Prior history of anterior cruciate ligament (ACL) reconstruction is associated with a greater risk of subsequent ACL injury in female collegiate athletes

ObjectivesThe risk of a subsequent anterior cruciate ligament (ACL) sprain is greater in high school aged female athletes with prior history of ACL reconstruction (ACLR) than in age-matched controls. The risk of a subsequent ACL injury in female collegiate athletes with prior ACLR is unknown. The primary purpose of this study was to determine the relative risk of a subsequent ACL injury in female collegiate athletes with prior ACLR when compared to age-matched controls. The secondary purpose of this study was to evaluate the ability of jump and hop tests to discriminate ACL injury risk.DesignProspective cohort.MethodsThree hundred and sixty female collegiate athletes (mean age 19.3 ± 1.4 years) representing the following sports: volleyball, soccer, and basketball were recruited.Subjects reported prior history of ACLR and standing long jump (SLJ) and single-leg hop (SLH) scores were collected during the preseason. Noncontact time-loss ACL and lower quadrant (i.e., low back and lower extremities) injuries were tracked by university athletic trainers.ResultsFemale collegiate athletes with a prior history of ACLR were 6 times (RR = 6.8 [95% CI: 1.4, 32.9] p-value = 0.007) more likely to experience an ACL injury than controls. Suboptimal performance on a battery of tests (SLJ ≤ 79% height, (B) SLH ≤ 69% height) was associated with a greater risk of lower quadrant injury (RR = 1.6 [95% CI: 1.1, 2.4] p-value = 0.028); however performance on these tests was not associated with ACL injury.ConclusionsFemale collegiate athletes should be screened for history of ACLR.     

Intra-rater reliability,inter-rater reliability and minimal detectable change of the posterior shoulder endurance test in elite athletes

ObjectiveInvestigate intra-rater and inter-rater reliability of the posterior shoulder endurance test (PSET) and calculate minimal detectable change (MDC) to establish measurement properties and inform use of the PSET in practice.Study designTest-retest reliability. Setting: British Canoe Slalom National Training Centre.ParticipantsTwelve participants (7 male, 5 female; 22.5 ± 4.48 years; 73.4 ± 6.36 kg) were investigated by two physiotherapists with >10 years’ experience.Main outcome measureIntraclass correlation coefficients (ICC) were calculated for intra-rater reliability (ICC 3,1) and inter-rater reliability (ICC 2,1) and used to calculate MDC.ResultsIntra-rater reliability scores were 0.84 and 0.85 for rater A and B, respectively, with 95% confidence interval (CI) crossing moderate to excellent reliability for both raters (0.5–0.75 and > 0.9). Inter-rater reliability scores were 0.74 and 0.63 at baseline and follow-up, respectively, with 95% CI crossing poor to good reliability in both time points (<0.5 and >0.75). MDC95% for intra-rater scores was 6 repetitions, MDC95% for inter-rater scores was 8 repetitions at baseline and 9 repetitions at follow-up.ConclusionThe PSET has acceptable intra-rater reliability but further work is needed to narrow the CI to an appropriate level for inter-rater reliability. The MDC calculated helps clinicians interpret changes in tests scores.     

Feasibility and reliability of pain pressure threshold measurements in patellar tendinopathy

Patellar tendinopathy is a common and often difficult to treat overuse injury which is characterized by activity-related anterior knee and focal palpation tenderness of the patellar tendon. The clinical diagnosis is mainly based on clinical examination, in which the yardstick is a non-standardized manual palpation. To standardize this palpation procedure the use of an algometer seems applicable. The purpose of this study was to investigate the feasibility and reliability of the algometer in patellar tendinopathy. A cross sectional study was carried out.The algometer was applied to the patellar tendon in 20 asymptomatic volleyball players to measure the ‘normal’ pressure pain threshold. The inter-rater reliability was analyzed in 54 athletes with symptomatic patellar tendinopathy, the intra-rater reliability was analyzed in 48 athletes with symptomatic patellar tendinopathy. During the procedure difficulties were described, the SEM, intra class correlations and limits of agreement were determined using the Bland and Altman method. The feasibility of the algometer is adequate. The PPT of asymptomatic athletes differs significantly (p < .001) from athletes with a diagnosis of patellar tendinopathy. The inter-rater (ICC 0.93) and intra-rater (ICC 0.60) reliability of the pain pressure threshold are adequate to moderate. Although further research is warranted PPT algometry seems to be a feasible, reliable and useful tool in the diagnosis and treatment evaluation of athletes with patellar tendinopathy.     

Functional movement screen test: A reliable screening test for young elite ice hockey players

ObjectivesTo determine inter-rater and intra-rater reliability of the Functional Movement Screen (FMS) test among young elite hockey players.DesignReliability study.SettingInter-rater reliability was evaluated by two raters in the field. All performances were videotaped. Two other raters evaluated the videos once and then again 6 weeks later to determine intra-rater reliability. A weighted kappa statistic was used to analyze intra-rater and inter-rater reliability of each FMS sub-test, while an intra-class correlation coefficient (ICC) was calculated for the total score.ParticipantsTwenty-eight male hockey players aged 13–16.Main OutcomeFMS total and sub-tests scores.ResultsThe video raters demonstrated excellent intra-rater reliability for the total score, with an ICC of 0.96 (95% CI; 0.92–0.98) and 0.96 (95% CI; 0.91–0.98). The field raters achieved excellent inter-rater reliability for the total score, with an ICC of 0.96 (95% CI; 0.92–0.98). Sub-test analysis showed good agreement among all four raters for five of the seven main sub-tests.ConclusionFMS is a reliable test for young elite hockey players. Further research should be done to assess the predictive validity of the FMS test within this population so that physiotherapists may eventually use it as an injury prevention tool.     

Two-dimensional motion analysis of dynamic knee valgus identifies female high school athletes at risk of non-contact anterior cruciate ligament injury

Purpose

Female athletes are at greater risk of non-contact ACL injury. Three-dimensional kinematic analyses have shown that at-risk female athletes have a greater knee valgus angle during drop jumping. The purpose of this study was to evaluate the relationship between knee valgus angle and non-contact ACL injury in young female athletes using coronal-plane two-dimensional (2D) kinematic analyses of single-leg landing.

Methods

Two hundred ninety-one female high school athletes newly enrolled in basketball and handball clubs were assessed. Dynamic knee valgus was analysed during single-leg drop jumps using 2D coronal images at hallux–ground contact and at maximal knee valgus. All subjects were followed up for 3 years for ACL injury. Twenty-eight (9.6%) of 291 athletes had ACL rupture, including 27 non-contact ACL injuries. The injured group of 27 knees with non-contact ACL injury was compared with a control group of 27 randomly selected uninjured knees. The relationship between initial 2D movement analysis results and subsequent ACL injury was investigated.

Results

Dynamic knee valgus was significantly greater in the injured group compared to the control group at hallux–ground contact (2.1 ± 2.4 vs. 0.4 ± 2.2 cm, P = 0.006) and at maximal knee valgus (8.3 ± 4.3 vs. 5.1 ± 4.1 cm, P = 0.007).

Conclusion

The results of this study confirm that dynamic knee valgus is a potential risk factor for non-contact ACL injury in female high school athletes. Fully understanding the risk factors that increase dynamic knee valgus will help in designing more appropriate training and interventional strategies to prevent injuries in at-risk athletes.

Level of evidence

Prognostic studies, Level II.

     

Relationship between foot posture index and weight bearing computed tomography 3D biometrics to define foot alignment

BackgroundThe Foot Posture Index (FPI) was originally validated only against two dimensional radiographic imaging at the time of its inception since weight bearing three dimensional (3D) imaging did not exist. This technology is now widely available but it is not known if the FPI will continue to correlate well against it.Research question: How does the clinical assessment tool of FPI correlate against 3D biometrics of foot alignment assessed on weight bearing computerised tomography (WBCT)?MethodsThe FPI and 3D biometrics of 66 feet in 33 patients presenting to a single foot and ankle unit were assessed by two observers independently. All measurements were assessed for intra-rater and inter-rater reliability, and the association between the clinically assessed FPI and radiologically assessed 3D biometrics was identified.ResultsThe FPI demonstrated excellent intra-rater and good inter-rater reliability. All 3D biometric measures demonstrated excellent intra-rater and inter-rater reliability. A strong and significant correlation was identified between the FPI and 3D biometrics overall although subgroup analysis revealed the strength of association dropped when the hindfoot had a valgus alignment.SignificanceThis study confirmed that the FPI is a valid tool for assessing foot position. However, correlation between the FPI and 3D biometrics fell in the valgus aligned hindfoot so caution must be used when the FPI is used for assessment in this population.     

Trunk muscle endurance tests: Reliability, and gender differences in athletes

Adequate trunk muscle endurance may play an important role in injury-free performance among athletes. However, reliability of tests of isometric trunk muscle endurance in common use has not been clearly established and few studies have reported normative data for athletes. This study first examined intra-rater and inter-rater reliability of the side bridge endurance test and a test of trunk flexor endurance in a group of non-athletes, then measured performance of a group of elite athletes on tests of trunk muscle endurance commonly used in the clinic. The side bridge endurance test and the trunk flexor endurance test were found to have high intra-rater and inter-rater reliability, albeit with relatively large standard error of measurement (S.E.M.) values. In contrast with previous studies of non-athletes, male athletes had equivalent holding times on the Biering–Sørensen trunk extensor endurance test to those of female athletes. However, female athletes had significantly lower holding times on the side bridge endurance tests than their male counterparts. The implication of the significant difference in endurance performance between male and female athletes in some muscle groups but not others is that testing and training of trunk muscle endurance should be ‘multidirectional’ for all athletes who aim to optimise performance and minimise injury risk.     

The TiltMeter app is a novel and accurate measurement tool for the weight bearing lunge test

ObjectivesThe weight bearing lunge test is increasing being used by health care clinicians who treat lower limb and foot pathology. This measure is commonly established accurately and reliably with the use of expensive equipment. This study aims to compare the digital inclinometer with a free app, TiltMeter on an Apple iPhone.DesignThis was an intra-rater and inter-rater reliability study. Two raters (novice and experienced) conducted the measurements in both a bent knee and straight leg position to determine the intra-rater and inter-rater reliability. Concurrent validity was also established.MethodsAllied health practitioners were recruited as participants from the workplace. A preconditioning stretch was conducted and the ankle range of motion was established with the weight bearing lunge test position with firstly the leg straight and secondly with the knee bent. The measurement device and each participant were randomised during measurement.ResultsThe intra-rater reliability and inter-rater reliability for the devices and in both positions were all over ICC 0.8 except for one intra-rater measure (Digital inclinometer, novice, ICC 0.65). The inter-rater reliability between the digital inclinometer and the tilmeter was near perfect, ICC 0.96 (CI: 0.898–0.983); Concurrent validity ICC between the two devices was 0.83 (CI: ?0.740 to 0.445).ConclusionsThe use of the Tiltmeter app on the iPhone is a reliable and inexpensive tool to measure the available ankle range of motion. Health practitioners should use caution in applying these findings to other smart phone equipment if surface areas are not comparable.     

Lower preseason reactive strength index scores are associated with injury in female collegiate volleyball players but not male collegiate basketball players

ObjectivesFunctional tests are used by sports medicine professionals to discriminate injury risk in athletes. One test that has shown promise is the drop vertical jump (DVJ); however, it is primarily used to evaluate measures associated with anterior cruciate ligament injury. The DVJ test can also be used to calculate the reactive strength index (RSI); a measure used to assess an athlete’s power. The ability of the RSI to discriminate injury risk is unknown. The purpose of this study was to prospectively evaluate the ability of preseason RSI scores to identify athletes at risk for a noncontact time-loss injury to the low back or lower extremities.DesignProspective cohort.MethodsOne hundred and fifty-five male collegiate basketball (BB) players and 117 female collegiate volleyball (VB) players were recruited for this study. DVJ tests were performed in a motion capture lab.ResultsFemale VB players with a RSI 0.9125 m/s or less (30.48 cm box) were 4 times (relative risk = 4.2 [95% CI: 1.0, 17.7]; p-value = 0.024) more likely to be injured. There was no association between preseason scores and injury in the male BB athletes.ConclusionRSI scores should be collected for female collegiate VB players as part of a preseason screen.     

Reliability of the Thomas test for assessing range of motion about the hip

ObjectivesRehabilitative protocols and research are significantly influenced by the ability to perform reliable measures of specific physical attributes or functions. The hypothesis was that the Thomas test for evaluating range of motion about the hip joint is a reliable clinical assessment tool.SubjectsParticipants (n=54) were between the ages of 18 and 45, and had no history of trauma.MethodsThree Board-Certified Athletic Therapists assessed hip range of motion using pass/fail and goniometer scoring systems. A re-test session was completed seven to ten days later.ResultsStatistically, Kappa values for pass/fail scoring (intra-rater ℜ=0.47, inter-rater ℜ=0.39) and ICC values (intra-rater ℜ=0.52, inter-rater ℜ=0.60) for goniometer data both indicated that the Thomas test demonstrated poor intra and inter-rater reliability. However, measurement error values (SEM=1°, ME=2°, and CV=15%) and Bland and Altman plots demonstrated that there was only a small degree of intra-rater variance for each examiner when executing the Thomas test in a clinical setting.ConclusionsResults call into question the statistical reliability of the Thomas test, but provide clinicians with important information regarding the reliability limits of the Thomas test when used to clinically evaluate hip range of motion and ilio-psoas muscle flexibility in a physically active population. More research is required in order to determine the variables that may confound statistical reliability of this orthopaedic technique that is commonly used in a clinical setting to assess hip function.     

Tibial ACL insertion site length: correlation between preoperative MRI and intra-operative measurements

Purpose

This study was undertaken primarily to identify the tibial insertion site length of ruptured ACL fibres in patients undergoing primary ACL reconstruction. A secondary aim was to evaluate the correlation of pre- and intra-operative measurements.

Methods

In 146 patients undergoing primary ACL reconstruction, a preoperative measurement on MRI of the tibial ACL insertion site length was taken by two raters and then compared with single surgeon’s intra-operative measurements using a specialized ruler. Inclusion criteria were primary ACL reconstruction and MRI performed within 3 months prior to surgery on one specific MRI machine at the study centre. Inter-rater and intra-rater reliability based on intra class correlation (ICC) was calculated. Additionally, correlation between preoperative and postoperative measurements and the anthropometric data was assessed using Pearson correlation.

Results

The tibial ACL insertion site had a mean length of 16.6 ± 1.6 mm (11.9–21.0) as measured by MRI, and 16.4 ± 1.6 mm (11.0–20.0) as measured intra-operatively. The ICCs for intra- and inter-rater reliability of the MRI measurements were 0.99 (95 % CI 0.97; 0.99; p < 0.001) and 0.81 (95 % CI 0.75; 0.86; p < 0.001), respectively. Regression analysis demonstrated, after controlling for subject height and weight, that the MRI measurements significantly predicted intra-operative measurement of tibial insertion site length (β = 0.796; R ²-change 0.77; p < 0.001).

Conclusion

Preoperative measurement of the tibial ACL length is possible using MRI and can be a valuable aid in more efficient preoperative planning given the knowledge of expected dimensions of special knee structures.

Level of evidence

III.

     

Is it safe for extended-role radiographers to measure migration percentage in children with cerebral palsy?

IntroductionIn the surveillance of children with cerebral palsy, the measurement of migration percentage is used to identify children at risk of hip dislocation. Early identification of children at risk facilitates early intervention with less invasive surgical procedures to prevent further deterioration.The aim of this study is to evaluate the safety of the measurements of migration percentage for surveillance in cerebral palsy by extended-role radiographers by evaluating the reliability and validity of measurements performed by these professionals.MethodsA sample of thirty pelvic x-rays were selected from the local cerebral palsy database. A range of hip displacement was selected including some challenging borderline x-rays. All ten extended-role radiographers completed measurements using TraumaCAD which were repeated at a minimum of 4 weeks.Inter-rater and intra-rater reliability was calculated using intraclass correlation coefficients. The accuracy and safety of the system was evaluated by converting measurements into referral categories (red, amber or green) and cohen's kappa was calculated when categories were compared to measurements to orthopaedic surgeonResultsThe inter-rater reliability between radiographers was 0.938 (95% CI 0.914–0.991). The intra-rater reliability was 0.941 (95% CI 0.931–0.949).The percentage agreement was 94.8% for green, 93.8% for amber and 98.2% for red hips. The weighted kappa value was 0.923 (95% CI 0.889–0.957).ConclusionThe reliability and accuracy of radiographer measurement of migration percentage is excellent. It is safe for radiographers to calculate the migration percentage using semi-automated software for the surveillance of children with cerebral palsy.Implications for practiceWe recommend the measurement of migration percentage may be performed by extended-role radiographers to deliver accurate and reliable measurements for use in cerebral palsy surveillance.     

Hand-held dynamometry strength measures for internal and external rotation demonstrate superior reliability,lower minimal detectable change and higher correlation to isokinetic dynamometry than externally-fixed dynamometry of the shoulder

ObjectivesTo investigate inter and intra-rater reliability of hand held (HHD) and externally fixed (EFD) dynamometry for shoulder internal (IR) and external rotation (ER) strength and their correlation to isokinetic testing.DesignWithin participant, inter and intra-rater reliability study.ParticipantsTwenty active, healthy male and female participants underwent testing by two examiners.Outcome measuresIntra-class coefficients (ICC), percentage standard error of measurement (%SEM), and percentage minimal detectable change (%MDC) were calculated for inter-rater, intra-day and intra-rater, inter-week reliability. Maximum and average of three repetitions were compared to the isokinetic results at three speeds (60°/sec, 180°/sec, 240°/sec) for both concentric and eccentric contractions.ResultsInter and intra-tester values demonstrated good to high agreement (HHD, ICC range = 0.89–0.97, %SEM = 4.80–8.60%, %MDC = 13.29–23.70%; EFD, ICC = 0.88–0.96, %SEM = 6.60–11.00%, %MDC = 18.40–30.04%). HHD and EFD showed moderate to very strong correlations to the isokinetic testing (HHD, r = 0.45–0.86; EFD, r = 0.49–0.83).ConclusionsThe results of this study indicate that both EFD and HHD are suitable for clinical practice and research. Hand-held dynamometry is preferred due to its higher intra- and inter-rater reliability and smaller MDC and lower SEM.     

Efficacy of ACL injury risk screening methods in identifying high‐risk landing patterns during a sport‐specific task

Screening methods sensitive to movement strategies that increase anterior cruciate ligament (ACL) loads are likely to be effective in identifying athletes at‐risk of ACL injury. Current ACL injury risk screening methods are yet to be evaluated for their ability to identify athletes' who exhibit high‐risk lower limb mechanics during sport‐specific maneuvers associated with ACL injury occurrences. The purpose of this study was to examine the efficacy of two ACL injury risk screening methods in identifying high‐risk lower limb mechanics during a sport‐specific landing task. Thirty‐two female athletes were screened using the Landing Error Scoring System (LESS) and Tuck Jump Assessment. Participants' also completed a sport‐specific landing task, during which three‐dimensional kinematic and kinetic data were collected. One‐dimensional statistical parametric mapping was used to examine the relationships between screening method scores, and the three‐dimensional hip and knee joint rotation and moment data from the sport‐specific landing. Higher LESS scores were associated with reduced knee flexion from 30 to 57 ms after initial contact (P = 0.003) during the sport‐specific landing; however, no additional relationships were found. These findings suggest the LESS and Tuck Jump Assessment may have minimal applicability in identifying athletes' who exhibit high‐risk landing postures in the sport‐specific task examined.     

Can the workload–injury relationship be moderated by improved strength,speed and repeated-sprint qualities?

Objectives

The aim of this study was to investigate potential moderators (i.e. lower body strength, repeated-sprint ability [RSA] and maximal velocity) of injury risk within a team-sport cohort.

Interrater reliability of the injury reporting of the injury surveillance system used in international athletics championships

Objectives

The quality of epidemiological injury data depends on the reliability of reporting to an injury surveillance system. Ascertaining whether all physicians/physiotherapists report the same information for the same injury case is of major interest to determine data validity. The aim of this study was therefore to analyse the data collection reliability through the analysis of the interrater reliability.

Test-retest,intra- and inter-rater reliability of the reactive balance test in healthy recreational athletes

ObjectiveThe reactive balance test (RBT) is a recently developed neurocognitive balance test. The aim of this study was to determine test-retest, intra- and inter-rater reliability of the RBT in healthy recreational athletes.DesignReliability study design.SettingPrimary.ParticipantsTwenty-one volunteers (age = 22 ± 1 years, height = 175 ± 9 cm, weight = 69 ± 7 kg) participated.InterventionsThe two experimental trials were separated by an average of 33 ± 15 days. During experimental trials participants performed the Y-balance test (to determine maximal reach distances), and RBT once.Main outcome measuresVisuomotor response time and accuracy. Test-retest, intra- and inter-rater reliability were estimated for both these RBT outcome measures.ResultsExcellent intra- and inter-rater reliability was observed for visuomotor response time and accuracy. Test-retest reliability for visuomotor response time was considered good, while moderate test-retest reliability was found for accuracy.ConclusionsOur results indicate that overall test-retest, intra- and inter-rater reliability of the RBT was moderate to excellent. Thus, the RBT possesses acceptable reliability to use in group level analyses. Future research should further determine the clinimetric properties of the RBT in specific populations and research the RBT along the sport injury continuum.     

Intra- and interrater reliability of the ‘lumbar-locked thoracic rotation test’ in competitive swimmers ages 10 through 18 years

ObjectivesMeasuring thoracic spine mobility can be of interest to competitive swimmers as it has been associated with shoulder girdle function and scapular position in subjects with and without shoulder pain. At present, no reliability data of thoracic spine mobility measurements are available in the swimming population. This study aims to evaluate the within-session intra- and interrater reliability of the “lumbar-locked rotation test” for thoracic spine rotation in competitive swimmers aged 10 to 18 years. This reliability study is part of a larger prospective cohort study investigating potential risk factors for the development of shoulder pain in competitive swimmers.DesignWithin-session, intra- and inter-rater reliability.SettingCompetitive swimming clubs in Belgium.Participants21 competitive swimmers.Main outcome measuresIntra- and inter-rater reliability of the lumbar-locked thoracic rotation test.ResultsIntraclass correlation coefficients (ICCs) ranged from 0.91 (95% CI 0.78 to 0.96) to 0.96 (0.89–0.98) for intra-rater reliability. Results for inter-rater reliability ranged from 0.89 (0.72–0.95) to 0.86 (0.65–0.94) respectively for right and left thoracic rotation.ConclusionResults suggest good to excellent reliability of the lumbar-locked thoracic rotation test, indicating this test can be used reliably in clinical practice.     

Reliability and validity of a return to sports testing battery for the shoulder

ObjectiveTo determine the validity, intra- and inter-rater, and absolute reliability of a return to sport testing battery for the shoulder in a healthy cohort.DesignCross-sectional design. All participants completed a battery of strength (isokinetic, isometric, and repetition to failure) and functional assessments on two occasions. Concurrent validity to isokinetic testing was assessed, and intra-rater, inter-rater, and absolute reliability were established for all assessments.SettingControlled clinical environment.ParticipantsThirty healthy adults active in recreational sports participated, mean age 24.0 ± 1.6 years;Main outcome measuresCorrelations (Pearson’s r), reliability (Intraclass Correlation Coefficient), Standard error of the measurement, Minimal detectable change.ResultsCorrelations to isokinetic assessments at 60° & 180°/second were moderate to strong for isometric (r: 0.68–0.80) and functional testing (r: 0.55–0.83) and weak for repetition to failure testing (r: 0.37–0.74). All isokinetic (ICC: 0.88–0.94), isometric (ICC: 0.83–0.94), and functional assessments (ICC: 0.80–0.92) had good to excellent intra-rater reliability, while repetition to failure testing had poor to moderate reliability (ICC: 0.48–0.57). The inter-rater reliability of the isometric assessments was moderate to excellent (ICC: 0.71–0.92) across movements. Expressed as a percentage of the mean, the standard error of the measurement ranged from 7% to 25% and the minimal detectable change ranged from 20% to 69% across all assessment methods.ConclusionThe isokinetic, isometric, and functional assessments used in this return to sports testing battery demonstrates acceptable validity and reliability. Further refinement to the methods used to assess muscular endurance is needed to improve reliability. This study offers clinicians information that can be utilized in clinical decision-making as it relates the testing battery’s psychometric properties.