Considerations for the Medical Management of the Circus Performance Artist and Acrobat.

Medical management of the circus performer encompasses a wide variety of multicultural, transdisciplinary and multifaceted decision-making considerations. There is a paucity of research evidence investigating both the unique diversity of skill sets and cultural considerations in addition to injury patterns of performers within the circus environment. Since a previously established framework for supporting the health and well-being of the circus performer across various aspects of medical management does not exist in the literature, most recommendations in this regard must come from practical experience working with this highly specialized performance athlete population. The purpose of this clinical commentary is to provide the reader with a greater understanding of the unique challenges associated with the medical management of performance artists and acrobats as well as recommendations for developing an integrated approach for mitigating injury risk within a highly specialized, diverse athlete population. LEVEL OF EVIDENCE: 5.

Shifting Focus: A Clinician's Guide to Understanding Neuroplasticity for Anterior Cruciate Ligament Rehabilitation.

Neuroplasticity after anterior cruciate ligament (ACL) injury has lingering effects throughout rehabilitation and can influence reinjury risk upon returning to sport if not addressed. Various neural compensatory strategies have been identified following ACL injury, which appear to not be rectified with typical therapy. Thus, further consideration is warranted, addressing the neurophysiologic and neurocognitive aspects of injury when developing a rehabilitation program. Integration of external focus of control strategies, neurocognition, motor planning, unanticipated sensory processing, and load management provide an efficient and effective method for improving motor learning and control throughout the rehabilitation process. Rehabilitation exercises that incorporate unique sports-specific challenges can target the visual processing and anticipatory reaction components of motor control to reduce motor errors that increase injury risk when returning to activity. The neurocognitive demands of returning to sport of efficient decision making and motor patterning amid a rapidly changing competitive environment require novel and clinically implemental strategies.

THEORETICAL APPLICATIONS OF BLOOD FLOW RESTRICTION TRAINING IN MANAGING CHRONIC ANKLE INSTABILITY IN THE BASKETBALL ATHLETE.

Chronic ankle instability (CAI) is a common dysfunctional state in the basketball population accompanied by pain, weakness and proprioceptive deficits which greatly affect performance. Research evidence has supported the use of blood flow restriction (BFR) training as an effective treatment strategy for improving muscle strength, hypertrophy and function following injury in a variety of patient populations. In managing CAI, it is important to address proximal and distal muscle weakness, pain, and altered proprioception to reduce the likelihood of re-occurring ankle injury. The ability to mitigate acute and cumulative strength and muscle volume losses through the integration of BFR after injury has been supported in research literature. In addition, applications of BFR training for modulating pain, improving muscle activation and proximal muscle strength have recently been suggested and may provide potential benefit for athletes with CAI. The purpose of this clinical commentary is to discuss background evidence supporting the implementation of blood flow restriction training and use a theoretical model for managing CAI as well as to suggest novel treatment strategies using this method. LEVEL OF EVIDENCE: 5.

UTILIZATION OF ImPACT TESTING TO MEASURE INJURY RISK IN ALPINE SKI AND SNOWBOARD ATHLETES.

BACKGROUND: While studies that have examined the prevalence of musculoskeletal injuries in alpine skiing and snowboarding exist, there has been no discussion of how neurocognitive deficits may influence such injuries. Recent authors have identified a possible link between Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) testing results and the prevalence of musculoskeletal injury in athletic populations. However, no study has specifically examined this in the alpine skiing and snowboard athletes who sustain injury and those that do not. HYPOTHESIS/PURPOSE: The purpose was to review injury data and ImPACT test results within the local ski/snowboard population to determine if there was a difference in components of ImPACT test scores between injured and non-injured athletes. It was hypothesized that differences would exist in component scores on ImPACT testing between injured and non-injured athletes. STUDY DESIGN: Retrospective cohort study. METHODS: Injury records and baseline ImPACT testing scores for 93 athletes aged 14-17 participating in a local ski and snowboard club during the 2009-2012 seasons were gathered retrospectively. Injuries documented for the lower and upper extremity included ligament sprains, muscle strains, contusions, dislocation/subluxation, fractures and concussions. Athletes who sustained any of these listed injuries were categorized within the injured athlete group. Each component of ImPACT test scores was compared between gender and for injury status within skiing and snowboarding disciplines using a series of two-way analysis of variance tests. RESULTS: There was no difference between non-injured and injured females as well as non-injured and injured males in reaction time and visual motor speed (VMS), however there was an interaction between gender and injury status on composite reaction time and visual motor speed, or VMS. The composite reaction time for females was 4.7% faster with injury while males without injury had a composite reaction time that was slower by 5.8%. Females had a 4.1% higher mean VMS score with injury while males had a 14.4% higher VMS score without injury. CONCLUSION: Future research may consider prospectively examining neurocognitive testing scores and injury prevalence within the disciplines of snowboarding and both alpine and freestyle skiing. LEVELS OF EVIDENCE: Level 3.

Case series of first metatarsophalangeal joint injuries in division 1 college athletes.

CONTEXT: Injuries of the first metatarsophalangeal (hallux MP) joint can be debilitating in the athletic population. Turf toe and plantar plate injuries are typically diagnosed similarly. However, variance in injury mechanism as well as compromised integrity of soft tissue and ligamentous structures make it difficult to accurately diagnose specific hallux MP injuries. Recent literature has supported the use of both radiographic imaging and the Lachman test as reliable indicators of joint instability in the presence of hallux MP injuries. To date, research supporting specific rehabilitation interventions and return-to-play decision making for hallux MP injuries has been limited to case studies and suggested guidelines from literature reviews. There is limited evidence suggesting specific criteria for surgical and nonsurgical decision making in conjunction with rehabilitation progressions to return an athlete to sport when managing hallux MP injuries. EVIDENCE ACQUISITION: A literature search was performed using Medline, PubMed, and Google Scholar to find and review articles from 1970 to 2013 that addressed the basic anatomy of the plantar plate, injuries to this anatomical structure, and the evaluation, diagnosis, surgical and nonsurgical management, and rehabilitation of these injuries, specifically in the athletic population. Medical information for each case was gathered from electronic medical records from the individual athletes cited in this case series, which included imaging reports, rehabilitation documentation, and both evaluation and surgical reports. No statistical analysis was used. STUDY DESIGN: Case series. LEVEL OF EVIDENCE: Level 4. RESULTS: Treatment plans for each case varied depending on surgical and nonsurgical intervention and rehabilitation outcomes. However, each athlete was able to return to sports-specific activities. CONCLUSION: Successful outcomes for hallux MP injuries are contingent on thorough evaluation, appropriate clinical decision making with regard to surgical versus nonsurgical treatment planning, and a multidisciplinary team approach for ensuring a safe return to sport. STRENGTH-OF-RECOMMENDATION TAXONOMY SORT: C.

Rehabilitation strategies addressing neurocognitive and balance deficits following a concussion in a female snowboard athlete: a case report.

UNLABELLED: Head injuries, including concussions, in athletes can account for an extended period of time lost from sports competition. Neurocognitive and balance deficits which may linger following a concussion affect an athlete's ability to return to sport safely. If these deficits are not specifically addressed in a rehabilitation program then the athlete may be at risk for not only additional concussions but possible musculoskeletal injury. ImPACT testing is a reliable method for identifying neurocognitive deficits and assists in the development of a neurocognitive training program. The information gathered from ImPACT may also indicate risk for musculoskeletal injuries. Research evidence suggesting specific rehabilitation strategies and interventions addressing neurocognitive deficits following a concussion is lacking. Progressions in a neurocognitive training program may include the integration of balance, reaction training, and activities that address memory deficits. The purpose of this case report is to discuss the evaluation and treatment plan for a female snowboard athlete following a concussion. LEVEL OF EVIDENCE: 5.