The American Journal of Sports Medicine

Background: Decisions regarding safe return to play after concussion in sport remain difficult.

Objective: To determine whether a concussed player returned to play using an individual clinical management strategy is at risk of impaired performance or increased risk of injury or concussion.

Study Design: Cohort study; Level of evidence, 3.

Methods: All elite Australian football players were followed for 4 seasons. Players were recruited into the study after sustaining a concussive injury. Outcome measures included performance statistics (disposals per hour match-time), injury rates, and recurrence of concussion on return to play. A subset of players had brief screening cognitive tests performed at baseline and after their concussion. Noninjured players matched for team, position, age, and size were chosen as controls.

Results: A total of 199 concussive injuries were observed in 158 players. Sixty-one concussive injuries were excluded from analysis because of incomplete data (45 players) or presence of concurrent injury (16 players). Of the 138 concussive injuries assessed, 127 players returned to play without missing a game (92%). The remainder of concussed players returned to play after missing a single game (8%). Overall, there was no significant decline in disposal rates in concussed players on return to competition. Furthermore, there were no significant differences in injury rates between concussed and team, position, and game-matched controls. In the subset of players who had completed screening cognitive tests, all had returned to their individual baseline performance before being returned to play.

Conclusion: Return to play decisions based on individual clinical assessment of recovery allows safe and appropriate return to sport following a concussive injury.

Background: Although the use of meniscal allografts to replace severely damaged or absent menisci is commonplace, little is known about the effects of donor age on the biochemical and biomechanical properties of human menisci.

Hypothesis: The mechanical and biochemical properties of human medial and lateral menisci from donors less than 45 years of age do not vary with donor age.

Study Design: Controlled laboratory study.

Methods: Thirty-three lateral and 25 medial menisci from 34 donors (26 male and 8 female) ranging from 15 to 44 years of age were harvested and immediately stored at —80°C. The outer third of each meniscus was subjected to static and dynamic tensile analysis. In addition, the biochemical composition (collagen, proteoglycan, and water content) of these samples was analyzed.

Results: There was no correlation between donor age and static tensile stiffness for either the lateral (R2 = .003) or medial (R2 = .002) meniscus. Likewise, there was no correlation between donor age and dynamic tensile modulus for either the lateral or medial meniscus. Although there was a weak, positive correlation between water content and age in both lateral (R2 = .22) and medial (R2 = .25) menisci, there was no effect of age on collagen or proteoglycan content. There were no differences (P > .05) between female and male menisci in any of the measured biomechanical or biochemical parameters tested.

Conclusion: The tensile properties, as well as the collagen and proteoglycan content, of menisci from donors less than 45 years of age were not age dependent.

Clinical Relevance: The age of the donor does not appear to affect the initial tensile properties of menisci from donors less than 45 years of age.

Background: In 1982, the Lysholm score was first published as a physician-administered score in the American Journal of Sports Medicine. The Tegner activity scale was published in 1985.

Hypothesis: The Lysholm and Tegner scores are valid as patient-administered scores and responsive at early time points after treatment of anterior cruciate ligament tears.

Study Design: Cohort study (Diagnosis); Level of evidence, 1.

Methods: All patients were treated for an anterior cruciate ligament tear. For responsiveness, the Lysholm score (n = 1075) and Tegner activity level (n = 505) were measured preoperatively and 6, 9, 12, and 24 months postoperatively. For test-retest (n = 50), scores were measured at 2 years postoperatively and again within 4 weeks by questionnaire. For criterion validity (n = 170), patients completed the Short Form-12 and the International Knee Documentation Committee score in addition to Lysholm and Tegner instruments. For all other analyses, preoperative Lysholm score (n = 1783) or Tegner activity levels (n = 687) were collected.

Results: There was acceptable test-retest reliability for both the Lysholm (intraclass correlation coefficient = 0.9) and Tegner (intraclass correlation coefficient = 0.8) scores. The minimum detectable change for Lysholm was 8.9 and for Tegner was 1. The Lysholm demonstrated acceptable internal consistency. The Lysholm correlated with the International Knee Documentation Committee (r = .8) and the Short Form-12 (r = .4), and Tegner correlated with the Short Form-12 (r = .2). Both scores had acceptable floor and ceiling effects and all hypotheses were significant. The Lysholm and Tegner were responsive to change at each of the time points.

Conclusion: After 25 years of changes in treatment of anterior cruciate ligament injuries, the Lysholm knee score and the Tegner activity scale demonstrated acceptable psychometric parameters as patient-administered scores and showed acceptable responsiveness to be used in early return to function after anterior cruciate ligament treatment.

Background: The Lysholm score and Tegner activity scale are commonly used to document outcomes after arthroscopic knee surgery. These outcomes measurements are subjective in nature and evaluate performance and activity restrictions both before and after surgery, making them a valuable research tool when judging the effectiveness of surgical treatment.

Purpose: To establish a normal knee data set for the Lysholm and Tegner rating systems, as well as to show how these scores are affected by age and gender.

Study Design: Cross-sectional study; Level of evidence, 3.

Methods: A subjective questionnaire that included both the Lysholm score and Tegner activity grading scale was completed by 488 subjects in the community who considered their knee function normal. Any subject reporting a history of injury or surgery was excluded from the study. The average age was 41 years (range, 18-85), with 244 men and 244 women qualifying for statistical analysis.

Results: The average Lysholm score was 94 (range, 43-100), and the average Tegner activity level was 5.7 (range, 1-10). The Lysholm score and age demonstrated no correlation. The Tegner activity level was inversely correlated with age. The average Tegner activity level for men was 6.0, and the average activity scale for women was 5.4. There was no significant difference in the Lysholm score between men and women.

Conclusion: These data acquired from a normal, healthy population provide a standard point of reference for the injured or postsurgical knee. These data also serve as ideal tools when counseling patients about realistic expectations after surgery, based on age and gender.

Background: Marrow stimulation techniques such as drilling or microfracture are first-line treatment options for symptomatic cartilage defects. Common knowledge holds that these treatments do not compromise subsequent cartilage repair procedures with autologous chondrocyte implantation.

Hypothesis: Cartilage defects pretreated with marrow stimulation techniques will have an increased failure rate.

Study Design: Cohort study; Level of evidence, 2.

Methods: The first 321 consecutive patients treated at one institution with autologous chondrocyte implantation for full-thickness cartilage defects that reached more than 2 years of follow-up were evaluated by prospectively collected data. Patients were grouped based on whether they had undergone prior treatment with a marrow stimulation technique. Outcomes were classified as complete failure if more than 25% of a grafted defect area had to be removed in later procedures because of persistent symptoms.

Results: There were 522 defects in 321 patients (325 joints) treated with autologous chondrocyte implantation. On average, there were 1.7 lesions per patient. Of these joints, 111 had previously undergone surgery that penetrated the subchondral bone; 214 joints had no prior treatment that affected the subchondral bone and served as controls. Within the marrow stimulation group, there were 29 (26%) failures, compared with 17 (8%) failures in the control group.

Conclusion: Defects that had prior treatment affecting the subchondral bone failed at a rate 3 times that of nontreated defects. The failure rates for drilling (28%), abrasion arthroplasty (27%), and microfracture (20%) were not significantly different, possibly because of the lower number of microfracture patients in this cohort (25 of 110 marrow-stimulation procedures). The data demonstrate that marrow stimulation techniques have a strong negative effect on subsequent cartilage repair with autologous chondrocyte implantation and therefore should be used judiciously in larger cartilage defects that could require future treatment with autologous chondrocyte implantation.

Background: Anterior cruciate ligament reconstruction successfully reduces anterior knee instability, but its effect on rotatory stability is not fully understood. In addition, a definitive method for the quantitative evaluation of rotatory instability remains to be established.

Hypothesis: Measurement of anterolateral tibial translation by open magnetic resonance imaging could positively correlate with the clinical grading of the pivot-shift test and would clarify residual rotatory abnormalities not shown by conventional methods for measurement of anterior stability.

Study Design: Controlled laboratory study.

Methods: An anterior cruciate ligament—reconstructed group (n = 21) and an anterior cruciate ligament—deficient group (n = 20) were examined using a Slocum anterolateral rotatory instability test in open magnetic resonance imaging. Anterior tibial translation was measured at the medial and lateral compartments by evaluating sagittal images. Clinical knee stability was evaluated before the above measurement using the pivot-shift test, KT-2000 arthrometer, and stress radiography. A cutoff value for anterolateral tibial translation relating to pivot-shift was determined using a receiver operating characteristic curve.

Results: Side-to-side differences of anterolateral tibial translation correlated with clinical grade of the pivot-shift test and stress radiography but not with KT-2000 arthrometry in both groups. The cutoff value was established as 3.0 mm. Although the mean anterolateral translation showed no difference, 9 reconstructed knees revealed greater than 3 mm of anterolateral tibial translation, whereas only 3 uninjured knees did.

Conclusion: Measurement using an open magnetic resonance imaging successfully quantified the remaining rotatory instability in anterior cruciate ligament—reconstructed knees.

Clinical Relevance: This method is a useful means for quantifying anterior cruciate ligament function to stabilize tibial rotation.

Background: Hip arthroscopy represents a new and minimally invasive method of treating patients with femoroacetabular impingement (FAI). However, participation in popular sports after this procedure has not yet been analyzed.

Hypotheses: Arthroscopic treatment of FAI increases the level of popular sports activities, and this level of activity correlates with the clinical outcome in terms of pain and function.

Study Design: Case series; Level of evidence, 4.

Methods: Fifty-three patients (41 male, 12 female) were evaluated preoperatively and after a mean follow-up of 2.4 years (range, 2-3.2 years) after arthroscopic osteoplasty for cam and mixed FAI. Evaluation included the type and level of sports activities (sports frequency score [SFS]) as well as clinical outcome in terms of pain (VAS) and function (nonarthritic hip score [NAHS]).

Results: Forty-five of the 53 patients had regularly participated in popular sports until the first occurrence of FAI symptoms. Preoperatively, only 4 of these 45 patients had maintained their accustomed level of activity. At the final follow-up, 31 patients had returned to their full accustomed level of activity. None of the patients who had not been active in sports before the first occurrence of symptoms of FAI (n = 8) had begun participation in sports after arthroscopic osteoplasty. The SFS significantly increased from 0.78 to 1.84 (P < .001), and the mean VAS pain score significantly improved from 5.7 (range, 1-9) to 1.5 (range, 0-6) points (P < .001). The NAHS improved from 54.4 (range, 28.75-92.5) to 85.7 (range, 47.5-100) (P < .001). There was no significant correlation between SFS and NAHS (r = .051, P = .35), as well as between SFS and VAS pain score (r = .159, P = .140) preoperatively, but a significant correlation was seen at the time of the last postoperative follow-up (SFS/NAHS: r = .392, P = .003; SFS/VAS: r = .242, P = .049). The 3 most frequent sports activities postoperatively were biking, hiking, and fitness.

Conclusion: Arthroscopic osteoplasty can significantly improve the rate and level of popular sports activities in patients with FAI. The level of postoperative sports activity directly correlates with the clinical outcome in terms of pain and function.

Background: A number of arthroscopic techniques have been introduced in the treatment of displaced anterior tibial spine fractures. Several of the procedures are technically demanding or include a second removal operation of metallic implants.

Purpose: The purpose of this study is to describe and evaluate an arthroscopic technique using bioabsorbable nails in displaced anterior tibial spine fractures.

Study Design: Case series; Level of evidence, 4.

Methods: Sixteen consecutive patients, aged 7 to 15 years, with anterior tibial spine fractures type II and III according to Meyers and McKeever, were treated with arthroscopic fixation of the fragment using bioabsorbable nails. After 2 to 5 years, 13 of the patients were evaluated with regard to anterior knee laxity, range of motion, hop tests, Lysholm knee scoring scale, and activity level. Postoperative surgical complications were registered in the whole group of patients.

Results: One of the 13 patients had an increased anterior knee laxity of 3 mm. Extension deficits of 5° were seen in 4 patients and flexion deficits of 5° to 10° in 3 patients. One patient had an outcome of <90% of the uninjured side in the hop tests. Eleven patients were excellent, 1 was good, and 1 was poor according to the Lysholm knee scoring scale. There was no influence on activity level. There were no inflammatory reactions and all fractures healed without complications. In 1 case, the arthroscopy was converted into an open procedure because of technical problems, still using the bioabsorbable nails.

Conclusion: The outcome is comparable with other procedures. A second operation for removal of metallic implants is avoided.

Background: Overhead athletes report an inconsistent return to their previous level of sport and satisfaction after arthroscopic SLAP lesion repair.

Hypothesis: Arthroscopic biceps tenodesis offers a viable alternative to the repair of an isolated type II SLAP lesion.

Study Design: Cohort study; Level of evidence, 3.

Methods: Twenty-five consecutive patients operated for an isolated type II SLAP lesion between 2000 and 2004 were evaluated at a mean of 35 months postoperatively (range, 24-69). Patients with associated instability, rotator cuff rupture, posterosuperior impingement, or previous shoulder surgery were excluded. Ten patients (10 men) with an average age of 37 years (range, 19-57) had a SLAP repair performed with suture anchors. Fifteen patients (9 men and 6 women) with an average age of 52 years (range, 28-64) underwent arthroscopic biceps tenodesis performed with an absorbable interference screw. Arthroscopic diagnosis and treatment were performed by a single experienced shoulder surgeon, and all patients were reviewed by an independent examiner.

Results: In the repair group, the Constant score improved from 65 to 83 points; however, 60% (6 of 10) of the patients were disappointed because of persistent pain or inability to return to their previous level of sports participation. In the tenodesis group, the Constant score improved from 59 to 89 points, and 93% (14/15) were satisfied or very satisfied. Thirteen patients (87%) were able to return to their previous level of sports participation following biceps tenodesis, compared with only 20% (2 of 10) after SLAP repair (P = .01). Four patients with failed SLAP repairs underwent subsequent biceps tenodesis, resulting in a successful outcome and a full return to their previous level of sports activity.

Conclusion: Arthroscopic biceps tenodesis can be considered an effective alternative to the repair of a type II SLAP lesion, allowing patients to return to a presurgical level of activity and sports participation. The results of biceps reinsertion are disappointing compared with biceps tenodesis. Furthermore, biceps tenodesis may provide a viable alternative for the salvage of a failed SLAP repair. As the age of the 2 treatment groups differed, these findings should be confirmed by future studies.

Background: Superior labral anterior posterior tears have been described as symptomatic lesions in shoulders of patients of varying ages. It is unknown if age affects clinical outcome of arthroscopic fixation of type II superior labral anterior posterior repairs.

Hypothesis: Clinical outcome of arthroscopic fixation of isolated type II superior labral anterior posterior tears differs between younger (<40 years) and older (≥40 years) patients.

Study Design: Cohort study; Level of evidence, 3.

Methods: Clinical results of arthroscopic fixation of isolated unstable type II superior labral anterior posterior repairs were compared between 25 patients younger than 40 years (group 1) and 25 patients aged 40 years or older (group 2). Patients with concomitant procedures, prior/subsequent shoulder surgeries, and use of non—suture anchor devices were excluded. Outcomes at a minimum 1-year follow-up were assessed using range of motion measurements and the American Shoulder and Elbow Surgeons questionnaire as compared with preoperative data. Ability and time to return to prior level of activity were assessed.

Results: At a mean 3-year follow-up, there were statistically significant improvements in American Shoulder and Elbow Surgeons scores for both groups (P < .0001) but no significant difference between final American Shoulder and Elbow Surgeons scores (group 1, 91; group 2, 87; P > .198). Both groups demonstrated good or excellent results in >80% of patients. A traumatic mechanism of injury (P = .0346) and presence of osteoarthritis (P = .0401) were independent factors resulting in significantly lower postoperative scores. There were statistically significant differences in preoperative and postoperative range of motion for internal rotation (group 1, P = .0321) and forward elevation (group 2, P = .0003). Return to prior level of activity was similar between younger and older age groups: 80% versus 74%. Time to return to sport was prolonged for group 2 (11.0 months) compared with group 1 (8.45 months). Patients without osteoarthritis were significantly more likely to return to previous levels of activity than were those who had osteoarthritis (P = .0044).

Conclusion: Good to excellent results and high return to prior level of activity can be expected for the majority of properly indicated patients who undergo isolated type II superior labral anterior posterior repairs, regardless of age. Subtle deficits in range of motion were experienced by both age groups; this did not seem to affect final outcomes. The presence of osteoarthritis was associated with lower American Shoulder and Elbow Surgeons scores and inability to return to prior level of activity. Time to return to activity was prolonged for the older group.

Background: Microfracture technique is commonly used to treat symptomatic chondral lesions of the knee. Performance outcomes and attrition rates associated with this injury/surgery in National Basketball Association athletes are unclear.

Hypothesis: National Basketball Association players undergoing microfracture for symptomatic chondral lesions of the knee will have demonstrable differences in performance compared with preinjury and with matched controls.

Study Design: Case control study; Level of evidence, 3.

Methods: We evaluated 24 National Basketball Association players who underwent microfracture between 1997 and 2006. Descriptive data and performance data for the first full season preceding and following the index surgery were collected. Data were obtained from 48 matched controls. Univariate/multivariate statistical methods were used to assess change in performance and return to play.

Results: Thirty-three percent (8 of 24) of National Basketball Association athletes who underwent microfracture surgery never returned to play in the National Basketball Association. Fourteen players returned to play in the National Basketball Association for >1 season. Within-group comparisons revealed that points scored (P = .008) and minutes played (P = .045) were reduced postoperatively. No performance variables were significantly different when averaged over 40 minutes of play. When compared with controls, cases experienced a significant decline in points per game (P = .013). Multiple regression analysis revealed that cases were 8.15 times less likely to remain in the National Basketball Association than controls (P = .005) after the index year.

Conclusion: Players undergoing microfracture for knee chondral injuries are at risk for not returning to the National Basketball Association postoperatively. With the exception of points per game, athletes returning exhibited similar performance postoperatively compared with matched controls.

Background: There have been few biomechanical studies to clarify which size of a glenoid defect is critical. However, those studies have assumed that the defect occurred anteroinferiorly. Recent studies have reported that the defect is located anteriorly rather than anteroinferiorly. Therefore, the effect of the anterior, not anteroinferior, glenoid defect on shoulder stability needs to be investigated.

Hypothesis: The anterior glenoid defect would have a similar effect on anterior shoulder stability as that of the anteroinferior glenoid defect.

Study Design: Controlled laboratory study.

Methods: Eight fresh-frozen cadaveric shoulders were used (mean age, 74 years). The specimen was attached to a shoulder-testing device with the arm in abduction and external rotation. An osseous defect was created stepwise with a 2-mm increment of the defect width. The stability ratio was used to evaluate joint stability. With a 50-N axial force, the translational force applied to the humeral head was measured by a force transducer.

Results: The stability ratio without a defect (32% ± 6%) significantly decreased after creating a 6-mm defect (17% ± 5%; P = .0001), which was equivalent to 20% of the glenoid length.

Conclusion: An osseous defect at 3 o’clock with a width that was equal to or greater than 20% of the glenoid length significantly decreased anterior stability.

Clinical Relevance: The results suggest that reconstruction of the glenoid concavity might be necessary in shoulders with an anterior glenoid defect of at least 20% of the glenoid length.

Background: There is inadequate evidence to determine when to perform surgery on anterior cruciate ligament—deficient knees.

Purpose: To study the association between timing of anterior cruciate ligament reconstruction and the risk of having meniscal tears and cartilage lesions.

Study Design: Cohort study (prognosis); Level of evidence, 2.

Methods: All patients registered in the Norwegian National Knee Ligament Registry who had undergone primary anterior cruciate ligament reconstruction from 2004 and throughout 2006 were reviewed. Logistic regression analyses were used to estimate the relationship between time from injury until anterior cruciate ligament surgery and the risk of meniscal tears or cartilage lesions.

Results: Of a total of 3475 patients, there were 909 patients (26%) with cartilage lesions, 1638 patients (47%) with meniscal tears, and 527 patients (15%) with both cartilage and meniscal lesions. The odds of a cartilage lesion in the adult knee (>16 years) increased by 1.006 (95% confidence interval, 1.003-1.010) for each month that elapsed from injury to surgery. The cartilage in young adults (17-40 years) deteriorated further with an increase in odds of 1.03 (95% confidence interval, 1.02-1.05) related to the aging in years of the patient. The odds for meniscal tears in young adults increased by 1.004 (95% confidence interval, 1.002-1.006) for each month that elapsed since injury. The presence of 1 degenerative lesion increased the odds of having the other degenerative lesion by between 1.6 and 2.0 in all patient groups.

Conclusion: The odds of a cartilage lesion in the adult knee increased by nearly 1% for each month that elapsed from the injury date until the surgery date and that of cartilage lesions were nearly twice as frequent if there was a meniscal tear, and vice versa.

Background: Anatomic double-bundle reconstruction has been thought to better simulate the anterior cruciate ligament anatomy. It is, however, a technically challenging procedure, associated with longer operation time and higher cost.

Hypothesis: Double-bundle anterior cruciate ligament reconstruction using a single femoral and tibial tunnel can closely reproduce intact knee kinematics.

Study Design: Controlled laboratory study.

Methods: Eight fresh-frozen human cadaveric knee specimens were tested using a robotic testing system to investigate the kinematic response of the knee joint under an anterior tibial load (130 N), simulated quadriceps load (400 N), and combined torques (5 N·m valgus and 5 N·m internal tibial torques) at 0°, 15°, 30°, 60°, and 90° of flexion. Each knee was tested sequentially under 4 conditions: (1) anterior cruciate ligament intact, (2) anterior cruciate ligament deficient, (3) single-bundle anterior cruciate ligament reconstruction using quadrupled hamstring tendon, and (4) single-tunnel—double-bundle anterior cruciate ligament reconstruction using the same tunnels and quadrupled hamstring tendon graft as in the single-bundle anterior cruciate ligament reconstruction.

Results: Single-tunnel—double-bundle anterior cruciate ligament reconstruction more closely restored the intact knee kinematics than single-bundle anterior cruciate ligament reconstruction at low flexion angles (≤30°) under the anterior tibial load and simulated muscle load (P < .05). However, single-tunnel—double-bundle anterior cruciate ligament reconstruction overconstrained the knee joint at high flexion angles (≥60°) under the anterior tibial load and at 0° and 30° of flexion under combined torques.

Conclusion: This double-bundle anterior cruciate ligament reconstruction using a single tunnel can better restore anterior tibial translations to the intact level compared with single-bundle anterior cruciate ligament reconstruction at low flexion angles, but it overconstrained the knee joint at high flexion angles.

Clinical Relevance: This technique could be an alternative for both single-bundle and double-tunnel—double-bundle anterior cruciate ligament reconstructions to reproduce intact knee kinematics and native anterior cruciate ligament anatomy.

Background: The tools for measuring the congruence angle with digital radiography software can be difficult to use; therefore, the authors sought to develop a new, easy, and reliable method for measuring patellofemoral congruence.

Hypothesis: The linear displacement measurement will correlate well with the congruence angle measurement.

Study Design: Cohort study (diagnosis); Level of evidence, 2.

Methods: On Merchant view radiographs obtained digitally, the authors measured the congruence angle and a new linear displacement measurement on preoperative and postoperative radiographs of 31 patients who suffered unilateral patellar dislocations and 100 uninjured subjects. The linear displacement measurement was obtained by drawing a reference line across the medial and lateral trochlear facets. Perpendicular lines were drawn from the depth of the sulcus through the reference line and from the apex of the posterior tip of the patella through the reference line. The distance between the perpendicular lines was the linear displacement measurement. The measurements were obtained twice at different sittings. The observer was blinded as to the previous measurements to establish reliability. Measurements were compared to determine whether the linear displacement measurement correlated with congruence angle.

Results: Intraobserver reliability was above r2 = .90 for all measurements. In patients with patellar dislocations, the mean congruence angle preoperatively was 33.5°, compared with 12.1 mm for linear displacement (r2 = .92). The mean congruence angle postoperatively was 11.2°, compared with 4.0 mm for linear displacement (r2 = .89). For normal subjects, the mean congruence angle was —3° and the mean linear displacement was 0.2 mm.

Conclusion: The linear displacement measurement was found to correlate with congruence angle measurements and may be an easy and useful tool for clinicians to evaluate patellofemoral congruence objectively.

Background: The modified Jobe and Docking techniques are commonly used to reconstruct the elbow’s ulnar collateral ligament.

Hypothesis: Valgus laxity and kinematic coupling after these reconstructive procedures are similar to those of the native ulnar collateral ligament.

Study Design: Controlled laboratory study.

Methods: Testing was conducted on 10 pairs of cadaver elbows using a 4 degrees of freedom loading system. Subfailure valgus loads were applied to the native elbows at different flexion angles; motion and ligament elongation were measured. The elbows were then loaded to failure in valgus at 90° of flexion. The reconstructive techniques were then applied and testing was repeated.

Results: Only the resting length of the anterior portion of the ulnar collateral ligament anterior bundle remained isometric throughout range of motion. Valgus laxity was nearly equal for the native and reconstructed ligaments at flexion angles of 90° or higher. However, both reconstructions provided less valgus stability than the native ulnar collateral ligament at low flexion angles. Kinematic coupling decreased with increased flexion for both native and reconstructed ligaments.

Conclusion: The modified Jobe and Docking techniques reconstruct restraint of the native ulnar collateral ligament to valgus laxity and kinematic coupling at 90° of flexion and higher angles where peak valgus torque is experienced in the throwing elbow.

Clinical Relevance: Both reconstructions provide valgus stability comparable to that of the native ulnar collateral ligament at 90° and higher, helping to explain their success in treating throwing athletes. Both reconstructions provide less valgus stability than the native ulnar collateral ligament at low flexion angles, suggesting that patients undergoing ulnar collateral ligament reconstruction should be cautioned against activities that provide valgus stress at low elbow flexion angles, such as side-arm throwing. This study suggests caution against overtightening the reconstructions at the common 30° of flexion.

Background: Functional ankle instability (FAI) may be prevalent in as many as 40% of patients after acute lateral ankle sprain. Altered afference resulting from damaged mechanoreceptors after an ankle sprain may lead to reflex inhibition of surrounding joint musculature. This activation deficit, referred to as arthrogenic muscle inhibition (AMI), may be the underlying cause of FAI. Incomplete activation could prevent adequate control of the ankle joint, leading to repeated episodes of instability.

Hypothesis: Arthrogenic muscle inhibition is present in the peroneal musculature of functionally unstable ankles and is related to dynamic peroneal muscle activity.

Study Design: Cross-sectional study; Level of evidence, 3.

Methods: Twenty-one (18 female, 3 male) patients with unilateral FAI and 21 (18 female, 3 male) uninjured, matched controls participated in this study. Peroneal maximum H-reflexes and M-waves were recorded bilaterally to establish the presence or absence of AMI, while electromyography (EMG) recorded as patients underwent a sudden ankle inversion perturbation during walking was used to quantify dynamic activation. The H:M ratio and average EMG amplitudes were calculated and used in data analyses. Two-way analyses of variance were used to compare limbs and groups. A regression analysis was conducted to examine the association between the H:M ratio and the EMG amplitudes.

Results: The FAI patients had larger peroneal H:M ratios in their nonpathological ankle (0.399 ± 0.185) than in their pathological ankle (0.323 ± 0.161) ( P = .036), while no differences were noted between the ankles of the controls (0.442 ± 0.176 and 0.425 ± 0.180). The FAI patients also exhibited lower EMG after inversion perturbation in their pathological ankle (1.7 ± 1.3) than in their uninjured ankle (EMG, 3.3 ± 3.1) (P < .001), while no differences between legs were noted for controls (P >" xbd="1958" xhg="1938" ybd="1851" yhg="1826"/> .05). No significant relationship was found between the peroneal H:M ratio and peroneal EMG (P > .05).

Conclusion: Arthrogenic muscle inhibition is present in the peroneal musculature of persons with FAI but is not related to dynamic muscle activation as measured by peroneal EMG amplitude. Reversing AMI may not assist in protecting the ankle from further episodes of instability; however dynamic muscle activation (as measured by peroneal EMG amplitude) should be restored to maximize ankle stabilization. Dynamic peroneal activity is impaired in functionally unstable ankles, which may contribute to recurrent joint instability and may leave the ankle vulnerable to injurious loads.

Background: There are many techniques described to repair acute distal biceps tendon ruptures. The authors’ objective is to report the results of a single-incision technique using a combination of a soft tissue button and biotenodesis interference screw with accelerated rehabilitation.

Hypothesis: Dual fixation of a distal biceps rupture will allow for early return to function.

Study Design: Case series; Level of evidence, 4.

Methods: From February 2004 to July 2007, 41 elbows in 40 patients had repair of an acute distal biceps tendon rupture (<6 weeks) through an anterior incision using a soft tissue button and interference screw combined technique. The patients were evaluated pre- and postoperatively with a physical examination, radiographs, and the Andrews-Carson elbow score. Nine patients were unavailable for follow-up. The remaining 31 patients (32 elbows) were contacted for a telephone interview at an average of 24 months postoperatively.

Results: The preoperative Andrews-Carson score averaged 168 and the postoperative Andrews-Carson score averaged 196 points at final clinical follow-up. There was a statistically significant difference between the pre- and postoperative Andrews-Carson scores (P < .001). One patient had heterotopic ossification associated with decreased pronation and supination. Two superficial radial nerve palsies completely resolved by final follow-up. The average postoperative time to resume normal activities or return to work was 6.5 weeks.

Conclusion: Repair of acute distal biceps tendon ruptures using a soft tissue button and interference screw technique through a limited anterior incision can allow for accelerated rehabilitation and early return to function.

Background: Little has been written about the operative repair of recurrent anterior instability of the shoulder in a single sport: in this case, Judo.

Purpose: The clinical efficacy of the Neer modified inferior capsular shift as an open procedure for injured judokas was investigated.

Study Design: Case series; Level of evidence, 4.

Methods: Fifty athletes (42 male and 8 female, 52 shoulders) took part in this study. The average age at surgery was 20 years (range, 14-38 years), and the mean follow-up period was 61 months (range, 24-172 months). The operation was performed on 29 tsurité (a lapel grip) shoulders and on 23 hikité (a sleeve grip) shoulders. The 2 grips are functionally and technically different from each other.

Results: Three cases of shoulder instability (5.8%) recurred after surgery. The average loss of external rotation was 9.6° with the arm at the side and 11.6° with the arm in 90° of abduction. The average Rowe and UCLA scores were 37.3 and 20.8 points preoperatively and 86.7 and 32.4 points at the final follow-up, respectively (P < .05). The return rate to the near-preinjury sports activity levels (>90% recovery: grades 1 and 2) was significantly lower in the tsurité shoulders (48.1%) than in the hikité shoulders (85.7%).

Conclusion: The overall recovery of more than 90% of preinjury activity levels in judo was 65% after modified inferior capsular shift for traumatic anterior instability of the shoulder. The tsurité shoulder should be treated with minimal restriction limitation in external rotation so that it is not limited postoperatively.

Background: No previous research has investigated the diagnostic validity of magnetic resonance imaging for acute versus chronic meniscal tears using comparable materials and methods.

Hypothesis: There is no difference in the diagnostic validity of magnetic resonance imaging for acute versus chronic meniscal tears in young adults.

Study Design: Cohort study (diagnosis); Level of evidence, 2.

Methods: A total of 628 young adult military personnel underwent magnetic resonance imaging and arthroscopy of the knee over a 6-year period. Inclusion criteria were met by 82 patients with acute knee trauma (magnetic resonance imaging within 30 days from trauma) and 40 patients with chronic knee symptoms (symptoms lasting over 6 months before magnetic resonance imaging). The original magnetic resonance imaging and arthroscopy records were reviewed twice by a musculoskeletally trained radiologist, blinded to previous magnetic resonance imaging and arthroscopy findings. Interobserver correlations and intraobserver reliability were calculated and reported. Arthroscopy served as the gold standard when calculating the diagnostic values of magnetic resonance imaging for acute and chronic meniscal tears.

Results: The median age of the patients was 20 years (range, 18-25). Magnetic resonance imaging detected acute meniscal tears with sensitivity of 67%, specificity of 93%, and diagnostic accuracy of 88% and chronic meniscal tears with 64%, 91%, and 86%, respectively. There was no statistically significant difference in magnetic resonance imaging results between the 2 groups.

Conclusion: The diagnostic validity of magnetic resonance imaging is similar for meniscal tears in acute knee trauma and in knee symptoms lasting over 6 months in young adults. The results also suggest that effusion or hemarthrosis do not weaken the diagnostic validity of magnetic resonance imaging. The magnetic resonance imaging sensitivity achieved in the present study was relatively poor, but the specificity was good for both acute and chronic meniscal tears. Despite negative magnetic resonance imaging findings at the acute stage of knee trauma, patient monitoring and readiness for arthroscopy should be considered if justified by the patient’s symptoms.

Background: Syndesmotic ankle injuries are not easy to recognize when an associated fracture or frank diastasis is not present. There is a need for a simple, fast, inexpensive, and easily reproducible diagnostic tool to assess the integrity of the distal tibiofibular synedesmosis.

Hypothesis: Dynamic ultrasound (US) examination can accurately diagnose anteroinferior tibiofibular ligament (AITFL) rupture. Study Design: Cohort study (diagnosis); Level of evidence, 2.

Methods: We evaluated 3 groups: 9 consecutive professional athletes with recent AITFL rupture, a control group of 18 subjects without a history of ankle injury, and 20 patients with lateral ankle sprain. The dynamic US examination was performed in neutral (N), forced internal rotation (IR), and external rotation (ER) of the foot for measuring the tibiofibular clear space on the anterior aspect of the ankle, at the level of the AITFL, 1 cm proximal to the joint line.

Results: The mean age of the study group was 27 years (range, 16-32). Magnetic resonance imaging (MRI) confirmed the diagnosis of AITFL rupture in all cases. Differences between the injured and control group were statistically significant for the N, IR, and ER positions (P < .001) and for the measured Δ between the AITFL in the ER and N positions (P < .01). The difference in the tibiofibular clear space between the 2 ankles of the injured athletes was significantly different compared with the control athletes for all 3 positions (P < .001). The measured difference between the ER and N positions for both sides of the study group showed a specificity and sensitivity of 100% (P < .001; cutoff point of 0.9 mm and 0.7 mm, respectively). The Δ (Δ = ER — N) of the injured side showed a specificity and sensitivity of only 89% (P < .001; cutoff point of 0.4 mm). Additionally, the third group with the history of lateral ankle sprain showed, as expected, that this type of injury does not correlate with AITFL injury on dynamic US examination.

Conclusion: We conclude that dynamic US examination can be used to accurately diagnose an AITFL rupture. This preliminary study has found the described method to be a simple, inexpensive, and easily reproducible examination.

Background: Glenohumeral internal rotation deficit, often diagnosed in players of overhead sports, has been associated with the development of secondary shoulder lesions.

Hypothesis: Asymptomatic players of different overhead sports will exhibit variable degrees of glenohumeral internal rotation deficit.

Study Design: Cross-sectional study; Level of evidence, 3.

Methods: Fifty-four asymptomatic male volunteers (108 shoulders) divided into 3 groups (tennis players, swimmers, control group) underwent measurements of glenohumeral internal and external rotation using clinical examination with scapular stabilization. Measurements of dominant and nondominant shoulders were compared within and between groups. Glenohumeral internal rotation deficit (GIRD) was defined as the difference in internal rotation between the nondominant and dominant shoulders.

Results: In tennis players, mean GIRD was 23.9° ± 8.4° (P < .001); in swimmers, 12° ± 6.8° (P < .001); and in the control group, 4.9° ± 7.4° (P = .035). Dominant shoulders showed significant difference between all groups, and the difference in internal rotation of the dominant shoulder between the group of tennis players in comparison with the control group (27.6°, P < .001) was greater than the difference in internal rotation of the dominant shoulder found in the group of swimmers compared with the control group (17.9°, P < .001). Between tennis players and swimmers, the difference in internal rotation of the dominant shoulder was 9.7° (P = .002).

Conclusion: Dominant limbs showed less glenohumeral internal rotation than the nondominant limbs in all groups, with the deficit in the group of tennis players about twice the deficit found for swimmers. Mean difference between limbs in the control group was less than 5°, which is within normal parameters according to most studies. There were statistically significant differences between all groups when dominant shoulders were compared with each other, differences that were not compensated by external rotation gain. Tennis players had the least range of motion, followed by swimmers.

Internal impingement of the shoulder is a pathologic condition characterized by excessive or repetitive contact of the greater tuberosity of the humeral head with the posterosuperior aspect of the glenoid when the arm is abducted and externally rotated. This arm positioning leads to rotator cuff and glenoid labrum impingement by the bony structures of the glenohumeral joint. Although some degree of contact between these structures occurs under normal conditions, to date most of the orthopaedic literature has focused on internal impingement as a disease state that affects overhead athletes and is characterized by the development of articular-sided rotator cuff tears and posterosuperior labral lesions. The precise cause of these impingement lesions remains unclear. However, it is believed that varying degrees of glenohumeral instability, posterior capsular contracture, and scapular dyskinesis may play a role in the development of symptomatic internal impingement. The purpose of this article is to review the pathomechanics, clinical complaints, physical examination findings, and imaging findings that are associated with internal impingement. The results of treatment will be reviewed, and a diagnostic and therapeutic algorithm for the management of internal impingement is presented.