Hamstring Strain Injury in Athletes.

Hamstring strain injury (HSI) may result in considerable impairment, activity limitation, and participation restriction, including time lost from competitive sports. This CPG includes sports-related overloading and overstretching injuries to myofascial or musculotendinous structures in any combination of the 3 hamstring muscles (the semitendinosus, semimembranosus, and biceps femoris). J Orthop Sports Phys Ther 2022;52(3):CPG1-CPG44. doi:10.2519/jospt.2022.0301.

Testing to Identify Submaximal Effort: Lifting to a Perceived 50% Effort vs. an Assigned Submaximal Load.

ABSTRACT: Swift, MC, Townsend, R, Edwards, D, and Loudon, J. Testing to identify submaximal effort: Lifting to a perceived 50% effort vs. an assigned submaximal load. J Strength Cond Res 36(8): 2115-2120, 2022-The ability to accurately measure effort during postinjury functional testing allows for the validation of displayed physical limitations by injured workers. The Cross-Reference Testing System (XRTS) has been developed to identify submaximal efforts through distraction-based dynamic material handling testing. The XRTS material handling assessment compares dynamic lifts of weights in a crate and lifts using a lever arm device. The purpose of this study was to determine whether subjects lifting an assigned submaximal load influence test results compared with subjects lifting to but not exceeding a 50% perceived effort. Subjects in group A ( n = 35) were assigned the condition to attempt to lift to but not exceed a randomly assigned weight value for both the crate lift and XRTS at 3 lifting heights. Subjects in group B ( n = 32) were asked to lift to but not exceed 37.5 lb from the same 3 lifting heights. The reproducibility of effort was measured with current validity criteria for distraction-based material handling testing. Using the percent difference values, a 2 × 3 (group, lifting height) analysis of variance (ANOVA) was performed to test the hypothesis. The alpha level was set at 0.05. The mean percent change between comparative lifts was 31.13%, 95% CI (22.51-39.75) for group A and 29.26% 95% CI (21.91-36.61) for group B. The 2 × 3 ANOVA demonstrated no significant difference ( p = 0.751) between groups. The results indicate attempting to lift to a perceived 50% effort was not significantly different from attempting to lift to but not exceed an assigned submaximal load.

Dynamic and Static Assessment of Single-Leg Postural Control in Female Soccer Players.

PURPOSE/BACKGROUND: Various methods are available for assessment of static and dynamic postural stability. The primary purpose of this study was to investigate the relationship between dynamic postural stability as measured by the Star Excursion Balance Test (SEBT) and static postural sway assessment as measured by the TechnoBody™ Pro-Kin in female soccer players. A secondary purpose was to determine side-to-side symmetry in this cohort. METHODS: A total of 18 female soccer players completed testing on the SEBT and Technobody™ Pro-Kin balance device. Outcome measures were anterior, posterior medial, and posterior lateral reaches from the SEBT and center of pressure in the x- and y-axes as well as SD of movement in the forward/backward and medial/lateral directions from the force plate on left and right legs. Bivariate correlations were determined between the 8 measures. In addition, paired Wilcoxon signed-rank tests were performed to determine similarity between limb scores. RESULTS: All measures on both the SEBT and postural sway assessment were significantly correlated when comparing dominant with nondominant lower-extremities with the exception of SD of movement in both x- and y-axes. When correlating results of the SEBT with postural sway assessment, a significant correlation was found between the SEBT right lower-extremity posterior lateral reach (r = .567, P < .05) and summed SEBT (r = .486, P < .05) and the center of pressure in the y-axis. A significant correlation was also found on the left lower-extremity, with SD of forward/backward movement and SEBT posterior medial reach (r = -.511, P < .05). CONCLUSIONS: Dynamic postural tests and static postural tests provide different information to the overall assessment of balance in female soccer players. Relationship between variables differed based on the subject's lower-extremity dominance.

Decision-Making Data: Expectations for Reproducibility of Lifting on Separate Days.

PURPOSE: The purpose of this study was to explore the difference in maximal lifting capability between 2 modes of lifting (traditional crate and XRTS Lever Arm) over multiple days. The differences in absolute strength values were compared with existing criteria for sincere effort during distraction-based lifting. In addition, rate of perceived exertion (RPE) is presented for the 2 modes of lifting on each day. PRIMARY PRACTICE SETTING: Workers' compensation. METHODOLOGY AND SAMPLE: Forty-four subjects between the ages of 20 and 44 years participated in this study. Investigators established 1 repetition maximum (RM) for each subject performing the crate lift. Subjects were randomly assigned 5 weights ranging from 10% to 100% of their determined 1RM and asked to give their rating of perceived exertion after each lift. The same procedure was repeated 2-5 days later using the XRTS Lever Arm. Paired t tests and Spearman's correlation coefficient were used for data analysis. Alpha was set at less than .05. RESULTS: There was a statistically significant difference (p < .04) between maximal lift values for the 2 lifting modes. The percent difference between the modes of lifting was 10.5% ± 6.4%. In addition, there was a positive correlation between the RPE on the 2 modes of lifting (p = .87). IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: A functional capacity evaluation (FCE) is typically ordered after the completion of physical rehabilitation and before releasing a patient to full or modified duty. In addition to assessing the ability to function within normal job demands, an assessment of effort by the participant typically takes place during an FCE. Case managers and physicians are presented with information, allowing them to make comparisons between functional lifting abilities displayed during treatment sessions and the FCE. These comparisons may often take place with the subpoena of medical records and may be discussed during the deposition or trial process. If an FCE takes place at a different facility than the physical therapy or work conditioning treatment, 2 different modes of lifting may take place based on the equipment within each facility. The results of this study indicate that the 2 modes of lifting on separate days meet established criteria for lift comparison testing during FCEs.

BIOMECHANICS AND PATHOMECHANICS OF THE PATELLOFEMORAL JOINT.

The patellofemoral joint is a joint that can be an area of concern for athletes of various sports and ages. The joint is somewhat complex with multiple contact points and numerous tissues that attach to the patella. Joint forces are variable and depend on the degree of knee flexion and whether the foot is in contact with the ground. The sports medicine specialist must have a good working knowledge of the anatomy and biomechanics of the patellofemoral joint in order to treat it effectively.

The master female triathlete.

The world of triathlon has expanded to include all ages and both sexes. One of the largest growing age groups is the master female athlete. It is important for the physical therapist to understand the special needs of this population in order to adequately care for master female athletes so they can participate at a high level and injury-free. Biology of aging, injury prevention and a suggested training program are presented in this Masterclass article.

Return to sport after open and microdiscectomy surgery versus conservative treatment for lumbar disc herniation: a systematic review with meta-analysis.

BACKGROUND: Lumbar disc herniation has a prevalence of up to 58% in the athletic population. Lumbar discectomy is a common surgical procedure to alleviate pain and disability in athletes. We systematically reviewed the current clinical evidence regarding athlete return to sport (RTS) following lumbar discectomy compared to conservative treatment. METHODS: A computer-assisted literature search of MEDLINE, CINAHL, Web of Science, PEDro, OVID and PubMed databases (from inception to August 2015) was utilised using keywords related to lumbar disc herniation and surgery. The design of this systematic review was developed using the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Methodological quality of individual studies was assessed using the Downs and Black scale (0-16 points). RESULTS: The search strategy revealed 14 articles. Downs and Black quality scores were generally low with no articles in this review earning a high-quality rating, only 5 articles earning a moderate quality rating and 9 of the 14 articles earning a low-quality rating. The pooled RTS for surgical intervention of all included studies was 81% (95% CI 76% to 86%) with significant heterogeneity (I(2)=63.4%, p<0.001) although pooled estimates report only 59% RTS at same level. Pooled analysis showed no difference in RTS rate between surgical (84% (95% CI 77% to 90%)) and conservative intervention (76% (95% CI 56% to 92%); p=0.33). CONCLUSIONS: Studies comparing surgical versus conservative treatment found no significant difference between groups regarding RTS. Not all athletes that RTS return at the level of participation they performed at prior to surgery. Owing to the heterogeneity and low methodological quality of included studies, rates of RTS cannot be accurately determined.

Conservative management of femoroacetabular impingement (FAI) in the long distance runner.

Femoroacetabular impingement (FAI) is one cause of anterior hip pain that may occur in a long distance runner. By definition FAI is due to bony abutment of the femoral neck and the acetabulum. This occurs primarily with end-ranges of hip flexion and adduction. An understanding of running mechanics and performing a thorough examination will help the clinician provide an appropriate intervention for these athletes. A course of conservative treatment that includes patient education, manual therapy and strengthening should be tried prior to surgical management.

Functional movement screen scores in a group of running athletes.

The purpose of this study was to determine the mean values of the functional movement screen (FMS) in a group of long-distance runners. The secondary aims were to investigate whether the FMS performance differed between sexes and between young and older runners. Forty-three runners, 16 women (mean age = 33.5 years, height = 165.2 cm, weight = 56.3 kg, and body mass index [BMI] = 20.6) and 27 men (mean age = 39.3 years, height = 177.6 cm, weight = 75.8 kg, and BMI = 24.2) performed the FMS. All the runners were injury-free and ran >30 km·wk. Independent t-tests were performed on the composite scores to examine the differences between men and women and also between young (<40 years) and older runners (>40 years). Contingency tables (2 × 2) were developed for each of the 7 screening tests to further look at the differences in groups for each single test. The χ values were calculated to determine significant differences. Statistical significance was set at p ≤ 0.05. There was no significant difference in the composite score between women and men. There were significant differences between the sexes in the push-up and straight leg test scores, with the women scoring better on each test. A significant difference was found in the composite scores between younger and older runners (p < 0.000). Additional score differences were found for the squat, hurdle step, and in-line lunge tests with the younger runners scoring better. This study provided mean values for the FMS in a cohort of long-distance runners. These values can be used as a reference for comparing FMST scores in other runners who are screened with this tool.

The efficacy of manual joint mobilisation/manipulation in treatment of lateral ankle sprains: a systematic review.

BACKGROUND: Lateral ankle sprains are common and can have detrimental consequences to the athlete. Joint mobilisation/manipulation may limit these outcomes. OBJECTIVE: Systematically summarise the effectiveness of manual joint techniques in treatment of lateral ankle sprains. METHODS: This review employed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A computer-assisted literature search of MEDLINE, CINHAL, EMBASE, OVID and Physiotherapy Evidence Database (PEDro) (January 1966 to March 2013) was used with the following keywords alone and in combination 'ankle', 'sprain', 'injuries', 'lateral', 'manual therapy', and 'joint mobilisation'. The methodological quality of individual studies was assessed using the PEDro scale. RESULTS: After screening of titles, abstracts and full articles, eight articles were kept for examination. Three articles achieved a score of 10 of 11 total points; one achieved a score of 9; two articles scored 8; one article scored a 7 and the remaining article scored a 5. Three articles examined joint techniques for acute sprains and the remainder examined subacute/chronic ankle sprains. Outcome measures included were pain level, ankle range of motion, swelling, functional score, stabilometry and gait parameters. The majority of the articles only assessed these outcome measures immediately after treatment. No detrimental effects from the joint techniques were revealed in any of the studies reviewed. CONCLUSIONS: For acute ankle sprains, manual joint mobilisation diminished pain and increased dorsiflexion range of motion. For treatment of subacute/chronic lateral ankle sprains, these techniques improved ankle range-of-motion, decreased pain and improved function.

Diagnostic accuracy of clinical tests for assessment of hamstring injury: a systematic review.

STUDY DESIGN: Systematic literature review. BACKGROUND: The diagnosis of a hamstring injury has traditionally relied on various clinical measures (eg, palpation, swelling, manual resistance), as well as the use of diagnostic imaging. But a few studies have suggested the use of specific clinical tests that may be helpful for the diagnostic process. OBJECTIVE: To summarize the current literature on the diagnostic accuracy of orthopaedic special tests for hamstring injuries and to determine their clinical utility. METHODS: A computer-assisted literature search of the MEDLINE, CINAHL, and Embase databases (along with a manual search of grey literature) was conducted using key words related to diagnostic accuracy of hamstring injuries. To be considered for inclusion in the review, the study required (1) patients with hamstring or posterior thigh pain; (2) a cohort, case-control, or cross-sectional design; (3) inclusion of at least 1 clinical examination test used to evaluate hamstring pathology; (4) comparison against an acceptable reference standard; (5) reporting of diagnostic accuracy of the measures (sensitivity [SN], specificity [SP], or likelihood ratios); and (6) publication in English. SN, SP, and positive and negative likelihood ratios were calculated for each diagnostic test. RESULTS: The search strategy identified 602 potential articles, of which only 3 articles met the inclusion criteria, with only 1 of these 3 articles being of high quality. Two of the studies investigated a single special test, whereas the third article examined a composite clinical assessment employing various special tests. The SN values ranged from 0.55 (95% confidence interval [CI]: 0.46, 0.69) for the active range-of-motion test to 1.00 (95% CI: 0.97, 1.00) for the taking-off-the-shoe test. The SP values ranged from 0.03 (95% CI: 0.00, 0.22) for the composite clinical assessment to 1.00 (95% CI: 0.97, 1.00) for the taking-off-the-shoe test, active range-of-motion test, passive range-of-motion test, and resisted range-of-motion test. The use of a single special test demonstrated stronger SP than SN properties, whereas the composite clinical assessment demonstrated stronger SN than SP properties. CONCLUSION: Very few studies have investigated the utilization of clinical special tests for the diagnosis of hamstring injuries. Further studies of higher quality design are suggested prior to advocating independent clinical utilization of these special tests. LEVEL OF EVIDENCE: Diagnosis, level 3b.

Lower extremity kinematics in running athletes with and without a history of medial shin pain.

PURPOSE/BACKGROUND: Medial shin pain (MSP) is a common complaint that may stop an athlete from running. No previous study has identified deficits in pelvic, hip or knee motion as potential contributing factors to MSP. The purpose of this study was to investigate the differences in kinematics during running between uninjured athletes and those with MSP. Secondary analyses investigated differences in limbs between groups and differences between sexes. METHODS: This case-control study investigated fourteen runners aged 18-40 years old with a history of unilateral MSP and fourteen runner controls. Three dimensional lower quarter kinematics were captured as runners ran on a treadmill. Specifically, peak hip internal rotation (IR), frontal plane pelvic tilt (PT) excursion, and knee flexion were examined. RESULTS: Groups were similar in age, mass, height, and training mileage. Subjects with a history of MSP demonstrated significantly greater frontal plane PT (P = 0.002, Effect size = 0.55) and peak hip IR (P = 0.004, Effect size = 0.51); and less knee flexion (P = 0.02, Effect size = 0.46) than the control group. No significant difference was found in kinematics of the MSP group during their involved side stance phase as compared to their non-involved side. CONCLUSIONS: Runners with MSP displayed greater PT excursion, peak hip IR, and decreased knee flexion while running as compared to a control group. These results should help guide treatment for the running athlete that experiences MSP. LEVEL OF EVIDENCE: 3b.

A literature review of studies evaluating gluteus maximus and gluteus medius activation during rehabilitation exercises.

Recently, clinicians have focused much attention on the importance of hip strength for the rehabilitation of not only patients with low back pain but also lower extremity pathology. Properly designing a rehabilitation program for the gluteal muscles requires careful consideration of biomechanical principles, such as length of the external moment arm, gravity, and subject positioning. Understanding the anatomy and function of these muscles also is essential. Electromyography (EMG) provides a useful means to determine muscle activation levels during specific exercises. Descriptions of specific exercises, as they relate to the gluteal muscles, are described. The specific performance of these exercises, the reliability of such EMG measures, and descriptive figures are also detailed. Of utmost importance to practicing clinicians is the interpretation of such data and how it can be best used in exercise prescription when formulating a treatment plan.

Dancers with achilles tendinopathy demonstrate altered lower extremity takeoff kinematics.

STUDY DESIGN: Controlled laboratory study using a cross-sectional design. OBJECTIVES: To analyze lower extremity kinematics during takeoff of a "saut de chat" (leap) in dancers with and without a history of Achilles tendinopathy (AT). We hypothesized that dancers with AT would demonstrate different kinematic strategies compared to dancers without pathology, and that these differences would be prominent in the transverse and frontal planes. BACKGROUND: AT is a common injury experienced by dancers. Dance leaps such as the saut de chat place a large demand on the Achilles tendon. METHODS: Sixteen female dancers with and without a history of AT (mean ± SD age, 18.8 ± 1.2 years) participated. Three-dimensional kinematics at the hip, knee, and ankle were quantified for the takeoff of the saut de chat, using a motion analysis system. A force platform was used to determine braking and push-off phases of takeoff. Peak sagittal, frontal, and transverse plane joint positions during the braking and push-off phases of the takeoff were examined statistically. Independent samples t tests were used to evaluate group differences (α = .05). RESULTS: The dancers in the tendinopathy group demonstrated significantly higher peak hip adduction during the braking phase of takeoff (mean ± SD, 13.5° ± 6.1° versus 7.7° ± 4.2°; P = .046). During the push-off phase, dancers with AT demonstrated significantly more internal rotation at the knee (13.2° ± 5.2° versus 6.9° ± 4.9°; P = .024). CONCLUSION: Dancers with AT demonstrate increased peak transverse and frontal plane kinematics when performing the takeoff of a saut de chat. These larger displacements may be either causative or compensatory factors in the development of AT.

Does the Friel Anaerobic Threshold Test Accurately Detect Heart Rate Deflection in Trained Cyclists?

The Friel Anaerobic Threshold Test (FATT) has been used to determine anaerobic threshold (AT). The FATT suggests AT occurs near the heart rate deflection point (HRDP) at a rating of perceived exertion (RPE) of 17. PURPOSE: The primary purpose of this study was to determine 1) whether the HRDP could be determined using the FATT, 2) examine differences between HRVT and HR that coincided Borg's rating of perceived exertion (RPE) of 17, and 3) if riding position (hoods or aero) would influence performance. METHODS: Fourteen male cyclists (30.4 ± 7.41years of age; 151.8 ± 60.4 cycled miles/week) participated in the study. Each subject performed the FATT on two occasions within one week. RESULTS: The findings of this study suggest that the FATT can determine HRDP in trained cyclists while riding in the hoods position but not the aero position. No significant difference was found between the hoods and aero position for HRVT as measured by the metabolic cart. Our data suggest that HR at an RPE of 15 more accurately reflects the HRVT than the RPE of 17. A low, non-significant correlation was found for both the hoods and aero (0.41 and 0.44, respectively; p > 0.20) for the HR at RPE of 17. CONCLUSION: The findings of this study suggest that the FATT can determine HRDP in trained cyclists. However, HRDP was identified in the cyclists preferred riding position. When performing the FATT, HRVT at an RPE of 15 should be used to estimate VT over the suggested RPE of 17.

Static progressive stretch brace as a treatment of pain and functional limitations associated with plantar fasciitis: a pilot study.

Plantar fasciitis is a common and hard-to-treat disorder of the foot. Numerous studies have compared various stretching exercises, but the use of a day-wear static progressive stretch brace has not been studied. A randomized, single-blinded trial was conducted to compare the effectiveness of a static progressive stretch brace to standard care of active stretching exercises. Thirteen subjects (12 women and 1 man; mean age, 42 +/- 9.0 years) with plantar fasciitis participated in this study between January 2004 and March 2007. Subjects were randomized to either an exercise group (static stretch group, n = 8) or a brace group (static progressive stretch group, n = 9) for an 8-week treatment period and 1-month follow up. Both groups received basic off-the-shelf foot orthoses. Data were available for 7 subjects in the exercise group and 6 in the brace group. Pain and functional limitations were evaluated with the Foot Functional Index pain subscale, the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale, and great toe extension motion. Overall pain and morning pain improved in both groups as compared with baseline measures (repeated-measures analysis of variance, P = .04 and P = .02, respectively). Functional rating also improved in both groups (repeated-measures analysis of variance, P = .005). No changes were found in either group with great toe extension range of motion. In addition, there was no significant group difference or interaction with time and group with any measures. Both interventions (static, exercise, and brace stretching) were beneficial for treating pain and functional limitations, suggesting that static progressive stretch brace is an effective alternative option to static stretching exercises for people with plantar fasciitis.

Use of foot orthoses and calf stretching for individuals with medial tibial stress syndrome.

Use of orthotics and calf stretching may alleviate symptoms in runners with medial tibial stress syndrome (MTSS). The objective of this study was to determine which patients with MTSS have a positive response to off-the-shelf foot orthoses and calf stretching based on selected clinical tests to establish a clinical prediction rule. This prospective cohort/predictive validity study enrolled 23 women and men aged 22 to 44 years with symptoms of MTSS. Interventions included off-the-shelf basic foot orthotics and calf stretching. Fifteen of the 23 runners had a 50% reduction of pain in 3 weeks of intervention. Duration was a significant factor that differentiated groups. Although an initial treatment for runners with MTSS may include off-the-shelf orthotics and calf stretching, this regimen should be only one component of an individualized rehabilitation program.

Validity of a total body recumbent stepper exercise test to assess cardiorespiratory fitness.

Maximum oxygen consumption ([latin capital V with dot above]o2max) is the primary measure for cardiorespiratory fitness, and the [latin capital V with dot above]o2max value achieved on the treadmill using the Bruce protocol is considered the gold standard. A novel exercise test using a total body recumbent stepper (TBRS) would be an alternative for measuring [latin capital V with dot above]o2max in healthy individuals. Furthermore, the TBRS exercise test (TBRS-XT) may be beneficial for individuals such as those with stroke, who cannot tolerate a treadmill or cycle ergometer test due to hemiparesis, increased tone in the extremities, or balance deficits. The purpose of the study was to assess the validity and reliability of the TBRS-XT in determining [latin capital V with dot above]o2max in healthy adults. Twenty-two healthy adults (9 women, 13 men; 26.9 +/- 6.1 years of age) participated in 2 maximum exercise tests in random order. One exercise test was performed on the treadmill using the Bruce protocol and the other exercise test was the TBRS-XT. Statistical analysis of the data was conducted using simple linear regression where the response variable was the [latin capital V with dot above]o2max from the Bruce protocol and the predictor variable was the [latin capital V with dot above]o2max from the TBRS-XT. A 95% prediction interval was used to assess the strength of the prediction of [latin capital V with dot above]o2 from the Bruce protocol with R2 = 0.851. Preliminary data suggest that the TBRS-XT may be a valid test to predict [latin capital V with dot above]o2max when treadmill testing is not feasible. This would allow clinicians an alternative method for exercise testing and prescription to promote healthy lifestyle interventions for a variety of patient populations.

The effectiveness of active exercise as an intervention for functional ankle instability: a systematic review.

Functional ankle instability (FAI) is a term used to describe an ankle that easily 'gives way' with activity. There have been many proposed causes of FAI including joint proprioceptive deficiency, muscle weakness, balance control impairments, and delayed muscle reaction time, none of which has proven to be the exclusive cause of FAI. Treatment becomes difficult when the causative factor of the injury is obscure. This systematic review evaluates the clinical trials involving conservative exercise interventions in FAI and examines the changes induced by the exercise treatments to the various potential FAI factors. Sixteen articles describing the active exercise treatment of FAI were analysed using Sackett's levels of evidence and were examined for scientific rigor. From this review, it can be concluded that conservative treatment interventions including balance, proprioceptive and muscle strengthening exercises are effective for patients with FAI in decreasing the incidence of giving-way episodes, improving balance stability, and improving function.