACL rupture. OUTCOMES: The patient was able to achieve at least 90% strength symmetry and pass all necessary functional criteria to return to sports by 9 months post surgery. Two year follow up data indicated that the patient was able to make a full return to previous level of athletic activity, as well as maintain lower extremity strength and power over time. DISCUSSION: Objective outcome measures, rehabilitation protocols and time frame for return to sports for skeletally immature patients following physeal sparing or all epiphyseal ACL-R are not well described in the literature. This case report outlines objective measures of strength and functional recovery in a patient from this unique population. As ACL-R in the skeletally immature patient is studied more, new information on rehabilitation progression and outcomes may alter the rehabilitation program and timeline for return to unrestricted activity. LEVEL OF EVIDENCE: 4, Case Report.