Post-Operative Sport Participation and Satisfaction With Return To Activity After Matrix-Induced Autologous Chondrocyte Implantation In The Knee
Authors: Ebert JR, Janes GC, Wood DJ
Returning to a satisfactory activity level is expected by patients after cartilage repair, and may define overall surgical success. The purpose of this study was to investigate: 1) the level and improvement in activity in patients at two years after matrix-induced autologous chondrocyte implantation (MACI), 2) what factors are associated with post-operative (and improvement in) activity level, and 3) whether patients are satisfied with their ability to participate in recreational and/or sporting activities. One hundred and fifty patients that underwent MACI were included in this analysis (83 tibiofemoral and 67 patellofemoral). All patients completed the Tegner Activity Scale (TAS) and the Knee Injury and Osteoarthritis Outcome Score (KOOS) pre-surgery and at two years (range: 24-26 months) post-surgery, as well as a questionnaire evaluating satisfaction with their ability to return to recreational and sporting activities. The TAS significantly improved (p<0.001) from 2.97 (SD 0.92, range 0-7) to 4.09 (SD 1.49, range 0-9), while the KOOS Sport significantly improved (p<0.0001) from 27.5 (SD 23.1, range 0-95) to 61.1 (SD 27.3, range 0-100). Overall, 88 patients (59%) improved ≥1 point on the TAS, while 121 patients (81%) improved ≥10 points on the KOOS Sport, previously reported as the minimal detectable change for each. Patient age, duration of symptoms (DOS) and gender were associated with post-operative activity level, though body mass index (BMI), defect size and concomitant procedures were not. Overall, 128 patients (85%) were satisfied with their ability to return to recreational activities, with 99 (66%) satisfied with sport participation. The two-year TAS, and TAS improvement, were significantly associated with satisfaction in performing recreational activities (two-year TAS, rho=-0.42, p<0.0001; TAS improvement, r=-0.33, p<0.0001) and sport participation (two-year TAS, rho=-0.49, p<0.0001; TAS improvement, r=-0.37, p<0.0001). The authors concluded that the TAS and KOOS Sport significantly improved after MACI, though only 59% of patients improved ≥1 point on the TAS. Despite this, 85% and 66% of patients were satisfied with their ability to return to recreational activities and participate in sport, respectively. Age, DOS and gender were associated with activity, and overall these findings can be used to provide realistic activity expectations to patients undergoing MACI.Abstract | Full Article (subscribers only) | Purchase Article
Authors: Courtney CA, Aoyagi K, Fernandez-de-la-Penas C, Madeleine P
Unaccustomed eccentric exercise during sport or training may lead to delayed onset muscle soreness (DOMS), which has been demonstrated to influence postural control, potentially resulting in further injury. Afferent sensory input is critical to effective postural control, but little is known about somatosensory changes at the knee following induction of DOMS of the quadriceps muscle. The ‘soreness’ or hyperalgesia associated with DOMS has been postulated to occur because of damage to/inflammation of the exercised muscle, however, effects on central nociceptive mechanisms, which are known to induce altered postural responses, have been less studied. In this study, it was hypothesized that DOMS of the quadriceps muscle would result in widespread hyperalgesia and hypoesthesia at the knee. Therefore, the purpose of this study was to investigate the effects of DOMS on knee somatosensory changes in asymptomatic healthy participants. Thirty participants (15 males and 15 females) took part in the study. Eccentric exercise consisted of 10 sets of 10 maximum eccentric quadriceps contractions performed with the dominant knee. Outcome measures consisted of pain intensity (Visual Analog Scale), pressure pain threshold (PPT), vibration perception threshold (VPT) and proprioception, measured via threshold to detection of passive motion (TDPM) at the knee, at three different assessment time points: (1) pre-eccentric exercise; (2) immediately and (3) 48 hours post-eccentric exercise. Not surprisingly, pain intensity increased and PPT of the vastus medialis and rectus femoris muscles decreased (hyperalgesia) immediately post-exercise on the exercised limb. However, at 48 hours, hyperalgesia was demonstrated at other lower extremity muscles, including bilaterally at the tibialis anterior muscles, and also at the hand. Evidence of hypoesthesia was also demonstrated. VPT and TDPM increased (worsened) ipsilaterally both immediately and 48 hours after exercise, and TDPM increased bilaterally at 48 hours. Females demonstrated greater impairment in TDPM than males at 48 hours. Expanding distribution of hyperalgesia, ipsilaterally impaired VPT and bilaterally impaired proprioception were demonstrated in the presence of DOMS. Inflammation from unaccustomed eccentric exercise may induce neuroplastic changes in nociceptive pathways resulting in wider distribution of pain and hypoesthesia. Abstract | Full Article (subscribers only) | Purchase Article
The Influence of Hip Joint Angle on the Ratio Between Adduction and Abduction Torque In Experienced, Recreational Male Ice Hockey Players
Authors: Welsch P, Howitt S, Howarth SJ
Strains of the adductor muscle group of the hip are common amongst ice hockey players. The ratio of isometric strengths between the hip adductors and abductors has been offered as a risk factor for hip adductor strain; however, there is no description for how the ratio between hip adductor and abductor strength varies as a function of hip abduction angle. The aim of this study was to determine the influence of hip joint abduction angle on measured ratios of hip adduction to abduction torque in experienced, recreational, male hockey players. The primary null hypothesis for this study was that hip joint abduction angle would not influence hip adduction-to-abduction torque ratios in male hockey players. Twelve uninjured, male, recreational hockey players, with a minimum experience level of midget AAA/minor competitive or equivalent. Participants performed maximal isometric side-lying hip adduction and abduction exertions against a rigidly constrained load cell at 0, 10, and 20 degrees of hip abduction. Measured peak torques from each exertion were used to derive the hip adductor-to-abductor torque ratio. Kinematics of the trunk, pelvis, and lower limbs were monitored using an optoelectronic motion capture system. Adductor-to-abductor torque ratio increased from 1.49 (SD = 0.20), to 1.92 (SD = 0.20) and to 2.30 (SD = 0.54) with successively increasing hip abduction angle (p < 0.001). Peak torque was significantly different between all angles (p ≤ 0.016) except between adduction exertions performed at 10 and 20 degrees of abduction (p = 0.895). Small changes in hip angle during the exertion were coincident with exertion direction, which confirmed the isometric nature of the task. The authors concluded that the hip abduction angle has a significant impact on the measured adductor-to-abductor torque ratio. The ratio increased due to a combination of increased adductor torque and decreased abductor torque as the hip abduction angle increased.Abstract | Full Article (subscribers only) | Purchase Article
Authors: Jagger K, Frazier A, Aron A, Harper B
The Modified Star Excursion Balance Test (MSEBT) and the Y-Balance Test- Lower Quarter (YBT-LQ) are utilized to assess dynamic postural stability. These assessments cannot be used interchangeably secondary to kinematic variations and performance differences. A Modified Y-Balance Test-Lower Quarter (MYBT-LQ) was developed to determine if a modification allows performance scores to be directly compared to the MSEBT. The purpose of this research was to determine if reach distances were similar for young, healthy individuals between three different balance tests: the YBT-LQ, the MYBT-LQ, and the MSEBT. Twenty-eight participants (17 males, 11 females) were recruited from a convenience sample of young, healthy adults. Participants completed all testing within a single session and performed three trials in each direction, on each leg, for all balance tests. Scoring performance was calculated for each balance test using the average normalized reach distance in the anterior, posterolateral, and posteromedial directions. A one-way ANOVA was used to compare between-subject posteromedial and posterolateral scores, while anterior scores were analyzed using a Kruskal Wallis test. The intraclass correlation coefficient (ICC) was used to determine within-subject participant performance reliability. Analyses indicated significant differences in the posterolateral and posteromedial reach directions between the YBT-LQ and MSEBT and between the MYBT-LQ and MSEBT, while no significant difference was found between the YBT-LQ and MYBT-LQ in any direction. No anterior reach differences were noted between any of the tests. Within-subject ICCs showed a very strong level of agreement between right and left anterior and right posteromedial reaches between all three tests, while only the YBT-LQ and MYBT-LQ demonstrated very strong agreement in all directions. The authors concluded that the reach performance on the MSEBT differed from the performance on the YBT-LQ and MYBT-LQ in the anterior, posteromedial and posterolateral directions in this population. These findings further support the difference in motor control strategies used during these tests.Abstract | Full Article (subscribers only) | Purchase Article
Authors: Seeber GH, Lierly M, Bassett C, Douthit C, Wilhelm M, Matthijs A, Matthijs O, Lazovic D, Brismee JM, Gilbert K, Sizer P
Due to the lack of verifiable iliotibial band elongation in response to stretching, the anatomical, biomechanical, and physiological responses to treatment of iliotibial band syndrome remain unclear. The lateral intermuscular septum, consisting of multiple myofibroblasts, firmly anchors the iliotibial band to the femur. The purpose of this in-situ study was to examine the constraining effect of the lateral IMS on available passive hip adduction range of motion in un-embalmed cadavers. It was hypothesized that an iliotibial band-septum-complex release would significantly increase passive hip adduction. Metal markers were inserted into selected anatomical landmarks in eleven un-embalmed human cadavers. With the specimen supine, the test-side lower limb was passively adducted until maximum passive hip adduction was reached. This movement was repeated three times each within two conditions: (1) band-septum-complex intact and (2) band-septum-complex dissected. Digital video of marker displacement was captured throughout each trial. Still images from a start and an end position were extracted from each video sequence. A custom Matlab program was used to calculate frontal plane hip adduction angle changes from obtained images. Mean change in passive hip adduction after band-septum-complex release was -0.3° (SD 1.6°;95% CI: -1.33,0.76). A paired samples t-test revealed a non-significant difference (t=-.611; p=.555) in passive hip adduction for the band-septum-dissected condition (18.8±3.9°) versus the band-septum-intact condition (18.5°±4.7°). The authors concluded that the lateral intermuscular septum does not appear to have a constraining effect on passive hip adduction in un-embalmed cadavers.
Abstract | Full Article (subscribers only) | Purchase ArticleBiomechanical Matching of Low Back External Demands During The Open- and Closed-Chain Side Bridge
Authors: Tuff T, Beach T, Howarth SJ
The side-bridge (SB) is a commonly used closed-chain task to assess trunk muscle endurance and side-to-side endurance asymmetry. An open-chain variation of the SB, that positions the participant in an inclined side-lying posture, may be useful for those who report shoulder pain or fatigue as the reason for terminating the closed-chain SB. Low back loading demands of the open- and closed-chain variations should be matched to facilitate comparison of SB endurance measures. The purpose of this study was to quantify the low back reaction moments during the open- and closed-chain SB and determine the appropriate open-chain angle of inclination that matches the lateral bend moment magnitude of the closed-chain SB. Upper body and trunk postural data were obtained during the closed-chain SB and during the open-chain SB at each of four inclination angles from a group of eight healthy male adults. Ground reaction force (GRF) data were also collected during the closed-chain SB. Low back reaction moments were calculated using a static ‘top-down’ linked segment model in both SB variations. Latent growth modeling was used to determine the angle of inclination in the open-chain SB that produced a low back lateral bend moment that matched the closed-chain SB. Sensitivity of the matching open-chain inclination angle was evaluated by rotating the measured GRF vector from the closed-chain SB by five degrees clockwise and counter-clockwise in the frontal plane. The open-chain inclination angle that best matched the loading demands of the closed-chain SB was 38±12 degrees. Clockwise rotation of the measured GRF in the closed-chain SB increased the matching inclination angle to 56±17 degrees. Counter-clockwise rotation reduced the matching inclination angle to 17±11 degrees. Secondary descriptive analysis of spine posture and off-axis low back moments revealed biomechanically relevant differences between SB positions. The authors found that the average open-chain SB angle of inclination matched the closed-chain SB approximated the 45-degree recommendation offered in the literature. Differences in spine posture and off-axis low back reaction moments, and the potential impact on holding times, should be considered if using the open-chain SB.Abstract | Full Article (subscribers only) | Purchase Article
Authors: Howe LP, Bampouras TM, North JS, Waldron M
The identification of asymmetrical inter-limb ankle dorsiflexion range of motion (DF ROM) has the potential to influence the course of treatment during the rehabilitation process, with limitations in ankle DF ROM potentially increasing injury risk. However, reliability for methods to identify ankle DF ROM asymmetries remain under described in the literature. The purpose of this study was to determine the reliability of the trigonometric calculation method for measuring ankle DF ROM during the weight-bearing lunge test (WBLT) for both a single limb and the symmetry values. The secondary purpose was to establish values of ankle DF ROM asymmetry and identify the influence of leg dominance on ankle DF ROM. Ankle DF ROM was measured bilaterally in 50 healthy and recreationally active participants (28 men, 22 women, age = 22 ± 4 years, height = 172.8 ± 10.8 cm, body mass 71.5 ± 15.1 kg), using the trigonometric measurement method during the WBLT. Each ankle was measured twice in a single testing session to establish within-session reliability. Values are presented for asymmetries in DF ROM. No differences were identified between the dominant and non-dominant limb (p = 0.862). Within-session reliability for measuring a single limb was classified as ‘good’ (ICC = 0.98) with a minimal detectable change value of 1.7°. For measuring ankle DF ROM asymmetry, reliability was established as ‘good’ (ICC = 0.85) and a minimal detectable change value of 2.1° was determined. Although symmetry in ankle DF ROM may not be assumed, the magnitude of asymmetry may be less than previously reported in a population of recreationally active individuals. Discrepancies between previous research and the findings of the present study may have been impacted by differences in measurement methods. Furthermore, clinicians should be aware that the error associated with measures of asymmetry for ankle DF ROM during the WBLT is greater than that of a single limb.
Abstract | Full Article (subscribers only) | Purchase ArticleLower Extremity Aerobic Exercise as a Treatment for Shoulder Pain
Authors: Wassinger CA, Lumpkins L, Sole G
Shoulder girdle pain is a common disabling complaint with a high lifetime prevalence. Interventions aimed at decreasing shoulder pain without stressing shoulder girdle structures have the potential to improve participation in multimodal shoulder rehabilitation programs. The aim of this study was to determine the acute effects of moderate intensity lower extremity exercise on mechanically induced shoulder pain in individuals without shoulder injury. It was hypothesized that participants would exhibit less shoulder pain, as indicated by increased pain thresholds, following lower extremity exercise. Thirty healthy participants were recruited to participate in this study. Pain pressure algometry was used to mechanically induce shoulder pain over the infraspinatus muscle belly. This was performed on the dominant shoulder before and immediately after performing 10 minutes of moderate intensity lower extremity exercise using a recumbent exercise machine. Heart rate and rate of perceived exertion were measured following exercise. Repeated measures ANOVA was used to compare pain pressure threshold scores between the baseline and post-exercise time points. Significance was set at p ≤ 0.05 a priori. Effect size (ES) was calculated using Glass’s Delta. Moderate intensity lower extremity aerobic exercise led to significantly (F=8.471, p=0.003) decreased evoked shoulder pain in healthy adults with moderate effect sizes (0.30-0.43). The authors found that lower extremity aerobic exercise significantly decreased pain of the infraspinatus in this sample of young healthy participants. Utilization of lower extremity exercise may be of benefit for younger patients to decreased acute shoulder pain.Abstract | Full Article (subscribers only) | Purchase Article
Authors: Halle R, Crowell M, Goss D
Post-operative range of motion (ROM) loss and pain can limit quality of life, prolong functional return to activity, and may be sport/career threatening. Dry needling (DN) is intended assist in the treatment of these complaints. The purpose of this study was to determine if the addition of upper quarter DN to a rehabilitation protocol is more effective in improving ROM, pain, and functional outcome scores when compared to a rehabilitation protocol alone after shoulder stabilization surgery. Thirty-nine post-operative shoulder patients were randomly allocated into two groups: (1) standard of care rehabilitation (control group) (2) standard of care rehabilitation plus dry needling (experimental group). Patients pain, ROM, and functional outcome scores were assessed at baseline (4 weeks post-operative), and at 8 weeks, 12 weeks, and 6 months post-operative. Of 39 enrolled patients, 20 were allocated to the control group and 19 to the experimental group. At six-month follow up, there was a statistically significant improvement in shoulder flexion ROM in the control group. Aside from this, there were no significant differences in outcomes between the two treatment groups. Both groups showed improvement over time. No adverse events were reported. The authors concluded that dry needling of the shoulder girdle in addition to standard of care rehabilitation after shoulder stabilization surgery did not significantly improve shoulder ROM, pain, or functional outcome scores when compared with standard of care rehabilitation alone. Both groups improvement was largely equal over time. The significant difference in flexion at the six-month follow up may be explained by additional time spent receiving passive range of motion (PROM) in the control group. These results provide preliminary evidence that dry needling in a post-surgical population is safe and without significant risk of iatrogenic infection or other adverse events.Abstract | Full Article (subscribers only) | Purchase Article
Authors: Boyce D, Wempe H, Campbell C, Fuehne S, Zylstra E, Smith G, Wingard C, Jones R
There is a paucity of literature about the adverse events associated with Therapeutic Dry Needling (TDN). Much of the literature surrounding adverse events associated with TDN has been extrapolated from the acupuncture literature. Given that acupuncture and TDN are distinctly different in their application and proposed mechanisms, adverse events associated with TDN should be examined specifically. The purpose of this study was to determine and report the type of adverse events associated with the utilization of TDN. Four hundred and twenty physical therapists participated in this study. Information related to minor and major adverse events that occurred during 20,464 TDN treatment sessions was collected. Each physical therapist respondent was asked to fill out two weekly self-reported electronic surveys over a six-week period. One survey was related to “minor adverse events” (i.e., pain, bleeding, bruising), while the other was related to “major adverse events” (i.e., pneumothorax, excessive bleeding, prolonged aggravation). Following the six-week period, descriptive statistics were used to describe the adverse events (AE) associated with TDN and calculate the frequencies of those events. A total of 7,531 minor AE’s were reported, indicating that 36.7% of the reported TDN treatments resulted in a minor AE. The top three minor AE’s were bleeding (16%), bruising (7.7%), and pain during dry needling (5.9 %). The average ratio of minor AE’s for all respondents across all weeks was 0.53 or approximately one event for every two patients. Twenty major AE’s were reported out of the 20,494 treatments for a rate of <0.1% (1 per 1,024 TDN treatments). No associations were noted between the frequency of adverse events and the number of patients treated, practitioner age, level of education, years in practice, level of training or months experience with dry needling. The authors concluded that minor AE’s such as mild bleeding, bruising, and pain during TDN were common and major AE’s were rare. Physical therapists and other medical practitioners need to be aware of the risks of TDN. Based on the findings of this study the overall risk of a major adverse event during TDN is small.Abstract | Full Article (subscribers only) | Purchase Article
Authors: Kiesel K, Burklow M, Garner MB, Hayden J, Hermann AJ, Kingshott E, McCullough G, Ricard R, Stubblefield G, Volz J, Waskiewicz D, Englert A
Dysfunctional breathing (DB) is common (60-80%) in adults. Individuals with DB may have decreased pain thresholds, impaired motor control and balance, and movement dysfunction. These impairments likely adversely affect performance. Research has demonstrated that DB is multi-dimensional and includes biochemical, biomechanical, and psychophysiological categories. The purpose of this study was to test the impact of breathing exercises in an otherwise healthy population of individuals diagnosed with at least one category of DB. It was hypothesized that the exercise program would normalize at least one category of DB. An experimental group with DB was recruited, then the control group was matched for gender, age, BMI and activity. Baseline breathing metrics were obtained for each category of breathing dysfunction: capnography for biochemical (ETCO2 of < 35mmHg at rest = DB), HI-LO for biomechanical (upper chest or paradoxical patterns = DB), and Self-Evaluation of Breathing Questionnaire (SEBQ ≥ 25 = DB) and Nijmegen Questionnaire (≥ 22 = DB) for psychophysiological. The experimental group performed a four-week progression of home breathing exercises, once daily and the control group continued normal activities (no interventions). Re-testing of all outcome measures was performed after four weeks. Thirty-five individuals comprised the participant sample (16 experimental, 19 control, mean age 26.0 years, mean BMI of 24.3). There were no statistically significant differences between groups at baseline. Eighty-one percent of subjects in the experimental group improved in at least one category compared to 21% of subjects in the control group. Seventy-eight percent of subjects with biomechanical category of DB in the experimental group normalized this dysfunction, while none normalized in the control group, which was statistically significantly different. Twenty-seven percent of subjects with biochemical DB in the experimental group normalized, while only 25% in the control group which was not statistically different. There were only two subjects in each group with the psychophysiological category, therefore no analysis was performed. Home exercises were effective in reversing the biomechanical category of DB in 78% of young, otherwise healthy adults versus no exercise. However, the exercises did not affect the biochemical category of DB. Performing a set of home exercises may be effective option for fitness and rehabilitation providers to suggest for clients to normalize biomechanical breathing dysfunction.
Abstract | Full Article (subscribers only) | Purchase ArticleEffects of Lower Extremity and Trunk Kinetic Chain Recruitment on Serratus Anterior Muscle Activation During Forward Punch Plus Exercise on Stable and Unstable Surfaces
Authors: Kaur N, Bhanot K, Ferreira G
The stabilizing action of the serratus anterior (SA) muscle is vital in maintaining normal scapulothoracic rhythm. This warrants investigation of exercises to discern which are best to activate the SA muscle. Recruitment of the muscles in the trunk and extremity kinetic chain during exercises has demonstrated increased SA activation due to the myofascial connections between various segments of the body. Variation of surfaces during an exercise has also been shown to alter the muscle recruitment patterns. The primary purpose of this study was to determine the effects of trunk and lower extremity kinetic chain muscle recruitment on the SA muscle activity while on an unstable surface. The secondary purpose was to determine if the SA muscle activity would change when the surface stability during the exercises was reduced. Surface electromyographic activity of the SA, latissimus dorsi (LD), external oblique (EO) on the dominant, and femoral adductor (FA) muscles on the non-dominant side and gluteus maximus bilaterally was analyzed during forward punch plus (FPP) and two of its’ variations: FPP with closed chain serape (CS), FPP with open chain serape (OS) on stable and unstable surface in twenty-one healthy males. A two-way repeated measure ANOVA was used to determine the difference in the muscle activation between exercises, surfaces, and interaction between these two variables. A separate one-way repeated measures ANOVA with Sidak post hoc test was used for comparisons between stable and unstable surfaces. (p≤0.05). Muscle activity was statistically significantly higher for the CS and the OS exercises compared to the FPP for all the muscles except for the LD within the same surface. There was no significant difference in muscle activity for any of the muscles when compared between stable and unstable surfaces. The authors concluded that incorporating the trunk and lower extremity kinetic chain during the FPP exercise increased the SA activation on both stable and unstable surfaces. However, the type of surface did not influence the activation of any muscle across exercises. The results of this study further strengthen the benefit of the kinetic chain exercises but also caution that adding an unstable surface to an exercise does not always imply higher muscle activation.
Abstract | Full Article (subscribers only) | Purchase ArticleCASE REPORTS
Multi-Ligament Knee Reconstruction and Novel Meniscus Radial Repair Technique, with Return to Olympic Level Skiing: A Case Report
Authors: DePhillipo NN, Berning K, LaPrade RF
Multi-ligament knee injuries (MLKI) can be debilitating and often career ending injuries for athletes. Current literature reports on outcomes following these injuries for return to activities of daily life; however, there is a paucity of evidence evaluating the return to sport following a MLKI. The purpose of this case report is to describe the treatment and outcome following a MLKI and novel meniscus radial repair technique in which the athlete returned to compete in the 2018 Winter Olympic Games 14 months post-operatively. Abstract | Full Article (subscribers only) | Purchase Article
Returning a Special Operations Candidate to Duty following an Airborne Operation Injury: A Case Report
Authors: Gutschick JH, Lazicki RS
Musculoskeletal injuries are recognized as the leading health problem and primary source of injury, disability, and financial burden across the military. Special Operations Forces are at an increased risk of musculoskeletal injury due to increased physical demands, precipitous deployments, and continual training and deployment cycles. Multiple injury screening tools exist, yet decisions to return to duty are frequently deferred to individual institutional protocol or provider clinical decision making, with no accepted gold standard. The purpose of this case report is to describe the application of a system to return a Special Operations Forces candidate to duty following an ankle injury sustained during a military static line airborne operation while in the Special Forces Qualification Course.
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Authors: Zouita ZBM, Salah B, Behm DG, Chaouachi A
Isokinetic testing of the trunk is ubiquitous in the literature and with training, however, there is a lack of normative data for adolescents and adult athletes. The purpose of the current review is to present and summarize data about isokinetic trunk strength assessment relative to young, adolescent and adult athletes. Testing position variations, reliability values by age groups, utilization of strength measures and normative data by age groups have been discussed. The information presented within this review are of practical importance for assessment of isokinetic trunk strength to appraise the athlete’s current strength level and provide suitable conditioning training program. Abstract | Full Article (subscribers only) | Purchase Article