Adam S. Lepley

Clinical Scenario: Ankle sprains are the most prevalent athletic-related musculoskeletal injury treated by athletic trainers, often affecting activities of daily living and delaying return to play. Most of these cases present with pain and swelling in the ankle, resulting in decreased range of motion and strength deficits. Due to these impairments, proper treatment is necessary to avoid additional loss of play and prevent future injuries. Recently, there has been an increased use of deep oscillation therapy by clinicians to manage pain and swelling following a variety of injuries, including ankle sprains. However, very little evidence has been produced regarding the clinical effectiveness of deep oscillation therapy, limiting its application in therapeutic rehabilitation of acute lateral ankle sprains. Clinical Question: Is deep oscillation therapy effective in reducing pain and swelling in patients with acute lateral ankle sprains compared with the current standard of care protection, rest, ice, compression, and elevation? Summary of Key Findings: The literature was searched for studies of level 2 evidence or higher that investigated deep oscillation therapy on pain and inflammation in patients with lateral ankle sprains. Three randomized control trials were located and appraised. One of the 3 studies demonstrate a reduction in pain following 6 weeks of deep oscillation therapy compared with the standard of care or placebo interventions. The 2 other studies, 1 utilizing a 5-day treatment and the other a 1 time immediate application, found no differences in deep oscillation therapy compared with the standard of care. Clinical Bottom Line: There is inconclusive evidence to support the therapeutic use of deep oscillation therapy in reducing pain and swelling in patients with acute lateral ankle sprains above and beyond the current standard of care. In addition, the method of treatment application and parameters used may influence the effectiveness of deep oscillation therapy. Strength of Recommendation: Level B.

Quadriceps muscle dysfunction is common following anterior cruciate ligament reconstruction (ACLR). Data considering the diversity of neural changes, in-concert with morphological adaptations of the quadriceps muscle, are lacking. We investigated bilateral differences in neural and morphological characteristics of the quadriceps muscle in ACLR participants (n = 11, month post-surgery: 69.4 ± 22.4) compared to controls matched by sex, age, height, weight, limb dominance, and activity level. Spinal reflex excitability was assessed using Hoffmann reflexes (H:M); corticospinal excitability was quantified via active motor thresholds (AMT) and motor-evoked potentials (MEP) using transcranial magnetic stimulation. Cortical activation was assessed using a knee flexion/extension task with functional magnetic resonance imaging (fMRI). Muscle volume was quantified using structural MRI. Muscle strength and patient-reported outcomes were also collected. 2 × 2 RM ANOVAs were used to evaluate group differences. Smaller quadriceps muscle volume (total volume, rectus femoris, vastus medialis, and intermedius) and lower strength were detected compared to contralateral and control limbs. Individuals with ACLR reported higher levels of pain and fear and lower levels of knee function compared to controls. No differences were observed for H:M. ACLR individuals demonstrated higher AMT bilaterally and smaller MEPs in the injured limb, compared to the controls. ACLR participants demonstrated greater activation in frontal lobe areas responsible for motor and pain processing compared to controls, which were associated with self-reported pain. Our results suggest that individuals with ACLR demonstrate systemic neural differences compared to controls, which are observed concurrently with smaller quadriceps muscle volume, quadriceps muscle weakness, and self-reported dysfunction.

Lepley, AS, Joseph, MF, Daigle, NR, Digiacomo, JE, Galer, J, Rock, E, Rosier, SB, and Sureja, PB. Sex differences in mechanical properties of the Achilles tendon: Longitudinal response to repetitive loading exercise. J Strength Cond Res 32(11): 3070–3079, 2018—Sex differences have been observed in the mechanical properties of the Achilles tendon, which may help to explain the increased risk of injury in men. However, the response and recovery of tendon mechanics to repetitive loading exercise, as well as sex-dependent responses, are not well understood. The purpose of our study was to compare Achilles tendon mechanical properties between men and women before, immediately after, and 60 minutes after a repetitive loading exercise. Seventeen female (age: 24.0 ± 3.9 years; height: 167.4 ± 6.9 cm; and mass: 64.9 ± 8.5 kg) and 18 male (age: 23.9 ± 2.4 years; height: 179.2 ± 5.09 cm; and mass: 78.4 ± 8.7 kg) recreationally active individuals volunteered. Using isokinetic dynamometry and diagnostic ultrasound, baseline levels of Achilles tendon force, elongation, stiffness, stress, strain, and Young's modulus were assessed before 100 successive calf-raise exercises using a Smith machine at 20% of participant body mass. Outcomes were reassessed immediately and 60 minutes after exercise. Women exhibited less Achilles tendon force, stiffness, stress, and modulus compared with men, regardless of time point. Both sexes responded to repetitive loading exercise similarly, with immediate decreases in mechanical properties of the Achilles tendon from baseline to immediately after exercise. Tendon properties were observed to be equal to baseline values at 60-minute postexercise. Baseline differences in tendon properties may help to explain the disparity in injury risk because both sexes responded to and recovered from exercise similarly. Future research should aim to include additional time points (both leading up to and after 60 minutes), and assess tendon responses to more sport-specific activities, while also including patients diagnosed with Achilles tendon injuries.

Context: : Interactions among muscle strength, pain, and self-reported outcomes in patients with anterior cruciate ligament reconstruction (ACLR) are not well understood. Clarifying these interactions is of clinical importance because improving physical and psychological function is thought to optimize outcomes after ACLR.Objective: : To examine the relationships among neuromuscular quadriceps function, pain, self-reported knee function, readiness to return to activity, and emotional response to injury both before and after ACLR.Design: : Descriptive laboratory study.Patients or Other Participants: : Twenty patients (11 females and 9 males; age = 20.9 ± 4.4 years, height = 172.4 ± 7.5 cm, weight = 76.2 ± 11.8 kg) who were scheduled to undergo unilateral ACLR.Main Outcome Measure(s): : Quadriceps strength, voluntary activation, and pain were measured at presurgery and return to activity, quantified using maximal voluntary isometric contractions (MVICs), central activation ratio, and the Knee Injury and Osteoarthritis Outcome Score pain subscale, respectively. Self-reported knee function, readiness to return to activity, and emotional responses to injury were evaluated at return to activity using the International Knee Documentation Committee questionnaire (IKDC), ACL Return to Sport After Injury scale (ACL-RSI), and Psychological Response to Sport Injury Inventory (PRSII), respectively. Pearson product moment correlations and linear regressions were performed using raw values and percentage change scores.Results: : Presurgical levels of pain significantly predicted 31% of the variance in the ACL-RSI and 29% in the PRSII scores at return to activity. The MVIC and pain collected at return to activity significantly predicted 74% of the variance in the IKDC, whereas only MVIC significantly predicted 36% of the variance in the ACL-RSI and 39% in the PRSII scores. Greater increases in MVIC from presurgery to return to activity significantly predicted 49% of the variance in the ACL-RSI and 59% of the variance in the IKDC scores.Conclusion: : Decreased quadriceps strength and higher levels of pain were associated with psychological responses in patients with ACLR. A comprehensive approach using traditional rehabilitation that includes attention to psychological barriers may be an effective strategy to improve outcomes in ACLR patients.

Objective: : To evaluate the current evidence concerning kinematic and kinetic strategies adopted during dynamic landing tasks by patients with anterior cruciate ligament reconstruction (ACLR). Data Sources: : PubMed, Web of Science. Study Selection: : Original research articles that evaluated kinematics or kinetics (or both) during a landing task in those with a history of ACLR were included. Data Extraction: : Methodologic quality was assessed using the modified Downs and Black checklist. Means and standard deviations for knee or hip (or both) kinematics and kinetics were used to calculate Cohen d effect sizes and corresponding 95% confidence intervals between the injured limb of ACLR participants and contralateral or healthy matched limbs. Data were further stratified by landing tasks, either double- or single-limb landing. A random-effects–model meta-analysis was used to calculate pooled effect sizes and 95% confidence intervals. Data Synthesis: : The involved limbs of ACLR patients demonstrated clinically and significantly lower knee-extension moments during double-legged landing compared with healthy contralateral limbs and healthy control limbs (Cohen d range = −0.81 to −1.23) and decreased vertical ground reaction forces when compared with healthy controls, regardless of task (Cohen d range = −0.39 to −1.75). Conclusions: : During single- and double-legged landing tasks, individuals with ACLR demonstrated meaningful reductions in injured-limb knee-extension moments and vertical ground reaction forces. These findings indicate potential unloading of the injured limb after ACLR, which may have significant implications for secondary ACL injury and long-term joint health.

Background:Studies have demonstrated beneficial effects of exercise on cardiovascular disease biomarkers for healthy individuals; however, a comprehensive review regarding the effect of exercise on cardiovascular disease biomarkers in at-risk populations is lacking.Methods:A literature search was performed to identify studies meeting the following criteria: randomized controlled study, participants with pathology/activity limitations, biomarker outcome (total cholesterol, high-density lipoprotein, low-density lipoprotein, C-reactive protein, insulin, triglycerides, or glucose), and exercise intervention. Means and standard deviations from each biomarker were used to calculate standardized Cohen’sdeffect sizes with 95% confidence intervals.Results:In total, 37 articles were included. The majority (44/57; 77%) of data points demonstrated moderate to strong effects for the reduction in total cholesterol, triglycerides, and low-density lipoprotein, and elevation in high-density lipoprotein following exercise. The majority of data points demonstrated strong effects for reductions in blood glucose (24/30; 80%) and insulin (23/24; 96%) levels following exercise intervention.Conclusion:Evidence is heterogeneous regarding the influence of exercise on cardiovascular disease biomarkers in at-risk patients, which does not allow a definitive conclusion. Favorable effects include reductions in triglycerides, total cholesterol, low-density lipoprotein, glucose, and insulin, and elevation in high-density lipoprotein following exercise intervention. The strongest evidence indicates that exercise is favorable for the reduction in glucose and cholesterol levels among obese patients, and reduction of insulin regardless of population.

Purpose and hypothesis Individuals with an anterior cruciate ligament reconstruction (ACLR) are susceptible to persistent disability, weight gain and the development of knee osteoarthritis. It remains unclear whether body mass index (BMI) is a factor that influences disability following ACLR. The purpose of this study was to determine the association between BMI and self-reported disability [International Knee Documentation Committee (IKDC) Index] in individuals with a unilateral ACLR. We hypothesized that lower BMI would associate with higher IKDC. Methods BMI and IKDC were measured in 668 individuals with a unilateral ACLR (60.9% female, BMI 24.4 ± 3.7 kg/m², IKDC 84.7 ± 11.9%). Bivariate associations were conducted between BMI and IKDC for the entire sample and selected subsets (gender, ACLR graft type and history of meniscal injury). Multiple regression analyses were used to determine the impact of potential covariates (Tegner score, age and months since ACLR) for significant bivariate associations. After accounting for covariates, there were no significant associations between BMI and IKDC when separately evaluating the cohort based on either gender or history of a concomitant meniscal injury. The odds of achieving age- and gender-matched healthy population average IKDC scores for those with low ( 0.001, n.s.) after accounting for covariates. BMI uniquely predicted a significant but negligible amount of variance in IKDC in individuals with a patellar tendon autograft (ΔR ² = 0.015, n.s.). Individuals with low BMI demonstrated higher odds (odds ratio = 1.45; 1.05–1.99) of achieving population average IKDC scores compared to participants with high BMI. Conclusions There was a significant but negligible correlation between lower BMI and lesser disability in individuals with unilateral ACLR and individuals who are underweight or of normal BMI demonstrated higher odds of achieving population average IKDC scores compared to overweight or obese individuals. While an overall association was found between lower BMI and lesser disability, the magnitude of the association remains negligible; therefore, BMI was not a strong clinical predictor of successful ACLR outcomes in this cohort of patients with unilateral ACLR. Level of evidence Cross-sectional prognostic study, Level II.

Ir ascent and descent in patients with acute ACL injury and at return to activity after ACL reconstruction. Methods Twenty individuals with unilateral ACL injury (age, 20.9 ± 4.4 yr; height, 172.4 ± 7.5 cm; mass, 76.2 ± 12.2 kg) that were scheduled to undergo surgical reconstruction were compared with 20 healthy matched controls (age, 21.7 ± 3.7 yr; height, 173.7 ± 9.9 cm; mass, 76.1 ± 19.7 kg). Lower extremity biomechanics were recorded using three-dimensional motion analysis during stair ascent and descent at two testing sessions (before surgery and at approximately 6 months after surgery or when they were allowed to return to unrestricted physical activity). Time between sessions for healthy participants was matched on the basis of the ACL group. Peak sagittal and frontal plane knee and hip joint angles and moments, joint angles at initial contact, and joint excursions across stance phase were evaluated. Results The ACL-injured limb of patients experienced smaller knee extension moments than the uninjured limb and healthy controls during stair ascent and descent (P < 0.05) before and 6 months after ACL reconstruction. During stair ascent, ACL patients experienced more extended knee joint positions and less sagittal plane knee joint excursions, coupled with greater frontal plane hip joint excursions (P < 0.05). Conclusions Patients with ACL injury experience reductions in knee flexion angle and knee extension moments during stair walking. These alterations were observed both before and after reconstruction, suggesting that early gait retraining interventions may be beneficial in these patients....