Paper submitted before conversion to SI units was required.

Surgical reconstruction of the anterior cruciate ligament (ACL) using a patellar tendon autograft is a common orthopaedic procedure. Complications such as arthrofibrosis, patellar fracture, significant donor site pain, and quadriceps muscle weakness can occur from this procedure. Previous studies have not documented the effects of isolated graft procurement without concomitant ligamentous reconstruction on the donor extremity.

This case study documents the clinical outcome results of an individual who underwent a central one-third graft harvest from his contralateral uninjured knee for an ACL graft of his injured ACL-deficient knee. The results indicate that at 4 months following graft procurement, the knee extensors were equal to the preoperative isokinetic test results of that leg. In addition, the patient exhibited full range of motion and no patellofemoral complaints or dysfunction. At 12 months postsurgery, the graft donor leg was 5-9% stronger than the preoperative test results. The results of this case study suggest that isolated harvesting of a 10-mm central patellar tendon free graft may not result in significant quadriceps muscle weakness or contribute to donor site pain.

J Orthop Sports Phys Ther. 1993;18(6):692-697.

Study Design: Descriptive postoperative follow-up research. Objectives: The purpose of this investigation was to describe the return-to-competition rate and functional outcome of overhead athletes following arthroscopic thermal-assisted capsular shrinkage (TACS). Background: Traditional open procedures to correct instability in overhead athletes, such as capsulolabral repairs and capsular shifts, have produced less-than-favorable results, which have led to the development of TACS. Currently there are no long-term follow-up studies documenting the efficacy of this procedure in groups greater than 31 subjects or for a time period greater than 27 months. Methods and Measures: Two hundred thirty-one consecutive overhead athletes who due to symptoms of hyperlaxity had previously undergone a TACS procedure from 1997 to 1999 were selected for inclusion in the study. During a 1-month period, 130 of these athletes (mean age ± SD, 24 ± 6 years; 113 male, 17 female) were contacted by phone for follow-up at a mean of 29.3 months postoperatively (range, 15.4-46.6 months). Of the 130, 105 participated in baseball (80 pitchers), 14 in softball, 4 in football (quarterbacks), 4 in tennis, and 3 in swimming. Fifty-four (42%) subjects were professional, 49 (38%) collegiate, 16 (12%) high school, and 11 (8%) recreational athletes. One hundred twenty-three of the 130 (95%) underwent 1 or more concomitant procedure(s) at the time of TACS. Most commonly performed were labral debridements (69%), rotator cuff debridements (65%), and superior labral repairs (35%). Subjects who returned to competition were retrospectively evaluated using a modified Athletic Shoulder Outcome Rating Scale to subjectively assess pain, strength and endurance, stability, intensity, and performance. Overall results were based on a 90-point scale with scores of 80 to 90 representing excellent, 60 to 79 good, 40 to 59 fair, and less than 40 poor results. Results: One hundred thirteen out of 130 subjects (87%) returned to competition. Mean (±SD) time from surgery to return to competition was 8.4 ± 4.6 months. Mean outcome score for all subjects was 79/90; 75 (66%) subjects had excellent, 24 (21%) good, 11 (10%) fair, and 3 (3%) poor result. The mean outcome score for males was 80/90 and for females was 70/90. Conclusions: The majority of overhead athletes (87%) successfully returned to competition following a TACS procedure with good-to-excellent long-term outcomes (88%). Based on the results of this study, TACS of the glenohumeral joint is a viable option for overhead athletes with pathological instability.

J Orthop Sports Phys Ther. 2003;33(8):455–467.

Key Words: acquired laxity, baseball, rehabilitation, shoulder, shoulder instability

Study Design: Prospective single-group repeated-measures design. Objectives: To quantify electromyographic (EMG) muscle activity of the infraspinatus, teres minor, supraspinatus, posterior deltoid, and middle deltoid during exercises commonly used to strengthen the shoulder external rotators. Background: Exercises to strengthen the external rotators are commonly prescribed in rehabilitation, but the amount of EMG activity of the infraspinatus, teres minor, supraspinatus, and deltoid during these exercises has not been thoroughly studied to determine which exercises would be most effective to achieve strength gains. Methods and Measures: EMG measured using intramuscular electrodes were analyzed in 10 healthy subjects during 7 shoulder exercises: prone horizontal abduction at 100° of abduction and full external rotation (ER), prone ER at 90° of abduction, standing ER at 90° of abduction, standing ER in the scapular plane (45° abduction, 30° horizontal adduction), standing ER at 0° of abduction, standing ER at 0° of abduction with a towel roll, and sidelying ER at 0° of abduction. The peak percentage of maximal voluntary isometric contraction (MVIC) for each muscle was compared among exercises using a 1-way repeated-measures analysis of variance (P<.05). Results: EMG activity varied significantly among the 7 exercises. Sidelying ER produced the greatest amount of EMG activity for the infraspinatus (62% MVIC) and teres minor (67% MVIC). The greatest amount of activity of the supraspinatus (82% MVIC), middle deltoid (87% MVIC), and posterior deltoid (88% MVIC) was observed during prone horizontal abduction at 100° with full ER. Conclusions: Results from this study provide initial information to develop rehabilitation programs. It also provides information helpful for the design and conduct of future studies.

J Orthop Sports Phys Ther. 2004;34(7):385-394. doi:10.2519/jospt.2004.0665 

Key Words: dynamic stabilization, infraspinatus, supraspinatus, teres minor

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

Articular cartilage lesions of the knee joint are common in patients of varying ages. Some articular cartilage lesions are focal lesions located on one aspect of the tibiofemoral or patellofemoral joint. Other lesions can be extremely large or involve multiple compartments of the knee joint and these are often referred to as osteoarthritis. There are numerous potential causes for the development of articular cartilage lesions: joint injury (trauma), biomechanics, genetics, activities, and biochemistry. Numerous factors also contribute to symptomatic episodes resulting from lesions to the articular cartilage: activities (sports and work), joint alignment, joint laxity, muscular weakness, genetics, dietary intake, and body mass index.

Athletes appear to be more susceptible to developing articular cartilage lesions than other individuals. This is especially true with specific sports and subsequent to specific types of knee injuries. Injuries to the anterior cruciate ligament and/or menisci may increase the risk of developing an articular cartilage lesion. The treatment for an athletic patient with articular cartilage lesions is often difficult and met with limited success. In this article we will discuss several types of knee articular cartilage injuries such as focal lesions, advanced full-thickness lesions, and bone bruises. We will also discuss the risk factors for developing full-thickness articular cartilage lesions and osteoarthritis, and describe the clinical evaluation and nonoperative treatment strategies for these types of lesions in athletes.

J Orthop Sports Phys Ther. 2006; 36(10):815-827. doi:10.2519/jospt.2006.2303

Key Words: chondral lesion, exercise, nonoperative treatment, nutrition, tibiofemoral joint