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Open access

The Effects of Contralateral Trunk Tilt on Elbow Varus Torque in Baseball Pitchers: A Critically Appraised Topic

Sierra Hakanson, Samuel T. Johnson, Emily C. Norcross, and Cathleen N. Brown

Clinical Scenario: Ulnar collateral ligament injuries are common in baseball pitchers, with excessive elbow varus torque linked to medial elbow injuries. Trunk tilt, or motion in the frontal plane, could be an identifiable and modifiable factor in medial elbow loading. Clinical Question: In high school through professional baseball pitchers, how does increased contralateral trunk tilt compared with no/limited contralateral trunk tilt influence elbow varus torque? Summary of Key Findings: Four studies were included: all were labeled as “controlled” or “descriptive laboratory studies,” representing cross-sectional observational analytic design. One study compared biomechanics of professional pitchers with and without ulnar collateral ligament reconstruction. Two studies measured biomechanics in college pitchers, one of which also included simulations of joint angles. The fourth study measured biomechanics of high school pitchers. All studies measured trunk tilt and its relationship to elbow varus torque, with 3 of the studies linking increased contralateral trunk tilt with increased elbow varus torque. Clinical Bottom Line: Moderate evidence indicated as contralateral trunk tilt increased, so did elbow varus torque, indicating trunk tilt may be a modifiable factor to decrease medial elbow loading during pitching. Strength of Recommendation: Majority consistent findings from the level 3 cross-sectional observational analytic designs suggest grade B evidence in support of trunk tilt as a factor in increasing elbow varus torque.

Open access

Weak Hip Strength Increases Dynamic Knee Valgus in Single-Leg Tasks of Collegiate Female Athletes

Kyndell R. Crowell, Ryan D. Nokes, and Nicole L. Cosby

Clinical Scenario: Dynamic knee valgus (DKV) is a mechanical alteration in the knee that leads to increased risk of injury. Weakness of hip musculature in hip abduction (HABD), extension (HEXT), and external rotation (HER) may contribute to increased DKV in single-leg landing tasks. Focused Clinical Question: Is decreased hip strength associated with an increase in DKV during a single-leg landing task in collegiate female athletes? Summary of Key Findings: Three studies were included: One randomized control trial (RCT), one cohort study, and one case-control. All three studies found that decreases in HABD and HER strength contributed to increased DKV during single-leg landing tasks. One study also found that the hip extensors contribute to controlling hip adduction, a common factor in many mechanisms of injuries. These three studies recommended strengthening HABD, HEXT, and HER to decrease DKV and reduce the risk of injury at the knee. Clinical Bottom Line: Weak HABD, HEXT, and HER contribute to increased DKV in college female athletes, but strengthening HABD, HEXT, and HER can lead to decreases in DKV and, overall, reduce the risk of injury at the knee. Strength of Recommendation: These articles were graded with a level of evidence of III or higher, giving a grade of B strength of recommendation that weak HABD, HEXT, and HER are associated with increased DKV in collegiate female athletes.

Open access

The Nocebo Effect and Pediatric Concussion

Michael W. Kirkwood, David R. Howell, Brian L. Brooks, Julie C. Wilson, and William P. Meehan III

While placebo effects are well recognized within clinical medicine, “nocebo effects” have received much less attention. Nocebo effects are problems caused by negative expectations derived from information or treatment provided during a clinical interaction. In this review, we examine how nocebo effects may arise following pediatric concussion and how they may worsen symptoms or prolong recovery. We offer several suggestions to prevent, lessen, or eliminate such effects. We provide recommendations for clinicians in the following areas: terminology selection, explicit and implicit messaging to patients, evidence-based recommendations, and awareness of potential biases during clinical interactions. Clinicians should consider the empirically grounded suggestions when approaching the care of pediatric patients with concussion.

Open access

Reliability of the ForceFrame With and Without a Fixed Upper-Limb Mold in Shoulder Rotation Strength Assessments Compared With Traditional Hand-Held Dynamometry

Jamon Couch, Marc Sayers, and Tania Pizzari

Context: An imbalance between shoulder internal rotation (IR) and external rotation (ER) strength in athletes is proposed to increase the risk of sustaining a shoulder injury. Hand-held (HHD) and externally fixed dynamometry are reliable forms of assessing shoulder IR and ER strength. A new externally fixed device with an attachable fixed upper-limb mold (The ForceFrame) exists; however, its reliability in measuring shoulder strength is yet to be investigated. Objective: To determine the test–retest reliability of the ForceFrame, with and without the fixed upper-limb mold, in the assessment of shoulder IR and ER strength, as compared with HHD. Design: Test–retest reliability study. Setting: Laboratory, clinical. Participants: Twenty-two healthy and active individuals were recruited from the university community and a private physiotherapy practice. Main Outcome Measures: Maximal isometric shoulder IR and ER strength was measured using the ForceFrame and traditional HHD in neutral and at 90° shoulder abduction. Mean (SD) strength measures were calculated. Test–retest reliability was analyzed using intraclass correlation coefficients (3, 1). The SEM and minimal detectable change were calculated. Results: Good to excellent test–retest reliability was found for all shoulder strength tests across HDD and ForceFrame dynamometry (intraclass correlation coefficients [3, 1] = .854–.916). The minimal detectable changes ranged between 25.61 and 41.84 N across tests. Test–retest reliability was not affected by the dynamometer or testing position. Conclusions: The results from this study indicate that both the ForceFrame and HHD are suitable for measuring shoulder strength in clinical practice. The use of the fixed upper-limb mold with the ForceFrame does not improve reliability.

Open access

Test–Retest Reliability of Single-Leg Time to Stabilization Following a Drop-Landing Task in Healthy Individuals

Aaron Byrne, Clare Lodge, and Jennifer Wallace

Context: Single-leg stability has been associated with injury risk and is a key component of many injury prevention interventions. Methods of measuring single-leg stability are varied yet often unreliable. Objective: To establish within- and between-day test–retest reliability for single-leg time to stabilization (SL-TTS) following a drop-landing maneuver of 20 cm in height among a healthy cohort. Design: Test–retest reliability study. Setting: Healthy cohort from a third-level educational institution. Participants: Nineteen (11 females and 8 males) healthy individuals. Main Outcome Measures: The SL-TTS in the vertical plane. Results: The SL-TTS showed good within-day (intraclass correlation coefficient = .715) and excellent between-day (intraclass correlation coefficient = .83) test–retest reliability. The minimal detectable change was calculated as 171.6 ms for within-day contexts and 123.8 ms for between-day contexts. Conclusions: This method of measuring SL-TTS is reliable and could be used to detect changes over time in a healthy cohort. This could be of value to clinicians in injury risk factor identification or assessing the effectiveness of single-leg stability training. However, further research is needed to investigate its reliability in pathological populations.

Open access

Diagnostic Accuracy of Musculoskeletal Ultrasound on Long Head Biceps Tendon Pathologies

Jennifer L. Ostrowski, Alexa Beaumont, and Emily Dochterman

Clinical Scenario: Pathologies of the long head of the biceps brachii (LHB) tendon are a source of shoulder pain in many people. It is important to have a reliable assessment of the LHB tendon to make an accurate diagnosis and provide the correct treatment or referral if necessary. Shoulder ultrasound is very accurate in the diagnosis of rotator cuff tears. However, its ability to detect pathologies of the LHB tendon is still unclear. Clinical Question: In patients with shoulder pain, can musculoskeletal ultrasound accurately diagnose LHB tendon pathologies? Summary of Key Findings: Four high-quality cohort studies met inclusion criteria and were included in the critical appraisal. The STrengthening the Reporting of OBservational studies in Epidemiology checklist was used to score the articles on methodology and consistency. Three studies evaluated accuracy in diagnosis of full-thickness tears and found high sensitivity (SN) and specificity (SP). Three studies evaluated accuracy in diagnosis of partial-thickness tears and found low SN and negative predictive value, but high SP and positive predictive value. Two studies evaluated tendon subluxation/dislocation and found high SN and SP. Two studies evaluated tendinitis and found moderate SN and high SP. Clinical Bottom Line: There is moderate to strong evidence to support the use of musculoskeletal ultrasound in diagnosis of LHB tendon pathology. Strength of Recommendation: There is grade B evidence that musculoskeletal ultrasound can accurately diagnose full-thickness tears and tendon subluxation/dislocation; can rule in partial-thickness tears (based on SP and positive predictive value), but not rule out partial-thickness tears; and can rule in tendinitis (based on SP and positive predictive value), but not rule out tendinitis.

Open access

Hand-Held Shoulder Strength Measures Correlate With Isokinetic Dynamometry in Elite Water Polo Players

Félix Croteau, Shawn M. Robbins, and David Pearsall

Context: Previous authors suggest that lack of strength is an important risk factor for injuries in water polo. Hand-held dynamometers have potential as a clinical tool to measure strength, but they have not been validated in water polo players. Objective: The purpose of this study was to estimate intertrial variability and concurrent validity of hand-held dynamometer shoulder strength measurements in elite water polo players. Methods: A total of 19 male and 20 female elite water polo players performed isometric external (ER) and internal (IR) rotation strength tests against a hand-held dynamometer bilaterally in supine position with the shoulder in a 90–90 position. In addition, concentric IR and ER was captured at 90 deg/s with an isokinetic dynamometer, and torque values were determined near the 90–90 position. Main Outcome Measures: Spearman correlation coefficients were calculated for ER torque, IR torque, and ER/IR ratios between the devices. Two-way mixed-model intraclass correlations were used to assess intertrial variability. Results: Correlations between the devices were strong to very strong (ρ = .65–.82, P < .01) for absolute IR and ER but low for ER/IR ratios (ρ = .29, P = .07). There was less agreement at higher torque values. Intertrial variability was low with intraclass correlation values .88 to .93, P < .05. Conclusions: These results show that hand-held dynamometers are adequate clinical alternatives to measure absolute shoulder strength in water polo players. Stronger players may require stronger evaluators to resist the player’s push and obtain reliable results.

Open access

Test–Retest Reliability of a Functional Reaction Time Assessment Battery

Robert C. Lynall, Rachel S. Johnson, Landon B. Lempke, and Julianne D. Schmidt

Context: Reaction time is commonly assessed postconcussion through a computerized neurocognitive battery. Although this measure is sensitive to postconcussion deficits, it is not clear if computerized reaction time reflects the dynamic reaction time necessary to compete effectively and safely during sporting activities. Functional reaction time assessments may be useful postconcussion, but reliability must be determined before clinical implementation. Objective: To determine the test–retest reliability of a functional reaction time assessment battery and to determine if reaction time improved between sessions. Design: Cohort. Setting: Laboratory. Participants: Forty-one participants (21 men and 20 women) completed 2 time points. Participants, on average, were 22.5 (2.1) years old, 72.5 (11.9) cm tall, had a mass of 71.0 (13.7) kg, and were mostly right leg and hand dominant (92.7%). Interventions: Participants completed 2 clinical reaction time tests (computerized Stroop and drop stick) and 5 functional reaction time tests (gait, jump landing, single-leg hop, anticipated cut, and unanticipated cut) across 2 sessions. Drop stick and functional reaction time assessments were performed in single (motor task only) and dual task (motor task with cognitive task). Main Outcome Measures: Reaction time (in seconds) was calculated during all assessments. Test–retest reliability was determined using 2-way mixed-effects intraclass correlation coefficients (3, k). Paired samples t tests compared mean reaction time between sessions. Results: Test–retest reliability was moderate to excellent for all reaction time outcomes (intraclass correlation coefficients [3, k] range = .766–.925). Several statistically significant between-session mean differences were observed, but effect sizes were negligible to small (d range = 0.05–0.44). Conclusions: The functional reaction time assessment battery displayed similar reliability to the standard computerized reaction time assessment battery and may provide important postinjury information, but more research is needed to determine clinical utility.

Open access

The Utilization of Core Exercises in Patients With Patellofemoral Pain: A Critically Appraised Topic

Emma F. Zuk, Gyujin Kim, Jacqueline Rodriguez, Brandon Hallaway, Amanda Kuczo, Shayna Deluca, Kirsten Allen, Neal R. Glaviano, and Lindsay J. DiStefano

Clinical Scenario: Patellofemoral pain (PFP) is characterized by general anterior knee pain around the patella and is one of the most prevalent knee conditions. PFP is challenging to treat due to a wide range of contributing factors and often has chronic, reoccurring symptoms. Traditional treatment focuses on quadriceps and gluteal strengthening with minimal emphasis on deep trunk musculature. Recently, there has been a growing body of literature supporting the beneficial effects of core stability exercises as a treatment option for PFP. Clinical Question: Are core stability exercises coupled with traditional rehabilitation more effective than only traditional rehabilitation techniques for decreasing pain in patients with PFP? Summary of Key Findings: Three articles met the inclusion criteria and investigated core strengthening exercises as a treatment for PFP. Two studies investigated a 4-week exercise protocol and demonstrated a greater decrease in pain when compared to the control group. The third study examined the effects of a 6-week program where both the intervention and control groups resulted in similar reduction of pain. All articles included received a minimum of 6 on the PEDro scale. Clinical Bottom Line: There is evidence that supports core stability exercise protocols coupled with traditional rehabilitation as being more effective in reducing pain in patients with PFP when compared to traditional rehabilitation alone. Strength of Recommendation: The grade of A is recommended based on the Strength of Recommendation Taxonomy.

Open access

Exercise Programs Targeting Scapular Kinematics and Stability Are Effective in Decreasing Neck Pain: A Critically Appraised Topic

Chris M. Edwards

Clinical Scenerio: Neck pain is a costly symptom in both civilian and military worlds. While traditional treatments include deep neck flexor stabilizing exercises, manual therapy, electrical therapy, and other nonsurgical interventions, scapular orientation and stability training has emerged as a possible tool to reduce neck pain severity. Methods that can be coached at a distance could be of value in virtual appointments or circumstances where access to a qualified manual therapist is limited. Focused Clinical Question: What is the effectiveness of including exercise programs targeting scapular kinematics and stability to decrease neck pain? Summary of Key Findings: Exercise programs targeting scapular kinematics and stability, with coaching and individualized progressions, appear to reduce neck pain severity. Clinical Bottom Line: Evidence supports the inclusion of exercises for scapular kinematics and stability at a prescription of 3 sessions per week, with a duration of 4 or 6 weeks. Exercise programs should include a “learning” or coaching phase to ensure exercises are performed as intended, and exercise progressions should be based on participant ability rather than predetermined timelines. Further research is needed to better understand the benefits of this potential strategy and the statistical impact of scapular-focused exercise interventions on neck pain in specific populations like military and athletes. Strength of Recommendation: There is ‘Fair’ to ‘Good’ evidence from 2 level 1b single-blind randomized control studies and 1 level 2b pre-post test control design study supporting the inclusion of exercise programs targeting scapular kinematics and stability to decrease chronic neck pain severity.