[
editorial
]
Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at University of Pennsylvania Library on January 12, 2015. For personal use only. No other uses without permission. Copyright © 2014 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
We Can Do Better KEVIN E. WILK, PT, DPT, FAPTA Champion Sports Medicine, Physiotherapy Associates, Birmingham, AL. American Sports Medicine Institute, Birmingham, AL. J Orthop Sports Phys Ther 2014;44(9):634-635. doi:10.2519/jospt.2014.0112
T
ypically, the goal of any rehabilitation program is to return the patient/athlete to the preinjury level. This is the frequently used benchmark reported in the literature when determining rehabilitation goals or describing the outcomes following anterior cruciate ligament (ACL) injury or reconstruction.1,2,10-13,17 Additionally, it is often used in characterizing almost any other type of injury or condition, including ulnar collateral ligament injuries, throwingshoulder pathologies, hip impingement and labral tears, back injuries, and ankle sprains. The first question we should ask ourselves is, “Is returning a patient to the preinjury level good enough?” Let’s take, for instance, an active patient who has sustained a noncontact ACL injury. Ardern et al3 reported in a meta-analysis of 48 studies and 5770 patients that only 63% returned to preinjury levels of function. Furthermore, only 44% returned to competitive sports. Paterno et al15 reported on patients returning to sports following ACL reconstruction, noting that they were twice as likely to sustain an injury to the opposite knee. We often assume that the rehabilitation program should be focused on obtaining a preinjury level of function; however, typically we have no idea what that preinjury level actually was, because no preinjury data exist. Thus, we utilize the patient’s uninjured side as the gold standard or “normal” in our comparison. The unfortunate reality in utilizing the uninjured limb as a goal for returning a patient post–ACL injury and reconstruction to activity is that over the course of time, from injury to recovery, the unin-
jured side undergoes a loss of quadriceps strength,7-9,11 neuromuscular control,20 and therefore functional ability. The second question we should ask ourselves is, “Is comparison to the uninvolved side good enough?” We often strive for preinjury levels that are compromised and known to be insufficient. In the case of the patient with a noncontact ACL injury, there are predisposing factors that might have contributed to the injury, including valgus collapse of the knee10; weakness of the hip10,16; faulty muscle firing patterns10; and improper running, jumping, landing, and cutting mechanics.6,14 Often, normal isn’t what we think it is. It isn’t whatever the opposite extremity exhibits. Barber-Westin and Noyes4 reported, in a systematic review of athletes returning to sports following ACL reconstruction, that the 2 most common objective criteria utilized were lower extremity muscle strength and limb symmetry. This is especially true when comparing the throwing shoulder’s range of motion and strength to the nonthrowing shoulder.5,19 Every rehabilitation program must not only be individualized but also have the overarching goal of obtaining an enhanced and improved level of whole-
body functional ability. The rehabilitation program should identify, address, and correct all specific predisposing factors that may lead to another injury by addressing the physical, biomechanical, environmental, and psychological factors of the whole person during the rehabilitation process. The postinjury program should progressively strive for enhanced levels of total-body function throughout the rehabilitation process. Furthermore, patients should be adequately educated in regard to injury risks, prevention, and conditioning programs, including the need to continue an active program of exercise and drills, to maintain the gains realized during rehabilitation. The truth is, people are at greater risk for injury and reinjury if we strive to return them back to their daily activities, work, and sports without obtaining an improved level of whole-body function. A significant risk factor for a second ACL injury is a first ACL injury.18 We need to make everyone aware that the preinjury level and the opposite side are insufficient markers for returning any patient to activity, and using these standards is a safety risk that places the patient in jeopardy for another injury. Third-party payers or referral sources cannot continue to claim that the patient has completed physical therapy and no longer requires rehabilitation because the patient has obtained a preinjury level of function in the face of the reality that significant risks to the patient still exist without an enhanced higher level of physical function and performance.
634 | september 2014 | volume 44 | number 9 | journal of orthopaedic & sports physical therapy
44-09 Editorial-Wilk.indd 634
8/15/2014 7:01:43 PM
Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at University of Pennsylvania Library on January 12, 2015. For personal use only. No other uses without permission. Copyright © 2014 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Let’s not compromise our standards by taking the path of least resistance and using the lowest common denominator in formulating our rehabilitation programs. Let’s strive to help make our patients better than they were before injury and less likely to sustain the same injury again, an injury to the opposite extremity, or an injury to another body part. Creating an expectation for gaining a higher level of functional ability that minimizes risk of reinjury and maximizes patient safety will ultimately be a more cost-effective approach to overall patient health and well-being, while eliciting a better level of care that will improve the functional outcomes of our patients. We should do better, we can do better, and we must do better. t
REFERENCES 1. Ardern CL, Taylor NF, Feller JA, Webster KE. Return-to-sport outcomes at 2 to 7 years after anterior cruciate ligament reconstruction surgery. Am J Sports Med. 2012;40:41-48. http:// dx.doi.org/10.1177/0363546511422999 2. Ardern CL, Webster KE, Taylor NF, Feller JA. Return to the preinjury level of competitive sport after anterior cruciate ligament reconstruction surgery: two-thirds of patients have not returned by 12 months after surgery. Am J Sports Med. 2011;39:538-543. http://dx.doi. org/10.1177/0363546510384798 3. Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med. 2011;45:596-606. http://dx.doi. org/10.1136/bjsm.2010.076364
4. B arber-Westin SD, Noyes FR. Objective criteria for return to athletics after anterior cruciate ligament reconstruction and subsequent reinjury rates: a systematic review. Phys Sportsmed. 2011;39:100-110. http://dx.doi.org/10.3810/ psm.2011.09.1926 5. Brown LP, Niehues SL, Harrah A, Yavorsky P, Hirshman HP. Upper extremity range of motion and isokinetic strength of the internal and external shoulder rotators in Major League Baseball players. Am J Sports Med. 1988;16:577-585. 6. Chappell JD, Creighton RA, Giuliani C, Yu B, Garrett WE. Kinematics and electromyography of landing preparation in vertical stop-jump: risks for noncontact anterior cruciate ligament injury. Am J Sports Med. 2007;35:235-241. http:// dx.doi.org/10.1177/0363546506294077 7. Chmielewski TL, Stackhouse S, Axe MJ, SnyderMackler L. A prospective analysis of incidence and severity of quadriceps inhibition in a consecutive sample of 100 patients with complete acute anterior cruciate ligament rupture. J Orthop Res. 2004;22:925-930. http://dx.doi. org/10.1016/j.orthres.2004.01.007 8. Farquhar SJ, Chmielewski TL, Snyder-Mackler L. Accuracy of predicting maximal quadriceps force from submaximal effort contractions after anterior cruciate ligament injury. Muscle Nerve. 2005;32:500-505. http://dx.doi.org/10.1002/ mus.20366 9. Hart JM, Pietrosimone B, Hertel J, Ingersoll CD. Quadriceps activation following knee injuries: a systematic review. J Athl Train. 2010;45:87-97. http://dx.doi.org/10.4085/1062-6050-45.1.87 10. Hewett TE, Di Stasi SL, Myer GD. Current concepts for injury prevention in athletes after anterior cruciate ligament reconstruction. Am J Sports Med. 2013;41:216-224. http://dx.doi. org/10.1177/0363546512459638 11. Holder-Powell HM, Di Matteo G, Rutherford OM. Do knee injuries have long-term consequences for isometric and dynamic muscle strength? Eur J Appl Physiol. 2001;85:310-316. 12. Kvist J. Rehabilitation following anterior cruciate ligament injury: current recommendations for sports participation. Sports Med.
2004;34:269-280. 13. L ynch AD, Logerstedt DS, Grindem H, et al. Consensus criteria for defining ‘successful outcome’ after ACL injury and reconstruction: a Delaware-Oslo ACL cohort investigation. Br J Sports Med. In press. http://dx.doi.org/10.1136/ bjsports-2013-092299 14. Noyes FR, Barber-Westin SD. Neuromuscular retraining intervention programs: do they reduce noncontact anterior cruciate ligament injury rates in adolescent female athletes? Arthroscopy. 2014;30:245-255. http://dx.doi. org/10.1016/j.arthro.2013.10.009 15. Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of second ACL injuries 2 years after primary ACL reconstruction and return to sport. Am J Sports Med. 2014;42:1567-1573. http://dx.doi. org/10.1177/0363546514530088 16. Powers CM. The influence of abnormal hip mechanics on knee injury: a biomechanical perspective. J Orthop Sports Phys Ther. 2010;40:42-51. http://dx.doi.org/10.2519/ jospt.2010.3337 17. Shelbourne KD, Sullivan AN, Bohard K, Gray T, Urch SE. Return to basketball and soccer after anterior cruciate ligament reconstruction in competitive school-aged athletes. Sports Health. 2009;1:236-241. http://dx.doi. org/10.1177/1941738109334275 18. Waldén M, Hägglund M, Ekstrand J. High risk of new knee injury in elite footballers with previous anterior cruciate ligament injury. Br J Sports Med. 2006;40:158-162. http://dx.doi. org/10.1136/bjsm.2005.021055 19. Wilk KE, Obma P, Simpson CD, Cain EL, Dugas JR, Andrews JR. Shoulder injuries in the overhead athlete. J Orthop Sports Phys Ther. 2009;39:38-54. http://dx.doi.org/10.2519/ jospt.2009.2929 20. Wojtys EM, Huston LJ. Neuromuscular performance in normal and anterior cruciate ligament-deficient lower extremities. Am J Sports Med. 1994;22:89-104.
SEND Letters to the Editor-in-Chief JOSPT welcomes letters related to professional issues or articles published in the Journal. The Editor-in-Chief reviews and selects letters for publication based on the topic’s relevance, importance, appropriateness, and timeliness. Letters should include a summary statement of any conflict of interest, including financial support related to the issue addressed. In addition, letters are copy edited, and the correspondent is not typically sent a version to approve. Letters to the Editor-in-Chief should be sent electronically to [email protected]. Authors of the relevant manuscript are given the opportunity to respond to the content of the letter.
journal of orthopaedic & sports physical therapy | volume 44 | number 9 | september 2014 |
44-09 Editorial-Wilk.indd 635
635
8/15/2014 7:01:43 PM
editorial
]
Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at University of Pennsylvania Library on January 12, 2015. For personal use only. No other uses without permission. Copyright © 2014 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
We Can Do Better KEVIN E. WILK, PT, DPT, FAPTA Champion Sports Medicine, Physiotherapy Associates, Birmingham, AL. American Sports Medicine Institute, Birmingham, AL. J Orthop Sports Phys Ther 2014;44(9):634-635. doi:10.2519/jospt.2014.0112
T
ypically, the goal of any rehabilitation program is to return the patient/athlete to the preinjury level. This is the frequently used benchmark reported in the literature when determining rehabilitation goals or describing the outcomes following anterior cruciate ligament (ACL) injury or reconstruction.1,2,10-13,17 Additionally, it is often used in characterizing almost any other type of injury or condition, including ulnar collateral ligament injuries, throwingshoulder pathologies, hip impingement and labral tears, back injuries, and ankle sprains. The first question we should ask ourselves is, “Is returning a patient to the preinjury level good enough?” Let’s take, for instance, an active patient who has sustained a noncontact ACL injury. Ardern et al3 reported in a meta-analysis of 48 studies and 5770 patients that only 63% returned to preinjury levels of function. Furthermore, only 44% returned to competitive sports. Paterno et al15 reported on patients returning to sports following ACL reconstruction, noting that they were twice as likely to sustain an injury to the opposite knee. We often assume that the rehabilitation program should be focused on obtaining a preinjury level of function; however, typically we have no idea what that preinjury level actually was, because no preinjury data exist. Thus, we utilize the patient’s uninjured side as the gold standard or “normal” in our comparison. The unfortunate reality in utilizing the uninjured limb as a goal for returning a patient post–ACL injury and reconstruction to activity is that over the course of time, from injury to recovery, the unin-
jured side undergoes a loss of quadriceps strength,7-9,11 neuromuscular control,20 and therefore functional ability. The second question we should ask ourselves is, “Is comparison to the uninvolved side good enough?” We often strive for preinjury levels that are compromised and known to be insufficient. In the case of the patient with a noncontact ACL injury, there are predisposing factors that might have contributed to the injury, including valgus collapse of the knee10; weakness of the hip10,16; faulty muscle firing patterns10; and improper running, jumping, landing, and cutting mechanics.6,14 Often, normal isn’t what we think it is. It isn’t whatever the opposite extremity exhibits. Barber-Westin and Noyes4 reported, in a systematic review of athletes returning to sports following ACL reconstruction, that the 2 most common objective criteria utilized were lower extremity muscle strength and limb symmetry. This is especially true when comparing the throwing shoulder’s range of motion and strength to the nonthrowing shoulder.5,19 Every rehabilitation program must not only be individualized but also have the overarching goal of obtaining an enhanced and improved level of whole-
body functional ability. The rehabilitation program should identify, address, and correct all specific predisposing factors that may lead to another injury by addressing the physical, biomechanical, environmental, and psychological factors of the whole person during the rehabilitation process. The postinjury program should progressively strive for enhanced levels of total-body function throughout the rehabilitation process. Furthermore, patients should be adequately educated in regard to injury risks, prevention, and conditioning programs, including the need to continue an active program of exercise and drills, to maintain the gains realized during rehabilitation. The truth is, people are at greater risk for injury and reinjury if we strive to return them back to their daily activities, work, and sports without obtaining an improved level of whole-body function. A significant risk factor for a second ACL injury is a first ACL injury.18 We need to make everyone aware that the preinjury level and the opposite side are insufficient markers for returning any patient to activity, and using these standards is a safety risk that places the patient in jeopardy for another injury. Third-party payers or referral sources cannot continue to claim that the patient has completed physical therapy and no longer requires rehabilitation because the patient has obtained a preinjury level of function in the face of the reality that significant risks to the patient still exist without an enhanced higher level of physical function and performance.
634 | september 2014 | volume 44 | number 9 | journal of orthopaedic & sports physical therapy
44-09 Editorial-Wilk.indd 634
8/15/2014 7:01:43 PM
Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at University of Pennsylvania Library on January 12, 2015. For personal use only. No other uses without permission. Copyright © 2014 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Let’s not compromise our standards by taking the path of least resistance and using the lowest common denominator in formulating our rehabilitation programs. Let’s strive to help make our patients better than they were before injury and less likely to sustain the same injury again, an injury to the opposite extremity, or an injury to another body part. Creating an expectation for gaining a higher level of functional ability that minimizes risk of reinjury and maximizes patient safety will ultimately be a more cost-effective approach to overall patient health and well-being, while eliciting a better level of care that will improve the functional outcomes of our patients. We should do better, we can do better, and we must do better. t
REFERENCES 1. Ardern CL, Taylor NF, Feller JA, Webster KE. Return-to-sport outcomes at 2 to 7 years after anterior cruciate ligament reconstruction surgery. Am J Sports Med. 2012;40:41-48. http:// dx.doi.org/10.1177/0363546511422999 2. Ardern CL, Webster KE, Taylor NF, Feller JA. Return to the preinjury level of competitive sport after anterior cruciate ligament reconstruction surgery: two-thirds of patients have not returned by 12 months after surgery. Am J Sports Med. 2011;39:538-543. http://dx.doi. org/10.1177/0363546510384798 3. Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med. 2011;45:596-606. http://dx.doi. org/10.1136/bjsm.2010.076364
4. B arber-Westin SD, Noyes FR. Objective criteria for return to athletics after anterior cruciate ligament reconstruction and subsequent reinjury rates: a systematic review. Phys Sportsmed. 2011;39:100-110. http://dx.doi.org/10.3810/ psm.2011.09.1926 5. Brown LP, Niehues SL, Harrah A, Yavorsky P, Hirshman HP. Upper extremity range of motion and isokinetic strength of the internal and external shoulder rotators in Major League Baseball players. Am J Sports Med. 1988;16:577-585. 6. Chappell JD, Creighton RA, Giuliani C, Yu B, Garrett WE. Kinematics and electromyography of landing preparation in vertical stop-jump: risks for noncontact anterior cruciate ligament injury. Am J Sports Med. 2007;35:235-241. http:// dx.doi.org/10.1177/0363546506294077 7. Chmielewski TL, Stackhouse S, Axe MJ, SnyderMackler L. A prospective analysis of incidence and severity of quadriceps inhibition in a consecutive sample of 100 patients with complete acute anterior cruciate ligament rupture. J Orthop Res. 2004;22:925-930. http://dx.doi. org/10.1016/j.orthres.2004.01.007 8. Farquhar SJ, Chmielewski TL, Snyder-Mackler L. Accuracy of predicting maximal quadriceps force from submaximal effort contractions after anterior cruciate ligament injury. Muscle Nerve. 2005;32:500-505. http://dx.doi.org/10.1002/ mus.20366 9. Hart JM, Pietrosimone B, Hertel J, Ingersoll CD. Quadriceps activation following knee injuries: a systematic review. J Athl Train. 2010;45:87-97. http://dx.doi.org/10.4085/1062-6050-45.1.87 10. Hewett TE, Di Stasi SL, Myer GD. Current concepts for injury prevention in athletes after anterior cruciate ligament reconstruction. Am J Sports Med. 2013;41:216-224. http://dx.doi. org/10.1177/0363546512459638 11. Holder-Powell HM, Di Matteo G, Rutherford OM. Do knee injuries have long-term consequences for isometric and dynamic muscle strength? Eur J Appl Physiol. 2001;85:310-316. 12. Kvist J. Rehabilitation following anterior cruciate ligament injury: current recommendations for sports participation. Sports Med.
2004;34:269-280. 13. L ynch AD, Logerstedt DS, Grindem H, et al. Consensus criteria for defining ‘successful outcome’ after ACL injury and reconstruction: a Delaware-Oslo ACL cohort investigation. Br J Sports Med. In press. http://dx.doi.org/10.1136/ bjsports-2013-092299 14. Noyes FR, Barber-Westin SD. Neuromuscular retraining intervention programs: do they reduce noncontact anterior cruciate ligament injury rates in adolescent female athletes? Arthroscopy. 2014;30:245-255. http://dx.doi. org/10.1016/j.arthro.2013.10.009 15. Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of second ACL injuries 2 years after primary ACL reconstruction and return to sport. Am J Sports Med. 2014;42:1567-1573. http://dx.doi. org/10.1177/0363546514530088 16. Powers CM. The influence of abnormal hip mechanics on knee injury: a biomechanical perspective. J Orthop Sports Phys Ther. 2010;40:42-51. http://dx.doi.org/10.2519/ jospt.2010.3337 17. Shelbourne KD, Sullivan AN, Bohard K, Gray T, Urch SE. Return to basketball and soccer after anterior cruciate ligament reconstruction in competitive school-aged athletes. Sports Health. 2009;1:236-241. http://dx.doi. org/10.1177/1941738109334275 18. Waldén M, Hägglund M, Ekstrand J. High risk of new knee injury in elite footballers with previous anterior cruciate ligament injury. Br J Sports Med. 2006;40:158-162. http://dx.doi. org/10.1136/bjsm.2005.021055 19. Wilk KE, Obma P, Simpson CD, Cain EL, Dugas JR, Andrews JR. Shoulder injuries in the overhead athlete. J Orthop Sports Phys Ther. 2009;39:38-54. http://dx.doi.org/10.2519/ jospt.2009.2929 20. Wojtys EM, Huston LJ. Neuromuscular performance in normal and anterior cruciate ligament-deficient lower extremities. Am J Sports Med. 1994;22:89-104.
SEND Letters to the Editor-in-Chief JOSPT welcomes letters related to professional issues or articles published in the Journal. The Editor-in-Chief reviews and selects letters for publication based on the topic’s relevance, importance, appropriateness, and timeliness. Letters should include a summary statement of any conflict of interest, including financial support related to the issue addressed. In addition, letters are copy edited, and the correspondent is not typically sent a version to approve. Letters to the Editor-in-Chief should be sent electronically to [email protected]. Authors of the relevant manuscript are given the opportunity to respond to the content of the letter.
journal of orthopaedic & sports physical therapy | volume 44 | number 9 | september 2014 |
44-09 Editorial-Wilk.indd 635
635
8/15/2014 7:01:43 PM
