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Category: Sports; Midfoot/Forefoot Introduction/Purpose: Lisfranc injuries encompass a spectrum of injuries to the tarsometatarsal (TMT) joint complex from ligamentous sprains to fractures with dislocation. While studies have shown it is possible to return to sport (RTS) after low- energy injuries, no literature exists demonstrating RTS after homolateral fracture/dislocation of all 5 metatarsals. We present a novel surgical technique for repair of homolateral Lisfranc fracture/dislocation of the 1st-5th metatarsals. Fusion of the 2nd and 3rd TMT joints provides stability of the middle column. Internal bracing of the 1st TMT joint gives stability while preserving greater physiologic motion in a high-level athlete. Methods: A dorsal approach is used for fusion of the 2nd and 3rd TMT joints with medial approach for internal bracing of the 1st TMT joint. 2nd and 3rd metatarsals were denuded of cartilage, and the fusion site was fully prepared. Rigid fixation was applied to the fusion sites. Guidewire for the cannulated Internal Brace system is inserted into the base of the 1st metatarsal. Fluoroscopic imaging confirmed positioning and the 3.4mm drill is passed over the wire, followed by the cannulated tap. A 4.75mm Swivelock anchor with Fibertape suture is inserted into the metatarsal base. The guidewire is placed in a reciprocating position on the medial cuneiform. The 2.7 mm drill is passed over the wire, followed by the 3.5 mm tap. A 3.5 mm Swivelock is then loaded with the Fiberwire from the 1st metatarsal. Tensioning is performed, and the 3.5 mm Swivelock is inserted into the medial cuneiform. Results: The athlete was cleared to return to full competition 9 months following surgery with physical exam demonstrating stability in both dorsiflexion and abduction. Weight bearing x-rays showed no evidence of hardware failure and no instability in the 1st TMT joint. CT scan demonstrated solid fusion of 2nd and 3rd TMT joints and maintained anatomic reduction of the 1st TMT joint. At 1-year post-op, patient was having pain over the 4th TMT joint. He had a second surgery to remove an exostosis at the 4th TMT joint as well as remove the screw from the 3rd metatarsal to the middle cuneiform. His pain had resolved at most recent follow up. He returned to game action in the final game of his senior season. Conclusion: The literature demonstrates return to sport is possible for athletes with Lisfranc injuries though the data focuses on either purely ligamentous injuries or Myerson type B and C fractures. This case study demonstrates a novel surgical approach to homolateral fracture/dislocation. While return to sport in this athlete took longer than lower-energy injuries, it is possible for athletes with homolateral displacement to return to full competition.

Background: Lisfranc injuries encompass a spectrum of injuries to the tarsometatarsal (TMT) joint complex from ligamentous sprains to fractures with dislocation. While studies have shown it is possible to return to sport (RTS) after low-energy injuries, no literature exists demonstrating RTS after homolateral fracture/dislocation of all 5 metatarsals. Indications: We present a novel technique for repair of homolateral Lisfranc fracture/dislocation of metatarsals 1-5 which may be used in high-level athletes attempting to return to competition. Technique Description: A dual approach is utilized, with a dorsal approach to allow for fusion of the 2nd and 3rd TMT joints and medial approach for internal bracing of the 1st TMT joint. The 2nd and 3rd metatarsals were denuded of all cartilage and the fusion site was fully prepared. Rigid fixation was applied to the fusion sites and then stability of the 1st TMT was reassessed. A guidewire for the cannulated InternalBrace (Arthrex; Naples, FL) system is initially inserted into the base of the 1st metatarsal. Positioning is confirmed with fluoroscopic imaging and the 3.4 mm drill is passed over the wire, followed by the cannulated tap. A 4.75 mm SwiveLock anchor (Arthrex; Naples, FL) with FiberTape suture (Arthrex; Naples, FL) is then inserted into the metatarsal base. The guidewire is placed in a reciprocating position on the medial cuneiform. The 2.7 mm drill is passed over the wire, followed by the 3.5 mm tap. A 3.5 mm SwiveLock anchor is then loaded with the FiberTape suture from the 1st metatarsal. Tensioning is performed, and the 3.5 mm SwiveLock anchor is inserted into the medial cuneiform. Results: The athlete was cleared to return to full competition 9 months following surgery. Physical examination demonstrated stability in dorsiflexion and abduction. Both weight-bearing x-rays and computed tomography scans showed no evidence of hardware failure, no instability of the 1st TMT joint, and solid fusion of the 2nd and 3rd TMT joints. Discussion/Conclusion: Current literature demonstrates that RTS is possible for athletes suffering from low-energy Lisfranc injuries. This novel surgical technique is the first to demonstrate return to sport of a high-level athlete from homolateral fracture/dislocation of all 5 metatarsals.

Background: Functionality testing following anterior cruciate ligament (ACL) reconstruction can benefit clinicians and patients in determining readiness for return to sport. While a component of a multifactorial decision, inability to perform well on these tests predicts increased risk of reinjury. As of 2013, only 41% of orthopaedic surgeons report using strength or functionality testing in evaluating patients for return to sport (RTS). Indications: In the intermediate to late stages of their rehabilitation program, patients may undergo these tests to determine readiness and safety to return to sport. Technique Description: The tests described in this video include the single and triple hop for distance, triple crossover hop, single and double vertical leg jump tasks, drop jump landing task, and isokinetic and isometric strength testing. Results: Clinicians who incorporate these tests into patient rehabilitation programs may reduce patient risk of ACL reinjury by 75% to 84%. The limb symmetry index (LSI) is a reliable calculated measure for these tests, with a strong reliability for the hop tests. The limb symmetry index can be calculated for each test and represents the ratio of measured performance of the involved, or post-ACL reconstruction, leg when compared against the uninvolved leg. The commonly used limb symmetry index threshold for passing each hop test is 90%. Patients who score 90% or greater on each of these tests are less likely to experience knee reinjury. Discussion/Conclusion: The ability of knee strength and functionality tests in determining RTS following ACL reconstruction has been highlighted as a tool in potentially reducing risk of knee reinjury. Other isometric and isokinetic testing can be used in addition to the described functionality tests but may not be possible in certain practices due to equipment and funding limitations. Usage of these strength and functionality tests, in conjunction with clinician evaluation, may lead to more optimal outcomes for patients and lower rates of reinjury. Psychological assessment may aid in evaluating patient readiness for return to sport. Importantly, further sport-specific testing is still recommended and will optimize patient outcomes.

Background: Blood flow restriction (BFR) training restricts arterial inflow and venous outflow from the extremity and can produce gains in muscle strength at low loads. Low-load training reduces joint stress and decreases cardiovascular risk when compared with high-load training, thus making BFR an excellent option for many patients requiring rehabilitation. Indications: Blood flow restriction has shown clinical benefit in a variety of patient populations including healthy patients as well as those with osteoarthritis, anterior cruciate ligament reconstruction, polymyositis/dermatomyositis, and Achilles tendon rupture. Technique Description: This video demonstrates BFR training in 3 clinical areas: upper extremity resistance training, lower extremity resistance training, and low-intensity cycling. All applications of BFR first require determination of total occlusion pressure. Upper extremity training requires inflating the tourniquet to 50% of total occlusion pressure, while lower extremity exercises use 80% of total occlusion pressure. Low-load resistance training exercises follow a specific repetition scheme: 30 reps followed by a 30-second rest and then 3 sets of 15 reps with 30-seconds rest between each. During cycle training, 80% total occlusion pressure is used as the patient cycles for 15 minutes without rest. Results: Augmenting low-load resistance training with BFR increases muscle strength when compared with low-load resistance alone. In addition, low-load BFR has demonstrated an increase in muscle mass greater than low-load training alone and equivalent to high-load training absent BFR. A systematic review determined the safety of low-load training with BFR is comparable to traditional high-intensity resistance training. The most common adverse effects include exercise intolerance, discomfort, and dull pain which are also frequent in patients undergoing traditional resistance training. Severe adverse effects including deep vein thrombosis, pulmonary embolism, and rhabdomyolysis are exceedingly rare, less than 0.006% according to a national survey. Patients undergoing BFR rehabilitation experience less perceived exertion and demonstrate decreased pain scores compared with high-load resistance training. Conclusion: Blood flow restriction training is an effective alternative to high-load resistance training for patients requiring musculoskeletal rehabilitation for multiple disease processes as well as in the perioperative setting. Blood flow restriction has been shown to be a safe training modality when managed by properly trained physical therapists and athletic trainers.

Background: Dry needling is an increasingly popular technique for relieving musculoskeletal pain, through targeting myofascial trigger points. Existing evidence indicates that dry needling is effective in short-term management of pain, with research showing efficacy in improving functional outcomes when compared to other treatments. Indications: Myofascial trigger points may result in range of motion limitations and muscle weakness. Noninvasive treatments for musculoskeletal pain associated with myofascial trigger points, such as stretching or warm compresses, may not provide significant benefit for patients. Dry needling is a minimally invasive technique that provides significant short-term functional improvement and analgesia for musculoskeletal pain associated with myofascial trigger points, seen with reductions in visual analog scale (VAS) pain scores and decreased need for pharmacologic therapies. Technique Description: This video demonstrates dry needling at the tensor fascia latae, extensor carpi radialis longus , and gastrocnemius muscles. Myofascial trigger points and important anatomical landmarks are identified and labeled. A needle is inserted into the region of the myofascial trigger point to a depth of 10 to 100 mm and remains in situ for about 10 to 20 seconds with the use of a piston technique, although this time varies dependent upon patient response. Results: Dry needling may significantly decrease pain and improve functional outcomes in patients with short-term musculoskeletal ailments. Randomized controlled trials have examined dry needling for fibromyalgia, mechanical neck pain, myofascial pain, and following total knee arthroplasty, with these finding significant reductions in pain scores in short-term follow-up. A randomized single-blind placebo-controlled trial found dry needling with exercise to be more effective than sham dry-needling and exercise. Dry needling may provide improved long-term analgesia but also results in increased pain during the procedure and increased soreness afterwards. Pain relief may not last beyond 6 months, although little research investigating long-term outcomes has been performed. Discussion/Conclusion: The usage of dry needling in clinical settings is increasing, as it has shown strong efficacy in providing short-term pain relief and ability to improve functional outcomes. Dry needling is a simple, minimally invasive technique that is easily and quickly learned by physical therapists and may provide great benefits to patients.