The Utilization of Diagnostic Musculoskeletal Ultrasound in the Evaluation of Gluteus Medius Tendon Pathology: A Perspective for Rehabilitation Providers.

Gluteus medius tendon pathology, encompassing tendinopathy and tears, is a significant source of lateral hip pain and functional impairment. Traditional diagnostic approaches have relied on clinical examination and magnetic resonance imaging (MRI). However, the advent of diagnostic musculoskeletal ultrasound (MSKUS) has transformed the evaluation process. Musculoskeletal ultrasound has emerged as a highly valuable diagnostic tool in the evaluation of gluteus medius tendon pathology, offering a non-invasive, cost-effective, and dynamic assessment method. This modality provides real-time visualization of soft tissue, enabling the detailed examination of tendon structure, vascularity, and associated musculature. For rehabilitation providers, understanding the application, strengths, and limitations of diagnostic MSKUS can enhance clinical decision-making, facilitate targeted therapeutic interventions, and potentially expedite the recovery process. This article reviews the application of MSKUS in diagnosing gluteus medius tendon pathology and its implications for rehabilitation practice. This should help to equip rehabilitation professionals with knowledge to better integrate this diagnostic tool into their clinical repertoire.

Management of High Ankle Sprains Utilizing the Tightrope Surgical Procedure - A Novel Approach for a Rapid Return to Play.

The distal tibiofibular joint is described as a syndesmosis. The syndesmosis is important to the structural integrity of the ankle joint by maintaining the proximity of the tibia, fibula, and talus. Syndesmotic or high ankle sprains, involving the syndesmotic ligaments, pose a significant rehabilitative challenge due to their intricate anatomy, prolonged recovery periods following injury, and high susceptibility to persistent disability. Traditional management strategies have often been conservative, marked by lengthy periods of immobilization and a gradual return to activity. Severe syndesmotic injuries with diastasis have been treated surgically with screw fixation which may require a second intervention to remove the hardware and carries an inherent risk of breaking the screw during rehabilitation. Another fixation technique, the Tightrope™, has gained popularity in treating ankle syndesmosis injuries. The TightRope™ involves inserting Fiberwire® through the tibia and fibula, which allows for stabilization of the ankle mortise and normal range of motion. The accelerated rehabilitation protocol promotes early weight-bearing and has been shown to expedite the return to sport. This emerging strategy has shown promise in reducing recovery time as it is now possible to return to sport in less than 2 months after a tightrope repair and accelerated rehabilitation, compared with 3-6 months post screw fixation. This clinical commentary delves into this novel approach, highlighting the procedure, rehabilitation protocols, and the implications for physical therapy practice. Level of Evidence: V.

Beyond the Basics of Athletic Hip Evaluation.

ABSTRACT: There is a growing trend in the world of orthopedics and sports medicine revolving around the nonarthritic hip. The incidence of hip arthroscopy has exponentially grown in the past decade and despite the importance of the recognition of these hip pathologies as contributors to pain and dysfunction, there is an ever-increasing rate of "failed" procedures emerging in the literature. The etiology of femoroacetabular impingement (FAI) syndrome and associated pathologies of the hip are now better understood. With this understanding there appears a tendency to point a finger at the hip joint without consideration for the involvement of the surrounding joints or extraarticular structures. Because of the nature of the morphological condition of FAI and the high incidence of a gradual progression of pain and impairments over time, as opposed to an acute injury, there is a need for a more robust assessment of the hip. The purpose of this commentary is to discuss the importance of a combined traditional orthopedic exam, imaging, and movement assessment in diagnosis and treatment recommendations in those with nonarthritic hip pain. It is our belief that this combined model can assist in identifying movement dysfunction that may lead to poor surgical outcomes and developing improved nonoperative or preoperative care pathways. LEVEL OF EVIDENCE: Level V.

THE RELATIONSHIP BETWEEN SEGMENTAL ROLLING ABILITY AND LUMBAR MULTIFIDUS ACTIVATION TIME.

BACKGROUND: Segmental rolling has been utilized as an assessment and intervention tool to identify and affect dysfunction of the upper quarter, core, and lower quarter. One theory to explain dysfunctional segmental rolling is a lack of segmental spinal control / stabilization. Faulty muscle firing sequencing has been related to poor spinal stability, however to date, no assessment tool exists to evaluate a patient's motor coordination of local and global musculature. PURPOSE: The purpose of this study was to assess the temporal sequence of lumbar multifidus activation associated with anterior deltoid activation, and to determine if faulty sequencing was associated with the inability to segmentally roll in subjects without mobility restrictions. The authors hypothesized that in individuals who could not roll, a multifidus muscle onset latency relative to a prime mover activation would be present. In addition, a subset of the individuals with an inability to roll were utilized for a pilot study examining the ability to address the firing pattern with corrective exercise. METHODS: Twenty healthy subjects (13 females, 7 males), ages 19-25, participated in the study. Each subject underwent an upper and lower quarter screen and assessment of thoracic spine mobility. Subjects were excluded from the study if they had previous spine surgery, or were currently experiencing back pain. In addition, subjects who had any disease, disorders, or pathology that would hinder participation in segmental rolling or who had spinal movement contraindications were excluded. Since shoulder flexion is performed during the study, participants who had shoulder pathology or contraindications to upper extremity movement were excluded as well. Subjects with less than 50 degrees of trunk rotation were excluded from the study due to a possible physical mobility limitation that would prevent proficient segmental rolling. Included subjects were assessed on their ability to segmentally roll. Subjects who could complete the rolling task were placed in cohort A ("can roll"), and subjects who could not roll were placed in cohort B ("can't roll").Electromyographic (EMG) activity of the multifidus was recorded adjacent to the lamina of the L4 vertebrae using intramuscular fine-wire electrodes. EMG activity of the anterior deltoid was also recorded with a surface electrode during a single arm movement into shoulder flexion. While in a standing position, subjects were instructed to move their right upper arm into flexion as quickly as possible. Subjects flexed their shoulder to 90 degrees for three trials while muscle activity was recorded. Data were high-pass filtered at 30 Hz to remove baseline artifact, and the onset EMG times was selected as the point at which EMG increased two SD above baseline levels. Onset of the multifidus muscle was reported relative to that of the prime mover (anterior deltoid). Muscle onset latency was defined as the time difference between the onset of contraction of the multifidus and the anterior deltoid. RESULTS: Nine subjects were placed in cohort A, 11 subjects were placed in cohort B. The mean firing time of the lumbar multifidus for the cohort A was 16.67msec before the anterior deltoid, and the mean firing time of the lumbar multifidus for cohort B was 57.36msec after the anterior deltoid. There was a statistically significant difference (p<0.00) in the firing time between cohorts A and B. CONCLUSIONS: In subjects who could segmentally roll, the multifidus muscle activation always preceded that of the prime mover muscle activation. In subjects who could not segmentally roll, the results of this study confirm that there is a multifidus muscle onset latency relative to the activation of the anterior deltoid. The inability to segmentally roll may be related to faulty sequencing of lumbar multifidus firing.

ROLLING REVISITED: USING ROLLING TO ASSESS AND TREAT NEUROMUSCULAR CONTROL AND COORDINATION OF THE CORE AND EXTREMITIES OF ATHLETES.

UNLABELLED: Rolling is a movement pattern seldom used by physical therapists for assessment and intervention with adult clientele with normal neurologic function. Rolling, as an adult motor skill, combines the use of the upper extremities, core, and lower extremities in a coordinated manner to move from one posture to another. Rolling is accomplished from prone to supine and supine to prone, although the method by which it is performed varies among adults. Assessment of rolling for both the ability to complete the task and bilateral symmetry may be beneficial for use with athletes who perform rotationally-biased sports such as golf, throwing, tennis, and twisting sports such as dance, gymnastics, and figure skating. When stability-based dysfunction exists, the rolling patterns can be used as intervention techniques, and have the ability to affect dysfunction of the upper quarter, core, and lower quarter. By applying proprioceptive neuromuscular facilitation (PNF) principles, the therapist may assist patients and clients who are unable to complete a rolling pattern. Examples given in the article include distraction/elongation, compression, and manual contacts to facilitate proper rolling. The authors assert that therapeutic use of the developmental pattern of rolling with techniques derived from PNF can be creatively and effectively utilized in musculoskeletal rehabilitation. Preliminary results from an exploration of the mechanism by which rolling may impact stability is presented, and available updated evidence is provided. The purpose of this clinical commentary is to describe techniques for testing, assessment, and treatment of dysfunction, using case examples that incorporate rolling. LEVEL OF EVIDENCE: 5.

The role of the scapula.

UNLABELLED: Previously, the scapular musculature was often neglected in designing a rehabilitation protocol for the shoulder. In the past two decades a significant amount of research has been performed in order to help identify the role of the scapula in upper extremity function. Weakness of the scapular stabilizers and resultant altered biomechanics could result in: 1) abnormal stresses to the anterior capsular structures of the shoulder, 2) increased possibility of rotator cuff compression, and 3) decreased shoulder complex neuromuscular performance. This clinical commentary presents facts about the anatomy and biomechanics of the scapula and surrounding musculature, and describes the pathomechanics of scapular dysfunction. The focus is upon the assessment of dysfunction and retraining of the scapular musculature. LEVEL OF EVIDENCE: 5.

Publishing your work in a journal: understanding the peer review process.

Manuscripts have been subjected to the peer review process prior to publication for over 300 years. Currently, the peer review process is used by almost all scientific journals, and The International Journal of Sports Physical Therapy is no exception. Scholarly publication is the means by which new work is communicated and peer review is an important part of this process. Peer review is a vital part of the quality control mechanism that is used to determine what is published, and what is not. The purpose of this commentary is to provide a description of the peer review process, both generally, and as utilized by The International Journal of Sports Physical Therapy. It is the hope of the authors that this will assist those who submit scholarly works to understand the purpose of the peer review process, as well as to appreciate the length of time required for a manuscript to complete the process and move toward publication.

Postoperative rehabilitation guidelines for hip arthroscopy in an active population.

CONTEXT: With the evolution of hip arthroscopy has come an increased recognition of intra-articular hip pathologies and improved techniques for their management. Whereas mechanical problems can often be corrected through surgery, functional deficits must be corrected through the rehabilitation process. Therefore, the evolution of hip arthroscopy has necessitated a progression in hip rehabilitation to ensure optimal postsurgical results. EVIDENCE ACQUISITION: Literature review was conducted with PubMed, EMBASE, and PEDro (1992 to 2009) with the terms hip, rehabilitation, and physical therapy. RESULTS: Although it is generally accepted that rehabilitation after hip arthroscopy is important, there is limited evidence-based research to support the rehabilitative guidelines. CONCLUSION: The common goal of hip rehabilitation should remain focused on the return to pain-free function of the hip joint. Outcome data indicate that this goal is being met; however, further data are required to completely validate the long-term success of hip rehabilitation after arthroscopy.

Using rolling to develop neuromuscular control and coordination of the core and extremities of athletes.

Rolling is a movement pattern seldom used by physical therapists for assessment and intervention with adult clientele with normal neurologic function. Rolling, as an adult motor skill, combines the use of the upper extremities, core, and lower extremities in a coordinated manner to move from one posture to another. Rolling is accomplished from prone to supine and supine to prone, although the method by which it is performed varies among adults. Assessment of rolling for both the ability to complete the task and bilateral symmetry may be beneficial for use with athletes who perform rotationally-biased sports such as golf, throwing, tennis, and twisting sports such as dance, gymnastics, and figure skating. Additionally, when used as intervention techniques, the rolling patterns have the ability to affect dysfunction of the upper quarter, core, and lower quarter. By applying proprioceptive neuromuscular facilitation (PNF) principles, the therapist may assist patients and clients who are unable to complete a rolling pattern. Examples given in the article include distraction/elongation, compression, and manual contacts to facilitate proper rolling. The combined experience of the four authors is used to describe techniques for testing, assessment, and treatment of dysfunction, using case examples that incorporate rolling. The authors assert that therapeutic use of the developmental pattern of rolling with techniques derived from PNF is a hallmark in rehabilitation of patients with neurologic dysfunction, but can be creatively and effectively utilized in musculoskeletal rehabilitation.

The chop and lift reconsidered: integrating neuromuscular principles into orthopedic and sports rehabilitation.

The upper extremity bilateral PNF patterns, better known as the "chop and lift" are well known to physical therapists. These patterns which utilize spiral and diagonal motions of the upper extremity can be used for both assessment and treatment of sports and orthopedic injuries. Half kneeling and tall kneeling postures fall between low-level postures such as rolling and 4-point, and high-level postures of standing and walking. Half kneeling and tall kneeling can be considered transitional postures. When the chop and lift patterns are used in conjunction with the half and tall kneeling developmental postures, the techniques are an excellent assessment of core stability/instability. Combinations of the upper extremity patterns and the developmental postures can be powerful corrective training techniques. The combined experience of the three authors is used to describe techniques for equipment setup, testing, assessment, and treatment of athletic imbalances. These techniques require and promote instantaneous local muscular activity as developmental postures and balance reactions are incorporated. The therapeutic use of both PNF and developmental patterns has been a hallmark of rehabilitation of patients with neurologic dysfunction, but can be equally and effectively applied in the sports and orthopedic rehabilitation setting.

Can Serious Injury in Professional Football be Predicted by a Preseason Functional Movement Screen?

BACKGROUND: Little data exists regarding injury risk factors for professional football players. Athletes with poor dynamic balance or asymmetrical strength and flexibility (i.e. poor fundamental movement patterns) are more likely to be injured. The patterns of the Functional Movement Screen(™) (FMS) place the athlete in positions where range of motion, stabilization, and balance deficits may be exposed. OBJECTIVES: To determine the relationship between professional football players' score on the FMS(™) and the likelihood of serious injury. METHODS: FMS(™) scores obtained prior to the start of the season and serious injury (membership on the injured reserve for at least 3 weeks) data were complied for one team (n = 46). Utilizing a receiver-operator characteristic curve the FMS(™) score was used to predict injury. RESULTS: A score of 14 or less on the FMS(™) was positive to predict serious injury with specificity of 0.91 and sensitivity of 0.54. The odds ratio was 11.67, positive likelihood ratio was 5.92, and negative likelihood ratio 0.51. DISCUSSION AND CONSCLUSION: The results of this study suggest fundamental movement (as measured by the FMS(™)) is an identifiable risk factor for injury in professional football players. The findings of this study suggest professional football players with dysfunctional fundamental movement patterns as measured by the FMS(™) are more likely to suffer an injury than those scoring higher on the FMS(™).

Scapular muscle recruitment pattern: electromyographic response of the trapezius muscle to sudden shoulder movement before and after a fatiguing exercise.

STUDY DESIGN: Test-retest reliability study and single-group repeated measures design. OBJECTIVES: To evaluate the muscle latency times of the 3 portions of the trapezius muscle to a sudden arm movement in normal shoulders and to determine if this recruitment pattern is altered as a result of fatigue. BACKGROUND: It has been suggested that shoulder impingement may be related to altered muscle activity and muscle fatigue in the scapular stabilizers. Fatigue-induced changes in latency times of the trapezius might influence scapular stability. METHODS AND MEASURES: Muscle latency times were investigated in 30 healthy shoulders with surface electromyography. Muscle activity was measured in all 3 sections of the trapezius and the middle deltoid muscle during a sudden downward falling movement of the arm. Subsequently the shoulder was fatigued on an isokinetic dynamometer, after which muscle latency time measurement was repeated. RESULTS: ANOVA for repeated measures revealed significant differences in latency times (P < 0.05) among the 4 muscles of interest. Although there were no significant differences among the 3 sections of the trapezius muscle, they all were recruited after the initialization of the deltoid muscle. The recruitment order of the shoulder muscles did not change with muscle fatigue. However, after fatigue, muscle responses were significantly slower in all muscles except for the lower trapezius (P < 0.05). CONCLUSIONS: There is a specific recruitment sequence in the shoulder muscles in response to a sudden arm movement characterized by initial activation of the middle deltoid muscle and followed by simultaneous contraction of all 3 sections of the trapezius. This muscle activation pattern is delayed but not altered with fatigue.