Utilization of Blood Flow Restriction Therapy with a Former Triathlete After Total Knee Arthroplasty: A Case Report.

Introduction and Purpose: Knee osteoarthritis (OA) is a common condition that limits function and reduces quality of life. Total knee arthroplasty (TKA) is a surgical procedure that replaces the joint surfaces to address anatomical changes due to knee OA. While TKA improves symptoms and function, postoperative impairments are common, including reduced quadriceps strength. Blood flow restriction (BFR) may be a viable option for patients following TKA, as it can improve strength with a minimal amount of joint loading compared to traditional strength training. The purpose of this case report is to describe the impact of BFR use in an individual after TKA, employing pain measurements, quantitative sensory testing, patient-reported outcome measures, physical performance tests, and muscle strength and power testing to explore potential treatment effects and identify potential predictors of response for future studies. Case Description: A 49-year-old former female triathlete with a history of knee injury and arthroscopic surgery underwent a right TKA and sought physical therapy (PT) due to pain, limited range of motion (ROM), and knee instability during weight bearing activity. PT interventions included manual therapy, gait training, and a home program. Despite participating in supervised PT, she had persistent pain, ROM deficits, and muscle weakness 16 weeks following TKA. BFR was incorporated into her home program, 16-weeks postoperatively. The Short Form McGill Pain Questionnaire-2 (SF-MPQ-2) and Numeric Pain Rating Scale (NPRS) were used to measure pain. Quantitative sensory testing included pressure pain threshold (PPT) and two-point discrimination (TPD) to measure change in sensory perception. Patient-reported outcome measures to assess perceived physical function were the Knee injury and Osteoarthritis Outcome Score (KOOS) and the KOOS- Joint Replacement (KOOS-JR). Physical performance was measured through the 30-second fast walk test (30SFW), timed stair climb test (SCT), 30-second chair standing test (CST), and the timed up and go (TUG). Knee ROM was assessed through standard goniometry. Knee extensor and flexor muscle strength and power were measured with an instrumented dynamometer for isokinetic and isometric testing, generating a limb symmetry index (LSI). Outcomes: Pain and quantitative sensory testing achieved clinically meaningful improvement suggesting reduced sensitivity during and after BFR utilization. Perceived physical function and symptoms significantly improved, particularly in sports and recreation activities, and were best captured in the KOOS, not the KOOS-JR. Physical performance reached clinically meaningful improvement in walking speed, chair stand repetitions, and timed stair climb tests after BFR. Isokinetic and isometric strength and power in knee extensors and flexors increased significantly after BFR compared to the uninvolved leg as determined by LSI. Discussion: In this case, BFR appeared to be a safe and well-tolerated intervention. The results suggest potential benefits in terms of increased function, strength, power, and reduced pain in this specific person after TKA. Comprehensive pain and sensory assessments alongside clinical measures may help identify suitable patients for BFR after TKA. The KOOS-Sport & Recreation subscale may be more responsive to monitor functional recovery compared to the KOOS-JR, possibly due to the subject's athletic background. Level of Evidence: 4.

Males with patellofemoral pain have altered movements during step-down and single-leg squatting tasks compared to asymptomatic males: A cross-sectional study.

Background and Aims: Patellofemoral pain (PFP) is common in males, causing reduced physical activity and chronic pain. One proposed cause of PFP is aberrant biomechanics during tasks loading the patellofemoral joint. Consistent evidence exists for females with PFP, but it is uncertain if males with PFP have altered biomechanics. This study investigated the kinematics of males with PFP compared to pain-free males during forward step-down (StDn) and single-leg squat (SLSq). Methods: A cross-sectional study including 40 males aged 20-39 years (28.28 ± 5.46) was conducted (20 PFP, 20 pain-free). Participants performed StDn and SLSq while motion was captured with a video-based motion capture system (Motion Analysis Corporation). Triplanar peak angles and angular ranges of motion (ROM) of the trunk, pelvis, and weight-bearing hip, knee, and ankle were dependent variables. Mixed-model ANOVA tests were used to determine the presence of significant interactions and main effects of group and task. Results: Males with PFP had significantly lower peak knee adduction angles compared to pain-free males (p = 0.01). Significant group x task interactions were found for hip and pelvis ROM (p < 0.05). PFP participants had increased hip and pelvis ROM during StDn in the frontal and transverse planes but reduced or nearly equal ROM for these variables during SLSq. Peak hip adduction, hip internal rotation, contralateral pelvic drop and anterior tilt, trunk flexion, and ankle dorsiflexion were greater during StDn compared to SLSq (p < 0.05). ROM of the hip, pelvis, trunk, and ankle were greater during StDn compared to SLSq (p < 0.05). Conclusion: Males with PFP had reduced peak knee adduction angles in StDn and SLSq. Males with PFP demonstrated increased hip and pelvis ROM during StDn versus SLSq, particularly in the frontal and transverse planes. Clinicians should consider StDn as a clinical test since aberrant movement may be easier to detect than in SLSq.

Greater number of weekly stairs climbed is associated with lower low back pain prevalence among female but not male physical therapists.

INTRODUCTION: Certain cardiovascular health benefits of stair climbing are now widely accepted, but no prior studies have as yet been found linking the quantity of stairs climbed to low back pain (LBP) morbidity. Low back pain is a common musculoskeletal impairment, and research has begun to show an association between LBP and gluteus maximus (GM) weakness. With stair climbing being the activity which most activates GM, the aim of the present research was to assess the relationship between stair ambulation and LBP prevalence. The hypothesis of this cross-sectional study was that individuals with LBP would report a significantly lower numbers of stair flights climbed compared with individuals without LBP. METHODS: A survey tool was developed and distributed via email to a convenience sample of orthopedic physical therapists. Survey items included information regarding medical history, physical activity, workplace, and LBP factors, using a one-year prevalence period. RESULTS: A total of 363 respondents took the survey and, after application of exclusion criteria, 248 records remained in our final sample. When analyzing all genders together, non LBP (NLBP) respondents reported a mean of 51.62 flights climbed per week; and LBP respondents reported 37.82 flights climbed per week, with P = 0.077. When males and females were analyzed separately, a statistically significant difference in mean number of flights of stairs climbed was found among female respondents (61.51 flights climbed for NLBP and 35.61 flights climbed for LBP females; P = 0.031). When analyzed based on chronicity of LBP, an even stronger association between stairs climbed and LBP prevalence was found for female respondents with acute LBP (P = 0.009). CONCLUSIONS: More weekly stairs climbed was associated with a lower LBP prevalence among females, especially with respect to acute LBP. Randomized, longitudinal research is, however, required to confirm a relationship between stair climbing and LBP.

Patient-Reported Outcome Measures for Adults and Adolescents With Patellofemoral Pain: A Systematic Review of Construct Validity, Reliability, Responsiveness, and Interpretability Using the COSMIN Methodology.

OBJECTIVE: We aimed to appraise the construct validity, reliability, responsiveness, and interpretability of patient-reported outcome measures (PROMs) used to assess function and pain in adults and adolescents with patellofemoral pain (PFP). DESIGN: Systematic review of measurement properties LITERATURE SEARCH: We searched the PubMed, CINAHL, Scopus, SPORTDiscus, and Cochrane Library databases from inception to January 6, 2022. STUDY SELECTION CRITERIA: We included studies that assessed the measurement properties of English-language PROMs for PFP and their cultural adaptations and translations. DATA SYNTHESIS: Using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology, we determined overall ratings and quality of evidence for construct validity, internal consistency, reliability, measurement error, and responsiveness. We extracted data related to interpretability for clinical use. RESULTS: After screening 7066 titles, 61 studies for 33 PROMs were included. Only 2 PROMs had evidence of "sufficient" or "indeterminate" quality for all measurement properties. The Knee injury and Osteoarthritis Outcome Score patellofemoral subscale (KOOS-PF) had "low" to "high" quality evidence for a rating of "sufficient" for 4 measurement properties. The Lower Extremity Functional Scale (LEFS) had very low-quality evidence for a "sufficient" rating for 4 measurement properties. The KOOS-PF and LEFS were rated "indeterminate" for structural validity and internal consistency. The KOOS-PF had the best interpretability with reported minimal important change and 0% ceiling and floor effects. No studies examined cross-cultural validity. CONCLUSION: The KOOS-PF and LEFS had the strongest measurement properties among PROMs used for PFP. More research is needed, particularly regarding structural validity and interpretability of PROMs. J Orthop Sports Phys Ther 2023;53(8):1-20. Epub: 20 June 2023. doi:10.2519/jospt.2023.11730.

Patient-Reported Outcome Measures for Adults and Adolescents with Patellofemoral Pain: A Systematic Review of Content Validity and Feasibility Using the COSMIN Methodology.

OBJECTIVE: To assess the content validity and feasibility of patient-reported outcome measures (PROMs) used to assess pain and function in adults and adolescents with patellofemoral pain (PFP). DESIGN: Systematic review. LITERATURE SEARCH: We searched the databases PubMed, CINAHL, Scopus, SPORTDiscus, and the Cochrane Library from inception to January 6, 2022. STUDY SELECTION CRITERIA: We included studies that described the development or evaluation of the content validity of English-language PROMs for PFP, as well as their translations and cultural adaptations to different languages. DATA SYNTHESIS: Using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology, we determined overall ratings and quality of evidence for the relevance, comprehensiveness, and comprehensibility of PROMs. We extracted data related to feasibility for clinical use (eg, administration time and scoring ease). RESULTS: Forty-three studies for 33 PROMs were included. The overall quality of most studies was "inadequate" due to failure to engage stakeholders and/or ensure adherence to rigorous qualitative research procedures. Of all PROMs evaluated, the Knee injury and Osteoarthritis Outcome Score-Patellofemoral subscale (KOOS-PF), was the only PROM with sufficient content validity components. Quality of evidence for content validity of the KOOS-PF was low. Most PROMs were rated feasible for clinical and research purposes. CONCLUSION: Most PROMs used to measure pain and function in patients with PFP have inadequate content validity. The KOOS-PF had the highest overall content validity. We recommend the KOOS-PF for evaluating pain and function (in research and clinical practice) in adults and adolescents with PFP. J Orthop Sports Phys Ther 2023;53(1):23-39. Epub: 18 October 2022. doi:10.2519/jospt.2022.11317.

Survey of confidence and knowledge to manage patellofemoral pain in readers versus nonreaders of the physical therapy clinical practice guideline.

OBJECTIVES: To compare beliefs of physical therapists (PTs) who read the clinical practice guideline (CPG) for the management of individuals with patellofemoral pain (PFP) to those who have not read the CPG. DESIGN: Cross-sectional study. SETTING: Online survey. PARTICIPANTS: 494 currently licensed/registered PTs or physiotherapists. MAIN OUTCOME MEASURES: Respondents answered Likert-based or open-ended questions regarding the diagnosis, prognosis, risk factors, and management of individuals with PFP, as well as confidence for managing individuals with PFP, especially the ability to identify beneficial and non-beneficial interventions. We dichotomized responses into participants who read (READERS) and did not read (NonREADERS) the CPG. RESULTS: Most respondents held inaccurate beliefs about risk factors and prognosis; however, READERS' beliefs better aligned with the CPG than NonREADERS (P < 0.01). Most respondents correctly agreed that hip and knee exercise was the recommended treatment strategy; yet NonREADERS believed in implementing unsupported passive treatments (P < 0.01). READERS reported greater confidence in managing individuals with PFP, delivering evidence-based interventions, identifying less beneficial treatments, and locating evidence-based resources than NonREADERS (P < 0.01). CONCLUSION: While READERS and NonREADERS held accurate beliefs for exercise-based treatment for PFP, greater knowledge translation is needed to counter inaccurate beliefs regarding risk factors, prognostic factors, and passive treatments.

A Case of Thoracic Spondylosis Deformans and Multilevel Instrumented Spinal Fusion in an 84-Year-Old Male.

Spondylosis deformans is a type of spinal claw osteophytosis which can be found on the anterolateral vertebral bodies of any region, and which consists of protrusions of intervertebral disc tissue covered by a bony shell. We report here a case of thoracic spondylosis deformans and multilevel instrumented fusion found during routine dissection of a cadaver. Theories of the etiology of this condition are reviewed in general, and with respect to this specific case and the potential interaction of the presenting comorbidities. The clinical implications of these osteophytes, including musculoskeletal and visceral sequelae, are also discussed.

The Validity, Reliability, Measurement Error, and Minimum Detectable Change of the 30-Second Fast-Paced Walk Test in Persons with Knee Osteoarthritis: A Novel Test of Short-Distance Walking Ability.

OBJECTIVE: To develop and establish the reliability, validity, measurement error, and minimum detectable change of a novel 30-second fast-paced walk test (30SFW) in persons with knee osteoarthritis (OA) that is easy to administer and can quantify walking performance in persons of all abilities. METHODS: Twenty females with symptomatic knee OA (mean age [SD] 58.30 [8.05] years) and 20 age- and sex-matched asymptomatic controls (57.25 [8.71] years) participated in the study. Participants completed questionnaires of demographic and clinical data, the Knee Injury and Osteoarthritis Outcome Score (KOOS), and the 36-item Short Form Health Survey (SF-36) followed by 30SFW performance. Participants returned 2-7 days later and performed the 30SFW again. RESULTS: The knee OA group reported function that was worse than controls (all KOOS subscales; P < 0.0001). The 30SFW intrarater and interrater reliability were excellent [ICC (2,1) = 0.95-0.99]. Knee OA participants walked a shorter distance in the 30SFW than controls (mean [SD]: OA 44.4 m [9.5 m]; control 58.1 m [7.8 m]; P < 0.0001). Positive strong correlations were found between the 30SFW and the KOOS-Activity of Daily Living, SF-36-Physical Functioning, and SF-36-Physical Health Composite scores (P < 0.0001). A nonsignificant, weak correlation between 30SFW and SF-36-Mental Health scores was present (r = 0.32, P = 0.05). CONCLUSION: The 30SFW has excellent intrarater and interrater reliability. The 30SFW demonstrated excellent known groups, convergent, and discriminant validity as a measure of short-distance walking ability in persons with knee OA. Clinicians and researchers should consider using the 30SFW to quantify walking ability in persons with knee OA and assess walking ability change.

Patellofemoral Pain.

Patellofemoral pain (PFP) is a common musculoskeletal-related condition that is characterized by insidious onset of poorly defined pain, localized to the anterior retropatellar and/or peripatellar region of the knee. The onset of symptoms can be slow or acutely develop with a worsening of pain accompanying lower-limb loading activities (eg, squatting, prolonged sitting, ascending/descending stairs, jumping, or running). Symptoms can restrict participation in physical activity, sports, and work, as well as recur and persist for years. This clinical practice guideline will allow physical therapists and other rehabilitation specialists to stay up to date with evolving PFP knowledge and practices, and help them to make evidence-based treatment decisions. J Orthop Sports Phys Ther. 2019;49(9):CPG1-CPG95. doi:10.2519/jospt.2019.0302.

DO MALES WITH PATELLOFEMORAL PAIN HAVE POSTEROLATERAL HIP MUSCLE WEAKNESS?

BACKGROUND: Patellofemoral pain is common in physically active adults. Females with patellofemoral pain have been shown to have posterolateral hip muscle weakness, but there is a paucity of research examining hip muscle strength in males with patellofemoral pain. HYPOTHESIS/PURPOSE: The purpose of this study was to examine posterolateral hip muscle strength in males with patellofemoral pain compared to asymptomatic males. It was hypothesized that males with patellofemoral pain would have decreased strength of the hip extensor, hip external rotator, and hip abductor muscles compared to healthy, asymptomatic males. STUDY DESIGN: Descriptive, cross-sectional. METHODS: Thirty-six adult males with patellofemoral pain and 36 pain-free males participated in the study. The patellofemoral pain group were required to have retropatellar pain reproduced by activities that loaded the patellofemoral joint (squatting, descending stairs, etc.). Peak isometric torque of the hip extensors, hip external rotators, and hip abductors was measured with an instrumented dynamometer. Torque was normalized by body mass and height. Between-group differences were analyzed with parametric or non-parametric tests, as appropriate. The level of significance was adjusted for multiple comparisons. RESULTS: Hip extensor torque was significantly reduced in the patellofemoral pain group compared to the control group (p = .0165). No differences were found between groups for the hip external rotators or hip abductors (p > .0167). CONCLUSION: Males with patellofemoral pain appear to have weakness of the hip extensors, but unlike females with patellofemoral pain, they do not appear to have weakness of the hip abductors or hip external rotators. The findings of this study suggest that muscle strength factors associated with patellofemoral pain in males may be different from muscle strength factors in females. Clinicians examining and designing plans of care for male patients with patellofemoral pain should consider that the hip abductors and hip external rotators may not be weak in men with this condition. LEVEL OF EVIDENCE: Level 3.

A 6-week hip muscle strengthening and lumbopelvic-hip core stabilization program to improve pain, function, and quality of life in persons with patellofemoral osteoarthritis: a feasibility pilot study.

BACKGROUND: Patellofemoral joint (PFJ) osteoarthritis (OA) is prevalent in middle-aged and older adults. Despite this, there are minimal studies which have examined conservative interventions for PFJ OA. Weakness of proximal lower extremity muscles is associated with PFJ OA. It is unknown if a hip muscle strengthening and lumbopelvic-hip core stabilization program will improve symptoms and function in persons with PFJ OA. This study examined the feasibility and impact of a 6-week hip muscle strengthening and core stabilization program on pain, symptoms, physical performance, peak muscle torques, and quality of life in persons with PFJ OA. METHODS: Ten females with PFJ OA and ten age- and sex-matched controls participated in baseline tests. PFJ OA participants attended ten twice-a-week hip strengthening and core stabilization exercise sessions. Outcome measures included questionnaires, the Timed-Up-and-Go, and peak isometric torque of hip and quadriceps muscles. Data were tested for normality; parametric and non-parametric tests were used as appropriate. RESULTS: At baseline, the PFJ OA group had significantly worse symptoms, slower Timed-Up-and-Go performance, and lower muscle torques than control participants. PFJ OA group adherence to supervised exercise sessions was adequate. All PFJ OA participants attended at least nine exercise sessions. Five PFJ OA participants returned 6-month follow-up questionnaires, which was considered fair retention. The PFJ OA participants' self-reported pain, symptoms, function in daily living, function in sport, and quality of life all improved at 6 weeks (P < 0.05). Timed-Up-and-Go time score improved at 6 weeks (P = 0.005). Peak hip external rotator torque increased (P = 0.01). Improvements in pain and self-reported function were no longer significant 6 months following completion of the intervention. CONCLUSIONS: PFJ OA participants were adherent to the supervised sessions of the intervention. Improvement in symptoms, physical performance, and muscle torque were found after 6 weeks. Participant retention at 6 months was fair, and significant changes were no longer present. Our findings suggest that a hip strengthening and core stabilization program may be beneficial to improve symptoms, function, and physical performance in persons with PFJ OA. Future studies are needed, and additional measures should be taken to improve long-term adherence to exercise. TRIAL REGISTRATION: ClinicalTrials.gov NCT02825238. Registered 6 July 2016 (retrospectively registered).

THE INFLUENCE OF EXTRINSIC FACTORS ON KNEE BIOMECHANICS DURING CYCLING: A SYSTEMATIC REVIEW OF THE LITERATURE.

BACKGROUND: The knee is susceptible to injury during cycling due to the repetitive nature of the activity while generating torque on the pedal. Knee pain is the most common overuse related injury reported by cyclists, and intrinsic and extrinsic factors can contribute to the development of knee pain. PURPOSE: Due to the potential for various knee injuries, this purpose of this systematic review of the literature was to determine the association between biomechanical factors and knee injury risk in cyclists. STUDY DESIGN: Systematic review of the literature. METHODS: Literature searches were performed using CINAHL, Ovid, PubMed, Scopus and SPORTDiscus. Quality of studies was assessed using the Downs and Black Scale for non-randomized trials. RESULTS: Fourteen papers were identified that met inclusion and exclusion criteria. Only four studies included cyclists with knee pain. Studies were small with sample sizes ranging from 9-24 participants, and were of low to moderate quality. Biomechanical factors that may impact knee pain include cadence, power output, crank length, saddle fore/aft position, saddle height, and foot position. Changing these factors may lead to differing effects for cyclists who experience knee pain based on specific anatomical location. CONCLUSION: Changes in cycling parameters or positioning on the bicycle can impact movement, forces, and muscle activity around the knee. While studies show differences across some of the extrinsic factors included in this review, there is a lack of direct association between parameters/positioning on the cycle and knee injury risk due to the limited studies examining cyclists with and without pain or injury. The results of this review can provide guidance to professionals treating cyclists with knee pain, but more research is needed. LEVEL OF EVIDENCE: 3a.

DISTAL FIBULAR STRESS FRACTURE IN A FEMALE RECREATIONAL RUNNER: A CASE REPORT WITH MUSCULOSKELETAL ULTRASOUND IMAGING FINDINGS.

BACKGROUND AND PURPOSE: This case report describes a physical therapist's use of diagnostic ultrasound imaging in the decision making process used to refer a patient to a physician for a suspected fibular stress fracture. The purpose of this case report is to 1) describe the history, subjective examination, and objective examination findings of a fibular stress fracture, 2) describe the ultrasound findings associated with a fibular stress fracture, and 3) describe the decision making process of a physical therapist in the decision to refer the patient to a medical physician for further work-up. CASE DESCRIPTION: A 52-year-old female recreational runner with a recent increase in running intensity self-referred to a physical therapist with a 19-day history of lateral lower leg pain. Examination revealed relatively normal ankle range of motion, mild weakness of ankle invertors and evertors, no increase in pain with resisted muscle tests of the ankle, and tenderness to palpation over the fibularis brevis muscle and distal fibula. Diagnostic ultrasound examination of the fibularis muscles revealed cortical irregularity of the distal third of the fibula in the location of tenderness. OUTCOMES: The physical therapist used the abnormal ultrasound findings, running history, symptoms, and physical examination for differential diagnosis, and decided to refer the patient to a physician for further examination. Radiographs revealed a fibular stress fracture. Follow-up ultrasound imaging demonstrated a mixed hypoechoic-hyperechoic appearance of the fibular cortex typical of healing fracture and the presence of bony callus. DISCUSSION: Diagnostic ultrasound imaging is increasingly being used by physical therapists to guide rehabilitation. Ultrasound imaging of musculotendinous structures may display adjacent bone. Physical therapists should be knowledgeable of normal and abnormal bony ultrasound imaging findings. Abnormal ultrasound findings may be one sign indicating the need to refer a patient for consultation by a physician.

Physical performance measurement in persons with patellofemoral osteoarthritis: A pilot study.

BACKGROUND: Patellofemoral osteoarthritis (PFOA) is associated with pain and decreased self-reported function. The impact of PFOA on actual physical performance is currently unknown. OBJECTIVE: To investigate the impact of PFOA on physical performance and pain. METHODS: Eight participants aged 40-65 years with bilateral, symptomatic, radiographic PFOA and 7 age- and gender-matched pain-free control participants without radiographic PFOA were studied. Physical performance was measured with the Timed-Up-and-Go (TUG) and 50-foot Fast-Paced-Walk (FPW) tests. Dependent variables included time to complete the TUG and FPW; pretest-posttest change in pain intensity (TUG and FPW); and self-reports of perceived knee pain, stiffness, and physical function. Data were analyzed with nonparametric statistics. RESULTS: The PFOA group TUG time was longer than the control group (p=0.01). No difference between groups was found for FPW time. Pretest-posttest pain increased for the TUG and FPW in PFOA participants (p< 0.05). The PFOA group reported greater knee pain, stiffness, and less physical function than controls (previous 48 hours) (p < 0.01). CONCLUSIONS: Symptomatic, radiographic PFOA is associated with increased pain during the TUG and FPW tests and longer time required to complete the TUG. The TUG may be a more sensitive test of physical performance in PFOA.

The impact of sagittal plane hip position on isometric force of hip external rotator and internal rotator muscles in healthy young adults.

PURPOSE/BACKGROUND: Hip external rotator (ER) and internal rotator (IR) muscle weakness is theorized to be associated with lower extremity injury in athletes including knee ligament tears and patellofemoral pain. Previous studies investigating hip musculature strength have utilized various sagittal plane hip positions for testing. The relationship between results at these different positions is unknown. METHODS: Eighty healthy, pain-free young adults participated in the study: 40 female, mean age 22.90 (± 2.32) years, and 40 male, mean age 23.50 (± 2.15) years. Peak isometric torque of bilateral hip ER and IR were tested at 90° and 0° of hip flexion with an instrumented dynamometer. Peak muscle forces were calculated. Peak forces were normalized by body mass. Mean normalized force was calculated for dominant and non-dominant limbs for ER and IR in both positions. Male and female data were analyzed separately with paired t-tests (2-tailed). Reference values for average muscle force and torque were calculated for dominant and non-dominant limbs for both hip positions. RESULTS: Hip IR normalized peak force was greater at 90° compared to 0° flexion position bilaterally in both genders (p < .01). Hip ER normalized peak force was greater at 90° compared to 0° flexion in dominant limbs of both genders and in non-dominant limbs of males (p < .01). Non-dominant hip ER normalized force in females was greater at 90° versus 0° flexion; however, it was not significant (p = .092). Post hoc analysis of normalized average force (average over 5-second contraction) yielded similar results. CONCLUSION: Clinicians and researchers should use consistent positioning for testing of hip ER and IR strength. This will improve certainty of determining if a patient's strength has changed or if differences between groups are present. Reference values reported will be useful in order to determine if weakness is present and to set goals, particularly in cases of bilateral involvement. LEVEL OF EVIDENCE: 2b.

Frontal plane knee and hip kinematics during sit-to-stand and proximal lower extremity strength in persons with patellofemoral osteoarthritis: a pilot study.

Increased joint stress and malalignment are etiologic factors in osteoarthritis. Static tibiofemoral frontal plane malalignment is associated with patellofemoral osteoarthritis (PFOA). Patellofemoral joint stress is increased by activities such as sit-to-stand (STS); this stress may be even greater if dynamic frontal plane tibiofemoral malalignment occurs. If hip muscle or quadriceps weakness is present in persons with PFOA, aberrant tibiofemoral frontal plane movement may occur, with increased patellofemoral stress. No studies have investigated frontal plane tibiofemoral and hip kinematics during STS in persons with PFOA or the relationship of hip muscle and quadriceps strength to these motions. Eight PFOA and seven control subjects performed STS from a stool during three-dimensional motion capture. Hip muscle and quadriceps strength were measured as peak isometric force. The PFOA group demonstrated increased peak tibial abduction angles during STS, and decreased hip abductor, hip extensor, and quadriceps peak force versus controls. A moderate inverse relationship between peak tibial abduction angle and peak hip abductor force was present. No difference between groups was found for peak hip adduction angle or peak hip external rotator force. Dynamic tibiofemoral malalignment and proximal lower extremity weakness may cause increased patellofemoral stress and may contribute to PFOA incidence or progression.

Automobilization intervention and exercise for temporomandibular joint open lock.

Temporomandibular joint disorders (TMDs) are common and may cause temporomandibular joint (TMJ) locking, pain, and disability. Evidence supports use of manual therapy and exercise for treatment of TMDs including disk displacement limiting full mouth opening, TMJ 'closed lock'. Only limited case studies describe management of TMJ 'open lock', a condition due to posterior disk displacement (PDD) or TMJ anterior dislocation (TMJ-AD). Reported treatment for open lock includes splinting and intraoral joint manipulation. This case report describes a novel extraoral automobilization using the mandibular elevator muscles to treat TMJ open lock in a 22-year-old male after intraoral joint mobilization failed. The exercise program used to restore neuromuscular control for post-reduction management is described. Short term results of automobilization were excellent with restored ability to swallow, speak normally, and achieve occlusion. Long term results at 14 months were good: the patient was pain-free, could swallow and speak normally, had no recurrence of TMJ locking, and minimal disability. Limited right lateral excursion range and left mandibular deviation during mouth opening indicated possible persistence of PDD. This case suggests that mandibular elevator automobilization and masticatory muscle exercise may be useful to treat TMJ open lock and should be considered to treat PDD and TMJ-AD.