Blood Flow Restriction Training in Patients With Rotator Cuff Tendinopathy: A Randomized, Assessor-Blinded, Controlled Trial.

OBJECTIVES: To investigate the effects of low-load blood flow restriction (BFR) training on shoulder muscle thickness, rotator cuff (RC) strength, and shoulder symptoms in patients with RC tendinopathy. DESIGN: A randomized, assessor-blinded, controlled trial. SETTINGS: Physiotherapy clinic at a university. PARTICIPANTS: Twenty-eight patients were randomized into an 8-week (2 times/week) shoulder rehabilitation, that is, BFR or non-BFR group. INTERVENTIONS: BFR training. MAIN OUTCOME MEASURES: (1) RC, deltoid, scapula retractor, and biceps muscle thicknesses and shoulder internal rotation (IR) and external rotation (ER) strengths. (2) Shoulder pain/function. RESULTS: The BFR group had a greater increase in biceps muscle thickness ( P = 0.002) and shoulder IR strength at 60 degrees/s ( P = 0.040) than the non-BFR group. No differences between the 2 groups were observed in other measurements. Significant improvements in supraspinatus, infraspinatus, and scapula retractor muscle thicknesses and in shoulder ER and IR strengths were observed over time in both the groups (all P < 0 .05). Also, shoulder pain decreased and shoulder function increased over time in both the groups (all P < 0 .05). CONCLUSIONS: Low-load BFR training resulted in a greater increase in biceps thickness and shoulder IR strength compared with the non-BFR group in patients with RC tendinopathy. However, there was no superiority of either exercise training regarding the RC, scapula retractor, deltoid muscle thicknesses, or improvements in shoulder ER strength and shoulder pain/function. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER: The study was registered in ClinicalTrials.gov named Blood Flow Restriction Training in Patients with Shoulder Pain and the registration number is NCT04333784.

Effects of Different Frequencies of Physical Therapy Visits on Shoulder Function After Arthroscopic Rotator Cuff Repair.

OBJECTIVE: There is no consensus about the optimal frequency of patient visits during the rehabilitation program after arthroscopic rotator cuff repair (ARCR). This study aimed to investigate the short- and long-term effects of high-frequency (HF) and low-frequency (LF) visits of the patients in the first 12 weeks of rehabilitation after ARCR. METHODS: This was a quasi-randomized study with 2 parallel groups. Forty-seven patients with ARCR were included in 2 different patient visit frequency protocols (HF = 23, LF = 24) in 12 weeks of postoperative rehabilitation. Patients in the HF group visited the clinic twice a week, whereas patients in the LF group visited once every 2 weeks for the first 6 weeks and once a week for the following 6 weeks. Both groups performed the same exercise protocol. Outcome measurements were pain and range of motion measured at baseline; at the 3rd, 5th, 8th, 12th, and 24th weeks; and at 1-year follow-up. Shoulder function was assessed at the 12th and 24th weeks and at 1-year follow-up with an American Shoulder and Elbow Surgeons score. RESULTS: There was a significant group × time interaction in pain intensity during the activity between the groups. The activity pain intensity was higher in the LF group (4.2 points) at 8 weeks post surgery than in the HF group (2.7 points) (mean difference: 1.5 points, P < .05), whereas it was similar in both groups at other time periods. The interaction term was not significant between the groups for pain intensity during rest and night through the 1-year follow-up. No group × time interactions were observed in shoulder range of motion and American Shoulder and Elbow Surgeons score over the postoperative period. CONCLUSION: Both rehabilitation programs at different visit frequencies after ARCR showed similar clinical results in the long term. A supervised, controlled rehabilitation program with LF visits in the first 12 weeks after surgery can be sufficient to achieve optimal clinical results and reduce rehabilitation-related costs after ARCR. IMPACT: This study highlights that LF treatment protocols under the supervision of the therapist can be adopted after the arthroscopic rotator cuff repair to achieve successful results while decreasing the treatment costs. Physical therapists should plan the treatment sessions efficiently for the compliance of the patients to the exercise treatment. LAY SUMMARY: If you are a patient with arthroscopic rotator cuff repair, a supervised, controlled rehabilitation program with low-frequency visits in the first 12 weeks after surgery could help you achieve the best outcome and help lower the costs of rehabilitation. A total of 3 visits in the first 6 weeks might be sufficient (once every 2 weeks). More frequent visits (1-2 visits a week) should happen 6 to 12 weeks after the surgery.

Recovery of the shoulder kinematics after reverse shoulder arthroplasty.

BACKGROUND: There is very limited information about the changes in shoulder kinematics in patients with reverse shoulder arthroplasty. The aim of the study was to investigate the changes in the scapulohumeral rhythm and shoulder kinematics over time after the reverse shoulder procedure. METHODS: Nineteen patients with reverse shoulder arthroplasty (age: 65.8 ± 10.3 years) were included to the study. During arm elevation in the sagittal and scapular planes, operated shoulder kinematics (humerothoracic elevation, glenohumeral elevation, scapulohumeral rhythm, and scapular rotations) were assessed using an electromagnetic tracking system at the postoperative 3rd, 6th, and 18th months. Asymptomatic shoulder kinematics were also assessed at the postoperative 18th month. Shoulder function was assessed using The Disabilities of the Arm Shoulder and Hand score at the postoperative 3rd, 6th, and 18th months. FINDINGS: Maximum humerothoracic elevation increased from 98° to 109° over the postoperative period (p = 0.01). The scapulohumeral rhythm was similar on the operated and asymptomatic shoulders at the final follow-up (p = 0.11). Both the operated and asymptomatic shoulder demonstrated similar scapular kinematics at the postoperative 18th month (p > 0.05). The Disabilities of the Arm Shoulder and Hand score decreased over time in the postoperative period (p < 0.05). INTERPRETATION: Shoulder kinematics may be improved after reverse shoulder arthroplasty in the postoperative period. Focusing on scapular stabilization and deltoid muscle control in the postoperative rehabilitation program may enhance the shoulder kinematics and upper extremity function.

Sports activity level after ACL reconstruction is predicted by vastus medialis or vastus medialis obliquus thickness, single leg triple hop distance or 6-m timed hop, and quality of life score.

PURPOSE: Recovery after anterior cruciate ligament reconstruction (ACLR) may take > 2 years, and younger athletes have higher re-injury risk. The purpose of this prospective longitudinal study was to determine how the early to mid-term Tegner Activity Level Scale (TALS) scores of athletically active males ≥ 2 years post-ACLR follow-up was predicted by bilateral isokinetic knee extensor and flexor torque, quadriceps femoris thickness, single leg hop test performance, and self-reported knee function (Knee Injury and Osteoarthritis Outcome Score (KOOS); International Knee Documentation Committee (IKDC) Subjective Assessment score). METHODS: After ACLR with a hamstring tendon autograft and safely returning to sports at least twice weekly, 23 men (18.4 ± 3.5 years of age) were evaluated at final follow-up (mean = 4.5, range = 2-7 years). Exploratory forward stepwise multiple regression was used to determine the relationship between independent surgical and non-surgical lower limb variables peak concentric isokinetic knee extensor-flexor torque at 60°/sec and 180°/sec, quadriceps femoris muscle thickness, single leg hop test profile results, KOOS subscale scores, IKDC Subjective Assessment scores, and time post-ACLR on TALS scores at final follow-up. RESULTS: Subject TALS scores were predicted by KOOS quality of life subscale score, surgical limb vastus medialis obliquus (VMO) thickness, and surgical limb single leg triple hop for distance (SLTHD) performance. Subject TALS scores were also predicted by KOOS quality of life subscale score, non-surgical limb vastus medialis (VM) thickness, and non-surgical limb 6 m single leg timed hop (6MSLTH) performance. CONCLUSION: TALS scores were influenced differently by surgical and non-surgical lower extremity factors. At ≥ 2 years post-ACLR, ultrasound VM and VMO thickness measurements, single leg hop tests that challenge knee extensor function, and self-reported quality of life measurements predicted sports activity levels. The SLTHD test may be better than the 6MSLTH for predicting long-term surgical limb function.

Association between quadriceps muscle thickness and knee function in anterior cruciate ligament reconstructed athletes: a cross-sectional study.

OBJECTIVE: This study aimed to investigate the association between vastus medialis obliquus (VMO), rectus femoris (RF), and vastus lateralis (VL) muscle thickness and quadriceps isokinetic strength, single-leg hop performance, and self-reported knee function in male athletes who had undergone anterior cruciate ligament reconstruction (ACLR). METHODS: Forty-two male athletes [mean ± standard deviation, age: 21.4 ± 3.4 years], who had undergone ACLR and had cleared to return to activity, were included in this study. Real-time ultrasound images of VMO, RF, and VL thicknesses were obtained from both reconstructed and contralateral limbs. Concentric quadriceps peak torque at 60°/s and 180°/s, single-leg hop for Distance (SLHD), and self-reported knee function scores were also assessed. Linear regression analysis and student t tests were used for statistical analysis. RESULTS: In reconstructed limb, greater VMO, RF, and VL thicknesses were associated with greater quadriceps peak torque at 60°/s (p = .008, r2 = 0.46) and at 180°/s (p = .006, r2 = 0.47). Greater quadriceps thickness was related to greater SLHD score in reconstructed limb (p = .002, r2 = 0.21). Self-reported knee function scores were not related to quadriceps thickness. VMO, RF, and VL thicknesses were smaller in reconstructed limb compared to contralateral limb (p < .001, p = .01, and p = .002, respectively). CONCLUSION: Quadriceps thickness by using ultrasound was associated with concentric quadriceps strength and single-leg hop distance in individuals who had undergone ACLR. However, quadriceps thickness was not related to self-reported knee function. The ultrasonography may be included in the evaluation of the knee function after ACLR, and it may be a useful and easy method in the follow-up of the quadriceps strength recovery following ACLR.

Tender point examination with palpation in different shoulder pathologies: A retrospective study.

BACKGROUND: Shoulder pain is a common symptom for non-traumatic shoulder pathologies and affects 4.7-66.7% of entire population. Even with the latest technological advantages, palpation still is a cost and time efficient tool to evaluate the shoulder pathologies. Our aim was to investigate and compare palpation findings in different shoulder pathologies. METHOD: We used first assessments of impingement syndrome (IS) (n = 205), rotator cuff tear (RCT) (n = 185) and frozen shoulder (FS) (n = 210) patients who received treatment between 2010 and 2019 years. Two experienced physiotherapists palpated predefined points: long head of biceps brachii, pectoralis minor, lateral intermuscular septum, proximal tendons of extensor group. These points categorized into "proximal", "mid-proximal", "mid-distal", "distal", "irregular". We also grouped patients by their BMIs. RESULTS: We found RCT patients had higher BMI than IS and FS patients (p < 0.001, p = 0.001); more tender intermuscular septum points and night pain than IS patients (p = 0.001, p = 0.003) and more extensor group proximal tendon points than IS and FS patients (p < 0.001, p = 0.001). "No tenderness" group had lesser resting pain than distal group (p < 0.001) and lesser activity and night pain than middle-proximal, middle-distal, and distal groups (all ps < 0.002). Distal group had higher night pain than middle-proximal group (p = 0.003). Morbidly obese patients had higher night pain than normal and overweight patients (p = 0.003 and p = 0.009). CONCLUSIONS: Tender point distribution varies depending on the pathology with biceps brachii being the most common. RCT patients had higher night pain related to more distal tender points. Patients with higher night pain had increased tenderness in septum intermuscular and extensor muscles' proximal tendons.

The repeatability of 3-dimensional scapular kinematic analysis during bilateral upper extremity movements.

Although three-dimensional electromagnetic systems are widely used to evaluate the 3-dimensional scapular kinematics their reliability when testing bilateral upper extremity tasks is unknown. The purpose of this study was to investigate the repeatability of the scapular kinematic analyses using the Flock of Birds (FOB) system during bilateral upper extremity movements. Twenty-one volunteers without shoulder problems were included (aged 24.8 years; body mass index averaged 21.2 kg/m2) to the study. Scapular internal-external rotation, upward-downward rotation, and anterior-posterior tilt was recorded during bilateral arm elevation on sagittal, scapular and frontal planes. Measurements were repeated at 5-7 days intervals. Intra-session and inter-session repeatability were determined using intraclass correlation coefficients (ICC) scores and standard errors of measurements (SEM). The ICC scores were found to be 0.81 to 0.99 for intra-session measurements and 0.60 to 0.83 for inter-session measurements. The SEM scores were 0.8°-3.4° and 2°-7.2° for the intra and inter-session measurements respectively. The repeatability of the FOB system was excellent for the intra-session measurements, but it was weaker for the inter-session measurements. These results support the use of the FOB system for assessing scapular orientation but the analyses should be conducted more carefully when it is applied to the longitudinal measurements.

Effects of Using Insoles of Different Thicknesses in Older Adults: Which Thickness Has the Best Effect on Postural Stability and Risk of Falling?

BACKGROUND: Postural stability (PS) problems arise as individuals grow older, and as a result, risk of falling (RoF) increases in older adults. We sought to examine the effects of insoles of various thicknesses on PS and RoF in older adults. METHODS: Fifty-six study participants had PS and RoF evaluated statically and dynamically under five different conditions: barefoot, only-shoes, with 5-mm insoles, with 10-mm insoles, and with 15-mm insoles. Standard shoes with identical features were used. To avoid time-dependent problems, these assessments were performed under the same conditions in 3 consecutive weeks. The average of these three values was recorded. RESULTS: Insoles of different thicknesses significantly affected static PS (overall: P =.003; mediolateral [ML]: P =.021; anteroposterior [AP]: P =.006), static RoF (overall, ML, and AP: P < .001), dynamic RoF (overall: P = .003; ML: P = .042; AP: P = .050), and dynamic PS (overall: P = .034; AP: P = .041) but not dynamic PS ML (P = .071). For static PS overall, dynamic PS AP, static RoF overall and ML, and dynamic RoF overall and ML, the highest PS scores and the lowest RoF were recorded when using 10-mm insoles (P < .05). CONCLUSIONS: The use of insoles of different thicknesses has been shown to be effective on all RoF and PS measurements except dynamic PS ML. The 10-mm-thick insole was a better option for elderly individuals to increase PS and reduce RoF compared. For older adults, 10-mm-thick insoles made of medium-density Plastozote may be recommended to help improve PS and reduce RoF.

Cross-education improves quadriceps strength recovery after ACL reconstruction: a randomized controlled trial.

PURPOSE: The aim of this study was to investigate the effects of concentric and eccentric cross-education (CE) on quadriceps strength and knee function recoveries after anterior cruciate ligament (ACL) reconstruction. METHODS: Forty-eight patients (age: 29.5 ± 6.8 years, body mass index: 26.1 ± 3.2 kg/m2) who had undergone ACL reconstruction with hamstring tendon autograft were included in the study. The patients were randomly divided into three groups when they reached four weeks post surgery: (1) concentric CE (n = 16); (2) eccentric CE (n = 16); and (3) control (n = 16). All groups followed the same post-surgical rehabilitation program for their reconstructed limb. Additionally, the two experimental groups followed eight weeks of isokinetic training for the uninjured knee at 60°/s for 3 days per week. Quadriceps maximum voluntary isometric strength (MVIC) was measured during the 4th week (pre-training), 12th week (post training), and 24th week post surgery. The single-leg hop distance and International Knee Documentary Committee (IKDC) scores were also evaluated during the 24th week post surgery. Analysis of variance was used for statistical analysis. RESULTS: Group-by-time interaction was significant for quadriceps MVICs for reconstructed and healthy limbs (p = 0.02). Quadriceps strength of both knees was greater in concentric and eccentric CE groups compared to control group during the 12th- and 24th weeks post surgery (p < 0.05). Strength gain was 28% and 31% in concentric and eccentric CE groups, respectively, when compared with the control group. Concentric and eccentric CE had similar effects on quadriceps strength recovery (n.s.). IKDC score, and single-leg hop distances were not significantly different among groups (n.s.). CONCLUSIONS: Concentric and eccentric quadricep strengthening of healthy limbs in early phases of ACL rehabilitation improved post-surgical quadriceps strength recovery of the reconstructed limb. CE should be integrated into ACL reconstruction rehabilitation, especially in the early rehabilitative phases to restore quadriceps strength. LEVEL OF EVIDENCE: Randomized controlled trial, Level I.

A three-dimensional scapular motion analysis in patients with arthroscopic anterior capsulolabral repair of the shoulder: The effect of scapular stabilization taping.

BACKGROUND: The aim of this study was to investigate the scapular kinematics during dynamic humeral movements in patients with arthroscopic anterior capsulolabral repair of the shoulder along with the potential biomechanical corrective effects of scapular stabilization taping. METHODS: Twenty patients with unilateral traumatic anterior shoulder instability and arthroscopic anterior capsulolabral repair participated in the study. Dynamic shoulder kinematics were assessed during the scapular plane shoulder elevation for both the operated and non operated shoulders and also under two conditions: no-taping and taping. Statistical analysis to compare sides and conditions was performed with analysis of variance models. RESULTS: The scapula was more internally rotated position in operated shoulders than in non operated shoulders. Furthermore, the scapula was less internally rotated and more downwardly rotated at 120° of elevation in the taping condition. CONCLUSIONS: Operated shoulders demonstrated kinematics alterations when compared to non operated shoulders underwent arthroscopic anterior capsulolabral repair. Additionally, changes in the scapular orientation with the taping was very small but followed a pattern, which would be suggested to be an orientation that potentially produce more scapular stability and to increase stress on the inferior glenohumeral ligament.

Shoulder kinematics and mobility adaptations in water-polo players.

BACKGROUND: There is limited research to demonstrate how scapular kinematics and shoulder-related physical characteristics are affected in water-polo players, who undertake swimming and repetitive throwing activity. The aim of this study was to investigate possible adaptations in the three-dimensional scapular kinematics and in glenohumeral internal rotation, external rotation range of motion and shoulder posterior-capsule tightness in water-polo players. METHODS: Fourteen water-polo players and 14 asymptomatic volunteers participated in the study. The scapular kinematics were recorded using an electromagnetic tracking device during the scapular plane shoulder elevation. Additionally, shoulder range of motion and posterior-capsule tightness were evaluated. Analysis of variance models were used to make comparisons between groups. RESULTS: Although there was a trend toward increased scapular internal rotation and downward rotation in the throwing shoulders of water-polo players, comparisons revealed there was no significant differences in kinematics, shoulder internal-external range of motion and posterior-capsule tightness between the throwing shoulders of the players and dominant shoulders of the control participants. CONCLUSIONS: The throwing shoulders of water-polo players did not demonstrate alterations in shoulder kinematics and mobility parameters.

Comparison of short-term effects of mobilization with movement and Kinesiotaping on pain, function and balance in patellofemoral pain.

OBJECTIVE: The aim of this study was to compare the short-term effects of Mobilization with movement (MWM) and Kinesiotaping (KT) on patients with patellofemoral pain (PFP) respect to pain, function and balance. METHODS: Thirty-five female patients diagnosed with unilateral PFP were assigned into 2 groups. The first group (n = 18) received two techniques of MWM intervention (Straight Leg-Raise with Traction and Tibial Gliding) while KT was applied to the other group (n = 17). Both groups received 4 sessions of treatment twice a week for a period of 2 weeks with a 6-week-home exercise program. Pain severity, knee range of motion, hamstring flexibility, and physical performance (10-step stair climbing test, timed up and go test), Kujala Patellofemoral Pain Scoring and Y-Balance test were assessed. These outcomes were evaluated before the treatment, 45 min after the initial treatment, at the end of the 4-session-treatment during 2-week period and 6 weeks later in both groups. RESULTS: Both treatment groups had statistically significant improvements on pain, function and balance (p < 0.05). Pain at rest (p = 0.008) and the hamstring muscle flexibility (p = 0.027) were demonstrated significant improvements in favor of MWM group. CONCLUSIONS: Our results demonstrated similar results for both treatment techniques in terms of pain, function and balance. The MWM technique with exercise had a short-term favorable effect on pain at rest and hamstring muscle flexibility than the KT technique with exercise in patients with PFP. LEVEL OF EVIDENCE: Level I, therapeutic study.

Translation and cross-cultural adaptation of the anterior cruciate ligament-return to sport after injury (ACL-RSI) scale into Turkish.

PURPOSE: To translate and culturally adapt the anterior cruciate ligament-return to sport after injury (ACL-RSI) scale into Turkish (ACL-RSI-Tr) and examine and evaluate the psychometric properties of the Turkish version in individuals who have undergone anterior cruciate ligament (ACL) reconstruction. METHODS: The ACL-RSI was forward- and back-translated, culturally adapted and validated on ninety-three Turkish individuals who had undergone ACL reconstruction (5 females, 88 males; age 28.7 ± 8.6 years; body mass 80.1 ± 13.9 kg; height 178.8 ± 6.9 cm; body mass index 25.0 ± 3.7 kg/m2). All patients completed the translated ACL-RSI, Tampa Scale of Kinesiophobia (TSK), Knee injury and Osteoarthritis Outcome Score (KOOS) and International Knee Documentary Committee (IKDC) and Lysholm questionnaires. We then analysed the internal consistency, reliability and validity of the newly formed ACL-RSI-Tr scale. RESULTS: The ACL-RSI-Tr showed good internal consistency (Cronbach's alpha 0.86) and test-retest reliability (ICC 0.92) and was significantly correlated with the KOOS 'quality of life' (r = 0.58, p < 0.002), 'symptoms and stiffness' (r = 0.35, p = 0.001), 'pain' (r = 0.49, p < 0.001), 'sports' (r = 0.44, p < 0.001) and 'daily life' (r = 0.42, p < 0.001) subscales. The ACL-RSI-Tr also correlated significantly with the TSK (r = - 0.45, p < 0.001), Lysholm (r = 0.45, p < 0.001) and IKDC (r = 0.44, p < 0.001) scores. CONCLUSIONS: The Turkish version of the ACL-RSI scale was valid, discriminant, consistent and reliable in patients who had undergone ACL reconstruction. This score could be useful to evaluate the effect of psychological factors on return to sport following ACL surgery. LEVEL OF EVIDENCE: Diagnostic study, Level I.