Quadriceps architecture in individuals with patellofemoral pain: A systematic review.

OBJECTIVES: To identify differences in architectural parameters (size, fiber/pennation angle, fiber length, and echogenicity) of the quadriceps muscle, as a whole or any individual part of it, using imaging techniques in individuals with patellofemoral pain (PFP) compared to contralateral, asymptomatic limb or separate control group. BACKGROUND: Quadriceps muscles imbalance and weakness were proposed as risk factors for developing PFP. Although the muscle architecture (size, pennation/fiber angle and fiber length) is highly associated with skeletal muscle strength, it is not clear whether atrophy or any changes in architectural parameters of the quadriceps are presented in the PFP patients. METHODS: Observational studies in which the total size of the quadriceps or individual parts of it were measured using imaging techniques in the PFP patients were included in this review. Electronic databases (PubMed, SCOPUS, PEDro, CINAHL, WOS, and EMBASE) were searched between January 1990 and December 2019 with no restriction of language. Study selection and data extraction and quality assessment were conducted by two independent reviewers. RESULTS: Five cross-sectional studies were eligible to include in this review. Three out of five included studies that assessed the total size of the quadriceps and reported no significant differences between the PFP and healthy control group. Two out of five of the studies assessed the total size of the quadriceps between the symptomatic and asymptomatic limb of the PFP patients and reported the statistical difference between limbs. Only one study measured the fiber angle of the VMO muscle at the patella. Controversial results were found between studies that assessed the size of individual parts of the quadriceps. CONCLUSION: Due to the controversial results of the included studies, this systematic review failed to draw a conclusion on the role of quadriceps atrophy in PFP pathology. The limitation in PFP literature considering pennation/fiber angle, echogenicity and fiber length of individual parts of the quadriceps muscle, rises the need for research that focuses on the biomechanical properties of the quadriceps in PFP patients.

Iliopsoas muscle thickness and pelvic alignment in pronated and normal foot postures.

It is hypothesized that the subtalar hyperpronation may provoke the development of a biomechanical chain of events in lower extremity alignment. Several studies have shown that pelvic alignment may alter in the presence of immediate foot hyperpronation induced by external forces. It is unknown whether these alterations are presented in chronic foot hyperpronation or not. It is also unknown if these potential postural changes could affect iliopsoas muscle size. Therefore, it appears necessary to carry out thorough research in this study. Twenty nine females with pronated foot posture and twenty seven females with normal foot posture participated in this study. The iliopsoas muscle was measured using ultrasound imaging (USI). Pelvic angle (PA) was measured using reflective markers and digital photography. Intrarater reliability of USI for the iliopsoas muscle thickness was also measured. The results indicated that the iliopsoas muscle thickness and the PA were not different in individuals with pronated foot compared to the normal foot group. However, a good intrarater reliability of USI was found for measuring the iliopsoas muscle thickness.

Asymmetry of Cervical Multifidus and Longus Colli Muscles Size in Participants With and Without Cervical Radicular Pain.

OBJECTIVES: The aim of this study was to determine the asymmetry of cervical multifidus (MF) and longus colli (LC) muscles in patients with unilateral chronic radicular neck pain (CRNP) and healthy subjects using ultrasonography. MATERIALS AND METHODS: Ninety five individuals (50 patients with unilateral CRNP and 45 healthy subjects) participated in this study. The size of the cervical MF and LC muscles; anterior posterior dimension (APD) and lateral dimension (LD); were bilaterally measured in a relaxed state using ultrasonography. RESULTS: Patients with CRNP showed greater asymmetry in the cervical MF and LC muscles size than the healthy subjects. The mean percentages differences between sides for MF and LC muscles size was higher in patients than that of healthy subjects (for both APD and LD; P<0.05). The ratio of smaller to larger dimensions of the cervical MF and LC muscles for patients were significantly less than that of healthy controls (for both APD and LD; P< 0.05). CONCLUSION: The results indicated that cervical MF and LC muscles showed higher asymmetry between sides and lesser ratio of smaller size to larger size in patients with CRNP as compared with healthy subjects. Current results confirmed the presence of MF and LC muscles atrophy in subjects with CRNP.

The effect of functional stretching exercises on functional outcomes in spastic stroke patients: A randomized controlled clinical trial.

BACKGROUND: Stroke is the biggest cause of disability in adults. Spasticity is a primary impairment of stroke with a highly variable prevalence. In the present research, we aimed to determine the impact of functional stretching exercises on functional outcomes in stroke patients. METHODS: Thirty stroke patients were randomized into two groups-Experimental group and control group for the purposes of the study. The subjects in the experimental group participated in a functional stretching training program at the rehabilitation center thrice a week for four weeks. The subjects in both groups were evaluated in 3 intervals, once at baseline, once at the end of the program, and once at 2 months following the program. Clinical assessments, such as measuring spasticity, were conducted using the Modified Modified Ashworth Scale (MMAS). Functional outcomes were also evaluated, using the Timed Up and Go (TUG) test, as well as the Timed 10-Meter Walk Test (WTT). Friedman test in SPSS version 22.0 was used to analysis the response variables with respect to each stage of evaluation. Spearman rank correlation was also used to measure correlation among clinical assessments and functional outcomes. RESULTS: The comparison between two groups showed significant differences only in the Modified Modified Ashworth Scale and Visual Analogue Scale (VAS) post treatment. The experimental group showed significant differences in the MMAS (p = 0.002), WTT (p < 0.001), and TUG (p < 0.001) scores. Nevertheless, the scores of the control group were not significantly different in different stages of evaluation. CONCLUSION: The findings of the study suggest that using functional stretching exercises can improve functional outcomes in chronic spastic stroke patients.

Quadriceps force production during straight leg raising at different hip positions with and without concomitant ankle dorsiflexion.

OBJECTIVE: Due to the significant prevalence of knee disorders and patellofemoral pain syndrome, as well as the importance of quadriceps strengthening in knee rehabilitation programs, it is necessary to specify the best method to activate and strengthen the quadriceps muscles. The current study aimed at comparing the maximum generated isometric force during an active straight-leg-raising (SLR) maneuver in a sitting position by changing the hip rotational position with and without the simultaneous contraction of the ankle dorsiflexor muscles. METHODOLOGY: The current study was performed on 30 healthy males recruited with a non-random and available sampling method. The maximum generated force was measured during the SLR maneuver in six compound internal and external rotations and in a neutral position with and without ankle dorsiflexor contraction. The obtained generated force was analyzed using repeated measures ANOVA. RESULTS: The generated forces in the SLR with and without contracting the ankle dorsiflexors were significantly different (p = 0.001), and taking different positions of hip rotation led to significant changes in the generated force (p = 0.005). CONCLUSION: The adoption of external hip rotation with the contraction of ankle dorsiflexors during the SLR maneuver generated the most force. Based on the interaction of these conditions, the general recommendation is to perform the SLR exercise in an external hip rotation with the simultaneous contraction of the ankle dorsiflexors in subjects with quadriceps muscle weakness.

Multifidus muscle size changes at different directions of head and neck movements in females with unilateral chronic non-specific neck pain and healthy subjects using ultrasonography.

OBJECTIVE: The aim of the study was to compare the dimensions of cervical multifidus muscle (CMM) in different conditions. METHODS: Twenty five women with neck pain and 25 healthy subjects participated in this study. The dimensions of the CMM were measured at rest, 50% and 100% maximum isometric voluntary contraction (MIVC) at six directions of neck movements, using ultrasonography. RESULTS: The size of multifidus was smaller in patients than healthy individuals at rest state (P < 0.05). A significant smaller CMM dimension was found in the affected side compared with unaffected side in patients group (P < 0.05). The result of ANOVA for MLD showed a significant difference for contraction levels (P < 0.001) and neck movements (P < 0.001) in both groups. The MLD of the CMM was significantly different between CMM at rest and 50%, and 100% MIVC (P < 0.001). No significant differences were found between the groups at 50% and 100% MIVC (P > 0.05 in both instances). The most prominent CMM size change was observed during neck extension, flexion, ipsilateral lateral-flexion, and ipsilateral rotation, respectively (P < 0.05). CONCLUSIONS: Results of the present study indicate that the size of CMM was decreased in patients with neck pain in rest state. The size of CMM changes in all directions of neck movements, although the most prominent was during neck extension. This points out CMM stabilization role's in different directions of neck movements.

A comparison of foot kinetic parameters between pronated and normal foot structures during forward jump landing.

BACKGROUND: Pronated foot is one of the most important factors that may lead to musculoskeletal injuries of the lower extremities. It is known that in a pronated foot, excessive mechanical loads are applied to the lower limb structures, which result in the altered foot biomechanics, including vertical ground reaction forces (VGRFs) and rate of loading (ROL). Therefore, the aim of this study was to determine the changes in foot kinetic parameters in the pronated compared to the normal foot structures. METHODS: In this cross-sectional study, 15 individuals (mean age of 23.27 ± 3.28 years) with asymptomatic pronated feet and 15 normal subjects (mean age of 23.40 ± 3.11 years) were recruited from both genders by using a simple non-random sampling method. VGRF, ROL, and the resultant vector of time to stabilization (RVTTS) were evaluated during the forward jump landing task by using a force plate. RESULTS: The findings showed that the following parameters were significantly higher in the group of pronated feet than in the normal subjects: VGRF (3.30 ± 0.17 vs. 2.81 ± 0.15, p = .042), ROL (0.10 ± 0.01 vs. 0.07 ± 0.006, p = .020), and RVTTS (2592.80 ± 141.24 vs. 2114.00 ± 154.77, p = .030). CONCLUSION: All the measured foot kinetic parameters were higher in the pronated foot subjects than in the normal participants. An impaired movement control and greater forces imposed on the foot region of the pronated foot, compared to the normal foot individuals, were discovered indicating the former group's possible increase of susceptibility to various musculoskeletal injuries.

A comparison of lower limb muscle activation pattern using voluntary response index between pronated and normal foot structures during forward jump landing.

BACKGROUND: Pronated of the foot is one of the important factors contributing to musculoskeletal problems affecting the lower extremities. It is known that in a pronated foot, excessive mechanical load is applied to the lower limb structures which may result in altered biomechanics and muscle activation patterns. The aim of this study was to determine changes in the muscle activation pattern of the lower extremities in individuals with pronated, compared to normal, feet, using the voluntary response index (VRI). METHODS: In this cross sectional study, 15 asymptomatic pronated foot individuals (mean age 23.27 ± 3.28 years) and 15 normal subjects (mean age 23.40 ± 3.11 years) were recruited by simple non-random sampling. Electrical activities of gluteus medius (GM), vastus lateralis (VL), vastus medialis (VM), biceps femoris, semitendinosus (ST), and medial gastrocnemius (MG) muscles were recorded during a forward jump landing task. Voluntary response index (VRI) variables, included similarity index (SI) and magnitude (Mag) were also evaluated. RESULTS: Muscle activity of VM (p < 0.001) and ST (p = 0.010) were significantly higher but VL (p = 0.039) and MG (p = 0.001) were significantly lower in pronated foot, compared to normal subjects. Similarity index was found to be different (p < 0.001) between pronated foot and healthy individuals. No significant difference was found in terms of Mag between the two groups (p = 0.576). CONCLUSION: The altered pattern of lower limb muscle activation identified in the pronated foot during landing may be attributed to the different activation involving VL, VM, MG and ST muscles. Adaptations to the biomechanical effects, due to the pronated foot causing altered activation of VL, VM, MG, and ST muscles, results in an altered pattern of muscle activation. This change in activation pattern may harm the effectiveness of movement control processes; and might also predispose individuals with pronated feet, to injuries. It seems that an altered motor strategy with the aim of minimizing biomechanical changes, predisposes individuals to injuries. However, further large scale studies are needed to support the findings of the present study.

Immediate effect of common peroneal nerve electrical stimulation on quadriceps muscle arthrogenic inhibition in patients with knee osteoarthritis.

OBJECTIVE: To investigate the immediate effect of electrical stimulation of the common peroneal nerve on the maximum voluntary activation of the quadriceps muscle in patients with knee osteoarthritis. METHODOLOGY: Fifteen subjects with knee osteoarthritis (mean age: 50.5 ± 13 years) participated in this study. To measure the arthrogenic inhibition ratio of quadriceps, a burst of electrical stimulation was superimposed on the maximum voluntary contraction, and the percentage of change in the force production was computed. The same measurement was also performed with concurrent electrical stimulation of the common peroneal nerve. RESULTS: All the patients with knee osteoarthritis showed significant arthrogenic inhibition of the quadriceps muscle. The stimulation of the common peroneal nerve was able to reduce this inhibition and increase the capacity of the muscle to produce a significantly higher knee extension force (p = 0.028). CONCLUSIONS: Electrical stimulation of the common peroneal nerve concurrent with the maximum voluntary effort can remove the arthrogenic inhibition of the quadriceps muscle in patients with knee osteoarthritis. This finding could have clinical implications in the management of patients with knee disorders.

A comparison of the effect of the active release and muscle energy techniques on the latent trigger points of the upper trapezius.

BACKGROUND/AIM: The increasing use of computer in daily life has brought about numerous musculoskeletal problems. Impairments in the head, neck and shoulders are more common compared with the other parts of the body. The aim of this study was to compare the effect of two manual treatments in two separate groups, i.e., active release technique (ART) and muscle energy technique (MET) on the latent trigger points (LTrPs) in the upper trapezius muscle. The set criteria in the study included the active range of cervical lateral flexion, pain intensity on the visual analog scale (VAS), and the upper trapezius muscle thickness. SUBJECTS AND METHODS: This clinical trial study assessed the outcome measures within and between groups before and after the intervention. The target population were 64 (32 males, 32 females) participants who had been selected from among the staff members and the students of a rehabilitation school, and the employees of an engineering company who had LTrPs in their upper trapezius muscle and were from 18 to 50 years old. RESULTS: The immediate effects of MET and ART on the patients of each groups with LTrPs in their upper trapezius muscle were increased active range of cervical lateral flexion (P < 0.001), decreased pain intensity on VAS (P < 0.05) and decreased thickness of the upper trapezius muscle (P < 0.01). CONCLUSION: Both manual techniques of ART and MET reduced the symptoms of LTrPs in the upper trapezius in the two groups equally, neither technique being superior to the other.

Reliability of digital photography for assessing lower extremity alignment in individuals with flatfeet and normal feet types.

AIM: The aim of this study was to investigate the intratester reliability of digital photographic method for quantifying static lower extremity alignment in individuals with flatfeet and normal feet types. METHODS: Thirteen females with flexible flatfeet and nine females with normal feet types were recruited from university communities. Reflective markers were attached over the participant's body landmarks. Frontal and sagittal plane photographs were taken while the participants were in a standardized standing position. The markers were removed and after 30 min the same procedure was repeated. Pelvic angle, quadriceps angle, tibiofemoral angle, genu recurvatum, femur length and tibia length were measured from photographs using the Image j software. RESULTS: All measured variables demonstrated good to excellent intratester reliability using digital photography in both flatfeet (ICC: 0.79-0.93) and normal feet type (ICC: 0.84-0.97) groups. CONCLUSION: The findings of the current study indicate that digital photography is a highly reliable method of measurement for assessing lower extremity alignment in both flatfeet and normal feet type groups.

Reliability of assessment of upper trapezius morphology, its mechanical properties and blood flow in female patients with myofascial pain syndrome using ultrasonography.

OBJECTIVE: In the present study, the intra-rater reliability of upper trapezius morphology, its mechanical properties and intramuscular blood circulation in females with myofascial pain syndrome were assessed using ultrasonography. DESIGN: A total of 37 patients (31.05 ± 10 years old) participated in this study. Ultrasonography producer was set up in three stages: a) Gray-scale: to measure muscle thickness, size and area of trigger points; b) Ultrasound elastography: to measure muscle stiffness; and c) Doppler imaging: to assess blood flow indices. RESULTS: According to data analysis, all variables, except End Diastolic Velocity (EDV), had excellent reliability (>0.806). Intra-class Correlation Coefficient (ICC) for EDV was 0.738, which was considered a poor to good reliability. CONCLUSION: The results of this study introduced a reliable method for developing details of upper trapezius features using muscular ultrasonography in female patients. These variables could be used for objective examination and provide guidelines for treatment plans in clinical settings.

Quantification of dry needling on myofascial trigger points using a novel ultrasound method: A study protocol.

INTRODUCTION: Myofascial pain syndrome (MPS) is a neuromuscular dysfunction consisting of both motor and sensory abnormalities. Considering the high prevalence of MPS and its related disabilities and costs, this study was designed to determine the reliability of new ultrasonographic indexes of the upper trapezius muscle as well as the sensitivity and specificity of 2D ultrasound imaging for diagnostic purposes. Furthermore, we sought to evaluate the effectiveness of dry needling (DN) on studied ultrasonographic indexes. MATERIALS AND METHODS: This study will be performed in two steps with two different designs. The first is a pilot study and was designed as a semi-experimental study to determine the sensitivity and specificity of ultrasonography for the diagnosis of MPS and the reliability of ultrasonographic measurements like muscle thickness, area of myofascial trigger points (MTrPs) in longitudinal view, echogenicity of MTrPs in longitudinal view, echogenicity of muscle with MTrPs in longitudinal and transverse views, and pennation angle of upper trapezius muscle. The second study is an interventional study which was designed to investigate the effectiveness of DN on ultrasonographic measurements, for which the reliability was determined in the first study. CONCLUSION: we will quantify the effectiveness of DN on MTrPs and muscle tissue by using novel ultrasonographic indexes. The results of the current study will provide baseline information to design more interventional studies to improve the evaluation of other treatments of MPS.

Differences in cervical multifidus muscle thickness during isometric contraction of shoulder muscles: a comparison between patients with chronic neck pain and healthy controls.

OBJECTIVE: The purposes of this study were to (1) measure the thickness of cervical multifidus muscle (CMM) in different maximal voluntary contraction percentages of isometric contraction of shoulder muscles, (2) evaluate the differences of the CMM thickness in different directions of the shoulder movement, and (3) compare the changes in the CMM thickness of participants with neck pain and also of healthy individuals. METHODS: Twenty healthy men (age, 27.45 ± 4.37 years; height, 177 ± 4.66 cm; weight, 72.85 ± 6.46 kg) and 20 men with chronic mechanical neck pain (age, 28.90 ± 5.53 years; height, 176 ± 5.98 cm; weight, 73.15 ± 7.82 kg) participated in the study. Both the right and left CMM thicknesses were measured using an ultrasound device while participants performed isometric contraction of shoulder muscles in 6 movement directions. RESULTS: In both groups, an increment of CMM thickness followed as the increase of isometric force (P < .01).The increase of muscle thickness of healthy participants was substantially more than the chronic mechanical neck pain participants (P = .03). Although no significant difference of CMM thickness was seen among the effects of the 6 force directions (P > .05), there was a significant difference of activity noted between the left and right sides (P = .047). CONCLUSION: The results of the present study indicate that isometric contraction of shoulder muscles caused an increase in the CMM thickness regardless of force direction. This increase was seen in both groups of healthy participants and patients with neck pain. However, less thickness changes were observed in participants with neck pain, which may be interpreted as reduced CMM activity in such people.

The effects of isometric contraction of shoulder muscles on cervical multifidus muscle dimensions in healthy office workers.

It is argued that cervical multifidus muscles (CMM) are responsible for providing neck stability. However, whether they are actually activated during the tasks performed by the upper extremities to the neck is still unknown. Therefore, the aim of this study was to examine the effects of isometric contraction of shoulder muscles on the dimensions of CMM. Twenty three healthy males voluntarily participated in this study. Ultrasonography imaging of CMM was conducted at rest and at 25%, 50%, 75%, and 100% of maximal voluntary contraction of shoulder muscles in 6 directions of shoulder movements. Anterior-posterior dimension (APD), lateral dimension (LD), shape ratio and multiplied linear dimension (MLD) of cervical multifidus were measured. The APD of CMM was increased while LD and shape ratio were decreased by shoulder muscles contraction (P < 0.01).

The effect of fatigue and velocity on the relative timing of hamstring activation in relation to quadriceps.

Inter-muscular coordination has an important role in proper function and prevention of injuries in the knee joint. The purpose of this study was to characterize the effect of velocity and fatigue on the relative activation onset of hamstring to quadriceps muscles during knee extension. Thirty one healthy and non-athletic volunteers (24 women, 7 men) were recruited for the study. The onset time of vastus medialis, vastus lateralis, rectus femoris, medial and lateral hamstring were measured during maximum voluntary extension of the knee joint at velocities of 45° /s, 150° /s & 300° /s before and after fatigue and the mean delay onset of all pairs of H-Q were measured. A two-way repeated measures ANOVA test was used to compare across the mean delayed onset of hamstring related to quadriceps muscles at various velocities. Hamstring muscle showed a delayed activation related to quadriceps and increasing the velocity of shortening has a prominent effect on the inter-muscular coordination with early activation of hamstring related to quadriceps muscles (F = 6.7, p < 0.002 for Biceps-rectus femoris, F = 6.31, p < 0.003 for semitendinosus-rectus femoris, F = 6.26, p < 0.003 for biceps-vastus lateralis, F = 5.98, p < 0.004 for semitendinosus-vastus lateralis, F = 3.19, p < 0.04 for biceps-vastus medialis and F = 3.2, p < 0.04 for semitendinosus-vastus medialis). This could predispose these muscles to over strain and possible injuries. The main effect of fatigue condition and its interaction with velocity however, showed statistically nonsignificant result.

Ultrasonography of longus colli muscle: A reliability study on healthy subjects and patients with chronic neck pain.

In this study, the reliability of the longus colli muscle (LCM) size was assessed in a relaxed state by a real time ultrasonography (US) device in a group of healthy subjects and a group of patients with chronic neck pain. Fifteen healthy subjects (19-41 years old) and 10 patients with chronic neck pain (27-44 years old) were recruited for the purpose of this study. LCM size was measured at the level of thyroid cartilage. Two images were taken on the same day with an hour interval to assess the within day reliability and the third image was taken 1 week later to determine between days reliability. Cross sectional area (CSA), anterior posterior dimension (APD), and lateral dimension (LD) were measured each time. The shape ratio was calculated as LD/APD. Intraclass correlation coefficients (ICC) and standard error of measurement (SEM) were computed for data analysis. The ICC of left and right CSA for within day and between days reliability in healthy subjects were (0.90, 0.93) and (0.85, 0.82), respectively. The ICC of left and right CSA for within day and between days reliability in patients with neck pain were (0.86, 0.82) and (0.76, 0.81), respectively. The results indicated that US could be used as a reliable tool to measure the LCM dimensions in healthy subjects and patients with chronic neck pain.

Ultrasonography of the cervical muscles: a critical review of the literature.

OBJECTIVE: This article presents a review of the literature concerning size measurement of cervical muscles using real-time ultrasound imaging (RUSI) in patients with neck pain and in healthy populations. METHODS: A literature search from 1996 to December 2009 making use of Science Direct and PubMed databases was conducted. Medical Subject Headings and other terms were as follows: ultrasonography, cervical, muscle, neck, size, pain, validity, reliability, neck pain, and healthy subjects. We included studies using RUSI for assessing cervical paraspinal muscles both in healthy subjects and in patients with neck pain. We assessed muscles investigated and the reliability and validity of the method used. RESULTS: The literature search yielded 16 studies. Twelve (75%) studies assessed the posterior muscles, whereas in the remaining 4 (25%), the anterior muscles were studied. Three studies quantified the size of the muscles during contraction; 3 assessed the relationship between cross-sectional area, linear dimensions, and anthropometric variables; 1 evaluated the training-induced changes in muscle size; 1 assessed the differences in muscle shape and cross-sectional area of cervical multifidus between patients with chronic neck pain and controls; 8 studies looked at the reliability of using RUSI in patients with neck pain or healthy subjects; and 3 studies evaluated the validity of RUSI compared with magnetic resonance imaging. CONCLUSIONS: This literature review has shown that there are not sufficient studies for assessing neck muscles with RUSI. It seems that using constant landmarks, knowledge of anatomy and function of target muscle, and a proper definition of muscle borders can help to take a clear image. Standardized position of the subject, correct placement of the transducer, and using multiple RUSI for statistical analyses may improve results.