Physical Therapist's Guide to Low Back Pain

Physical Therapist's Guide to Low Back Pain

If you have low back pain, you are not alone. At any given time, about 25% of people in the United States report having low back pain within the past 3 months. In most cases, low back pain is mild and disappears on its own. For some people, back pain can return or hang on, leading to a decrease in quality of life or even to disability.

If your low back pain is accompanied by the following symptoms, you should visit your local emergency department immediately:

• Loss of bowel or bladder control
• Numbness in the groin or inner thigh

These symptoms might indicate a condition called "cauda equina syndrome," in which nerves at the end of the spinal cord are being squeezed.

 

Signs and Symptoms

The symptoms of low back pain vary a great deal. Your pain might be dull, burning, or sharp. You might feel it at a single point or over a broad area. It might be accompanied by muscle spasms or stiffness. Sometimes, it might spread into one or both legs.

There are 3 different types of low back pain:

• Acute - pain lasting less than 3 months
• Recurrent – acute symptoms come back
• Chronic – pain lasting longer than 3 months

Most people who have an episode of acute pain will have at least one recurrence.

Often, low back pain occurs due to overuse, strain, or injury. It could be caused by too much bending, twisting, lifting—or even too much sitting. But just as often, the actual cause of low back pain isn't known, and symptoms usually resolve on their own.

Although low back pain is rarely serious or life threatening, there are several conditions that may contribute to low back pain, such as:

• Degenerative disk disease
• Lumbar spinal stenosis
• Fractures
• Herniated disk
• Osteoarthritis
• Osteoporosis
• Tumors of the spine

 

How Is It Diagnosed?

Your physical therapist will perform a thorough evaluation that includes:

• A review of your health history
• Questions about your specific symptoms
• Tests to identify any problems with posture, flexibility, muscle strength, joint mobility, and movement
• Tests to identify signs or symptoms that could indicate a serious health problem, such as a herniated disk, broken bone, or cancer
• Assessment of how you use your body at work, at home, during sports, and at leisure

For most cases of low back pain, imaging tests such as x-rays, computed tomography (CT) scans, and magnetic resonance imaging (MRI) are not helpful for diagnosing the cause. However, if your physical therapist suspects that your low back pain might be caused by a serious health condition, the therapist will refer you to other health care professionals for evaluation.

 

How Can a Physical Therapist Help?

Your physical therapist can help you improve or restore mobility and reduce low back pain—in many cases, without expensive surgery or the side effects of medications.

If you are having low back pain right now:

• Stay active, and do as much of your normal routine as possible (bed rest for longer than a day can actually slow down your recovery.)
• If your pain lasts more than a few days or gets worse, schedule an appointment to see your physical therapist.

Not all low back pain is the same, so your treatment should be tailored to for your specific symptoms and condition. Once the examination is complete, your physical therapist will evaluate the results, identify the factors that have contributed to your specific back problem, and design an individualized treatment plan for your specific back problem. Treatments may include:

• Manual therapy, including spinal manipulation, to improve the mobility of joints and soft tissues
• Specific strengthening and flexibility exercises
• Education about how you can take better care of your back
• Training for proper lifting, bending, and sitting; for doing chores both at work and in the home; and for proper sleeping positions
• Assistance in creating a safe and effective physical activity program to improve your overall health
• Use of ice or heat treatments or electrical stimulation to help relieve pain

Can this Injury or Condition be Prevented?

As experts in restoring and improving mobility and movement in people’s lives, physical therapists play an important role not only in treating persistent or recurrent low back pain, but also in preventing it and reducing your risk of having it come back.

Physical therapists can teach you how to use the following strategies to prevent back pain:

• Participate in regular strengthening and stretching exercises to keep your back, stomach, and leg muscles strong and flexible
• Keep your body in alignment, so that it can be more efficient when you move
• Keep good posture – don’t slouch!
• Use good body positioning at work, home, or during leisure activities.
• Keep the load close to your body during lifting
• Ask for help before lifting heavy objects
• Use an assistive device, such as a dolly or wheelbarrow, to transport heavy objects
• Maintain a regular physical fitness regimen—staying active can help to prevent injuries

 

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat people who have low back pain. You may want to consider:

• A physical therapist who is experienced in treating people with orthopedic, or musculoskeletal, problems.
• A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopedic physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

• Get recommendations from family and friends or from other health care providers.
• When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with low back pain.
• During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

Article originally appeared on www.apta.org.  Click the following link to view original article: http://www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=d0456c65-7906-4453-b334-d9780612bdd3Bottom of Form 

Physical Therapist's Guide to Labral Tear

An unstable shoulder joint can be the cause or the result of a labral tear. "Labral" refers to the glenoid labrum—a ring of cartilage that surrounds the base of the shoulder joint. Injuries to the labrum are common, can cause a great deal of pain, and may make it hard to move your arm. A labral tear can occur from a fall or from repetitive activities or sports that require you to use your arms raised above your head. Some labral tears can be managed with physical therapy; in severe cases, surgery may be required to repair the torn labrum.

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What is a Labral Tear?

The glenoid labrum provides extra support for the shoulder joint, helping to keep it in place. A labral tear occurs when part of this ring is disrupted, frayed, or torn. Tears may lead to shoulder pain, an unstable shoulder joint, and, in severe cases, dislocation of the shoulder. Likewise, a shoulder dislocation can result in labral tears.
When you think of the shoulder joint, picture a golf ball (the head of the upper-arm bone, or humerus) resting on a golf tee (the glenoid fossa, a shallow cavity or socket located on the shoulder blade, or scapula). The labrum provides a rim for the socket (golf tee) so that the humerus (golf ball) does not easily fall off. If the labrum is torn, it is harder for the humerus to stay in the socket. The end result is that the shoulder joint becomes unstable and prone to injury.
Because the biceps tendon attaches to the shoulder blade through the labrum, labral tears can occur when you put extra strain on the biceps muscle, such as when you throw a ball. Tears also can result from pinching or compressing the shoulder joint when the arm is raised overhead. There are 2 types of tears:

• Traumatic labral tears usually happen because of a single incident, such as a shoulder dislocation or an injury from heavy lifting. People who use their arms raised over their heads—such as weight lifters, gymnasts, and construction workers—are more likely to have traumatic labral tears. Activities the force is at a distance from the shoulder, such as striking a hammer or swinging a racquet, also can create shoulder joint problems.
• Nontraumatic labral tears most often occur because of muscle weakness or shoulder joint instability. When the muscles that stabilize the shoulder joint are weak, more stress is put on the labrum, leading to a tear. People with nontraumatic tears tend to have more "looseness" or greater mobility throughout all their joints, which might be a factor in the development of a tear.

Labral Tear: See More Detail

 

 

How Does it Feel?

With a labral tear, you might have:

• Pain over the top of your shoulder
• "Popping," "clunking," or "catching" with shoulder movement,  because the torn labrum has "loose ends" that are flipped or rolled within the shoulder joint during arm movement and that may even become trapped between the upper arm and shoulder blade
• Shoulder weakness, often on one side
• A feeling that your shoulder joint will pop out

How Is It Diagnosed?

Not all labral tears cause symptoms. In fact, when tears are small, many people are able to function without pain. In some instances, the labrum might even heal on its own, if care is taken not to stress the injured tissues. Due to the lack of blood supply available at the labrum, complete healing may be difficult. The shoulder with a labral tear may pop or click without being painful; however, if a tear progresses, it is likely to lead to pain and weakness.
If your physical therapist suspects that you may have a labral tear, the therapist will review your health history and perform an examination that is designed to test the condition of the glenoid labrum (the ring of cartilage at the base of the shoulder). The tests will place your shoulder in positions that may recreate some of your symptoms, such as "popping," "clicking," or mild pain. Using this examination, your physical therapist will determine whether your shoulder joint is unstable. Magnetic resonance imaging (MRI) also may be used. Labral tears may be difficult to diagnose with certainty without arthroscopic surgery, where a tube-like instrument called an arthroscope is inserted into the joint through a small incision to view or repair an injury.

 

How Can a Physical Therapist Help?

When labral tears cause minor symptoms but don’t cause shoulder instability, they usually are treated with physical therapy. Your physical therapist will:

• Educate you about positions or activities to avoid
• Tailor a treatment plan for your recovery
• Design specific shoulder strengthening exercises, such as external rotation and internal rotation exercises, to help support the joint and decrease strain on the glenoid labrum
• Design stretching exercises, such as the cross-body stretch or the doorway stretch, to help improve the function of the muscles surrounding the shoulder
• Perform a special technique called manual therapy to decrease pain and improve movement

In more severe cases, when conservative treatments are unable to completely relieve the symptoms of a labral tear, surgery may be required to re-attach the torn labrum. Following surgery, your physical therapist will show you how to slowly and safely return to your daily activities.
A surgically repaired labrum takes 9 to 12 months to completely heal. Immediately following the repair, you should avoid putting excessive stress or strain on the repaired labrum and should increase stress to your shoulder slowly over time. Your physical therapist is trained to gradually introduce activity in a safe manner to allow you to return to your usual activities without re-injuring the repaired tissues. 

 

Can this Injury or Condition be Prevented?

Forceful activities with the arms raised overhead may increase the likelihood of developing a labral tear. To avoid putting excessive stress on the labrum, you need to develop strength in the muscles that surround the shoulder and scapula. Your therapist will:

• Design exercises to help you strengthen your shoulder
• Show you how to avoid potentially harmful positions
• Determine when it is appropriate for you to return to your normal activities
• Train you to properly control your shoulder movement and modify your activities to reduce your risk of sustaining a labral injury 

 

Real Life Experiences

After a day of heavy upper-body lifting at the gym, Jill notices that her shoulder is aching. She ignores the discomfort, thinking that it’s just post-workout soreness, and she continues with her normal routine. But when Jill returns to the gym the following week, she is unable to exercise as aggressively as she usually does because of right shoulder pain. Almost every time she raises her arm overhead, she feels a “clicking” in the shoulder that was never there before. What should she do?

• Rest.Jill should avoid overhead activities, to allow the irritated tissues to heal.
• Ice. Ice applied to the shoulder may help decrease her pain and any swelling.

Rest and ice do not completely get rid of her symptoms, so Jill decides to visit a physical therapist. The therapist conducts an examination designed to detect the amount of injury and how it is affecting her shoulder’s function. Based on the findings of the physical exam, Jill’s physical therapist determines her diagnosis is consistent with a labral injury and recommends the following treatments:

• Strengthening exercises. Improving the strength of the muscles of the shoulder will help Jill decrease the stresses placed on the torn labrum and allow for better healing. The therapist designs external rotation and internal rotation exercises that target the muscles of the shoulder blade and the shoulder joint.;
• Stretching exercises. An imbalance in the muscles or a decrease in flexibility can result in poor posture or excessive stress within the shoulder joint. Jill's therapist prescribes stretching exercises to restore the normal balance of the muscles surrounding the shoulder to help them work better together.
• Education. Education is an important part of any physical therapy treatment plan.  If Jill understands the injury, the reasons for modifying her activities, and the importance of doing the exercises provided by the physical therapist, she can help decrease her risk of future injury.
• Home exercise program. A home exercise program is an important companion to treatment in the physical therapy clinic. The physical therapist identifies the stretching and strengthening exercises that will help her continue to make improvements and meet her goals.

Following 6 weeks of physical therapy, Jill begins a progressive return to her weight-lifting activities. Her physical therapist gives her instruction in proper lifting techniques and training intensity, and Jill is able to make a safe and effective transition back to her lifting program. If Jill's pain and other symptoms return, her physical therapist will work with her and with an orthopedist to help determine whether she needs surgery to repair her labrum.
This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case. 

 

Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.
APTA has determined that the following articles provide some of the best scientific evidence for how to treat labral tears. The articles report recent research and give an overview of the standards of practice for treatment both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free access of the full article, so that you can read it or print out a copy to bring with you to your health care provider.
Mazzocca AD, Cote MP, Solovyova O, et al. Traumatic shoulder instability involving anterior, inferior, and posterior labral injury: a prospective clinical evaluation of arthroscopic repair of 270° labral tears. Am J Sports Med. 2011;39:1687-1696.  Article Summary on PubMed.
Dodson CC, Altchek DW. SLAP lesions: an update on recognition and treatment. J Orthop Sports Phys Ther. 2009;39:71-80. Article Summary on PubMed.
Keener JD, Brophy RH. Superior labral tears of the shoulder: pathogenesis, evaluation, and treatment. J Am Acad Orthop Surg. 2009;17:627-637. Article Summary on PubMed.

Acknowledgement: Charles Thigpen, PhD, PT, ATC and Lane Bailey, PT, DPT, CSCS
This article originally appeared on http://www.apta.org/.  Click here for the actual link to the article: http://www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=99c2e561-5a77-450c-867a-2e2edaaa9b7c

 

Physical Therapist's Guide to Anterior Cruciate Ligament (ACL) Tear

·         Physical Therapist's Guide to Anterior Cruciate Ligament (ACL) Tear

An anterior cruciate ligament (ACL) tear is an injury to the knee commonly affecting soccer players, basketball players, skiers, gymnasts, and other athletes. About 70% of ACL tears are the result of non-contact injuries; 30% are the result of direct contact (player-to-player, player-to-object). Women are 4-6 times more likely than men to experience an ACL tear.

Usually, you will be examined by a physical therapist or an orthopedic surgeon immediately following injury. Most people who sustain an ACL tear will undergo surgery to repair the tear; however, some people may avoid surgery by modifying their physical activity so that they don't put a lot of stress on the knee. A select group can actually return to vigorous physical activity following rehabilitation without having surgery.

Your physical therapist, together with your surgeon, can help you determine if non-operative treatment (rehabilitation without surgery) is a reasonable option for you. If you elect to have surgery, your physical therapist will help you both prepare for surgery and recover your strength and movement following surgery.

What is an ACL Tear?

The ACL is one of the major ligaments (bands of tissue) connecting the thigh bone to the shin bone. It can tear if you:

o    Twist your knee while keeping your foot planted on the ground

o    Stop suddenly while running

o    Suddenly shift your weight from one leg to the other

o    Jump and land on an extended (straightened) knee

o    Stretch the knee farther than you should

o    Experience a direct hit to the knee

 

How Does it Feel?

When you tear the ACL, you may feel a sharp, intense pain or hear a loud "pop" or snap. You might not be able to walk on the injured leg because you can’t support your weight through your knee joint. Usually, the knee will swell immediately (within minutes to a few hours), and you might feel that your knee "gives way" when you walk or put weight on it. 

How Is It Diagnosed?

If you see your physical therapist first, your therapist will conduct a thorough evaluation that includes reviewing your health history. Your therapist will ask you whether you:

o    Felt pain or heard a pop when you jumped, stopped quickly when running, turned your leg with your foot on the ground, or stretched your knee farther than usual

o    Had a direct hit to the leg while your foot was planted on the ground

o    Saw severe swelling around the knee in the first 2-3 hours following the injury

o    Felt your knee buckling or giving way when you tried to get up from a chair, walk up and down stairs, or turn while walking

Your physical therapist also will perform special tests to help determine the likelihood that you have an ACL tear. For instance, the therapist may bend your knee and gently pull on the lower leg (called the "anterior drawer" test or the "Lachman" test). The therapist also might use the "pivot shift" test, gently bending and twisting your knee at the same time. (You might feel some discomfort or instability during these tests, which is normal.) Your therapist may use additional tests to assess possible damage to other parts of your knee.

The orthopedic surgeon may order further tests, including magnetic resonance imaging (MRI), to confirm the diagnosis and also to rule out other possible damage to the knee. 

How Can a Physical Therapist Help?

Once an ACL tear has been diagnosed, you will work with your surgeon and physical therapist to decide if you should have surgery or if you can try to manage your recovery without surgery. If you don’t have surgery, your therapist will work with you to restore your muscle strength, endurance, and coordination so that you can return to your regular activities. In some cases, the therapist may help you to learn to modify your physical activity so that you put less stress on your knee. If you decide to have surgery, your therapist can help you both before and after the procedure.

Treatment Without Surgery

Current research evidence has identified a specific group of patients (called "copers") who have the potential for success without surgery. These patients have injury only to the ACL, and no episodes of "giving way" since the initial injury. There are specific functional tests—such as the Knee Outcomes Survey, the Global Rating of Knee Function, and the timed hop test—that can help the physical therapist identify this group of patients. If you fall into this category, your physical therapist will design a specific physical therapy treatment program for you, most likely including electrical stimulation to the quadriceps muscle, cardiovascular strengthening, traditional muscle strengthening, and balance training.

Treatment Before Surgery

Some orthopedic surgeons refer their patients to a physical therapist for a short course of rehabilitation before surgery. Your therapist will help you decrease your swelling, increase the range of movement of your knee, and strengthen your thigh muscles (quadriceps).

You might have what is known as a "quadriceps lag." This is when you try to raise your leg straight in the air, but you can't control the knee, and your leg bends slightly. Research shows that improving this condition before surgery leads to better outcomes after surgery. Your therapist might use electrical stimulation to help you straighten your leg.

Treatment After Surgery

Your orthopedic surgeon will provide postsurgery instructions. Physical therapists have developed and published guidelines on knee stability and movement problems, which recommend the following actions.

Bearing weight. Immediately after surgery, you will use crutches to walk. The amount of weight you are allowed to put on your leg and how long you use the crutches will depend on the type of reconstructive surgery you had. Your physical therapist will guide you through this part of your rehabilitation.

Icing and compression. Immediately after your surgery, your physical therapist will control your swelling with a cold application, such as an ice sleeve that fits around your knee and compresses it.

Bracing. Almost all surgeons will give you a brace to limit your knee movement (range of motion) after your surgery. Some will give you a brace to use during sports a little further along during your recovery. Your physical therapist will fit you with the brace and teach you how to use it safely.

Exercises to increase your ability to move. You will begin some exercises almost immediately following surgery. In the first week, your physical therapist will help you with your range of motion and teach you gentle exercises that you can do at home. The focus will be on regaining full movement of your knee. If you're like most people, this will take some time.

You will do exercises without pressure on your leg (called "non-weight-bearing exercises") and ones that have you placing weight on your leg ("weight-bearing exercises"). These exercises might be limited to a specific range of motion to protect your newly healing ACL graft. Your therapist might use electrical stimulation to help restore your quadriceps (thigh) muscle strength and help you achieve those last few degrees of straightening the knee.

Exercises to increase your strength. In the first 4 weeks after surgery, your physical therapist will help you increase your ability to put weight on your knee, using a combination of weight-bearing and non-weight-bearing exercises. The exercises will focus on your quadriceps and hamstrings (thigh muscles) and might be limited to a specific range of motion to protect the new ACL. Your therapist might use electrical stimulation to help restore your quadriceps strength.

During weeks 5 through 12, you can expect to begin to walk without crutches and regain a normal walking pattern. Your therapist will increase the intensity of your exercises and add balance exercises to your program. After 3-4 months, your thigh muscles should have about 75% of the strength of the muscles on your uninjured side. During this time, you and your therapist will be planning your return to higher-level activity.

Return to your sport or physical activity. You may begin balance exercises, running, jumping, hopping, and other exercises specific to your sport. This phase varies greatly from person to person. One study found that the return to moderate and strenuous sports varied between 6 and 12 months after surgery. You might be ready to return to your sport if:

o    You no longer have pain and swelling

o    You have no feelings of instability during sport-specific activities, such as cutting, jumping, and landing

o    Your quadriceps strength is 90% of that on your uninjured side

o    Your performance of the 1-legged hop test is at 90% of that on the uninjured side

Remember, each surgeon might have a specific plan for you; these are only broad guidelines describing what you might expect for your recovery.   

Can this Injury or Condition be Prevented?

Current research shows that the percentage of ACL tears has been reduced in certain populations. Much of the research on ACL tears has been conducted with female collegiate athletes, because women are 4-6 times more likely to have this injury. Researchers have made the following recommendations for a preventive exercise program:

o    The program should be designed to improve balance, strength, and sports performance. Strengthening your core (abdominal) muscles is key to preventing injury, in addition to strengthening your thigh and leg muscles.

o    Exercises should be done 2 or 3 times per week and should include sport-specific exercises.

o    The program should last no fewer than 6 weeks.

Although most exercise studies have been conducted with female athletes, the findings may benefit male athletes as well. 

Real Life Experiences

Anita is a star college basketball player—until she comes down from a rebound and feels a pop in her knee and can no longer stand on it. She's taken to the training room, where the physical therapist conducts an evaluation, including the Lachman and anterior drawer tests. The results of both tests are positive, and the therapist notices an increase in her swelling just in the 30 minutes that she spends in the training room. He suspects an ACL tear and refers her to an orthopedic surgeon. As the physical therapist suspected, Anita is diagnosed with an ACL tear.

After a short course of treatment by a physical therapist, Anita has surgery the following month. After surgery, she returns to her physical therapist and begins her rehabilitation. After 5 weeks, she is able to walk normally, fully extending her knee with no pain or feelings of instability. During the next 2 months, she visits her physical therapist 2 times a week and works on her strength and balance. She finds that the hardest exercises are the balance exercises, which require her to balance on a piece of foam or a rocker board while throwing a ball.

About 4 months after surgery, Anita is allowed to begin jogging, then running; at 5 months, she starts exercises that involve jumping up and down or that mimic basketball activities such as rebounding. During these activities, the therapist has Anita concentrate on proper landing techniques so that she lessens the chance of reinjuring her knee when she returns to play.

After 8 months, Anita is allowed to practice with her team. She has no problems with her knee following surgery and returns to competition 11 months after her surgery.

This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case. 

What Kind of Physical Therapist Do I Need?

Although all physical therapists are prepared through education and experience to treat a variety of conditions or injuries, you may want to consider:

o    A physical therapist who is experienced in treating people with orthopedic, or musculoskeletal, problems.

o    A physical therapist who is a board-certified clinical specialist or who has completed a residency or fellowship in orthopedic physical therapy has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists with these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist:

o    Get recommendations from family and friends or from other health care providers.

o    When you contact a physical therapy clinic for an appointment, ask about the physical therapist's experience in helping people with ACL tears.

During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

  Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.

The following articles provide some of the best scientific evidence related to physical therapy treatment of ACL tears. The articles report recent research and give an overview of the standards of practice for treatment both in the United States and internationally. The article titles are listed by year and are linked either to a PubMed* abstract of the article or to free access of the full article, so that you can read it or print out a copy to bring with you to your health care provider.

Ritter RC, Axe MJ, Godges JJ, Logerstedt DS, Snyder-Mackler L. Knee stability and movement coordination impairments: knee ligament sprain. J Orthop Sports Phys Ther. 2010;40:A1-A37. Free Article.

Eitzen I, Moksnes H, Snyder-Mackler L, Risberg MA. A progressive 5-week exercise therapy program leads to significant improvement in knee function early after anterior cruciate ligament injury. J Orthop Sports Phys Ther. 2010;40:705-721. Free Article.

Risberg MA, Holm I. The long-term effect of 2 postoperative rehabilitation programs after anterior cruciate ligament reconstruction: a randomized controlled clinical trial with 2 years of follow-up. Am J Sports Med. 2009;37:1958-1966. Epub 2009 Jun 25. Free Article.

Hurd WJ, Axe MJ, Snyder-Mackler L. A 10-year prospective trial of a patient management algorithm and screening examination for highly active individuals with anterior cruciate ligament injury: Part 1, outcomes. Am J Sports Med. 2008;36:40-47. Epub 2007 Oct 16. Free Article.

Benjaminse A, Gokeler A, van der Schans CP. Clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis. J Orthop Sports Phys Ther. 2006;36:267-288. Article Summary on PubMed.

Hewett TE, Ford KR, Myer GD. Anterior cruciate ligament injuries in female athletes: part 2, a meta-analysis of neuromuscular interventions aimed at injury prevention. Am J Sports Med. 2006;34:490-498. Article Summary on PubMed.

Beynnon BD, Johnson RJ, Abate JA, Fleming BC, Nichol CE. Treatment of anterior cruciate ligament injuries, part 2. Am J Sports Med. 2005;33:1751-1767. Article Summary on PubMed.

Fitzgerald GK, Piva SR, Irrgang JJ. A modified neuromuscular electrical stimulation protocol for quadriceps strength training following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 2003;33:492-501. Article Summary on PubMed.

*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI).  PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.

Acknowledgement: Christopher Bise, PT, MS, DPT

Article originally appeared on http://www.apta.org/ (http://www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=d8e73ca8-71f4-48a7-92f8-675bca38232c)