Reliability limits of the modified Thomas test for assessing rectus femoris muscle flexibility about the knee joint

A comparative study of the efficacy of instrument-assisted soft tissue mobilization and massage techniques in patients with patellofemoral joint pain

Purpose

The aim of this study was to compare the clinical efficacy of instrument-assisted soft tissue mobilization (IASTM) and manipulative therapy Tui-na techniques in the treatment of patients with patellofemoral joint pain syndrome, and to evaluate their impact on pain relief, functional improvement, and joint range of motion.

Methods

In this study, 25 patients with patellofemoral pain syndrome were enrolled, comprising of an intervention group of 13 patients who received IASTM treatment and a control group of 12 patients who received Tui-na manipulation therapy. The treatment cycle lasted for 4 weeks, featuring two interventions per week. Before treatment, the visual analog pain scale (VAS) of the knee, Lysholm score of the knee, modified Thomas test (MTT), and maximum isometric strength of the extensor muscles of the lower limbs were measured and recorded for both groups. After the first and last treatments, the aforementioned indexes were reassessed, and the maximum isometric muscle strength of the lower extremity extensors was measured only after 4 weeks of treatment had been completed.

Results

There was no significant difference in the basic information of the two intervention groups (p > 0. 05). After the first treatment and 4 weeks of treatment, the Lysholm score in both groups significantly improved (p < 0. 05), indicating that both interventions can improve the function of patients' lower limbs. However, the Lysholm score in the IASTM group significantly increased compared with that of the massage group after 4 weeks of treatment, indicating that its improvement in functional performance is superior. Both groups showed significant improvement in knee joint pain after the first treatment and 4 weeks of treatment (p < 0. 05), with the IASTM group having a lower VAS score and better pain improvement after 4 weeks of treatment. The strength of the two intervention groups significantly increased after the maximum isometric muscle strength test of the lower limb extensor muscles before and after 4 weeks of treatment (p < 0. 05). After the MTT test, the extension angle, deviation angle, and hip abduction angle of the tested legs in the two intervention groups were significantly reduced (p < 0. 001), indicating an improvement in lower limb joint mobility.

Conclusion

Instrument-assisted soft tissue mobilization treatment and Tui-na manipulation therapy significantly reduced pain, improved knee flexibility, and increased range of motion of the lower extremity in patients with PFPS. However, IASTM treatment significantly improved pain and function and sustained pain in the short to medium-term post-trial period.

Clinical trial registration

www.isrctn.com, ISRCTN88098928.

Validity and reliability of a new hip flexor muscles flexibility assessment tool: The reactive hip flexor (RHF) test

BACKGROUND

The modified Thomas test is the most used and most reliable test to assess the hip flexors' flexibility. However it does not evaluate the interaction of both legs. The objective of this study is to propose a new assessment tool for hip flexor flexibility, the Reactive Hip Flexion (RHF) Test.

METHODS

An observational, intra-test, and test-retest study with repeated measures was carried out with the aim of assessing the validity and reliability of the RHF Test. The participants were males and females aged between 18 and 35 years old who had a training schedule of at least 2 days a week, without a musculoskeletal lower limb or lumbopelvic pathology. The reliability of the test was examined using the intraclass correlation coefficients (ICCs) by a two-way random model to establish inter-rater reliability and a two-way mixed model to assess intra-rater reliability. The precision was measured by the standard error of measurement (SEM). In addition, the minimum detectable change (MDC95%) was calculated.

RESULTS

Twenty-six participants (52 hips) (47% female) completed the study. No correlations were observed between anthropometric variables and RHF peak force or active knee extension (AKE) measurements. There was an excellent intra-rater and inter-rater ICC in the hip flexors' reactive peak force and the AKE measurements, with a low SEM.

CONCLUSIONS

This study demonstrated that the proposed RHF test technique is valid and reliable when used in healthy youth population.

Intra and interrater reliability for lower limb flexibility assessment using photogrammetry

INTRODUCTION

Photogrammetry represents an advancement in the flexibility evaluation, and although it was highly explored for postural assessment, there is a scarcity of studies analyzing lower limb angular measurements using it. The purpose of this study is to verify the reliability of intrarater and interrarater photogrammetry in assessing lower limb flexibility.

METHODS

This was a randomized cross-sectional observational study with test-retest design and a two-day interval. Thirty healthy, physically active adults were included. Three novice raters assessed the participants through flexibility tests of iliopsoas, hamstring, quadriceps and gastrocnemius on two occasions, and independently analyzed the captured images to establish reliability. Intraclass correlation coefficient (ICC), standard error of measurement (SEM), and minimal detectable change (MDC) were calculated.

RESULTS

Intrarater reliability was excellent for iliopsoas (ICC = 0.96; SEM = 1.4; MDC = 3.8), hamstring (ICC = 0.99; SEM = 1.1; MDC = 3.1), quadriceps (ICC = 0.99; SEM = 0.8; MDC = 2.3) and gastrocnemius (ICC = 0.98; SEM = 0.9; MDC = 2.5). Interrater reliability was excellent for iliopsoas (ICC = 0.94; SEM = 1.7; MDC = 4.6) and gastrocnemius (ICC = 0.91; SEM = 2.1; MDC = 5.8), but good for hamstring (ICC = 0.90; SEM = 2.8; MDC = 7.9) and quadriceps (ICC = 0.85; SEM = 3.0; MDC = 8.3).

CONCLUSIONS

The excellent intrarater and good to excellent interrater reliability suggest that photogrammetry assessment of lower limb flexibility by novice raters is reliable. However, clinicians should consider the higher threshold of range of motion change necessary to outweigh measurement error due to interrater variability.

The Falcon Test: An Observer Agreement Study in Subjects With and Without Anterior Knee Pain

Introduction

A shortened rectus femoris muscle has been associated with many different musculoskeletal problems. Assessing rectus femoris muscle length is commonly performed using the Modified Thomas Test. However, this test position is often difficult to assume and there are difficulties with reliably measuring rectus femoris length. A method that that uses an easier position to assume and could be more reliable would be beneficial to therapists. The purpose of this study was to determine observer agreement using a new test for assessment of rectus femoris length. A second purpose was to determine if those with anterior knee pain have different rectus femoris muscle length than those without anterior knee pain.

Method

Fifty-three participants with and without anterior knee pain were enrolled. Rectus femoris muscle length was measured lying prone with the leg measured on the table while the non-measured leg was off the table in a position of 90° hip flexion. Rectus femoris muscle was lengthened by passively bending the knee until a firm end-feel. The angle of knee flexion was then measured. The process was then repeated after a brief rest period.

Results

Observer agreement assessing rectus femoris length using this method showed "almost perfect" reliability for both intra- and inter-rater testing: intra-rater: ICC = .99, [CI95: .98-.99], inter-rater: ICC = .96, [CI95: .92- .98]. Agreement for the sub-sample of those with anterior knee pain (N=16) showed "almost perfect" reliability for intra-rater (ICC 1,1 = .98); [CI95: 0.94-.99] and inter-rater reliability (ICC 2,1 = 0.88); [CI95: 0.70 -.95]. No differences were noted in rectus femoris length between those without and those with anterior knee pain (t= 0.82, p> 0.01); [CI95: -7.8 -3.33]; (SEM = 1.3°; MDC=3.6°).

Conclusion

This new method of assessing rectus femoris length is reliable between and within raters. No differences were noted in rectus femoris length between those with anterior knee pain and those without.

Running capacity in children with bilateral cerebral palsy: What are the biomechanical and neuromotor differences between runners and walkers?

BACKGROUND

Running is a high-level locomotor activity requiring more from joints, muscles and a more complex interaction of the neuromuscular system than walking. High-level locomotor activity has the potential to shed light on motor function deficits that lower-level activity does not reveal. Therefore, the study aimed to compare biomechanical and neuromotor function between a group of children with bilateral cerebral palsy who are able and unable to run.

METHODS

Retrospectively, children with bilateral cerebral palsy aged between 6 and 18 years who completed a clinical gait analysis between 2006 and 2019 were included. Participants were categorized as walkers or runners based on the presence of a double floating phase. Spasticity, selectivity, muscle weakness, and passive range of motion of the lower limbs were measured and dichotomized as «normal» or «abnormal» based on reference values. Functional tasks reflecting balance (standing on one leg) and power (single leg and two-legged jumps) were realized and evaluated as failure or success.

FINDINGS

75 children with bilateral cerebral palsy (53 runners/22 walkers) were included. Children classified as runners were stronger (hip flexors, p = 0.006; hip abductors, p = 0.022; knee flexors, p = 0.001; dorsiflexors, p = 0.014), had greater selectivity (hip flexors, p = 0.011; dorsiflexors, p = 0.001; plantiflexors, p = 0.043) and lower spasticity at the knee extensors (p = 0.045). No differences were observed in the passive range of motion between the two groups. Children classified as runners performed better at all tasks of balance and power (p < 0.05).

INTERPRETATION

Flexors muscles strength and selectivity and knee extensor spasticity are key points for running ability in children with bilateral cerebral palsy.

Individualized Analysis of Lateral Asymmetry Using Hip-Knee Angular Measures in Soccer Players: A New Methodological Perspective of Assessment for Lower Limb Asymmetry

This study aimed to: (1) determine the magnitude and direction of lateral asymmetry in well-trained soccer players using hip and knee ROM tests; (2) inquire if asymmetry relies on the ROM test performed and/or gender; and (3) establish asymmetry thresholds for each ROM test to individualize lower-limbs asymmetry. One hundred amateur soccer players were assessed using hip–knee ROM tests: Straight Leg Raise, modified Thomas Test, hip internal rotation and external rotation, hip abduction (ABD) and adduction (ADD), Nachlas Test and Rigde Test. There are significant differences between tests when determining the magnitude of lateral asymmetry (F = 3.451; p = 0.001; η_p² = 0.031) without significant differences between gender (F = 0.204; p = 0.651; η_p² = 0.001). Asymmetry threshold results differ significantly between using a fixed or a specific threshold (F = 65.966; p = 0.001; η_p² = 0.985). All tests indicate that the direction of asymmetry is towards the dominant limb. In conclusion, the ROM test used determines the magnitude and direction of the lateral asymmetry of the amateur soccer players. The ABD and ADD are the ROM tests that showed higher percentages of asymmetry, without differences between female and male soccer players. Using a specific asymmetry threshold formula can classify more players as asymmetrical than with a fixed threshold.

Predicting Hamstring Strains in Soccer Players Based on ROM: An Analysis From a Gender Perspective

Purpose: The aim of this study was to explore if specific hip and knee range-of-movement (ROM) tests can predict a risk factor for hamstring strain (HS) injury in male and female soccer players. Methods: One hundred amateur soccer players (56 men and 44 women) performed six tests to determine hip and knee ROM: straight leg raise test (SLR), modified Thomas test (TT), hip internal and external rotation (ER), hip abduction and adduction, Nachlas test and Ridge test. A logistic regression analysis was carried out to create a predictive model for HS injuries. Results: The percentage of HS injury was 20.45% and 30.35%, for female and male players. The logistic regression showed a significant model for both genders on the logit of suffering an HS injury with active-SLR and TT variables for females (R²_CS = 0.491; R²_N = 0.771) and active SLR and ER variables for males (R²_CS = 0.623; R²_N = 0.882). The predictive models correctly classify 95.5% and 94.6% of cases presenting good sensitivity (77.8% and 88.2%) and full (100%) and high (97.4%) specificity respectively. Furthermore, female players showed a greater ROM than males (p ≤ 0.01). Conclusion: Both female and male soccer players that suffered a HS injury had lower ROM in SLR, NT and RT and higher ROM in the TT that non-injured players. The tests that most likely predict HS injury are SLR and TT in females and SLR and ER in males. Thus, it is suggested to including specific exercises in amateur soccer players training programs to improve hip and knee ROM for injury prevention.

Effectiveness of workplace active rest programme on low back pain in office workers: a stepped-wedge cluster randomised controlled trial

OBJECTIVE

This study aimed to investigate the effectiveness of workplace active rest programme (WARP) on chronic low back pain (LBP) among office workers.

DESIGN

A closed cohort, stepped-wedge cluster randomised trial was conducted. The total duration of the study was 16 weeks (4 weeks for each step). Sequence allocation was randomised, but no one was blinded.

SETTING

This study was conducted in three offices in a Japanese electronics company. One office was for the administrative department, the others are for the engineering department.

PARTICIPANTS

We recruited 29 office workers with LBP greater than 3 months. LBP due to specific injury or disease was excluded. The median age was 38 years, and 26 (90%) were male. All participants completed the study.

INTERVENTIONS

In the intervention phase, participants performed WARP comprising frequent stand-up and individualised brief exercise/physical activity during work. Physical therapists held an LBP workshop and developed tailor-made programmes before introducing WARP. We instructed participants to perform WARP at five timings during work. Control phase was set before the intervention and participants stayed as usual.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was pain intensity of LBP assessed using the Brief Pain Inventory. The secondary outcomes were work productivity loss measured using the Work Limitations Questionnaire, LBP disability assessed using the Roland-Morris Disability Questionnaire, psychosocial subscale assessed using the STarT Back Screening Tool and physical activity measured using triaxial accelerometers. These outcomes were collected at baseline and at 4-month follow-up evaluation.

RESULTS

In the intention-to-treat analysis, WARP did not show any significant effects on pain intensity (β, 0.01; 95% CI -0.50 to 0.52) and on the secondary outcomes. The median adherence to WARP was 28.6% (IQR, 16.8-41.1), which was equal to 1.43 times per day. No adverse effect was observed.

CONCLUSIONS

The present study was unable to confirm the effectiveness of active rest in improving LBP. Hence, further study needs to investigate its effectiveness.

TRIAL REGISTRATION NUMBER

UMIN000033210.

Reliability of a Smartphone Goniometric Application in the Measurement of Hip Range of Motion Among Experienced and Novice Clinicians

CONTEXT

Deficits in the hip range of motion are associated with hip and groin injuries. Accurate and reliable goniometric measurements are important in identifying those at risk of injury and determining the efficacy of treatment interventions. Smartphone goniometric applications are regularly used to assess joint ranges of motion; however, there is limited knowledge on the reliability of this method in relation to the hip, particularly between clinicians with different levels of experience.

OBJECTIVE

To determine the intratester and intertester reliability of a smartphone clinometer application for the assessment of hip goniometric measurements in healthy volunteers by an experienced and novice clinician.

DESIGN

Reliability study.

SETTING

University Athletic Therapy facility.

PARTICIPANTS

Physically active, university students.

MAIN OUTCOME MEASURES

The study determined the intra- and intertester (experienced vs novice clinician) reliability of goniometric measurements of the hip joint (modified Thomas test and seated hip internal and external rotation) using a smartphone goniometric application. Intraclass correlation coefficients (ICCs), standard error of measurement, and minimal detectable change at a 95% confidence interval were used to assess reliability.

RESULTS

Goniometric measurements demonstrated good to excellent relative intratester reliability for the modified Thomas test (ICC = .94), external rotation (ICC = .93-.95), and internal rotation (ICC = .80-.81). Intertester reliability for expert and novice clinicians was also excellent for the modified Thomas test (ICC = .98), external rotation (ICC = .95), and internal rotation (ICC = .92). Intratester and intertester standard error of measurement and minimal detectable change at 95% confidence interval values were similar for both testers and ranged from 1.9° to 3.6° and 5° to 10.1° and from 1.1° to 2.3° and 2.9° to 6.5°, respectively.

CONCLUSION

Smartphone-based goniometric measurements of hip range of motion have high intratester and intertester reliability for novice and expert clinicians. It may be a useful, simple, and inexpensive resource for clinicians.

Effect of releasing quadratus lumborum muscle on hip and knee muscle length in asymptomatic individuals

BACKGROUND

Quadratus lumborum muscle (QL) is one of several muscles subject to tightness and relevant to symptoms in the back and hip. Although releasing the tight QL seems to resolve these symptoms in clinic, no study has investigated the effects of such releasing on the length of the hip and knee muscles.

OBJECTIVE

To compare muscle length of the hip and knee joints between pre- and post-releasing the QL.

METHODS

A quasi-experimental design (one-group pretest-posttest design) was conducted. Thirty asymptomatic participants with mean age of 20.40 years took part in the study. An examiner assessed the participants' pelvic transverse gliding movement in standing and rotation of the upper trunk in supine to perceive the end feel of tissue resistance. The side with perceived more muscle tension was selected for receiving muscle release. Before manually releasing the QL, the participant was in the modified Thomas test position and pre-test range of motion (ROM) of hip flexion, hip abduction, and knee flexion angles was measured using a standard goniometer. After releasing the QL, the aforementioned angles were measured for post-test ROM.

RESULTS

The hip flexion angle was significantly reduced after releasing the QL (p < 0.05), whereas no statistically significant differences were found for the other 2 angles (p > 0.05).

CONCLUSION

The length of iliopsoas muscle was increased after releasing the QL. The findings may be due to continuous fascial connection and similar attachment of the origins of these 2 muscles.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03016559.

Translation, and interobserver and test-retest reliability of the Brazilian Portuguese version of Children's Hospital Oakland Hip Evaluation Scale for patients with sickle cell disease

BACKGROUND

The Children's Hospital Oakland Hip Evaluation Scale is a disease-specific tool for the clinical and functional assessment of the hip in sickle cell disease.

OBJECTIVES

To translate the tool into Brazilian Portuguese and evaluate the interobserver and test-retest reliability.

METHODS

Eighteen patients diagnosed with sickle cell disease and a mean age of 49±11.9 years participated in the study. The scale was applied by two evaluators who did not speak to each other regarding their understanding of the tool and who had no prior training. Interobserver and test-retest reliability of individual items and of the total score were evaluated using the intraclass correlation coefficient and the Bland-Altman method.

RESULTS

When the overall score for each hip was considered, the test-retest intraclass correlation coefficient score for the right hip was 0.95 (0.89-0.98) and for the left hip it was 0.96 (0.91-0.98). Considering all assignments (total score), the score was 0.96 (0.90-0.98). The test-retest intraclass correlation coefficient varied from 0.76 to 1 for 18 of the 27 items (excellent) and from 0.53 to 0.75 for nine items (moderate). When the overall score for each hip was considered, the interobserver intraclass correlation coefficient for both hips was 0.94 (0.86-0.98). Considering all assignments, the total score was 0.94 (0.86-0.98). The interobserver intraclass correlation coefficient varied from 0.48 to 0.75 for 18 out of 27 items (moderate) and varied from 0.77 to 1 for the remaining nine items (excellent).

CONCLUSION

The results demonstrate that the Brazilian version of the Children's Hospital Oakland Hip Evaluation Scale presented adequate interobserver and test-retest reliability and that the version can be used to evaluate clinical function in sickle cell disease patients, producing consistent, standardized and reproducible results.

CURRENT CONCEPTS AND TREATMENT OF PATELLOFEMORAL COMPRESSIVE ISSUES

Patellofemoral disorders, commonly encountered in sports and orthopedic rehabilitation settings, may result from dysfunction in patellofemoral joint compression. Osseous and soft tissue factors, as well as the mechanical interaction of the two, contribute to increased patellofemoral compression and pain. Treatment of patellofemoral compressive issues is based on identification of contributory impairments. Use of reliable tests and measures is essential in detecting impairments in hip flexor, quadriceps, iliotibial band, hamstrings, and gastrocnemius flexibility, as well as in joint mobility, myofascial restrictions, and proximal muscle weakness. Once relevant impairments are identified, a combination of manual techniques, instrument-assisted methods, and therapeutic exercises are used to address the impairments and promote functional improvements. The purpose of this clinical commentary is to describe the clinical presentation, contributory considerations, and interventions to address patellofemoral joint compressive issues.

The modified Thomas test is not a valid measure of hip extension unless pelvic tilt is controlled

The modified Thomas test was developed to assess the presence of hip flexion contracture and to measure hip extensibility. Despite its widespread use, to the authors’ knowledge, its criterion reference validity has not yet been investigated. The purpose of this study was to assess the criterion reference validity of the modified Thomas test for measuring peak hip extension angle and hip extension deficits, as defined by the hip not being able to extend to 0º, or neutral. Twenty-nine healthy college students (age = 22.00 ± 3.80 years; height = 1.71 ± 0.09 m; body mass = 70.00 ± 15.60 kg) were recruited for this study. Bland–Altman plots revealed poor validity for the modified Thomas test’s ability to measure hip extension, which could not be explained by differences in hip flexion ability alone. The modified Thomas test displayed a sensitivity of 31.82% (95% CI [13.86–54.87]) and a specificity of 57.14% (95% CI [18.41–90.10]) for testing hip extension deficits. It appears, however, that by controlling pelvic tilt, much of this variance can be accounted for (r = 0.98). When pelvic tilt is not controlled, the modified Thomas test displays poor criterion reference validity and, as per previous studies, poor reliability. However, when pelvic tilt is controlled, the modified Thomas test appears to be a valid test for evaluating peak hip extension angle.

USING THE SELECTIVE FUNCTIONAL MOVEMENT ASSESSMENT AND REGIONAL INTERDEPENDENCE THEORY TO GUIDE TREATMENT OF AN ATHLETE WITH BACK PAIN: A CASE REPORT

BACKGROUND

Despite the multidirectional quality of human movement, common measurement procedures used in physical therapy examination are often uni-planar and lack the ability to assess functional complexities involved in daily activities. Currently, there is no widely accepted, validated standard to assess movement quality. The Selective Functional Movement Assessment (SFMA) is one possible system to objectively assess complex functional movements. The purpose of this case report is to illustrate the application of the SFMA as a guide to the examination, evaluation, and management of a patient with non-specific low back pain (LBP).

CASE DESCRIPTION

An adolescent male athlete with LBP was evaluated using the SFMA. It was determined that the patient had mobility limitations remote to the site of pain (thoracic spine and hips) which therapists hypothesized were leading to compensatory hypermobility at the lumbar spine. Guided by the SFMA, initial interventions focused on local (lumbar) symptom management, progressing to remote mobility deficits, and then addressing the local stability deficit.

OUTCOMES

All movement patterns became functional/non-painful except the right upper extremity medial rotation-extension pattern. At discharge, the patient demonstrated increased soft tissue extensibility of hip musculature and joint mobility of the thoracic spine along with normalization of lumbopelvic motor control. Improvements in pain exceeded minimal clinically important differences, from 2-7/10 on a verbal analog scale at initial exam to 0-2/10 at discharge.

DISCUSSION

Developing and progressing a plan of care for an otherwise healthy and active adolescent with non-specific LBP can be challenging. Human movement is a collaborative effort of muscle groups that are interdependent; the use of a movement-based assessment model can help identify weak links affecting overall function. The SFMA helped guide therapists to dysfunctional movements not seen with more conventional examination procedures.

LEVEL OF EVIDENCE

Level 4.

Changes in hip flexor passive compliance do not account for improvement in vertical jump performance after hip flexor static stretching

To date, there is limited research investigating stretching of antagonist muscles and its effects on agonist muscle function. The purpose of this research was to investigate the effects of pre-static stretching (pre-SS) of the hip flexor musculature on passive hip extension range of motion (ROM) and vertical jump height. Fifteen subjects reported to the laboratory on 4 separate days (D1, D2, D3, and D4). D1 was for familiarization, while on D2 to D4, subjects randomly completed 1 of 3 intervention conditions; no stretch (CON), hip flexor stretch (HFS), or hip extensor stretch (HES). Subject's pre- and post-intervention hip extension ROM were measured before performing 3 sets of pre- and post-maximal counter-movement vertical jumps. Vertical jump height was normalized to baseline for data analysis. A repeated-measures ANOVA with post hoc paired sample t-tests revealed a significant increase in vertical jump height in the HFS condition (1.74% ± 0.73; p ≤ 0.05) when compared with CON (-1.34% ± 0.96) or HES (-1.74% ± 0.65) conditions. There was also a significant increase in hip extension ROM after the HFS stretching protocol (6.5 ± 2.75%; p ≤ 0.05) when compared with the CON protocol (-1.73 ± 3.26); however, no significant difference when compared with the HES protocol (1.84 ± 2.79). A correlation analysis showed that the relative hip laxity of each subject had no effect on response to either condition nor did the magnitude of hip ROM change predict improvement in vertical jump. These results suggest that performing SS of the hip flexors may enhance vertical jump performance independent of changes in passive compliance of the hip flexor muscular tendon unit.

EMG Analysis and Sagittal Plane Kinematics of the Two-Handed and Single-Handed Kettlebell Swing: A Descriptive Study

INTRODUCTION

Kettlebell (KB) swing exercises have been proposed as a possible method to improve hip and spinal motor control as well as improve power, strength, and endurance.

PURPOSE

To describe electromyographic (EMG) and sagittal plane kinematics during two KB exercises: the two-handed KB swing (THKS) and the single-handed KB swing (SHKS). In addition, the authors sought to investigate whether or not hip flexor length related to the muscular activity or the kinematics of the exercise.

METHODS

Twenty-three healthy college age subjects participated in this study. Demographic information and passive hip flexor length were recorded for each subject. A maximum voluntary isometric contraction (MVIC) of bilateral gluteus maximus (GMAX), gluteus medius (GMED), and biceps femoris (BF) muscles was recorded. EMG activity and sagittal plane video was recorded during both the THKS and SHKS in a randomized order. Normalized muscular activation of the three studied muscles was calculated from EMG data.

RESULTS

During both SHKS and THKS, the average percent of peak MVIC for GMAX was 75.02% ± 55.38, GMED 55.47% ± 26.33, and BF 78.95% ± 53.29. Comparisons of the mean time to peak activation (TTP) for each muscle showed that the biceps femoris was the first muscle to activate during the swings. Statistically significant (p < .05), moderately positive correlations (r = .483 and .417) were found between passive hip flexor length and % MVIC for the GMax during the SHKS and THKS, respectively.

CONCLUSIONS

The THKS and SHKS provide sufficient muscular recruitment for strengthening of all of the muscles explored. This is the first study to show significant correlations between passive hip flexor length and muscular activation of hip extensors, particularly the GMax. Finally, the BF consistently reached peak activity before the GMax and GMed during the SHKS.

LEVEL OF EVIDENCE

Level 3.

REHABILITATION AFTER HIP ARTHROSCOPY AND LABRAL REPAIR IN A HIGH SCHOOL FOOTBALL ATHLETE: A 3.6 YEAR FOLLOW-UP WITH INSIGHT INTO POTENTIAL RISK FACTORS

BACKGROUND

Hip arthroscopy is a common surgical technique for the correction of intraarticular pathology. While surgical success is often determined by anatomical correction, post-operative rehabilitation serves an essential role in restoring pre-morbid activity levels. A paucity of long-term post-operative rehabilitation outcomes exists in the literature lending uncertainty to the long-standing efficacy of interventions and associated risk for future injury.

CASE DESCRIPTION

This case report describes the progress of a male subject 3.6 years after left hip arthroscopy with labral repair. Detailed clinical measures and insight into potential risk factors are presented as a follow-up to a previously published case report.

OUTCOME

A 3.6-year follow-up assessment revealed potential risk factors that may have predisposed the subject to future pathology. The most profound finding was the subject's complaint of contralateral right hip pain and examination findings suggesting intraarticular pathology. His left surgical hip presented with no reported problems or significant findings. The examination also revealed an anterior tilted pelvis, muscle length deficits, and hip muscle weakness which may have contributed to his right hip pain or may be risk factors for future pathology in both hips. It appeared that these impairments affected his gait and performance on functional tests.

DISCUSSION

This case report describes the 3.6 year follow-up for a young adult male subject after unilateral left hip arthroscopy and acetabular labral repair. The re-examination findings and risk factors identified at the follow-up may provide insight into the need for long-term surveillance among post-surgical individuals. Detailed reporting of the long-term effects of a post-operative program after hip arthroscopy is non-existent in the literature and the current findings suggest the potential need for mitigating risk in the non-surgical hip. Future longitudinal studies are needed to develop a consensus on the best interventions for these patients.

LEVEL OF EVIDENCE

4-Case Report.

Repeatability and comparison of clinical tests in children with spastic diplegia and with typical development,

Objective The aims of this study were to evaluate the reliability of three range of motion tests (Straight Leg Raise, Modified Thomas, and Duncan-Ely) using photographic measurements in children with spastic diplegic cerebral palsy (SD) and with typical development (TD). Methods A cross-sectional test-retest design was applied to compare muscle-tendon unit shortening tests between groups. Results The tests showed reliability that ranged from good to excellent (ICC > 0.8), except for the Thomas Test for the bi-articular hip flexor muscle-tendon unit of the TD group (ICC = 0.7). Differences between groups were found in all tests (p < 0.05), except when the range of motion of the bi-articular hip flexor muscles was assessed using the Thomas test (p > 0.05). Conclusion Children with SD presents a smaller range of motion than the TD group. However, the Thomas Test for the bi-articular hip flexor muscles was unable to determine differences between children with spastic diplegic cerebral palsy from that with typical development.

Reliability of the modified Thomas test using a lumbo-plevic stabilization

[Purpose] The purpose of this study was to examine the test-retest reliability of the modified Thomas test using lumbo-pelvic stabilization. [Subjects] Thirteen subjects (male=10, female=3) with hip flexor tightness voluntarily participated in the study. [Methods] The participants underwent the modified Thomas test under three conditions: 1) the general modified Thomas test (GM), 2) active lumbo-pelvic stabilization (ALS), and 3) passive lumbo-pelvic stabilization (PLS). Intra-class correlation coefficients (ICC) were used to determine the test-retest reliability of the knee joint angle measurement under three conditions. The standard error of measurement (SEM) and minimal detectable difference (95% confidence interval) (MDD⁹⁵) were calculated for each measurement to assess absolute consistency. [Results] The ALS (ICC = 0.99) and PLS (ICC = 0.98) methods for the modified Thomas test were more reliable than GM method (ICC = 0.97). The MDD⁹⁵ score for the ALS method, 2.35 degrees, indicated that a real difference existed between two testing sessions compared with the scores for the PLS (3.70 degrees) and GM methods (4.17 degrees) [Conclusion] Lumbo-pelvic stabilization is one of the considerations for precise measurement and may help to minimize measurement error when evaluating hip flexor tightness using the modified Thomas test.

Reliability of goniometric and trigonometric techniques for measuring hip-extension range of motion using the modified Thomas test

CONTEXT

Goniometric assessment of hip-extension range of motion is a standard practice in clinical rehabilitation settings. A weakness of goniometric measures is that small errors in landmarking may result in substantial measurement error. A less commonly used protocol for measuring hip range of motion involves applying trigonometric principles to the length and vertical displacement of the upper part of the lower extremity to determine hip angle; however, the reliability of this measure has never been assessed using the modified Thomas test.

OBJECTIVE

To compare the intrarater and interrater reliability of goniometric (GON) and trigonometric (TRIG) techniques for assessing hip-extension range of motion during the modified Thomas test.

DESIGN

Controlled laboratory study.

SETTING

Institutional athletic therapy facility.

PATIENTS OR OTHER PARTICIPANTS

A total of 22 individuals (12 men, 10 women; age range, 18-36 years) with no pathologic knee or back conditions.

MAIN OUTCOME MEASURE(S)

Hip-extension range of motion of each participant during a modified Thomas test was assessed by 2 examiners with both GON and TRIG techniques in a randomly selected order on 2 separate days.

RESULTS

The intraclass correlation coefficient (ICC) revealed that the reliability of the GON technique was low for both the intrarater (ICC = 0.51, 0.54) and interrater (ICC = 0.30, 0.65) comparisons, but the reliability of the TRIG technique was high for both intrarater (ICC = 0.90, 0.95) and interrater (ICC = 0.91, 0.94) comparisons. Single-factorial repeated-measures analyses of variance revealed no mean differences in scoring within or between examiners for either measurement protocol, whereas a difference was observed when comparing the TRIG and GON tests due to the differences in procedures used to identify landmarks.

CONCLUSIONS

Using the TRIG technique to measure hip-extension range of motion during the modified Thomas test results in superior intrarater and interrater reliability when compared with the GON technique.

Immediate effects of hip mobilization on pain and baropodometric variables--a case report

Manual therapy is an important tool for the treatment of musculoskeletal disorders of mechanical origin. Since the hip is an important structure for weight bearing as well as static and dynamic balance, it is suggested that hip impairments may affect weight distribution. Both static and dynamic balance are dependent on adequate joint mobility which in the presence of any kind of alteration can lead to modifications of plantar pressure distribution patterns which, in turn, can be detected by computerized baropodometry. The aim of this study was to verify clinical and baropodometric immediate effects of a single session of hip mobilization in a patient with chronic anterior hip pain. A physically active 21-year old patient underwent a pre-intervention assessment which included pain rating, active and passive range of movement, passive accessory movement as well as static and dynamic barodometry. The intervention consisted of an anteroposterior grade III + mobilization of the right hip, which was conducted with patient in left side-lying with the right hip flexed at approximately 45°. After the intervention, the patient's pain was reduced and there was an improvement in the active movement related to the pain generation. Baropodometric assessment showed plantar peak pressures shift on both feet, from forefoot to rear foot, and there was also reduction in anteroposterior center of pressure displacement on static recording.

Concurrent validity of digital inclinometer and universal goniometer in assessing passive hip mobility in healthy subjects

BACKGROUND

Hip range of motion is an important component in assessing clinical orthopedic conditions of the hip, low back and lower extremities. However it remains unclear as to what constitutes the best tool for clinical measurement. The purpose of this study was to investigate the concurrent validity of passive range of motion (ROM) measurements of hip extension and hip internal and external rotation using a digital inclinometer and goniometer.

DESIGN

Criterion Standard.

SETTING

Clinical research laboratory.

PARTICIPANTS

30 healthy subjects without pain, radicular symptoms or history of surgery in the low back or hip regions.

MAIN OUTCOME MEASURES

Passive hip range of motion for extension, hip internal rotation and hip external rotation. A digital inclinometer and universal goniometer were utilized as the tools for comparisons between measurements.

RESULTS

There was a statistically significant difference (p < 0.05) between the goniometer and digital inclinometer in measured hip ROM except for measurements of right hip external rotation (p > 0.05). The mean difference between the goniometer and digital inclinometer in left hip extension, internal rotation and external rotation were 3.5°, 4.5° and 5.0° respectively. The mean difference between the two devices in right hip extension, internal rotation and external rotation were 2.8°, 4.2° and 2.6° respectively. On average, the difference between the goniometer and digital inclinometer in extension was 3.2°, internal rotation was 4.5° and external rotation was 3.8°. The digital inclinometer had greater measurement during EXT and ER. Furthermore, there was no statistically significant difference (p > 0.05) in hip ROM between the left and right side for either goniometric or digital inclinometer measurements.

CONCLUSIONS

This results of this study indicate that a significant difference exists between the two devices in all measurements with exception of right hip extension. The differences were noted to be between 3-5 degrees for all planes measured. These findings suggest that caution should be used if these two devices are to be used interchangeably to quantify passive hip range of motion in either clinical practice or when comparing studies that utilize different instruments.

LEVEL OF EVIDENCE

2b.