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Acute and Chronic Tendon Injuries: Factors Affecting the Healing Response and Treatment

Michelle A. Sandrey

Objective:

Tendons have biomechanical properties based on collaborative remodeling of all their cells through normal lysis and synthesis. This review assesses factors that affect the healing response and presents solutions for rehabilitating acute and chronic tendon injuries.

Data Sources:

MEDLINE (1970–2002) and SPORTDiscus (1970–2002). Key words searched were tendon, tendinitis, tendinosis, tendinopathy, rehabilitation, ultrasound, NSAIDs, exercise, mobilization, aging, immobilization, and healing.

Data Synthesis:

The biomechanical roles tendons play change throughout one’s lifetime and are influenced by maturation and aging, injury and healing, immobilization, exercise, medications, and therapeutic modalities. Suggestions from animal, case, and clinical studies are varied but provide solutions in the treatment of acute and chronic tendon injuries.

Conclusions and Recommendations:

All factors that affect the tendon structure should be considered in a rehabilitation program. Therapeutic exercise, medications, or therapeutic modalities should never be used as a stand-alone therapy.

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Effects of Acute and Chronic Pathomechanics on the Normal Histology and Biomechanics of Tendons: A Review

Michelle A. Sandrey

Objective:

To present the basic concepts of normal composition and structure of tendons and indicate how they are affected by acute and chronic tendon-injury pathomechanics.

Data Sources:

MEDLINE (1970-1999) and SPORTDiscus (1970-1999) were searched using the key words pathoanatomic, tendinitis, tendinosis, biomechanics, pathomechanics, histology, chronic, and mechanical behavior.

Data Synthesis:

Acute loading modes to tendons are based on the response of tendons to tensile and compressive stress. Chronic loading modes are based on frictional forces and repetitive movement.

Conclusions and Recommendations:

With an appreciation of the pathologic changes in acute tendon injuries, the clinician can better understand injury mechanics and the healing process. Until we know more about what is happening in and around the tendon, principally in the early and late phases of chronic injury we will not be able to adequately address injury classification of structures and, hence, the pathomechanics of chronic injury

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Which Low Back Instability Tests Should Be Incorporated Into a Stabilization Classification Exam for Athletes?: A Critically Appraised Topic

Michelle A. Sandrey

Clinical Question: Is there sufficient evidence to determine which low back instability tests should be incorporated into a stabilization classification exam for athletes? Clinical Bottom Line: There is moderate level 2 evidence to include, but not to use in isolation, the prone instability test along with other instability tests in a stabilization classification exam.

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The Efficacy of a Passive Stretching Intervention for Overhead Athletes: A Critically Appraised Topic

Michelle A. Sandrey

Focused Clinical Question: Does a passive stretching protocol, whether immediate or long-term, improve range of motion and decrease posterior shoulder tightness in overhead athletes? Clinical Bottom Line: There is moderate level 2 evidence to support the incorporation of passive stretching for overhead athletes to increase range of motion or decrease posterior shoulder tightness.

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Which Specific Angle Measurement Criteria Should be Used to Define Forward Head and Rounded Shoulder Posture: An Evidence-Based Commentary

Michelle A. Sandrey

Abstract: Postural distortions in the upper limb are prevalent and change the anatomical alignment, which alters force couples and the biomechanics of the body. Forward head posture (FHP) and rounded shoulder posture (RSP) are the two that are most prevalent. Measurement techniques using the craniovertebral angle for FHP and forward shoulder angle for RSP have been used both clinically and in the literature. However, what is not known is what specific criteria can be consistently used to define FHP and RSP as reference angles lack vigorous validity and there is a shortage of quantity, quality, and consistency of the evidence. Thus, there is much to be learned about postural classifications and the effect on the kinetic chain, supporting the need for further research in this area. As it is important to classify those who may need exercise and therapeutic intervention, following evidence-informed practice to inform decision-making clinicians should continue to evaluate posture, as well as examine scapular kinematics and muscle activity and the effects of interventions to improve posture. Therefore, determining whether FHP and RSP are present is paramount for the treatment to be successful.

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The Inclusion of a Complementary Running Progression Program in the Rehabilitation of Acute Hamstring Injuries: A Critically Appraised Topic

Michelle A. Sandrey

Introduction/Clinical Scenario : As many hamstring injuries occur when the hamstrings are in a lengthened state during the deceleration phase of running when the muscle is eccentrically contracting to slow the body down this functional aspect needs to be addressed. Thus, a rehabilitation program with a focus on progressive targeted eccentric hamstring exercises by gradually placing and exposing the muscle to eccentric force in a lengthened state supplemented with progressive running drills should be evaluated. Focused Clinical Question : Does the inclusion of a complementary running progression program for the rehabilitation of an acute hamstring injury reduce the time to safe return to sport with less hamstring reinjury occurrence for an athletic population? Summary of Key Findings: Three studies assessed the inclusion of a progressive running program with several types of running progression parameters addressed. Progressive running drills will load the hamstring in a functional manner, with a gradual increase in velocity of movement and lengthening of the muscle. Clinical Bottom Line : It appears that a complementary progressive running program within an acute hamstring rehabilitation program should be included as it caused no further harm and does not tend to increase hamstring reinjury occurrence. Strength of Recommendation : There is grade B evidence to include a complementary running progression program within an acute hamstring rehabilitation program.

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Effects of a 4-Week Dynamic-Balance-Training Program Supplemented With Graston Instrument-Assisted Soft-Tissue Mobilization for Chronic Ankle Instability

Jessica L. Schaefer and Michelle A. Sandrey

Context:

A dynamic-balance-training (DBT) program supplemented with the Graston instrument-assisted soft-tissue mobilization (GISTM) technique has not been evaluated collectively as a treatment in subjects with chronic ankle instability (CAI).

Objective:

To examine the effects of GISTM in conjunction with a DBT program on outcomes associated with CAI, including pain and disability, range of motion (ROM), and dynamic postural control.

Design:

Pretest/posttest, repeated measures.

Setting:

High school and a Division I mid-Atlantic university.

Participants:

Thirty-six healthy, physically active individuals (5 female, 31 male; age 17.7 ± 1.9 y; height 175.3 ± 14.6 cm) with a history of CAI as determined by an ankle-instability questionnaire volunteered to be in this study.

Interventions:

Subjects were randomly assigned to 1 of 3 intervention groups: both treatments (DBT/GISTM, n = 13), DBT and a sham GISTM treatment (DBT/GISTM-S, n = 12), or DBT and control—no GISTM (DBT/C, n = 11). All groups participated in a 4-wk DBT program consisting of low-impact and dynamic activities that was progressed from week to week. The DBT/GISTM and DBT/GISTM-S groups received the GISTM treatment or sham treatment twice a week for 8 min before performing the DBT program. Pretest and posttest measurements included the Foot and Ankle Ability Measure (FAAM), FAAM Sport, the visual analog scale (VAS), ankle ROM in 4 directions, and the Star Excursion Balance Test (SEBT) in 3 directions.

Main Outcome Measures:

FAAM and FAAM-Sport scores, VAS, goniometric ROM (plantar flexion, dorsiflexion, inversion, eversion), and SEBT (anterior, posteromedial, posterolateral).

Results:

Subjects in all groups posttest demonstrated an increase in FAAM, FAAM Sport, ROM, and SEBT in all directions but not in VAS, which decreased. No other results were significant.

Conclusion:

For subjects with CAI, dynamic postural control, ROM, pain and disability improved pretest to posttest regardless of group membership, with the largest effects found in most measures in the DBT/GISTM group.

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Improvement in Dynamic Balance and Core Endurance After a 6-Week Core-Stability-Training Program in High School Track and Field Athletes

Michelle A. Sandrey and Jonathan G. Mitzel

Context:

Core training specifically for track and field athletes is vague, and it is not clear how it affects dynamic balance and core-endurance measures.

Objective:

To determine the effects of a 6-week core-stabilization-training program for high school track and field athletes on dynamic balance and core endurance.

Design:

Test–retest.

Setting:

High school in north central West Virginia.

Participants:

Thirteen healthy high school student athletes from 1 track and field team volunteered for the study.

Interventions:

Subjects completed pretesting 1 wk before data collection. They completed a 6-wk core-stabilization program designed specifically for track and field athletes. The program consisted of 3 levels with 6 exercises per level and lasted for 30 min each session 3 times per week. Subjects progressed to the next level at 2-wk intervals. After 6 wk, posttesting was conducted

Main Outcome Measures:

The subjects were evaluated using the Star Excursion Balance Test (SEBT) for posteromedial (PM), medial (M), and anteromedial (AM) directions; abdominal-fatigue test (AFT); back-extensor test (BET); and side-bridge test (SBT) for the right and left sides.

Results:

Posttest results significantly improved for all 3 directions of the SEBT (PM, M, and AM), AFT, BET, right SBT, and left SBT. Effect size was large for all variables except for PM and AM, where a moderate effect was noted. Minimal-detectable-change scores exceeded the error of the measurements for all dependent variables.

Conclusion:

After the 6-wk core-stabilization-training program, measures of the SEBT, AFT, BET, and SBT improved, thus advocating the use of this core-stabilization-training program for track and field athletes.

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The Effects of Eversion Fatigue on Frontal Plane Joint Position Sense in the Ankle

Michelle A. Sandrey and Timothy E. Kent

Context:

There is limited information on fatigue of the evertors on frontal plane joint position sense (JPS).

Objective:

To examine the effects of isokinetic concentric-eccentric fatigue of the evertors on frontal plane JPS of the ankle.

Design:

A 2 × 4 factorial design.

Setting:

Research Laboratory.

Patients or Other Participants:

40 male and female healthy subjects.

Interventions:

JPS was tested at 10° and 20° of inversion and 5° and 10° of eversion in a nonfatigued/fatigued condition. After fatigue of evertors was determined on an isokinetic device, post fatigue testing of JPS occurred.

Main Outcome Measures:

JPS absolute error (AE) for inversion and eversion.

Results:

Main effect for condition and angle were significant with pre/post fatigue. There were overestimation of angles postfatigue with AE greater at 20° of inversion (P = .003), followed by 10° of inversion (P < .001), 10° of eversion (P = .005), and 5° of eversion (P = .005).

Conclusion:

When the ankle evertors were fatigued, the AE for JPS was significantly higher at all test angles.

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The Effect of Hip Joint Mobilizations Using a Mobilization Belt on Hip Range of Motion and Functional Outcomes

Alex Brun and Michelle A. Sandrey

Context: Joint mobilizations have been studied extensively in the literature for the glenohumeral joint and talocrural joint (ankle). Consequently, joint mobilizations have been established as an effective means of improving range of motion (ROM) within these joints. However, there is a lack of extant research to suggest these effects may apply within another critical joint in the body, the hip. Objective: To examine the immediate effects of hip joint mobilizations on hip ROM and functional outcomes. Secondarily, this study sought to examine the efficacy of a novel hip mobilization protocol. Design: A prospective exploratory study. Setting: Two research labs. Patients or Other Participants: The study included 19 active male (n = 8) and female (n = 11) college students (20.56 [1.5] y, 171.70 [8.6] cm, 72.23 [12.9] kg). Interventions: Bilateral hip mobilizations were administered with the use of a mobilization belt. Each participant received hip joint mobilization treatments once during 3 weekly sessions followed immediately by preintervention and postintervention testing/measurements. Testing for each participant occurred once per week, at the same time of day, for 3 consecutive weeks. Hip ROM was the first week, followed by modified Star Excursion Balance Test the second week and agility T test during the third week. Main Outcomes Measures: Pretest and posttest measurements included hip ROM for hip flexion, extension, abduction, adduction, internal and external rotation, as well as scores on the modified Star Excursion Balance Test (anterior, posterolateral, and posteromedial directions) and agility T test. Results: A significant effect for time was found for hip adduction, internal and external rotation ROM, as well as the posterolateral and posteromedial directions of the modified Star Excursion Balance Test. A separate main effect for both limbs was found for adduction and internal rotation ROM. Conclusion: Isolated immediate changes in ROM and functional outcomes were evident. Further evaluation is needed.