Evaluating Functional Performance Tests in those with Non-arthritic Intra-articular Hip Pain: An International Consensus Statement.

Background: Non-arthritic intra-articular hip pain, caused by various pathologies, leads to impairments in range of motion, strength, balance, and neuromuscular control. Although functional performance tests offer valuable insights in evaluating these patients, no clear consensus exists regarding the optimal tests for this patient population. Purpose: This study aimed to establish expert consensus on the application and selection of functional performance tests in individuals presenting with non-arthritic intra-articular hip pain. Study Design: A modified Delphi technique was used with fourteen physical therapy experts, all members of the International Society for Hip Arthroscopy (ISHA). The panelists participated in three rounds of questions and related discussions to reach full consensus on the application and selection of functional performance tests. Results: The panel agreed that functional performance tests should be utilized at initial evaluation, re-evaluations, and discharge, as well as criterion for assessing readiness for returning to sports. Tests should be as part of a multimodal assessment of neuromuscular control, strength, range of motion, and balance, applied in a graded fashion depending on the patient's characteristics. Clinicians should select functional performance tests with objective scoring criteria and prioritize the use of tests with supporting psychometric evidence. A list of recommended functional performance tests with varying intensity levels is provided. Low-intensity functional performance tests encompass controlled speed in a single plane with no impact. Medium-intensity functional performance tests involve controlled speed in multiple planes with low impact. High-intensity functional performance tests include higher speeds in multiple planes with higher impact and agility requirements. Sport-specific movement tests should mimic the patient's particular activity or sport. Conclusion: This international consensus statement provides recommendations for clinicians regarding selection and utilization of functional performance tests for those with non-arthritic intra-articular hip pain. These recommendations will encourage greater consistency and standardization among clinicians during a physical therapy assessment.

Adductor Strains in Athletes.

Acute adductor injuries are a common occurrence in sport. The overall incidence of adductor strains across 25 college sports was 1.29 injuries per 1000 exposures, with men's soccer (3.15) and men's hockey (2.47) having the highest incidences. As with most muscle strains there is a high rate of recurrence for adductor strains; 18% in professional soccer and 24% in professional hockey. Effective treatment, with successful return to play, and avoidance of reinjury, can be achieved with a proper understanding of the anatomy, a thorough clinical exam yielding an accurate diagnosis, and an evidence-based treatment approach, including return to play progression.

Flexor-Pronator Mass Training Exercises Selectively Activate Forearm Musculature.

Purpose/Hypothesis: The flexor-pronator mass of the forearm contributes dynamic stability to the medial elbow. Training this muscle group is essential for overhead athletes, however, there is lack of evidence supporting use of training exercises. The purpose of this study was to measure the extent of EMG activity of the flexor pronator musculature during two distinct forearm strengthening exercises using resistance bands. It was hypothesized that two exercises would elicit at least moderate level of muscle activity, but the activation would be different in the pronator versus the flexor muscles. Materials/Methods: 10 healthy subjects (all males, age 36±12 years) were included. Surface EMG activity was measured on three muscles of the dominant-side forearm: flexor carpi ulnaris (FCP), flexor digitorum superficialis (FDS), and pronator teres (PT). After measurement of maximal voluntary contraction (MVC) for each muscle, subjects performed wrist ulnar deviation and forearm pronation exercises using elastic band resistance. Resistance was set to elicit moderate exertion (5/10 on the Borg CR10 scale). Order of exercise was randomized and three repetitions of each exercise were performed. Mean peak EMG activity in each muscle across repetitions during the eccentric phase of each exercise was calculated and expressed as a percentage of MVC. Moderate level of activity was defined as 21% of MVC or higher. Peak normalized EMG activity in each muscle was compared using two-way (exercise x muscle) repeated-measures ANOVA with post-hoc pairwise comparisons if a significant interaction was found. Results: There was an exercise by muscle interaction effect (p<0.001). The ulnar deviation exercise selectively activated FCU (40.3%) versus FDS (19.5%, p=0.009) and PT (21.5%, p=0.022). Conversely, the pronation exercise selectively activated FDS (63.8%, p=0.002) and PT (73.0%, p=0.001) versus FDS (27.4%). Conclusion: The ulnar deviation and pronation exercises using elastic band resistance studied targeted and activated the flexor-pronator mass musculature. The ulnar deviation and pronation exercises using elastic band resistance are practical and effective means of training the flexor-pronator mass. These exercises can be readily prescribed to athletes and patients as part of their arm care program.

Challenges in the Development of Intravenous Neurokinin-1 Receptor Antagonists: Results of a Safety and Pharmacokinetics Dose-Finding, Phase 1 Study of Intravenous Fosnetupitant.

Oral NEPA is the fixed-combination antiemetic comprising netupitant (neurokinin-1 receptor antagonist [NK1 RA]) and palonosetron (5-hydroxytryptamine-3 receptor antagonist [5-HT3 RA]). Intravenous (IV) NEPA, containing fosnetupitant, a water-soluble N-phosphoryloxymethyl prodrug of netupitant, has been developed. Fosnetupitant does not require excipients or solubility enhancers often used to increase IV NK1 RA water solubility, preventing the occurrence of hypersensitivity and infusion-site reactions associated with these products. In this phase 1 study, subjects received a 30-minute placebo or fosnetupitant (17.6-353 mg) infusion and an oral NEPA or placebo capsule, with 2-sequence crossover treatment for fosnetupitant 118- to 353-mg dose cohorts. IV fosnetupitant safety and pharmacokinetics were evaluated, and its equivalence to an oral netupitant 300-mg dose was defined. Overall, 158 healthy volunteers were enrolled. All adverse events (AEs) were mild or moderate in intensity. Doppler-identified infusion-site asymptomatic thrombosis occurred in 5.4% (fosnetupitant) and 1.2% (oral NEPA) of subjects. The frequency or number of treatment-related AEs did not increase with ascending fosnetupitant doses. The most common treatment-related AEs were headache (fosnetupitant, 8.1%; oral NEPA, 12.7%) and constipation (fosnetupitant, 1.4%; oral NEPA, 7.5%). A fosnetupitant 235-mg dose was equivalent, in terms of netupitant exposure, to 300-mg oral netupitant. The safety profile of a single fosnetupitant 235-mg infusion was similar to that of single-dose oral NEPA.

Use of a Non-Pharmacological Pain Relief Kit to Reduce Opioid Use Following Orthopedic Surgery: A Prospective Randomized Study.

Introduction: Opioid prescription to treat pain among orthopedic surgery patients remains common practice in the United States but overprescribing opioids can lead to abuse. The purpose of this study was to determine the effect of a multimodal non-pharmacological 'pain relief kit' on pain, function, and opioid consumption in individuals recovering from orthopedic surgery. Hypothesis: Patients provided with the pain relief kit would consume less opioid medication, report lower pain levels, and have better functional outcome scores than the control group. Level of Evidence: 2b. Methods: Fifty-three subjects (18 women, 35 men) having orthopedic surgery were randomly assigned to either receive the Pain Relief Kit (treatment) or control group. At the first postoperative physical therapy visit (within 1 week of surgery) the treatment group was provided elastic resistance bands, kinesiology tape, Biofreeze, and a hot/cold pack as part of the Pain Relief Kit. Patients completed the SF-36 and either the DASH or LEFS questionnaires consistent with their surgery at baseline and four weeks post-op. Both groups reported daily pain (Visual Analogue Scale), opioid use, and over the counter medication use. The treatment group also recorded daily kit modality use. Results: There was no significant difference in total opioid use between the treatment (108±252 milligram morphine equivalents) and control groups (132±158 MME; p=0.696). Opioid use and pain declined from week one to four with no difference between groups (p<0.001). Outcome scores and SF-36 scores improved from week one to four with no difference between groups (p<0.001). Conclusion: A non-pharmacological pain relief kit did not have an effect on opioid use in this patient population nor did it improve pain relief or function compared to controls.

Band Pull-Apart Exercise: Effects of Movement Direction and Hand Position on Shoulder Muscle Activity.

Background/Purpose: The Elastic band pull-apart exercise is commonly used in rehabilitation. It involves pulling an elastic resistance band with both hands in horizontal abduction or diagonal arm movements. The extent of muscle activation during this exercise is unknown. The purpose of this study was to measure the electromyographic (EMG) activity of shoulder-girdle muscles during the pull-apart exercise using resistance bands and to determine the effects of arm position and movement direction on shoulder-girdle muscle activity. Materials/Methods: Surface EMG activity was measured on the infraspinatus, upper trapezius, middle trapezius, lower trapezius and posterior deltoid of the dominant shoulder. After measurement of maximal voluntary contraction (MVC) for each muscle, subjects performed the band pull-apart exercise in three hand positions (palm up, neutral, palm down) and three movement directions (diagonal up, horizontal, diagonal down). Elastic band resistance was chosen to elicit moderate exertion (5/10 on the Borg CR10 scale). The order of the exercises was randomized and three repetitions of each exercise were performed. Mean peak EMG activity in each muscle across the repetitions was calculated and expressed as a percentage of MVC. Peak normalized EMG activity in each muscle was compared in two-way (hand position x direction) repeated-measures ANOVA. Results: Data were collected from 10 healthy subjects (all males, age 36±12 years). Peak muscle activity ranged from 15.3% to 72.6% of MVC across muscles and exercise conditions. There was a significant main effect of hand position for the infraspinatus and lower trapezius, where muscle activity was highest with the palm up hand position (p < 0.001), and for the upper trapezius and posterior deltoid, where muscle activity was highest with the palm down position (p-value range < 0.001-0.004). There was a significant main effect of movement direction, where the diagonal up direction demonstrated the highest muscle activity for the infraspinatus, upper trapezius, lower trapezius, and posterior deltoid (p-value range < 0.001-0.02). Conclusion: Altering hand position and movement direction during performance of an elastic band pull-apart exercise can affect magnitudes of shoulder-girdle muscle activity. Clinicians may alter a patient's hand position and movement direction while performing the band pull-apart exercise in order to increase muscle activity in target muscles or diminish muscle activity in other muscles. Level of Evidence: 2b.

Predictive value of magnetic resonance imaging in outcomes of nonsurgical treatment of lateral epicondylitis.

BACKGROUND: The diagnosis of lateral epicondylitis is typically made on the basis of clinical history and examination. However, magnetic resonance imaging (MRI) is often used to supplement evaluation of the patient with a painful elbow and can identify extensor carpi radialis brevis (ECRB) tendon tears. The objective of this study was to determine if ECRB tear size on MRI could be used as a prognostic indicator for patients with recalcitrant lateral epicondylitis and partial ECRB tears. METHODS: Forty-one patients with recalcitrant lateral epicondylitis and a partial ECRB tear on MRI were identified (22 men and 19 women; age: 49 ± 8 years; height: 165 ± 36 mm; weight: 73 ± 18 kg). Patients were divided into two groups based on whether they underwent surgery or not. Nonsurgical treatment was evaluated by the Disabilities of the Arm, Shoulder, and Hand questionnaire, and surgery was considered a failure of nonsurgical treatment. Nonsurgical treatment was variable and included a mixture of physical therapy, rest, injection therapy, and splinting. RESULTS: Of the 41 patients, 5 patients opted for immediate surgery and 36 patients were treated nonsurgically. Of those 36 patients, 11 patients had symptom relief, 19 patients had subsequent surgery, and 6 patients chose not to have surgery despite continued symptoms. Tear size on MRI did not differ significantly between the patients who had symptom relief with nonsurgical treatment and the other patients (7.7 ± 4.3 mm vs. 9.7 ± 2.5 mm, P = .07). DISCUSSION: Only 11 of 41 patients (27%) with recalcitrant lateral epicondylitis and ECRB tear had symptom relief with nonsurgical treatment. However, ECRB tendon defect size on MRI did not predict success or failure of nonsurgical treatment.

The Role of Cetirizine in the Changing Landscape of IV Antihistamines: A Narrative Review.

Since 1955, the only available H1 antihistamines for intravenous administration have been first-generation formulations and, of those, only intravenously administered (IV) diphenhydramine is still approved in the USA. Orally administered cetirizine hydrochloride, a second-generation H1 antihistamine, has been safely used over-the-counter for many years. In 2019, IV cetirizine was approved for the treatment of acute urticaria. In light of this approval, this narrative review discusses the changing landscape of IV antihistamines for the treatment of histamine-mediated conditions. Specifically, IV antihistamines will be discussed as a treatment option for acute urticaria and angioedema, as premedication to prevent infusion reactions related to anticancer agents and other biologics, and as an adjunct treatment for anaphylaxis and other allergic reactions. Before the development of IV cetirizine, randomized controlled trials of IV antihistamines for these indications were lacking. Three randomized controlled trials have been conducted with IV cetirizine versus IV diphenhydramine in the ambulatory care setting. A phase 3 trial of IV cetirizine 10 mg versus IV diphenhydramine 50 mg was conducted in 262 adults who presented to the urgent care/emergency department with acute urticaria requiring antihistamines. For the primary efficacy endpoint, defined as change from baseline in a 2-h patient-rated pruritus score, non-inferiority of IV cetirizine to IV diphenhydramine was demonstrated (score - 1.6 vs - 1.5, respectively; 95% CI - 0.1, 0.3). Compared with IV diphenhydramine, IV cetirizine demonstrated fewer adverse effects including less sedation, a significantly shorter length of stay in the treatment center, and fewer returns to the treatment center at 24 and 48 h. Similar findings were demonstrated in another phase 2 acute urticaria trial and in a phase 2 trial assessing IV cetirizine for pretreatment for infusion reactions in the oncology/immunology setting. IV cetirizine is associated with similar patient outcomes, fewer adverse effects, and increased treatment center efficiency than IV diphenhydramine.

Resisted adduction sit-up test (RASUT) as a screening tool for pelvic versus hip pathology.

Groin pain is a common symptom in hip and pelvic pathology and differentiating between the two remains a challenge. The purpose of this study was to examine whether a test combining resisted adduction with a sit-up (RASUT) differentiates between pelvic and hip pathology. The RASUT was performed on 160 patients with complaints of hip or groin pain who subsequently had their diagnosis confirmed by magnetic resonance imaging (MRI) or surgery. Patients were categorized as having pelvic pathology (athletic pubalgia or other) or hip pathology (intra-articular or other). Athletic pubalgia was defined as any condition involving the disruption of the pubic aponeurotic plate. Sensitivity, specificity, positive predictive accuracy, negative predictive accuracy and diagnostic odds ratios were computed. Seventy-one patients had pelvic pathology (40 athletic pubalgia), 81 had hip pathology and 8 had both. The RASUT was effective in differentiating pelvic from hip pathology; 50 of 77 patients with a positive RASUT had pelvic pathology versus 29 of 83 patients with a negative test (P < 0.001). RASUT was diagnostic for athletic pubalgia (diagnostic odds ratio 6.08, P < 0.001); 35 of 45 patients with athletic pubalgia had a positive RASUT (78% sensitivity) and 73 of 83 patients with a negative RASUT did not have athletic pubalgia (88% negative predictive accuracy). The RASUT can be used to differentiate pelvic from hip pathology and to identify patients without athletic pubalgia. This is a valuable screening tool in the armamentarium of the sports medicine clinician.

MAPPING TENDERNESS TO PALPATION PREDICTS RETURN TO PLAY FOLLOWING ACUTE HAMSTRING STRAIN.

INTRODUCTION/PURPOSE: Currently there is little evidence supporting the use of objective tests, measures, or imaging to help predict time to return to sport (RTS) following a hamstring strain. The purpose of this study is to investigate the predictive value of tenderness to palpation (TTP) as measured by area and location following hamstring strain. STUDY DESIGN: Case Series. METHODS: Nineteen male athletes (age 28 ± 9 yr) who sustained an acute hamstring strain underwent hamstring tenderness mapping on initial evaluation. The length and width of tenderness of the hamstring was identified with manual palpation, outlined in pen, and was then calculated as a percentage of the length and width of the posterior thigh. All patients underwent the same hamstring rehabilitation protocol with remapping performed at specific stages in rehabilitation. The association between mapping tenderness indices and RTS was assessed by linear regression. RESULTS: The average length of the area of tenderness was 22 ± 12% with an average RTS of 43 ± 36 days. The length of the area of tenderness measured on initial evaluation was a strong predictor of RTS (R2 = 0.58, p<0.001; y = 2.3x - 6.2). Area of injury (R2 = 0.36, p = 0.006) and age (R2 = 0.27, p = 0.024) were also related to RTS, while width of injury (R2 = 0.006, p = 0.75) and location of injury were not (proximal-distal p = 0.62, medial-lateral p = 0.64). Adding age with length of injury into a multiple regression analysis improved the prediction of RTS (R2 = 0.73). The relationship between RTS and length of tenderness was relatively unchanged when the additional mapping indices taken during the course of rehabilitation were added to the analysis (R2 = 0.61, p<0.001; y = 2.3x - 4.4). This indicates that the regression equation can be used to estimate RTS regardless of when in the post injury/rehabilitation process the mapping is performed. CONCLUSIONS: The length of the area of tenderness to palpation of the injured hamstring muscle was highly predictive of RTS time. Based on the regression equation a patient with a length of tenderness of 10% would have an estimated RTS time of 17 days, while a tenderness length of 30% would be estimated to return in 63 days. This hamstring mapping technique described was predictive of the RTS and may be a useful clinical tool. LEVEL OF EVIDENCE: IIb.

Can Weakness in End-Range Plantar Flexion After Achilles Tendon Repair Be Prevented?

BACKGROUND: Disproportionate end-range plantar flexion weakness, decreased passive stiffness, and inability to perform a heel rise on a decline after Achilles tendon repair are thought to reflect increased tendon compliance or tendon lengthening. Since this was first noted, we have performed stronger repairs and avoided stretching into dorsiflexion for the first 12 weeks after surgery. HYPOTHESIS: Using stronger repairs and avoiding stretching into dorsiflexion would eliminate end-range plantar flexion weakness and normalize passive stiffness. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Achilles repairs with epitendinous augmentation were performed on 18 patients. Plantar flexion torque, dorsiflexion range of motion (ROM), passive joint stiffness, and standing single-legged heel rise on a decline were assessed at 43 ± 24 months after surgery (range, 9 months to 8 years). Maximum isometric plantar flexion torque was measured at 20° and 10° of dorsiflexion, neutral position, and 10° and 20° of plantar flexion. Passive dorsiflexion ROM was measured with a goniometer. Passive joint stiffness was computed from the increase in passive torque from 10° to 20° of dorsiflexion. Tendon thickness was measured by use of digital calipers. Plantar flexion electromyographic (EMG) data were recorded during strength and functional tests. Analysis of variance and chi-square tests were used to assess weakness and function. RESULTS: Marked weakness was evident on the involved side at 20° of plantar flexion (deficit, 26% ± 18%; P < .001), with no weakness at 20° of dorsiflexion (deficit, 6% ± 17%; P = .390). Dorsiflexion ROM was decreased 5.5° ± 8° (P = .015), and tendon width was 8 ± 3 mm greater on the involved side (P < .001). Passive joint stiffness was similar between the involved and noninvolved sides. Only 2 of 18 patients could perform a decline heel rise on the involved side compared with 18 of 18 on the noninvolved side (P = .01). No difference in EMG amplitude was found between the involved and noninvolved sides during the strength or heel rise tests. CONCLUSION: The use of stronger repair techniques and attempts to limit tendon elongation by avoiding dorsiflexion stretching did not eliminate weakness in end-range plantar flexion. EMG data confirmed that end-range weakness was not due to neural inhibition. Physiological changes that alter the force transmission capability of the healing tendon may be responsible for this continued impairment. This weakness has implications for high-demand jumping and sprinting after Achilles tendon repair.

Multicenter evaluation of a new closed system drug-transfer device in reducing surface contamination by antineoplastic hazardous drugs.

PURPOSE: Results of a study to evaluate the effectiveness of a recently introduced closed system drug-transfer device (CSTD) in reducing surface contamination during compounding and simulated administration of antineoplastic hazardous drugs (AHDs) are reported. METHODS: Wipe samples were collected from 6 predetermined surfaces in compounding and infusion areas of 13 U.S. cancer centers to establish preexisting levels of surface contamination by 2 marker AHDs (cyclophosphamide and fluorouracil). Stainless steel templates were placed over the 6 previously sampled surfaces, and the marker drugs were compounded and infused per a specific protocol using all components of the CSTD. Wipe samples were collected from the templates after completion of tasks and analyzed for both marker AHDs. RESULTS: Aggregated results of wipe sampling to detect preexisting contamination at the 13 study sites showed that overall, 66.7% of samples (104 of 156) had detectable levels of at least 1 marker AHD; subsequent testing after CSTD use per protocol found a sample contamination rate of 5.8% (9 of 156 samples). In the administration areas alone, the rate of preexisting contamination was 78% (61 of 78 samples); with use of the CSTD protocol, the contamination rate was 2.6%. Twenty-six participants rated the CSTD for ease of use, with 100% indicating that they were satisfied or extremely satisfied. CONCLUSION: A study involving a rigorous protocol and 13 cancer centers across the United States demonstrated that the CSTD reduced surface contamination by cyclophosphamide and fluorouracil during compounding and simulated administration. Participants reported that the CSTD was easy to use.

EMG OF SHOULDER MUSCLES DURING REACTIVE ISOMETRIC ELASTIC RESISTANCE EXERCISES.

BACKGROUND: Traditionally, shoulder isometrics are introduced in the early stages of shoulder rehabilitation. A patient's isometric torque output is based on a subjective perception of force generation. By utilizing elastic resistance elongation (strain) to standardize force output, clinicians could prescribe shoulder therapeutic isometrics based on % maximum voluntary contraction (%MVC). PURPOSE/HYPOTHESIS: The purpose of this study was to measure electromyographic (EMG) activity and determine the %MVC during shoulder flexion, external rotation and abduction isometrics at varying lengths of TheraBand® elastic resistance. It was hypothesized that increased elongation of progressive resistance bands would proportionately increase the %MVC of the shoulder musculature. STUDY DESIGN: Laboratory design using healthy subjects. METHODS: Eight healthy subjects (16 shoulders) (5 females, 3 males; avg. age 29.2) were tested. Surface EMG electrodes were placed over the anterior deltoid, middle deltoid, and infraspinatus muscles. A force transducer was anchored to a stable surface with its corresponding end in series with an extremity strap securely holding the elastic band. Subjects were asked to maintain shoulder position for the proper isometric contraction (flexion, abduction and external rotation) while taking incremental steps away from the anchored elastic resistance, to the beat of a metronome to clearly marked distances on the floor (50, 100, 150, 200 and 250% of band elongation). This was repeated with yellow, red, green, and blue TheraBand® resistance levels. Maximum voluntary contractions for both force and EMG were collected for each subject in all three test positions. EMG data were normalized and expressed as a %MVC. RESULTS: For external rotation and flexion, the infraspinatus and anterior deltoid activity increased with band elongation (p<0.01) and progressive colors (p<0.01). The increases in EMG activity with elongation plateaued with the yellow and red bands but continued to increase with the green and blue bands (p<0.01). The increase in infraspinatus and anterior deltoid EMG activity with progressive band color was more apparent for green and blue bands compared with yellow and red band (p<0.01). For the abduction exercise, middle deltoid activity increased with band elongation (p<0.01) and progressive color (p<0.01). In all three exercises, there was an increase in force exerted by the band with increasing length and band color (p < 0.001). However, while there were clear increases in force from red to green to blue, there was no difference in force between yellow and red regardless of elongation (p<0.01). CONCLUSION: Isometric flexion, external rotation and abduction muscle activity can be accurately prescribed clinically by adjusting the elongation and resistance associated with progressive colors of resistance bands. LEVEL OF EVIDENCE: 3.

Rehabilitation After Hamstring-Strain Injury Emphasizing Eccentric Strengthening at Long Muscle Lengths: Results of Long-Term Follow-Up.

CONTEXT: Hamstring-strain injuries have a high recurrence rate. OBJECTIVE: To determine if a protocol emphasizing eccentric strength training with the hamstrings in a lengthened position resulted in a low recurrence rate. DESIGN: Longitudinal cohort study. SETTING: Sports-medicine physical therapy clinic. PARTICIPANTS: Fifty athletes with hamstring-strain injury (age 36 ± 16 y; 30 men, 20 women; 3 G1, 43 G2, 4 G3; 25 recurrent injuries) followed a 3-phase rehabilitation protocol emphasizing eccentric strengthening with the hamstrings in a lengthened position. MAIN OUTCOME MEASURES: Injury recurrence; isometric hamstring strength at 80°, 60°, 40°, and 20° knee flexion in sitting with the thigh flexed to 40° above the horizontal and the seat back at 90° to the horizontal (strength tested before return to sport). RESULTS: Four of the 50 athletes sustained reinjuries between 3 and 12 mo after return to sport (8% recurrence rate). The other 42 athletes had not sustained a reinjury at an average of 24 ± 12 mo after return to sport. Eight noncompliant athletes did not complete the rehabilitation and returned to sport before initiating eccentric strengthening in the lengthened state. All 4 reinjuries occurred in these noncompliant athletes. At time of return to sport, compliant athletes had full restoration of strength while noncompliant athletes had significant hamstring weakness, which was progressively worse at longer muscle lengths (compliance × side × angle P = .006; involved vs noninvolved at 20°, compliant 7% stronger, noncompliant 43% weaker). CONCLUSION: Compliance with rehabilitation emphasizing eccentric strengthening with the hamstrings in a lengthened position resulted in no reinjuries.

Functional Outcomes After Double-Row Versus Single-Row Rotator Cuff Repair: A Prospective Randomized Trial.

BACKGROUND: The functional benefits of double-row (DR) versus single-row (SR) rotator cuff repair are not clearly established. PURPOSE: To examine the effect of DR versus SR rotator cuff repair on functional outcomes and strength recovery in patients with full-thickness tears. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: Forty-nine patients were randomized to DR or SR repairs; 36 patients (13 women, 23 men; mean age, 62 ± 7 years; 20 SR, 16 DR) were assessed at a mean 2.2 ± 1.6 years after surgery (range, 1-7 years; tear size: 17 medium, 13 large, 9 massive). The following data were recorded prior to surgery and at follow-up: Penn shoulder score, American Shoulder and Elbow Surgeons (ASES), and Simple Shoulder Test (SST) results; range of motion (ROM) for shoulder flexion, external rotation (ER) at 0° and 90° of abduction, and internal rotation (IR) at 90° of abduction; and shoulder strength (Lafayette manual muscle tester) in empty- and full-can tests, abduction, and ER at 0° of abduction. Treatment (SR vs DR) × time (pre- vs postoperative) mixed-model analysis of variance was used to assess the effect of rotator cuff repair. RESULTS: Rotator cuff repair markedly improved Penn, ASES, and SST scores (P < .001), with similar improvement between SR and DR repairs (treatment × time, P = .38-.10) and excellent scores at follow-up (DR vs SR: Penn, 91 ± 11 vs 92 ± 11 [P = .73]; ASES, 87 ± 12 vs 92 ± 12 [P = .21]; SST, 11.4 ± 1.0 vs 11.3 ± 1.0 [P = .76]). Patients with DR repairs lost ER ROM at 0° of abduction (preoperative to final follow-up, 7° ± 10° loss [P = .013]). ER ROM did not significantly change with SR repair (5° ± 14° gain, P = .16; treatment by time, P = .008). This effect was not apparent for ER ROM at 90° of abduction (treatment × time, P = .26). IR ROM improved from preoperative to final follow-up (P < .01; SR, 17° ± 27°; DR, 7° ± 21°; treatment × time, P = .23). Rotator cuff repair markedly improved strength in empty-can (54%), full-can (66%), abduction (47%), and ER (54%) strength (all P < .001), with no difference between SR and DR repairs (P = .23-.75). All clinical tests with the exception of the lift-off test were normalized at follow-up (P < .05). CONCLUSION: Outcomes were not different between SR or DR repair, with generally excellent outcomes for both groups. Rotator cuff repair and subsequent rehabilitation markedly improved shoulder strength.

The Effect of a High Pitch Volume on Musculoskeletal Adaptations in High School Baseball Pitchers.

BACKGROUND: Shoulder range of motion and strength adaptations occur at an early age in baseball pitchers. PURPOSE/HYPOTHESIS: The purpose of this study was to examine the effect of pitch volume on in-season and year-to-year range of motion (ROM) and strength adaptations in high school baseball pitchers. The hypothesis was that a high pitch volume will not affect range of motion asymmetries but will impair supraspinatus strength. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Pre- and postseason ROM and strength measures were performed on pitchers from 3 high schools for 4 consecutive seasons, for a total of 95 player-seasons (mean ± SD participant age, 16 ± 1 years). Preseason measures were repeated the next year on players returning to the teams, for a total of 71 consecutive player-seasons. ROM tests included internal-external rotation and posterior shoulder flexibility. Strength tests (hand-held dynamometer) included internal-external rotation, supraspinatus, and scapular retraction. Pitchers were categorized by pitch count for the season (high, >400; moderate, 180-400; low, <180). ROM and strength changes in the dominant versus nondominant arm were assessed by analysis of variance. RESULTS: Dominant versus nondominant ROM differences did not change from pre- to postseason (P = .36-.99) or from one year to the next (P = .46-.86), with no effect of pitch volume (P = .23-.87). Supraspinatus strength decreased in the dominant arm during the season, with 13% loss in high-volume pitchers (P < .001) and insignificant losses in moderate- (6%) and low-volume pitchers (2%). Strength in other tests was unaffected by pitch volume. Consistent with physical development, strength increased bilaterally from one year to the next (supraspinatus, 12%; external rotation, 15%; internal rotation, 14%; scapular retraction, 23%; P < .001). Supraspinatus strength gain in the dominant arm was affected by prior pitch volume (P = .02): 24% in low-volume pitchers (P < .01), with no significant change in moderate-volume (0%; P = .99) or high-volume (5%; P = .99) pitchers. CONCLUSION: Dominant versus nondominant ROM differences did not progress during the season, or from one year to the next, and were unaffected by pitch volume. A high pitch volume was associated with in-season supraspinatus weakness and diminished strength gains from one year to the next. In conclusion, a high pitch volume appeared to have a catabolic effect on supraspinatus strength.

Doha agreement meeting on terminology and definitions in groin pain in athletes.

BACKGROUND: Heterogeneous taxonomy of groin injuries in athletes adds confusion to this complicated area. AIM: The 'Doha agreement meeting on terminology and definitions in groin pain in athletes' was convened to attempt to resolve this problem. Our aim was to agree on a standard terminology, along with accompanying definitions. METHODS: A one-day agreement meeting was held on 4 November 2014. Twenty-four international experts from 14 different countries participated. Systematic reviews were performed to give an up-to-date synthesis of the current evidence on major topics concerning groin pain in athletes. All members participated in a Delphi questionnaire prior to the meeting. RESULTS: Unanimous agreement was reached on the following terminology. The classification system has three major subheadings of groin pain in athletes: 1. Defined clinical entities for groin pain: Adductor-related, iliopsoas-related, inguinal-related and pubic-related groin pain. 2. Hip-related groin pain. 3. Other causes of groin pain in athletes. The definitions are included in this paper. CONCLUSIONS: The Doha agreement meeting on terminology and definitions in groin pain in athletes reached a consensus on a clinically based taxonomy using three major categories. These definitions and terminology are based on history and physical examination to categorise athletes, making it simple and suitable for both clinical practice and research.

Athletic pubalgia and associated rehabilitation.

BACKGROUND: Evaluation and treatment of groin pain in athletes is challenging. The anatomy is complex, and multiple pathologies often coexist. Different pathologies may cause similar symptoms, and many systems can refer pain to the groin. Many athletes with groin pain have tried prolonged rest and various treatment regimens, and received differing opinions as to the cause of their pain. The rehabilitation specialist is often given a non-specific referral of "groin pain" or "sports hernia." The cause of pain could be as simple as the effects of an adductor strain, or as complex as athletic pubalgia or inguinal disruption. The term "sports hernia" is starting to be replaced with more specific terms that better describe the injury. Inguinal disruption is used to describe the syndromes related to the injury of the inguinal canal soft tissue environs ultimately causing the pain syndrome. The term athletic pubalgia is used to describe the disruption and/or separation of the more medial common aponeurosis from the pubis, usually with some degree of adductor tendon pathology. TREATMENT: Both non-operative and post-operative treatment options share the goal of returning the athlete back to pain free activity. There is little research available to reference for rehabilitation guidelines and creation of a plan of care. Although each surgeon has their own specific set of post-operative guidelines, some common concepts are consistent among most surgeons. Effective rehabilitation of the high level athlete to pain free return to play requires addressing the differences in the biomechanics of the dysfunction when comparing athletic pubalgia and inguinal disruption. CONCLUSION: Proper evaluation and diagnostic skills for identifying and specifying the difference between athletic pubalgia and inguinal disruption allows for an excellent and efficient rehabilitative plan of care. Progression through the rehabilitative stages whether non-operative or post-operative allows for a focused rehabilitative program. As more information is obtained through MRI imaging and the diagnosis and treatment of inguinal disruption and athletic pubalgia becomes increasingly frequent, more research is warranted in this field to better improve the evidence based practice and rehabilitation of patients. LEVELS OF EVIDENCE: 5.