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26.  CONSERVATIVE MANAGEMENT OF SPORTS HERNIA IN A PROFESSIONAL GOLFER: A CASE REPORT 
Study Design:
Case Report
Background
Activity‐limiting groin pain is relatively common in athletes who participate in sports which involve rapid or repetitive twisting, cutting, and/or kicking. Despite the reported prevalence of this condition in athletes, there is still much controversy as to the anatomical structures involved and most effective treatment approach. There is limited evidence favoring conservative management of sports hernia as opposed to surgical intervention in professional athletes, and there are no reports of sports hernia management in the professional golf population. The purpose of this case report is to describe the conservative management and decision making used with a professional golfer with symptoms consistent with a sports hernia which allowed for successful return to prior level of sport participation.
Case Presentation
The subject of this case report is a professional golfer who developed lower abdominal and groin pain after changes in conditioning routine. Clinical presentation was consistent with a diagnosis of sports hernia. Rehabilitation of this athlete included a structured core muscle retraining program which utilized a step wise progression through the neurodevelopmental sequence in order to allow for development of neuromuscular control and stability required for return to golf.
Outcome
This athlete was able to return to full golf participation after 13 physical therapy visits over 4 weeks.
Discussion
The available evidence supports surgical intervention over conservative management in the treatment of sports hernia in the athletic population. A structured and comprehensive rehabilitation program addressing core muscle weakness and contributing impairments adjacent to injury may be a beneficial treatment option prior to surgical repair potentially allowing return to sport in some athletes.
Levels of Evidence:
4
PMCID: PMC4223293  PMID: 25383252
conservative management; neuromuscular retraining; sports hernia
27.  HIP MUSCLE STRENGTH AND ENDURANCE IN FEMALES WITH PATELLOFEMORAL PAIN: A SYSTEMATIC REVIEW WITH META‐ANALYSIS 
Purpose/Background:
Patellofemoral pain (PFP) is a common knee conditions experienced by adolescents and young adults, seen particularly in women. Clinicians and researchers need to understand how proximal, local, or distal factors may influence the development of PFP and affect individuals once they have developed PFP. Proximal factors are the focus of recent studies and the purpose of this systematic review was to determine if females with PFP have hip muscle strength or endurance deficits when compared to their unaffected leg and to comparison groups.
Methods:
A systematic review was conducted to identify relevant studies in the databases PubMed, PEDro, ScienceDirect and EBSCOhost up to June 2013. Data including study design, participants demographic data, and assessments of hip muscle strength or endurance were extracted from individual trials. The mean differences of hip muscles strength or endurance between females with PFP and healthy controls or unaffected side were extracted or calculated from individual trials and, when possible, a meta‐analysis was performed.
Results:
Ten cross‐sectional studies were included in this review. Concerning isometric strength, pooled data reported deficit in hip abduction, extension, external rotation and flexion but no deficit in adduction and internal rotation when compared with healthy controls. When compared with the unaffected side, deficit in hip abduction was reported in two studies and deficit in extension and external rotation in one study. Studies with isokinetic strength evaluation reported deficit in abduction but contradictory results for extensors and rotators in females with PFPS. Finally, one study reported hip endurance deficit in extension and one found no significant differences in hip endurance compared to control subjects.
Conclusion:
The results of this systematic review confirm that females with PFPS have deficit in hip muscle strength compared with healthy controls and the unaffected side but are contradictory concerning endurance.
Level Of Evidence:
2a
PMCID: PMC4196322  PMID: 25328820
Endurance; Female; Hip; patellofemoral pain; strength
28.  INJURY RISK IS ALTERED BY PREVIOUS INJURY: A SYSTEMATIC REVIEW OF THE LITERATURE AND PRESENTATION OF CAUSATIVE NEUROMUSCULAR FACTORS 
Background:
Active adults commonly present with lower extremity (LE) injuries from a variety of professional and amateur sports activities. Decreased LE function significantly alters daily life and subsequent injuries increase this impact. The purpose of this systematic review was to examine the association between previous injury and the risk of re‐injury, and to describe the changes in kinematics and motor programming that may contribute to this relationship.
Methods:
A preliminary search was conducted to determine the four most common LE injuries on PubMed, CINAHL and Web of Science. These injuries, in a healthy active adult population, were hamstring strain (HS), anterior cruciate ligament injury (ACL), achilles tendon pathology, and ankle sprain. After these injuries were established, the search for this systematic review found evidence relating these injuries to re‐injury. Articles related to degenerative changes were excluded. Twenty‐six articles were included in the systematic review detailing the risk of re‐injury from a previous injury and were graded for quality.
Results:
ACL injury was linked to a successive injury of the same ACL, and other injuries in the LE. HS was associated with subsequent ipsilateral HS and knee injuries. Previous achilles tendon rupture increased the risk of an analogous injury on the contralateral side. An ankle sprain was associated with a re‐injury of either the ipsilateral or the contralateral ankle. Post‐injury changes were present in strength, proprioception, and kinematics, which may have led to overall changes in motor control and function.
Conclusion:
This review provides insight into the changes occurring following common LE injuries, how these changes potentially affect risk for future injury, and address the needs of the active adult population in rehabilitation.
Clinical Relevance:
Current research on previous injury and re‐injury is of high quality, but scarce quantity. Deficits following an injury are known, but how these deficits correlate or lead to re‐injury requires further exploration.
Level of Evidence:
1
PMCID: PMC4196323  PMID: 25328821
Injury; motor programming; re‐injury
29.  NORMATIVE DATA FOR HOP TESTS IN HIGH SCHOOL AND COLLEGIATE BASKETBALL AND SOCCER PLAYERS 
Purpose/Background:
Objective, reliable, and valid functional tests may assist with the decision‐making process for rehabilitation as well as assist in pre‐participation screening for targeted interventions to prevent noncontact lower extremity injuries. The purpose of this study was to determine normative values in high school and college basketball and soccer players for four hop tests: the single hop for distance, the triple hop for distance, the crossover hop for distance, and the 6‐m timed hop.
Methods:
A sample of convenience of 372 (185 females, 187 males) healthy high school and collegiate student‐athletes were included in the study (mean age 17.37 years, range 14‐24): 200 were soccer players and 172 were basketball players. Limb dominance was determined based on which extremity participants would choose to kick a ball for distance. A coin flip was used to determine which limb was tested first. Hop test order was randomized using a Latin square design. Participants performed one practice hop and three measured hops for each hop test on each limb. The average hop score for each limb was used for calculations.
Results:
Significant differences in test performance were found between sexes and levels of competition, p < 0.0005, with males performing better than females and collegiate athletes performing better than high school athletes for all hop tests. There were no clinically relevant differences between dominant sports. There were also no clinically relevant differences between dominant and non‐dominant limbs. Normative values for each hop test were proposed, based on sex and level of competition.
Conclusions:
These findings indicate that separate hop test standards should be used based on participant sex and level of competition. While some statistically significant differences were found between limbs, these differences did not appear to be functionally relevant. Further studies are needed to determine if sport‐specific normative hop test values should be utilized and to examine normal limb symmetry indices in specific populations.
Levels of Evidence:
2A
PMCID: PMC4196324  PMID: 25328822
ACL; return to sport; hop test; functional performance testing
30.  RELATIONSHIPS BETWEEN CORE ENDURANCE, HIP STRENGTH, AND BALANCE IN COLLEGIATE FEMALE ATHLETES 
Purpose/Background:
Lower extremity injuries such as Anterior Cruciate Ligament (ACL) tears remain a concern in collegiate female athletes. Core endurance and hip strength reportedly influence ACL and lower extremity injury risk. Good neuromuscular control, as measured by the Star Excursion Balance Test (SEBT) test is associated with decreased lower extremity injuries. The exact relationships between core endurance, hip strength, and balance (SEBT scores), and how they impact one another in the female collegiate athlete remain unclear. Thus, the purpose of this study was to investigate relationships between core endurance, hip strength, and balance in collegiate female athletes.
Methods:
Forty collegiate female athletes (19.6±1.1yrs, 163.1±7.8cm, 61.3±6.5kgs) performed the SEBT in anterior, posterolateral, and posteromedial directions bilaterally (% leg length), McGill's anterior, posterior, and left and right plank core endurance tests (seconds), and hip abductor, flexor, extensor, and external rotator isometric strength tests bilaterally (N) using handheld dynamometry. Pearson's product moment correlations examined relationships between core endurance, hip strength, and balance. A linear regression analysis examined whether core endurance and hip strength influenced balance (p≤0.05).
Results:
Anterior SEBT scores were fairly positively correlated with hip flexor and extensor strength. Posterolateral SEBT scores were fairly positively correlated with hip abductor, extensor, and flexor strength (p=0.02‐to‐0.004; r=0.26‐to‐0.45). Fair positive correlations existed between posterior core endurance and hip extensor strength bilaterally (right: p=0.02, r=0.37; left: p=0.003, r=0.47). Core endurance and SEBT scores were not correlated (p>0.05). Core endurance and hip strength did not influence SEBT scores (p=0.47).
Conclusions:
Overall, hip strength, but not core endurance was related to SEBT scores in collegiate female athletes. Females with greater hip flexor, extensor, and abductor strength also had better anterior and posterolateral SEBT scores. Having females participate in hip muscle strengthening programs may help improve their SEBT balance scores, as a measure of their neuromuscular control and influence their ACL and lower extremity injury risk.
Level of Evidence:
2b
PMCID: PMC4196325  PMID: 25328823
Anterior Cruciate Ligament (ACL); lower extremity; Star Excursion Balance Test (SEBT); trunk endurance
31.  SIDESTEP AND CROSSOVER LOWER LIMB KINEMATICS DURING A PROLONGED SPORT‐LIKE AGILITY TEST 
Background:
Non‐contact anterior cruciate ligament (ACL) injuries in athletes occur more often towards the end of athletic competitions. However, the exact mechanisms of how prolonged activity increases the risk for ACL injuries are not clear.
Purpose:
To determine the effect of prolonged activity on the hip and knee kinematics observed during self‐selected cutting maneuvers performed in a timed agility test.
Methods:
Nineteen female Division I collegiate soccer players completed a self‐selected cutting agility test until they were unable to meet a set performance time (one standard deviation of the average baseline trial). Using the 3D dimensional coordinate data the cut type was identified by the principle investigators. The 3D hip and knee angles at 32ms post heel strike were analyzed using a two‐factor, linear mixed model to assess the effect of prolonged activity and cut type on the recorded mean hip and knee angles.
Results:
Athletes performed either sidestep or crossover cuts. An effect of cut type and prolonged activity was seen at the hip and knee. During the prolonged activity trials, the knee was relatively more adducted and both the hip and knee were less flexed than during the baseline trials regardless of cut type. Regardless of activity status, during sidestep cuts, the hip was more internally rotated and abducted, and less flexed than during crossover cuts while the knee was more abducted and less flexed during the sidestep than crossover cuts.
Conclusions:
During a sport‐like agility test, prolonged activity appears to predispose the athlete to position their knee in a more extended and abducted posture and their hip in a more extended posture. This position has been suggested to place stress on the ACL and potentially increase the risk for injury. Clinicians may want to consider the effects of prolonged activity on biomechanical risk factors for sustaining ACL injuries in the design of intervention strategies to prevent ACL injuries.
Level of Evidence:
Level 4
PMCID: PMC4196326  PMID: 25328824
ACL injury; cutting; motion; knee
32.  COMPARISON OF ISOMETRIC ANKLE STRENGTH BETWEEN FEMALES WITH AND WITHOUT PATELLOFEMORAL PAIN SYNDROME 
Introduction:
Proximal and distal influences on the knee may be related as etiological factors of patellofemoral pain syndrome (PFPS). The distal factors include subtalar excessive pronation as well as medial tibia rotation, but no study has investigated whether ankle weakness could lead to alterations that influence the patellofemoral joint. Thus, the purpose of this study was to compare the ankle dorsiflexor and invertor muscles strength, as well as rearfoot eversion and the Navicular Drop Test (NDT) in females with PFPS to a control group of females of similar demographics without PFPS.
Methods:
Forty females, between 20 and 40 years of age (control group: n=20; PFPS group: n=20) participated. Rearfoot eversion range of motion and the NDT were assessed for both groups. The Numeric Pain Rating Scale and the Anterior Knee Pain Scale were used to evaluate the level of pain and the functional capacity of the knee during activities, respectively. Isometric ankle dorsiflexor and invertor strength was measured using a handheld dynamometer as the dependent variable.
Results:
The isometric strength of the dorsiflexor and invertor muscle groups in females with PFPS was not statistically different (P>0.05) than that of the control group. There was no statistically significant difference between groups for rearfoot eversion and NDT (p>0.05).
Discussion/Conclusion:
These results suggest that there is no difference between isometric ankle dorsiflexion and inversion strength, the NDT, and rearfoot eversion range of motion in females with and without PFPS.
Level of evidence:
3‐b
PMCID: PMC4196327  PMID: 25328825
Ankle; handheld dynamometer; knee; patella; strength
33.  THE EFFECT OF EXERCISE AND TIME ON THE HEIGHT AND WIDTH OF THE MEDIAL LONGITUDINAL ARCH FOLLOWING THE MODIFIED REVERSE‐6 AND THE MODIFIED AUGMENTED LOW‐DYE TAPING PROCEDURES 
Purpose/Background:
No evidence exits regarding the magnitude of the change in foot posture following the “modified reverse‐6” (MR6) taping procedure, either alone or in combination with the “low‐dye” (LD) taping technique. The purpose of this study was to investigate the change in the height and width of the midfoot after application of the MR6 and the MR6 plus the LD (MR6+LD) taping technique and determine how long those changes last.
Methods:
Eleven individuals (2 female and 9 male) were recruited for this study and were tested under each of two experimental conditions, the MR6 and the MR6+LD taping technique. The order of testing for the two conditions was randomly determined. For each condition, the height and width of the midfoot at 50% of each subject's foot length was initially measured and then again immediately following the application of the tape. These measurements were repeated four hours later immediately prior to running two miles on a treadmill, again immediately after running, and finally after another four hours.
Results:
The dorsal arch height increased significantly with both the MR6 and MR6+LD taping, but only the MR6+LD remained statistically greater after four hours, a bout of exercise and again at the end of the day. The mean width of the midfoot significantly decreased with both taping procedures. The change in the width of the midfoot remained significantly decreased in both taping conditions after exercise and throughout the day.
Conclusions:
Both taping procedures are able to significantly change the height and width of the medial longitudinal arch of the foot, but the change lasted longer when the two taping procedures were combined.
Levels of Evidence:
Level 3, Prospective Cohort Study
PMCID: PMC4196328  PMID: 25328826
Adhesive Taping; Durability; Foot and Ankle
34.  VALIDATION OF A NEW METHOD FOR ASSESSING SCAPULAR ANTERIOR‐POSTERIOR TILT 
Background:
Electromagnetic tracking systems have enabled some investigators and clinicians to measure tri‐planar scapular motion; yet, they are not practical and affordable options for all clinicians. Currently, the ability to affordably quantify scapular motion is limited to monitoring only the motion of scapular upward rotation, with use of a digital inclinometer.
Hypothesis/Purpose:
The objective of this study was to determine the criterion‐related validity of a modified digital inclinometer when used to measure the motion of scapular anterior‐posterior (AP) tilt.
Materials & Methods:
Thirteen volunteers, free from any history of shoulder injury, reported for a single testing session. Each subject underwent a brief shoulder and posture examination in order to confirm the absence of pathology. Subjects actively performed clinically relevant amounts of humeral elevation in the scapular plane while in a seated position. An electromagnetic tracking system (Ascension Technology, Burlington, VT) and a modified inclinometer (Pro 360, Baseline®, Fabrication Enterprises, White Plains, NY) were used to acquire scapular AP tilt over the same shoulder motions. Criterion‐related validity was determined using Pearson Product Moment correlations.
Results:
Correlation analyses revealed significant moderate to good associations (r = 0.63 to 0.86, p < 0.01) between scapular AP tilt measures obtained with a digital inclinometer and an electromagnetic tracking system.
Conclusions
A modified digital inclinometer is a moderately valid device to use for the quantification of scapular AP tilt. Further study is warranted to establish reliability and to validate use of the device in patients with shoulder injury or pathology. The modified inclinometer expands the clinician's ability to quantify scapular kinematic motion during the clinical evaluation and rehabilitation process.
Level of Evidence:
Level 3
PMCID: PMC4196329  PMID: 25328827
inclinometer; scapula; scapular kinematics shoulder; validity
35.  THE RELATIONSHIP BETWEEN GLENOHUMERAL JOINT TOTAL ROTATIONAL RANGE OF MOTION AND THE FUNCTIONAL MOVEMENT SCREEN™ SHOULDER MOBILITY TEST 
Purpose/Background:
Side to side asymmetry in glenohumeral joint rotation correlates with injury risk in overhead athletes. The purpose of the current study was to identify the relationship between side‐to‐side asymmetries in glenohumeral joint total rotational range of motion and shoulder mobility test scores from the Functional Movement Screen™ in collegiate overhead athletes. The authors hypothesized that asymmetries of > 10° in glenohumeral total rotation would not be associated with asymmetrical findings in the Functional Movement Screen™ (FMS) shoulder mobility test.
Methods:
Passive glenohumeral total rotational range of motion and the shoulder mobility test of the FMS were measured during pre‐participation examinations in 121 NCAA male and female Division II collegiate overhead athletes from varied sports. Passive shoulder range of motion was measured in supine at 90° of abduction, with the humerus in the scapular plane using two measurers and a bubble goniometer. A Pearson Chi‐square analysis, p<.05 was used to associate the presence of asymmetries in glenohumeral joint rotation and in the FMS shoulder mobility test in each subject.
Results:
40/114 (35.1%) athletes demonstrated asymmetries in total glenohumeral rotation. 45/114 (39.5%) athletes demonstrated asymmetries in the shoulder mobility test. Only 17 of the 45 subjects who demonstrated asymmetry on the shoulder mobility test also demonstrated glenohumeral joint rotation differences of > 10°. Athletes with asymmetries in rotation of > 10° were not any more likely to have asymmetries identified in the shoulder mobility test (95% CI=.555‐2.658, P=.627).
Conclusions
Glenohumeral joint range of motion is one of multiple contributors to performance on the FMS shoulder mobility test, and alone, did not appear to influence results. The FMS shoulder mobility test should not be used alone as a means of identifying clinically meaningful differences of shoulder mobility in the overhead athlete. Clinicians working with overhead athletes may consider using both assessments as a complete screening tool for injury prevention measures.
Level of Evidence:
Level 3
PMCID: PMC4196330  PMID: 25328828
functional movement asymmetry; Functional Movement ScreenTM; glenohumeral joint rotation; overhead athlete
36.  OHIO PHYSICAL THERAPISTS' ACCURACY IN IDENTIFYING ABNORMALITIES ON DIAGNOSTIC IMAGES WITH AND WITHOUT A CLINICAL VIGNETTE 
Background:
A strong understanding of diagnostic imaging has been advocated for physical therapists. There have been recent changes in physical therapy curricula and increased opportunities to utilize imaging during clinical practice
Purpose:
The aim of this study was to explore the ability of practicing clinicians to accurately identify selected musculoskeletal conditions on plain‐film radiograph (X‐ray), magnetic resonance imaging (MRI), and computed tomography scan (CT scan). Further, to determine whether improvements in identification of pathology occur when the clinical scenario is added to the imaging and whether there are related training/exposure factors.
Methods:
A cross‐ sectional electronic survey was sent out to physical therapists in the state of Ohio. Participants were asked to identify conditions (cervical fracture, anterior cruciate ligament tear, and avascular necrosis of the femoral head) first given diagnostic images only, and then given the images and a clinical scenario.
Results:
Eight hundred sixty‐six surveys of the 7537 sent out were eligible for analysis. With clinical scenarios, 61.3% of respondents were correct with the ACL injury identified on MRI, 36.4% for identification of the cervical spine fracture on CT and 25.6% for identification of avascular necrosis on plain film. The accuracy significantly improved (p<0.01) with the addition of the clinical information for all three of the diagnoses. The most remarkable improvement was seen with the AVN diagnosis on plain film radiograph (365.5% improvement), followed by the ACL injury on MRI (27.2% improvement) and cervical fracture diagnosis on CT scan (17.8% improvement). Finally, formal and informal training, board certification through the APTA and to a lesser extent, degree level, all improved diagnostic accuracy.
Conclusions:
A clinical scenario paired with images notably improved identification of pathology. Physical therapists were better at identifying the ACL pathology that was presented on MRI. This is a common diagnosis to physical therapists and was paired with a relatively common imaging modality. This study suggests that physical therapists can improve accuracy with identifying pathologies on diagnostic images through a physical therapy curriculum or post‐graduation through certifications and continuing education.
Level of Evidence:
Level 4
PMCID: PMC4196332  PMID: 25328830
certifications; degree; diagnostic imaging; education; survey
37.  UTILIZATION OF AUTOREGULATORY PROGRESSIVE RESISTANCE EXERCISE IN TRANSITIONAL REHABILITATION PERIODIZATION OF A HIGH SCHOOL FOOTBALL‐PLAYER FOLLOWING ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: A CASE REPORT 
Background and Purpose:
The Autoregulatory Progressive Resistance Exercise (APRE) model of periodization is an effective form of resistance training programming for short‐term training cycles in healthy athletic populations that has yet to be effectively described in literature in application for rehabilitation purposes. The purposes of this case report are to: 1) review the periodization concepts outlined in the APRE model, 2) to detail the use of the APRE periodization programming through the rehabilitation of a high school football player using the back squat exercise after anterior cruciate ligament reconstruction (ACLR) and 3), to examine the applicability of this method in the transitional period from skilled rehabilitation to strength and conditioning for which a current disconnect exists.
Case Description:
Starting at 20 weeks post‐operatively, a 17‐year‐old male high school football player recovering from ACLR was able to show a 10 lb daily average increase with the 10 RM protocol, a 6 lb daily average increase during the 6RM protocol, and a 6.3 lb average increase with the 3RM protocol.
Outcomes:
A two‐repetition maximum of 390 lbs was performed in the back squat at the conclusion of the program at 39 weeks post‐operatively.
Discussion:
The results of this case report strengthen the current limited knowledge regarding periodization during the later phases of rehabilitation and the transition back to sport participation time period, while at the same time providing new insights for future protocol considerations in rehabilitating athletes. The APRE method of periodization provides an individualized progressive resistive protocol that can be used to safely and effectively increase strength in both healthy populations and individuals recovering from injury during short‐term training cycles.
Levels of Evidence:
Therapy, Level 4‐Case report
PMCID: PMC4196333  PMID: 25328831
Back squat; periodization; physical therapy
38.  TREATMENT OF NONSPECIFIC THORACIC SPINE PAIN WITH TRIGGER POINT DRY NEEDLING AND INTRAMUSCULAR ELECTRICAL STIMULATION: A CASE SERIES 
Study Design:
Case Series.
Background and Purpose:
Myofascial trigger points (MTrPs) are a common occurrence in many musculoskeletal issues and have been shown to be prevalent in both subjects with nonspecific low back pain and whiplash associated disorder. Trigger point dry needling (DN) has been shown to reduce pain and improve function in areas such as the cervical and lumbar spine, shoulder, hip, and knee, but has not been investigated in the thoracic spine. The purpose of this case series was to document the use of DN with intramuscular electrical stimulation (IES) in subjects with nonspecific thoracic spine pain.
Case Description:
The subjects were both active duty military males aged 31 and 27 years who self‐referred to physical therapy for thoracic spinal pain. Physical examination demonstrated thoracic motor control dysfunction, tissue hypertonicity, and tenderness to palpation of bilateral thoracic paraspinal musculature in both subjects. This indicated the presence of possible MrTPs. Objective findings in the first subject included painful thoracic flexion and bilateral rotation in each of these planes of movement. Pain reduction was observed when postural demands of the spine and trunk musculature were reduced through positional changes. Patient 1 demonstrated pain with posterior to anterior (P/A) pressure at T9 to T12. The second subject had bilaterally limited and painful thoracic rotation actively with normal passive rotation and demonstrated pain with P/A pressure at T4 to T7.
Intervention:
The subjects were treated with DN and IES for a total of two visits each. DN was performed to paraspinal and multifidus musculature at the levels of elicited pain with P/A testing and IES set at a frequency level of 4 (1.5Hz) for 20 minutes.
Outcomes:
Subject 1 reported reduced pain with standing flexion from a 62mm VAS score on initial evaluation to 26mm at his second visit. Subject 2 reported being “quite a bit better” in symptoms on the GROC following his second treatment. His VAS score reported following weightlifting activities changed from 43mm on initial evaluation to 20mm at his second visit. Both subjects also demonstrated a 10 degree improvement in active thoracic spinal rotation (on the right for Subject 1 and bilateral for Subject 2) following their second treatment.
Discussion:
Both subjects demonstrated motor control dysfunctions and pain with P/A pressure in the thoracic spine. With the use of DN and IES, immediate reduction was seen in subject perceived symptoms, and pain free ROM was improved. Extended treatment and follow up was not plausible due to the high pace tempo and demands of their operational training schedule. With research indicating the influence of MTrPs on a multitude of musculoskeletal issues and the prevalence of thoracic spine pain, further research is indicated for examining the effects of DN and IES for motor control and painful conditions occurring in the thoracic spine.
Level of Evidence:
Level 4
PMCID: PMC4196334  PMID: 25328832
Dry needling; intramuscular electrical stimulation; myofasical trigger points; thoracic spine pain
39.  RETURN TO SWIMMING PROTOCOL FOR COMPETITIVE SWIMMERS: A POST‐OPERATIVE CASE STUDY AND FUNDAMENTALS 
A large percentage of swimmers report shoulder pain during their swimming career. Shoulder pain in swimmers has been attributed to duration of swim practice, total yardage, and break down in stroke technique. Rehabilitation programs are generally land‐based and cannot adequately address the intricacies of the swimming strokes. Return to swimming protocols (RTSP) that address progression of yardage are scarce, yet needed. The purpose of this clinical commentary is to familiarize the clinician with the culture and vernacular of swimming, and to provide a suggested yardage based RTSP for high school and collegiate level swimmers.
Level of Evidence:
5
PMCID: PMC4196335  PMID: 25328833
Freestyle stroke; technique; yardage
40.  KINESIOLOGY TAPING AND THE WORLD WIDE WEB: A QUALITY AND CONTENT ANALYSIS OF INTERNET‐BASED INFORMATION 
Background:
Due to limited regulation of websites, the quality and content of online health‐related information has been questioned as prior studies have shown that websites often misrepresent orthopaedic conditions and treatments. Kinesiology tape has gained popularity among athletes and the general public despite limited evidence supporting its efficacy. The primary objective of this study was to assess the quality and content of Internet‐based information on Kinesiology taping.
Methods:
An Internet search using the terms “Kinesiology tape” and “kinesiology tape” was performed using the Google search engine. Websites returned within the first two pages of results, as well as hyperlinks embedded within these sites, were included in the study. These sites were subsequently classified by type. The quality of the website was determined by the Health On the Net (HON) score, an objective metric based upon recommendations from the United Nations for the ethical representation of health information. A content analysis was performed by noting specific misleading versus balanced features in each website.
Results:
A total of 31 unique websites were identified. The majority of the websites (71%) were commercial. Out of a total possible 16 points, the mean HON score among the websites was 8.9 points (SD 2.2 points). The number of misleading features was significantly higher than the balanced features (p < 0.001). Fifty‐eight percent of sites used anecdotal testimonials to promote the product. Only small percentages of websites discussed complications, alternatives, or provided accurate medical outcomes. Overall, commercial sites had a greater number of misleading features compared to non‐commercial sites (p = 0.01).
Conclusions:
Websites discussing Kinesiology tape are predominantly of poor quality and present misleading, imbalanced information. It is of ever‐increasing importance that healthcare providers work to ensure that reliable, balanced, and accurate information be available to Internet users.
Level of Evidence:
IV
PMCID: PMC4196331  PMID: 25328829
Internet information; kinesiology tape; quality
41.  BEYOND STATISTICAL SIGNIFICANCE: CLINICAL INTERPRETATION OF REHABILITATION RESEARCH LITERATURE 
Evidence‐based practice requires clinicians to stay current with the scientific literature. Unfortunately, rehabilitation professionals are often faced with research literature that is difficult to interpret clinically. Clinical research data is often analyzed with traditional statistical probability (p‐values), which may not give rehabilitation professionals enough information to make clinical decisions. Statistically significant differences or outcomes simply address whether to accept or reject a null or directional hypothesis, without providing information on the magnitude or direction of the difference (treatment effect). To improve the interpretation of clinical significance in the rehabilitation literature, researchers commonly include more clinically‐relevant information such as confidence intervals and effect sizes. It is important for clinicians to be able to interpret confidence intervals using effect sizes, minimal clinically important differences, and magnitude‐based inferences. The purpose of this commentary is to discuss the different aspects of statistical analysis and determinations of clinical relevance in the literature, including validity, significance, effect, and confidence. Understanding these aspects of research will help practitioners better utilize the evidence to improve their clinical decision‐making skills.
Level of evidence:
5
PMCID: PMC4197528  PMID: 25328834
Clinical significance; evidence based practice; statistical significance
42.  ELEVATING QUALITY WITH MANDITORY USE OF STANDARD REPORTING GUIDELINES 
The Editorial staff of The International Journal of Sports Physical Therapy (IJSPT) is dedicated to the review, critical appraisal, and publication of high quality scientific and clinical research, systematic reviews, meta‐analyses, and case reports. As IJSPT progresses through its' ninth year of providing high quality research evidence as well as relevant clinical commentary and suggestions for the international sports physical therapy community, we offer the following editorial.
We, along with many other prestigious journals are committed to elevating the quality of published research related to disability and rehabilitation and agree to adherence to the following reporting guidelines, which will be required by IJSPT as of January 1, 2015. Many of these guidelines are all ready in place and have been implemented by IJSPT.
This Editorial is a reprint of a previously published Editorial in The Archives of Physical Medicine and Rehabilitation, and is used with permission. (http://dx.doi.org/10.1016/j.apmr.2013.12.010)
For citation purposes, please use the original publication details: Chan L, Heinemann AW, and Roberts J, Elevating the Quality of Disability and Rehabilitation Research: Mandatory use of the Reporting Guidelines. Archives of Physical Medicine and Rehabilitation, 2014: 95: 414‐417
PMCID: PMC4127503  PMID: 25133069
43.  THE VALIDITY OF 2‐DIMENSIONAL MEASUREMENT OF TRUNK ANGLE DURING DYNAMIC TASKS 
Purpose/Background:
Injury screening methods that use three‐dimensional (3D) motion analysis accurately predict the risk of injuries, yet are expensive. There is great need for valid, cost‐effective techniques that can be used in large‐scale assessments. Utilizing two‐dimensional (2D) measures of lateral trunk motion may identify athletes at risk for lower extremity injury. The purpose of this research was to determine the strength of the relationships between 2D and 3D calculations of lateral trunk angle for female athletes performing a single‐leg cross drop landing.
Methods:
Twenty‐one high‐school female volleyball players performed a single‐leg cross drop landing onto a force plate. The 3D angular trunk motion was calculated, and four different 2D measures of lateral trunk angle were calculated for both left and right landing leg. A one‐way multivariate analysis of variance was used to compare 2D measures to the 3D measurements, and Pearson correlations were used to determine the strength of these relationships.
Results:
The angle formed by the medial shoulder joint center, medial ASIS, and vertical line (LTA4) was similar to the 3D measures of lateral trunk angle during landing (r‐values ≥ 0.62; p‐values ≤ 0.003; mean differences, ‐1.0° to 1.2°).
Conclusions:
Given the recent focus on the role of the trunk in lower extremity injury, using the 2D LTA4 assessment may expand existing assessments into a composite model that can more accurately assess female athletes at risk for injury than models that do not include trunk analysis.
Clinical Relevance:
Existing models that enable clinicians to effectively identify female athletes at risk for lower extremity injury may be enhanced by including accurate assessments of lateral trunk motion.
PMCID: PMC4127504  PMID: 25133070
Female; kinematics; risk assessment; trunk displacement
44.  COMPARISON OF THE IMMEDIATE EFFECT OF DIFFERENT TYPES OF TRUNK EXERCISE ON THE STAR EXCURSION BALANCE TEST IN MALE ADOLESCENT SOCCER PLAYERS 
Purpose/Background:
Trunk exercises, such as trunk stabilization exercises (SE) and conventional trunk exercises (CE), are performed to improve static or dynamic balance. Recently, trunk exercises have also been often used as part of warm‐up programs. A few studies have demonstrated the immediate effects of SE and CE on static balance. However, immediate effects on dynamic balance are not yet known. Therefore, the purpose of this study was to compare the immediate effect of SE with that of CE on the Star Excursion Balance Test (SEBT).
Methods:
Eleven adolescent male soccer players (17.9 ± 0.3 years, 168.5 ± 5.4 cm, and 60.1 ± 5.1 kg) participated in this study. A crossover design was used, and each participant completed three kinds of testing sessions: SE, CE, and non‐exercise (NE). Experiments took place for three weeks with three testing sessions, and a 1‐week interval was provided between different conditions. Each testing session consisted of three steps: pretest, intervention, and posttest. To assess dynamic balance, the SEBT score in the anterior, posteromedial, and posterolateral directions was measured before and 5 minutes after each intervention program. The data of reach distance were normalized with the leg length to exclude the influence of the leg length on the analysis.
Results:
The SEBT composite score was significantly improved after the SE (p < 0.05) but did not change after the CE and NE (p > 0.05). Furthermore, in the SE condition, SEBT scores of the posterolateral and posteromedial directions were significantly improved at the posttest, compared with those at the pretest (p < 0.05).
Conclusions:
This study demonstrated the immediate improvements in the posteromedial and posterolateral directions of the SEBT only after the SE. This result suggests that the SE used in this study is effective in immediately improving dynamic balance.
Levels of Evidence:
3b
PMCID: PMC4127505  PMID: 25133071
Core training; dynamic balance; sit‐up; stabilization exercise
45.  EFFECTS OF POSTURAL CONTROL MANIPULATION ON VISUOMOTOR TRAINING PERFORMANCE: COMPARATIVE DATA IN HEALTHY ATHLETES 
Purpose/Background:
Visuomotor ability is an important parameter for neurologic function and effective sport performance. Adding a balance challenge during a structured eye‐hand coordination task, such as hitting lights on a light board (Dynavision™), has not been previously reported. Using Division I football players, the aim of this study was to determine normative data on a dual‐task performance regimen combining a visuomotor light board task with a balance task. The intent is to use such normative data and baseline data as part of a concussion management program.
Methods:
Division I college football team members, n=105, were consented. Subjects first performed Dynavision™ D2™ Visuomotor Training Device (D2™) eye‐hand coordination tasks, the A* and the RT; they then performed the same tasks with an added balance challenge, standing on a BOSU® ball.
Results:
Ninety‐four athletes completed the full testing procedure on the D2™ system. The mean score of the A* test was 93 ± 11.0 hits per minute; and the mean on the A* test with the added BOSU® balance challenge was 83.7 ± 9.2 hits per minute. The mean RT time was 0.33 ± 0.036 seconds. Mean reaction time increased to 0.38 ± 0.063 while the subject stood on the BOSU® ball. Performance on the D2™ A* and RT were both statistically significantly different in the dual task condition (p<0.05).
Conclusions:
Results show an approximate 10% decline in D2™ performance when healthy individuals stand on a BOSU® ball. From the data presented here, the authors determined that there is a 10% decrement in performance when one's balance is challenged on the BOSU® ball. A fall in performance of substantially greater than 10% may indicate abnormal vestibulocerebellar regulatory processing of balance and motion. Further research, using these normative data is needed to determine more specific parameters for definitions of impairment and return‐to‐play and if there is utility for such studies as part of a concussion management program.
Level of Evidence:
III
PMCID: PMC4127506  PMID: 25133072
Balance; postural control; vestibular; Dynavision™; concussion
46.  OFF‐SEASON TRAINING HABITS AND PRESEASON FUNCTIONAL TEST MEASURES OF DIVISION III COLLEGIATE ATHLETES: A DESCRIPTIVE REPORT 
Purpose/Background:
Division III (D III) collegiate coaches are challenged to assess athletic readiness and condition their athletes during the preseason. However, there are few reports on off‐season training habits and normative data of functional assessment tests among D III athletes. The purpose of this study was to examine off‐season training habits of D III athletes and their relationships to the standing long jump (SLJ) and single‐leg hop (SLH) tests.
Methods:
One‐hundred and ninety‐three athletes (110 females, age 19.1 ± 1.1 y; 83 males, age 19.5 ± 1.3 y) were tested prior to the start of their sports seasons. Athletes reported their off‐season training habits (weightlifting, cardiovascular exercise, plyometric exercise, and scrimmage) during the six weeks prior to the preseason. Athletes also performed three maximal effort SLJs and three SLHs.
Results:
Male athletes reported training more hours per exercise category than their female counterparts. Mean SLJ distances (normalized to height) were 0.79 ± 0.10 for females and 0.94 ± 0.12 for males. Mean SLH distances for female athletes' right and left limbs were 0.66 (± 0.10) and 0.65 (± 0.10), respectively. Mean SLH distances for male athletes' right and left limbs were 0.75 (± 0.13) and 0.75 (± 0.12), respectively. Several significant differences between off‐season training habits and functional test measures were found for both sexes: males [SLJ and weightlifting (p = 0.04); SLH and weightlifting (p = 0.04), plyometrics (p = 0.05)]; females [SLJ and plyometrics (p = 0.04); SLH and scrimmage (p = 0.02)].
Conclusion:
This study provides normative data for off‐season training habits and preseason functional test measures in a D III athlete population. Greater SLJ and SLH measures were associated with increased time during off‐season training.
Clinical Relevance:
The findings between functional tests and off‐season training activities may be useful for sports medicine professionals and strength coaches when designing their preseason training programs.
Level of Evidence:
4
PMCID: PMC4127507  PMID: 25133073
college; field test; functional test; single‐leg hop; standing long jump
47.  REDUCED HIP STRENGTH IS ASSOCIATED WITH INCREASED HIP MOTION DURING RUNNING IN YOUNG ADULT AND ADOLESCENT MALE LONG‐DISTANCE RUNNERS 
Study Design:
Controlled laboratory study.
Background and Purpose:
Anterior knee pain is one of the most common running symptoms reported in the literature. While the exact etiology is unknown, a lack of hip strength is suggested to contribute to abnormal running mechanics. The purpose of this research study was to evaluate the association between isokinetic hip strength and 3‐D running kinematics.
Methods:
33 male high school and collegiate cross country runners participated in this study. Peak isokinetic hip abductor and hip extensor strength were assessed. Each subject also completed a treadmill running protocol at a self‐selected speed (mean = 3.8 m/s). 3‐D kinematic data were collected at 240 Hz using a 10‐camera motion capture system. Pearson correlation coefficients were used to determine the relationship between hip strength and hip range of motion (ROM) during the stance phase of running (p<0.05).
Results:
Peak isokinetic hip extensor torque was inversely correlated with transverse plane hip ROM (r = −.387, p = .026) but was not significantly related to sagittal plane hip ROM or frontal plane hip ROM. Peak isokinetic hip abductor torque was inversely correlated with frontal plane hip ROM (r=−.462, p=.008) but was not significantly related to either sagittal plane hip ROM or transverse plane hip ROM. Peak isokinetic hip extensor torque and peak isokinetic hip abductor torque were not significantly related to knee kinematics in any plane.
Conclusions:
Peak isokinetic hip extensor torque and peak isokinetic hip abductor torque are associated with transverse plane and frontal plane hip kinematics, but not knee kinematics.
Levels of Evidence:
Level 3b
PMCID: PMC4127508  PMID: 25133074
cross country; hip strength; isokinetic testing; running biomechanics.
48.  PATELLOFEMORAL PAIN SUBJECTS EXHIBIT DECREASED PASSIVE HIP RANGE OF MOTION COMPARED TO CONTROLS 
Background:
Patellofemoral pain is a common condition without a clear mechanism for its presentation. Recently significant focus has been placed on the hip and its potential role in patellofemoral pain (PFP). The majority of the research has examined hip strength and neuromuscular control. Less attention has been given to hip mobility and its potential role in subjects with PFP.
Purpose/Aim:
The purpose of this study was to compare passive hip range of motion (ROM) of hip extension and hip internal and external rotation in subjects with PFP and healthy control subjects. The hypothesis was that subjects with PFP would present with less total hip ROM and greater asymmetry than controls.
Design:
Two groups, case controlled.
Setting:
Clinical research laboratory
Participants:
30 healthy subjects without pain, radicular symptoms or history of surgery in the low back or lower extremity joints and 30 subjects with a diagnosis of PFP.
Main Outcome Measures:
Passive hip extension, hip internal rotation (IR) and hip external rotation (ER). A digital inclinometer was used for measurements.
Results:
There was a statistically significant difference (p<0.001) in hip passive extension between the control group and the PFP group bilaterally. Mean hip extension for the control group was 6.8° bilaterally. For the PFP group, the mean hip extension was −4.0° on the left and −4.3° on the right. This corresponds to a difference of means between groups of 10.8° on the left and 11.1° on the right with a standard error of 2.1°. There was no statistically significant difference (p>0.05) in either hip IR or ER ROM or total rotation between or within groups.
Conclusions:
The results of this study indicate that a significant difference in hip extension exists in subjects with PFP compared to controls. These findings suggest that passive hip extension is a variable that should be included within the clinical examination of people with PFP. It may be valuable to consider hip mobility restrictions and their potential impact on assessment of strength and planned intervention in subjects with PFP.
Level of Evidence:
2b
PMCID: PMC4127509  PMID: 25133075
Hip; inclinometer; patellofemoral pain; passive range of motion
49.  EFFECT OF ANKLE BRACES ON LOWER EXTREMITY MUSCLE ACTIVATION DURING FUNCTIONAL EXERCISES IN PARTICIPANTS WITH CHRONIC ANKLE INSTABILITY 
Background:
Ankle bracing and rehabilitation are common methods to reduce the rate of recurrent ankle sprain in participants with chronic ankle instability (CAI). CAI participants utilize less muscle activity when performing functional exercises compared to healthy controls. The effect of ankle braces on muscle activity during functional exercises in participants with CAI has not been previously studied.
Purpose:
To determine the effect of bracing on motor output as demonstrated by surface EMG amplitudes in participants with CAI during single limb, eyes closed balance, star excursion balance, forward lunge, and lateral hop exercises.
Methods:
A descriptive laboratory study was performed. Fifteen young adults with CAI performed functional exercises with and without ankle braces while surface EMG signals were recorded from the tibialis anterior, peroneus longus, lateral gastrocnemius, rectus femoris, biceps femoris, and gluteus medius. The main outcome measures were normalized surface EMG amplitudes (root mean square area) for each muscle, muscles of the shank (distal three muscles), muscles of the thigh (proximal three muscles), and total muscle activity (all six muscles) of the lower extremity. A paired t‐test was performed for each dependent variable to compare conditions. The level of significance was set a priori at p ≤ 0.05 for all analyses.
Results:
During the forward lunge, bracing significantly reduced muscle activity pre‐initial contact in the lateral gastrocnemius and post‐initial contact in the peroneus longus. During the star excursion balance anterior reach the peroneus longus, lateral gastrocnemius, rectus femoris, and gluteus medius had significantly less muscle activity during braced trials. Bracing significantly reduced thigh and total muscle activity during the anterior reach and gluteus medius activity during the posterolateral reach. There were no differences between braced and unbraced conditions during the single limb eyes closed balance, star excursion balance posteromedial reach, or during lateral hop exercises.
Conclusions:
Clinicians should be aware of the decreased muscle activity that occurs during common rehabilitation exercises when patients with CAI complete those activities while wearing ankle braces.
Level of Evidence:
Level III
PMCID: PMC4127510  PMID: 25133076
Ankle brace; ankle sprain; therapeutic exercise
50.  THE EFFECTS OF CONVENTIONAL PHYSICAL THERAPY AND ECCENTRIC STRENGTHENING FOR INSERTIONAL ACHILLES TENDINOPATHY 
Study Design:
Single‐blind, randomized, clinical trial.
Background:
The effect of eccentric training for mid‐portion Achilles tendinopathy is well documented; however, its effect on insertional Achilles tendinopathy is inconclusive. The primary purpose of this study was to investigate the effect of eccentric training on pain and function for individuals with insertional Achilles tendinopathy.
Methods:
All patients received a 12‐week conventional strengthening protocol. Patients who were randomly assigned to the experimental group received additional eccentric exercises. Patients completed the Short Form‐36 Health and Bodily Pain Surveys, the Foot and Ankle Outcomes Questionnaire, and the Visual Analog Scale at initial evaluation, after 6 weeks of therapy, and at 12 weeks after therapy.
Results:
Thirty‐six patients (20 control and 16 experimental; average age 54 years; 72% women) completed the study. Both groups experienced statistically significant decreases in pain and improvements in function. No statistically significant differences were noted between the groups for any of the outcome measures.
Conclusion:
Conventional physical therapy consisting of gastrocnemius, soleus and hamstring stretches, ice massage on the Achilles tendon, and use of heel lifts and night splints with or without eccentric training is effective for treating insertional Achilles tendinopathy.
Level of Evidence:
Level 2
PMCID: PMC4127511  PMID: 25133077
Achilles tendinopathy; eccentric training; posterior heel pain

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