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1.  REHABILITATION OF A 23‐YEAR‐OLD MALE AFTER RIGHT KNEE ARTHROSCOPY AND OPEN RECONSTRUCTION OF THE MEDIAL PATELLOFEMORAL LIGAMENT WITH A TIBIALIS ANTERIOR ALLOGRAFT: A CASE REPORT 
Background:
Patellar dislocations are traumatic injuries that occur most often in individuals under the age of twenty and are related to sports and physical activity. Currently, there are no published reports describing the rehabilitation of younger males after arthroscopy and open reconstruction of the medial patellofemoral ligament (MPFL) using a tibialis anterior allograft.
Case Description:
The subject of this case report was a 23 year‐old recreational male athlete who underwent right knee arthroscopic patellar chondroplasty, lateral retinacular release, partial lateral menisectomy, and an open MPFL reconstruction with a tibialis anterior allograft after sustaining a second patellar dislocation. The purpose of this case report is to present the functional outcomes as well as the rehabilitation strategy used during the treatment of this athlete.
Outcome:
The patient returned to his prior level of activity after finishing 22 weeks of physical therapy. At a one‐year follow‐up, the patient reported pain‐free physical activity including weight training, running, and recreational basketball.
Discussion:
The results of this four‐phase rehabilitation program with this subject were excellent. However, research beyond single subject case reports on post‐operative rehabilitation for knee arthroscopy and open MPFL reconstruction with a tibialis anterior allograft is lacking. This is the first report that describes a rehabilitation strategy for this procedure. Although there was a successful rehabilitation outcome, future research is necessary to establish optimal rehabilitation guidelines as well as normative milestones for individuals who undergo this surgery.
Level of Evidence:
4‐Case Report
PMCID: PMC4004126  PMID: 24790782
Patellofemoral; ligament; dislocation; instability; rehabilitation
2.  DEVELOPMENT OF A PRELIMINARY CLINICAL PREDICTION RULE TO IDENTIFY PATIENTS WITH NECK PAIN THAT MAY BENEFIT FROM A STANDARDIZED PROGRAM OF STRETCHING AND MUSCLE PERFORMANCE EXERCISE: A PROSPECTIVE COHORT STUDY 
Background and Purpose:
Neck pain is a significant problem and many treatment options exist. While some studies suggest exercise is beneficial for individuals with non‐specific neck pain clinicians have few tools to assist in the decision making process. Therefore, the purpose of this study was to derive a preliminary clinical prediction rule (CPR) for identifying patients with neck pain (NP) who may respond to an exercise‐based treatment program. Exercise‐based interventions have demonstrated positive outcomes in patients with NP, however it is unclear which patients are more likely to respond to this treatment approach.
Methods:
Consecutive patients with a primary report of nonspecific NP with or without arm pain were recruited. All patients participated in a standardized exercise program and then were classified as having a successful or non‐successful outcome at 6 weeks. Potential predictor variables were entered into a stepwise regression analysis. Variables retained in the regression model were used to develop a multivariate CPR that can be used to classify patients with NP that may benefit from exercise‐based treatment. A 6‐month follow up of the patients was used to evaluate the long‐term effects.
Results:
Ninety‐one patients were enrolled in the study of which 50 had a successful outcome. A CPR with 5 variables was identified (Neck Disability Index score < 18/50, presence of shoulder protraction during static postural assessment, patient does not bicycle for exercise, cervical side bending < 32°, and Fear Avoidance Belief Questionnaire–Physical Activity Score < 15). If 4 of the 5 variables were present, the probability of a successful outcome shifted from 56% to 78% (+LR 2.97). At 6 months no significant difference existed in self‐reported outcomes between those considered positive on the rule for a successful outcome and those negative on the rule for a successful outcome.
Conclusions:
The proposed CPR may identify patients with NP likely to benefit from exercise‐based treatment in the short term. However, long‐term follow up did not demonstrate a significant difference between groups.
Level of Evidence:
2b
PMCID: PMC3867069  PMID: 24377062
Clinical prediction rule; exercise; neck pain
3.  DIFFERENTIAL DIAGNOSIS OF DEEP GLUTEAL PAIN IN A FEMALE RUNNER WITH PELVIC INVOLVEMENT: A CASE REPORT 
Background:
Gluteal injuries, proximal hamstring injuries, and pelvic floor disorders have been reported in the literature among runners. Some suggest that hip, pelvis, and/or groin injuries occur in 3.3% to 11.5% of long distance runners. The purpose of this case report is to describe the differential diagnosis and treatment approach for a patient presenting with combined hip and pelvic pain.
Case description:
A 45-year-old female distance runner was referred to physical therapy for proximal hamstring pain that had been present for several months. This pain limited her ability to tolerate sitting and caused her to cease running. Examination of the patient's lumbar spine, pelvis, and lower extremity led to the initial differential diagnosis of hamstring syndrome and ischiogluteal bursitis. The patient's primary symptoms improved during the initial four visits, which focused on education, pain management, trunk stabilization and gluteus maximus strengthening, however pelvic pain persisted. Further examination led to a secondary diagnosis of pelvic floor hypertonic disorder. Interventions to address the pelvic floor led to resolution of symptoms and return to running.
Outcomes:
Pain level on the Visual Analog Scale decreased from 7/10 to 1/10 over the course of treatment. The patient was able to return to full sport activity and improved sitting tolerance to greater then two hours without significant discomfort.
Discussion:
This case suggests the interdependence of lumbopelvic and lower extremity kinematics in complaints of hamstring, posterior thigh and pelvic floor disorders. This case highlights the importance of a thorough examination as well as the need to consider a regional interdependence of the pelvic floor and lower quarter when treating individuals with proximal hamstring pain.
Level of Evidence:
Level 4
PMCID: PMC3812833  PMID: 24175132
runner; pelvic floor; hip pain
4.  REHABILITATION OF A PARTIALLY TORN DISTAL TRICEPS TENDON AFTER PLATELET RICH PLASMA INJECTION: A CASE REPORT 
Background:
Platelet Rich Plasma (PRP) is an emerging non‐surgical intervention used for the treatment of tendon and ligament pathology. Despite the growing popularity of PRP in musculoskeletal medicine, there is a paucity of research that describes appropriate rehabilitation procedures following this intervention.
Case Description:
This case report presents the rehabilitation strategy used following a PRP injection for a patient with a partially torn distal triceps tendon who previously failed physical therapy interventions.
Outcome:
The patient returned to light weight training and coaching activity after completing 15 visits over a 3 month period. One month after discharge, the patient reported pain‐free activities of daily living and a return to previously performed gym activities.
Discussion:
PRP presents a viable treatment option for individuals who are recalcitrant to conservative interventions yet elect to avoid more invasive surgical measures. Despite the growing popularity of PRP, a paucity of evidence exists to guide physical therapists in the rehabilitation process of these patients. The rehabilitation strategies used in a patient who had a PRP injection for a partial triceps tendon tear are outlined. Although this case report highlights a successful rehabilitation outcome, future research regarding the concomitant effects of PRP injection and rehabilitation for tendon pathology are needed.
Level of Evidence:
4‐Case Report
PMCID: PMC3679635  PMID: 23772345
Growth factor; platelet; stem cell
5.  THE RELIABILITY AND CONCURRENT VALIDITY OF MEASUREMENTS USED TO QUANTIFY LUMBAR SPINE MOBILITY: AN ANALYSIS OF AN IPHONE® APPLICATION AND GRAVITY BASED INCLINOMETRY 
Purpose/Aim:
This purpose of this study was to investigate the reliability, minimal detectable change (MDC), and concurrent validity of active spinal mobility measurements using a gravity‐based bubble inclinometer and iPhone® application.
Materials/Methods:
Two investigators each used a bubble inclinometer and an iPhone® with inclinometer application to measure total thoracolumbo‐pelvic flexion, isolated lumbar flexion, total thoracolumbo‐pelvic extension, and thoracolumbar lateral flexion in 30 asymptomatic participants using a blinded repeated measures design.
Results:
The procedures used in this investigation for measuring spinal mobility yielded good intrarater and interrater reliability with Intraclass Correlation Coefficients (ICC) for bubble inclinometry ≥ 0.81 and the iPhone® ≥ 0.80. The MDC90 for the interrater analysis ranged from 4° to 9°. The concurrent validity between bubble inclinometry and the iPhone® application was good with ICC values of ≥ 0.86. The 95% level of agreement indicates that although these measuring instruments are equivalent individual differences of up to 18° may exist when using these devices interchangeably.
Conclusions:
The bubble inclinometer and iPhone® possess good intrarater and interrater reliability as well as concurrent validity when strict measurement procedures are adhered to. This study provides preliminary evidence to suggest that smart phone applications may offer clinical utility comparable to inclinometry for quantifying spinal mobility. Clinicians should be aware of the potential disagreement when using these devices interchangeably.
Level of Evidence:
2b (Observational study of reliability)
PMCID: PMC3625792  PMID: 23593551
Inclinometer; range of motion; smart phone; spine
6.  UPPER BODY PUSH AND PULL STRENGTH RATIO IN RECREATIONALLY ACTIVE ADULTS 
Introduction:
Agonist to antagonist strength data is commonly analyzed due to its association with injury and performance. The purpose of this study was to examine the agonist to antagonist ratio of upper body strength using two simple field tests (timed push up/timed modified pull up) in recreationally active adults and to establish the basis for reference standards.
Methods:
One hundred eighty (180) healthy recreationally active adults (111 females and 69 males, aged 18‐45 years) performed two tests of upper body strength in random order: 1. Push‐ups completed during 3 sets of 15 seconds with a 45 second rest period between each set and 2. Modified pull‐ups completed during 3 sets of 15 seconds with a 45 second rest period between each set.
Results:
The push‐up to modified pull‐up ratio for the males was 1.57:1, whereas females demonstrated a ratio of 2.72:1. The results suggest that for our group of healthy recreationally active subjects, the upper body “pushing” musculature is approximately 1.5–2.7 times stronger than the musculature involved for pulling.
Conclusions:
In this study, these recreationally active adults displayed greater strength during the timed push‐ups than the modified pull‐ups. The relationship of these imbalances to one's performance and or injury risk requires further investigation. The reference values, however, may serve the basis for future comparison and prospective investigations. The field tests in this study can be easily implemented by clinicians and an agonist/antagonist ratio can be determined and compared to our findings.
Level of Evidence:
2b
PMCID: PMC3625793  PMID: 23593552
Muscle imbalance; strength ratio; upper body strength
7.  THE RELIABILITY AND CONCURRENT VALIDITY OF SHOULDER MOBILITY MEASUREMENTS USING A DIGITAL INCLINOMETER AND GONIOMETER: A TECHNICAL REPORT 
Purpose/Aim:
This study investigated the intrarater reliability and concurrent validity of active shoulder mobility measurements using a digital inclinometer and goniometer.
Materials/Methods:
Two investigators used a goniometer and digital inclinometer to measure shoulder flexion, abduction, internal and external rotation on 30 asymptomatic participants in a blinded repeated measures design.
Results:
Excellent intrarater reliability was present with Intraclass Correlation Coefficients (ICC- 3,k) for goniometry ≥ 0.94 and digital inclinometry ≥ 0.95. The concurrent validity between goniometry and digital inclinometry was good with ICC (3,k) values of ≥ 0.85. The 95% limits of agreement suggest that the difference between these two measurement instruments can be expected to range from 2° to 20°.
Conclusions:
The results cautiously support the interchangeable use of goniometry and digital inclinometer for measuring shoulder mobility measurements. Although reliable, clinicians should consider the 95% limits of agreement when using these instruments interchangeably as clinically significant differences are likely to be present.
Level of evidence:
2b
PMCID: PMC3362980  PMID: 22666645
Goniometry; inclinometry; reliability; shoulder; validity
8.  CAN UPPER EXTREMITY FUNCTIONAL TESTS PREDICT THE SOFTBALL THROW FOR DISTANCE: A PREDICTIVE VALIDITY INVESTIGATION 
Introduction:
Understanding the relationships between performance tests and sport activity is important to the rehabilitation specialist. The purpose of this study was two- fold: 1) To identify if relationships exist between tests of upper body strength and power (Single Arm Seated Shot Put, Timed Push-Up, Timed Modified Pull-Up, and The Davies Closed Kinetic Chain Upper Extremity Stability Test, and the softball throw for distance), 2) To determine which variable or group of variables best predicts the performance of a sport specific task (the softball throw for distance).
Methods:
One hundred eighty subjects (111 females and 69 males, aged 18-45 years) performed the 5 upper extremity tests. The Pearson product moment correlation and a stepwise regression were used to determine whether relationships existed between performance on the tests and which upper extremity test result best explained the performance on the softball throw for distance.
Results:
There were significant correlations (r=.33 to r=.70, p=0.001) between performance on all of the tests. The modified pull-up test was the best predictor of the performance on the softball throw for distance (r2= 48.7), explaining 48.7% of variation in performance. When weight, height, and age were added to the regression equation the r2 values increased to 64.5, 66.2, and 67.5 respectively.
Conclusion:
The results of this study indicate that several upper extremity tests demonstrate significant relationships with one another and with the softball throw for distance. The modified pull up test was the best predictor of performance on the softball throw for distance.
PMCID: PMC3109892  PMID: 21712942
functional testing; upper body strength; upper body power

Results 1-8 (8)