February 2018

Efficacy of the Stretch Band Ankle Traction Technique in the Treatment of Pediatric Patients with Acute Ankle Sprains:  A Randomized Control Trial.

Authors:  Iammarino K, Marrie J, Selhorst M, Lowes L
Ankle injuries account for up to 40% of all sport related injuries. These injuries can result in weeks to months of missed sport or work. The PRICE (Protection, Rest, Ice, Compression, Elevation) treatment is standard care for most acute ankle sprains.  Recently, early mobilization in adults has been shown to decrease time off from sport or work, and the likelihood of developing chronic instability. To date, no research has been performed assessing the effectiveness of early mobilization in pediatric patients (<18 years). Therefore, the purpose of this study was twofold: (1) to determine if early ankle joint mobilization using elastic band traction is effective and (2) assess the occurrence of adverse events with this technique in the pediatric population.  Patients with an acute ankle sprain of <7 days referred to physical therapy were randomly assigned to receive early mobilization or PRICE.  Early mobilization was performed using a stretch band ankle traction technique.  Both groups received a standardized rehabilitation program.  Pain, edema, ankle strength (using hand-held dynamometry), and the Foot and Ankle Disability Index (FADI) were measured at both initial evaluation and at discharge. The number of days before return to sport and the number of treatment sessions were also variables of interest.  Forty-one pediatric patients were recruited for participation (mean age 14.6 + 1.9 years).  Both treatment groups had clinically significant improvements in pain, edema, strength, and FADI scores.  No significant differences in outcomes were noted between treatment groups.  Mean number of days for return to sport for the PRICE group was 26.33 + 7.14 and the early mobilization group was 26.63 + 14.82, the difference between groups was not significant (p= 0.607). The number of total visits for the PRICE group of 8.07 + 2.63 and the early mobilization groups of 8.5 + 1.57, was also not statistically significantly different (p= 0.762). There were no reported adverse events with early mobilization. The authors concluded that early mobilization appears to be a safe intervention in pediatric patients with an acute ankle sprain.  Early mobilization resulted in similar outcomes when compared to traditional PRICE treatment. A high drop-out rate in both treatment groups was a limitation of this randomized trial.Abstract  |  Full article (subscribers only)  |  Purchase article

Acute Lateral Ankle Sprain Prediction in Collegiate Women’s Soccer Players.

Authors:  McCann RS, Kosik KB, Terada M, Beard MQ, Buskirk GE, Gribble PA
Women’s soccer has among the highest injury rates in collegiate sports, and lateral ankle sprains (LAS) are among the most commonly occurring injuries in that athletic population. However, no established LAS prediction model exists for collegiate women’s soccer players. The purpose of this study was to develop a prediction model for acute LAS injuries in collegiate women’s soccer players utilizing previous ankle sprain history, height, mass, and BMI as potential predictors. The authors’ hypothesized that collegiate women’s soccer players with greater height, mass, and body mass index (BMI), as well as a previous history of ankle sprain would have greater odds of sustaining a LAS. Forty-three NCAA Division I women’s soccer players’ (19.7±1.1yrs, 166.8±3.7cm, 60.8±4.4kg) height, mass, and BMI were measured one week before beginning preseason practices. Additionally, participants reported whether or not they had sustained a previous ankle sprain. The team athletic trainer tracked LASs over the competitive season. Independent t-tests, binary logistic regression analyses, receiver operating characteristic (ROC) curves, and diagnostic statistics assessed the ability of the variables to differentiate between those that did and did not sustain a LAS.  Participants that sustained a LAS (n=8) were significantly taller than those that did not sustain a LAS (n=35) (t41=-2.87, p=0.01, d=0.83[0.03,1.60]). A logistic regression analysis (odds ratio=1.30[1.00,1.70]) and area under the ROC curve analysis (AUROC=0.73[0.58,0.89], p=0.04) further exhibited predictive value of height. A height cutoff score of 167.6cm demonstrated excellent sensitivity (0.88), moderate specificity (0.51), and a favorable diagnostic odds ratio (7.5). A logistic regression analysis (odds ratio=1.87[1.22,1.98]) exhibited predictive value of previous ankle sprain history. That variable was also associated with good sensitivity (0.75) and specificity (0.71) within the model, as well as a favorable DOR (7.37).  Mass and BMI demonstrated no predictive value for LAS.  The authors concluded that taller collegiate women’s soccer players and those with previous ankle sprain history may have a greater predisposition to LAS.

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The Reliability of a Novel Heel-Rise Test versus Goniometry to assess Plantarflexion Range of Motion.

Authors:  Ness BM, Sudhagoni RG, Tao H, Full OR, Seehafer LO, Walder CM, Zimney K
Ankle plantarflexion (PF) active range of motion (ROM) is traditionally assessed in a non-weight-bearing (NWB) position with a universal goniometer. However, a convenient, reliable, low-cost means of assessing functional PF active ROM in a weight-bearing (WB) position has yet to be established. The purpose of this study was to compare the intra- and inter-rater reliability of PF active ROM measurements obtained from a goniometric NWB assessment, and a functional heel-rise test (FHRT) performed in WB. Two physical therapy student examiners, blinded to each other’s measurements, assessed PF active ROM through a NWB goniometric technique and a FHRT on all subjects within the same test session. Intra- and inter-rater reliability values were calculated using an intraclass correlation coefficient (ICC2,1, ICC2,k) and 95% confidence intervals. Standard error of measurement (SEM) and minimal detectable change (MDC) were recorded for each method.  43 healthy participants (mean ± SD, age: 22.7 ± 1.7 years, height: 1.7 ± 0.1 m, mass: 77.8 ± 17.2 kg) completed testing procedures.  The within-session intra-rater reliability (ICC2,1) estimates were observed for goniometry (right: 0.96, left: 0.95 – 0.97) and FHRT (right: 0.99, left: 0.99), as well as the inter-rater reliability (ICC2,k) of goniometry (right: 0.79, left: 0.79) and FHRT (right: 0.79, left: 0.87).  Goniometry SEM (3.3 – 3.6°) and MDC (9.2 – 9.8°) were observed, in addition to FHRT SEM (0.6 cm) and MDC (1.6 – 1.7 cm). A weak correlation was found between FHRT and goniometric measurements (r = -0.03 – 0.13). The authors concluded that the FHRT was found to have good to excellent intra- and inter-rater reliability, similar to goniometric measurement. The lack of agreement between these measurements requires further exploration of the WB assessment of ankle PF active ROM.

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Ultrasonographic Assessment of Neck Muscular Size and Range of Motion in Rugby Players.

Authors:  Hemelryck W, Calistri J, Papadopoulou V, Theunissen S, Dugardeyn C, Balestra C
World Rugby Union laws are constantly evolving towards stringent injury-prevention, particularly for contested scrums, since front row players are most at risk of cervical spine injuries. Recently, some countries have also introduced tailored training programs and minimum performance requirements for playing in the front row. Nevertheless, these approaches lack an objective assessment of each cervical muscle that would provide protective support. Since front row players are the most at risk for cervical spine injuries due to the specific type of contact during scrums, the purpose of this study was to ascertain whether significant differences exist in neck muscle size and range of motion between front row players and players of other positions, across playing categories. One hundred and twenty-nine sub-elite male subjects from various first-team squads of Belgian Rugby clubs were recruited. Subjects were grouped according to age: Junior (J) < 19 years old, Senior (S) 19 to 35 years old and Veteran (V) > 35 years old; as well as playing position: Front row players (J=10, S=12, V=11 subjects), (Rest of the) pack (J=12, S=12, V=10), backs (J=10, S=11, V=11). An age-matched control group of non-rugby players was also recruited (J=10, S=10, V=10). For each subject, the total neck circumference (NC) and the cervical range of motion (CROM) were measured. In addition, the thickness of the trapezius (T), splenius capitis (SCa), semispinalis capitis (SCb), semispinalis cervicis (SPC), sternocleidomastoid muscles (SCOM), and the total thickness of all four structures (TT), were measured using ultrasonography.  In each age category, compared to controls, rugby players were found to have decreased CROM, an increase in neck circumference (NC), and increased total thickness (TT), trapezius (T), semispinalis capitis (SCb) and sternocleidomastoid muscles (SCOM) sizes. For junior players, the thickness of the semispinalis cervicis (SPC) was also increased compared to controls. The CROM was decreased in front row players compared to pack and back players for all age categories; Front row seniors also showed an increase in trapezius (T), splenius capitis (SCa), semispinalis capitis (SCb) and total thickness (TT), compared to back players. In regard of the differences in cervical values found between player positions, the implementation of both range of motion and echography muscle thickness assessments could serve to create an additional measurement for all front row players, that could complement current pre-participation screening used by rugby federations by objectively monitoring muscular size and motion amplitude around the cervical spine.

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A Comparative Study of Passive Shoulder Rotation Range of Motion, Isometric Rotation Strength and Serve Speed Between Elite Tennis Players With and Without History of Shoulder Pain.

Authors:  Moreno-Perez V, Elvira JLL, Fernandez-Fernandez J, Vera-Garcia FJ
Glenohumeral internal rotation deficit and external rotation strength have been associated with the development of shoulder pain in overhead athletes. The objective of this study was to examine bilateral passive shoulder rotational range of motion (ROM), isometric rotational strength, and unilateral serve speed in elite tennis players with and without shoulder pain history (PH and NPH, respectively) and compare between dominant and non-dominant limbs and between groups. Fifty-eight elite tennis players were distributed into the PH group (n = 20) and the NPH group (n = 38). Serve velocity, dominant and non-dominant passive shoulder external and internal rotation (ER and IR) ROM, total arc of motion (TAM: the sum of IR and ER ROM), ER and IR isometric strength, bilateral deficits and ER/IR strength ratio were measured in both groups. Questionnaires were administered in order to classify characteristics of shoulder pain. The dominant shoulder showed significantly reduced IR ROM and TAM, and increased ER ROM compared to the non-dominant shoulder in both groups. Isometric ER strength and ER/IR strength ratio were significantly lower in the dominant shoulder in the PH group when compared with the NPH group. No significant differences between groups were found for serve speed. These data show specific adaptations in the IR, TAM and ER ROM in the dominant shoulder in both groups. Isometric ER muscle weakness and ER/IR strength ratio deficit appear to be associated with history of shoulder injuries in elite tennis players. It would be advisable for clinicians to use the present information to design injury prevention programs.

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Shoulder External Rotator Strength in Response to Various Sitting Postures: A Controlled Laboratory Study.

Authors:  Pheasant S, Hatdt R, Gottstein T, Grasso A, Lombard N, Stone B

The forward head rounded shoulder (FHRS) sitting posture has been associated with decreased shoulder complex muscle strength and function.  Upon clinical observation, the adverse effects of the FHRS sitting posture on shoulder complex isometric muscle strength is also present when testing controls for scapular position.  The purpose of the study was to assess the effect of various sitting postures on shoulder external rotator muscle isometric strength when the strength testing controls for scapular position. One hundred subjects ages 20-26 participated in the study. Each subject was placed in a neutral cervical sitting (NCS) posture which was maintained for five minutes after which the strength of the dominant shoulder external rotators was immediately tested with the glenohumeral joint in the neutral position using a Micro-FET3 Hand Held Muscle Testing Dynamometer (HHMTD). Each subject was returned to the NCS posture for subsequent external rotator strength testing after five minutes in a FHRS sitting posture, five additional minutes in the NCS posture and five minutes in a retracted cervical sitting (RCS) posture resulting in each subjects’ external rotator strength being tested on four occasions. Subjects were randomized for order between the FHRS and RCS postures. Mean strength values for each condition were normalized to the mean strength value for the 1st NCS condition for each subject. A statistically significant decline in shoulder external rotator strength following the FHRS sitting posture occurred compared to the appropriate postural conditions (p<.05). A frequency analysis revealed that 36% of the subjects demonstrated greater than 10% decline in external rotator strength following five minutes in the FHRS sitting posture.  The average percentage of strength decline in those with greater than a 10% reduction in external rotator strength was 19%. Sixty-four percent of the subjects experienced less than a 10% decline in shoulder external rotator strength in response to the FHRS sitting posture. Shoulder external rotator strength declined 8% following five minutes in the FHRS sitting posture. A sub-population of 36% demonstrated an average decline of 19% in shoulder external rotator strength following five minutes in the FHRS sitting posture. The strength decline appears to resolve over the short-term by returning to the NCS posture.

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Trunk Lean During a Single-Leg Squat is Associated with Trunk Lean During Pitching.

Authors:  Plummer HA, Oliver GD, Powers CM, Michener LA

Impaired trunk motion during pitching may be a risk factor for upper extremity injuries. Specifically, increased forces about the shoulder and elbow have been observed in pitchers with excessive contralateral trunk lean during pitching.  Because of the difficulty in identifying abnormal trunk motions during a high-speed task such as pitching, a clinical screening test is needed to identify pitchers who may present with impaired trunk motion during pitching. The purpose of this study was to determine the relationship between the degree of lateral trunk lean during the single-leg squat and amount of trunk lean during pitching and if trunk lean during pitching can be predicted from lean during the single-leg squat. Seventy-three young baseball pitchers (11.4 ± 1.7 years; 156.3 ± 11.9 cm; 50.5 ± 8.8 kg) participated. An electromagnetic tracking system was used to obtain trunk kinematic data during a single-leg squat task (lead leg) and at maximum shoulder external rotation of a fastball pitch. Pearson correlation coefficients for trunk lean during the single-leg squat and pitching were calculated. A linear regression analysis was performed to determine if trunk lean during pitching can be predicted from lean during the single-leg squat. There was a positive correlation between trunk lean during the single-leg squat and trunk lean during pitching (r= 0.53; p<0.001). Lateral trunk lean during the single-leg squat predicted the amount of lateral trunk lean during pitching (R2= 0.28; p< 0.001).  A moderate positive correlation was observed between trunk lean during an SLS and pitching. Trunk lean during the single-leg squat explained 28% of the variance in trunk lean during pitching.

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Maximal Hip and Knee Muscle Strength Are Not Related to Neuromuscular Pre-activity During Sidecutting Maneuver: A Cross-sectional Study.

Authors:  Husted RS, Bencke J, Holmich P, Anderson LL, Thorborg K, Bandholm T, Gliese B, Lauridsen HB, Myklebust G, Aagaard P, Zebis MK
Reduced lower extremity muscle strength as well as reduced lower extremity muscle pre-activity (defined as muscular activity just prior to initial ground contact) during high-risk movements are factors related to increased risk of non-contact ACL injury in adolescent female athletes. A strong relationship exists between muscle strength and muscle activity obtained during an isometric contraction, however, whether these two measures are related when muscle activity is obtained during a movement associated with a high risk of non-contact ACL injury is not known. Absence or presence of such a relationship may have implications for which training modalities to choose in the prevention of ACL injuries. The purpose of this study was to examine the relationship between maximal muscle strength of the hip extensors, hip abductors and knee flexors and the pre-activity of these muscle groups recorded during a sidecutting maneuver (high-risk movement) in adolescent female soccer and handball athletes. Eighty-five adolescent (age 16.9±1.2 years) female elite handball and soccer athletes were assessed for maximal hip extensor, hip abductor and knee flexor muscle strength; and muscle pre-activity (electromyography recordings over a 10 ms time interval prior to foot ground contact) of the gluteus maximus (Gmax), gluteus medius (Gmed), biceps femoris (BF) and semitendinosus (ST) during a standardized sidecutting maneuver. The results of the correlation analyses demonstrated poor and statistically non-significant correlations. Maximal hip extensor force (N/kg bw) and Gmax pre-activity [rs = 0.012 (95% CI -0.202 – 0.224), p = 0.91], maximal hip abductor force (N/kg bw) and Gmed pre-activity [rs = 0.171 (95% CI -0.044 – 0.371), p = 0.11], maximal knee flexor force (N/kg bw) and BF pre-activity [rs = 0.049 (95% CI -0.166 – 0.259), p = 0.65], and maximal knee flexor force and ST pre-activity [rs = 0.085 (95% CI -0.131 – 0.293), p = 0.44].  In the present exploratory study, the results imply that no relationship exists between maximal lower extremity isometric muscle strength and lower extremity muscle pre-activity during sidecutting. This means that athletes with low muscle strength may not necessarily demonstrate high (or low) muscle pre-activity during sidecutting – a well-known risk movement for sustaining non-contact ACL injury.

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2D- and 3D-Kinematics during Lateral Step-down Testing in Individuals with Anterior Cruciate Ligament Reconstruction.

Authors:  Mostaed MF, Werner DM, Barrios J
The lateral step-down test is an established clinical evaluation tool to assess quality of movement in patients with knee disorders. However, this test has not been investigated in individuals after anterior cruciate ligament reconstruction (ACLR) in association with quantitative 3D motion analysis. The purpose of this study was to determine the strength of association between visually-assessed quality of movement during the lateral step-down test and 3D lower limb kinematics in patients with history of ACLR. A second purpose was to compare kinematics between subgroups based on the presence or absence of faulty alignments during the task. The final purpose was to compare visually-assessed quality of movement scores between box heights during lateral step-down testing. Twenty subjects at least one year status post-ACLR (18 females, age of 24.5±4.6 years and body mass index of 23.4±2.3 kg/m2) performed the lateral step-down test unilaterally on the surgical limb atop four and six inch boxes. A board-certified orthopedic physical therapist scored overall quality of movement during the lateral step-down test using established criteria during 2D video playback. Lower limb kinematics were simultaneously collected using 3D motion capture. An alpha level of 0.05 was used for all statistical treatments. Overall 2D quality of movement score significantly correlated (r=0.47-0.57) with 3D hip adduction and hip internal rotation across box heights. Across box heights, the presence of faulty pelvic alignment differentiated a subgroup exhibiting less peak knee flexion, and the presence of faulty knee alignment differentiated a subgroup exhibiting greater peak hip adduction. The six inch box elicited worse quality of movement compared to the four inch box. These results suggest that visually-assessed quality of movement is associated with several kinematic variables after ACLR. 2D movement deviations at the pelvis appear to consistently relate to less knee flexion, and 2D deviations at the knee appear to suggest greater hip adduction. Generally, poorer quality of movement was observed for the six inch box height. Clinically, these data suggest that interventions targeting hip abductor and knee extensor strength and neuromuscular control may be useful in the presence of poor quality of movement during lateral step-down testing.

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Quantifying Frontal Plane Knee Kinematics in Subjects With Anterior Knee Pain: The Reliability and Concurrent Validity of 2D Motion Analysis.<

Authors:  Ramirez M, Negrete R, Hanney WJ, Kolber MJ
Two-dimensional (2D) analysis has the potential to identify individuals at risk for knee injury by measuring genu valgus during sport related tasks. The reliability of 2D mobile motion analysis in measuring genu valgus during a single leg hop test on individuals with anterior knee pain has not been examined. The purpose of this study was to assess the reliability and concurrent validity of 2D mobile motion analysis and compare it to visual observation while analyzing dynamic genu valgus during a single leg hop test in subjects with anterior knee pain. Nineteen subjects experiencing anterior knee pain completed a single leg hop test with both lower extremities. Two investigators independently estimated the degrees of genu valgus with visual observation alone during the subjects’ single leg hop. After the visual estimation, the investigators watched the video again using the 2D Spark Motion Pro™ application to pause the video and measured the amount of knee valgus with a virtual goniometer tool on the application. Inter-rater reliability was calculated using intraclass correlation coefficients (ICC) model 2, k and intra-rater reliability using model 3, k.  Minimal detectable change, concurrent validity and limits of agreement were calculated. Visual observation alone demonstrated interrater reliability ICCs of 0.682-0.685 on the symptomatic and non-symptomatic lower extremities respectively. The inter-rater reliability using the 2D application had ICC’s of 0.927 and 0.792 on the symptomatic and non-symptomatic lower extremities respectively. The concurrent validity for 2D analysis and visual observation on the symptomatic lower extremity had ICC values of 0.96 (rater A) and 0.85 (rater B). The non-symptomatic lower extremity demonstrated concurrent validity ICC values of 0.95(rater A) and 0.65(rater B). The standard error of measurement(SEM) was 3.89° and 3.25° for the symptomatic and non-symptomatic lower extremity(LE) respectively for visual observation. When using the Spark Motion Pro™ application the SEM was 1.64° and 2.71° for the symptomatic and non-symptomatic LE respectively. The minimal detectable change (MDC) using visual observation alone was 5.5° and 4.6°. When using the application, it was noted at 2.32° and 3.83° on the symptomatic and non-symptomatic LE respectively.  The results of this study support the use of a 2D mobile application as a reliable tool for measuring knee valgus in symptomatic subjects and offers reduced error (SEM= 1.64°) when compared to visual observation alone (SEM= 3.89°).

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Isokinetic Assessment of Muscular Strength and Balance in Brazilian Elite Futsal Players.

Authors:  Nunes R, Dellagrana RA, Nakamura FY, Buzzachera CF, Almeida FAM, Flores LJF, Guglielmo LGA, da Silva SG
Strength asymmetries are related to knee injuries in intermittent sports players. The purpose of this study was to examine whether elite futsal players demonstrate strength asymmetries during knee isokinetic testing applying the Croisier criteria. Forty male elite (27.9 ± 6.5 years) Brazilian futsal players participated in the study. The testing protocol required players to perform concentric contractions of both quadriceps and hamstring muscles at angular velocities of 60°·s-1 and 240°·s-1 and eccentric contractions of hamstring at 30°·s-1 and 120°·s-1. Conventional (concentric:concentric) and mixed (eccentric:concentric) hamstrings/quadriceps (H/Q) ratios were calculated. Subjects were determined to have an imbalanced strength profile if an athlete had at least two parameters that were asymmetrical across speeds and conditions. Asymmetry was operationally defined as peak torque asymmetry greater than 15% in bilateral comparison, and H/Q ratio less than 0.47 for conventional and 0.80 for mixed conditions. Significant differences were observed between preferred and nonpreferred limbs in the concentric contractions of flexors at 240°·s-1 and eccentric contractions of extensors and flexors at 30°·s-1 and 120°·s-1. However, these asymmetries did not exceed 15%. The conventional and mixed H/Q ratios were greater in the preferred than in non-preferred limbs, but only the mixed hamstringsecc/quadriceps conc in the non-preferred limbs showed values lower than recommended (<0.80). In addition, 50% of elite futsal players had preseason strength imbalances per the developed criteria. The authors concluded that the studied elite futsal players had preseason strength imbalances, which may increase the risk of hamstring injuries.

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Acute Effects of Different Anterior Thigh Self-Massage on Hip Range of Motion in Trained Men.

Authors:  Monteiro ER, Vigotsky AD, Novaes JS, Skarabot J
Self-massage is a ubiquitous intervention similar to massage, but performed by the recipient him- or herself rather than by a therapist, most often using a tool (e.g., foam roller, roller massager). Self-massage has been found to have a wide range of effects. It is particularly known for increasing flexibility acutely, although not always. The variability of the results in previous studies may potentially be a function of the tool used. Recent findings also suggest that self-massage exerts global effects. Therefore, increased flexibility should be expected in the areas adjacent to the ones treated. The purpose of this study was to investigate the acute effects of foam rolling and rolling massage of anterior thigh on hip range-of-motion (ROM) – i.e., hip extension and hip flexion – in trained men.  Eighteen recreationally active, resistance trained males visited the lab on two occasions over a 4-day period separated by at least a day. Each session included two baseline ROM measures of passive hip flexion and extension taken in a randomized fashion. Recording of baseline measures was followed by the intervention of the day, which was either foam rolling or rolling massage of the anterior thigh as per randomization. Immediately post intervention, passive hip flexion and hip extension ROM were reassessed. In order to assess the time course of improvements in ROM, hip flexion and hip extension ROM were reevaluated at 10, 20, and 30 minutes post-intervention.  Hip flexion and hip extension ROM increased immediately following both interventions (foam rolling or roller massager) and remained increased for 30 minutes post intervention. Foam rolling was statistically superior in improving hip flexion and hip extension ROM immediately post intervention. However, immediately post-intervention was the only time point that measurements exceeded the minimum detectable change for both interventions.  The authors concluded that both foam rolling and rolling massage appear to be effective interventions for improving hip flexion and extension ROM when applied to the anterior thigh, but the observed effects are transient in nature.

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Strengthening the Gluteus Maximus in Subjects with Sacroiliac Dysfunction.

Authors:  Added MAN, de Freitas DG, Kasawara KT, Martin RL, Fukuda TY
The literature has emphasized the use of exercise as an intervention for individuals with lumbopelvic pain. However, there is limited information to guide clinicians in exercise selection for those with sacroiliac (SI) joint dysfunction. Altered function of the gluteus maximus has been found in those with SI joint dysfunction. The objective of this case series was to assess the effectiveness of an exercise program directed at increasing gluteus maximus strength in those with clinical tests positive for SI joint dysfunction. The eight subjects in this series presented with lumbopelvic pain and clinical evidence of SI joint dysfunction. Each subject underwent 10 treatments over five weeks consisting of five exercises directed at strengthening the gluteus maximus. Radiological assessment and clinical examination were performed to rule out potential concurrent pathologies. Visual analog pain scale, the Oswestry Disability Index, and strength assessed via hand held dynamometry were measured pre- and post-intervention. A significant (p<0.001) weakness in gluteus maximus was noted when comparing the uninvolved and involved sides pre-intervention. After completing the strengthening exercise program over 10 visits, statistically significant (p<0.002) increases in gluteus maximus strength and function were found, as well as a decrease in pain. All subjects were discharged from physical therapy and able to return to their normal daily activities. The results of this case series support the use of gluteus maximus strengthening exercises in those with persistent lumbopelvic pain and clinical tests positive for SI joint dysfunction.

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The Utilization of Mulligan Concept Thoracic Sustained Natural Apophyseal Glides on Patients Classified with Secondary Impingement Syndrome: A Multi-Site Case Series.

Authors:  Andrews DP, Odland-Wolf KB, May J, Baker R, Nasypany A
Secondary impingement syndrome (SIS) is a common complaint in the sporting population particularly among athletes engaging in overhead activities. While symptoms may be present at the shoulder with patients complaining of SIS, spinal alignment or dysfunction can influence scapular positioning and overall shoulder girdle function. As an adjunct therapy to traditional interventions for SIS, thoracic high-velocity low-amplitude (HVLA) thrusts have been utilized and correlated with patient reported decreases in pain. Mulligan Concept (MC) thoracic sustained natural apophyseal glides (SNAGs) are an emerging treatment intervention utilized to treat patients with shoulder pain and dysfunction as the evidence supporting an interdependent relationship between the thoracic spine and the shoulder is growing. The purpose of this case series was to investigate the effects of one MC thoracic SNAG treatment session on subjects classified with SIS, while utilizing a classification-based treatment protocol. Seven subjects classified with SIS were treated utilizing a MC thoracic SNAG. The Numeric Rating Scale (NRS) was administered at initial evaluation, immediately following intervention, and at the 48-h follow-up to identify patient-reported pain during range of motion, manual strength testing, and special tests of the shoulder.  Investigators collected the Shoulder Pain and Disability Index (SPADI) at initial evaluation and the 48-h follow-up to identify patient-reported dysfunction. Following one MC thoracic SNAG treatment (3 sets of 10 repetitions), minimal clinically important differences (MCIDs) were reported utilizing the NRS. A decrease in pain during active shoulder abduction (ABD) was detected immediately post-treatment, and the NRS change scores for resisted external rotation (RER) and active ABD were statistically different and clinically important at the 48-h follow-up. Based on the results of this case series, thoracic SNAGs may influence short-term pain levels and shoulder mobility in the included subjects with SIS and support the concept of regional interdependence (RI) between the thoracic spine and glenohumeral joint. Continued exploration into the proposed benefits of the MC thoracic SNAG treatment as an adjunct therapy when treating patients complaining of SIS is warranted.

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Patellofemoral Chondral Defect in a Preadolescent Skier: A Case Report in Early Sport Specialization.

Authors:  DePhillipo NN, Cinque ME, Kennedy NI, Chahla J, Moatshe G, LaPrade RF
Early sport specialization (ESS) refers to intense training year round in a specific sport starting at a young age with no or limited participation in other sports. This approach to training is highly controversial; recent literature suggests that this type of specialized training could be a contributing source to overuse injuries in youth athletes. The purpose of this case report was to describe a patellofemoral articular cartilage defect of the knee in a preadolescent skier due to overuse and repetitive microtrauma as a result of ESS. Cartilage injuries and osteochondral defects are very common in adolescent athletes and often go undiagnosed. Allied healthcare professionals must be educated on the known causes of recurrent knee effusions and how early sport specialization may result in overuse injuries to knee joint cartilage.

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