VOLUME THIRTEEN, NUMBER THREE

 
2018Masthead_V13N3


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June 2018

SYSTEMATIC REVIEW – META ANALYSIS
Is Multi-Joint Or Single Joint Strengthening More Effective In Reducing Pain And Improving Function In Women With Patellofemoral Pain Syndrome? A Systematic Review And Meta-Analysis.
Authors:  Scali K, Roberts J, McFarland M, Marino K, Murray L
Patellofemoral pain syndrome is one of the most common causes of knee pain, especially in the female population. Conflicting evidence exists on whether a multi-joint strengthening program produces superior outcomes when compared to a single joint approach. The aim of this systematic review and meta-analysis was to investigate the effectiveness of a multi-joint strengthening program compared to a traditional single joint strengthening program in reducing pain and improving function in females diagnosed with patellofemoral pain syndrome. A computer-based search was performed. Data were extracted for the following information: exercises prescribed, outcome measures, and overall results from the study.  Five studies, each of high quality based on the PEDro scale, met the inclusion criteria for this systematic review and meta-analysis. Statistically different outcomes were found that favored the multi-joint intervention group for short-term and long-term self-reported pain and functional pain, short-term functional performance, and long-term self-reported function. The results of this review show that statistically significant data are available that favor implementing a multi-joint exercise program in comparison to a single joint program for the reduction of pain in females with patellofemoral pain syndrome. Limited statistical evidence, however, is available to support a multi-joint program over a single joint program in the improvement of short-term functional performance and long-term self-reported function in females with patellofemoral pain syndrome. 

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Exercise Therapy in the Non-Operative Treatment of Full-Thickness Rotator Cuff Tears: A Systematic Review.
Authors:  Jeanfavre M, Husted S, Leff G
Although commonly prescribed, the evidence to support exercise therapy (ET) and conservative management for the treatment of full-thickness rotator cuff tears (FTT) is equivocal. Therefore, the purpose of this systematic review of the literature was to examine the current evidence available for ET in the treatment of FTT and to provide a formal Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group recommendation. Five databases were systematically searched to evaluate the effectiveness of ET for FTT. Inclusion criteria: experimental or observational studies of adults clinically diagnosed with FTT, or massive, or inoperable tears that contained a treatment group that received ET for FTT. Exclusion criteria included: history of surgical repair, concurrent significant trauma, neurological impairment, and level V studies. Articles were assessed for quality, the level of evidence (I – V) and GRADE of recommendation (A to F) was determined. Data extraction included: demographics, specific interventions, and outcomes. Thirty-five studies were included: nine randomized controlled studies, six cohort studies, 15 case series and five case reports. There were 2010 shoulders in 1913 subjects with an average age of 64.2 years, 54% males, 73% of tears were >1 cm and 37% were classified as massive. Based on studies that reported, >58% of tears were >1 year and 73% were atraumatic. Of the non-operatively treated cohorts that reported the respective outcomes: 78% improved in pain (9/10 cohorts that reported statistically significant differences [stat-sig] p<0.05), 81% improved in ROM (14/14 cohorts that reported, met stat-sig), 85% improved in strength (7/8 cohorts that reported, met stat-sig), 84% improved in functional outcomes (17/17 cohorts that reported, met stat-sig). Dissatisfied outcomes occurred in 15% of patients, who then transitioned to surgery. The authors concluded that the current literature indicates GRADE B recommendation (moderate strength) to support the use of ET in the management of FTT. There is further need for well-designed randomized controlled trials.

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The Effect of Bracing and Balance Training On Ankle Sprain Incidence Among Athletes: A Systematic Review With Meta-Analysis.
Authors:  Bellows R, Wong C
Ankle sprains are common musculoskeletal injuries in the athletic population that have been addressed with prevention strategies that include bracing and balance training. Many authors have examined ankle sprain incidence after bracing or balance training in athletes at different levels of competition and in various sports. No systematic review has analyzed the results of both interventions. The purpose of this review was to compare the effect of balance training and bracing in reducing the incidence and relative risk of ankle sprains in competitive athletes, with or without prior injury, across different sports. A literature search of four databases was conducted for randomized control trials that reported ankle sprain incidence published from 2005 through 2016. Included articles studied high school, college, or professional level athletes with or without a history of a prior sprain, who received bracing or balance training as an intervention compared to a non-intervention control group. Methodological study quality was assessed by two reviewers using the PEDro scale. Group incidence and relative risk were determined to assess the preventative effect of bracing or balance training compared to control. Eight articles were included in the study. Methodological quality of the available evidence contained in the systematic review was moderate. Five of the included studies examined the effect of balance training, two studied the effect of bracing, and one studied the effect of bracing and balance training compared to a control condition. In all eight studies, athletes in the control condition did not receive any intervention. Athletes who wore braces had fewer ankle sprains (p=0.0037) and reduced their risk of sprains by 64% (RR=0.36)compared to controls, based on analysis of 3,581 subjects. Athletes performing balance training had fewer ankle sprains (p=0.0057) and reduced their risk by 46% (RR=0.54) compared to controls, based on analysis of 3,577 subjects.  The findings of the current systematic review and meta-analysis support the use of bracing and balance training to reduce the incidence and relative risk of ankle sprains in athletic populations. Clinicians can utilize this information to educate their patients on wearing a brace or performing balance training exercises to decrease the risk of an ankle sprain.

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ORIGINAL RESEARCH
Comparison Of The "Back in Action" Test Battery To Standard Hop Tests And Isokinetic Knee Dynamometry In Patients Following Anterior Cruciate Ligament Reconstruction.
Authors:  Ebert JR, Edwards P, Currie J, Smith A, Joss B, Ackland T, Buelow J, Hewitt B
Limb symmetry after anterior cruciate ligament reconstruction may be evaluated using maximal strength and hop tests, which are typically reported using Limb Symmetry Indices (LSIs) which may overestimate function. The purpose of this study was to compare the Back in Action (BIA) test battery to standard hop and muscle strength tests used to determine readiness to return to sport (RTS). Over two test sessions, 40 ACLR patients were assessed at a mean 11.3 months post-surgery. Initially, participants completed the 6 m timed hop and the single, triple and triple crossover hops for distance, and isokinetic knee extensor and flexor strength assessment. The second session involved completion of the BIA battery, including stability tests, single and double leg countermovement jumps (CMJ), and plyometric, speedy jump, and quick feet tests. Pass rates for test batteries were statistically compared, including the BIA, a four-hop battery (≥90% LSI in every one of the four hop tests) and a combined 4-hop and strength battery (≥90% LSI in every one of the four hop tests, as well as ≥90% for both peak knee extensor and flexor strength). LSI differences between the four standard hop tests and the BIA single limb functional tests (the single limb CMJ and the speedy jump test) were evaluated. Significantly fewer participants passed the BIA battery (n=1, 2.5%), compared with the four-hop test battery (n=27, 67.5%) (p<0.001) and the four-hop test and isokinetic strength battery (n=17, 42.5%) (p<0.001). Collectively, LSI’s for the standard hop tests were significantly higher than the BIA functional single limb tests (difference = 12.9%, 95% CI: 11.1% to 14.6%, p<0.001). The BIA test battery appears to include some single limb functional tests that are more physically challenging than standard hop and isokinetic strength tests, highlighted by the significantly lower mean LSI’s during the single limb BIA tests and the lower pass rate when employing the BIA protocol.

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The Lower Extremity Grading System (LEGS) to Evaluate Baseline Lower Extremity Perfromance in High School Athletes.
Authors:  Smith J, DePhillipo N, Azizi S, McCabe A, Beverine C, Orendurff M, Pun S, Chan C
Lower extremity athletic injuries result in impairments in balance, power, and jump-landing mechanics. Unilateral injury has bilateral effects and the literature supports the importance of assessing neuromuscular impairments such as balance, power, and jumping mechanics following injury and for safe return to sport after injury rehabilitation. Currently, individual tests are established in the literature, but no combined approach or clinical tool exists for this purpose. The purpose of this study is to describe and provide the initial data for the Lower Extremity Grading System (LEGS), comprised of three neuromuscular components, for use as a baseline pre-season assessment for high school athletes to assess lower extremity performance. Furthermore, this study focuses on the differences in baseline lower extremity performance outcomes between male and female soccer and basketball athletes.   One hundred and eighty-five high school basketball, and soccer athletes (94 female, 91 male; mean age = 15.6 ± 4.4) participated. The participants were administered the LEGS assessment during the preseason for their respective sports, which includes three component tests: (1) Y-balance test, (2) drop vertical jump test, (3) triple-crossover-hop-for-distance test. Participants’ scores on each test were recorded, and then totaled to present an overall LEGS composite score. Participants’ baseline LEGS scores were then analyzed according to sex and sport, and standard normal distribution was calculated for all scores to enable percentile rankings to be established. Mean scores and standard deviation for each functional performance test are presented. Furthermore, a LEGS composite score combining the test scores was established and presented as a normal distribution curve allowing for further comparison and analysis. The mean LEGS composite score for males was 700.3 (± 76.6), while the mean LEGS composite score for females was 587.4 (± 51.6). Statistically different LEGS composite scores were found between males and females. The current findings present descriptive data for the utility of the LEGS as a neuromuscular baseline assessment before high school sports participation and/or as a tool for assessing return to sports after injury rehabilitation. The LEGS may augment current assessment tools and may serve as a composite score and combined approach to the assessment of lower extremity risk of injury and readiness to return to sports.

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Pre-season Lower Extremity Functional Test Scores Are Not Associated with Lower Quadrant Injury – A Validation Study with Normative Data on 395 Division III Athletes.
Authors:  Brumitt J, Wilson V, Ellis N, Peterson J, Zita C, Reyes J
Pre-season performance on the lower extremity functional test (LEFT), a timed series of agility drills, has been previously reported to be associated with future risk of lower quadrant (LQ = low back and lower extremities) injury in Division III (D III) athletes. Validation studies are warranted to confirm or refute initial findings. The primary purpose of this study was to examine the ability of the LEFT to discriminate injury occurrence in D III athletes, in order to validate or refute prior findings. It was hypothesized that female and male D III athletes slower at completion of the LEFT would be at a greater risk for a non-contact time-loss injury during sport. Secondary purposes of this study are to report other potential risk factors based on athlete demographics and to present normative LEFT data based on sport participation. Two hundred and six (females = 104; males = 102) D III collegiate athletes formed a validation sample. Athletes in the validation sample completed a demographic questionnaire and performed the LEFT at the start of their sport’s preseason. Athletic trainers tracked non-contact time-loss LQ injuries during the season. A secondary analysis of risk based on preseason LEFT performance was conducted for a sample (n = 395) that consisted of subjects in the validation sample (n = 206) as well as athletes from a prior LEFT related study (n = 189). Male athletes in the validation sample completed the LEFT [98.6 (± 8.1) seconds] significantly faster than female athletes [113.1 (± 10.4) seconds]. Male athletes, by sport, also completed the LEFT significantly faster than their female counterparts who participated in the same sport. There was no association between preseason LEFT performance and subsequent injury, by sex, in either the validation sample or the combined sample. Females who reported starting primary sport participation by age 10 were two times (OR = 2.4, 95% CI: 1.2, 4.9; p = 0.01) more likely to experience a non-contact time-loss LQ injury than female athletes who started their primary sport at age 11 or older. Males who reported greater than three hours per week of plyometric training during the six-week period prior to the start of the preseason were four times more likely (OR = 4.0, 95% CI: 1.1, 14.0; p = 0.03) to experience a foot or ankle injury than male athletes who performed three or less hours per week.  The LEFT could not be validated as a preseason performance measure to predict future sports injury risk.  The data presented in this study may aid rehabilitation professionals when evaluating an injured athlete’s ability to return to sport by comparing their LEFT score to population norms.

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Two-year ACL Reinjury Rate of 2.5%: Outcomes Report Of The Men In A Secondary ACL Injury Prevention Program (ACL-SPORTS).
Authors:  Arundale A, Capin J, Zarzycki R, Smith A, Snyder-Mackler L
The Anterior Cruciate Ligament-Specialized Post-Operative Return to Sports (ACL-SPORTS) randomized control trial (RCT) examined an evidence-based secondary ACL injury prevention training program, involving progressive strengthening, agility training, and plyometrics. The RCT examined the benefit of the training program with and without a neuromuscular training technique called perturbation training.  The purpose of this study was to report the return to sport and second ACL injury incidence outcomes of the men in the ACL-SPORTS trial. Forty cutting and pivoting sport male athletes participated in the ACL-SPORTS trial, return to sport testing, and in follow-up sessions at one and two years after ACL reconstruction. Variables of interest at one and two years were return to sport, return to their preinjury level of sport, and second ACL injuries. Mean time to passing return to sport criteria, the number of athletes returning to sport and preinjury level of sport and the incidence proportion of second ACL injuries were calculated. Athletes passed return to sport criteria 232±99 days after ACLR. One year after ACL reconstruction 95% had returned to sport, 78% at their preinjury level. Two years after ACL reconstruction all athletes had returned to sport, 95% at their preinjury level and only one athlete had a second ACL injury.  The results of this study indicate that men in the ACL-SPORTS trial had much higher return to sport rates and much lower second ACL injury rates than those reported in the literature.

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Influence of Anterior Cruciate Ligament Reconstruction on Dynamic Postural Control.
Authors: Heinert B, Willett K, Kernozek T
Athletes that have had anterior cruciate ligament (ACL) reconstruction are at a greater risk for reinjury. The relationship between ACL reconstruction and the dynamic postural sway index (DPSI) has not yet been examined. The purpose of this study was to examine the DPSI in a surgically reconstructed ACL limb compared to the uninjured leg in athletes that had been cleared for sport. It was hypothesized that in a bilateral limb comparison, the leg that underwent ACL reconstruction would demonstrate poorer postural stability measures (greater DPSI) during a single leg landing activity as compared to the non-surgical limb.  14 subjects (7 male, 7 female; age range 16-23 years) with a history of unilateral ACL reconstruction and clearance for return to sport (mean 14 months post-operatively, range 8 to 24 months) performed five single leg hops over a 12 inch hurdle in the anterior direction from a distance corresponding with 40% of their height, onto a force platform. DPSI for the medial-lateral, anterior-posterior, vertical directions and a composite score were calculated for each trial on the surgical and non-surgical legs. A multivariate analysis with repeated measures was used to compare surgical and non-surgical legs for the total DPSI measure as well as for each component. Significant differences (p < .05) in dynamic postural stability were observed in the medial-lateral, anterior-posterior, vertical indices and DPSI total between the surgical and non-surgical limb. Deficits in dynamic postural control persist in ACL-reconstructed limbs compared to the non-surgical limb after the clearance for full activity. Clinicians should consider assessing single limb dynamic stability prior to releasing the athlete back to full activity. 

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Altered Sagittal Plane Hip Biomechanics in Adolescent Male Distance Runners with a History of Lower Extremity Injury.
Authors:  Lachniet PB, Taylor-Haas J, Paterno M, DiCesare C, Ford K
Lower extremity overuse injuries, including bone stress injuries (BSI), are common in runners and may result in prolonged recovery and time off from running. Identifying risk factors for running-related overuse injuries may have a clinically relevant role in prevention of these injuries. The purpose of this study was to compare an adolescent and young adult population of male runners known to have a history of BSI with an injury-free cohort and retrospectively assess for kinematic differences that may differentiate the two cohorts. Twenty-five male high school and collegiate cross-country runners were enrolled. Ten self-reported a prior history of BSI consisting of lower extremity stress fracture or shin splints/ medial tibial stress syndrome and were categorized as injured (INJ). Fifteen self-reported no prior history of lower extremity injury and were categorized as uninjured (UNINJ). All runners were pain-free at time of testing.  Runners ran at a self-selected speed on a treadmill with retro-reflective markers attached to thorax, pelvis, and each lower extremity segment. Three-dimensional kinematic calculations were made during stance phase (initial treadmill heel contact to toe off) and averaged over 20 steps. One-way ANCOVA was used to compare kinematic differences at the hip and knee between the INJ and UNINJ cohort.  Runners in the INJ group demonstrated greater peak hip flexion during stance phase on both the right limb [INJ=32.5°(±3.8°) vs. UNINJ=26.9°(±4.6°); p<0.01] and the left limb [INJ=31.2°(±4.8°) vs. UNINJ=26.8°(±3.1°); p=0.01] when compared to the UNINJ group. No significant difference in step length or step rate between the INJ and UNINJ cohorts was noted when normalized to height and weight (p=0.39 and 0.39). The results of this study demonstrate increased peak stance phase hip flexion in a population of young adult male runners with a previous history of BSI. This association may represent an important preliminary finding in the development of a clinically relevant tool to identify risk of BSI. Due to the retrospective nature of this study, future prospective investigations are warranted to validate these findings to determine if these alterations are compensatory following an injury or predictive of a future injury.

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Reliability of Two-dimensional Video-Based Running Gait Analysis.
Authors:  Reinking M, Dugan L, Ripple N, Schleper K, Scholz H, Spadino J, Stahl C, McPoil T
While two-dimensional (2D) video running analysis is commonly performed in the clinical setting, the reliability of quantitative measurements as well as effect of clinical experience has not been studied.  The purpose of this study was to assess the intra-rater and inter-rater reliability of six different raters using 2D video analysis of sagittal and frontal plane kinematic variables while running on a treadmill. Running videos from 10 individuals (five female, five male) with a mean age of 22.8 years were selected for analysis.  Two raters had over 10 years of experience with running video analysis and the other four raters had no prior experience.  Before beginning analyses, the senior investigator conducted two hours of training with all raters to review the measurement procedures and the movement analysis software program.  After completing training and one practice analysis, each rater assessed four 60-second video clips for the 10 runners twice (20 total). A minimum of one week separated the two assessments on each runner.  The order of the runner analyses were randomly assigned and each rater completed a single analysis within 24 hours.  After the rater had completed their initial assessment on all 10 runners, a second analysis was completed one week later with a different order of randomization. Eight sagittal plane (SAG) and four frontal plane (FRT) quantitative variables were measured for the left and right lower extremities on all 10 runners.  Intra- and inter-rater reliability was assessed using intraclass correlation coefficients (ICC) and standard error of the measurement (SEM). The intra-rater ICC values for experienced raters ranged from 0.75 to 0.98 for the SAG and 0.45 to 0.96 for FRT variables. The inter-rater ICC values between the experienced raters ranged from 0.76 to 0.99 for the SAG and 0.82 to 0.98 for FRT variables. The intra-rater ICC values for inexperienced raters ranged from 0.54 to 0.99 for the SAG and 0.08 to 0.97 for FRT variables.  The inter-rater ICC values between the inexperienced raters ranged from 0.93 to 0.99 for the SAG and 0.79 to 0.98 for FRT variables.  Intra-rater SEM values based on average means of all raters ranged from 1 to 47% of the mean values obtained for the SAG and from 6 to 158% for the FRT variables. The intra-rater and inter-rater reliability levels were higher for SAG quantitative variables assessed in this study in comparison to FRT variables. Experience does not appear to be a factor when consistency is required with repeated analyses on the same runner.

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Short-term Effects of Trigger Point Dry Needling On Pain And Disability In Subjects With Patellofemoral Pain Syndrome.
Authors:  Sutlive T, Golden A, King K, Morris WB, Morrison JE, Moore J, Koppenhaver S
Patellofemoral pain syndrome (PFPS) is a prevalent knee disorder. A novel yet increasingly popular treatment for PFPS is trigger point dry needling (DN). The purpose of this study was to determine if DN is more effective at reducing pain and disability than a sham treatment in individuals with PFPS. Sixty military health care beneficiaries (36 males) with a clinical diagnosis of PFPS were recruited and completed the study. Subjects underwent a standardized clinical examination and were randomized into a DN or sham treatment group. DN treatment consisted of insertion of an acupuncture-like needle into six sites in the quadriceps femoris muscles of the symptomatic lower extremity based on a palpation examination.  The sham grouped received a simulated treatment with a sharp object and needle guide tube without puncturing the skin. Self-reports of pain, disability, and overall status were collected before treatment, immediately after treatment and at 72 hours. Data were analyzed with separate 2x2 repeated measures analysis of variance, with independent variables being Group (DN vs. sham) and Time (pre-treatment vs. immediately post-treatment, and pre-treatment vs. 72 hours). The hypothesis of interest in each case was the Group*Time interaction. The alpha-level was set a priori to .05 using 2-tailed tests. Both groups exhibited a clinically meaningful reduction in pain based on numeric pain rating scale scores immediately post-treatment and at 72 hours, but there was no statistically significant difference between groups (p=0.219, 0.310).  There was no significant difference between groups for any other outcome measures.  These data suggest that DN treatment is not more effective than a sham DN treatment at reducing short-term pain and disability in individuals with PFPS when used as an isolated treatment approach.    

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Comparison of Three Different Density Type Foam Rollers on Knee Range of Motion and Pressure Pain Threshold: A Randomized Controlled Trial.
Authors:  Cheatham S, Stull K
Foam rolling is a popular form of roller massage. To date, no studies have examined the therapeutic effects of different density type rollers. Understanding the different densities may provide clinicians with the knowledge to accurately prescribe a particular foam roller and safely progress the client. The purpose of this study was to compare the effects of three different density type foam rollers on prone passive knee flexion range of motion (ROM) and pressure pain thresholds (PPT) of the quadriceps musculature. Thirty-six recreationally active adults were randomly allocated to one of three groups: soft density, medium density, and hard density foam roller. The intervention lasted a total of two minutes. Outcome measures included prone passive knee flexion ROM and PPT. Statistical analysis included parametric and non-parametric tests to measure changes among groups. Between group comparisons revealed no statistically significant differences between all three rollers for knee ROM (p=.78) and PPT (p=.37). Within group comparison for ROM revealed an 8 degree(p< 0.001) post-intervention increase for the medium and hard density rollers and a 7 degree (p< 0.001) increase for the soft density roller. For PPT, there was a post-intervention increase of 180 kPa (p< 0.001) for the medium density roller, 175 kPa (p< 0.001) for the soft density roller, and 151 kPa (p< 0.001) for the hard density roller. All three roller densities produced similar post-intervention effects on knee ROM and PPT. These observed changes may be due to a local mechanical and global neurophysiological response from the pressure applied by the roller. The client’s pain perception may have an influence on treatment and preference for a specific foam roller. Clinicians may want to consider such factors when prescribing foam rolling as an intervention.

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Influence of Topically Applied Menthol Cooling Gel on Soft Tissue Thermodynamics and Arterial and Cutaneous Blood Flow At Rest.
Authors:  Hunter A, Grigson C, Wade A
Topical application of menthol is a popular form of cold therapy and chemically triggers cold receptors and increases cutaneous blood flow. However, although cutaneous blood flow increases, it remains unknown where this increase arises from. Intramuscular temperature assessment may indirectly indicate a change in muscular blood flow. The purpose of this study was to establish intramuscular temperature, blood flow responses and subjective temperature sensation following application of menthol-based cooling gel to the anterior thigh. Twenty (age: 21.4 + 1.7) healthy males were treated on three separate days in random order with ice, a menthol-based gel or placebo gel (participant single blinded) on one anterior thigh. All measurements were taken at baseline and for 80 mins following treatment: 1) Skin, core, and intramuscular temperatures (1 & 3cm deep); 2) femoral arterial blood flow (duplex ultrasound); 3) cutaneous blood flow (laser Doppler) and 4) subjective report of cold sensation. Ice and both gels decreased (p<0.0001, CI (Ice): -5.2 to -6.2 and CI (gels)-1.4 to -2.5) intramuscular temperature by 5.7 and 1.9 °C respectively, but by 80 mins were similar to each other (1.5-2°C less than pre-treatment). Skin temperature mirrored muscle temperature with 8.8 and 4.2°C respective decline for ice and gels. Menthol gel increased (p<0.0001) cutaneous blood flow by 0.3 ml/min compared to unaltered flow associated with the placebo gel and a decline of 0.3ml/min for the ice. Menthol gel cold sensation was subjectively reported to be cooler (p<0.0001) than the other two treatments. Core temperature and arterial flow were unaffected.  This is the first study to demonstrate the intramuscular cooling effect of menthol-based gel. However, the likely cause was from evaporative cooling despite menthol-derived increases in cutaneous blood flow and cooling sensation. 

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Pitching Mechanics in Female Youth Fastpitch Softball.
Authors:  Oliver G, Plummer H, Washington J, Saper M, Dugus J, Andrews J

Fastpitch softball is a popular sport for young females. However, data are limited describing youth pitching mechanics. Normative data describing pitching mechanics in the two youngest player pitch leagues are critical to gaining an improved understanding of proper mechanics in an attempt to establish injury prevention programs. Therefore, the purpose of this study was to (1) examine pitching mechanics in Little League softball pitchers and (2) examine the relationship of these mechanics and participant anthropometrics to ball velocity. Twenty-three softball pitchers (11.4 ± 1.5 years; 154.6 ± 10.5 cm; 51.0 ± 8.0 kg) classified in Little League Softball Divisions participated. An electromagnetic tracking system was used to collect kinematic data for three fastball trials. Three maximum effort fastballs for strikes over a regulation distance to a catcher were selected for analysis. Pitching motion was divided into three events: top of back swing, stride foot contact, and ball release. Youth who were older (r=0.745, p < 0.001) and taller (r=0.591, p = 0.003) achieved greater ball velocity. Trunk kinematics revealed that greater trunk flexion throughout the three throwing events of top of back swing (r=0.429, p=0.041), stride foot contact (r=0.421, p=0.046), and ball release (r=0.475, p=0.022) yielded greater ball velocity. Additionally, greater trunk rotation to the throwing arm side (r=0.450, p=0.031) at top of back swing and greater trunk lateral flexion to the glove side at ball release (r=0.471, p=0.023) resulted in greater ball velocity. The significant relationships found between pitching mechanics and ball velocity only occurred at the trunk, which may highlight the importance of utilizing the trunk to propel the upper extremity in dynamic movements.

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Reference Values for Glenohumeral Joint Rotational Range Of Motion In Elite Tennis Players.<
Authors:  Nutt C, Mirkovic M, Hill R, Ranson C, Cooper S
Due to the repetitive overhead activity involved in playing tennis and the physical demands of the game, shoulder joint injury is common. There is limited research available describing sport specific risk factors for injury in tennis, however, changes in shoulder rotational range of motion (ROM) have been associated with injury in other overhead ‘throwing’ type sports. This study had two purposes: i) to identify reference values for passive glenohumeral joint rotational ROM in elite tennis players, and, ii) to investigate differences in ROM between various age groups of players. Data was collected at national performance camps held at a National Tennis Centre between September 2012 and July 2015. One hundred and eighty-four tennis players aged between 11 and 24 years took part. All had a top eight national ranking within their respective age group. Participants were divided into three age groups; under 14 years, 14-15 years, and 16 years and over. The main outcome measures were dominant and non-dominant internal and external rotation as well as total glenohumeral joint passive ROM. Reduced internal, and greater external rotation passive ROM were identified on the dominant side (p < 0.05), however, no side-to-side differences in total rotation ROM were found (p > 0.05). A glenohumeral joint internal rotation deficit (GIRD) was prevalent on the dominant side, which increased in magnitude with rising player age. Differences in dominant side internal and external rotation ROM were identified between age groups with the 14-15-year olds having less internal and greater external rotation than the under 14-year olds and the over 16-year old athletes (p < 0.05). The total range of motion values were not found to differ between age groups (p > 0.05).  This study provides reference values for glenohumeral joint rotational ROM in elite tennis players and demonstrates age specific differences. Future studies should investigate links between changes in ROM and injury risk.

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CASE SERIES / STUDIES
Rehabilitation Considerations for An Uncommon Injury of the Knee: A Case Report.
Authors:  Baumann E, Rice W, Selhorst M
Chronic instability of the proximal tibiofibular joint (PTFJ) is an uncommon condition that accounts for <1% of knee injuries. The mechanism of injury is a high-velocity twisting motion on a flexed knee. Surgical management is controversial due to complications; however, surgeons are now utilizing ligament reconstruction to restore stability. There is a paucity of information in the literature regarding postoperative care and rehabilitation after PTFJ reconstruction. The purpose of this case report is to describe the post-surgical rehabilitation for an adolescent athlete following PTFJ ligament reconstruction using a modified anterior cruciate ligament reconstruction (ACL) post-operative rehabilitation protocol.

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The Use of Serial Platelet Rich Plasma Injections with Early Rehabilitation to Expedite Grade III Medial Collateral Ligament Injury in A Professional Athlete: A Case Report.
Authors:  Bagwell M, Wilk K, Colberg R, Dugas J
Medial collateral ligament (MCL) injuries are one of the most commonly treated knee pathologies in sports medicine. The MCL serves as the primary restraint to valgus force. The large majority of these injuries do not require surgical intervention.  The results of this case report indicate that the use of LR-PRP and early rehabilitation shows promise in treating an acute grade 3 MCL injury. Future research utilizing randomized controlled trials are needed.

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LITERATURE REVIEW
Evidence-Based Procedures for Performing the Single Leg Squat and Step-Down Tests in Evaluation of Non-Arthritic Hip Pain: A Literature Review.
Authors:  McGovern R, Martin R, Christoforetti J, Kivlan B
Functional performance tests are commonly utilized in screening for injury prevention, evaluating for athletic injuries, and making return-to-play decisions. Two frequently performed functional performance tests are the single leg squat and step-down tests. The purpose of this study was to systematically review the available psychometric evidence for use of the single leg squat and step-down tests for evaluating non-arthritic hip conditions and construct an evidence-based protocol for test administration. A search of the PubMed and SPORTSDiscus databases was performed. Psychometric evidence of reliability, validity, and responsiveness to support the use of the both tests were collected. The protocols used for administering these tests were extracted, summarized, and combined. Fifty-six total articles met the inclusion criteria and were included in the review. Evidence for reliability and validity was available to support the use of the single leg squat and step-down tests. Both tests assess for neuromuscular control of the hip and surrounding muscular structures. Evaluation of these functional movement patterns enable the clinician to assess for limitations that may cause an increase in hip pain and dysfunction. The single leg squat and step-down tests can assess for kinematic and biomechanical deficiencies and may be useful in the evaluation process for individuals with non-arthritic hip pain. The authors of this review present a comprehensive evidence-based protocol for standardized performance of these tests.

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Evaluating the Progress of Mid-Portion Achilles Tendinopathy During Rehabilitation: A Review of Outcome Measures For Muscle Structure and Function, Tendon Structure, and Neural and Pain Associated Mechanisms.
Authors:  Murphy M, Rio E, Debenham J, Docking S, Travers M, Gibson W
Alterations in tendon structure and muscle performance have been suggested as mechanisms driving improvement in pain and function with mid-portion Achilles tendinopathy (AT). However, few trials have used consistent outcome measures to track differences in muscle structure and function, tendon structure and neural and pain associated mechanisms. The objectives of this review were to: 1) Identify the outcomes measures used in trials utilising loading protocols for mid-portion AT that assess muscle structure and performance, tendon structure and neural and pain associated mechanisms in order to report on the reliability of the identified measures, and 2) Propose a summary of measures for assessment of muscle structure and function, tendon structure and neural and pain associated mechanisms in patients with AT.  Three electronic databases were searched from inception until May 2016 for studies using loading protocols for mid-portion AT. Twenty-eight studies were included; seven assessed muscle, 21 assessed tendon and two assessed neural and pain associated mechanisms. Evidence suggests that isokinetic dynamometry, eccentric-concentric heel raise tests, single leg drop counter-movement jumps or hopping are the most reliable ways to assess muscular adaptation. Assessment of tendon structure is unlikely to have any benefit given it does not appear to correlate to clinical outcomes. The neural and pain associated mechanisms have not been thoroughly investigated. 

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CLINICAL COMMENTARY
Theoretical Applications of Blood Flow Restriction Training in Managing Chronic Ankle Instability in the Basketball Athlete.
Authors:  Faltus J, Owens J, Hedt C
Chronic ankle instability (CAI) is a common dysfunctional state in the basketball population accompanied by pain, weakness and proprioceptive deficits which greatly affect performance. Research evidence has supported the use of blood flow restriction (BFR) training as an effective treatment strategy for improving muscle strength, hypertrophy and function following injury in a variety of patient populations. In managing CAI, it is important to address proximal and distal muscle weakness, pain, and altered proprioception to reduce the likelihood of re-occurring ankle injury. The ability to mitigate acute and cumulative strength and muscle volume losses through the integration of BFR after injury has been supported in research literature. In addition, applications of BFR training for modulating pain, improving muscle activation and proximal muscle strength have recently been suggested and may provide potential benefit for athletes with CAI. The purpose of this clinical commentary is to discuss background evidence supporting the implementation of blood flow restriction training and use a theoretical model for managing CAI as well as to suggest novel treatment strategies using this method.

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