Fatigue affects quality of movement more in ACL-reconstructed soccer players than in healthy soccer players.

PURPOSE: Athletes who meet return to play (RTP) criteria after anterior cruciate ligament reconstruction (ACLR) rehabilitation still have a substantially increased risk of second ACL injury. One of the contributing factors to this increased risk could be that the RTP criteria are often not tested in an ecologically valid environment and in a fatigued state. The purpose of this cross-sectional case-control study was to investigate the influence of neuromuscular fatigue on both movement quantity and quality in fully-rehabilitated soccer players after ACLR and to compare them with healthy soccer players. METHODS: ACL-reconstructed soccer players (n = 14) and healthy soccer players (n = 19) participated in the study and were matched by playing level and training hours. RTP measurements were performed on the soccer field, in both a non-fatigued and fatigued state. The RTP measurements focussed on both movement quantity (hop tests) and quality [countermovement jump with a Landing Error Scoring System (LESS) score]. RESULTS: Movement quantity did not differ between ACL-reconstructed and healthy soccer players, both expressed in absolute values and the LSI-D/ND (calculated as dominant/non-dominant*100%). However, movement quality decreased more in the ACL-reconstructed soccer players in the fatigued state compared to the non-fatigued state. CONCLUSIONS: Ideally, RTP measurements should focus on movement quality and should be conducted on the soccer field in a fatigued state, creating an ecologically valid environment. The LSI-D/ND can be used as an outcome parameter for RTP measurements of movement quantity and should be at least 95%. LEVEL OF EVIDENCE: Therapeutic, Level III.

Hip muscle strength is decreased in middle-aged recreational male athletes with midportion Achilles tendinopathy: A cross-sectional study.

OBJECTIVE: Investigating differences in hip muscle strength between athletes with Achilles tendinopathy (AT) and asymptomatic controls. DESIGN: Cross-sectional case-control study. SETTING: Sports medical center. PARTICIPANTS: Twelve recreational male athletes with mid-portion AT and twelve matched asymptomatic controls. OUTCOME MEASURES: Isometric strength of the hip abductors, external rotators, and extensors was measured using a handheld dynamometer. Functional hip muscle performance was evaluated with the single-leg squat. The Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire was completed to determine clinical severity of symptoms. RESULTS: Compared to controls, participants with AT demonstrated 28.9% less isometric hip abduction strength (p = 0.012), 34.2% less hip external rotation strength (p = 0.010), and 28.3% less hip extension strength (p = 0.034) in the injured limb. Similar differences were found for the non-injured limb (26.7-41.8%; p < 0.03). No significant differences were found in functional hip muscle performance between the injured and non-injured limb or between the groups, and no significant correlation was found between hip muscle strength and VISA-A scores. CONCLUSION: Recreational male athletes with chronic mid-portion AT demonstrated bilateral weakness of hip abductors, external rotators, and extensors compared to their asymptomatic counterparts. These findings suggest that hip muscle strength may be important in the assessment and rehabilitation of those with AT.

Hip joint pathology: relationship between patient history, physical tests, and arthroscopy findings in clinical practice.

The purpose of this retrospective cohort study was to (a) describe the clinical presentation of femoroacetabular impingement (FAI) and hip labral pathology; (b) describe the accuracy of patient history and physical tests for FAI and labral pathology as confirmed by hip arthroscopy. Patients (18-65 years) were included if they were referred to a physical therapist to gather pre-operative data and were then diagnosed during arthroscopy. Results of pre-operative patient history and physical tests were collected and compared to arthroscopy. Data of 77 active patients (mean age: 37 years) were included. Groin as main location of pain, the Anterior Impingement test (AIT), Flexion-Abduction-External Rotation (FABER) test, and Fitzgerald test had a high sensitivity (range 0.72-0.91). Sensitivity increased when combining these tests (0.97) as either groin as main location of pain and a positive FABER test or a positive AIT and a positive FABER test were the shortest most sensitive combinations. The results of this study point out that in clinical practice absence of groin as main location of pain combined with a negative FABER test or the combination of a negative AIT and a negative FABER test are suggested to rule out the diagnosis of symptomatic FAI and/or labral pathology.

Physical therapy aimed at self-management versus usual care physical therapy after hip arthroscopy for femoroacetabular impingement: study protocol for a randomized controlled trial.

BACKGROUND: Femoroacetabular impingement has been recognized as a common cause of hip pain and dysfunction, especially in athletes. Femoroacetabular impingement can now be better treated by hip arthroscopy but it is unclear what postoperative rehabilitation of hip arthroscopy should look like. Several rehabilitation protocols have been described, but none presented clinical outcome data. These protocols also differ in frequency, duration and level of supervision. We developed a rehabilitation protocol with supervised physical therapy which showed good clinical results and is considered usual care in our treatment center. However, it is unknown whether, due to the relatively young age and low complication rate of hip arthroscopy patients, rehabilitation based on self-management might lead to similar results. The aims of this pilot study are (1) to determine feasibility and acceptability of the self-management intervention, (2) to obtain a preliminary estimate of the difference in effect between physical therapy aimed at self-management versus usual care physical therapy in patients who undergo hip arthroscopy for femoroacetabular impingement. METHODS/DESIGN: Thirty participants (aged 18-50 years) scheduled for hip arthroscopy will be included and randomized (after surgery) to either self-management or usual care physical therapy in this assessor-blinded randomized controlled trial. After surgery, the self-management group will perform a home-based exercise program three times a week and will receive physical therapy treatment once every 2 weeks for 14 weeks. The usual care group will receive physical therapy treatment twice a week for 14 weeks and will perform an additional home-based exercise program once a week. Assessment will occur preoperatively and at 6, 14, 26 and 52 weeks after surgery. Primary outcomes are feasibility, acceptability and preliminary effectiveness. Feasibility and acceptability will be determined by the willingness to enroll, recruitment rate, adherence to treatment, patient satisfaction, drop-out rate and adverse events. Preliminary effectiveness will be determined using the following outcomes: the International Hip Outcome Tool 33 and hip functional performance as measured with the Single Leg Squat Test 14 weeks after surgery. DISCUSSION: The results of this study will be used to help decide on the need, feasibility and acceptability of a large-scale randomized controlled trial. TRIAL REGISTRATION: This protocol was registered with the Dutch Trial Registry (NTR5168) on 8 May 2015.

Eccentric exercise training in chronic mid-portion Achilles tendinopathy: a systematic review on different protocols.

Although eccentric exercise training has shown favorable results in chronic mid-portion Achilles tendinopathy, the optimum dosage remains unknown. A systematic review of the literature was performed in accordance with the PRISMA guidelines, in order to describe different exercise protocols and to determine the most effective training parameters. An extensive search in MEDLINE, EMBASE, CINAHL, and CENTRAL revealed 14 randomized and clinical controlled trials. Strong evidence was found for the Alfredson exercise protocol. In this 12-week protocol, exercises are performed 3 × 15 repetitions twice daily, both with a straight and bent knee. Exercises are performed at slow speed, and load is increased when exercises are without pain. Strong evidence was also found for gradual onset of exercises during the first week of the Alfredson program, but no uniformity of protocols exists. Other exercise protocols did achieve similar results, but many studies had some methodological shortcomings or lacked a detailed description of their training parameters. Because of the heterogeneity of study populations and outcome measures, and lack of reporting of training compliance data, a definitive conclusion regarding the most effective training parameters could not be made. Further research comparing the content of different exercise protocols is warranted.

Evidence-based rehabilitation following anterior cruciate ligament reconstruction.

Following a bone-patellar tendon-bone autograft (BPTB) or four-stranded semitendinosus/gracilis tendons autograft (ST/G) anterior cruciate ligament (ACL) reconstruction, the speed and safety with which an athlete returns to sports (or regains the pre-injury level of function) depends on the rehabilitation protocol. Considering the large differences in clinical and outpatient protocols, there is no consensus regarding the content of such a rehabilitation program. Therefore, we conducted a systematic review to develop an optimal evidence-based rehabilitation protocol to enable unambiguous, practical and useful treatment after ACL reconstruction. The systematic literature search identified 1,096 citations published between January 1995 and December 2006. Thirty-two soundly based rehabilitation programs, randomized clinical trials (RCT's) and reviews were included in which common physical therapy modalities (instruction, bracing, cryotherapy, joint mobility training, muscle-strength training, gait re-education, training of neuromuscular function/balance and proprioception) or rehabilitation programs were evaluated following ACL reconstruction with a BPTB or ST/G graft. Two reviews were excluded because of poor quality. Finally, the extracted data were combined with information from background literature to develop an optimal evidence-based rehabilitation protocol. The results clearly indicated that an accelerated protocol without postoperative bracing, in which reduction of pain, swelling and inflammation, regaining range of motion, strength and neuromuscular control are the most important aims, has important advantages and does not lead to stability problems. Preclinical sessions, clear starting times and control of the rehabilitation aims with objective and subjective tests facilitate an uncomplicated rehabilitation course. Consensus about this evidence-based accelerated protocol will not only enhance the speed and safety with which an athlete returns to sports, but a standardized method of outcome measurement and reporting will also increase the evidential value of future articles.