VOLUME FOURTEEN, NUMBER TWO

 
2019Masthead_V14N2

April, 2019

ERRATUM

ORIGINAL RESEARCH

Use of 2-Dimensional Sagittal Kinematic Variables to Estimate Ground Reaction Force During Running.
Authors:  White JD, Carson N, Baum BS, Reinking MF, McPoil TG
Variations in vertical loading rates have been associated with overuse injuries of the lower extremity; however, they are typically collected using 3-dimensional motion capture systems and in-ground force plates not available to most clinicians because of cost and space constraints. The purpose of this study was to determine if kinetic measures commonly used to describe lower extremity loading characteristics could be estimated from step rate and specific sagittal plane kinematic variables captured using 2-dimensional motion analysis during treadmill running. Ten high school cross-country runners (4 men and 6 women) voluntarily consented to participate in this study.  Reflective markers were placed on each lower extremity over multiple anatomical landmarks. Participants were then asked to run on the instrumented treadmill at their preferred running speed. When the participants indicated they were in their typical running pattern, they continued to run at their preferred speed for a minimum of five minutes. After three minutes of running at their preferred running speed, the participant’s step rate was counted and after running for four minutes, video and ground reaction force data were recorded for 60 seconds. All running motion data were recorded using a single high-speed camera at 240 frames per second and ground reaction force data were sampled at 1000 Hz. Mean kinematic values between the left and right extremities for all 10 participants were not significantly different. Consequently, data for the left and right extremities were grouped for all further analyses. The stepwise forward regression to predict vertical ground reaction force resulted in a five-variable model (step rate and four kinematic variables) with R2 = 0.56. The stepwise forward regression to predict average loading rate also resulted in a five kinematic variable model with R2 = 0.51. The authors concluded that step rate and sagittal plane kinematic variables measured using a simplified 2-dimensional motion analysis approach with a single high-speed camera can provide the clinician with a reasonable estimate of ground reaction force kinetics during treadmill running.

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Validity of Hand-Held Dynamometry in Measuring Quadriceps Strength and Rate of Torque Development.
Authors:   Lesnak J, Anderson D, Farmer B, Katsavelis D, Grindstaff TL
A hand-held dynamometer (HHD) offers a reliable and valid method to quantify quadriceps strength in a clinical environment. While measures of peak strength provide functional insights, most daily activities are performed quickly and do not require maximum strength. Rate of torque development (RTD) measures better reflect both the demands of daily activity and athletic movements. The capacity to obtain RTD measures in clinical settings is possible with a HHD, but the validity of RTD measures has not been quantified.  The purpose of this study was to determine the validity of a HHD to measure quadriceps isometric strength metrics compared to isometric strength measures obtained on an isokinetic dynamometer. It was hypothesized that the HHD would be a valid measure of peak torque and RTD at all time intervals when compared to the isokinetic dynamometer. Twenty healthy participants (12 male, 8 female) (age=23.7±2.9 years, height=174.6±10.1 cm, mass=76.4±15.9 kg, and Tegner=6.7 ±1.2) performed maximum isometric quadriceps contractions on an isokinetic dynamometer and with a HHD. Outcome measures included quadriceps peak torque and RTD at three intervals (0-100, 0-250 ms, and average). Pearson product-moment correlation coefficients and Spearman’s rank correlation coefficient were used to determine relationships between devices. The authors found that there was a significant correlation between the isokinetic dynamometer and the HHD for peak torque (p<.001, r=.894) and all RTD measurements (p<.002, r=.807; ρ=.502-.604). Bland-Altman plot LOA indicated the HHD overestimated peak torque values (19.4±53.2 Nm) and underestimated all RTD measurements (-55.2±190.7 Nm/s to -265.2±402.6 Nm/s).  Overall, these results show it is possible to obtain valid measures of quadriceps peak torque and late RTD using a HHD. Measures of early RTD and RTDAvg obtained with a HHD were more variable and should be viewed with caution.

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Defining Lower Extremity Dominance: The Relationship Between Preferred Lower Extremity and Two Functional Tasks.
Authors:  Carcia CR, Cacolice PA, McGeary S
A commonly utilized operational definition of lower extremity (LE) dominance assumes the LE with which a participant prefers to kick a ball with is the same preferred LE a participant would choose for a unilateral landing task. The purpose of this study was to determine the relationship between the preferred lower extremity (LE) when performing a unilateral landing and kicking task. The authors hypothesized a strong correlation between the LE the participant chose for the landing task and the LE the participant chose for the kicking task would be evident. A convenience sample of 50 (age = 21.9±0.9 years; sex = 27 female; 23 male; height = 170.6±10.8 cm; weight = 73.3±18.3 kg) healthy, recreationally active college aged students performed two tasks (kicking a ball; unilateral drop jump landing) in a counterbalanced order.   Thirty-three participants kicked and landed with their right LE; 14 kicked with the right and landed on their left; two kicked and landed with their left and one participant kicked with their left and landed on their right LE. The Phi Coefficient ( p = 0.18) indicated little to no relationship between the preferred LE for kicking a ball and landing from a drop jump. Similarly, the Chi-squared statistic revealed no differences between observed and expected frequencies  (p = 0.23). When studying anterior cruciate ligament injury mechanisms in the laboratory, most investigators examine characteristics of the dominant LE. Dominance is frequently defined by which LE the individual kicks a ball with. The majority of ACL injuries however occur to the landing or plant LE. Hence, LE limb selection based on this approach may be flawed. The authors found that a significant relationship was not evident between the preferred LE for kicking a ball and a unilateral landing in a group of healthy recreationally active college aged students. The data suggests the preferred LE for kicking a ball and a unilateral landing task is not necessarily the same.

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The Modified Star Excursion Balance and Y-Balance Test Results Differ when Assessing Physically Active Healthy Adolescent Females.
Authors:  Bulow A, Anderson J, Leiter J, MacDonald P, Peeler J
The modified Star Excursion Balance Test (mSEBT) and Y-Balance Test (YBT) are two common methods for clinical assessment of dynamic balance. Clinicians often use only one of these test methods and one outcome factor when screening for lower extremity injury risk. Dynamic balance scores are known to vary by age, sex and sport. The physically active adolescent female is at high risk for sustaining lower extremity injuries, specifically to the anterior cruciate ligament (ACL). Thus clarity regarding the use of dynamic balance testing results in adolescent females is important. To date, no studies have directly compared the various outcome factors between these two dynamic balance tests for this population. The purpose of this study was to determine if there was an association between the mSEBT and YBT scores for measured reach distances, calculated composite score and side-to-side limb asymmetry in the ANT direction in physically active healthy adolescent females. Twenty-five healthy, physically active female adolescents (mean age, 14.0 ± 1.3 years) participated. Reach distances, a composite score and side-to-side limb asymmetry for the mSEBT and YBT, for each limb, were compared and examined for correlation. There were significant differences and moderate to excellent relationships between the measured reach directions between the mSEBT and the YBT. Injury risk classification, based on limb asymmetry in the anterior reach direction, differed between the tests. However, the calculated composite scores from the two tests did not differ.  The authors concluded that performance scores on a particular reach direction should not be used interchangeably between the mSEBT and YBT in physically active adolescent females, and should not be compared these scores to previously reported values for other populations.

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Interrater and Test-retest Reliability of the Y-Balance Test in Healthy, Early Adolescent Female Athletes.
Authors:  Greenberg ET, Barle M, Glassman E, Jung MK
Adolescence is the stage of development marked by peak rates of skeletal growth resulting in impaired dynamic postural control and increased injury risk, especially in female athletes.  Reliable tests of dynamic postural control are needed to help identify athletes with balance deficits and assess changes in limb function after injury. The purpose of this study was to estimate the interrater and test-retest (intrarater) reliability of the Y-Balance Test in a group of early adolescent females over a one-month period when administered by novice raters. Twenty-five early adolescent females (mean age 12.7 ± 0.6 years) participated.  Two physical therapy student raters, randomly selected from a pool of five, simultaneously assessed each subject’s performance on the Y-Balance Test and were blinded to each other’s results.  Twenty-one subjects returned for a second session (mean 32.3± 9.6 days) and were assessed by the same two raters, blinded to previous measurements.  Maximum and normalized reach distances and composite scores of the right and left limbs were collected.  Intraclass correlation coefficients (ICC) were calculated for between rater and between session agreement. Measurement error and minimal detectable change values were calculated for clinical interpretation. Interrater reliability was excellent for all reach directions and composite scores of the right limb (ICC 0.973-0.998) and left limb (ICC 0.960-0.999) except for the day 1 left anterior reach which was good (ICC 0.811). Test-retest reliability were moderate to excellent for the right limb (ICC 0.681- 0.908) and moderate to good for left limb (ICC 0.714 - 0.811). Minimal detectable change values for the right and left limbs ranged between 2.02-3.62% and 2.77-3.63%, respectively. The authors concluded that the Y-Balance Test is a reliable tool to assess dynamic balance in early adolescent females and may be utilized in a clinical setting to monitor function over a one-month time interval. Between rater differences were mainly attributed to disparities in subjective test requirements and not quantitative measures of reach distance.

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Efficacy of Perturbation-Enhanced Neuromuscular Training on Hamstring and Quadriceps Onset Time, Activation and Knee Flexion During a Tuck- Jump Task.

Authors:  Letafatkar A, Rajabi R, Minoonejad H, Rabiei P
Deficits in dynamic neuromuscular control of the knee may contribute to the higher injury incidence of the anterior cruciate ligament (ACL), specifically in female athletes. Little is known about the effects of preventive training programs on muscle onset time and activation during functional tasks. The purpose of this study was to evaluate the efficacy of perturbation-enhanced neuromuscular training on hamstring and quadriceps onset time and activation, and knee flexion angle in female athletes with quadriceps dominance (QD) deficit during a tuck-jump (TJ) task. Thirty-one collegiate female athletes with neuromuscular quadriceps dominance deficit randomly divided into experimental (n=16) and control (n=15) group. The experimental group performed a six-week perturbation training (18 sessions). Electromyograhic (EMG) assessment of quadriceps and hamstring activation and knee flexion angles during a TJ task were completed at baseline and after six weeks. A significant decrease in the preparatory(p=0.003) and reactive (p=0.013) quadriceps-hamstring (Q/H) co-activation ratio was found in the experimental group. Perturbation training markedly decreased latency in medial hamstring (MH) (p=0.001), vastus medialis (VM) (p=0.004) and lateral hamstring (LH) (p=0.031), while latency increased for rectus femoris (RF) (p=0.001) and vastus lateralis (VL) (p=0.023) during a TJ task. The experimental group had average increases of 41.1%, 40.8%, and 39.5% in initial knee flexion, peak knee flexion and knee flexion displacement angle during the TJ task, respectively. The authors found increased preparatory VM and MH activities and decreased Q/H co-activation ratio, decreased VM and MH latency represent preprogrammed motor strategies learned during the perturbation training. This observed neuromuscular adaptation during TJ task could potentially reduce the risk for non-contact ACL injury.

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A Novel Test to Assess Change of Direction: Development, Reliability, and Rehabilitation Considerations.
Authors:  Worst H, Henderson N, Decarreau R, Davies G
Several researchers have investigated functional testing with regard to return to sport decision making.  Change of direction activities play a role in the advancement of rehabilitation as an athlete progresses towards return to sport. Few studies have assessed tests that measure change of direction tasks. The primary purpose of this study was to establish test-retest and intra- and inter-rater reliability of performing the Change of Lateral Direction (COLD) test. The second purpose was to provide normative data for healthy college aged subjects performing the COLD test. The final purpose of this study was to assess the role of fatigue while performing lateral change of direction tasks. Thirty-three female and 18 male healthy college students (mean age=25.5) were tested on two occasions, one week apart. Subjects started out standing on a standard 4” step and rapidly altered stepping to tape markers on either side of the step as many times as possible for 30 seconds. The total number of steps achieved in 30 seconds was video recorded and watched later to count steps in order to determine reliability. The effect of fatigue was assessed by subdividing the 30 second trial into three increments: 0-10 seconds (T0-10), 11-20 seconds (T11-20), and 21-30 seconds (T21-30).  Normative data for session 1 and session 2 were 76.0 (+/-10.9) and 80.1 (+/-11.2) steps respectively. Inter-rater (ICC: 0.994-0.996) and intra-rater (ICC: 0.930-0.984) reliability was excellent.  Test-retest reliability demonstrated a strong correlation (r=0.88) between session 1 and session 2. A significant decline (p<0.001) in total number of steps was demonstrated between T0-10 and T21-30, as well as T11-20 and T21-30 during both session 1 and session 2. The COLD test demonstrated excellent inter-rater and intra-rater reliability. A possible fatigue effect occurred at T21-30. Because of the ease of administration, minimal equipment required, and excellent intra and inter-rater reliability, the COLD test provides an excellent functional change of direction test. This test could be used for serial reassessment during pre-season screening, rehabilitation, or return to sport. 

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Injury Incidence in Competitive Cross-Country Skiers: A Prospective Cohort Study.
Authors:  Worth SGA, Reid DA, Howard AB, Henry SM  
Endurance sports, including cross-country skiing, require long hours of repetitive training potentially increasing the chance of injury, yet injury incidence and risk factors for adult cross-country skiers remain relatively unexplored. Data for elite adult north American competitive cross-country skiers is unexplored. A 12-month prospective surveillance study was undertaken to calculate the injury incidence and exposure of cross-country skiers. Injuries by anatomic location and mechanism of injury were calculated. Further, the relationships between new injury and the participant’s demographics and physical assessment parameters were examined. The aims of this study were to determine the injury incidence and any risk factors for injury in elite adult north American cross-country skiers. Elite cross-country skiers (35 men, 36 women) self-reported demographics, injury history, and injury and training surveillance monthly over 12 months. t-tests compared the mean number of injuries per individual, per 1,000 training/exposure hours between anatomic regions, type of injuries, and seasons. Spearman’s correlation analyses tested the relationship between new injury and Movement Competency Screen (MCS) score, past injury, total training time, and running training time. To determine if new injury could be predicted from any demographic data, intake physical measures, or, monthly injury, training and racing data, a regression model was developed. Overall, 58% of participants (18 men, 23 women) completed the study, and reported 3.81 injuries per 1,000 training/exposure hours. Over 12-months, lower extremity injury incidence (2.13) was higher than upper extremity (0.46) and trunk injury incidence (0.22) (p < 0.05). Non-traumatic/overuse injury incidence (2.76) was higher than acute injury incidence (1.05) (p < .05). Non-ski-season injury incidence (5.25) was not statistically higher than ski-season injury incidence (2.27) (p = 0.07). New injuries were positively correlated with previous injury (p < 0.05), but not with any other variables (p > 0.05).  In this year-long monthly survey of injuries and training load in elite adult north American cross-country skiers, new injuries were positively correlated with previous injury. Lower extremity, and non-traumatic/overuse injuries had the highest incidence rates. There was no significant correlation between new injuries and physical assessment parameters or training load.

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Evaluating the Relationship between Clinical Assessments of Apparent Hamstring Tightness: A Correlational Analysis.
Authors:  Hansberger BL, Loutsch R, Hancock C, Bonser R, Zeigel A, Baker RT
Hamstring tightness is a common condition than can be assessed via the active knee extension (AKE), passive straight leg raise (PSLR), V-sit and reach (VSR), and finger-floor-distance (FFD). The purpose of this study was to investigate the relationships between four common clinical tests of apparent hamstring tightness. A secondary purpose was to compare the differences in correlations between sub-groups based on positive test findings.  Recreationally active individuals (N=81; 23.7 ± 5.9 years) performed the AKE, PSLR, VSR, and FFD in a randomized order, and subsequent correlational analyses were conducted.   Strong correlations were identified between the VSR and FFD (r = -.798, r2 = .637, p < .001); moderate correlations were demonstrated between the PSLR and FFD (r = -.565, r2 = .319, p < .001) and PSLR and VSR (r = .536, r2 = .287, p < .001). Low correlations were found between the PSLR and AKE (r = -.284, r2 = .081, p=0.01), AKE and VSR (r = -.297, r2 = .088, p = .007), and AKE and FFD (r = .263, r2 = .069, p = .018). If one assessment was identified in a subject as dysfunctional, all relationships were affected, regardless of which assessment was dysfunctional. The AKE, one of the most common measures for apparent hamstring tightness, has low correlations with the other assessments. Based on the findings of this study, it is possible that not all assessments of AHT are measuring the same phenomena, with each involving different factors of perceived hamstring length.

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The Effect of Novel Ankle Realigning Socks on Dynamic Postural Stability in Individuals with Chronic Ankle Instability.
Authors:  Kobayashi T, Watanabe K, Ito T, Tanaka M, Shida M, Katayose M, Gamada K
A dynamic postural stability deficit has been suggested to be present in individuals with chronic ankle instability (CAI). Interventions to improve postural control in individuals with CAI have been reported, but they required a long period of and compliance with interventions. The purpose of this study was to examine the effect of novel ankle-realigning socks on dynamic postural stability in individuals with CAI using the star excursion balance test (SEBT). Twenty-eight control and 22 subjects with CAI (who were tested in both barefoot and with socks) were enrolled. The weight-bearing ankle dorsiflexion range of motion (DF-ROM) and SEBT were measured in the control group, the barefoot CAI group, and the CAI with socks group. In addition, subjective ankle instability during SEBT was measured using a visual analog scale (0 - 100).  DF-ROM was 48.3 ± 7.4º in the control group, 43.3 ± 8.0º in the barefoot CAI group, and 45.7 ± 6.8º in the CAI with socks group. DF-ROM was significantly less in the barefoot CAI group than in the control group. The SEBT scores were significantly less in the barefoot CAI group than in the control group in all directions. The SEBT score was significantly larger in the CAI with socks group than in the barefoot CAI group in the posteromedial, posterior, and posterolateral directions. In addition, there were no significant differences between the control group and the CAI with socks group in six directions.  The authors concluded that wearing the novel ankle-realigning socks immediately improved dynamic postural stability as measured by the SEBT and subjective ankle instability in individuals with CAI.
 
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Comparison Of Lateral Abdominal Muscle Thickness In Young Male Soccer Players With And Without Low Back Pain.
Authors:  Noormohammadpour P, Mirzaei S, Moghadam N, Mansournia MA, Kordi R
While researchers have investigated low back pain (LBP) and its association with the thickness of trunk muscles in the general population, few articles have studied this relationship in athletes. The purpose of this study was to compare the lateral abdominal muscle thickness and other possible functional risk factors in young soccer players with and without LBP.  Thirty young male soccer players, with and without LBP, from the Premier League participated in this study. The thicknesses of the external oblique, internal oblique and transversus abdominis muscles were measured via musculoskeletal ultrasound imaging, bilaterally. In addition, hamstring flexibility, lumbar spine flexion range of motion, and trunk extensor muscle endurance were measured and were compared in those with and without the history of LBP. The mean age of the subjects was 17.4 (+/- 1.1) years. There was no statistically significant difference between groups (p > 0.05). Subjects with a history of LBP during their lifetime of sports participation (sports life), within the prior year, and within the last month had statistically significant lower external oblique muscle thickness bilaterally (p<0.05). Subjects with a sports life history of LBP had lower internal oblique muscle thickness on both sides (p<0.05). Moreover, those with a sports life history of LBP had significantly less hamstring flexibility than the non-LBP group on the dominant limb (p <0.05). In this sample group of young soccer players, abdominal muscle ultrasound measurements were different between players with and without LBP. Further longitudinal studies are needed to evaluate the role of these muscles as LBP risk factor for soccer players.

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Characterization of Cervical Spine Impairments in Children and Adolescents Post-Concussion.
Authors:  Tiwari D, Goldberg A, Yorke A, Marchetti GF, Alsalaheen B
Patients with concussion may present with cervical spine impairments, therefore accurate characterization of cervical post-concussion impairments is needed to develop targeted physical therapy interventions. The purpose of this study was to characterize the type, frequency and severity of cervical impairments in children and adolescents referred for physical therapy after concussion. A retrospective analysis was conducted for 73 consecutive children and adolescents who received cervical physical therapy following a concussion. Data was classified into six broad categories. The frequency and intensity of cervical impairments within and across the categories was reported.  Ninety percent of patients demonstrated impairments in at least three out of five assessment categories whereas 55% demonstrated impairments in at least four out five assessment categories. Of the five assessment categories, posture (99%) and myofascial impairment (98%) demonstrated highest impairment frequency followed by joint mobility (86%) and muscle strength (62%). Cervical joint proprioception was the least commonly evaluated assessment category.   The authors found a high prevalence of cervical spine impairments was observed in the subjects included in this study with muscle tension, joint mobility, and muscle strength being most commonly affected. The categories of impairments examined in this cohort were consistent with the recommendations of the most recent clinical practice guidelines for neck pain. This study provides preliminary data to support the framework for a cervical spine evaluation tool in children and adolescents following concussion.

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Post-Concussive Changes in Balance and Postural Stability Measured with CaneSense™ and the Balance Error Scoring System (BESS) in Division I Collegiate Football Players: A Case Series.
Authors:  Feigenbaum LA, Kim KJ, Gaunaurd IA, Kaplan LD, Scavo VA, Bennett C, Gailey RS
Impairments in postural stability have been identified following sports-related concussion. CaneSense™ is a recently developed mobile lower limb motion capture system and mobile application for movement assessment which provides an objective measure of postural stability. One of the components within CaneSense™ is the Post-Concussive Excursion Index (PCEI), a measure of postural stability expressed as a percentage of symmetry between lower limbs. The purpose of this case series is to examine pre- and post-concussion differences using two separate measures, CaneSense™, and a known test, the Balance Error Scoring System (BESS), in  Division I collegiate football players.  A convenience sample of eight football players diagnosed with a concussion, were the subjects in this case series. All subjects underwent baseline testing prior to the start of pre-season camp consisting of the single limb stance (SLS) test with CaneSense™ and the BESS test. Twenty-four to 72 hours following their concussion, SLS with CaneSense™ test and the BESS test, were administered. Segmental excursions for the thigh and shank segments for each lower limb were combined into the Post-Concussion Excursion Profile (PCEP), which represents each segment’s maximum excursion in the medial-lateral and anterior-posterior direction.  The PCEI is a single metric generated to quantify differences within subjects by comparing the PCEP value between lower limbs during SLS where 100% suggests absolute symmetry. The PCEI value decreased significantly post-concussion (41.43 ± 15.53% vs. 87.41 ± 6.05%, p < 0.001) demonstrating a 52.6% decrease in inter-limb symmetry when compared to baseline values. There was an unanticipated 36.36% improvement in composite BESS performance post-concussion (10.5 ± 4.87 errors vs. 16.5 ± 8.49 errors, p = 0.10). Differences in inter-limb postural stability were found in subjects post-concussion. By assessing postural stability in both lower limbs individually, using the PCEI, impairments were detected that otherwise would have likely gone undiagnosed using the BESS test alone.

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CLINICAL COMMENTARY
Rehabilitation Following Distal Biceps Repair.
Authors:  Logan CA, Shahien A, Haber D, Foster Z, Farrington A, Provencher MT
Distal biceps rupture is less common than injury to the proximal biceps; however, injury distally has profound functional implications on activities which rely on power during elbow flexion and forearm supination. The majority of distal biceps ruptures can be treated with surgical repair of the distal biceps utilizing either a single or two-incision technique; both of which achieve comparable improved outcomes and reported minimal pain and disability at two years. Safe and effective rehabilitation following distal biceps repair is accomplished through a phased progression, with avoidance of premature stress to the healing soft tissue repair. The purpose of this clinical commentary is to provide a concise review of distal biceps tendon injury, including relevant anatomy, etiology, diagnosis, and operative intervention as well as post-operative factors influencing the pursuit of a criterion based, progressive rehabilitation program after distal biceps tendon repair. This commentary seeks to provide an update on current treatment strategies used in distal biceps rehabilitation with accompanying scientific rationale.

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Rehabilitation Following Subscapularis Tendon Repair.
Authors:  Altintas B, Bradley H, Logan CA, Delvecchio B, Anderson N, Millett PJ  
Subscapularis (SSC) tendon tears are less common than tears of the remaining rotator cuff tendons, but one with serious consequences given its function as one of the main internal rotators and anterior stabilizers. Mild fraying involving the upper third of the tendon can be treated non-operatively; however, more substantive tears usually require repair in cases of pain or functional impairment. Given the importance of the subscapularis tendon in maintaining stability of the glenohumeral joint and performing internal rotation of the arm, surgical intervention with emphasis on repair may be recommended to eliminate pain and restore strength. Postoperative rehabilitation through phased progression is utilized to avoid premature stress on the healing tissue while enabling early return to daily activities. The purpose of this clinical commentary is to provide an evidence-based description of postoperative rehabilitation following SSC tendon repair with guidance for safe and effective return to activity and sports. 

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