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The diagnostic capabilities of advanced imaging have increasingly enabled clinicians to delineate between structural alterations and injuries more efficiently than ever before. These impressive gains have unfortunately begun to provide a reliance on imaging at the loss of quality in the clinical examination. Ideally, imaging of the shoulder complex is performed to confirm the provisional diagnosis developed from the history and clinical exam rather than to create such. This clinical commentary will provide the framework for both basic and advanced uses of imaging as well as discussion of evolving modalities.
Level of Evidence:
PMCID: PMC3811741  PMID: 24175143
Throwing athlete; shoulder pain; imaging; diagnosis
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)
PMCID: PMC3625799  PMID: 23593558
Functional outcomes; shoulder instability; throwing shoulder
Acromioclavicular injuries are quite common and approaches to early management of those that are described as a Type III are controversial. The Rockwood Type III classification implies complete disruption of the acromioclavicular and coracoclavicular ligaments, resulting in inferior positioning of the scapula and, thus, the glenohumeral complex while the clavicle appears more superiorly prominent. Clinical management can include surgical or conservative techniques. This case report outlines the decision making process related to this type of injury, as applied in the diagnosis and management of 61 year‐old recreational athlete.
Level of Evidence
5 (Single Case report)
PMCID: PMC3474304  PMID: 23091789
Acromioclavicular injury; functional outcomes; shoulder separation; Type III management
Historically, patellofemoral pain syndrome (PFPS) has been viewed exclusively as a knee problem. Recent findings have suggested an association between hip muscle weakness and PFPS. Altered neuromuscular activity about the hip also may contribute to PFPS; however, more limited data exist regarding this aspect. Most prior investigations also have not concurrently examined hip and knee strength and neuromuscular activity in this patient population. Additional knowledge regarding the interaction between hip and knee muscle function may enhance the current understanding of PFPS. The purpose of this study was to compare hip and knee strength and electromyographic (EMG) activity in subjects with and without PFPS.
Eighteen females with PFPS and 18 matched controls participated in this study. First, surface EMG electrodes were donned on the gluteus medius, vastus medialis, and vastus lateralis. Strength measures then were taken for the hip abductors, hip external rotators, and knee extensors. Subjects completed a standardized stair-stepping task to quantify muscle activation amplitudes during the loading response, single leg stance, and preswing intervals of stair descent as well as to determine muscle onset timing differences between the gluteus medius and vastii muscles and between the vastus medialis and vastus lateralis at the beginning of stair descent.
Females with PFPS demonstrated less strength of the hip muscles. They also generated greater EMG activity of the gluteus medius and vastus medialis during the loading response and single leg stance intervals of stair descent. No differences existed with respect to onset activation of the vastus medialis and vastus lateralis. All subjects had a similar delay in gluteus medius onset activation relative to the vastii muscles.
Rehabilitation should focus on quadriceps and hip strengthening. Although clinicians have incorporated gluteus medius exercise in rehabilitation programs, additional attention to the external rotators may be useful.
Level of Evidence: 4
PMCID: PMC3230156  PMID: 22163090
gluteus medius; knee; patella; surface electromyography
Study Design:
Correlation study
To objectively evaluate the relationship between core stability and athletic performance measures in male and female collegiate athletes.
The relationship between core stability and athletic performance has yet to be quantified in the available literature. The current literature does not demonstrate whether or not core strength relates to functional performance. Questions remain regarding the most important components of core stability, the role of sport specificity, and the measurement of core stability in relation to athletic performance.
A sample of 35 volunteer student athletes from Asbury College (NAIA Division II) provided informed consent. Participants performed a series of five tests: double leg lowering (core stability test), the forty yard dash, the T-test, vertical jump, and a medicine ball throw. Participants performed three trials of each test in a randomized order.
Correlations between the core stability test and each of the other four performance tests were determined using a General Linear Model. Medicine ball throw negatively correlated to the core stability test (r –0.389, p=0.023). Participants that performed better on the core stability test had a stronger negative correlation to the medicine ball throw (r =–0.527). Gender was the most strongly correlated variable to core strength, males with a mean measurement of double leg lowering of 47.43 degrees compared to females having a mean of 54.75 degrees.
There appears to be a link between a core stability test and athletic performance tests; however, more research is needed to provide a definitive answer on the nature of this relationship. Ideally, specific performance tests will be able to better define and to examine relationships to core stability. Future studies should also seek to determine if there are specific sub-categories of core stability which are most important to allow for optimal training and performance for individual sports.
PMCID: PMC3109894  PMID: 21713228
6.  Effects of 2 Ankle Fatigue Models on the Duration of Postural Stability Dysfunction 
Journal of Athletic Training  2005;40(3):191-194.
Context: Muscle fatigue is generally categorized in 2 ways: that caused by peripheral weakness (peripheral fatigue) and that caused by a progressive failure of voluntary neural drive (central fatigue). Numerous variables have been studied in conjunction with fatigue protocols, including postural stability, maximum voluntary contraction force, and reaction time. When torque recordings fall below 50% of a maximum voluntary contraction, the muscle is described as fatigued, but whether this value is a good indicator of fatigue has not been studied.
Objective: To compare the effects of 2 ankle musculature fatigue protocols (30% and 50%) on the duration of postural stability dysfunction.
Design: To assess differences between the 30% and 50% fatigue protocols, we calculated a 1 between-groups factor (subjects) and 2 within-groups factors (fatigue, test) analysis of variance.
Setting: E.J. Nutter Athletic Training Facility.
Patients or Other Participants: Twenty subjects (10 men, 10 women; age = 21.15 ± 2.23 years; height = 172.97 ± 9.86 cm; mass = 70.62 ± 14.60 kg) volunteered for this study. Subjects had no history of lower extremity injury, vestibular or balance disorders, functional ankle instability, or head injury in the past 6 months.
Intervention(s): On separate days, subjects performed isokinetic fatiguing contractions of the plantar flexors and dorsiflexors in a 30% protocol (70% decrease in strength) and a 50% protocol (50% decrease in strength).
Main Outcome Measure(s): Baseline and postfatigue postural stability scores were determined before and after the isokinetic fatiguing contractions. Plantar-flexion peak-torque measurements were obtained for the 2 fatiguing protocols. Three prefatigue and 12 postfatigue postural stability trials were recorded. Velocities for testing were 60°/s for plantar flexion and 120°/s for dorsiflexion.
Results: Sway velocity was significantly greater when the ankle was fatigued to 30% (1.56°/s) than in the 50% condition (1.36°/s). For the 30% protocol, sway was significantly impaired when the pretest condition (1.19°/s) was compared with posttest trial 1 (2.34°/s), trial 2 (2.37°/s), and trial 3 (1.71°/s). For the 50% protocol, sway was significantly impaired when the pretest condition (1.27°/s) was compared with posttest trial 1 (2.02°/s).
Conclusions: The 30% fatigue protocol resulted in significantly longer impairment of postural stability than the 50% protocol. Because the 30% protocol resulted in a greater effect but was relatively short-lived (approximately 75 to 90 s), it is more useful for research purposes.
PMCID: PMC1250260  PMID: 16284640
equilibrium; sway velocity; peripheral fatigue; isokinetic activity; balance
7.  Plantar Fasciitis and the Windlass Mechanism: A Biomechanical Link to Clinical Practice 
Journal of Athletic Training  2004;39(1):77-82.
Plantar fasciitis is a prevalent problem, with limited consensus among clinicians regarding the most effective treatment. The purpose of this literature review is to provide a systematic approach to the treatment of plantar fasciitis based on the windlass mechanism model.
Data Sources:
We searched MEDLINE, SPORT Discus, and CINAHL from 1966 to 2003 using the key words plantar fasciitis, windlass mechanism, pronation, heel pain, and heel spur.
Data Synthesis:
We offer a biomechanical application for the evaluation and treatment of plantar fasciitis based on a review of the literature for the windlass mechanism model. This model provides a means for describing plantar fasciitis conditions such that clinicians can formulate a potential causal relationship between the conditions and their treatments.
Clinicians' understanding of the biomechanical causes of plantar fasciitis should guide the decision-making process concerning the evaluation and treatment of heel pain. Use of this approach may improve clinical outcomes because intervention does not merely treat physical symptoms but actively addresses the influences that resulted in the condition. Principles from this approach might also provide a basis for future research investigating the efficacy of plantar fascia treatment.
PMCID: PMC385265  PMID: 16558682
heel pain; pronation; rehabilitation
9.  Nerve Injury in Athletes Caused by Cryotherapy 
Journal of Athletic Training  1992;27(3):235-237.
Cryotherapy is a therapeutic modality frequently used in the treatment of athletic injuries. In very rare circumstances, inappropriate use in some individuals can lead to nerve injury resulting in temporary or permanent disability of the athlete. Six cases of cold-induced peripheral nerve injury from 1988 to 1991 at the Sports Medicine Center at Duke University are reported. Although disability can be severe and can render an athlete unable to compete for several months, each of these cases resolved spontaneously. Whereas the application of this modality is typically quite safe and beneficial, clinicians must be aware of the location of major peripheral nerves, the thickness of the overlying subcutaneous fat, the method of application (with inherent or additional compression), the duration of tissue cooling, and the possible cryotherapy sensibility of some individuals.
PMCID: PMC1317252  PMID: 16558167

Results 1-9 (9)