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ObjectiveTo produce a best evidence synthesis of exercise prescription used when treating shoulder pathology in the overhead athlete.DesignA systematic review of exercises used in overhead athletes including case studies and clinical commentaries.Data sourcesMEDLINE, PubMed, SPORTDiscus and CINAHL from database inception through July 8, 2016.MethodsWe examined data from randomised controlled trials and prospective cohort (level I–IV evidence) studies that addressed exercise intervention in the rehabilitation of the overhead athlete with shoulder pathology. Case studies and clinical commentaries (level V evidence) were examined to account for expert opinion-based research. Data were combined using best evidence synthesis and graded (A–F) recommendations (Centre for Evidence-Based Medicine).ResultsThere were 33 unique exercises in six level I–IV studies that met our inclusion criteria. Most exercises were single-plane, upper extremity exercises performed below 90oof elevation. There were 102 unique exercises in 33 level V studies that met our inclusion criteria. These exercises emphasised plyometrics, kinetic chain and sport-specific training.Conclusions and relevanceOverall, evidence for exercise interventions in overhead athletes with shoulder pathology is dominated by expert opinion (grade D). There is great variability between exercise approaches suggested by experts and those investigated in research studies and the overall level of evidence is low. The strongest available evidence (level B) supports the use of single-plane, open chain upper extremity exercises performed below 90° of elevation and closed chain upper extremity exercises. Clinical expert pieces support a more advanced, global treatment approach consistent with the complex, multidimensional nature of sport.

Background The ability to predict injury is difficult. Prior injury is the only risk factor that has been reported consistently in multiple research studies. Convenient and easy to perform, physical performance tests (PPTs) have great allure as prognostic factors. Methods 11 PPTs were issued to 359 participants over the course of three seasons of National Collegiate Athletic Association Division I athletic competition. Injuries were monitored and reported in a centralised university tracking system. Exploratory factor analysis was performed in order to group the PPTs into constructs. The relationship between injury and these PPT-based constructs and other known predictors of injury was explored using univariate and multivariate regression. Results PPTs clustered into five constructs: (1) active motion, (2) power, (3) hip stability, (4) flexibility and (5) motor control. When these five were placed into a multiple regression equation along with known risk factors (age, body mass index (BMI), gender, excessive flexibility and past injury), hip stability and active motion were predicted injury. In addition, motor control predicted non-traumatic injury. Past injury did not predict injury in the multivariate model. Summary In college athletes, hip stability, active motion and motor control as assessed through PPTs can be useful as part of preseason screening. These PPT-related constructs seem to have a mediating effect on the relationship between past injury and future injury. This study provides the rationale to test targeted interventions to address these limitations. Clinical trial registration number NCT01804894.

Objective In parts 1 and 2 of this systematic review, the methodological quality as well as the quality of the measurement properties of physical performance tests (PPTs) of the lower extremity in athletes was assessed. In this study, part 3, PPTs of the upper extremity in athletes are examined. Methods Database and hand searches were conducted to identify primary literature addressing the use of upper extremity PPTs in athletes. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed and the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist was used to critique the methodological quality of each paper. The Terwee Scale was used to analyse the quality of the measurement properties of each test. Results 11 articles that examined 6 PPTs were identified. The 6 PPTs were: closed kinetic chain upper extremity stability test (CKCUEST), seated shot put (2 hands), unilateral seated shot put, medicine ball throw, modified push-up test and 1-arm hop test. Best evidence synthesis provided moderate positive evidence for the CKCUEST and unilateral seated shot put. Limited positive evidence was available for the medicine ball throw and 1-arm hop test. Conclusions There are a limited number of upper extremity PPTs used as part of musculoskeletal screening examinations, or as outcome measures in athletic populations. The CKCUEST and unilateral seated shot put are 2 promising PPTs based on moderate evidence. However, the utility of the PPTs in injured populations is unsubstantiated in literature and warrants further investigation.

Objective To review the quality of literature and measurement properties of physical performance tests (PPTs) of the lower extremity in athletes. Methods Using the PICOS method we established our research question as to whether individual PPTs of the lower extremity have any relationship to injury in competitive athletes ages 12 years to adult (no limit). A search strategy was constructed by combining the terms ‘lower extremity’ and synonyms for ‘performance test’ and names of performance tests with variants of the term ‘athlete’. After examining the knee in part 1 of this 2 part series, the current report focuses on findings in the rest of the lower extremity. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed and the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist was used to critique the methodological quality of each paper. A second measure was used to analyse the quality of the measurement properties of each test. Results Thirty-one articles examined the measurement properties of 14 PPTs pertaining to the lower extremity. The terminology used to name and describe the tests and methodology by which the tests were conducted was inconsistent. The star excursion balance test performed in three directions (anterior, posteromedial, and posterolateral) appears to be the only test to be associated with increased injury risk. There is moderate evidence that the one leg hop for distance and the hexagon hop can distinguish between normal and unstable ankles. There is also moderate evidence that the medial hop can distinguish between painful and normal hips in dancers. Conclusions Currently, there is relatively limited research-backed information on PPTs of the lower extremity in athletes. We would suggest convening an international consortium comprised of experts in sports to standardise the descriptions and methodologies, and to set forth a research agenda to establish definitively the measurement properties of the most common PPTs.

House wine is the abstruse alcoholic drink sold by restaurants to thirsty, unquestioning individuals who are looking for the path of least resistance. House wine is easily accessible, simplifies an oft-complex process and ‘feels’ like its highbrow cousins. House wine is alluring to sellers of wine because it appeals to the masses and is profitable. House wine meets a need; but its packaging (usually a box) is generally looked down upon by discerning consumers since it signals lack of quality. > Unfortunately, orthopedic special tests are the house wine of the research community and diagnostic accuracy studies are the cheap containers in which they are served. Before you object too strenuously, we submit the following case (or box, sticking with the theme). Like cheap wine, orthopaedic special tests are ubiquitous. Our quick search of PubMed using ‘diagnostic accuracy and orthopaedic tests’ revealed 539 articles (most of them relevant). Beyond primary literature, a Google search for orthopaedic special tests elicited 967, 000 results including textbooks and websites. Textbooks frequently introduce a litany of tests; often including similar tests with variable names and no discriminating properties. YouTube is laden with demonstrations of selected tests. This popularity begs the question, ‘Why?’ For the sellers of the ‘house wine’, for example, researchers and journals, orthopaedic tests …

Monitoring athletes is fundamental to exploring the relationship between load and risk of injury. Traditionally, load monitoring in sport was limited to single metrics of external load such as running mileage, but this has recently advanced to quantification of multiple internal (eg, heart rate and rating of perceived exertion) and external loading variables (eg, running speed, watts produced, on-field impacts and number of accelerations). A 2016 consensus statement by the International Olympic Committee on load in sport and risk of injury highlighted that sport-specific guidelines for load management were lacking; empirical data must develop beyond a few select sports and populations.1 Forthcoming research must incorporate load measures relevant and specific to sports of interest. Popular multidirectional sports such as volleyball or basketball have significant jumping demands. Although we know the distinct movement patterns that can cause injuries during landing (ie, dynamic lower extremity valgus and stiff-legged landings),2 jumping and landing loads have been vastly understudied and we do not know when these movement strategies might transition from occasional aberrant mechanics to injurious …

Objective To systematically review and critique the evidence regarding the diagnostic accuracy of physical examination tests for the scapula in patients with shoulder disorders. Methods A systematic, computerised literature search of PubMED, EMBASE, CINAHL and the Cochrane Library databases (from database inception through January 2012) using keywords related to diagnostic accuracy of physical examination tests of the scapula. The Quality Assessment of Diagnostic Accuracy Studies tool was used to critique the quality of each paper. Results Eight articles met the inclusion criteria; three were considered to be of high quality. Of the three high-quality studies, two were in reference to a ‘diagnosis’ of shoulder pain. Only one high-quality article referenced specific shoulder pathology of acromioclavicular dislocation with reported sensitivity of 71% and 41% for the scapular dyskinesis and SICK scapula test, respectively. Conclusions Overall, no physical examination test of the scapula was found to be useful in differentially diagnosing pathologies of the shoulder.

There is level 1 evidence that ‘proximal control’ exercises are effective in the management of common musculoskeletal injuries of the lower extremity.1 2 However, there is little agreement on what ‘proximal control’ entails. A meta-analysis by Sugimoto et al 2 examined neuromuscular training for ACL injury prevention and found that exercises incorporating a ‘proximal control’ component (OR 0.33, 95% CI 0.23 to 0.47) were comparable to strength-based exercise or ‘multiple exercise’ interventions. Sugimoto et al 2 chose a global definition of proximal control (any exercise involving segments proximal to the knee joint) which included full-body dynamic warm-up programmes with plyometrics, jumps/hops, bounding, and various running and agility movements. One might argue that while these full-body interventions represent an integrated holistic approach, calling them ‘proximal control’ is inaccurate, as they fail to incorporate hip-specific exercises as the next ‘proximal’ link in the kinetic chain. In comparison, a review by Lack et al 1 reported on the benefits of proximal control interventions for patellofemoral pain syndrome defining ‘proximal control’ as ‘exercises directed at the hip or lumbopelvic musculature or both.’ Consequently, Lack et al ’s review1 was limited to more traditional static, …

Objective To compile histological and imaging research detailing the microvascularity of the rotator cuff and determine the clinical application of these findings for clinicians. Methods A computer-assisted literature search of MEDLINE (1966 to September 2008) using keywords related to blood flow to the shoulder and limited to humans and English language. A hand search was also performed by three of the authors. Results Nineteen studies met inclusion and exclusion criteria. Conclusions The relationship between the variables of vascularity, age and degeneration remains unclear. Recent studies with stronger design and better technology support the fact that increased vascularity is a normal response to smaller tears, but that as tear size increases the healing response fails and decreased vascularity is observed. Also, impingement may cause hypovascularity. These studies support the possibility that people without symptoms may have normal blood flow even with ageing. Finally, exercise may increase blood flow to the rotator cuff. These findings have both surgical and rehabilitation implications.

Objective: To compile and critique research on the diagnostic accuracy of individual orthopaedic physical examination tests in a manner that would allow clinicians to judge whether these tests are valuable to their practice. Methods: A computer-assisted literature search of MEDLINE, CINAHL, and SPORTDiscus databases (1966 to October 2006) using keywords related to diagnostic accuracy of physical examination tests of the shoulder. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool was used to critique the quality of each paper. Meta-analysis through meta-regression of the diagnostic odds ratio (DOR) was performed on the Neer test for impingement, the Hawkins2Kennedy test for impingement, and the Speed test for superior labral pathology. Results: Forty-five studies were critiqued with only half demonstrating acceptable high quality and only two having adequate sample size. For impingement, the metaanalysis revealed that the pooled sensitivity and specificity for the Neer test was 79% and 53%, respectively, and for the Hawkins2Kennedy test was 79% and 59%, respectively. For superior labral (SLAP) tears, the summary sensitivity and specificity of the Speed test was 32% and 61%, respectively. Regarding orthopaedic special tests (OSTs) where meta-analysis was not possible either due to lack of sufficient studies or heterogeneity between studies, the list that demonstrates both high sensitivity and high specificity is short: hornblowers’s sign and the external rotation lag sign for tears of the rotator cuff, biceps load II for superior labral anterior to posterior (SLAP) lesions, and apprehension, relocation and anterior release for anterior instability. Even these tests have been under-studied or are from lower quality studies or both. No tests for impingement or acromioclavicular (AC) joint pathology demonstrated significant diagnostic accuracy. Conclusion: Based on pooled data, the diagnostic accuracy of the Neer test for impingement, the Hawkins2Kennedy test for impingement and the Speed test for labral pathology is limited. There is a great need for large, prospective, well-designed studies that examine the diagnostic accuracy of the numerous physical examination tests of the shoulder. Currently, almost without exception, there is a lack of clarity with regard to whether common OSTs used in clinical examination are useful in differentially diagnosing pathologies of the shoulder.

What did I do? The first aim of my PhD involved reviewing the literature to determine whether common, established physical performance tests demonstrated predictive validity with regard to lower extremity injuries in athletic populations. The second aim was to prospectively examine the association of physical performance tests performed in the preseason with injury acquired during the season. ### Why did I do it? As a clinician scientist, it is my personal belief, and one shared with others,1 2 that injury is best explained by a dynamic systems model. Within this model, there are numerous inter-related variables such that the change in one variable affects all other variables. As I spoke with clinicians, an increasing number were speaking with certainty that asymmetry on slowly performed tests was predictive of injury. This simple mechanism of testing did not seem to fit with the …

Athletic injury and its sequelae remain a primary concern of sports professionals globally. As a result, screening athletes to predict injury is of great interest, especially if the screening/testing procedure is non-invasive, effective, and efficient. One such procedure of increasing popularity is the functional movement screen (FMS), which, in 2007, was reported to predict injury in American football players in a single season.1 The FMS attempts to identify fundamental movement patterns that simultaneously measure range of motion, stability, and balance1 and shows moderate evidence for acceptable reliability when deriving a composite score.2 The FMS attempts to take a comprehensive approach to assess human movement and encourages clinicians to look beyond impairments and isolated single joint motion and explore more comprehensive movement patterns representative of those used in daily activities and sport. Considering the growing popularity of the FMS both clinically and in research literature, its merits warrant closer analysis. A composite score of ≤14 on the FMS is commonly …

Objective To review the measurement properties of physical performance tests (PPTs) of the knee as each pertain to athletes, and to determine the relationship between PPTs and injury in athletes age 12 years to adult. Methods A search strategy was constructed by combining the terms ‘lower extremity’ and synonyms for ‘performance test’, and names of performance tests with variants of the term ‘athlete’. In this, part 1, we report on findings in the knee. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed and the Co nsensus-based S tandards for the selection of health M easurement In struments (COSMIN) checklist was used to critique the methodological quality of each paper. A second measure was used to analyse the quality of the measurement properties of each test. Results In the final analysis, we found 29 articles pertinent to the knee detailing 19 PPTs, of which six were compiled in a best evidence synthesis. The six tests were: one leg hop for distance (single and triple hop), 6 m timed hop, crossover hop for distance, triple jump and single leg vertical jump. The one leg hop for distance is the most often studied PPT. There is conflicting evidence regarding the validity of the hop and moderate evidence that the hop test is responsive to changes during rehabilitation. No test has established reliability or measurement error as assessed by the minimal important change or smallest detectable change. No test predicts knee injury in athletes. Conclusions Despite numerous published articles addressing PPTs at the knee, there is predominantly limited and conflicting evidence regarding the reliability, agreement, construct validity, criterion validity and responsiveness of commonly used PPTs. There is a great opportunity for further study of these tests and the measurement properties of each in athletes.

It was with great interest that we read the recent BMJ editorial by professors Lohmander and Roos1 that challenged the orthopaedic and sports world to have greater evidence to support interventions. We would place ourselves firmly on their bandwagon as we examine the evidence supporting physical performance tests (PPTs) in athletes. A PPT is aptly named as each requires an athlete to perform a physical task that is believed to be a component of sports activity. PPTs are simple, portable, low-tech assessments and as such, are quite attractive. Representative of PPTs is the single leg hop test2 and its variations (triple, crossover, and timed 6 m hop), which are ubiquitous in sports rehabilitation environments. PPTs are routinely used to predict/determine if: 1. An athlete will be injured at some future time based on substandard performance of the test (injury prediction); 2. The athlete will perform at a higher level than his or her peers for the foreseeable future …

Background This article provides clinicians with a user9s guide on the performance of the shoulder physical examination tests most supported by current evidence from a recent systematic review published in the British Journal of Sports Medicine . Discussion A description of clinical shoulder tests is provided with explanations on exact testing procedures and complimentary photographs.

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