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1.  COMPARISON OF HIP AND KNEE STRENGTH AND NEUROMUSCULAR ACTIVITY IN SUBJECTS WITH AND WITHOUT PATELLOFEMORAL PAIN SYNDROME 
Purpose/Background:
Historically, patellofemoral pain syndrome (PFPS) has been viewed exclusively as a knee problem. Recent findings have suggested an association between hip muscle weakness and PFPS. Altered neuromuscular activity about the hip also may contribute to PFPS; however, more limited data exist regarding this aspect. Most prior investigations also have not concurrently examined hip and knee strength and neuromuscular activity in this patient population. Additional knowledge regarding the interaction between hip and knee muscle function may enhance the current understanding of PFPS. The purpose of this study was to compare hip and knee strength and electromyographic (EMG) activity in subjects with and without PFPS.
Methods:
Eighteen females with PFPS and 18 matched controls participated in this study. First, surface EMG electrodes were donned on the gluteus medius, vastus medialis, and vastus lateralis. Strength measures then were taken for the hip abductors, hip external rotators, and knee extensors. Subjects completed a standardized stair-stepping task to quantify muscle activation amplitudes during the loading response, single leg stance, and preswing intervals of stair descent as well as to determine muscle onset timing differences between the gluteus medius and vastii muscles and between the vastus medialis and vastus lateralis at the beginning of stair descent.
Results:
Females with PFPS demonstrated less strength of the hip muscles. They also generated greater EMG activity of the gluteus medius and vastus medialis during the loading response and single leg stance intervals of stair descent. No differences existed with respect to onset activation of the vastus medialis and vastus lateralis. All subjects had a similar delay in gluteus medius onset activation relative to the vastii muscles.
Conclusion:
Rehabilitation should focus on quadriceps and hip strengthening. Although clinicians have incorporated gluteus medius exercise in rehabilitation programs, additional attention to the external rotators may be useful.
Level of Evidence: 4
PMCID: PMC3230156  PMID: 22163090
gluteus medius; knee; patella; surface electromyography
2.  COMPARISON OF ANKLE ARTHROMETRY TO STRESS ULTRASOUND IMAGING IN THE ASSESSMENT OF ANKLE LAXITY IN HEALTHY ADULTS 
Purpose/Background:
Ultrasonography (US) may aid the assessment of the anterior talofibular ligament (ATFL) injury after lateral ankle sprains by allowing the clinician to visualize and measure talocrural laxity. Comparison of US against another objective method of ankle laxity assessment, such as ankle arthrometry (AA), is needed. The purpose was to evaluate the relationship between the ATFL length measurements measured from stress US images to the inversion and anterior drawer displacement measured with AA in healthy subjects.
Methods:
This descriptive laboratory study included 26 ankles from healthy subjects. The apparent length of the ATFL was measured using US during anterior drawer (USAD) and inversion (USINV) stress and the translation of the talocrural joint was measured using AA during anterior drawer (AAAD) and inversion (AAINV) stress. Percent change in length for USAD and USINV were quantified. Intraclass correlation coefficients and pearson product moment correlations Bland-Altman limits of agreement were calculated between relevant variables.
Results:
USAD and USINV percent change in length were positively correlated (r = .76). Bland Altman analysis revealed a mean difference of 5.38 mm (95% CI: –3.5 to 12 mm) with the AAAD producing higher values than the USAD. No significant correlations were found between the US and AA variables, however the absolute AAAD and AAINV variables were also positively correlated (r = .61).
Conclusions:
The US and AA variables were not directly correlated when measuring inversion and anterior laxity in healthy ankles. Differences between the devices that may affect this include different rates of joint loading, patient position and method of assessing laxity. The AA results demonstrated greater anterior displacement. Results may differ in ankle injured subjects who may demonstrate increases in anteroposterior and inversion laxity.
Level of Evidence:
2b. Exploratory study in healthy cohort.
PMCID: PMC3230157  PMID: 22163091
ankle laxity; anterior displacement; inversion rotation; percent length change
3.  RELIABILITY OF THE SITTING HAND PRESS-UP TEST FOR IDENTIFYING AND QUANTIFYING THE LEVEL OF SCAPULAR MEDIAL BORDER POSTERIOR DISPLACEMENT IN OVERHEAD ATHLETES 
Background:
The lack of proper scapular kinematics can limit the function of the entire shoulder complex.1,3 Many forms of scapular dyskinesis have been proposed along with tests to measure for the position and motion associated with those positional and movement faults (2,4-6). While scapular internal rotation has been listed among the forms of scapular dyskinesis there has not been a reliable test documented in the literature that examines this motion. The purpose of this study was to determine whether an innovative scapular medial border posterior displacement measurement device has adequate inter-rater and intra-rater reliability when used at rest and during the sitting hand press up test.
Methods:
16 male Division III baseball players free of upper limb injury for the previous 12 months participated in the study. Posterior scapular displacement measures were taken on each subject in a resting static posture and while performing a sitting hand press up test. Subjects were tested twice within 24 hours by two separate examiners. Intraclass correlation coefficients (ICC) were calculated to determine intra-rater and inter-rater reliability.
Results:
The intra-rater reliability for rater 1 was .97 (95% confidence interval [CI]= .91-.98), for the rest position and .95 (95% CI= .86-.98) for the sitting hand press-up position. Intra-rater reliability for rater 2 was .99 (95% CI= .97-.99) for the rest position and .98 (95% CI=. 95-.99) for the sitting hand press-up position. The ICCs for inter-rater reliability of the scapular medial border posterior displacement measurement in at the rest position and the sitting hand press-up position were .89 (95% CI= .81-.96) and .89 (95% CI= .80-.96) respectively.
Conclusions:
The findings of this study indicate that the measurement of medial border posterior displacement using this device demonstrates good to excellent inter-rater and intra-rater reliability.
PMCID: PMC3230158  PMID: 22163092
reliability; scapular dyskinesis; sitting hand press up test
4.  EFFECTS OF FOREFOOT RUNNING ON CHRONIC EXERTIONAL COMPARTMENT SYNDROME: A CASE SERIES 
Introduction:
Chronic exertional compartment syndrome (CECS) is a condition that occurs almost exclusively with running whereby exercise increases intramuscular pressure compromising circulation, prohibiting muscular function, and causing pain in the lower leg. Currently, a lack of evidence exists for the effective conservative management of CECS. Altering running mechanics by adopting forefoot running as opposed to heel striking may assist in the treatment of CECS, specifically with anterior compartment symptoms.
Case Description:
The purpose of this case series is to describe the outcomes for subjects with CECS through a systematic conservative treatment model focused on forefoot running. Subject one was a 21 y/o female with a 4 year history of CECS and subject two was a 21 y/o male, 7 months status-post two-compartment right leg fasciotomy with a return of symptoms and a new onset of symptoms on the contralateral side.
Outcome:
Both subjects modified their running technique over a period of six weeks. Kinematic and kinetic analysis revealed increased step rate while step length, impulse, and peak vertical ground reaction forces decreased. In addition, leg intracompartmental pressures decreased from pre-training to post-training. Within 6 weeks of intervention subjects increased their running distance and speed absent of symptoms of CECS. Follow-up questionnaires were completed by the subjects at 7 months following intervention; subject one reported running distances up to 12.87 km pain-free and subject two reported running 6.44 km pain-free consistently 3 times a week.
Discussion:
This case series describes a potentially beneficial conservative management approach to CECS in the form of forefoot running instruction. Further research in this area is warranted to further explore the benefits of adopting a forefoot running technique for CECS as well as other musculoskeletal overuse complaints.
PMCID: PMC3230159  PMID: 22163093
anterior compartment syndrome; fasciotomy; forefoot running; shin splints
5.  ELECTROMYOGRAPHIC ACTIVITY OF SCAPULAR MUSCLES DURING DIAGONAL PATTERNS USING ELASTIC RESISTANCE AND FREE WEIGHTS 
Purpose/Background:
Abnormalities in glenohumeral rhythm and neuromuscular control of the upper trapezius (UT), middle trapezius (MT), lower trapezius (LT) and serratus anterior (SA) muscles have been identified in individuals with shoulder pain. Upper extremity diagonal or proprioceptive neuromuscular facilitation (PNF) patterns have been suggested as effective means of activating scapular muscles, yet few studies have compared muscular activation during diagonal patterns with varying modes of resistance. The purpose of this study is to determine which type of resistance and PNF pattern combination best elicits electromyographic (EMG) activity of the scapular muscles.
Methods:
Twenty one healthy subjects with no history of scapulohumeral dysfunction were recruited from a population of convenience. Surface electrodes were applied to the SA, UT, MT and LT and EMG data collected for each muscle as the subject performed resisted UE D1 flexion, UE D1 extension, UE D2 flexion and UE D2 extension with elastic resistance and a three pound weight.
Results:
No significant differences were found between scapular muscle activity during D1 flexion when using elastic resistance and when using a weight. UT, MT and LT values were also not significantly different during D2 flexion when using elastic resistance vs. using a weight. The activity of the SA remained relatively the same during all patterns. The LT activity was significantly greater during D2 flexion with elastic resistance than during the D1 flexion and D1 extension with elastic resistance. MT activity was significantly greater during D2 flexion with elastic resistance as compared to all other patterns except D2 flexion with a weight. UT activity was significantly greater during flexion patterns than extension patterns.
Conclusions:
The upper extremity PNF pattern did significantly affect the mean UT, MT and LT activity but was not found to significantly affect SA activity. The type of resistance did not significantly change muscle activity when used in the same diagonal patterns.
PMCID: PMC3230160  PMID: 22163094
elastic resistance; electromyography; proprioceptive neuromuscular facilitation; scapular musculature
6.  THE CLINICAL UTILITY OF FUNCTIONAL PERFORMANCE TESTS WITHIN ONE-YEAR POST-ACL RECONSTRUCTION: A SYSTEMATIC REVIEW 
Introduction:
A tear of the anterior cruciate ligament (ACL) represents a significant injury for an athlete that requires substantial time away from sport, and significant rehabilitation after reconstruction. The physical therapist is responsible to determine when a patient is capable of tolerating the physical demands of daily activities and to attempt to prevent re-injury. Physical or functional performance tests (FPTs) are one mechanism used to evaluate the athlete's physical skills and capabilities prior to returning to sports participation. The purpose of this systematic review is to critically examine the clinical utility of functional performance tests used with patients less than or equal to one year post ACL reconstruction.
Methods:
A systematic review of the relevant literature was performed using PRISMA guidelines. A total of twelve studies were included for analysis.
Results:
Two independent blinded reviewers then analyzed and rated the final included articles (n=12) utilizing the Newcastle-Ottawa Scale (NOS). Percent overall agreement between raters for the NOS was 88% with a fixed-marginal kappa (κ) of 0.80. Of the 12 included articles, the FPTs were utilized as an outcome measure within the study design (41.7%) or studied as a measure of function (58.3%). Among those studies that used FPTs as a “measure of function” 71.4% studied a battery of FPTs, while 28.6% studied a single test. None of the studies utilized FPTs as a measure to determine readiness to return to sport.
Discussion:
FPTs are being utilized with patients, less than or equal to one year post ACL reconstruction, either as an assessment of functional performance or as an outcome measure. No studies identified a FPT or test battery that has construct or predictive validity for “return to sport” in athletic population one-year post-ACL reconstruction. The identification of the critical elements within the return to sport construct may allow lower extremity performance tests to be developed or test batteries assembled to incorporate the appropriate tests to examine all of these elements deemed critical. Additionally the current FPTs should undergo content and predictive validation to assist the sports physical therapist in determining the readiness of the athlete for return to sport.
PMCID: PMC3230161  PMID: 22163095
ACL reconstruction; athlete; physical performance measure
7.  COMPREHENSIVE STRENGTH TRAINING PROGRAM FOR A RECREATIONAL SENIOR GOLFER 11-MONTHS AFTER A ROTATOR CUFF REPAIR 
Background and Purpose:
Golf is a popular sport played by hundreds of thousands of individuals of all ages and of varying skill levels. An orthopedic or sports-related injury and/or surgery may limit an individual's sport participation, require him/her to complete a course of rehabilitation, and initiate (or resume) a sport-specific training program. Unlike the availability of evidence to guide postsurgical rehabilitation and sport-specific training of athletes from sports other than golf, there have only been two reports describing outcomes after surgery and for golfers. The purpose of this case report is to present a post-rehabilitation return to sport-training program for a recreational golfer 11-months after a rotator cuff repair.
Case Description:
The subject, a 67-year old female, injured her right shoulder requiring a rotator cuff repair 11-months prior to her participation in a golf fitness training program. The subject participated in six training sessions over seven week period consisting of general strengthening exercises (including exercises for the rotator cuff), exercises for the core, plyometrics, and power exercises.
Outcomes:
The subject made improvements in power and muscular endurance of the core. She was able to resume golf at the completion of the training program.
Discussion:
The subject was able to make functional improvements and return to golf after participation in a comprehensive strength program. Additional studies are necessary to improve program design for golfers who wish to return to sport after shoulder surgery.
PMCID: PMC3230162  PMID: 22163096
golf; return-to-sport; senior; kettlebells; plyometrics
8.  CHEST INJURIES, WHAT THE SPORTS PHYSICAL THERAPIST SHOULD KNOW 
Chest injuries in contact and collision sports are relatively rare, particularly those that are life threatening. However, as with every sports related injury, one must initially consider life threatening situations that may occur as a result of collision with another player, a stationary object, or being struck with some type of object (missile). In other words, as is the case in all acute sports injury assessment, the mechanism of injury must be considered when evaluating the injured athlete on the field as well as on the sidelines. The Sports Physical Therapist (PT) must look for several initial life threatening conditions as well as be aware of and monitor for the development of these symptoms during the subsequent evaluation of the athlete. The purpose of this clinical commentary is to review the presentation and management of several emergent conditions associated with injuries to the chest and thorax.
PMCID: PMC3230163  PMID: 22163097
Chest injury; commotio cordis; flail chest; pneumothorax
9.  ERRATUM 
PMCID: PMC3230164  PMID: 22163098
10.  KNEE KINEMATICS FOLLOWING ACL RECONSTRUCTION IN FEMALES; THE EFFECT OF VISION ON PERFORMANCE DURING A CUTTING TASK 
Purpose/Background:
Specific movement patterns have been identified as influential in ACL injury; however several key kinematic variables that might be predictive of future performance have not been fully investigated. The purpose of this research was to: 1) determine if subjects with ACL reconstruction display different displacement, velocity, and time to peak ground reaction force (GRF) during cutting activities than healthy subjects, 2) observe if subjects with visual disruption display differences in these variables, and 3) determine if visual disruption alters these variables in subjects with ACL reconstruction relative to healthy subjects.
Methods:
Seventeen healthy female subjects and 17 female subjects with unilateral ACL reconstruction (ACLR) performed 40 trials of a cutting movement during which knee position was measured via a 3D electromagnetic system. Visual conditions were randomized to disrupt vision for 1 second as the subject began the cutting movement, or allow full vision for movement duration. Independent variables were lead/push off leg (ACLR limb or healthy non-dominant limb) and vision (disrupted or full). 2-way ANOVAs were utilized to determine differences between knee kinematics using dependent variables of displacement (m), absolute velocity (m/sec), and time to reach peak GRF (% of cut).
Results:
Knee displacement was significantly less for ACLR (.76±.11; .75±.16) than non-dominant (.85±.08; .87±.12). Knee velocity was significantly slower for ACLR (.81±.14; .84±.16) than non-dominant (.92±.11; .97±.14). A significant interaction was noted for displacement and average velocity (p<.05). Time to reach peak GRF was significantly longer for ACLR (79.41±2.28) than non-dominant (76.65±4.41).
Conclusions:
Subjects with ACLR displayed less knee displacement, slower velocity, and an increased time to reach peak GRF relative to healthy subjects' non-dominant knee. Visual disruption appeared to have some effect on movement, as noted by interaction effects. These movement adjustments may be indicative of an altered motor program that allows for successful and safe task completion while reducing the forces and load on the knee.
Level of Evidence: Level 2
PMCID: PMC3233270  PMID: 22163089
ACL reconstruction; Female; Kinematics; Lower extremity; Movement patterns
11.  DIFFERENCES IN CHANGE SCORES AND THE PREDICTIVE VALIDITY OF THREE COMMONLY USED MEASURES FOLLOWING CONCUSSION IN THE MIDDLE SCHOOL AND HIGH SCHOOL AGED POPULATION 
Background:
A battery of tests is commonly used to measure disability with and recovery from concussion. A number of different concussion-oriented assessment tests exist and each is considered useful. To the authors' knowledge, no study has compared the scores of these tests during recovery in the middle school and high school aged population to see how each change over time.
Purpose:
The purposes of this study were to analyze clinical data of concussed middle school and high school aged athletes to determine the concurrent and predictive validity for post-concussion syndrome (PCS) of the Post-Concussion Symptom Scale (PCSS), Balance Error Scoring System (BESS), and the five subscales of the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT).
Methods:
The study was a retrospective chart review performed on middle school and high school aged individuals with a diagnosis of concussion from the years 2008-2010 within the Akron Children's Hospital Sports Medicine system. To be eligible for inclusion in the dataset, each subject required a baseline measurement for each of the three tests (and all five subscales of the ImPACT) and a post-test measure. The mean age of the population was 15.38 years (SD = 1.7) and ranged from 11 to 19 years. Pearson product correlation tests (correlation matrix) were used to analyze the concurrent validity of the test items during recovery following a concussion. Receiver operating characteristics (ROC) curves were used to determine the predictive validity of initial scores for developing PCS.
Results:
The correlation matrix captured five statistically significant findings; however, these suggested only weak to mild correlations. Five test items yielded an area under the curve (AUC) greater than 0.50 but only one was statistically significant. After qualitative evaluation, only one of the three tests (including the five subscales of the ImPACT) was useful in predicting post-concussion syndrome.
Conclusion:
This study suggests that there is poor concurrent validity among three commonly used concussion tests and there is no baseline score that predicts whether post-concussion syndrome will occur.
Level of Evidence:
2b
PMCID: PMC3163995  PMID: 21904694
Concussion; Diagnostic accuracy; Post-concussion syndrome; Validity
12.  MANAGEMENT OF ACUTE SPORTS INJURIES AND MEDICAL CONDITIONS BY PHYSICAL THERAPISTS: ASSESSMENT VIA CASE SCENARIOS 
Purpose/Background:
Some physical therapists (PTs) provide services at sporting events, but there are limited studies investigating whether PTs are properly prepared to provide such services. The purpose of this study was to assess acute sports injury and medical condition management decision-making skills of PTs.
Methods:
A Web-based survey presented 17 case scenarios related to acute medical conditions and sport injuries. PTs from the Sports Physical Therapy Section of The American Physical Therapy Association were e-mailed a cover letter/Web link to the survey and invited to participate over a 30-day period. Data were analyzed using SPSS 18.0.
Results:
A total of 411 of 5158 PTs who were members of the Sports Physical Therapy Association in 2009 and had valid e-mail addresses completed the survey, of which 389 (7.5%) were appropriate for analysis. Over 75.0% of respondents felt “prepared” or “somewhat prepared” to provide immediate care for 13 out of 16 medical conditions, with seizures, spinal cord injuries, and internal organ injuries having the lowest percentages. Over 75.0% of the respondents made “appropriate” or “overly cautious” decisions for 11 of the 17 acute injury or medical condition cases.
Conclusions:
Results of the current study indicate that PTs felt more “prepared” and tended to make “appropriate” return to play decisions on the acute sports injury and medical condition case studies more often than coaches who participated in a similar study, regardless of level of importance of the game or whether the athlete was a starter vs. non-starter. However, for PTs who plan on assisting at sporting events, additional preparation/education may be recommended, such as what is taught in an emergency responder course.
PMCID: PMC3163996  PMID: 21904695
Acute sports injury management; return to play decisions
13.  A PILOT SURVEY ON INJURY AND SAFETY CONCERNS IN INTERNATIONAL SLEDGE HOCKEY 
Objective:
To describe sledge hockey injury patterns, safety issues and to develop potential injury prevention strategies.
Design:
Pilot survey study of international sledge hockey professionals, including trainers, physiotherapists, physicians, coaches and/or general managers.
Setting:
Personal encounter or online correspondence.
Respondents:
Sledge hockey professionals; a total of 10 respondents from the 5 top-ranked international teams recruited by personal encounter or online correspondence.
Main Outcome Measurements:
Descriptive Data reports on sledge athlete injury characteristics, quality of rules and enforcement, player equipment, challenges in the medical management during competition, and overall safety.
Results:
Muscle strains and concussions were identified as common, and injuries were reported to affect the upper body more frequently than the lower body. Overuse and body checking were predominant injury mechanisms. Safety concerns included excessive elbowing, inexperienced refereeing and inadequate equipment standards.
Conclusions:
This paper is the first publication primarily focused on sledge hockey injury and safety. This information provides unique opportunity for the consideration of implementation and evaluation of safety strategies. Safety interventions could include improved hand protection, cut-resistant materials in high-risk areas, increased vigilance to reduce intentional head-contact, lowered rink boards and modified bathroom floor surfacing.
PMCID: PMC3163997  PMID: 21904696
Disabled athlete; Paralympic; sledge hockey
14.  THE INFLUENCE OF HEEL HEIGHT ON SAGITTAL PLANE KNEE KINEMATICS DURING LANDING TASKS IN RECREATIONALLY ACTIVE AND ATHLETIC COLLEGIATE FEMALES 
Purpose:
To determine if heel height alters sagittal plane knee kinematics when landing from a forward hop or drop landing.
Background:
Knee angles close to extension during landing are theorized to increase ACL injury risk in female athletes.
Methods:
Fifty collegiate females performed two single-limb landing tasks while wearing heel lifts of three different sizes (0, 12 & 24 mm) attached to the bottom of a sneaker. Using an electrogoniometer, sagittal plane kinematics (initial contact [KAIC], peak flexion [KAPeak], and rate of excursion [RE]) were examined. Repeated measures ANOVAs were used to determine the influence of heel height on the dependent measures.
Results:
Forward hop task- KAIC with 0 mm, 12 mm, and 24 mm lifts were 8.88±6.5, 9.38±5.8 and 11.28±7.0, respectively. Significant differences were noted between 0 and 24 mm lift (p<.001) and 12 and 24 mm lifts (p=.003), but not between the 0 and 12 mm conditions (p=.423). KAPeak with 0 mm, 12 mm, and 24 mm lifts were 47.08±10.9, 48.18±10.3 and 48.88±9.7, respectively. A significant difference was noted between 0 and 24 mm lift (p=.004), but not between the 0 and 12 mm or 12 and 24 mm conditions (p=.071 and p=.282, respectively). The RE decreased significantly from 2128/sec±52 with the 12 mm lift to 1958/sec±55 with the 24 mm lift (p=.004). RE did not differ from 0 to 12 or 0 to 24 mm lift conditions (p=.351 and p=.086, respectively). Jump-landing task- No significant differences were found in KAIC (p=.531), KAPeak (p=.741), or the RE (p=.190) between any of the heel lift conditions.
Conclusions:
The addition of a 24 mm heel lift to the bottom of a sneaker significantly alters sagittal plane knee kinematics upon landing from a unilateral forward hop but not from a drop jump.
PMCID: PMC3163998  PMID: 21904697
ACL; heel lift; kinematics; landing
15.  THE NAVICULAR POSITION TEST – A RELIABLE MEASURE OF THE NAVICULAR BONE POSITION DURING REST AND LOADING 
Background:
Lower limb injuries are a large problem in athletes. However, there is a paucity of knowledge on the relationship between alignment of the medial longitudinal arch (MLA) of the foot and development of such injuries. A reliable and valid test to quantify foot type is needed to be able to investigate the relationship between arch type and injury likelihood. Feiss Line is a valid clinical measure of the MLA. However, no study has investigated the reliability of the test.
Objectives:
The purpose was to describe a modified version of the Feiss Line test and to determine the intra- and inter-tester reliability of this new foot alignment test. To emphasize the purpose of the modified test, the authors have named it The Navicular Position Test.
Methods:
Intra- and inter-tester reliability were evaluated of The Navicular Position Test with the use of ICC (interclass correlation coefficient) and Bland-Altman limits of agreement on 43 healthy, young, subjects.
Results:
Inter-tester mean difference -0.35 degrees [–1.32; 0.62] p = 0.47. Bland-Altman limits of agreement –6.55 to 5.85 degrees, ICC = 0.94. Intra-tester mean difference 0.47 degrees [–0.57; 1.50] p = 0.37. Bland-Altman limits of agreement –6.15 to 7.08 degrees, ICC = 0.91.
Discussion:
The present data support The Navicular Position Test as a reliable test of the navicular bone position during rest and loading measured in a simple test set-up.
Conclusion:
The Navicular Position Test was shown to have a high intraday-, intra- and inter-tester reliability. When cut off values to categorize the MLA into planus, rectus, or cavus feet, has been determined and presented, the test could be used in prospective observational studies investigating the role of the arch type on the development of various lower limb injuries.
PMCID: PMC3163999  PMID: 21904698
Foot; Feiss Line; reliability; alignment; pronation
16.  SHOULDER PAIN AND DYSFUNCTION SECONDARY TO NEURAL INJURY 
Study Design:
Resident's Case Study
Background/Introduction:
The reports of spinal accessory nerve injury in the literature primarily focus on injury following surgical dissection or traumatic stretch injury. There is limited literature describing the presentation and diagnosis of this injury with an unknown cause. The purpose of this case report is to describe the clinical decision-making process that guided the diagnosis and treatment of a complex patient with spinal accessory nerve palsy (SANP) whose clinical presentation and response to therapy were inconsistent with the results of multiple diagnostic tests.
Case Description:
The patient was a 27-year-old female triathlete with a five month history of right-sided neck, anterior shoulder, and chest pain.
Outcome:
Based on the physical exam, magnetic resonance imaging, radiographs, electrodiagnostic and nerve conduction testing, the patient was diagnosed by her physician with right sterno-clavicular joint strain and scapular dyskinesis and was referred to physical therapy. Care was initiated based on this initial diagnosis. Upon further examination and perusal of the literature, the physical therapist proposed a diagnosis of spinal accessory nerve injury. Intervention included manual release of soft tissue tightness, neuromuscular facilitation and sport-specific strengthening, resulting in full return to functional and sport activities. These interventions focused on neurological re-education and muscular facilitation to address SANP as opposed to a joint sprain and dysfunction, as initially diagnosed.
Discussion:
Proper diagnosis is imperative to effective treatment in all patients. This case illustrates the importance of a thorough examination and consideration of multiple diagnostic findings, particularly when EMG/NCV tests were negative, the cause was not apparent, and symptoms were less severe than other cases documented in the literature.
Level of Evidence:
Diagnosis, level 4
PMCID: PMC3164000  PMID: 21904699
Differential diagnosis; shoulder pain; spinal accessory nerve palsy; sterno-clavicular pain; triathlete
17.  POSTACTIVATION POTENTIATION: AN INTRODUCTION 
Improving strength and power in the athlete who is being rehabilitated is a central focus of the sports physical therapist, particularly in the terminal phases of rehabilitation where the emphasis shifts to readiness to return to sport and sports performance enhancement. High load strength training and power training through plyometric exercises are two key components of performance enhancement programs. A current concept in the strength and conditioning literature that is relatively unknown in sports physical therapy is postactivation potentiation (PAP). Even though we have limited data and there may be limited application of the concept of PAP for the sports physical therapist, awareness of this phenomenon is important nonetheless. The purpose of this clinical commentary is to introduce the sports physical therapist to the concept of PAP.
PMCID: PMC3164001  PMID: 21904700
complex training; power training; postactivation potentiation; strength training
18.  INTEGRATION OF STRENGTH AND CONDITIONING PRINCIPLES INTO A REHABILITATION PROGRAM 
Background and Purpose:
Rehabilitation and strength and conditioning are often seen as two separate entities in athletic injury recovery. Traditionally an athlete progresses from the rehabilitation environment under the care of a physical therapist and/or athletic trainer to the strength and conditioning coach for specific return to sport training. These two facets of return to sport are often considered to have separate goals. Initial goals of each are often different due to the timing of their implementation encompassing different stages of post-injury recovery. The initial focus of post injury rehabilitation includes alleviation of dysfunction, enhancement of tissue healing, and provision of a systematic progression of range-of-motion and strength. During the return to function phases, specific return to play goals are paramount. Understanding of specific principles and program parameters is necessary when designing and implementing an athlete's rehabilitation program. Communication and collaboration amongst all individuals caring for the athlete is a must. The purpose of this review is to outline the current evidence supporting utilization of training principles in athletic rehabilitation, as well as provide suggested implementation of such principles throughout different phases of a proposed rehabilitation program.
Evidence Acquisition:
The following electronic databases were used to identify research relevant to this clinical commentary: MEDLINE (from 1950–June 2011) and CINAHL (1982–June 2011), for all relevant journal articles written in English. Additional references were accrued by independent searching of references from relevant articles.
Results:
Currently evidence is lacking in the integration of strength and conditioning principles into the rehabilitation program for the injured athlete. Numerous methods are suggested for possible utilization by the clinician in practice to improve strength, power, speed, endurance, and metabolic capacity.
Conclusion:
Despite abundance of information on the implementation of training principles in the strength and conditioning field, investigation regarding the use of these principles in a properly designed rehabilitation program is lacking.
PMCID: PMC3164002  PMID: 21904701
periodization; program design; rehabilitation; strength; training
19.  THE USE OF CARDIOPULMONARY RESUSCITATION AND THE AUTOMATED EXTERNAL DEFIBRILLATOR IN THE PRACTICE OF SPORTS PHYSICAL THERAPY 
During the initial assessment of the injured athlete, the Sports Physical Therapist (PT) must first be concerned with life-threatening emergencies such as absence of breathing and pulse. The sports PT must also be aware of the possibility of “sudden cardiac death” that could occur in others, including coaches, officials, and fans. If the PT assumes the role of “most medical” person at the contest or event, the responsibility for life saving action falls squarely on their shoulders. Therefore, skills and ongoing certification in cardio- pulmonary resuscitation techniques and the use of an automated external defibrillator are a basic necessity. These skills are required as part of the specialty practice of sports PT (BLS Healthcare Provider course or CPR for the Professional Rescuer in addition to completion of the First Responder Course OR credentials as an EMT or ATC), and are mandatory for being qualified to sit for the exam to become a sports certified specialist (SCS) by the American Board of Physical Therapy Specialties (ABPTS).3
PMCID: PMC3164003  PMID: 21904702
automated external defibrillator; cardiopulmonary resuscitation and emergency response
20.  ELECTROMYOGRAPHIC ANALYSIS OF GLUTEUS MEDIUS AND GLUTEUS MAXIMUS DURING REHABILITATION EXERCISES 
Purpose/Background:
Previous research studies by Bolga, Ayotte, and Distefano have examined the level of muscle recruitment of the gluteal muscles for various clinical exercises; however, there has been no cross comparison among the top exercises from each study. The purpose of this study is to compare top exercises from these studies as well as several other commonly performed clinical exercises to determine which exercises recruit the gluteal muscles, specifically the gluteus medius and maximus, most effectively.
Methods:
Twenty-six healthy subjects participated in this study. Surface EMG electrodes were placed on gluteus medius and maximus to measure muscle activity during 18 exercises. Maximal voluntary muscle contraction (MVIC) was established for each muscle group in order to express each exercise as a percentage of MVIC and allow standardized comparison across subjects. EMG data were analyzed using a root-mean-square algorithm and smoothed with a 50 millisecond time reference. Rank ordering of the exercises was performed utilizing the average percent MVIC peak activity for each exercise.
Results:
Twenty-four subjects satisfied all eligibility criteria and consented to participate in the research study. Five of the exercises produced greater than 70%MVIC of the gluteus medius muscle. In rank order from highest EMG value to lowest, these exercises were: side plank abduction with dominant leg on bottom (103%MVIC), side plank abduction with dominant leg on top (89%MVIC), single limb squat (82%MVIC), clamshell (hip clam) progression 4 (77%MVIC), and font plank with hip extension (75%MVIC). Five of the exercises recruited gluteus maximus with values greater than 70%MVIC. In rank order from highest EMG value to lowest, these exercises were: front plank with hip extension (106%MVIC), gluteal squeeze (81%MVIC), side plank abduction with dominant leg on top (73%MVIC), side plank abduction with dominant leg on bottom (71%MVIC), and single limb squat (71%MVIC). Four of the exercises produced greater than 70%MVIC for both gluteus maximus and medius muscles.
Conclusions:
Higher %MVIC values achieved during performance of exercises correlate to muscle hypertrophy.20,22 By knowing the %MVIC of the gluteal musculature that occurs during various exercises, potential for strengthening of the gluteal muscles can be inferred. Additionally, exercises may be rank ordered to appropriately challenge the gluteal musculature during rehabilitation.
PMCID: PMC3201064  PMID: 22034614
gluteus medius; gluteus maximus; muscle recruitment; rehabilitation exercise
21.  CERVICOGENIC HEADACHES: AN EVIDENCE-LED APPROACH TO CLINICAL MANAGEMENT 
Cervicogenic headache (CGH), as the diagnosis suggests, refers to a headache of cervical origin. Historically, these types of headaches were difficult to diagnose and treat because their etiology and pathophysiology was not well-understood. Even today, management of a CGH remains challenging for sports rehabilitation specialists. The purpose of this clinical suggestion is to review the literature on CGH and develop an evidence-led approach to assessment and clinical management of CGH.
PMCID: PMC3201065  PMID: 22034615
Headache; neck pain; muscle imbalance
22.  THE RIDDELLTM RIPKORD SYSTEM FOR SHOULDER PAD REMOVAL IN A CERVICAL SPINE INJURED ATHLETE: A PARADIGM SHIFT 
Since the inception of the term Sports Medicine Athletic Trainers, Sports Physical Therapists, Paramedics, and Emergency Room Physicians have faced a number of challenges when it comes to providing care to an equipment laden athlete suspected of having a cervical spine or serious head injury. The same equipment that is designed to protect the player may significantly impede the medical team when it comes to diagnosing and treating cervical spine and head injuries. Incorrectly removing the helmet and shoulder pads from a football player with a cervical spine injury, may lead to unwanted motion of the cervical spine during removal. It is the purpose of this article to review the current concepts relating to equipment removal and to introduce a novel system for quick and easy removal of football shoulder pads called the Riddell™RipKord system.
PMCID: PMC3109891  PMID: 21712941
emergency management; cervical spine injury; equipment removal
23.  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
24.  FUNCTIONAL MOVEMENT SCREENTM NORMATIVE VALUES IN A YOUNG, ACTIVE POPULATION 
Background:
The Functional Movement ScreenTM (FMSTM) is a screening instrument which evaluates selective fundamental movement patterns to determine potential injury risk. However, despite its global use, there are currently no normative values available for the FMSTM.
Objectives:
To establish normative values for the FMSTM in a population of active, healthy individuals. Secondary aims were to investigate whether performance differed between males and females, between those with and without a previous history of injury, and to establish real-time inter-rater reliability of the FMSTM.
Methods:
Two hundred and nine (108 females and 101 males) physically active individuals, aged between 18 and 40 years, with no recent (<6 weeks) history of musculoskeletal injury were recruited. All participants performed the FMSTM and were scored using the previously established standardized FMSTM criteria. A representative sub-group participant sample (28%) determined inter rater reliability.
Results:
The mean composite FMSTM score was 15.7 with a 95% confidence interval between 15.4 and 15.9 out of a possible total of 21. There was no statistically significant difference in scores between females and males (t207 = .979, p = .329), or those who reported a previous injury and those who did not (t207 = .688, p= .492). Inter-rater reliability (ICC3,1) for the composite FMSTM score was .971, demonstrating excellent reliability. Inter-rater reliability (Kappa) for individual test components of the FMSTM demonstrated substantial to excellent agreement (0.70 — 1.0).
Discussion and Conclusion:
This cross-sectional study provides FMSTM reference values for young, active individuals, which will assist in the interpretation of individual scores when screening athletes for musculoskeletal injury and performance factors.
PMCID: PMC3109893  PMID: 21713227
Pre-participation screening; Functional Movement ScreenTM; injury risk; athletic performance
25.  A PILOT STUDY OF CORE STABILITY AND ATHLETIC PERFORMANCE: IS THERE A RELATIONSHIP? 
Study Design:
Correlation study
Objectives:
To objectively evaluate the relationship between core stability and athletic performance measures in male and female collegiate athletes.
Background:
The relationship between core stability and athletic performance has yet to be quantified in the available literature. The current literature does not demonstrate whether or not core strength relates to functional performance. Questions remain regarding the most important components of core stability, the role of sport specificity, and the measurement of core stability in relation to athletic performance.
Methods:
A sample of 35 volunteer student athletes from Asbury College (NAIA Division II) provided informed consent. Participants performed a series of five tests: double leg lowering (core stability test), the forty yard dash, the T-test, vertical jump, and a medicine ball throw. Participants performed three trials of each test in a randomized order.
Results:
Correlations between the core stability test and each of the other four performance tests were determined using a General Linear Model. Medicine ball throw negatively correlated to the core stability test (r –0.389, p=0.023). Participants that performed better on the core stability test had a stronger negative correlation to the medicine ball throw (r =–0.527). Gender was the most strongly correlated variable to core strength, males with a mean measurement of double leg lowering of 47.43 degrees compared to females having a mean of 54.75 degrees.
Conclusions:
There appears to be a link between a core stability test and athletic performance tests; however, more research is needed to provide a definitive answer on the nature of this relationship. Ideally, specific performance tests will be able to better define and to examine relationships to core stability. Future studies should also seek to determine if there are specific sub-categories of core stability which are most important to allow for optimal training and performance for individual sports.
PMCID: PMC3109894  PMID: 21713228

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