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Objective: To assess differences in physical therapists' exercise prescription and confidence in return-to-sport readiness between girl and boy patients undergoing rehabilitation post-ACLR., Design: Cross-sectional survey., Methods: 115 physical therapist responses were collected in an electronic survey. Demographics were captured and therapists were asked to assess the appropriateness of exercises and intensity of prescription for case vignettes of an adolescent boy and girl at four different phases of post-ACLR rehabilitation. Wilcoxon signed-rank tests were performed for paired comparisons among physical therapists' responses to the boy and girl vignettes., Results: Physical therapists' exercise prescription and confidence in return-to-sport readiness differed for the boy and girl vignettes post-ACLR, specifically during the return-to-sport phase. When exercise was performed with perceived ideal form, physical therapists indicated it was more appropriate to maintain or progress the exercise for girls and had more confidence in girls' ability to return-to-sport. When the exercise was performed with perceived poor form, physical therapists indicated it was more appropriate to maintain or progress the exercise for boys and had more confidence in boys' ability to return-to-sport., Conclusion: A patient's gender may influence exercise prescription and return-to-sport expectations of physical therapists, which may contribute to disparities in patient outcomes between genders post-ACLR., Competing Interests: Declaration of Competing interest Gregory D. Myer consults with commercial entities to support commercialization strategies and applications to the US Food and Drug Administration but has no direct financial interest in commercialization of the products. Dr. Myer's institution receives current and ongoing grant funding from National Institutes of Health/NIAMS (grants U01AR067997, R01AR070474, R01AR055563, R01AR076153, R01AR077248, and R61AT012421), the Department of Defense (grant W81XWH22C0062), and the Arthritis Foundation Osteoarthritis Clinical Trial Network. Dr. Myer has received industry-sponsored research funding to his institutions related to injury prevention and sport performance and has current ongoing funding from Arthrex Inc. to evaluate ACL surgical treatment optimization strategies. Dr. Myer receives author royalties from Human Kinetics and Wolters Kluwer. Dr. Myer is an inventor of biofeedback technologies (patent US11350854B2, Augmented and Virtual Reality for Sport Performance and Injury Prevention Application, approved July 6, 2022, software copyrighted) designed to enhance rehabilitation and prevent injuries, which receives licensing royalties. There are no other author conflicts of interest to disclose., (Copyright © 2025 Elsevier Ltd. All rights reserved.)

Background: Considerable variability exists in the described clinical and radiographic indications for use, surgical techniques, postoperative management, and risk profile after trochleoplasty for the management of patellofemoral instability (PFI). In areas of clinical uncertainty, a cohesive summary of expert opinion and identification of areas of variation in current practice can be useful in guiding current practice and future research efforts., Purpose: To assess the current indications for use, surgical techniques, postoperative rehabilitation practices, and observed complication profile for trochleoplasty in the management of PFI among surgeons who perform this procedure., Study Design: Cross-sectional study., Methods: A 21-item cross-sectional survey was developed to evaluate trochleoplasty in its current practice among surgeons around the world. The survey was distributed between December 2021 and April 2022 to the orthopaedic surgeon membership of multiple national and international knee, arthroscopy, and sports medicine societies to identify any surgeon with experience performing the trochleoplasty procedure in practice for the management of PFI. Descriptive statistics of survey responses were performed to address study aims, and univariate analyses were performed to compare differences between high- and low-volume trochleoplasty surgeons., Results: Survey distribution identified 32 orthopaedic surgeons with experience performing the trochleoplasty procedure. Procedural indications were most commonly felt to be met with Dejour classification of B or D on magnetic resonance imaging. Trochleoplasty was felt by most to be appropriate as a primary surgical intervention for PFI. A majority of surgeons utilized a Bereiter (thin-flap) trochleoplasty technique with suture-based fixation and performed concurrent medial patellofemoral ligament reconstruction, but other concomitant procedures varied. Range-of-motion precautions and bracing practices varied among respondents, and arthrofibrosis was the most frequently cited observed complication. High- and low-volume trochleoplasty surgeons differed in their radiographic and age-based indications for the procedure., Conclusion: Study findings indicated that variation exists in the surgical indicators, technique, and postoperative rehabilitation practices of trochleoplasty surgeons, with specific differences noted between high- and low-volume trochleoplasty surgeons. The results of this survey identified areas of equipoise and treatment variation that should direct future research efforts in the study of the trochleoplasty procedure., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: B.A.W. has received education payments from Arthrex. J.A.S. has received education payments from Arthrex and Micromed and nonconsulting fees from Arthrex. L.H.R. has received education payments from Gotham Surgical and honoraria from AcelRx Pharmaceuticals. N.A.F. has received education payments and nonconsulting fees from Arthrex. S.N.P. has received consulting fees from Pfizer. J.L.P. has received education payments from Arthrex, consulting fees from Arthrex and JRF Ortho, and nonconsulting fees from Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2025.)

Context: Social determinants of health including insurance type, income, race, and ethnicity have been shown to influence the utilization of physical therapy and recovery after an orthopedic injury. The influence of social determinants of health on the utilization of physical therapy and recovery from concussion is not well understood., Design: Prospective observational registry study in a specialty concussion program., Methods: Patients diagnosed with a concussion using the Postconcussion Symptom Inventory and the visio-vestibular examination (VVE) who were also referred to physical therapy were included. The main outcomes of interest were the number of days from referral to initial physical therapy evaluation and the number of physical therapy visits completed. Information related to patients' age, race, ethnicity, sex, insurance type, and Child Opportunity Index was extracted from the registry. Multivariate and univariate regressions were used to assess the associations of each sociodemographic characteristic with the outcomes., Results: A total of 341 patients diagnosed with concussion between January 2017 and December 2023 met inclusion criteria. The average age was 14.77, and 64% were female. Patients' age, race, ethnicity, insurance type, and Child Opportunity Index were not associated with days to evaluation or length of care in physical therapy. Higher PCSI scores in children under 12 years (coefficient: 0.17, 95% CI, 0.06-0.29) and female sex (coefficient: 1.2, 95% CI, 0.26-2.1) were associated with a longer course of care in physical therapy. Patients with an abnormal VVE score had on average 2.1 more physical therapy visits than those with a normal VVE score (coefficient: 2.1, 95% CI, 0.73-3.5)., Conclusions: Higher PCSI scores in children, female sex, and higher VVE scores in general predicted a longer course of care in physical therapy. Implementation of a clinical care pathway for concussion care using the PCSI and the VVE may be one strategy to help mitigate systemic factors that might otherwise negatively influence access to physical therapy.

Background: Axial extensor mechanism alignment is routinely assessed in patients with patellofemoral instability.Although many of these assessments are described using magnetic resonance imaging, it is plausible that ultrasound (US) imaging could be utilized to provide similar information in a more cost-effective and time-efficient manner., Purpose: To (1) describe and assess the reliability of a novel measure of extensor mechanism alignment of the patellofemoral joint using musculoskeletal US and (2) establish the construct validity of this measure through comparison of patients with and without patellar instability., Study Design: Cohort study (diagnosis); Level of evidence, 3., Methods: Patients with (n = 24; 14.2 ± 3.1 years; 83% female) and without (n = 26; 14.7 ± 2.8 years; 69% female) a clinical history of patellofemoral instability (PFI) participated. Extensor mechanism alignment was assessed bilaterally on US, measuring the distance between the midpoint of the patellar tendon to the lateral trochlear ridge (MPT-LTR). Interrater reliability of the measurements was assessed using the intraclass correlation coefficient (ICC), with a minimum of 1 week between measurements for test-retest reliability. Differences between limbs were assessed using paired-samples t tests, and between-group differences were compared using independent-samples t tests., Results: Patients with PFI demonstrated a significantly smaller MPT-LTR distance than healthy controls on both their involved (8.1 ± 3.6 vs 12.6 ± 2.6 mm) and uninvolved (8.9 ± 3.4 vs 12.9 ± 2.4 mm) limbs ( P  < .001 for both), indicating greater lateralization of the patellar tendon relative to the trochlea. There were no differences found between limbs for either patients with PFI ( P  = .26) or controls ( P  = .46). Interrater reliability was good (ICC = 0.785; 95% confidence interval [CI], 0.579-0.890), and test-retest reliability (n = 8) was excellent (ICC = 0.958; 95% CI, 0.790-0.992)., Conclusion: The US-based MPT-LTR distance demonstrated good-to-excellent reliability. When compared with controls, the MPT-LTR distance was smaller in patients with PFI, indicating greater lateralization of the extensor mechanism., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: B.W. has received education payments from Arthrex and hospitality payments from Smith & Nephew and Stryker. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2024.)

Medial patellofemoral ligament (MPFL) reconstruction, typically used to restore stability to the patellofemoral joint after dislocation, often requires extensive rehabilitation to address acute impairment related to surgical intervention and also underlying non-anatomical deficits that may have contributed to the index injury. Rehabilitation guidelines, including objective functional performance assessment criteria, are lacking in the literature. We sought to summarize the clinical guidelines for rehabilitation and return to activity assessment after MPFL reconstruction as advocated by the member organizations of the Pediatric Research in Sports Medicine (PRiSM) Patellofemoral Research Interest Group (PF-RIG). We obtained and reviewed MPFL rehabilitation guidelines from 11 member organizations of the PRiSM PF-RIG, extracting information on weight-bearing advancement, bracing, use of supplemental strengthening modalities, and any objective criteria for advancing rehabilitation phases. We found highly variable agreement among guideline parameters at each treatment stage, with time-based criteria most widely used for early progression. Although functional metrics like strength or movement tests were more widely used in later phases of rehabilitation, there was substantial variation in testing mode and level of acceptable performance. Our review found that significant variability exists in current practice among PRiSM and PF-RIG member institutions regarding rehabilitation standards after MPFL reconstruction. Although we found broad consensus that objective strength or performance criteria should be employed to establish a better framework for clinical decision-making, most current guidelines lack standardization and sufficient detail to guide ideal clinical practice., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

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., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Purpose: To compare the clinical and patient-reported outcomes of adolescent patients who underwent anterior cruciate ligament reconstruction (ACLR) with quadriceps tendon (QT) versus hamstring tendon (HT) autograft., Methods: This was a retrospective cohort study of adolescent patients aged 18 years or younger treated at a single tertiary care children's hospital who underwent primary transphyseal ACLR using QT or HT between January 2018 and December 2019. All patients had minimum 6-month follow-up. Outcomes included isokinetic strength testing, postoperative Patient-Reported Outcomes Measurement Information System and International Knee Documentation Committee scores, and complications; these were compared between the QT and HT cohorts., Results: A total of 84 patients (44 HT and 40 QT patients) were included. The QT cohort had a higher proportion of male patients (62.5% vs 34.1%, P = .01). At 3 months, HT patients had a lower hamstring-quadriceps (H/Q) strength ratio (60.7 ± 11.0 vs 79.5 ± 18.6, P < .01) and lower Limb Symmetry Index in flexion (85.6 ± 16.1 vs 95.5 ± 15.7, P = .01) whereas QT patients had a lower Limb Symmetry Index in extension (67.3 ± 9.5 vs 77.4 ± 10.7, P < .01). The H/Q ratio at 6 months was lower in HT patients (59.4 ± 11.5 vs 66.2 ± 7.5, P < .01). Patient-Reported Outcomes Measurement Information System and International Knee Documentation Committee scores were not different at 3 months or latest follow-up. QT patients had more wound issues (20.0% vs 2.3%, P = .01). Patients receiving HT autograft had more ipsilateral knee injuries (18.2% vs 2.5%, P = .03), but there was no difference in graft failure for ACLR using HT versus QT (9.1% vs 2.5%, P = .36)., Conclusions: There were no differences in patient-reported outcome measures between patients receiving QT autografts and those receiving HT autografts. Patients with QT grafts had more postoperative wound issues but a lower rate of ipsilateral knee complications (graft failure or meniscal tear). Differences in quadriceps and hamstring strength postoperatively compared with the contralateral limb were observed for adolescent ACLR patients receiving QT and HT autografts, respectively. This contributed to higher H/Q ratios seen at 3 and 6 months postoperatively for patients receiving QT autografts., Level of Evidence: Level III, retrospective comparative therapeutic study., Competing Interests: Disclosures The authors report the following potential conflicts of interest or sources of funding: I.G. receives travel support from Stryker and receives educational support from Liberty Surgical, outside the submitted work. R.L.P. receives educational support from Gotham Surgical Solutions and Devices and receives personal fees from Stryker and DePuy Synthes Sales, outside the submitted work. T.J.G. receives grant support for unrelated research from Vericel and receives personal fees from Arthrex, outside the submitted work. All other authors (J.T.B., A.C.S., E.G., and C.J.D.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Full ICMJE author disclosure forms are available for this article online, as supplementary material., (Copyright © 2023 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Objective: To compare physical therapy (PT) utilization, timing of return-to-sport (RTS) test and hop test performance by age and between sexes in youth after anterior cruciate ligament reconstruction (ACLR)., Design: Multicenter retrospective cohort., Methods: A retrospective review of adolescents after primary ACLR was conducted. Participants completed return-to-sport (RTS) tests including single-legged hop testing. PT frequency, average weekly visits, and timing of RTS test were calculated. T-tests assessed the effect of age and sex on average weekly PT visits and multivariable logistic regressions assessed odds of passing hop tests., Results: 289 participants were included (15.7 ± 1.9 years). There was no difference in average weekly PT visits (p = 0.321) or time to RTS test (p = 0.162) by age. There were significant differences in average weekly PT visits (p = 0.047) and mean time from surgery to RTS test (p = 0.048) between sexes with small effect sizes (d = 0.24 and d = 0.21, respectively). Age and sex had no effect on odds of passing hop tests (OR, 1.29; 95% CI, 0.71-2.35 and OR, 0.79; 95%CI, 0.43-1.45, respectively)., Conclusion: In a youth cohort, age and sex may have no clinically important effect on PT visit utilization, timing of RTS test or hop test performance., Competing Interests: Declaration of competing interest None, (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Objective: Assess inter- and intra-rater reliability of the Qualitative Analysis of Single Leg Squat (QASLS) during a single-leg triple hop landing in subjects following anterior cruciate ligament reconstruction (ACLR). Explore if differences in reliability existed between novice and experienced clinicians. Determine if QASLS scores differed between the surgical and nonsurgical limbs., Design: Repeated Measures., Participants: 20 subjects ≥6 months post-ACLR., Methods: Subjects were recorded performing a single-leg triple hop bilaterally. Videos were independently rated by five raters (2 physical therapists and 3 physical therapy students). Intraclass correlation coefficient (ICC) was calculated to measure reliability of the QASLS on the surgical limb. Wilcoxon signed-rank test was utilized to assess if differences in QASLS scores existed between limbs., Results: The cumulative inter-rater reliability was moderate (ICC (2,1): 0.703) and the cumulative intra-rater reliability was good (ICC (3,1): 0.857). Little difference was found between experienced and novice raters for inter- and intra-rater reliability. There was no statistically significant difference in QASLS scores between limbs (P = 0.64)., Conclusion: The QASLS tool offers moderate inter- and good intra-rater reliability for evaluating movement quality during a single-leg triple hop landing, irrespective of rater experience. Additionally, there was no observed difference in QASLS scores between surgical and nonsurgical limbs., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

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., Competing Interests: The authors declared that there are no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2023.)

Background: COVID-19 restrictions created a period of disrupted sports participation for youth athletes. The physical conditioning, sports training habits, and patterns of sports activity resumption upon returning to normal sports activity are currently unknown., Purpose/hypothesis: This study aimed to determine the extent to which youth athletes maintained their training levels during the early stages of the COVID-19 pandemic and understand the strategies that enhanced motivation and adherence to a training regimen while in isolation. A secondary aim was to analyze how youth athletes returned to activity and identify injuries associated with prolonged sports interruption., Study Design: Observational / Survey Study., Methods: A survey designed to determine activity changes, type of organized instruction, and athlete preferences for training support were distributed by email using snowball sampling methodology to athletes 14-21 years old who were involved in competitive sports when pandemic restrictions were enacted. As sports activities resumed, a follow-up survey was distributed to the same respondents to identify feelings of preparedness, training habits, and injuries., Results: Of the155 subjects (mean age 16.1 ± 2 years, 64.5% female) that completed the initial survey, 98% reported a stoppage of in-person sports participation and 70% decreased their exercise/training volume, with 41% (n=63) reporting > 50% reduction. Most athletes (86%) received instruction from coaches, with written workouts (70%) being most common; however, most athletes (70%) preferred instructor-led, group training sessions. Of the 43 subjects that completed the follow-up survey (34% response rate), there was an increase in athletic exposures compared to mid-pandemic levels, and 25% reported sustaining a sports-related injury shortly after resuming sports activities., Conclusions: Pandemic-related sports restrictions resulted in a significant reduction in youth athlete training and conditioning. Coaches attempted to maintain training via the use of written workouts; however, athletes preferred instructor-led, group training sessions. There was a rapid resumption of sports activities, which may have contributed to the high rate of injuries in this study., Level of Evidence: 3., Competing Interests: We, the authors, affirm that we have no financial or commercial affiliations related to the performance or outcome of this manuscript.

Objective: Examine the effect of insurance type on physical therapy (PT) utilization and outcomes within pediatric and adolescent patients after anterior cruciate ligament reconstruction., Design: Multicenter retrospective cohort study., Methods: PT visits and functional hop test performance were extracted into a shared database. The average number of PT visits per week was assessed overall and by time period. Independent samples t-test examined the effect of insurance on PT utilization and the effect of insurance status on the odds of passing single-legged hop tests was assessed using multivariable logistic regression., Results: A total of 281 patients (15.7 ± 1.9, 42% female) were included in this analysis. Of these, 128 (45%) had public insurance. Publicly insured patients experienced a longer delay from surgery to hop test (8.3vs7.7 months, p = 0.009), attended overall fewer PT visits per week (0.92vs1.04, p = 0.005), with most of the decreased frequency occurring between weeks 7-24. Insurance status had a significant effect on the odds of passing the single leg hop test (2.72; 95%CI, 1.27-5.81)., Conclusion: Publicly insured patients average a lower number of weekly PT visits, experienced a longer delay from surgery to hop testing and were 2.7 times less likely to pass the single leg hop for distance test., Competing Interests: Declaration of competing interest We, the authors, affirm that we have no financial or commercial affiliations related to the performance or outcome of this manuscript., (Copyright © 2022. Published by Elsevier Ltd.)

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., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: The aim of this systematic review was to evaluate studies reporting on the effects of therapeutic ultrasound on the physis., Summary of Key Points: Eight studies were included in the final analysis, all of which were animal studies. At higher doses, studies found skin and bone necrosis and inhibition of growth, while in lower doses some studies found that ultrasound had a transient stimulatory effect on growth, increased thickness of the hypertrophic zone, and increased thickness of the whole growth plate. Overall, experimental evidence in animal models suggests that therapeutic ultrasound, even at low doses, might induce microscopic changes to the histology of the growth plate., Conclusion: While we found no reports of growth disturbance in humans, given the histological changes found in animal studies, the current limited literature seems to support the recommendation that the application of therapeutic ultrasound around the physis should be avoided., Competing Interests: The authors declare no conflicts of interest, (Copyright © 2021 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.)

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.

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 (R 2 = 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., Competing Interests: Conflict of Interest Statement: We, the authors, affirm that we have no financial or commercial affiliations related to the performance or outcome of this manuscript., (© 2020 by the Sports Physical Therapy Section.)

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., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: T.J.G. has received educational support from Arthrex and Liberty Surgical. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

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., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

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.

Background: Surgical outcomes following isolated posterior cruciate ligament reconstruction (PCLR) have been noted to be less satisfactory than the anterior cruciate ligament. Limited understanding of optimal rehabilitation has been implicated as a contributing factor., Hypothesis/purpose: The purpose of this review was to gather the literature related to isolated PCLR rehabilitation, extract and summarize current rehabilitation guidelines, identify timeframes and functional measurements associated with common rehabilitation topics and provide recommendations for future research., Study Design: Literature review., Methods: A literature review was performed for scientific publications that include a detailed rehabilitation program following isolated PCLR, published between January 2005 and March 2018. Data related to weight-bearing, knee range of motion (ROM), brace usage, specific exercise recommendations and suggestions for return to running and sport activities were extracted and categorized., Results: A total of 44 articles met inclusion criteria. Post-operative weight-bearing was discussed in 35 articles with recommendations ranging from no restriction to 12 weeks of limitations. Forty-two articles recommended the use of immediate post-operative bracing, the majority of which positioned the knee in full extension, with duration of use ranging from one to 12 weeks post-operatively. Although 30 articles offered detailed descriptions of ROM activity, there was significant variability in timing of initiation, angular excursion and progression of range of motion. Suggested timeframes for returning to sports activity ranged from four to 12 months, with only four articles providing specific objective strength or functional performance criteria necessary for progression., Conclusions: There is substantial variation in nearly all aspects of published descriptors of rehabilitation following isolated PCLR. Most protocols are based upon biomechanical principles and clinical expertise, relying solely on timeframe from surgery to support rehabilitation decision making. Evidence to compare patient outcomes with specific loading, ROM progression and exercise strategies is currently lacking. Only a small number of protocols incorporate the use of specific objective performance goals to facilitate return to sport decision making.

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.

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., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: A portion of this study was funded by the Legacy Fund Grant awarded by the Sports Section of the American Physical Therapy Association.

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.

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.

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., (© 2015 The Author(s).)

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.

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.

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.

The scapula plays an important role in shoulder function and requires both significant mobility and stability. Normal motion is 3-dimensional, and during arm elevation consists of upward rotation, posterior tilting, and external rotation as well as clavicular elevation and retraction. Examination should include visual observation, symptom alterations tests, testing of muscle strength, and flexibility of key structures including the pectoralis minor, posterior shoulder and thoracic spine. Treatment consists of graded resistive exercise, neuromuscular retraining, stretching, manual therapy, and taping where necessary. Although several studies suggest a relationship between abnormal scapular motion and symptoms, strong evidence directly supporting a causal relationship is lacking and further work is necessary to clarify this relationship.