• A Cross-Sectional Study Comparing Overhead Activities of Senior Tennis Players With and Without Shoulder Pain
  • Keywords: Shoulder Study, Shoulder Injury, Tennis, Kinematics

• A Cross-Sectional Study Comparing Overhead Activities of Senior Tennis Players With and Without Shoulder Pain – Poster
  • Keywords: Shoulder Study, Shoulder Injury, Tennis, Kinematics

• Case Study: Diagnostic Ultrasound of Achilles Tendinopathy – how does Diagnostic Ultrasound fit into physiotherapy practice?
  • Keywords: Diagnostic Ultrasound, Achilles Tendinopathy

• Functional Movement Screening – Is it a valid injury predictor in Sport?

• Prevention and Management of Tennis Elbow
  • Keywords: Tennis elbow, Lateral Epicondylitis, Elbow Injury

• Effects of Back Pain on Overhead Hitting and Throwing

• Prevention and Rehabilitation of Thrower’s Elbow

• Management of ACL Ruptures in Skiers
  • Keywords: ACL Rupture, Anterior Cruciate Ligament, Knee Injury

• Quadriceps Dysfunction in Patello Femoral Pain Syndrome

• Spine Injuries in Sport

• Biomechanical Analysis and Measurement of Vertical Jump as a Performance Indicator in Basketball

Copyright
All articles on this site are copyright © 2025 of Suegnet Meyer and Meyer & Associates Sports Physiotherapists. Transmission or reproduction of the contents, beyond that allowed by fair use as defined in the copyright laws requires the written permission of the copyright owners. Please provide proper attribution when referencing or sharing content.

The post Index of Key Research Articles first appeared on Meyer Physio.

Published: 7 June 2020

MSc Sports Physiotherapy Dissertation

University of Bath, 2018

Abstract

Study Design

Cross-sectional design

Background

Repetitive overhead activity during tennis is a causative factor of shoulder pain. Age and playing years will influence shoulder movement and possibly result in shoulder injuries for throwers and hitting athletes. Literature assessing the shoulder movements of senior overhead athletes with shoulder pain exist, but correlation with serve kinematics is lacking.

Objectives

This study compares the effect of shoulder overhead activities on senior tennis player – with and without shoulder pain. The differences between movement patterns by means of inertial measurement and shoulder clinical assessments were assessed and correlated with the effect of age and playing history.

Methods

Twenty-two advanced level senior tennis players were divided into 2 groups: Older Asymptomatic group (OA), (n=12; males : females = 6 : 6; aged 56.6 ±8.3 years; 24.8 ±16.5 playing experience years), and Older Symptomatic group (OS), (n=10; males : females = 7 : 3; aged 53.7 ±13.6 years; 38.7 ±16.8 playing experience years).

A Clinical assessment (using an inclinometer) of glenohumeral internal rotation (GIR), glenohumeral external rotation, total range of motion (TROM) and scapula upward rotation were recorded.

A dynamometer determined muscle strength and ratios for shoulder Internal Rotators, External Rotators (ER), Middle and Lower Trapezius. Kinematics measures were collected during flat tennis serve by an inertial measurement system.

Results

By comparing between-groups humeral acceleration (Hum_a), OS-Hum_a was significantly increased by 42% (p<0.001). Both OA and OS-groups presented with reduced TROM and GIR.  OS-TROM and OS-GIR were significant inverse correlated (p<0.05, p<0.01) with OS-Hum_a. OS-Scapular Angular velocity (Scap_ω) and OS-Hum_ ω were elevated.

Conclusion

Age and Pain may have caused the OS-group to modify their technique due to a reduced OS-TROM and OS-GIR and an increased OS-Hum_a, Hum_ω and Scap_ω, causing stress on the shoulder joint and musculature.  It is important to promote shoulder mobility by including sleeper and cross-body posterior shoulder stretches.

Keywords

Tennis, overhead injury, kinematics

Related Articles

Shoulder Study Poster

Disclaimer

The contents of this article –  A Cross-Sectional Study Comparing Overhead Activities of Senior Tennis Players With and Without Shoulder Pain, is aimed at medical professionals. It is provided here for informational purposes only and should not be treated as medical or health management advice. The materials herein are not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your doctor, physiotherapist or other health care provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read in this article or website. Reliance on any information provided herein is solely at your own risk.

Copyright

The content of this article and dissertation – A Cross-Sectional Study Comparing Overhead Activities of Senior Tennis Players With and Without Shoulder Pain, is copyright © 2025 of Suegnet Meyer and Meyer & Associates Sports Physiotherapists. Transmission or reproduction of the contents, beyond that allowed by fair use as defined in the copyright laws requires the written permission of the copyright owners. Please provide proper attribution when referencing or sharing content.

The post A Cross-Sectional Study Comparing Overhead Activities of Senior Tennis Players With and Without Shoulder Pain first appeared on Meyer Physio.

Author: Suegnet Meyer, MSc, BPHYST, PGCert MSK US.

Published: 6 June 2020

Copyright © 2025 of Suegnet Meyer. All rights reserved.

Slide 1: Non-insertional or Mid-portion Achilles tendinopathy: Does Diagnostic Ultrasound fit into Physiotherapy Practice?

This presentation was constructed as part of completing a postgraduate qualification in Musculoskeletal Sonography (PGCert MSK US) at Brunel University, 2020. This case study data has been anonymised and patient consent obtained.

Slide 2 : Case description

A 54-year-old female walker, presented at the clinic with left mid-portion achilles pain that was present for the last 3 months (Figure 1). No co-morbidities or red flags were present. The athlete was taking NSAIDS that provided some relief.

The athlete had very high expectation to return to sport. The question was if the US imaging can predict the outcome and safely return to sport?

Slide 3: Clinical presentation and Diagnostic Tests.

On assessment, the cardinal symptom was pain, 3cm proximal to the insert of the achilles tendon on the calcaneus. The tendon contours presented with swelling and tendeness over the AT mid-portion.

A functional limitation was demonstrated during a single heel raise when comparing to the opposite side. Biomechanically, the left forefoot was in a varus stance. Weakness of the posterior kinetic chain was observed.

The Victorian Institute of Sport Assessment- Achilles Questionnaire (VISA-A), demonstrated a low score, (Robinson et al, 2001). A reduced VISA-A score usually indicate an increased pain and severity of Achilles tendinopathy.

No difference exists between different the three clinical tests for Achilles tendinopathy: Palpation of 2-6cm proximal to AT insertion and crepitus, the Painful arc sign and the Royal London Hospital test (Sensitivity = 0.568, Specificity = 0.833), were present, (Maffulli, 2003; 2020). By performing clinical testing, is usually sufficient to diagnose mid-portion Achilles tendinopathy. However, the current case, an US Scan, Doppler studies and measurements were considered, to rule out further pathology for instance partial tears.

Slide 4: Prevalence and region of the injury

Achilles tendinopathy is a common overuse injury. The prevalence of mid-portion achilles tendinopathy is high, at approximately 60% of all reported achilles injuries in runners between the ages of 21 to 60 years. De Jongh et al (2011), determined the incidence of 2.35 in every 1000 runners.

The location of the injury has been described as the mid-portion of the Achilles which is located between 2-6cm proximal of the Achilles insertion onto the calcaneus, (Figure 2).

Slide 5 : Aetiology of Achilles tendinopathy

The aetiology of Achilles tendinopathy is mostly unknown. It is hypothesised that the cause may be multifactorial with key element of overuse that will affect the healing response of the hypo-vascular middle third of the AT. Other extrinsic and intrinsic factors may also have an influence on the AT.

Extrinsic factors include : Changes in training patterns which a loading component together with errors in foot wear causes overuse. Other factors for instance hard surfaces or changing of the surface that the athlete is training or playing on may aggravte the tendon. The dysfunction ie weakness or length of Gastrocnemicus and particularly Soleus may play a role. The incraesed body weight in correlation with the athlete’s height (Leung et al 2008). Biomechanical factors for instance a cavus or forefoot varus or chronic lateral ankle instability may also contribute to the development of Achilles tendinopathy (Maffulli, 2003).

Medication for instance Fluoroquinolones enhances MMP3 release and inhibit tenocyte proliferation while cortico-steroids reduce collagen & matrix synthesis, (Parmar, 2007).

Intrinsic factors that influence the tendon composition for instance metabolic diseases – Diabetes Mellitus and Hypercholesterolemia, may cause early ruptures of AT. Inflammatory Arthropathic & other rheumatologic disorders will also have a negative effect on tendons, (Maffulli, 2003; Maffulli, 2019; Molyneux, 2017).

Slide 6 : Pathophysiology of Achilles Tendinopathy

Many pathophysiological tendinopathy theories have been proposed.

Cook & Purdam (2009), proposed the Tendinopathy Continuum. The Continuum consist of three phases: the Reactive phase, the Disrepair phase and the Degenerative phase. The three phases may be well established on Diagnostic Ultrasound imaging but do not correlate with the patient’s symptoms and cannot predict outcome. Furthermore, Cook (2012), proposed the effect of excessive compressive loads the may also have an effect on tendinopathy.

The role of the stretch shortening cycle & transferring force from the gastrocnemius & soleus has also been researched, (Sibernagel, 2007). Recent studies have assessed tendon morphology and mechanical properties (Arya, 2010; Coombes, 2018; Corrigan, 2020; Zhang, 2017). This new research may hold the key in predicting tendinopathy management and outcome.

Slide 7 : Performing the Diagnostic Ultrasound Scan and creating images

Prior to performing the ultrasound scan, patient consent was obtained. The patient was placed with the feet over the side of the plinth, with the ankles at 90 degrees of dorsiflexion (Figure 3). The ESSR scan protocol was followed. Some of the ultrasound images are presented here.

Slide 8 : Ultrasound images: Longitudinal view of the AT insertion.

The image produced here demonstrates the calcaneal insertion of the AT. Note the Anisotropy that is displayed by the open arrow. The AT is slightly hypo-echoic and the fibrillar pattern is not very well defined. The Kager’s fat pad appears normal and no retro-calcaneal bursa is present (Figure 4).

Slide 9 : Longitudinal view of Mid-portion AT

The mid-portion of the AT is distended, and presents hypo-echoic with a loss of the fibrillar pattern. It is measured at 1.04cm, (Figure 5). An advantage of ultrasound is to perfom a quick measurement of the opposite AT. Biachi et al (2014), estimate that a normal AT thickness is approximately 0.5cm.

Many have debated which is more accurate view to perform the tendon thickness measurements. In this study, longitudinal or cross-sectional and wide-view studies produced very similar measurements.

Slide 10 : Ultrasound image of cross-section of the mid-portion AT

The mid-portion cross-sectional view identifies some an-echoic regions in the posterior medial quadrant of the tendon which may indicate some moderate tendon degeneration. The fibrillar pattern is not well defined and the tendon presents hypo-echoic, indicating moderate degenerative tendinopathy, (Figure 6). The anterior-posterior cross-sectional tendon measurements are measured (1.09 x 1.92cm).

Slide 11 : Power Doppler study of the Mid-portion AT

The Ultrasound Power Doppler is a valuable novel tool of Diagnostic Ultrasound. This useful tool is unique to Diagnostic Ultrasound and one of the biggest differences when compared to MRI. Doppler Ultrasound is more sensitive than Colour Doppler when assessing soft tissue structures. Power Doppler, which is not bound by the direction of blood flow, but simply indicate that blood flow is present. If it is taken in consideration that a normal mid-portion AT is hypo-vascular, then this increased signalling on Power Doppler is most certainly abnormal, (Figure 7a & b). The Power Doppler is more sensitive to smaller blood vessels. The signalling indicate an increase of blood flow or vascularisation which is associated with hyperemia, an inflammatory reaction and tendinopathy.

Many have discussed the clinical significance of Doppler signalling. It was thought that an increased Power Doppler presentation indicate an increased severity and worse clinical outcome of tendinopathy, (Yang et al, 2010). However, recent studies have demonstrated that Doppler blood flow is not a reliable measure to correlate patient symptoms, (De Vos et al, 2007; Docking et al, 2015). However, ongoing studies are researching the possibility of Doppler Surface Area Quantification that may be a reliable method to correlate with the severity of symptoms, (Van der Vlist et al, 2020).

Further attention should be paid to the small Saphenous vein posterior-lateral aspect of ankle, that must not be confused with hyperemia, (Martonoli, 1993).

Slide 12 : Diagnostic Ultrasound Machine settings

The ultrasound scan was performed by using a GE LogiqQ (GE Healthcare, Wautwatosa, WI). A Linear Transducer L4-12t was used at a frequency setting of 13MHz. The frequency setting is determined by the structure depth. If the structure is superficial, the frequency used will be higher with a shorted wavelength. The higher the frequency setting will reduce the ultrasound wavelength (λ) and reduce the wave penetration. Thus ultrasound beam will penetrate less due the shorter wavelength (f=¹/λ). Further settings will also optimise the image for instance the gain, focus and depth settings, (Figure 9).

Slide 13 : Physics Principles in Diagnostic Ultrasound

For easy comprehension of the physics principals of the Diagnostic Ultrasound scan of tendons, it is important to consider the tendon histopathological changes that occur. This will explain the pathological appearances of structures on the scan imaging.

Histology in tendinosis

During tendinopathy an increase in cell numbers occur. Due to this cell proliferation, tenocytes arrangement changes. The shift of proteoglycan content to hydrophilic proteoglycans are caused by an increased water content. This presents as oedema and thickening of the affected tendon. On Diagnostic Ultrasound a reduction in echogenicity (thus darker) will be presented and the tendon thickness dimensions will increase, (Docking, 2015, Smith et al 2009a; Smith et al 2009b).

Fibrillar disorganisation

In a normal tendon, Type 1 Collagen is presented as hyper-echoic ultrasound image. The healthy fibres are arranged parallel towards each other. The ultrasound beam is projected at a perpendicular angle, the reflected single beam image will be presented as a well-defined fibrillar pattern. The healthy tendon will appear hyper-echoic or bright.

During tendinopathic changes the haphazard arrangement of the fibres occur. Collagen Type 1 changes to Type 2 & 3. The fibrillar pattern is now aberrant. The perpendicular ultrasound beam is projected upon the tendon, creating multiple reflections & shadowing due to fibrillar disorganisation. The tendon will then appear hypo-echoic (darker) with the absence of the fibrillar pattern. For this reason, black or an-echoic regions determined in longitudinal and cross-sectional views, usually indicate tearing or degeneration, (Docking et al 2015; Smith et al 2009a; Smith et al 2009b).

Slide 14 : Physics Principles in Diagnostic Ultrasound

Anisotropy

Anisotropy is the major pitfall in any MSK ultrasound. This occur when the ultrasound beam lack reflection since the beam was not perpendicular to the structure, (Smith et al 2009a; Smith et al 2009b). This will appear darker and can easily be mistaken for tears or tendinosis, (Docking, 2015; Leung et al 2007). By moving the transducer at various angles and interrogating the structure in longitudinal and cross-sectional views, will eliminate this error, (Figure 10 a & b).

Slide 15 : Physics in Diagnostic Ultrasound

Error in Measurements

Errors in the measurement of tendons may occur due to incorrect probe skills. This may result in overestimating the tendon calibre. In the cross-sectional measurement (Figure 11), it is important to ensure that the US beam is perpendicular to avoid any artifactual hypo-echoic pattern (Leung et al 2007). During longitudinal measurements, the anatomical torsion of the AT must be taken in consideration to avoid any measurement errors, (Pekala et al, 2017).

Slide 16 : The Diagnostic Ultrasound report

Slide 17 : Evidence based literature relating to Diagnostic Ultrasound

Which Image is gold standard when assessing AT tendinopathy?

The accuracy, sensitivity and validity of Diagnostic Ultrasound compared to MRI when assessing AT tendinopathy to determine what is the gold standard imaging modality (Table 1). Accuracy is defined by the number of correct imaging diagnoses, both abnormal and normal imaging, divided by the total number of cases. While sensitivity – number of correct abnormal imaging diagnoses divided by the total number of symptomatic cases, (Khan, 2003). According to

Contrast-enhanced MRI (CME-MRI) good correlation histopathology in chronic Achilles tendinopathy (Shalabi, 2002). CME-MRI showed a greater sensitivity in comparison to US when assessing hypoechoic achilles tendinopathy, (Docking, 2015; Movin et al, 1998).

Slide 18 : Evidence based literature relating to Diagnostic Ultrasound

Which Imaging modality is the gold standard in the assessment of AT tendinopathy?

MRI is expensive but provide good soft tissue contrast detail. US is cheaper assessment and easy to perform as a point of care in clinic but is operator depended. It has the advantage functionality of Doppler blood flow (Smith, 2009a; Smith, 2009b).

It is suggested that if Diagnostic Ultrasound is inconclusive, MRI should be considered, as MRI is more objective in the assessment of Achilles tendinopathy (Neuhold, 1992).

Slide 19 : Evidence based literature relating to Diagnostic Ultrasound

Is the scan telling the whole story?

The mechanisms of tendon injury remain poorly understood, but the characteristics of injured tendons are well documented histologically, biochemically and at imaging. These three investigation techniques reveal distorted tendon appearance, hypercellularity, disorganized collagen bundles, increased proteoglycan content and neovascularization in chronic tendinopathic tendons. (Longo, 2009; Rees, 2009).

Can Imaging Predict the Onset of Pain or Clinical Outcome in Achilles tendinopathy?

Clinical usefulness of imaging has been criticised extensively. The clinical assessment of AT tendinopathy is sufficient, and it is unnecessary to determine morphological changes as it does not represent the patient symptoms or clinical outcome (De Jonge, 2015; Ryan, 2015). 

Other studied – Structural changes & measurements may be a predictor for the likelihood of developing symptoms, (Jhingan, 2011; Hirschmuller, 2012, Leung, 2007).

Good patient outcome: It is important to assess the tendon morphology and structure aim to provide better patient expectations. Currently, the norm is to manage patients with 3 months of exercise therapy prior to consider any other treatment, (Alfredson, 2007). 

It is agreed that to image the shape, size and measurement of tendons does not correlate with capabilities of the tendon load transferring & absorption. 

However, a recent study compared the initial diagnostic measurements, patient reported outcome Visa-A,  Calf muscle endurance single heel raise until fatigue , and continues shear-wave elastography  that was followed it up at 6 months and again at 1 year, n=59.

The result was that an initial US AT measurements thickness are associated with VISA-A outcome and muscle function that can be used as an outcome predictor for patients with symptoms up to 1 year, (Corrigan, 2020)

Slide 20: Summary of Evidence Based Practice

In clinical Physiotherapy practice:

• Assess Achilles tendinopathy by clinical assessment, single heel raise, VISA-A outcome s and measurements in combination with the VISA-A scores to guide the outcome. Consider MRI if any doubts exists.
• Shear-wave Elastography, in combination with US, outcome measurements and single heel raise assessment hold promising results to predict outcome for patients with symptoms less than 1 year.
• Uncertainty whether measures of Achilles tendon structure and morphology can inform decisions regarding correct type of exercise treatment or safe return to sport.

Slide 21 : Learning points

Point of Care Assessment of Achilles tendinopathy: Clinical Assessment, USS, VISA-A outcome measurement and single leg heel raise may predict a better outcome.

If USS result is inconclusive perform an MRI.

Shear-wave Elastography, in combination with US, outcome measurements and single heel raise assessment hold promising results to predict outcome for patients with symptoms less than 1 year.

Uncertainty whether measures of Achilles tendon structure and morphology can inform decisions regarding correct type of exercise treatment or safe return to sport.

Future research: Shear-wave elastography in combination with USS to determine effective AT exercise programmes and RTS.

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Copyright
The content of this article and slide show – Case Study: Diagnostic Ultrasound of Achilles Tendinopathy is copyright © 2025 of Suegnet Meyer and Meyer & Associates Sports Physiotherapists. Transmission or reproduction of the contents, beyond that allowed by fair use as defined in the copyright laws requires the written permission of the copyright owners. Please provide proper attribution when referencing or sharing content.

The post Case Study: Diagnostic Ultrasound of Achilles Tendinopathy first appeared on Meyer Physio.

Published: 16 August 2018

MSc Sports Physiotherapy – Poster for Dissertation

University of Bath, 2018

Poster for MSc dissertation 2018 – A cross-sectional study comparing overhead activities of senior tennis players with and without shoulder pain

Related Articles

A Cross-Sectional Study Comparing Overhead Activities of Senior Tennis Players With and Without Shoulder Pain

Disclaimer

The contents of this article and poster –  A Cross-Sectional Study Comparing Overhead Activities of Senior Tennis Players With and Without Shoulder Pain, is aimed at medical professionals. It is provided here for informational purposes only and should not be treated as medical or health management advice. The materials herein are not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your doctor, physiotherapist or other health care provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read in this article or website. Reliance on any information provided herein is solely at your own risk.

Copyright

The content of this article and poster – A Cross-Sectional Study Comparing Overhead Activities of Senior Tennis Players With and Without Shoulder Pain, is copyright © 2025 of Suegnet Meyer and Meyer & Associates Sports Physiotherapists. Transmission or reproduction of the contents, beyond that allowed by fair use as defined in the copyright laws requires the written permission of the copyright owners. Please provide proper attribution when referencing or sharing content.

The post Shoulder Study Poster first appeared on Meyer Physio.

Functional movement screening (FMS) is a tool that consist of 7 tests. It is widely used by trainers, coaches and therapists to predict if an athlete is at risk of injury. Many have raised their scepticism regarding the true value of using these tests as injury predictor.

In a recent systematic review (Moran et al., 2017), documented that FMS composite scores prediction and injuries that occurred, did not correlate. ‘Moderate’ evidence exist  ‘against’ using FMS in football injury prediction. Limited and conflicting evidence exists in basketball, running, police and firefighters. Various cases were assessed and ‘strong’ evidence was found that a high FMS composite scores, predicting a high injury risk, only resulted in a small amount of injuries sustained in military personnel. Although FMS has good to excellent inter- and intra-reliability, it is advised not to base injury prediction on FMS, as it is inaccurate.

Reference:

Moran, R., Schneiders, R.W., Mason, J., Sullivan, S.J., (2017). Do Functional Movement Screen (FMS) composite scores predict subsequent injury? A systematic review with meta-analysis. British Journal of Sports Medicine. DOI:10.1136/bjsports-2016-096938

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During throwing the thoracic spine influence the scapulo-thoracic position and glenohumeral motion. A thoracic kyphosis produce both abduction and protraction of the scapula and changes the orientation of the glenoid. This reduces the clearing space for the humeral head and increase anterior translation.

Thoracic rotation

Trunk pre-rotation towards the dominant side adds force that obliques externus may be able to generate increased force due to greater ROM. Counter-Clockwise Thoracic rotation limitation (for right handed pitchers in the late cocking phase) will reduce forward acceleration of the throwing arm (Pappas et al., 1985).

Ribs

The ribs and the costo-vertebral connections limit motion in the thoracic spine but also create a stable base that can translate the forces from the kinetic chain below to the muscles of the upper extremity for a more effective throw.

Thoracolumbar fascia

Thoracic lumbar fascia which anchors numerous muscles and has a role in providing trunk rotation and maintaining the semi-rigid cylinder shape which is important during pitching. It also helps with maintaining the rigidity of the vertebral column. This fascia functions better with the trunk in flexion. Thus, developing excessive lumbar lordosis will reduce this stabilisation effect.
Furthermore, McGill & Hoodless (1990) indicated that the L4/5 disc is subject to rotational forces of 4800N during pitching. The Thoracic lumbar fascia has a crucial role to play to dissipate the rotational forces on the intervertebral discs and facets during pitching (Young et al., 1996). If reduced lumbar lateral flexion exist: During throwing with the humerus in abduction, the lumbar spine needs to lateral flex away from the pitching arm and the trunk needs to rotate to fully able the shoulder to reach the cocking position.
If reduced L4/5 or L5/S1 ROM is present, this will reduce the ‘pivot point’ of the lumbar region. Due to this lack of lower spinal ROM, higher segments need to compensate, placing the pivot point much higher in the lumbar segments but also less efficient transference of force from the pelvis causing increased loading on the upper extremity.

Hips

The Psoas muscle attaches to T12-L5 and have an influence on the spinal biomechanics. A shortened Psoas affects the lumbar disks as well as hip extension range of motion (Bogduk et al., 1992).
Burkhart et al., (2000), described increase upper extremity stress due to reduced knee flexion during the cocking phase of the serve. Due to limited knee flexion, force transference is reduced from the lower limb and trunk to the upper limb. This will increase the load on the elbow and shoulder by 23-27%. It is therefore important to have sufficient bilateral hip and knee flexibility to reduced stress on the upper limb. The spine and pelvis are the force generators during limb acceleration in throwing. Kibler (1991) describes hip inflexibilities in the overhead athlete causing improper femur and foot position.

The Thrower’s Painful Hip 
Tennis players with tight and excessive strong hip external rotators causing reduced internal rotation on the contralateral side of the serving arm forces the femur into external rotation while the foot is planted. Pappas et al. (1985), documented that pitchers with painful hips on the dominant throwing side have limited and stiff external hips rotators hip rotation.
Shortened hip flexors will increase the anterior pelvic tilt causing poorly controlled lumbar lordosis and reduce stride length (Young et al., 1996). There is a definite relation between SLAP lesions and reduced hip rotation.

References

1. Bogduk, N., Pearcy, M., & Hadfield, G. (1992). Anatomy and biomechanics of Psoas Major. Clinical Biomechanics, 7, 109-119.
2. Burkhart, S.S., Morgan, C.D., & Kibler, W.B., (2000). Throwing injuries in the shoulder: the dead arm revisited. Clinical Sports Medicine, 19, 125-158.
3. Burkhart, S.S., Morgan, C.D., & Kibler, W.B., (2003). The disabled throwing shoulder: spectrum of pathology Part 1: Patho-anatomy and biomechanics. Arthroscopy, 19(4), 404-420.
4. Kibler WB (1991). The role of the scapula in the overhead throwing motion. Contemp Orthop, 22(5); 525-532.
5. McGill, S.M., Hoodless, K. (1990). Measured and modelled static and dynamic axial trunk torsion during twisting in males and females. Journal of Biomedical Engineering 12(5):403-409.
6. Pappas A.M., Zawacki R.M., (1985). Rehabilitation of the pitching Shoulder American Journal of Sports Medicine 13(4); 223-235.
7. Young, L.J., Herring S.A., Press J.M., Casazza B.A., (1996). The influence of the spine on the shoulder in the throwing athlete. Journal of Back and Musculoskeletal rehabilitation 7; 5-17.

Disclaimer

The contents of this article – Effects of Lower Back Pain on Overhead Hitting and Throwing, is aimed at medical professionals. It is provided here for informational purposes only and should not be treated as medical or health management advice. The materials herein are not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your doctor, physiotherapist or other health care provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read in this article or website. Reliance on any information provided herein is solely at your own risk.

Copyright

The content of this article – Effects of Lower Back Pain on Overhead Hitting and Throwing, is copyright © 2016 of Suegnet Meyer and Meyer & Associates. Transmission or reproduction of the contents, beyond that allowed by fair use as defined in the copyright laws requires the written permission of the copyright owners.

The post Effects of Back Pain on Overhead Hitting and Throwing first appeared on Meyer Physio.

Medial or inside elbow pain may be caused by performing repetitive badminton overhead smashing. These forceful strokes cause inside elbow stress on the elbow (or medial valgus stress), (Fleisig et al., 1996), and may have the following consequences: golfer’s elbow (flexor-pronator tear or tendinosis), nerve irritation (ulnar neuritis), or Ulnar Collateral Ligament (UCL) sprains or ruptures, (Bell, 2006). This ongoing stress on the elbow causes further damage by overloading the bony elbow structures at the back and cause loose bodies and more instability (Safran, 2004).

2. Risk factors to other players and how to prevention this injury

Badminton is explosive and consists of repetitive jumping and lunging. The player must perform fast directional changes with the racket-arm, doing combination of rapid arm throwing movements similar to baseball throwing or tennis serving. This causes excessive strain on the arm, (Faude et al., 2007). Male badminton players perform the smash frequently since this is a very effective way to score points. The inside elbow is stabilised against valgus stress, primarily by the UCL and to a lesser extent by the flexor-pronator complex (FPC), (Safran & Baillargeon, 2005). The UCL provides support against this valgus stress when the elbow is flexed between 20°-120°, and is under maximum stress when flexed at 70°. When the player plays frequently, the FPC becomes fatigued and cannot provide effective support to the inside elbow. This may result in micro-tears, inflammation and later cause FPC degeneration (tendinosis), (Ciccotti et al., 2004). While preforming the smash, valgus stress in the late cocking and early acceleration phase may produce medial sheering force of 300N, and 900N compression forces on the elbow. The UCL can only tolerate 64N safely, consequently it is prone to injury, (Flesig et al., 1995), especially with a faulty technique.

2.1 Faulty technique assessment within the kinetic chain

Faulty techniques can be identified by slow-motion video analysis of different strokes. Faulty techniques cause unnecessary strain on the body resulting in injury. By identifying the problem the coach can improve the technique, optimize force generation and reduce load on the elbow (Eygendaal et al., 2007). For example when excessive wrist flicking is performed during strokes, strain is caused on the FDC resulting in reduced force generation, (Sakurai & Ohtsuki, 2000). Skilled badminton players should use the shoulder and forearm rotation to produce force with lower energy cost to produce an effective smash, (Marshall & Elliott, 2000).
The kinetic chain describes a sequence of movements that follow-on from each other to produce the maximal amount of force, (Kibler et al., 2013). The legs produce force that is then transferred up the kinetic chain to the back, trunk, into the arm, and finally to the racket to produce a stroke. Video analysis can identify players with inadequate leg performance, reduced trunk rotation, poor core and scapular control, or incorrect sequencing of movements, which can then be corrected, (Wilk et al., 2012).

2.2 Fitness and skill

Fitness, skill, mental power, tactics, balance and coordination (neuro-muscular control (NMC)) are essential in badminton. Players train and play in an anaerobic energy system. Their anaerobic fitness should be tested regularly for optimum success during matches, (Chin et al., 1995). Skilled players reduce fatigue by resorting to the stored elastic energy of muscles (stretch-shortening cycle) of the shoulder rotators, (Genevois et al., 2013) and the forearm rotators, and the pre-stretching energy from quadriceps before jumping to perform the smash, (Tsai & Chang, 1998). This should be trained to increase efficiency.

2.3 High velocity versus gender

Baseball pitchers pitching with a higher ball velocity have an increased risk of elbow injury and receiving surgery, (Bushnell, 2010). Likewise, male badminton players perform frequent high velocity smashes. Males are able to do this due to a higher racket grip velocity and faster shoulder rotation, abduction and elbow extension to produce a faster smash, (Salim et al., 2010). UCL injuries are known to reduce shuttle accuracy and velocity, with lack of stamina and strength, (Safran, 2005), which may explain why AB’s performance was unsatisfactory in Malaysia.

2.4 Playing frequency and reduced upper limb range of motion (ROM)

Overuse injuries are usually quite common at the beginning of a new season when preseason conditioning was ineffective, or more towards the end of the season when the players are fatigued, (Jorgensen & Winge, 1990). Players that participate in competitions for longer than 8 months in the year are at risk of injury, (Shanley & Thigpen, 2013). Frequent, excessive volumes of overhead strokes reduce soft tissue flexibility, for instance: dominant shoulder inward rotation (IROM), (Wilk et al., 2011), and total shoulder rotation range of motion (TROM), that may cause additional stress on the inside elbow and UCL, (Eygendaal, 2007; Garrison et al., 2012). TROM and IROM are indicators of soft tissue restriction, (Couppe et al., 2014).
During excessive playing, elbow extension ROM reduces due to a flexor contracture or scarring that requires mobilisation, (Wilk et al., 2004). Identifying and improving restricted flexibility may promote upper limb biomechanical force production and translation with-in the kinetic chain, (Kibler, 2013).
Educating players about the importance of limiting excessive overhead activity, proper warm-up and maintaining flexibility whilst training may reduce injury, (Wilk, 2004). Screening and injury prevention programmes should be performed throughout the year to benchmark wrist, elbow and shoulder strength and ROM, monitor fitness and improve strength, endurance and flexibility to support the demands of badminton, (Ellenbecker et al., 2010; Shanley & Tightpin, 2013).

3. Management

Medial elbow pain should be assessed by taking a thorough patient history, physical assessment and imaging. Medial epicondylitis is indicated by pain and weakness with resisted wrist flexion and pronation. By pressing slightly below and to the front of the medial epicondyle causes pain, (Ciccotti et al., 2004). If numbness or weakness of the small and ring finger is present, nerve conductive tests needs to be performed to rule out ulnar neuritis, (Ciccotti, 2004). Alternatively referred pain from the neck may also be the cause, (Lee & Lee-Robinson, 2010). The ‘Milking manoeuvre’ test identifies valgus instability, (O’Driscoll et al., 2005). Dynamic ultrasound or MRI arthrogram is used to identify UCL injuries, flexor-pronator tears, tendinosis or calcification, (Azar et al., 2000; Nazarian et al., 2003).
Rehabilitation
Due to the sudden onset of pain and lack of performance, a UCL sprain is suspected. An initial non-surgical UCL rehabilitation consisting of an initial protected phase, intermediate phase, advance strength training phase and RTS is advised, (Modified guidelines: Wilk, 2012).

3.1 Initial protective phase

Aims:

• Reduce inflammation and pain
• Promote ligament healing
• Regain optimum pain free ROM
• Avoid muscle atrophy

1. Discontinue badminton with ‘active rest’. Avoid any further injury to the medial elbow structures for example heavy lifting and gripping. The kinetic chain needs to be taken into consideration and strong emphasis should be on core, scapular stability and shoulder strengthening, (Ellenbecker et al., 2009).
2. Treatment for the FPC: Ice and anti-inflammatory medication, transcutaneous electrical nerve stimulation, (Chesterton et al., 2009), and Cyriax treatment, (Trudel et al., 2004, Kohia et al., 2008) may reduce pain. Low intensity ultrasound increases protein synthesis, (Haker & Lundeberg, 1991), and laser treatment improves cell function, (Oken et al., 2008). Platelet rich plasma promotes UCL and FPC healing, (Halpernet et al., 2012; Podesta et al., 2013). Isometric elbow and wrist flexor and extensor exercises should be performed to avoid any further muscle wasting. Gentle stretching of the wrist flexors and pronators should be performed, (Wilk, 2004).
3. Elbow joint mobilisation: the physiotherapist may use Grade I-II mobilisation techniques and gradually progressing to Grade III-IV in weeks 3-4, to reduce pain and improve ROM (Maitland, 1987; Wilk, 2004).
4. Shoulder and arm strengthening: the concept of strengthening all components of the arm should apply. By strengthening the scapula stabilisers using high repetitions and low resistance endurance at varying speeds will be promoted. By applying manual resistance above the elbow, Serratus anterior, Trapezius and Rhomboids can be strengthened to provide stability, (Ellenbecker, 2009). Rotator cuff strengthening using manual resistance to activate the posterior cuff and scapular stabilisation during prone extension and horizontal abduction, (Wilk, 2013).
5. Lower limb and core strengthening: Leg press, squats and calve heel raises will promote force production in the lower limb kinetic chain. Additionally, progressing to lower limb plyometrics to increase the quadriceps elastic energy, improves power production with reduced fatigue during the single leg smash, (Tsai & Chang, 1998).

3.2 Intermediate phase

Aims:

• Maximise elbow range of motion and flexibility
• Improve strength and endurance
• Improve stability

The elbow joint capsule has a tendency to form adhesions with scarring of brachialis muscle. This needs to be reduced to maximise elbow extension by means of a low load, light resistance extension stretch for a duration of 10-15 minutes, 4 times per day. The arm, in pronation and elbow extension (figure 1), is attached to an elastic band providing a long duration light loaded (LDLL) stretch, (Wilk, 2004). This aim is to reach full elbow extension ROM at 3-4 weeks.

Figure 1: LDLL stretching (from: Ellenbecker et al., 2009)

2. Elbow flexion and extension: progression to concentric biceps and triceps strengthening can be introduced, if no pain is present. Concentric (muscle- shortening) triceps contraction improves racket velocity during the acceleration phase and needs to be trained, (Fleisig, 1995). During elbow extension the whipping effect may cause overload. Biceps need to be strengthened in an eccentric way (muscle lengthening) to oppose this, (Eygendaal, 2007).
3. The FPC provides dynamic elbow stability (Davidson et al 1995) and must be gradually loaded with concentric and then progressive ongoing eccentric loading, using elastic bands and light weights, (Cook & Purdam, 2009; Ellenbecker, 2010; Lewis, 2013 ) and continued stretching (Ellenbecker et al., 2002).
4. Posterior shoulder structures: sleeper stretch and the modified side-lying cross-body stretch mobilise the posterior shoulder structures. This can also be performed while the player is lying down, fixating the scapula and performing horizontal adduction across the chest, (Ludewig & Reynolds, 2009; Wilk, 2012; Shanley & Thigpen, 2013).
5. Myofacial release of the posterior shoulder structures and the forearm may improve mobility of the upper limb, (Travell & Simmons, 1999).
6. Upper limb rhythmic stabilisation that promotes dynamic stabilisation and neuromuscular control (NMC) may be increased and progressed to isotonic exercises, (Wilk, 2013).
7. Core stability and trunk rotational exercises must be performed for example medicine ball trunk rotation and swissball core strength training. Leg and core exercises that enhance NMC and flexibility that is specific to the needs of this player, for example hamstrings flexibility, (Shanley & Thigpen, 2013).

3.3 Advanced phase

Criteria for progression:

• Full pain-free ROM without any tenderness or laxity
• Elbow flexor & extensor strength improvements
• Good NMC and proprioception

Aims:

• To increase strength, power and endurance
• Improve NMC with progression to high speed drills

1. Progressive arm strength training: Thrower’s Ten isotonic programme should be followed to strengthen the upper limb with Theraband and dumbbells. This is a comprehensive programme to improve strength, endurance and power in preparation for overhead strokes, (Wilk, 2012).
2. Ongoing biceps and FPC eccentric training should be incorporated at varying speeds and loads.
3. Isokinetic training: Furthermore wrist and elbow isokinetic strength training can be implemented at speeds of 180’and 300’ per second for 15-20 repetitions to promote strength and endurance, (Ellenbecker, 1991; Ellenbecker, 2009). This includes concentric and eccentric training for the wrist flexors, pronators and eccentric elbow flexors in a protective capacity, (Lauder et al., 2012), as well as eccentric shoulder external rotation and concentric internal rotation, (Van Cingel et al., 2007).
4. Weight training: gym equipment may be introduced for bench-press, seated rowing and Latissimus Dorsi pull-downs, (Wilk, 2012).
5. Plyometrics must be carefully implemented without any discomfort, (Wilk, 2013; Ellenbecker, 2013). This can be done by wrist flicks and snaps (Figure 2). Distal arm strengthening with ball dribbling on the wall (Figure 3), and progress to internal shoulder rotation ball tossing (Figure 4), (Ellenbecker, 2013).
Figure 2: Wrist flicks (From: Ellenbecker, 2013)

6. Technique analysis: Video stroke technique analysis should be performed and errors should be corrected, (Wilk, 2004).
7. Interval badminton programme (IBP), (Wilk, 2004): by introducing the IBP, the phased return to sport is established and confidence promoted. Proper warm-up including flexibility should be introduced and consistently used in future, (Shanley & Thigpen, 2013). Correct stroke mechanisms as determined by the video analysis should be applied under the supervision of the coach. Efficient communication should exist between the athlete, coach and other rehabilitation professionals to ensure that effective progression is established and regression or re-injury is avoided.
Some discomfort during and after the implementation of the IBP is acceptable, however, the player needs to stop if pain is sharp and inform the physiotherapist, (Reinold et al., 2002). By using alternative days, the first week will be played at 50% of maximal stroke force during forearm and backhand while week 3-4 will be at 75% of maximum force with correct technique using forearm and backhand strokes. At week 3, power strokes are performed at 50% force. At 4-6 weeks 100% force of forearm and backhand strokes will be introduced with power strokes at 75%. Progressive amounts of each stroke will be performed. If this is successful, phased return to 3 games may be initiated. Again, gradual progression from 1.5 sets to full matches, without any elbow pain. The IBP must be introduced and progressed very carefully. If pain is present, the player needs to be reassessed and the management reconsidered, (Wilk, 2012).

Figure 3: Distal Arm Strength training with ball dribbling (From: Ellenbecker, 2013)

Figure 4: Internal shoulder rotation ball tossing (From: Ellenbecker, 2013).

3.4 Return to Sport may be considered after week 14

Criteria:

• Completed Thrower’s Ten programme, IBP and fitness testing.
• Pain free and full ROM, palpation & no laxity present
• Isokinetic ratios must be comparable to the non-dominant side. Comparative dominant elbow flexion strength should be 10-20% more while elbow extension ought to be 5-15% greater in elbow extension compared to the non-dominant side, (Wilk et al., 1993). Dominant side forearm pronation should measure 10-25% stronger, (Ellenbecker, 1991).

4. RTS Recommendations

If rehabilitation is successful, the player may compete after 12-14 weeks, with between-competition re-assessment to avoid re-injury, (Rettig et al., 2001; Wilk, 2004; Lavellee et al., 2013). Returning to competition will be on 17/06/14, with a phased return. The next competitions will be 14/10/14, 11/11/14 and 17/12/2014, to provide the player time to continue with further rehabilitation and avoid overloading. If, at 3 months of rehabilitation, ongoing medial elbow pain, UCL pathology or pain at 75% of hitting, is present, surgery should be considered, indicting an early season end, (Cain et al., 2010; Lavallee, 2013). The ‘Tommy John surgery’ rehabilitation is 11months, (Dodson et al., 2006).
Due to the excessive demand of badminton, all players are at risk, but especially males that perform a faster frequent smash, (Salim et al., 2010). Care should be taken to avoid overloading by participating too frequent in competitions, causing excessive fatigue. Good technique, warm-up and flexibility is important. Overhead activity should be limited. Regular screening that include assessing FPC symptoms or UCL laxity, should be performed.

5. Conclusion

Badminton players must perform all year round conditioning that includes strength training and fitness conditioning together with proper warm-up and stretching. The players should receive regular screening to assess shoulder and elbow ROM loss or FPC pain. Proper technique modifications may be helpful to avoid tissue overload, fatigue and complications.

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Author: Suegnet Meyer

Introduction

The Anterior Cruciate Ligament (ACL) is the primary knee stabiliser that prevents anterior laxity of the tibia in relation to the femur and provides rotational knee stability (Negus et al., 2012). In the United States, approximately 200,000 Anterior Cruciate Ligament Reconstructions (ACLR) are performed annually at a cost of $3 billion (Brophy et al., 2009). Devastating evidence estimates up to 10% of professional alpine skiers will end their careers due to ACL ruptures or tears (Pujol et al., 2007).

Aim

This Clinical Guidance is aimed at Physiotherapists, Strength & Conditioning Coaches and Doctors to prevent and manage ACL ruptures during professional downhill, freestyle skiing and ski-cross during off-season.

Method

A search was performed on Cochrane Collaboration, the York Centre for Reviews and Dissemination, and the United States Agency for Health Care Policy and Research. These systematic reviews provided guidelines to create this evidence based tool. The level of evidence is graded according to criteria described by the Centre of Evidence Based Medicine Oxford United (CEBM) (http://www.cebm.net/). See Figure 1. Evidence strength was rated according to Guyatt et al. (1995).

	Level 1 Evidence
	Level 2 Evidence
	Level 3 Evidence

FIGURE 1: Level of evidence according to CEBM

Clinical Guidelines recommendations

• Conservative versus Surgical treatment
• Timing of Surgery
• Prehabilitation
• Single versus Double bundle techniques
• Grafts choices
• Outcome measurements
• Cryotherapy
• Therapeutic exercise
• Accelerated versus Non-Accelerated rehabilitation
• Open versus Closed chain exercises
• Neuromuscular Training
• Neuromuscular Electrical Stimulation
• Knee Bracing
• Home-based versus Supervised rehabilitation
• Injury prevention

Injury Incidence

No decline in ACL injuries and re-injury rates in professional alpine skiers is reported (Pujol, 2007). This statistics shows primary ACL injury rate at 5.7 per 100 skier-seasons with a 19% re-injury rate and a bilateral ACL injury incidence of 30.5%. During professional skiing, these injuries affect both sexes equally (Pujol, 2007; Westin et al., 2012). In contrast, more female recreational skiers sustain ACL injuries (Flørenes et al., 2009).

Injury Mechanism

Professional skiers endure deceleration from high speeds, jumping, cutting and pivoting, placing stress on the knees resulting in non-contact ACL injuries (Griffin et al., 2006). Injuries occur during hard landings when rigid ski boots induce tibial anterior drawer injuries (Natri et al., 1999; Flørenes, 2009), while the athletes assume seated posture and quadriceps contracts maximally (Johnson 1995). Bere et al., (2014) described the “slip-catch” mechanism: the skier loses balance backwards or inwards during turning. The inside edge of the outer ski catches the snow causing forced valgus and tibial internal rotation position.

Intervention

1. Conservative versus Surgical Management

Cochrane reported inconclusive evidence of ACL injury management (Linko et al., 2005).
Using a pre-screening criteria can determine the ‘copers’ or ‘non-copers’, indicating who will return to sport (RTS) without surgery (Fitzgerald et al., 2000; Hurd et al., 2008; Logerstedt et al., 2010a). These potential ‘copers’ can be conservatively managed by perturbation neuromuscular training (NMT) (Fitzgerald, 2000). However, this will be a minority of skiers that may be considered for short term conservative management to complete a season (Fitzgerald, 2000).
Anterior Cruciate Ligament Reconstruction (ACLR) is indicated for active adolescents with a good prognosis of 85% to RTS. It is unlikely for active adolescents to return to the same sporting level with conservative management only (Ramski et al., 2013).
ACLR is cost-effective, at $38,121 per repair in comparison to rehabilitation alone that may include knee instability risk at $88,538. (Lubowitz et al., 2011; Mather et al., 2013).

Surgical management is indicated for active adolescents wanting to return to high level sport. ACLR is more cost-effective than rehabilitation only.

2. Timing of Surgery

Optimal surgical timing is controversial. Ideally the outcome must be optimised with minimal post-operative complications.
A systematic review demonstrated surgery may be performed from 2 days post-trauma (Andernord et al., 2013). Another review found that ACLR can be performed from one week post-injury together with a moderately accelerated programme with a low post-operative stiffness risk (Kwok et al., 2013).
Rapid surgical intervention after an acute ACL rupture may cause arthrofibrosis (Cosgarea et al., 1995; Mauro et al., 2008). Delaying surgery for high-level athletes, or athletes with increased knee instability post-injury, may cause secondary meniscal injuries and degenerative Osteoarthritis (OA) (Beynnon et al., 2005; Amin et al., 2008; Ajuied et al., 2013). Post-surgical complications include deep vein thrombosis (Ramos et al., 2008) and septic arthritis (Van Tongel et al., 2007).

Surgery should not be performed too soon due to arthrofibrosis risk but a lengthy delay may cause OA or meniscal injuries.

3. Prehabilitation

Prehabilitation aims to enhance postoperative outcome. Aims and criteria for progression to surgery include: Minimal knee swelling, full range of motion (ROM) including knee extension, normal gait and Quadriceps strength (Ditmeyer et al., 2002).
A pre-operative 6-week home-based and gym programme consisting of NMT and strengthening programme resulted in enhanced postoperative outcomes. Pre-operative improvements (hop tests and quadriceps hypertrophy) were evident. These enhancements were still present 12-weeks post-operative (Shaarani et al., 2013).

A prehabilitation programme will enhance the post-operative outcome up to 12 weeks.

4. Surgical technique: Double-Bundle (DB) or Single-Bundle (SB) choice

The ACL consists of 2 distinct bundles. The ACLR is performed by drilling either a single or double tunnel through the tibia and femur, to pass the graft through.
Cochrane reported no difference in outcome scores when performing SB compared to DB ACLR (Tiamklang et al., 2012; Bjornsson et al., 2013; Xu et al., 2013).
A meta-analysis showed DB as the superior technique since it provides better rotational stability. This may not affect the functional outcome compared to SB (Li et al., 2014). DB may reduce re-rupture rates but is more invasive and technically demanding (Tiamklang, 2012).
In the short term, DB is cost-effective due to low revision rates. However, long term follow-up is indicated (Paxton et al., 2010).

Effective DB technique improves rotational stability, less re-rupture rates and has short term cost-effectiveness, compared to SB technique.

5. Grafts Choices

Cochrane reviews demonstrate no significant difference of knee stability is achieved when using either Hamstring (HT) or Patella tendon (BPTB) graft techniques (Liden et al., 2007; Maletis et al., 2007; Magnussen et al., 2011; Mohtadi et al., 2011).
After discussion with the patient, the surgeon will choose the suitable graft. Consideration should be: type of sport, age, accelerated rehabilitation and RTS (Magnussen, et al., 2010; Rahr-Wagner, et al., 2014).
The more frequently the surgeon performs ACLR the better the outcome. Surgeons with a lower volume ACLR (52 ACLR in 12 months) (Lyman et al., 2009). Hospitals hosting two or fewer ACLR monthly are 32% more likely to have a 90-day post-operative readmission, in contrast to hospitals performing more than 10 ACLR monthly (Lyman, 2009).

ACLR using HT and BPTB showed identical knee stability outcomes.

Different types of grafts

Various graft types are available:

• Autografts
• Allografts
• Artificial grafts

a. Autografts (harvested from the patient)

Hamstring graft (HT)

• Surgical suspension fixation is used. This may increase longitudinal movement between fixation point and graft resulting in bone tunnel enlargement, compromising knee stability (Webster et al., 2001).
• Reduces knee flexion and internal rotation strength.
• Takes longer to heal (9-12 weeks)(Weiler et al., 2002) causing later RTS.
• Additional infection risk (Maletis et al., 2013b).
• Although more popular due to lower donor morbidity, the revision rate during the first year is higher in youngsters (Maletis et al., 2013a; Persson et al., 2014), and re-rupture rate is (1.82 time higher) for the age group

Patella tendon graft (BPTB)

• A screw-in fixation is used (Anderson et al., 2001).
• Complications: anterior knee pain, patella fractures, inability to kneel.
• Heals faster (6 weeks) than HT (Papageorgiou et al., 2001) and quicker RTS (Weiler et al., 2002).
• Used in younger age group (<20 years) when accelerated rehabilitation is required (Magnussen et al., 2010).
• Causes less OA due to increased stability ((Li et al., 2012; Rahr-Wagner, 2014).

b. Allograft (harvested from external donor)

ACLR performed with fresh frozen allograft that has not been chemically treated or irradiated, produced equivalent clinical outcome compared to autografts (Lamblin et al., 2013).

c. Artificial Grafts: Ligament Advance Reinforcement System (LARS)

LARS is a polyester graft that compares well to BPTB. It may be used in athletes performing high demanding sport with a 6-months RTS (Pan et al., 2013). It may cause post-operative synovitis (Klein et al., 1992). Uncertainty exists over long term OA risk (Pichon et al., 2007).

Autografts and untreated fresh frozen allografts produce similar clinical outcome.

6. Outcome measurement

Hop tests

Standardised functional outcome measures determine rehabilitation progression and RTS. The single-limb hop tests measure neuromuscular ability and dynamic knee stability, and demonstrates good test-retest reliability (ICC) in normal young subjects (Noyes et al., 1991; Ross et al., 2002).
During ACL rehabilitation the hop tests measured with good reliability and validity (7.05% – 12.96%) (Reid et al., 2007).

Patient assessed health outcome

Various patient-assessed health instruments with varying validity, measures patients’ perception of the ACLR outcome.
The Knee Injury and Osteoarthritis Outcome Score(KOOS) measures symptoms and disability with responsiveness values (MDC95) to change: pain, symptoms, daily living activities, sport and recreational and knee specific quality of life, but lacked addressing mental health domains(Garratt et al., 2004; Wright, 2009; Logerstedt et al., 2010a).
International Knee Documentation Committee 2000 form(IKDC) is a joint-specific outcome that measures symptoms, function, and sports activity aimed at various knee ailments with good test-retest value especially in bigger groups (Collins et al., 2011; Logerstedt 2010a). However, Irrgang et al.(2006), demonstrated that due to higher MDC95- values, responsiveness may be compromised.
The Knee Outcome Survey-Activities of Daily Living Scale(KOS-ALDS) is responsive to knee functional assessment with good test-retest (ICC 0.97) and minimal detectable changed values for MDC95 (Irrgang et al., 1998).

KOOS, IKDC or KOS-ALDS, and Hop tests may be used to assess pain, disability, function and clinical presentation changes during rehabilitation. Effective communication between the patient and the MDT will optimise rehabilitation and outcome to RTS.

Rehabilitation Interventions

7. Cryotherapy

Cryotherapy is used for post-operative pain and swelling reduction and to promote knee ROM and drainage. Evidence confirmed the cryotherapeutic analgesic effect, however no change was shown for ROM or drainage (Raynor et al., 2005).

It is recommended that cryotherapy is used for pain relief immediate post-operative and ongoing during the first weeks of rehabilitation.

8. Therapeutic Exercise

Eccentric, concentric and NMT is used during rehabilitation to improve quadriceps contractions.
Eccentric rehabilitation is effective to improve quadriceps strength. NMT improves motor learning in addition to strength training. Eccentric training improves quadriceps strength better than concentric exercises (Gokeler et al., 2013).

Rehabilitation should be a combination of concentric, eccentric, and NMT.

9. Accelerated Versus Non-accelerated rehabilitation

Shelbourne & Nitz (1990), described accelerated rehabilitation by initially aiming to restore full weight bearing, knee extension and optimising quadriceps activity.
According to a study, 85% of participant with BPTB accelerated group (19-weeks) and non-accelerated BPTB group (32-weeks), showed almost equivalent anterior posterior laxity (1.3mm difference) after the first 3-months, postoperative. After the two year follow-up the outcome were again similar for both groups (Beynnon et al., 2011).

19-week accelerated rehabilitation is possible when using BPTB ACLR.

10. Open Kinetic (OKC) and Closed Kinetic Chain exercises (CKC)

OKC is performed while the foot is not planted, by performing leg extensor resistance training using ankle weights. OKC increases anterior tibial translation (Beynnon et al., 1997), which may result in increased graft stress causing knee laxity. However, OKC may increase quadriceps torque, resulting in accelerated rehabilitation and RTS.
During CKC the foot is supported by using a leg-press machine (Andersson et al., 2009). CKC promotes joint compression and knee stability (Beynnon et al., 1997).
Uncertainty exists in the quantity of quadriceps loading that can safely be applied to gain quadriceps strength improvements in HT graft rehabilitation. During the initial HT post-surgical phase, graft necrosis takes place causing optimum graft weakness at 6-8 weeks (Scheffler et al., 2008). HT graft stress would cause more instability and needs to be protected.
OKC for HT graft, from 90-45° knee flexion can be safely performed from 4-weeks post-operatively without stressing the HT graft, resulting in improved quadriceps strength (Fukuda et al., 2013). Further studies should assess the frequency and magnitude of quadriceps activation allowed.

OKC exercises to strengthen quadriceps are allowed for HT at 4-weeks but is limited to 90-45° as it places stress on the graft, while CKC places less stress on the graft.

11. Neuromuscular training (NMT)

NMT is the facilitation of movement training progressions from single plane low intensity training to multi-planar complex power training, resulting in improved joint kinaesthesia, stability, acceleration and deceleration (Hewett et al., 2002). In addition, NMT reduces ACL re-injury (Johansson et al., 1991) and includes balance, proprioception and plyometrics.
A combination of NMT and strengthening produce better outcomes than only strength training exercises after 6 months (Risberg et al., 2007) and also confirmed during 2 and 4 year follow-ups (Risberg & Holm 2009). NMT improved global knee function and pain relief, while strengthening improved hamstring strength after two years post-operative.

Rehabilitation should combine NMT and strength training to increase knee stability and movement coordination during supervised physiotherapy.

12. Neuromuscular Electrical stimulation (NMES)

Postoperative quadriceps inhibition is caused by arthrogenic muscle inhibition (Palmieri et al., 2004).
Combining NMES and quadriceps exercises improves quadriceps contraction during the first 4 weeks post-operative (Kim et al., 2010).
NMES is not a substitute for muscle volitional exercises (Bax et al., 2005), but will promote quadriceps contraction initially.
NMES compared to a standard post-operative strength programme improved the quadriceps strength of the NMES group by an average of 29% after 6-month follow-up (Feil et al., 2011). Inconclusive evidence exists to show whether NMES has any effect on functional performance or patient-orientated outcomes.

NMES may contribute to quadriceps contraction in the first weeks postoperatively, but patient-orientated outcomes may not be influenced.

13. Knee Bracing

Post-surgical bracing (0-6 weeks) has no beneficial influence on ACLR outcome, pain or knee stability (Wright et al., 2008a, Andersson et al., 2009).
No evidence was found that functional bracing reduces re-injury in 100 patients during land-based exercise (McDevitt et al., 2004).
However, functional knee bracing may enhance the proprioceptive input during downhill ski (Nemeth et al., 1997). Functional bracing showed reduced ACL re-injury during 6 seasons. The non-braced skiers were 3.9 times more likely to re-injure than the braced skiers (Sterett et al., 2006).

Post-operative bracing has no role in ACLR. Functional bracing may be effective in downhill skiing.

14. Home–based rehabilitation versus supervised rehabilitation

The quality and cost of rehabilitation protocols are influenced by home-based versus supervised rehabilitation.
Evidence showed no difference between home- and clinic-based groups assessed by knee ROM, laxity, strength and function (six months to one year) (Andersson et al., 2009).

A combined supervised- and home-programme will be more beneficial and cost effective during rehabilitation.

15. ACL Injury prevention and performance enhancing

Avoidance of knee compression, hip abduction torque and tibial internal rotation is essential for ski prevention programmes. By strengthening the hip abductor, extensor and hamstrings may contribute to protecting the knee against forces (Bere et al., 2014).
Injuries may be reduced by NMT, educational tools and interventions (Gagnier et al., 2013). Awareness videos and training programmes reduce injuries in professional skiers (Ettlinger et al., 1995). These videos prevented injuries by teaching skiers to identify and respond correctly when at risk of sustaining injury.
NMT should be implemented during the training of young female adolescents. This will counteract the neuromuscular deficiencies that develop at a later adolescent developmental phase, resulting in altered mechanics and injuries (Myer et al., 2013).
Injury prevention is effective (Walden et al., 2012). Injury reduction of 64% was achieved (N=4564, between ages of 12-17). Injuries occurred at -0.07 (95% CI -0.13 to 0.001) per 1,000 playing hours in favour of the preventative group (Walden, 2012).
A preventative programme must be encouraged by all MDT members. The programme must have a duration of 10 to 20 minutes, thrice weekly during pre-season and once weekly during season (Grindstaff et al., 2006).
Inconclusive evidence for the effectiveness and type of male injury prevention programmes exist (Alentorn-Geli et al., 2014).
Numbers-needed-to-treat is between 108-120 training players to prevent one ACL injury (Sugimoto et al., 2012a). Further research to improve the screening process together with sport specific prophylactic programmes are required.
The correct ski binding should be used for the level of skier and be adjusted properly to reduce ACL injuries (Young et al., 1976).

Effective prevention programmes need to be sport specific. Preventative videos are effective to educate skiers.

References

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• Wright, R.W., Preston, E., Fleming, B.C., Amendola, A., Andrish, J.T., Bergfeld, J.A., Dunn, W.R., Kaeding, C., Kuhn, J.E., Marx, R.G., McCarty, E.C., Parker, R.C., Spindler, K.P., Wolcott, M., Wolf, B.R., Williams, G.N. (2008a). A systematic review of anterior cruciate ligament reconstruction rehabilitation: part I: continuous passive motion, early weight bearing, postoperative bracing, and homebased rehabilitation. The Journal of Knee Surgery, 21(3): 217-224.
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• Yoo, J.H., Lim, B.O., Ha, M., Lee, S.W., Oh, S.J., Lee, Y.S., & Kim, J.G. (2010). A meta-analysis of the effect of neuromuscular training on the prevention of the anterior cruciate ligament injury in female athletes. Knee Surgery, Sports Traumatology, Arthroscopy, 18(6): 824-830.
• Young, R., Aronsson, D., Johnson, R., Ettlinger, C., Shealy, J., (1976). The etiology of ski injuries: An eight year study of the skier and his equipment. The Orthopaedic clinics of North America, 7(1): 13-29.
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• Centre of Evidence based medicine Oxford United Kingdom (http://www.cebm.net) Accessed 16/2/2014.

Disclaimer

The contents of this article – Management of ACL Ruptures in Skiers, is aimed at medical professionals. It is provided here for informational purposes only and should not be treated as medical or health management advice. The materials herein are not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your doctor, physiotherapist or other health care provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read in this article or website. Reliance on any information provided herein is solely at your own risk.

Copyright

The content of this article – Management of ACL Ruptures in Skiers, is copyright © 2016 of Suegnet Meyer and Meyer & Associates. Transmission or reproduction of the contents, beyond that allowed by fair use as defined in the copyright laws requires the written permission of the copyright owners.

The post Management of ACL Ruptures in Skiers first appeared on Meyer Physio.

PFPS vs Pain

Hodges et al (2009) induced pain by injecting fat pads which did cause delayed VMO. With the increasing or aggravating the pain caused decrease in VM muscle activation. Furthermore swelling can also cause reduced VMO activity. Stokes et al., (1984) injected 10ml of fluid causing VM to inhibited while VL was inhibited only after injecting 40ml fluid. Swelling and Pain will inhibit VMO activation according to these studies and be a contributing factor to PFPS.

Influence of the hip & foot on PFPS?

In addition to my previous answer last week, weakness of the hip abductors and external rotators can cause PFPS as demonstrated by Souza & Powers (2009). Increased hip internal rotation ROM with weakness of hip abductor muscles were observed in females suffering from PFPS (in weight bearing). Powers (2003) also previously documented that since the patella is influenced by the interaction of proximal and distal segments that abnormal tibia and femur motion in the transverse and frontal planes have an effect on the PFJ. This highlights the importance of stability of the hip (strength training of hip abductors and external rotators) and the foot. This will also have a better long term effect and prevent further injury.

Rehabilitation of the VM / VMO to Optimise Patello-Femoral mechanics

Beside taking the hip Abductor strength and feet biomechanical factors as well as muscle lengths of gastrocs/soleus/hamstrings in consideration, rehab in closed chain kinematics :

Method

To make sure that the VMO is optimally rehabilitated, firstly educate the patient how to static contract the VM (pain free) by locating and palpating the VM or using EMG feedback. By using PF tape or ice brushing can facilitate VM contraction. The patient needs to train VM contraction regularly during the day. Since optimum contraction will be in a closed chain, persue weight bearing position but in a pain free ROM. By watching out for signs of fatigue, posture positioning of the foot and hip, and preferrebly in closed chain, get the patient to do this frequently during the day to promote the neuro-muscular pattern and try to facilitate the VM contraction and endurance. Progresssion for endurance and strength in larger range of motion can be achieved by using terminal extension with theraband. Assess what ROM gives them pain during function (stairs) and break the components down and strengthen the knee/hip in that spesific range but still be aware of pain as a contraindication and keep icing to reduce pain and inflammation. Taping may also help. Use a raised chair height or perhaps the side of a desk and let them train, controlling the VM while getting up from this elevated position instead of working through a full range of motion, causing pain that they are unable to tolerate anyway. If this is tollerated, progress mini squats supported to single leg squats with support, then without support, but ensuring no pain with good hip foot knee control and posture. Progressive weight training can then be introduced and sport specific exercises.

References

1. Bolgla, L. A., Malone, T.R. Umberger B.R., (2011). Comparison of hip and knee strength and neuromuscular activity in subjects with and without patella femoral pain syndrome. The International Journal of Sports Physical Therapy. 6(4) : 285-296.
2. Cagnie B, Elliott JM, O’Leary S, D’hooge R, Dickx N, Danneels LA (2011). Muscle functional MRI as an imaging tool to evaluate muscle activity. Journal of Orthopaedic & Sports Physical Therapy; 41 (11): 896–903.
3. Hodges PW., Mellor R., Crossley K., Bennell K. (2009). Pain induce by injecting hypertonic saline into the infra patellar fat pad an effect on coordination of the quadriceps muscle. Arthritir Rheum 61); 70-77.
4. O’Leary S, Cagnie B, Reeve A, Jull G, Elliott JM (2011). Is there altered activity of the extensor muscles in chronic mechanical neck pain? A functional magnetic resonance imaging study. Arch Phys Med Rehabil. 2011; 92 (6): 929–34.
5. Pattyn, E., Verdonker, P., Adelheid. S., Van Tiggelen, D., (2013). Muscle functional MRI to evaluate quadriceps dysfunction in patella femoral pain. Medicine and science in sports and exercise: 45 (6) 1023-1030.
6. Powers, CM., (2003). The influence of altered lower extremity kinematics on patellofemoral joint dysfunction : a theoretical perspective. Journal of Orthopaedic Sports Physical Therapy. 33(11):639-646.
7. Souza RB, Powers CM. (2009). Differences in hip kinematics, muscle strength and muscle activation between subjects with and without patella femoral pain. Journal of Orthopaedic Sports Physical Therapy 39(1) 12-19.
8. Stokes M., Young A., (1984). The contribution of reflex inhibition to arthrogenous muscle weakness. Clinical Science. 67: 7-14.

Disclaimer

The contents of this article – Quadriceps Dysfunction in Patello Femoral Pain Syndrome, is aimed at Physiotherapists and other medical professionals. It is provided here for informational purposes only and should not be treated as medical or health management advice. The materials herein are not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your doctor, physiotherapist or other health care provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read in this article or website. Reliance on any information provided herein is solely at your own risk.

Copyright

The content of this article – Quadriceps Dysfunction in Patello Femoral Pain Syndrome, is copyright © 2016 of Suegnet Meyer and Meyer & Associates. Transmission or reproduction of the contents, beyond that allowed by fair use as defined in the copyright laws requires the written permission of the copyright owners.

The post Quadriceps Dysfunction in Patello Femoral Pain Syndrome first appeared on Meyer Physio.

Introduction

This literature review looks at Cervical Injuries that occur during participation in sport. It looks at injuries that happen in sport with frequent impact, e.g. Rugby and American Football, and also injuries due to continuous strain induced by high G-forces, e.g. Motorsport, Bobsleigh and Skeleton.

Aims

The aims of this literature review are to establish: 1) Which muscles stabilise the neck? 2) Which Cervical Strengthening (CS) exercises are most effective? 3) Whether cervical strengthening is effective for rehabilitation and injury prevention?

Method

For this study, literature from 1990 to October 2013 found via the databases of Google Scholar, Pedro, Pubmed, SportsDiscus and Web of Knowledge, using keyword examples ‘cervical injury’, ’stinger’ ,’g-force’ and ‘neck strengthening’, was reviewed. Furthermore, mainly high quality original studies as well as studies identified from the reference lists were used. ‘Grey literature’ (e.g. reputable websites, online discussions and dissertations) were included.

Spine Injuries in Rugby and American Football

Serious cervical injuries were reduced, since rule modifications in high collision sport of Rugby and Football. Unfortunately minor traumatic cervical injuries still occur. Tackling is a major injury cause, especially during match-play and makes up 34-56% of all rugby injuries (Brooks et al., 2005; McIntosh et al., 2010). The American National Football League reported during 1997 to 2006, 300 players were injured with 350 games missed due to neural traction injuries (Qureshi & Hecht, 2010). Minor injuries, e.g. neural traction injuries, transient brachial plexopathy or ‘stingers’, occur frequently during tackling (Weinberg, 2003). The injury mechanism is uncertain. It is suggested that: a brachial plexus traction injury occurs when the neck is forced into lateral flexion together with shoulder depression (Clancy et al., 1977); or off-centre axial force causing cervical nerve root compression during cervical hyperextension and ipsilateral lateral flexion trauma (Watkins 1986, Levitz et al., 1997); or a direct supraclavicular blow resulting in a brachial plexus compression injury (Di Benedetto & Markey 1984). The frequent minor compression injuries during tackling cause cervical sprain injuries, inflammation and secondary degeneration (Meyer et al., 1994), which can result in cervical stenosis (Torg et al., 1986) and may cause altered cervical spine mechanics (Levitz et al., 1997).

Spine Injuries in Motorsport, Bobsleigh and Skeleton

Cervical spines of racing drivers and bob-skeleton athletes are affected by gravity force (g-force) related stressors causing axial force, vibration, mechanical shock, whiplash injuries and concussion (Mansfield & Marshall, 2001; Minoyama & Tsuchida, 2004; Engebretsen et al., 2010). These forces cause sheering, buckling and strain on the cervical region together with accidents that may have impact of more than 25G’s (http://www.bbc.co.uk/sport/0/formula1/24976578). A study of single seated car races found 1.2 injuries per 1000 competitors per race and 0.9 injuries per 1000 competitors per single saloon car race. Saloon drivers suffered 53.2% cervical sprain injuries (Minoyama & Tsuchida (2004).
The bob-skeleton is a small sled without brakes. The athlete drops onto the sled in prone and reaches speeds of 120-135km/hr while g-forces can exceed 5G’s at various angulations including labyrinth track or hairpin bends. Helmets are the only head protection against high g-forces and accidents (http://www.olympic.org/skeleton). During the Winter Olympics 2010, 6% of Bob-skeleton athletes suffered cervical injuries and 5% suffered concussion (Engebretsen et al., 2010). Cervical injuries occur in collision and g-force related sports resulting in injury.
Strength training is suggested as rehabilitation and injury prevention in these sports. However the effectiveness of cervical strengthening (CS) is questionable.

1. The Cervical stabilisers:

The deep cervical flexors (DCF) and extensors (DCE) create a stabilising sleeve around the spine and become dysfunctional during cervical disorders (Falla et al., 2004c; O’Leary et al., 2013). If a specific stabilising muscle group is targeted and trained accurately, an increase muscle activity would cause directional stability and reduce the spinal neutral zone (Panjabi, 1992a & Panjabi, 1992b).
DCE
The DCE: Semispinalis cervicis, Multifidus, Rotatores muscles and the cranio-cervical extensors function as the dorsal inter-segmental neck stabilisers, producing extension and located close to the vertebrae. Multifidus consist of 77% Type I and 23% Type II fibre composition with small moment arms to create only capacity of 1Nm but fibre type can be transient to type II (Uhlig et al., 1995; Boyed-Clarke et al., 2002; Anderson et al., 2005). Due to changes on Cross-sectional area (CSA), DCE muscle dysfunction is implied in whiplash and cervical pain (Elliott et al., 2006; Elliott et al., 2008). In addition, reduced muscle activation has been shown on muscle functional MRI (mfMRI) (O’Leary et al., 2012). Future research in dynamic situation is required to assess muscle activation in various dynamic exercise via mfMRI.
Longus Colli & Capitis (DCF)
The DCF is a spinal stabiliser controlling the cervical lordosis and intervertebral motion (Mayoux-Benhamou et al., 1994). A CSA of Longus Colli demonstrated 53% type I and 47% type II fibre composition indicating a phasic as well as a postural function (Boyed-Clarke et al., 2001). The DCF fibres attach to the cervical vertebral laminae and maintain the cervical posture against gravity and have an antagonistic relationship with Multifidus (Mayoux-Benhamou et al., 1994). The superficial flexors Anterior Scaleni (AS) & Sternocleidomastoid (SCM) are unable to control the segmental motion and result in uncontrolled motion if no DCF activation occurs (Falla et al., 2007). The AS & SCM EMG measurements will increase due to over activity while the DCF will have reduced muscle activation. Fatigue sets in if overtraining occurs at low loading and is more apparent at 25% of the maximal voluntary contraction (MVC). When planning a training programme excessive loading and fatigue must be avoided to avoid since it will result in deactivation of the DCF (Falla et al., 2004e).
Initially, the DCF was described as one functional unit (Falla et al., 2004a; Falla et al., 2004d). Recently, it was confirmed by mfMRI that the DCF is activated during cranio-cervical flexion (CCF). It showed that Longus Colli functions optimally to control the cervical lordosis during CCF while Longus Capitis controls CCF with cervical flexion (CF) (Cagnie et al., 2008).

2. The Best CS exercises.

Acute cervical pain

During acute cervical pain and dysfunction distorted neuromuscular function occurs between the superficial and DCF and needs to be relearnt by selective CCF training using a Pressure Biofeedback (Stabilizer Chattanooga South Pacific Australia) (Falla et al., 2003a; Falla et al., 2003b; Jull et al., 2008; Jull et al., 2009). Promoting good posture by lifting the sternum and nodding ‘yes’ will increase DCF activation, reduce cervical lordosis and improve the muscular force-length relationship (Falla et al., 2007). Others, however, promote good posture by advising to ‘stick the chest out and avoid shoulder protraction’ (Weinberg, 2003; Charbonneau et al., 2012).
Various cervical strengthening (CS) methods exist, e.g. manual isometrics, buddy- assisted- and swissball CS, wrestling forwards- and back-bridging (www.boksmart.co.za, Frounfelter, 2008), theraband (www.thera-bandacademy.com) and isokinetic training.

Cervical extensors

Cervical extensors are strengthened with higher loads with good results (Ylinen et al., 2003; Falla et al., 2013). An increased CSA and noted neuromuscular adaptations showed improvement of the Splenius Capitus, Semispinalis Capitis & Cervicis and Multifidus after dynamic high resistance exercise in healthy subjects (Conley et al., 1997a). Furthermore after 12 weeks of high load training, T2 MRI investigations showed hypertrophic changes of 25% for the DCE (Conley et al., 1997b). The optimum position where Semispinalis muscle works is at 15 degrees CF in extension (Elliott et al., 2010).

Theraband

Using low cost Theraband for isometric, concentric and eccentric CS, which can be performed in any direction. Initially, starting with isometric training in the neutral position reduced risk of injury to the cervical structures exist (Qureshi & Hecht, 2010). However, research has shown that painful necks of females can be strengthened with a high load of 1x15reps of 80% of maximal isometric contraction 5x.week-1, and then reduced to 3x.week-1. Theraband has significantly strengthened isometric cervical flexion (+110%), Rotation (+76%), and extension (+69%) in combination with aerobic exercises (Ylinen et al., 2003). In the 2 year – follow-up muscle strength had improved by 44% flexion and rotation together with 27% in extension (Ylinen et al., 2006). Cervicogenic headache in females improved by using high loading strengthening and endurance Theraband exercises 5x.week-1 (Ylinen et al., 2010). Theraband can safely be used during initial rehabilitation to reduce pain and headache by doing relatively high isometric resistance 3-5x.week-1.
In a study of fighter pilots during flight, EMG muscle activation was recorded to determine how much training load is required to avoid injury at various Gz-levels. At low Gz-levels (+1Gz) training load should be performed at 15% of a maximal voluntary contraction (MVC). Training with Theraband is indicated for athletes who participate at very low G-forces or during initial rehabilitation (Netto et al., 2007).
It has been shown that Theraband causes lower EMG peak muscle activation in comparison to Cybex and provides less resistance during strengthening (Burnett et al., 2008).

Isokinetics

Dynamic strengthening and progressive loading with isokinetics are used effectively in final rehabilitation or injury prevention in healthy subjects. It has been shown that training at 3x.week-1 for 12 weeks with progressive loading increases muscle strength. Male aviators followed a dynamic resistance programme for flexion and extension at 40% and 75% of 10RM, but were tested isometrically and dynamically. Isometric improvement shown after 4 weeks was 32.7% and at 8 weeks it was 32.7%. Extension improved in all the weeks significantly. Dynamic strength improved 39.2% after 8 weeks and 49.3% at 12 weeks (Taylor et al., 2006). Strength training duration should be 10-12 weeks for neural adaptation and hypertrophic changes to take place in the muscle (Taylor et al., 2006). It is evident that dynamic testing values are much higher which may question differences of assessment methods. Isokinetic strength training is measured with ease, however due to differing equipment used during studies and different populations it is challenging to make a reliable comparison between studies. Additionally isokinetic units are expensive and training is not performed in a sport specific position (Burnett et al., 2008).

Multi-Cervical Unit (MVU)

The MVU is used in the aviation industry. A study was performed using dynamic concentric and eccentric loading at 24-114% of MVC for 2x.week-1 for a duration of 10 weeks. It demonstrated MVC significantly improved isometric neck strength (64.4% Flexion; 62.9% Extension; and 62.9% Left lateral flexion) in comparison to Control. Theraband improved 42% for Flexion only (Burnett et. al, 2005).

Rugby trends

Interestingly, good results have been shown in current rugby trends (iCSP-discussion), using a dynamic force equalising system (patent 2012-E80664(56) that permits active rotation and movement while functional training takes place to enhance the head being stationary and integrating reflex activity of the senses and vestibulum (www.gatheresystems.com, Peek & Gatherer, 2005; Brooks & Kemp, 2011). The system causes strengthening in an active movement and is controlled. It excludes harmful axial and shear forces during training in sport specific positioning. It can be used for rehabilitation and injury prevention. Further investigation is required.

3. Is strength training effective for rehabilitation and injury prevention?

Pain conditions: CS and reduced pain

Low load craniocervical flexion and higher load strength and endurance exercises in females (Randløv et al., 1998; Ylinen et al., 2003; Falla et al., 2007 & 2013) together with both genders (Highland et al., 1992; Jordan et al., 1998; Chiu et al., 2005) and longer term training (Ylinen et al., 2006; Ylinen et al., 2010) have been shown to reduce cervical pain and improve strength. In long term studies, patient compliance influenced results (Hakkinen et al., 2008). Pain can influence the strength training measurements. By measuring the effect on the sympathetic nervous system it has been shown that exercise can provide immediate pain relief response (O’Leary et al., 2007). CS in combination with other passive modalities can also reduce pain (Jordan et al., 1998; Bronfort et al., 2001). Furthermore, improvements observed in the control groups is explained by fear reduction, a biological variant or due to frequent testing that reduces pain (Ylinen et al., 2003; Chiu et al., 2005). This shows the importance of using randomised controlled studies.

Healthy subjects: CS improvements, gender and age

CS has improved in healthy subjects but usually at higher loading (Pollock et al., 1993; Conley 1997a & 1997b; Jordan et al,1999; Burnett et al., 2005; Mansell et al., 2005; Taylor et al., 2006). Some of these results would be influenced by including both genders in a study. Males have higher isometric neck strength compared to females during flexion (20%) and extension (25%) (Jordan et al., 1999). Females sustain higher acceleration forces post-strength training (Mansell et al., 2005), hence during whiplash injuries, acceleration speeds sustainable in different genders vary for males and females: 5g and 3.5g-force respectively (Vasavada et al., 2001). In addition females have smaller heads and reduced anterior-posterior dimension of C3-C7 vertebrae influencing the acceleration force and explains why women are more prone to whiplash (Jordan et al., 1999; Vasavada et al., 2008). Studies indicate that age or gender difference does not change the fibre composition (Boyed-Clarke et al., 2001). Nevertheless, due to these facts mixed gender studies should be assessed with caution.

Protective equipment

Protective equipment and improved skill help avoid neck injuries. In a comparative neck strength study, no differences were found between asymptomatic aviators exposed to G-forces and non-aviators (Seng et al., 2003). It was suggested that it was due to the use of protective equipment. Technique modification is also suggested in rugby to prevent injuries (Brooks & Kemp, 2010). Training positions needs to be taken in account when strengthening and enhanced tackling skills according to player position will prevent injuries (McIntosh et al., 2010).

Correct Training mode

A certain training mode would produce specific results (O’Leary et al., 2012). A study that used slow isoinertial CS in football, resulted in minimal improvements with no EMG muscle activation changes whilst performing a tackle. In another study, involving footballers, an 8 week isotonic resistance programme was performed and head-neck dynamic stability was then tested by unanticipated weights that were dropped from a small height. Although the isometric strength did improve by 15%, no dynamic head-neck segment stability, muscle stiffness or EMG differences, were found (Mansell et al., 2005). Plyometric training was suggested. It is possible that insufficient loading was used in training and that exercises were not in a dynamic mode or perhaps an insufficient motor learning pattern (Lisman, 2009; Falla et al., 2013). Specific strength training requires a specific training mode to achieve the end goal.

Anticipation

It is suggested that during an anticipation action, muscle tone would increase however if the impact is unanticipated an injury would occur (Mihalik et al., 2011). During tackling, the axial loading causes loss of the cervical lordosis and subsequent buckling. Injuries occur in 2-31ms (measured at direct vertical loading while the player will be in an oblique position) while muscle reflex activating only happens at 60ms, however a certain amount of muscle stiffness would be present (Nightingale et al., 1996; Nightingale et al., 2000). Hence, if the player is able to anticipate the impact and by increasing the tone and stiffness, the impact may be reduced with lower risk of injury, indicating CS as a means of injury prevention.

Proprioception

Proprioception resistance training improves muscle strength. A recent study demonstrated that resistance together with proprioception improved cervical strength by 29.3% while the CSA increased by 18.9%-32.3% while the resistance only group improved by 8.9-9.9% (Kramer et al., 2013). Proprioception facilitates a neuromuscular response where the brain stimulates the cervical muscles causing hypertrophic changes in the proprioceptive group. The cervical spine needs to balance the head and stabilise the senses. There is an interaction between the vision stimuli and vestibular sense organ of the head together with the proprioceptors of the neck. In addition vision has a huge effect on the cervical spine muscle activation to perform at an optimum level (Keshner et al., 1995).

4. Further studies

Further high quality studies should aim to standardise muscle strengthening measurements in sporting populations. Further research should explore the integration of proprioceptive training in strengthening programmes to enhance neuromuscular response for improvement of rehabilitation and injury prevention.

Conclusion

Cervical strengthening is used in the rehabilitation of cervical injuries and injury prevention of collision and G-force related sports. Strength training that integrates correcting the neuromuscular performance of DCE and DCF and then progressing with loading has shown to be successful in rehabilitation of cervical injuries. The programme needs to take factors like fatigue and pain and gender into account to optimise results. CS for injuries has not been refuted but may not be a single modality to achieve optimum response. Other protection, for example safety equipment and skill may provide additional benefit to prevent injuries. Further studies needs to consider the implementation of more neuromuscular training in combination with strength training to deliver optimum results in rehabilitation and for injury prevention in sport.

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