SYNOPSIS: Anterior cruciate ligament (ACL) injuries in skeletally immature individuals remain a challenge for the child, the parents, orthopedic surgeons, and physical therapists. The main challenges are the potential risk of recurrent instability and secondary injuries following non-operative treatment, and the risks involved with surgical treatment due to the vulnerability of the epiphyseal growth plates. In this paper we first present the physiological background for the considerations that have to be made upon advising on treatment alternatives for skeletally immature individuals after ACL injury. The implications from the continuous musculoskeletal development on treatment decisions are emphasized. No randomized controlled trials have been performed to investigate the outcome from different treatment algorithms. There is no consensus in the literature on clinical treatment decision criteria on whether a skeletally immature child should undergo transphyseal ACL reconstruction, physeal sparing ACL reconstruction, or non-operative treatment. Additionally, well described rehabilitation programs designed for either non-operative treatment or post-operative rehabilitation has not been published. Based on the current available evidence we propose a treatment algorithm for the management of ACL injuries in skeletally immature children. Finally, we suggest directions for future prospective studies which should include development of valid and reliable outcome measures and specific rehabilitation programs.

J Orthop Sports Phys Ther, Epub 4 September 2011. doi:10.2519/jospt.2012.3608

KEY WORDS: ACL, children, growth plates, kids, rehabilitation, surgery

STUDY DESIGN: Case report. BACKGROUND: Symptomatic accessory navicular can be a source of pain and disability. Treatment considerations for dancers may be different because of the increased demands on the foot, the repetitive nature of the movements, and the specific footwear required. The purpose of this report is to describe the management (1 conservative and 1 post-operative) of 2 adolescent dancers with symptomatic accessory navicular. CASE DESCRIPTIONS: Case 1 was an 11 year old female who underwent surgical excision of a symptomatic accessory navicular. Case 2 was a 15 year old female managed non-surgically following a traumatic injury that caused pain judged to be related to her accessory navicular. Treatment included pain management, range of motion exercises, trunk and lower extremity strengthening, balance and proprioception training, orthoses, cross-training, and a guided return-to-dance progression. OUTCOMES: Both patients had improved pain, dance technique, strength, and patient-reported outcome scores that allowed a full return to dance. DISCUSSION: The 2 dancers presented here had foot pain believed to be related to a symptomatic accessory navicular. In both cases, treatment targeted specific impairments to improve function and disability. The guided progression of activities was intended to facilitate a return to dance that protected healing tissues and prevented a recurrence of symptoms. Clinicians should be aware of the effect of non-surgical management of a symptomatic accessory navicular in the young dancer and potentially effective treatment options for this condition. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther, Epub 25 January 2012. doi:10.2519/jospt.2012.3809

KEY WORDS: ballet, dance, foot

STUDY DESIGN: Controlled laboratory study. BACKGROUND: Varus knee instability arising from lateral collateral ligament (LCL) injury increases stress on cruciate ligament grafts, often resulting in failure of reconstructed ligaments. In contrast to the medial collateral ligament (MCL), little is known about the structural properties of the LCL. OBJECTIVES: To compare the tensile properties of the LCL and MCL complex of the human knee joint. METHODS: Ten fresh-frozen cadaveric knees (mean ± SD, age 81±11 years), free of gross musculoskeletal pathology, were obtained. Following dissection, the length, width, and thickness of the ligaments were measured using calipers and bone-ligament-bone preparations were mounted in a uniaxial load frame. After preconditioning, specimens were extended to failure at a rate of 500mm/min (approximately 20%.s^-1). Force and crosshead displacement were used to calculate structural properties including stiffness, yield strength, ultimate tensile strength, and failure energy. RESULTS: The fan-shaped MCL was significantly longer (60%, P<.001), wider (680%, P<.001), and thinner (19%, P=.009) than the cord-like LCL. The LCL failed at either the fibular attachment (n=6) or midsubstance (n=4), while failure of the MCL primarily occurred at the femoral attachment (n=7). Although the ultimate tensile strength of the MCL (mean ± SD, 799±209 N) was twice that of the LCL (392±104 N, P<.001), there was no significant difference in stiffness of the ligaments (MCL, 63±14 N/mm; LCL, 59±12 N/mm). CONCLUSIONS: Despite differences in geometry and strength, there was no significant difference in stiffness of the MCL and LCL when tested in vitro.

J Orthop Sports Phys Ther, Epub 25 October 2011. doi:10.2519/jospt.2012.3919

KEY WORDS: biomechanics, lateral collateral ligament, medial collateral ligament, tensile properties

STUDY DESIGN: Controlled laboratory study using a single cohort design. OBJECTIVES: To determine if balance in older adults could be significantly improved with foot orthotic intervention. BACKGROUND:  Poor balance has been associated with risk for falls. Limited evidence exists indicating that foot orthoses influence balance. METHODS: Thirteen individuals older than 65 who reported at least 1 unexplained fall during the past year and who demonstrated poor balance participated in the study.  Subjects were tested for one-leg stance, tandem stance, tandem gait, and alternating step tests during the first (SCREEN) and second (PRE) sessions prior to foot orthotic intervention. Tests were repeated during the second testing session immediately after custom foot orthotic intervention (POST), and 2 weeks following foot orthotic use (FU).  SCREEN and PRE measures were compared for stability using absolute difference computations and Friedman's rank test.  PRE, POST, and FU data were analyzed using the Friedman's rank test (alpha = 0.05) with Bonferroni correction for multiple post-hoc comparisons. RESULTS: Each balance measure was statistically equivalent between the SCREEN and PRE measurements.  One-leg stance times for PRE were significantly less than POST (P = .002) and FU (P = .013) measurements.  Tandem stance times for PRE were significantly less than POST (P = .013) and FU (P = .013) measurements.  Steps taken for the tandem gait test during the PRE measurements were significantly fewer than steps taken for the FU test (P = .007).  Steps taken during the alternating step test for the PRE test were significantly fewer than steps taken during the POST (P = .002) and FU (P =.001) tests.  POST and FU measurements were not significantly different for any of the 4 outcome measures. CONCLUSIONS: The results provide preliminary evidence that foot orthoses can effect improvement in balance measures for older adults.

J Orthop Sports Phys Ther, Epub 25 January 2012. doi:10.2519/jospt.2012.3944

KEY WORDS: falls, geriatrics, orthoses, postural control, stability

STUDY DESIGN: Cross sectional cohort study. OBJECTIVE: To investigate the differences in the level of activation of neck-shoulder muscles between elite swimmers with and without shoulder pain during a functional upper limb task. BACKGROUND: Previous studies have reported altered motor control of the neck-shoulder muscles in patients with chronic neck-shoulder pain. Whether the activation of neck-shoulder muscles is altered among elite swimmers suffering from shoulder pain is unknown. METHODS: Surface electromyography (SEMG) from the sternocleidomastoid (SCM), upper trapezius (UT), and anterior scalene (SCL) muscles was recorded bilaterally in 17 elite swimmers (9 men, 8 women; mean ± SD age: 21±3 years) with unilateral shoulder pain, and 17 age- and sex matched elite swimmers without pain. Root mean square (RMS) values were calculated and normalized to assess the level of muscular activation 5 seconds before, 120 seconds and 150 seconds into, and 10 seconds after a functional upper limb task. RESULTS: The repeated measures revealed significant differences between both groups for RMS of both SCL (F=3.733; P=0.016), but not for the SCM and UT muscles. Swimmers with shoulder pain had higher normalised RMS in both SCL muscles at 120s (78% on average) and 150s (86% on average) into and 10s post-task (40% on average) as compared with swimmers without shoulder pain (P<0.05). CONCLUSIONS: The elite swimmers with shoulder pain demonstrated greater activation of the SCL muscles during a functional task and a lower ability to relax the SCL muscles after completion of the task than elite swimmers without shoulder pain. The present findings suggest altered pattern of cervical muscle activation on elite swimmers with shoulder pain during performance of a functional task.

J Orthop Sports Phys Ther, Epub 25 January 2012. doi:10.2519/jospt.2012.3875

KEY WORDS: electromyography, neck, scalene