Volume Thirteen Number Four

 
2018Masthead_V13N4-1
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August 2018

SYSTEMATIC REVIEW – META ANALYSIS
Influence of Patient Demographics and Graft Types on ACL Second Injury Rates in Ipsilateral Versus Contralateral Knees:  A Systematic Review and Meta-Analysis.
Authors:  Nawasreh Z, Adams G, Pryzbylkowski O, Logerstedt D
There is inconsistency in the reported rates of second anterior cruciate ligament (ACL) injuries per limb, patients’ sex and graft types after primary ACL reconstruction (ACLR). There is also inconsistency regarding the influence of these factors on occurrence of second ACL injury after primary ACLR. The purpose of this analysis was to determine the rate of second ACL injury, to either the ipsilateral graft or contralateral healthy ACL, as influenced by sex, age, and graft types and to determine the influence of the same factors on the occurrence of second ACL injury after primary ACLR. A computerized search of MEDLINE, CINAHL, and SPORTDiscus was conducted using combinations of these terms: ACL, ACLR, re-injury, re-rupture, revisions, contralateral tear, ipsilateral graft tear, and second injury. Studies were required to report the number or percentage of sex, graft type, ipsilateral graft and contralateral ACL injuries after ACLR. Rates of second ACL injuries and pooled dichotomous data were calculated using random-effect proportion meta-analysis. The pooled rate of second ACL injuries (ipsilateral graft and contralateral ACL) was 6.11%. A slightly higher rate of ipsilateral graft injuries (3.29%) than contralateral ACL injuries (2.82%) (OR: 1.09 [95%CI: 0.89, 1.34] was reported. Ipsilateral graft injuries occurred earlier (median: 20 months) than contralateral ACL injuries (median: 36.3 months). Men had lower rate of second ACL injuries (5.67%) than women (6.84%) (OR: 0.92 [95%CI: 0.70, 1.20]). Significantly higher rate of ipsilateral graft injuries (3.40%) occurred in men compared to contralateral ACL injuries (2.26%) (OR: 1.53 [95CI%: 1.33, 1.77]), while women had significantly higher rate of contralateral ACL injuries (3.75%) compared to ipsilateral graft injuries (3.09%) (OR: 0.73 [95%CI: 0.55, 0.96]). The rate of second ACL (ipsilateral graft and contralateral ACL) injuries was higher in patients with hamstring tendon (HT) autograft (5.83%) than bone-patella tendon-bone autograft (BPTB) (5.10%) (p=0.04) and allografts (3.12%) (p<0.0001). The rate of ipsilateral graft injuries was significantly higher than contralateral ACL injuries in all graft types (p<0.001).  Injuries to the ipsilateral graft are more common than contralateral ACL, with ipsilateral graft injuries occurring nearly 16 months earlier after ACLR. More women sustain second ACL injuries compared to men, with men incurring more injuries to the ipsilateral graft and women to the contralateral ACL. Furthermore, second ACL injuries are more common in patients with HT autograft, BPTB autograft, and then allograft; with second ipsilateral graft injuries higher than contralateral ACL injuries regardless of graft types.   

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Risk Factors Associated with Non-Contact Anterior Cruciate Ligament Injury: A Systematic Review.  
Authors:  Pfeifer CE, Beattie PF, Sacko RS, Hand A
With the increasing number of individuals participating in sports every year, injury – specifically anterior cruciate ligament (ACL) injury – remains an inherent risk factor for participants. The majority of ACL injuries occur from a non-contact mechanism, and there is a high physical and financial burden associated with injury. Understanding the risk factors for ACL injury may aid in the development of prevention efforts.  The purpose of this review was to synthesize and appraise existing literature for risk factors associated with non-contact anterior cruciate ligament (ACL) injury in both sexes. An electronic literature search was conducted utilizing the MEDLINE database and The Cochrane library for articles available through February 2016. All titles and abstracts were reviewed and full text articles meeting eligibility criteria were assessed in detail to determine inclusion or exclusion. Articles reviewed in full text were reviewed for scientific evidence of risk factors for ACL injury. Results from studies were extracted and initially classified as either intrinsic or extrinsic risk factors, and then further categorized based upon the evidence presented in the studies meeting inclusion criteria. Data extracted from eligible studies included general study characteristics (study design, sample characteristics), methodology, and results for risk factors included. Principal findings of this systematic review identified the following risk factors for ACL injury in both sexes: degrading weather conditions, decreased intercondylar notch index or width, increased lateral or posterior tibial plateau slope, decreased core and hip strength, and potential genetic influence. Neuromuscular and biomechanical risk factors may be addressed through neuromuscular preventative training programs. Though some extrinsic and other inherent physiological factors tend to be non-modifiable, attempts to improve upon those modifiable factors may lead to a decreased incidence of ACL injury.

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ORIGINAL RESEARCH
Modifying Stance Alters the Peak Knee Adduction Moment During a Golf Swing.
Authors:  Hooker QL, Shapiro R, Malone T, Pohl MB
The knee joint is one of the most frequently injured regions in the game of golf, and the loads experienced by the knee during the golf swing are typically greater than during other activities of daily living. Altering movement patterns is a common strategy that can be used to reduce loading on the knee joint but has received little attention during studies of the golf swing. The primary aim of this study was to examine the effect altering golf stance has on the lead limb peak external knee adduction moment. Twenty healthy participants were recruited for a 3-dimensional biomechanical analysis wherein participants hit three golf shots with a driver using the following stance conditions: self-selected, bilateral 0° foot angle, bilateral 30º foot angle, wide stance width, and narrow stance width. Both the 30° foot angle (0.80 ± 0.51 Nm) and wide stance width (0.89 ± 0.49 Nm) conditions significantly decreased (p < 0.001) the lead limb peak external knee adduction moment compared to the self-selected (1.15 ± 0.58 Nm) golf stance. No significant differences (p = 0.109) in swing speed were found between any of the stance conditions. The externally rotated foot position and wider stance width decreased the lead limb peak external knee adduction moment without hindering swing speed. Modifying stance could be a viable option for golfers who wish to continue playing the sport at a high level, while reducing potential detrimental loads at the knee joint. 

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The Musculoskeletal Readiness Screening Tool- Athlete Concern for Injury and Prior Injury Associated with Future Injury.
Authors:   Terry AC, Thelen MD, Crowell M, Goss DL
The Musculoskeletal Readiness Screening Tool (MRST) was developed in an effort to consistently predict injury among military personnel. Current injury prediction tools have not consistently predicted injury in this population.  The MRST is comprised of the weight bearing forward lunge, modified deep squat, closed kinetic chain upper extremity stability test (CKCUEST), forward step down with eyes closed, stationary tuck jump, unilateral wall sit hold, and subjective, individual perceived level of risk for injury. The Feagin hop and self-reported history of injury were also included in this study protocol. The Feagin hop was a functional test used consistently by the orthopedic department located at the testing site as well as used in a recent study aimed at defining a return to duty screen; self-reported history of injury has been identified as a potential predictor of injury. The purpose of this study was to examine whether MRST scores, as a composite as individual components, were predictive of a United States Military Academy Preparatory School (USMAPS) student athlete sustaining a future musculoskeletal injury. MRST scores were collected for 141 student athletes (mean age 18.63 ±1.31) at USMAPS.  The injury surveillance period was nine months. Students participated in regularly occurring military specific training and various sports. Mean scores were compared between injured and uninjured groups; binary logistic regression model was also completed.  Seventy students sustained an injury. The top activities resulting in injury included football (36%) and basketball (11%) with injuries predominantly located in the lower extremity including the knee (24%), hip (15%), and ankle (14%).  Composite MRST scores were not statistically different between injured (12.58 ± 2.16) and uninjured (13 ± 2.27) groups. There was an association between those with a personal concern for future injury and actual injury (p=.04).  There was an association between those reporting a prior injury in the preceding 12 months and those incurring an injury at USMAPS (p=.04). The MRST composite scores were not predictive of injury in this population. Previous injury and personal concern for injury were significant injury predictors.

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Injury Identification: The Efficacy of the Functional Movement Screen™ in Female and Male Rugby Union Players.
Authors:  Armstrong R, Greig M
Rugby union is a collision sport which is associated with a high injury rate and therefore the development of effective injury prevention strategies is required. This study aimed to determine whether the Functional Movement Screen™ (FMS™) components can predict injury in female and male rugby union players and whether differences exist in the FMS™ scores of injured and non-injured players. Sixty-four female university rugby union players (age: 20.39 ± 1.91 years) and 55 male university rugby union players (age: 21.05 ± 1.35 years) completed the FMS™ which assesses seven functional movements on a scale of 0 to 3 and provides a total or composite score out of 21. Players were subsequently monitored for injury during the season and injury rates calculated. The training injury rates for females were 5.80 injuries/1000 hours and males 5.34 injuries/1000 hours while the match injury rates for females was 55.56 injuries/1000 hours and males 46.30 injuries/1000 hours. FMS™ composite score demonstrated a significant difference between injured females and non-injured males (p = 0.01) and a combined sample comparison of injured and non-injured subjects was significant (p = 0.01). FMS™ composite score was not a good predictor of injury however as FMS™ individual components predicted 37.4% of the variance in total days injured in females. ROC curve analysis revealed an injury cut off score of 11.5 for both females and males and provided a sensitivity and specificity of 0.90 and 0.86 and 0.88 and 1.00 respectively. The combined sample FMS™ composite score of ‘multiple injuries’ participants demonstrated no significant difference to non-injured (p = 0.31) and single injury subjects (p = 0.76). Injury rates between female rugby and male rugby were similar with match injury rates higher in females. The FMS™ can be used to identify those players with the potential to develop injury and the FMS™ injury cut off point was 11.5 for both female rugby and male rugby athletes. Individual components of the FMS™ are a better predictor of injury than FMS™ composite score.

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Intra-Rater Test-Retest Reliability and Response Stability of the Fusionetics™ Movement Efficiency Test.
Authors:  Cornell DJ, Ebersole KT
A new functional movement assessment, known as the Fusionetics™ Movement Efficiency (ME) Test, has recently been introduced in the literature. Before the potential clinical utility of the ME Test can be examined, the reliability of this assessment must be established. The purpose of this study was to examine the intra-rater test-retest reliability of the Fusionetics™ ME Test. ME Test data were collected among 23 (6 males, 17 females) university students (mean ± SD, age = 25.96 ± 3.16 yrs; height = 170.70 ± 9.96 cm; weight = 66.89 ± 12.67 kg) during sessions separated by 48 hours (Day 1, Day 2). All participants completed the seven sub-tests of the ME Test: 2-Leg Squat, 2-Leg Squat with Heel Lift, 1-Leg Squat, Push-Up, Shoulder Movements, Trunk Movements, and Cervical Movements. Overall ME Test scores and ME Test scores for each individual sub-test were calculated on a scale of 0 - 100 (worst – best) based on commonly observed movement compensations associated with each sub-test. Intraclass correlation coefficients (ICC3,1) statistics indicated that the intra-rater test-retest reliability of the Overall ME Test and individual sub-tests ranged from fair-to-excellent (ICC3,1 range = 0.55 – 0.84). Statistically significant differences in ME Test scores were identified between Day 1 and Day 2 among the 2-Leg Squat with Heel Lift (p = 0.015) and Cervical Movements (p = 0.005) sub-tests. In addition, a large range in the standard error of the measure (SEM) and minimal detectable change values (MDC90% & MDC95%) were identified within individual sub-tests of the ME Test (SEM range = 7.05 – 13.44; MDC90% range = 16.40 – 31.27; MDC95% range = 19.53 – 37.25), suggesting that the response stability varies among these individual sub-tests. Prevalence-adjusted bias-adjusted kappa statistics (κPABA) suggest that 55 of the 60 (92%) individual movement compensations hold moderate-to-almost perfect intra-rater test-retest reliability (κPABA range = 0.30 – 1.00).  Excellent intra-rater test-retest reliability of the Overall ME Test score was identified, and thus, clinicians can reliably utilize the Fusionetics™ ME Test to assess change in functional movement quality across time.  However, caution should be taken if utilizing an individual sub-test to assess functional movement quality over time.

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Altering Cadence or Vertical Oscillation During Running: Effects on Running Related Injury Factors.
Authors:  Adams D, Pozzi F, Willy R, Carrol A, Zeni J
Wearable devices validly assess spatiotemporal running parameters (cadence, vertical oscillation and ground contact time), but the relationship between these parameters and lower limb loading parameters (loading rate, peak vertical ground reaction force [vGRF] and braking impulse) is unknown. The purpose of this study was to characterize changes in lower limb loading parameters  in runners instructed to run with increased cadence or low vertical oscillation, and to determine whether the change in spatiotemporal parameters predicted the changes in lower limb loading parameters. Twenty healthy runners completed three running trials in three conditions: baseline, high cadence, and low vertical oscillation. Spatiotemporal parameters were measured with a wearable device and lower limb loading was measured using an instrumented treadmill. Spatiotemporal and loading parameters were analyzed between running conditions via a repeated measure ANOVA. A hierarchical regression model was used to determine if changes in spatiotemporal parameters predicted the change of loading parameters during conditions. High cadence and low oscillation conditions reduced average vertical loading rate (p = 0.013 and p = 0.002, respectively), instantaneous vertical loading rate (p = 0.022 and p = 0.001, respectively), and peak vGRF (p = 0.025 and p < 0.001, respectively). Braking impulse was significantly lower in the high cadence condition compared to baseline (p < 0.001), but not during the low oscillation (p = 1.000). The increase in cadence during the high cadence condition predicted the reduction of instantaneous vertical loading rate (r2 = 0.213, p = 0.041) and braking impulse (r2 = 0.279, p = 0.017). The reduction in vertical oscillation was more predictive of the change of peak vGRF in both running conditions (high cadence, r2 = 0.436, p = 0.009; low oscillation r2 = 0.748, p < 0.001).   While both higher cadence and lower vertical oscillation resulted in reduced loading rates during running, cueing to reduce vertical oscillation was more successful in reducing peak vGRF and only the higher cadence condition reduced braking impulse. These findings will inform clinicians who wish to use wearable devices for running gait modification to select injury-specific gait retraining cues.

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Leg-length Inequality and Running-Related Injury Among High School Runners.
Authors:  Rauh M
Participation in high school cross-country continues to increase with over 492,000 participants during the 2016-17 cross-country season. Several studies have indicated a high incidence of running-related injuries (RRI) in high school cross-country runners. Risk factors for RRI can be divided between intrinsic and extrinsic risk factors. Intrinsic risk factors such as structural asymmetries have received less attention in recent years.  The primary purposes of the current study were to (1) describe the prevalence of leg-length inequality among female and male high school cross-country runners, and (2) to determine whether leg-length inequality was associated with increased RRI injury in female and male high school cross-country runners. Three hundred ninety-three (222 males, 171 females) athletes competing in high school cross-country running were followed, prospectively. The runners’ right and left leg-lengths were measured with a standard cloth tape measure in a supine position. Incidence of low back/lower extremity RRI during practices or competitive events was monitored using the Daily Injury Report. A similar percentage of leg-length inequality greater than 0.5 cm was found among female (19.3%) and male (22.1%) runners. No statistically significant associations were found between leg-length inequality and (RRI) for female or male runners, with the exception that after adjusting for BMI, males with a leg-length inequality >1.5 cm were over seven times more likely to incur a lower leg RRI (Adjusted Odds Ratio=7.47; 95%CI: 1.5, 36.9; p=0.01) than males with a leg-length inequality <0.5 cm. Side of RRI was not associated with side of longer limb length.   While leg-length inequality was not associated with RRI, in general, males with a leg-length inequality >1.5 cm were at greater likelihood of sustaining a lower leg RRI.

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The Effects of an Acute Bout of Foam Rolling on Hip Range of Motion on Different Tissues.
Authors:  Hall M, Smith JC
Foam Rolling (FR) has steadily gained in popularity as an intervention to increase range of motion (ROM) and reduce pain. It is believed that FR can remove restrictions due to fascial adhesions, thus improving ROM. FR has been proposed as a means to increase ITB length as a means to achieve these outcomes.  Previous research has focused on the effects of FR over both muscle and fascia tissue together.  However, no studies have examined the effects of FR over fascial tissue not containing muscle. The purpose of this study was to compare the acute effect of a single bout of foam rolling (FR) over the Iliotibial Band (ITB) compared to FR over the gluteal muscle group on hip adduction passive range of motion (PROM). Twenty-seven participants were recruited for the study. Each participant performed three sessions: FR over tissue devoid of muscle, the ITB (PFR), FR over contractile tissue, the gluteal muscles (AFR), and a session without FR (control) in a randomized order. Hip adduction PROM was measured in a pre-post manner for each session. Results of the repeated measures ANOVA showed a significant interaction across session and time (F(2, 25) = 25.202, p <0.001, ηp2 = 0.502, 1 – β = 1.000). Post-hoc analysis showed the AFR post-test measure was significantly different from both control (p < 0.001) and PFR counterparts (p < 0.001). FR over the gluteal muscle group lead to a 14.8% improvement in hip adduction ROM, with PFR only a 2% improvement. A single bout of FR over a myofascial group appears to increase PROM in healthy young adults, whereas FR over the ITB itself (primarily fascial tissue) does not.  This suggests the conventional theory behind FR may need to be reevaluated.  

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No Effect of Kinesiology Tape on Passive Tension, Strength or Quadriceps Muscle Activation of During Maximal Voluntary Isometric Contractions In Resistance Trained Men.

Authors:  deFreitas FS, Brown LE, Gomes WA, Behm DG, Marchetti PH
Kinesiology Tape (KT) is widely used in sports rehabilitation and by those performing physical activity, however, there is no consensus in the scientific literature about its effectiveness on performance, strength or muscle activation. The purpose of this study was to measure the acute effects of KT in static rest, and during knee extension maximal voluntary isometric contraction (MVIC) performance in resistance trained men.  Eighteen young, healthy, trained males (age: 25±6 years, height: 176.0±5cm, and mass: 81.8±8.0kg) volunteered to participate. Initially, they were in a relaxed sitting position of 90 degrees knee flexion with their limb supported by the machine lever arm to measure passive tension of the tissues of the knee joint. Then, they performed three MVIC trials of five seconds each with a three-minute rest between trials, in four randomized experimental conditions, with 10-min rest between conditions: (a) control, no taping; (b) Knee Sleeve; (c) KT; and (d) sham. During all MVICs, peak force, impulse, and muscle activation of the vastus lateralis (integrated electromyography [IEMG] and median frequency) were measured.  Repeated measures ANOVAs revealed no statistical differences between conditions for passive tension (p>0.05), peak force (p>0.05), impulse (p>0.05), IEMG (p>0.05), or median frequency (p>0.05). KT does not influence passive tension during static position at 90 degrees of knee flexion. KT does not affect quadriceps activation or force production during a maximal voluntary isometric contraction in the same position.

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Electromyographic Analysis of Gluteus Maximus, Gluteus Medius, and Tensor Fascia Latae During Therapeutic Exercises With and Without Elastic Resistance.

Authors:  Bishop BN, Greenstein J, Etnoyer-Slaski JL, Sterling H, Topp R
Strengthening and activation of the gluteus maximus and gluteus medius while minimizing the contribution of the tensor fascia latae are important components in the treatment of many lower limb injuries. Previous researchers have evaluated a myriad of exercises that activate the gluteus maximus (GMax) and gluteus medius (GMed), however, limited research has been performed describing the role of the addition of elastic resistance to commonly used exercises. The primary purpose of this study was to determine the gluteal-to-tensor fascia latae muscle activation (GTA index) and compare electromyographic muscle activation of the GMax, GMed, and TFL while performing 13 commonly prescribed exercises designed to target the GMax and GMed. The secondary purpose of this study was to compare muscle activation of the GMax, GMed, and TFL while performing a subgroup of three matched exercises with and without elastic resistance. A sample of 11 healthy, physically active male and females, free of low back pain and lower extremity injuries, were recruited for the study. Surface electromyography was used to quantify the normalized EMG activation of the gluteus maximus, gluteus medius, and tensor fascia latae while performing 13 exercises. Three of these exercises were performed with and without elastic resistance. The maximal voluntary isometric contraction was established for each muscle and order in which the exercises were performed was randomized to minimize the effect of fatigue. The relative activation of the gluteal muscles were compared to the tensor fascia latae and expressed as the GTA index. Clams with and without resistance, running man gluteus maximus exercise on the stability trainer, and bridge with resistance, generated the highest GTA index respectively. Significant differences in activation of the TFL occurred between clams with and without resistance. The findings are consistent with those of previous investigators who reported that the clam exercise optimally activated the gluteal muscles while minimizing tensor fascia latae activation.

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Relative Joint Contribution to Joint Hypermobility in Rugby Players, Netballers and Dancers: The Need For Careful Consideration of Lumbar Flexion.
Authors:  Armstrong R
Generalized joint hypermobility is commonly measured using the Beighton and Horan Joint Mobility Index which provides a Beighton score of 0-9. Generally, scores of ≥4 are classified as hypermobile however joint hypermobility classification lacks consistency across the literature. The aim of the study was to compare the relative contribution of five joints to joint hypermobility scores in female and male rugby players, female netball players, female dancers and male and female age matched controls. Joint hypermobility was assessed in 286 subjects using the Beighton and Horan Joint Mobility Index. Subjects were assigned a Beighton score of 0-9. These scores were then categorized using three different joint hypermobility classification systems and results were analyzed using a Pearsons Chi Square (x2) to report the relative contributions of each joint to  hypermobility scores. Significant differences existed for group and gender analysis at the left and right 5th metacarpophalangeal joints, left and right thumb, left and right elbow and lumbar spine (p < 0.001). Lumbar flexion demonstrated significant differences and large effect sizes for all groups. This effect size was reduced to a moderate effect size when male against female analysis was performed and joint hypermobility was greater in females in comparison to males. The knee joint demonstrated the lowest hypermobility across all populations and ranged from 3% in male rugby players to 24% in female dancers. Seven hypermobile knees existed in males and 53 in females. Female dancers had the highest prevalence (93%) of hypermobile lumbar flexion and all female groups had a higher prevalence of hypermobile lumbar flexion than males. The removal of lumbar flexion from the total Beighton score had no effect on joint hypermobility prevalence in males in contrast to females where changes were demonstrated. Joint hypermobility classification of female dancers should consider the high prevalence of hypermobility of lumbar flexion in interpretation. The consideration of separate classification systems for males and females, and between athletes of different sports and dancers may aid future understanding

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Scapular Substitution after Rotator Cuff Repair Correlates with Postoperative Patient Outcome.
Authors:  Baumgarten KM, Osborn R, Schweinle WE, Zens MJ, Helssper EA
Scapular substitution is an alteration of scapulohumeral kinematics that may occur when patients have shoulder pain or dysfunction. These abnormal scapular kinematic patterns have been recognized in patients with rotator cuff tears. It remains unknown if 1) normal scapular kinematics can be restored with rehabilitation after rotator cuff repair surgery and 2) abnormal scapular kinematics are associated with inferior patient-determined outcome scores, range of motion, or strength. The purpose of this study was to determine 1) if scapular substitution can be decreased or improved with rehabilitation after rotator cuff repair surgery and 2) if the presence or amount of scapular substitution was correlated with patient-determined outcome scores, range of motion, or strength after rotator cuff repair surgery. Forty-eight patients who underwent post-operative rehabilitation after an arthroscopic rotator cuff repair were reviewed for this study.  The outcomes measures of interest included:  patient-determined outcome scores (WORC, Simple Shoulder Test, the ASES Score, the Shoulder Activity Score, and the SANE rating), identification and quantification of scapular substitution, active range of motion, and strength. Outcomes were prospectively collected up to 12 months after surgery and assessed retrospectively. As patients progress through their first year of rehabilitation after a rotator cuff repair, the amount of scapular substitution decreases but remains statistically significantly greater than the contralateral, asymptomatic side. At all post-operative time points, patients with scapular substitution, (determined subjectively by a physical therapist), had 1) inferior WORC, ASES, SANE, and SST scores, 2) inferior flexion, abduction, and external rotation range of motion, and 3) inferior scaption strength compared to those patients without subjective scapular substitution.  Rehabilitation decreases but does not normalize the amount of scapular substitution up to one year after rotator cuff repair. Subjective identification of scapular substitution is associated with inferior patient-determined outcome scores, range of motion, and strength.  

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Biomechanical Influences of a Postural Compression Garment on Scapular Positioning.
Authors:  Gascon SS, Gilmer GG, Hanks MM, Washington JK, Oliver GD
The scapula is a critical link utilized in the kinetic chain to achieve efficient overhead movement to transfer energy from the lower extremity to the upper extremity. Additionally, daily activities such as sitting at a computer or driving in a car may negatively influence an individual’s ability to maintain proper body posture and therefore compromise those movements. To reduce these negative influences, posture garments have been designed to cue the individual in maintaining and improving posture and alignment, specifically targeting scapular positioning. The purpose of this study was to compare scapular positioning between a IntelliSkin™ posture-cueing compression garment and a generic performance garment on scapular kinematics during static standing. Forty active females (1.68 ± 0.07 m; 67.29 ± 11.25 kg) stood in a natural standing position while wearing two different garments: IntelliSkin posture-cueing compression garment and a generic performance garment. Kinematic data were collected at 100 Hz using an electromagnetic tracking system (trakSTAR, Ascension Technologies, Inc., Burlington, VT, USA) synced with The MotionMonitor (Innovative Sports Training, Chicago, IL, USA). Repeated measures ANOVAs revealed a statistically significant Shirt by Side interaction for scapular protraction/retraction (F(1,39) = 52.91, p ≤ 0.05) and main-effect of Shirt for scapula anterior/posterior tilt (F(1,39) = 96.45, p ≤ 0.05). Individuals showed increased retraction and posterior tilt while wearing the IntelliSkin™ posture-cueing compression garment. The results of the current study indicate that the IntelliSkin™ posture-cueing compression garment improved scapular positioning during static standing posture. The IntelliSkin™ posture-cueing compression garment may provide clinicians an adjunct strategy to include with rehabilitative protocols.  

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Reliability and Validity of the HALO Digital Goniometer for Shoulder Range of Motion in Healthy Subjects.
Authors:  Correll S, Field J, Hutchinson H, Mickevicius G, Fitzsimmons A, Smoot B
Range of motion (ROM) of the shoulder is an integral component of assessment of musculoskeletal shoulder impairments. ROM is typically measured using a universal goniometer (UG). The UG has demonstrated good intra and inter-rater reliability for measuring shoulder ROM, although limitations exist. In recent years, alternative measurement devices such as smartphone applications and digital goniometers have been introduced, potentially addressing some of the shortcomings of the UG. Limited research is available on the validity and reliability of these alternative devices, including the laser-guided digital goniometer, in measuring shoulder ROM. The purpose of this study was to investigate the intra- and inter-rater reliability and concurrent validity of a laser-guided digital goniometer (HALO) for measuring active shoulder ROM.  A convenience sample of healthy volunteers was recruited. To be eligible, participants were required to be between 18 and 75 years of age and able to actively move at least one shoulder into 90° of glenohumeral abduction. Self-report of previous significant shoulder injury; previous shoulder surgery; current bilateral shoulder pain; current neck or upper back pain; or referred pain into the upper extremity were exclusion criteria. Active shoulder flexion, abduction, internal rotation, and external rotation were measured for each shoulder. Two evaluators measured each motion twice with each device (HALO and the UG) per shoulder. The intra-class correlation coefficient (ICC) for reliability and validity/agreement between devices was calculated using a two-way mixed model with a 95% confidence interval.  Data were analyzed for 75 shoulders from 41 participants (seven participants had only one shoulder evaluated). Intra-rater reliability ICCs are between 0.82 and for the HALO, and 0.83 to 0.95 for the UG. Inter-rater reliability for the HALO was 0.89 to 0.98 and for the UG was 0.90 to 0.98. The ICCs for agreement, comparing the HALO digital goniometer to the UG ranged from 0.79 to 0.99. This study provides evidence that the HALO digital goniometer can be a reliable and valid tool for measuring shoulder ROM in individuals with healthy shoulders. However, the two devices should not be used interchangeably to evaluate a single individual’s change over time for any motion.

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CASE SERIES / STUDIES

Treating Groin and Hip Flexor Pain Using Primal Reflex Release Technique™:  A Case Series.
Authors:  Stevenson VF, Baker RT, Nasypany A
The nervous system plays a significant role in groin/hip flexor pain which is a common complaint in the active population. Patient examinations that lack consideration of the nervous system’s involvement may result in chronic pain and dysfunctional breathing patterns due to continuously excited (also known as “up-related”) primal reflexes. Primal Reflex Release Technique™ (PRRT™) is a novel treatment paradigm that was designed to calm primal reflexes from their excitatory state. The purpose of this case series was to describe the effects of down-regulating primal reflexes using PRRT™ on pain, function, and breathing pattern dysfunction in subjects who presented with groin and hip flexor pain and exhibited hyperesthesia to TriggerRegions™ in areas of respiration.

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Osteochondritis Dissecans Of The Radial Head In A Young Athlete: A Case Report.
Authors:  Mourad F, Maselli F, Patuzzo A, Siracusa A, Filippo L, Dunning J, de las Penas C
Elbow pain is common in young gymnasts and is frequently encountered by physical therapists working in direct access outpatient clinics. Most elbow pain is benign; however, non-specific symptoms can mask serious medical pathologies, as is the case with osteochondritis dissecans (OCD). OCD is a joint condition in which bone underneath the cartilage of a joint dies due to lack of blood flow. Risk factor analysis, palpable joint tenderness and swelling, joint locking, and a history of high intensity repetitive activities may inform the clinical reasoning; however, the diagnosis of OCD is best made using magnetic resonance imaging (MRI). The purpose of this case report is to describe the main components of the history and physical examination that led to OCD differential diagnosis.

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LITERATURE REVIEW
Rehabilitation Following Isolated Posterior Cruciate Ligament Reconstruction: A Literature Review of Published Protocols.
Authors:  Senese M, Greenberg E, Lawrence T, Ganley T
Surgical outcomes following isolated posterior cruciate ligament reconstruction (PCLR) have been noted to be less satisfactory than the anterior cruciate ligament. Limited understanding of optimal rehabilitation has been implicated as a contributing factor. The purpose of this review was to gather the literature related to isolated PCLR rehabilitation, extract and summarize current rehabilitation guidelines, identify timeframes and functional measurements associated with common rehabilitation topics and provide recommendations for future research. A literature review was performed for scientific publications that include a detailed rehabilitation program following isolated PCLR, published between January 2005 and March 2018. Data related to weight-bearing, knee range of motion (ROM), brace usage, specific exercise recommendations and suggestions for return to running and sport activities were extracted and categorized. A total of 44 articles met inclusion criteria. Post-operative weight-bearing was discussed in 35 articles with recommendations ranging from no restriction to 12 weeks of limitations. Forty-two articles recommended the use of immediate post-operative bracing, the majority of which positioned the knee in full extension, with duration of use ranging from one to 12 weeks post-operatively. Although 30 articles offered detailed descriptions of ROM activity, there was significant variability in timing of initiation, angular excursion and progression of range of motion. Suggested timeframes for returning to sports activity ranged from four to 12 months, with only four articles providing specific objective strength or functional performance criteria necessary for progression. There is substantial variation in nearly all aspects of published descriptors of rehabilitation following isolated PCLR. Most protocols are based upon biomechanical principles and clinical expertise, relying solely on timeframe from surgery to support rehabilitation decision making. Evidence to compare patient outcomes with specific loading, ROM progression and exercise strategies is currently lacking.  Only a small number of protocols incorporate the use of specific objective performance goals to facilitate return to sport decision making.

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CLINICAL COMMENTARY
Rehabilitation Following Sternoclavicular Joint Reconstruction for Persistent Instability.
Authors:  Logan C, Shahien A, Altintas B, Millett PJ
Sternoclavicular (SC) joint instability is a rare injury, but one with profound implications given its proximity to vital structures and function as the only true articulation between the upper extremity and axial skeleton. The majority of SC joint instability can be treated non-operatively; however, there is a role for reconstruction in the presence of instability that results in pain and dysfunction that is refractory to conservative management or deformity resulting in functional impairment. Given the lack of inherent osseous stability at the sternoclavicular joint and the role of ligaments as primary stabilizers, surgical intervention with emphasis on ligament reconstruction may be recommended. Safe and effective rehabilitation is conducted through phase progression, with avoidance of premature stress to the healing soft tissue graft. The purpose of this clinical commentary is to provide the senior author’s rehabilitation protocol, which utilizes the available scientific literature to inform phase content and progression.

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Theoretical Roller Massage: A Commentary on Clinical Standards and Survey of Physical Therapy Professionals.
Authors:  Cheatham SW, Stull KR
Roller massage (RM) has become a popular intervention used by rehabilitation professionals and active individuals. The emerging popularity has resulted in the production of various types of rollers and a growing body of research on the therapeutic effects and science behind RM. Despite the growing popularity and research, there is no consensus on clinical standards such as a describing the intervention, indications, precautions, contraindications, and assessment. There have been no specific peer reviewed publications that have discussed such standards. This leaves a gap in the knowledge regarding how clinicians are integrating the RM research into their clinical practice. The purpose of this clinical commentary is to discuss proposed clinical standards for RM.

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