Functional tests have been used primarily to assess an athlete's fitness or readiness to
return to sport. The purpose of this prospective cohort study was to determine the ability of the
standing long jump (SLJ) test, the single‐leg hop (SLH) for
distance test, and the lower extremity functional test (LEFT) as preseason screening
tools to identify collegiate athletes who may be at increased risk for a time‐loss
sports‐related low back or lower extremity injury.
A total of 193 Division III athletes from 15 university teams (110 females, age 19.1
± 1.1 y; 83 males, age 19.5 ± 1.3 y) were tested prior to their sports
seasons. Athletes performed the functional tests in the following sequence: SLJ, SLH, LEFT. The
athletes were then prospectively followed during their sports season for occurrence of low back or
Female athletes who completed the LEFT in $118 s were 6 times more likely
(OR=6.4, 95% CI: 1.3, 31.7) to sustain a thigh or knee injury. Male
athletes who completed the LEFT in #100 s were more likely to experience a time‐loss
injury to the low back or LE (OR=3.2, 95% CI: 1.1, 9.5) or a foot or
ankle injury (OR=6.7, 95% CI: 1.5, 29.7) than male athletes who
completed the LEFT in 101 s or more. Female athletes with a greater than 10%
side‐to‐side asymmetry between SLH distances had a 4‐fold increase in foot
or ankle injury (cut point: >10%; OR=4.4, 95% CI: 1.2,
15.4). Male athletes with SLH distances (either leg) at least 75% of
their height had at least a 3‐fold increase (OR=3.6, 95% CI: 1.2,
11.2 for the right LE; OR=3.6, 95% CI: 1.2, 11.2 for left LE) in low back or
The LEFT and the SLH tests appear useful in identifying Division III athletes at risk for a low
back or lower extremity sports injury. Thus, these tests warrant further consideration as
preparticipatory screening examination tools for sport injury in this population.
The single‐leg hop for distance and the lower extremity functional test, when
administered to Division III athletes during the preseason, may help identify those at risk for a
time‐loss low back or lower extremity injury.
Level of Evidence:
epidemiology; functional test; single‐leg hop; lower extremity functional test
Foam rollers are used to mimic myofascial release techniques and have been used by therapists, athletes, and the general public alike to increase range of motion (ROM) and alleviate pressure points. The roller‐massager was designed to serve a similar purpose but is a more portable device that uses the upper body rather than body mass to provide the rolling force.
A roller massager was used in this study to examine the acute effects on lower extremity ROM and subsequent muscle length performance.
Seven male and ten female volunteers took part in 4 trials of hamstrings roller‐massager rolling (1 set – 5 seconds, 1 set – 10 seconds, 2 sets – 5 seconds, and 2 sets – 10 seconds) at a constant pressure (13 kgs) and a constant rate (120 bpm). A group of 9 participants (three male, six female) also performed a control testing session with no rolling intervention. A sit and reach test for ROM, along with a maximal voluntary contraction (MVC) force and muscle activation of the hamstrings were measured before and after each session of rolling.
A main effect for testing time (p<0.0001) illustrated that the use of the roller‐massager resulted in a 4.3% increase in ROM. There was a trend (p=0.069) for 10s of rolling duration to increase ROM more than 5s rolling duration. There were no significant changes in MVC force or MVC EMG activity after the rolling intervention.
The use of the roller‐massager had no significant effect on muscle strength, and can provide statistically significant increases in ROM, particularly when used for a longer duration.
Flexibility; hamstrings; performance; roller‐massager; self myofascial release; stretching
Several examination tests are currently used for diagnosing a supraspinatus lesion. The empty can (EC) test is currently considered the gold standard for testing, but full can (FC) testing is also utilized. Both of these tests do not fully eliminate the deltoid synergistic when resistance is applied. A new diagonal horizontal adduction (DHA) technique has been developed for evaluation of the supraspinatus that has not yet been compared with the existing techniques (EC/FC). Cross‐sectional analysis (CSA) change during contraction as an ultrasonographic means of visualizing and measuring contraction of the supraspinatus has been reported previously.
The purpose of this study was to use diagnostic musculoskeletal ultrasound (MSK) to compare CSA of the supraspinatus during the FC, EC, and the DHA tests.
The supraspinatus muscle of 37 healthy, uninjured volunteers (21 males and 16 females, mean age of 26.9) were visualized and CSA was captured during 4 randomly assigned test positions (including control) using MSK.
A one‐way Analysis of Variance with repeated measures of the mean CSA obtained in the testing positions was performed followed by least significant difference (LSD) for post‐hoc analysis. Significant differences (p < 0.05) were found between the mean CSA of the controls and the CSA of each of the three testing procedures analyzed using the MSK. There were no significant differences (p < 0.05) in CSA between any of the three testing procedures.
In this study, MSK visualized and objectified activity of the supraspinatus muscle as evidenced through increased mean CSA when resisted. All the testing positions (FC, EC, and DHA) demonstrated significantly increased mean CSA of the muscle when isometrically contracted when compared to the resting control. The DHA procedure also elicited significant increase in CSA of the supraspinatus. However, no significant difference was found between the CSA of the DHA when compared to the FC and EC tests.
Level of Evidence:
Cross‐sectional analysis; supraspinatus testing; ultrasound diagnostics
The Myotonometer® is an electronic tissue compliance meter that has been used to quantify the compliance of soft tissues. The Myotonometer® may be a valuable tool to measure the effectiveness of interventions commonly used to increase tissue compliance in individuals with posterior shoulder tightness (PST). Limited data exist on reliability and responsiveness of the Myotonometer® for assessment of soft tissues about the shoulder; therefore, the purpose of this study is to determine the intra‐ and inter‐session reliability and responsiveness of the Myotonometer® in measuring tissue compliance of the posterior shoulder musculature in asymptomatic subjects with PST.
Fifteen asymptomatic subjects with unilateral shoulder range of motion deficits attended two measurement sessions to assess the compliance of the tissues overlying the posterior deltoid, infraspinatus, and teres musculature. Analyses of reliability and responsiveness were conducted using intra‐class correlation coefficients (ICCs) and the determination of minimal detectible change (MDC).
Intra‐session ICC values ranged from 0.69 to 0.91 for all muscles with MDC never exceeding 1.0 mm. Inter‐session ICC values were best for the posterior deltoid, which averaged 0.82, compared to the infraspinatus and the teres complex, which averaged 0.42 and 0.5 respectively. Inter‐session MDC ranged from 0.55 to 1.20 mm across all muscles.
Clinicians can reliably detect relatively small changes in tissue compliance within a single treatment session utilizing the Myotonometer®. The Myotonometer® can reliably detect changes between sessions for tissues overlying the posterior deltoid; however, observed change in the infraspinatus and teres musculature must be above 1 mm to achieve meaningful change and account for decreased inter‐session reliability.
Level of Evidence:
Glenohumeral Internal Rotation Deficit; responsiveness; tissue compliance
The semitendinosus‐gracilis tendon autograft is often used to reconstruct the anterior cruciate ligament. Tendon regeneration appears to occur for most individuals in the short term, but little is known about the long‐term effects of graft harvest. The purpose of this study was to describe the effect of semitendinosis‐gracilis tendon graft harvest on muscle and tendon morphology at least five years following reconstruction in a case series.
Magnetic resonance images were taken of the knees of three subjects at least five years following anterior cruciate ligament reconstruction. These subjects represented the different regeneration patterns at the time of return‐to‐sport. Muscle and tendon morphology were analyzed by calculating the volume, peak cross‐sectional area, and length of the knee flexors. Muscle and tendon morphological changes were analyzed individually, and then in combination as defined as a knee flexor group.
Muscle and tendon regeneration continued in those tendons that had begun regeneration at the time of return‐to‐sports in two subjects. There was significant additional muscle degeneration in those muscles whose tendons had not regenerated at the time of return‐to‐sports, in the remaining subject. Compensatory hypertrophy of the remaining knee flexors restored the knee flexor group to near preoperative peak cross‐sectional area and volume across the each of the three case subjects.
Knee flexor morphology at the time of return‐to‐sports foreshadowed the long‐term outcome in the three studied subjects. Preservation of the tendon sheath in situ may play a role in tendon regeneration. When tendon regeneration did not occur, fatty infiltration of the muscle may be a worst‐case outcome. Semitendinosus‐gracilis muscle synergists demonstrated hypertrophy, perhaps in an effort to compensate for knee flexor group morphology deficits that existed after Semitendinosus gracilis tendon graft harvest.
Semitendinosus and gracilis tendon harvest technique may play a role in regeneration. Additionally, knee flexor morphology at the time of return‐to‐sports may foreshadow the long‐term outcome.
Level of Evidence:
prospective (longitudinal) cohort ‐ level II
Anterior cruciate ligament; magnetic resonance imaging; tendon regrowth
Exercise‐related leg pain (ERLP) is a common problem in runners. The purposes of this study were to 1) report ERLP occurrence among adult community runners; 2) determine ERLP impact on daily activities; and 3) determine if there is a relationship between ERLP occurrence and selected potential risk factors including sex, age, years of running, ERLP history, body mass index (BMI), orthotic use, menstrual function, and training variables.
Community runners registered for a local race were invited to complete a questionnaire including demographics and potential risk factors. Analyses of differences (t‐test) and relationships (Chi‐square) were conducted and relative risk (RR) values were calculated.
225 registered runners (105 male, 120 female) participated; 63.6% reported ERLP history, and 35.1% reported ERLP in the 3 months preceding the race with bilateral medial ERLP as the most common presentation. Of the 79 runners who experienced ERLP during the 3 months preceding the race, ERLP caused 41.8% to reduce their running and interfered with walking or stair climbing in < 10%. Chi square analyses showed no significant association of sex, menstrual function, orthotic use, or BMI with ERLP occurrence. Significant associations were observed between ERLP history and ERLP occurrence in the previous year (RR=3.39; 2.54‐4.52 95% CI), and between ERLP in the 3 months preceding the race and both years running and training mileage. Greater ERLP occurrence was observed in runners with less than 3 years experience (RR = 1.53; 1.08‐2.17 95% CI) and runners who ran fewer than 15 miles/week (RR = 1.47; 1.04‐2.08 95% CI). Those runners with < 3 years running experience and a race pace of 9 min/mile or > were at greater risk for ERLP when compared to other participants (RR=1.53; 1.07‐2.18 95% CI).
Interfering ERLP was common among this group of community runners. Risk factors included ERLP history, training mileage < 15 miles/week, and < 3 years running experience. Further investigation is warranted to identify factors which may increase a community runner's risk of developing ERLP.
Level of Evidence:
Exercise‐related leg pain; running; overuse injury
To analyze the effectiveness of the American Red Cross Emergency Response Course (ARC ERC) in improving decision‐making skills of physical therapists (PTs) and third semester clinical doctorate student physical therapists (SPTs) when assessing acute sports injuries and medical conditions.
An existing questionnaire was modified, with permission from the original authors of the instrument. The questionnaire was administered to PTs and SPTs before the start of and immediately after the completion of 5 different ARC ERCs. The overall percentages of “Appropriate” responses for the 17 case scenarios were calculated for each participant for the pre‐and post‐tests. Participants also rated their perceived level of preparedness for managing various conditions using a 5‐point Likert Scale (ranging from Prepared to Unprepared). The overall percentage of “Prepared/Somewhat Prepared” responses for the 16 medical conditions was calculated for each participant for the pre‐and post‐tests. In addition, mean Likert scale scores were calculated for level of perceived preparedness for each of the 16 medical conditions. Paired t‐tests, calculated with SPSS 20.0, were used to analyze the data.
37 of 37 (100.0%) of eligible PTs and 45 of 48 (93.8%) of eligible SPTs completed the pre‐ and post‐test questionnaires. The percentage of “Appropriate” responses for all 17 cases in the aggregate (PTs: 76.8% pre‐test, 89.0% post‐test; SPTs: 68.5%, 84.3%), as well as the percentage of “Prepared/Somewhat Prepared” responses for all conditions in the aggregate (PTs: 67.5%, 96.5%; SPTs: 37.1%, 90.6%) were significantly different from pre‐test to post‐test (P = .000). There was also a significant difference (P < .05) in the mean overall preparedness Likert scale scores from pre‐test to post‐test for each medical condition for the SPT's, and 15 of the 16 medical conditions (muscle strains: P = .119) for the PTs.
The ARC ERC appears to be effective in improving both PTs' and SPTs' decision‐making skills related to acute sports injuries and medical conditions, as both “Appropriate” responses and perceived level of preparedness improved.
Level of Evidence:
acute injuries; course effectiveness; decision‐making
Platelet Rich Plasma (PRP) is an emerging non‐surgical intervention used for the treatment of tendon and ligament pathology. Despite the growing popularity of PRP in musculoskeletal medicine, there is a paucity of research that describes appropriate rehabilitation procedures following this intervention.
This case report presents the rehabilitation strategy used following a PRP injection for a patient with a partially torn distal triceps tendon who previously failed physical therapy interventions.
The patient returned to light weight training and coaching activity after completing 15 visits over a 3 month period. One month after discharge, the patient reported pain‐free activities of daily living and a return to previously performed gym activities.
PRP presents a viable treatment option for individuals who are recalcitrant to conservative interventions yet elect to avoid more invasive surgical measures. Despite the growing popularity of PRP, a paucity of evidence exists to guide physical therapists in the rehabilitation process of these patients. The rehabilitation strategies used in a patient who had a PRP injection for a partial triceps tendon tear are outlined. Although this case report highlights a successful rehabilitation outcome, future research regarding the concomitant effects of PRP injection and rehabilitation for tendon pathology are needed.
Level of Evidence:
Growth factor; platelet; stem cell
With an increasing number of pre‐adolescents participating in sports, anterior cruciate ligament injuries and resultant reconstruction in the skeletally immature athlete are becoming more common. Many different surgical techniques and rehabilitation protocols have been proposed for the treatment of anterior cruciate ligament (ACL) injuries, but there is a lack of agreement as to which approach results in the best outcome. Rehabilitation protocols have marked variation regarding postoperative weight bearing, immobilization, bracing, and length.
This is a case of a ten year old female who sustained bilateral ACL tears within the period of a year. The purpose of this case report is to describe the early result and subsequent rehabilitation following bilateral physeal‐sparing all‐epiphyseal ACL reconstructions on a skeletally immature patient with a three‐year follow‐up.
The early post‐surgical recovery period on the first injured knee was complicated by knee stiffness requiring manipulation. Following this minor setback, the patient met all physical therapy goals and had no additional complications. The rehabilitation after the second surgery followed a typical course. At three‐year follow‐up, the patient had grown an additional seven inches, with radiographic evidence of symmetric physeal growth and joint stability. She has returned to playing competitive sports.
Discussion and Conclusion:
This innovative physeal‐sparing technique has huge implications as, historically; the feared complication of growth disturbance and angular deformity from transphyseal ACL reconstruction has complicated the management of ACL injuries in children and pre‐adolescents. This case report demonstrates the success of this technique, and the subsequent rehabilitation, as this patient did not experience a reduction in long‐term bone growth.
Level of Evidence:
5 Case Report
Background and Purpose:
Joint infection is a rare but serious complication after knee injury that should be part of a physical therapist's differential diagnosis. This case report presents the care of a 17 year‐old female athlete with septic arthritis from a Fusobacterium infection after sustaining a right lateral meniscus tear. Joint pathology combined with the aggressive infectious agent led to arthrofibrosis of her knee joint and resultant activity limitations and participation restrictions. The purpose of this case report is to highlight a rare and unique pathology, the serious effects that a joint infection can have on musculoskeletal function, and the challenges encountered during the rehabilitation process.
The subject was a 17 year‐old volleyball player who injured her right knee while playing volleyball. Within 7 days, the subject developed a severe joint infection that spread into surrounding gluteal, quadriceps, and gastrocnemius musculature. The infection was surgically debrided eight times during a 10‐week inpatient hospital stay. A manipulation under anesthesia was performed to restore range of motion in her knee joint. Outpatient physical therapy was initiated 4 days later in order to restore musculoskeletal function.
Over eight months of physical therapy services were utilized to address the impairments and activity limitations caused by her joint dysfunction. She met her physical therapy goals and made significant improvements on the Knee Outcome Survey and the Lower Extremity Functional Scale. Success in physical therapy and completion of additional strength training exercise allowed this subject to return to competitive softball at the club level during her freshman year of college.
Though rare after musculoskeletal injury, joint infection can lead to soft tissue damage, partial or complete degradation of articular cartilage, and arthrofibrosis causing significant disability. Physical therapists must incorporate evidence‐based treatment principles including eccentric exercise, core stability, and lower extremity strength training along with sports‐specific rehabilitation into the treatment plan in order to address activity limitations and meet physical therapy goals.
Level of Evidence:
Level 4‐Single Case report
Fusobacterium necrophorum infection; knee; rehabilitation
Hamstring strain injuries are among the most common injuries seen in sports. Management is made difficult by the high recurrence rates. Typical time to return to sport varies but can be prolonged with recurrence. Eccentric strength deficits remain post‐injury, contributing to reinjury. Eccentric training has shown to be an effective method at prevention of hamstring injury in multiple systematic reviews and prospective RCTs but limited prospective rehabilitation literature. Functional dry needling is a technique that has been reported to be beneficial in the management of pain and dysfunction after muscle strains, but there is limited published literature on its effects on rehabilitation or recurrence of injury.
The purpose of this case report is to present the management and outcomes of a patient with hamstring strain, treated with functional dry needling and eccentric exercise.
The subject was an 18‐year‐old collegiate pole‐vaulter who presented to physical therapy with an acute hamstring strain and history of multiple strains on uninvolved extremity. He was treated in Physical Therapy three times per week for 3 weeks with progressive eccentric training and 3 sessions of functional dry needling.
By day 12, his eccentric strength on the involved extremity was greater than the uninvolved extremity and he reported clinically meaningful improvement in outcome scores. By Day 20, he was able to return to full sports participation without pain or lingering strength deficits.
The patient in this case report was able to return to sport within 20 days and without recurrence. He demonstrated significant decreases in pain and dysfunction with dry needling. He had greater strength on the injured extremity compared to contra‐lateral previously injured extremity.
This case illustrates the use of functional dry needling and eccentric exercise leading to a favorable outcome in a patient with hamstring strain.
Level of Evidence:
Functional Dry Needling; Hamstring; Eccentric Exercise
Accurate diagnosis and management of knee pain with or without mechanical symptoms challenges the physical therapist's clinical reasoning skills. Meniscal cysts are one relatively rare disorder of the knee that can cause both pain and mechanical symptoms and are frequently associated with a meniscal tear. In patients with suspected meniscal cysts, systematic differential diagnosis and sound clinical reasoning encourages appropriate integration of the clinical examination with diagnostic imaging. These case reports describe two different presentations of lateral parameniscal cysts where integration of the clinical examination with appropriate imaging allowed the physical therapist to provide a timely and appropriate intervention. In both cases, the diagnostic process is described along with the subsequent interventions that lead to positive outcomes.
Level of Evidence:
5 (Case Report)
Differential diagnosis; imaging; meniscal cyst
Lumbopelvic‐femoral conditions are common and may be associated with asymmetrical musculoskeletal and respiratory impairments and postural mal‐alignment called a Left Anterior Interior Chain (AIC) pattern. An inherent pattern of asymmetry involves the trunk/ribs/spine/pelvis/hip joints and includes the tendency to stand on the right leg and shift the center of gravity to the right which may result for example, in a tight left posterior hip capsule, poorly approximated left hip, long/weak left adductors, internal obliques (IO) and transverse abdominus (TA), short/strong/over active paraspinals and muscles on the right anterior outlet (adductors, levator ani and obturator internus), a left rib flare and a decreased respiratory diaphragm zone of apposition (ZOA).
A therapeutic exercise technique that can address impairments associated with postural asymmetry may be beneficial in improving function, reducing and/or eliminating pain causation, and improving breathing. The Right Sidelying Left Respiratory Adductor Pull Back is an exercise designed to affect alignment of the lumbopelvic‐femoral region by influencing the left posterior ischiofemoral ligament, ZOA and right anterior outlet and left anterior inlet (rectus femoris, sartorius), activating/shortening the left adductors, left IO/TA's and inhibiting/lengthening the paraspinals, bilaterally.
The exercise technique is often used by Physical Therapists, Physical Therapist assistants and Athletic Trainers as an initial exercise to positively affect position/alignment of the lumbopelvic‐femoral region, referred to as “repositioning,” by clinicians who use it. Four published case studies have used similar exercises to address the above impairments associated with a Left AIC pattern and in each 100% improvement in function and pain intensity was described. This particular exercise technique is relatively new and warrants future research.
Adductors; left AIC; postural restoration
This purpose of this study was to investigate the reliability, minimal detectable change (MDC), and concurrent validity of active spinal mobility measurements using a gravity‐based bubble inclinometer and iPhone® application.
Two investigators each used a bubble inclinometer and an iPhone® with inclinometer application to measure total thoracolumbo‐pelvic flexion, isolated lumbar flexion, total thoracolumbo‐pelvic extension, and thoracolumbar lateral flexion in 30 asymptomatic participants using a blinded repeated measures design.
The procedures used in this investigation for measuring spinal mobility yielded good intrarater and interrater reliability with Intraclass Correlation Coefficients (ICC) for bubble inclinometry ≥ 0.81 and the iPhone® ≥ 0.80. The MDC90 for the interrater analysis ranged from 4° to 9°. The concurrent validity between bubble inclinometry and the iPhone® application was good with ICC values of ≥ 0.86. The 95% level of agreement indicates that although these measuring instruments are equivalent individual differences of up to 18° may exist when using these devices interchangeably.
The bubble inclinometer and iPhone® possess good intrarater and interrater reliability as well as concurrent validity when strict measurement procedures are adhered to. This study provides preliminary evidence to suggest that smart phone applications may offer clinical utility comparable to inclinometry for quantifying spinal mobility. Clinicians should be aware of the potential disagreement when using these devices interchangeably.
Level of Evidence:
2b (Observational study of reliability)
Inclinometer; range of motion; smart phone; spine
This case presents the challenges of management associated with a young throwing athlete presenting with a history of bilateral anterior shoulder instability. This athlete had multiple surgical interventions over a three‐year period. The imaging modalities provided partial elucidation (at best) of the true picture of the pathology. This case report outlines the decision making process utilized to provide individualized care to a young throwing athlete with bilateral glenohumeral joint instability, recurrent dislocations, and resultant glenoid bone loss.
Level of Evidence:
5 (Single Case report)
Functional outcomes; shoulder instability; throwing shoulder
Quadriceps function is an important outcome following lower extremity injury and surgery. Measurements of quadriceps function are particularly helpful initially post surgery, however traditional quadriceps strength measures like isokinetic testing are contraindicated during this time period. Inclusion of dynamic musculoskeletal ultrasound imaging in the clinical setting has been beneficial in understanding quadriceps activation specifically rectus femoris (RF) contraction; however, there is a paucity of literature in this area. The purpose of the current study was to describe the cross‐sectional area (CSA) of the RF across varying knee flexion angles.
Forty‐five adult recreational athletes were recruited for the study (21 males, 24 females). All subjects underwent tests of maximal volitional isometric contractions of the knee extensors at 0, 30, 60 and 90 degrees of knee flexion. During the trials, musculoskeletal ultrasound images of the RF at 15 cm from the superior pole of the patella were taken at rest and during contraction for each of the angular positions. Mixed model ANOVAs (angle x sex) were utilized to examine the differences between males and females for different angular positions. These analyses were conducted for the resting CSA, active CSA, and the contractile index (resting – active).
RF cross‐sectional area increased with increasing angles of knee flexion for both the resting and active conditions. The contractile index consistently decreased as knee flexion angle increased. No statistically significant interactions or main effects for sex were observed, although differences were observed in the trajectories of the data sets for males and females.
RF CSA is dependent on knee flexion angle in both males and females. As a result, the assessment of RF CSA should be conducted in a standardized position if this variable is to be utilized as a meaningful measure of muscle size during rehabilitation. Additional research should seek out which factors are associated with clinically relevant factors that effect RF CSA across the range of knee flexion.
Level of Evidence:
Cross‐sectional area; isometric; muscle activation; ultrasound imaging
While the use of functional knee braces for return to sports or high level physical activity after ACL reconstruction (ACLR) is controversial, brace use is still prevalent.1,2,3,4,5 All active patients in the practice are braced after ACLR and must pass a battery of sports tests before they return to play in their brace. Criteria include a 90% score on 4 one‐legged hop tests9 burst superimposition strength test,10 Knee Outcome Survey Activities of Daily Living Scale,8 and a global rating of knee function.
The purpose of this study was to describe the use of criterion‐based guidelines to determine if athletes who had undergone an ACLR function better with or without their functional brace, one year after surgery.
Sixty‐four patients post ACLR performed 4 one‐legged hop tests,9 burst superimposition strength test,10 and completed the Knee Outcome Survey Activities of Daily Living Scale,8 and a global rating of knee function one year after surgery with and without their brace.
Participants included 35 men and 29 women with a mean age of 25 years. The Mean Knee Outcome Survey Activities of Daily Living score was 98%, and the global rating was 97%. Of the subjects, one patient failed hop testing by at least one criterion with and without the brace. Three additional patients failed the test while braced but passed un‐braced, and one patient passed with the brace, but failed without the brace. Subjects performed significantly better un‐braced than braced in all hop tests: single leg hop braced = 101%; un‐braced = 107% (p<0.001); cross‐over hop braced = 100%; un‐braced = 105% (p<0.001); triple hop braced = 99%; un‐braced = 101% (p=0.003); timed hop braced = 98%; un‐braced = 103% (p = 0.004).
Sixty‐two of 64 patients continued to score above return to play criteria one year after ACLR. All but two subjects in the cohort performed better un‐braced than braced. Based on the criterion set for this testing session, 62/64 individuals performed well enough to discontinue use of their brace.
Level of Evidence:
ACL; functional brace; hop tests; knee
Female athletes have high rates of lower extremity (LE) injuries. Core strength (CS) and hip external rotator (HER) strength have been suggested to be factors that influence LE injury risk. Better balance has also been shown to decrease LE injury risk. Still, little research has examined whether core strength and hip muscle strength can influence LE balance. Therefore the purpose of the current study was to examine the relationships between core strength, hip ER strength and lower extremity balance as measured by the Star Excursion Balance Test (SEBT).
CS was examined via the bent knee lowering test (BKLT) (grades 1‐5). Hip external rotator (HER) strength was measured singularly (HERL and HERR and combined (HERCOM) assessed via hand held dynamometry (reported in Newtons), and balance assessed via the SEBT expressed as % leg length, bilaterally in the postero‐medial, postero‐lateral, anterior directions and as a combined score (SEBTCOM). All outcomes were assessed in 45 female lacrosse players (16.0 ± 5.9 yrs, 65.1 ± 2.4 cm, 57.3 ± 7.4 kgs, experience=5.9 ± 2.9 yrs). Pearson product‐moment correlations examined relationships between the BKLT, HER and SEBT. Linear regression analyses examined possible influences of CS and HER on balance (p ≤ .05).
SEBTCOM was not correlated with BKLT [r(45)=–.20, p=.18] or HERCOM [r(45)=.20, p=.18]. There was no correlation between HER strength and CS (BKLT) [r(45)=.20, p=.20]. Overall scores on the BKLT were not correlated with any of the three balance SEBT scores. HERL [r(45)=.36, p=.02] and HERR [r(45)=.30, p=.05] were moderately positively correlated with left posteromedial SEBT direction. HERCOM and BKLT did not predict overall SEBTCOM balance scores (r2=.068, p=.23).
BKLT scores and combined HER strength did not correlate with LE balance, as measured by the SEBT, in female lacrosse players. However, HER strength of both the left and right LE's (singularly) was moderately correlated with scores on one reach direction (left posteromedial) but not with combined SEBT scores. Researchers should continue to examine whether core and hip muscles influence LE balance.
Level of Evidence:
Balance; bent knee lowering test; hand held dynamometry; transversus abdominis
Anterior knee pain is a clinical syndrome characterized by pain experienced perceived over the anterior aspect of the knee that can be aggravated by functional activities such as stair climbing and squatting. Two taping techniques commonly used for anterior knee pain in the clinic include the McConnell Taping Technique (MT) and the Kinesio Taping® Method (KT®).
The purpose of this study was to compare the effectiveness of KT® and the MT versus no tape in subjects with anterior knee pain during a squat lift and stair climbing.
Pretest‐ posttest design.
A total of 20 subjects (15 female, 5 male) with unilateral anterior knee pain were recruited. The mean age of the subjects was 24 (+/–3) years, with a mean weight of 160 (+/–28) pounds.
Each participant was tested during two functional activities; a squat lift with a weighted box (10% of his/her body weight, plus the weight [8.5 pounds] of the box) and stair climbing under three conditions: 1) no tape, 2) MT and 3) KT®. Pain levels were assessed (verbally) using the 0‐10 Numeric Pain Intensity Scale.
The median (interquartile range [IQR]) pain during squat lift was 2 (2.75) for no tape, 1 (1) for KT®, and 0.5 (2) for McConnell, with no significant differences between the groups. During the stair activity the median (IQR) pain was 1.5 (2.75) for no tape, 1 (1.75) for KT®, and 1 (1.75) for MT with a significant difference (p=0.024) between the groups. Further analysis determined that the only a significant difference was (p=0.034) between the no tape and the KT® conditions.
The results of this study found that both the KT® and the MT may be effective in reducing pain during stair climbing activities.
Level of Evidence:
Level 2, Prospective Cohort study
Anterior Knee Pain; Kinesio Taping® Method; McConnell Taping Technique
The purpose of this study was to investigate if the risk of injury declines with increasing weekly running volume before a marathon race.
The study was a retrospective cohort study on marathon finishers. Following a marathon, participants completed a web‐based questionnaire. The outcome of interest was a self‐reported running‐related injury. The injury had to be severe enough to cause a reduction in distance, speed, duration or frequency of running for at least 14 days. Primary exposure was self‐reported average weekly volume of running before the marathon categorized into below 30 km/week, 30 to 60 km/week, and above 60 km/week.
A total of 68 of the 662 respondents sustained an injury. When adjusting for previous injury and previous marathons, the relative risk (RR) of suffering an injury rose by 2.02 [95% CI: 1.26; 3.24], p < 0.01, among runners with an average weekly training volume below 30 km/week compared with runners with an average weekly training volume of 30‐60 km/week. No significant differences were found between runners exceeding 60 km/week and runners running 30‐60 km/week (RR=1.13 [0.5;2.8], p=0.80).
Runners may be advised to run a minimum of 30 km/week before a marathon to reduce their risk of running‐related injury.
Level of Evidence:
Running‐related injury; marathon; risk factors; running volume.
Individuals with chronic ankle instability (CAI) often have impairments in ankle range of motion (ROM) and balance. There is limited evidence that these impairments are related in individuals with CAI. The purpose of this study was to determine the relationship between ankle dorsiflexion ROM and dynamic balance in individuals with CAI.
Forty‐five participants (age=23.2±2.8 y, height=172.1±10.8 cm, mass=70.6±13.3 kg, Foot and Ankle Ability Measure Sport= 71.2±11.7, Modified Ankle Instability Instrument= 6.4±1.3) volunteered for this study. Ankle dorsiflexion ROM was measured in a weight‐bearing position while dynamic balance was measured using the Star Excursion Balance Test (SEBT) in the anterior, posteromedial, and posterolateral directions. Linear regression was used to determine the relationship between ankle dorsiflexion ROM and measures of dynamic balance.
There were fair positive correlations between dorsiflexion ROM and the anterior reach direction (r = .55, r2= .31, P < .001), posterolateral reach direction (r = .29, r2 = .09, P = .03), and the composite SEBT scores (r = .30, r2 = .09, P= .02). There was little or no relationship between ankle dorsiflexion and the posteromedial reach direction (r = .01, r2 = .001, P = .47).
Ankle dorsiflexion ROM can influence dynamic balance, specifically the anterior reach portion of the SEBT.
Individuals with CAI who demonstrate impairments in dorsiflexion ROM may also demonstrate difficulty with portions of the SEBT. Clinicians may use this information to better optimize rehabilitation programs that address ankle dorsiflexion ROM and dynamic balance.
Level of Evidence:
Ankle sprain; functional ankle instability; postural control
Agonist to antagonist strength data is commonly analyzed due to its association with injury and performance. The purpose of this study was to examine the agonist to antagonist ratio of upper body strength using two simple field tests (timed push up/timed modified pull up) in recreationally active adults and to establish the basis for reference standards.
One hundred eighty (180) healthy recreationally active adults (111 females and 69 males, aged 18‐45 years) performed two tests of upper body strength in random order: 1. Push‐ups completed during 3 sets of 15 seconds with a 45 second rest period between each set and 2. Modified pull‐ups completed during 3 sets of 15 seconds with a 45 second rest period between each set.
The push‐up to modified pull‐up ratio for the males was 1.57:1, whereas females demonstrated a ratio of 2.72:1. The results suggest that for our group of healthy recreationally active subjects, the upper body “pushing” musculature is approximately 1.5–2.7 times stronger than the musculature involved for pulling.
In this study, these recreationally active adults displayed greater strength during the timed push‐ups than the modified pull‐ups. The relationship of these imbalances to one's performance and or injury risk requires further investigation. The reference values, however, may serve the basis for future comparison and prospective investigations. The field tests in this study can be easily implemented by clinicians and an agonist/antagonist ratio can be determined and compared to our findings.
Level of Evidence:
Muscle imbalance; strength ratio; upper body strength
Background and Purpose:
Myofascial trigger points (MTrPs) are widely accepted by clinicians and researchers as a primary source of regional neuromusculoskeletal pain. Trigger point dry needling (TrP‐DN) is an invasive procedure that involves stimulation of MTrPs using an monofilament needle. The purpose of this case report is to report the outcomes of TrP‐DN and intramuscular electrical stimulation (IES) as a primary treatment intervention in a subject with chronic low back pain.
The subject was a 30‐year‐old female, active duty military, who was referred to physical therapy for low back and right posterolateral hip pain. She noticed symptoms after suffering a lumbar flexion injury while picking up a barbell during weight training. Physical examination demonstrated findings that supported the diagnosis of lumbar segmental instability with a right hip stability dysfunction. Objective findings included a multi‐segmental flexion movement pattern dysfunction and MTrPs in the right gluteus maximus and gluteus medius muscles with deep palpation. The subject was treated with TrP‐DN and IES for a total of two visits. Bilateral L3 and L5 multifidus and right gluteus maximus and medius muscles were treated, along with implementing a home exercise program consisting of core stability exercises.
The subject reported no existing pain and disability on the Numerical Pain Rating Scale and Oswestry Disability Questionnaire and a large perceived change in recovery on the Global Rating of Change at final follow‐up. Physical examination was normal, demonstrating no observed impairments or functional limitations, including normal multi‐segmental flexion and no MTrPs with deep palpation.
The subject was able to return to full military active duty without any physical limitations and resumed pre‐injury activity levels, including the ability to resume all activities without pain. There is much promise regarding the use of TrP‐DN with IES intervention for the treatment of lumbar and/or hip stability dysfunction. Future research is recommended to determine if TrP‐DN intervention, with and without IES, is effective for other body regions and long‐term subject outcomes.
Level of Evidence:
Dry needling; intramuscular electrical stimulation; low back pain; myofasical trigger points
Lisfranc injuries are a challenging diagnosis for the sports physical therapist because of the lack of data on how to rehabilitate them properly. To date, the available rehabilitation literature has focused on the mechanism of injury and the conservative management of this injury. Furthermore, there is a lack of consensus on the appropriate testing and return to play criteria for an athlete recovering from this perplexing injury. This case describes a high school athlete whose primary sport was football, but was injured during wrestling. He suffered a Lisfranc injury and subsequently underwent surgical fixation. The purpose of this case report is to focus on the exercise, functional progression, and return to sport criteria utilized after operative treatment of a Lisfranc ligament injury.
Level of Evidence:
Closed chain rehabilitation Lisfranc joint; midfoot injury; tarsometatarsal joint
Background and Purpose:
Many researchers acknowledge the importance of “training errors” as the main cause of running‐related injuries. The purpose of this clinical commentary is to present a theoretical framework for the assumption that some running‐related injuries among rear‐foot strikers develop due to rapidly changing running volume, while others develop due to rapidly changing running pace.
Description of Topic with Related Evidence:
Evidence from clinical and experimental studies is presented to support the assertion that rapid change in running volume may lead to the development of patellofemoral pain syndrome, iliotibial band syndrome, and patellar tendinopathy, while change in running pace may be associated with the development of achilles tendinopathy, gastrocnemius injuries, and plantar fasciitis.
Discussion/Relation to Clinical Practice:
If this assertion is correct, bias may be prevented in future studies by categorizing injuries into volume or pacing injuries. However, more work is needed to provide further evidence in support of this approach. Future investigations of the link between training patterns and injury development should be designed as large‐scale prospective studies using objective methods to quantify training patterns.
Level of evidence:
Etiology; running pace; running‐related injury; training volume