Long-term results of a randomized study on anterior cruciate ligament reconstruction with or without a synthetic degradable augmentation device to support the autograft.

PURPOSE: The aim was to compare the outcome of anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone (BPTB) autograft, with and without a poly(urethane urea) augmentation device. METHODS: Patients were randomized to BPTB reconstruction with a synthetic degradable augmentation device (n = 96) or without augmentation (n = 105). Follow-ups were made during 4 years after surgical treatment with the KT1000 arthrometer for objective evaluation of sagittal stability. The Tegner scoring system for assessment of physical activity level and the Knee injury Osteoarthritis Outcome Score (KOOS) for assessment of knee-specific health were evaluated after 4 and 12 years. RESULTS: KT1000 tests showed a significant decrease in mean manual maximum side-to-side difference after 4 years in both patients with and those without augmentation, without any statistical difference between the groups (n.s.). Pre-injury, 76 and 80% of the patients, respectively, reported Tegner level 7-10. Pre-surgery, the corresponding figures were 6 and 5%, and at 4 years, 33 and 30 %. Twelve years after ACL reconstruction, both groups had significantly higher KOOS scores in function in sports and recreational activities (p < 0.001) and knee-related quality of life (p < 0.001) compared to before surgical treatment. In 10 patients, the augmentation device was removed, in six of these because of insufficient screw fixation to femur and in four due to swelling/hydrops. CONCLUSION: This study showed no significant difference in clinical outcome with use of an additional synthetic augmentation device in a single-bundle BPTB ACL reconstruction compared with non-augmentation, in short, intermediate, or long-term perspective. LEVEL OF EVIDENCE: Therapeutic study, Level I.

Total proximal hamstring ruptures: clinical and MRI aspects including guidelines for postoperative rehabilitation.

The aim of this article is to provide a state-of-the-art review for treatment of acute, total proximal hamstring tendon ruptures. For total proximal hamstring tendon ruptures, early (<2-3 w) surgical refixation minimizes muscle atrophy and facilitates a somewhat predictable time course for healing and rehabilitation. A postoperative rehabilitation program is detailed that has been used by one physical therapist for the past 7 years on over 200 patients with surgical repair for total proximal hamstring tendon rupture. One re-rupture has occurred, 7 months after surgery, following the rehabilitation program described herein. The rehabilitation program, including avoidance of postoperative bracing, appears effective for total proximal hamstring ruptures. Early surgery together with a specific rehabilitation program appears to be the treatment of choice for timely and safe return to sport and an active lifestyle. Level of evidence V.

Forward lunge: a training study of eccentric exercises of the lower limbs.

A few studies have shown that eccentric exercise is effective for prevention and treatment of muscle injuries. Most earlier studies on eccentric exercises have used training with advanced equipment. Forward lunges are considered eccentric exercises, and they may be performed without any equipment. These exercises are commonly used by sprint runners. We performed a prospective, randomized, 6-week training study comparing the effects of walking or jumping forward lunges on hamstring and quadriceps strength and function. Thirty-two soccer players were included in the study. The forward lunge training was done as an addition to ordinary soccer training twice a week for 6 weeks. The outcome was measured by the maximal hamstring and quadriceps strength tests and by functional tests with 1-leg hop tests and 30-m sprint runs. Overall muscle pain was evaluated using a visual analogue scale score, and local pain was estimated with an algometer. Whereas the walking lunge improved hamstring strength, the jumping lunge resulted in sprint running improvements. Algometer testing showed a general increase in the pain detection thresholds of all subjects, including the controls. Thus, precautions should be taken when algometers are used for temporal studies of pain. Walking and jumping forward lunges can be used for improving hamstring strength and running speed in young soccer player. The findings may have relevance when designing protocols for prevention and rehabilitation of muscle injuries.

A prospective 2-year follow-up study of plantar incisions in the treatment of primary intermetatarsal neuromas (Morton's neuroma).

BACKGROUND: The aim of this prospective study, with a mean 29 (minimum 24) months follow-up was to evaluate the outcome of surgical treatment with a longitudinal, plantar incision of primary Morton's neuromas. METHODS: All 55 patients (59 feet) had their pre-and post-operative pain assessed using VAS, and pre-operative radiographs evaluated. Two independent orthopedic surgeons performed the follow-up examinations. RESULTS: Histology confirmed positive neuromas in all cases and there were only three minor complications. There was 88% reduction of pain at follow-up and 86% of all patients rated the overall satisfaction with the results as excellent or good. For those patients engaged in sports activities, the corresponding figure was 93%. CONCLUSIONS: Surgery with a plantar incision seems to be a reliable and safe intervention of primary Morton's neuromas, with only limited number of minor complications and a subjective satisfactory outcome, well in accordance with other studies, using different, surgical approaches.

Proximal hamstring strains of stretching type in different sports: injury situations, clinical and magnetic resonance imaging characteristics, and return to sport.

BACKGROUND: Hamstring strains can be of at least 2 types, 1 occurring during high-speed running and the other during motions in which the hamstring muscles reach extreme lengths, as documented for sprinters and dancers. HYPOTHESIS: Hamstring strains in different sports, with similar injury situations to dancers, also show similarities in symptoms, injury location, and recovery time. STUDY DESIGN: Case series (prognosis); Level of evidence, 4. METHODS: Thirty subjects from 21 different sports were prospectively included. All subjects were examined clinically and with magnetic resonance imaging (MRI). The follow-up period lasted until the subjects returned to or finished their sport activity. RESULTS: All injuries occurred during movements reaching a position with combined extensive hip flexion and knee extension. They were located proximally in the posterior thigh, close to the ischial tuberosity. The injuries were often complex, but 83% involved the semimembranosus and its proximal free tendon. Fourteen subjects (47%) decided to end their sports activity. For the remaining 16 subjects, the median time for return to sport was 31 weeks (range, 9-104). There were no significant correlations between specific clinical or MRI parameters and time to return to sport. CONCLUSIONS: In different sports, an injury situation in which the hamstring muscles reach extensive length causes a specific injury to the proximal posterior thigh, earlier described in dancers. Because of the prolonged recovery time associated with this type of injury, correct diagnosis, based on history and palpation, and adequate information to the subject are essential.

Plantar versus dorsal incision in the treatment of primary intermetatarsal Morton's neuroma.

BACKGROUND: Only few studies have compared plantar and dorsal incisions in the treatment of primary intermetatarsal Morton's neuroma (PIMN). The results and guidelines are, however, still controversial, mainly due to confounding factors and study design. The present study is an attempt to systematically compare the two approaches. MATERIALS AND METHODS: With a 2- to 5-year followup, we retrospectively compared the results of 125 patients (132 feet) with PIMN. All specimens had histology assessments. Longitudinal plantar incisions were performed by one experienced surgeon (n = 69) and dorsal incisions by another (n = 56). Records were reviewed, questionnaires evaluated, and physical examinations performed by one of two independent orthopaedic surgeons. RESULTS: Histology verified nerve resections in all specimens except in three cases of missed nerves in the dorsal group. There were significant differences, in favor of the plantar group, regarding long-term sensory loss, postoperative sick-leave weeks and complications. The clinical outcome regarding postoperative pain at followup and overall satisfaction rating were similar. CONCLUSION: We conclude that the two surgical approaches were comparable for clinical outcome and patient satisfaction at followup, whereas significant differences, in favor of plantar incisions, were present regarding residual sensory loss and number of complications. The more serious complication with the dorsal approach, missed neuroma, may result in an increased risk of failure with the dorsal incision.

Self-rated pain and perceived health in relation to stress and physical activity among school-students: a 3-year follow-up.

The aim of this longitudinal study was to assess changes with age regarding prevalence of pain and perceived health in a student population, as well as change over time at grade level. Pain included frequency of headache, abdominal, and musculoskeletal pain and perceived health included problems sleeping and/or if they often felt tired, lonely, and sad. If gender, age (grade level), stress, physically activity were related to pain and health complaints were tested with multivariate logistic regression analysis. The students (n=1908) came from randomly selected schools throughout Sweden and attended grades 3, 6 and 9 (ages 9, 12 and 15 at the onset of the year) in 2001. Three years later, 67% (n=1276) of the same students answered a questionnaire that was constructed for the purpose of the studies. The responses given by the same students showed that girls' complaints of pain and perceived health increased with age and boys decreased. Over half (56%) of the girls and two-thirds (67%) of the boys reported no frequent complaints either year. At grade level most variables were rated the same as three years earlier by the same age group. Stress was significantly related to pain and health complaints for girls and the risk of complaints, as calculated with odds ratio, was most evident for students who were characterized as being physically inactive in 2001 and remained inactive three years later. Jointly, significant predictors, such as stress, being physically inactive, gender and grade level, explained 8-20% of the frequent complaints.

Acute first-time hamstring strains during slow-speed stretching: clinical, magnetic resonance imaging, and recovery characteristics.

BACKGROUND: Hamstring strains can be of 2 types with different injury mechanisms, 1 occurring during high-speed running and the other during stretching exercises. HYPOTHESIS: A stretching type of injury to the proximal rear thigh may involve specific muscle-tendon structures that could affect recovery time. STUDY DESIGN: Case series (prognosis); Level of evidence, 2. METHODS: Fifteen professional dancers with acute first-time hamstring strains were prospectively included in the study. All subjects were examined, clinically and with magnetic resonance imaging, on 4 occasions after injury: at day 2 to 4, 10, 21, and 42. The clinical follow-up period was 2 years. RESULTS: All dancers were injured during slow hip-flexion movements with extended knee and experienced relatively mild acute symptoms. All injuries were located proximally in the posterior thigh close to the ischial tuberosity. The injury involved the semimembranosus (87%), quadratus femoris (87%), and adductor magnus (33%). All injuries to the semimembranosus involved its proximal free tendon. There were no significant correlations between clinical or magnetic resonance imaging parameters and the time to return to preinjury level (median, 50 weeks; range, 30-76 weeks). CONCLUSION: Stretching exercises can give rise to a specific type of strain injury to the posterior thigh. A precise history and careful palpation provide the clinician enough information to predict a prolonged time until return to preinjury level. One factor underlying prolonged recovery time could be the involvement of the free tendon of the semimembranosus muscle.

Eccentric treatment for patellar tendinopathy: a prospective randomised short-term pilot study of two rehabilitation protocols.

OBJECTIVE: To compare the efficacy and safety of two eccentric rehabilitation protocols for patients with symptomatic patellar tendinopathy. A new eccentric overload training device was compared with the present standard eccentric rehabilitation programme on a decline board. DESIGN: Prospective, randomised clinical trial. SETTING: Sports rehabilitation clinic, university sports laboratory, supplemented with home exercises. PATIENTS: 20 competitive and recreational athletes, all with clinical diagnosis of patellar tendinopathy, verified by MRI or ultrasound imaging. INTERVENTIONS: A 12-week rehabilitation period, either with bilateral eccentric overload strength training using the Bromsman device twice a week or with unilateral eccentric body load training using a decline board twice a week, supplemented with daily home exercises. OUTCOME MEASURES: The primary outcome was pain and function, assessed by the Swedish Victorian Institute of Sport Assessment for Patella (VISA-P) score. Secondary outcome measures were isokinetic muscle torque, dynamic function and muscle flexibility, as well as pain level estimations using visual analogue scale (VAS). Side effects were registered. RESULTS: Both treatment groups improved in the short term according to the VISA-P scores during the 12-week rehabilitation period. However, there were no significant differences between the groups in terms of pain and function. After a 3-month rehabilitation period, most patients could be regarded as improved enough to be able to return to training and sports. No serious side effects were detected in either group. CONCLUSION: In patients with patellar tendinopathy pain, two-legged eccentric overload training twice per week, using the new device (Bromsman), was as efficient and safe as the present standard daily eccentric one-legged rehabilitation-training regimen using a decline board.

Prevalence and co-occurrence of self-rated pain and perceived health in school-children: Age and gender differences.

In this nationwide study, 1975 students from grades 3, 6, and 9 (ages 9, 12, and 15 at the onset of the year), were recruited from randomly selected schools, which represented different geographical areas throughout Sweden. The main aim of the study was to assess the prevalence of self-reported pain (headache, abdominal, and musculoskeletal pain) and perceived health (problems sleeping and/or if they often felt tired, lonely and sad). A second aim was to study the co-occurrence among different pain and health variables. The students, (n = 1908 distributed by grade 3: 255 girls and 305 boys, grade 6: 347 girls and 352 boys, grade 9: 329 girls and 320 boys) answered retrospectively (three months) a specially designed questionnaire. Fifty percent (50%) of the students reported that they had experienced pain, either as headache, abdominal pain or musculoskeletal pain, within the recall period. Gender differences were especially noticeable for headaches, where twice as many girls (17%, n = 159) than boys (8%, n = 80) reported that they suffered such pain at least once a week or more often. Co-occurrence among the variables was moderate (0.3-0.5). For the total of the seven variables, the perception of pain and health complaints decreased with age for boys from grades 3 to 9, while multiple complaints increased for girls.

Acute first-time hamstring strains during high-speed running: a longitudinal study including clinical and magnetic resonance imaging findings.

BACKGROUND: Hamstring muscle strain is one of the most common injuries in sports. Still, knowledge is limited about the progression of clinical and magnetic resonance imaging characteristics and their association with recovery time in athletes. HYPOTHESIS: Knowing the anatomical location and extent of an acute first-time hamstring strain in athletes is critical for the prognosis of recovery time. STUDY DESIGN: Case series (prognosis); Level of evidence, 2. METHODS: Eighteen elite sprinters with acute first-time hamstring strains were prospectively included in the study. All subjects were examined, clinically and with magnetic resonance imaging, on 4 occasions after injury: at day 2 to 4, 10, 21, and 42. The clinical follow-up period was 2 years. RESULTS: All sprinters were injured during competitive sprinting, and the primary injuries were all located in the long head of the biceps femoris muscle. There was an association between the time to return to pre-injury level (median, 16; range, 6-50 weeks) and the extent of the injury, as indicated by the magnetic resonance imaging parameters. Involvement of the proximal free tendon, as estimated by MRI, and proximity to the ischial tuberosity, as estimated both by palpation and magnetic resonance imaging, were associated with longer time to return to pre-injury level. CONCLUSION: Careful palpation during the first 3 weeks after injury and magnetic resonance imaging investigation performed during the first 6 weeks after injury provide valuable information that can be used to predict the time to return to pre-injury level of performance in elite sprinting.

Child-parent agreement on reports of disease, injury and pain.

BACKGROUND: Studies on school students are indicating that somatic complaints and pain have increased during the past decades. Throughout this period there has been a change in methodology from proxy reports by parents to having the students themselves act as the respondents, possible explaining some of the increase in prevalence. The aim of this study was to compare the agreement of answers from students with answers given by their parents regarding the students' medical background and subjective rating of perceived health with specific focus on frequency of headache, musculoskeletal pain and tiredness. METHODS: The participating students came from eleven different schools in Sweden. The schools were a sub sample of randomly selected schools originally participating in a larger multidisciplinary base study. Those 8th grade students present at school on the test date became the subjects of the investigation. A total of 232 students answered, assisted by the test leader, a specially designed self-complete questionnaire at school. Their parents were, at the same time, contacted and 200 answered a similar mailed-out questionnaire. One hundred and eighty-six (186) corresponding student-same parent questionnaires were registered for which comparisons of answers could be made and analysis conducted. RESULTS: When a child is in good health, in absence of diseases, pain and injuries, his or her assessment matches up with their parent. Children and parents also showed agreement in cases of severe injuries and frequent (daily) complaints of knee pain. Less frequent headaches, back- and musculoskeletal pain and other complaints of minor injuries and less wellbeing, such as students' tiredness, were all under-reported and under-rated by their parents. CONCLUSION: When assessing the perceived health and wellbeing of students, their own expressions should be the basis for the data collection and analysis rather than relying entirely on parental reports.

Knee joint kinaesthesia and neuromuscular coordination during three phases of the menstrual cycle in moderately active women.

An increased incidence of sports related injuries in the premenstrual phase as well as in the menstrual phase of the menstrual cycle has been described. This may be explained by alterations in proprioception and neuromuscular coordination due to hormonal variations. Prospective, within women analysis of knee joint kinesthesia and neuromuscular coordination were performed by repeated measures analysis of variance in three hormonally verified phases of three consecutive menstrual cycles. Thirty-two healthy, moderately active female subjects volunteered to participate in the study. Twenty-five of the subjects performed at least one hormonally verified menstrual cycle. A specially designed device was used to investigate knee joint kinaesthesia and neuromuscular coordination was measured with the square hop test. These tests were carried out in the menstrual phase, ovulation phase and premenstrual phase determined by hormone analyses in three consecutive menstrual cycles. An impaired knee joint kinaesthesia was detected in the premenstrual phase and the performance of square hop test was significantly improved in the ovulation phase compared to the other two phases. The results of this study indicate that the variation of sex hormones in the menstrual cycle has an effect on performance of knee joint kinaesthesia and neuromuscular coordination.

Injuries during physical activity in school children.

During the spring of 2001, 1975 children, from grades 3, 6 and 9 participated in a nationwide, multidisciplinary collaboration study. The students came from randomly selected classes throughout Sweden, representing different geographical and socio-economic areas. The aim of this study was to collect and evaluate self-reported injuries and associated factors during various physical activities as recalled retrospectively for 3 months by the students. Every sixth student (n=299 or 16%) reported 306 injuries. Twice as many girls than boys were injured during physical education class. Ninth-grade students reported relatively more injuries during organized sports than during physical education class and leisure activities. There were no age or gender differences in incidence rate during leisure activities. Most injuries were minor, as 70% were back in physical activity within a week. Half of the students (50%) reported that they previously had injured the same body part. Primary care of the injured student was, with the exception of a family member, most often carried out by the physical education teacher or coach, which accentuates the importance of continuous sports medicine first aid education for this group.

Altered postural control during the luteal phase in women with premenstrual symptoms.

The purpose of this study was to investigate postural control in women with and without premenstrual symptoms (PMS) in three hormonally verified phases of the menstrual cycle. Thirty-two women were recruited to participate in the study and 25 of these women were included in the results. Menstrual cycle phases were determined by sex hormone analyses in serum and LH detection in urine. A prospective rating of PMS was used to divide the subjects into two groups: one with PMS (cyclic) and one without (non-cyclic). For measurement of postural control, subjects stood on a force platform (AMTI) in two-legged stance (eyes open and closed) and one-legged stance (eyes open and closed). There were no significant differences in the two-legged stance between the phases of the menstrual cycle or between groups. In one-legged stance with eyes open, there was a significant increase in postural displacement in the mid-luteal phase in the cyclic group, but no differences were detected between phases in the non-cyclic group. These findings may be related to the previously reported increased injury rate and psychomotor slowing in the luteal phase in women with PMS.

Evaluation of general joint laxity, shoulder laxity and mobility in competitive swimmers during growth and in normal controls.

The aim of the study was to evaluate differences between competitive swimmers and a reference group of school children concerning general joint laxity, laxity of the glenohumeral joint and range of motion in the shoulder. Materials and methods. Competitive swimmers (n = 120) were compared with references consisting of age and gender matched school children (n = 1277). General joint laxity was evaluated with the Beighton score. Anterior glenohumeral laxity was assessed according to the drawer test, and inferior glenohumeral laxity according to the sulcus test. Shoulder rotation was measured with a goniometer. RESULTS: Male swimmers of both age groups showed a higher degree of general joint laxity compared with the reference group while 9-year-old female swimmers alone had a lower degree of general joint laxity compared with references. No significant difference concerning shoulder laxity was noticed between groups. There was a decreased internal rotation in male and female swimmers as compared with the reference group. External rotation was reduced in female swimmers as compared with the female references. The same result was observed in male swimmers, but only at the age of 12 years. CLINICAL CONSEQUENCE: Competitive swimming in children seems to lead to a decreased range of motion with regard to shoulder rotation. However, the reason for this is still unclear and further investigations are needed.

Psychometric properties of a Swedish translation of the VISA-P outcome score for patellar tendinopathy.

BACKGROUND: Self-administrated patient outcome scores are increasingly recommended for evaluation of primary outcome in clinical studies. The VISA-P score, developed at the Victorian Institute of Sport Assessment in Melbourne, Australia, is a questionnaire developed for patients with patellar tendinopathy and the patients assess severity of symptoms, function and ability to participate in sport. The aim of this study was to translate the questionnaire into Swedish and to study the reliability and validity of the translated questionnaire and resultant scores. METHODS: The questionnaire was translated into Swedish according to internationally recommended guidelines for cross-cultural adaptation of self-report measures. The reliability and validity were tested in three different populations. The populations used were healthy students (n = 17), members of the Swedish male national basketball team (n = 17), considered as a population at risk, and a group of non-surgically treated patients (n = 17) with clinically diagnosed patellar tendinopathy. The questionnaire was completed by 51 subjects altogether. RESULTS: The translated VISA-P questionnaire showed very good test-retest reliability (ICC = 0.97).The mean (+/- SD) of the VISA-P score, at both the first and second test occasions was highest in the healthy student group 83 (+/- 13) and 81 (+/- 15), respectively. The score of the basketball players was 79 (+/- 24) and 80 (+/- 23), while the patient group scored significantly (p < 0.05) lower, 48 (+/- 20) and 52 (+/- 19). CONCLUSIONS: The translated version of the VISA-P questionnaire was linguistically and culturally equivalent to the original version. The translated score showed good reliability.

Sports massage after eccentric exercise.

BACKGROUND: The use of sports massage is very common in the athletic community. However, only a few studies have shown any therapeutic effect of massage. HYPOTHESIS: Sports massage can improve the recovery after eccentric exercise. STUDY DESIGN: Prospective randomized clinical trial. METHODS: Sixteen subjects performed 300 maximal eccentric contractions of the quadriceps muscle bilaterally. Massage was given to 1 leg, whereas the other leg served as a control. Subjects were treated once daily for 3 days. Maximal strength was tested on a Kin-Com dynamometer, and functional tests were based on 1-leg long jumps. Pain was evaluated using a visual analog scale. RESULTS: There was a marked loss of strength and function of the quadriceps directly after exercise and on the third day after exercise. The massage treatment did not affect the level or duration of pain or the loss of strength or function following exercise. CONCLUSION: Sports massage could not improve the recovery after eccentric exercise.

Muscle strength and endurance do not significantly vary across 3 phases of the menstrual cycle in moderately active premenopausal women.

OBJECTIVE: To investigate muscle strength and muscle endurance in women during 3 well-determined phases of the menstrual cycle: early follicular phase, ovulation phase, and midluteal phase. DESIGN: Prospective, within-woman analysis was performed of muscle strength and muscle endurance by repeated measures analysis of variance in 3 hormonally verified phases of 2 consecutive menstrual cycles. PARTICIPANTS: Fifteen female subjects with moderate physical activity level and regular menstrual cycles volunteered to participate in the study. Analyses are based on 10 subjects who completed 2 consecutive menstrual cycles with hormonally verified phases. MAIN OUTCOME MEASUREMENTS: Handgrip strength, 1-leg hop test, isokinetic muscle strength, and muscle endurance were measured in 2 consecutive menstrual cycles in the early follicular phase, in the ovulation phase, and in the midluteal phase. Isokinetic muscle strength and endurance were tested with knee extension exercise on a standard instrument. Menstrual cycle phases were determined by analysis of sex hormone levels in serum, and ovulation was detected by luteinizing hormone surge in urine. RESULTS: No significant variation in muscle strength or muscle endurance could be detected during different well-determined phases of the menstrual cycle. CONCLUSIONS: This study detected no significant variation in muscle strength and muscle endurance during the menstrual cycle. In contrast to other studies showing variations in strength and endurance during the menstrual cycle, the present study was hormonally validated and was repeated in 2 consecutive menstrual cycles. However, it is unknown whether these data in moderately active university students would be relevant to the highly trained woman athlete.