Clinical Scenario: Chronic exertional compartment syndrome (CECS) is a condition related with ischemia of the body’s tissue due to increases in intracompartmental pressures, which involves, among other symptoms, pain with exertion. CECS is often overlooked or misdiagnosed due to an ambiguous presentation. Diagnostic accuracy of CECS and subsequent management can be improved when contributing factors are known. Research is lacking on the type of patient most likely to experience CECS, highlighting the need for identification of common demographic characteristics among affected individuals. Clinical Question: What are the common demographic characteristics among patients exhibiting CECS of the lower leg? Summary of Key Findings: Four studies were identified (1 prospective consecutive study, 2 retrospective reviews, and 1 retrospective cohort study) that examined common characteristics among patients with CECS. Conflicting evidence exists on whether CECS is more commonly seen in men or in women. CECS has often been reported in young, active individuals but may present in older populations as well. Soccer, field hockey, lacrosse, competitive running, and speed skating have been associated with an increased likelihood of CECS development. Clinical Bottom Line: Current evidence has identified commonalities in sex, age, and sport participation as characteristics often present among individuals experiencing lower leg CECS. Other factors, such as overuse, trauma, diabetes, and gait mechanics, have also been identified in association with CECS. Further data through future prospective studies will help confirm the type of patient mostly likely to experience CECS. Strength of Recommendation: Grade B evidence exists that certain sex, age, and sport participation demographic characteristics are common among patients with CECS of the lower leg.
Kelsey M. Rynkiewicz, Lauren A. Fry and Lindsay J. DiStefano
Scott Benson Street and Thomas Kaminski
Clinical Scenario: Hamstring injuries are the most prevalent lower-extremity injury among soccer players. The Fédération Internationale de Football Association (FIFA) has addressed this issue by developing the FIFA 11+ program, which is focused on improving strength and decreasing the incidence of lower-extremity injuries in the sport. This critically appraised topic focuses on this program as well as one of its components, the Nordic hamstring exercise, in the prevention of hamstring injuries. Clinical Question: Does the FIFA 11+ program prevent hamstring injuries in college-aged male soccer players? Summary of Key Findings: Four studies were selected to be critically appraised. The PEDro checklist was used to score the articles on methodology and consistency. All 4 articles demonstrated support for the clinical question. Clinical Bottom Line: There is moderate evidence to support the use of the FIFA 11+ program and Nordic hamstring exercise as part of a college soccer team’s warm-up routine. Strength of Recommendation: Grade B evidence exists in support of incorporating the FIFA 11+ program to reduce the incidence of hamstring injuries in male college soccer players.
Cameron Haun, Cathleen N. Brown, Kimberly Hannigan and Samuel T. Johnson
Clinical Scenario: Deformation of the arch, as measured by navicular drop (ND), is linked to lower-extremity musculoskeletal injuries. The short foot exercise (SFE) has been used to strengthen the intrinsic foot muscles that support the arch. Clinical Question: Does the SFE decrease ND in healthy adults? Summary of Key Findings: Three studies that examined the use of the SFE on ND were included. A randomized control trial that compared the SFE to a towel-curl exercise and a control group found no significant differences between the 3 groups. A randomized control trial compared the SFE to the use of arch support insoles in individuals with a flexible flatfoot and found a significant improvement in the SFE group. A prospective cohort study, without a control group, reported a significant decrease in ND following a 4-week SFE intervention without a regression at an 8-week follow-up. Overall, two of the three studies reported a significant reduction in ND following an SFE. Clinical Bottom Line: There is preliminary data supporting the use of the SFE to decrease ND—particularly in individuals with a flexible flatfoot. However, issues with the study designs make it difficult to interpret the data. Strength of Recommendation: Due to limited evidence, there is grade B evidence to support the use of the SFE to decrease ND.
Jordan Bettleyon and Thomas W. Kaminski
Clinical Scenario: Low-level laser therapy (LLLT) is a controversial topic for its use in athletic recovery, mainly due to inconsistency in research regarding the application of LLLT. Articles on LLLT have assessed its effectiveness in untrained humans through pain scales, functional scales, and blood draws, and it has been found capable in nonathletic rehabilitative use. The controversy lies with LLLT in the recovering athlete. Not only do athletes need to perform at high levels, but each sport is unique in the metabolic demands placed on the athletes’ bodies. This modality can alter chemical mediators of the inflammatory process, specifically blood lactate (BL) and creatine kinase (CK). During soccer contests, it is a common problem for athletes to have an average CK level of 800 U/L and BL of 8 mmol·L, increasing delayed-onset muscle soreness and fatigue. Micro-CK level elevation is associated with cellular membrane damage, localized hypoxia, and electrolyte imbalances, hindering the recovery process. Clinical Question: Does LLLT decrease muscle-damaging mediators effecting player fatigue and delayed-onset muscle soreness after performance in soccer athletes versus sham treatment? Summary of Key Findings: In 3 studies, preperformance, postperformance, or preperformance and postperformance LLLT was performed and evaluated BL (2 of 3) and CK (2 of 3). In each article, BL and CK showed a significant decrease (P < .05) when performed either preperformance or postperformance versus the control group. The greatest decrease in these mediators was noticed when postperformance laser therapy was performed. Clinical Bottom Line: LLLT at 10, 30, or 50 J performed at a minimum of 2 locations on the rectus femoris, vastus lateralis, and vastus medialis bilaterally for 10 seconds each is significant in decreasing blood serum levels of BL and CK when performed postexercise. Strength of Recommendations: All 3 articles obtained a Physiotherapy Evidence Database score of ≥8/10.
Xin He, Hio Teng Leong, On Yue Lau, Michael Tim-Yun Ong and Patrick Shu-Hang Yung
Context: Altered lower-limb biomechanics have been observed during landing task in patients with anterior cruciate ligament reconstruction (ACLR), which increases the risk of secondary anterior cruciate ligament injury. However, the alteration in neuromuscular activity of the lower-extremity during landing task is not clear. Objective: To compare the muscle activity pattern assessed by electromyography between the involved limb of patients with ACLR and the contralateral limb or control limb of matched healthy subjects during landing task. Evidence Acquisition: Database of PubMed, Ovid, Scopus, and Web of Science from the inception of the databases until July 2019, using a combination of keywords and their variations: (anterior cruciate ligament OR ACL) AND (electromyography OR EMG) AND (landing OR land). Studies that assessed lower-extremity muscle activity patterns during landing task in patients with ACLR and compared them either with the contralateral side or healthy controls were included. Evidence Synthesis: Of the 21 studies, 16 studies reported altered muscle activity pattern during landing tasks when compared with either the healthy controls or the contralateral side. For the specific muscle activity patterns, the majority of the studies showed no significant difference in reactive muscle activity, and comparisons across studies revealed a possible trend toward the early onset of quadriceps and hamstring activity and increased cocontraction of the involved limb. There are inconsistent findings regarding the alteration in muscle timing and preparatory muscle activity. Conclusions: Patients with ACLR displayed an altered muscle activity pattern during landing tasks, even though they were considered to be capable for sport return. Nevertheless, a firm conclusion could not be drawn due to great heterogeneity in the subject selection and study methods.
Christopher J. Burcal, Sunghoon Chung, Madison L. Johnston and Adam B. Rosen
Background: Region-specific patient-reported outcomes (PROs) are commonly used in rehabilitation medicine. Digital versions of PROs may be implemented into electronic medical records and are also commonly used in research, but the validity of this method of administration (MOA) must be established. Purpose: To determine the agreement between and compare the test–retest reliability of a paper version (FAAM-P) and digital version (FAAM-D) of the Foot and Ankle Ability Measure (FAAM). Study Design: Randomized, nonblinded, crossover observational study. Methods: A total of 90 adults were randomized to complete the FAAM-P or FAAM-D first, and then completed the second MOA (first day [D1]). The FAAM-D was a digital adaptation of both FAAM-P subscales on Qualtrics. Identical test procedures were completed 1 week later (D2). Data were removed if a participant scored 100% on both MOA, reported injury between D1 and D2, or did not complete both MOA. Agreement was assessed on 46 participants between the 2 MOA using intraclass correlation coefficients (ICC) at D1. There was good-to-excellent test–retest reliability for the FAAM activities of daily living. Results: The authors observed good agreement between the FAAM-P and FAAM-D for the activities of daily living (ICC = .88) and sport scales (ICC = .87). Test–retest reliability was good-to-excellent for the FAAM activities of daily living (FAAM-P: ICC = .87; FAAM-D: ICC = .89) and sport (FAAM-P: ICC = .71; FAAM-D: ICC = .91). Conclusions: The MOA does not appear to affect the responses on the FAAM; however, the authors observed slightly higher reliability on the FAAM-D. The FAAM-D is sufficient to be used for generating practice-based evidence in rehabilitation medicine.
Mayrena I. Hernandez, Kevin M. Biese, Dan A. Schaefer, Eric G. Post, David R. Bell and M. Alison Brooks
Context: Sport specialization among youth athletes has been associated with increased risk of overuse injuries. Previous research demonstrates that children perceive specialization to be beneficial in making their high school team and receiving athletic college scholarships. Previous research demonstrates that parents play a significant role in their child’s sport experience. However, it is unknown if parents and children answer questions related to specialization factors in a similar manner. Objective: To evaluate the beliefs of youth athletes and parents on factors related to sport specialization and evaluate the level of agreement between dyads on sports specialization. Design: Cross-sectional. Setting: Online and paper surveys. Patients or Other Participants: Aim 1: 1998 participants (993 children and 1005 parents). Aim 2: 77 paired parent–child dyads. Interventions: Self-administered survey. Main Outcome Measures: The responses were summarized via frequency and proportions (%). Chi-squares were calculated between parent and child responses. Kappa coefficients were calculated for dyads to determine level of agreement. Sport specialization was classified using a common 3-point scale. Results: The parents were more concerned about risk of injury in sports compared with children (P < .001, χ2 = 231.4; parent: extremely: 7.1%; child: extremely: 3.7%). However, children were more likely to believe that specialization was associated with their chances of obtaining an athletic college scholarship compared with parents (P < .001, χ2 = 201.6; parent: very/extremely likely: 13.7%; child: very/extremely likely: 15.8%). Dyad subanalysis indicated a moderate level of agreement for “quitting other sports to focus on one sport” (κ = .50) and a low level of agreement for “identifying a primary sport” (κ = .30) and “training >8 months per year in primary sport” (κ = .32). Conclusions: Parents and youth athletes had differing beliefs on the factors related to sport specialization. Dyad analysis shows that parents and children answer sport specialization classification questions differently. Health care providers should be aware of these differences, and messaging should be individualized to the audience.
Theodore Kent Kessinger, Bridget Melton, Theresa Miyashita and Greg Ryan
Clinical Scenario: Manipulation of exercise variables in resistance training (RT) is an important component in the development of muscular strength, power, and hypertrophy. Currently, most research centers on untrained or recreationally trained subjects. This critically appraised topic focuses on studies that center on the well-trained subject with regard to frequency of training. Clinical Question: In well-trained male subjects, is there an association between RT frequency and the development of muscular strength and hypertrophy? Summary of Key Findings: Four studies met the inclusion criteria and were included for analysis. All studies showed that lower-frequency training could elicit muscular strength and hypertrophy increases. One study suggested that a higher frequency compared with a lower frequency may provide a slight benefit to hypertrophic development. One study reported a greater level of delayed onset muscle soreness with lower frequency training. The 4 studies demonstrate support for the clinical question. Clinical Bottom Line: Current evidence suggests that lower-frequency RT produces equal to greater improvements on muscular strength and hypertrophy in comparison to higher-frequency RT when volume is equated. The evidence is particularly convincing when lower-frequency RT is associated with a total-body training protocol in well-trained male subjects. Strength of Recommendation: There is moderate-to-strong evidence to suggest that lower-frequency RT, when volume is equated, will produce equal to greater improvements on muscular strength and hypertrophy in comparison to higher-frequency RT.
Abbey Thomas and Jeffrey B. Driban
Jennifer L. Rizzo
The diagnosis of thoracic outlet syndrome (TOS) is challenging and primarily determined by clinical examination. Symptoms such as numbness and tingling in the arms when raised above the head make the rehabilitation process difficult due to the various manifestations of TOS presented to the athletic trainer (AT). An AT should understand the intricate anatomical characteristics of the thoracic outlet and how various TOS presentations may impact treatment. In this clinical commentary, I provide my own insights for understanding TOS from my perspective as a patient and AT. These insights are valuable when making diagnostic, therapeutic, and prognostic clinical decisions.