Gabrielle OBrien

November 1, 2016
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Annotated Source List

ACL Tear. 2016. Pivot, Medbridge. Accessed 29 Oct. 2016.

This video describes how an anterior cruciate ligament tear may occur (jumping
or changing direction quickly on a planted foot), gives a brief anatomical description of
the knee, the functions of the knee, and the consequences of ACL injuries. Three bones
comprise the knee: the femur, tibia, and patella. Four ligaments connect the knee: one on
each side of the joint, and two between the tibia and femur (the anterior cruciate ligament
and the posterior cruciate ligament). The ligaments allow the knee to bend and twist
naturally. The ACL is more commonly injured than the PCL. If the ACL is partially or
completely torn, the tibia can slide forward past the femur, decreasing the stability of the
knee. PCL, meniscus (both medial and lateral), and collateral ligaments (both medial and
lateral) are also often injured along with the ACL. Physical therapy helps to restore
stability and function to the knee after ACL injuries, while reducing pain and swelling.
This video was recommended to me by my mentor and comes from the
Pivot/Medbridge website (a source I would not have been able to access had my mentor
not given me the login information). The video was intended for ACL tear patients to
watch to better understand their injury, so it is written in fairly simple terms. However,
this is still a very helpful source because it is a comprehensive overview of the anterior
cruciate ligament, its functions, and injuries that may affect it. This video is also useful
because it explains the anatomy of the knee, including some ligaments that I was not
previously aware of. Additionally because this source is a video, it is an effective way for
me to visualize the ACL and better understand it.

American Physical Therapy Association, 22 June 2016, www.apta.org/. Accessed 5 Oct.

2016.

The American Physical Therapy Association website provides an in depth

description of what the APTA does, what their vision is, careers in the field of physical
therapy, and the latest news/research in the world of physical therapy. The APTA is an
individual membership professional organization with over 93,000 members that strives
to advance physical therapy research, education, and practice. The website also lists
several careers for both physical therapists and physical therapists assistants as well as
potential settings for these jobs (hospitals, outpatient clinics, homes, sports training
facilities). In addition, the website describes the level of education required to become a
licensed physical therapist-- a graduate degree from an accredited physical therapy
program plus a passing score on the national licensure exam. The APTA also has an
online pamphlet named Guide To Physical Therapist Practice on their website which
outlines how the most effective patient care may be administered in physical therapy.
Under the News and Publications section of the APTA website are several articles
concerning modern research, new techniques, and the role of physical therapy in the
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national healthcare system. The website also has a link to the APTA Journal which is a
database that I can access for published research articles on many different areas of
physical therapy.
This source is useful to me because it comes from the main physical therapy
association in the United States. This website will be a good place for me to obtain
current information and to learn about new data found in studies throughout the year.
Also, the portion of the website devoted to careers in physical therapy will be an
excellent source to use to explore the different sectors of physical therapy and learn the
specifics of each one. This source will also be beneficial for me because APTA members
are primarily certified physical therapists so the information published on the website is
valid and can be referenced.

"Anterior Cruciate Ligament (ACL) Injuries." OrthoInfo, edited by Stuart J.

Fischer, American Academy of Orthopaedic Surgeons, Mar. 2014. Accessed 14
Oct. 2016.

This source is an overall description of the anterior cruciate ligament and the
injuries it most commonly sustains. The anterior cruciate ligament is one of the four
ligaments that connects the femur, tibia, and kneecap. Two of the other four ligaments in
this region are collateral ligaments that control sideways motion of the knee and brace it
against unusual movement. The other ligament is also a cruciate ligament and, with the
ACL, controls back and forth movement of the knee. The ACL, which runs diagonally in
the middle of the knee, also functions to prevent the tibia from sliding out in front of the
femur and provides rotational stability. Injuries to the ACL are graded on a scale, with 1
being the least severe and 3 being the most severe/most common. ACL injuries can be
caused by rapid changes of movement, sudden stops, deceleration, and direct contact.
Studies have shown that female athletes are more likely than male athletes to sustain ACL
tears due to differences in neuromuscular control, physical conditioning, pelvis/lower
extremity alignment, and the effect of estrogen on ligament properties. There are two
treatment options for ACL injuries: surgical (generally for younger athletes wishing to
return to sports) and nonsurgical (typically for older, less active patients). In nonsurgical
treatment, the torn ACL cannot be fully repaired, but the knee can still be
stabilized/strengthened through the use of a brace and physical therapy. Surgical
treatment includes reconstruction, during which the torn ligament is replaced with a
tissue graft (which can be obtained from a variety of sources). After the surgery, physical
therapy returns motion to the joint and surrounding muscles and then increases strength
by increasing stress to protect the ACL. The goal of physical therapy is to allow the
patient to resume pre-injury activities.
This source is very valuable to me because it gives me an overview of what the
anterior cruciate ligament is and what happens when it is injured. It is important for me to
have in-depth, background knowledge on the ligament because if I do not, I will not be
able to understand any of the research concerning ACL rehabilitation techniques that I
read. Becoming familiar with the function, anatomy, and terms concerning the ACL will
help me to fully comprehend not just research reports, but what my mentor tells me when
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he treats patients who have sustained ACL injuries. This source is also helpful to me
because it comes from an association of orthopedic surgeons. As patients often have
injuries severe enough to necessitate surgery, the fields of orthopedics and physical
therapy are closely related. Thus, to have a good understanding of physical therapy, I
must also be familiar with orthopedics.

"Anterior Cruciate Ligament Reconstruction Rehabilitation Protocol." Centers for

Orthopaedics. Accessed 18 Oct. 2016.

This source is a copy of the actual protocol for rehabilitation following anterior
cruciate ligament reconstruction from one of the largest physical therapy centers in
Maine, Ortho Access at the Centers for Orthopaedics. The protocol has different
procedures for different types of ACL surgeries, including anterior cruciate ligament
reconstruction with complex meniscus tear and anterior cruciate ligament reconstruction
with simple meniscus tear. The protocol includes the timeline that should be followed and
the specific exercises that the patient should complete. Within two to four weeks, the
patient should begin range of motion exercises (eg. passive stretching, wall/heel slides),
functional closed-chain exercises (modified lunges, mini squat, leg press), balance
exercises, core stability, stationary bike, and pool workouts. There are different
limitations depending on the type of graft that was performed. Within four to six weeks,
the intensity is increased and single-leg workouts are introduced (squats, weight
machines, step-downs). Within six to eight weeks, lateral training is introduced. Within
eight to ten weeks, lower ranges of motion are strengthened (30-80 degree knee flexion).
Home training programs are reviewed and continued. By fourteen weeks, the patient may
start jogging (assuming adequate quadriceps control). The patient must also pass a
functional test that consists of specific, standardized exercises. The protocols for the other
types of ACL surgeries are similar to this general protocol, with slight modifications.
This source is useful to me because it is extremely applicable. It lists several
examples of exercises that are used at an actual physical therapy clinic in Maine. While I
plan on also obtaining the protocol that Pivot would use for ACL reconstruction
rehabilitation, it is useful to establish a baseline and know the general exercises. It is also
helpful to become familiar with the type of language that is used throughout many of
these exercises. This source is also helpful because it provides a timeline of when each
new type of movement can be introduced and which treatments should be used. Knowing
the types of exercises that are generally used in rehabilitation and the timeframe in which
they occur is critical in understand how the anterior cruciate ligament is healed through
physical therapy.
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Chiaia, Theresa, and Polly De Mille. "ACL Injury Prevention Tips and Exercises:
Stay Off the Sidelines!" Hospital for Special Surgery, 24 Mar. 2009.
Accessed 18 Oct. 2016.

This source is a webpage taken from the Hospital for Special Surgery website and
was written by two physical therapists. The article, aimed at young athletes, describes
several exercises that can be done to increase body awareness, strength (especially in hips
and thighs), and balance in the knees and ankles. This will prevent anterior cruciate
ligament injuries by teaching athletes how to move with good alignment, protecting the
knees. The physical therapists also suggest always warming up and stretching before
games. Several exercises are described, all of which aim to improve flexibility, strength
(especially in core, hips, and legs), balance, agility, and ability to jump/land safely. The
exercises listed include squats, single leg deadlifts, walking lunges, planks, and four
different jump patterns around cones. It is also strongly recommended that the athlete rest
in order to prevent injuriesit is just as important to get a good nights sleep, take days
off, and alternate hard workouts with easy workouts.
This source is helpful to me because it gives examples of actual exercises that can
be done. If I see a patient at Pivot with an ACL injury, or even a patient that is believed to
be at risk for an ACL injury, I expect to see them perform many of these exercises so it is
good to be familiar with them beforehand. This article is also interesting to me because I
have done many of the exercises at soccer practices as part of an ACL injury prevention
program. In order for my project to focus on ACL tears, it is important that I balance
applicable sources like this with more recent research reports so that I can stay updated
with the latest information concerning the anterior cruciate ligament.

Chung, Eun Ji, et al. "A Biodegradable Tri-Component Graft for Anterior Cruciate
Ligament Reconstruction." Tissue Engineering and Regenerative Medicine, 21
Nov. 2014. Accessed 30 Oct. 2016.

This source is a research report for a study that was done to explore the possibility
of using a biodegradable and synthetic tri-component graft instead of an autograft in ACL
reconstruction. The reason for this is that, while these autografts do allow for superior
healing and anchoring through bone-to-bone regeneration, the autografts also have risks
such patellar rupture and donor site morbidity (complications in the healing process
caused by taking a source from a donor). The synthetic tri-component graft would not
have these problems. The novel graft was used to reconstruct the anterior cruciate
ligament of rabbits and within six weeks, all of the rabbits were weight-bearing and had
returned function to the knee. Thus, the study concluded that the tri-component graft is
promising strategy to regenerate the tissue types necessary for ACL repair and, with
future research, may be used as a graft in ACL reconstruction.
This source is unique because it focuses on the medical aspect of anterior cruciate
ligamentsthe actual reconstruction surgery. Also, it is the first study I have come across
that used animals as subjects instead of humans. The data found in this study could be
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critical in the future for developing a new, less risky way to repair the ACL. This source
is useful to me because it exposes me to a different part of the ACL repair process, which
helps me to gain a better understanding of the ligament as a whole.

Cordasco, Frank A., Dr. "Knee Arthroscopy for ACL Reconstruction, Meniscal
Repair, and Other Knee Problems." Hospital for Special Surgery, 20 Nov.
2009. Accessed 18 Oct. 2016.

This source is about a general procedure used to treat issues of the knee joint
(including anterior cruciate ligament tears) called knee arthroscopy. Knee arthroscopy is a
minimally invasive procedure in which the orthopedic surgeon makes small incisions in
the knee and then inserts a small camera (which projects images onto a screen) and fiber
optics to light the interior space. The first knee arthroscopy was completed in 1918 (albeit
without the fiber optics). The advantage of knee arthroscopy is to gain multiple views
inside the joint so that the patella does not have to be dislocated. Knee arthroscopy is
performed once the swelling has gone down and the patient has regained almost full
range of motion. The most common arthroscopy surgeries performed in the knee are to
repair the ACL and/or meniscus. This is because ACL injuries are often seen in
conjunction with meniscus tears as the injuries often occur at the same time and a torn
ACL leads to a greater risk of tearing the meniscus. Complete ACL tears are repaired
either with an autograft (tissue taken from patients own knee) or an allograft (tissue
taken from a cadaver or donor, used for older patients). Autografts are obtained from the
bone-patellar tendon-bone graft, hamstring tendon graft, or quadriceps tendon graft.
Depending on the sport, females are two to six times more likely to tear their ACL than
males. Most young athletes undergo ACL reconstruction surgery because if they do not,
they will experience persistent pain and instability and are more at risk for degenerative
arthritis.
This source is extremely helpful to me because it is an in depth description of
ACL reconstruction surgery. In order to have a holistic view on the anterior cruciate
ligament and the injuries it sustains, I want to look at, not just physical therapy, but every
part of the process. This means that I need information on the ACL itself, what happens
when it is injured, what causes it to sustain injuries, how it is repaired, and the
rehabilitation process. As I am particularly interested in ACL tears in female athletes, this
article is helpful in reiterating that females are significantly more likely than males to
injure their ACL. Although this article was written by an orthopedic surgeon, the
language used is fairly easy to comprehend and the process is logical.

Delapez, Matt. Interview. 26 Oct. 2016.

This interview was with Matt Delapez, a Physical Therapy Assistant at Pivot.
Matt has been with Pivot for three years. He attended Towson University for his
undergraduate degree, where he double majored in exercise science and sport
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management. Matt knew that he wanted to pursue a career in the medical field and picked
physical therapy because he wanted to be able to interact directly with patients and see
their daily progression. Matt was first exposed to physical therapy when he underwent
treatment for a fractured hand while he was attending Towson. What has surprised Matt
the most about physical therapy during his career has been the vast array of patients that
he has treated. For example, Matt held an internship in the neonatal intensive care unit
where he worked with premature babies, helping them tone their muscles and maintain
posture. During his undergraduate studies, Matt conducted much research, such as the
efficacy of dry needling versus manual therapy. He has also done research concerning
anterior cruciate ligament tears and suggested looking into Q angle differences as a cause
for females predisposition to injury. While working at Pivot, Matt is also taking classes
at Howard Community College and applying to graduate schools so that he may earn his
physical therapy degree.

DeLuca, Anthony J. "Treating Traumatic Injuries with Precision and Caution." The
American Chiropractor, vol. 37, no. 5, May 2015.

This article is about the most common types of injuries sustained from automobile
crashes and the appropriate physical therapy that patients must undergo to recover. As car
crashes are often at such a high velocity, the effects can be devastating and generally
involve the spinal and cervical regions. Specifically, patients often experience whiplash
and spinal cord compression. These conditions can be effectively treated through physical
therapy, specifically by chiropractors. The goal of this type of treatment is to increase
range of motion, reduce pain, and restore function to the neck and head region. To
achieve this, many different types of therapies are employed. For example, Trigger Point
Therapy is a technique in which a therapeutic massager applies direct pressure or
ischemic compression. During Acupressure, the doctor uses their thumb to apply pressure
to specific spots to increase or decrease blood flow in that area.
Physiotherapy uses muscle stimulation and ultrasound to reduce swelling and restore
musculoskeletal movement. The article also lists several exercises that the patient can do
at home (chin tilts, chin tucks, shoulder blade squeezes) and stresses the importance of
the exercises being done frequently, not just during therapy sessions.
This source is important to me as it shows that physical therapy can be used to
treat even the most serious of injuries, such as those caused by automobile crashes. This
article comes from The American Chiropractor magazine, which is written by and for
chiropractors. While my internship is not at a chiropractic firm, there are many patients
that come in with back and neck pain, and thus similar techniques are applied to them as
those that chiropractors use. This article is also helpful as it describes the overall goal of
physical therapy (to increase range of motion and reduce pain). While spinal injuries may
not pertain to my research project specifically, it is still useful to see specific techniques
and therapies used for these patients.
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Diehl, Lee. "Returning to Sports After ACL InjuryNot Just Physical." (2016).

This source focuses not on the actual anterior cruciate ligament itself or injuries to
the ligament, but on the process of beginning physical activity again. Specifically, the
article focuses on psychological barriers that may prevent athletes from returning to their
pre-injury level of activity. Studies have found that 1 in 3 athletes do not return to the
same level of competition after an ACL injury, despite being physically healthy. This is
because athletes often have a fear of re-injury, pain related fear of movement, and low
confidence in knee function. Some athletes, particularly those with a solid support system
(physical therapist, athletic trainer, strength/conditioning coach, and a position coach),
are able to overcome these fears. For those that do not have as much help, however,
techniques such as positive self-talk, relaxation, and appropriate goal setting can improve
adherence to rehab, reduce stress/anxiety, and improve self-efficacy.
This source is helpful to me because it is very current and gives a different
perspective on ACL injury. All of my other sources have focused on the physical aspects
of the anterior cruciate ligament, but in order for me to have a comprehensive
understanding of the ligament, I need to look at the mental aspects as well. Thus, this
source gives me a description of how a patients mentality may affect their recovery
process after an ACL tear. If the patient does not believe they will make a full
recovery/regain function in their knee, it could hold them back from sports, which could
in turn prevent them from strengthening the ACL. Therefore, an important part of the
recovery process is maintaining the patients self-confidence and reminding them to stay
positive.

Galland, Mark. "Preventing ACL Tears - Why Are ACL Tears More Common In Female
Athletes?" Orthopaedic Specialists of NC. Accessed 20 Oct. 2016.

This source describes why anterior cruciate ligament tears are more common in
female athletes than any other demographic. Theories that have been proposed are that
estrogen weakens the ligament, females have a wider pelvis which increases the stress put
on the ACL, and differences in females biomechanics. It is this last reason that Dr.
Galland believes puts females more at risk; females move differently than males. For
example, females knees are more turned in medially, females bend their knees less when
jumping/landing, and females jump/run with the soles of their feet in a more rigid
position, directed away from the bodys center of gravity. The best ways to offset these
predispositions to injury for females are a preventative rehabilitation program and
making a conscious effort to maintain a body position in which the knees and hips are
bent, weight is in the balls of the feet, and the chest is up.
This source is helpful to me in that it answers a question I have come across in my
research: why are females more at risk for ACL injury? Many sources I have seen have
stated there is no clear reason why (which is something I must consider when reading this
article as there is no research offered to support Dr. Gallands theory). However, the lack
of research supporting this theory is actually beneficial to me as it gives me a specific
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question to focus on and look for more in my future research. This source is also helpful
to me because it has the links to several other pages of information on the hip, knee,
spine, and sports medicine.

Geier, David, Dr., and Steven Kleinman. "Electrical Stimulation: Opinions of

Sports Medicine Experts." Sports Medicine Simplified, 23 June 2012.
Accessed 19 Oct. 2016.

This article is about electrical stimulation and its application as a treatment

option. Electrical stimulation is the use of an electrical current to cause an effect on the
tissue being targeted and can be used to address pain, inflammation, muscle spasm,
muscle atrophy, enhancing delivery of medicine through the skin, and healing skin
incisions or bone fractures. Electrical stimulation can work in many different ways,
including stimulating muscles to contract, stimulating nerves to decrease pain, increasing
blood flow (which speeds healing and reduces inflammation), and stimulating cells to
reproduce. Electrical stimulation can also be called Transcutaneous Electrical
Neuromuscular Stimulation. The article also states that electrical stimulation can be used
while the patient is exercising. The purpose of this is to stimulate weaker muscles to
contract, improving strength quicker/more efficiently. Electrical stimulation can also be
used in conjunction with heat or ice for pain relief.
This article is helpful to me in further explaining what electrical stimulation is,
how it works, and when it should be applied. Electrical stimulation is something that
nearly every patient at Pivot uses, and something that I regularly set up as an intern.
Therefore, it is important for me to have a thorough understanding of it. While I have
seen many of the techniques mentioned in the article, I am not familiar with the use of
electrical stimulation while a patient is moving. This article is reliable because it is
written both by an orthopedic surgeon/sports medicine specialist and by a physical
therapist.

Gerber, J. Parry, et al. "Effects of Early Progressive Eccentric Exercise on

Muscle Size and Function After Anterior Cruciate Ligament Reconstruction: A
1-Year Follow-up Study of a Randomized Clinical Trial." American Physical
Therapy Association, vol. 89, no. 1, Jan. 2009.

This source is a research report on the effect of a certain recovery method after
ACL repair surgery. The experiment was conducted on forty participants, twenty were in
the control group and the other twenty received the treatment. The treatment was early
progressive eccentric exercises that lasted 12 weeks (and began 3 weeks after surgery)
and the effect of the treatment was tested based on muscle size and function. The reason
the experiment was conducted was because there is a lack of rehabilitation techniques
immediately following anterior cruciate ligament reconstruction that safely overload
muscle to effectively minimize atrophy of the muscles. The early progressive eccentric
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exercises that were implemented were designed to control pain, regain full range of
motion of the knee, and attain muscle function. The results of the study showed that the
group of participants that received the treatment improved significantly more in muscle
volume of the quadriceps femoris and the gluteus maximus compared to the control
group. The results also showed that the treatment helped to increase hopping distance and
muscle strength. The results were obtained one year after patients had surgery.
This source is helpful to me for many reasons. First, it is a professional study that
was conducted on actual patients and a professional research report that was published in
the American Physical Therapy Association Journal. This is helpful to me because it
gives me exposure to papers on par with what I would read and with research that I
would conduct in the field of physical therapy. The source is also helpful to me in that it
is an in depth description of effective recovery techniques for anterior cruciate ligament
tears. The report also gives a general timeline of the recovery process following ACL
reconstruction surgery and provides detailed information regarding how the study was
conducted/how the results were measured.

Hafeez, Andeela, et al. "'Q' Angle." Edited by Venus Pagare. Physiopedia.

Accessed 27 Oct. 2016.

This source is a general description of the Quadriceps angle and how it is formed.
The Q angle is formed by a line representing the line of force of the quadriceps, made by
connecting a point near the anterior superior iliac spine (a bony projection of the iliac
bone near the base of the pelvis) to the mid-point of the patella. The Q angle can be
physically measured in a patient while the patient is standing with the knee near full
extension (but not hyperextended) using a piece of string and a protractor. The normal
score for females is between thirteen and eighteen degrees. An increase in Q angle
measure may be caused by femoral anteversion, external tibial torsion, laterally displaced
tibial tubercle, and gene valgum. Increases in Q angle may be harmful by causing an
increase in the compression of the lateral patella and influencing neuromuscular response
and quadriceps reflex response time.
This source is helpful to me because it explains what the Q angle is. I have seen
research about how females having a greater Q angle measure may be a factor in the
predisposition of females to ACL injuries, but I did not really understand what a Q angle
means. By knowing what the Q angle is and how it is measured, I will be able to better
understand the causes of ACL injuries. This source is also valuable because it lists related
research to the Q angle from the PubMed journal. For example, the article has a link to a
research report titled Do Lower-Body Dimensions and Body Composition Explain
Vertical Jump Ability? This could be a source for me to utilize in the future to further
research anterior cruciate ligament function.
Gabrielle OBrien
November 1, 2016
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Joseph, Darren. Interview. Oct. 2016.

My mentor, Darren Joseph, is a Doctor of Physical Therapy at Pivot Physical

Therapy in Clarksville, MD. He obtained his undergraduate degree from Oakwood
University in Huntsville, Alabama and then earned his Doctorate in Physical Therapy
from Andrews University in Berrien Springs, MI. Through internships in various settings,
including a hospital clinic, he has become familiar with many different types of physical
therapy. He is known for his strong interpersonal skills that make each session not only
effective but also enjoyable. My mentor has told me that because physical therapy can be
painful, it is important to keep the patient talking so they keep breathing. If they are not
breathing, the treatment is not as effective. As such, my mentor not only asks patients
how they are feeling, any differences theyve noticed with their body, etc. but also makes
a point of connecting with the patient, asking them about their hobbies, families, and
other personal questions. Three years ago when I was a patient, this helped me to relax
and prevented the physical therapy sessions from becoming something I dreaded. As an
intern, I have seen how establishing relationships with patients creates trust between the
therapist and patient so that the patient will push themselves further than they normally
would, ultimately speeding up the rehabilitation process.

Lee, Rick. "Why Physical Therapy Is Important After Surgery?" Benton Physical
Therapy, Accessed 22 Oct. 2016.

This article explains the importance of undergoing physical therapy after surgery
and the benefits it provides. While surgery provides major relief, physical therapy is
critical in keeping the recovery process moving forward. One benefit of physical therapy
after surgery is to regain mobility. Whether the patient is engaging in lighter activities
such as walking or running a marathon, physical therapy is the best way for the patient to
regain mobility as therapists will rehabilitate not only the surgery site, but also the
muscles and joints surrounding the site. Another benefit of physical therapy post-surgery
is that it speeds up the recovery process. Physical therapy also helps to minimize scar
tissue, allowing patients to rebuild healthy muscle.
This source is helpful to me in providing a broad perspective. This is because the
article does not focus on specific techniques or injuries, but explains why physical
therapy in general is helpful after surgery. Many of the patients that I have encountered at
Pivot have had surgery for a variety of reasons so this helps me understand how they got
there and the process they are going through now. This article is also helpful in reiterating
one of the things my mentor has repeatedly told methat the goal of physical therapy is
to regain motion. As range of motion can be severely limited due to surgery, it is
important that physical therapy works to restore motion.
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Luks, Howard J. "Physical Therapy and ACL Injuries: What You Dont Know Might
Hurt You." Howard J. Luks, MD., 9 Apr. 2014. Accessed 29 Oct. 2016.

This source explains the importance of physical therapy in the anterior cruciate
ligament repair process. The article explains that ACL reconstruction surgery will not be
effective if the patient does not undergo quality physical therapy. To ensure that the
physical therapy will be successful, the patient should pick a therapist who understands
the sport or activity they are trying to return to, has a step-by-step, personalized plan for
their rehab, account for psychological barriers/will help them feel normal back on the
field/court, and communicates with the surgeon. In addition to picking a good physical
therapist, it is also important for the patient to not rush back into their sport/activity. This
is because 70% of ACL injuries are non-contact, meaning that the reason for the injury
was the way the patient moved. It takes time to reteach a patient how to move properly
and develop healthy habits/techniques.
This source is helpful because it provides a general view on how to approach the
rehabilitation process as a patient. I have not been looking at any sources from the
patients view but I think it is important to because to be a good physical therapist, you
must understand the patient. This source is also useful because it reiterates many of the
findings that I have found from my previous research, such as there are often
psychological barriers that inhibit the patient and most ACL injuries are non-contact.

Ma, Benjamin C. "ACL Reconstruction." MedlinePlus, National Institute of

Health, 9 May 2015. Accessed 19 Oct. 2016.

This source describes the surgery performed to reconstruct the anterior cruciate
ligament after it has been torn. Knee arthroscopy is used to assist the surgeon in viewing
the joint better. Once the ACL has been located, it is first removed using a shaver. Then,
small tunnels are drilled into the bone to place the tissue through (either from a donor or
the patient themselves depending on if an allograft or autograft is being used). This tissue
takes the place of the ACL. The new ligament is attached to the bone with screws and the
bone tunnels are filled in as the incision heals. There are risks to the procedure, but they
are standard risks associated with most surgeries (blood clots, infection, injury to a
nearby blood vessel, allergic reaction to anesthesia). After the surgery, a knee brace and
crutches are generally used for one to four weeks. Patients then undergo physical therapy,
typically for four to six months.
This source is helpful to me in further explaining how anterior cruciate ligament
repair surgery works. While my previous source on ACL surgery focused on the knee
arthroscopy portion of the procedure, this source focuses on the actual replacement of the
ligament. This source is also helpful in giving a general overview of the entire surgical
process, including the prep and post-operation. The source does not give an in depth
description of how physical therapy helps ACL patients recover, but it does mention the
timeline (four to six months is generally required). Finally, this source is helpful because
it is more recent than my other sources concerning ACL reconstruction surgery.
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McDaniel, Larry W., et al. "Reducing The Risk Of ACL Injury In Female Athletes."
Contemporary Issues In Education Research, vol. 3, no. 3, Mar. 2010, pp.
15-20.

This article explains what the anterior cruciate ligament is, what happens when it
is injured, and why females are more likely than males to tear their ACL. The reasons this
source cites as making females eight times more likely than males are anatomical,
hormonal, biomechanical, and strength differences. Anatomically, females have wider
hips than males and their knees have a greater degree of extension than males. Females
also activate their hamstring less when decelerating than males do. Females also have
higher levels of estrogen and progesterone, especially during days 1 and 2 of the
menstrual cycle, which puts them more at risk for ACL injury according to a study done
in which 38 female athletes with ACL tears completed salivary sex hormone profiling.
The article also proposes that there may be a kinetic chain relationship between ACL
injuries and previous ankle injuries, suggesting that ACL prevention programs must
involve ankle strengthening/rehabilitation. Another important part of ACL injury
prevention is a proper warm-up program prior to exercise. This program must focus on
stretching, strengthening, and improving balance.
This source is helpful to me in continuing my focus on the anterior cruciate
ligament, and specifically why females are more at risk for ACL injury than males. By
repeating what I have already found in several other sources on reasons, this source gives
more credibility to certain theories. This source also includes scientific evidence and cites
research that has been done concerning females predisposition to ACL injury. For
example, this source cites research that supports the effect of fluctuating hormone levels
on ACL weakness. The source also cited data that supports the fact that females are
indeed more likely than males to tear their ACL. If I continue to focus on anterior
cruciate ligament injuries, this article will help me to support any claims/theories I
propose with actual data.

Nguyen, Anh-Dung, et al. "Relationships Between Lower Extremity Alignment and

the Quadriceps Angle." PubMed Central, 7 June 2010. National Center for
Biotechnology Information. Accessed 26 Oct. 2016.

This research, conducted at the Applied Neuromechanics Research Laboratory,

investigated the extent to which select lower extremity alignment characteristics of the
hip, pelvis, knee, and foot are related to the Q angle. The impact of the alignment of the
left lower extremity on the magnitude of the Q angle, so named because it is the
quadriceps angle, was studied in two hundred eighteen participants (one hundred and two
males and one hundred and sixteen females). It was found that the alignment of the knee
and hip is indeed associated with the Q angle in both males and females. Specifically, the
tibiofemoral angle and femoral anteversion most strongly resulted in a greater Q angle.
While the primary purpose of the study was not to find differences between males and
females, the study did suggest that females have a greater Q angle because they have
Gabrielle OBrien
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greater tibiofemoral angle and femoral anteversion compared to males. The study
concludes that, while the Q angle may not be a sufficient indicator of ACL injuries by
itself, a combination of static alignment characteristics increase the knee valgus (joint is
twisted outward from the body) and rotational position that commonly cause ACL
injuries.
This source is useful to me in further exploring anterior cruciate ligament injuries.
As it is an actual research report, much of the language is advanced and difficult to
understand. However while this makes the report harder to read, it is also beneficial in
familiarizing me with the language used in the scientific community. Like most research,
this study is unable to draw concrete conclusions due to a multitude of factors that could
have affected the process and inconclusive data. The researchers are still able to draw
theories, some of which are supported by data. The report also cites several other studies
that have been done on the cause of ACL injuries and evaluates the validity of each of
these studies. Because all questions were not answered in the research, the report
suggests several areas of study that should be explored in the future to gain a better
understanding of the subject.

Osborne, Maria. "Why Do Females Injure Their Knees Four to Six Times More Than
MenAnd What Can You Do About It?" Women's Integrated Services in
Health, July-Aug. 2012, pp. 1-6.

This source, written by physical therapist Maria Osborne at the University of

Colorado Hospital, is about why females are more likely than men to injure their knees.
In addition to explaining what the anterior cruciate ligament is and how it can be injured,
the article states that there is a four to six fold greater incidence of ACL injuries in female
compared to male athletes playing the same sport. There are several reasons for this
discrepancy. First, females use their quadriceps muscle a great deal more than their
hamstring muscle when decelerating from a sprint, creating instability in the knee. Males,
however, use their hamstring muscle more than their quadriceps when decelerating,
allowing the hamstring to absorb the change in speed. Additionally, using video
sequences of ACL injuries in female athletes, doctors have determined four common
motor components that lead to improper body mechanics: the knees buckle inward when
landing from a jump, the injured knee is straight, most to all of the weight is on one leg,
and the trunk tends to be tilted laterally. Females are also more at risk due to the larger
fluctuation of estrogen and relaxin, which influences the function of the nerves and
muscles. The article states that there is not sufficient evidence to support the theories that
footwear and anatomy factor into risk for ACL injury. The source also describes
prevention techniques, such as the ACL Risk Reduction program (which there is a link to
a video for), and the FIFA 11+ program (a 15 minute warm-up program that focuses on
agility, landing techniques/plyometrics, and core strength). The source also explains
several different treatment options and the advantages/disadvantages to each.
While the treatment options described in this source are similar to those I have
found in many other sources, the reasons females are more at risk and the prevention
techniques are unique. Thus, this article is helpful to me in providing me with more
Gabrielle OBrien
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information on the anterior cruciate ligament, and more specifically, why females are
more at risk for ACL injuries than males. It was also helpful to see some of the
techniques researchers used to gain data and form their theories (such as using video
sequencing). This source is also useful because it has a link to a video that goes through
the ACL Risk Reduction program so that I can see how the exercises are actually
supposed to be performed instead of just reading about it. This article also described a
new neuromuscular training program I had not previously seen, the FIFA 11+ program.

Owen, Jessica L., et al. "Is there evidence that proprioception or balance training can
prevent anterior cruciate ligament (ACL) injuries in athletes without previous
ACL injury?" American Physical Therapy Association Journal, vol. 86, no. 10,
Oct. 2006.

This source uses the example of a collegiate level female soccer player to describe
the benefits of physical therapy in preventing anterior cruciate ligament injuries. Physical
therapy works in injury prevention through the use of muscle strengthening, increased
flexibility, and improved balance. Educating athletes on proper movement and bracing
can also be used to prevent ACL tears. The main focus of this particular source, however,
is the use of proprioception and balance training to prevent ACL injury. For the research,
proprioception was defined as the awareness of a body segments orientation and
movement. Balance training was defined to include exercises focusing on awareness of
posture and maintaining equilibrium without shifting support. The conclusion of the
research was that while there was not strong evidence directly proving the effectiveness
of proprioception and balance training in ACL injury prevention, there was a decrease in
ACL injuries within the treatment group.
This source is helpful to me in demonstrating a research study that has already
been done on anterior cruciate ligament injuries. The article also describes specific injury
prevention techniques that I was not previously aware of. In addition, the article cites
several other articles that relate to ACL injuries, which I may use as future sources. This
source also serves as a model that I can reference for writing a professional research
paper.

"Physical Therapy." Funk & Wagnalls New World Encyclopedia (2016): 1p. 1.
Funk & Wagnalls New World Encyclopedia. Web. 23 Oct. 2016.

This source is a general description of physical therapy as a whole. It gives a

definition of physical therapy (scientific physical procedures used to treat patients with a
disability, disease, or injury to achieve and maintain functional rehabilitation and to
prevent malfunction or deformity). The article also gives the potential locations of
physical therapy clinics (hospitals, nursing homes, schools, and rehabilitation centers).
The types of treatment commonly used in physical therapy are manual muscle testing,
electrical testing, perceptual/sensory testing, and measuring the range of motion. As the
Gabrielle OBrien
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goal of physical therapy is to allow the patient to return to their normal activities (be it at
a high level, such as competitive sports, or at a lower level, such as walking up stairs in
the home), it is important that before treatment begins, an evaluation/functional activity
test is done to ascertain the patients capabilities. During treatment, patients are often
given cold packs (as in cryotherapy) or heat (through hot packs, ultrasonic waves, or
diathermy). To counter muscle atrophy and provide pain relief, electrical stimulation may
be applied. Another critical part of treatment is exercises that increase coordination,
strength, endurance, and range of motion. The article also discusses the careers available
in the field of physical therapy and the licensing/education requirements that
accompanies them.
This source is helpful to me because it provides a broad view of physical therapy
and the techniques it employs. For example, it mentions electrical stimulation as a way to
provide pain relief and prevent atrophy. Electrical stimulation is something that is used
regularly at Pivot and something I almost always set up for patients every time I am
there. This article is also helpful to me because it reiterates the two main goals of physical
therapy: to increase strength and range of motion. I can use this source as an outline of
the process of physical therapy and as a definition for the field. Finally, because there are
so many different careers in physical therapy, this source conveniently has several of
them listed in one place.

Pivot Physical Therapy, Levlane, www.pivotphysicaltherapy.com/. Accessed 7 Oct. 2016.

The Pivot Physical Therapy website contains much information on the company
including the goals/mission of Pivot, different locations around the country, and various
physical therapy techniques employed by Pivot. The mission of Pivot is to provide
quality care for superior outcomes using reputable clinician. The definition of physical
therapy, according to Pivot, is the treatment or management of physical disability,
movement, malfunction, or pain by exercise, massage, aquatic therapy, etc., without the
use of medicine or surgery. While Pivot treats a wide range of patients and injures, the
company also provides highly specialized therapies such as dry needling (a technique
using a solid filament needle to by musculoskeletal specialists to treat muscle trigger
points in order to restore normal muscle and joint function), golf rehab, and lymphedema
(a therapy designed for cancer patients to address the swelling of soft tissues that result
from cancer-related surgeries). The website also has a blog portion called the
Newsroom in which current articles are shared concerning new studies in the field of
physical therapy, recent awards won by Pivot therapists, the expansion of Pivot on the
East Coast, and other stories relating to physical therapy.
This source is very valuable to me because it is the website of the physical
therapy firm I intern for. Knowing exactly how Pivot views their mission and
methodology helps me to better understand the company and the techniques I may see my
mentor use on patients. It is also beneficial for me to see the different therapies Pivot
offers as the particular office I work for does not offer all of them. Also, as I am not sure
which specific field of physical therapy I wish to enter, it is critical for me to know my
options. The Newsroom will be an extremely helpful asset for me as well. This is because
Gabrielle OBrien
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it has a lot of up-to-date research, studies, and events pertaining to physical therapy. This
will help me stay current in what is happening in the field of physical therapy and alert
me to potential research topics.

Porucznik, Mary Ann. "Athletes Risk Second ACL Injury After ACL Reconstruction."
American Academy of Orthopaedic Surgeons, Aug. 2013. Accessed 27 Oct.
2016.

This source is a clinical publication in the American Academy of Orthopaedic

Surgeons journal that describes the increased risk of knee re-injury especially for females.
Citing a study conducted by Mark V. Paterno, the source states that the overall rate of
another injury to the ACL (in the same or opposite knee) within 2 years is six times
greater for athletes who have undergone ACL reconstruction than those who have never
had an ACL injury. The study also found that females are twice as likely to injure the
opposite knee if they have had ACL reconstruction. The study was conducted on 78
patients (59 female and 19 male) and 47 control athletes who had never had an ACL tear.
The significance of this study is that it highlights the need to re-examine current
rehabilitation and return to sport protocols following ACL injuries.
This source is helpful to me because it focuses on a different part of anterior
cruciate ligament injuriesthe risk it puts athletes at for further injury. This is applicable
to physical therapy because if consistent trends are found of athletes re-injuring their
knees, then changes need to be made to the physical therapy treatment they are receiving.
This source is also useful because from the American Academy of Orthpaedic Surgeons,
which is a new journal that I can use for future sources because I subscribed to it (for
free).

Reid, Andrea, et al. "Hop Testing Provides a Reliable and Valid Outcome Measure
During Rehabilitation After Anterior Cruciate Ligament Reconstruction."
American Physical Therapy Association, vol. 87, no. 3, Mar. 2007.

This source is a report on a study conducted to determine the reliability and

longitudinal validity of hop testing as an outcome measure during rehabilitation after
anterior cruciate ligament reconstruction surgery. The study was conducted on forty-two
patients, all between ages fifteen and forty-five, who had received ACL reconstruction
surgery. Within twenty-two weeks prior to surgery, participants performed four hop tests
(tests differed in whether they tested distance, time, or both) four different times. In
addition to the hop tests, patients completed the Lower Extremity Functional Scale and a
global rating of change questionnaire. The results of the study showed that the hop tests
were a valid and reliable performance-based outcome measure, suggesting that hop tests
be used in future research and clinical practice.
This source is extremely helpful to me in my research concerning the anterior
cruciate ligament because it focuses not on rehabilitation techniques, but on ways to
Gabrielle OBrien
November 1, 2016
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measure the progress a patient has made. This is arguably even more important than
specific techniques because the only way the effectiveness of the techniques can be
measured is if there is a valid and reliable way to measure them. By proving that the hop
test is an outcome measure that produces consistent results, the data has a practical
application not just in research, but in physical therapy clinics themselves. This source is
also helpful to me in showing me a realistic example of physical therapy research.

Risberg, May Arna, et al. "Neuromuscular Training Versus Strength Training

During First 6 Months After Anterior Cruciate Ligament Reconstruction: A
Randomized Clinical Trial." American Physical Therapy Association, vol. 87,
no. 6, June 2007.

This report describes a study conducted to determine the effect of a six-month

neuromuscular training program versus a traditional strength training program following
anterior cruciate ligament reconstruction. The differences between the programs were
mainly the types of exercises each involved and the muscles they targeted. Seventy-four
subjects were split into the two training programs. The effect was measured using
standardized measures, including the Cincinnati Knee Score, visual analog scales, hop
tests, and isokinetic muscle strength. It was found that participants in the neuromuscular
training program improved considerably more than participants in the other group in the
Cincinnati Knee Score and visual analog scales. This indicated that future ACL
rehabilitation methods should include neuromuscular training. Prior to this study, there
was very little evidence and research concerning neuromuscular training programs and
strength training programs.
Although this source is slightly outdated, it is still beneficial in showing me
another example of research conducted concerning anterior cruciate ligament tears and
reconstruction. This study focused on two training programs and the differences between
them in their effect on recovery. By researching the types of ACL reconstruction
techniques, I am gaining a better understanding on the muscle itself and what happens
when it is damaged. This article was also from the American Physical Therapy
Association Journal, which is beneficial in itself by exposing me to the language used and
the types of research conducted in the field of physical therapy.

Sluka, Kathleen A., et al. "What Makes Transcutaneous Electrical Nerve

Stimulation Work? Making Sense of the Mixed Results in the Clinical
Literature." American Physical Therapy Association, vol. 96, no. 10, 11
July 2013.

This source excerpt from the American Physical Therapy Association journal is
about Transcutaneous Electrical Nerve Stimulation (TENS). Introduced in 1967, TENS is
an electrotherapeutic procedure that is used to control pain. The use of TENS has recently
come under much scrutiny as an effective procedure, but this article states that there are
Gabrielle OBrien
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many factors that were not adequately considered in the research that says TENS is
ineffective. First, the intensity of TENS must be taken into account-- at a low amplitude
TENS will have no effect, but at a strong (but still comfortable) amplitude TENS can
make a positive difference. Additionally, habituation must be taken into account. Even
during just one session, a patient can become used to TENS so that the level that used to
be strong enough no longer is strong enough. Thus the intensity must be adjusted
accordingly. TENS also must be used repeatedly to have a long lasting effect because
electrical stimulation reduces the central excitability of neurons and restores pain
inhibition. The frequency of the stimulation must also be taken into account as different
frequencies produce different results. The article concludes that further scrutiny of the
clinical literature is needed to calculate the effectiveness of TENS, but the treatment
should not be disregarded.
This source is useful to me because electrical stimulation is a very common part
of treatment techniques at Pivot and it is important for me to be familiar with how it
works and what different types of stimulation exist. I also want to be knowledgeable of
what I am doing and why I am doing it when I set up electrical stimulation for patients.
While this source is fairly recent (2013), it would be interesting for me to look at even
more recent research to see if a conclusion regarding TENS was universally met. This
source also helps me in providing an example of how, not clinical research, but secondary
research (looking through existing literature/research reports) may be conducted.

Trulsson, Anna, et al. "Altered Movement Patterns and Muscular Activity During
Single and Double Leg Squats in Individuals with Anterior Cruciate Ligament
Injury." BioMed Central, vol. 16, no. 28, 2015.

This source is a research report on a study done in which individuals with anterior
cruciate ligament injuries performed certain movements. Sixteen participants (ten of
whom were female) with unilateral ACL ruptures did single and double leg squats. The
movements were scored by Test for Specified Patterns and Surface Electromyography in
hip, thigh, and shank muscles. The reasoning behind this study was that individuals with
ACL injuries often show altered movement patterns, partly due to sensorimotor control.
The research found that there were deviations between movements of the injured and
non-injured side during single and double leg squats.Correlations were also found
between deviating muscular activity and specific altered movement patterns, suggesting
that altered sensorimotor control is an indication. The significance of this data was to
support the idea that quantitative assessments of altered movement patterns should be
considered in anterior cruciate ligament rehabilitation.
This research report is helpful to me in giving me further information on the anterior
cruciate ligament injuries and the rehabilitation process. This source not only produced
evidence supporting the correlation between ACL injury and altered movement, but also
explained why (altered sensorimotor control). This source is also useful to me because it
comes from a new journal (BioMed Central), which I have not used before. Therefore, I
can use it in the future to find more sources relating to the anterior cruciate ligament.
Finally, because this source is a formal research report, it helps me to see what a
Gabrielle OBrien
November 1, 2016
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professional study looks like, how the report is formatted, and the language that is
commonly used.

"You've Torn Your ACL. Now What?" Harvard Health Letter, Nov. 2010, pp. 4-5.

This article describes a study done in Sweden and Denmark in 2010 that followed
121 active young adults who tore their anterior cruciate ligament (ACL). Half of the
subjects were randomly assigned to treatment through physical therapy and surgery,
while the other half were assigned to treatment through just physical therapy (although
surgery was an option for them two years later). The study found that, after two years,
there was no substantial difference between the subjects who had and had not gotten
surgery. During surgery, the injured ACL is replaced with a piece of a tendon. Patients
often experience pain for days to weeks after surgery and generally take six months to be
active again. The significance of this study is that it is the first time there has been
definitive proof that surgery is not always necessary in treating ACL tears. Advantages to
avoiding surgery include a faster recovery, no risk of infection, and saving money. The
ACL, which is a band of tissue that stabilizes the knee, runs medial to the knee and
prevents the tibia from sliding past the femur. ACL tears are very common (about
200,000 happen per year in the US) and are caused by sudden changes of direction.
Young girls are most susceptible to ACL tears as increased estrogen levels and
differences in muscle strength/alignment loosen ligaments.
This article is extremely helpful to me as it gives me more information on a
subject I am very interested in, ACL tears. While the article is slightly outdated and
treatment techniques may have varied since then, the study it describes is still relevant.
Most patients with torn ACLs still seek out surgery as they feel it is necessary, however
this article proves it is not. This article is also useful to me as it provides a definition of
the anterior cruciate ligament and its function, and explains how it can be injured. This
gives me good background information on a very common type of injury that prompts
patients to see a physical therapist. This particular injury is also very interesting to me
because as a female soccer player, I have seen many people who have torn their ACLs
and witnessed their recovery.