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David J Berkoff1, Larry E Miller2,3, Jon E Block31Department of Orthopedics, University of North Carolina School of Medicine, Chapel Hill, NC; 2Miller Scientific Consulting Inc, Arden, NC; 3The Jon Block Group, San Francisco, CA, USAAbstract: Intra-articular corticosteroid and hyaluronic acid injections provide short-term symptom amelioration for arthritic conditions involving structural damage or degenerative changes in the knee. Conventional palpation-guided anatomical injections frequently result in inaccurate needle placement into extra-articular tissue and adjacent structures. The purpose of this review was to determine the effect of ultrasound guidance on the accuracy of needle placement, clinical outcomes, and cost-effectiveness in comparison with anatomical landmark-guided intra-articular large joint injections, with particular emphasis on the knee. A total of 13 relevant studies were identified; five studied the knee, seven studied the shoulder, one used both the knee and shoulder, and none studied the hip. Ultrasound was used in seven studies; the remaining studies utilized air arthrography, fluoroscopy, magnetic resonance arthrography, or magnetic resonance imaging. Across all studies (using all imaging modalities and all joints), needle placement accuracy ranged from 63% to 100% with ultrasound and from 39% to 100% with conventional anatomical guidance. Imaging guidance improved the accuracy of intra-articular injections of the knee (96.7% versus 81.0%, P < 0.001) and shoulder (97.3% versus 65.4%, P < 0.001). In particular, ultrasound guidance of knee injections resulted in better accuracy than anatomical guidance (95.8% versus 77.8%, P < 0.001), yielding an odds ratio of 6.4 (95% confidence interval 2.9–14). Ultrasound guidance notably improves injection accuracy in the target intra-articular joint space of large joints including the knee. The enhanced injection accuracy achieved with ultrasound needle guidance directly improves patient-reported clinical outcomes and cost-effectiveness.Keywords: injection, intra-articular, knee, ultrasound

After an anterior cruciate ligament (ACL) injury, people need secondary prevention strategies to identify osteoarthritis at its earliest stages so that interventions can be implemented to halt or slow the progression toward its long-term burden. The Osteoarthritis Action Alliance formed an interdisciplinary Secondary Prevention Task Group to develop a consensus on recommendations to provide clinicians with secondary prevention strategies that are intended to reduce the risk of osteoarthritis after a person has an ACL injury. The group achieved consensus on 15 out of 16 recommendations that address patient education, exercise and rehabilitation, psychological skills training, graded-exposure therapy, cognitive-behavioral counseling (lacked consensus), outcomes to monitor, secondary injury prevention, system-level social support, leveraging technology, and coordinated care models. We hope this statement raises awareness among clinicians and researchers on the importance of taking steps to mitigate the risk of osteoarthritis after an ACL injury., (© by the National Athletic Trainers' Association, Inc.)

Context: The Osteoarthritis Action Alliance formed a secondary prevention task group to develop a consensus on secondary prevention recommendations to reduce the risk of osteoarthritis after a knee injury., Objective: Our goal was to provide clinicians with secondary prevention recommendations that are intended to reduce the risk of osteoarthritis after a person has sustained an anterior cruciate ligament injury. Specifically, this manuscript describes our methods, literature reviews, and dissenting opinions to elaborate on the rationale for our recommendations and to identify critical gaps., Design: Consensus process., Setting: Virtual video conference calls and online voting., Patients or Other Participants: The Secondary Prevention Task Group consisted of 29 members from various clinical backgrounds., Main Outcome Measure(s): The group initially convened online in August 2020 to discuss the target population, goals, and key topics. After a second call, the task group divided into 9 subgroups to draft the recommendations and supportive text for crucial content areas. Twenty-one members completed 2 rounds of voting and revising the recommendations and supportive text between February and April 2021. A virtual meeting was held to review the wording of the recommendations and obtain final votes. We defined consensus as >80% of voting members supporting a proposed recommendation., Results: The group achieved consensus on 15 of 16 recommendations. The recommendations address patient education, exercise and rehabilitation, psychological skills training, graded-exposure therapy, cognitive-behavioral counseling (lacked consensus), outcomes to monitor, secondary injury prevention, system-level social support, leveraging technology, and coordinated care models., Conclusions: This consensus statement reflects information synthesized from an interdisciplinary group of experts based on the best available evidence from the literature or personal experience. We hope this document raises awareness among clinicians and researchers to take steps to mitigate the risk of osteoarthritis after an anterior cruciate ligament injury., (© by the National Athletic Trainers' Association, Inc.)

Background: Therapies for arthrofibrosis after knee surgery are needed to prevent loss of joint function. Interleukin-1 receptor antagonists (IL-1RA) have shown promise in treating established arthrofibrosis in pilot clinical studies. The objective of this study was to evaluate the ability of intra-articular injection of IL-1RA to prevent knee joint contracture in a post-traumatic knee immobilization model., Methods: 20 male Sprague Dawley rats were block randomized into two groups: control and IL-1RA. Rats underwent intra-articular surgical trauma of the right knee with placement of an immobilization suture, securing the knees in 150° flexion. On post-operative days 1 and 8, each group received a 0.1 ml intra-articular injection of either saline (control) or anakinra (IL-1RA:single dosage; 2.63 mg/kg). Rats were euthanized fourteen days after surgery and the immobilization femorotibial angles were measured on the operative limbs with the suture and musculature intact. Subsequently, musculature was removed and femorotibial angles were measured in the operative and non-operative limbs with a defined extension moment applied with the posterior capsule intact or cut. A contracture angle was calculated as the angular difference between the operative and non-operative limb., Results: The immobilization knee flexion angle did not differ (P = 0.761) between groups (control: 152 ± 9; IL-1RA: 150 ± 11). The joint contracture angles (smaller angle = improved outcome) were reduced by 12 degrees on average in the IL-1RA group compared to the control for both the capsule intact (P = 0.024) and cut (P = 0.019) states., Conclusions: Intra-articular IL-1RA injection was found to diminish knee extension deficits associated with arthrofibrosis in a post-traumatic joint immobilization model., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: PSW was loaned equipment from Bioventus LLC. DJB received support for an educational conference from Phillips Sonosite Inc., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Ultrasound Tissue Characterization (UTC) is a modality that can be utilized to characterize tendon tissue structure using ultrasonographic imaging paired with a computer algorithm to distinguish echo-types. Several studies have demonstrated UTCs ability to distinguish Achilles tendon morphology changes, but no study has established normative data of the Achilles tendon in the general population. The aim of this study was to determine UTC echo-type distribution in the Achilles tendon in an asymptomatic population. UTC scans were completed and analyzed on 508 participants without Achilles tendinopathy. Dedicated UTC-algorithms were used to distinguish and calculate echo-type percentages and the fiber type distribution was compared. The overall sample echo-type percentages demonstrated greater levels of Type I and II echo-types, 65.73% and 32.00%, respectively, and lower levels of Type III and IV echo-types, 1.74% and 0.57%, respectively. In addition, females had lower levels of Echo-type I compared to men and greater levels of echo-type II (p < 0.001). We also found that African-Americans had significantly greater amounts of echo-type I and lesser amounts of echo-type II when compared to Caucasians (p < 0.05). The results of this study create a normative data set for future UTC studies to utilize as a baseline for the evaluation of Achilles tendons. In addition, it demonstrated tendon type differences between sexes and races that need to be accounted for in future studies., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Context: Prior research has not established if overloading or underloading movement profiles are present in symptomatic and asymptomatic athletes with patellar tendon structural abnormality (PTA) compared to healthy athletes., Objective: The purpose was to compare involved limb landing biomechanics between male athletes with and without patellar tendinopathy., Design: Cross-sectional study Setting: Laboratory Patients or Other Participants: 43 males were grouped based on patellar tendon pain & ultrasound imaging of the proximal patellar tendon: symptomatic with PTA (SYM-PTA; n=13; 20±2yrs; 1.8±0.1m; 84±5kg), asymptomatic with PTA (ASYM-PTA; n=15; 21±2yrs; 1.8±0.1m; 82±13kg), and healthy control (CON; n=15; 20±2yrs; 1.8±0.1m; 79±12kg)., Main Outcome Measures: 3D biomechanics were collected during double-limb jump-landing. Kinematic (knee flexion angle (KF)) and kinetic (vertical ground reaction force (VGRF); internal knee extension moment (KEM); patellar tendon force (FPT)) variables were analyzed as continuous waveforms during the stance phase for the involved limb. Mean values were calculated for each 1% of stance, normalized over 202 data points (0-100%), and plotted with 95% confidence intervals. Statistical significance was defined as a lack of 95% CI overlap for ≥ 6 consecutive data points., Results: SYM-PTA had lesser KF than CON throughout the stance phase. ASYM-PTA had lesser KF than CON in the early and late stance phase. SYM-PTA group had lesser KEM and FPT than CON in early stance, as well as ASYM-PTA in mid-stance., Conclusions: Male athletes with SYM-PTA demonstrated a patellar tendon load-avoidance profile compared to ASYM-PTA and CON athletes. ASYM-PTA did not show evidence of overloading compared to CON. Our findings support the need for individualized treatments for athletes with tendinopathy to maximize load-capacity., Trial Registry: ClinicalTrials.gov (#XXX).

Objectives: To a) determine the acute effects of a single-dose patellar tendon isometric exercise protocol on involved limb landing biomechanics in individuals with patellar tendinopathy and asymptomatic patellar tendon pathology, and b) determine if individuals with patellar tendinopathy demonstrated changes in pain following a single-dose patellar tendon isometric exercise protocol., Design: Single-blinded randomized cross-over trial., Setting: Laboratory; PARTICIPANTS: 28 young male athletes with symptomatic (n = 13, age: 19.62 ± 1.61) and asymptomatic (n = 15, age: 21.13 ± 1.88) patellar tendinopathy., Main Outcome Measures: Participants completed a single-dose patellar tendon isometric exercise protocol and a sham-TENS protocol, randomized and separated by 7-10 days. Pain-levels during a single-limb decline squat (SLDS) and three-dimensional biomechanics were collected during a double-limb jump-landing task before and after each intervention protocol. A mixed-model repeated measures ANOVA was conducted to compare change scores for all dependent variables., Results: There were no group × intervention interactions for change in pain (F (1, 26)  = 0.555, p = 0.463). There was one significant group × intervention interaction for vertical ground reaction force (VGRF) (F (1, 26)  = 5.33, p = 0.029). However, post-hoc testing with Bonferroni correction demonstrated no statistical significance for group (SYM: t = -1.679, p = 0.119; ASYM: t = -1.7, p = 0.107) or intervention condition (isometric: t = -2.58, p = 0.016; sham-TENS: 0.72, p = 0.460). There were no further significant group × intervention interactions (p > 0.05)., Conclusions: A single-dose patellar tendon isometric exercise protocol did not have acute effects on landing biomechanics or pain levels in male athletes with patellar tendinopathy or asymptomatic patellar tendon pathology., Competing Interests: Declaration of competing interest None declared., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Objective: To examine differences in biomechanical and physical activity load in young male athletes with and without patellar tendinopathy., Design: Cross-sectional cohort study., Methods: Forty-one young male athletes (15-28 years of age) were categorized into 3 distinct groups: symptomatic athletes with patellar tendon abnormalities (PTA) (n = 13), asymptomatic athletes with PTA (n = 14), and a control group of asymptomatic athletes without PTA (n = 14). Participants underwent a laboratory biomechanical jump-landing assessment and wore an accelerometer for 1 week of physical activity monitoring., Results: The symptomatic group demonstrated significantly less patellar tendon force loading impulse in the involved limb compared with both the control and asymptomatic groups ( P <.05), with large effects ( d = 0.91-1.40). There were no differences in physical activity between the 3 groups ( P >.05)., Conclusion: Young male athletes with symptomatic patellar tendinopathy demonstrated smaller magnitudes of patellar tendon force loading impulse during landing compared to both asymptomatic athletes with patellar tendinopathy and healthy control participants. However, these 3 distinct groups did not differ in general measures of physical activity. Future investigations should examine whether comprehensively monitoring various loading metrics may be valuable to avoid both underloading and overloading patterns in athletes with patellar tendinopathy. J Orthop Sports Phys Ther 2020;50(3):158-166. Epub 6 Jan 2020. doi:10.2519/jospt.2020.9065 .

Background: Tetracycline antibiotics inhibit matrix metalloproteinases and pro-inflammatory cytokines implicated in the pathogenesis of tendinopathy, while microsphere formulations allow sustained release of drug contents. The purpose of this study was to evaluate the ability of a local minocycline microsphere injection to restore normal tendon properties in a rat model of collagenase-induced patellar tendinopathy., Methods: A total of 22 rats were randomly assigned to the control (n = 11) or minocycline (n = 11) group and received bilateral patellar tendon injections of collagenase. After 7 days, the minocycline group received the minocycline microsphere treatment and the control group received phosphate buffered solution. Pain was assessed via activity monitors and Von Frey filament testing. At 4 weeks post-collagenase injections, animals were euthanized., Results: Cage crossings significantly decreased among all rats 2-3 days following each injection period, however, tactile allodynia measures did not reflect this injury response. Biomechanical properties, interleukin-1 beta levels, and glycosaminoglycan content did not differ between groups. While not statistically significant, levels of leukotriene B 4 were lower in the minocycline group compared to controls ( p  = 0.061), suggesting a trend., Conclusions: Our study further characterizes the collagenase model of tendinopathy by demonstrating no evidence of central sensitization with collagenase-induced injury. We found no adverse effect of intratendinous injections of minocycline-loaded poly-lactic-co-glycolic acid microspheres, although no therapeutic effect was observed. Future studies involving a more substantial tendon injury with a greater inflammatory component may be necessary to more thoroughly evaluate the effects of minocycline on tendon pathology., (© 2019 Prof. PK Surendran Memorial Education Foundation. Published by Elsevier, a division of RELX India, Pvt. Ltd. All rights reserved.)

Interleukin-1 (IL1) is a cytokine that plays a role in inflammation and is a potential contributor to the inflammation present in tendinopathy. Its inhibition may be of use in the treatment of tendinopathy and has been a target for treatment. To evaluate how an IL1-receptor antagonist (IL1-RA) reverses pathologic changes associated with established patellar tendinopathy, we randomized 48 Sprague-Dawley retired breeder rats into three groups having weekly bilateral patellar tendon injections for 6 weeks. The control group received 0.1 mL saline for 6 weeks. The intervention groups were treated with 0.1 mL 2% carrageenan for 4 weeks. Beginning at week three, the IL1-RA group received 0.94 mg of the IL1-RA (2.5 mg/kg) added to the 0.1 mL 2% carrageenan and 0.94 mg of the IL1-RA alone for the final 2 weeks, while the CAR received 0.1 mL saline for the final 2 weeks. Animals were euthanized 6 weeks after initial injection. The CAR group demonstrated significantly (P < 0.05) shorter tendon lengths (7.81 ± 0.44 mm) than the control (8.25 ± 0.58 mm) and IL1-RA (8.34 ± 0.52 mm) group (P < 0.05). Macroscopically, plaque-like formations were reduced and margins of the tendon were more evident in the IL1-RA group compared to the CAR group. CAR group demonstrated significantly greater histopathologic changes (inflammatory cell density, disorganization of collagen, nuclear rounding, and angiogenesis) than the control and IL1-RA group. No significant difference in mechanical properties of the tendon was noted. These findings demonstrate IL1-RA can reduce pathologic changes in the patellar tendon in an established tendonitis model although did not demonstrate a difference in mechanical properties., (© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Ultrasound tissue characterization (UTC) is an imaging tool used to quantify tendon structural integrity. UTC has quantified Achilles tendon (AT) acute response to load in athletes; however, AT response to cumulative load over a season is unknown. The purpose of this study was to evaluate AT response across a four-month competitive season in collegiate cross-country (XC) runners. Participants (n=21; male=9, female=12; age=19.8±1.2 years; height=171.9±8.9 cm; weight=60.2±8.5 kg) were imaged using the UTC device with a 10-MHz linear-array transducer mounted in a tracking device. The device captures images at 0.2 mm intervals along the AT. UTC algorithms quantified the stability of pixel brightness over every 17 contiguous transverse images into four echo types (I-IV). A total of 168 scans (n=21, bilateral limbs) were performed monthly across the four-month season (Aug=M1, Sep=M2, Oct=M3, Nov=M4). Echo-type percentages (%) were calculated from each scan. Generalized estimating equations (GEE) linear regression models evaluated echo-type % change (β) over the season (M1=reference). Type I increased from M1 to M4 (β=9.10, P<.01; 95%CI: 7.01, 11.21) and Type II decreased from M1 to M3 (β=-2.71, P=.018; 95%CI: -4.96, -0.47) and M1 to M4 (β=-10.19, P<.01; 95%CI: -12.22, -8.17). Type III increased from M1 to M3 (β=0.42, P=.003; 95%CI: 0.19, 0.65) and M1 to M4 (β=0.49, P=.002; 95%CI: 0.18, 0.81), Type IV increased from M1 to M4 (β=0.57, P<.01; 95%CI: 0.29, 0.84). A positive adaptation in AT structural integrity was observed over the XC season, with a ~10% shift from Type II to Type I UTC echo types, suggesting AT resilience to a competitive season of repetitive loading in highly trained runners., (© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

A 31-year-old female runner presented to physical therapy via direct access with an 8-month history of atraumatic left lateral calf pain. Following 1 month of physical therapy, the patient was referred to an orthopaedic sports medicine physician. Ultrasound imaging revealed a 2-cm hypoechoic mass with well-defined margins in the left proximal lateral soleus, while Doppler ultrasound demonstrated increased color flow surrounding the mass. Magnetic resonance imaging findings were consistent with a nerve sheath tumor, and ultrasound-guided tissue biopsy determined the mass to be a benign peripheral nerve sheath tumor. J Orthop Sports Phys Ther 2017;47(2):125. doi:10.2519/jospt.2017.6780.

Background: Subacromial space distance and forward head and shoulder posture are common characteristics resulting from swim training. These alterations can cause abnormal scapular kinematics and positioning, potentially increasing compression of structures in the subacromial space and increasing the risk for the development of swimmer's shoulder., Purpose: To evaluate the effect of the swim training season on subacromial space distance and forward head and forward shoulder posture as well as to determine the relationship between these variables., Study Design: Cohort study; Level of evidence, 2., Methods: Included in the study were 43 competitive adolescent swimmers and 29 nonoverhead adolescent athletes (controls) who were not currently experiencing any shoulder, neck, or back pain that limited their participation in sports activity. All participants were evaluated 3 times: once before the start of the swim training season and then at 2 follow-up sessions 6 and 12 weeks after the initial testing session. At each testing session, each participant completed a physical examination that included evaluation of posture and subacromial space distance., Results: Swimmers had significantly greater decreases in subacromial space distance during the training season compared with nonoverhead athletes. Swimmers also demonstrated significantly greater increases in forward shoulder posture compared with nonoverhead athletes. A significant relationship was noted between changes in forward shoulder posture and changes in subacromial space distance from the baseline testing session to the assessment 6 weeks after baseline assessment. As forward shoulder posture increased, subacromial space significantly decreased., Conclusion: Because of their training load, swimmers experience a decrease in subacromial space distance and an increase in forward shoulder posture over the course of 12 weeks of training, potentially making these athletes more vulnerable to the development of shoulder pain and injury., (© 2016 The Author(s).)

Background and Purpose: The accurate performance of physical therapy exercises can be difficult. In this evolving healthcare climate it is important to continually look for better methods to educate patients. The use of handouts, in-person demonstration, and video instruction are all potential avenues used to teach proper exercise form. The purpose of this study was to examine if a corrected error video (CEV) would be as effective as a single visit with a physical therapist (PT) to teach healthy subjects how to properly perform four different shoulder rehabilitation exercises., Study Design: This was a prospective, single-blinded interventional trial., Methods: Fifty-eight subjects with no shoulder complaints were recruited from two institutions and randomized into one of two groups: the CEV group (30 subjects) was given a CEV comprised of four shoulder exercises, while the physical therapy group (28 subjects) had one session with a PT as well as a handout of how to complete the exercises. Each subject practiced the exercises for one week and was then videotaped performing them during a return visit. Videos were scored with the shoulder exam assessment tool (SEAT) created by the authors., Results: There was no difference between the groups on total SEAT score (13.66 ± 0.29 vs 13.46 ± 0.30 for CEV vs PT, p = 0.64, 95% CI [-0.06, 0.037]). Average scores for individual exercises also showed no significant difference., Conclusion/clinical Relevance: These results demonstrate that the inexpensive and accessible CEV is as beneficial as direct instruction in teaching subjects to properly perform shoulder rehabilitation exercises., Level of Evidence: 1b.

This study evaluated if inhibiting IL1-β activity with an IL1-receptor antagonist (IL1-RA) will prevent pathologic changes commonly seen in tendinopathy. Thirty-six Sprague-Dawley retired-breeder rats were divided into three groups having weekly bilateral patellar tendon injections: CON (0.1 ml Saline), CAR (0.1 ml 2% carrageenan), IL1-RA (0.1 ml 2% CAR plus 0.94 mg of the IL1-RA, 2.5 mg/kg). Carrageenan was used to establish tendinopathy in two groups due to its ability to develop tendinopathy in prior studies. Animals were euthanized 3 weeks after initial injection. The CAR group demonstrated significantly (p < 0.05) shorter tendon lengths (8.61 ± 0.38 mm) relative to CON (8.94 ± 0.38 mm) that was prevented in the IL1-RA (9.02 ± 0.30 mm) as well as significantly increased collagenase activity in the CAR (0.061 ± 0.043) compared to CON (0.027 ± 0.015) (p<  0.05). By histological evaluation, the CAR group demonstrated significantly greater inflammation than IL1-RA, and CON (p < 0.05). CAR showed a trend for increased cross-sectional area relative to CON that was absent in the IL1-RA. IL1-RA can effectively inhibit the development of mechanical, chemical, and histologic changes seen with carrageenan-induced tendonitis., (© 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.)

Context: Alterations to upper extremity physical characteristics of competitive swimmers (posture, range of motion [ROM], and subacromial-space distance) are commonly attributed to cumulative training load during a swimmer's competitive career. However, this accepted clinical belief has not been established in the literature. It is important to understand whether alterations in posture and associated physical characteristics occur as a result of sport training or factors other than swimming participation to better understand injury risk and possible interventions., Objective: To compare posture, subacromial-space distance, and glenohumeral external-rotation, internal-rotation, and horizontal-adduction ROM between adolescent competitive swimmers and nonoverhead athletes., Design: Cross-sectional study., Setting: Local swimming pools and high school athletic training rooms., Patients or Other Participants: Forty-four competitive adolescent swimmers and 31 nonoverhead athletes who were not currently experiencing any elbow, shoulder, neck, or back pain that limited their sport activity., Intervention(s): Posture, subacromial-space distance, and glenohumeral ROM were measured using photography, diagnostic ultrasound, and a digital inclinometer, respectively., Main Outcome Measure(s): Forward shoulder posture, forward head posture, normalized subacromial-space distance, internal-rotation ROM, and external-rotation ROM., Results: No clinically significant differences existed between swimmers and nonoverhead athletes for posture, normalized subacromial-space distance, or external- or internal-rotation ROM. Swimmers presented with less horizontal-adduction ROM than nonoverhead athletes., Conclusions: Factors other than swimming participation, such as school and technology use, play important roles in the adaptation of physical characteristics in adolescents. Adolescents, regardless of swimming participation, presented with postural deviations. It is important to consider factors other than swimming participation that contribute to alterations in physical characteristics to understand injury risk and injury-prevention strategies in competitive adolescent swimmers.

The use of point-of-care ultrasound (US) by non-radiologists is not new and the expansion into sports medicine practice is relatively young. US has been used extensively to evaluate the musculoskeletal system including the diagnosis of muscle, tendon and bone injuries. However, as sports medicine practitioners we are responsible for the care of the entire athlete. There are many other non-musculoskeletal applications of US in the evaluation and treatment of the athlete. This paper highlights the use of US in the athlete to diagnose pulmonary, cardiac, solid organ, intra-abdominal and eye injuries., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: To evaluate the effects of whole body vibration (WBV) and local muscle vibration (LMV) on quadriceps function after experimental knee effusion (ie, simulated pathology)., Design: Randomized controlled trial., Setting: Research laboratory., Participants: Healthy volunteers (N=43) were randomized to WBV (n=14), LMV (n=16), or control (n=13) groups., Interventions: Saline was injected into the knee to induce quadriceps arthrogenic muscle inhibition (AMI). All groups then performed isometric squats while being exposed to WBV, LMV, or no vibration (control)., Main Outcome Measures: Quadriceps function was assessed at baseline, immediately after effusion, and immediately and 5 minutes after each intervention (WBV, LMV, control) via voluntary peak torque (VPT) and the central activation ratio (CAR) during maximal isometric knee extension on a multifunction dynamometer., Results: The CAR improved in the WBV (11.4%, P=.021) and LMV (7.3%, P<.001) groups immediately postintervention, but they did not improve in the control group. Similarly, VPT increased by 16.5% (P=.021) in the WBV group and 23% (P=.078) in the LMV group immediately postintervention, but it did not increase in the control group. The magnitudes of improvements in the CAR and VPT did not differ between the WBV and LMV groups., Conclusions: Quadriceps AMI is a common complication following knee pathology that produces quadriceps dysfunction and increases the risk of posttraumatic osteoarthritis. Quadriceps strengthening after knee pathology is often ineffective because of AMI. WBV and LMV improve quadriceps function equivocally after simulated knee pathology, effectively minimizing quadriceps AMI. Therefore, these stimuli may be used to enhance quadriceps strengthening, therefore improving the efficacy of rehabilitation and reducing the risk of osteoarthritis., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Post-surgical seromas and cysts have been reported across many surgical subspecialties including orthopaedics. Treatments include both invasive surgical approaches and more recently reported non-invasive techniques. Non-invasive approaches currently include compressive wrapping, vasopneumatic cryotherapy, and motion exercises. Persistent lesions have been treated with talc or doxycycline sclerodesis. This case presents a patient with a post-arthroscopic seroma that was treated with fibrin glue in an outpatient setting. Fibrin glue has not been reported in the post-arthroscopy outpatient setting to address cystic lesions. This case suggests a viable non-invasive treatment option for these lesions. Level of evidence V.

Background: Massive irreparable rotator cuff tears in patients without advanced glenohumeral arthritis can pose a challenge to surgeons. Numerous management strategies have been utilized, and studies have shown varied results with regard to shoulder pain, range of motion, strength, and overall function., Hypothesis: Patients undergoing repair of massive irreparable rotator cuff tears through a mini-open approach with the use of human dermal tissue matrix allograft would demonstrate an improvement in pain, range of motion, strength, and subjective functional outcomes., Study Design: Case series; Level of evidence, 4., Methods: We performed a prospective observational study of 24 patients who underwent interposition repair of massive rotator cuff tears using human dermal allograft. All patients were evaluated preoperatively and postoperatively by the treating surgeon. Data were collected preoperatively and postoperatively for an average 3-year follow-up period (range, 29-40 months). Active range of motion as well as supraspinatus and infraspinatus strength was assessed. Subjective outcome measures included pain level (visual analog scale of 0-10, with 10 = severe pain), American Shoulder and Elbow Score (ASES), and Short-Form 12 (SF-12) score. Imaging evaluation to assess for repair integrity was performed using static and dynamic ultrasonography at final follow-up., Results: Mean pain level decreased from 5.4 to 0.9 (P = .0002). Mean active forward flexion and external rotation motion improved from 111.7° to 157.3° (P = .0002) and from 46.2° to 65.1° (P = .001), respectively. Mean shoulder abduction improved from 105.0° to 151.7° (P = .0001). Supraspinatus and infraspinatus strength improved from 7.2 to 9.4 (P = .0003) and from 7.8 to 9.3 (P = .002), respectively. Mean ASES improved from 66.6 to 88.7 (P = .0003). Mean SF-12 scores improved from 48.8 to 56.8 (P = .03). One partial graft retear occurred because of patient noncompliance during postoperative rehabilitation. However, this patient still demonstrated improvement in pain, motion, and subjective outcomes at final follow-up. Ultrasonography demonstrated "fully intact" repairs in 76% of patients. All remaining patients had "partially intact" repairs. There were no complete tears., Conclusion: In our series of carefully selected candidates, all patients demonstrated a significant improvement in pain, range of motion, and strength. Subjective outcome measures, including mean ASES and SF-12 scores, also demonstrated significant improvement at an average 3-year follow-up.

In the United States there are now approximately 521 marathons, and in 2005 approximately 432,000 participants completed one. The number of frequent runners (more than 100 days a year) is estimated at over 11 million. When one of these patients presents to the emergency department with cardiac complaints, the risk profile and evaluation may be different than in sedentary subjects. The first and most important step to patient evaluation is the history. An electrocardiogram (ECG) should be obtained in all patients with suspected cardiac complaints. Depending on the study and what is defined as abnormal, 40-80% of athletes' ECGs will show some abnormality. A normal ECG has a 96% negative predictive value for ruling out structural cardiovascular abnormalities, but a positive predictive value for disease of only 7%. The electrocardiogram, cardiac enzymes, and stress testing are useful, but should be interpreted in the context of the sport and the athlete. Echocardiography and cardiac magnetic resonance imaging are indicated for the diagnosis of certain conditions. Cardiology consultation or inpatient evaluation may be indicated when a specific disease process is suspected based on history, physical examination, or ECG. Some patients may require follow-up for further diagnostic testing.

Prolonged training leads to changes in autonomic cardiac balance. This sympathetic and parasympathetic balance can now be studied using heart rate variability (HRV). Studies have shown that endurance athletes have an elevated level of parasympathetic tone in comparison to sedentary people. The effect of resistance training on autonomic tone is less clear. We hypothesized a significant difference in HRV indices in endurance-trained vs. power-trained track-and-field athletes. One hundred forty-five athletes (58 women) were tested prior to the 2004 U.S.A. Olympic Trials. Heart rate variability data were collected using the Omegawave Sport Technology System. Subjects were grouped according to training emphasis and gender. The mean age of the athletes was 24.8 years in each group. There were significant (p < 0.01) differences by sex in selected frequency domain variables (HFnu, LFnu, LH, LHnu) and for PNN50 (p < 0.04) for the time domain variables. Two-factor analyses of variance showed differences for only the main effect of sex and not for any other grouping method or interaction. Elite athletes have been shown to have higher parasympathetic tone than recreational athletes and nonathletes. Our data show differences by sex, but not between aerobically and power-based athletes. Whether this is due to an aerobic component of resistance training, an overall prolonged training effect, or some genetic difference remains unclear. Further study is needed to assess the impact of resistance training programs on autonomic tone and cardiovascular fitness. This information will be valuable for the practitioner to use in assessing an athlete's response to a prescribed training regimen.

Acute angle closure glaucoma is an ocular emergency that is treatable with prompt and appropriate intervention. Recognition of this disease entity is sometimes difficult. We report a case of bilateral acute angle closure glaucoma in a 55-year-old, otherwise healthy individual, and discuss the different ways the condition may present. The anatomic and pathophysiologic progression leading to an event of angle closure is discussed and treatment modalities available to the Emergency Physician are presented.