A case of an athlete with accessory nerve injury has not been previously reported although there have been a number of case reports and case series of non‐athletes with accessory nerve injury. This case study reports motor control intervention for an amateur baseball pitcher with isolated paralysis of the right trapezius who lost pitching control after changing his pitching technique. The subject was able to restore ball control during overhead throwing after physiotherapy.
The subject of this case report was a 20‐year‐old amateur male baseball pitcher, who presented with long‐standing isolated paralysis of the right trapezius and a six month history of loss of ball control with shoulder pain during pitching. He was seen for a second opinion following unsuccessful conservative management and underwent physiotherapy to restore his ball control during pitching. Restriction of cervical rotation range of motion and decreased position sense during shoulder abduction and external rotation were revealed in the physical examination. Proprioceptive exercise was commenced with and without visual feedback to acquire a reproducible abduction angle in the cocking phase of a baseball pitch. His pitching form was modified to ensure his arm was being raised effectively in the cocking phase. Pitching drills that were utilized were targeted motor control of the upper quarter, and were progressed in steps. Cervical joint mobilization was undertaken to allow adequate range of motion for visualization of the target while pitching.
His position sense and cervical range of motion were restored. His pitching control was restored with conservative therapy on by the eighth week of intervention.
The subject was able to return to competitive level of amateur baseball with accurate ball control. This case report demonstrates that achievement of control of a skilled upper quarter activity, such as baseball pitching, is possible with conservative management even in the presence of paralysis of trapezius, a major contributor to the movement.
Level of Evidence:
4 (single case report)
Amateur baseball pitcher; ball control; isolated trapezius paralysis; proprioceptive exercise
Background and Purpose:
Proximal humeral fractures are relatively uncommon injuries. While previous research has led to effective clinical and diagnostic evaluation and treatment of proximal fractures, less is currently known regarding the typical evaluation and treatment of midshaft humeral fractures. The purpose of this case is to describe the clinical reasoning and utilization of diagnostic imaging in the physical therapy management of a midshaft humeral fracture, sustained during the course of rehabilitation of a proximal humerus fracture.
A 63‐year‐old female recreational tennis player presented to physical therapy, progressing well following a proximal humeral fracture, sustained 18 weeks prior. During the course of care, the patient had a significant regression in range of motion and function, with increased pain, following a seemingly trivial injury. Based on a cluster of subjective and objective flags, the therapist was concerned about a new fracture. The therapist communicated findings with a physician and recommended plain film radiographs before continuing therapy.
Radiographs showed an oblique displaced fracture extending through the midshaft of the humerus. The patient ultimately underwent surgical plating. At one‐year post injury e‐mail follow up, she had functional mobility of her left arm, and was playing tennis recreationally three times a week.
In this case, a patient who was progressing well following a proximal humeral fracture sustained a separate displaced fracture of the midshaft of the humerus, not associated with therapy. Her reported mechanism was not consistent with a typical injury. This highlights the need for clinicians, specifically physical therapists, to cluster subjective information, objective data, and the patient's medical history when interpreting patient appropriateness for therapy, and to optimize outcomes.
Level of Evidence:
5 (single case report)
clinical reasoning; humeral fracture; radiograph; tennis
Background and Purpose:
Isolated fractures involving the first rib are rare and often difficult to diagnose. There is a paucity of literature regarding isolated fractures and even fewer reported cases involving those due to contact. The purpose of this case report is to describe the mechanism of injury, differential diagnosis, rehabilitation, and return to sport decision making for an isolated first rib fracture secondary to acute trauma in a collegiate football player.
An 18 year‐old right‐hand dominant male collegiate football player was involved in a facemask‐to‐facemask collision during a football game while playing defensive back. His chief complaint during the sideline evaluation was left‐sided neck and shoulder pain with concomitant clicking reported with active movement of his left shoulder.
A musculoskeletal ultrasound performed in the training room suggested a possible scapular spine fracture. However, a subsequent magnetic resonance image revealed an acute isolated anterolateral fracture of the first rib. The subject was treated conservatively with extensive rehabilitation and was able to return to full participation for summer training camp as well as the fall football season at the same level of play as prior to injury.
An isolated first rib fracture is extremely rare due to the unique anatomical location of the first rib posterior to the clavicle, as well as the surrounding shoulder girdle and associated layer of musculature. Identifying this injury can be challenging due to vaguely reported symptoms and the paucity of reported incidences. In the setting of an isolated injury, conservative management including structured rehabilitation can lead to successful outcomes and return to play. This is the first published rehabilitation guideline for an acute isolated first‐rib fracture secondary to trauma.
Level of Evidence:
4 – Single case report
First rib fracture; football athlete; shoulder pain
Movement ability is an often‐overlooked component of sports science and
sports medicine research and needs to be considered alongside the appraisal of
physical fitness and performance characteristics. To achieve this, a standardised
assessment tool is required. The purpose of this paper is to introduce a new
method for assessing movement ability and present results for intra‐ and
National level female football players (n=17) were assessed
using a novel movement assessment tool, the Athletic Ability Assessment
(AAA). Athletes were assessed according to the scoring criteria by
the primary researcher in real‐time and via video on two separate occasions
to estimate intra‐tester reliability. Inter‐tester reliability was
estimated using the difference between five other testers'
The intra‐tester minimal detectable change (MDC) for the
composite AAA score was 2.9 points (90% confidence limits; 2.3
– 4.2 points) (2.5%; 2.0 – 3.6%)
with an intraclass correlation coefficient (ICC) of 0.97
(0.92 – 0.99). Inter‐tester MDC for the composite AAA
score was 2.8 points (2.5 – 3.3 points) (2.4%;
2.1 – 2.8%) with an ICC 0.96 (0.94 –
0.98) Individual exercise scores for the intra‐ and
inter‐tester show a similar range MDC of between 0.4 – 1.1 points
and kappa statistic level of agreement between 0.32 ‐0.77.
Results of the reliability analysis suggest high levels of agreement between
scorers for total scores and provide reference values for minimal detectable
changes using the AAA. The aim of the AAA is to become a reliable movement
assessment protocol that addresses specific sporting populations. The reliability
of AAA scoring established in this study is the first step in supporting the
utilization of the AAA in future research.
Level of evidence:
Functional movement; reliability; screening
A new 16‐item physical performance measure screening battery (16‐PPM) was developed in order to expand on established movement based qualitatively scored functional screening batteries to encompass a broader spectrum of quantitatively scored functional constructs such as strength, endurance, and power.
The purpose of this study was quantify the real‐time tests‐retest and expert versus novice interrater reliability of the 16‐PPM screen on a group of physically active college‐aged individuals. The authors' hypothesized that the test‐retest and interrater reliability of quantitatively‐scored performance measures would be highly correlated (ICC ≥ 0.75) and that qualitatively‐scored movement screening tests would be moderately correlated (Kw = 0.41‐0.60).
Cohort reliability study
Nineteen (8 males, 11 females) healthy physically active college‐aged students completed the 16‐PPM on two days, one week apart.
The majority of the quantitatively scored components of the 16‐PPMs demonstrated good expert‐novice interrater reliability (ICC > 0.75), while qualitatively scored tests had moderate (Kw = 0.41‐0.60) to substantial (Kw = 0.61‐0.80) agreement. Test‐retest reliability was consistent between raters, with most quantitatively scored PPMs exhibiting superior reliability to the qualitatively scored PPMs.
The 16‐PPM test items showed good test‐retest and interrater reliability. However, results indicate that expert raters may be more reliable than novice raters for qualitatively scored tests. The validity of this 16‐PPM needs to be determined in future studies.
Physical performance screening batteries may be used to help identify individuals at risk for future athletic injury; however, current PPMs that rely on qualitatively scored movement screens have exhibited inconsistent and questionable injury prediction validity. The addition of reliable quantitatively scored PPMs may complement qualitatively scored PPMs to improve the battery's predictive ability.
Level of Evidence:
Functional screen; physical performance measures; reliability
Distance running offers a method to improve fitness but also has a risk of lower limb overuse injuries. Foot strike technique has been suggested as a method to alter loading of the lower limb and possibly minimize injury risk. However, there is a dearth of information regarding neuromuscular response to variations in running techniques. The purpose of this investigation was to compare the EMG activity that occurs during FFS running and RFS running, focusing on the biceps femoris, semitendenosis, rectus femoris, vastus medialis oblique, tibialis anterior (TA), medial head of gastrocnemeus (MGas), lateral head of gastrocnemius (LGas), and soleus.
healthy adults (6 male, 8 female; age, 24.2 ± 0.8 years, height 170.1 ± 7.8 cm; mass 69.8 ±10.9 kg; Body Mass Index 24.1 ± 3.0 kg·m2) participated in the study. All participants performed a RFS and FFS running trial at 8.85 kph. A 3D motion capture system was used to collect kinematic data and electromyography was used to define muscle activity. Two‐tailed paired t‐tests were used to examine differences in outcomes between RFS and FFS conditions.
The ankle was significantly more plantarflexed during FFS running (p = .0001) but there were no significant differences in knee and hip angles (p = .618 & .200, respectively). There was significantly less activity in tibialis anterior (TA) (p < .0001) and greater activity in the MGas (p= .020) during FFS running. The LGas and soleus did not change activity (p = .437 & .490, respectively).
FFS running demonstrated lower muscular activity in the TA and increased activation in the MGas.
FFS and RFS running have the potential to off‐load injury prone tissues by changing between techniques. However, future studies will be necessary to establish more direct mechanistic connections between running technique and injury.
Electromyography (EMG); kinematics; neuromuscular adaptation
Clinical assessment of lower limb kinematics during dynamic tasks may identify individuals who demonstrate abnormal movement patterns that may lead to etiology of exacerbation of knee conditions such as patellofemoral joint (PFJt) pain.
The purpose of this study was to determine the reliability, validity and associated measurement error of a clinically appropriate two‐dimensional (2‐D) procedure of quantifying frontal plane knee alignment during single limb squats.
Nine female and nine male recreationally active subjects with no history of PFJt pain had frontal plane limb alignment assessed using three‐dimensional (3‐D) motion analysis and digital video cameras (2‐D analysis) while performing single limb squats. The association between 2‐D and 3‐D measures was quantified using Pearson's product correlation coefficients. Intraclass correlation coefficients (ICCs) were determined for within‐ and between‐session reliability of 2‐D data and standard error of measurement (SEM) was used to establish measurement error.
Frontal plane limb alignment assessed with 2‐D analysis demonstrated good correlation compared with 3‐D methods (r = 0.64 to 0.78, p < 0.001). Within‐session (0.86) and between‐session ICCs (0.74) demonstrated good reliability for 2‐D measures and SEM scores ranged from 2° to 4°.
2‐D measures have good consistency and may provide a valid measure of lower limb alignment when compared to existing 3‐D methods.
Assessment of lower limb kinematics using 2‐D methods may be an accurate and clinically useful alternative to 3‐D motion analysis when identifying individuals who demonstrate abnormal movement patterns associated with PFJt pain.
Level of Evidence:
Patellofemoral joint pain; dynamic knee valgus; functional tasks
Researchers suggest that decreased strength of the gluteus medius (GMed) and the gluteus maximus (GMax) muscles contributes to the etiology of various orthopedic pathologies of the knee. Currently, equivocal evidence exists regarding Electromyography (EMG) activity of gluteal musculature during weightbearing (WB) and non‐weightbearing (NWB) exercise. The purpose of this study was to compare GMed and GMax muscle activation during WB functional exercise and NWB 10 repetition maximum (RM) exercises.
Surface EMG electrodes recorded the muscle activity of the GMax and GMed as subjects performed three sets of 10 repetitions of the following exercises: (1) forward step‐up, (2) lateral step‐up, (3) 10 repetition maximum (10 RM) side‐lying hip abduction and (4) 10 RM prone hip extension. The 10 RM resistances were determined one week prior to data collection.
The GMed was recruited significantly more during side‐lying 10 RM than the remaining exercises (side‐lying, 99.9±17% vs. lateral step‐up, 61±20%; Forward step‐up, 62.7±18.2%; prone, 38±22.2%)(p<0.001). The GMax was recruited to the greatest extent during prone 10 RM hip extension (prone, 100.7±14.5% vs. forward step‐up, 28.7±18.7%; lateral step‐up, 31±19.9%; side‐lying, 38±23.3%)(p<0.001).
These results suggest that performing a 10 RM NWB exercise results in greater muscle activation than two functional WB exercise without load in young, healthy individuals. In addition, forward and lateral step‐ups failed to effectively recruit the GMax at a high enough level to achieve a strengthening stimulus. The GMed was recruited to a higher extent than the GMax during the stepping tasks which might be further augmented if the activity is performed with an additional external load.
Level of Evidence:
Electromyography; functional; hip strengthening
Neuromuscular Electrical Stimulation is a common intervention to address muscle weakness, however presents with many limitations such as fatigue, muscle damage, and patient discomfort that may influence its effectiveness. One novel form of electrical stimulation purported to improve neuromuscular re‐education is Patterned Electrical Neuromuscular Stimulation (PENS), which is proposed to mimic muscle‐firing patterns of healthy individuals. PENS provides patterned stimulating to the agonist muscle, antagonist muscle and then agonist muscle again in an effort to replicate firing patterns.
The purpose of this study was to determine the effect of a single PENS treatment on knee extension torque and quadriceps activation in individuals with quadriceps inhibition.
18 subjects (10 males and 8 females: 24.2±3.4 years, 175.3±11.8cm, 81.8±12.4kg) with a history of knee injury/pain participated in this double‐blinded randomized controlled laboratory trial. Participants demonstrated quadriceps inhibition with a central activation ratio of ≤90%. Maximal voluntary isometric contraction of the quadriceps and central activation ratio were measured before and after treatment. The treatment intervention was a 15‐minute patterned electrical stimulation applied to the quadriceps and hamstring muscles with a strong motor contraction or a sham group, who received an identical set up as the PENS group, but received a 1mA subsensory stimulation. A 2×2 (group × time) ANCOVA was used to determine differences in maximal voluntary isometric contraction and central activation ratio between groups. The maximal voluntary isometric contraction was selected as a covariate due to baseline differences.
There were no differences in change scores between pre‐ and post‐intervention for maximal voluntary isometric contraction: (PENS: 0.09±0.32Nm/kg and Sham 0.15±0.18Nm/kg, p=0.713), or central activation ratio:(PENS: ‐1.22±6.06 and Sham: 1.48±3.7, p=0.270).
A single Patterned Electrical Neuromuscular Stimulation treatment did not alter quadriceps central activation ratio or maximal voluntary isometric contraction. Unlike other types of muscle stimulation, PENS did not result in a reduction of quadriceps torque.
Level of Evidence:
Electrical stimulation; muscle inhibition; quadriceps torque
Poor activation of the serratus anterior (SA) muscle may result in abnormal shoulder rhythm, and secondarily contribute to impingement and rotator cuff tears. Sequential activation of the trunk, pelvis, and lower extremity (LE) muscles is required to facilitate the transfer of appropriate forces from these body segments to the upper extremity. Myofascial connections that exist in the body, and LE and trunk muscles (TM) activity may influence scapular and upper limb activity. The purpose of this study was to investigate the effect of simultaneous recruitment of the LE muscles and TM on the SA muscle activation when performing a forward punch plus (FPP) and six variations of the FPP exercise.
Experimental, within‐subject repeated measures.
Surface electromyographic (EMG) activity of the SA, latissimus dorsi, and external oblique muscles on the dominant side, bilateral gluteus maximus muscles, and contra‐lateral femoral adductor muscles were analyzed in forward punch plus (FPP) movement and six variations in twenty one healthy male adults. The percentage of maximum voluntary isometric contraction (%MVIC) for each muscle was compared across various exercises using a 1‐way repeated –measures analysis of variance with Sidak pair wise comparison as post‐hoc test (p < 0.05).
Pairwise comparisons found that the EMG activity of the serratus anterior (SA) during the FPP with contralateral closed chain leg extension (CCLE), FPP with ipsilateral closed chain leg extension (ICLE), FPP with closed chain serape effect (CS), and FPP with open chain serape effect (OS) showed significantly higher EMG activity than the FPP.
Simultaneous recruitment of the lower extremity and trunk muscles increases the activation of the SA muscle during the FPP exercise.
Rehabilitation clinicians should have understanding of the kinetic chain relationships between the LE, the trunk, and the upper extremity while prescribing exercises. The results of this study may improve clinicians' ability to integrate the kinetic chain model in a shoulder rehabilitation program.
Level of Evidence:
Electromyography; kinetic chain; myofascial connections; serratus anterior
Differences in humeral torsion have been observed between overhead athletes and non‐athletes. Although humeral torsion may be an adaptive process for athletic performance, it may be associated with injury. Methods for measuring humeral torsion have consisted of radiography, computer tomography, and ultrasound imaging. However, diagnostic imaging may be costly and not available to all clinicians. The implementation of clinical assessments may be an alternative way to measure humeral torsion. Before clinical measures can be recommended, these assessments need to be evaluated for validity and reliability of each test. The purpose of this study was to assess the intratester and intertester reliability of three clinical tests, intratester reliability of ultrasound measures, and the validity of each clinical test to ultrasound measures.
Thirty participants (male: 12, female: 18; age: 20±2 years; height: 174.24±9.35 cm; mass: 70.53±11.06 kg; body mass index: 23.13±2.47 kg/m2; years in sport: 9±4 years) with experience in overhead sports were assessed for humeral torsion, bilaterally. Humeral torsion was assessed using musculoskeletal ultrasound by a single assessor, and using three separate clinical assessments by two independent assessors. Clinical assessments included the angle of rotation during both the bicipital tuberosity palpation with the shoulder abducted at 90 degrees (Palp90) or 45 degrees (Palp45), and the angle of external rotation during horizontal adduction (HADD).
Intratester reliability for the ultrasound measure was good (ICC=0.907), along with intratester reliability for both assessors across each clinical assessment (ICC's > 0.769). Poor to moderate reliability was observed between assessors for each clinical assessment (ICC=0.256 Palp90, ICC=0.419 Palp45, ICC=0.243 HADD. Only the Palp90 measure had a fair but significant (r=0.326, p=0.011) relationship with ultrasound measures.
Individual assessors can achieve reliable ultrasound, bicipital tuberosity palpation and HADD values across multiple trials; however, these measures are not consistent between assessors. Additionally, only one clinical test had a fair but significant relationship with ultrasound measures. Improved testing procedures may be needed to increase between assessor reliability and strength of relationships to ultrasound measures. Current application of clinical assessments to measure humeral torsion is limited.
Level of Evidence:
3b; Grade of Recommendation C
athletes; overhead; shoulder
During the 2013‐14 school year, over 763,000 female athletes participated in interscholastic running sports in the United States. Recent studies have indicated associations between the female athlete triad (Triad) and stress fracture or other musculoskeletal injuries in elite or collegiate female running populations. Little is known about these relationships in an adolescent interscholastic running population. The purpose of this study was to determine the associations between Triad and risk of lower extremity musculoskeletal injury among adolescent runners.
Eighty‐nine female athletes competing in interscholastic cross‐country and track in southern California were followed, prospectively. The runners were monitored throughout their respective sport season for lower extremity musculoskeletal injuries. Data collected included daily injury reports, Eating Disorder Examination Questionnaire (EDE‐Q) that assessed disordered eating attitudes/behaviors, a questionnaire on menstrual history and demographic characteristics, a dual‐energy x‐ray absorptiometry scan that measured whole‐body bone mineral density (BMD) and body composition (lean tissue and fat mass), and anthropometric measurements.
Thirty‐eight runners (42.7%) incurred at least one lower extremity musculoskeletal injury. In the BMD Z‐score ≤ ‐1 standard deviation (SD) adjusted model, low BMD relative to age (BMD Z‐score of ≤ ‐1SD) was significantly associated (Odds Ratio [OR]=4.6, 95% confidence interval [CI]: 1.5‐13.3) with an increased occurrence of musculoskeletal injury during the interscholastic sport season. In the BMD Z‐score ≤ ‐2 SDs adjusted model, a history of oligo/amenorrhea was significantly associated (OR=4.1, 95% CI: 1.2‐13.5) with increased musculoskeletal injury occurrence.
Oligo/amenorrhea and low BMD were associated with musculoskeletal injuries among the female interscholastic cross‐country and track runners.
Regular, close monitoring of adolescent female runners during seasonal and off‐season training may be warranted, so that potential problems can be recognized and addressed promptly in order to minimize the risk of running injury.
Level Of Evidence:
Adolescent runners; bone mineral density; disordered eating; females; menstrual dysfunction; musculoskeletal injuries
Background and Purpose:
Every ten years the American Board of Physical Therapy Specialties conducts a practice analysis to revalidate and revise the description of specialty practice for sports physical therapy (SPT). The primary purpose of this paper is to describe the process and results of the most recent analysis, which defines the competencies that distinguish the subspecialty practice of (SPT). Additionally, the study allowed for the comparison of responses of board certified specialists in SPT to respondents who were not specialists while reflecting on demographic changes and evolving trends since the previous analysis of this physical therapy specialty practice was conducted 10 years ago.
A survey instrument based on guidelines from the American Board of Physical Therapy Specialties was developed by the Sports Specialty Council (SSC) and a panel of subject matter experts (SME) in SPT to re‐evaluate contemporary practice. The instrument was pilot tested and following revisions, was sent to 1780 physical therapists, 930 of whom were board certified specialists in SPT and 850 of whom were randomly selected members of the Sports Physical Therapy Section (SPTS) who were not board certified specialists in SPT. 414 subjects returned completed surveys for a 23% response rate. 235 of the respondents were known to be board certified sports specialists, 120 did not indicate their specialty status, and 35 were non‐specialists in SPT. All were members of the SPTS of the American Physical Therapy Association. The survey responses were analyzed using descriptive statistics. Univariate comparisons were performed using parametric and nonparametric statistical tests in order to evaluate differences between specialist and non‐specialist item responses.
The survey results were reviewed by the SSC and a panel of SME. Using a defined decision making process, the results were used to determine the competencies that define the specialty practice of SPT. Survey results were also used to develop the SPT specialty board examination blueprint and define the didactic curriculum required of accredited SPT residency programs. A number of significant comparisons between the specialists and non‐specialists were identified.
The competency revalidation process culminated in the publication of the 4th edition of the Sports Physical Therapy Description of Specialty Practice in November of 2013. This document serves to guide the process related to the attainment and maintenance of the board certified clinical specialization in SPT. In anticipation of the continued evolution of this specialty practice, this process will be repeated every 10 years to reassess the characteristics of these providers and the factors they consider critically important and unique to the practice of SPT.
Continued Competence; Practice Validation; Sports Certified Specialist; Sports Physical Therapy Clinical Specialization
Background and Incidence:
Ischial tuberosity fracture and its associated complications are an under recognized diagnosis in the adolescent athlete. Apophyseal injuries of the pelvis in the skeletally immature athlete can occur in multiple locations but are most common at the ischial tuberosity, affecting males more commonly than females.
Description of Injury and Current Management:
The most common cause of ischial tuberosity avulsion fracture is a quick eccentric load to the proximal hamstrings, occurring with kicking as in soccer, football, or dance. Signs and symptoms are similar to a proximal hamstring injury but avulsion injuries often go undiagnosed, as radiographs are not frequently obtained. In acute cases, rest and relative immobilization are the recommended course of care. In chronic cases, including those with delayed diagnosis, or those that remain symptomatic after initial care due to non‐union or associated sciatic nerve adhesions, surgery is often performed in order to restore normal anatomy, alleviate symptoms, and help return the athlete to full activity.
The authors' share a novel treatment approach consisting of ultrasound guided percutaneous needle fenestration for the treatment of three adolescent athletes with symptomatic delayed diagnoses of ischial tuberosity fractures. Needle fenestration was followed by a physical therapy progression which was developed based on tissue healing rates, symptom presentation, and the available literature related to proximal hamstring injuries.
Two athletes reported elimination of pain, full functional recovery and return to sport without limitations as measured by use of the Numeric Pain Rating Scale, the Global Rating of Change Scale, and the Lower Extremity Functional Scale. One athlete reported elimination of pain and full functional recovery and chose to return to a new sport. Symptoms of possible concurrent hamstring syndrome are discussed as well the management of this condition.
This case series introduced a novel approach for treatment of symptomatic delayed union ischial tuberosity fractures in three adolescents prior to consideration of surgical intervention. Percutanous needle fenestration and the described subsequent rehabilitation provided positive treatment outcomes in the presented cases, including full return to athletic and recreational endeavors.
Level of Evidence:
Adolescent apophyseal injury; ischial tuberosity avulsion; percutaneous fenestration; percutaneous tenotomy
Background and Purpose:
Quadriceps weakness is a common finding following knee injuries or surgery, and can be associated with significant functional limitations. This weakness or muscle inhibition may be due to central inhibitory mechanisms, rather than local peripheral dysfunction. Lumbopelvic manipulation has been shown to effect efferent muscle output by altering nociceptive processing. The purpose of this report is to describe the physical therapy management of anterior knee pain and chronic quadriceps weakness utilizing side‐lying rotational lumbar thrust manipulation and therapeutic exercise for an individual eight months status‐post ACL reconstruction
A 20 year‐old male presented to physical therapy eight months following anterior cruciate ligament (ACL) reconstruction of the left knee with primary complaints of residual anterior knee pain and quadriceps weakness. The subject was treated with a multimodal approach using side‐lying rotational lumbar thrust manipulation in addition to therapeutic exercise.
The subject was seen in physical therapy for eight sessions over eight weeks. Lower Extremity Functional Scale (LEFS) scores improved from 58/80 to 72/80, quadriceps force, measured by hand‐held dynamometry (HHD), was improved from 70.6 lbs to 93.5 lbs and the subject was able to return to pain free participation in recreational sports.
Therapeutic exercises can facilitate improved quadriceps strength, however, in cases where quadriceps weakness persists and there is concurrent pain, other interventions should be considered. In this case, lower quarter stabilization exercise and lumbar thrust manipulation was associated with improved functional outcomes in a subject with anterior knee pain and quadriceps weakness. Side‐lying rotational lumbar thrust manipulation may be a beneficial adjunctive intervention to exercise in subjects with quadriceps weakness.
Level of Evidence:
5, Single case report
ACL; knee; manipulation; manual therapy
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:
Athlete; diagnostic accuracy; examination; hip joint
Researchers have identified sex‐differences in lower extremity muscle activation during functional activities that involve landing and cutting maneuvers. However, less research has been conducted to determine if muscle activation differences occur during rehabilitation exercises. The purpose of this investigation was to determine if sex‐differences exist for activation amplitudes of the trunk and hip muscles during four single leg squat (SLS) exercises.
Eighteen males and 16 females participated. Surface electromyography (EMG) was used to determine muscle activity of the abdominal obliques (AO), lumbar extensors (LE), gluteus maximus (GMX), and gluteus medius (GM) during four SLS exercises. Data were expressed as a percentage of a maximum voluntary isometric contraction (% MVIC). A 2 X 4 mixed‐model analysis of variance with repeated measures was used to determine the interaction between sex and exercise on each muscle's activity.
No interaction effect existed between sex and exercise. A main effect for sex existed for the GM and LE. On average, females generated 39% greater GM (27.6 ± 10.4 % MVIC versus 19.8 ± 10.5 % MVIC) and 40% greater LE (8.0 ± 2.8 % MVIC versus 5.7 ± 2.8 % MVIC) activity than males. All subjects, regardless of sex, demonstrated similar GMX and AO activity. Overall EMG values ranged from 11.0 % MVIC to 14.7 % MVIC for the GMX and 5.7 % MVIC to 8.8 % MVIC for the AO.
None of the subjects generated sufficient EMG activity for strength gains. Females generated a moderate level of GM activity appropriate for neuromuscular re‐education/endurance. Males generated a low level of GM activity that may not necessarily be sufficient to improve GM function. Subjects exhibited low levels of EMG activity for the other muscles. These findings suggest that clinicians modify and/or prescribe different exercises than those studied herein for the purpose of improving GM, GMX, AO, and LE function.
Level of Evidence:
electromyography; exercise; hip; sex
The utilization of hip arthroscopy to treat non‐arthritic pain in athletes continues to grow in popularity. Though numerous protocols have been described in the literature, there is no current evidence‐based consensus regarding the postoperative management of patients undergoing hip arthroscopy. Intraoperative findings determine the specific surgical procedure and subsequently play a role in postoperative rehabilitation. Current protocols are primarily based on tissue healing properties, patient tolerance, and clinician experience. General recommendations regarding range‐of‐motion initiation, weight bearing progression, and strength activities exist. Though relatively uncommon, postoperative complications have been described. Clinicians should be aware of factors, both surgical and rehabilitation‐related, that may affect a patient's postoperative progression. In order to assess patients’ postoperative improvement, clinicians must utilize outcome measures that effectively assess the functional status level of active individuals following hip arthroscopy. The development of criteria‐based programs may improve the consistency of rehabilitation and potentially aid in providing patients a safe, efficient return to athletics.
Hip; acetabular labrum; rehabilitation
Evaluation and treatment of groin pain in athletes is challenging. The anatomy is complex, and multiple pathologies often coexist. Different pathologies may cause similar symptoms, and many systems can refer pain to the groin. Many athletes with groin pain have tried prolonged rest and various treatment regimens, and received differing opinions as to the cause of their pain. The rehabilitation specialist is often given a non‐specific referral of “groin pain” or “sports hernia.” The cause of pain could be as simple as the effects of an adductor strain, or as complex as athletic pubalgia or inguinal disruption. The term “sports hernia” is starting to be replaced with more specific terms that better describe the injury. Inguinal disruption is used to describe the syndromes related to the injury of the inguinal canal soft tissue environs ultimately causing the pain syndrome. The term athletic pubalgia is used to describe the disruption and/or separation of the more medial common aponeurosis from the pubis, usually with some degree of adductor tendon pathology.
Both non‐operative and post‐operative treatment options share the goal of returning the athlete back to pain free activity. There is little research available to reference for rehabilitation guidelines and creation of a plan of care. Although each surgeon has their own specific set of post‐operative guidelines, some common concepts are consistent among most surgeons. Effective rehabilitation of the high level athlete to pain free return to play requires addressing the differences in the biomechanics of the dysfunction when comparing athletic pubalgia and inguinal disruption.
Proper evaluation and diagnostic skills for identifying and specifying the difference between athletic pubalgia and inguinal disruption allows for an excellent and efficient rehabilitative plan of care. Progression through the rehabilitative stages whether non‐operative or post‐operative allows for a focused rehabilitative program. As more information is obtained through MRI imaging and the diagnosis and treatment of inguinal disruption and athletic pubalgia becomes increasingly frequent, more research is warranted in this field to better improve the evidence based practice and rehabilitation of patients.
Levels of Evidence:
Adductor strain; athletic pubalgia; groin pain; rehabilitation; sports hernia transversus abdominis
Soft tissue injuries of the hip and pelvis are common among athletes and can result in significant time loss from sports participation. Rehabilitation of athletes with injuries such as adductor strain, iliopsoas syndrome, and gluteal tendinopathy starts with identification of known risk factors for injury and comprehensive evaluation of the entire kinetic chain. Complex anatomy and overlapping pathologies often make it difficult to determine the primary cause of the pain and dysfunction. The purpose of this clinical commentary is to present an impairment‐based, stepwise progression in evaluation and treatment of several common soft tissue injuries of the hip and pelvis.
Level of Evidence:
adductor strain; gluteal tendinopathy; hip; iliopsoas syndrome; pelvis
Hamstring injuries are common at all levels of sport, however recurrence rates are disproportionate compared to other soft tissue injuries. Age and previous injury are supported in the literature as risk factors for hamstring injury; nonetheless, debate exists regarding modifiable risk factors. Restoration of peak torque length using lengthening eccentrics and core stability interventions appear to reduce incidence of re‐injury. The purpose of this clinical commentary is to review examination techniques and rehabilitation considerations in order to identify important risk factors to reduce recurrence after hamstring strain and total rupture.
Discussion/Relation to Clinical Practice:
Novel clinical examination techniques both at time of acute injury and prior to return to sport may provide valuable prognostic information. Restoration of core stability, neuromuscular control and lengthening eccentric hamstring interventions are proposed key components to reduce hamstring re‐injury.
Levels of Evidence:
Eccentrics; hamstring injury; recurrence risk factors
Rehabilitation following hip arthroscopy for femoroacetabular impingement (FAI) and labral‐chondral dysfunction has evolved rapidly over the past 15 years. There have been multiple commentaries published on rehabilitation following hip arthroscopy without any published standardized objective criteria to address the advancement of the athlete through the phases of rehabilitation. The purpose of this clinical commentary is to describe a criteria driven algorithm for safe integration and return to sport rehabilitation following hip arthroscopy. The criteria based program allows for individuality of the athlete while providing guidance from early post‐operative phases through late return to sport phases of rehabilitation. Emphasis is placed on the minimum criteria to advance including healing restraints, patient reported outcomes, range of motion, core and hip stability, postural control, symmetry with functional tasks and gait, strength, power, endurance, agility, and sport‐specific tasks. Evidence to support the criteria will be offered as available. Despite limitations, this clinical commentary will offer a guideline for safe return to sport for the athlete while identifying areas for further investigation.
Level of Evidence:
Arthroscopy; hip; rehabilitation
The literature describing the characteristic features of femoroacetabular impingement (FAI) has been on the rise, increasing awareness of this pathology in the young, active population. The physical therapist should consider FAI as a contributing factor to anterior hip pain, impairments, and functional deficits of the lower quarter. The dynamic interplay of anatomical variations, pain, and muscle function and their effects on gait in patients with FAI, however, is poorly understood. Small sample populations and variability in radiological, demographic, and clinical presentations in those with FAI have precluded meaningful insight into gait analysis and FAI, reiterating the need for further research in this domain.
The purpose of this clinical commentary is to review the literature that defines normal gait at the hip joint and abnormal gait as a result of FAI and labral pathology or surgery aimed at correcting it. Secondarily, the authors aim to offer clinicians a strategy to progress the post‐surgical patient to normal, unassisted gait while reducing the risk for anterior hip pain. Lastly, the authors of this commentary aim to identify specific areas for future research directed at therapeutic interventions in patients with FAI and those who have undergone surgery to correct it.
Level of Evidence:
Anterior hip pain; biomechanics; femoroacetabular impingement; gait; gait analysis
Total Hip Athroplasty (THA) is a common procedure in orthopedic surgery to address severe osteoarthritis (OA) in the hip joint. With the burgeoning “baby boomer” generation and older athletes who wish to return to competitive levels of sports, understanding how sporting activity affects THA outcomes is becoming exceptionally important. The purpose of this review is to characterize the current recommendations and risks for returning to sports after THA, as well as discuss the implications of the changing demographic and level of expectation on rehabilitation paradigms.
Although the actual risks associated with participating in sports after THA are unknown, there are concerns that higher levels of physical activity after THA may increase risk for fracture, dislocation and poor long‐term outcomes. Evidence surrounding the specific effect of sporting activity on wear after THA is conflicting. Newer alternatives such as metal‐on‐metal hip resurfacing are expected to provide better durability but there are concerns of systemic metal ions from mechanical wear, although the impact of these ions on patient health is not clear.
Tracking outcomes in patients participating in higher level activities after THA presents a problem. Recently the High Activity Arthroplasty Score has been developed in response to the need to quantify higher level of physical activity and sports participation after joint arthroplasty. This measure has been shown to have a higher ceiling effect than other common outcome measures.
There is little prospective evidence regarding the likelihood of poor clinical outcomes with higher level of sporting activity. There is some evidence to suggest that wear may be related to activity level, but the impact on clinical outcomes is conflicting. When advising an athlete considering returning to sport after THA, consider their preoperative activity level, current physical fitness, and specific history including bone quality, surgical approach and type of prosthesis.
Level of evidence:
Activity; arthroplasty; high‐impact; joint replacement; sports
Activity‐limiting groin pain is relatively common in athletes who participate in sports which involve rapid or repetitive twisting, cutting, and/or kicking. Despite the reported prevalence of this condition in athletes, there is still much controversy as to the anatomical structures involved and most effective treatment approach. There is limited evidence favoring conservative management of sports hernia as opposed to surgical intervention in professional athletes, and there are no reports of sports hernia management in the professional golf population. The purpose of this case report is to describe the conservative management and decision making used with a professional golfer with symptoms consistent with a sports hernia which allowed for successful return to prior level of sport participation.
The subject of this case report is a professional golfer who developed lower abdominal and groin pain after changes in conditioning routine. Clinical presentation was consistent with a diagnosis of sports hernia. Rehabilitation of this athlete included a structured core muscle retraining program which utilized a step wise progression through the neurodevelopmental sequence in order to allow for development of neuromuscular control and stability required for return to golf.
This athlete was able to return to full golf participation after 13 physical therapy visits over 4 weeks.
The available evidence supports surgical intervention over conservative management in the treatment of sports hernia in the athletic population. A structured and comprehensive rehabilitation program addressing core muscle weakness and contributing impairments adjacent to injury may be a beneficial treatment option prior to surgical repair potentially allowing return to sport in some athletes.
Levels of Evidence:
conservative management; neuromuscular retraining; sports hernia