VOLUME TWELVE NUMBER SIX

 
2017Masthead_V12N6Cover

November 2017

Introduction to the Movement System as the Foundation for Physical Therapist Practice Education and Research.
Authors:  Saladin L, Voight ML
DOI: 10.16603/ijspt20170858
In 2013, the APTA adopted an inspiring new vision, “Transforming society by optimizing movement to improve the human experience.”  This vision for our profession calls us to action as physical therapists to transform society by using our skills, knowledge, and expertise related to the movement system in order to optimize movement, promote health and wellness, mitigate the progression of impairments, and prevent the development of (additional) disability. The guiding principle of the new vision is “identity,” can it be summarized as “The physical therapy profession will define and promote the movement system as the foundation for optimizing movement to improve the health of society.”  Recognition and validation of the movement system is essential to understand the structure, function, and potential of the human body.   As currently defined, the “movement system” represents the collection of systems (cardiovascular, pulmonary, endocrine, integumentary, nervous, and musculoskeletal) that interact to move the body or its component parts. By better characterizing physical therapists as movement system experts, we seek to solidify our professional identity within the medical community and society.  The physical therapist will be responsible for evaluating and managing an individual’s movement system across the lifespan to promote optimal development; diagnose impairments, activity limitations, and participation restrictions; and provide interventions targeted at preventing or ameliorating activity limitations and participation restrictions.

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The How and Why of the Movement System as the Identity of Physical Therapy.
Author:  Sahrmann S
DOI: 10.16603/ijspt20170862
The Movement System was adopted as the identity of physical therapy as one of the 8 guiding principles accompanying the Vision Statement of 2013. At its inception physical therapy was considered more of a technical field rather than that of a professional field. Physicians were to diagnose the patient’s problem and the therapist was to follow the prescription provided by the physician with the primary purpose being to relieve symptoms such as pain or muscle weakness. Even by the 1960’s, the prescription became more of a referral and there was recognition that therapists were making decisions about the patient’s treatment and discharge disposition. The role of the physical therapist in pathokinesiologic problems has been well accepted over the years but as insights are gained about the role of movement in musculoskeletal pain, the concept of kinesiopathologic problems is being defined. Whether the movement dysfunction is from a pathokinesiologic or a kinesiopathologic mechanism, the underlying physiologic process is movement which is the composite action of the movement system. This article provides a brief discussion of the steps leading to promotion of the identity and the reasons that further defining and promoting the movement system as the body system for which physical therapists are responsible is necessary for the full recognition of the profession. As suggested by the kinesiopathologic concept of movement inducing pathology, physical therapists can address the cause of musculoskeletal problems and not just symptoms or consequences such as the pathoanatomic problem.

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Diagnosis Dialog: Recap and Relevance to Recent APTA Actions.
Author:  Norton BJ
DOI: 10.16603/ijspt20170870
For at least 40 years, physical therapists have been contemplating the issue of diagnosis.  After the profession chose to require completion of doctoral-level training for entry into the profession, making some decisions about diagnosis became essential. In the 2004 Maley Lecture, Cynthia Coffin-Zadai called the profession to action on the question of diagnosis. One response to her call was the formation of a group of physical therapists from across the country to engage in an extended conversation about diagnosis. The Diagnosis Dialog group first met in St. Louis in 2006 and at the end of the meeting they decided to continue the discussion at another meeting. In fact, they met a total of 13 times over 10 years. The purposes of this article are to a) summarize briefly some of the topics that were discussed and b) demonstrate the relevance of those discussions to recent APTA actions regarding the adoption of the movement system as the core of physical therapist practice, education, and research.

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Changing our Diagnostic Paradigm: Movement System Diagnostic Classification.
Authors:  Ludewig PM, Kamonseki DH, Staker JL, Lawrence RR, Camargo PR, Braman JP
DOI: 10.16603/ijspt20170884
Proper diagnosis is a first step in applying best available treatments, and prognosticating outcomes for clients. Currently, the majority of musculoskeletal diagnoses are classified according to pathoanatomy. However, the majority of physical therapy treatments are applied toward movement system impairments or pain. While advocated within the physical therapy profession for over thirty years, diagnostic classification within a movement system framework has not been uniformly developed or adopted. We propose a basic framework and rationale for application of a movement system diagnostic classification for atraumatic shoulder pain conditions, as a case for the broader development of movement system diagnostic labels. Shifting our diagnostic paradigm has potential to enhance communication, improve educational efficiency, facilitate research, directly link to function, improve clinical care, and accelerate preventive interventions.

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The Movement System in Education.
Authors:  Hoogenboom BJ, Sulavik M
DOI: 10.16603/ijspt20170894
Although many physical therapists have begun to focus on movement and function in clinical practice, a significant number continue to focus on impairments or pathoanatomic models to direct interventions.  This paradigm may be driven by the current models used to direct and guide curricula used for physical therapist education. The methods by which students are educated may contribute to a focus on independent systems, rather than viewing the body as a functional whole. Students who enter practice must be able to integrate information across multiple systems that affect a patient or client’s movement and function. Such integration must be taught to students and it is the responsibility of those in physical therapist education to embrace and teach the next generation of students this identifying professional paradigm of the movement system. The purpose of this clinical commentary is to describe the current state of the movement system in physical therapy education, suggest strategies for enhancing movement system focus in entry level education, and envision the future of physical therapy education related to the movement system. Contributions by a student author offer depth and perspective to the ideas and suggestions presented.

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LITERATURE REVIEW

The Impact of Attentional Focus on the Treatment of Musculoskeletal and Movement Disorders.
Authors:  Hunt C, Paez A, Folmer E
DOI: 10.16603/ijspt20170901
Treatment plans employed by physical therapists involved in musculoskeletal rehabilitation may follow a conventional medical-model approach, isolating care at the tissue level but neglecting consideration for neurocognitive contributions to recovery. Understanding and integration of motor learning concepts into physical therapist practice is integral for influencing the human movement system in the most effective manner. One such motor learning concept is the use of verbal instruction to influence the attentional focus of the learner. Evidence suggests that encouraging an external focus of attention through verbal instruction promotes superior motor performance, and more lasting effects of a learning experience than an internal focus of attention. Utilizing an external focus of attention when instructing a patient on a motor task may facilitate improved motor performance and improved functional outcomes in treatment plans devised to address musculoskeletal injury and movement disorders. The purpose of this review is to summarize the basic principles of motor learning and available evidence on the influence an external focus of attention has on motor learning and performance, including the benefits of an external focus of attention over an internal focus of attention and how therapists may inadvertently encourage the latter. Furthermore, the benefits of possessing greater awareness of neurocognitive mechanisms are discussed to exhibit how implementing such concepts into musculoskeletal rehabilitation can maximize treatment outcomes.

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ORIGINAL RESEARCH

Retention of Movement Technique: Implications for Primary Prevention of ACL Injuries.
Authors:  Welling W, Benjaminse A, Gokeler A, Otten B
DOI: 10.16603/ijspt20170908
Retention of movement technique is crucial in anterior cruciate ligament (ACL) injury prevention programs. It is unknown if specific instructions or video instructions result in changes in kinematic and kinetic measures during a relatively short training session, and in a retention test one week later. The purpose of this study was to investigate the effects of verbal external focus (EF), verbal internal focus (IF), and video instructions (VI) on landing technique (i.e. kinematics and kinetics) during training and retention.  This study compared verbal EF, verbal IF, VI and CTRL group. Forty healthy athletes were assigned to the IF (n=10), EF (n=10), VI (n=10) or CTRL group (n=10). A jump-landing task was performed as a baseline, followed by two training blocks (TR1 and TR2) and a post test. Group specific instructions were offered in TR1 and TR2. In addition, subjects in the IF, EF and VI groups were free to ask for feedback after every jump in TR1 and TR2. One week later, a retention test was conducted without specific instructions or feedback. Kinematics and kinetics were captured using an 8-camera motion analysis system.

Males and females in the EF and VI instruction group showed beneficial results during and after the training session, in terms of improved landing technique. Retention was achieved after only a short training session. The authors concluded that ACL injury prevention programs should include EF and/or VI instructions to improve kinematics and kinetics and achieve retention.

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The Relationship Between Segmental Rolling Ability and Lumbar Multifidus Activation Time.
Authors:  Clark N, Voight ML, Campbell A, Pierce S, Sells P, Cook R, Henley C, Schiller L
DOI: 10.16603/ijspt20170921
Segmental rolling has been utilized as an assessment and intervention tool to identify and affect dysfunction of the upper quarter, core, and lower quarter. One theory to explain dysfunctional segmental rolling is a lack of segmental spinal control / stabilization. Faulty muscle firing sequencing has been related to poor spinal stability, however to date, no assessment tool exists to evaluate a patient's motor coordination of local and global musculature. The purpose of this study was to assess the temporal sequence of lumbar multifidus activation associated with anterior deltoid activation, and to determine if faulty sequencing was associated with the inability to segmentally roll in subjects without mobility restrictions. Twenty healthy subjects (13 females, 7 males), ages 19-25, participated in the study. Each subject underwent an upper and lower quarter screen and assessment of thoracic spine mobility. Subjects were excluded from the study if they had undergone previous spine surgery, were currently experiencing back pain, or if they had less than 50 degrees of trunk rotation. In addition, subjects who had any disease, disorders, or pathology that would hinder participation in segmental rolling or who had spinal movement contraindications were excluded. Participants who had shoulder pathology or contraindications to upper extremity movement were also excluded. Included subjects were assessed on their ability to segmentally roll. Subjects who could complete the rolling task were placed in cohort A (“can roll”), and subjects who could not roll were placed in cohort B (“can’t roll”). Electromyographic (EMG) activity of the multifidus was recorded using intramuscular fine-wire electrodes and EMG activity of the anterior deltoid was recorded with a surface electrode during a single arm movement into shoulder flexion. Subjects flexed their shoulder to 90 degrees for three trials while muscle activity was recorded.  Data were high-pass filtered at 30 Hz to remove baseline artifact, and the onset EMG times was selected as the point at which EMG increased two SD above baseline levels. Onset of the multifidus muscle was reported relative to that of the prime mover (anterior deltoid). Muscle onset latency was defined as the time difference between the onset of contraction of the multifidus and the anterior deltoid. Nine subjects were placed in cohort A, 11 subjects were placed in cohort B. The mean firing time of the lumbar multifidus for the cohort A was 16.67msec before the anterior deltoid, and the mean firing time of the lumbar multifidus for cohort B was 57.36msec after the anterior deltoid. There was a statistically significant difference in (p<0.00) in the firing time between cohorts A and B. In subjects who could segmentally roll, the multifidus muscle activation always preceded that of the prime mover muscle activation.  In subjects who could not segmentally roll, the results of this study confirm that there is a multifidus muscle onset latency relative to the activation of the anterior deltoid.  The inability to segmentally roll may be related to faulty sequencing of lumbar multifidus firing.

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Correlation of Self-Reported Outcome Measures and the Selective Functional Movement Assessment (SFMA): An Exploration of Validity.
Authors:  Riebel M, Crowell M, Dolbeer J, Szymanek E, Goss D
DOI: 10.16603/ijspt20170931
The Selective Functional Movement Assessment (SFMA) is a clinical model used to assist diagnosis and treatment of musculoskeletal disorders by identifying dysfunctions in movement patterns.  Based on the premise that addressing movement dysfunction is associated with an improvement in patient outcomes, the validity of the SFMA would be strengthened by observed improvement in self-reported function being associated with change in movement patterns. The purpose of this study was to explore the validity of the SFMA by determining if a correlation existed between a change in self-reported outcome measures and attributes of the assessment. Eighty-five subjects (20.3 ± 1.6 years) were administered the Patient-Specific Functional Scale and one of four region-specific outcome measures followed by the seven SFMA top-tier movements. When deemed appropriate for discharge or following six weeks of therapy by an independent physical therapist, each subject repeated the outcome measures and was re-evaluated on the top-tier tests by the same initial assessor who was blinded to the subject’s self-reported outcomes. Correlations between changes in outcome measures, number of painful movements and measures of movement quality (number of dysfunctional movements and criterion scores) were calculated with Spearman rank correlation coefficients. Subjects were analyzed as a consolidated group and by each region based on primary complaint. Fair to good positive correlations between improvements in self-reported outcomes and decreases in the number of painful patterns were noted for the complete dataset and for those with shoulder girdle and lumbopelvic complaints (r2 = 0.28, 0.52, and 0.41, respectively). Subjects with lumbopelvic complaints demonstrated fair positive correlations with improvements in self-reported outcomes and decreases in the number of dysfunctional patterns (r2 = 0.41 and 0.46). No correlations between changes in outcome measures and criterion score were observed. The authors concluded that improvements in self-reported outcome measures were associated with fewer painful movement patterns of the SFMA. Improvements in self-reported function were not related to changes in movement quality, except for subjects presenting with lumbopelvic complaints.

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Validity of Functional Screening Tests to Predict Lost-Time Lower Quarter Injury in a Cohort of Female Collegiate Athletes: A Case Series.
Authors:  Walbright PD. Walbright N, Ojha H, Davenport T
DOI: 10.16603/ijspt20170948
Lower quarter injuries account for more than 50% of all injuries in collegiate athletics. Neuromuscular screening tests could potentially identify athletes who are at risk for sustaining an injury. While previous research has studied individual tests, the authors of this paper are unaware of any study that has compared diagnostic accuracy of multiple neuromuscular screening tests within one study cohort. The purpose of this study was to examine the accuracy of three common neuromuscular screening tests to predict the occurrence of a lower quarter injury in female collegiate volleyball and basketball players.   Thirty-five subjects underwent a pre-season screening by performing the Y-Balance test, the Functional Movement ScreenTM and Single Leg Hop test. Data were collected on lower quarter injury incidence, lost practice time, and lost competition time among subjects throughout the course of one season. Receiver operating characteristics curves were plotted and area under the curve was calculated to assess the relationship between lower extremity injury incidence and the scores of the functional tests. Lost-time injuries occurred in 11 athletes (31.4%), of whom, six athletes (17.1%) lost 50 hours or greater. There were no significant relationships between occurrence of a lost-time lower extremity injury and scores on any of the three tests. Positive and negative likelihood ratios all included the value of 1.0. The authors concluded that although reliable, the screening tests under study did not appear to demonstrate adequate validity to predict lower quarter injury risk within these female collegiate athletes.

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Relationship of Preseason Movement Screens with Overuse Symptoms in Collegiate Baseball Players.
Authors:  Busch AM, Clifton DR, Onate JA, Ramsey VK, Cromartie F
DOI: 10.16603/ijspt20170960
The shoulder mobility screen of the Functional Movement Screen™ (FMS™) and the upper extremity patterns of the Selective Functional Movement Assessment (SFMA) assess global, multi-joint movement capabilities in the upper-extremities. Identifying which assessment can most accurately determine if baseball players are at an increased risk of experiencing overuse symptoms in the shoulder or elbow throughout a competitive season may reduce throwing-related injuries requiring medical attention. The purpose of this study was to determine if preseason FMS™ or SFMA scores were related to overuse severity scores in the shoulder or elbow during the preseason and competitive season. Sixty healthy, male, Division III collegiate baseball players (mean age = 20.1 ± 2.0 years) underwent preseason testing using the FMS™ shoulder mobility screen, and SFMA upper extremity patterns. Their scores were dichotomized into good and bad movement scores, and were compared to weekly questionnaires registering overuse symptoms and pain severity in the shoulder or elbow during the season. Poor FMS™ performance was associated with an increased likelihood of experiencing at least one overuse symptom during the preseason independent of grade and position (adjusted odds ratio [OR] = 5.14, p = 0.03). Poor SFMA performance was associated with an increased likelihood of experiencing at least one overuse symptom during the preseason (adjusted OR = 6.10, p = 0.03) and during the competitive season (adjusted OR = 17.07, p = 0.03) independent of grade and position. The authors concluded that the FMS™ shoulder mobility and SFMA upper extremity pattern performance were related to the likelihood of experiencing overuse symptoms during a baseball season. Participants with poor FMS™ performances may be more likely to experience at least one overuse symptom in their shoulder or elbow during the preseason. Additionally, individuals with poor SFMA performances may be more likely to report overuse symptoms during the preseason or competitive season.

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Static Balance Measurements in Stable and Unstable Conditions Do Not Discriminate Groups of Young Adults Assessed by the Functional Movement Screen.™
Authors:  Trindade MA, Toledo AM, Cardoso JR, Souza IE, Mendes FA, Santana LA, Carregaro RL
DOI: 10.16603/ijspt20170967
The Functional Movement Screen™ (FMS™) has been the focus of recent research related to movement profiling and injury prediction. However, there is a paucity of studies examining the associations between physical performance tasks such as balance and the FMSTM screening system. The purpose of this study was to compare measures of static balance in stable and unstable conditions between different groups divided by FMSTM scores. A secondary purpose was to discern if balance indices discriminate the groups divided by FMSTM scores. Fifty-seven physically active subjects (25 men and 32 women; mean age of 22.9 ± 3.1 yrs) participated. The outcome was unilateral stance balance indices, including: Anteroposterior Index; Medial-lateral Index, and Overall Balance Index in stable and unstable conditions, as provided by the Biodex balance platform. Subjects were dichotomized into two groups, according to a FMS cut-off score of 14: FMS1 (score >14) and FMS2 (score ≤14). The independent Students t-test was used to verify differences in balance indices between FMS1 and FMS2 groups. A discriminant analysis was applied in order to identify which of the balance indices would adequately discriminate the FMSTM groups.  Comparisons between FMS1 and FMS2 groups in the stable and unstable conditions demonstrated a higher unstable Anteroposterior index for FMS2 (p=0.017). No significant differences were found for other comparisons (p>0.05). The indices did not discriminate the FMSTM groups (p>0.05). The authors concluded that the balance indices adopted in this study were not useful as a parameter for identification and discrimination of healthy subjects assessed by the FMS™.

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The Functional Movement Screen™ (FMS™) in Elite Young Soccer Players Between 14 and 20 Years: Composite Score, Individual Test Scores and Asymmetries.
Authors:  Marques VB, Medeiros T, Stigger F, Nakamura FY, Baroni BM
DOI: 10.16603/ijspt20170977
The Functional Movement Screen™ (FMS™) is a widely used seven-test battery used by practitioners working in sport medicine. The FMS™ composite score (sum of seven tests) in soccer athletes from different competitive levels has been well explored in literature, but the specific movement deficits presented by young high competitive level players remains unclear. The aim of the present study was to provide a detailed description of the performance of elite young soccer players (age 14-20 years) on the FMS™ testing battery. One-hundred and three young soccer players (14-20 years) from a premier league club were assessed by two experienced raters using the FMS™ testing battery. FMS™ composite score, individual-test scores and asymmetries were considered for analysis, and comparisons between age categories were performed. FMS™ composite scores ranged from 9 to 16 points (median=13 points). 82% of the athletes had a composite score ≤14 points, and 91% were classified into the “Fail” group (score 0 or 1 in at least one test). Almost half of athletes (48%) had poor performance (i.e., individual score <2) in the “deep squat” test. Most of athletes in the younger categories (under-15 and under-16) had poor performance in the “trunk stability push-up” test (70%) and in the “rotary stability” test (74%). Asymmetry in at least one of five unilateral FMS™ tests was found in 65% of athletes.  The authors concluded that high-performance young soccer players have important functional deficits, especially in tasks involving deep squat and trunk stability, as well as high prevalence of asymmetry between right and left body side.

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The Relationship Between Pre-Operative and Twelve-Week Post-Operative Y-Balance and Quadriceps Strength In Athletes With An Anterior Cruciate Ligament Tear.
Authors:  Hallagin C, Garrison JC, Creed K, Bothwell JM, Goto S, Hannon J
DOI: 10.16603/ijspt20170986
Pre-operative quadriceps strength may have a positive influence on post-operative function and outcomes at time of return to sport. Little consideration has been given to quadriceps strength during the early post-operative timeframes. Twelve-weeks post-operative anterior cruciate ligament reconstruction (ACL-R) is considered a critical time point for progression in the rehabilitation process. There is currently limited research looking at the relationship between clinical measurements pre-operatively and at 12-weeks following ACL-R. The primary purpose of this study was to examine the differences between Y-Balance Test Lower Quarter (YBT-LQ) and isokinetic quadriceps strength tested pre-operatively and post-operatively following ACL-R (12-weeks). Thirty-nine participants (15.6±1.5 y/o) were diagnosed with an ACL tear and were undergoing rehabilitation to return to a sport requiring cutting and pivoting were included. YBT-LQ and isokinetic quadriceps strength were assessed pre-operatively and at 12 weeks after ACL-R. YBT-LQ composite scores were calculated bilaterally and isokinetic quadriceps strength was tested using the Biodex Multi-Joint Testing and Rehabilitation System. Paired t-tests were used to determine mean group differences between YBT-LQ and isokinetic quadriceps strength scores pre-operatively and at 12-weeks post-operative. A Pearson Correlation was performed to determine relationships between variables at both time points. There was a significant improvement in YBT-LQ composite scores from pre-operative to 12 weeks post-operative on both the involved (Pre-operative: 89.0±7.7; 12 weeks: 94.1±7.1, p<0.001) and uninvolved (Pre-operative: 92.6±6.2; 12 weeks: 97.6±6.8, p<0.001) limbs. Quadriceps strength decreased significantly from pre-operative to 12-weeks on the involved limb (Pre-operative: 82.3ftlbs±38.6; 12-weeks: 67.9ftlbs±27.4, p<0.01), but no differences were found on the uninvolved limb (Pre-operative: 117.3ftlbs±42.0; 12-weeks: 121.7ftlbs±41.5, p= 0.226). The authors concluded that involved limb quadriceps strength decreases from time of pre-operative to 12-weeks following ACL-R.

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CASE REPORT / SERIES
A Combined Treatment Approach Emphasizing Impairment-Based Manual Therapy and Exercise for Hip-Related Compensatory Injury in Elite Athletes: A Case Series.
Authors:  Short S, Short G, Strack D, Anloague P, Brewster B
DOI: 10.16603/ijspt20170994
Athletes experiencing hip, groin, and low back pain often exhibit similar clinical characteristics. Individuals with hip, groin and low back pain may have the presence of multiple concurrent pathoanatomical diagnoses. Regardless, similar regional characteristics and dysfunction may contribute to the patient’s chief complaint, potentially creating a sub-group of individuals that may be defined by lumbopelvic and hip mobility limitations, motor control impairments, and other shared clinical findings. The purpose of this case series is to describe the conservative management of elite athletes, within the identified aforementioned sub-group, that emphasized regional manual therapy interventions, and therapeutic exercise designed to improve lumbopelvic and hip mobility, stability and motor control. Five elite athletes were clinically diagnosed by a physical therapist with primary pathologies including adductor-related groin pain (ARGP), femoral acetabular impingement (FAI) with acetabular labral lesion and acute, mechanical low back pain (LBP). Similar subjective, objective findings and overall clinical profiles were identified among all subjects.  Common findings aside from the chief complaint included, but were not limited to, decreased hip range of motion (ROM), impaired lumbopelvic motor control and strength, lumbar hypomobility in at least one segment, and a positive hip flexion-adduction-internal rotation (FADIR) special test. A three-phase impairment-based physical therapy program was implemented to resolve the primary complaints and return the subjects to their desired level of function. Acute phase rehabilitation consisted of manual therapy and fundamental motor control exercises.  Progression to the sub-acute and terminal phases was based on improved subjective pain reports and progress with functional impairments. As the subjects progress through the rehabilitation phases, the delivery of physical therapy interventions were defined by decreased manual therapies and an increased emphasis and priority on graded exercise. Significant reductions in reported pain (>2 points Numeric Pain Rating Scale), improved reported function via functional outcome measures (Hip and Groin Outcome Score), and continued participation in sport occurred in all five cases without the need for surgical intervention. The athletes described in this case series make up a common clinical sub-group defined by hip and lumbopelvic mobility restrictions, lumbopelvic and lower extremity motor control impairments and potentially other shared clinical findings. Despite differences in pathoanatomic findings, similar objective findings were identified and similar treatment plans were applied, potentially affecting the movement system as a whole. Subjects were conservatively managed allowing continued participation in sport within their competitive seasons. Comprehensive conservative treatment of the athletes with shared impairments, as described in this case series, may be of clinical importance when managing athletes with hip, groin, and low back pain.

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