Gerard A. Malanga

The relationship between lower extremity injury, low back pain, and hip muscle strength in male and female collegiate athletes.

ObjectiveTo determine the relationship of previous lower extremity (LE) injury and/or low back pain (LBP) on hip abduction and extension strength. DesignCohort study of college athletes at time of preparticipation screening physical. SettingAn NCAA Division I college. ParticipantsTwo hundred ten college athletes (140 males and 70 females) from an NCAA Division I school. Main Outcome MeasuresMean and maximal hip abduction and extension strengths were recorded using a specially designed dynamometer anchoring station. Previous injury to the LE or LBP in the past year was recorded via personal interview at the time of screening and verified by review of previous injury records. ResultsA significant difference in side-to-side symmetry of maximum hip extension strength was observed in female subjects who reported LE injury or LBP as compared to those who did not. Side-to-side difference in hip strength, however, did not differ between male athletes, regardless of reported LE injury or LBP status. ConclusionFemale athletes appear to have a differing response of the proximal hip musculature to LE injury or LBP, as compared with their male counterparts. Research is under way to further validate these findings. Clinical RelevanceThis study provides some reasoning to support the screening of hip strength during the preparticipation physical, as it may be important in the prevention of LE injury and LBP in collegiate athletes.

Hip muscle imbalance and low back pain in athletes: influence of core strengthening

PURPOSE The influence of a core-strengthening program on low back pain (LBP) occurrence and hip strength differences were studied in NCAA Division I collegiate athletes. METHODS In 1998, 1999, and 2000, hip strength was measured during preparticipation physical examinations and occurrence of LBP was monitored throughout the year. Following the 1999-2000 preparticipation physicals, all athletes began participation in a structured core-strengthening program, which emphasized abdominal, paraspinal, and hip extensor strengthening. Incidence of LBP and the relationship with hip muscle imbalance were compared between consecutive academic years. RESULTS After incorporation of core strengthening, there was no statistically significant change in LBP occurrence. Side-to-side extensor strength between athletes participating in both the 1998-1999 and 1999-2000 physicals were no different. After core strengthening, the right hip extensor was, on average, stronger than that of the left hip extensor (P = 0.0001). More specific gender differences were noted after core strengthening. Using logistic regression, female athletes with weaker left hip abductors had a more significant probability of requiring treatment for LBP (P = 0.009) CONCLUSION The impact of core strengthening on collegiate athletes has not been previously examined. These results indicated no significant advantage of core strengthening in reducing LBP occurrence, though this may be more a reflection of the small numbers of subjects who actually required treatment. The core program, however, seems to have had a role in modifying hip extensor strength balance. The association between hip strength and future LBP occurrence, observed only in females, may indicate the need for more gender-specific core programs. The need for a larger scale study to examine the impact of core strengthening in collegiate athletes is demonstrated.

Relationship between hip muscle imbalance and occurrence of low back pain in collegiate athletes: a prospective study.

Nadler SF, Malanga GA, Feinberg JH, Prybicien M, Stitik TP, DePrince M: Relationship between hip muscle imbalance and occurrence of low back pain in collegiate athletes: a prospective study. Am J Phys Med Rehabil 2001;80:572–577. ObjectiveTo assess whether athletes with strength imbalance of the hip musculature would be more likely to require treatment for low back pain (LBP) over the ensuing year. DesignThe study population included 163 National Collegiate Athletic Association Division I college athletes (100 males and 63 females) undergoing preparticipation sports physicals. Institutional review board approval was obtained to acquire and analyze hip muscle strength data. A commercially available dynamometer (Chatillon, Lexington, KY) incorporated into a specially designed anchoring station was used for testing the hip extensors and abductors. The maximum force generated for the hip abductors and extensors was used to calculate a percentage difference between the right and left hip extensors and abductors. Treatment of athletes by the athletic trainers for LBP unrelated to blunt trauma over the ensuing year was recorded. ResultsOf all athletes, 5 of 63 females and 8 of 100 males required treatment for LBP. Logistic regression analysis indicated that for female athletes, the percentage difference between the right and left hip extensors was predictive of whether treatment for LBP was required over the ensuing year (P = 0.05). There was no significant association noted for the percentage difference between the right and left hip abductors in females and for the percentage difference between both the right and left hip abductors and right and left hip extensors in males requiring treatment for LBP. ConclusionsThese data support our results from our previous cohort study, adding validity to the concept of hip muscle imbalance being associated with LBP occurrence in female athletes. This research further supports the need for the assessment and treatment of hip muscle imbalance in individuals with LBP.

A randomized controlled evaluation of low-intensity laser therapy: Plantar fasciitis

OBJECTIVE To determine whether low-intensity laser irradiation, a widespread but controversial physical therapy agent, is an effective treatment of plantar fasciitis. DESIGN A randomized, double-blinded, placebo-controlled clinical study. SETTING A sports medicine clinic. SUBJECTS Thirty-two otherwise healthy individuals with plantar fasciitis of more than 1 months duration. INTERVENTION Dummy or active irradiation with a 30 mW .83 microm GaAlAs continuous-wave infrared (IR) diode laser three times a week for 4 weeks. MEASUREMENTS Morning pain, pain with toe walking, tenderness to palpation, windlass test response, medication consumption, and orthotic use were evaluated immediately before the study, as well as at the midpoint and end of treatment. Subjects were also evaluated at a follow-up 1 month after their last treatment. RESULTS No significant differences were found between the groups in any of the outcome measures either during treatment or at the 1-month follow-up. Treatment, however, was well tolerated and side effects were minimal. CONCLUSIONS Low-intensity IR laser therapy appears safe but, at least within the parameters of this study, is not beneficial in the treatment of plantar fasciitis.

Complications of interlaminar cervical epidural steroid injections: a review of the literature.

Study Design. A comprehensive literature review. Objectives. To review and critically evaluate the past literature focusing on incidence and clinical presentation of complications associated with interlaminar cervical epidural steroid injection (ICESI). The overall goal is to guide the direction of future research and improve clinical care by increasing awareness of complications, their presentations, and management. Summary of Background Data. Although ICESI is considered a relatively safe procedure, a number of minor and major complications have been reported across the literature. Thus far, reports of complications are limited to retrospective studies, case reports, and data extrapolated from lumbar and thoracic procedures. As a result, the past literature has been of limited value with regard to facilitating both clinical care and future research efforts. Methods. Medical databases were searched for studies of ICESI. The bibliographies of these papers were then searched as well. Papers focusing on cervical techniques that did not involve injection into the epidural space were discarded, as were studies of thoracic and lumbar spine injections. Reports of complications associated with ICESI were further subdivided into major and minor categories. Results. The reported rate of complications associated with ICESI varied between 0 and 16.8%. Conclusion. There are significant limitations in the available literature discussing the complications associated with ICESI, but they strongly suggest that ICESI is a relatively safe procedure. Numerous potential adverse reactions have been associated with ICESI, with the vast majority being minor and transient in nature. However, serious complications may also result and may be technique related. Injectionists should be aware of the clinical presentations, rates, potential consequences, and appropriate techniques to avoid these complications. More studies are needed with specific focus on cervical complication rates, standardization of injection techniques, and differentiation between complications and poor efficacy. In addition, the use of a prospective randomized blinded controlled design would be beneficial.

Outcomes After Ultrasound-Guided Platelet-Rich Plasma Injections for Chronic Tendinopathy: A Multicenter, Retrospective Review

To determine whether ultrasound‐guided platelet‐rich plasma (PRP) injections are an effective treatment for chronic tendinopathies.

Nonoperative Treatment of Low Back Pain

Low back pain is a common problem with substantial social and economic issues. Physicians continue to have difficulty managing this condition despite an increased awareness of its magnitude. In addition, there is a misperception about the outcome of patients affected with low back pain; most continue to suffer from pain. We present a nonoperative approach and review various diagnostic and treatment strategies with respect to both scientific and clinical merit. Although many treatment strategies have not been well proved in the scientific literature, thoughtful review of the available information provides a basis for the use of these treatment methods in the patient with refractory pain. This approach can be used in conjunction with existing information to assist clinicians in the management of patients with acute low back pain.

Functional performance deficits in athletes with previous lower extremity injury.

ObjectiveTo evaluate the influence of previously treated, though clinically resolved, lower extremity injury on performance in a timed 20-meter shuttle run. DesignCase control study. SettingNational Collegiate Athletic Association (NCAA) Division I college during the 2000/2001 preparticipation physicals. ParticipantsNCAA Division I athletes (n = 213) participated in this research study. Athletes were excluded if they presently had an unresolved lower extremity injury or low back pain. Main Outcome MeasuresTime to complete a 20-meter shuttle run was recorded. Previous lower extremity injury and college year were recorded via a short questionnaire. ResultsA significantly slower response time on the 20-meter shuttle run was observed in freshman athletes with a history of a lower extremity injury, as compared with freshmen without a previous injury (p = 0.01). No significant difference was noted in nonfreshman collegiate athletes regardless of injury history (p = 0.98). ConclusionKinetic chain deficits may exist long after symptomatic recovery from injury resulting in functional deficits, which may be missed on a standard physical assessment. The slower shuttle run times observed in freshmen with previous lower extremity injury may be a manifestation of insufficient treatment received at the high school level or the benefit of a mandatory core strengthening program in returning athletes. Further study is necessary to identify and validate the cause-and-effect relationship. Clinical RelevanceThis study may support residual functional deficits in incoming college athletes, which may be related to inadequate care in the high school setting.

Evidence-informed management of chronic low back pain with nonsteroidal anti-inflammatory drugs, muscle relaxants, and simple analgesics

The management of chronic low back pain (CLBP) has proven to be very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing amongst available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence-Informed Management of Chronic Low Back Pain Without Surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.

A Call for a Standard Classification System for Future Biologic Research: The Rationale for New PRP Nomenclature

Autologous cell therapies including platelet‐rich plasma (PRP) and bone marrow concentrate (BMC) are increasingly popular options for soft tissue and joint‐related diseases. Despite increased clinical application, conflicting research has been published regarding the efficacy of PRP, and few clinical publications pertaining to BMC are available. Preparations of PRP (and BMC) can vary in many areas, including platelet concentration, number of white blood cells, presence or absence of red blood cells, and activation status of the preparation. The potential effect of PRP characteristics on PRP efficacy is often not well understood by the treating clinician, and PRP characteristics, as well as the volume of PRP delivered, are unfortunately not included in the methods of many published research articles. It is essential to establish a standard reporting system for PRP that facilitates communication and the interpretation and synthesis of scientific investigations. Herein, the authors propose a new PRP classification system reflecting important PRP characteristics based on contemporary literature and recommend adoption of minimal standards for PRP reporting in scientific investigations. Widespread adoption of these recommendations will facilitate interpretation and comparison of clinical studies and promote scientifically based progress in the field of regenerative medicine.