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Ben A. Bloomer and Chris J. Durall

Clinical Scenario:

Patellofemoral pain syndrome (PFPS) is one of the most common disorders affecting the lower extremities. To improve function and decrease pain, affected individuals often undergo a guided rehabilitation program. Traditional programs have concentrated on quadriceps strengthening and other knee-focused exercises, but recent literature suggests that adding hip-muscle strengthening may improve outcomes. This review was conducted to determine the extent to which current evidence supports the addition of hip-muscle strengthening to a knee-focused strengthening and stretching program in the treatment of PFPS.

Focused Clinical Question:

Does the addition of hip-muscle strengthening to a knee-focused strengthening and stretching program improve outcomes in patients with PFPS?

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Luke M. Mueller, Ben A. Bloomer, and Chris J. Durall

Clinical Scenario:

Anterior cruciate ligament (ACL) injuries are associated with a lengthy recovery time, decreased performance, and an increased rate of reinjury. To improve performance of the injured knee, affected athletes often undergo surgical reconstruction and rehabilitation. Determining when an athlete is ready to safely return to play (RTP), however, can be challenging for clinicians. Although various outcome measures have been recommended, their ability to predict a safe RTP is questionable.

Focused Clinical Question:

Which outcome measures should be used to determine readiness to return to play after ACL reconstruction?

Open access

Chelsey Klimek, Christopher Ashbeck, Alexander J. Brook, and Chris Durall

Clinical Scenario: CrossFit is a form of exercise that incorporates rapid and successive high-intensity ballistic movements. As CrossFit is an increasingly popular fitness option, it is important to determine how rates of injury compare to more traditional forms of exercise. This review was conducted to ascertain the incidence of injury with CrossFit relative to other forms of exercise. Focused Clinical Question: Are injuries more common with CrossFit training than other forms of exercise? Summary of Key Findings: (1) The literature was searched for studies that compared injury rates among individuals who participated in CrossFit fitness programs to participants in other exercise programs. (2) The search initially yielded >100 results, which were narrowed down to 3 level 2b retrospective cohort studies that were deemed to have met inclusion/exclusion criteria. (3) In all 3 reviewed studies, the reported incidences of injuries associated with CrossFit training programs were comparable or lower than rates of injury in Olympic weightlifting, distance running, track and field, rugby, or gymnastics. Clinical Bottom Line: Current evidence suggests that the injury risk from CrossFit training is comparable to Olympic weightlifting, distance running, track and field, rugby, football, ice hockey, soccer, or gymnastics. Injuries to the shoulder(s) appear to be somewhat common with CrossFit. However, the certitude of these conclusions is questionable given the lack of randomization, control, or uniform training in the reviewed studies. Clinicians should be aware that injury is more prevalent in cases where supervision is not always available to athletes. This is more often the case for male participants who may not actively seek supervision during CrossFit exercise. Strength of Recommendation: Level 2b evidence from 3 retrospective cohort studies indicates that the risk of injury from participation in CrossFit is comparable to or lower than some common forms of exercise or strength training.

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Laura A. Verbruggen, Melissa M. Thompson, and Chris J. Durall

Plantar fasciitis is one of the most common musculoskeletal disorders of the foot. Initial treatment of plantar fasciitis is typically conservative and may include heel padding, steroid injections, night splinting, calf stretching, ultrasound, foot orthoses, and taping. However, while custom foot orthoses are a common treatment method for plantar fasciitis, there is often a waiting period of a few weeks for them to be manufactured and delivered. Therefore, taping of the foot is often used as a temporary treatment to alleviate pain during the initial waiting period. Furthermore, taping may also be used as an alternative to foot orthoses for patients who may not tolerate the plantar pressures of an orthotic or for tight-fitting footwear that may not accommodate insoles. Specifically, the low-Dye taping (LDT) technique is one of the most frequently used methods, and recent literature has suggested that it may improve pain outcomes. Therefore, this critically appraised topic was conducted to determine the extent to which current evidence supports the use of LDT to reduce pain in patients with plantar fasciitis.

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Kirk Krumrei, Molly Flanagan, Josh Bruner, and Chris Durall

Clinical Scenario:

Injuries are somewhat commonplace in highly active populations. One strategy for reducing injuries is to identify individuals with an elevated injury risk before participation so that remediative interventions can be provided. Preparticipation screenings have traditionally entailed strength and flexibility measures thought to be indicative of inflated injury risk. Some researchers, however, have suggested that functional movements/tasks should be assessed to help identify individuals with a high risk of future injury. One assessment tool used for this purpose is the Functional Movement Screen (FMS). The FMS generates a numeric score based on performance attributes during 7 dynamic tasks; this score is purported to reflect future injury risk. Expanding interest in the FMS has led researchers to investigate how accurately it can identify individuals with an increased risk of injury.

Focused Clinical Question:

Can the Functional Movement Screen accurately identify highly active individuals with an elevated risk of injury?

Open access

Erica M. Willadsen, Andrea B. Zahn, and Chris J. Durall

Clinical Scenario: A variety of training approaches have been adopted in anterior cruciate ligament (ACL) prevention programs, including neuromuscular control training, core stability training, balance training, and plyometric exercise. This review was conducted to determine if current evidence supports one of these training approaches over the others for reducing noncontact ACL injuries in adolescent female athletes. Focused Clinical Question: What is the most effective training approach for preventing noncontact ACL injuries in adolescent and/or high school–aged female athletes? Summary of Key Findings: A literature search generated 2 level 1b randomized control trials and 1 level 2b cohort study. Plyometric training resulted in decreased knee valgus during landing in 3 studies and increased knee flexion at landing in 2 studies. Balance training or neuromuscular training led to decreased knee valgus and increased knee-flexion angles with landing in 2 studies. Core stability training had conflicting effects on knee valgus and knee-flexion angles at landing, with 1 study reporting no effect and another reporting an undesirable decrease in knee joint flexion angle at landing. Clinical Bottom Line: Based on this review, plyometric training, balance training, and neuromuscular training approaches appear sensible to include in ACL prevention programs for female athletes to help decrease knee valgus and knee flexion during landing. Core stability training may be somewhat beneficial for decreasing knee valgus angles at landing, although may have nominal or even deleterious effects on knee-flexion angle at landing, and thus should be implemented with caution. Strength of Recommendation: Our recommendations were derived from the results of 2 level 1b randomized control trials and 1 level 2b cohort study.

Open access

Julie A. Fuller, Heidi L. Hammil, Kelly J. Pronschinske, and Chris J. Durall

Clinical Scenario: Acute patellar dislocations during adolescence often lead to future patellar instability. Two common treatment options include nonoperative treatment or operative repair of injured structures. Focused Clinical Question: In adolescents with acute patellar dislocation, how does operative stabilization compare with nonoperative treatment for reducing dislocation recurrence? Summary of Key Findings: Three studies were included: 2 randomized controlled trials and 1 nonrandomized study. All studies compared operative and nonoperative treatment outcomes in adolescents who experienced an acute patellar dislocation. Each study included nonoperative treatment such as patellar bracing and quadriceps strengthening. The operative treatments utilized in each study included lateral retinacular release and medial retinacular repair. All 3 of the studies included a follow-up of at least 6 years. Two of the studies concluded there to be no significant difference between treatment groups regarding redislocation rate, pain, and function. The third study reported a lower redislocation rate following operative treatment. Clinical Bottom Line: Reviewed evidence suggests that outcomes are similar when comparing operative and nonoperative treatment approaches with little agreement as to which is the optimal plan of action. Strength of Recommendation: One level II randomized controlled trial and a level III nonrandomized study suggest that patellar dislocation recurrence rates are similar among operative and nonoperative treatment approaches, while another level II randomized controlled trial suggests that an operative approach is superior.

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Danielle M. DeBruyne, Marina M. Dewhurst, Katelyn M. Fischer, Michael S. Wojtanowski, and Chris Durall

Clinical Scenario:

Increasing the length of the muscle–tendon unit may prevent musculotendinous injury. Various methods have been proposed to increase muscle–tendon flexibility, including self-mobilization using foam rollers or roller massagers, although the effectiveness of these devices is uncertain. This review was conducted to determine if the use of foam rollers or roller massagers to improve hamstrings flexibility is supported by moderate- to high-quality evidence.

Clinical Question:

Are foam rollers or roller massagers effective for increasing hamstrings flexibility in asymptomatic physically active adults?

Summary of Key Findings:

The literature was searched for studies on the effects of using foam rollers or roller massagers to increase hamstrings flexibility in asymptomatic physically active adults. Four randomized controlled trials were included; 2 studies provided level 2 or 3 evidence regarding foam rollers and 2 studies provided level 2 or 3 evidence regarding roller massagers. Both roller-massager studies reported increases in hamstrings flexibility after treatment. Data from the foam-roller studies did not demonstrate a statistically significant increase in hamstrings flexibility, but 1 study did demonstrate a strong effect size.

Clinical Bottom Line:

The reviewed moderate-quality studies support the use of roller massagers but provide limited evidence on the effectiveness of foam rolling to increase hamstrings flexibility in asymptomatic physically active adults. Flexibility gains may be improved by a longer duration of treatment and administration by a trained therapist. Gains appear to decline rapidly postrolling. Neither device has been shown to confer a therapeutic benefit superior to static stretching, and the effectiveness of these devices for preventing injury is unknown.

Strength of Recommendation:

Grade B evidence supports the use of roller massagers to increase hamstrings flexibility in asymptomatic physically active adults.

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Chris J Durall, George J Davies, Thomas W Kernozek, Mark H Gibson, Dennis CW Fater, and J Scott Straker

Context:

It has been hypothesized that the fibers of the infraspinatus and subscapularis superior to the glenohumeral axis of rotation contribute directly to arm elevation.

Objective:

To test this hypothesis by assessing the impact of 5 weeks of concentric isokinetic humeral-rotator training in a modified neutral position on scapular-plane arm-elevation peak torque.

Design:

Prospective, pretest/posttest with control group.

Participants:

24 female and 6 male noninjured college students (N = 30).

Main Outcome Measures:

Scapular-plane-elevation peak torque at 60, 180, and 300°/s.

Results:

Repeated-measures ANOVA indicated no difference in peak torque between groups at any of the angular velocities tested (P < .05)

Conclusions:

5 weeks of concentric isokinetic humeral-rotator training did not significantly increase scapular-plane-elevation peak torque.