Joseph H. Feinberg

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.

Low Back Pain in College Athletes: A Prospective Study Correlating Lower Extremity Overuse or Acquired Ligamentous Laxity With Low Back Pain

Study Design. A prospective evaluation of the incidence of low back pain in college athletes was under‐taken. Objectives. To evaluate prospectively leg length discrepancy, hip flexor tightness, and lower extremity acquired laxity or overuse as predictive factors for low back pain in college athletes. Summary of Background Data. A pilot study found an association between low back pain and the factors to be studied. Several allusions to the kinetic chain theory appear in the literature, but little prospective research has been done in examining the effects of lower extremity involvement on the back. Methods. Two‐hundred fifty‐seven college athletes representing nine varsity sports were screened during a preseason sports physical examination. Measures of flexibility, ligamentous stability, leg length discrepancy, and overuse syndromes were recorded. Athletes were observed throughout the ensuing year for low back pain requiring treatment by the athletic trainer. Those athletes with low back pain as the result of direct trauma to the region were excluded from the data. Results. Twenty‐four athletes (9.3%) received treatment for low back pain. Thirteen of 87 women (15%) compared with 11 of 170 men (6%) required treatment for low back pain (P = 0.048). Of 57 athletes with lower extremity acquired laxity or overuse, low back pain developed in 14 (P < 0.001). Conclusions. Athletes with lower extremity acquired ligamentous laxity or overuse may be at risk for the development of noncontact low back pain during athletic competition. Female athletes with lower extremity involvement appeared to have a higher incidence of low back pain treatment compared with their male counter‐parts. Inflexibility of the lower extremities or leg length discrepancy were not associated with future low back pain treatment.

Parsonage-Turner Syndrome

Parsonage-Turner Syndrome (PTS), also referred to as idiopathic brachial plexopathy or neuralgic amyotrophy, is a rare disorder consisting of a complex constellation of symptoms with abrupt onset of shoulder pain, usually unilaterally, followed by progressive neurologic deficits of motor weakness, dysesthesias, and numbness. Although the etiology of the syndrome is unclear, it is reported in various clinical situations, including postoperatively, postinfectious, posttraumatic, and postvaccination. The identification of the syndrome in the postoperative patient remains a challenge as symptoms may easily be attributed to sequelae of surgical positioning, postoperative recovery, or postanesthetic block pain. The purpose of this review is to bring forth salient, identifiable factors which may assist the surgical clinician in identifying the condition sooner. An early and proper diagnosis affords the opportunity to treat the patient accordingly and to the satisfaction of both surgeon and patient.

Teres minor denervation on routine magnetic resonance imaging of the shoulder

ObjectiveTo try to define an association between clinical history and the finding of isolated teres minor denervation on routine magnetic resonance (MR) examination of the shoulder.DesignA retrospective review of all shoulder MR examinations performed at our institution over a 2-year period (n=2,563)PatientsAll patients and MR examinations demonstrating isolated denervation of the teres minor muscle as determined by review of this subset of patients (n=61)ResultsA 3% incidence of isolated teres minor denervation was found. No patient had a clinical history concerning the classic quadrilateral space syndrome, and no patient had a structural lesion in the quadrilateral space.ConclusionsIsolated teres minor denervation is not an uncommon finding on routine shoulder MR imaging and may be associated with pathology other than a structural lesion in and about the axillary neurovascular structures, such as rotator cuff injuries and traction injury on the axillary nerve sustained during a glenohumeral joint translational event.

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.

Spectral analysis during fatigue. Surface and fine wire electrode comparison.

Fine wire (FW) intramuscular electrodes and spectral analysis have not previously been used to quantify metabolic muscle fatigue in deep muscles not accessible with surface electrodes. This study compares initial median frequency (IMF) and decline in median frequency with fatigue (SLOPE) using surface and FW electrodes. Eighteen men performed isometric biceps contractions for 100 s. Electromyographic signals were collected using FW and surface electrodes. The recordings of SLOPE was greater with FW (-0.44 v -0.23 %IMF/s) and IMF was higher (195 v 69 Hz). Intrasession reliability for slope was better with FW electrode (intraclass correlation coefficient (ICC) = 0.74; P<0.0001) than with the surface electrode (ICC = 0.43; P = 0.006), but intersession reliability was best with the surface electrode (ICC = 0.50; P = 0.03). Spectral analysis using FW electrodes provides earlier detection of muscle fatigue and can be used in deep muscles, but the reliability must be improved before clinical application.

Imaging and electrodiagnostic work-up of acute adult brachial plexus injuries

Imaging and electrodiagnostic studies form an essential part of the evaluation of the patient with traumatic brachial plexopathy, enabling clarification of surgical options, prognostication of outcome and formulation of postoperative management. The primary objective of imaging is to identify pre-ganglionic injury indicative of nerve root avulsion. The presence of one or more nerve root avulsion injuries is a critical factor in surgical decision-making and the prognosis of surgical reconstruction. CT myelography is the current imaging modality of choice for this purpose. Initial electrodiagnostic (EDX) testing is ideally performed no sooner than 4 weeks following injury unless otherwise clinically indicated. Follow-up testing can be helpful at approximately 6 week intervals. The sensory nerve amplitudes are the most important component of nerve conduction testing in distinguishing between pre- and post-ganglionic injuries. Electromyographic studies will also assist in the determination of a pre- from post-ganglionic injury, the level of plexus involvement and identify potential donor nerves that may be suitable for use as transfers.

EMG: myths and facts.

Electrodiagnostic testing, more commonly known as the EMG test, to many is a “black box.” It is a commonly ordered test that can provide very definitive information that is often not well understood. A large amount of information is usually provided, yet most clinicians rely primarily on the concluding statements, which may or may not be well substantiated. Added insight into this test demands understanding some basic facts about the “EMG” test and dispelling some of the myths.Electrodiagnostic testing, more commonly known as the EMG test, to many is a Bblack box.^ It is a commonly ordered test that can provide very definitive information that is often not well understood. A large amount of information is usually provided, yet most clinicians rely primarily on the concluding statements, which may or may not be well substantiated. Added insight into this test demands understanding some basic facts about the BEMG^ test and dispelling some of the myths.