Context:Injuries of the first metatarsophalangeal (hallux MP) joint can be debilitating in the athletic population. Turf toe and plantar plate injuries are typically diagnosed similarly. However, variance in injury mechanism as well as compromised integrity of soft tissue and ligamentous structures make it difficult to accurately diagnose specific hallux MP injuries. Recent literature has supported the use of both radiographic imaging and the Lachman test as reliable indicators of joint instability in the presence of hallux MP injuries. To date, research supporting specific rehabilitation interventions and return-to-play decision making for hallux MP injuries has been limited to case studies and suggested guidelines from literature reviews. There is limited evidence suggesting specific criteria for surgical and nonsurgical decision making in conjunction with rehabilitation progressions to return an athlete to sport when managing hallux MP injuries.Evidence Acquisition:A literature search was performed using Medline, PubMed, and Google Scholar to find and review articles from 1970 to 2013 that addressed the basic anatomy of the plantar plate, injuries to this anatomical structure, and the evaluation, diagnosis, surgical and nonsurgical management, and rehabilitation of these injuries, specifically in the athletic population. Medical information for each case was gathered from electronic medical records from the individual athletes cited in this case series, which included imaging reports, rehabilitation documentation, and both evaluation and surgical reports. No statistical analysis was used.Study Design:Case series.Level of Evidence:Level 4.Results:Treatment plans for each case varied depending on surgical and nonsurgical intervention and rehabilitation outcomes. However, each athlete was able to return to sports-specific activities.Conclusion:Successful outcomes for hallux MP injuries are contingent on thorough evaluation, appropriate clinical decision making with regard to surgical versus nonsurgical treatment planning, and a multidisciplinary team approach for ensuring a safe return to sport.Strength-of-Recommendation Taxonomy (SORT):C.

Medical management of the circus performer encompasses a wide variety of multicultural, transdisciplinary and multifaceted decision-making considerations. There is a paucity of research evidence investigating both the unique diversity of skill sets and cultural considerations in addition to injury patterns of performers within the circus environment. Since a previously established framework for supporting the health and well-being of the circus performer across various aspects of medical management does not exist in the literature, most recommendations in this regard must come from practical experience working with this highly specialized performance athlete population. The purpose of this clinical commentary is to provide the reader with a greater understanding of the unique challenges associated with the medical management of performance artists and acrobats as well as recommendations for developing an integrated approach for mitigating injury risk within a highly specialized, diverse athlete population. Level of Evidence 5

Chronic ankle instability (CAI) is a common dysfunctional state in the basketball population accompanied by pain, weakness and proprioceptive deficits which greatly affect performance. Research evidence has supported the use of blood flow restriction (BFR) training as an effective treatment strategy for improving muscle strength, hypertrophy and function following injury in a variety of patient populations. In managing CAI, it is important to address proximal and distal muscle weakness, pain, and altered proprioception to reduce the likelihood of re-occurring ankle injury. The ability to mitigate acute and cumulative strength and muscle volume losses through the integration of BFR after injury has been supported in research literature. In addition, applications of BFR training for modulating pain, improving muscle activation and proximal muscle strength have recently been suggested and may provide potential benefit for athletes with CAI. The purpose of this clinical commentary is to discuss background evidence supporting the implementation of blood flow restriction training and use a theoretical model for managing CAI as well as to suggest novel treatment strategies using this method.

Neuroplasticity after anterior cruciate ligament (ACL) injury has lingering effects throughout rehabilitation and can influence reinjury risk upon returning to sport if not addressed. Various neural compensatory strategies have been identified following ACL injury, which appear to not be rectified with typical therapy. Thus, further consideration is warranted, addressing the neurophysiologic and neurocognitive aspects of injury when developing a rehabilitation program. Integration of external focus of control strategies, neurocognition, motor planning, unanticipated sensory processing, and load management provide an efficient and effective method for improving motor learning and control throughout the rehabilitation process. Rehabilitation exercises that incorporate unique sports-specific challenges can target the visual processing and anticipatory reaction components of motor control to reduce motor errors that increase injury risk when returning to activity. The neurocognitive demands of returning to sport of efficient decision making and motor patterning amid a rapidly changing competitive environment require novel and clinically implemental strategies.

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