COMPREHENSIVE POST‐ARTHROSCOPIC MANAGEMENT OF A MIDDLE‐AGED ADULT WITH GLENOHUMERAL OSTEOARTHRITIS: A CASE REPORT

Comprehensive Arthroscopic Management (CAM) is a new glenohumeral debridement procedure developed as a joint preserving alternative to total shoulder arthroplasty (TSA). The procedure consists of several arthroscopic components including: A. scar tissue and chondral debridement, B. synovectomy, C. inferior humeral osteoplasty, D. capsular release, E. axillary nerve decompression, and F. tenodesis of the long head of the biceps. In this case, an active, middle age patient who failed physical therapy treatment and corticosteroid injections was evaluated and diagnosed with glenohumeral osteoarthritis. Anterior‐ posterior (AP) and axillary radiographs showed grade IV changes of the articular cartilage, confirming the diagnosis. The patient was not an ideal candidate for TSA because of her age, activity level, and concern for implant survival; therefore surgical intervention was performed using the CAM procedure. After the surgery, the patient demonstrated increased joint space as shown using radiographic imaging. The patient underwent intensive postoperative rehabilitation with a heavy emphasis on joint range of motion (ROM) and capsular mobility. By eight weeks she achieved 85% active ROM compared to her uninvolved shoulder, and a 55% improvement on the Pennsylvania Shoulder Score. Radiographic imaging provided an understanding of the severity of the arthritic changes present in this patient, identified the limited potential of continued conservative management, and showed structural changes that may be correlated with improved function following the surgical intervention. For patients less than 55 years of age diagnosed with severe glenohumeral osteoarthritis, the CAM procedure and intensive, motion focused therapy presents a promising treatment combination.

Level of Evidence:

IIIb     

A SURVEY OF EXERCISE‐RELATED LEG PAIN IN COMMUNITY RUNNERS

Purpose/Background:

Exercise‐related leg pain (ERLP) is a common problem in runners. The purposes of this study were to 1) report ERLP occurrence among adult community runners; 2) determine ERLP impact on daily activities; and 3) determine if there is a relationship between ERLP occurrence and selected potential risk factors including sex, age, years of running, ERLP history, body mass index (BMI), orthotic use, menstrual function, and training variables.

Methods:

Community runners registered for a local race were invited to complete a questionnaire including demographics and potential risk factors. Analyses of differences (t‐test) and relationships (Chi‐square) were conducted and relative risk (RR) values were calculated.

Results:

225 registered runners (105 male, 120 female) participated; 63.6% reported ERLP history, and 35.1% reported ERLP in the 3 months preceding the race with bilateral medial ERLP as the most common presentation. Of the 79 runners who experienced ERLP during the 3 months preceding the race, ERLP caused 41.8% to reduce their running and interfered with walking or stair climbing in < 10%. Chi square analyses showed no significant association of sex, menstrual function, orthotic use, or BMI with ERLP occurrence. Significant associations were observed between ERLP history and ERLP occurrence in the previous year (RR=3.39; 2.54‐4.52 95% CI), and between ERLP in the 3 months preceding the race and both years running and training mileage. Greater ERLP occurrence was observed in runners with less than 3 years experience (RR = 1.53; 1.08‐2.17 95% CI) and runners who ran fewer than 15 miles/week (RR = 1.47; 1.04‐2.08 95% CI). Those runners with < 3 years running experience and a race pace of 9 min/mile or > were at greater risk for ERLP when compared to other participants (RR=1.53; 1.07‐2.18 95% CI).

Conclusion:

Interfering ERLP was common among this group of community runners. Risk factors included ERLP history, training mileage < 15 miles/week, and < 3 years running experience. Further investigation is warranted to identify factors which may increase a community runner''s risk of developing ERLP.

Level of Evidence:

2b.     

EFFECTS OF A SEASON OF SUBCONCUSSIVE CONTACT ON CHILD‐ SCAT3 SCORES IN 8‐12 YEAR‐OLD MALE ATHLETES

Background

Each year, over 173,000 children and adolescents visit emergency departments due to sports and recreation related concussions, an increase of 60% over the last decade due to the rise in the number of children participating in sport. While numerous authors have sought to address the epidemiology of concussions across multiple age groups who participate in contact sports, a recent review of literature did not reveal a substantial amount of published articles that addressed the issue of subconcussive contact. Multiple tools have been developed to assess acute episodes of concussion. Among the assessment protocols many include an assessment of balance, short and long term memory recall, and balance. The Child‐SCAT3 was designed specifically to evaluate concussions in children 5‐12 years of age.

Objective

The purpose of this study was to determine the effect of a season of subconcussive contact on Child‐SCAT3 scores in 8‐12 year old males compared to their age matched peers who participated in non‐contact sports. A secondary purpose was to evaluate how scores of the sub‐ components of the Child‐SCAT3 compare between contact and non‐contact athletes.

Design

A prospective cohort study was performed of 71 male athletes (58 football, 13 baseball) ages 8‐12 (contact mean age 10.30 years, SD 1.20; non‐contact mean age 10.03 years, SD 1.26) over the course of a season.

Methods

Portions of The Child‐SCAT3 were administered and scored in pre‐adolescent athletes prior to and following a season of participation in football (contact sport group) and baseball (non‐contact sport group). The outcome measures of interest included the portions related to Cognitive ability, Balance, and Coordination.

Results

No statistically significant differences were found in group, time or time and group interaction for any of the utilized portions of the Child‐SCAT3. Statistically significant differences were found between groups for preseason cognitive orientation and postseason immediate memory. Cognitive orientation and coordination were also found to be statistically significantly improved across both groups over the course of the season.

Limitations

This study was potentially limited by the number of control subjects tested.

Conclusions

A season of subconcussive contact in football was not detrimental to cognitive and balance scores on the Child‐SCAT3.

Level of Evidence

3     

EFFECTS OF A DRY‐LAND STRENGTHENING PROGRAM IN COMPETITIVE ADOLESCENT SWIMMERS

Background

Shoulder pain is common in competitive young swimmers. A relationship between shoulder strength and shoulder soreness in competitive young swimmers may indicate need for strengthening.

Purpose

To determine if a shoulder exercise program will improve shoulder strength and decrease pain in competitive young swimmers.

Study Design

Randomized control

Methods

Participants (10 control, 11 experimental), randomly assigned to a control or experiment group, completed the 12 week program. Strength was measured prior to the study for shoulder flexion, abduction, external rotation, internal rotation, and extension on the dominant arm using handheld dynamometry. The experimental group was then assigned exercises to be performed three times per week. The control group was instructed not to perform the exercises. All participants were re‐tested at six and twelve weeks following initiation of the study.

Results

The changes in strength for each muscle group and pain were compared between groups using a mixed design two‐way ANOVA. The experimental group significantly increased external rotation strength compared to the control group. Shoulder soreness was not significantly different between groups.

Conclusion

Adolescents who perform shoulder strengthening significantly increased their external rotation strength compared to adolescents who only participated in a regular swimming regimen.     

VALIDATION OF A NEW METHOD FOR ASSESSING SCAPULAR ANTERIOR‐POSTERIOR TILT

Background:

Electromagnetic tracking systems have enabled some investigators and clinicians to measure tri‐planar scapular motion; yet, they are not practical and affordable options for all clinicians. Currently, the ability to affordably quantify scapular motion is limited to monitoring only the motion of scapular upward rotation, with use of a digital inclinometer.

Hypothesis/Purpose:

The objective of this study was to determine the criterion‐related validity of a modified digital inclinometer when used to measure the motion of scapular anterior‐posterior (AP) tilt.

Materials & Methods:

Thirteen volunteers, free from any history of shoulder injury, reported for a single testing session. Each subject underwent a brief shoulder and posture examination in order to confirm the absence of pathology. Subjects actively performed clinically relevant amounts of humeral elevation in the scapular plane while in a seated position. An electromagnetic tracking system (Ascension Technology, Burlington, VT) and a modified inclinometer (Pro 360, Baseline®, Fabrication Enterprises, White Plains, NY) were used to acquire scapular AP tilt over the same shoulder motions. Criterion‐related validity was determined using Pearson Product Moment correlations.

Results:

Correlation analyses revealed significant moderate to good associations (r = 0.63 to 0.86, p < 0.01) between scapular AP tilt measures obtained with a digital inclinometer and an electromagnetic tracking system.

Conclusions

A modified digital inclinometer is a moderately valid device to use for the quantification of scapular AP tilt. Further study is warranted to establish reliability and to validate use of the device in patients with shoulder injury or pathology. The modified inclinometer expands the clinician''s ability to quantify scapular kinematic motion during the clinical evaluation and rehabilitation process.

Level of Evidence:

Level 3     

IMMEDIATE EFFECTS OF A DYNAMIC ROTATION‐SPECIFIC WARM‐UP ON X‐FACTOR AND X‐FACTOR STRETCH IN THE AMATEUR GOLFER

Background

Recent evidence suggests performing a warm‐up prior to golf can improve performance and reduce injuries. While some characteristics of effective golf warm‐ups have been determined, no studies have explored the immediate effects of a rotational‐specific warm‐up with elements of motor control on the biomechanical aspects of the full X‐Factor and X‐Factor Stretch during the golf swing.

Methods

Thirty‐six amateur golfers (mean ± SD age: 64 ± 8 years old; 75% male) were randomized into a Dynamic Rotation‐Specific Warm‐up group (n=20), or a Sham Warm‐up group (n=16). X‐Factor and X‐Factor Stretch were measured at baseline and immediately following the warm‐up. Mixed model ANCOVAs were used to determine if a Group*Time interaction existed for each variable with group as the between‐subjects variable and time as the within‐subjects variable.

Results

The mixed model ANCOVAs did not reveal a statistically significant group*time interaction for X‐Factor or X‐Factor Stretch. There was not a significant main effect for time for X‐Factor but there was for X‐Factor Stretch. These results indicate that neither group had a significant effect on improving X‐Factor, however performing either warm‐up increased X‐Factor Stretch without significant difference between the two.

Conclusions

The results of this study suggest that performing the Dynamic Rotation‐Specific Warm‐up did not increase X‐Factor or X‐Factor Stretch when controlled for age compared to the Sham Warm‐up. Further study is needed to determine the long‐term effects of the Dynamic Rotation‐Specific Warm‐up on performance factors of the golf swing while examining across all ages.

Level of Evidence

2b     

INTRA‐RATER AND INTER‐RATER RELIABILITY OF THE FIVE IMAGE‐BASED CRITERIA OF THE FOOT POSTURE INDEX‐6

Purpose/Background:

The Foot Posture Index‐6 (FPI‐6) is considered a simple quantification tool to assess static foot alignment. Palpation of the foot is required for assessment of one of the six criteria that comprise the FPI‐6; the remaining five criteria may be evaluated using still‐frame photographs. Using only the image‐based criteria may allow multiple clinicians to evaluate large groups of patients quickly. Reliability using only these five image‐based criteria has not been established. The purposes of the current study were to establish the inter‐ and intra‐rater reliability using five image‐based criteria from the Foot Posture Index‐6 (FPI‐6) as well as to examine the agreement between the raters in identifying foot type using the composite five FPI scores.

Methods:

Forty participants (23 females, 17 males; 23.67 ± 8.49 years; 64.59 ± 14.43 kg; 166.07 ± 11.79 cm) volunteered for this study. An investigator took three photos with a digital camera of the medial longitudinal arch, posterior ankle, and of the talonavicular joint approximately 45° from the posterior calcaneus for both right and left feet. Two investigators assessed the five image‐based criteria of the FPI‐6 for both feet of 40 participants on three occasions separated by a day. Inter‐and intra‐rater reliability were assessed with Intraclass Correlation Coefficients (ICC_3,2). The amount of agreement for classification of foot posture type between the two raters was assessed with Cohen''s kappa coefficient. Significance was set a priori at P < 0.05.

Results:

The inter‐rater reliability was poor to moderate for all three sessions (ICC_3,2 = 0.334‐0.634). For the foot posture classification, the amount of agreement between two raters was poor for left (κ= 0.12) and right (κ= 0.19) feet. The intra‐rater reliability was excellent for left (ICC_3,2=0.956) and right feet (ICC_3,2=0.959).

Conclusions:

Excellent intra‐rater and poor to moderate inter‐rater reliability was found using only the five image‐based criteria of the FPI‐6. However, the classification of foot posture did not improve the amount of agreement between raters. Therefore, caution is needed when interpreting FPI scores from five image‐based criteria.

Levels of Evidence:

3b     

SIDELINE MANAGEMENT OF ACUTE DISLOCATION OF THE GLENOHUMERAL JOINT‐ A UNIQUE APPROACH TO ATHLETE SELF‐REDUCTION

The acute anterior dislocation of the glenohumeral joint (GHJ) poses a challenge to sports medicine providers at all levels and in all settings. This macrotraumatic injury occurs in athletes who participate in a wide variety of sports, most typically as a result of contact or collision mechanisms. Quick and effective relocation of the GHJ is an important skill for on the sideline or on the field management of this type of dislocation when appropriate and allowable by facility protocol. This clinical suggestion describes one possible technique for athlete self‐reduction that may be appropriate in some circumstances. This is in contrast to forcible reduction by the health professional, which is outside of the scope of this clinical commentary.

Level of Evidence:

5     

COMPARING THE EFFECTS OF SELF‐MYOFASCIAL RELEASE WITH STATIC STRETCHING ON ANKLE RANGE‐OF‐MOTION IN ADOLESCENT ATHLETES

Background:

Increased flexibility is often desirable immediately prior to sports performance. Static stretching (SS) has historically been the main method for increasing joint range‐of‐motion (ROM) acutely. However, SS is associated with acute reductions in performance. Foam rolling (FR) is a form of self‐myofascial release (SMR) that also increases joint ROM acutely but does not seem to reduce force production. However, FR has never previously been studied in resistance‐trained athletes, in adolescents, or in individuals accustomed to SMR.

Objective:

To compare the effects of SS and FR and a combination of both (FR+SS) of the plantarflexors on passive ankle dorsiflexion ROM in resistance‐trained, adolescent athletes with at least six months of FR experience.

Methods:

Eleven resistance‐trained, adolescent athletes with at least six months of both resistance‐training and FR experience were tested on three separate occasions in a randomized cross‐over design. The subjects were assessed for passive ankle dorsiflexion ROM after a period of passive rest pre‐intervention, immediately post‐intervention and after 10, 15, and 20 minutes of passive rest. Following the pre‐intervention test, the subjects randomly performed either SS, FR or FR+SS. SS and FR each comprised 3 sets of 30 seconds of the intervention with 10 seconds of inter‐set rest. FR+SS comprised the protocol from the FR condition followed by the protocol from the SS condition in sequence.

Results:

A significant effect of time was found for SS, FR and FR+SS. Post hoc testing revealed increases in ROM between baseline and post‐intervention by 6.2% for SS (p < 0.05) and 9.1% for FR+SS (p < 0.05) but not for FR alone. Post hoc testing did not reveal any other significant differences between baseline and any other time point for any condition. A significant effect of condition was observed immediately post‐intervention. Post hoc testing revealed that FR+SS was superior to FR (p < 0.05) for increasing ROM.

Conclusions:

FR, SS and FR+SS all lead to acute increases in flexibility and FR+SS appears to have an additive effect in comparison with FR alone. All three interventions (FR, SS and FR+SS) have time courses that lasted less than 10 minutes.

Level of evidence:

2c     

TEST‐RETEST CONSISTENCY OF A POSTURAL SWAY ASSESSMENT PROTOCOL FOR ADOLESCENT ATHLETES MEASURED WITH A FORCE PLATE

Purpose/Background:

Postural control assessments can provide a powerful means of detecting concussion‐related neurophysiological abnormalities and are considered an important part of the concussion management processes. Studies with college athletes indicate that postural sway analyzed using complexity metrics may provide a sensitive and novel way to detect post‐concussion postural control impairments. The purpose of this study was to determine if a postural sway assessment protocol (PSAP) measured using a force plate system can serve as a reliable assessment tool for adolescent athletes.

Methods:

The short‐term and long‐term test‐retest reliability of the PSAP was examined in a group of adolescent female athletes under eyes open and eyes closed conditions. Detrended fluctuation analysis was used to evaluate the complexity of the times series data (i.e., degree of self‐similarity across time scales). Conventional measures of standard deviation and total path length (distance traveled by the center‐of‐pressure) were also assessed.

Results:

The complexity and conventional measures generally demonstrated good reliability coefficients for short‐term and long‐term test‐retest reliability with both eyes open and eyes closed conditions. Intra‐class Correlation Coefficient (ICC) values ranged from .38‐.90 The highest ICC values corresponded with the short‐term reliability for the eyes open condition, while the lower ICC values corresponded with the long‐term reliability for the eyes closed condition.

Conclusions:

The results of this study indicate that the PSAP demonstrated good short‐term and long‐term test‐retest reliability. In addition, no evidence of learning effects was elicited through this study. Future studies should further explore the validity and feasibility of the use of this protocol for different age groups, different types of athletes, and longitudinal evaluations of post‐concussion impairments.

Clinical Relevance:

This study provides preliminary support for the utility of a postural sway assessment protocol measured using a force plate for use with adolescent athletes.

Level of Evidence:

Level III     

COMPARISON OF THE EFFECTS OF AN EIGHT‐WEEK PUSH‐UP PROGRAM USING STABLE VERSUS UNSTABLE SURFACES

Background and Purpose:

Recently, the trend among physical training and rehabilitation professionals is the use of resistance exercise on unstable equipment in order to increase the effort of the agonist and stabilizing muscles. It is unknown if performing exercises on unstable surfaces provides a greater training stimulus as compared to training on a stable training surface. Therefore, the purpose of this research was to compare the effect that push‐up training on stable and unstable surfaces had on strength performance in healthy young men.

Methods:

Thirty subjects with experience in resistance training participated in push‐up training two days per week for eight weeks on one of three different surfaces: the floor (Tp), the T‐Bow® (TBp) or the BOSU® (Bp).

Results:

Strength, as measured by one repetition maximum (1‐RM) and muscle endurance, as measured by number of pushups performed did not improve significantly (p>0.05) for any of the intervention groups.

Conclusions:

The addition of unstable surfaces in push‐up training does not provide greater improvement in muscular strength and endurance than push up training performed on a stable surface in young men.

Levels of Evidence:

3b     

THE EFFECTS OF ANTICIPATION ON THE MECHANICS OF THE KNEE DURING SINGLE‐LEG CUTTING TASKS: A SYSTEMATIC REVIEW

Background

ACL injuries are common in sports, which has resulted in the development of risk screening and injury prevention programs to target modifiable neuromuscular risk factors. Previous studies which have analyzed single‐leg cutting tasks have reported that the anticipation status of the task (pre‐planned vs. unanticipated) has a significant effect on the mechanics of the knee.

Hypothesis/Purpose

The purpose of this systematic review is to assess the effect of anticipation on the mechanics of the knee in the sagittal, frontal, and transverse planes during tasks which athletes frequently perform during competition.

Study Design

Systematic Review

Methods

The following databases were searched using relevant key words and search limits: Pub Med, SPORTDiscus, CINAHL, and Web of Science. A modified version of the Downs and Black checklist was used to assess the methodological quality of the articles by two independent reviewers.

Results

284 articles were identified during the initial database search. After a screening process, 34 articles underwent further review. Of these articles, 13 met the criteria for inclusion in this systematic review.

Conclusions

It appears that tasks which do not allow a subject to pre‐plan their movement strategy promote knee mechanics which may increase an athlete''s risk of injury.

Clinical Relevance

Clinicians involved in the development and implementation of ACL injury risk screening and prevention programs may want to consider incorporating tasks which do not allow time for pre‐planning. These unanticipated tasks may more closely mimic the demands of the sports environment and may promote mechanics which increase the risk of injury.

Level of Evidence

Level 1b     

THE EFFICACY OF TAPING FOR ROTATOR CUFF TENDINOPATHY: A SYSTEMATIC REVIEW AND META‐ANALYSIS

Background

Rotator cuff (RC) tendinopathy is a highly prevalent musculoskeletal disorder. Non‐elastic taping (NET) and kinesiology taping (KT) are common interventions used by physiotherapists. However, evidence regarding their efficacy is inconclusive.

Objective

To examine the current evidence on the clinical efficacy of taping, either NET or KT, for the treatment of individuals with RC tendinopathy.

Study Design

Systematic review and meta‐analysis

Methods

A literature search was conducted in four bibliographical databases to identify randomized controlled trials (RCT) that compared NET or KT to any other intervention or placebo for treatment of RC tendinopathy. Internal validity of RCTs was assessed with the Cochrane Risk of Bias tool. A qualitative or quantitative synthesis of evidence was performed.

Results

Ten trials were included in the present review on overall pain reduction or improvement in function. Most RCTs had a high risk of bias. There is inconclusive evidence for NET, either used alone or in conjunction with another intervention. Based on pooled results of two studies (n=72), KT used alone resulted in significant gain in pain free flexion (MD: 8.7 ° 95%CI 8.0 ° to 9.5 °) and in pain free abduction (MD: 10.3 ° 95%CI 9.1 ° to 11.4 °). Based on qualitative analyses, there is inconclusive evidence on the efficacy of KT when used alone or in conjunction with other interventions on overall pain reduction or improvement in function.

Conclusion

Although KT significantly improved pain free range of motion, there is insufficient evidence to formally conclude on the efficacy of KT or NET used alone or in conjunction with other interventions in patients with RC tendinopathy.

Level of Evidence

Therapy, level 1a     

THE VALIDITY OF 2‐DIMENSIONAL MEASUREMENT OF TRUNK ANGLE DURING DYNAMIC TASKS

Purpose/Background:

Injury screening methods that use three‐dimensional (3D) motion analysis accurately predict the risk of injuries, yet are expensive. There is great need for valid, cost‐effective techniques that can be used in large‐scale assessments. Utilizing two‐dimensional (2D) measures of lateral trunk motion may identify athletes at risk for lower extremity injury. The purpose of this research was to determine the strength of the relationships between 2D and 3D calculations of lateral trunk angle for female athletes performing a single‐leg cross drop landing.

Methods:

Twenty‐one high‐school female volleyball players performed a single‐leg cross drop landing onto a force plate. The 3D angular trunk motion was calculated, and four different 2D measures of lateral trunk angle were calculated for both left and right landing leg. A one‐way multivariate analysis of variance was used to compare 2D measures to the 3D measurements, and Pearson correlations were used to determine the strength of these relationships.

Results:

The angle formed by the medial shoulder joint center, medial ASIS, and vertical line (LTA4) was similar to the 3D measures of lateral trunk angle during landing (r‐values ≥ 0.62; p‐values ≤ 0.003; mean differences, ‐1.0° to 1.2°).

Conclusions:

Given the recent focus on the role of the trunk in lower extremity injury, using the 2D LTA4 assessment may expand existing assessments into a composite model that can more accurately assess female athletes at risk for injury than models that do not include trunk analysis.

Clinical Relevance:

Existing models that enable clinicians to effectively identify female athletes at risk for lower extremity injury may be enhanced by including accurate assessments of lateral trunk motion.     

CLINICAL EFFECTIVENESS OF KINESIOLOGICAL TAPING ON PAIN AND PAIN‐FREE SHOULDER RANGE OF MOTION IN PATIENTS WITH SHOULDER IMPINGEMENT SYNDROME: A RANDOMIZED,DOUBLE BLINDED,PLACEBO‐CONTROLLED TRIAL

Background:

Kinesiological taping (KT) is commonly used to improve symptoms associated with musculoskeletal disorders. However, review of the literature revealed minimal evidence to support the use of KT in treatment of shoulder disorders and controversy exists regarding the effect of KT in patients with shoulder impingement syndrome (SIS).

Objective:

The purpose of this study was to investigate the effect of KT on pain intensity during movement, pain experienced during the night (nocturnal pain), and pain‐free shoulder range of motion (ROM) immediately after taping, after three days and after one week, in patients with SIS.

Design:

Randomized, Double blinded, Placebo‐controlled design.

Participants:

A total of 30 patients with SIS participated in this study. Patients were assigned randomly to a control (N = 15) and an experimental group (N = 15).

Methods:

The patients in the experimental group received a standardized therapeutic KT. The standardized, placebo neutral KT was applied for control group. KT was applied two times with a three day interval, remaining on during the 3 day interval. Both groups followed the same procedures. Pain‐free active ROM during shoulder abduction, flexion, and elevation in the scapular plane was measured. Visual analogue scale (VAS) for pain intensity during movement or nocturnal pain and was assessed at baseline, immediately after KT, after three days, and one week after KT.

Results:

The result of repeated measures ANOVA showed a significant change in pain level during movement, nocturnal pain, and pain‐free ROM (p = 0.000) after KT in the experimental group. In the ANCOVA, controlling for pre‐test scores, change in pain level at movement (p = 0.009) and nocturnal pain (p = 0.04) immediately after KT was significantly greater in the experimental group than in control group. There was no significant difference in ROM measures (p > 0.05) between groups immediately after KT. No significant differences were found between the two groups in the after one week measurements of pain intensity and shoulder ROM.

Conclusion:

The KT produces an immediate improvement in the pain intensity at movement and nocturnal pain in patients with SIS.

Level of Evidence:

1     

A STUDY OF THE PROTEOLYTIC FERMENTS OF THE LARGE LYMPHOCYTES IN A CASE OF ACUTE LEUK?MIA

The leucocytes of the blood of normal individuals and of patients showing a marked polymorphonuclear leucocytosis contain enzymes capable of digesting coagulated blood serum in neutral, alkaline or acid solutions. The cells in pus that is composed principally of polymorphonuclear leucocytes and the leucocytes of the circulating blood in myelogeneous leukæmia contain similar proteolytic enzymes, which act best when the reaction is alkaline. The leucocytes of the circulating blood and of the enlarged lymph nodes from a case of large cell, acute, lymphatic leukæmia contain proteolytic enzymes that act qualitatively in much the same way as the leucocytes of pus and as the white corpuscles of the blood in myelogenous leukæmia. These large lymphocytes in acute lymphatic leukæmia can be differentiated biologically from the small lymphocytes in chronic lymphatic leukæmia which possess no proteolytic enzymes, and from the large endothelioid cells of the hyperplastic lymph glands which are proteolytic only in the presence of acid. These results seem to show that the large cells of the so-called acute lymphatic leukæmia are not true lymphocytes, but are nearly related to the granular myelocytes and should probably be considered as the forerunners to these cells.