Combined Sections Meeting
Sports Physical Therapy Section
Abstracts: Platform Presentations
SPL1-SPL28
The abstracts below are presented as prepared by the authors.
The accuracy and content of each abstract remain the responsibility
of the authors. In the identification number above each abstract,
SPL designates a Sports Physical Therapy Section platform presentation.
SPL01
CONTRIBUTION OF LOWER EXTREMITY STRENGTH AND POSTURAL
STABILITY TO PERFORMANCE ON THE STAR EXCURSION BALANCE TEST
Paterno MV, Schmitt LC, Ford K, Hewett T
Sports Medicine Biodynamics, Cincinnati Children’s Hospital Medical
Center, Cincinnati, OH
PURPOSE/HYPOTHESIS: Performance on the star excursion balance test
(SEBT) is predictive of lower extremity (LE) injuries in young athletes.
Performance on the SEBT is theorized to be dependent on LE and core
strength, as well as balance. However, the underlying mechanisms that
contribute to improved performance on the SEBT have yet to be delin-
eated in the literature. Therefore, the purpose of this study was to eval-
uate what measures of LE strength and balance predict success on the
SEBT. We hypothesized that hip abduction and knee extension strength
would be most predictive of success on the SEBT.
NUMBER OF SUBJECTS: Thirty-six (23 female, 13 male) young, healthy ath-
letes (age = 17.0  2.4 years, height = 167.2  9.2 cm, mass = 62.7 
13.5 kg) with no prior history of lower extremity injury participated in
this study.
MATERIALS/METHODS: Each subject performed the SEBT on their domi-
nant limb. This test required the subject to reach in the anterior, pos-
terior-medial (PM) and posterior-lateral (PL) direction with their con-
tralateral foot, while standing on the reference limb. A composite reach
score was determined by calculating the sum of the distance reached in
the anterior, PM and PL directions and normalizing to leg length. This
served as the dependent variable. In addition, each subject had their LE
strength and dynamic postural stability assessed. Isokinetic hip abduc-
tion, knee extension and knee flexion strength were assessed bilaterally
using the Biodex isokinetic dynamometer. Hip abduction was assessed in
a standing position at 120°/s and knee strength was assessed in a seated
position at 180°/s. All strength variables were normalized to body weight.
Single limb postural stability was assessed on the Biodex stability system
and reported as the variability of movement during a 20-second trial on
an unstable platform. Stepwise linear regression was used to determine
if variables of strength and postural stability would predict performance
on the SEBT.
RESULTS: The subjects demonstrated a mean composite, normalized reach
of 86.7  9.0% of their leg length on the SEBT. Variability in dynamic
postural stability was the only significant predictor of performance on
the SEBT (r2 = 0.156, P = .02). No measures of LE strength predicted
performance on the SEBT.
journal of orthopaedic & sports physical therapy | volume 39 | number 1 | january 2009 | a101
CONCLUSIONS: No one specific measure of LE strength predicted perfor-
mance on the SEBT. Success with dynamic postural stability was the only
variable that was predictive of success on the SEBT, however this rela-
tionship was relatively weak. Further research is required to determine
the influence of other potential variables on SEBT performance.
CLINICAL RELEVANCE: Our results show that there is no one specific strength
or balance variable that strongly predicts composite performance on the
SEBT, which indicates that a combination of strength and balance may
be required. The SEBT is reported to be predictive of lower extremity in-
juries in a young athletic population. Injury prevention programs should
address strength and postural stability deficits in order to potentially re-
duce injury risk.
SPL02
SEX DIFFERENCES IN THE INFLUENCE OF SAGITTAL AND FRONTAL PLANE
LOWER EXTREMITY STRENGTH ON POSTURAL STABILITY FOLLOWING
ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION
Paterno MV, Schmitt LC, Ford K, Hewett T
Sports Medicine Biodynamics, Cincinnati Children’s Hospital Medical
Center, Cincinnati, OH
PURPOSE/HYPOTHESIS: Dynamic postural stability is affected by anterior
cruciate ligament (ACL) injury and may take up to 12 months to return
after reconstruction (ACLR). In addition, current evidence shows sex dif-
ferences influence the timing of recovery of postural stability following
ACLR. However, no prior studies have attempted to evaluate the predic-
tive relationship between lower extremity strength and dynamic postur-
al stability. The purpose of this study was to determine if sex influenced
the predictors of performance during a postural stability task following
ACLR. We hypothesized that measures of frontal plane strength would
predict dynamic postural stability in the female subjects after ACLR,
while measures of sagittal plane strength would be predictive of postural
stability in the male subjects.
NUMBER OF SUBJECTS: Thirty-four patients (20 female, 14 male, age = 15.7
 2.8 years) following ACLR, who where released to return to sports,
and 36 healthy control subjects (23 females, 13 males, age = 17.0  2.4
years) were enrolled.
MATERIALS/METHODS: All subjects executed 3 20 second, single-leg, pos-
tural stability trials while standing on an unstable platform (Biodex sta-
bility system, Shirley, NY). During these trials, variability of postural sta-
bility was collected in degrees and this served as the dependent variable.
Independent variables of isokinetic hip abduction, knee extension and
 Combined Sections Meeting
knee flexion were assessed with an isokinetic dynamometer (Biodex).
Hip abduction was assessed at 120°/s in a standing position. Knee flexion
and extension were assessed in a seated position at 180°/s. All strength
variables were normalized to body weight. Stepwise linear regression was
used to determine variables of lower extremity strength that predicted
variability in dynamic postural stability.
RESULTS: In healthy individuals, sagittal plane strength, specifically isoki-
netic hamstring strength assessed at 180°/s, was the only predictor of
postural stability variability (females: r2 = 0.306; P = .008, males: r2 =
0.416; P = .017). In males following ACLR, knee extensor strength at
180°/s predicted variability in postural stability (r2 = 0.504, P = .007). In
females following ACLR, hip abduction strength predicted task perfor-
mance (r2 = 0.391; P = .003).
CONCLUSIONS: Healthy subjects, absent of ACL injury and males follow-
ing ACLR utilized sagittal plane muscle recruitment strategies to pre-
dict success with a dynamic postural stability task. Conversely, in females
following ACLR, hip abduction strength predicted postural stability
variability.
CLINICAL RELEVANCE: After ACLR, males appear to rely on sagittal plane
muscular recruitment strategies at the knee to assist in postural stability
tasks, while females appear to rely on frontal plane strategies at the hip.
These findings of sex differences in impairments following ACLR may
underlie the mechanistic differences seen in ACL injury and support the
theory that gender specific rehabilitation after ACLR is needed to ad-
dress the unique deficits seen in this high risk cohort.
SPL03
INFLUENCE OF INTERMITTENT VISUAL DEPRIVATION ON KNEE MOVEMENT
TRAJECTORIES FOLLOWING ACL RECONSTRUCTION IN FEMALES
Bjornaraa J, DiFabio R
Doctor of Physical Therapy, College of St Catherine, Minneapolis, MN;
Program in Physical Therapy, University of Minnesota, Minneapolis, MN
PURPOSE/HYPOTHESIS: Females participating in sports with pivoting and
jumping suffer 4 to 6 times greater rates of ACL injury than males. Spe-
cific biomechanical and neuromuscular dysfunction has been identified
as influential in ACL injury. However, more global knee trajectories have
not been investigated. The purpose of this research was to: (1) deter-
mine if ACL reconstructed subjects display different movement patterns
of the knee during cutting activities than healthy subjects, (2) observe if
subjects with visual disruption display different knee movement trajec-
tories than with vision available, and (3) determine if visual deprivation
alters knee movement patterns in ACL reconstructed subjects more sig-
nificantly than in healthy subjects.
NUMBER OF SUBJECTS: Seventeen healthy female subjects (25.3  6 y)
and 17 female subjects with an ACL reconstruction (26.5  6.3 y) were
studied.
MATERIALS/METHODS: A 3-D electromagnetic system measured knee posi-
tion during a cutting motion from an athletic stance position. Anatomic
bony landmarks on the pelvis, thigh, and shank were digitized for data cap-
ture. Subjects stood on a force platform and were instructed to catch a ball
and cut immediately to the direction indicated by a specific tone (40 trials).
Visual conditions were randomized so that shutter glasses either disrupted
vision for 1 second as the subject began the cutting movement, or remained
open for the duration of movement. A 2-way ANOVA was used to deter-
mine differences between knee trajectories using variables of absolute ve-
locity, amount of gross knee oscillation, and time to reach peak GRF.
RESULTS: Eleven of 16 velocity comparisons demonstrated significant-
ly slower knee velocities for ACL reconstructed subjects. ACL recon-
structed subjects displayed reduced knee vertical axis oscillations in 3
of 4 comparisons with healthy subjects. ACL reconstructed subjects dis-
played increased time to reach peak GRF over healthy subjects in all 4
comparisons. With visual disruption, more oscillatory knee motion oc-
curred along the vertical axis in 2 of 4 comparisons. Interactions between
group and vision were noted, further emphasizing stated differences be-
a102 | january 2009 | volume 39 | number 1 | journal of orthopaedic & sports physical therapy
tween healthy and ACL groups. No differences existed between the re-
constructed and nonsurgical knees within the ACL group.
CONCLUSIONS: ACL reconstructed subjects displayed movement patterns
that differed from healthy subjects and may be indicative of a new motor
program that allows for successful task completion while reducing the
forces and load on the knee. Overall visual disruption appeared to have
minimal effects on movement; however data suggest the use of a new de-
fault motor program without vision.
CLINICAL RELEVANCE: Many female athletes post ACL reconstruction want
to return to sport without restriction. This research suggests that chang-
es in movement patterns exist that may result in increased risk of rein-
jury or reduced athletic performance. When developing interventions to
improve knee function during sport, it might be advisable to focus on ve-
locity of movement and lower extremity control and power.
SPL04
CLINICAL FACTORS THAT DIFFER BETWEEN RETURN TO SPORT STATUS
GROUPS IN PATIENTS WITH ACL RECONSTRUCTION
Lentz TA, Tillman SM, Moser MW, Indelicato PA, George SZ,
Chmielewski TL
Shands Rehabilitation, UF and Shands Orthopaedics and Sports Medicine
Institute, Gainesville, FL; Orthopedics and Rehabilitation, University
of Florida, Gainesville, FL; Physical Therapy, University of Florida,
Gainesville, FL
PURPOSE/HYPOTHESIS: An estimated 50% of patients do not return to the
same sport following anterior cruciate ligament reconstruction (ACLR),
and 35% to 70% return with decreased levels of performance. Multiple
clinical factors, such as pain intensity, knee range of motion (ROM) defi-
cits, quadriceps weakness, and fear of movement/reinjury, have been as-
sociated with disability following ACLR. It is not established how these
factors differ between individuals that return to preinjury levels of sports
performance after ACLR versus those that return to sport at a reduced
performance level or change sport. The purpose of this study was to com-
pare clinical factors (impairment, psychological, and function) between
return to sports status groups 1 year after ACLR.
NUMBER OF SUBJECTS: 31 patients (18 male; mean age = 24.2 years, range,
15-48 years) with unilateral ACLR and preinjury Tegner Activity Rating
Score greater than 4.
MATERIALS/METHODS: Subjects were tested approximately 1 year postsurgery
(mean = 47.6  6.4 weeks). The Tegner Activity Rating Scale was used to de-
termine preinjury and current levels of sports participation. Clinical assess-
ment included knee range of motion (ROM), side-to side difference in ante-
rior knee joint laxity (KT1000 arthrometer), isokinetic quadriceps strength,
pain intensity (Question #4,Short Form-8 General Health Questionnaire)
and fear of movement/reinjury (Tampa Scale of Kinesiophobia,TSK-11).
Function was assessed with the International Knee Documentation Com-
mittee subjective form (IKDC) and a single-leg forward hop test (SLH).
Results from quadriceps strength and SLH were normalized to the unin-
jured side to create a symmetry index. Subjects were divided into Return to
Sports (RTS) or No Return to Sports (NRTS) groups based on the answer
to “Have you returned to the same level of sports as before your injury?” In-
dependent samples t tests were used to determine group differences in pre-
and post-Tegner score and clinical measures.
RESULTS: Thirteen subjects were assigned to RTS. Preinjury Tegner scores
were similar between groups (7.9 versus 8.6, P = .26). Tegner scores at 1
year postsurgery were not different between groups (6.6 versus 7.6, P =
.20) however, there was a decrease in preinjury to follow-up score for pa-
tients in the NRTS group only (8.6 versus 6.8, P<.001). Average pain in-
tensity (0.38 versus 1.0, P = .012) and TSK-11 (16.0 versus 21.4, P = .003)
scores were lower and IKDC scores (92.8 versus 80.8, P = .001) were
higher in RTS compared to NRTS. Knee ROM deficit, knee laxity, quad-
riceps index and SLH were similar between groups.
CONCLUSIONS: Pain intensity, fear of movement/reinjury, and self-report
of function were clinical factors that differed between RTS and NRTS
 Combined Sections Meeting
groups and indicate less impairment in the RTS group.
CLINICAL RELEVANCE: Clinical factors that differed between groups in this
study can be used in prospective studies to determine their ability to pre-
dict return-to-sport status after ACLR. Further research will determine
if other impairment, physical performance, or self-report measures dif-
fer based on post-ACLR return-to-sport status.
SPL05
THE UTILITY OF OBJECTIVE MEASUREMENTS IN RETURN TO SPORT
DECISIONS POST ACLR
Lynch AD, Axe MJ, Snyder-Mackler L
Physical Therapy, University of Delaware, Newark, DE; First State Ortho-
paedics, Newark, DE
PURPOSE/HYPOTHESIS: The decision on when to return to sports after ACL
reconstruction is often based on empirical observations and the practitio-
ner’s opinion as opposed to objective functional measurements. Surgeons
and therapists may have certain arbitrary time frames for the beginning
of certain activities, including running, agility training and return to
sports that are not based in measurable events. The University of Dela-
ware has developed objective criteria, which measure strength, function-
al performance and self rating to determine when return to sport is ap-
propriate. Patients must pass these criteria to ensure adequate strength
and function before they are permitted to begin sport activities.
NUMBER OF SUBJECTS: Twenty-two consecutive post-ACLR subjects, re-
cruited as part of a larger study, were followed from surgery, through
postoperative rehabilitation until they passed full RTS criteria.
MATERIALS/METHODS: The RTS protocol consists of isometric strength test-
ing of the quadriceps, a functional hop battery (both >90% symmetry),
the Knee Outcome Scores Activities of Daily Living Scale (KOS-ADLS)
and a global rating of perceived function (GR) (>90% self rating). Seven
of these individuals passed RTS criteria at or before the 5-month postop
visit (127  17 days; range, 76-155 days). They also returned for 6-month
(184 days) testing following the same protocol. Nine additional individu-
als passed the RTS criteria at the time of the 6-month follow-up test.
RESULTS: For the group achieving RTS before 6 months, the results of
the functional test battery were not significantly different from the re-
sults at their previous functional test, with the exception of 1 subject, who
did not pass RTS criteria due to a decrease in quadriceps index. There
were no significant mean differences at 6 months between the group who
passed RTS criteria at 6 months and those who did not. These individu-
als showed varied reasons for not passing RTS criteria: 3 displayed less
than 90% strength, 1 less than 90% in hop scores, 2 <90% in hops and
strength, 2 <90% self-report and 1 <90% on all established criteria.
CONCLUSIONS: Many practitioners choose an arbitrary time frame for their
patients to return to sports. In a sample of 22 patients, 7 passed return to
sport criteria in a time frame of 5 months or less after ACL reconstruc-
tion. At 6 months, 9 of 22 subjects did not pass RTS, indicating that this
arbitrary time frame may be too early for some individuals to return.
These groups did not display significant differences at 6 months as the
reason for not passing varied throughout the group.
CLINICAL RELEVANCE: This suggests that a battery of tests to challenge pa-
tients in all aspects of sport may be necessary to assess readiness as no 1
aspect was deficient through the whole group. This small sample, which
will continue to grow, provides evidence for the need of objective return
to sport criteria as opposed to empirically based return to sport deci-
sions, as athletes may be held out of athletic participation for too long or
allowed to return before they are ready.
SPL06
FUNCTIONAL PERFORMANCE AT THE TIME OF RETURN TO SPORT
FOLLOWING ACL RECONSTRUCTION: THE IMPACT OF QUADRICEPS
STRENGTH ASYMMETRY
Schmitt LC, Paterno MV, Hewett T
Sports Medicine Biodynamics Center, OT and PT Dept, Dept of Pediatrics,
journal of orthopaedic & sports physical therapy | volume 39 | number 1 | january 2009 | a103
Cincinnati Children’s Hospital Medical Center, University of Cincinnati
College of Medicine, Cincinnati, OH; Sports Medicine Biodynamics Center,
Depts of Pediatrics, Orthopaedic Surgery, Biomedical Engineering and
Rehabilitation Sciences, Cincinnati Children’s Hospital Medical Center,
University of Cincinnati College of Medicine, Cincinnati, OH
PURPOSE/HYPOTHESIS: After ACL reconstruction (ACLR), quadriceps fem-
oris (QF) strength deficits persist for up to 2 years, long after return to
high-level activities. The impact of QF strength deficits at the time of re-
turn to sport (RTS) on function is unknown. We investigated the impact
of QF strength deficits at this time on the function of athletes following
ACLR. We hypothesized that greater strength deficits would be associat-
ed with decreased function and that strength deficits would predict func-
tion after controlling for pain, symptoms and graft type.
NUMBER OF SUBJECTS: Twenty-six participants were recruited follow-
ing primary, unilateral ACLR (19 females; mean, 16 years of age; range,
14-22 years). All were cleared for sports and planned to return to play.
Twelve athletes (10 females, 16 years of age; range, 14-19 years) without
history of injury served as controls.
MATERIALS/METHODS: QF strength was assessed with a maximal isometric
contraction and Quadriceps Index was calculated (QI = involved force/
uninvolved force*100%). The ACLR group was classified into a high-
quadriceps (HQ) group (QIl90%, n = 12) or a low-quadriceps (LQ)
group (QI<85%, n = 11). Those with QI = 85% to 89% were excluded (n
= 3). All controls had QIl90%. Function was assessed with the IKDC
and single-leg hop tests. For each hop test, a limb symmetry index (LSI
= involved/uninvolved*100%) was calculated. The Knee injury and Os-
teoarthritis Outcome Score (KOOS) was used to assess knee pain and
symptoms (ie, swelling, stiffness). Group differences were evaluated with
analysis of variance and least significant difference tests (Pg.05). Hierar-
chical regressions were used to determine if QI predicted hop test scores
after controlling for pain, symptoms and graft type.
RESULTS: QI was lowest in the LQ group (QI = 71%, P<.01) and there
was no difference between the HQ (QI = 98%) and control groups (QI =
100%)(P = .68). The LQ group had the lowest IKDC scores (LQ = 79,HQ
= 90,C = 99, Pg.02) and the lowest LSI on the single hop (LQ = 88%,HQ
= 99%,C = 101%, Pg.01) and triple hop (LQ = 91%,HQ = 98%,C = 100%,
Pg.01). LSI did not differ between the HQ and control groups on any
test. Regression analysis showed that single hop scores were predicted
by graft type (r2 change = 0.17, P = .05) and QI (r2 change = 0.35, P<.01).
Similar results were found for the triple hop (graft type, r2 change = 0.20,
P = .05 and QI, r2 change = 0.16, P = .05).
CONCLUSIONS: Significant QF strength deficits were present in 48% of
the athletes cleared for sports. QF strength deficits are associated with
decreased function, beyond the influences of pain, symptoms and graft
type. Further study of the impact of strength deficits on function, perfor-
mance and knee mechanics is necessary.
CLINICAL RELEVANCE: RTS without normalized QF strength may alter joint
mechanics and predispose the knee to cartilage damage. Evidence-based
guidelines for RTS after ACLR should be established. These data indicate
that strength deficits are associated with decreased function and those
without deficits perform similarly to controls. Further investigation is
needed to establish evidence-based RTS criteria following ACLR.
SPL07
RATE OF KNEE EXTENSOR TORQUE DEVELOPMENT IS REDUCED AFTER ACL
RECONSTRUCTION
Cosgrave MM, Hovis PW, Chmielewski TL
Physical Therapy, University of Florida, Gainesville, FL
PURPOSE/HYPOTHESIS: Quadriceps strength levels are used to assist clin-
ical decision-making in patients with anterior cruciate ligament (ACL)
reconstruction. Typically, quadriceps strength is measured with isokinet-
ic testing, and torque values are compared between sides (ie, quadriceps
index). However, the quadriceps index does not provide information on
how quickly torque is generated. The ability to generate greater torque
 Combined Sections Meeting
in short intervals may be important for protecting knee articular surfac-
es as patients transition back to high-impact activity. The purpose of this
pilot study was to compare rate of knee extensor torque development be-
tween sides in patients 16 weeks after ACL reconstruction. We hypoth-
esized that the rate of knee extensor torque development would be de-
creased on the surgical side (SS) compared to the nonsurgical (NS) side.
NUMBER OF SUBJECTS: Six subjects with ACL reconstruction (3 males;
mean age = 16.8  2.6 years; time from surgery = 113.8  1.5 days).
MATERIALS/METHODS: Following a 5-minute warm-up on a stationary bi-
cycle, subjects were seated and stabilized in an isokinetic dynamometer
(Biodex System3). The lever arm was set to move at 60°/s. Subjects were
given 3 practice trials at 50% effort followed by 30 seconds of rest and 3
maximal effort trials. Knee extensor torque was recorded in Newton-m,
and the trial with the highest peak torque was selected for analysis. Raw
torque data were filtered with a zero-lag fourth order Butterworth filter
and values were normalized to body weight (BW). Normalized rate of
torque development was calculated in 3 time intervals (0-50, 0-100, and
0-200 milliseconds) using the formula change in torque/change in time.
Time intervals were selected to coincide with time of peak vertical force
in many high-impact activities. A 2 (side) × 3 (time) repeated-measures
ANOVA was calculated with the main effect for side being of primary in-
terest. Post hoc testing was performed with paired t tests.
RESULTS: There was a significant main effect for side (P = .05). Post hoc
testing revealed lower rate of torque values for SS in the 0 to 100 milli-
seconds (SS, 0.65  0.23 BW/s; NS, 0.79  0.26 BW/s; P = .050) and
0-200 milliseconds (SS, 0.56  0.22 BW/s; NS, 0.72  0.24 BW/s; P =
.021) intervals.
CONCLUSIONS: At 16 weeks following ACL reconstruction, rate of knee ex-
tensor torque development in the first 200 milliseconds appears to be
decreased on the surgical side compared to the nonsurgical side.
CLINICAL RELEVANCE: Rate of knee extensor torque development is a poten-
tial addition to clinical measurements to assist clinical decision-making
for patients with ACL reconstruction.
SPL08
CLINICAL OUTCOMES UPDATE ON THE PRESURGICAL TRAINING OF ACL-
DEFICIENT ATHLETES
DiStasi S, Snyder-Mackler L
University of Delaware, Newark, DE
PURPOSE/HYPOTHESIS: Effects of perturbation training on ACL-deficient
athletes without dynamic knee instability have been established, but
have not been studied on those presenting with recurrent instability and
daily functional limitations. We hypothesized that the group receiving
perturbation and progressive strengthening will demonstrate signifi-
cant functional gains when compared with those receiving progressive
strengthening only.
NUMBER OF SUBJECTS: 45 subjects total, demographic and baseline infor-
mation. 42 subjects completed preintervention and postintervention
testing on 4 functional outcome measures. 23 out of 42 participants
were able to complete preintervention and postintervention timed hop
testing.
MATERIALS/METHODS: Forty-five Level I/II athletes were screened and
identified as noncopers utilizing the University of Delaware ACL screen-
ing tool. Demographic and baseline information was recorded for each
participant. Subjects were randomized into 1 of 2 treatment groups: pro-
gressive strengthening only (STR) or progressive strengthening supple-
mented with perturbation training (PERT). Forty-two of the subjects
classified were evaluated before and after intervention using 4 clinical
performance measures. Only 23 subjects within this cohort performed
timed hop testing at both testing sessions.
RESULTS: The Knee Outcome Survey Activities of Daily Living (KOS-ADL)
showed a significant time by group interaction (F = 4.930, P = .032)
(STR pre: 72.58%  18.50, post = 87.54%  8.413; PERT pre = 79.50%
 12.62, post = 85.94%  8.06), while the Global Rating Scale showed
a104 | january 2009 | volume 39 | number 1 | journal of orthopaedic & sports physical therapy
a time effect (F = 13.936, P = .001) with no group interaction (STR pre
= 57.04%  22.05, post = 72.29%  13.35; PERT pre = 69.89%  17.61,
post = 77.67%  12.29). Timed Hop (THP) scores showed a main effect
of group (F = 9.0, P = .007) with subjects receiving perturbation training
demonstrating significant improvement (F = 7.038, P = .015) (STR pre
= 94.60%  8.827, post = 97.07%  7.76; PERT pre = 73.01%  17.73,
post 93.18%  17.33). Neither group demonstrated significant gains in
strength or quadriceps index.
CONCLUSIONS: Both the strength and perturbation groups demonstrated
improvements on functional scores. Larger sample size may reveal addi-
tional interaction effects in strength and quadriceps index.
CLINICAL RELEVANCE: In this cohort, gains in objective, physical perfor-
mance testing are not always reflected in subjects’ self-report scores. Fur-
ther investigation of within group differences could elucidate function-
al changes over time.
SPL09
TIMELINE FOR NONCOPERS TO RETURN TO SPORT
Hartigan EH, Snyder-Mackler L
Physical Therapy, University of Delaware, Newark, DE
PURPOSE/HYPOTHESIS: Evidence indicates that quadriceps strength defi-
cits are ubiquitous after ACL rupture and continue following ACL re-
construction. The University of Delaware uses criteria to determine
readiness to return to sports which includes achieving 90% or greater
on strength and functional assessments. We hypothesized that a great-
er number of athletes who received perturbation training in conjunction
with strength training would achieve quadriceps strength indexes, hop
score indexes, and self-reported questionnaire scores of 90% or greater
at 3 and 6 months following ACL reconstruction compared to those who
received strength training alone.
NUMBER OF SUBJECTS: 29.
MATERIALS/METHODS: Twenty-nine ACL deficient subjects, classified as
noncopers, were randomly assigned to 2 groups who participated in 10
preoperative rehabilitation sessions. One group performed progressive
quadriceps strength training exercises (STR = 15 subjects) while the oth-
er group performed both progressive quadriceps strength training and
perturbation training exercises (PERT = 14 subjects). Both groups re-
ceived the same postoperative intervention. Quadriceps indexes (QI),
4 hop score indexes (single, crossed and triple hop distances; 6 meter
timed hop), Knee Outcome Survey-Activity of Daily Living Scale (KOS-
ADLS) and Global Rating Scale (GRS) were measured before and after
the preoperative intervention and 3 and 6 months following ACL recon-
struction. Maximal isometric quadriceps strength and single-legged hops
were assessed for each limb and used to calculate the QI and hop indexes
respectively. Frequency counts were determined for those who achieved
90% or greater on the QI, each hop index, and each self-reported score.
Mann-Whitney Tests were used to compare frequency of passing each
criterion between groups at 3 months and 6 months.
RESULTS: There were no differences between groups in the percent of ath-
letes who returned to sport at 3 months (P = .963; Pert, 6.7%; Str, 6.3%)
or 6 months (P = .617; Pert, 40%; Str, 31.3%) after ACL reconstruction.
There were no differences in performance scores during return to sport
testing between groups 3 months after surgery. However the perturba-
tion group demonstrated a significantly greater number of athletes who
rated themselves greater than 90% on the GRS (P = .033; Pert, 91.7; Str,
53.3) 6 months after surgery.
CONCLUSIONS: Even with our intense preoperative and postoperative in-
tervention paradigm, the majority of these noncopers did not pass rig-
orous return to play criteria 6 months after ACL reconstruction regard-
less of groups. Almost half of the strength only group did not feel that the
overall knee function (GRS) was at least 90% compared to preinjury lev-
els, whereas over 90% of the perturbation group did achieve this criteri-
on by 6 months after surgery.
CLINICAL RELEVANCE: When standardized rigorous criteria are used for re-
 Combined Sections Meeting
turn to sport after ACL reconstruction, less than half of the patients who
undergo intensive rehabilitation are ready to return to sport at 6 months
after surgery.
SPL10
THE USE OF AN OVER-THE-COUNTER ARCH SUPPORT MODIFIED WITH AN
8° WEDGE TO RESOLVE LATERAL KNEE PAIN IN A CREW ATHLETE
Goodstadt NM, Manal TJ
Physical Therapy, University of Delaware, Newark, DE
BACKGROUND AND PURPOSE: To describe the resultant benefit of using ex-
cessive medial arch support to reduce lateral knee pain, when standard
treatment techniques failed.
CASE DESCRIPTION: The patient presented 4 months after hyperextending
his left knee from jumping in a shallow lake. Early after the injury he
reported an inability to flex or extend his knee, or weight bear without
pain. He was unable to continue participating in the fall crew season
and sought medical attention from a local orthopedic surgeon, who di-
agnosed him with ITB bursitis after a negative MRI. With no change af-
ter resting, he tried to resume his participation in crew and noted con-
tinuing pain for 1 to 3 hours, after a 3-hour training session. The pain
was localized to the posterolateral corner and occurred with deep squat-
ting during land training. He was then referred for PT. On initial evalua-
tion, the patient had no effusion, full and symmetrical ROM with pain at
end range flexion. His tibiofemoral joint mobility displayed greater ER
on the left with reproduction of his pain. All ligamentous tests, meniscal
tests, and ITB length tests were negative. On palpation he had no ten-
derness over the lateral joint line or the ITB, however the postero-lateral
popliteal fossa region felt boggy and thick with 3/10 tenderness. Quad-
riceps strength testing was considered normal with his left quadriceps at
86% of his right. Functional bilateral squat test reproduced his pain at
120°, and self reports on the KOS and GRS were 79% and 85%, respec-
tively. At this time, we were unable to rule out an undiagnosed meniscal
tear, as his pain was in the region of the posterolateral joint line and all
ligament tests were negative. Our only impairment and functional limi-
tation was pain with deep squat and prolonged standing. As a result, we
modified his training program to avoid deep squatting and brought him
in to try noxious electrical stimulation and soft tissue mobilization for
pain. With no immediate change in pain in the first 3 sessions, hamstring
stretching and proximal tibio-fibular mobilization with movement were
attempted without resolution of pain in the next 2 sessions. A verbal con-
sultation was then initiated and a trial of medial arch support to his left
foot was attempted to reduce compression of his lateral joint line.
OUTCOMES: With treatments of the impairments around the knee over the
first 5 visits, the patient displayed no change. After the addition of an 8°
medial arch support his pain reduced to 0/10, and his KOS and GRS in-
creased to 94% and 90%, respectively, and he was able to return to row-
ing without pain.
DISCUSSION: In light of no confirmed pathology in the athlete’s lateral
knee, and poor response to standard pain management techniques, a
change to the athletes foot mechanics with a modified OTC arch support
proved successful in returning him to a competitive level. After 6 months
of un-resolving pain, our athlete was back to full function and pain free.
SPL11
FACTORS CONTRIBUTING TO PATELLOFEMORAL PAIN SYNDROME IN
FEMALE, MILITARY RESERVISTS
Roush JR, Hoban W, Kane M, Priest A, Randall T, Toth L
Physical Therapy Program, A T Still University of Health Sciences, Mesa, AZ
PURPOSE/HYPOTHESIS: Patellofemoral pain syndrome (PFPS) is a multifac-
eted problem that in the past has been investigated using primarily pain
as a primary focus of the research, and with limited use of function in un-
derstanding the problems associated with it. The purpose of this study
was to determine which factors may contribute to PFPS as measured us-
ing a primarily functional scale in female, military reserve personnel.
journal of orthopaedic & sports physical therapy | volume 39 | number 1 | january 2009 | a105
NUMBER OF SUBJECTS: Subjects were 39 females who were United States
Army Reserve members and were completing the United States Army’s
yearly physical fitness test. The subjects were members of a Army re-
serve hospital unit; Both officers and enlisted personnel participated in
the study. Mean age was 33.55 years (SD, 10.68); height was 1.62 m (SD,
0.32); weight was 66.40 kg (SD, 10.51); and BMI was 24.91 (SD, 3.72).
MATERIALS/METHODS: Measurements of age, body mass index, Q-angle, hip
abduction strength, hip external rotation strength, hip anteversion, tib-
ial rotation, femoral length, tibial length, and navicular drop were mea-
sured and were the independent variables for the analysis. The anteri-
or knee pain questionnaire (Kujala) was used to determine functional
limitations for the subjects and the dependent variable in the analysis.
Q-angles were measured using a digital camera and the NIH ImageJ
program. Isometric strength was measured using a Chatillon hand-held
dynamometer. Hip anteversion and tibial rotation was measured using
a standard dynamometer. Femoral length, tibial length, and navicular
drop were measured using a standard tape measure. A regression analy-
sis was used to determine the influence of these factors in patellofemoral
pain syndrome as measured with the Kujala questionnaire.
RESULTS: Seventy-eight knees were used for the analysis. Using a multiple
regression model, age (r = .33), body mass index (r = –.28), and Q-an-
gle (r = .24) were significant factors (P<.05) for patellofemoral pain syn-
drome as measured with the anterior knee pain questionnaire. Non-sig-
nificant factors (P>.05) were hip external rotation strength (r = .19), hip
abduction strength (r = –.01), hip anteversion (r = –.22), tibial rotation
(r = .03), femoral length (r = –.22), tibial length (r = –.09), and navicular
drop (r = .05). A regression equation was calculated for the significant
factors, with a multiple r of .47 (Multiple r2 = .22); predicted y = 104.11,
.38 (age), .83 (BMI)  1.37 (Q-angle).
CONCLUSIONS: No single factor was found to contribute more than anoth-
er. There are most likely more intrinsic and extrinsic factors that contrib-
ute to the problem than those investigated in this study. Issues of motor
control may be another factor that should be investigated.
CLINICAL RELEVANCE: Patellofemoral pain syndrome is a multifaceted
problem that requires a multifaceted approach for intervention and
treatment.
SPL12
TIBIOFEMORAL AND PATELLOFEMORAL ALIGNMENT DURING A SINGLE-
LEG SQUAT: AN MRI STUDY
Noehren B, Barrance P, Davis I
Department of Physical Therapy, University of Delaware, Newark, DE;
Rehabilitation Engineering Analysis Laboratory, Kessler Medical Reha-
bilitation Research and Education Center, West Orange, NJ
PURPOSE/HYPOTHESIS: Patellofemoral pain syndrome is believed to be re-
lated, in part, to malalignment of the patellofemoral joint. This can re-
sult from increased dynamic knee valgus during loading on a flexed knee.
While a static posture, the single-leg squat has been shown to relate to
other dynamic activities such as running and jumping. Recent advances
with MRI have allowed the 3-dimensional measurement of patellofem-
oral alignment during upright, weight bearing postures, such as the sin-
gle-leg squat. Therefore, the purpose of this study was to determine if
single-leg squats performed with apparent genu valgus adversely influ-
enced the alignment of the patellofemoral joint. We hypothesized that a
single-leg squat in valgus will result in increased knee external rotation,
knee abduction, as well as increased lateral patellar tilt, displacement
and rotation, compared to a neutrally aligned squat.
NUMBER OF SUBJECTS: Five healthy subjects participated in this study. To
be included, subjects were between the ages of 18 to 40 years old, were
injury free, and had no contraindications for MRI.
MATERIALS/METHODS: MRI scans were performed in an upright scanner
(FONAR Corp, Melville, NY) in 3 conditions. Subjects first stood on 1 leg
in full extension. They then performed a single-leg squat to 30° of knee
flexion with as much knee valgus as possible. This apparent valgus was
 Combined Sections Meeting
achieved through adduction and internal rotation of the femur. Finally,
they performed a 30° single-leg squat in a neutrally aligned position. The
knee flexion position was ascertained using a custom jig. All scans were
performed using a gradient echo sequence of 1.5 mm sagittal slices, TR
16.6, TE 5.6, FA 40, and scan time 2:18 min. The external cortical surface
of the femur, tibia, fibula, and patella were then digitized. A bone surface
matching algorithm was used to match points and compute 3-D joint an-
gles. The difference between the valgus position and neutral position was
then calculated and the average change was reported.
RESULTS: Knee abduction only increased by 0.6° in the valgus squat. This
further supports that the valgus is truly apparent, resulting from femo-
ral adduction and internal rotation. However, knee external rotation in-
creased by 7.6° during the valgus squat. This difference is likely due to
the increased femoral rotation used to assume the apparent valgus posi-
tion. Lateral spin of the patella increased by 2.6°. Two subjects demon-
strated a mean increase of 4.5° in lateral tilt, while 2 others exhibited an
increase of 2.5 mm in lateral displacement.
CONCLUSIONS: Based upon these data, a squat performed in apparent val-
gus results in an increase in knee external rotation as well as lateral pa-
tellar tilt, spin and translation.
CLINICAL RELEVANCE: These preliminary results suggest that loading on a
flexed knee with apparent genu valgus leads to lateral malalignment of
the patellofemoral joint. This likely reduces the patellofemoral contact
area leading to increased contact stresses. With repetitive loading, this
may contribute to the etiology of patellofemoral pain syndrome.
SPL13
CHANGES IN FEMORAL NERVE H-REFLEX FOLLOWING LUMBOPELVIC
MANIPULATION IN SUBJECTS WITH PATELLOFEMORAL PAIN SYNDROME
Moore J, Baethge S, Anderson K, Bailey S, Mason J, Boyles R,
Greathouse D, Sutlive T
US Army-Baylor University, Ft Sam Houston, TX
BACKGROUND AND PURPOSE: Patients with patellofemoral pain syndrome
(PFPS) often present with weakness, poor motor control, and inhibition
of the quadriceps muscles. Recently, lumbopelvic manipulation (LPM) has
been found to be helpful for a subgroup of patients with PFPS. Previous re-
searchers have used femoral nerve H-reflex testing to assess both quadri-
ceps inhibition in postoperative ACL subjects and changes associated with
LPM. Therefore the purpose of this study was to describe the change in
femoral nerve H-reflex following LPM in subjects with unilateral PFPS.
CASE DESCRIPTION: Fourteen subjects with unilateral PFPS (10 male, 4 fe-
male) with an age range 23 to 50 years (mean = 36.1) participated in the
study. Outcome measures of interest were: (1) bilateral femoral nerve H-
reflex latency; (2) single assessment numeric evaluation (SANE); and (3)
numerical pain rating scale (NPRS). All measures were taken at baseline,
after a pain provocation protocol (squatting and a treadmill run), and
then again following LPM.
OUTCOMES: The subjects in our case series demonstrated a mean increase
in femoral nerve H-reflex latency following the run and a mean decrease
in latency following the LPM in both the involved and noninvolved limbs.
Mean differences between the limbs were 1.13 milliseconds, 0.22 milli-
seconds, and 0.72 milliseconds at baseline, postrun, and postmanipula-
tion, respectively. Five of the 14 subjects showed a clinically significant
increase in NPRS scores from baseline to postrun, 9 of the 14 showed no
change. None of the subjects reported a clinically significant decrease in
NPRS scores during this time period. Four of the 14 subjects showed a
clinically significant decrease in NPRS scores from postrun to postma-
nipulation, 13 of the 14 showed no change, and 1 of 14 showed a clinical-
ly significant increase during this time period. The SANE scores demon-
strated a 6.07 increase in function from baseline to postrun and a 6.43
functional increase from postrun to post-LPM.
DISCUSSION: We observed that femoral nerve H-reflex latency may be in-
fluenced by running as well as lumbopelvic manipulation, even though
the running protocol did not significantly increase the NPRS in the ma-
a106 | january 2009 | volume 39 | number 1 | journal of orthopaedic & sports physical therapy
jority of subjects. Self-reported function as measured by the SANE, how-
ever, decreased postrun and then increased above baseline scores after
the LPM indicating there may be a relationship between LPM and lev-
el of perceived function in subjects with symptomatic PFPS. Due to low
power and a small sample size, future research is needed to further ex-
plain these trends in addition to more clearly identifying the relation-
ship that exists between LPM and H-reflex measurements as it relates to
quadriceps inhibition in subjects with PFPS.
SPL14
LANDING ADAPTATIONS FOLLOWING ISOLATED LATERAL MENISCUS
TEARS IN ATHLETES
Minning S, Ford K, Myer GD, Mangine RE, Colosimo AJ,
Hewett T
Sports Medicine, NovaCare Rehabilitation/Select Medical, Cincinnati, OH;
Sports Medicine Biodynamics, Cincinnati Children’s Hospital Medical
Center, Cincinnati, OH; Pediatrics and Orthopedic Surgery, University of
Cincinnati, Cincinnati, OH
PURPOSE/HYPOTHESIS: The lateral meniscus bears much of the weight
when the knee is loaded during weight-bearing activities. Partial or com-
plete meniscectomy has been shown to have a direct impact on contact
stresses and may have potentially detrimental effects on knee joint func-
tion. Objective functional outcomes following isolated radial lateral me-
niscus tears in the athlete between the ages of 14 to 25 are rare. The
objectives of this study were to determine if there were biomechanical
differences in landings between legs as compared to control athletes 3
months after surgery. We hypothesized that following a lateral meniscec-
tomy, athletes aged 14 to 25 years old would demonstrate altered land-
ing biomechanics during a functional task but would not demonstrate
strength differences.
NUMBER OF SUBJECTS: Nine subjects (7 male and 2 female; 20.1  2.8
years) who had undergone first-time isolated radial lateral meniscus
tears were tested 3 months following partial lateral meniscectomies and
compared to 9 sex, age, height, weight, and sport controls.
MATERIALS/METHODS: Subjects and controls were instrumented with 37
retroreflective markers. A 10-camera motion analysis system and 2 force
platforms were used to collect 3 trials of bilateral drop-landings. A 2-by-
2 ANOVA was used to test the interaction between side (involved versus
uninvolved) and group (patient versus control).
RESULTS: The patient group landed with a decreased internal knee exten-
sor moment during the drop landing task compared to the uninvolved side
and controls (interaction P<.05). However, the involved limb quadriceps
strength was not decreased compared to the contralateral or control limbs
in unloaded open chain isokinetic strength (P>.05). Decreased IKDC scores
were significantly related (r = 0.69; P<.05) to the decreased internal knee
extensor moment of the involved limb for the investigational subjects.
CONCLUSIONS: Three months following lateral meniscectomy surgery and
release to play, the subjects employed compensation strategies during
landing. Decreased internal knee extensor moment of the knee joint may
be related to reduced knee force absorption potential from the removed
lateral meniscus and may not be related to strength deficits.
CLINICAL RELEVANCE: At a time when most athletes have returned to com-
petition following meniscectomy, compensation strategies were still be-
ing employed with landing activities. In addition, these strategies may
be unrelated to quadriceps strength and harder to identify clinically pri-
or to return to sports.
SPL15
INTERTASK CORRELATION OF FRONTAL PLANE KNEE POSITION AND
MOMENT IN FEMALE COLLEGIATE ATHLETES
Harty CM, DuPont CE, Chmielewski TL, Mizner RL
Physical Therapy, Eastern Washington University, Spokane, WA; Physical
Therapy, University of Florida, Gainesville, FL
PURPOSE/HYPOTHESIS: Female athletes have higher risk for anterior cru-
 Combined Sections Meeting
ciate ligament (ACL) injury than males in the same sports. Gender dif-
ferences in frontal plane knee position and loading contribute to injury
risk. A variety of tasks have been used to assess frontal plane movement
patterns in female athletes, but little work has been done to evaluate how
knee movement compares across tasks. Knowledge of how various tasks
compare would aid in appropriate task selection for injury prevention
screening examinations. The purpose of our study was to evaluate: (1) in-
tertask differences in female athletes during step-down (SD), single-leg
land (SLL), and drop vertical jump (DVJ) tasks; (2) assess correlations
in frontal plane kinetics and kinematics of the knee across tasks; and (3)
determine the correlation between standing knee abduction angle and
peak knee abduction angles.
NUMBER OF SUBJECTS: Thirty-seven collegiate female athletes from cutting
and pivoting sports participated (age, 20  1; BMI, 25  2).
MATERIALS/METHODS: Lower extremity kinematic and kinetic data from
the dominant leg were collected using a 7-camera VICON 624c motion
capture system (250 Hz) and 2 force plates (1500 Hz) during a static
standing calibration, SD and SLL from a 20 cm height, and a DVJ from
a 31-cm height. Variables of interest were peak knee abduction angle and
moment during the eccentric phase of each task. External knee moments
were normalized to body weight (BW). Differences in means between
tasks were analyzed with repeated-measures ANOVA with paired t tests
as post hoc tests. Pearson correlation coefficients were used to evaluate
the relationship between the variables of interest across tasks (alpha =
.05).
RESULTS: There were significant differences (P<.001) in frontal plane knee
angle and moment between tasks (ABD ANGLE  SD, –7.9°  4.5°;
SLL, –4.2°  3.8°; DVJ, 7.1°  4.5°; ABD MOMENT  SD, –0.28  0.16
BW; SLL –0.82  0.31 BW; DVJ, 0.50  0.25 BW). Moderate to strong
positive correlations (P<.01) were found across tasks for peak knee ab-
duction angle (SD SLL, 0.81; SD DVJ, 0.72; SLL DVJ, 0.74) and moment
(SD SLL, 0.623; SD DVJ, 0.43; SLL DVJ, 0.55). Knee valgus calculated
during the standing calibration had no significant relationships to peak
frontal plane knee position during any task (P>.05, r<0.09).
CONCLUSIONS: While the SD, SLL, and DVJ tasks have substantially dif-
ferent demands on the knee joint, there are moderate to strong relation-
ships across tasks in the variables predictive of ACL injury. Static stand-
ing knee position did not play a role in influencing dynamic frontal plane
knee position.
CLINICAL RELEVANCE: Female athletes who demonstrate at-risk knee po-
sition and loading are likely to do so across tasks. If it is inappropriate
to screen an athlete in rehabilitation with a high demand jumping task,
there may be utility in using a less demanding alternative like the SD.
The lack of relationship between static and dynamic frontal plane knee
angle suggests that neuromuscular control may be contributing to the
significant intertask relationships.
SPL16
EFFECTS OF GENDER AND CATCHING A BALL ON BIOMECHANICS OF A
SIDE-CUT MANEUVER
Ferdie R, Carlstedt K, Willson JD, Kernozek TW
Physical Therapy, University of Wisconsin-La Crosse, La Crosse, WI
PURPOSE/HYPOTHESIS: Noncontact anterior cruciate ligament (ACL) inju-
ries are particularly common among female basketball players who rou-
tinely anticipate or handle a ball while running and cutting. Previous
studies reveal that females perform side-cuts with altered lower extrem-
ity (LE) biomechanics versus males. Previous studies also suggest that
catching a ball influences LE muscle recruitment patterns during simu-
lated athletic events. However, no previous studies have explored a po-
tential differential effect of gender with anticipation or use of the upper
extremities to catch a ball on 3-dimensional LE biomechanics during a
side-cut. Therefore, the purpose of this study was to test for differential
gender effects on LE mechanics during a side-cut with and without the
anticipation or use of their upper extremities to catch a ball. We hypoth-
journal of orthopaedic & sports physical therapy | volume 39 | number 1 | january 2009 | a107
esized that females would demonstrate decreased peak hip and knee sag-
ittal plane angles and moments and increased peak hip and knee frontal
plane angles and moments with anticipation or use of their upper ex-
tremities to catch a ball during testing relative to males.
NUMBER OF SUBJECTS: Nineteen female and 19 male intercollegiate basket-
ball athletes participated in this study.
MATERIALS/METHODS: Three-dimensional LE kinematics and kinetics were
recorded during the stance phase of 15 side-cuts with the dominant limb
for each subject. During each side-cut, subjects experienced 1 of 3 ran-
domly chosen conditions: no pass, a fake pass, or a chest pass. Average
peak hip and knee sagittal and frontal plane angles and moments were
calculated for each subject and submitted to 2 × 3 mixed ANOVA (be-
tween [gender] × within [condition]) for analysis.
RESULTS: No statistically significant gender by condition interactions were
identified. Females performed all 3 conditions with 6° greater peak knee
abduction (P<.01), 60% greater peak hip abduction moments (P<.01),
and 25% smaller peak knee extension moments (P<.01). Both male and
female subjects demonstrated 4° more knee flexion (P = .03), 12% small-
er knee extension moments (P = .02), and 2° less hip adduction (P = .01)
during the fake pass and chest pass conditions.
CONCLUSIONS: Anticipation of a pass or catching a pass during a side-cut
was not associated with changes in LE mechanics that were unique to
females. Rather, females consistently demonstrated differences in LE
mechanics compared with males in each test condition. These gender
differences in LE mechanics may contribute to the gender bias for ACL
injuries. Anticipation of a pass or catching a pass during the side-cut
significantly affected LE kinematics and kinetics for both male and fe-
male athletes.
CLINICAL RELEVANCE: These results indicate that small modifications to
laboratory protocols that more closely simulate participation in athletic
events can significantly affect LE mechanics. Efforts to more closely re-
produce athletic environments when performing controlled laboratory
studies of LE mechanics may lend more insight to the factors that influ-
ence ACL loads for both male and female athletes.
SPL17
TRUNK, HIP, AND THIGH MUSCLE ACTIVATION DURING SINGLE-LEG
WEIGHT-BEARING EXERCISES
Bolgla LA, Cruz M, Hayes L, Minning A, Smith T, Scott DR
Medical College of GA, Augusta, GA; Athletico, Chicago, IL
PURPOSE/HYPOTHESIS: Clinicians routinely prescribe single-leg weight
bearing exercises to strengthen the lower extremity. Researchers have
primarily examined thigh muscle activation with minimal attention to
the hip and trunk muscles. The purpose of this study was to quantify
trunk, hip, and thigh muscle activations during these type exercises. We
hypothesized that the subjects would exhibit similar amplitudes for each
muscle during the exercises.
NUMBER OF SUBJECTS: Eighteen healthy subjects (mean age, 24.9  4.2
years)
MATERIALS/METHODS: Surface electrodes were placed on the rectus abdo-
minis, abdominal obliques, lumbar extensors, gluteus maximus, gluteus
medius, and vastus medialis. An 8-channel Myopac EMG system col-
lected data as subjects performed 15 repetitions of the following single-
leg weight bearing exercises: wall slide, mini-squat, lateral step-down,
and front step-down. Subjects initially performed 2 maximum volun-
tary isometric contractions (MVIC) as to express data as a percent MVIC
(%MVIC). Ten subjects repeated the MVIC after exercise to establish
MVIC reliability. Data from the last 10 repetitions were averaged and
used for statistical analysis. Intraclass correlation coefficients (ICC) were
used to determine MVIC reliability. Separate analyses of variance with
repeated measures were used to identify differences in muscle activation
across exercise. Level of significance was established at the .05 level and
adjusted using the Bonferroni-Holm correction.
RESULTS: MVIC ICCs exceeded .90. The trunk muscles had similar acti-
 Combined Sections Meeting
vation (P>.05) ranging from 5 to 8 %MVIC across all exercises. The hip
muscles had similar activation (P>.05) ranging from 10 to 24 %MVIC
during the mini-squat, lateral step-down, and front step-down. The glu-
teus maximus (18.4  8.1 %MVIC; P<.001) and gluteus medius (28.0
 13.7 %MVIC; P = .01) had greater activation during the wall squat.
The vastus medialis had similar activation (P>.05) ranging from 45 to 51
%MVIC across all exercises.
CONCLUSIONS: Similar activation of the trunk muscles suggested gener-
al cocontraction for spinal stability. The overall low levels implied that
these exercises would be inappropriate for trunk strengthening. Overall,
hip muscle activation levels did not reach the threshold for strengthening
effects (<40 %MVIC), suggesting that these be used for muscle re-educa-
tion and endurance. The hip muscles had significantly greater activation
during the wall slide. This exercise differed as subjects leaned against a
wall with the feet placed in front of the body. This position moved the
body’s center of mass posterior to the base of support, resulting in great-
er muscle activation. Clinicians may consider using this exercise later in
the rehabilitation process. The thigh muscle had sufficient activation for
strengthening effects (>40 %MVIC) for each exercise. Any of these exer-
cises would be appropriate for strengthening effects.
CLINICAL RELEVANCE: This study quantified activation of the trunk, hip, and
thigh muscles during single-leg weight bearing exercises. Clinicians may
use these findings when developing a progressive exercise program.
SPL18
A TRAINING PROGRAM PROVEN EFFECTIVE IN THE ACL-DEFICIENT
POPULATION ASSISTED AN IN-SEASON LACROSSE PLAYER TO RETURN TO
PLAY FOLLOWING AN ACUTE PCL INJURY
Schmitt LA
Physical Therapy, University of Delaware, Newark, DE
BACKGROUND AND PURPOSE: The purpose of this case presentation is to de-
scribe a rehabilitation program of a patient who sustained an acute PCL
injury in an ACL deficient knee. The impairment based program includ-
ed 10 sessions of “perturbation” and agility training and allowed the ath-
lete to return to play 7 weeks after the PCL injury. This rehabilitation
program has demonstrated effectiveness in assisting in return to sport
following acute ACL injury, however, has not been evaluated in patients
with acute PCL involvement.
CASE DESCRIPTION: Subject: The patient was an 18-year-old male who sus-
tained a partial PCL tear playing dodge ball just prior to the start of his
high school lacrosse season. Complicating this acute PCL injury, his knee
had been ACL deficient for 2 years. Data: On evaluation 2 weeks following
injury, knee active range of motion (ROM) was lacking 4° extension to 135°
flexion on the involved side and hyper 6° to 142° on the uninvolved side.
Tibiofemoral joint swelling when milked returned immediately (grade 2+).
Quadriceps maximum volitional isometric contraction (MVIC) assessed
by burst superimposition testing at 60° of knee flexion was 98% of the un-
involved side indicating that strength was not impaired. ROM and effu-
sion impairments were resolved after 3 physical therapy treatments and
“perturbation” and agility training were added. “Perturbation” training, as
described by Fitzgerald et al, 2000, is a rapid, systematic introduction of
unexpected, destabilizing forces on various surfaces. The goal of this train-
ing is to allow the athlete to develop an automatic response to unexpected
forces to assist in efforts to return the athlete to sport.
OUTCOMES: He completed 13 physical therapy sessions, including 10 vis-
its of “perturbation” and agility training. At the completion of the train-
ing program, functional testing revealed the involved quadriceps MVIC
remained similar to the initial evaluation and all hop scores, as described
by Noyes (1991), were greater than 100% when compared to the other
side. The patient was able to successfully return to his senior year of la-
crosse without further injury or complaints.
DISCUSSION: Conclusion: Five weeks of Physical Therapy including “per-
turbation” and agility training assisted a lacrosse player in returning to
his competitive season within 7 weeks after PCL injury.
a108 | january 2009 | volume 39 | number 1 | journal of orthopaedic & sports physical therapy
SPL19
RELATIONSHIP OF SHOULDER ROTATION TO SHOULDER GIRDLE STRENGTH
AND SCAPULA POSITION IN PROFESSIONAL PITCHERS
Thigpen CA, Reinold MM, Padua D, Schneider R, DiStefano
MJ, Gill TJ
Athletic Training and Physical Therapy, University of North Florida,
Jacksonville, FL; Boston Red Sox, Boston, MA; Orthopedics, Massachusetts
General Hospital, Boston, MA; Exercise and Sport Science, University of
North Carolina at Chapel Hill, Chapel Hill, NC; Balance Physical Therapy,
Carrboro, NC
PURPOSE/HYPOTHESIS: Shoulder external (ER) and internal (IR) rotation
range of motion (ROM), shoulder girdle strength, and scapula position
are thought to be important clinical considerations when examining the
pitching shoulder. There is strong evidence that pitchers exhibit altered
shoulder ER/IR ROM. These alterations are believed to influence shoul-
der girdle position and force production by changing muscles’ normal
length tension relationships. However, there is little evidence to support
this theory. Therefore, the purpose of this study was to examine the rela-
tionship of ER/IR ROM on shoulder girdle strength and position.
NUMBER OF SUBJECTS: Professional baseball pitchers (n = 98; mean age,
22; height, 189 cm; weight, 94 kg) were tested during spring training
over a 2-year period. All pitchers were asymptomatic and participating
without restriction, in all training, practice, and games. Subjects that had
undergone a shoulder surgery within the last 12 months were excluded.
MATERIALS/METHODS: A digital inclinometer (DI) was used to assess su-
pine ER/IR at 90° abduction and sitting scapula upward/downward ro-
tation (U-D) and anterior/posterior tilt (A-P) at rest. Scapula position
was assessed based on previously validated techniques using a DI with
small dowels attached allowing for palpation of the bony landmarks
while avoiding the periscapular musculature. Greater scapula upward ro-
tation and posterior tilt are indicated by positive values. Isometric mus-
cle strength was measured for the posterior rotator cuff (PRC), lower tra-
pezius (LT), and serratus anterior (SA) using a handheld dynamometer
over a 5-second trial. Position and force application were consistent as
described by Kendall. Peak force was recorded in Newtons then normal-
ized to body weight. Two trials were performed for each measure then
averaged for statistical analysis. Pearson product moment correlations
were used to assess the relationship between ER/IR ROM and PRC, LT,
and SA strength, and U-D, A-P (Bg.05).
RESULTS: There was a negative association between ER and IR with PRC
(r = –0.57, –0.63; P<.01) LT (r = –0.59, –0.70; P<.01), and SA (r = –0.49,
–0.54; P<.01) strength. These results indicate that shoulder rotation is
moderately and inversely related to shoulder girdle strength. There was
also a negative correlation between IR and ER ROM with scapula pos-
terior tilt (r = –0.74, –0.79; P<.001) indicating that pitchers with great-
er shoulder rotation ROM tended to rest in greater posterior tilt. There
were no statistically significant associations between ER/IR ROM with
U-D.
CONCLUSIONS: Our results show that professional pitchers who tended to
have increased shoulder rotation ROM demonstrated weaker isomet-
ric strength measures for the PRC, LT, and SA. Additionally, as pitch-
ers shoulder rotation decreased their scapula tended to be positioned in
a greater anterior tilt.
CLINICAL RELEVANCE: These results suggest there is an apparent interde-
pendence between shoulder mobility and strength, and position. Clini-
cians should carefully consider shoulder rotation ROM and its relation-
ship to scapular position and shoulder girdle strength in pitchers.
SPL20
INTERRATER RELIABILITY OF A SCAPULAR CLASSIFICATION SYSTEM IN THE
MUSCULOSKELETAL EXAMINATION OF PROFESSIONAL BASEBALL PLAYERS
Ellenbecker TS, Kibler B, Bailie DS, Caplinger R, Davies G,
Riemann BL
Physiotherapy Associates Scottsdale Sports Clinic, Scottsdale, AZ; Lexing-
 Combined Sections Meeting
ton Clinic Sports Medicine, Lexington, KY; Physical Therapy Department,
Armstrong Atlantic University, Savannah, GA; The Orthopaedic Clinic
Association, Scottsdale, AZ; Milwaukee Brewers Baseball Club, Milwaukee,
WI
PURPOSE/HYPOTHESIS: The purpose of this study was to prospectively mea-
sure the intertester reliability of a scapular classification system in the ex-
amination of professional baseball players.
NUMBER OF SUBJECTS: Seventy-one healthy uninjured professional base-
ball players (pitchers and catchers) between the ages of 18 and 32 volun-
teered to participate in this investigation.
MATERIALS/METHODS: A digital video camera (Sony Handycam) was used
to film all 71 subjects performing 5 repetitions of scapular plane eleva-
tion while holding a 2-pound weight. A filming distance of 10 feet was
used with the camera mounted on a tripod at a height of 4 feet. Film-
ing occurred during spring training physicals. Two orthopaedic surgeons
and 2 physical therapists then independently viewed the videos of the
71 players using a published scapular classification method placing each
players’ scapulae into 1 of 4 classifications: type I, inferior angle promi-
nent, type II, medial border prominent, type III excessive superior trans-
lation, and type IV normal scapular movement and positioning. Inter-
rater reliability analysis using the Kappa (L) statistic was performed to
determine consistency among raters for 3 sets of analyses: (1) classifying
each scapula into 1 of the 4 types; (2) classifying each scapula as being
abnormal (types I-III) or normal (type IV); (3) classifying both scapula
as both being symmetrical (both normal or both abnormal) or asymmet-
rical (1 normal, 1 abnormal).
RESULTS: Low interrater reliability was revealed for all analyses. In clas-
sifying each scapula as 1 of the 4 types, reliability was k = 0.245 (P<.001;
95% CI: 0.176, 0.315) for the left limb and k = 0.186 (P<.001; 95% CI:
0.111, 0.261) for the right limb. When considering the dichotomous clas-
sifications (abnormal versus normal) reliability was k = .264 (P<.001;
95% CI: .130, .399) for left and k = .157 (P = .004; 95% CI: .049, .265)
for right. For bilateral symmetry/asymmetric reliability was k = .084 (P
= .447; 95% CI: –.132, .300).
CONCLUSIONS: Visual observation and classification of scapular move-
ment has shown low interrater reliability in this investigation. Contin-
ued development and research on clinical evaluation of the scapula and
the identification of scapular dyskinesis is needed.
CLINICAL RELEVANCE: This study provides objective analysis of a clinical
evaluation method used to identify scapular dyskinesis. Current evalu-
ation strategies for clinical use appear to have limitations in the iden-
tification of subtle scapular abnormalities. Further research is needed
to refine and develop clinical evaluation methods for the scapulothorac-
ic joint.
SPL21
ALTERNATION EXISTS IN ELBOW JOINT ACTIVE REPLICATION (EJAR) IN
COLLEGE PITCHERS FOLLOWING SIMULATED GAME THROWING
Manske RC, Smith B, Cox K, Stovak M
Physical Therapy, Wichita State University, Wichita, KS; Family Medi-
cine, Via Christi Regional Medical Center, Wichita, KS
PURPOSE/HYPOTHESIS: Joint proprioception and kinesthesia are the abili-
ties to determine position sense and detect joint movement. Lack of joint
proprioceptive sensation contributes to nonphysiological joint loading
and injury. Fatigue has been shown to hamper upper extremity senso-
rimotor function and can result in the inability to maintain ideal me-
chanics during throwing. The purpose of this study was to determine if
EJAR sense is altered following a simulated 3 inning pitching sequence.
NUMBER OF SUBJECTS: Sixteen male collegiate pitchers participated in the
study. Data were prospectively collected on 2 days prior to the spring
baseball season.
MATERIALS/METHODS: On day 1, each pitcher was taken through all proce-
dures to rule out a learning effect as a cause of differences. Active elbow
range of motion (ROM) was measured in both elbows via standard goni-
journal of orthopaedic & sports physical therapy | volume 39 | number 1 | january 2009 | a109
ometric measurement technique. This ROM was used to determine po-
sitions used for further study of EJAR position sense. Because each ath-
lete has his own unique elbow ROM, the total ROM of the elbow was
determined and a percentage of that ROM was used to calculate the dif-
ferent positions to be tested. Percentages of elbow ROM used for EJAR
were 20%, 35%, 50% and 80% of complete elbow motion. The pitcher
was asked to close his eyes and his elbow was then passively taken to the
given position and held for 10 seconds. The elbow was returned to full
extension and the athlete was asked to actively reproduce the angle for
each of the 4 angles tested. The opposite elbow was tested in the same
manner. On the second test date (minimum of 1 week later), the pitch-
ers were again assessed for prethrowing AJAR, after which they were
asked to throw a simulated 3 inning game that included 2 innings of 15
pitches and 1 inning of 14 pitches. Immediately following their third in-
ning, elbow EJAR testing was performed in the same manner as prior
to throwing.
RESULTS: A mixed design 2-way ANOVA was used to analyze the differ-
ences between the replication data on 2 different days and the dominant
and nondominant elbows. Data analysis indicated no change in EJAR of
the nondominant elbow at any angle tested. The dominant elbow dem-
onstrated significant loss of EJAR following simulated throwing. Signifi-
cant differences occurred at the 35% and 80% angles (P<.05).
CONCLUSIONS: Significant differences exist in dominant EJAR sense fol-
lowing simulated 3 innings of throwing. Because joint proprioception is
thought to be an important component of joint stabilization, an altera-
tion in joint position sense may increase the risk of elbow injury dur-
ing throwing.
CLINICAL RELEVANCE: This study demonstrates that the act of pitching
causes a loss of active elbow active joint replication in the dominant
throwing elbow.
SPL22
PREVALENCE AND RELATIONSHIP OF MENSTRUAL DYSFUNCTION AND
MUSCULOSKELETAL INJURY IN FEMALE HIGH SCHOOL ATHLETES
Thein-Nissenbaum J, Rauh MJ, McGuine TA, Carr KE, Loud KJ
Department of Orthopedics and Rehabilitation, University of Wisconsin
School of Medicine and Public Health, Madison, WI; Rocky Mountain
University of Health Professions, Provo, UT; University of Wisconsin
Sports Medicine Center, Madison, WI; Department of Family Medicine,
University of Wisconsin School of Medicine and Public Health, Madison,
WI; Northeastern Ohio Universities College of Medicine, Akron, OH
PURPOSE/HYPOTHESIS: The interrelationships between disordered eating
(DE), menstrual dysfunction (MD) and bone loss is known as the Female
Athlete Triad Syndrome. Although MD has been studied in elite athletes,
few studies have examined MD in adolescent athletes. The purpose of
this study was to determine the prevalence and relationship of menstru-
al dysfunction (MD) and musculoskeletal injury (MI) among high school
athletes. We hypothesized that (1) the prevalence of MD would be higher
in athletes participating in aesthetic sports (AES) than athletes compet-
ing in team/anaerobic (TA) and endurance (END) sports, and (2) that
athletes reporting MD would be at greater risk of MI.
NUMBER OF SUBJECTS: We prospectively followed 334 female athletes
(mean age, 15.4  1.2 years) who competed on an interscholastic sport,
cheer or dance team from 3 Wisconsin public high schools.
MATERIALS/METHODS: Menstrual history/status and MI were assessed us-
ing the Healthy Wisconsin High School Female Athlete Survey. MI was
defined as any injury incurred from sport participation during the 2006-
2007 school year, and MD was defined as less than 9 menses in the past
12 months or menses not started by age 15. Athletes were classified into
3 sport group types based on their initial participation in the study. Over-
all, 51.9% athletes competed on sports considered TA, 35.1% END, and
13.0% AES. Odds ratios [OR] and 95% confidence intervals [CI] were
calculated to determine the risk relationships between menstrual sta-
tus and MI.
 Combined Sections Meeting
RESULTS: The athletes’ average age of menarche was 12.4 years (SD, 1.1).
Of the 334 subjects, 58 (17.4%) met the criteria for MD. Overall, 2.1% of
the athletes reported primary amenorrhea, and 8.1% and 23.7% reported
secondary amenorrhea (3 or more menses consecutively missed during
past 12 months) and oligomenorrhea (menses cycles 35 or more days),
respectively. Forty-four percent reported their periods became lighter/
farther apart or completely stopped during the sport season. Although
not statistically significant (P = .27), athletes competing in AES sports
reported a higher percent of MD (28.2%) than athletes in END (18.6%)
or TA (17.0%) sports. Athletes who reported delayed menstruation were
almost twice as likely to have MD (OR = 1.8, 95% CI: 1.4-2.4). During the
season, 216 athletes (64.7%) incurred an injury. No significant associa-
tion was found between MD and MI (OR, 0.8; 95% CI: 0.5-1.5). A strong
trend was found between oligomenorrhea and injury (OR, 3.5; 95% CI:
0.9-12.9; P = .06) among END athletes.
CONCLUSIONS: Although MD was not associated with injury in our study,
athletes reporting later age of menarche or oligomenorrhea were at in-
creased risk for injury during the sport season. While the prevalence of
MD was highest among AES athletes, of concern was MD being elevated
among END and TA athletes.
CLINICAL RELEVANCE: As prior studies have found MD related to injury or
low bone mineral density, our findings suggest the need for screening fe-
male high school athletes for MD.
SPL23
ASSOCIATIONS OF LOWER EXTREMITY INJURY WITH DISORDERED EATING,
MENSTRUAL DYSFUNCTION, AND LOW BONE MINERAL DENSITY AMONG
FEMALE HIGH SCHOOL TRACK AND FIELD AND CROSS-COUNTRY RUNNERS
Rauh MJ, Nichols JF, Barrack MT
Graduate Program in Orthopaedic and Sports Physical Therapy, Rocky
Mountain University of Health Professions, Provo, UT; Department of
Exercise and Nutritional Sciences, San Diego State University, San Diego,
CA; Graduate Group in Nutritional Biology, University of California-
Davis, Davis, CA
PURPOSE/HYPOTHESIS: Injuries account for substantial morbidity among
young women competing in interscholastic sports. We explored the rela-
tionships between disorders of the female athlete triad (disordered eating
[DE], menstrual dysfunction [MD], low bone mineral density [BMD])
and increased risk of lower extremity injury in female high school track
and field athletes and cross-country runners.
NUMBER OF SUBJECTS: We prospectively followed 94 (age, 15.6  1.3 years)
female athletes who participated in interscholastic cross-country and
track and field in Southern California.
MATERIALS/METHODS: Baseline data included the Eating Disorder Exam-
ination Questionnaire (EDE-Q) for assessing eating attitudes and be-
haviors, a questionnaire highlighting menstrual history, and the athletes
were measured for BMD by DXA. Low bone mass was defined as a BMD
value l1 SD below age-matched reference data at any measurement site.
Lower extremity injuries (low back, hip, knee, shin, calf, ankle, foot) data
were recorded by athletic trainers and coaches throughout the season
using the Athletic Health Care System Daily Injury Report. Odds ratio
(OR) estimates and 95% confidence intervals (CIs) were used to deter-
mine the relationship of each triad component and risk of injury.
RESULTS: Thirty-nine athletes (41.5%) had a confirmed injury. Of the 94
athletes, 10.6% met the criteria for DE (l4.0 on EDE-Q), 22.3% report-
ed MD, and 31.9% exhibited low BMD for their age. Ten athletes (10.6%)
met criteria for any 2 components, and 2 (2.1%) met the criteria for all
3 components. Using multivariable logistic regression, only low BMD
was significantly associated with lower extremity injury after adjusting
for age, gynecological age, lean tissue mass, and all triad components.
Athletes with low BMD were 6 times more likely (OR, 6.1; 95% CI: 2.0-
18.7; P = .001) to incur a lower extremity injury than athletes with nor-
mal BMD levels. Athletes who reported MD were almost 3 times more
likely to incur a lower extremity injury than athletes reporting normal
a110 | january 2009 | volume 39 | number 1 | journal of orthopaedic & sports physical therapy
menses during the past year, but only a strong trend was observed (OR,
2.8; 95% CI: 0.8-9.9; P = .09). A nonsignificant association was found
between DE and lower extremity injury (OR, 1.9; 95% CI: 0.4-8.8; P =
.39). Athletes with low BMD were also almost 5 times more likely (OR,
4.6; 95% CI: 1.4-16.8; P = .02) to incur a shin injury than athletes with
normal BMD levels.
CONCLUSIONS: These findings indicate that female high school track and
field athletes and cross-country runners with low BMD are at greater risk
of lower extremity injury.
CLINICAL RELEVANCE: As low BMD was related to injury risk, high school
athletes’ training regimens and diet should be monitored with efforts to
minimize factors such as over-training and inadequate caloric intake that
may affect bone health. Athletes reporting menstrual dysfunction may
require additional observation during their training.
SPL24
HIGH SCHOOL GIRLS’ CROSS-COUNTRY RUNNING INJURIES: A 20-YEAR
LONGITUDINAL STUDY
Rauh MJ, Beachy G
Graduate Program in Orthopaedic and Sports Physical Therapy, Rocky
Mountain University of Health Professions, San Diego, CA; Punahou
School, Honolulu, HI
PURPOSE/HYPOTHESIS: Girls’ cross-country has continued to grow in pop-
ularity the past few decades. However, few studies have examined the
risk of injury in girls’ cross-country prospectively for 2 or more seasons.
The purpose of this longitudinal study was to determine the incidence
of injury among girl high school cross-country runners over a 20-year
period.
NUMBER OF SUBJECTS: We studied 1474 girl athletes who participated in
interscholastic cross-country at a Hawaii high school during 1988 to
2008.
MATERIALS/METHODS: Data included all injuries that resulted from run-
ning in a cross-country practice or meet. An injury was defined as any
athlete complaint that required the attention of the athletic trainer, re-
gardless of the time lost from activity. Athletic exposure (AEs) data (each
athlete’s daily participation in a practice or meet where she was at a risk
for injury) was also collected. Cumulative incidence (percent of athletes
injured) and incidence rates per 1000 AEs (total number of injuries/total
number of AEs) were calculated for overall incidence, and for practices/
meets, body location, injury type, and injury severity (time lost from par-
ticipation due to injury). Rate ratios (RR) and 95% confidence intervals
(CIs) were used to compare practice and meet injury rates.
RESULTS: There were 678 injuries for an overall cumulative incidence of
46.0% and injury rate of 6.6/1000 AEs. Overall, the rate injury during
practices (7.0/1000 AEs) was almost twice the rate in meets (4.0/1000
AEs) (RR, 1.8; 95% CI: 1.3-2.3; P = .01). The incidence of injury was
highest at the knee (1.50/1000 AEs), shin (1.43/1000 AEs) and ankle
(1.39/1000 AEs). Over 50% (50.4%) of injuries were classified as ten-
dinitis in nature (3.31/1000 AEs). Of these, 35.8% were shin splint or
stress reaction injuries (1.1/1000 AEs). The rates were also high for mus-
cle strain (1.76/1000 AEs) and sprain (1.08/1000 AEs) injuries. The in-
cidence for stress fracture was low (0.06/1000 AEs). Most (57.2%) in-
juries were minor (no time lost) in severity (3.76/1000 AEs). Injury
rates for mild (1-7 days lost), moderate (8-21 days lost) and severe (22
or more days lost) injuries were (2.44/1000 AEs), (0.25/1000 AEs), and
0.12/1000 AEs), respectively.
CONCLUSIONS: Similar to prior reports, the results of this study suggest
that girl cross-country runners are at high risk for knee and lower leg
(shin) injuries, especially those resulting from repetitive strain impact/
overuse.
CLINICAL RELEVANCE: The data suggest the need to monitor girls’ cross-
country training programs during the season to determine if certain
training distances, intensities, terrains or surfaces are more likely to in-
crease a runner’s risk of injury, especially during practices. Preseason
 Combined Sections Meeting
screening by sports medicine professionals to identify risk factors (eg,
malalignment, muscle imbalances, prior injury, preseason fitness/train-
ing) should also be conducted as a preventive approach for identifying
girl runners at higher risk of injury.
SPL25
COMPARISON OF PERFORMANCE ON THE STAR EXCURSION BALANCE TEST
BY SPORT, COMPETITION LEVEL, AND GENDER
Plisky PJ, Gorman PP, Kiesel K, Butler RJ, Rauh MJ
ProRehab, PC, Evansville, IN; Physical Therapy, University of Evansville,
Evansville, IN
PURPOSE/HYPOTHESIS: The Star Excursion Balance Test (SEBT) is fre-
quently used in preparticipation physicals, rehabilitation examinations,
return to sport testing, and research. However, there are few published
reports comparing performance on the test in different athletic popula-
tions. Therefore, the purpose of this study was to compare performance
data on the SEBT in athletes by sport, competition level, and gender.
Our primary hypothesis was that there would be significant differences
in performance on the SEBT between groups.
NUMBER OF SUBJECTS: Five hundred ninety-eight male and female athletes
from 14 sports were tested during preparticipation physicals at 8 junior
high schools, 8 high schools, and 2 colleges.
MATERIALS/METHODS: After standardized video instruction and 6 practice
trials, SEBT reach distance was measured from the most distal aspect
of the stance foot to the most distal aspect of the reach foot in the ante-
rior, posteromedial, and posterolateral directions using an instrument-
ed device (the Y Balance Test). The reach foot was required to maintain
standard height from the ground and was not allowed to touch down.
The greatest reach of 3 trials for each direction was used for analysis and
was normalized to limb length. The variables of interest were the ante-
rior, posteromedial, posterolateral, composite reach distance, and reach
asymmetry in all directions. Statistical analysis was performed using a
3-way ANOVA (sport by competition level by gender). When appropri-
ate, follow-up testing for significant interactions in the 3-way ANOVA
were performed using 1-way ANOVAs for sport, competition level and
gender. Bonferroni post hoc testing was carried out using p-value of 0.05
to detect significant differences.
RESULTS: The results of this testing revealed a significant difference among
sports for right/left posteromedial and posterolateral reach asymmetry
and composite reach distance (scores ranged from 92.8  7.8 to 99.5 
5.7, P<.05). Golf and basketball players had the lowest composite reach
distance while soccer players and wrestlers had the greatest composite
reach distance (P<.05). Junior high athletes had a greater posteromedi-
al reach asymmetry and significantly shorter composite reach distance
(93.4  8.2 percent for junior high and 96.6  7.6 percent for the other
competitions levels, P<.05). Women had greater asymmetry in all reach
directions and significantly decreased composite reach distance (95.5 
7.4 percent for women and 97.4  7.6 percent for men, P<.05).
CONCLUSIONS: There were significant differences in performance on the
SEBT among sports, competition level, and gender.
CLINICAL RELEVANCE: Since there were significant differences in reach dis-
tances among sports, competition level, and gender, the sports med-
icine clinician should consider this information when interpreting the
results of the SEBT. This further emphasizes the importance of norma-
tive data in multiple sport populations and the need for population spe-
cific (eg, gender, sport, and competition level) injury risk thresholds for
the SEBT.
SPL26
FUNCTIONAL MOVEMENT TEST SCORES IMPROVE FOLLOWING AN OFF-
SEASON INTERVENTION PROGRAM
Kiesel K, Plisky PJ, Butler RJ
Physical Therapy, University of Evansville, Evansville, IN; ProRehab,
Evansville, IN
journal of orthopaedic & sports physical therapy | volume 39 | number 1 | january 2009 | a111
PURPOSE/HYPOTHESIS: Researchers have reported that athletes with poor
dynamic balance or asymmetrical strength and flexibility (ie, poor fun-
damental movement patterns) are more likely to be injured. The funda-
mental movement patterns tested in the Functional Movement Screen
(FMS) place the athlete in positions where ROM, stabilization, and bal-
ance are assessed simultaneously. The FMS is comprised of 7 tests and
scored on a 0 to 3 ordinal scale. It has been reported that profession-
al football players scoring less than or equal to 14 on the FMS are more
likely to be injured. Additionally, the presence of at least 1 asymmetry
on any of the 5 right/left tests has also been shown to increase injury
risk. The purpose of this study was to determine if an off-season inter-
vention program was effective in improving FMS scores in professional
football players.
NUMBER OF SUBJECTS: Sixty-two.
MATERIALS/METHODS: Pre and post intervention FMS scores were obtained
on 62 professional football players who completed a 7-week off-season
program. The subjects grouped by position with lineman and lineback-
ers (lineman) in 1 group n = 32 and all others players in the other group
(nonlineman) n = 30. The program included corrective exercises which
were prescribed based on the results of each player’s pretest score. The
exercises were progressed in a standardized manner with goal of achiev-
ing the best possible movement strategy related to each of the 7 tests. The
program also included traditional strength, power, speed and agility ac-
tivities. A repeated-measures ANOVA using pre/post test scores (time)
as the dependent variable and position (lineman and nonlineman) as the
between subjects factor was conducted with the significance level set at
P<.05. Pre/post intervention frequency counts were calculated on asym-
metry (presence of at least 1) and cut score (g14 or >14).
RESULTS: The mean pretest score for the lineman was 11.8 and 13.3 for the
nonlineman. The mean post test score for the lineman was 14.8 and 16.3
for the nonlineman. There was a positive main effect for time (P<.001)
and there was no time-by-position interaction (P = .78) indicating both
groups significantly improved. Thirty-two subjects improved from less
than or equal to 14 to greater than 14, 23 failed to improve beyond 14 and
7 subjects pretest scores were greater than 14. 31 subjects had an asym-
metry at pretest and 31 subjects did not. Following the intervention, 42
players were free of asymmetry and 20 players continued to demonstrat-
ed asymmetry.
CONCLUSIONS: The results suggest fundamental movement characteristics
measured by the FMS do improve following an intervention designed to
address dysfunctional movements. Further research is required to deter-
mine if injury risk is reduced when a player improves his score beyond
the established cut-off of 14 and/or asymmetry is resolved.
CLINICAL RELEVANCE: Injury prevention and performance enhancement
programs should consider including the FMS or a similar movement
screen and associated exercises with the goal of injury reduction and per-
formance improvement.
SPL27
EFFECTS OF AGE ON LOWER EXTREMITY JOINT STIFFNESS AND LOADING
RATES IN RUNNERS
Williams DB, Simmerman RA
Physical Therapy, East Carolina University, Greenville, NC
PURPOSE/HYPOTHESIS: Running is known to have a positive influence on a
person’s overall physical fitness and health. More than 30 million Amer-
icans run for recreation or competition. Many of these individuals con-
tinue to run well past the age of 60. Because of the significant neuromus-
cular, bony and joint changes that occur with aging, associated changes
in running mechanics would be expected. The purpose of this study was
to compare knee stiffness, ankle stiffness and vertical loading rate in run-
ners across the adult lifespan. It was hypothesized that older runners
would demonstrate greater joint stiffness and loading rates compared
to younger runners.
NUMBER OF SUBJECTS: Forty-seven recreational runners participated in
 Combined Sections Meeting
this study. Subjects were required to run at least 6 miles/week and be RESULTS: Patients had significant GIRD (31°), loss of ER ROM (22°) and
free from current lower extremity injuries at the time of data collection. increased posterior shoulder tightness (35°) on initial evaluation (all
MATERIALS/METHODS: A lower extremity physical evaluation and a 3-di- P<.01). Physical therapy (4.7  3.7 weeks range 3-12 weeks) improved
mensional running analysis were completed. Three dimensional data GIRD (26  14), ER ROM loss (14  20), and posterior shoulder tight-
was collected via an 8-camera motion analysis system (240 Hz) and 2 ness (27  19; all P<.01). SST improved from 5  3 to 11  1 (P<.01),
force plates (1980 Hz). Retroreflective markers were placed bilaterally with 12 patients having complete resolution of symptoms and 10 pa-
on segments of the rearfoot, shank, thigh and pelvis by a single research- tients having some residual symptoms. A greater improvement in poste-
er. The subjects ran down a 20-m runway at a speed of 3.35 m/s. Speed rior shoulder tightness was seen in patients with complete resolution of
was monitored with photocells and only trials within 5% of the target symptoms compared with patients with residual symptoms (35° versus
speed were accepted. Commercial software was used to determine joint 18°, P<.05). Improvements in GIRD and ER ROM loss were not differ-
kinematic and kinetic measures. Subjects’ results were grouped accord- ent between patients with and without resolution of symptoms (GIRD
ing to age: <40 years (n = 11), 40 to 60 years (n = 17), and >60 years (n = 25° versus 28°, P = .57; ER ROM 14° versus 15°, P = .84).
18). Joint stiffness at the knee and ankle and loading rate were calculat- CONCLUSIONS: Resolution of symptoms after physical therapy treatment
ed and averaged for each group. Joint stiffness was defined as the change for internal impingement was related to correction of posterior shoulder
in moment over the change in angular displacement and evaluated dur- tightness but not correction of GIRD.
ing weight acceptance phase of stance. Loading rate was defined as the CLINICAL RELEVANCE: Physical therapists should address stretching the
change in vertical ground reaction force over the change in time. A 1-way posterior shoulder in patients with internal impingement.
analysis of variance was used to compare the differences in ankle stiff-
ness, knee stiffness and loading rate between groups.
RESULTS: No significance was found in ankle stiffness (P = .26) or knee
stiffness (P = .11) between groups. Loading rate was statistically signif-
icant (P = .05) between age groups. However, ankle and knee stiffness
were significantly greater in subjects <40 compared to >60 (P = .05).
Overall, the results demonstrate that with increasing age, ankle and knee
stiffness decreases and loading rate increases.
CONCLUSIONS: This study has shown that runners change biomechanical-
ly as they age. Older runners display decreased lower extremity stiffness
but exhibit increased initial loading rates. These changes may be the re-
sult of neuromuscular changes (active stiffness) that occur with aging
or a compensation to reduce increased loading rate (passive stiffness) in
the lower extremity.
CLINICAL RELEVANCE: The overall goal of this research is to decrease older
runners’ risk of overuse injuries as well as increase or maintain perfor-
mance. Strength training, gait retraining, and running shoe design spe-
cific to aging runners are potential mechanisms for intervention.

SPL28 [NOT ON SCHEDULE]

CORRECTION OF POSTERIOR SHOULDER TIGHTNESS IS ASSOCIATED WITH
SYMPTOM RESOLUTION IN PATIENTS WITH INTERNAL IMPINGEMENT
Tyler TF, Nicholas SJ, Mullaney M, McHugh MP
NISMAT, New York, NY
PURPOSE/HYPOTHESIS: Glenohumeral internal rotation deficit (GIRD) and
posterior shoulder tightness has been linked to internal impingement.
The purpose of this study was to determine if improvements in GIRD
and/or decreased posterior shoulder tightness are associated with a res-
olution of symptoms.
NUMBER OF SUBJECTS: Twenty-two patients (11 men, 11 women; age 41  3
years) diagnosed with internal impingement were studied.
MATERIALS/METHODS: Inclusion criteria were GIRD >10°, a positive reloca-
tion test and posterior superior shoulder pain. Passive internal rotation
(IR) and external rotation (ER) range of motion (ROM) was assessed
at 90° of shoulder abduction. Posterior shoulder tightness was assessed
with cross chest adduction in side-lying. Treatment involved stretching
and mobilization of the posterior shoulder. The Simple Shoulder Test
(SST) was administered on initial evaluation and discharge. Changes in
GIRD, ER ROM and posterior shoulder tightness were compared be-
tween patients with complete resolution of symptoms (SST 12/12) ver-
sus patients with residual symptoms (SST <12/12) using independent t
tests. Based on the variability of GIRD and posterior shoulder tightness
in patients with internal impingement reported in previous studies it was
estimated that an 11° difference in GIRD improvement and an 8° differ-
ence in posterior shoulder tightness improvement could be detected be-
tween patients with and without resolution of symptoms at P<.05 with
80% power in a sample of 22 patients. Mean  SD reported.

a112 | january 2009 | volume 39 | number 1 | journal of orthopaedic & sports physical therapy