Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology

No Issue Number

• A comparative assessment of alternatives to the full-leg radiograph for determining knee joint alignment
  Background: The purpose of this study was to assess the concurrent validity of alternative measures of frontal plane knee alignment, namely the radiographic anatomic axis and two clinical measures in patients complaining of knee malalignment as compared with the mechanical axis on full-length radiograph of lower limbs. Methods: The knee-alignment angle was measured in 100 knees of 50 subjects with the chief complaint of frontal knee malalignment according to the following methods: lower-limb mechanical axis on radiograph, lower-limb anatomic axis on radiograph, distance between medial femoral condyles or medial malleoli using a calliper and lower-limb alignment using a goniometer. Data were analyzed using Pearson's correlation coefficient and simple linear regression. Results: The anatomic axis best correlated with the mechanical axis (r = 0.93, P<0.001), followed closely by the intercondylar/intermalleolar distance measured by calliper (r = 0.89, P<0.001). Significant correlation was also found between the mechanical-axis angle and the lower limb axis measured by goniometer (r = 0.67, P<0.001). Conclusions: The anatomic axis on radiograph, the calliper method and to a lesser extent the goniometer measurement appear to be valid alternatives to the mechanical axis on full-leg radiograph for determining frontal plane knee alignment. These alternative measures have the potential to provide useful information regarding knee alignment and may increase the assessment of this parameter by clinicians and researchers.
  DOI: 10.1186/1758-2555-4-40
  
• The influence of electromyographic biofeedback therapy on knee extension following anterior cruciate ligament reconstruction: a randomized controlled trial
  Background: Loss of knee extension and a deficit in quadriceps strength are frequently found following anterior cruciate ligament (ACL) reconstruction. The aim of this study was to investigate whether the addition of Eletromyographic Biofeedback (EMG BFB) therapy for the vastus medialis muscle to the in the early phase of the standard rehabilitation programme could improve the range of knee extension and strength after ACL reconstruction more than a standard rehabilitation programme. The correlation between EMG measurement and passive knee extension was also investigated.MethodSixteen patients, all of whom underwent endoscopic ACL reconstruction using patellar tendon autograft, were randomly assigned to two groups:Control group (8 patients): standard rehabilitation protocol; with full weight-bearing postoperative, knee brace (0[degree sign] extension, 90[degree sign] flexion), electrical stimulation, aquatics and proprioceptive training.The EMG BFB group (8 patients): EMG BFB was added to the standard rehabilitation protocol within the first postoperative week and during each session for the next 6 weeks.Each patient attended a total of 16 outpatient physiotherapy sessions following surgery. High-Heel-Distance (HHD) Test, range of motion (ROM) and integrated EMG (iEMG) for vastus medialis were measured preoperatively, and at the 1, 2, 4 and 6-week follow ups. Additionally, knee function, swelling and pain were evaluated using standardized scoring scales. Results: At 6 weeks, passive knee extension (p < 0.002) and the HHD Test were significantly (p < 0.01) better in the EMG BFB group compared to controls. Integrated EMG (vastus medialis) of the EMG BFB group also showed a significant increase after 2 (p < 0.01) and 6 (p < 0.01) weeks. At the 6-week follow up, no significant (p > 0.01) differences were found between the two groups for the assessment of knee function, swelling and pain. Conclusion: The results indicate that EMG BFB therapy, in the early phase of rehabilitation after ACL reconstruction, is useful in enhancing knee extension. Improved innervation of the vastus medialis can play a key role in the development of postoperative knee extension. EMG BFB therapy is a simple, inexpensive and valuable adjunct to conventional therapeutic modalities.
  DOI: 10.1186/1758-2555-4-41
  
• Nature and incidence of upper limb injuries in professional cricket players a prospective observation
  IntroductionCricket is the most popular sport in India, and is gaining in importance in all south-east Asian countries. The purpose of this study was to prospectively investigate the incidence, nature, and site of acute upper limb injuries sustained by professional cricketers of north India over a period of one year.Material & methods95 cricket players (mean age 18.9 years) were prospectively evaluated for nature and incidence of upper limb injuries from 1st November 2008 to 31st October 2009. For the purpose of comparison the calculated injury incidence included injuries sustained during match as well as practice. Injuries were also grouped according to the type of cricket activities such as batting or fielding. Results: Out of 95 players evaluated, 24 were bowlers, 19 were batsmen, 8 were wicket keepers and the other 44 cricketers declared themselves as all rounders. There were a total of 16 upper limb injuries in 16 (16.8%) players. The majority of injuries (10/16) occurred while fielding. Out of 16 injuries, 11 were seen in hand, 3 were observed in elbow, while 2 patients suffered from shoulder problem. Twelve were acute injuries while 4 were classified as repetitive stress injuries (RSI). Conclusion: The incidence of upper limb injuries in cricketers at the professional and semi-professional level is significant, causing them to miss matches or practice for a significant number of days. This is the first study of Indian cricketers which documents the high incidence of upper limb injuries. The study highlights the importance of injury surveillance for Indian cricket. It is a concern which needs to be addressed by the players, coaches, teachers, administrators and medical personnel involved with cricket.
  DOI: 10.1186/1758-2555-4-42
  
• Arthroscopic resection of multiple ossifying tumors in the infrapatellar fat pad
  A 49 year-old male visited a nearby clinic five years back with a complaint of pain in the right knee during exercise. Plain radiographs revealed absence of any anomalies. He began to feel a lumpy mass in his right knee two years back. The pain worsened, on imaging, an anomaly was identified in the infrapatellar fat pad of his right knee, and he was subsequently referred to our department where he was hospitalized. On examination, a mass extending on either side of the patellar tendon was identified along with rigid tenderness in that area. The knee's range of motion was 0degrees-130degrees, and knee flexion was accompanied by pain. The results of blood tests were normal. A plain radiograph of the knee revealed multiple ossifying tumors at a site consistent with the infrapatellar fat pad. T1-weighted MRI exhibited low-signal intensity, while T2-weighted MRI exhibited a mosaic-shaped tumor. We performed arthroscopic surgery to excise the tumor. The patient resumed work shortly after surgery and did not experience any pain during the two year postoperative observation period. The joint's range of motion improved to the extent that it was comparable with that of the left knee. No recurrence was observed on radiographic examination. In past studies, resection of similar tumors has been performed with an arthrotomy; however, we performed arthroscopic resection on our patient, who demonstrated a quick improvement in symptoms and range of motion after surgery. We believe that arthroscopic surgery is a feasible option to consider while treating such cases
  DOI: 10.1186/1758-2555-4-43
  
• Simple method for confirming tibial osteotomy during total knee arthroplasty
  Background: Achieving precise implant alignment is crucial for producing good outcomes after total knee arthroplasty (TKA). We introduce a simple method for confirming the accuracy of tibial osteotomy during TKA.FindingsTwo metallic markers were placed on the skin 20 cm apart, one on the tibial tuberosity and other on the tibial crest, points that are easily identified and palpated intraoperatively. Anteroposterior radiographs of the legs were obtained. We defined the line along the markers as the tuberosity line. The osteotomy line is perpendicular to the anatomical axis of the tibia. We then calculated the angle between these two lines and designated it the osteotomy angle. We set the osteotomy angle of the protractor, and cut the bone parallel to the osteotomy line of the protractor. Postoperatively, we analyzed the varus angle of the tibial osteotomy in 35 TKAs using the protractor. The average of the varus angle of the tibial osteotomy was 89.4[degree sign] +/- 1.6[degree sign] (95% confidence interval of -1.0976, 0.0119). There was no significant difference from the target angle of 90[degree sign] (p = 0.055). The varus angles of 90[degree sign] and 90[degree sign] +/- 2[degree sign] for the tibial osteotomy were 42.9% and 82.9%, respectively. Conclusions: We determined the accuracy of the tibial osteotomy in the coronal plane using the protractor to be satisfactory.
  DOI: 10.1186/1758-2555-4-44
  
• Coordinative variability and overuse injury
  Overuse injuries are generally defined as a repetitive micro-trauma to tissue. Many researchers have associated particular biomechanical parameters as an indicator of such injuries. However, while these parameters have been reported in single studies, in many instances, it has been difficult to verify these parameters as causative to the injury. We have investigated overuse injuries, such as patella-femoral pain syndrome, using a dynamical systems approach. Using such methods, the importance of the structure of coordinative variability (i.e. the variability of the interaction between segments or joints) becomes apparent. We view coordinative variability as functionally important to the movement and different from end-point or goal variability. Using concepts derived from the work of Bernstein, we conducted studies using a continuous relative phase and/or modified vector coding approaches to investigate the coordinative variability of overuse injuries. Consistently, we have found that the higher variability state of a coordinative structure is the healthy state while the lower variability state is the unhealthy or pathological state. It is clear that very high coordinative variability could also result in injury and that there must be a window of 'higher variability' in which non-injured athletes function. While this finding that coordinative variability is functional has been shown in several studies, it is still not clear if reduced variability contributes to or results from the injury. Studies are currently underway to determine the potential reasons for the reduced variability in injured athletes. Nevertheless, our laboratory believes that this understanding of how joints interact can be important in understanding overuse injuries.
  DOI: 10.1186/1758-2555-4-45
  
• Contralateral anterior cruciate ligament injury after anterior cruciate ligament reconstruction: a case controlled study
  Purpose: The purpose of this present study was to examine contralateral ACL injury cases after ACL reconstruction, to determine the characteristics of such injuries. Methods: We performed a retrospective analysis of 24 patients with contralateral ACL injury after ACL reconstruction. The control group consisted of 200 cases with unilateral ACL injury. The following were examined in the contralateral group: timing of the contralateral ACL injury, and the situations of the initial and contralateral ACL injuries. The following items were compared between the contralateral and control groups: age at the time of initial injury, level of competitive sports using Tegner activity scores, knee anterior laxity (KT-1000), and the ratio (%) of affected to unaffected legs in the strengths of the knee extensor and flexor muscles 6 months after surgery. Results: Examination of injury situations showed that approximately 70% of the contralateral group was injured in situations similar to those at their initial injuries. There were no significant differences between the two groups in age at the time of initial injury , Tegner activity scores, knee anterior laxity, and the strengths of the knee extensor, flexor muscles and H/Q ratio 6 months after reconstruction. But, the age at the time of initial injury trended to be low in contralateral group Conclusions: Knee anterior laxity and muscle weakness of the reconstructed legs six months following surgery were not individually related to contralateral ACL injury occurring approximately two years after surgery.
  DOI: 10.1186/1758-2555-4-46
  
• A variant of a type V lateral clavicle fracture involving a posteriorly displaced medial segment. A case report
  The clavicle connects the shoulder girdle to the axial skeleton, providing support and mobility for optimal upper extremity function. Fractures of the clavicle account for up to 4% of all fractures and comprise up to 44% of all injuries to the shoulder girdle. We present a 63-year-old female patient who suffered what appeared to be a minimally displaced Type V lateral clavicle fracture after a fall as evidenced by an anteroposterior shoulder radiograph. However, an axillary projection demonstrated the proximal segment to be posteriorly displaced and buttonholed through the trapezius musculature with tenting of the skin. The patient underwent an open reduction and Kirschner wire fixation of the fracture with complete healing, subsequent removal of the hardware and return to her previous level of function six months following surgery. After an extensive literature search, we believe this is the first case report documenting a variant of a Type V lateral clavicle fracture, specifically with significant posterior displacement of the proximal segment, mimicking a Type IV AC separation. This fracture pattern is unstable and represents a double disruption of the superior shoulder suspensory complex. Surgical management was successful in returning our patient back to her previous activity of daily living.
  DOI: 10.1186/1758-2555-4-47
  
• Management of degenerative rotator cuff tears: a review and treatment strategy
  The aim of this review was to present an over view of degenerative rotator cuff tears and a suggested management protocol based upon current evidence. Degenerative rotator cuff tears are common and are a major cause of pain and shoulder dysfunction. The management of these tears is controversial, as to whether they should be managed non-operatively or operatively. In addition when operative intervention is undertaken, there is question as to what technique of repair should be used. This review describes the epidemiology and natural history of degenerative rotator cuff tears. The management options, and the evidence to support these, are reviewed. We also present our preferred management protocol and method, if applicable, for surgical fixation of degenerative rotator cuff tears.
  DOI: 10.1186/1758-2555-4-48
  
• Treatment of stress fracture of the olecranon in throwing athletes with internal fixation through a small incision
  The present study is a report of retrospective case series of stress fracture of the olecranon. Six patients presented posterior elbow pain in throwing in baseball and softball, but fracture was not diagnosed in radiographs. We detected stress fracture of the olecranon using computed tomographic (CT) scan and treated the patient with internal fixation with a headless cannulated double threaded screw through a small skin incision. All patients returned to competitive level without elbow complaints after the operation.When throwing athletes present with unusual posterior elbow pain and no significant findings on radiographs, a CT scan examination should be performed. We recommend surgical treatment of internal fixation with a screw through a small skin incision, as a good option for stress fracture of the olecranon in order to allow early return to sports activity in competitive athletes.
  DOI: 10.1186/1758-2555-4-49
  

  No Issue Number

• A new era in sports science: the launch of BMC Sports Science, Medicine and Rehabilitation
  This Editorial celebrates the launch of BMC Sports Science, Medicine and Rehabilitation within the BMC series of journals published by BioMed Central. BMC Sports Science, Medicine and Rehabilitation incorporates the recently closed Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology (SMARTT) with an expanded scope and Editorial Board. BMC Sports Science, Medicine and Rehabilitation will fill its own niche in the BMC series alongside other companion journals including BMC Physiology, BMC Musculoskeletal Disorders and BMC Surgery.
  DOI: 10.1186/2052-1847-5-1
  
• Influence of navigation system updates on total knee arthroplasty
  Background: The purpose of this study was to evaluate the influence of image-free computer-assisted navigation system update on outcome in total knee arthroplasty. Methods: Thirty-three knees were replaced using the Stryker 3.1 image-free navigation system and 49 knees were replaced using the Stryker 4.0 system. One surgeon took part in all procedures as chief surgeon or first assistant. All patients received the Stryker Scopio NRG CR total knee prosthesis. We compared the accuracy of component positioning measured using radiographs and CT scans, operating time and clinical outcome 1 year after surgery. Results: The mean hip-knee-ankle, frontal femoral and tibial component angle were 179.8° (ideally implanted 85%), 89.8° (88%), 90.4° (88%) respectively for the 3.1 group and 179.5° (96%), 90.6° (92%), 90.2° (94%) for the 4.0 group. The mean sagittal tibial component angle was 85.5° (82%) for the 3.1 group and 85.6° (92%) for the 4.0 group. The mean rotational femoral and tibial component angle were −0.5° (81%), −0.7° (73%) for the 3.1 group and 0.0° (84%), 0.4° (72%) for the 4.0 group. There were no statistically significant findings with regard to component positioning.Operating time was significantly longer in the 3.1 group (3.1 group: 137 min, 4.1group: 125 min, P  < 0.01).No significant difference was detected in postoperative clinical outcome. Conclusion: The navigation system update from Stryker 3.1 to Stryker 4.0 reduced operating time by 12 min. However, there were no statistically significant findings with regard to component positioning and clinical outcome.
  DOI: 10.1186/2052-1847-5-10
  
• The association between functional movement and overweight and obesity in British primary school children
  Background: The purpose of this study was to examine the association between functional movement and overweight and obesity in British children. Methods: Data were obtained from 90, 7--10 year old children (38 boys and 52 girls). Body mass (kg) and height (m) were assessed from which body mass index (BMI) was determined and children were classified as normal weight, overweight or obese according to international cut offs. Functional movement was assessed using the functional movement screen. Results: Total functional movement score was significantly, negatively correlated with BMI (P = .0001). Functional movement scores were also significantly higher for normal weight children compared to obese children (P = .0001). Normal weight children performed significantly better on all individual tests within the functional movement screen compared to their obese peers (P <0.05) and significantly better than overweight children for the deep squat (P = .0001) and shoulder mobility tests (P = .04). Overweight children scored significantly better than obese in the hurdle step (P = .0001), in line lunge (P = .05), shoulder mobility (P = .04) and active straight leg raise (P = .016).Functional movement scores were not significantly different between boys and girls (P > .05) when considered as total scores. However, girls performed significantly better than boys on the hurdle step (P = .03) and straight leg raise (P = .004) but poorer than boys on the trunk stability push-up (P = .014). Conclusions: This study highlights that overweight and obesity are significantly associated with poorer functional movement in children and that girls outperform boys in functional movements.
  DOI: 10.1186/2052-1847-5-11
  
• Determinants of pain, functional limitations and health-related quality of life six months after total knee arthroplasty: results from a prospective cohort study
  Background: Total knee arthroplasty (TKA) is an effective procedure. However, for some patients, the outcomes are not satisfactory. Identification of TKA determinants could help manage these patients more efficiently. The purpose of this study was to identify pre- and perioperative determinants of pain, functional limitations and health-related quality of life (HRQoL) 6 months after TKA. Methods: 138 participants were recruited from 3 hospitals in Quebec City, Canada and followed up until 6 months after surgery. Data were collected through review of the subjects’ medical files and structured telephone interviews before and 6 months after TKA. Pain and functional limitations were measured with the Western Ontario and McMaster Osteoarthritis Index (WOMAC) and HRQoL was measured with the SF-36 Health Survey. Independent variables included demographic, socioeconomic, psychosocial, clinical and surgical characteristics of participants as well as data on health services utilization. Stepwise multiple regression analysis was used to assess the strength of the associations between the independent variables and the WOMAC and SF-36 scores. Results: Higher preoperative pain, cruciate retaining implants and the number of complications were significantly associated with worse pain 6 months after TKA (p  < 0.05) and explained 11% of the variance of the WOMAC pain score. Higher preoperative functional limitations, being single, separated, divorced or widowed, being unemployed or retired and the number of complications were significantly associated (p  < 0.05) with worse functional limitations 6 months after TKA and explained 16% of the variance of the WOMAC function score. Lower preoperative HRQoL, contralateral knee pain, higher psychological distress and comorbidities were significantly associated (p  < 0.05) with worse HRQoL 6 months after TKA and explained 23% of the variance of the SF-36 physical functioning score. Conclusions: Several variables were found to be significantly associated with worse outcomes 6 months after TKA and may help identify patients at risk of poorer outcome. The identification of these determinants could help manage patients more efficiently and may help target patients who may benefit from extensive rehabilitation.
  DOI: 10.1186/2052-1847-5-2
  
• Constraints influencing sports wheelchair propulsion performance and injury risk
  The Paralympic Games are the pinnacle of sport for many athletes with a disability. A potential issue for many wheelchair athletes is how to train hard to maximise performance while also reducing the risk of injuries, particularly to the shoulder due to the accumulation of stress placed on this joint during activities of daily living, training and competition. The overall purpose of this narrative review was to use the constraints-led approach of dynamical systems theory to examine how various constraints acting upon the wheelchair-user interface may alter hand rim wheelchair performance during sporting activities, and to a lesser extent, their injury risk. As we found no studies involving Paralympic athletes that have directly utilised the dynamical systems approach to interpret their data, we have used this approach to select some potential constraints and discussed how they may alter wheelchair performance and/or injury risk. Organism constraints examined included player classifications, wheelchair setup, training and intrinsic injury risk factors. Task constraints examined the influence of velocity and types of locomotion (court sports vs racing) in wheelchair propulsion, while environmental constraints focused on forces that tend to oppose motion such as friction and surface inclination. Finally, the ecological validity of the research studies assessing wheelchair propulsion was critiqued prior to recommendations for practice and future research being given.
  DOI: 10.1186/2052-1847-5-3
  
• An interview with Michael Carmont, Section Editor for the Surgery, traumatology, and rehabilitation section on sports traumatology research: acute, overuse and chronic problems, early return to play and long-term outcomes
  Michael Carmont is Consultant Orthopaedic Surgeon working at the Princess Royal Hospital, Telford and Northern General Hospital, Sheffield. He is interested in sports injuries of the knee, foot and ankle, and has a specialist interest in anterior cruciate ligament reconstruction and the management of Achilles tendon rupture. He is the Section Editor for the Surgery, traumatology, and rehabilitation section of BMC Sports Science, Medicine and Rehabilitation. In this interview we find out a little more about the key issues in this field of research.
  DOI: 10.1186/2052-1847-5-5
  
• The SPLASH/ICPC integrity marathon in Ibadan, Nigeria: incidence and management of injuries and marathon-related health problems
  Background: The growing interest in marathon runners and marathons in Nigeria has not been reflected in reports of injuries and other health problems associated with these events. This study therefore outlines the incidence of injuries, marathon-related health problems and delivery of physiotherapy at the maiden and second editions of the Splash 105.5 FM/ICPC Integrity Marathon in Ibadan city, south-west Nigeria in 2009 and 2010. Methods: Using a data entry sheet, demographics and information on running experience, past and present injuries and other health problems reported en route and at the finish line by the runners were documented. The prevalence of injuries and other health problems reported by previous and first-time runners were compared. Results: In both events, 16.3% and 17.2% of the runners respectively reported injuries with significant occurrence in first-time runners (p = 0.003 for 2009; p = 0.002 for 2010) mostly at the finish line. The reported injury type and site were muscle cramps and the thigh (39.7% and 76.4% respectively). Heat exhaustion was reported by 42.8% of runners in 2009 and 56.3% in 2010. Cryotherapy was mostly used in combination with other physiotherapy modalities in both years. Conclusion: Most of the injuries and other health problems were reported by first-time marathon runners mainly at the finish line. The most reported site of injury was the thigh while muscle cramps and heat exhaustions were the most reported types of injuries and health problems. First-time marathon runners should be adequately informed of the predisposition to injury during marathons and adequate body conditioning should be emphasized. Ample preparation and effective involvement of the physiotherapy team is essential for management of injured runners en route and at the finish line in a marathon.
  DOI: 10.1186/2052-1847-5-6
  
• Bronchial hyperresponsiveness testing in athletes of the swiss paralympic team
  Background: The aim of this study was to assess airway hyperresponsiveness to eucapnic voluntary hyperventilation and dry powder mannitol challenge in athletes aiming to participate at the Paralympic Games 2008 in Beijing, especially in athletes with spinal cord injury. Methods: Forty-four athletes with a disability (27 with paraplegia (group 1), 3 with tetraplegia (group 2) and 14 with other disabilities such as blindness or single limb amputations (group 3) performed spirometry, skin prick testing, measurement of exhaled nitric oxide, eucapnic voluntary hyperventilation challenge test (EVH) and mannitol challenge test (MCT). A fall in FEV1 of >=10% in either challenge test was deemed positive for exercise-induced bronchoconstriction. Results: Fourteen (32%) athletes were atopic and 7 (16%) had a history of physician-diagnosed asthma. Absolute lung function values were significantly lower in patients of group 1 and 2 compared to group 3. Nine (20%) athletes were positive to EVH (8 paraplegics, 1 tetraplegic), and 8 (18%) athletes were positive to MCT (7 paraplegics, 1 tetraplegic). Fourteen (22.7%) subjects were positive to at least one challenge; only three athletes were positive to both tests. None of the athletes in group 3 had a positive test. Both challenge tests showed a significant association with physician-diagnosed asthma status (p = 0.0001). The positive and negative predictive value to diagnose physician-diagnosed asthma was 89% and 91% for EHV, and 75% and 86% for MCT, respectively. Conclusion: EVH and MCT can be used to identify, but especially exclude asthma in Paralympic athletes.
  DOI: 10.1186/2052-1847-5-7
  
• An interview with Per Renstrom on his personal perspective of the changes and developments in the sports medicine field over the last 40 years
  Per Renstrom, PhD, is an Emeritus Professor at the Karolinska Institutet in Sweden and is a well-respected figure in the field of orthopedic sports medicine. His particular interests are in surgery, rehabilitation, prevention of sports injuries, biomechanics of the knee and ankle, and in particular the healing process of injuries to the Achilles tendon. He has co-authored over 170 original scientific publications and in this article we find out a little more about his thoughts on how the sports medicine field has changed during his time as an active researcher and member of various sports societies.
  DOI: 10.1186/2052-1847-5-8
  
• Standardization of the functional syndesmosis widening by dynamic U.S examination
  Background: Dynamic US examination is a convenient, accurate, inexpensive and reproducible diagnostic tool for assessing the integrity of the distal tibiofibular syndesmosis in ankle injuries. However normal values for physiological functional widening of the anterior tibiofibular clear space in healthy subjects has yet to be determined. The purpose of this study was to determine normal values for the syndesmosis clear space on ultrasound examination. Methods: We evaluated 110 healthy subjects. A dynamic U.S examination was performed in neutral (N), forced internal rotation (IR) and external rotation (ER) of the ankle. In each position the anterior tibiofibular clear space was measured at the level of the anterior inferior tibio-fibular ligament (AITFL). Height and calf length were also recorded. Results were analyzed in relation to age, activity, dominant leg and gender. Results: Mean age was 32 years (range 16–60). There were 59 males and 51 females. 60% were professional athletes. Mean height was 173 cm (range 149–192). Functional Mean position measurements for clear space opening were: N=3.7mm, IR=3.6mm and ER=4.0mm. In younger men and women the clear space was significantly wider in neutral (Men: Y=3.8, O=3.4 \ Women: Y=3.8, O=3.4) and with rotational force application (Men ER: Y=4.1, O=3.6 \ Women ER: Y=4.1, O=3.8) compared to older subjects (p <0.05). There was no correlation with activity, height or the leg length.Females had a higher syndesmosis widening ratio (ER/N) under stress than males (p <0.01) this tended to occur more commonly in active subjects. Conclusions: Normal values for the syndesmosis clear space on ultrasound examination were determined as 3.78mm in neutral, 3.64mm in internal rotation and 4.08mm in external rotation. The clear space was shown to decrease with age both as an absolute measure and when rotational stresses are applied. Females tend to have a larger clear space and a greater functional widening.These findings provide a useful reference for radiologists and sports physicians when performing ultrasound assessment of ankle syndesmotic injuries and we encourage use of this modality.
  DOI: 10.1186/2052-1847-5-9
  
• Influence of navigation system updates on total knee arthroplasty
  Background: The purpose of this study was to evaluate the influence of image-free computer-assisted navigation system update on outcome in total knee arthroplasty. Methods: Thirty-three knees were replaced using the Stryker 3.1 image-free navigation system and 49 knees were replaced using the Stryker 4.0 system. One surgeon took part in all procedures as chief surgeon or first assistant. All patients received the Stryker Scopio NRG CR total knee prosthesis. We compared the accuracy of component positioning measured using radiographs and CT scans, operating time and clinical outcome 1 year after surgery. Results: The mean hip-knee-ankle, frontal femoral and tibial component angle were 179.8[degree sign] (ideally implanted 85%), 89.8[degree sign] (88%), 90.4[degree sign] (88%) respectively for the 3.1 group and 179.5[degree sign] (96%), 90.6[degree sign] (92%), 90.2[degree sign] (94%) for the 4.0 group. The mean sagittal tibial component angle was 85.5[degree sign] (82%) for the 3.1 group and 85.6[degree sign] (92%) for the 4.0 group. The mean rotational femoral and tibial component angle were -0.5[degree sign] (81%), -0.7[degree sign] (73%) for the 3.1 group and 0.0[degree sign] (84%), 0.4[degree sign] (72%) for the 4.0 group. There were no statistically significant findings with regard to component positioning.Operating time was significantly longer in the 3.1 group (3.1 group: 137 min, 4.1group: 125 min, P < 0.01).No significant difference was detected in postoperative clinical outcome. Conclusion: The navigation system update from Stryker 3.1 to Stryker 4.0 reduced operating time by 12 min. However, there were no statistically significant findings with regard to component positioning and clinical outcome.
  DOI: 10.1186/2052-1847-5-10
  
• A case report of semitendinosus tendon autograft for reconstruction of the meniscal wall supporting a collagen implant
  PurposeDescribe the evolution of the reconstruction of meniscal rim with semitendinosus tendon in a patient with knee pain after a subtotal meniscectomy and absence of meniscal wall.Method32 years old male with a six-month history of the left knee pain after a subtotal meniscectomy. The MRI indicated a small internal meniscal remainder without posterior horn attachment. Taking this absence as a relative contraindication for implant and meniscal transplantation, the reconstruction of a new meniscal wall with semitendinosus tendon autograft was considered. A collagen meniscal implant was attached to the new wall five months later. Results: After two years the patient referred only non specific discomfort with full pain relief in the medial compartment. The MRI revealed integration of implants without significant degenerative changes compared to previous images. Conclusions: This staged technique was designed to restore medial meniscus-like biologic tissue in a symptomatic patient following arthroscopic subtotal meniscectomy with a significant loss of the peripheral meniscus rim. Symptomatic improvement was obtained at two years follow-up.
  DOI: 10.1186/2052-1847-5-4
  
• An interview with Per Renstrom on his personal perspective of the changes and developments in the sports medicine field over the last 40 years
  Per Renstrom, PhD, is an Emeritus Professor at the Karolinska Institutet in Sweden and is a well-respected figure in the field of orthopedic sports medicine. His particular interests are in surgery, rehabilitation, prevention of sports injuries, biomechanics of the knee and ankle, and in particular the healing process of injuries to the Achilles tendon. He has co-authored over 170 original scientific publications and in this article we find out a little more about his thoughts on how the sports medicine field has changed during his time as an active researcher and member of various sports societies.
  DOI: 10.1186/2052-1847-5-8
  
• Standardization of the functional syndesmosis widening by dynamic U.S examination
  Background: Dynamic US examination is a convenient, accurate, inexpensive and reproducible diagnostic tool for assessing the integrity of the distal tibiofibular syndesmosis in ankle injuries. However normal values for physiological functional widening of the anterior tibiofibular clear space in healthy subjects has yet to be determined. The purpose of this study was to determine normal values for the syndesmosis clear space on ultrasound examination. Methods: We evaluated 110 healthy subjects. A dynamic U.S examination was performed in neutral (N), forced internal rotation (IR) and external rotation (ER) of the ankle. In each position the anterior tibiofibular clear space was measured at the level of the anterior inferior tibio-fibular ligament (AITFL). Height and calf length were also recorded. Results were analyzed in relation to age, activity, dominant leg and gender. Results: Mean age was 32 years (range 16--60). There were 59 males and 51 females. 60% were professional athletes. Mean height was 173 cm (range 149--192). Functional Mean position measurements for clear space opening were: N=3.7mm, IR=3.6mm and ER=4.0mm. In younger men and women the clear space was significantly wider in neutral (Men: Y=3.8, O=3.4 \ Women: Y=3.8, O=3.4) and with rotational force application (Men ER: Y=4.1, O=3.6 \ Women ER: Y=4.1, O=3.8) compared to older subjects (p<0.05). There was no correlation with activity, height or the leg length.Females had a higher syndesmosis widening ratio (ER/N) under stress than males (p<0.01) this tended to occur more commonly in active subjects. Conclusions: Normal values for the syndesmosis clear space on ultrasound examination were determined as 3.78mm in neutral, 3.64mm in internal rotation and 4.08mm in external rotation. The clear space was shown to decrease with age both as an absolute measure and when rotational stresses are applied. Females tend to have a larger clear space and a greater functional widening.These findings provide a useful reference for radiologists and sports physicians when performing ultrasound assessment of ankle syndesmotic injuries and we encourage use of this modality.
  DOI: 10.1186/2052-1847-5-9
  

  VOL 1 NUMBER 2009

• The relationship between lower extremity alignment and Medial Tibial Stress Syndrome among non-professional athletes
  ObjectiveTo determine the relationship between lower extremity alignment and MTSS amongst non-professional athletesDesignIn a prospective Study, sixty six subjects were evaluated. Bilateral navicular drop test, Q angle, Achilles angle, tibial angle, intermalleolar and intercondylar distance were measured. In addition, runner's height, body mass, history of previous running injury, running experience was recorded. Runners were followed for 17 weeks to determine occurrence of MTSS. Results: The overall injury rate for MTSS was 19.7%. The MTSS injury rate in girls (22%) was not significantly different from the rate in boys (14.3%). Most MTSS injuries were induced after 60 hours of exercise, which did not differ between boys and girls. There was a significant difference in right and left navicular drop (ND) in athletes with MTSS. MTSS had no significant correlation with other variables including Quadriceps, Tibia and Achilles angles, intercondylar and intermaleolar lengths and lower extremity lengths.LimitationAll measurements performed in this study were uniplanar and static. The small sample size deemed our main limitation. The accurate assessment of participants with previous history of anterior leg pain for MTSS was another limitation. Conclusion: Although a significant relationship between navicular drop and MTSS was found in this study; there was not any significant relationship between lower extremity alignment and MTSS in our sample study.
  DOI: 10.1186/1758-2555-1-11
  
• Multidirectional instability of the shoulder - current concept
  A guest editorial on the multidirectional instability of the shoulder
  DOI: 10.1186/1758-2555-1-12
  
• Challenging for cartilage repair
  No description available
  DOI: 10.1186/1758-2555-1-13
  
• Understanding acute ankle ligamentous sprain injury in sports
  This paper summarizes the current understanding on acute ankle sprain injury, which is the most common acute sport trauma, accounting for about 14% of all sport-related injuries. Among, 80% are ligamentous sprains caused by explosive inversion or supination. The injury motion often happens at the subtalar joint and tears the anterior talofibular ligament (ATFL) which possesses the lowest ultimate load among the lateral ligaments at the ankle. For extrinsic risk factors to ankle sprain injury, prescribing orthosis decreases the risk while increased exercise intensity in soccer raises the risk. For intrinsic factors, a foot size with increased width, an increased ankle eversion to inversion strength, plantarflexion strength and ratio between dorsiflexion and plantarflexion strength, and limb dominance could increase the ankle sprain injury risk. Players with a previous sprain history, players wearing shoes with air cells, players who do not stretch before exercising, players with inferior single leg balance, and overweight players are 4.9, 4.3, 2.6, 2.4 and 3.9 times more likely to sustain an ankle sprain injury. The aetiology of most ankle sprain injuries is incorrect foot positioning at landing – a medially-deviated vertical ground reaction force causes an explosive supination or inversion moment at the subtalar joint in a short time (about 50 ms). Another aetiology is the delayed reaction time of the peroneal muscles at the lateral aspect of the ankle (60–90 ms). The failure supination or inversion torque is about 41–45 Nm to cause ligamentous rupture in simulated spraining tests on cadaver. A previous case report revealed that the ankle joint reached 48 degrees inversion and 10 degrees internal rotation during an accidental grade I ankle ligamentous sprain injury during a dynamic cutting trial in laboratory. Diagnosis techniques and grading systems vary, but the management of ankle ligamentous sprain injury is mainly conservative. Immobilization should not be used as it results in joint stiffness, muscle atrophy and loss of proprioception. Traditional Chinese medicine such as herbs, massage and acupuncture were well applied in China in managing sports injuries, and was reported to be effective in relieving pain, reducing swelling and edema, and restoring normal ankle function. Finally, the best practice of sports medicine would be to prevent the injury. Different previous approaches, including designing prophylactice devices, introducing functional interventions, as well as change of games rules were highlighted. This paper allows the readers to catch up with the previous researches on ankle sprain injury, and facilitate the future research idea on sport-related ankle sprain injury.
  DOI: 10.1186/1758-2555-1-14
  
• Iliotibial band release as an adjunct to surgical management of patellar stress fracture in the athlete: a case report and review of the literature
  Stress fracture of the patella is rare. In this report, a case of patellar stress fracture occurring in an amateur athlete is presented, and an operative adjunct to the surgical management of this condition is proposed.A review of the English literature identified 21 previous cases of stress fracture of the patella, the majority in young athletes. None of these reports discussed treatment addressing the pathological process contributing to patellar stress fracture.The subject of this case report is a young male netballer who presented with a transverse stress fracture in the inferior third of his patella, on a background of patellofemoral overload. The patient underwent open reduction and internal fixation of his patella, combined with release of the iliotibial band. He returned to training after 6 weeks.The previous literature suggests that operative fixation is indicated for the treatment of displaced patellar stress fractures. Iliotibial band release, as a surgical adjunct to this treatment, may address the pathology of these fractures, and facilitate a return to sport at the highest level.
  DOI: 10.1186/1758-2555-1-15
  
• The relation between athletic sports and prevalence of amenorrhea and oligomenorrhea in Iranian female athletes
  Background: In 1992, the concept of female athlete triad was introduced to describe the interrelated problems of amenorrhea, eating disorders and osteoporosis seen in female athletes. To gain a clearer picture of amenorrhea/oligomenorrhea in Iran, one of the main components of the female athlete triad, we therefore established this study on the prevalence of amenorrhea/oligomenorrhea in elite Iranian female athletes, also evaluating the risk factors of these disorders in the same population. Methods: This study performed as a cross-sectional study. All elite Iranian female athletes of 34 sports federation, including female athletes in national teams and medalists of Tehran were invited to participate. A total of 788 (95% response rate) returned the questionnaires and were examined. Younger athletes under the age of menarche were excluded. Each athlete completed a self-administered questionnaire, which covered the following questions about participant's demographic information, athletic history, history of injuries and menstrual pattern. In order to diagnose the causes of amenorrhea/Oligomenorrhea including polycystic ovary syndrome(PCOS), participants with amenorrhea/Oligomenorrhea underwent further investigation. They were evaluated by following Para clinic investigation, and an ultrasonographic study of ovary. Results: The age ranged from 13–37 (mean = 21.1, SD = 4.5). Seventy one (9.0%) individuals had amenorrhea/oligomenorrhea, among those, 11 (15.5%) had PCOS.There was also a positive association between amenorrhea/oligomenorrhea and the following: age under 20 OR; 2.67, 95%CI(1.47 – 4.85), weight class sports OR; 2.09, 95%CI(1.15 – 3.82), endurance sports OR; 2.89, 95%CI(1.22 – 6.84), late onset of menarche OR; 3.32 95%CI(1.04–10.51), and use of oral contraceptive pills OR; 6.17, 95%CI(3.00 – 12.69). Intensity of training sport or BMI were not risk factors. Conclusion: These findings support the previous findings in the literature that the prevalence of amenorrhea/oligomenorrhea is high in athletes. Furthermore, we provided the first report on the prevalence of PCOS in female athletes with amenorrhea/oligomenorrhea. Athletes would be greatly benefited by greater general awareness about the complications of amenorrhea/oligomenorrhea.To increase awareness of exercise-associated menstrual cycle irregularities, it is necessary to design complete and comprehensive education programs for female athletes, their parents, their coaches, and the relevant authorities.
  DOI: 10.1186/1758-2555-1-16
  
• Medial patellofemoral ligament injury patterns and associated pathology in lateral patella dislocation: an MRI study
  Background: Lateral Patella dislocations are common injuries seen in the active and young adult populations. Our study focus was to evaluate medial patellofemoral ligament (MPFL) injury patterns and associated knee pathology using Magnetic Resonance Imaging studies. Methods: MRI studies taken at one imaging site between January, 2007 to January, 2008 with the final diagnosis of patella dislocation were screened for this study. Of the 324 cases that were found, 195 patients with lateral patellar dislocation traumatic enough to cause bone bruises on the lateral femoral trochlea and the medial facet of the patella were selected for this study. The MRI images were reviewed by three independent observers for location and type of MPFL injury, osteochondral defects, loose bodies, MCL and meniscus tears. The data was analyzed as a single cohort and by gender. Results: This study consisted of 127 males and 68 females; mean age of 23 yrs. Tear of the MPFL at the patellar attachment occurred in 93/195 knees (47%), at the femoral attachment in 50/195 knees (26%), and at both the femoral and patella attachment sites in 26/195 knees (13%). Attenuation of the MPFL without rupture occurred in 26/195 knees (13%). Associated findings included loose bodies in 23/195 (13%), meniscus tears 41/195 (21%), patella avulsion/fracture in 14/195 (7%), medial collateral ligament sprains/tears in 37/195 (19%) and osteochondral lesions in 96/195 knees (49%). Statistical analysis showed females had significantly more associated meniscus tears than the males (27% vs. 17%, p = 0.04). Although not statistically significant, osteochondral lesions were seen more in male patients with acute patella dislocation (52% vs. 42%, p = 0.08). Conclusion: Patients who present with lateral patella dislocation with the classic bone bruise pattern seen on MRI will likely rupture the MPFL at the patellar side. Females are more likely to have an associated meniscal tear than males; however, more males have underlying osteochondral lesions. Given the high percentage of associated pathology, we recommend a MRI of the knee in all patients who present with acute patella dislocation.
  DOI: 10.1186/1758-2555-1-17
  
• Partial isolated rupture of the popliteus tendon in a professional soccer player: a case report
  The complete isolated rupture of the popliteus tendon has been described as a rare injury and this report describes the case of a 31-year-old soccer player who sustained a partial rupture of the popliteus tendon during a game. The injury was suspected clinically and at MRI but confirmed only by the arthroscopic examination. The treatment consisted in open debridment with no tendon repair or augmentation. Seven weeks post-operation the patient was symptom-free and returned to competitive professional soccer at the same preinjury level. The clinical and arthroscopic findings of the case reported suggest a possible overuse disease with degenerative expression.
  DOI: 10.1186/1758-2555-1-18
  
• The free moment in walking and its change with foot rotation angle
  Background: This investigation characterized the time-history pattern of the free moment (FM) during walking and, additionally, assessed whether walking with either an internally or externally rotated foot position altered the FM's time-history. Methods: Force plate and foot kinematic data were acquired simultaneously for 11 healthy subjects (6 males, 5 females) while walking at their self-selected comfortable speed in 3 foot rotation conditions (normal, internal and external). The FM was calculated and normalized by the product of each participant's body weight and height prior to extraction of peak FM, occurrence of peak FM in stance and net relative impulse. Differences in these values across foot rotation conditions were assessed using separate one-way, repeated measures analysis of variance and subsequent pair-wise comparisons. Results: The average FM pattern during normal walking exhibits a biphasic shape: resisting inward rotation during approximately the first half of stance and outward rotation during the latter part of stance. While no differences in peak FM or net relative impulse were observed between the internal foot rotation condition and normal walking, the external foot rotation condition resulted in significantly greater peak FM and relative net impulse in comparison to normal walking. Conclusion: The differences in selected FM variables between normal walking and the external foot rotation condition are attributable to individual subject response to walking with an externally rotated foot. In this condition, some subjects displayed a FM pattern that was similar to that recorded during normal walking, while others displayed markedly larger FM patterns that are comparable in magnitude to those reported for running. The larger FM values in these latter subjects are speculated to be a result of excessive transverse plane body movements. Whilst further investigation is warranted regarding the FM time-history characteristics during walking, our results indicate that the FM may provide useful information in assessment of gait.
  DOI: 10.1186/1758-2555-1-19
  
• Knee stability assessment on anterior cruciate ligament injury: clinical and biomechanical approaches
  Anterior cruciate ligament (ACL) injury is common in knee joint accounting for 40% of sports injury. ACL injury leads to knee instability, therefore, understanding knee stability assessments would be useful for diagnosis of ACL injury, comparison between operation treatments and establishing return-to-sport standard. This article firstly introduces a management model for ACL injury and the contribution of knee stability assessment to the corresponding stages of the model. Secondly, standard clinical examination, intra-operative stability measurement and motion analysis for functional assessment are reviewed. Orthopaedic surgeons and scientists with related background are encouraged to understand knee biomechanics and stability assessment for ACL injury patients.
  DOI: 10.1186/1758-2555-1-20
  
• Graft healing in anterior cruciate ligament reconstruction
  Successful anterior cruciate ligament reconstruction with a tendon graft necessitates solid healing of the tendon graft in the bone tunnel. Improvement of graft healing to bone is crucial for facilitating an early and aggressive rehabilitation and ensuring rapid return to pre-injury levels activity. Tendon graft healing in a bone tunnel requires bone ingrowth into the tendon. Indirect Sharpey fiber formation and direct fibrocartilage fixation confer different anchorage strength and interface properties at the tendon-bone interface. For enhancing tendon graft-to-bone healing, we introduce a strategy that includes the use of periosteum, hydrogel supplemented with periosteal progenitor cells and bone morphogenetic protein-2, and a periosteal progenitor cell sheet. Future studies include the use of cytokines, gene therapy, stem cells, platelet-rich plasma, and mechanical stress for tendon-to-bone healing. These strategies are currently under investigation, and will be applied in the clinical setting in the near future.
  DOI: 10.1186/1758-2555-1-21
  
• Between-day reliability of electromechanical delay of selected neck muscles during performance of maximal isometric efforts
  Background: The purpose of this study was to assess the between-day reliability of the electromechanical delay (EMD) of selected neck muscles during the performance of maximal isometric contractions in five different directions. Methods: Twenty-one physically active males participated in two testing sessions separated by seven to eight days. Using a custom-made fixed frame dynamometer, cervical force and surface electromyography (EMG) were recorded bilaterally from the splenius capitis, upper trapezius and sternocleidomastoid muscles during the performance of efforts in extension, flexion, left and right lateral bending, and protraction. The EMD was extracted using the Teager-Kaiser Energy Operator. Reliability indices calculated for each muscle in each testing direction were: the difference in scores between the two testing sessions and corresponding 95% confidence intervals, the standard error of measurement (SEM) and intra-class correlation coefficients (ICC). Results: EMD values showed no evidence of systematic difference between the two testing sessions across all muscles and testing directions. The SEM for extension, flexion and lateral bending efforts ranged between 2.5 ms to 4.8 ms, indicating a good level of measurement precision. For protraction, SEM values were higher and considered to be imprecise for research and clinical purposes. ICC values for all muscles across all testing directions ranged from 0.23 to 0.79. Conclusion: EMD of selected neck muscles can be measured with sufficient precision for the assessment of neck muscle function in an athletic population in the majority of directions tested.
  DOI: 10.1186/1758-2555-1-22
  
• Anti-inflammatory management for tendon injuries - friends or foes'
  Acute and chronic tendon injuries are very common among athletes and in sedentary population. Most physicians prescribe anti-inflammatory managements to relieve the worst symptoms of swelling and pain, including non-steroidal anti-inflammatory drugs, corticosteroids and physical therapies. However, experimental research shows that pro-inflammatory mediators such as prostaglandins may play important regulatory roles in tendon healing. Noticeably nearly all cases of chronic tendon injuries we treat as specialists have received non-steroidal anti-inflammatory drugs by their physician, suggesting that there might be a potential interaction in some of these cases turning a mild inflammatory tendon injury into chronic tendinopathy in predisposed individuals. We are aware of the fact that non-steroidal anti-inflammatory drugs and corticosteroids may well have a positive effect on the pain control in the clinical situation whilst negatively affect the structural healing. It follows that a comprehensive evaluation of anti-inflammatory management for tendon injuries is needed and any such data would have profound clinical and health economic importance.
  DOI: 10.1186/1758-2555-1-23
  
• Lower trunk kinematics and muscle activity during different types of tennis serves
  Background: To better understand the underlying mechanisms involved in trunk motion during a tennis serve, this study aimed to examine the (1) relative motion of the middle and lower trunk and (2) lower trunk muscle activity during three different types of tennis serves - flat, topspin, and slice. Methods: Tennis serves performed by 11 advanced (AV) and 8 advanced intermediate (AI) male tennis players were videorecorded with markers placed on the back of the subject used to estimate the anatomical joint (AJ) angles between the middle and lower trunk for four trunk motions (extension, left lateral flexion, and left and right twisting). Surface electromyographic (EMG) techniques were used to monitor the left and right rectus abdominis (LRA and RRA), external oblique (LEO and REO), internal oblique (LIO and RIO), and erector spinae (LES and RES). The maximal AJ angles for different trunk motions during a serve and the average EMG levels for different muscles during different phases (ascending and descending windup, acceleration, and follow-through) of a tennis serve were evaluated. Results: The repeated measures Skill × Serve Type × Trunk Motion ANOVA for maximal AJ angle indicated no significant main effects for serve type or skill level. However, the AV group had significantly smaller extension (p = 0.018) and greater left lateral flexion (p = 0.038) angles than the AI group. The repeated measures Skill × Serve Type × Phase MANOVA revealed significant phase main effects in all muscles (p < 0.001) and the average EMG of the AV group for LRA was significantly higher than that of the AI group (p = 0.008). All muscles showed their highest EMG values during the acceleration phase. LRA and LEO muscles also exhibited high activations during the descending windup phase, and RES muscle was very active during the follow-through phase. Conclusion: Subjects in the AI group may be more susceptible to back injury than the AV group because of the significantly greater trunk hyperextension, and relatively large lumbar spinal loads are expected during the acceleration phase because of the hyperextension posture and profound front-back and bilateral co-activations in lower trunk muscles.
  DOI: 10.1186/1758-2555-1-24
  
• Intraosseous Ganglion in the Subchondral Region of the Lateral Femoral Condyle in an 11-year-old girl: a Case Report
  We report the case of a patient with intraosseous ganglion in the lateral femoral condyle. An 11-year-old girl presented with right knee pain following a twisting injury. Plain radiographs of the knee showed a small circumscribed radiolucency with a thin sclerotic margin in the subchondral region of the lateral femoral condyle. Although the image findings and location are not typical, the lesion was tentatively diagnosed as osteochodritis dissecans. Six months after the conservative treatment with a break from vigorous sports activities, the size of the bony lesion had not decreased. Thus, we performed arthroscopy to make a definitive diagnosis. Arthroscopic examination revealed an area with dimple and surface irregularity at the lateral femoral condyle. On excision of the overlying tissue, the lesion was cystic containing brown mucous fluid. No association between the cyst and the articular structures was observed. Histologic examination of the resected cyst wall showed dense fibrous tissue with spotty areas of calcification. Base on these findings, we made a diagnosis of intraosseous ganglion. At the nine-month postoperative follow-up, the radiographic examination showed healing of the lesion. We speculate that the lesion in this case might have occurred as a result of repetitive overstress or microtrauma.
  DOI: 10.1186/1758-2555-1-25
  
• Sagittal realignment osteotomy for increased posterior tibial slope after opening-wedge high tibial osteotomy: a case report
  A 40 year old welder who underwent opening-wedge high tibial osteotomy for correction of alignment in a varus knee developed persistent pain with loss of knee extension. The posterior tibial slope increased from 9 degrees to 20 degrees after the osteotomy and caused the anteromedial knee pain and limited extension. The patient then underwent a revision osteotomy using a closing wedge technique to correct tibial slope. The osteotomy was performed, first from the medial cortex in the lateral direction, and second in the anteroposterior direction to remove the tibial bone in wedge shape and obtain full extension of the knee. The posterior tibial slope decreased to 8 degrees after the revision osteotomy and the patients returned to pain-free daily life. We reviewed this unique technique for correction of sagittal malalignment using a closing-wedge osteotomy for revision after opening-wedge osteotomy.
  DOI: 10.1186/1758-2555-1-26
  
• Time dependence of changes of two cartilage layers in anterior cruciate ligament insertion after resection on chondrocyte apoptosis and decrease in glycosaminoglycan
  Background: The purpose of this study is to clarify the differences in time-dependent histological changes (chondrocyte apoptosis and glycosaminoglycan (GAG) layer thickness decrease) between uncalcified fibrocartilage (UF) and calcified fibrocartilage (CF) layers at the anterior cruciate ligament (ACL) insertion after ACL resection of rabbits. Methods: Forty male Japanese white rabbits underwent ACL substance resection in the right knee (resection group) and same operation without resection in the left knee (sham group). Animals were sacrificed 1, 2, 4 and 6 weeks after surgery. Results: In the UF layer, the apoptosis rate in the resection group was significantly higher than that in the sham group at 1 and 2 weeks. The GAG layer thicknesses of the UF layer in the resection group at 1, 2, 4 and 6 weeks were lower than those in the sham group. In the CF layer, the apoptosis rate in the resection group was significantly higher than that in the sham group at 2 and 4 weeks. The GAG layer thickness of the CF layer in the resection group was lower than that in the sham group only at 6 weeks. Conclusion: The increase in chondrocyte apoptosis rate preceded the decrease in GAG layer thickness in both layers. In the UF layer, the increase in chondrocyte apoptosis rate and the decrease in GAG layer thickness preceded those in the CF layer. Using a surviving ligament and minimizing a debridement of ACL remnant during ACL reconstruction may be important to maintain cartilage layers of ACL insertion. An injured ACL should be repaired before degenerative changes of the insertion occur.
  DOI: 10.1186/1758-2555-1-27
  
• Traumatic fracture-dislocation of the hip following rugby tackle: a Case report
  Posterior fracture-dislocation of hip is uncommonly encountered in rugby injuries. We report such a case in an adult while playing rugby. The treating orthopaedician can be caught unaware and injuries in such sports can be potentially misdiagnosed as hip sprains. Immediate reduction of the dislocation was performed in theatres. The fracture was fixed with two lag screws and a neutralization plate. This led to early rehabilitation and speedy recovery with return to sporting activities by 12 months.
  DOI: 10.1186/1758-2555-1-28
  

  VOL 2 NUMBER 2010

• Medial and lateral discoid menisci: a case report
  Discoid menisci on both medial and lateral tibial plateau are very rare abnormalities. We report a 44-year-old woman with bilateral medial and lateral discoid menisci. She also had anomalous insertion of discoid medial meniscus to anterior cruciate ligament, and pathologic medial patellar plica on the right knee. Meniscectomies has been performed for her torn discoid menisci with satisfactory result on the latest follow-up.
  DOI: 10.1186/1758-2555-2-21
  
• Grip strength measurements at two different wrist extension positions in chronic lateral epicondylitis- comparison of involved vs. uninvolved side in athletes and non-athletes: a case-control study
  Background: Lateral epicondylitis is a common sports injury of the elbow caused due to altered muscle activation during repetitive wrist extension in many athletic and non-athletic endeavors. The amount of muscle activity and timing of contraction eventually is directly dependent upon joint position during the activity. The purpose of our study was to compare the grip strength in athletes with lateral epicondylalgia in two different wrist extension positions and compare them between involved and uninvolved sides of athletes and non-athletes. Methods: An assessor-blinded case-control study of eight athletes and twenty-two non-athletes was done. The grip strength was measured using JAMAR(R) hand dynamometer in kilograms-force at 15 degrees (slightly extended) and 35 degrees (moderately extended) wrist extension positions (maintained by wrist splints) on both involved and uninvolved sides of athletes and non-athletes with unilateral lateral epicondylitis of atleast 3 months duration. Their pain was to be elicited with local tenderness and two of three tests being positive- Cozen's, Mill's manoeuvre, resisted middle finger extension tests. For comparisons of grip strength, Wilcoxon signed rank test was used for within-group comparison (between 15 and 35 degrees wrist extension positions) and Mann-Whitney U test was used for between-group (athletes vs. non-athletes) comparisons at 95% confidence interval and were done using SPSS 11.5 for Windows. Results: Statistically significant greater grip strength was found in 15 degrees (27.75 +/- 4.2 kgms in athletes; 16.45 +/- 4.2 kgms in non-athletes) wrist extension than at 35 degrees (25.25 +/- 3.53 kgm in athletes and 14.18 +/- 3.53 kgm in non-athletes). The athletes had greater grip strength than non-athletes in each of test positions (11.3 kgm at 15 degrees and 11.07 kgm at 35 degrees) measured. There was also a significant difference between involved and uninvolved sides' grip strength at both wrist positions (4.44 +/- .95 kgm at 15 degrees and 4.44 +/- .86 kgm in 35 degrees) which was significant (p<.05) only in non-athletes. Conclusion: The grip strength was greater in 15 degrees wrist extension position and this position could then be used in athletes with lateral epicondylalgia for grip strength assessment and designing wrist splint in this population.
  DOI: 10.1186/1758-2555-2-22
  
• First-time patellar dislocation with resultant habitual dislocation two years later, which was not demonstrated on plain X-rays halfway: a case report
  We present an instructive case of habitual left patellar dislocation in which the patella had appeared odd due to lateral tilt relative to contralateral side, but had been radiologically confirmed to be on the trochlea at 1 year prior to the referral. An 11-year-old girl presented to our hospital 2 years after the left patella had dislocated with a 'giving way' when cutting to the left. Our physical and radiological examinations confirmed that the left patella was laterally tilted in the patellar groove with the knee in extension but was dislocated in flexion beyond 45degrees. In spite of these findings, she had been untreated at the previous hospital since all plain X-rays, including a skyline patellar view, had failed to demonstrate the dislocation. Consequently, in addition to reconstruction of medial patellofemoral ligament, she had to undergo a lateral retinacular release, which might have been unnecessary if treated earlier. This case illustrates that first-time patellar dislocation can gradually lead to habitual dislocation subsequently, and that cautious physical examinations in regard to patella tracking are essential since radiological examinations do not always reveal the pathophysiology of patellar instability.
  DOI: 10.1186/1758-2555-2-23
  
• Painful knee joint after ACL reconstruction using biodegradable interference screws- SPECT/CT a valuable diagnostic tool' A case report
  In the last decades interest among arthroscopic surgeons in using biodegradable interference screws has grown. In the past a variety of screw related problems such as screw breakage, intraarticular migration, allergic or foreign body reactions and tunnel enlargement have been reported.With the presented case we strive to introduce combined single photon emission computerized tomography and conventional computer tomography (SPECT/CT) as new diagnostic imaging modality and illustrate the possible clinical value in patients after ACL reconstruction. We report the case of a painful knee due to a foreign body reaction and delayed degradation of the biodegradable interference screws after ACL reconstruction. The MRI showed an intact ACL graft in continuity, a possible tibial cyclops lesion and a patella infera. There was no increased fluid collection within the bone tunnels. The 99mTc-HDP-SPECT/CT (combined single photon emission computerized tomography and conventional computer tomography) clearly identified a highly increased tracer uptake around and within the tibial and femoral tunnels and the patellofemoral joint. On 3D-CT out of the SPECT/CT data the femoral graft attachment was shallow (50% along the Blumensaat`s line) and high in the notch. At revision arthroscopy a diffuse hypertrophy of the synovium, scarring of the Hoffa fat pad and a cyclops lesion of the former ACL graft was found. The interference screws were partially degraded and under palpation a grey fluid-like substance drained at pressure into the joint. The interference screws were partially degraded and under palpation and pressure a grey fluid-like substance drained into the joint. The interference screws and the ACL graft were removed and an arthrolysis performed.In the case presented it was most likely a combination of improper graft placement, delayed degradation of the interference screws and unknown biological factors. The too shallow and high ACL graft placement might have led to roof impingement, chronic intraarticular inflammation and hence the delayed degradation of the screws.SPECT/CT has facilitated the establishment of diagnosis, process of decision making and further treatment in patients with knee pain after ACL reconstruction. FromDue to the combination of structural (tunnel position in 3D-CT) and metabolic information (tracer uptake in SPECT/CT) the patient`s cause of the pain was established.
  DOI: 10.1186/1758-2555-2-24
  
• Arthroscopic treatment of a medial meniscal cyst using a posterior trans-septal approach: a case report
  Arthroscopic partial menisectomy followed by cyst decompression is currently recommended for treatment of a meniscal cyst. However, it is doubtful whether partial menisectomy should be performed on cysts communicating with the joint in cases without a meniscal tear on its surface since meniscal function will be sacrificed. In this report, a meniscal cyst arising from the posterior horn of the medial meniscus without meniscal tear on its surface was resected using an arthroscopic posterior trans-septal approach. A 59 year-old male presented to our hospital with popliteal pain when standing up after squatting down. Magnetic resonance imaging revealed a multilobulated meniscal cyst arising from the posterior horn of the medial meniscus extending to the posterior septum with a grade 2 meniscal tear by Mink's classification. The medial meniscus was intact on the surface on arthroscopic examination. The meniscal cyst and posterior septum were successfully resected using a posterior trans-septal approach without harming the meniscus. This is the first report on a meniscal cyst being resected using an arthroscopic posterior trans-septal approach with a 9-month follow-up period.
  DOI: 10.1186/1758-2555-2-25
  
• High-intensity mechanical therapy for loss of knee extension for worker's compensation and non-compensation patients
  Background: Knee flexion contractures have been associated with increased pain and a reduced ability to perform activities of daily living. Contractures can be treated either surgically or conservatively, but these treatment options may not be as successful with worker's compensation patients. The purposes of retrospective review were to 1) determine the efficacy of using adjunctive high-intensity stretch (HIS) mechanical therapy to treat flexion contractures, and 2) compare the results between groups of worker's compensation and non-compensation patients. Methods: Fifty-six patients (19 women, 37 men, age = 51.5 +/- 17.0 years) with flexion contractures were treated with HIS mechanical therapy as an adjunct to outpatient physical therapy. Mechanical therapy was only prescribed for those patients whose motion had reached a plateau when treated with physical therapy alone. Patients were asked to perform six, 10-minute bouts of end-range stretching per day with the ERMI Knee Extensionater(R) (ERMI, Inc., Atlanta, GA). Passive knee extension was recorded during the postoperative visit that mechanical therapy was prescribed, 3 months after beginning mechanical therapy, and at the most recent follow-up. We used a mixed-model 2 x 3 ANOVA (group x time) to evaluate the change in passive knee extension between groups over time. Results: Regardless of group, the use of adjunctive HIS mechanical therapy resulted in passive knee extension deficits that significantly improved from 10.5 degrees +/- 5.2 degrees at the initial visit to 2.6 degrees +/- 3.5 degrees at the 3 month visit (p<0.001). The degree of extension was maintained at the most recent follow-up (2.0 degrees +/- 2.9 degrees), which was significantly greater than the initial visit (p<0.001), but did not differ from the 3 month visit (p=0.23). The gains in knee extension did not differ between worker's compensation and non-compensation patients (p=0.56). Conclusions: We conclude that the adjunctive use of HIS mechanical therapy is an effective treatment option for patients with knee flexion contractures, regardless of whether the patient is being treated as part of a worker's compensation claim or not.
  DOI: 10.1186/1758-2555-2-26
  
• Comparison between clinical grading and navigation data of knee laxity in ACL-deficient knees
  Background: The latest version of the navigation system for anterior cruciate ligament (ACL) reconstruction has the supplementary ability to assess knee stability before and after ACL reconstruction. In this study, we compared navigation data between clinical grades in ACL-deficient knees and also analyzed correlation between clinical grading and navigation data. Methods: 150 ACL deficient knees that received primary ACL reconstruction using an image-free navigation system were included. For clinical evaluation, the Lachman, anterior drawer, and pivot shift tests were performed under general anesthesia and were graded by an examiner. For the assessment of knee stability using the navigation system, manual tests were performed again before ACL reconstruction. Navigation data were recorded as anteroposterior (AP) displacement of the tibia for the Lachman and anterior drawer tests, and both AP displacement and tibial rotation for the pivot shift test. Results: Navigation data of each clinical grade were as follows; Lachman test grade 1+: 10.0 mm, grade 2+: 13.2 mm, grade 3+: 14.5 mm, anterior drawer test grade 1+: 6.8 mm, grade 2+: 7.4 mm, grade 3+: 9.1 mm, pivot shift test grade 1+: 3.9 mm / 21.5 degrees, grade 2+: 4.8 mm / 21.8 degrees, and grade 3+: 6.0 mm / 21.1 degrees. There were positive correlations between clinical grading and AP displacement in the Lachman, and anterior drawer tests. Although positive correlations between clinical grading and AP displacement in pivot shift test were found, there were no correlations between clinical grading and tibial rotation in pivot shift test. Conclusions: In response to AP force, the navigation system can provide the surgeon with correct objective data for knee laxity in ACL deficient knees. During the pivot shift test, physicians may grade according to the displacement of the tibia, rather than rotation.
  DOI: 10.1186/1758-2555-2-27
  
• A novel technique of rotator cuff repair using spinal needle and suture loop
  Background: We present a simple technique of arthroscopic rotator cuff repair using a spinal needle and suture loop. Methods: With the arthroscope laterally, a spinal needle looped with PDS is inserted percutaneously into the shoulder posteriorly and penetrated through the healthy posterior cuff tear margin. Anteriorly, another spinal needle loaded with PDS is inserted percutaneously to engage the healthy tissue at the anterior tear margin. The suture in the anterior needle is then delivered into the suture loop of the posterior needle using a suture retriever. The posterior needle and loop are then pulled out carrying the anterior suture with it. The two limbs of this suture are then retrieved through a cannula for knotting. The same procedure is then repeated for additional suturing. Suture anchors placed over the greater tuberosity are used to complete the repair. Conclusion: This is an easy method of rotator cuff repair using simple instruments and lesser time, hence can be employed at centers with less equipment and at reduced cost to the patient.
  DOI: 10.1186/1758-2555-2-28
  
• Anterior Cruciate Ligament repair with LARS (Ligament Advanced Reinforcement System): A Systematic Review
  Background: Injury to the anterior cruciate ligament (ACL) of the knee is common. Following complete rupture of the ACL, insufficient re-vascularization of the ligament prevents it from healing completely, creating a need for reconstruction. A variety of grafts are available for use in ACL reconstruction surgery, including synthetic grafts. Over the last two decades new types of synthetic ligaments have been developed. One of these synthetic ligaments, the Ligament Advanced Reinforcement System (LARS), has recently gained popularity.The aim of this systematic review was to assess the current best available evidence for the effectiveness of the LARS as a surgical option for symptomatic, anterior cruciate ligament rupture in terms of graft stability, rehabilitation time and return to pre-injury function.MethodThis systematic review included studies using subjects with symptomatic, ACL ruptures undergoing LARS reconstruction. A range of electronic databases were searched in May 2010. The methodological quality of studies was appraised with a modified version of the Law critical appraisal tool. Data relating to study characteristics, surgical times, complication rates, outcomes related to knee stability, quality of life, function, and return to sport as well as details of rehabilitation programs and timeframes were collected. Results: This review identified four studies of various designs, of a moderate methodological quality. Only one case of knee synovitis was reported. Patient satisfaction with LARS was high. Graft stability outcomes were found to be inconsistent both at post operative and at follow up periods. The time frames of rehabilitation periods were poorly reported and at times omitted. Return to pre-injury function and activity was often discussed but not reported in results. Conclusions: There is an emerging body of evidence for LARS with comparable complication rates to traditional surgical techniques, and high patient satisfaction scores. However, this systematic review has highlighted several important gaps in the existing literature that require future prospective investigation. The findings of this review were equivocal with regards to other measures such as graft stability and long term functional outcomes. While the importance of rehabilitation following LARS is well recognised, there is limited evidence to guide rehabilitation protocols.
  DOI: 10.1186/1758-2555-2-29
  
• Deciphering the pathogenesis of tendinopathy: a three-stage process
  Our understanding of the pathogenesis of "tendinopathy" is based on fragmented evidences like pieces of a jigsaw puzzle. We propose a "failed healing theory" to knit these fragments together, which can explain previous observations. We also propose that albeit "overuse injury" and other insidious "micro trauma" may well be primary triggers of the process, "tendinopathy" is not an "overuse injury" per se. The typical clinical, histological and biochemical presentation relates to a localized chronic pain condition which may lead to tendon rupture, the latter attributed to mechanical weakness. Characterization of pathological "tendinotic" tissues revealed coexistence of collagenolytic injuries and an active healing process, focal hypervascularity and tissue metaplasia. These observations suggest a failed healing process as response to a triggering injury. The pathogenesis of tendinopathy can be described as a three stage process: injury, failed healing and clinical presentation. It is likely that some of these "initial injuries" heal well and we speculate that predisposing intrinsic or extrinsic factors may be involved. The injury stage involves a progressive collagenolytic tendon injury. The failed healing stage mainly refers to prolonged activation and failed resolution of the normal healing process. Finally, the matrix disturbances, increased focal vascularity and abnormal cytokine profiles contribute to the clinical presentations of chronic tendon pain or rupture. With this integrative pathogenesis theory, we can relate the known manifestations of tendinopathy and point to the "missing links". This model may guide future research on tendinopathy, until we could ultimately decipher the complete pathogenesis process and provide better treatments.
  DOI: 10.1186/1758-2555-2-30
  
• Anatomical significance of a posterior horn of medial meniscus: the relationship between its radial tear and cartilage degradation of joint surface
  Background: Traumatic injury and surgical meniscectomy of a medial meniscus are known to cause subsequent knee osteoarthritis. However, the difference in the prevalence of osteoarthritis caused by the individual type of the medial meniscal tear has not been elucidated. The aim of this study was to investigate what type of tear is predominantly responsible for the degradation of articular cartilage in the medial compartment of knee joints. Methods: Five hundred and forty eight cadaveric knees (290 male and 258 female) were registered in this study. The average age of cadavers at death was 78.8 years old (range: 52-103 years). The knees were macroscopically examined and their medial menisci were classified into four groups according to types of tears: "no tear", "radial tear of posterior horn", "other types of tear" and "worn-out meniscus" groups. The severity of cartilage degradation in their medial compartment of knee joints was evaluated using the international cartilage repair society (ICRS) grading system. We statistically compared the ICRS grades among the groups using Mann-Whitney U test. Results: The knees were assigned into the four groups: 416 "no tear" knees, 51 "radial tear of posterior horn" knees, 71 "other types of tear" knees, and 10 "worn-out meniscus" knees. The knees with substantial meniscal tears showed the severer ICRS grades of cartilage degradation than those without meniscal tears. In addition, the ICRS grades were significantly severer in the "radial tear of posterior horn" group than in the "other types of tear" group, suggesting that the radial tear of posterior horn in the medial meniscus is one of the risk factors for cartilage degradation of joint surface. Conclusions: We have clarified the relationship between the radial tear of posterior horn in the medial meniscus and the severer grade of cartilage degradation. This study indicates that the efforts should be made to restore the anatomical role of the posterior horn in keeping the hoop strain, when patients' physical activity levels are high and the tear pattern is simple enough to be securely sutured.
  DOI: 10.1186/1758-2555-2-1
  
• Intra-articular angiolipoma of the knee: a case report
  We report a case of intra-articular angiolipoma of the knee. This case report describes our experience in excising an intra-articular angiolipoma of the knee joint. Complete resection under arthroscopy was performed in a 30-year-old man. Two years after the surgery, no evidence of recurrence was seen. Intra-articular angiolipomas should be considered in the differential diagnosis of intra-articular masses in adolescents with recurrent hemarthrosis without trauma.
  DOI: 10.1186/1758-2555-2-10
  
• Improvement in low back movement control, decreased pain and disability, resulting from specific exercise intervention
  Background: The study was conducted to assess whether patient-specific functional impairment and experienced daily disability improved after treatment to address active movement control of the low back.MethodA prospective study was carried out in two outpatient physiotherapy practices in the German-speaking part of Switzerland. 38 patients (17 males and 21 females) suffering from non-specific low back pain (NSLBP) and movement control impairment were treated. The study participants had an average age of 45 +/-13 years, an average height of 170 +/- 8 cm and an average weight of 73 +/- 15 kg. Patients were assessed prior and post treatment. Treatment was aimed at improving movement control of the lumbar spine, pain and disability. Six physiotherapists treated each patient on average nine times (SD 4.6). Treatment effects were evaluated using a set of six movement control tests (MCT), patient-specific functional pain scores (PSFS) and a Roland and Morris disability questionnaire (RMQ). Means, standard deviations, confidence intervals and paired t-tests were calculated. The effect size (d) was based on the change between t1 (time prior intervention) and t2 (time post intervention) using a significance level of p <0.05, with d>0.8 being considered a large effect. Power calculations were performed for type I & II error estimation. Results: Movement control (MCT) showed a 59% improvement from 3.2 (max 6) to 1.3 positive tests (ES 1.3, p <0.001), d = 1.3; complaints (PSFS) decreased 41% from 5.9 points (max 10) to 3.5 (ES 1.3, p <0.001), d = 1.3; and disability (RMQ) decreased 43% from 8.9 to 5.1 points (ES 1.0, p <0.001), d = 1. Conclusions: The results of this controlled case series study, based on prior and post intervention, showed that movement control, patient specific functional complaints and disability improved significantly following specific individual exercise programs, performed with physiotherapeutic intervention. The results obtained warrant performance of a randomized controlled trial (RCT) to substantiate our findings
  DOI: 10.1186/1758-2555-2-11
  
• Functional tissue engineering of ligament healing
  Ligaments and tendons are dense connective tissues that are important in transmitting forces and facilitating joint articulation in the musculoskeletal system. Their injury frequency is high especially for those that are functionally important, like the anterior cruciate ligament (ACL) and medial collateral ligament (MCL) of the knee as well as the glenohumeral ligaments and the rotator cuff tendons of the shoulder. Because the healing responses are different in these ligaments and tendons after injury, the consequences and treatments are tissue- and site-specific. In this review, we will elaborate on the injuries of the knee ligaments as well as using functional tissue engineering (FTE) approaches to improve their healing. Specifically, the ACL of knee has limited capability to heal, and results of non-surgical management of its midsubstance rupture have been poor. Consequently, surgical reconstruction of the ACL is regularly performed to gain knee stability. However, the long-term results are not satisfactory besides the numerous complications accompanied with the surgeries. With the rapid development of FTE, there is a renewed interest in revisiting ACL healing. Approaches such as using growth factors, stem cells and scaffolds have been widely investigated. In this article, the biology of normal and healing ligaments is first reviewed, followed by a discussion on the issues related to the treatment of ACL injuries. Afterwards, current promising FTE methods are presented for the treatment of ligament injuries, including the use of growth factors, gene delivery, and cell therapy with a particular emphasis on the use of ECM bioscaffolds. The challenging areas are listed in the future direction that suggests where collection of energy could be placed in order to restore the injured ligaments and tendons structurally and functionally.
  DOI: 10.1186/1758-2555-2-12
  
• The differential effects of core stabilization exercise regime and conventional physiotherapy regime on postural control parameters during perturbation in patients with movement and control impairment chronic low back pain
  Background: The purpose of the present study was to examine the differential effect of core stability exercise training and conventional physiotherapy regime on altered postural control parameters in patients with chronic low back pain (CLBP). As heterogeneity in CLBP population moderates the effect of intervention on outcomes, in this study, interventions approaches were used based on sub-groups of CLBP. Methods: This was an allocation concealed, blinded, sequential and pragmatic control trial. Three groups of participants were investigated during postural perturbations: 1) CLBP patients with movement impairment (n = 15, MI group) randomized to conventional physiotherapy regime 2) fifteen CLBP patients with control impairment randomized to core stability group (CI group) and 3) fifteen healthy controls (HC). Results: The MI group did not show any significant changes in postural control parameters after the intervention period however they improved significantly in disability scores and fear avoidance belief questionnaire work score (P<0.05). The CI group showed significant improvements in Fx, Fz, and My variables (p<0.013, p<0.006, and p<0.002 respectively with larger effect sizes: Hedges's g > 0.8) after 8 weeks of core stability exercises for the adjusted p values. Postural control parameters of HC group were analyzed independently with pre and post postural control parameters of CI and MI group. This revealed the significant improvements in postural control parameters in CI group compared to MI group indicating the specific adaptation to the core stability exercises in CI group. Though the disability scores were reduced significantly in CI and MI groups (p<0.001), the post intervention scores between groups were not found significant (p<0.288). Twenty percentage absolute risk reduction in flare-up rates during intervention was found in CI group (95% CI: 0.69-0.98). Conclusions: In this study core stability exercise group demonstrated significant improvements after intervention in ground reaction forces (Fz, Mz; g > 0.8) indicating changes in load transfer patterns during perturbation similar to HC group.Trial registration: UTRN 095032158-06012009423714
  DOI: 10.1186/1758-2555-2-13
  
• Effects of methods of descending stairs forwards versus backwards on knee joint force in patients with osteoarthritis of the knee: a clinical controlled study
  Background: The aim of this study was to investigate the kinetic characteristics of compensatory backward descending movement performed by patients with osteoarthritis of the knee. Methods: Using a three-dimensional motion analysis system, we investigated lower extremity joint angles, joint moments, joint force of the support leg in forward and backward descending movements on stairs, and joint force of the leading leg at landing in 7 female patients with osteoarthritis of the knee. Results: Compared with the forward descending movement, knee joint angle, joint moment and joint force of the support leg all decreased in the backward descending movement. Joint force of the leading leg at landing was also reduced in the backward descending movement. In addition, we confirmed that the center of body mass was mainly controlled by the knee and ankle joints in the forward descending movement, and by the hip joint in the backward descending movement. Conclusions: Since it has been reported that knee flexion angle and extensor muscle strength are decreased in patients with osteoarthritis of the knee, we believe that backward descending movement is an effective method to use the hip joint to compensate for these functional defects. In addition, due to the decreased knee joint force both in the leading and support legs in backward descending movement, the effectiveness of compensatory motion for pain control and knee joint protection was also suggested.
  DOI: 10.1186/1758-2555-2-14
  
• Treatment of chronic anterior shoulder dislocation by open reduction and simultaneous Bankart lesion repair
  Background: Untreated chronic shoulder dislocation eventually leads to functional disability and pain. Open reduction with different fixation methods have been introduced for most chronic shoulder dislocation. We hypothesized that open reduction and simultaneous Bankart lesion repair in chronic anterior shoulder dislocation obviates the need for joint fixation and leads to better results than previously reported methods. Methods: Eight patients with chronic anterior dislocation of shoulder underwent open reduction and capsulolabral complex repair after an average delay of 10 weeks from injury. Early motion was allowed the day after surgery in the safe position and the clinical and radiographic results were analyzed at an average follow-up of one year. Results: The average Rowe and Zarin's score was 86 points. Four out of eight shoulders were graded as excellent, three as good and one as fair (Rowe and Zarins system). All patients were able to perform their daily activities and they had either mild or no pain. Anterior active forward flexion loss averaged 18 degrees, external active rotation loss averaged 17.5 degrees and internal active rotation loss averaged 3 vertebral body levels. Mild degenerative joint changes were noted in one patient. Conclusion: The results show that the overall prognosis for this method of operation is more favorable than the previously reported methods and we recommend concomitant open reduction and capsulolabral complex repair for the treatment of old anterior shoulder dislocation.Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group])
  DOI: 10.1186/1758-2555-2-15
  
• Mechanics Rules Cell Biology
  Cells in the musculoskeletal system are subjected to various mechanical forces in vivo. Years of research have shown that these mechanical forces, including tension and compression, greatly influence various cellular functions such as gene expression, cell proliferation and differentiation, and secretion of matrix proteins. Cells also use mechanotransduction mechanisms to convert mechanical signals into a cascade of cellular and molecular events. This mini-review provides an overview of cell mechanobiology to highlight the notion that mechanics, mainly in the form of mechanical forces, dictates cell behaviors in terms of both cellular mechanobiological responses and mechanotransduction.
  DOI: 10.1186/1758-2555-2-16
  
• Electromyographic analysis of the three subdivisions of gluteus medius during weight-bearing exercises
  Background: Gluteus medius (GM) dysfunction is associated with many musculoskeletal disorders. Rehabilitation exercises aimed at strengthening GM appear to improve lower limb kinematics and reduce pain. However, there is a lack of evidence to identify which exercises best activate GM. In particular, as GM consists of three distinct subdivisions, it is unclear if GM activation is consistent across these subdivisions during exercise. The aim of this study was to determine the activation of the anterior, middle and posterior subdivisions of GM during weight-bearing exercises. Methods: A single session, repeated-measures design. The activity of each GM subdivision was measured in 15 pain-free subjects using surface electromyography (sEMG) during three weight-bearing exercises; wall squat (WS), pelvic drop (PD) and wall press (WP). Muscle activity was expressed relative to maximum voluntary isometric contraction (MVIC). Differences in muscle activation were determined using one-way repeated measures ANOVA with post-hoc Bonferroni analysis. Results: The activation of each GM subdivision during the exercises was significantly different (interaction effect; p < 0.001). There were also significant main effects for muscle subdivision (p < 0.001) and for exercise (p < 0.001). The exercises were progressively more demanding from WS to PD to WP. The exercises caused significantly greater activation of the middle and posterior subdivisions than the anterior subdivision, with the WP significantly increasing the activation of the posterior subdivision (all p < 0.05).DiscussionPosterior GM displayed higher activation across all three exercises than both anterior and middle GM. The WP produced the highest %MVIC activation for all GM subdivisions, and this was most pronounced for posterior GM. Clinicians may use these results to effectively progress strengthening exercises for GM in the rehabilitation of lower extremity injuries.
  DOI: 10.1186/1758-2555-2-17
  
• The incidence of total hip arthroplasty after hip arthroscopy in osteoarthritic patients
  ObjectiveTo assess the incidence of total hip arthroplasty (THA) in osteoarthritic patients who were treated by arthroscopic debridement and to evaluate factors that might influence the time interval from the first hip arthroscopy to THA.DesignRetrospective clinical series Methods: Follow-up data and surgical reports were retrieved from 564 records of osteoarthritic patients that have had hip arthroscopy between the years 2002 to 2009 with a mean follow-up time of 3.2 years (range, 1-6.4 years). The time interval between the first hip arthroscopy to THA was modelled as a function of patient age; level of cartilage damage; procedures performed and repeated arthroscopies with the use of multivariate regression analysis. Results: Ninety (16%) of all participants eventually required THA. The awaiting time from the first arthroscopy to a hip replacement was found to be longer in patients younger than 55 years and in a milder osteoarthritic stage. Patients that experienced repeated hip scopes had a longer time to THA than those with only a single procedure. Procedures performed concomitant with debridement and lavage did not affect the time interval to THA. Conclusions: In our series of arthroscopic treatment of hip osteoarthritis, 16% required THA over a period of 7 years. Factors that influence the time to arthroplasty were age, degree of osteoarthritis and recurrent procedures.
  DOI: 10.1186/1758-2555-2-18
  
• Sudden cardiac death athletes: a systematic review
  Previous events evidence that sudden cardiac death (SCD) in athletes is still a reality and it keeps challenging cardiologists. Considering the importance of SCD in athletes and the requisite for an update of this matter, we endeavored to describe SCD in athletes. The Medline (via PubMed) and SciELO databases were searched using the subject keywords "sudden death, athletes and mortality". The incidence of SCD is expected at one case for each 200,000 young athletes per year. Overall it is resulted of complex dealings of factors such as arrhythmogenic substrate, regulator and triggers factors. In great part of deaths caused by heart disease in athletes younger than 35 years old investigations evidence cardiac congenital abnormalities. Athletes above 35 years old possibly die due to impairments of coronary heart disease, frequently caused by atherosclerosis. Myocardial ischemia and myocardial infarction are responsible for the most cases of SCD above this age (80%). Pre-participatory athletes' evaluation helps to recognize situations that may put the athlete's life in risk including cardiovascular diseases. In summary, cardiologic examinations of athletes' pre-competition routine is an important way to minimize the risk of SCD.
  DOI: 10.1186/1758-2555-2-19
  
• Clinical and arthroscopic findings in recreationally active patients
  ObjectiveTo examine the diagnostic accuracy of standard clinical tests for the shoulder in recreational athletes with activity related pain. Design: Cohort study with index test of clinical examination and reference standard of arthroscopy. Setting: Sports Medicine clinic in Sheffield, U.K. Participants: 101 recreational athletes (82 male, 19 female; mean age 40.8 +/- 14.6 years) over a six year period. Interventions: Bilateral evaluation of movements of the shoulder followed by standardized shoulder tests, formulation of clinical diagnosis and shoulder arthroscopy conducted by the same surgeon. Main Outcome Measurements: Sensitivity, specificity, likelihood ratio for a positive test and over-all accuracy of clinical examination was examined retrospectively and compared with arthroscopy. Results: Isolated pathology was rare, most patients (72%) having more than one injury recorded. O'Brien's clinical test had a mediocre sensitivity (64%) and over-all accuracy (54%) for diagnosing SLAP lesions. Hawkins test and Jobe's test had the highest but still not impressive over-all accuracy (67%) and sensitivity (67%) for rotator cuff pathology respectively. External and internal impingement tests showed similar levels of accuracy. When a positive test was observed in one of a combination of shoulder tests used for diagnosing SLAP lesions or rotator cuff disease, sensitivity increased substantially whilst specificity decreased. Conclusions: The diagnostic accuracy of isolated standard shoulder tests in recreational athletes was over-all very poor, potentially due to the majority of athletes (71%) having concomitant shoulder injuries. Most likely, this means that many of these injuries are missed in general practice and treatment is therefore delayed. Clinical examination of the shoulder should involve a combination of clinical tests in order to identify likely intra articular pathology which may warrant referral to specialist for surgery.
  DOI: 10.1186/1758-2555-2-2
  
• Novel strategies in tendon and ligament tissue engineering: Advanced biomaterials and regeneration motifs
  Tendon and ligaments have poor healing capacity and when injured often require surgical intervention. Tissue replacement via autografts and allografts are non-ideal strategies that can lead to future problems. As an alternative, scaffold-based tissue engineering strategies are being pursued. In this review, we describe design considerations and major recent advancements of scaffolds for tendon/ligament engineering. Specifically, we outline native tendon/ligament characteristics critical for design parameters and outcome measures, and introduce synthetic and naturally-derived biomaterials used in tendon/ligament scaffolds. We will describe applications of these biomaterials in advanced tendon/ligament engineering strategies including the utility of scaffold functionalization, cyclic strain, growth factors, and interface considerations. The goal of this review is to compile and interpret the important findings of recent tendon/ligament engineering research in an effort towards the advancement of regenerative strategies.
  DOI: 10.1186/1758-2555-2-20
  
• Pattern and management of sports injuries presented by Lagos state athletes at the 16th National Sports Festival (KADA Games 2009) in Nigeria
  Background: There is a dearth of information on the epidemiology of sports injuries in Nigeria. The study was aimed at documenting sports injuries sustained by Lagos state athletes during the 16th National Sports Festival (KADA Games 2009). It was also aimed at providing information on treatments offered to injured athletes. Methods: The study was carried out at Amadu Bello Stadium Complex, sporting arena of the Murtala Square and the team Lagos mini clinic. Participants were accredited Lagos state athletes who at one point in time during the games required treatment from any of the members of the medical team. Demographic data of athletes, type of injuries, body parts injured and treatment modalities used were documented and analysed using descriptive statistics. Results: Within the period of the games, a total of 140 sports injuries were documented from 132 athletes with an approximate male to female ratio of 2:1 and age ranging from 15-38 years. Most of the injuries reported by the athletes were "minor" injuries. Muscle strain was the most common type of injury (31.4%) followed by ligament sprains (22.9%). The lower extremities were the most injured body region accounting for 50% of all injuries. Over 60% of injuries presented by the athletes were from basketball, cricket, hockey, rugby and baseball. Cryotherapy was the most frequently used treatment modality, followed by bandaging and massage with anti-inflammatory gels. Conclusion: Establishing injury prevention programmes directed at the lower extremities may help reduce the risk of injuries to the lower extremities. Since cryotherapy was the most used treatment modality, it is suggested that it should be made abundantly available to the medical team preferably in forms of portable cold sprays for easy transportation and application during the games. It is also important that physiotherapists form the core of the medical team since they are trained to apply most of these treatment modalities and they also play a major role in establishing injury prevention routines. This data provides information that will be useful to both state and federal medical teams in preparing for future games.
  DOI: 10.1186/1758-2555-2-3
  
• Management of Tennis Elbow with sodium hyaluronate periarticular injections
  Objectives: To determine the efficacy and safety of peri-articular hyaluronic acid injections in chronic lateral epicondylosis (tennis elbow).DesignProspective randomized clinical trial in primary care sport medicine.Patients: Three hundred and thirty one consecutive competitive racquette sport athletes with chronic (>3 months) lateral epicondylosis were administered 2 injections (first injection at baseline) into the subcutaneous tissue and muscle 1 cm. from the lateral epicondyle toward the primary point of pain using a two-dimensional fanning technique. A second injection was administered 1 week later.Outcomes measures: Assessments were done at baseline, days 7, 14, 30, 90 and 356. Efficacy measures included patient's visual analogue scale (VAS) of pain at rest (0-100mm) and following assessment of grip strength (0-100mm). Grip strength was determined using a jamar hydraulic hand dynamometer. Other assessments included patients' global assessment of elbow injury (5 point categorical scale; 1=no disability, 5=maximal disability), patients' assessment of normal function/activity (5 point categorical scale), patients/physician satisfaction assessment (10 point categorical scale), time to return to pain-free and disability-free sport and adverse events as per WHO definition. Differences between groups were determined using an intent-to-treat ANOVA. Results: Average age of the study population was 49 years (+/- 12 years). One hundred and sixty-five patients were randomized to the HA and 166 were randomized to the control groups. The change in VAS pain was -6.7 (+/- 2.0) for HA vs -1.3 (+/- 1.5) for control (p<0.001). The VAS post handgrip was -7.8 (+/- 1.3) vs +0.3 (+/- 2.0) (p<0.001) which corresponded to a significant improvement in grip of 2.6kg in the HA vs control groups (p<0.01). Statistically significant improvement in patients' global assessment of elbow injury (p<0.02), patients' assessment of normal function/activity (p<0.05) and patients/physician satisfaction assessment (p<0.05) were also observed favoring the HA group. Time to return to pain-free and disability-free sport was 18 (+/- 11) days in the HA group but was not achieved in the control group. VAS changes were maintained in the HA group at each followup while those in the control significantly declined from baseline. Assessment of patient and physician satisfaction continued to favor the HA group at subsequent followup. Conclusion: Peri-articular HA treatment for tennis elbow was significantly better than control in improving pain at rest and after maximal grip testing. Further, HA treatment was highly satisfactory by patients and physicians and resulted in better return to pain free sport compared to control.
  DOI: 10.1186/1758-2555-2-4
  
• The effect of an external magnetic force on cell adhesion and proliferation of magnetically labeled mesenchymal stem cells
  Background: As the strategy for tissue regeneration using mesenchymal stem cells (MSCs) for transplantation, it is necessary that MSCs be accumulated and kept in the target area. To accumulate MSCs effectively, we developed a novel technique for a magnetic targeting system with magnetically labeled MSCs and an external magnetic force. In this study, we examined the effect of an external magnetic force on magnetically labeled MSCs in terms of cell adhesion and proliferation. Methods: Magnetically labeled MSCs were plated at the bottom of an insert under the influence of an external magnetic force for 1 hour. Then the inserts were turned upside down for between 1 and 24 hours, and the number of MSCs which had fallen from the membrane was counted. The gene expression of MSCs affected magnetic force was analyzed with microarray. In the control group, the same procedure was done without the external magnetic force. Results: At 1 hour after the inserts were turned upside down, the average number of fallen MSCs in the magnetic group was significantly smaller than that in the control group, indicating enhanced cell adhesion. At 24 hours, the average number of fallen MSCs in the magnetic group was also significantly smaller than that in control group. In the magnetic group, integrin alpha2, alpha6, beta3 BP, intercellular adhesion molecule-2 (ICAM-2), platelet/endothelial cell adhesion molecule-1 (PECAM-1) were upregulated. At 1, 2 and 3 weeks after incubation, there was no statistical significant difference in the numbers of MSCs in the magnetic group and control group. Conclusions: The results indicate that an external magnetic force for 1 hour enhances cell adhesion of MSCs. Integrin alpha2, alpha6, beta3 BP, ICAM-2, PECAM-1 might be involved in the process of cell adhesion of MSCs after using an external magnetic force. Moreover, there is no difference in cell proliferation after using an external magnetic force on magnetically labeled MSCs.
  DOI: 10.1186/1758-2555-2-5
  
• A displaced stress fracture of the femoral neck in an adolescent female distance runner with female athlete triad: A case report
  This report presents a case of a displaced stress fracture of the femoral neck in an adolescent female distance runner with amenorrhea. Both reduction and internal fixation were performed early after the injury. At 24 months postoperatively, magnetic resonance imaging and bone scintigraphy showed no positive signs of femoral head necrosis and bone union was confirmed on plain X-ray. A medical examination for the presence of the signs of the female athlete triad by checking weight, calorie intake and menstrual cycles is most important to prevent such stress fractures. Athletes as well as their coaches or parents therefore need to understand female athlete triad.
  DOI: 10.1186/1758-2555-2-6
  
• Retear of anterior cruciate ligament grafts in female basketball players: a case series
  Background: Incidence of anterior cruciate ligament (ACL) injuries in young female basketball players is higher than that in male basketball players. Graft retears are more frequent with the increasing number of ACL reconstructions. The present study aimed to examine the incidence of retears in competitive female basketball players. Methods: Sixty-four female basketball players (aged 12 to 29 years) who underwent primary anatomic double-bundle ACL reconstruction using hamstring grafts participated in the study. We investigated incidence, mechanism, and patient characteristics of ACL graft retears. Mann-Whitney U test was used for statistical analysis, and the level of significance was determined at P < 0.05. Results: Six patients suffered from ACL graft retear (9.4%). Mean duration between primary ACL reconstruction and incidence of retears was 11.7 months. However, there were no other postoperative graft ruptures after 24 months. Primary injury and retear mechanisms varied by patient. At six months after the primary ACL reconstruction surgery, mean quadriceps and hamstring strengths were 81% and 87%, respectively, indicating favorable recovery of muscle strength. However, preoperative quadriceps and hamstring strength in the retear group were 65% and 71%, respectively. In particular, preoperative quadriceps strength in the retear group demonstrated a lower value than that in the uninjured group (P < 0.05). Conclusions: We observed a high incidence of ACL graft retears in competitive female basketball players, as previously reported. Considering the timing of graft retear occurrences, an early return to playing basketball should be avoided following ACL reconstruction. Closer attention should be paid to player preoperative condition, as well as muscle strength and postoperative status.
  DOI: 10.1186/1758-2555-2-7
  
• The kinematics of upper extremity reaching-a reliability study on people with and without shoulder impingement syndrome
  Background: Tasks chosen to evaluate motor performance should reflect the movement deficits characteristic of the target population and present an appropriate challenge for the patients who would be evaluated. A reaching task that evaluates impairment characteristics of people with shoulder impingement syndrome (SIS) was developed to evaluate the motor performance of this population. The objectives of this study were to characterize the reproducibility of this reaching task in people with and without SIS and to evaluate the impact of the number of trials on reproducibility. Methods: Thirty subjects with SIS and twenty healthy subjects participated in the first measurement session to evaluate intrasession reliability. Ten healthy subjects were retested within 2 to 7 days to assess intersession reliability. At each measurement session, upper extremity kinematic patterns were evaluated during a reaching task. Ten trials were recorded. Thereafter, the upper extremity position at the end of reaching and total joint excursion that occurred during reaching were calculated. Intraclass correlation coefficient (ICC) and minimal detectable change (MDC) were used to estimate intra and intersession reliability. Results: Intrasession reliability for total joint excursion was good to very good when based on the two first trials (0.77 < ICC < 0.99), and very good when based on either the first or last five trials (ICC > 0.92). As for end-reach position, intrasession reliability was very good when using either the two first, five first or last five trials (ICC > 0.82). Globally, MDC were smaller for the five last trials. Intersession reliability of total joint excursion and position at the end of reaching was good to very good when using the mean of the two or five first trials (0.69 < ICC < 0.95), and very good when using the mean of the ten trials (ICC > 0.82). For most joints, MDC were smaller when using all ten trials. Conclusions: The reaching task proposed to evaluate the upper limb motor performance was found reliable in people with and without SIS. Furthermore, the minimal difference necessary to infer a meaningful change in motor performance was determined, indicating that relatively small changes in task performance can be interpreted as a change in motor performance.
  DOI: 10.1186/1758-2555-2-8
  
• Uncommon cause for anterior knee pain: Aggressive aneurysmal bone cyst of the patella
  A 56-year-old man presented with a two month history of increasing anterior knee pain without previous trauma. As usual we recommended physiotherapy with stretching exercises of the quadriceps muscle. Since symptoms did not improve after 6 weeks MRI was performed. Surprisingly a hyperintense lobulated mass of the patella with small fluid-filled cavities at the inferior pole was revealed. We performed an open biopsy to exclude any malignancy and diagnosed an aneurysmal bone cyst. Further examination with CT scans showed an aggressive behaviour with cortical breakthrough.We performed an intralesional curettage with additional high-speed burring and bone cement packing. Sixteen months later the patient was free from any complaints and without signs of local recurrence.Primary bone tumors of the patella are extremely rare and occurrence of aneurysmal bone cysts in this localization is very uncommon. This case report indicates that although anterior knee pain is a very frequent and usually harmless symptom, it is essential to consider that it might also be caused by more severe disorders such as bone tumors.
  DOI: 10.1186/1758-2555-2-9
  

  VOL 3 NUMBER 2011

• Shoulder muscle endurance: the development of a standardized and reliable protocol
  Background: Shoulder muscle fatigue has been proposed as a possible link to explain the association between repetitive arm use and the development of rotator cuff disorders. To our knowledge, no standardized clinical endurance protocol has been developed to evaluate the effects of muscle fatigue on shoulder function. Such a test could improve clinical examination of individuals with shoulder disorders. Therefore, the purpose of this study was to establish a reliable protocol for objective assessment of shoulder muscle endurance. Methods: An endurance protocol was developed on a stationary dynamometer (Biodex System 3). The endurance protocol was performed in isotonic mode with the resistance set at 50% of each subject's peak torque as measured for shoulder external (ER) and internal rotation (IR). Each subject performed 60 continuous repetitions of IR/ER rotation. The endurance protocol was performed by 36 healthy individuals on two separate occasions at least two days apart. Maximal isometric shoulder strength tests were performed before and after the fatigue protocol to evaluate the effects of the endurance protocol and its reliability. Paired t-tests were used to evaluate the reduction in shoulder strength due to the protocol, while intraclass correlation coefficients (ICC) and minimal detectable change (MDC) were used to evaluate its reliability. Results: Maximal isometric strength was significantly decreased after the endurance protocol (P<0.001). The total work performed during the last third of the protocol was significantly less than the first third of the protocol (P < 0.05). The test-retest reliability of the post-fatigue strength measures was excellent (ICC>0.84). Conclusions: Changes in muscular performance observed during and after the muscular endurance protocol suggests that the protocol did result in muscular fatigue. Furthermore, this study established that the resultant effects of fatigue of the proposed isotonic protocol were reproducible over time. The protocol was performed without difficulty by all volunteers and took less than 10 minutes to perform, suggesting that it might be feasible for clinical practice. This protocol could be used to induce local muscular fatigue in order to evaluate the effects of fatigue on shoulder kinematics or to evaluate changes in shoulder muscle endurance following rehabilitation.
  DOI: 10.1186/1758-2555-3-1
  
• Maci - a new era '
  Full thickness articular cartilage defects have limited regenerative potential and are a significant source of pain and loss of knee function. Numerous treatment options exist, each with their own advantages and drawbacks. The goal of this review is to provide an overview of the problem of cartilage injury, a brief description of current treatment options and outcomes, and a discussion of the current principles and technique of Matrix-induced Autologous Chondrocyte Implantation (MACI). While early results of MACI have been promising, there is currently insufficient comparative and long-term outcome data to demonstrate superiority of this technique over other methods for cartilage repair.
  DOI: 10.1186/1758-2555-3-10
  
• Autologous Chondrocyte Implantation (ACI) for the Treatment of Large and Complex Cartilage Lesions of the Knee
  Background: Complex cartilage lesions of the knee including large cartilage defects, kissing lesions, and osteoarthritis (OA) represent a common problem in orthopaedic surgery and a challenging task for the orthopaedic surgeon. As there is only limited data, we performed a prospective clinical study to investigate the benefit of autologous chondrocyte implantation (ACI) for this demanding patient population. Methods: Fifty-one patients displaying at least one of the criteria were included in the present retrospective study: (1.) defect size larger than 10 cm2; (2.) multiple lesions; (3.) kissing lesions, cartilage lesions Outerbridge grade III-IV, and/or (4.) mild/moderate osteoarthritis (OA). For outcome measurements, the International Cartilage Society's International Knee Documentation Committee's (IKDC) questionnaire, as well as the Cincinnati, Tegner, Lysholm and Noyes scores were used. Radiographic evaluation for OA was done using the Kellgren score.Results and Discussion: Patient's age was 36 years (13-61), defects size 7.25 (3-17.5) cm2, previous surgical procedures 1.94 (0-8), and follow-up 30 (12-63) months. Instruments for outcome measurement indicated significant improvement in activity, working ability, and sports. Mean ICRS grade improved from 3.8 preoperatively to grade 3 postoperatively, Tegner grade 1.4 enhanced to grade 3.39. The Cincinnati score enhanced from 25.65 to 66.33, the Lysholm score from 33.26 to 64.68, the Larson score from 43.59 to 79.31, and Noyes score from 12.5 to 46.67, representing an improvement from Cincinnati grade 3.65 to grade 2.1. Lysholm grade 4 improved to grade 3.33, and Larson grade 3.96 to 2.78 (Table 2), (p<0.001). Patients with kissing cartilage lesions had similar results as patients with single cartilage lesions. Conclusion: Our results suggest that ACI provides mid-term results in patients with complex cartilage lesions of the knee. If long term results will confirm our findings, ACI may be a considered as a valuable tool for the treatment of complex cartilage lesions of the knee.
  DOI: 10.1186/1758-2555-3-11
  
• Firm Insoles Effectively Reduce Hemolysis in Runners during Long Distance Running - A Comparative Study
  Background: Shock absorbing insoles are effective in reducing the magnitude and rate of loading of peak impact forces generated at foot strike during running, whereas the foot impact force during running has been considered to be an important cause of intravascular hemolysis in long distance runners. Objective of this study was to evaluate the intravascular hemolysis during running and compare the effect of two different types of insoles (Soft and Firm) on hemolysis. Methods: Twenty male long and middle distance runners volunteered to participate in this study. We selected two insoles (Soft and Firm) according to their hardness level (SHORE 'A' scale). Participants were randomly assigned to the soft insole (group 1) and firm insole (group 2) group with ten athletes in each group. Each athlete completed one hour of running at the calculated target heart rate (60-70%). Venous blood samples were collected before and immediately after running. We measured unconjucated bilirubin (mg/dl), lactate dehydrogenase (u/ml), hemoglobin (g/l) and serum ferritin (ng/ml) as indicators of hemolysis. Results: Our study revealed a significant difference in the mean values of unconjucated bilirubin (P<0.05) while running with soft insoles indicating the occurrence of hemolysis in this group of athletes. Graphical analysis revealed an inverse relationship between hardness of insoles and hemolysis for the observed values. Conclusion: Our results indicate that intravascular hemolysis occurs in athletes during long distance running and we conclude that addition of firm insoles is an effective way of reducing the amount of hemolysis in runners compared to soft insoles.
  DOI: 10.1186/1758-2555-3-12
  
• Effect of a 6-week dynamic neuromuscular training programme on ankle joint function: A Case report
  Background: Ankle joint sprain and the subsequent development of chronic ankle instability (CAI) are commonly encountered by clinicians involved in the treatment and rehabilitation of musculoskeletal injuries. It has recently been advocated that ankle joint post-sprain rehabilitation protocols should incorporate dynamic neuromuscular training to enhance ankle joint sensorimotor capabilities. To date no studies have reported on the effects of dynamic neuromuscular training on ankle joint positioning during landing from a jump, which has been reported as one of the primary injury mechanism for ankle joint sprain. This case report details the effects of a 6-week dynamic neuromuscular training programme on ankle joint function in an athlete with CAI. Methods: The athlete took part in a progressive 6-week dynamic neuromuscular training programme which incorporated postural stability, strengthening, plyometric, and speed/agility drills. The outcome measures chosen to assess for interventional efficacy were: (1) Cumberland Ankle Instability Tool (CAIT) scores, (2) Star Excursion Balance Test (SEBT) reach distance, (3) ankle joint plantar flexion during drop landing and drop vertical jumping, and (4) ground reaction forces (GRFs) during walking. Results: CAIT and SEBT scores improved following participation in the programme. The angle of ankle joint plantar flexion decreased at the point of initial contact during the drop landing and drop vertical jumping tasks, indicating that the ankle joint was in a less vulnerable position upon landing following participation in the programme. Furthermore, GRFs were reduced whilst walking post-intervention. Conclusions: The 6-week dynamic neuromuscular training programme improved parameters of ankle joint sensorimotor control in an athlete with CAI. Further research is now required in a larger cohort of subjects to determine the effects of neuromuscular training on ankle joint injury risk factors.
  DOI: 10.1186/1758-2555-3-13
  
• Effects of Jump and Balance Training on Knee Kinematics and Electromyography of Female Basketball Athletes during a Single Limb Drop Landing: Pre-post intervention study
  Background: Some research studies have investigated the effects of anterior cruciate ligament (ACL) injury prevention programs on knee kinematics during landing tasks; however the results were different among the studies. Even though tibial rotation is usually observed at the time of ACL injury, the effects of training programs for knee kinematics in the horizontal plane have not yet been analyzed. The purpose of this study was to determine the effects of a jump and balance training program on knee kinematics including tibial rotation as well as on electromyography of the quadriceps and hamstrings in female athletes. Methods: Eight female basketball athletes participated in the experiment. All subjects performed a single limb landing at three different times: the initial test, five weeks later, and one week after completing training. The jump and balance training program lasted for five weeks. Knee kinematics and simultaneous electromyography of the rectus femoris and Hamstrings before training were compared with those measured after completing the training program. Results: After training, regarding the position of the knee at foot contact, the knee flexion angle for the Post-training trial (mean (SE): 24.4 (2.1) deg) was significantly larger than that for the Pre-training trial (19.3 (2.5) deg) (p < 0.01). The absolute change during landing in knee flexion for the Post-training trial (40.2 (1.9) deg) was significantly larger than that for the Pre-training trial (34.3 (2.5) deg) (p < 0.001). Tibial rotation and the knee varus/valgus angle were not significantly different after training. A significant increase was also found in the activity of the hamstrings 50 ms before foot contact (p < 0.05). Conclusions: The jump and balance training program successfully increased knee flexion and hamstring activity of female athletes during landing, and has the possibility of producing partial effects to avoid the characteristic knee position observed in ACL injury, thereby preventing injury. However, the expected changes in frontal and transverse kinematics of the knee were not observed.
  DOI: 10.1186/1758-2555-3-14
  
• Effects of different initial bundle tensioning strategies on the outcome of double-bundle ACL reconstruction: a cohort study
  Background: This study was performed to investigate the effects of different strategies and initial tension applied to each one of the bundles, antero-medial (AM) and postero-lateral (PL), on clinical outcome in double bundle (DB) ACL reconstruction. Methods: One hundred fifty-one primary unilateral DB ACL reconstructions performed by a single surgeon from 1994 through 2002 were included in the study with a follow-up of at least 24 months. They were divided in the following 3 groups: Group I - Higher initial tension applied manually in the AM bundle compared to PL. II - Higher tension applied in the PL bundle compared to AM. III - The 2 bundles were attempted to be equally tensioned. All fixations were performed in 30 degrees of flexion. Group I = 59 patients, group II = 53 patients and group III = 39 patients. The groups had no statistical differences concerning demographic distribution. Clinical outcome was retrospectively evaluated by use of knee range of motion, manual knee laxity tests, KT-1000, Lysholm knee scale, subjective recovery scale and sports performance recovery scale. The differences of data were analyzed among the three groups. Results: Group I showed a significant extension deficit compared with groups II and III. ANOVA revealed a significant difference of anterior laxity measured by the KT-1000 (average KT difference of 2.1, 2.1 and 1.2mm in Group I, II and III, respectively). A statistical difference was found among the three groups regarding subjective and sports performance recovery scales with Group II showing higher scores in recovery than Group I. Conclusions: The current clinical study does not recommend manual maximum of initial tension applied to the anteromedial or posterolateral bundles with graft tension imbalance at 30 degrees of flexion in double-bundle ACL reconstruction to achieve a better clinical outcome.
  DOI: 10.1186/1758-2555-3-15
  
• Evaluation of movements of lower limbs in non-professional ballet dancers: hip abduction and flexion
  Background: The literature indicated that the majority of professional ballet dancers present static and active dynamic range of motion difference between left and right lower limbs, however, no previous study focused this difference in non-professional ballet dancers. In this study we aimed to evaluate active movements of the hip in non-professional classical dancers. Methods: We evaluated 10 non professional ballet dancers (16-23 years old). We measured the active range of motion and flexibility through Well Banks. We compared active range of motion between left and right sides (hip flexion and abduction) and performed correlation between active movements and flexibility. Results: There was a small difference between the right and left sides of the hip in relation to the movements of flexion and abduction, which suggest the dominant side of the subjects, however, there was no statistical significance. Bank of Wells test revealed statistical difference only between the 1st and the 3rd measurement. There was no correlation between the movements of the hip (abduction and flexion, right and left sides) with the three test measurements of the bank of Wells. Conclusion: There is no imbalance between the sides of the hip with respect to active abduction and flexion movements in non-professional ballet dancers.
  DOI: 10.1186/1758-2555-3-16
  
• One Strategy for Arthroscopic Suture Fixation of Tibial Intercondylar Eminence Fractures Using the Meniscal Viper Repair System
  ABSTRACT Background: Principles for the treatment of tibial intercondylar eminence fracture are early reduction and stable fixation. Numerous ways to treatment of this fracture have been invented. We designed a simple, low-invasive, and arthroscopic surgical strategy for tibial intercondylar eminence fracture utilizing the Meniscal Viper Repair System used for arthroscopic meniscal suture. Methods: We studied 5 patients, who underwent arthroscopic suture fixation that we modified. The present technique utilized the Meniscal Viper Repair System for arthroscopic suture of the meniscus. With one handling, a high-strength ultra-high molecular weight polyethylene(UHMWPE) suture can be passed through the anterior cruciate ligament (ACL) and the loops for suture retrieval placed at both sides of ACL. Surgical results were evaluated by the presence or absence of bone union on plain radiographs, postoperative range of motion of the knee joint, the side-to-side differences measured by Telos SE, and Lysholm scores. Results: The reduced position achieved after surgery was maintained and good function was obtained in all cases. The mean distance of tibia anterior displacement and assessment by Lysholm score showed good surgical results. Conclusion: This method simplified the conventional arthroscopic suture fixation and increased its precision, and was applicable to Type II fractures that could be reduced, as well as surgically indicated Types III and IV. The present series suggested that our surgical approach was a useful surgical intervention for tibial intercondylar eminence fracture.
  DOI: 10.1186/1758-2555-3-17
  
• Stretching positions for the coracohumeral ligament: Strain measurement during passive motion using fresh/frozen cadaver shoulders
  Background: Contracture of the coracohumeral ligament is reported to restrict external rotation of the shoulder with arm at the side and restrict posterior-inferior shift of the humeral head. The contracture is supposed to restrict range of motion of the glenohumeral joint. Methods: To obtain stretching position of the coracohumeral ligament, strain on the ligament was measured at the superficial fiber of the ligament using 9 fresh/frozen cadaver shoulders. By sequential measurement using a strain gauge, the ligament strain was measured from reference length (L0). Shoulder positions were determined using a 3 Space Tracker System. Through a combination of previously reported coracohumeral stretching positions and those observed in preliminary measurement, ligament strain were measured by passive external rotation from 10degrees internal rotation, by adding each 10degrees external rotation, to maximal external rotation. Results: Stretching positions in which significantly larger strain were obtained compared to the L0 values were 0degrees elevation in scapula plane with 40degrees, 50degrees and maximum external rotation (5.68%, 7.2%, 7.87%), 30degrees extension with 50degrees, maximum external rotation (4.20%, 4.79%), and 30degrees extension + adduction with 30degrees, 40degrees, 50degrees and maximum external rotation (4.09%, 4.67%, 4.78%, 5.05%)(P<0.05). No positive strain on the coracohumeral ligament was observed for the previously reported stretching positions; ie, 90degrees abduction with external rotation or flexion with external rotation. Conclusions: Significant strain of the coracohumeral ligament will be achieved by passive external rotation at lower shoulder elevations, extension, and extension with adduction.
  DOI: 10.1186/1758-2555-3-2
  
• Comparison of the incidence, nature and cause of injuries sustained on dirt field and artificial turf field by amateur football players
  Background: Data on the incidence, nature, severity and cause of match football injuries sustained on dirt field are scarce. The objectives of this study was to compare the incidence, nature, severity and cause of match injuries sustained on dirt field and artificial turf field by amateur male football players. Methods: A prospective two-cohort design was employed. Participants were 252 male football players (mean age 27 years, range 18-43) in 14 teams who participated in a local championship carried on a dirt field and 216 male football players (mean age 28 years, range 17-40) in 12 teams who participated in a local championship carried on a artificial turf field in the same zone of the city.Injury definitions and recording procedures were compliant with the international consensus statement for epidemiological studies of injuries in football. Results: The overall incidence of match injuries for men was 36.9 injuries/1000 player hours on dirt field and 19.5 on artificial turf (incidence rate ratio 1.88; 95% CI 1.19- 3.05).Most common injured part on dirt field was ankle (26.7%) and on artificial turf was knee (24.3%). The most common injury type in the dirt field was skin injuries (abrasion and laceration) and in the artificial turf was sprain and ligament injury followed by haematoma/contusion/bruise.Most injuries were acute (artificial turf 89%, dirt field 91%) and resulted from player-to-player contact (artificial turf 59.2%, dirt field 51.4%).Most injuries were slight and minimal in dirt field cohort but in artificial turf cohort the most injuries were mild. Conclusions: There were differences in the incidence and type of football match injuries sustained on dirt field and artificial turf.
  DOI: 10.1186/1758-2555-3-3
  
• Patterns of weight loss and supplement consumption of male wrestlers in Tehran
  Background: To evaluate the weight loss behavior of male wrestlers in Tehran. Methods: This study was a population-based cross sectional survey. Subjects were 436 wrestlers randomly selected from the wrestling clubs in Tehran employing cluster sample setting method. Subjects were interviewed based on a designed questionnaire. Body fat levels were measured based on skin fold measurements. Results: Weight loss methods practiced by 62% of all subjects during the previous year employing rapid ([less than or equal to]7days before the matches) and gradual (>7 days before the matches) weight reduction methods (73% and 34% of wrestlers who reduced their weight respectively). In addition, opinions on weight reduction, the methods of weight loss used, and the side effects of the weight loss practices as well as consumption of supplements among the subjects were reported in this study. The mean percentage of body fat of subjects was 15.9%. Conclusions: Rapid weight loss for matches and the use of unsafe methods of weight reduction such as fasting, and fluid reduction methods as well as acute side effects of weight loss were prevalent among wrestlers in Tehran. Some preventive measures including education and new rules such as scheduling weigh-ins immediately prior to the competitions and mat-side weigh-in are needed to prevent these unhealthy practices. The weight loss behaviors of these wrestlers should be changed from using dehydration methods to using gradual methods of weight loss.
  DOI: 10.1186/1758-2555-3-4
  
• Combined Autologous Chondrocyte Implantation (ACI) with supra-condylar femoral varus osteotomy, following lateral growth-plate damage in an adolescent knee: 8-year follow-up
  We report the 8-year clinical and radiographic outcome of an adolescent patient with a large osteochondral defect of the lateral femoral condyle, and ipsilateral genu valgum secondary to an epiphyseal injury, managed with autologous chondrocyte implantation (ACI) and supracondylar re-alignment femoral osteotomy. Long-term clinical success was achieved using this method, illustrating the effective use of re-alignment osteotomy in correcting mal-alignment of the knee, protecting the ACI graft site and providing the optimum environment for cartilage repair and regeneration. This is the first report of the combined use of ACI and femoral osteotomy for such a case.
  DOI: 10.1186/1758-2555-3-5
  
• The highly accurate anteriolateral portal for injecting the knee.
  Background: The extended knee lateral midpatellar portal for intraarticular injection of the knee is accurate but is not practical for all patients. We hypothesized that a modified anteriolateral portal where the synovial membrane of the medial femoral condyle is the target would be highly accurate and effective for intraarticular injection of the knee. Methods: 83 subjects with non-effusive osteoarthritis of the knee were randomized to intraarticular injection using the modified anteriolateral bent knee versus the standard lateral midpatellar portal. After hydrodissection of the synovial membrane with lidocaine using a mechanical syringe (reciprocating procedure device), 80 mg of triamcinolone acetonide was injected into the knee with a 2.0-in (5.1-cm) 21-gauge needle. Baseline pain, procedural pain, and pain at outcome (2 weeks and 6 months) were determined with the 0-10 cm Visual Analogue Pain Score (VAS). The accuracy of needle placement was determined by sonographic imaging. Results: The lateral midpatellar and anteriolateral portals resulted in equivalent clinical outcomes including procedural pain (VAS midpatellar: 4.6+/-3.1 cm; anteriolateral: 4.8+/-3.2 cm; p =0.77), pain at outcome (VAS midpatellar: 2.6+/-2.8 cm; anteriolateral: 1.7+/-2.3 cm; p= 0.11), responders (midpatellar: 45%; anteriolateral: 56%; p=0.33), duration of therapeutic effect (midpatellar: 3.9+/-2.4 months; anteriolateral: 4.1+/-2.2 months; p=0.69), and time to next procedure (midpatellar: 7.3+/-3.3 months; anteriolateral: 7.7+/-3.7 months; p=0.71). The anteriolateral portal was 97% accurate by real-time imaging. Conclusion: The modified anteriolateral bent knee portal is an effective, accurate, and equivalent alternative to the standard lateral midpatellar portal for intraarticular injection of the knee.Trial Registration: ClinicalTrials.gov (Sponsored by the U.S. National Institutes of Health) NCT00651625.
  DOI: 10.1186/1758-2555-3-6
  
• Anterior cruciate ligament reconstruction using quadriceps tendon autograft for adolescents with open physes - a technical note
  Background: One major concern in the treatment of ACL lesions in children and adolescents with open physes is the risk of iatrogenic damage to the physes and a possibly resulting growth disturbance.Purpose: The primary purpose of this article is to describe our technique of a transphyseal ACL reconstruction using quadriceps tendon-bone autograft in children and adolescents with open growth plates. The secondary aim is to report our early results in terms of postoperative growth disturbances which are considered to be a major concern in this challenging group of patients. It was our hypothesis that with our proposed technique no significant growth disturbances would occur. Methods: From January 1997 to December 2007 49 consecutive children and adolescents with open growth plates were treated for a torn ACL using the aforementioned surgical technique. The patients (28 males and 21 females) with a median age at surgery of 13 (range 8-15) years were retrospectively evaluated. Outcome measures were follow-up radiographs (weight-bearing long leg radiographs of the injured and uninjured knee, anteroposterior and lateral views, a tangential view of the patella and a tunnel view of the injured knee) and follow-up notes (6 weeks, 3, 6, 12 months and until closing of physes) for occurrence of any tibial and/or femoral growth changes. Results: All of the 49 patients had a sufficient clinical and radiological follow-up (minimum 5 years, rate 100%). 48 cases did not show any clinical and radiological growth disturbance. One case of growth disturbance in a 10.5 years old girl was observed. She developed a progressive valgus-flexion deformity which was attributed to a malplacement of the autograft bone block within the femoral posterolateral epiphyseal plate leading to an early localized growth stop. None of the patients were reoperated due to ACL graft failure. Five of the patients underwent revision ACL surgery due to another adequate sports trauma after the growth-stop. The tibial fixation screw had to be removed under local anaesthesia in 10 patients. Conclusions: The described ACL reconstruction technique represents a promising alternative to previously described procedures in the treatment of children and adolescents with open growth plates. Using quadriceps tendon future graft availability is not compromised, as the most frequently used autograft-source, ipsilateral hamstring tendons, remains untouched.
  DOI: 10.1186/1758-2555-3-7
  
• Multiple lumbar transverse process stress fractures as a cause of chronic low back ache in a young fast bowler - a case report
  A rare case of multilevel transverse process stress fractures as a cause of low back ache in a professional cricket player has been presented. The report discusses the possible mechanism of such an injury in a cricket player and also highlights the preventive and therapeutic aspects of management in such patients. The report also stresses upon the need for early identification of such sports related injuries to prevent long term morbidity in the athletes.
  DOI: 10.1186/1758-2555-3-8
  
• Static Stretching Does Not Alter Pre and Post-landing Muscle Activation
  Static stretching may result in various strength and power deficiencies. Prior research has not determined, however, if static stretching causes a change in muscle activation during a functional task requiring dynamic stability. The purpose of this study was to determine if static stretching has an effect on mean pre and postlanding muscle (vastus medialis VM, vastus lateralis VL, medial hamstring MH, and biceps femoris BF) activity. Methods: 26 healthy, physically active subjects were recruited, from which 13 completed a 14-day static stretching regimen for the quadriceps and hamstrings. Using the data from the force plate and EMG readings, a mean of EMG amplitude was calculated for 150 msec before and after landing. Each trial was normalized to an isometric reference position. Means were calculated for the VM, VL, MH, and BF from 5 trials in each session. Measures were collected pre, immediately following the 1st stretching session, and following 2 weeks of stretching. Results: A 14-day static stretching regimen resulted in no significant differences in pre or postlanding mean EMG amplitude during a drop landing either acutely or over a 14-day period. Conclusions: Static stretching, done acutely or over a 14-day period does not result in measurable differences of mean EMG amplitude during a drop landing. Static stretching may not impede dynamic stability of joints about which stretched muscles cross.
  DOI: 10.1186/1758-2555-3-9