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1.  Teres Minor Hypertrophy is a Common and Negative Predictor of Outcomes after Rotator Cuff Repair 
Orthopaedic Journal of Sports Medicine  2016;4(7 suppl4):2325967116S00102.
The teres minor has received increased attention in its role as a rotator cuff muscle, particularly in the setting of large infraspinatus tears. Studies have shown that it plays an important beneficial role after total (TSA) and reverse (RSA) shoulder arthroplasty, as well as in maintenance of function in the setting of infraspinatus wasting in patients with large rotator cuff tears. No study, however, has investigated how often teres minor hypertrophy occurs in a population of rotator cuff tears, whether it occurs in the absence of infraspinatus tearing, or whether it is a positive or negative prognostic indicator on outcomes after rotator cuff repair. The purpose of this study was to determine the prevalence of teres minor hypertrophy in a cohort of patients undergoing rotator cuff repair, and to determine its prognostic effect, if any, on outcomes after surgical repair.
Over a 3 year period, all rotator cuff repairs performed in a single practice by 3 American Shoulder and Elbow Society (ASES) member surgeons were collected. One hundered forty-four patients who had preoperative and postoperative (ASES) outcomes (minimum 2 year), and preoperative Magnetic Resonance Imaging (MRI) were included in the study. All MRIs were evaluated for rotator cuff tear tendon involvement, tear size, and Goutallier changes of each muscle. In addition, occupational ratios were determined for the supraspinatus, infraspinatus, and teres minor muscles. Patients were divided into 2 groups, based upon whether they had teres minor hypertrophy or not, based on a previously established definition. A 2 way univariate ANOVA was used to determine the effect of teres minor hypertrophy(tear size by hypertrophy) and Goutallier changes(tear size by fatty infiltration) on ASES change scores(α=0.05)
Teres minor hypertrophy was a relatively common finding in this cohort of rotator cuff patients, with 51% of all shoulders demonstrating hypertrophy. Interestingly, in patients without an infraspinatus tear, teres minor hypertrophy was still present in 19/40 (48%) of patients. Teres minor hypertrophy had a significant, negative effect ASES scores after rotator cuff repair in patients with and without infraspinatus tearing, infraspinatus atrophy, and fatty infiltrative changes(P<0.05). In general, the presence of teres minor hypertrophy demonstrated a 15% lower score (Figure 1) than when no hypertrophy was present, and this was consistent across all tear sizes, independent of Goutallier changes.
Teres minor hypertrophy is a common finding in the setting of rotator cuff tearing, including in the absence of infraspinatus tearing. Contrary to previous publications, the presence of teres minor hypertrophy in patients with rotator cuff repair does not appear to be protective as a compensatory mechanism. While further study is necessary to determine the mechanism or implication of teres minor hypertrophy in setting of rotator cuff repair, our results show it is not a positive predictor of outcomes following rotator cuff repair.
Summary Sentence:
The mechanism of teres minor hypertrophy was found to be a negative predictor in rotator cuff repair after pre and post-op measures were collected on patients undergoing cuff repair.
PMCID: PMC4968368
2.  Effectiveness of a Preseason Prevention Program on Arm Injury Risk Factors 
Orthopaedic Journal of Sports Medicine  2016;4(3 suppl3):2325967116S00066.
Deficits in posterior shoulder flexibility and strength have been identified as modifiable risk factors for pitching injuries. There are no studies showing the effect of a prevention program on arm injuries and associated risk factors such as strength and ROM. The purpose of this study was to assess the effectiveness of a preseason prevention program to resolve these deficits in adolescent pitchers.
Baseball pitchers (n=143 age=15.7±1.2; height=165.0±43.8cm; weight=72.2±12.6kg) participating in all team activities were block randomized by school to intervention (INV n=88) or control (CON n=76) groups. The INV group received an Athletic Trainer supervised posterior shoulder flexibility and strengthening program (3x/week for 8-weeks). The CON group participated in their usual training. All pitchers participated in a 4-week interval-throwing program immediate to the start of practice. Bilateral shoulder ROM and strength were assessed pre-post program using a digital inclinometer (DI) to measure supine external rotation(ER), internal rotation (IR), and horizontal adduction (HA) ROM with the scapula stabilized at 90 degrees of abduction. Standard manual muscle testing was used for strength assessments using a hand held dynamometer with arm at the side(ER-0) and in supine 90 degrees/90 degrees (ER-90, IR-90) then normalized to body weight (BW). Injuries were recorded over the subsequent baseball season. Two trials were averaged and used to calculate deficits (non-dominant-dominant) and pre-post change scores to examine the ability of the program to ameliorate baseline deficits associated with injury risk. A one-way ANOVA was used to compare change scores between groups and a 2-way ANOVA (group by injury) to examine the change scores influence on injury (α=0.05).
The INV group displayed a greater reduction in IR deficit(INV=7.3 degrees ±11;CON=1.8 degrees ±9;F(1,106)=5.1,P=0.01) P=0.05) and HA deficit(INV=3.3 degrees ±13; CON= -2.4 degrees ±11;F(1,106)=6.7,P=0.01) compared to the CON group. The INV group also maintained their dominant ER-0: IR-90 ratio (INT=-1.6 ±5%BW; CON= -3.5 ±5%BW; F (1,106) =2.1, P=0.09) compared to the CON group. There were 19 arm injuries over the subsequent season (INV=11; CON=8 arm injuries). Control group pitchers who went on to suffer an injury did not decrease their HA deficit (Uninjured=3.0 degrees ±10;Injured=-9.5 degrees ±14;F(1,106)=3.3,P=0.03) or their IR deficit went on to suffer an injury(Uninjured=-1.7 degrees ±8;Injured 8.5 degrees ±13;F(1,106)=3.8,P=0.02). There were no other differences between or among groups (P>0.05).
Adolescent pitchers displayed clinically meaningful improvements in posterior shoulder flexibility (HA and IR) and maintenance of their ER: IR ratio during an Athletic Trainer supervised preseason program. The improvements in HA and IR deficits were associated with decreased injury risk over the course of the subsequent high school season. Thus, a targeted pre-season program appears to be effective in improving HA deficit and impacting injury risk. Further studies are warranted to confirm our results.
PMCID: PMC4901918
3.  Humeral Torsion as a Risk Factor for Shoulder and Elbow Injury in Professional Baseball Pitchers 
Orthopaedic Journal of Sports Medicine  2015;3(7 suppl2):2325967115S00080.
Participation in baseball causes increased mechanical stress to the throwing arm and has been linked to alterations in shoulder range of motion (ROM) and bony morphology. Range of motion changes, specifically GIRD, has been associated with increased shoulder injury. However, the role of humeral torsion is unclear in shoulder injury. The purpose of this study was to prospectively compare humeral torsion (HT) in professional pitchers who remain healthy as compared with those who go on to suffer shoulder injuries.
We prospectively measured and observed 255 professional pitcher-player seasons prior to 2009-2013 spring training. Bilateral HT was assessed in pitchers who were currently asymptomatic and participating without restriction, in all training, and practices. Humeral torsion was assessed via validated, indirect ultrasonography. Two trials of HT were averaged for data analysis. The side-to-side difference in HT was calculated by subtracting the dominant arm (D) HT from the non-dominant (ND) HT. The pitchers were then followed for the development of shoulder injury over the course of each season. Separate mixed model ANOVAs(side X injury) were used to compare pitchers’ dominant and non-dominant HT between those who suffered shoulder injury to those who did not miss games due to arm injury (α=0.05). Tukey's Post-Hoc tests were used to determine minimum significant differences for significant interaction effects.
We observed 30 shoulder injuries. Pitchers with previous elbow injuries(n=30) were excluded from the comparison.(Table 1) Pitchers who suffered a shoulder injury displayed 3.5° less D humeral retrotorsion compared to those pitchers without injury(n=195; P=0.04).(Figure 1).
This study showed that pitchers with decreased humeral retrotorsion had a significantly increased risk of shoulder injury. Decreased humeral retrotorsion may hinder the ability of the shoulder to obtain needed ROM, thus increasing stress to the shoulder in late cocking and follow through. Our results should be viewed in context of the relatively small injury numbers but provide preliminary evidence that the influence of HT should be closely examined when considering shoulder injury risk in professional pitchers.
PMCID: PMC4901637
4.  Professional Pitchers Display Differences in Ulnar Collateral Ligament Morphology and Elbow Gapping Following UCLR Compared to Uninjured Pitchers 
Orthopaedic Journal of Sports Medicine  2015;3(7 suppl2):2325967115S00082.
Ulnar collateral ligament reconstruction(UCLR) of the elbow has received much attention given the rise in incidence among all pitchers. Recent studies have demonstrated stress ultrasonography is a critical tool in the evaluation of the UCL. . No study, has dynamically evaluated the UCL in uninjured professional pitchers under stress, nor has any study evaluated the ability of UCL reconstruction (UCLR) to restore normal kinematics. The purpose of this study was to compare ulnohumeral gapping and UCL thickness in both uninjured professional pitchers and those who had undergone UCLR during a moving valgus stress test. We hypothesized that the UCL will be thicker and the ulnohumeral joint will display adaptive gapping in D arms compared to ND arms. Furthermore we hypothesized that UCLR would restore gapping and UCL morphology.
Ultrasonography was used to assess the UCL of 70 asymptomatic professional baseball pitchers during spring training (history of UCLR, n=6). A 5-MHz linear-array transducer was used to capture images of the dominant (D) and non-dominant (ND) throwing elbows at the maximal cocking position under two loaded conditions within the moving valgus stress test arc:(1) gravity stress and (2)-10 lbs of valgus force using a dynamometer. Ulnohumeral gapping and UCL thickness was measured on sagittal images using the OsiriXTM platform. All measures displayed reliability with intraclass correlation coefficients (ICC) ranging from ICC(2,1)=0.94 -0.98 with Standard error of measure (SEM) of 0.14-0.26 mm for intra-rater and ICC(2,k)= 0.82-0.87; SEM=0.38-0.65mm for inter-rater reliability. Separate mixed model ANOVAs(side X UCL) were used to compare pitchers’ D and ND arm variables between those with UCLR to those who never had a UCL injury.(α=0.05)
The D arms of uninjured pitchers demonstrated increased gapping compared to ND arm (5.4 ± 1.2vs4.7± .86 p=0.001) Players with a UCLR demonstrated decreased gapping compared to both the ND and uninjured D arms of professional pitchers. (2.6±2.9 vs 4.2±1.2; P=0.002), Furthermore, the UCLR elbows demonstrated greater D arm ligament thickness when compared to D arms in pitchers without UCL injury history(.17±.07vs.11 ±.08;P=0.03).
This is the first study to our knowledge evaluating stress ultrasonography of the UCL during the moving valgus stress test in professional pitchers. Our data demonstrates that the UCLR results in a thicker, stiffer construct with less medial elbow gapping than even the normal condition. Using ultrasound to evaluate the UCL it was shown to be reliable, more efficient and provides a clinically feasible method to assess UCL thickness, loaded joint gapping, and stiffness post-UCLR. Future studies may consider this approach to evaluate surgical techniques and graft types for UCL reconstruction
PMCID: PMC4901639
5.  Predictive Risk of Ulnar Collateral Ligament Injury Based on Ligament Morphology and Dynamic Abnormalities in Professional Baseball Pitchers Using Stress Ultrasonography 
Orthopaedic Journal of Sports Medicine  2015;3(7 suppl2):2325967115S00162.
Ulnar collateral ligament (UCL) injury of the elbow is a common and debilitating problem seen frequently in elite baseball pitchers. Ultrasound has been shown to be a useful diagnostic tool in evaluating UCL injuries. We hypothesized that the evaluation using stress ultrasound (US) of the elbow to measure both the morphology of the UCL and the ulnohumeral joint space gapping as a surrogate for UCL incompetence will be helpful to predict UCL injury in professional baseball pitchers.
Ultrasound imaging was used to assess the medial joint laxity of both arms of 70 asymptomatic professional baseball pitchers during spring training. Medial joint laxity and UCL morphology was assessed using OsiriX Imaging Software under 2 conditions: (1) gravity valgus load and (2) 10 lbs of valgus load using a handheld dynamometer with the shoulder in the maximal cocking position and the elbow in 90° of flexion. Two trials of resting position, elbow gapping, and UCL thickness were collected, measured and averaged for data analysis. Intra and inter rater reliability was established and maintained with ICC's in the acceptable range for all measures (.84-.99). One-way ANOVA (α=0.05) was used to compare pitchers’ dominant variables between those with a prospective UCL injury to those who never had a UCL injury. Receiver Operating Curve (ROC) was used to identify pitchers who, based on elbow gapping measures (by cut score), were at high-risk versus those at low risk for UCL injury. (AUC > .70; α=0.05).
Players with a prospective UCL injury (n=7) presented with a trend toward wider (mm) D arm resting joint opening (4.9± 1.2 vs. 4.0±1.1; p=0.07), significantly wider gapped opening (6.5± 1.2 vs. 5.3 ± 1.2; p=0.01) and greater peak stiffness (nm) (.17±.09 vs. 10 ±.07; p=0.03) when compared to pitchers without UCL injury history (n=63). Figure 1 displays larger values of dynamic elbow gapping differentiated between UCL injured (>5.5 mm) and uninjured pitchers (AUC=0.77; p=0.02).
Our data suggests that changes present in the UCL and detectable on ultrasound may help distinguish elbows at risk for later clinical UCL insufficiency. Screening using ultrasound of UCL thickness, loaded joint gapping, and stiffness may help predict the likelihood of elbow injury in professional baseball pitchers.
PMCID: PMC4901748
6.  Influence of a Prevention Program on Arm Injury Risk: An RCT in Adolescent Pitchers 
Orthopaedic Journal of Sports Medicine  2014;2(2 Suppl):2325967114S00089.
High school pitchers are at three times greater risk of an upper extremity (UE) injury compared to position players, with most (69%) injuries occurring during the first month of the season. Therefore, a prevention program for pitchers targeting known risk factors may reduce their injury risk, particularly early in the season. The purpose of this study was to determine the effectiveness of a preseason training program in decreasing the injury rate and altering the pattern of UE injuries in a cohort of high school pitchers.
Healthy high school pitchers (n=196) who were participating in all team activities were block randomized by school to intervention (INV, n=103) or control (CON, n=93) groups. The INV group received a scapular stability, rotator cuff strength, and posterior shoulder flexibility program (3 times/week for 8 consecutive weeks) supervised by an Athletic Trainer. The CON group participated in the teams’ usual preseason training. Training activities for all teams were recorded. All players participated in a 4-week interval-throwing program. Athletic exposures (AEs), injury incidence (participation absence or limitation due to injury) were tracked from the first day of practice until the last day of competition. Incidence rates were calculated per 1,000 AEs and monthly trends for injury were examined for occurrence by group, injury history, and body location. As a secondary analysis, published injury rates from 2009 in the same high schools were compared to their 2012 data. Rate ratios (RR) and 95% confidence intervals (CIs) were used to compare injury rates by group, injury history, body location, and year.
Overall, there were 27 UE injuries incurred among the pitchers; 15 in the INT group (10 shoulder & 5 elbow injuries) and 12 in the CON group (10 shoulder & 2 elbow injuries). The injury rate was similar in the INT and CON groups (RR=0.86; 95% CI: 0.43-2.2). The pattern of arm injuries throughout the season was evenly distributed in both groups. In 2012, 67% of CON teams were observed participating in a general “arm care” program as compared to 6% of CON teams in 2009. Previous arm injury did not increase the risk of an UE injury in the INV group (RR=1.0; 95% CI: 0.38-2.8) but did increase the risk of an UE injury almost 4-fold (RR= 3.7,95% CI: 1.3-10.7) in the CON group. The injury incidence rate for pitchers was 12 times higher in 2009 (29.3/1,000 AEs) than in 2012 (3.4/1,000 AEs) (RR=11.6, 95% CI: 7.1-16.1). The risks of shoulder (RR=11.0; 95% CI: 6.6-15.4) and elbow injury (RR=12.6; 95% CI: 8.0-17.3) were higher in 2009 compared to 2012. The pattern of upper extremity injuries was higher in the first quarter of the season compared to 2012 (See Figure 1).
The main finding of this study is that INV and CON pitchers had a similar injury rate, however, the overall injury rates were significantly lower in 2012 than in 2009. Thus it appears that a general “arm care” and interval-throwing program may also be effective in reducing the injury rate in high school pitchers, perhaps in the early part of the season as injury rates based on the differences in rates between 2012 and 2009. Pitchers with a previous injury in the INV group were less likely to suffer an injury in 2012 than pitchers’ with a previous injury in the CON group. Thus, a targeted pre-season conditioning program may help reduce the injury risk in pitchers with a history of of previous arm injury. Further studies are warranted to confirm our results.
PMCID: PMC4597555
Journal of neuroscience research  2011;89(12):10.1002/jnr.22738.
Glucose is the primary metabolic fuel for the mammalian brain and a continuous supply is required to maintain normal CNS function. The transport of glucose across the blood-brain barrier (BBB) into the brain is mediated by the facilitative glucose transporter GLUT-1. Prior studies (Simpson et al. 2001) had revealed that the conformations of the GLUT-1 transporter were different in luminal (blood facing) and abluminal (brain facing) membranes of bovine cerebral endothelial cells, based on differential antibody recognition. In this study we have extended these observations and using a combination of 2D-PAGE/Western blotting and immunogold electron microscopy we determined that these different conformations are exhibited in vivo and arise from differential phosphorylation of GLUT-1 and not from alternative splicing or altered O- or N-linked glycosylation.
PMCID: PMC3835747  PMID: 21910135
8.  Professional Pitchers with GIRD Display Greater Dominant Humeral Retrotorsion than Pitchers with Normal ROM 
Orthopaedic Journal of Sports Medicine  2013;1(4 Suppl):2325967113S00093.
Glenohumeral internal rotation deficit (GIRD) in the dominant shoulder of a throwing athlete is a previously recognized phenomenon which has been associated with upper extremity injury. The relationship between GIRD and humeral torsion has not clearly been elucidated. The purpose of this study was to compare humeral torsion between professional pitchers presenting with GIRD and those with normal ROM.
Humeral torsion and shoulder range of motion (ROM) was measured in 128 professional pitchers prior to spring training from 2009-2012. Shoulder external (ER) and internal (IR) ROM was assessed in 90º of abduction with the scapula stabilized. Humeral torsion was measured via ultrasound using previously described and validated methods. GIRD was defined as the loss of internal rotation > 15º with a concomitant loss of 10º total arc of motion. The side-to-side difference in HT was calculated by subtracting the dominant arm (D) HT from the non-dominant (ND) HT. A mixed model ANOVA(side X GIRD) were used to compare pitchers dominant and non-dominant HT between pitchers with GIRD to those without GIRD. Independent t-tests were used to compare the side to side difference in HT between pitchers with GIRD and those without (α=0.05).
Pitchers with GIRD displayed alterations in ROM (ER=131.8±14.3, IR= 29.1±10.1, Total Arc=160.9±15.5 ) compared with those with normal ROM (ER=132.0±14.2 , IR= 40.5±11.3 , Total Arc= 172.5 ±16.2 ). Pitchers with GIRD displayed significantly less humeral torsion (i.e. greater retro torsion) in their dominant arm compared to those without (GIRD=4.4±12.0º, Normal=10.4±11.6º, P=0.002). Pitchers with GIRD also displayed a greater side to side difference in humeral retro torsion (GIRD=19.5±11.9 compared with 12.4±12.4º, P=0.001). There was no difference in non-dominant humeral torsion in pitchers with and without GIRD (P>0.05).
Professional pitchers who display deficits in total arc of motion on the internal rotation side greater than 15º tend to also have greater dominant humeral retro torsion and greater side to side differences. An adaptive increase in humeral retro torsion in the dominant arm due to repetitive throwing may limit internal rotation in the follow through phase of the throwing motion. This, in turn, may increases forces on the posterior soft tissues of the glenohumeral joint leading to the development of GIRD. Given that deficits in total arc of motion and internal rotation are associated with increased arm injury risk future studies should examine the amount of humeral torsion that predisposes a shoulder to develop GIRD.
PMCID: PMC4588918
9.  Twice recurrent gallstone ileus: a case report 
Gallstone ileus is a rare cause of bowel obstruction and results from the passage of gallstones into the bowel.
Case presentation
We present the case of an 83-year-old Caucasian woman who had three episodes of gallstone ileus, each of which was managed with simple enterotomy. This sequence is one of the first reported in the medical literature and may be seen to challenge the traditional surgical approach of enterotomy alone.
The available evidence comparing enterotomy alone with combined enterotomy, cholecystectomy, and fistula closure in the management of gallstone ileus is reviewed. Neither approach is clearly identified as superior, but available series suggest that simple enterotomy may be safer than a combined approach and does not result in a higher rate of recurrent biliary disease.
PMCID: PMC3492071  PMID: 23095215
Recurrent gallstone ileus; enterotomy; fistulectomy
10.  Future doctors 
PMCID: PMC2697049  PMID: 19531612
11.  An investigation of the relationship between measures of pain intensity, pain affect, and disability, in patients with shoulder dysfunction 
Numerous outcomes measures can be used to capture and differentiate change in different constructs comprising recovery. Consequently, patients are often burdened by completing a number of measures which involves considerable time and effort. The purpose of this longitudinal, observational study was to identify the number of dimensions in a battery of self-report findings in a patient population who received shoulder injections to investigate the association of the instruments.
Ninety-nine subjects, with diagnoses of adhesive capsulitis, labral injuries, rotator cuff injuries, and osteoarthritis completed outcomes measures including five different forms of pain intensity measures, the McGill Short Form Questionnaire, and the Disabilities of the Arm, Shoulder, and Hand Questionnaire. Change scores were calculated at 4 weeks and an exploratory factor analysis (EFA) with varimax rotation was used to analyze dimensionality. The relationship between the raw scores of the seven measures was investigated using a correlation matrix.
The EFA yielded only one factor and the raw score correlations demonstrated very strong, significant associations. The finding of a single factor suggests that in this sample of patients, only one dimension of change, most likely a change in pain, is represented by the seven individual outcomes measures.
In this isolated example, one outcomes measure would have been sufficient in determining outcome and could have reduced the administrative burden to the caregivers and the patients.
PMCID: PMC3172941  PMID: 22547916
Shoulder; Outcomes measures; Factor analysis
12.  Glutamate permeability at the blood-brain barrier in insulinopenic and insulin-resistant rats 
The influence of diabetes on brain glutamate (GLU) uptake was studied in insulinopenic (streptozotocin (STZ)) and insulin-resistant (diet-induced obesity (DIO)) rat models of diabetes. In the STZ study, adult male Sprague-Dawley rats were treated with STZ (65 mg/kg iv) or vehicle and studied 3 weeks later. STZ rats had elevated plasma levels of glucose, ketone bodies and branched-chain amino acids; brain uptake of GLU was very low in both STZ and control rats, examined under conditions of normal and greatly elevated (by iv infusion) plasma GLU concentrations. In the DIO study, rats ingested a palatable, high-energy diet for 2 weeks, and were then divided into weight tertiles: rats in the heaviest tertile were designated DIO, rats in lightest tertile diet-resistant (DR), and rats in the intermediate tertile controls. DIO and DR rats continued to consume the high-energy diet for 4 more weeks, while control rats were switched to standard rat chow. All rats were studied at 6 weeks (subgroups were examined under conditions of normal or elevated plasma GLU concentrations). DIO rats ate more food and were heavier than DR or control rats, and had higher plasma leptin levels and insulin:glucose ratios. In all diet groups, the BBB showed very low GLU penetration, and was unaffected by plasma GLU concentration. Brain GLU uptake also did not differ among the diet groups. Together, the results indicate that the BBB remains intact to the penetration of GLU in two models of diabetes under the conditions examined.
PMCID: PMC2813370  PMID: 19793593
insulin; brain capillaries; endothelial cells; dicarboxylic amino acids; leptin; diabetes; streptozotocin; diet-induced obesity
13.  Diagnostic Accuracy and Association to Disability of Clinical Test Findings Associated with Patellofemoral Pain Syndrome 
Physiotherapy Canada  2010;62(1):17-24.
Purpose: To investigate the diagnostic accuracy and association to disability of selected functional findings or physical examination tests for patellofemoral pain syndrome (PFPS) in patients with anterior knee pain.
Methods: A sample of 76 consecutive patients with anterior knee pain was further subdivided into PFPS and other diagnoses. Routine physical examination tests were examined in a prospective, consecutive-subjects design for a cohort of patients with anterior knee pain. Diagnostic accuracy findings, including sensitivity, specificity, positive (PPV) and negative (NPV) predictive value, and positive (LR+) and negative (LR−) likelihood ratios, were calculated for each test. PPV and NPV reflect the percentage of time of positive or a negative test (respectively) accurately captures the diagnosis of the condition. LR+ and LR− reflect alterations in post-test probability when the test is positive or negative (respectively). Lastly, associations to disability (International Knee Documentation Committee (IKDC) subjective form) were calculated for each clinical finding.
Results: Diagnostic accuracy analyses of individual functional assessment and situational phenomena suggest that the strongest diagnostic test is pain encountered during resisted muscle contraction of the knee (PPV=82%; LR+=2.2; 95% CI: 0.99–5.2). Clusters of test findings were substantially more diagnostic, with any two of three positive findings of muscle contraction, pain during squatting, and pain during palpation yielding the following values: PPV=89%; LR+=4.0 (95% CI: 1.8–10.3). No individual or clustered test findings were significantly associated with the IKDC score.
Conclusion: Combinations of functional assessment tests and situational phenomena are diagnostic for PFPS and may serve to rule in and rule out the presence of PFPS. Single findings are not related to disability scores (IKDC).
PMCID: PMC2841549  PMID: 21197175
diagnostic accuracy; International Knee Documentation Committee; patellofemoral pain syndrome; sensitivity; specificity; International Knee Documentation Committee; précision des diagnostics; syndrome fémoro-rotulien; syndrome fémoro-patellaire; spécificité
14.  Glenohumeral Internal Rotation Deficit in the Asymptomatic Professional Pitcher and its Relationship to Humeral Retroversion 
The purpose of this study was to determine if glenohumeral internal rotation deficits (GIRD) exist in an asymptomatic population of professional pitchers, and to assess whether these changes are primarily a bony or soft tissue adaptation. Twenty three, active, asymptomatic professional (Major League Baseball) pitchers volunteered for the study. Clinical measures of glenohumeral ranges of motion, laxity, GIRD, as well as radiographic measures of humeral retroversion were taken by two independent orthopaedic surgeons. Data comparing side to side differences in range of motion, laxity, and humeral retroversion were analyzed for statistical significance using a paired t-test for continuous data and a Chi-squared test for ordinal data, with a significance set at 0.05. Evaluations of statistical correlations between different measurement parameters were accomplished using a Pearson product moment correlation. We hypothesized GIRD will be positively correlated with humeral retroversion (HR) in the pitching arm. All clinical and radiographic measures were made in the field, at spring training, by physicians of both private and institutional based sports medicine practices. For the entire group, significant differences were exhibited for HR, external rotation at 90° and internal rotation at 90°, for dominant vs. non-dominant arms. GIRD of greater than 25° was noted in 10/23 of pitchers. In this group, HR was significantly increased and correlated to GIRD. No such increase or correlation was noted for the non-GIRD group. GIRD is a common finding in asymptomatic professional pitchers, and is related to humeral retroversion. Thus internal rotation deficits should not be used as the sole screening tool to diagnose the disabled throwing shoulder.
Key pointsGIRD is relatively common in asymptomatic baseball pitchers (35-43%).Large ranges (-45 to 5°) and a large standard deviation (±16°) were noted suggesting that GIRD is quite variable in this population.GIRD is a variable measure in the asymptomatic population, and therefore should not be used as sole proof for the disabled throwing shoulder.
PMCID: PMC3763355  PMID: 24150137
Glenohumeral internal rotation; humeral retroversion; pitcher ROM
15.  Developing a health surveillance strategy for professional footballers in compliance with UK health and safety legislation 
The need for health surveillance for professional footballers has been assessed against criteria specified in UK health and safety legislation. As footballers suffer from chronic injuries under normal playing conditions, professional football clubs have a requirement to implement health surveillance programmes to protect their players. A health surveillance programme, based on benchmarking a player's fitness and addressing the issues of pre-recruitment, pre-season, during-season, post-season, and rehabilitation assessment, is proposed.
PMCID: PMC1332616  PMID: 9192131
football; health surveillance; legislation

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