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Evidence‐based clinical examination and assessment of the athlete with hip joint related pain is complex. It requires a systematic approach to properly differentially diagnose competing potential causes of athletic pain generation. An approach with an initial broad focus (and hence use of highly sensitive tests/measures) that then is followed by utilizing more specific tests/measures to pare down this imprecise differential diagnosis list is suggested. Physical assessment measures are then suggested to discern impairments, activity and participation restrictions for athletes with hip‐join related pain, hence guiding the proper treatment approach.
Level of Evidence:
PMCID: PMC4223284  PMID: 25383243
Athlete; diagnostic accuracy; examination; hip joint
2.  What Performance Characteristics Determine Elite Versus Nonelite Athletes in the Same Sport? 
Sports Health  2013;5(6):542-547.
There are significant data comparing elite and nonelite athletes in anaerobic field and court sports as well as endurance sports. This review delineates specific performance characteristics in the elite athlete and may help guide rehabilitation.
Evidence Acquisition:
A Medline search from April 1982 to April 2012 was undertaken for articles written in English. Additional references were accrued from reference lists of research articles.
In the anaerobic athlete, maximal power production was consistently correlated to elite performance. Elite performance in the endurance athlete is more ambiguous, however, and appears to be related to the dependent variable investigated in each individual study.
In anaerobic field and court sport athletes, maximal power output is most predictive of elite performance. In the endurance athlete, however, it is not as clear. Elite endurance athletes consistently test higher than nonelite athletes in running economy, anaerobic threshold, and VO2max.
PMCID: PMC3806174  PMID: 24427430
elite versus nonelite athlete; performance characteristics; endurance athlete
3.  Nonoperative Treatment in Lumbar Spondylolysis and Spondylolisthesis 
Sports Health  2013;5(3):225-232.
Both spondylolysis and spondylolisthesis can be diagnosed across the life span of sports-participating individuals. Determining which treatments are effective for these conditions is imperative to the rehabilitation professional.
Data Sources:
A computer-assisted literature search was completed in MEDLINE, CINAHL, and EMBASE databases (1966-April 2012) utilizing keywords related to nonoperative treatment of spondylolysis and/or spondylolisthesis. Reference lists were also searched to find all relevant articles that fit our inclusion criteria: English language, human, lumbar pain with diagnosed spondylolysis and/or spondylolisthesis, inclusion of at least 1 nonoperative treatment method, and use of a comparative study design.
Data Extraction:
Data were independently extracted from the selected studies by 2 authors and cross-referenced. Any disagreement on relevant data was discussed and resolved by a third author.
Ten studies meeting the criteria were rated for quality using the GRADE scale. Four studies found surgical intervention more successful than nonoperative treatment for treating pain and functional limitation. One study found no difference between surgery and nonoperative treatment with regard to future low back pain. Improvement was found in bracing, bracing and exercises emphasizing lumbar extension, range of motion and strengthening exercises focusing on lumbar flexion, and strengthening specific abdominal and lumbar muscles.
No consensus can be reached on the role of nonoperative versus surgical care because of limited investigation and heterogeneity of studies reported. Studies of nonoperative care options suffered from lack of blinding assessors and control groups and decreased patient compliance with exercise programs.
PMCID: PMC3658408  PMID: 24427393
spondylolysis; spondylolisthesis; nonoperative treatment
Restricted hip mobility has shown strong correlation with various pathologies of the hip, lumbar spine and lower extremity. Restricted mobility can consequently have deleterious effects not only at the involved joint but throughout the entire kinetic chain. Promising findings are suggesting benefit with skilled joint mobilization intervention for clients with various hip pathologies. Supervised home program intervention, while lacking specifically for the hip joint, are demonstrating promising results in other regions of the body. Application of an accompanying home program for the purpose of complementing skilled, in clinic intervention is advisable for those clients that respond favorably to such methodology.
Level of Evidence:
PMCID: PMC3811738  PMID: 24175151
Hip joint; Home program; Mobilization
Determine the reliability of two different modified (MOD1 and MOD2) testing methods compared to a standard method (ST) for testing trunk flexion and extension endurance.
Twenty‐eight healthy individuals (age 26.4 ± 3.2 years, height 1.75 ± m, weight 71.8 ± 10.3 kg, body mass index 23.6 ± 3.4 m/kg2).
Trunk endurance time was measured in seconds for flexion and extension under the three different stabilization conditions. The MOD1 testing procedure utilized a female clinician (70.3 kg) and MOD2 utilized a male clinician (90.7 kg) to provide stabilization as opposed to the ST method of belt stabilization.
No significant differences occurred between flexion and extension times. Intraclass correlations (ICCs3,1) for the different testing conditions ranged from .79 to .95 (p <.000) and are found in Table 3. Concurrent validity using the ST flexion times as the gold standard coefficients were .95 for MOD1 and .90 for MOD2. For ST extension, coefficients were .91 and .80, for MOD1 and MOD2 respectively (p <.01).
These methods proved to be a reliable substitute for previously accepted ST testing methods in normal college‐aged individuals. These modified testing procedures can be implemented in athletic training rooms and weight rooms lacking appropriate tables for the ST testing.
Level of Evidence:
PMCID: PMC3474305  PMID: 23091786
Core; stabilization; trunk endurance
Background and Purpose:
Rehabilitation and strength and conditioning are often seen as two separate entities in athletic injury recovery. Traditionally an athlete progresses from the rehabilitation environment under the care of a physical therapist and/or athletic trainer to the strength and conditioning coach for specific return to sport training. These two facets of return to sport are often considered to have separate goals. Initial goals of each are often different due to the timing of their implementation encompassing different stages of post-injury recovery. The initial focus of post injury rehabilitation includes alleviation of dysfunction, enhancement of tissue healing, and provision of a systematic progression of range-of-motion and strength. During the return to function phases, specific return to play goals are paramount. Understanding of specific principles and program parameters is necessary when designing and implementing an athlete's rehabilitation program. Communication and collaboration amongst all individuals caring for the athlete is a must. The purpose of this review is to outline the current evidence supporting utilization of training principles in athletic rehabilitation, as well as provide suggested implementation of such principles throughout different phases of a proposed rehabilitation program.
Evidence Acquisition:
The following electronic databases were used to identify research relevant to this clinical commentary: MEDLINE (from 1950–June 2011) and CINAHL (1982–June 2011), for all relevant journal articles written in English. Additional references were accrued by independent searching of references from relevant articles.
Currently evidence is lacking in the integration of strength and conditioning principles into the rehabilitation program for the injured athlete. Numerous methods are suggested for possible utilization by the clinician in practice to improve strength, power, speed, endurance, and metabolic capacity.
Despite abundance of information on the implementation of training principles in the strength and conditioning field, investigation regarding the use of these principles in a properly designed rehabilitation program is lacking.
PMCID: PMC3164002  PMID: 21904701
periodization; program design; rehabilitation; strength; training
7.  The assessment of function. Part II: clinical perspective of a javelin thrower with low back and groin pain 
Assessment of an individual’s functional ability can be complex. This assessment should also be individualized and adaptable to changes in functional status. In the first article of this series, we operationally defined function, discussed the construct of function, examined the evidence as it relates to assessment methods of various aspects of function, and explored the multi-dimensional nature of the concept of function. In this case report, we aim to demonstrate the utilization of a multi-dimensional assessment method (functional performance testing) as it relates to a high-level athlete presenting with pain in the low back and groin. It is our intent to demonstrate how the clinician should continually adapt their assessment dependent on the current functional abilities of the patients.
PMCID: PMC3360488  PMID: 23633887
Functional testing; Physical performance tests; Physical therapy
8.  Lumbo-Pelvic-Hip Complex Pain in a Competitive Basketball Player 
Sports Health  2011;3(1):70-72.
Establishing the cause of lumbo-pelvic-hip complex pain is a challenge for many clinicians. This case report describes the mechanism of injury, diagnostic process, surgical management, and rehabilitation of a female high school basketball athlete who sustained an injury when falling on her right side. Diagnostics included clinical examination, radiography of the spine and hip joint, magnetic resonance imaging arthrogram, 3-dimensional computed tomography scan, and computed tomography of the hip joint. A systematic multidisciplinary clinical approach resulted in the patient’s return to previous functional levels.
PMCID: PMC3445188  PMID: 23015993
hip pain; acetabular labral tear; hip arthroscopy; low back pain
Medial shin pain (MSP) is a common complaint that may stop an athlete from running. No previous study has identified deficits in pelvic, hip or knee motion as potential contributing factors to MSP. The purpose of this study was to investigate the differences in kinematics during running between uninjured athletes and those with MSP. Secondary analyses investigated differences in limbs between groups and differences between sexes.
This case-control study investigated fourteen runners aged 18–40 years old with a history of unilateral MSP and fourteen runner controls. Three dimensional lower quarter kinematics were captured as runners ran on a treadmill. Specifically, peak hip internal rotation (IR), frontal plane pelvic tilt (PT) excursion, and knee flexion were examined.
Groups were similar in age, mass, height, and training mileage. Subjects with a history of MSP demonstrated significantly greater frontal plane PT (P = 0.002, Effect size = 0.55) and peak hip IR (P = 0.004, Effect size = 0.51); and less knee flexion (P = 0.02, Effect size = 0.46) than the control group. No significant difference was found in kinematics of the MSP group during their involved side stance phase as compared to their non-involved side.
Runners with MSP displayed greater PT excursion, peak hip IR, and decreased knee flexion while running as compared to a control group. These results should help guide treatment for the running athlete that experiences MSP.
Level of Evidence:
PMCID: PMC3414067  PMID: 22893855
Exercise related leg pain; running; overuse injuries; shin splints
10.  The assessment of function: How is it measured? A clinical perspective 
Testing for outcome or performance can take many forms; including multiple iterations of self-reported measures of function (an assessment of the individual’s perceived dysfunction) and/or clinical special tests (which are primarily assessments of impairments). Typically absent within these testing mechanisms is whether or not one can perform a specific task associated with function. The paper will operationally define function, discuss the construct of function within the disablement model, will overview the multi-dimensional nature of ‘function’ as a concept, will examine the current evidence for functional testing methods, and will propose a functional testing continuum. Limitations of functional performance testing will be discussed including recommendations for future research.
PMCID: PMC3172944  PMID: 22547919
Functional testing; International Classification of Functioning; Physical performance tests; Physical therapy
11.  Performance Enhancement in the Terminal Phases of Rehabilitation 
Sports Health  2011;3(5):470-480.
There is a dearth of literature on the performance enhancement in the recovering athlete in the terminal phases of rehabilitation. There are established training methods that target strength, power, speed, endurance, and metabolic capacity that all lead to performance enhancement.
Evidence Acquisition:
A PubMed search from 1980 to 2010 was undertaken for articles in English. Additional references were accrued from reference lists of research articles.
Multiple options are available to improve strength, power, speed, endurance, and metabolic capacity during rehabilitation.
Sports clinicians have several components to address in the rehabilitation of a recovering athlete in addition to performance enhancement. Sports clinicians should focus their efforts on increasing power, a product of maximum force and speed of performance.
PMCID: PMC3445218  PMID: 23016045
performance enhancement; rehabilitation; complex training; plyometric training; heavy chain training; strength training; speed training; postactivation potentiation
12.  Periodization 
Sports Health  2010;2(6):509-518.
Clinicians are constantly faced with the challenge of designing training programs for injured and noninjured athletes that maximize healing and optimize performance. Periodization is a concept of systematic progression—that is, resistance training programs that follow predictable patterns of change in training variables. The strength training literature is abundant with studies comparing periodization schemes on uninjured, trained, and untrained athletes. The rehabilitation literature, however, is scarce with information about how to optimally design resistance training programs based on periodization principles for injured athletes. The purpose of this review is to discuss relevant training variables and methods of periodization, as well as periodization program outcomes. A secondary purpose is to provide an anecdotal framework regarding implementation of periodization principles into rehabilitation programs.
Evidence Acquisition:
A Medline search from 1979 to 2009 was implemented with the keywords periodization, strength training, rehabilitation, endurance, power, hypertrophy, and resistance training with the Boolean term AND in all possible combinations in the English language. Each author also undertook independent hand searching of article references used in this review.
Based on the studies researched, periodized strength training regimens demonstrate improved outcomes as compared to nonperiodized programs.
Despite the evidence in the strength training literature supporting periodization programs, there is a considerable lack of data in the rehabilitation literature about program design and successful implementation of periodization into rehabilitation programs.
PMCID: PMC3438871  PMID: 23015982
periodization; undulating periodization; nonlinear periodization; linear periodization

Results 1-12 (12)