Rehabilitation guidelines following arthroscopic shoulder stabilisation surgery for traumatic instability - a Delphi consensus.

BACKGROUND: There is no consistent approach to rehabilitation following arthroscopic shoulder stabilisation surgery (ASSS) in the UK. The aim of this study was to agree a set of post-operative guidelines for clinical practice. METHOD: Expert stakeholders (surgeons, physiotherapists and patients) were identified via professional networks and patient involvement and engagements groups. A three-stage online Delphi study was undertaken. Consensus was defined by the OMERACT threshold of 70% agreement. RESULTS: 11 surgeons, 22 physiotherapists and 4 patients participated. It was agreed patients should be routinely immobilised in a sling for up to 3 weeks but can discard earlier if able. During the immobilisation period, patients should move only within a defined "safe zone." Permitted functional activities include using cutlery, lifting a drink, slicing bread, using kitchen utensils, wiping a table, light dusting, pulling up clothing, washing/drying dishes. Closing car doors or draining saucepans should be avoided. Through range movements can commence after 4 weeks, resisted movements at 6 weeks. Patients can resume light work as they feel able and return to manual work after 12 weeks. Return to non-contact sports when functional markers for return to play are met was agreed. Return to contact sport is based on function & confidence after a minimum of 12 weeks. Additional factors to consider when determining rehabilitation progression: functional/physical milestones, patient's confidence and presence of kinesiophobia. The preferred outcome measure is the Oxford Instability Shoulder Score. CONCLUSION: This consensus provides expert recommendations for the development of rehabilitation guidelines following ASSS. CONTRIBUTION OF THE PAPER.

Rehabilitation following shoulder arthroscopic stabilisation surgery: A survey of UK practice.

Background: Optimal rehabilitation following arthroscopic shoulder stabilisation for traumatic anterior instability is unknown. The purpose of this study was to establish current UK practice for this patient group. Methods: A self-administered online questionnaire was developed and distributed to UK surgeons and physiotherapists. Results: 138 responses were received. Routine immobilisation was reported in 79.7% of responses with a cross-body sling being the preferred position (63.4%). Duration of immobilisation and timescales to initiate movement were highly variable. Return to light work was advised when patients felt able (25.4%) or after 6 weeks (26.1%). 58.7% recommended waiting for 12 weeks to return to manual work. 56% recommended non-contact sport could be resumed after 12 weeks. For contact sport, recommendations varied from 6 weeks (3.8%) to 6 months (5.8%). Psychological readiness was the most frequently cited criteria for return to play (58.6%). Factors such as hyperlaxity (40.6%), age (32.6%) and kinesiophobia (28.3%) were not considered as relevant as reported quality of surgical fixation (50%). Conclusion: There is no clear consensus regarding optimal post-operative rehabilitation following arthroscopic shoulder stabilisation. Further work is required to establish high value, personalised pathways for this patient group.

Kinetic chain revisited: consensus expert opinion on terminology, clinical reasoning, examination, and treatment in people with shoulder pain.

BACKGROUND: The purpose of this study was to reach consensus on the most appropriate terminology and issues related to clinical reasoning, examination, and treatment of the kinetic chain (KC) in people with shoulder pain among an international panel of experts. METHODS: A 3-round Delphi study that involved an international panel of experts with extensive clinical, teaching, and research experience in the study topic was conducted. A search equation of terms related to the KC in Web of Science and a manual search were used to find the experts. Participants were asked to rate items across 5 different domains (terminology, clinical reasoning, subjective examination, physical examination, and treatment) using a 5-point Likert-type scale. An Aiken coefficient of validity (V) ≥0.7 was considered indicative of group consensus. RESULTS: The participation rate was 30.2% (n = 16), whereas the retention rate was high throughout the 3 rounds (100%, 93.8%, and 100%). A total of 15 experts from different fields and countries completed the study. After the 3 rounds, consensus was reached on 102 items: 3 items were included in the "terminology" domain; 17 items, in the "rationale and clinical reasoning" domain; 11 items, in the "subjective examination" domain; 44 items, in the "physical examination" domain; and 27 items, in the "treatment" domain. Terminology was the domain with the highest level of agreement, with 2 items achieving an Aiken V of 0.93, whereas the domains of physical examination and treatment of the KC were the 2 areas with less consensus. Together with the terminology items, 1 item from the treatment domain and 2 items from the rationale and clinical reasoning domain reached the highest level of agreement (V = 0.93 and V = 0.92, respectively). CONCLUSION: This study defined a list of 102 items across 5 different domains (terminology, rationale and clinical reasoning, subjective examination, physical examination, and treatment) regarding the KC in people with shoulder pain. The term "KC" was preferred and a agreement on a definition of this concept was reached. Dysfunction of a segment in the chain (ie, weak link) was agreed to result in altered performance or injury to distal segments. Experts considered it important to assess and treat the KC in particular in throwing or overhead athletes and agreed that no one-size-fits-all approach exists when implementing shoulder KC exercises within the rehabilitation process. Further research is now required to determine the validity of the identified items.

2022 Bern Consensus Statement on Shoulder Injury Prevention, Rehabilitation, and Return to Sport for Athletes at All Participation Levels.

SYNOPSIS: There is an absence of high-quality evidence to support rehabilitation and return-to-sport decisions following shoulder injuries in athletes. The Athlete Shoulder Consensus Group was convened to lead a consensus process that aimed to produce best-practice guidance for clinicians, athletes, and coaches for managing shoulder injuries in sport. We developed the consensus via a 2-round Delphi process (involving more than 40 content and methods experts) and an in-person meeting. This consensus statement provides guidance with respect to load and risk management, supporting athlete shoulder rehabilitation, and decision making during the return-to-sport process. This statement is designed to offer clinicians the flexibility to apply principle-based approaches to managing the return-to-sport process within a variety of sporting backgrounds. The principles and consensus of experts working across multiple sports may provide a template for developing additional sport-specific guidance in the future. J Orthop Sports Phys Ther 2022;52(1):11-28. doi:10.2519/jospt.2022.10952.

An investigation of a Kerlan-Jobe Orthopaedic Clinic shoulder and elbow score in elite canoe slalom: Establishing measurement properties to make practice recommendations.

OBJECTIVE: To investigate the test-retest reliability and validity of the Kerlan-Jobe Orthopaedic Clinic shoulder and elbow score (KJOC) in elite Canoe Slalom athletes and determine its ability to predict future shoulder pain. DESIGN: Observational study with embedded test-retest reliability study. SETTING: British Canoe Slalom National Training Centre. PARTICIPANTS: Nineteen athletes from the British Canoe Slalom team for the 2019 season. MAIN OUTCOME MEASURES: The KJOC was completed at the start of winter training and start of the 2019 competitive season. Current, historical (6-months pre-questionnaire) and prospective (4-months post-questionnaire) shoulder injuries were recorded. RESULTS: Test-retest reliability was found to be excellent (ICC3,1 = 0.97), with a minimal detectable change (MDC95%) of 6.7. Compared to uninjured athletes, currently injured and historically injured athletes scored significantly lower (p = 0.002 and p = 0.011, respectively), with the difference between means > MDC95%. A cut-off of 88 was found to be predictive of shoulder pain (AUC: 0.779; sensitivity: 0.60; specificity: 0.95; positive likelihood ratio: 11.4). CONCLUSION: The KJOC demonstrated excellent reliability and can distinguish between athletes with and without current or historical shoulder pain. A KJOC score of <88 was associated with increased risk of shoulder pain. The KJOC should be completed as part of a risk profile for shoulder pain.

The Test-Retest Reliability of Bilateral and Unilateral Force Plate-Derived Parameters of the Countermovement Push-Up in Elite Boxers.

CONTEXT: Maximal power describes the ability to immediately produce power with the maximal velocity at the point of release, impact, and/or take off-the greater an athlete's ability to produce maximal power, the greater the improvement of athletic performance. In reference to boxing performance, regular consistent production of high muscular power during punching is considered an essential prerequisite. Despite the importance of upper limb power to athletic performance, presently, there is no gold standard test for upper limb force development performance. OBJECTIVE: To investigate the test-retest reliability of the force plate-derived measures of countermovement push-up in elite boxers. DESIGN: Test-retest design. SETTING: High Performance Olympic Training Center. PARTICIPANTS: Eighteen elite Olympic boxers (age = 23 [3] y; height = 1.68 [0.39] m; body mass = 70.0 [17] kg). INTERVENTION: Participants performed 5 repetitions of countermovement push-up trials on FD4000 Forcedeck dual force platforms on 2 separate test occasions 7 days apart. MAIN OUTCOME MEASURES: Peak force, mean force, flight time, rate of force development, impulse, and vertical stiffness of the bilateral and unilateral limbs from the force-time curve. RESULTS: No significant differences between the 2 trial occasions for any of the derived bilateral or unilateral performance measures. Intraclass correlation coefficients indicated moderate to high reliability for performance parameters (intraclass correlation coefficients = .68-.98) and low coefficient of variation (3%-10%) apart from vertical stiffness (coefficient of variation = 16.5%-25%). Mean force demonstrated the greatest reliability (coefficient of variation = 3%). In contrast, no significant differences (P < .001) were noted between left and right limbs (P = .005-.791), or between orthodox or southpaw boxing styles (P = .19-.95). CONCLUSION: Force platform-derived kinetic bilateral and unilateral parameters of countermovement push-up are reliable measures of upper limb power performance in elite-level boxers; results suggest unilateral differences within the bilateral condition are not the norm for an elite boxing cohort.

Intra-rater reliability, inter-rater reliability and minimal detectable change of the posterior shoulder endurance test in elite athletes.

OBJECTIVE: Investigate intra-rater and inter-rater reliability of the posterior shoulder endurance test (PSET) and calculate minimal detectable change (MDC) to establish measurement properties and inform use of the PSET in practice. STUDY DESIGN: Test-retest reliability. SETTING: British Canoe Slalom National Training Centre. PARTICIPANTS: Twelve participants (7 male, 5 female; 22.5 ± 4.48 years; 73.4 ± 6.36 kg) were investigated by two physiotherapists with >10 years' experience. MAIN OUTCOME MEASURE: Intraclass correlation coefficients (ICC) were calculated for intra-rater reliability (ICC 3,1) and inter-rater reliability (ICC 2,1) and used to calculate MDC. RESULTS: Intra-rater reliability scores were 0.84 and 0.85 for rater A and B, respectively, with 95% confidence interval (CI) crossing moderate to excellent reliability for both raters (0.5-0.75 and > 0.9). Inter-rater reliability scores were 0.74 and 0.63 at baseline and follow-up, respectively, with 95% CI crossing poor to good reliability in both time points (<0.5 and >0.75). MDC95% for intra-rater scores was 6 repetitions, MDC95% for inter-rater scores was 8 repetitions at baseline and 9 repetitions at follow-up. CONCLUSION: The PSET has acceptable intra-rater reliability but further work is needed to narrow the CI to an appropriate level for inter-rater reliability. The MDC calculated helps clinicians interpret changes in tests scores.

Investigation of the Closed Kinetic Chain Upper Extremity Stability Test in elite canoe/kayak slalom athletes.

OBJECTIVE: To investigate the correlation of arm length with different CKCUEST measures and determine if a modification of the test position (modified-CKCUEST), or normalisation of the CKCUEST (normalised-CKCUEST) score after testing, control for arm length most effectively. STUDY DESIGN: Quasi Experimental. SETTING: British Canoe Slalom National Training Centre. PARTICIPANTS: Thirteen (5 male, 8 female) asymptomatic national squad canoe/kayak slalom athletes were recruited during winter profiling. MAIN OUTCOME MEASURE: Three measures of the CKCUEST were investigated. The CKCUEST, hands 36 inches apart; modified-CKCUEST, hands arm width apart (measured as C7 spinous process to tip of middle finger); and normalised-CKCUEST (measured as CKCUEST score/arm length). RESULTS: A significant positive correlation was found between arm length and the CKCUEST score (r = 0.807; p = 0.001) and normalised-CKCUEST score (r = 0.654; p = 0.015). No significant correlation was found between the modified-CKCUEST score and arm length (p = 0.745). A statistically significant difference between narrow and wide hand positions, greater than the minimal detectable change, was found (p = 0.000). CONCLUSIONS: Arm length has a significant impact on CKCUEST score. The modified-CKCUEST score corrected for arm length where the normalised-CKCUEST score did not. Modifying the CKCUEST to individual anthropometrics needs to be performed pre-testing when comparisons are being made between individuals or groups.

The epidemiology of injuries in English professional squash; A retrospective analysis between 2004 and 2015.

OBJECTIVES: There have been no reported comprehensive injury reports of elite squash players during training and competition. We reviewed the reported injuries during training and competition during 2004-2015. DESIGN: A retrospective analysis of the injury records was carried out between the periods of 2004-2015 of all athletes who were funded by England squash. SETTING: In competition and training. PARTICIPANTS: Elite England Squash players, 67 athletes (45 males, 22 females), with an age range of 18-35 (average 25 years). MAIN OUTCOME MEASURES: The players' age, sex, location, region affected and description of each injury. RESULTS: Injury data was collected from The main region of the body injured was the lower limb: 76.48%, broken down further as: ankle/heel - 20.81%; thigh - 12.69%; knee -10.83%; hip/groin - 9.48%; buttock - 7.45%; lower leg - 7.61%; and foot - 7.61%. CONCLUSIONS: Professional squash players have a high incidence of lower limb injuries from participation in their sport. The majority of these injuries occur around the ankle and heel, and are of soft tissue in nature.

The Test-Retest Reliability of Force Plate-Derived Parameters of the Countermovement Push-Up as a Power Assessment Tool.

CONTEXT: Muscular power output of the upper limb is a key aspect of athletic and sporting performance. Maximal power describes the ability to immediately produce power with maximal velocity at the point of release, impact, or takeoff, with research highlighting that the greater an athlete's ability to produce maximal power, the greater the improvement in athletic performance. Despite the importance of upper-limb power for athletic performance, there is presently no gold-standard test for upper-limb force development performance. OBJECTIVE: The aim of this study was to investigate the test-retest reliability of force plate-derived measures of the countermovement push-up in active males. DESIGN: Test-retest design. SETTING: Controlled laboratory. PARTICIPANTS: Physically active college athletes (age 24 [3] y, height 1.79 [0.08] m, body mass 81.7 [9.9] kg). INTERVENTION: Subjects performed 3 repetitions of maximal effort countermovement push-up trials on Kistler force plates on 2 separate test occasions 7 days apart. MAIN OUTCOME MEASURES: Peak force, mean force, flight time, rate of force development, and impulse were analyzed from the force-time curve. RESULTS: No significant differences between the 2 trial occasions were observed for any of the derived performance measures. Intraclass correlation coefficient and within-subject coefficient of variation calculations indicated performance measures to have moderate to very high reliability (intraclass correlation coefficient = .88-.98), coefficient of variation = 5.5%-14.1%). Smallest detectable difference for peak force (7.5%), mean force (8.6%), and rate of force development (11.2%) were small to moderate. CONCLUSION: Force platform-derived kinetic parameters of countermovement push-up are reliable measurements of power in college-level athletes.

Vibration as an adjunct to exercise: its impact on shoulder muscle activation.

PURPOSE: There is an interest within elite sport in understanding the impact of a vibrating platform as an adjunct to exercise in the training and rehabilitation of throwing athletes. However, there has been no comprehensive evaluation of its impact on the rotator cuff muscles or its effect on the timing of shoulder muscle recruitment more globally. METHODS: Twenty healthy participants were recruited with EMG recorded from 15 shoulder girdle muscles. Isometric shoulder flexion at 25% maximal voluntary contraction was performed in three testing scenarios [no vibration; whole body vibration (WBV); and arm vibration (AV)]. A press up and triceps dips with and without vibration were also performed. Muscular recruitment was assessed pre- and post-vibration exposure as participants initiated forward flexion. RESULTS: Activation of the anterior deltoid (p = 0.002), serratus anterior (p = 0.004), and rotator cuff muscles (p = 0.004-0.022) occurred significantly earlier following exposure to vibration. Significantly greater activation was seen in the anterior, middle and posterior deltoid, upper, middle and lower trapezius, serratus anterior, teres major, latissimus dorsi, supraspinatus, and infraspinatus when the isometric contraction was performed with either WBV and/or AV (p = < 0.001-0.040). Similarly, increased activation was also demonstrated during the press up and triceps dips when performed with vibration. CONCLUSION: The use of vibration as an adjunct to exercise provokes a near global increase in shoulder muscle activation level. Furthermore, exposure to vibration alters muscular recruitment improving readiness for movement. This has potential implications within elite sport for both training and game preparation; however, further longitudinal work is required.

The short-term effect of swimming training load on shoulder rotational range of motion, shoulder joint position sense and pectoralis minor length.

BACKGROUND: Shoulder pain or injury is the most common issue facing elite competitive swimmers and the most frequent reason for missed or modified training. Literature suggests that highly repetitive upper limb loading leads to inappropriate adaptations within the shoulder complex. The most likely maladaptations to occur are variations in shoulder rotational range of motion, reduction in joint position sense and shortened pectoralis minor length. This has yet to have been confirmed in experimental studies. The aim of this study was to investigate the short-term effects of swimming training load upon internal and external rotation range of motion, joint position sense and pectoralis minor length. METHOD: Sixteen elite swimmers training in the British Swimming World Class programme participated. Measures of internal and external range of motion, joint position sense error score and pectoralis minor length were taken before and after a typical 2 h swimming session. RESULTS: Following swimming training shoulder external rotation range of motion and pectoralis minor length reduced significantly (-3.4°, p = <0.001 and -0.7 cm, p = <0.001, respectively), joint position sense error increased significantly (+2.0° error angle, p = <0.001). Internal rotation range of motion demonstrated no significant change (-0.6, p = 0.53). DISCUSSION: This study determined that elite level swimming training results in short-term maladaptive changes in shoulder performance that could potentially predispose them to injury.

Can grip strength be used as a surrogate marker to monitor recovery from shoulder fatigue?

Muscular fatigue impacts on normal shoulder function, which is particularly pertinent to throwing athletes. This study aimed to investigate the relationship between grip strength and shoulder muscle fatigue to evaluate the role of grip strength as a surrogate measure for upper limb performance. Twenty healthy participants were recruited. EMG was recorded from 15 shoulder muscles during different fatiguing contractions: an initial baseline recording (Fat-Baseline); after a shoulder exhausting exercise regime (Fat-Exhaustion); and after a 10 min rest period (Fat-Recovery). Grip strength was similarly measured in the same conditions. Grip strength differed significantly across the testing scenarios (p = 0.012-<0.001). Greater fatigue was seen in anterior deltoid, middle deltoid, posterior deltoid and supraspinatus in the Fat-Exhaustion contraction as compared to the Fat-Baseline contraction (p = <0.001-0.043). Greater fatigue was seen during the Fat-Recovery contraction for the trapezius, serratus anterior and biceps brachii as compared to the Fat-Exhaustion contraction (p = 0.008-0.038). Grip strength decreased following an exhausting exercise protocol but recovered to baseline following a rest period. Conversely, EMG indices of fatigue did not recover. Additional fatigue was seen reflecting a reorganisation of movement strategy. Therefore, susceptibility to injury still exists if grip strength alone is used as a barometer of upper limb performance.

Anterior internal impingement of the shoulder in rugby players and other overhead athletes.

BACKGROUND/OBJECTIVE: Impingement syndromes are a common cause of shoulder pain in overhead athletes. Anterior internal impingement is a recently suggested mechanism for activity-related pain of the shoulder. Impingement syndromes were initially described to occur due to repetitive or excessive contact between the rotator cuff and other structures in the shoulder. METHODS: This is a retrospective, clinical case study reporting 54 consecutive cases of anterior internal impingement in overhead athletes, of which 28 (51.2%) cases were of rugby players. All had undergone physiotherapy without relief of the symptoms. Of 54, there were 45 male and 9 female patients with an average age of 27 years (range, 17-51). The mean duration from injury to surgery was 40.7 weeks (range, 5-364). Of the 54 patients, 29 (53.7%) were full-time professional and 25 (46.3%) were semiprofessional or recreational athletes. The players associated the onset of pain occurred following an injury in 29/54 cases (53.4%), whereas in the remaining 25 cases (46.2%), a gradual onset of symptoms was described. All 54 patients could demonstrate a "functional impingement sign" in positioning their arm and provoke pain. RESULT: On examination, the examiner could reproduce the same pain in 38/54 (70.3%) patients only. Of the 54 patients, "SLAP tests" including O'Brien's test, Palm up test, and compression rotation test were positive in shoulders of 39 (72.2 %) patients, Jobe's test in 27 (50%), Gerber's lift off test in 6 (11%), and Hawkin's test in 6 (11%) patients. During arthroscopic assessment, impinging flap tears were found in 44 (81.4%) patients from the SLAP, whereas undersurface rotator cuff flap tears were found in 24 (44.4%), flap tears from the anterior or inferior labrum were found in 16 (29.6%), and distal subscapularis flap tears were found in 10 (18.5%) patients. Only in 12/54 patients (22.2%) was an isolated pathology found, in all cases SLAP tears. Treatment included vaporisation and excision of the impinging flaps. In 15/54 (27.7%) patients, repair of an unstable SLAP tear was undertaken using absorbable suture anchors and fibre wires. All athletes returned to their previous activity level within 17.2 weeks (range, 6-36) from surgery and were discharged when they claimed that they were symptom free. CONCLUSION: This series of anterior internal impingement, which we believe is the largest in the literature to date, demonstrates the value of an to assess and successfully treat overhead athletes with anterior impingement syndrome.

Testing Shoulder Pain Mapping.

OBJECTIVE: A previous study on shoulder pain mapping showed specific pain patterns for common shoulder disorders. This study aimed to test those patterns for accuracy, modify shoulder pain mapping as needed, and observe their reliability and validity. METHODS: This prospective study used a two-step process and was undertaken to determine its potential utility in daily practice. New shoulder pain patients marked their pain, its character and severity, on a custom-made mapping form. Then a researcher blinded to the diagnoses gave their estimations on the basis of previously established maps, and they were correlated with final diagnoses. Subsequently, a guide table was developed on how to read the maps, and intertester reliability was performed with three independent testers. RESULTS: The study included 194 patients, and the overall accuracy for estimations was between 45.4% and 49.5%. The sensitivity was high, especially for instability, followed by calcific tendinitis, acromio-calvicular joint pathology, and impingement. The intertester reliability showed clinically significant agreement between testers for both disease groups (κ = 0.70) and individual disorders (κ = 0.52). CONCLUSIONS: This was a unique and extensive study on shoulder pain mapping. The study concluded that pain mapping could be a useful adjunct to the clinical assessment of patients with shoulder pain and can be used in the primary care setting as well as secondary care and for research.

Do changes in hand grip strength correlate with shoulder rotator cuff function?

BACKGROUND: Shoulder pain as a result of rotator cuff pathology is one of the most common musculoskeletal complaints presenting within primary care. Assessment of hand grip strength has been proposed as an indicator of rotator cuff function. This experimental study assessed the relationship between grip strength and shoulder lateral rotator muscle strength in a number of different shoulder positions, aiming to investigate whether such a relationship existed and whether grip strength could be used as a functional assessment tool for the posterior cuff. METHODS: Twenty-seven healthy, physically active, volunteers (19 males, eight females) with no history of shoulder, upper limb or neck injury comprised the study group. The mean (SD) age was 19.8 (5.7) years (range 18 years to 23 years). Grip strength (measured with hand grip dynamometer) and lateral rotator strength (measured with a hand held dynamometer) was measured at neutral, 90° abduction, and 90° abduction with 90° external rotation. RESULTS: The correlation between grip strength and shoulder lateral rotation strength ranged between r = 0.91 (r (2 )= 0.84) and r = 0.72 (r (2 )= 0.52) across all positions. CONCLUSIONS: A strong correlation between grip strength and lateral rotator strength was shown at all positions for both left and right hands, suggesting that assessment of grip strength could be used as a rotator cuff monitor of recruitment function.

Relationship between extrinsic factors and the acromio-humeral distance.

BACKGROUND: Maintenance of the subacromial space is important in impingement syndromes. Research exploring the correlation between biomechanical factors and the subacromial space would be beneficial. OBJECTIVES: To establish if relationship exists between the independent variables of scapular rotation, shoulder internal rotation, shoulder external rotation, total arc of shoulder rotation, pectoralis minor length, thoracic curve, and shoulder activity level with the dependant variables: AHD in neutral, AHD in 60° arm abduction, and percentage reduction in AHD. DESIGN: Controlled laboratory study. METHOD: Data from 72 male control shoulders (24.28years STD 6.81 years) and 186 elite sportsmen's shoulders (25.19 STD 5.17 years) were included in the analysis. The independent variables were quantified and real time ultrasound was used to measure the dependant variable acromio-humeral distance. RESULTS: Shoulder internal rotation and pectoralis minor length, explained 8% and 6% respectively of variance in acromio-humeral distance in neutral. Pectoralis minor length accounted for 4% of variance in 60° arm abduction. Total arc of rotation, shoulder external rotation range, and shoulder activity levels explained 9%, 15%, and 16%-29% of variance respectively in percentage reduction in acromio-humeral distance during arm abduction to 60°. CONCLUSION: Pectorals minor length, shoulder rotation ranges, total arc of shoulder rotation, and shoulder activity levels were found to have weak to moderate relationships with acromio-humeral distance. Existence and strength of relationship was population specific and dependent on arm position. Relationships only accounted for small variances in AHD indicating that in addition to these factors there are other factors involved in determining AHD.

The Inter-rater Reliability of the Functional Movement Screen Within an Athletic Population Using Untrained Raters.

Elias JE. The inter-rater reliability of the functional movement screen within an athletic population using untrained raters. J Strength Cond Res 30(9): 2591-2599, 2016-The functional movement screen (FMS) is a commonly used screening tool designed to identify restrictions to movement patterns and increased injury risk using 7 predesigned tests. The purpose of this study was to analyze the inter-rater reliability of scoring of the FMS using a group of "untrained" subjects. Additionally, the study also examined if clinical experience level had any effect on reliability. Twenty fully qualified Physiotherapists working at the English Institute of Sport, with elite athletes, volunteered to participate in the study. The group comprised both level 2 and level 3 physiotherapists based on clinical experience levels. Five elite athletes, free from injury, were recruited and videoed completing 6 of the 7 FMS tests using a 3 camera system. The videos were scored by each Physiotherapist using the standardized scoring sheet, as developed by Cook et al. Each practitioner marked each athlete completing the 6 tests. The total scores were calculated for each athlete (maximum score of 18). The inter-rater reliability of the test was shown to be high, intraclass coefficient 0.906. An independent t test showed no significant differences between the level 2 and level 3 practitioners in the total scores (p = 0.502). The results of the test indicate that the FMS is a reliable screening tool when used by untrained practitioners in determining faulty movement patterns and that clinical experience level does not affect the reliability, therefore it may be a useful tool in the screening of athletic populations.

Acromiohumeral Distance During Neuromuscular Electrical Stimulation of the Lower Trapezius and Serratus Anterior Muscles in Healthy Participants.

CONTEXT: Compromise to the acromiohumeral distance has been reported in participants with subacromial impingement syndrome compared with healthy participants. In clinical practice, patients with subacromial shoulder impingement are given strengthening programs targeting the lower trapezius (LT) and serratus anterior (SA) muscles to increase scapular posterior tilt and upward rotation. We are the first to use neuromuscular electrical stimulation to stimulate these muscle groups and evaluate how the muscle contraction affects the acromiohumeral distance. OBJECTIVE: To investigate if electrical muscle stimulation of the LT and SA muscles, both separately and simultaneously, increases the acromiohumeral distance and to identify which muscle-group contraction or combination most influences the acromiohumeral distance. DESIGN: Controlled laboratory study. SETTING: Human performance laboratory. PATIENTS OR OTHER PARTICIPANTS: Twenty participants (10 men and 10 women, age = 26.9 ± 8.0 years, body mass index = 23.8) were screened. INTERVENTION(S): Neuromuscular electrical stimulation of the LT and SA. MAIN OUTCOME MEASURE(S): Ultrasound measurement of the acromiohumeral distance. RESULTS: Acromiohumeral distance increased during contraction via neuromuscular electrical stimulation of the LT muscle (t(19) = -3.89, P = .004), SA muscle (t(19) = -7.67, P = .001), and combined LT and SA muscles (t(19) = -5.09, P = .001). We observed no differences in the increased acromiohumeral distance among the 3 procedures (F(2,57) = 3.109, P = .08). CONCLUSIONS: Our results supported the hypothesis that the muscle force couple around the scapula is important in rehabilitation and scapular control and influences acromiohumeral distance.

Task based rehabilitation protocol for elite athletes following Anterior Cruciate ligament reconstruction: a clinical commentary.

Anterior Cruciate ligament (ACL) injuries are one of the most common and devastating knee injuries sustained whilst participating in sport. ACL reconstruction (ACLR) remains the standard approach for athletes who aim to return to high level sporting activities but the outcome from surgery is not assured. Secondary morbidities and an inability to return to the same competitive level are common following ACLR. One factor which might be linked to these sub-optimal outcomes may be a failure to have clearly defined performance criteria for return to activity and sport. This paper presents a commentary describing a structured return to sport rehabilitation protocol for athletes following ACLR. The protocol was developed from synthesis of the available literature and consensus of physiotherapists and strength and conditioning coaches based in the home country Institute of Sports within the United Kingdom.