Evidence-Based Physical Examination for the Diagnosis of Subscapularis Tears: A Systematic Review.

CONTEXT: There is a renewed interest in diagnosing and treating subscapularis tears, but there is a paucity of clinical guidance to optimize diagnostic decision-making. OBJECTIVE: To perform a literature review to evaluate advanced maneuvers and special tests in the diagnosis of subscapularis tears and create a diagnostic algorithm for subscapularis pathology. DATA SOURCES: PubMed, MEDLINE, Ovid, and Cochrane Reviews databases. STUDY SELECTION: Inclusion criteria consisted of level 1 and 2 studies published in peer-reviewed scientific journals that focused on physical examination. STUDY DESIGN: Systematic review. LEVEL OF EVIDENCE: Level 2. DATA EXTRACTION: Individual test characteristics (bear hug, belly press, lift-off, Napoleon, and internal rotation lag sign) were combined in series and in parallel to maximize clinical sensitivity and specificity for any special test evaluated in at least 2 studies. A secondary analysis utilized subjective pretest probabilities to create a clinical decision tree algorithm and provide posttest probabilities. RESULTS: A total of 3174 studies were identified, and 5 studies met inclusion criteria. The special test combination of the bear hug and belly press demonstrated the highest positive likelihood ratio (18.29). Overall, 3 special test combinations in series demonstrated a significant impact on posttest probabilities. With parallel testing, the combination of bear hug and belly press had the highest sensitivity (84%) and lowest calculated negative likelihood ratio (0.21). CONCLUSION: The combined application of the bear hug and belly press physical examination maneuvers is an optimal combination for evaluating subscapularis pathology. Positive findings using this test combination in series with a likely pretest probability yield a 96% posttest probability; whereas, negative findings tested in parallel with an unlikely pretest probability yield a 12% posttest probability.

A 71-year-old man with a rare rhabdoid brain tumour: using a multidisciplinary medical and rehabilitative model of care.

Atypical rhabdoid tumours (AT/RTs) of pineal origin are rare in adults with rapid progression and poor prognosis. We present the case of a 71-year-old man with confusion and memory loss who was diagnosed with a pineal AT/RT after genetic analysis. Due to his limited functional capacity and goal to return home with family, a multidisciplinary care approach was essential for coordination of medical management, radiation treatment and acute inpatient rehabilitation. After diagnosis and rehabilitation, his functional ability improved allowing him to tolerate cranial irradiation, initiate systemic chemotherapy and eventually returned home for a brief period with an improved quality of life. His progress was temporary due to rapid progression of the tumour. He required additional aggressive oncological treatment and was admitted for subsequent inpatient rehabilitation before opting for hospice care. This case underscores the importance of a multidisciplinary approach to cancer treatment in a patient with a rare and aggressive brain tumour, while respecting the individual goals of patients and their families.

Analysis of Football Injuries by Position Group in Division I College Football: A 5-Year Program Review.

OBJECTIVE: The purpose of this study was to evaluate injury characteristics by position groups. DESIGN: Prospective, observational study. SETTING: A single, major Division I collegiate football program. PARTICIPANTS: All players on a collegiate football program each fall regular season. INDEPENDENT VARIABLES: Exposure to Division I collegiate football and position groups. MAIN OUTCOME MEASURES: Injury rates (IRs) per 1000 athlete exposures (AEs) and injury rate ratios (IRRs) were calculated and analyzed for all monitored injury variables, which included time in the season, body part, type of injury, game and practice injuries, mechanism of injury, and type of exposure. RESULTS: During the 2012 to 2016 fall regular seasons, there were 200 reported injuries sustained from 48 615 AE. The overall 5-year IR was 4.11 per 1000 AEs (3.57-4.72 95% confidence intervals). Skill players sustained the highest IR in the preseason (IR, 7.56) compared with line (IR, 4.26) and other (IR, 4.10) position groups. In addition, skill players demonstrated a significantly higher IRR compared with the line (IRR, 1.75, P < 0.05) and other (IRR, 1.85, P < 0.05) position groups. CONCLUSIONS: Skill players sustained most of their injuries in the preseason, whereas the linemen and other position groups suffered most of their injuries in the first half of the regular season. Skill players demonstrated a significantly higher IR in preseason, noncontact mechanism injuries, and injuries to the upper leg and thigh compared with line and other position groups. Efforts to reduce soft-tissue muscle strains in skill players targeting the preseason may provide one of the best opportunities to significantly decrease current football IRs, whereas efforts to reduce contact exposures may have the greatest effect on concussions and contact mechanism injuries for the other position group. There were no significant differences in IRs between position groups and type of exposure.

Evaluating strategies and outcomes following rotator cuff tears.

INTRODUCTION: Rotator cuff tear surgical repair techniques have significantly progressed. However, tendon retear following primary repair persistently occurs at high rates. Rehabilitation protocols, surgical fixation techniques, biologic therapy with scaffolds, platelet-rich plasma, and even stem cell applications are under study to promote adequate tendon healing. METHODS: A nonsystematic query of the PubMed database was conducted in July 2016 utilizing the search terms "rotator cuff repair," "tear," "rehabilitation," "scaffold," "platelet-rich plasma," and "stem cell" to identify, analyze, and summarize relevant studies. CONCLUSION: Individualized rehabilitation protocols may be the best approach for small to medium sized tears. Surgical fixation will continue to be debated as modifications to single-row technique and increases in suture number have improved tensile strength. Double-row repairs have been associated with higher costs. Transosseous equivalent technique exhibits comparable subjective and objective outcomes to single- and double-row repair at two-year follow-up. Biocompatible scaffold augmentation has showed inconsistent short-term results. Platelet-rich plasma has lacked uniformity in treatment preparation, administration, and outcome measurement with mixed results. Few human studies have suggested decreased retear rates and improved repair maintenance following bone marrow-derived mesenchymal stem cell augmentation. This review reiterated the necessity of additional high-quality, large-sample studies to develop any final verdict regarding efficacy.

Factors Affecting Return to Play After Primary Achilles Tendon Tear: A Cohort of NFL Players.

BACKGROUND: Achilles tendon tears are potentially career-ending injuries for professional athletes. For players in the National Football League (NFL), return requires not only surgery and extensive rehabilitation but also the ability to compete in a market with limited positions that annually introduces new recruits. PURPOSE/HYPOTHESIS: We authors sought to evaluate factors related to return to play (RTP) and changes in performance following a primary Achilles tear. Our hypothesis was that "skilled" position players and those drafted in later rounds would return at a lower rate as compared with "unskilled" position players and higher draft-round players. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: From a previously established database, 80 NFL players were identified as having primary Achilles tendon tears between the 2009 and 2014 seasons. RTP was defined as playing in a regular season or postseason game following injury. Probability of RTP was modeled as a function of time after injury in Kaplan-Meier analysis with demographic variables assessed via generalized linear models. Twelve players (15%) experienced a subsequent Achilles tendon tear during or after the study period and were included in the overall RTP rate but were excluded from performance analyses owing to the confounding effects of an ipsilateral retear or contralateral tear. RESULTS: The overall RTP rate was 61.3%. Age, number of prior seasons, position type, or draft round status did not significantly affect RTP when evaluated with Kaplan-Meier analysis. In the season before their injury, players who did RTP played in a significantly greater number of regular season games (13.7) compared with players who did not RTP (8.71) (P = .011). Players who did not RTP exhibited a significant decrease in performance in the season preceding injury (12.7 regular season games played 2 seasons preinjury vs 8.71 regular season games played 1 season prior preinjury;, P = .019). Players who returned did not display a significant change in the number of games played or started in seasons following injury when >1 season after return was evaluated. CONCLUSION: Rate of RTP following primary Achilles tendon tears may be lower than previously published. However, for those able to return, performance only in the season immediately following injury appears to be affected; players return to preinjury levels if given the opportunity to play >1 season after injury.

Effect of Concussions on Lower Extremity Injury Rates at a Division I Collegiate Football Program.

BACKGROUND: Football has one of the highest injury rates (IRs) in sports, ranging from 4.1 to 8.6 per 1000 athlete-exposures (AEs). Previous research has reported that athletes may be at an increased risk of suffering lower extremity (LE) injuries after a concussion. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate the rate of LE injuries in collegiate football athletes after a concussion. We predicted that the overall LE IR would increase after a concussion and that each position group would also demonstrate a similar increase in LE injuries after a concussion. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Daily attendance and injury records were prospectively collected by licensed team medical providers for the 2012 through 2016 college football regular seasons. Each injury report included the date of injury, position group, body part injured, and type of injury. IRs per 1000 AEs with 95% CIs were calculated to evaluate LE injuries at different time points after a concussion (remainder of season, next season, any additional seasons) and by months (<6 months, 6-12 months, >12 months). Mid-P exact tests were utilized to establish injury rate ratios (IRRs) to compare the IR between variables. RESULTS: There was no significant difference in LE IRRs between the athletes post- versus preconcussion (P = .20) or between the postconcussion and no concussion (control) athletes (P = .08). There was an increased LE IR beyond 12 months in the postconcussion group (IR, 9.08 [95% CI, 3.68-18.89]) compared with the no concussion group (IR, 2.88 [95% CI, 2.04-3.96]) (IRR, 3.16 [95% CI, 1.21-7.15]; P = .02). Line position players had an increase in LE injuries after a concussion (IRR, 6.22 [95% CI, 1.31-23.68]; P = .03) compared with linemen with no concussion. CONCLUSION: There was no initial increase in LE IRs immediately after a concussion; however, there was an increased LE IR more than 12 months after a concussion. There was no increase in LE IRs demonstrated by skill and other position groups. Line position players experienced an increased LE IR the next season after a concussion or greater than 12 months after the injury.

Previous foot injuries associated with a greater likelihood of Achilles tendon ruptures in professional American football players.

OBJECTIVES: The purpose of this study was to build on current understanding of Achilles tendon (AT) ruptures in football through the examination of lower extremity injury rates (IR) in the season prior to AT rupture. METHODS: An online review was conducted to document AT ruptures in the National Football League (NFL) from the 2010-11 through 2016-17 seasons. Player-specific information was gathered through the online search, injury reports, or video analysis. Injury incidence was recorded for each season. Descriptive statistics were calculated for all variables. IRs per 1000 athlete-exposures with 95% confidence intervals (CI) were established. Injury rate ratios (IRR) with 95% CI were calculated to evaluate differences in IR with statistical significance established at p < 0.05. RESULTS: From the 2010-11 to 2016-17 NFL seasons, 109 AT ruptures were identified. 36 athletes participated in the NFL the season prior and sustained a total of 40 injuries. Thirty-two (32/40, 80%) of the injuries involved the lower extremity. The most frequent body parts injured in the NFL season prior to AT rupture were the knee (n = 8, 22.5%), upper leg and thigh (n = 7, 17.5%), lower leg and shin (n = 5, 12.5%), and ankle (n = 5, 12.5%). The overall IR for the AT rupture group was not significantly different than the NFL group (IRR: 0.94, 0.68-1.31 95% CI, p = 0.73). The AT rupture group demonstrated a significantly increased rate of foot injuries compared to the NFL cohort (IRR: 2.58, 1.16-5.77 95% CI, p = 0.02). CONCLUSION: There was an increased identified incidence of AT ruptures in the NFL from 2010 to 2017 compared to AT ruptures reported from 1997 to 2002. There was no significant difference in lower extremity IR the season prior to AT rupture. Only foot injuries demonstrated an increased IR the season prior to AT rupture compared to an NFL cohort. Eleven athletes sustained 2 AT ruptures and all 11 players sustained the subsequent AT rupture to the contralateral limb.

A concise evidence-based physical examination for diagnosis of acromioclavicular joint pathology: a systematic review.

OBJECTIVES: The clinical examination of the shoulder joint is an undervalued diagnostic tool for evaluating acromioclavicular (AC) joint pathology. Applying evidence-based clinical tests enables providers to make an accurate diagnosis and minimize costly imaging procedures and potential delays in care. The purpose of this study was to create a decision tree analysis enabling simple and accurate diagnosis of AC joint pathology. METHODS: A systematic review of the Medline, Ovid and Cochrane Review databases was performed to identify level one and two diagnostic studies evaluating clinical tests for AC joint pathology. Individual test characteristics were combined in series and in parallel to improve sensitivities and specificities. A secondary analysis utilized subjective pre-test probabilities to create a clinical decision tree algorithm with post-test probabilities. RESULTS: The optimal special test combination to screen and confirm AC joint pathology combined Paxinos sign and O'Brien's Test, with a specificity of 95.8% when performed in series; whereas, Paxinos sign and Hawkins-Kennedy Test demonstrated a sensitivity of 93.7% when performed in parallel. Paxinos sign and O'Brien's Test demonstrated the greatest positive likelihood ratio (2.71); whereas, Paxinos sign and Hawkins-Kennedy Test reported the lowest negative likelihood ratio (0.35). CONCLUSION: No combination of special tests performed in series or in parallel creates more than a small impact on post-test probabilities to screen or confirm AC joint pathology. Paxinos sign and O'Brien's Test is the only special test combination that has a small and sometimes important impact when used both in series and in parallel. Physical examination testing is not beneficial for diagnosis of AC joint pathology when pretest probability is unequivocal. In these instances, it is of benefit to proceed with procedural tests to evaluate AC joint pathology. Ultrasound-guided corticosteroid injections are diagnostic and therapeutic. An ultrasound-guided AC joint corticosteroid injection may be an appropriate new standard for treatment and surgical decision-making. LEVEL OF EVIDENCE: II - Systematic Review.

Effect of position, time in the season, and playing surface on Achilles tendon ruptures in NFL games: a 2009-10 to 2016-17 review.

OBJECTIVES: Achilles tendon (AT) ruptures are a potentially career-altering and ending injury. Achilles tendon ruptures have a below average return-to-play rate compared to other common orthopaedic procedures for National Football League (NFL) players. The objective of this study was to monitor the incidence and injury rates (IR) of AT ruptures that occurred during the regular season in order to evaluate the influence of player position, time of injury, and playing surface on rupture rates. METHODS: A thorough online review was completed to identify published injury reports and public information regarding AT ruptures sustained during regular season and post-season games in the National Football League (NFL) during the 2009-10 to 2016-17 seasons. Team schedules, player position details and stadium information was used to determine period of the season of injury and playing surface. IRs were calculated per 100 team games (TG). Injury rate ratios (IRR) were utilized to compare IRs. RESULTS: During eight monitored seasons, there were 44 AT ruptures in NFL games. A majority of AT ruptures were sustained in the first eight games of the regular season (n = 32, 72.7%). There was a significant rate difference for the first and second four-game segments of the regular season compared to the last two four-game segments of the regular season. Defensive players suffered a majority of AT ruptures (n = 32, 72.7%). The IR on grass was 1.00 per 100 TG compared to 1.08 per 100 TG on artificial turf (IRR: 0.93, p = .80). CONCLUSION: A significant increase in AT ruptures occurred in the first and second four game segments of the regular season compared to the last two-four game segments of the regular season. Defensive players suffered a majority of AT ruptures compared to offensive or specialist players. There was no difference between AT rupture rates and playing surface in games.

A practical, evidence-based, comprehensive (PEC) physical examination for diagnosing pathology of the long head of the biceps.

BACKGROUND: Clinical examination of the shoulder joint has gained attention as clinicians aim to use an evidence-based examination of the biceps tendon, with the desire for a proper diagnosis while minimizing costly imaging procedures. The purpose of this study is to create a decision tree analysis that enables the development of a clinical algorithm for diagnosing long head of biceps (LHB) pathology. METHODS: A literature review of Level I and II diagnostic studies was conducted to extract characteristics of clinical tests for LHB pathology through a systematic review of PubMed, Medline, Ovid, and Cochrane Review databases. Tests were combined in series and parallel to determine sensitivities and specificities, and positive and negative likelihood ratios were determined for each combination using a subjective pretest probability. The "gold standard" for diagnosis in all included studies was arthroscopy or arthrotomy. RESULTS: The optimal testing modality was use of the uppercut test combined with the tenderness to palpation of the biceps tendon test. This combination achieved a sensitivity of 88.4% when performed in parallel and a specificity of 93.8% when performed in series. These tests used in combination optimize post-test probability accuracy greater than any single individual test. CONCLUSION: Performing the uppercut test and biceps groove tenderness to palpation test together has the highest sensitivity and specificity of known physical examinations maneuvers to aid in the diagnosis of LHB pathology compared with diagnostic arthroscopy (practical, evidence-based, comprehensive examination). A decision tree analysis aides in the practical, evidence-based, comprehensive examination diagnostic accuracy post-testing based on the ordinal scale pretest probability.

Effect of Exposure Type and Timing of Injuries in Division I College Football: A 4-year Single Program Analysis.

BACKGROUND: Football players compete with a high risk of injury due to the sport. With the recent efforts to improve safety, the National Collegiate Athletic Association (NCAA) established new terminology to clearly define exposure types and reduce the number of high contact exposures. OBJECTIVES: To compare football injury rates (IR) with a focus on game versus practice, time in season of injury, mechanism of injury and utilizing recent exposure types defined by the NCAA (live contact, full-pads and non-contact). METHODS: Licensed medical professionals monitored a college football program regular season from 2012-2015. Each injury was classified by timing of the injury, mechanism of injury, and whether it occurred in game or practice. Player attendance and type of exposure (non-contact, full-pad or live contact, which involves live tackling to the ground and/or full-speed blocking and can occur in full-pad or half-pad ('shell') equipment) was documented. IR were calculated per 1000 athlete-exposures (AE). Mid-exact P tests compared rates between variables. RESULTS: The game IR was over three times as high as the practice IR (p < .001). Live contact exposures had the greatest IR of 5.702/1000 AE and were seven times more likely to produce an injury compared to non-contact exposures (p < .001); whereas, live contact exposures were about two times more likely to produce an injury compared to full-pad exposures (p = .004). The majority of injuries observed occurred from a contact mechanism (IR: 2.508/1000 AE). The highest IR during the fall football season occurred in the pre-season at 5.769/1000 AE. CONCLUSION: Overall IR observed in this cohort were lower than prior studies published before recent NCAA rule changes and guideline implementation to improve athlete safety. Athletes in this cohort were at significantly increased risk of injury from live contact exposures.

Hybrid Graft Anterior Cruciate Ligament Reconstruction: A Predictable Graft for Knee Stabilization.

Trauma to the anterior cruciate ligament (ACL) is a season-ending injury and involves months of activity modification and rehabilitation. The annual incidence of ACL tears in the United States is approximately 200,000, which allows for a broad range of individualized treatment options. Various surgical techniques, including transtibial and independent tunnel drilling, allograft and autograft tissue, and various implants, have been described in the literature. This article describes the indications and technique for a hybrid soft tissue graft for ACL reconstruction. Autologous grafts eliminate the risk of disease transmission and have recently been shown to have a lower rerupture rate, particularly in younger, active patients; however, the harvesting of autologous hamstring grafts carries a risk of donor-site morbidity, iatrogenic injury of the graft, and inadequate graft size. In contrast to a traditional autologous soft tissue graft, the hybrid graft allows for graft size customization for a desired reconstruction, especially in cases where autograft hamstrings may be iatrogenically damaged or of inadequate size when harvested. The goal of a hybrid graft ACL reconstruction is to provide a favorable-sized graft with clinical outcomes comparable with autologous soft tissue grafts. In contrast to a traditional autologous soft tissue graft, this technique provides another option in the event of unforeseen deficiencies or complications associated with harvesting and preparation of the autologous gracilis and semitendinosis soft tissue graft.