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Clinical Scenario: Quadriceps atrophy and weakness are common after anterior cruciate ligament reconstruction (ACLR). Blood flow restriction (BFR) therapy, alone or in combination with exercise, has shown some promise in promoting muscular hypertrophy. This review was conducted to ascertain the extent to which current evidence supports the use of BFR for reducing quadriceps atrophy following ACLR in comparison with standard care. Clinical Question: Is BFR more effective than standard care for reducing quadriceps atrophy after ACLR? Summary of Key Findings: The literature was searched for studies that directly compared BFR treatment to standard care in patients with ACLR. Three level I randomized control trial studies retrieved from the literature search met the inclusion criteria. Clinical Bottom Line: Reviewed data suggest that a short duration (13 d) of moderate-pressure BFR combined with low-resistance muscular training does not appear to measurably affect quadriceps cross-sectional area. However, a relatively long duration (15 wk) of moderate-pressure BFR combined with low-resistance muscular training may increase quadriceps cross-sectional area to a greater extent than low-resistance muscular training alone. The results of the third randomized control trial suggest that employing BFR while immobilized in the early postoperative period may reduce quadriceps atrophy following ACLR. Additional data are needed to establish if the benefits of BFR on quadriceps atrophy after ACLR outweigh the inherent risks and costs. Strength of Recommendation: All evidence for this review was level 1 (randomized control trial) based on the Centre for Evidence-Based Medicine criteria. However, the findings were inconsistent across the 3 studies regarding the effects of BFR on quadriceps atrophy resulting in a grade “B” strength of recommendation.

Clinical Scenario: Low-intensity aerobic exercise (LIAEX) below the threshold of symptom exacerbation has been shown to be superior to rest for resolving prolonged (>4 wk) symptoms following sport-related concussion (SRC), but the effects of LIAEX earlier than 4 weeks after SRC need to be elucidated. Focused Clinical Question: Does LIAEX within the first 4 weeks following SRC hasten symptom resolution? Summary of Key Findings: Two randomized controlled trials (RCT) and 1 nonrandomized trial involving adolescent athletes (10–19 y) were included. One RCT reported faster recovery time with LIAEX versus placebo stretching. Likewise, recovery time was faster with LIAEX versus rest in the nonrandomized trial, but not in the underpowered RCT, although effect sizes were similar between these studies (0.5 and 0.4, respectively). All 3 studies reported a reduction in concussion symptom severity with LIAEX; however, the magnitude of symptom reduction across the recovery timeline was greater in the LIAEX group than the rest group in the nonrandomized trial, but not the 2 RCTs. Importantly, no adverse effects or incidence of delayed recovery from LIAEX were reported in any of the studies. Clinical Bottom Line: LIAEX initiated within 10 days after SRC may facilitate a faster recovery time versus placebo stretching or rest, although additional clinical trials are strongly advised to verify this. Strength of Recommendation: Level 1b and 2b evidence suggests subsymptom exacerbation LIAEX may decrease Postconcussion Symptom Scale scores and hasten symptom resolution in adolescent athletes following SRC.

Clinical Scenario:Ankle sprains account for roughly 10% of sport-related injuries in the active population. The majority of these injuries occur from excessive ankle inversion, leading to lateral ligamentous injury. In addition to pain and swelling, limitations in ankle range of motion (ROM) and self-reported function are common findings. These limitations are thought to be due in part to loss of mobility in the talocrural joint. Accordingly, some investigators have reported using high-velocity, low-amplitude thrust-manipulation techniques directed at the talocrural joint to address deficits in dorsiflexion (Df) ROM and function. This review was conducted to ascertain the impact of talocrural joint-thrust manipulation (TJM) on DF ROM, selfreported function, and pain in patients with a history of ankle sprain.Focused Clinical Question:In patients with a history of inversion ankle sprain, does TJM improve outcomes in DF ROM, self-reported function, and/or pain?

Clinical Scenario:Injuries are somewhat commonplace in highly active populations. One strategy for reducing injuries is to identify individuals with an elevated injury risk before participation so that remediative interventions can be provided. Preparticipation screenings have traditionally entailed strength and flexibility measures thought to be indicative of inflated injury risk. Some researchers, however, have suggested that functional movements/tasks should be assessed to help identify individuals with a high risk of future injury. One assessment tool used for this purpose is the Functional Movement Screen (FMS). The FMS generates a numeric score based on performance attributes during 7 dynamic tasks; this score is purported to reflect future injury risk. Expanding interest in the FMS has led researchers to investigate how accurately it can identify individuals with an increased risk of injury.Focused Clinical Question:Can the Functional Movement Screen accurately identify highly active individuals with an elevated risk of injury?

In female athletes the risk of anterior cruciate ligament (ACL) injury during impact-related activities such as landing is higher compared to males. Both how and why this occurs has been at the forefront of orthopedic sports medicine research over the past 20 years. Many individuals with an ACL-deficient knee compensate for joint instability in an effort to remain physically active. Yet others do not compensate and are faced with a reduction in their activities and/or meniscus tears and eventually osteoarthritis. In this article we attempt to link 2 distinct but related scientific disciplines (in vivo motion analysis assessment and computational modeling) to show how these techniques have emerged as powerful tools in our understanding of knee function. Normal knee function and the biomechanics of the ACL-deficient (ACLd) and ACL-reconstructed (ACLr) knee are summarized. Basic experiments concerning the mechanism of noncontact ACL injury as well as performance adaptations in ACLd and ACLr knees are reviewed, and the biomechanics of the normal, ACLd, and ACLr knees under more strenuous activities, such as landing from a jump, are provided.

This study was performed to determine the test-retest reliability and the relationship between 2 tests of trunk flexor muscular endurance-a prone bridge and a modified V-sit. Hold times (in seconds) were measured on 60 healthy volunteers from a University community (17 men, 43 women). Both tests were performed at 1-week intervals. The test-retest reliability of each test was assessed with a subgroup of 10 participants during 3 additional testing sessions at 1-week intervals. One examiner collected all data. Intraclass correlation coefficients (2, 1) with the prone bridge were 0.95 and 0.71 with the modified V-sit. The mean hold time was 92.8 ± 44.4 seconds during the prone bridge and 141.7 ± 104.1 seconds during the modified V-sit. Pearson's correlation coefficients between the 2 tests ranged from r = 0.52 (men + women) to r = 0.87 (men only). Intersession reliability with a single examiner was higher with the prone bridge compared with that in the modified V-sit. Modifications to the V-sit resulted in a lower test-retest reliability than was previously reported. Correlations between prone bridge and modified V-sit test scores were low, which may be attributable to the differences in the level of trunk flexor muscle activation between the tests.

L umbar spine injury is extremely pervasive and can be extraordinarily debilitating. It has been estimated that up to 80% of adults eventually will develop some form of low back pain (12). In addition, it has been estimated that 10–15% of all sporting injuries involve the spine (21, 35–37). The compressive, shear, tensile, and torsional forces on the lumbar spine during resistance training may be sufficient to cause injury, especially if these forces are concentrated by virtue of the exerciser’s mechanics. In this article we will review briefly the anatomy and pathologic mechanics of common lumbar spine injuries during weight training and discuss strategies for injury prevention. Our intent is not to provide an exhaustive review of lumbar spine pathologies, nor is it to enable strength and conditioning professionals to diagnose and to treat lumbar spine injuries. Instead, we hope to raise awareness of common resistance exercises that putatively are more likely to cause lumbar spine injury. In addis u m m a r y

Summary Objective To review recent research on the efficacy of physical therapy for patients with adhesive capsulitis. Design Search of Medline and CINAHL databases for studies published between January 1990 and December 2000. Inclusion criteria Non-operative experimental or descriptive research-based outcomes studies of physical therapy. Main outcome measures Methodological quality scoring using 16 predetermined criteria with 100% (16/16) indicating highest quality. Results Quality scores of the 12 studies that met inclusion criteria ranged from 38% to 69% (mean 54%). By design, scores were highest for the reviewed retrospective and randomised controlled studies. Conclusions How efficacious physical therapy is for patients with adhesive capsulitis is uncertain. Reviewed studies suggest that many patients treated with physical therapy benefited from reduced symptoms, increased mobility, and/or functional improvement. However, the lack of rigour and poor standardisation of terminology, methodology, and outcome measurements in these investigations undermines their validity and clinical application. More rigorous investigations are needed to compare the effects and costs of individual physical therapy interventions.

Clinical Scenario:Anterior cruciate ligament (ACL) injuries are associated with a lengthy recovery time, decreased performance, and an increased rate of reinjury. To improve performance of the injured knee, affected athletes often undergo surgical reconstruction and rehabilitation. Determining when an athlete is ready to safely return to play (RTP), however, can be challenging for clinicians. Although various outcome measures have been recommended, their ability to predict a safe RTP is questionable.Focused Clinical Question:Which outcome measures should be used to determine readiness to return to play after ACL reconstruction?

Context: Benign neck pain is common in athletes and is usually the result of minor sprains, strains, or contusions. Athletes with neck pain may have deficits in cervical and/or upper thoracic mobility, muscle recruitment, strength and endurance, repositioning acuity, postural stability, and oculomotor control. Evidence Acquisition: A Medline search was performed via PubMed to locate articles of any publication date through December 2011 using the search terms cervical pain, neck pain, athlete, athletic, therapeutic exercise, and rehabilitation. Reference lists of retrieved articles were searched for additional relevant references. Results: Therapeutic exercise has promise as an intervention for individuals with neck pain, although reports on isolated athletic populations are lacking. To date, recommendations for specific therapeutic exercises have been derived largely from anecdotal or uncontrolled level IV or V evidence. Conclusion: Clinicians should consider deficits, functional limitations, irritability level, and the sport’s cervical spine stress profile when selecting exercises for athletes with neck pain.

Context:Impaired postural control in single-limb stance and aberrant drop-landing mechanics have been implicated separately as risk factors for noncontact anterior cruciate ligament (ACL) injury, but associations between these variables has not been reported.Objective:To determine whether there are associations between single-limb postural control and drop-landing mechanics.Setting:University motion-analysis laboratory.Design:Single-leg-landing kinematic and kinetic data were collected after participants dropped from a hang bar. Postural-control variables COP excursion and velocity were assessed during single-leg barefoot standing on a force platform.Participants:A convenience sample of 24 healthy women.Main Outcome Measures:Pearson product–moment correlation coefficients.Results:Strong associations were measured between maximal knee-abduction moment and COP excursion (r = .529, P = .003) and average COP velocity (r = .529, P = .003). Strong inverse associations were measured between minimum hip-flexion angle and COP excursion (r = −.521, P = .003) and average COP velocity (r = −.519, P = .003).Conclusions:Participants with decreased postural control had higher knee-abduction moments and a more extended hip on landing, which have been implicated separately as risk factors for ACL injury. A longitudinal prospective analysis is needed to determine whether force-platform postural-control measures can identify athletes at risk for ACL injury.

Low-back pain (LBP) in women gymnasts is relatively common. This investigation was performed to evaluate the effects of a preseason training program for the trunk extensor, lateral flexor, and flexor muscles on LBP occurrence during the subsequent competitive season. The training group consisted of 15 collegiate women gymnasts. The control group consisted of 15 nonathlete collegiate women. Pre- and posttesting for all participants consisted of static endurance tests for the trunk extensors, lateral flexors, and flexors. After pretesting, the training group completed 10 weeks of biweekly training consisting of non-foot-supported back extensions and side bridges, in addition to their usual trunk flexor exercises. The control group did not perform any specialized trunk muscle training. Mean improvements in trunk endurance, based on multivariate analysis of variance at the 5% level of significance, were significantly greater in the training group than in the control group. Mean improvements in endurance in the training group were 47 seconds for the lateral trunk flexors, 34 seconds for the trunk extensors, and 80 seconds for the trunk flexors. During the subsequent gymnastics season, none of the gymnasts reported new episodes of LBP. One gymnast with chronic LBP reported a recurrence of LBP during the season. None of the gymnasts reported that the training program adversely affected their gymnastic performance. These data suggest that training the trunk musculature twice per week during a 10-week period with a relatively simple floor exercise protocol was an effective stimulus to improve trunk endurance measures. It is encouraging that none of the gymnasts reported new episodes of LBP during the subsequent competitive gymnastics season.

Background and Purpose. Postural stability has been shown to be impaired after a lateral ankle sprain (LAS) and after immersion cryotherapy in healthy ankles. This study was performed to determine the effects of cryotherapy on postural stability after LAS. Method. A single-session, repeated measures design was used. Fifteen 18- to 29-year-old males (mean age 21.33 ± 3.54, height 71.23 ± 2.50 cm, mass 170.33 ± 19.77 kg) with relatively recent grade I LAS volunteered. Medial-lateral postural sway variability was assessed during single-leg barefoot stance using a Bertec force platform. Sway was tested before cryotherapy (‘Pre’), immediately after 20 minutes of lower-leg immersion cryotherapy (‘Post0’), and 10 and 20 minutes after cryotherapy (‘Post10’ and ‘Post20’). Both legs were tested (individually) before cryotherapy; the involved leg was tested alone after cryotherapy. The uninvolved leg served as a control. Results. Postural sway variability of the involved le was significantly greater than the uninvolved le before cryotherapy (p = 0.001). Postural sway variability of the involved le was also significantly greater than the uninvolved LE during Post0 (p = 0.000), Post10 (p = 0.000) and Post20 testing (p = 0.003) with the largest increase in sway variability occurring at Post0. Conclusions. Medial-lateral postural sway variability was greater after LAS. This effect was augmented by immersion cryotherapy. Copyright © 2008 John Wiley & Sons, Ltd.

summaryThe conventional back squat (CBS) is commonly employed to enhance strength in the lower extremities. The suspended chain squat (SCS) provides a unique challenge to the musculature of the ankle, knee, hip, abdomen, and lumbar spine and may be a beneficial adjunct to any sports training or reha

Chris J. Durall, MS, PT, SCS, ATC, CSCSPhysical Therapy ProgramCreighton UniversityRobert C. Manske, MPT, CSCSPhysical Therapy ProgramWichita State UniversityGeorge J. Davies, MEd, PT, SCS, ATC, CSCSPhysical Therapy ProgramUniversity of Wisconsin-La CrosseKeywords: shoulder; injury; impingement; instability.ONE OF THE PRIMARY RESPON-sibilities of the personal trainer orstrength and conditioning special-ist is educating clients in properexercise techniques. More impor-tantly, however, the strength andconditioning professional must beable to design exercise programsthat are appropriate and safe foreach client. Because there is awide range of exercises to choosefrom when targeting specific mus-cles or muscle groups, it is sensi-ble to avoid exercises that aremore likely to lead to injury. Injuries to the shoulder arerelatively common among weighttrainers and can be career-threat-ening to those at the competitivelevel (14, 26). Fortunately, mostshoulder injuries from resistancetraining are minor musculo-ten-donous strains or ligamentous-capsular sprains. However, whenimproper exercises or exercisetechniques are utilized, resistancetraining may exacerbate or con-tribute to the development ofglenohumeral joint hyperlaxity,instability (19, 21), or impinge-ment (8, 9, 12, 16).In this article we will identifyshoulder exercises commonly per-formed in fitness centers that maycontribute to or exacerbate gleno-humeral joint injury. Alternativeexercises that may be substitutedwill be described along with the ra-tionale for the variations. It is be-yond the scope of this article to pre-sent an exhaustive review ofcontraindicated exercises for allknown shoulder pathologies;rather, glenohumeral joint patholo-gies commonly associated with re-sistance exercises will be dis-cussed. Avoiding risky exerciseshelps prevent injury in healthyclients and further tissue damagein clients recovering from injury.