• Logerstedt DS, Snyder-Mackler L, Ritter RC, Axe MJ. Knee pain and mobility impairments: meniscal and articular cartilage lesions. J Orthop Sports Phys Ther 2010;40(6):A1-A35. doi:10.2519/jospt.2010.0304
  

J Orthop Sports Phys Ther 2010;40(9):597.

J Orthop Sports Phys Ther 2010;40(9):598-601.

The patient was a 32-year-old male who sustained a noncontact left knee injury during a quick pivot on a planted left foot, while playing flag football. Radiographs of the left knee revealed findings consistent with a tibial spine avulsion fracture, while magnetic resonance imaging confirmed a medial tibial spine avulsion fracture. Bone marrow edema was noted in a pivot shift injury pattern involving the lateral femoral condyle and the lateral tibial plateau, and there was also a fracture of the posterior lateral tibial cortex at the site of the bone marrow edema. To determine the best course of treatment, a computed tomography scan was ordered to better visualize the extent of the avulsion fracture. The computed tomography scan demonstrated a comminuted fracture through the tibial spine.

J Orthop Sports Phys Ther 2010;40(9):594. doi:10.2519/jospt.2010.0414

KEY WORDS: computed tomography, knee, magnetic resonance imaging, radiography

The patient was a 14-year-old female with a 4-year history of left anterolateral foot and ankle pain of insidious onset that was first noticed while playing soccer. After a lack of progress with conservative measures for her left foot and ankle pain, the patient was evaluated by an orthopaedic surgeon. While conventional radiographs of the foot and ankle were normal, magnetic resonance imaging revealed generalized bone marrow edema in the navicular bone with irregularity along the lateral margin of the navicular bone and adjacent anterior margin of the anterior process of the calcaneus. These findings suggested possible sequelae of osteonecrosis or a partial coalition between the lateral margin of the navicular bone and anterior process of the calcaneus. Computed tomography scanning revealed focal osteochondral bone changes along the lateral margin of the navicular bone and anterior process of the calcaneus. Surgery was performed 3 months later, which involved excision of a fibrous calcaneonavicular tarsal coalition.

J Orthop Sports Phys Ther 2010;40(9):595. doi:10.2519/jospt.2010.0415

KEY WORDS: ankle, computed tomography, foot, magnetic resonance imaging

The Orthopaedic Section of the American Physical Therapy Association presents this sixth set of clinical practice guidelines on Achilles pain, stiffness, and muscle power deficits that are characteristic of Achilles Tendinitis. These clinical practice guidelines are linked to the International Classification of Functioning, Disability, and Health (ICF). The purpose of these practice guidelines is to describe evidence-based orthopaedic physical therapy clinical practice and provide recommendations for (1) examination and diagnostic classification based on body functions and body structures, activity limitations, and participation restrictions, (2) interventions provided by physical therapists, (3) and assessment of outcome for common musculoskeletal disorders.

J Orthop Sports Phys Ther. 2010:40(9):A1-A26. doi:10.2519/jospt.2010.0305

KEY WORDS: APTA, clinical practice guidelines, ICD, ICF, Orthopaedic Section

STUDY DESIGN: Controlled cohort repeated-measures experimental design. OBJECTIVES: To determine if a neuromuscular training program (NMTP) focused on core stability and lower extremity strength would affect performance on the star excursion balance test (SEBT). We hypothesized that NMTP would improve SEBT performance in the experimental group and there would be no side-to-side differences in either group. BACKGROUND: The SEBT is a functional screening tool that is used to assess dynamic stability, monitor rehabilitation progress, assess deficits following an injury, and identify athletes at high risk for lower extremity injury. The SEBT requires lower extremity coordination, balance, flexibility, and strength. METHODS: Twenty uninjured female soccer players (13 experimental, 7 control) participated. Players trained together as a team, so group allocation was not randomized. The SEBT was administered prior to and following 8 weeks of NMTP in the experimental group and 8 weeks of no NMTP in the control group. A 3-way mixed-model ANOVA was used to determine the effect of group (experimental versus control), training (pretraining versus posttraining), and limb (right versus left). RESULTS: After participation in a NMTP, subjects demonstrated a significant improvement in the SEBT composite score (mean ± SD) on the right limb (pretraining, 96.4% ± 11.7%; posttraining, 104.6% ± 6.1%; P = .03) and the left limb (pretraining, 96.9% ± 10.1%; posttraining, 103.4% ± 8.0%; P = .04). The control group had no change on the SEBT composite score for the right (pretraining, 95.7% ± 5.2%; posttraining, 94.4% ± 5.2%; P = .15) or the left (97.4% ± 7.2%; 93.6% ± 5.0%; P = .09) limb. Further analysis identified significant improvement for the SEBT in the posterolateral direction on both the right (P = .008) and left (P = .040) limb and the posteromedial direction of the left limb (P = .028) in the experimental group. CONCLUSION: Female soccer players demonstrated an improved performance on the SEBT after NMTP that focused on core stability and lower extremity strength. LEVEL OF EVIDENCE: Performance enhancement, level 2b-.

J Orthop Sports Phys Ther 2010;40(9):551-558, Epub 6 August 2010. doi:10.2519/jospt.2010.3325

KEY WORDS: core stability, core strengthening, injury prevention training, trunk neuromuscular control

STUDY DESIGN: Prospective cohort study. OBJECTIVES: To measure changes in muscle strength, range of motion, and function from 2 weeks before to 6 months after total knee arthroplasty (TKA) and compare outcomes with data from a control group consisting of healthy adults. BACKGROUND: Total knee arthroplasty successfully alleviates pain from knee osteoarthritis, but deficits in function can persist long term. How impairments and functional limitations change over the first 6 months after TKA, compared to data from healthy adults, has not been well reported in the literature. METHODS: Twenty-four patients who underwent a primary unilateral TKA were compared to healthy adults (n = 17). All patients participated in a standardized rehabilitation program following surgery. Isometric quadriceps torque was assessed using an electromechanical dynamometer. Range of motion was measured actively and passively. Functional performance was assessed using the stair-climbing test, timed up-and-go test, 6-minute walk test, and single-limb stance time. Patients underwent testing at 2 weeks preoperatively and at 1, 3, and 6 months postoperatively. RESULTS: Compared to healthy older adults, patients performed significantly worse at all times for all measures (P<.05), except for single-limb stance time at 6 months (P>.05). One month postoperatively, patients experienced significant losses from preoperative levels in all outcomes. Patients recovered to preoperative levels by 6 months postoperatively on all measures, except knee flexion range of motion, but still exhibited the same extent of limitation they did prior to surgery. CONCLUSION: The persistent impairments and functional limitations 6 months after TKA with standard rehabilitation suggest that more intensive therapeutic approaches may be necessary to restore function of patients following TKA to the levels of healthy adults. LEVEL OF EVIDENCE: Therapy, level 2b.

J Orthop Sports Phys Ther 2010;40(9):559-567, Epub 6 August 2010. doi:10.2519/jospt.2010.3317

KEY WORDS: joint replacement, older adults, osteoarthritis, rehabilitation

Letters to the Editor-in-Chief of JOSPT as follows:

• "Manual Magic: The Method Is Not the Trick" and Authors' Response
• "Moving Past Sleight of Hand" and Authors' Response
• "Core Muscle Activation During Swiss Ball and Traditional Abdominal Exercises" and Authors' Response

J Orthop Sports Phys Ther 2010;40(8):535-541. doi:10.2519/jospt.2010.0201

J Orthop Sports Phys Ther 2010;40(8):542-549.

Traditionally, placebo has been associated with using an inert substance, in part so the subsequent response could
be attributed to the target treatment, controlling for the confound of a “placebo effect.” Placebo’s link with inert substances is so strong that “sham treatment” is a common synonym, and widespread placebo use is discouraged—even when there is supporting evidence for its effectiveness. Recent research has helped to redefine placebo, and this editorial will highlight key information supporting a contemporary view of placebo.

J Orthop Sports Phys Ther 2010;40(8):452-454. doi:10.2519/jospt.2010.0107

KEY WORDS: placebo effect, study design

STUDY DESIGN: Case series. BACKGROUND: Few studies have defined the dosage and specific techniques of manual therapy and exercise for rehabilitation for patients with subacromial impingement syndrome. This case series describes a standardized treatment program for subacromial impingement syndrome and the time course and outcomes over a 12-week period. CASE DESCRIPTION: Ten patients (age range, 19-70 years) with subacromial impingement syndrome defined by inclusion and exclusion criteria were treated with a standardized protocol for 10 visits over 6 to 8 weeks. The protocol included a 3-phase progressive strengthening program, manual stretching, thrust and nonthrust manipulation to the shoulder and spine, patient education, activity modification, and a daily home exercise program of stretching and strengthening. Patients completed a history and measures of impairments and functional disability at 2, 4, 6, and 12 weeks. OUTCOMES: Treatment success was defined as both a 50% improvement on the Disabilities of the Arm, Shoulder, and Hand (DASH) score and a global rating of change of at least “moderately better.” At 6 weeks, 6 of 10 patients had a successful (mean ± SD) DASH outcome score (initial, 33.9 ± 16.2; 6 weeks, 8.1 ± 9.2). At 12 weeks, 8 of 10 patients had a successful DASH outcome score (initial, 33.1 ± 14; 12 weeks, 8.3 ± 6.4). As a group, the largest improvement was in the first 2 weeks. The most common impairments for all 10 patients were rotator cuff and trapezius muscle weakness (10 of 10 patients), limited shoulder internal rotation motion (8 of 10 patients), and reduced kyphosis of the midthoracic area (7 of 10 patients). DISCUSSION: A program aimed at strengthening rotator cuff and scapular muscles, with stretching and manual therapy aimed at thoracic spine and the posterior and inferior soft-tissue structures of the glenohumeral joint appeared to be successful in the majority of patients. This case series describes a comprehensive impairment-based treatment which resulted in symptomatic and functional improvement in 8 of 10 patients in 6 to 12 weeks. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2010;40(8):474-493. doi:10.2519/jospt.2010.3223

KEY WORDS: manipulation, pain, rotator cuff, shoulder, supraspinatus

STUDY DESIGN: Case report. BACKGROUND: Cognitive behavioral therapy (CBT) is an effective intervention for patients with persistent pain. Recent research indicates that physical therapists self-perceive a lack of knowledge, skills, and time to provide this intervention. The purpose of this case report is to describe how specific CBT strategies can be integrated with multimodal physical therapist management of a patient with persistent low back pain. CASE DESCRIPTION: The patient was a 70-year-old female with activity limitations of walking, standing, and forward bending. Oswestry Disability Questionnaire score was 19/50 and Fear-Avoidance Belief Questionnaire physical activity subscale was 23/24. The Low Back Activity Confidence Scale revealed 19%, 100%, and 84% for function, symptom self-regulation, and exercise, respectively. CBT-based patient education was provided in combination with manual therapy and exercise. CBT techniques included cognitive restructuring, goal setting, activity pacing, problem-solving strategies, graded exposure, encouraging exposure to pleasant experiences, and maintenance strategies. OUTCOMES: The patient was discharged after 7 visits distributed over 21 weeks. Her Oswestry Disability Questionnaire score was reduced 10% and Fear-Avoidance Belief Questionnaire physical activity subscale score reduced 48%. On the Low Back Activity Confidence Scale the patient’s scores were 19%, 87%, and 94% for function, symptom self-regulation, and exercise, respectively. DISCUSSION: This case report describes the use of CBT techniques during patient education by a physical therapist. The patient demonstrated clinically measurable and significant improvements in disability. Improvements in both self-efficacy beliefs related to exercise and activity avoidance beliefs were associated with improvement in disability. Additional research is needed to determine best practices for CBT-based patient education by physical therapists. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2010;40(8):494-501. doi:10.2519/jospt.2010.3264

KEY WORDS: chronic pain, graded exposure, lumbar spine

The patient was a 33-year-old woman with a chief complaint of midthoracic spine pain. Anterior-posterior and lateral radiographs of the thoracic spine revealed superior and inferior endplate deformities and a mild reduction of stature of the T9 vertebral body, which were suspicious for a fracture. Computed tomography scans revealed cortical irregularity of the vertebral body of T9, however, magnetic resonance imaging of the thoracic spine was negative. Given the magnetic resonance imaging findings, the smooth, well-defined cortical defect, and the absence of paraspinal hemorrhaging on the computed tomography scan, it was hypothesized that this may not have been an acute fracture. Rather, the cortical irregularity of the anterior vertebral body of T9 seen on computed tomography could have instead represented normal nutrient vascular channels. The patient was referred to an orthopaedic surgeon, who recommended conservative management by a physical therapist.

J Orthop Sports Phys Ther 2010;40(8):533. doi:10.2519/jospt.2010.0412

KEY WORDS: computed tomography, magnetic resonance imaging, radiographs

The patient was a 13-year-old male soccer player who was referred to a physical therapist with complaints of persistent worsening left medial knee pain with weight-bearing activity. Physical examination revealed no signs of joint effusion, lower extremity range-of-motion or strength discrepancies, ligamentous compromise, or tenderness to palpation. However, the patient reported discomfort with weight bearing, and a slightly antalgic gait was observed. Knee radiographs revealed a concave lucency involving the medial femoral condyle, consistent with an osteochondritis dissecans lesion. Magnetic resonance imaging confirmed an osteochondritis dissecans lesion of the medial femoral condyle, and the patient was diagnosed with stage I juvenile osteochondritis dissecans of the knee. Conservative management by a physical therapist was the recommended treatment, and after 6 months, the patient no longer complained of left knee pain, and repeat knee radiographs demonstrated evidence of a healing osteochondritis dissecans lesion.

J Orthop Sports Phys Ther 2010;40(8):534. doi:10.2519/jospt.2010.0413

KEY WORDS: magnetic resonance imaging, medial femoral condyle, radiographs

The JOSPT offers invited reviews of current titles. The July 2010 column includes 5 reviews of the following books: Against the Tide: Back Pain Treatment —The Breakthrough; Solutions for Complex Upper Extremity Trauma; Biomechanical Analysis of Fundamental Human Movements; AO Manual of Fracture Management: Elbow and Forearm; and Color Atlas of Human Anatomy Volume 1: Locomotor System.

J Orthop Sports Phys Ther 2010;40(7):448-450.

The patient was a 27-year-old male pilot referred to a physical therapist for a suspected left acromioclavicular joint injury following a fall 3 weeks prior. Physical examination revealed decreased active shoulder flexion, decreased supraspinatus strength, and a positive Hawkins test. Radiographs were ordered and the anterior-posterior radiographic view showed an incomplete nondisplaced fracture in the superior aspect of the greater tuberosity. The patient was placed in a sling for 4 weeks and performed passive range-of-motion exercises to maintain shoulder mobility. Radiographs at 7 weeks following the injury revealed a healed greater tuberosity fracture.

J Orthop Sports Phys Ther 2010;40(7):447. doi:10.2519/jospt.2010.0411

KEY WORDS: radiographs, shoulder

The editorial announces JOSPT's new mobile edition and describes the features of the mobile website.

J Orthop Sports Phys Ther 2010;40(6):334-335. doi:10.2519/jospt.2010.0106

KEY WORDS: JOSPT, website

J Orthop Sports Phys Ther 2010;40(6):378-381.

The Orthopaedic Section of the American Physical Therapy Association presents this fifth set of clinical practice guidelines on knee pain and mobility impairments, linked to the International Classification of Functioning, Disability, and Health (ICF). The purpose of these practice guidelines is to describe evidence-based orthopaedic physical therapy clinical practice and provide recommendations for (1) examination and diagnostic classification based on body functions and body structures, activity limitations, and participation restrictions, (2) interventions provided by physical therapists, (3) and assessment of outcome for common musculoskeletal disorders.

J Orthop Sports Phys Ther 2010:40(6):A1-A35. doi:10.2519/jospt.2010.0304

The reviewer list on page A1 and the Affiliations and Contacts on page A31 of the original article were amended in the September 2010 Erratum, and the article PDF with the Erratum page included is provided here. Please see: September 2010 Erratum

KEY WORDS: APTA, clinical practice guidelines, ICD, ICF, Orthopaedic Section

The patient was a 68-year-old man who had undergone a right total hip arthroplasty 3 years prior. He complained of progressively worsening right hip pain. Physical examination findings were consistent with a positive sign of the buttock. A triple-bone scan showed increased radio-pharmaceutical activity, which is consistent with infection. Subsequent aspiration of the right hip revealed infection, which was treated with antibiotics before the patient underwent a revision total hip arthroplasty.

J Orthop Sports Phys Ther 2010;40(6):377. doi:10.2519/jospt.2010.0410

KEY WORDS: computed tomography, hip, triple-phase bone scan

The patient was a 53-year-old male with a chief complaint of right wrist pain of insidious onsent for the past month. The patient reported no recent trauma, but said he had multiple falls while skiing and mountain biking. Wrist radiographs and magnetic resonance imaging revealed ulnar variance and signs of osteonecrosis of the lunate, or Kienbock's disease. The patient underwent a radial shortening osteotomy in an effort to reduce compressive forces on the lunate and further fragmentation and collapse.

J Orthop Sports Phys Ther 2010;40(6):376. doi:10.2519/jospt.2010.0409

KEY WORDS: magnetic resonance imaging, radiography, wrist

STUDY DESIGN: Controlled laboratory study. OBJECTIVES: To clarify whether differences in surface stability influence trunk muscle activity. BACKGROUND: Lumbar stabilization exercises on unstable surfaces are performed widely. One perceived advantage in performing stabilization exercises on unstable surfaces is the potential for increased muscular demand. However, there is little evidence in the literature to help establish whether this assumption is correct. METHODS: Nine healthy male subjects performed lumbar stabilization exercises. Pairs of intramuscular fine-wire or surface electrodes were used to record the electromyographic signal amplitude of the rectus abdominis, the external obliques, the transversus abdominis, the erector spinae, and lumbar multifidus. Five exercises were performed on the floor and on an unstable surface: elbow-toe, hand-knee, curl-up, side bridge, and back bridge. The EMG data were normalized as the percentage of the maximum voluntary contraction, and data between doing each exercise on the stable versus unstable surface were compared using a Wilcoxon signed-rank test. RESULTS: With the elbow-toe exercise, the activity level for all muscles was enhanced when performed on the unstable surface. When performing the hand-knee and side bridge exercises, activity level of the more global muscles was enhanced when performed on an unstable surface. Performing the curl-up exercise on an unstable surface, increased the activity of the external obliques but reduced transversus abdominis activation. CONCLUSION: This study indicates that lumbar stabilization exercises on an unstable surface enhanced the activities of trunk muscles, except for the back bridge exercise.

J Orthop Sports Phys Ther 2010;40(6):369-375. doi:10.2519/jospt.2010.3211

KEY WORDS: electromyography, lumbar spine, multifidus, transversus abdominis

STUDY DESIGN: Controlled laboratory study using a cross-sectional design. OBJECTIVES: To evaluate knee joint dynamics in elite volleyball players with and without a history of patellar tendinopathy, focusing on mechanical energy absorption and generation. We hypothesized that tendinopathy would be associated with
reduced net joint work and net joint power. BACKGROUND: Patellar tendinopathy is a common, debilitating injury affecting competitive volleyball players. METHODS: Thirteen elite male players with and without a history of patellar tendinopathy (mean ± SD age, 27 ± 7 years) performed maximum-effort volleyball approach jumps. Sagittal plane knee joint kinematics, kinetics, and energetics were quantified in the lead limb, using data obtained from a force platform and an 8-camera motion analysis system. Vertical ground reaction forces and pelvis vertical velocity at takeoff were examined. Independent sample t tests were used to evaluate group differences (α = .05). RESULTS: The tendinopathy group, compared to controls, demonstrated significant reductions (approximately 30%) in net joint work and net joint power during the eccentric phase of the jump, with no differences in the concentric phase. Positive to-negative net joint work and net joint power ratios were significantly higher in the tendinopathy group, which had a net joint work ratio of 1.00 (95% CI: 0.77, 1.24) versus 0.76 (95% CI: 0.64, 0.88) for controls, and a net joint power ratio of 1.62 (95% CI: 1.15, 2.10) versus 1.00 (95% CI: 0.80, 1.21) for controls. There were no significant differences in net joint moment, angular velocity, or range of motion. Peak vertical ground reaction forces were lower for the tendinopathy group, while average vertical ground reaction forces and pelvis vertical velocity were similar. CONCLUSION: Patellar tendinopathy is associated with differences in sagittal plane mechanical energy absorption at the knee during maximum-effort volleyball approach jumps. Net joint work and net joint power may help define underlying mechanisms, adaptive effects, or rehabilitative strategies for individuals with patellar tendinopathy.

J Orthop Sports Phys Ther 2010;40(9):568-576, Epub 27 May 2010. doi:10.2519/jospt.2010.3313

KEY WORDS: biomechanics, eccentric, energetics, joint kinetics, tendon

STUDY DESIGN: Cross-sectional study. OBJECTIVE: To evaluate the relationship between the occurrence of falls and muscle strength, flexibility, and balance in postmenopausal women with and without osteoporosis. BACKGROUND: Osteoporosis and falls are common problems encountered in the elderly. METHODS: A total of 133 women with and 133 without osteoporosis, aged 60 years or greater, were included in the study. Women were interviewed about clinical and social demographic characteristics and the occurrence of falls in the previous 12 months. The variables evaluated were presence of osteoporosis, muscle strength, flexibility, and balance. RESULTS: A significantly higher percentage of women with osteoporosis (51%) compared to those without osteoporosis (29%) had a history of at least 1 fall within the previous 12 months. There was a significant and inverse association between trunk extension strength and trunk flexion range of motion with falls. Logistic regression analyses showed that the variables associated with falls were trunk extension strength and presence of osteoporosis. Greater trunk extension strength was associated with a lower risk for falls (odds ratio, 0.97), while the presence of osteoporosis increased fall risk by a factor of 2.17. CONCLUSIONS: A greater percentage of women with postmenopausal osteoporosis had a history of 1 or more falls within the previous year and a higher risk of recurrent falls than women without osteoporosis. Muscle strength of the lumbar spine and the presence of osteoporosis are intrinsic factors associated with the risk of falls.

J Orthop Sports Phys Ther 2010;40(9):582-588, Epub 27 May 2010. doi:10.2519/jospt.2010.3239

KEY WORDS: balance, bone density, flexibility, muscle strength, postmenopausal

STUDY DESIGN: Cross-sectional investigation. BACKGROUND: There is some evidence that interventions directed to improving back muscle endurance (BME) in adolescents are effective in reducing low back pain, with anecdotal evidence of improved performance. However, the mechanisms responsible for this improvement remain unclear. OBJECTIVE: To identify the relationship between physical, lifestyle, and psychological variables and BME in a large adolescent population, while controlling for back pain and gender. METHODS: One thousand four-hundred thirty-five adolescents (702 females, 733 males; mean ± SD age, 14.0 ± 0.2 years) completed a range of physical, lifestyle, and psychological assessments. The group mean ± SD height and body mass were 164 ± 8 cm and 57.1 ± 12.6 kg, respectively. Linear regression was used to investigate the univariate association between each of the physical, lifestyle, and psychological variables and BME. Backwards stepwise multivariate linear regression was used to determine statistically significant independent correlates of BME. RESULTS: The final multivariate model explained 15.3% of the variance in BME and included at least 1 variable from the physical, lifestyle, and psychological domains. Adolescents who exercised less, watched more television, had a higher body mass index, sat in a more flexed trunk posture (more slumped), and had lower self-efficacy had lower BME. CONCLUSIONS: All the physical and lifestyle variables linked with poorer BME performance in this investigation are indicative of reduced back muscle activation and/or deconditioning. Psychological predictors may have direct and/or indirect links with BME.

J Orthop Sports Phys Ther 2010;40(8):517-523; Epub 27 May 2010. doi:10.2519/jospt.2010.3369

KEY WORDS: adolescents, back muscle endurance, exercise, performance, Raine study

STUDY DESIGN: Clinical measurement, criterion standard. OBJECTIVES: To investigate the validity of real-time ultrasound imaging (USI) to measure individual anterior hip muscle cross-sectional area. BACKGROUND: The hip flexor muscles are important for hip joint function and could be affected by joint pathology or injury. Objectively documenting individual anterior hip muscle size can be useful in identifying muscle size asymmetry and monitoring treatment efficacy for patients with hip problems. USI offers a novel method of measuring individual muscle size in the clinic, but its validity in measuring the anterior hip muscles has not been investigated. METHODS: Nine healthy participants (5 males, 4 females) underwent imaging of their iliopsoas, sartorius, and rectus femoris muscles with USI and magnetic resonance imaging. Bilateral muscle cross-sectional areas were measured on images from both modalities. RESULTS: There was no significant difference (P>.05) in mean cross-sectional area measurements from USI and magnetic resonance imaging for each muscle. Agreement between measurements was high for the iliopsoas (left: intraclass correlation coefficient [ICC_3,1] = 0.86; 95% confidence interval [CI]: 0.51, 0.97; right: ICC_3,1 = 0.88; 95% CI: 0.57, 0.97), sartorius (left: ICC_3,1 = 0.82; 95% CI: 0.41, 0.96; right: ICC_3,1 = 0.81; 95% CI: 0.39, 0.95), and rectus femoris (left: ICC_3,1 = 0.85; 95% CI: 0.49, 0.96; right: ICC_3,1 = 0.89; 95% CI: 0.61, 0.97). Reliability of measuring each muscle with USI was high between 2 trials (ICCs_3,1 = 0.84 to 0.94). CONCLUSION: USI is a valid measure of iliopsoas, sartorius, and rectus femoris muscle size in healthy people, as long as a strict measurement protocol is followed.

J Orthop Sports Phys Ther 2010;40(9):577-581, Epub 13 May 2010. doi:10.2519/jospt.2010.3286

KEY WORDS: iliopsoas, MRI, rectus femoris, reliability, sartorius

SYNOPSIS: Injuries to the posterolateral corner of the knee pose a significant challenge to sports medicine team members due to their complex nature. Identifying posterolateral corner injuries is paramount to determining proper surgical management of the injured athlete, with the goal of preventing chronic pain, instability, and/or surgical failure. Postoperative rehabilitation is based on the specific structural involvement and surgical procedures. A firm understanding of the anatomy and biomechanics of the structures of the posterolateral corner is essential for successful rehabilitation outcomes. Emphasis is placed on protection of the healing surgical repair/reconstruction, with gradual restoration of range of motion, strength, proprioception, and dynamic function of the knee. The purpose of this paper is to provide an overview of the anatomy, biomechanics, and mechanism of injury for posterolateral corner injuries, with a review of clinical examination techniques for identifying these injuries. Furthermore, a review of current surgical management and postoperative guidelines is provided. LEVEL OF EVIDENCE: Diagnosis/therapy, level 5.

J Orthop Sports Phys Ther 2010;40(8):502-516; Epub 13 May 2010. doi:10.2519/jospt.2010.3269

KEY WORDS: fibular collateral ligament, multiligamentous knee injuries, rehabilitation

SYNOPSIS: Orthopaedic physical therapy is considered safe, based on a lack of reported harms. Most of the research until now has focused on benefits. Consideration of benefits and harm involves informed consent, clinical decision making, and cost-benefit analyses. Benefits and harms are treatment and dosage specific. There is currently an insufficient number of dosage trials in orthopaedic physical therapy to identify optimal dosage for common interventions, including exercise and manual therapy. Published cases of severe adverse events following chiropractic manipulation illustrate the need for physical therapy to have high-quality data documenting the safety of orthopaedic physical therapy, including cervical manipulation. A recent systematic review identified poor reporting standards of harms within clinical research in this area. Lack of standardization of terminology has contributed to this problem. Pharmacovigilence provides a framework for terms that orthopaedic physical therapy can adapt and thereafter adopt into clinical practice and research. Adverse events are unexpected events that occur following an intervention without evidence of causality. Where temporality of an event is highly suggestive of causality, the term “adverse reaction” may be more appropriate. Future studies in orthopaedic physical therapy should adopt the CONSORT statement extension on the reporting of harms, published in 2004, to ensure better reporting. Consistent reporting of harms in both research and clinical practice requires professional consensus on terminology pertaining to harms, as well as defining what constitutes an adverse event or an adverse reaction. Widespread consultation and consensus should support optimal definitions and processes and facilitate their implementation into practice. This paper is focused on theoretical considerations and evidence in terms of harm reporting within physical therapy using cervical manual therapy as an example.

J Orthop Sports Phys Ther 2010;40(8):455-463, Epub 13 May 2010. doi:10.2519/jospt.2010.3229

KEY WORDS: harm, manipulation, manual therapy, neck

STUDY DESIGN: Longitudinal single-cohort study. OBJECTIVE: To characterize the time course of performance adaptations during a postsurgical exercise intervention following a single-level microdiscectomy. BACKGROUND: Patients with a recent history of lumbar microdiscectomy are functionally limited, weak, have compromised paraspinal musculature, and benefit from an exercise program. METHODS: Patients (n = 48) with a single-level microdiscectomy participated in a 12-week (36 sessions) comprehensive strength and endurance exercise program starting 4 to 6 weeks postsurgery. Lumbar extensor strength was quantified as the degree from horizontal on a modified Sorensen test procedure. Patients unable to assume the horizontal position were assumed to have strength deficits. Lumbar muscular endurance performance was quantified by the amount of time patients could hold the Sorensen test position at the horizontal. The time rate of lumbar muscular endurance adaptations were analyzed using longitudinal growth curve modeling. RESULTS: The adherence rate of this program was low (67%). Twenty percent of the patients were identified as having strength deficits. These deficits were corrected in all patients within 3 to 9 weeks. Linear mixed-model results suggest an improvement of 5.6 seconds in hold time per week of exercise. Both the initial level of endurance and the rates of improvements were highly individualized. CONCLUSION: The time course of musculoskeletal performance adaptations in persons with a history of lumbar surgery is highly individualized. When compared to normative endurance times, the results of this study indicate that the number of sessions and duration of therapy needed to generate meaningful adaptations of the paraspinal musculature is longer than what is typically provided in the clinic postsurgery. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2010;40(6):336-344, Epub 13 May 2010. doi:10.2519/jospt.2010.3141

KEY WORDS: herniated disc, low back pain, physical endurance, rehabilitation

J Orthop Sports Phys Ther 2010;40(5):326-332.

The patient was a 44-year-old man who reported palmar/ulnar-sided right wrist pain after injuring his wrist while
playing golf. Although pain and function were improved at 6 months following the injury with conservative treatment measures and golfing with a modified grip, the patient was still limited during golf. This prompted the ordering of
additional wrist radiographs, which included a carpal tunnel view, that revealed a fracture at the base of the hook
of the hamate. The patient was referred to an orthopaedic surgeon and underwent a hook of hamate excision, and at 12 weeks following surgery, he had returned to full golfing activities without limitations.

J Orthop Sports Phys Ther 2010;40(5):325. doi:10.2519/jospt.2010.0408

KEY WORDS: carpal tunnel view radiograph, golf, radiographs, wrist

The patient was a 32-year-old woman diagnosed with grade III spondylolisthesis at the age of 18. While the patient had not experienced back pain in recent years, she anticipated a recurrence of symptoms during her final trimester of pregnancy. Lumbar magnetic resonance imaging was used to confirm the presence of grade IV spondylolisthesis.

J Orthop Sports Phys Ther 2010;40(5):324. doi:10.2519/jospt.2010.0407

KEY WORDS: lumbar spine, magnetic resonance imaging

Medical care historically has had a strong association with magic, illusion, and secrecy. Although we profess to be
modern healthcare practitioners, utilizing manual therapy techniques, and strive for evidence-based practice, the reality is that one of the most ubiquitous of all manual therapy techniques, manipulation, is obscured by illusive
and ill-defined terminology. As a first step in moving from magician to modern clinician, we recently proposed a
nomenclature intended to standardize and clarify the terminology used in describing specific manual therapy techniques, recommending the use of 6 key characteristics. The persistent obfuscations appear to be aimed at
obscuring the differentiation of manipulation from mobilization. The time has come for a more precise delineation
between manipulation and mobilization and to move beyond seeing these valuable interventions simply as some sleight-of-hand technique.

J Orthop Sports Phys Ther 2010;40(5):253-255. doi:10.2519/jospt.2010.0105

KEY WORDS: manipulation, mobilization, terminology

STUDY DESIGN: Controlled laboratory study using a repeated-measures, counterbalanced design. OBJECTIVES: To test the ability of 8 Swiss ball exercises (roll-out, pike, knee-up, skier, hip extension right, hip extension left, decline push-up, and sitting march right) and 2 traditional abdominal exercises (crunch and bent-knee sit-up) on activating core (lumbopelvic hip complex) musculature. BACKGROUND: Numerous Swiss ball abdominal exercises are employed for core muscle strengthening during training and rehabilitation, but there are minimal data to substantiate the ability of these exercises to recruit core muscles. It is also unknown how core muscle recruitment in many of these Swiss ball exercises compares to core muscle recruitment in traditional abdominal exercises such as the crunch and bent-knee sit-up. METHODS: A convenience sample of 18 subjects performed 5 repetitions for each exercise. Electromyographic (EMG) data were recorded on the right side for upper and lower rectus abdominis, external and internal oblique, latissimus dorsi, lumbar paraspinals, and rectus femoris, and then normalized using maximum voluntary isometric contractions (MVICs). RESULTS: EMG signals during the roll-out and pike exercises for the upper rectus abdominis (63% and 46% MVIC, respectively), lower rectus abdominis (53% and 55% MVIC, respectively), external oblique (46% and 84% MVIC, respectively), and internal oblique (46% and 56% MVIC, respectively) were significantly greater compared to most other exercises, where EMG signals ranged between 7% to 53% MVIC for the upper rectus abdominis, 7% to 44% MVIC for the lower rectus abdominis, 14% to 73% MVIC for the external oblique, and 16% to 47% MVIC for the internal oblique. The lowest EMG signals were consistently found in the sitting march right exercise. Latissimus dorsi EMG signals were greatest in the pike, knee-up, skier, hip extension right and left, and decline push-up (17%-25% MVIC), and least with the sitting march right, crunch, and bent-knee sit-up exercises (7%-8% MVIC). Rectus femoris EMG signal was greatest with the hip extension left exercise (35% MVIC), and least with the crunch, roll-out, hip extension right, and decline push-up exercises (6%-10% MVIC). Lumbar paraspinal EMG signal was relative low (less than 10% MVIC) for all exercises. CONCLUSIONS: The roll-out and pike were the most effective exercises in activating upper and lower rectus abdominis, external and internal obliques, and latissimus dorsi muscles, while minimizing lumbar paraspinals and rectus femoris activity.

J Orthop Sports Phys Ther 2010;40(5):265-276, Epub 22 April 2010. doi:10.2519/jospt.2010.3073

KEY WORDS: crunch, EMG, low back pain, lumbar spine, rectus abdominis, sit-up

STUDY DESIGN: Systematic literature review. OBJECTIVE: To evaluate the quality and outcomes of published research papers on the topic of fatigue-induced biomechanical changes in single-limb landings. BACKGROUND: Lower extremity fatigue causes a number of biomechanical alterations that may increase the risk of knee injury. It has therefore been suggested that fatigue elements be incorporated into injury prevention programs. For this to be successful, protocols that reliably induce fatigue need to be identified and the effect fatigue has on the lower-limb joints needs to be documented. METHODS: A systematic review was conducted to identify published studies that assessed the effect of fatigue on lower-limb biomechanics during single-limb landing tasks. Studies were identified by searching 6 databases, reference lists, and citation tracking. The methodological quality of each paper was assessed, and effect sizes were calculated to allow comparison of results across studies. RESULTS: Eight studies met the inclusion criteria. Numerous methodological differences between the studies made synthesis of data challenging. There was some evidence to show that vertical ground reaction forces and hip and knee joint moments were reduced after fatigue. Kinematic changes were less consistent and require further study. CONCLUSION: The current body of studies showed mixed findings, particularly in relation to landing kinematics after fatigue. Future studies should focus on developing standardized fatigue protocols that include both local and central fatigue effects and monitor progression of fatigue over time. This area of research should be extended to include individuals recovering from musculoskeletal injury or surgery.

J Orthop Sports Phys Ther 2010;40(8):464-473, Epub 22 April 2010. doi:10.2519/jospt.2010.3295

KEY WORDS: anterior cruciate ligament, kinematics, kinetics, knee joint

STUDY DESIGN: Clinical measurement, reliability. OBJECTIVE: To compare intrarater and interrater reliability of shoulder internal rotation (IR) passive range of motion measurements utilizing a standard supine position and a sidelying position. BACKGROUND: Glenohumeral IR range of motion deficits are often noted in patients with shoulder pathology. Excellent intrarater reliability has been found when measuring this motion. However, interrater reliability has been reported as poor to fair. Some clinicians currently use a sidelying position for IR stretching with patients who have shoulder pathology. However, no objective data exist for IR passive range of motion measured in this sidelying position, either in terms of reliability or normative values. METHODS: Seventy subjects (mean age, 36.8 years), with (n = 19) and without (n = 51) shoulder pathology, were included in this study. Shoulder IR passive range of motion of the dominant shoulder or involved shoulder was measured by 2 investigators in 2 positions: (1) a standard supine position, with the shoulder at 90°of abduction, and (2) in sidelying on the tested side, with the shoulder flexed to 90°. RESULTS: Intrarater reliability for supine measurements was good to excellent (ICC_3,1 = 0.70-0.93) and for sidelying measurements was excellent (ICC_3,1 = 0.94-0.98). Interrater reliability was fair to good for the supine measurement (ICC_2,2 = 0.74-0.81) and good to excellent for the sidelying measurement (ICC_2,2 = 0.88-0.96). The mean (range) value of the dominant shoulder sidelying IR passive range of motion was 40° (11° to 69°) for healthy subjects and 25° (–16° to 49°) for subjects with shoulder pathology. CONCLUSIONS: For subjects with shoulder pathology, measurements of shoulder IR made in the sidelying position had superior intrarater and interrater reliability compared to those in the standard supine position.

J Orthop Sports Phys Ther 2010;40(9):589-594, Epub 22 April 2010. doi:10.2519/jospt.2010.3197

KEY WORDS: glenohumeral joint, goniometry, motion, rehabilitation

STUDY DESIGN: Case report. BACKGROUND: Differential diagnosis for patients with radial wrist pain requires consideration of systemic disease, referred pain to the radial aspect of the wrist, and local dysfunction. The list of possible local dysfunctions should include De Quervain syndrome, as well as entrapment neuropathy of the superficial radial nerve. CASE DESCRIPTION: The patient was a 57-year-old man with right radial wrist pain of 6 months’ duration. The referral diagnosis was De Quervain syndrome, but a previous course of electrophysical agents-based physical therapy management had been unsuccessful. The physical examination ruled out the cervical, shoulder, elbow, and wrist joints as possible sources of pain. In this case, the diagnosis of entrapment neuropathy of the superficial radial nerve, rather than De Quervain syndrome, was primarily based on the symptom provocation resulting from a modified radial bias upper limb nerve tension test. Based on this diagnosis, treatment consisted of active and passive exercises using neurodynamic techniques. OUTCOMES: After 1 treatment session, the patient noted changes with regard to current pain intensity and function that exceeded the minimal clinically important difference and the minimal detectable change, respectively. After only 2 treatment sessions, the patient reported a complete resolution of symptoms and a full return to work. DISCUSSION: This case report critically evaluates the diagnostic process for patients with radial wrist pain and suggests neuropathy of the superficial sensory branch of the radial nerve as a differential diagnostic option. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2010;40(6):361-368, Epub 22 April 2010. doi:10.2519/jospt.2010.3210

KEY WORDS: De Quervain syndrome, neuropathy, superficial sensory branch radial nerve, thumb

STUDY DESIGN: Bench research, cross-sectional. OBJECTIVE: To determine if the effects of low-intensity pulsed ultrasound (LIPUS) on matrix synthesis change at different stages of tendon healing. BACKGROUND: LIPUS is effective in promoting tendon healing by stimulation of matrix synthesis. The timing of initiation and duration of LIPUS treatment have been shown to affect its effectiveness to promote tendon healing, suggesting a change of tissue responses to LIPUS stimulation. Understanding how the cellular responses to LIPUS stimulation change during tendon healing is thus important. METHODS: In a rat model of patellar tendon donor site injury, a single sonication of LIPUS or mock sonication was delivered to the injured knee of the rats on the fourth, 14th or 28th day postinjury. Tendon samples were harvested at 4 hours and 24 hours after sonication and the mRNA expression of COL1A1, COL3A1, decorin, biglycan, and TGF-beta 1 was analyzed. RESULTS: The results showed that a single sonication of LIPUS increased COL1A1 and COL3A1 mRNA in healing patellar tendons when administered on the fourth or 14th day postinjury, but not when administered on the 28th day postinjury. Both decorin and biglycan mRNA were decreased by treatment with LIPUS on the 28th day postinjury. Our results showed that LIPUS enhanced collagen synthesis in vivo only during the granulation phase. Matrix remodeling may be affected by LIPUS with the suppressed expression of decorin and biglycan. CONCLUSION: Our findings suggest that LIPUS should be applied during the granulation phase but not during the remodeling phase, to promote tendon healing.

J Orthop Sports Phys Ther 2010;40(7):422-429, Epub 22 April 2010. doi:10.2519/jospt.2010.3254

KEY WORDS: collagens, matrix synthesis, tendon healing, therapeutic ultrasound

STUDY DESIGN: Clinical measurement, cross-sectional. OBJECTIVES: To compare cervical mobilization forces applied by physiotherapists and students, and the factors associated with forces for each group. BACKGROUND: Cervical spine joint mobilization is a common manual technique for treating patients with mechanical neck pain. But little is known about the forces applied during this technique. Potential variability between therapists may result from clinical experience or may be due to factors present in individuals prior to clinical practice exposure. METHODS: One hundred sixteen practicing physiotherapists and 120 physiotherapy students without clinical experience applied grades I through IV posteroanterior mobilization to the premarked C2 and C7 spinous and articular processes of 1 of 67 asymptomatic subjects. An instrumented table recorded applied forces (N), force amplitudes (N), and oscillation frequencies (Hz), and a custom device measured subjects’ spinal stiffness (N/mm). Independent t tests were used to compare the forces applied by therapists and students, intraclass correlation coefficients were used to determine variability, and linear regression was used to establish factors associated with applied forces. RESULTS: Students’ forces were generally lower (mean difference, 15.7 N for grades III and IV; P<.001) and applied with slower oscillation frequencies (0.12 Hz; P<.001) than therapists’ forces. Similar factors were associated with applied forces for both groups: male gender and greater subject body weight were associated with higher applied forces, and greater C2 stiffness with lower forces. Having thumb pain was associated with lower applied forces for therapists but higher ones for students. CONCLUSIONS: Students apply lower forces than therapists. Similar factors appear to affect applied forces regardless of clinical experience.

J Orthop Sports Phys Ther 2010;40(7):392-401, Epub 22 April 2010. doi:10.2519/jospt.2010.3274

KEY WORDS: manipulation, manual therapy, neck, students

STUDY DESIGN: Cross-sectional laboratory study. OBJECTIVE: To determine whether individuals with spinal pain and those who have undergone spinal surgery have difficulty discriminating small movement differences using a spinal proprioception test for active flexion movements. BACKGROUND: Structures contributing to proprioception may be affected during disc replacement surgery. Postsurgical assessment of proprioceptive ability to make discriminations in the range used for maintaining upright postural stability is needed to inform postoperative rehabilitation. METHODS: Proprioceptive sensitivity to differences between lumbar spine movements of 11°, 13°, 15°, 17°, and 19° of forward flexion was measured in unrestrained standing, with vision of the target obscured. Individuals after disc replacement (n = 16), with disc degeneration and discogenic back pain (n = 19), and without back pain (n = 18) performed 50 movement trials and stated the amount of movement performed for each trial (11°, 13°, 15°, 17°, or 19°). RESULTS: The pattern of discrimination scores between adjacent lumbar flexion movement pairs shown by the individuals in the discogenic back pain group differed significantly from the disc replacement and healthy control groups (P = .024), which were not significantly different from each other. Although mean discrimination scores averaged over all movement pairs did not differ significantly between the groups, participants with discogenic back pain discriminated between the 2 smallest lumbar flexion movements significantly better than those in the other 2 groups (P = .013). CONCLUSION: The greater sensitivity of the individuals with disc pain to discriminate between the 2 smallest flexion movements was interpreted as a contrast effect arising from differences between the groups in usual upright posture, with disc replacement restoring the same pattern of posture as seen for healthy controls.

J Orthop Sports Phys Ther 2010;40(7):439-446, Epub 15 April 2010. doi:10.2519/jospt.2010.3149

KEY WORDS: disc degeneration, discogenic pain, lumbar spine, movement discrimination

STUDY DESIGN: Prospective cohort study with repeated measures. OBJECTIVE: To establish the responsiveness of the Simple Shoulder Test (SST) in comparison to other commonly used clinical outcomes in patients undergoing shoulder arthroplasty. BACKGROUND: Responsiveness statistics are a useful means to compare different outcomes in terms of their ability to detect clinical change. While the responsiveness of the SST has been established for rotator cuff repair, it has not been determined for patients undergoing arthroplasty. METHODS: Patients undergoing shoulder arthroplasty (n = 120) were evaluated prior to surgery and 6 months after. The evaluation included the SST, Disabilities of the Arm, Shoulder and Hand questionnaire, range of motion, and isometric strength. Responsiveness to change was assessed using standardized response mean (SRM), while longitudinal construct validity was evaluated using Pearson correlation. Receiver operating characteristics curves were plotted to determine clinically important difference of SST. RESULTS: The SST and Disabilities of the Arm, Shoulder and Hand questionnaire were highly responsive (SRM, >1.70) for this population. For the assessment of impairment, range of motion (SRM, 0.64-1.03) was moderately to highly responsive, while isometric strength was minimally to moderately responsive (SRM, 0.32-0.69). The clinically important difference of the SST was established at 3.0 SST points. Pearson correlations indicated moderate associations between the change scores of the SST and the Disabilities of the Arm, Shoulder and Hand questionnaire (r = 0.49). CONCLUSIONS: The SST has been previously shown to be valid and highly reliable. The present results show that the SST is also responsive following shoulder arthroplasty and that it has a clinically important difference of 3.0 SST points. This should provide confidence to clinicians who wish to use a brief shoulder-specific measure in their practice.

J Orthop Sports Phys Ther 2010;40(7):413-421, Epub 15 April 2010. doi:10.2519/jospt.2010.3209

KEY WORDS: psychometric properties, questionnaire, responsiveness, shoulder

STUDY DESIGN: Systematic literature review. OBJECTIVE: To perform a systematic review of randomized controlled trials assessing the effects of neuromuscular electrical stimulation (NMES) on quadriceps strength, functional performance, and self-reported function after anterior cruciate ligament reconstruction. BACKGROUND: Conflicting evidence exists regarding the effectiveness of NMES following anterior cruciate ligament reconstruction. METHODS: Searches were performed for randomized controlled trials using electronic databases from 1966 through October 2008. Methodological quality was assessed using the Physiotherapy Evidence Database Scale. Between-group effect sizes and 95% confidence intervals (CIs) were calculated. RESULTS: Eight randomized controlled trials were included. The average Physiotherapy Evidence Database Scale score was 4 out of possible maximum 10. The effect sizes for quadriceps strength measures (isometric or isokinetic torque) from 7 studies ranged from –0.74 to 3.81 at approximately 6 weeks postoperatively; 6 of 11 comparisons were statistically significant, with strength benefits favoring NMES treatment. The effect sizes for functional performance measures from 1 study ranged from 0.07 to 0.64 at 6 weeks postoperatively; none of 3 comparisons were statistically significant, and the effect sizes for self-reported function measures from 1 study were 0.66 and 0.72 at 12 to 16 weeks postoperatively; both comparisons were statistically significant, with benefits favoring NMES treatment. CONCLUSION: NMES combined with exercise may be more effective in improving quadriceps strength than exercise alone, whereas its effect on functional performance and patient-oriented outcomes is inconclusive. Inconsistencies were noted in the NMES parameters and application of NMES. LEVEL OF EVIDENCE: Therapy, level 1a–.

J Orthop Sports Phys Ther 2010;40(7):383-391, Epub 15 April 2010. doi:10.2519/jospt.2010.3184

KEY WORDS: ACL, electromodality, postsurgical knee rehabilitation, randomized clinical trials

STUDY DESIGN: Controlled laboratory study using a cross-sectional design. OBJECTIVES: To examine the kinematics and kinetics of the trunk and the physical characteristics of trunk and hip in golfers with and without a history of low back pain (LBP). BACKGROUND: Modified swing patterns and general exercises have been suggested for golfers with back pain. Yet we do not know what contributes to LBP in golfers. To create and validate a low back-specific exercise program to help prevent and improve back injuries in golfers, it may be valuable to understand the differences in biomechanical and physical characteristics of golfers with and without a history of LBP. METHODS: Sixteen male golfers with a history of LBP were matched by age and handicap with 16 male golfers without a history of LBP. All golfers underwent a biomechanical swing analysis, trunk and hip strength and flexibility assessment, spinal proprioception testing, and postural stability testing. RESULTS: The group with a history of LBP demonstrated significantly less trunk extension strength at 60°/s and left hip adduction strength, as well as limited trunk rotation angle toward the nonlead side. No significant differences were found in postural stability, trunk kinematics, and maximum spinal moments during the golf swing. CONCLUSION: Deficits observed in this study may affect a golfer’s ability to overcome the spinal loads generated during the golf swing over time. Exercises for improving these physical deficits can be considered, although the cause-effect of LBP in golfers still cannot be determined.

J Orthop Sports Phys Ther 2010;40(7):430-438, Epub 15 April 2010. doi:10.2519/jospt.2010.3152

KEY WORDS: balance, flexibility, golf swing, proprioception, strength

STUDY DESIGN: Cohort study. OBJECTIVES: To describe calf muscle endurance recovery and to explore factors predictive of poor calf muscle endurance recovery 1 year after surgical repair of an Achilles tendon rupture (ATR). BACKGROUND: ATR is a common sports-related injury and is often managed with open surgical repair. After ATR repair most patients return to usual activities 6 months after surgery. However, calf endurance impairment can persist up to 6 years, possibly impacting performance of daily activities and sport. METHODS: A secondary analysis of a 73-patient cohort from a randomized controlled trial assessing the effects of early weight bearing after surgical repair of an ATR was performed. Calf muscle endurance recovery was measured by single-heel raises using a customized counting device at 6 months and 1 year postoperatively. Descriptive statistics were used to outline recovery of calf muscle endurance. Physical and patient-reported outcomes were examined for their association with calf-muscle endurance recovery. Multiple linear regression analysis was performed to explore variables associated with recovery of calf endurance 1 year postoperatively. RESULTS: Mean recovery of calf muscle endurance was 76% at 1 year. Multivariate regression analysis showed an association of being female, reporting no resting pain at 3 months, and physical functioning and calf endurance at 6 months, with better recovery of calf endurance at 1 year. CONCLUSIONS: Calf muscle endurance at 1 year remained impaired in a considerable portion of the sample. Pain, gender, and physical functioning are likely important factors in determining recovery of calf muscle endurance. LEVEL OF EVIDENCE: Prognosis, level 2b.

J Orthop Sports Phys Ther 2010;40(6):345-351, Epub 15 April 2010. doi:10.2519/jospt.2010.3204

KEY WORDS: ankle, gender, plantar flexors, prognosis

SYNOPSIS: Age-related hyperkyphosis is an exaggerated anterior curvature in the thoracic spine that occurs commonly with advanced age. This condition is associated with low bone mass, vertebral compression fractures, and degenerative disc disease, and contributes to difficulty performing activities of daily living and decline in physical performance. While there are effective treatments, currently there are no public health approaches to prevent hyperkyphosis among older adults. Our objective is to review the prevalence and natural history of hyperkyphosis, associated health implications, measurement tools, and treatments to prevent this debilitating condition. LEVEL OF EVIDENCE: Diagnosis/prognosis/therapy, level 5.

J Orthop Sports Phys Ther 2010;40(6):352-360, Epub 15 April 2010. doi:10.2519/jospt.2010.3099

KEY WORDS: aging/geriatrics, kyphosis, osteoporosis, postural relationships, thoracic spine

STUDY DESIGN: A case report and literature review. BACKGROUND: Optimizing clinical outcomes following lumbar disc surgery is a research priority; however, relatively little attention has been paid to the postoperative management of this population. The transversus abdominis and lumbar multifidus (LM) muscles appear to play a unique role in lumbar spine stability, and may relate to clinical outcome following lumbar disc surgery. The purpose of this case report was to describe the preoperative LM morphology, clinical outcome, and change in transversus abdominis and LM muscle activation in a patient following lumbar disc surgery and motor control exercise initiated in the early postoperative period. CASE DESCRIPTION: A 29-year-old female underwent an 8-week postoperative rehabilitation program emphasizing motor control exercises to restore trunk muscle function 10 days following lumbar disc surgery. OUTCOMES: The patient experienced clinically important improvements in pain and disability following the postoperative rehabilitation program. Substantial improvements in muscle activation were observed of the transversus abdominis and the LM at the L4-5 level. Minimal change in LM activation and a higher proportion of intramuscular fat was observed at the L5-S1 level. DISCUSSION: This case report represents limited evidence regarding the feasibility of instituting a rehabilitation program in the early postoperative period following lumbar disc surgery. Improvements in clinical status and muscle function were observed, and a differential change in muscle activation between the L4-5 and L5-S1 levels was noted. The literature regarding rehabilitation following lumbar disc surgery, as well as the neuromuscular changes observed in this population, was reviewed. Additionally, a novel method of examining LM morphology was described and suggestions were made for directions of future research. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2010;40(7):402-412, Epub 12 April 2010. doi:10.2519/jospt.2010.3332

KEY WORDS: adipose, discectomy, exercise therapy, rehabilitation, skeletal muscle, ultrasonography

STUDY DESIGN: Randomized crossover double-blinded placebo-controlled trial. OBJECTIVE: To investigate if low-level laser therapy (LLLT) can affect biceps muscle performance, fatigue development, and biochemical markers of postexercise recovery. BACKGROUND: Cell and animal studies have suggested that LLLT can reduce oxidative stress and inflammatory responses in muscle tissue. But it remains uncertain whether these findings can translate into humans in sport and exercise situations. METHODS: Nine healthy male volleyball players participated in the study. They received either active LLLT (cluster probe with 5 laser diodes; λ = 810 nm; 200 mW power output; 30 seconds of irradiation, applied in 2 locations over the biceps of the nondominant arm; 60 J of total energy) or placebo LLLT using an identical cluster probe. The intervention or placebo were applied 3 minutes before the performance of exercise. All subjects performed voluntary elbow flexion repetitions with a workload of 75% of their maximal voluntary contraction force until exhaustion. RESULTS: Active LLLT increased the number of repetitions by 14.5% (mean ± SD, 39.6 ± 4.3 versus 34.6 ± 5.6; P = .037) and the elapsed time before exhaustion by 8.0% (P = .034), when compared to the placebo treatment. The biochemical markers also indicated that recovery may be positively affected by LLLT, as indicated by postexercise blood lactate levels (P<.01), creatine kinase activity (P = .017), and C-reactive protein levels (P = .047), showing a faster recovery with LLLT application prior to the exercise. CONCLUSION: We conclude that pre-exercise irradiation of the biceps with an LLLT dose of 6 J per application location, applied in 2 locations, increased endurance for repeated elbow flexion against resistance and decreased postexercise levels of blood lactate, creatine kinase, and C-reactive
protein. LEVEL OF EVIDENCE: Performance enhancement, level 1b.

J Orthop Sports Phys Ther 2010;40(8):524-532; Epub 12 April 2010. doi:10.2519/jospt.2010.3294

KEY WORDS: biceps, skeletal muscle damage, skeletal muscle performance

DESIGN: A randomized controlled trial. OBJECTIVE: To investigate the immediate effects on pressure pain thresholds over latent trigger points (TrPs) in the masseter and temporalis muscles and active mouth opening following atlanto-occipital joint thrust manipulation or a soft tissue manual intervention targeted to the suboccipital muscles. BACKGROUND: Previous studies have described hypoalgesic effects of neck manipulative interventions over TrPs in the cervical musculature. There is a lack of studies analyzing these mechanisms over TrPs of muscles innervated by the trigeminal nerve. METHODS: One hundred twenty-two volunteers, 31 men and 91 women, between the ages of 18 and 30 years, with latent TrPs in the masseter muscle, were randomly divided into 3 groups: a manipulative group who received an atlanto-occipital joint thrust, a soft tissue group who received an inhibition technique over the suboccipital muscles, and a control group who did not receive an intervention. Pressure pain thresholds over latent TrPs in the masseter and temporalis muscles, and active mouth opening were assessed pretreatment and 2 minutes posttreatment by a blinded assessor. Mixed-model analyses of variance (ANOVA) were used to examine the effects of interventions on each outcome, with group as the between-subjects variable and time as the within-subjects variable. The primary analysis was the group-by-time interaction. RESULTS: The 2-by-3 mixed-model ANOVA revealed a significant group-by-time interaction for changes in pressure pain thresholds over masseter (P<.01) and temporalis (P = .003) muscle latent TrPs and also for active mouth opening (P<.001) in favor of the manipulative and soft tissue groups. Between-group effect sizes were small. CONCLUSIONS: The application of an atlanto-occipital thrust manipulation or soft tissue technique targeted to the suboccipital muscles led to an immediate increase in pressure pain thresholds over latent TrPs in the masseter and temporalis muscles and an increase in maximum active mouth opening. Nevertheless, the effects of both interventions were small and future studies are required to elucidate the clinical relevance of these changes. LEVEL OF EVIDENCE: Therapy, level 1b.

J Orthop Sports Phys Ther 2010;40(5):310-317, Epub 12 April 2010. doi:10.2519/jospt.2010.3257

KEY WORDS: cervical manipulation, muscle trigger points, neck, TMJ, upper cervical

STUDY DESIGN: Case-control and reliability study. OBJECTIVES: To compare foot and ankle characteristics between individuals with and without patellofemoral pain syndrome (PFPS) and to identify reliable weight-bearing foot and ankle measurements for use in future research on PFPS. BACKGROUND: PFPS is a common presentation to sports medicine and orthopaedic clinics. Characteristics of the foot and ankle are often linked with PFPS development, although evidence to support this link is equivocal and there is a lack of consensus on how best to evaluate these characteristics. METHODS: A variety of weight-bearing foot and ankle measurements were evaluated by 3 raters of varying experience in 20 individuals with PFPS and 20 controls matched by age, sex, height, and body mass. Between-group comparisons were made for each measurement using data from an experienced podiatrist blinded to group assignment of the participants. Intrarater and interrater reliability was compared between all measurements using the first 15 participants from each group. RESULTS: Between-group comparisons showed that the individuals in the PFPS group had a more pronated foot posture when assessed by the foot posture index and longitudinal arch angle, and for all measurements relative to subtalar joint neutral. Foot posture index, normalized navicular drop, and calcaneal angle relative to subtalar joint neutral measurements also possessed high reliability in both groups when used by experienced raters. Reliability was not influenced by rater experience or the presence of PFPS for relaxed-stance foot posture measurements. Both tester inexperience and the presence of PFPS reduced reliability for all measurements of foot posture relative to subtalar joint neutral and measurement of weight-bearing ankle dorsiflexion. CONCLUSION: The foot posture index, normalized navicular drop, and calcaneal angle relative to subtalar joint neutral are all reliable and sensitive to group differences when used in a population with PFPS. Individuals with PFPS possess a more pronated foot posture and increased foot mobility compared to controls. Prospective evaluation of these measurements is now required to determine whether they contribute to the development of PFPS.

J Orthop Sports Phys Ther 2010;40(5):286-296, Epub 12 April 2010. doi:10.2519/jospt.2010.3227

KEY WORDS: aetiology, chondromalacia, knee, posture

The JOSPT offers invited reviews of current titles. The April 2010 column includes 7 reviews of the following books: Biological Joint Reconstruction: Alternatives to Arthroplasty; Tension-type and Cervicogenic Headache: Pathophysiology, Diagnosis, and Management; AO Handbook: Musculoskeletal Outcomes Measures and Instruments (Volumes 1 and 2); Arthroscopic Techniques of the Knee: A Visual Guide; Arthroscopic Techniques of the Shoulder: A Visual Guide; Manipulative Thrust Techniques: An Evidence Based Approach; and Functional Testing in Human Performance.

J Orthop Sports Phys Ther 2010;40(4):239-244.