Anterior knee laxity is greater in athletic females who attain menarche at a younger age.

PURPOSE: Females with above-average anterior knee laxity values are at increased risk of anterior cruciate ligament (ACL) injury. The purpose of this study was to examine the effects of menarche age (MA) and menarche offset on anterior knee laxity in young, physically active women. METHODS: Anterior knee laxity (KT-2000) and menstrual characteristics (per self-report) were recorded in 686 Slovenian sportswomen from team handball, volleyball and basketball club sports (average years sport participation: 7.3 ± 3.6 years). Females were stratified into four groups based on their self-reported age at menarche: 9-11, 12, 13 and 14+ years. Anterior knee laxity was compared across MA groups using a univariate analysis of variance (ANOVA) with Bonferroni correction, with and without controlling for factors that could potentially differ between groups and influence anterior knee laxity. Females were then stratified into four groups based on the number of years they were away from their age at onset of menarche. Groups were compared using a univariate ANOVA with Bonferroni correction, with and without controlling for factors that differed between groups and could influence anterior knee laxity. RESULTS: Anterior knee laxity was greater in females who attained menarche at 12 years of age (6.4 ± 1.5 mm) or younger (6.6 ± 1.6 mm) compared to 14 years of age or older (5.8 ± 1.2 mm) (p < 0.001; partial η2 = 0.032). Anterior knee laxity was 0.7-1.4 mm greater in females who were 5 or more years away from menarche compared to those who were within 2 years of menarche (5.8 ± 1.3 mm; p < 0.001). CONCLUSION: Anterior knee laxity is greater in females who attained menarche at a younger age and in females who are 5 or more years postmenarche. Age of menarche represents a critical pubertal event that is easy for women to recall and may provide important insights into factors that moderate anterior knee laxity, a risk factor for ACL injury in women. LEVEL OF EVIDENCE: Level IV.

Sickle cell crisis presenting as livedo racemosa.

Sickle cell disease is a monogenic hemoglobinopathy that results in the abnormal production of hemoglobin S, which yields the characteristic sickle-shaped red blood cells. Sickle cell vaso-occlusive crisis is a painful complication of sickle cell disease caused by red blood cell entrapment within the microcirculation. The resulting tissue ischemia triggers a secondary inflammatory process involved in the pathogenesis of varying inflammatory skin conditions. Chronic leg ulcers are the most common skin presentation in sickle cell disease. A 58-year-old woman with sickle cell disease presented with systemic edematous plaques with the most notable involvement of her bilateral legs, which exhibited reticulated purpuric patches with central pallor. We report a case highlighting an unusual presentation of livedo racemosa as the presenting sign in a patient with sickle cell disease in vaso-occlusive crisis.

Do rocker-sole shoes influence postural stability in chronic low back pain? A randomised trial.

BACKGROUND: People with chronic low back pain (CLBP) demonstrate greater postural instability compared with asymptomatic individuals. Rocker-sole shoes are inherently unstable and may serve as an effective balance training device. This study hypothesised that wearing rocker-sole shoes would result in long-term improvement in barefoot postural stability in people with CLBP. METHODS: 20 participants with CLBP were randomised to wear rocker-sole or flat-sole shoes for a minimum of 2 hours each day. Participants were assessed barefoot and shod, over three 40 s trials, under 4 posture challenging standing conditions. The primary outcome was postural stability assessed by root mean squared error of centre of pressure (CoP) displacement (CoPRMSE AP) and mean CoP velocity (CoPVELAP), both in the anteroposterior direction, using force plates. Participants' were assessed without knowledge of group allocation at baseline, 6 weeks and 6 months (main outcome point). Analyses were by intention-to-treat. RESULTS: At 6 months, data from 11 of 13 (84.6%) of the rocker-sole and 5 of 7 (71.4%) of the flat-sole group were available for analysis. At baseline, there was a mean increase in CoPRMSE AP (6.41 (2.97) mm, p<0.01) and CoPVELAP (4.10 (2.97) mm, p<0.01) in the rocker-sole group when shod compared with barefoot; there was no difference in the flat-sole group. There were no within-group or between-group differences in change in CoP parameters at any time point compared with baseline (1) for any barefoot standing condition (2) when assessed shod eyes-open on firm ground. CONCLUSIONS: Although wearing rocker-sole shoes results in greater postural instability than flat-sole shoes, long-term use of rocker-sole shoes did not appear to influence postural stability in people with CLBP.

Literature review of post-traumatic stress disorder in the critical care population.

AIM: To determine which factors relate to the development of post-traumatic stress disorder, in adult patients who are admitted to critical care units. BACKGROUND: Patient survival rates from critical care areas are improving each year and this has led to interest in the long-term outcomes for patients who have been discharged from such environments. Patients typically require invasive and extensive treatment, which places a stress on physical and mental health. Prevalence estimates of post-traumatic stress disorder in the critical care discharge population vary from 5-63%, yet it remains unclear what the predisposing factors are. DESIGN: A systematised review. METHOD: Subject heading and keyword searches were conducted in MEDLINE, CINAHL, PsycINFO and ScienceDirect, with 23 articles identified that examined the relationship between critical care and the development of post-traumatic stress disorder. RESULTS: Three main themes were identified; Critical Care Factors, Patient Factors and Experience Factors. Eight key and three potential causative factors were found: younger age, female, previous psychiatric history, length of ICU stay, benzodiazepine sedation, use of stress hormones, delusional memory and traumatic memory, delirium, GCS score of ≤9 on admission & use of mechanical restraint. CONCLUSIONS: Post-traumatic stress reactions can be strongly related to the development and presence of traumatic and delusional memories. Younger patients may exclude themselves from research to avoid their traumatic thoughts. The role of prior psychiatric illness is unknown. Distinction between 'factual' and 'false' or delusional memory as occurs in the literature maybe unhelpful in understanding trauma reactions. RELEVANCE TO CLINICAL PRACTICE: There are around 38,000 occupied critical care beds each year in England. The scale of the issue is therefore substantial. Risk factors can be isolated from available evidence and provide a rudimentary risk assessment tool to inform practice development in this area.

The effect of open kinetic chain knee extensor resistance training at different training loads on anterior knee laxity in the uninjured.

BACKGROUND: The commonly used open kinetic chain knee extensor (OKCKE) exercise loads the sagittal restraints to knee anterior tibial translation. OBJECTIVE: To investigate the effect of different loads of OKCKE resistance training on anterior knee laxity (AKL) in the uninjured knee. STUDY DESIGN: non-clinical trial. METHODS: Randomization into one of three supervised training groups occurred with training 3 times per week for 12 weeks. Subjects in the LOW and HIGH groups performed OKCKE resistance training at loads of 2 sets of 20 repetition maximum (RM) and 20 sets of 2RM, respectively. Subjects in the isokinetic training group (ISOK) performed isokinetic OKCKE resistance training using 2 sets of 20 maximal efforts. AKL was measured using the KT2000 arthrometer with concurrent measurement of lateral hamstrings muscle activity at baseline, 6 weeks and 12 weeks. RESULTS: Twenty six subjects participated (LOW n = 9, HIGH n = 10, ISOK n = 7). The main finding from this study is that a 12-week OKCKE resistance training programme at loads of 20 sets of 2RM, leads to an increase in manual maximal AKL. CONCLUSIONS: OKCKE resistance training at high loads (20 sets of 2RM) increases AKL while low load OKCKE resistance training (2 sets of 20RM) and isokinetic OKCKE resistance training at 2 sets of 20RM does not.

Effect of repeated passive anterior loading on human knee anterior laxity.

BACKGROUND: Increased knee anterior laxity results when the anterior cruciate ligament is injured. This increased laxity can cause knee dysfunction. Until recently this laxity was believed to be only diminished through surgery. But recent findings indicate that knee anterior laxity may be decreased with repeated loading of the knee. OBJECTIVE: The purpose of this study was to test the hypothesis that regular passive anterior loading of the uninjured human knee would enhance its stiffness. STUDY DESIGN: Randomized controlled trial. METHODS: Knee anterior laxity was tested using an arthrometer in 22 young, uninjured females before, during and after a 3 month period during which passive anterior loading was applied by a trained physiotherapist over 5 sessions per week to a randomly assigned knee. RESULTS: Knee anterior laxity was not affected by the passive anterior loading of the knee. CONCLUSIONS: Given that in this study repeated passive loading of the knee did not change knee anterior laxity, it would be easy to conclude that this training is ineffective and no further research is required. We caution against this given the relatively short duration and possibly insufficient intensity of the training and the population studied; individuals with normal joint laxity. We recommend that future research be performed that consists of individuals with lax joints who receive training for prolonged periods.

The effect of knee extensor open kinetic chain resistance training in the ACL-injured knee.

PURPOSE: To investigate the effect of different loads of knee extensor open kinetic chain resistance training on anterior knee laxity and function in the ACL-injured (ACLI) knee. METHODS: Fifty-eight ACLI subjects were randomised to one of three (12-week duration) training groups. The STAND group trained according to a standardised rehabilitation protocol. Subjects in the LOW and HIGH group trained as did the STAND group but with the addition of seated knee extensor open kinetic chain resistance training at loads of 2 sets of 20 repetition maximum (RM) and 20 sets of 2RM, respectively. Anterior knee laxity and measurements of physical and subjective function were performed at baseline, 6 and 12 weeks. Thirty-six subjects were tested at both baseline and 12 weeks (STAND n = 13, LOW n = 11, HIGH n = 12). RESULTS: The LOW group demonstrated a reduction in 133 N anterior knee laxity between baseline and 12 weeks testing when compared to the HIGH and the STAND groups (p = 0.009). Specifically, the trained-untrained knee laxity decreased an average of approximately 5 mm in the LOW group while remaining the same in the other two groups. CONCLUSION: Twelve weeks of knee extensor open kinetic chain resistance training at loads of 2 sets of 20RM led to a reduction in anterior knee laxity in the ACLI knee. This reduction in laxity does not appear to offer any significant short-term functional advantages when compared to a standard rehabilitation protocol. These results indicate that knee laxity can be decreased with resistance training of the thigh muscles. LEVEL OF EVIDENCE: Randomised controlled trial, Level II.

The effect of thigh muscle activity on anterior knee laxity in the uninjured and anterior cruciate ligament-injured knee.

PURPOSE: The main purpose of this study was to describe the nature of the relationship between hamstring muscle activity and anterior knee laxity. METHODS: This was a cross-sectional study. Anterior knee laxity was measured at 133N and manual maximal forces using the KT2000 knee arthrometer, in 8 ACL-injured and 13 uninjured individuals. Electromyographic activity of the lateral hamstrings was measured during laxity testing. Subjects contracted the hamstrings during anterior knee laxity testing at eight predetermined levels of maximal voluntary isometric contraction. RESULTS: Volitional contraction of the lateral hamstrings reduced anterior knee laxity logarithmically for both the 133N and manual maximal tests in both the ACL-injured and uninjured knees. A simple linear regression model, with the log of percentage of maximum lateral hamstrings activity as the sole predictor, explained approximately 70-80% of the variation in anterior knee laxity. Both ACL-injured and uninjured subjects reduced anterior knee laxity at the same rate with increases in muscle activity. However, initial lateral hamstrings muscle activity had a greater effect on percentage anterior knee laxity scores in the ACL-injured as compared to the uninjured knee. CONCLUSIONS: Lateral hamstrings activity reduces anterior knee laxity in a nonlinear manner, whereby the initial lower level of activation produces the greatest change in anterior knee laxity. Therefore, hamstrings muscle activity must be monitored during anterior knee laxity testing.

Inter-rater reliability of the GNRB® knee arthrometer.

BACKGROUND: In clinical settings, where arthrometers are mainly used by different clinicians, knowing the inter-rater reliability of the instrument is crucial in order for the results from different examiners to be accurately interpreted and limitations fully understood. The aim of this study was to evaluate the inter-rater reliability of the GNRB® knee arthrometer. METHODS: Knee anterior laxity in both knees was tested in a group of young, uninjured subjects (N=27, 13 females) by two examiners. Knee anterior laxity was calculated at test forces of 134 N and 250 N with values presented for the unstandardised and standardised conditions (relative to patellar stabilisation force). RESULTS: The ICCs ranged from 0.220 to 0.424. CONCLUSIONS: The inter-rater reliability of the GNRB® knee arthrometer is low.

Assessment of body mapping sportswear using a manikin operated in constant temperature mode and thermoregulatory model control mode.

Regional sweating patterns and body surface temperature differences exist between genders. Traditional sportswear made from one material and/or one fabric structure has a limited ability to provide athletes sufficient local wear comfort. Body mapping sportswear consists of one piece of multiple knit structure fabric or of different fabric pieces that may provide athletes better wear comfort. In this study, the 'modular' body mapping sportswear was designed and subsequently assessed on a 'Newton' type sweating manikin that operated in both constant temperature mode and thermophysiological model control mode. The performance of the modular body mapping sportswear kit and commercial products were also compared. The results demonstrated that such a modular body mapping sportswear kit can meet multiple wear/thermal comfort requirements in various environmental conditions. All body mapping clothing (BMC) presented limited global thermophysiological benefits for the wearers. Nevertheless, BMC showed evident improvements in adjusting local body heat exchanges and local thermal sensations.

When to consider Mohs surgery.

A long-standing malignant lesion or a tumor in a cosmetically sensitive area are 2 instances in which Mohs micrographic surgery yields superior results.

Bench testing of a knee joint arthrometer.

The KT1000 and KT2000 knee joint arthrometers (MEDmetric Corp, San Diego, California) have been shown to overestimate the measurement of knee joint sagittal laxity. The purpose of this study was to investigate the accuracy of the KT arthrometers as measures of anterior and posterior linear displacement. The anterior and posterior linear displacements of 3 KT arthrometers (2 KT1000 arthrometers and 1 KT2000 arthrometer) were compared with the simultaneous displacement measured by a precision linear Vernier Dial Test Indicator (Davenport Ltd, London, United Kingdom). The displacement calculated using the analog output of the KT2000 was also compared with the values on the KT2000 displacement dial. Compared with the Vernier Dial Test Indicator, the KT arthrometers overestimated anterior linear displacement by between 22% and 24%. True anterior displacement for all 3 arthrometers, as recorded by the Vernier Dial Test Indicator, was found by multiplying the KT value by 0.79. When compared with the Vernier Dial Test Indicator, the KT arthrometers underestimated posterior linear displacement by between 18% and 19%. True posterior displacement, as recorded by the Vernier Dial Test Indicator, was found by multiplying the KT1000 value by 1.17 and the KT2000 value by 1.16. The internal apparatus of the KT2000 and KT1000 knee joint arthrometers overestimates anterior displacement and underestimates posterior displacement with a predictable relative systematic error. Future validation studies should use these correction equations to assess the accuracy of the KT arthrometers. Sagittal plane knee laxity measured with the KT devices requires systematic correction for optimal accuracy.

Effectiveness of rocker sole shoes in the management of chronic low back pain: a randomized clinical trial.

STUDY DESIGN: Multicenter, assessor-blind, randomized, clinical trial. OBJECTIVE: To compare the effectiveness of rocker sole footwear to traditional flat sole footwear as part of the management for people with low back pain (LBP). SUMMARY OF BACKGROUND DATA: During the past decade, persistent advertising has claimed that footwear constructed with a rocker sole will reduce LBP. However, there is no robust evidence to support these claims. METHODS: One hundred fifteen people with chronic LBP were randomized to wear rocker sole shoes or flat sole shoes for a minimum of 2 hours each day while standing and walking. Primary outcome was the Roland Morris Disability Questionnaire (RMDQ). In addition, participants attended an exercise and education program once a week for 4 weeks and wore their assigned shoes during these sessions. Participants were assessed without their knowledge of group allocation prerandomization, and at 6 weeks, 6 months, and 1 year (main outcome point). Analysis was by intention-to-treat method. RESULTS: At 12 months, data from 44 of 58 (77.2%) of the rocker sole group and 49 of 57 (84.5%) of the flat sole group were available for analysis. In the rocker sole group, mean reduction in RMDQ was -3.1 (95% CI [confidence interval], -4.5 to -1.6), and in the flat sole group, it was -4.4 (95% CI, -5.8 to -3.1) (a greater negative value represents a greater reduction in disability). At 6 months, more people wearing flat shoes compared with those wearing rocker shoes demonstrated a minimal clinically important improvement in disability (53.2% and 31.1%, respectively; P = 0.03). Between-group differences were not significant for RMDQ or any secondary outcomes (e.g., pain) at any time. People reporting pain when standing and walking at baseline (n = 59) reported a greater reduction in RMDQ at 12 months in the flat sole group (-4.4 [95% CI, -6.0 to -2.8], n = 29) than the rocker sole group (-2.0 [95% CI, -3.6 to -0.4], n = 30) (P < 0.05). CONCLUSION: Rocker sole shoes seem to be no more beneficial than flat sole shoes in affecting disability and pain outcomes in people with chronic LBP. Flat shoes are more beneficial for LBP aggravated by standing or walking. LEVEL OF EVIDENCE: N/A.

Robotic knee laxity testing: reliability and normative data.

PURPOSE: To evaluate the reliability of the GeNouRoB knee arthrometer and present normative values of knee anterior laxity using this device on young females. METHODS: Anterior laxity in both knees was tested in two groups of young, uninjured females using the hamstrings electromyography biofeedback feature of the device. There were 13 participants in the group tested for reliability and 23 for the normative study. Laxity (mm of movement of the proximal tibia in the anterior direction relative to the femur) was calculated at test forces of 134 N and 250 N with values presented for the unstandardised and standardised (relative to stabilisation force) conditions. RESULTS: The relative reliability (95% limits of agreement) of the device for laxity at a test force of 134 N was 2 to 3mm. Left knee anterior laxity was almost 1mm greater than the right. CONCLUSIONS: The relative reliability of the GeNouRoB arthrometer is comparable to the KT device. In agreement with previous work on the nonrobotic KT arthrometer, the knee anterior laxity values found with the GeNouRoB are greater in the left as compared to the right knee.

The immediate effects of open kinetic chain knee extensor exercise at different loads on knee anterior laxity in the uninjured.

BACKGROUND: There is evidence that anterior laxity may be affected by knee extensor open kinetic chain (OKC) exercise with responses being load-dependent. The aim of this study is to evaluate the immediate and short-term changes in passive knee anterior laxity following a single session of OKC knee extensor exercise. METHODS: Thirty two participants were randomly allocated to perform either high load (20 sets of 2 repetitions) or low load (2 sets of 20 repetitions) knee extensor OKC exercise with knee anterior laxity assessed before exercise, immediately after exercise and 45 and 90min after exercise with a KT-2000 arthrometer using a 133N force. RESULTS: A significant effect of time was observed on knee laxity (p<0.001). However, a significant interaction of time and group was not found (p=0.54) and so the results presented here are for the combined (low and high load) group mean±standard deviation knee anterior laxity (mm) in the exercised leg: 7.2±2.2 (baseline), 8.2±2.3 (immediate post exercise, 14% change from baseline), 8.1±2.3 (45min post exercise, 12% change from baseline), and 7.7±2.2/0.29 (6.9) (90min post exercise, 7% change from baseline). CONCLUSION: OKC knee extensor exercise at high loads and low loads causes an immediate increase in knee laxity that begins to decrease within 90min.

Using the knee-specific Hughston Clinic Questionnaire, EQ-5D and SF-6D following arthroscopic partial meniscectomy surgery: a comparison of psychometric properties.

PURPOSE: To compare the psychometric properties of the Hughston Clinic Questionnaire (HCQ), EQ-5D and SF-6D in patients following arthroscopic partial meniscectomy surgery. METHODS: A total of 84 participants (86% men; mean age 40) were recruited. The questionnaires were completed on average 5 days, 6 weeks and 6 months after surgery and compared for internal consistency, convergent validity, sensitivity to change and floor and ceiling effects. RESULTS: Internally, the HCQ was the most consistent instrument (α = 0.923) followed by the SF-6D and EQ-5D. The EQ-5D and SF-6D were moderately correlated with the HCQ (ρ = 0.499 and 0.394, respectively). Six weeks after surgery, the most sensitive measures were the HCQ and EQ-5D (effect size: 2.04 and 0.99, respectively), at 6 months, with a smaller cohort (n = 42), again it was the HCQ and EQ-5D (effect size: 2.03 and 1.04, respectively). The SF-6D demonstrated no ceiling or floor effect during the study; the HCQ demonstrated a ceiling affect for 5% of respondents at 6 months after surgery compared to 26% of respondents for the EQ-5D. CONCLUSION: For this patient population, our findings indicated that the EQ-5D was more consistently responsive to change over time, as a utility index was better at distinguishing differences between groups and reflected the results of the joint-specific HCQ for knee recovery better than the SF-6D. It is therefore recommended that for similar populations, the EQ-5D is preferable to the SF-6D for utilisation alongside the HCQ.

Rate and risk of anterior cruciate ligament injury among sportswomen in Slovenia.

CONTEXT: Anterior cruciate ligament (ACL)-injury rate is greater among female athletes than among male athletes. OBJECTIVE: To investigate the rate and risk of ACL injury among Slovenian sportswomen playing professional basketball, team handball, or volleyball. DESIGN: Prospective cohort study. SETTING: The Slovenian National Organizations of basketball, team handball, and volleyball. PATIENTS OR OTHER PARTICIPANTS: During the 2003-2004 season, we prospectively followed 585 Slovenian sportswomen registered in the Slovenian National Organizations of basketball, team handball, and volleyball. MAIN OUTCOME MEASURE(S): We asked sportswomen and coaches to document the occurrence of every significant traumatic knee injury requiring medical attention. Injury rate and injury risk were calculated for sportswomen in each sport group. To calculate injury rate, we estimated the average exposure of each sportswoman during the research period. RESULTS: During the 2003-2004 season, 585 Slovenian sportswomen sustained 12 ACL injuries. The ACL-injury risk was different in athletes participating in the various sports, with basketball players having the greatest ACL-injury risk and volleyball players having the lowest ACL-injury risk (P  =  .04). The risk of ACL injury among Slovenian sportswomen was 2.1 per 100 athletes (95% confidence interval  =  0.9, 3.2), whereas the rate of ACL injury was 0.037 per 1000 exposure hours (95% confidence interval  =  0.016, 0.06). CONCLUSIONS: Overall differences in injury risk were found among sports, but no differences were noted among divisions within sports. No differences for injury rate were observed between or within sports. The rate and risk of ACL injury among Slovenian sportswomen are high, with basketball players having the greatest ACL-injury risk.

Is knee laxity change after ACL injury and surgery related to open kinetic chain knee extensor training load?

OBJECTIVE: The purpose of this study was to evaluate whether knee anterior laxity changes after anterior cruciate ligament injury and surgery are related to aspects of thigh muscle resistance training during rehabilitation. DESIGN: Forty-nine subjects (13 females) diagnosed with an anterior cruciate ligament-deficient knee or who had undergone anterior cruciate ligament reconstructive surgery participated in this study. The subjects trained their knee extensors in the open kinetic chain during a 6-wk program, and the relationship of aspects of training (for example, absolute resistance load) and other factors to anterior laxity change during this period were analyzed using linear regression analysis. RESULTS: The only factor found to be significantly related (r = -0.347) to anterior knee laxity change was average absolute load used in training the knee extensors. CONCLUSIONS: These results offer some early clinical support for increasing the strain on the anterior cruciate ligament graft (in patients treated with reconstruction) or other passive restraints to anterior tibial displacement, during rehabilitation after anterior cruciate ligament injury and reconstruction surgery to promote decreased knee anterior laxity.