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1.  RELATIONSHIP BETWEEN ISOKINETIC KNEE STRENGTH AND JUMP CHARACTERISTICS FOLLOWING ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION 
Background
Clinicians are often challenged when making return‐to‐play decisions following anterior cruciate ligament reconstruction (ACL‐R). Isokinetic strength and jump performance testing are common tools used to make this decision. Unfortunately, vertical jump performance standards have not been clearly established and many clinicians do not have access to isokinetic testing equipment.
Purpose
To establish normative jump and strength characteristics in ACL‐R patients cleared by an orthopedic physician to return‐to‐play and to determine if relationships exist between knee isokinetic strength measurements and jump characteristics described using an electronic jump map system.
Study Design
Descriptive laboratory study.
Methods
Thirty‐three ACL‐R patients who had been cleared to return to athletic competition participated in this study. Twenty‐six of these ACL‐R participants were also matched to 26 asymptomatic athletes based on sex, limb, height, and mass to determine isokinetic strength and jump characteristic differences between groups. Jump tests consisted of single leg vertical, double leg vertical, and a 4‐jump single leg vertical jump assessed using an electronic jump mat system. Independent t‐tests were used to determine differences between groups and multiple regression analyses were used to identify any relationships between jump performance and knee strength (p<0.05).
Results
The ACL‐R group had lower vertical jump capabilities and some bilateral knee strength deficiencies compared to the matched control group. The ACL‐R group also showed several moderate‐to‐strong positive relationships for both knee extension and flexion strength with several jump performance characteristics, such as single and double leg vertical jump height.
Conclusion
The current results indicate that ACL‐R patients present with several knee strength and vertical jump differences compared to a matched control group at the time of return‐to‐play. Also, ACL‐R patient's performance on an electronic jump mat system is strongly related to isokinetic knee strength measures.
Level of Evidence
2b
PMCID: PMC4458914  PMID: 26075142
Anterior cruciate ligament; functional tests; isokinetic strength; jump mat; return‐to‐play; vertical jump
2.  DEMOGRAPHIC AND EPIDEMIOLOGICAL TRENDS IN PATELLOFEMORAL PAIN 
Background
Understanding the demographics of patellofemoral pain is important to determine the best practices in diagnosis and treatment of this difficult pathology. The occurrence of patellofemoral pain has been reported from isolated sports medicine clinics and from within the military, but its incidence has never been examined in the general population within the United States.
Purpose
The purpose of this study was to examine the reported occurrence of patellofemoral pain for those individuals seeking medical care and to compare that to all other pathologies that result in anterior knee pain, such as tendinopathies, patella subluxation, osteoarthritis, or meniscal and bursal conditions. Occurrence rates were examined across sex, age and region within a large healthcare provider database that contains over 30 million individuals.
Methods
Data were queried with the PearlDiver Patient Record Database, a national database containing orthopedic patient records. Two common International Classification of Disease, Ninth Revision (ICD‐9) codes for patellofemoral pain (717.7 – Patella Chondromalacia and 719.46 – Pain in joint, lower leg) were utilized and were searched from the years 2007‐2011. The top twenty additional ICD‐9 codes that were concurrently coded with 717.7 and 719.46 were removed from the data. Chi‐squared and Mantel‐Haenszel tests were utilized to identify statistically significant differences in the diagnosis of patellofemoral pain between sex, age, and year.
Results
During this five‐year period, there were 2,188,753 individuals diagnosed with patellofemoral pain. The diagnosis was more common in females compared to males with 1,211,665 and 977,088 cases respectfully (p<0.001). Statistically significant differences between ages was found, with 50‐59 year olds having the most cases with 578,854, p<0.001. And, during the five‐year examination period, there was a steady increase between 2007‐2011, p<0.01.
Conclusion
Patellofemoral pain was diagnosed between 1.5% and 7.3% of all patients seeking medical care within the United States. Females experienced patellofemoral pain more often than males and there was a steady increase of cases in the United States during the 2007‐2011 examination period. The diagnosis of patellofemoral pain increased with age and the 50‐59 year old age group had the most cases.
Level of Evidence
2b
PMCID: PMC4458915  PMID: 26075143
Anterior knee pain; chondromalacia; epidemiology
3.  THE EFFECT OF A PELVIC COMPRESSION BELT ON FUNCTIONAL HAMSTRING MUSCLE ACTIVITY IN SPORTSMEN WITH AND WITHOUT PREVIOUS HAMSTRING INJURY 
Background
There is evidence that applying a pelvic compression belt (PCB) can decrease hamstring and lumbar muscle electromyographic activity and increase gluteus maximus activity in healthy women during walking. Increased isokinetic eccentric hamstring strength in the terminal range (25 ° ‐ 5 °) of knee extension has been reported with the use of such a belt in sportsmen with and without hamstring injuries. However, it is unknown whether wearing a pelvic belt alters activity of the hamstrings in sportsmen during walking.
Purpose
To examine the effects of wearing a PCB on electromyographic activity of the hamstring and lumbopelvic muscles during walking in sportsmen with and without hamstring injuries.
Study design
Randomised crossover, cross‐sectional study.
Methods
Thirty uninjured sportsmen (23.53 ± 3.68 years) and 20 sportsmen with hamstring injuries (22.00 ± 1.45 years) sustained within the previous 12 months participated in this study. Electromyographic amplitudes of the hamstrings, gluteus maximus, gluteus medius and lumbar multifidus were monitored during defined phases of walking and normalised to maximum voluntary isometric contraction. Within‐group comparisons [PCB vs. no PCB] for the normalised electromyographic amplitudes were performed for each muscle group using paired t tests. Electromyographic change scores [belt – no belt] were calculated and compared between the two groups with independent t tests.
Results
No significant change was evident in hamstring activity for either group while walking with the PCB (p > 0.050). However, with the PCB, gluteus medius activity (p ≤ 0.028) increased in both groups, while gluteus maximus activity increased (p = 0.025) and multifidus activity decreased (p < 0.001) in the control group. The magnitude of change induced by the PCB in gluteus medius activity was similar between groups (p = 0.760). No statistically significant baseline differences in no belt scores were evident between groups for the investigated muscles (p ≥ 0.050).
Conclusion
Application of a PCB had individual‐specific effects on electromyographic activity of injured and uninjured hamstrings during walking, resulting in no significant changes within or between the two groups. Future studies investigating effects of the PCB on hamstring activity in participants with acute injury and during a more demanding functional activity such as running are warranted.
Level of evidence
Level 3
PMCID: PMC4458916  PMID: 26075144
Athletic injury; hamstring; orthotic; surface electromyography; walking
4.  FUNCTIONAL MOVEMENT SCREEN NORMATIVE VALUES AND VALIDITY IN HIGH SCHOOL ATHLETES: CAN THE FMS™ BE USED AS A PREDICTOR OF INJURY? 
Background
Limited information exists regarding injury risk factors for high school athletes. The Functional Movement Screen (FMS™) has been used to identify functional movement impairments and asymmetries, making it a potential predictor of injury.
Hypothesis/Purpose
To determine if the FMS™ is a valid predictor of injury in high school athletes and to identify a potential new FMS™ cutoff score for this population.
Study Design
Prospective Cohort
Methods
167 high school athletes among several sports were scored using the FMS™ and were monitored for injury during a single season. Likelihood ratios were calculated to determine how much a subject's total FMS™ score influenced the post‐test probability of becoming injured.
Results
Of the 167 participants, 39 sustained a musculoskeletal injury. Of all component scores, the in‐line lunge scores were significantly higher for injured players. For shoulder mobility, scores were significantly lower for injured players. No statistically significant associations were found between total FMS™ scores and injury status.
Conclusion
The FMS™ may be useful for recognizing deficiency in certain movements, however this data suggests that the FMS™ should not be used for overall prediction of injury in high school athletes throughout the course of a season. Normative data from a large sample size is now available in the high school athlete demographic.
Level of Evidence
3
PMCID: PMC4458917  PMID: 26075145
Functional Movement Screen (FMS™); high school athlete; injury risk factors; sports injury
5.  A COMPARISON OF CHANGE IN 3D SCAPULAR KINEMATICS WITH MAXIMAL CONTRACTIONS AND FORCE PRODUCTION WITH SCAPULAR MUSCLE TESTS BETWEEN ASYMPTOMATIC OVERHEAD ATHLETES WITH AND WITHOUT SCAPULAR DYSKINESIS 
Background
The significance of scapular dyskinesis is being challenged due to a lack of the association with pain and ability to predict injury in athletic populations. However, it is unknown whether asymptomatic overhead athletes with dyskinesis cope by normalizing scapular position with higher demand activities.
Hypothesis/Purpose
The purpose of this study was to compare change in scapular kinematics from an active unweighted contraction to a maximal isometric contraction in asymptomatic overhead athletes with and without scapular dyskinesis. Secondarily, force generated with manual muscle tests were explored for differences and relationships with kinematics.
Study Design
Cross‐sectional laboratory study
Methods
Twenty‐five matched asymptomatic overhead athletes with (n=14) and without (n=11) scapular dyskinesis, defined with a reliable and validated clinical method, participated in this study. Three‐dimensional scapular kinematics were evaluated in an active unweighted condition, and during maximal isometric contractions at 90 ° of shoulder flexion. Isometric force produced with lower trapezius and serratus anterior manual muscle tests were assessed with a dynamometer. Changes in scapular kinematics were compared between groups. Differences in force generated with manual muscle tests between groups and relationships with kinematics were explored.
Results
Athletes with dyskinesis demonstrated greater deficits in scapular upward rotation with maximal contraction (p=<0.001), less external rotation (p=0.036) and weaker lower trapezius manual muscle test strength (p=0.031). Lower trapezius (p=0.003;r=0.57) and serratus anterior (p=0.042;r=0.41) manual muscle test strength deficits were fair to moderately associated with a lack of scapular upward rotation during maximal contraction.
Conclusion
Small to moderate changes in scapular kinematics are normal responses to a maximal contraction, but with scapular dyskinesis this response is accentuated. Athletes with dyskinesis generate less force with lower trapezius manual muscle testing compared to athletes without dyskinesis. Decreased strength with lower trapezius and serratus anterior manual muscle testing was also related to a lack of upward rotation in all athletes.
Level of Evidence
3
PMCID: PMC4458918  PMID: 26075146
Shoulder; biomechanics upper extremity; scapula; strength testing
6.  TOTAL ARC OF MOTION IN THE SIDELYING POSITION: EVIDENCE FOR A NEW METHOD TO ASSESS GLENOHUMERAL INTERNAL ROTATION DEFICIT IN OVERHEAD ATHLETES 
Background
Total arc of motion (TA) measured in a supine position has been utilized as a method to detect the presence of glenohumeral internal rotation deficit (GIRD) in overhead athletes. A component of supine TA is supine internal rotation (IR) range of motion (ROM), which has many variables including the amount and location of manual stabilization. A sidelying position for gathering IR ROM has recently been proposed and, when combined with supine external rotation (ER) ROM, constitutes a new method of quantifying TA. This new sidelying TA method, however, has no normative values for overhead athletes.
Purpose
The purposes of this study were to develop normative values for sidelying TA in overhead athletes, determine any ROM difference between supine and sidelying TA, and examine side‐to‐side differences within the two TA methods. A secondary purpose of the study was to examine for any effect of gender or level of competition on the two TA methods.
Study Design
Cross‐sectional study.
Methods
Passive supine IR ROM, supine ER ROM, and sidelying IR ROM were gathered on bilateral shoulders of 176 collegiate and recreational overhead athletes (122 male [21.4 ± 4.7 years, 71.7 ± 2.7 inches, 25.3 ± 2.7 BMI] and 54 female [21.4 ± 5.4 years, 67.6 ± 3.0 inches, 22.5 ± 2.37 BMI]).
Results
Sidelying TA mean for the dominant shoulder was 159.6 °±15.0 °; the non‐dominant shoulder was 163.3 °±15.3 °. Sidelying TA for both shoulders (p < 0.0001) was 14 ° less than supine TA. Both TA methods exhibited a 4 ° dominant‐shoulder deficit (p < 0.0001). For the dominant and non‐dominant shoulder, respectively, there was no gender (p = 0.38, 0.54) or level of competition (p = 0.23, 0.39) effect on sidelying TA.
Conclusion
In overhead athletes, sidelying TA is a viable alternative to supine TA when examining for the presence of GIRD. Gender and level of competition does not significantly affect sidelying TA, so the mean of 160 ° on the dominant shoulder and 163 ° on the non‐dominant shoulder can be used by clinicians.
Level of Evidence
Level 3
PMCID: PMC4458919  PMID: 26075147
Bubble inclinometer; range of motion; shoulder internal rotation; shoulder reliability; total arc of motion
7.  AN ELASTIC EXERCISE BAND MOUNTED WITH A BANDCIZER™ CAN DIFFERENTIATE BETWEEN COMMONLY PRESCRIBED HOME EXERCISES FOR THE SHOULDER 
Background
Home‐exercise is commonly prescribed for rehabilitation of the shoulder following injury. There is a lack of technology available to monitor if the patient performs the exercises as prescribed.
Purpose
The purpose of this study was to investigate the validity of using three dimensional (3D) gyroscope data recorded with the Bandcizer™ sensor to differentiate between three elastic band exercises performed in the shoulder joint: abduction, flexion, and external rotation.
Design
Concurrent validity study.
Methods
This study was performed over two phases. In the first phase, 20 subjects performed three sets of 10 of shoulder abduction, external rotation and flexion exercises with a Thera‐Band mounted with a Bandcizer, while supervised by a physical therapist. The Bandcizer has an inbuilt three‐dimensional gyroscope, capable of measuring angular rotation. Gyroscope data were analyzed in Matlab, and a one‐way ANOVA was used to test for significant differences between each of the three exercises. An algorithm was then created in Matlab based on the exercise‐data from the gyroscope, to enable differentiation between the three shoulder exercises. Twenty new subjects were then recruited to cross‐validate the algorithm and investigate if the algorithm could differentiate between the three different shoulder exercises.
Results
A blinded assessor using the Matlab algorithm could correctly identify 56 out of 60 exercise sets. The kappa agreement for the three exercises ranged between 0.86‐0.91.
Conclusion
The ability to differentiate between the home exercises performed by patients after shoulder injury has great implications for future clinical practice and research. When home exercises are the treatments‐of‐choice, clinicians will be able to quantify if the patient performed the exercise as intended. Further research should be aimed at investigating the feasibility of using the Bandcizer™ in a home‐based environment.
Word count
2429
Level of Evidence
2
PMCID: PMC4458920  PMID: 26075148
Adherence; Bandcizer; gyroscope; rehabilitation
8.  IMPACT SHOULDER ANGLES CORRELATE WITH IMPACT WRIST ANGLES IN STANDING BACK HANDSPRINGS IN PREADOLESCENT AND ADOLESCENT FEMALE GYMNASTS 
Background and Purpose
In gymnastics, the wrist is exposed to many different stresses including increased extension, especially during back handsprings. Currently a wrist extension angle during impact that places the wrist in danger has not been established. The purpose of this study was to: (1) determine the mean impact wrist angle during a standing back handspring in female preadolescent and adolescent gymnasts and (2) determine which factors predict impact wrist angles.
Methods
Fifty female gymnasts from six facilities, ages 8—15 were included in this study. Each gymnast completed a questionnaire about gymnastics participation and history of wrist pain. Active range of motion of the shoulder, elbow, wrist, hip, and ankle was measured. Each gymnast was asked to perform a standard back handspring, which was videotaped. The wrist and shoulder flexion angles, at maximum impact, were recorded and measured using motion analysis software. Two—sample t—test was used to assess the relationship between impact wrist angle and wrist pain. Multiple linear regression was used to determine the association between related variables and impact wrist angle.
Results
The mean back handspring impact wrist angle was 95°. Fifteen subjects (30%) reported wrist pain. Years of participation (p=0.02) and impact shoulder angle (p=0.04) were predictive of impact wrist angles.
Conclusion
Shoulder angles and years of participation correlate with impact wrist angles during the performance of a standing back handspring. Future studies are necessary to determine if addressing these factors can affect the impact wrist angles.
Level of Evidence
3
PMCID: PMC4458921  PMID: 26075149
Back handspring; gymnastics; wrist
9.  SILENT DELTOID ATROPHY IN BEACH VOLLEYBALL PLAYERS: A REPORT OF TWO CASES AND LITERATURE REVIEW 
While examining the shoulders of 91 professional and semi‐professional beach volleyball players, the authors observed two cases of grave atrophy of the deltoid muscle following painless axillary neuropathy, not resulting from any trauma. The causes, the clinical history and the untreated history of the entrapment of the axillary nerve in the quadrilateral space in sportsmen, are discussed on the basis of the presentation of the two cases illustrated and from existing literature.
Level of Evidence
4
PMCID: PMC4458922  PMID: 26075150
axillary nerve entrapment; quadrilateral space syndrome; sport related axillary neuropathy
10.  IMPROVED PRESSURE PAIN THRESHOLDS AND FUNCTION FOLLOWING NOXIOUS ELECTRICAL STIMULATION ON A RUNNER WITH CHRONIC ACHILLES TENDINOPATHY: A CASE REPORT 
Background and Purpose
Achilles tendinopathy is a common overuse injury sustained by athletes including runners. The use of noxious electrical stimulation for the treatment of chronic tendinopathies is a novel treatment intervention, which may alter pain perception and serve as adjunct technique in the recovery of painfree function. The purpose of this case report is to demonstrate the use of noxious electrical stimulation for the treatment of chronic, bilateral Achilles tendinopathy that was resistant to conservative treatment using plantarflexor eccentric exercise.
Case Description
A 27‐year old male runner was referred to physical therapy with a 7‐year history of bilateral Achilles tendinopathy. He scored a 73/80 on the Lower Extremity Functional Scale (LEFS) and a 64% on the Victorian Institute of Sports Assessment‐Achilles (VISA‐A). Pain pressure threshold testing of the Achilles tendon was performed, followed by a single session of noxious electric stimulation to bilateral Achilles tendons, and the subject was instructed to continue with eccentric gastroc‐soleus complex strengthening as previously performed.
Outcomes
Pain pressure threshold testing was performed to the mid‐portion of the posterior Achilles tendon. The left Achilles tendon mean was 10.50kg and right Achilles tendon was 8.33kg prior to the noxious stimulation intervention. Twenty‐four hours after the noxious stimulation treatment, improvements in mean pain threshold testing were found for both the left (16.31kg) and right (12.36kg) Achilles tendons. At one month after the physical therapy noxious stimulation session, the subject was able to progress his workouts to include sprints and interval training. His LEFS improved to 76/80 and his VISA‐A improved to 96%.
Discussion
The case illustrates the successful pain reduction and return to progressive sports activity in a runner with chronic Achilles tendinopathy. The utilization of noxious electric stimulation may have altered the pain perception of the nervous system as evidenced by the improvement in pain pressure threshold testing. Future studies on the application of noxious electric stimulation on chronic Achilles tendinopathy may help support the benefit of this intervention on pain and function.
Level of Evidence
Therapy, Level 4.
PMCID: PMC4458923  PMID: 26075151
Achilles tendinopathy; noxious electrical stimulation; pain; running
11.  CUBOID MANIPULATION AND EXERCISE IN THE MANAGEMENT OF POSTERIOR TIBIALIS TENDINOPATHY: A CASE REPORT 
Background and Purpose
Posterior tibialis tendinopathy is a prevalent musculoskeletal condition often resulting in gait abnormalities along with medial ankle and foot pain. The purpose of this case report is to describe the treatment of a patient with a three year history of posterior tibialis tendinopathy utilizing a combination of cuboid manipulation and exercise.
Case Description
The patient was a 23‐year old female recreational runner and collegiate basketball player reporting a three year history of chronic left ankle and lower leg pain. Outcome measures included the numeric pain rating scale, lower extremity functional scale, strength, passive joint mobility, and functional activities including running distance. Standard care for the treatment of tendinopathy was followed for six weeks with minimal functional improvements. Clinical reasoning skills were applied to redirect the hypothesis implicating limitations in cuboid‐calcaneus internal rotation joint mobility contributing to a posterior tibialis tendinopathy. Manipulation at this joint was utilized to restore mobility. This intervention resulted in an immediate reduction in symptoms and improved functioning. Both muscle strengthening and functional task training were implemented post manipulation.
Outcomes
At discharge, the patient reported full recovery and no pain with running 14 miles. Her lower extremity functional score improved to 78/80, posterior tibialis strength increased to 4/5 and the patient was able to perform 12 single leg heel raises without pain.
Discussion
By restoring cuboid internal rotation mobility, associated midtarsal pronation, and lower extremity neuromuscular control, the posterior tibialis muscle was able to perform efficiently, thus resolving the chronic tendinopathy and returning the patient to optimum functional ability of running.
Level of Evidence
4
PMCID: PMC4458924  PMID: 26075152
posterior tibialis tendon dysfunction; cuboid; manipulation; clinical reasoning.
12.  REACTIVE NEUROMUSCULAR TRAINING RESULTS IN IMMEDIATE AND LONG TERM IMPROVEMENTS IN MEASURES OF HAMSTRING FLEXIBILITY: A CASE REPORT 
Background and Purpose
Hamstring tightness is a common complaint among active individuals and patients are traditionally classified with tight hamstrings based on commonly accepted clinical exams including the active knee extension, active straight leg raise, and passive straight leg raise tests. Apparent hamstring tightness is a condition that is present in patients who have the perception of hamstring tightness and are classified with a tissue extensibility dysfunction but demonstrate immediate gains in hamstring range of motion following an intervention that does not address a tissue length dysfunction. Reactive neuromuscular training can be used as part of the evaluative process used to classify and treat patients with apparent hamstring tightness. The purpose of this case report was to identify, treat, and report the outcomes experienced when using a reactive neuromuscular training technique on a patient who was classified with hamstring inflexibility based on traditional testing methods.
Case Description
A 20 year‐old female softball player presented with a chief complaint of hamstring tightness of more than four years duration. The patient tested positive for hamstring inflexibility based on traditional testing methods. The patient was then treated using a reactive neuromuscular training technique in which the patient resisted a manual anterior to posterior force at the abdomen, sternum and across the hips while simultaneously bending forward at the hips in an attempt to touch her toes.
Outcomes
Following one reactive neuromuscular training treatment session the patient tested negative for hamstring inflexibility based on traditional testing methods and maintained those results at a five‐week follow‐up appointment.
Discussion
The subject in this case report demonstrated the effectiveness of reactive neuromuscular training in identifying and treating apparent hamstring tightness. Based on these findings, clinicians should consider using reactive neuromuscular training to properly classify and treat patients with a chief complaint of hamstring “tightness.”
Level of Evidence
4 (single case report)
PMCID: PMC4458925  PMID: 26075153
Apparent hamstring tightness; patient classification; treatment based classification
13.  THE MANAGEMENT OF ILIOTIBIAL BAND SYNDROME WITH A MULTIFACETED APPROACH: A DOUBLE CASE REPORT 
Background and Purpose
Iliotibial Band Syndrome (ITBS) has commonly been thought of as an overuse injury in runners. The exact etiology of ITBS is not well understood and there is no consensus on how to properly manage it. The purpose of this case series is to present a comprehensive model that utilizes a review of the current literature and the concept of regional interdependence as a foundation for the treatment of ITBS in runners.
Case Descriptions
The first subject was a 36‐year old female, referred from an orthopedic physician with the diagnosis of left iliotibial band friction syndrome. She reported a 9/10 stabbing pain on a visual analog scale (VAS) in the left lateral knee at mile two while running. The second subject was a 41‐year old female with a referral to physical therapy from an orthopedic surgeon for left iliotibial band tendinitis. She reported the symptoms beginning one month prior to her presentation to therapy, and that she would get an 8/10 stabbing pain on a VAS in the left lateral knee at mile three while running. Both subjects complained of the onset of lateral knee pain at a consistent mileage that forced them to stop running. Neither of them initially reported pain in adjoining regions, but did recall some low back stiffness from time to time when questioned further. The concept of regional interdependence, as well as neuromuscular re‐education, and strengthening interventions in conjunction with addressing the contributing factors of training errors, shoe wear, running surface, and program design were utilized.
Outcomes
At a six‐month follow‐up, subject one had successfully completed a half marathon without knee pain. At a nine‐month follow‐up, subject two was able to run five miles, twice weekly and 10 miles once weekly without pain or symptoms.
Discussion
These case reports demonstrate the successful management of ITBS in two subjects using a multifaceted approach based on the current literature and the concept of regional interdependence.
PMCID: PMC4458926  PMID: 26075154
Iliotibial band syndrome; manual therapy; physical therapy; regional interdependence; running injuries
14.  PERFORMANCE OPTIMIZATION AND INJURY PREVENTION STRATEGIES FOR THE ARMY PHYSICAL FITNESS TEST: TECHNIQUE MATTERS 
The Army Physical Fitness Test (APFT) is a biannual training requirement for all soldiers. The Army has made significant overall fitness gains by developing functional and comprehensive Physical Readiness Training (PRT) programs, but more emphasis on individualized physical fitness test taking technique is warranted in order to optimize performance. The purpose of this clinical commentary is to provide clinicians with several examples of APFT performance enhancement techniques that can potentially be applied not only in the Army, but throughout the military and in the sports community where general fitness assessments are routinely administered.
Level of Evidence
5
PMCID: PMC4458927  PMID: 26075155
Fitness assessments; Army Physical Fitness Test; human performance optimization
15.  DRY NEEDLING FOR MYOFASCIAL TRIGGER POINT PAIN: A CLINICAL COMMENTARY 
Sports and orthopaedic physical therapists have long used a multitude of techniques in order to address pain and dysfunction associated with myofascial trigger points. One technique in particular has recently received overwhelming attention: trigger point dry needling (DN). Despite its efficacy and low risk, questions remain as to its effectiveness, safety, and whether the technique is within the scope of practice of physical therapists. Therefore, the purpose of this clinical commentary is to summarize the current literature related to the associated mechanisms of action of DN, the safety of DN, as well as to discuss relevant scope of practice concerns.
Level of Evidence
5
PMCID: PMC4458928  PMID: 26075156
Dry needling; TDN; DN; Trigger point dry needling
16.  CORRIGENDUM 
PMCID: PMC4458929  PMID: 26075157
17.  THE RELIABILITY OF REHABILITATIVE ULTRASOUND IMAGING IN THE MEASUREMENT OF INFRASPINATUS MUSCLE FUNCTION IN THE SYMPTOMATIC AND ASYMPTOMATIC SHOULDERS OF PATIENTS WITH UNILATERAL SHOULDER IMPINGEMENT SYNDROME 
Background:
Rehabilitative ultrasound Imaging (RUSI) is increasingly used in the management of musculoskeletal conditions as it provides an objective measure of muscle function while being less invasive than needle electromyography. While research has documented the ability to reliably measure trunk muscles in patients with back pain, no study to date has used RUSI to quantify infraspinatus muscle function in patients with shoulder impingement syndrome (SIS).
Hypothesis/Purpose:
The purpose of this study was to examine the intra‐rater and inter‐rater reliability of measuring infraspinatus muscle thickness with RUSI and to compare such measures during resting versus contracted muscle states and in the symptomatic versus asymptomatic shoulders in patients with SIS.
Study Design:
Cross‐sectional, measurement study
Methods:
Fifty‐two participants with unilateral SIS underwent a standard baseline examination to include RUSI of the infraspinatus muscle bilaterally. Images were acquired at rest and during a submaximal isometric contraction, by two novice examiners. The isometric contraction was elicited by having prone participants externally rotate their shoulder from a position of 90° abduction into a dynamometer and hold a static force of 20 mmHg (approximately 20‐30% maximal voluntary contraction). Images were captured using a standardized placement of the transducer placed just inferior to the spine of the scapula along the medial scapular border and measured off‐line using Image J software (V1.38t, National Institutes of Health, Bethesda, Maryland).
Results:
Estimates (ICCs) for thickness measurements ranged between 0.96 and 0.98 for intra‐rater reliability and between 0.87 and 0.92 for inter‐rater reliability. Reliability was substantially lower (ICC = 0.43 to 0.79) for calculations of percent thickness change. The infraspinatus muscle was significantly thicker when contracted (19.1mm) than during rest (16.2mm) in both shoulders (p < 0.001). There was also a statistically significant interaction between contraction state and shoulder (p = 0.026), indicating that the change in thickness that occurred during contraction was significantly smaller in the symptomatic shoulder than in the asymptomatic shoulder.
Conclusion:
RUSI measurements of infraspinatus muscle thickness appear to be highly reliable, both within the same examiner and between different examiners, in patients with SIS. Moreover, such measurements were different in rested and contracted states of the infraspinatus, as well as, between the symptomatic and asymptomatic shoulders of patients with unilateral SIS.
Level of evidence:
Level 2
PMCID: PMC4387720  PMID: 25883861
Infraspinatus muscle; muscle function; reliability; shoulder impingement syndrome; shoulder pain; ultrasound imaging
18.  CONCURRENT VALIDITY AND RELIABILITY OF 2D KINEMATIC ANALYSIS OF FRONTAL PLANE MOTION DURING RUNNING 
Purpose:
Three‐dimensional motion analysis is the “gold standard” for evaluating kinematic variables during treadmill running. However, its use is limited by temporal and financial restraints. Therefore, the purpose of this study was to assess the concurrent validity and reliability of 2D video analysis for frontal plane kinematic variables during treadmill running.
Methods:
Twenty‐four healthy male and female collegiate cross‐country runners completed a running protocol at a self‐selected speed. Frontal plane kinematic data were collected using 3D and 2D motion analysis systems. Variables of interest included contralateral pelvic drop (CPD), peak hip adduction angle (HADD), and peak knee abduction angle (KABD). Pearson Product Correlation Coefficients were used to determine the relationship between the 3D and 2D systems for each variable. Intra‐Class Correlation Coefficients (ICC) were used to assess intra‐rater reliability of the user of the 2D software.
Results:
The 2D testing method demonstrated excellent intra‐rater reliability for peak HADD (ICCs: 0.951‐0.963), peak CPD (0.958‐0.966), and peak KABD (ICCs: 0.955‐0.976). Moderate correlations between 2D and 3D measures of HADD on the left (0.539; p=0.007) and the right (0.623; p=0.001) and peak KABD on the left (0.541; p=.006) lower extremity were found. No statistically significant correlation of CPD was found between the 2D and 3D systems. The 2D measure of CPD had a strong correlation to the 2D assessment of HADD on both the left (0.801; p=0.0001) and the right (0.746; p=0.0001) extremity.
Conclusion:
These findings and the ease of data capture using 2D software provide support for the utility of 2D video analysis in the evaluation of frontal plane variables, specifically HADD.
Level of evidence:
2B
PMCID: PMC4387721  PMID: 25883862
2D video analysis; contralateral pelvic drop; hip adduction; running
19.  RELIABILITY OF VIDEO‐BASED QUANTIFICATION OF THE KNEE‐ AND HIP ANGLE AT FOOT STRIKE DURING RUNNING 
Introduction:
In clinical practice, joint kinematics during running are primarily quantified by two‐dimensional (2D) video recordings and motion‐analysis software. The applicability of this approach depends on the clinicians’ ability to quantify kinematics in a reliable manner. The reliability of quantifying knee‐ and hip angles at foot strike is uninvestigated.
Objective:
To investigate the intra‐ and inter‐rater reliability within and between days of clinicians’ ability to quantify the knee‐ and hip angles at foot strike during running.
Methods:
Eighteen recreational runners were recorded twice using a clinical 2D video setup during treadmill running. Two blinded raters quantified joint angles on each video twice with freeware motion analysis software (Kinovea 0.8.15)
Results:
The range from the lower prediction limit to the upper prediction limit of the 95% prediction interval varied three to eight degrees (within day) and nine to 14 degrees (between day) for the knee angles. Similarly, the hip angles varied three to seven degrees (within day) and nine to 11 degrees (between day).
Conclusion:
The intra‐ and inter rater reliability of within and between day quantifications of the knee‐ and hip angle based on a clinical 2D video setup is sufficient to encourage clinicians to keep using 2D motion analysis techniques in clinical practice to quantify the knee‐ and hip angles in healthy runners. However, the interpretation should include critical evaluation of the physical set‐up of the 2D motion analysis system prior to the recordings and conclusions should take measurement variations (3‐8 degrees and 9‐14 degrees for within and between day, respectively) into account.
Level of evidence:
3
PMCID: PMC4387722  PMID: 25883863
kinematics; knee‐ and hip angles; motion‐analysis software; reliability; running
20.  LOWER EXTREMITY OVERUSE BONE INJURY RISK FACTORS IN COLLEGIATE ATHLETES: A PILOT STUDY 
Background and Purpose:
There is limited evidence regarding risk factors for lower extremity overuse bone injury (LEOBI) in collegiate athletes. The purposes of the study were to: 1) determine incidence of LEOBI in selected sports and its impact on athletic participation and ADL, 2) assess risk relationships between LEOBI and selected risk factors, and 3) establish the viability of using calcaneal densitometry as a screening tool to identify risk for LEOBI.
Study Design:
Prospective analytical cohort design
Methods:
Collegiate athletes in selected sports (swimming/diving, women’s soccer, field hockey, cross‐country/track) at one university were invited to participate. Consenting athletes completed an initial questionnaire including demographic information, history, and menstrual function. Measurements included height/weight, hip abductor strength, foot posture index, and calcaneal bone mineral density. Athletes were monitored for potential LEOBI for nine months and an algorithm was used to determine if physician referral was required. The primary outcome of interest was the occurrence of physician‐diagnosed LEOBI. If LEOBI was diagnosed by the physician, the athlete completed a follow‐up visit including a repeat bone mineral density scan. All athletes were invited for a repeat scan at the end of the year and completed a final questionnaire. Athlete demographics were summarized using descriptive statistics and differences in continuous risk factors were analyzed using t‐tests and ANOVA. Finally, risk relationships for categorical variables were analyzed using chi‐square and relative risk.
Results:
84 athletes (64 female, 20 male) consented to participate. Over the study period, eight athletes (one male, seven females) were diagnosed with LEOBI (LEOBI group), five with stress fractures and three with medial tibial stress syndrome. The other 76 athletes who did not have a diagnosis of LEOBI were placed in the non‐LEOBI group. Five of the eight were cross‐country/track athletes; no swimming/diving athletes had bone injury. Sport (cross‐country/track) had a significant relative risk value of 2.26 (95% CI = 1.18‐4.32) for LEOBI. There was no association between LEOBI occurrence and sex, hip abductor strength, body mass index, foot type, and menstrual function. There was no difference in bone mineral density at initial or follow‐up measures between LEOBI and non‐LEOBI groups (p>.05) when analyzing all athletes. When analyzing ground‐based athletes only at follow‐up (n=44), athletes with LEOBI had lower bone mineral density of right (p = .05) and left (p =.07) calcaneus. The relative risk for developing LEOBI based on calcaneal bone mineral density below the mean of the study participants was 2.1 (95%CI = 1.09‐3.35) on the left and 1.53 (95% CI=.80‐ 3.06) on the right.
Conclusion:
The incidence of LEOBI in this population of athletes was approximately 10%. Risk factors were sport (cross‐country/track) and decreased left calcaneal bone mineral density. This study supports the use of calcaneal bone mineral density as a screening measurement for LEOBI risk and suggests the need for further investigation into additional LEOBI risk factors.
Level of evidence:
2
PMCID: PMC4387723  PMID: 25883864
Bone density; medial tibial stress syndrome; overuse injury; risk; stress fracture
21.  CLINICAL OBSERVATION AND ANALYSIS OF MOVEMENT QUALITY DURING PERFORMANCE ON THE STAR EXCURSION BALANCE TEST 
Study Design:
Observational
Background:
The Star Excursion Balance Test (SEBT) is used to evaluate dynamic postural control and screen for injury risk. No prior studies have investigated whether the quality of movement during the SEBT has clinical value and can adequately predict injury.
Purpose:
To develop a visual assessment tool and evaluate the relationship between movement quality and SEBT outcomes.
Methods:
One hundred healthy subjects were included. Baseline demographic, limb length, and individual SEBT performance data were collected. SEBT outcomes were obtained and used to classify individuals as at‐risk or not at‐risk. At‐risk individuals demonstrated anterior right/left reach distance difference greater than 4 cm, and/or normalized composite reach distance less than 89.6% for males or 94% for females. Three independent reviewers, blinded to SEBT outcomes, assessed the anterior reach test on videotape. Reviewers underwent training on a scoring system to assess movement quality at the trunk, pelvis, and knee. The total score of movement faults was used to determine interrater reliability and calculate sensitivity and specificity, in addition to positive and negative predictive values of SEBT outcome.
Results:
Seventy‐one subjects were classified as at risk. Interrater reliability of movement scoring was poor‐moderate for the trunk and pelvis (κ=0.18‐0.43), and moderate for the knee (κ=0.5‐0.6). Rater agreement for total movement score was fair‐moderate (W=0.64‐0.73). Rater assessment of aberrant movement was not predictive of SEBT performance. However, subjects deemed at risk had fewer movement faults per rater assessment. Raters displayed moderately strong specificity (0.59‐0.82) and poor sensitivity (0.14‐0.39) in knee assessment to detect at risk performance on the SEBT.
Conclusion:
Clinical observation of knee movement demonstrated acceptable interrater reliability and moderately strong specificity to detect at‐risk SEBT outcome. Total movement score across all regions demonstrated fair‐moderate agreement. Subjects who were at risk tended to have fewer movement faults.
Level of evidence:
3
PMCID: PMC4387724  PMID: 25883865
Lower extremity; postural stability; Star Excursion Balance Test
22.  EVALUATION OF A TREATMENT ALGORITHM FOR PATIENTS WITH PATELLOFEMORAL PAIN SYNDROME: A PILOT STUDY 
Background:
Treatment of patellofemoral pain syndrome (PFPS) has been extensively studied in physical therapy literature. Patients with PFPS demonstrate quadriceps and hip musculature weakness, altered lower extremity (LE) kinematics, and decreased LE flexibility. Psychosocial factors have also been identified as an important factor in patients with PFPS. The authors hypothesize that an ordered approach addressing each of these impairments sequentially will result in greater improvement in PFPS symptoms. The purpose of this pilot study was to assess the feasibility of performing a randomized trial and to determine the sample size necessary to examine the validity of this hypothesis.
Methods:
Patients received a sequential treatment approach using a PFPS treatment algorithm (PFPS Algorithm) designed by the authors. Patients were evaluated assessing psychosocial factors, flexibility, LE kinematics, and LE strength. Impairments that were found in the evaluation were addressed sequentially over the episode of care. Patients were prescribed therapy two times per week for six weeks. Pain, Anterior Knee Pain Scale (AKPS), and Global Rating of Change (GROC) were measured at evaluation and discharge.
Results:
Thirty consecutive patients with PFPS who were referred to physical therapy were enrolled in the pilot study. All phases of the feasibility study including recruitment, treatment protocols and data collection were effectively carried out. One hundred percent of patients treated with the PFPS algorithm who completed the prescribed treatment had a clinically significant improvement in the AKPS and GROC. A floor effect was noted with NPRS with 38% of patients unable to achieve clinically significant improvement.
Conclusions:
With minor changes to the protocol and outcome measures used, a full randomized trial is feasible and merited. Steps must be taken to reduce the high drop‐out rate among both groups.
Level of Evidence:
1b
PMCID: PMC4387725  PMID: 25883866
Patellofemoral pain; knee pain; physical therapy
23.  BIOMECHANICAL LOADS DURING COMMON REHABILITATION EXERCISES IN OBESE INDIVIDUALS 
Background:
Squats and lunges are commonly prescribed rehabilitation exercises used to improve performance across a wide spectrum of patient populations. However, biomechanical studies have mainly examined young, normal weight populations performing these exercises at a difficulty level potentially too challenging for obese individuals. Understanding how obesity and different levels of difficulty affect lower extremity biomechanics could help to inform rehabilitation approaches used for obese individuals.
Purpose:
The purpose of this study was to analyze and compare the lower extremity kinematics and kinetics in obese and normal weight females during performance of progressively more difficult squat and lunge exercises.
Study Design:
Cross‐sectional study design
Methods:
Ten obese females (mean age, 37.4 years; BMI 39.2 ± 3.7 kg/m2) and ten normal‐weight, age‐matched female controls (38.1 years, BMI < 23 kg/m2) volunteered for the study. Each group performed two exercises, each in three different iterations: squatting at three standardized knee angles (60°, 70°, and 80°) and lunging at three standardized distances (1.0, 1.1, and 1.2 times tibial length). Three dimensional motion analysis using infrared markers and force plates was used to calculate range of motion as well as hip, knee, ankle and support moments (normalized for body weight). A repeated measures ANOVA model was used to determine between and within group differences.
Results:
Support moments were higher in obese females for squat 70° (p=0.03) and 80° (p=0.01). Ankle extensor moments were higher in obese females for squat 80° (p=0.04). During lunge at all levels (1.0, 1.1, and 1.2), hip extensor moments were higher in obese subjects (p=0.004, 0.003, and 0.007 respectively). Within group, the support moments were significantly higher during squat 80° than squat 60° (p=0.01) in obese females. A non‐linear relationship was found between hip moments and BMI during squat 60°, 70°, and 80°.
Conclusion:
During two commonly prescribed rehabilitation exercises (squat and lunge), there were significantly greater support moments in obese individuals compared to normal controls. The non‐linear associations between kinetic and anthropometric measures make the assessment of how best to approach exercise in obese individuals challenging.
Level of evidence:
Level 3
PMCID: PMC4387726  PMID: 25883867
Biomechanics; lunge; obesity; physical therapy; squat
24.  THE VALIDITY AND RELIABILITY OF A NEW INSTRUMENTED DEVICE FOR MEASURING ANKLE DORSIFLEXION RANGE OF MOTION 
Purpose/Background:
A restriction in ankle dorsiflexion range of motion (ROM) has been linked to several clinical manifestations such as metatarsalgia, heel pain, nerve entrapment, ankle joint equinus, patellar and ankle injuries. The purpose of the present study was to examine the validity and reliability of the Leg Motion system for measuring ankle dorsiflexion ROM.
Study Design:
Descriptive repeated‐measures study.
Methods:
Twenty‐six healthy male university students were recruited to test the reliability of the Leg Motion system, which is a portable tool used for assessment of ankle dorsiflexion during the weight‐bearing lunge test. The participants were tested two times separated by two weeks and measurements were performed at the same time of the day by the same single rater. To test the validity of the Leg Motion system, other maximal ankle dorsiflexion ROM assessments (goniometer, inclinometer and measuring tape) were measured in a single session (i.e., the first test session) during the weight‐bearing lunge position using a standard goniometer, a digital inclinometer and a measuring tape measure with the ability to measure to the nearest 0.1 cm.
Results:
Paired t‐tests showed the absence of significant differences between right and left limb measurements of dorsiflexion in all tests. Mean values ± standard deviations were as follows: Leg Motion test (left 11.6cm±3.9; right 11.9cm ±4.0), tape measure (left 11.6cm±4.0; right 11.8cm±4.2), goniometer (left 40.6º±5.2; right 40.6º±5.2), and digital inclinometer (left 40.0º±5.8; right 39.9º±5.6). The Leg Motion composite values (i.e., average of the two legs) showed a significant (p<0.05) positive correlation with the tape measure (r=0.99), with the goniometer (r=0.66), and with the digital inclinometer (r=0.72).
Conclusions:
The results of the present study provide evidence to support the use of the Leg Motion system as a valid, portable, and easy to use alternative to the weight‐bearing lunge test to assess ankle dorsiflexion ROM in healthy participants.
Level of evidence:
2b.
PMCID: PMC4387727  PMID: 25883868
Ankle dorsiflexion; goniometer; inclinometer; weight‐bearing lunge
25.  COMPARING THE EFFECTS OF SELF‐MYOFASCIAL RELEASE WITH STATIC STRETCHING ON ANKLE RANGE‐OF‐MOTION IN ADOLESCENT ATHLETES 
Background:
Increased flexibility is often desirable immediately prior to sports performance. Static stretching (SS) has historically been the main method for increasing joint range‐of‐motion (ROM) acutely. However, SS is associated with acute reductions in performance. Foam rolling (FR) is a form of self‐myofascial release (SMR) that also increases joint ROM acutely but does not seem to reduce force production. However, FR has never previously been studied in resistance‐trained athletes, in adolescents, or in individuals accustomed to SMR.
Objective:
To compare the effects of SS and FR and a combination of both (FR+SS) of the plantarflexors on passive ankle dorsiflexion ROM in resistance‐trained, adolescent athletes with at least six months of FR experience.
Methods:
Eleven resistance‐trained, adolescent athletes with at least six months of both resistance‐training and FR experience were tested on three separate occasions in a randomized cross‐over design. The subjects were assessed for passive ankle dorsiflexion ROM after a period of passive rest pre‐intervention, immediately post‐intervention and after 10, 15, and 20 minutes of passive rest. Following the pre‐intervention test, the subjects randomly performed either SS, FR or FR+SS. SS and FR each comprised 3 sets of 30 seconds of the intervention with 10 seconds of inter‐set rest. FR+SS comprised the protocol from the FR condition followed by the protocol from the SS condition in sequence.
Results:
A significant effect of time was found for SS, FR and FR+SS. Post hoc testing revealed increases in ROM between baseline and post‐intervention by 6.2% for SS (p < 0.05) and 9.1% for FR+SS (p < 0.05) but not for FR alone. Post hoc testing did not reveal any other significant differences between baseline and any other time point for any condition. A significant effect of condition was observed immediately post‐intervention. Post hoc testing revealed that FR+SS was superior to FR (p < 0.05) for increasing ROM.
Conclusions:
FR, SS and FR+SS all lead to acute increases in flexibility and FR+SS appears to have an additive effect in comparison with FR alone. All three interventions (FR, SS and FR+SS) have time courses that lasted less than 10 minutes.
Level of evidence:
2c
PMCID: PMC4387728  PMID: 25883869
Ankle; dorsiflexion; flexibility; self‐massage; stretching

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