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Case report.Traumatic glenohumeral dislocations with concomitant rotator cuff and capsular injuries present a unique and challenging surgical and rehabilitative condition, particularly in the overhead-throwing athlete. Multiple injuries of the shoulder complex create the potential for complications in the course of recovery and place a full return to high-level sport at risk. The purpose of this case report is to present the multiphased rehabilitation approach of an elite professional quarterback after an acute 330° capsulolabral reconstruction and rotator cuff repair as a result of a luxatio erecta injury.A 26-year-old male professional football player, a quarterback, sustained a right luxatio erecta shoulder dislocation while trying to recover a fumble during a regular-season game. The injury occurred when he was hit in the back of his throwing shoulder, which was in an abducted and externally rotated position, while lying on the ground. Five days postinjury, he underwent a 330° capsulolabral repair, with concomitant rotator cuff repair and subacromial decompression. He completed 28 weeks of a multiphased rehabilitation program.The patient returned to play in the National Football League (NFL) 8 months later, for the start of the next season, during which he had his most productive year as a professional quarterback, leading the league in passing yards and finishing third in the league for the number of touchdowns. Since the injury, the patient has played 6 consecutive seasons, starting over 96 consecutive, regular-season games and maintaining a very high level of play.This case report highlights the clinical decision-making process and management of this rare, severe injury.

Synopsis There is a growing body of evidence documenting loads applied to the anterior cruciate ligament (ACL) for weight-bearing and non—weight-bearing exercises. ACL loading has been quantified by inverse dynamics techniques that measure anterior shear force at the tibiofemoral joint (net force primarily restrained by the ACL), ACL strain (defined as change in ACL length with respect to original length and expressed as a percentage) measured directly in vivo, and ACL tensile force estimated through mathematical modeling and computer optimization techniques. A review of the biomechanical literature indicates the following: ACL loading is generally greater with non—weight-bearing compared to weight-bearing exercises; with both types of exercises, the ACL is loaded to a greater extent between 10° to 50° of knee flexion (generally peaking between 10° and 30°) compared to 50° to 100° of knee flexion; and loads on the ACL change according to exercise technique (such as trunk position). Squatting with excessiv...

Synopsis Rehabilitation following anterior cruciate ligament surgery continues to change, with the current emphasis being on immediate weight bearing and range of motion, and progressive muscular strengthening, proprioception, dynamic stability, and neuromuscular control drills. The rehabilitation program should be based on scientific and clinical research and focus on specific drills and exercises designed to return the patient to the desired functional goals. The goal is to return the patient's knee to homeostasis and the patient to his or her sport or activity as safely as possible. Unique rehabilitation techniques and special considerations for the female athlete will also be discussed. The purpose of this article is to provide the reader with a thorough scientific basis for anterior cruciate ligament rehabilitation based on graft selection, patient population, and concomitant injuries. J Orthop Sports Phys Ther 2012;42(3):153–171. doi:10.2519/jospt.2012.3741

Case report.Joint stiffness, also called arthrofibrosis, remains the primary complication following any reconstructive knee surgery. Acute anterior cruciate ligament surgery, performed with concomitant multiple ligamentous repair and/or reconstruction, further increases the likelihood of developing impaired knee motion following surgery. The purpose of this case report is to present a criteria-based approach to the postoperative management of a multiligament knee injury.A 25-year-old male professional football player sustained a contact injury to his right knee while making a tackle during a regular season game in 2007. He underwent an acute anterior cruciate ligament reconstruction, with concomitant posterolateral corner repair, biceps femoris/iliotibial band repair, lateral collateral ligament repair, and a medial meniscocapsular junction repair. He completed 17 weeks of a multiphased rehabilitation program that emphasized immediate range of motion, low-load long-duration stretching, therapeutic exercise, neuromuscular reeducation/perturbation training, plyometrics, and sport-specific functional drills. Electrical neurostimulation was implemented during the early stages of rehabilitation to control postoperative pain and to promote a steady progression of therapeutic exercise activity.The patient was cleared to begin sport-specific activity 7 months after major multistructure reconstructive knee surgery. He began the 2008 season on the physically-unable-to-perform list, but was activated midseason and played in every game thereafter. During the 2009 and 2010 seasons, he played all regular season games and all playoff games as a starter, and continues to start as a defensive cornerback in the National Football League.This case report highlights the clinical decision-making process and management involved in an acute multiple ligamentous knee injury/reconstruction.Therapy, level 4.

Controlled laboratory study using a repeated-measures, counterbalanced design.To test the ability of 8 Swiss ball exercises (roll-out, pike, knee-up, skier, hip extension right, hip extension left, decline push-up, and sitting march right) and 2 traditional abdominal exercises (crunch and bent-knee sit-up) on activating core (lumbopelvic hip complex) musculature.Numerous Swiss ball abdominal exercises are employed for core muscle strengthening during training and rehabilitation, but there are minimal data to substantiate the ability of these exercises to recruit core muscles. It is also unknown how core muscle recruitment in many of these Swiss ball exercises compares to core muscle recruitment in traditional abdominal exercises such as the crunch and bent-knee sit-up.A convenience sample of 18 subjects performed 5 repetitions for each exercise. Electromyographic (EMG) data were recorded on the right side for upper and lower rectus abdominis, external and internal oblique, latissimus dorsi, lumbar paraspinals, and rectus femoris, and then normalized using maximum voluntary isometric contractions (MVICs).EMG signals during the roll-out and pike exercises for the upper rectus abdominis (63% and 46% MVIC, respectively), lower rectus abdominis (53% and 55% MVIC, respectively), external oblique (46% and 84% MVIC, respectively), and internal oblique (46% and 56% MVIC, respectively) were significantly greater compared to most other exercises, where EMG signals ranged between 7% to 53% MVIC for the upper rectus abdominis, 7% to 44% MVIC for the lower rectus abdominis, 14% to 73% MVIC for the external oblique, and 16% to 47% MVIC for the internal oblique. The lowest EMG signals were consistently found in the sitting march right exercise. Latissimus dorsi EMG signals were greatest in the pike, knee-up, skier, hip extension right and left, and decline push-up (17%-25% MVIC), and least with the sitting march right, crunch, and bent-knee sit-up exercises (7%-8% MVIC). Rectus femoris EMG signal was greatest with the hip extension left exercise (35% MVIC), and least with the crunch, roll-out, hip extension right, and decline push-up exercises (6%-10% MVIC). Lumbar paraspinal EMG signal was relative low (less than 10% MVIC) for all exercises.The roll-out and pike were the most effective exercises in activating upper and lower rectus abdominis, external and internal obliques, and latissimus dorsi muscles, while minimizing lumbar paraspinals and rectus femoris activity. J Orthop Sports Phys Ther 2010;40(5):265-276, Epub 22 April 2010. doi:10.2519/jospt.2010.3073.

Controlled laboratory biomechanics study using a repeated-measures, counterbalanced design.To compare patellofemoral joint force and stress between a short- and long-step forward lunge both with and without a stride.Although weight-bearing forward-lunge exercises are frequently employed during rehabilitation for individuals with patellofemoral joint syndrome, patellofemoral joint force and stress and how they change with variations of the lunge exercise are currently unknown.Eighteen subjects used their 12-repetition maximum weight while performing a short- and long-step forward lunge both with and without a stride. Electromyography, ground reaction force, and kinematic variables were put into a biomechanical optimization model, and patellofemoral joint force and stress were calculated as a function of knee angle.Visual observation of the data show that during the forward lunge, patellofemoral joint force and stress increased progressively as knee flexion increased, and decreased progressively as knee flexion decreased. Between 70 degrees and 90 degrees of knee flexion, patellofemoral joint force and stress were significantly greater when performing a forward lunge with a short step compared to a long step (P.025). Between 10 degrees and 40 degrees of knee flexion, patellofemoral joint force and stress were significantly greater when performing a forward lunge with a stride compared to without a stride (P.025).When the goal is to minimize patellofemoral joint force and stress during the forward lunge performed between 0 degrees to 90 degrees knee angles, it may be prudent to perform the lunge with a long step compared to a short step and without a stride compared to with a stride, because patellofemoral joint force and stress magnitudes were greater with a short step compared to a long step at higher knee flexion angles and were greater with a stride compared to without a stride at lower knee flexion angles.

Articular cartilage lesions of the knee joint are common in patients of varying ages. Some articular cartilage lesions are focal lesions located on one aspect of the tibiofemoral or patellofemoral joint. Other lesions can be extremely large or involve multiple compartments of the knee joint and these are often referred to as osteoarthritis. There are numerous potential causes for the development of articular cartilage lesions: joint injury (trauma), biomechanics, genetics, activities, and biochemistry. Numerous factors also contribute to symptomatic episodes resulting from lesions to the articular cartilage: activities (sports and work), joint alignment, joint laxity, muscular weakness, genetics, dietary intake, and body mass index. Athletes appear to be more susceptible to developing articular cartilage lesions than other individuals. This is especially true with specific sports and subsequent to specific types of knee injuries. Injuries to the anterior cruciate ligament and/or menisci may increase the risk of developing an articular cartilage lesion. The treatment for an athletic patient with articular cartilage lesions is often difficult and met with limited success. In this article we will discuss several types of knee articular cartilage injuries such as focal lesions, advanced full-thickness lesions, and bone bruises. We will also discuss the risk factors for developing full-thickness articular cartilage lesions and osteoarthritis, and describe the clinical evaluation and nonoperative treatment strategies for these types of lesions in athletes.

Pathology of the superior aspect of the glenoid labrum (SLAP lesion) poses a significant challenge to the rehabilitation specialist due to the complex nature and wide variety of etiological factors associated with these lesions. A thorough clinical evaluation and proper identification of the extent of labral injury is important to determine the most appropriate nonoperative and/or surgical management. Postoperative rehabilitation is based on the specific surgical procedure as well as the extent, location, and mechanism of labral pathology and associated lesions. Emphasis is placed on protecting the healing labrum, while gradually restoring range of motion, strength, and dynamic stability of the glenohumeral joint. The purpose of this paper is to provide an overview of the anatomy and pathomechanics of SLAP lesions and review specific clinical examination techniques used to identify these lesions, including 3 newly described tests. Furthermore, a review of the current surgical management and postoperative rehabilitation guidelines is provided.

Descriptive postoperative follow-up research.The purpose of this investigation was to describe the return-to-competition rate and functional outcome of overhead athletes following arthroscopic thermal-assisted capsular shrinkage (TACS).Traditional open procedures to correct instability in overhead athletes, such as capsulolabral repairs and capsular shifts, have produced less-than-favorable results, which have led to the development of TACS. Currently there are no long-term follow-up studies documenting the efficacy of this procedure in groups greater than 31 subjects or for a time period greater than 27 months.Two hundred thirty-one consecutive overhead athletes who due to symptoms of hyperlaxity had previously undergone a TACS procedure from 1997 to 1999 were selected for inclusion in the study. During a 1-month period, 130 of these athletes (mean age +/- SD, 24 +/- 6 years; 113 male, 17 female) were contacted by phone for follow-up at a mean of 29.3 months postoperatively (range, 15.4-46.6 months). Of the 130, 105 participated in baseball (80 pitchers), 14 in softball, 4 in football (quarterbacks), 4 in tennis, and 3 in swimming. Fifty-four (42%) subjects were professional, 49 (38%) collegiate, 16 (12%) high school, and 11 (8%) recreational athletes. One hundred twenty-three of the 130 (95%) underwent 1 or more concomitant procedure(s) at the time of TACS. Most commonly performed were labral debridements (69%), rotator cuff debridements (65%), and superior labral repairs (35%). Subjects who returned to competition were retrospectively evaluated using a modified Athletic Shoulder Outcome Rating Scale to subjectively assess pain, strength and endurance, stability, intensity, and performance. Overall results were based on a 90-point scale with scores of 80 to 90 representing excellent, 60 to 79 good, 40 to 59 fair, and less than 40 poor results.One hundred thirteen out of 130 subjects (87%) returned to competition. Mean (+/-SD) time from surgery to return to competition was 8.4 +/- 4.6 months. Mean outcome score for all subjects was 79/90; 75 (66%) subjects had excellent, 24 (21%) good, 11 (10%) fair, and 3 (3%) poor result. The mean outcome score for males was 80/90 and for females was 70/90.The majority of overhead athletes (87%) successfully returned to competition following a TACS procedure with good-to-excellent long-term outcomes (88%). Based on the results of this study, TACS of the glenohumeral joint is a viable option for overhead athletes with pathological instability.

Glenohumeral joint instability is a common pathology observed in the orthopedic and sports medicine settings. Overhead athletes often exhibit a certain degree of acquired laxity that can lead to various pathologies. Unfavorable results often observed with traditional open procedures to correct instability in the overhead athlete have led to the development of arthroscopic thermal-assisted capsular shrinkage (TACS). TACS is not commonly used as an isolated procedure in overhead athletes; various procedures are often performed concomitantly. The overall outcome greatly depends on a postoperative rehabilitation program that must be assessed and adjusted frequently based on several factors. Knowledge of the basic science of TACS as well as emphasis on dynamic stabilization, proprioception, and neuromuscular control are vital to the rehabilitation program for overhead athletes. The purpose of this paper is to discuss the basic science and clinical application of thermal-assisted capsular shrinkage of the glenohumeral joint as well as the postoperative rehabilitation for the overhead athlete and the patient with congenital laxity and related multidirectional instability.

Significant contemporary advances have permitted a more comprehensive understanding and development of some interesting concepts about the glenohumeral joint. The purpose of this review paper was to discuss current concepts related to the anatomic stabilizing structures of the shoulder joint complex and their clinical relevance to shoulder instability. The clinical syndrome of shoulder instability represents a wide spectrum of symptoms and signs which may produce various levels of dysfunction, from subtle subluxations to gross joint instability. The glenohumeral joint attains functional stability through a delicate and intricate interaction between the passive and active stabilizing structures. The passive constraints include the bony geometry, glenoid labrum, and the glenohumeral joint capsuloligamentous structures. Conversely, the active constraints, also referred to as the active mechanisms, include the shoulder complex musculature, the proprioceptive system, and the musculoligamentous relationship. The interaction of the active and passive mechanisms which provide passive and active glenohumeral joint stability will be thoroughly discussed in this paper.

It is important to examine the functional relationships between commonly performed clinical tests and to resolve inconsistencies in previous investigative results. The purpose of this study was to determine if a correlation exists between three commonly performed clinical tests: isokinetic isolated knee concentric muscular testing, the single-leg hop test, and the subjective knee score in anterior cruciate ligament reconstructed knees. To determine if a relationship exists would be beneficial to clinicians in determining patient progression, treatment modification, and return-to-sport objective parameters. Several investigators have analyzed two of these parameters, but no one has investigated three parameters to date. Additionally, this study explored the concept of limb acceleration and deceleration during high-speed isokinetics and its relationship to function. Fifty patients were randomly selected (29 males) with a mean age of 23.7 years (range 15-52). The subjects completed a subjective knee score questionnaire that rated symptoms (pain, swelling, giving way) and specific sport function and completed an overall knee score assessment. The patients were then evaluated performing three one-legged functional tests: 1) hop for distance, 2) timed hop, and 3) cross-over triple hop. Isokinetic testing was performed on a Biodex dynamometer at 180, 300, and 450 degrees/sec for knee extension/flexion. The patients' mean value of the self-assessed knee rating was 86 points. Sixty-four percent of the patients exhibited normal limb symmetry (within 85%) on all three single-leg hop tests. Sixteen percent exhibited quadriceps strength at least 90% of the contralateral limb isokinetically. A positive correlation was noted between isokinetic knee extension peak torque (180, 300 degrees/sec) and subjective knee scores, and the three hop tests (p0.001). A statistical trend was noted between knee extension acceleration and deceleration range at 180 and 300 degrees/sec for the timed hop test and triple cross-over hop (r = 0.48, r = 0.49, r = 0.51, r = 0.49). No positive correlations were found for isokinetic test results for the knee flexors.

Because of the popularity of sports participation, sports physical therapists must recognize in the athlete the many clinical conditions that occur about the elbow. The purpose of this paper is to present the most common elbow problems that an athlete may encounter and to provide information to facilitate recognition of elbow pathology. This information is essential before initiating treatment. An attempt is made to include sprains, strains, neuropathies, dislocations, fractures, contusions, vascular insults, and skin problems in the distal humerus, elbow, and proximal forearm of both the immature and mature athlete. Comprehension of the mechanism of injury aids clinical evaluation and rehabilitation and enhances early return to activity.

While the sports medicine community should be proud of the advances in treatment and rehabilitation of throwing injuries, much work is still needed. The bottom line is that there are too many season-ending or career-ending injuries. Perhaps nowhere is this more evident than in professional baseball, where virtually every pitcher sustains a serious injury at some point in his career. There are three opportunities for sports medicine practitioners to keep pitchers on the mound—prevent injuries, treat injuries, and rehabilitate injuries. While we talk about all three approaches, most of our focus has been on treatment and rehabilitation, with less attention given to injury prevention. J Orthop Sports Phys Ther 1998;27(3):187-188. doi:10.2519/jospt.1998.27.3.187