Changes in Running Kinematics and Kinetics Following a 10 km Run.

Background: Little is known about changes in kinetics or kinematics following a 10 km training run. This information has implications on risk of running-related injury. Purpose: The purpose of this study was to examine the effect of a 10 km run on running kinematics and kinetics in a sample of experienced runners. Study Design: Cross-Sectional Study. Subjects: Nineteen runners ages 18-48 (7 female, 12 male) consented to participate including eight (3 female, 5 male) ultra-runners, and 11 (4 female, 7 male) recreational runners. Methods: Following collection of demographic data and completion of a short running survey, participants did a 6-minute run at their self-selected running speed to acclimate to the instrumented treadmill. Reflective markers were placed over designated anatomical landmarks on both sides of the pelvis as well as the left lower extremity and marked with a skin pen. Subjects then ran on the treadmill and 30 seconds of video data were recorded at 240 frames/sec using a high-speed camera for the sagittal plane and the frontal plane. Simultaneously, ground reaction forces (GRFs) were recorded at 1200 Hz through the treadmill's embedded force plates. Each runner then ran 10 km on a paved trail at their self-selected pace. Immediately following the run, reflective markers were reattached, guided by markings placed before the run, and a 30-second post-run trial of the video and GRF data were recorded. Video data were analyzed using Kinovea software to measure the kinematic variables of interest. Paired t-tests with Bonferroni corrections were used to find if significant differences existed between pre- and post-run data for all kinematic and kinetic variables. Results: No significant or clinically relevant differences existed between the pre- and post-run measurements for the kinematic or kinetic variables. The only significant difference noted between the ultra-runners and recreational runners was that the ultra-runners had significantly higher cadence (p=0.045). Conclusions: A 10 km run at a self-selected pace did not result in change in the mean kinematic or kinetic variables in this group of experienced runners. Ultra-runners employ higher cadence than recreational runners, but their kinematics and kinetics are similar. Level of Evidence: Level 3.

Analysis of Calcaneal Bone Mineral Density (cBMD) in Healthy College Students.

BACKGROUND: There is limited evidence describing the relationship between calcaneal bone mineral density (cBMD) and activity level, menstrual history, or the development of bone stress injury (BSI). HYPOTHESIS/PURPOSE: The purposes of this study were to: 1) examine the influence of physical activity on cBMD in healthy college students (HCS), 2) determine if there is an association between cBMD, body mass index (BMI), sex, menstrual history, and history of BSI in HCS, and 3) compare the cBMD of HCS to cBMD data collected on intercollegiate athletes (ICA) from a previous study. STUDY DESIGN: Cross-sectional design. METHODS: This cross-sectional study recruited a convenience sample of HCS at one institution. Subjects provided self-reported injury and menstrual history, completed a physical activity questionnaire, and cBMD and BMI measures were obtained. Descriptive statistics, statistical analyses of relationships (Chi-square and relative risk), logistic regression, and differences (t-tests) were used in the statistical analyses. RESULTS: One hundred three HCS (82 female, 21 male; age 21.9 ± 1.13) consented to participate. The composite score for work, leisure, and sport activity ranged from 5.6 to 11.1 (7.9 ± 1.1) for HCS subjects. There was no significant correlation between cBMD and physical activity in HCS, however, a significant correlation was found between reported age of onset of menstruation and left and right cBMD (r = -0.22 and r = -0.23; p < 0.05) and history of secondary amenorrhea and history of BSI (r = 0.32; p < 0.05). There was no difference in cBMD between the male ICA and male HCS, but highly significant differences in cBMD between the female ICA and female HCS groups (p < 0.000). CONCLUSIONS: Age of menarche and secondary amenorrhea are significantly associated with cBMD and history of BSI in HCS subjects, respectively. Differences in cBMD among the HCS subjects were not related to activity level. cBMD was significantly lower in female HCS as compared to female ICA. This difference in cBMD between ICA and HCS may be activity related. LEVEL OF EVIDENCE: Level 3.

Comparison of 2-D and 3-D Analysis of Running Kinematics and Actual Versus Predicted Running Kinetics.

Background: Providing clinicians with an accurate method to predict kinetic measurements using 2D kinematic motion analysis is crucial to the management of distance runners. Evidence is needed to compare the accuracy of 2D and 3D kinematic measurements as well as measured and estimated kinetic variables. Purposes: The objectives of this study were to (1) compare 2D video analysis of running kinematics with gold standard 3D motion capture and, (2) to evaluate published equations which estimate running kinetics using 2D kinematic and spatiotemporal values and modify these equations based on study findings. Design: Controlled laboratory study, cross-sectional design. Methods: Runners who averaged at least 20 miles per week were invited to participate. Athletes ran on an instrumented treadmill at their preferred training pace for a 6-minute warm-up. Markers were placed over designated anatomical landmarks on both sides of the pelvis as well as the left lower extremity. Subjects then ran at their preferred speed and kinematic data were recorded using both the 2D and 3D camera systems at 240 frames/second. Additionally, ground reaction forces were recorded at 1200Hz. 2D and 3D kinematic values were compared and published kinetic prediction formulas were tested. Linear regression was used to develop new prediction equations for average loading rate (AVG_LR), peak vertical ground reaction force (VERT_GRF), and peak braking force (PK_BRK). Paired t-tests were used to assess differences between the 2D and 3D kinematic variables and the measured (MEAS) and calculated (CALC) kinetic variables. Results: Thirty runners (13 men and 17 women) voluntarily consented to participate in this study and the mean age of the participants was 31.8 years (range 20 to 48 years). Although significant differences existed, all 2D kinematic measures were within 2°-5° of 3D kinematic measures. Published prediction equations for AVG_LR and VERT_GRF were supported, but new prediction equations showed higher R2 for AVG_LR (0.52) and VERT_GRF (0.75) compared to previous work. A new prediction equation for PK_BRK was developed. No significant differences were found between the MEAS and CALC kinetic variables using the new equations. Conclusion: Accurate predictions of kinetic variables can be made using spatiotemporal and 2D kinematic variables. Level of Evidence: Level 2.

Ultrasonographic Validation for Needle Placement in the Tibialis Posterior Muscle.

BACKGROUND: The tibialis posterior (TP) muscle plays an important role in normal foot function. Safe, efficacious therapeutic approaches addressing this muscle are necessary; however, the location of the muscle in the deep posterior compartment can create challenges. PURPOSE: The purpose of this study was to assess the accuracy of needle placement in the TP muscle and determine the needle placement in relation to the neurovascular structures located within the deep compartment. DESIGN: Cross Sectional Study. METHODS: Needle placement and ultrasound imaging were performed on 20 healthy individuals. A 50 mm or 60 mm needle was inserted between 30 - 50% of the tibial length measured from the medial tibiofemoral joint. The needle was inserted in a medial to lateral direction into the right extremity with the patient in right side lying. Placement of the needle into the TP muscle was verified with ultrasound imaging, and the shortest distance from the needle to the posterior tibial artery and tibial nerve was measured. The depth from the skin to the superficial border of the TP muscle was also measured. RESULTS: Ultrasonography confirmed the needle filament was inserted into the TP muscle in all 20 individuals and did not penetrate the neurovascular bundle in any individual. The mean distance from the needle to the tibial nerve and posterior tibial artery was 10.0 + 4.7 mm and 10.2 + 4.7 mm respectively. The superficial border of the TP muscle from the skin was at a mean depth of 25.8 + 4.9 mm. CONCLUSION: This ultrasound imaging needle placement study supports placement of a solid filament needle into the TP muscle with avoidance of the neurovascular structures of the deep posterior compartment when placed from a medial to lateral direction at 30-50% of the tibial length. LEVEL OF EVIDENCE: 2b.

Differences in Lower Extremity Kinematics Between High School Cross-Country and Young Adult Recreational Runners.

BACKGROUND: While previous research has assessed running kinematics for age-related differences that could increase the risk of a running-related injury, none of these studies have included high school aged runners or assessed running kinematics using 2-dimensional video analysis. PURPOSE: The purpose of this study was to compare sagittal plane kinematics during treadmill running in high school cross-country and young adult recreational runners using 2-dimensional motion analysis techniques. METHODS: Twenty-five high school cross-country runners (13 women, 12 men) and 25 young adult recreational runners (12 women, 13 men) consented to participate in this study. Reflective markers were placed on each lower extremity over multiple anatomical landmarks. After a five-minute acclimation period in which the participants ran on a treadmill at their preferred running speed, video data were recorded at 240 frames per second for all participants while they continued to run on the treadmill. RESULTS: There were no significant differences between left and right extremities. The young adult recreational runners exhibited significantly greater vertical excursion of the center of mass (t = 4.64, p = .0001) compared to the high school runners. There was no significant difference between the two age groups regarding the six other sagittal plane variables. CONCLUSIONS: The young adult recreational runners demonstrated an increased center-of-mass vertical excursion in comparison to high school cross-country runners. In addition, the results obtained in this study for kinematic variables using 2-dimensional motion analysis were similar to previously reported studies using 3-dimensional motion analysis, demonstrating that 2-dimensional motion analysis could be used for analyzing sagittal plane running kinematics in clinical settings. LEVEL OF EVIDENCE: 4, Controlled laboratory study.

USE OF 2-DIMENSIONAL SAGITTAL KINEMATIC VARIABLES TO ESTIMATE GROUND REACTION FORCE DURING RUNNING.

BACKGROUND: Variations in vertical loading rates have been associated with overuse injuries of the lower extremity; however, they are typically collected using 3-dimensional motion capture systems and in-ground force plates not available to most clinicians because of cost and space constraints. PURPOSE: The purpose of this study was to determine if kinetic measures commonly used to describe lower extremity loading characteristics could be estimated from step rate and specific sagittal plane kinematic variables captured using 2-dimensional motion analysis during treadmill running. STUDY DESIGN: Observational Study. METHODS: Ten high school cross-country runners (4 men and 6 women) voluntarily consented to participate in this study. Reflective markers were placed on each lower extremity over multiple anatomical landmarks. Participants were then asked to run on the instrumented treadmill at their preferred running speed. When the participants indicated they were in their typical running pattern, they continued to run at their preferred speed for a minimum of five minutes. After three minutes of running at their preferred running speed, the participant's step rate was counted and after running for four minutes, video and ground reaction force data were recorded for 60 sec. All running motion data were recorded using a single high-speed camera at 240 frames per second and ground reaction force data were sampled at 1000 Hz. RESULTS: Mean kinematic values between the left and right extremities for all 10 participants were not significantly different. Consequently, data for the left and right extremities were grouped for all further analyses. The stepwise forward regression to predict vertical ground reaction force resulted in a five-variable model (step rate and four kinematic variables) with R2 = 0.56. The stepwise forward regression to predict average loading rate also resulted in a five kinematic variable model with R2 = 0.51. CONCLUSIONS: Step rate and sagittal plane kinematic variables measured using a simplified 2-dimensional motion analysis approach with a single high-speed camera can provide the clinician with a reasonable estimate of ground reaction force kinetics during treadmill running. LEVEL OF EVIDENCE: 4, Controlled laboratory study.

RELIABILITY OF TWO-DIMENSIONAL VIDEO-BASED RUNNING GAIT ANALYSIS.

BACKGROUND: While two-dimensional (2D) video running analysis is commonly performed in the clinical setting, the reliability of quantitative measurements as well as effect of clinical experience has not been studied. PURPOSE: The purpose of this study was to assess the intra-rater and inter-rater reliability of six different raters using 2D video analysis of sagittal and frontal plane kinematic variables while running on a treadmill. STUDY DESIGN: Cross-sectional Study. METHODS: Running videos from 10 individuals (five female, five male) with a mean age of 22.8 years were selected for analysis. Two raters had over 10 years of experience with running video analysis and the other four raters had no prior experience. Before beginning analyses, the senior investigator conducted two hours of training with all raters to review the measurement procedures and the movement analysis software program. After completing training and one practice analysis, each rater assessed four 60-second video clips for the 10 runners twice (20 total). A minimum of one week separated the two assessments on each runner. The order of the runner analyses were randomly assigned and each rater completed a single analysis within 24 hours. After the rater had completed their initial assessment on all 10 runners, a second analysis was completed one week later with a different order of randomization. Eight sagittal plane (SAG) and four frontal plane (FRT) quantitative variables were measured for the left and right lower extremities on all 10 runners. Intra- and inter-rater reliability was assessed using intraclass correlation coefficients (ICC) and standard error of the measurement (SEM). RESULTS: The intra-rater ICC values for experienced raters ranged from 0.75 to 0.98 for the SAG and 0.45 to 0.96 for FRT variables. The inter-rater ICC values between the experienced raters ranged from 0.76 to 0.99 for the SAG and 0.82 to 0.98 for FRT variables. The intra-rater ICC values for inexperienced raters ranged from 0.54 to 0.99 for the SAG and 0.08 to 0.97 for FRT variables. The inter-rater ICC values between the inexperienced raters ranged from 0.93 to 0.99 for the SAG and 0.79 to 0.98 for FRT variables. Intra-rater SEM values based on average means of all raters ranged from 1 to 47% of the mean values obtained for the SAG and from 6 to 158% for the FRT variables. CONCLUSIONS: The intra-rater and inter-rater reliability levels were higher for SAG quantitative variables assessed in this study in comparison to FRT variables. Experience does not appear to be a factor when consistency is required with repeated analyses on the same runner. LEVEL OF EVIDENCE: 4, Controlled laboratory study.

Medial Tibial Stress Syndrome in Active Individuals: A Systematic Review and Meta-analysis of Risk Factors.

CONTEXT: Medial tibial stress syndrome (MTSS) is a common condition in active individuals and presents as diffuse pain along the posteromedial border of the tibia. OBJECTIVE: To use cross-sectional, case-control, and cohort studies to identify significant MTSS risk factors. DATA SOURCES: Bibliographic databases (PubMed, Scopus, CINAHL, SPORTDiscus, EMBASE, EBM Reviews, PEDRo), grey literature, electronic search of full text of journals, manual review of reference lists, and automatically executed PubMed MTSS searches were utilized. All searches were conducted between 2011 and 2015. STUDY SELECTION: Inclusion criteria were determined a priori and included original research with participants' pain diffuse, located in the posterior medial tibial region, and activity related. STUDY DESIGN: Systematic review with meta-analysis. LEVEL OF EVIDENCE: Level 4. DATA EXTRACTION: Titles and abstracts were reviewed to eliminate citations that did not meet the criteria for inclusion. Study characteristics identified a priori were extracted for data analysis. Statistical heterogeneity was examined using the I2 index and Cochran Q test, and a random-effects model was used to calculate the meta-analysis when 2 or more studies examined a risk factor. Two authors independently assessed study quality. RESULTS: Eighty-three articles met the inclusion criteria, and 22 articles included risk factor data. Of the 27 risk factors that were in 2 or more studies, 5 risk factors showed a significant pooled effect and low statistical heterogeneity, including female sex (odds ratio [OR], 2.35; CI, 1.58-3.50), increased weight (standardized mean difference [SMD], 0.24; CI, 0.03-0.45), higher navicular drop (SMD, 0.44; CI, 0.21-0.67), previous running injury (OR, 2.18; CI, 1.00-4.72), and greater hip external rotation with the hip in flexion (SMD, 0.44; CI, 0.23-0.65). The remaining risk factors had a nonsignificant pooled effect or significant pooled effect with high statistical heterogeneity. CONCLUSION: Female sex, increased weight, higher navicular drop, previous running injury, and greater hip external rotation with the hip in flexion are risk factors for the development of MTSS.

CURRENT CONCEPTS IN THE TREATMENT OF PATELLAR TENDINOPATHY.

Patellar tendon pain is a significant problem in athletes who participate in jumping and running sports and can interfere with athletic participation. This clinical commentary reviews patellar tendon anatomy and histopathology, the language used to describe patellar tendon pathology, risk factors for patellar tendinopathy and common interventions used to address patellar tendon pain. Evidence is presented to guide clinicians in their decision-making regarding the treatment of athletes with patellar tendon pain. LEVEL OF EVIDENCE: 5.

Lower extremity overuse bone injury risk factors in collegiate athletes: a pilot study.

BACKGROUND AND PURPOSE: There is limited evidence regarding risk factors for lower extremity overuse bone injury (LEOBI) in collegiate athletes. The purposes of the study were to: 1) determine incidence of LEOBI in selected sports and its impact on athletic participation and ADL, 2) assess risk relationships between LEOBI and selected risk factors, and 3) establish the viability of using calcaneal densitometry as a screening tool to identify risk for LEOBI. STUDY DESIGN: Prospective analytical cohort design. METHODS: Collegiate athletes in selected sports (swimming/diving, women's soccer, field hockey, cross-country/track) at one university were invited to participate. Consenting athletes completed an initial questionnaire including demographic information, history, and menstrual function. Measurements included height/weight, hip abductor strength, foot posture index, and calcaneal bone mineral density. Athletes were monitored for potential LEOBI for nine months and an algorithm was used to determine if physician referral was required. The primary outcome of interest was the occurrence of physician-diagnosed LEOBI. If LEOBI was diagnosed by the physician, the athlete completed a follow-up visit including a repeat bone mineral density scan. All athletes were invited for a repeat scan at the end of the year and completed a final questionnaire. Athlete demographics were summarized using descriptive statistics and differences in continuous risk factors were analyzed using t-tests and ANOVA. Finally, risk relationships for categorical variables were analyzed using chi-square and relative risk. RESULTS: 84 athletes (64 female, 20 male) consented to participate. Over the study period, eight athletes (one male, seven females) were diagnosed with LEOBI (LEOBI group), five with stress fractures and three with medial tibial stress syndrome. The other 76 athletes who did not have a diagnosis of LEOBI were placed in the non-LEOBI group. Five of the eight were cross-country/track athletes; no swimming/diving athletes had bone injury. Sport (cross-country/track) had a significant relative risk value of 2.26 (95% CI = 1.18-4.32) for LEOBI. There was no association between LEOBI occurrence and sex, hip abductor strength, body mass index, foot type, and menstrual function. There was no difference in bone mineral density at initial or follow-up measures between LEOBI and non-LEOBI groups (p>.05) when analyzing all athletes. When analyzing ground-based athletes only at follow-up (n=44), athletes with LEOBI had lower bone mineral density of right (p = .05) and left (p =.07) calcaneus. The relative risk for developing LEOBI based on calcaneal bone mineral density below the mean of the study participants was 2.1 (95%CI = 1.09-3.35) on the left and 1.53 (95% CI=.80- 3.06) on the right. CONCLUSION: The incidence of LEOBI in this population of athletes was approximately 10%. Risk factors were sport (cross-country/track) and decreased left calcaneal bone mineral density. This study supports the use of calcaneal bone mineral density as a screening measurement for LEOBI risk and suggests the need for further investigation into additional LEOBI risk factors. LEVEL OF EVIDENCE: 2.

Competency revalidation study of specialty practice in sports physical therapy.

BACKGROUND AND PURPOSE: Every ten years the American Board of Physical Therapy Specialties conducts a practice analysis to revalidate and revise the description of specialty practice for sports physical therapy (SPT). The primary purpose of this paper is to describe the process and results of the most recent analysis, which defines the competencies that distinguish the subspecialty practice of (SPT). Additionally, the study allowed for the comparison of responses of board certified specialists in SPT to respondents who were not specialists while reflecting on demographic changes and evolving trends since the previous analysis of this physical therapy specialty practice was conducted 10 years ago. METHODS: A survey instrument based on guidelines from the American Board of Physical Therapy Specialties was developed by the Sports Specialty Council (SSC) and a panel of subject matter experts (SME) in SPT to re-evaluate contemporary practice. The instrument was pilot tested and following revisions, was sent to 1780 physical therapists, 930 of whom were board certified specialists in SPT and 850 of whom were randomly selected members of the Sports Physical Therapy Section (SPTS) who were not board certified specialists in SPT. 414 subjects returned completed surveys for a 23% response rate. 235 of the respondents were known to be board certified sports specialists, 120 did not indicate their specialty status, and 35 were non-specialists in SPT. All were members of the SPTS of the American Physical Therapy Association. The survey responses were analyzed using descriptive statistics. Univariate comparisons were performed using parametric and nonparametric statistical tests in order to evaluate differences between specialist and non-specialist item responses. RESULTS: The survey results were reviewed by the SSC and a panel of SME. Using a defined decision making process, the results were used to determine the competencies that define the specialty practice of SPT. Survey results were also used to develop the SPT specialty board examination blueprint and define the didactic curriculum required of accredited SPT residency programs. A number of significant comparisons between the specialists and non-specialists were identified. CONCLUSION: The competency revalidation process culminated in the publication of the 4th edition of the Sports Physical Therapy Description of Specialty Practice in November of 2013. This document serves to guide the process related to the attainment and maintenance of the board certified clinical specialization in SPT. In anticipation of the continued evolution of this specialty practice, this process will be repeated every 10 years to reassess the characteristics of these providers and the factors they consider critically important and unique to the practice of SPT.

A survey of exercise-related leg pain in community runners.

PURPOSE/BACKGROUND: Exercise-related leg pain (ERLP) is a common problem in runners. The purposes of this study were to 1) report ERLP occurrence among adult community runners; 2) determine ERLP impact on daily activities; and 3) determine if there is a relationship between ERLP occurrence and selected potential risk factors including sex, age, years of running, ERLP history, body mass index (BMI), orthotic use, menstrual function, and training variables. METHODS: Community runners registered for a local race were invited to complete a questionnaire including demographics and potential risk factors. Analyses of differences (t-test) and relationships (Chi-square) were conducted and relative risk (RR) values were calculated. RESULTS: 225 registered runners (105 male, 120 female) participated; 63.6% reported ERLP history, and 35.1% reported ERLP in the 3 months preceding the race with bilateral medial ERLP as the most common presentation. Of the 79 runners who experienced ERLP during the 3 months preceding the race, ERLP caused 41.8% to reduce their running and interfered with walking or stair climbing in < 10%. Chi square analyses showed no significant association of sex, menstrual function, orthotic use, or BMI with ERLP occurrence. Significant associations were observed between ERLP history and ERLP occurrence in the previous year (RR=3.39; 2.54-4.52 95% CI), and between ERLP in the 3 months preceding the race and both years running and training mileage. Greater ERLP occurrence was observed in runners with less than 3 years experience (RR = 1.53; 1.08-2.17 95% CI) and runners who ran fewer than 15 miles/week (RR = 1.47; 1.04-2.08 95% CI). Those runners with < 3 years running experience and a race pace of 9 min/mile or > were at greater risk for ERLP when compared to other participants (RR=1.53; 1.07-2.18 95% CI). CONCLUSION: Interfering ERLP was common among this group of community runners. Risk factors included ERLP history, training mileage < 15 miles/week, and < 3 years running experience. Further investigation is warranted to identify factors which may increase a community runner's risk of developing ERLP. LEVEL OF EVIDENCE: 2b.

The effect of foot orthotic use on exercise related leg pain in cross country athletes.

OBJECTIVES: The purposes of this research were to (1) investigate the effect of foot orthotic use on exercise related leg pain (ERLP) in cross-country (XC) athletes, and (2) determine if an association between foot type and foot orthotic use exists. DESIGN: Prospective cohort design. SETTING: High schools and colleges in a Midwestern metropolitan region. PARTICIPANTS: 213 high school and college XC athletes (107 male, 106 female). MATERIALS/METHODS: Participants were seen before the fall XC season for classification of foot type, visual orthotic inspection, and questionnaire completion regarding foot orthotic use and ERLP. Statistical analysis of relationships (chi-square) was conducted. RESULTS: 37 of the 213 XC athletes (17.4%) used foot orthotics; 31 of the 37 athletes using foot orthotics (83.8%) reported a history of ERLP. Of these 31 athletes, 17 (54.8%) were using orthotics for ERLP and 15 reported a decrease in ERLP with orthotic use. Fourteen athletes were using orthotics for a reason other than ERLP and only 2 reported a decrease in ERLP with orthotic use. Athletes using orthotics included all three foot types (pronated, neutral, supinated) with no relationship between orthotic use and foot type. CONCLUSION: One-sixth of the XC athletes used foot orthotics and most using orthotics for ERLP reported a decrease in ERLP symptoms. The majority of athletes using orthotics for reasons other than ERLP reported no change in ERLP symptoms. There was no association between foot type and orthotic use.

The relationship between isotonic plantar flexor endurance, navicular drop, and exercise-related leg pain in a cohort of collegiate cross-country runners.

PURPOSE: The purpose of this study was to examine the relationships between isotonic ankle plantar flexor endurance (PFE), foot pronation as measured by navicular drop, and exercise-related leg pain (ERLP). BACKGROUND: Exercise-related leg pain is a common occurrence in competitive and recreational runners. The identification of factors contributing to the development of ERLP may help guide methods for the prevention and management of overuse injuries. METHODS: Seventy-seven (44 males, 33 females) competitive runners from five collegiate cross-country (XC) teams consented to participate in the study. Isotonic ankle PFE and foot pronation were measured using the standing heel-rise and navicular drop (ND) tests, respectively. Demographic information, anthropometric measurements, and ERLP history were also recorded. Subjects were then prospectively tracked for occurrence of ERLP during the 2009 intercollegiate cross-country season. Multivariate logistic regression analysis was used to examine the relationships between isotonic ankle joint PFE and ND and the occurrence of ERLP. RESULTS: While no significant differences were identified for isotonic ankle PFE between groups of collegiate XC runners with and without ERLP, runners with a ND >10 mm were almost 7 times (OR=6.6, 95% CI=1.2-38.0) more likely to incur medial ERLP than runners with ND <10 mm. Runners with a history of ERLP in the month previous to the start of the XC season were 12 times (OR=12.3, 95% CI=3.1-48.9) more likely to develop an in-season occurrence of ERLP. CONCLUSION: While PFE did not appear to be a risk factor in the development of ERLP in this group of collegiate XC runners, those with a ND greater than 10 mm may be at greater odds of incurring medial ERLP. LEVEL OF EVIDENCE: 2b.

Tendinopathy in athletes.

Overuse related tendon pain is a significant problem in sport and can interfere with and, in some instances, end an athletic career. This article includes a consideration of the biology of tendon pain including a review of tendon anatomy and histopathology, risk factors for tendon pain, semantics of tendon pathology, and the pathogenesis of tendon pain. Evidence is presented to guide the physical therapist in clinical decision-making regarding the examination of and intervention strategies for athletes with tendon pain.

Foot orthoses in lower limb overuse conditions: a systematic review and meta-analysis--critical appraisal and commentary.

REFERENCE/CITATION: Collins N, Bisset L, McPoil T, Vicenzino B. Foot orthoses in lower limb overuse conditions: a systematic review and meta-analysis. Foot Ankle Int. 2007;28(3):396-412. CLINICAL QUESTION: Among patients with or at risk for musculoskeletal overuse conditions, (1) do foot orthoses provide clinically meaningful improvements, and (2) are foot orthoses cost-effective? DATA SOURCES: Studies published through September 28, 2005, were identified by using MEDLINE, EMBASE, CINAHL and Pre-CINAHL, Physiotherapy Evidence Database (PEDro), PubMed, SPORTDiscus, Biological Abstracts, Web of Science, Allied Health and Complementary Medicine Database, and the full Cochrane Library. The authors did not provide the search strategy used. Reference lists of included randomized controlled trials (RCTs) and identified systematic reviews were searched by hand. STUDY SELECTION: Studies were included if (1) they were RCTs that included the use of foot orthoses (either custom or prefabricated) in 1 of the intervention groups, (2) the clinical problem was an overuse condition as defined by the American College of Foot and Ankle Orthopedics and Medicine guidelines for which foot orthoses were recommended, and (3) at least 1 clinically relevant outcome was measured for a minimum of 1 week. Limits were not placed on year of publication, status of publication, or language. DATA EXTRACTION: The journal, authors, and author affiliations of included RCTs were masked from 2 of the reviewers who independently assessed the included RCTs for methodologic quality using a modified PEDro scale plus 3 additional items (justification of sample size, use of outcome measures with known validity and reliability, and reporting of adverse or side effects). Disagreements on methodologic quality were resolved with consensus or by a third reviewer. The effect sizes for the included RCTs were represented by relative risk (RR) for dichotomous outcomes and standardized mean difference (SMD) for continuous data. Confidence intervals (CIs) were reported for RR and SMD. Study data were extracted directly from each of the included studies. If provided, data from intention-to-treat analysis were extracted. Study authors were contacted when insufficient data were reported. A meta-analysis (random-effects model) was conducted using Review Manager (version 4.2; The Nordic Cochrane Centre, Copenhagen, Denmark). MAIN RESULTS: The search identified 3192 potentially relevant studies. Full articles were retrieved for 327 studies. Twenty-two of the 327 studies met the inclusion criteria. Because the authors of 1 study used the same methods to report on 2 populations, a total of 23 RCTs were included in the systematic review. Prevention of lower limb overuse conditions with the use of foot orthoses was reported in 8 RCTs (7 studies). The effect of foot orthoses in the treatment of lower limb overuse conditions was reported in 15 RCTs. Of the 23 RCTs, the cost-effectiveness of foot orthoses was reported in 2 and the adverse effects of foot orthoses were reported in 8. Across the prevention RCTs, data were available for analysis for a range of 47 to 417 participants with 8 to 16 weeks of follow-up. Based on 4 RCTs in which the researchers examined prevention of lower limb overuse conditions with foot orthoses versus control in military personnel, the RR was 1.49 (95% CI  =  1.07, 2.08). A clinically beneficial effect size was set a priori at 1.5 or greater for the foot-orthoses group or at 0.7 or less for the comparison group. Based on 2 RCTs reported in 1 study of the use of custom versus prefabricated foot orthoses for prevention of lower limb overuse conditions, no significant difference in risk was found (RR  =  1.14, 95% CI  =  0.90, 1.44). In their calculating and reporting of RR, the authors do not appear to have followed convention. Across the treatment RCTs, data were available for analysis for a range of 18 to 133 participants with 8 to 52 weeks of follow-up. The authors of the treatment RCTs reported a variety of outcome measures. Two of these, patient-perceived treatment effect (PPE) and pain on the visual analog scale (VAS), were used to calculate an overall treatment effect (PPE as RR and VAS as SMD). Based on 2 RCTs examining foot orthoses versus control, no significant difference in PPE was found (RR  =  1.01, 95% CI  =  0.61, 1.68). Based on 2 RCTs in which custom versus prefabricated foot orthoses were examined, no significant difference in PPE was found (RR  =  0.88, 95% CI  =  0.42, 1.81). The VAS data reported in the text appear to contradict the VAS data reported in Figure 2 for foot orthoses versus control for the treatment of lower limb overuse conditions. Specifically, the lower limit of the CI in the text was negative (-0.28) and in Figure 2 was positive. Because of this apparent contradiction, we did not interpret these data. Authors of 2 RCTs reported cost-effectiveness, but the data could not be pooled. Adverse events were reported in 8 of the 22 studies. The most common adverse effect reported was discomfort, which was the main reason for discontinuing foot-orthoses use in 2 studies. CONCLUSIONS: The evidence supports the use of foot orthoses to prevent a first occurrence of lower limb overuse conditions and shows no difference between custom and prefabricated foot orthoses. The evidence was insufficient to recommend foot orthoses (custom or prefabricated) for the treatment of lower limb overuse conditions.

Risk factors for self-reported exercise-related leg pain in high school cross-country athletes.

CONTEXT: Prevention of exercise-related leg pain (ERLP) has not been successful because ERLP risk factors are not well known. OBJECTIVE: To determine the percentage of high school cross-country (XC) athletes who reported a history of ERLP in their running careers, to identify the percentage of athletes who reported an occurrence of ERLP during 1 XC season, and to investigate the association of selected factors (age, high school year, years of high school running, sex, ERLP history, body mass index [BMI], foot type, and training distance) and the occurrence of ERLP. DESIGN: Prospective cohort study. SETTING: Six local high schools. PATIENTS OR OTHER PARTICIPANTS: One hundred twenty-five high school XC athletes (62 females, 63 males). MAIN OUTCOME MEASURE(S): All athletes completed an initial ERLP questionnaire, and foot type was visually assessed. After the season, athletes were asked to complete a Web-based questionnaire regarding the seasonal occurrence of ERLP. Statistical analyses of differences (t tests) and associations (chi(2), relative risk) were conducted. RESULTS: A total of 103 of the 125 athletes (82.4%) reported a history of ERLP, with 81 athletes reporting ERLP occurrence within the month preceding completion of the initial questionnaire. Bilateral medial leg pain was the most common ERLP presentation. More than half of the athletes (58.4%) with an ERLP history reported that the pain had interfered with XC participation. Ninety-three athletes responded to the postseason questionnaire, and 45 (48.0%) reported ERLP seasonal occurrence. Most athletes (97.8%) who experienced the seasonal occurrence of ERLP had a history of ERLP. No associations were noted between ERLP history or seasonal occurrence and age, high school year, years of high school running, sex, BMI, foot type, or training distance. CONCLUSIONS: Both a history of ERLP and the seasonal occurrence of ERLP were common among these XC athletes. The only risk factor identified for ERLP season occurrence was ERLP history.

Prospective evaluation of physiologic uptake detected with true whole-body 18F-FDG PET/CT in healthy subjects.

UNLABELLED: PET is a molecular imaging modality used to assess metabolic activity. Little is known about the physiologic uptake of radiopharmaceuticals such as (18)F-FDG in healthy subjects. This study was designed to identify and describe normal patterns of physiologic uptake of (18)F-FDG in healthy adult subjects and to examine the influence of low-level muscle activity during the (18)F-FDG uptake phase. METHODS: Twenty healthy adults received an intravenous injection of (18)F-FDG and were subsequently scanned with a combined PET/CT scanner. The CT scan was used to accurately identify the location of (18)F-FDG uptake. Of the 20 subjects, 10 were randomly selected to perform a low-level muscle activity during the 1-h (18)F-FDG uptake phase. The PET/CT images were fused, and the location and intensity of metabolic activity were described for all subjects. RESULTS: Muscle activity during the (18)F-FDG uptake phase affected the pattern of (18)F-FDG distribution on PET scans. In addition, the tissue uptake of (18)F-FDG, although variable, showed some consistency among tissue types. CONCLUSION: The data suggested that technologists should be aware of low-level muscle activity before and during uptake to avoid potential false-positive interpretations. The data also showed that there is some variability in the normal physiologic uptake of (18)F-FDG across subjects. Finally, the results suggested that (18)F-FDG uptake may be used for the evaluation of muscle activity.

Menstrual function in female high school cross-country athletes.

UNLABELLED: Menstrual function in adolescent athletes has received limited investigation. OBJECTIVE: In a sample of female high school cross-country (XC) athletes, the purposes of the investigation were to (1) describe menstrual function (history and inseason), (2) describe the relationship between menstrual function and variables including body mass index (BMI), high school year, current year of running, total years running, training distance, racing pace, additional organized sport participation other than XC, and participation in XC practices and races, (3) determine the relationship between menstrual function and self-reported interfering exercise related leg pain (ERLP), and (4) determine the relationship between menstrual function history and menstrual function during a XC season. STUDY GROUP: 62 female high school XC athletes. METHODS: A prospective cohort design was used. Athletes were asked to complete an initial questionnaire querying several variables including menstrual function and ERLP history. At the end of the XC season, athletes were asked to complete a postseason questionnaire regarding menstrual function and ERLP during the XC season. RESULTS: Of the athletes, 25.8% (16/62) reported abnormal menstrual function history and 34.9% reported abnormal menstrual function inseason. Abnormal menstrual function history was a risk for previous interfering ERLP (RR = 3.00, CI: 1.09, 8.29), and abnormal menstrual function history was a risk for abnormal menstrual function inseason (RR = 4.11, CI: 1.75, 9.62). CONCLUSIONS: Abnormal menstrual function was present in this sample of athletes and was a risk for previous interfering ERLP and future episodes of abnormal menstrual function.

Competency revalidation study of specialty practice in sports physical therapy.

PURPOSE: The primary purpose of this study was to revalidate the competencies that define the practice of sports physical therapy. Additionally, the study allowed for the comparison of responses of board certified specialists in sports physical therapy to respondents who were not specialists. METHODS: A survey instrument based the on American Board of Physical Therapy Specialties practice analysis template and The Guide to Physical Therapist Practice was developed by the Sports Specialty Council and a panel of subject matter experts in sports physical therapy. The instrument was sent to 630 physical therapists, 315 of whom were board certified specialists in sports physical therapy and 315 of whom were randomly selected members of the Sports Physical Therapy Section who were not board certified specialists in sports physical therapy. Two hundred and thirty seven subjects returned completed surveys for a 41% response rate. One hundred and fifty eight respondents were sports specialists RESULTS: The survey results were reviewed by the Sports Specialty Council and another panel of subject matter experts. Using a defined decision making process, the results were used to determine the competencies that define the specialty practice of sports physical therapy. Survey results were also used to develop the sports physical therapy specialty board examination blue print. A number of significant comparisons between the specialists and non-specialists were identified. CONCLUSION: The competency revalidation process culminated in the publication of the Sports Physical Therapy Description of Specialty Practice. This document serves to guide the process related to the attainment and maintenance of the board certified clinical specialist in sports physical therapy.