Knee Special Interest Group Newsletter  
January 2020 
SIG Leadership
Chair: Brandon Schmitt 
Vice Chair: Kelcie Wittman 

State of the SIG:
Happy Knee Year (sorry, couldn't resist)! We here at the Knee SIG are excited for the potential the new year brings. There are some exciting changes underway. We are currently working to restructure the SIG with additional leadership positions which will add member educational opportunities. On that note, I would like to welcome Connor Fedge as Education Committee chair and Chris Lafever as Practice committee chair. We will be adding Communication and Membership committees in the near future and then we will begin filling out the committees. Please don't hesitate to reach out and get involved if any of these pique your interest. As always, your feedback is greatly appreciated, especially in this period of transition, as this is uncharted territory. We need your help to make the SIG meaningful to your clinical practice.
Brandon Schmitt, Knee SIG Chair

Knee Programming at CSM Denver:  
We have some great programming set for Denver. Thanks to all those volunteering their time and energy to put together such great Science Meets Practice Programming.
Angela Hutchinson Smith, PT, DPT  and  Elizabeth Ann Wellsandt, PT, DPT, PhD
Drew Thomas Jenk, PT, DPT Mark Vincent Paterno, PT, MBA, PhD  and  Trent Ray Nessler, PT, DPT
James Craig Garrison, PT, ATC, PhD  and  Joseph Patrick Hannon, PT
George James Davies, PT, DPT, MEd, FAPTA Ronald Wayne Courson, PT Robert C Manske, PT, DPT, MEd  and  Michael James Tankovich, PT, DPT, ATC

Highlights from TCC 2019:
By Connor Fedge
  • Extreme environmental conditions offer unique challenges to the athlete and the medical team. Preparation for adverse events requires having the proper equipment available, recognizing signs/symptoms, and having a well rehearsed emergency action plan.

  • An athlete's low back evaluation has to consider what the demands of their sport are, as well as the athlete's multi joint ROM and strength. For example, a volleyball player with poor shoulder mobility may be excessively extending and rotating from their low back in order to achieve the overhead position. Even if interventions improve their low back symptoms, the demands of their sport are placing excessive stress to the area. Therefore, their "back pain" would benefit from interventions to improve overhead motion.

  • Clinical diagnosis of "who needs RTC surgery" is poor (even by the best clinician), yet certain populations have improved outcomes with properly timed surgery (improper diagnosis worsens outcomes). Scapular mechanics and positioning, are critical towards maintaining the integrity of the repair.

  • It is challenging but important to control for lumbo-pelvic motion when assessing an athlete's hip. However, in addition to assessing the isolated joint, it is crucial to screen for the hip/spine relationship due to their interaction. Additionally, as physical therapists we cannot change the presence of FAI, but we can maximize the strength and range that the athlete has available.

Winter Journal Club:

By Keraloos Abdelmessih

Background: Injury to the Anterior Cruciate Ligament (ACL) is fairly common in the athletic population. A majority of athletes consider surgical reconstruction (ACLr) of the ligament to return to prior level of function and participate in their respective sport in a competitive capacity. The spotlight has turned to return to sport (RTS) decision making to maximize efficiency of rehabiliation and safely return the athlete back to the sport. The average time frame of 7-9 months following ACLr has been reported for RTS, with some accelerated programs of <6 months. A battery of "functional" tests (single hop, triple hop, cross-over hop, 6m timed hop) in addition to isokinetic strength testing of the quadriceps and hamstrings are often utilized, as components of criterion based return to play, have been developed to assist making RTS decisions. These tests result in a limb symmetry index (LSI) ratio, along with asseessment of movement quality, steer the decision making to RTS.
Purpose: The purpose of this critical review was to examine current research of the horizontal hop tests including reliability, sensitivity and relationships with other constructs to predict outcomes of ACLr and re-injury rates of involved limbs.
Current Research: LSI target guidelines were initially set at 85% but more recent studies have reported increased outcomes with target guidelines set at 90% for an athlete to "pass" the battery of hop tests. Strong reliability has been reported of the LSI with ICC values of 0.92 for the single hop test, 0.88 for the triple hop test, and 0.84 the for cross-over hop test. The 6m timed hop test has reported ICC values as low as 0.66. Factors such as timing error, athlete familiarization, and other measurement errors are to be considered with reviewing literature on these tests.
Diving deeper in to the results of each test can focus the clinician on specific abnormalities to be addressed such as strength, rate of torque development, reactive and breaking forces. There is a psychological component to implementing these tests, as fear may limit demonstration of maximal performance during the hop tests. Of note, progress should be objectively recorded during the rehabiliation process of the athlete to identify true progress.
These hop tests were compared to alternatives such as unilateral vertical hop, repeated vertical hop/rebound, and side hop/rotational hop tests. Compared to the 4 hop tests, the unilateral vertical hop test has shown to have decreased specificity but increased sensitivity in identifying individuals with a history of ACLr. The review mentions the risk for false-positives, which may hinder athletes from returning to sport as safely as possible. Some research suggests that vertical jumps may be a superior approach to assessing functional capabilities of the knee joint. In addition, drop jumps may have an advantage in identifying biomechanical deficits.
Conclusions: The current practice of utilizing all 4 hop tests may not be entirely necessary, with no greater ability to identify an abnormality than with 2 hop tests in an athlete during the rehabiliation process post ACLr. More than one hop test is recommended to increase sensitivity. The time utilized with the unneccsary testing may be allotted to increased time assessing movement quality and overall athlete readiness to RTS. Additionally, pre-injury comparisons of the involved limb to the contralateral limb is recommended to allow for a better baseline than post injury contralateral limb comparison. Ultimately, clinicians should utilize careful discretion when making RTS decisions. These tests should be utilized in conjunction with an expert's assessment of movement quality and addressing of functional impairments to maintain the athlete's competitive capacity and prevent re-injury.
Discussion Questions:
How practical is it to test the contralateral limb pre-injury, especially with a traumatic mechanism of injury? Should the testing be required for all athletes participating in high risk sports?
Does criterion based return to play decision making leave room for confirmation biases?
Does hop tessting neglect the movement quality portion of rehabiliation? How can we qualify movement in a clinical setting?
What other RTS tests are out there in regards to post ACLr? How reliable are these tests? (i.e. quad index, hip HHD, psych readiness).

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