Michael J. Mullaney

The role of hip muscle function in the treatment of patellofemoral pain syndrome.

Background Previous literature has associated hip weakness with patellofemoral pain syndrome. Hypothesis Improvements in hip strength and flexibility are associated with a decrease in patellofemoral pain. Study Design Cohort study; Level of evidence, 2. Methods Thirty-five patients with patellofemoral pain syndrome, aged 33 ± 16 years (29 women, 6 men; 43 knees), were evaluated and placed on a 6-week treatment program. Hip flexion, abduction, and adduction strengths, Thomas and Ober test results, and visual analog scale scores for pain with activities of daily living as well as with exercise were documented on initial evaluation and again 6 weeks later. Treatment consisted of strength and flexibility exercises primarily focusing on the hip. Results Hip flexion strength improved by 35% ± 8.4% in 26 lower extremities treated successfully, compared with –1.8% ± 3.5% in 17 lower extremities with an unsuccessful outcome (P< .001). Before treatment, there were positive Ober test results in 39 of 43 lower extremities; positive Thomas test results were seen in 31 of 43 lower extremities. A successful outcome with a concurrent normalized Ober test result was seen in 83% (20/24) of lower extremities, and successful outcomes with normalized Thomas test results were seen in 80% (16/20) of lower extremities. A combination of improved hip flexion strength (> 20%) as well as normal Ober and Thomas test results was seen in 93% of successfully treated cases (14/15 lower extremities), compared with 0% success (0/5 lower extremities) if there was no change in hip flexion strength (< 20%) and if Ober and Thomas test results remained positive. Conclusions Improvements in hip flexion strength combined with increased iliotibial band and iliopsoas flexibility were associated with excellent results in patients with patellofemoral pain syndrome.

Risk Factors for Noncontact Ankle Sprains in High School Football Players The Role of Previous Ankle Sprains and Body Mass Index

Background In a previous study, we noted a possible connection between an athletes weight and risk of ankle sprain. Hypothesis A high body mass index and a history of a previous ankle sprain increase the risk of a subsequent noncontact sprain. Study Design Cohort study; Level of evidence, 2. Methods One hundred fifty-two athletes from 4 football teams were observed (2 varsity and 2 junior varsity). Two teams were observed for 3 seasons, and 2 teams were observed for 1 season. Before each season, body mass, height, history of previous ankle sprains, and ankle tape or brace use were recorded. Results There were 24 ankle sprains, of which 15 were noncontact inversion sprains (11 grade I, 3 grade II, 1 grade III; incidence, 1.08 per 1000 athlete-exposures). Injury incidence was higher in athletes with previous ankle injuries (2.60 vs 0.39; P< .001). Body mass index was also a risk factor (P< .05): injury incidence was 0.52 for players with a normal body mass index, 1.05 for players at risk of overweight, and 2.03 for overweight players. Injury incidence was 0.22 for normal-weight players with no previous ankle sprain compared with 4.27 for overweight players who had a previous sprain. Conclusion An overweight player who had a previous ankle sprain was 19 times more likely to sustain a noncontact ankle sprain than was a normal-weight player with no previous ankle sprain. Clinical Relevance Ankle sprain prevention strategies should be targeted at football players with a high body mass index and a history of previous ankle sprains.

Risk Factors for Noncontact Ankle Sprains in High School Athletes The Role of Hip Strength and Balance Ability

Background Ankle sprains are among the most common sports injuries. Hypothesis Poor balance as measured on a balance board and weakness in hip abduction strength are associated with an increased risk of noncontact ankle sprains in high school athletes. Study Design Cohort study; Level of evidence, 2. Methods One hundred sixty-nine high school athletes (101 male athletes, 68 female athletes) from football, mens basketball, mens soccer, womens gymnastics, womens basketball, and womens soccer were observed for 2 years. Balance in single-limb stance on an instrumented tilt board and hip flexion, abduction, and adduction strength (handheld dynamometer) were assessed in the preseason. Body mass, height, generalized ligamentous laxity, previous ankle sprains, and ankle tape or brace use were also documented. Results There were 20 noncontact inversion ankle sprains. Balance ability (P= .72), hip abduction strength (P= .66), hip adduction strength (P= .41), and hip flexion strength (P= .87) were not significant risk factors for ankle sprains. The incidence of grade II and grade III sprains was higher in athletes with a history of a previous ankle sprain (1.12 vs 0.26 per 1000 exposures, P< .05). A higher body mass index in male athletes was associated with increased risk (P< .05). The combination of a previous injury and being overweight further increased risk (P< .01). Conclusion Balance as measured on a balance board and hip strength were not significant indicators for noncontact ankle sprains. The apparent high injury risk associated with the combination of a history of a previous ankle sprain and being overweight in male athletes warrants further examination.

Correction of Posterior Shoulder Tightness Is Associated With Symptom Resolution in Patients With Internal Impingement

Background Glenohumeral internal rotation deficit (GIRD) and posterior shoulder tightness have been linked to internal impingement. Purpose To determine if improvements in GIRD and/or decreased posterior shoulder tightness are associated with a resolution of symptoms. Study Design Cohort study; Level of evidence, 3. Methods Passive internal rotation and external rotation (ER) range of motion (ROM) at 90° of shoulder abduction and posterior shoulder tightness (cross-chest adduction in side lying) were assessed in 22 patients with internal impingement (11 men, 11 women; age 41 ± 13 years). Treatment involved stretching and mobilization of the posterior shoulder. The Simple Shoulder Test (SST) was administered on initial evaluation and discharge. Changes in GIRD, ER ROM, and posterior shoulder tightness were compared between patients with complete resolution of symptoms versus patients with residual symptoms using independent t tests. Results Patients had significant GIRD (35°), loss of ER ROM (23°), and posterior shoulder tightness (35°) on initial evaluation (all P < .01). Physical therapy (7 ± 2 weeks; range, 3-12 weeks) improved GIRD (26° ± 14°; P < .01), ER ROM loss (14° ± 20°), and posterior shoulder tightness (27° ±19°). The SST improved from 5 ± 3 to 11 ± 1 (P < .01). A greater improvement in posterior shoulder tightness was seen in patients with complete resolution of symptoms (n = 12) compared with patients with residual symptoms (35° vs 18°; P < .05). Improvements in GIRD and ER ROM loss were not different between groups (GIRD, 25° vs 28°, P = .57; ER ROM, 14° vs 15°, P = .84). Conclusion Resolution of symptoms after physical therapy treatment for internal impingement was related to correction of posterior shoulder tightness but not correction of GIRD.

Reliability of shoulder range of motion comparing a goniometer to a digital level

Abstract The clinical use of digital levels, for joint measurement, may be a viable alternative to standard goniometry. The purpose of this study was to determine the intra- and intertester reliability of a construction grade digital level compared to the standard universal goniometer for measurements for active assisted shoulder range of motion (ROM). Two experienced physical therapists measured shoulder flexion, external rotation (ER), and internal rotation (IR) ROM bilaterally, on two different occasions, in 20 patients (9 males, 11 females, 18–79 years old) with unilateral shoulder pathology, using a goniometer and a digital level. Relative reliability was assessed by using intraclass correlation coefficients (ICC), and absolute reliability was assessed by using 95% limits of agreement (LOA). Intratester ICCs ranged from 0.91 to 0.99, and LOA ranged from 3° to 9° for measurements made with the goniometer and digital level. Intertester ICCs ranged from 0.31 to 0.95, and LOA ranged from 6° to 25°. For the comparison of goniometric vs. digital level ROM, ICCs ranged from 0.71 to 0.98. ER and IR ROM were 3–5° greater for the digital level than the goniometer (p < 0.01). Goniometric vs. digital level LOA ranged from 6° to 11° for shoulder flexion. Both measurement techniques had excellent intratester reliability, but for intertester reliability ICCs were 20% lower and LOA were 2.3 times higher than intratester values. Reliability estimates were similar between the digital level and the goniometer. However, because glenohumeral rotation was 3–5° greater for the digital level than the goniometer (systematic error), the two methods cannot be used interchangeably. On the basis of the average intratester LOA for the goniometer and the digital level, a change of 6–11° is needed to be certain that true change has occurred. For comparison of measures made by two different therapists, a change is of 15° is required to be certain a true change has occurred. A digital level can be used to reliably measure shoulder ROM but should not be used interchangeably with a standard goniometer.

The Effectiveness of a Balance Training Intervention in Reducing the Incidence of Noncontact Ankle Sprains in High School Football Players

Background A high body mass index and previous ankle sprains have been shown to increase the risk of sustaining noncontact inversion ankle sprains in high school football players. Hypothesis Stability pad balance training reduces the incidence of noncontact inversion ankle sprains in football players with increased risk. Study Design Cohort study; Level of evidence, 2. Methods Height, body mass, history of previous ankle sprains, and current ankle brace/tape use were documented at the beginning of preseason training in 2 high school varsity football teams for 3 consecutive years (175 player-seasons). Players were categorized as minimal risk, low risk, moderate risk, and high risk based on the history of previous ankle sprain and body mass index. Players in the low-, moderate-, and high-risk groups (ie, any player with a high body mass index and/or a previous ankle sprain) were placed on a balance training intervention on a foam stability pad. Players balanced for 5 minutes on each leg, 5 days per week, for 4 weeks in preseason and twice per week during the season. Postintervention injury incidence was compared with preintervention incidence (107 players-seasons) for players with increased risk. Results Injury incidence for players with increased risk was 2.2 injuries per 1000 exposures (95% confidence interval, 1.1-3.8) before the intervention and 0.5 (95% confidence interval, 0.2-1.3) after the intervention (P < .01). This represents a 77% reduction in injury incidence (95% confidence interval, 31%-92%). Conclusion The increased risk of a noncontact inversion ankle sprain associated with a high body mass index and a previous ankle sprain was eliminated by the balance training intervention.

Muscle Strength and Range of Motion in Adolescent Pitchers With Throwing-Related Pain Implications for Injury Prevention

Background A high prevalence of throwing-related shoulder and elbow pain has been documented in adolescent baseball pitchers. Hypothesis Pitchers with a history of throwing-related pain will have weakened dominant-arm posterior shoulder musculature and greater dominant-arm glenohumeral total range of motion (ROM) loss compared with pitchers without throwing-related pain. Study Design Controlled laboratory study. Methods Twenty-three adolescent pitchers (age 15.7 ±1.4 years) were tested. Twelve pitchers had throwing-related pain in the prior season and were currently symptom-free, while the remaining 11 pitchers had no such history of pain. Internal and external rotation ROM and muscle strength (lower trapezius, middle trapezius, rhomboids, latissimus dorsi, supraspinatus, internal rotators, external rotators) were measured bilaterally. Dominant versus nondominant differences in ROM and strength were compared between pitchers with and without throwing-related pain. Results As a whole, the group of 23 pitchers had a loss of internal rotation ROM (13° ± 10°, P < .001) and gain in external rotation ROM (11° ± 10°, P < .001) on the dominant versus nondominant arm, with no effect on total ROM (2° ± 7° loss, P = .14). There was no difference in bilateral comparison of total ROM between pitchers with and without throwing-related pain. Dominant versus nondominant muscle strength was lower (P < .05) for the pain group versus nonpain group for the middle trapezius (7% ± 19% vs 22% ± 12%) and supraspinatus (−4% ± 27% vs 14% ± 14%) and higher (P < .05) for the internal rotators (19% ± 14% vs 6%±12%). Conclusion Throwing-related pain in this population may be due to the inability of weakened posterior shoulder musculature to tolerate stress imparted on it by adaptively strengthened propulsive muscles. Clinical Relevance Selective posterior shoulder strengthening may be indicated in rehabilitative and injury prevention programs for adolescent pitchers.

Weakness in End-Range Plantar Flexion After Achilles Tendon Repair

Background Separation of tendon ends after Achilles tendon repair may affect the tendon repair process and lead to postoperative end-range plantarflexion weakness. Hypothesis Patients will have disproportionate end-range plantarflexion weakness after Achilles tendon repair. Study Design Descriptive laboratory study. Methods Four-strand core suture repairs of Achilles tendon were performed on 1 female and 19 male patients. Postoperatively, patients were nonweightbearing with the ankle immobilized for 4 weeks. Plantarflexion torque, dorsiflexion range of motion, passive joint stiffness, toe walking, and standing single-legged heel rise (on an incline, decline, and level surface) were assessed after surgery (mean, 1.8 years postoperative; range, 6 months-9 years). Maximum isometric plantarflexion torque was measured at 20° and 10° of dorsiflexion, neutral, and 10° and 20° of plantar flexion. Percentage strength deficit (relative to noninvolved leg) was computed at each angle. Passive dorsiflexion range of motion was measured goniometrically. Passive joint stiffness was computed from increase in passive torque between 10° and 20° of dorsiflexion, before isometric contractions. Results Significant plantarflexion weakness was evident on the involved side at 20° and 10° of plantar flexion (34% and 20% deficits, respectively; P < .001), with no torque deficits evident at other angles (6% at neutral, 3% at 10° of dorsiflexion, 0% at 20° of dorsiflexion). Dorsiflexion range of motion was not different between involved and noninvolved sides (P = .7). Passive joint stiffness was 34% lower on the involved side (P < .01). All patients could perform an incline heel rise; 14 patients could not perform a decline heel rise (P < .01). Conclusion Disproportionate weakness in end-range plantar flexion, decreased passive stiffness in dorsiflexion, and inability to perform a decline heel rise are evident after Achilles tendon repair. Possible causes include anatomical lengthening, increased tendon compliance, and insufficient rehabilitation after Achilles tendon repair. Clinical Relevance Impairments will have functional implications for activities (eg, descending stairs and landing from a jump). Weakness in end-range plantar flexion may be an unrecognized problem after Achilles tendon repair.

Upper and Lower Extremity Muscle Fatigue After a Baseball Pitching Performance

Background Previous studies have estimated joint torques and electromyogram activity associated with the pitching motion. Although previous studies have investigated the influence of extended pitching (fatigue) on kinematic and kinetic parameters, no attempts have been made to quantify the fatigue associated with a pitching performance. Purpose Considering previous investigations on muscle activity during pitching, this study investigated muscle fatigue in upper and lower extremity muscle groups after a pitching performance. Study Design Descriptive laboratory study. Methods Thirteen baseball pitchers from 4 universities and 1 independent minor league team were tested before and after 19 games. Pitchers threw an average of 99 pitches during an average of 7 innings. Shoulder, scapular, and lower extremity muscle strengths were assessed using a handheld dynamometer before and after the pitching performances. Results Baseline strength tests revealed that the pitching arm was 12% weaker (P =. 02) in the empty can test (supraspinatus) compared to the contralateral side. Postgame shoulder strength tests revealed selective fatigue of 15% in shoulder flexion (P =. 02), 18% fatigue in internal rotation (P =. 03), and 11% fatigue in shoulder adduction (P =. 01). Minimal fatigue was noted in the empty can test, scapular stabilizers, and hip musculature. Conclusions A trend toward significant baseline strength in internal rotation together with significant selective postgame fatigue on internal rotation of the dominant upper extremity indicate that the internal rotators experience a high performance demand during pitching. Weakness in the empty can test on the dominant arm combined with minimal postgame fatigue was surprising given that studies and injury patterns have indicated a high performance demand on the supraspinatus during pitching.

A Prospectively Randomized Double-Blind Study on the Effect of Initial Graft Tension on Knee Stability after Anterior Cruciate Ligament Reconstruction:

Background No consensus exists on the amount of tension that should be applied to anterior cruciate ligament grafts to best facilitate graft incorporation and re-create normal knee mechanics. Hypothesis Differences in initial graft tension will affect postoperative knee stability. Study Design Prospective, randomized, double-blind clinical trial. Methods Forty-nine patients undergoing bone-patellar tendon-bone autograft anterior cruciate ligament reconstruction by a single surgeon were randomized into high-tension (n = 27) and low-tension (n = 22) groups. Grafts were set at 90 N or 45 N. Arthrometric measurements (KT-1000 arthrometer manual maximum) of anterior tibial displacement and knee range of motion were made before surgery and at 1 week and an average of 20 months after surgery. Knee outcome scores were collected before and after surgery, and a single-leg hop test was also performed at final follow-up. Results After anterior cruciate ligament reconstruction, anterior tibial displacement was significantly greater in the patients in the low-tension group (P < .05). The side-to-side difference in anterior tibial displacement in the high-tension and low-tension groups was 1.1 ± 1.7 mm versus 2.4 ± 2.4 mm 1 week after surgery and 2.2 ± 1.6 mm versus 3.0 ± 2.2 mm at follow-up. Five patients had abnormal anterior tibial displacement (>5 mm side-to-side difference), and all were in the low-tension group (P <.05). Knee outcome scores improved with surgery (P < .01), with similar results for low-tension and high-tension groups. Hop test deficits were not different between groups. Conclusions Initial graft tension affects the restoration of knee stability. A graft tension of 45 N was not sufficient for restoring knee stability.