Background:Criterion-based assessment of shoulder function includes screenings, such as the Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST), to help identify deficits in stability, neuromuscular control, and proprioception. However, normative performance for the CKCUEST has been predominantly established in elite and collegiate athletes, and it has been shown that arm length, sex, and weight may influence performance. Purpose:To compare performance and establish agreement between standard versus arm-length-normalized testing positions in adolescent athletes and establish population-specific reference values. Study Design:Cross Sectional. Methods:Healthy athletes (ages 14-18 years) recruited from local teams, clubs, and youth sports organizations performed two conditions of the CKCUEST, standard and arm-length-normalized. Performance differences were evaluated using a Wilcoxon signed-rank test, with effect sizes (r), while agreement between conditions was assessed using intraclass correlation coefficients and Bland-Altman analysis. Spearman correlations were used to assess associations with participant demographics and Mann-Whitney U tests were performed to compare contact versus overhead athletes. Results:One hundred fifty-four athletes (120 male, 16.5±1.2 years, 75.8±18.0 kg) participating in baseball, football, lacrosse, volleyball, basketball, water polo, and tennis were included for analysis. Performance was greater on the arm-length-normalized condition (standard: 23.0±5.8 taps; normalized: 23.9±5.5 taps, p<0.001). Agreement between conditions was good (ICC=0.86, 95%CI=0.80-0.90). The average change between conditions was -0.86±2.92 [-12.00-8.00], and 53.9% of participants performed better on the arm-length-normalized condition. Contact athletes performed more taps (standard: 25.0±6.0 taps; normalized: 25.3±5.9 taps) than overhead (standard: 20.2±4.2 taps; normalized: 21.9±4.5 taps, p<0.001) athletes. Conclusion:Performance on the arm-length-normalized condition was greater than performance at the standard distance condition in healthy adolescent athletes. The influence of arm length, body mass, and sport type suggests the arm-length-normalized condition is more suitable for assessment and differences between sport types highlights the importance of population-specific measures and reference values. Level of Evidence:3.
# Background Calcific tendinopathy can be difficult to diagnose and manage from a traditional, non-invasive physical therapy perspective. However, there is preliminary evidence supporting the use of diagnostic ultrasound and dry needling interventions to evaluate and treat the pain and disability associated with this chronic condition. The purpose of this case report was to describe the integration of diagnostic ultrasound in the successful evaluation and multi-modal treatment of a patient with calcific patellar tendinopathy. # Case Presentation A 46-year-old active female with a six-week history of anterior knee pain, presented to the physical therapy clinic for a direct-access evaluation. The history and physical examination were consistent with the diagnosis of patellar tendinopathy. Diagnostic ultrasound confirmed the presence of patellar tendinopathy with multiple calcifications at the inferior pole of the patella. Treatment progression included spinal/extremity manipulation, ultrasound guided needle fenestration, electrical dry needling, and exercise. Outcomes included the numeric pain rating scale (NPRS), lower extremity functional scale (LEFS), Global Rating of Change (GROC), strength, and assessment of tissue healing with diagnostic ultrasound. # Outcomes The patient was treated for 18 visits over 24 weeks. The multi-modal intervention resulted in clinically meaningful reductions in the NPRS and LEFS, with optimal recovery to strength training. Reductions in calcific foci and tendon tissue healing was also confirmed with diagnostic ultrasound. Outcomes were tracked at 3, 6, 9, and 11-months.
# Background Peroneal muscles are the primary stabilizers against ankle inversion movements associated with lateral ankle sprains. Individuals with chronic ankle instability (CAI) demonstrate peroneal muscle deficits including decreased strength, slower nerve conduction velocity, and reduced cross-sectional area. Ultrasound (US) imaging provides a valid, cost-effective method to assess peroneal muscle size and quality following rehabilitation. # Hypothesis/Purpose To determine peroneal muscle size and quality changes using US imaging following impairment-based rehabilitation in patients with CAI. # Study Design Prospective cohort study. # Methods Twenty-six patients with CAI (age: 21.9 ± 3.5 years; 18 females, 8 males) completed an 8-session, 4-week impairment-based rehabilitation program addressing range of motion, balance, strength, and functional performance deficits with emphasis on peroneal activation exercises. US imaging assessed peroneal muscle cross-sectional area (CSA) in sidelying and bipedal stance positions and echogenicity (a measure of muscle quality) in bipedal stance for both limbs before and after rehabilitation. Paired t-tests were used to compare pre- and post-rehabilitation values. # Results Significant (p < 0.01) increases in CSA were observed in the trained limb during sidelying (3.44 ± 0.99 to 3.72 ± 0.98 cm²) and bipedal stance (3.46 ± 1.05 to 4.31 ± 0.98 cm²) positions. Similar CSA increases occurred in the untrained limb. Echogenicity significantly decreased in the trained limb (70.2 ± 9.91 to 65.7 ± 8.68, p = 0.01), indicating improved muscle quality, with no significant changes in the untrained limb. # Conclusion An 8-session, 4-week impairment-based rehabilitation program resulted in significant peroneal muscle CSA increases in patients with CAI, with cross-education effects observed in the untrained limb. Muscle quality, as measured by echogenicity, improved in the trained limb, supporting neuromuscular benefits of targeted rehabilitation. Impairment-based rehabilitation should be incorporated into CAI management programs. # Level of Evidence 3
The glenoid labrum surrounds the glenoid fossa augmenting its depth and diameter. Along with the glenohumeral capsule and ligaments, it is crucial for shoulder stability. Glenoid labral injuries are very common due to both sports and trauma to the shoulder. When torn the labrum can cause shoulder instability, pain and dysfunction, causing a limitation of function for many essential shoulder movements used in daily living. Lesions of the glenoid labrum require an accurate diagnosis so that decisions about conservative versus surgical treatment can be determined. An accurate diagnosis of labral tears is essential for appropriate treatment planning and optimizing patient outcomes. Diagnostic musculoskeletal ultrasound (MSKUS) has become an imaging modality that is widely used in the assessment of several shoulder pathologies. It offers a portable, real-time, and cost-effective alternative that is gaining traction in rehabilitation and sports medicine settings. MSKUS has emerged as a valuable, non-invasive imaging modality for evaluating glenoid labral tissue. In fact, almost the entire labrum can be visualized using MSKUS. This manuscript will review the utility of MSKUS in evaluating glenoid labrum tissue quality, sonographic techniques, and clinical implications for those in the rehabilitation profession. By integrating MSKUS into clinical practice, providers can improve the accuracy of diagnosis, enhance diagnostic confidence, monitor healing progression, and guide rehabilitation strategies to optimal patient outcomes for those with glenoid labral injuries.
# Background Handheld dynamometry (HHD) has been recommended in return-to-play (RTP) assessments following shoulder injuries; however, variations in testing methods limits interpretation of results. In contrast, isokinetic dynamometry is considered gold-standard for assessment of strength but is less accessible than HHD. Further assessment is needed to identify which shoulder HHD testing positions best reflect isokinetic dynamometry values and can be used to guide RTP practices in adolescent athletes. # Purpose To compare HHD strength values of shoulder internal rotators (IR) and external rotators (ER) to isokinetic values in healthy youth athletes. # Study Design Cross Sectional # Methods Healthy, youth athletes aged 14-18 years with no history of upper extremity musculoskeletal or neuromuscular conditions or injuries in the prior six months were recruited from local teams, clubs, and youth sports organizations. Participants completed strength testing on dominant (DOM) and non-dominant (NON) limbs in three HHD testing positions: prone, seated, and supine. Isokinetic testing (Biodex) was completed seated at 60 degrees/second. Differences between Biodex measures and HHD conditions, as well as between HHD conditions, were evaluated using Wilcoxon signed-rank tests with effect sizes (r) and intraclass correlation coefficients (ICCs). # Results A total of 64 participants (37 male; 16.8±1.0 years) participating in primarily football, baseball, lacrosse, volleyball, and basketball were included for analysis. Seated HHD for IR differed from Biodex on both limbs (p<0.001) and from prone on the non-dominant limb (p<0.001). Between HHD positions for the IR's, seated differed from prone and supine bilaterally (DOM: p<0.001; NON: p<0.001). For the ER’s, HHD measures differed from Biodex in all positions (DOM: p<0.001; NON: p<0.001). Between ER HHD positions, seated differed from prone and supine bilaterally (DOM: p<0.001; NON: p<0.001). Agreement between Biodex and HHD positions was consistently small for ER (DOM: ICCs=0.28-0.43; NON: 0.29-0.38) and was strongest in prone for IR (DOM: ICC=0.81, 95%CI=0.69-0.88; NON: ICC=0.84, 95%CI=0.65-0.92). # Conclusion This study demonstrated that HHD shows agreement with isokinetic dynamometry for strength of the shoulder IR’s in adolescent athletes when assessed in prone or supine; however, HHD is poorly correlated with isokinetic strength measures of the ER’s. # Level of Evidence 3
