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Andreas Schweizer and Robert Hudek

The aim was to investigate differences of the kinetics of the crimp and the slope grip used in rock climbing. Nine cadaver fingers were prepared and fixated with the proximal phalanx in a frame. The superficial (FDS) and deep (FDP) flexor tendons were loaded selectively and together with 40 N in the crimp grip (PIP joint flexed 90°/DIP joint hyperextended) and the slope grip position (<25° flexed/50° flexed respectively). Five different grip sizes were tested and the flexion force which was generated to the grip was measured. In the crimp grip the FDP generated more flexion force in small sized holds whereas the FDS generated more force in the larger holds. During the slope grip the FDP was more effective than the FDS. While both tendons were loaded, the flexion force was always greater during crimp grip compared with the slope grip. The FDP seems to be most important for very small holds using the crimp grip but also during slope grip holds whereas the FDS is more important for larger flat holds.

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Alison R. Valier, Ryan S. Averett, Barton E. Anderson and Cailee E. Welch Bacon

Clinical Scenario:

Shoulder pain is a common musculoskeletal complaint and is often associated with shoulder impingement. The annual incidence of shoulder pain is estimated to be 7% of all injuries, and is the third-most-common type of musculoskeletal pain. Initial treatment of shoulder impingement follows a conservative plan and emphasizes rehabilitation programs as opposed to surgical interventions. Shoulder rehabilitation programs commonly focus on strengthening the muscles of the shoulder complex and, more specifically, the rotator cuff. The rotator cuff is a primary dynamic stabilizer of the glenohumeral joint, using both eccentric and concentric contractions. The posterior rotator cuff, including teres minor and infraspinatus, works eccentrically to decelerate the arm during overhead throwing. Exercises to strengthen the rotator cuff and the surrounding dynamic stabilizers of the shoulder girdle vary and include activities such as internal and external rotation, full-can lifts, and rhythmic stabilizations. Traditionally, shoulder rehabilitation programs have focused on isotonic concentric contractions. Common strengthening exercises typically involve movements that result in shortening the muscle length while simultaneously loading the muscles. However, recent attention has been given to eccentric exercises, which involve lengthening of the muscle during loading, for the treatment of a variety of different tendinopathies including those of the Achilles and patellar tendons. The eccentric, or lengthening, motion is thought to be beneficial for people who are involved in activities that place eccentric stress on their shoulder, such as overhead throwers. Based on studies related to the Achilles tendon, eccentric exercise may positively influence the tendon structure by increasing collagen production and decreasing neovascularization. The changes that occur as a result of eccentric exercises may improve function, strength, and performance and decrease pain more than concentric programs, producing better patient outcomes. Although eccentric strength training has been shown to provide strength gains, there are no clear guidelines as to the inclusion of this form of exercise training in shoulder rehabilitation programs for the purposes of improving function and decreasing pain.

Focused Clinical Question:

Does adding an eccentric-exercise component to the rehabilitation program of patients with shoulder impingement improve shoulder function and/or decrease pain?

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Renato Semadeni and Kai-Uwe Schmitt

Objective:

In this study a numerical model of a skier was developed to investigate the effect of different rehabilitation strategies after anterior cruciate ligament (ACL) rupture.

Methods:

A computer model using a combined finite-element and multibody approach was established. The model includes a detailed representation of the knee structures, as well as all major leg muscles. Using this model, different strategies after ACL rupture were analyzed.

Results:

The benefit of muscle training to compensate for a loss of the ACL was shown. The results indicate that an increase of 10% of the physiological cross-sectional area has a positive effect without subjecting other knee structures to critical loads. Simulating the use of a hamstring graft indicated increasing knee loads. A patellar-tendon graft resulted in an increase of the stress on the lateral collateral ligament.

Conclusion:

Muscle training of both extensors and flexors is beneficial in medical rehabilitation of ACL-deficient and ACL-reconstructed knees.

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Michael R. McCarthy, Barton P. Buxton, W. Douglas B. Hiller, James R. Doyle and Denis Yamada

In an attempt to quantify the current standards in surgical procedures and rehabilitation protocols utilized to treat patients with anterior cruciate ligament (ACL)-deficient knees, a 19-question survey was sent to members of the Hawaii Orthopedic Association. The findings indicated that only 54% (30/56) of the respondents were performing ACL reconstructions, of which 87% (26/30) were performing an intra-articular procedure and none were performing extra-articular procedures exclusively. The findings further indicate that 80% (24/30) of the 30 respondents performing ACL reconstructions were using an arthroscopically assisted, bone-tendon-bone autograft procedure. However, in marked contrast to the uniformity that existed concerning the surgical procedure, there was a drastic difference in the rehabilitation protocols and procedures that were recommended postoperatively. The most apparent differences in rehabilitation protocols existed in the utilization and initiation of open versus closed type kinetic chain exercises and activities.

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Allyson M. Carter, Stephen J. Kinzey, Linda F. Chitwood and Judith L Cole

Context:

Proprioceptive neuromuscular facilitation (PNF) is commonly used before competition to increase range of motion. It is not known how it changes muscle response to rapid length changes.

Objective:

To determine whether PNF alters hamstring muscle activity during response to rapid elongation.

Design:

2 X 2 factorial.

Setting:

Laboratory.

Participants:

Twenty-four women; means: 167.27 cm, 58.92 kg, 21.42 y, 18.41% body fat, 21.06 kg/m2 BMI.

intervention:

Measurements before and after either rest or PNF were compared.

Main Outcome Measures:

Average muscle activity immediately after a rapid and unexpected stretch, 3 times pretreatment and posttreatment, averaged into 2 pre-and post- measures.

Results:

PNF caused decreased activity in the biceps femoris during response to a sudden stretch (P = .04). No differences were found in semitendinosus activity (P = .35).

Conclusions:

Decreased muscle activity likely results from acute desensitization of the muscle spindle, which might increase risk of muscle and tendon injury.

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Kevin E. Wilk, James R. Andrews, William G. Clancy Jr., Heber C. Crockett and James W. O'Mara Jr.

Treatment of posterior cruciate ligament (PCL) injuries has changed considerably in recent years. This article discusses current rehabilitation for PCL disruptions in athletes. The treatment of PCL injuries varies somewhat based on the chronicity (acute vs. chronic) of injury and associated pathologies. The authors provide their treatment algorithm for the acute and chronic PCL-injured-knee patient. Nonoperative rehabilitation is discussed with a focus on immediate motion, quadriceps muscle strengthening, and functional rehabilitation. A discussion of the biomechanics of exercise is provided, with a focus on tibiofemoral shear forces and PCL strains. Surgical treatment is also discussed, with the current surgical approach being either the two-tunnel or the one-tunnel patellar tendon autograft procedure. The rehabilitation program after surgery is based on the healing constraints, surgical technique, biomechanics of the PCL during functional activities, and exercise. With the new changes in surgical technique and in the rehabilitation process, the authors believe that the outcome after PCL reconstruction will be enhanced.

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Benno M. Nigg, Gerald K. Cole and Gert-Peter Brüggemann

Impact forces have been speculated to be associated with the development of musculoskeletal injuries. However, several findings indicate that the concepts of “impact forces” and the paradigms of their “cushioning” may not be well understood in relation to the etiology of running injuries and that complex mechanisms may be responsible for injury development during running. The purposes of this paper are (a) to review impact mechanics during locomotion, (b) to review injuries and changes of biological tissue due to impact loading, and (c) to synthesize the mechanical and biological findings. In addition, directions for future research are discussed. Future research should address the development of noninvasive techniques to assess changes in the morphology and biochemistry of bone, cartilage, tendon, and ligaments; researchers should also try to simulate impact loading during activities such as running, focusing on the interaction of the various loading parameters that determine the acceptable windows of loading for biological tissues.

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Mark S. De Carlo, Kecia E. Sell, K. Donald Shelbourne and Thomas E. Klootwyk

It is well established that intra-articular anterior cruciate ligament reconstruction with autogenous bone-patellar tendon-bone graft provides satisfactory long-term stability. However, the rehabilitation programs employed following this surgical procedure have been a topic of considerable debate. This paper describes an accelerated rehabilitation protocol that is divided into four phases. The first phase encompasses the preoperative period, during which the patient will work to decrease swelling and restore range of motion and strength. The second phase involves Weeks 1 and 2 following surgery, with the patient emphasizing immediate terminal knee extension and weight bearing. The final two phases involve improving lower extremity strength and full return to daily and athletic activities. This accelerated rehabilitation protocol has resulted in an earlier return of range of motion and strength without compromising ligamentous stability.

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Sheri A. Hale

Objective:

To review the etiology of patellar tendinopathy as it relates to clinical management of chronic patellar-tendon disease in athletes.

Data Sources:

Information was gathered from a MEDLINE search of literature in English using the key words patellar tendinitis, patellar tendonitis, patellar tendinosis, patellar tendinopathy, and jumper’s knee.

Study Selection:

All relevant peer-reviewed literature in English was reviewed.

Data Synthesis:

The etiology of patellar tendinopathy is multifactorial, incorporating both intrinsic and extrinsic factors. Age, muscle flexibility, training program, and knee-joint dynamics have all been associated with patellar tendinopathy. The roles of gender, body morphology, and patellar mobility in patellar tendinopathy are unclear.

Conclusions:

The pathoetiology of patellar tendinopathy is a complex process that results from both an inflammatory response and degenerative changes. There is a tremendous need for research to improve our understanding of the pathoetiology of patellar tendinopathy and its clinical management.

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Geraldine L. Pellecchia, Holly Hamel and Peter Behnke

The purpose of this study was to compare an established protocol of modalities and transverse friction massage (MOD & TFM) with iontophoresis of dexamethasone and lidocaine (IONTO) in the treatment of patients with infrapatellar tendinitis. Thirty cases with infrapatellar tendinitis were randomly assigned to either the MOD & TFM or the IONTO intervention. Subjects still symptomatic after six sessions of intervention received the alternate treatment protocol. Four measures were used to assess patient status: a functional index questionnaire, a visual analog pain scale, a rating of tenderness with palpation of the involved tendon, and the number of step-ups needed to elicit pain. In response to the MOD & TFM intervention, only the number of step-ups performed to elicit pain showed significant improvement. All status measures improved significantly with the IONTO intervention. The results suggest that iontophoresis may be more effective and efficient in decreasing pain, reducing inflammation, and promoting healing in patients with infrapatellar tendinitis.