STUDY DESIGN: Case report. BACKGROUND: Joint stiffness, also called arthrofibrosis, remains the primary complication following any reconstructive knee surgery. Acute anterior cruciate ligament surgery, performed with concomitant multiple ligamentous repair and/or reconstruction, further increases the likelihood of developing impaired knee motion following surgery. The purpose of this case report is to present a criteria-based approach to the postoperative management of a multiligament knee injury. CASE DESCRIPTION: A 25-year-old male professional football player sustained a contact injury to his right knee while making a tackle during a regular season game in 2007. He underwent an acute anterior cruciate ligament reconstruction, with concomitant posterolateral corner repair, biceps femoris/iliotibial band repair, lateral collateral ligament repair, and a medial meniscocapsular junction repair. He completed 17 weeks of a multiphased rehabilitation program that emphasized immediate range of motion, low-load long-duration stretching, therapeutic exercise, neuromuscular reeducation/perturbation training, plyometrics, and sport-specific functional drills. Electrical neurostimulation was implemented during the early stages of rehabilitation to control postoperative pain and to promote a steady progression of therapeutic exercise activity. OUTCOMES: The patient was cleared to begin sport-specific activity 7 months after major multistructure reconstructive knee surgery. He began the 2008 season on the physically-unable-to-perform list, but was activated midseason and played in every game thereafter. During the 2009 and 2010 seasons, he played all regular season games and all playoff games as a starter, and continues to start as a defensive cornerback in the National Football League. DISCUSSION: This case report highlights the clinical decision-making process and management involved in an acute multiple ligamentous knee injury/reconstruction. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2011;41(9):675-686. doi:10.2519/jospt.2011.3453

KEY WORDS: ACL, anterior cruciate ligament, arthrofibrosis, posterolateral corner

The manner of acquiring strength-testing data may influence the results of an investigation. The purpose of this study was to determine if a significant difference exists between windowed and unwindowed data collection during isokinetic testing of the shoulder abductors/adductors. Fifty healthy professional baseball pitchers participated in this study. Testing was performed on a Biodex isokinetic dynamometer at 180 and 300°/sec for both the throwing and nonthrowing shoulders. Testing procedures regarding testing protocol, repetitions, positioning, and stabilization followed established guidelines for each subject. Statistical analysis was performed using a paired t-test with a p < 0.01 level of significance. Statistically significant differences were demonstrated between windowed and unwindowed mean peak torque data for both shoulders at both test speeds. The results indicated an average nonthrowing arm difference of 20.2 ft/lbs at 180°/sec and 51.7 ft/lbs at 300°/ sec for the abductors. In each instance, the unwindowed mean peak torque values were higher than the windowed values, and significant end range torque spikes were elicited during unwindowed data collection. The nonthrowing adductors exhibited an average of 39.3 and 48.3 ft/lb differences at 180 and 300°/sec, respectively. The throwing shoulder demonstrated average abductor differences of 25.6 ft/lbs at 180°/sec and 47.7 ft/lbs at 300°/sec. The average throwing adductor difference was 24.4 ft/lbs and 54.6 ft/lbs, respectively, at both test speeds. This investigation offers clinical relevance for those using isokinetic testing of the shoulder abductors/adductors in demonstrating the significant differences between windowed and unwindowed data, identifying torque spike data misinterpretation, and describing a clinical means of controlling aberrant torque production during testing.

J Orthop Sports Phys Ther 1992;15(2):107-112.

Key Words: isokinetics, shoulder testing, torque spikes, windowed data

J Orthop Sports Phys Ther 1993;17(6):305-317.

Key Words: rehabilitation, elbow joint complex, baseball injuries

J Orthop Sports Phys Ther 1993;18(1):365-378.

Key Words: shoulder joint, rehabilitation, current concepts

Pathology of the superior aspect of the glenoid labrum (SLAP lesion) poses a significant challenge to the rehabilitation specialist due to the complex nature and wide variety of etiological factors associated with these lesions. A thorough clinical evaluation and proper identification of the extent of labral injury is important to determine the most appropriate nonoperative and/or surgical management. Postoperative rehabilitation is based on the specific surgical procedure as well as the extent, location, and mechanism of labral pathology and associated lesions. Emphasis is placed on protecting the healing labrum, while gradually restoring range of motion, strength, and dynamic stability of the glenohumeral joint. The purpose of this paper is to provide an overview of the anatomy and pathomechanics of SLAP lesions and review specific clinical examination techniques used to identify these lesions, including 3 newly described tests. Furthermore, a review of the current surgical management and postoperative rehabilitation guidelines is provided.

J Orthop Sports Phys Ther. 2005;35(5):273-291. doi:10.2519/jospt.2005.1701

Key Words: dynamic stability, glenohumeral, rehabilitation, shoulder

Significant contemporary advances have permitted a more comprehensive understanding and development of some interesting concepts about the glenohumeral joint. The purpose of this review paper is to discuss current concepts related to the anatomic stabilizing structures of the shoulder joint complex and their clinical relevance to shoulder instability. The clinical syndrome of shoulder instability represents a wide spectrum of symptoms and signs that may produce various levels of dysfunction, from subtle subluxations to gross joint instability. The glenohumeral joint attains functional stability through a delicate and intricate interaction between the passive and active stabilizing structures. The passive constraints include the bony geometry, glenoid labrum, and the glenohumeral joint capsuloligamentous structures. Conversely, the active constraints - also referred to as the active mechanisms - include the shoulder complex musculature, the proprioceptive system, and the musculoligamentous relationship. The interactions of the active and passive mechanisms, which provide passive and active glenohumeral joint stability, are thoroughly discussed in this paper.

J Orthop Sports Phys Ther. 1997;25(6):364-379.

Key Words: glenohumeral joint, anatomy, instability

Thorough descriptions of specific physical examination tests used to determine glenohumeral instability are lacking in the scientific literature. The purpose of this paper is to discuss the importance of the subjective history and illustrate the physical examination of the glenohumeral joint. Additionally, the authors illustrate specific stability assessment tests for the glenohumeral joint based on current basic science and clinical research. The physical examination of a patient whose history suggests subtle glenohumeral joint instability may be extremely difficult for the clinician due to the normal amount of capsular laxity commonly present in most individuals. An essential component of the physical examination is a thorough and meticulous subjective history, which includes the mechanisms of injury and/or dysfunction, chief complaint, level of disability, and aggravating movements. The physical examination must include an assessment of motion, static stability testing, muscle testing, and a neuralgic assessment. It is important that the clinician have a comprehensive understanding of various stability testing maneuvers. The evaluation techniques discussed in this paper should assist the clinician in determining the passive stability of the glenohumeral joint.

J Orthop Sports Phys Ther. 1997;25(6):380-389.

Key Words: glenohumeral joint, instability, assessment

1993 Breg Excellence in Research Award paper. Presented at the 15th Annual Sports Physical Therapy Section Team Concept Meeting, Williamsburg, VA, October 15-17, 1993.

It is important to examine the functional relationships between commonly performed clinical tests and to resolve inconsistencies in previous investigative results. The purpose of this study was to determine if a correlation exists between 3 commonly performed clinical tests: isokinetic isolated knee concentric muscular testing, the single-leg hop test, and the subjective knee score in anterior cruciate ligament reconstructed knees. To determine if a relationship exists would be beneficial to clinicians in determining patient progression, treatment modification, and return-to-sport objective parameters. Several investigators have analyzed 2 of these parameters, but no one has investigated 3 parameters to date. Additionally, this study explored the concept of limb acceleration and deceleration during high-speed isokinetics and its relationship to function. Fifty patients were randomly selected (29 males) with a mean age of 23.7 years (range 15-52). The subjects completed a subjective knee score questionnaire that rated symptoms (pain, swelling, giving way) and specific sport function and completed an overall knee score assessment. The patients were then evaluated performing 3 1-legged functional tests: 1) hop for distance, 2) timed hop, and 3) cross-over triple hop. Isokinetic testing was performed on a Biodex dynamometer at 180,300, and 450°/sec for knee extension/flexion. The patients' mean value of the self-assessed knee rating was 86 points. Sixty-four percent of the patients exhibited normal limb symmetry (within 85%) on all 3 single-leg hop tests. Sixteen percent exhibited quadriceps strength at least 90% of the contralateral limb isokinetically. A positive correlation was noted between isokinetic knee extension peak torque (180, 300°/sec) and subjective knee scores, and the 3 hop tests (p<.001). A statistical trend was noted between knee extension acceleration and deceleration range at 180°/sec and 300°/sec for the timed hop test and triple crossover hop (r = 0.48, r = 0.49, r = 0.51, r = 0.49). No positive correlations were found for isokinetic test results for the knee flexors.

J Orthop Sports Phys Ther. 1994;20(2):60-73.

Key Words: knee joint stability, anterior cruciate ligament, muscle strength, functional testing