ORIGINAL RESEARCH INJURY RISK IS ALTERED BY PREVIOUS ...

The International Journal of Sports Physical Therapy | Volume 9, Number 5 | October 2014 | Page 583

ORIGINAL RESEARCH

INJURY RISK IS ALTERED BY PREVIOUS INJURY:

A SYSTEMATIC REVIEW OF THE LITERATURE AND

PRESENTATION OF CAUSATIVE NEUROMUSCULAR

FACTORS

Jessica Fulton, PT, DPT, HFS1

Kathryn Wright, PT, DPT1

Margaret Kelly, PT, DPT, CSCS1

Britanee Zebrosky, PT, DPT, CSCS1

Matthew Zanis, PT, DPT, ATC, CSCS1

Corey Drvol, PT, DPT1

Robert Butler, PT, PhD1

ABSTRACTBackground: Active adults commonly present with lower extremity (LE) injuries from a variety of professional and amateur sports activities. Decreased LE function significantly alters daily life and subsequent injuries increase this impact. The purpose of this systematic review was to examine the association between previous injury and the risk of re-injury, and to describe the changes in kinematics and motor programming that may contribute to this relationship.

Methods: A preliminary search was conducted to determine the four most common LE injuries on PubMed, CINAHL and Web of Science. These injuries, in a healthy active adult population, were hamstring strain (HS), anterior cruciate ligament injury (ACL), achilles tendon pathology, and ankle sprain. After these injuries were established, the search for this systematic review found evidence relating these injuries to re-injury. Articles related to degenerative changes were excluded. Twenty-six articles were included in the systematic review detailing the risk of re-injury from a previ-ous injury and were graded for quality.

Results: ACL injury was linked to a successive injury of the same ACL, and other injuries in the LE. HS was associ-ated with subsequent ipsilateral HS and knee injuries. Previous achilles tendon rupture increased the risk of an analo-gous injury on the contralateral side. An ankle sprain was associated with a re-injury of either the ipsilateral or the contralateral ankle. Post-injury changes were present in strength, proprioception, and kinematics, which may have led to overall changes in motor control and function.

Conclusion: This review provides insight into the changes occurring following common LE injuries, how these changes potentially affect risk for future injury, and address the needs of the active adult population in rehabilitation.

Clinical Relevance: Current research on previous injury and re-injury is of high quality, but scarce quantity. Deficits following an injury are known, but how these deficits correlate or lead to re-injury requires further exploration.

Keywords: Injury, motor programming, re-injury

Level of Evidence: 1

1 Duke University, Durham, NC, USA

CORRESPONDING AUTHORRobert J. Butler, PT, PhDDoctor of Physical Therapy DivisionDuke UniversityDUMC 104002Durham, NC 27705Phone: 919.681.7225Fax: 919.684.1846E-mail: [email protected]

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INTRODUCTIONAttempts at healthy living spur an increase in activ-ity in the adult population and consequently, also in the risk for injury. Traumatic and atraumatic inju-ries are a common consequence of new or increased activity. Following injury, patients often experience decreased functional capacity. Several authors have described previous injury as the greatest risk fac-tor for future injury secondary to changes along the kinematic chain, i.e. proprioceptive deficits, reduced range of motion, excessive flexibility, and scar tis-sue accumulation.1-3 Knowledge of these intrinsic changes may benefit rehabilitation models for active adults with the potential of reducing re-injury rates and improving quality of life, while also helping to lower overall medical costs.

A recent systematic review of the literature (SR) determined that the most common lower extremity injuries in a healthy active adult population were, in no specific order, hamstring strain (HS), ante-rior cruciate ligament (ACL) injury, achilles tendon pathology, and ankle sprain. Due to the intricate relationships between joints during movement of the lower extremity, changes often occur at sites other than the initial point of injury.4 Regional inter-dependence is an important key to understanding how anatomic variables occurring within the kinetic chain may contribute to re-injury.5 Previously, researchers have examined these common inju-ries and the subsequent changes in kinematics and motor programming.2,6-9 However, the connection of these changes to subsequent lower extremity inju-ries has not been examined.

The purpose of this systematic review is to establish the most common lower extremity injuries and the risk of re-injury or subsequent injury as it relates to alterations in kinematics and motor programing. This review combines an analysis of established data on the risk of re-injury following a lower extremity injury with a qualitative discussion on the factors that contribute to this relationship. By developing a greater understanding of the kinematic and motor programming changes following injury, the authors hope to illuminate how one injury to the lower extremity may increase the risk for re-injury or sub-sequent injury. By integrating information on the relationship between injury and subsequent injury,

rehabilitation could focus on not only the immediate injury, but also potentially reducing future injury.

METHODSA five-stage process was used to select studies. The first stage involved a search on PubMed, CINAHL, and Web of Science using the search terms “injuries AND lower extremity AND prevalence AND adults”. This search provided data that was utilized to select the four most common injuries that occur in the lower extremities. This search yielded 158 articles of which 17 were ruled in based on a title and abstract screen. From here the articles were read for full text and six articles were chosen for their specific research on injury prevalence according to these search terms. From the information presented in these articles, the four most common musculoskele-tal injuries were determined to be ankle sprain, ACL injury, HS, and achilles injury.

The second search for the topic of the current review utilized the terms “ankle sprain OR ACL injury OR Achilles injury OR hamstring strain AND previous injury” in PubMed and CINAHL (Figure 1). A filter of “ages 19-44” was applied to this search. Next, two independent reviewers performed an initial assess-ment of the identified papers based on title. For all assessments, inclusion criteria included articles dealing with an active, healthy, athletic population (including military personnel); directly related to one of the four selected injuries; concerned with motor control or kinematics; as well as describing injury as a result of re-injury. Articles dealing with osteoarthritis or degenerative injury were excluded. Articles writ-ten in languages other than English were excluded, unless a translated version was available. These crite-ria were chosen based on the immense return utiliz-ing the selected search terms and the need to specify the population most likely at risk for re-injury. Sec-ond, two independent reviewers performed an assess-ment based on the articles’ abstract. For both the title and abstract assessments, all articles that received a “Yes” rating by one reviewer were kept. Finally, a full text review was performed, dividing articles equally among three teams of reviewers. Each team of two independent reviewers assessed each set. Any arti-cles published before the year 2000 were excluded. Articles that received a split rating (one “Yes” and


one “No”) were reviewed by another independent reviewer who made the final decision.

Four independent reviewers using the Quality Assessment of Diagnostic Accuracy Studies (QUA-DAS) tool completed grading of the articles regard-ing injury as a risk of re-injury.10 The QUADAS is a 14-question tool to determine the internal and exter-nal validity of a study. The questions are answered “yes, no, N/A or unclear”, for which one point is awarded for every “yes” answer. The QUADAS exam-ines such biases as spectrum, selection, disease progression, and verification bias. Two reviewers graded articles related to ACL injuries and HS, while two other reviewers graded articles regarding Achil-les and ankle injuries. After independently grading these articles, each pair came to a consensus on scor-ing criteria for each article. A score of 10 or more was considered “high quality, low risk of bias” and a score below 10 was considered “low quality, high risk of bias”.11 Cook states, “systematic reviews that use the QUADAS instrument provide a qualitative assessment of design with recognition that weak-nesses in selected regions may alter some test find-ings more than others.”10(p. 98) Thus, with this grading

system it can be stated that despite possible bias(es) existing within an article, overall quality could still be considered to be good. One of the articles, Friel et al,12 was not evaluated using the QUADAS due to the study design being Ex-post Facto. Therefore, two independent reviewers individually graded this article as “poor”, “fair”, or “good” and came to a con-sensus on the grading of the article.

All five articles for ACL injury relating to subsequent injury were of high quality and low risk of bias, with scores ranging from 10 to 12 based on the QUADAS criteria. Of the seven HS related studies; only one was graded to be of low quality and high risk of bias, with a score of 8. The other articles ranged from a score of 10 to 13, indicating high quality and low risk of bias. Similarly, high quality and low risk of bias was evident in the three articles for the Achil-les group, with scores ranging from 11 to 12, and the ankle injury group where the ten studies scores ranged from 11 to 13. With these findings and analy-ses, the authors concluded that appropriate designs have been formulated and implemented resulting in outcomes that could be used for evidence-based practice.

Figure 1. Flow of literature search and review of studies


RESULTS

Hamstring StrainFive articles were found correlating HS with subse-quent strains of the same muscle group (Appendix 1). In a study analyzing elite level Australian foot-ball players, the authors concluded that a HS strain within the previous 12 months was a strong predic-tor of future HS.3 The football players were 4.3 times more likely to incur another HS as opposed to players without history of previous HS.3 In a similar popula-tion of Australian football players and track and field athletes, 34% of HS were recurrences and previous strain was the most common reason for subsequent HS.13 In addition, 27% of all HS in the Australian Foot-ball League (AFL) were caused by previous HS, which increased the risk of recurrence by 11.6. It is unclear, however, if the cause of increased recurrence is due to accumulated microscopic muscle damage or the presence of a single injurious event.16 No matter the cause of HS, the research clearly indicates that previ-ous HS is an important risk factor for future HS.14,15

Anterior Cruciate Ligament InjuryACL injury has been linked to a successive injury of the same ACL and other impairments or injuries in the lower extremity (Appendix 2). In one study, ACL graft ruptures occurred in 6.4% of subjects and a contralateral ACL rupture followed at a frequency of 5.7%.17 In addition to a previous injury of the ACL, activity level after the injury was indicated to predict another injury of the same or contralateral ACL.17 In elite footballers, 70% of current ACL injuries occurred on the same leg as a previous ACL injury.2 Ten per-cent of subjects in another study reported traumati-cally reinjuring their knee, resulting in disruption of the graft, between four and twelve months after ACL reconstruction.18 Research indicates that re-injury can occur to the same or contralateral ACL following an initial ACL injury, when that injury was treated conservatively or surgically. Inadequate landing force attenuation was identified as imposing abnor-mal forces after reconstruction on the musculoskele-tal components, thus increasing the risk of re-injury.19

Achilles Tendon Injury There is little research exploring achilles tendon injury and its effect on re-injury or subsequent injury (Appendix 3). However, one article discussed that

following an Achilles tendon injury among the adult population, risk of re-injury is greater in individuals 30 years or younger.20 Another study linked previ-ous Achilles tendon rupture to a risk of an analogous injury on the contralateral side, stating that an indi-vidual is 176 times more likely to injure the opposite side approximately 3.1 years later compared to an individual without a previous Achilles tendon pathol-ogy. The authors proposed a multifactorial explana-tion to this connection suggesting an increased risk due to degenerative changes, a genetic predisposition for tendon ruptures, or disuse atrophy of the contra-lateral tendon from overall decreased physical activ-ity due to immobilization of the injured leg.21

Ankle SprainIn accordance with the research, a single ankle sprain is the most common injury resulting in a secondary sprain of the ipsilateral or contralateral ankle among the active adult population (Appendix 4). In a study investigating the effect of ankle sprain on recurrent ankle sprains in 202 elite Greek track athletes, there was a higher risk of re-injury for low-grade ankle sprains as opposed to high-grade ankle sprains.22 The authors discovered that 17.8 percent of their athletes suffered a second lateral ankle sprain by the end of the follow-up period.22 In another study involving 65 professional male football play-ers, the recurrence of a secondary ankle sprain fol-lowing the same initial injury was 50 percent higher than those without a previous ankle sprain. The authors also found that 75.38 percent of these ath-letes had sustained multiple ankle sprains (63.27 percent in bilateral ankles; 24.49 percent in the dominant ankle only) during their entire career up until the point at which the study was concluded.23 Pefanis et al found that a previous ankle sprain was the most important statistical factor leading to a subsequent ankle sprain, increasing the occurrence by 21 percent.24 Additional research in this area has suggested that leg dominance may be a factor lead-ing to injury. Williams and colleagues reported that in college freshman physical education students 59 percent of recurrent ankle sprains occurred in the dominant foot among 44 of the 241 participants.25 In conclusion, the results of this SR indicate that an ankle sprain is linked to both re-injury and subse-quent injury to the contralateral side.

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DISCUSSIONThe results of this systematic review revealed a relationship between previous injury and re-injury in each lower extremity injury that was studied. Overall, the vast majority of articles reviewed dis-cussed this relationship in detail and suggested many possibilities for why this trend exists. Re-injury was suggested to be associated with deficits in neuromuscular factors that are present following injuries.2,3,18,21,26 The goal of this discussion will be to qualitatively examine the changes that were iden-tified in papers examined that occurred post-injury and how they were proposed to link injury to re-injury. Following injury, researchers have identified alterations occurring in strength, proprioception, and kinematics, which have led to overall changes in motor control and function.2,13,15,25,27-35 This combi-nation of insight may offer valuable information to clinicians for reduction of re-injury.

Strength deficits between affected and unaffected limbs as well as imbalances between muscle groups have been documented post hamstring strain, post ACL rupture, and post Achilles tendon rup-ture.7,9,15,27-29,33,36,37 Without recovering muscle strength of involved muscles following an initial injury, the stability of joints, biomechanics of motion, and the ability to safely participate in activity are likely com-promised. Several authors suggested that incorpo-rating strength training and standards for strength following injury is necessary in order to decrease long-term muscular deficits that could go on to affect kinematics and motor control both proximal and dis-tal to the injury, further increasing the risk of subse-quent injury.7,9,15,27-29,33,36,37

Proprioceptive deficits, altered muscular recruit-ment patterns, and changes in static and dynamic stability occur from altered neuronal firing and decreased sensory awareness within joint and mus-cle tissue following ACL rupture, Achilles tendon injury, and ankle sprains.9,19,31,38-52 Authors of papers reviewed described variations in postural sway, gait mechanics, and decreased dynamic stability within functional activities that might place individuals at higher risk for re-injury.39,40,42,48,50

Changes in strength and proprioception, which very likely occur together, contribute to the next factor

to be addressed: changes in lower extremity bio-mechanics following injury. The observed biome-chanical changes that have been documented are changes in peak torque, altered gait mechanics, and intra-articular and intra-muscular forces (including, compressive, tensile, and shear forces) in the ham-string, ACL, and ankle.13,30,47,48,53-58 Comprehensive biomechanical evaluation of the patient is pertinent in order to correctly develop treatment strategies that positively affect vectors of force displacement within the body, with the aim of normalizing joint mechanics. Suboptimal mechanics during high-level functional tasks have at times been associated with risk of future sports injuries.59-61 The authors of this systematic review believe that by examining and addressing joint kinematics post injury, patients may have the potential to return to functional activ-ity at a greater rate and avoid potential re-injury.

This systematic review adequately describes the major risk of re-injury post initial injury in the adult population. The high risk of re-injury described, stresses the importance of comprehensive rehabili-tation that uses the theory of regional interdepen-dence to adequately mitigate local, proximal, and distal deficits in strength, proprioception, and lower extremity mechanics.5 Future research establishing standards for the aforementioned deficits and devel-oping rehabilitation programming that addresses these limitations is important, and it may be possible to remove the previous injury risk factor component with regard to risk of future injury. In addition to the health benefits of preventing re-injury, medical costs may also be reduced which would lower the economic burden of the initial injury.

Limitations to the study are typical of those attrib-uted to systematic reviews. This paper focused on the four most common lower extremity injuries; however, the breadth of injuries incurred in the adult population extends beyond those examined in this research. Additionally, this research cannot be expanded beyond the active adult population. While the relationship between injury and re-injury was described, the ability to generalize the qualitatively identified variables including kinematic alterations, motor control deficits, and musculoskeletal changes to other injuries requires further exploration. To maintain the focus of this SR, the authors did not


attempt to discuss a standardized way to examine a patient for these changes, nor was it appropriate to discuss specific interventions to treat these impair-ments as these components were beyond the scope of this systematic review. Although there were stan-dardized criteria for inclusion and exclusion of arti-cles, the selection process has inherent inter-rater reliability concerns, such that a third party reviewer was utilized if raters could not agree.

Future StudiesFuture research should be performed in order to determine standardized outcome tools that could be used to objectively identify changes that occur following injury that relate to the risk for future injury. Based on the current research, it appears that it would be beneficial to include outcome tools that assess a patient’s movement patterns following injury in order to optimize function from a regional interdependence approach prior to returning the patient to his/her previous level of activity. These tests may be beneficial in examining patients post-treatment to assess for functional return to activity. Furthermore, research should be performed in order to identify the most beneficial interventions and strategies used to address changes following injury and to develop protocols to reduce risk of re-injury.

CONCLUSIONIn conclusion, this systematic review of the literature identified and reviewed 26 articles, which describe a relationship between injury and re-injury for the four most common lower extremity injuries. Overall, the studies on re-injury were of moderate to high qual-ity, but the quantity of research was scarce. Evidence regarding the hamstring strain, ACL rupture, achil-les tendon injury, and ankle sprain are of moderate to high quality in relation to this topic, aside from one article with a low quality rating.3 More analysis on the relationship between injury and re-injury is needed. Motor control and kinematic deficits follow-ing injury have been suggested, but their direct rela-tion to re-injury requires further exploration.

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Titl

e A

utho

r Po

pula

tion

(age

, ge

nder

, act

ivity

) S

AD

AU

Qydut sfo

e pyT

sgnidni Fni a

M

Pred

icto

rs o

f ham

strin

g in

jury

at t

he e

lite

leve

l of

Aus

tralia

n fo

otba

ll (2

006)

Gab

be,B

.J., e

t al.

22

2 el

ite m

ale

Aus

tralia

n fo

otba

ll pl

ayer

s, be

twee

n 17

-37

yea

rs o

ld fr

om 6

M

elbo

urne

AFL

clu

bs d

urin

g pr

e-se

ason

of 2

002

"A p

ositi

ve h

amst

ring

inju

ry h

isto

ry (s

usta

ined

dur

ing

the

prev

ious

12

mon

ths)

was

iden

tifie

d as

the

stro

nges

t pre

dict

or o

f su

bseq

uent

ham

strin

g in

jury

and

supp

orts

the

findi

ngs o

f sev

eral

st

udie

s.”

8troho

C

Intri

nsic

risk

fact

ors o

f no

n-co

ntac

t qua

dric

eps

and

ham

strin

g st

rain

s in

socc

er: a

pro

spec

tive

stud

y of

100

pr

ofes

sion

al p

laye

rs

(201

0)

Fous

ekis

,K.,

et a

l. 10

0 pr

ofes

sion

al so

ccer

pl

ayer

s, be

twee

n 19

-28

year

s ol

d, fr

ee o

f inj

ury

for a

t lea

st

6 m

onth

s prio

r to

test

ing

“For

the

deve

lopm

ent o

f ham

strin

g st

rain

s in

socc

er p

laye

rs, t

wo

func

tiona

l asy

mm

etrie

s of t

he lo

wer

lim

bs (i

soki

netic

stre

ngth

an

d le

g le

ngth

) are

acc

ount

able

, with

pre

viou

s his

tory

of s

train

s in

the

sam

e m

uscl

e gr

oup

bein

g ra

ther

redu

ctiv

e of

the

odds

of

this

inju

ry.”

31tr oho

C

Pred

ictin

g ha

mst

ring

stra

in in

jury

in e

lite

athl

etes

(200

4)

Bro

cket

t,C.L

, et a

l. 27

ath

lete

s, 26

mal

es &

1

fem

ale,

23

AFL

pla

yers

& 4

tra

ck-a

nd-f

ield

ath

lete

s, be

twee

n 19

-33

year

s old

.

“If t

he o

ptim

um le

ngth

for a

ctiv

e te

nsio

n is

rath

er sh

ort,

in te

rms

of th

e m

uscl

e’s w

orki

ng ra

nge,

it fo

llow

s tha

t mor

e of

the

desc

endi

ng li

mb

will

be

incl

uded

with

in th

e w

orki

ng ra

nge.

Tha

t, in

turn

, inc

reas

es th

e ris

k of

dam

age.

"

Con

trolle

d La

bora

tory

Stu

dy

11

Clin

ical

risk

fact

ors f

or

ham

strin

g m

uscl

e st

rain

(200

1)

Ver

rall,

et a

l.

114

mal

es fr

om tw

o pr

ofes

sion

al A

ustra

lian

Foot

ball

Leag

ues,

mea

n ag

e 21

.6 y

ears

.

“The

re w

as a

sign

ifica

ntly

incr

ease

d ris

k of

inju

ry w

ith o

lder

ag

e, b

eing

of a

borig

inal

des

cent

, a p

ast h

isto

ry o

f pos

terio

r thi

gh

inju

ry, a

pas

t his

tory

of k

nee

inju

ry, a

nd a

pas

t his

tory

of o

stei

tis

pubi

s.”

Pros

pect

ive

Coh

ort

12

Clin

ical

pre

dict

ors o

f tim

e to

retu

rn to

co

mpe

titio

n an

d of

re

curr

ence

follo

win

g ha

mst

ring

stra

in in

el

ite A

ustra

lian

foot

balle

rs (2

008)

War

ren,

et a

l.

59 e

lite

mal

e A

ustra

lian

foot

ball

play

ers,

mea

n ag

e 24

ye

ars,

who

mis

sed

at le

ast o

ne

gam

e du

e to

inju

ry.

“Nin

e pl

ayer

s (15

%) e

xper

ienc

ed a

recu

rren

ce o

f the

ir ha

mst

ring

inju

ry w

ithin

the

first

3 w

eeks

of r

etur

ning

to p

lay”

Pr

ospe

ctiv

e O

bser

vatio

nal

13

The

rela

tions

hip

betw

een

prev

ious

ha

mst

ring

inju

ry a

nd

the

conc

entri

c is

okin

etic

kne

e m

uscl

e st

reng

th o

f iris

h ga

elic

fo

otba

llers

(200

8)

O'S

ulliv

an, e

t al.

44

mal

e ga

elic

foot

ball

play

ers,

mea

n ag

e 21

.2 y

ears

. "E

vide

nce

of h

amst

ring

mus

cle

wea

knes

s and

mus

cle

stre

ngth

im

bala

nce

in g

aelic

foot

balle

rs a

fter p

revi

ous h

amst

ring

inju

ry"

Pros

pect

ive

Obs

erva

tiona

l 10

Effe

cts o

f Prio

r H

amst

ring

Stra

in

Inju

ry o

n St

reng

th,

Flex

ibili

ty, a

nd

Run

ning

Mec

hani

cs

(201

0)

Sild

er, e

t al.

18 in

divi

dual

s inv

olve

d in

ru

nnin

g-re

late

d sp

orts

with

a

prev

ious

ham

strin

g in

jury

, be

twee

n 18

-45

year

s old

.

"Our

resu

lts su

gges

t tha

t, w

hile

scar

tiss

ue m

ay b

e pr

esen

t in

subj

ects

with

a p

rior h

amst

ring

inju

ry, t

hese

und

erly

ing

mor

phol

ogic

al c

hang

es d

o no

t app

ear t

o be

dis

cern

able

in te

rms

of fu

nctio

nal s

treng

th m

easu

res,

or m

uscu

lote

ndon

stre

tch

and

neur

omus

cula

r pat

tern

s dur

ing

sprin

ting.

"

Pros

pect

ive

Coh

ort

11

Appen

dix

1.

Ham

stri

ng S

trai

n R

e-in

jury

Pap

ers


Titl

e A

utho

r Po

pula

tion

(age

, ge

nder

, act

ivity

) M

ain

Find

ings

T

ype

of

stud

y Q

UA

DA

S

Hig

h ris

k of

new

kne

e in

jury

in

elite

foot

balle

rs w

ith p

revi

ous

ante

rior c

ruci

ate

ligam

ent i

njur

y (2

006)

Wal

de ́n

, M.,

et

al.

310

Mal

e Sw

edis

h Le

ague

pla

yers

, m

ean

age

25 y

ears

. 24

AC

L in

jure

d, 2

86 A

CL

heal

thy.

“Tot

al, 7

15 in

jurie

s wer

e re

cord

ed, a

nd 6

25 (8

7%)

wer

e lo

cate

d to

the

low

er li

mbs

. Of t

he in

jurie

s to

the

low

er e

xtre

miti

es in

the

AC

L in

jure

d gr

oup,

70%

(3

8/54

) aff

ecte

d a

limb

with

a p

revi

ous A

CL

inju

ry.”

Pros

pect

ive

Coh

ort

12

Fact

ors a

ffec

ting

retu

rn to

spor

ts

afte

r ant

erio

r cru

ciat

e lig

amen

t re

cons

truct

ion

with

pat

ella

r ten

don

and

ham

strin

g gr

aft:

a pr

ospe

ctiv

e cl

inic

al in

vest

igat

ion

(200

6)

Gob

bi,A

., et

al.

10

0 at

hlet

es, 6

7 m

ales

& 3

3 fe

mal

es,

mea

n ag

e 28

yea

rs. A

thle

tes p

layi

ng in

sp

orts

at r

egio

nal/n

atio

nal l

evel

s/re

c sp

orts

at l

east

3x/

wee

k, w

ith n

orm

al

cont

rala

tera

l kne

e, th

ose

w/ p

art.

men

isce

ctom

ies

“Tw

o pa

tient

s pre

sent

ed w

ith p

ersi

sten

t clic

king

and

ca

tchi

ng d

urin

g th

e fir

st y

ear p

ost-A

CL…

In a

noth

er

case

(HT

graf

t), re

-inju

ry to

the

oper

ated

kne

e w

as

docu

men

ted”

Long

itudi

nal

10

Nor

mal

ized

mot

or fu

nctio

n bu

t im

paire

d se

nsor

y fu

nctio

n af

ter

unila

tera

l non

-rec

onst

ruct

ed A

CL

inju

ry: p

atie

nts c

ompa

red

with

un

inju

red

cont

rols

(200

8)

Age

berg

, et a

l. 56

indi

vidu

als,

36 m

ales

& 2

0 fe

mal

es, b

etw

een

15-4

5 ye

ars o

ld w

ho

wer

e A

CL

defic

ient

with

an

unin

jure

d co

ntra

late

ral e

xtre

mity

.

“The

impa

ct o

f the

se fi

ndin

gs o

n th

e ris

k of

su

stai

ning

re-in

jurie

s req

uire

s fur

ther

stud

ies,

and

ther

e m

ay b

e a

brea

kpoi

nt a

t whi

ch th

e di

scre

panc

y be

twee

n m

otor

and

sens

ory

func

tion

beco

mes

a ri

sk

fact

or d

urin

g m

ore

stre

nuou

s act

ivity

.”

Cro

ss-s

ectio

nal

12

Effe

cts o

f ear

ly p

rogr

essi

ve

ecce

ntric

exe

rcis

e on

mus

cle

size

an

d fu

nctio

n af

ter a

nter

ior c

ruci

ate

ligam

ent r

econ

stru

ctio

n: a

1-y

ear

follo

w-u

p st

udy

of a

rand

omiz

ed

clin

ical

tria

l (20

09)

Ger

ber,J

.P.,

et

al.

40 p

atie

nts w

ith A

CL-

R, b

etw

een

18-

50 y

ears

old

, who

wer

e m

oder

atel

y ac

tive

prio

r to

inju

ry. R

ando

mly

as

sign

ed: G

roup

1 re

ceiv

ing

early

pr

ogre

ssiv

e ec

cent

ric e

xerc

ise

and

Gro

up 2

rece

ivin

g st

anda

rd re

hab.

“Of t

hose

not

retu

rnin

g fo

r 1-y

ear f

ollo

w-u

p,

4 pa

rtici

pant

s tra

umat

ical

ly re

inju

red

thei

r inv

olve

d kn

ee b

etw

een

4 an

d 12

mon

ths f

ollo

win

g in

itial

AC

L-R

, cau

sing

gra

ft di

srup

tion.

”

Ran

dom

ized

C

ontro

l Tria

l 11

Clo

sed

kine

tic c

hain

alo

ne

com

pare

d to

com

bine

d op

en a

nd

clos

ed k

inet

ic c

hain

exe

rcis

es fo

r qu

adric

eps s

treng

then

ing

afte

r an

terio

r cru

ciat

e lig

amen

t re

cons

truct

ion

with

resp

ect t

o re

turn

to

spor

ts: a

pro

spec

tive

mat

ched

fo

llow

-up

stud

y (2

000)

Mik

kels

en,C

., et

al.

44 in

divi

dual

s, be

twee

n 18

–40

year

s ol

d w

ith a

firs

t-eve

r uni

late

ral A

CL

inju

ry a

nd a

hea

lthy

cont

rala

tera

l leg

. R

ando

mly

ass

igne

d: G

roup

1 tr

aine

d w

ith C

KC

and

Gro

up 2

trai

ned

with

C

KC

for f

irst 6

wee

ks, t

hen

OK

C fo

r qu

adric

eps m

uscl

e.

Of t

he 2

2 pa

tient

s in

grou

p 2,

“12

retu

rned

to sp

ort a

t th

e sa

me

leve

l as b

efor

e th

e in

jury

, eig

ht p

atie

nts h

ad

redu

ced

thei

r act

ivity

leve

l and

/or c

hang

ed to

a le

ss

knee

dem

andi

ng sp

ort d

ue to

impa

ired

knee

func

tion

in th

ree

patie

nts,

soci

al a

nd fa

mily

reas

ons i

n th

ree,

an

d th

e fe

ar o

f rei

njur

ing

the

knee

in tw

o. O

ne p

atie

nt

did

not r

etur

n to

any

type

of s

port

due

to a

new

kne

e in

jury

of t

he c

ontra

late

ral l

eg. O

ne p

atie

nt w

as n

ot

phys

ical

ly a

ctiv

e ei

ther

bef

ore

or a

fter A

CL

reco

nstru

ctio

n.”

Ran

dom

ized

C

ontro

l Tria

l 11

Appen

dix

2.

AC

L R

e-In

jury

Pap

ers


Titl

e A

utho

r Po

pula

tion

(a

ge,

gend

er, a

ctiv

ity)

Mai

nfin

ding

sT

ype

of st

udy

QU

AD

AS

Bio

mec

hani

cal

Beh

avio

r of t

he

Plan

tar

Flex

or M

uscl

e-Te

ndon

U

nit a

fter a

n A

chill

es T

endo

n R

uptu

re (2

001)

Bre

ssel

, et a

l. 40

indi

vidu

als,

26 m

ales

& 1

4 fe

mal

es, m

ean

age

51.4

yea

rs,

volu

ntee

red

for t

he st

udy.

All

subj

ects

wer

e in

volv

ed in

at l

east

lig

ht/ r

ecre

atio

nal a

ctiv

ity a

nd h

ad

rupt

ured

thei

r Ach

illes

tend

on m

ore

than

1 y

ear b

efor

e th

e st

udy.

Stiff

ness

and

vis

coel

astic

pro

perti

es, s

uch

as to

rque

re

laxa

tion,

wer

e si

mila

r bet

wee

n th

e in

volv

ed a

nd

unin

volv

ed li

mbs

. How

ever

, oth

er m

easu

rem

ents

, suc

h as

pe

ak p

assi

ve to

rque

, cal

f circ

umfe

renc

e, a

nd m

axim

al

isom

etric

pla

ntar

flex

or to

rque

, wer

e gr

eate

r in

the

unin

volv

ed li

mb.

Incr

ease

d va

lues

for s

tiffn

ess m

ay

pred

ispo

se th

e m

uscl

e-te

ndon

uni

t to

furth

er d

amag

e.

Expe

rimen

tal

12

Con

trala

tera

l ten

don

rupt

ure

risk

is

incr

ease

d in

in

divi

dual

s with

a

prev

ious

Ach

illes

te

ndon

rupt

ure

(200

4)

Aro

en, e

t al.

168

patie

nts,

142

mal

es &

26

fem

ales

, med

ian

age

38.5

yea

rs a

t tim

e of

inju

ry, w

ho h

ad A

chill

es

rupt

ure

betw

een

1990

and

199

7 at

a

Nor

way

hos

pita

l.

Gre

atly

incr

ease

d ris

k of

rupt

ure

of c

ontra

late

ral A

chill

es

tend

on in

thos

e w

ho h

ad a

pre

viou

s rup

ture

on

one

side

. Th

e au

thor

s pro

pose

d th

at th

is c

ould

be

due

to a

gen

etic

pr

edis

posi

tion

for t

endo

n ru

ptur

es, t

hat t

he in

jury

is c

ause

d by

deg

ener

ativ

e ch

ange

s, or

that

dis

use

atro

phy

of th

e co

ntra

late

ral t

endo

n du

e to

imm

obili

zatio

n of

the

inju

red

leg

cont

ribut

ed to

the

inju

ry.

Ret

rosp

ectiv

e Se

lf-R

epor

t Q

uest

ionn

aire

11

Intri

nsic

Ris

k Fa

ctor

s fo

r the

Dev

elop

men

t of

Ach

illes

Ten

don

Ove

ruse

Inju

ry (2

006)

Mah

ieu,

et a

l. 69

mal

e of

ficer

cad

ets a

t the

Bel

gian

R

oyal

Mili

tary

aca

dem

y, m

ean

age

18 y

ears

.

10/6

9 ha

d A

chill

es o

veru

se in

jurie

s dur

ing

the

6 w

eeks

of

basi

c tra

inin

g. T

hose

with

low

e r p

lant

ar fl

exor

stre

ngth

and

in

crea

sed

dors

iflex

ion

RO

M w

ere

at g

reat

er ri

sk o

f thi

s in

jury

. Aut

hors

hyp

othe

size

d th

at st

rong

er m

uscl

e st

reng

th

prod

uces

stro

nger

tend

ons t

hat c

ould

bet

ter d

eal w

ith

exce

ssiv

e fo

rce.

Coh

ort (

Pros

pect

ive)

11

Appen

dix

3.

Ach

illes

Ten

don

Re-

inju

ry P

aper

s


Titl

e A

utho

r Po

pula

tion

(age

, ge

nder

, act

ivity

) S

AD

AU

Qydutsfo

epyT

sgnidn iFnia

M

Inve

rtor a

nd e

verto

r stre

ngth

in

trac

k an

d fie

ld a

thle

tes w

ith

func

tiona

l ank

le in

stab

ility

(2

011)

Edou

ard,

et a

l. Tr

ack

and

field

fem

ale

athl

etes

be

twee

n 15

-40

year

s old

with

a

hist

ory

of la

tera

l ank

les s

prai

ns

The

ever

tor m

uscl

e st

reng

th w

as h

ighe

r tha

n th

e in

verto

r m

uscl

e st

reng

th in

the

dom

inan

t sid

e fo

r all

grou

ps, e

xcep

t fo

r the

gro

up w

ith a

pre

viou

s his

tory

of a

nkle

spra

in. A

n el

evat

ed a

nkle

Eve

rtor/I

nver

tor R

atio

(> 1

.0) h

as b

een

iden

tifie

d as

an

impo

rtant

indi

cato

r of a

nkle

spra

in

susc

eptib

ility

; oth

erw

ise,

it c

ould

be

an in

verto

r stre

ngth

w

eakn

ess i

n su

bjec

ts w

ith F

AI.

Cro

ss-S

ectio

nal

12

The

Effe

ct o

f Lat

eral

Ank

le

Spra

in o

n D

orsi

flexi

on R

ange

of

Mot

ion,

Pos

terio

r Ta

lar G

lide,

and

Join

t Lax

ity

(200

2)

Den

egar

, et a

l.

12 a

thle

tes,

5 m

ales

& 7

fe

mal

es, b

etw

een

18-2

2 ye

ars

old

with

a h

isto

ry o

f lat

eral

an

kle

spra

in w

ithin

the

last

6

mon

ths w

ho h

ad re

turn

ed to

sp

ort p

artic

ipat

ion

Res

idua

l lig

amen

tous

laxi

ty w

as c

omm

only

foun

d fo

llow

ing

late

ral a

nkle

spra

in. D

orsi

flexi

on ra

nge

of m

otio

n w

as re

stor

ed in

the

popu

latio

n st

udie

d de

spite

evi

denc

e of

re

stric

ted

post

erio

r glid

e of

the

talo

crur

al jo

int.

Alth

ough

re

stor

atio

n of

phy

siol

ogic

al ra

nge

of m

otio

n w

as a

chie

ved,

re

sidu

al jo

int d

ysfu

nctio

n pe

rsis

ted.

Ret

rosp

ectiv

e St

udy

12

Exam

inin

g N

euro

mus

cula

r C

ontro

l Dur

ing

Land

ings

on

a Su

pina

ting

Plat

form

in

Pers

ons W

ith a

nd W

ithou

t A

nkle

Inst

abili

ty (2

011)

Gut

ierr

ez, e

t al.

45 a

ctiv

e, h

ealth

y pa

rtici

pant

s be

twee

n 18

-30

year

s old

wer

e di

vide

d in

to 3

gro

ups:

ank

le

inst

abili

ty, l

ater

al a

nkle

spra

in,

and

cont

rol

Whe

n la

ndin

g on

a d

evic

e bu

ilt to

sim

ulat

e th

e m

echa

nism

of

a la

tera

l ank

le sp

rain

(sup

inat

ion)

, the

ank

le in

stab

ility

gr

oup

disp

laye

d si

gnifi

cant

ly in

crea

sed

prep

arat

ory

and

reac

tive

pero

neal

act

ivat

ion,

whi

le th

e La

tera

l Ank

le S

prai

n gr

oup

dem

onst

rate

d in

crea

sed

prep

arat

ory

tibia

lis a

nter

ior

mus

cle

activ

atio

n.

Con

trolle

d La

bora

tory

Stu

dy

12

Mec

hani

cal I

nsta

bilit

y A

fter

an A

cute

Lat

eral

Ank

le S

prai

n (2

009)

Hub

bard

, et a

l. 16

subj

ects

with

a fi

rst-t

ime

acut

e un

ilate

ral a

nkle

spra

in, 7

m

ales

& 9

fem

ales

, mea

n ag

e 19

.5 y

ears

. 16

heal

thy

cont

rols

, 7

mal

es &

9 fe

mal

es, m

ean

age

20.4

yea

rs.

The

lack

of s

igni

fican

t diff

eren

ces i

n m

echa

nica

l lax

ity

over

an

8-w

eek

perio

d su

gges

ts th

at n

atur

al re

cove

ry o

f la

xity

take

s lon

ger t

han

8 w

eeks

.

Coh

ort

11

Seria

l tes

ting

of p

ostu

ral

cont

rol a

fter a

cute

late

ral

ankl

e sp

rain

(200

1)

Her

tel,

et a

l. 17

you

ng a

dults

, 9 m

ales

& 8

fe

mal

es, m

ean

age

21.8

yea

rs

who

sust

aine

d un

ilate

ral a

cute

m

ild to

mod

erat

e la

tera

l ank

le

spra

ins

Indi

vidu

als w

ith p

ostu

ral c

ontro

l im

pairm

ents

are

like

ly to

ha

ve la

rger

CO

P ex

curs

ions

and

thus

, lar

ger s

um o

f ex

curs

ions

thro

ugho

ut a

tria

l. El

evat

ed m

easu

res o

f po

stur

al c

ontro

l dur

ing

stat

ic S

LS h

ave

not b

een

show

n to

pr

edic

t rec

urre

nt a

nkle

spra

in w

ith p

rolo

nged

func

tiona

l an

kle

inst

abili

ty. H

owev

er, t

he la

ck o

f bal

ance

trai

ning

af

ter a

cute

LA

S ap

pear

s to

pred

ispo

se a

nkle

-inju

red

subj

ects

to re

curr

ent s

prai

n

Long

itudi

nal

11

Intri

nsic

Ris

k Fa

ctor

s of

Non

cont

act A

nkle

Spr

ains

in

Socc

er (2

012)

Fous

ekis

, et a

l.

100

prof

essi

onal

socc

er

play

ers,

mea

n ag

e 23

.6 y

ears

w

ho h

ad su

stai

ned

no in

jury

for

the

past

6 m

onth

s wer

e as

sess

ed fo

r ank

le jo

int

asym

met

ries

The

logi

stic

regr

essi

on a

naly

sis r

evea

led

3 si

gnifi

cant

pr

edic

tors

of n

onco

ntac

t ank

le sp

rain

s: (A

) ecc

entri

c is

okin

etic

stre

ngth

asy

mm

etrie

s of a

nkle

dor

sal a

nd p

lant

ar

flexo

rs; (

B) i

ncre

ased

BM

I; an

d (C

) inc

reas

ed b

ody

wei

ght.

This

stud

y fo

und

that

ther

e is

not

an

incr

ease

d ris

k fo

r la

tera

l ank

le li

gam

ent i

njur

y af

ter s

uffe

ring

a pr

ior a

nkle

in

jury

.

Coh

ort

12

Appen

dix

4.

Ank

le R

e-in

jury

Pap

ers


Titl

e A

utho

r Po

pula

tion

(age

, ge

nder

, act

ivity

) S

AD

AU

Qydutsfo

epyT

sgnidn iFnia

M

Ipsi

late

ral H

ip A

bduc

tor

Wea

knes

s Afte

r Inv

ersi

on

Ank

le S

prai

n (2

006)

Frie

l, et

al.

C

onve

nien

ce sa

mpl

e of

23

indi

vidu

als,

betw

een

18-5

2 ye

ars o

ld w

ith a

his

tory

of a

t le

ast 2

ank

le sp

rain

s to

the

sam

e si

de

Sign

ifica

nt w

eakn

ess i

n th

e hi

p ab

duct

or m

uscl

es o

n th

e in

volv

ed si

de a

s com

pare

d w

ith th

e un

invo

lved

lim

b of

su

bjec

ts w

as fo

und

with

chr

onic

ank

le sp

rain

, whi

ch c

an

cont

ribut

e to

incr

ease

d ris

k fo

r re-

inju

ry.

Ex-P

ost F

acto

D

esig

n N

/A

Rei

njur

y A

fter A

cute

Lat

eral

A

nkle

Spr

ains

in E

lite

Trac

k an

d Fi

eld

Ath

lete

s (20

09)

Mal

liaro

poul

os,

et a

l. 20

2 el

ite m

ale

and

fem

ale

Gre

ek tr

ack

athl

etes

with

acu

te

late

ral a

nkle

spra

ins

Low

-gra

de a

nkle

spra

ins r

esul

t in

a hi

gher

risk

of r

e-in

jury

th

an h

igh-

grad

e an

kle

spra

ins a

t a 2

4-m

onth

follo

w-u

p.

Gra

de II

inju

ries s

how

ed a

sign

ifica

ntly

hig

her r

ate

of re

-in

jury

than

gra

des I

and

III A

. The

re w

as n

o si

gnifi

cant

di

ffer

ence

in ti

me

betw

een

orig

inal

inju

ry a

nd re

-inju

ry

base

d on

gra

de o

f inj

ury.

Coh

ort (

Prog

nosi

s)

12

Tibi

ofem

oral

ang

le a

nd it

s re

latio

n to

ank

le sp

rain

oc

curr

ence

(200

9)

Pefa

nis,

et a

l. 45

hig

h-le

vel b

aske

tbal

l, so

ccer

, and

vol

leyb

all m

ale

athl

etes

, mea

n ag

e 23

yea

rs.

The

fact

ors c

ontri

butin

g m

ore

to a

n an

kle

spra

in w

ere

prev

ious

sim

ilar i

njur

y, fo

llow

ed b

y B

MI,

and

age.

TFA

w

as p

rove

n to

be

stat

istic

ally

non

-sig

nific

ant a

nd d

oes n

ot

seem

to b

e a

fact

or th

at c

ould

incr

ease

the

prob

abili

ty o

f sp

rain

ing

an a

nkle

.

Pros

pect

ive

11

The

effe

ct o

f Q-a

ngle

on

ankl

e sp

rain

occ

urre

nce

(200

9)

Pefa

nis,

et a

l. 45

hig

h-le

vel b

aske

tbal

l, so

ccer

, and

vol

leyb

all m

ale

athl

etes

, mea

n ag

e 23

yea

rs.

The

fact

ors c

ontri

butin

g m

ore

to a

n an

kle

spra

in w

ere

prev

ious

sim

ilar i

njur

y, fo

llow

ed b

y B

MI a

nd a

ge. Q

-ang

le

was

show

n to

be

stat

istic

ally

non

-sig

nific

ant a

nd d

oes n

ot

seem

to b

e a

fact

or th

at c

ould

incr

ease

the

chan

ces o

f sp

rain

ing

an a

nkle

.

Pros

pect

ive

11

Intri

nsic

risk

fact

ors f

or

inve

rsio

n an

kle

spra

ins i

n m

ale

subj

ects

(200

5)

Will

ems,

et a

l. 24

1 m

ale

Phys

. Ed.

stud

ents

, m

ean

age

18.3

yea

rs w

ho w

ere

fres

hman

at t

he G

hent

U

nive

rsity

.

44 o

f the

241

sust

aine

d an

inve

rsio

n sp

rain

with

in th

e 1-

3 ye

ar fo

llow

-up,

4 sp

rain

ed b

oth

ankl

es.

Thos

e w

ith sl

ower

ru

nnin

g sp

eed,

less

car

dior

espi

rato

ry e

ndur

ance

, les

s ba

lanc

e, d

ecre

ased

dor

sifle

xion

mus

cle

stre

ngth

, dec

reas

ed

dors

iflex

ion

RO

M, l

ess c

oord

inat

ion,

and

fast

er re

actio

n of

th

e tib

ialis

ant

erio

r and

gas

trocn

emiu

s mus

cles

are

at a

gr

eate

r ris

k of

ank

le sp

rain

s.

Pros

pect

ive

Coh

ort S

tudy

13

Appen

dix

4.

Ank

le R

e-in

jury

Pap

ers

(con

tinue

d)

ORIGINAL RESEARCH INJURY RISK IS ALTERED BY PREVIOUS ...

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