Using an Arthrometer to Quantify Ankle Laxity: An Infographic Summary.

Lateral ankle sprains are a common musculoskeletal injury. The anterior talofibular ligament (ATFL) is the primary ligament involved and is assessed via an anterior drawer test. Clinically assessing joint laxity has been a subjective task. Evaluating both magnitude of translation and quality of the endfeel has presented challenges. Until recently, a reliable and valid arthrometer to test joints other than the knee has not been available. The Mobil-Aider arthrometer has undergone bench testing for validity, reliability testing in healthy persons, and most recently the testing of participants for pathology. A summary of these studies is available in the Online Supplement. The goal of this study was to determine the ability of the arthrometer to objectively identify the anterior translation of the ankle and the relationship to the clinical diagnosis. The participant was evaluated by a physician and magnitude of ankle sprain was determined. An arthrometer was used to perform an anterior drawer test (uninjured before injured, 3 measures each) in the prone position. Both clinicians were blinded to the data of the other. There were 30 participants, 10 per group (uninjured, 1° sprain, 2° sprain). Mann-Whitney U testing found significant differences between the control and grade 1 ankle sprain groups (P < .001), the control and grade 2 ankle sprain groups (P < .001), and the grade 1 and grade 2 ankle sprain groups (P = .004). There was ± 0.31 mm difference in anterior translation between healthy ankles, whereas there was 1.11 mm and 2.16 mm difference between ankles in grade 1 and grade 2 sprains, respectively. The anterior drawer test is the gold standard for clinical ATFL testing, but the subjective nature of this test poses challenges. Technology is available to assess ankle joint laxity and enhance the objectivity of patient assessment and throughout the recovery process. An arthrometer is a valuable tool in quantifying orthopaedic examination.

Comparative Analysis of Predetermined Axillary Crutch Length Settings to Individualized Fittings.

Axillary crutches are the most common assistive devices given to individuals with musculoskeletal injuries in an acute care setting. Nurses are frequently the care provider fitting injured individuals with crutches. This study compared the crutch length determined by the crutch manufacturer's height setting with the crutch length attained after applying a standard clinical protocol for crutch fitting. A total of 116 adults with lower extremity injuries were enrolled. Self-reported height was documented as well as initial crutch length as indicated by the numbers on the push-button feature of the crutches. Subject height with and without shoes was measured. Proper crutch length was then determined using the method described by Bauer et al. (1991). No change between the initial and adjusted crutch settings was made in 43% of the subjects. Change was made in 57% of the subjects: lengthening in 40% and shortening in 17% of subjects. This study revealed the predetermined crutch settings are unreliable and should simply be used as a starting point during a personalized fitting.

Comparison of Anterior Ankle Translation With and Without Ankle Braces.

BACKGROUND: Lateral ankle sprains are a common musculoskeletal injury. Ankle braces are frequently used to prevent ankle injuries. AIM: The purpose of this study was to examine the anterior translation of the talocrural joint of 2 ankle braces relative to a control. METHODS: Ankle mobility was assessed with the Mobil-Aider arthrometer in 3 conditions: TayCo ankle brace, Aircast ankle brace, and control. Three measures were recorded for each condition. RESULTS: Thirty participants (9 male and 21 female patients) participated. Friedman's analysis of variance found significant between-group differences for the trial with the largest translation. Wilcoxon signed-ranks post hoc testing found significant between-group differences between the control and TayCo (P < .001) and the control and Aircast conditions (P < .001). Post hoc power analysis revealed a Kendall's W of 0.804. CLINICAL APPLICATION: The TayCo brace is unique in that it is worn on the outside of the athletic shoe, whereas the Aircast is composed of lateral constraints worn inside the shoe. Both braces provided significant constraint over anterior talus translation when compared to control. The TayCo brace (51%-52% of control) was also significantly better than the Aircast (58%-59% of control) with less anterior translation permitted. This may be instrumental in preventing ankle injuries. LEVEL OF EVIDENCE: 2b.

Assessing Lateral Ankle Sprains With a New Arthrometer.

BACKGROUND: Lateral ankle sprains are a common musculoskeletal injury across a variety of activities. Researchers have sought to identify a method to objectively assess joint laxity with a device that is simple to use and affordable. AIM: The purpose of this study was to assess the use of an ankle arthrometer on individuals with ankle sprains. METHODS: The participant was evaluated by the physician and the degree of ankle sprain was identified. In the prone position, the arthrometer was used to perform an anterior drawer test (uninjured before injured, 3 measures each). Both clinicians were blinded to the data of the other. RESULTS: There were 30 participants, 10 in each group (uninjured, grade 1 sprain, grade 2 sprain). Mann-Whitney U testing found significant differences between the control and grade I ankle sprain groups (P < .001), the control and grade II ankle sprain groups (P < .001), and the grade I and grade II ankle sprain groups (P = .004). There was ±0.31-mm difference in anterior translation between healthy ankles, whereas there was 1.11- and 2.16-mm difference between ankles in grade 1 and grade 2 sprains, respectively. CLINICAL APPLICATION: Despite the manual anterior drawer test being convenient, the subjectivity makes it unreliable. This study is consistent with prior literature about the difference in translation (millimeters) between the uninjured and injured ankles corresponding to the magnitude of ankle laxity. This study also contributes to the evolving evidence to support the relationship of a ratio of measures (injured/uninjured) as an objective measure of laxity. These comparisons to the individual's healthy ankle mitigate the variability of the normative values. The use of an arthrometer to assess ankle joint laxity enhances the objectivity of patient assessment throughout the recovery process. LEVELS OF EVIDENCE: Level III.

Reliability and Validity of an Innovative Device for ACL Testing: The Mobil-Aider™.

BACKGROUND: Knee disorders prevalence is estimated at more than 50% in a lifetime. There are over 250,000 anterior cruciate ligament (ACL) injuries per year in the United States. There are over 175,000 ACL reconstructions annually. This study was a double-blinded design to establish the reliability and validity of a new orthopedic device to measure linear translation of the tibia on the femur (ACL testing). METHODS: A Zeiss Smartzoom microscope was used as the gold standard to assess the ability of the Mobil-Aider™ to measure linear translation. Sixty blinded measures were taken with each of 6 different devices. RESULTS: Both the intraclass correlation and the Pearson correlation were .986. The Cronbach alpha reliability analysis was 0.992. Independent 1-sample t tests were performed on the differences between the Mobil-Aider™ and Zeiss values, and were not found to be significant (P = .42); that is, they were the same. Bland-Altman plot and a linear regression revealed no propositional bias. Finally, with 360 measures over 6 devices, the power of this study was calculated to be 100%. DISCUSSION: This data are the first step in establishing reliability and concurrent validity of a new device. As a result of the current data, the Mobil-Aider™ device is deemed a promising orthopedic tool for use in assessing the laxity of the ACL. Additional testing needs to be performed on both healthy and injured knees. CONCLUSIONS: There is potential for the Mobil-Aider™ to contribute to the assessment of ACL injuries, but additional human testing is needed.

Instrument-assisted soft tissue mobilization increases myofascial trigger point pain threshold.

BACKGROUND: A myofascial trigger point (MTrP) has been defined as a hyperirritable, palpable nodule in a skeletal muscle. The signs and symptoms of a MTrP include muscle pain, weakness, and dysfunction. MTrPs are common problems associated with soft tissue pathology. Having an intervention to decrease MTrP pain can be clinically valuable. PURPOSE: To determine if a series of six instrument-assisted soft tissue mobilization (IASTM) treatments rendered over three weeks would influence the pressure pain threshold (PPT) of a myofascial trigger point (MTrP). METHODS: Randomized, control trial of healthy individuals (n = 29) with MTrPs in the upper trapezius muscle. The intervention was six IASTM treatments rendered over three weeks. Each treatment included 1 min of sweeping with the GT-1/HG-2 (handle bar), 1 min of swivel with the knob of the GT-1/HG-2 directly over the MTrP, 2 min of fanning with the GT-4/HG-8 (convex single bevel), and concluded with 1 min of sweeping with GT-1/HG-2. The outcome measure used a dolorimeter to compare PPT before and after three weeks in both the treatment and control groups. RESULTS: Paired t-test for PPT pre-test and post-test of the control and treatment groups were p = 0.42159 and p = 0.00003, respectively. A one-way ANOVA of the control and IASTM groups revealed a statistically significant difference (p < 0.0001). The power calculation was greater than 0.99. CONCLUSIONS: A 5-min intervention using three IASTM techniques can effectively increase the PPT of a MTrP in six treatments over a three-week period of time.

Validity and Reliability of 2 Goniometric Mobile Apps: Device, Application, and Examiner Factors.

CONTEXT: Smartphones are being used in a variety of practice settings to measure joint range of motion (ROM). A number of factors can affect the validity of the measurements generated. However, there are no studies examining smartphone-based goniometer applications focusing on measurement variability and error arising from the electromechanical properties of the device being used. OBJECTIVE: To examine the concurrent validity and interrater reliability of 2 goniometric mobile applications (Goniometer Records, Goniometer Pro), an inclinometer, and a universal goniometer (UG). DESIGN: Nonexperimental, descriptive validation study. SETTING: University laboratory. PARTICIPANTS: 3 physical therapists having an average of 25 y of experience. MAIN OUTCOME MEASURES: Three standardized angles (acute, right, obtuse) were constructed to replicate the movement of a hinge joint in the human body. Angular changes were measured and compared across 3 raters who used 3 different devices (UG, inclinometer, and 2 goniometric apps installed on 3 different smartphones: Apple iPhone 5, LG Android, and Samsung SIII Android). Intraclass correlation coefficients (ICCs) and Bland-Altman plots were used to examine interrater reliability and concurrent validity. RESULTS: Interrater reliability for each of the smartphone apps, inclinometer and UG were excellent (ICC = .995-1.000). Concurrent validity was also good (ICC = .998-.999). Based on the Bland-Altman plots, the means of the differences between the devices were low (range = -0.4° to 1.2°). CONCLUSIONS: This study identifies the error inherent in measurement that is independent of patient factors and due to the smartphone, the installed apps, and examiner skill. Less than 2° of measurement variability was attributable to those factors alone. The data suggest that 3 smartphones with the 2 installed apps are a viable substitute for using a UG or an inclinometer when measuring angular changes that typically occur when examining ROM and demonstrate the capacity of multiple examiners to accurately use smartphone-based goniometers.

Influence of instrument assisted soft tissue treatment techniques on myofascial trigger points.

OBJECTIVE: The purpose of this study was to examine the influence of instrument assisted soft tissue techniques (IASTT) on myofascial trigger points (MTrP). DESIGN: Randomized, controlled study with the researcher assessing the MTrP sensitivity blinded to the treatment rendered. PARTICIPANTS: Phase 1 = 27; Phase 2 = 22. INTERVENTION: MTrPs were identified in the upper back. In phase 1, two MTrPs (right & left) were identified. One was treated with IASTT, the other was a control. In phase 2, one MTrP was identified in a treatment and a control group. In each phase, the treatment groups received six treatments of IASTT. OUTCOME MEASURES: Sensitivity threshold of the MTrP was assessed with a dolorimeter. RESULTS: There was a significant improvement in both groups over time but there was no difference between the treatment and control groups. CONCLUSIONS: The use of a pressure dolorimeter may have served as a form of ischemic compression treatment. This assessment tool may have been a mitigating factor in the over-shadowing any potential influence of the IASTT on the MTrP. Thus, another assessment tool needs to be identified for MTrP assessment. Until that technique is identified, the effect of IASTT on MTrPs in inconclusive.

Effects of MagPro™ on muscle performance.

Athletes are on an endless quest to enhance performance and are frequently barraged by products that purport to contribute to various components of athletic activity. The purpose of this study was to determine if MagPro™ influenced muscle flexibility or muscle endurance. This was a double-blind, randomized, controlled study using a repeated-measures design. The Institutional Review Board approved consent was obtained. The participants were healthy, physically active adults (n = 38 for phase 1; n = 18 for phase 2). Two creams were used: MagPro™ (Mg cream) and a placebo. In phase 1, each cream was applied to the gastroc-soleus muscles. A stretching protocol was completed, and ankle dorsiflexion was compared. In phase 2, 1 cream was applied to both quadriceps muscles. An endurance protocol using a Life Fitness bicycle was completed. The procedure was repeated with the other cream on the quadriceps muscle 1 week later. For the flexibility phase, an analysis of variance with repeated measures revealed no difference between the 2 creams (p = 0.50), but there was a change in the flexibility over time (p = 0.00). For the endurance phase, paired t-tests revealed that there was no significant difference between the first (p = 0.26) or second (p = 0.35) cycling bouts of either cream. Likewise, there were no differences between the first and second cycling bouts of both the creams (MagPro™ p = 0.46; Placebo p = 0.08). Despite previous studies demonstrating improved performance with Mg supplements, MagPro™ did not enhance the outcome measures of this study. Examination of alternative application techniques and other outcome measures would be appropriate.

Effect of ischemic pressure using a Backnobber II device on discomfort associated with myofascial trigger points.

OBJECTIVE: The purpose of this study was to assess the effectiveness of ischemic pressure on myofascial trigger point (MTrP) sensitivity. DESIGN: Randomized, controlled study with the researcher assessing MTrP sensitivity blinded to the intervention. PARTICIPANTS: Twenty-eight people with two MTrPs in the upper back musculature. INTERVENTION: The sensitivity of two MTrPs in the upper back was assessed with a JTECH algometer. One of the two MTrPs was randomly selected for treatment with a Backnobber II, while the other served as a control. OUTCOME MEASURES: Pre- and post-test pressure-pain thresholds of the MTrPs RESULTS: There was a significant difference between the pre- and post-test sensitivities of the treated and non-treated MTrPs (p=0.04). CONCLUSIONS: The results of this study confirm that the protocol of six repetitions of 30-s ischemic compression with the Backnobber II rendered every other day for a week was effective in reducing MTrP irritability.

Effect of patterned electrical neuromuscular stimulation on vertical jump in collegiate athletes.

BACKGROUND: Patterned electrical neuromuscular stimulation (PENS) uses the electrical stimulation of sensory and motor nerves to achieve a skeletal muscle contraction using an electromyogram-derived functional pattern. PENS is used extensively for neuromuscular reeducation and treatment of muscle disuse atrophy. PURPOSE: To explore the effectiveness of PENS as applied to the quadriceps muscles on the vertical jump of an athletic population. STUDY DESIGN: Experimental with control and repeated measures over time. METHODS: Healthy college athletes (54 women, 75 men) were divided into 3 groups (control, n = 30; jump, n = 33; and jump with PENS, n = 63). There was no difference among groups' height and weight. Athletes performed a baseline standing vertical jump using a vertical jump system. The control group continued its normal daily activities with no jumping tasks included. The jump groups performed 3 sets of 12 repetitions with a 2-minute rest between sets at a frequency of 3 times per week. The PENS group did the jumping with the coordination of an electrical stimulation system. Vertical jump was retested after 6 weeks of intervention and 2 weeks after cessation. RESULTS: A 3-way repeated measures analysis of variance for time (control, jump alone, jump with PENS) revealed a significant difference (P < 0.05) for time and an interaction between time and treatment, as well as a significant difference for the PENS group from baseline to posttest and for the jump group from posttest to follow-up jump. There was no significant difference between groups for the baseline vertical jump. CONCLUSIONS: This study demonstrated that 6 weeks of vertical jump training coordinated with PENS resulted in a greater increase than jumping only or control. This pattern of stimulation with PENS in combination with jump training may positively affect jumping.

Comparison of tissue heating between manual and hands-free ultrasound techniques.

The objective of this single-factor repeated-measures design was to examine the effectiveness of tissue heating with a hands-free ultrasound (US) technique compared to a hand-held US transducer using the Rich-Mar AutoSound unit. US is a therapeutic modality often used to provide deep tissue heating. Recently, a "hands-free" US unit was introduced by Rich-Mar Incorporated. This unit allows the clinician to choose the mode of US delivery, using either a handheld (manual) transducer or a hands-free device that pulses the US beam through the transducer. However, the Center for Medicare and Medicaid Services has deemed delivery of US via a hands-free unit to be investigational. Forty volunteers over 18 years of age participated. Treatment was provided at a 3-MHz US frequency. Muscle temperature was measured with 26-gauge, 4-cm Physiotemp thermistors placed in the triceps surae muscle. The depth of thermistor placement was at 1 - and 2-cm deep. One calf was treated with a manual transducer (5-cm(2) US head at three times the effective radiating area [ERA]), and one calf was treated with the hands-free transducer (14-cm(2) [ERA]). Both methods used a 1.5 W/cm(2) intensity for 10 minutes. The manual technique used an overlapping circular method at 4 cm/sec, and the hands-free method used a sequential pulsing at 4 cm/sec. Tissue temperatures were recorded at baseline and every 30 seconds. The hands-free technique resulted in a tissue temperature increase from 33.68 to 38.7 degrees C and an increase from 33.45 to 40.1 degrees C using the manual technique at 1-cm depth. The tissue temperature increase at the 2-cm depth was from 34.95 to 35.44 degrees C for the hands-free device and 34.44 to 38.42 degrees C for the manual device. Thus, there was a significant difference between the hands-free and the manual mode of US delivery for the 3-MHz frequency (5.02 degrees C vs. 6.65 degrees C at 1 cm and 1.49 degrees C vs. 3.98 degrees C at 2 cm). In this study, the "hands-free" device did not result in the same level of tissue heating as the manual technique. The hands-free device has the advantage of not needing a clinician present to deliver the modality but a therapeutic level of heating was not achieved at the 2-cm tissue depth. Thus, the efficacy of the "hands-free" treatment is in question.

Effect of analgesic nerve block electrical stimulation in a patient with adhesive capsulitis.

Although the pathophysiology of adhesive capsulitis is poorly understood, the primary goal of therapeutic intervention is to restore pain-free, functional range of motion (ROM) of the shoulder. Pain and muscle guarding, particularly of the subscapularis muscle, are common impairments that occur with adhesive capsulitis. The purpose of this case report is to describe a novel approach to help the pain-muscle guarding-pain cycle associated with pain and limited shoulder motion in a patient with a medical diagnosis of adhesive capsulitis. The patient was a 64-year-old female with adhesive capsulitis. Outcome variables were the Shoulder Pain and Disability Index (SPADI), internal rotation (IR) and external rotation (ER) ROM, and rotational lack. Twelve treatments of moist heat, analgesic nerve block electrical stimulation, contract/relax exercises for shoulder IR/ER, and Pendulum/Codman exercises were administered. After both 2 and 4 weeks of treatment, the patient demonstrated marked improvements in all areas. Overall, there was a 78-106% increase in ROM (IR and ER) and a 50-83% improvement in functional mobility (rotational lack & SPADI). It appears that analgesic electrical stimulation may have helped decrease the pain-muscle guarding cycle associated with adhesive capsulitis to enhance functional outcomes in a timely manner.

Exploration of a variation of the bottle buoyancy technique for the assessment of body composition.

Hydrostatic weighing has long been recognized as a reliable and valid method for the assessment of body composition. An alternative method known as bottle buoyancy (BB) was introduced by Katch, Hortobagyi, and Denahan in 1989. The purpose of this clinical investigation was to determine the accuracy of the BB technique using an 11-L container. Sixteen individuals (8 men, 8 women) were weighed hydrostatically using a chair/scale and the BB technique. The overall intraclass correlation coefficient for the two techniques was 0.9537. A 2-variable ANOVA was significant for gender but not for technique, and there was no interaction between variables. Thus, the BB technique appears to be an accurate substitute for the chair/scale technique for hydrostatic weighing. The BB method does not involve elaborate equipment and is portable. It could be improved with the use of multiple bottles of various volumes or a calibrated bottle to minimize the number of trials needed for accurate measurements. BB is a valuable, simple clinical tool for assessing body composition based on the principles of hydrostatic weighing and can be performed in any high school, college, or community swimming pool.

Anterior cruciate ligament reconstruction: clinical outcomes of patella tendon and hamstring tendon grafts.

An injury to the ACL can result in significant functional impairment. It has been estimated that more than 100,000 new ACL injuries occur each year. Surgeons employ numerous techniques for reconstruction of the ACL. Of critical importance is the source of the graft to replace the damaged ACL. The graft choices include autografts (the patient's own tissue), allografts (donor tendon), and synthetic/prosthetic ligaments. Tissue harvest sites for autografting include the middle third of the patella tendon, the quadriceps tendon, semitendinosus tendon, gracilis tendon, iliotibial band, tensor fascia lata, and the Achilles tendon. Selection of the type of graft material is predicated upon the tissue's ability to tolerate high levels of stress. Likewise, the clinical presentation and functional outcome is related to the graft material selected. This manuscript specifically examined the patella tendon and hamstring tendon grafts. Numerous manuscripts that studied the outcomes of these graft materials were compiled to help the clinician appreciate the advantages and disadvantages of each of the graft materials. Outcome measures such as thigh circumference, knee range of motion, isokinetic strength, knee stability, pain, and vertical jump/1-leg hop were incorporated. The purpose of this manuscript was to compare and contrast the clinical presentation of patients who underwent an ACL reconstruction using the patella tendon versus the hamstring tendons. This information can be valuable to the clinician when considering the rehabilitation protocol after ACL reconstruction.