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Journal: The Journal of orthopaedic and sports physical therapy


Study Design Cross-sectional repeated measures. Background Rehabilitation of diastasis rectus abdominis (DRA) generally aims to reduce the inter-rectus distance (IRD). We tested the hypothesis that activation of the transversus abdominis (TrA) before a curl-up would reduce IRD narrowing, with less linea alba (LA) distortion/deformation, which may allow better force transfer between sides of the abdominal wall. Objectives This study investigated behavior of the LA and IRD during curl-ups performed naturally and with preactivation of the TrA. Methods Curl-ups were performed by 26 women with DRA and 17 healthy control participants using a natural strategy (automatic curl-up) and with TrA preactivation (TrA curl-up). Ultrasound images were recorded at 2 points above the umbilicus (U point and UX point). Ultrasound measures of IRD and a novel measure of LA distortion (distortion index: average deviation of the LA from the shortest path between the recti) were compared between 3 tasks (rest, automatic curl-up, TrA curl-up), between groups, and between measurement points (analysis of variance). Results Automatic curl-up by women with DRA narrowed the IRD from resting values (mean U-point between-task difference, -1.19 cm; 95% confidence interval [CI]: -1.45, -0.93; P<.001 and mean UX-point between-task difference, -0.51 cm; 95% CI: -0.69, -0.34; P<.001), but LA distortion increased (mean U-point between-task difference, 0.018; 95% CI: 0.0003, 0.041; P = .046 and mean UX-point between-task difference, 0.025; 95% CI: 0.004, 0.045; P = .02). Although TrA curl-up induced no narrowing or less IRD narrowing than automatic curl-up (mean U-point difference between TrA curl-up versus rest, -0.56 cm; 95% CI: -0.82, -0.31; P<.001 and mean UX-point between-task difference, 0.02 cm; 95% CI: -0.22, 0.19; P = .86), LA distortion was less (mean U-point between-task difference, -0.025; 95% CI: -0.037, -0.012; P<.001 and mean UX-point between-task difference, -0.021; 95% CI: -0.038, -0.005; P = .01). Inter-rectus distance and the distortion index did not change from rest or differ between tasks for controls (P≥.55). Conclusion Narrowing of the IRD during automatic curl-up in DRA distorts the LA. The distortion index requires further validation, but findings imply that less IRD narrowing with TrA preactivation might improve force transfer between sides of the abdomen. The clinical implication is that reduced IRD narrowing by TrA contraction, which has been discouraged, may positively impact abdominal mechanics. J Orthop Sports Phys Ther 2016;46(7):580-589. doi:10.2519/jospt.2016.6536.

Concepts: Standard deviation, Analysis of variance, Absolute deviation, Scientific method, Transversus abdominis muscle, Abdomen, Linea alba, Rectus abdominis muscle


Synopsis The hallmark features of patellar tendinopathy are (1) pain localized to the inferior pole of the patella and (2) load related pain that increases with the demand on the knee extensors, notably in activities that store and release energy in the patellar tendon. While imaging may assist in differential diagnosis, the diagnosis of patellar tendinopathy remains clinical, as asymptomatic tendon pathology may exist in people who have pain from other anterior knee sources. A thorough examination is required to diagnose patellar tendinopathy and contributing factors. Management of patellar tendinopathy should focus on progressively developing load tolerance of the tendon, the musculoskeletal unit, and the kinetic chain as well as addressing key biomechanical and other risk factors. Rehabilitation can be slow and sometimes frustrating. This review aims to assist clinicians with key concepts related to examination, diagnosis, and management of patellar tendinopathy. Difficult clinical presentations (eg, highly irritable tendon, systemic comorbidities) as well as common pitfalls such as unrealistic rehabilitation timeframes and over-reliance on passive treatments are also discussed. J Orthop Sports Phys Ther, Epub 21 Sep 2015. doi:10.2519/jospt.2015.5987.

Concepts: Medical diagnosis, Femur, Medical terms, Patellar ligament, Differential diagnosis, Patella, Knee, Tibia


Study Design Groin pain is common in athletes participating in multidirectional sports and has traditionally been considered a difficult problem to understand, diagnose, and manage. This may be due to sparse historical focus on this complex region in sports medicine. Until recently, there was no agreement regarding terminology, definitions, and classification of groin pain in athletes. This has made clear communication between clinicians difficult, and the results of research difficult to interpret and implement into practice. However, during the past decade the field has evolved rapidly, and an evidence-based understanding is now emerging. This clinical commentary discusses the clinical examination (subjective history, screening, physical examination); imaging; testing of impairments, function, and performance, and; management of athletes with groin pain in an evidence-based framework. J Orthop Sports Phys Ther, Epub 6 Mar 2018. doi:10.2519/jospt.2018.7850.

Concepts: Problem solving, Medical history, Inspection, Mental status examination, Medical diagnosis, General medical examination, Medicine, Physical examination


Patellofemoral pain (PFP) is a common musculoskeletal-related condition that is characterized by insidious onset of poorly defined pain, localized to the anterior retropatellar and/or peripatellar region of the knee. The onset of symptoms can be slow or acutely develop with a worsening of pain accompanying lower-limb loading activities (eg, squatting, prolonged sitting, ascending/descending stairs, jumping, or running). Symptoms can restrict participation in physical activity, sports, and work, as well as recur and persist for years. This clinical practice guideline will allow physical therapists and other rehabilitation specialists to stay up to date with evolving PFP knowledge and practices, and help them to make evidence-based treatment decisions. J Orthop Sports Phys Ther. 2019;49(9):CPG1-CPG95. doi:10.2519/jospt.2019.0302.


Sports-related concussions (SRC) occur due to biomechanical forces to the head or neck that can result in pathophysiological changes in the brain. The musculature of the cervical spine has been identified as one potential factor in reducing SRC risk as well as underlying sex differences in SRC rates. Recent research has demonstrated that linear and rotational head acceleration, as well as the magnitude of force, upon impact is influenced by cervical spine biomechanics. Increased neck strength and girth is associated with reduced linear and rotational head acceleration during impact. Past work has also shown that overall neck strength and girth are lower in athletes with SRC. Additionally, differences in cervical spine biomechanics are hypothesized as a critical factor underlying sex differences in SRC rates. Specifically, compared to males, females tend to have less neck strength and girth which is associated with increased linear and rotational head acceleration. Although our ability to detect SRC has greatly improved, our ability to prevent SRCs from occurring and decrease the severity of clinical outcomes post-injury is limited. However, we suggest, along with others, that cervical spine biomechanics is a modifiable factor in reducing SRC risk. We review the role of the cervical spine in reducing SRC risk, and how this differs dependent on sex. We discuss clinical considerations for the examination of the cervical spine and the potential clinical relevance for SRC prevention. Additionally, we provide suggestions for future research examining cervical spine properties as modifiable factors in reducing SRC risk. J Orthop Sports Phys Ther, Epub 15 Jan 2019. doi:10.2519/jospt.2019.8582.


STUDY DESIGN: Controlled laboratory study, repeated measures design. OBJECTIVES: To compare hip abductor muscle activity during selected exercises using fine-wire electromyography (EMG), and determine which exercises are best for activating gluteus medius and the superior portion of gluteus maximus while minimizing activity of tensor fascia lata (TFL). BACKGROUND: Abnormal hip kinematics (i.e. excessive hip adduction and internal rotation) has been linked to certain musculoskeletal disorders. The TFL is a hip abductor but also internally rotates the hip. As such, it may be important to select exercises that activate the gluteal hip abductors while minimizing activation of TFL. METHODS: Twenty healthy persons participated. EMG signals were obtained from the gluteus medius, superior gluteus maximus, and TFL muscles using fine-wire electrodes as subjects performed 11 different exercises. Normalized EMG signal amplitude was compared among muscles for each exercise using multiple 1-way repeated measures analyses of variance (ANOVAs). A descriptive gluteal-to-TFL muscle activation (GTA) index was used to identify preferred exercises for recruiting the gluteal muscles while minimizing TFL activity. RESULTS: Both gluteal muscles were significantly (P<.05) more active than TFL in unilateral and bilateral bridging, quadruped hip extension (knee flexed and extending), the clam, side-stepping, and squatting. The GTA index ranged from 18 to 115, and was highest for the clam (115), side-step (64), unilateral bridge (59), and both quadruped exercises (50). CONCLUSION: If the goal of rehabilitation is to preferentially activate the gluteal muscles while minimizing TFL activation, then the clam, side-step, unilateral bridge, and both quadruped hip extension exercises would appear to be most appropriate.J Orthop Sports Phys Ther, Epub 16 November 2012. doi:10.2519/jospt.2013.4116.

Concepts: Extension, Adduction, Hip, Muscle, Gluteus maximus muscle, Gluteal muscles, Gluteus medius muscle, Electromyography


Study Design Randomized clinical trial. Objectives To compare the effectiveness of the Alfredson’s eccentric heel drop protocol with a “do-as-tolerated” protocol for non-athletic individuals with mid-portion Achilles tendinopathy. Background The Alfredson’s protocol recommends the completion of 180 eccentric heel drops a day. However, completing this large number of repetitions is time-consuming and potentially uncomfortable. There is a need to investigate varying exercise dosages that minimize the discomfort yet retain the clinical benefits. Methods Twenty-eight individuals from outpatient physiotherapy departments were randomized to either the standard (n=15) or the “do-as-tolerated” (n=13) 6 week intervention protocol. Apart from repetition volume all other aspects of management were standardized between groups. Tendinopathy clinical severity was assessed with the Victoria Institute of Sports Assessment - Achilles (VISA-A) questionnaire. Pain intensity was assessed using a visual analogue scale (VAS). Both were assessed at weeks 0, 3, and 6. Treatment satisfaction was assessed at week 6. Adverse effects were also monitored. Results There was a statistically significant within-group improvement in VISA-A score for both groups (standard: P=.03; “do-as-tolerated”: P<.001) and VAS pain for the "do-as-tolerated" (P=.001) at week 6 based on the intention-to-treat analysis. There was a statistically significant between-group difference in VISA-A scores at week 3 based on both the intention-to-treat (P=.004) and per protocol analyses (P=.007), partly due to a within-group deterioration at week 3 for the standard group. There was no statistically significant between-group difference for VISA-A and VAS pain scores at week 6, completion of the intervention. There was no significant association between satisfaction and treatment groups at week 6. No adverse effects were reported. Conclusion Performing a 6-week "do-as-tolerated" program of eccentric heel drop exercises, compared to the recommended 180 repetitions per day, did not lead to lesser improvement for individuals with mid-portion Achilles tendinopathy based on the VISA-A and VAS scores. Level of Evidence Therapy, Level 2b. J Orthop Sports Phys Ther, Epub 21 November 2013. doi:10.2519/jospt.2014.4720.

Concepts: Experimental design, Effectiveness, Pharmaceutical industry, Pharmacology, Clinical research, Epidemiology, Clinical trial, Randomized controlled trial


Study Design Case report. Background Prognosis for adhesive capsulitis has been described as self-limiting and can persist for 1-3 years. Conservative treatment including physical therapy is commonly advised. Case Description The patient was a 54 year old female with primary symptoms of shoulder pain and loss of motion consistent with adhesive capsulitis. Manual physical therapy intervention initially consisted of joint mobilizations of the shoulder region and thrust manipulation of the cervicothoracic region. Although manual techniques seemed to cause some early functional improvement, continued progression was limited by pain. Subsequent examination identified trigger points in the upper trapezius, levator scapula, deltoid and infraspinatus muscles that were treated with dry needling to decrease pain and allow for higher grades of manual intervention. Outcomes The patient was treated for a total of 13 visits over a 6 weeks period. After trigger point dry needling was introduced on the third visit, improvements in pain-free shoulder range of motion and functional outcome measures, including SPADI and QuickDASH, exceeded the minimal clinically important difference after 2 treatment sessions. At discharge the patient had achieved significant improvements in shoulder range of motion in all planes and outcome measures were significantly improved. Discussion This case report describes the clinical reasoning behind the use of trigger point dry needling in the treatment of a patient with adhesive capsulitis. The rapid improvement seen in this patient following the initiation of dry needling to the upper trapezius, levator scapula, deltoid and infraspinatus muscles suggests that surrounding muscles may be a significant source of pain in this condition. Level of Evidence Therapy, level 4. J Orthop Sports Phys Ther, Epub 21 November 2013. doi:10.2519/jospt.2014.4915.

Concepts: Injuries, Improve, Trigger point, Supraspinatus muscle, Clavicle, Massage, Acupuncture, Shoulder


The International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) led the development of a framework to help clinicians assess and manage people who may have serious spinal pathology. While rare, serious spinal pathology can have devastating and life-changing or life-limiting consequences, and must be identified early and managed appropriately. Red flags (signs and symptoms that might raise suspicion of serious spinal pathology) have historically been used by clinicians to identify serious spinal pathology. Currently, there is an absence of high-quality evidence for the diagnostic accuracy of most red flags. This framework is intended to provide a clinical-reasoning pathway to clarify the role of red flags. J Orthop Sports Phys Ther, Epub 21 May 2020. doi:10.2519/jospt.2020.9971.


SYNOPSIS: Ice hockey goaltenders are a specialized population of athletes because of the unique physical demand that the position, especially those who employ the butterfly technique, places on their lower extremities, specifically at the hip. It is no surprise that hip injuries are a common occurrence among goalies. A review of the biomechanical literature has demonstrated that stressing the hip in flexion and end-range internal rotation, the position goaltenders commonly use, puts the hip in an “at risk” position for injury and is likely a major contributing factor to overuse hip injuries. The stress on a goaltender’s hip is further intensified by the presence of bony deformities, such as cam or pincer type femoroacetabular impingement (FAI), which can lead to chondrolabral junction and articular cartilage injuries. There have been few published reports of goaltenders functional outcomes following FAI surgery and to our knowledge no studies have yet identified the specific challenges presented in the rehabilitation of goaltenders post FAI surgery. Here we present a 6-phase return to skating program as part of the rehabilitation protocol that was developed to aid hockey goaltenders recovering from surgery. LEVEL OF EVIDENCE: Therapy, level 5. J Orthop Sports Phys Ther. Epub 12 February 2013. doi:10.2519/jospt.2013.4430.

Concepts: Ice, Hockey, Ice hockey goaltenders, Kingston, Ontario, Articular cartilage repair, Knee, Ice hockey, Goaltender