STUDY DESIGN: Prospective cohort study. OBJECTIVES: To characterize knee cartilage change in individuals with knee osteoarthritis (KOA) who have completed a therapeutic exercise program. BACKGROUND: While therapeutic exercise is frequently used successfully to improve pain and function in individuals with KOA, no studies have reported the volume of cartilage change or individual factors that may impact volume of cartilage change in those completing an exercise program for KOA. METHODS: Thirteen individuals with KOA underwent magnetic resonance imaging to quantify cartilage volume change in the weight-bearing regions of the medial and lateral femoral condyles and the entire surface of the tibial plateaus from baseline to 1-year follow-up. Body structure and function measures were taken for body mass index, knee axis alignment, knee motion, and knee strength. Activity limitations and activity levels were also measured prior to the therapeutic exercise program, using the Western Ontario and McMaster Universities Osteoarthritis Index and the Physical Activity Scale for the Elderly. At 6 months from baseline, follow-up clinical measurements of knee strength and motion were performed. At 1 year from baseline, imaging of the knee cartilage and knee alignment were performed, and participants completed the Western Ontario and McMaster Universities Osteoarthritis Index and Physical Activity Scale for the Elderly. RESULTS: The central region of the medial femoral condyle (cMF) had a median volume of cartilage loss of 3.8%. The other 3 knee tibiofemoral articular surfaces had minimal median cartilage volume change. Individuals were dichotomized into progressors (n = 6) and nonprogressors (n = 7), based on the standard error of measurement of cartilage volume change for the cMF. Progressors were younger, had a larger body mass index, had a higher Kellgren-Lawrence grade in the medial compartment of the knee, and had a greater increase in knee varus alignment from baseline to 1-year follow-up. The progressors also had frontal plane hip and knee kinetics during baseline gait analysis that potentially increased medial knee joint loading. CONCLUSION: The loss of cMF cartilage volume was highly variable and the median loss of cartilage was within the range previously reported. Seven of the 13 individuals did not have cMF cartilage volume loss greater than the standard error of measurement. Change in cartilage volume of the cMF may be influenced to a greater extent by personal factors than by completion of a therapeutic exercise program. Additional research is needed to decipher the interactions among therapeutic exercise and personal characteristics that impact knee cartilage loss.

J Orthop Sports Phys Ther 2011;41(10):708-722, Epub September 2011. doi:10.2519/jospt.2011.3633

KEY WORDS: arthritis, biomechanics, magnetic resonance imaging, MRI

STUDY DESIGN: Case report. BACKGROUND: Patellar fracture is a rare but significant complication following anterior cruciate ligament (ACL) reconstruction when using a bone-patellar tendon-bone (BPTB) autograft. The purpose of these case reports is to describe 2 cases in which patellar fracture occurred during rehabilitation after ACL reconstruction using a BPTB. CASE DESCRIPTION: Both patients were 23-year-old males referred for rehabilitation after ACL reconstruction using a BPTB autograft. They were both progressing satisfactorily in rehabilitation until sustaining a fracture of the patella. One fracture occurred during the performance of the eccentric phase of a knee extension exercise during the sixth week of rehabilitation (7 weeks postsurgery), whereas the other fracture occurred during testing of the patientís quadriceps maximum voluntary isometric contraction in the ninth week of rehabilitation (10 weeks postsurgery). Both patients were subsequently treated with open reduction and internal fixation of the patella. DISCUSSION: During rehabilitation following ACL reconstruction using BPTB autograft, clinicians should consider the need to balance the sometimes-competing goals of improving quadriceps strength while providing protection to the healing graft, minimization of patellofemoral pain, and protection of the patellar donor site. LEVEL OF EVIDENCE: Harm, level 4.

J Orthop Sports Phys Ther 2009;39(4):278-286, Epub 15 December 2008. doi:10.2519/jospt.2009.2864

KEY WORDS: ACL, failure, knee, load, strain

Study Design: Randomized clinical trial, single-masked. Objectives: To determine the effectiveness of using a modified neuromuscular electrical stimulation (NMES) training program as an adjunct treatment for improving quadriceps strength and physical function in rehabilitation following anterior cruciate ligament reconstruction (ACLR). Background: NMES training for quadriceps strengthening has previously been shown to be an effective adjunct treatment following ACLR when performed against isometric resistance using a dynamometer with the knee positioned in flexion. We developed a modified version of published NMES protocol because some patients have difficulty tolerating the existing protocol and many clinics may not have instrumented dynamometers. There is a need to determine the effectiveness of this modified protocol. Methods and Measures: Forty-three subjects who had undergone ACLR were randomly assigned to either a group that received (NMES group) or did not receive (comparison group) the NMES treatment in conjunction with their rehabilitation. Group means for quadriceps strength and self-reported measures of knee function were compared after 12 and 16 weeks of rehabilitation. The proportion of subjects in each group achieving clinical criteria to initiate ambulation without crutches, treadmill running, and agility training at selected times during rehabilitation were also compared. Results: The NMES group demonstrated moderately greater quadriceps strength at 12 weeks (effect size, 0.48), and moderately higher levels of self-reported knee function at both 12 (effect size, 0.72) and 16 (effect size, 0.65) weeks of rehabilitation compared to the comparison group. A greater proportion of subjects in the NMES group achieved clinical criteria for advancing to agility training at 16 weeks. Conclusions: The modified NMES quadriceps training protocol can be a useful adjunct to ACLR rehabilitation programs, but the treatment effect is smaller than what has been reported in previous studies.

J Orthop Sports Phys Ther. 2003;33(9):492-501.

Key Words: ACL, clinical trial, knee, strengthening, training

Single leg hop tests are commonly used as physical performance measures of function and are also commonly used to evaluate progress in knee rehabilitation programs, particularly for individuals recovering from anterior cruciate ligament injury or reconstructive surgery. While there is some evidence that hop tests may show promise as a predictive measure for identifying individuals who are at risk for recurrent dynamic instability, further work is needed to clearly define the role of hop test measurements for this purpose. The purposes of this clinical commentary are to review the research that has been done to establish hop tests as a physical performance measure of function, to discuss neuromuscular and biomechanical considerations related to hop performance and dynamic knee stability, to discuss existing evidence that supports the potential for hop tests as a predictor of dynamic knee stability, and to discuss considerations for future studies that are designed to more clearly define the role of hop tests in predicting dynamic knee stability.

J Orthop Sports Phys Ther. 200l;31(10):588-597.

Key Words: anterior cruciate ligament, functional performance testing, hop tests

Nonoperative management of anterior cruciate ligament (ACL) rupture has not been a successful option for those who participate in high-level physical activity. However, there are instances when patients may want to attempt to return to physically demanding activities with nonoperative rehabilitation for an ACL injury. The purpose of this commentary is to describe guidelines for nonoperative management of physically active individuals with ACL injuries who wish to return to preinjury levels of physical activity. The guidelines are based on the results of 2 clinical studies that improved the overall success of nonoperative management of physically active individuals with ACL ruptures. A decision-making process for selecting appropriate candidates for nonoperative management (rehabilitation candidates) is described. Individuals are classified as rehabilitation candidates if they have no concomitant ligament or mensical damage associated with the ACL injury, have a unilateral ACL injury, and meet all 4 of the following criteria: (1) timed hop test score of 80% or more of the uninjured limb, (2) Knee Outcome Survey Activities of Daily Living Scale score of 80% or more, (3) global rating of knee function of 60% or more, and (4) no more than 1 episode of giving way since the incident injury to the time of testing. Individuals meeting the criteria of a rehabilitation candidate undergo an intensive rehabilitation program before returning to high-level activity. The rehabilitation program consisting of lower extremity muscle strength training, cardiovascular endurance training, agility and sport-specific skill training, and a training program using balance perturbations is described.

J Orthop Sports Phys Ther. 2000;30(4):194-203.

Key Words: anterior cruciate ligament, knee, rehabilitation

Study Design: Test-retest reliability study.
Objective: To determine interrater reliability of the modified scapular assistance test (SAT). The modified SAT is designed to assess the contribution of scapular motion to shoulder pain.
Background: Abnormal scapular motion has been implicated in different shoulder disorders. However, there is a lack of clinical evaluation tools to assess the scapular component of shoulder dysfunction.
Methods and Measures: Forty-six subjects who were referred to physical therapy for treatment of various shoulder pathologies were recruited for this study. The modified SAT was performed on each participant by 2 different examiners. Percent agreement and kappa coefficient were utilized to determine interrater reliability of the modified SAT.
Results: The kappa coefficient and percent agreement were 0.53 and 77%, respectively, when the test was performed in the scapular plane, and 0.62 and 91%, respectively, when the test was performed in the sagittal plane.
Conclusions: The modified SAT possesses acceptable interrater reliability for clinical use.

 J Orthop Sports Phys Ther. 2006;36(9):653-660. doi:10.2519/jospt.2006.2234

Key Words: measurement, scapula, shoulder