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Physical examination education begins early for medical learners. A hindrance to physical exam competency is lack of exposure to pathology in standardized patient settings. This research focuses on improving medical education through the utilization of cadavers that have undergone a soft-embalming technique: the Thiel method. Three scenarios were created in four Thiel cadavers: anterior cruciate ligament (ACL) tear, posterior cruciate ligament (PCL) tear, and sham incision. Students were asked to diagnose ACL tears using the Lachman exam. A total of 54 learners participated in the study. Post-surveys indicated most learners: (1) prefer to use standardized patients (SPs) and soft-embalmed cadavers in their physical examination courses, (2) increased their confidence in performing the Lachman exam on real patients, and (3) enhanced their Lachman technique. SPs ultimately cannot volitionally reproduce the physical exam findings of ACL deficiency. Consequently, learners cannot accurately identify positive versus negative examination findings. Thiel-embalmed cadavers are a valuable resource for physical examination education. (Journal of Surgical Orthopaedic Advances 30(2):112-115, 2021).

INTRODUCTION: The prevalence of ACL injuries is increasing in previous years. One of the most common studied kinematic risk factors related to ACL injuries is a resultant weak, leg axis alignment known as the dynamic knee valgus angle presented during a vertical drop jump [8, 14, 15]. Hewett et. al. concluded that a knee valgus angle was a primary predictor of the mechanism that leads to an ACL rupture [8]. By increasing the excessive knee valgus angle during a two-legged DVJ, an athlete is in turn increasing the possibility of a high knee valgus moment, which can increase the anterior tibial translation as well as the load on the ACL several-fold and the chances for an ACL tear [4]. METHODS: In our study, ten collegiate female participants, including ballet and non-ballet athletes performed two-legged DVJs for 6 different flexor and extensor muscles while digital recordings of knee valgus angle were captured at initial contact and push off with simultaneous collection of EMG data. RESULTS: Results displayed statistical significance for the average valgus angle to estimated GRF ratio for the non-dominant leg at push-off between the ballet and non-ballet athletes (0.8 ± 0.43 vs. 1.8 ± 0.33 degrees/N, p < 0.05). In addition, we also found that the hip extensor activity significantly increased for the non-ballet group and that the lateral thigh CCI noticeably increased for the non-dominant leg for the non-ballet group, which could be indicative of the noticeable difference in the biceps femoris muscle activation for the non-ballet group when comparing sports type. In addition, statistically significant interactions between sports type and leg type for vastus medialis and gluteus maximus were produced. Observed results also indicated that there was an increase in overall variability for the dominant leg of the non-ballet athletes amongst all studied muscles and for the non-dominant leg for the ballet group specifically studying the gluteus maximus muscle activity. DISCUSSION: Relatively, the non-ballet group could be at a higher risk for increase in femoral adduction, hip adduction, and tibial external rotation, and overall predict a larger knee valgus moment; therefore, the non-ballet group could potentially be at a higher risk for an ACL injury than the ballet group. In addition, there is potential in continued research of neuromuscular differences between ballet and non-ballet athletes to further investigate the vastus medialis and the gluteus maximus muscle activations as well as to investigate the knee valgus moment values.

ABSTRACT Skier’s Edge: Biomechanical Analysis Benjamin T. Johannes The Skier’s Edge trainer can be used by novice or expert skiers. Testing was performed to analyze if the use of the Skier’s Edge could reduce in shear forces of the valgus moment on the knee joint and anterior cruciate ligament (ACL) due to lesser fatigue of muscle and a higher hamstring to quadricep (H/Q) ratio activity. This leads to a reduction of improper form and an increase in balance. Experiments performed observed the change in muscle activity with the use of the Skier’s Edge over time when compared to other forms of workout (elliptical and or a traditional ski conditioning workout). Comparison of the three workout methods was completed by collecting kinematic, kinetic and electromyographic (EMG) data. Each participant, 9 male skiers (22±3 years old, 70.56±3.44 inches, 206±54 lbs.) and 6 female skiers (22±4 years old, 66.25±3.25 inches, 148±72 lbs.), were separated into even groups between the workout types. Data was collected initially and after a four-week period of exercise for each respective workout group. A relative valgus moment was found with the force and valgus angle data and an H/Q ratio was created using the vastus medialis and semitendinosus EMG data for the respective muscles. The findings of this study show that there were no significant differences between the workout types for either reduction of valgus moment or an increase in H/Q ratio which are indicators of reduced ACL injury. Trends in the data indicate that the elliptical workout may have a positive impact on H/Q when compared to the Skier’s Edge workout. Recommendation for future study includes having participants complete a more intense and longer workout period or to focus on the elliptical and Skier’s Edge workout to test for significant differences to aid in ACL injury reduction.

Background: Historically the identification of ACL injuries upon initial presentation is low and considerable diagnostic delays have been reported. However, specific evidence on the individual elements of, and factors which influence delay, is lacking. Aims: The overarching aim was to provide a comprehensive picture of delay to diagnosis and specialist consultation, including factors which influence delay. An additional aim was to determine whether the approach to examining acute knee injuries varied as a consequence of varying patient presentation or experience of the assessing clinician. Methods: Study 1: Cross -sectional survey. Study 2: Non-participant direct observation methodology. Results: Data from 194 patients were analysed in the survey. Only 15.5% of patients were given a correct diagnosis of ACL rupture at the initial consultation. Median delay to diagnosis was 67.5 days (IQR= 15 to 178 days) and specialist consultation 108 days (IQR= 38 to 292 days). The factors most influential on delay were whether a follow-up appointment was arranged after attending A&E, whether the site of attendance operated an acute knee clinic and whether MRI was performed. The direct observation study showed wide variation in approach to injury assessment. Specialist clinicians performed the most comprehensive examination. A&E clinicians were more likely to assess for bony, neurovascular and gross tendon injuries as opposed to ligamentous or meniscal injury. Conclusions: The diagnostic rate of ACL injury at initial presentation remains low. Considerable delays to diagnosis and specialist consultation are apparent following ACL injury, the majority of which is attributable to health system delay.

Objective: Patient-specific musculoskeletal models have emerged as a reliable method to study how tibiofemoral joint (TFJ) morphology influences anterior cruciate ligament (ACL) injuries. However, there are no such models for adolescent populations that can be scaled to accommodate growth. To serve as the foundation for such models, the objective of this thesis was therefore to i) build a patient-specific model of natural knee motion in an ACL-injured (ACLi) adolescent sample using joint congruency and ii) to attempt to reconstruct patient-specific simplified articular contacts using principal component analysis (PCA). Design: Twelve magnetic resonance images (MRI) of ACi adolescents were segmented and used to generate spheres of simplified TFJ articulations. A congruence-based optimization algorithm was used to determine the envelope of tibiofemoral configurations that optimize joint congruency. Descriptive statistics were used to compare model outputs to existing literature. Combinations of marker trajectories and anthropometrics were used to determine the feasibility of reconstructing articular sphere simplifications using PCA. Root-mean squared error (RMSE) was used to compare predicted sphere contacts to MRI-extracted contacts. Results: Average knee joint anglesof the femur with respect to the tibia was slightly abducted and externally rotated, with a range of motion (ROM) of 1.60º ± 0.66 and 7.64 º ± 2.34 across 102° of flexion respectively. The percent elongation of the posterior cruciate ligament (PCL) varied the most across participants (8.65 ± 6.2%) compared to the ACL (2.34 ± 2.1%), MCL (1.41 ± 0.5%) and LCL (1.75 ± 1.6%) respectively. The combination of femur markers and anthropometrics was able to reconstruct simplified tibiofemoral articulations the best, but not within 5 mm of RMSE. Conclusion: Inter-subject variability in passive kinematic motion derived from patient-specific morphology highlights the need for personalized and accessible musculoskeletal models in growing populations. Furthermore, simplified distal femur morphology can be reconstructed from anthropometrics and marker positions, but proximal tibia morphology requires more information.

Non-contact injuries can occur when athletes use poor or inconsistent mechanics during typical sport-related movements like landing from a jump. Anterior cruciate ligament (ACL) injuries are especially devastating, and certain populations like female athletes and athletes with a previous ACL reconstruction (ACLR) are at greater risk of suffering an ACL injury, with altered biomechanical strategies being one proposed reason. Asymmetric landings where one limb experiences greater landing force can decrease joint stability and place the overloaded limb at greater risk for ACL injury. Additionally, a stiff landing, characterized by increased ground reaction force (GRF), extended joints at initial ground contact, and decreased joint flexion throughout the landing, has been proposed to increase ACL injury risk. While load distribution between limbs is a common landing assessment to determine injury risk, it is unclear what role limb stiffness plays in the likelihood of experiencing an ACL injury. Limb stiffness is simply the deformation of the limb in response to the downward force applied to the lower limb during ground contact, which can be approximated using GRF. Limb stiffness has been commonly used to assess performance in running, hopping, and jumping, however, its relationship with injury risk during landings is relatively unexplored. Past research has revealed that the ACL experiences peak strain prior to initial ground contact when the knee is at or near full extension. Additionally, expert video analyses have determined that ACL injuries most likely occur within 50 milliseconds of ground contact. It is possible that limb stiffness and limb stiffness asymmetry can be used during the early impact phase of landings to reveal ACLR- and sex-specific landing mechanics differences when the ACL appears to be most vulnerable. Moreover, game-like, sport-specific landing tasks with a greater horizontal component that load the ACL and those that divert attention away from landing strategies may uncover differences that do not appear in standard, controlled laboratory tasks. The overall goal of this project was to use limb stiffness, limb stiffness asymmetry, and related measures to analyze the early landing phase mechanics of groups at greater risk for ACL injury during game-like, sport-specific landings. First, in an ACLR cohort, greater knee power and knee work asymmetries were found when compared to healthy recreational athletes, supporting previous literature that found that athletes with an ACLR land unevenly by offloading their surgical limb. However, limb stiffness asymmetry was not different between groups, implying that the groups may have modulated limb stiffness differently between limbs. Second, minimal sex-by-task interactions were determined for landings that varied by horizontal approach prior to initial ground contact. Significant differences were found for most measures across tasks overall, however, male and female athletes displayed similar landing mechanics, indicating that expected sex-specific differences may not exist during the immediate landing phase when ACL injuries are thought to occur. Last a landing task that mimicked a ball in mid-air and diverted attention away from landing mechanics produced a sex-by-task interaction for peak impact force but no other measure. When comparing each sex-task pairing, a trend for greater peak impact force by female athletes during the distracted landing (p=0.098) was found which may indicate that future tasks with additional external focuses or another game-like component will reveal anticipated sex-specific differences. Increased time between limbs for initial ground contact for female athletes also revealed that a time-synchronized assessment of between-limb coordination may be beneficial for future research. / Doctor of Philosophy / Non-contact injuries can occur when athletes use poor or inconsistent mechanics during typical sport-related movements like landing from a jump. Anterior cruciate ligament (ACL) injuries are especially tough, and certain populations like female athletes and athletes with a previous ACL reconstruction surgery (ACLR) are at greater risk of suffering an ACL injury, with different movement techniques being one proposed reason. Uneven landings where one limb has greater landing forces can decrease joint posture and place the overloaded limb at greater risk for ACL injury. Additionally, a stiff landing, defined by larger ground reaction force (GRF), extended joints at initial ground contact, and decreased joint flexion throughout the landing, is thought to increase ACL injury risk. While landing force distribution between limbs is a common way of evaluating landings to determine injury risk, it is unclear what role limb stiffness plays in the likelihood of experiencing an ACL injury. Limb stiffness is simply the deformation of the limb in response to the downward force applied on the lower limb during ground contact, which can be estimated using GRF. Limb stiffness has been commonly used to assess performance in running, hopping, and jumping, however, its relationship with injury risk during landings is pretty limited. Past research has revealed that the ACL experiences maximum stretch prior to initial ground contact when the knee is or is almost completely straight. Additionally, expert video investigations have determined that ACL injuries most likely occur within 50 milliseconds of ground contact. It is possible that limb stiffness and limb stiffness asymmetry can be used during the early impact phase of landings to reveal sex- and ACLR-specific landing mechanics differences when the ACL appears to be most in danger. Additionally, game-like, sport-specific landing tasks with a greater horizontal element that load the ACL and those that redirect attention away from landing strategies may show differences that do not appear in basic laboratory tasks. The overall goal of this project was to use limb stiffness, limb stiffness asymmetry, and related measures to examine the early landing phase techniques of groups at greater risk for ACL injury during game-like, sport-specific landings. First, in a group of athletes with a previous ACLR, greater knee storage differences between limbs were found when compared to healthy recreational athletes, supporting previous research studies that found that athletes with an ACLR land unevenly by offloading their surgical limb. However, limb stiffness asymmetry was not different between groups, implying that the groups may have regulated limb stiffness differently between limbs. Second, only a couple measures were significantly affected by the combined effect of sex and task during landings that were different due to their horizontal element. Significant differences were found for most measures across tasks overall, however, male and female athletes had similar landing techniques, showing that the expected differences between sexes may not happen very early in the landing phase when ACL injuries are thought to happen. Last, a landing task that imitated a ball in mid-air and redirected attention away from landing mechanics produced a larger sex-specific difference for peak impact force compared to a basic landing task. When comparing each sex-task pairing, a trend for greater peak impact force by female athletes during the distracted landing (p=0.098) was found which may show that future tasks with additional distractions or another game-like element will reveal expected differences between sexes. Increased time between limbs for initial ground contact for female athletes also revealed that looking at the coordination of both limbs on the same timescale may be useful for future research.

Bakgrund: Främre korsbandsskador är vanliga i idrotten och korsbandsrekonstruktion bedöms främst vara aktuellt för unga personer med höga krav på knäfunktion, till exempel elitidrottare. Rehabiliteringen är en lång och krävande process där både fysiologiska och psykologiska aspekter är viktiga. Motivation är associerat med återgång till idrott och elitidrottare återgår till idrott på samma nivå i högre utsträckning jämfört med icke-elitidrottare. Däremot är det oklart vad som motiverar elitidrottaren till rehabilitering. Syfte: Syftet var att undersöka sex elitidrottares upplevelser och erfarenheter kring motivation till rehabilitering i syfte att återgå till elitidrott efter en främre korsbandsrekonstruktion.Metod:Kvalitativ deskriptiv design. Semistrukturerade intervjuer genomfördes och bearbetades med kvalitativ innehållsanalys. Totalt intervjuades sex elitidrottande män och kvinnor inom idrotterna ishockey, innebandy och basket. Resultat: Analysen resulterade i sex kategorier: ”Rehabiliteringen är ett maraton och inte en sprint”, ”Viktigt med stöd från laget och omgivningen”, ”Olika psykologiska aspekter hos elitidrottare påverkar”, ”Att vara, eller inte vara elitidrottare”, ”Motivation är sällan svart eller vitt”, ”Fysioterapeutens viktiga roll under rehabiliteringen” samt femton underkategorier. Konklusion: Stöd från laget, anhöriga och vänner var viktigt, likaså samarbetet med fysioterapeuten som också ledde till en känsla av trygghet. Informanterna beskrev att motivation kom både inifrån och utifrån. Resultatet kan hjälpa såväl fysioterapeuter som idrottare att identifiera och applicera strategier för att öka motivationen under rehabiliteringen. / Background: Anterior cruciate ligament injuries are common in sports and reconstructions are largely considered relevant for young people with high demands on knee function e.g., elite athletes. Rehabilitation is a long and demanding process in which physical and psychological aspects are important. Motivation is associated with return to sport and elite athletes return to sport at the same level in greater extent than non-elite-athletes. However, it is unclear what motivates the elite athletes to rehabilitate.  Purpose: The aim was to investigate six elite athletes’ views and experiences about motivation to rehabilitation with the purpose to return to elite sports after an anterior cruciate ligament reconstruction.  Method: Qualitative descriptive design. Semi-structured interviews that were analyzed trough a qualitative content analysis. Six elite athletes from the sports ice-hockey, floorball and basketball were interviewed.Result:The analysis resulted in six categories: ”Rehabilitation is a marathon and not a sprint”, ”The importance of support from the team and the surrounding”, “Different psychological aspects in elite athletes influence”, To be, or not to be an elite athlete”, ”Motivation is rarely black or white”, ”The physiotherapist´s important role during the rehabilitation” and fifteen sub-categories. Conclusion: Support from the team, relatives and friends was considered important as well as collaboration with the physiotherapist which also led to a feeling of security. The informants described that motivation was both internal and external. The result may assist both physiotherapist and athletes to identify and apply strategies to increase motivation during rehabilitation.

The Functional Movement Screen (FMS), invented in 1995, has been adopted among Division One sports programs across the country. Being a women’s soccer player at the University of Central Florida (UCF), this particular topic had been of interest for years. The FMS is a series of seven tests evaluated at the beginning and end of each season. The UCF team's preventative rehabilitation was based upon the measurements from the FMS testing. The team engaged in preventative rehabilitation three times a week. Each year of my membership, the team of 28 to 30 players had no less than two anterior cruciate ligament tears each season. This research explored the effectiveness of the Functional Movement Screening, and its' predictive ability regarding injury to possibly prevent future injuries. The purpose of this study was to review literature of multiple studies exploring the Functional Movement Screen, the anterior cruciate ligament, and, specifically, the recent spike in women's collegiate soccer injuries. This study also examined and included findings from five years of FMS scoring data from the UCF women's soccer team. The study consisted of 43 participants, 29 in the control group and 14 in the test group (those who suffered and ACL tear). They were females, ages 18-23, and of fit manner. Multivariate analysis, independent and dependent T-Tests, and Leven's test ran these data. This study also investigated the reliability of the Functional Movement Screen and analyzed data about anterior cruciate ligament injuries among women’s collegiate soccer players. Recommendations for future protocols and implications for coaches, trainers, and women soccer players are provided.

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