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Craig Denegar

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Brian Klucinec, Craig Denegar and Rizwan Mahmood

During the administration of therapeutic ultrasound, the amount of pressure at the sound head-tissue interface may affect the physiological response to and the outcome of treatment. Speed of sonification; size of the treatment area; frequency, intensity, and type of wave; and coupling media are important parameters in providing the patient with an appropriate ultrasound treatment. Pressure variations affect ultrasound transmissivity, yet pressure differences have been virtually unexplored. The purpose of this study was to assess the effects of sound head pressure on acoustic transmissivity. Three trials were conducted whereby pig tissue was subjected to increased sound head pressures using manufactured weights. The weights were added in 100 g increments, starting with 200 g and finishing with 1,400 g. Increased pressure on the transmitting transducer did affect acoustic transmissivity; acoustic energy transmission was increased from 200 g (0.44 lb) up to and optimally at 600 g (1.32 lb). However, there was decreased transmissivity from 700 to 1, 400 g (1.54 to 3.00 lb).

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Craig R. Denegar and Donald W. Ball

The reliability and precision of measurement in sports medicine are of concern in both research and clinical practice. The validity of conclusions drawn from a research project and the rationale for decisions made about the care of an injured athlete are directly related to the precision of measurement. Through analysis of variance, estimates of reliability and precision of measurement can be quantified. The purpose of this manuscript is to introduce the concepts of intraclass correlation as an estimate of reliability and standard error of measurement as an estimate of precision. The need for a standardized set of formulas for intraclass correlation is demonstrated, and it is urged that the standard error of measurement be included when estimates of reliability are reported. In addition, three examples are provided to illustrate important concepts and familiarize the reader with the process of calculating these estimates of reliability and precision of measurement.

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Matthew P. Callahan, Craig R. Denegar and Craig A. Segree

Orthotics are commonly prescribed for the treatment of lower extremity injuries secondary to hyperpronation. However, the efficacy of vacuum-molded orthotics has not been established. We assessed the effects of vacuum-molded orthotics on pain and level of function in athletes suffering from plantar fasciitis, medial tibial stress syndrome, or knee pain secondary to hyperpronation. Fourteen athletes assessed their pain and level of function during athletic activity before being fitted for orthotics (Professional Rx, SuperFeet In-Shoe Systems Inc.) and weekly for 7 weeks following break-in. Five athletes (36%) reported complete pain resolution and eight (57%) reported substantial improvement. Eight athletes (57%) reported full return to athletic participation and five (36%) reported substantial improvement in athletic function. One athlete failed to respond to treatment. Results indicate that vacuum-molded orthotics are an effective treatment for lower extremity overuse injuries secondary to hyperpronation.

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Jennifer M. Medina McKeon, Craig R. Denegar and Jay Hertel

The purpose of this study was to formulate a predictive equation to discriminate males from females using static and dynamic lower extremity (LE) alignments. Twenty-four healthy adults volunteered to participate. Three-dimensional motion analysis was used to assess the kinematics of the right hip and knee during two functional tasks. Six measures of static LE alignment were also performed. Statistical comparisons were made between males and females for all variables. Static and dynamic variables that were significantly different by sex were entered into separate discriminant analyses for each task. The resulting equations were each able to correctly predict 87% of the subjects by sex. Fifty-eight percent and 55% of the variance was explained by sex for the vertical jump and plant & jump, respectively. The frontal plane hip angle was the best predictor of sex for both tasks. While there were statistically significant differences between the sexes for static measures of LE alignment, kinematic measures were better at discriminating between sexes.

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Phillip Gribble, Jay Hertel, Craig Denegar and William Buckley


The SMART™ software system offers low-cost kinematic analysis through digitization of video from a single camera. The reliability and validity of this product have not been reported.


To assess the reliability and validity of the SMART software during a simple static task and dynamic task.


Test–retest to compare assumed neutral and goniometrically measured joint angles in the sagittal plane of the lower extremity.


Research laboratory.


7 in a static task, 16 young, physically active in a dynamic task.


Measurement error of the SMART system ranged from 0.29° ± 1.98° to 11.07° ± 1.77°. The interrater reliability (ICC2,1) values ranged from .60 to .92 for the static task and from .76 to .89 for the dynamic task.


Based on the results of both studies, the SMART system offers a low-cost alternative for reporting single-plane kinematics during an individual frame of video during static stances and slow dynamic tasks with strong reliability and reasonable validity.

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Lauren C. Olmsted and Craig Denegar

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Jennifer E. Earl, Jay Hertel and Craig R. Denegar


Dynamic malalignment (DM), abnormal muscle activation, and static malalignments all might lead to patellofemoral pain (PFP) but have not been examined using a multifactorial approach.


To determine which measures of static malalignment, DM, and muscle-onset times best predict PFP.

Design and Setting:

Between-subjects, laboratory.


2 groups (PFP and uninjured) of 16 subjects each.


EMG and 3-D kinematic data were recorded during a step-down. Five static-alignment assessments were performed.


Three discriminant analyses using injury as the grouping variable and static measures, joint angles, and EMG onsets as the predictor variables. A final combined discriminant analysis using the most predictive variables from each set.


The static-alignment discriminant function was most predictive (81.3% correct), followed by the kinematic (69%) and the EMG (67%) functions. The final discriminant function included iliotibial-band flexibility, navicular drop, pronation, knee flexion, hip adduction, gluteus medius, and vastus medialis obliquus onset time and correctly classified 92.3% of PFP subjects.


PFP can most accurately be predicted when multiple measures of lower extremity function are considered together.

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Luzita I. Vela, Douglas E. Haladay and Craig Denegar

Patient Scenario:

A 21-year-old male rodeo athlete complains of acute low back pain (LBP) after a bareback event. The athlete wishes to compete in a rodeo event in 4 d.

Clinical Outcomes Assessment:

Given the questionable validity and reliability of traditional clinical examination techniques for LBP, a treatment subgroup classification system combined with clinical outcomes assessment provides greater insight into suitable clinical interventions and patient response to treatment. Four LBP treatment subgroups based on the patient’s clinical presentation and symptoms have been established: manipulation, stabilization, specific exercise, and traction. Manipulation subgroup research has produced a valid clinical prediction rule (CPR). The Visual Analog Scale, Numeric Rating Scale (NRS), Oswestry Low Back Pain Disability Index (ODI), Roland Morris Disability Questionnaire, Short Form 36 (SF-36), and Global Rating of Change Scale are valid, reliable, and responsive outcomes instruments with established values for minimum clinically important difference (MCID). These instruments document important changes in disablement and health-related quality of life in patients with low back injury, as well as demonstrate treatment outcomes.

Clinical Decision Making:

On examination the athlete presents with moderate pain and disability as measured by the NRS, ODI, and SF-36 and meets all 5 criteria for the manipulation subgroup, indicating a high likelihood of success with manipulative therapy when following the guidelines presented in the CPR. Expected outcomes values, based on MCID values, were met after 1 treatment. Preferred outcomes, based on physical activity requirements for sport, were met on day 4.

Clinical Bottom Line:

LBP generators are difficult to establish using traditional clinical examination techniques. The combined use of clinical criteria, using an LBP subgroup system, and baseline outcomes measures should guide treatment. Benchmarks should be guided by established MCID values for each instrument.

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Michael F. Joseph, Kathryn Taft, Maria Moskwa and Craig R. Denegar

Study Design:

Systematic literature review.


To assess the efficacy of deep friction massage (DFM) in the treatment of tendinopathy.


Anecdotal evidence supports the efficacy of DFM for the treatment of tendinopathy. An advanced understanding of the etiopathogenesis of tendinopathy and the resultant paradigm shift away from an active inflammatory model has taken place since the popularization of the DFM technique by Cyriax for the treatment of “tendinitis.” However, increasing mechanical load to the tendinopathic tissue, as well as reducing molecular cross-linking during the healing process via transverse massage, offers a plausible explanation for observed responses in light of the contemporary understanding of tendinopathy.

Evidence Acquisition:

The authors surveyed research articles in all languages by searching PubMed, Scopus, Pedro, CINAHL, PsycINFO, and the Cochrane Library using the terms deep friction massage, deep tissue massage, deep transverse massage, Cyriax, soft tissue mobilization, soft tissue mobilisation, cross friction massage, and transverse friction massage. They included 4 randomized comparison trials, 3 at the extensor carpi radialis brevis (ECRB) and 1 supraspinatus outlet tendinopathy; 2 nonrandomized comparison trials, both receiving DFM at the ECRB; and 3 prospective noncomparison trials—supraspinatus, ECRB, and Achilles tendons. Articles meeting inclusion criteria were assessed based on PEDro and Centre for Evidence-Based Medicine rating scales.


Nine studies met the inclusion criteria.

Evidence Synthesis:

The heterogeneity of dependent measures did not allow for meta-analysis.


The varied locations, study designs, etiopathogenesis, and outcome tools used to examine the efficacy of DFM make a unified conclusion tenuous. There is some evidence of benefit at the elbow in combination with a Mills manipulation, as well as for supraspinatus tendinopathy in the presence of outlet impingement and along with joint mobilization. The examination of DFM as a single modality of treatment in comparison with other methods and control has not been undertaken, so its isolated efficacy has not been established. Excellent anecdotal evidence remains along with a rationale for its use that fits the current understanding of tendinopathy.