VOLUME THIRTEEN, NUMBER SIX

 
2018Masthead_V13N6

December 2018

SYSTEMATIC REVIEW – META ANALYSIS

Is There Evidence For An Association Between Changes in Training Load and Running-Related Injuries? A Systematic Review
Authors:  Damsted C, Glad S, Nielsen RO, Sørensen H,  Malisoux L
Sudden changes (increases and decreases) in training load have been suggested to play a key role in the development of running-related injuries. However, the compiled evidence for an association between change in training load and running-related injury does not exist.  Therefore, the purpose of the present systematic review was to compile the evidence from original articles examining the association between changes in training load and running-related injuries.  Four databases (Pubmed/Medline, SPORTDiscus, Embase, and Scopus) were systematically searched. Articles were included if 1) the study design was a randomized trial, a prospective cohort study, a cross-sectional study or a case-control study, 2) participants were runners between 18-65 years, and 3) specific information on changes in training load was provided. Methodological quality of included articles was assessed using the Newcastle Ottawa Scale or the PEDro rating scale. Four articles fulfilled the eligibility criteria of which three found an association between increases in training load and an increased risk of running-related injuries: This association was shown by an increased injury risk amongst runners if they: 1) recently had performed one or more changes in either velocity and/or distance and/or frequency compared with the non-injured runners (p=0.037), 2) increased their average weekly running distance by more than 30% compared to an increase of less than 10% (Hazard Ratio =1.59 (95% Confidence Interval: 0.96; 2.66)), 3) increased their total running distance significantly more the week before the injury origin compared with other weeks (mean difference: 86%; 95% Confidence Interval: 12%; 159%, p=0.026). However, no difference was found between a 10% and a 24% average increase in weekly volume (HR=0.8, 95% CI: 0.6; 1.3).  The authors concluded that very limited evidence exists supporting that a sudden change in training load is associated with increased risk of running-related injury among amateur and novice runners.

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ORIGINAL RESEARCH

The Start-To-Run Distance and Running-related Injury Among Obese Novice Runners: A Randomized Trial
Authors:  Bertelsen ML, Hansen M, Rasmussen S, Nielsen RO
High body mass index is associated with an increased risk of running-related injury among novice runners. However, the amount of running participation plays a fundamental explanatory role in regards to running-related injury development. Therefore, the purpose of this study was to investigate if the risk of running-related injury among obese novice runners (BMI 30-35) was different when the start-to-run distance was 3km per week instead of 6km per week. The authors hypothesized that a start-to-run distance of 3km per week would be associated with 20% fewer running-related injuries and significantly fewer symptoms of overuse injury than a start-to-run distance of 6km per week among obese novice runners.  Fifty-six obese novice runners were enrolled and randomized to receive one of the two following running programs: (i) a 4-week running program with a start-to-run distance of 3km per week including three sessions with 1km running per session (n=29), or (ii) a 4-week running program with a start-to-run distance of 6km per week including three sessions with 2km running per session (reference group, n=27). In both programs, the weekly running distance was increased by 10% each week throughout the follow-up. The intention-to-treat analysis revealed a protective cumulative risk difference of -16.3% (95%CI: -43.8%; 11.3%, p=0.25) after four weeks. Importantly, some participants completed much more running than prescribed (n=5) and some never uploaded any training data (n=15). Therefore, a supplementary per-protocol analysis was performed revealing a cumulative risk difference of -31.2% (95%CI: -57.0%; -5.2%, p=0.02) after four weeks. Furthermore, in the per-protocol analysis, the cumulative risk difference of overuse-injury symptoms was -47.8% (95%CI: -81.0%; -14.6%, p=0.01) after four weeks of running. The authors concluded that a 3km reduction from 6km per week to 3km per week in the start-to-run distance appears to be associated with fewer running-related injuries and significantly fewer symptoms of overuse injury.

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Comparison of Hip Internal and External Rotation between Intercollegiate Distance Runners and Non-Running College Students
Authors:  Cannon A, Finn K,  Yan Z
The increased incidence of lower extremity injury in runners compared to the general population is well documented. The amount of passive hip rotation and the position of hip flexion or extension at which it occurs may be factors related to injury incidence. The purpose of the current study was.to measure and compare hip rotation passive range of motion in male and female runners and non-runners at 0 and 90 degrees (°) of hip flexion. Eighteen Division II collegiate distance runners (9 female, 9 male, mean age =19.1, +/- 1.1 years) who had run for an average of 7.1 (SD=1.7) years participated in the study. Twenty non-runners (10 female, 10 male, mean age=19.6, +/- 1.1 years) from the same institution were also recruited.  Passive hip internal rotation (IR) and external rotation (ER) were measured with a universal goniometer in 90° of hip flexion in a seated position, and in 0° of hip flexion in prone position.  There was a significant difference in IR measured in 0° of hip flexion, between runners and non-runners (F(1,37)=8.04, p=.007). Additionally, the difference in IR between males (36.68 +/-9.19 degrees) and females (45.99 +/- 9.12) was significantly different (F(1,37)=20.79, p=.001). There were no other statistically significant differences in measurements between groups. The authors concluded that collegiate runners had significantly greater passive hip IR when measured at 0° of hip flexion compared to the non-runners. Female runners had significantly greater passive hip IR compared to the male participants across both runners and non-runners.

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Comparison of Non-Contact and Contact Time-Loss Lower Quadrant Injury Rates in Male
Collegiate Basketball Players: A Preliminary Report

Authors:   Brumitt J, Hutchison MK, Houck J, Isaak D, Engilis A, Loew J, Duey D, Nelson K, Arizo K
Male collegiate basketball (BB) players are at risk for musculoskeletal injury. The rate of time-loss injury in men’s collegiate BB, for all levels of National Collegiate Athletic Association (NCAA) competition, ranges from 2.8 to 4.3 per 1000 athletic exposures (AE) during practices and 4.56 to 9.9 per 1000 AE during games. The aforementioned injury rates provide valuable information for sports medicine professionals and coaches. However, many of the aforementioned studies do not provide injury rates based on injury mechanism, region of the body, or player demographics. Therefore, the pupose of this study was two-fold.  The first purpose was to report lower quadrant (LQ = lower extremities and low back region) injury rates, per contact and non-contact mechanism of injury, for a cohort of male collegiate basketball (BB) players.  The second purpose was to report injury risk based on prior history of injury, player position, and starter status.  A total of 95 male collegiate BB players (mean age 20.02 ± 1.68 years) from 7 teams (NCAA Division II = 14, NCAA Division III = 43, NAIA = 21, community college = 17) from the Portland, Oregon region were recruited during the 2016-2017 season to participate in this study.  Each athlete was asked to complete an injury history questionnaire. The primary investigator collected the following information each week from each team’s athletic trainer: athletic exposures (AE; 1 AE = game or practice) and injury updates.   Thirty-three time-loss LQ injuries occurred during the study period.  The overall time-loss injury rate was 3.4 per 1000 AE.  Division III BB players had the highest rates of injury.  There was no difference in injury rates between those with or without prior injury history.  Guards had a significantly greater rate of non-contact time-loss injuries (p = 0.04). The authors found that guards experienced a greater rate of LQ injury than their forward/center counterparts.  Starters and athletes with a prior history of injury were no more likely to experience a non-contact time-loss injury than nonstarters or those without a prior history of injury.  

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Non-Contact Anterior Cruciate Ligament and Lower Extremity Injury Risk Prediction Using Functional Movement Screen and Knee Abduction Moment: An Epidemiological Observation of Female Intercollegiate Athletes
Authors:  Landis SE, Baker RT, Seegmiller  JG
Modifiable risk factors associated with non-contact anterior cruciate ligament (ACL) injuries are highly debated, yet the incidence rate of ACL injury continues to increase. Measures of movement quality may be an effective method for identifying individuals who are at a high risk of injury. The purpose of this study was to investigate whether a movement screen and/or a drop-jump landing (DJL) task could identify female individuals at a higher risk for sustaining non-contact lower extremity (LE) injuries, particularly ACL injuries.   187 women (mean age 19.5 ± 1.21 years) who played collegiate soccer, volleyball, or basketball completed the Functional Movement Screen (FMS™) and a drop-jump landing task. Weekly injury reports of participants who sustained a non-contact LE injury were collected. FMS™ scores (both total score and individual screens) and Knee Abduction Moment (KAM) values from the DJL task, were compared between injured and uninjured sample populations.  A statistically significant difference (t = 1.98, p = 0.049) was observed in the FMS™ scores between the injured (ACL and LE injury) and uninjured groups. Prior ACL injury was also a significant predictor of LE injury (OR = 4.4, p = 0.01).   The authors concluded that the FMS™ can be used to identify collegiate female athletes who are at an increased risk of sustaining a non-contact ACL or LE injury. Female collegiate athletes that score 14 or less on the FMS™ have a greater chance of sustaining a non-contact LE injury than those who score above 14.

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The Effect of Knee Joint Cooling on Isokinetic Torque Production of the Knee Extensors: Considerations for Application
Authors:  Rhodes D,  Alexander J
Physical cryotherapy is commonly used in sport for the management of injury or during recovery, however the effects on concentric isokinetic strength appear unclear when considering the effect of joint cooling distal to the anterior thigh. The purpose of this study was to investigate the effect of cooling of the knee joint on quadriceps concentric isokinetic torque production. Fourteen healthy male participants volunteered for this study, all of whom regularly played competitive sports (mean age 20.24±1.51years; body mass 80.34±11.34Kg and height 179.45±6.59cm). 800 g of crshed ice was applied over the anterior knee joint for 20 minutes. Concentric quadriceps strength was measured using an isokinetic dynamometer (IKD) by measuring concentric peak (PkT) and average torque (AvT) outputs at pre-, immediately post and 20 minutes post cooling intervention. Additionally, skin surface temperature (Tsk), was measured using a hand-held thermometer at the mid-point (a point between the base and the apex) of the patella at the same time intervals. Significant main effects reported for PkT, for time post-ice application (p=0.02, ɳ2=0.161). Post-hoc analysis revealed pre-ice application PkT to be significantly higher (p ≤0.003) than all other timepoints. Quadratic regression analysis revealed a strong correlation between reductions in quadriceps torque production and time post application (r=0.82). The quadratic pattern of recovery displays a minima of 17.28-minutes and maxima of 34.56-minutes post ice application. AvT post-ice application demonstrated significant main effects for time post-ice application (p=0.03, ɳ2=0.152). Post-hoc analysis revealed pre-ice application  AvT to be significantly higher (p ≤0.005) than at all other timepoints. Quadratic regression analysis revealed a strong correlation between reductions in quadriceps torque production and time post application (r=0.80). The quadratic pattern of recovery displays a minima of 18.38-minutes and maxima of 36.76-minutes post ice application. Tsk reduced significantly, immediately post intervention (p ≤0.05) without returning to baseline measures at 20-minutes post (p ≤0.05). The authors found that isokinetic peak torque values of the quadriceps diminish after cryotherapy application to the knee joint and are not fully recovered at 20 minutes post application on the knee. These findings could have potential implications for participation in activity immediately following ice application.

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The influence of Sensorimotor Training Modalities on Balance, Strength, Joint Function, and Plantar Foot Sensitivity in Recreational Athletes With A History of Ankle Sprain: A Randomized Controlled Pilot Study
Authors:  Deussen S, Alfuth M
Ankle sprains frequently result in persistent sensorimotor deficits. Sufficient evidence of effects of sensorimotor training using unstable devices on physical functions is lacking. There is no insight as to whether simultaneous tactile stimulation of plantar foot mechanoreceptors using textured surfaces may influence outcomes in people with a history of ankle sprain. The purpose of this study was to investigate the potential effects of sensorimotor training using unstable textured surfaces on balance, strength, joint function, and plantar sensitivity in recreational athletes with a history of ankle sprain.  Nineteen recreational athletes (6 females, 13 males; mean age: 29 ± 7 years) with a history of ankle sprain and self-reported sensation of instability participated.  Self-reported function of the ankle joint, plantar cutaneous detection threshold to light touch, balance during single-leg stance as well as maximal isometric strength of the ankle joint in eversion and inversion were measured. Participants were randomly allocated to either a training group using unstable textured surfaces or a training group using unstable smooth surfaces or a control group. Outcome measurements were repeated after six weeks of training and at follow-up after 10 weeks. Within and between group differences were analyzed using ANOVA, Friedman tests, or Kruskal Wallis tests (p<0.05) and post-hoc tests with Bonferroni correction. Correlations between outcome-parameters from baseline measurements were analyzed using Spearman’s rho (p<0.05).  No significant between-group differences were detected in all outcome measures. However, a significant increase of strength in eversion was found for the training group using textured surfaces after 10 weeks (p=0.01). A moderate correlation existed between plantar detection threshold of metatarsal head (MT) I and strength of inversion (r = 0.51, p<0.05) before training across all groups. There were moderate negative correlations between balance parameters and strength in eversion (r = -0.57 – -0.64, p≤0.01) as well as plantar detection thresholds at MT V (r = -0.48 – -0.62, p<0.05) at baseline across all groups. The authors concluded that a  six-week sensorimotor training using unstable smooth and textured surfaces demonstrated no significant differences in balance, strength in eversion and inversion, plantar foot sensitivity, and self-reported ankle instability between training groups and the control group in recreational athletes with a history of ankle sprain.

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Relationship of Movement Screens with Past Shoulder or Elbow Surgeries in Collegiate Baseball Players
Authors:  Busch AM,  Clifton DR, Onate JA
Upper extremity injuries commonly occur in baseball players, and can often necessitate surgical interventions. Athletes recovering from previous surgeries may be at greater risk of a secondary injury due to potential residual deficits in global movement. Identifying individuals with residual movement dysfunction following surgery during a pre-participation examination may help health care professionals identify baseball players who may be at a greater risk of re-injury in their throwing arms so that appropriate interventions can be developed. The purpose of this study was to assess relationships between history of shoulder or elbow surgeries and Functional Movement Screen (FMS™) shoulder mobility scores or Selective Functional Movement Assessment (SFMA) upper extremity patterns in collegiate baseball players.  One hundred seventy-six healthy, male, Division III collegiate baseball players (mean age = 19.65 ± 1.52 years) underwent preseason screening using the FMS™ shoulder mobility screen, and SFMA upper extremity patterns. Total FMS™ scores were dichotomized into “good” and “poor” groups (good = 2 or 3, poor = 0 or 1). SFMA scores were dichotomized into “good” and “poor” groups (good = functional non-painful (FN), poor = dysfunctional painful (DP), dysfunctional non-painful (DN), and functional painful (FP).  Dichotomized FMS™ and SFMA scores were compared to questionnaire data regarding history of shoulder or elbow surgeries. Thirty participants (17%) reported a previous shoulder or elbow surgery in their dominant arms.  Past surgeries in the shoulder or elbow were not related to FMS™ (odds ratio [OR]=0.74, 95% confidence interval [CI]=0.30, 1.82), p=0.52) or SFMA performance (OR=0.93, 95%CI=0.38, 2.27, p=0.88) independent of grade and playing position. The authors demonstrated that a history of shoulder or elbow surgery was not related to performance on the FMS™ shoulder mobility test or SFMA upper extremity patterns. Differences in the dates of surgery at the time of testing, and sport-specific adaptations of the upper extremities that are common in baseball players due to the cumulative tissue stress from years of throwing at the collegiate level, may explain these insignificant findings.

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Comparison of Core Stability and Balance in Athletes With and Without Shoulder Injuries
Authors:  Pontillo M, Silfies S, Butowicz CM, Thigpen C, Sennett B, Ebaugh D
Relationships between core stability and lower extremity injuries have been described in the literature; however, evidence of the relationship between upper extremity injuries, core stability, and balance is limited.   The purpose of this study was to compare clinical measures of core stability and balance between athletes with and without non-traumatic shoulder injuries. Eighty athletes (54 males, age: 21.2+3.3 years) participated in this study. Forty athletes with a current shoulder injury were matched to healthy athletes by age, gender, BMI, and sport. Athletes completed clinical core stability tests including flexor and extensor endurance tests, double leg lower test (°) and balance tests including single leg stance under eyes open and eyes closed conditions, and the Y-balance test. MANOVAs were used to assess group differences. No statistically significant differences existed between athletes with and without shoulder injuries for clinical tests of core stability, F(1,78)=0.97, p=0.41; η2=0.04. No statistically significant differences existed between injured athletes with and without shoulder injuries for static and dynamic balance measures, F(1,78)=0.86, p=0.53;  η2=0.07. Although core stability is widely incorporated in rehabilitation of athletes with shoulder injuries, performance on these clinical tests did not differ in the group of athletes assessed in this study.

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Acute Effects of Muscle Energy Technique and Joint Mobilization on Shoulder Tightness in Youth Throwing Athletes: A Randomized Controlled Trial
Authors:  Reed ML, Begalle RL, Laudner KG
Posterior shoulder tightness (PST), defined as limited glenohumeral (GH) horizontal adduction and internal rotation motion, is a common occurrence in overhead athletes, particularly baseball and softball players, as a result of the extreme forces on the GH joint and the high number of throwing repetitions. Despite clinical evidence suggesting the use of joint mobilizations and muscle energy techniques (MET) for treating PST, there currently are no data examining the overall effectiveness of joint mobilizations and MET to determine optimal treatment for posterior shoulder tightness. Therefore that purpose of this study was to compare the acute effectiveness of MET and joint mobilizations for reducing posterior shoulder tightness, as measured by passive GH horizontal adduction and internal rotation ROM, among high school baseball and softball players. Forty-two asymptomatic high school baseball and softball players were randomly assigned to one of three groups (14 MET, 14 joint mobilization, 14 control). Glenohumeral passive adduction and internal rotation ROM were measured in all participants in a pre-test post-test fashion. Between testing, the joint mobilization group received one application of GH posterior joint mobilizations. The MET group received one cycle of MET applied to the GH horizontal abductors. The control group received no intervention. Posttest measures were completed immediately following intervention or a similar amount of time resting for the control group and then again 15 minutes later. One-way analyses of covariance showed that the MET group had significantly more horizontal adduction ROM post-treatment compared to the control group (p=0.04). No significant differences existed between groups in horizontal adduction (p>0.16) or internal rotation (p>.28) or at the 15-minute posttests (p>0.70). The results of this study indicate the application of MET to the horizontal abductors provides acute improvements to GH horizontal adduction ROM in high school baseball and softball players, while joint mobilizations provide no improvements.

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CASE SERIES / STUDIES
Conservative Treatment Continuum for Managing Femoroacetabular Impingement Syndrome and Acetabular Labral Tears in Surgical Candidates: A Case Series
Authors:  Narveson JR,  Haberl MD, Vannatta N, Rhon D
Femoroacetabular impingement Syndrome (FAIS) and the often-associated acetabular labral tears (ALTs) are challenging to treat and consensus to guide effective management is lacking. Recent guidelines suggest physical therapy is beneficial, yet the guidance for specific interventions is unclear. The purpose of highlighting these cases was to describe the outcomes and the clinical reasoning process driving conservative management of subjects with FAIS and ALTs that were deemed surgical candidates. Six subjects (20 - 65 years old) with confirmed FAIS and/or ALTs were included. Subjects were assigned to different treatment pathways based on their individual presentation. Three subjects were categorized as having primary mobility impairments and three were categorized with primary neuromuscular control impairments. Treatment intensity was adjusted according to the individual nature of symptoms, and on average lasted 81 days. Clinically important improvements were seen on all self-reported outcome measures (International Hip Outcome Tool – 33, Numeric Pain Rating Scale, Patient Specific Functional Scale, and Global Rating of Change). At two years, none of the subjects had elected surgical management.  These cases illustrate the clinical reasoning process utilized to prioritize subjects’ treatment along a continuum of neuromuscular control and mobility. The treatment approach also illustrates successful management of potential surgical candidates that elected to forego surgery after satisfactory completion of conservative management.

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Clinical Reasoning in the Face of Uncertainty: Conservative Physical Therapy Management of a Teenage Athlete Diagnosed with a Proximal Humeral Non-ossifying Fibroma
Authors:  Reynolds TJ, Costello M, Coviello JP
There have been few published studies regarding the treatment of patients with non-ossifying fibromas (NOFs), either conservatively or operatively. The purpose of this case report was to discuss the clinical presentation and conservative management of a teenage athlete diagnosed with a proximal humerus NOF. Thorough assessment of both neuromechanical sensitivity and musculoskeletal impairments may provide for the utilization of conservative treatment options for individuals with symptomatic NOFs.

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Rehabilitation of Chronic Brachial Plexus Neuropraxia and Loss of Cervical Extension in a High School Football Player: A Case Report
Authors:  Hartley RA, Kordecki ME
Brachial plexus neuropraxia (BPN), or "burners” and “stingers", affect 50-65% of football players, with a high rate of recurrence and the potential, in rare cases, for catastrophic injury. Existing literature on rehabilitation of these athletes is limited. The purpose of this case report is to describe the successful and comprehensive rehabilitation of a subject with recurrent brachial plexus neuropraxia using range of motion exercises, cervical and peri-scapular strengthening, stabilization exercises, and activity modification.  Regaining full upper body range of motion, strength, and dynamic stability, as well as normalizing tackling form, is essential to resolving BPN and preventing recurrence.  

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Efficacy of Reflexive Neuromuscular Stabilization during Treatment of Scapular Dyskinesia in an Overhead Athlete: A Case Report
Authors:  Cramer J
Shoulder injuries are common amongst overhead athletes.  Dysfunctional motor patterns (scapular dyskinesis) may be the cause or result.  Improperly treated, they can sideline athletes or reduce quality of life.  Functional tests, like those in the Selective Functional Movement Assessment (SFMA), help discern and properly identify dysfunction, paving the way for interventions like reflexive neuromuscular stabilization (RNS).  RNS focuses on restoring proper motor control and may positively influence healing.   In this case report, the use of the SFMA along with a traditional orthopedic examination allowed for proper identification and location of the dysfunctional motor patterns.  The coupling of a traditional modality with RNS proved to be a beneficial treatment combination for this subject as it provided a clinically meaningful resolution of his condition.  

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CLINICAL COMMENTARY / CURRENT CONCEPTS
Supraspinatus Tendon Pathomechanics: A Current Concepts Review
Authors:  Spargoli G
Tendinopathy of the supraspinatus muscle is a frequent cause of shoulder pain. Although it is a common condition, the pathophysiology is not fully understood. The purpose of this clinical commentary is to provide an overview of the pathophysiology of supraspinatus tendinopathy and discuss the conservative treatment solutions.  Knowledge of the general concepts regarding the development of supraspinatus tendinopathy, and of the healing process should guide physiotherapists when proposing treatment options. Physical modalities commonly utilized for supraspinatus tendinopathy such as: laser, ultrasound, and shock-wave therapy have little and contradictory evidence. Exercise in form of eccentric training may be considered as it seems to have beneficial effects, however, more research is needed.

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