Background and Purpose:
Weight‐bearing foot structure may influence postural control by either decreasing the base of support (BOS) or increasing the passive instability of the joints of the foot. Poor postural control has been implicated as the main causative factor for foot and ankle injuries. The purpose of this study was to examine the influence of forefoot postures on postural stability during single limb stance.
Sixty healthy individuals between the ages of 18 to 31 were selected using a purposive sampling procedure based on forefoot angle measurements and categorized into three groups; high forefoot varus (≥8°) (n=20), neutral forefoot varus (1°‐8°) (n=20) and low forefoot varus group (≤1°) (n=20). Static foot measurements, including relaxed rearfoot angle and navicular drop, and foot dimentsions were performed. Height and weight were also recorded for all the subjects. Center of Pressure (COP) excursion in Anterior‐posterior (AP) and Medial‐lateral (ML) planes and Stability Index (SI) with eyes open and eyes closed conditions were also measured using the force platform.
Strong correlations were found between forefoot angle and rearfoot angle (r=0.71, p<0.01), forefoot angle and navicular drop (r=0.58, p<0.01), and between rearfoot angle and navicular drop (r=0.661, p<0.01). There were no correlations (p>0.05) between the forefoot angle and all the five COP measures, except between forefoot angle and SI with eyes closed (r= ‐0.25 p<0.01).
There is a significant positive correlation between forefoot angle and rearfoot angle and between forefoot angle and navicular drop. Forefoot angles did not affect the maximum AP COP and ML COP excursions or SI in healthy subjects.
Level of evidence:
Center of pressure; forefoot varus; navicular drop; postural control; rearfoot angle; stability index
Adherence to rehabilitation is widely accepted as vital for recovery and return to play following sports injuries. Medical management of concussion is centered around physical and cognitive rest, a theory largely based on expert opinion, not empirical evidence. Current research on this topic focuses on factors that are predictive of adherence to rehabilitation, but fails to examine if patient adherence leads to a better outcome. The purpose of this study was to determine the adherence tendencies of adolescents to treatment recommendations provided by a sports‐medicine physician after a concussion and to determine if adherence to each recommendation was a predictor of treatment duration.
Participants were enrolled in the study at their initial visit to the Sports‐Medicine Center for medical care after a sports‐related concussion. Individual treatment recommendations provided by a sports‐medicine physician for concussion were recorded over the course of each participant’s care. Once released from medical care, each participant was contacted to complete an online questionnaire to measure self‐reported adherence tendencies to each treatment recommendation. Adherence was measured by two constructs: 1) the reported receptivity to the recommendation and 2) the frequency of following the recommendation. Exploratory univariate Poisson regression analyses were used to describe the relationship between adherence behaviors and the number of days of treatment required before the participant was returned to play.
Fifty‐six questionnaires were completed, by 30 male and 26 female adolescent athletes. The self‐reported adherence tendencies were very high. None of the measures of adherence to the treatment recommendations were significant predictors of the number of days of treatment; however, there was a clear tendency in five of the six rest parameters (physical rest, cognitive rest with restrictions from electronics, and cognitive rest with restrictions from school), where high levels of adherence to rest resulted in an increased average number of days of treatment (slower recovery) and those who reported being less adherent recovered faster.
Adolescents were generally adherent to the physician recommendations. Those participants who reported being less adherent to physical and cognitive rest generally recovered faster than those who reported higher levels of adherence to these recommendations. As time progresses after the initial injury, physical and mental rest may be less effective to hasten recovery than more active treatment recommendations.
Level of evidence:
Adherence; adolescent; concussion; recovery; rest
Background and Purpose:
The purpose of this case report is to describe the clinical reasoning process involved with the differential diagnosis and management of a 69 year‐old male runner reporting a six month history of insidious onset of left sided low back and buttock pain of low to medium degree of irritability. The case presented describes the utilization of clinical reasoning by a clinician in fellowship training when a patient with atypical adverse neurodynamic dysfunction related to running was encountered.
The patient’s physical examination was relatively unremarkable. Assessment of the patient’s subjective history, self‐report measures [Oswestry Disability Index (ODI), global rating of change scale (GROC)], objective findings, and tests and measures led to a working diagnosis of atypical adverse peripheral neurodynamic dysfunction. The lumbar spine, sacroiliac joint, hip joint and lower extremity were ruled out by a comprehensive subjective and objective examination. The diagnosis of adverse neurodynamic dysfunction became a diagnosis of exclusion.
Returning two and a half weeks after initial evaluation the patient reported no pain with running. Twelve weeks after the initiation of physical therapy, the patient was contacted via email. He was sent, and asked to fill out an ODI. The patient demonstrated an improvement in ODI from 10% to 2%. He also reported that he continued to run after treatment without pain.
Determining the source of a patient complaint can occasionally be an arduous undertaking. Pathological sources of a patient’s symptoms may not be easily determined. Development of differential diagnosis and clinical reasoning skills is imperative. Improving clinical reasoning skills requires deliberate practice through reflective thinking before, during, and after patient interactions. Refinement of these skills leads to the primary goal of identifying the patient’s clinical presentation, thus matching it with the most effective treatment approach.
Level of evidence:
Differential diagnosis; nerve tension; physical therapy
Background and Purpose:
Lateral thigh pain, commonly referred to as greater trochanteric pain syndrome (GTPS) and/ or iliotibial band syndrome (ITBS) is commonly treated by the physical therapist. Lateral thigh pain is commonly treated by the physical therapist. The sources of lateral thigh pain are commonly attributed to GTPS and/ or ITBS though various pathologies may contribute to this pain, of which trigger points (TrPs) may be an etiology. Dry needling (DN) is an intervention utilized by physical therapists where a monofilament needle is inserted into soft tissue in order to reduce pain to improve range of motion/ motor control dysfunction. This can assist with facilitation of return to prior level of function. The purpose of this case report is to report the outcomes of a patient with lateral hip and thigh pain treated with DN as a primary intervention strategy.
The subject was an active 78‐year‐old female recreational walker who was referred to physical therapy for chronic left lateral hip and thigh pain of greater than one‐year duration without a clear mechanism of injury. She had a history of previous physical therapy treatment for the same condition, and previous therapeutic intervention strategies were effective for approximately two to three months duration prior to return of pain symptoms. Physical examination supported a diagnosis of GTPS/ ITBS. Subjective reports denoted sleep deficit due to pain lying on the left side at night and difficulty walking more than five minutes. Objective findings included decreased strength of the hip musculature and reproduction of pain symptoms upon flat palpation in specific locations throughout the lateral hip and thigh regions. She was treated for eight weeks using only DN to determine the effectiveness of DN as a primary intervention strategy, as previous physical therapy interventions were inconsistent and were only beneficial in the short‐term.
Clinically meaningful improvements were noted in disability and pain, as measured by the Lower Extremity Functional Scale and Quadruple Visual Analog Scale. Improvement in strength was not an objective measure being assessed, however, lower extremity strength improvement was noted upon final physical examination. This case report focused on pain reduction for improved function rather than strength improvement. Improvements in pain and disability were subjectively reported. The subject was able to lie on her left side at night, which improved her ability to sleep. She was also able to tolerate walking approximately twenty to thirty minutes for improved community ambulation needs.
This case report presents promising outcomes for the use of DN in the treatment of chronic lateral hip and thigh pain. Further research is recommended to determine if DN is clinically beneficial independent of other therapeutic interventions such as exercise, myofascial release/ massage, non‐thrust mobilization, or manipulation.
Level of evidence:
Dry needling; hip pain; iliotibial band; trochanteric bursitis
Despite recent advances in anterior cruciate ligament reconstruction (ACL) surgical techniques, an improved understanding of the ACL’s biomechanical role, and expanding research on optimal rehabilitation practices in ACL‐reconstructed (ACLR) patients, the re‐tear rate remains alarmingly high and athletic performance deficits persist after completion of the rehabilitation course in a large percentage of patients. Significant deficits may persist in strength, muscular activation, power, postural stability, lower extremity mechanics, and psychological preparedness. Many patients may continue to demonstrate altered movement mechanics associated with increased injury risk. The purpose of this clinical commentary and literature review is to provide a summary of current evidence to assist the rehabilitation professional in recognizing, assessing, and addressing factors which may have been previously underappreciated or unrecognized as having significant influence on ACLR rehabilitation outcomes.
A literature review was completed using PubMed, Medline, and Cochrane Database with results limited to peer‐reviewed articles published in English. 136 articles were reviewed and included in this commentary.
Barriers to successful return to previous level of activity following ACLR are multifactorial.Recent research suggests that changes to the neuromuscular system, movement mechanics, psychological preparedness, and motor learning deficits may be important considerations during late stage rehabilitation.
Level of evidence:
Level 5‐ Clinical Commentary
Anterior Cruciate Ligament (ACL); biomechanics; exercise; injury prevention; knee
Pitchers may be at greater risk of injury in comparison to other overhead throwing athletes due to the repetition of the pitching motion. It has been reported that approximately 30% of all baseball injuries occur in the lower body. This may be related to limited hip mobility, which can compromise pitching biomechanics while placing excessive stress on the trunk and upper quarter. Hip motion and strength measurements have been reported in professional baseball pitchers but have not been reported in collegiate pitchers.
The purpose of this study was to report preliminary findings for passive hip motion and isometric hip muscle strength in collegiate pitchers and compare them to previously published values for professional level pitchers.
Cross sectional study
Twenty‐nine collegiate baseball pitchers (age = 20.0 + 1.4 years, height = 1.88 + 0.06 m; weight = 89.3 + 10.7 kg; body mass index = 25.3 + 2.5 kg/m2) were recruited. Subjects were assessed for hip internal rotation (IR) and external rotation (ER) passive motion, hip anteversion or retroversion, gluteus maximus, gluteus medius, hip internal rotator, hip external rotator strength, and lumbo‐pelvic control with the prone active hip rotation test as described by Sahrmann. Statistical analysis included calculation of subject demographics (means and SD) and use of a two‐tailed t‐test (p >0.05).
Fifty‐two percent of the right‐handed and 50% of the left‐handed pitchers demonstrated poor lumbo‐pelvic motor control with an inability to stabilize during active hip IR and ER even though isolated strength deficits were not detected at a significant level. There were no significant differences in hip passive motion or gluteus medius strength between right and left‐handed pitchers. Differences did exist between collegiate data and previously published values for professional pitchers for IR motion measured in prone and gluteus maximus strength. Hip retroversion was present in 55% of the pitchers primarily in both limbs with four of the pitchers presenting with retroversion singularly in either the stride or trail limb where the ER rotation motion was greater than the IR.
Assessing mobility and muscle strength of the lower quarter in isolation can be misleading and may not be adequate to ensure the potential for optimal pitching performance. These findings suggest that lumbo‐pelvic control in relation to the lower extremities should be assessed as one functional unit. This is the first study to explore hip motion, strength, and lumbo‐pelvic control during active hip rotation in collegiate baseball pitchers.
Baseball; collegiate; hip; lumbo‐pelvic motion
Non‐specific low back pain is a common condition often without a clear mechanism for its presentation. Recently more attention has been placed on the hip and its potential contributions to non‐specific chronic low back pain (NSCLBP). Emphasis in research has mainly been placed on motor control, strength and endurance factors in relation to NSCLBP. Limited focus has been placed on hip mobility and its potential contribution in subjects with NSCLBP.
The aim of this study was to compare passive ROM in hip extension, hip internal rotation, hip external rotation and total hip rotation in active subjects with NSCLBP to healthy control subjects. The hypothesis was that active subjects with NSCLBP would present with decreased total hip ROM and greater asymmetry when compared to controls.
Two group case controlled
Clinical research laboratory
30 healthy subjects without NSCLBP and 30 active subjects with NSCLBP. Subjects categorized as NSCLBP were experiencing pain in the low back area with or without radicular symptoms of greater than three months duration.
Main Outcome Measure
Passive hip extension (EXT), hip internal rotation (IR), hip external rotation (ER) and total hip rotation ROM. A digital inclinometer was used for measurements.
There was a statistically significant difference (p<0.001) in hip passive extension ROM between the control group and the NSCLBP group bilaterally. Mean hip extension for the control group was 6.88 bilaterally. For the NSCLBP group, the mean hip extension was ‐4.28 bilaterally. This corresponds to a difference of means between groups of 10.88. There was no statistically significant differences (p>0.05) in hip IR, ER, or total rotation ROM between groups.
The results of this study indicate that a significant difference in hip extension exists in active subjects with NSCLBP compared to controls. It may be important to consider hip mobility restrictions and their potential impact on assessment of strength in NSLBP subjects. Future studies may be needed to investigate the relationship between measurements and intervention strategies.
Level of Evidence
Hip extension; hip mobility; hip rotation; inclinometer; non‐specific low back pain
As the number of sports participants continues to rise, so does the number of sports injuries. Establishing a valid method of identifying athletes at elevated risk for injury could lead to intervention programs that lower injury rates and improve overall athlete performance. The Functional Movement Screen (FMS)™ is an efficient and reliable method to screen movement patterns during the performance of specific tasks. The purpose of this study is to explore the association between pre‐season FMS TM scores and the development of injury in a population of collegiate athletes
Descriptive epidemiology study
FMS™ scores were obtained for 160 collegiate athletes and injury development was tracked throughout the season. These athletes were both male and female and participated in contact and non‐contact sports. Redundancies were utilized with injury data collection, including medical record reviews and interviews with team athletic trainers, to ensure that all injuries requiring medical attention were captured. At the conclusion of the season, a logistic regression analysis was performed to determine which combination of factors best predicted injury.
Athletes with an FMS™ composite score at 14 or below combined with a self‐reported past history of injury were at 15 times increased risk of injury. A positive likelihood ratio of 5.8 was calculated which improved the probability of predicting injury from 33% pretest to 74% posttest.
This study adds to the growing body of evidence demonstrating a predictive relationship between FMS™ composite scores and past history of injury with the development of future injury
Level of Evidence
3, Non‐random prospective cohort design
Functional Movement Screen™; Injury prediction; Sports Injury
International sports programs have established pre‐participation athletic screening procedures as an essential component to identify athletes that are at a high risk of becoming injured. The Functional Movement Screen (FMS™) is a screening instrument intended to evaluate deficiencies in the mobility and stability of an athlete that might be linked to injury. To date, there are no published normative values for the FMS™ in adolescent school aged children. The purpose of this study was to establish normative values for the FMS™ in adolescent school aged children (10 to 17 years). Secondary aims were to investigate whether the performance differed between boys and girls and between those with or without previous history of injury.
1005 adolescent school students, including both males and females between the ages of 10 and 17 years who fulfilled the inclusion and exclusion criteria, were selected for the study. The test administration procedures, instructions and scoring process associated with the standardized version of the test were followed in order to ensure accuracy in scoring. The components of the FMS™ include the deep squat, hurdle step, in‐line lunge, shoulder mobility, active straight leg raise, trunk stability push up, and rotary stability.
The mean composite FMS™ score was 14.59 (CI 14.43 ‐ 14.74) out of a possible total of 21. There was a statistically significant difference in scores between females and males (p= .000). But no statistically significant difference in scores existed between those who reported a previous injury and those who did not report previous injury (p=.300). The variables like age (r= ‐.038, p=.225), height(r= .065, p= .040), weight (r=.103, p=.001) did not show a strong correlations with the mean composite score.
This study provides normative values for the FMS™ in adolescent school aged children, which could assist in evaluation of functional mobility and stability in this population.
Level of evidence
Adolescent aged school children; Functional Movement Screen™; normative values
The squat is a fundamental movement of many athletic and daily activities. Methods to clinically assess the squat maneuver range from simple observation to the use of sophisticated equipment. The purpose of this study was to examine the reliability of Coach's Eye (TechSmith Corp), a 2‐dimensional (2D) motion analysis mobile device application (app), for assessing maximal sagittal plane hip, knee, and ankle motion during a functional movement screen deep squat, and to compare range of motion values generated by it to those from a Vicon (Vicon Motion Systems Ltd) 3‐dimensional (3D) motion analysis system.
Twenty‐six healthy subjects performed three functional movement screen deep squats recorded simultaneously by both the app (on an iPad [Apple Inc]) and the 3D motion analysis system. Joint angle data were calculated with Vicon Nexus software (Vicon Motion Systems Ltd). The app video was analyzed frame by frame to determine, and freeze on the screen, the deepest position of the squat. With a capacitive stylus reference lines were then drawn on the iPad screen to determine joint angles. Procedures were repeated with approximately 48 hours between sessions.
Test‐retest intrarater reliability (ICC3,1) for the app at the hip, knee, and ankle was 0.98, 0.98, and 0.79, respectively. Minimum detectable change was hip 6°, knee 6°, and ankle 7°. Hip joint angles measured with the 2D app exceeded measurements obtained with the 3D motion analysis system by approximately 40°. Differences at the knee and ankle were of lower magnitude, with mean differences of 5° and 3°, respectively. Bland‐Altman analysis demonstrated a systematic bias in the hip range‐of‐motion measurement. No such bias was demonstrated at the knee or ankle.
The 2D app demonstrated excellent reliability and appeared to be a responsive means to assess for clinical change, with minimum detectable change values ranging from 6° to 7°. These results also suggest that the 2D app may be used as an alternative to a sophisticated 3D motion analysis system for assessing sagittal plane knee and ankle motion; however, it does not appear to be a comparable alternative for assessing hip motion.
Level of Evidence
Functional movement; range of motion; reliability; squat
The epidemiology and aetiology of hamstring injuries in sport have been well documented. Kinesiology tape has been advocated as a means of improving muscle flexibility, with potential implications for injury prevention. Purpose: To compare the temporal pattern of efficacy of kinesiology tape and traditional stretching techniques on hamstring extensibility. Study Design: Controlled laboratory study. Methods: Thirty recreationally active male participants (Mean ± SD: age 21.0 ± 0.1 years; height 180 ± 6 cm; mass 79.4 ± 6.9 kg) completed an active knee extension assessment (of the dominant leg) as a measure of hamstring extensibility. Three experimental interventions of equal time duration were applied in randomized order: Kinesiology tape (KT), static stretch (SS), proprioceptive neuromuscular facilitation (PNF). Measures were taken at baseline, +1, +10 and +30 mins after each intervention. The temporal pattern of change in active knee extension (AKE) was modelled as a range of regression polynomials for each intervention, quantified as the regression coefficient. Results: With baseline scores not statistically different between groups, and baseline AKE set at 100%, PNF showed a significant improvement immediately post‐intervention (PNF+1 = 107.7 ± 8.2%, p = .01). Thereafter, only KT showed significant improvements in active knee extension (KT+10 = 106.0 ± 7.1%, p = .05; KT+30 = 106.9 ± 5.0%, p = .02). The temporal pattern of changes in active knee extension after intervention was best modelled as a positive quadratic for KT, with a predicted peak of 108.8% baseline score achieved at 24.2 mins. SS was best modelled as a negative linear function, and PNF as a negative logarithmic function, reflecting a rapid decrease in active knee extension after an immediate positive effect. Conclusion: Each intervention displayed a unique temporal pattern of changes in active knee extension. PNF was best suited to affect immediate improvements in hamstring extensibility, whereas kinesiology tape offered advantages over a longer duration. Clinical Relevance: The logistics of the sporting or clinical context will often dictate the delay between intervention and performance. Our findings have implications for the timing and choice of intervention aimed at increasing hamstring extensibility in relation to performance.
Level of Evidence
Flexibility; hamstring; kinesiology tape; stretching
Interpretation of Lachman testing when evaluating the status of the anterior cruciate ligament (ACL) typically includes a numerical expression classifying the amount of translation (Grade I, II, III) in addition to a categorical modifier (Grade A [firm] or B [absent]) to describe the quality of the passive anterior tibial translation's endpoint. Most clinicians rely heavily on this tactile sensation and place value in this judgment in order to render their diagnostic decision; however, the reliability and accuracy of this endpoint assessment has not been well established in the literature.
The purpose of this study was to determine the intertester reliability of endpoint classification during the passive anterior tibial translation of a standard Lachman test and evaluate the classification's ability to accurately predict the presence or absence of an ACL tear.
Prospective, blinded, diagnostic reliability and accuracy study.
Forty‐five consecutive patients with a complaint of knee pain were independently evaluated for the endpoint classification during a Lachman test by two physical therapists before any other diagnostic assessment. The 21 men and 24 women ranged in age from 20 to 64 years (mean +/‐ SD age, 40.7 +/‐ 14) and in acuity of knee injury from 30 to 365 days (mean +/‐ SD, 238 +/‐157).
17 of the 45 patients had a torn ACL. The agreement between examiners on A versus B endpoint classification was 91% with a kappa coefficient of 0.72. In contrast, classification agreement based on the translational amount had an agreement of 65% with a weighted kappa coefficient of 0.52. The sensitivity of the endpoint grade alone was 0.81 with perfect specificity resulting in a positive likelihood ratio of 6.2 and a negative likelihood ratio of 0.19. The overall accuracy of the Lachman test using the endpoint assessment grade alone was 93% with a number needed to diagnose of 1.2.
Nominal endpoint classification (A or B) from a Lachman test is a reliable and accurate reflection of the status of the ACL. The true dichotomous nature of the test's interpretation (positive vs. negative) is well‐served by the quality of the endpoint during passive anterior tibial translation.
Level of Evidence
ACL; anterior cruciate ligament; diagnosis; knee; Lachman test; reliability; sensitivity; specificity
A belt‐stabilized hand‐held dynamometer (HHD) offers the ability to quantify quadriceps muscle strength in a clinical environment, but a limitation is participant discomfort at the interface between the HHD and the tibia. The purpose of this study was to quantify the level of discomfort associated with a modified belt‐stabilized HHD configuration compared to a standard belt‐stabilized configuration and an isokinetic dynamometer. The secondary purpose of this study was to determine the validity and reliability of a modified configuration used to measure quadriceps strength compared to the “gold‐standard” isokinetic dynamometer.
Twenty healthy participants (5 males, 15 females; age=24.7±2.2 years, height=171.1±8.8 cm, mass=72.0±18.7 kg) performed maximal knee extension isometric contractions during each of three testing conditions: isokinetic dynamometer, standard configuration with HHD placement on the tibia, and an alternative configuration with the HHD interfaced with the leg of a table. Discomfort was quantified using a Visual Analog Scale (VAS). Differences in discomfort and torque (N•m) associated with the testing positions were determined using Friedman test or repeated measures analysis of variance. Validity was quantified using Pearson correlations and within‐session intrarater reliability was determined using an intraclass correlation coefficient (ICC2,1) and associated confidence intervals (95% CI).
The isokinetic dynamometer configuration resulted in the least discomfort (p< .01) and the modified configuration was more comfortable than the standard configuration (p= .003). There was a significant correlation between measures from the isokinetic dynamometer and the standard configuration (r=.87) and modified configuration (r=.93). Within‐session intrarater reliability was good for both the standard configuration (ICC2,1=0.93) and modified configuration (ICC2,1=0.93) conditions.
The use of the modified belt‐stabilized HHD configuration, where the HHD was interfaced with the leg of a table, offers a more comfortable alternative compared to the standard belt‐stabilized configuration to obtain isometric quadriceps strength measures in a clinical environment. This configuration is also a valid and reliable alternative to the “gold standard” isokinetic dynamometer when testing isometric quadriceps strength at 90° of knee flexion.
Level of Evidence
Diagnostic, Level 3
knee extension; muscle; quadriceps; torque
Almost all research using participants wearing barefoot‐style shoes study elite runners or have participants with a history of barefoot style shoe training run on a treadmill when shod or barefoot. Wearing barefoot‐style shoes is suggested as a method of transition between shod and barefoot running. Static and dynamic balance exercises also are recommended. However, little information is available on the effects five‐toed barefoot style shoes have on static balance. The purpose of this study was to examine balance of subjects barefoot, wearing Vibram FiveFingers™ barefoot‐style shoes, and regular athletic shoes with eyes closed when using the Biodex Balance System‐SD™.
This was a repeated measures study.
Forty nine participants aged 18‐30 years without lower extremity injury or experience wearing barefoot‐style shoes were tested for static balance on the Biodex Stability System™ with their eyes closed while wearing Vibram FiveFingers™, athletic shoes, or barefoot. Three trials of 10 seconds for each footwear type were completed. Repeated measures analysis of variance with Bonferroni's correction was used to analyze the degrees of sway in the anterior‐posterior and medial lateral directions. An overall stability index was also calculated by the Biodex.
For anterior‐posterior and overall indices, differences were found between all conditions. Participants wearing athletic shoes demonstrated the smallest anterior‐posterior stability index (least sway) and spent the most time in the innermost concentric circular zone. Medial‐lateral indices were not different for any condition.
Wearing Vibram FiveFingers™ provided better overall and anterior‐posterior static balance than going barefoot. While differences between Vibram FiveFingers™ and barefoot are significant, results may reflect statistical significance rather than any clinical difference in young, uninjured individuals.
It would appear that Vibram FiveFingers™ mimic going barefoot and may be a bridge for exercising in preparation for barefoot exercise.
Level of Evidence
static balance; Biodex; postural control; postural index; Vibram FiveFingers
Ultimate Frisbee (Ultimate) is a limited‐contact team sport growing in popularity, particularly as a collegiate club sport. In 2011, over 947,000 people played Ultimate. Sex, age, skill level, and physical demands of the sport place each player at risk for injury, yet there is limited information on the number of injuries with regard to clinical research. The purpose of this study is to identify injury reporting trends in Ultimate Frisbee against other collegiate club sports and examine correlation with sex, body region, and medical recommendations and to discuss associated risk of injury.
Athletes who sustained an injury related to participation in their respective club sport attended a physical therapy sports clinic, underwent screening, and were provided direction for injury management. Data was collected on various elements of each case with descriptive statistical analysis performed to catalog injury characteristics. Chi‐square analyses were performed to compare proportions between sports, sex, and body region.
Ultimate accounted for 143 (31.0%) of the 461 reported injury cases collected from all club sports. Female injuries represented 101 (70.6%) of the 143 Ultimate cases, whereas men totaled 42 (29.4%) (p<0.001). Women had significantly more foot/ankle (26) than men (4) (p<.001) and more lumbar/flank (9) injuries than men (2) (p=.022).
Ultimate accounted for one of the highest number of reported injuries among all club sports. Women reported injuries more than twice as frequently as men. The majority of reported Ultimate injuries involved the lower extremity. Injury trends observed are similar to those previously reported in several NCAA Intercollegiate sports.
Level of Evidence
College club sports; epidemiology; Ultimate Frisbee
Exercise induced lower leg pain (EILP) is a commonly diagnosed overuse injury in recreational runners and in the military with an incidence of 27‐33% of all lower leg pain presentations. This condition has proven difficult to treat conservatively and patients commonly undergo surgical decompression of the compartment by fasciotomy. This case series investigates the clinical outcome of patients referred with exertional lower leg pain symptoms of the anterior compartment of the lower leg following a gait re‐training intervention program.
10 patients with exercise related running pain in the anterior compartment of the lower leg underwent a gait re‐training intervention over a six‐week period. Coaching cues were utilized to increase hip flexion, increase cadence, to maintaining an upright torso, and to achieve a midfoot strike pattern. At initial consult and six‐week follow up, two‐dimensional video analysis was used to measure kinematic data. Patients self reported level of function and painfree running were recorded throughout and at one‐year post intervention.
Running distance, subjective lower limb function scores and patient's pain improved significantly. The largest mean improvements in function were observed in ‘running for 30 minutes or longer’ and reported ‘sports participation ability’ with increases of 57.5% and 50%, respectively. 70% of patients were running painfree at follow‐up. Kinematic changes affected at consultation were maintained at follow‐up including angle of dorsiflexion, angle of tibia at initial contact, hip flexion angle, and stride length. A mean improvement of the EILP Questionnaire score of 40.3% and 49.2%, at six‐week and one‐year follow up, respectively.
This case series describes a conservative treatment intervention for patients with biomechanical overload syndrome/exertional compartment syndrome of the anterior lower leg. Three of the four coaching cues affected lasting changes in gait kinematics. Significant improvements were shown in painfree running times and function.
Level of Evidence
Chronic exertional compartment syndrome; biomechanical overload syndrome; overuse injury; gait analysis; running
Background & Purpose
Much attention has been solely paid to physical outcome measures for return to sport after injury in the past. However, current research shows that the psychological component of these injuries can be more predictive of return to sport than physical outcome measures. The purpose of this case report is to describe the successful return to sport following surgery of a complicated tibia and fibula fracture of a Division I collegiate women's soccer player with a low level of kinesiophobia.
A 22‐year‐old female sustained a closed traumatic mid‐shaft fracture of her tibia and fibula. During a high velocity play she sustained a direct blow while colliding with an opposing player's cleats. As a result of the play, her distal tibia was displaced 908 to the rest of her leg. She underwent a closed reduction and tibial internal fixation with an intramedullary rod. Outcome scores were tracked using the IKDC and TSK‐11. The IKDC measures symptoms, function, and sport activity related to knee injuries. The TSK‐11 measures fear of movement and re‐injury, which was important to assess during this case due to the gruesome nature of the injury.
At 4 months, the subject became symptomatic over the fibula and was diagnosed with a fibular nonunion fracture. This was unexpected due to the low incidence of and usual asymptomatic nature of fibular nonunion fractures, which required an additional surgery. TSK‐11 scores ranged from 19‐20 throughout, signifying low levels of kinesiophobia. IKDC scores improved from 8.05 to 60.92. The subject ultimately signed a professional soccer contract.
The rehabilitation of this subject was complex due to her low levels of kinesiophobia, self‐guided overtraining, and the potential role they may have had in her fibular nonunion fracture. This case study demonstrates a successful outcome despite a unique injury presentation, multiple surgeries, and low levels of kinesiophobia. While a low level of kinesiophobia can be detrimental to rehabilitation compliance, it may have benefited her in the long‐term.
Level of Evidence
Fracture; kinesiophobia; soccer
Background and Purpose
Neck pain is a common complaint treated by the physical therapist. Trigger points (TrPs) have been studied as a source of neuromusculoskeletal pain, though the ability of clinicians to accurately locate a TrP is not well supported. Dry needling (DN) is an intervention utilized by physical therapists where a monofilament needle is inserted into soft tissue in order to reduce pain thereby facilitating return to prior level of function. The purpose of this case report is to report the outcomes of DN as a primary treatment intervention for acute, non‐specific cervical region pain.
The subject was an active 64‐year‐old female who self‐ referred for cervical pain following lifting heavy boxes while moving into a new home. She had a history of multi‐level cervical fusion and recurrent cervical pain that physical therapy helped to control over the past few years. Physical examination supported a diagnosis of acute cervical region strain. Objective findings included decreased cervical active range of motion (AROM) and upper extremity strength, as well as, reproduction of pain symptoms upon palpation indicating the likelihood of TrPs in the right upper trapezius, levator scapula, supraspinatus, and infraspinatus musculature. She was treated using DN to the aforementioned muscles for two sessions, and no other interventions were performed in order to determine the effectiveness of DN as a primary intervention strategy without other interventions masking the effects of DN.
Clinically meaningful improvements were noted in pain and disability, as measured by the Neck Disability Index and Quadruple Visual Analog Scale. Physical examination denoted minimal to no change in cervical AROM (likely associated with multi‐level fusion), except for right lateral flexion, and no change in shoulder flexion/ abduction MMT.
The patient was able to return to daily and work activities without further functional limitations caused by pain. This case report shows promising outcomes for the use of DN in the treatment of non‐specific cervical region strain. Further research is recommended to determine if DN is clinically beneficial independent of other therapeutic interventions/ postural corrections such as general or specific exercises targeting the affected musculature, or other “manual” therapy techniques such as manipulation or non‐thrust mobilization.
Level Of Evidence
Cervical strain; dry needling; myofascial trigger points; neck pain
Background and Purpose
The majority of all soccer injuries affect the lower extremities. Regardless of whether the injured limb is an athlete’s preferred kicking or stance leg, a lower extremity injury may affect their ability to impact the ball. Sport‐specific biomechanical progressions to augment loading and gradually reintroduce a player to the demands of sport have been developed for upper extremity sports such as baseball, softball, tennis, and golf. Generalized return to soccer progressions have also been published in order to assist clinicians in safely returning athletes to sport; however, there are no specific progressions for the early stages of kicking designed to introduce stance leg loading and kicking leg impact. Thus, the purpose of this clinical commentary was to review the existing literature elucidating the biomechanics of kicking a soccer ball and propose a progressive kicking program to support clinicians in safely returning their soccer athletes to the demands of sport.
Description of Topic
The interval kicking program (IKP) describes clinical guidelines for readiness to begin a kicking program as well as possible readiness to return to sport measures. The program is performed on alternate days integrating therapeutic exercise and cardiovascular fitness. The IKP gradually introduces a player to the loading and impact of kicking. The progression increases kicking distance (using the markings of a soccer field as a guide), volume, and intensity and uses proposed soreness rules, effusion guidelines, and player feedback in order to assist clinicians in determining readiness for advancement though the stages. The IKP also recommends utility of specific tests and measures to determine readiness for return to sport.
Gradual reintroduction to sport specific demands is essential for a safe return to soccer. This return to sport progression provides a framework integrating injury specific therapeutic exercise, cardiovascular fitness, and the return to kicking progression, to assist clinicians in initiating an athletes’ return to soccer.
Level Of Evidence
Kicking; Lower Extremity Injury; Soccer
A case of an athlete with accessory nerve injury has not been previously reported although there have been a number of case reports and case series of non‐athletes with accessory nerve injury. This case study reports motor control intervention for an amateur baseball pitcher with isolated paralysis of the right trapezius who lost pitching control after changing his pitching technique. The subject was able to restore ball control during overhead throwing after physiotherapy.
The subject of this case report was a 20‐year‐old amateur male baseball pitcher, who presented with long‐standing isolated paralysis of the right trapezius and a six month history of loss of ball control with shoulder pain during pitching. He was seen for a second opinion following unsuccessful conservative management and underwent physiotherapy to restore his ball control during pitching. Restriction of cervical rotation range of motion and decreased position sense during shoulder abduction and external rotation were revealed in the physical examination. Proprioceptive exercise was commenced with and without visual feedback to acquire a reproducible abduction angle in the cocking phase of a baseball pitch. His pitching form was modified to ensure his arm was being raised effectively in the cocking phase. Pitching drills that were utilized were targeted motor control of the upper quarter, and were progressed in steps. Cervical joint mobilization was undertaken to allow adequate range of motion for visualization of the target while pitching.
His position sense and cervical range of motion were restored. His pitching control was restored with conservative therapy on by the eighth week of intervention.
The subject was able to return to competitive level of amateur baseball with accurate ball control. This case report demonstrates that achievement of control of a skilled upper quarter activity, such as baseball pitching, is possible with conservative management even in the presence of paralysis of trapezius, a major contributor to the movement.
Level of Evidence:
4 (single case report)
Amateur baseball pitcher; ball control; isolated trapezius paralysis; proprioceptive exercise
Background and Purpose:
Proximal humeral fractures are relatively uncommon injuries. While previous research has led to effective clinical and diagnostic evaluation and treatment of proximal fractures, less is currently known regarding the typical evaluation and treatment of midshaft humeral fractures. The purpose of this case is to describe the clinical reasoning and utilization of diagnostic imaging in the physical therapy management of a midshaft humeral fracture, sustained during the course of rehabilitation of a proximal humerus fracture.
A 63‐year‐old female recreational tennis player presented to physical therapy, progressing well following a proximal humeral fracture, sustained 18 weeks prior. During the course of care, the patient had a significant regression in range of motion and function, with increased pain, following a seemingly trivial injury. Based on a cluster of subjective and objective flags, the therapist was concerned about a new fracture. The therapist communicated findings with a physician and recommended plain film radiographs before continuing therapy.
Radiographs showed an oblique displaced fracture extending through the midshaft of the humerus. The patient ultimately underwent surgical plating. At one‐year post injury e‐mail follow up, she had functional mobility of her left arm, and was playing tennis recreationally three times a week.
In this case, a patient who was progressing well following a proximal humeral fracture sustained a separate displaced fracture of the midshaft of the humerus, not associated with therapy. Her reported mechanism was not consistent with a typical injury. This highlights the need for clinicians, specifically physical therapists, to cluster subjective information, objective data, and the patient's medical history when interpreting patient appropriateness for therapy, and to optimize outcomes.
Level of Evidence:
5 (single case report)
clinical reasoning; humeral fracture; radiograph; tennis
Background and Purpose:
Isolated fractures involving the first rib are rare and often difficult to diagnose. There is a paucity of literature regarding isolated fractures and even fewer reported cases involving those due to contact. The purpose of this case report is to describe the mechanism of injury, differential diagnosis, rehabilitation, and return to sport decision making for an isolated first rib fracture secondary to acute trauma in a collegiate football player.
An 18 year‐old right‐hand dominant male collegiate football player was involved in a facemask‐to‐facemask collision during a football game while playing defensive back. His chief complaint during the sideline evaluation was left‐sided neck and shoulder pain with concomitant clicking reported with active movement of his left shoulder.
A musculoskeletal ultrasound performed in the training room suggested a possible scapular spine fracture. However, a subsequent magnetic resonance image revealed an acute isolated anterolateral fracture of the first rib. The subject was treated conservatively with extensive rehabilitation and was able to return to full participation for summer training camp as well as the fall football season at the same level of play as prior to injury.
An isolated first rib fracture is extremely rare due to the unique anatomical location of the first rib posterior to the clavicle, as well as the surrounding shoulder girdle and associated layer of musculature. Identifying this injury can be challenging due to vaguely reported symptoms and the paucity of reported incidences. In the setting of an isolated injury, conservative management including structured rehabilitation can lead to successful outcomes and return to play. This is the first published rehabilitation guideline for an acute isolated first‐rib fracture secondary to trauma.
Level of Evidence:
4 – Single case report
First rib fracture; football athlete; shoulder pain
Movement ability is an often‐overlooked component of sports science and
sports medicine research and needs to be considered alongside the appraisal of
physical fitness and performance characteristics. To achieve this, a standardised
assessment tool is required. The purpose of this paper is to introduce a new
method for assessing movement ability and present results for intra‐ and
National level female football players (n=17) were assessed
using a novel movement assessment tool, the Athletic Ability Assessment
(AAA). Athletes were assessed according to the scoring criteria by
the primary researcher in real‐time and via video on two separate occasions
to estimate intra‐tester reliability. Inter‐tester reliability was
estimated using the difference between five other testers'
The intra‐tester minimal detectable change (MDC) for the
composite AAA score was 2.9 points (90% confidence limits; 2.3
– 4.2 points) (2.5%; 2.0 – 3.6%)
with an intraclass correlation coefficient (ICC) of 0.97
(0.92 – 0.99). Inter‐tester MDC for the composite AAA
score was 2.8 points (2.5 – 3.3 points) (2.4%;
2.1 – 2.8%) with an ICC 0.96 (0.94 –
0.98) Individual exercise scores for the intra‐ and
inter‐tester show a similar range MDC of between 0.4 – 1.1 points
and kappa statistic level of agreement between 0.32 ‐0.77.
Results of the reliability analysis suggest high levels of agreement between
scorers for total scores and provide reference values for minimal detectable
changes using the AAA. The aim of the AAA is to become a reliable movement
assessment protocol that addresses specific sporting populations. The reliability
of AAA scoring established in this study is the first step in supporting the
utilization of the AAA in future research.
Level of evidence:
Functional movement; reliability; screening
A new 16‐item physical performance measure screening battery (16‐PPM) was developed in order to expand on established movement based qualitatively scored functional screening batteries to encompass a broader spectrum of quantitatively scored functional constructs such as strength, endurance, and power.
The purpose of this study was quantify the real‐time tests‐retest and expert versus novice interrater reliability of the 16‐PPM screen on a group of physically active college‐aged individuals. The authors' hypothesized that the test‐retest and interrater reliability of quantitatively‐scored performance measures would be highly correlated (ICC ≥ 0.75) and that qualitatively‐scored movement screening tests would be moderately correlated (Kw = 0.41‐0.60).
Cohort reliability study
Nineteen (8 males, 11 females) healthy physically active college‐aged students completed the 16‐PPM on two days, one week apart.
The majority of the quantitatively scored components of the 16‐PPMs demonstrated good expert‐novice interrater reliability (ICC > 0.75), while qualitatively scored tests had moderate (Kw = 0.41‐0.60) to substantial (Kw = 0.61‐0.80) agreement. Test‐retest reliability was consistent between raters, with most quantitatively scored PPMs exhibiting superior reliability to the qualitatively scored PPMs.
The 16‐PPM test items showed good test‐retest and interrater reliability. However, results indicate that expert raters may be more reliable than novice raters for qualitatively scored tests. The validity of this 16‐PPM needs to be determined in future studies.
Physical performance screening batteries may be used to help identify individuals at risk for future athletic injury; however, current PPMs that rely on qualitatively scored movement screens have exhibited inconsistent and questionable injury prediction validity. The addition of reliable quantitatively scored PPMs may complement qualitatively scored PPMs to improve the battery's predictive ability.
Level of Evidence:
Functional screen; physical performance measures; reliability
Distance running offers a method to improve fitness but also has a risk of lower limb overuse injuries. Foot strike technique has been suggested as a method to alter loading of the lower limb and possibly minimize injury risk. However, there is a dearth of information regarding neuromuscular response to variations in running techniques. The purpose of this investigation was to compare the EMG activity that occurs during FFS running and RFS running, focusing on the biceps femoris, semitendenosis, rectus femoris, vastus medialis oblique, tibialis anterior (TA), medial head of gastrocnemeus (MGas), lateral head of gastrocnemius (LGas), and soleus.
healthy adults (6 male, 8 female; age, 24.2 ± 0.8 years, height 170.1 ± 7.8 cm; mass 69.8 ±10.9 kg; Body Mass Index 24.1 ± 3.0 kg·m2) participated in the study. All participants performed a RFS and FFS running trial at 8.85 kph. A 3D motion capture system was used to collect kinematic data and electromyography was used to define muscle activity. Two‐tailed paired t‐tests were used to examine differences in outcomes between RFS and FFS conditions.
The ankle was significantly more plantarflexed during FFS running (p = .0001) but there were no significant differences in knee and hip angles (p = .618 & .200, respectively). There was significantly less activity in tibialis anterior (TA) (p < .0001) and greater activity in the MGas (p= .020) during FFS running. The LGas and soleus did not change activity (p = .437 & .490, respectively).
FFS running demonstrated lower muscular activity in the TA and increased activation in the MGas.
FFS and RFS running have the potential to off‐load injury prone tissues by changing between techniques. However, future studies will be necessary to establish more direct mechanistic connections between running technique and injury.
Electromyography (EMG); kinematics; neuromuscular adaptation