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Background A comprehensive battery of tests are used to inform return to play decisions following anterior cruciate ligament (ACL) reconstruction. Performance measures contribute to patient function, but it is not clear if achieving symmetrical performance on strength and hop tests is sufficient or if a patient also needs to meet minimum unilateral thresholds. Hypothesis/Purpose To determine the association of quadriceps strength and single-leg forward hop performance with patient-reported function, as measured by the IKDC Subjective Knee Form (IKDC), during late-stage ACL rehabilitation. A secondary purpose was to determine which clinical tests were the most difficult for participants to pass. Study Design Descriptive Laboratory Study Methods Forty-eight individuals with a history of ACL-R (32 female, 16 male; mean±SD age=18.0±2.7 y; height=172.4±7.6 cm; mass=69.6±11.4 kg; time since surgery=7.7±1.8 months; IKDC=86.8±10.6) completed the IKDC survey, quadriceps isometric strength, and single-leg forward hop performance. The relationship between IKDC scores and performance measures (LSI and involved limb) was determined using stepwise linear regression. Frequency counts were used to determine whether participants met clinical thresholds (IKDC ≥ 90%, quadriceps and single-leg forward hop LSI ≥ 90%, quadriceps peak torque ≥ 3.0 Nm/kg, and single-leg forward hop ≥ 80% height for females and ≥ 90% height for males). Results Quadriceps LSI and involved limb peak torque explained 39% of the variance in IKDC scores while measures of single-leg forward hop performance did not add to the predictive model. Nearly 90% of participants could not meet established clinical thresholds on all five tests and quadriceps strength (LSI and peak torque) was the most common unmet criteria (71% of participants). Conclusions During late-stage ACL rehabilitation deficits in quadriceps strength contribute more to patient function and are greater in magnitude compared to hop test performance. Level of evidence Cross-Sectional Study, Level 3, This study investigates the association of quadriceps strength and single-leg forward hop performance with patient-reported function, during late-stage ACL rehabilitation, as well as which tests are more difficult to pass.

Following anterior cruciate ligament (ACL) reconstruction limb dominance for performing tasks is not considered when making rehabilitation progression decisions. The purpose of this study was to determine if strength and functional outcomes differ between individuals who injured their preferred or nonpreferred jumping limb and to determine if these same outcomes differ between individuals who injured their preferred or nonpreferred limb used to kick a ball. A secondary purpose was to determine the association of quadriceps strength and single-leg forward hop performance with patient self-reported function. Forty individuals with ACL reconstruction (age = 20.0 ± 4.6 years, height = 174.2 ± 12.7 cm, mass = 71.2 ± 12.7 kg, time since surgery = 5.3 ± 0.8 months) were included in the study. Primary outcome measures included, International Knee Documentation Committee Subjective Knee Form (IKDC) scores, quadriceps limb symmetry index (LSI) values, and single-leg forward hop LSI values. Limb preference was defined two ways, kicking a ball and performing a unilateral jump. There were no significant differences between groups based on injury to the preferred limb to kick a ball for any of the outcome variables. Individuals who injured their nonpreferred jumping limb demonstrated significantly (p = 0.05, d = 0.77) lower single-leg forward hop LSI values (81.1% ± 19.5%) compared to individuals who injured their preferred jumping limb (94.1% ± 12.6%), but demonstrated no differences in IKDC scores or quadriceps LSI values. Quadriceps LSI and single-leg forward hop LSI explained 73% of the variance in IKDC scores, but quadriceps LSI had the strongest association (r = 0.790). These findings suggests that limb preference influences single forward hop LSI values and should be considered following ACL reconstruction.

Background Return to activity decisions after anterior cruciate ligament reconstruction (ACL-R) are limited by functional performance tests often performed in a non-fatigued state. Fatigue can improve test sensitivity, but current methods to induce fatigue are typically bilateral tasks or focus on the quadriceps muscle in isolation. Hypothesis/Purpose To determine the effects of a two-minute lateral step-down fatigue test compared to a 30-second side-hop test on single-leg forward hop distance in healthy individuals. It was hypothesized that participants would demonstrate decreased hop distance with both tests, but the two-minute lateral step-down fatigue test would result in greater deficits in single-leg forward hop distance. Study Design Randomized crossover. Methods Twenty healthy participants (16 females, 4 males; age = 23.7±3.0 years, height = 153.8±36.2 cm; mass = 64.4±12.8 kg; Tegner = 6.8±1.2) were asked to perform single-leg forward hop for distance pre- and post-fatigue. Participants were randomly assigned to one of the two fatigue tests, 30-second side-hop or 2-minute lateral step-down test, during the first visit. They returned within a week and performed the same sequence of tests but underwent whichever fatigue test was not assigned at the prior visit. Results There was a significant decrease (p < 0.001) in single-leg forward hop distance following the 30-second side-hop test (pre = 134.1±23.7 cm, post = 126.2±24.4 cm) and the two-minute lateral step-down test (pre = 135.0±26.1 cm, post = 122.7±27.4 cm). The decrease in hop distance was significantly greater (p < 0.001) for the two-minute lateral step-down test compared to the 30-second side-hop test. Conclusion The two-minute lateral step-down test resulted in a greater decrease in hop performance compared to the 30-second side-hop test. The results establish a threshold for expected changes that occur in a healthy population and that can then be compared with an injured athlete population. The two-minute lateral step-down exercise may be an effective method of inducing fatigue to better mimic performance in a sports environment to inform return-to-sport decisions. Level of Evidence Level 1b- Therapy.

Background Low back, pelvic, and lower extremity pain are common during and after pregnancy. Understanding differences in mechanics between pregnant and non-pregnant females is a first step toward identifying potential pathological mechanisms. The primary purpose of this study was to compare joint kinetics and muscle activation during gait between females during and after pregnancy to nulliparous females. Methods Twenty pregnant females completed testing on three occasions (second trimester, third trimester, and post-partum), while 20 matched, nulliparous controls were tested once. Motion capture, force data, and surface electromyography were averaged across seven trials during gait. Lower extremity kinematics, lower extremity moments and work normalized to pre-pregnancy body mass, work distribution, and peak and average muscle activation amplitude were calculated. Independent t-tests were conducted between pregnant and nulliparous females at each time point. Results Compared to controls, peak hip abductor moments were greater throughout and after pregnancy. Females in second trimester also demonstrated greater sagittal negative ankle work and greater percent contribution of the ankle and smaller percent contribution of the hip to negative work. Compared to controls, during third trimester there were greater knee abductor, ankle plantarflexor, and ankle dorsiflexor moments and greater work at the ankle and total work. Several moment and work variables continued to be elevated post-partum compared to controls. Gluteus maximus muscle activation amplitude was smaller in second trimester and post-partum compared to controls. Significance While overall joint demands were greater during and after pregnancy, there was a smaller relative sagittal utilization of the hip early in pregnancy and smaller gluteus maximus muscle amplitude during second trimester and post-partum. Because the gluteus maximus muscle contributes to force closure and dynamic stability of the low back and pelvis, relative gluteus maximus disuse, concurrent with increased joint loads, could potentially contribute to pain during and after pregnancy.

Background Previous studies have reported that persons with femoroacetabular impingement syndrome (FAIS) have diminished posterior tilt of the pelvis during functional tasks. It is not known how this movement impairment impacts pelvifemoral coordination during weightbearing and non-weightbearing movements. Methods Fifteen persons with a diagnosis of FAIS and 15 matched controls performed a deep squat (weightbearing) and a maximum height stepping task (non-weightbearing). Peak hip flexion, posterior pelvis tilt excursion, and the ratio of sagittal plane pelvis to femur motion during the period of pelvis posterior tilt were calculated for each task. Two factor ANOVAs were used to evaluate differences between groups and tasks. Findings With regards to peak hip flexion, there were no significant group differences for either task. When averaged across tasks, the FAIS group exhibited significantly less posterior tilt excursion (12.1° (SD 9.1°) vs 20.6° (SD 9.3°)) and smaller pelvifemoral ratios (0.24 (SD 0.14) vs 0.39 (SD 0.16)) compared to the control group. Interpretation Persons with FAIS exhibit altered pelvifemoral coordination regardless of weightbearing status. This finding suggests that decreased hip and/or lumbopelvic mobility may contribute to altered movement patterns at the hip.

BACKGROUND AND PURPOSE Body-weight-supported treadmill training has been shown to be an effective intervention to improve walking characteristics for individuals who have experienced a stroke. A pressure-controlled treadmill utilizes a sealed chamber in which air pressure can be altered in a controlled manner to counteract the effects of gravity. The focus of this case study was to assess the immediate and short-term impact of a pressure-controlled treadmill to improve gait parameters, reduce fall risk, improve participation, and reduce the self-perceived negative impact of stroke in an individual with chronic stroke. CASE DESCRIPTION The subject was an 81-year-old man (14.5 months poststroke). He had slow walking speed, poor endurance, and multiple gait deviations. INTERVENTION The subject trained 4 times per week for 4 weeks (40 minutes per session) on a pressure-controlled treadmill (AlterG M320) to counter the influence of gravity on the lower extremities. OUTCOMES Following training, self-selected gait speed increased from 0.50 m/s to 0.96 m/s, as measured by the 10-meter walk test. Stride length increased from 0.58 m to 0.95 m after training and to 1.00 m at 1-month follow-up. Peak hip flexion increased from 3.7° to 24.6° after training and to 19.4° at 1-month follow-up. Peak knee flexion increased from 19.4° to 34.3° after training and to 42.7° at 1-month follow-up. Measures of endurance, fall risk, and percentage of perceived recovery also were found to improve posttraining. DISCUSSION Training with a pressure-controlled treadmill may be a viable alternative to traditional body-weight-supported treadmill training for persons poststroke. Additional studies with larger sample sizes are needed to elucidate the role of pressure-controlled treadmill training in this population. Video abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A97).

Context: Hip rotation range of motion (ROM) is commonly assessed in individuals with lower extremity or spine pathology. It remains unknown which hip rotation ROM testing position is most reliable. Objective: To compare interrater and intrarater reliabilities between hip internal rotation (IR) and external rotation (ER) ROM in supine and seated positions. Study Design: Controlled laboratory study. Setting: University research laboratory. Participants: A total of 19 participants (11 females and 8 males; age = 23.5 [1.2] y; height = 173.2 [8.6] cm; and mass = 69.2 [13.4] kg) without hip, knee, low back, or sacroiliac pain within the preceding 3 months or history of hip or low back surgery were recruited. Interventions: Three testers obtained measures during 2 testing sessions. Passive supine and seated hip IR and ER ROM were performed with the hip and knee flexed to 90°. Main Outcome Measures: The primary outcome measures were hip IR and ER ROM in supine and seated positions (in degrees). Interrater and intrarater reliabilities were calculated using intraclass correlation coefficients (ICCs). Minimal detectable change was calculated. Differences between supine and seated hip IR and ER ROM values were assessed using paired t tests (significance level was .05). Results: Supine hip IR and ER ROM interrater and intrarater reliabilities were excellent (ICC = .75–.91). Seated hip IR ROM interrater and intrarater reliabilities were good (ICC = .64–.71). Seated hip ER ROM interrater reliability was good (ICC = .65), and intrarater reliabilities were good to excellent (ICC = .65–.82). Minimal detectable change values for supine and seated hip IR and ER ROM ranged from 6.1° to 8.6°. There were significant differences between supine and seated positions for hip IR and ER ROM (41.6° vs 44.5°; P P Conclusion: Supine hip rotation had higher interrater and intrarater reliabilities. Hip IR and ER ROM values differed significantly between supine and seated positions and should not be used interchangeably.

To compare the efficacy of posterolateral hip muscle strengthening versus quadriceps strengthening in reducing pain and improving health status in persons with patellofemoral pain (PFP).Comparative control trial.Rehabilitation facility.Persons with a diagnosis of PFP (N=36; 18 men, 18 women).Patients were alternately assigned to a posterolateral hip muscle strengthening group (9 men and 9 women) or a quadriceps strengthening group (9 men and 9 women). The posterolateral hip muscle strengthening group performed hip abductor and external rotator strengthening exercises, whereas the quadriceps strengthening group performed quadriceps strengthening exercises (3 times a week for 8wk).Pain (visual analog scale [VAS]) and health status (Western Ontario McMaster Universities Osteoarthritis Index [WOMAC]) were assessed at baseline, postintervention, and 6-month follow-up.Significant improvements in VAS and WOMAC scores were observed in both groups from baseline to postintervention and baseline to 6-month follow-up (P.001). Improvements in VAS and WOMAC scores in the posterolateral hip exercise group were superior to those in the quadriceps exercise group postintervention and at 6-month follow-up (P.05).Although both intervention programs resulted in decreased pain and improved function in persons with PFP, outcomes in the posterolateral hip exercise group were superior to the quadriceps exercise group. The superior outcomes obtained in the posterolateral hip exercise group were maintained 6 months postintervention.

Purpose To evaluate the effect of varying degrees of simulated cam morphology on acetabular stress magnitude and location using a finite element model with 1 subject that incorporates population-specific hip/pelvis kinematics during a squat task. Methods A reference model of the hip joint was created from magnetic resonance images obtained from 1 asymptomatic 28-year-old man without femoroacetabular impingement (FAI) morphology or hip dysplasia (alpha angle 41.9°, lateral center edge angle 34.0°, neck-shaft angle 137°, and no visible articular cartilage lesions or bone marrow edema on magnetic resonance). The femoral head/neck geometry was manipulated to mimic different cam morphology severities as reported in a previous study (minimum, moderate, and large). Peak hip and pelvis squat kinematics from healthy individuals (hip flexion 112.6°, abduction 10.5°, internal rotation 14.8°) and persons with FAI (hip flexion 106.3°, abduction 10.5°, internal rotation 8.9°) were applied to the control and cam models. Relative acetabular joint stress values and location of contact were the variables of interest. Results Average von Mises stress values for control, minimum, moderate, and large cam models were 9.64, 9.27, 11.36, and 28.43 MPa, respectively. Contact in the control and minimum cam models occurred within the acetabular cup. In the moderate and large cam models, contact shifted anterosuperiorly within the acetabular cup and to anterosuperior acetabular rim, respectively. Conclusions Despite simulating lower degrees of hip flexion and internal rotation, increased stress and a shift in contact location were observed in the simulated models of FAI. This finding suggests that decreased hip internal rotation in this population during functional tasks may be the result of bony abutment. Clinical Relevance Clinicians should be cautious about prescribing deep squats for persons with cam morphology. Performing squat exercises with neutral or external hip rotation may limit bony abutment at high hip flexion angles.

Background Previous studies have indicated that hip and pelvis kinematics may be altered during functional tasks in persons with femoroacetabular impingement. The purpose of this study was to compare hip and pelvis kinematics and kinetics during a deep squat task between persons with cam femoroacetabular impingement and pain-free controls. Methods Fifteen persons with cam femoroacetabular impingement and 15 persons without cam femoroacetabular impingement performed a deep squat task. Peak hip flexion, abduction, and internal rotation, and mean hip extensor, adductor, and external rotator moments were quantified. Independent t-tests (α 0.05) were used to evaluate between group differences. Findings Compared to the control group, persons with cam femoroacetabular impingement demonstrated decreased peak hip internal rotation (15.2° (SD 9.5°) vs. 9.4° (SD 7.8°); P = 0.041) and decreased mean hip extensor moments (0.56 (SD 0.12) Nm/kg vs. 0.45 (SD 0.15) Nm/kg; P = 0.018). In addition persons in the cam femoroacetabular impingement group demonstrated decreased posterior pelvis tilt during squat descent compared to the control group, resulting in a more anteriorly tilted pelvis at the time peak hip flexion (12.5° (SD 17.1°) vs. 23.0° (SD 12.4°); P = 0.024). Interpretation The decreased hip internal rotation observed in persons with cam femoroacetabular impingement may be the result of bony impingement. Furthermore, the decrease in posterior pelvis tilt may contribute to impingement by further approximating the femoral head–neck junction with the acetabulum. Additionally, decreased hip extensor moments suggest that diminished hip extensor muscle activity may contribute to decreased posterior pelvis tilt.