Return to Play after Posterior Cruciate Ligament Injuries.

PURPOSE OF REVIEW: Posterior cruciate ligament injuries can be treated conservatively with a structured rehabilitation program or with surgical reconstruction. Treatment algorithms are based on a variety of factors including the patient's presentation, physical exam, and desired level of activity. The goal is to return the patient to their athletic pursuits with a stable and pain-free knee. Return to play and activities should be individualized based on the patient's injury and progression through rehabilitation. This article provides a review of the current treatments for posterior cruciate ligament injuries and the respective rehabilitation protocols, outcomes after each treatment option, and specific return to play criteria. RECENT FINDINGS: Current research shows excellent outcomes and return to play with conservative treatment of isolated posterior cruciate ligament injuries. Return to play algorithms stress the importance of quadriceps strengthening throughout the recovery process and emphasize inclusion of plyometrics and sport-specific training. Rehabilitation plays a critical role in the outcome after posterior cruciate ligament injury and the ability to return to athletics. The primary focus of post-injury or post-operative rehabilitation is to restore function, as it relates to range of motion, strength, and proprioception, while mitigating swelling and pain. The patients' desired sport and level of play dictate return to play timelines. The literature supports the use of non-operative management of isolated PCL injuries in athletes and non-athletes with excellent functional and patient-reported outcomes.

ACL Rehabilitation Progression: Where Are We Now?

PURPOSE OF REVIEW: With the increase of publications available to the rehabilitation specialist, there is a need to identify a progression to safely progress the patient through their post-operative ACL reconstruction rehabilitation program. Rehabilitation after ACL reconstruction should follow an evidence-based functional progression with graded increase in difficulty in activities. RECENT FINDINGS: Clinicians should be discouraged not to use strict time frames and protocols when treating patients following ACL reconstruction. Rather, guidelines should be followed that allow the rehabilitation specialists to progress the patient as improvements in strength, edema, proprioception, pain, and range of motion are demonstrated. Prior to returning to sport, specific objective quantitative and qualitative criteria should be met. The time from surgery should not be the only consideration. The rehabilitation specialist needs to take into account tissue healing, any concomitant procedures, patellofemoral joint forces, and the goals of the patient in crafting a structured rehabilitation program. Achieving symmetrical full knee extension, decreasing knee joint effusion, and quadriceps activation early in the rehabilitation process set the stage for a safe progression. Weight bearing is begun immediately following surgery to promote knee extension and hinder quadriceps inhibition. As the patient progresses through their rehabilitative course, the rehabilitation specialist should continually challenge the patient as is appropriate based upon their goals, their levels of strength, amount of healing, and the performance of the given task.

Clinical and Ultrasonographic Evaluations of the Shoulders of Elite Swimmers.

BACKGROUND: Shoulder pain is a common problem in competitive swimmers, but the structural alterations in elite-level competitive swimmers are not well known. HYPOTHESIS: Adaptive changes are common in the rotator cuff, bursa, labrum, and capsule in elite swimmers, and such abnormalities are related to factors concerning training and correlate with symptoms. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: The study population was the 2008 United States Olympic swimming team. All athletes completed standardized scales on shoulder pain and function and provided data on their training history and history of shoulder pain or injuries. Each athlete also underwent a comprehensive physical examination of both shoulders, followed by an evaluation of the rotator cuff, biceps, and bursa using ultrasound with dynamic images to assess for subcoracoid impingement and subacromial impingement. RESULTS: A history of shoulder pain was reported by 29 of 42 (66%) athletes. Morphological changes consistent with tendinosis were common in the biceps (33/46 shoulders; 72%) and supraspinatus/infraspinatus (44/46 shoulders; 96%). Subcoracoid impingement was seen in 17 of 46 shoulders (37%), with subacromial impingement seen in 34 of 41 shoulders (83%). There was an increased odds ratio (OR) for biceps tendinosis in older swimmers (OR, 1.92; 95% CI, 1.23-3.00; P = .004) and in swimmers who had missed a competition because of shoulder pain (OR, 9.76; 95% CI, 1.13-84.3; P = .038). There was an increased OR for rotator cuff tendinosis in swimmers who reported worse scores for pain with activities (OR, 0.10; 95% CI, 0.01-0.78; P = .028) and in those with a positive sulcus sign (OR, 33.2; 95% CI, 3.09-355; P = .004). There was an increased OR for impingement in swimmers with a positive sulcus sign (OR, 5.40; 95% CI, 0.80-36.3; P = .083), worse pain scores (OR, 0.44; 95% CI, 0.22-0.87; P = .019), and a partial rotator cuff tear (OR, 31.2; 95% CI, 3.58-272; P = .002). CONCLUSION: We found a high prevalence of rotator cuff and biceps tendinopathy, which was associated with increased symptoms. Tendinosis was also more common in swimmers with a positive sulcus sign, suggesting a role for shoulder laxity.

Rehabilitation of meniscal injury and surgery.

Meniscal cartilage plays an essential role in the function and biomechanics of the knee joint. The meniscus functions in load bearing, load transmission, shock absorption, joint stability, joint lubrication, and joint congruity. Individuals today are increasingly more active in later decades of life. Although the incidence of meniscal pathology is difficult to estimate, this increased exposure to athletic activity increases the risk of injury to these structures. Hede and coworkers reported the mean annual incidence of meniscus tears as 9.0 in males and 4.2 in females per 10,000 inhabitants. Tears were found to be more common in the third, fourth, and fifth decades of life. It has become clearer in recent decades that meniscal excision leads to articular cartilage degeneration. Degenerative changes have been found to be directly proportional to the amount of meniscus removed. Therefore, it has been generally recognized that the amount of meniscal tissue removed should be minimized, repaired, or replaced. Whether a meniscal lesion is treated conservatively or surgically, the rehabilitation program will play an important role in the functional outcome. This article will discuss these programs and the various treatment strategies employed.

Rehabilitation following meniscal repair.

It has become increasingly more evident that the meniscus plays an important role in contributing to knee joint longevity. Advances in surgical techniques by orthopaedic surgeons to repair traumatized menisci have led to better long term outcomes, decreasing the incidence of articular cartilage degeneration. Advances have also been made in rehabilitative techniques following meniscal repair. These techniques along with sound rehabilitation principles to include a criteria based progression have contributed to excellent outcomes and earlier return to function and sport. The role of the meniscus, recent advances in surgical repair and the current post-operative rehabilitation techniques employed by sports rehabilitation specialists today are discussed.