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This update is intended as a means for us to help keep busy clinicians in the medical community up to date with recent research as it relates to physical therapy. Hopefully, this will increase the options you have when prescribing physical therapy for your patients.
Factors Contributing to the Development of Medial Tibial Stress Syndrome in High School Runners
Bennett JE, Reinking MF, Pluemer B, Pentel A, Seaton M, Killian C. JOSPT. 2001; 31(9); 504-10.
The majority of injuries that runners experience are due to overuse (54-75%). Tibial stress syndrome accounts for 10.7% of the injuries in men and 16.8% in women. This study analyzed structural deformities as an influence on medial tibial stress syndrome (MTSS). Previous studies have shown that subjects who overpronate are at more risk of lower extremity injuries and those with pes cavus or pes planus feet are at an increased risk of stress fractures.
These researchers chose from a pool of 125 high school runners for a total of 250 limbs. Their inclusion criteria for the “injured” group were symptoms consistent with MTSS and pain with palpation along the medial border of the tibia. Twenty five limbs on 15 subjects met these standards. They randomly selected 25 “uninjured” limbs for comparison. Thirteen of the subjects were female, just two were male.
They chose four common lower extremity measures that could be done in a standard screen as a basis of comparison and to see if predictor variables for developing MTSS could be established. These measurements included navicular drop, resting calcaneal position, tibiofibular varum, and gastrocnemius length.
Descriptive statistics showed a significant difference between the injured and non-injured runners in navicular drop test measurements. The injured group had an average navicular drop of 6.8 mm vs. 3.6 mm in the non-injured group. The other three measurements were not significantly different between the two groups. This supports the results of previous studies that found a greater degree of pronation contributes to the development of MTSS.
Although this study did not use diagnostic imaging for the identification of the MTSS and did not incorporate biomechanical analyses of running techniques to allow for dynamic differences between the runners, it does provide a general prediction model that may help provide early identification of runners that may be at an increased risk of developing MTSS.
Therapists at Renaissance Physical Therapy NW are well trained in gait analysis
and are able to help screen athletes to assess their risk for injury as well
as helping rehabilitate those who do have an overuse injury and teaching
them strategies to help prevent reoccurrence.
Rehabilitation After Anterior Cruciate Ligament Reconstruction in the Female Athlete
Wilk, et.al. Journal of Athletic Training 1999; 34 (2): 177-193
The purpose of this article was to discuss an effective rehabilitation program for the treatment of female athletes after reconstructive anterior cruciate ligament (ACL) surgery. The authors discuss eight characteristics that are unique to female athletes, requiring specific training drills. These drills are used to challenge the neuromuscular system through proprioception, kinesthesia, dynamic joint stability, neuromuscular control and perturbation training activities.
The authors contend that “ACL injuries are the most common severe ligamentous injuries incurred by athletes. The typical mechanism of injury is sudden deceleration with twisting, pivoting or change in direction.” According to the authors, at least 60% of these injuries are due to a non-contact mechanism. Female athletes appear to be more susceptible to this type of injury, especially when involved in jumping sports such as basketball, soccer, volleyball and gymnastics.
The eight risk factors and rehabilitation recommendations given for consideration in ACL rehabilitation for the female athlete are:
- Females exhibit a wider pelvis and increased genu valgum. It is important to address dynamic control of valgus moment at the knee joint, using specific neuromuscular training drills.
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- Female athletes primarily recruit the quads as knee stabilizers. So retraining of the neuromuscular pattern to dynamically co-activate the hamstrings and the quads during knee stabilization is necessary.
- Females generate muscular force slower than males. Training should include drills for speed and timing, using plyometric exercises.
- Jumping athletes lose hip control upon landing. Control of hip and trunk needs to be relearned through therapy and home exercises.
- Less developed thigh musculature has been noted in female athletes. The hip musculature must be retrained to assist in stabilization.
- Genu recurvatum (knee hyperextension) and increased knee laxity are more prevalent in women. This can be reduced by training the athlete to control knee extension.
- Less effective dynamic stabilization also occurs in women. Therefore, it is important to enhance neuromuscular control and protection pattern reflexes.
- Poorer muscular endurance rates have been reported. Training female athletes to enhance muscular endurance is important.
The authors provide a specific, week by week, protocol to address post-surgical
rehabilitation of the female athlete, which incorporates the principles above.
Use of these techniques has also shown to be beneficial as a preventative measure
against non-contact ACL injuries. The increasing number of females now participating
in sports, as well as the increased incidence of ACL injuries makes it very
important that a specific rehabilitation and prevention program be implemented
as part of training the female athlete.
Effect of Superficial Heat, Deep Heat, and Active Exercise Warm-Up on Extensibility of the Plantar Flexors
Knight CA, Rutledge CR, Cox ME, Acosta M, Hall SJ. Physical Therapy. June 2001, 81(6). 1206-14.
Stretching is important to improve muscular performance and prevent injury. Physical Therapists often use heat to improve stretch applied to soft tissue structures during treatment sessions. Typically, methods such as dynamic warm-up, moist heat packs, or continuous ultrasound are used to heat muscular structures. The authors of this study compared the use of these methods to stretching alone in order to determine which is most effective.
The authors studied ninety seven subjects, randomly assigned to one of five groups. Group 1 was the control group and did not stretch. Group 2 performed stretching only. Group 3 performed stretching after a dynamic warm-up of active heel raises. Group 4 received 15 minutes of superficial, moist heat to the plantar flexors prior to stretching. Group 5 received seven minutes of continuous ultrasound before stretching.
The stretching protocol for groups 2-5 was four 20-second runner’s stretches with a 10-second rest between stretches. A runner’s stretch is a stretch of the plantar flexors performed by leaning against a wall with the extremity to be stretched behind the body in a lunge position. The body weight is then leaned forward to increase the stretch. The stretches were performed 3 times per week for 6 weeks. Dorsiflexion range of motion measurements were taken initially and then at the end of weeks 2, 4, and 6. 
No changes were noted in active range of motion (AROM) or passive range of motion (PROM) for the control group throughout the experiment. After 2 weeks all experimental groups demonstrated improvements in AROM, but only group 5 (the ultrasound group) had improvements in PROM. After 4 weeks all experimental groups demonstrated similar gains in AROM and PROM. After 6 weeks, only group 5 demonstrated improvement in AROM. Groups 2 (stretching alone), group 4 (moist heat), and group 5 (ultrasound) had gains in PROM after 6 weeks, but group 3 (dynamic warm-up) did not show progress with PROM. Overall, group 5 had the greatest gains in AROM and PROM at 6.2 degrees and 7.35 degrees, respectively.
This study shows that heating
of muscular structures prior to stretching can increase extensibility. Deep
heating will provide the best ROM measurements, whether it be AROM or PROM.
This study only applies to healthy subjects, but extrapolation to injured
or post-surgical tissues is also possible. This stretching protocol was 3
times per week, but most home programs are performed 2-3 times per day. This
suggests that greater gains can be made in a shorter period of time with
a good home exercise program and proper instruction. At
Renaissance Physical Therapy NW, we provide home exercises for every patient
at the time of their initial visit in order to allow the optimal gains
in the shortest amount of time.
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