Michael P. Reiman

Nonoperative and Operative Management of Snapping Scapula

Snapping scapula is a painful crepitus of the scapulothoracic articulation. This crepitus is a grinding or snapping noise with scapulothoracic motion that may or may not accompany pain. This condition is commonly seen in overhead-throwing athletes. Treatment of patients with this syndrome begins with nonoperative methods; when nonoperative treatment fails, several surgical options exist. This article will discuss both nonoperative and operative management of this common shoulder condition.

Physical fitness predicts functional tasks in individuals with Down syndrome.

UNLABELLED Individuals with Down syndrome (DS) exhibit reduced strength and aerobic capacity, which may limit their ability to perform functional tasks of daily living. PURPOSE This study was conducted to examine the relationship between timed performance on functional tasks of daily living and age, knee isometric strength, and peak aerobic capacity in a group of individuals with DS. METHODS This was a cross-sectional study involving 35 individuals (27 +/- 7.5 yr) with DS. Participants completed an isometric test of knee extensor and flexor strength, an individualized exercise test to measure peak aerobic capacity, and three timed functional tasks of daily living, which included chair rise, gait speed, and stair ascent and descent. Multiple regression analyses were performed to examine the relationship between timed task performance and age, knee isometric strength, and peak aerobic capacity. RESULTS The multiple regression models explained 11-29% of the variance in timed task performance. Knee extensor strength was the most influential variable in predicting timed task performance (squared semipartial correlation coefficient [sr2] = 0.11-0.20), followed by aerobic capacity (sr2 = 0.10-0.14). Age was not a significant predictor of timed task performance. CONCLUSION These findings suggest that physical fitness (defined here as aerobic capacity and knee extensor strength) limits the ability of adults with DS to perform functional tasks of daily living. Randomized controlled trials should be performed to test the probable causal relationship between exercises designed to improve physical fitness and functional tasks of daily living.

A literature review of studies evaluating gluteus maximus and gluteus medius activation during rehabilitation exercises

Recently, clinicians have focused much attention on the importance of hip strength for the rehabilitation of not only patients with low back pain but also lower extremity pathology. Properly designing a rehabilitation program for the gluteal muscles requires careful consideration of biomechanical principles, such as length of the external moment arm, gravity, and subject positioning. Understanding the anatomy and function of these muscles also is essential. Electromyography (EMG) provides a useful means to determine muscle activation levels during specific exercises. Descriptions of specific exercises, as they relate to the gluteal muscles, are described. The specific performance of these exercises, the reliability of such EMG measures, and descriptive figures are also detailed. Of utmost importance to practicing clinicians is the interpretation of such data and how it can be best used in exercise prescription when formulating a treatment plan.

Diagnostic accuracy of clinical tests of the hip: a systematic review with meta-analysis

Background Hip Physical Examination (HPE) tests have long been used to diagnose a myriad of intra-and extra-articular pathologies of the hip joint. Useful clinical utility is necessary to support diagnostic imaging and subsequent surgical decision making. Objective Summarise and evaluate the current research and utility on the diagnostic accuracy of HPE tests for the hip joint germane to sports related injuries and pathology. Methods A computer-assisted literature search of MEDLINE, CINHAL and EMBASE databases (January 1966 to January 2012) using keywords related to diagnostic accuracy of the hip joint. This systematic review with meta-analysis utilised the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for the search and reporting phases of the study. Der-Simonian and Laird random effects models were used to summarise sensitivities (SN), specificities (SP), likelihood ratios and diagnostic OR. Results The employed search strategy revealed 25 potential articles, with 10 demonstrating high quality. Fourteen articles qualified for meta-analysis. The meta-analysis demonstrated that most tests possess weak diagnostic properties with the exception of the patellar-pubic percussion test, which had excellent pooled SN 95 (95% CI 92 to 97%) and good specificity 86 (95% CI 78 to 92%). Conclusion Several studies have investigated pathology in the hip. Few of the current studies are of substantial quality to dictate clinical decision-making. Currently, only the patellar-pubic percussion test is supported by the data as a stand-alone HPE test. Further studies involving high quality designs are needed to fully assess the value of HPE tests for patients with intra- and extra-articular hip dysfunction.

Best tests/clinical findings for screening and diagnosis of patellofemoral pain syndrome: a systematic review

BACKGROUND Diagnosis of patellofemoral pain syndrome (PFPS) is commonly performed using a myriad of clinical and imaging-based criteria. OBJECTIVES The objective of this systematic literature review was to summarize the research on accuracy of individual clinical tests/findings for PFPS. DATA SOURCES MEDLINE, ProQuest Nursing and Allied Health, Cochrane Trials, PEDro, and CINAHL. STUDY SELECTION OR ELIGIBILITY CRITERIA: PRISMA guidelines were followed for this review. To be considered for review, the study required: (1) a description of a clinical test or tests used for diagnosing PFPS (including a test that was combined with another finding such as patient history), (2) a report of the diagnostic accuracy of the measures (e.g., sensitivity and specificity), and (3) an acceptable reference standard for comparison. STUDY APPRAISAL OR SYNTHESIS METHODS: Quality Assessment of Studies of Diagnostic Accuracy (QUADAS) scores were completed on each selected article. Sensitivity, specificity, and negative and positive likelihood ratios (LR-/LR+) were calculated for each diagnostic test described. RESULTS The systematic search strategy and hand search revealed 704 potential articles, 9 of which met the criteria for this review; analysing a total of 22 PFPS clinical tests. After assessment using the QUADAS score, 1 of the 9 articles was of high quality. The tests with the highest reported diagnostic value were also associated with studies that had the lowest QUADAS values. CONCLUSION A majority of the studies that have investigated diagnostic accuracy of clinical tests for PFPS demonstrate notable design or reporting biases, and at this stage, determining the best tests for diagnosis of PFPS is still difficult.

Diagnostic accuracy of clinical tests for the diagnosis of hip femoroacetabular impingement/labral tear: a systematic review with meta-analysis

Background Surgery for hip femoroacetabular impingement/acetabular labral tear (FAI/ALT) is exponentially increasing despite lacking investigation of the accuracy of various diagnostic measures. Useful clinical utility of these measures is necessary to support diagnostic imaging and subsequent surgical decision-making. Objective Summarise/evaluate the current diagnostic accuracy of various clinical tests germane to hip FAI/ALT pathology. Methods A computer-assisted literature search of MEDLINE, CINAHL and EMBASE databases using keywords related to diagnostic accuracy of the hip joint, as well as the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for the search and reporting phases of the study. Quality assessment of bias and applicability was conducted using the Quality of Diagnostic Accuracy Studies-2 (QUADAS-2). Random effects models were used to summarise sensitivities (SN), specificities (SP), diagnostic odds ratio (DOR) and respective confidence intervals (CI). Results The employed search strategy revealed 21 potential articles, with one demonstrating high quality. Nine articles qualified for meta-analysis. The meta-analysis demonstrated that flexion-adduction-internal rotation (pooled SN ranging from 0.94 (95% CI 0.90 to 0.97) to 0.99 (95% CI 0.98 to 1.00); DOR 5.71 (95% CI 0.84 to 38.86) to 7.82 (95% CI 1.06 to 57.84)) and flexion-internal rotation (pooled SN 0.96 (95% CI 0.81 to 0.99); DOR 8.36 (95% CI 0.41 to 171.3) tests possess only screening accuracy. Conclusions Few hip physical examination tests for diagnosing FAI/ALT have been investigated in enough studies of substantial quality to direct clinical decision-making. Further high-quality studies across a wider spectrum of hip pathology patients are recommended to discern the confirmed clinical utility of these tests. Trials registration number PROSPERO Registration # CRD42014010144.

A Randomized Controlled Single-Blinded Comparison of Stretching Versus Stretching and Joint Mobilization for Posterior Shoulder Tightness Measured by Internal Rotation Motion Loss

Background: Posterior shoulder tightness, as demonstrated by limited internal rotation range of motion, is a suggested factor in many shoulder pathologies. Methods to increase posterior shoulder mobility may be beneficial. Hypothesis: Shoulder internal rotation range of motion will not change with either of 2 interventions: cross-body stretch alone and cross-body stretch plus posterior capsule joint mobilization. Study Design: Randomized controlled single-blinded clinical trial. Methods: The study comprised 39 college-age asymptomatic participants (7 men, 32 women) who were randomly assigned to 1 of 2 groups: stretching only (n, 20) and stretching plus posterior joint mobilizations (n, 19). All had a between-shoulder difference of internal rotation of 10° or more. Shoulder internal and external rotation was measured before and after a 4-week intervention period and 4 weeks postintervention. Participants in the stretching-only group performed the cross-body stretch on the limited side. Those in the other group (cross-body stretch plus joint mobilization) were treated with posterior joint mobilization techniques on the limited side. Results: Overall means for internal rotation of the treated shoulders significantly increased over baseline at the end of the intervention period and at 4 weeks postintervention. External rotation in all shoulders remained unchanged. By the end of intervention, total motion increased significantly from baseline but decreased significantly from the end of intervention to 4 weeks postintervention. Although not statistically significant, the second group (cross-body stretch plus joint mobilization) had greater increases in internal rotation. At 4 weeks postintervention, the second group had maintained its internal rotation gains to a greater degree than those of the stretching-only group. Conclusion: Internal rotation increased in both groups. Inclusion of joint mobilization in a rehabilitation program created trends toward increased shoulder internal rotation mobility. Clinical Relevance: Both methods—cross-body stretch and cross-body stretch plus joint mobilization—may be beneficial for those with limited internal rotation range of motion.

Femoroacetabular impingement surgery: are we moving too fast and too far beyond the evidence?

Femoroacetabuler impingement (FAI) is becoming increasingly recognised as a potential pathological entity for individuals with hip pain. Surgery described to correct FAI has risen exponentially in the past 10 years with the use of hip arthroscopy. Unfortunately, the strength of evidence supporting both the examination and treatment of FAI does not appear to accommodate this exponential growth. In fact, the direction currently taken for FAI is similar to previously described paths of other orthopaedic and sports medicine pathologies (eg, shoulder impingement, knee meniscus tear) for which we have learned valuable lessons. The time has come for improved terminology, study design, and focus on delineation of successful treatment variables in the interest of those individuals with clinical indications of FAI so that we can appropriately address their needs.

The effect of progressive resistance training on leg strength, aerobic capacity and functional tasks of daily living in persons with Down syndrome

Purpose. The purpose of this study was to examine the effect of progressive resistance training on leg strength, aerobic capacity and physical function in persons with Down syndrome (DS). Method. Thirty persons with DS (age 28 SD 8 years) were assigned to an intervention or control group. The intervention group performed resistance training 2 days per week for 10 weeks. Participants performed tests to measure isometric and isokinetic knee extensor and flexor peak torque, peak aerobic capacity and timed performance on chair rise, walking and stair ascent and descent. Result. Persons with DS receiving the intervention significantly increased their isokinetic knee extensor and flexor peak torque [[Absolute change (post minus pre-value) was 17.0 SD 29.6 and 12.6 SD 18.9 N m, respectively]] and isometric knee extensor peak torque at angles of 45° (2.9 SD 23.2 N m), 60° (3.0 SD 22.9 N m) and 75° (14.2 SD 30.0 N m). These changes were significantly greater than in the control group. In addition, the time to ascend (−0.3 SD 0.8 s) and descend (−0.6 SD 0.9 s) stairs significantly decreased in the intervention group compared to the control group. Conclusion. These findings show that progressive resistance training is an effective intervention for persons with DS to improve leg strength and stair-climbing ability.

Eccentric training for prevention of hamstring injuries may depend on intervention compliance: a systematic review and meta-analysis

Background Hamstring injury is a prevalent muscle injury in sports. Inconclusive evidence exists for eccentric hamstring strengthening to prevent hamstring injuries. One reason for this discrepancy may be the influence intervention non-compliance has on individual study estimates, and therefore pooled estimates. Objective This systematic review aims to determine the effect of eccentric hamstring strengthening on the risk of hamstring injury and quantitatively explores the impact of intervention non-compliance on the precision, heterogeneity and strength of pooled estimates. Methods A computer-assisted literature search of Medline, CINAHL, Cochrane, EMBASE, AMED, SportDiscus and PEDro databases was conducted with keywords related to eccentric strengthening and hamstring injury. The search was conducted from the end of a previous comprehensive review forward (1 December 2008 to 31 December 2013). Random-effects models were used for both main effects and a sensitivity analysis. Pooled estimate precision was measured with a confidence limit ratio (confidence limit ratio (CLR); upper limit divided by the lower limit) and heterogeneity was assessed with I2, Cochranes-Q and τ2. A protocol was not registered for this review. Results Four out of 349 studies met the inclusion criteria. In main effects analysis, eccentric hamstring training did not reduce the risk of hamstring injury (risk ratio [RR]=0.59 ((95% CI 0.24 to 1.44)). This estimate was imprecise (CLR=6.0) with significant heterogeneity (p value 0.02, 69.6% variation and t2=0.57). Subjects compliant with eccentric strengthening had a significant (RR=0.35 ((95% CI 0.23 to 0.55)) reduction in hamstring injuries. This estimate was precise (CLR=2.4) and homogenous (p value=0.38, 2.8% variation and t2=0.007). Conclusions The null-biased effect in using intent-to-treat methods from intervention non-compliance has a substantial impact on the precision, heterogeneity and the direction and strength of pooled estimates. Eccentric strengthening, with good compliance, appears to be successful in prevention of hamstring injury.