STUDY DESIGN: Nonexperimental methodological study. OBJECTIVES: To determine the interrater and intrarater reliability and validity of using observational risk-screening guidelines to evaluate dynamic knee valgus. BACKGROUND: A deficiency in the neuromuscular control of the hip has been identified as a key risk factor for noncontact anterior cruciate ligament (ACL) injury in postpubescent females. This deficiency can manifest itself as a valgus knee alignment during tasks involving hip and knee flexion. There are currently no scientifically tested methods to screen for dynamic knee valgus in the clinic or on the field. METHODS: Three physiotherapists used observational risk-screening guidelines to rate 40 adolescent female soccer players according to their risk of ACL injury. The rating was based on the amount of dynamic knee valgus observed on a drop-jump landing. Ratings were evaluated for intrarater and interrater agreement using kappa coefficients. Sensitivity and specificity of ratings were evaluated by comparing observational ratings, with measurements obtained using 3-dimensional (3-D) motion analysis. RESULTS: Kappa coefficients for intrarater and interrater agreement ranged from 0.75 to 0.85, indicating that ratings were reasonably consistent over time and between physiotherapists. Sensitivity values were inadequate, ranging from 67% to 87%. This indicated that raters failed to detect up to a third of "truly high-risk" individuals. Specificity values ranged from 60% to 72%, which was considered adequate for the purposes of the screening. CONCLUSION: Observational risk screening is a practical and cost-effective method of screening for ACL injury risk. Rater agreement and specificity were acceptable for this method, but sensitivity was not. To detect a greater proportion of individuals at risk of ACL injury, coaches and clinicians should ensure that they include additional tests for other high-risk characteristics in their screening protocols. LEVEL OF EVIDENCE: Prognosis, level 4.

J Orthop Sports Phys Ther 2009;39(9):665-674, Epub 19 March 2009. doi:10.2519/jospt.2009.3004

KEY WORDS: female, knee, movement analysis, neuromuscular, soccer

STUDY DESIGN: Case control study. OBJECTIVES: To compare the amount of forward head posture (FHP) and cervical range of motion between patients with moderate carpal tunnel syndrome (CTS) and healthy controls. We also sought to assess the relationships among FHP, cervical range of motion, and clinical variables related to the intensity and temporal profile of pain due to CTS. BACKGROUND: It is plausible that the cervical spine may be involved in patients with CTS. No studies have investigated the possible associations among FHP, cervical range of motion, and symptoms related to CTS. METHODS: FHP and cervical range of motion were assessed in 25 women with CTS and 25 matched healthy women. Side-view pictures were taken in both relaxed-sitting and standing positions to measure the craniovertebral angle. A CROM device was used to assess cervical range of motion. Posture and mobility measurements were performed by an experienced therapist blinded to the subjects’ condition. Differences in cervical range of motion were examined using the nonparametric Mann-Whitney U test. A 2-way mixed-model analysis of variance (ANOVA) was used to evaluate differences in FHP between groups and positions. RESULTS: The ANOVA revealed significant differences between groups (F = 30.4; P<.001) and between positions (F = 6.5; P<.01) for FHP assessment. Patients with CTS had a smaller craniovertebral angle (greater FHP) than controls (P<.001) in both standing and sitting. Additionally, patients with CTS showed decreased cervical range of motion in all directions when compared to controls (P<.001). Only cervical flexion (r_s = –0.43; P = .02) and lateral flexion contralateral to the side of the CTS (r_s = –0.51; P = .01) were associated with the reported lowest pain experienced in the preceding week. A positive association between FHP and cervical range of motion was identified in both groups: the smaller the craniovertebral angle (reflective of a greater FHP), the smaller the range of motion (r values between 0.27 and 0.45; P<.05). Finally, cervical range of motion and FHP were negatively associated with age in the control group but not in the group with CTS. CONCLUSIONS: Patients with mild/moderate CTS exhibited a greater FHP and less cervical range of motion, as compared to healthy controls. Additionally, a greater FHP was associated with a reduction in cervical range of motion. However, a cause-and-effect relationship cannot be inferred from this study. Future research should investigate if FHP and restricted cervical range of motion is a consequence or a causative factor of CTS and related symptoms (eg, pain).

J Orthop Sports Phys Ther 2009;39(9):658-664, Epub 19 March 2009. doi:10.2519/jospt.2009.3058

KEY WORDS: CROM, CTS, neck

STUDY DESIGN: Experimental laboratory study. OBJECTIVES: The primary purpose was to investigate the independent effects of current amplitude, pulse duration, and current frequency on muscle fatigue during neuromuscular electrical stimulation (NMES). A second purpose was to determine if the ratio of the evoked torque to the activated area could explain muscle fatigue. BACKGROUND: Parameters of NMES have been shown to differently affect the evoked torque and the activated area. The efficacy of NMES is limited by the rapid onset of muscle fatigue. METHODS AND MEASURES: Seven healthy participants underwent 4 NMES protocols that were randomly applied to the knee extensor muscle group. The NMES protocols were as follows: standard protocol (Std), defined as 100-Hz, 450-µs pulses and amplitude set to evoke 75% of maximal voluntary isometric torque (MVIT); short pulse duration protocol (SP), defined as 100-Hz, 150-µs pulses and amplitude set to evoke 75% of MVIT; low-frequency protocol (LF), defined as 25-Hz, 450-µs pulses and amplitude set to evoke 75% of MVIT; and low-amplitude protocol (LA), defined as 100-Hz, 450-µs pulses and amplitude set to evoke 45% of MVIT. The peak torque was measured at the start and at the end of the 4 protocols, and percent fatigue was calculated. The outcomes of the 4 NMES protocols on the initial peak torque and activated cross-sectional area were recalculated from a companion study to measure torque per active area. RESULTS: Decreasing frequency from 100 to 25 Hz decreased fatigue from 76% to 39%. Decreasing the amplitude and pulse duration resulted in no change of muscle fatigue. Torque per active area accounted for 57% of the variability in percent fatigue between Std and LF protocols. CONCLUSIONS: Altering the amplitude of the current and pulse duration does not appear to influence the percent fatigue in NMES. Lowering the stimulation frequency results in less fatigue, by possibly reducing the evoked torque relative to the activated muscle area.

J Orthop Sports Phys Ther 2009;39(9):684-692, Epub 24 June 2009. doi:10.2519/jospt.2009.3045

KEY WORDS: amplitude, frequency, NMES, pulse duration

The patient was an 18-year-old male collegiate pitcher who was referred to physical therapy for the treatment of chronic posterior right shoulder pain, which was most noticeable during the late cocking phase of throwing. Previous imaging was interpreted as normal. Despite a completed course of rehabilitation and diagnostic arthroscopy 3 months prior, the patient's shoulder pain did not improve. Additional radiographs and a magnetic resonance arthrogram were ordered, which revealed an exostosis along the posterior inferior glenoid rim. Following arthroscopic removal of the exostosis, the patient's symptoms resolved and he is now throwing without pain or limitations.

J Orthop Sports Phys Ther 2009;39(9):702. doi:10.2519/jospt.2009.0409

KEY WORDS: baseball, magnetic resonance imaging, radiographs, shoulder, Stryker view