Volume Eleven Number Three



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June 2016

A systematic review of the exercises that produce optimal muscle ratios of the scapular stabilizers in normal shoulders.
Authors:  Schory A, Bidinger E, Wolf J, Murray L
The purpose of this systematic review was to determine the exercises that optimize muscle ratios of the periscapular musculature for scapular stability and isolated strengthening.  A systematic search was performed in PubMed, CINAHL, SPORTDiscus, Scopus, and Discovery Layer. Studies were included if they examined the muscle activation of the upper trapezius compared to the middle trapezius, lower trapezius, or serratus anterior using EMG during open chain exercises. Fifteen observational studies met the inclusion criteria for the systematic review. Exercises with optimal ratios were eccentric exercises in the frontal and sagittal planes, especially flexion between 180° and 60°. External rotation exercises with the elbow flexed to 90° also had optimal ratios for activating the middle trapezius in prone and side-lying positions.  Exercises with optimal ratios for the lower trapezius were prone flexion, high scapular retraction, and prone external rotation with the shoulder abducted to 90° and elbow flexed.  Exercises with optimal ratios for the serratus anterior were the diagonal exercises and scapular protraction.  The authors of this review identified optimal positions and exercises for periscapular stability exercises. Standing exercises tend to activate the upper trapezius at a higher ratio, especially during the 60-120° range.  The upper trapezius was the least active, while performing exercises in prone, side-lying, and supine positions.
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The Relationship Between Core Endurance and Back Dysfunction in Collegiate Male Athletes With and Without Nonspecific Low Back Pain.
Authors:  Abdelraouf OR,  Abdel-aziem AA
Physical activity and sports can be associated with low back pain. However, little is known about the relationship between core stability and nonspecific low back pain (LBP) among athletes.  The purpose of this study was to investigate the relationship between core endurance and back dysfunction in collegiate male athletes with and without nonspecific LBP.  Fifty-five male collegiate athletes from a variety of sports were recruited for this study. Their mean age was 21.50 ± (2.54) years, mean weight was 70.96 ± (5.33) kg., and mean height was 174.38 ± (4.37) cm. Thirty athletes with non-specific LBP and twenty five healthy athletes were assessed using McGill’s anterior, posterior, and left and right plank core endurance tests (seconds) and for dysfunction using the Micheli functional scale (MFS). Pearson’s product moment correlations examined the relationships between core endurance and MFS.  There were significant differences regarding the measured core endurance tests between the healthy athletes group and the nonspecific LBP group (p <0.05). Good negative (r = -0.794) and moderate negative (r = -0.541) correlations were found between MFS and trunk extensor and flexor endurance tests, respectively.  The results of this study imply that poor core endurance is likely associated with nonspecific LBP in collegiate athletes. Injury risk reduction and management programs for the athletic population should include strategies that emphasize endurance of the core muscles especially the trunk extensors and flexors.
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Association Between Rowing Injuries and the Functional Movement Screen in Female Collegiate Division I Rowers.
Authors:  Clay H, Mansell J, Tierney R
Approximately 48 percent of rowing injuries are due to overuse and females sustain injury more commonly than males. The Functional Movement Screen (FMS) is a screening tool utilized to identify the risk of musculoskeletal injury in field sport athletes based on movement patterns. It has not been used to identify risk of injury in rowing. The purpose of this study was to determine if the scores on the FMS are predictors of incidence of all injuries, including low back pain (LBP) in female collegiate rowers during one season of rowing.  Investigators performed pre-season FMS screening and collected demographic data, rowing data, and Oswestry Low Back Pain questionnaire scores on thirty-seven Division I female collegiate rowers (33 rowers and 4 coxswains). Based on FMS scores, individuals were grouped “high” or “low” risk for injury.  Injury reports and patient complaints of LBP over the course of a season were compared to FMS group.  Low back pain was present in 25 out of the 37 participants over the season.  Those in the high risk group were significantly more likely to experience LBP during the season (p=.036) and reported a 58 percent greater mean in years of rowing experience (p=.008) than individuals in the low risk group. Those with a history of LBP were six times more likely to experience LBP during season (p=.027).  The results indicated that rowers at a high risk of injury (per FMS categorization) and more years of rowing experience have a higher probability of sustaining LBP. Results could be due to chronic overuse associated with the rowing motion.
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Accuracy of Self-Reported Foot Strike Pattern in Intercollegiate and Recreational Runners During Shod Running.
Authors:  Bade MB, Aaron K, McPoil TG
Clinicians are interested in the foot strike pattern (FSP) in runners because of the suggested relationship between the strike pattern and lower extremity injury. The purpose of this study was to assess the ability of collegiate cross-country runners and recreational runners to self-report their foot strike pattern during running.  Twenty-three collegiate cross-country and 23 recreational runners voluntarily consented to participate. Inclusion criteria included running at least 18 miles per week, experience running on a treadmill, no history of lower extremity congenital or traumatic deformity, or acute injury three months prior to the start of the study.  All participants completed a pre-test survey to indicate their typical foot strike pattern during a training run (FSPSurvey). Prior to running, reflective markers were placed on the posterior midsole and the vamp of the running shoe.  A high-speed camera was used to film each runner in standing and while running at his or her preferred speed on a treadmill.  The angle between the vector formed by the two reflective markers and the superior surface of the treadmill was used to calculate the foot strike angle (FSA).  To determine the foot strike pattern from the video data (FSPVideo), the static standing angle was subtracted from the FSA at initial contact of the shoe on the treadmill.  In addition to descriptive statistics, percent agreement and Chi square analysis was used to determine distribution differences between the video analysis results and the survey.  The results of the chi-square analysis on the distribution of the FSPSurvey in comparison to the FSPVideo were significantly different for both the XCRunners (p < .01; Chi-square = 8.77) and the REC Runners (p < .0002; Chi-square = 16.70).  The cross-country and recreational runners could correctly self-identified their foot strike pattern 56.5% and 43.5% of the time, respectively.  The findings of this study suggest that the clinician cannot depend on an experienced runner to correctly self-identify their FSP.  Clinicians interested in knowing the FSP of a runner should consider performing the two-dimensional video analysis described in this paper.
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Reproducibility of the Modified Star Excursion Balance Test Composite and Specific Reach Direction Scores
Authors:   van Lieshout R,  Reijneveld AE, van den Berg SM, Haerkens GM, Koenders NH, de Leeuw AJ,   van Oorsouw RG,  Paap D, Scheffer E, Weterings S, Stukstette MJ
The mSEBT is a screening tool used to evaluate dynamic balance. Most research investigating measurement properties focused on intrarater reliability and was done in small samples. To know whether the mSEBT is useful to discriminate dynamic balance between persons and to evaluate changes in dynamic balance, more research into intra- and interrater reliability and Smallest Detectable Change (synonymous with minimal detectable change) is needed.  The purpose of this study was to estimate intra- and interrater reliability and smallest detectable change of the mSEBT in adults at risk for ankle sprain.  Fifty-five healthy young adults participating in sports at risk for ankle sprain participated (mean ± SD age, 24.0 ± 2.9 years). Each participant performed three test sessions within one hour and was rated by two physical therapists (session 1, rater 1; session 2, rater 2; session 3, rater 1). Participants and raters were blinded for previous measurements. Normalized composite and reach direction scores for the right and left leg were collected. Analysis of variance was used to calculate intraclass correlation coefficient values for intra- and interrater reliability. Smallest detectable change values were calculated based on the standard error of measurement.  Intra- and interrater reliability for both legs was good to excellent (intraclass correlation coefficient ranging from 0.87 to 0.94). The intrarater smallest detectable change for the composite score of the right leg was 7.2% and for the left 6.2%. The interrater smallest detectable change for the composite score of the right leg was 6.9% and for the left 5.0%.  The authors concluded that the mSEBT is a reliable measurement instrument to discriminate dynamic balance between persons. Most Smallest Detectable Change values of the mSEBT appear to be large.
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Influence of Injury on Dynamic Postural Control in Runners.
Authors:  Meardon S, Klusendorf A, Kernozek T
Injury has been linked with altered postural control in active populations. The association between running injury and dynamic postural control has not been examined. The purpose of this study was to examine dynamic postural control in injured and uninjured runners using the Star Excursion Balance Test (SEBT), Time to Stabilization (TTS) of ground reaction forces following a single-leg landing, and postural stability indices reflecting the fluctuations in GRFs during single-leg landing and stabilization tasks (forward and lateral hop). It was hypothesized that dynamic postural control differences would exist between runners with a history of injury that interrupted training for ≥7 days (INJ) when compared to runners without injury (CON).   Twenty-two INJ (14 F, 8 M; 23.7±2.1 y; 22.3±2.8 kg/m2; 29.5±16.3 mi/wk) currently running >50% pre-injury mileage without pain were compared with twenty-two matched CON (14F, 8M; 22.7±1.2 y; 22.7±2.7 kg/m2; 31.2±19.6 mi/wk). The INJ group was stratified by site of injury into two groups (Hip/Thigh/Knee and Lower Leg/Ankle/Foot). Leg length-normalized anterior, posterolateral, and posteromedial reach distances on the SEBT, medial/lateral and anterior/posterior ground reaction force TTS, directional postural stability indices, and a composite dynamic postural stability index (DPSI), were assessed using mixed model ANOVA (?=0.05) and effect sizes (d).  No group X direction interaction or group differences were observed for the SEBT (p=0.51, 0.71) or TTS (p=0.83, 0.72) measures. A group X direction interaction was found for postural stability indices during the forward landing task (p<0.01). Both Hip/Thigh/Knee and Lower leg/Ankle/Foot INJ groups demonstrated a greater vertical postural stability index (VPSI) (p=0.01 for both, d=0.80, 0.95) and DPSI (p=0.01, 0.02, d=0.75, 0.93) when compared to CON suggesting impaired balance control. A group X direction interaction was also found for postural stability indices during the lateral landing task (p=0.03). Only the Hip/Thigh/Knee INJ runners displayed a greater VPSI (p=0.01, d=0.91) and DPSI (p=0.017, d=0.89) compared to when compared to CON.  The authors found that when compared to CON, INJ runners demonstrated impaired dynamic control of vertical forces when performing the single leg landing and stabilization tasks.
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Pre- and Post-Operative Self-reported Function and Quality of Life in Women With and Without Generalized Joint Laxity Undergoing Hip Arthroscopy for Femoroacetabular Impingement.
Authors:  Pontiff M, Ithurburn MP, Ellis T, Cenkus K, Di Stasi S
Lower limb Generalized joint laxity is more prevalent in women than men and may lead to poorer post-operative outcomes in select orthopedic populations. There are no studies examining peri-operative function in patients with generalized joint laxity (GJL) and femoroacetabular impingement (FAI).   The purpose of this study was to determine the difference in perceived function and quality of life as measured by the Hip Outcome Score ADL subscale (HOS-ADL), International Hip Outcomes Tool (iHOT-33) and the Short Form 12-Item Health Survey (SF-12) in women with and without GJL prior to and six months after undergoing hip arthroscopy for FAI.  Peri-operative data were collected from women with FAI from November 2011-September 2014. Lax subjects were women with laxity scores ≥4/9 on the Beighton and Horan Joint Mobility Index; Nonlax subjects were women with laxity scores <4/9. Functional outcomes were evaluated using the HOS-ADL, iHOT-33, PCS-12, and the MCS-12 pre-operatively and at 6 months post-operatively. Change scores (post-score – pre-score) were calculated for each outcome measure and compared between groups, along with pre-operative and post-operative means, using Mann-Whitney U tests.   166 women met the inclusion criteria: Nonlax (n=131), Lax (n=35). There were no statistically significant differences between groups in pre-operative functional outcomes (all p> .05). Additionally, there were no statistically significant differences between groups in post-operative means or change scores, respectively, for HOS-ADL (p=.696, .358), iHOT-33 (p=.550, .705), PCS-12 (p=.713, .191), and MCS-12 (p=.751, .082). Laxity score was not associated with any post-operative functional outcome score or change score (all p >.05).  The authors concluded that women with and without generalized joint laxity do not appear to report differences in hip function in the 6-month peri-operative period before and after hip arthroscopy for FAI.
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Ankle Joint Control During Single-legged Balance Using Common Balance Training Devices – Implications for Rehabilitation Strategies
Authors:  Strøm M, Thorborg K, Bandholm T, Tang L, Zebis M, Nielsen K, Bencke J
A lateral ankle sprain is the most prevalent musculoskeletal injury in sports. Exercises that aim to improve balance are a standard part of the ankle rehabilitation process. In an optimal progression model for ankle rehabilitation and prevention of future ankle sprains, it is important to characterize different balance exercises based on level of difficulty and sensori-motor training stimulus.  The purpose of this study was to investigate frontal-plane ankle kinematics and associated peroneal muscle activity during single-legged balance on stable surface (floor) and three commonly used balance devices (Airex®, BOSU® Ball and wobble board).  Nineteen healthy subjects performed single-legged balance with eyes open on an Airex® mat, BOSU® Ball, wobble board, and floor (reference condition). Ankle kinematics were measured using reflective markers and 3-dimensional recordings and expressed as inversion-eversion range of motion variability, peak velocity of inversion and number of inversion-eversion direction changes.  Peroneus longus EMG activity was averaged and normalized to maximal activity during maximum voluntary contraction (MVC), and in addition amplitude probability distribution function (APDF) between 90 and 10% was calculated as a measure of muscle activation variability.   Balancing on BOSU® Ball and wobble board generally resulted in increased ankle kinematic and muscle activity variables, compared to the other surfaces. BOSU® Ball was the most challenging in terms of inversion-eversion variability while wobble board was associated with a higher number of inversion-eversion direction changes. No differences in average muscle activation level were found between these two surfaces, but the BOSU® Ball did show a more variable activation pattern in terms of APDF.  The results showed large kinematic variability among different balance training devices and these differences are also reflected in muscle activation variability. The two most challenging devices were BOSU® Ball and Wobble board compared to Airex® and floor. The results of this study can guide clinicians who wish to implement a gradual progression of ankle rehabilitation and prevention exercises by taking the related ankle kinematics and muscle activity into account.
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Predicting Foot Progression Angle during Gait using Two Clinical Measures in Healthy Adults, A Preliminary Study.
Authors:  Cibulka MT, Winters K, Kampwerth T, McAfee B, Payne L, Roeckenhaus T, Ross SA
The foot progression angle (FPA) is related to the transverse plane rotation of the lower extremities and associated with many lower extremity conditions.   The purpose of this study was to examine how two commonly used clinical measures, tibio-fibular torsion (TF) and hip rotation, can be used to predict FPA during gait in healthy adults.   Passive hip internal and external rotation ranges of motion and TF torsion were measured with a12-inch goniometer while the FPA (degrees of toe-in/out) was measured with the GAITRite during mid-stance in sixty participants. The data was analyzed using a multiple regression model.  Hip ER was not significant and was therefore excluded from the final model. The final model included passive hip IR and TF torsion (F= 19.64; p< .001; multiple R2 = .41; adjusted R2 =. 39). Simple binary correlations showed that hip IR had a moderate negative correlation (r= - .40) with FPA (the greater the hip IR, the greater the toeing in) while TF torsion had a positive correlation (r= .39) with FPA (the greater the external TF torsion. the greater the toeing out).  The authors concluded that a greater amount of passive hip IR predicts in-toeing while greater TF torsion predicts out-toeing of the foot during mid-stance phase of gait.
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Strength Exercises Combined with Dry Needling with Electrical Stimulation Improve Pain and Function in Patients with Chronic Rotator Cuff Tendinopathy: A Retrospective Case Series
Authors: Pavkovich ES
Multiple etiologies for rotator cuff tendinipathy (RTCT) exist, and many individuals seek treatment for this psthology.  Strengthening exercises (SE) have been reported to be effective in the treatment of RTCT, but there is limited evidence on the effectiveness of dry needing (DN) for this condition.  The purpose of this retrospective case series was to investigate DN to various non-trigger point-based anatomical locations coupled with strengthening exercises (SE) as a treatment strategy to decrease pain and increase function in healthy patients with chronic RTC pathology.  Eight patients with RTCT were treated 1-2 times per week for up to eight weeks, and no more than sixteen total treatment sessions of SE and DN.  Outcomes were tested at baseline and upon completion of therapy.  A long-term outcome measure follow up averaging 8.75 months (range 3 to 20 months) was also performed.  The outcome measures included the Visual Analog Scale (VAS) and the Quick Dash (QD).  Clinically meaningful improvements in disability and pain in the short term and upon long-term follow up were demonstrated for each patient.  The mean VAS was broken down into best (VASB), current (VASC), and worst (VASW) rated pain levels and the mean was calculated for the eight patients.  The mean VASB improved from 22.5 mm at the initial assessment to 2.36 mm upon completion of the intervention duration.  The mean VASC improved from 28.36 mm to 5.0 mm, and the mean VASW improved from 68.88 mm to 13.25 mm.   At the long-term follow up (average 8.75 months), The mean VASB, VASC, and VASW scores were 0.36 mm, 4.88 mm, and 17.88 mm respectively.  The QDmean for the eight patients improved from 43.09 at baseline to 16.04 at the completion of treatment.  At long-term follow-up, the QDmean was 6.59.   The author concluded that clinically meaningful improvements in pain and disability were noted with the intervention protocol.  All subjects responded positively to the intervention and reported quality of life was improved for each subject.  The results of this case series show promising outcomes for the combination of SE and DN in the treatment of chronic RTCT.  
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Physical Therapy Intervention for Medial Patellofemoral Ligament Reconstruction after Repeated Lateral Patellar Subluxation/Dislocation.
Authors: Vitale TE, Mooney B,  Vitale A, Apergis D, Wirth S, Grossman  MG
The incidence of patellar subluxation or dislocation is more prevalent in females than in males. There are many contributing factors involving the hip, knee, and ankle that lead to patellar subluxation. A patellar position of lateral tilt with glide may indicate weakness of the vastus medialis oblique (VMO) and adductors, increased tightness in the iliotibial band, and overpowering of the vastus lateralis. Patella alta can predispose an individual to lateral dislocation due to the patella placement outside of the femoral trochlear groove with a disadvantage of bony stability. Other factors that may cause the patella to laterally sublux or dislocate during a functional activity or sporting activity include a position of femoral external rotation, tibial internal rotation, and excessive contraction of the vastus lateralis. The medial patellofemoral ligament (MPFL) aids in the prevention of a lateral patellar subluxation or dislocation.  In cases where there is recurrent subluxation/dislocation and magnetic resonance imaging confirms a MPFL tear, a reconstruction may be the treatment of choice.  The purpose of this case series is to describe the post-surgical physical therapy management of MPFL reconstructions, outcomes using the Modified Cincinnati Knee Outcome Measure (MCKOM) and to propose staged physical therapy interventions for this pathology in the form of a treatment progression.  Post-operative management data and outcomes were retrospectively collected using a detailed chart review methodology from seven subjects who underwent MPFL reconstruction.  The Modified Cincinnati Knee Outcome Measure (MCKOM) was analyzed for each participant in four sections that were most important to the return and maintenance of participation in sport.  At follow-up the mean scores for the seven subjects in Section 3 (instability) was 19.3/20, Section 4 (overall activity level) was 17.3/20, Section 7 (running activity) was 4.5/5, and Section 8 (jumping and twisting) was 4.3/5. Overall all subjects scored over an 80 which indicated excellent results for return to activity/sport.   In this case series, seven subjects after MPFL reconstruction returned to sport or functional activity following a physical therapy treatment progression including proprioceptive-focused, and dynamic rehabilitation, along with a home exercise program.
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A Multidisciplinary Approach to the Rehabilitation of a Collegiate Football Player Following Ankle Fracture: A Case Report.

Authors: Feigenbaum LA, Kaplan LD, Musto T,  Gaunaurd IA, Gailey RS,  Kelley WP,  Alemi TJ, Espinosa B, Mandler E,  Scavo VA, West DC
Multiple rehabilitation factors including overall wellness need to be considered when an athlete returns to sport after an injury.  The purpose of this case report is to describe a multidisciplinary approach for return to sport of a Division I collegiate football player following a traumatic ankle fracture requiring surgical repair. The assessment and treatment approach included the use of a performance-based physical therapy outcome measure, self-reported functional abilities, body composition assessments, and nutritional counseling.  A 21 year-old running back fractured his lateral malleolus due to a mechanism of injury of excessive eversion with external rotation of the ankle. Surgical intervention included an open reduction internal fixation (ORIF) of the fibula and syndesmosis. In addition to six months of rehabilitation, the patient received consultations from the team sports nutritionist specialist to provide dietary counseling and body composition testing.  The Comprehensive High-level Activity Mobility Predictor-Sport (CHAMP-S), a performance-based outcome measure, self-report on the Foot and Ankle Disability Index (FADI-ADL, FADI-S), and body composition testing using whole body densitometry (BOD POD®), were administered throughout rehabilitation.   The subject was successfully rehabilitated, returned to his starting role, and subsequently was drafted by a National Football League (NFL) franchise.  High-level mobility returned to above pre-injury values, achieving 105% of his preseason CHAMP-S score at discharge. Self-reported function on the FADI-ADL and FADI-Sport improved to 100% at discharge.  Body fat percentages decreased (13.3% to 11.9%) and fat mass decreased (12.0 kg to 11.0kg).  Lean body mass (78.1 kg to 81.5 kg) and lbm/in increased (1.14 kg/in to 1.19 kg/in).  His BMI changed from 29.8 kg/m2 to 30.6 kg/m2.   This case report illustrates the positive effects of a multidisciplinary approach where combining physical therapy and nutritional counseling demonstrated value with return to sport preparation and success following ankle fracture. A targeted physical therapy program combined with a personalized nutrition intervention based on body composition assessment assisted this athlete in avoiding deconditioning (atrophy, decreased aerobic capacities, and increases in body fat) often observed during postoperative care.
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Tibiofemoral Joint Mobilization in the Successful Management of Patellofemoral Pain Syndrome: A Case Report
Authors: Lantz JM, Emerson-Kavchak AJ, Mischke JJ, Courtney CA
Patellofemoral pain syndrome (PFPS) is a common source of anterior knee pain.  Controversy exists over the exact clinical findings which define PFPS, thus, diagnosis and management can be challenging for clinicians.  There is paucity in the literature concerning joint mobilization as treatment for PFPS, particularly at the tibiofemoral joint, as standard management is currently focused on therapeutic exercise, orthotics, bracing and taping. Therefore, the purpose of this case report is to describe the effects of tibiofemoral joint mobilization in the successful treatment of an individual with chronic PFPS as it relates to pain, function and central processing of pain.  The subject was a 28-year-old female with a two year history of left anterior, inferior patellar knee pain consistent with chronic PFPS.  She demonstrated diminished pressure pain threshold (PPT) and allodynia at the anterior knee, suggesting a component of central sensitization to her pain.  She met several common diagnostic criteria for PFPS, however, only tibiofemoral anterior-posterior joint mobilization increased her pain. Subsequent treatment sessions (Visits 1-6) consisted of solely joint mobilization supplemented by instruction in a home exercise program (therapeutic exercise and balance training).  As outcomes improved, treatment sessions (Visits 7-8) consisted of solely therapeutic exercise and balance training with focus on return to independent pain free functional activity.   Improvements consistent with the minimally clinically important difference were noted on the Kujala Anterior Knee Pain Scale, Numeric Pain Rating Scale, Global Rating of Change (GROC). Scores on the Fear Avoidance-Belief Questionnaire (6/24 to 2/24 PA, 31/42 to 5/42 W), PPT (119 to 386 kPa) and Step Down Test (11 to 40 steps) also demonstrated improvement. At a two month follow up, the subject reported continued improvement in functional activity, 0/10 pain and GROC =+5.  This case describes the successful use of tibiofemoral joint mobilization in a subject with chronic PFPS and supports the use of joint mobilization as management in PFPS, particularly in cases where a centrally mediated component of pain may be present.  
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Partial Articular Supraspinatus Tendon Avulsion (PASTA) Lesion. Current Concepts in Rehabilitation.
Authors:  Spargoli G
Rotator cuff pathology can contribute to shoulder pain and may affect sport activities, work, and activities of daily living. Partial articular supraspinatus tendon avulsion (PASTA) lesion represents a very common type of rotator cuff pathology seen in rehabilitation. When conservative treatment fails, surgery is generally required. Success of recovery depends on several factors, for example:  repair techniques, healing process related to timing, rehabilitation programs, and patient compliance with home exercises. To date, most treatment modalities and rehabilitation programs are based on clinical experience rather than scientific evidence. Therefore, the purpose of this clinical commentary is to provide an overview on the PASTA lesion, discuss the common treatment approaches adopted to date and to propose a rehabilitation program based on the available scientific evidence.
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Physical therapy management of ice hockey athletes: from the rink to the clinic and back.
Authors:  Wolfinger CR, Davenport TE
The increasing number of athletes playing hockey compels rehabilitation professionals working in orthopedic and sports settings to understand the unique functional demands of ice hockey and the patterns of injuries they may promote.   The purpose of this clinical perspective is to: (1) discuss the functional implications of different positions and age levels on injury prevalence within the sport; (2) summarize the seven most common injuries sustained by ice hockey athletes; and (3) present a conceptual model for the clinical management and prevention of these injuries by rehabilitation professionals.  Research evidence is available to support the prevalence of injuries sustained while participating in ice hockey, as well as the most effective clinical treatment protocols to treat them. Most of the existing protocols are based on clinical and sports experience with incorporation of scientific data.  This clinical commentary reviews the current concepts of ice hockey injury care and prevention, based on scientific information regarding the incidence, mechanism, rehabilitation protocols, prognosis, and prevention of injuries.  Science-based, patient-centered reasoning is integral to provide the highest quality of rehabilitative and preventative care for ice hockey athletes by physical therapists.
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