VOLUME FOURTEEN NUMBER ONE

 
201(Masthead_V14N1

February 2019

Erratum

SYSTEMATIC REVIEW – META ANALYSIS

Diagnostic Accuracy Of The Lever Sign In Detecting Anterior Cruciate Ligament Tears:  A Systematic Review and Meta-Analysis
Authors:  Abruscato K, Browning K, Deleandro D, Menard Q, Wilhelm M, Hassan A
The anterior cruciate ligament (ACL) is one of the most commonly injured ligaments in the knee. With the prevalence of ACL tears increasing, there is a growing need for clinical tests to rule in and rule out a suspected tear. A new clinical test for detecting ACL tears has been introduced with preliminary studies showing promising results.The purpose was to systematically review and analyze information from the current literature on the diagnostic accuracy of the Lever Sign Test for the use of diagnosing anterior cruciate ligament (ACL) injuries in a clinical setting. A computerized search of PubMed, Cinahl, Scopus, and Proquest databases as well as a hand-search was completed on all available literature using keywords relating to the diagnostic accuracy of the Lever Sign Test. A quality assessment was performed on each article included in this review utilizing the Quality Assessment of Diagnostic Accuracy Studies (QUADAS).  Eight articles were included, with only three studies exhibiting high quality, however the study samples were heterogenous. Included studies indicated that the Lever Sign test is both sensitive and specific in diagnosing ACL tears. Pooled sensitivity and specificity were 0.77 and 0.90, respectively. The negative likelihood ratio is 0.22 and the positive likelihood ratio is 6.60. It can be conculed from this review that The Lever Sign test is comparable to other clinical tests used in current practice to detect an ACL rupture. The pooled data from current available literature on the Lever Sign indicate that a positive or negative test should result in a moderate shift in post-test probability. This test may be used in addition to other tests to rule in and rule out the presence of an ACL rupture.

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Examination Of Gluteus Maximus Electromyographic Excitation Associated With Dynamic Hip Extension During Body Weight Exercise: A Systematic Review
Authors:  Macadam P, Feser EH
Hip extension is an important action in daily activities (standing, stepping and walking) and sporting actions (running, sprint-running and jumping). Though several different exercises exist, a comprehensive understanding of which exercises best target the gluteus maximus (Gmax) and the magnitude of muscular excitation associated with each exercise is yet to be established. The purpose of this systematic review was to describe the electromyographic (EMG) excitation of the Gmax during body weight exercises that utilize hip extension.  A systematic approach was used to search Pubmed, Sports Discuss, Web of Science and Science Direct. Articles that examined injury‐free participants of any age, gender or excitation level were included.  Articles were excluded when not available in English, where studies did not normalize EMG excitation to maximum voluntary isometric contraction (MVIC), where a load or resistance was added to the exercise, or where no hip extension occurred. Exercises were grouped into vertical and horizontal (anteroposterior or posteroanterior) force vectors. Thirty-nine studies of high methodological quality were retained for analysis. Twenty-five exercises were performed in the vertical vector (average: 33.4% MVIC, highest: single leg wall squat 86% MVIC), fourteen exercises were performed in the horizontal (anteroposterior) force vector (average: 32.8% MVIC, highest: single leg bridge 54.2% MVIC, while thirty-eight exercises were included in the horizontal (posteroanterior) vector (average: 30.4% MVIC, highest: plank with bent leg hip extension 106.2% MVIC).  The differences in subject’s backgrounds, exercise technique and the methodological approaches varied between studies, most notably in the different positions used for obtaining MVIC, which could have dramatically impacted normalized levels of gluteal activation. The findings from this review provide an indication of Gmax muscle excitation generated by a variety of hip extension body weight exercises, which may assist practitioners in making exercise selection decisions for programming.

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ORIGINAL RESEARCH
The Effects of Posterior Tibial Mobilization on Meniscal Movement: An In-Situ Investigation
Authors:  Lilly S, Seeber GH, Smith MP, McGaugh JM, James CR, Brismee JM, Sizer PS
Anterior knee pain during knee extension may be related to a meniscal movement restriction and increased meniscal load during function. One method of treatment for hypomobility involves the use of manual posterior mobilization of the tibia to specifically target the meniscotibial interface of the knee joint.  The purpose of this study was to measure motion at a cadaveric medial meniscus anterior horn during a posterior tibial mobilization. Eight unembalmed cadaveric knee specimens were mounted in a custom apparatus and markers were placed in the medial meniscus, tibia and femur. The tibia was posteriorly mobilized in two randomized knee positions (0 degrees and 25 degrees) using three randomly assigned loads (44.48N, 88.96N, and 177.93N). Markers were photographed and digitally measured and analyzed.   All load x position conditions produced anterior displacement of the meniscus on the tibia, where the displacement was significant [t (7) = -3.299; p = 0.013] at 0 degrees loaded with 177.93N (mean 0.41±0.35 mm). The results of 2(position) x 3(load) repeated measures ANOVA for meniscotibial displacement produced no significant main effects for load [F (2,14) = 2.542; p = .114) or position [F (1,7) = 0.324, p= .587]. All load x position conditions produced significant posterior tibial and meniscal displacement on the femur. The 2(position) x 3(load) repeated measures ANOVA revealed a significant main effect for load for both femoral marker displacement relative to the tibial axis [F (2,14) = 77.994; p < .001] and meniscal marker displacement relative to the femoral marker [F (2,14) = 83.620; p < .001].  The use of a mobilization technique to target the meniscotibial interface appears to move the meniscus anteriorly on the tibia. It appears that this technique may be most effective at the end range position.

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Comparison of Patella Alignment and Cartilage Biomarkers in Young Adult Females with and Without Patellofemoral Pain: A Pilot Study
Authors:   Bolgla LA, Gordon R, Sloan G, Pretlow LG, Lyon M, Fulzele S
Evidence suggests that individuals with patellofemoral pain (PFP) may develop patellofemoral joint osteoarthritis (PFJOA). Limited data exist regarding an absolute association between PFP and PFJOA. Understanding this relationship will support the need for early interventions to manage PFP.  This study was conducted to determine if females with PFP have a patella position and cartilage biomarkers similar to individuals with PFJOA. It was hypothesized that females with PFP and excessive patella lateralization would have higher cartilage biomarker levels than controls. It also was hypothesized that a significant association would exist between pain and cartilage biomarker levels in subjects with excessive patella lateralization. Pain was assessed using a 10-cm visual analog scale (VAS) for activity pain over the previous week. Patella offset position (RAB angle) was measured using diagnostic ultrasound. Urine was collected and cartilage biomarkers quantified by analyzing C-telopeptide fragments of type II collagen (uCTX-II). Independent t-tests were used to determine between-group differences for RAB angle and uCTX-II. Bivariate correlations were used to determine associations between VAS and uCTX-II for females with PFP.  Subjects (age range 20 to 30 years) had similar RAB angles (p = 0.21) and uCTX-II (p = 0.91). A significant association only existed between VAS scores and uCTX-II for females with PFP who had a RAB angle > 13° (r = 0.86; p = 0.003). Comparison of uCTX-II in the 25-to-30-year-old females with PFP and excessive patella lateralization in the current study to published normative data showed that this cohort had elevated biomarkers. These findings support that a certain cohort of individuals with PFP have features similar to individuals with confirmed PFJOA (patella lateralization and elevated biomarkers). Additional studies are needed to determine if interventions can reverse not only pain but biomarker levels.

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The Effects Of Whole Body Vibration On Vertical Jump, Power, Balance, and Agility In Untrained Adults
Authors:  Wallmann HW, Bell DL, Evans BL, Hyman AA, Goss GK, Paicely AM
Despite the increased use of whole body vibration among athletes, there is limited literature on its acute effects within heterogeneous populations such as untrained adults or recreational athletes. The purpose of this study was to investigate the acute effects of whole body vibration on vertical jump, power, balance, and agility for untrained males and females. It was hypothesized that there would be an effect on each outcome variable. Twenty males and sixteen females, mean age 24.5 years, were assessed for vertical jump height and power as measured by the Myotest accelerometer, balance as measured by the NeuroCom Balance Master System, and agility as measured by a modified T-test. Each session consisted of a five-minute treadmill warm-up, a practice test, a baseline measurement, a two-minute rest period, whole body vibration at 2 mm and 30 Hz for 60 seconds, and a final measurement. Three different counterbalanced testing sessions were separated by a minimum of 48 hours in between sessions to minimize fatigue.  Significant differences existed for both genders for main effect of time for Agility (p = 0.022); end point excursion Left (p = 0.007); and maximum endpoint excursion Left (p = 0.039). Differences for main effect of gender revealed females performed better than males in the following respects: end point excursion Right (p = 0.035); end point excursion Left (p = 0.014); maximum endpoint excursion Right (p = 0.024); and maximum endpoint excursion Left (p = 0.005). Males performed better than females in two respects: Agility (p < 0.0005) and power (p < 0.0005). A significant interaction was observed between time and gender for vertical jump (p = 0.020). Simple main effects revealed males jumped higher than females during both pre and post intervention, p < 0.0005. Females had a significant decrease in the vertical jump post intervention (p = 0.05).  Results indicated that whole body vibration produced significant differences in the main effect of time and agility, and end point and maximum end point excursion Left for both genders, acutely. Females performed better in balance compared to males and poorer in vertical jump, but males performed better in agility and power.

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Investigation of Optimal Lumbar Spine Posture during a Simulated Landing Task in Elite Gymnasts
Authors:  Sonvico L, Spensor SM, Fawcett L, Bucke J, Heneghan NR, Rushton A
Lumbar spine range of motion (ROM) is a key component of injury prevention and normative data has not currently been determined for an elite gymnastics population.  In current clinical practice, it is commonplace to measure sagittal spinal alignment, during ‘high-load, low-dynamic’ control tasks, subjectively, while also only considering the lumbar spine as a single segment.  The purpose of this sudy was to develop normative data for total lumbar spine ROM and ROM during a simulated landing task (SLT) in an elite gymnastics population, evaluating findings in the context of the existing biomechanical literature.  Lumbar spine and low lumbar spine (LLS) ROM during a SLT were measured, using the Dorsa Vi: Vi Perform™ system in asymptomatic male and female elite gymnasts. Values for maximal ROM and LLS angle during the SLT were collated and descriptively analyzed.  Lumbar ROM and posture was evaluated in relation to the current biomechanical literature and a proposed Conceptual Compressive Lumbar Load Distribution Model (CCLLDM). Thirty elite gymnasts (15 male, 15 female), participated.  Participants were members of the British Artistic Gymnastics elite senior and junior training program and were between the ages of 16 to 30 years. Mean (SD) maximal lumbar spinal movements were 64.23˚ (6.34°) for flexion and 25.89˚ (11.14°) for extension.  During the SLT, participants performed lumbar spine flexion of 15.96˚ (8.80°), when considered as a single segment. When considering the lumbar spine as a two segment model the LLS position during the SLT was towards end range anterior pelvic tilt, suggesting LLS extension.  These data provide a baseline for asymptomatic lumbar spine movements in an elite gymnastics population and provides insight into upper and lower lumbar spine movement during a SLT.  The data and newly developed CCLLDM provide clinicians with a potential framework to identify sporting skills that may be associated with increased spinal tissue load.

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Neuromuscular Adaptions Following A Daily Strengthening Exercise in Individuals With Rotator Cuff Related Shoulder Pain: A Pilot Case-Control Study
Authors:  Seitz AL, Podlecki LA, Melton ER, Uhl TL
The goal of therapeutic exercise is to facilitate a neuromuscular response by increasing or decreasing muscular activity in order to reduce pain and improve function. It is not clear what dosage of exercise will create a neuromuscular response. The purpose of this study was to assess the effects following a three-week home program of a daily single exercise, the prone horizontal abduction exercise (PHA), on neuromuscular impairments of motor control as measured by scapular muscle EMG amplitudes, strength, and secondarily outcomes of self-reported pain and function between individuals with and without subacromial pain syndrome.  Twenty-five individuals participated; eleven with shoulder pain during active and resistive motions (Penn Shoulder Score: 77±11) and 14 matched healthy controls (Penn Shoulder Score: 99±27) (p < 0.001). Participants underwent baseline and follow up testing at three weeks including surface electromyography (EMG) of the serratus anterior, upper, and lower trapezius of the involved (painful group) or matched shoulder (control group) during an elevation task and maximal isometric shoulder strength testing. All participants were instructed in a PHA exercise to be performed daily (3 sets; 10 reps). Subjects logged daily exercise adherence. Neuromuscular adaptations were defined by changes in EMG amplitudes (normalized to MVIC) of serratus anterior, upper trapezius, and lower trapezius and strength. Secondary outcomes of self-reported pain and function were also compared between groups following the three-week intervention. After three weeks of a daily PHA exercise, the painful group demonstrated a greater decrease in baseline-elevated EMG amplitudes in the lower trapezius by 7% (95%CI 2.6-11%) during the concentric phase of the overhead lifting task (p=0.006). EMG amplitudes of the healthy control group did not change at three-week follow-up. Additionally, the change in serratus anterior mean EMG amplitude in the painful group -1.6% (IQR -22.9 to 0.8%) was significantly greater (p=0.033) than the healthy group change score, 2.5% (IQR -2.3 to 5.7%) during the eccentric phase (p=0.034). While the painful group was weaker in abduction and flexion at baseline and follow up, both groups had a significant increase in all strength measures (p≤0.014). Concurrent with increased strength and normalizing EMG amplitudes, the painful group significantly improved on the Penn Shoulder Score with a mean change 9.8 points (95%CI=7.0, 12.6) (p<0.001).  In this pilot case-control study, a single home exercise performed daily for three weeks demonstrated neuromuscular adaptations with improvements in muscle activity and strength. These were concurrent with modest, yet significant improvements pain and function in individuals with mild rotator cuff related shoulder pain.

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Volleyball Overhead Swing Volume and Injury Frequency Over the Course of a Season
Authors:  Wolfe H, Poole K, Tezanos AGV, English R, Uhl TL
Overuse injuries are common in volleyball; however, few studies exist that quantify the workload of a volleyball athlete in a season. The relationship between workload and shoulder injury has not been extensively studied in women’s collegiate volleyball athletes. This study aims to quantify shoulder workloads by counting overhead swings during practice and matches. The purpose of the current study is to provide a complete depiction of typical overhead swings, serves, and hits, which occur in both practices and matches. Researchers observed practice and match videos and counted overhead serves and attacks of 19 women’s collegiate volleyball players for two seasons. Serves, overhead hits, and total swings (serves + hits) were the dependent variables; event (matches and practice) along with position (defensive specialists, setter, outside hitter, and middle blocker) were the independent variables. The season was divided into pre-season and season accounting in order to examine musculoskeletal injury frequency and swing volume workload.  Across all positions except outside hitters twice as many total swings occurred in practices compared to matches (p=.002) resulting in an average of 19 (CI95 16.5, 21.5) more swings in practice than in matches. The average number of total swings during the pre-season 47.1 (CI95 44.1, 50.1) was significantly greater than average swings per session during the competitive season 37.7 (CI95 36.4, 38.9) (p <0.001) resulting in a mean difference of 9.4 (CI95 6.1, 12.7) swings. The number of athletes limited in participation or out due to a musculoskeletal injury during the pre-season (2.9%) was greater than during the season (1.1%) (p=0.042).  These findings indicate that women’s collegiate volleyball athletes swing more during practices than in matches. The higher average number of serves in the pre-season and the greater frequency of musculoskeletal injuries requiring participation restriction or removal from participation suggest that a concordant relationship may exist between workload and injury variables.

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The Relationship Between Pitching Volume and Arm Soreness in Collegiate Baseball Pitchers
Authors:  Lazu AL, Love SD, Butterfield TA, English R, Uhl TL
Excessive baseball pitch volume has been associated with increased risk of injury in adolescents. However, many collegiate athletes report non-time loss injuries over the course of the season. It is unknown how pitch volume throughout a collegiate baseball season affects arm soreness. The primary purpose of this study was to determine the relationship between pitch volume and self-reported arm soreness. A secondary purpose was to determine the relationship between change in pitch volume and change in arm soreness over the course of the season for collegiate baseball pitchers. Seven collegiate baseball pitchers volunteered to participate in a yearlong prospective study. The seven pitchers reported daily pitch volume and level of soreness from the fall through spring collegiate baseball season during practices and games. The athletic trainer, a member of the research team, tracked athletic exposures and injuries for the entire season. Frequency counts of athletic exposures were categorized by game, practice, conditioning and injury status. Frequency counts of pitch volume was categorized by game, game bullpen, practice bullpen, flat ground, long toss and warm-up pitches. The pitch volume and soreness levels for each athlete were used to determine the relationship between these two variables using a Pearson correlation. The seven pitchers were involved with 1,256 athletic exposures and a total of 54,151 throws, averaging 7,735 throws per player for the entire season. The pitch volume and self-reported arm soreness for the entire season revealed a correlation of r = .72 (p = .004). The relationship between change in pitch volume and change in arm soreness was r = .635 (p = .001) over the season. There was a moderate significant correlation between arm soreness and pitch volume across the whole season. This relationship was maintained when evaluating weekly changes.   

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Intra- and Inter-rater Reliability of the Selective Functional Movement Assessment (SFMA) in Healthy Participants
Authors:  Stanek JM, Smith J, Petrie J
The Selective Functional Movement Assessment (SFMA) is a popular assessment tool used to observe and detect components of dysfunctional movement patterns. The goal of the assessment is to identify impairments throughout the kinetic chain that may be contributing to movement dysfunction and/or pain. The purpose of this research was to determine the intra- and inter-rater reliability of the 10 top-tier movements of the SFMA using the categorical scoring system. It was hypothesized the intra- and inter-rater reliability of the SFMA would be acceptable with variations based on the objectivity of the scoring criteria and the experience of the rater.  25 (17 male, 8 female), physically active participants (age: 21.2±1.6years, height: 177.1±10.7cm, weight: 74.9±13.9kg) were independently assessed in real time by three clinicians during two separate visits to the lab using a standard instructional script. Clinicians had varying levels of experience with the SFMA and the two visits occurred a minimum of 48 hours and maximum of seven days apart. Results from each clinician were compared within and between raters using the Kappa coefficient and ratings of absolute agreement. Overall, slight to substantial intra- and inter-rater reliability were observed using the categorical scoring tool, although variations existed depending on the movement pattern. Kappa coefficients for intra-rater reliability ranged from 0.21-1.00, while % absolute agreement ranged from 0.64-1.00. Inter-rater reliability for the same measures ranged from 0.11-0.89 and 0.52-0.96 respectively. Clinicians certified in the SFMA with the greatest amount of experience using the SFMA demonstrated higher intra-rater reliability. Similarly, higher inter-rater reliability was found between certified raters with the most experience.  Certified SFMA raters with greater amounts of experience can demonstrate adequate intra- and inter-rater reliability using the categorical scoring method.

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Implementing a Standardized Interventional Exercise Regimen to Improve Functional Movements in Female Collegiate Athletes
Authors:  Tejani AS, Middleton EF, Huang M, Dimeff RJ
Interventional exercises have been developed to help athletes improve scores on the Functional Movement Screen™ (FMS™). However, there is a paucity of research on the effects of a similar program in female athletes, as well as the effects of a standardized corrective exercise regimen. The purpose of this study was to assess whether an in-season, standardized interventional exercise program improves FMS™ score asymmetry and the composite score of female collegiate athletes.  Forty-one (mean age 19.5 ± 1.2 years; body mass, 70.6 ± 11.5 kg ; height, 1.70 ± 0.083 m) NCAA Division III female soccer (n=10), softball (n=17), and basketball (n=14) players participated in this study. The athletes completed the FMS™ screens prior to their season, regularly participated in four in-season standardized corrective exercises throughout three to four month athletic seasons, and completed the FMS™ screens in the post-season. The average score of all athletes before the season was 15.52 ± 0.63 and 16.04 ± 0.72 after the season. While the mean score of soccer players increased from 14.80 ± 0.92 to 16.1 ± 1.52 and the mean score of softball players increased from 15.83 ± 1.89 to 16.72 ± 1.41 at the end of the season, the mean score of basketball players dropped from 15.93 ± 1.49 to 15.29 ± 1.59. Women’s basketball players experienced a decrease in their composite FMS™ score (x̅ = -0.571, p<0.01), while women’s soccer players (x̅=+1.30, p<0.05) and softball players (x̅=+1.12, p<0.05) experienced an increase in mean score 2.28 times and 1.96 times greater in magnitude than the decrease in basketball players’ composite FMS™, respectively. Fewer total athletes demonstrated asymmetries at postseason testing, decreasing from 24 at pre-season testing to 15 at postseason testing (p<0.01). Significant differences were not noted between athlete age and FMS™ scores (p>0.05).  Standardized interventional programs during athletic teams’ seasons may be used to help increase FMS™ scores and reduce asymmetry. Though more studies are warranted to address the negative effects of this standardized program in women’s basketball players, this study demonstrated that the number of asymmetries significantly decreased from pre- to postseason among soccer and softball players, which may have implications for higher resistance to injury.

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Can Injury Risk Category Be Changed In Athletes? An Analysis Of An Injury Prevention System
Authors:  Huebner BJ, Plisky PJ, Kiesel KB, Schwartzkof-Phifer K
Researchers have used an injury risk algorithm utilizing demographic data, injury history, the Functional Movement Screen™ (FMS™) and Lower Quarter Y Balance Test™ (YBT™) scores to categorize individual injury risk.  The purpose of this study was to identify if a group-based hybrid injury prevention program utilizing key factors from previous research with the addition of an individualized approach can modify the injury risk category of athletes. Forty-four female subjects (ages 14-17) were recruited from a local high school soccer team. Pre-participation testing included demographic data, injury history, FMS™ and YBT™ to determine of each athletes’ injury risk category using the Move2Perform algorithm.  Post-testing took place after an eight-week exercise-based intervention program was completed. McNemar analysis was utilized to assess changes in the injury risk categories. A significant number of athletes (21 of 44) moved to lower risk categories at posttest (p=0.000; Z=-3.869). Of the 32 athletes in the High Risk category at pretest, 16 were Low Risk after the intervention (p=0.002). A pre-season group injury prevention training program with individually prescribed corrective exercises, resulted in a significant number of subjects decreasing their injury risk category.  The primary statistically significant decrease of injury risk category was seen in the Moderate Risk individuals moving down to Slight. There were three athletes that moved from the Substantial Risk category to Slight, however, this change was not statistically significant. 

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LITERATURE REVIEW
Non-Operative Management of Individuals with Non-Arthritic Hip Pain: A Literature Review
Authors:  McGovern RP, Martin RL, Kivlan BR, Christoforetti JJ
Non-arthritic hip pain is defined as being related to pathologies of the intra-articular structures of the hip that can be symptomatic. A trial of non-operative management is commonly recommended before consideration of surgery for individuals with non-arthritic hip conditions. There is a need to describe a non-operative or conservative treatment plan for individuals with non-arthritic hip pain. The purpose of this literature review was to systematically examine the literature in order to identify and provide evidence for non-operative or conservative management of individuals with non-arthritic hip pain. A proposed home exercise program is provided for individuals with non-arthritic hip pain. A literature search of PubMed, Medline, SPORTSDiscus, and CINAHL was conducted.  Keywords included: “hip” AND “femoroacetabular impingement” OR “labral tear.” Studies were included if they described non-operative management for individuals with non-arthritic hip pain. Studies were excluded if they recommended a trial of conservative treatment without specific management or interventions and/or activity modification without specific details for intervention.  A total of 49 studies met the eligibility criteria and were included in the review. Rehabilitation recommendations were identified from manuscripts including clinical trials, case series, discussion articles, or systematic reviews related to the non-operative or conservative management of non-arthritic hip pain. Rehabilitation interventions focused on patient education, activity modification, limitation of aggravating factors, an individualized physical therapy protocol, and use of a home exercise program. Rehabilitation should address biomechanical deficiencies with neuromuscular training of the hip and lumbopelvic regions. While the current literature on non-operative management is limited, future randomized control trials will establish the effectiveness of specific physical therapy protocols for individuals with non-arthritic hip pain.

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CLINICAL COMMENTARY
Treatment of Rotator Cuff Tendinopathy as a Contractile Dysfunction. A Clinical Commentary
Authors:  Spargoli G
Rotator cuff (RC) tendinopathy is a common disorder affecting many individuals, both in athletic and sedentary settings. Etiology of RC pathology or the most effective conservative treatment are not totally understood. The Mechanical Diagnosis and Treatment (MDT®) method is a widely known rehabilitative technique that allows therapists to diagnose and treat spinal and peripheral mechanical disorders. Therefore, the purpose of this clinical commentary is to briefly describe RC tendinopathy and its management using the MDT® method.  The MDT® method may offer a practical, inexpensive, and effective solution to management of RC tendinopathies that present with a mechanical component.

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Restoring Knee Extensor Strength After Anterior Cruciate Ligament Reconstruction: A Clinical Commentary
Authors:  Buckthorpe M, LaRosa G, Della Villa F 
One of the main priorities of rehabilitation after anterior cruciate ligament reconstruction (ACLR) surgery is the restoration of knee extensor muscle strength. Residual deficits in knee extensor muscle size and strength after injury are linked to poor biomechanics, reduced knee function, increased knee osteoarthritis risk, as well as heightened risk of re-injury upon return to sport. Most studies indicate that knee extensor muscle strength is typically not resolved prior to return to sport. This clinical commentary discusses strategies to optimize and accelerate the recovery of knee extensor strength post-surgery, with the purpose to support the clinician with evidence-based strategies to implement into clinical practice. Principally, two strategies exist to normalize quadriceps strength after surgery, 1) limiting strength loss after injury and surgery and 2) maximizing and accelerating the recovery of strength after surgery. Optimal preparation for surgery and a focused attempt to resolve arthrogenic muscle inhibition are essential in the pre and post-operative period prior to the inclusion of a periodized strength training program. Often voluntary strengthening alone is insufficient to fully restore knee extensor muscle strength and the use of electrical stimulation and where necessary the use of blood flow restriction training with low loads can support strength recovery, particularly in patients who are significantly load compromised and experience pain during exercise. Resistance training should employ all contraction modes, utilize open and closed kinetic chain exercise of both limbs, and progress from isolated to functional strength training, as part of a periodized approach to restoring neuromuscular function. Furthermore, thinking beyond the knee musculature and correcting core and hip dysfunction is also important to ensure an optimal knee extension strengthening program. The purpose of this clinical commentary is to provide a series of evidenced based strategies which can be implemented by clinicians responsible for the rehabilitation of patients after ACLR.  

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