Physical Therapy Practice

THE MAGAZINE OF THE ORTHOPAEDIC SECTION, APTA

VOL. 17, NO. 4 2005 ORTHOPAEDIC ORTHOPAEDIC Physical Therapy Practice VOL. 17, NO. 4 2005

inthisissue regularfeatures

8 | Posterior Heel Flare and Chronic Exertional Anterior 5 | Editor’s Corner Compartment Syndrome: A Case Study 6 | President’s Message Michael T. Gross, Bing Yu, Robin M. Queen 29 | Book Reviews 14 | Anterior Cruciate Ligament Reconstruction: Surgical Management and Postoperative Rehabilitation Considerations 36 | Web Watch Marie-Josee Paris, Reg B. Wilcox III, Peter J. Millett 47 | Occupational Health SIG Newsletter 26 | Comparison of Standard Blood Pressure Cuff 49 | Foot and Ankle SIG Newsletter and a Commercially Available Pressure Biofeedback Pain Management SIG Newsletter Unit While Performing Prone Lumbar Stabiization Exercise 52 | Ward Mylo Glasoe, Reginald R. Marquez, 54 | Performing Arts SIG Newsletter Whittney J. Miller, Anthony J. Placek 58 | Animal Physical Therapist SIG Newsletter 32 | Congratulations Newly Orthopaedic Certified Specialists 60 | Advertiser Index 37 | Board of Director’s Meeting Minutes 40 | 2006 CSM Schedule 42 | Platform Presentations

optpmission publicationstaff

The mission of the Orthopaedic Section of the Managing Editor & Advertising Advisory Council American Physical Therapy Association is to be the Sharon L. Klinski G. Kelley Fitzgerald, PT, PhD, OCS leading advocate and resource for the practice of Orthopaedic Section, APTA Joe Kleinkort, PT, MA, PhD, CIE Orthopaedic Physical Therapy. The Section will serve 2920 East Ave So, Suite 200 Becky Newton, MSPT its members by fostering quality patient/client care and La Crosse, Wisconsin 54601 Stephen Paulseth, PT, MS promoting professional growth through: 800-444-3982 x 202 Robert Rowe, PT, DMT, MHS, 608-788-3965 FAX FAAOMPT • enhancement of clinical practice, Email: [email protected] Gary Smith, PT, PhD • advancement of education, and Editor Michael Wooden, PT, MS, OCS • facilitation of quality research. Christopher Hughes, PT, PhD, OCS

Publication Title: Orthopaedic Physical Therapy Practice Statement of Frequency: Quarterly; April, June, August, and December Authorized Organization’s Name and Address: Orthopaedic Section, APTA, Inc., 2920 East Avenue South, Suite 200, La Crosse, WI 54601-7202

Orthopaedic Physical Therapy Practice (ISSN 1532-0871) is the official magazine of the Orthopaedic Section, APTA, Inc. Copyright 2005 by the Orthopaedic Section/APTA. Nonmember subscriptions are available for $30 per year (4 issues). Opinions expressed by the authors are their own and do not necessarily reflect the views of the Orthopaedic Section. The editor reserves the right to edit manuscripts as necessary for publication. All requests for change of address should be directed to the La Crosse Office. All advertisements which appear in or accompany Orthopaedic Physical Therapy Practice are accepted on the basis of conformation to ethical physical therapy standards, but acceptance does not imply endorsement by the Orthopaedic Section. Orthopaedic Physical Therapy Practice is indexed by Cumulative Index to Nursing & Allied Health Literature (CINAHL).

Orthopaedic Practice Vol. 17;4:05 3 Orthopaedic Section Directory officers

President: Vice President: Treasurer: Director: Director: Michael T. Cibulka, DPT, Thomas G. McPoil, Jr, PT, Joe Godges, DPT, MA, OCS James Irrgang, PT, PhD, ATC William H. O’Grady, PT, DPT, MHS, OCS PhD, ATC Kaiser PT Residency University of Pittsburgh OCS, FAAOMPT, AAPM Jefferson County Rehab 1630 W University Heights Drive & Fellowships Department of Physical Therapy 1214 Starling St & Sports Clinic South Flagstaff, AZ 86001 6107 West 75th Place Sennett at Atwood Streets Steilacoom, WA 98388-2040 1330 YMCA Drive, Suite 1200 (928) 523-1499 Los Angeles, CA 90045-1633 Pittsburgh, PA 15260 (253) 588-5662 (Office) Festus, MO 63028 (928) 523-9289 (FAX) (310) 215-3664 (Office) (412) 432-1237 (Office) [email protected] (636) 937-7677 (Office) [email protected] (310) 215-0780 (FAX) (412) 647-1454 (FAX) Term: 2005-2008 (636) 931-8808 (FAX) Term 2004 - 2007 [email protected] [email protected] [email protected] Term: 2005-2008 Term: 2003-2006 Term: 2004 - 2007 chairs

MEMBERSHIP EDUCATION PROGRAM INDEPENDENT STUDY COURSE ORTHOPAEDIC PRACTICE Chair: Chair: Editor: Editor: Scott Adam Smith, MPT Ellen Hamilton, PT, OCS Mary Ann Wilmarth, DPT, MS, OCS, Christopher Hughes, PT, PhD, OCS 29 Lawrence Street 720 Montclair Road, Ste 100 MTC, CertMDT School of Physical Therapy Hicksville, NY 11801 Birmingham, AL 35213 10 Nollet Dr Slippery Rock University (516) 681-5647 (Office) (205) 298-9101 Andover, MA 01810-6312 Slippery Rock, PA 16057 [email protected] (205) 599-4535 (FAX) (978) 682-8802 (724) 738-2757 [email protected] [email protected] [email protected] Members: Hunter Bowie, Julia Chevan, Vice Chair: John Childs, Melissa Corriveau, Managing Editor: Managing Editor: Beth Jones, PT, DPT, MS, OCS Byron Russell, Terry Trundle Kathy Olson Sharon Klinski Members: Dee Daley, Bob Duvall, (800) 444-3982, x213 (800) 444-3982, x202 Deborah Gross-Saunders, Kristinn Heindrichs, [email protected] [email protected] Joe Kleinkort, Deborah Lechner, David McCune, Tara Manal, Cheryl Mauer, Stephen Paulseth, Chris Powers, Christopher Scott, Jeff Stenbach

RESEARCH ORTHOPAEDIC SPECIALTY PRACTICE PUBLIC RELATIONS/ Chair: COUNCIL Chair: MARKETING G. Kelley Fitzgerald, PT, PhD, OCS Chair: Robert (Bob) H Rowe, PT, DMT, Chair: University of Pittsburgh Rob Landel, PT, DPT, OCS MHS, FAAOMPT Richard Watson, PT Department of Physical Therapy Division of Independent Health Professions 126 Oak Leaf Drive 1266 Berkshire Lane 6035 Forbes Tower University of Southern California Slidell, LA 70461-5006 Barrington, IL 60010-6508 Pittsburgh, PA 16260 1540 E. Alcazaar St, CHP 155 (985) 645-9329 (847) 726-9181 (412) 383-6643 (Office) Los Angeles, CA 90033 [email protected] (703) 935-4754 (FAX) (412) 383-6629 (FAX) (323) 442-2912 [email protected] [email protected] (323) 442-1515 (FAX) Members: Bill Boissonnault, Joe Farrell, [email protected] Helene Fearon, Jay Irrgang, Aimee Klein, Members: Amanda Adams, Members: Paul Beattie, Gregory Hicks, Stephen McDavitt, Ken Olson, Cheryl Dimapasoc, Michelle Spicka, Lori Michen, Sheri Silfies Members: Amice Klein, Robert Johnson Richard Smith, Debbie Todd Michael Tollan

FINANCE AWARDS JOSPT NOMINATIONS Chair: Chair: Editor-in-Chief: Chair: Joe Godges, DPT, MA, OCS Thomas G. McPoil, Jr, PT, PhD, ATC Guy Simoneau, PT, PhD, ATC Leza Hatch, PT, MSPT, MA, OCS (See Treasurer) (See Vice President) Marquette University [email protected] P.O. Box 1881 Members: John Childs, Steve Clark, Members: Gary Hunt, Susan Appling, Milwaukee, WI 53201-1881 Members: Pamela Duffy, Kyndall Boyle Pam White Carl DeRosa, Dale Schuit (414) 288-3380 (Office) (414) 288-5987 (FAX) [email protected] Executive Director/Publisher: Edith Holmes [email protected]

SPECIAL INTEREST GROUPS APTA BOARD LIAISON Orthopaedic Section OCCUPATIONAL HEALTH SIG PAIN MANAGEMENT SIG Stephen Levine, PT, DPT, MSHA Web site: Deborah Lechner, PT, MS - President Joe Kleinkort, PT, MA, PhD, CIE - President [email protected] www.orthoopt.org FOOT AND ANKLE SIG ANIMAL PT SIG 2005 HOUSE OF DELEGATES Bulletin Board feature also Stephen G. Paulseth, PT, MS, SCS - President Deborah Gross-Saunders, PT - President REPRESENTATIVE included. PERFORMING ARTS SIG Bob Rowe, PT, DMT, MHS, FAAOMPT Susan Clinton, PT, MHS - President Check it out soon.

officepersonnel

Terri DeFlorian, Executive Director ...... x204 ..... tdefl[email protected] Kathy Olson, Managing Editor ISC ...... x213 .... [email protected] Tara Fredrickson, Executive Associate ...... x203 ..... [email protected] Carol Denison, ISC Processor/Receptionist ... x215 .... [email protected] Sharon Klinski, Managing Editor J/N ...... x202 ..... [email protected]

4 Orthopaedic Practice Vol. 17;4:05 editor’scorner Christopher Hughes, PT, PhD, OCS Editor, OP

Change and Opportunity

As we approach a New Year, we here at be publishing only case reports. that all important stepping stone OP are busy trying to stay fresh with new Have you treated an interest- to get you started in the right di- ideas and also continue to meet the needs ing case that readers might not rection. Beginning writers may of the Section members. The one change we have seen or read about before? find the book by Irene McEwen1 are excited about is our new cover. Have you seen a patient recently to be a useful guide to collecting As you probably have noticed, we switched who presented with a unique and organizing the case report. from a green to blue cover recently, but we problem? Have you been a rehabilitation The deadline for submission to meet our were still looking for a new dynamic design provider for a patient who has undergone a April publication date is March 3, 2006. and layout. We wanted the design to reflect unique surgery? If you have, then we would As always we look forward to the contri- the progressive nature of the Section and also be interested in having you write up your bution of the readership in making OP the current practice. We at OP were very excited case and sharing it with the readership. Case pulse of what is happening in the practice of when the graphic artist, Tracey Armstrong reports can make interesting reading and orthopaedic physical therapy. of The Morgan Group, presented the design be a valuable activity in contributing to the to us. In fact we were so excited with what professional growth of the author. For those REFERENCE she came up with that we decided to run it who serve as clinical instructors to students 1. Writing Case Reports: A How to Manual this issue rather than wait for the New Year. on their affiliations this may also be a great for Clinicians. 2nd ed. McEwen I, ed. We hope that this cover change represents project to work on collaboratively with the Alexandria, Va: American Physical another step forward for OP. student to help mentor them through the Therapy Association; 2001. On another note I am requesting that you process. the reader consider becoming a contribu- If you have ever had ambitions on writing Christopher Hughes, PT, PhD, OCS tor to the 2006 OP special issue which will for publication, case reporting can serve as Editor, OP

Orthopaedic Practice Vol. 17;4:05 5 president’smessage Michael T. Cibulka, PT, DPT, MHS, OCS President, Orthopaedic Section, APTA, Inc.

Today was one of those beautiful au- tion office staff in La Crosse, Tara is the ‘fall back’ person, tumn days where the sky is deep blue, the WI. Although I could spend what ever needs to get done air cool and crisp, the trees are just chang- this time on many other im- and someone else can’t do it, ing their colors, and football season is in full portant issues, I am going to Tara does it—from answering swing--my favorite time of the year. Carmel spend this time bragging on the Section phone to helping apples, pumpkin pie, chili along with sweat- our staff at the Orthopaedic out one of the other office staff ers, sweatshirts, and the chill in the air that Section’s office. with their responsibility. Tara, goes with it. Speaking of chill I just got back First our Executive Direc- like Terri, is both durable and from Lacrosse, WI where the weather was tor, Terri Deflorian. Terri dependable. Sounds like I am cool but the Orthopaedic Section’s Board of has been with the Section for 17 years. This talking about a Maytag washing machine. Director’s Meeting was not. We had a very last year when we were having some money Well Tara is definitely no Maytag, but she busy and productive meeting. Things are re- problems, the Finance Committee suggested has all of the qualities of one. Hard work- ally looking up right now, our Independent that Terri should take over the accounting ing, a ubiquitous smile, more common sense Study Courses continue to bring in consid- and financial work for the Section (with than my Grandma, and nice as pie, that is erable money, membership keeps climbing some help). This was no easy task; however, Tara. People often ask me why we (the Or- (15,156), a new Current Concepts Indepen- Terri took it over and not only did she take thopaedic Section) have stayed in Lacrosse dent Study Course with a group of experi- it over but she has done an unbelievable job. after George Davies and Jim Gould (who enced clinician/writers is getting close to be- This has saved the Section nearly $35,000 started JOSPT) have left and I tell them it is ing released, and our Research Endowment a year. Terri has also, with the help of the because of the staff, hard working and con- Fund used to fund research continues to Board, updated and revised the Section’s pol- sistent, nice, dependable people. That’s why grow. We are also planning a number of new icies and procedures. This is no easy or fun the Section office is still in La Crosse. things that, although I can’t tell you much task. Terri’s approval rating by her own office So is it just because of Terri and Tara? No yet, has the Board of Directors excited about peers and the Orthopaedic Section Board is I have not yet mentioned Sharon. Sharon the future. Hopefully, in my next President’s at its highest level. This is at a time when Klinski is but another reason we have not left Message I will be able to update you on an Terri’s personal life has been very demand- La Crosse. Sharon is like the other Nords we exciting new program we are planning. I will ing. Terri has 2 young children and a dis- have at our office. Sharon not only edits and give you a clue—we are working on an ap- abled husband. Just recently, Terri’s husband publishes Orthopaedic Physical Therapy Prac- proach that would give orthopaedic physi- had a major medical problem that put him tice but also 8 other journal and newsletters. cal therapists help in guiding orthopaedic in the hospital for some time. Terri, when Recently two of the Journals—the Journal of physical therapy practice. most would probably give up, took care of Neurologic Physical Therapy and the Journal On to sadder details I know most of you her real family while also still taking care of of Geriatric Physical Therapy—Sharon pub- by now have probably heard that Jules Roth- her Orthopaedic Section family. I am ex- lishes were accepted in Index Medicus. She is stein passed away. The Research Section at tremely proud to work with Terri and I know a one woman working machine. Sorry Sha- CSM on Saturday night is having a special her devotion, although first to her family, is ron that sounds too mechanical. Sharon is celebration of Jules life. Because Jules’ was also unswervingly to the Orthopaedic Sec- much more than just a great worker. She has also an Orthopaedic Section member and tion. She dedicates her time, her effort, and saved the Orthopaedic Section thousands of because so many of our members knew and her heart to making sure things run well. dollars in production costs by how efficiently respected Jules so much, we are going to de- How can Terri juggle this? Well I must she manages the Journals and Newsletters lay the start of our Section Awards Celebra- say she is very well organized but she also she is responsible for publishing. Like the tion as well as shorten the time. I am sure receives a lot of help from Tara Frederickson, rest of the staff, Sharon is dependable, car- that most members understand why we are the Executive Associate. Tara, like Terri has ing, and soft spoken, but don’t be late for doing this and hope that we can celebrate been with the Section for a long time. Tara your President’s Message. She is skillful and Jules’ life along with those special recipients has learned to juggle a number of jobs at the tactful in accomplishing the task of meeting of Orthopaedic Section awards. Orthopaedic Section office. Before, we had her deadlines. Above all Sharon is a wonder- Being President of the Orthopaedic Sec- a full time person for CSM, now Tara does ful and loving mom, someone who cares tion has been a most humbling and reward- that along with many other jobs that in- deeply about her family. I am just happy that ing job. I am very thankful to have a great clude assisting SIGs, Education Groups, and she considers the Orthopaedic Section part group of Board members and our great Sec- managing the Orthopaedic Section website. of her family.

6 Orthopaedic Practice Vol. 17;4:05 I am not through bragging. Sorry for gets the job done. Kathy ��������������������� I hope you did not mind ������������� the prolix; however, I must go on I have 2 like a fine wine is slow to that I talked about some- more people to brag about. Kathy Olson age and just keeps getting thing more than just is the Managing Editor of Independent better with time. physical therapy in this Study Courses (ISC). The ISC program Last but not least is President’s Message. One is our ‘bread and butter’ when it comes to Carol Denison, our new- thing I learned long ago ���������������� revenue. Without the ISCs our dues would est employee. Carol has ��������������������������������������� is to give praise when it is be considerably higher than what they are. been with the Ortho- due. Also, I don’t like (no Also, the money made allows us to give to paedic Section for only I hate) being considered the Foundation for Physical Therapy, Di- 8 months, however, she �������������� obsequious nor do I fancy ������������������� versity 2000, Research Grants, and much has settled in quite nice- myself a sycophant by any ����������� more. Thus, Kathy’s job is vital. She has to ly. She is quiet, reserved, ���������������� stretch of the imagination balance the job of nurturing writers who are and I think a bit shy; ��������������������� but just someone who re- ������������������� not being compensated much to finish their however, that’s probably spects the hard work per- monograph without admonishing them off. because I just have not The August/September 2005 issue formed by our staff. Our This takes a special person. Kathy is that had the chance to get to of Coulee Region Women. Front: Section’s office staff rarely kind of special person, soft spoken and kind, know her like the other Terri and Tara. Back: Kathy, Carol, is given the praise or the and Sharon. sweet and sincere, Kathy has what it takes to staff. What I do know limelight they deserve. It do the job. Our ISC program has brought about Carol is she is very is not only the Orthopae- in $342,433 this year. Now I know this is nice, hard working (I think it’s the Swede or dic Section Board that recognizes our staff not all just from Kathy, we have some really German in all of them...I am not sure), and but the region as they were just featured in great ISC topics; however, Kathy is the of- very dependable. Ya, Ya, das is gut, ein beir the Coulee Region Women magazine. With- fice person who keeps things moving. Kathy bitter, und ya ever watch Fargo, well that’s out our staff there would be no Orthopaedic works closely with Mary Ann Wilmarth, our La Crosse! Maybe one day I will learn the Section. So if you go to CSM, please say hi ISC Editor, to try to keep things on time. mixture of languages I hear. Oh Yah! Your to them and tell them thank you for all that This is an impossible task, but Kathy usually darn tootin I will before I go! they do.

Orthopaedic Practice Vol. 17;4:05 7 Posterior Heel Flare and Chronic Exertional Anterior Compartment Syndrome: A Case Study

Michael T. Gross, PT, PhD Bing Yu, PhD Robin M. Queen, PhD

INTRODUCTION partment,3,9-11 and the progressive develop- run in these shoes.” The shoe in question Chronic exertional anterior compartment ment of muscle hypertrophy with regular (Adidas Response Trail; Adidas America; syndrome is an entity characterized by pain exercise.12 Pain typically has been associated Spartanburg, SC) appeared to have a posi- localized to the anterolateral aspect of the leg with ischemia of tissues within the compart- tive posterior flare, with the midsole mate- with weight bearing exercise. The pain usu- ment.3,11-13 Other competing explanations rial inclined away from the posterior aspect ally has an onset within the first few minutes for the pain include stimulation of pressure of the shoe (Figure 1). The outersole mate- of exercise1 and typically occurs at the same receptors in the compartmental fascia and rial also had a posterior extension from the time during the exercise session.2,3 The pain periosteum14 or biochemical factors.12,14 midsole material. These shoe construction usually subsides with rest and is minimal un- The principle author’s clinical experience features would theoretically increase the mo- less the exercise is resumed. Varying reports suggests that mechanical movement factors ment arm (d ) for the ground reaction force of incidence rates for chronic exertional an- may sometimes contribute to the develop- relative to the ankle joint axis (Figure 2) for terior compartment syndrome have been re- ment of chronic exertional anterior compart- a rearfoot strike pattern. This increase in ported.4,5 Qvarfordt et al4 reported on a se- ment syndrome. Several runners who were moment arm would increase the plantarflex- ries of 108 patients who complained of lower pronounced rearfoot strikers reported abate- ion moment caused by the ground reaction leg pain and were referred for intracompart- ment of symptoms associated with chronic force, thereby increasing the dorsiflexion mental pressure analysis. These investigators exertional anterior compartment syndrome moment demands for anterior compartment reported that 14% of their patients were after they had adopted a midfoot or forefoot muscles. The patient’s symptoms of anterior diagnosed with chronic exertional anterior foot strike pattern. Running with a rear- leg pain with running disappeared as soon as compartment syndrome based on intracom- foot strike pattern down steep hills also has she discontinued use of these shoes for run- partmental pressures that were elevated dur- been associated in our clinic with chronic ning. ing exercise and for as long as 40 minutes exertional anterior compartment syndrome. This initial clinical experience stimulated following exercise. Styf et al5 reported that Both scenarios place increased demands on our interest in the possible link between 27% of 98 patients with anterior leg pain ankle dorsiflexor muscles within the anterior posterior heel flare and chronic exertional were diagnosed with chronic exertional an- compartment. These muscles must produce anterior compartment syndrome. The expe- terior compartment syndrome based on in- appreciable dorsiflexion moment under these rience also sensitized our clinic personnel to tracompartmental pressure measurements. conditions to control ankle joint plantarflex- this possible relationship and enabled us to Both groups of investigators reported that ion eccentrically during the initial portion of identify in the following case study another other common diagnoses for their series were stance phase. patient who demonstrated the possible link tibial periostitis and compromise of the su- The purpose of this case study is tode- perficial peroneal nerve.4,5 scribe another mechanical factor that may One commonly accepted position regard- be associated with increased demands for ing the pathophysiology of this condition muscle tension from anterior compart- suggests that pressure within the anterior ment muscles and, therefore, the etiology compartment rises with exercise and may of chronic exertional anterior compartment compromise arterial supply that enters the syndrome. This mechanical issue was first compartment6 or vascular circulation with- brought to our attention by a patient who in the compartment,6,7 leading to ischemic reported experiencing symptoms consistent conditions. Pressure elevation within the with chronic exertional anterior compart- compartment has been attributed to the in- ment syndrome when she ran with a particu- Figure 1. Positive posterior flare of Adidas crease in the interstitial water volume in the lar pair of shoes. She also described feeling Response Trail (Adidas America; Spartanburg, 4,8 SC) shoe. The midsole material under the heel muscle, stiffness of the fascia that defines as though “my forefoot is being forcefully is inclined away from the posterior aspect of the the anterior and lateral aspects of the com- thrown to the ground whenever I walk or shoe and the outersole has a posterior extension.

8 Orthopaedic Practice Vol. 17;4:05 between posterior heel flare and chronic ex- leg, and the left anterior compartment ap- heel flare compared with the patient’s run- ertional anterior compartment syndrome. peared slightly more taut during palpation ning shoes (Figure 4). The patient was asked than the right anterior compartment. to run in these shoes over the same ground CASE REPORT An examination15 of the patient’s running surface used for running gait observation for History shoes (Brooks Beast; Brooks Sports, Inc.; the first pair of shoes. She ran for 5 minutes A 48-year-old woman was referred to our Bothell, WA) indicated that they had the and reported having no left leg pain during clinic for evaluation of left anterolateral leg following relative characteristics: straight the running. pain. She reported that the onset of the pain last, stiff heel counter, and increased stiff- occurred following completion of a marathon ness of the medial midsole materials. The Laboratory Testing 3 years prior to her physical therapy visit to midsole materials under the heel generally The patient came to our motion analysis our clinic. The initial left anterolateral leg were stiff in response to manual compres- laboratory for kinematic and kinetic studies discomfort was minimal, and she was still sion. We also noted an appreciable positive of her running gait with both pairs of shoes. able to run for exercise. She fell, however, 2 flare of the midsole material posterior to the We were specifically interested in the ground months later and incurred a contusion to the heel of the shoe. This became more notice- reaction force data and the ankle joint mo- anterolateral aspect of the left leg. This inci- able when a vertically oriented goniometer ment demands in the sagittal plane. The dent resulted in increasing discomfort to the was held against the most posterior aspect of patient wore her own loose fitting running anterolateral leg over the next 3 months, at the shoe’s sole material, and the distance be- shorts and singlet. The authors applied ret- which time she stopped running because of tween the anterior ruler edge and the shoe’s roreflective markers over the lateral tibial the pain she was experiencing. She resumed heel counter was appreciated (Figure 3). condyle, lateral malleolus, and a point on running approximately 1 year later on a The principle author then observed the the lateral leg midway between the other two treadmill and experienced intermittent pain patient’s running gait on a flat level sur- lateral leg markers. These markers were used with treadmill running twice per week dur- face. The patient reported the onset of left to define 3-dimensional position of the leg ing the 18 months prior to her clinic visit. anterolateral leg pain after approximately 2 in laboratory space. minutes of running. None of the movement A Bertec Model 4060A (Bertec Corpora- Physical Examination characteristics during her running appeared tion, Worthington, OH) force plate secured The principle author conducted a clinical excessive or abnormal during this time.16 to the ground via a concrete anchoring sys- examination for structural alignment and Stance and swing times appeared symmetric tem was used to acquire ground reaction soft tissue extensibility that has been de- and normal; as did rearfoot to leg orientation force data at a sampling rate of 1,000 Hz. scribed in the literature.15 The results of this in the frontal plane and ankle, knee, and hip Five S-VHS video cameras were used to ac- examination were unremarkable in that the joint kinematics in the sagittal plane. A sag- quire position data of retroreflective mark- patient did not demonstrate any joint ma- ittal view of her running gait indicated that ers at a sampling rate of 60 frames/sec. Low lalignment or soft tissue extensibility issue she used a rearfoot strike pattern for initial power flood lights were used to illuminate that could be linked to her anterolateral leg contact with the ground. the retroreflective markers. The cameras pain (eg, excessive pronation or tightness of The patient had worn another pair of shoes and force plate were time synchronized by a the triceps surae muscle group). She report- (Asics 126; Asics Tiger Corporation; Irvin, manually triggered light in the field of view ed mild discomfort with palpation of the an- Calif) to the clinic. She reported using these of each camera and an electric impulse con- terior compartment of the left leg compared shoes for everyday walking. These shoes ducted to an additional analog channel in with the anterior compartment of the right had a noticeably less pronounced posterior the analog data acquisition system.

Figure 4. Qualitative assessment of the pos- Figure 3. Qualitative assessment of the posteri- terior heel flare for the Asics 126 (Asics Tiger or heel flare for the Brooks Beast (Brooks Sports, Corporation; Irvin, Calif) running shoe. A straight- Inc.; Bothell, Wash) running shoe. A straightedge edge is held perpendicular to the support surface Figure 2. Positive posterior flare tends to is held perpendicular to the support surface against the most posterior aspect of the shoe. increase the moment arm distance (d ) between against the most posterior aspect of the shoe. The anterior edge of the ruler makes contact the ground reaction force and the ankle joint Space between the anterior edge of the ruler and with the posterior aspect of the heel counter just at heel strike. the posterior aspect of the heel counter is noted. above the shoe’s midsole material.

Orthopaedic Practice Vol. 17;4:05 9 The patient practiced self-selected velocity of the knee and ankle joint centers during locations of the knee joint center, the ankle running trials over the force plate within the data reduction. joint center, and lateral and medial malleoli calibration volume until 5 successive trials were used to determine the frontal plane of result in acceptable footstrikes of the study Data Reduction the tibia and orientation of the tibial refer- lower extremity on the force plate. The ap- The videotape records from each camera ence frame. The ground reaction force vec- proach distance in front of the force plate were digitized at a sampling rate of 60 Hz tor and moment vector were transferred to was 10 meters, and approximately 5 meters using the Peak Performance Motus video- the ankle joint center and considered as the was available for deceleration following foot graphic data acquisition system (Peak Per- ankle joint resultant force vector and mo- strike on the force plate. She rested for ap- formance, Englewood, CO). The two-di- ment vector with an assumption that the proximately one minute between all succes- mensional digitized video coordinates of the mass of the foot and shoe was negligible. sive running trials. The patient performed 5 reflective markers were synchronized and The ankle resultant force and moment vec- acceptable running trials with each of the two converted to real-life 3-dimensional coor- tors were then transformed to the tibial ref- pairs of shoes. An acceptable running trial dinates using a direct linear transformation erence frame in terms of anterior-posterior, was defined as the entire test foot contacting procedure instrumented in the MSDLT medial-lateral, and superior-inferior compo- the force plate, and no obvious targeting of version 4.5 computer program package nents and dorsiflexion-plantarflexion, inver- the force plate evidenced by asymmetric step (MotionSoft, Chapel Hill, NC). The 3-di- sion-eversion, and internal-external rotation lengths during the approach leading up to mensional coordinates were filtered using a components. foot strike on the force plate. recursive fourth-order Butterworth digital To enhance multiple trial comparisons, At the completion of the running trials, 2 filter17 with an estimated optimum off fre- the ankle kinematics and kinetics were nor- additional retroreflective markers were placed quency of 7.14 Hz18 in the MSDLT version malized to the duration of stance phase. on the patient’s leg: the medial malleolus and 4.5 computer program package. Stance phase in each trial was divided into the medial tibial condyle. The patient was The locations of the medial malleolus and 100 equal time intervals with each interval videotaped in a standing position with these medial tibial condyle markers were estimat- representing 1% of the total duration of the additional markers in place. The purpose of ed from the locations of the markers over the stance phase. Each ankle kinematic or kinet- these additional markers was to determine lateral malleolus, lateral tibial condyle, and ic measure was then re-sampled from 0% to during the running trials the location of the lateral mid-shank in each frame of each trial. 100% of the stance phase using linear inter- markers on the medial malleolus and medial The location of knee joint center was deter- polation. This re-sampling also enabled the tibial condyle relative to the tibial reference mined as the mid-point of the line between mean representation of 3 trials for each shoe frame defined by the markers on the lateral the lateral and medial tibial condyle markers. condition for ground reaction force data and malleolus, lateral aspect of the shank, and The location of the ankle joint center was es- for dorsiflexion-plantarflexion moment re- lateral tibial condyle. The additional mark- timated as the mid-point of the line between quirements. ers were also used to determine the position the lateral and medial malleoli markers. The RESULTS Dorsiflexion-plantarflexion moment re- �������������������������������������� quirements for the 2 shoes during the entire- �� ������������������� ty of stance phase are represented in Figure �� 5. Because the patient’s complaint involved anterior compartment pain, we were inter- � ested in the data that involved dorsiflexion � � �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� ��� ��� moment requirements for the two shoes. ��� The peak dorsiflexion moment requirements were 23.1 N*m for the Brooks shoe and 11.7 ��� ��� N*m for the Asics shoe, with the peak for ��� the Brooks shoe representing a 97% increase ���� relative to the peak for the Asics shoe (Figure 6). ���� The peak ground reaction force during ���� the portion of stance phase for which dor- �������������� siflexion moment was required was 860 N for the Brooks shoe and 804 N for the ����� ������ Asics shoe, representing only a 7% increase in peak force for the Brooks shoe relative Figure 5. Mean dorsiflexion-plantarflexion moment requirements at the ankle during stance phase to the Asics shoe (Figure 7). Anterior-pos- (normalized to % stance) of running gait for 3 trials for each study shoe. terior components of the ground reaction

10 Orthopaedic Practice Vol. 17;4:05 force can also contribute to sagittal plane dorsiflexion-plantarflexion moment require- �������������������������������� ments. Posteriorly directed shear force on the foot causes plantarflexion moment about �� the ankle joint, requiring internal dorsiflex- ion moment production. Anterior-posterior �� components of the ground reaction force for the two shoe conditions, however, appeared very similar (Figure 8). The initial impact �� phase data for the Asics shoe appear slightly

greater in magnitude in terms of posteriorly ������ �� directed shear force compared to data for the Brooks shoe (Figure 8). �

DISCUSSION � Our qualitative clinical observations and � � � � � � � � � �� �� �� �� �� �� �� �� �� �� �� �� �� the laboratory kinetic data for this patient �������������� provide some preliminary evidence indi- ����� ������ cating that posterior heel flare may be a mechanism of injury for chronic exertional anterior compartment syndrome. The ini- Figure 6. Mean dorsiflexion moment requirements at the ankle isolated from Figure 5. Peak tial clinic visit revealed the patient’s ability dorsiflexion requirement of the Brooks shoe is nearly twice the dorsiflexion moment requirement for to run for 5 minutes without discomfort us- the Asics shoe. ing a shoe with a less pronounced posterior heel flare. Running with shoes with a more pronounced heel flare resulted in the onset ������������������� of pain within 2 minutes. Caution must be ��������������������� exercised in expressly implicating the differ- ences in posterior heel flare, since these 2 ���� shoes also differed with regard to other de- ���� sign features. The midsole material under the heel of the Brooks shoe was qualitatively ���� stiffer to manual compression than the Asics ��� shoe. The Brooks shoe also had stiffer- re ���

inforcement of the medial midsole and heel ������� counter than did the Asics shoe. ��� The quantitative laboratory data, however, ��� provide additional support for drawing a link � between posterior heel flare and overload of � � �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� the anterior compartment muscles. The peak ����������������� dorsiflexion moment demand for the Brooks shoe was approximately double the peak dor- ����� ������ siflexion moment requirement for the Asics shoe. We assumed that the mass of the foot Figure 7. Mean data for vertical component of the ground reaction force during stance phase of and shoe were negligible contributors to the running gait for 3 trials for each study shoe. Peak vertical force for the Brooks shoe is 7% greater dorsiflexion moment requirements. Given than the peak dorsiflexion moment requirement for the Asics shoe during the time when dorsiflexion this assumption, moment demands are de- moment is required at the ankle (data to the left of the vertical line). termined by the product of the sagittal plane ground reaction force resultant and the mo- ment arm for this resultant force. The pos- peak vertical component of the ground reac- explain the nearly 100% increase in peak teriorly directed component of the sagittal tion force when a dorsiflexion moment was dorsiflexion moment requirement for the plane ground reaction force did not differ required for the Brooks shoe was 7% greater Brooks shoe. With the ground reaction force appreciably between the 2 shoes during the than the peak vertical force for the Asics data being relatively equivalent between the initial portion of running stance phase. The shoe. This 7% increase, however, would not 2 shoes, the data for dorsiflexion moment re-

Orthopaedic Practice Vol. 17;4:05 11 previous work that involves an analysis of ����������������������������� the effects of lateral heel flare. Running shoes ��������������������� with increased lateral heel flare have been as- sociated with increased initial eversion and ��� eversion velocity secondary to a longer mo- ment arm for the ground reaction force.19 ��� These longer moment arms were thought ��� to cause greater eversion moments, effecting �� greater magnitude eversion accelerations and velocities. � � � �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� ��� ��� ������� CLINICAL IMPLICATIONS ���� The results of this case study suggest that ���� increased posterior heel flare may be associ- ated with the development of chronic exer- ���� tional anterior compartment syndrome. We �������������� suggest that clinicians inspect this aspect of ����� ������ shoe design for patients who have symptoms consistent with chronic exertional anterior compartment syndrome, and who walk or Figure 8. Mean data for anterior-posterior component of the ground reaction force during stance run using a rearfoot strike pattern. Use of phase of running gait for 3 trials for each study shoe. shoewear with a less pronounced posterior heel flare may be an appropriate part of the intervention plan for these individuals. the ankle joint axis for a runner who uses a rearfoot strike pattern. The 2 shoes also REFERENCES may have been positioned differently by the 1. Blackman PG. A review of chronic patient relative to the ground surface, plac- exertional compartment syndrome d� ing the initial point of ground contact more in the lower leg. Med Sci Sports Ex.

d� posteriorly on the sole of the Brooks shoe 2000;32(3Suppl):S4-10. than the Asics shoe. Finally, our qualitative 2. Black KP, Schultz TK, Cheung NL. impression during the clinical examination Compartment syndromes in athletes. of the patient was that the midsole material Clin Sports Med. 1990;9:471-487. under the heel for the Brooks shoe was ap- 3. Martens MA, Moeyersoons JP. Acute preciably stiffer than the midsole material and recurrent effort-related compart- Figure 9. Compression of the midsole material for the Asics shoe. This difference in mate- ment syndrome in sports. Sports Med. under the heel at heel strike effectively moves rial properties may have resulted in greater 1990;9:62-68. the line of the sagittal plane ground reaction compression of the Asics midsole material force anteriorly, thereby decreasing the moment 4. Qvarfordt P, Christenson JT, Eklof B, arm distance for this force as it produces during initial contact at the heel of the shoe Ohlin P, Saltin B. Intramuscular pres- moment about the ankle joint. compared with compression of the stiffer sure, muscle blood flow, and skeletal midsole materials for the Brooks shoe. Com- muscle metabolism in chronic anterior pression of the midsole material at heel strike tibial compartment syndrome. Clin quirement suggest that the ground reaction effectively moves the sagittal plane ground Orthop Relat Res. 1983;179:284-289.

force moment arms were appreciably differ-23 reaction force more anteriorly, thereby de- 5. Styf J. Diagnosis of exercise-induced ent between the 2 shoes. creasing the moment arm for this force as it pain in the anterior aspect of the lower Several factors may be involved in effecting produces moment at the ankle joint (Figure leg. Am J Sports Med. 1988;16:165- a difference between the 2 shoes with regard 9). Greater compression of the heel midsole 169. to moment arm distances for the ground re- material for the Asics shoe, therefore, would 6. Matsen FA. Compartment syndrome: action forces. The 2 shoes had appreciably also have resulted in decreased dorsiflexion a unified concept. Clin Orthop Rel Res. different posterior inclinations for the mid- moment requirement for this shoe compared 1975;113:8-14. sole and outersole materials as evidenced by with the Brooks shoe. 7. Reneman RS. The anterior and the Figures 3 and 4. The more posterior inclina- Although we were unable to identify any lateral compartmental syndrome of tion of the Brooks shoe effectively moves the previous investigations pertaining to poste- the leg due to intensive use of muscles. ground reaction force more posteriorly from rior heel flare, our results are consistent with Clin Orthop Relat Res. 1975;113:69-80.

12 Orthopaedic Practice Vol. 17;4:05 8. Veith RG, Matsen FA, Newell SG. Sports Med. 1989;7:331-339. Biomech. 1998;14:223-237. Recurrent anterior compartmental 14. Balduini FC, Shenton DW, O’Conner 19. Nigg BM, Morlock M. The influence syndromes. Physician Sportsmed. KH, Heppenstall RB. Chronic of lateral heel flare of running shoes on 1980;8:80-88. exertional compartment syndrome: pronation and impact forces. Med Sci 9. Detmer DE. Chronic shin splints. Correlation of compartment pressure Sports Exerc. 1987;19:294-301. Sports Med. 1986;3:436-446. and muscle ischemia utilizing P- 10. Detmer DE, Sharpe EK, Sufit RL, NMR spectroscopy. Clin Sports Med. Girdley FM. Chronic compartment 1993;12:151-165. Michael Gross is Professor, Division of syndrome: diagnosis, management, 15. Gross MT. Lower quarter screening Physical Therapy, Program in Human and outcomes. Am J Sports Med. for skeletal malalignment-Suggestions Movement Science, University of North 1985;13:163-170. for orthotics and shoewear. J Orthop Carolina at Chapel Hill; Bing Yu is 11. Martens MA, Backaert AM, Vermaut Sport Phys Ther. 1995;21:389-405. Associate Professor, Division of Physical G, Mulier JC. Chronic leg pain in 16. Cavanagh PR, ed. Biomechanics of Therapy, Program in Human Movement athletes due to a recurrent compart- Distance Running. Champaign, Ill: Science, University of North Carolina at ment syndrome. Am J Sports Med. Human Kinetics Publishers, Inc.; Chapel Hill; and Robin Queen is Director 1984;12:148-151. 1990:35-164. of the Michael W. Krzyzewski Human 12. Amendola A, Rorabeck CH. Chronic 17. Winter DA, Sidewall HG, Hobson Performance Lab and Department of exertional compartment syndrome. In: DA. Measurement and reduction of Surgery, Duke University, Durham, NC. Welsh RP, Shepard RJ, eds. Current noise in kinematics of locomotion. J Therapy in Sports Medicine. Toronto: Biomech. 1974;7:157-159. BC Decker; 1985:250-252. 18. Yu B, Andrews JG. The relationship 13. Styf J. Chronic exercise-induced pain between free limb motions and per- in the anterior aspect of the lower leg. formance in the triple jump. J Applied

Orthopaedic Practice Vol. 17;4:05 13 Anterior Cruciate Ligament Reconstruction: Surgical Management and Postoperative Rehabilitation Considerations

Marie-Josée Paris, PT Reg B. Wilcox III, PT, DPT, MS Peter J. Millett, MD, MSc

INTRODUCTION BASIC ANATOMY AND been made with respect to graft choice and Surgical techniques for anterior cruci- FUNCTION fixation, and perioperative management, in- ate ligament (ACL) reconstruction have The ACL restrains anterior translation of cluding rehabilitation. These advances have progressed in the past 20 to 30 years. In the tibia, and prevents tibial rotation and led to increased functional outcomes and the 1970s, ACL reconstructions were done varus/valgus stresses to the knee. Participat- early return to activity.10 through large arthrotomies, using non-ana- ing in sports and activities in which pivot- tomic, extra-articular reconstructions, with ing occurs where the foot is planted, the ADVANCEMENTS IN long postoperative periods of immobiliza- knee is flexed, and a change in direction is SURGICAL TECHNIQUES tion.1,2 In the 1980s, large arthrotomies needed puts one at a higher risk for an ACL Over the past 20 years, multiple scien- were replaced by arthroscopic, anatomic, injury. Basketball, skiing, and football are tific and empirical studies on ACL recon- intra-articular reconstructions. Arthroscopy examples of sports in which a high number struction have been completed, leading to eliminated the need for prolonged postop- of ACL injuries occur.6 The ACL is also very a greater understanding of factors influenc- erative immobilization, and accelerated re- susceptible to injury in contact sports. It can ing postsurgical outcome, including patient habilitation protocols were established. In be damaged along with the medial collateral selection and graft selection.4,5,7,10-21 When the 1990s, the rehabilitation protocols were ligament when there is an associated valgus it comes to patient selection for operative advanced further to allow athletes an early stress. A force that results in the tibia be- and nonoperative management, the most return to sports.2 Today, while there is less ing driven forward, the femur being driven important factor that may lead to graft fail- variability in the surgical techniques used, backward, or in the knee joint being severely ure is noncompliance with the postoperative there remains variability in the types of sur- hyperextended may also result in damage to regimen.4 Other factors that impact patient gical grafts used. The most commonly used the ACL. selection and the surgical decision-making grafts for ACL reconstruction are the bone- The ACL does not heal well without sur- process are the patient’s physiological age, patellar-tendon-bone autograft, semitendi- gery.7 This is most likely due to the amount occupation, symptomatology, and desired nosus autograft, and the semitendinosus/ of force involved in the injury, the lack of activity level, as well as the presence of as- gracilis autografts and allografts.3,4 The suc- blood supply to the ligament, and its intra- sociated collateral ligament insufficiency, the cess of a patient’s recovery who has under- articular location. However, about one- presence of generalized ligamentous instabil- gone an ACL reconstruction is predicated on third of all patients can expect a fair to good ity, open growth plates, or the need for rapid several factors including surgical technique, outcome without surgery.8 Typically, these rehabilitation.4,5 graft selection, prevention of postoperative patients who do well without surgery are The most commonly used grafts for ACL complications, patient compliance, and older or less active, and modify their activ- reconstruction are the bone-patellar-tendon- postoperative rehabilitation.4,5 The post- ity level following injury, including avoiding bone autograft, semitendinosus autograft, operative rehabilitation regimen must be pivoting sports/activities. Generally, young- and the semitendinosus/gracilis autografts guided by principles such as the early return er and/or active individuals do not do well and allografts.4 Using an autograft elimi- of knee range of motion (ROM), especially with nonoperative treatment. This is due to nates the risk of disease transmission, but extension, while obtaining and maintaining the expectation of continuing to participate can cause donor site morbidity.18 a relatively stable physiological state of the in sports that require high levels of pivoting. knee joint (homeostasis). Strengthening, Active patients with an ACL deficiency are Bone-Patellar Tendon-Bone proprioception exercises, and early weight at risk for reinjury, including meniscal tears Autograft bearing have also become guiding princi- and/or articular damage, leading to subse- The ipsilateral bone-patellar-tendon-bone ples.2 The purpose of this paper is to outline quent degenerative changes in the knee. Pa- autograft has been considered the gold stan- current surgical and postoperative factors tients who opt for surgical reconstruction of dard graft for ACL reconstruction since that should be considered when establishing the ACL can expect restored stability of the it was described by Jones in 1963.4,18 The the rehabilitation program for a patient fol- knee and return to preinjury levels of activ- advantages of this graft include its high ul- lowing ACL reconstruction. ity.9 Over the past 20 years, advances have timate tensile strength and stiffness, rapid

14 Orthopaedic Practice Vol. 17;4:05 bone to bone interface healing (6-8 weeks)22 with notchplasty. In addition, the same one million.38 Since 1985, the Food and and revascularization, which can allow the aggressive postoperative rehabilitation pro- Drug Administration has mandated screen- patient to initiate an accelerated rehabilita- tocol10,34,35 was instituted for both groups. ing of all allograft tissue for viruses. Another tion program and in turn, decrease risk of They reported no significant difference be- potential disadvantage of allografts include postsurgical morbidity.20 Disadvantages and tween patellar tendon and hamstring tendon greater failure or delay of biologic incorpora- complications include anterior knee pain, grafts with respect to the Lysholm score,36 tion than with autografts, in turn delaying extensor mechanism dysfunction, patellar Lachman and pivot shift test results, thigh the return to activity in order to protect the fractures, patellar tendon ruptures, and ar- circumference, return to sports, reduction in graft.18 Graft selection in practice is often throfibrosis.9,23,24,26 Complications during activity, jumping, and ability to do hard cuts based on patients’ activity levels, needs, and graft fixation include inappropriate patellar and pivots 2 years after surgery. In 2003, age. Most surgeons tend to use patellar tendon length, poor femoral fixation, poor Feller and Webster5 completed a prospective tendon autografts for patients with high- tibial fixation, graft disruption, and femo- randomized clinical trial of 65 patients to demand activities such as cutting, pivoting ral wall disruption.25 Contralateral patellar compare both grafts as well as to assess the or jumping sports, or skiing. For patients tendon autografts are also used, but there is functional outcome at 3 years postoperative- who are older or have lower demand activi- a risk of donor site morbidity in the unin- ly. In this study, the same surgeon performed ties, the hamstring grafts are used. Finally, volved knee.18,20 the procedures, but different graft fixation allografts may be preferred by patients who methods were used. They found that at 3 elect to have transplanted tissue, or for pa- Semitendinosus/Gracilis years after surgery, there was no significant tients over age 45, for patients with arthritis, Tendon Graft difference between bone-patellar tendon- evidence of instability, or for patients who The use of hamstring autografts -has be graft (31 patients) and combined semiten- do not have any donor tissue. come more common due to the evolution dinosus and gracilis hamstring tendon grafts In 2001, a survey of the American Ortho- of surgical techniques, including the use of (34 patients) in terms of functional outcome. paedic Society for Sports Medicine3 regard- the four strand, quadruple loop combina- However, patients who had the patellar ten- ing current practices and opinions in ACL tion of semitendinosus and gracilis tendons, don graft reported pain on kneeling and had reconstruction yielded responses from 855 and due to the advancement in graft fixation increased extension deficits compared to the members (76% response rate). Seventy- options. The advantages of this graft include patients who had the hamstring graft. In the eight percent of members preferred bone-pa- decreased risk of postsurgical complications group of patients who had the hamstring tellar tendon-bone grafts. The respondents found with bone-patellar tendon-bone auto- graft, there was an increase in anterior knee had an average of 17 years experience in grafts. The morbidity from harvesting the laxity as measured by the KT-1000 arthrom- orthopaedic practice. Of the surgeons who semitendinosus and gracilis tendons is mini- eter and radiological evidence of widening of used multiple graft types, 75% preferred us- mal because flexion strength returns com- the femoral tunnel, but this did not translate ing hamstring autografts for patients with pletely. The hamstring tendons regenerate, into decreased function. These authors sug- open physes around the knee, for patients and extensor mechanism problems, such as gested that hamstring tendon grafts might with patellofemoral pathology, and in pa- anterior knee pain, kneeling pain, quadriceps be indicated for patients who still have open tients undergoing revision ACL reconstruc- weakness, patellar fracture, and patellar ten- growth plates, whereas the patellar tendon tion surgery. Only 3 of the respondents used don rupture are less common and severe.27-33 grafts may be more suitable in a ‘loose’ knee. allografts exclusively, but no description of The principal disadvantage of the hamstring Furthermore, a patient whose occupation the graft selection criteria was given in this autograft compared to the bone-patellar ten- or sport involves kneeling may have a bet- case. Other allograft tissue options include don-bone autograft is increased anterior knee ter long-term outcome with the hamstring the Achilles, anterior tibialis tendon, and laxity, but its correlation with any functional graft. posterior tibialis tendons.18 No use of syn- deficits remains unclear.5,18,21 Other disad- thetic grafts was documented in this survey. vantages include lower returns to preinjury Allografts levels of activity and increased healing time The advantages of allograft tissue are that Synthetic Grafts of soft tissue to bone interface.18,22 Surgical there is no donor site morbidity and that the In the late 1970s and early 1980s, syn- complications during harvesting include in- tissue is readily available, thus eliminating thetic materials were used to substitute tis- adequate length or width and transection of the step of graft harvesting during surgery. sue grafts with an objective of developing the tendons.25 As a result, the patient does not experience a graft that would be stronger, more rigid, In 2002, Shaieb et al21 completed a pro- any of the postsurgical deficits associated and therefore would allow early mobilization spective, randomized study to compare the with either patellar or hamstring tendon and rapid return to sports. These synthetic overall outcome at a minimum of 2 years harvesting. The greatest disadvantage to materials included permanent (true), scaf- after single-incision ACL reconstruction. allograft use is the potential risk of disease fold (ingrowths), and stents (augmentation Seventy patients, with either autogenous transmission.4,18,20,37 However, with proper devices).20,37 In 1997, Frank et al15 reported patellar tendon graft or hamstring tendon precautions and adequate laboratory stud- that 40% to 78% of the 855 synthetic liga- autografts, were studied. Both grafts were ies, the theoretical risk of processing bone ments tracked over a period of 15 years had fixed with interference screws by the same from an unrecognized carrier of the human failed over time. They failed secondary to surgeon using the same surgical technique immunodeficiency virus is one in more than debris, tissue reactions, and mechanical

Orthopaedic Practice Vol. 17;4:05 15 limitations of the grafts. The Gore-Tex ACL the uninvolved knee. In 1983, Shelbourne cial to prevent the sequelae of arthrofibrosis is a true prosthetic that was designed to al- and Nitz10 discontinued the use of rigid im- such as patella baja and progressive joint de- low immediate fixation, therefore accelerate mobilization and began using continuous generation.24 Once motion has been restored mobilization and weight bearing, leading to passive motion immediately postoperatively. and knee homeostasis has been controlled, earlier return to activity. It failed because of They began to note that patients who were strength training can be progressed as toler- lack of tissue ingrowth, fraying at the bone advancing or progressing their activities ear- ated. Electrical stimulation can be used to tunnels, and chronic effusions. The Dacron lier than recommended (and therefore were facilitate the active contraction of the quad- ligament was developed as a scaffold pros- noncompliant with the rehabilitation proto- riceps.2,24,26,43-46 thesis intended to prevent problems with col), were actually demonstrating improved It is crucial to initiate proprioception ex- stiffness that had been associated with other functional outcomes without an increase in ercises once pain and swelling are controlled. materials. However, complications from this knee instability compared to the patients Neuromuscular re-education is essential in prosthesis included rupture of the femoral who had been compliant with the recom- the prevention of knee injuries and in the or tibial insertion of the ligament, rupture mended rehabilitation protocol. Follow-up protection of the ACL graft.47 Muscular en- of the central body of the prosthesis and of the noncompliant patients over a 2-year durance is important and can be addressed elongation of the ligament.39 The Kennedy period revealed that there were no long-term with the use of a stationary bicycle, elliptical Ligament Augmentation Device (LAD) was adverse consequences of early weight bearing trainer, treadmill, and aquatherapy for long designed to provide protection to a prima- and full extension ROM. As a result, they durations with low resistance.24 ry ACL repair or to a patellar tendon graft developed the first accelerated rehabilitation As the patient advances through the weeks while it healed. In 2002, Weitzel et al37 protocol by the end of 1986. following ACL reconstruction surgery, stated that the LAD was predominantly of the loads being applied to the knee can be historic interest because primary repair of REHABILITATION gradually increased through the progression the ACL is not routinely performed. Kumar Basic Principles of therapeutic exercises, providing that knee and Maffulli40 note that excellent results can The rehabilitation process for patients homeostasis is maintained. There are several be obtained in primary ACL reconstructions having undergone ACL reconstruction is post-ACL rehabilitation protocols in the lit- without LAD. multifaceted. It includes patient education, erature.2,10,26,48 pain control, edema management, ROM, TREND TOWARDS strengthening exercises, gait training, agility Factors that Guide ACCELERATED drills, sport-specific drills, proprioception, Rehabilitation REHABILITATION PROTOCOLS and endurance exercises. The goal of these Patellar tendon autografts Rehabilitation following ACL reconstruc- interventions is to restore the patients’ prein- A number of prospective and retrospective tion is very important to restore range of mo- jury levels of function. Tissue healing stages studies have demonstrated the success of ac- tion, strength, proprioception, and function and graft fixation protection must be very celerated rehabilitation protocols for patients to allow return to preinjury levels of activity. carefully considered, especially in the early who have undergone an ACL reconstruc- In the 1970s and early 1980s, postsurgical postoperative phase. tion with a patellar tendon autograft.2,10,26,41 rehabilitation for patients recovering from The speed at which the above interventions Clinical pathways or protocols have been ACL reconstruction consisted of immobi- are progressed depends on a number of basic developed because of these studies, but the lization in long leg casts for 2 to 4 weeks, principles. In the immediate postoperative clinician must also consider the underlying followed by the use of a postoperative knee period (0-2 weeks), emphasis is placed on pathology and modify the pathway accord- brace. Weight bearing was restricted for ap- patient education, edema and pain control, ingly, while respecting basic rehabilitation proximately 6 weeks, followed by a gradual early protected weight bearing, and ROM. principles (Table 1). progression from partial weight bearing to In order to decrease the risk of arthrofibrosis weight bearing as tolerated, with the use of and extensor mechanism dysfunction, full Hamstring tendon autografts a brace. By 12 to 14 weeks after surgery, extension (equal to that of the uninvolved Howell and Taylor49 demonstrated the patients were allowed to progress to full knee) and 90° of flexion should be achieved safety of an accelerated rehabilitation proto- weight bearing. Typically, the postoperative by 7 to 10 days following surgery.2 Range col, without the use of a brace, for patients brace was not discontinued for daily activi- of motion goals are achieved with the use of with a hamstring tendon autograft. As de- ties until 4 months. Isokinetic evaluations continuous passive motion (CPM), passive scribed earlier, the hamstring autografts have began at 6 months postoperatively and con- and active-assisted ROM exercises, active been associated with increased anterior-pos- tinued through the 9th to 12th months.41,42 ROM exercises (with early activation of the terior laxity compared to patellar tendon It was typically the standard for patients to quadriceps and hamstring muscles), patellar grafts, but this increased laxity has not been be released to full, unrestricted activity once mobilizations and mobilization of the soft correlated to decreased function or increased they had full ROM, no pain or swelling, tissues, and weight bearing. In some cases, pain. The patients in this study returned to had completed a very structured functional the use of a brace is recommended to assist sports at 4 months after brace-free rehabili- progression including agility drills, and their in achieving full extension. Early recognition tation. Stability was measured at 4 months, quadriceps strength was greater than 80% of and management of motion deficits are cru- prior to patients returning to sports, and

Orthopaedic Practice Vol. 17;4:05 16 Table 1. Treatment Parameter based on Graft Type

Graft Type Weight-bearing Use of Passive range of Strength training/ Return to (WB) status Postoperative motion (PROM) proprioception running/sports brace and active range exercises of motion (AROM)

Patellar tendon Progression to full WB Immobilizer locked 0°-100° PROM in week Isometric knee extension and closed Backward running as of (accelerated without crutches by at 0° ext during 1; 0°-115° PROM in week 3; kinetic chain and proprioception week 4. Forward running rehab protocol); 10-14 days. ambulation for 0°- 125°AROM by week 10. exercises as of week 1. Progressive as of week 6. Gradual Wilk et al95 2-3 weeks. resistance extension exercises as return to sports as of of week 2. weeks 16-22.

Hamstring Progression to Immoblizer locked at 0°-90° PROM in week 1; Delay hamstring strengthening No running for 12 weeks, Tendon; Wilk full WB without 0° ext for ambulation 0°-105° PROM in week 2; until 4 weeks after surgery. At 5-6 no jumping for 12-14 et al95 crutches by until week 3. Then 0°-115° PROM in week 3; weeks, start submaximal isometric weeks, no twisting and 10-14 days. unlocked to 0°-125° 0°-130° PROM by weeks 4-7; hamstring contractions. At 6-8 hard cutting for 16 weeks until weeks 4-7. 0°-125°AROM by weeks 7-12. weeks, start light resistance and return to sports in exercises. At 8 weeks, start 5.5-6 months. progressive resistance exercises.

Hamstring Restricted WB with None. Cited Shelbourne and Nitz’s79 Unrestricted open and closed kinetic Running in a straight line Tendon; Howell crutches for 3 weeks, accelerated protocol: 0°-110° chain exercises started at week 4. at 8-10 weeks. Return to and Taylor36 with progression AROM in weeks 2-3; 0°-130° to sports by 4 months. to full WB without AROM in weeks 5-6. crutches by 6 weeks.

ACL Immediate WB Hinged brace or Flexion ROM: Peripheral tears: No isolated hamstring contraction 5-7 months. reconstruction with immobilizer locked in 90°-100° by week 2; 105°-115° for 8-10 weeks. No squatting past meniscal repair; full extension during by week 3; 120°-135° by week 60° of knee flexion for 8 weeks. Brotzman & Wilk, ambulation until 4; Complex tears: 90°-100° by No squatting with rotation or twisting Wilk et al13,95 weeks 2-3. week 2; 105°-110° by week 3; for 10-12 weeks. No lunges past 115°-120° by week 4. 75° knee flexion for 8 weeks.

ACL Microfracture No Recommendation ROM goals same as with No excess loading for 3-4 months. 6-9 months. reconstruction with Technique: Non-WB specified. accelerated rehab protocol for articular cartilage or toe-touch WB for isolated ACL reconstruction. pathology; 2-4 weeks; 50% WB Wilk et al95 in weeks 5-6; 75% WB in weeks 7-8.

ACL ACI Technique: Locked in extension 0°-90° in week 2; Open kinetic chain exercises Low-impact activities reconstruction with NWB for 2 weeks. for 2 weeks. 0°-105° by week 4; including proprioception, closed by 8 months. articular cartilage Toe-touch WB weeks 0°-125° by week 6; chain exercises and aquatherapy High-impact activities pathology; 3-6. 50% WB by 0°-135° by week 8. by week 6. by 12 months. Wilk et al95 week 6. Progression to full WB by week 8

Combined Partial WB to full WB Locked in extension Full AROM and PROM Closed kinetic chain exercises Running at 6 months. ACL-MCL injuries/ within 6 weeks. for week 1, then extension by weeks 1-2. performed in 0°-45° of flexion. Medial Return to sports by repair; Irrgang unlocked for 90°-100° flexion by week 4. hamstring to increase anteromedial 9-12 months. & Fitzgerald41 ambulation. Discontinue Full flexion by week 8. stability of knee. Caution with hip after 4-6 weeks when adduction exercises (i.e. valgus 90°-100° of flexion. stress imposed on the MCL)

Combined Full WB by week 2 No postoperative brace. No Recommendation specified. No Recommendation specified. No Recommendation ACL-MCL Functional brace in specified. injuries/repair; presence of varus Wilk et al95 movement during gait.

Combined Partial WB for 6 Locked in extension 0° knee ext week 1(avoid Quad sets and straight-leg Running by 6 months. ACL/LCL weeks for 6 weeks. hyperextension); 0°-90° for raises for 6 weeks. Progress Return to sports by injuries/repair; weeks 1-6; at week 6: to open and closed chain 9-12 months. Irrgang & full AROM. exercises-caution with hip Fitzgerald41 abduction exercises.

Combined Partial WB in week Locked in extension 0°-90° for 4-6 weeks. Passive No active hamstring Walking program ACL/PCL 1. WB as tolerated in weeks 1-4. Unlocked knee flexion by lifting proximal contraction for 6 weeks. Quad sets weeks 8-12. reconstruction; week 2. for gait training tibia. Full flexion ROM by and straight-leg raises. Open kinetic Running by 6 months. Irrgang & weeks 5-8. weeks 8-10. chain exercises from 75°-60° knee Return to sports by Fitzgerald41 flexion. Closed kinetic chain exer- 9-12 months. cises from 0°-45° knee flexion. Stationary bike-no toe clips.

Combined 50% WB on day 7; Used for 7-8 weeks, 0°-65° on day 5; 0°-75° on day Closed kinetic chain exercises Walking program ACL/PCL 75% WB day 12; Full then may need 7; 0°-90° on day 10; 0°-100° in week 3. Leg press week 4. week 12. Light running reconstruction; WB by week 4. functional brace. week 2; 0°-115° week 6; week 16. Agility drills Wilk et al95 0°-125° week 7. by 5 months.

Orthopaedic Practice Vol. 17;4:05 17 then at 2 years following surgery. The 2-year pain and swelling than patients with isolated near-normal appearance of the knee.56 Early evaluation revealed that 90% (37/41) of pa- ACL injuries. It is important to obtain and reconstruction of the ACL in these injuries tients’ knees were stable and functional. The maintain knee homeostasis prior to progress- facilitates the healing of the MCL by decreas- authors state that an increase in instability ing activities. ing valgus instability. In this study, the rate between 4 months and 2 years would have Some patients with this injury may under- of subsequent surgery was 5.2%, where only implied that the composite hamstring graft go a procedure involving microfracture or 1 out of 19 knee surgeries needed a second was not mature enough to tolerate the early autologous chondrocyte implantation (ACI). intervention for arthroscopic debridement return to sports and work activities. The 4 The goal of these procedures is to stimulate and lysis of adhesions. A study by Peterson patients’ knees that were unstable had been healing and repair. After the procedure in- and Laprell57 in 1999 had revealed a 15% detected at the 4-month follow-up evalua- volving the microfracture, the ROM goals rate of subsequent surgery for arthrofibrosis tion. The authors were unable to determine remain the same as with the standard reha- or cyclops lesions. Millett et al55 believe that a specific cause of graft failure for these cases bilitation protocol, with emphasis on early their preoperative protocol, which involves (Table 1). return of passive knee extension. When the restoring motion, quadriceps control, and cartilage defect is on the load bearing surface appearance of the knee may exclude patients Allografts of the femur or tibia, weight bearing is de- who would be at risk of developing motion A comparison studies of nonirradiated, layed to decrease the compression forces on problems. fresh-frozen patellar tendon autografts and the healing articular tissues (Table 1). If medial laxity is still present after ACL patellar tendon autografts has revealed few reconstruction, a MCL repair may be war- differences in outcomes using similar reha- ACL RECONSTRUCTION IN ranted.48 Combined ACL-MCL injuries are bilitation protocols.2 SETTING OF MULTILIGAMENT often managed postoperatively with a brace INJURIES to limit valgus rotation forces, whether or ACL reconstruction with Combined ACL-MCL Injuries not a MCL repair has been performed. The meniscal repair Patients with a combination ACL-MCL risk of postoperative loss of motion and ex- Meniscal injuries are commonly seen in (medical collateral ligament) injury may or cessive scar tissue formation is greater fol- combination with ACL injuries. The reha- may not require repair of the MCL to re- lowing MCL injuries due to the increased bilitation protocol should be modified based store knee stability and function. Recon- effusion that occurs with combined tissue on whether the meniscus was surgically re- struction of the ACL alone may provide damage and with extra-articular vascular- paired or if a partial menisectomy was per- adequate knee stability to allow the MCL ity. Therefore, range of motion exercises formed. In the presence of a partial menisec- to heal. It has been reported that individu- should be progressed more rapidly providing tomy, Wilk et al26 suggest that running and als who underwent ACL reconstruction and that homeostasis of the joint is maintained. jumping be delayed to protect the healing conservative management of the MCL had The use of the continuous passive motion meniscus. With a meniscal repair, modifi- superior ROM and faster strength gains in machine may also be especially beneficial cation of the rehabilitation protocol is more the short-term compared to those who had in these cases. Strengthening of the medial important. Range of motion is progressed both ligaments repaired. Long-term follow- hamstrings is crucial for anteromedial stabil- more slowly with complex tears than with up revealed that patients with ACL recon- ity of the knee, but hip adduction exercises peripheral tears. In some large meniscal re- struction and conservative management of should be performed with caution because pairs, where the posterior horn is involved, it MCL tear had excellent knee stability and of the valgus stress imposed on the MCL, may be preferable to limit flexion for 4 to 6 functional outcomes.51 The timing of ACL especially if the resistance is placed distal to weeks in order to avoid excessive load on the reconstruction has been a controversial sub- the knee joint. posterior horn of the meniscus. As with the ject. The standard of care has been to delay Shelbourne and Patel51 suggest that the lo- standard rehabilitation protocol, full passive ACL reconstruction for 3 weeks postinjury cation of the injury along the MCL should extension is crucial in the early postoperative in order to decrease the incidence of post- also be considered during the rehabilitation period (Table 1). operative arthrofibrosis, one of the most process. The MCL tears at the proximal origin common complications following this sur- or within the midsubstance of the ligament Articular cartilage pathology gery.24,52-54 In 2004, Millett et al55 reported tend to heal without residual laxity but with Articular cartilage defects occur very on their retrospective study of early ACL increased stiffness. However, MCL injuries commonly in the setting of an ACL injury. reconstruction in combined ACL-MCL at the distal insertion site tend to have a lesser Johnson et al50 reported an incidence of up injuries in 19 knees. Early reconstruction healing process and residual valgus laxity. In to 80%, with most defects presenting as was defined as being within 3 weeks of the this case, rehabilitation should be progressed bone bruises. It is important to delay high initial injury. The candidates for this early more slowly to allow for tissue healing. In shear or repetitive loading exercises to pro- reconstruction had to meet certain preop- the former case, the ROM exercises should tect the healing tissue. Patients with bone erative criteria, such as 0-120° knee ROM, be accelerated to prevent excessive scar tissue bruises also demonstrate antalgic gait for good quadriceps control (as measured by the formation and stiffness (Table 1). longer periods, and may complain of more ability to perform a straight leg raise), and

18 Orthopaedic Practice Vol. 17;4:05 Combined ACL/LCL Injuries tion and the associated strain on the healing occur during the surgical procedure. In ad- An injury to the LCL (lateral collateral PCL. In the event of a combined ACL/PCL dition, there are numerous potential compli- ligament) may result in varus instability, reconstruction, they recommend that open cations that are commonly seen by physical and the LCL may be reconstructed using an kinetic chain knee extension exercises be therapists during the rehabilitation process, Achilles tendon graft. Irrgang and Fitzger- limited to the range of 75° to 60° of flexion. such as anterior knee pain, arthrofibrosis, ald48 propose guidelines outlined in Table 1. In contrast, closed kinetic chain exercises are quadriceps weakness, extensor mechanism indicated because compression forces on the dysfunction, and donor site pain. Early mo- Combined ACL/PCL Injuries joint and co-contraction of the hamstring tion and decreased restrictions on weight Irrgang and Fitzgerald48 describe rehabili- and quadriceps decrease tibial translation bearing are now being advocated to prevent tation following a PCL (posterior cruciate (Table 1). Following surgery in the setting the risk of arthrofibrosis. Arthrofibrosis can ligament) reconstruction using an Achilles of single or multiligament injury, it is crucial be caused by a variety of factors other than tendon graft and they suggest that the same to restore full extension that is symmetrical immobilization, such as infection and graft guidelines should be used in the combined to the uninvolved knee. Irrgang and Fitzger- malpositioning. Physical therapists play ACL/PCL reconstructions. In 2000, these ald48 indicate that caution must be taken an important role in the early detection of authors stated that the maturation process with respect to gaining gross hyperextension motion loss in the immediate postoperative of the PCL graft and the loads that it can in the PCL reconstructed knee because this phase. Possible causes of motion loss are the withstand remain unclear. They have based can lead to elongation or failure of the graft presence of ACL nodules, fat pad scarring, their rehabilitation protocol on known knee and repair. They suggest a goal of 0° of ex- and/or adhesions. In some cases, motion biomechanics to incorporate exercises that tension for the patients having undergone loss can be managed with conservative, non- would reduce the strain on the PCL with this type of surgery, even if the extension operative treatment such as physical therapy respect to tibial translation. For example, ROM of the uninvolved knee is greater. and possibly manipulation of the knee un- they recommend that open kinetic chain der anesthesia. Millett et al24 have outlined knee flexion and hip extension exercises be POTENTIAL COMPLICATIONS the risks and complications associated with avoided in the early postoperative period FOLLOWING ACL manipulation under anesthesia, such as ar- because of the posterior translation of the RECONSTRUCTION ticular damage and fracture due to excessive tibia during unopposed hamstring contrac- As previously mentioned, problems can joint compression forces during the proce-

Orthopaedic Practice Vol. 17;4:05 19 dure. Because of these risks, the surgical au- 2 years, revealed that these patients had good Double Bundle ACL thor prefers to treat the majority of patients knee stability as assessed by Lachman, pivot There is growing interest in this technique with knee arthrofibrosis with arthroscopic shift tests and single leg hop tests. They had with an attempt to recreate anatomy more surgery to release adhesions and distend the 25 patients complete the 1999 International precisely. This technique involves placing capsule as indicated. However, Dodds et al58 Knee Documentation Committee (IKDC) femoral tunnels at the insertions of both the reported success in managing knee arthrofi- Subjective Knee Evaluation Form63 to assess antero-medial and postero-lateral bundles brosis with manipulation. They stated that symptoms of instability, activity level, and of the ACL with separate grafts. This place- manipulation might prevent the deteriora- overall knee function. They also used the vi- ment could restore knee kinematics and in tion of articular cartilage that can be caused sual analog score to document preinjury and situ force of the ACL reconstructed graft by gait deviations associated with persistent postoperative pain. Eighty-four percent of to approximate those of an intact ACL.66 flexion contractures. The majority of the 42 these patients reported tolerating very stren- Therefore, anatomical double-bundle recon- patients studied experienced hemarthrosis uous activities without ‘giving way’ of the struction may have biomechanical advan- following the manipulation, but this did knee. Seventy-two percent of these patients tages over the single ACL graft used today.67 not delay the initiation of physical therapy. reported being able to perform strenuous Whether they’ve undergone manipulation or very strenuous activities such as basket- Bioengineered ACL under anesthesia or arthroscopic release of ball, soccer, skiing, tennis, or heavy physical As previously discussed, prosthetic grafts adhesions, patients should initiate or resume work. No patients in the study had signs or have had high failure rates. In order for the physical therapy in order to ensure good symptoms of patellofemoral pain. next generation of prosthetic grafts to achieve functional outcomes and return to preinjury These positive findings led to the develop- long-term success, many factors need to be levels of activity. ment of a second study to assess the postop- considered. The prosthesis should cause erative stability of the knee more specifically. minimal patient morbidity and no risk of FUTURE DIRECTIONS OF This was done using the KT-1000 arthrom- infection or disease transmission. It should ACL RECONSTRUCTION AND eter on 45 patients at a mean of 20 months produce and maintain immediate stabiliza- REHABILITATION (range 12-29 months) following ACL recon- tion of the knee to allow aggressive rehabili- New Approaches in ACL struction with CQFT graft. Twenty-three tation and rapid return to preinjury levels of Reconstruction patients were excluded from the study for function. It should support and direct host Quadriceps tendon graft reasons including concomitant injuries, lack tissue ingrowth but also biodegrade at a rate Bone-patellar-tendon-bone and hamstring of normal contralateral knee for comparison, that will still provide mechanical stability as autografts are the most used autografts for known graft failures prior to their study, or the extra-cellular matrix is laid down. This ACL reconstruction at this time.3,4,5,14,17,59 inability to participate in the testing at the tissue ingrowth and organization should also Another autograft that is gaining popularity time. The goal was to objectively measure lead to maintaining the mechanical integrity is the quadriceps tendon graft, with 1 bone anterior tibial translation on both knees. of the ACL for the patient’s lifetime.37 The plug. Fu et al7 described donor site morbid- The acceptable range in side-to-side -differ use of silk as a biomaterial for use in ACL tis- ity with quadriceps tendon grafts to include ence of a fully functional graft was defined sue bioengineering is now being studied. Its quadriceps muscle atrophy, articular surface as 0 to 3 mm.59,64 A value of more than 3 advantages include low manufacturing costs, damage at harvesting, scar size, and location. to 5 mm defined a partially functional graft. availability, high mechanical strength, and In 2003, Theut et al59 reported on the use of a Values greater than 5 mm were defined as slow biodegrading rate. The immune re- central quadriceps free tendon graft (CQFT), arthrometric failure.59 They found that 84% sponse becomes negligible once the sericin, without a patellar bone plug, for both pri- of patients presented with a side-to-side dif- a gelatinous protein, is removed. The use of mary and revision ACL reconstruction. This ference of –2 to 3 mm, and 16% presented such a prosthetic graft would eliminate some graft is sometimes augmented and fixed by with a difference of more than 3 mm but of the morbidity and complications associ- various methods, including bone disk taken less or equal to 5 mm. No patients had a ated with autogenic and allogenic grafts. The from the tibia. An advantage of this graft is side-to-side difference greater than 5 mm, use of bioengineered grafts should therefore its cross-sectional area that is nearly double therefore there were no patients with an ar- allow for more aggressive rehabilitation and the central third of the patellar tendon. In thrometric graft failure. The authors state early return to sports, especially in high-level addition, biomechanical studies have shown that these values are comparable with other athletes, if the mechanical tensile strength that its mechanical properties are similar to KT-1000 values at a minimum of 2 years fol- and viability of these grafts can be optimized that of the patellar tendon.60-62 Theut et al59 lowing surgery as documented in the litera- at the time of surgery. report that they use the CQFT graft because ture.12,17,19,34,49,65 Theut et al concluded that it is easily harvested and seems to cause very their patients with CQFT ACL reconstruc- ACL Repair little morbidity. Their retrospective postop- tions had stable, highly-functional knees There is also a growing interest in primary erative assessment of 29 patients who had with little morbidity such as patellofemoral repair of the injured ACL. Improved ar- undergone ACL reconstruction with CQFT pain 2 years following surgery, leading to a throscopic surgical techniques and a better graft, with a minimum follow-up of at least high rate of patient satisfaction. understanding of the ACL’s healing process

Orthopaedic Practice Vol. 17;4:05 20 may contribute to the development of pro- health status as assessed by general health- portant in the setting of ever evolving surgi- cedures which may effectively help the na- status questionnaires. However, the reha- cal procedures, societal expectations for the tive ACL ‘heal’ into a functionally significant bilitation protocols and exercise instructions early return of function and return to sports, ligament. weren’t reported in detail; hence it would be and managed care constraints. difficult for clinicians to model their practice CLINICAL OUTCOMES after either group. Other studies68,69,72 have REFERENCES AND COST-EFFECTIVENESS better outlined the rehabilitation protocols 1. Blackburn TA,Jr. Rehabilitation of The success of ACL reconstruction- sur that were followed. They all differ slightly anterior cruciate ligament injuries. Or- gery depends on many variables. 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Current practices and but much controversy remains regarding lenge resides in the selection of these patients opinions in ACL reconstruction and frequency and duration of physical therapy and in the development of a home exercise rehabilitation: Results of a survey visits following ACL reconstruction.26,68-71 program. A goal-based approach to reha- of the american orthopaedic society This has become increasingly apparent bilitation would most likely simplify this for sports medicine. Am J Knee Surg. in the setting of reimbursement issues/con- process. These goals include restoration of 2001;14:85-91. straints and of managed care costs. In the ROM, progressive strengthening and pro- 4. Jaureguito JW, Paulos LE. Wh past, it was common for patients to attend prioception, and improvement of agility to grafts fail. 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Delitto A, Rose SJ, McKowen JM, the anterior cruciate and medial collat- ties in young adults. Knee Surg Sports Lehman RC, Thomas JA, Shively RA. eral ligaments. J Bone Joint Surg - Am. Traumatol Arthrosc. 1996;4:100-110. Electrical stimulation versus voluntary 1995;77-A:800-806. 63. Irrgang JJ, Anderson AF, Boland AL, exercise in strengthening thigh muscu- 52. Graf B, Uhr F. Complications of intra- et al. Development and validation of lature after anterior cruciate ligament articular anterior cruciate reconstruc- the international knee documentation surgery. Phys Ther.1988;68:660-663. tion. Clin Sports Med. 1988;7:835-848. committee subjective knee form. Am J 44. Paternostro-Sluga T, Fialka C, Alacam- 53. Hughston JC. Complications of ante- Sports Med. 2001;29:600-613. liogliu Y, Saradeth T, Fialka-Moser V. rior cruciate ligament surgery. Orthop 64. Daniel DM. Assessing the limits Neuromuscular electrical stimulation Clin North Am. 1985;16:237-240. of knee motion. 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Sterett WI, Hutton KS, Briggs KK, anterior cruciate ligament reconstruc- AA, Young JC. Electrical stimulation of Steadman JR. Decreased range of tion: A comparison of a lateral and an the thigh muscles after reconstruction motion following acute versus chronic anatomical femoral tunnel placement. of the anterior cruciate ligament. ef- anterior cruciate ligament reconstruc- Am J Sports Med. 2004;32:1825-1832. fects of electrically elicited contraction tion. Orthopedics. 2003;26:151-154. 67. Yagi M, Wong EK, Kanamori A, Deb- of the quadriceps femoris and ham- 57. Petersen W, Laprell H. Combined inju- ski RE, Fu FH, Woo SL. Biomechani- string muscles on gait and on strength ries of the medial collateral ligament cal analysis of an anatomic anterior of the thigh muscles. J Bone Joint Surg and the anterior cruciate ligament.early cruciate ligament reconstruction. Am J Am. 1991;73:1025-1036. ACL reconstruction versus late ACL Sports Med. 2002;30:660-666. 47. Lephart SM, Pincivero DM, Giraldo reconstruction. Arch Orthop Trauma 68. Beard DJ, Dodd CA. Home or super- JL, Fu FH. The role of proprioception Surg. 1999;119:258-262. vised rehabilitation following anterior in the management and rehabilitation 58. Dodds JA, Keene JS, Graf BK, Lange cruciate ligament reconstruction: A of athletic injuries. Am J Sports Med. RH. Results of knee manipula- randomized controlled trial. J Orthop 1997;25:130-137. tions after anterior cruciate ligament Sports Phys Ther. 1998;27:134-143. 48. Irrgang JJ, Fitzgerald GK. Rehabilita- reconstructions. Am J Sports Med. 69. De Carlo MS, Sell KE. The effects of tion of the multiple-ligament-injured 1991;19:283-287. the number and frequency of physical knee. Clin Sports Med. 2000;19:545- 59. Theut PC, Fulkerson JP, Armour EF, therapy treatments on selected out- 571. Joseph M. Anterior cruciate ligament comes of treatment in patients with 49. Howell,Lieutenant Colonel Stephen reconstruction utilizing central quad- anterior cruciate ligament recon- M., Taylor CMA. Brace-free rehabilita- riceps free tendon. Orthop Clin North struction. J Orthop Sports Phys Ther. tion, with early return to activity, for Am. 2003;34:31-39. 1997;26:332-339. knees reconstructed with a double- 60. Harris NL, Smith DA, Lamoreaux L, 70. Fischer DA, Tewes DP, Boyd JL, looped semitendinosus and gracilis Purnell M. Central quadriceps tend Smith JP, Quick DC. Home based graft. J Bone Joint Surg - Am. 1996;78- for anterior cruciate ligament recon- rehabilitation for anterior cruciate A:814-825. struction. part I: Morphometric and ligament reconstruction. Clin Orthop. 50. Johnson DL, Urban WP,Jr, Caborn biomechanical evaluation. Am J Sports 1998;(347):194-199. DN, Vanarthos WJ, Carlson CS. Med. 1997;25:23-28. 71. Timm KE. The clinical and cost-effec-

Orthopaedic Practice Vol. 17;4:05 23 tiveness of two different programs for rehabilitation following ACL recon- struction. J Orthop Sports Phys Ther. 1997;25:43-48. 72. Treacy SH, Barron OA, Brunet ME, Barrack RL. Assessing the need for extensive supervised rehabilitation fol- lowing arthroscopic ACL reconstruc- tion. Am J Orthop. 1997;26:25-29.

Marie-Josée Paris is a Senior Physical Therapist of Outpatient Services, Department of Rehabilitation Services at Brigham and Women’s Hospital in Boston, MA. Reg B. Wilcox III is the Clinical Supervisor at Outpatient Services, Department of Rehabilitation Services and Fellow, Center for Evidence Based Imaging, Department of Radiology at Brigham and Women’s Hospital. Peter J. Millett is an associate surgeon at Steadman Hawkins Clinic in Vail, CO.

24 Orthopaedic Practice Vol. 17;4:05 Comparison of Standard Blood Pressure Cuff and a Commercially Available Pressure Biofeedback Unit While Performing Prone Lumbar Stabilization Exercise

Ward Mylo Glasoe, PT, MA, ATC Reginald R. Marquez, MPT Whittney J. Miller, MPT Anthony J. Placek, MPT

INTRODUCTION ing’ the abdomen to recruit the transversus ferred if the pressure increases or if the pres- Biofeedback is used to complement stabi- abdominus muscle (Figure 2).4 The bladder sure drops by more than 10 mmHg.4,5 lization exercises for patients suffering back of the PBU is inflated and placed under the Blood pressure cuffs are required equip- pain.1 The pressure biofeedback unit (PBU) lower abdomen. The individual contracts ment in all clinics. Like the PBU, the pres- developed by the Chattanooga Group in the muscles of the lower abdomen with in- sure cuff is an inflatable bladder with an Hixson, TN is a commercial device for tent to reduce the pressure registered by the attached gauge (Figure 1). Since clinics al- which exercise protocols are described.2-4 PBU. The principle underlying the biofeed- ready have a blood pressure cuff, perhaps this The PBU is a 3-chamber air filled bladder back is that isolation in the recruitment of instrument might be adequate to provide with attached gauge (Figure 1) that indi- the transverse abdominus occurs when the pressure feedback to individuals performing rectly measures movement during exercise hollowing contraction drops the pressure of stabilization exercise in prone. The purpose through changes in bladder pressure. One biofeedback between 6 to 10 mmHg. Un- of this study was to examine whether cuff protocol recommends the action of ‘hollow- wanted substitution by other muscles is in- pressure measurements correlate with PBU measures obtained during the performance of prone stabilization exercise.

METHODS Subjects The Institutional Review Board of North- ern Illinois University approved this study and informed consent was obtained. Eigh- teen college students, 9 male and 9 female, were tested. Age ranged from 20 to 30 years. Each volunteer completed the Oswestry dis- ability questionnaire to assess the degree of functional impairment associated with low Figure 1. Pressure measurement devices used in this study. (A) Pressure Biofeedback Unit. back pain.6 Oswestry scores averaged 4% (B) Standard blood pressure cuff. (range 0 to 23%) indicating minimal dis- ability. Ten of the 18 subjects scored them- selves as having 0% disability. Excluded were subjects with severe spinal disability as identified by Oswestry scores greater than 60%, and subjects who were pregnant.

Procedures Subjects underwent a session of training using the PBU. Subjects were positioned prone on a firm mat. The PBU was placed beneath the abdomen just proximal to a line running between the anterior iliac crests and centered relative to the naval.4 Subjects Figure 2. Prone exercise with pressure biofeedback monitoring spinal movement. practiced drawing the abdomen up-and-in

26 Orthopaedic Practice Vol. 17;4:05 towards the spine under the guidance of an between methods. Figure 3 scattergram data standard blood pressure cuff inflated to 40 instructor self-trained in the prone hollow- pattern is offset, and shifted above the line mmHg. ing regimen of exercise. The session -con of identity towards the ‘y’ axis representing The authors recognize several limitations cluded when the instructor was satisfied that the cuff. This indicates that the percentage of the study. Examiners were not blinded, the subject could perform the hollowing ex- drop registered with the cuff was consistently the devices were not calibrated nor were reli- ercise while breathing normally and without larger but related. The drop in actual pres- ability of the measures assessed, and without substitutionary co-contraction of the gluteus sure recorded by the examiner for the two concurrent EMG data the suggested rela- maximus and erector spinae muscles. methods was remarkably similar (see Table). tionship between biofeedback and muscle Subjects rested for 30 minutes and were These findings suggest that the prone- hol activation is speculation. Furthermore, few then randomly assigned to each of the 2 test lowing protocol advocated by the manufac- subjects had back pain. While the subjects conditions (PBU vs. Cuff). The prone stabi- turer of the PBU can be replicated using a tested represent a younger population that lization exercise technique used in this study has been described elsewhere.4,5 The device placed beneath the abdomen was inflated to Table 1. Descriptive Statistics of Drop in Pressure Recorded with the Cuff and PBU (N = 18) baseline pressure. The PBU was inflated to Measurement Mean Range SD � 70 mmHg of pressure, the value displayed Cuff inflated to 40 mmHg with 2 mmHg resolution on a dial gauge Drop in pressure 2.7 mmHg 1 to 6 mmHg 2.0 (Figure 1).4 Based on subject experience, the Percent drop in pressure 6.7 %

cuff inflated to 40 mmHg of pressure felt PBU inflated to 70 mmHg similar to the PBU. Subjects performed 10 Drop in pressure 2.6 mmHg 1 to 7 mmHg 1.8 repetitions, holding each hollowing contrac����-�� �� � � � Percent����� drop�� � in� pressure� ���� �� ��� �3.7�� %��� ���� ��������� �� ������������ �� ��� ���� �� tion for 8 seconds. A 10-minute rest�� � was�� ��� ���� ��� ���������� ���������� ����������� ������������ given between test conditions. ��� ��� ���� � ���� ���� ���� ���� ������� �� � ��� Two examiners worked together to collect ��������� �� �������� �� ��� ���� �� ��������� ���� � ���� the data. One examiner gave commands to the subject, the other recorded the mean �� drop in mmHg pressure registered on the device.

Data Analysis �� Converting the data to percentage of pressure decrease allowed the PBU and cuff measurements to be statistically compared to � � �� assess agreement. An intraclass correlation � coefficient (3,1) and their 95% confidence � � 7 �

interval (CI), and standard errors of the � � measurement (SEM) were calculated. � � � � � RESULTS � � �

Table 1 shows the descriptive statistics for � �

the recorded data. An ICC of 0.67 was the �

� �

level of agreement between the 2 methods of � pressure measurement. The 95% CI limits around the ICC point estimate ranged from 0.29 to 0.86. The SEM value for percent- � age of pressure decrease was 3%, indicating consistency between measures occurred in a small range. � DISCUSSION � � � � �� �� �� Results of this experiment support the use ������� ��� ���� �� ��� of a standard blood pressure cuff to provide biofeedback for prone stabilization exercise. An ICC of 0.67 shows there was fair agree- Figure 2. The percent (%) drop in the PBU and cuff displayed in relationship to the line of identity ment for the percentage of pressure decrease with the calculated intraclass correlation coefficient.

Orthopaedic Practice Vol. 17;4:05 27 could develop back pain, a larger more di- ment for patients with back pain. The PBU of transversus abdominis function. verse sample would facilitate the generaliz- is the common pressure biofeedback instru- Physiother Research Int. 2002;7:239- ability of the data. Results could differ for ment for which exercise protocols are de- 249. other varied patient populations. scribed. Data presented in this work suggest 5. Richardson CA, Jull GA, Hodges PW, Difference in the material design of the that a blood pressure cuff may be used as an Hides J. Therapeutic Exercise for Spinal devices in conjunction with the prone test acceptable alternative to provide biofeedback Segmental Stabilization in Low Back position may have affected readings. Materi- when performing prone lumbar stabilization Pain: Scientific Basis and Clinical Ap- als used to construct the PBU are nonelastic. exercise. proach. London: Churchill Livingstone; By contrast, the blood pressure cuff is built 1999. from materials that expand when inflated. In REFERENCES 6. Fairbank JC, Couper J, Davies JB, prone the contour of the spine and abdomen 1. Asfour SS, Khalil TM, Waly SM, O’Brien JP. The Oswestry low back flattened the cuff, and in effect, prevent it Goldberg ML, Rosomoff RS, Roso- pain disability questionnaire. Physiother. from expanding when inflated. Other stabi- moff HL. Biofeedback in back muscle 1980;66:271-273. lization exercise protocols2,3 that incorporate strengthening. Spine. 1990;15:510- 7. Shrout PE, Fliess JL. Intraclass correla- measures of pressure biofeedback require the 513. tions: uses in assessing rater reliability. individual to lie supine with the PBU placed 2. Jull GA, Barrett C, Magee R, Ho P. Psychol Bull. 1979;86:420-428. beneath either the low back or neck. We did Further clinical clarification of the attempt to monitor cuff pressure while the muscle dysfunction in cervical head- individual exercised in supine. However, ache. Cephalalgia. 1999;19:179-185. Ward Mylo Glasoe is an Instructor at the highly variable readings were found because 3. Richardson CA, Jull GA. Muscle con- Program in Physical Therapy at the University the cuff inflated and rounded into the curva- trol-pain control. What exercises would of Minnesota in Minneapolis, MN. Reginald tures of the spine. you prescribe? Man Ther. 1995;1:2-10. R. Marquez, Whittney J. Miller, and 4. Storheim K, Bo K, Pederstad O, Jahn- Anthony J. Placek were (at the time of the CONCLUSION sen R. Intra-tester reproducibility of study) Physical Therapy Students at Northern Stabilization exercises are a popular treat- pressure biofeedback in measurement Illinois University in DeKalb, IL.

28 Orthopaedic Practice Vol. 17;4:05 bookreviews Coordinated by Michael J. Wooden, PT, MS, OCS

Curtis KA, Newman PD. the educational program. The information read format. Specific examples and tables are The PTA Handbook: Keys to is presented in 6 organized sections with a used to reach objectives. References, recom- Success in School and Career for ‘Putting into Practice’ exercise at the end of mended reading, and links to web sites are the Physical Therapist Assistant. each chapter to apply the information in the included. Each chapter ends with helpful Thorofare, NJ: Slack, Inc.; 2005, PTA program or clinical setting. ‘Putting it into Practice’ exercises. 306 pp. The first section provides an introduction The end of the book has several appendi- to physical therapy and how it will change in ces that the physical therapist assistant stu- What can Physical Therapist Assistant’s the future. A description of the PT-PTA pre- dent can refer to regarding APTA Code of do? Can they progress exercises? Can they ferred relationship, and the changing roles Ethics and Guide to Professional Conduct, take measurements? Can they discharge pa- of the physical therapist and the physical Standards of Practice for Physical Therapy, tients? These are only some of the questions therapist assistant in the health care environ- Direction and Supervision of the Physical that physical therapists have asked me. Even ment. Therapist Assistant, Levels of Supervision, with 12 years of experience as a physical The next 3 sections are a guide for the and Provision of Physical Therapy Interven- therapist assistant, I sometimes find it chal- physical therapist assistant student through tions and Related Tasks. lenging to answer them. I inform them of the educational program. Included are fi- The PTA Handbook: Keys to Success in my education, clinical experience, continu- nancial aspects of the PTA program, codes School and Career for the Physical Therapist ing education courses, company policies, of conduct, student expectations, as well as Assistant is a complete, easy-to-use resource and the laws regarding supervision of a PTA legal and ethical issues in physical therapy. for the physical therapist student who want under the direction of a Physical Therapist. Strategies are provided to aid the PTA stu- to achieve the most out of their education Developing a strong relationship of commu- dent in the learning process, test taking, and and career. I would highly recommend this nication and trust between the PT and PTA preparing papers. There are also chapters book for any PTA student, PT, PTA, or clin- is essential to providing quality, cost-effective providing helpful information to students ic manager. physical therapy care. with disabilities, and career transition stu- These questions, as well as the PTA’s role dents. Andrew MacFarlane, PTA in physical therapy are clearly explained by Section 5 emphasizes the importance of specific examples in this volume. The book evidence-based practice in physical therapy,  also demonstrates how PTAs can develop a and describes the role of the PTA in gather- successful partnership with the physical ther- ing and communicating information while Shultz SL, Houglum PA, Perrin DH. apist. delivering the established plan of care. There Examination of Musculoskeletal nd Two experienced and credible authors is a chapter on how to collect and to use ap- Injuries. 2 ed. 2005, Champaign, Ill: wrote this book. Dr. Curtis’ background propriate clinical information. With all of Human Kinetics; 698 pp., illus. includes a wide variety of experiences in the resources available to us today, I found clinical practice, staff development and su- this to be very helpful. The section con- This text is 1 of 5 in the Athletic Train- pervision, clinical research, and clinical and cludes with the benefits of membership of ing Education Series written primarily for academic teaching in physical therapy. Her the APTA and the advantages of attending athletic training students and as a reference academic teaching experience includes grad- conferences. for practicing athletic trainers. This text is uate courses in physical therapy professional The last section prepares the PTA student entirely devoted to examination principles issues, research methods, communication, for entering the job market, including taking and procedures. Treatment and manage- health education, career development, and the national exam in states where required, ment techniques are presented in the other psychosocial considerations in health care. and developing a resume. Samples of cover textbooks in the series referenced above. Ad- Ms. Newman is a physical therapist assistant letters and tips for interviewing are also ditionally, the aim of the text is to reflect the program director, and served as invited proj- included in this section. The final chapter competencies required for certification by ect reviewer of the PT-PTA Collaboration stresses the importance of communication the National Athletic Trainers Association Module developed by the National Assembly in developing successful relationships with (NATA). Examination of Musculoskeletal of Physical Therapist Assistants. the PTA’s supervising PT. What can you do Injuries 2nd ed. is a revision of the text As- This comprehensive text was written as a to promote a successful PT-PTA preferred sessment of Athletic Injuries, published in guide for physical therapist assistant students relationship? 2000. in making choices as they progress through Each chapter is presented in an easy-to- The text is divided into 3 parts. Part I

Orthopaedic Practice Vol. 17;4:05 29 presents principles of examination which in- primary care settings may find the emergent overuse injuries, spondylolysis, scoliosis, disc cludes chapters on nomenclature and injury examination procedures presented useful herniation, and mechanical low back pain. classification, observation, palpation; ex- in prioritizing of procedures. The presenta- Each chapter presents an anatomical review, amination of motion, strength, neurological tion of initial first responder examination etiology, signs and symptoms of the disorder, status; cardiovascular; and respiratory status. procedures for a variety of diagnoses is not and treatment of the condition. Part II discusses region specific examination a subject often presented in physical therapy Preventing dance injuries through biome- strategies for cervical, thoracic, lumbar spine; texts and was interesting. The checklists pro- chanically efficient training is the scope of shoulder and arm, elbow and forearm; leg, vided in the text would also be helpful for part 3 of the textbook. Chapters 9 through ankle and foot, knee, and thigh; hip, pelvis entry-level physical therapists in order to be 12 include a discussion of efficient warm-up, and groin; head and face; thorax and abdo- inclusive and thorough in their examination a biomechanical approach to injuries and men. Part III describes the recognition of procedures. I would highly recommend this consideration of the turnout position, flexi- general medical conditions. The information text for student athletic trainers or physical bility exercises, strengthening and stretching is presented on a body-system basis and dis- therapists that are interested in develop- of the muscles of the ankle and talus, and cusses common medical diagnoses seen by ing athletic training skills or certification pronation as a predisposing factor of overuse athletic trainers. through the NATA. injuries. The last portion of the text discusses Each section that deals with examination psychological concerns related to stress and principles begins with chapter objectives that Timothy J. McMahon, MPT, OCS performance, prevention of eating disorders, reflect the competencies within the chap- and the female athlete triad in dancers. ter. Sections begin with brief introductory This book also supplies recommended case presentations. Didactic information is  readings by the author and editors to sup- then developed. Where appropriate, the Solomon R, Solomon J, Minton S, port the discussions. A dance glossary and text describes how examination procedures eds. Preventing Dance Injuries, 2nd a medical glossary are provided to assist the are altered and prioritized due to acute or ed. Champaign, Ill: Human Kinetics; reader with the information presented. emergent situations and onsite examination 2005, 243 pp, illus. Dancers do have a unique set of issues dif- situations versus clinic situations. Examina- ferent from other athletes. It is helpful to tion checklists are provided in all areas in an This book was originally published in understand the expectations of a dancer and easily read format and are comprehensive. 1990 and was considered the initial text in the susceptibility they have towards particu- Printable versions of the checklists are avail- its field. In this revision, the book is sepa- lar injuries. This text is a very good reference able online on the publisher’s web site. All rated into 4 parts: Screening for Common for those clinicians who evaluate and treat examination procedures including special Dance Injuries; Diagnosing, Treating, and dancers. tests are effectively demonstrated through Rehabilitating Dance Injuries; Preventing photos, illustrations, and tables. Dance Injuries through Biomechanically Sylvia Mehl, PT, OCS At the end of each chapter a summary, Efficient Training; and lastly, Psychological review questions, and critical thinking ques- Concerns. tions are presented to help the reader to in- The first chapter discussed the epidemiol-  tegrate chapter constructs. A reference sec- ogy of dance injuries. It is the author’s belief Perrin DH. Athletic Taping and tion for each chapter is provided. The text that to prevent injuries, a clinician must un- Bracing, 2nd ed. Champaign, Ill: references mostly other texts on examination derstand the what, when, where, and how an Human Kinetics; 2005, 122 pp., illus. procedures. injury occurs. A sample of an intake survey Overall, the text accomplishes the goal of is provided. Physical screening procedures Athletic Taping and Bracing, 2nd edition providing relevant examination principles are discussed in the second chapter and are was written to serve as a guide for athletic and procedures for musculoskeletal injuries conducted by various professionals: kinesiol- training instructors and an aid to students in a sequential and logical format. Con- ogist, physician, athletic trainer, and physi- to help them understand and master the art structs are developed at a level consistent cal therapist. A discussion of the somatic and science of athletic taping and bracing. with an entry level or intermediate level cur- screening procedure using Bartenieff Funda- The author, David H. Perrin, PhD, ATC, a riculum course for student athletic trainers. mentals is reviewed in chapter 3. The funda- highly respected athletic trainer and educa- This text is clearly geared for the developing mentals identify inefficient motor function tor, published the first edition of this book athletic trainer and will likely be viewed as a and the potential for chronic injury. in 1995. necessary resource for instruction and review Part 2 of the textbook discusses common The book is comprised of 7 chapters. prior to certification examination. Experi- foot and ankle injuries, knee problems (me- Chapter 1 provides an introduction and enced physical therapists might find this text dial knee strain, patellofemoral pain, tendon- overview to taping and bracing within the somewhat cursory as this is an entry-level itis, torn ligaments/menisci and subluxing context of the practice of athletic training. text that covers many regions of the body and dislocating patellae), iliopsoas tendon- Chapters 2 through 7 take a regional ap- and other region specific texts are more ex- itis, stress factures, and spinal problems in proach to describing 36 different taping and haustive. Although, therapists working in dancers. Spinal problems emphasized are bracing techniques; each chapter also pro-

30 Orthopaedic Practice Vol. 17;4:05 vides outstanding anatomical illustrations, structors and students, this book is highly layers. There are also tests that the reader can relevant discussions of injury mechanisms, recommended for physical therapists or take to test their anatomical knowledge. The and basic stretching and strengthening ex- physical therapist students who would like web site and CD-ROMs are navigated easily, ercises that can help the athlete who has to improve their taping and bracing skills or even for a novice computer user. completed a rehabilitation program main- who use taping and bracing techniques as The text has been rearranged by body re- tain strength and flexibility. The following part of their treatment plans. gion instead of by body systems as in previ- regions of the body are covered by individual ous editions. The book is richly illustrated chapters within the book: (1) the foot, ankle, Michael D. Ross, PT, DHS, OCS with almost 2,000 photos and illustrations. and lower leg; (2) the knee; (3) the thigh, The book also contains the latest imaging hip, and pelvis; (4) the shoulder and arm; (5)  technology to further enhance the material. the elbow and forearm; and (6) the wrist and Clinically relevant information is included hand. Standring S, ed. Gray’s Anatomy: such as placement for the needle for caudal Chapters 2 through 7 begin with regional The Anatomical Basis of Clinical epidural injections, posture and ergonom- range of motion and anatomical descriptions Practice, 39th ed. Edinburgh: ics, EMG studies from gait analysis, etc. The and are then organized according to com- Elsevier Churchill Livingstone; 2005, 116 chapters are divided into 8 sections. mon injuries that occur at that body region 1627 pp, illus, with accompanying Sections are color-coded to allow for quick that can benefit from taping or bracing. For CD ROMs. reference to specific sections. The sections example, for the chapter on the foot, ankle, include Introduction and Systemic Review, and lower leg, the author describes injury Minimum system requirements Neuroanatomy, Head and Neck, Back and mechanisms, appropriate taping and brac- for CD-ROMs: Macroscopic Anatomy of the Spinal Cord, ing techniques, and basic exercises for ankle Pectoral Girdle and Upper Limb, Thorax, sprains, Achilles tendon strains and tendon- Windows: Windows 98 or higher, Pentium Abdomen and Pelvis, and Pelvic Girdle and itis, arch strains and plantar fasciitis, Mor- processor-based PC, 32 MB RAM (64 MB Lower Limb. Descriptive references follow ton’s neuroma, great-toe sprains, heel contu- recommended), 10 MB of available hard- each chapter. sions, and shin splints. The text is routinely disk space, 2x or faster CD-ROM drive, 800 The use of illustrations of imaging makes supplemented by high quality color illustra- x 600 resolution VGA monitor supporting this book unique. There are electron micro- tions and photographs. In the foot, ankle, thousands of colors (16 bit or greater), Inter- scope pictures showing different tissues to and lower leg chapter alone, for example, 12 net connection the use of CT scans and MRI showing nor- different taping and bracing techniques are mal and abnormal anatomy and pathology. described in great detail with 133 color il- Macintosh: Mac OS9 or higher, 64 MB The book is logically organized, making it lustrations and photographs supplementing RAM or greater, 10 MB of available hard- easy for the reader to find information. This the text. disk space, 2x or faster CD-ROM drive, 800 latest edition makes a valuable reference for The taping sequences presented in this x 600 resolution VGA monitor supporting any physical therapist regardless of the set- book are very thorough and are presented thousands of colors (16 bit or greater), Inter- ting in which they work. in a clear and understandable manner. An net connection excellent feature of the second edition of this Jeff Yaver, PT text is that the photographs that illustrate Gray’s Anatomy has been an accepted clas- taping sequences use tape with darkened sic since it was first published in 1858. As edges that allow readers to differentiate lay- the information and anatomical knowledge ers and patterns of tape applied in each step has increased over the years, Gray’s Anatomy of the procedure. Other improvements to has also grown in size and depth. this edition include the use of highly detailed The entire text is now available on line 2005 Clinical Research color illustrations and photographs and the with the purchase of the book. This site in- Grant Recipients Include: inclusion of key palpation and surface anat- cludes many options including weekly up- omy landmarks. This book also contains a dates, related web sites, and all of the images John P. Gerber, PT, DSc, ATC, SCS Eccentric resistance following ACL glossary of relevant terms and a brief list of from the book, which can be downloaded reconstruction: Can improvements suggested readings. Future editions of this into PowerPoint for presentation purposes. inmuscle size, strength, and book could be improved by discussing the There are links to Medline for some of the function be amplified in the early efficacy of taping and bracing and includ- references, which can be viewed. There are postoperative period? ing a CD-ROM, demonstrating some of the links to similar articles, which can also be ac- Amount granted: $9,500.00 more complex techniques. cessed. One of the CD-ROMs also contains Overall, this is an outstanding book that all of the images from the text. The reader has Angela Tate, PT, MS is well organized, easy to understand, and permission to use these for presentations and Identification of scapular dysfunction in overhead athletes clinically oriented. Although the stated au- the other CD-ROM has anatomical models Amount granted: $2,214.00 dience for this book is athletic training in- that can be manipulated and displayed in

Orthopaedic Practice Vol. 17;4:05 31 orthopaedicnews Congratulations Newly Orthopaedic Certified Specialists! All 451 of You!!

Adam Phillips Rufa, PT, MPT Carrol Anne Esterhuizen, PT, MHS, OCS, CPI Daniel Morgan Johnston, PT, OCS Aimee Catherine Guarriello, PT, MPT Carroll E Brown, PT, MS, OCS Daniel Paul Bien, PT, MSPT Alan A. Budnick, PT, MPT, OCS Catherine M. Barry, PT, MS, OCS Daniel Paul Fisher, PT, OCS Alex Michael Koszalinski, PT, DPT Cathleen A Latoof, PT, OCS Daniel Pauley, PT, OCS Amanda Smith-Socaris, PT, OCS Chad T. Durboraw, PT, MPT, OCS Daniel Roger Poulsen, II, PT, MA, OCS Amy Elizabeth Hilbert, PT, MPT Chantal M. McDonald, PT, MS, OCS Danny Joe Hollingsworth, PT, MPT Amy L. Mobius, PT, MSPT Charles T Hanson, PT, OCS Darlene M. Harmon, PT, MS Amy Selinger, PT, MS, OCS Cheryl B. Howard, PT, MS, OCS Darlene Marie Eubanks, PT, OCS Amy Sorg Bencic, PT, DPT Chesson Paul Clement, PT, BS Darren Mathew Heer, PT, MPT Amy Woods-Welsh, PT, MS, OCS Chris Adam Burmaster, PT, BSPT, OCS David A Boyce, PT, EdD, OCS, ECS Andrea E Naso McCuskey, PT, MS, OCS Chris Steven Custer, PT, BS David A. West, PT, OCS Andrea M Byrne, PT, OCS Christianne Marie Misetich-Hippe, PT, OCS David Anthony James, PT, MSPT Andrew Clifton Bennett, PT, DPT Christie Diane Karle, PT, OCS David Bertone, PT, OCS Andrew J Tatom, III, PT, DPT, OCS Christina Patricia Machielson, PT, MSPT David Cameron, PT, OCS Annette Quijada Jones, PT, OCS Christine M. Vincek, PT, DPT, OCS David Dean Van Zant, PT, DPT Annie Christine Raymond, PT, MPT Christine Marie Fissel, PT, MSPT, OCS, CSCS David O’Connor Dinn, PT, MS Barbara Tortora Grochowski, PT, MS, OCS Christopher A. LeVan, PT, OCS David P. Sucato, PT, MSPT, OCS Barry John Morin, PT, MSPT Christopher Daniel Gray, PT, OCS David Scott McIntosh, PT, OCS Bartholome Joseph Horrigan, PT, OCS Christopher G. Rosado, SPT, MPT David Scott Overby, PT, MHS Becky J Rodda, PT, MHS, OCS Christopher Glynn Alligood, PT, MS, OCS Dawn Bauer Underwood, PT, OCS Ben Waide, PT, OCS Christopher J. Stott, PT, BS Dawn Elizabeth Sitler, PT, OCS Bernardine Rene Thomas, PT, OCS Christopher James Izu, PT, MPT DeAnn Vandebogart Lee, PT, OCS Beth Ann Wieber, PT, OCS Christopher John Dahm, PT, MSPT Deborah A Hawke-Headley, PT, OCS Betina Bishop Bain, PT, BA Christopher John Linson, PT, OCS Deborah Ann Grange, PT, OCS Betsy P. Kelley, PT, OCS Christopher M Bajema, PT, MS, OCS Deborah Charmaine Oickle, PT, MHSc Betty Misao Shiba Shaw, PT, BS Christopher M. Kaczmarek, PT, OCS Deborah Nannette Wendt, PT, OCS Beverly J Klug Parrott, PT, MS, OCS Christopher Paul Derosa, PT, BS Debra J Alviso, DPT, OCS Biagio D. Mazza, PT, MPT Christopher S Ficke, PT, OCS Debra L Shaw-Davis, PT, DPT, MS, OCS Boyd Joseph Bender, PT, OCS Christopher Schoolfield, PT, MSPT Debra L. Powell, PT, BSPT Brendan John Toner, PT, OCS Christy Alliese Murr, PT, OCS Della Lee, PT, DPT Bret Edward McLeod, PT, MPT Cindy Ann Martin, PT, OCS Dennis Roger Blomberg, PT, BA Brett Alan Peterson, PT, MPT Cindy J Benson, PT, MPT, OCS Derek Robert Castonguay, PT, BSPT Brett Allen Altman, MPT, OCS, SCS, ATC Cindy Yi-hang Chu, PT, MPT Diane Cordeiro, PT, MPT, OCS Brett L. Bishop, PT, OCS Clare Monica Jones, PT, OCS Diane L. Piekara, PT, OCS Brian A. Gilbert, PT, OCS Clarke Douglas Brown, PT, DPT, ATC, OCS Diane Santos Lantagne, PT, MPT Brian Dale Elza, PT, DPT Clover Afton Farr, PT, MPT Don Alexander Padick, PT, MPT Brian Emmett Dougherty, PT, OCS Colleen Danielle Johnson, PT, OCS Donald Olsen, PT, EdD, OCS Brian John Eckenrode, PT, MSPT, OCS Colleen Marie Liaga, PT, OCS Douglas James Rich, PT, OCS Brian L Beaulieu, PT, MPT Colleen S McClain, PT, OCS Duane Scott Davis, PT, OCS Brian Randall Duncan, PT, MSPT Connie Lynn Bowin, PT, MA Dwight L. Baldoman, PT, OCS Brian Scott Jennings, PT, OCS Corey Paul Arcement, PT, OCS Edie Knowlton Benner, PT, MA, OCS Brian T. Swanson, PT, OCS Cori Marie Rowe, PT, OCS Edward Otto Hauschka, PT, MS Brian Thomas Taylor, PT, MPT Cory Jonathan Middel, PT, MPT Eileen M. O’Neill, PT, MPT Brian Thomas Wessel, PT, MPT Cory W. Peed, PT, OCS Elaine Anderson, PT, MPT, OCS Bruce Boswell Inniss, PT, MS, OCS Courtney L. Hamilton, PT, OCS Elissa Driban, PT, OCS Bruce R. Applegate, PT, OCS Craig Arthur Reeder, PT, BS Elizabeth Ailene Mason, PT, MSPT Bruce Randolph Snow, PT, MSPT Craig Kurtis Carlson, PT, MPT Elizabeth Evie Smith, PT, MSPT Bryan Alexander Regar, PT, OCS Craig Whitney O’Neil, PT, OCS Elizabeth K Corpuz, PT, MSPT Bryan Allison Kirkpatrick, PT, MSPT Crispino Abad Luzano, Jr., PT, BS Elizabeth S. Norris, PT, MS, OCS, PhD Bryan M. Downs, PT, MS Cristina Ann Neuwirth, PT, MPT Ellen S. Pescosolido, PT, MPA Burt Richard Reed, PT, OCS Curtis Joseph Goodwin, PT, OCS Emile Ignatius Yacoub, PT, DPT Camilla Darrow Fortune, PT, OCS Cynthia Ann Maurer, PT, DPT, OCS Emily J. Ladd, PT, OCS Cara Luree Wendel Wurst, PT, OCS Cynthia Dew Card, PT, MOMT, OCS Emily Rae Pomeroy, PT, OCS Carl J Mangione, PT, DPT Cynthia Louise McLean, MPT Eric Scott Grenier, PT, MPT Carol D. Blair, PT, OCS, SCS Dale Richard Corum, II, PT, OCS Erika Luise Wilbur, PT, MSPT Carol Griggers Johnston, PT, MPT Damien Thomas Scott, PT, MS Evan R Jones, PT, OCS Carolyn Wadsworth, PT, MS, OCS Daniel Chesley Kirk, PT, MPT Farzana Anjum, PT, OCS

32 Orthopaedic Practice Vol. 17;4:05 Frances A Hansen, PT, OCS Jacquelyn Hoagland Lockwood, PT, OCS Jeff T. Busha, PT, OCS Francine Noel-Ford, PT, DPT, OCS, MBA Jacques Leslie Beauchamp, DPT, SCS, OCS, ATC Jeffery Kyle Bradley, PT, MPT Gail Ellen Maciejewski, PT, OCS James A. Dronberger, PT, DPT Jeffrey M. Hetrick, PT, OCS Gary S. Struble, PT, DPT, OCS, MDT James Allen Kirk, PT, OCS Jennifer Anne Manning, PT, OCS Geoffrey Michael Kandes, PT, OCS James D. Foltz, PT, MPT Jennifer Cooper, PT, OCS George Alan Summers, PT, OCS James Daniel McCallum, PT, OCS Jennifer Dean Malecki, PT, OCS George S Young, DPT, OCS James Richard Caron, PT, OCS Jennifer Elizabeth Halvaksz, PT, MPT George T. Edelman, PT, OCS James T. Henricksen, PT, OCS Jennifer Erin Penrose, PT, OCS George Waldrip Birdsong, PT, OCS James W Moore, PT, OCS Jennifer Gayda Zoller, PT, OCS Gilbert A Schoos, PT, MA, OCS Jane Groeneweg Keehan, PT, MEd, OCS Jennifer H Hill Ryan, PT, MS, OCS Glenda K Maines, PT, OCS Jane Helmeczi, PT, MPT, OCS Jennifer Lynn Janes, PT, BA Greg Alan Harada, PT, DPT Janet Maria Caputo, PT, OCS Jennifer M. Masterson, PT, OCS Gregory Adrian Todd, PT, OCS Janet Marie King, PT, OCS Jennifer Marie Batchelor, PT, OCS Gregory T. Peake, PT, OCS Janice L Volk, PT, OCS Jenny Marie Braddock, PT, OCS Gregory Zevin, PT, OCS, MTC Janine E Nesin, DPT, OCS Jeremy Logan Schafer, PT, OCS Gretchen A. Seif, PT, MHS Janine Mary Moore, PT, MS Jeremy Shane Angaran, PT, DPT Haideh Victoria Plock, PT, MSPT Janna Elyse Woodrich, PT, OCS, Cert MDT, C Jessica R Nelsen, PT, OCS Halle L. Wilson, PT, DPT Jarol Lyn Baumann, PT, OCS Jill Elizabeth Solon, PT, MPT Heather Ann Milligan, PT, MSPT Jason Alden Winburne, PT, MPT Jill Joanna Tillman, PT, OCS Heather L. Jurca, PT, OCS Jason Dean Gauer, PT, MPT Jill Michele Tomasello, PT, OCS, FABDA Heather Matheson Shanahan, PT, MSPT Jason Ellis Mattox, PT, OCS Jiten Bhupendra Bhatt, PT, MPT, OCS Heidi Ozawa Contractor, PT, ATC, CSCS Jason Patrick Reiss, PT, MPT Joanne Macza, PT, BScPT Heidi Theresa Pickering, PT, MPT Jason Quentin Avakian, PT, OCS Joanne Zrenda Moore, PT, DHSC, OCS Holly Christine Tanner, PT, MA Jason W. Matthews, PT, MSPT Jodi Llacera Klein, PT, DPT, MS, OCS Holly E. Mrazek, PT, BS Jason William Bruns, PT, OCS Jodi Marie Boyd, PT, MSPT Ian F. Hazelton, PT, MSPT Jay A Bernasconi, PT, MS, OCS Jody Christine Dexter, PT, MPT Inna Keselman, PT, MPT Jay A. Smith, PT, OCS Joel Matthew Long, PT, OCS Irene F. Blehein, PT, OCS Jay Lamble, PT, MS, OCS, NCS Joey Edward Harbison, PT, BS Iulian Mihai Lugoj, PT, MS Jeanie Jong-Mi Kim, PT, MPT Johanna Gabbard, PT, OCS Jack Lee Ryals, Jr., PT, ATC Jeanna-Marie Barsamian, PT, DPT, OCS, ATC John Alan Kangas, PT, MPT Jacqueline H. Randa, PT, OCS Jeanne Kowal Smith, PT, MPA, OCS, DPT John Bradley McAlister, PT, BA Jacqueline Lynn Pollock, PT, OCS Jeff Giulietti, MPT, ATC, OCS, COMT John Charles Pearson, PT, OCS

Orthopaedic Practice Vol. 17;4:05 33 John Frederick Nelson, PT, BS Kimberley Anne Kules, PT, OCS Melanie F Reid, PT, OCS John G Annes, PT, MS Kirsten Gaines Transue, PT, MPT Melissa Catherine Kolski, PT, OCS John G Campbell, PT, MS, OCS Kirti Malik, PT, OCS Melissa Merritt, PT, OCS John Gregory Hogue, PT, OCS Kristen Elise Brehm, PT, OCS Melodie Mattson-Bell, PT, OCS John Keith Obsenares, PT, OCS Kristen Stairs Corderman, PT, OCS Michael Allan Andersen, PT, MS John Kyle Gibson, PT, OCS Kristin Kirk Sheehan, PT, MPT Michael B. Woody, PT, OCS John L. R. Gillanders, PT, OCS Kristina M. Welsome, PT, CFMT, MSPT, OCS Michael Brian Hoag, PT, MBA, OCS John Lennox Echternach, Jr., PT, MS Kyle Alan Watterson, PT, MS, ATC, OCS Michael C. Knob, PT, MSPT John Lockard, PT, OCS Kyle Owen Fleischmann, PT, MS Michael Charles Gayle, PT, MA John Mason Somerndike, PT, MPT Kyle Robert Adams, PT, MPT, CSCS Michael David Pile, PT, MSPT John Owen Tunnell, PT, OCS L.N. Shankarkrishnan, PT, OCS Michael Edward Zahn, PT, OCS John P Storck, PT, MPT Lance D Smith, PT, OCS Michael Gene Jacketta, PT, OCS John P. Dennis, PT, OCS Laura Ann Iverson, PT, OCS Michael James Cabiro, PT, BS John R. Martin, PT, OCS Laura Hagan, PT, MS Michael Paul Quesnell, PT, MPT John R. Ragonese, PT, MPT Laura Jean Homer, PT, OCS Michael T. Cibulka, PT, MHS, OCS John Randal Celestino, PT, GCS, MTC Laura Kenny, PT, OCS Michele Susan Townshend, PT, OCS John Russell Astrab, PT, MSPT Lauren Susan Yee, PT, OCS Michelle H. Cameron, PT, OCS John Todd Mansfield, PT, OCS Laurie Kathleen Barnum, PT, MPT Michelle Katreen Spicher, PT, OCS John Vincent Marrujo, PT, OCS Leigh Stalker deChaves, PT, OCS Michelle R Steinhagen, PT, DPT, OCS, CSCS Johnnie Brooks Burnett, PT, OCS Lenore Esther Filler, PT, OCS Mitchell T. Maione, PT, DPT, OCS, MTC Jolene L. Bennett, PT, MA, OCS Linda Jo Patterson, PT, OCS Mohammad Reza Nourbakhsh, PT, PhD Jonathan Chad Moore, PT, OCS Linda Monroe, PT, MPT, OCS Myra L Pumphrey, PT, OCS Jonathan David Keller, PT, MPT Linda T O’Connor, PT, MS, OCS Nancy Galloway Droege, PT, OCS Jonathan Robert Zecher, PT, OCS Lisa A. Grieco, PT, OCS Nancy Jane Platt, PT, MS, OCS Jonathan Wade Erhardt, PT, OCS Lisa Jean Shepard, PT, DPT Nathan James Lilley, PT, MPT Jose Antolin Dominguez, PT, MPT Lisa K Davis, PT, OCS Neil Scott Chernick, PT, MSPT Joseph C. Whelan, PT, OCS Lisa Marie Sottung, PT, OCS Neil Scott Dreben, PT, MPT Joseph D. Chanoi, PT, OCS Lois Louise Michaelis Goode, PT, OCS Nicholas Alan Austin, PT, MSPT, OCS Joseph G. Montalto, PT, MSPT Lori Ann Loveday, PT, OCS Nichole Michelle Chennault, PT, OCS Joseph Rahmon Kardouni, PT, OCS Lori J. Hogan, PT, MSPT Nicole Marie Marcelli, PT, BS Josephine J. Park, PT, MSPT Lori J. Monson, PT, MPT, OCS Nicole Michelle Haas, PT, MPT, OCS Joshua Casey Richling, PT, OCS Lorraine L. Mathieu, PT, OCS Pamela Sue Knickerbocker, PT, MS, OCS Judith A D’Annunzio, PT, OCS, MTC Lynn H. Watkins, PT, BS Patricia Anne Rouleau, PT, OCS Judith R Gale, PT, DPT, MPH, OCS Malisa Teresa Tantraphol, PT, DPT, OCS Patricia Anne Thoma, PT, OCS Julia C. Gorman, PT, OCS Marc David Cavallino, PT, OCS Patricia Joy Doyle, PT, OCS Julie A Pryde, PT, MS, OCS, SCS Marcie Harris Hayes, PT, DPT Patricia Lamas Beers, PT, OCS Julie Chita, PT, BA Margaret I Bradley, PT, MS, OCS Patricia Lynn Jakobi-Stopper, PT, OCS Julie L. Green, PT, MSPT Margaret M Hopson, PT, MA, OCS Patricia R. Nelson, PT, OCS Justin Barber Gornell, PT, DPT, OCS Marianne C. Ryan-Swanson, PT, BS, OCS Patricia Sulita, PT, OCS Justin Dennis Eisenhofer, PT, MPT Mark Alan Peterson, PT, OCS Patricia Wells Ireland, PT, MS, OCS Justin Zebulon Laferrier, PT, MSPT Mark Daniel Thomson, PT, FAAOMPT Patrick A Dillon, PT, OCS Karan W. Kelly, PT, OCS Mark E Howard, PT, OCS Patrick B Zell, PT, OCS Karen Anne Northrop, PT, OCS Mark Edward Deysher, PT, MPT Patrick John Fox, PT, OCS Karen Holtgrefe, PT, OCS Mark Eric Lester, PT, MPT Paul Anthony Norquist, PT, MPT Karen Louise Greeley, PT, OCS Mark Herbert Blakely, PT, OCS Paul Durant Stoneman, PT, MPT, OCS Karen O Granato, PT, MPT Mark L Marchino, PT, MHS, OCS Paul Eric Anderson, PT, OCS Kari L. Sturtevant, PT, OCS Mark R Langenbach, PT, MBA Paul Ernest Mintken, PT, OCS Karyn Lynn Staples, PT, MPT Mark R. Disalvo, PT, OCS Paul Fohrman, PT, OCS Kathleen Anderson, PT, MBA, OCS Mark Richard Siegel, PT, BS Paul J. Salvi, PT, BS Kathleen M Flanagan Stupansky, PT, OCS Mark S. McConnell, PT, MPT, OCS Paul L Christensen, PT, DPT, OCS, ATC Kathleen Tierney Geist, PT, OCS Mark T Kalinowski, PT, OCS Paul Michael McGhee, PT, OCS Kathryn Ellen Rittenberg, PT, OCS Marlon Kim Trespeses Borbon, PT, OCS Paula D Levinson, PT, OCS Kathryn P. Hemsley, PT, OCS Marnie Z. Clemens, PT, OCS Paula Marie Fulgham, PT, OCS Kay Scanlon, PT, OCS Marshall A. Hagins, PT, OCS Pauline R Patterson, PT, BS Kayla Marie Smith, PT, OCS Martin J. Kelley, PT, DPT, OCS Peter Barnett, PT, DPT, OCS Keith Maderazo Ancheta, PT, DPT Mary Ellen Shanahan, PT, BA Peter R Ouellette, PT, MEd, OCS Kelli A. Goedde, PT, OCS Mary Lynn Wilson, PT, BS Peter Richard Deffner, PT, OCS Kelly A. Hensler, PT, OCS Mary S. Stanford, PT, MPT Philip James Anderson, PT, OCS Kelly Emma Reed, PT, OCS Matthew Albert Rogers, PT, DPT Philip Molina, PT, DPT, OCS Kenneth George Shok, PT, OCS Matthew J. Smelas, PT, OCS Phillip Matthew Edwards, PT, BS Kenneth Wayne Roberts, Jr., PT, OCS Matthew Joseph Armentano, PT, MPT Phillip Sebastian May, PT, OCS Kevin Keith Dean, PT, OCS Matthew V Zurek, PT, OCS R. Dennis Leighton, PT, MS, OCS Kevin Michael McClenahan, PT, BS Maureen M. Clancy, PT, DPT Randal Norman Denton, PT, OCS, MS Kevin O’dell McAlister, PT, OCS Megan Gillespie Yount, PT, OCS Kevin Wong, PT, OCS Meghan Mulholland, PT, MPT, OCS (Continued on page 36)

34 Orthopaedic Practice Vol. 17;4:05 Randy Don Castleman, PT, MSPT, OCS Ryan David Klement, PT, BS Stephanie Kay Carter, PT, PhD Rebecca Ann Davidson, PT, BS Ryan T. Girrbach, PT, OCS Stephanie Nicole Maxfield, PT, MPT Rebecca Fishbein Guttentag, PT, OCS Sally A. Trilli-Coll, PT, OCS Stephanie R. Metz, PT, MSPT Rebecca L Kern-Steiner, PT, OCS Sally J. Barnette, PT, BS Stephen W Bannister, PT, EdD, OCS Rennie Maeda, PT, MS, OCS Samuel T Anaya, PT, DPT, OCS, MTC Steven R. Verhaaren, PT, OCS Rhodri L. Purcell, PT, OCS Sara A. Rogers, PT, MS, OCS Steven Solomon Nieto, PT, DPT, OCS Rhonda Sherwood Cornwell, PT, MPT Sara Michelle Grannis, PT, DPT Sundi M. Hondl, PT, OCS Richard Anthony Linkonis, PT, OCS Sarah DeWit Lusk, PT, OCS Susan Coel Clinton, PT, MHS, OCS Richard Anthony Tubre, PT, OCS Sarah Jane Waters, PT, OCS Susan Kay Kanai, PT, OCS Richard David Clubb, PT, MS Sarah Kathryn Anderson, PT, OCS, DPT, MTC Susan Keller Reischl, PT, OCS Richard David Holcombe, PT, BS Scott A. Steenhard, PT, MPT Susan Slater, PT, MPT, OCS Richard Dean Maas, PT, OCS Scott Adam Smith, PT, OCS Susan W. Priestman, PT, OCS Richard F. Haydt, PT, OCS Scott James Pringle, PT, MPT Suzanne Renee Johnson, PT, OCS Richard Kent Kurfman, PT, DPT, OCS, MTC Scott O’Neal Normile, PT, MS Swati M. Patel, PT, MSPT Richard P. Friscia, PT, MS, OCS, CSCS Sean Patrick Easley, PT, OCS Sylvia A Horton Mehl, PT, MS, OCS Richard Perry Hopson, PT, BSPT Shan M. Teixeira, PT, MOMT T. Kevin Robinson, PT, DSc, OCS Richard T Danielson, PT, MSPT Shari L. Min, PT, OCS, ATC Tamara Lee Perrine, PT, DPT, ATC Robert F. Crawford, PT, BS Shari Walters, PT, OCS Tammara Jo Moore, PT, OCS Robert M. Snow, PT, DPT Sharon Marion, PT, OCS Tarri Ann Randall, PT, OCS Robert Marston Barnes, DPT Shawna Ling Yee, PT, DPT Terri Lynn Welby-Zajec, PT, OCS Robert Nici, PT, MHS, OCS Shelley Lynn Budnick, PT, BSPT, OCS Terry L. Cox, PT, OCS Robert S. Cheng, PT, OCS, COMT Sherron Lorraine McGowan, PT, M.Ed Thomas A. Peters, PT, MPT, OCS Robin Evans Galley, PT, OCS Solomon Medrano Caddauan, PT, OCS Thomas Allen Buches, PT, MS, OCS Robin Litteral McCollough, PT, MSPT Staci Anne Grueber Wietfeld, PT, OCS Thomas Edward Bezemer, PT, MSPT Rodman McHenry, PT, ATC, OCS, CSCS Staci Leigh Cost, PT, OCS Thomas G Sutlive, PT, OCS Roger D Robinson, Jr., PT, OCS Stefany Dianne Spears, PT, DPT Thomas J. Curtis, PT, MS, DSc Ronald T Satow, PT, OCS Stella Dejesa Mendoza, PT, MPT Thomas Joseph Milucci, PT, BSPT Russell Shawne Biggers, PT, MPT Stephanie Frances Raefski, PT, MSPT Thomas W. Henry, PT, OCS

F R O M T H E webwatch http://vh.org/index.html education chair According to information posted on the A unique aspect of the site allows for lan- We are busy planning for website, Virtual Hospital (VH) has been in guage translation with a simple mouse click CSM 2006 in San Diego. existence since 1992 and originates from the into Spanish, German, Portuguese, Russian, University of Iowa. VH is a or Islandic language. Please plan to join us for digital health sciences The website is well orga- some great programming. library designed to nized. Each article link Our preconference course is meet the needs of shows a stamp that “Ergonomic Tools - health care provid- identifies the peer re- Helping Clients and ers and patients. view status, creation Your Business Everyday” The library con- date, and last revision on Wednesday Feb. 1. tains thousands of date of the material. We have multiple programs textbooks and booklets The primary goal of the Thursday through Saturday- please as well as Continuing Education Virtual Hospital digital library is to check our Section web page or (CE) information to health care providers. make the Internet a useful venue for the shar- the APTA web page. We have also The consumer/patient portion of the site is ing of medical information for health care changed the format of the Black easily navigated and offers expansive topical providers and patients. The site offers much Tie and Roses reception on index. There is also a separate section dedi- to both consumers and providers alike. Saturday night so that is an cated solely to children’s health issues. informal event with a disc jockey. Please come!

36 Orthopaedic Practice Vol. 17;4:05 Thomas William Janik, PT, OCS Timothy Gerard Weinzapfel, PT, OCS 2005 APTA Mandatory Bylaws Changes Timothy J. Barnett, PT, MSPT Timothy John Atkinson, PT, OCS Compliance Change #1 Timothy L Ainslie, PT, MS, OCS ARTICLE XV. AMENDMENTS Timothy Richard Waters, PT, OCS Section 2: Amendments Necessitated by Association Action Tobi Gwendolyne Fox, PT, DPT ADD THE FOLLOWING: Todd Eldon Davenport, PT, OCS If the intent of an amendment is editorial or to bring the Section’s bylaws into agreement with those Todd Gibbons Miller, PT, OCS of the Association, the amendment shall be made as required by the Bylaws Chair and shared with the Tonya Kehn Clines, PT, OCS Board of Directors. The Bylaws Chair shall notify the Section’s membership that such amendments have been made. Tracey Cosgrove, PT, OCS Traci L. Hazelton, PT, OCS Compliance Change #2 Tracy L. Carter, PT, OCS ARTICLE XII. FINANCE Trenton Joe Shumway, PT, MPT Section 3: Dues Tricia Joyce Altoonian, PT, MSPT A. Annual dues for members shall be as follows: Tuan Minh Nguyen, PT, MPT Active (other than Active-Student) - $50.00 Affiliate - $30.00 Student - $15.00 Active-Student - $15.00 Tyler Emerson Pomeroy, PT, MSPT, OCS, FAAOM Retired Affiliate - $30.00 Student Affiliate - $15.00 Retired Active Life Affiliate – zero dollars Vincent M. Whalen, PT, MS, OCS Life – zero dollars Virama Annegret Schmitten, PT, OCS Virginia Norene Christensen, PT, MS, OCS REPLACE WITH THE FOLLOWING: Wendy Sewell Byrd, PT, OCS Physical Therapist and Physical Therapist – Post-Professional Student: $50.00 Wendy W. Schoenewald, PT, OCS Physical Therapist Assistant, Retired Physical Therapist and Retired Physical Therapist Assistant: $30.00 William Bryant Miller, PT, OCS, CMPT Student Physical Therapist and Student Physical Therapist Assistant: $15.00 William Jonathan Wilbur, PT, MSPT, OCS Life Physical Therapist: zero dollars William Lee Confer, PT, OCS Life Physical Therapist Assistant: zero dollars Corresponding: zero dollars William Philip Slaughter, PT, OCS Wing Sze Fu, PT, PCS C. CHANGE AS FOLLOWS: Wolfgang J.A. Oswald, PT, OCS All dues changes approved by the Section membership and approved by the Associations’ Board of Directors Younghoon Kim, PT, MPT, OCS, CSCS before the Association’s deadline will become effective on the first of the Section’s Association’s next fiscal year.

BOARD OF DIRECTOR’S MEETING MINUTES OCTOBER 6-8, 2005

DRAFT======MINUTES======DRAFT

Michael Cibulka, President, called the Fall Meeting of the Board The meeting agenda was approved as amended. of Directors of the Orthopaedic Section, APTA, Inc. to order at 6:30 PM Central Standard Time on Thursday, October 6, 2005. =MOTION 1= Mr. McPoil moved that the Board of Directors create a task force to examine the structure of SIGs and Educa- Present: Absent: tion Groups on Thursday, October 12, 2006 (the day before the strategic planning meeting) with a report back to the Board of Michael Cibulka, President None Directors on October 13. ADOPTED (unanimous). The task Tom McPoil, Vice President force will include Joe Godges, Bill O’ Grady, Ellen Hamilton, and a representative from each SIG. Joe Godges, Treasurer Jay Irrgang, Director The Executive Committee discussed employee bonuses and a Bill O’Grady, Director decision was made to grant bonuses in 2005. Kelley Fitzgerald, Research Chair Ellen Hamilton, Education Chair The Executive Committee agreed that the Board of Directors Bob Rowe, Practice Chair meeting at CSM 2006 will be held on Friday, February 3 from 6:00–10:00 PM. There will be no Thursday night meeting and Steve Levine, APTA Board Liaison no Sunday meeting of the Board. Tara Fredrickson, Executive Associate Terri DeFlorian, Executive Director The Executive Committee discussed several items related to the Independent Study Courses. The August 23, 2005 Board of Directors conference call meeting minutes were approved as written.

Orthopaedic Practice Vol. 17;4:05 37 BOARD OF DIRECTOR’S MEETING MINUTES OCTOBER 6-8, 2005

=MOTION 2= Mr. McPoil moved that the Board of Directors BOARD OF DIRECTORS AS DEEMED NECESSARY write a letter to the Sports Physical Therapy Section inquiring TO CARRY ON THE WORK OF THE SECTION. about the Sports Section publishing an international Journal of MEMBERS OF APPOINTED COMMITTEES SHALL Sports Physical Therapy with the Canadian physiotherapy as- BE CURRENT SECTION MEMBERS IN GOOD sociation. ADOPTED (unanimous) STANDING.

=MOTION 3= Mr. Irrgang moved to amend the Section bylaws The Executive Committee discussed a name change for the as follows: Black Tie and Roses Reception. The name selected was the ARTICLE VIII. COMMITTEES Rose Award Celebration. Section1: Standing Committees A. Names The Executive Committee discussed working on trying to The standing committees shall be the following: combine the SIG receptions with the Rose Award Celebration Finance Committee to cut down on total cost of receptions. Nominating Committee Education Program Committee =MOTION 4= Mr. Cibulka moved to allow our corporate Orthopaedic Physical Therapy Practice Committee attorney to examine the CSM contract and financial Research Committee information to determine if the CSM contract is being Orthopaedic Specialty Council executed properly and within the scope of the law and to Practice Committee determine if any recourse is possible to recoup past income. Public Relations Committee ADOPTED (unanimous) Awards Committee Membership Committee =MOTION 5= Mr. Cibulka moved to have the Home Study Course Committee Orthopaedic Section donate $1,000 out of their benevolent giving fund to the Red Cross Hurricane Katrina relief fund. MOVE TO AMEND ARTICLE VIII. COMMITTEES, ADOPTED (unanimous) SECTION 1.A. BY SUBSTITUTION: SECTION 1: STRIKE =MOTION 6= Mr. Fitzgerald moved to approve the SECTION 2: RENUMBER SECTION 1 addition of Linda Van Dillen, PT, PhD as a member to the SECTION 3: FINANCE COMMITTEE Research Committee effective at the end of CSM 2006. A. COMPOSTION ADOPTED (unanimous) THE FINANCE COMMITTEE SHALL HAVE A LEASET THREE (3) MEMBERS IN ADDITION =MOTION 7= Mr. Fitzgerald moved to approve the appoint- TO THE TREASURER, WHO SHALL BE CHAIR. ment of Lori Michener as Chair of the Research Committee, EACH OF WHOM SHALL BE A CURRENT effective at the end of CSM 2006. ADOPTED (unanimous) SECTION MEMBER IN GOOD STANDING. B. FUNCTION =MOTION 8= Mr. Fitzgerald moved to allow Lori Michener TO ADVISE THE BOARD OF DIRECTORS ON to attend the Board of Directors Meeting at CSM 2006. MATTERS PERTAINING TO FINANCIAL NEEDS, ADOPTED (unanimous) GROWTH AND STABILITY, RESENTATION OF AN ANNUAL BUDGET TO THE BOARD OF =MOTION 9= Ms. DeFlorian moved that the Orthopaedic DIRECTORS, INVESTMENT POLICIES, Section reimburse $50 per day for meals ($10 for breakfast, AND COMPLIANCE WITH FINANCIAL $15 for lunch, $25 for dinner) to individuals who are eligible OBLIGATIONS TO APTA. to receive a reimbursement from the Section after their atten- C. APPOINTMENT dance at the meeting. ADOPTED (unanimous) REMAIN THE SAME D. TERM =MOTION 10= Mr. Cibulka moved that the Orthopaedic REMAIN THE SAME Section submit an NC-1 form for the nomination of Joan SECTION 3: RENUMBER SECTION 2 Bohmert, PT, MS for APTA Vice President in the 2006 election. ADOPTED (unanimous) SECTION 4: RENUMBER SECTION 3 – OTHER COMMITTEES The Board of Directors discussed the following issues related SUCH OTHER COMMITTEES, STANDING OR to JOSPT; increase in cost to the Section for 2006, partnering SPECIAL, SHALL BE ESTABLISHED BY THE with individuals who are not eligible to become members, and

38 Orthopaedic Practice Vol. 17;4:05 BOARD OF DIRECTOR’S MEETING MINUTES OCTOBER 6-8, 2005

the potential new journal to be published by the Sports =MOTION 15= Mr. Godges moved that the Board of Physical Therapy Section. Directors accept the following Finance Committee recommendations: =MOTION 11= Mr. McPoil moved that the Orthopaedic • Accept the Section’s 2004 audit Section form a task force to explore the options for improving • Do not increase Section dues at this time the transition from one president to another and report • Review the CSM disbursement received from APTA back to the Board of Directors by CSM 2006. • Decide whether or not to hold the 2006 Fall Strategic ADOPTED (unanimous) Planning meeting at the Section office or at a hotel • Approve the updated Finance Committee policies The Board of Directors discussed liaison activity associated • Appoint Steve Clark to a second term on the Finance with exhibiting at outside meetings and charged Rick Watson, Committee beginning June 2006 Public Relations/Marketing Committee Chair, to discuss this • Adopt the 2006 budget with his committee members and bring back to the CSM 2006 ADOPTED (unanimous) Board of Directors meeting. =MOTION 16= Mr. McPoil moved to approve the The Board of Directors discussed sending a Section designee to Board of Directors policy document and cover page. the 2006 Student Conclave to present. Bob Rowe was asked to ADOPTED (unanimous) be that designee. =MOTION 17= Mr. O’Grady moved to approve the The Board of Directors discussed putting forth names to the Board, Committee Chair, and SIG policy document. APTA Appointed Groups. The following individuals will be ADOPTED (unanimous) sent the APTA link with the appointed group form for them to complete: Bob Rowe, Advisory Panel on Practice; Rick =MOTION 18= Mr. Cibulka moved to approve the Watson, Advisory Panel on Public Relations, Kelley Fitzgerald, Membership Committee policy document and cover page. Advisory Panel on Research, and Tara Ridge, Committee on ADOPTED (unanimous) Clinical Residency and Fellowship Program Credentialing. =MOTION 19= Mr. McPoil moved to approve the The Board of Directors discussed possible nominees for APTA Education Committee policy document and cover page. Awards. Tom McPoil will spearhead gathering information and ADOPTED (unanimous) submitting to APTA. =MOTION 20= Mr. McPoil moved to approve the The To Be Completed items from the August 23 Board of Publications policy document and cover page. Directors conference call were discussed and updated. ADOPTED (unanimous)

=MOTION 12= Mr. O’Grady moved to amend the bylaws =MOTION 21= Mr. Irrgang moved to approve the of the Orthopaedic Section, Article VIII by substitution: Research Committee policy document and cover page. ADOPTED (unanimous) The Board of Directors discussed the ICF conference to be held at CSM 2006. Attendance will be by invitation only. The Board of Directors reviewed the Practice Committee policy document and cover page and decided to bring it =MOTION 13= Mr. McPoil moved to charge the back up for approval at the November Board of Directors Orthopaedic Section President to draft a letter to ABPTS and conference call meeting. copy the OSC. The letter will include a list of questions the Orthopaedic Section Board of Directors have regarding the =MOTION 22= Mr. McPoil moved to approve the Orthopaedic Specialist exam by the November Board of Independent Study Course policy document and cover page. Directors conference call meeting. ADOPTED (unanimous) ADOPTED (unanimous)

=MOTION 14= Mr. McPoil moved to charge the =MOTION 23= Mr. Irrgang moved to approve the Orthopaedic Section Delegate to communicate through Public Relations/Marketing policy cover page. appropriate channels concerns regarding clarification to ADOPTED (unanimous) the House of Delegate P06 position on specialization. ADOPTED (unanimous) The Board of Directors reviewed the Public Relations/Marketing policy document and charged

Orthopaedic Practice Vol. 17;4:05 39 BOARD OF DIRECTOR’S MEETING MINUTES OCTOBER 6-8, 2005

Rick Watson, Chair, to update and bring back to the =MOTION 26= Mr. Godges moved to approve the Animal Board of Directors meeting at CSM 2006. Physical Therapist SIG policy cover page. ADOPTED (unanimous) The Board of Directors reviewed the Awards Committee policy document and cover page and at the request of the Awards =MOTION 27= Mr McPoil moved that the Orthopaedic Committee Chair will table until the November Board of Section Board of Directors write a letter to the ABPTS stating Directors conference call. that because of indifference on the part of the ABPTS to concerns the Board has regarding the degradation of the The Board of Directors reviewed the Occupational Health Orthopaedic Certified Specialist, we are left with no choice SIG policy cover page and charged Bill O’Grady to ask the but to discourage our membership from taking the OCS SIG for clarification on what they mean by practice and exam as we proceed with the development of an OCS exam research initiatives. This will be brought back to the Board administered by the Section. DEFEATED (Mike Cibulka, at their November conference call meeting. Against; Tom McPoil, For; Joe Godges, Against; Jay Irrgang, Against; Bill O’Grady, Against) =MOTION 24= Mr. McPoil moved to approve the Foot and Ankle SIG policy cover page. ADOPTED (unanimous) Mr. Godges moved that the Orthopaedic Section Board of Directors draft a letter to the ABPTS addressing concerns =MOTION 25= Mr. O’Grady moved to approve the Pain related to the Orthopaedic Specialty Certification process. SIG policy cover page. ADOPTED (unanimous) A copy of the letter will be sent to the APTA Board of Directors and the Orthopaedic Specialty Council. The Board of Directors reviewed the Performing Arts SIG ADOPTED (unanimous) policy cover page and charged Jay Irrgang to contact the SIG and work with them on developing a purpose statement that The meeting adjourned at 2:10 PM CST on Saturday, is not a vision or a mission statement and bring back to the October 8, 2005. Board of Directors for approval on their November conference call meeting. Submitted by Terri A. DeFlorian, Executive Director

2006 CSM SCHEDULE CSM 2006 San Diego, CA

WEDNESDAY, February 1, 2006 PRECONFERENCE: 8:00 AM – 5:00 PM 1:00 PM – 5:00 PM Occupational Health PT Special Interest Group Pain Management Special Interest Group Ergonomics Tools - Helping Clients and Your Business Chronic Pain Assessment and Management with an Emphasis Everyday (OHSIG) on Fibromyalgia Miriam Joffee, PT; Drew Bossen, PT Maureen Simmonds, PT, PhD; Carolyn McManus, PT, MS, MA; Nancy Rich, PT, PhD, FACSM THURSDAY, February 2, 2006 1:00 PM – 5:00 PM 12:00 Noon – 4:30 PM Occupational Health PT Special Interest Group Research Platforms Session A On-site PT- Building an Effective Practice in Industry Research Platforms Session B Wayne Rath, PT, Dip. MDT 12:00 Noon – 3:00 PM 1:30 PM – 3:00 PM Lumbar Segmental Instability- Evidence and Integration Calling All Authors: Evidence for Effectiveness into Manual Physical Therapy Practice Mary Ann Wilmarth, DPT, MS, OCS, MTC, CertMDT; Timothy W. Flynn, PT, PhD, OCS, FAAOMPT; J. Haxby Christopher Hughes, PT, PhD, OCS, CSCS; Abbott, PT, MSC, FNZSP; Deydre Teyhen, PT, PhD, OCS Guy Simoneau, PT, PhD, ATC

40 Orthopaedic Practice Vol. 17;4:05 2:30 PM – 3:30 PM RobRoy L. Martin, PhD, PT, CSCS; Stephen F. Conti, MD; OCS Exam & DSP – What’s the Deal? Stephen Reischl, DPT, OCS Rick Ritter, PT, DPT, OCS; Joe Godges, DPT, MA, OCS 2:00 PM – 5:00 PM 3:00 PM - 4:30 PM PTA Education Group Programming Evidence-based Practice: Solving Clinical A. Michael Spitz, PTA Dilemmas in Orthopaedics 2:00 PM – 4:00 PM Carol A. Oatis, PT, PhD; Marian T. Hannan, DSc, MPH Research Exchange Center 3:30 PM - 4:30 PM Anthony Delitto, PT, PhD, FAPTA; G. Kelley Fitzgeral, ABPTS OCS Update PT, PhD, OCS; Robert S. Wainner, PT, PhD, OCS, ECS, Aimee Klein, PT, DPT, MS, OCS; Robert Landel, PT, DPT, FAAOMPT; Julie M. Fritz, PhD, PT, ATC; Michael Mueller, OCS, CSCS; Robert Johnson, PT, MS, OCS PT, PhD, FAPTA; Christopher Powers, PT, PhD; John Childs, PT, PhD, MBA, OCS, FAAOMPT; Sara R. Piva, PT, MS, 6:30 PM – 7:30 PM OCS, FAAOMPT; James J. Irrgang, PT, PhD, ATC; Business Meeting Daniel L. Riddle, PT, PhD; Steve Allison, PT, PhD, ECS; Pain Management Special Interest Group Deydre Teyhen, PT, PhD, OCS; Paul LaStayo, PT, PhD, CHT; 6:30 PM – 8:00 PM J. Parry Gerber, PT, DSc, ATC; Patrick Sparto, PT, PhD; Business Meeting Carolynn Patten, PT, PhD; Michael P. Johnson, PT, MS, OCS; Occupational Health PT Special Interest Group David Sinacore, PT, PhD 7:30 PM – 8:30 PM 5:00 PM – 6:00 PM Pain Management Special Interest Group Reception Business Meetings Performing Arts Special Interest Group FRIDAY, February 3, 2006 Foot & Ankle Special Interest Group PTA Education Group 8:00 AM – 11:00 AM Manual Therapy Education Group Integrated Control of Stability and Movement: 6:00 PM – 8:30 PM Perspectives from Orthopaedics & Geriatrics John A. Buford, PT, PhD; Deborah Givens Heiss, PT, PhD, Performing Arts Special Interest Group Reception DPT, OCS; John D. Borstad, PT, PhD; Deborah Kegelmeyer, EDPT, MS, GCS; Anne D. Kloos, PT, PhD, NCS SATURDAY, February 4, 2006 8:00 AM – 11:00 AM 8:30 AM – 11:00 AM Recent Advances in the Management and Rehabilitation Orthopaedic Section Business Meeting of Massive Rotator Cuff Tears 1:00 PM – 2:30 PM Martin Kelley, DPT, OCS; Brian Leggin, MS, PT, OCS; Research Platform Session A Charles Getz, MD Research Platform Session B 8:30 AM - 10:30AM 1:00 PM – 5:00 PM Research Platforms Session Animal Special Interest Group Programming 8:30 AM - 10:30 AM Hands, Hooves, & Paws: Collaborative Efforts in Case Study Presentations Animal Physical Therapy & Rehabilitation Brett Wood, DVM; Charles Evans, MPT, CCRP; 1:00 PM – 4:00 PM Diana Carman, PT; Ilaria F. Borghese, MS, MA OTR/L Evidence-based Clinical Practice Guidelines: Low Back & Ankle Sprain Guidelines 1:00 PM - 4:30 PM Eric J. Hendriks, PhD, MSc, RPT; Rob A. de Bie; Roger Knee/Patellofemoral Education Group Nelson, PT, PhD, FAPTA; Lori A. Michener, PT, PhD, ATC, SCS A Critical Review of Common Interventions for Patellofemoral Joint Dysfunction 1:00 PM – 5:00 PM Michael Gross, PT, PhD; Kay Crossley, PT, PhD; Performing Arts Special Interest Group Christopher Powers, PT, PhD; Irene Davis, PT, PhD Evaluation and Management of Lumbar and Pelvic Dysfunction in the Performing Artist 2:00 PM – 5:00 PM Michael Cibulka, PT, DPT, MHS, OCS; John D. Childs ,PT, Manual Therapy Education Group Programming PhD, MBA, OCS, FAAOMPT; Rob Watkins, MD; Shaw Manual Therapy and Exercise for Subacromial Impingement of Bronner, PT, MHS, EdM, PhD, OCS; Airelle O. Hunter, MPT, the Shoulder SCS, CSCS; Leigh Anne Roberts, PT, DPT, OCS Mark Bookhout, PT, MS 1:00 PM – 5:00 PM Foot & Ankle Special Interest Group Conservative and Surgical Management of the Arthritic Ankle

Orthopaedic Practice Vol. 17;4:05 41 2:00 PM – 5:00 PM 1:45 – 2:00 Primary Care Education Group Host, Helen Musculoskeletal Imaging for Physical Therapists Optimizing Strength and Functional Gains Post-hip Fracture John Meyer, PT, DPT, OCS 2:00 – 2:15 2:30 PM – 3:00 PM David Lake Rose Research Platform Passive 10 Minute Self-Stretching Protocol Increases Flexibility in Subjects with Limited Hamstring Flexibility 5:00 PM – 6:00 PM Business Meetings 2:15 – 2:30 Animal Special Interest Group Langhenry, Mary Primary Care Education Group Analysis of Knee Joint Biomechanics During Cycling in Patients with Total Knee Arthroplasty 7:00 PM - 7:30 PM Awards Ceremony 2:30 – 2:45 Monosa-Hefele, Giselle 7:30 PM – 11:00 PM Functional Outcomes of Hip and Knee Arthroplasty in Subacute Rose Award Celebration (formerly Black Tie Rehabilitation: Before and After the 75 Percent Rule and Roses Reception) 2:45 – 3:00 Enseki, Keelan Can Pain Distribution Distinguish Individuals with Labral PLATFORM PRESENTATIONS Tears from Individuals with Iliotibial Band Syndrome? 3:00 – 3:15 CSM 2006 San Diego, CA Warden, Stuart Low-intensity Pulsed Ultrasound Accelerates and a Nonsteroidal Anti-inflammatory Drug Delays Knee Ligament Healing 3:15 – 3:30 THURSDAY – Session A Martin, RobRoy 12:00 – 12:15 A 3-year Outcome Study of Hip Arthroscopy Chang, Alison 3:30 – 3:45 Flexion Contracture and Progression of Knee Osteoarthritis (OA) Martin, RobRoy 12:15 – 12:30 Evidence of Validity for the Hip Outcome Score (HOS) Sutlive, Thomas Based on Differential Item Functioning Development of a Clinical Prediction Rule for Classifying 3:45 – 4:00 Patients with Patellofemoral Pain Who Respond Successfully to Lumbo-Pelvic Manipulation Fergus, Andrea The Effects of a Knee Injury Prevention Jump Training Program 12:30 – 12:45 on the Landing Techniques and Neuromuscular Control of Schmitt, Laura Female Athletes Relationships among Factors Associated with Medial 4:00 – 4:15 Knee Osteoarthritis Loghmani, Mary 12:45 – 1:00 Instrument-assisted Cross Fiber Massage Accelerates Blanpied, Peter Knee Ligament Healing The Effects of Intra-articular Anesthesia on Muscle Reactions 4:15 – 4:30 During Perturbation Testing Crossley, Kay 1:00 – 1:15 Clinical Features Differ in Individuals with Patellar Souza, Richard Tendinopathy: Implications for Rehabilitation The Relationship between Femoral Anteversion and Femoral Segment Kinematics During a Step Down Maneuver THURSDAY – Session B 1:15 – 1:30 12:00 – 12:15 Piva, Sara Strunce, Joseph Reliability of Measures of Impairments Associated The Immediate Effects of Thoracic Spine Manipulation on -Pa with Patellofemoral Pain Syndrome tients with a Primary Complaint of Shoulder Pain 1:30 – 1:45 12:15 – 12:30 Piva, Sara Middag, Tansy Association between Impairments and Function in Individuals Digital Fluroscopic Video Assessment of Glenohumeral with Patellofemoral Pain Syndrome Migration: Static Versus Dynamic Arthrokinematics

42 Orthopaedic Practice Vol. 17;4:05 12:30 – 12:45 3:30 – 3:45 Ebaugh, David Zubcevik, Nevena Changes in Scapulothoracic and Glenohumeral Motion The Effect of Spring-Assist and Wedge-Rocker Shoes on Gait Following the Performance of a Shoulder External Rotator and Energy Expenditure in Subjects With Triceps Surae Muscle Fatigue Protocol Weakness During Self-Selected Walking Speed: A Case 12:45 – 1:00 Study Across Multiple Subjects Sum, Jonathan 3:45 – 4:00 Glenohumeral Joint Range of Motion, Rotational Muscle Moffit, Steven Strength, and Functional Self-report Following Shoulder A Comparison of Physical Therapy Outcomes in Individuals Arthroplasty with Cervical Spine Pain With and Without Thoracic 1:00 – 1:15 Manipulation Wilcox, Reg 4:00 – 4:15 Functional Outcomes Following Rotator Cuff Repair Based on McGaw, Scott Tissue Quality: A Pilot Study Factors Related to Success with the Use of Mechanical 1:15 – 1:30 Cervical Traction Gard, Kevin 4:15 – 4:30 Interrater Reliability of a Proposed Scapular Lindsay, Weston Classification System The Use of Evidence-based Treatment on Patients 1:30 – 1:45 with Headaches: A Pragmatic Case-Control Study Ward, Samuel The Operating Ranges of the Rotator Cuff Muscles: FRIDAY – Session A Implications for Injury and Rehabilitation 8:30 – 8:45 Fritz, Julie THURSDAY – Session B Does the Evidence for Spinal Manipulation Translate into Better 1:45 – 2:00 Outcomes in Routine Clinical Care for Patients with Occupa- tional Low Back Pain? Wang, Sharon Effectiveness of Two Physical Therapy Interventions for Increas- 8:45 – 9:00 ing Length in the Pectoralis Minor Muscle Silfies, Sheri 2:00 – 2:15 Analysis of Movement Coordination of the Lumbar Spine and Pelvis between Patients with Mechanical Low Back Pain Attrib- Hastings, Mary uted to Osteoligamentous Damage and Controls Effect of Metatarsal Pad Placement on Plantar Pressure at the Second Metatarsal Head 9:00 – 9:15 2:15 – 2:30 Rieger, Jennifer Ultrasound Imaging of the Deep Abdominal Muscles During Lott, Donovan Effect of Footwear and Orthotic Devices on Soft Tissue Core Stabilization Exercises Thickness and Pressure Variables of the Neuropathic Foot 9:15 – 9:30 2:30 – 2:45 Miller-Spoto, Marcia Mueller, Michael Physical Therapy Diagnosis in Clinical Practice: A Survey A Computational Model of the Diabetic Foot: Implications of Orthopedic Certified Specialists in the United States for Physical Therapy 9:30 – 9:45 2:45 – 3:00 Brennan, Gerard Neville, Christopher Identifying Subgroups of Patients with Low Back Pain: Affect of Stage II Posterior Tibialis Tendon Dysfunction A Randomized Clinical Trial on Muscle Length During Walking 9:45 – 10:00 3:00 – 3:15 George, Steven Sinacore, David Immediate Effect of Spinal Manipulation on Temporal Structural Polymorphism in Diabetic Foot Disease Summation of Pain 3:15 – 3:30 10:00 – 10:15 Cornwall, Mark Butler, Matthew Classification of Frontal Plane Rearfoot Motion Patterns A Randomized, Controlled Study Examining the Effect of Pilates on Physical Factors Related to Dynamic Trunk Stabiliza- tion in Subjects with Chronic and Recurrent Low Back Pain

Orthopaedic Practice Vol. 17;4:05 43 10:15 – 10:30 1:45 – 2:00 Butler, Matthew Danzl, Megan A Randomized, Controlled Study Examining the Effect of Examining Oral Contraception as a Contraindication for Spinal Pilates on Pain and Disability in Subjects with Chronic and Manipulation (High Velocity Thrusts): A Literature Review Recurrent Low Back Pain 2:00 – 2:15 Nourbakhsh, Mohammad FRIDAY – Session B (Case Reports) An Alternative Approach to Treating Lateral Epicondylitis: 8:30 – 8:45 A Randomized, Placebo-control, Double-blinded Study Ross, Michael 2:15 – 2:30 Cancer as a Cause of Low Back and Hip Pain in a Patient Seen Rancour, Jessica in a Direct Access Physical Therapy Setting The Influence of Superficial Precooling on a Static 8:45 – 9:00 Stretching Regimen: A Randomized Trial Troyer, Mark Differential Diagnosis of Endometriosis in a Patient with Non- SATURDAY – Session B specific Low Back Pain 1:00 – 1:15 9:00 – 9:15 Bronner, Shaw Gard, Kevin Reliability and Validity of Electrogoniometry for Measurement Eccentric Training for the Treatment of Patellar Tendinosis: A of Lower Extremity Dance Movement Case Study 1:15 – 1:30 9:15 – 9:30 Bronner, Shaw Hunter, Airelle Lower Extremity Functional Motion Requirements in Com- A Different Path of Treatment for a Patient with Persistent mon Dance Movements Quadriceps Weakness 1:30 – 1:45 9:30 – 9:45 Garlington, Mylah Rudolph, Katherine Prevalence of Joint Hypermobility and Correlation with Injury Development of a Smart Exercise Device in Professional and Student Modern Dancers: A Preliminary 9:45 – 10:00 Investigation Duszak, Kelly 1:45 – 2:00 Management of Patient with Sjogren’s Syndrome: A Case Bronner, Shaw Report Reliability and Validity of a New Electrogoniometer Ankle Sen- 10:00 – 10:15 sor for Lower Extremity Dance Movement Lin, Suh-Jen 2:00 – 2:15 The Reliability of the Six-Minute Walk Test in Persons with Smith, Heather Transtibial Amputation – A Preliminary Report Physical Therapy Management of Patients with Osteochondral 10:15 – 10:30 Lesions of the Talus Following Arthroscopic Drilling: A Case Series Ward, Samuel Stress-Dependent and Stress-Independent Gene Expression in 2:15 – 2:30 Rat Skeletal Muscle After a Single Bout of Exercise Noteboom, J Behaviors and Knowledge of Orthopedic Physical Therapists SATURDAY – Session A Regarding Cardiovascular Screening and Risk Determination 1:00 – 1:15 Rodriguez, Brian Factors Associated with Outcome in Patients with Symptoms Distal to the Elbow With or Without Neck Pain 1:15 – 1:30 Thackeray, Anne An Examination of the Reliability of a Classification Algorithm for Subgrouping Patients with Low Back Pain 1:30 – 1:45 Barakatt, Edward Validity and Reliability of Maitland’s Construct of LBP Irritability

44 Orthopaedic Practice Vol. 17;4:05 PRE-CONFERENCE COURSE Ergonomics Tools - Helping Clients and Your CSM Business Everyday 2006 • San Diego, CA

Wednesday, February 1, 2006 Course Description: This program introduces the participant to 4 commonly used ergonomics evaluation tools. These tools allow the user to objectively measure some of the more common ergonomics risk factors, then use an established problem solving process to develop cost-effective solutions. The program also addresses how to transition from providing rehab services to how to grow your ergonomics-related practice.

This course is expressly designed to enhance the evaluation skills of clinicians who integrate ergonomics into their practice. These tools provide reliable and objective data used to identify root cause, set reasonable limits, and develop recommendations for the reduction or elimination of ergonomics risk factors in the work setting. Attendees will be shown how to use each tool to evaluate a videotaped job, develop a list of primary problems, and then generate a list of potential solutions. To day will wrap up with a discussion about “the business of ergonomics”, pointing out pathways for clinicians to incorporate ergonomics into their business plans. Discussion will highlight how much the customer wants and needs to know about your analysis process, how to develop cost-effective solutions, how to know what is considered “value-added” by your customer for return business. Upon completion of this course, you’ll be able to: 1. Identify ergonomics risk factors and root causes 3. Prioritize ergonomics-related problems in the workplace 2. Utilize specific ergonomics analysis tools 4. Develop & implement solutions to resolve ergonomics-related problems using the six-step problem solving process Course Speakers: Miriam Joffee, PT, CPE; Drew Bossen, PT, MBA Contact Tara Fredrickson at the Orthopaedic Section for registration details and pricing information: [email protected] or 800/444-3982 x203

46 Orthopaedic Practice Vol. 17;4:05 occupationalhealth SPECIAL INTEREST GROUP | S P U O R G T S E R E T N I L A I C E P S

Post-Offer Screening: Is There An warehouse workers. They found significant decreases in inju- Opportunity In Your Neighborhood? ries and injury-related expenses over a 3.5 year period. Nassau3 As you wrap up the year and make plans for the next, are combined prework placement screening and case management opportunities in the Occupational Health Physical Therapy on for the injuries that occurred. This study, performed at a 250- your radar screen? Whether we are in private practice or part bed hospital, found that the number of injuries did not decrease of a hospital-based system we all make plans for growth, be it but the severity of the injuries were significantly less. Gassoway professional or business. If you are running your own practice, and Flory4 performed screening on nursing assistants at a re- the advantage of post-offer screening is working directly with gional health center. They found a slight decrease in injuries the employer. Your compensation is agreed upon prior to ser- requiring medical intervention and a more significant decrease vice and there are no prior approvals or ugly surprises at billing in job turnover rate. This study showed that the company saved time. The clinical advantages to this area of practice are that $6 for every $1 spent on screening. In a study that presents the 5 these evaluations are usually shorter than a full FCE, job ap- strongest evidence to date in support of post-offer, Littleton | . C N I , TA P A , N O I T C E S C I D E PA O H T R O plicants are typically motivated to perform well on the test, and tested physical plant applicants at a major university hospital paperwork is minimal. Post-offer screening provides an oppor- and found that the number of lost day cases decreased 18%, the tunity to serve both the employer and employee through injury total injury costs decreased 78%, and that for every $1 spent on prevention. However, there are some important clinical and post-offer screening the employer saved $18. The added benefit medico-legal issues to consider when doing post-offer screens. of these last two studies is that the only intervention used was the post-offer screen. THE OPTIMAL SEQUENCE FOR TESTING The Equal Employment Opportunity Commission (EEOC) PITFALLS TO AVOID has published Enforcement Guidance: Pre-employment Dis- In addition to pre-offer screens, there are some pitfalls to avoid ability-Related Questions and Medical Examination1 as well as in pre-employment testing. other guidelines related to pre-employment screening that can General Strength Testing. The concept of a one-size fits all be accessed online at http://www.eeoc.gov/policy/docs/preemp. generic strength test (such as a set of push-ups, sit-ups, aerobic html. Based on my review of this document, pre-employment step tests, or isokinetic strength tests) is appealing because of its functional screening is best performed after a conditional offer simplicity and ease of administration. However, such tests are has been made. According to the EEOCs guidelines, medi- not ADA compliant because they cannot be directly correlated cal examinations (such as monitoring blood pressure and heart to the demands of the job. All of the law suits lost by employ- rate) can be performed only after a conditional offer has been ers (and there have not been many) related to pre-employment made. Performing strenuous physical testing, such as is often screening have involved generic strength testing. H LT A E H L A N O I PAT U C C O the case in pre-employment screening, without monitoring Comparison to Normative Data. In pre-employment screen- these physiological parameters puts everyone at risk. In addi- ing, the ADA is violated when hiring decisions are made based tion, post-offer screening is more cost-effective for the employer on a comparison of the applicant to normative data. It does not as they do not have to screen every applicant, only the ones to matter whether the applicant is in the 5th percentile or the 95th whom they make a conditional offer. Employers will appreci- percentile as compared to a group of ‘norms.’ What matters is ate your making the recommendation for post-offer screening whether their abilities match the job demands. and pointing out that this approach works to their advantage. Predicting Future Injury. Some providers market their ser- This recommendation will go a long way toward building trust vices by claiming to be able to predict future injury. Unless between you and the employer. you have data to back you up it is best to avoid this potentially litigious claim. What we have to sell to employers is testing the EVIDENCE IN SUPPORT OF EFFECTIVENESS abilities of workers that can be matched to job demands. By There have been at least 5 research studies published since matching the worker’s abilities to the demands of work, we help 1994 that speak to the effectiveness of post-offer screening. the employers minimize the chances of injury and the associated “Reimer2 et al studied the effectiveness of pre-employment costs. No more, no less. screening combined with a worker fitness program for grocery Steps of the Process. To develop a valid, legally defensible,

Orthopaedic Practice Vol. 17;4:05 47 and cost-effective post-offer screens there are several steps that incumbent testing than to have them occur when the ap- should be followed with each employer: plicants are being tested. • Targeting the jobs. The employer may not need to screen • Monitoring Outcomes. Both you and the employer for all jobs within the organization. A few jobs may be should have an idea of what constitutes ‘success’ from the creating most of the injuries. By sitting down with the em- outset of the project. You need to evaluate the company’s ployer and looking at the injury data you can help identify prescreen injury incidence rates, severity, and related costs. the jobs that should be screened. You may perform fewer After 6 months to a year of screening, you can make a pre- screens in the short run but in the long run, if the employ- liminary comparison to the prescreen numbers. All parties er’s return on investment is high, you have long-term job need to agree on the desired or expected outcome. If you security. achieve your numbers, great. If you fall short, you can ana- • Performing job demands analysis. Identifying the physi- lyze the data to determine the reason and correct the prob- cal demands of work is the foundation of defensible post- lem. If you have no prior experience, look to the literature offer screening. If not done well or not done at all, the for some guidelines as to what you should expect. screens may not accurately reflect the job demands. If not In summary, post-offer screening is an opportunity to serve accurate, the employer is at risk. While the employer may employers, employees, and society through the prevention of be reluctant to spend the money on the job demands analy- work-related injuries. As with any opportunity to serve, physical sis, it is money well spent in the long run. therapists need to have knowledge of the research demonstrat- • Developing the test items and pass/fail criteria. If an ing effectiveness of this intervention and the medico-legal issues accurate job analysis is performed, selecting the test items surrounding it. We need to have reliable and valid assessment and the minimal requirements is a relatively easy task. In tools,5,6 and we must know how to apply them in a systematic cases where the materials or equipment create some un- and consistent manner. usual demands, it may be best for the company to loan these items to you for a simulation of the work demands. REFERENCES It is extremely important to use functional testing that has 1. U.S Equal Employment Opportunity Commission. established reliability and validity,5,6 for test items when EEOC Notice #915.002: ADA enforcement guidance possible. pre-employment disability-related questions and medical • Establishing procedures. There are a variety of procedural examinations. 1995:1-26. issues that will have to be resolved with each company: 2. Reimer DS, Halbrook BD, Dreyfuss PH, Tibiletti

ORTHOPAEDIC SECTION, APTA, INC. • How will applicants be referred to you? C. A novel approach to preemployment worker fit- • Where will testing occur? ness evaluations in a material-handling industry. Spine. • How will test results be handled? 1994;19:2026-2032. • How will test failures be handled? 3. Nassau DW. The effects of prework functional screening • How will you deal with any injuries that will on lowering an employer’s injury rate, medical costs, and occur during testing? lost work days. Spine. 1999;24:1-10. • How will the applicant who attends the screen with 4. Gassoway J, Flory V. Prework screen: Is it helpful in alcohol on his/her breath be handled? reducing injuries and cost? Work. 2000;15:101-106. • What will you do if an applicant is pregnant? 5. Littleton M. Cost-effectiveness of a prework screening There are no hard and fast rules for any of these decisions. program for the University of Illinois at Chicago Physical Each employer may want to handle these things just a little Plant. Work. 2003;21:243-250. differently. The important issue is consistency. Once poli- 6. Lechner DE, Jackson JR, Roth DL, Staaton KV. Reli- cies are in place for handling these issues, they must be fol- ability and validity of a newly developed test of physical lowed for each and every applicant. work performance. J Occup Med. 1994;36:997-1003. • Testing Incumbents. Many employers are reluctant to test SPECIAL INTEREST GROUPS | incumbents. They fear it will be perceived negatively by incumbents. The incumbents must be reassured that their test results will not be shared with the employer except as aggregate data (ie, an individual’s test results are not shared but the employer is told that 9 out of 10 employees passed the screen). While this step is not the easiest to accomplish with all employers, it is extremely beneficial if the validity of the screen is called into question. Incumbent testing provides additional proof of the validity of the screen. It can also be used as a mini-feasibility study. If there are any communication, procedural, or equipment problems with the system, then it is best to discover and correct during

48 Orthopaedic Practice Vol. 17;4:05 foot&ankle SPECIAL INTEREST GROUP | S P U O R G T S E R E T N I L A I C E P S President’s Report The Accessory Soleus: An Uncommon Source I was reading a guest editorial in the Private Practice Section of Distal Lower Extremity Pain magazine [Advance, 2005;14(4)] recently. The author discussed Stephen Paulseth, PT, SCS, ATC and Daniel Kim, ATC why we as professional physical therapists use far too many let- ters after our name to denote our academic and other achieve- The accessory soleus muscle is a fairly uncommon formof ments. His point is well taken, although it raises the issue about muscular anomaly, found in roughly 1% to 6% of the general certifications, the necessity, meaning, and then the utilization of population according to a recent study.1 Presence of the muscle said certification. Does the general population/consumer know is rarely symptomatic, but has been known to lead to swelling, what it means or what it permits us to do? I would tend to pain, or a combination.3 Its existence has also been linked to doubt it! tarsal tunnel syndrome due to compression or entrapment of In order to educate the consumer and referring physicians, we the tibial nerve.4 Detection of this muscular anomaly typically as Physical Therapists who treat foot and ankle disorders should occurs around the age of 20, and is more common among males establish some form of certification, or better yet, a fellowship. than females by a two to one ratio.3 This topic has been debated for several years in SIG Business There are a few different hypotheses regarding how this mus . C - N I , TA P A , N O I T C E S C I D E PA O H T R O Meetings and between colleagues. Other SIGs and Sections are cle anomaly arises. In 1913, Frohse and Frankel described the moving in this direction. In the medical community, a fellow- accessory soleus as an abnormal plantaris muscle whose origin ship indicates a level of excellence and notoriety. Although some migrated from the epicondyle of the femur to the tibia or the of you may oppose such a process and some are in favor, I would anterior surface of the soleus.7 Other studies have identified a like to hear from you on our SIG bulletin board or directly to separate plantaris muscle in addition to the accessory soleus,10,13 me. It will take a tremendous effort to establish the criteria that leading to another hypothesis that the muscle is actually a por- would be included in a fellowship. I for one am in favor of a tion of the normal soleus muscle which at some point separated, foot fellowship, not that any of us need to add letters to our probably early in development.2,5,6,8,10 It is possible that the typi- professional demarcation. cal presentation of symptoms during adolescence is due to an Our SIG is still looking for assistance from the membership increase in muscle mass during this time of development, and to establish a survey that will be sent to all entry-level physical could explain why men, who have more muscle mass are more therapy programs in order to ascertain the content being taught predisposed to having a symptomatic accessory soleus.3,4,11,14 pertinent to the foot and ankle. Like the other Orthopaedic The size, structure, and location of the accessory soleus have Section SIGs, we should be able to advise PT schools as well been seen to vary among different individuals. Depending on as continuing education instructors on the content and rele- the individual, the anomalous muscle can be seen on one ex- vance of their foot and ankle information. In addition, certain tremity or bilaterally, and it typically has its own fascia.2,4,8 The courses that are available to PTs should be evaluated by our SIG muscle can originate from the distal posterior portion of the E L K N A & T O O F | to enable them to make recommendations to our members. tibia, which is the most common origin, or from the fascia sur- This effort may help to synthesize the overwhelming variety of rounding the soleus muscle.2,4,8,9 The distal insertion of the ac- treatment techniques, evaluative strategies, and evidence that cessory soleus tendon is most commonly located on the calca- is valid. Of course, I must toot our SIGs own horn as it relates neus, just anterior and medial to the Achilles insertion on the to the next FASIG program at the CSM in San Diego. The calcaneal tuberosity. The tendon also may insert on the lateral program will include an excellent faculty who will thoroughly calcaneus, superior calcaneus, or blend in with the Achilles ten- discuss ankle injury and arthrosis. I hope that you all plan to don.2,4,8,9 The muscle is innervated by a branch of the tibial nerve attend this great program. As per the purpose of this periodical and blood is supplied by a branch of the posterior tibial artery.9 for our membership, we welcome treatment pearls, case studies, As mentioned earlier, most cases of accessory soleus muscle are new techniques, etc that you are using in the clinic and that can asymptomatic but have been known to cause problems in the be shared in OPTP. lower leg. Swelling along the medial aspect of the Achilles ten- don is the most common symptom that arises. In most cases, Stephen Paulseth pain will increase during or after exercise.9,11 Typically, the symp- President, FASIG toms are caused either as a result of tarsal tunnel syndrome, with the tibial nerve being entrapped or compressed by the muscle, or

Orthopaedic Practice Vol. 17;4:05 49 by a compartment-type syndrome with excessive pressure within but showed mild conductive slowing in the distal tibial nerve, the muscle fascia.11,12 Occasionally, the presence of the acces- right > left. Her orthopedist also prescribed 2 epidural injections sory muscle also makes it difficult to wear certain types of shoes, in 2004 which reduced her back pain but did not alter her lower boots, or other footwear. leg symptoms. According to Leswick, the problem is often unrecognized or Up until June 2005 the patient was not able to be fully func- mistaken for other types of soft tissue masses or disorders. The tional in her typical exercise routine or run, due to persistent presence of an accessory soleus muscle can be detected by MRI, calf pain. Physical therapy treatment for her leg symptoms com- which is the preferred means of study.11 Painful soft tissues menced at that time once/wk. Her pain was constant and se- masses can present with varying differential diagnoses, includ- vere but did not radiate from the medial mid-shaft tibia and ing ganglion, hematoma, lipoma, hemangioma, synovioma, and deep calf. Symptoms increased after standing for 5 minutes or sarcomas.11 Without knowledge of a soft tissue mass, differential walking with or without her foot orthotics for 2 minutes. Ob- diagnoses could include tarsal tunnel syndrome, medial tibial jectively, the patient presented with bilateral ankle dorsiflexion stress syndrome, posterior compartment syndrome, flexor hal- restriction with knees bent and straight, pes planus, os navicu- lucis longus syndrome, peripheral neuropathy, posterior tibialis laris with associated tibialis posterior deficits R > L, ineffective tendonitis, calf strain, deep vein thrombosis, Achilles tendonitis, stance and heel rise in gait, and negative lumbar or neural in-

| FOOT & ANKLE lumbar radiculitis, and contusion. volvement. Vibration testing and pulses of both LE were normal Most individuals who have an accessory soleus muscle are as- and palpation yielded increased tension and tissue thickening ymptomatic, and treatment is typically conservative or not done along the right medial border of the mid-tibia. The patient was at all. Individuals who present with symptoms have a few dif- referred back to her physician for diagnostic imaging of the pos- ferent treatment options, depending on the nature and cause of terior compartment of her tibia. Diagnosis of an accessory soleus the symptoms. Review of the literature suggests that surgical muscle bilaterally was confirmed by MRI (Figures 1 & 2). intervention is the most common form of treatment, particu- larly fasciotomy3 which has been effective for symptoms related MRI FINDINGS DISPLAY AN ACCESSORY SOLEUS. to compartment-type syndromes. If the accessory muscle pres- Physical therapy is to continue until possible surgical inter- ence is coupled with tarsal tunnel syndrome, excision seems to vention at a later time. Physical therapy has been effective to be effective in relieving pain. Other types of surgery include date as she is now able to walk for 25 minutes without symp- debulking, biopsy, and observation.3 Nonsurgical treatments toms other than feeling fatigued in her calf (R > L). It appears are scarcely documented in the literature, but the use of foot that over time with walking, the posterior muscles of the tibia orthoses and physical therapy have been reported to relieve pain become less active or effective due to fatigue and possibly deep in certain circumstances.12 posterior compartment dysfunction due to the fatigue. Foot po- The lack of evidence for nonsurgical treatment of this condi- sition alteration via foot orthoses and/or foot taping has helped tion is apparent. Albeit limited in its scope and validity, a report to increase the time of walking from 2 to 20 minutes in the

ORTHOPAEDIC SECTION, APTA, onINC. a patient seen in physical therapy for this problem recently first month of physical therapy. Soft tissue mobilization, manual prompted this article. therapy, ultrasound, deep suction tissue mobilization, ice, and tibialis posterior open and closed chain exercises were also used PATIENT EXAMPLE during this time. The addition of rocker shoes, medial calf un- The patient is a 27 y/o female who presented with chronic loading tape, and neural gliding has reduced her pain to the and severe bilateral (R > L) lower leg ‘tightness’ and pain which present level of moderate localized symptoms which only occurs began in 2001 after increasing her mileage of running on con- with walking for 25 minutes. crete. The patient has no co-morbidities, medical conditions, or Presently, the patient has increased her ankle dorsiflexion familial diseases. Her symptoms progressed over the next year ROM to 10° and her LE strength to 5/5 grossly, except soleus during activity despite commencing resistive training, stretch- (4/5) and tibialis posterior (4+/5). She experiences pain with so- ing, and curtailing running. In 2003 she sought medical advice leus specific exercises which of course limits her gait and tibial/ from a podiatrist who made her foot orthoses and referred her to foot control coupled with the tibialis posterior. A visit to an ad- a PT clinic. At that time her symptoms were constant and more ditional orthopedist suggested that she try UCBL orthoses to exquisite, especially with exercise. Physical therapy, consisting assist in gait and standing as well as to continue PT with greater primarily of modalities and exercises for 16 weeks, was ineffec- frequency. SPECIAL INTEREST GROUPS | tive according to the patient. She was not able to participate in sports or run and the pain commenced after walking for a few ASSESSMENT minutes. The literature is devoid of any RCT or case series of this con- In 2004 she began PT treatment for a lumbar HNP with ra- dition. Only select case studies have been published and show diculitis which was diagnosed with MRI and EMG/NCV. The minimal improvement without surgery. It appears that the pa- latter test was done to evaluate the effect that the lumbar condi- tient’s symptoms are consistent with a posterior compartment- tion had on her lower leg pain. The NCV test was ‘inconclusive’ like syndrome that causes calf weakness and pain but nonsig-

50 Orthopaedic Practice Vol. 17;4:05 ing condition. Clinicians should include this diagnosis in their differential list for lower leg problems.

REFERENCES 1. Agur AM, McKee N, Leekam R. Accessory soleus muscle. American Association of Clinical Anotomists Meeting; Jul 9-11, 1997; Honolulu, Hawaii. 2. Assoun J, Railhac JJ, Richardi G, Fajadet P, Fourcade D, Sans N. Ct and Mr of accessory soleus muscle. J | S P U O R G T S E R E T N I L A I C E P S Comput Assist Tomogr. 1995;19:333-335. 3. Brodie JT, Dormans JP, Gregg JR, Davidson RS. Ac- cessory soleus muscle. A report of 4 cases and review of literature. Clin Orthop. 1997;337:180-186. 4. DosRemedios ET, Jolly GP. The accessory soleus and recurrent tarsal tunnel syndrome: case report of a new surgical approach. J Foot Ankle Surg. 2000;39:194-197. 5. Faller A. Zur deutung der akzessorischen Kopfe des Schollenmuskels. Anat Anz. 1942;93:161-179. 6. Flower JM. Note on an accessory soleus muscle. J Anat. Figure 1. Sagittal view of the distal right lower extremity MRI. The 1931;65:548-549. accessory soleus muscle is positioned in the posterior portion of the lower limb, with the muscle body extending below the talocrural joint, 7. Frohse FM. Frankel Die Muskein des menschlichen just anterior to the Achilles tendon. Beines: in von Bardeleben k: Handbuch der Anatomie

des Menschen. Jena Gustav Fischer, Il band, Il Apt, . C N I , TA P A , N O I T C E S C I D E PA O H T R O Teil. 1913: 415-693. 8. Gordon SL, Matheson DW. The accessory soleus muscle. Clin Orthop. 1973;97:129-132. 9. Kurtoglu Z, Haluk U. Bilateral accessory soleus muscle. Turk J Med Sci. 2000;30:393-395. 10. Le Double AF. Traite des variation du systeme mus- culaire de l’homme. Paris, Schleicher Freres, tome 2. 1897:310-314. 11. Leswick DA, Chow V, Stoneham G. Accessory soleus muscle. Can Assoc Radiol J. 2003;54:313-315. 12. Pla ME, Dillingham TR, Spellman NT, Colon E, Jab- bari B. Painful legs and moving toes associates with tarsal tunnel syndrome and accessory soleus muscle. Mov Disord. 1996;11:82-86. 13. Sekiya S, Kumaki K, Yamada TK, Horiguchi M. Nerve supply to the accessory soleus muscle. Acta Anat Nip- pon. 1994;149:121-127. E L K N A & T O O F | 14. Yu JS, Resnick D. MR imaging of the accessory soleus muscle appearance in six patients and a review of the Figure 2. Transverse view of the distal lower extremity MRI, cut at literature. Skeletal Radiol. 1994;23:525-528. the left talocrural joint line. The accessory soleus is positioned in the posterior medial portion of the lower limb. nificant neural signs. A deep fascial band that eminates from the deep soleus medially and superiorly to the medial tibia is the likely culprit. The actual mechanism of dysfunction is not truly known. Due to her incomplete progress it is likely that surgi- cal fascial debridement will provide relief of symptoms. Physical therapy has provided benefit for this patient’s function but will not likely provide full return to running. There is a need for further research into this rare and frustrat-

Orthopaedic Practice Vol. 17;4:05 51 painmanagement SPECIAL INTEREST GROUP

President’s Message ing was to those of us whose lives he touched in a very personal Joe Kleinkort, PT, MA, PhD, CIE, CEAS, DAAPM way. The character and dignity in which he went through the tremendous adversity of his twilight years spoke volumes of the Loss is such an empty bittersweet word. It is shallow and so strong oak of a person that he truly was. Both of these men have insensitive. We have all heard of stories of loved ones who have left an indelible mark on our profession and to the cause of pain gone through much of this and close personal friends these past management. They will be truly and deeply missed. few months with so many natural disasters. Through all of this On a separate note, I would like to strongly encourage each of we have lost to our profession two towering pillars of strength, you to attend this year’s CSM. Join us for our first cocktail party | PAIN MANAGEMENT courage, and fortitude that emulate the very profession they before our Business Meeting which is scheduled for 6:30 PM on come from. They both in many different ways contributed to Friday. This will be a time to network and meet in person those the field of Pain Management. The both will be genuinely lost who are interested in pain management. We also have a wonder- in our profession. ful academic program scheduled this year and hope that all can Joe Kahn, PT, PhD, 79 of Syosset, NY, died June 25 after a attend. Finally may I wish each of you blessings on this holiday long illness. To those of us who knew him he was one of if not season and thank you for all of your support. the “GODFATHER” of pain management through his various uses of electrotherapy. He was such a tremendous mentor who Facing The Fear always had time to spend with a learning therapist until they got Anita L Davis, PT, MSM, CEASII it. His love for his profession and the students he touched was Brooks Health System evident in the time he spent and action to gently and lovingly Jacksonville, FL teach and care for their growth as they learned all they could about the endless techniques he would have to apply to various Once a patient crosses into the realm of chronic pain, mul- anomalies. I will never forget the many times we spent discuss- tiple factors begin to creep into the picture. The aspects of pain ing various applications of therapy and the one day that I actu- as identified by Stanley V. Paris PT, PhD include physical, ratio- ally taught laser to Joe in 1980! He addressed this in one of his nal, and emotional components (Manual Therapy: Treat Func- early electro books. But he taught me so much in so many ways tion not Pain). The balance of these 3 aspects can easily become ORTHOPAEDIC SECTION, APTA, INC. as he did so many other therapists in their professional walks. distorted with one issue becoming so large that it not only over- He loved to write and was finally able to finish The Principles shadows the physical component but may even drive it. and Practice of Electrotherapy which was published in 2000 and There are other issues that can have an equally dysfunctional has been translated into many languages. Any of us who ever effect on a person with primary pain issues. Finances and legali- came into contact with him will never ever forget the legacy that ties are known to have a powerful effect on one’s recovery and he left with us from the love of a profession and the love of the rehabilitation. As a therapist there is little that we can do to patient care. His heart was huge and his legacy even larger. We directly influence these circumstances for our patients. However all will miss you dear friend. there is one aspect that we can help our patients address to expe- Jules Rothstein, PT, PhD, FAPTA, at the age of 57, died Au- rience rehabilitation at its best. gust 27 after a long illness. I knew him as Editor-in-Chief of Fear can be a powerful motivator—or de-motivator. For fear Physical Therapy. All you would have to do is read his various to have power over one’s actions it need not present a threat of commentaries over the years as Editor of our journal to feel and pain or injury. The impact of fear cannot be ignored. Think of sense his tremendous love for our profession. One only has how we react to our own fears of heights, snakes, etc. Our natu- to read Journeys Beyond the Horizons, Mary McMillan Lecture ral instinct is to avoid that which we fear or perceive as unpleas- SPECIAL INTEREST GROUPS |2001 to tap into the respect and honor that he had, as well ant. For us this seldom deprives us of anything of significance. as the vision for our future. He contributed many books and I’m doing just fine keeping my feet on solid ground and have articles throughout the years but one of his greatest accomplish- no desire to climb higher than my step stool to clean the ceiling ments was that of giving us sage and often needed advice on fan. However the fear-avoidance model indicates that some may how to mold the future of our profession. Jules always was there interpret pain as a serious threat and thereby avoid tasks that to tell you how many ways his life was blessed. The largest bless- they perceive as painful. This then leads to an expectation of fear

52 Orthopaedic Practice Vol. 17;4:05 and further reduction in activity tolerance. daily tasks. Raw scores being the total of individual scores for But consider the patient who is ‘unsure’ about returning to each task. In looking at the average of the scores, individuals work lifting 50 lb containers, or the housewife who is ‘antsy’ have shown improvement up to 77%. about cleaning the bathtub and lower surfaces. Is this not their Addressing the fear component that pain patients experience way of expressing their fear? Left without treatment, this fear can lead to a dramatic increase in their functional abilities. In- could lead to performance anxiety, hesitancy, and a lack of confi- creasing their confidence and skill in performing tasks is also a dence. These repercussions can directly lead to faulty implemen- step toward prevention of potential chronic pain and reinjury. tation of body mechanics and motor recruitment, which can Being aware of the influence of fear is critical to our success in | S P U O R G T S E R E T N I L A I C E P S lead to reinjury or increased pain when the activity in question effectively treating the whole person and not just the pathology. is performed. If still unresolved, over time this would then lead Addressing the fear can be as easy as adding a few questions to to disuse, disability, and depression. the interview and staying in touch with the patient’s concerns. We have the ability to drastically change this and enhance For a percentage of our patients, they will always have pain. our patients’ lives. The first step would be identifying the act or However, pain need not limit their quality of life by fearing basic position that patients fear. It could be as easy as asking “What tasks. do you feel the least confident doing?” or “What task are you unsure of?” After all we don’t want to acknowledge it as a fear— REFERENCE that sounds too drastic and our patients may not respond as 1. Verbunt J, Seelen H, Vlaeyen JW, van der Heijden GJ, honestly as we anticipate with that wording. Knottnerus JA. Fear of injury and physical decondition- I address this within my population of patients with acute in- ing in patients with chronic low back pain. Arch Phys Med juries and pain who are approaching discharge and anticipating Rehabil. 2003;84:1227-1232. returning to their normal tasks, be it work or home. For these

I tend to ask one of the questions listed above. Their response . C N I , TA P A , N O I T C E S C I D E PA O H T R O guides me to address those specific tasks with cues and instruc- tions to maximize their performance and safety. For a fear of lift- ing, I begin with an empty container and perform basic lifting techniques with the patient. Then the weight is increased as they demonstrate better skill and strength. The final phase then pro- gresses to simulating the actual task as they would encounter at home or work. Beginning with the empty container reduces the fear of the task. As they succeed in light weight more is added as their confidence, skill, and strength increases. As these increase, their fear and apprehension of the task fades away. There is noth- ing better than having a goal of restoring 100% confidence in returning to work tasks. The other portion of patients that I see have chronic pain. These individuals are provided with a questionnaire that identi- fies over 20 various tasks. On the form they rank each activ- ity from 0-100 with 100 representing maximum fear. The large range allows greater sensitivity to change during treatment. At T N E M E G A N A M N I PA | the completion of their therapy, they receive another form to re- score the same items. Examples of activities listed on the ques- tionnaire include: lifting less than 20 lbs, lifting greater the 20 lbs, doing laundry, vacuuming, reaching to the floor, weeding, etc. Their treatment includes not only manual therapy and exer- cise activity but also a specific portion of time dedicated to actu- ally performing and practicing simulations of the tasks listed on the questionnaire. In this way, the patients are exposed to the task in a controlled and therapeutic environment. Modifications and instructions are given as necessary including increasing the task difficulty (weight) if appropriate. As this has been implemented, I’ve been able to measure both the initial fear score and the final fear score. Results clearly show decreased fear of basic activities. Using the raw numbers, pa- tients have shown up to 70% improvement in fear reduction of

Orthopaedic Practice Vol. 17;4:05 53 performingarts SPECIAL INTEREST GROUP

President’s Letter Lastly, I hope to see all of you at our next large gathering— Hello all! Combined Sections Meeting in San Diego. The PASIG is only This past year has seen many large scale world events and as good as its members. We need you and we need your input. the recent Hurricane devastation in the Gulf coast region did Hopefully, Susan Clinton will be back at her post as your new not leave the PASIG Board unscathed. Susan Clinton, the cur- PASIG President in the near future. We wish all of those affect- rent PASIG President, lives in New Orleans and was affected by ed by recent natural disasters a speedy recovery. Our thoughts Hurricane Katrina. She is thankfully doing well, but is still in are with you. recovery mode, traveling farther to work and dealing with the | PERFORMING ARTS necessary upheaval in that area—so I am stepping in on her be- Sincerely, half to write this installment of the “President’s Letter.” Hope- Jeff Stenback, PT, OCS fully anyone else in our membership affected by these storms is Immediate Past President in good health and surrounded by their family and loved ones. (Standing in for Susan Clinton) Having been through Hurricane Andrew in Miami back in 1992, I am certainly reminded of the very difficult months that General PASIG Programming for followed that storm for everyone and the great outpouring of CMS 2006 San Diego support from the rest of the country as a result. Despite these more sobering events, your Board continues to Evaluation and Management of Lumbar prepare for next CSM that occurs in early February 2006 in and Pelvic Dysfunction in the Performing Artist San Diego, California. Our Vice President, Tara Jo Manal, is The purpose of this course is to explore the evidence sur- busy developing our general programming lineup that I believe rounding the evaluation and treatment of the pelvis and lumbar will be exciting and not-to-be-missed. We will be focusing on area in performing artists. The course will include a review of SI the lumbopelvic region and all presentations are evidence-based joint dysfunction including the use of manipulation and case ex- with incorporation of competencies identified in our Descrip- ample of muscular imbalance/control strategies useful in cases of tion of Advanced Clinical Practice (DACP). This important hypermobility. Lumbar spine evaluation and manipulation will document has guided our decisions for programming content be reviewed from an evidence-based approach and an expansive and you should look for an upcoming issue of the Journal of review of nonoperative medical management will be presented. ORTHOPAEDIC SECTION, APTA, INC. Dance Medicine and Science (JDMS), Volume 9, Issue 2 for a Issues regarding diagnostic imaging, spinal injections, muscular published summary. Also at CSM 2006, we will be presenting injections, rigid bracing, and other medical interventions will be our second annual student scholarship award. In this issue, the presented. Cases presentations will be provided to reinforce and criteria for participation is included. expand on topics covered in the main program to include: non- Everyone should have been receiving the e-mailed citation operative management of a spinal stress fracture, lumbar spinal blasts on performing arts research/literature through the efforts stabilization training and evaluation, and return to performance of our Research Chair, Shaw Bronner. This is a great way to try considerations and progressions for the performing artists. and keep up with the various sources of current research avail- able to all of us today. We have received wonderful feedback Level: Multi Level from many of you, and we hope that this members-only benefit Objectives: Following this presentation the participant will continue to receive your support. will be able to: You will notice that in addition to the monthly citation 1. Identify theoretical dysfunction that can exist in the SIJ blasts, you will each be receiving a “membership blast” to help and apply techniques likely to demonstrate an improve- us update the ever-changing contact information on so many of ment in patient complaints. our members. This effort is important so that mailings can reach 2. Recognize patients with lumbar pain and dysfunction who SPECIAL INTEREST GROUPS | each of you in a timely fashion and possible opportunities for are likely to respond positively to a lumbar manipulation performing arts-related involvement can be directed your way. procedure. You should also be receiving a questionnaire regarding research 3. Recognize the need and understand the role of diagnostic within the performing arts that is designed to help us under- tests and invasive and noninvasive medical procedures in stand how we can facilitate the sharing of information/resources the management of lumbar and sacroiliac pain. and enable those who wish to do research in this area to do so. 4. Prepare a rehabilitation program for performing artists Please try to return these completed questionnaires quickly to with lumbar and sacroiliac dysfunction that includes re- expedite these efforts. turn to artistic activity progressions.

54 Orthopaedic Practice Vol. 17;4:05 Friday Feb 3, 2006 1:00-5:00 PM 3. The PASIG Education Committee Chairperson. 1:00-2:00 PM Notification of the Award: Lumbar Spine Mobilization and Manipulation: What Does The recipient of the award will be notified in December (of the the Evidence Tell Us and How Can It Be Applied to the year preceding the CSM for which the scholarship is being of- Performing Arts Population fered) by the PASIG Scholarship Chairperson. John David Childs, PT, PhD, OCS, FAAOMPT Nature of the Award: 2:00- 2:45 PM 1. The PASIG BOD will determine the monetary amount of | S P U O R G T S E R E T N I L A I C E P S SI Joint Dysfunction, Evaluation and Physical the reward annually based on the budget. Therapy Management 2. A certificate will be presented to the student at the PA- Mike Cibulka, PT, DPT, MHS, OCS SIG’s Business Meeting during CSM of the year of presen- tation. 2:45- 4:00 PM 3. This award is intended to defray the costs of attending Nonoperative Medical Management of Lumbar Pain CSM. Therefore, the monies awarded will be made avail- and Injury in Performing Artists able after submission of receipts verifying expenses in- Robert Watkins, Jr., MD curred to attend CSM. 4:00-5:00 PM 4. Announcement of the scholarship recipient will be made Case Studies in Performing Artists in the PASIG newsletter section of Orthopaedic Physical CASE 1: Muscular Imbalance Issues and SIJ Treatment Therapy Practice. in a Performing Artist Shaw Bronner, PT, MHS, EdM, OCS PASIG Research Committee CASE 2: Nonoperative Managment of Lumbar Stress Chair: Shaw Bronner Fractures in Dancers and Figure Skaters Members: Jeff Stenback, Jennifer Gamboa, Marshall Hagins, AEDIC SECTION, APT . C N I , TA P A , N O I T C E S C I D E PA O H T R O Airelle O. Hunter, PT, MPT, SCS, CSCS Sheyi Ojofeitimi, Brent Anderson CASE 3: Lumbar Spine Stabilization Training in Dancers Leigh Anne Roberts, PT, MPT, OCS To date, the Research Committee has sent out 4 Citation BLASTS. Three were sent to the entire Orthopaedic Section Performing Arts Special Interest Group membership. After that, if non-PASIG Orthopaedic Section members wanted to continue to receive the Citation BLASTS, PASIG Student Scholarship they needed to join the PASIG. Our SIG gained over 40 new Purpose: To recognize students for their contribution to per- members as a result of this initiative. If you have not received forming arts medicine and to assist in defraying the cost any of these BLASTS, please check your junk filter—it may be of attending the Combined Sections Meeting (CSM). filtering it out, or check with the Orthopaedic Section to ensure Eligibility: your e-mail address is current. If anyone would like to contrib- 1. You must be a member of the Performing Arts Special ute new citations to this effort, please e-mail me. Interest Group (PASIG). By now, members will have also received our PASIG research 2. You must be a student in an accredited physical therapy questionnaire. We ask that you support our committee efforts by program when the research was conducted. sending in your answers. Your replies will help us to develop our 3. Your abstract for a poster or platform presentation ab- programs and committee efforts to increase and focus perform- stract has been submitted and accepted to CSM. ing arts research. 4. You must attend CSM. We’re happy to report an increase in performing arts-relat- S T R A G N I M R O F R E P | 5. You must be listed as an author on the presentation. ed abstract submissions for Combined Sections Meeting 2006 6. You must participate in presenting the poster/platform. (from none in 2005). We will work to let PASIG members know 7. Deadline for submission of your abstract for consider- when these platforms and posters are being presented. Each pre- ation for the PASIG scholarship is November 1st of the senter always appreciates the support of their work by our at- year preceding the CSM for which the scholarship is be- tendance and discussion following their presentations may spur ing offered. new avenues of research—you never know. Criteria for Selection: 1. The importance of the contribution of the abstract to the DANCE/USA Medical Task Force physical therapy management of performing arts physical on Dancer Health therapy. DANCE/USA is a national service organization for profes- 2. The clinical implications derived or suggested from the sional dance. The Dance/USA Task Force on Dancer Health was abstract. charged with a mandate by the Council of Company Managers 3. The quality of the writing. (Dance/USA) to make recommendations on annual, post-hire, 4. The clarity of the clinical information/data presented. healthy dance screening. Award Committee: The committee consists of: 1. The PASIG Student Scholarship Committee Chairper- Chair (Dance Company/Organization): son. Richard Gibbs, MD (San Francisco Ballet) 2. The PASIG Research Committee Chairperson. Attendees (Dance Company/Organization):

Orthopaedic Practice Vol. 17;4:05 55 Julia Alleyne, MD (National Ballet of Canada), stand and support the common goals of this project. Steven Anderson, MD (Pacific Northwest Ballet), 3. A dance specific assessment is necessary for our unique Boyd Bender, PT (Pacific Northwest Ballet), population’s requirement. Shaw Bronner, PT (Alvin Ailey, ADAM Center 4. The Task Force recommends that the annual screenings at Long Island University), be mandatory and that the costs (including dancer’s Micky Cassella, PT (Boston Ballet, Boston Children’s time) be covered by the organization in order to opti- Hospital), mize our health goals. Erica Coffey, PT (Pittsburgh Ballet, UPMC Center for 5. The screening and intake forms must address compre- Rehab Services), hensive issues from the physical, emotional, nutritional, Allison Deleget (Harkness Center), and general health area. Julie Daugherty, PT (American Ballet Theater), 6. The final dance screen must be a streamlined user- Anne Dunning (Dance/USA), friendly document that can be easily used by health care Jennifer Gamboa, PT (Washington Ballet, Universal professionals. Ballet Academy), A preliminary outline of the screening was developed, based Greg Gilman, ATC (Texas Ballet Theater), on the most common injuries and problems seen by the medi- Linda Hamilton, PhD (New York City Ballet), cal group. The intrinsic factors contributing to these problems William Hamilton, MD (American Ballet Theater, were selected as most relevant to the individual dancer. Tests | PERFORMING ARTS New York City Ballet, School of American Ballet), were selected from both impairment and functional levels. David Johnson, MD (Washington Ballet), The acronym SCAMPS—Stability, Control (neuromuscular), Marika Molnar, PT (New York City Ballet, School of Alignment, Motion, Pain, Strength—was developed to ensure American Ballet), that all tests, measures, and medical history applicable to the Kathleen Nachazel, ATC (Pittsburgh Ballet, UPMC common injuries and problems were reviewed. M. Cassella Sports Medicine), was appointed Chair of the Screening Committee, charged Julie O’Connell, PT, ATC (Hubbard Street, Joffrey Ballet), with drafting a preliminary dance-screening document. Sheyi Ojofeitimi, PT (Alvin Ailey, ADAM Center at Long The Task Force agreed that the dance-screening instrument Island University), that is produced will have the following purpose: Elaine Redman, ATC (Radio City Music Hall), • To help dancers dance safely and artistically. Leigh Roberts, PT (Washington Ballet, Universal • To create intervention recommendations based on the Ballet Academy), screening information. Meg Schneider, ATC (Radio City Music Hall). • To develop a normative database of professional danc- Medical personnel from professional dance companies ers to extend our understanding of risk factors for future throughout the US and Canada met for 2 days in July in New injury. York City. Our goal was to come to consensus on the need and • To prevent injuries and decrease their cost (time loss, new objectives of an annual, post-hire, dance screening for profes- workers compensation costs, financial costs). sional company members. Ultimately, it was the feeling of the The Task Force will reconvene in the fall to review the docu- ORTHOPAEDIC SECTION, APTA, INC. group that participation in annual screening would benefit the ment and finalize their recommendations on a universal form. dancers through early understanding of their individual medical In addition, our next meeting will bring the dancers and their history, recognizing unaddressed problems, and developing bet- union into our discussion on implementing this worthy en- ter preventative programs to maintain their optimal well being. deavor. All agreed that use of a standardized form would facilitate pool- The second meeting of the DANCE/USA Medical Task ing of data in the aggregate to permit a better description of the Force on Dancer Health met on October 1 and 2. Attendees physical characteristics of professional dancers. Also agreed was included Medical Task Force Chair Richard Gibbs, MD (San that such a universal screen must have relevancy and applicabil- Francisco Ballet), Shaw Bronner, PT (Alvin Ailey, ADAM ity to many styles of dance (eg, ballet, modern dance, theater, Center at LIU), Micky Cassella, PT and Heather Southwick, etc.). PT (Boston Ballet, Boston Children’s Hospital), Andrea Dick- Presentations on current programs at New York City Ballet, erson (Dance/USA), Julie Daugherty, PT (American Ballet Pittsburgh Ballet, and Boston Ballet were made by L. Hamilton, Theater), Mj. Liederbach, PT, ATC (Harkness Center), Mari- E. Coffey and K. Nachazel, and M. Cassella respectively. Each ka Molnar, PT (New York City Ballet). Over August and Sep- emphasized that the implementation of formal annual screening tember, Micky Cassella, Chair of the Screening Committee, with the assistance of Heather Southwick produced a prelimi-

SPECIAL INTEREST GROUPS |and its sequelae have had an extremely positive effect on injury and time loss reduction. nary draft of the ‘Annual Health Assessment for Professional Core principals delineated at this and previous Task Force Dancers’ document. Work at this meeting focused on review meetings include: of this draft to refine it further. Our goal is to have a stan- 1. The absolute confidentiality of all individual medical in- dardized assessment that can be administered in 30 minutes formation. The guidelines of HIPPA would be followed. or less. The group also commented on a document written by 2. That both dancers and their union, AGMA, as well as the Richard Gibbs on the ‘Core Principles’ of the Medical Task dance organization’s artistic directors and administrators Force. This document reviews the purpose, guidelines, and ra- participate in the development process so that all under- tionale in the establishment of annual health assessments in 56 Orthopaedic Practice Vol. 17;4:05 professional dance companies. On Day 2, attendees met with a former dancer and union representative to get further feedback from the dancer’s perspective. A follow-up meeting is scheduled in NYC on January 7 and 8 to review the next assessment draft. In addition, the group will meet with members of the dancer union, AGMA, to as- sess their response and any recommendations they may have.

Following acceptance of the draft by the Task Force, a backup | S P U O R G T S E R E T N I L A I C E P S document with test instructions and references will be written. In addition, the Committee anticipates that findings during the assessment that recommend further musculoskeletal evaluation may require a secondary standardized evaluation form. It is an- ticipated that the final draft will be available for presentation to the Board and Company Managers at the DANCE/USA win- ter meeting in Washington DC on February 17th.

IADMS Consensus Project During the October Dance/USA meeting, MJ Liederbach made a brief presentation on her work on behalf of IADMS. This is a 3-year consensus program that aims to establish uni- form language and standards among its membership on issues surrounding injury and illness risk screenings, clinical testing methods, and injury reporting. . C N I , TA P A , N O I T C E S C I D E PA O H T R O MJ is endeavoring to collect, from as many teachers and health care practitioners from various disciplines as possible who work with dancers, the screening forms used by them to assess dance injury and illness risk, in advance of the Novem- ber IADMS annual meeting in Stockholm. The purpose of this collection process is to understand the breadth of information being collected, and to distill what items are found most com- monly. Unfortunately, information about this project was not provid- ed to the PASIG or Dance/USA Medical Teak Force until just prior to the DANCE/USA meeting. Therefore, her September 30th collection deadline has expired. MJ reported that other opportunities will arise and apologized for any communication failures. For further information on the scope, purpose, mis- sion, and vision of this project, please see the Fall 2005 IADMS newsletter and informational updates posted periodically on the IADMS website: www.iadms.org. Additional questions can be S T R A G N I M R O F R E P | addressed to Marijeanne Liederbach, MSPT, MSATC, CSCS, at [email protected].

PASIG Members Present The PASIG membership will be well represented at the up- coming annual IADMS conference in November in Stock- holm. The PASIG presenters and coauthors include Mylah Garlington, Gayanne Grossman, Marika Molnar, Marijeanne Liederbach, Sheyi Ojofeitimi, and Shaw Bronner. In addition, PASIG members Sheyi Ojofeitimi and Shaw Bronner were co- authors on posters presented at the recent International Society for Biomechanics in August in Cleveland. Please contact me with any suggestions for the Research Committee or to volunteer.

Shaw Bronner, PT, MHS, EdM, OCS Research Committee Chair Email: [email protected]

Orthopaedic Practice Vol. 17;4:05 57 animalpt SPECIAL INTEREST GROUP

President’s Message testing results. The physical examination addresses wounds, at- I hope everyone is enjoying the beauty of fall. The Animal rophy, reflexes, tone, skin sensation, gait, completing a clinical PT SIG will be conducting a very important strategic planning EMG using FES, joint range of motion, muscle girth, balance, session in Alexandria, VA on November 17th and 18th. All of proprioception, edema, pain, weight bearing abilities, and ob- the SIG members should have received an email with a survey. serving function and behavior. Locating the injury site and iden- The survey is an attempt to ascertain YOUR needs as members tifying the muscles are the focus of the examination. Prognosis so the officers and others present at the meeting can prepare for can be difficult to estimate initially, and is affected by the sever- the future of the SIG and the future of animal physical therapy. ity of injury, distance from the injury to the muscle (s) involved, The goals of the meeting are to plan for the next upcoming acute vs. chronic problem, and complications from wounds or years and set goals as to what we need to accomplish together fractures. | ANIMAL PHYSICAL THERAPISTas a group. Many of the members have been involved in the Goals for physical therapist intervention include return to full treatment of animals and are aware of many of the obstacles of function, increased strength of affected musculature, promotion physical therapists treating animals. If you have any thoughts of normal sensory input, improved weight bearing, improved or suggestions, please email me directly prior to our meeting at gait, increased balance, increased endurance, and improved joint [email protected] or if you would like to attend the meeting, stability. The initial rehabilitation protocol is aimed at prevent- please also let me know. ing fractures from falls, preventing pressure sores, and prevent- ing abnormal loading of joints. Utilizing thick bedding, confine- Deborah Gross Saunders, MSPT, OCS, CCRP ment to a small safe area, using orthotics or a sling support, and Certified Canine Rehabilitation Practitioner enhancing the environment are strategies to prevent problems. Wizard of Paws Physical Rehabilitation for Animals, LLC Treatment may include ESTIM, massage, ice, heat, ultrasound, www.wizardofpaws.net laser, acupressure, joint approximation, and balance activities. Neurotrophic stimulation (ESTIM) is a key component of the How I Treat Peripheral Nerve Injuries rehabilitation protocol and may be recommended 3 to 5 times in the Horse each week for approximately one hour. An initial active exer- cise plan involves hand walking on straight level surfaces, weight Peripheral nerve damage can be caused by degenerative chang- shifting, and walking over ground poles or caveletti. Treament es, metabolic processes, neoplasm, nutritional deficits, infec- can be progressed by adding walking backwards, circles, and ORTHOPAEDIC SECTION, APTA, tion,INC. inflammation, toxic influences, and most commonly, by figure eights. Balance and proprioception are challenged by us- trauma. In horses, trauma can occur in many situations such as ing uneven surfaces, sand, water, and moving around obstacles halter-breaking accidents, athletic injuries, trailer or road traf- (TTEAM serpentine and star). Strength and gait can be pro- fic accidents, pasture injuries, falls, kicks, and gunshot wounds. gressed by adding hills, inclines, swimming, stepping in/out of The nerves most often involved in the forelimb are the brachial a trailer, and gradually raising the cavaletti. Trotting, cantering, plexus (C6-T2), suprascapular (C6-C7), and radial (C8-T1). In and pasture turnout can be attempted as joint stability improves. the hind limb, the nerves most frequently injured include the Recovery time varies from a few weeks up to 9 to 12 months or sciatic (L6-S2), femoral (L4-L6), and peroneal (L6-S1). Nerve more. Additional factors that affect outcome include the physi- injuries can be classified as neurapraxia, axonotmesis, or neu- cal status of the animal, owner compliance, and financial com- rotmesis. Edema, pain, wounds, gait changes, impaired balance, mitment. and atrophy within 7 to 10 days are signs of nerve injury. Lin McGonagle, MSPT, LVT Rehabilitation of peripheral nerve injuries requires a Team Morningstar Animal Physical Therapy, Genoa, NY Approach where several professionals contribute to the out- come. Team members might include veterinarians specializing Rehab Redux

SPECIAL INTEREST GROUPS |in orthopaedics and neurology, a physical therapist, a veterinary (Announcing the reopening of Sports Medicine technician, the primary caregiver, the trainer, an orthotist, and and Rehabilitation) farrier. Alameda East Veterinary Hospital A Physical Therapist evaluation begins with taking a history We’ve added 10,000 additional square feet of state-of-the- and consulting with veterinarians for medical and diagnostic art everything. Alameda East Veterinary Hospital is proud to

58 Orthopaedic Practice Vol. 17;4:05 announce the grand opening of our newly renovated Sports ment, to bony agenesis, we can custom mold and design an Medicine & Rehabilitation facility! Our 10,000 square-foot assistive device to fit your critter with a supportive brace or transformation, including boarding and daycare, features: to even replace a missing limb. The Clare and Eugene Thaw Please join us in our celebration and take a tour of our trans-

Biomechanics Laboratory formed facility online at www.aevh.com. | S P U O R G T S E R E T N I L A I C E P S The first of its kind in private practice, the Biomechanics Laboratory uses force plates (kinetics) and sophisticated Caroline Adamson, MSPT, CCRP digital motion analysis (kinematics) for superlative analy- Director, Rehabilitation Services sis of the gait and weight-bearing properties of your canine Tammy Wolfe, BSPT, CCRP, GCFP companion. The Lab helps to diagnose sources of lameness, select an appropriate plan of care, and to test efficacy of treatments provided. Nutrition Center

With obesity becoming an increasing problem among our Animal SIG CSM Programming pets, Alameda East Veterinary Hospital has invested in an- A Multidisciplinary Event other ‘first:’ a DEXA (Dual Energy X-Ray Absorptiometry) by Ginamarie Epifano scanner that measures body mass composition including The Animal SIG welcomes CSM attendees to our educational programming. We have assembled a panel of speakers bone mineral density and body fat analysis. With an ini- who span several professions, giving many different perspectives tial reading, a customized nutritional course and exercise to the growing field of animal rehabilitation. AEDIC SECTION, APT . C N I , TA P A , N O I T C E S C I D E PA O H T R O program are determined for optimal well-being of the pet. Brett Wood, DVM and Charles Evans, PT of Dover Veterinary Hospital will collaboratively speak on current surgical techniques The seriously obese dog may board in our upscale Animal and corresponding rehabilitation protocols. LodgeTM for initial in-patient treatment and clinical su- Ilaria Borghese, OTR/L and owner of Therapaws, Inc. will then pervision. The nutrition center combines the talents of vet- speak on custom splinting for animals. On a different note, Diana Carman, PT of Athens Technical erinarians, canine nutritional advisors, and canine physical College will give an overview of hippotherapy, the utilization of rehabilitation therapists with technology for optimal, life- horses in human therapy. We invite you to join us for our business meeting, which will take place directly after programming long pet health. Hydrotherapy Center We present an in-ground lap pool with high pressure jets used to increase strength and endurance or just for gen- eral recreation. A slightly warmer in-ground therapy pool is used for more specific rehabilitation of orthopaedic and neurologic conditions. We now house 2 underwater tread- mills with jet and incline/decline capabilities and speeds of up to 7.5 mph. Public webcams are installed to view your pet in action online!

Treatment/ Modality Room T S I P A R E H T L A C I S Y H P L A M I N A | This cozy room allows us to consult with new patients and offers a quiet area to apply modalities such as ultrasound, electrical stimulation, extracorporeal shockwave therapy, Equi-Light, and a variety of manual techniques. Exercise Room Our ‘work out’ room is lined with 8 millimeters of rubber flooring and outfitted with a land treadmill, therapy balls, cavaletti rails, etc. to focus our rehabilitation on higher level activities such as balance, coordination, agility, and core strengthening. Even a simulated dog door is installed to al- low our patients to regain their normal activities of daily living. Custom Orthotic & Prosthetic Prescription Aligned with our ‘on call’ CPO, we design custom fit or- thotics and prosthetics for even the most unusual of cases. From a stretched tibial nerve in a lure coursing accident, Achilles mechanism avulsion (ie, ‘dropped hock’), scapulec- tomy secondary to osteosarcoma, torn cranial cruciate liga-

Orthopaedic Practice Vol. 17;4:05 59 advertisersindex

APTA Consulting Service ...... 7 Ola Grimsby ...... 28 Ph: 800/999-2782 ext 3146 • www.apta.org/memberservices Ph: 800.646-6128 • www.OlaGrimsby.com/OPTP Academy of Lymphatic Studies ...... 19 OrthoVet Splints ...... 59 Ph: 800/863-5935 • Email: [email protected] • www.acols.com Ph: 541/544-2435 • Fax: 541/544-2426 • www.orthovet.com Aiken Compounding Pharmacy ...... 33 Pain & Rehabilitation Medicine ...... 57 Ph: 866/649-1313 • Fax: 803/649-9494 Ph: 301/656-0220 • Fax: 301/654-033 • Email: [email protected] Balance Systems ...... 60 Phoenix, Inc...... 45 Ph: 800/874-0801 • www.flextend.com Ph: 406/549-8371 • Fax: 406/721-6195 Cardon Rehabilitation Products Inc...... Inside Front Cover The Pressure Positive Co...... 24 Ph: 800/944-7868 • Fax: 716/297-0411 Ph: 800/603-5107 • Fax: 610/754-6327 • www.pressurepositive.com DogLeggs ...... 53 The Prometheus Group ...... 25 Ph: 800/313-1218 • Fax: 703/391-9333 Ph: 603/749-0733 • Fax: 603/749-0511 • www.theprogrp.com End Range of Motion Improvement Inc...... 2 The Saunders Group, Inc...... Inside Back Cover Ph: 877/503-0505 • GetMotion.com Ph: 800/966-4305 • Fax: 952/368-9249 • www.3DactiveTrac.com ErgoScience Inc...... 46 Serola Biomechanics ...... Outside Back Cover Ph: 866/779-6447 • Fax: 205/879-3301 Ph: 815/636-2780 • Fax: 815/636-2781 • www.serola.net Evidence in Motion, LLC ...... 1 University of Indianapolis ...... 33 Ph: 210/364-7410 • Fax: 210/579-2637 • www.evidenceinmotion.com Ph: 317/788-4909 • Fax: 317/788-3542 • Email: [email protected] Institute of Physical Art ...... 13 University of St. Augustine ...... 35 Ph: 970-870-9521 • www.instituteofphysicalart.com Ph: 800/241-1027 • www.usa.edu MGH Institute of Health Professions ...... 45 UW Hospitals & Clinics ...... 24 Ph: 617/726-0422 • Email: [email protected] • www.mghihp.edu Ph: 608/265-8371 • Fax: 608/263-6574 • Email: [email protected] OPTP ...... 5 Ph: 763/553-0452 • Fax: 763/553-9355 • www.optp.com

60 Orthopaedic Practice Vol. 17;4:05 Non-Profit Org. U.S. Postage PAID Permit No. 25 La Crosse, WI Orthopaedic Physical Therapy Practice Orthopaedic Section, APTA, Inc. 2920 East Avenue South, Suite 200 La Crosse, WI 54601