Hip Abductor Strength Asymmetry: Relationship to Upper Extremity Injury in Professional Baseball Players.

BACKGROUND: Hip strength is an important factor for control of the lumbo-pelvic-hip complex. Deficits in hip strength may affect throwing performance and contribute to upper extremity injuries. HYPOTHESIS: Deficits in hip abduction isometric strength would be greater in those who sustained an upper extremity injury and hip strength would predict injury incidence. STUDY DESIGN: Prospective cohort study. LEVEL OF EVIDENCE: Level 3. METHODS: Minor League baseball players (n = 188, age = 21.5 ± 2.2 years; n = 98 pitchers; n = 90 position players) volunteered. Hip abduction isometric strength was assessed bilaterally with a handheld dynamometer in side-lying position, expressed as torque using leg length (N·m). Hip abduction strength asymmetry was represented by [(trail leg/lead leg) × 100]. Overuse or nontraumatic throwing arm injuries were prospectively tracked. Poisson regression models were used to estimate relative risk ratios associated with hip asymmetry; confounders, including history of prior overuse injury in the past year, were included. RESULTS: Hip abduction asymmetry ranged from 0.05% to 57.5%. During the first 2 months of the season, 18 players (n = 12 pitchers) sustained an upper extremity injury. In pitchers, for every 5% increase in hip abduction asymmetry, there was a 1.24 increased risk of sustaining a shoulder or elbow injury. No relationship between hip abduction strength and injury was observed for position players. CONCLUSION: Hip abduction asymmetry in pitchers was related to subsequent upper extremity injuries. The observed risk ratio indicates that hip abduction asymmetry may contribute a significant but small increased risk of injury. CLINICAL RELEVANCE: Hip abduction muscle deficits may affect pitching mechanics and increase arm stress. Addressing hip asymmetry deficits that exceed 5% may be beneficial in reducing upper extremity injury rates in pitchers.

Proposed Musculoskeletal Examination of Youth and Adolescent Baseball Players.

ABSTRACT: With a wide range of injuries in youth baseball, and more than 12 million amateur baseball players in the United States, a comprehensive list of tests and measures may be helpful to assess strength, mobility, and motor control throughout the kinetic chain to reduce risk of injury in this population. Many studies have looked at youth baseball players using a single test or a small number of tests to determine the prevalence of specific injuries in youth baseball, but to this author's knowledge, there is no comprehensive musculoskeletal screen published at this time specific to youth baseball. The purpose of this article is to review literature published over the last year relative to injury in youth and adolescent baseball players in an effort to update the reader on current concepts, risk factors in this population, and to provide an updated systematic screening process that may be used in reducing injury rates.

Professional Baseball Player Type and Geographic Region of Origin Impacts Shoulder External and Internal Rotation Strength.

BACKGROUND: Shoulder strength deficits are implicated in arm injuries and performance deficits in baseball players. PURPOSE: To characterize shoulder external (ER) and internal (IR) rotation strength in professional baseball players, and compare strength across player type (pitchers, position players) and geographic origin (North America, Latin America). STUDY DESIGN: Cross-sectional. METHODS: Minor league professional baseball players from North America and Latin America (n=242; age=22.4±2.3 years; n=135 pitchers and n=107 position players; n=162 North American and n=80 Latin American players) volunteered at spring training. Bilateral shoulder IR and ER isometric strength was measured in sitting with the arm at the side using a handheld dynamometer stabilized on a wall via a specialized jig. Strength was normalized to body weight, and compared using t-tests between player type and geographic area of origin (p < 0.05). RESULTS: Position players had greater strength in ER, IR and ER:IR (ER:0.7-2.7N/kg; IR:1.3-3.8N/kg; ER:IR ratio 0.36-1.22) compared to pitchers (ER:0.5-2.5N/kg; IR:0.6- 4.2N/kg; ER:IR ratio 0.44-1.16) on the throwing arm. North American pitchers had lower ER [MD= -0.4 (95%CI:-0.7,-0.2);p=0.002] and IR [MD= -0.2 (95%CI:-0.4,-0.1);p=0.006] than Latin American pitchers on the throwing arm. There were no differences between geographic groups for position players. DISCUSSION/CONCLUSIONS: Player position and geographic origin influence shoulder rotational strength values in professional baseball players. Position players have 14 - 20% higher ER and IR isometric strength than pitchers. Moreover, Latin American pitchers exhibited 11.8% greater ER strength and 16.7% greater IR strength as compared to North American pitchers. Normative values can be used to determine player deficits, declines in performance, and targets for return to play after injury. LEVEL OF EVIDENCE: Level II.

Little League Shoulder in a 15-Year-Old Male Baseball Pitcher.

A 15-year-old baseball pitcher presented to physical therapy with a 1-week history of acute right shoulder pain experienced during the acceleration phase of throwing. The week after physical therapy evaluation, the patient returned with radiographs and magnetic resonance imaging results that revealed lateral physeal widening with adjacent edema. Additionally, a nondisplaced labral tear was noted. In this case, imaging was necessary for an accurate diagnosis of lateral physeal widening, commonly referred to as "Little League shoulder." J Orthop Sports Phys Ther 2018;48(1):51. doi:10.2519/jospt.2018.7369.

Perioperative Testosterone Supplementation Increases Lean Mass in Healthy Men Undergoing Anterior Cruciate Ligament Reconstruction: A Randomized Controlled Trial.

BACKGROUND: Rehabilitation after repair of the anterior cruciate ligament (ACL) is complicated by the loss of leg muscle mass and strength. Prior studies have shown that preoperative rehabilitation may improve muscle strength and postoperative outcomes. Testosterone supplementation may likewise counteract this muscle loss and potentially improve clinical outcomes. PURPOSE: The purpose was to investigate the effect of perioperative testosterone administration on lean mass after ACL reconstruction in men and to examine the effects of testosterone on leg strength and clinical outcome scores. It was hypothesized that testosterone would increase lean mass and leg strength and improve clinical outcome scores relative to placebo. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Male patients (N = 13) scheduled for ACL reconstruction were randomized into 2 groups: testosterone and placebo. Participants in the testosterone group received 200 mg of intramuscular testosterone weekly for 8 weeks beginning 2 weeks before surgery. Participants in the placebo group received saline following the same schedule. Both groups participated in a standard rehabilitation protocol. The primary outcome was the change in total lean body mass at 6 and 12 weeks. Secondary outcomes were extensor muscle strength, Tegner activity score, and Knee injury and Osteoarthritis Outcome Score. RESULTS: There was an increase in lean mass of a mean 2.7 ± 1.7 kg at 6 weeks postoperatively in the testosterone group compared with a decrease of a mean 0.1 ± 1.5 kg in the placebo group (P = .01). Extensor muscle strength of the uninjured leg also increased more from baseline in the testosterone group (+20.8 ± 25.6 Nm) compared with the placebo group (-21.4 ± 36.7 Nm) at 12 weeks (P = .04). There were no significant between-group differences in injured leg strength or clinical outcome scores. There were no negative side effects of testosterone noted. CONCLUSION: Perioperative testosterone supplementation increased lean mass 6 weeks after ACL reconstruction, suggesting that this treatment may help minimize the effects of muscle atrophy associated with ACL injuries and repair. This study was not powered to detect differences in strength or clinical outcome scores to assess the incidence of testosterone-related adverse events. CLINICAL RELEVANCE: Supraphysiological testosterone supplementation may be a useful adjunct therapy for counteracting muscle atrophy after ACL reconstruction. Further investigation is necessary to determine the safety profile and effects of perioperative testosterone administration on leg strength and clinical outcomes after surgery. REGISTRATION: NCT01595581 (ClinicalTrials.gov).

Observational Scapular Dyskinesis: Known-Groups Validity in Patients With and Without Shoulder Pain.

Study Design Cross-sectional. Background The scapular dyskinesis test (SDT) has demonstrated reliability and validity, but its utility for clinical decision making is unclear. Objectives To characterize the prevalence of scapular dyskinesis in participants with and without shoulder pain, and to determine the influence of blinding to the presence of shoulder pain on prevalence of scapular dyskinesis. Methods Participants (n = 135), 67 with shoulder pain and 68 healthy controls, were included in this study. The SDT was performed by 2 examiners, from a total of 21 physical therapists. The second examiner was blinded to the participant's presence of shoulder pain. The SDT involved participants performing 5 repetitions of shoulder flexion and abduction, while the clinician observed for scapular dyskinesis, as characterized by scapular winging or dysrhythmia. Dyskinesis was rated as normal, subtle, or obvious. Ratings were collapsed into 2 groups, dyskinesis (subtle and obvious) and no dyskinesis (normal), as recommended by expert consensus. Results There were no significant differences for scapular dyskinesis prevalence between the shoulder pain group and control group during the SDT in abduction (shoulder pain, 67.2%; 95% confidence interval [CI]: 0.55, 0.77 and control group, 52.9%; 95% CI: 0.41, 0.64; P = .09) or flexion (shoulder pain, 67.2%; 95% CI: 0.55, 0.77 and control group, 61.8%; 95% CI: 0.50, 0.72; P = .51). There were significant differences (P ≤001) between the examiners' SDT ratings in the shoulder pain group. The unblinded examiner reported a higher prevalence when testing the involved shoulder for dyskinesis in flexion (blinded, 67.7%; 95% CI: 0.56, 0.78 and unblinded, 80%; 95% CI: 0.69, 0.88) and during abduction (blinded, 66.2%; 95% CI: 0.54, 0.76 and unblinded, 78.5%; 95% CI: 0.67, 0.87). Conclusion Scapular dyskinesis as assessed with the SDT is not more prevalent in those with shoulder pain. Rating was influenced by an examiner's knowledge of shoulder pain presence. Scapular dyskinesis may represent normal movement variability. Level of Evidence Diagnosis, level 4. J Orthop Sports Phys Ther 2017;47(8):530-537. Epub 6 Jul 2017. doi:10.2519/jospt.2017.7268.

Promoting physical therapists' use of research evidence to inform clinical practice: part 3--long term feasibility assessment of the PEAK program.

BACKGROUND: Evidence is needed to develop effective educational programs for promoting evidence based practice (EBP) and knowledge translation (KT) in physical therapy. This study reports long-term outcomes from a feasibility assessment of an educational program designed to promote the integration of research evidence into physical therapist practice. METHODS: Eighteen physical therapists participated in the 6-month Physical therapist-driven Education for Actionable Knowledge translation (PEAK) program. The participant-driven active learning program consisted of four consecutive, interdependent components: 1) acquiring managerial leadership support and electronic resources in three clinical practices, 2) a 2-day learner-centered EBP training workshop, 3) 5 months of guided small group work synthesizing research evidence into a locally relevant list of, actionable, evidence-based clinical behaviors for therapists treating persons with musculoskeletal lumbar conditions--the Best Practices List, and 4) review and revision of the Best Practices List, culminating in participant agreement to implement the behaviors in practice. Therapists' EBP learning was assessed with standardized measures of EBP-related attitudes, self-efficacy, knowledge and skills, and self-reported behavior at baseline, immediately-post, and 6 months following conclusion of the program (long-term follow-up). Therapist adherence to the Best Practice List before and after the PEAK program was assessed through chart review. RESULTS: Sixteen therapists completed the long-term follow-up assessment. EBP self-efficacy and self-reported behaviors increased from baseline to long-term follow-up (p < 0.001 and p = 0.002, respectively). EBP-related knowledge and skills showed a trend for improvement from baseline to long-term follow-up (p = 0.05) and a significant increase from immediate-post to long-term follow-up (p = 0.02). Positive attitudes at baseline were sustained throughout (p = 0.208). Eighty-nine charts were analyzed for therapist adherence to the Best Practices List. Six clinical behaviors had sufficient pre- and post-PEAK charts to justify analysis. Of those, one behavior showed a statistically significant increase in adherence, one had high pre- and post-PEAK adherence, and four were change resistant, starting with low adherence and showing no meaningful improvement. CONCLUSIONS: This study supports the feasibility of the PEAK program to produce long-term improvements in physical therapists' EBP-related self-efficacy and self-reported behavior. EBP knowledge and skills showed improvement from post-intervention to long-term follow-up and a trend toward long-term improvements. However, chart review of therapists' adherence to the participant generated Best Practices List in day-to-day patient care indicates a need for additional support to facilitate behavior change. Future versions of the PEAK program and comparable multi-faceted EBP and KT educational programs should provide ongoing monitoring, feedback, and problem-solving to successfully promote behavior change for knowledge translation.

Pelvic osteomyelitis presenting as groin and medial thigh pain: a resident's case problem.

STUDY DESIGN: Resident's case problem. BACKGROUND: Groin pain represents a diagnostic challenge and requires a diagnostic process that rules out life-threatening illness or disease processes. Osteomyelitis is a potential fatal disease process that requires accurate diagnosis and medical management. Osteomyelitis presents a problem for the outpatient physical therapist, as the described physical findings for the diagnosis of osteomyelitis are nonspecific. DIAGNOSIS: A 67-year-old man with groin and bilateral medial thigh pain was referred for physical therapy care to address right adductor weakness and generalized deconditioning. He had undergone extensive treatment for bladder cancer, with a recent radical cystoprostatectomy and cutaneous urinary diversion with an Indiana pouch. Postsurgical magnetic resonance imaging indicated normal findings, and the patient was currently being managed by an orthopaedic surgeon, who diagnosed the patient as having obturator nerve palsy. The physical therapist's examination produced findings inconsistent with this diagnosis. Subsequently, nuclear medicine studies revealed pubic symphysitis/osteomyelitis with secondary myositis, predominantly affecting the right adductor muscles. DISCUSSION: Osteomyelitis represents a difficult problem for the outpatient physical therapist. Careful consideration of red-flag symptoms and inconclusive physical testing indicate the need for further medical work-up. In this case, appropriate medical management led to improvement in patient function, highlighting the need for early diagnosis. LEVEL OF EVIDENCE: Differential diagnosis, level 4.

Randomized control trial to evaluate the effects of acute testosterone administration in men on muscle mass, strength, and physical function following ACL reconstructive surgery: rationale, design, methods.

BACKGROUND: The anterior cruciate ligament (ACL) is one of four major ligaments in the knee that provide stability during physical activity. A tear in the ACL is characterized by joint instability that leads to decreased activity, knee dysfunction, reduced quality of life and a loss of muscle mass and strength. While rehabilitation is the standard-of-care for return to daily function, additional surgical reconstruction can provide individuals with an opportunity to return to sports and strenuous physical activity. Over 200,000 ACL reconstructions are performed in the United States each year, and rehabilitation following surgery is slow and expensive. One possible method to improve the recovery process is the use of intramuscular testosterone, which has been shown to increase muscle mass and strength independent of exercise. With short-term use of supraphysiologic doses of testosterone, we hope to reduce loss of muscle mass and strength and minimize loss of physical function following ACL reconstruction compared to standard-of-care alone. METHODS/DESIGN: This study is a double-blinded randomized control trial. Men 18-50 years of age, scheduled for ACL reconstruction are randomized into two groups. Participants randomized to the testosterone group receive intramuscular testosterone administration once per week for 8 weeks starting 2 weeks prior to surgery. Participants randomized to the control group receive a saline placebo intramuscularly instead of testosterone. Lean mass, muscle strength and physical function are measured at 5 time points: 2 weeks pre-surgery, 1 day pre-surgery, and 6, 12, 24 weeks post-surgery. Both groups follow standard-of-care rehabilitation protocol. DISCUSSION: We believe that testosterone therapy will help reduce the loss of muscle mass and strength experienced after ACL injury and reconstruction. Hopefully this will provide a way to shorten the rehabilitation necessary following ACL reconstruction. If successful, testosterone therapy may also be used for other injuries involving trauma and muscle atrophy. TRIAL REGISTRATION: NCT01595581, REGISTRATION: May 8, 2012.

Promoting physical therapists' use of research evidence to inform clinical practice: part 2--a mixed methods evaluation of the PEAK program.

BACKGROUND: Clinicians need innovative educational programs to enhance their capacity for using research evidence to inform clinical decision-making. This paper and its companion paper introduce the Physical therapist-driven Education for Actionable Knowledge translation (PEAK) program, an educational program designed to promote physical therapists' integration of research evidence into clinical decision-making. This, second of two, papers reports a mixed methods feasibility study of the PEAK program among physical therapists at three university-based clinical facilities. METHODS: A convenience sample of 18 physical therapists participated in the six-month educational program. Mixed methods were used to triangulate results from pre-post quantitative data analyzed concurrently with qualitative data from semi-structured interviews and focus groups. Feasibility of the program was assessed by evaluating change in participants' attitudes, self-efficacy, knowledge, skills, and self-reported behaviors in addition to their perceptions and reaction to the program. RESULTS: All 18 therapists completed the program. The group experienced statistically significant improvements in evidence based practice self-efficacy and self-reported behavior (p < 0.001). Four themes were supported by integrated quantitative and qualitative results: 1. The collaborative nature of the PEAK program was engaging and motivating; 2. PEAK participants experienced improved self-efficacy, creating a positive cycle where success reinforces engagement with research evidence; 3. Participants' need to understand how to interpret statistics was not fully met; 4. Participants believed that the utilization of research evidence in their clinical practice would lead to better patient outcomes. CONCLUSIONS: The PEAK program is a feasible educational program for promoting physical therapists' use of research evidence in practice. A key ingredient seems to be guided small group work leading to a final product that guides local practice. Further investigation is recommended to assess long-term behavior change and to compare outcomes to alternative educational models.

Superior labrum anterior-to-posterior tear.

The patient was a 25-year-old male college student with a chief complaint of right shoulder pain. The patient was initially diagnosed with bicipital tendinitis by his physician and had been treated for 4 weeks by a physical therapist. However, his symptoms did not improve and he was unable to return to his preinjury activity levels, so he sought the services of another physical therapist for a second opinion. Due to concern for a labrum tear, the physical therapist referred the patient to an orthopaedic surgeon. Magnetic resonance arthrography revealed findings consistent with a superior labrum anterior-to-posterior tear.