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26.  POST OPERATIVE REHABILITATION OF GRADE III MEDIAL COLLATERAL LIGAMENT INJURIES: EVIDENCE BASED REHABILITATION AND RETURN TO PLAY 
The medial collateral ligament is the most commonly injured ligament of the knee, with injury generally sustained in the athletic population as a result of valgus contact with or without tibial external rotation. The capacity of the medial collateral ligament to heal has been demonstrated in both laboratory and clinical studies; however, complete ruptures heal less consistently and may result in persistent instability. When operative intervention is deemed necessary, anatomical medial knee reconstruction is recommended. Post-operative rehabilitation focuses on early motion and the return of normal neuromuscular firing patterns with progression based on attainment of specific phase criteria and goals. The purpose of this clinical commentary is to discuss the determinants of phase progression and the importance of objectively assessing readiness for advancement that is consistent with post-operative healing. Additional tests and validated measures to assess readiness for sport are also presented.
Level of Evidence
5
PMCID: PMC5159640  PMID: 27999730
Medial knee; medial collateral ligament; reconstruction; rehabilitation; return to sport; periodization
27.  CLINICAL COMMENTARY ON MIDFOOT AND FOREFOOT INVOLVEMENT IN LATERAL ANKLE SPRAINS AND CHRONIC ANKLE INSTABILITY. PART 2: CLINICAL CONSIDERATIONS 
Lateral ankle sprains (LAS) and chronic ankle instability (CAI) are common musculoskeletal injuries that are a result of inversion injury during sport. The midfoot and forefoot is frequently injured during a LAS, is often overlooked during clinical examination, and maybe contributory to the development of CAI. The purpose of part two of this clinical commentary and current concept review is to increase clinician's awareness of the contribution of midfoot and forefoot impairment to functional limitation and disability of individuals who experience LAS and CAI and to facilitate future research in this area. The importance of multisegmented foot and ankle assessment from a clinical and research perspective is stressed. Select physical assessment and manual therapeutic techniques are presented to assist the clinician in examination and treatment of the ankle-foot complex in patients with LAS and CAI.
PMCID: PMC5159641  PMID: 27999731
Gait; intrinsic foot muscles; joint mobilization; physical examination; rehabilitation
28.  FUNCTIONAL HOP TESTS AND TUCK JUMP ASSESSMENT SCORES BETWEEN FEMALE DIVISION I COLLEGIATE ATHLETES PARTICIPATING IN HIGH VERSUS LOW ACL INJURY PRONE SPORTS: A CROSS SECTIONAL ANALYSIS 
Background
Although functional tests including the single leg hop (SLH), triple hop (TH), cross over hop (COH) for distance, and the tuck jump assessment (TJA) are used for return to play (RTP) criteria for post anterior cruciate ligament (ACL) injury, sport-specific baseline measurements are limited.
Purpose
The purpose of this study was to examine differences in SLH, TH, and COH distance and limb symmetry index (LSI), as well as total scores, number of jumps, and individual flaws of the TJA in 97 injury-free Division I (DI) collegiate female student athletes participating in ACL injury prone vs. non ACL injury prone sports. The hypothesis was that significant mean differences and asymmetries (LSI) would exist between the two groups in SLH, TH, COH and TJA.
Study Design
Cross sectional.
Methods
Due to research suggesting inherent ACL injury risk associated with specific sport involvement, participants were grouped into high (HR, n=57) and low (LR, n=40) ACL injury risk based on participating in a sport with high or low ACL injury rates. The HR group was composed of athletes participating in soccer, basketball, and volleyball, while the LR group athletes participated in diving, cross country, and track and field. Participants performed all standard functional tests (SFT) and side-to-side differences for each participant as well as between group differences were assessed for the hop tests. The LSI, a ratio frequently used to gauge athletes’ readiness for RTP post injury, was also assessed for between group differences. The TJA was compared between the groups on individual flaws, overall scores, and number of jumps performed.
Results
No between group differences for hop distances were found, with medium to large effect sizes for SLH, TH, and COH. The HR group had a higher TJA score, number of jumps, and higher proportion of the flaw of ‘foot placement not shoulder width apart’.
Conclusion
Although most SFT's showed no significant differences between athlete groups, some differences were seen in the TJA; the HR group showed an increase in ‘foot placement not shoulder width apart’ flaw, higher overall flaw scores, and overall jumped more times compared to the LR group. These results may warrant caution in relying solely on SFT for RTP decisions, due to potential asymmetries seen in an uninjured population with baseline testing.
Level of Evidence
4
PMCID: PMC5095946  PMID: 27904796
Asymmetry; knee; return to play
29.  FUNCTIONAL OUTCOMES AFTER DISTAL BICEPS BRACHII REPAIR: A CASE SERIES 
Objectives
To investigate outcomes after surgical repair of distal biceps tendon rupture and the influence of arm dominance on isokinetic flexion and supination results.
Background/Purpose
While relatively uncommon, rupture of the distal biceps tendon can result in significant strength deficits, for which surgical repair is recommended. The purpose of this study was to assess patient reported functional outcomes and muscle performance following surgery.
Methods
A sample of 23 participants (22 males, 1 female), who had previously undergone surgical repair of the distal biceps tendon, were re-examined at a minimum of one year after surgery. Biodex isokinetic elbow flexion and supination testing was performed to assess strength (as measured by peak torque) and endurance (as measured by total work and work fatigue). The Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and Mayo Elbow Performance Scale (MEPS) were used to assess participants' subjectively reported functional recovery.
Results
At a mean of 7.6 years after surgical repair, there were no differences between the repaired and uninvolved elbows in peak torque (p = 0.47) or total work (p = 0.60) for flexion or supination. There was also no difference in elbow flexion work fatigue (p = 0.22). However, there was significantly less work fatigue in supination, which was likely influenced by arm dominance, as most repairs were to the dominant arm, F(1,22)=5.67, p = 0.03.
Conclusion
The long-term strength of the repaired elbow was similar to the uninvolved elbow after surgery to the distal biceps tendon. Endurance of the repaired elbow was similar in flexion but greater in supination, probably influenced by arm dominance.
Study design
Retrospective case series
Level of Evidence
Level 4
PMCID: PMC5095948  PMID: 27904798
Elbow; endurance testing; flexion; strength testing; supination
30.  THE EFFECTS OF INSTRUMENT ASSISTED SOFT TISSUE MOBILIZATION ON LOWER EXTREMITY MUSCLE PERFORMANCE: A RANDOMIZED CONTROLLED TRIAL 
Background
Instrument-Assisted Soft Tissue Mobilization (IASTM) is a non-invasive therapeutic technique used to theoretically aid in scar tissue breakdown and absorption, fascial mobilization, and improved tissue healing. Researchers have hypothesized that utilizing IASTM will improve muscular efficiency and performance; yet previous Investigations has been focused on treating injury.
Objective
The purpose of this investigation was to explore the effects of IASTM on muscle performance to assess if typical treatment application affected measures of muscular performance.
Design
A pretest-posttest randomized control design.
Participants
A convenience sample of 48 physically active adults (mean age 24 ± 4 years), randomly assigned to one of three groups: quadriceps treatment group, triceps surae treatment group, or control group.
Interventions
Participants performed a five-minute warm-up on a Monark bicycle ergometer before performing three countermovement vertical jumps (CMJ). Immediately after, the IASTM treatment was applied by one researcher for three minutes on each leg at the specified site (e.g., quadriceps) for those assigned to the treatment groups, while the control group rested for six minutes. Immediately following treatment, participants performed three additional CMJs. Pre- and post-testing included measures of vertical jump height (JH), peak power (PP) and peak velocity (PV).
Results
There were no statistically significant differences found between treatment groups in JH, PP, or PV or across pre- and post-test trials.
Conclusions
These preliminary findings suggest that standard treatment times of IASTM do not produce an immediate effect in muscular performance in healthy participants. This may help clinicians determine the optimal sequencing of IASTM when it is part of a pre-performance warm-up program. Future research should be conducted to determine the muscle performance effects of IASTM in individuals with known myofascial restriction and to determine optimal treatment parameters, such as instrument type, amount of pressure, and treatment time necessary to affect muscular performance.
Level of Evidence
1b
PMCID: PMC5159628  PMID: 27999718
Massage; myofascial release; instrument-assisted
31.  THE EFFECTIVENESS OF DRY NEEDLING AND STRETCHING VS. STRETCHING ALONE ON HAMSTRING FLEXIBILITY IN PATIENTS WITH KNEE PAIN: A RANDOMIZED CONTROLLED TRIAL 
Background
Recently, dry needling has emerged as a popular treatment for muscular pain and impairments. While there are numerous studies detailing the benefits of dry needling for pain, few studies exist examining the effects on soft tissue mobility.
Purpose
The purpose of this study was to determine if the addition of hamstring dry needling to a standard stretching program results in greater improvements in hamstring flexibility compared to sham dry needling and stretching in subjects with atraumatic knee pain. Additionally, squat range of motion, knee pain, and the Lower Extremity Functional Scale were compared between the two groups.
Study Design
Double blinded randomized controlled trial.
Methods
Thirty-nine subjects were randomized to receive either dry needling (n = 20) or sham (n = 19) dry needling in addition to hamstring stretching, to all detected hamstring trigger points on two visits. All dependent variables were measured at baseline, immediately post intervention, and 1, 3, and 7 days after the initial treatment. Each subject also performed hamstring stretching three times daily for one week.
Results
Significant improvements in hamstring range of motion and all other dependent variables were observed across time regardless of treatment group. However, the lack of significant time by group interactions indicated the improvements were not different between dry needling and sham dry needling groups.
Conclusions
The results of the current randomized controlled trial suggest that two sessions of dry needling did not improve hamstring range of motion or other knee pain-related impairments more than sham dry needling in a young active population with atraumatic knee pain.
Level of Evidence
Therapy, Level 2
PMCID: PMC5046961  PMID: 27757280
Flexibility; lower extremity; trigger point
32.  A DELPHI STUDY OF RISK FACTORS FOR ACHILLES TENDINOPATHY- OPINIONS OF WORLD TENDON EXPERTS 
Background and Purpose
Achilles tendinopathy can be a debilitating chronic condition for both active and inactive individuals. The identification of risk facors is important both in preventing but also treating tendinopathy, many factors have been proposed but there is a lack of primary epidemiological data. The purpose of this study was to develop a statement of expert consensus on risk factors for Achilles tendinopathy in active and sedentary patient populations to inform a primary epidemiological study.
Study design
Delphi study
Methods and Measures
An online Delphi study was completed inviting participation from world tendon experts. The consensus was developed using three rounds of the Delphi technique. The first round developed a complete list of potential risk factors, the second round refined this list but also separated the factors into two population groups – active/athletic and inactive/sedentary. The third round ranked this list in order of perceived importance.
Results
Forty-four experts were invited to participate, 16 participated in the first round (response rate 40%) and two dropped out in the second round (resulting in a response rate of 35%). A total of 27 intrinsic and eight extrinsic risk factors were identified during round one. During round two only 12 intrinsic and five extrinsic risk factors were identified as important in active/athletic tendinopathy while 14 intrinsic and three extrinsic factors were identified as important for inactive/sedentary tendinopathy.
Conclusions
Risk factors for Achilles tendinopathy were identified based on expert consensus, and these factors provide a basis for primary epidemiological studies. Plantarflexor strength was identified as the primary modifiable factor in the active/athletic group while systemic factors were identified as important in the inactive/sedentary group, many of the potential factors suggested for either group were non-modifiable. Non-modifiable factors include: previous tendinopathy, previous injury, advancing age, sex, steroid exposure, and antibiotic treatment.
Level of evidence
Level V
PMCID: PMC5046962  PMID: 27757281
Achilles tendinopathy; Delphi study; risk factors
33.  THE ADOLESCENT MEASURE OF CONFIDENCE AND MUSCULOSKELETAL PERFORMANCE (AMCAMP): DEVELOPMENT AND INITIAL VALIDATION 
Background
Although the relationship of self-efficacy to sports performance is well established, little attention has been paid to self-efficacy in the movements or actions that are required to perform daily activities and prepare the individual to resume sports participation following an injury and associated period of rehabilitation. There are no instruments to measure self-confidence in movement validated in an adolescent population.
Purpose
The purpose of this paper is to report on the development of the AMCaMP, a self-report measure of confidence in movement and provide some initial evidence to support its use as a measure of confidence in movement.
Methods
The AMCaMP was adapted from OPTIMAL, a self-report instrument that measures confidence in movement, which had been previously designed and validated in an adult population. Data were collected from 1,115 adolescent athletes from 12 outpatient physical therapy clinics in a single healthcare system.
Results
Exploratory factor analysis of the 22 items of the AMCaMP using a test sample revealed a three factor structure (trunk, lower body, upper body). Confirmatory factor analysis using a validation sample demonstrated a similar model fit with the data. Reliability of scores on each of three clusters of items identified by factor analysis was assessed with coefficient alpha (range = 0.82 to 0.94), Standard Error of Measurement (1.38 to 2.74), and Minimum Detectable Change (3.83 to 7.6).
Conclusions
AMCaMP has acceptable psychometric properties for use in adolescents (ages 11 to 18) as a patient-centric outcome measure of confidence in movement abilities after rehabilitation.
Level of Evidence
IV
PMCID: PMC5046963  PMID: 27757282
Adolescents; confidence; movement; rehabilitation; self-efficacy
34.  DIAGNOSTIC IMAGING IN A DIRECT-ACCESS SPORTS PHYSICAL THERAPY CLINIC: A 2-YEAR RETROSPECTIVE PRACTICE ANALYSIS 
Background
While advanced diagnostic imaging is a large contributor to the growth in health care costs, direct-access to physical therapy is associated with decreased rates of diagnostic imaging. No study has systematically evaluated with evidence-based criteria the appropriateness of advanced diagnostic imaging, including magnetic resonance imaging (MRI), when ordered by physical therapists. The primary purpose of this study was to describe the appropriateness of magnetic resonance imaging (MRI) or magnetic resonance arthrogram (MRA) exams ordered by physical therapists in a direct-access sports physical therapy clinic.
Study Design
Retrospective observational study of practice.
Hypothesis
Greater than 80% of advanced diagnostic imaging orders would have an American College of Radiology (ACR) Appropriateness Criteria rating of greater than 6, indicating an imaging order that is usually appropriate.
Methods
A 2-year retrospective analysis identified 108 MRI/MRA examination orders from four physical therapists. A board-certified radiologist determined the appropriateness of each order based on ACR appropriateness criteria. The principal investigator and co-investigator radiologist assessed agreement between the clinical diagnosis and MRI/surgical findings.
Results
Knee (31%) and shoulder (25%) injuries were the most common. Overall, 55% of injuries were acute. The mean ACR rating was 7.7; scores from six to nine have been considered appropriate orders and higher ratings are better. The percentage of orders complying with ACR appropriateness criteria was 83.2%. Physical therapist's clinical diagnosis was confirmed by MRI/MRA findings in 64.8% of cases and was confirmed by surgical findings in 90% of cases.
Conclusions
Physical therapists providing musculoskeletal primary care in a direct-access sports physical therapy clinic appropriately ordered advanced diagnostic imaging in over 80% of cases. Future research should prospectively compare physical therapist appropriateness and utilization to other groups of providers and explore the effects of physical therapist imaging privileging on outcomes.
Level of Evidence
Diagnosis, Level 3
PMCID: PMC5046964  PMID: 27757283
Diagnostic imaging; direct access; sports physical therapy
35.  THE RELATIONSHIP BETWEEN TRUNK ENDURANCE PLANK TESTS AND ATHLETIC PERFORMANCE TESTS IN ADOLESCENT SOCCER PLAYERS 
Background
Although it is believed that trunk function is important for athletic performance, few researchers have demonstrated a significant relationship between the trunk function and athletic performance. Recently, the prone plank and side plank tests have been used to assess trunk function.
Purpose
The purpose of this study was to investigate the relationships between trunk endurance plank tests and athletic performance tests, including whether there is a relationship between long distance running and trunk endurance plank tests in adolescent male soccer players.
Study design
Cross sectional study design.
Methods
Fifty-five adolescent male soccer players performed prone and side plank tests and seven performance tests: the Cooper test, the Yo-Yo intermittent recovery test, the step 50 agility test, a 30-m sprint test, a vertical countermovement jump, a standing five-step jump, and a rebound jump. The relationships between each individual plank test, the combined score of both plank tests, and performance tests were analyzed using the Pearson correlation coefficient.
Results
The combined score of plank tests was highly correlated with the Yo-Yo intermittent recovery test (r = 0.710, p < 0.001), and was moderately correlated with the Cooper test (r = 0.567, p < 0.001). Poor correlation was observed between the prone plank test and step 50 agility test (r = -0.436, p = 0.001) and no significant correlations were observed between plank tests and jump performance tests.
Conclusions
The results suggest that trunk endurance plank tests are positively correlated with the Yo-Yo intermittent recovery test, the Cooper test, and the step 50 agility test.
Level of Evidence
Level 2
PMCID: PMC5046965  PMID: 27757284
Agility; core strength; jump; long distance running; prone plank
36.  THE CLINICAL, FUNCTIONAL AND BIOMECHANICAL PRESENTATION OF PATIENTS WITH SYMPTOMATIC HIP ABDUCTOR TENDON TEARS 
Background
Hip abductor tendon (HAT) tearing is commonly implicated in greater trochanteric pain syndrome (GTPS), though limited information exists on the disability associated with this condition and specific presentation of these patients.
Purpose
To describe the clinical, functional and biomechanical presentation of patients with symptomatic HAT tears. Secondary purposes were to investigate the association between these clinical and functional measures, and to compare the pain and disability reported by HAT tear patients to those with end-stage hip osteoarthritis (OA).
Study Design
Prospective case series.
Methods
One hundred forty-nine consecutive patients with symptomatic HAT tears were evaluated using the Harris (HHS) and Oxford (OHS) Hip Scores, SF-12, an additional series of 10 questions more pertinent to those with lateral hip pain, active hip range of motion (ROM), maximal isometric hip abduction strength, six-minute walk capacity and 30-second single limb stance (SLS) test. The presence of a Trendelenburg sign and pelvis-on-femur (POF) angle were determined via 2D video analysis. An age matched comparative sample of patients with end-stage hip OA was recruited for comparison of all patient-reported outcome scores. Independent t-tests investigated group and limb differences, while analysis of variance evaluated pain changes during the functional tests. Pearson's correlation coefficients investigated the correlation between clinical measures in the HAT tear group.
Results
No differences existed in patient demographics and patient-reported outcome scores between HAT tear and hip OA cohorts, apart from significantly worse SF-12 mental subscale scores (p = 0.032) in the HAT tear group. Patients with HAT tears demonstrated significantly lower (p < 0.05) hip abduction strength and active ROM in all planes of motion on their affected limb. Pain significantly increased throughout the 30-second SLS test for the HAT tear group, with 57% of HAT tear patients demonstrating a positive Trendelenburg sign. POF angle during the test was not significantly associated with pain.
Conclusion
Patients with symptomatic HAT tears demonstrate poor function, and report pain and disability similar to or worse than those with end-stage hip OA. This information better defines and differentiates the presentation of these patients.
Level of Evidence
Level 3 case-controlled study, with matched comparison
PMCID: PMC5046966  PMID: 27757285
Assessment; clinical outcomes; hip abductor tears; patient presentation
37.  HIP AND GLENOHUMERAL PASSIVE RANGE OF MOTION IN COLLEGIATE SOFTBALL PLAYERS 
Background and Purpose
Range of motion deficits at the hip and glenohumeral joint (GHJ) may contribute to the incidence of injury in softball players. With injury in softball players on the rise, softball related studies in the literature are important. The purpose of this study was to examine hip and GHJ passive range of motion (PROM) patterns in collegiate softball players.
Hypothesis
It was hypothesized that the position players would exhibit significantly different PROM patterns than pitchers. Additionally, position players would exhibit significantly different side-to-side differences in PROM for both the hip and GHJ compared to pitchers.
Study Design
Prospective cohort study.
Methods
Forty-nine collegiate softball players (19.63 ± 1.15 years; 170.88 ± 8.08 cm; 72.96 ± 19.41 kg) participated. Passive hip and GHJ internal (IR) and external rotation (ER) measures were assessed. Glenohumeral PROM was measured with the participants supine with the arm abducted to 90 °. The measurements were recorded when the scapula began to move or a firm capsular end-feel was achieved. The hip was positioned in 90 ° of flexion and passively rotated until a capsular end-feel was achieved. Total PROM was calculated by taking the sum of IR and ER for both the hip and GHJ.
Results
No significant side-to-side PROM differences were observed in pitchers, at the GHJ or hip joint. Position players throwing side hip IR was significantly greater than the non-throwing side hip (p = 0.002). The non-throwing side hip had significantly greater ER compared to the throwing side hip (p = 0.002). When examining side-to-side differences at the GHJ, IR was significantly greater in the non-throwing shoulder (p = 0.047). No significant differences in total range of motion of the hip and GHJ were observed.
Conclusion
In the current study, position players displayed side-to-side differences in hip and GHJ IR PROM while no statistically significant differences were observed in the softball pitchers. The findings of the current study add to the body of literature related to PROM in throwing athletes, additionally these are the first hip IR and ER PROM data presented in softball players.
Level of Evidence
Level 3
PMCID: PMC5046967  PMID: 27757286
pitchers; position players; throwing; upper extremity
38.  ULTRASOUND MEASUREMENTS AND OBJECTIVE FORCES OF GLENOHUMERAL TRANSLATIONS DURING SHOULDER ACCESSORY PASSIVE MOTION TESTING IN HEALTHY INDIVIDUALS 
Background
Clinical examination of caspuloligamentous structures of the glenohumeral joint has historically been subjective in nature, as demonstrated by limited intra-rater and inter-rater reproducibility. Musculoskeletal diagnostic ultrasound was utilized to develop a clinically objective measurement technique for glenohumeral inferior and posterolateral translation.
Purpose
The purpose of this study was to measure the accessory passive force required to achieve end range glenohumeral posterolateral and inferior accessory translation, as well as, to quantify the amount of translation of the glenohumeral joint caused by the applied force.
Study Design
Cross-sectional descriptive correlational study
Methods
Twenty-five asymptomatic subjects between the ages of 18 and 30 were recruited via convenience sampling. Posterolateral and inferior shoulder accessory passive translation was assessed and measured using a GE LOGIQe ultrasound, while concurrently using a hand held dynamometer to quantify the passive force applied during assessment. Normative values for force and translation were described as means and standard deviations.
Results
Mean values for posterolateral translation were 6.5 +/− 4.0 mm on the right shoulder and 6.3 +/− 3.5 mm on the left with an associated mean force of 127.1 +/− 55.6 N and 114.4 +/− 50.7 N, respectively. Mean values for inferior translation were 4.8 +/− 1.7 mm on the right shoulder and 5.4 +/− 1.8 mm on the left with an associated mean force of 84.5 +/− 30.5 N and 76.1 +/− 30.1 N, respectively. There was a significant association between inferior translation and inferior force (r = .51). No significant association was found between posterolateral translation and posterolateral force. Significant differences were found between dominant and non-dominant shoulders for posterolateral translation, posterolateral force to produce translation, and inferior translation values.
Conclusions
Force data in the posterolateral and inferior direction is consistent with previously reported data for passive accessory motion testing at the shoulder. The results of this study provide data for glenohumeral translations and actual forces applied. Musculoskeletal diagnostic ultrasound can be a clinically relevant way to objectively measure the translation of the glenohumeral joint for assessing accessory passive motion joint translation while performing mobilizations or passive structure testing. This study provides a basis for comparison for healthy shoulder joints.
Level of Evidence
2b
PMCID: PMC5046968  PMID: 27757287
Diagnostic ultrasound; glenohumeral joint translation; handheld dynamometry
39.  CORRECTED ERROR VIDEO VERSUS A PHYSICAL THERAPIST INSTRUCTED HOME EXERCISE PROGRAM: ACCURACY OF PERFORMING THERAPEUTIC SHOULDER EXERCISES 
Background and Purpose
The accurate performance of physical therapy exercises can be difficult. In this evolving healthcare climate it is important to continually look for better methods to educate patients. The use of handouts, in-person demonstration, and video instruction are all potential avenues used to teach proper exercise form. The purpose of this study was to examine if a corrected error video (CEV) would be as effective as a single visit with a physical therapist (PT) to teach healthy subjects how to properly perform four different shoulder rehabilitation exercises.
Study Design
This was a prospective, single-blinded interventional trial.
Methods
Fifty-eight subjects with no shoulder complaints were recruited from two institutions and randomized into one of two groups: the CEV group (30 subjects) was given a CEV comprised of four shoulder exercises, while the physical therapy group (28 subjects) had one session with a PT as well as a handout of how to complete the exercises. Each subject practiced the exercises for one week and was then videotaped performing them during a return visit. Videos were scored with the shoulder exam assessment tool (SEAT) created by the authors.
Results
There was no difference between the groups on total SEAT score (13.66 ± 0.29 vs 13.46 ± 0.30 for CEV vs PT, p = 0.64, 95% CI [−0.06, 0.037]). Average scores for individual exercises also showed no significant difference.
Conclusion/Clinical Relevance
These results demonstrate that the inexpensive and accessible CEV is as beneficial as direct instruction in teaching subjects to properly perform shoulder rehabilitation exercises.
Level of Evidence
1b
PMCID: PMC5046969  PMID: 27757288
Exercises; shoulder; physical therapy; video
40.  SIXTY SECONDS OF FOAM ROLLING DOES NOT AFFECT FUNCTIONAL FLEXIBILITY OR CHANGE MUSCLE TEMPERATURE IN ADOLESCENT ATHLETES 
Background
Physiotherapists and other practitioners commonly prescribe foam rolling as an intervention, but the mechanistic effects of this intervention are not known.
Purpose
The aim of this investigation was to establish if a single bout of foam rolling affects flexibility, skeletal muscle contractility and reflected temperature.
Methods
Twelve adolescent male squash players were evaluated on two separate occasions (treatment and control visits) and were tested on both legs for flexibility of the hip flexors and quadriceps, muscle contractility (as measured by tensiomyography) and temperature of the quadriceps (assessed via thermography) at repeated time points pre- and post a 60s rolling intervention (pre-, immediately post, 5, 10, 15, and 30 minutes post). They rolled one leg on the treatment visit and did not perform rolling on the control visit.
Results
The main outcome measure was the flexibility of hip flexor and quadriceps at repeated time points up to 30 minutes post intervention. The average foam rolling force was 68% of subject's body weight. This force affected the combination of hip and quadriceps flexibility (p = 0.03; 2.4 degrees total increase with foam rolling) but not each muscle independently (p = 0.05 – 0.98) following a single 60s bout. Muscle contractility is not affected (p = 0.09 – 0.93) and temperature is not increased by foam rolling across time points (p = 0.19).
Conclusions
A single sixty-second bout of rolling applied to the quadriceps induces a small significant change in flexibility that is of little practical relevance, while muscle contractility and temperature remain unchanged. Investigation of larger doses of rolling is merited in athletic populations to justify current practice.
Level of Evidence
2c
PMCID: PMC5046970  PMID: 27757289
Adolescent; flexibility; tensiomyography; thermography
41.  BIPARTITE PATELLA IN 35-YEAR-OLD FITNESS INSTRUCTOR: A CASE REPORT 
Background and Purpose
The patella plays an important role in knee biomechanics and provides anterior coverage of the knee joint. One to two percent of the population has an anatomical variant of patella called a bipartite patella that usually does not case pain. However, occasionally after injury or overuse during sport it can be a source of anterior knee pain. The purpose of this case report was to present a rare variant of bipartite patella and highlight conservative treatment of this condition.
Study Design
Case Report
Case Description
A 35-year-old female patient presented with persistent bilateral non-traumatic anterior knee pain of a six-year duration that was enhanced by strenuous kinds of sport activity. Standard radiographs and MRI revealed the presence of bipartite patella with medial pole cartilage edema bilaterally. Conservative care including physical therapy, extracorporeal shock wave therapy (ESWT), and viscosupplementation was utilized.
Outcome
After treatment VAS decreased to 0/10 from 5/10 in the left knee and 1/10 from 5/10 in the right knee. The Kujala Scores improved after treatment to 100 and 95 for the left and right knees respectively. The subject returned to full sport activity and work as a fitness instructor without pain and limitations.
Discussion
This case describes a rare finding of bilateral medial bipartite patella and the successful use of physical therapy with viscosupplementation in patellar pain caused by bipartite patella. It also supports the use of Extra Corporeal Shock Wave Therapy in bipartite patella pain as a supplement for therapy.
Level of Evidence
4
PMCID: PMC5046971  PMID: 27757290
Anterior knee pain; bipartite patella; Magnetic resonance imaging
42.  MUSCULOSKELETAL SCREENING AND FUNCTIONAL TESTING: CONSIDERATIONS FOR BASKETBALL ATHLETES 
Background and Purpose
Youth participation in basketball is on the rise, with basketball one of the top five participation sports in Australia. With increased participation there is a need for greater awareness of the importance of the pre-participation examination, including musculoskeletal screening and functional performance testing as part of a multidisciplinary approach to reducing the risk for future injuries. As majority of all basketball injuries affect the lower extremities, pre-participation musculoskeletal screening and functional performance testing should assess fundamental movement qualities throughout the kinetic chain with an emphasis on lower extremity force characteristics, specifically eccentric loading tasks. Thus, the purpose of this clinical commentary is to review the existing literature elucidating pre-participation musculoskeletal screening and functional performance tests that can be used as a framework for rehabilitation professionals in assessing basketball athletes’ readiness to safely perform the movement demands of their sport.
Methods
Relevant articles published between 2000 and 2016 using the search terms ‘musculoskeletal screening’, ‘functional testing’, ‘youth athletes’, and ‘basketball’ were identified using MEDLINE. From a basketball-specific perspective, several relevant musculoskeletal assessments were identified, including: the Functional Hop Test Combination, the Landing Error Scoring System, the Tuck Jump Assessment, the Weight-Bearing Lunge Test, and the Star Excursion Balance Test. Each of these assessments creates movement demands that allow for easy identification of inefficient and/or compensatory movement tendencies. A basic understanding of musculoskeletal deficits including bilateral strength and flexibility imbalances, lower crossed syndrome, and dominance-related factors are key components in determination of injury risk.
Discussion
Assessment of sport-specific movement demands through musculoskeletal screening and functional performance testing is essential for rehabilitation professionals to determine movement competency during performance of fundamental movements related to basketball performance. Youth athletes represent a unique population due to their developing musculoskeletal and neuromuscular systems and should undergo pre-participation musculoskeletal screening for identification of movement limitations. Such an approach to musculoskeletal screening and functional performance may assist in identifying injury risk and also be useful at the end of rehabilitation in determining readiness to return to sport models.
Level of Evidence
Level 5
PMCID: PMC5046972  PMID: 27757291
Basketball; injury prevention; musculoskeletal screening; youth athletes
43.  A CLINICAL GUIDE TO THE ASSESSMENT AND TREATMENT OF BREATHING PATTERN DISORDERS IN THE PHYSICALLY ACTIVE: PART 1 
Background
Appropriate assessment and interventions for breathing patterns prior to assessment of the patient's musculoskeletal complaint may be beneficial. Breathing pattern disorders (BPDs) are remediable and influenced by biochemical, biomechanical, psychological, and/or unknown factors. The purpose of this clinical commentary is to demonstrate the integratration of a BPD assessment into a standard clinical musculoskeletal orthopedic examination.
Clinical Assessment
The observation of a patient's breathing pattern begins when they enter the clinic, is followed by palpation and orthopedic tests, which allows for proper classification of BPDs.
Outcomes
Disease-oriented measures guide the assessment and classification of BPD, while patient-oriented measures describe clinically important differences among patient values.
Classification
There are many possible variations of classifications of BPD, however, six primary dysfunctions found in the literature have become the foundation of the BPD assessment.
Discussion and Conclusion
Restoring proper breathing mechanics and neuromuscular motor control patterns during breathing may result in a decrease in pain, improved patient outcomes, and overall patient well being associated with their primary musculoskeletal complaint. A comprehensive evaluation of breathing patterns, as a part of an orthopedic examination, may guide a clinician in providing effective and appropriate treatments to decrease pain and improve function.
Level of Evidence
5
PMCID: PMC5046973  PMID: 27757292
Dysfunctional movement patterns; startle reflex; musculoskeletal pain
44.  PERTINENT DRY NEEDLING CONSIDERATIONS FOR MINIMIZING ADVERSE EFFECTS – PART TWO 
Background
Dry needling (DN) is an evidence based treatment technique that is accepted and used by physical therapists in the United States. This clinical commentary is the second in a two-part series outlining some of the pertinent anatomy and other issues that are needed for optimal utilization of this treatment modality. Part one was an overview of the thorax with a summary of reported adverse effects (AEs) and the underlying anatomy that could be used to minimize patient risk. As is the case with any intervention, the technique of dry needling has some inherent patient risk. The incidence of AEs with this procedure is typically low, ranging from zero to approximately 10 percent. Knowledge of the underlying anatomy can be a key factor associated with decreasing the likelihood of an AE.
Purpose/Objective
The second part of this clinical commentary goes beyond the thorax, to explore the anatomy associated with dry needling the abdomen, pelvis, and back. In the abdomen, pelvis and back, dry needling can penetrate the peritoneal cavity or adjacent organs, resulting in AEs. A physiological reaction that is an AE secondary to a needle insertion, pain or fear, is an autonomic vasovagal response. Additionally, suggestions for dealing with the fearful patient, the obese patient, universal precautions, and other clinical considerations, are discussed. The purpose of parts one and part two of this clinical commentary is to minimize the risk of a dry needling AE.
Conclusions/Implications
Dry needling is an effective adjunctive treatment procedure that is within the recognized scope of practice of the physical therapist. An evidence-based implementation of the procedure must be based on a thorough understanding of the underlying anatomy and the potential risks, with risks communicated to patients via informed consent.
Level of Evidence
Level 5
PMCID: PMC5046974  PMID: 27757293
Adverse effect; anatomy; dry needling; informed consent; pneumothorax; vasovagal response
45.  ULTRASONOGRAPHY, AN EFFECTIVE TOOL IN DIAGNOSING PLANTAR FASCIITIS: A SYSTEMATIC REVIEW OF DIAGNOSTIC TRIALS 
Background
Plantar fasciitis (PF) is the most common cause of heel pain that affects 10% of the general population, whether living an athletic or sedentary lifestyle. The most frequent mechanism of injury is an inflammatory response that is caused by repetitive micro trauma. Many techniques are available to diagnose PF, including the use of ultrasonography (US).
Purpose
The purpose of this study is to systematically review and appraise previously published articles published between the years 2000 and 2015 that evaluated the effectiveness of using US in the process of diagnosing PF, as compared to alternative diagnostic methods.
Methods
A total of eight databases were searched to systematically review scholarly (peer reviewed) diagnostic and intervention articles pertaining to the ability of US to diagnose PF.
Results
Using specific key words the preliminary search yielded 264 articles, 10 of which were deemed relevant for inclusion in the study. Two raters independently scored each article using the 15 point modified QUADAS scale.
Discussion
Six studies compared the diagnostic efficacy of US to another diagnostic technique to diagnose PF, and four studies focused on comparing baseline assessment of plantar fascia before subsequent intervention. The most notable US outcomes measured were plantar fascia thickness, enthesopathy, and hypoechogenicity.
Conclusion
US was found to be accurate and reliable compared to alternative reference standards like MRI in the diagnosis of PF. The general advantages of US (e.g. cost efficient, ease of administration, non-invasive, limited contraindications) make it a superior diagnostic modality in the diagnosis of PF. US should be considered in rehabilitation clinics to effectively diagnose PF and to accurately monitor improvement in the disease process following rehabilitation interventions.
Level of Evidence
1A
PMCID: PMC5048334  PMID: 27757279
plantar fascia; plantar fasciitis; ultrasound
46.  UTILIZATION OF ImPACT TESTING TO MEASURE INJURY RISK IN ALPINE SKI AND SNOWBOARD ATHLETES 
ABSTRACT
Background
While studies that have examined the prevalence of musculoskeletal injuries in alpine skiing and snowboarding exist, there has been no discussion of how neurocognitive deficits may influence such injuries. Recent authors have identified a possible link between Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) testing results and the prevalence of musculoskeletal injury in athletic populations. However, no study has specifically examined this in the alpine skiing and snowboard athletes who sustain injury and those that do not.
Hypothesis/Purpose
The purpose was to review injury data and ImPACT test results within the local ski/snowboard population to determine if there was a difference in components of ImPACT test scores between injured and non-injured athletes. It was hypothesized that differences would exist in component scores on ImPACT testing between injured and non-injured athletes.
Study design
Retrospective cohort study
Methods
Injury records and baseline ImPACT testing scores for 93 athletes aged 14-17 participating in a local ski and snowboard club during the 2009-2012 seasons were gathered retrospectively. Injuries documented for the lower and upper extremity included ligament sprains, muscle strains, contusions, dislocation/subluxation, fractures and concussions. Athletes who sustained any of these listed injuries were categorized within the injured athlete group. Each component of ImPACT test scores was compared between gender and for injury status within skiing and snowboarding disciplines using a series of two-way analysis of variance tests.
Results
There was no difference between non-injured and injured females as well as non-injured and injured males in reaction time and visual motor speed (VMS), however there was an interaction between gender and injury status on composite reaction time and visual motor speed, or VMS. The composite reaction time for females was 4.7% faster with injury while males without injury had a composite reaction time that was slower by 5.8%. Females had a 4.1% higher mean VMS score with injury while males had a 14.4% higher VMS score without injury.
Conclusion
Future research may consider prospectively examining neurocognitive testing scores and injury prevalence within the disciplines of snowboarding and both alpine and freestyle skiing.
Levels of Evidence
Level 3
PMCID: PMC4970840  PMID: 27525174
Musculoskeletal injury; neurocognitive deficits; neurocognitive testing
47.  THE EFFICACY OF AN EIGHT-WEEK CORE STABILIZATION PROGRAM ON CORE MUSCLE FUNCTION AND ENDURANCE: A RANDOMIZED TRIAL 
ABSTRACT
Background
Body armor is credited with increased survival rates in soldiers but the additional axial load may negatively impact the biomechanics of the spine resulting in low back pain. Multiple studies have found that lumbar stabilization programs are superior to generalized programs for patients with chronic low back pain. It is not known if such programs produce objective changes in trunk muscle function with wear of body armor.
Hypothesis/Purpose
An eight-week core stability exercise program would result in a larger improvement in physical endurance and abdominal muscle thickness than a control intervention. The purpose of this study was to assess the effectiveness of an eight-week core stability exercise program on physical endurance and abdominal muscle thickness with and without wear of body armor.
Study Design
Randomized controlled trial
Methods
Participants (N = 33) were randomized into either the core strengthening exercise group or the control group. Testing included ultrasound imaging of abdominal muscle thickness in hook-lying and standing with and without body armor and timed measures of endurance.
Results
There were statistically significant group by time interactions for transversus abdominis muscle contraction thickness during standing, both with (p = 0.018) and without body armor (p = 0.038). The main effect for hold-time during the horizontal side-support (p = 0.016) indicated improvement over time regardless of group. There was a significant group by time interaction (p = 0.014) for horizontal side-support hold-time when compliance with the exercise protocol was set at 85%, indicating more improvement in the core stabilization group than in the control group.
Conclusion
Performing an eight-week core stabilization exercise program significantly improves transversus abdominis muscle activation in standing and standing with body armor. When compliant with the exercises, such a program may increase trunk strength and muscle endurance.
Levels of Evidence
Therapy, Level 2b
PMCID: PMC4970841  PMID: 27525175
Body armor; lumbar stabilization; transversus abdominis
48.  A NEW CLINICAL MUSCLE FUNCTION TEST FOR ASSESSMENT OF HIP EXTERNAL ROTATION STRENGTH: AUGUSTSSON STRENGTH TEST 
ABSTRACT
Introduction
Dynamic clinical tests of hip strength applicable on patients, non–athletes and athletes alike, are lacking. The aim of this study was therefore to develop and evaluate the reliability of a dynamic muscle function test of hip external rotation strength, using a novel device. A second aim was to determine if gender differences exist in absolute and relative hip strength using the new test.
Methods
Fifty–three healthy sport science students (34 women and 19 men) were tested for hip external rotation strength using a device that consisted of a strap connected in series with an elastic resistance band loop, and a measuring tape connected in parallel with the elastic resistance band. The test was carried out with the subject side lying, positioned in 45 ° of hip flexion and the knees flexed to 90 ° with the device firmly fastened proximally across the knees. The subject then exerted maximal concentric hip external rotation force against the device thereby extending the elastic resistance band. The displacement achieved by the subject was documented by the tape measure and the corresponding force production was calculated. Both right and left hip strength was measured. Fifteen of the subjects were tested on repeated occasions to evaluate test–retest reliability.
Results
No significant test–retest differences were observed. Intra–class correlation coefficients ranged 0.93–0.94 and coefficients of variation 2.76–4.60%. In absolute values, men were significantly stronger in hip external rotation than women (right side 13.2 vs 11.0 kg, p = 0.001, left side 13.2 vs 11.5 kg, p = 0.002). There were no significant differences in hip external rotation strength normalized for body weight (BW) between men and women (right side 0.17 kg/BW vs 0.17 kg/BW, p = 0.675, left side 0.17 kg/BW vs 0.18 kg/BW, p = 0.156).
Conclusions
The new muscle function test showed high reliability and thus could be useful for measuring dynamic hip external rotation strength in patients, non–athletes and athletes. The test is practical and easy to perform in any setting and could therefore provide additional information to the common clinical hip examination, in the rehabilitation or research setting, as well as when conducting on–the–field testing in sports.
Level of evidence
3
PMCID: PMC4970842  PMID: 27525176
Dynamic test; hip external rotation; muscle strength; reliability
49.  COMPARISON OF RANGE OF MOTION, STRENGTH, AND HOP TEST PERFORMANCE OF DANCERS WITH AND WITHOUT A CLINICAL DIAGNOSIS OF FEMOROACETABULAR IMPINGEMENT 
ABSTRACT
Background
Dancers commonly experience anterior hip pain caused by femoroacetabular impingement (FAI) that interrupts training and performance in dance. A paucity of literature exists to guide appropriate evaluation and management of FAI among dancers.
Purpose
The purpose of this study was to determine if dancers with clinical signs of FAI have differences in hip range of motion, strength, and hop test performance compared to healthy dancers.
Study Design
Quasi-experimental, cohort comparison.
Methods
Fifteen dancers aged between 18- 21 years with clinical signs of FAI that included anterior hip pain and provocative impingement tests were compared to 13 age-matched dancers for passive hip joint range of motion, isometric hip strength, and performance of the medial triple hop, lateral triple hop, and cross-over hop tests.
Results
No statistically significant differences in range of motion were noted for flexion (Healthy = 145° + 7°; FAI = 147° + 10°; p=0.59), internal rotation (Healthy = 63° + 7°; FAI = 61° + 11°; p=0.50), and external rotation (Healthy = 37° + 9°; FAI = 34° + 12°; p=0.68) between the two groups. Hip extension strength was significantly less in the dancers with FAI (224 + 55 Newtons) compared to the healthy group (293 ± 58 Newtons; F(1,26) = 10.2; p=0.004). No statistically significant differences were noted for flexion, internal rotation, external rotation, abduction, or adduction isometric strength. The medial triple hop test was significantly less in the FAI group (354 ± 43 cm) compared to the healthy group (410 ± 50 cm; F(1,26) = 10.3; p = 0.004). Similar results were observed for the lateral hop test, as the FAI group (294 ± 38 cm) performed worse than the healthy controls (344 ± 54cm; F(1,26) = 7.8; p = 0.01). There was no statistically significant difference between the FAI group (2.7 ± 0.92 seconds) and the healthy group (2.5 ± 0.75 seconds) on the crossover hop test.
Conclusion
Dancers with FAI have less strength of the hip extensors and perform worse during medial and lateral hop triple tests compared to healthy dancers. Clinicians may use this information to assist in screening of dancers with complaints of hip pain and to measure their progress for return to dance.
Level of Evidence
3B, non-consectutive cohort study
PMCID: PMC4970843  PMID: 27525177
Dancers; femoroacetabular impingement; functional performance; hop test.
50.  THE EFFECT OF CONSERVATIVELY TREATED ACL INJURY ON KNEE JOINT POSITION Sense 
ABSTRACT
Background
Proprioception is critical for effective movement patterns. However, methods of proprioceptive measurement in previous research have been inconsistent and lacking in reliability statistics making it applications to clinical practice difficult. Researchers have suggested that damage to the anterior cruciate ligament (ACL) can alter proprioceptive ability due to a loss of functioning mechanoreceptors. The majority of patients opt for reconstructive surgery following this injury. However, some patients chose conservative rehabilitation options rather than surgical intervention.
Purpose
The purpose of this study was to determine the effect of ACL deficiency on knee joint position sense following conservative, non-operative treatment and return to physical activity. A secondary purpose was to report the reliability and measurement error of the technique used to measure joint position sense, (JPS) and comment on the clinical utility of this measurement.
Study Design
Observational study design using a cross-section of ACL deficient patients and matched uninjured controls.
Methods
Twenty active conservatively treated ACL deficient patients who had returned to physical activity and twenty active matched controls were included in the study. Knee joint position sense was measured using a seated passive-active reproductive angle technique. The average absolute angle of error score, between 10 °-30 ° of knee flexion was determined. This error score was derived from the difference between the target and repositioning angle.
Results
The ACL deficient patients had a greater error score (7.9 °±3.6) and hence poorer static proprioception ability that both the contra-lateral leg (2.0 °±1.6; p = 0.0001) and the control group (2.6 °±0.9; p = 0.0001). The standard error of the mean (SEM) of this JPS technique was 0.5 ° and 0.2 ° and the minimum detectable change (MDC) was 1.3 ° and 0.4 ° on asymptomatic and symptomatic subjects respectively.
Conclusion
This study confirms a static proprioceptive deficiency exists in the knee joint following ACL injury and rehabilitation, potentially due to a reduction in functioning mechanoreceptors in the ligament over time. The differences between the ACL deficient knee and the control group were above the SEMs and MDCs of the measurement which suggests clinical relevance. Longitudinal studies are needed to evaluate if patients who return to activity with a joint position sense deficiency develop secondary injuries.
Levels of Evidence
Individual Cohort Study (2b)
PMCID: PMC4970844  PMID: 27525178
Anterior cruciate ligament; joint position sense; knee

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