Rehabilitation and Return to Play Protocols After Anterior Cruciate Ligament Reconstruction in Soccer Players: A Systematic Review.

BACKGROUND: Rehabilitation after anterior cruciate ligament ACL reconstruction (ACLR) is crucial for safe return to play (RTP) and reducing the chances of a reinjury. Yet, there is no consensus on the ideal functional tests to assess rehabilitation progress in soccer players after ACLR. PURPOSE: The primary objective was to highlight the existing gap in the literature concerning the most effective standardized rehabilitation protocols and testing for facilitating successful RTP among soccer players. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review using PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) was conducted. Inclusion criteria encompassed original studies (level of evidence 1-4) that examined rehabilitation protocols, metrics of knee rehabilitation, and clinical outcomes after ACLR in soccer players. RESULTS: This review incorporated 23 studies, predominantly retrospective case series, with a total number of 874 soccer players who underwent ACLR and rehabiliation. 5 (21.7%) studies utilized an accelerated rehabilitation protocol, while 7 (30.4%) of studies utilized a criterion-based rehabilitation. A wide heterogeneity of data was extracted including functional tests of rehabilitation and RTP such as strength test batteries, hop test batteries, and movement quality assessments. Of the 23 selected studies, 2 (8.7%) used all 3 test batteries, 8 (34.8%) used 2 test batteries, 12 (52.2%) used 1 test battery, and 1 (4.3%) used 0 of the test batteries. The mean time between surgery and RTP ranged from 3 to 8 months with only 2 (8.7%) studies reporting complications after ACLR. Lastly, out of the total studies examined, 9 (39.1%) assessed patient-reported outcome measures (PROMs), all of which demonstrated significant improvement from the initial assessment to the final follow up. CONCLUSION: Soccer-specific rehabilitation after ACLR lacks standardization. Even though many studies have assessed protocols for optimal RTP and reduced secondary ACL injuries, there is a gap in the literature regarding the most effective protocols and RTP testing. The methodology reported by Kyritsis et al could serve as a foundation for future prospective randomized multicenter studies to establish a standard rehabilitation protocol and enable a successful return to soccer.

* Gelatin Scaffolds Containing Partially Sulfated Cellulose Promote Mesenchymal Stem Cell Chondrogenesis.

Articular cartilage has a limited capacity to heal after damage from injury or degenerative disease. Tissue engineering constructs that more closely mimic the native cartilage microenvironment can be utilized to promote repair. Glycosaminoglycans (GAGs), a major component of the cartilage extracellular matrix, have the ability to sequester growth factors due to their level and spatial distribution of sulfate groups. This study evaluated the use of a GAG mimetic, cellulose sulfate, as a scaffolding material for cartilage tissue engineering. Cellulose sulfate can be synthesized to have a similar level and spatial distribution of sulfates as chondroitin sulfate C (CSC), the naturally occurring GAG. This partially sulfated cellulose (pSC) was incorporated into a fibrous gelatin construct by the electrospinning process. Scaffolds were characterized for fiber morphology and overall stability over time in an aqueous environment, growth factor interaction, and for supporting mesenchymal stem cell (MSC) chondrogenesis in vitro. All scaffold groups had micron-sized fibers and maintained overall stability in aqueous environments. Increasing concentrations of the transforming growth factor-beta 3 (TGF-ß3) were detected on scaffolds with increasing pSC. MSC chondrogenesis was enhanced on the scaffold with the highest pSC concentration as seen with the highest collagen type II production, collagen type II immunostaining, expression of cartilage-specific genes, and ratio of collagen type II to collagen type I production. These studies demonstrated the potential of pSC sulfate as a scaffolding material for cartilage tissue engineering.

Chronic quadriceps rupture: treatment with lengthening and early mobilization without cerclage augmentation and a report of three cases.

In this study, 3 patients with chronic quadriceps tears and gaps < 2 cm were treated with a V-Y lengthening of the tendon, repair of the tendon through drill holes in the patella without cerclage augmentation, and early mobilization. The gap was < or = 2 cm following adequate surgical mobilization of the quadriceps tendon. Results of this technique are presented with a minimum of 1-year follow-up.

The accuracy of subacromial corticosteroid injections: a comparison of multiple methods.

Corticosteroids are commonly used in the treatment of the impingement syndrome. Efficacy, as well as accurate placement, have been questioned. The purpose of this prospective, randomized study is to assess the accuracy of subacromial injections and to correlate accuracy with short term clinical outcome at 3 months. Sixty shoulders, which were diagnosed with impingement syndrome, were randomized to receive a subacromial injection of corticosteroids, local anesthetic, and contrast dye from 1 of 3 locations: anterolateral, lateral, or posterior. Accuracy was confirmed by 3 radiographic views of the shoulder, while clinical ratings were assessed by the UCLA shoulder score and a 10-point visual pain analog scale during the initial, post-injection, and 3-month visits. The overall accuracy was 70%, with no difference among the 3 portals. Accuracy was not related to body mass index. Furthermore, accurate injections did not significantly improve the UCLA score, pain scale, or patient satisfaction at 3 months. In contrast, accurate injections produced a positive Neer's impingement test more often (35/39 vs 9/16; P = .009). Overall, there was an improvement in the UCLA score (26.2-32.2; P < .001) and a decrease in the pain scale (7.2-3.43; P < .001) at 3-month follow-up. In conclusion, the accuracy of injection was 70%. Clinical improvement did not correlate with accuracy; however, accuracy did reliably produce a positive impingement test. This multimodal treatment plan did produce significant improvement in shoulder function and pain level in the short term.

Anterior instability increases superior labral strain in the late cocking phase of throwing.

Superior labrum tears are common injuries in the throwing athlete. Sever contributing factors have been identified; however, the effects of instability on the superior labrum have not been studied. The goal of this cadaver study was to determine the effect of instability on superior labral strain in a model of the throwing motion. Six cadaver shoulders were mounted on an MTS machine with a strain gauge placed on the superior labrum. The shoulder was brought into the late cocking phase and strain measured before and after the introduction of a lesion to the inferior glenohumeral ligament to create anterior instability. Labral strain increased linearly in the late cocking phase of throwing in all specimens. Posterosuperior labral strain increased 160% in the unstable shoulders. This was a significant difference (P = .02). Instability increases strain in the posterosuperior labrum in the late cocking phase of throwing. This increased strain may render the labrum more prone to injury in the throwing or overhead athlete.

Avulsion fracture of the ulnar sublime tubercle in overhead throwing athletes.

BACKGROUND: Injuries to the ulnar collateral ligament are relatively common in throwing athletes and result from either acute traumatic or repeated valgus stress to the elbow. Avulsion fracture of the sublime tubercle of the ulna is a rarely reported site of ulnar collateral ligament injury. PURPOSE: We retrospectively reviewed our cases of ulnar collateral ligament injuries to study avulsion fractures of the sublime tubercle of the ulna. STUDY DESIGN: Case series. METHODS: Data, including radiographs and magnetic resonance imaging scans, were obtained by review of hospital and office records and by follow-up examination. Of 33 consecutive patients treated for ulnar collateral ligament injuries, 8 had avulsion fractures of the sublime tubercle of the ulna. All eight were male baseball players with dominant arm involvement, an average age of 16.9 years, and an average follow-up of 23.6 months. RESULTS: Six of eight patients had failure of nonoperative treatment and required surgical repair. Two of the six underwent ulnar collateral ligament reconstruction and four had direct repair of the sublime tubercle avulsion with bioabsorbable suture anchors. At last follow-up, all eight had returned to their preinjury level of activity. No patient had residual medial elbow pain or laxity. CONCLUSIONS: Diagnosis of sublime tubercle avulsion fracture is made with history, physical examination, and radiographic studies. Magnetic resonance imaging can help identify an avulsion fracture not visible radiographically and can help determine whether direct repair or reconstruction is needed.