The Effect of Hip Joint Mobilizations Using a Mobilization Belt on Hip Range of Motion and Functional Outcomes.

CONTEXT: Joint mobilizations have been studied extensively in the literature for the glenohumeral joint and talocrural joint (ankle). Consequently, joint mobilizations have been established as an effective means of improving range of motion (ROM) within these joints. However, there is a lack of extant research to suggest these effects may apply within another critical joint in the body, the hip. OBJECTIVE: To examine the immediate effects of hip joint mobilizations on hip ROM and functional outcomes. Secondarily, this study sought to examine the efficacy of a novel hip mobilization protocol. DESIGN: A prospective exploratory study. SETTING: Two research labs. PATIENTS OR OTHER PARTICIPANTS: The study included 19 active male (n = 8) and female (n = 11) college students (20.56 [1.5] y, 171.70 [8.6] cm, 72.23 [12.9] kg). INTERVENTIONS: Bilateral hip mobilizations were administered with the use of a mobilization belt. Each participant received hip joint mobilization treatments once during 3 weekly sessions followed immediately by preintervention and postintervention testing/measurements. Testing for each participant occurred once per week, at the same time of day, for 3 consecutive weeks. Hip ROM was the first week, followed by modified Star Excursion Balance Test the second week and agility T test during the third week. MAIN OUTCOMES MEASURES: Pretest and posttest measurements included hip ROM for hip flexion, extension, abduction, adduction, internal and external rotation, as well as scores on the modified Star Excursion Balance Test (anterior, posterolateral, and posteromedial directions) and agility T test. RESULTS: A significant effect for time was found for hip adduction, internal and external rotation ROM, as well as the posterolateral and posteromedial directions of the modified Star Excursion Balance Test. A separate main effect for both limbs was found for adduction and internal rotation ROM. CONCLUSION: Isolated immediate changes in ROM and functional outcomes were evident. Further evaluation is needed.

The Effect of Foam Rolling Versus IASTM on Knee Range of Motion, Fascial Displacement, and Patient Satisfaction.

CONTEXT: Soft tissue restrictions have been linked to poor flexibility and decreased range of motion (ROM). To decrease the soft tissue restrictions and ultimately increase ROM/flexibility, myofascial release techniques, such as foam rolling (FR) and instrument-assisted soft tissue mobilization (IASTM), have been used. However, the benefit regarding which technique is more beneficial remains unknown. OBJECTIVE: To examine the effects of myofascial release techniques (FR vs the instrumented portion of IASTM) on knee joint ROM, rectus femoris (RF) and biceps femoris (BF) fascial displacement, and patient satisfaction. DESIGN: Randomized controlled clinical trial. SETTING: Mid-Atlantic University. PARTICIPANTS: Twenty moderately active participants (age 21.1 [2.0] y) with variable levels of soft tissue restriction in the quadriceps and hamstrings started and completed the study. Participants were randomly assigned to 2 groups, FR or IASTM. INTERVENTIONS: All participants completed the same warm-up prior to the intervention. The FR group followed the proper FR protocol for gluteals/iliotibial band, quadriceps, and hamstrings/adductors, and the participants were monitored while the protocol was completed. The IASTM group received treatment on the gluteals/iliotibial band followed by the quadriceps, adductors, and hamstrings. Participants in both groups attended intervention sessions twice per week for 3 weeks. Prior to the start, knee ROM measurements were taken, along with fascial displacement measured via ultrasound. Upon completion of the study, posttest measurements were completed. A patient satisfaction survey was also administered at this time. MAIN OUTCOME MEASURES: Pretest to posttest knee ROM measurements, RF and BF fascial displacement, and patient satisfaction. RESULTS: Both groups improved pretest to posttest for knee-extension ROM, with a slight trend toward increased knee-extension ROM for the FR group. Both groups improved pretest to posttest for BF and RF fascial displacement, in favor of the IASTM group for BF fascial displacement. Both groups were equally satisfied. CONCLUSIONS: As both groups improved pretest to posttest, either treatment could be used.

The Effect of Fatigue on Leg Muscle Activation and Tibial Acceleration During a Jumping Task.

CONTEXT: Lower-extremity stress fractures (SFx) are a common occurrence during load-bearing activities of jumping and landing. To detect biomechanical changes during jumping postinjury, a fatigue model could be used. OBJECTIVE: To evaluate muscle activation in the lower leg and tibial accelerations (TAs) prefatigue to postfatigue following a jumping task in those with and without a history of SFx. DESIGN: Repeated-measures. SETTING: Athletic Training Research Lab. PARTICIPANTS: A total of 30 active college-aged students with and without a history of lower-extremity (leg or foot) SFx (15 males and 15 females; 21.5 [5.04] y, height = 173.5 [12.7] cm, weight = 72.65 [16.4] kg). INTERVENTION: A maximal vertical jump on one leg 3 times with arms folded across the chest prefatigue to postfatigue was performed. Fatigue protocol was standing heel raises on a custom-built platform at a pace controlled by a metronome until task failure was reached. Legs were tested using a randomized testing order. Electromyographic (EMG) surface electrodes were placed on the medial gastrocnemius, soleus, and tibialis anterior following a standardized placement protocol. A triaxial accelerometer was attached to the proximal anteromedial surface of the tibia. MAIN OUTCOME MEASURES: Linear envelopes of the medial gastrocnemius, soleus, and tibialis anterior and peak accelerations (resultant acceleration takeoff and landing). RESULTS: Significant interaction for leg × test for tibialis anterior with a posttest difference between SFx and control (P = .05). There were decreases in EMG linear envelope following fatigue for medial gastrocnemius (P < .01) and tibialis anterior (P = .12) pretest to posttest. At takeoff, TA was greater in the SFx contralateral leg in comparison with the control leg (P = .04). At landing, TA was greater in posttest (P < .01) and in the SFx leg compared with SFx contralateral (P = .14). CONCLUSION: A decrease in muscle activity and an increase in TA following fatigue were noted for all subjects but especially for those with a history of SFx.

Effect of Prophylactic Ankle-Brace Use During a High School Competitive Basketball Season on Dynamic Postural Control.

CONTEXT: Few studies have evaluated the long-term effects of prophylactic ankle-brace use during a sport season. OBJECTIVE: To determine the effects of prophylactic ankle-brace use during a high school basketball season on dynamic postural control and functional tests. DESIGN: Prospective repeated-measures design. SETTING: High school athletic facility. PARTICIPANTS: 21 healthy high school basketball athletes (13 girls, 8 boys). INTERVENTIONS: The order of testing was randomized using the Star Excursion Balance Test (SEBT) for posteromedial (PM), medial (M), and anteromedial (AM) directions and 3 functional tests (FT) consisting of the single-leg crossover hop, single-leg vertical jump, and the single-leg 6-m hop for time at pre-, mid-, and postseason. After pretesting, the ankle brace was worn on both limbs during the entire 16-wk competitive basketball season. MAIN OUTCOME MEASURES: SEBT for PM, M, and AM and 3 single-leg FTs. RESULTS: Dynamic postural control using the SEBT and the 3 FTs improved over time, notably from pretest to posttest. The left limb was different from the right limb during the single-leg vertical jump. Effect sizes were large for pretest to posttest for the 3 SEBT directions and 2 of the 3 FTs. CONCLUSIONS: The 16-wk basketball prophylactic ankle-brace intervention significantly improved dynamic postural control and single-limb FTs over time.

Effect of Prophylactic Ankle-Brace Use During a High School Competitive Basketball Season on Dynamic Postural Control.

CONTEXT: Few studies have evaluated the long-term effects of prophylactic ankle-brace use during a sport season. OBJECTIVE: To determine the effects of prophylactic ankle-brace use during a high school basketball season on dynamic postural control and functional tests. DESIGN: Prospective repeated-measures design. SETTING: High school athletic facility. PARTICIPANTS: 21 healthy high school basketball athletes (13 girls, 8 boys). INTERVENTIONS: The order of testing was randomized using the Star Excursion Balance Test (SEBT) for posteromedial (PM), medial (M), and anteromedial (AM) directions and 3 functional tests (FT) consisting of the single-leg crossover hop, single-leg vertical jump, and the single-leg 6-m hop for time at pre-, mid-, and postseason. After pretesting, the ankle brace was worn on both limbs during the entire 16-wk competitive basketball season. MAIN OUTCOME MEASURES: SEBT for PM, M, and AM and 3 single-leg FTs. RESULTS: Dynamic postural control using the SEBT and the 3 FTs improved over time, notably from pretest to posttest. The left limb was different from the right limb during the single-leg vertical jump. Effect sizes were large for pretest to posttest for the 3 SEBT directions and 2 of the 3 FTs. CONCLUSIONS: The 16-wk basketball prophylactic ankle-brace intervention significantly improved dynamic postural control and single-limb FTs over time.

Improvement in dynamic balance and core endurance after a 6-week core-stability-training program in high school track and field athletes.

CONTEXT: Core training specifically for track and field athletes is vague, and it is not clear how it affects dynamic balance and core-endurance measures. OBJECTIVE: To determine the effects of a 6-week core-stabilization-training program for high school track and field athletes on dynamic balance and core endurance. DESIGN: Test-retest. SETTING: High school in north central West Virginia. PARTICIPANTS: Thirteen healthy high school student athletes from 1 track and field team volunteered for the study. INTERVENTIONS: Subjects completed pretesting 1 wk before data collection. They completed a 6-wk core-stabilization program designed specifically for track and field athletes. The program consisted of 3 levels with 6 exercises per level and lasted for 30 min each session 3 times per week. Subjects progressed to the next level at 2-wk intervals. After 6 wk, posttesting was conducted MAIN OUTCOME MEASURES: The subjects were evaluated using the Star Excursion Balance Test (SEBT) for posteromedial (PM), medial (M), and anteromedial (AM) directions; abdominal-fatigue test (AFT); back-extensor test (BET); and side-bridge test (SBT) for the right and left sides. RESULTS: Posttest results significantly improved for all 3 directions of the SEBT (PM, M, and AM), AFT, BET, right SBT, and left SBT. Effect size was large for all variables except for PM and AM, where a moderate effect was noted. Minimal-detectable-change scores exceeded the error of the measurements for all dependent variables. CONCLUSION: After the 6-wk core-stabilization-training program, measures of the SEBT, AFT, BET, and SBT improved, thus advocating the use of this core-stabilization-training program for track and field athletes.

Effects of a 4-week dynamic-balance-training program supplemented with Graston instrument-assisted soft-tissue mobilization for chronic ankle instability.

CONTEXT: A dynamic-balance-training (DBT) program supplemented with the Graston instrument-assisted soft-tissue mobilization (GISTM) technique has not been evaluated collectively as a treatment in subjects with chronic ankle instability (CAI). OBJECTIVE: To examine the effects of GISTM in conjunction with a DBT program on outcomes associated with CAI, including pain and disability, range of motion (ROM), and dynamic postural control. DESIGN: Pretest/posttest, repeated measures. SETTING: High school and a Division I mid-Atlantic university. PARTICIPANTS: Thirty-six healthy, physically active individuals (5 female, 31 male; age 17.7 ± 1.9 y; height 175.3 ± 14.6 cm) with a history of CAI as determined by an ankle-instability questionnaire volunteered to be in this study. INTERVENTIONS: Subjects were randomly assigned to 1 of 3 intervention groups: both treatments (DBT/GISTM, n = 13), DBT and a sham GISTM treatment (DBT/GISTM-S, n = 12), or DBT and control-no GISTM (DBT/C, n = 11). All groups participated in a 4-wk DBT program consisting of low-impact and dynamic activities that was progressed from week to week. The DBT/GISTM and DBT/GISTM-S groups received the GISTM treatment or sham treatment twice a week for 8 min before performing the DBT program. Pretest and posttest measurements included the Foot and Ankle Ability Measure (FAAM), FAAM Sport, the visual analog scale (VAS), ankle ROM in 4 directions, and the Star Excursion Balance Test (SEBT) in 3 directions. MAIN OUTCOME MEASURES: FAAM and FAAM-Sport scores, VAS, goniometric ROM (plantar flexion, dorsiflexion, inversion, eversion), and SEBT (anterior, posteromedial, posterolateral). RESULTS: Subjects in all groups posttest demonstrated an increase in FAAM, FAAM Sport, ROM, and SEBT in all directions but not in VAS, which decreased. No other results were significant. CONCLUSION: For subjects with CAI, dynamic postural control, ROM, pain and disability improved pretest to posttest regardless of group membership, with the largest effects found in most measures in the DBT/GISTM group.

Predicting dynamic balance improvements following 4-weeks of balance training in chronic ankle instability patients.

OBJECTIVES: Balance training typically features as a central component of exercise-based rehabilitation programs for patients with lateral ankle sprain and chronic ankle instability (CAI). The purpose of this study was to conduct a responder/non-responder analysis using existing data to identify factors associated with improvements in dynamic balance performance in CAI patients. DESIGN: Secondary data analysis. METHODS: Data was used from 73 CAI patients who participated in 6 previous investigations that used the same balance training program. We defined treatment success as a patient exceeding the minimal detectable change score (8.15%) for the posteriomedial direction of the Star Excursion Balance Test (SEBT-PM). Baseline measures of participant and injury demographics, patient-reported function, and dynamic balance were entered into a step-wise logistic regression model to determine the best set of predictors of treatment success. RESULTS: Only 28 out of 73 patients (38.4%) demonstrated a successful improvement in SEBT-PM reach after balance training. Of the variables assessed, SEBT-PM reach distance ≤85.18% and self-reported function activities of daily living score ≤92.55% were significant predictors of treatment success (p<0.001). If a patient met both these criteria there was a 70% probability of a successful treatment, indicating a 31.6% increase in the probability of a meaningful balance improvement after completing balance training. CONCLUSIONS: Without screening, less than 40% of CAI patients experience a meaningful improvement in SEBT-PM following balance training. Completing a brief pre-treatment assessment of a patient- and clinician-oriented outcome can significantly improve the probability of determining patients with CAI who may improve dynamic balance after balance training.

Two 4-Week Balance-Training Programs for Chronic Ankle Instability.

CONTEXT: Traditional single-limb balance (SLB) and progressive dynamic balance-training programs for those with chronic ankle instability (CAI) have been evaluated in the literature. However, which training program may be more beneficial is not known. OBJECTIVE: To investigate the effects of a progressive hop-to-stabilization balance (PHSB) program compared with an SLB program on self-reported function, dynamic postural control, and joint position sense (JPS) where angle and direction were self-reported by participants with CAI. DESIGN: Randomized controlled clinical trial. SETTING: A single testing location in a mid-Atlantic state. PATIENTS OR OTHER PARTICIPANTS: A total of 18 participants (age = 18.38 ± 1.81 years; height = 175.26 ± 6.64 cm; mass = 75.79 ± 12.1 kg) with CAI. INTERVENTION(S): Participants were randomly assigned to the PHSB or SLB program. The PHSB and SLB groups pursued their 4-week programs 3 times a week. The PHSB group performed a battery of single-limb hop-to-stabilization exercises, while the SLB group performed a series of SLB exercises. Exercises were advanced throughout the 4 weeks for both groups. MAIN OUTCOMES MEASURE(S): Pretest and posttest measurements were the Foot and Ankle Ability Measure (FAAM)-Activities of Daily Living subscale; FAAM-Sports subscale; Star Excursion Balance Test in the anterior, posteromedial, and posterolateral directions; and weight-bearing JPS blocks (dorsiflexion, plantar flexion, inversion, eversion). RESULTS: A significant main effect of time was present for the FAAM-Activities of Daily Living, FAAM-Sports, Star Excursion Balance Test (anterior, posteromedial, and posterolateral directions), and JPS (dorsiflexion, plantar flexion, inversion), as posttest results improved for the PHSB and SLB groups. The main effect of group was significant only for the FAAM-Sports, with the SLB group improving more than the PHSB group. CONCLUSIONS: Either a 4-week PHSB or SLB can be used in athletes with CAI, as both programs resulted in similar gains.

Reliability of first ray position and mobility measurements in experienced and inexperienced examiners.

CONTEXT: Neither reliability nor validity data exist for the Root method of clinically assessing first ray position or mobility by experienced and inexperienced examiners. OBJECTIVE: To determine intrarater and interrater reliability for first ray position and mobility measurements in experienced and inexperienced examiners. DESIGN: Single-blind prospective reliability study. SETTING: Physical therapy clinic. PATIENTS OR OTHER PARTICIPANTS: Four examiners, 2 experienced and 2 inexperienced, obtained first ray position and mobility measurements. Both feet of 36 subjects (14 males, 22 females) were measured. INTERVENTION(S): Each examiner evaluated first ray position and mobility for each of the subjects' feet on 2 separate occasions using the manual assessment techniques described by Root. MAIN OUTCOME MEASURE(S): First ray position (normal, plantar flexed, dorsiflexed) and mobility (normal, hypermobile, hypomobile) decisions were made. RESULTS: We calculated kappa correlation coefficients for intrarater and interrater reliability. For position, intrarater and interrater reliability ranged from .03 to .27 for all examiners, experienced and inexperienced. For mobility, intrarater and interrater reliability ranged from .02 to .26 for experienced, inexperienced, and experienced/inexperienced. The percentage agreement (P(O)) values for all examiners were less than 58%. For individual values for position, intrarater and interrater reliability ranged from .00 to .26. For individual values for mobility, intrarater and interrater reliability ranged from .00 to .26. The P(O) values for all examiners were less than 50%. CONCLUSIONS: Clinical experience was not associated with higher kappa coefficients or P(O) values when examiners assessed first ray position or mobility. Clinicians should acknowledge the poor reliability of first ray measurements, especially when making treatment decisions. Finally, a validity study to compare the Root techniques with a gold standard is warranted.

Autologous growth factor injections in chronic tendinopathy.

REFERENCE: de Vos RJ, van Veldhoven PLJ, Moen MH, Weir A, Tol JL. Autologous growth factor injections in chronic tendinopathy: a systematic review. Br Med Bull. 2010;95:63-77. CLINICAL QUESTION: The authors of this systematic review evaluated the literature to critically consider the effects of growth factors delivered through autologous whole-blood and platelet-rich-plasma (PRP) injections in managing wrist-flexor and -extensor tendinopathies, plantar fasciopathy, and patellar tendinopathy. The primary question was, according to the published literature, is there sufficient evidence to support the use of growth factors delivered through autologous whole-blood and PRP injections for chronic tendinopathy? DATA SOURCES: The authors performed a comprehensive, systematic literature search in October 2009 using PubMed, MEDLINE, EMBASE, CINAHL, and the Cochrane library without time limits. The following key words were used in different combinations: tendinopathy, tendinosis, tendinitis, tendons, tennis elbow, plantar fasciitis, platelet rich plasma, platelet transfusion, and autologous blood or injection. The search was limited to human studies in English. All bibliographies from the initial literature search were also viewed to identify additional relevant studies. STUDY SELECTION: Studies were eligible based on the following criteria: (1) Articles were suitable (inclusion criteria) if the participants had been clinically diagnosed as having chronic tendinopathy; (2) the design had to be a prospective clinical study, randomized controlled trial, nonrandomized clinical trial, or prospective case series; (3) a well-described intervention in the form of a growth factor injection with either PRP or autologous whole blood was used; and (4) the outcome was reported in terms of pain or function (or both). DATA EXTRACTION: All titles and abstracts were assessed by 2 researchers, and all relevant articles were obtained. Two researchers independently read the full text of each article to determine if it met the inclusion criteria. If opinions differed on suitability, a third reviewer was consulted to reach consensus. The data extracted included number of participants, study design, inclusion criteria, intervention, control group, primary outcome measures (pain using a visual analog or ordinal scale or function), time of follow-up, and outcomes for intervention and control group (percentage improvement) using a standardized data-extraction form. Function was evaluated in 9 of the 11 studies using (1) the Nirschl scale (elbow function) or the modified Mayo score for wrist flexors and extensors, (2) the Victorian Institute of Sports Assessment-Patella score, a validated outcome measure for patellar tendinopathy, or the Tegner score for patellar tendinopathy, and (3) the rearfoot score from the American Orthopaedic Foot and Ankle Scale for plantar fasciopathy. The Physiotherapy Evidence Database (PEDro) scale contains 11 items; items 2-11 receive 1 point each for a yes response. Reliability is sufficient (0.68) for the PEDro scale to be used to assess physiotherapy trials. A score of 6 or higher on the PEDro scale is considered a high-quality study; below 6 is considered a low-quality study. The PEDro score results determined the quality of the randomized controlled trial (RCT), nonrandomized clinical trial, or prospective case series (≥6 or <6). A qualitative analysis was used with 5 levels of evidence (strong, moderate, limited, conflicting, or no evidence) to determine recommendations for the use of the intervention. The number of high-quality or low-quality RCT or nonrandomized clinical trial studies with consistent or inconsistent results determined the level of evidence (1-5). MAIN RESULTS: Using the specific search criteria, the authors identified 418 potential sources. After screening of the title or abstract (or both), they excluded 405 sources, which left 13 studies. After viewing the full text, they excluded 2 additional sources (a case report and a study in which the outcome measure was remission of symptoms and not pain or function), leaving 11 studies for analysis. Six of the 11 studies were characterized by an observational, noncontrolled design; the remaining 5 studies were controlled clinical trials, 2 of which had proper randomization. The mean number of participants included in the studies was 40.5 (range = 20 to 100). Three of the studies were on "tennis elbow," 1 on "golfer's elbow," 1 on wrist extensor or flexor tendinopathy, 3 on plantar fasciopathy, and 3 on chronic patellar tendinopathy. Based on the information reported, there was no standardization of frequency or method of growth factor injection treatment or of preparation of the volume, and an optimal mixture was not described. Autologous whole-blood injections were used in 8 studies; in 5 studies, the autologous whole-blood injection was combined with a local anesthetic. In contrast, a local anesthetic was used in only 1 of the 3 PRP injection studies. The authors of the other 2 studies did not report whether a local anesthetic was used. The number of autologous whole-blood and PRP injections varied, ranging from 1 to 3. The centrifuging process was single or double for the PRP injections. In 2 studies, calcium was added to activate the platelets. A visual analogue or ordinal pain scale was used in 10 of the 11 studies. Function was evaluated in 9 of the 11 studies using (1) the Nirschl scale in 4 elbow studies or the modified Mayo score at baseline in 1 elbow study, (2) the Victorian Institute of Sports Assessment-Patella score for 1 study and the Tegner score for 2 of the patellar tendinopathy studies, and (3) the rearfoot score of the American Orthopaedic Foot and Ankle Scale for 1 plantar fasciopathy study. Only 1 study used an appropriate, disease-specific, validated tendinopathy measure (Victorian Institute of Sports Assessment-Patella). All intervention groups reported a significant improvement in pain or function score (or both), with a mean improvement of 66% over a mean follow-up of 9.4 months. The control groups in these studies also showed a mean improvement of 57%. None of the pain benefits among the intervention groups were greater than those for the control group at final follow-up. In 4 of the studies, the control group and the autologous growth factor injection group had similar results in pain or function or both, whereas in 2 studies, the control group had greater relief in pain than the injection group. Eleven studies were assessed using the PEDro scale. The PEDro scores for these studies ranged from 1 to 7, with an average score of 3.4. Only 3 studies had PEDro scores of ≥6 and were considered high quality. The 3 high-quality plantar fasciopathy studies used autologous growth factor injections but did not show a significant improvement over the control group. One of the studies that showed no beneficial effect for the autologous growth factor injections was compared with corticosteroids. Compared with other treatments, level 1 (strong) evidence demonstrated that autologous growth factor injections did not improve pain or function in plantar fasciopathy. The PRP injection results were based on 3 low-quality studies, 2 for the patellar tendon and 1 for the wrist flexors-extensors; level 3 (limited) evidence suggests that PRP injections improve pain or function. CONCLUSIONS: Strong evidence indicates that autologous growth factor injections do not improve plantar fasciopathy pain or function when combined with anesthetic agents or when compared with corticosteroid injections, dry needling, or exercise therapy treatments. Furthermore, limited evidence suggests that PRP injections are beneficial. Except for 2 high-quality RCT studies, the rest were methodologically flawed. Additional studies should be conducted using proper control groups, randomization, blinding, and validated disability outcome measures for pain and function. Until then, the results remain speculative because autologous whole-blood and PRP injection treatments are not standardized.

Special physical examination tests for superior labrum anterior-posterior shoulder tears: an examination of clinical usefulness.

REFERENCE/CITATION: Calvert E, Chambers GK, Regan W, Hawkins RH, Leith JM. Special physical examination tests for superior labrum anterior-posterior shoulder injuries are clinically limited and invalid: a diagnostic systematic review. J Clin Epidemiol. 2009;62(5):558-563. CLINICAL QUESTION: The systematic review focused on diagnostic accuracy studies to determine if evidence was sufficient to support the use of superior labrum anterior-posterior (SLAP) physical examination tests as valid and reliable. The primary question was whether there was sufficient evidence in the published literature to support the use of SLAP physical examination tests as valid and reliable diagnostic test procedures. DATA SOURCES: Studies published in English were identified through database searches on MEDLINE, EMBASE, and the Cochrane database (1970-2004) using the search term SLAP lesions. The medical subject headings of arthroscopy, shoulder joint, and athletic injuries were combined with test or testing, physical examination, and sensitivity and specificity to locate additional sources. Other sources were identified by rereviewing the reference lists of included studies and review articles. STUDY SELECTION: Studies were eligible based on the following criteria: (1) published in English, (2) focused on the physical examination of SLAP lesions, and (3) presented original data. A study was excluded if the article was limited to a clinical description of 1 or more special tests without any research focus to provide clinical accuracy data or if it did not focus on the topic. DATA EXTRACTION: The abstracts that were located through the search strategies were reviewed, and potentially relevant abstracts were selected. Strict epidemiologic methods were used to obtain and collate all relevant studies; the authors developed a study questionnaire to record study name, year of publication, study design, sample size, and statistics. Validity of the diagnostic test study was determined by applying the 5 criteria proposed by Calvert et al. If the study met the inclusion and validity criteria, 95% confidence intervals were calculated for each sensitivity, specificity, and positive and negative likelihood ratio reported. No specific information was provided about the procedure if the reviewers disagreed on how the evaluation criteria were applied. MAIN RESULTS: The specific search criteria led to the identification of 29 full-text articles. The studies were reviewed, and inclusion and exclusion criteria were applied. This resulted in 14 excluded studies and 15 eligible studies for analysis. Of the 15 eligible studies, 1 evaluated only a single physical examination test for a SLAP lesion or biceps tendon injury, and 10 studies evaluated 2 to 6 physical examination tests for a SLAP lesion or biceps tendon injury. Nine studies reported sensitivities and specificities greater than 75%, 4 had sensitivities less than 75%, 3 had specificities less than 75%, 1 did not report sensitivity, and 2 did not report specificities. When validity was assessed for those 15 papers, only 1 study that evaluated the biceps tendon met the 5 critical appraisal criteria of Calvert et al and calculated 95% confidence intervals. When the Speed and Yergason tests were each compared with the gold standard (arthroscopy), the confidence intervals for the positive and negative likelihood ratios spanned 1. This indicated that the test result is unlikely to change the odds of having or not having the condition, respectively. CONCLUSIONS: The literature currently used as a reference for teaching in medical schools and continuing education lacks the necessary validity to help rule in or out a SLAP lesion or biceps tendon involvement. Based on the results from the systematic review conducted by Calvert et al, no tests clinically diagnose a SLAP lesion. This is a cause for concern as magnetic resonance imaging or magnetic resonance arthrography, which are frequently used to assess a possible SLAP lesion, may also have diagnostic flaws and may be cost prohibitive. Performing arthroscopy on every patient to rule the condition in or out is unethical, especially if a SLAP lesion is not present. More rigorous validity studies should be conducted for SLAP lesion physical examination tests using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool or Standards for Reporting Diagnostic Accuracy (STARD) criteria.

National Athletic Trainers' Association position statement: prevention of pediatric overuse injuries.

OBJECTIVE: To provide certified athletic trainers, physicians, and other health care professionals with recommendations on best practices for the prevention of overuse sports injuries in pediatric athletes (aged 6-18 years). BACKGROUND: Participation in sports by the pediatric population has grown tremendously over the years. Although the health benefits of participation in competitive and recreational athletic events are numerous, one adverse consequence is sport-related injury. Overuse or repetitive trauma injuries represent approximately 50% of all pediatric sport-related injuries. It is speculated that more than half of these injuries may be preventable with simple approaches. RECOMMENDATIONS: Recommendations are provided based on current evidence regarding pediatric injury surveillance, identification of risk factors for injury, preparticipation physical examinations, proper supervision and education (coaching and medical), sport alterations, training and conditioning programs, and delayed specialization.

Comparative effects of 6-week balance, gluteus medius strength, and combined programs on dynamic postural control.

CONTEXT: There are few outcomes-based studies that address hip strategy and gluteus medius strength (GMS) for maintaining dynamic postural control. OBJECTIVE: To determine whether GMS training, proprioception training, or a combination of the 2 has an effect on dynamic postural control. DESIGN: Pretest-posttest, repeated measures. SETTING: Sports-medicine clinic. PARTICIPANTS: 48 healthy male and female college students obtained via sample of convenience. INTERVENTIONS: Three 6-wk programs including exercises for proprioception, GMS, and combined. MAIN OUTCOMES MEASURES: Eight Star Excursion Balance Test (SEBT) reach distances and GMS for the dominant leg. RESULTS: There was no significant difference between groups. The combination group demonstrated the most improvements in SEBT reach distances, whereas the GMS group demonstrated the most improvement in GMS. CONCLUSION: Use of exercises for proprioception, GMS, or a combination of the 2 will help improve dynamic postural control in healthy, active individuals.

The effects of 6-week training programs on throwing accuracy, proprioception, and core endurance in baseball.

CONTEXT: With a limited number of outcomes-based studies, only recommendations for strength-training and rehabilitation programs can be made. OBJECTIVE: To determine the extent to which throwing accuracy, core stability, and proprioception improved after completion of a 6-week training program that included open kinetic chain (OKC), closed kinetic chain (CKC), and/or core-stability exercises. DESIGN: A 2 x 3 factorial design. SETTING: Division III college. PARTICIPANTS: 19 healthy baseball athletes with a control group of 15. INTERVENTIONS: Two 6-week programs including OKC, CKC, and core-stabilization exercises that were progressed each week. MAIN OUTCOME MEASURES: Functional throwing-performance index, closed kinetic chain upper extremity stability test, back-extensor test, 45 degrees abdominal-fatigue test, and right- and left-side bridging test. RESULTS: There was no significant difference between groups. An increase was evident in all pretest-to-posttest results, with improvement ranging from 1.36% to 140%. CONCLUSION: Both of the 6-week training programs could be used to increase throwing accuracy, core stability, and proprioception in baseball.

The effects of eversion fatigue on frontal plane joint position sense in the ankle.

CONTEXT: There is limited information on fatigue of the evertors on frontal plane joint position sense (JPS). OBJECTIVE: To examine the effects of isokinetic concentric-eccentric fatigue of the evertors on frontal plane JPS of the ankle. DESIGN: A2 x 4 factorial design. SETTING: Research Laboratory. PATIENTS OR OTHER PARTICIPANTS: 40 male and female healthy subjects. INTERVENTIONS: JPS was tested at 10 degrees and 20 degrees of inversion and 5 degrees and 10 degrees of eversion in a nonfatigued/fatigued condition. After fatigue of evertors was determined on an isokinetic device, post fatigue testing of JPS occurred. MAIN OUTCOME MEASURES: JPS absolute error (AE) for inversion and eversion. RESULTS: Main effect for condition and angle were significant with pre/post fatigue. There were overestimation of angles postfatigue with AE greater at 20 degrees of inversion (P = .003), followed by 10 degrees of inversion (P < .001), 10 degrees of eversion (P = .005), and 5 degrees of eversion (P = .005). CONCLUSION: When the ankle evertors were fatigued, the AE for JPS was significantly higher at all test angles.

Three-MHz Ultrasound Heats Deeper Into the Tissues Than Originally Theorized.

OBJECTIVE: To measure muscle temperature of ultrasound at 1-MHz and 3-MHz frequencies at a depth of 2.5 cm and to compare treatment durations for vigorous heating (increase of 4 degrees C) and for heating to 40 degrees C. DESIGN AND SETTING: A counterbalanced, repeated-measures design with 1 fixed, independent variable, 1.5-W/cm(2) ultrasound treatment (1 MHz, 3 MHz, or control [sham]) using a Theratouch 7.7 ultrasound device. Dependent variables were end-treatment temperature at 2.5 cm, time to vigorous heating, and time to reach 40 degrees C. SUBJECTS: Eighteen healthy volunteers (age = 24.6 +/- 2.3 years, height = 173.0 +/- 9.7 cm, mass = 72.0 +/- 16.3 kg) without a history of lower leg injury. MEASUREMENTS: The medial triceps surae intramuscular temperature at 2.5 cm was measured every 10 seconds using an implantable thermocouple. Each of the 3 ultrasound frequencies was applied in counterbalanced order at 24-hour intervals. RESULTS: Ultrasound of 3 MHz produced both vigorous heating (at 3.4 minutes) and an absolute temperature of 40 degrees C (at 4 minutes). CONCLUSIONS: Our results suggest that 3-MHz ultrasound heats 0.5 cm deeper than suggested by others. With our machine, 3-MHz ultrasound was more effective in heating muscle at this depth than 1-MHz ultrasound.

The Bactericidal And Cytotoxic Effects Of Antimicrobial Wound Cleansers.

OBJECTIVE: Wound care is a part of daily activity for many athletic trainers. Knowing which cleansers are effective against the bacteria that most commonly cause infection and whether they are toxic to healthy cells enables athletic trainers to make educated decisions on which cleanser to use. We compared the bactericidal effectiveness and cytotoxicity to human fibroblast cells of 4 cleansers at various dilutions. DESIGN AND SETTING: A 4 x 4 factorial design was used for the cytotoxicity testing. The independent variables were type and dilution of cleanser. The dependent variable was cell viability of the human fibroblast cells. We used a 2 x 3 x 4 x 4 factorial design for the bacterial testing. The independent variables were type and dilution of bacteria and type and dilution of cleanser. The dependent variable was the bactericidal action of the cleanser on the bacteria. SUBJECTS: Human foreskin samples were used to obtain a line of fibroblast cells. Bacterial samples were obtained from an athletic training clinic, isolated from swabs of a whirlpool water supply valve (Pseudomonas aeruginosa) or skin surface (Staphylococcus aureus). MEASUREMENTS: We obtained bactericidal measurements by testing isolated Gram-negative (Pseudomonas aeruginosa) and Gram-positive (Staphylococcus aureus) bacteria. Minimum and maximum concentrations were identified according to bactericidal effectiveness. Cytotoxicity measurements were obtained from spectrophotometer readings of a neutral red assay for fibroblast cell viability. Final dilutions tested were determined by pilot testing. RESULTS: At the 1:5 dilution of product in sterile 0.9% saline, both Cinder Suds and Nitrotan and hydrogen peroxide were different from the control with regard to Pseudomonas aeruginosa. At the 1:10 dilution, both Betadine and hydrogen peroxide were different from the control with regard to Pseudomonas aeruginosa. These 2 cleansers were also different from each other. At the 1:10 dilution, only Betadine was not different from the control for the cytotoxicity testing. CONCLUSIONS: Betadine was both effective against bacteria and not harmful to human fibroblast cells at a 1:10 dilution of a commercially purchased solution.

Effect of short duration electromagnetic field exposures on rat mass.

Daily preexposure and postexposure mass measurements of 65 rats (young males and females, old males) a proprietary pulsed wound healing field, pulsed electromagnetic field, (PEMF), or their control fields for 4 h/day for 21 days. Statistical analysis of mass changes over time showed that young rats exposed to PEMF lost more mass and recovered it more slowly compared to controls (2-4% more loss) than did older PEMF exposed rats or any 60 Hz exposed rats. We conclude that daily preexposure and postexposure mass measurements are needed to adequately assess the effects of electromagnetic fields on body mass.