Neurocognitive and Reactive Return to Play Testing Protocol in Overhead Athletes Following Upper Extremity Injury.

The incidence of upper extremity (UE) injuries in sport, particularly with the shoulder and elbow in baseball/softball players, appears to be increasing yearly, especially in younger age athletes. Improving the objective criteria and testing methods used to determine return to play (RTP) readiness following non-operative or post-operative management of UE injuries is one aspect of the rehabilitation process that may significantly help in reducing reinjury rates. Currently, the majority of clinicians are still using post operative time frame and/or strength/range of motion as their main criteria for clearance to RTP following UE injury. This demonstrates an inadequate reflection of the actual unpredictable, dynamic environment athletes are returning to participate in. In our clinical experiences, objective testing to allow for clearance to sport participation should incorporate neurocognitive and reactive testing to promote improvements in the athlete's ability to dual task and focus/concentrate on the multi-dimensional tasks at hand. We know that neuroplastic changes occur following UE injury resulting in decreased proprioception and increased motor activation with simple UE tasks. Currently the research on UE return to play testing is limited. The purpose of this clinical commentary was to describe the utilization and provide reference values for a series of reactive neurocognitive UE tests, to assist with RTP, in high school and collegiate overhead athletes (baseball and softball) utilizing the Blaze Pod light system. The use of a more dynamic reactive testing battery may decrease the reinjury rates when an athlete is cleared for participation by measuring readiness in chaotic circumstances that are more reflective of the sporting environment the athlete is working to return to resulting in a greater sense of confidence, performance and prevention of reinjuries.

The Golfer's Fore, Fore +, and Advanced Fore + Exercise Program: An Exercise Series and Injury Prevention Program for the Golfer.

Golf is increasing in popularity with 24.8 million golfers in the U.S. in 2020, a 2% increase from the previous year. This number increased to 37.5 million in 2021 which can be further broken down to 25.1 million on course and 12.4 million participating in off course activities. Playing golf does not come without risk of injury, with an annual incidence between 15.8% and 40.9% in amateurs and 31% in professional golfers. Most injuries in golf occur due to overuse (82.6%) and only a small percentage occur from a single traumatic event (17.4%). Injuries most commonly occur at the low back followed by the wrist. Injury prevention programs have shown to be successful in other sports however to date there are no studies assessing a golfer's specific program. The purpose of this clinical commentary is to describe three individualized and unsupervised golf exercise programs (The Golfer's Fore, Fore+, and Advanced Fore+), of varying difficultly, designed to reduce the risk of injury, improve strength/mobility, and optimize performance. Level of Evidence: 5.

The Need To Change Return to Play Testing in Athletes Following ACL Injury: A Theoretical Model.

The incidence of knee injuries in sport, particularly involving the ACL, appears to be increasing yearly, especially in younger age athletes. Even more concerning is the frequency of ACL reinjury also appears to be increasing year after year. Improving the objective criteria and testing methods used to determine return to play (RTP) readiness following ACL surgery is one aspect of the rehabilitation process that can significantly help in reducing reinjury rates. Currently, the majority of clinicians are still using post operative time frames as their number one criterion for clearance to RTP. This flawed method demonstrates an inadequate reflection of the true unpredictable, dynamic environment athletes are returning to participate in. In our clinical experience, objective testing to allow for clearance to sport participation following an ACL injury should incorporate neurocognitive and reactive testing due to the nature of the injury typically occurs because of failed control of unanticipated reactive movements. The purpose of this manuscript is to share a neurocognitive testing sequence we currently employ consisting of 8 tests in 3 categories: Blazepod tests, reactive shuttle run tests, and reactive hop tests. The use of a more dynamic reactive testing battery may decrease the reinjury rates when an athlete is cleared for participation by measuring readiness in chaotic circumstances that are more truly reflective of the sporting environment the athlete is working to return to and in the process give them a greater sense of confidence.

Periostin-expressing Schwann cells and endoneurial cardiac fibroblasts contribute to sympathetic nerve fasciculation after birth.

BACKGROUND: The intracardiac nervous system (ICNS) is composed of neurons, in association with Schwann cells (SC) and endoneurial cardiac fibroblasts (ECF). Besides heart rhythm control, recent studies have implicated cardiac nerves in postnatal cardiac regeneration and cardiomyocyte size regulation, but cardiac SC and ECF remain understudied. During the postnatal period, the ICNS undergoes intense remodeling with nerve fasciculation and elongation throughout the myocardium, partially guided by the extracellular matrix (ECM). Here we report the origins, heterogeneity, and functions of SC and ECF that develop in proximity to neurons during postnatal ICNS maturation. METHODS AND RESULTS: Periostin lineage (Postn+) cells include cardiac Remak SC and ECF during the postnatal period in mice. The developmental origins of cardiac SC and ECF were examined using Rosa26eGFP reporter mice bred with Wnt1Cre, expressed in Neural crest (NC)-derived lineages, or tamoxifen-inducible Tcf21MerCreMer, expressed predominantly in epicardial-derived fibroblast lineages. ICNS components are NC-derived with the exceptions of the myelinating Plp1+ SC and the Tcf21+ lineage-derived intramural ventricular ECF. In addition, Postn+ lineage GFAP- Remak SC and ECF are present around the fasciculating cardiac nerves. Whole mount studies of the NC-derived cells confirmed postnatal maturation of the complex ICNS network from P0 to P30. Sympathetic, parasympathetic, and sensory neurons fasciculate from P0 to P7 indicated by co-staining with PSA-NCAM. Ablation of Postn+ cells from P0 to P6 or loss of Periostin leads to reduced fasciculation of cardiac sympathetic nerves. In addition, collagen remodeling surrounding maturing nerves of the postnatal heart is reduced in Postn-null mice. CONCLUSIONS: Postn+ cells include cardiac SC and ECF during postnatal nerve maturation, and these cells have different embryonic origins. At P7, the Postn+ cells associated with cardiac nerves are mainly Remak SC and ECF. Ablation of the Postn+ cells from P0 to P6 and also loss of Postn in Postn-null mice leads to reduced fasciculation of cardiac nerves at P7.

A specialized population of Periostin-expressing cardiac fibroblasts contributes to postnatal cardiomyocyte maturation and innervation.

During the postnatal period in mammals, the cardiac muscle transitions from hyperplasic to hypertrophic growth, the extracellular matrix (ECM) undergoes remodeling, and the heart loses regenerative capacity. While ECM maturation and crosstalk between cardiac fibroblasts (CFs) and cardiomyocytes (CMs) have been implicated in neonatal heart development, not much is known about specialized fibroblast heterogeneity and function in the early postnatal period. In order to better understand CF functions in heart maturation and postnatal cardiomyocyte cell-cycle arrest, we have performed gene expression profiling and ablation of postnatal CF populations. Fibroblast lineages expressing Tcf21 or Periostin were traced in transgenic GFP reporter mice, and their biological functions and transitions during the postnatal period were examined in sorted cells using RNA sequencing. Highly proliferative Periostin (Postn)+ lineage CFs were found from postnatal day 1 (P1) to P11 but were not detected at P30, due to a repression of Postn gene expression. This population was less abundant and transcriptionally different from Tcf21+ resident CFs. The specialized Postn+ population preferentially expresses genes related to cell proliferation and neuronal development, while Tcf21+ CFs differentially express genes related to ECM maturation at P7 and immune crosstalk at P30. Ablation of the Postn+ CFs from P0 to P6 led to altered cardiac sympathetic nerve patterning and a reduction in binucleation and hypertrophic growth with increased fetal troponin (TroponinI1) expression in CM. Thus, postnatal CFs are heterogeneous and include a transient proliferative Postn+ population required for cardiac nerve development and cardiomyocyte maturation soon after birth.

Inhibition of fibronectin polymerization alleviates kidney injury due to ischemia-reperfusion.

Fibrosis is a common feature of chronic kidney disease; however, no clinical therapies effectively target the progression of fibrosis. Inhibition of fibronectin polymerization with the small peptide pUR4 attenuates fibrosis in the liver and heart. Here, we show that pUR4 decreases renal fibrosis and tissue remodeling using a clinically relevant model of kidney injury, unilateral ischemia-reperfusion. This work highlights the benefits of inhibiting matrix polymerization, alone or in conjunction with cell-based therapies, as a novel approach to diminish the maladaptive responses to ischemic kidney injury that lead to chronic renal failure.

Technique Tip: Single-Incision Endoscopic Plantar Fasciotomy.

Two-incision endoscopic plantar fasciotomy (EPF) is an accepted surgical technique in the treatment of recalcitrant plantar fasciitis. Single-incision plantar fasciotomy is a relatively new technique in the surgeons' armamentarium; however, it is not without pitfalls, specifically poor visualization. This article aims to help the foot and ankle surgeon make a smooth transition from 2-incision EPF to single-incision EPF while maintaining optimum visualization. LEVELS OF EVIDENCE: Level V: Expert opinion.

Osteobiologics in foot and ankle surgery.

Osteobiological agents are a welcome addition to the surgeon's armamentarium. These products should always be thought of as a complement to good surgical principles and construct. As history has shown, nothing outperforms the osteogenic properties of autograft bone. Even if allograft is procured for use, an attempt should be made to combine it with autograft if possible, given the primary indexprocedure in which it will be used. Structural support from corticocancellous autografts is also greater than allografts, which lose mechanical strength during the sterilization and preservation process. Bone fillers without structural support should be used only when there are other means of cortical contact. The ability of the human skeletal system to repair itself is amazing. Osseous healing relieson a complicated series of intrinsic and extrinsic factors. Some of these factors include a stable fixation construct, nutritional status, good surgical technique, and good decision making. Autogenous bone graft remains the gold standard, and the presence of native growth factors and osteogenic cells is mandatory to repair these deformities. When this microenvironment is disruptive, nonunion may result.Understanding the mechanisms of bony healing contributes to the available osteobiologics, which give the foot and ankle surgeon additional tools to enhance the reparative process of bony defects and the ability of the foot to restore itself.

Midfoot crush injuries.

Treatment of midfoot injuries is surgical or nonsurgical, depending on the injury, the location, and the extent of the injury. Minor injuries usually heal with casting or bracing, whereas more unstable injuries typically need surgery for stability. Whether the injury is in a weight-bearing portion of the foot is also a consideration for surgery. The importance of treating midfoot injuries adequately is shown in how the midfoot is needed for function with weight bearing and its relationship between the front and the back of the foot. It is also important to ensure that the patient is able to ambulate with a reasonably normal gait.

Addressing stage II posterior tibial tendon dysfunction: biomechanically repairing the osseous structures without the need of performing the flexor digitorum longus transfer.

The clinical presentation of adult flatfoot can range from a flexible deformity with normal joint integrity to a rigid, arthritic flat foot. Debate still exists regarding the surgical management of stage II deformities, especially in the presence of medial column instability. This article reviews and discusses various surgical options for the correction of stage II flatfoot reconstructive procedures. The authors discuss their opinion that is not always necessary to transfer the flexor digitorum longus tendon to provide relief and stability in this patient population. The anatomy, diagnosis, and current treatments of flexible flatfoot deformity are discussed.

Correction of frontal plane rotation of sesamoid apparatus during the Lapidus procedure: a novel approach.

The Lapidus procedure affords correction of a multitude of first ray pathologic entities. When reconstructing the first ray using the Lapidus procedure, the relocation of the first metatarsal over the sesamoid bones with frontal plane rotation should be considered one of the key components. In the present technical report, we have described a bunion correction with emphasis on sesamoid reduction through indirect frontal plane manipulation. Our technique, borne from applied basic anatomy of the first metatarsophalangeal joint, uses intact soft tissues about the first metatarsophalangeal joint to reduce subluxed or dislocated sesamoids.

Use of femoral locking plate for salvage of failed ankle arthoplasty after trauma.

When total ankle arthroplasty fails, few good options are available for salvage. We report a case of total ankle arthroplasty displacement after trauma. The injury was initially repaired with an anterior ankle arthrodesis plate for ankle fusion. On the follow-up radiographs taken during the fourth postoperative week, internal fixation failure was noted. A second revision was undertaken, using a femoral locking plate to obtain tibiotalocalcaneal fusion. We present this case as an alternative method for developing a stable construct in revising total ankle take down.