AN ELASTIC EXERCISE BAND MOUNTED WITH A BANDCIZER? CAN DIFFERENTIATE BETWEEN COMMONLY PRESCRIBED HOME EXERCISES FOR THE SHOULDER

Background

Home‐exercise is commonly prescribed for rehabilitation of the shoulder following injury. There is a lack of technology available to monitor if the patient performs the exercises as prescribed.

Purpose

The purpose of this study was to investigate the validity of using three dimensional (3D) gyroscope data recorded with the Bandcizer™ sensor to differentiate between three elastic band exercises performed in the shoulder joint: abduction, flexion, and external rotation.

Design

Concurrent validity study.

Methods

This study was performed over two phases. In the first phase, 20 subjects performed three sets of 10 of shoulder abduction, external rotation and flexion exercises with a Thera‐Band mounted with a Bandcizer, while supervised by a physical therapist. The Bandcizer has an inbuilt three‐dimensional gyroscope, capable of measuring angular rotation. Gyroscope data were analyzed in Matlab, and a one‐way ANOVA was used to test for significant differences between each of the three exercises. An algorithm was then created in Matlab based on the exercise‐data from the gyroscope, to enable differentiation between the three shoulder exercises. Twenty new subjects were then recruited to cross‐validate the algorithm and investigate if the algorithm could differentiate between the three different shoulder exercises.

Results

A blinded assessor using the Matlab algorithm could correctly identify 56 out of 60 exercise sets. The kappa agreement for the three exercises ranged between 0.86‐0.91.

Conclusion

The ability to differentiate between the home exercises performed by patients after shoulder injury has great implications for future clinical practice and research. When home exercises are the treatments‐of‐choice, clinicians will be able to quantify if the patient performed the exercise as intended. Further research should be aimed at investigating the feasibility of using the Bandcizer™ in a home‐based environment.

Word count

2429

Level of Evidence

2     

THROWING INJURIES IN THE ADOLESCENT ATHLETE

Introduction:

Adolescents ranging in age from 11–15 (early‐mid adolescence) comprise the largest percentage of baseball and softball athletes in the United States. Shoulder and elbow injuries are commonly experienced by these athletes with baseball pitchers and softball position players most likely to be injured.

Common Injuries:

Physeal injury often termed “Little League” shoulder or elbow is common and should be differentiated from soft tissue injuries such as biceps, rotator cuff, or UCL injuries. Regardless of diagnosis, rehabilitation of these athletes’ shoulder and elbow injuries provide a unique challenge given their rapidly changing physical status.

Treatment:

Common impairments include alterations in shoulder range of motion, decreased muscle performance, and poor neuromuscular control of the scapula, core, and lower extremity. A criterion based, progressive rehabilitation program is presented. Discharge from formal rehabilitation should occur only when the athlete has demonstrated a resolution of symptoms, acceptable ROM, muscle performance, and neuromuscular control while progressing through a symptom free return to sport.

Prevention of Reinjury:

Reintegration into the desired level of sport participation should be guided by the sports medicine professional with a focus on long‐term durability in sport performance as well as injury prevention. A prevention program which includes parent, coach, and athlete education, regular screening to identify those athletes at the highest risk, and monitoring athletes for the development of risk factors or warning signs of injury over the course of participation is indicated.

Level of Evidence:

5     

POSTERIOR STERNOCLAVICULAR JOINT DISLOCATION IN A DIVISION I FOOTBALL PLAYER: A CASE REPORT

Posterior dislocation of the sterno‐clavicular (SC) joint is a rare injury in athletes. It normally occurs in high collision sports such as American football or rugby. Acute posterior dislocations of the SC joint can be life‐threatening as the posteriorly displaced clavicle can cause damage to vital vascular and respiratory structures such as the aortic arch, the carotid and subclavian arteries, and the trachea. The potential severity of a posterior SC joint dislocation provides multiple challenges for clinicians involved in the emergency care and treatment of this condition. Integration of clinical examination observations, rapid critical thinking, and appropriate diagnostic imaging are often required to provide the best management and outcome for the injured athlete. The criterion for return‐to‐play and participation in collision sports after suffering a posterior dislocation of the SC joint are unclear due to the rarity of this injury. The purpose of this case report is to describe the management, from the initial on‐field evaluation through the return‐to‐sport, of a collegiate Division I football player following a traumatic sports‐related posterior SC joint dislocation. The rehabilitation process and the progression to return to participation are also presented and briefly discussed.

Level of Evidence

4‐Single case report     

THE RELATIONSHIP BETWEEN GLENOHUMERAL JOINT TOTAL ROTATIONAL RANGE OF MOTION AND THE FUNCTIONAL MOVEMENT SCREEN? SHOULDER MOBILITY TEST

Purpose/Background:

Side to side asymmetry in glenohumeral joint rotation correlates with injury risk in overhead athletes. The purpose of the current study was to identify the relationship between side‐to‐side asymmetries in glenohumeral joint total rotational range of motion and shoulder mobility test scores from the Functional Movement Screen™ in collegiate overhead athletes. The authors hypothesized that asymmetries of > 10° in glenohumeral total rotation would not be associated with asymmetrical findings in the Functional Movement Screen™ (FMS) shoulder mobility test.

Methods:

Passive glenohumeral total rotational range of motion and the shoulder mobility test of the FMS were measured during pre‐participation examinations in 121 NCAA male and female Division II collegiate overhead athletes from varied sports. Passive shoulder range of motion was measured in supine at 90° of abduction, with the humerus in the scapular plane using two measurers and a bubble goniometer. A Pearson Chi‐square analysis, p<.05 was used to associate the presence of asymmetries in glenohumeral joint rotation and in the FMS shoulder mobility test in each subject.

Results:

40/114 (35.1%) athletes demonstrated asymmetries in total glenohumeral rotation. 45/114 (39.5%) athletes demonstrated asymmetries in the shoulder mobility test. Only 17 of the 45 subjects who demonstrated asymmetry on the shoulder mobility test also demonstrated glenohumeral joint rotation differences of > 10°. Athletes with asymmetries in rotation of > 10° were not any more likely to have asymmetries identified in the shoulder mobility test (95% CI=.555‐2.658, P=.627).

Conclusions

Glenohumeral joint range of motion is one of multiple contributors to performance on the FMS shoulder mobility test, and alone, did not appear to influence results. The FMS shoulder mobility test should not be used alone as a means of identifying clinically meaningful differences of shoulder mobility in the overhead athlete. Clinicians working with overhead athletes may consider using both assessments as a complete screening tool for injury prevention measures.

Level of Evidence:

Level 3     

RELIABILITY OF STRENGTH AND PERFORMANCE TESTING MEASURES AND THEIR ABILITY TO DIFFERENTIATE PERSONS WITH AND WITHOUT SHOULDER SYMPTOMS

Background

Upper extremity physical performance measures exist but none have been universally accepted as the primary means of gauging readiness to return to activity following rehabilitation. Few reports have described reliability and/or differences in outcome with physical performance measures between individuals with and without shoulder symptoms.

Hypotheses/Purpose

The purpose of this study was to establish the reliability of traditional upper extremity strength testing and the CKCUEST in persons with and without shoulder symptoms as well as to determine if the testing maneuvers could discriminate between individuals with and without shoulder symptoms. The authors hypothesized that strength and physical performance testing would have excellent test/re‐test reliability for individuals with and without shoulder symptoms and that the physical performance maneuver would be able to discriminate between individuals with and without shoulder symptoms.

Methods

Male and female subjects 18‐50 years of age were recruited for testing. Subjects were screened and placed into groups based on the presence (Symptomatic Group) or absence of shoulder symptoms (Asymptomatic Group). Each subject performed an isometric strength task, a task designed to estimate 1‐repetition maximum (RM) lifting in the plane of the scapula, and the closed kinetic chain upper extremity stability test (CKCUEST) during two sessions 7‐10 days apart. Test/re‐test reliability was calculated for all three tasks. Independent t‐tests were utilized for between group comparisons to determine if a performance task could discriminate between persons with and without shoulder symptoms.

Results

Thirty‐six subjects (18/group) completed both sessions. Test/re‐test reliability for each task was excellent for both groups (intraclass correlations ≥ .85 for all tasks). Neither strength task could discriminate between subjects in either group. Subjects with shoulder symptoms had 3% less touches per kilogram of body weight on the CKCUEST compared to subjects without shoulder symptoms but this was not statistically significantly different (p=.064).

Conclusions

The excellent test/re‐test reliability has now been expanded to include individuals with various reasons for shoulder symptoms. Traditional strength testing does not appear to be the ideal assessment method for making discharge and/or return to activity decisions due to the inability to discriminate between the groups. The CKCUEST could be utilized to determine readiness for activity as it was trending towards being discriminatory between known groups.

Level of Evidence

Basic Science Reliability Study, Level 3     

ACUTE EFFECTS OF INSTRUMENT ASSISTED SOFT TISSUE MOBILIZATION FOR IMPROVING POSTERIOR SHOULDER RANGE OF MOTION IN COLLEGIATE BASEBALL PLAYERS

Background:

Due to the repetitive rotational and distractive forces exerted onto the posterior shoulder during the deceleration phase of the overhead throwing motion, limited glenohumeral (GH) range of motion (ROM) is a common trait found among baseball players, making them prone to a wide variety of shoulder injuries. Although utilization of instrument‐assisted soft tissue mobilization (IASTM), such as the Graston® Technique, has proven effective for various injuries and disorders, there is currently no empirical data regarding the effectiveness of this treatment on posterior shoulder tightness.

Purpose:

To determine the effectiveness of IASTM in improving acute passive GH horizontal adduction and internal rotation ROM in collegiate baseball players.

Methods:

Thirty‐five asymptomatic collegiate baseball players were randomly assigned to one of two groups. Seventeen participants received one application of IASTM to the posterior shoulder in between pretest and posttest measurements of passive GH horizontal adduction and internal rotation ROM. The remaining 18 participants did not receive a treatment intervention between tests, serving as the controls. Data were analyzed using separate 2× 2 mixed‐model analysis of variance, with treatment group as the between‐subjects variable and time as the within‐subjects variable.

Results:

A significant group‐by‐time interaction was present for GH horizontal adduction ROM with the IASTM group showing greater improvements in ROM (11.1°) compared to the control group (‐0.12°) (p <0.001). A significant group‐by‐time interaction was also present for GH internal rotation ROM with the IASTM group having greater improvements (4.8°) compared to the control group (‐0.14°) (p < 0.001).

Conclusions:

The results of this study indicate that an application of IASTM to the posterior shoulder provides acute improvements in both GH horizontal adduction ROM and internal rotation ROM among baseball players.

Level of Evidence:

2b     

REGIONAL INTERDEPENDENCE OF THE HIP AND LUMBO‐PELVIC REGION IN DIVISON II COLLEGIATE LEVEL BASEBALL PITCHERS: A PRELIMINARY STUDY

Background

Pitchers may be at greater risk of injury in comparison to other overhead throwing athletes due to the repetition of the pitching motion. It has been reported that approximately 30% of all baseball injuries occur in the lower body. This may be related to limited hip mobility, which can compromise pitching biomechanics while placing excessive stress on the trunk and upper quarter. Hip motion and strength measurements have been reported in professional baseball pitchers but have not been reported in collegiate pitchers.

Purpose

The purpose of this study was to report preliminary findings for passive hip motion and isometric hip muscle strength in collegiate pitchers and compare them to previously published values for professional level pitchers.

Study Design

Cross sectional study

Methods

Twenty‐nine collegiate baseball pitchers (age = 20.0 + 1.4 years, height = 1.88 + 0.06 m; weight = 89.3 + 10.7 kg; body mass index = 25.3 + 2.5 kg/m2) were recruited. Subjects were assessed for hip internal rotation (IR) and external rotation (ER) passive motion, hip anteversion or retroversion, gluteus maximus, gluteus medius, hip internal rotator, hip external rotator strength, and lumbo‐pelvic control with the prone active hip rotation test as described by Sahrmann. Statistical analysis included calculation of subject demographics (means and SD) and use of a two‐tailed t‐test (p >0.05).

Results

Fifty‐two percent of the right‐handed and 50% of the left‐handed pitchers demonstrated poor lumbo‐pelvic motor control with an inability to stabilize during active hip IR and ER even though isolated strength deficits were not detected at a significant level. There were no significant differences in hip passive motion or gluteus medius strength between right and left‐handed pitchers. Differences did exist between collegiate data and previously published values for professional pitchers for IR motion measured in prone and gluteus maximus strength. Hip retroversion was present in 55% of the pitchers primarily in both limbs with four of the pitchers presenting with retroversion singularly in either the stride or trail limb where the ER rotation motion was greater than the IR.

Conclusion

Assessing mobility and muscle strength of the lower quarter in isolation can be misleading and may not be adequate to ensure the potential for optimal pitching performance. These findings suggest that lumbo‐pelvic control in relation to the lower extremities should be assessed as one functional unit. This is the first study to explore hip motion, strength, and lumbo‐pelvic control during active hip rotation in collegiate baseball pitchers.

Evidence Level

2     

REHABILITATION AFTER HIP ARTHROSCOPY AND LABRAL REPAIR IN A HIGH SCHOOL FOOTBALL ATHLETE

Study Design:

Case Report

Background:

Femoral acetabular impingement (FAI) has been implicated in the etiology of acetabular labral tears. The rehabilitation of younger athletes following arthroscopic surgery for FAI and labral tears is often complex and multifactorial. A paucity of evidence exists to describe the rehabilitation of younger athletes who have undergone arthroscopic hip surgery.

Case Presentation:

This case report describes a four-phase rehabilitation program for a high school football player who underwent hip arthroscopy with a labral repair and chondroplasty.

Outcomes:

The player returned to training for football 16 weeks later and at the 4 month follow-up was pain free with no signs of FAI.

Discussion:

There is little evidence regarding the rehabilitation of younger athletes who undergo arthroscopic hip surgery. This case study described a four phase rehabilitation program for a high school football player who underwent hip arthroscopy and labral repair. The patient achieved positive outcomes with a full return to athletic activity and football. The overall success of these patients depends on the appropriate surgical procedure and rehabilitation program.

Key Words:

Femoral acetabular impingement (FAI), hip, hip impingement

Level of evidence:

4-Case report     

ASSOCIATIONS BETWEEN THE FEMALE ATHLETE TRIAD AND INJURY AMONG HIGH SCHOOL RUNNERS

Purpose/Background:

During the 2013‐14 school year, over 763,000 female athletes participated in interscholastic running sports in the United States. Recent studies have indicated associations between the female athlete triad (Triad) and stress fracture or other musculoskeletal injuries in elite or collegiate female running populations. Little is known about these relationships in an adolescent interscholastic running population. The purpose of this study was to determine the associations between Triad and risk of lower extremity musculoskeletal injury among adolescent runners.

Methods:

Eighty‐nine female athletes competing in interscholastic cross‐country and track in southern California were followed, prospectively. The runners were monitored throughout their respective sport season for lower extremity musculoskeletal injuries. Data collected included daily injury reports, Eating Disorder Examination Questionnaire (EDE‐Q) that assessed disordered eating attitudes/behaviors, a questionnaire on menstrual history and demographic characteristics, a dual‐energy x‐ray absorptiometry scan that measured whole‐body bone mineral density (BMD) and body composition (lean tissue and fat mass), and anthropometric measurements.

Results:

Thirty‐eight runners (42.7%) incurred at least one lower extremity musculoskeletal injury. In the BMD Z‐score ≤ ‐1 standard deviation (SD) adjusted model, low BMD relative to age (BMD Z‐score of ≤ ‐1SD) was significantly associated (Odds Ratio [OR]=4.6, 95% confidence interval [CI]: 1.5‐13.3) with an increased occurrence of musculoskeletal injury during the interscholastic sport season. In the BMD Z‐score ≤ ‐2 SDs adjusted model, a history of oligo/amenorrhea was significantly associated (OR=4.1, 95% CI: 1.2‐13.5) with increased musculoskeletal injury occurrence.

Conclusion:

Oligo/amenorrhea and low BMD were associated with musculoskeletal injuries among the female interscholastic cross‐country and track runners.

Clinical Relevance:

Regular, close monitoring of adolescent female runners during seasonal and off‐season training may be warranted, so that potential problems can be recognized and addressed promptly in order to minimize the risk of running injury.

Level Of Evidence:

2     

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     

GLENOHUMERAL ROTATIONAL RANGE OF MOTION DIFFERENCES BETWEEN FAST BOWLERS AND SPIN BOWLERS IN ELITE CRICKETERS

Background:

The shoulder, particularly the glenohumeral joint with its predominant reliance upon soft tissues for stability is prone to injury among the cricketers who bowl regularly. These shoulder injuries are more common in spin bowlers than fast bowlers. A decreased internal rotational difference and increased external rotational difference exist when comparing the dominant shoulder with non‐dominant shoulder between overarm cricketers and non‐throwing wicket keepers.

Purpose:

To compare the glenohumeral internal and external rotation range of motion differences between fast bowlers and spin bowlers.

Methods:

A cross‐sectional design was utilized for this study. Thirty‐five fast bowlers and 31 spin bowlers from an elite group were recruited based on the selection criteria. Glenohumeral passive internal and external rotational differences between dominant and non‐dominant shoulders were measured using a standardized mechanical inclinometer.

Results:

Independent t‐tests revealed a statistically significant difference for external rotational difference (p=0.005) between fast and spin bowlers and no such difference for internal rotational difference (p=0.549) between them at 0.05 level.

Conclusion:

External rotational difference is significantly different between fast bowlers and spin bowlers but not internal rotational difference.

Level of Evidence:

Level 4     

REHABILITATION OF A SURGICALLY REPAIRED RUPTURE OF THE DISTAL BICEPS TENDON IN AN ACTIVE MIDDLE AGED MALE: A CASE REPORT

Background:

Complete rupture of the distal tendon of the biceps brachii is relatively rare and there is little information to guide therapists in rehabilitation after this injury. The purposes of this case report are to review the rehabilitation concepts used for treating such an injury, and discuss how to modify exercises during rehabilitation based on patient progression while adhering to physician recommended guidelines and standard treatment protocols.

Case Presentation:

The patient was an active 38‐year old male experienced in weight‐training. He presented with a surgically repaired right distal biceps tendon following an accident on a trampoline adapted with a bungee suspension harness. The intervention focused on restoring range of motion and strengthening of the supporting muscles of the upper extremity without placing undue stress on the biceps brachii.

Outcomes:

The patient was able to progress from a moderate restriction in ROM to full AROM two weeks ahead of the physician''s post‐operative orders and initiate a re‐strengthening protocol by the eighth week of rehabilitation. At the eighth post‐operative week the patient reported no deficits in functional abilities throughout his normal daily activities with his affected upper extremity.

Discussion:

The results of this case report strengthen current knowledge regarding physical therapy treatment for a distal biceps tendon repair while at the same time providing new insights for future protocol considerations in active individuals. Most current protocols do not advocate aggressive stretching, AROM, or strengthening of a surgically repaired biceps tendon early in the rehabilitation process due to the fear of a re‐rupture. In the opinion of the authors, if full AROM can be achieved before the 6^th week of rehabilitation, initiating a slow transition into light strengthening of the biceps brachii may be possible.

Level of evidence:

4‐Single Case report