VOLUME FIFTEEN NUMBER FOUR

 
2020Masthead_V15N4

August 2020

ORIGINAL RESEARCH
The Reliability of Clinical Balance Tests Under Single-Task and Dual-Task Testing Paradigms in Uninjured Active Youth and Young Adults.  
Authors:  Manaseer TS, Whittaker JL, Isaac C, Schneider K, Roberts MR, Gross DP
Previous researchers have suggested that balance control deficits are detected more accurately with dual-task testing than single-task testing. However, it is necessary to examine the clinimetric properties of dual-task testing before employing it in clinical and research settings. The purpose of this study was to examine and compare the relative and absolute reliability of the Balance Error Scoring System (BESS), Tandem Gait Test (TGT), and Clinical Reaction Time (CRT) under single and dual-task conditions in uninjured active youth and young adults. Twenty-three individuals [9 female; median age 17 years] completed three trials of the BESS, TGT, and CRT under single and dual-task testing conditions during testing session one. Two raters assessed participants to assess inter-rater reliability. Either later on the same day or the following day, the protocol was repeated by one rater to assess intra-rater reliability. The average of three trials was used to calculate intra-rater (between-session) and inter-rater (within-session) intraclass correlation coefficient (ICC), standard error of measurement (SEM), minimal detectable change (MDC), and Cohen’s Kappa coefficient for tests as appropriate under both conditions. Bland-Altman plots (mean difference and 95% limits of agreement) were used to assess for a systematic error associated with a learning effect.  Only one participant attended the second session on the following day, while 22 participants (95%) attended the second session within four hours after testing session one. Under single-task testing, estimated ICCs, SEMs, MDCs, and Kappa coefficients ranged from 0.24 to 0.99, 0.3 to 23, 0.8 to 64, and 0.03 to 0.64, respectively. Under dual-task testing, estimated ICCs, SEMs, MDCs, and Kappa coefficients ranged from 0.70 to 0.99, 0.4 to 17, 1.1 to 47, and 0.39 to 0.83, respectively. A learning effect was identified for all tests under all conditions. The authors concluded that the BESS is the only clinical test that demonstrated acceptable reliability for clinical use under single-task testing conditions. The BESS, TGT, and CRT all demonstrated acceptable reliability for clinical use under dual-task testing conditions. A practice session should be used to reduce the possible learning effect that was seen.  

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The Influence of Visual Fixation on Hop Test Performance.
Authors:   Ness BM, Zimney K, Kernozek T, Schweinle WE, Schweinle A
It has been recognized that anterior cruciate ligament (ACL) injuries typically occur when athletes are attending to a secondary task or object, including teammates, opponents, and/or a goal. Commonly applied tests after ACL injury include a series of hop tests to determine functional status, yet these do not control for visual fixation. The purpose of this study was to examine the influence of visual fixation during two functional hop tests in healthy individuals. Participants performed the crossover triple hop for distance (XHOP) on the left lower limb, and the medial triple hop for distance (MHOP) on the right. For the hop test only conditions, participants were not instructed where to fix their vision while performing the hop test. The visual fixation condition required participants to fix their vision on an alternating plus/minus sign at the center of a display monitor located in front of the participant while performing each hop test, respectively. A re-test session occurred 48-72 hours after the initial test session in order to examine reliability. Thirty-four healthy adults (age: 24.0 ± 3.9 years) completed testing procedures, performing the XHOP and MHOP under standard and visual fixation conditions. Of those participants, twelve completed a retest session for reliability analysis.  Hop distance was not altered by the addition of visual fixation (p = 0.27), with trivial effect sizes found across conditions (d = 0.02 – 0.07); however, the addition of visual fixation slightly improved within- and between-session intrarater reliability, standard error of measurement, and minimal detectable change of the MHOP. Hop distance during the XHOP and MHOP was not influenced by visual fixation.  Measurement of both the XHOP and MHOP was reliable, but lacked precision. Measurement properties for the MHOP including within- and between-session reliability, standard error of measurement, and minimal detectable change improved slightly with the addition of visual fixation compared to normal MHOP procedures.  

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The Influence of Attentional Focus on Landing Stiffness in Female Athletes:  A Cross-Sectional Study.
Authors:  Almonroeder TG, Jayawickrema J, Richardson CT, Mercker KL  
Anterior cruciate ligament injury prevention often involves instructing athletes to reduce landing stiffness. Instructions promoting an external focus appear to result in superior motor performance for a wide range of tasks; however, the effect of attentional focus on landing stiffness has not been examined. The purpose of this study was to compare the influence of instructions promoting an internal focus vs. those promoting an external focus on landing stiffness. It was hypothesized that both types of instructions would reduce landing stiffness vs. landings performed prior to instruction. It was also hypothesized that participants would demonstrate a greater reduction in landing stiffness when provided with instructions promoting an external focus. Sixteen female athletes (basketball, soccer, volleyball) completed drop landings while force and kinematic data were collected. Participants first performed drop landings with their typical technique (baseline). They then received instructions promoting an internal focus and an external focus before performing additional drop landings. Peak force, time-to-peak force, leg stiffness, and hip, knee, and ankle sagittal plane angles were analyzed. Both types of instructions resulted in lower landing forces, less leg stiffness, and greater hip and knee flexion versus at baseline. However, athletes demonstrated more knee flexion at the time of the peak force (59.4 ± 9.6° vs. 56.0 ± 9.5°) and less leg stiffness (69.5 ± 17.9 Nkg-1/m vs. 84.0 ± 38.1 Nkg-1/m) when provided with instructions promoting an external focus, compared to when they were provided with instructions promoting an internal focus. Instructions promoting an external focus appear to result in a greater reduction in landing stiffness. Clinicians should consider providing instructions promoting an external focus when training athletes to reduce lower extremity stiffness during drop landings. The findings from this study may help to inform clinicians involved in movement pattern re-training for female athletes.

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Hand Grip Strength in Senior Athletes: Normative Data and Community-Dwelling Comparisons.
Authors:  Jordre B, Schweinle W
Hand grip strength is supported as a valid physical capacity measure in older adults. Normative values for community-dwelling older adult hand grip strength were recently updated. With the majority of community-dwelling older adults identified as sedentary, it is likely that current norms represent a group that is relatively inactive. A sub-population of senior athletes who actively engage in exercise and competitive sport have consistently demonstrated superior performance on measures of physical capacity when compared to the general population. Normative values for hand grip strength have not been established for this unique group of aging athletes. The purpose of this study was to establish hand grip strength norms for senior athletes and to compare these outcomes to available normative data in community-dwelling older adults.  Measures of hand grip strength were taken on 2,333 senior athletes registered to compete in the National Senior Games between 2011 and 2017. Findings were divided into age and gender categories consistent with community-dwelling norms. Student t tests were used to compare senior athlete means to community-dwelling norms. Cohen’s d was calculated to estimate the effect size of each comparison. Normative values for senior athlete hand grip strength are reported in kilograms by age, gender and hand dominance. For each age and gender category tested, senior athletes demonstrate dominant hand grip strength that ranges from 8.6-11.1 kg higher for males and 5.5 to 8.9 kg higher for females (p values<.0001) than published community-dwelling norms. Non-dominant grip strengths were also significantly higher (p values<.0001). Effect sizes were medium to large (Cohen’s ds = 0.44-1.5). Senior athletes demonstrate hand grip strength that is significantly higher than their community-dwelling peers and more similar to a younger community-dwelling population. The population-specific norms presented here will assist health care providers in more accurately assessing this high-functioning subset of aging adults.

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Analysis of Range of Motion in Female Recreational Tennis Players With and Without Lateral Elbow Tendinopathy.
Authors:  Lucado AM, Dale RB, Kolber MJ, Day JM
Intrinsic factors including altered joint motion in the upper extremity may lead to altered biomechanics in tennis players and could result in symptoms of lateral elbow tendinopathy. The purpose of this study was to compare upper extremity passive motion and elbow carrying angle between three groups of women: recreational tennis players with LET, non-symptomatic recreational tennis players, and a control group of non-tennis players. A convenience sample of 63 women was recruited and placed into one of the three groups: non-symptomatic tennis players (NSTP), symptomatic tennis players (STP), and a control group. Elbow carrying angle, passive range of motion of the shoulder, elbow, forearm, and wrist were measured during a single session. A significant difference was found between the groups for wrist flexion (p=0.00), forearm pronation (p =0.002), elbow flexion (p =0.020) and extension (p =0.460), as well as shoulder internal rotation (p = 0.00). No significant differences were found in other motions or carrying angle between the three groups (p =0.059). Post-hoc comparisons indicated that shoulder internal rotation and wrist flexion was less in both STP and NSTP groups compared with the control group. Elbow flexion and forearm pronation were greater in STP than the other two groups. Impairments including loss of shoulder internal rotation and wrist flexion and greater motion at the elbow and forearm were found in the UE of symptomatic tennis players. Evaluation of passive motion and muscle length should be performed prior to establishing a rehabilitation plan for symptomatic tennis players.

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The Relationship Between Chronic Low Back Pain and Physical Factors in Collegiate Pole Vaulters: A Cross-Sectional Study.
Authors:  Enoki S, Kuramochi R, Murata Y, Tokutake G, Shimizu T  
The low back is the most common injury location in pole vaulters, and low back pain (LBP) can easily become chronic. Therefore, knowing the physical characteristics of athletes experiencing repeated LBP may be beneficial for recovery and injury prevention. The purpose of this study was to describe and analyze the physical characteristics of pole vaulters with chronic LBP. Twenty male pole vaulters participated in this study. A questionnaire was used to garner descriptive and personal data, including personal best performance in the pole vault.  Additionally, the following physical characteristics were measured: 1) isokinetic muscle strength of hip and knee flexors and extensors, 2) active/passive range of motion and muscle flexibility in multiple joints and regions, 3) performance on the Functional Movement Screen™ (FMS™) and 4) spinal column alignment. Subjects were categorized using the questionnaire and divided into two groups, one with and one without chronic LBP.  The personal best performance and angle on the active straight leg raise test (SLR) were significantly lower and smaller, respectively, in the chronic LBP group than in the non-chronic LBP group. Additionally, the difference between the passive SLR angle and active SLR angle (∆SLR) was significantly larger in the chronic LBP group than in the non-chronic LBP group. Those with chronic LBP had were more likely to have a FMS™ composite score ≤14. The active SLR angle and ∆SLR were significantly smaller and larger, respectively, in the chronic LBP group than in the non-chronic LBP group. This may be because of the poor stability of trunk or incompetence of the kinetic chain required for raising the lower limbs. The chronic LBP group had a significantly higher probability of having an FMS™ composite score of ≤14. it may be important to examine the active straight leg raise (vs. passive only), and fundamental movements as screened by the FMS™ in pole vaulters.

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Functional Movement and Dynamic Balance in Entry Level University Dancers.
Authors:   Misegades J, Rasimowicz M, Cabrera J, Vaccaro K, Kenar T, DeLuccio J, Stapleton D
Dance requires integration and synergy between movement, postural stability, and body alignment to effectively execute the technical and aesthetic requirements of the performance. Evaluation of movement competency and dynamic balance provides opportunity to identify dysfunctional movement which may negatively impact both artistic and technical aspects of dance performance. Investigation of the relationships between movement competency and postural control may aid in technical development, performance improvement, and ultimately injury reduction. Although the Functional Movement Screen™ (FMS™) and Y-Balance Test (YBT) have assessed movement competency in athletes, they have not been used extensively in the performing arts. The purposes of this investigation were to examine movement competency in university dancers using the FMS™ and YBT and to determine the relationship between functional movement and dynamic balance. Fifteen, injury-free, female members (19.1 ± 1.18 years old) of an introductory university ballet class volunteered to participate. Pearson product correlations were used to determine relationships between variables.  The mean composite FMS™ score was 15.32 ± 2.30.  Shoulder mobility (SM) (r=0.63, p=0.01), In-line lunge (ILL) (r=0.64, p=0.01), and Deep Squat (DS) (r=0.62, p=0.01) were correlated with composite FMS™ score. Overall composite YBT score was 86.62% ± 8.17%.   Reach asymmetry was 3.25 cm ± 3.53 cm (anterior), 4.06 cm ± 3.59cm (posteromedial (PM)), and 3.28cm ± 2.61cm (posterolateral (PL)). Composite FMS™ score was not correlated with composite YBT composite score (r=0.44, p=0.10). A moderate to good correlation was found between the ILL and YBT composite score (r=0.64, p=0.01).  Collectively the results indicate the FMS™ and YBT do not measure the same constructs. However, the associations between individual components of the FMS™ and YBT indicate a relationship between certain movements and dynamic balance, supporting their combined use in a dancer injury risk management program.  

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Fear-Avoidance and Self-Efficacy Psychosocial Factors Are Altered After Partial Meniscectomy and Associated With Rehabilitation Outcomes.
Authors:  Hsu CJ, George SZ, Chmielewski TL
Little research has examined how psychosocial factors change over time and influence rehabilitation outcomes following meniscectomy. This information can inform the need to assess and address psychosocial factors in meniscectomy rehabilitation. The purpose of this study was to examine changes in fear-avoidance and self-efficacy psychosocial factors from pre-surgery to one year after meniscectomy and their associations with rehabilitation outcomes. The hypothesis was that psychosocial factors would improve following meniscectomy, and less improvement in psychosocial factors would be associated with less improvement in rehabilitation outcomes. Twenty-five patients with partial meniscectomy participated.  Testing time points were pre-surgery, after post-surgical rehabilitation, and one-year post-surgery. Fear avoidance (pain catastrophizing and kinesiophobia) and self-efficacy (knee-related activity) psychosocial factors were assessed with the Pain Catastrophizing Scale (PCS), the Tampa Scale for Kinesiophobia (TSK-11), and Knee Activity Self-efficacy (KASE) questionnaires; respectively. Rehabilitation outcomes were quadriceps strength, evaluated with isokinetic testing at 60°/sec; knee pain, measured with the Numeric Pain Rating Scale (NPRS); and self-reported knee function, measured with the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF). PCS scores improved from pre-surgery to after post-surgical rehabilitation, while TSK-11 and KASE scores improved from pre-surgery to after post-surgical rehabilitation and from after post-surgical rehabilitation to 1-year post-surgery. Pre-surgery PCS and KASE scores were associated with 1-year post-surgery NPRS score (r=0.50) and quadriceps peak torque (r=0.48), respectively. From pre-surgery to 1-year post-surgery, change in TSK-11 score was associated with change in NPRS score (r=0.65), and change in KASE score was associated with change in IKDC-SKF score (r=0.44). From pre-surgery to after post-surgical rehabilitation, changes in TSK-11 and KASE scores were associated with changes in NPRS (TSK-11, r=0.47; KASE, r=-0.50) and IKDC-SKF scores (TSK-11, r=-0.39; KASE, r=0.71). From after post-surgical rehabilitation to 1-year post-surgery, changes in KASE score was associated with changes in IKDC-SKF score (r=0.59). Assessment of pain catastrophizing and knee activity self-efficacy pre-surgery might help to identify patients at risk for sustained knee pain and quadriceps muscle weakness. Decreasing kinesiophobia and increasing knee activity self-efficacy were associated with improved knee pain and function.  

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A Four-Week Training Program with the Nordic Hamstring Exercise During Preseason Increases Eccentric Strength of Male Soccer Players.
Authors:  Oliveira NT, Medeiros TM, Vianna KB, Oliveira GDS, Ribeiro-Alvares JBDA, Baroni BM
The Nordic hamstring exercise (NHE) is an effective strategy to prevent hamstring strain injuries in soccer players. The current literature recommends a 10-week training program with three sessions per week, but the short preseason period and the congested schedule make difficult for high-performance soccer teams to apply the NHE as recommended. The purpose of this study was to examine the effect of a pragmatic NHE training program during a four-week preseason period on eccentric knee flexor strength of high-performance soccer players. This study included 25 under-20 male soccer players from a premier league club. They performed eight sessions of NHE (3 sets of 6-10 repetitions, twice a week) during the four-week preseason period. The eccentric knee flexor strength was evaluated during the NHE execution on a custom-made device, before and after the training program. The NHE training program significantly increased the players’ eccentric knee flexor strength in both right (∆=13%; p<0.001; effect size=0.97) and left limbs (∆=13%; p<0.001; effect size=0.92). Individual analysis identified 76% of the players as responders to the NHE training program (∆=16%; effect size=1.60), and 24% as non-responders (∆=3%; effect size=0.24). A four-week training program with NHE performed twice a week is feasible in the real-world of high-performance soccer clubs and increases the eccentric knee flexor strength of male soccer players.

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Acute Outcomes of Myofascial Decompression (Cupping Therapy) Compared to Self-Myofascial Release on Hamstring Pathology After A Single Treatment

Authors:  Warren AJ, LaCross Z, Volberding JL, O’Brien MS  
Myofascial decompression (MFD), or cupping, and self-myofascial release (SMR) are common techniques utilized to treat soft tissue injuries and increase flexibility.  MFD is a negative pressure soft tissue treatment technique using suction to manipulate the skin and underlying soft tissues. One method of SMR is a foam roller, where a patient rolls his/her bodyweight over a dense foam cylinder in a self-massaging fashion to mobilize soft tissues for the body part treated. The purpose of this investigation was to examine the acute effects on hamstring flexibility and patient-rated outcome measures comparing two soft tissue treatments, 1) MFD, and 2) a moist heat pack with SMR using a foam roller in patients with diagnosed hamstring pathology. Seventeen collegiate athletes [13 males (20.6+/- years; 184.9+/-cm; 90.8+/-kg) and 4 females (20.5+/-years; 167.1+/-cm; 62.7+/-kg)] with diagnosed hamstring pathology (mild strain and/or symptoms of tightness, pain, decreased strength, and decreased flexibility) were randomly assigned to receive MFD or SMR. The MFD group (n=9) received three minutes of static treatment using six plastic-valve suction cups along the hamstrings followed by 20 repetitions of active movement with cups in place. SMR (n=8) received 10 minutes of heat treatment over the hamstrings followed by 60 seconds of general mobilization over the entire hamstring area, and 90 seconds of targeted foam rolling on the area of most perceived tightness.  Passive hamstring flexibility (ROM) and a patient-rated outcome measure [Perceived Functional Ability Questionnaire (PFAQ)] were assessed before and immediately after treatment. The Global Rating of Change measure (GROC) was administered post-intervention. Passive ROM and subjective PFAQ measures for overall flexibility and flexibility of the hamstrings were significantly different from pre- to post-intervention measurements regardless of the treatment received. A significant difference was found in favor of the MFD group for the GROC values. The findings suggest that both treatments are beneficial in increasing hamstring length. Patients though felt an enhanced treatment effect using MFD over SMR for perceived benefits to hamstring flexibility.   

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Investigation of Primary and Second Anterior Cruciate Ligament Tears Using a Geographic Database.
Authors:  McMurray NS, Bates NA, Fischer S, Schilaty ND, Hewett TE  
The incidence of anterior cruciate ligament (ACL) injuries has been estimated at 1 in 3500 individuals in the literature. Second ACL tears represent 7-14% of all ACL tears. The location of ACL tears has been noted to be primarily proximal. The purpose of this study was to corroborate previous data as well as to add novel data to the literature regarding the location of ACL tears, risk factors associated with second ACL tears, and correlation between hearing a “pop” at the time of injury and concomitant injuries. A geographic database containing the medical records of individuals in a rural county in the midwestern portion of the USA was utilized to identify ACL injuries that occurred in the county from 2011 to 2016. A total of 743 ACL injuries were identified, which were reviewed and stratified by primary and second tears, sex, race, age, activity level, number of “pops” heard at time of injury, side of injury, location of tear, graft type used in reconstruction, location of fixation, and concomitant injuries. ACL tear location was noted to be primarily midsubstance (44.1%) or proximal (34.1%). The majority of individuals (56.3%) who reported hearing “multiple pops” at the time of injury sustained multiple types of concomitant injuries. The incidence of second ACL tears was 16.8% of total ACL injuries. Second ACL tears were associated with multiple factors, including tear type (p <0.015) and tear location (p <0.022). When comparing primary versus second ACL tears, no significant difference in concomitant injuries was noted. The majority of ACL tears (78.2%) occur in the midsubstance or proximal fibers. Hearing multiple “pops” at the time of injury may be associated with more concomitant injuries. The incidence of second ACL tears in this population was comparable to previous studies. Second ACL injuries differed statistically from primary injuries in association with tear type and location.

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Knowledge of Vestibular Ocular Dysfunction and Utilization of Vestibular Ocular Motor Screening (VOMS) Tool Components Among Professional Sports League Athletic Trainers.
Authors:  Bliss RA, Carr WD  
The Vestibular Ocular Motor Screen (VOMS) is a relatively new measurement tool intended for the non-vestibular practitioner to identify vestibular ocular dysfunction (VOD) following sport related concussion (SRC). Specific knowledge of VOD and usage of the VOMS among athletic trainers in professional sports leagues is currently unknown. The purpose of this study was to examine knowledge of VOD following SRC and utilization of the VOMS tool and other vestibular ocular tests and measures among athletic trainers in professional sports. A total of 117 athletic trainers from Major League Baseball, the National Basketball Association, the National Football League and Major League Soccer, with a mean of 17 ± 9 years in the athletic training profession were surveyed via Qualtrics™ with a response rate of 33%. The survey contained three primary sub-sections; demographics, knowledge of vestibular ocular deficits following SRC, and VOMS component utilization at baseline, acute and return-to-play phases of management. Total knowledge scores as well as percentage of utilization based on concussion management stages were calculated.  The average percentage correct on the knowledge items was 56% (range of 30% to 65%).  There was no difference in knowledge score among athletic trainers with formal post-professional concussion training (p =0.29) compared to those with no formal training. There was no relationship found between total years practicing and total knowledge score, r= -.128, (p = 0.17). Smooth pursuit testing was the most commonly utilized (70%) in clinical practice and Visual Motion Sensitivity (VMS) was the least utilized (17%).  Balance assessment measures to examine vestibular functioning remained the highest utilized examination technique at all-time points in management of SRC. The range of correct responses from 30% to 65% indicates that at the time of survey the participants had decreased knowledge of VOD following SRC. There was low overall utilization of all VOMS components despite recent evidence showing good sensitivity and low false positive rates in SRC. The results of this study identify an opportunity for future training specific to vestibular-ocular impairments and assessment following concussion injury.  

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CLINICAL COMMENTARY
A Ten Task-Based Progression in Rehabilitation After ACL Reconstruction: From Post-Surgery to Return to Play – A Clinical Commentary.
Authors:  Buckthorpe M, Della Villa F
There is a need to improve patient outcomes after anterior cruciate ligament reconstruction (ACLR). To do this likely involves a strong focus on optimizing rehabilitation processes and practices. Movement re-training is considered an important element of rehabilitation after ACLR, but there is a lack of knowledge on the ‘how’ and ‘what’ movement re-training should occur after ACLR. In its basic form, movement re-training after ACLR is about progressing a patient through gradually more demanding tasks from the point of being able to walk to being able to perform highly complex sports movements. However, there is a lack of guidance on when to implement certain tasks (e.g. when to begin running) and how to transition between tasks. This commentary presents a 10 task progressions system which can form an important aspect of the movement-based re-training process, providing structure and patient autonomy. Monitoring knee function and movement and neuromuscular status to safely transition between these tasks is important. Although this task-based progression is designed for patients following a rehabilitation program after ACLR, it may have generalizability for all major lower limb injuries. The task-based progression was formed by combining theory, the best available evidence, and significant practice experience applied to movement re-training after ACLR. This approach supports patient autonomy, medical team communication and collaboration and can provide structure to the movement re-training process.

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Return to Sport Participation Criteria Following Shoulder Injury: A Clinical Commentary.
Authors:  Wilk KE, Bagwell MS, Davies GJ, Arrigo CA
The shoulder complex is frequently injured during sports. The tremendous mobility of the shoulder makes returning to sport participation following shoulder injury a challenging task for both the clinician and athlete. Return to sport decision making is a sequential, criterion-based process. Assessment of patient reported outcomes, range of motion, strength, and functional performance must all be considered. Numerous tests are available for the clinician to determine whether a patient is ready to return to sports following a shoulder injury or surgery. A different set of tests should be utilized for the overhead athlete (microtrauma injury) compared to the patient with a macrotraumatic shoulder injury because of the differing demands and sports requirements. Use of pre-determined criteria, available in the literature, minimizes the reliance on the subjective element alone during takes athlete progression and provides everyone involved in the process with known, pre-established, measurable markers and goals that must be achieved prior to progressing to practice and returning to competition. This type of performance progression assessment testing provides the clinician with a useful set of tools to objectively assist and guide the determination regarding when an athlete can safely progress back to practice and then return to unrestricted athletic activities. The purpose of this clinical commentary is to review the current literature on return to sport criteria and provide evidence-informed and clinically useful guidelines and recommendations to aid in clinical decision making for return to sports after shoulder micro- and macro-traumatic injuries.

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CLINICAL SUGGESTION
Functional Joint Mobilizations for Patellofemoral Pain Syndrome: A Clinical Suggestion.

Authors:  Jayaseelan DJ, Holshouser C, McMurray MW
Patellofemoral pain syndrome (PFPS) is often effectively managed with appropriate exercise prescription, yet in many cases PFPS related symptoms can become persistent and result in reduced daily, functional and sport-related activity levels. Patellofemoral mobilizations may be incorporated to minimize the impact of mobility deficits, and are frequently performed in the patellofemoral joint’s open-packed position of knee extension. However, many individuals with PFPS have pain during weight-bearing activities requiring knee flexion such as stairs, squatting, or running. Therefore, it seems reasonable that utilizing joint mobilizations in more symptomatic functional positions may enhance treatment plans. The purpose of this clinical suggestion is to present patellofemoral joint mobilization options in positions more closely replicating positions of symptom provocation, in an effort to offer clinicians different intervention strategies for the challenging condition of PFPS.

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