Concurrent Criterion-related Validity, Reliability, and Responsiveness to Treatment of the Figure-of-Four Position for Measurement of Anterior Hip Joint Structures Tightness.

OBJECTIVE: The objective of this study was to examine the intra- and intertester reliability, concurrent criterion-related validity, and responsiveness to treatment of the "figure-of-four" position. METHODS: A total of 52 asymptomatic male soccer players participated in this study. The intraclass correlation coefficient (2, 1) was used to determine intra- and intertester reliability of the figure-of-four position. Pearson product moment correlation coefficients examining the association between the figure-of-four position and goniometric measurements of hip extension and external rotation were used to establish concurrent validity. To evaluate responsiveness to treatment, the figure-of-four position was assessed by a blinded examiner before and immediately after the application of a stretching technique or control intervention. RESULTS: Excellent reliability (intraclass correlation coefficient > 0.75) was obtained for both intra- and intertester reliability of the figure-of-four position. Overall, the figure-of-four position and goniometric measurements of both hip extension and external rotation were significantly correlated. However, no significant treatment effects were observed for the figure-of-four position. CONCLUSION: The results of this study demonstrated that the figure-of-four position is a reliable and valid way to obtain information on tightness of anterior hip joint structures in male soccer players. However, responsiveness to treatment of the figure-of-four position should be questioned.

A Word of Caution for Future Studies in Patellofemoral Pain: A Systematic Review With Meta-analysis.

BACKGROUND: Patellar maltracking is widely accepted as an underlying mechanism of patellofemoral pain. However, methodological differences in the literature hinder our ability to generate a universal quantitative definition of pathological patellofemoral kinematics (patellar maltracking) in patellofemoral pain, leaving us unable to determine the cause of patellofemoral pain. PURPOSE: To systematically review the literature to provide evidence regarding the influence of confounding variables on patellofemoral kinematics. STUDY DESIGN: Systematic review and random effects meta-analysis of control-case studies. METHODS: A literature search of case-control studies that evaluated patellofemoral kinematics at or near full extension and were written in English was conducted using Embase, PubMed, Scopus, and Web of Science up to September 2019. Cases were defined as patients with patellofemoral pain. Studies were eliminated if they lacked quantitative findings; had a primary aim to assess therapy efficacy; or included participants with osteoarthritis and/or previous trauma, pathology, or surgery. A quality assessment checklist was employed to evaluate each study. Meta-analyses were conducted to determine the influence of confounding variables on measures of patellofemoral kinematics. RESULTS: Forty studies met the selection criteria, with quality scores ranging from 13% to 81%. Patient characteristics, data acquisition, and measurement methods were the primary sources of methodological variability. Active quadriceps significantly increased lateral shift (standardized mean difference [SMD]shift = 0.33; P = .0102) and lateral tilt (SMDtilt = 0.43; P = .006) maltracking. Individuals with pain secondary to dislocation had greater effect sizes for lateral maltracking than had those with isolated patellofemoral pain (ΔSMDshift = 0.71, P = .0071; ΔSMDtilt = 1.38, P = .0055). CONCLUSION: This review exposed large methodological variability across the literature, which not only hinders the generalization of results, but ultimately mitigates our understanding of the underlying mechanism of patellofemoral pain. Although our meta-analyses support the diagnostic value of maltracking in patellofemoral pain, the numerous distinct methods for measuring maltracking and the limited control for cofounding variables across the literature prohibit defining a single quantitative profile. Compliance with specific standards for anatomic and outcome measures must be addressed by the scientific and clinical community to establish methodological uniformity in this field.

The effect of tape on glenohumeral rotation range of motion in elite junior tennis players.

OBJECTIVE: The purpose of this study was to establish if, in elite junior tennis players, there is a difference between the dominant and nondominant shoulders in the internal and external range of motion (ROM) of the shoulder and to examine the effect of taping the dominant shoulder on glenohumeral internal and external rotation ROM. DESIGN: Measurement of glenohumeral rotational ROM was performed on the dominant and nondominant shoulders in supine with the humerus abducted to 90 degrees. SETTING: Training room at the New South Wales Institute of Sport tennis center, Homebush, New South Wales, Australia. PARTICIPANTS: Eleven asymptomatic male subjects and 10 asymptomatic female subjects from an elite junior training squad participated in the study. INTERVENTION: Humeral head repositioning with tape. MAIN OUTCOME MEASURE: Glenohumeral ROM. RESULTS: A statistically significant decrease in internal rotation for both the male and female groups between the dominant and nondominant shoulders, but only the female group had a significant increase in external rotation in the dominant compared with the nondominant shoulder. There was also a statistically significant increase in range between the tape and no tape conditions for each rotation condition. CONCLUSIONS: The specific application of tape to the glenohumeral joint can immediately increase rotational ROM in the dominant arm of tennis players.

Gluteal taping improves hip extension during stance phase of walking following stroke.

The aim of this study was to determine whether gluteal taping on the affected side improved hip extension during stance phase of walking for persons following stroke. Fifteen subjects who had suffered a stroke months to years previously resulting in mild to moderate gait impairments participated in the study. Their gait was measured under control, sham, and gluteal taping conditions, in random order. For each condition, subjects walked at a self-selected and a fast speed. Hip angle relative to that obtained during quiet standing, step length, stride length and walking velocity were measured. Hip extension increased significantly with gluteal taping (p < 0.05) for both walking speeds at late stance phase of walk compared to sham taping and control. The mean absolute difference between gluteal and control conditions for self-selected velocity was 14.2 degrees (95% CI 8.6 to 19.8) whereas the difference between sham and control conditions was 2.0 degrees (95% CI -2.0 to 6.0). Also, for both speeds, step length on the unaffected side increased significantly with gluteal taping compared with either the control or placebo conditions. The absolute difference between gluteal taping and control conditions at self-selected velocity was 3.3 cm (95% CI 2.2 to 4.3) and between sham and control conditions was 0.6 cm (95% CI -0.8 to 1.9). Affected step length and walking velocity, however, remained unchanged. Lastly, there was no significant difference between the control and sham taping condition for any of the measured variables. Gluteal taping may be a useful adjunct to current rehabilitation gait training strategies.

Running Injuries: The Infrapatellar Fat Pad and Plica Injuries.

When considering knee pain in runners, clinicians differentiate sources of symptoms and determine their cause. Knee problems arise when a runner increases the amount/frequency of the loading through the lower limb. The way the loading is distributed through the knee determines which tissues are abnormally loaded. Knee problems cannot be considered in isolation, requiring a thorough investigation of static and dynamic lower limb mechanics, and footwear and surfaces. This article examines potential sources of knee pain and explores the role of the infrapatellar fat pad and synovial plica in the mechanics of the knee and its involvement in knee symptoms.

Biomechanical, neuromuscular and knee pain effects following therapeutic knee taping among patients with knee osteoarthritis during walking gait.

BACKGROUND: Knee osteoarthritis is one of the most debilitating diseases associated with aging, and is estimated to affect 9% of men and 18% of women over 65years of age. Knee osteoarthritis affects the condylar surfaces of the joint and if left untreated generally leads to the slow and painful degeneration of the joint and surrounding structures. With few non-invasive treatment options for osteoarthritis patients, this study investigated the effect of therapeutic taping on knee pain in combination with spatiotemporal, kinematic, kinetic and muscle activation measures. METHODS: Fifteen participants (10 male, 5 female) with radiographic diagnosed knee osteoarthritis attended a single testing session and walked along at a self-selected pace under three different conditions (no tape, sham tape, therapeutic tape). The conditions were randomised within each testing session. Knee pain, lower limb biomechanics and muscle activation were analysed using a one-way repeated measures ANOVA to determine if any differences existed between the three taping conditions (α=0.05). FINDINGS: Therapeutic knee taping was shown to significantly reduce the self-reported levels of knee joint pain during straight line walking. No significant differences in spatiotemporal, knee kinetic, knee kinematic or lower limb muscle activation variables were observed between the taping conditions. INTERPRETATION: There is evidence supporting the use of therapeutic knee taping for the management of osteoarthritis related knee pain. Future research is recommended to better understand the complex acute neuro-musculoskeletal adaptations that explain these positive knee pain findings.

Physical therapy improves knee flexion during stair ambulation in patellofemoral pain.

PURPOSE: This study aimed to examine whether a physical therapy intervention, designed to reduce pain and improve the neuromotor control resulted in greater improvements in stance-phase knee flexion during stair ambulation in individuals with patellofemoral pain. The relationship between changes in stance-phase knee flexion and changes in pain, disability, and onset timing of individual vasti activity was also examined. METHODS: Forty participants aged 40 yr or younger diagnosed with patellofemoral pain were randomly allocated to a physical therapy (N = 21) or placebo (N = 19) treatment group. Stance-phase knee flexion was measured in two dimensions using a PEAK movement analysis system during stair ambulation. Individuals were divided into those with improvements in onset of vastus medialis obliquus (VMO) activity relative to that of the vastus lateralis (VL) of more or less than 10 ms. RESULTS: Groups were similar at baseline. After the 6-wk intervention, individuals in the physical therapy group had significantly greater changes in knee flexion at heel strike (mean difference 4 degrees, 95% CI = 2-7 degrees) and peak stance-phase knee flexion (mean difference 9 degrees, 95% CI = 5-12 degrees) than those in the placebo group. No differences were noted during stair ascent. Individuals with greater change in the onset timing of the vasti had greater improvements in stance-phase knee flexion. Changes in usual pain in the week before testing and change in the vasti onset timing were independent predictors of change in stance-phase knee flexion during stair descent, together accounting for 27-40% of the variability in knee motion. CONCLUSIONS: Physical therapy intervention resulted in significantly greater changes in knee joint motion than a placebo treatment, and these changes in knee motion were partly related to changes in pain and changes in onset timing of the vasti.

Knee flexion during stair ambulation is altered in individuals with patellofemoral pain.

UNLABELLED: Reduced knee flexion is a logical gait adaptation for individuals with patellofemoral pain (PFP) to lessen the patellofemoral joint reaction force and minimise pain during stair ambulation. This gait adaptation may be related to the co-ordination of individual vasti components. PURPOSE: This study investigated the amount of stance-phase knee flexion in individuals with (n=48) and without (n=18) PFP using a cross-sectional design. The relationship between stance-phase knee flexion and onset timing of individual vasti activity was also examined. METHOD: Stance-phase knee flexion was measured in 2-dimensions using a PEAK movement analysis system during stair ascent and descent. Individuals with PFP were separated into those with synchronous onset of the EMG activity of vastus medialis obliquus (VMO) and vastus lateralis (VL), and those where the onset of VMO EMG activity was delayed relative to the VL. RESULTS: The amount of knee flexion at heel-strike and peak was less in the individuals with PFP compared with the healthy controls. In addition, there were trends towards individuals with PFP who had a delayed EMG onset of VL having reduced knee flexion during stair descent compared with PFP individuals with simultaneous vasti onsets and the control participants. CONCLUSION: These results indicate that the amount of stance-phase knee flexion is lower in individuals with PFP and that this may be related to onset timing of the vasti.

Simultaneous feedforward recruitment of the vasti in untrained postural tasks can be restored by physical therapy.

BACKGROUND AND PURPOSE: Physical therapy rehabilitation strategies are commonly directed at the alteration of muscle recruitment in functional movements. The aim of this study was to investigate whether feedforward strategies of the vasti in people with patellofemoral pain syndrome can be changed by a physical therapy treatment program in a randomised, double blind, placebo controlled trial. SUBJECTS: Forty (25 female, 15 male) subjects aged 40 yrs or less (27.2+/-7.8 yrs). METHODS: Subjects were allocated to either a placebo treatment or a physical therapy intervention program. The postural challenge used as the outcome measure was not included in the training program. Electromyography (EMG) onsets of vastus medialis obliquus (VMO), vastus lateralis (VL), tibialis anterior and soleus were assessed before and after the six week standardised treatment programs. RESULTS: At baseline the EMG onset of VL occurred prior to that of VMO in both subject groups. Following physical therapy intervention there was a significant change in the time of onset of EMG of VMO compared to VL with the onsets occurring simultaneously. This change was associated with a reduction in symptoms. In contrast, following placebo intervention the EMG onset of VL still occurred prior to that of VMO. CONCLUSION AND DISCUSSION: The results indicate that the feedforward strategy used by the central nervous system to control the patella can be restored. Importantly, the data suggest that this intervention produced a change that was transferred to a task that was not specifically included in the training program. Furthermore, the change in motor control was associated with clinical improvement in symptoms.

Physical therapy alters recruitment of the vasti in patellofemoral pain syndrome.

PURPOSE: To investigate the effect of physical therapy treatment on the timing of electromyographic (EMG) activity of the vasti in individuals with patellofemoral pain syndrome (PFPS). METHODS: Sixty-five (42 female, 23 male) participants aged 40 yr or less (29.2 +/- 7.8 yr) diagnosed with PFPS. Participants were randomly allocated into physical therapy treatment (McConnell-based) or placebo groups. Treatment programs were standardized and consisted of six-treatment sessions over 6 wk. Vastus medialis oblique (VMO) and vastus lateralis (VL) EMG activity was recorded with surface electrodes during a stair-stepping task and onsets of EMG activity were measured pre- and post-treatment. RESULTS: Before treatment, the EMG onset of VL occurred before that of VMO in both participant groups. After physical therapy intervention, there was a reduction in symptoms, and this improvement was associated with a significant change in the time of onset of VMO EMG compared with that of VL in both phases of the stair-stepping task. After physical therapy treatment, the onset of VMO preceded VL in the eccentric phase and occurred at the same time in the concentric phase of the stair-stepping task. There was no change in time of EMG onset in the placebo group. CONCLUSION: This study demonstrates that a "McConnell"-based physical therapy treatment regime for PFPS alters the motor control of VMO relative to VL in a functional task and this is associated with a positive clinical outcome.

Physical therapy for patellofemoral pain: a randomized, double-blinded, placebo-controlled trial.

BACKGROUND: Although physical therapy forms the mainstay of nonoperative management for patellofemoral pain, its efficacy has not been established. HYPOTHESIS: Significantly more pain relief will be achieved from a 6-week regimen of physical therapy than from placebo treatment. STUDY DESIGN: Multicenter, randomized, double-blinded, placebo-controlled trial. METHODS: Seventy-one subjects, 40 years of age or younger with patellofemoral pain of 1 month or longer, were randomly allocated to a physical therapy or placebo group. A standardized treatment program consisted of six treatment sessions, once weekly. Physical therapy included quadriceps muscle retraining, patellofemoral joint mobilization, and patellar taping, and daily home exercises. The placebo treatment consisted of sham ultrasound, light application of a nontherapeutic gel, and placebo taping. RESULTS: Sixty-seven participants completed the trial. The physical therapy group (N = 33) demonstrated significantly greater reduction in the scores for average pain, worst pain, and disability than did the placebo group (N = 34). CONCLUSIONS: A six-treatment, 6-week physical therapy regimen is efficacious for alleviation of patellofemoral pain.

The physical therapist's approach to patellofemoral disorders.

Management of patellofemoral pain is no longer a conundrum if the therapist can determine the underlying causative factors and address those factors in treatment. It is imperative that the patient's symptoms are significantly reduced. This often is achieved by taping the patella, which not only decreases the pain but also promotes an earlier activation of the VMO and increases quadriceps torque. Management needs to include specific VMO training, gluteal-control work, stretching tight lateral structures, and appropriate advice regarding the foot, whether it is orthotics, training, or taping.

Management of a difficult knee problem.

Chronic disabling patellofemoral (PF) pain and instability can have significant effects on patient function and lifestyle. Although the management of PF pain has improved greatly, there is still a category of patient who tends to have recalcitrant symptoms, which are difficult to manage. The patient often bounces from practitioner to practitioner, physiotherapist as well as surgeon, for some relief of symptoms. However, often the underlying source of the pain is not well understood, so treatment can aggravate the symptoms. The following case report demonstrates the effectiveness of physiotherapy in managing a complex clinical case of a 40 year old patient with bilateral PF symptoms of severe right knee pain and a subluxing left patella, as well as left hip pain. Some background is given as to the source of the right knee pain with magnetic resonance imaging (MRI) supporting the diagnosis and treatment progression. The initial MRI demonstrated marked redundancy of the patellar tendon, resulting in patella baja (infera). Two years and ten treatments later, the patient, who originally could barely walk, was playing tennis for the first time in 25 years. Her MRI showed a complete resolution of the patella baja (infera), indirectly implying an improvement in quadriceps tone, as well as, resolution of the subchondral bone marrow oedema at the lateral patellar facet. Physiotherapists should not give up on patients with chronic musculoskeletal conditions as much can be done for them. These patients need clinicians to persevere, because certainly, for both patient and therapist, the rewards are great.

Evaluation and treatment of disorders of the infrapatellar fat pad.

The infrapatellar fat pad (IFP), also known as Hoffa's fat pad, is an intracapsular, extrasynovial structure that fills the anterior knee compartment, and is richly vascularized and innervated. Its degree of innervation, the proportion of substance-P-containing fibres and close relationship to its posterior synovial lining implicates IFP pathologies as a source of infrapatellar knee pain. Though the precise function of the IFP is unknown, studies have shown that it may play a role in the biomechanics of the knee or act as a store for reparative cells after injury. Inflammation and fibrosis within the IFP, caused by trauma and/or surgery can lead to a variety of arthrofibrotic lesions including Hoffa's disease, anterior interval scarring and infrapatellar contracture syndrome. Lesions or mass-like abnormalities rarely occur within the IFP, but their classification can be narrowed down by radiographical appearance. Clinically, patients with IFP pathology present with burning or aching infrapatellar anterior knee pain that can often be reproduced on physical exam with manoeuvres designed to produce impingement. Sagittal MRI is the most common imaging technique used to assess IFP pathology including fibrosis, inflammation, oedema, and mass-like lesions. IFP pathology is often successfully managed with physical therapy. Passive taping is used to unload or shorten an inflamed IFP, and closed chain quadriceps exercises can improve lower limb control and patellar congruence. Training of the gluteus medius and stretching the anterior hip may help to decrease internal rotation of the hip and valgus force at the knee. Gait training and avoiding hyperextension can also be used for long-term management. Injections within the IFP of local anaesthetic plus corticosteroids and IFP ablation with ultrasound guided alcohol injections have been successfully explored as treatments for IFP pain. IFP pathology refractory to physical therapy can be approached through a variety of operative treatments. Arthroscopic partial resection for IFP impingement and Hoffa's disease has showed favourable results; however, total excision of the IFP performed concomitantly with total knee arthroplasty (TKA) resulted in worse results when compared with TKA alone. Arthroscopic debridement of IFP fibrosis has been successfully used to treat extension block following anterior cruciate ligament reconstruction, and arthroscopic anterior interval release has been an effective treatment for pain associated with anterior interval scarring. Arthroscopic resection of infrapatellar plicae and denervation of the inferior pole of the patella have also been shown to be effective treatments for refractory infrapatellar pain.

Passive and dynamic shoulder rotation range in uninjured and previously injured overhead throwing athletes and the effect of shoulder taping.

OBJECTIVES: To investigate: (1) the passive and dynamic shoulder internal (IR) and external (ER) rotation range of motion (ROM) of 2 groups of asymptomatic overhead throwing athletes: one group who had never experienced shoulder symptoms and another who had shoulder symptoms >12 months ago, (2) the effect of taping on the passive and dynamic IR-ER ROM in both these groups. DESIGN: A within-subject repeated measures analysis of variance design to determine the differences in passive and dynamic shoulder rotation range and the effect of shoulder taping on the rotation range in a group of uninjured and previously injured overhead throwing athletes. SETTING: Academic institution sports medicine setting. PARTICIPANTS: Twenty-six overhead throwing collegiate athletes: 17 with no history of shoulder injury and 9 with previous shoulder injury. METHODS: Passive shoulder ROM was measured with a goniometer with the subject in the supine position. To measure dynamic ROM, the subjects sat on a chair and threw a handball into a net. An 8-camera Vicon Motion Capture system recorded markers placed on the upper limb and trunk. Dynamic ROM was calculated with inverse kinematics by using OpenSim. MAIN OUTCOME MEASUREMENT: Shoulder IR-ER ROM. RESULTS: Dynamic IR-ER ROM was significantly greater than passive IR-ER ROM (P < .0001). There was no difference in passive IR-ER ROM between the uninjured and previously injured overhead throwing athletes. However, there was a significant difference in the total dynamic IR-ER ROM, whereby the overhead throwing athletes who had never experienced shoulder symptoms had less IR-ER ROM than the previously injured group (173.9° versus 196.9°, respectively; P = .049). Taping the shoulder increased the passive ROM in both groups of subjects (P < .001), increased the dynamic IR-ER ROM in the uninjured subjects, but decreased the dynamic IR-ER ROM in the previously injured subjects, although this was not statistically significant (P = .07). CONCLUSIONS: Passive IR-ER ROM is a poor indication of dynamic shoulder function. Athletes who have had a previous shoulder injury demonstrate a greater dynamic IR-ER ROM than athletes who have never had a shoulder injury. Shoulder taping decreased the dynamic range of the previously injured athlete, so that it was nearer the dynamic range of the uninjured athlete. Shoulder taping might provide increased protection for the injured athlete by decreasing the dynamic IR-ER ROM and by facilitating better shoulder and scapular muscle control. Further studies are necessary to demonstrate whether this finding is clinically significant.