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December 2016

A Systematic Review and Meta-analysis Comparing Cardiopulmonary Exercise Test Values Obtained From the Arm Cycle and the Leg Cycle Respectively in Healthy Adults
Authors:  Larsen RT, Christensen J, Tang LH, Keller C, Doherty P, Zwisler AD. Taylor RS, Langberg H
The cardiopulmonary exercise test (CPET) assesses maximal oxygen uptake (VO2max) and is commonly performed on a leg cycle ergometer (LC). However, some individuals would rather perform the CPET on an arm cycle ergometer (AC). The objectives of this study were to undertake a systematic review and meta-analysis of the difference in VO2 max achieved by AC compared to LC in healthy adults and to explore factors that may be predictive of this difference. The differences in VO2max (ACLCdiff) were pooled across studies using random effects meta-analysis and three different methods were used to estimate the ratio between the values obtained from the tests (ACLCratio). This paper included 41 studies with a total of 581 participants. The mean ACLCdiff across studies was 12.5 ml/kg/min and 0.89 l/min with a mean ACLCratio of 0.70. The ACLCdiff was lower in studies with higher mean age and lower aerobic capacity.  There is linear association between the AC and LC values in healthy adults. The AC values were on average 70% of the LC values. The magnitude of this difference appeared to be reduced in studies on older and less active populations.
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The Effects of Instrument Assisted Soft Tissue Mobilization on Lower Extremity Muscle Performance: A Randomized Controlled Trial
Authors: MacDonald N, Baker R, Cheatham SW
Instrument-Assisted Soft Tissue Mobilization (IASTM) is a non-invasive therapeutic technique used to theoretically aid in scar tissue breakdown and absorption, fascial mobilization, and improved tissue healing. Researchers have hypothesized that utilizing IASTM will improve muscular efficiency and performance; yet previous investigation has been focused on treating injury.  Therefore, the purpose of this investigation was to explore the effects of IASTM on muscle performance to assess if typical treatment application affected measures of muscular performance. A convenience sample of 48 physically active adults (mean age 24±4 years), randomly assigned to one of three groups: quadriceps treatment group, triceps surae treatment group, or control group.  Participants performed a five-minute warm-up on a Monark bicycle ergometer before performing three countermovement vertical jumps (CMJ). Immediately after, the IASTM treatment was applied by one researcher for three minutes on each leg at the specified site (e.g., quadriceps) for those assigned to the treatment groups, while the control group rested for six minutes. Immediately following treatment, participants performed three additional CMJs. Pre- and post-testing included measures of vertical jump height (JH), peak power (PP) and peak velocity (PV).  The authors found that there were no statistically significant differences found between treatment groups in JH, PP, or PV or across pre- and post-test trials.  These preliminary findings suggest that standard treatment times of IASTM do not produce an immediate effect in muscular performance in healthy participants. This may help clinicians determine the optimal sequencing of IASTM when it is part of a pre-performance warm-up program.
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Immediate Effects of Deep Trunk Muscle Training on Swimming Start Performance
Authors: Iizuka S, Imai A, Koizumi K, Kaneoka K
In recent years, deep trunk muscle training has been adopted in various sports, including swimming. This is performed both in everyday training and as part of the warm-up routine before competitive races. It is suggested that trunk stabilization exercises are effective in preventing injury, and aid in improving performance. However, conclusive evidence of the same is yet to be obtained. The time of start phase of swimming is a factor that can significantly influence competition performance in a swimming race.  If trunk stabilization exercises can provide instantaneous trunk stability, it is expected that they will lead to performance improvements in the start phase of swimming. Therefore, the purpose of this study was to investigate the immediate effect of trunk stabilization exercises on the start phase in swimming.  Nine elite male swimmers (mean age 20.2 ± 1.0 years; height 174.4 ± 3.5 cm; weight 68.9 ± 4.1 kg) performed the swimming start movement. The measurement variables studied included flying distance, and the time and velocity of subjects at hands’ entry and on reaching five meters.  Measurements were taken in trials immediately before and after the trunk stabilization exercises. A comparison between pre- and post-exercise measurements was assessed.  The time to reach five meters (T5m) decreased significantly after trunk stabilization exercises, by 0.019 s (p=0.02). Velocity at entry (Ventry) did not demonstrate significant change, while velocity at five meters (V5m) increased significantly after the exercises (p=0.023). In addition, the speed reduction rate calculated from Ventry and V5m significantly decreased by 5.17% after the intervention (p=0.036).  The authors concluded that trunk stabilization exercises may help reduce the time from start to five meters in the start phase in swimming. The results support the hypothesis that these exercises may improve swimming performance.
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Changes in Dynamic Balance and Hip Strength After an Eight-week Conditioning Program in NCAA Division I Female Soccer (football) Athletes
Authors:  Ness BM, Constock BA, Schweinle WE
Lower extremity injury commonly affects female soccer athletes. Decreased dynamic balance and hip strength are identified risk factors for lower extremity injury. Little is known about how these factors adapt to a training stimulus in this population. The purpose of this study was to retrospectively investigate changes in lower extremity dynamic balance and isometric hip strength in Division I collegiate female soccer athletes after participating in an eight-week strength and conditioning program. As part of a standard testing battery, soccer athletes completed athletic performance pre- and post-testing separated by an eight-week off-season conditioning program consisting of overall strength and technical skill development. Testing included lower extremity dynamic balance assessment through the Star Excursion Balance Test (SEBT) and isometric hip abduction and external rotation (ER) strength testing, normalized to limb length and percent body mass, respectively. Athletes rested for one week prior to post-testing.  Seventeen healthy Division I female soccer athletes (age: 18.8 ± 0.9 years, height: 1.7 ± 0.06 m, mass: 68.0 ± 8.2 kg) completed the protocol. Significant improvements in SEBT composite reach distance were observed in the dominant (DOM) (3.6 ± 4.8%, 95% CI: 1.1 to 6.0) and non-dominant (NDOM) (4.8 ± 6.1%, 95% CI: 1.7 to 7.9) limbs. Significant improvements in DOM hip ER strength (2.4 ± 2.3%, 95% CI: 1.3 to 3.6) and DOM SEBT anterior reach (2.1 ± 2.8%, 95% CI: 0.6 to 3.5) were observed. Large effect sizes were observed for DOM and NDOM hip ER strength gains (0.87 – 1.0), while small-moderate effect sizes were noted for the anterior reach direction (0.40 – 0.66). Further, DOM hip ER strength gains were significantly associated with DOM anterior reach performance improvements (r2 =0.37, p<.01).  DOM hip ER strength gains appear to be associated with improved lower extremity dynamic balance on the ipsilateral limb for the SEBT anterior reach direction in collegiate, Division I female soccer athletes after an eight-week conditioning program.
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Improvements in Knee Extension Strength are Associated with Improvements in Self-reported Hip Function Following Arthroscopy for Femoroacetabular Impingement Syndrome
Authors: Davis CC, Ellis TJ, Amesur AK, Hewett TE, DiStasi S
Recovery of strength is critical for return to sport, and is a known predictor of functional outcomes in post-surgical orthopedic populations. Muscle weakness is a known impairment in patients with femoroacetabular impingement syndrome (FAIS) but whether improvements in muscle strength after arthroscopy are associated with improved hip function is unknown. The purpose of this study was to examine the relationships between changes in hip and thigh muscle strength and self-reported function in athletes undergoing arthroscopy for FAIS.  Twenty-eight athletes underwent strength testing and completed the Hip Outcome Score Activities of Daily Living (HOS-ADL) and Sports (HOS-S) subscales prior to and six months after surgery. Isokinetic knee extension and flexion strength were measured using a Biodex dynamometer at 60°/s and 300°/s. Isometric hip abduction strength was measured using a custom dynamometer. Changes in strength, limb symmetry, and HOS scores were assessed using paired t-tests. Spearman’s rank correlations were used to examine relationships between change in involved limb strength and change in HOS scores. Subjects were tested an average of 32 days before and 178 days after surgery. HOS-ADL and HOS-S subscales improved by a mean of 19.021.1 and 23.831.9, respectively, over time (p<0.001). Hip abduction strength did not increase over time in either limb (p≥0.27). Involved limb knee flexion and extension strength did not increase significantly over time (p-values: 0.10-0.48) with the exception of knee extension at 300°/s (p=0.04). Uninvolved limb knee extension strength at both velocities and knee flexion strength at 60°/s improved significantly over time (p<0.012). Increases in normalized knee extension strength (60°/s) of the involved limb were significantly correlated with improvements on the HOS-ADL (r=0.431; 0=0.025) and HOS-S (r=0.439; p=0.025). There were no significant relationships between changes in involved limb hip abduction or knee flexion strength and HOS subscales (p≥0.123).   Therefore, the authors concluded that improvements in knee extension strength were associated with improvements in self-reported hip function in athletes following arthroscopy for FAIS. Individuals with knee extension strength deficits prior to surgery may benefit from targeted knee extension strengthening during post-operative rehabilitation to improve functional outcomes.
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Effect of Different Foam Rolling Volumes on Knee Extension Fatigue

Authors:  Monteiro ER, Neto VGC
Foam rolling (FR) is a common intervention utilized for the purpose of acutely increasing range-of-motion without subsequent decreases in performance. FR is characterized as an active technique which subject performs upon themselves. Thus, it is believed that the accumulated fatigue can influence whether the task can be continued.  The purpose of this study was to analyze the effect of different foam rolling volumes on fatigue of the knee extensors. Twenty-five recreationally active females (age 27.7 ± 3.56 y, height 168.4 ± 7.1 cm, weight 69.1 ± 10.2 kg) were recruited for the study. The experiment involved three sets of knee extensions with a pre-determined 10 repetition maximum load to concentric failure. Then, subjects performed the control (CONT) and foam rolling (FR) conditions. FR conditions consisted of different anterior thigh rolling volumes (60-, 90-, and 120-seconds) which were performed during the inter-set rest period. After that, the fatigue index was calculated and compared between each experimental condition. Fatigue index indicates how much (%) resistance to fatigue the subjects experienced, calculated by the equation: (thidset/firstset) x 100.  Fatigue index was statistically significantly greater (greater fatigue resistance) for CONT compared to FR90 (p = 0.001) and FR120 (p = 0.001). Similarly, higher fatigue resistance was observed for FR60 when compared to FR120 (p = 0.048). There were no significant differences between the other conditions (p > 0.005). The finding of foam rolling fatigue index decline (less fatigue resistance) as compared to control conditions may have implications for foam rolling prescription and implementation, in both rehabilitation and athletic populations. For the purposes of maximum repetition performance, foam rolling should not be applied to the agonist muscle group between sets of knee extensions. Moreover, it seems that volumes greater than 90-seconds are detrimental to the ability to continually produce force.
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Measuring Sport-Specific Physical Abilities in Male Gymnasts:  The Men’s Gymnastics Functional Measurement Tool
Authors:  Sleeper MD, Kenyon LK, Elliott JM, Cheng S
Despite the availability of various field-tests for many competitive sports, a reliable and valid test specifically developed for use in men’s gymnastics has not yet been developed. The Men’s Gymnastics Functional Measurement Tool (MGFMT) was designed to assess sport-specific physical abilities in male competitive gymnasts. The purpose of this study was to develop the MGFMT by establishing a scoring system for individual test items and to initiate the process of establishing test-retest reliability and construct validity.  A total of 83 competitive male gymnasts ages 7-18 underwent testing using the MGFMT.  Thirty of these subjects underwent re-testing one week later in order to assess test-retest reliability.  Construct validity was assessed using a simple regression analysis between total MGFMT scores and the gymnasts’ USA-Gymnastics competitive level to calculate the coefficient of determination (r2). Test-retest reliability was analyzed using Model 2 Intraclass correlation coefficients (ICC). Statistical significance was set at the p<0.05 level.  The relationship between total MGFMT scores and subjects’ current USA-Gymnastics competitive level was found to be good (r2 = 0.63). Reliability testing of the MGFMT composite test score showed excellent test-retest reliability over a one-week period (ICC=0.97). Test-retest reliability of the individual component tests ranged from good to excellent (ICC = 0.75-0.97).  The results of this study provide initial support for the construct validity and test-retest reliability of the MGFMT.
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The reliability of FABER test hip range of motion measurements
Authors:  Bagwell JJ, Bauer L, Gradoz M, Grindstaff TL
The Flexion ABduction External Rotation (FABER) test has been suggested to have utility for the measurement of hip range of motion, although normative data, reliability, and minimal detectable change (MDC) of such measurements have not been established. The purpose of this study was to determine normative FABER height, assess inter- and intra-rater reliability and MDC for FABER, and compare traditional FABER measurements to methods which account for differences in thigh length.  Nineteen healthy participants without low back, hip, or knee pain in the preceding three months were recruited. Measurements were performed during two sessions (three to seven days between sessions) by three clinicians. FABER height and thigh length measurements were performed. Thigh length normalized FABER range of motion (ROM) and FABER ROM symmetry were calculated. One tester also measured FABER with a digital inclinometer. Inter- and intra-rater reliability were calculated using interclass correlation coefficients (ICC) and mean MDC values were calculated.  Mean values for FABER height and normalized FABER ROM were 12.4 + 2.8 and 0.30 + 0.07, respectively. Inter-rater reliability for FABER and normalized FABER were good (ICC 0.67-0.68) and between session intra-rater reliability were good to excellent (ICC 0.76-0.86). Mean FABER and normalized FABER ROM MDC were 3.7 cm and 0.04, respectively. Mean FABER ROM symmetry was 2.0 + 0.9 cm with poor inter-rater reliability (ICC 0.20), poor to good intra-rater reliability (ICC 0.38-0.66), and mean MDC of 4.0 cm. FABER measured with a ruler, normalized FABER ROM, and inclinometry all resulted in excellent intra-rater reliability, with the highest ICC being demonstrated for inclinometry (ICC 0.86, 0.86, and 0.91).  Overall, FABER measurements were reliable, whether normalized to thigh length or not.   Furthermore, use of inclinometry may increase reliability. Reliability was poor to good when assessing symmetry between limbs.
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Modifying Marching Technique in Military Service Members With Chronic Exertional Compartment Syndrome: A case series

Authors: Helmhout PH, Diebal-Lee A, Poelsma LR, Harts CC, Zimmermann WO
The long-term effectiveness of both operative and non-operative management approaches for Chronic Exertional Compartment Syndrome of the lower legs (CECS) is moderate at best. Positive outcomes have recently been reported on modifying running technique in individuals with CECS. The purpose of this case series was to evaluate a training program aimed at changing marching technique in individuals with CECS, based on principles that aim to eliminate heel strike and decrease impact during foot strike.   Six service members with CECS underwent a five-week training program aimed at modifying marching technique. The program was comprised of foot/lower leg strengthening exercises, perception drills, and treadmill/outdoor marching bouts. Self-assessed leg condition, marching endurance performance, and kinematic/kinetic measurements were assessed at baseline (T0), post-treatment (T5), and nine months post-intervention (T40).   Moderate to fair pre- to post improvements on the self-assessed leg condition outcomes were demonstrated for most participants (4% to 73% improvements). These scores continued to improve until the 9 month follow-up. Marching performance improved during the intervention period in all but one subject, ranging from 6% to 38% improvement in marching time. Kinematic and kinetic data showed pre- to post-intervention changes that were reflective of the marching technique modification in most subjects. Post-intervention pain profiles of participants during marching showed that, in most subjects, the onset of leg pain was delayed compared to baseline.  A five-week intervention aimed at altering marching technique has demonstrated moderately promising results in a group of service members with CECS of the lower legs who had previously undergone other conservative management interventions without success. Due to the relatively small sample size and the variability in subject outcomes, further research is warranted.
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Acute Tearing of the Oblique Abdominal Wall Insertion Onto the Iliac Crest in an Australian Football Player: A Case Report
Authors:  Murphy M, Stockden M, Breidahl B
Tears of the abdominal obliques have previously been reported in the vicinity of the lower ribs but they have not been reported in the vicinity of the iliac crest. The purpose of this case report was to describe the mechanism of injury and diagnosis of a distal abdominal oblique tear and subsequent rehabilitation programming.  A 21-year-old male Australian football player experienced acute right-sided abdominal pain during a game while performing a commonly executed rotation skill. He was assessed clinically before being further examined with ultrasound and magnetic resonance imaging which revealed a rupture of the abdominal oblique wall at its insertion onto the iliac crest. The player then underwent a structured and graduated rehabilitation program with clear key performance indicators to optimize return to play and prevent recurrence.  The player was able to return to play at 35 days post injury and had no recurrence or complications at 12 month follow up post injury.  This is the first time an abdominal oblique wall rupture at its insertion onto the iliac crest has been reported. In players with acute abdominal pain following twisting an insertional oblique tear should be considered as a differential diagnosis. A structured rehabilitation program may also help optimize an athlete’s return to play after distal abdominal oblique rupture.
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An Intervention-Based Clinical Reasoning Framework to Guide the Management of Thoracic Pain in a Dancer: A Case Report
Authors:  Collins CK, Masaracchio M, Kirker K, Hanney W, Liu X
As a result of the anatomical proximity of the thoracic spine to the cervical, lumbar, and shoulder regions, dysfunction in the thoracic spine can influence pain, mobility, and stability across these areas. Currently, a paucity of evidence exists addressing treatment of individuals with primary thoracic pain, especially in young, athletic patients. Furthermore, current research discussing clinical reasoning frameworks focus on the differential diagnostic process. The purpose of this case report was to present a framework that describes the clinical reasoning process for the implementation and sequencing of procedural interventions for the management of a dancer with thoracic pain.  A 21-year-old female dancer presented to physical therapy with a medical diagnosis of thoracic pain. The patient reported exacerbation of left thoracic pain with prolonged sitting, twisting/arching her back during dance, and lifting >15 lbs overhead. Examination revealed hypomobility with positive pain provocation during mobility testing of T1-T3 and the sternocostal junction of ribs 2-4, with associated muscle guarding palpated in the left iliocostalis thoracis and levator scapula. Following 10 visits, the patient had no pain, no functional deficits, and a Global Rating of Change (GROC) of +6. She returned to full competition, and a 3-month follow-up revealed continued success with dancing and a GROC of +7.  This case report described the successful management of a dancer with primary thoracic pain using a clinical reasoning framework for the sequencing of procedural interventions, while incorporating Olson’s impairment-based classification system. A combination of manual therapy techniques and neuromuscular control exercises were incorporated to address mobility, stability, mobility on stability, and skill level impairments, which allowed the patient to return to dance activities safely.
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From Acute Achilles tendon Rupture to Return to Play –  A Case Report Evaluating Recovery of Tendon Structure, Mechanical Properties, Clinical and Functional Outcomes
Authors:  Zeller JA, Cortes DH, Silbernagel KG
Achilles tendon rupture results in significant functional deficits regardless of treatment strategy (surgical versus non-surgical intervention). Recovery post-rupture is highly variable, making comprehensive patient assessment critical. Assessment tools may change along the course of recovery as the patient progresses – for instance, moving from a seated heel-rise to standing heel-rise to jump testing. However, tools that serve as biomarkers for early recovery may be particularly useful in informing clinical decision-making.  The purpose of this case report was to describe the progress of a young, athletic individual following Achilles tendon rupture managed non-surgically, using patient reported and functional performance outcome measures and comprehensively evaluating Achilles tendon structure and function incorporating a novel imaging technique (cSWE).  The subject is a 26 year-old, female basketball coach who sustained an Achilles tendon rupture and was managed non-surgically.  The subject was able to steadily progress using a gradual tendon loading treatment approach well-supported by the literature.  Multiple evaluative techniques including the addition of diagnostic ultrasound imaging and continuous shear wave elastography (cSWE) to standard clinical tests and measures were used to assess patient-reported symptoms, tendon structure, and tendon functional performance. Five assessments were performed over the course of 2-14 months post-rupture. By the 14-month follow-up, the subject had achieved full self-reported function. Tendon structural and mechanical properties showed similar shear modulus by 14 months, however, viscosity continued to be lower and tendon length longer on the ruptured side. Functional performance, evidenced by the heel-rise test and jump tests, also showed a positive trajectory, however, deficits of 12-28% remained between ruptured and non-ruptured sides at 14 months. This case report outlines comprehensive outcomes assessment in an athletic individual following non-surgically managed Achilles tendon rupture using a wide variety of tools that capture different aspects of tendon health. Interestingly, the course of recovery of patient symptoms, functional performance, and tendon structure do not occur in the same time frame. Therefore, it is important to assess patient outcomes using multiple outcome measures encompassing different aspects of patient performance to ensure the patient is progressing steadily with rehabilitation.
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A Non-Operative Approach to the Management of Chronic Exertional Compartment Syndrome in a Triathlete: A Case Report

Authors:  Gilden B, Collins CK
Chronic Exertional Compartment Syndrome (CECS) causes significant exercise related pain secondary to increased intra-compartmental pressure (ICP) in the lower extremities.  CECS is most often treated with surgery with minimal information available on non-operative approaches to care.  This case report presents a case of CECS successfully managed with physical therapy.  A 34-year-old competitive triathlete experienced bilateral anterior and posterior lower leg pain measured with a numerical pain rating scale of 7/10 at two miles of running.  Pain decreased to resting levels of 4/10 two hours post exercise.  The patient was diagnosed with bilateral CECS with left lower extremity ICP at rest measured at 36 mmHg (deep posterior), 36-38 mmHg (superficial posterior), and 25 mmHg (anterior).  Surgery was recommended. The patient chose non-operative care and was treated with physical therapy using a Functional Manual Therapy approach aimed at addressing myofascial restrictions, neuromuscular function and motor control deficits throughout the lower quadrant for 23 visits over 3.5 months.  At discharge the patient had returned to running pain free and training for an Olympic distance triathlon.  The Lower Extremity Functional Scale improved from 62 to 80.  The patient reported minimal post exercise tightness in bilateral lower extremities.  Left lower extremity compartment pressure measurements at rest were in normal ranges measuring at 11 mmHg (deep posterior), 8 mmHg (superficial posterior), 19 mmHg (anterior), and 10 mmHg (lateral).  Three-years post intervention the patient remained pain free with a Global Rating of Change of +6.  This case report describes the successful treatment of a triathlete with Functional Manual Therapy resulting in a return to competitive sports without pain.
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Post-Operative Rehabilitation of Grade III Medial Collateral Ligament Injuries:  Evidence Based Rehabilitation and Return to Play

Authors:  Logan CA, O’Brien L, LaPrade RF
The medial collateral ligament is the most commonly injured ligament of the knee, with injury generally sustained in the athletic population as a result of valgus contact with or without tibial external rotation. The capacity of the medial collateral ligament to heal has been demonstrated in both laboratory and clinical studies; however, complete ruptures heal less consistently and may result in persistent instability. When operative intervention is deemed necessary, anatomical medial knee reconstruction is recommended.  Post-operative rehabilitation focuses on early motion and the return of normal neuromuscular firing patterns with progression based on attainment of specific phase criteria and goals.  The purpose of this clinical commentary is to discuss the determinants of phase progression and the importance of objectively assessing readiness for advancement that is consistent with post-operative healing.  Additional tests and validated measures to assess readiness for sport are also presented.
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Clinical Commentary on Midfoot and Forefoot Involvement in Lateral Ankle Sprains and Chronic Ankle Instability. Part 2: Clinical Considerations.
Authors:  Fraser JJ, Feger MA, Hertel J
Lateral ankle sprains (LAS) and chronic ankle instability (CAI) are common musculoskeletal injuries that are a result of inversion injury during sport. The midfoot and forefoot is frequently injured during a LAS, but is often overlooked during clinical examination, and may be contributory to the development of CAI. The purpose of Part Two of this clinical commentary and current concept review is to increase clinician’s awareness of the contribution of midfoot and forefoot impairment to functional limitation and disability of individuals who experience LAS and CAI and to facilitate future research in this area. The importance of multi-segmented foot and ankle assessment from a clinical and research perspective is stressed. Select physical assessment and manual therapeutic techniques are presented to assist the clinician in examination and treatment of the ankle-foot complex in patients with LAS and CAI.
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