The American Journal of Sports Medicine

Background: Orthopaedic injuries negatively affect the academic lives of children.

Hypothesis: The timing of anterior cruciate ligament (ACL) and medial patellofemoral ligament (MPFL) reconstructions affects academic performance in school-aged athletes.

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

Methods: Records of patients ≤18 years old who underwent ACL or MPFL reconstructions from 2001-2007 were reviewed retrospectively. Subjects had been administered a unique questionnaire to evaluate school life in the immediate postoperative period as well as International Knee Documentation Committee (IDKC), Lysholm, and Kujala knee-specific questionnaires. Patients were in 1 of 3 study cohorts: group A (surgery during school year), group B (surgery during school holiday), and group C (surgery during summer break).

Results: There were 62 subjects (53 ACL and 12 MPFL reconstructions). A higher proportion of patients in group A required being driven to school (88.5%) than groups B (63.6%) or C (64.7%) (P < .05). A lower proportion of patients in group A returned to school immediately after surgery (3.8%) than groups B (36.4%) or C (88.2%) (P < .005). Among children who had never failed a test before surgery, a higher proportion of patients in group A failed a test (36.4%) after return to school than groups B (0%) or C (0%) (P < .05). Patients in group C had higher mean Likert scores (4.5) than groups A (3.8) or B (3.7) (P = .05) in response to the question “my grades suffered in my classes.” Delay in surgery was negatively correlated with IKDC, Lysholm, and Kujala questionnaire scores (P < .05).

Conclusion: In school-aged athletes with ligamentous knee injuries receiving operative treatment, surgery on a school day causes more academic difficulties than surgery during a holiday or summer break. Academic benefits of delaying surgery during the school year must be weighed against potentially worse outcomes encountered with prolonged surgical delay.

Background: Biodegradable cross-pins have been shown to provide higher failure loads than do screws for fixation of hamstring tendons under laboratory conditions.

Purpose: To compare the clinical results of biodegradable pins (RigidFix) and interference screws (BioCryl) for fixation of hamstring grafts in arthroscopically assisted anterior cruciate ligament reconstruction.

Study Design: Randomized controlled trial; Level of evidence, 1.

Methods: To test the hypothesis of a difference of 1.0 ± 1.2 mm in anterior knee laxity between the two fixation options, 54 patients were randomly assigned to groups via a block randomization scheme and sealed envelopes. All patients underwent standardized hamstring graft reconstruction and had similar postoperative aftercare by an accelerated rehabilitation protocol. Measures assessed at baseline and after 1 and 2 years of follow-up included (1) the side-to-side difference in anterior laxity (KT-1000 arthrometer), (2) Short Form 36 physical and mental component scores, and (3) the International Knee Documentation Committee form scores.

Results: After 1 and 2 years, 26 and 21 patients in the BioCryl group and 28 and 24 patients in the RigidFix group were available for follow-up examination. No significant difference was noted in instrumented anterior translation between BioCryl and RigidFix fixation: 1 year, 0.11 (95% CI, —0.60 to 0.82; P = .7537); 2 years, 0.33 (95% CI, —0.43 to 1.08 mm; P = .3849). Also, there were no significant differences in the mean physical and mental component scores and International Knee Documentation Committee form scores and in overall complication and surgical revision rates. A pin dislocation was classified as the sole procedure-specific serious adverse event.

Conclusion: Bioresorbable pins do not provide better clinical results than do resorbable interference screws for hamstring graft fixation in anterior cruciate ligament reconstruction surgery.

Background: This study was designed to investigate differences in recovery in male and female soccer athletes.

Hypotheses: Soccer players with a history of concussion will perform worse on neurocognitive testing than players without a history of concussion. Furthermore, female athletes will demonstrate poorer performance on neurocognitive testing than male athletes.

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

Methods: Computer-based neuropsychological testing using reaction time, memory, and visual motor-speed composite scores of the ImPACT test battery was performed postconcussion in soccer players ranging in age from 8 to 24 years (N = 234; 141 females, 93 males). A multivariate analysis of variance was conducted to examine group differences in neurocognitive performance between male and female athletes with and without a history of concussion.

Results: Soccer players with a history of at least 1 previous concussion performed significantly worse on ImPACT than those who had not sustained a prior concussion ( F = 2.92, P = .03). In addition, female soccer players performed worse on neurocognitive testing (F = 2.72, P = .05) and also reported more symptoms (F = 20.1, P = .00001) than male soccer players. There was no significant difference in body mass index between male and female players (F = .04, P = .85).

Conclusion: A history of concussion and gender may account for significant differences in postconcussive neurocognitive test scores in soccer players and may play a role in determining recovery. These differences do not appear to reflect differences in mass between genders and may be related to other gender-specific factors that deserve further study.

Background: The intent of double-bundle anterior cruciate ligament reconstruction is to reproduce the normal anterior cruciate ligament anatomy and improve knee joint rotational stability. However, no consensus has been reached on the advantages of this technique over the single-bundle technique.

Hypothesis: We hypothesized that double-bundle anterior cruciate ligament reconstruction could provide better intraoperative stability and clinical outcome than single-bundle reconstruction.

Type of study: Cohort study; Level of evidence, 2.

Methods: Forty patients with anterior cruciate ligament injury in one knee were recruited; 20 were allocated to a double-bundle anterior cruciate ligament reconstruction group and 20 to a single-bundle anterior cruciate ligament reconstruction group. Intraoperative stabilities at 30° of knee flexion were compared between the 2 groups using a navigation system. Clinical outcomes including Lysholm knee scores, Tegner activity scores, Lachman and pivot-shift test results, and radiographic stabilities were also compared between the 2 groups after a minimum of 2 years of follow-up.

Results: Intraoperative anterior and rotational stabilities after anterior cruciate ligament reconstruction in the double-bundle group were significantly better than those in single-bundle group (P = .020 and P < .001, respectively). Nineteen patients (95%) in each group were available at a minimum 2-year follow-up. Clinical outcomes including Lysholm knee and Tegner activity scores were similar in the 2 groups at 2-year follow-up (P > .05). Furthermore, stability results of the Lachman and pivot-shift tests, and radiologic findings at 2-year follow-up failed to reveal any significant intergroup differences ( P > .05).

Conclusion: Although double-bundle anterior cruciate ligament reconstruction produces better intraoperative stabilities than single-bundle anterior cruciate ligament reconstruction, the 2 modalities were found to be similar in terms of clinical outcomes and postoperative stabilities after a minimum of 2 years of follow-up.

Background: There are few reports in the literature detailing the arthroscopic treatment of multidirectional instability of the shoulder.

Hypothesis: Arthroscopic management of symptomatic multidirectional instability in an athletic population can successfully return athletes to sports with a high rate of success as determined by patient-reported outcome measures.

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

Methods: Forty patients (43 shoulders) with multidirectional instability of the shoulder were treated via arthroscopic means and were evaluated at a mean of 33.5 months postoperatively. The mean patient age was 19.1 years (range, 14-39). There were 24 male patients and 16 female patients. Patients were evaluated with the American Shoulder and Elbow Surgeons and Western Ontario Shoulder Instability scoring systems. Stability, strength, and range of motion were also evaluated with patient-reported scales.

Results: The mean American Shoulder and Elbow Surgeons score postoperatively was 91.4 of 100 (range, 59.9-100). The mean Western Ontario Shoulder Instability postoperative percentage score was 91.1 of 100 (range, 72.9-100). Ninety-one percent of patients had full or satisfactory range of motion, 98% had normal or slightly decreased strength, and 86% were able to return to their sport with little or no limitation.

Conclusion: Arthroscopic methods can provide an effective treatment for symptomatic multidirectional instability in an athletic population.

Background: Arthroscopy of the hip joint is a relatively new diagnostic and therapeutic option for labral tears.

Purpose: More data are needed to characterize the utility and effectiveness of hip arthroscopy and identify patient-related factors that might predict functional outcome.

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

Methods: This retrospective study with prospective follow-up examined the clinical outcomes of 52 consecutive patients undergoing hip arthroscopy for labral tears. Outcomes measures included clinical outcome and the modified Harris hip score. Any complications associated with the procedure were recorded. Exclusion criteria included age younger than 18 years or prior ipsilateral hip surgery.

Results: Mean patient age was 42 years. Mean follow-up was 4.8 years. Twenty-one patients (40.4%) had a traumatic cause of the labral tears. Eight patients (15.4%) had possible secondary gain issues. Four (7.7%) patients suffered transient nerve palsies; in 1 case, the guide wire broke during initial cannulation. Three patients (5.8%) went on to total hip arthroplasty after hip arthroscopy. On multivariate analysis, left-sided surgery, a higher preoperative activity level, and duration of symptoms greater than 18 months were found to be positive predictors of good or excellent outcomes. Smoking and secondary gain issues were significant negative predictors of good or excellent outcomes. Only prior level of activity was a significant positive predictor of return to activity after surgery. A traumatic cause of the labral tear was a significant negative predictor of return to activity. Chondromalacia and osteoarthritis were not significant predictors of negative outcome. Postoperative modified Harris hip score improved 40% from 56.8 preoperatively to 80.4 (P < .001). No cases of patients with secondary gain issues achieved good or excellent outcomes. Overall percentage of good or excellent outcomes was 56%, or 66% when those with secondary gain issues were excluded; 84% of patients were able to return to sports or equivalent level of preoperative recreational activity. Neither preoperative radiographic osteoarthritis nor grade of intraoperative chondromalacia predicted postoperative outcome.

Conclusion: This series supports the hypothesis that hip arthroscopy provides safe and reliable improvement of labral symptoms in the majority of patients.

Background: Female athletes have a higher risk of anterior cruciate ligament injury than their male counterparts who play at similar levels in sports involving pivoting and landing.

Hypothesis: The competitive female basketball players who participated in a sports injury prevention training program would show better muscle strength and flexibility and improved biomechanical properties associated with anterior cruciate ligament injury than during the pretraining period and than posttraining parameters in a control group.

Study Design: Controlled laboratory study.

Methods: A total of 22 high school female basketball players were recruited and randomly divided into 2 groups (the experimental group and the control group, 11 participants each). The experimental group was instructed in the 6 parts of the sports injury prevention training program and performed it during the first 20 minutes of team practice for the next 8 weeks, while the control group performed their regular training program. Both groups were tested with a rebound-jump task before and after the 8-week period. A total of 21 reflective markers were placed in preassigned positions. In this controlled laboratory study, a 2-way analysis of variance (2 × 2) experimental design was used for the statistical analysis (P < .05) using the experimental group and a testing session as within and between factors, respectively. Post hoc tests with Sidak correction were used when significant factor effects and/or interactions were observed.

Results: A comparison of the experimental group’s pretraining and posttraining results identified training effects on all strength parameters (P = .004 to .043) and on knee flexion, which reflects increased flexibility (P = .022). The experimental group showed higher knee flexion angles (P = .024), greater interknee distances (P = .004), lower hamstring-quadriceps ratios ( P = .023), and lower maximum knee extension torques (P = .043) after training. In the control group, no statistical differences were observed between pretraining and posttraining findings (P = .084 to .873). At pretraining, no significant differences were observed between the 2 groups for any parameter (P = .067 to .784). However, a comparison of the 2 groups after training revealed that the experimental group had significantly higher knee flexion angles (P = .023), greater knee distances ( P = .005), lower hamstring-quadriceps ratios (P = .021), lower maximum knee extension torques (P = .124), and higher maximum knee abduction torques (P = .043) than the control group.

Conclusion: The sports injury prevention training program improved the strength and flexibility of the competitive female basketball players tested and biomechanical properties associated with anterior cruciate ligament injury as compared with pretraining parameters and with posttraining parameters in the control group.

Clinical Relevance: This injury prevention program could potentially modify the flexibility, strength, and biomechanical properties associated with ACL injury and lower the athlete’s risk for injury.

Background: Several medial patellofemoral ligament reconstruction procedures have been proposed to manage recurrent patellar dislocation.

Hypothesis: Reconstruction of the medial patellofemoral ligament using a hamstring graft with a 2 transverse patellar tunnels technique is an effective treatment for recurrent patellar dislocation in patients without any evident predisposing factors.

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

Methods: Twenty-eight patients with chronic patellar instability without any anatomic predisposing factors, experiencing recurrent unilateral patellar dislocation, were included in the study. Evaluation included the modified Cincinnati and the Kujala scores, anthropometry, plain radiography, and isokinetic dynamometry.

Results: The average follow-up was 3.1 years (range, 2.5-4 years). The mean modified Cincinnati score increased from 52 preoperatively to 89 (P = .001). The mean Kujala scores increased from 45 preoperatively to 83 (P = .03). The muscle volume of the thigh of the operated limb increased with time, but remained less well developed than the nonoperated limb (P = .04). The mean Insall-Salvati index was 1.1 (range, 0.9-1.2) preoperatively and remained within normal range (1.1 [range, 0.9 to 1.2]) (P = .07), at latest follow-up. Significant isokinetic strength differences were found between the operated and the contralateral limbs (.05 < P < .006), even at the latest follow-up. Three patients experienced a new patellar dislocation.

Conclusion: Medial patellofemoral ligament reconstruction using hamstring tendon passed through a double patellar transverse bony tunnel technique is a safe, reliable management option for recurrent patellar dislocation in patients without any predisposing anatomic factors.

Background: There is controversy regarding the relationship between patellofemoral pain syndrome (PFPS) and insufficiency of the vastus medialis obliquus (VMO). The conventional clinical practice of VMO strengthening for PFPS has been challenged for lack of evidence. The purpose of this study was to observe the difference in sonographic findings of the VMO between patients with PFPS and healthy adults.

Hypothesis: The morphological characteristics of the VMO are different between patients with PFPS and healthy adults.

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

Methods: Fifty-four patients with PFPS and 54 age-, gender-, body height—, and body weight—matched healthy adults as controls were enrolled in the study to measure by sonography the insertion level, fiber angle, and volume of the VMO at its insertional portion to detect differences between patients with PFPS and healthy controls.

Results: The insertion level, fiber angle, and VMO volume were all significantly smaller in the PFPS group than in the control group (P < .05). Multivariate analysis of variance has revealed a Wilks λ value of .845 and an F value of 5.640 (P = .001).

Conclusion: There was a significant difference in the 3 VMO measures between patients with PFPS and the healthy controls. Individuals might be predisposed to PFPS by different VMO characteristics, including insertion level and fiber angle. The current study cannot determine whether the observed morphological differences were the results of atrophy in response to pain or if they represent dysplasia that was predisposed to pain development. The clinical manifestations of VMO characteristics should be thoroughly investigated in other populations.

Clinical Relevance: The function of the VMO is important to consider in the rehabilitation of patients with PFPS.

Background: Glenohumeral instability is a common injury sustained by young athletes. Surprisingly, little is known regarding the incidence of glenohumeral instability in collegiate athletes or the relevant risk factors for injury. A better understanding of the populations most at risk may be used to develop preventive strategies.

Hypothesis: The incidence of glenohumeral instability in collegiate athletics is high, and it is affected by sex, sport, type of event, and mechanism of injury.

Study Design: Descriptive epidemiologic study.

Methods: The National Collegiate Athletic Association injury database was queried for all glenohumeral instability events occurring between the years 1989 and 2004. An analysis of the injuries was performed by sport, activity (competition versus practice), sex, type of event (primary versus recurrent), mechanism of injury, and time loss from athletic performance. Incidence rates and incidence rate ratios were calculated.

Results: A total of 4080 glenohumeral instability events were documented for an incidence rate of 0.12 injuries per 1000 athlete exposures. The sport with the greatest injury rate was men’s spring football, with 0.40 injuries per 1000 athlete exposures. Overall, athletes sustained more glenohumeral instability events during games than practices (incidence rate ratio [IRR], 3.50; 95% confidence interval [CI], 3.29-3.73). Male athletes sustained more injuries than did female athletes (IRR, 2.67; 95% CI, 2.43-2.93). Female athletes were more likely to sustain an instability event as the result of contact with an object (IRR, 2.43; 95% CI, 2.08-2.84), whereas male athletes were more likely to sustain an event from player contact (IRR, 2.74; 95% CI, 2.31-3.25). Time lost to sport (>10 days) occurred in 45% of glenohumeral instability events.

Conclusion: Glenohumeral instability is a relatively common injury sustained by collegiate athletes. More injuries occurred during competition and among male athletes.

Background: Lateral ankle sprains can lead to persistent disability in athletes. The authors studied the effect of a lateral ankle sprain on reinjury occurrence in the same region.

Hypothesis: There will be no difference in reinjury rate between low-grade (grades I and II) and high-grade (IIIA and IIIB) acute lateral ankle sprains.

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

Methods: From 1996 to 2004, the authors managed 202 elite Greek track and field athletes for an acute lateral ankle sprain. Sprains were classified into 4 degrees (I, II, IIIA, and IIIB). The same rehabilitation protocol was prescribed for all the athletes. The rate of a lateral ankle reinjury was recorded in the 24 months following injury.

Results: At a follow-up of 24 months, 36 of 202 athletes (17.8%) experienced a second lateral ankle sprain. Of the 79 athletes with a grade I injury, 11 (14%) experienced a recurrence during the study period. Of the 81 athletes with a grade II injury, 23 (29%) experienced a recurrence during the study period. Of the 36 athletes with a grade IIIA injury, 2 (5.6%) experienced a recurrence during the study period. Of the 6 athletes with a grade IIIB injury, none experienced a recurrence during the study period.

Conclusion: Athletes with a grade I or II lateral ankle sprain are at higher risk of experiencing a reinjury. Low-grade acute lateral ankle sprains result in a higher risk of reinjury than high-grade acute lateral ankle sprains.

Background: There is a lack of knowledge on the primary and secondary static stabilizing functions of the posterior oblique ligament (POL), the proximal and distal divisions of the superficial medial collateral ligament (sMCL), and the meniscofemoral and meniscotibial portions of the deep medial collateral ligament (MCL).

Hypothesis: Identification of the primary and secondary stabilizing functions of the individual components of the main medial knee structures will provide increased knowledge of the medial knee ligamentous stability.

Study Design: Descriptive laboratory study.

Methods: Twenty-four cadaveric knees were equally divided into 3 groups with unique sequential sectioning sequences of the POL, sMCL (proximal and distal divisions), and deep MCL (meniscofemoral and meniscotibial portions). A 6 degree of freedom electromagnetic tracking system monitored motion after application of valgus loads (10 N·m) and internal and external rotation torques (5 N·m) at 0°, 20°, 30°, 60°, and 90° of knee flexion.

Results: The primary valgus stabilizer was the proximal division of the sMCL. The primary external rotation stabilizer was the distal division of the sMCL at 30° of knee flexion. The primary internal rotation stabilizers were the POL and the distal division of the sMCL at all tested knee flexion angles, the meniscofemoral portion of the deep MCL at 20°, 60°, and 90° of knee flexion, and the meniscotibial portion of the deep MCL at 0° and 30° of knee flexion.

Conclusion: An intricate relationship exists among the main medial knee structures and their individual components for static function to applied loads.

Clinical Significance: Interpretation of clinical knee motion testing following medial knee injuries will improve with the information in this study. Significant increases in external rotation at 30° of knee flexion were found with all medial knee structures sectioned, which indicates that a positive dial test may be found not only for posterolateral knee injuries but also for medial knee injuries.

Background: There is limited information regarding directly measured load responses of the posterior oblique and superficial medial collateral ligaments in isolated and multiple medial knee ligament injury states.

Hypotheses: Tensile load responses from both the superficial medial collateral ligament and the posterior oblique ligament would be measurable and reproducible, and the native load-sharing relationships between these ligaments would be altered after sectioning of medial knee structures.

Study Design: Descriptive laboratory study.

Methods: Twenty-four nonpaired, fresh-frozen adult cadaveric knees were distributed into 3 sequential sectioning sequences. Buckle transducers were applied to the posterior oblique ligament and the proximal and distal divisions of the superficial medial collateral ligament; 10 N·m valgus moments and 5 N·m internal and external rotation torques were applied at 0°, 20°, 30°, 60°, and 90° of knee flexion.

Results: With an applied valgus and external rotation moment, there was a significant load increase on the posterior oblique ligament compared with the intact state after sectioning all other medial knee structures. With an applied external rotation torque, there was a significant load decrease on the proximal division of the superficial medial collateral ligament from the intact state after sectioning all other medial knee structures. With an applied external rotation torque, the distal division of the superficial medial collateral ligament experienced a significant load increase from the intact state after sectioning the posterior oblique ligament and the meniscofemoral division of the deep medial collateral ligament.

Conclusion: This study found alterations in the native load-sharing relationships of the medial knee structures after injury. Sectioning both the primary and secondary restraints to valgus and internal/external rotation of the knee alters the intricate load-sharing relationships that exist between the medial knee structures.

Clinical Significance: In cases in which surgical repair or reconstruction is indicated, consideration should be placed on repairing or reconstructing all injured medial knee structures to restore the native load-sharing relationships among these medial knee structures.

Background: An anterolateral approach to the tibial tunnel of posterior cruciate ligament reconstruction is used to reduce the sharpness of the graft-tunnel angle, the so-called killer turn effect. However, with the anterolateral approach, the tunnel might be widened into an ovoid shape because of the small angle between the tunnel and the anterolateral cortex.

Hypothesis: The fixation strength of the posterior cruciate ligament graft in the tibial tunnel will be weaker in the anterolateral approach compared with the anteromedial approach.

Study Design: Controlled laboratory study.

Methods: Twenty paired cadaveric tibias were used. Tibial tunnels were made using following approaches: an anteromedial approach for 10 tibias and an anterolateral approach for 10 tibias. The anterior cortex-tunnel angle and the diameter of the tunnel entrance were measured by 2-dimensional computed tomographic scans. After fixation of the Achilles tendon allograft with a biodegradable screw, the maximal strength of the graft at failure was measured using a materials testing machine.

Results: The mean cortex-tunnel angle was 47.5° ± 9.3° in the anteromedial approach group and 28.3° ± 7.4° in the anterolateral approach group. The mean long diameter of the tunnels in the anteromedial approach group was 10.6 ± 1.0 mm and in the anterolateral approach group it was 14.0 ± 1.5 mm. These two parameters showed statistically significant differences between the 2 groups (P < .01). The mean maximum load at failure for the anteromedial approach group was 385.4 ± 139.7 N, and for the anterolateral approach group it was 225.1 ± 144.1 N. This difference was statistically significant (P = .021).

Conclusion: The anterolateral approach resulted in a tunnel with a wider entrance, a more acute cortex-tunnel angle, and a lower maximal load at failure compared with tunnels created using the anteromedial approach.

Clinical Relevance: The use of additional fixation methods, such as post ties or ligament washers and screws, should be considered when using an anterolateral approach for tibial tunnel of posterior cruciate ligament reconstruction.

Background: Chondrolysis has been reported as a sequela of arthroscopic shoulder surgery. Although the causes have yet to be fully elucidated, basic science and clinical evidence suggest a multifactorial origin. Surgical treatment in young patients with glenohumeral chondrolysis is particularly challenging, with little outcome data.

Hypothesis: Glenohumeral chondrolysis has several causes and patterns of presentation. Biological resurfacing is a viable treatment option for symptomatic glenohumeral arthritis.

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

Methods: Twenty patients (mean age, 19.7 years; range, 13.1-33.8) were referred for management of extensive glenohumeral arthritis after arthroscopy glenohumeral surgery (mean time postoperatively, 26 months; range, 3-73). Sixteen patients had an intra-articular pain pump placed for 2 to 3 days; 2 patients demonstrated prominent implants; and 2 had thermal treatment. Patients underwent revision surgery, including 7 biological resurfacings of the glenoid and humeral head, 4 biological resurfacings of the humeral head alone, and 7 other procedures. Eight patients having biological resurfacing were assessed just before the revision surgery, at a mean time of 3.1 years after revision (range, 1.9-6.5), with the American Shoulder and Elbow Surgeon scale and Simple Shoulder Test, Short Form 12 (physical and mental components), and visual analog scale score for pain.

Results: Patient outcomes scores improved from 51 to 71 (American Shoulder and Elbow Surgeon scale, P < .01), 7 to 10 (Simple Shoulder Test, P < .02), and 5 to 3 (visual analog scale, P < .01). Preoperative range of motion demonstrated modest improvements from 119° to 132° of flexion, 42° to 41° of external rotation, and internal rotation from L2 to T12 level. Two patients required an additional surgery: 1 total shoulder arthroplasty and 1 capsular release with debridement.

Conclusion: Severe glenohumeral arthritis is a devastating postoperative complication of glenohumeral arthroscopy. Although not a universal finding, the use of glenohumeral pain pumps is a concern, as well as suboptimal anchor placement. Biological resurfacing permits modest functional improvement in a challenging shoulder condition.

Background: Severe glenoid bone loss in recurrent anterior glenohumeral instability is rare and difficult to treat.

Purpose: The authors present a surgical technique using allogeneic bone grafting for open anatomic glenoid reconstruction in addition to the capsular shift procedure.

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

Methods: Nine consecutive patients with a history of recurrent anterior shoulder instability underwent reconstruction of large bony glenoid erosion with a femoral head allograft combined with an anteroinferior capsular shift procedure. Preoperative computed tomographic and arthroscopic evaluation was performed to confirm a ≥120° osseous defect of the anteroinferior quadrant of the glenoid cavity, which had an “inverted-pear” appearance. Patients were followed for at least 4.5 years (range, 4.5-14). Serial postoperative radiographs were evaluated. Functional outcomes were assessed using Rowe scores.

Results: All grafts showed bony union within 6 months after surgery. The mean Rowe score improved to 84 from a preoperative score of 24. The mean loss of external rotation was 7° compared with the normal shoulder. One subluxation and 1 dislocation occurred after grand mal seizures during follow-up. These 2 patients regained shoulder stability after closed reduction. The remaining patients did not report recurrent instability. All patients resumed daily activities without restricted motion.

Conclusion: This technique for open reconstruction is viable for the treatment of recurrent anterior glenohumeral instability with large bony glenoid erosion.

Background: Over 7 million students participate in high school athletics annually. Despite numerous health benefits, high school athletes are at risk for injury.

Hypothesis: Severe injury rates and patterns differ by gender and type of exposure.

Study Design: Descriptive epidemiology study.

Methods: Sports-related injury data were collected during the 2005-2007 academic years from 100 nationally representative United States high schools via RIO (Reporting Information Online). Severe injury was defined as any injury that resulted in the loss of more than 21 days of sports participation.

Results: Participating certified athletic trainers (ATCs) reported 1378 severe injuries during 3 550 141 athlete-exposures (0.39 severe injuries per 1000 athletic exposures). Football had the highest severe injury rate (0.69), followed by wrestling (0.52), girls’ basketball (0.34), and girls’ soccer (0.33). The rate in all boys’ sports (0.45) was higher than all girls’ sports (0.26) (rate ratio [RR], 1.74; 95% confidence interval [CI], 1.54-1.98; P < .001). However, among directly comparable sports (soccer, basketball, and baseball/softball), girls sustained a higher severe injury rate (0.29) than boys (0.23) (RR, 1.28; 95% CI, 1.08-1.52; P = .006). More specifically, girls’ basketball had a higher rate (0.34) than boys’ basketball (0.24) (RR, 1.43; 95% CI, 1.10-1.86; P = .009). Differences between boys’ and girls’ soccer and baseball/softball were not statistically significant. The severe injury rate was greater in competition (0.79) than practice (0.24) (RR, 3.30; 95% CI, 2.97-3.67; P < .001). Nationally, high school athletes sustained an estimated 446 715 severe injuries from 2005-2007. The most commonly injured body sites were the knee (29.0%), ankle (12.3%), and shoulder (10.9%). The most common diagnoses were fractures (36.0%), complete ligament sprains (15.3%), and incomplete ligament sprains (14.3%). Of severe sports injuries, 0.3% resulted in medical disqualification for the athletes’ career, and an additional 56.8% resulted in medical disqualification for the entire season. One in 4 (28.3%) severe injuries required surgery, with over half (53.9%) being knee surgeries.

Conclusion: Severe injury rates and patterns varied by sport, gender, and type of exposure. Because severe injuries negatively affect athletes’ health and often place an increased burden on the health care system, future research should focus on developing interventions to decrease the incidence and severity of sports-related injuries.

Background: Greater trochanteric pain syndrome is often a manifestation of underlying gluteal tendinopathy. Extracorporeal shock wave therapy is effective in numerous types of tendinopathies.

Hypothesis: Shock wave therapy is an effective treatment for chronic greater trochanteric pain syndrome.

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

Methods: Thirty-three patients with chronic greater trochanteric pain syndrome received low-energy shock wave therapy (2000 shocks; 4 bars of pressure, equal to 0.18 mJ/mm 2; total energy flux density, 360 mJ/mm2). Thirty-three patients with chronic greater trochanteric pain syndrome were not treated with shock wave therapy but received additional forms of nonoperative therapy (control). All shock wave therapy procedures were performed without anesthesia. Evaluation was by change in visual analog score, Harris hip score, and Roles and Maudsley score.

Results: Mean pretreatment visual analog scores for the control and shock wave therapy groups were 8.5 and 8.5, respectively. One, 3, and 12 months after treatment, the mean visual analog score for the control and shock wave therapy groups were 7.6 and 5.1 (P < .001), 7 and 3.7 (P < .001), and 6.3 and 2.7 ( P < .001), respectively. One, 3, and 12 months after treatment, mean Harris hip scores for the control and shock wave therapy groups were 54.4 and 69.8 (P < .001), 56.9 and 74.8 (P < .001), and 57.6 and 79.9 (P < .001), respectively. At final follow-up, the number of excellent, good, fair, and poor results for the shock wave therapy and control groups were 10 and 0 (P < .001), 16 and 12 (P < .001), 4 and 13 (P < .001), and 3 and 8 (P < .001), respectively. Chi-square analysis showed the percentage of patients with excellent (1) or good (2) Roles and Maudsley scores (ie, successful results) 12 months after treatment was statistically greater in the shock wave therapy than in the control group (P < .001).

Conclusion: Shock wave therapy is an effective treatment for greater trochanteric pain syndrome.

Background: Recurrent patellar dislocations are common injuries in children and adolescents. The subjective and functional results of soft tissue surgical management in a population that was skeletally immature at the time of surgery have not been reported.

Hypothesis The 3-in-1 procedure is an effective treatment for recurrent patellar dislocation in skeletally immature patients.

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

Methods: Twenty-five skeletally immature patients (age at operation, 13.5 ± 3.8 years) who were practicing sports and suffering from recurrent unilateral patellar dislocation were included in the study and followed until skeletal maturation. Clinical evaluation included the modified Cincinnati rating system and the Kujala score, anthropometry, plain radiography, and isokinetic dynamometry.

Results: The average follow-up was 3.8 years (range, 2.5-6 years). The mean modified Cincinnati score increased from 51.7 ± 12.6 preoperatively to 94.3 ± 10.8 (P < .02), while the mean Kujala scores increased from 52.4 ± 12.7 preoperatively to 93.8 ± 14.2 (P < .02). The Insall-Salvati index remained essentially unchanged, being 1.04 ± 0.2 preoperatively and 1.02 ± 0.3 at latest follow-up. Significant differences were found between the operated and the contralateral limb in the various isokinetic strength variables at all angular velocities measured at the latest follow-up (.05 < P < .0042).

Conclusion: The 3-in-1 procedure is a safe, reliable management option for recurrent patellar dislocation in skeletally immature patients. Side-to-side differences in isokinetic strength and in anthropometric indices persist despite subjective success of the procedure.

Background: Varus-valgus (LAXVV) and internal-external (LAXIER) rotational knee laxity have received attention as potential contributing factors in anterior cruciate ligament injury. This study compared persons with above- and below-average LAXVV and LAXIER values on hip and knee neuromechanics during drop jump landings.

Hypothesis: People with greater LAXVV and LAXIER values will have greater challenges controlling frontal and transverse plane knee motions, as evidenced by greater joint excursions, joint moments, and muscle activation levels during the landing phase.

Study Design: Descriptive laboratory study.

Methods: Recreationally active participants (52 women and 44 men) between 18 and 30 years old were measured for LAXVV and LAXIER and for their muscle activation and transverse and frontal plane hip and knee kinetics and kinematics during the initial landing phase of a drop jump. The mean value was obtained for each sex, and those with above-average values on LAXVV and LAXIER (LAXHIGH = 17 women, 16 men) were compared with those with below-average values (LAXLOW = 18 women, 17 men).

Results: Women with LAXHIGH verus LAXLOW were initially positioned in greater hip adduction and knee valgus and also produced more prolonged internal hip adduction and knee varus moments as they moved toward greater hip adduction and internal rotation as the landing progressed. These patterns in LAX HIGH women were accompanied by greater prelanding and postlanding muscle activation amplitudes. Men with LAXHIGH versus LAXLOW also demonstrated greater hip adduction motion and produced greater internal hip internal rotation and knee varus and internal rotation moments.

Conclusion: Participants with greater LAXVV and LAXIER landed with greater hip and knee transverse and frontal plane hip and knee motions.

Clinical Relevance: People (especially, women) with increased frontal and transverse plane knee laxity demonstrate motions associated with noncontact anterior cruciate ligament injury mechanisms.

Background: Rotator cuff tears are common and not well-understood shoulder problems. Structural and mechanical inhomogeneity of the supraspinatus tendon complicates accurate prediction of risk of tear propagation and may affect appropriate clinical treatment.

Hypothesis: We propose that interactions between the supraspinatus and infraspinatus tendons are critical to load bearing at the glenohumeral joint and warrant investigation.

Study Design: Controlled laboratory study.

Methods: Principal strains in the infraspinatus tendon of cadaveric human shoulders were evaluated with increasing anterior full-thickness supraspinatus tendon tear sizes and loading to evaluate whether a mechanical interaction between the supraspinatus and infraspinatus tendons exists. A constant nominal load was attached to the infraspinatus throughout all experimental conditions.

Results: Increasing supraspinatus tendon tear width from intact and 33% to 66% and increasing supraspinatus tendon load caused an increase in maximum and a decrease in minimum principal strain in the infraspinatus tendon. Increasing the supraspinatus tendon tear size from intact to 33% of the width had no significant effect on infraspinatus tendon strain.

Conclusion: Supraspinatus and infraspinatus tendons mechanically interact. The observed significant increase in maximum and decrease in minimum principal strain was concurrent in both the infraspinatus and supraspinatus tendons.

Clinical Relevance: Changes in infraspinatus tendon strain associated with increases in supraspinatus tendon tear size and loading may shield a torn supraspinatus tendon from further injury or may have an effect on the load-bearing capacity of the infraspinatus tendon. Results also imply that the effect of a small tear that does not compromise the confluent region between the supraspinatus and infraspinatus tendon may be localized, eliminating its effect on infraspinatus tendon strain.

Background: Clinical tests are a key element in diagnosing shoulder lesions.

Purpose: This study examined the clinical utility of traditional and new examination tests, the upper cut for biceps injuries, and the modified dynamic labral shear for superior glenoid labral lesions.

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

Methods: A total of 325 consecutive patients who were seen for shoulder pain underwent a standardized clinical testing battery. Six clinical tests that have been previously reported in the literature (Yergason’s, Speed’s, bear hug, belly press, O’Brien’s, and anterior slide) and 2 new examination tests (upper cut and modified dynamic labral shear) were performed. Clinical examination findings were correlated with findings in those who came to surgery (101 patients). Sensitivity, specificity, accuracy, positive/ negative predictive value, and positive/negative likelihood ratio were calculated for each test. A binary logistic regression analysis was used to determine which tests produced the most significant findings.

Results: For biceps disease, the bear hug and upper cut were most sensitive (0.79 and 0.73, respectively), whereas the belly press and Speed’s test were most specific (0.85 and 0.81, respectively). The upper cut was most accurate (0.77) and produced the highest positive likelihood ratio (3.38). For labral injury, the modified dynamic labral shear demonstrated sensitivity of 0.72, specificity of 0.98, accuracy of 0.84, and a positive likelihood ratio of 31.57. A binary logistic regression analysis revealed that the combination of the upper cut and Speed’s tests were significantly better at detecting biceps lesions (P = .021, R2 = .400) than other tests, whereas labral lesions were best identified by combination of the modified dynamic labral shear and O’Brien’s maneuvers (P = .045, R2 = .641).

Conclusion: The new tests are helpful additions to the clinical examination for shoulder injury. The modified dynamic labral shear test demonstrates high scores for clinical utility and exhibits a high likelihood ratio, indicating a significant probability of affecting the clinical decision, which should moderately or significantly improve the diagnostic conclusion and allow the clinician to be more efficient in making an accurate diagnosis.

Overuse disorders of tendons, or tendinopathies, present a challenge to sports physicians, surgeons, and other health care professionals dealing with athletes. The Achilles, patellar, and supraspinatus tendons are particularly vulnerable to injury and often difficult to manage successfully. Inflammation was believed central to the pathologic process, but histopathologic evidence has confirmed the failed healing response nature of these conditions. Excessive or inappropriate loading of the musculotendinous unit is believed to be central to the disease process, although the exact mechanism by which this occurs remains uncertain. Additionally, the location of the lesion (for example, the midtendon or osteotendinous junction) has become increasingly recognized as influencing both the pathologic process and subsequent management.

The mechanical, vascular, neural, and other theories that seek to explain the pathologic process are explored in this article. Recent developments in the nonoperative management of chronic tendon disorders are reviewed, as is the rationale for surgical intervention. Recent surgical advances, including minimally invasive tendon surgery, are reviewed. Potential future management strategies, such as stem cell therapy, growth factor treatment, and gene transfer, are also discussed.