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ABSTRACT: Purpose: Little is known of the potential long term gait alterations that occur after an anterior cruciate ligament (ACL) reconstruction. In particular, variables such as impact loading which have been previously associated with joint deterioration have not been studied in walking and running after an ACL reconstruction. The purpose of this study was to define the alterations in impact forces, loading rates, and the accompanying sagittal plane kinematic and kinetic mechanics at the time of impact between the ACL reconstructed group and a healthy control group.Methods: 40 females (20 ACL reconstruction, 20 controls) participated in the study. An instrumented gait analysis was performed on all subjects. Between group and limb comparisons were made for initial vertical impact force, loading rate, sagittal plane knee and hip angles as well as moments.Results: During walking and running the ACL cohort had significantly greater initial vertical impact force (p=0.002 and p= 0.001), and loading rates (p=0.03 and p= 0.01), as well as a smaller knee extensor moment and hip angle during walking (p=0.000 and p=0.01). There was a trend towards a smaller knee moment and hip angle during running (p=0.08 and p=0.06) as well as a larger hip extensor moment during walking (p=0.06) in the ACL group. No differences were found for hip extensor moment during running, knee angles between groups during walking or running. Lastly, no between limb differences were found for any variable.Conclusion: Gait deviations such as elevated impact loading and loading rates do not resolve long term after the individual has resumed previous activity levels and may contribute to the greater risk of early joint degeneration in this population.
Medicine and science in sports and exercise 04/2013; · 3.71 Impact Factor
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ABSTRACT: BACKGROUND:Serum cartilage oligomeric matrix protein (sCOMP) is a biomarker for cartilage degradation. Patient-reported outcomes (PRO) are used to document postinjury recovery and may be used to prospectively identify changes in the course of a season. It is unknown what effect intense, continuous physical activity has on sCOMP levels and PRO values in athletes over the duration of a soccer season.Hypothesis/ PURPOSE:The purpose of this study was to longitudinally document sCOMP levels and to determine whether changes in PROs occur in collegiate soccer athletes during a season. The hypotheses tested were that sCOMP levels and PRO scores would remain stable over the duration of the spring soccer season. STUDY DESIGN:Case series; level of evidence, 4. METHODS:Twenty-nine National Collegiate Athletic Association Division-I soccer athletes (18 men, 11 women; age, 19.6 ± 1.2 years; height, 177.8 ± 7.4 cm; mass, 73.8 ± 10.2 kg) participated in 3 (pre-[T(1)], mid-[T(2)], and postseason [T(3)]) data collection sessions. Subjects were included if they were participants in the spring soccer season and were free of severe knee injury at the time of data collection. At each session, subjects completed PROs (Lysholm, International Knee Documentation Committee scores) before serum collection. RESULTS:For sCOMP (ng/mL), there was a significant effect for time, with significant increases at T(2) (1723.5 ± 257.9, P < .001) and T(3) (1624.7 ± 231.6, P = .002) when compared with T(1)(1482.9 ± 217.9). For each of the PROs, there was a significant effect for time from T(1)-T(3), and at T(2)-T(3) for the IKDC. CONCLUSION:These data indicate sCOMP levels increased as athletes reported an increased level of function over time. However, the differences in sCOMP levels did not reach the calculated minimal detectable change (MDC) value and the differences in PRO scores did not reach previously calculated MDC values. It is unclear whether these increases in sCOMP levels were caused by an increase in cartilage matrix breakdown or turnover. Even though these elevations may not be clinically meaningful, this biomarker may have the potential to be used for future research studies investigating the effects of exercise on overall joint health in longitudinal studies. In addition, these results indicate fluctuations in sCOMP occur during a competitive season and must be taken into consideration for future biomarker studies.
The American journal of sports medicine 09/2012; · 3.61 Impact Factor
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ABSTRACT: PURPOSE: Localized articular cartilage degeneration in the patellofemoral joint is a common but yet understudied condition in younger patients. The purpose of this paper was to determine whether there are significant differences in radiographic alignment between those with and without isolated lateral patellofemoral degeneration. METHODS: Subjects with isolated symptomatic lateral patellofemoral degeneration and control subjects with no radiographic degeneration participated in the study. Variables of interest included the Caton-Deschamps index, sulcus angle, lateral patellofemoral angle, Dejour classification of trochlear dysplasia, patella linear displacement and the tibial tubercle-trochlear groove distance. RESULTS: We found significant differences between the patellofemoral degeneration group versus control group, respectively, for the Caton-Deschamps index (1.12 ± 0.1 vs. 1.00 ± 0.1), lateral patellofemoral angle (10.6 ± 4.3 vs. 16.6 ± 5.5) and tibial tubercle-trochlear groove distance (16.6 ± 4.0 vs. 9.0 ± 4.3). However, we found no difference in the sulcus angle (141.2 ± 8.2 vs. 137.0 ± 6.0), patella linear displacement (3.7 ± 1.9 vs. 4.0 ± 1.7) or in the Dejour Classification. CONCLUSION: It appears that isolated lateral patellofemoral degeneration is associated with specific radiographic indices. Even though the radiographic measures in patients with degeneration may not be considered pathologic, they are "high normal" and may represent a risk factor for the development of focal chondral degeneration in the lateral trochlea and patella. LEVEL OF EVIDENCE: III.
Knee Surgery Sports Traumatology Arthroscopy 01/2012; · 2.21 Impact Factor
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ABSTRACT: Degenerative, retracted, massive rotator cuff tears present surgeons with distinct challenges. Patient selection is key to a successful outcome. Treatment strategies range from non-operative to progressively more complex surgical options, including debridement, partial repair, complete repair utilizing margin convergence and interval slides, tendon transfers, arthrodesis, and arthroplasty. The rationale behind each of these options and more are discussed along with guidance for selecting the appropriate treatment strategy for individual patients. Outcomes of various treatment approaches are discussed as well to facilitate surgeons to successfully manage patients with retracted and degenerative tears of the rotator cuff.
Medicine and sport science. 01/2012; 57:153-67.
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ABSTRACT: Tendinopathy of the long head of the biceps is a common cause of anterior shoulder pain. As such, the anatomy and function of the tendon as well as its pathophysiology and different treatment methods have been studied extensively. The pathophysiology is a spectrum beginning with inflammation and leading to tendon degeneration. Different clinical tests and imaging modalities may all be employed to help aid in diagnosis. Conservative management is the first-line treatment, but surgical intervention may be warranted. In general, tenotomy or tenodesis is performed depending, among other things, on the age and activity level of the patient. There are several different methods for tenodesis, each with certain advantages and disadvantages. Patient factors must be considered when choosing the optimal treatment.
Medicine and sport science. 01/2012; 57:76-89.
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ABSTRACT: Female runners have a high incidence of developing patellofemoral pain. Abnormal mechanics are thought to be an important contributing factor to patellofemoral pain. However, the contribution of abnormal trunk, hip, and foot mechanics to the development of patellofemoral pain within this cohort remains elusive. Therefore the aim of this study was to determine if significant differences during running exist in hip, trunk and foot kinematics between females with and without patellofemoral pain.
32 female runners (16 patellofemoral pain, 16 healthy control) participated in this study. All individuals underwent an instrumented gait analysis. Between-group comparisons were made for hip adduction, hip internal rotation, contra-lateral pelvic drop, contra-lateral trunk lean, rearfoot eversion, tibial internal rotation, as well as forefoot dorsiflexion and abduction
The patellofemoral pain group had significantly greater peak hip adduction and hip internal rotation. No differences in contra-lateral pelvic drop were found. A trend towards reduced contra-lateral trunk lean was found in the patellofemoral pain group. No significant differences were found in any of the rearfoot or forefoot variables but significantly greater shank internal rotation was found in the patellofemoral pain group.
We found greater hip adduction, hip internal rotation and shank internal rotation in female runners with patellofemoral pain. We also found less contra-lateral trunk lean in the patellofemoral pain group. This may be a potential compensatory mechanism for the poor hip control seen. Rehabilitation programs that correct abnormal hip and shank kinematics are warranted in this population.
Clinical biomechanics (Bristol, Avon) 11/2011; 27(4):366-71. · 1.76 Impact Factor
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ABSTRACT: Randomized clinical trial.
To determine if females with patellofemoral pain syndrome (PFPS) who perform hip strengthening prior to functional exercises demonstrate greater improvements than females who perform quadriceps strengthening prior to the same functional exercises.
Although PFPS has previously been attributed to quadriceps dysfunction, more recent research has linked this condition to impairment of the hip musculature. Lower extremity strengthening has been deemed an effective intervention. However, research has often examined weight-bearing exercises, making it unclear if increased strength in the hip, quadriceps, or both is beneficial.
Thirty-three females with PFPS performed either initial hip strengthening (hip group) or initial quadriceps strengthening (quad group) for 4 weeks, prior to 4 weeks of a similar program of functional weight-bearing exercises. Self-reported pain, function, and functional strength were measured. Isometric strength was assessed for hip abductors, external rotators, and knee extensors. A mixed-model analysis of variance was used to determine group differences over time.
After 4 weeks, there was less mean ± SD pain in the hip group (2.4 ± 2.0) than in the quad group (4.1 ± 2.5) (P = .035). From baseline to 8 weeks, the hip group demonstrated a 21% increase (P<.001) in hip abductor strength, while that remained unchanged in the quad group. All participants demonstrated improved subjective function (P<.006), objective function (P<.001), and hip external rotator strength (P = .004) from baseline to testing at 8 weeks.
Both rehabilitation approaches improved function and reduced pain. For patients with PFPS, initial hip strengthening may allow an earlier dissipation of pain than exercises focused on the quadriceps.
The Journal of orthopaedic and sports physical therapy. 06/2011; 41(8):560-70.
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ABSTRACT: Evaluating change in patients over time can be challenging to any health care provider. Response shift theory is based on the change typology of alpha, beta, and gamma change and proposes that residual changes in self-response measures occur over time. These changes are the result of recalibration, reconceptualization, and reprioritization of internal standards and references utilized for self-appraisal. Failing to account for response shift may result in over- or under-reporting of true physiologic change. The purpose of this paper is to review the components of response shift, identify research designs used to detect it, and present a model for its practical application to rehabilitation of both acute and chronic disabilities. Awareness of response shifts throughout the rehabilitation process may be beneficial in guiding patient goal-setting, treatment, and education. Of particular emphasis is the role that the rehabilitation specialist can have in using the response shift process to result in the highest possible perceived quality of life for each individual patient.
Journal of allied health 01/2011; 40(1):31-8.
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ABSTRACT: Lateral epicondylitis usually responds well to nonoperative management. A limited number of refractory cases may require surgical intervention. The objective of this study was to assess the outcome of arthroscopic release of the extensor carpi radialis brevis (ECRB) tendon in a consecutive series of patients.
A retrospective review of 36 patients with lateral epicondylitis treated surgically between January 2001 and January 2004 was performed. There were 24 men and 12 women averaging 42 years at the time of surgery. In all patients, nonoperative management failed, and they underwent surgery at a mean of 19 months after the onset of symptoms. An arthroscopic release of the ECRB was performed. Data collection was performed by an independent examiner.
Operative findings included 28% of patients with significant intra-articular synovitis and 36% with a Baker type 1 lesion, 39% with a type 2 lesion, and 25% with a type 3 lesion. At a mean follow-up of 3.5 years, the mean Mayo Clinic elbow score was 11.1 (range, 5 to 12). By use of visual analog scales, pain improved from 1.5 +/- 1.3 preoperatively to 8.1 +/- 2.4 at follow-up (P < .01). Of the patients, 10 (31%) reported mild pain with strenuous activities and 2 (6%) received no benefit from the procedure. Patients required a mean of 3.8 weeks to return to regular activities and 7 weeks to return to full work duties. No serious complications were identified.
Arthroscopic release of the ECRB is a viable option for recalcitrant lateral epicondylitis. This procedure appears to be safe and effective and allows for management of associated intra-articular pathology.
Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 07/2010; 19(5):651-6. · 1.93 Impact Factor
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ABSTRACT: The use of osteochondral allografts to treat focal osteochondral lesions continues to gain popularity, supported by long-term results. Clinicians must be knowledgeable concerning the possible risks of disease transmission, graft rejection, infection, and graft failure to advise the patient and obtain an informed consent. With advancing scientific and clinical research, future operative indications will likely continue to expand. A significant amount of literature regarding storage methods has recently been published; it is hoped that continued research will lead to techniques for prolonged graft storage to prevent availability concerns.
Clinics in sports medicine 05/2009; 28(2):285-301, ix. · 1.33 Impact Factor
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ABSTRACT: Functional exercises are often used in strengthening programs after lower extremity injury. Activation levels of the stabilizing hip muscles have not been documented.
To document the progression of hip-muscle activation levels during 3 lower extremity functional exercises.
Cross-sectional.
Laboratory.
44 healthy individuals, 22 women and 22 men. Intervention: Subjects, in 1 testing session, completed 3 trials each of the lunge (LUN), single-leg squat (SLSQ), and step-up-and-over (SUO) exercise.
Root-mean-square muscle amplitude (% reference voluntary muscle contraction) was measured for 5 muscles during the 3 exercises: rectus femoris (RF), dominant and nondominant gluteus medius (GMed_D and GMed_ND), adductor longus (ADD), and gluteus maximus (GMX).
The RF, GMAX, and GMed_D were activated in a progression from least to greatest during the SUO, LUN, and SLSQ. The progression for the GMed_ND activation was from least to greatest during the SLSQ, SUO, and then LUN. Activation levels of the ADD showed no progression.
Progressive activation levels were documented for muscles acting on the hip joint during 3 functional lower extremity exercises. The authors recommend using this exercise progression when targeting the hip muscles during lower extremity strengthening.
Journal of sport rehabilitation 03/2009; 18(1):91-103. · 1.07 Impact Factor
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ABSTRACT: Although a tibial inlay technique for posterior cruciate ligament reconstruction is advantageous, metallic screw fixation of the bone block is required. This may pose problems for future surgery (eg, osteotomies, total knee replacement).
There is no significant difference in the biomechanical integrity of bone block fixation using stainless steel versus bioabsorbable screw fixation of the tibial inlay graft in posterior cruciate ligament reconstruction.
Controlled laboratory study.
Fourteen human cadaveric knees were randomized to receive either stainless steel or bioabsorbable screw fixation of a bone-patellar tendon-bone graft. Cyclic tensile testing of each construct was performed, followed by a load-to-failure test. Digital video digitization was used to optically determine tendon graft deformation.
Cyclic creep deformation showed no significant difference between the 2 groups (P = .8). The failure load (stainless steel, 461 +/- 231 N; bioabsorbable, 638 +/- 492 N; P = .7) and linear stiffness (stainless steel, 116 +/- 22 N/mm, bioabsorbable, 106 +/- 44 N/mm; P = .6) also showed no significant difference between the 2 groups. Optically measured graft deformation was not significant for distal (P = .7) and midsubstance (P = .8) regions, while proximal deformation was significantly higher for bioabsorbable fixation (P = .02). All samples failed at the tibial insertion site with the tibial bone block fracturing at the screws.
Bioabsorbable screw fixation using a tibial inlay technique does not compromise the strength and stiffness characteristics afforded by metallic fixation. From a biomechanical perspective, bioabsorbable screws are a viable alternative to metal in the context of tibial inlay reconstruction.
Use of bioabsorbable fixation can potentially eliminate future hardware problems after posterior cruciate ligament reconstruction using a tibial inlay technique.
The American journal of sports medicine 02/2009; 37(4):748-53. · 3.61 Impact Factor
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ABSTRACT: Transosseous patellar tunnels commonly are used in the repair of acute or chronic patellar tendon or quadriceps tendon ruptures. Commonly, a small diameter (2.0-3.5 mm) drill bit is used to create these drill tunnels. However, drill bits are relatively brittle and susceptible to breakage. The use of a larger diameter smooth Steinmann pin (3/32") is recommended to create transosseous patellar tunnels to eliminate this potential complication.
The journal of knee surgery 08/2007; 20(3):249-50.
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ABSTRACT: Foot injuries are common in athletes. Injuries to the midfoot and, particularly, the Lisfranc joint are less common, but they have a high risk of ending the athlete's season or even career. Lisfranc injuries can be difficult to diagnose, and they often lead to a disastrous outcome when missed. Weight-bearing radiographs of the foot are recommended to confirm the diagnosis, although advanced imaging also may be required. Lisfranc injuries with less than 2 mm of diastasis on weight-bearing radiographs can be treated without weight bearing in a short leg cast or a walking boot for 6 weeks. Lisfranc injuries with more significant displacement or instability require operative intervention. Physicians who evaluate athletic injuries should be vigilant not to miss these injuries. Familiarity with the subtle clinical signs of a Lisfranc injury and knowledge of the basic treatment algorithm will help clinicians manage these injuries successfully.
Clinical Journal of Sport Medicine 08/2007; 17(4):311-5. · 2.12 Impact Factor
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ABSTRACT: In the last 2 decades many authors have described the use of an isolated lateral retinacular release for the treatment of patellar instability. This review analyzes the published long-term results of this procedure for the treatment of patellar instability. The isolated use of a lateral retinacular release of the patella has not proven to be of long-term benefit for the treatment of patellar instability. It may be used as an adjunct procedure to a proximal or distal realignment of the extensor mechanism. Various pitfalls of a lateral release for patellar instability are discussed.
Sports medicine and arthroscopy review 07/2007; 15(2):57-60. · 1.16 Impact Factor
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ABSTRACT: The past 30 years have brought remarkable change in the evolution of ACL surgery. Surgeons have recognized the important role of the ACL and developed techniques for its reconstruction. As these techniques evolved, certain themes echo throughout the historical literature. Dynamic, nonisometric operations have not worked well, nor have synthetic substitutes. Perhaps most importantly, the more anatomic the reconstruction, the better it was able to restore patient function and the more predictable the result. Technological advances allowed these techniques to be refined so that they are now routinely performed with less tissue trauma, faster recovery, and reproducibly excellent results. This article reviews the historical surgical progress that has evolved coupled with overlapping controversies and concepts, which have impacted surgical changes.
The journal of knee surgery 05/2007; 20(2):95-104.
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The journal of knee surgery 02/2007; 20(1):39-40.
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The journal of knee surgery 11/2006; 19(4):278-84.
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Orthopedics 11/2006; 29(10):898-903. · 2.66 Impact Factor
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The journal of knee surgery 08/2006; 19(3):220-30.
