The patient was a 47-year-old woman who had been referred to a physical therapist following an anterior cruciate ligament reconstruction of the left knee, using a bone-patellar tendon-bone autograft. While temporary within-session knee extension range-of-motion gains were recorded following physical therapist interventions, there was a lack of sustained improvement. Magnetic resonance imaging revealed an intact anterior cruciate ligament graft and a moderate joint effusion, as well as an area of intra-articular arthrofibrosis anterior to the anterior cruciate ligament graft. The patient underwent arthroscopic surgery and, after debridement of the joint arthrofibrosis, was referred to the physical therapist. Following 2 months of treatment, the patient demonstrated full symmetrical knee range of motion, reported no pain, and had initiated a running program without difficulty.

J Orthop Sports Phys Ther 2011;41(1):32. doi:10.2519/jospt.2011.0401

KEY WORDS: ACL, magnetic resonance imaging

STUDY DESIGN: Case series. CASE DESCRIPTION: Five consecutive collegiate Division I wrestlers, with a mean age of 20.2 years (range, 18-22 years), were treated postsurgical stabilization to address posterior glenohumeral joint instability. All received physical therapy postoperatively, consisting of range-ofmotion, strengthening, and plyometrics exercises, neuromuscular re-education, and sport-specific training. Functional outcome scores using the Penn Shoulder Score questionnaire were recorded at postsurgical initial evaluation and discharge. Isometric shoulder strength, measured with a handheld dynamometer at discharge, was compared with measurements made during preseason screening. OUTCOMES: Postsurgery, upon initial physical therapy evaluation, scores on the Penn Shoulder Score questionnaire ranged from 37 to 74 out of 100. All 5 wrestlers improved with rehabilitation such that their scores at discharge ranged from 81 to 91 out of 100. Mean external rotation-internal rotation strength ratio for the involved shoulder was 73.5% (range, 55.9%-88.7%) preseason and 80.9% (range, 70.2%-104.1%) postrehabilitation. Four patients were able to return to wrestling over a period of 1 season, with no episodes of reinjury to their surgically repaired shoulder. DISCUSSION: Current research on posterior glenohumeral instability is limited, due to the relatively rare diagnosis and infrequent need for surgical intervention. Providing a structured physical therapy program following this surgical procedure appeared to have assisted in a return to full functional activities and sports. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2009;39(7):550-559, Epub 24 February 2009. doi:10.2519/jospt.2009.2952

KEY WORDS: dislocation, dynamic stability, glenohumeral, joint instability, strength

STUDY DESIGN: Case series. CASE DESCRIPTION: Four patients who had developed knee extension motion loss following anterior cruciate ligament reconstruction were referred to physical therapy for treatment. They were treated with drop-out casting and completed a Lower Extremity Functional Scale at baseline, at the time of application of the drop-out casting, and at discharge. OUTCOMES: Three males and 1 female with a mean age of 20.5 years (range, 18-22 years) were referred to physical therapy a mean of 31 days (range, 19-49 days) following bone-patella tendon-bone autograft anterior cruciate ligament reconstruction. The mean number of physical therapy sessions attended was 29.5 visits (range, 20-47 visits). The mean improvement in knee extension range of motion (ROM) and knee flexion ROM prior to the application of drop-out casting was 4.3^o (range, -1^o to 10^o) and 24.3^o (range, 0^o to 40^o), respectively. The mean improvement on the Lower Extremity Functional Scale was 10.3 points prior to drop-out casting. At time of discharge, the total mean improvement in knee extension ROM loss was 11.0^o (range, 4^o to 15^o), knee flexion ROM was 30.8^o (range, 22^o to 35^o), and Lower Extremity Functional Scale was 12 points (range, -5 to 21 points). Two of the patients were able to complete a running program without difficulty, while the other 2 patients had difficulty with higher-level activities. DISCUSSION: Despite the low incidence of knee extension ROM loss following surgery, the inability to achieve full knee extension does occur and can have debilitating consequences. When early emphasis of full passive knee extension has been inadequate, these results suggest that improving knee extension motion without inhibiting knee flexion motion is possible with the use of a drop-out cast. Future research should focus on comparison of drop-out casting to dynamic splinting, as well as the optimal frequency and duration of low-load long-duration stretching using a drop-out cast.

J Orthop Sports Phys Ther. 2007;37(7):404-411, published online 29 May 2007. doi:10.2519/jospt.2007.2466

KEY WORDS:  arthrofibrosis, knee extension lag, splinting, stiff knee

Study Design: Nonrandomized 2-group post-test only. Objective: To compare scapular position and orientation between subjects with and without impingement syndrome. Background: Abnormal scapular motion is commonly believed to be a contributing factor to shoulder impingement syndrome. Methods and Measures: Twenty nonimpaired subjects with a mean age of 34.3 (± 7.5 years) and 17 patients with impingement syndrome with a mean age of 45.8 (± 11.0) participated. A 3-dimemionaI electromechanical digitizer was used to measure scapular position and orientation in 3 planes. Measurements were taken with the arm at the side, elevated in the scapular plane to horizontal, and at maximum elevation. One-way analysis of variance was used to compare nonimpaired subjects to the impingement group and the symptomatic and asymptomatic sides within the impingement group. Five scapular kinematic variables were assessed at each arm position. Orientation was described by posterior tilting angle, upward rotation angle, and internal rotation angle. Position was described by medial-lateral position and superior-inferior position and determined by the distance from the scapula centroid to the seventh cervical vertebra (C7). Results: During scapular plane elevation of the arm, the scapula showed a general pattern of increasing posterior-tilt angle, increasing upward-rotation angle, and decreasing internal-rotation angle in both impingement and nonimpaired groups. Also, the scapula moved to a more superior position and a slightly more medial position with increasing arm elevation. Compared to nonimpaired subjects (34.6° ± 9.7), those with impingement demonstrated a significantly lower posterior tilting angle of the scapula in the sagittal plane (25.1° ± 9.1). Subjects with impingement also demonstrated higher superior-inferior scapular position with maximal arm elevation (5.2 cm ± 1.6 below the first thoracic vertebrae) compared to nonimpaired subjects (7.5 cm ± 1.5). Conclusions: These results suggest that altered scapular kinematics may be an important aspect of the impingement syndrome.

J Orthop Sports Phys Ther. 1999;29(10):574-586.

Key Words: impingement, kinematics, rotator cuff, scapula, shoulder

Studies of the passive support provided by ankle braces have focused primarily on inversion support. The goal of this study was to develop a technique to measure the support provided by ankle braces in all rotational directions and to use this technique to compare four common braces (Ascend™, Swede-O™, Aircast™, and Active Ankle™) For this purpose, a 6 degrees-of-freedom linkage was used to measure the flexibility of the ankle complex in 10 healthy subjects. Each subject was tested without brace support and with each of the 4 braces. Testing was repeated on each subject on 2 different occasions. The angular displacement at specified moment values and the 4 segmental flexibility values obtained from the loading portion of the moment-angular displacement data were used in the data analysis. Repeated measure analysis of variance followed by a Student Neuman-Keuls test at p < 0.05 was performed. This statistical analysis was used to identify significant differences among the braces and differences between each brace and the no brace condition. Each of the 4 braces provided significant support in inversion, eversion, and internal rotation, but the amount of support varied significantly among the braces. In external rotation, only the stirrup braces provided significant support. The braces also varied significantly in the amount of interference with dorsiflexion and plantar flexion. Clinicians may be assisted by objective data on the amount and nature of passive support when prescribing braces to their patients.

J Orthop Sports Phys Ther. 1997;26(6):299-309.

Key Words: ankle, braces, passive support