JOURNAL OF ATHLETIC TRAINING - Ability Group

Journal of Athletic Training S-1

JOURNAL OF ATHLETIC TRAININGOfficial Publication of the National Athletic Trainers’ Association, Inc Volume 48, Number 3, Supplement, 2013

INDEXES: Currently indexed in PubMed Central, Focus on Sports Science & Medicine (ISI: Institute for Scientific Information), Research Alert (ISI: Institute for ScientificInformation), Physical Education Index, SPORT Discus (SIRC: Sport Information Research Centre, Canada), CINAHL (Cumulative Index to Nursing & Allied HealthLiterature), AMED (The Allied and Alternative Medicine Database), PsycINFO (American Psychological Association), and EMBASE (Elsevier Science).The Journal of Athletic Training (ISSN 1062-6050) is published quarterly ($225 for 1-year subscription, $255 foreign) by The National Athletic Trainers’ Association, Inc,2952 Stemmons Freeway, Dallas, TX 75247. Periodicals postage paid at Dallas, TX, and at additional mailing offices.POSTMASTER: Send address changes to: Journal of Athletic Training c/o NATA, 2952 Stemmons Freeway, Dallas, TX 75247. CHANGE OF ADDRESS: Request foraddress change must be received 30 days prior to date of issue with which it is to take effect. Duplicate copies cannot be sent to replace those undelivered as a result of failureto send advance notice. ADVERTISING: Although advertising is screened, acceptance of the advertisement does not imply NATA endorsement of the product or the viewsexpressed. Rates available upon request. The views and opinions in the Journal of Athletic Training are those of the authors and not necessarily of The National AthleticTrainers’ Association, Inc. Copyright 2013 by The National Athletic Trainers’ Association, Inc. All rights reserved. Printed in the U.S.A.

NATA Foundation Board ofDirectorsMark Hoffman, PhD, ATCPresidentOregon State University

Michelle D. Boyd, MS, ATCTruman State University

Free Communications ReviewSubcommitteeJennifer E. Earl-Boehm, PhD, ATCVice ChairUniversity of Wisconsin, Milwaukee

Joseph M. Hart, III, PhD, ATCUniversity of Virginia

Lisa Jutte, PhD, ATC, LATXavior University

Thomas Kaminski, PhD, ATC, FACSMUniversity of Delaware

Stephanie Mazerolle, PhD, ATCUniversity of Connecticut

Melanie L. McGrath, PhD, ATCUniversity of Nebraska-Omaha

Sara Nottingham, EdD, ATCChapman University

Darin A. Padua, PhD, ATCUniversity of North Carolina,Chapel Hill

William Pitney, EdD, ATCNorthern Illinois University

Brian Ragan, PhD, ATCStudent Awards ChairOhio University

Stephen Straub, PhD, ATCQuinnipiac University

Charles A. Thigpen, PhD, ATC, PTProaxis Therapy

Kavin Tsang, PhD, ATCCalifornia State University, Fullerton

Susan Yeargin, PhD, ATCUniversity of South Carolina

NATA Foundation ResearchCommitteeDarin A. Padua, PhD, ATCChairUniversity of North Carolina,Chapel Hill

Jennifer E. Earl-Boehm, PhD, ATCVice Chair for Free CommunicationsUniversity of Wisconsin, Milwaukee

Brian G. Ragan, PhD, ATCVice Chair for AwardsOhio University

Troy BlackburnUniversity of North Carolina, ChapelHill

Steven P. Broglio, PhD, ATCUniversity of Michigan

Michael S. Ferrara, PhD, ATCUniversity of Georgia

Joseph M. Hart, III, PhD, ATCUniversity of Virginia

Tricia Hubbard, PhD, ATCUniversity of North Carolina,Charlotte

Lennart D. Johns, PhD, ATCQuinnipiac University

Kristen L. Kucera, PhD, ATCDuke University

Timothy A. McGuine, PhD, ATCUniversity of Wisconsin HealthSports Medicine Work Center

Robert T. Floyd, EdD, ATCUniversity of West Alabama

Craig Garrison, PhD, ATC, PTTexas Health Ben Hogan SportsMedicine

M. Susan Guyer, DPE, ATC, LATSpringfield College

MaryBeth Horodyski, EdD, ATCUniversity of Florida

Scott J. Johnson, MSED, ATC, LATOld Dominion University

Robert D. Kersey, PhD, ATCCalifornia State University–Fullerton

John Mayes, MS, ATC, LATCAEOS Project, Inc

David H. Perrin, PhD, ATCUniversity of North Carolina,Greensboro

Richard Ray, EdD, ATCHope College

Robb Rehberg, PhD, ATC, NREMTWilliam Paterson University

Valerie Rich Moody, PhD, ATC, LATUniversity of Montana

Clark Simpson, MBA, ATC, LATMiddletown, IN

Jeffrey Smith, MS, ATCUniversity of Massachusetts,Amherst

Walter “Kip” Smith, MEd, ATC, LATIndiana University

Timothy Speicher, PhD, ATCOgden, UT

Patti Tripp, PhD, ATC, LATUniversity of Florida

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S-2 Volume 48 • Number 3 (Supplement) May 2013

Take this Supplement to Las Vegas and use it as a guide to theFree Communications Sessions

Dear NATA Members and Friends:

We are pleased to present the annual Supplement to the Journal of Athletic Training. This Supplementcontains abstracts presented at the 2013 NATA Annual Meeting & Clinical Symposia in Las Vegas,Nevada as part of the NATA Foundation Free Communications Program.

The Free Communications Program provides certified athletic trainers, students and other healthcareproviders an opportunity to present and learn about the latest in athletic training research. Research ispresented in oral and poster formats and includes general research, NATA Foundation-fundedresearch, thematic posters, clinical case reports and our Student Exchange program posters. Abstractsof the research are printed here in the order of presentation at the NATA Annual Meeting in Las Vegasfor your convenience. Free Communications presentations represent a wide range of research andclinical interests. In addition, the Clinical Case Reports sessions allow you to test your clinicalassessment skills. We encourage you to attend these presentations.

We also urge you to attend the sessions featuring research funded by the NATA Foundation. The NATAFoundation funds research and a variety of educational programs, including summits on issues criticalto athletic training, as well as annual scholarships to undergraduate and graduate students of athletictraining.

Support from NATA members, corporations, and other affiliated groups make this supplement and allof our programs possible. Please note projects funded by the NATA Foundation and by the generouscontributions of our donors are specified in this Supplement. To make an investment in the future of theprofession, please contact us today at 800-TRY-NATA, extension 147.

NATA and the NATA Foundation are pleased to offer this supplement as a service to NATA members.We hope that it provides theoretical and practical information you can use to improve youreffectiveness as a certified athletic trainer. Thank you for your support!

Sincerely,

Mark A. Hoffman, PhD, ATC James Thornton, MA, ATCPresident, NATA Research & Education Foundation President, NATA

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Dear Colleagues:

On behalf of the National Athletic Trainers’ Association Research & Education Foundation and theFree Communications Sub-Committee, we would like to thank all the authors who submitted abstractsto the Free Communications Program. We are happy to report a record number of submissions againthis year with the total exceeding 500 Peer Reviewed and Student Exchange Track submissions,combined. We are excited about this year’s Free Communications Program as we believe it containsan exciting mix of both high caliber research reports and clinical case studies. Please keep in mindthat we consider oral and poster presentations to be equal in terms of caliber and encourage cliniciansand researchers to attend both oral and posters sessions.

We would also like to take this opportunity to extend a special thanks to the all of the NATAFoundation staff and especially Patsy Brown; and Rachael Oats, CAE whose attention to detail anddedication makes the Free Communications Program possible. Additionally, many individuals haveworked very hard to review submissions, schedule presentations, and produce this Supplement to theJournal of Athletic Training. Therefore, we would like to thank and recognize the efforts of the FreeCommunications Committee including: Joe Hart, PhD, ATC; Lisa Jutte, PhD, ATC; Tom Kaminski,EdD, ATC; Stephanie Mazerolle, PhD, ATC; Melanie McGrath, PhD, ATC; Sara Nottingham, EdD,ATC; Darin Padua, PhD, ATC; Brian Ragan, PhD, ATC; Stephen Straub, PhD, ATC; Charles Thigpen,PhD, ATC, PT; Kavin Tsang, PhD, ATC and Susan Walker-Yeargin, PhD, ATC for their long hours ofabstract reviews and preparation for the Free Communications programming. Lastly, we wish to thankLeslie Neistadt and the staff at the editorial office of the Journal of Athletic Training for making theSupplement possible.

As we move forward, we continually try to improve and make the review process more transparent.Our goal is to be as inclusive as possible while maintaining the high level of scholarship that readersexpect of the Journal of Athletic Training. We appreciate the feedback we have received fromauthors, and suggestions are always welcomed and discussed in committee meetings to furtherimprove the process.

We look forward to seeing you in Las Vegas. Please take the opportunity to attend the FreeCommunications evidenced-based forums, peer reviewed oral and poster sessions, and the studentexchange poster presentations. Please note that projects funded by the NATA Research & EducationFoundation are specified in this Supplement. Finally, if you have the opportunity, please offer yourthanks to those recognized above.

Sincerely,

Jennifer E. Earl-Boehm, PhD, ATC

Vice Chair for Free Communications,NATA Research & Education Foundation Research Committee

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JOURNAL OF ATHLETIC TRAININGOfficial Publication of the National Athletic Trainers’ Association, Inc Volume 48, Number 3, Supplement, 2013

Table of Contents Moderator Page

Free Communications: Palm BTuesday, June 25, 20138:00AM-9:15AM ........... Master’s Oral Student Award................................... Finalists ................................... Brian Ragan, PhD, ATC ........................................... S-11

9:30AM-10:45AM ......... Doctoral Oral Student Award................................... Finalists ................................... Brian Ragan, PhD, ATC .......................................... S-15

11:00AM-12:30PM ........ Thematic Poster: Hydration and................................... Cooling Interventions .............. Michelle Cleary, PhD, ATC ..................................... S-19

12:45PM-2:00PM .......... Thematic Poster: Clinical Assessment of Movement................................... Dysfunctions ........................... Anh-Dung Nguyen, PhD, ATC ................................ S-25

2:15PM-3:45PM ............ Thematic Poster: Factors that Influence................................... Concussion Assessment ........... Michael Ferrara, PhD, ATC .................................... S-30

Wednesday, June 26, 20138:00AM-9:00AM .......... Thematic Poster Spitfire: Neuromuscular and Biomechanical Consequences...................................of ACL Reconstruction.. ......... Grace Golden, PhD, ATC, CSCS ............................. S-36

9:15AM-10:15AM ........ Management of Osteochondral................................... Injuries ..................................... James Onate, PhD, ATC ......................................... S-42

10:30AM-11:30AM ..... Knee Evidence-Based Forum ..................................................................................... S-46

Thursday, June 27, 20138:00AM-9:00AM .......... Shoulder Evidence-Based Forum ............................................................................... S-479:15AM-10:30AM ........ Adaptations and Kinetic Chain.................................. in Pitchers ................................ Jeffrey Cooper, MS, ATC ........................................ S-48

11:45PM-12:45PM ....... Thematic Poster Spitfire: Emerging Technologies in.................................. Athletic Training ...................... Joseph Hart, PhD, ATC............................................ S-52

3:15PM-4:45PM ........... Thematic Poster: Socialization, Retention and................................. Work-Life Balance ................... Sara Nottingham, EdD, ATC, CSCS ........................ S-58

Free Communications: Palm CTuesday, June 25, 20138:00AM-9:00AM ......... Neuromuscular Characteristics of Dance.................................. and Warrior Populations ........... Jatin Ambegaonkar, PhD, ATC, OT ........................ S-64

9:15AM-10:15AM ....... Knowledge and Perception.................................. of Concussions .......................... Johna Register-Mihalik, PhD, ATC ......................... S-67

10:30AM-11:45PM ...... Various Approaches for Classroom................................. and Clinical Education ............... Jolene Henning, EdD, ATC, LAT ............................ S-70

12:00PM-1:00PM ........Education Evidence-Based Forum ............................................................................... S-741:15PM-2:30PM ..........Ankle Injury Epidemiology ....... Cathleen Brown-Crowell, PhD, ATC ....................... S-752:45PM-3:45PM ..........Ankle Evidence-Based Forum...................................................................................... S-79

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Moderator Page

Wednesday, June 26, 20138:00AM-8:45AM ......... Abdominal Conditions Case.................................Studies ...................................... Michael Milligan, MD, CAQSM ............................... S-80

9:15AM-10:15AM ....... Impact of Preseason on Exertional................................ Heat Illness ................................ Kristen Kucera, PhD, ATC ....................................... S-83

Thursday, June 27, 20138:00AM-9:15AM .........Kinesio Taping Across................................. the Spectrum ............................. Mark Merrick, PhD, ATC ........................................ S-87

9:30AM-10:30AM .......Risk Factors and Management of.................................Patellofemoral Pain ................... Megan Quinlevan, ATC ............................................ S-91

11:45AM-12:45PM ......Prospective Clinical Trials................................. in Athletic Training ................... Darin Padua, PhD, ATC ........................................... S-95

3:00PM-5:00PM ..........Concussion Education and.................................Policy ........................................ Tricia Kasamatsu, MA, ATC .................................... S-99

Free Communications: Palm DTuesday, June 25, 20138:00AM-9:15AM ......... Patient Related Outcome, Correlation to Clinical

.................... or Lab Measures ....................... Jennifer Earl-Boehm, PhD, ATC ........................... S-1059:30AM-10:45AM ....... Stumped: Differential Diagnosis in Athletic................................. Training .................................... Kate Pfile, PhD, ATC ............................................. S-109

11:00AM-11:45AM ..... Prehospital Care of the................................. Injured Athlete .......................... Julianne Schmidt, MA, ATC .................................... S-114

12:00PM-1:00PM ........ Spine Evidence-Based Forum ................................................................................... S-1171:15PM-2:30PM .......... Emergent Conditions in Athletes................................. (Case Study) ............................ Mark Hoffman, PhD, ATC ...................................... S-118

2:45PM-3:45PM .......... Assessment of the Throwing................................. Athlete ...................................... Steve Tucker, PhD, ATC ........................................ S-123

Wednesday, June 26, 20138:00AM-9:00AM ......... Manual Therapy ....................... Tricia Hubbard Turner, PhD, ATC ......................... S-1269:15AM-10:15AM ....... What Cryotherapy Cannot Do . Jennifer Ostrowski, PhD, ATC ............................... S-12910:30AM-11:30AM ..... Modalities Evidence-Based Forum ............................................................................ S-132

Thursday, June 27, 2013

8:00AM-9:00AM ......... Taping/Bracing/Orthotic................................. Interventions ............................ Mitchell Cordova, PhD, ATC ................................ S-132

12:00PM-12:45PM ...... Elbow Injury Case ................... Ned Bergert, ATC, PTA ........................................ S-1373:15pm-4:30pm ........ Non-Mechanical Factors Associated................................. with Injury ............................... Brian Pietrosimone, PhD, ATC ............................. S-140

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Editor-in-ChiefCraig R. Denegar,PhD, ATC, PT, FNATAUniversity of ConnecticutStorrs, CT

Editorial Staff

Managing EditorLeslie E. Neistadt, ELSSaint Louis UniversitySt Louis, MO

Editorial Assistant Erick Richman Columbus, GA

Business Office ManagerJohn Honaman, MBA, CFRENational AthleticTrainers’Association, IncDallas, TX

Page

Free Communications, Poster Presentations: Mandalay Bay South Convention Center

Wednesday, June 26, 2013, 10:00AM-5:00PM

Thursday, June 27, 2013, 10:00AM-5:00PM

Student Exchange Posters: Authors present 10:00AM-10:30AM

Authors A-L present 10:30AM-11:15AM, Authors M-Z present 11:15AM-12:00PM

Friday, June 28, 2013, 10:00AM-1:00PM

Undergraduate Poster Award Finalists .......................................................................................................... S-133Master Poster Award Finalists ...................................................................................................................... S-137Doctoral Poster Award Finalists .................................................................................................................... S-141Lower Extremity Neuromechanics ............................................................................................................... S-145Psychometrics .............................................................................................................................................. S-165Concussion ................................................................................................................................................... S-176Ankle Instability ............................................................................................................................................ S-195Lower Extremity Injury ................................................................................................................................ S-209Education ..................................................................................................................................................... S-223Therapeutic Intervention .............................................................................................................................. S-230Case Studies ................................................................................................................................................. S-250

Awards

The New Investigator Award ............................................................................................................................ S-7Freddie H. Fu, MD .......................................................................................................................................... S-8

The Doctoral Dissertation Award ..................................................................................................................... S-9David H. Perrin, PhD, ATC, FNATA, FACSM ...............................................................................................S-10

Index

Author Index ................................................................................................................................................ S-292

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The New Investigator AwardPresented in Honor of Freddie H. Fu, MD

Timothy Butterfield, PhD, ATCUniversity of Kentucky

When Tim Butterfield injured his knee herding cattle at a dairy farm in 1984, he could not have predicted he would one day have hisown laboratory, designing new equipment and methods to further athletic training research and practice. Like many athletic trainers,Butterfield only discovered the profession after his injury.

“I didn’t realize what sports medicine was,” he says, though he was no stranger to medicine of another sort. Butterfield grew up on adairy farm and worked for veterinarians since he was 12 years old. His career path changed when his injury led him to Pete Farrell,the head athletic trainer at Potsdam State. Eventually, Butterfield would take over that position from the retiring Farrell.

First, however, he had to change direction. Although he was nearly ready to graduate with his biology degree, he delayed graduationto meet the necessary undergraduate requirements to study athletic training as a graduate student. After 2 years of study and aninternship at Messiah College, he attended Old Dominion University for his master’s while serving as the head athletic trainer atVirginia Wesleyan College.

Butterfield was originally to be 1 of 2 athletic trainers at the school, but when the second person didn’t show, Marty Bradley, theathletic trainer at Old Dominion, told him to go at it alone. Butterfield sees it as the “best experience I could have gotten, to see whatbeing a head athletic trainer was like. I’ve always loved responsibility falling on my shoulders,” he remembers, “and being givenenough of a leash or rope to hang myself or do well.”

After working as the head football athletic trainer at Mansfield University for 5 years, he was offered the position that inspired him tostudy athletic training at Potsdam State. Not only did he return to his alma mater, but he also began teaching for the first time. “I likedthe opportunity to see a difference in students over time,” he says.

After 3 years at Potsdam, Butterfield moved to the University of Calgary to earn his doctorate and then to The Ohio State Universityto research and teach. There, he found himself specializing in muscle. “Muscle, unlike other tissues, is irritable and activatable,changes its function and form, and does many things we don’t understand to this day.”

Butterfield’s interest in muscle manifests in his research, which focuses on the effectiveness of massage. He saw many teams usingmassage therapy in the athletic training room of the 1996 Atlanta Olympics, despite little actual evidence justifying its use. “Whatwe’re doing now is finding that different loads, durations, frequencies all have a huge impact and difference on how the muscle cellsignals to stimulate inflammation, damage, and repair.”

He got another “long piece of rope to work with” when Carl Mattacola and Tim Uhl invited him to the University of Kentucky. Hewas given an empty space on the 4th floor, some start-up money, and free reign. “Five and a half years later, we’re still doing this,”he says. The lab has developed, among other projects, bottle nipples for testing premature infant tongue strength, noveldynamometers, massage devices, and speech therapy tools.

Currently, Butterfield is researching manipulation of the immune response after exercise and delaying atrophy though massage. “If wekeep finding novel data, we’ll keep writing the grants. I would like to get into some aging work, because we’re all getting older. Andthe more active we can stay, the more healthy we’ll be.”

In addition to Farrell and his family, Butterfield thanks Sandy Bush, ATC; Robert H. Shank, EdD, ATC, EMT-B; Marty Bradley,MS, ATC; Terry Zablocki, ATC, EMT; Scott Johnson, MA, ATC; Thomas Best, MD, PhD; and Walter Herzog, PhD.

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Dr. Freddie H. Fu, a longtime advocate of certified athletic trainers, is a well-respected physician whose work insports medicine has earned repeated honors.

The 1996 winner of the NATA President’s Challenge Award, Dr. Fu is the David Silver Professor of OrthopaedicSurgery and Chairman of the Department of Orthopedic Surgery at the University of Pittsburgh School of Medicine andUniversity of Pittsburgh Medical Center.

He has been the head team physician for the University of Pittsburgh Department of Athletics since 1986. He also wasinstrumental in establishing the Sports and Preventive Medicine Institute in 1985. Under his leadership, the facility –now called the UPMC Center for Sports Medicine – has grown into the region’s largest, most comprehensive sportsmedicine center, regarded among the best in the country.

Dr. Fu holds secondary appointments as Professor of Physical Therapy and Health, Physical and Recreation Education.He was awarded an honorary doctorate of science degree from Point Park University and an honorary doctorate ofpublic service from Chatham College.

Known worldwide for his pioneering surgical techniques to treat sports-related injuries to the knee and shoulder and hisextensive research in the biomechanics of such injuries, Dr. Fu performs surgery at UPMC and sees patients at theUPMC Center for Sports Medicine. He also directs the University of Pittsburgh’s Sports Medicine Fellows Society.

Dr. Fu is the editor of 26 major orthopedic textbooks and author of 75 book chapters on managing sports injuries. Hehas authored or co-authored 180 peer-reviewed articles and has given more than 600 national and internationalpresentations.

Former president of the Pennsylvania Orthopaedic Society, he is a member of 40 other professional and academicmedical organizations including the prestigious Herodicus Society. Currently he serves as Second Vice President ofthe International Society of Arthroscopy, Knee Surgery and Orthopedic Sports Medicine and will assume thepresidency of ISAKOS in 2009. He is also on the Board of the American Orthopaedic Society for Sports Medicineand the Orthopaedic Research and Education Foundation. Dr. Fu has served as chairman of the board and executivemedical director of the UPMC/City of Pittsburgh Marathon, company physician and board member for the PittsburghBallet Theatre, and team physician for Mt. Lebanon High School.

Freddie H. Fu, MD

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The Doctoral Dissertation AwardPresented in Honor ofDavid H. Perrin, PhD, ATCSponsored by Friends of Dr. Perrin

Dorice Hankemeier, PhD, ATCBall State University

Many high school students ignore their injuries until they’re forgotten, but a young Dorice Hankemeier askedherself, “why is this taking so long to get better?” Nearing the end of her time in high school, Hankemeier decided toseek more information to better understand her experience with injury and recovery. She graduated from CentralCollege (Pella, IA) in 1997 and then went on to earn a MSEd from Old Dominion University in 2003, practicing invarious clinical athletic training positions throughout. In 2008, she began her doctoral program at Old Dominiongraduating in 2011 with a cognate in curriculum and instruction.

Her research looks empirically at how athletic training students are being taught evidence-based practice and howthey are using those lessons. “We’re teaching our students these things, but,” she asks, “clinically, how are theyimplementing them?” Her dissertation follows the tiered, Scandinavian model, consisting of 3 parts. The first,“Approved Clinical Instructors’ Perspectives on Evidence-Based Practice Implementation Strategies for Students,”was published in the JAT in 2011. The second and third projects, “Perceptions of Approved Clinical Instructors:Barriers in the Implementation of Evidence-Based Practice” and “ Use of Evidence-Based Practice Among AthleticTraining Educators, Clinicians, and Students, Part 1: Perceived Importance, Knowledge, and Confidence” werepublished recently in JAT. “When I was an undergraduate student, I never would have thought about going on to pursuemy doctorate. I was really focused on the clinical aspect of athletic training, but as I progressed through my master’sdegree I became more interested in teaching and the educational component of athletic training.”

Currently teaching and researching at Ball State in Muncie, IN, Hankemeier continues to strive for more and recallsthat her “mentors saw in me that I could be successful in AT and always pushed me to get better.” Today, she is “alwayslooking for a new way of doing things and not just settling for where I was.” With her colleagues, Hankemeierreceived an NATA program grant to develop free, online evidence-based practice modules; 15 are now available to themembership on the NATA Web site. Hankemeier sees long-reaching effects of paired research and recommendations.“I think we’re just scratching the surface in some of the areas of outcomes assessment of athletic training programswhich will become even more critical as we continue to move athletic training education forward,” as will looking athow athletic trainers fit into the interprofessional team of health care.

“We need the data first,” she says, but predicts a need for “global assessment” of athletic training education that goesbeyond comparing BOCpassing rates. Although she hopes her research will help the athletic training professioncontinue to develop, she also strives to directly inspire her own students and “lead by example, not taking everythingat face value but encouraging students to become critical thinkers.”

Hankemeier thanks her undergraduate mentors John Roslien, ATC; Leslie Duinink, ATC; Pam Richards, EdD, forinstilling a passion for the profession and challenging her to reach higher; Bonnie Van Lunen, PhD, ATC, for being astrong professional mentor and continually pushing her to new heights and areas of interest; friends SarahManspeaker, PhD, ATC; Cailee McCarty, PhD, ATC; and Stacey Gaven, PhD, ATC, for being strong supporters of herresearch; and her parents, Marv and Sara Hankemeier, who instilled the value of education and showed her whatworking hard truly meant.

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David H. Perrin, PhD, ATC, FNATA, FACSM

David H. Perrin, PhD, ATC, is a respected researcher, educator, mentor and friend of athletic training. This 2003 NATAHall of Fame inductee is a noted pioneer of terminal degrees in sports medicine, and his dedication to athletic trainingis making an impact on the profession’s development even today.

Serving as editor-in-chief of the Journal of Athletic Training and founding editor of the Journal of Sport Rehabilitationare only two of Dr. Perrin’s significant achievements. Others include being awarded NATA’s Sayers “Bud” MillerDistinguished Educator Award in 1996, Most Distinguished Athletic Trainer Award in 1998, and All-UniversityOutstanding Teaching Awards from the University of Virginia in 1997 and 1998.

Dr. Perrin has built research education programs at the undergraduate, master’s, and doctoral levels and has fullydedicated himself to mentoring and developing future scholars. Dr. Perrin makes every effort to maximize his students’potential by offering sound advice and helping them make the most of their educational programs. Many of his studentshave gone on to bright careers in the profession, as researchers, program directors, clinical supervisors, and award-winning scholars.

Dr. Perrin continues to mentor students and serve as a leader in the profession. He is provost at University of NorthCarolina at Greensboro. He oversees five academic departments, nearly 75 faculty members and more than 1200students. The school’s Ph.D. program in the Department of Exercise and Sport Science has been recognized as one ofthe country’s best programs. Dr. Perrin remains involved in the profession by teaching a class and advising doctoralstudents who are certified athletic trainers. He also continues to write in athletic training and has recently publishedthree books.

The NATA Foundation Doctoral Dissertation Award, presented in honor of David H. Perrin, recognizes outstandingdoctoral student research and is a fitting tribute to a man who has dedicated the duration of his career to mentoring anddeveloping future scholars.

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Free Communications, Oral Presentations: Master’s Oral Student Award FinalistsTuesday, June 25, 2013, 8:00AM-9:15AM, Palm B; Moderator: Brian Ragan, PhD, ATC1 3 3 7 6 M O E M

Cold Shower As A TreatmentFor Exercise-InducedHyperthermiaBuening BJ, McDermott BP,Bonacci JB, Ganio MS, KavourasSA, Adams JD, Matthews A,Tucker MA: University ofArkansas, Fayetteville, AR

Context: Exertional heat illnesses arecommon in individuals exercising inthe heat. Exertional heat stroke,although not as common as heatexhaustion, is the most severe heatillness. Without rapid and effectivetreatment, exertional heat stroke canbe fatal. Clinicians sometimesstruggle with the feasibility ofaccessible cold-water immersion(CWI). Experts have recommendedthe use of a cold shower (CSH) whenCWI is not feasible. Objective:Evaluate the efficacy of whole-bodycooling when hyperthermicparticipants are cooled utilizingcontinual dousing with CSH. Design:Randomized, counter-balancedcontrolled study. Setting: Humanperformance laboratory (33.4 ± 0.9°C; 26.3 ± 3.2%RH). Patients orOther Participants: 17 participants(175.2 ± 6.9cm, 70.4 ± 8.7kg, agerange: 19-35yrs.) volunteered.Interventions: Participantsexercised volit ionally for amaximum of 90min in a controlledenvironment on 2 separateoccasions. Exercise mode, duration,intensity and fluid consumption werematched between trials. Followingexercise, participants receivedeither CSH (water temperature: 20.8± 0.80°C) while seated or sat in achair (CON) for 15min. All data wascollected in the sameenvironmentally controlled room.Main Outcome Variables: Rectaltemperature (T

re) and heart rate (HR)

were recorded every minute duringtreatment. Thirst and thermalperception, rating of perceivedexertion, and muscle pain sensation

were taken every 5min duringtreatment. Repeated measuresANOVAs were utilized to comparedifferences between trials. Bonferronicorrections were utilized whenappropriate. Alpha was set to d” 0.05.Results: T

re (CSH: 39.09 ± 0.25°C;

CON: 39.04 ± 0.38°C; P=.927) andHR (CSH: 174 ± 17bpm; CON: 173 ±19bpm; P=.967) were not differentthroughout exercise for CSH and CONtrials. Thirst (P=.600), thermal(P=.694), perceived exertion(P=.637) and muscle pain (P=.307)during exercise were similar betweentrials. Both T

re and HR significantly

decreased over time during rest,regardless of treatment (Pd”.001).However, decreases in T

re (P=.278)

and HR (P=.236) over time werenot significantly different betweenCSH and CON. However, overallcooling rate for CSH was0.069°C.min-1 (range: 0.02 –0.14°C.min-1) and was significantlyfaster than during CON (0.047 ±0.02°C.min-1; range: 0.013 –0.081°C.min-1; P=.031). Overall, HRdecreased to a greater extent duringCSH (45 ± 20bpm) compared to CON(27 ± 20bpm; P=.002). Thirst(P=.005) and thermal perception(P<.001) were reduced to a greaterextent with CSH compared to CONfollowing exercise. Conclusions: CSH,despite perceptual benefits, is notclinically supported for the treatmentof exercise-induced hyperthermia. Itcould take approximately 2-5 times aslong to cool a hyperthermic victim withCSH compared to previous CWI data.Clinicians should continue to utilizeCWI for exertional heat stroke, andshould make every effort to have thisavailable for the rapid treatment ofpatients when environmental conditionsincrease risk of heat illness.

1 3 2 6 8 M O D I

Validation Of The Ottawa AnkleRules For Acute Foot And AnkleInjuries Over TimeGray KA, Ragan BG, Starkey C:Ohio University, Athens, OH

Context: The original and ModifiedOttawa Ankle Rules (MOAR) weredeveloped as clinical decision rules(CDRs) for the emergency departmentsetting to determine the need forradiographs following foot or ankleinjury. However, these CDRs have notbeen validated as an immediate sport-related clinical evaluation tool.Objective: To test the validity of theMOAR when applied within 30 minfollowing sport-related injury. DesignCross-sectional. Setting: NCAA Iathletics, collegiate club sports, andhigh schools. Patients or OtherParticipants: Thirty-three datacollectors were ATs working withintercollegiate (n = 10), college clubsports (n = 2), and high school (n =21) populations. Data were collectedusing a standardized instrument. Datacollection occurred for 11 monthsduring 2011-2012. Interventions:Following the initial and/or re-examination of an acute foot or ankleinjury, the AT completed an inventoryidentifying the key MOAR diagnosticfindings and clinical diagnosis. Oncethe patient was cleared forparticipation, a definitive diagnosiswas made, or no further interventionwas required, the data collectorsubmitted the instruments to theresearch team. Main OutcomeMeasures: A 2x2 contingency tableidentified the number of true positive,true negative, false positive, and falsenegative findings. To assess the validitymeasures of diagnostic accuracy,positive predictive value (PPV),negative predictive value (NPV),sensitivity (Sn), specificity (Sp),positive likelihood ratio (LR+), andnegative likelihood ratio (LR-) werecalculated. Results: Eighty-four acute

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examinations were performed within30 min of the initial injury (mean timebetween the injury and examinationwas 6.0 ± 8.4 min). Thirty-three ofthe 84 (39.3%) examinations met theMOAR criteria, 5 (15.2%) werepositive for a fracture. No fractureswere reported in the 51 cases that didnot meet the MOAR referralrequirements. In all modelsexamined the Sn =1.0, NPV = 1.0,and the LR- was zero. The overall allaccuracy of the MOAR was .67, PPV= .15, Sp = .60, and LR+ = 2.86.Using only weight bearing statusyielded an accuracy to .56, PPV =.12, Sp = .53, and LR+ = 2.14.Examining only the palpationpredictor variables decreasedaccuracy to .35, PPV = .08, Sp = .30,and LR+ = 1.44. Conclusions:Negative findings on the MOARaccurately ruled out the need forradiographs, but positive findings arepoorly predictive of the presence ofa fracture. The pooled findings ofpalpation and weight-bearing statusare better predictors than palpationor weight-bearing status alone. Theabsence of false negative findingslends further validity to the MOAR.

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Anterior Cruciate LigamentReconstruction ParticipantsExhibit Deficits In QuadricepsStrength And Up-Regulation OfCorticospinal ExcitabilityClements AE, Lepley AS, EricksenHM, Sohn DH, Levine JW, GribblePA, Pietrosimone BG: Universityof Toledo, Toledo, OH

Context: Neuromuscular dysfunctionof the quadriceps is a hallmarkimpairment following anteriorcruciate ligament reconstruction(ACLr), which can include deficitsin quadriceps strength and activation,contributed to by alterations inneural excitability. It is thought thattraditional ACLr therapeuticexercise regimens will regainnormal function of spinal-reflexiveand corticospinal excitabili typathways, yet little is known abouthow these neuromuscular outcomesare affected years following ACLr.Knowing how neuromusculardeficits are affected will provideevidence essential to thedevelopment of improvedrehabilitation strategies for ACLr.Objective: Evaluate differences inquadriceps strength, activation,spinal-reflexive excitability andcorticospinal excitability betweenACLr individuals with high levels ofself-reported dysfunction andhealthy controls. Design: Case-control study. Setting: Researchlaboratory. Patients or OtherParticipants: Nine unilateral ACLrpatients (2M/7F, 21.1±2.2years;170.8±11.6cm, 74.6±20.7kg,48.1±29.6 months post-surgery)were compared to twenty-twohealthy controls (7M/15F, 23.0±4.0years; 171.1±8.3cm, 71.1± 11.9kg). All ACLr patients scored lessthan 85% on the International KneeDocumentation Committeequestionnaire (IKDC; 73.5±9.0).Interventions: Vastus medialisstrength, voluntary activation, spinal-reflexive excitabili ty and

corticospinal excitabili ty weretested in the injured limb of ACLrparticipants and in a randomlyassigned limb of healthy controls.Main Outcome Measures:Quadriceps strength was assessed viamaximal voluntary isometriccontractions (MVIC) performed at90° of knee flexion and normalizedto body mass. Quadriceps activationwas determined by using the centralactivation ratio (CAR) obtainedthrough the burst superimpositiontechnique. Quadriceps spinal-reflexexcitabili ty was assessed usingmaximal Hoffmann reflexesnormalized to maximal muscleresponses (H:M). Quadricepscorticospinal excitabili ty wasmeasured via motor evokedpotentials (MEP) elicited at 120%of active motor threshold andnormalized to maximal muscleresponses. Independent t-tests wereperformed to identify differencesbetween groups, and alpha was set apriori at P<0.05. Results: ACLrparticipants demonstrated signifi-cantly less strength (ACLr MVIC:2.32Nm/kg±0.72; Healthy MVIC:3.19Nm/kg±1.1; t

29 = -2.17, p=0.03)

and higher corticospinal excitability(ACLr MEP: 0.051±0.044; HealthyMEP: 0.023±0.01; t

29 = 2.65,

p=0.01) compared to healthycontrols. There were no differencesbetween groups in activation (ACLrCAR: 0.88±0.12; Healthy CAR:0.92±0.09; t

29 = -0.96, p=0.34) or

spinal-reflexive excitability (ACLrH:M: 0.24±0.16; Healthy H:M:0.20±0.11; t

29 = 0.85, p=0.39).

Conclusions: ACLr participantswith IKDC<85 had significantly lessstrength and higher corticospinalexcitability than healthy controls;however, they did not differ fromhealthy participants in quadricepsactivation or spinal-reflexiveexcitability. The up-regulation ofcorticospinal excitability in the ACLrgroup may be a post-injurymechanism to maximize quadriceps

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activation, explaining similaractivation levels between groups.However, corticospinal up-regulationalone may not be a sufficient strategyto develop or maintain quadricepsstrength. Further research shouldidentify what factors contribute todeficits in quadriceps strength, andwhich factors can be clinicallymodified to improve strength.

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Patient, Injury, And AssessmentCharacteristics Of Sport-Related Concussions At InitialEvaluation: A Report From TheAthletic Training Practice-BasedResearch NetworkKostishak N, Anderson B, LamKC, Valovich McLeod TC: A. T.Still University, Mesa, AZ

Context: Most studies describingconcussion assessment practices haveused self-report surveys and havereported wide variation in practices.Understanding real-time concussionassessment practices, through a reviewof medical records, can provide abetter understanding of the initialclinical presentation and subsequentmanagement of the injury. Objective:To describe the patient, injury, andassessment characteristics of sport-related concussion at initial evaluation.Design: A retrospective analysis ofelectronic medical records (EMR).Setting: Athletic Training Practice-Based Research Network (AT-PBRN).Patients or Other Participants: 623patients (392 male, 231 female,age=17.0±1.8 years) diagnosed with aconcussion by an athletic trainer (AT).Interventions: Patient records from57 AT-PBRN clinical practice sitesbetween October 2009-October 2012were reviewed. All records werecompleted by an AT utilizing a web-based EMR. Concussed patients wereidentified by concussion-specificdiagnostic codes (ICD-9: 850.0,850.5, 850.9). Main OutcomeMeasures: Frequencies anddescriptive statistics were utilized todescribe patient (sex, sport, age),injury (time of injury, mechanism ofinjury, initial treatment plan, loss ofconsciousness, presence of amnesiaand the assessment of cranial nervefunction, coordination, range ofmotion, and strength) and assessment(% of initial evaluation componentscompleted by ATs) characteristics.Results: Generic injury demographicforms were completed for 623

concussions, with football accountingfor 49.6% (n=309). Most occurredduring an in-season game (49.4%,n=308) or practice (32.1%, n=200)and the primary mechanism of injurywas contact (84.1%, n=524). Theinitial treatment plan included AT-initiated treatment (41.7%, n=260)and referral to the emergencydepartment (5.0%, n=31), teamphysician (7.4%, n=46), familyphysician (13.2%, n=82), and forimaging (1.3%, n=8). A concussion-specific evaluation form wascompleted for 60.4% (n=376) ofcases. Loss of consciousness wasnoted in 4.0% (n=25), post-traumaticamnesia in 8.3% (n=52), retrogradeamnesia in 6.6% (n=41), and aphasiain 1.4% (n=9) of cases. Pupillary size(93.4%, n=351), response (93.9%,n=353), and movement (88.6%,n=333) were normal in most patients.Coordination was also normal in mostpatients, whether tested by the heel-to-knee (31.6%, n=119), finger-to-nose (66.0%, n=248) or Romberg(44.9%, n=168) test. Individual cranialnerves were normal in 85.9-90.7%(n=323-341) of cases. With respect toassessment practices, ATs did notassess pulse (75.3%, n=283), bloodpressure (100%, n=376), coordination(26.3-64.6%, n=99-243), cranialnerves (8.5%, n=32), range of motion(9.3%, n=35), or strength (17.1%,n=64) for the indicated percentage ofcases. Conclusions: As expected,many of the clinical tests performedduring an initial concussion evaluationwere normal, ruling out an intracranialinjury. Appropriate documentation waslacking, evident by the difference in thenumber of concussions identifiedcompared to completed evaluationforms. Furthermore, vitals,coordination, and cranial nerves werenot tested at initial evaluation, whichdisregards best practices. Cliniciansshould improve documentation ofconcussion assessment to ensure bestpractices and liability protection.

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Oculomotor Function InCollegiate Student-AthletesWith A Previous History OfSport-Related ConcussionBraun PA, Kaminski TW, SwanikCB, Knight CA: University ofDelaware, Newark, DE

Context: Current clinical tools thatdiagnose and assess concussedathletes do not include a componentfor measuring oculomotor function.Researchers in optometry andneurology have shown that eyemovement deficits in subjects with ahistory of acquired brain injury exist,but these measurements have not beenimplemented utilizing an athleticpopulation, or a population with ahistory of sport-related concussion.Objective: The purpose of this studywas to determine if sport-relatedconcussion creates lasting deficits inoculomotor function and learning, asmeasured by the King-Devick (KD)Test. Design: Quasi-experimental, expost facto. Setting: Athletic trainingresearch laboratory. Patients orOther Participants: Conveniencesampling was utilized to evaluateoculomotor function in one hundredseventy NCAA Division-I collegiateathletes. Seventy-three (40 males,33 females, age=19.7±1.3 yrs. ,height= 177.4±10.6 cm, mass=79.0±17.2 kg) had a previous historyof sport-related concussion (meannumber of concussions =1.5±1.3,mean recovery time=8.6±12.9 days,time since most recentconcussion=28.7±28.0 months). Theremaining participants (45 males, 52females, age=19.7± 1.3 yrs. ,height=175.6±10.2 cm, mass=77.1±16.3 kg) had no previoushistory of head injury.Interventions: Objective measure-ments were obtained through the useof the KD Test which assesses thespeed of rapid number naming tocapture impairments in eyemovement and is becoming a widelyaccepted tool for rapid sideline

concussion screening. The testinvolves 3 separate cards each witha different series of numbers. Inorder to effectively study learningeffects, a total of two test trials werecompleted. Main OutcomeMeasures: The total time (seconds)to complete the KD Test (all 3 cards)was compared between groups(control vs. experimental). Theindependent variable was theparticipants’ history of concussion.The improvement time (learningeffect) was also evaluated betweenthe first and second trials acrossgroups. Separate ANOVAs were usedto compare means between the twogroups for both total t ime andimprovement time. Results: Nosignificant differences existedbetween groups for oculomotorfunction (F

1,168=0.870, p=0.352) or

learning effect (F1,166

=0.253,p=0.615). The control grouprevealed a mean completion time of38.21±6.17s as compared to theexperimental group mean time of39.12±6.48s. Results from learningeffect scores were very similar aswell. The experimental group with noprevious history of concussionposted a mean improvement time of2.48±2.87s, while the previouslyconcussed group had a meanimprovement of 2.68±2.12s.Conclusions: The oculomotor nervecan be damaged following sport-relatedconcussion, especially with rotationalimpacts. Evidence from this studyhowever, suggests that no long-termdeficits in oculomotor function orlearning exist in the collegiate student-athlete population who has sustainedconcussions. These findings help tostrengthen the current concussiondefinition with regard to the transientnature of the associated symptoms.Additional research involving acutelyconcussed athletes studied along acontinuum of recovery is warranted.

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Free Communications, Oral Presentations: Doctoral Oral Student Award FinalistsTuesday, June 25, 2013, 9:30AM-10:45AM, Palm B; Moderator: Brian Ragan, PhD, ATC1 3 F 1 0 D O B I

Predictors Of Frontal PlaneKnee Kinematics During ASingle-Leg Squat Task InFemales With PatellofemoralPainGoto S, Padua DA: SportsMedicine Research Laboratory,University of North Carolina,Chapel Hill, NC

Context: Decreased gluteal and thighmuscle strength has been suggested tocontribute to altered frontal plane kneekinematics in individuals withpatellofemoral pain (PFP).Strengthening of these muscles isoften a component of PFPrehabilitation programs. However,there is little research investigating theassociation between gluteal and thighmuscle strength with frontal plane kneekinematics in those with PFP.Objective: To examine theassociation between frontal plane kneekinematics and strength of the glutealand knee extensor musculature inthose with PFP. Design: Cross-sectional regression. Setting:Research laboratory. Patients or OtherParticipants: Sixteen females withPFP participated in this study(Age=25.3±6.1 years; Height=164.5±8.5cm; Mass=61.4±11.1Kg).Participants with PFP had at least twomonths of anterior, lateral or retropatellar pain during walking, running,stair ascent or descent, squatting, and/or sitting for an extended period oftime, no other lower extremity injurieswithin six months prior to the testing,and negative findings on examinationof ligaments and menisci.Interventions: Knee abduction anglewas assessed using a seven-camerainfrared optical motion capture systemwhile participants performed threeseparate single-leg squat (SLS) tasksat a standardized speed. Three separatemaximum voluntary isometriccontraction (MVIC) trials during hipabduction (HAB

MVIC), hip extension

(HEXTMVIC

), hip external rotation

(HERMVIC

), hip adduction, and kneeextension (KEXT

MVIC) were assessed

using a hand-held dynamometer. MainOutcome Measures: Knee abduction(KAB) angle at the time of maximalknee flexion was averaged across threeseparate SLS trials. Peak values wereaveraged across three trials for eachMVIC measure. Separate Pearsonproduct moment correlations wereperformed to identify the associationbetween KAB angle and each MVICmeasure. A backward stepwise multipleregression analysis was performedusing those MVIC variablessignificantly associated with KAB todetermine the association between theKAB angle and MVIC variables( ˜<0 .05) . Results: We observedsignificant correlations between KABangle with HAB

MVIC (r=0.56, p=0.029),

and HERMVIC

(r=0.548, p=0.034), anda trend correlations with HEXT

MVIC

(r=0.457, p=0.087). Regressionanalysis revealed that both HAB

MVIC

and HERMVIC

were predictive of KABangle during the SLS in those with PFP(R2=0.44, p=0.032). Conclusion:Based on these findings, the combinationof HAB

MVIC and HER

MVIC predicted

nearly half of the variability in KAB angleduring the SLS in individuals with PFP.However, neither HEXT

MVIC nor

KEXTMVIC

were associated with KAB.Less HAB

MVIC and

HER

MVIC are associated

with greater KAB angle. Increased KABhas been suggested to increase contactpressure at the patellofemoral joint,which leads to cause pain. These findingssuggest that exercises focused onimproving HAB

MVIC and HER

MVIC may be

effective for decreasing KAB duringfunctional tasks in PFP patients.

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The Effects Of Two AnkleDestabilization Devices OnElectromyography MeasuresDuring Walking In Patients WithChronic Ankle InstabilityDonovan L, Hart JM, Hertel J:University of Virginia,Charlottesville, VA

Context: Individuals with chronicankle instability (CAI) have been shownto have deficits in neuromuscularcontrol and altered gait patterns. Ankledestabilization devices may improveneuromuscular control by increasinglower extremity muscle activation,which may improve ankle stability.Objective: To compare EMGactivation of lower extremity musclesduring walking gait while wearing 2different ankle destabilization devices.Design: Crossover. Setting:Laboratory. Patients or OtherParticipants: Fifteen young adultswith CAI (height=173±11cmmass=72±14kg age=23±4 sex=M:5F:10) participated. Intervention(s):Surface EMG electrodes were placedover the anterior tibialis (AT),peroneus longus (PL), and lateralgastrocnemius (LG). Subjects walkedshod, with an ankle destabilizationdevice (ADD), and an ankledestabilization sandal (ADS) in randomorder. The protocol consisted of 30seconds of treadmill walking at 4.83km/h during each condition. Stancetime was determined with footswitches. Main Outcome Measures:Normalized amplitudes (100ms pre-and 200ms post-initial contact) andtime of onset activation relative toinitial contact were analyzed for 9steps. Muscle activation wasdetermined for each muscle if theamplitude was 10 SD over the meanamplitude during quiet standing. Anegative value for time of onsetrepresents muscle activation prior toinitial contact. Percent of activationwas calculated as the proportion of thetotal time across the stride cycle that

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the amplitude was greater than thepreviously described threshold. Eachdependent variable was comparedusing a repeated measures ANOVA andpost-hoc t-tests as appropriate. Thelevel of significance was set a prioriat Pd”0.05. Results: The pre-contactamplitudes of the PL and LG weresignificantly greater in the ADD (PL0.34±0.18, p=0.003; LG 0.22±0.15p=0.003) and ADS (PL 0.30±0.11,p=0.003; LG: 0.18±0.15, p=0.028)conditions when compared to shod(PL 0.20±0.10; LG 0.09±0.05). Thepost-contact amplitude of the AT wassignificantly lower in the ADD(2.17±1.95, p=0.031) and the ADS(2.24±2.14, p=0.015) conditionswhen compared to shod (3.02±2.92).The post-contact amplitude of the PLwas significantly greater in the ADD(1.62±0.97, p=0.001) and the ADS(1.33±0.64, p<0.001) conditionswhen compared to shod (0.76±0.37).The AT was activated significantlylater in the ADD (-0.23±0.13ms,p=0.003) and the ADS (-0.30±0.14ms, p=0.009) conditionswhen compared to shod (-0.36±0.17ms). The AT, PL and LGwere activated significantly longeracross the stride cycle in the ADD(AT 61.1±30.3%, p<0.028; PL48.8±11.9%, p=0.001; LG 31.4±17.4%, p=0.05) condition, but onlythe AT and PL were higher in the ADS(AT 60.9±28.8%, p=0.001; PL44.4±12.7%, p=0.005) conditionwhen compared to shod (AT53.1±26.7%; PL 36.0±10.3%; LG21.1±12.2%). Conclusions: Bothankle destabilization devices causedsubstantial alterations in muscleactivity during walking. Thedestabilization devices may beuseful adjuncts for use inrehabilitation programs for CAI.

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Instrumented AnteriorMobilization Of The AnkleJoint Increases ContralateralSomatosensory CortexActivation In Healthy SubjectsNeedle AR, Baumeister J,Schubert M, Reinecke K,Higginson JS, Swanik CB:University of Delaware, Newark,DE, and University of Paderborn,Paderborn, Germany

Context: Ankle joint loading and jointmobilization have been demonstratedto affect the nervous system at multiplelevels, resulting in increased jointsensation and tied closely to themagnitude of motor responses.Whi le p rev ious research hasquantified changes in peripheralafferent traffic as well as reflexivemotor activity, it remains unknownwhether activation can be measuredin the somatosensory cor texduring joint loading. This datawould provide ini t ia l evidenceregarding how sensory integrationof joint loading is occurring in thecentral nervous system, even atminimal force levels such as thoseprovided during joint mobilization.Objective: To investigate the effectof anterior joint mobilizations atthe ankle joint on contralateralsomatosensory cortex activity usingelectroencephalography (EEG).Design: Single group post-test only.Setting: University laboratory.Patients or Other Participants:Nine subjects (2 male, 7 female,21.0±2.6yrs, 165.0±9.0cm, 62.2± 13.2kg) with no history of injuryto the ankle joint participated inthis study. All subjects were rightleg dominant . Intervent ions:Subjects were fitted with an EEGcap fo l lowing in te rna t iona lstandards ( impedance<5k˜) andask to lay supine on a treatmenttab le as a modi f ied anklearthrometer was used to load theankle from -30N to 125N. A totalof 50 trials were performed on thedominant l eg , wi th 5 seconds

be tween each t r i a l . Da ta wasco l lec ted a t 1000Hz. MainOutcome Measures: Event -related desynchronization (ERD,%) in upper Alpha Frequency (10-12Hz) was used to detect changesin maximal ERD amplitude from aperiod of baseline (BASE, -2000 to-1000 ms prior to loading), andthe f i r s t 2000ms of loadapplication (LOAD1=0 to 1000ms;LOAD2=1000 to 2000ms) for theCP3 e lec t rode pos i t ion , whichrepresents the contralateralsomatosensory area of the cortex.Bonferroni corrected T-tests wereused to compare ERD changesbetween BASE, LOAD1 and LOAD2conditions. Results: Ankle loadcauses a significant increase inERD in the contralateral hemispherefrom BASE (0.6±0.7%) to LOAD1(36.8 ±16.6%, p<0.0001) as well asfrom BASE to LOAD2 (LOAD2=33.4±15.2%, p<0.0001). Nosignif icant difference could bedemons t ra ted be tween LOADcondi t ions . Conclus ions:Anterior joint mobilization at theankle increases upper Alpha ERDduring the first 2000ms of jointloading and suggests an activationof the con t ra la te ra l somato-sensory cor tex whi le load i sapplied. This data is the first tode tec t a l t e ra t ions in cor t i ca lac t iv i ty dur ing in -v ivo jo in tloading, and lends support to asignificant role of the brain duringankle joint mobilizations, even atre la t ive ly smal l loads . Th isapproach cou ld improve ourunders tanding of sensory in te-gration that must occur betweenthe sensation of injurious loadsand the formation of a reflexiveresponse. Future invest igat ionsusing this methodology may targethow somatosensory cor texac t iva t ion i s a f fec ted amongpathologic populations, and acrossvar ious t rea tments .

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Long-Term Upper ExtremityMotor Performance FollowingConcussion: A PreliminaryInvestigationMartini DN, Scott SM, WeindorfJH, Hudson SR, Broglio SP:Neurotrauma ResearchLaboratory, University ofMichigan, Ann Arbor, MI

Context: Sport related concussion hashistorically been viewed as a transientinjury void of long term consequences.Emerging evidence however, suggestschanges to gait and balance can persistyears after symptoms resolution.Investigations into upper extremitymotor performance have not beenconducted. Objective: The purposeof this investigation is to evaluate fordifferences in upper extremity motorperformance between previouslyconcussed and unconcussed youngadults. We hypothesize that thepreviously concussed participants willdemonstrate impaired motorperformance. Design: Cross-sectional study design. Setting:Research laboratory. Patients orOther Participants: A total of 27young adults (20.6yrs, 71.6kg,174.3cm) with (n=14; 20.1yrs, 72.3kg,174.5cm, 2.0 concussions, 3.1yearsprior) and without (n=13; 21.1yrs,70.7kg, 174.1cm) a history ofdiagnosed concussions volunteeredfor this investigation. Interventions:Each participant completed a single, 15minute evaluation of upper extremitymotor performance on the ULTrABoard. The evaluation consisted ofunilateral and bilateral responses tolighted targets in the vertical andhorizontal planes. Main OutcomeMeasures: The primary variablesevaluated were average time betweentargets on all conditions; average timesbetween horizontal targets for the rightand left hands; average times betweenhorizontal and vertical targets for theright and left hands. The averageresponse times between targets werecompared using independent samples

t-tests and Cohen’s d was calculated asa measure of effect size. Significancewas noted when p<0.05. Results:Significantly slower responses(concussed vs controls) to the lightedtargets were recorded by those with aprevious concussion for the averagetime between targets on all conditions(0.71s+0.10 vs 0.63s+0.09, d=0.79,p=0.05) and the average time betweenhorizontal targets for the left hand(0.60s+0.04 vs 0.54s+0.07, d=0.91,p=0.03). Non-significant differenceswith large effects sizes were seen forthe average time between horizontaltargets for the right hand (0.62s+0.08vs 0.58s+0.05, d=.63, p=0.11) andaverage times between horizontal andvertical targets for the right hand(0.76s+0.06 vs 0.71s+0.08, d=0.74,p=0.07) and left hand (0.74s+0.05 vs0.70s+0.08, d=0.68, p=0.09).Conclusions: These data are the firstto demonstrate long-term changes tomotor performance in the upperextremity in those with a concussionhistory. These findings parallelprevious work indicating lowerextremity deficits in a similar cohort.How these deficits may manifest inlater life is not clear, but the deficitsto recognition and response to thelighted targets may have implicationsto sport performance. This projectwas funded by the RackhamGraduate School and the NationalAthletic Trainers’ Association –Research and Education Foundation

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Effects Of Exercise OnMeasures Of Cerebral BloodFlow Integrity Using The BrainAcoustic Monitor In HealthyIndividualsAcocello S, Broshek D, Cooke A,Saliba S: University of Virginia;Charlottesville, VA, and ActiveSignal Technologies, Inc,Baltimore, MD

Context: Standard assessment ofconcussion does not currently includemeasurements of physiologicaldeficits, such as cerebral blood flow,immediately post-injury. A new device,the Brain Acoustic Monitor (BAM), ispurported to detect cerebral bloodflow changes that occur after mildtraumatic brain injury through theamplification and comparison of soundwaves created by cerebral arteries anda reference artery in a peripheral limb.Were clinicians to begin using thisdevice in an athletic population as anassessment tool immediatelyfollowing injury, it is necessary toexamine what effect exercise has onthe stability of BAM measures.Objective: To determine the effect ofexercise on outcomes associated withthe Brain Acoustic Monitor. Design:Repeated-measures pretest-posttest.Setting: Laboratory. Participants:20 healthy, recreationally activeindividuals (10 males and 10 females;age: 23.4±4.3years, height:173.4±10.9cm, mass: 69.1±14.2kg)volunteered. Interventions: Ten 10-second BAM measurements wereobtained every 15 minutes for one hourprior to and following (T1=immediate, T2 = 15min post; T3 =30min post; T4 = 45min post, T5 =60min post) completion of a 20minute treadmill program. Thetreadmill program consisted of a 5minute warm-up period and 15 minutesof sustained submaximal exercise.Subjects were asked to maintain a pacethat would equate to a Borg Rating ofPerceived Exertion of 14 out of 20.Speed was manipulated by the subject

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to maintain this level of exertion.Main Outcome Measures: Theoutcome measures associated withthe Brain Acoustic Monitor are leftbrain (LB) and right brain (RB) ratioand divergence (measured involtage). Ratio is a measure of thepositive to negative acoustic signaldeflection given by the cerebralarteries. Divergence is thedifference in component frequenciesbetween the brain signal and theperipheral arterial reference. Thethree best measures taken at the timepoint immediately prior to exerciseand at each time interval following(T1, T2, T3, T4, T5) were averagedand analyzed using a 4 separate 6-factor ANOVAs. Results: Pretestmeasures (3.75 ± 0.89V) of LB ratiowere significantly greater than thoseobtained at T1 (2.74 ± 0.64V; t=3.65,p=0.002), T2 (3.03 ± 0.61V; t=2.52,p=0.021), and T3 (3.17 ± 0.60V;t=2.37, p=0.03). No other t imepoints were significantly differentfor LB Ratio, RB Ratio (F

(5,15)=2.25,

p=0.103), LB Divergence(F

(5,15)=1.65, p=0.208), or RB

Divergence (F(5,15)

=0.609, p=0.70).Conclus ions : These resu l t sindicate that minimal alteration inBAM measures of cerebral bloodflow occurs following 20 minutesof aerobic exercise. Some changein LB ra t io was seen bu t th i schange was not found in RB ratiomeasures. This suggests that duringclinical use, a 30 to 45 minutewaiting period may be indicatedbefore accurate measurements ofcerebral blood flow integrity canbe ob ta ined us ing the BAM.

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Free Communications, Thematic Poster Presentations: Hydration and CoolingInterventionsTuesday, June 25, 2013, 11:00AM-12:30AM, Palm B; Moderator: Michelle Cleary, PhD, ATC1 3 2 4 5 S O E X

Influence Of Cold WaterImmersion On Recovery OfElite Triathletes In TheIronman World ChampionshipsStearns RL, Casa DJ, DeMartiniJK, Huggins RA, Munõz CX,Pagnotta KD, Volk BM, KupchakBR, Maresh CM: Korey StringerInstitute, Department ofKinesiology, University ofConnecticut, Storrs, CT

Context: Ironman Triathlons imposeintense physiological stresses. Cold-water immersion has been debated toimprove recovery, however, no studyhas examined its effect following anIronman. Objective: Examine theimpact of cold-water immersion onrecovery following an IronmanTriathlon. Design: Observational fieldstudy. Setting: 2011 Ironman WorldChampionships in Kona, Hawaii(28.9°C, 71% relative humidity).Patients or Other Participants: 33subjects (n=22 males, 11 females)entered in the Ironman WorldChampionships (Mean±SD: age=40±11y; height=174.5±9.1cm;percent body fat=11.4±4.1%). Inter-ventions: Ten minutes of cold-waterimmersion to the sternal notch(10.4±0.2°C) immediately upon racefinish. Subjects were randomized postrace into a control group (CON) orintervention group (CWI). Datacollection occurred prior to (PRE),immediately post (POST), 16 hours(16h) and 40 hours (40h) post race.Main Outcome Measures: Myo-globin (MYO), creatine kinase (CK),interleukin-6 (IL6), cortisol (CORT),C-reactive protein (CRP) and delayedonset muscle soreness (DOMS). Atwo-way mixed model ANOVAexamined differences across time andbetween groups. Pearson’s bivariatecorrelations compared finishing timeand percent of time spent during bike(%B) and run (%R) sections. Alpha

level was set a priori at 0.05. Hedges’g effect sizes were calculated.Results: CWI group (n=12;height=175.8±6.4cm; percent bodyfat=11.3±4.7%; finish time(hr:min)=10:30±00:50h) was similar(p>0.05) to CON (n=21; height=173.5±8.4cm; percent bodyfat=11.5±4.4%; finish time=11:21±1:33h) except for age(CWI=34±11y vs CON=43±10y;p=0.020). There was no significantdifference between CWI and CON forany variable across time (CK, MYO,IL6, CORT, CRP, DOMS). However, anoverall effect of time occurred for allvariables. CK, MYO, CRP, and DOMSwere significantly elevated POST( 6 3 7 ± 2 9 8 I U / L ( p < 0 . 0 0 1 ) ,43±15nmol/L (p<0.001), 24.76±15.24nmol/L (p=0.025), 76.8±13.3mm (p<0.001), respectively) andremained elevated through 40h(706±559IU/L (p<0.001), 4±4nmol/L(p=0.016), 2.34±1.16mg/dL 222.86±110.48nmol/L (p<0.001), 63.2±24.8mm (p<0.001), respectively). IL6significantly increased POST0.67±0.18pg/dl; (p<0.001) however,returned to similar PRE values at 40h(0.004±0.003pg/dL). CORT wassignificantly elevated at POST(3461±658nmol/L; (p<0.001).Moderate effect sizes occurred forMYO at 16h (0.40), while small effectsizes occurred at POST for CORT (-0.29), CK (0.28), and IL6 (-0.30). IL6was correlated with finish time at 16h(r=0.378, p=0.30) and %B (r=0.454,p=0.008) at POST. %R was correlatedwith CK at 16h (r=0.349, p-0.047) and40h (r=0.365, p=0.37). Conclusions:The Ironman resulted in significantlyelevated muscle damage andinflammatory markers. No effect ofCWI vs CON was observed within theexamined time frame. However,indices for muscle damage and DOMSremained elevated through the 40htime point, therefore observation of

potential effects of CWI on return toPRE values past 40h was not possible.IL6 and CORT returned to similar PREvalues by 40h. Thus, one bout of CWIimmediately following an ironmanrace did not affect markers of muscledamage or inflammation up to 40hpost race compared to CON.

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Thermoregulatory Responses InTriathletes During A CompetitiveIronman Race In A WarmEnvironmentDeMartini JK, Casa DJ, StearnsRL, Creighton BC, Muñoz CX,Apicella JM, Huggins RA: KoreyStringer Institute, Department ofKinesiology, University ofConnecticut, Storrs, CT

Context: The unique stress of anIronman triathlon involving a 2.4 mileswim, 112 mile bike, and 26.2 mile runleads to extreme yet variablephysiological and biochemical stress.Thermoregulatory responses duringultra-endurance exercise are oftenlimited to measurements before andafter exercise, warranting furtherinvestigation of repeated monitoringof the thermoregulatory demandsimposed on the body during this event.Objective: Observe the response ofgastrointestinal temperature (T

gi) in

triathletes during a full Ironmandistance triathlon race. Design:Observational field study. Setting:2012 Lake Placid Ironman Triathlon(WBGT= 22.1 ± 2.0°C). Patientsor Other Participants: Ironmantriathletes participating in the 2012Lake Placid Ironman (n=27;age=39.9 ± 8.0y; height=174 ±11cm; body mass=73.1 ± 9.6kg;body fat=15.13 ± 6.19%).Interventions: All participants tookan ingestible temperature sensor theevening before the Ironman race. T

gi

was recorded via handheld receiverbefore the race (PRE), during theswim-to-bike transition (T1), duringthe bike-to-run transition (T2), andimmediately following the race(POST). Data were analyzed via one-way ANOVA and are presented asmean ± standard deviation.Additionally, a Pearson correlationwas performed to examine therelationship between delta (POST-PRE) thermoregulatory response( ˜ T

gi) and finish time. Significance

level was set a priori at p<0.05.Main Outcome Measures: T

gi,

finish time. Results: Mean finishtime was 790.26 ± 87.01min. MeanT

gi at PRE (n=27), T1 (n=16), T2

(n=25), and POST (n=27) were37.39 ± 0.34°C, 38.06 ± 0.42°C,38.27 ± 0.28°C, and 38.42 ± 0.55°C,respectively. T

gi was significantly

higher from PRE to POST race (1.03± 0.6°C; p<0.001). Additionally, T

gi

was significantly elevated at T1 andT2 compared to PRE (p<0.001),while T

gi was also significantly

higher at POST compared to T1(p=0.037). Pearson correlationrevealed no significant interactionbetween ˜T

gi and finish time (r=

-0.17, p>0.05) Conclusions:Ironman competitors are a uniquecohort of athletes who are exposedto extreme physiological demandsdue to the ultra-endurance nature oftheir sport. In-race monitoringprovided an enhanced understandingof the thermoregulatory response tothe Ironman race. The Ironman eventresulted in a significantly higher T

gi

at all time points compared to pre-race measurements, while T

gi was not

correlated to finish time.Additionally, l ikely due to theintense biomechanical nature andprolonged exposure toenvironmental conditions, thecombined bike and run portions ofthe race resulted in a further increasein T

gi. However, despite being

exposed to physical, environmental,nutrit ional, and biochemicalstressors that resulted in mildhyperthermia, the participants wereable to avoid a detrimental rise in T

gi

and potential of a subsequent heatillness that is commonly seen inhigher intensity exercise.

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Body Temperature In BaseballUmpires Wearing Cooling VestsDuring ActivityMcDermott BP, Erickson SM,Sroufe AM, Letendre MA:University of Arkansas,Fayetteville, AR; Umpire MedicalServices, Major League Baseball,New York, NY; Jasper CountyHospital, Rensselaer, IN

Context: Exertional heat illnessremains a potential for those employedin environmental extremes. Baseballumpires have attempted externalmechanisms to assist bodytemperature maintenance duringactivity. Previous research onpreventive cooling vests (CV) andthermoregulation have focused onmoderate to severe temperaturedifferences at the modality-skininterface. Objective: Determineeffectiveness of CV that creates aminor thermal gradient at themodality-skin interface on bodytemperature and thermal sensationresponses in baseball umpires duringwork. Design: Observational fieldstudy. Setting: Single Arizona fallleague baseball season (92.6 ± 3.5°F,13 ± 7%RH). Patients or OtherParticipants: 12 baseball umpires(183.9 ± 6.5cm, 95.5 ± 9.6kg, 23.8± 4.7 % body fat) rotated coveragebetween 3 stadiums and voluntarilyparticipated. Interventions:Participants were randomly assignedto wear a CV (HTFx, Inc.,Melbourne, FL) that changes phaseat 50°F or no vest (NV) under normalpadding and uniform umpiring.Subjects took an ingestiblethermistor to quantify gastro-intestinal temperature (T

GI) at least

5 hours prior to data collection.Umpires reported to a researcherlocated near a dugout every ½-inningfor T

GI and thermal sensation

assessment. Data collectionincluded 20 total games and analysiswas run on 18 plate umpire (PUM)and 48 field umpire (FUM) games.

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Main Outcome Measures: TGI

,thermal sensation, and averageincrease in T

GI for every ½-inning.

Repeated measures ANOVAs wereused to analyze treatmentdifferences. Independent t-testswere used to identify differences inaverage T

GI increases. Alpha was set

a priori at d”0.05. Results: TGI

wassignificantly increased compared topre-game at every time point after1.5 innings in PUM (pd”.042) andFUM (pd”.001). T

GI was consistently

lower, although not significantly(p=.469), with CV (100.40 ±0.19°F) compared to NV (100.59 ±0.19°F) in PUM. Similarly, FUMdemonstrated non-significant T

GI

differences (CV: 100.13 ± .12°F;NV: 100.27 ± 0.13°F; p=.428). Onaverage, T

GI was 0.19°F and 0.14°F

less with CV than NV for PUM andFUM, respectively. There was asignificant attenuation in the averageincrease in T

GI in PUM with CV

versus NV (p=.038), but not FUM(p=.236). Thermal sensation wassignificantly increased after 5.5innings compared to pre-game inPUM (pd”.025), and after 0.5 inningsin FUM (pd”.001). Thermalsensation was significantlydecreased with CV in FUM (CV:5.2 ± 0.1; NV: 5.6 ± 0.1;p=.032),but not PUM (CV: 5.1 ± 0.2; NV:5.6 ± 0.2; p=.150), despite a largermean difference (PUM: 0.5vs. FUM: 0.4). Conclusions:CV provided favorable resultsin preventing a rise in T

GI in PUM.

FUM demonstrated positive, butnot significant advantages. Futureresearch is warranted using CV onparticipants engaging in more intenseexercise and with greater thermo-regulatory challenge to determineclinical applicability of CV.

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Comparison Of Practice VersusGame Hydration Behaviors InCollegiate Women’s SoccerYeargin SW, Minton DM, Torres-McGehee TM, Rosehart S, PaperS, Whittington E, Sutton K,Emerson CC: University of SouthCarolina, Columbia, SC

Context: Time constraints duringsoccer games and team dynamicsduring practices provide challengingcircumstances to optimize hydrationstrategies. Previous research hasexamined hydration behaviors incollegiate women’s soccer playersduring preseason practices. However,behavior difference between practicesand games has not yet been explored.Objective: To observe and comparehydration status and fluid intake duringgames and practices. Design:Observational crossover design.Setting: Outdoor soccer field duringAugust environmental conditions.Patients or Other Participants: Ten(19±1yo, 171.6±4.3cm, 65.6±9.6kg)DI collegiate women’s soccer players,representing a variety of positions.Participants attended an informationalmeeting and signed a consent formprior to participating. Interventions:The independent variable was playingactivity with two levels- game andpractice. Players participated in bothconditions. Five practices and 3 gameswere observed within 10 days. For preand post practices and games, playersarrived to the locker room andprovided a urine sample and a semi-nude weight, which calculated bodymass loss(BML) and sweat rates(SR).To record fluid consumed duringpractice, each player was provided twofluid bottles, one containing acarbohydrate-electrolyte beverage(CEB) and one water. Playing/activitytime was recorded for each playerduring games and for groups duringpractices via an activity log.Researchers did not intervene in anyother manner. Main OutcomeMeasures: Dependent variablesincluded practice/game activity time,

volume consumed(L), SR(L/hr), urinespecific gravity(U

sg) via clinical

refractometer, urine color (Ucol

) viacolor chart, and BML(kg). One wayANOVA was conducted for fluidconsumed, SR, and hydration statusvariables. Post hoc paired t-tests wereconducted for hydration statusvariables. Results: Players consumedmore fluids during games thanpractices(1.7±0.7L vs. 0.8±0.5L;P<0.001).Participants consumedmore water during games thanpractices(1.1±0.7L vs.0.5±0.4L;P<0.001) as well as CEB (0.6±0.5Lvs. 0.5±0.3L; P=0.79), respectively.SR were greater during games thanpractices(1.6±0.5L/hr vs. 0.8±0.3L/hr;P<0.001). Activity time was longer inpractices than games(1.6±0.3hrs vs.1.4±0.4hrs; P=0.039). Players arrivedto games hydrated(1.014±0.007μG,3±1) compared (P<0.001) to minimaldehydration for practices (1.020±0.008μG, 4±1). BML during games andpractices(0.7±1.0kg vs 0.6±0.7kg)were similar. Practice hydration statusincreased pre to post for U

sg

(1.020±0.008 μG vs 1.022±0.012,P=0.336) and U

col (4±1vs 4±1;

P=0.020;) respectively. Gamehydration status also increased preto post for U

sg (1.013±0.006 μG

vs 1.024±0.008, P<0.001) andU

col (3±1vs 5±1; P<0.001)

respectively. Conclusions: Despitetime constraints during games,players employed hydration strategiesthat took advantage of thetime, resulting in greater consumptionof fluids compared to practice. Evenwith the significant consumption offluids, the higher intensity of gamesresulted in higher sweat rates and fluidlosses, ultimately eliciting greaterchanges in hydration status. Activitytime was increased during practices,however break opportunities wereanecdotally more frequent, anddecreased fluid consumption wasoffset by lower sweat rates.

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Individualized RehydrationProtocol Resulted In GreaterRelative Fluid ReplacementThan Ad Libitum HydrationDuring A 20-km Trail Race InThe HeatLopez RM, Casa DJ, Jensen K,Bailey B, Ballard K, DeMartiniJK, Kupchak B, Lee E, PagnottaK, Roti M, Stearns RL, Volk BM,Yamamoto LM, Armstrong LE,Maresh CM: University ofConnecticut, Storrs, CT, andUniversity of South Florida,Tampa, FL

Context: Proper hydration isimperative for athletes striving forpeak physical performance and idealphysiological training responses.Although laboratory research hasshown that hydration significantlyaffects an athlete’s physicalperformance and physiologicalresponses, an optimal method of fluidreplacement in the field settingremains undefined. Objective: Toinvestigate how two distinct hydrationprotocols affect physiologicalresponses and performance during a20-km trail running race. Design:Randomized, counter-balanced,crossover design. Setting: Fieldsetting (trails) in a warm environment(Mean±SD: WBGT 28.3 ± 1.9°C)Participants: Well-trained male(n=8) and female (n=5) runners(39±1y; 175 ± 9cm; 67.5 ± 11.1kg; 13.4± 4.6% body fat) volunteered for studyparticipation. Intervention:Participants completed two 20-kmtrail races (5 x 4-km loop) with 2different hydration protocols: (1) adlibitum (AL) condition and (2)individualized rehydration (IR)condition. At nine water stations, ALparticipants drank as much fluid as theychose and IR participants drank aprescribed volume of water to replacetheir pre-determined, estimated sweatlosses. Data were analyzed usingrepeated measures ANOVA (post hocpaired t-tests, significance at Pd”0.05).

Main Outcome Measures: Percentbody mass (BM) loss, heart rate (HR),gastrointestinal temperature (T

GI),

time, plasma volume (PV) shifts, urineosmolality (U

osm), and serum

electrolytes. Results: HR and TGI

responses were similar betweenconditions. Subjects drank only 32 ±13% of their water losses in AL and66 ± 13% of their water losses in theIR trial (P<0.001). Concordantly, ALexperienced greater BM losses (-2.6± 0.5%) compared to IR (-1.3 ± 0.5%;P<0.001). A relative hydration deficitin AL vs. IR hydrated participants wasfurther corroborated by U

osm

differences between pre- and post-race (-273 ± 146mOsm (AL) vs. -145± 215mOsm (IR), P=0.032), andchanges in %PV in AL (-4.9 ± 5.5%)vs. IR (-1.0 ± 4.6%; P= 0.013). Pre-to post-race changes in serumelectrolytes (Na+ and Cl-) were alsogreater in AL than IR (P<0.001).Overall race times between groupswere similar. Conclusions: Anindividualized rehydration protocolreplaced double the amount of fluidloss than ad libitum drinking during a20-km trail race. Differences in fluidconsumption negatively affectedseveral hydration indices with ALcompared to the IR protocol. Despitea clear, quantitative difference inhydration level, AL and IR did notdiffer in HR, T

GI, or race performance.

While IR did not completely replacesweat losses, it is recommended thatathletic trainers utilize individualsweat rates when designing fluidreplacement protocols. A moreaccurate method of individualizingfluid intake prescription would likelyresult in greater than 66%replacement of body water loss andperhaps more favorable performancebenefits in future studies.

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Hydration Measures Of DivisionI Collegiate Female SoccerGoalkeepers And Field PlayersMinton DM, Torres-McGehee TM,Yeargin SW, Rosehart S, Paper S,Whittington E, Sutton K, EmersonCC: University of South Carolina,Columbia, SC

Context: Much of the hydrationresearch within competitive soccer hasutilized male athletes; additionally,goalkeepers (GK) are often excludedfrom research studies. Although GKdo not cover as much distance duringpractices as field players (FP), theyare required to perform high intensity,short duration activities requiringstrength, speed, and agility. Objective:To determine hydration measuresamong female GK and FP during 11days of pre-season practice. Design:Observational cohort study. Setting:Practice facility of a Division Icollegiate female soccer team in theSoutheastern United States. Patientsor Other Participants: Participantswere 17 (3 GK and 14 FP) femalecollegiate soccer players (age =19+1yrs, height = 168.2+5.9cm,and weight = 63.8+7.0kg.) Playersrepresented all education levels andFP represented all positions.Intervention(s): All hydrationmeasures were assessed for 11days (14 practices) during pre-season training. Participantsprovided a urine sample and weighedpre- and post-practice. Urine wasmeasured for urine specific gravity(U

sg) and urine color (U

col). Weight

was measured semi-nude. Volumeof fluid consumed (V

fluid) during

activity was measured foreach player by providingindividualized water and carbo-hydrate-electrolyte beverage (CEB)bottles. Practice time was recordedfor each practice, from the beginningof warm-up to the end of the cool-down session. Sweat rate (SR) wascalculated by using change in bodymass and V

fluid. Main Outcome

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Measure(s): Usg

, Ucol

, percent changein body mass (%˜BM), SR, V

fluid, and

practice time. Repeated measuresANOVAs were used to determinedifferences in all dependent variablesbetween GK and FPs over the 14practices. Results: GK practicedsignificantly more than FP(1.87+0.5hrs vs. 1.69+0.4hrs, P =0.003). GK consumed similar V

fluid

(total = 1.1+0.6L; water = 0.5+0.4L,CEB = 0.7+0.5L) compared to FP(total =1.1+0.6L; water = 0.7+0.6L,CEB = 0.6+0.4L). SR was also similarfor both GK and FP (0.7+0.4L/hr and0.8+0.5L/hr, respectively). There wereno significant differences between GKand FP for %˜BM, U

sg, or U

col. Mean

pre-practice Usg

= 1.020+0.001μGand did not significantly increase post-practice (1.021+0.002μG). Mean%˜BM = -0.5+0.5%. Conclusion:While GK practiced longer, theyconsumed similar amounts of fluidduring practice and hydration measureswere not significantly different than theFP. Overall, players reported euhydratedand maintained this status. Anexplanation for these results may be thecontinuous education and pre-seasonhydration measures (e.g., pre-post bodymass measures) by the team’s athletictrainer, potentially impacting our resultsand supporting the role of athletictrainers in hydration education. Despitedifferences in practice time, GK and FPare similar in SR and hydration measuresduring pre-season practice. Athletictrainers should be aware ofthese similarities to minimize riskof dehydration. Future research shouldexamine female soccer playersat different competitive levelsand during the season.

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Validity And Reliability Of TwoDigital Refractometers To AManual Refractometer And UrineColorEmerson CC, Minton DM, Torres-McGehee TM, Yeargin SW:University of South Carolina,Columbia, SC

Context: Monitoring athletes’ urinespecific gravity (U

sg) is recommended

by the National Athletic Trainers’Association to prevent heat illness andimprove performance. Refractometryis considered the gold standard formeasuring U

sg; however, the use of

manual refractometers can be time-consuming and subject to user error.Digital refractometers are time-efficient and reduce subjectivity,however limited research hasexamined the validity and reliability ofdigital refractometers and no studieshave examined this in an athleticpopulation. Objective: To determinethe validity and reliability of twocommonly used digital refractometermodels to a manual refractometer(MAN) and urine color (U

col). Design:

Descriptive study. Setting: Division Icollegiate female soccer teampractice facility. Patients or OtherParticipants: Participants were 26female collegiate soccer players(19+1yrs, 168.6+3.0cm, 65.1+8.6kg). Intervention(s): As part of alarger study, participants provided pre-and post-activity urine samples over 19days (23 practices and 3 games). Urinewas analyzed by a MAN, a “pen-like”digital refractometer requiring theprism to be dipped into the sample(DIP), and a second digitalrefractometer requiring ~3ml ofsample to be pipetted on to the prism(PIP). U

col was assessed using a U

col

chart. Calibration was ensured prior toeach data flight for each instrument.Main Outcome Measure(s): U

sg,

measured by MAN, DIP, and PIP, andU

col. Pearson r correlations were used

to determine the relationship between

each of the refractometer models andU

col. Bland-Altman analysis was used

to determine mean estimation bias anddirection and 95% limits of agreementamong refractometers. Results: Atotal of 714 urine samples wereutilized for comparisons. Mean U

sg for

MAN = 1.021+0 . 0 0 8 ˜ G, DIP =1.020+0 . 0 0 7 ˜ G, and PIP =1.019+0.007˜G. Mean U

col = 5+2.

Strong, significant, correlations werefound between each of therefractometer models (MAN-DIP: r=0.98; MAN-PIP: r =0.97; and DIP-PIP: r =0.97; P<0.001). U

col was also

significantly correlated, albeitmoderately, to each of therefractometers (r =0.60, P<0.001).Bland-Altman analysis revealed amean error of 0.001+0.002 ˜G forDIP and 0.002+0.002 ˜G for PIP. Agreater percentage of samples withmeasurement error e”0.005˜G wasfound for PIP (61/741, 8.5%) than DIP(26/741, 3.6%). PIP and DIP bothhad a trend to underestimate U

sg

compared to the MAN.Misclassification as euhydratedwhen the MAN indicatedhypohydrated (defined as U

sg

>1 .021˜G) occurred morefrequently with PIP samples (8.5%,61/714) than DIP (5.0%, 36/714).Conclus ion: DIP and PIPmeasurements of U

sg were similar

to MAN, however t ended tounderestimate U

sg and were more

l ikely to classify samples aseuhydrated when MAN classifiedthose samples as hypohydrated.Athletic trainers should be awareof po ten t ia l e r ror when us ingdigital refractometers to monitorU

sg. Future research is needed to

examine the validi ty of digi talre f rac tometers compared top lasma hydra t ion measures .

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Reoccurring ExertionalRhabdomyolysis In A Division IICollegiate Football Athlete: ACase ReportBennett CC, Eley DM, Berry DC:Saginaw Valley State University,University Center, MI

Background: The purpose of thiscase report is to document thetreatment and outcome of reoccurringexertional rhabdomyolysis in a 22-year-old male Division II collegiatefootball player (mass=92.9kg,height=180.3cm). The athlete firstbegan experiencing symptoms whenhe was 15-years-old playing highschool (sophomore) football. It wasnot until he was 18-years-old and beganparticipating in collegiate football thathis condition was diagnosed. During astrenuous preseason football practice,he began experiencing full bodymuscle cramping with a burningsensation in his abdomen. The athletictraining staff treated the athlete forsevere cramping using cold-waterimmersion and oral fluids. Unable tocontrol the cramping, the athlete wastransported via EMS to the emergencydepartment (ED). Evaluated at the ED,diagnostic testing (CBC and urinalysis)were positive for abnormal values ofCreatine (1.66 mg/dl), Creatine Kinase(9,277 U/L), Bilirubin (2.5 mg/dl),Aspartate Aminotransferase (122 U/L), and hematuria suggesting adiagnosis of exertional rhab-domyolysis. Differential Diagnosis:Dehydration, electrolyte imbalance,potassium deficiency, myalgia,inflammatory myositis, exertionalheat-related illnesses. Treatment: Theathlete was admitted to the hospital for4-days where he received intravenousfluids (3-days) while undergoingadditional CBC and urinalysis testing.Once his CK levels decreased to nearnormal (males=38-174 U/L), he wasdischarged. Due to the lack ofstandardized care for exertionalrhabdomyolysis, the athlete wascleared to return to play by his family

physician and team physician with anunderstanding that he would report anyrecognized symptoms upon initialdevelopment. Since this episode, heexperienced six additional bouts ofexertional rhabdomyolysis (over a 5-year period), two events, whichoccurred during preseason practicesneeding, advanced medical attention.Normally, the athlete was treated fordehydration, myalgia, and musclecramping. Treatment includedincreased clear liquid intake, NSAIDS,and hot compresses until symptomshad subsided. The athlete was educatedon his condition and possibleoutcomes if symptoms were leftuntreated. He continues to participatewith physician clearance.Uniqueness: Exertional rhab-domyolysis is a common form ofrhabdomyolysis, affecting individualsparticipating in novel and intenseexercise to which they areunaccustomed. This athlete was notnew to the sport and supposedlyunderstood the sport’s physicaldemands, but still experiencedsubsequent episodes whileparticipating in collegiate football.Even with education and constantreminding, he managed to suffer twomore episodes needing emergentmedical care. Both episodes occurredduring preseason where the athleteexperienced periods of intensetraining. However, prior to beingdiagnosed and educated, he freelyadmitted he would have continued toexert himself further past his maximalthreshold, which could have had fatalconsequences. Conclusions: Athletictrainers are well trained in themanagement of musculoskeletalinjuries, environmental illnesses, andin medical emergencies. However,exertional rhabdomyolysis, aspresented in this case, may be acondition that commonly goesundiagnosed because of thecommonality of symptomsexperienced in other injuries andillnesses. Athletic trainers need to be

aware of the clinical features ofexertional rhabdomyolysis to ensureathletes are not undiagnosed as theclinical features often mimic those ofmuscle cramping and heat-relatedillnesses. Evaluating clinicians mustperform a thorough history andfocused exam, in addition to orderinga serum CK and urinalysis. In thisclinical setting, a CK equal to orgreater than five times normal or aurine dipstick testing positive forblood with no demonstrable red bloodcells upon microscopic assessmentconfirms the diagnosis. A urine orserum myoglobin is more definitivewhen expeditiously available. Aftertreatment for exertional rhab-domyolysis, athletic trainers andphysicians must risk-stratify athletesfor risk of recurrence, consider furthertesting, and make the decision onwhen, if, and under what conditions theathlete can safely return to play.

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Free Communications, Oral Presentations: Clinical Assessment of MovementDysfunctionsTuesday, June 25, 2013, 12:45PM-2:00PM, Palm B; Moderator: Anh-Dung Nguyen, PhD, ATC1 3 4 3 4 M O I N

Investigation Of TheMeasurement Properties Of TheFunctional Movement Screen™In High School AthletesMonfreda AM, Anderson B,Neumann M, Valovich McLeod TC:Athletic Training Program, A.T. StillUniversity, Mesa, AZ

Context: Functional movement is anessential component to any athleticactivity. The Functional MovementScreen (FMS) consists of seven testsused to evaluate fundamentalmovement patterns. The reliability ofthe clinical scoring system has beenpublished, however there is minimalresearch investigating the reliability ofthe research scoring criteria in highschool athletes. Objective: Toinvestigate the intra- and inter-raterreliability of the FMS research scoringcriteria in high school athletes.Design: Inter- and Intra-raterreliability. Setting: Local highschools and outpatient physical therapyfacilities. Patients or OtherParticipants: Convenience sample of30 high school athletes (15 females, 15males; age 15.8±1.4 years, height181.4±39.1cm, mass 67.4±6.9kg).Interventions: Each subjectcompleted the FMS while beingvideotaped from an anterior and lateralview. Tests included: deep squat (DS),hurdle step (HS), in-line lunge (ILL),shoulder mobility (SM), active straightleg raise (ALSR), trunk stability push-up (TSPU), and rotary stability (RS).Videos were imported and edited, priorto video scoring. The primaryresearcher scored both live and videoversions on two separate occasions,with the secondary and tertiaryresearchers scoring videos only. Itshould be noted each researcher hadvarious levels of training with the FMS,with wide individual experience.Descriptive statistics and ICC’s werecalculated for the FMS research

scoring criteria, evaluating both theindividual tests and total score.Reliability of the test scores wascalculated using intra-classcorrelation coefficients [ICC, (2,1)].Main Outcome Measures: Thedependent variable was the researchscoring criteria, including bothindividual test scores and the totalscore. Results: The intra-raterreliability of the FMS researchscoring criteria total score wasICC=.83 The following testsdemonstrated good reliability(ICC>.75): HS total, SM right, SMtotal, ASLR left, TSPU, RS left. Testswith ICC’s below .75 included: DS,HS right, HS left, ILL right, ILL left,ILL total, SM left, ASLR right, ASLRtotal, RS right, and RS total. Inter-rater reliability of the researchscoring total score was ICC=.87.Individual tests resulting in ICCs>.75,including: HS right, SM right, SMleft, SM total, ASLR right, ASLR left,ASLR total, and TSPU. The followingtests demonstrated poor-moderatereliability with ICCs <.75: DS, HSleft, HS total, ILL right, ILL left, ILLtotal, RS right, RS left, and, RS total.Conclusions: The reliability of theresearch total score for both intra- andinter-rater reliability was good.However, the reliability of theindividual test scores varied,indicating the need for more researchassessing the degree of agreementbetween individual tests. It isrecommended for clinicians to obtainappropriate training to improve thepotential for increased reliability,especially of the individual tests. Italso seems to be more advantageousto score the FMS live, which allowsthree-dimensional views of the tests.

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Functional Measures And BodyMass Index As Predictors OfLower Extremity Injury AmongCollegiate Football PlayersGribble PA, Ford A, Morrell M,Pietrosimone BG: University ofToledo, Toledo, OH

Context: Researchers and cliniciansoften seek ways to predict and preventlower extremity injury. The starexcursion balance test (SEBT) and theFunctional Movement Screen (FMS)have been suggested as tools forpredicting acute lower extremity (LE)injury. However, the injury predictioncapability of the SEBT and FMS forcollegiate football athletes is notestablished. Body mass index (BMI)may be another potential predictor ofinjury, but has had little applicationamong collegiate football athletes. Byutilizing these screening tools,clinicians may be able to identifyathletes at risk for LE injury andrecommend proper preventativeintervention strategies. Objective: Todetermine the capability of the SEBT,FMS and BMI to predict acute ankleand knee injury in collegiate footballplayers. Design: Prospective cohort.Setting: Athletic training facility.Patients or Other Participants: Onehundred eighty, NCAA Division Ifootball players (19.79± 1.38yrs;1.86±0.07m,102.29±18.92kg)volunteered to participate.Interventions: Prior to the 2010-2011 and 2011-2012 football seasons,participants completed a singlesession in which height and mass, theanterior reach of the SEBT (A-SEBT)and all seven stations of the FMS (deepsquat, hurdle step, in-line lunge,shoulder mobility, active straight legraise, trunk stability push-up, androtary stability) were evaluated. MainOutcome Measures: Dynamicpostural control was measuredbilaterally using A-SEBT. The meanof three reaches (cm), expressed as a

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percentage of the stance limb length(cm), was used. Each station of theFMS is scored on a 0-3 scale, with atotal possible composite score of 21points indicating a perfectperformance. The lowest score ofthree attempts in each station was usedto create the total score. BMI wascalculated with the following equation:weight (kg)/[height (m)]2. CertifiedAthletic Trainers tracked and reportedtraumatic ankle and knee injuries.After the competition season, athleteswere placed in an injured (traumaticankle or knee injury; n=33) oruninjured (n=147) group. Sensitivityand specificity were used to createpositive and negative likelihood ratios,from which diagnostic odds ratios(DOR) were created separately foreach outcome measure. Results Forthe A-SEBT, a normalized reachdistance of 70.84% was associatedwith strong sensitivity (0.79) andmoderate specificity (0.55), with aDOR of 4.63. For the FMS, a score of15.5 was associated with low-moderate sensitivity (0.42) and strongspecificity (0.74), with a DOR of 2.08.For BMI, a score of 28.97 wasassociated with moderate sensitivity(0.58) and specificity (0.63), with aDOR of 2.34. Conclusions: SpecificSEBT, FMS and BMI measuressuggested a LE injury was 2-5 timesmore likely to occur during theseason. Clinicians and researchersshould continue to examine whatcombination of screening measuresare the most efficient to implement.

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Functional Movement ScreenAnd Beighton And Horan JointMobility Index Scores BetweenLevels Of Pubescence InAthletesPaszkewicz JR, McCarty CW, Van Lunen BL: Old DominionUniversity, Norfolk, VA, and A.T.Still University, Mesa, AZ

Context: The pubertal growth spurtmay cause alterations in jointflexibility, joint laxity, muscularstrength, balance, and coordination,which could result in an increasedincidence of musculoskeletal injuries.The Functional Movement ScreenTM

(FMS) and the Beighton and HoranJoint Mobility Index (BHJMI) may begood clinical tools to identify thesechanges that occur duringadolescence. While the BHJMI hasbeen shown to identify differences injoint laxity in the adolescentpopulation, there is no evidencewhether the FMS can identify suchdifferences among children.Objective: To compare FMS andBHJMI scores between gender andpubertal maturation in 8-14 year oldathletes. Design: Cross-Sectional.Setting: Various athletic facilities.Participants: Sixty-six youth athletesactively participating on an organizedathletic team (29 females, 37 males,11.45±1.98 years, 151.16±12.67cm,41.90±12.86kg). Participants werecategorized into three maturationalcategories [pre-pubescent (PRE),early-pubescent (PUB), post-pubescent (POST)] based on thePubertal Maturation ObservationalScale that was completed by theparticipants’ parent or legal guardianprior to participation. Interventions:Participants performed each BHJMItest (9) once, each FMS task (7) amaximum of three times (highestscore was documented as task score),and the three FMS clearing tests. If theclearing test was positive, zero wasscored for the corresponding FMStask. The scores of each BHJMI test

and FMS task were tabulated intocomposite scores. Main OutcomeMeasures: The dependent variableswere BHJMI and FMS compositescores. The independent variables werematuration stage (3) and gender (2).Between and with-in group differenceswere calculated using separate 2x3factorial ANOVAs (Pd”0.05) for eachdependent variable. In the presence ofan interaction or main effect, Fisher’sLSD post-hoc comparisons werecalculated. A Spearman Rho (r)analysis of correlation was utilized toassess relationships between FMS andBHJMI composite scores. Results:There was a significant increase inFMS scores (P=0.032) but not BHJMIscores (PRE=2.69±0.40, PUB=1.96±0.40, POST=3.13±0.43, P=0.131)across pubertal stages. POST subjects(15.91±0.47) had significantly greaterFMS scores (P=0.008) than the PREsubjects (14.28±0.44) and PUBsubjects (14.55±0.44; P=0.039). Nodifferences were identified betweengender and FMS scores(males=15.16±0.38, females =14.67±0.35, P=0.351) or BHJMI scores(males=2.36±0.35, females= 2.83±0.32, P=0.321). No significantinteractions were found betweengender and pubescence regarding theBHJMI composite scores (P=0.503)or FMS composite scores (P=0.216).There was no correlation betweenFMS composite scores and BHJMIcomposite scores (P=0.89) [r(s)=-0.017] Conclusions: Our resultssuggest that the FMS may be a goodclinical tool for assessingmusculoskeletal alterations that occuras a result of the pubertal growth spurtsince it can discriminate betweenmaturation stages whereas the BHJMImay not. A prospective extension ofthis study to include follow-up ofinjured participants appearsworthwhile to determine if the FMScan suitably predict injury inthe adolescent population.

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Functional Movement Screen™Differences Exist Between Maleand Female Adolescent AthletesNeumann M, Anderson BL, HuxelBliven KC: A. T. Still University,Mesa, AZ

Context: Injury prevention andathletic performance are reliant uponintegration of adequate mobility,stability, and neuromuscular control toproduce fundamental movementpatterns, including squatting andlunging. Several movement screensexist to assess the quality of functionalmovement and ultimately determineinjury risk. The Functional MovementScreen™ (FMS) is a commonly usedtool, and evidence suggests thatathletes who score <14 points on theFMS are at increased risk for injury.However, there is minimal researchinvestigating FMS score differencesand injury risk between healthy maleand female athletes. Objective: Toinvestigate sex differences in FMSindividual test and total scores ofhealthy adolescent athletes. Design:Cross-sectional. Patients or OtherParticipants: Sixty healthyadolescent athletes (Male=31,age=16.0±1.1 yrs, height=177.1±8.1cm, weight=75.1±11.0 kg; Female=29, age=15.9±1.3 yrs, height=166.5±7.8 cm, weight= 61.8 ±7.4 kg)of convenience were tested.Interventions: Participantsperformed the FMS, which comprises7 functional movement tests,including: deep squat, hurdle step, in-line lunge, shoulder mobility, activestraight leg raise, trunk stability pushup, rotary stability and 3 clearancetests. Main Outcome Measures: Thedependent variables were FMSindividual test scores and total scorefor composite (individual test scorerange=0-3 pts, total=21pts) andresearch (individual test scorerange=0-8, 0-12, 0-18, or 0-20 pts,total=100 pts) scoring methods.Lower scores indicate functionalmovement deficits and increased

injury risk. Mann-Whitney U testswere used to determine sexdifferences in individual and totalcomposite and research scores.Results: Females scored significantlylower on the following individual FMStests: hurdle step (Composite:females=0.2±0.4 pts vs. males=0.45±0.5 pts, P=0.046), in-line lunge(Composite: females=2.2±0.7 pts vs.males=2.6±0.5 pts, P<0.001;Research: females=13.9±4.8 pts vs.males=17.1±2.9 pts, P=0.009), andtrunk stability push-up (Composite:females=2.2±0.7 pts vs. males=2.6±0.5 pts, P=0.043; Research:females=13.9±4.8 pts vs. males=17.1±2.9 pts, P=0.009). Femalesalso scored significantly lower thanmales on both the composite[females=13.8±1.8 pts, 95%C.I.(13.2, 14.5), males=15.3±2.1 pts,95% C.I.(14.5, 16.0), ES=0.82,P=0.004] and research total scores[females=53.2±10.7 pts, 95%C.I.(49.2, 57.3), males=63.1±12.5 pts,95% C.I.(58.5, 67.7), ES=0.91,P=0.001]. Conclusions: Healthyfemale athletes did not perform aswell as healthy male athletes on theFMS, as indicated by lowerindividual test and total scores.The individual tests (hurdle step,in-line lunge, and trunk stabilitypush-up) that females scored lowerthan males incorporate componentsof core stability, balance, posturalcontrol, and strength. These resultsindicate that females may be ata higher risk for injury than males,possibly due to deficits in corestabilization, neuromuscular control,and coordinated movement patterns.Clinicians should be aware ofthese sex differences when using theFMS and developing injuryprevention programs to addresspotential injury risk factors. Furtherresearch is warranted regardingsex differences, and interventionsto improve FMS scores.

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Kinematic Differences BetweenThose With And Without MedialKnee Displacement During ASingle Leg SquatMauntel TC, Begalle RL, Cram TR,Frank BS, Hirth CJ, Blackburn JT,Padua DA: Sports MedicineResearch Laboratory; Universityof North Carolina, Chapel Hill, NC

Context: Knee valgus is described asa risk factor for lower extremity (LE)injuries, such as ACL rupture. Clinicalmovement assessments are animportant aspect of injury preventionscreening and program development,as laboratory based motion analysistesting for knee valgus motion is notclinically feasible. Identifying medialknee displacement (MKD) as a markerof knee valgus motion is describedduring clinical movementassessments; however, the validity ofMKD as an indicator of valgus motionhas yet to be determined. Objective:To compare frontal and transverseplane knee and hip angles betweenparticipants who display visual MKD(MKD group) during a single leg squat(SLS) to those who do not (CONgroup). Design: Cross-sectional.Setting: Research laboratory.Participants: Forty, healthy,physically active adults volunteered toparticipate in this study (CON: n=20,age=20.2±1.5yr, height= 173.1±10.1cm, mass= 71.0±14.6kg; MKD:n=20, age=20.2±1.8yr, height=173.8± 8.8cm, mass=71.8±14.7kg).MKD members displayed medialdisplacement of the patella relative tothe great toe on at least three of fiveSLS trials, whereas the CON membersmaintained neutral patellar alignment.Interventions: Participantscompleted five SLS trials to 60-degrees of knee flexion with theirdominant leg foot flat on the ground,toes pointed forward, and non-dominant leg flexed at the hip andknee. An electromagnetic motiontracking system was used to quantifyknee and hip joint angles during the

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descent phase (initiation of kneeflexion to peak knee flexion). MainOutcome Measures: Peak frontal andtransverse plane knee and hip jointangles were averaged across five trials.A single MANOVA was performed tocompare peak frontal and transverseplane knee and hip joint angles betweengroups. Follow-up one-way ANOVAswere performed as post-hoc analyses.Results: A significant difference wasidentified between the MKD and CONgroup kinematics (Wilks’Lambda=.575, F

7,32=3.130, P=.012,

˜ 2=.406). Follow-up one-wayANOVAs revealed significantlygreater peak knee valgus(F

1,38=15.263, P<.001) in the MKD

(-12.79±5.62) compared to the CON(-6.08±5.23). There were no othersignificant differences between groupsfor peak knee flexion (P=.320, effectsize=.459), knee external (P=.905,effect size=.038) or internal rotation(P=.486, effect size=.222), hipadduction (P=.497, effect size=.217),or hip external (P=.877, effectsize=.049) or internal rotation(P=.416, effect size=.260) (˜ d”.05).Conclusions: Visual observation ofMKD is a biomechanically validclinical assessment of peak kneevalgus angle during a SLS. On average,there was 6-degrees more peak kneevalgus in the MKD compared to theCON group, which represents a largedifference between groups (effectsize=1.24). In contrast, the presenceof MKD does not appear to beindicative of increased knee rotation,hip rotation, or hip adduction. Whilethe presence of MKD is a validindicator of increased knee valgusmotion, the relationship betweenMKD and increased risk of LE injuryrequires further study.

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Medial Knee Displacement IsAssociated With Youth SoccerPlayer Sex And AgeFrank BF, DiStefano LJ, PaduaDA: The University of NorthCarolina at Chapel Hill, Chapel Hill,NC, and The University ofConnecticut, Storrs, CT

Context: Sex differences in lowerextremity injury biomechanics mayinfluence the greater incidence of ACLinjury in female youth soccer athletes.However, it is not clear when sexdifferences in lower extremitybiomechanics, such as medial kneedisplacement (MKD) emerge duringmaturation. Objective: The purposeof this study was two-fold: 1)Determine if there is a relationshipbetween sex and MKD frequency, 2)Determine if there is a difference inMKD prevalence between females andmales across age-groups. Design:Cross-Sectional. Setting: Fieldlaboratory. Patients or OtherParticipants: Elite-level club soccerathletes (n= 214) in middle school(11-13 year old age-group) (44 males,48 females; age= 12 ±1 yrs, height=153.4 ±7.7 cm, mass= 40.4 ±6.2 Kg)and high school (14-18 year old age-group) (66 males, 56 females; age= 16±1 yrs, height= 169.9 ±8.1 cm, mass=59.7 ±8.6 Kg) volunteered for thisstudy. Interventions: Participantsperformed 3 jump-landings from a 30-cm high box at a distance half of eachindividual’s height from a white linemarked on the ground in front of thebox. Participants were instructed tojump from the box, land forward of theline, then immediately jump formaximum height. Main OutcomeMeasure: Participants werevideotaped and evaluated for thepresence of MKD (at least oneinstance of the center of the patelladisplaced medial to, or in-line with thegreat toe) during ground contact. Chi-square tests of association wereconducted to determine if MKDfrequency was associated with sex

between age-groups. Odds ratios (OR)were calculated if a significant (P<0.05) association was observed.Results: Overall, there was asignificant association between sexand MKD frequency (X2 (1, N= 214)=11.90, P <0.001); femalesdemonstrated greater MKD frequencycompared to males (OR= 3.69, 95%CI= 1.70, 7.99). There was noassociation between sex and MKDfrequency in the middle school age-group (X2 (1, N= 92)= 1.01, P=0.315). However, an associationbetween sex and MKD was observedin the high school age-group (X2 (1,N= 122)= 13.42, P <0.001); femalesdemonstrated a greater MKDfrequency compared to males (OR=8.24, 95% CI= 2.31, 29.45).Conclusions: The sex difference inMKD prevalence appears to be drivenby age, as there was no sex differencein the prevalence of MKD betweenmiddle school-aged soccer athletes.However, high school-aged femalesoccer athletes had over 8 timesgreater odds of MKD comparedto their male counterparts. MKDis commonly observed during ACLinjury episodes. The higher prevalenceof MKD in high school female soccerathletes may help explain the risein ACL injury risk in females frommiddle school to high school.Acknowledgements: Funding providedby the National Academy of SportsMedicine and the National BasketballAthletic Trainers Association.

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Landing Error Scoring System(LESS) Differences BetweenSingle-Sport And Multi-SportFemale High School AthletesBeese ME, Joy EA, Switzler CL,Hicks-Little CA: University ofUtah, Salt Lake City, UT

Context: The prevalence of singlesport specialization (SSS) is becomingmore popular in youth sports. Deficitsin functional movement have beenshown to predispose athletes to injury.With this increase in early SSS, it isunclear whether there is a link betweenSSS and an increased risk of kneeinjury. Objective: The purpose of thisstudy was to identify functionalmovement deficits between SSSathletes and multi-sport (M-S)athletes. The study goal was to identifyassociations that would aid in thedevelopment of specialized trainingprograms that could be implementedthroughout the year to reduce the riskof injury. Design: Observationalstudy. Setting: A soccer practice fieldand sports medicine researchlaboratory. Patients or OtherParticipants: Forty (n = 21 SSS, n =19 M-S) female high school athletevolunteers, ages 14-18 (Mean age15.18 SD+/- 1.12) were recruitedthrough local soccer clubs and anOlympic Development Program(ODP). All single sport athletes playedsoccer. Interventions: Allparticipants completed 3 trials of thestandard LESS jump landing task whichwas recorded and then analyzed at alater date. The subjects performed adouble-leg jump from a 30cmplatform, landing on a rubber mat at adistance of half their body height.Upon landing, the subjectsimmediately performed a maximumvertical jump. Main OutcomeMeasures: Values were assigned toeach trial using the LESS scoringcriteria. The LESS score is a count of“errors” on a range of easily observableitems of movement with a total of 17scored items. Scores range from 0-3

errors (Excellent), 4-5 (Good), 6(Moderate), and 7 or more (Poor). The3 scored trials were then averagedbefore a t-test was utilized to teststatistical significance betweengroups. Alpha was set a priori at 0.05.Results: Mean scores for SSS groupwere 6.84 (SD ± 1.81) while the meanscores for the M-S group were 6.07(SD ± 1.93). T-value = 1.309 (P>.05)Conclusions: These results indicatethat participation in soccer alone,compared to participation in multiplesports does not significantly impactLESS scores in adolescent femalesoccer players. However, the LESSscores indicate that the majority ofathletes are at moderate risk for a kneeinjury regardless of the number ofsports played (mean LESS score in themoderate to poor range). Adolescentathletes should participate in trainingthat works to correct these deficits inorder to reduce injury risk. Moreresearch is needed to identify whatinterventions would be mostsuccessful at reducing these risks.

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Free Communications, Thematic Poster Presentations: Factors that InfluenceConcussion AssessmentTuesday, June 25, 2013, 2:15PM-3:45PM; Palm B; Moderator: Michael Ferrara, PhD, ATC1 3 2 3 9 M O S P

Predicting Clinical ConcussionMeasures At Baseline Based OnAcademic Profile And MotivationTrinidad KJ, Schmidt JD,Register-Mihalik JK, Groff D, GotoS, Guskiewicz KM: University ofNorth Carolina at Chapel Hill,Chapel Hill, NC; Select PhysicalTherapy, Durham, NC; WakeMedHealth and Hospitals, Raleigh, NC

Context: Baseline concussionmeasures may be influenced by anathlete’s academic abilities. Likewise,previous research suggest that anathlete’s level of motivation at the timeof testing influences baseline testingperformance. Objective: Todetermine if unweighted high schoolgrade point average (hsGPA),Scholastic Assessment Test (SAT)scores, and motivation scores predictneurocognitive and postural controlperformance at baseline. Design:Cross-sectional study. Setting:Clinical-Research Center. Parti-cipants: 88 NCAA Division 1incoming student-athletes for which allpredictor variables were available tothe researchers (age: 18.58±0.52years, height: 175.67±12.75 cm,mass: 15.85±20.28 kg). Participantsreported for baseline testing prior totheir playing season. Interventions:Participants completed a com-puterized neurocognitive test (CNSVital Signs), a balance exam (SensoryOrganization Test: SOT), and a measureof test-taking motivation (Rey’s DotCounting Test). Motivation wasassessed following completion of thebaseline concussion assessment. SATand hsGPA were obtained from theuniversity admissions and registraroffices. Main Outcome Measures:The following domains standard scoreswere taken from the neurocognitivetest battery and used as criterionvariables: verbal memory, visualmemory, psychomotor speed, reaction

time, complex attention, cognitiveflexibility, processing speed,executive functioning, and reasoning.The composite equilibrium score wasused from the SOT as a criterionvariable for balance. Ten separatemultivariate regression models wereused with SAT, hsGPA, and motivationas predictors (a priori alpha =0.05).Results: hsGPA was a significantpredictor of the processing speedstandard score (103.73±15.57,F

3,82=3.73, p = 0.014; R2=0.12). SAT

score was a significant predictor of thecomplex attention standard score(95.07±36.40, F

3,82=3.32, p = 0.024;

R2=0.11) and the SOT composite score(76.90±7.07, F

3,78=6.31, p = <0.001;

R2=0.20). However, these modelsexplained only 12% of the variancein the processing speed standardscore, 11% of the variance in thecomplex attention standard score,and 20% of the variance in the SOTComposite score. We did not observeany other significant predictors.Conclusions: Baseline motivation,SAT score, and hsGPA explained someof variance in baseline measures ofcognitive flexibility, processing speed,and postural control. However, ourmodel does not explain enough ofthe variance in these scores to be ableto accurately estimate an athlete’sbaseline performance. Furtherresearch is necessary to identify otherfactors that might help cliniciansbetter assess the validity of an athletes’neurocognitive and postural controlmeasures relative to their individualcapabilities. We suggest that clinicianscontinue to consider motivationand academic profile when interpretingbaseline and post-concussionmeasures in the clinical decisionmaking process as some ofthe variance was explained with thesevariables. Academic profileinformation can also be easily ob-

tained via a demographic question-naire prior to baseline testing.

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The Acute Effect Of StimulantIngestion On ImPACT TestPerformancePower ME: Marist College,Poughkeepsie, NY

Context: The management of mildtraumatic brain injury (MTBI) hasbecome an area of great concern andcontroversy in the athletic setting.Numerous states have adoptedlegislation mandating evaluationprocedures and return to play criteriafor interscholastic athletics, whileother sport governing bodies haveadopted similar policies. Many ofthese recommend neurocognitive testslike Immediate Post-ConcussionAssessment and Cognitive Testing(ImPACT™) as a management tool.Due to the restrictive nature of currentmanagement plans, anecdotalconcerns have been raised regardingathletes trying to cheat the assessmentand return to play sooner. Variousstimulants have been shown to improvereaction time, visual informationprocessing and working memory,which are similar to the tasks usedduring ImPACT™. Thus, it is possiblethat stimulant use could improveperformance during neurocognitivetesting for MTBI. Objective: Thepurpose of this investigation was toexamine the effects of a nutritionalsupplement containing stimulants onImPACT™ performance. Design: Arandomized and counterbalanceddouble blind cross over design wasused. Setting: ImPACT™ wasperformed on a desktop computer in aquiet, fully enclosed and illuminatedroom at normal room temperature.Participants: Health males andfemales (age=20.6±1.2 y, height=168.5±10.7 cm, mass= 67.6 ±15.2 kg)with no history of physician diagnosedhead injury, learning disability or anyform of attention deficit disordervolunteered. Potential subjects wereexcluded if they were prescribed anytype of stimulant or monoamineoxidase inhibitor for regular use.

Interventions: Subjects wereassessed at the same time of day underthree conditions, treatment, placeboand control with each separated by aperiod of one week. During thetreatment condition, subjects ingested5.5 g of a supplement (Jacked 3D™,USPlabs) containing a proprietaryblend that included caffeine and 1,3-dimethylamylamine (DMAA) incapsule form with water. The placebocondition consisted of 5.5 g ofdextrose in identical capsule form.Main Outcome Measures:ImPACT™ composite scores forverbal and visual memory, visual motorspeed, reaction time, impulse controland a cognitive efficiency index (CEI)were compared under each of the threeconditions and were assessed 30 minafter ingestion. Results: A significantdifference was observed (F

2,22=4.31,

p=.026) when comparing reactiontime, as the subjects reacted fasterduring the treatment condition(.535±.03 s) as compared to theplacebo (.553±.03 s) and control(.554±.03 s) conditions. A significantdifference (F

2,22=4.07, p=.031) was

also observed for the CEI, as thesubjects scored higher during thetreatment condition (.486±.09) ascompared to the placebo (.415±.10)and control (.409±.12) conditions.Conclusions: The results suggestthat stimulant ingestion 30 min priorto test administration results inimproved reaction time, visualprocessing speed and memory.However, the question of clinicalsignificance remains, as it is unclearif this would result in an earlierreturn to play decision.

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The Number Of Words AndWord Choice Can Improve TheStandardized Assessment OfConcussion ScoresMc Elhiney DS, Ragan BG: OhioUniversity, Division of AthleticTraining, Athens, OH

Context: The StandardizedAssessment of Concussion (SAC) is acommon concussion-screening toolused to assess the effects of sport-related concussions. The baseline-postinjury comparison recommended bythe National Athletic Trainers’Association (NATA) is an individual-centered approach that emphasizes thevalidity and accuracy of baseline testscores. The validity of the SACbaseline memory scores has beenquestioned with because many of thememory items not do meet acceptablepsychometric thresholds, mostlybecause the items are “too easy.”Objective: To create 5 alternativeversion of the immediate and delayedmemory section and then compare theoriginal version to the 5 alternativememory versions using Raschmodeling. Design: Observationaldesign. Setting: Laboratory.Participants: Six hundred twenty-fiveparticipants with no history ofconcussion in the previous 6 months(aged 21.38 ± 1.77 yrs; n = 282 men,n = 343 women) volunteered for thisstudy. Intervention: Participants weregiven 1 of 6 different versions of theSAC. Each version had a differentmemory subset (S1 = Original SAC,S2 = All words from the original 3versions (5items) given in one list, S3= 10 new words, S4 = 10 new words,S5 = 10 new words, and S6 = S3+8news words+8 new words). Commonitems (orientation and concentrationitems) were used to anchor the 6versions so the all memory itemswould be placed on the commonmetric in relative position. MainOutcome Measures: The Rasch-calibrated item difficulties for the

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memory items for the 6 SAC versions.A one-way ANOVA with post-hocanalysis was performed to assess ifthere were any differences across thememory items for the 6 versions (˜ =0.05). Descriptive statistics of theparticipants’ abilities were examined.Results: Mean item difficulty,standard deviation and range for eachversion: (mean ± SD; Range): S1 (-2.05± 1.88; -4.86 to 1.38 logits), S2 (0.61± 1.15; -1.96 to 2.01 logits), S3 (0.17± 1.32; -4.01 to 1.75 logits), S4 (0.54± 1.03; -2.01 to 2.13 logits), S5 (0.59± 1.00; -2.36 to 3.26 logits), and S6(0.85 ± 1.28; -4.86 to 3.26 logits).There was a significant difference inmean difficulty between versions(F(5,196) = 29.8; P = 0.05). S1 wassignificantly different than the other5 versions. Mean person abilities foreach version were S1 (0.79 ± 0.89logits), S2 (0.13 ± 0.53 logits), S3(0.03 ± 0.54 logits), S4 (0.25 ± 0.76logits), S5 (0.25 ± 0.53 logits), and S6(0.33 ± 0.41 logits). Conclusions:Our results show that increasing theamount of words and word difficultycan improve the precision of baselinescores. Even though 6 differentversions were administered, Raschmodeling allows for person’s ability tobe placed on the same scale.

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Rasch Model Fit Indices MayHelp Identify Effort WithBaseline Concussion TestingLaFevor ME, McElhiney DS,Ragan BG: Ohio University,Division of Athletic Training,Athens, OH

Context: One major problem facingpre-season concussion testing is theassumption that athletes give 100percent effort, forcing scores toreflect current “true” ability to makepost-injury comparisons possible. It isall too common that professionalathletes indicate that they deliberatelydo poorly on the baseline test to avoidnot playing after scoring poorly on thesecond test following a concussion.This intentional deceit represents amajor problem in concussion testing.While some concussion-testingprograms attempt to identify abnormalperformance, they are severely limitedin capability. There is a need to developmethodology to identify abnormalresponses associated with sub-maximal effort in concussion testing.Objective: To examine various Rasch-based person fit indices and thresholdsfor operationalize a participant givingfull effort. Design: Observationaldesign. Setting: Laboratory. Patientsor Other Participants: Six hundredand twenty-five participants with nohistory of concussion in the previous6 months (mean ± sd: aged 21.38 ±1.86 years; n= 282 men, n= 343women) volunteered for this study.Because participants had no reason tonot want to do well on the baseline test,it is assumed that all participants gavefull effort. Interventions:Participants were administered 1 of 6versions of the StandardizedAssessment of Concussion. Data fromall 6 versions were calibrated using theRasch model using common items(orientation and concentration) asanchor items and model data fit wasgood. Person ability estimates werecalculated with appropriate infit andoutfit statistics. These fit statistics

represent how well the examinees’responses match the expectedresponses from the model. Theadvantage of the Rasch model is that itis highly unlikely an examinee wouldknow which items to respondpositively to, thus increasing thenumber of abnormal responsesresulting in an elevated fit index.Thresholds below 1.5 and 2.0 wereused to identify participants giving fulleffort. Data were analyzed withWinsteps 3.75.0. Any person with fitindices greater than the thresholds wasconsidered to be misfit. MainOutcome Measures: The dependentvariables were the number of peoplewith fit indices greater than thethreshold. The smaller the number offull-effort people that fall outside thethreshold, the better the performanceof the threshold. Results: Using the1.5-fit threshold, 15/625 (2.4%) ofparticipants were identified by the infitstatistic, 33/625 (5.3%) by the outfit,and 40/625 (6.4%) by either infitor outfit. Using the 2.0 threshold,0/625 (0%) participants wereidentified by the infit statistic, 20/625(3.2%) by the outfit, and 20/625(3.2%) by either infit or outfit.Conclusions: Effort is essential toensure validity during concussiontesting. Both thresholds performedwell in classifying participants as fulleffort. These results support theexamination of these thresholds in alarge diagnostic accuracy study.

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Influences On AnnualComputerized NeurocognitiveBaseline Test Performance InCollegiate Student-AthletesBeidler E, Acocello S, Hertel J,Broshek DK, Saliba S: Universityof Virginia, Charlottesville, VA

Context: Baseline neurocognitivetesting aids clinicians in themanagement of sport-relatedconcussions, but no universalguidelines have been determined forfrequency of reassessment. Researchhas shown significant change over timein high school student-athletes’ scoreswarranting annual reassessments, butit is unknown if collegiate student-athletes should be similarly tested.Objective: To determine whichfactors significantly predictConcussion Resolution Index (CRI)baseline measurements. Design:Retrospective Case Series Setting:Sports Medicine Clinic Patients orOther Participants: 450 Division Ivarsity student-athletes (274 males/176 females; age: 19±1years)Interventions: A retrospectiveanalysis was completed on CRIbaseline tests administered betweenAugust 2006 and December 2011.Main Outcome Measures: CRIcomposite scores: complex reactiontime (CRT), simple reactiontime(SRT), and processing speed(PS)were collected for repeated baselinetests. Prediction variables includedage, gender, history of concussion,history of learning disorder, timebetween baseline tests, performanceon initial baseline test, performanceon most recent baseline test, and sport.Grouping was performed using numberof consecutive tests taken and analysisof predictors for each test (2nd, 3rd, 4th,and 5th baselines) included only thosesubjects who had taken thecorresponding number of tests (i.e. allsubjects did not complete 5consecutive tests). Step-wise linearregression models were fit todetermine which factors predicted

subsequent baseline test scores.Results: Regression analysesrevealed various predictors amongcomposite scores. Initial baselinescore was a significant predictor ofall composites (Test 2: CRT,r2˜=0 .303 ,p<0 .001; SRT, r 2˜ =0.232,p<0.001; PS, r2˜ = 0 . 4 9 5 ,p<0.001; Test 3: CRT, r2˜=0.05,p<0.001; SRT, r2˜ =0 .078 ,p<0.001; PS, r2˜=0.034,p<0.001;Test 4: CRT, r2˜=0.027,p=0.03; PS,r2˜=0 .02 ,p=0.004; Test 5: SRT,r2˜=0.234,p=0.006) except Test 4SRT (r2˜=0.348,p=0.226) and Test5 CRT (r2˜=0.491,p=0.169) and PS(r2˜=0.681,p=0.48). Most recentbaseline score was a significantpredictor of all composites on alltests taken (Test 3: CRT, r2˜=0.298;SRT, r2˜=0.32; PS, r2˜=0.593; Test4: CRT, r2˜=0.552; SRT, r2˜=0.289;PS, r 2˜ = 0 . 8 0 1 ; Test 5: CRT,r2˜=0 .491 ; SRT, r2˜=0 .393; PS,r2˜=0.681; p<0.005 for a l l ) .Additionally, CRT was predicted bygender, showing females performedbetter than males (Test 2,r2˜=0.18,p=0.001) and age, showingan improvement in score as ageincreased (Test 3, r2˜ = 0 . 0 1 6 ,p=0.044). SRT was predicted bysport (Test 3, r2˜=0.019,p=0.021)and history of concussion (Test 4,r2˜=0 .059 ,p=0 .011). PS wassignificantly predicted by gender(Test 2, r2˜ = 0 . 0 1 8 , p ˆ 0 . 0 0 1 ) .Conclusions: These results showthat initial and most recent baselinetests are the most useful in predictingsubsequent CRI performance. Therewas, however, no consistency in asingle demographic or self-reportvariable as a predictor ofneurocognitive function. This couldindicate influence of some unknown,unmeasured factors such asmaturation, sport type (i.e. collisionvs. non-collision), duration/level ofparticipation, testing environmentand frequency of testing. Until thesefactors are investigated and can be

controlled, it is recommended thatreassessment of collegiate student-athletes occur annually.

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Baseline Factors AffectingNeurocognitive Performance OnA Concussion Assessment TestLittleton AC, Guskiewicz KM:University of North Carolina atChapel Hill, Chapel Hill, NC

Context: Baseline concussion testingof all athletes has been recommended,so that measures of athletes’ pre-injury performance can be used as anaccurate comparison post-injury.Widespread baseline testing is notalways feasible and recent literaturehas shown that comparison tonormative data agrees with comparisonto individualized baselines for themajority of neurocognitive domains. However, certain individuals, such asthose with learning disabilities and ahistory of concussion may benefitfrom individualized base-lines. Objective: To determine theeffect of previous concussion history,presence of learning disability,psychiatric disorder and baseline totalsymptom score on neurocognitiveperformance. Design: Cross-sectional. Setting: Clinical researchcenter. Patients or Other Parti-cipants: Two-hundred forty DivisionI college athletes (age: 19.41±1.21,height: 70.01±4.90 in, weight:78.12±18.03 kg). Individualsidentified with a previous concussion,learning disability, attention deficithyperactivity disorder (ADHD) orpsychiatric disorder and/or a totalbaseline symptom score of 5 or morewere placed into a significant historygroup (HX, n=121), all otherindividuals were placed into a controlgroup (CON, n=119). Inter-ventions: Subjects were administeredthe computerized neurocognitive testCNS Vital Signs (CNSVS), includinga baseline symptom checklist and ahistory questionnaire. The mainoutcome measures of the HX and CONgroup were compared usingindependent t-tests. Main OutcomeMeasures: CNSVS standard scoresfor verbal memory, visual memory,

processing speed, executive function,psychomotor speed, reaction time,complex attention and cognitiveflexibility. Results: The HX groupdemonstrated significantly lowerscores, indicating worse performanceon 4 of the 8 CNSVS domainsanalyzed, including verbal memory(94.59±19.72 vs. 100.98±17.95,p=0.009), executive function(95.12±18.922 vs. 100.54±15.00,p=0.015), complex attention(85.16±68.99 vs. 100.99±26.42,p=0.018) and cognitive flexibility(93.71±20.07 vs. 100.25±15.27,p=0.005). There were no significantdifferences observed between thegroups on visual memory, processingspeed, psychomotor speed, or reactiontime. Conclusion: Certain collegeathletes, including those with a historyof one or more previous concussions,a learning disability, ADHD,psychiatric disorder and/or a totalbaseline symptom score of 5 or moremay perform worse than a normativesample on select neurocognitivedomains. Therefore, baseline testing isessential for individuals with asignificant history. Additionally, ifindividuals with a significant historysustain a concussion and do not have abaseline test, their post-injury scoresshould be interpreted carefully.

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The Effect Of The EnvironmentOn Sport ConcussionAssessment Tool 2 (SCAT2)ScoresSmith DH, Bowman TG, BradneyDA, Cowden NE: Old DominionUniversity, Norfolk, VA, andLynchburg College, Lynchburg,VA

Context: With the incidence ofconcussion in sport on the rise, it iscrucial that the concussionassessment tools utilized by healthcare professionals be accuratelyadministered. It may be important toconsider the environment of testadministration between baseline andpost-concussion assessment to allowappropriate examination and return toplay decisions. Previous work hasfound that the testing environmentalters Balance Error Scoring Systemscores. However, there is limitedresearch on the effect of testingenvironment on Sport ConcussionAssessment Tool 2 (SCAT2) scoresalthough it is the recommendedexamination tool for concussion.Objective: To determine if testingenvironment has an effect on SCAT2scores in healthy collegiate clubathletes. Design: Experimental,randomized controlled clinical trial.Setting: Uncontrolled sideline of anathletic field during a practice and aquiet controlled classroom. Patientsor Other Participants: A total of 18healthy male club lacrosse players(age=20.39±1.46 years, height=180.17±6.92 cm, mass=81.89±8.92kg) and 15 healthy female club soccerplayers (age=19.41±1.24 years,height=158.53±6.81 cm, mass=58.85±7.53 kg) with no history of headinjury within the last 12 months, nolower extremity injuries reportedwithin the past 2 months, and nohistory of Attention Deficit Disorderor Attention Deficit HyperactivityDisorder volunteered to participate.Interventions: Participantscompleted the SCAT2 test in 2

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environments, controlled quietclassroom and uncontrolled sideline,in 2 testing sessions approximately8.05±1.63 days apart. We counter-balanced the testing sessions to reducea practice effect altering the results.Main Outcome Measures: TheSCAT2 is a written standardizedconcussion test comprised of eightcomponents: symptom score, physicalsigns score, Glasgow coma scale,Maddocks score, cognitiveassessment, balance examination,coordination examination, andcognitive assessment. We used aMANOVA to examine the differencesbetween testing environments for the8 component scores and the totalscore of the SCAT2. Results: Wefound statistically significant groupmean differences between testingenvironments in the combineddependent variables for males(multivariate F

7,28=6.759, P<0.001, 1-

˜ = 0 . 9 9 8 , ˜2=0.628), females(multivariate F

6,23=8.306, P<0.001, 1-

˜ = 0 . 9 9 9 , ˜2=0.684), and acombination of both sexes(multivariate F

7,58=11.098, P<0.001,

1-˜=1.000, ˜2=0.573). The modifiedBESS was most affected by theenvironmental differences in males(F

1,34=17.118, P<0.001, 1-˜=0.981,

˜ 2=0.311), females (F1,28

=23.805,P<0.001, 1-˜=0.997, ˜2=0.432), andboth sexes combined (F

1,64=36.767,

P<0.001 , 1 - ˜=1 .00 , ˜2=0.351).Conclusions: SCAT2 scores wereimpaired when we tested participantsin a sideline environment comparedwith a quiet clinical environment. Anoutside, uncontrolled environmentcan potentially alter SCAT2 scoressignificantly from an inside,controlled environment potentiallydue to several factors includingnoise level, weather, playing surface,or interference from coaches andteammates. We recommend baselineSCAT2 testing be administered in anenvironment in which testing afterinjury will most likely be conducted.

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Psychometric Evaluation Of TheStandardized Assessment OfConcussion In High SchoolStudent-AthletesHaley JT, Mc Elhiney DS, RaganBG, Kang M: Middle TennesseeState University, Murfreesboro,TN, and Division of AthleticTraining, Ohio University, Athens,OH

Context: The StandardizedAssessment of Concussion (SAC) is aconcussion screening tool used toidentify concussions by comparing abaseline score with a post-injury score.Previous studies have examined thevalidity and reliability of the SAC test;however, one of the most fundamentalevaluations, classic item analysiswhich evaluates the psychometricproperties (i.e., item difficulty anddiscrimination) of the items, has notbeen examined in high school student-athletes Objective: The purpose ofthis study was to perform an classicitem analysis on the SAC in order toexamine its validity as a baselinemeasurement for use in high schoolstudent-athletes. Design: Observa-tional design. Setting: Athletic Traineradministered the SAC in a quiet roomaway from distractions. Patients orOther Participants: One Hundredforty-two high school student-athletes(89=M, 53=F; mean age = 16.13 SD= 1.18) with no history of concussionwithin the previous 6 months wererecruited for this study.Interventions: The SAC test iscomprised of 4 sections assessingorientation, immediate memory,concentration, and delayed memory.Three versions of the SAC, reportedas equivalent, were counterbalancedand given to each participant. MainOutcome Measures: Iteman software(V 3.6) was used to calculate itemdifficulty and item discrimination.Item difficulty (P) is reported as aproportion of those who answered anitem correctly. Item discrimination(r

pb) is reported as a point biserial

correlation. National Commission forCertifying Agencies (NCCA)standards were used to evaluate whichitem statistics were appropriate.Acceptable item difficulty ranged from0.10 to 0.92. Acceptable itemdiscrimination was a point-biserialcorrelation of >0.10. Based on theacceptable item difficulty andacceptable item discrimination, anitem determination was determined todecide whether or not the item wasacceptable. Results: All threeversions of the SAC had unacceptableitems (A = 50%, B = 60%, C =63.33%). The vast majority of theunacceptable items were in theorientation and immediate memorysections. All five orientation itemswere considered unacceptable in thethree versions. Of the 15 items in theimmediate memory section ofversions A, B, and C, there were 10,12, and 14 unacceptable items,respectively. Conclusions: Thisstudy demonstrates that some items onthe SAC are too easy in the high schoolpopulation, which produces a ceilingeffect. Increasing number ofacceptable items in the current SACis important to ensure the safety ofathletes returning to play followingconcussion. Future research shouldfocus on altering the SAC (i.e.,modifying existing items or testingnew items) in order to improve theitem psychometrics of the SAC.

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Free Communications, Thematic Spitfire Session: Neuromuscular andBiomechanical Consequences of ACL ReconstructionWednesday, June 26, 2013, 8:00AM-9:00AM; Palm B; Moderator: Grace Golden, PhD, ATC, CSCS1 3 1 0 7 D O N E

Quadriceps Activation AndSpinal-Reflexive ExcitabilityPredicts Quadriceps StrengthFollowing Anterior CruciateLigament ReconstructionLepley AS, Clements AE, EricksenHM, Sohn DH, Levine JW, GribblePA, Pietrosimone BG: Universityof Toledo, Toledo, OH

Context: Quadriceps weakness iscommon following anterior cruciateligament reconstruction (ACLr) andoften persists long after patientsresume normal activity. Neuralinhibition of the quadriceps maycontribute to this ongoing weakness,which could lead to prolongeddisability within this population.New rehabilitative strategies thatattempt to overcome neuralinhibition by increasing voluntaryactivation through stimulation ofneural pathways have been proposedto improve muscle strength.Understanding how neuralexcitability and voluntary activationcontribute to muscle strength iscrit ical in developing newtherapeutic techniques that willultimately improve functionfollowing injury. Objective: Toevaluate the ability of quadricepsactivation and spinal-reflexiveexcitability to predict quadricepsstrength in patients with ACLr.Design: Descriptive laboratorystudy. Setting: Research laboratory.Patients or Other Participants:Twenty-five patients with a history ofACLr (17 Female, 8 Male; age: 21.5± 3.9years; height: 171±10.5cm;weight: 71.8±17.1kg; 49.9±37.8months post-surgery) who had beenmedically cleared for fullparticipation in physical activitywere included in this study.Interventions: Vastus medialisstrength, voluntary activation andspinal-reflexive excitability were

tested in the injured limb in a randomorder. Main Outcome Measures:Quadriceps strength was assessed viamaximal voluntary isometriccontractions (MVIC) normalized tobody mass (Nm/kg) and performedat 90° of knee flexion in anisokinetic dynamometer. Quadricepsactivation was determined by usingthe central activation ratio (CAR)obtained through the burstsuperimposition technique.Quadriceps spinal-reflexiveexcitabili ty was assessed usingmaximal Hoffmann reflexesnormalized to maximal muscleresponses (H:M). Simple PearsonProduct correlations wereperformed to determine if spinal-reflex excitability and voluntaryactivation had a higher relation tostrength. Both voluntary activationand spinal-reflexive excitability werehierarchically added into a multipleLinear Regression to determinetheir ability to predict quadricepsstrength. The change in R2 to themodel from the addition of eachpredictor variable was also analyzed.Alpha was set a priori at P<0.05.Results: H:M (r = 0.528; P<0.01)had slightly higher relation to MVICthan CAR (r = 0.525; P<0.01). Theoverall multiple regression modelsignificantly predicted 45% of thevariance in quadriceps strength (R2

= 0.451, P=0.01; MVIC= 1.85H:M

+2.55CAR

- 0.081). Initial imputationof H:M into the model accounted for27.8% (R2=0.278, P<0.01) of thevariance in MVIC. The subsequentaddition of CAR accounted for asignificant increase of 17.3% (˜R2

= 0.173, P=0.01) in the predictioncapabili ty of the model.Conclusions: Quadriceps activationand spinal-reflexive excitabilitypredicted nearly half of the variancein quadriceps strength of ACLrpatients. This may be interpreted asevidence that neural pathways are

essential in generating quadricepsstrength in ACLr patients.Interventions targeting neuralpathways may be beneficialto restore optimal quadricepsstrength following surgery andpotentially improve function.

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Preoperative QuadricepsActivation Is Associated WithPostoperative QuadricepsActivation, Not Strength,Following Anterior CruciateLigament ReconstructionLepley LK, Palmieri-Smith RM:University of Michigan, Ann Arbor,MI

Context: It is well accepted thatgreater preoperative quadricepsstrength leads to a better recovery ofstrength following anterior cruciateligament (ACL) reconstruction.Although quadriceps activation failureis considered to contribute to thequadriceps weakness that lingersfollowing ACL reconstruction, theimpact of preoperative quadricepsactivation on postoperative quadricepsstrength and activation is lessunderstood. It seems plausible thatbetter preoperative quadricepsactivation can help improve therecovery of quadriceps function post-surgery. Understanding the factors thatcontribute to the best postoperativequadriceps function could helpclinicians design more effectivepreoperative interventions.Objective: Determine if quadricepsactivation and strength prior to ACLreconstruction are related topostoperative quadriceps function.Design: Descriptive laboratory study.Setting: University Laboratory.Patients or Other Participants:Thirty-nine individuals post-ACLinjury (18 male, 21 female; age19.21±5.0 yrs; height 1.74±0.01 m;mass 72.89±16.1 kg) reported fortesting on two occasions: post-ACLinjury (2.47±2.4 months) and post-ACL surgery once they returned toactivity (7.35±1.1 months).Interventions: Quadriceps activationwas assessed using the burstsuperimposition technique, andquantified by averaging three trials ofthe central activation ratio. Threemaximal knee extension trialscollected via an isokinetic

dynamometer at 60°/second wereaveraged and normalized to subjectbody mass (Nm/kg) to quantifyquadriceps strength. Main OutcomeMeasures: Linear regressions wereused to examine the relationshipbetween 1) preoperative andpostoperative activation, 2)preoperative activation andpostoperative strength and 3)preoperative and postoperativestrength. Results: Preoperativequadriceps activation was found to beassociated with postoperativeactivation (R2=0.169, b=0.412,P=0.009), but not strength (R2=0.018,b=-0.134, P=0.416). Preoperativestrength was associated withpostoperative strength (R2=0.268,b=0.518, P=0.001). Conclusions:ACL patients with better preoperativequadriceps activation and strengthrecovered quadriceps activation andstrength better than those with lowerpreoperative quadriceps function.Because previous research hasdemonstrated a relationship betweenquadriceps activation and strength inhealthy individuals, we had anticipatedthat preoperative quadriceps activationwould affect postoperative quadricepsstrength. However, our data indicatesthat preoperative quadriceps activationis not a good predictor ofpostoperative strength. Preoperativeactivation may be mediated by otherfactors such as pain and effusion.Rehabilitation programs for ACLpatients should focus on maximizingquadriceps activation and strengthprior to surgery to optimize thesemeasurements of quadriceps functionpostoperatively. Supported by NIHGrant K08 AR053152-01A2

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Anterior Cruciate LigamentInjury Causes BiomechanicalAlterations In Both The InjuredAnd Non-Injured Leg: The JUMPACL StudyGoerger BM, Marshall SW, BeutlerAI, Blackburn JT, Wilckens JH,Padua DA: George MasonUniversity, Manassas, VA; TheUniversity of North Carolina atChapel Hill, Chapel Hill, NC;Uniformed Services University ofthe Health Sciences, Bethesda,MD; Johns Hopkins University,Baltimore, MD

Context: Those with anterior cruciateligament (ACL) injury andreconstruction (ACLR) display lowerextremity biomechanics that maypredispose them to subsequent ACLinjury and osteoarthritis. There islimited evidence regarding whetherthese factors are induced by ACLR orexisted prior to injury. Objective: Todetermine the effect of ACL injury andACLR on lower extremitybiomechanics. Design: Repeatedmeasures, case-cohort Setting:Research laboratory Participants:Seventy participants of the JUMP ACLstudy, a multi-year prospective studyconducted at the United States serviceacademies to identify risk factors fornoncontact ACL injury, completedtesting for this analysis, 31 whosuffered an ACL injury (Cases) and 39who did not. Because unilateralbiomechanics were collected duringinitial testing, Cases were divided intothose that injured the tested limb(ACLR-INJ: n=12 (8 males, 4females), Age=21.42±0.79 years,Height=174.29±7.56 cm, Mass=76.25±9.95 kg) and those that injuredthe non-tested limb (ACLR-NINJ:n=19 (9 males, 10 females), Age=21.47±0.77 years, Height= 170.05±9.13 cm, Mass=72.87±12.78 kg).Participants who never suffered anACL injury (CON: n=39 (20 males, 19females), Age=20.98±0.73 years,Height:172.73±8.99 cm, Mass=

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73.11±13.16 kg) were matched forcohort year, academy, and gender.Interventions: Three-dimensionallower extremity kinematics andkinetics were collected during adouble-leg jump landing during initialenrollment in the JUMP ACL studyprior to ACL injury and ACLR(Baseline) and following ACL injuryand ACLR (Follow-Up). MainOutcome Measures: Joint angles atinitial ground contact (IGC), peakvalues during the landing phase (LP),and normalized internal jointmoments, vertical ground reactionforce (VGRF), and anterior tibialshear force (ATSF) were recordedduring LP. Mixed model (Time:Baseline, Follow-Up; Group: ACLR-INJ, ACLR-NINJ, CON) analyses ofcovariance (Gender) were performedfor each dependent variable. Results:ACL injury and ACLR caused anincrease in hip adduction(F

(2,66)=3.773, p=0.028) and knee

valgus angles (F(2,66)

=3.957,p=0.024) at IGC for both ACLR-INJ(Hip Adduction: Baseline=-11.12°±6.64°, Follow-Up= 0.02°±9.65°; Knee Valgus: Baseline=2.61°±6.54°, Follow-Up=-4.22°±5.78°) and ACLR-NINJ (HipAdduction: Baseline=-9.00°±6.61°,Follow-Up=0.41°±9.61°; KneeValgus: Baseline=1.33°±6.51°,Follow-Up=-4.84°±5.76°) groups.Both groups demonstrated adecrease in peak knee varus angleduring LP (F

(2, 66)=5.198, p=0.008)

(ACLR-INJ: Baseline=7.48°±7.48°,Follow-Up=1.28°±7.14° ; ACLR-NINJ: Baseline=9.27°±7.44°,Follow-Up=0.55°±7.11°). TheACLR-NINJ group demonstrated anincrease in peak knee valgus angleduring LP (F

(2,66)=3.768, p=0.028)

(ACLR-INJ: Baseline=-5.26°±8.19°, Follow-Up=-11.61°±7.74°).The ACLR-INJ group demonstrateda decrease in peak knee extensionmoment (F

(2,66)=4.509, p=0.015)

(ACLR-INJ: Baseline=-0.23±0.06Nm/BH*BW, Follow-Up=-0.17±

0.04 Nm/BH*BW), peak hip flexionmoment (F

(2,66)=3.847, p=0.026)

(ACLR-INJ: Baseline=-0.26±0.10 Nm/BH*BW, Follow-Up=-0.14±0.07 Nm/BH* BW), and ATSF(F

(2,66)=4.530, p=0.014) (ACLR-INJ:

Baseline =1.25±0.32 N/BW, Follow-Up=0.92±0.25 N/BW). TheCON group only demonstrated anincrease in peak internal kneerotation angle during LP(F

(2,66)=4.204, p=0.019) (CON:

Baseline=9.18°±8.66°, Follow-Up=17.10°±8.23°). Conclusions:ACL injury and ACLR causesalterations in hip and kneekinematics for both the injuredand non-injured limb, and may berelated to continued avoidance ofloading the injured limb.

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Gender Differences In LowerExtremity NeuromuscularFunction Following 30 MinutesOf Sub-Maximal Exercise In ACLReconstructed IndividualsKuenze C, Hertel J, Hart JM:University of Virginia,Charlottesville, VA

Context: Return to physical activityis the primary goal of many patientsfollowing ACL reconstruction. Theeffects of a return to exercise in thepresence of lower extremityneuromuscular dysfunction remainunclear however; those who return toa higher level a physical activity appearto be at a higher risk for knee jointosteoarthritis (OA). Female patientshave been shown to be less likely toreturn to high levels of physicalactivity as well as more likely todevelop post-traumatic knee joint OAover time. Objective: To comparequadriceps neuromuscular functionafter exercise between males andfemales with ACL reconstructedknees. Design: Descriptive laboratorystudy. Setting: Laboratory. Patientsor Other Participants: Twenty-sixrecreationally active persons (13M/13F: age=24.1±4.4yrs, height=179.1±9.8cm, mass=80.1±9.4kg,time since surgery= 43.5±37.0mo;age=24.2±5.6yrs, height =163.0±5.9cm, mass =62.3 ±8.3kg, timesince surgery= 45.8±42.7mo) with ahistory of unilateral, primary ACLreconstruction at least 6 months priorto testing. Interventions: 30 minutesof continuous exercise comprised ofrepeated bouts of 5 minutes of uphillwalking and 1 minute of body weightsquatting and step-ups. MainOutcome Measures: Normalizedknee extension maximal voluntaryisometric contraction (MVIC) torque,quadriceps central activation ratio(CAR) before and after exercise.While participants performed maximalisometric knee extension, an electricalstimulus was triggered causing atransient increase in torque (SIB). CAR

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was calculated as (MVIC/SIB)*100.Separate 2 (gender: male, female) x 2(time: baseline, pre-exercise) repeatedmeasures ANOVAs were performedfor knee extension torque,superimposed burst torque, andquadriceps CAR. Separate independentsamples t-tests were performed tocompare pre- to post-exercise changein knee extension torque,superimposed burst torque, andquadriceps CAR between genders.Results: There was a significant groupx time interaction for knee extensiontorque (F

(1,24)= 4.72, P=0.04) with

females (pre-exercise=2.56±0.70Nm/kg; post-exercise=2.28±0.65 Nm/kg) experiencing a decline in kneeextension torque while males (pre-exercise=2.63±0.68 Nm/kg; post-exercise=2.62±0.55 Nm/kg) did not.There was no significant group x timeinteraction for quadriceps CAR(F

(1,24)=4.02, P=0.06) however, there

was a significant time main effect(P=0.02, pre-exercise=75.2±13.4%;post-exercise=71.2±13.2%) forquadriceps CAR with participantsexperiencing a reduction in quadricepsactivation following exerciseregardless of group. The percentreduction in knee extension MVICtorque (t

(24)=2.60, P=0.02) and

quadriceps CAR (t(24)

=2.27, P=0.03)experienced by male participants( C A R = - 1 . 4 5 ± 9 . 4 5 % ,MVIC=1.94±12.17%) was smallerthan those measured in femaleparticipants (CAR=-8.69±6.59%,M V I C = - 1 0 . 3 2 ± 1 1 . 8 4 % ) .Conclusions: Female participantsexperienced reductions in isometricknee extension torque and quadricepscentral activation ratio following30 minutes of exercise. The reducedfatigability seen in male participantsmay be indicative of compensatorystrategies developed followingACL reconstruction in order to copewith continuous exercise bydecreasing the demand on thequadriceps during exercise.

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Unipedal Postural Control AfterExercise In Individuals With ACLReconstructed KneesGoetschius J, Kuenze C, Saliba S,Hart JM: University of Virginia,Charlottesville, VA

Context: Returning to exercise andsport is a common goal for patientsfollowing anterior cruciate ligamentreconstruction (ACL-R).Sensorimotor deficits may impede onpatients ability to return to pre-injurylevels of activity. The effects ofexercise in patients with ACL-R mayprovide information aboutsensorimotor changes experienced inthis population as they return tophysical activity. Objective: Tocompare the effects of 36-minutes ofcontinuous exercise on unipedalpostural control in ACL-R individualsand healthy controls. Design: 2(Group: ACL-R, control) x 2 (Time:baseline, post-exercise) descriptivelaboratory study. Setting: Laboratory.Patients or Other Participants:Forty recreationally active volunteers:Twenty (sex= 10F/10M, age=25.5±5.5yrs, height= 1.8±0.1m,mass= 76.7±14.4kg, time-from-surgery: 5.0±4.3yrs) with a history ofprimary, non-complicated ACL-R atleast 6 months prior and twenty healthycontrols (sex= 10F/10M, age=24.6±5.0yrs, height= 1.7±0.1m,mass= 65.2±12.1kg). Interventions:A series of 6 repeated cycles (eachlasting 6-minutes, total=36 minutes),Each cycle included 5-minutes ofinclined treadmill walking and 1-minute of jumping exercises. Heartrate, rating of perceived exertion weremonitored prevent exhaustion. MainOutcome Measures: Three 10-second trials of static, unipedal stancewith eyes closed and arms crossedwere assessed using a force plate andcenter of pressure (COP) excursions.Medial-lateral (COP

ML-SD) and anterior

posterior (COPAP-SD

) standarddeviations, velocity (COP

Vel), and area

(COPArea

) were calculated. COPML-SD

,

COPAP-SD

, and COP

Area were analyzed

using nonparametric statistics. Groupdifferences at baseline and post-exercise were assessed using Mann-Whitney U tests, and baseline to post-exercise changes in groups wereassessed using Wilcoxin Signed Ranks.COP

Vel was analyzed using parametric

statistics; effects of group andexercise were assessed using a 2x2ANOVA with repeated measures.Results: COP

ML-SD,

COP

AP-SD, or

COPArea

was no different betweengroups at baseline or post-exercise.Exercise had no effect on COP

ML-SD in

the ACL-R group (1.10[0.93, 1.20] to1.15[0.93,1.38], p=0.530), butsignificantly increased COP

ML-SD in the

control group (1.15[0.93, 1.28] to1.20[1.10, 1.30], p=0.040). Exercisesignificantly increased COP

AP-SD in the

ACL-R (1.15[1.00, 1.38] to 1.40[1.10,1.68], p=0.007) and control (1.20[1.00, 1.58] to 1.45[1.20, 1.90],p<0.001) groups. Exercisesignificantly increased COP

Area in

the ACL-R (22.65[19.20, 26.35]to 29.90[18.65, 39.60], p=0.014) andcontrol (24.55[16.73, 32.98] to32.85[25.08, 47.35, p=0.023) groups.On average, COP

Vel significantly

increased (p=0.013) from baseline( A C L - R = 8 . 8 1 ± 2 . 2 4 ,control=9.92±2.73) to post-exercise( A C L - R = 9 . 6 9 ± 2 . 4 4 ,control=10.87±2.97), but there wereno significant group (p=0.081)or group x time (p=0.415) effects.Conclusions: ACL-R does not effectpostural control in a rested state.An exercise-induced increase inCOP measures suggests individualsmust adjust to the constraintsof exercise by broadeningsensorimotor strategies. ACL-Rpatients may be limited in their abilityto properly adapt to the constraintsof exercise. This may place themat greater risk for functional jointproblems when attempting to returnto sport and exercise.

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Quadriceps Function AfterRepeated Bouts Of Exercise InPatients With ACLReconstructionChang EW, Kim KM, Hart JM,Hertel J: Oregon State University,Corvallis, OR; Texas StateUniversity, San Marcos, TX;University of Virginia,Charlottesville, VA

Context: Quadriceps activationfailure and weakness have beenreported in patients with anteriorcruciate ligament reconstructions(ACL-R). Limited information isavailable regarding the quadricepsresponse after exercise in people withACL-R. Objective: To compareneuromuscular function of thequadriceps following repeated bouts ofexercise between individuals with andwithout a history of ACL-R. Design:Case-control. Setting: Laboratory.Patients or Other Participants:Eight subjects with unilateral ACL-R(age=24.8±5.1yrs, height =176.7±14.2cm, mass=82.9±17.9kg) and 10healthy subjects (age=26.9±5.3yrs,h e i g h t = 1 7 3 . 8 ± 8 . 5 c m ,mass=70.2±12.4kg) participated.Interventions: All subjects performed30 minutes of exercise on twoconsecutive days. In each 30-minexercise, there were 5 repeated cyclesof aerobic and nonaerobic exercise,each of which consisted of 5-mintueincremental treadmill walking and 1-minute of jumping exercises. MainOutcome Measures: Knee extensiontorque and CAR were measured duringa knee extension maximal voluntaryisometric contraction (MVIC). CARwas measured as the ratio betweenMVIC and the peak torque generatedby an electrical stimulation deliveredto the thigh superimposed during theMVIC test. Outcomes were recorded4 times: before and after exercise onthe first and second day of exercise andcompared with a 2X4 repeatedmeasures ANOVA and post hoc testingwhere appropriate. Results: There was

a significant group by time interactionfound for knee extension torque in thereconstructed side limbs(F

3,48=4.64,P=.006). On day 1, ACL-

R (2.85±.33 Nm/kg) were significantlyweaker compared to healthy atbaseline(3.84±.30 Nm/kg, P=0.01).Knee extension torque significantlydecreased approximately 21%following exercise(P=0.01) in thehealthy group whereas the ACL-Rgroup only experienced on average a9% reduction(P=0.13). On day 2, theknee extension torques of the healthygroup before exercise weresignificantly lower than pre-exercisetorques on day 1(P=0.03), indicatinglack of full recovery of quadricepsstrength 24 hours after exercise. Incontrast, the pre-exercise kneeextension torques of the ACL-R groupwere not different between day 1 and2(P=0.73). For a group comparisonof pre-exercise torques on Day 2, theACL-R group tended to have lowerknee extension torque comparedto healthy controls, but the differencewas not statistically significant(P=0.07). Following exercise theextension torques significantlydecreased in both groups:approximately 15% reduction found inthe healthy group(P<0.001)and approximately 11% reductionfound in the ACL-R group(P=0.03)Conclusions: ACL-R patients areweaker and less activated than healthycontrols. ACL-R patients respondto exercise differently and appearto experience less deteriorationof quadriceps strength after a singlebout of exercise, but not after 2bouts of daily exercise.

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Fatigue Alters Hip BiomechanicsAnd Postural Stability InFemales With Anterior CruciateLigament ReconstructionGilsdorf CM, Frank BF, GoergerBM, Prentice WE, Padua DA: TheUniversity of North Carolina atChapel Hill, Chapel Hill, NC, andGeorge Mason University,Manassas, VA

Context: Females with a history ofACL injury and subsequent surgicalreconstruction (ACLR) are at high riskfor future ACL injury. Fatigue mayinfluence the increased risk of futureinjury in these individuals by alteringlower extremity (LE) biomechanics orbalance. However, there is limitedresearch investigating the effects offatigue in females with ACLR.Objective: To determine the effect offatigue on hip and knee biomechanicsand balance in females with ACLR.Design: Cross-sectional, repeatedmeasures. Setting: Researchlaboratory. Patients or OtherParticipants: Fourteen physicallyactive females with ACLR(age=19.64±1.5 years; height=163.52±6.18 cm; weight=62.6±13.97kg) volunteered for this study.Interventions: Participantsperformed a fatigue protocolconsisting of repeated, weighted squats(30% bodyweight) from 0° to 60° ofknee flexion at a rate of 25 squatcycles per minute. The fatigueprotocol was terminated whenparticipants fell four squat cyclesbehind the set rate or failed tocomplete two sequential squat cycles.LE biomechanics were assessedduring five jump-landing trials. Thejump-landing task consisted ofparticipants jumping forward(distance=50% of body height) froma box (height=30 cm) onto a forceplate. Balance was assessed asparticipants stood on their involvedlimb with their eyes closed (3 trials,20 sec each trial) while on a forceplate. All measures were performed

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before and after the fatigue protocolon the ACLR limb. Paired t-tests wereperformed to compare LEbiomechanics and balance variablesbefore and after the fatigue protocol.Main Outcome Measures: LEbiomechanical variables were definedas three-dimensional hip and knee jointdisplacements (degrees) and peak jointmoments (normalized to body weight* height). These variables wereaveraged across 5-trials during theloading phase (time from initialcontact to peak knee flexion). Balancewas quantified as the sway path (cm),averaged across 3-trials. Results: Hipflexion displacement (t=2.23,P=0.044; pre-fatigue=45.19±14.10,post-fatigue=47.48±14.21) andmoment (t=2.14; P=0.052; pre-fatigue=1.66±0.68, post-fatigue=1.91±0.62) were significantlyincreased from pre- to post-fatigue.No other LE biomechanical variableswere altered after fatigue (P>0.05).Sway path was also significantlyincreased after the fatigue protocol(t=3.925; P=0.002; pre-fatigue=102.54±19.36 cm, post-fatigue=124±34.51 cm). Conclusions: Weobserved increased hip flexiondisplacement and moment during ajump-landing and decreased single-legbalance in females ACLR limb afterfatigue. Increased hip flexion isdescribed during ACL injurymechanisms and decreased balance isassociated with increased risk of futureACL injury in those with ACLR. Thus,fatigue in ACLR females may partiallyexplain the high risk of future ACLinjury in these individuals. Futureresearch examining the relationshipbetween fatigue and risk of future ACLinjury in those with ACLR is warranted.

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Free Communications, Oral Presentations: Management of OsteochondralInjuriesWednesday, June 26, 2013, 9:15AM-10:15AM; Palm B; Moderator: James Onate, PhD, ATC1 3 3 9 8 D O M U

Differences In Self-ReportedPain And Function For PatientsWith Anterior Cruciate LigamentInjury When ComparedAccording To Bone BruiseLesion SeverityHoch JM, Mattacola CG, Bush HM,Gonzalez L, Hewett TE, MedinaMcKeon JM, Lattermann C:University of Kentucky, Lexington,KY; Old Dominion University,Norfolk, VA; Appalachian StateUniversity, Boone, NC; Ohio StateUniversity, Columbus, OH

Context: There is inconsistentevidence regarding differences in self-reported pain and function in patientsfollowing anterior cruciate ligament(ACL) injury when comparedaccording to the presence or absenceof bone bruise lesions (BBL).Classifying individuals based on theseverity of the BBL is more specificand may provide better criteria forstratifying self-reported pain andfunction in ACL-injured patients.Objective: To determine ifdifferences in self-reported pain andfunction would be observed forpatients with differing BBL severities(Costa-Paz (CPC) I, II, or III). Design:Cross-sectional. Setting: Ortho-paedic clinic. Patients or OtherParticipants: A convenience sampleof 51 subjects participated. Only onesubject was classified as CPC-I;therefore, the final analysis includesonly patients with CPC-II and CPC-IIIBBL (CPC-II: 15males, 13females,age:21.8+9.2years, height: 172.7+8.2cm, mass:74.5 +19.7kg, CPC-III:11males, 11 females, age:20.3+8.8years, height: 174.8+9.3cm,mass: 78.1+ 19.5kg). Subjects had anMRI documenting ACL injury andconcomitant BBL, and an evaluation byorthopaedic physician within 4 weeksfollowing injury. Interventions: Theseverity of each BBL was determined

and subjects were classified accordingto their most severe BBL (CPC-II:n=28; CPC-III: n=22). MainOutcome Measures: Three patientreported outcome measures werecompleted (Knee Injury andOsteoarthritis Outcome Score(KOOS)), International KneeDocumentation Committee (IKDC),and the Short-Form 12 (SF-12). Thedependent variables (DV) were scoreson the KOOS subscales: KOOS-Pain,KOOS-Function, KOOS-Activities ofDaily Living, KOOS-Quality of Life(QOL), KOOS-Sport, the IKDC scoreand the SF-12 Physical and Mentalcomponents. An ANCOVA wasemployed to determine if differencesin the DV are present when subjectsare compared according to differingBBL severities (CPC-II and CPC-III).Covariates included age, total numberof BBL, total BBL volume and timeelapsed from injury to data collection.Alpha was set a priori at p<0.05.Adjusted means and associated 95%confidence intervals (95%CI) arepresented for significant differences.Results: While controlling forconfounding variables, the resultsindicated patients with CPC-III BBLreported lower scores on the KOOS-Sport (9.6, 95%CI:2.0-17.2)compared to patients with CPC-II BBL(21.5, 95%CI:14.7-28.3, p=0.03). Inaddition, while controlling forconfounding variables, the resultsindicated patients with CPC-III BBLreported lower scores on the KOOS-QOL (23.9, 95%CI:17.1-30.8)compared to patients with CPC-II BBL(34.6, 95%CI:28.5-40.7, p=0.03).There were no other significantdifferences between the two groupsfor all other DVs (p>0.05).Conclusions: The severity of BBLinfluences several patient reportedoutcomes including the KOOS-Sportand KOOS-QOL. When confoundingvariables are controlled for, subjects

with CPC-III BBL reported greaterdifficulty in performing sport relatedactivities and lower quality of lifescores compared to the CPC-II group.Our findings support the impact ofconcomitant BBL on patient reportedoutcomes in patients with ACL injuryand the use of a severity classificationsystem for future research studiesinvestigating BBL outcomes.

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Bilateral Knee OsteochondritisDissecans In An AdolescentMale AthleteWood JM, Hackett TR, Ashton JM:The Steadman Clinic, Vail, CO

Background: This case presents a 17-year-old male student-athlete whoparticipates in football, basketball andweight lifting. Patient presented withchief complaint of sharp pain andweakness of the left knee. Initial injuryoccurred seven months earlier whenthe patient twisted his left knee landinga jump. Initially left knee was stiff butnot painful. He finished football andbasketball season but discomfortprogressively increased. Restingalleviated symptoms while activityexacerbated his pain, weakness anddiscomfort. Patient had no priorhistory of left knee pathology.Examination revealed mild left kneeeffusion. Patient had point tendernessover the distal medial femoral condyle(MFC) and medial joint line. Left kneeROM was 0ˆ-120ˆ; right knee was0 ˆ - 1 4 0 ˆ . A slight increase in painnoted with McMurray’s testing,negative Wilson’s test was present.Radiographs and magnetic resonanceimaging (MRI) of the left knee wereobtained prior to surgical intervention.At the patient’s one year follow-up hischief complaint was persistent kneepain of the contralateral knee withinsidious onset. Symptoms includedright knee popping, catching andclicking with running and walking, andchange in his gait pattern. Patient wastender to palpation over right medialjoint line and MFC. Right knee ROMwas 0ˆ-120ˆ with pain at terminalflexion. ROM of left knee was 0ˆ-130without pain. Patient had right kneepain with valgus stress. Radiographsand MRI of right knee were thenobtained. Differential Diagnosis:Spontaneous osetonecrosis of theknee, medial collateral ligamentinjury, insufficiency fracture,chondroblastoma, osteosarcoma,chondral fracture/stress fracture,

osteochondritis dissecans (OCD),synovial chondromatosis, infection/osteomyelitis, meniscal pathology,rheumatoid arthritis, slipped capitalfemoral epiphysis (SCFE).Treatment: Radiographs and MRI ofleft knee showed evidence of 15 mmOCD lesion involving theweightbearing MFC with intactoverlying cartilage. Based on imaging,physical examination, and failure ofconservative management, a left kneearthroscopy and retrograde drilling ofMFC with chondroplasty wasperformed. Postoperatively treatmentincluded pain medications, knee brace,crutches, and physical therapy. Patientwas extremely satisfied with left kneeprocedure outcome at one yearfollow-up and had returned to sportwithout recurrent symptoms.Radiographs and MRI of right kneerevealed similar OCD lesion involvingthe inferior lateral aspect of the MFCand evidence of open growth plates.Conservative treatment trial wasrecommended prior to any additionalsurgical procedures. Uniqueness:Symptomatic OCD lesions are rareand can be commonly overlooked onradiographic studies. Bilateral lesionsare even more uncommon (only 15-30% of cases). Etiology of OCDlesions remains unclear, but has beenlinked to repetitive trauma. OCDlesions classically involve lateralaspect of MFC (51% of cases). OCDlesions in skeletally immature patientsare most likely to heal with or withoutsurgical intervention. In this case,surgical intervention stimulatedhealing of OCD lesion after skeletalmaturity. OCD lesions that fail to healare commonly treated with cartilagerestoration procedures (includingautograft or allograft mosaicplasty/OATS). OCD lesions originate prior toskeletal maturity and should not beconfused with osteochondral defects,which are traumatic in origin andcommonly occur after skeletalmaturity. Conclusions: The patient isan adolescent athlete diagnosed with

symptomatic OCD lesions of bilateralMFC’s. Surgery was recommended inhope of decreasing likelihood ofprogression to an unstable OCD andpotential loose body. OCD thatbecome unstable can lead todegenerative joint problemsincluding osteoarthritis. OCD is arare disease in the generalpopulation, an important cause ofjoint pain in physically activeadolescents, and proper diagnosisand treatment of a young athlete bysports medicine professional ispertinent to joint preservation. D

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/doi/pdf/10.4085/1062-6050-48.3.s1 by guest on 27 August 2020


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Osteochondral AllograftTransplantation In A NCAADivision Ii IntercollegiateWomen’s Basketball AthleteGruber DM, Sefcik N, Peterson K:Ashland University, Ashland, OH

Background: A 20-year-old femaleintercollegiate basketball playerexperienced pain and effusion of aninsidious onset during preseasonworkouts in September of 2010. Thepatient’s chief complaints were painand stiffness along the medialpatellofemoral border and joint line.The patient also stated she felt apalpable soft tissue mass along themedial patellofemoral borderfollowing workouts. Duringexamination, the athletic trainerfound no signs of trauma other thansuperior and medial joint effusionindicative of intra articular injury tothe knee. Ligamentous and functionaltesting provided little evidence as tothe causation of the effusion. Thepatient was referred to the TeamPhysician for further evaluationfollowing two weeks of minimalprogression with symptomaticinterventions of NSAIDs, inter-mittent compression, and quadstrengthening. DifferentialDiagnosis: Patellar Tendinitis,Medial Retinacular Sprain,Chondramalacia, SymptomaticSynovial Plica, PatellofemoralPain Syndrome, PatellofemoralInstability. Treatment: Followingexamination by the Team Physician,an MRI was ordered to rule outstructural deformities and identifythe palpable soft t issue mass.Results of the MRI concluded a fullthickness chondral injury to thepatella along with a separatedfragment from the inferior pole. Theindividual was referred to a localorthopedic for follow up. At this time,the orthopedic felt an injection of 2ccKenalog and a patellofemoral J bracewould allow the individual to

participate until season’s end. When nosymptomatic relief was provided bythe injection, a second opinion wassought from another orthopedicsurgeon. Following this evaluation inNovember 2010, the patient underwentan abrasion chondroplasty of thepatella and removal of loose bodies.The patient did not return to basketballactivities during the 2010-11 season.Two months following this surgery,symptoms returned. At this point, aconservative approach of non weightbearing activity and isometric quadstrengthening was instructed from thephysician to reduce symptoms. In May2011, the patient began experiencingincreasing pain and effusion upon allweight bearing activity. She was thenreferred to another orthopedicspecialist for an osteochondralallograft transplantation. During thisvisit, June 2011, a final course ofaction was detailed for the patient inorder to resume her intercollegiateathletics career. Initially, a surgery todebride the patella and removed loosebodies was performed. Visco-supplementation was then utilizedduring the Fall of 2011 to allow thepatient to participate in basketball forthe 2011-12 season. Following thebasketball season in March 2012, aDeNovo allograft cartilagetransplantation was performed.Uniqueness: Evidenced basedoutcomes of allograft cartilagetransplantation in young and activepatient populations are limited. Alongwith this, multiple factors such asBMI, defect size, pre-existingconditions, and length of elapsed timebefore the transplantation confoundthe problem for athletic trainers as theyadvise patients, parents, and coacheson courses of action for return toactivity. Conclusions: The allografttransplantation was the only optionavailable to allow the athlete to returnto play prior to her eligibility toexpire. As of this submission, thepatient has been cleared to return to

intercollegiate basketball for the2012-13 season. She has experiencedno setbacks. This case highlights theconundrum of evidenced basedtreatment and rehabilitation algorithmsfor athletic trainers managingosteochondral defects, particularly onthe patellofemoral surface. Very littleRCTs exist for younger and activepopulations. Athletic trainers wouldbenefit from the knowledge ofsurgical protocol, graft failure rates,osteochondral hypertrophy, andosteoarthritis are all complicationsthat are byproducts of surgery.

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Comparison Of The OccurrenceOf Response-Shift AmongSporting And Non-SportingAutologous ChondrocyteImplantation(ACI) PatientsHoward JS, Mattacola CG,Lattermann C: University ofKentucky, Lexington, KY

Context: Response-shift is thephenomenon by which an individual’sstandards for evaluation change overtime due to a change in internalstandards, values, or constructdefinition. Response-shift has beenobserved in a variety of populationsincluding knee arthroplasty andcartilage patients. Failure to accountfor response-shift may result in overor under-reporting treatment effectson health related quality oflife(HRQL). The capacity toparticipate in sports greatly influencesathletes’ perceived HRQL. Whetherathletes are more prone to response-shift following interventions thatrestrict physical activity has not beenpreviously explored. Objective: Ourpurpose was to determine if patientsundergoing ACI who reported highlevels of sports participationexperienced greater response-shiftfollowing ACI than non/low-levelsports participants. It washypothesized that those individualswho prospectively self-identifiedthemselves as sporting wouldexperience more response-shift due tothe physical limitations imposedfollowing ACI (restrictions in weightbearing, physical activity, etc.).Design: Case-control Setting:Orthopaedic Clinic Patients:Individuals undergoing ACI who self-identified as non-sporting (n=25,34.6±7.1yrs, 92.6kg, 173cm) or assporting (n=22, 35.6±9.2yrs, 92.0kg,189.2cm). Intervention: All patientsunderwent ACI for the repair ofsymptomatic articular cartilagedefects. The “Then-Test” method was

used to evaluate response-shift in thefollowing patient reportedoutcomes(PROs) – the SF-36Physical Component Scale(SF-36PCS), the IKDC Subjective KneeEvaluation Form, and the LysholmKnee Scale. Each PRO was completedpre-ACI and 6 and 12 months post-surgery. At 6 and 12 months anadditional “then” version of each PROwas also completed. The “then”version was identical to the originalexcept that patients were instructed toassess how they were pre-ACI. It istheorized that by completing the then-test and post-test PROs at the sametime point the same frame-of-reference is utilized.Main OutcomeMeasures: Response-Shift (RS=then-score – pre-score) and Response-ShiftMagnitude (RSM=|then-score – pre-score|) were calculated at 6 and 12months. Independent t-tests were usedto compare RS and RSM valuesbetween groups at 6 and 12 months.Results: There were no differencesbetween groups for age, BMI, or defectsize. There were no differences in RSat 6 or 12 months or in RSM at 6months for any of the PROs. RSM at12 months was greater in the sportingthan non-sporting group for the IKDC(15.80±13.26 vs. 6.06±5.42,p=0.005), SF-36PCS (10.33±8.04 vs.5.72±4.90, p=0.046), and Lysholm(16±14 vs. 8±5, p=0.029).Conclusions: These results suggestthat sporting patients may recalibrate,reprioritize, or reconceptualize theirpersonal definition of physicalfunction during the first year followingACI. The failure to find a differencein RS values suggests that theresponse-shift experienced isnot uniform in direction and variesfrom patient-to-patient. Futureresearch is needed to determine if thisvariability in direction may beassociated with expectations forsurgery or intent to return to sports.

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Knee Evidence-Based ForumWednesday, June 26, 2013, 10:30AM-11:30AM; Palm B; Moderators:

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Shoulder Evidence-Based ForumThursday, June 27, 2013, 8:00AM-9:00AM; Palm B; Moderators:

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Free Communications, Oral Presentations: Adaptations and Kinetic Chain inPitchersThursday, June 27, 2013, 9:15AM-10:30AM; Palm B; Moderator: Jeffrey Cooper, MS, ATC1 3 1 3 4 F O N E

Excessive Glenoid RetroversionIs Associated With IncreasedRotator Cuff Strength In TheShoulderOwens BD, Campbell SE, PeckKY, Westrick RB, Cameron KL:Keller Army Hospital, United StatesMilitary Academy, West Point, NY

Context: The rotator cuff muscles arecritical secondary stabilizers in theshoulder. Increased glenoidretroversion has been associated withthe risk of posterior shoulderinstability; however, the impact ofincreased glenoid retroversion onrotator cuff strength remains unclear.Objective: To examine theassociation between glenoidretroversion and rotator cuff strengthin the shoulder. Design and Setting:This study represents a cross-sectionalanalysis of baseline data from aprospective cohort study conducted ata US Service Academy. Participants:574 college freshmen with no historyof glenohumeral joint instability atbaseline or during the 4 year follow-up period were included in the currentstudy. The average age, height, andweight of participants was 18.77±0.97years, 176.81±8.48 cm, and73.80±12.45 kg, respectively.Intervention/Methods: Baseline datacollected upon entry into the studyincluded bilateral MRI assessments ofglenoid version. All measures ofglenoid version were performed by amusculoskeletal radiologist blinded toall other baseline data. Rotator cuffstrength was also assessed at baselineusing a hand held dynamometer.Internal and external rotation strengthwas assessed with the glenohumeraljoint positioned in neutral and in 45ºof abduction. Main OutcomeMeasures: The primary dependentvariables of interest were the fourmeasures of rotator cuff strength. The

independent variable consisted of fourlevels based on quartile cut points forthe degree of glenoid retroversion.Four separate one-way ANOVAs, alongwith Scheffe post-hoc tests, were usedto examine mean between groupdifferences in rotator cuff strengthwith shoulder as the unit of analysis.Results: We observed significantmain effects for internal(F

3,1144=11.79, p<0.001) rotation

strength in neutral. Scheffe post-hocanalyses demonstrated that internalrotation strength was significantlyhigher in subjects in the upper quartile(4Q:53.65±13.99) for glenoidretroversion when compared to thosein the lower three quartiles(3Q:49.98±14.47, 2Q:49.09±13.04,1Q:46.93±13.16), respectively.Similar main effects were observedfor external (F

3,1144=9.62, p<0.001)

rotation strength in neutral and internal(F=13.66

3,1144, df=3, p<0.001) and

external (F3,1144

=15.70, p<0.001)rotation strength in 45º of abductionand post-hoc analyses demonstratedthat all rotator cuff strength measureswere significantly higher in subjectsin the upper quartile for glenoidretroversion when compared tothose in the lower three quartiles.No other significant between groupdifferences were observed.Conclusions: Increased glenoidretroversion has been previouslyassociated with acute posteriorshoulder instability. The increasedrotator cuff strength observedin those in the upper quarti lefor glenoid retroversion inthe current study may represent anacquired compensatory mechanismin these secondary stabilizers ofthe glenohumeral joint.

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The Acute Effects Of Hold-RelaxProprioceptive NeuromuscularFacilitation With VibrationTherapy On GlenohumeralInternal Rotation DeficitTucker WS, Slone SW: Universityof Central Arkansas, Conway, AR,and Lindenwood University -Belleville, Belleville, IL

Context: Glenohumeral internalrotation deficit (GIRD) is believed tobe a strong contributing factor toshoulder injuries in overhead throwingathletes. Clinicians use variousstretching techniques to prevent theonset of and treat GIRD. It is unknownwhich stretching technique is the mosteffective treatment for GIRD.Objective: To compare the acuteeffects of hold-relax proprioceptiveneuromuscular facilitation (PNF) withand without vibration therapy onglenohumeral internal rotation inindividuals with GIRD. Design: Two-within (stretch x time) comparison.Setting: Controlled laboratory.Patients or Other Participants:Eleven male overhead and formeroverhead athletes (19.8±1.4 years,184.5±4.5 cm, 91.8±11.6 kg)presenting with GIRD. Interventions:Participants reported for threeseparate sessions with a minimum ofseven days between sessions. At eachsession, three pretest maximumpassive glenohumeral internal rotationmeasurements were taken andaveraged on the throwing dominantshoulder with a digital protractor. Therewas a 60 second rest between eachpretest measurement. At each session,participants performed one of threerandomly assigned stretches: hold-relax PNF (PNF), hold-relax PNF incombination with a whole bodyvibration unit set at 30 Hz (PNF-V) andstatic stretch (SS). All stretchesinvolved a 30 second static stretch,

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while the PNF and PNF-V stretchesincluded a six second isometriccontraction prior to the static stretch.Three trials were performed for eachstretch with a 60 second rest betweentrials. Immediately after each trial,posttest maximum passiveglenohumeral internal rotationmeasurements were taken andaveraged with a digital protractor. Theindependent variables were stretch(PNF, PNF-V and SS) and time (pretestand posttest). Main OutcomeMeasures: The dependent variableswere the mean glenohumeral internalrotation measurements taken at thepretest and posttest. The influence ofstretch and time on meanglenohumeral internal rotation wascompared using a 3x2 factorialANOVA with repeated measures onboth variables (Pd”0.05). Tukey posthoc testing was applied in the event ofa significant interaction. Results:There was a stretch-by-timeinteraction (F

2,20=34.697; P<0.001).

Post hoc testing revealed that the PNFposttest (73.0±10.4°) was greater thanthe PNF pretest (60.0±11.8°), thePNF-V posttest (74.7±10.0°) wasgreater than the PNF-V pretest(57.4±10.4°), and the SS posttest(67.0±10.7°) was greater than the SSpretest (60.1±9.4°). Whencomparing the posttest values,the PNF-V posttest was greater thanthe SS posttest. Conclusions: All threestretches (PNF, PNF-V and SS)resulted in acute increases inglenohumeral internal rotation inindividuals presenting with GIRD. ThePNF-V stretch resulted in the greatestincrease in glenohumeral internalrotation and was significantly morethan the SS stretch. Utilization ofhold-relax PNF with vibration therapymay be clinically beneficial forindividuals with GIRD. Future researchinvestigating the long-term effectivenessof these stretching techniques onglenohumeral internal rotation is warranted.

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The Relationship BetweenClinically Measured HipRotational Motion And ShoulderBiomechanics During ThePitching MotionLaudner K, Wong R, Onuki T,Meister K, Lynall R: Illinois StateUniversity, Normal, IL, and TexasMetroplex Institute for SportsMedicine and Orthopedics,Arlington, TX

Context: Throwing a baseball has beendescribed as a kinetic chain of eventsthat begins with the development ofpower in the lower extremity, whichis then transmitted through the coreand finally to the upper extremity priorto ball release. Although, manyclinicians have hypothesized thataltered motion at one segment in thischain can affect the forces placed ondistal segments, little research hasexplored these relationships.Objective: To determine if alterationsin hip rotational motion affect theamount of external rotation torque orhorizontal adduction of the dominantshoulder developed during thethrowing motion. Design: Cross-sectional. Setting: Athletic trainingroom. Participants: Thirty-four,asymptomatic, NCAA Division Ibaseball pitchers (age=20±1.3 years;height=187.2±5.8 cm; mass=86.9±6.8kg) participated. Interventions: Wemeasured bilateral hip rotational ROMin a prone position using a digitalinclinometer. We measured externalrotation torque and maximumhorizontal adduction motion of thethrowing shoulder using a three-dimension, high speed video capturesystem. Separate multiple regressionanalyses were used to determine ifrelationships existed between hipexternal rotation ROM and externalrotation torque produced at thethrowing shoulder, as well as maximumshoulder horizontal adduction motionduring the throwing motion (p<.05).Main Outcome Measures:Dependent variables included shoulder

external rotation torque and maximumshoulder horizontal adduction motionduring the throwing motion. Results:The averages and standard deviationsfor shoulder external rotation torqueand shoulder horizontal adductionduring the throwing motion were5.1±1.0 % body weight x height and21.0º±8.1º. The clinically measuredlead leg internal, external, and total arcof rotational ROM were 27.7º±5.9º,35.8º±3.4º, and 63.4º±7.0º. Trail leginternal, external, and total arc ofrotational ROM were 28.9º±7.2º,35.4º±6.2º, and 64.2º±8.4º. Multipleregression analyses showed that thetotal hip rotational motion of the leadleg measured clinically had asignificant relationship with shoulderexternal rotation torque (r=.56,P=.003) during the throwing motion.Both lead leg hip external rotation (r=-.39, P=.02) and internal rotation(r=.42, P=.009) ROM madesignificant individual contributions tothis relationship. Lead leg externalrotation ROM had a significantnegative relationship with shoulderhorizontal adduction during thethrowing motion (r=-.36, P=.04). Thetotal rotational motion of the trail leghad a significant relationship withshoulder horizontal adduction motion(r=.43, P=.04). However, trail legexternal rotation was the onlysignificant contributor to thisrelationship (r=-.35, P=.04). Noother significant relationships werenoted (r<.37, P>.11). Conclusions:Our results demonstrate that alteredhip rotational ROM measuredclinically has a direct effect on theamount of dominant shoulder externalrotation torque and horizontaladduction during the throwing motion.Because of these relationshipsclinicians should consider utilizingstretches, which target hip rotationROM, in an effort to minimize thekinetic forces and excessive motionplaced on the throwing shoulder.

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Improper Trunk RotationSequence Is Associated WithIncreased Maximal ShoulderExternal Rotation Angle AndShoulder Joint Force DuringBaseball PitchingOyama S, Yu B, Padua DA,Blackburn JT, Li L, Myers JB:Department of Health andKinesiology, University of TexasSan Antonio, San Antonio, TX,and Department of Exerciseand Sport Science, Universityof North Carolina at ChapelHill, Chapel Hill, NC

Context: In a coordinated throwingmotion, peak pelvis rotation velocityis reached before the peak upper torsorotation velocity, so that angularmomentum can be transferredeffectively from the proximal (pelvis)to distal (upper torso) segment.Despite the fact that upper extremitykinematics and kinetics duringthrowing are highly influenced by trunkkinematics, the effects of proper vs.improper trunk rotation sequence onbaseball pitching performance (ballspeed) and upper extremitybiomechanics linked to commonpitching-related upper extremityinjuries have not been investigated.Objective: To investigate the effectsof trunk rotation sequence on ballspeed and upper extremity kinematicsand kinetics linked to injuries in highschool baseball pitchers. Design:Cross-sectional study. Setting:Biomechanics laboratory. Patients orOther Participants: Seventy-threehealthy high school baseball pitchers( d o m i n a n c e = 5 7 - r i g h t / 1 6 - l e f t ,age=15.5±1.2years, height =179.3±7 . 3 c m , m a s s = 7 2 . 7 ± 9 . 8 k g ) .Interventions: Three-dimensionalkinematics of the pitching motion werecaptured using a motion capturesystem. The pitches were performeduntil at least 3 strike-pitches werecaptured. Main Outcome Measures:Timings of peak pelvis and upper torsorotation velocity (% pitching time =

time from stride foot contact to ballrelease), maximal shoulder externalrotation angle (MaxER), elbowextension angle at ball release(ElbEXT), peak shoulder proximalforce, shoulder internal rotationmoment, and elbow varus momentwere calculated from the markercoordinate data. Subjects wereconsidered to have a proper vs.improper trunk rotation sequencewhen the peak pelvis rotation velocityreached before vs. after the peak uppertorso rotation velocity beyond themargin of standard error ofmeasurement (±3.7% pitching time),respectively. Subjects in whom thedifference in timing of peak pelvis andupper torso velocities was within themargin of error were excluded.Dependent variables were comparedbetween groups using independent t-tests (˜<.05). Results: Subjects withimproper trunk rotation sequence(n=33) demonstrated greater MaxER(mean difference=7.2°±2.9°, 95%CI=1.39°-13.0°, t

54=2.5, p=.016) and

greater shoulder proximal force (meandifference=9.2±3.9%body weight,95%CI=1.4-16.9%, t

54=2.4, p=.021)

compared to those with proper trunkrotation sequence (n=23). There wereno group differences in ElbEXT, ballspeed, or the other joint kineticvariables (p>.05). Conclusions: Nosignificant difference observed in ballspeed or joint moments suggest thatother factors may have a largerinfluence on these variables.Anatomically, the greater MaxER isassociated with increased risk ofposterior impingement and superiorlabral anterior-posterior lesion.Additionally, increased shoulderproximal force that resists distractionof the shoulder during arm-acceleration is linked to increasedtensile stress on the rotator cuff andbiceps-labral complex. Therefore,improper trunk rotation sequence maybe harmful to the throwing shoulder.Methods to identify pitchers withimproper trunk rotation sequence

without a motion capture system, andto correct the improper technique need tobe investigated in order to apply thisobservation to prevention of pitching-related upper extremity injuries.

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assigned to one of two training groupsfor 7 weeks; a traditional endurancetraining group (ET) (n=21) or a powertraining group (PT) (n=25).Interventions: The ET group performeda traditional endurance progressionrelative to the number of repetitionsand time incorporating static and linearexercise movements of the pelvis,spine and trunk. The PT group receivedundulating blocked periodizationconsisting of endurance, strength andpower movements specific tothrowing. Main Outcome Measures:Peak throwing velocity (km/h)normalized for body weight (kg),muscular endurance prone plank tests(seconds) and power output from aone-repetition maximum chop test(watts/Kg body weight) weremeasured pre- and post- intervention.Student’s independent t-tests wereused to compare differences betweenthe change score for all dependentvariables with alpha level set at pd”.05.Results: The peak throwing velocitychange score was significantly fasterby 6±2% in the PT group (ET= .01±.1km/h/kg of body weight, PT= .08±.03km/h/kg of body weight, p< .001) atpost-intervention compared to the ETgroup. Muscular endurance was notdifferent between groups (ET= 154±54, PT= 151±42, p= .901). Thepower chop test improved in PT group(105 ±68 watts) compared to the ETgroup (20 ±78 watts) (p<.001)CONCLUSION: This is the first studyto demonstrate improvementsin muscle performance for theproximal segments simultaneouslywith a sport performance measure inthrowing velocity. Sport specifictraining that targets the pelvis, spineand trunk is beneficial to muscularpower measures and throwingperformance. KEYWORDS: SpinalStability; Core Stability, ExerciseTraining, Performance Assessment

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Effects Of A Sport SpecificTraining Program TargetingThe Pelvis, Spine And TrunkOn Throwing Velocity AndMuscular Power And EnduranceMeasures In College ThrowingAthletesPalmer TG, Mattacola CG, Uhl TL,Hewett TE, Howell D, Viele K :University of Cincinnati,Cincinnati, OH; University ofKentucky, Lexington, KY; OhioState University, Columbus, OH;Eastern Kentucky University,Richmond, KY; Berry Consultants,Austin, TX

Context: The ability to stabilize andactively control the pelvis, spine andtrunk, has been reported to influencesport performance yet there is limitedevidence supporting thatimprovements in sport result fromchanges in the muscles supporting thepelvis, spine and trunk. Traditionalinterventions lack sport specificmethods which target both themuscular power and endurancecapabilities of the pelvis, spine, andtrunk. Objective: To investigate theeffect a traditional endurance trainingprogram and a sport specific powertraining program have on throwingvelocity, muscular endurance andpower measures of the proximalsegments. We hypothesized therewould be a significant difference (pd•.05) in change scores for throwingvelocity, muscular power and muscularendurance between groups. Design: Arandomized clinical trial with blockedstratification for sex and position wasimplemented with a pre- to post-intervention design. Setting: Field andresearch laboratory. Patients or OtherParticipants: Forty-six healthy (meanage = 20 ± 1.3 years, height = 175.7 ±8.7 cm, weight = 79 ± 13.9 Kg),Division III collegiate female softball(n=17) and male baseball (n=29)players from the same institutionvolunteered and were randomly

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Free Communications, Thematic Spitfire Session: Emerging Technologies inAthletic TrainingThursday, June 27, 2013, 11:45AM-12:45PM; Palm B; Moderator: Joseph Hart, PhD, ATC1 3 2 6 5 U O M U

Inter-Rater Reliability Of TheMovement And Activity InPhysical Space(MAPS) System: GeospatialFunctional Outcome MeasuresWarner KD, David SL, Ragan BG:Ohio University, Division of AthleticTraining, Athens, OH

Context: Functional outcomemeasures are critically important forevaluating the effectiveness of clinicaltreatments and tracking diseaseprogression. The measures currentlyused in clinical settings are unable toaccount for factors, such asenvironment, that can influencefunction. In an attempt to address thismeasurement issue, we have developedand validated the Movement andActivity in Physical Space (MAPS)system, which combines physicalactivity and geospatial data, providingan assessment of real-world functionacross multiple days. Objective: Toexamine the inter-rater reliability ofthe MAPS system variables. Design:Observational. Setting: Laboratory.Participants: Two teams of 2 raters,all trained in MAPS processing andcurrently using MAPS system in otherprojects, volunteered for this study.Interventions: The raters processed6 days of MAPS data from a pastproject. The 6 days of unprocessedMAPS data were chosen from 3individuals for data processing basedon the difficulty and complexity inprocessing with 2 days simple/lighttravel, 2 moderate days, and 2complex/extensive travel days. Thesedata had participants wear an ActiLifeGT3X+ accelerometer on the non-dominant hip and clipped a GPSreceiver to their belt during all wakinghours except when bathing. Each teamprocessed the 6 days of data to extractthe 11 MAPS system variables. Main

Outcome Measures: The 11 MAPSsystem variables were total physicalactivity counts (TPAC), total physicalactivity counts at home (TPACH), totalphysical activity counts at locationsother than home (TPACL), total stepcounts (TSC), total step counts at home(TSCH), total step counts at locationsother than home (TSCL), total time athome (TTH), total time at locationsother than home (TTL), total numberof trips away from home (TL), totalnumber of instrumental trips (IT), andtotal number of discretional trips (DT).Each team examined the same 6 daysof unprocessed MAPS data andcalculated each of the MAPS systemvariables for each day. Inter-raterreliability was examined by calculatinginterclass correlation coefficients(ICC 3,1) for each of the 11 variables.An ICC of .7 was consideredacceptable and an ICC of .8 or greaterconsidered good. Results: The ICCsfor most of the MAPS variables wereconsidered good with TPAC=.98;TPAL=.99; TPAH=.96; TSC=1.0;TSL=.99; TSH=.97; TTL=.78;TTH=.74; TL=.98; IT=.92; DT=.82.Conclusions: Overall, the ratingteams produced very good inter-raterreliability for 9 MAPS variables withacceptable ICCs for TTH and TTL.These time variables are related toone another and future proceduralwork should be done to reduce theerror. The results support multiplerating teams to be able processand combine data, which will allowfor larger MAPS studies to beconducted at multiple sites.

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Comparison Of StandardGoniometry Versus An IphoneGoniometry AccelerometerApplication To Measure KneeFlexion And ExtensionEley DM, Tomczyk KM, Berry DC:Saginaw Valley State University,University Center, MI

Context: Measuring range of motion(ROM) is standard practice whenconducting an injury evaluation. ROMis quantified using a standardgoniometer (SG); but due totechnological advances, alternativemethods using iPhone applicationsmay offer clinicians a quick, moreefficient tool. Objective: To comparethe relationship between knee flexion(KF) and extension (KE) active ROM(AROM) using SG and the iPhoneapplication, Goniometer (App).Design: Quasi-experimental.Setting: Athletic training laboratory.Participants: Forty-one participants,16 males and 25 females (age=20.5±1.1; height =171.4 cm±8.4cm;mass= 73.9kg±16.51) free of lowerextremity injuries, surgery or pain for6 months to the dominant limbparticipated. Interventions:Participants were placed supine for asingle session measurement of KF andKE AROM by two independent ratersusing the dominant limb (used to kicka ball). To control measurement error,a polyvinyl chloride (PVC) frame wasplaced at the pelvis to maintain a 90°hip angle. Measurements werecounterbalanced to control effect bias.Standard goniometric AROM wasassessed using commonly reportedlandmarks; lateral epicondyle (axis),long axis of femur (stationary arm),and long axis of fibula (moveable arm).To measure AROM subjectsmaximally flexed and extended theknee while maintaining a 90° hip angle.

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iPhone App (Goniometer, Jinfra)landmarks included; quadriceps tendon1” proximal from superior patella pole(position 1), and along anterior tibia1” distal from tibial tuberosity(position 2). Once maximal jointmovement was obtained, the iPhonewas placed horizontally along position1. “Start” was pressed to measureposition 1. This was repeated forposition 2 with “End” pressed in orderto calculate. Person Product MomentCorrelation Coefficients werecalculated to determine therelationships between KF and KE SGand the App. An intraclass correlation(ICC

2,1) measured KF and KE inter-

rater reliability. Main OutcomeMeasures: SG and App KF and KEAROM measured in degrees. Results:Combined SG and app mean (SEM)rater scores for KE were 30.5° (1.6°)and 18.6° (1.7°), respectively.Combined KF rater mean (SEM)scores for SG and app were 135.7°(.89°) and 128.6° (1.8°), respectively.Significant relationships were alsofound between combined rater SG andapp for KE, r (39) = .848, P = .000and KF, r (39) = .502, P = .001. ICCmeasurements for inter-raterreliability values for KE and KF were.805 (95% CI: .663 to .891) and .318(95% CI: .015 to .567), respectively.Conclusions: A significantrelationship between SG and the Appsuggests that the iPhone App may bean option for assessing KF and KEAROM; however inter-rater reliabilitydemonstrated poor to moderatereliability between raters. Due to poorinter-rater reliability the iPhoneGoniometer app should be avoidedwhen different clinicians aremeasuring a patient’s ROM.

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A Comparison Of StandardGoniometry VersusDrgoniometer Ipad/Iphone AppFor Measuring Knee Flexion AndExtensionTomczyk KM, Eley DM, Berry DC:Saginaw Valley State University,University Center, MI

Context: Range of motionmeasurements are commonly used byclinicians when conducting a physicalexamination, traditionally assessedusing a goniometer. However, standardgoniometry (SG) measurements havedemonstrated inconsistent andsometimes unreliable resultsprompting clinicians to search foralternative methods of consistentlyassessing ROM such as through the useof iPad/iPhone applications.Objective: To compare therelationship between knee flexion(KF) and extension (KE) active ROM(AROM) using SG and the iPad/iPhonepaid application DrGoniometer (app).Design: Quasi-experimental.Setting: Athletic training laboratory.Participants: Forty-one participants,16 males and 25 females(age=20.5±1.1; height=171.4 cm±8.4cm; mass=73.9 kg±16.51) free oflower extremity injuries, surgery/painfor 6 months to the dominant side.Interventions: Participants wereplaced supine for a single sessionmeasurement of KF and KE ROM bytwo independent raters using thesubjects’ dominant leg (used to kick aball). To control measurement error, apolyvinyl chloride (PVC) frame wasplaced at the pelvis to maintain a 90°hip joint angle. Measurements werecounterbalanced to control effect bias.Standard goniometric AROM wasassessed using commonly reportedlandmarks; lateral epicondyle (axis),long axis of femur (stationary arm),and long axis of fibula (moveable arm).Subjects then maximally flexed andextended the knee while maintaining a90° hip joint angle to collect AROM.The app landmarks included; lateral

epicondyle (axis), greater trochanter(stationary arm), and lateral malleolus(moveable arm). Once maximal jointmovement was obtained a digitalphotograph using the iPad/iPhone appwas recorded. The app automaticallycalculated ROM by manuallymanipulating three markers so a redcircle with a cross inside was placedon the anatomical landmarksidentified above. To ensure properpositioning the app provided a reddotted line that connects the individualreference points to ensure properalignment. Person Product MomentCorrelation Coefficients werecalculated to determine therelationship between KF and KE SGand the app. An intraclass correlation(ICC

2,1) measured KF and KE inter-

rater reliability. Main OutcomeMeasures: KF and KE AROMmeasurements for SG and appmeasured in degrees. Results:Combined SG and app mean (SEM)rater scores for KE were 30.5° (1.6°)and 28.9° (1.6°), respectively.Combined KF mean (SEMS) scoresfor SG and app were 135.7° (.89°) and136.7° (.91°), respectively. Significantrelationships were found betweencombined rater SG and app for KE,r(39)=.907, P=.000 and KF,r(39)=.865, P=.000. ICCmeasurements for inter-raterreliability values for KE and KF were.785 (95% CI: .631-.879) and .877(95% CI: .781-.933), respectively.Conclusions: A significantrelationship existed between SGand the Dr.Goniometer app suggestingthat the application may be a viableoption for assessing knee AROM.The Dr.Goniometer app is a quickand easy tool that allows for long-term data storage and may helpimprove patient motivation.

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Accuracy Of On-Person GPSUnits In Tracking Static AndDynamic Movement In PatientsJackson MJ, Medel M, Sinha G,Ragan BG: Ohio University,Athens, OH

Context: The use of GPS units is morecommon in athletic training to trackfunctionality post-injury. The accuracyof tracking individuals has not beenfully substantiated although we haveestablished validity evidence in post-surgical knee patients. Objective: Todetermine the accuracy of GPS unitsin participant-tracking research.Design: Observational study. Setting:Free-living environment. Patients orOther Participants: Three GPSreadings of National Geodetic Survey(NGS) benchmarks and 3 differentunits tracked participant movement on84 corners of 21 rectangular artinstallations in the campusBicentennial Park to test the accuracyof GPS data. Interventions: Twotypes of movements were tracked totest the accuracy of GPS units: staticand dynamic. NGS were used for staticmovements with extremely accuratelocations using markers to comparethe accuracy of GPS units with respectto the known locations of thebenchmarks. The dynamic movementswere tracked following specificpatterns whose locations are known.Main Outcome Measures: The GPSunits have some error but it has notbeen established for static anddynamic measures. The units offer agreat method for tracking individualfunctionality in non-laboratorysettings. The efficacy must beexplored. ArcGIS, a mapping software,was used to track the data and offerspatial analysis of the GIS data. TheNGS benchmarks offer the staticmeasures of the GPS units. Fordynamic movement, ArcGIS was usedto pinpoint known locations and theerror of the GPS units was cited.Results: All dedicated GPS units wererelatively similar in terms of the

magnitude of the true and relativeerrors at most static sites. True errorsfor the Land Air Sea (LAS) GPS deviceranged 2-7m and relative errors from4-10m. Interestingly, the least accuratereadings were for the urban sites thatwere in close proximity to buildings.The error of the units for the dynamictracking are as follows, starting withmean and followed by standarddeviation: Garmin Oregon with WAASenabled (high priced market item)2.13m and 1.18. There were two LASGPS used in the study and theirdescriptive statistics are as follows:mean = 3.74m and standard deviation= 2.52; mean = 3.74m and standarddeviation of 1.52. Conclusions: On aglobal scale, accuracy within 3.5m isa well-performing GPS measure. On asmaller scale, 3.5m should be able tohelp distinguish between anindividual’s locations. The efficacy ofthe LAS (3.5m accuracy), a cheaperand comparable version to the highperformance Garmin Oregon (2.13maccuracy), can be used sufficiently totrack an individual’s position duringthe course of the study. The costeffectiveness of the Garmin Oregonis not worth the greater accuracy itoffers. The LAS GPS units willsufficiently complete the task oftracking participant movement.

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Test-Retest Reliability Of TheStability Evaluation Test OfThe VSR™-Sport In A PediatricSampleHanline VL, Olson BL: SouthDakota State University,Brookings, SD

Context: The Stability Evaluation Test(SET) of the Neurocom® VSR™-Sporthas been introduced as a clinicalmeasure of balance, particularly foryouth who have suffered a sport-related concussion (SRC). The SETrequires the participant to completethe Balance Error Scoring System(BESS) protocol while on the forceplate; however, instead of a ratermeasuring errors (as in the BESS), theforce plate measures changes in centerof gravity (or sway velocity) providinga more objective measure ofimpairment. Although clinicallyacceptable test-retest reliability hasbeen established for the BESS, test-retest reliability has not beenestablished for the SET protocol in apediatric sample. Objective: Toexamine test-retest reliability of theSET protocol of the VSR™-Sport in apediatric sample using clinicallyrelevant timeframes and to investigategender and age group differences ontest-retest reliability in this sample.Design: Repeated Measures Design.Setting: Boys and Girls Club ofBrookings. Patients or OtherParticipants: Fifty–four healthychildren (33 males and 21 females,age=8.2±1.9yr; height =131.5±12.5cm; weight=31.4±11.1 kg) freefrom injury or illness known to affectbalance completed all three testingsessions. Interventions: The SETprotocol consists of 6 conditionslasting 20 seconds each (3 hard and 3soft surface stances). Participantscompleted the SET three times overthe course of 35 days: day 1, day 30and day 35. The testing seriesrepresents points of clinicalmanagement following SRC. MainOutcome Measures: Sway velocity

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(deg/sec) of each condition and acomposite of the SET was measuredat day 1, day 30 and day 35. Aninterclass correlation coefficient(ICC) was used to calculate test-retestreliability for three testing timeframes(Day 1-Day 30, Day 30-Day 35, Day1-Day 35). ICC’s were also calculatedto determine test-retest reliability forgender and age group (younger cohort(5-7yr) and older cohort (8-15yr)).Results: Each testing timeframeelicited clinically acceptable (greaterthan .80) test-retest reliability forcomposite SET scores: Timeframe1ICC=.91 (.84-.95, 95% CI),Timeframe 2 ICC=.92(.86-.95, 95%CI) and Timeframe 3 ICC=.86 (.76-.92, 95% CI). Although some variationexisted in test-retest reliability whencomparing males to females and ayounger cohort to an older cohort, allICC’s demonstrated clinicallyacceptable findings. Conclusions:Strong test-retest reliability isnecessary to ensure that impairmentsdefined post-concussion are due to thecondition, and not unreliable tests.Findings support strong test-retestreliability of the SET in a healthypediatric sample when delivered overtimeframes following currentconcussion management protocols.Although some variation in reliabilityexists when gender and age groupare considered separately, reliabilityremains clinically acceptable.The ability to measure sway velocityrather than balance errors allowsfor an objective measurementof balance over time.

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Validation Of Postural StabilityAssessment UsingAccelerometer And GyroscopicMeasuresGraber DK, Schindler DD, HirschJR, Kana DE, Linder SM, AlbertsJL: Cleveland Clinic Sports Health,Cleveland, OH, and BiomedicalEngineering, Cleveland Clinic,Cleveland, OH

Context: Field experts have called foran objective assessment of posturalstability to be included as part of acomprehensive concussion manage-ment program. However, the balanceassessment most commonly utilized inthe management of athletes withconcussion, the Balance Error ScoringSystem (BESS), suffers from floorand ceiling effects in addition to poorinter- and intra-rater reliability.Conversely, sophisticated measures ofpostural stability such as the SensoryOrganization Test lack the portabilityand accessibility for widespread in-field use. Objective: The objectiveof this project was to develop andvalidate a reliable, portable, and cost-effective method of objectivelyquantifying postural stability as part ofthe Cleveland Clinic Concussion (C3)Application for the comprehensiveassessment of concussion-relatedimpairments. Design: A prospectivelongitudinal study was utilized.Setting: The validation study wasconducted in the Neural ControlResearch Lab at the Cleveland Clinic.Participants: A volunteer sample of49 high school and college-agestudents (14-25) participated in thestudy. Participants were not eligibleif they had a history of concussionwithin the past 6 months or had anymusculoskeletal or neurologiccondition resulting in impairedbalance. Interventions: Participantscompleted the entire SensoryOrganization Test (SOT) consisting ofthree 20-second trials for each of thesix conditions. Simultaneously,

accelerometer and gyroscopic datawere collected with the iPad2 affixedto the participant’s sacrum with astandard weight-lifting belt. Thetransmission of data from the iPad2was synchronized with the NeuroComsystem to ensure temporal alignmentof data collected by the two systems.Main Outcome Measures: Anterior-Posterior (AP) measure of posturalstability was calculated using data fromthe accelerometer and gyroscopenative to the iPad2, and validatedagainst AP equilibrium scorescalculated during simultaneousperformance of the NeuroComSensory Organization Test. A bivariatecorrelation analysis was completedbetween the NeuroCom EquilibriumScores (ES) and iPad2 EquilibriumScores for each of the six conditionsand for the Composite ES. Results:Equilibrium Scores as calculated fromaccelerometer and gyroscopic datafrom the iPad2 correlated significantlywith NeuroCom equilibrium scores ineach of the six SOT conditions (r=0.44to 0.93; p<0.01) as well as thecomposite equilibrium score (r=0.95;p<0.01). Conclusions: Acceler-ometer and gyroscopic data from theiPad2 provide an accurate andobjective measure of postural stabilitythat could be used in the objectiveassessment of balance. This consumerelectronics device is ideally suited tobe used in clinical and sportenvironments to provide a portablemethod of balance assessment, and canbe included as part of a comprehensiveconcussion management program.

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Validation Of Accelerometry AsA Physical Rest Monitor DuringConcussion RecoveryWells KA, Farnsworth JL,McElhiney DS, David SL, RaganBG: Ohio University, Athens, OH,and Middle Tennessee StateUniversity, Murfreesboro, TN

Context: Current concussionguidelines call for physical andcognitive rest after sustaining aconcussion. Patient compliance withthese recommendations relies onsubjective patient reports. There islittle research into monitoring patientcompliance with physical and cognitiverest in the free living environment. Tobetter treat concussed athletes andevaluate these guidelines objectivemonitoring measures are needed.Accelerometry is applied in studies totrack an individual’s physical activity(PA) level using activity counts and hasbeen validated in various PA trials. Ithas the potential to monitor adherenceto physical rest (PR) following aconcussion. Objective: To validatethe use of accelerometry inmonitoring patient compliance withPR following a concussion. Design:Observational matched-pair design.Setting: Free-living conditions.Patients or Other Participants: Atotal of 14 participants, (mean age:19.8±1.0 yrs; females n= 7, males n=7) DI and DIII collegiate varsity or clubsport athletes volunteered for the study(concussed group (n=7) and controlgroup (n=6); one control was removedfor non-compliance). Matchedcontrols were uninjured teammates.Interventions: The independentvariable was group membership(concussed or matched-control).Participants wore an ActigraphGT3X+ accelerometer on the hipduring waking hours, carried an on-person GPS device, and completed anactivity diary for 5 days afterconcussion diagnosis. All concussedparticipants followed a concussionprotocol recommending physical and

cognitive rest. Matched-controls weremonitored during the same timeperiod. Independent t-tests (˜= 0.05)with Bonferoni adjustments were usedto determine differences in PAbetween the concussed and controlgroups. Main Outcome Measures:The dependent variables (per day) weremean total PA counts, mean PA countsaway from the home, mean PA countsat home. The amount of time spentaway from home, and the total numberof trips travelled were examined toensure travel behavior was similaracross groups. Results: There was asignificant difference in mean total PAcounts (t(11) =2.9; p<0.05) betweenconcussed athletes (Mean±SD:298,158±116,704 counts) andcontrols (450,271±67,130 counts.)There was a significant difference inPA counts (t(11) =2.5; p<0.05)between concussed athletes(224,661±100,306 counts) andcontrols (104,201±66,297 counts).There was no significant difference inPA at home (t(11)= 0.522; p>0.05)between concussed athletes(70,129±43,193 counts) and controls(58,609±34,962 counts). There was nosignificant difference regarding theamount of time spent away from thehome (t(11)=-0.9; p>0.05) or thenumber of trips travelled (t(10)=-0.1;p>0.05) (concussed 465±79 min,4.4±1.3 trips, control 472±166 min,4.5±0.8 trips). Conclusions:Accelerometry is sensitive to PAchanges associated with PRrecommendations during concussionrecovery. The change appears to berelated to activities away from home.The travel patterns and activity at homewas not altered. This provides validityevidence for the use of accelerometryin monitoring adherence to PRprotocols for concussed athletes.

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Objective Assessment OfFunction Following Head InjuryUsing Movement And Activity InPhysical Space (MAPS) ScoresFarnsworth JL, Mc Elhiney D, KimY, Kang M, Ragan BG: MiddleTennessee State University,Kinesmetrics Lab, Murfreesboro,TN, and Ohio University, Divisionof Athletic Training, Athens, OH

Context: Current concussionmeasures focus primarily onmeasuring patient impairments, areclinic-based tests (ie, neurologicalexam in front of a computer), and donot evaluate overall patient function.The Movement and Activity in PhysicalSpace (MAPS) system can provide anobjective measure of overall functionin free-living environment by usingaccelerometry, on-person globalpositioning system (GPS) device, andgeographic information systems(GIS). The MAPS system has beenvalidated in post-surgical kneepatients. Objective: To establishvalidity evidence for MAPS scores asobjective measures of function inconcussion patients. Design:Observational repeated measuresmatched-pair design. Setting:Environmental free-living conditions.Patients or Other Participants: Atotal of 14 university athletes (n = 7concussed, n = 7 healthy control; aged:mean ± SD, 19.7±1.0yrs) participatedin this study. The healthy controls werematched for age, sex, sport, perceivedphysical activity level, and major.Interventions: Participants wore anActigraph GT3X+ accelerometer ontheir hip and an on-person GPSreceiver for up to 10 days except forwhen sleeping or bathing. Thesedevices measure activity counts(intensity), and step counts (volume)each minute and location (latitude/longitude). GPS data were verified byparticipants through the use of self-reported travelogues. MAPS scoreswere calculated by combining datafrom the GPS and accelerometer for

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each day to assess patient function.Participants also completed dailysymptom questionnaires. MainOutcome Measures: The dependentvariables were 6 scores: MAPSintensity (MAPS

I), MAPS volume

(MAPSV), total symptom load,

symptom severity, symptom“bothersomeness”, and symptomfrequency. Convergent validityevidence for MAPS was assessedusing Pearson correlation (˜ = 0.05)examining the relationship betweenMAPS scores and self-reportedsymptom scores. Known-groupdifference validity evidence wasassessed using independent t-tests (˜= 0.05) evaluating differences in meanMAPS

I and MAPS

v scores between the

concussion and control groups.Results: The MAPS

I and MAPS

V

scores and self-reported symptomscores were significantly correlatedwith total symptom load (r = -0.32; p= 0.01, r = -0.33; p = 0.01), symptomseverity (r = -0.30; p = 0.02, r = -.31;p = 0.01), symptom “bothersomeness”(r = -0.32; p= 0.01, r = -0.32; p =0.01), and symptom frequency (r =-0.32, p= 0.01; r=-.31, p = 0.01),respectively. There was no significantdifferences (t

12 = -1.11, p =.29: t

12 =

-0.36, p =.73, between the concussion(M±SD; MAPS

I 1,523.4±1,068.9;

MAPSv 46.0±40.0) and control groups

(M±SD; MAPSI 2,231.8±1,314.4;

MAPSv 50.3±25.0). Conclusions:

Our correlation results providedevidence of convergent validity forMAPS scores in a concussionpopulation during recovery. Althoughthere were no significant groupdifferences the data did show theexpected inverse relationship betweenfunction and symptoms in all 4symptom measures. Additionalvalidity evidence to support the use ofMAPS scores is needed.

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Free Communications, Oral Presentations: Socialization, Retention and Work-Life BalanceThursday, June 27, 2013, 3:15PM-4:45pm; Palm B; Moderator: Sara Nottingham, EdD, ATC, CSCS1 3 1 5 0 D O P E

Programmatic FactorsAssociated With AthleticTraining Student RetentionDecisionsBowman TG, Hertel J, WathingtonHD: Lynchburg College,Lynchburg, VA, and University ofVirginia, Charlottesville, VA

Context: Athletic training educationprograms (ATEPs) are charged withmeeting an increased demand forathletic trainers with adequategraduates. Currently, it remainsunknown what the retention rate is forATEPs nationwide and whatprogrammatic factors are associatedwith the retention rates of athletictraining students (ATSs). Objective:Determine the retention rate for ATSsnationwide and the programmaticfactors associated with ATSretention. Design: Cross-sectionalonline questionnaire. Setting:Undergraduate ATEPs. Patients orOther Participants: Programdirectors (PDs) of all Commissionon Accreditation of Athletic TrainingEducation (CAATE) accreditedundergraduate ATEPs were asked tocomplete an online questionnaire.We obtained responses from 177 outof the 343 PDs (51.6%). Themajority of respondents representedATEPs at publicly funded (50.3%)Master’s institutions (47.5%) withsmall enrollments (1000-3000students) (26.6%) andpredominantly National CollegiateAthletic Association Division 1sponsored athletics (42.4%). TheATEPs represented had beenaccredited for 10.7±4.0 years andrequired 2.8±0.6 academic years ofclinical education. Programdirectors admitted an average of16.0±13.9 students into the ATEPannually, most doing so after

completion of two semesters ofcoursework (51.4%). The programdirectors held their positions for8.0±6.0 years. Interventions: Anonline questionnaire, developedbased upon the current literature,was sent to all PDs of CAATEaccredited undergraduate ATEPs.We asked them for demographic andfactual information about theirinstitution, ATEP, and themselves.We pilot tested the questionnaire onthree separate occasions to reducemeasurement error and provideconstruct validity. Main OutcomeMeasures: We asked the PDs toidentify the percentage of ATSs whograduated from their ATEP out of thetotal number of ATSs admitted intotheir ATEP over the past 5 years. Weused multiple regression to evaluatethe ability of the demographic andfactual variables to predict the ATSretention rate. Results: Theparticipants reported an averageretention rate of 81.0±17.9%(range=9%-100%). We found asignificant prediction equation(F

4,167=16.39, R2=0.282, P<0.001)

using the timing of formal admissioninto the ATEP (P<0.001, R2=0.162),the number of years the ATEPs hadbeen accredited (P<0.001,R2=0.068), the number of studentsadmitted to the ATEP annually(P<0.01, R2=0.032), and the numberof years the PD had held theirposition at their current institution(P=0.04, R2=0.019). Conclusions:We believe that delaying the formaladmission of prospective studentsmay aid professional socializationallowing ATSs to make an informeddecision to enter an ATEP. We alsobelieve ATEPs with a rich history ofsuccess and consistent leadershipcan provide an environment thatfosters ATS retention. Program

directors should carefully considerhow many students to admit intothe ATEP annually as individualattention from faculty, staff, andclinical preceptors may alterpersistence decisions of ATSs.

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Work-Life Balance In TheDivision I Clinical Setting FromThe Perspective Of The HeadAthletic TrainerMazerolle SM, Goodman A, PitneyWA: University of Connecticut,Storrs, CT; Appalachian StateUniversity, Boone, NC; NorthernIllinois Universi DeKalb, IL

Context: Work-life balance (WLB)has been examined in the collegiatelevel from multiple perspectives,expect for the athletic trainer (AT)serving in a managerial or leadershiprole. Evidence suggests those insupervisory roles can help facilitateWLB for their employees, yet little isknow about the challenges they faceindividually due to their role.Objective: Investigate challengeswith WLB faced by the Head AT andstrategies used in achieving WLB.Design: Qualitative study usingstructured interviews. Setting: Web-based management system. Patientsor Other Participants: Eighteentotal Head ATs (13 males, 5 females)volunteered to participate in ourasynchronous, online interview. Theaverage age of the participants was 44years ± 8 and they had on average 22 ±7 years of experience. Of the 18, 15(83%) were married/partnered and 3(17%) were single. Eight of 17 (44%)were married with children. Only oneof our Head ATs did not have travelduties associated with their jobresponsibilities. Data Collectionand Analysis: Participants respondedto a series of questions by journalingtheir thoughts and experiences. Weincluded multiple analyst triangulation,stakeholder checks, and peer review toestablish data credibility. We analyzedthe data via a general inductiveapproach. Results: Two higher orderthemes emerged from our analysis ofthe data to speak of the individualexperiences of the Head AT: 1)Organizational challenges and 2)WLB strategies. The OrganizationalChallenges theme portrays the factors

causing issues with WLB for the HeadAT and contained 2 lower orderthemes: 1) lack of autonomy and 2)role demands. The WLB strategiestheme included those strategiesemployed personally by the Head ATto promote WLB and contained 3lower order themes: 1) prioritizationof commitments, 2) strategic boundarysetting and 3) work-family integration.Four additional themes emerged fromthe data regarding methods used byHead ATs to promote WLB amongsttheir staff members: 1) modelingWLB, 2) encouraging disengagementfrom the AT role, 3) cooperation andcommunity workplace, and 4)administrative support andunderstanding. These four themesaddress the leadership role assumedby the Head AT and their use ofinformal strategies to encourageWLB. Conclusions: Head ATs aresusceptible to experiencing work-lifeimbalance, just like those ATs in non-supervisory roles. The causes,although not avoidable, aremanageable. Head ATs are encouragedto prioritize their personal time andmake efforts to spend time away fromtheir demanding positions as well asreduce, when possible the number ofadditional responsibilities that canimpede upon time available to get awayfrom work. Furthermore, Head ATs areadvocates for WLB and are makingefforts to help their ATs fulfill WLBby modeling the concept themselves,as well as promoting a cohesive andsupportive work environment.

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Managing Motherhood In TheNCAA Division I Setting: TheRole Of Mentorship And FemaleAthletic TrainersBarone CM, Mazerolle SM,Ferraro EM, Goodman A:University of Connecticut, Storrs,CT, and Appalachian StateUniversity, Boone, NC

Context: One of the greatest catalystsfor turnover in the profession amongwomen is motherhood, especially ifemployed at the Division I collegiatelevel. We know that the medicaleducation literature regularlyidentifies the importance of rolemodels in value, attitude, andprofessional character formation.However, there is very limitedresearch examining the role ofmentorship and professional rolemodels as it relates to female athletictrainers’ (FATs) perceptions ofmotherhood and retention. Objective:To evaluate perceptions ofmotherhood and retention in relationto mentorship and role modelsamongst FATs currently employed inthe collegiate setting. Design:Structured, online asynchronousinterviews. Setting: Female BOCcertified ATCs working at the DivisionI setting. Patients or OtherParticipants: 27 FATs (single=14;married=6; married with children=7)employed in the NCAA Division Isetting volunteered. Average age of theparticipants was 34 ± 8. All were full-time BOC certified with an average 11± 7 years of clinical experience. DataCollection and Analysis: Parti-cipants responded to a series ofquestions by journaling their thoughtsand experiences via QuestionPro™.Multiple analyst triangulation and peerreview were included as steps toestablish data credibility. The data wasanalyzed borrowing from the principlesof general inductive approach.Results: The first theme, impact ofrole models/mentors, highlights thecapacity of a male or female role model

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to positively or negatively influencecareer and WLB perceptions ofwomen working in the Division Isetting. The second theme desire forfemale role models/mentors, speaksto the participant’s desire to see morewomen in the profession handle thedemands of motherhood and thedemands of a taxing clinical setting.Women who have had female mentorsare more positive on the prospect ofbalancing the rigors of motherhood andthe demands of their jobs. Our FATswho did not have a female mentor, yetwanted one were apprehensive abouttheir longevity in the field of athletictraining, because of motherhood.Conclusions: Similar to previousresearch it appears as though theprospect of raising a family andbalancing the demands of Division Iseem daunting for most women.However, mentorship/role models area valuable tool for perseverance in theprofession and at the highly demandingclinical settings. Our results coincidewith research in other medicalprofessions, identifying theimportance of role models on females.As more FATs remain in theprofession who are able to maintainwork-life balance and are available toserve as role models, it is conceivablethat the attitudes of other women maystart to change. Future inquiry shouldexamine the impact of role models atclinical settings outside of Division Iand ways to increase role modelexposure to female athletic trainers.

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Retention And Attrition FactorsFor Male Athletic Trainers In TheNational Collegiate AthleticAssociation Division-I SettingGoodman A, Mazerolle SM, PitneyWA: Appalachian State University,Boone, NC; University ofConnecticut, Storrs, CT; NorthernIllinois University, DeKalb, IL

Context: Social support, autonomy,and job satisfaction are among thefactors influencing female athletictrainers’ (ATs) decision to persist inthe National Collegiate AthleticAssociation Division-I (NCAA D-I)setting, while work-life balance issuesand role overload are factors leadingthem to depart. These factors may notbe similar for male ATs. Objective:Gain insight into the factors whichaffect male ATs’ decisions to persistat or depart the NCAA D-I setting.{Banerjee, 2004 #30}Design:Qualitative study. Setting: NCAA D-I institutions. Patients or OtherParticipants: A total of 19 current(n = 11) and former (n = 8) employeesparticipated in our study. The currentemployees averaged 6 ± 6 years ofNCAA D-I clinical experience, 66 ±10 working hours per week during thetraditional sport season, and 34 ± 5years of age. The former employeesaveraged 15 ± 11 years of NCAA D-Iexperience, 66 ± 5 working hours perweek during the traditional sportseason, and 45 ± 11 years of age. DataCollection and Analysis: Data werecollected via in-depth, semi-structuredinterviews, and transcribed verbatim.Two researchers followed the steps ofa grounded theory study and analyzeddata independently. Data saturationguided recruitment, while a peerreview and member checks establishedcredibility. Results: Two mainpersistence themes emerged from thedata: 1) D-I atmosphere and 2)workplace environment. The level ofcollegiality and support along with anexciting and competitive atmospherewere reasons for persistence. Four

departure themes emerged from theformer employee data: 1) role strain,2) work-family conflict, 3) roletransition, and 4) lack of advancement.The role strain theme contained 2subthemes; role conflict and roleoverload. The lack of advancementtheme also contained 2 subthemes;lack of promotion and lack ofcompensation. Male ATs experiencedrole overload and role conflict thatcreated an imbalance between workand family. A lack of promotionalchances and low salaries wereimplicated as reasons to depart theirrole. For those with more years ofservice, taking an opportunity to reduceone’s responsibilities and move towardretirement were common departurestrategies. Conclusions: Ourfindings regarding reasons to persistor leave the NCAA D-I setting arecomparable to those within theliterature. Issues with salary, careeradvancement and role transition are notunique attrition factors, but have notbeen found among female ATs. Uniqueto the profession is the competitiveatmosphere which is satisfying formany ATs and influenced persistence.Future research needs to examine thecareer intentions of ATs, regardless ofgender as well as the satisfaction ofthose ATs who depart the professionto determine if a career/setting changemitigated their concerns.

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Perceptions Of RetentionIndicators In Athletic TrainingJuzeszyn LS, Kahanov L,Eberman LE, Pitney WA: IndianaState University, Terre Haute, IN,and Northern Illinois University,DeKalb, IL

Context: Attrition in the professionof athletic training notably occurs inlarge numbers between five and tenyears of work experience creating aprofession dominated by young, entry-level practitioners. Theoreticalconstructs are currently used toexplain the retention issues in athletictraining, yet an assessment ofindividuals who have left theprofession is lacking. Objective: Toassess reasons why athletic trainers lettheir athletic training certification (AT-C) lapse and leave the athletic trainingprofession. Design: Cross sectional-observational study. Setting: InternetSurvey. Patients or OtherParticipants: We recruited 1000former certified athletic trainers wholet their certification lapse within thepast 5 years. Eighty-four of the 1000email addresses were undeliverableleaving 916 viable participantswith198 respondents for a 22%response rate. Interventions: Weadministered the survey online anddetermined face/content validity witha review of three certified athletictrainers (experience range 12±8years), factor analysis, and strongindication of internal consistency(Cronbach’s alpha=0.98). MainOutcome Measures: The surveyconsisted of 18 questions, including9 demographic questions, 7 matricesregarding aspects of retention, and twoopen-ended questions to assess copingstrategies. The matrices employed 5-point Likert scales to measureagreement (1=strongly disagree to5=strongly agree. We used a Kruskal-Wallis to assess work/family issues.We assessed gender, age, relationshipstatus, employment setting, highesteducation level, and children on three

constructs identified in the factoranalysis: work/family, work-related,and burnout. Results: Participantsvaried in the demographiccharacteristics suggesting weidentified a diverse population ofrespondents. Overall, work-relatedand work/family issues that contributeto retention were neutral with theexception of irregular hours(mean=3.7±1.3) and salary(mean=3.9±1.4). In addition, maleand female respondents indicatedrelatively neutral perceptions onburnout factors. Burnout factorscontributed to retaining women morethan men regarding hopelessness(H=7.201, d.f.=1, p=0.007), loss ofidealism (H=4.757, d.f.=1, p=0.029),detachment to others (H=4.179,d.f.=1, p=0.041), and pessimisticthinking (H=4.800, d.f.=1, p=0.028).Those in relationships and withchildren also experienced work/familyand burnout factors comparatively,including added responsibility at home(H=26.235, d.f.=3, p<0.001),children/parenting responsibilities(H=26.235, d.f.=3, p<0.001), feelingdown in the dumps (H=7.909, d.f.=3,p=0.048), difficulty concentrating(H=8.093, d.f.=3, p=0.044), feelingsof depression (H=9.112, d.f.=3,p=0.028), and feelings of frustration(H=8.405, d.f.=3, p=0.038).Conclusion(s): Symptoms of burnoutand life stressors contribute to thelack of retention in the professionmore in females, yet previouslytheorized attributes such as staffingissues, demanding schedule, roleambiguity, role strain and lack offlexibility do not appear to be factors.Life-work issues such as salary andirregular work hours were greaterfactors in retention than previouslynoted in the literature. Women appearto be more affected by and work/family issues contributing to retention.

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Factors And Strategies ThatContribute To Work LifeBalance Of Female AthleticTrainers Employed In The NCAADivision I SettingFerraro EM, Mazerolle SM,Barone CM, Goodman A:University of Connecticut, Storrs,CT, and Appalachian StateUniversity, Boone, NC

Context: Work life balance (WLB)can be challenging particularly forfemale athletic trainers (FATs).Evidence suggests FATs persist in theprofession because of job enjoyment,increased autonomy, and social supportnetworks. Departure factors such aslong hours, travel, and inflexibility ofschedules often comprise issues withWLB. Time management, supportnetworks, and setting boundaries arestrategies used to find WLB, however,little is known about the strategiesFATs use to maintain WLB in theDivision I setting as they seem tostruggle more with finding WLBpotentially due to the responsibilitiesassociated with motherhood.Objective: To gain insight ofcontributing factors and strategiesused by FATs employed in the DivisionI collegiate setting to fulfill WLB.Design: Structured, onlineasynchronous interviews viaQuestionPro™ Setting: NCAADivision I Collegiate setting. Patientsor Other Participants: 27 FATs(single=14; married=6; married withchildren=7) currently employed asfull-time ATs in the NCAA Division Isetting participated. Majority of FATswere contracted for 12 months andworked 58±19 hours a week. Primarysport coverage responsibility waswomen’s basketball (9 FATs) followedby women’s soccer (7 FATs) andfootball and volleyball (3 FATs). DataCollection and Analysis: FATsresponded to a series of open-endedquestions via reflective journalingusing QuestionPro™, a secure datatracking website. The survey was

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Anticipatory Socialization Period—participants were challenged bymentors and instructors early ineducational experiences to setthemselves apart from others; 2) InitialPreparatory Experiences—volunteeractivities with the teams, workingsanctioned off season developmentalleague competitions, camps, orengaging in internships were necessaryto network with professional teamathletic trainers and gain entry into thework setting; 3) Sacrifice—participants expressed financial andfamily time sacrifices in order towork in the professional setting; and4) Learning through Networking—professional team societies representa strong brotherhood or fraternitywhereby the participants could rely onothers for advice and informationrelated to the nature of the roles in theprofession along with emotionalsupport and educational experiences.Conclusions: Being challenged toexcel and take the initiative to engagein preparatory experiences such asvoluntary or low-pay internships,camps, and team sponsored activitiesappears necessary to network withprofessional ATs and gain entry into theprofessional sport setting. Onceinducted into the sport context,personal sacrifice is essentially aconstant throughout the AT’s career inprofessional sports. High levelfinancial reward may require movingfrom an assistant’s position into a headAT position or by being promotedfrom minor leagues to the majorleague level. The professional sportsetting emphasizes the learning ofthe role through personal interactionsvia a network of professional societymembers who offer social supportand educational opportunities toone another to facilitate thesocialization and advancement of itsmembers. This project was funded bythe National Basketball AthleticTrainers’ Association Foundation

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The Professional SocializationOf Athletic Trainers In TheProfessional Sport ContextPitney WA, Abdenour TE,Mazerolle SM: Northern IllinoisUniversity, DeKalb, IL; San DiegoState University, San Diego, CA;University of Connecticut, Storrs,CT

Context: The professionalsocialization process consists ofrecruitment, anticipatory sociali-zation, organizational socialization,and role continuance. To date, theprofessional socialization of athletictrainers (ATs) in high school, college,and clinical/rehabilitation settings hasbeen investigated, but a lack ofinformation pertaining to professionalsocialization of ATs in the professionalsport context has been neglected.Objective: To gain insight andunderstanding of the anticipatory andorganizational socializationexperiences of ATs working in theprofessional sport settings with anemphasis on identifying aspects ofgaining entry into the professionalsetting and those experiences that bestprepare individuals for work in theprofessional context. Design:Qualitative study using one-on-onephone interviews. Setting:Professional sport. Patients or OtherParticipants: 12 males aged (M ± SD)47 ± 8 with 23 ± 9 years ofexperiences were recruited fromprofessional teams in baseball,basketball, football, and hockey viapurposive sampling as well as snowballsampling. Data Collection andAnalysis : In-depth, one-on-oneinterviews were conducted. Theinterviews were digitally recorded andtranscribed verbatim. Textual data wasanalyzed using inductive contentanalysis. Trustworthiness wasestablished with multiple analysttriangulation and peer debriefing.Results: Four themes emerged fromthe inductive analysis: 1) High Levelof Professional Challenge During

piloted prior to distribution. Data wasexamined borrowing from theprinciples of general inductiveapproach. Trustworthiness wasestablished by multiple analysttriangulation, member interpretivereview, and peer review. Results:Regardless of marital status,participants indicated 3 main factorsinfluencing WLB; hours worked andtravel, inflexibility and control of workschedules, and salary. These factorshave been shown to affect retention bypressuring ATs to sacrifice time spentwith family and limiting personal time,while insufficiently meeting theirfinancial needs. FATs who weremarried and/or had children found theability to prioritize and have separationfrom work as useful strategies tofulfill WLB. Single FATs utilized timeaway through exercise as a means toachieve WLB. Regardless of maritalstatus, the main factor necessary toaccomplish WLB was to have a strongsupport system both at work andhome. No formal policies or strategieswere in place to help mothers achievea work life balance. Conclusions: Asindicated in previous research, FATsexperience issues with WLB in theDivision I setting. FATs shouldcontinue to make time away from therole of athletic trainer and asthe literature indicates, capitalizeon informal resources such as co-worker support as a means to maintainWLB. WLB strategies are useful, butformal policies need to be establishedto help retain FATs in the profession.Future research may investigate whatpolicies and strategies can beemployed to achieve WLB.

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Supervising Athletic Trainers’Perspectives On ProfessionalSocialization Of GraduateAssistant Athletic Trainers InThe Collegiate SettingThrasher AB, Walker SE,Hankemeier DA, Pitney WA: BallState University, Muncie, IN, andNorthern Illinois University,DeKalb, IL

Context: Many newly credentialedathletic trainers gain initial workexperience as Graduate Assistants(GA) in the college setting, yet it isunknown how they are socialized intotheir roles. Exploring the perceptionsof GA supervisors in the collegiatesetting as to how GAs are socializedcould provide insight into how thisprocess occurs. Objective: Toexplore how GAs are socialized in thecollegiate setting. Design:Consensual Qualitative Research(CQR) Setting: Individual phoneinterviews Patients or OtherParticipants: 21 collegiate ATs whohad supervised GAs in the collegiatesetting for a minimum of eight yearsparticipated in this study (16 male, 5female; years of supervisionexperience: 14.6±6.6). Participantswho met the inclusion criteria wererecruited via an email from the Boardof Certification database. Interviewswere conducted until data saturationoccurred. Data Collection andAnalysis: Data were collectedvia phone interviews which wererecorded and transcribed verbatim.Data were analyzed via a four-personconsensus team who independentlycoded the data and compared ideasuntil a consensus was reached anda codebook was created. Anindependent auditor analyzed thedomains and core ideas to ensurereliability. Trustworthiness wasestablished through member checksand multi-analyst triangulation, whichis the nature of consensual qualitativeresearch. Results: Five themesemerged: 1) GA Role expectations, 2)

Previous preparation, 3) GA RoleOrientation, 4) Program’s role insupporting and developing GAs, and 5)Shortcomings and success.Supervisors expected the GAs toprovide coverage for their respectivesport at the level of a new clinician;however, supervisors often expectedthe GAs to function autonomously asexperienced full-time ATs. Themajority of the supervisors believedthat GAs were adequately prepared todeliver patient care but lacked theconfidence and skills to communicateeffectively with coaches, parents, andphysicians regarding patient care.Supervisors perceived GAs lack theability to fully execute their variousroles (e.g., progress patients throughrehabilitation), which was often due toa lack of hands-on experience. GAswere oriented to their roles andexpectations both formally (e.g.,orientation/weekly meetings) andinformally (e.g., mentorship wheninitiated by GA or immediate roleimmersion). Supervisors believedpersonal characteristics of theindividual GA (e.g., arrogance)inhibited their effectiveness in theirrole more so than their professionalpreparation. Supervisors reportintervening or mentoring as away to professionally develop theGAs and address their shortcomings.Supervisors felt most GAs adaptto their role over time (e.g., from 1to 6 months) and are successfulat meeting expectations. Conclusion:Superv isors be l ieved graduateassis tantships are important inthe professional growth of newATs to help transition them intoclinical practice. Supervisors arerespons ib le fo r p rofess iona l lydeve lop ing GAs, bu t severa lsuperv i sors have unrea l i s t i cexpectations for GAs to practiceas exper ienced ATs .

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Free Communications, Oral Presentations: Neuromuscular Characteristics ofDance and Warrior PopulationsTuesday, June 25, 2013, 8:00AM-9:00AM, Palm C; Moderator: Jatin Ambegaonkar, PhD, ATC, OT1 3 0 5 8 F O M U

Neck Strength, Flexibility,Posture, And ProprioceptionDifferences Between HealthyMale And Female Soldiers InThe US 101st Airborne Division(Air Assault)McFate DA, Nagai T, Abt JP, SellTC, Smalley BW, Wirt MD,Lephart SM: NeuromuscularResearch Laboratory, Departmentof Sports Medicine and Nutrition,School of Health andRehabilitation Sciences,University of Pittsburgh,Pittsburgh, PA; US Army Schoolof Aviation Medicine, Fort Rucker,AL; Blanchfield Army CommunityHospital, Fort Campbell, KY

Context: Neck pain is a commoncomplaint of military personnel,especially in female populations.Researchers have identified severalmusculoskeletal and neuromuscularcharacteristics that may predisposeindividuals to neck pain such asdecreased muscular strength. In manycases female Soldiers are assigned tothe same military occupationalspecialties (MOS) as male Soldiersand are required to perform identicalduties under similar physicaldemands. This combination mayultimately place females at greaterrisk of musculoskeletal injuriesincluding neck pain. Objective: Todetermine if neck strength, flexibility,posture, and proprioceptiondifferences existed between healthymale and female Soldiers. Design:Cross-sectional study. Setting:Research laboratory. Participants: Atotal of 12 female (Age=29.8±4.7years, height=164.5±9.2 cm,weight=68.7±3.6 kg) and 12 maleSoldiers (Age=29.2±3.9 years,height=175.2±5.6 cm., weight=82.1±9.8 kg) were recruited. Subjectswere matched based on age (±3 years)and MOS. All subjects were free of

musculoskeletal injuries preventingactive duty. Interventions: Allsubjects underwent the followingassessments: cervical strength,shoulder strength, cervical flexibility,forward head and shoulder posture,pectoralis minor length, and cervicalproprioception. Strength was measuredusing hand-held dynamometry with theexception of shoulder elevation, whichwas tested using an isokineticdynamometer. Flexibility wasmeasured using a cervical range ofmotion instrument, and posture wasmeasured using a carpenters’ double-square device. Proprioception wasdetermined using a 3D motion capturesystem. All tests were performedbilaterally when possible. Paired t-testswere used to compare genders withsignificance set at p< 0.05 a priori.Main Outcome Measures: Thedependent variables were peak force(normalized to body mass) for neckflexion, extension, lateral flexion,rotation, and shoulder abduction/elevation, cervical range of motion(ROM) for flexion, extension, lateralflexion, and rotation, forward head(FH), right/left shoulder posture (RSP,LSP), pectoralis minor length, andcervical active joint position sense.Results: Female Soldiersdemonstrated significantly lessstrength across all measurements(p<0.05). Female Soldiers alsodemonstrated significant increases incervical rotation ROM (F: 80.5±6.2°,M: 74.3±4.8°, p=0.013) andsignificant decreases in FH(F:20.5±1.5 cm, M:22.2±1.4 cm,p=0.015), RSP (F:14.4±2.7 cm,M:17.1±2.7cm, p=0.009), LSP(F:13.7±2.3 cm, M:15.6±2.3 cm,p=0.026). Conclusions: The currentresults indicate gender-relateddifferences in various musculoskeletalcharacteristics. Female Soldiersdisplayed better flexibility and postureand similar proprioception compared

to male Soldiers, but they hadsignificantly less strength which maypredispose them to injury. Femalestypically have a smaller body size thanmales, which would indicate a need forincreased muscular strength relative tobody mass in order to safely andproperly perform the occupationaltasks required of them. Decreasedmuscular strength also influences jointstability, which may contribute toincreased injury risk. Further researchshould focus on identifying modifiablerisk factors for neck pain anddeveloping interventions influencingthose characteristics. Supported byUSAMRMC #W81XWH-11-2-0097

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Effect Of A Lower ExtremityInjury Prevention Program OnPhysical Performance ScoresIn Military RecruitsPeck KY, DiStefano LJ, MarshallSW, Padua DA, Beutler AI, de laMotte SJ, Cameron KL: KellerArmy Hospital, United StatesMilitary Academy, West Point,NY; University of Connecticut,Storrs, CT; University of NorthCarolina, Chapel Hill, NC;Uniformed Services University ofthe Health Sciences, Bethesda,MD

Context: The implementation ofinjury prevention programs in athleticshas become more common due toemerging evidence supporting theirefficacy. Many of these programs aredesigned to improve movementpatterns associated with lowerextremity injury; however, the impactof these programs on general physicalperformance has not been evaluated.Objective: The purpose of this studywas to compare physical performancescores between subjects whoparticipated in a lower extremity injuryprevention program during warm-upand those who performed a standardwarm-up. Design: Cluster randomizedcontrolled trial. Setting: US ServiceAcademy. Participants: 1068college freshmen entering theacademy in June 2011.Interventions: Groups performedone of two 10-minute warm-ups 2-3times per week for six weeks. Theintervention group performed theDynamic Integrated MovementEnhancement (DIME) warm-upconsisting of 10 exercises designed toimprove lower extremity alignment,decrease ground reaction forces duringlanding, and increase lower extremitybalance and core strength. The controlgroup performed the Army PreparationDrill consisting of 10 exercisesdesigned to prepare soldiers forphysical training exercises. Bothgroups completed the same

num<text>ber of sessions. At the endof basic training, all subjectscompleted the Army Physical FitnessTest (APFT) which includes a timed 2-mile run and 2 minutes each of push-ups and sit-ups. Main OutcomeMeasures: The main outcomemeasures were raw and scaled scoresfor the three APFT events as well asthe total APFT score. Initially,independent t-tests were used toassess between group differences foreach dependent variable. Importantvariables were carried forward intomultivariable logistic regressionmodels to control for the influence ofconfounding variables such as genderand BMI. Results: Subjects in theintervention group completed the 2-mile run 20 (95%CI: 9.27, 31.14)seconds faster when compared to thecontrol group (p<.001). On average,subjects in the DIME group completedthe run in 808(±79) seconds comparedto the control group who completedthe run in 828(±102) seconds. Thiscorresponded with significantly higherscaled scores for the 2-mile run in theDIME group (p<0.001). There wereno significant differences in push-upor sit-up scores between the groups;however, significantly higher totalAPFT scores were observed in theDIME group (275±32) whencompared to the control group(269±34) (p<.001). Similar resultswere observed in multivariable modelsafter controlling for gender and BMI.Conclusions: Injury preventionprograms have become increasinglypopular based on preliminary researchsupporting their efficacy. However,because many of these programs aretime-consuming they are not alwayswell-received by coaches. Ourfindings suggest that the DIME grouphad better cardiovascular fitness andoverall fitness scores when comparedto the control group after a six-weeklower extremity injury preventionintervention. Whether the DIMEprogram influences skill-relatedfitness remains unclear.

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Female Dancers StabilizeEarlier Than RecreationallyActive Females Following AJump Landing TaskPye ML, Ross SE, Schmitz RJ,Shultz SJ: University of NorthCarolina at Greensboro,Greensboro, NC

Context: Poor balance has beenassociated with increased anteriorcruciate ligament (ACL) injury risk.Dancers are more stable than athletesduring single leg static stance, whichmay in part explain dancer’s decreasedincidence of ACL injury. However, thefunctional implications of staticbalance measures have beenquestioned given the dynamic natureof sport. Whether dancers are alsomore stable during a dynamic balancetask than athletes has not beeninvestigated. Objective: To comparedynamic balance in collegiate dancersand recreationally active individuals.Design: Descriptive cohort study.Setting: Laboratory setting. Patientsor Other Participants: Six femaledancers (DA) [19.8 ± 1.2 yrs, 161.7 ±5.2 cm, 58.0 ± 8.6 kg] and 6recreationally active females (RA)[22.2 ± 1.6 yrs, 162.3 ± 8.0 cm, 63.0± 5.6 kg]) with jumping experience. Allparticipants were healthy andparticipated in a minimum 30 minutesof physical activity 3 times a week.Dancers were also required to have atleast 5 years of contemporary or ballettraining. Intervention: Participantsperformed 3 trials of a jumpstabilization task. This consisted of aforward jump that was standardized toa distance of 40% the participant’sheight. Subjects jumped over a 25 cmbarrier and landed on a single limb ona force plate. They were then requiredto hold the single limb stance for 10s. Both dominant (stance limb) andnon-dominant limbs were tested inshoe and barefoot conditions. All trialswere counterbalanced. Groundreaction force data were acquired(1000Hz) over 10 s. Main Outcome

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Measures: Time to Stabilization(TTS) (s) was defined as the point atwhich an unbound third orderpolynomial fit to the ground reactionforce reached values of the groundreaction force of a stable single limbstance. TTS was computed foranterior-posterior (AP) and medial-lateral (ML) directions. Differencesbetween DA and RA were assessedusing independent t-tests (P<0.05) andcalculating effect sizes. Results:Dancers stabilized sooner in the APdirection on the dominant limb in theshoe condition (DA= 2.55± 0.7 s; RA=3.85 ± 0.9 s; P =0.02). No othersignificant differences were noted.However, a large effect size (Cohen’sd=0.76) was observed in the APdirection on the dominant limb duringthe barefoot condition with dancersagain stabilizing sooner (DA= 2.83 ±0.8 s; RA= 3.40 ± 0.7 s; P =0.21).Conclusions: The TTS measure issensitive for detecting dynamicbalance differences between healthydancers and recreationally activefemales. Dancers require less timeto stabilize compared to recreationallyactive individuals on the dominant limbin the AP direction. Future researchmay explore the relationship betweendancers’ ability to stabilize quicklyfollowing a jump landing task and theirlow incidence of ACL injury.

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Coordination Variability IsHigher In Non-Dancers Than InDancers During A Jumping TaskJarvis DN, Armour Smith J, KuligK: University of SouthernCalifornia, Los Angeles, CA

Context: Movements are often studiedthrough biomechanical analysis ofindividual joints or segments, but thestudy of coordination patterns acrossmultiple segments provides a more in-depth approach to the examination ofskilled athletic movements. Inaddition, movement variability acrossrepeated trials is related to athleticskill and plays an important role insports performance. Characterizationof coordination patterns and variabilityin persons of varying athletic skill willindicate qualities associated with elitetask performance. Objective: Toexamine trunk and lower extremity(LE) kinematics and coordinationvariability in dancers and non-dancersduring rate-controlled sautés (bipedalvertical dance jumps). Design: Cross-sectional. Setting: Biomechanicsresearch laboratory. Participants:Twenty healthy females; ten(age=24.8± 2.2 years; weight=57.7±7.1 kg; height=1.63 ±0.07 m) with noprior formal dance training, and ten(age=27.1 ±3.5 years; weight=58.4±5.9 kg; height=1.65 ±0.07 m)professional dancers with an average20.8±5.3 years of dance training.Interventions: A three-dimensionalmotion analysis system was used tocollect kinematic data. Participantsperformed 20 consecutive sautés at acontrolled rate of 95 beats per minute.Sagittal plane kinematics of the middle10 consecutive jumps for eachparticipant were calculated. MainOutcome Measures: Kinematicvariability was assessed using the meanstandard deviation of angulardisplacement for individual joints ortrunk segments. The vector codingmethod was used to quantifycoordination variability between theknee and ankle, hip and knee, and

thoracic and lumbar segments. Themean coupling angle across the10 trials was calculated for eachparticipant using circular statistics,and the angular deviation ofthe coupling angle was used to assesscoordination variability. Overall trunkand LE variability trends betweengroups were examined usingindependent t-tests (p<0.05).Results: Kinematic profiles weresimilar between the two groups,indicating that both groups weresuccessful in performing thejumping task. Kinematic variabilitywas higher for non-dancers (3.2±1.8°)than for dancers (2.3±1.6°) in theLE joints (p<0.01), but there wasno difference between groups forthe trunk (p=0.16). However, thedifference in LE variability betweengroups was only 0.9°, which is smallerthan the standard error of measurefor the three lower extremity joints(SEM ankle=0.9°, knee=2.1°,hip=3.3°). When looking atcoordination variability betweenjoints, non-dancers had highervariability (38.0±8.9° trunk; 21.5±16.8° LE) than dancers (31.8±8.5°trunk; 16.4±15.6° LE) for both lowerextremity (p<0.001) and trunk(p=0.009) couplings. Conclusions:Trained dancers demonstrate similarkinematics but lower coordinationvariability compared to non-dancersduring a simple jumping task.Examination of coordinationbetween joints may allow for amore thorough understanding ofskilled athletic movements thankinematic analysis alone.

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Secondary School AthleticTrainers’ Referral Patterns ForPatients Following Sport-Related ConcussionMcCarty CW, Mayfield RM,Parsons JT, Valovich McLeod TC:A.T. Still University, Mesa, AZ

Context: As state concussion lawscontinue to evolve, it is important tounderstand the factors that influenceathletic trainers’ (AT) decisions to referpatients following sport-relatedconcussion. It is also valuable todetermine whether ATs’ haveestablished interprofessionalrelationships to ensure the propermanagement of patients followingsport-related concussion. However, itis unclear whether ATs in the secondaryschool setting have direct access toother healthcare professionals.Objective: To determine secondaryschool ATs’ referral patterns foradolescent athletes following sport-related concussion. Design: Cross-sectional survey design. Setting: Self-reported online survey. Patients orOther Participants: 851 clinicians(25.9% response rate) from aconvenience sample of ATs practicingin the secondary school setting (308males, 376 females, 167 missing,age=37.28±10.13). Interventions:Participants were solicited via emailto complete the Athletic Trainers’Beliefs, Attitudes, and Knowledge ofPediatric Athletes with Concussions(BAKPAC-AT) survey. The BAKPAC-AT consisted of several multipartquestions to assess ATs’ currentpractices regarding referrals followingsport-related concussion andestablished relationships with otherhealthcare professionals. MainOutcome Measures: The dependentvariables were participants’ responsesto the referral and establishedrelationship questions. Descriptive

Free Communications, Oral Presentations: Knowledge and Perception ofConcussionsTuesday, June 25, 2013, 9:15AM-10:15AM, Palm C; Moderator: Johna Register-Mihalik, PhD, ATC

statistics were reported to describeoverall practices. Separate forwardstepwise binary logistic regressionanalyses (p<.05) were used todetermine whether any personal (yearscertified, experience in secondaryschool setting) or school (enrollment,type, presence of football) factorspredicted ATs’ decisions to referpatients to physicians following sport-related concussion. Results: Amajority of ATs (77.8%, n=662) referadolescent athletes to a physicianfollowing sport-related concussion.Nearly half of these respondents(48.8%, n=415) indicated they refer100% of concussion cases per year.The most influential factors that leadto a referral were state law (40.3%,n=343), personal preference (34.7%,n=295), and school district policy(24.8%, n=211). The regressionanalyses revealed no significantpersonal or school predictorsregarding ATs’ referral decisions tophysicians. ATs most commonlyreported having an establishedrelationship with sports-medicinefellowship physicians (80%, n=596),neurologists (33%, n=243),neuropsychologists (27%, n=201) andphysician assistants (27%, n=197),while 7% of respondents (n=52) do nothave established relationships withother healthcare providers. ATs“always” (18%, n=106) and “almostalways” (37%, n=220) referredpatients to a sports medicine physician,yet despite having establishedrelationships, “rarely” referred toneurologists (39%, n=93) andneuropsychologists (36%, n=72), and“never” referred to physicianassistants (37%, n=73). Conclusions:Most ATs refer patients to physiciansfollowing sport-related concussion,and occasionally refer to otherhealthcare professionals. While state

regulation and personal preferencewere primary factors influencingreferral decisions, it is unclear atwhat point of care the referraloccurs. Because effective referralcan impact the outcome of a case,future research should assess whenreferral decisions occur and whatfactors lead ATs to refer to healthcareprofessionals other than physicians.

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Concussion Occurrence AndPerception Survey For Athletes(COPSA)McDevitt J, Tierney RT, Bright N,Komaroff E: Temple University,Philadelphia, PA

Context: Underreporting ofconcussions is a problem in highschool athletics. Additionally, little isknown as to what factors influence theathletes’ unwillingness to reportconcussive signs and symptoms (s/s).Objective: Identify athletes’perception, reporting values, andoccurrence of concussive s/s. Design:Survey study. Setting: Urban highschools. Participants: 302 male andfemale athletes participating in a2010-2011 sport. Response rate was20.13%. Interventions: A constructvalidation process was used to designa paper and pencil survey. Flesch-Kincaid program was utilized to ensureappropriate wording. A panel of survey-research design and concussionexperts evaluated the survey’s contentvalidity. Athletes were grouped intohigh head impact sport (HHIS), lowhead impact sport (LHIS), or both (B).Frequency statistics and chi-squareswere used to analyze data. Three(group) x three (response) chi-squareanalyses were used to test associationsin response options between groups (p= .05). Significant chi-squares werefollowed up with pair wise 2 x 3 chi-squares using a Bonferroni correction(p = .017) as needed. Main OutcomeMeasure(s): Athletes responded todemographic information andconcussion s/s data across 4 domains(knowledge, concern, report, andoccurrence). Athletes answered yes orno questions as well as questions usinga 5-point likert scale. Results: Overhalf of LHIS athletes and 20% ofHHIS athletes reported they did nothave any concussion knowledge (p=.002). Seventy-two percent of LHISathletes were “maybe concerned”about poor balance (p = .001), and overhalf of HHIS athletes “would not even

think about being concerned“ aboutpoor balance (p= .007). Leastconcerning s/s were extra sad (42%),noise hurts my head (34%), nervous(33%), and easily tired (30%).Seventy-one percent of the LHISathletes and 50% of HHIS athletesreported they “may report” feelingeasily fatigued (p =.014). Signs andsymptoms least likely to be reportedwere grumpy (36%), nervous (30%),and extra sad (27%). Almost 30% ofHHIS athletes stated they “sometimes”get dizzy after a sports-related headimpact (p = .003). Sixty-three percentof athletes participating in B reported“sometimes” feeling dizzy after asports-related head impact (p = .003).The most commonly occurring s/s that“sometimes” or “always” occur aftera head impact were headache (40%,9%), dizzy (29%, 5%), blurred vision(24%, 3%), and “dinged” (19%, 4%).Conclusion: Urban high schoolathletes are concerned and wouldreport s/s that are overtly detrimentalto their health, but those s/s that occurmost often after a head impact athletesseem to be less concerned about andmay not report those s/s. Athletictrainers should be aware of the s/sthat are occurring most often andthat students are less likely tobe concerned or report.

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Preliminary Analysis OfConcussion Occurrence AndPerception Among CollegiateAthletesBright NB, McDevitt JK, TierneyRT: Kinesiology Department,Biokinetics Research Laboratory-Athletic Training Division, TempleUniversity, Philadelphia, PA

Context: Each year concussionsaccount for an estimated 300,000 to3.8 million injuries in the UnitedStates. However, due to suspectedunderreporting of concussions, theseare likely underestimates as manyathletes may be unaware of themechanisms and/or signs andsymptoms (s/s) of said injury.Objective: To elucidate collegiateathletes’ knowledge, concern,reporting habits, and occurrence ofconcussive s/s using the ConcussionOccurrence and Perception Surveyfor Athletes (COPSA). Design: TheCOPSA is an anonymous, cross-sectional, paper-and-pencil survey.Setting: Two- and four-year urbancolleges. Patients or OtherParticipants: A volunteer sample ofcollegiate athletes completed thesurvey; of the 100 surveys distributed,88 were returned (88% response rate).The forty-nine male (60.5%) and 32female (seven unanswered) athletessurveyed ranged in age from 18 to30 years with primary participationin over 14 sports (e.g., base/softball,boxing, football, rugby, swimming,track). Athletes reported an average12.56 ± 5.08, 4.79 ± 2.69, 2.75 ±1.41, and 1.73 ± 0.88 years ofparticipation in their primary (n =75), secondary (n = 34), tertiary (n= 20), and quaternary (n = 13) sport,respectively and primarily playedgymnastics (48.8%), soccer (17.5%),and base/softball (15%).Interventions: The COPSA wascreated using a construct-validationprocess and underwent content validityusing a panel of survey-research andconcussion experts. Athletes were

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recruited via a researcher-initiatedteam meeting and those willingto participate completed the surveyand submitted them to a designated box.Athletes were defined as thosecurrently participating on a sports teamat their institution. Main OutcomeMeasures: Concussive knowledge,concern, reporting habits andoccurrence by indicating: “yes” or“no” to 3 questions: “I know aboutsports-related head injuries andconcussions, “Sports-related headinjuries are a problem in the sport(s)I play,” and “There are things I cando to prevent/minimize sports-relatedhead injuries”; “not”, “maybe”, or “veryconcerned”; “definitely not”, “maybe”,or “definitely tell”; “never”,“sometimes”, or “always experience”regarding 19 concussive s/s post-impact, respectively. Data wereanalyzed via frequency distributions.Results: Athletes were mostconcerned with and more likely toreport overt signs of concussion (e.g.loss of consciousness, 81% andvomiting, 69%). However, those witha history of concussion (n=25)frequently stated these overt signs neveroccurred (60%, 63%, respectively).Overall, athletes claimed to know some(64.8%) to quite a lot (31.8%) aboutconcussions, but responded that they“might be” concerned or report amajority (15/19) of their concussive s/s. Conclusions: Possible confusionand suspected underreporting ofconcussions warrant increased educationi n i t i a t i v e s . S p o r t s - m e d i c i n eprofessionals should capitalize onthe notion that most collegiate athletesbelieve there are things they can do toprevent/minimize the injury and properlyeducate athletes regarding its s/s andhighly individualistic presentation.

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Secondary School AthleticTrainers’ Knowledge AndPerceptions Of AcademicAccommodations FollowingSport-Related ConcussionMayfield RM, McCarty CW,Parsons JT, Valovich McLeod TC:A.T. Still University, Mesa, AZ

Context: Sport-related concussionsnot only affect sport participation, butcan also hinder academic success.There has been recent emphasis oncognitive rest and appropriatelymanaging return-to-learn as part of acomprehensive concussion program.Following a sport-related concussion,student-athletes may benefit fromacademic accommodations (AA) in theclassroom; however athletic trainers’(AT) knowledge and use of AA isunknown. Objective: To determinesecondary school ATs’ knowledge andperceptions of 504 plans,individualized education programs(IEP), and ATs’ role in AA. Design:Cross-sectional design. Setting: Self-reported online survey. Patients orOther Participants: 851 clinicians(25.9% response rate) from aconvenience sample of ATs that werecurrently practicing in the secondaryschool setting (308 males, 376females, 167 missing, age=37.28±10.13). Interventions:Participants were solicited via emailto complete the Athletic Trainers’Beliefs, Attitudes, and Knowledge ofPediatric Athletes with Concussions(BAKPAC-AT) survey. The BAKPAC-AT consisted of several multipartquestions to assess ATs’ knowledgeand perceptions regarding 504 plans,IEPs, and ATs role in returning student-athletes back into the classroom.Independent variables includedemployment status (full-time vs. part-time), employment model (direct vs.outreach), years certified, and yearsof experience in the secondary schoolsetting. Main Outcome Measures:The dependent variables wereparticipants’ responses to the AA

questions. Spearman correlationswere used to assess relationships andMann Whitney U and Chi Square tests(p<.05) were used to identifydifferences. Results: Respondentsreported 44±0.33% of sport-relatedconcussions managed received AA.Respondents employed directly by theschool were more knowledgeable of504 plans (p<.001), IEP (p<.001), andhad a greater belief that AT’s shouldhave a role in AA. There were nosignificant differences betweenemployment status and knowledge of504 plans (p=.143), IEP (p=.856), orperceptions of AT’s role in AA(p=.219). There was a significantpositive correlation between thenumbers of years certified andknowledge regarding 504 plans(r=.343, p<.001) and IEP (r=.328, p<.001). A significant relationship wasalso found between years ofexperience at the secondary schooland 504 plan knowledge (r=.347p<.001), and IEP knowledge (r=.327,p<. 001). There were no significantassociations between years certified(r=.057, p=.138) or years ofsecondary school experience (r=.001,p=.970) regarding perceptions of ATs’role in AA. Conclusions: ATsemployed directly by the secondaryschool and those with moreexperience as a secondary school ATwere more knowledgeable of AA. Thismay be the result of knowledge gainedas a member of the school staff.Understanding AA is important for allATs, as the prescription of cognitiverest and return-to-learn is becomingmore widely recommended inconcussion management. Furtherresearch should be conducted gatheringprospective information of AA forstudent-athletes following sport-related concussion as well as educatingATs on the importance of addressingacademics following concussion.

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Free Communications, Oral Presentations: Various Approaches for Classroomand Clinical EducationTuesday, June 25, 2013, 10:30AM-11:45PM; Palm C; Moderator: Jolene Henning, EdD, ATC, LAT1 3 0 0 8 F O P E

The Entry-Level Masters RouteTo Certification: ProgramStandards, Outcomes AndStudent CharacteristicsOstrowski JL: Weber StateUniversity, Ogden, UT

Context: Entry-Level Mastersathletic training education programs(ELM ATEPs) have increased by over400% in the past 10 years, howeverlittle is known about characteristics ofstudents who enroll or about thestandards of programs themselves.Objective: Explore characteristics ofELM athletic training students (MATS)to develop a profile; explore ATEPrequirements, retention and BOC passrates, and placement rates. Design:Cross-sectional survey design.Setting: Online survey. Patients orOther Participants: All ELMProgram Directors (PDs) listed on theCAATE website as of April 2012 werecontacted. PDs were asked tocomplete a survey and to forward asurvey link to MATS currently enrolledin their ATEP. 79 MATS (136 surveysforwarded; 58% response rate) and 11PDs (25 PDs contacted; 44%response rate) completed the surveys.MATS: average age 24.7 years (range:21-42); 68% female, 56% first-yearMATS. Average years experience asPD: 8 (SD: 3.6; range: 3-12).Interventions: Surveys administeredonline via Formstack.com. Surveyresponses were returned to the serveras anonymous data. Main OutcomeMeasures: MATS survey:demographics (age, race, standing inATEP), characteristics of under-graduate education, rationale forenrolling in ELM program, perceivedlevel of preparation to become acertified AT. PD survey: demographics(number of years as PD, PD’s route tocertification), history of ATEP,retention/graduation/BOC pass rates,graduation requirements, perceived

preparation of MATS to practice asATs. Descriptive statistics and non-parametric correlations werecalculated. Results: MATS survey:profile of MATS is a student in theirmid-20s, Caucasian, received BachelorDegree in exercise science < 2 yearsprior to entering an ELM program.Geographical area and institution’sreputation were primary contributingfactors in choosing an ELM program.Following graduation 93.5% plannedto seek employment using ATCcredential. No significant DVcorrelations. PD survey: 91% first-to-second year average retention rate;81% average two-year graduation rate.Average first-time BOC pass ratereported was 91.7% (three-yearaggregate). 91% of ELM ATEPsrequire a thesis or structured researchproject. The lowest BOC pass rateswere reported in ATEPs withoutstructured research requirements(r=0.762, p=0.006). Significantcorrelation between retention ratesand graduation rates (r=0.696,p=0.025). Conclusions: Despitespeculation regarding the future ofathletic training education, little isknown about the ELM route tocertification. A profile of MATS willaid in ATEP recruitment efforts. Ourdata indicates that the overwhelmingmajority of ELM graduates willpractice professionally using their ATCcredential (93.5% MATS report,93.6% PD report). First-time BOCpass rates reported in ELM ATEPs arewell above the national average. TheELM route to certification appears toproduce high-quality athletic trainerswho are likely to remain in the field.Institutions considering developing anELM program should stronglyconsider incorporating a thesis orstructured research project.

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Employers’ Knowledge LevelsOf The Various Types Of AthleticTraining Education ProgramsBurgess MJ, McCarty CW,Laidlaw CR, Van Lunen BL: OldDominion University, Norfolk, VA,and A.T. Still University, Mesa, AZ

Context: As athletic trainingeducation continues to evolve, it isessential that employers have anunderstanding of the differencesbetween the types of athletic trainingeducation programs (ATEPs) so theycan make the best hiring decisions.Objective: To assess athletic trainingemployers’ perceived knowledge(PKn), objective knowledge (ObjK),and their confidence in theirknowledge (CfK) of the types ofATEPs available within athletictraining. Design: Cross-sectionalsurvey. Setting: Web-based survey.Patients or Other Participants: 133of 420 employers (31.67% responserate) from a convenience sample ofemployers from the NATA publicvacancy notice (79 males, 54 females,age=42.89±9.84) participated in thestudy. Participants were separated byjob type, which included 65 clinicians,42 educators, and 26 administrators.Interventions: Participants weresolicited via email (between Fall 2010and Spring 2012) to complete theonline survey. The PKn sectionincluded four Likert-scale items(range 1-4) regarding howknowledgeable participants perceivedthemselves regarding professionalATEPs, professional master’s ATEPs,and post-professional ATEPs. TheObjK and CfK sections included 12multiple-choice questions (MCQ)about the different ATEPsaccompanied by a Likert-scale item(range 1-4) assessing their CfK foreach MCQ. Reliability from anunrelated pilot sample (n=13) for the

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OKn section was determined to beexcellent; percent agreementaveraged 96% with a range of83.33%-100%. Main OutcomeMeasures: The independent variablewas employer job type (educator,clinician, administrator) anddependent variables were PKn, ObjK,and CfK composite scores. ObjKscores were calculated by awardingone point for each question answeredcorrectly (maximum score=12). PKnand CfK scores were attained bytotaling all values and calculatingthe average value back to the Likertscale (total divided by 4). Higherscores indicated higher perceivedknowledge or a higher confidencein their knowledge. Significantdifferences (P<.05) were calculatedusing one-way ANOVAs and Kruskal-Wallis H tests. Results: Overall,participants perceived themselves“moderately knowledge-able” (3.11/4.0±0.73) of ATEPs, howevercomposite ObjK scores were7.27±2.86 (CI=6.78-7.76). Despitemediocre composite ObjK scores,employers were “moderatelyconfident” (3.04/4.0±0.68) in theirObjK responses. Job type wasassociated with higher PKn scores(H(2)=20.36,P<0.001), ObjK scores(F=19.26,P<0.001), and ConKscores (H(2)=29.99,P<0.001).Educators had higher PKn scores(3.51/4.0±0.50), ObjK scores(9.26±2.26,CI=8.55-9.97), and CfKscores (3.48/4.0±0.50) thanclinicians (PKn=3.01/4.0±0.67,ObjK=6.48±2.56,CI=5.84-7.11,CfK=2.84/4.0±0.52) and admin-istrators (PKn=2.72/4.0±0.90,ObjK= 6.04 ±2.82,CI=4.90-7.18,CfK=2.81/4.0±0.91), indicating thatthey were more knowledgeable andmore confident of the differencesbetween ATEPs than the other twogroups. Conclusions: Findings fromthis study suggest that employers areonly moderately familiar withdifferences between ATEPs. Withonly limited knowledge of thequalifications attained from each type

of ATEP, employers may have difficultyselecting the best candidate foremployment. As educationalprogramming continues to change, it isessential to educate employers aboutqualifications from differing programs.

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The Relationships AmongWorkload, Instructor ApproachTo Teaching, And StudentEvaluation Of TeachingWilkinson RD: University ofWisconsin – Milwaukee,Milwaukee, WI

Context: Instructors in Commissionon Accreditation of Athletic TrainingEducation (CAATE) accreditedAthletic Training Education Programs(ATEPs) have various workloadassignments, including teaching,research, administration, and/orathletic training sport coverage(ATSC). Most commonly, the dual-appointment model consists ofteaching and ATSC. Role strain occurswhen an individual has difficultymeeting the obligations associatedwith multiple roles; commonlyexperienced by dual-appointmentinstructors. Various factors mayimpact instructor approach to teaching(IAT) and student evaluation ofteaching (SET), including workload.Objective: The purpose of this studywas to determine the relationshipsamong workload, IAT, and SET inCAATE accredited Wisconsin ATEPs.Design: Self-administered surveysaddressing workload, the Approachesto Teaching Inventory (ATI), and theStudent Evaluation of EducationalQuality (SEEQ) instrument. Setting:Wisconsin ATEPs. Patients or OtherParticipants: Instructors (n = 25,mean age 40.12 ± 8.293) includedcertified athletic trainers (AT)teaching classroom-based courses.Program directors were asked toforward recruitment materials to theirAT instructors. Undergraduate students(n = 200) enrolled in courses taughtby instructor participants were alsosurveyed. Instructors were asked toforward recruitment materials to theirstudents. Interventions: Instructorscompleted a questionnaire addressingworkload and the ATI. Each ATIquestion was labeled Student Focused(SF) or Teacher Focused (TF). Meanscores for SF and TF questions were

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established. Students completed aquestionnaire including the SEEQ,regarding their instructor. The ATI andSEEQ have demonstrated positivereliability and validity. MainOutcome Measures: The SEEQincludes nine sub-sets: Learning,Enthusiasm, Organization, GroupInteraction, Individual Rapport,Breadth, Examinations, Assignments,and Overall. Mean scores from theoverall total and the sub-sets weredetermined. Data were analyzed todetermine statistically significantrelationships (p<.05), utilizing thePearson correlation coefficient.Results: There was a statisticallysignificant positive relationship (.553,p=.005) between the SF mean andthe total SEEQ mean. SEEQ sub-setsalso demonstrated statisticallysignificant positive relationships withthe SF mean, including Enthusiasm(.582, p=.003), Group Interaction(.527, p=.008), Individual Rapport(.492, p=.015), Breadth (.421,p=.040), Assignments (.453, p=.026),and Overall ( .559, p=.005).Addi t iona l ly, a s ta t i s t i ca l lysignificant positive relationship(.506, p=.010) existed betweenATSC workload and the TF mean.Conclus ions : In th i s s tudy,ins t ruc tors wi th h igher SFmeans rece ived h igher SEEQscores. A SF approach has beenlinke to improved student learningoutcomes . Addi t iona l ly, in -structors carrying ATSC were foundto approach their teaching frommore of a TF approach. ATSCworkload may have a negat iveimpact on approach to teaching.Time and/or role strain may bel imi t ing fac tors fo r exp lor ingalternative teaching techniques fordua l -appoin tment ins t ruc tors .Fur ther research i s needed toconfirm the educational impact ofthe dua l -appoin tment model .

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A Small Group StandardizedPatient Encounter ImprovesAthletic Training Students’Psychosocial Intervention AndReferral Skills.Walker SE, Thrasher AB: BallState University, Muncie, IN

Context: Athletic trainers providesocial support, counseling,intervention, and referral to patientsduring clinical practice but reportreceiving little to no experiencedeveloping these skills during theireducation. Standardized patients (SPs)can provide this learning experience tobetter prepare students for clinicalpractice. Objective: The purpose ofthis study was to examine the effectsof a small group SP encounter onathletic training students’interpersonal communication,psychosocial intervention, and referralskills (PIR). Design: Quasi-experimental. Setting: OneMidwestern university. Patients orOther Participants: All athletictraining students (N=39, 14 male, 25female, aged 21.67±1.30) who hadcompleted the Psychology of Injurycourse during the fall semester of2006-2009 and were enrolled in aCurrent Concepts of Athletic Trainingcourse during the spring semesterparticipated in this study.Interventions: During the fifth weekof the spring semester, theexperimental group (n=20; spring2007 and spring 2009) engaged in asmall group SP encounter. Randomlyassigned to groups containing three orfour, the participants interacted with aSP with a cocaine addiction needingPIR. Verbal feedback was provided ontheir performance during and after theencounter from the SP, a clinician, andinstructor who were present during allsmall group SP encounters. Thecontrol group (n=19; spring 2008 and2010) received no intervention. Toevaluate the effectiveness of the SPencounter, all participants individuallyevaluated a SP with an eating disorder

needing PIR ten weeks into each springsemester. Interpersonal commu-nication and PIR were assessed by theinstructor using a checklist (e.g.,inquired as to perception of weight,listened, made referral). Anexperienced researcher/clinician inPIR reviewed the checklist to establishvalidity. Checklist reliability wasestablished via inter rater reliabilitymeasures between the instructor andSP (ICC .781). Main OutcomeMeasures: The independent variablewas the small group SP encounter andthe dependent variable was thestudents’ interpersonal and PIRperformance measured by thechecklist. An independent t-testdetermined the effects of theintervention on interpersonalcommunication and PIR skills. Datawere analyzed using SPSS (Version15.0, SPSS Inc. Chicago, IL) with analpha level of .05. Results: Anindependent t-test revealed asignificant increase in performance bythe experimental group on their PIRskills (p=0.001) but no differencebetween the two groups oninterpersonal communication skills(p=0.346). The checklist from theinstructor revealed that on PIR skills,the experimental group completed anaverage of 4.55±1.88 out of nine skillscorrectly while the control group onlycompleted 2.63±1.21 correctly.Conclusion: A small group SPencounter did improve students’ PIRskills. These results suggest a smallgroup SP encounter provides anefficient clinical educationalexperience to better prepare athletictraining students for clinical practice.

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An Examination of theExperiences of Athletic TrainingPreceptors with DifferentAmounts Of Clinical And ClinicalTeaching ExperienceNottingham SL: ChapmanUniversity, Orange, CA

Context: The 2012 Commission onAccreditation on Athletic TrainingEducation(CAATE) standards includeseveral changes that allow moreinstitutional autonomy whendetermining the qualifications andpreparation of preceptors.ClinicalEducation Coordinators (CECs) mustmake educated decisionsregarding theselection and training of preceptors,yet minimal research exists inthis areato guide their decisions. Objective:To explore the experiencesofpreceptors with different amounts ofclinical and clinical teachingexperience toprovide informationregarding the selection and preparationof preceptors.Design: Descriptivequalitative interview study. Setting:Three undergraduate CAATE-accredited Athletic Training EducationPrograms (ATEPs). Participants:17preceptors (8 males, 9 females; 9.88±9.46 years of clinical experience;5.06±3.92 years of clinical teachingexperience) working in the university,communitycollege, rehabilitationclinic, and high school settings.Participants were selectedthrough acombination of purposeful andconvenience sampling and had tobecurrent preceptors for a CAATE-accredited ATEP. Participants wererecruitedthrough the CECs of threeinstitutions, and the researcher soughtto interviewparticipants with a widerange of clinical and clinical teachingexperience. Data was collected untilvariety of participant experiences wasobtained and saturationof dataoccurred. Data Collection andAnalysis: The researcher interviewedparticipants using an individual, in-person, semi-structured format.

Interviewswere recorded, transcribedverbatim, and analyzed using theprocess of open,axial, and selectivecoding with ATLAS.ti software.Trustworthiness was established bymember-checking interviews withparticipants and having twopeerdebriefers critically review the dataand researcher’s findings. Results:Fourcategories emerged from the data,including benefits, preparation,qualifications,and challenges of beinga preceptor. While participantsdescribed it wasbeneficial to havestudents, they also faced severalchallenges, includingbalancing theirresponsibilities as a clinician andpreceptor and keeping theirknowledgecurrent. Participants discussed thatmentorship from other preceptorsandpast experiences as students wereprimary contributors to their role asapreceptor, whereas preceptor trainingand communication of expectations bytheCEC could have been improved tobetter prepare them for their preceptorrole.Participants described thatclinical experience, willingness to bea preceptor, andconfidence were themain qualifications for becoming apreceptor. Conclusions:The results ofthis study provide several points forCECs to consider whenselecting andpreparing preceptors. CECs shouldensure that potentialpreceptors areconfident, established cliniciansbefore becoming preceptors.Inaddition, CECs should ensure thatthey are adequately preparingandcommunicating with preceptorsbefore and after they take on thatresponsibility.Lastly, educators andresearchers should consider thechallenges faced bypreceptors anddevelop strategies for managing thesechallenges, such ascreating efficientevaluation tools, providing easilyaccessible continuingeducationopportunities, and developingmentorship programs for preceptors.

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Education Evidence-Based ForumTuesday, June 25, 2013, 12:00PM-1:00PM; Palm C; Moderators:

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Free Communications, Oral Presentations: Ankle Injury EpidemiologyTuesday, June 25, 2013, 1:15PM-2:30PM; Palm C: Moderator: Cathleen Brown-Crowell, PhD, ATC1 3 1 9 7 M O I N

Prevalence Of Functional AnkleInstability In High School AndDivision I College AthletesTanen LM, Docherty CL, Van DerPol BJ, Simon J, Schrader JW:Indiana University, Bloomington,IN

Context: While much research existson the epidemiology of lateral anklesprains, there is little information thatinvestigates the prevalence offunctional ankle instability (FAI).Ankle sprains are a common sportsinjury and are often regarded as trivialby athletes and coaches however,further work needs to be done toincrease awareness of residualsymptoms of a lateral ankle sprainincluding FAI. Objective: Thepurpose of this study is to determinethe prevalence of FAI among highschool and collegiate athletes.Design: Cross-sectional survey.Setting: Pre-participation physicalexaminations, pre-season parentmeetings, team meetings. Patients orOther Participants: We collected atotal of 672 questionnaires. Onehundred sixty participants wereexcluded due to either incompletequestionnaires or a history offractures. A total of 512 subjectsremained (316 collegiate athletes [186males, 130 females, 19.6±1.2 years]and 196 high school athletes [113males, 83 females, 15.8±1.2 years]);response rate of 76%. Interventions:All athletes completed theCumberland Ankle Instability Tool(CAIT) on both ankles. Subjects alsoanswered a series of questions relatedto demographic background including:age, sex, sport, and history of lowerleg fracture. For collegiate athletes, aquestionnaire packet was distributedduring the required pre-participationphysicals. For high school athletes,parental consent was obtained prior todistributing questionnaires at pre-participation physicals, pre-seasonparent meetings, or individual team

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Effect Of Lateral Ankle SprainOn Self-Reported Disability OverA Two-Week PeriodMcLeod MM, Hafner R, HarkeyMS, Gribble PA, Pietrosimone BG:University of Toledo, Toledo, OH

Context: Previous lateral ankle sprain(LAS) is a risk-factor for recurrentankle sprain and development ofchronic ankle instability (CAI).Increased self-reported disability is acommon complaint in those with CAI.Although acute LAS patients frequentlyreturn back to physical activity withintwo-weeks following initial injury,limited objective investigations existon the effect of LAS on self-reporteddisability and restoration of function.Objective: Determine differences inself-reported disability following acuteLAS over time, compared to healthycontrols. Design: Case-Control.Setting: Research laboratory. Patientsor Other Participants: Ten LAS patients(3M, 7F, 20.80±1.75yrs, 172.21±11.09cm, 71.29±18.54kg) and 9healthy controls (4M, 5F, 20.44±1.51yrs, 174.98±9.11cm, 75.10±17.05kg) participated. Inter-ventions: Participants incurring a LASduring intercollegiate or recreationalsports completed the Foot and AnkleDisability Index (FADI) and FADISport (FADI-Sp) questionnaires within36 hours(h), and at 5, 7, 10, and 14days(d) following the initial sprain.FADI and FADI-Sp questions arerelated to self-reported disabilityduring activities of daily living, andphysical activity, respectively. LASparticipants underwent treatment asdirected by their individual healthcareprofessional. Main OutcomeMeasures: FADI and FADI-Sp scoreswere computed as percentages, withsmaller values indicating greaterdisability. Separate 2x5 (group by time)repeated measures analyses of variancewere performed to determinedifferences for the FADI and FADI-Sp.Greenhouse-Geisser corrections were

applied where sphericity was violated.Post-hoc dependent t-tests wereperformed to determine differenceswithin groups over time. Independentt-tests were performed post-hoc todetermine differences between groupsat each time interval. Alpha level wasset a priori at P<0.05. Results: Therewas a significant group by timeinteraction for the FADI (F

1. 2.091=9.90,

P<0.01) and FADI-Sp (F1. 1.862

=7.69,P<0.01). FADI was significantly lowerin LAS group compared to healthygroup (100±0.00%, all time points) at36h (72.43±12.33%, P<0.01), 5d(88.30±9.40%, P<0.01), 7d (90.06±9.11%, P<0.01), 10d (88.19±15.71%, P<0.01), and 14d(95.71±5.04%, P<0.01). FADI-Sp wassignificantly lower in LAS groupcompared to healthy group(100±0.00%, all time points) at 36h(55.82±25.04%, P=0.01), 5d (71.98±16.04%, P<0.01), 7d (80.35±15.83%, P<0.01), 10d (77.75±23.64%, P<0.01), and 14d(90.33±10.39%, P<0.01). FADI wassignificantly lower between timepoints 36h-5d (P<0.01), 36h-7d(P<0.01), 36h-10d (P=0.03), 36h-14d (P<0.01), 5d-14d (P=0.02), and7d-14d (P=0.03) for LAS group. Also,FADI-Sp was significantly lowerbetween 36h-5d (P=0.02), 36h-7d(P=0.01), 36h-14d (P<0.01), 5d-7d(P=0.04), 5d-14d (P=0.01), 7d-14d(P=0.03) for LAS group. Conclusions:Self-reported disability remainedlower in the LAS group at all time -points with the greatest increases inself-reported disability between 36h-5d for FADI and FADI-Sp. For FADI,there was no significant increasebetween 5d-7d and 5d-10d, whereassignificant increases were observedbetween all time points for FADI-Spexcept 10d. Further studies shoulddetermine if prolonged deficits inself-reported function predict deficitsin long-term joint health.

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meetings. Athletes who scored lessthan or equal to 23 on the CAIT wereidentified as having FAI. Frequencieswere calculated to determine theoverall prevalence and percentage ofunilateral and bilateral FAI. SeparateChi-square test of independence wascalculated comparing the frequency ofFAI in men and women and in highschool and college athletes. MainOutcome Measures: Presence orabsence of FAI were the dependentvariables. Results: Of all participants,23.4% were identified as having FAI,half of these participants had FAIbilaterally and the remainder hadunilateral FAI. High school athletes aremore likely to have FAI than theircollegiate counterparts (x2(1)=10.45,p<.001). Specifically 31.1% of thesurveyed high school athletes had FAI(13.3% had unilateral FAI and 17.9%had bilateral FAI) while only 18.7% ofthe college athletes had FAI (10.8%had unilateral FAI and 7.9 had bilateralFAI). FAI was also more prevalentamong women than men in both highschool (x2(1)=5.01, p=.01) andcollegiate settings (x2(1)=10.13,p=.01). Overall, 32.1% of the womenin this study were identified as havingFAI, compared to only 17.4% of themen. Conclusions: A higherpercentage of both unilateraland bilateral FAI exists among highschool and female athletes. Athletictrainers, physicians and coachesshould pay special attention tothese populations as they are at ahigher risk for developing FAI.

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Does Severity Of A PreviousAnkle Injury Influence Region-Specific And Generic Health-Related Quality Of Life InCollegiate Athletes?Lam KC, Bay RC: A.T. StillUniversity, Mesa, AZ

Context: Health-related quality of life(HRQOL) characterizes the impact aninjury, condition, or treatment has onvarious health domains (eg, physical,emotional, social) from the patient’spoint-of-view. Previous findings incollege athletes suggest that a positiveknee injury history may negativelyimpact knee-specific HRQOL but notgeneric HRQOL. It is unknown ifsimilar findings exist in individualswith a previous ankle injury.Objective: To determine whetherregion-specific (Foot and AnkleAbility Measure [FAAM]) and generic(Short Form 12 [SF-12]) HRQOLdiffers in collegiate athletes based onthe severity of a previous ankle injury.Design: Cross-sectional. Setting:Athletic training facilities. Patientsor Other Participants: Two hundredand seventy-two intercollegiateathletes, who were medically clearedfor full participation, were included inthe study. Sixty-five athletes reporteda previous severe ankle injury (SAI),defined as an injury causing loss ofparticipation for e”10 days (male=32,female=33, age=19.5±1.6 years,height=175.8±10.7 cm, mass=72.0±12.4 kg), 63 reported a previousmild ankle injury (MAI), defined as aninjury causing loss of participation for>1 but <10 days (male=32,female=31, age=19.1±1.2 years,height=174.6±10.9 cm, mass=69.4±12.2 kg), and 144 reported noprevious ankle injury (NAI) (male=85,female=59, age=19.4±1.5 years,height=175.3±11.7 cm, mass=71.7±13.0 kg). Interventions: Theindependent variable was injury historygroup. Participants completed theFAAM (21 items) and SF-12 (12items) during a single testing session.Main Outcome Measures:

Dependent variables included theFAAM total score and the 8 SF-12subscale scores (Physical Functioning[PF], Role Physical [RP], Bodily Pain[BP], General Health [GH], Vitality[VT], Social Functioning [SOF], RoleEmotional [RE], Mental Health [MH]).All scores range from 0-100, withhigher scores indicating betterHRQOL. Generalized linear modelswere used for group comparisons.Group differences were evaluatedwith pairwise comparisons(Bonferroni), pd”.05. Results:Significant differences were reportedfor the FAAM total score (p<.001,SAI=94.7±0.7, MAI=98.0±0.7, NAI=99.7±.5), RP (p=.02, SAI=87.1±1.9,MAI=91.8±1.9, NAI=93.4±1.2), BP(p=.04, SAI=79.2±3.0, MAI =86.9±3.0, NAI=88.4±2.0), MH (p=.04,SAI=72.3±2.2, MAI=79.2±2.2, NAI=78.3±1.5). Pairwise comparisonreported group differences betweenthe SAI and NAI groups but nodifferences for the MAI group whencompared to other groups. No groupdifferences (p>.05) were reported forthe remaining SF-12 subscales: PF(SAI=96.2±1.2, MAI=98.1±1.2,NAI=97.2±0.8), GH (SAI=85.5±2.0,MAI=82.5±1.9, NAI=85.0±1.3), VT(SAI=66.8±2.5, MAI=72.0±2.5,NAI=69.0±1.6), SOF (SAI=84.4±2.7,MAI=88.6±2.6, NAI=88.2±1.7), RE(SAI=88.1±2.0, MAI=91.7±2.0,NAI=90.6±1.3). Conclusions:Despite returning to full participation,individuals with a previous SAI tend toreport difficulties completingactivities of daily living (ADL), morepain with ADLs, and lower mentalhealth satisfaction than individualswith no ankle injury history. Ourfindings suggest that, unlike previousknee injuries, previous ankle injuriescan negatively impact both region-specific and generic HRQOL.Clinicians should be aware thatindividuals with a previous SAI maycontinue to experience HRQOLdeficits despite being medicallycleared for full participation.

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The Severity Of A PreviousAnkle Injury Does Not ImpactPostural ControlWilliams TA, Kulow SM, ValovichMcLeod TC, Lam KC: A.T. StillUniversity, Mesa, AZ

Context: The evaluation of posturalcontrol is an important component tothe management of sport-relatedinjuries. While current evidenceindicates that postural control isnegatively impacted by a previousankle injury and chronic ankleinstability, it is unknown whether theseverity of a previous ankle injury,based upon total time loss, influencespostural control. Objective: Todetermine whether the severity of aprevious ankle injury impacts posturalcontrol as measured by the StabilityEvaluation Test (SET), an instrumentedversion of the Balance Error ScoringSystem (BESS). Design: Cross-sectional. Setting: Athletic trainingfacilities. Patients or OtherParticipants: Intercollegiate athleteswho had a history of a severe ankleinjury (SAI), defined as an injurycausing loss of participation for e”10days (male=12, female=26,age=19.3±1.3 years, height =173.3±10.1 cm, mass=69.0±10.2 kg), a mildankle injury (MAI), defined as aninjury causing loss of participation for>1 but <10 days (male=19,female=18, age=19.2±1.2 years,height=176.0±12.2 cm, mass=69.5±13.2 kg), and no ankle injury(NAI) (male=52, female=35,age=19.4±1.4 years, height= 175.5±11.4 cm, mass=72.1±13.0 kg). Allparticipants were medically clearedfor participation with no restrictions.Interventions: The independentvariable was injury history group.Participants completed the SET, aseries of 20-second balance tests on aportable force plate under the six BESSstance conditions: double-leg firm(DFi), single-leg firm (SFi), tandemfirm, (TFi), double-leg foam (DFo),single-leg foam (SFo), and tandem

foam (TFo). Main OutcomeMeasures: Dependent variablesincluded sway velocity (SV) and BESSerror scores (ES) for each stancecondition. SV (deg/sec) was definedas the ratio of the distance traveled bythe center of gravity to the time of thetrial. ES were counts of errorscommitted during each condition.Generalized linear models wereutilized for group comparisons andgroup differences were furtherevaluated with pairwise comparisons(Bonferroni), p<.05. Results:Significant group differences werereported for SV (p=.001) and ES(p=.01) for the TFo condition.Pairwise comparisons indicated thatthe SAI group (SV=6.35±0.34,ES=5.13±0.39) demonstratedsignificantly higher SV and ES than theNAI group (SV=4.79±0.28,ES=3.78±0.26). No significantdifferences were found whencomparing the MAI (SV=5.53±0.35,ES=4.11±0.39) with the SAI or the NAIgroup. No other group differenceswere reported for the remainingconditions for SV (p<.13) or ES(p<.13). Conclusions: Our findingssuggest that the severity of a previousankle injury does not generally impactpostural control when measured by theSET or the BESS. Differencesreported between the SAI groupand NAI group suggest that the TFostance may be useful in identifyingpotential postural control deficits incollegiate athletes. Futureinvestigations should determinewhether postural control deficitsdemonstrated in the TFo stancecondition are clinically significant (eg,predisposes the individual to an ankleor lower extremity injury).

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Self-Perceived Ankle InstabilityCorrelates With Poor ClinicalBalance AssessmentsLinens SW, Ross SE, Arnold BL:Georgia State University, Atlanta,GA; University of North Carolina atGreensboro, Greensboro, NC;Virginia Commonwealth University,Richmond, VA

Context: A variety of balance testshave differentiated stable and unstableankles. However, few studies havedetermined the relationship betweenself-reported instability and clinicalbalance measures associated withchronic ankle instability (CAI).Objective: To investigate therelationship between self-perceivedankle instability with clinical balancemeasures. Design: Correlational.Setting: Laboratory. Participants:CAI subjects had a history of anklesprains and symptoms of “giving way”(N=17; 168±9 cm; 68±12 kg; 23±4yrs) and stable ankle subjects (SA) hadno history of ankle injuries (N=17;168±8 cm; 66±12 kg; 23±3 yrs).Interventions: Self-perceived ankleinstability was measured using theCumberland Ankle Instability Tool(CAIT). CAI and SA subjectsperformed single leg balance on theinjured leg or a side matched leg,respectively. Subjects performed 4clinical balance tests: 1) Time-In-Balance (TIB); 2) Foot Lift Test (FLT);3) Star Excursion Balance Test(SEBT) in posteromedial reachdirection; and 4) Side-To-Side Hop(SSH). For TIB, subjects stood on thetest leg with their eyes closed for upto 60 s. Subjects’ time-in-balance wasrecorded as the time when balance waslost by touching down with non-weightbearing leg or as 60 s if they remainedbalanced. The FLT required subjectsto stand on the test leg for 30 s witheyes closed. The number of times apart of the foot was lifted or thecontralateral foot touched down weretallied. The SEBT required subjectsto stand on their test leg and reach for

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maximum distance with thecontralateral leg in posteromedialdirection. For the SSH subjectscompleted 10 side-to-side 30 cm hopsas quickly as possible. Balance testswere counterbalanced. Pearsonproduct-moment correlations werecalculated between CAIT scores andeach balance measure. Alpha level wasset a priori (0.05). Main OutcomeMeasures: The degree of perceivedankle instability was quantified withtotal score on CAIT (lesserscores=greater instability). Balancewas quantified with length of timebalancing (s) for TIB, frequency offoot lifts (score) for FLT, distancereached (normalized to leg length) forSEBT, and time (s) to complete SSH.Poor balance was indicated by lesstime-in-balance, greater frequency offoot lifts, shorter reach distance onSEBT, and longer time to completeside hops. Results: SignificantPearson product-moment correlationcoefficients were found between CAITand TIB (r=-0.35, P< 0.05) and FLT(r=.43; P< 0.05). No correlation(P>.05) was found between CAIT andSEBT (r=0.32) or SSH (r=-0.23).Conclusions: While each test can beused to identify balance deficitsassociated with CAI, the TIB and FLTare the only balance tests that have arelationship with self-perceivedfeelings of instability. Our results alsoindicate that among clinical tests staticbalance measures are more indicativeof self-perceived instability thandynamic balance measures.

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Ankle Evidence-Based ForumTuesday, June 25, 2013, 2:45PM-3:45PM; Palm C; Moderators:

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Free Communications, Oral and Thematic Presentations: Abdominal ConditionsCase StudiesWednesday, June 26, 2013, 8:00AM-8:45AM; Palm C; Moderator: Michael Milligan, MD, CAQSM1 3 0 4 9 U C

Abdominal Pain In A CollegiateSoftball PlayerPouliot S, Rothbard M, Geiger A:Southern Connecticut StateUniversity, New Haven, CT

Background: A 22 year-old femalesoftball player presented to the athletictrainer with abdominal pain, nausea,constipation, post-prandial fullness,and unexplained 12.73kg weight lossequaling 22% of her body weight overa four-month period. The pain wasdescribed as severe, constant, andunbearable upon ingestion of food.Initial examination by the athletictrainer revealed abdominal bloating,palpable tenderness, and weak pulses.The patient’s previous medical historywas significant for idiopathicabdominal pain for four years prior andstatus-post five months chole-cystectomy. Differential Diagnosis:intestinal cancer, ovarian cancer,ovarian cysts, Crohn’s disease, Ciliacdisease, and gastroparesis.Treatment: Upon examination, shewas disqualified from athleticparticipation and was referred to a PCP.Physician examination confirmed theathletic trainer’s findings and ordereda vaginal ultrasound that identifiedovarian cysts, and an abdominal CTscan that revealed intestinalinflammation indicating the possibilityof cancerous cells. A second CT-scanwith contrast was unremarkable, rulingout cancer. The patient was referred toa gastroenterologist for additionaltesting. An endoscopy andcolonoscopy were performed. Resultswere unremarkable. A 90-minutegastric emptying test was thenperformed, which demonstratedsignificant delayed gastric emptying.A preliminarily diagnoses ofgastroparesis was made. Erythromycinwas prescribed to facilitate intestinalmotility, which had no effect on hersymptoms. With her condition

deteriorating the athletic trainerreferred the patient to the hospital.While hospitalized for two weeks, abrachial PICC line insertion for TPNfeeding was established, whichstabilized her condition. Afterdischarge and consultation, she wasreferred to a motility specialist andwas admitted to a different hospital.A four-hour gastric emptyingscintigraphy test was administered.After one hour, 90% of the foodremained in her stomach. After fourhours, 75% remained, confirminggastroparesis. To improve intestinalmotility she was prescribed 10mg ofDomperidone® bid, which wasprogressively increased over fourdays to 20mg tid, but with noimprovement. An MRA was ordered,identifying abdominal vasculardamage. Specifically, the medianarcuate ligament appeared to beblocking the inferior mesentericartery and vagus nerve, causingdiminished blood flow and nervesignals to the stomach. Two dayspost-discharge, the PICC lineappeared to be infected, the patientdisplayed signs of renal failure, andshe was referred back to the hospital.The PICC line was removed. Sheunderwent surgery for a Jejunostomytube insertion providing 1560 mL ofVital AF 1.2 Cal™ every day and wasreleased from the hospital one weeklater. During a follow-upconsultation by the athletic trainer,the patient was permanentlydisqualified from athleticparticipation based on her conditionand augmented nutritional intake.Status post 8 months, a Mickey tubewas inserted to replace theJejunostomy tube, which is expectedto remain in place indefinitely.Uniqueness: Gastroparesis is a raredisorder with an incident rate of0.0001% in non-diabetics; however,it typically affects people with long-

term diabetes and females over theage of 30. Also, the patient did notpresent with other risk factorsassociated with gastroparesis, whichinclude systemic sclerosis,hypothyroidism, and anticholinergic,narcotic and antidepressantmedications. Conclusion: Gastro-paresis is a condition that inhibitsgastric emptying without anintestinal blockage. In this case, itappeared that a vascular andneuromuscular dysfunction limitedgastric emptying, and food neverreached the intestines for furtherdigestion and absorption. Gastro-paresis has a poor prognosis andsignificantly impacts the life anddaily activities of those affected.Although gastroparesis is generallyincurable, effective communication bythe patient, athletic trainers, andphysicians and highly specialized promptmedical care helped save her life. Thiscase presented unique challenges inrecognizing, treating, and managing thispatient who must live and cope with thislifelong debilitating condition.

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Ulcerative Colitis In A HighSchool Football PlayerStollery JC, Filep EM, Lopez RM:University of South Florida,Tampa, FL

Background: This case involves a 16-year-old varsity high school footballplayer (height: 172.7 cm weight: 73.5kg) at the position of free safety. Thisathlete had no previous history ofchronic illnesses or injury prior to thecurrent condition; however, his familyhistory revealed that one of hisrelatives has Crohn’s Disease. Duringsummer break, the athlete went onvacation and became ill upon his return.The athlete presented with bloodydiarrhea and abdominal pain 7 weeksbefore preseason football. Hecontinued to experience diarrhea andlost a significant amount of weight,weighing 63.5 kg. He was taken to thehospital and placed on the antibioticFlaggyl for 4-6 weeks. After 6 weeks,he experienced bloody stool again andwas taken to the hospital and admittedfor 5 days. The hospital admittanceoccurred one week before the start ofpreseason football. DifferentialDiagnosis: Intestinal infection,ulcerative colitis, Crohn’s disease,irritable bowel syndrome Treatment:A colonoscopy during the secondhospital visit revealed ulcers lining thecolon, leading to a diagnosis ofulcerative colitis. The athlete wasplaced on the steroid Asacol todecrease the inflammation of his colonand reduce diarrhea. He was notcleared for activity until stool wasclear of blood. During this time, hisappetite increased, and he began tryingto gain weight. A strict diet andadequate hydration helped achieveweight gain. Fatigue was a limitingfactor in ADLs; however, he wascleared to participate in conditioningactivities with the football team duringthe second week of preseason. Theathletic trainer designed arehabilitation program consisting ofcardiovascular conditioning and full

body strength training, which theathlete completed as tolerated. Whenthe athlete began this rehabilitation, histotal weight loss was approximately10.0 kg (~ 22 lbs). During recon-ditioning, the athlete often reportedfeelings of depression, fear and anxietyto the athletic trainer. The athlete alsoexperienced frequent, intense,uncontrollable urges to go to thebathroom that often interrupted school,practice, games and rehabilitation. Theathlete also experienced an accident inschool, which devastated hisrehabilitation process and psyche.Finally, after approximately 12 weeks,he received clearance from a pediatricgastrointestinal specialist and wasgiven a new medication regimen(Cimzia, a once-monthly subcutaneousinjection). At this time, he was thenable to complete a full week of footballpractice and participate in the thirdgame of the season. His weightincreased to 70.3 kg, and he was ableto participate as a starter for the fifthfootball game. Throughout theremainder of the season, his weightloss from the diarrhea was controlledby the Cimzia injections; however, hestill suffered from occasional bouts ofdiarrhea and abdominal pain.Uniqueness: This disease is rarelyseen in adolescent athletes. Ulcerativecolitis is a genetic condition that willlast the athlete’s lifetime. Themanagement of ulcerative colitis isdifficult in the initial stages; inparticular, the combination of thiscondition with athletic activity madeit more challenging for the athlete toreturn to ADLs. The infection thattriggered the disease was Aeromonassobria, found in contaminated waterand fish and was contracted while theathlete was on vacation. Conclusions:For an adolescent, ulcerative colitiscan be a devastating condition. Theathletic trainer should be empatheticand understanding when dealing withthis athlete. It is necessary to form aplan and communicate this plan

with the athlete, parents, coaches,teachers and guidance counselors.This plan should include educationabout the condition, excused trips tothe bathroom during class/practicewithout asking, ensuring properhydration and nutrition, corestrengthening and cardiovascularconditioning, and proper storage ofmedications at the school.

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Residual Stump Appendicitis inthe Competitive Athlete: A CaseReportBonnett JH, Smith JJ, Watson DJ:University of Delaware, Newark,DE

Background: Following a 7 to 10 dayperiod of non-specific abdominal pain,a 19 year-old male intercollegiatefootball player underwent alaparoscopic appendectomy for aruptured appendix. Surgeons foundinflammation and infection throughoutthe abdominal cavity along with agangrenous appendix. One week laterhe had a Computed Tomography (CT)guided drainage of two pelvicabscesses containing murky fluid. Theathlete was cleared for return-to-playprogression three weeks later andbegan progressively increasingconditioning and strength trainingexercises in preparation for return tofootball practice. Approximately 8weeks after the initial appendectomy,the athlete reported to the athletictraining room presenting with right-sided flank pain. The athlete reportedthat the previous training session hadbeen an upper body work-out focusingon chest, arms, back and coremusculature. A physical examinationrevealed rebound tenderness in theright upper and lower quadrants andnausea with no other acute distress.His bowel sounds were diminished.The athlete was sent by the TeamPhysician for a CT scan of the abdomenand pelvis with intravenous contrast.Imaging showed inflammation andincreased free fluid in the abdomen anda 10 millimeter tubular structure in thepericecal area. Following consultationwith the general surgeon, it wasbelieved that the inflammation was aresult of the original appendicitis. Theathlete was administered oralantibiotics in order to control theinfection. Two days later, the athletereported increased pain and he wasreferred to the general surgeon andadmitted to the hospital for intravenous

antibiotics. Differential Diagnosis:Abdominal abscess, Post-surgicaladhesions, Peritonitis, Cholecystitis,Kidney stone, Ruptured bowel, Musclestrain Treatment: On the day ofadmission, the athlete underwentlaparoscopic exploration of theabdominal cavity including irrigationand drainage. Surgeons found aresidual, several millimeter long tip ofthe original appendix adhered to thecolon which they then excised. Thepost-operative diagnosis was residualstump appendicitis and abdominalabscess. The athlete was dischargedtwo days later following an uneventfulrecovery. Over the past eight weeks,his activity has gradually increased tolight running and lifting while payingspecial attention to any signs ofabdominal pain or abnormalities.Upon clearance from his surgeon, theathlete will begin full-contact footballdrills. No more complications haveoccurred and the athlete continues toprogress through his return-to-playprotocol. Uniqueness: Residualstump appendicitis is a residualinflammation of the remnants of aremoved appendix. It is a rare,underreported condition. Of thoseprevious cases, there is only one othercase where surgeons found a residualtip of the appendix. This case involveda middle-aged adult rather than acompetitive young athlete. Further, thereported time frame for thedevelopment of this condition rangesfrom 2 months to 50 years. This casepresented with an accelerated timeframe, likely due to the demands onthe body as a result of participation inintercollegiate athletics. Con-clusions: In this case, a young,competitive athlete with a recentappendectomy presented with acuteabdominal symptoms includingrebound tenderness and nausea whichproved to be residual stumpappendicitis. For the clinician who isfaced with an athlete presenting withabdominal pain, nausea, and vomiting,

who has recently had an abdominalsurgery, there are many commoncauses that should be considered, bothsurgical and non-surgical. Conditionsnot related to previous surgery couldinclude kidney stones, cholecystitis,muscle strains, and bowel obstruction.Surgically related diagnoses forabdominal pain may include abdominalabscess, post-surgical adhesions, andperitonitis. Sports health careprofessionals should consider residualstump appendicitis in the differentialdiagnosis for all athletes with aprevious history of appendectomy.

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Free Communications, Oral Presentations: Impact of Preseason on ExertionalHeat IllnessWednesday, June 26, 2013, 9:15AM-10:15AM; Palm C; Moderator: Kristin Kucera, PhD, ATC1 3 0 6 9 D O E M

Athletic Trainer Staff Size,Number Of Exertional HeatIllness Events, And Use OfExertional Heat IllnessPrevention Strategies In USHigh School Football ProgramsKerr ZY, Casa DJ, Comstock RD,Marshall SW: University of NorthCarolina, Chapel Hill, NC;University of Connecticut, Storrs,CT; The Research Institute atNationwide Children’s Hospital,Columbus, OH

Context: An estimated 6,500 highschool football student-athletes aretreated annually for exertional heatillness (EHI). Variable athletic trainer(AT) coverage may lead to disparitiesin implementing EHI preventionstrategies. Lack of AT coverage mayalso lead to an increase in thefrequency of EHI events. Objective:To compare the prevalence of EHIprevention strategies and number ofEHI events in the 2011 high schoolfootball pre-season between highschool programs staffed by one ATversus multiple ATs. Design: Cross-sectional study. Setting: NATA-affiliated ATs providing care to highschool football student-athletes duringthe 2011 pre-season. Patients orOther Participants: We contacted6,343 ATs that provided care to footballstudent-athletes in the 2011 pre-seasonfrom a membership list provided bythe NATA. ATs completed the onlinequestionnaire (n=1,137; 17.9%). Oursample represented ATs from all 50 USstates except Alaska and Rhode Island,states not considered high risk for pre-season EHI events. Most were male(51.8%), had over 10 years experience(57.9%), and had an average age of37.0 years (±10.2). Interventions:ATs answered questions via an onlinequestionnaire pertaining to: number ofATs, high schools’ demographics, EHIprevention strategies implemented(e.g., cold water immersion,

The Georgia Study: The Risk ofExertional Heat Illnesses in HighSchool PlayersFerrara MS, Cooper ER, Miles JD,Curry PR, Grundstein A, Casa D,Powell JP: The University ofGeorgia, Athens, GA

Context: Exertional heat illness (EHI)is a fairly common occurrence infootball particularly in the first coupleof weeks of the pre-season with heatcramps accounting for about 75% ofall EHI cases while heat exhaustion andheat syncope (HS/HE) accounted forthe remaining 25%. Numerousinvestigators have posed variouspreventive measures to reduce the rateof EHI but it is difficult to develop adirect cause and effect relationshipbetween variables and reducing theillness rate. The purpose of this studywas to evaluate the incidence rates ofEHI’s during football and to determineif there was a relationship between therate of EHI, the week of practice andthe environment. Design: Pro-spective observational epidemio-logical design. Setting: Inter-scholastic (IS) institutions (GeorgiaHigh School Association members)representing 5 geographical regions(North, Central, Metro Atlanta,Southeast, and Southwest).Participants: IS football players from23 schools in the state of Georgia forthe 2009 – 2011 seasons, during themonths of August and September.Interventions: EHI types wererecorded by athletic trainers for theirrespective schools. EHI definitionswere based on the NATA positionstatement: heat cramps (HC), heatexhaustion (HE), heat syncope (HS),and heat stroke (STR). There were norecorded STR’s during the 3-yearperiod. Main Outcome Measures:EHI’s were recorded during allpractice, conditioning, and gameactivities held during the 3-year

reporting period. Any EHI thatresulted in a participant beingrestricted from continuation of activityconstituted an occurrence. The overallEHI’s was calculated and the HS andHE variables were combined into onevariable (HS/HE). IR was calculatedwith 95% confidence intervals (CI).Results: There were 651 reported EHIoccurrences with 200,937 athlete-exposures (AE) recorded for an overallIR of 3.24/1000AE (95%CI=3.00,3.50). For HS/HE, there were a totalof 174 reported cases for an overallIR of 0.87/1000AE (95%CI=0.74,1.00). We founds that 49% (IR=1.84/1000AE; 95% CI=1.46, 2.29) of theHS/HE cases occurred during the firstweek of practice 23% (IR=1.55/1000AE; 95%CI=1.10, 2.12) in week2, 11% (IR=0.74/1000AE; 95%CI=0.44, 1.17) in week 3 and 9%(IR=0.63/1000AE; 95%CI=0.35,1.06) in week 4. We also found that79% of the EHI’s occurred at a WBGTless than 300C WBGT during thecourse of the project and for the firstweek of practice, 61% of the EHI’soccurred at a WBGT of less than 300C.Conclusion: To our knowledge,this was the first ever, large-scales tudy d i rec t ly re la t ing to ISfootball players where EHI wasrelated to WBGT. This data is ofparamount importance in seekingto determine where the risks aregreatest and what variables may bechanged or manipulated to makesport activities in the pre-seasonperiod safer for the participants.We found that the significant EHIcases (HS/HE) occurred during thefirst 2 weeks of practice at WBGTthat is not considered extreme. AsEHI policies are developed, thef i r s t two weeks prov ided thegreatest risk of HS/HE case and allpreventive measures should beemployed to mitigate these risks.

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Demographics of ExertionalHeat Illnesses AmongInterscholastic Football AthletesDuring August/September: A3-Year StudyCooper ER, Miles JD, Curry PJ,Grundstein A, Ferrara MS: TheUniversity of Georgia, Athens, GA

Context: American interscholastic(IS) football players encounter manydifferent illnesses/injuries during pre-season practice sessions in thesummer months. Exertional heatillness (EHI) is one area of concern.Questions have been raised as towhether or not these EHI occurrencerisk rates vary among playerdemographics; academic class of theparticipants, their specific position onthe team, and the level of play.Objective: To determine who issustaining EHI’s among IS footballparticipants with respect to academicrank, player position, and level ofparticipation on the team for ISinstitutions in the state of Georgia.Design: Prospective observationalepidemiological design. Setting:Interscholastic institutions (GeorgiaHigh School Association members)representing 5 geographical districts(North, Central, Metro Atlanta,Southeast, and Southwest).Participants: IS football playersfrom 23 schools in the state ofGeorgia for the 2009 – 2011 seasons,during the months of August andSeptember. Interventions: EHI typeswere recorded by athletic trainers fortheir respective schools. EHIdefinitions were based on the NATAposition statement: heat cramps (HC),heat exhaustion (HE), heat syncope(HS), and heat stroke (STR). Therewere no recorded STR’s during the 3-year period. Overall EHI’s (OEHI), HCand significant EHI’s (HS and HE weretabulated as one variable due to lownumbers of HS) were calculated(SEHU). Main Outcome Measures:EHI’s were recorded during allpractice, conditioning, and game

activities held during the 2 monthreporting period. Any EHI thatresulted in a participant beingrestricted from continuation of activityconstituted an occurrence. Results:A total of 652 EHI’s (477 HC, 175SEHI’s) were recorded over the 3-yearperiod. Percent of overall OEHI andpercent of SEHI cases reported byacademic class were: freshman(OEHI=11%, SEHI=18%), sopho-more (OEHI=23%, SEHI= 30%),juniors (OEHI=26%, SEHI= 26%) andseniors (OEHI=40%, SEHI=26%). Byoffensive player position, lineman hadthe greatest number of episodes(OEHI=35%, SEHI=51%), followedby running backs (OEHI=31%,SEHI=22%) and wide receivers(OEHI=20%, SEHI=16%). De-fensively, lineman once again had thegreatest occurrences (OEHI=39%,SEHI= 61%), followed by defensivebacks (OEHI=34%, SEHI=18%) andlinebackers (OEHI=28%, SEHI=21%). Level of play indicated that“starters” represented the largestnumber of recorded EHI’s (OEHI=72%, SEHI=54%), followed by“substitutes” (OEHI=27%, SEHI=45%) and non-players (OEHI=1%,SEHI=1%). Conclusion: This datademonstrates specific playercharacteristics which can be used bythe athletic trainer to determine higherrisk populations to monitor during pre-season, regular practice sessions andgames. Observationally, linemen(offensive & defensive) experience ahigher number of SEHI’s than all otherpositions. In addition, participantswho are labeled “starters” had a greateroccurrence of OEHI than “substitutes”,however the risk for SEHI’s weresimilar between these two groups.Athletic trainers can use this data toformulate strategies to reduce EHIoccurrence among these target groups.This project was funded by the NATAResearch & Education Foundation.

monitoring ambient temperature, etc.),and number of EHI events in the 2011pre-season. We categorized ourrespondents based as ATs working bythemselves (“Solo”; n=221) during the2011 pre-season or those reportingadditional staff (“Assisted”; n=916).Additional staff included high school/college student AT assistants,volunteer ATs, or staff/volunteerphysicians. Main OutcomeMeasures: Using independent samplet-tests, we compared the number ofimplemented EHI preventionstrategies and number of treated EHIevents between “Solo” and “Assisted”ATs. Using chi-square tests, wecompared the prevalence of specificEHI prevention strategiesimplemented between “Solo” and“Assisted” ATs. Results: In the 2011football pre-season, ATs utilized 7.6 ±2.5 different EHI prevention strategiesand 0.5 ±1.4 EHI events were treatedper high school football program. Thenumbers of EHI prevention strategiesand EHI events were positivelycorrelated (P=0.02). “Assisted” ATsutilized more EHI preventionstrategies than “Solo” ATs (7.9 vs. 6.5;P<0.001). Assisted ATs were morelikely to use the following EHIprevention strategies than “Solo” ATs:“Checked environmental temperature”(75.9% vs. 59.7%; P<0.001); and“Filled immersion tub with ice waterprior to start of practice” (48.9% vs.26.7%; P<0.001). “Assisted” and“Solo” ATs did not differ in the numberof EHI events treated in the 2011 pre-season (0.52 vs. 0.44 per program;P=0.39). Conclusions: Althoughconsidered a rare event, a high numberof EHI events occurred during the pre-season. High school football programsmust ensure that AT staff, regardlessof their number, have adequateresources to implement EHIprevention strategies, and are welltrained to identify and manage EHI.Study funded in part by Society forPublic Health Education/CDCStudent 2012 Fellowship in Injury/Violence Prevention and Control.

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Acclimatization In GeorgiaInterscholastic Football Players:A Three-Year PerspectiveMiles JD, Curry PJ, Cooper ER,Grundstein AJ, Ferrara MS: TheUniversity of Georgia, Athens, GA

Context: Proper acclimatization canmitigate the risk of exertional heatillness (EHI) during the pre-seasonperiod. Physiologic changes due toacclimatization begin to take placewithin the first 3-5 days of heatexposure and continue for up to 2-3months. However, there have beenminimal field-based studies todetermine the actual acclimatizationperiod for interscholastic (IS) footballplayers. Objective: To evaluateacclimatization trends in IS footballplayers in Georgia. Design:Prospective epidemiological design.Setting: Interscholastic institutionsfrom 5 geographic regions in the stateof Georgia (North, Metro Atlanta,Central, Southeast, Southwest)Participants: IS football athletesfrom 23 schools in Georgia forAugust, 2009-2011 seasons.Interventions: An ATC was identifiedat each school and recorded allathlete-exposure (AE), EHI, andpractice duration data. EHI types wereidentified as heat cramps (HC), heatexhaustion (HE), heat syncope (HS),and heat stroke (STR) as defined by theNational Athletic Trainers’ AssociationPosition Statement. Due to the lownumber of HS’s, HS and HE werecombined to form one variable (HS/HE). Main Outcome Measures: Thedependent variable was EHIoccurrences (HS/HE) and theindependent variables were practiceweek and practice duration. Injuryrates (IR) were calculated using thefollowing equation: number ofinjuries/number of athlete exposures(AE) x 1000 with 95% confidenceintervals (CI). Results: In August,there were 141 HS/HE’s recorded and106,782AE for three seasons resultingin an overall IR of 1.32/1000AE

(95%CI=1.10, 1.54). IR’s for HS/HEwere highest in week 1, 1.84/1000AE(95%CI=1.45, 2.30) and were 1/3 ofthat by week 4, 0.63/1000AE(95%CI=0.34, 1.09). During weekone, the IR was 1.04/1000AE(95%CI=0.53, 1.85) for practices<120 min., but the rate increased 2.5times for practices lasting 120-150min. (2.41/1000AE, 95%CI=1.61,3.48) and increased 4.5 times forpractices lasting e”3 hrs. (4.72/1000AE, 95%CI=1.79, 5.15). Forweek two of practice, the IR was 0.50/1000AE (95%CI=0.16, 1.20) forpractices lasting up to 150 min.,showing 30 minutes ofacclimatization. For the third week,another 30 minutes of acclimatizationwas seen for a 180-minute practicesession (0.85/1000AE, 95%CI=0.58, 1.21). Conclusion: Thesedata are the first to demonstrateacclimatization in adolescents in afield-based setting. The first twoweeks of practice had the greatestrisk of EHI. For the first week,practices lasting longer than 120minutes, and those lasting longerthan150 minutes in the second weekdemonstrated an increased risk.Importantly, these data showacclimatization from the first weekto the second week, with botha decrease in the HS/HE IR’s fromweek 1 to week 4 a long wi thathletes’ ability to acclimatize,wi ths tand ing an add i t iona l 30minutes o f p rac t ice per weekthrough. Athle t ic Trainers andother authorities should use thisda ta to c rea te acc l imat iza t ionguidelines for football, decreasingserious EHI events. This projectwas funded by the NATA Research& Educa t ion Founda t ion .

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A Climate Assessment Of BestFootball Practice TimesGrundstein A, Cooper E, Miles JD,Curry PR, Ferrara MS: Universityof Georgia, Athens, GA

Context: Football players are amongthe most susceptible athletes to heat-related illnesses. Practices arevariously held in the morning and/orafternoon but no study has examinedfrom a climate perspective which timeof the day provides the safest trainingconditions with regard to heatexposure. Objective: To determine thebest times to schedule footballpractices to minimize exposure tooppressive heat. Design: Ob-servational study. Setting: Weatherstations across the United States.Patients or Other Participants:None. Interventions: A 15-yearclimatology (1991-2005) of Augustwet bulb globe temperatures (WBGT)was computed for 217 locationsacross the contiguous United Statesusing weather station observations anda physically-based WBGT model.Main Outcome Measures: TheACSM (2007) WBGT guidelines wereused to determine the risk categories.We examined six, 3-hour trainingsession times (6-9 a.m., 7-10 a.m., 8-11 a.m., 3-6 p.m., 4-7 p.m., 5-8 p.m.LDT) to identify how the WBGT varieswith the time of day the practicesession was held and how frequentlythe WBGT during those sessionsexceeded key ACSM safety thresholdswhere practices would need to belimited (30.1oC) or canceled (32.3oC).Results: Across the country, morningpractices had lower WBGT values anda lower frequency of exceeding ACSMsafety standards than afternoonpractice times. Climatologically,WBGTs were lowest for 6-9 a.m.practices and greatest for those at 3-6p.m., with WBGT values averagingalmost 7oC greater during the 3-6 p.m.session. Starting a morning practiceone (two) hours after 6 a.m. increasedthe WBGT by an average of 1.7±0.5oC

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(3.7±0.9oC). Importantly, only a smallpercentage of hours (<2.5%)exceeded the critical 32.3oC thresholdfor canceling practice at any station for6-9 a.m. sessions, increasing up to amaximum of 10% between 8-11 a.m.Afternoon practice sessions morefrequently exceeded safety standardswith some locations experiencing upto 20% (66%) of hours exceeding the32.3oC (30.1oC) thresholds. Startingthe practice session one (two) hoursafter 3 p.m., resulted in an averagedecrease in WBGT of 0.8±0.2oC(1.9±0.3oC). Further, delaying the starttime by one (two) hours decreased thepercentage of exceedance relative tothe 3-6 p.m. period by 40±9%(70±9%) for the 32.3oC threshold and35±6% (66±8%) for the 30.1oCthreshold for those stations (+1standard deviation) with the greatestpercentage of hours that exceeded theACSM thresholds. Conclusions:Climatologically, mornings from 6-9 a.m. are the best times to practiceto minimize exposure to oppressiveheat. While afternoons are hotter,delaying the start of practice a fewhours may substantially reduce thelikelihood of oppressive conditionsand the probability of a practicebeing limited or cancelled.

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Heat & Hydration Evidence-Based ForumWednesday, June 26, 2013, 10:30AM-11:30AM; Palm C; Moderator:

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Free Communications, Oral Presentations: Kinesio Taping Across the SpectrumThursday, June 27, 2013, 8:00AM-9:15AM; Palm C; Moderator: Mark Merrick, PhD, ATC1 3 4 3 1 M O N E

The Effects Of Kinesio Taping®On Postural Control Deficits InHealthy Ankles, Copers, AndIndividuals With FunctionalAnkle InstabilityShields C, Needle AR, Rose WC,Swanik CB, Kaminski TW:University of Delaware, Newark,DE

Context: Ankle sprains are the mostcommon injury among physically activepeople, with common sequelaeincluding functional ankle instability(FAI). Copers are a cohort who havesprained their ankle but not suffered anyfurther dysfunction. Kinesio® Tape hasemerged as a technique that mayimprove joint stability; however,limited research has investigated itsefficacy among injured populations.Objective: To examine the immediateand prolonged effects of KinesioTaping® on postural control in healthy,coper, and functionally unstable ankles.Design: Cross-sectional study.Setting: Athletic training researchlaboratory. Patients or OtherParticipants: Sixty physically active,college-aged participants (35 females,25 males, height=72.5±9.7cm,mass=74.2±16.2kg, age=21.5±2.6yrs.)participated in this study. Subjects werestratified into healthy, coper, or FAIusing the Cumberland Ankle InstabilityTool and history of ankle sprain.Interventions: Each participantperformed 20-second single-limbbalance trials on a force plate with eyesclosed. Testing was performed priorto tape application (PRE), immediatelyfollowing (KT-I), at 24-hours (KT-24),and immediately after tape removal(POST). Separate 2-way repeated-measures ANOVA’s (p£ 0.05) wereconducted comparing group and tapecondition. Pairwise comparisons wereused for post-hoc analysis with aBonferroni correction to control formultiple comparisons. Cohen’s d

effect sizes (ES) were calculated forstatistically significant measures.Main Outcome Measures:Independent variables included groupand tape condition; while dependentvariables included time-to-boundary(TTB) and traditional center-of-pressure (COP) measures in both themediolateral (ML) and antero-posterior (AP) planes. Results:Significant differences betweengroups were observed for AP COPstandard deviation (F

2,57=4.31,

p=0.018) and range (F2,57

=4.92,p=0.011). Significant differencesbetween tape conditions for ML TTBabsolute minima (F

3,159=3.61,

p=0.015) and standard deviation(F

3,138=5.71, p=0.002), and AP TTB

standard deviation (F3,141

=3.32,p=0.029) were also observed.Pairwise comparisons revealed largeto medium effect sizes for groupdifferences and small effect sizesfor differences across tapeconditions. FAI displayed higherCOP standard deviation( h e a l t h y = 0 . 0 1 2 ± 0 . 0 0 2 m ,FAI=0.014±0.003m, p=0.027, ES=0.56) and range (healthy=0.065±0.012m, FAI= 0.075±0.017m, p=0.021, ES=0.83)compared to healthy ankles, as wellas increased COP range comparedto copers (copers=0.065±0.012m,p=0.033, ES=0.83). Improvementswere observed in ML TTB absoluteminima from PRE (0.116±0.064s)to KT-24 (0.133±.065s, p=0.025,ES=0.15), as well as, increases inML TTB standard deviation fromKT-I (1.975±1.786s) to KT-24(0.926 ±0.486s, p=0.002, ES=0.14)and from KT-24 to POST(1.780±1.696s, p=0.009, ES=0.06).Conclusions: As functionallyunstable ankles demonstrateddiminished postural control usingtraditional COP measures, our datasupport the use of these variables

for identifying impairments amongthis subset. Furthermore, significantdifferences in tape conditionwere found for only three variableswith very small effect sizes,suggesting Kinesio® tape doesnot affect static postural control.This data agrees with previousresearch on effects of Kinesio® tapeon dynamic postural control. Futureresearch may investigate alternatetaping techniques that may improvebalance deficits in FAI. D

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Effects Of Kinesio Tape OnQuadriceps Function In PatientsWith A History Of Knee JointInjuriesDavis B, Kim KM, Hart JM, HertelJ: Hampden-Sydney College,Hampden-Sydney, VA; TexasState University, San Marcos,TX; University of Virginia,Charlottesville, VA

Context: Quadriceps dysfunctioncommonly persists in people with ahistory of knee injury or surgery.Modalities such as ice, heat,transcutaneous electrical nervestimulation, and joint mobilizationhave been shown to improvequadriceps dysfunction by removingthe underlying cause, arthrogenicmuscle inhibition. Kinesio Tape (KT)has been used clinically in this patientpopulation however theneurophysiologic rationale for its useis lacking. Objective: To comparequadriceps function in patients with ahistory of knee joint injury, andevidence of quadriceps arthrogenicmuscle inhibition, after application ofKT. Design: Randomized controlled,single blinded study. Setting:Laboratory. Patients or OtherParticipants: Sixteen subjects with adocumented history of knee injury orsurgery and quadriceps centralactivation ratio (CAR) less than 90%participated. Subjects were randomlyallocated to either KT (7 males, 1female; age=25±5.0 years; height=178.1±7.5cm; mass=78.9±14.1kg)or sham group (2 males, 6 females;age=23±3.5 years; height =175.3±11.7cm; mass=74.6±16.0kg). Inter-ventions: The KT group received ataping treatment using elastic KTcovering from anterior inferior iliacspine to patella with approximately75% of elastic tension in the mid lineof the thigh. The sham group receiveda sham taping treatment using a non-elastic tape (Cover-Roll). Subjectsremained in the lab for 2 post-treatment measures and returned 24-

48 hrs later for follow up measures.Subjects wore their taping interventionfor the duration of the study. MainOutcome Measures: A blindedassessor obtained H

max:M

max ratios for

the quadriceps at baseline,immediately following treatment, 20minutes following treatment and at24-48 hours following treatment.Knee extension torque and CAR weremeasured during a knee extensionmaximal voluntary isometriccontraction (MVIC) at baseline andafter 24-48 hours. CAR was measuredas the ratio between MVIC and thepeak torque generated by an electricalstimulation delivered to the thighsuperimposed during the MVIC test.A 2X4 ANOVA was used for H

max:M

max

and a 2X2 ANOVA was used for kneeextension torque and CAR. Results:There was no significant interactionsfor quadriceps H

max:M

max (F

3,42=

1.94,P =0.14). The ratios did notchange over t ime (F

3,42

=0.52,P=0.67) and were notdifferent between groups (F

1,14=

0.55,P=0.47). There were nointeractions for knee extensiontorque (F

1,14=0.007,P=0.93) or

quadriceps CAR (F1,14

= 0.03,P=0.86). Neither knee extensiontorque nor quadriceps CAR weredifferent over t ime (Torque:F

1,14=0.004,P=0.95, CAR: F

1,14=

0.92,P=0.35) or between groups(Torque: F

1,14=0.25,P=0.63, CAR:

F1,14

=0.39,P=0.54). Conclusions:KT did not change quadricepsneurophysiologic functionimmediately after or after a shortperiod of t ime in patients withhistory of knee injuries and withevidence of quadriceps dysfunction.

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Kinesiology Taping DoesNot Improve ShoulderProprioception, ShoulderStrength, Or ScapularKinematics In Healthy OrShoulder ImpingementSubjects: A Preliminary ReportKeenan KA, Akins JS, Varnell MS,Abt JP, Sell TC, Lovalekar MT,Lephart SM: NeuromuscularResearch Laboratory, Departmentof Sports Medicine and Nutrition,School of Health and RehabilitationSciences, University of Pittsburgh,Pittsburgh, PA

Context: Kinesiology tape (KT) usein the clinical setting is growing;however, little evidence-basedresearch exists to support/refute itsuse. KT has been asserted to reducepain, alter muscle activation, enhanceproprioception, and promoteposturalalignment, which may becrucial when treating patients withsubacromial impingement syndrome(SIS). Objective: To determine theeffect of KT on shoulderproprioceptionstrength, and scapularkinematics (SK) in healthy and SISsubjects. Design: Placebocontrolledquasi-experimental study. Setting:Research laboratory. Participants:Data were collected on 10 healthy,physically active (age=25.78±3.78years, height=1.69±0.09 m,mass=67.18±14.25 kg) and 9physically active SIS participants(age=26.39±4.20 years, height=1.73±0.10 m, mass=77.52±14.87kg). Control subjects had no history ofmusculoskeletal shoulder pathology;SIS subjects were diagnosed by ahealthcare professional and presentedwith clinical signs of impingement.Interventions: Tests were performedon the dominant side (arm used tomaximally throw a ball) for controlsand impinged side for SIS subjects. Allcontrol subjects (n=10) received KTand SIS subjects were randomized toreceive KT (n=5) or sham taping (ST,

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Kinesio Tape For The Lower LegShifts Lateral Plantar ForcesDuring GaitCaccese JB, Griebert MC, NeedleAR, Kaminski TW: University ofDelaware, Newark, DE

Context: Kinesio taping (KT) hasbecome widely used in sports medicineover recent years for variouspathologies. Mechanical support andincreased proprioception are proposedbenefits, but little evidence exists asto the efficacy of KT. Previousresearch suggests that KT changestiming of plantar forces amongpatients with a history of medial tibialstress syndrome (MTSS). It is unclearhow KT may affect the magnitude ofthese plantar forces. Objective: Toexamine effects of lower leg KT onplantar forces in healthy subjects andsubjects with a history of MTSS.Design: Pre-test post-test withcontrol group. Setting: Biomechanicslaboratory. Patients or OtherParticipants: Forty physically activesubjects (20 male, 20 female)volunteered for this study. Twentysubjects had no history of exercise-related leg pain and twenty subjectshad a history of MTSS. Interventions:Subjects were asked to walk barefootacross a pressure mat system prior totape application (PRE), immediatelyfollowing application of KT to thelower leg (KT-I), and 24-hours afterKT use (KT-24). Tape was applieddirectly to the skin from the superiorthird of the medial tibia to the arch ofthe foot at 75% tension. Five trialswere collected for each condition toensure a reliable recording. MainOutcome Measures: Each trial waspartitioned so the foot was divided intosix areas: medial forefoot (MFF),medial midfoot (MMF), medialrearfoot (MRF), lateral forefoot(LFF), lateral midfoot (LMF), andlateral rearfoot (LRF). The dependentvariable was normalized peak force (N/kgbw). A 3-way repeated-measuresANOVA was used to determine if

n=4). Taping was performed by acertified kinesiology tape practitionerusing the method recommended by thecertifying organization. Participantswere tested pre- and post-application.Threshold to detect passive motion(TTDPM) was assessed using anisokinetic dynamometer (passivemode, 0.25°/s) for shoulder internal/external rotation (IR/ER, 3 repetitionseach). Path of motion replication(POMR) and SK were assessed usinga 3D motion analysis system andcustom guide (POMR: D2proprioceptive neuromuscularfacilitation pattern, 3 repetitions each;SK: scaption, 5 repetitions humeralelevation/depression). Isokineticshoulder IR/ER strength was assessedusing an isokinetic dynamometer (60°/s, 5 repetitions each). Post-test/pre-test differences were calculated. Datawere analyzed by group using one-sample Wilcoxon Signed Rank Tests.Mann-Whitney U tests were used toassess differences between groups(Controls vs. KT, KT vs. ST). Statisticalsignificance was set at p<0.05 apriori. Bonferonni corrections wereapplied to each variable category.Main Outcome Measures: Meanabsolute error and root mean squarederror in degrees were calculated forTTDPM (IR/ER) and POMR (3Dhumeral position), respectively.Scapular positions were extracted at90° and 120° of humeral elevation/depression. Average peak torque wasnormalized to body weight (%BW) forshoulder IR/ER. Results: Nosignificant differences weredemonstrated in TTDPM (p-range:0.273-0.893), POMR (prange:0.028-0.799), strength (p-range:0.225-1.000), or SK (p-range:0.043-1.000) when analyzed bygroup. No significant differences weredemonstrated between groups inTTDPM (p-range:0.190-0.733),POMR (05range:0.0.142-1.000),strength (prange: 0.286-0.95), or SK(p-range:0.071-1.000). Conclusions:Preliminary findings indicate that

taping does not appear to aid/impairshoulder proprioception, strength, orSK. Future research should explore ifsimilar results can be replicated withlarger sample sizes and in otherpathological groups. Supported byFreddie H. Fu, MD Graduate ResearchAward and University of Pittsburgh,School of Health and RehabilitationSciences Research Development Fund

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differences existed across tapeconditions, foot areas, and groups.Results: A significant interactioneffect of condition, area, and groupwas observed for peak force(F10,380=2.788, p=0.002). Pairwisecomparisons revealed that KT loweredpeak forces in the LFF(PRE=1.12±0.28 N/kgbw, KT-I=1.01±0.20 N/kgbw, KT-24=1.02±0.23 N/kgbw, p<0.02) and LMF(PRE=0.35±0.27 N/kgbw, KT-I=0.29±0.26 N/kgbw, KT-24=0.31±0.28 N/kgbw, p<0.03) in healthycontrols, but not MTSS subjects (LFF:PRE=0.98±0.30 N/kgbw, KT-I=1.01±0.31 N/kgbw, KT-24=1.03±0.40 N/kgbw, p>0.05; LMF:PRE=0.27±0.24 N/kgbw, KT-I=0.29±0.24 N/kgbw, KT-24=0.31±0.28N/kgbw). KT also increased LRF peakforces from PRE (Healthy=0.95±0.14N/kgbw, MTSS=0.86±0.15 N/kgbw)to KT-I (Healthy=1.01±0.19 N/kgbw,MTSS=0.95±0.26 N/kgbw)in bothgroups (p<0.05). Conclusions: Ourresults suggest that the use of KT onthe lower leg may increase the lateralforces in the rearfoot in healthy andMTSS subjects, potentially due toinitial contact occurring in a moresupinated position. However, weobserve that forces in the midfoot andforefoot are decreased, suggesting abeneficial role of the tape. Whilelimited effects of KT were observedin the MTSS group, there were nobaseline differences in plantar forcesobserved in our subset of patients, incontrast to previous studies.

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Free Communications, Oral Presentations: Risk Factors and Management ofPatellofemoral PainThursday, June 27, 2013, 9:30AM-10:30AM; Palm C; Moderator: Megan Quinlevan, ATC1 3 1 5 2 F O I N

Gender-Specific BiomechanicalProfiles For The DevelopmentOf Patellofemoral PainBoling MC, Nguyen A, Padua DA,Marshall SW, Cameron KL,Beutler AI: University of NorthFlorida, Jacksonville, FL; HighPoint University, High Point, NC;University of North Carolina,Chapel Hill, NC; Keller ArmyHospital, West Point, NY;Uniformed Services University ofthe Health Sciences, Bethesda,MD

Context: Females are reported to havea two times greater risk of developingpatellofemoral pain (PFP) ascompared to males. In order to betterunderstand this gender discrepancy inthe risk of developing PFP, it isimperative that researchers investigatethe risk factors for PFP that arespecific to males and females.Objective: To prospectively comparelower extremity kinematics, strength,Q-angle, and navicular drop betweenthose who developed PFP and thosewho did not develop PFP in a cohortof males and females. Design:Cohort. Setting: US ServiceAcademies. Patients or OtherParticipants: The cohort consisted of4019 participants (1455 females:age=18.6±0.8yrs, height =165.7±6.5cm, mass=62.9±7.9kg; 2470males: age=18.9±0.9, height=177.86±6.9cm, mass= 77.25±12.0kg) who were freshmen at thetime of enrollment in the currentinvestigation. Interventions: Eachparticipant underwent a baselinebiomechanical assessment includingthree-dimensional motion analysisduring three trials of a jump-landingtask, assessment of peak and meanisometric strength of thigh and hipmusculature (two trials), andmeasurement of Q-angle and naviculardrop (three trials). Following baseline

data collection, participants werefollowed prospectively for a maximumof 4 years to identify those diagnosedwith PFP. Incident PFP was determinedby a manual review of medical recordsby the principal investigator. MainOutcome Measures: Sagittal,frontal, and transverse plane hip andknee kinematics during the jump-landing task at initial contact (IC) and50% of stance phase (50%), mean andpeak isometric strength [normalized tobody weight (%BW)] of the kneeflexors, knee extensors, hip extensors,hip abductors, hip internal rotators, andhip external rotators, Q-angle, andnavicular drop were included in thedata analysis. Separate one-wayanalyses of variance were performedto compare each dependent variablebetween individuals who developedPFP during the follow up period andthose who did not develop PFP formales and females, separately(P<0.05). Results: 188 participants(94 females, 94 males) werediagnosed with PFP during thefollow-up period. In males, the PFPgroup displayed less knee flexion(16.9±7.5° vs. 20.2±7.9°; P=0.01)and greater hip external rotation (-5.5±7.6° vs. -3.2 ±0.04°; P=0.01) atIC, greater hip abduction mean(0.35±0.09%BW vs. 0.33± 0.08%BW; P=0.03) and peak (0.42±0.09%BW vs. 0.39±0.09%BW; P=0.02) strength, and greater naviculardrop (8.2±3.5mm vs. 7.5±2.8mm;P=0.02) compared to males who didnot develop PFP. In females, the PFPgroup displayed less knee externalrotation at IC (-1.8±7.3° vs. -3.8±7.5°; P=0.02), greater knee internalrotation at 50% (3.8±9.7° vs.1.5±9.7°; P=0.04), greater hipextension peak strength (0.30±0.08%BW vs. 0.27±0.08%BW;P=0.01), and less hip abductionmean strength (0.28±0.07%BW vs.

0 .30± 0 .08% BW; P=0.04)compared to females who did notdevelop PFP. Conclusions: Bio-mechanical risk factor profiles forPFP appear to differ between malesand females. These findings may beused to develop ef fec t ive PFPin jury preven t ion programsspecif ic to gender. (Funded byR01-AR050461001 and R03-A R 0 5 7 4 8 9 - 0 1 A 1 ) D

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Altered Hip Adductor – GluteusMedius Activation DifferencesAnd Knee Valgus In Those WithPatellofemoral PainAminaka N, Pietrosimone BG,Gribble P: University ofWisconsin-La Crosse, LaCrosse, WI, and Universityof Toledo, Toledo, OH

Context: Gluteus medius (GMed)weakness in patients withpatellofemoral pain (PFP) has beenobserved previously. However, there islimited evidence of neuromuscular andkinematic alterations related to GMedfunction. Furthermore, it is unknownwhether the muscular imbalancebetween the hip adductor (HA) groupand the lateral hip musculature exists,which may contribute to furtherkinematic deficits in those with PFP.Objective: Determine if there weredifferences in HA and GMed activationonset and knee kinematics betweenPFP and healthy participants. Design:Case-control. Setting: Researchlaboratory. Patients or OtherParticipants: Twenty PFP (13F/7M,21.45±3.90years, 169.96±10.47cm,71.30±14.50kg) and twenty healthyparticipants (13F/7M, 21.35±3.76years, 172.21±9.24cm, 69.68±9.78kg) volunteered. Interventions:Knee valgus/varus angles during stancephase of stair ambulation wereobtained using 3-D motion analysis, inorder to obtain the mean valgus angleduring the first 30% of the stancephase. A positive value indicated kneevalgus. Additionally, electro-myographic recordings of the HA andGMed were obtained to identify thedifferences in the activation onsetsrelative to footstrike. A negative valueindicated that HA activated earlier thanthe GMed. Main OutcomeMeasures: Dependent variablesincluded the HA-GMed activationdifference (H-G) and the mean kneevalgus angle, during stair ascent anddescent, separately. Independentvariables included group (PFP,Healthy) and limb (asymptomatic,

symptomatic). For each DV during thetwo phases of stair ambulation,separate two-way (Group, Limb)ANOVA’s were utilized for statisticalanalysis. Significance was set a prioriat P<0.05. Effect sizes (Cohen’s d)with 95% confidence intervals alsowere calculated. Results: Asignificant effect for limb was foundfor H-G during stair ascent(F

1,38=4.193, P=0.048, d=0.34

[95%CI=-0.29, 0.96]). Theasymptomatic side had earlieractivation of HA relative to GMed,compared to the symptomatic side( S y m p = - 1 5 5 . 0 2 ± 1 3 4 . 1 3 m s e c ,Asymp=-211.16±188.04msec). Asignificant group difference was foundfor H-G during stair descent,indicating that the PFP group displayedearlier activation of HA relative toGMed, compared with the healthygroup (F

1,38=6.862, P=0.013, d=-0.61

[-1.25, 0.02], PFP=-24.24±132.16msec, Healthy =50.42±104.49msec). For knee valgus duringascent, there was a significant groupdifference (F

1,38=6.424, P=0.016,

d=0.67 [0.03, 1.31]). The PFP groupdisplayed more knee valgus, comparedto the healthy group (PFP=-0.12±6.23°, Healthy=-4.23±5.80°).A significant group difference was alsofound for knee valgus angle duringdescent. The PFP group displayedmore knee valgus compared to thehealthy group (F

1,38=7.452, P=0.01,

d=0.75 [0.11, 1.39], PFP= 1.73±4.14°, Healthy=-1.035±3.01°).Conclusion: An imbalance betweenthe medial and lateral thigh/hipmusculature exists in those with PFP,which may lead to increased kneevalgus during activity. The resultssupport the previous literatureon muscular and kinematic deficitsin PFP patients, and may suggest thatexcessive or premature activationof HA may possibly cause inhibitionof GMed. Reestablishing musclebalance in the lower extremityshould be a continued focus inrehabilitation of PFP patients.

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Differences In Pelvic And TrunkKinematics Among Those WithAnd Without PatellofemoralPainBazett-Jones DM, Earl-Boehm J,Bolgla L, Hamstra-Wright KL,Emery CA, Ferber R: Departmentof Health & Human MovementSciences, Carroll University,Waukesha, WI; Department ofHuman Movement Sciences,University of Wisconsin-Milwaukee, Milwaukee, WI;Department of Physical Therapy,Georgia Health SciencesUniversity, Augusta, GA;Department of Kinesiology &Nutrition, University of Illinois atChicago, Chicago, IL; Faculty ofKinesiology, University of Calgary,Calgary, Canada

Context: Patellofemoral pain (PFP)is the most common injury in runningand jumping sports. Investigators havereported reduced hip and trunk strengthand differences in hip and kneemechanics in those with PFP. However,no study has investigated pelvis andtrunk mechanics in this population.Objective: To compare sagittal,frontal, and transverse plane pelvis andtrunk mechanics in those with andwithout PFP. Design: Cross-sectional. Setting: Researchlaboratory. Patients or OtherParticipants: 31 controls (17females, 14 males: age= 27.0±77.1years; mass=68.4±11.5kg;height=173.0±9.2cm) and 46 PFPpatients (25 females, 21 males:age=29.0±7.1 years; mass= 75.5±20.4kg; height=171.3±17.8cm)volunteered to participate. PFPparticipants were assessed by an ATand met inclusion criteria based onBoling (2006). The controlparticipants were free from lowerextremity injury and had no history ofPFP. All participants exercisedregularly a minimum of 30 minutes atleast 3 days/week. For the PFPparticipants the most painful knee was

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tested, and this was matched to thecontrols. Interventions: Theindependent variables were sex (male,female) and group (PFP, Control).Three-dimensional kinematic datawere collected at 200 Hz and groundreaction force data were collected at1000 Hz while participants ran (3.5-4.5 m/s) wearing standard footwear.After several practice trials, 5 trialswere recorded. Main OutcomeMeasures: The dependent variableswere stance phase peak absolute jointangles of the pelvis (APT, drop/lift,rotation) and trunk (FTL, contra- andipsilateral lean, right and left rotation).2X2 ANOVAs were performed toidentify differences between theindependent variables (P<0.05) andpost-hoc tests were performed withTukey (P<0.0125). Results: Therewas a significant group x sexinteractions for APT (P=0.020). Post-hoc comparisons indicated thatfemales with PFP demonstratedsignificantly less (P<0.001) peak APTthan female controls (PFP=3.7±6.0°,Control=13.5±6.9°) and malecontrols (10.9±6.7°, P=0.006). Therewas no significant difference(P=0.096) in peak APT betweenfemales and males (8.1±6.1°) withPFP. Main effects for sex were foundfor peak pelvic lift (males: 3.7±2.1°,females: 5.3±2.0°, P=0.003), FTL(males: 15.7±5.6°, females: 12.3±5.9°, P=0.016) and peak right (males:12.0±4.7°, females: 17.0±5.8°,P<0.001) and left (males: 10.7±4.4°,females: 13.9±6.0°, P=0.003) trunkrotation. There were no significantdifferences in other variablesmeasured (P>0.05). Conclusions:Decreased APT in females with PFP,combined with decreased FTL, mayshift the center of mass posteriorly.This would increase the knee extensordemand and patellar compression,making women more susceptible toPFP. This might also be acompensatory strategy resulting fromPFP. Individuals with PFP do notexhibit compensatory lateral trunk leanor pelvic drop. Females in general

demonstrate greater transverse planemotion at the trunk during running,potentially showing the importance ofhip and trunk muscular training infemales, possibly as a preventativemeasure for PFP. Funded by the NATAREF: 808OUT003R, AlbertaInnovates: Health Solutions,Wisconsin Athletic Trainers’Association, and UW-MilwaukeeCollege of Health Sciences.

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Prospective Pain And FunctionOutcomes After 6-Weeks OfRehabilitation ForPatellofemoral Pain SyndromeHamstra-Wright KL, Earl-BoehmJ, Bolgla L, Emery CA, Ferber R:Department of Kinesiology &Nutrition, University of Illinois atChicago, Chicago, IL; Departmentof Human Movement Sciences,University of Wisconsin-Milwaukee, Milwaukee, WI ;Department of Physical Therapy,Georgia Health SciencesUniversity, Augusta, GA; Facultyof Kinesiology, University ofCalgary, Calgary, Canada

Context: Therapeutic exercise is acommon intervention for a frequentlydiagnosed knee injury, patellofemoralpain syndrome (PFPS). Recent resultsfrom our randomized controlled trial(RCT) study indicate 6-weeks ofrehabilitation focused onstrengthening knee or hip/coremusculature are equally effective inreducing pain and increasing functionin physically active individuals withPFPS. However, pain and functionaloutcomes after treatment remainunknown. Objective: To assessdifferences in pain and function post-rehabilitation (6-WK) compared to 6-months post-rehabilitation (6-MOS)in PFPS patients who experiencedtreatment success compared to thosewho did not. Design: Single-blindRCT multi-centered study. Setting:Four clinical research laboratoriesacross North America. Patients orOther Participants: 202 PFPS patients,assessed by an AT and meetinginclusion criteria based on Boling etal. (2006), volunteered to participate(67 males, 135 females: age=29.36±7.33 years, mass=69.46±14.17 kg, height=170.86±9.48cm). Interventions: PFPS patientswere randomly assigned to a treatmentprotocol (knee vs. hip/core). Eachpatient visited an AT 3 times/week over6-weeks for rehabilitationprogression. After completion of the

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treatment protocol, PFPS patientswere asked to discontinue theexercises and report back to thelaboratory in 6-months. MainOutcome Measures: Pain andfunction were measured at 6-WK and6-MOS using a 10 cm visual analogscale (VAS) and the anterior knee painscale (AKPS). Treatment success wasdefined a priori as a decrease in VASby 3 cm and/or an increase in AKPSof 8 points (maximum points possible:100). Differences in pain and functionover time (6-WK, 6-MOS) andbetween groups (successful,unsuccessful) were assessed using two2x2 repeated measures ANOVAs(Pd”0.05). Results: Of the 202patients, 141 reported successfuloutcomes and 105 provided 6-WK and6-MOS VAS and/or AKPS data. Thirty-eight of the 202 patients wereunsuccessful and 26 provided 6-WKand 6-MOS VAS and/or AKPS data.There were no differences in pain overtime in patients reporting successfuloutcomes (6-WK: 2.12±2.09 cm, 6-MOS: 2.29±2.37 cm, F

1,129=21.55 ,

P=0.99, n=105) nor in patientsreporting unsuccessful outcomes (6-WK: 4.42±2.43 cm, 6-MOS:4.25±2.60 cm, F

1,129=21.55, P=0.99,

n=26). There were also no differencesin function over time in patientsreporting successful outcomes (6-WK: 89.40±10.48, 6-MOS:88.59±11.07, F

1,118=18.35, P=0.72,

n=98) nor in patients reportingunsuccessful outcomes (6-WK:78.68±9.93, 6-MOS: 78.91±10.51,F

1,118=18.35, P=0.72, n=22).

Regardless of time, the successfulgroup had lower VAS (2.19±2.23 cm,P=0.00) and higher AKPS scores(89.06±10.76, P=0.00) compared tothe unsuccessful group (4.34±2.49cm, 79.22±10.39). Conclusions: At6-months post-treatment, patientsexperienced no increases in pain ordecreases in function regardless ofwhether reporting successful orunsuccessful outcomes at 6-weekspost-treatment. Therapeutic exercise

focused on knee or hip/core strengthappears to be an appropriateintervention for physically activePFPS patients. Funded by the NATAREF: 808OUT003R and AlbertaInnovates: Health Solutions.

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Free Communications, Oral Presentations: Prospective Clinical Trials in AthleticTrainingThursday, June 27, 2013, 11:45AM-12:45PM; Palm C; Moderator: Darin Padua, PhD, ATC1 3 3 0 0 F O I N

Kinematic Risk Factors ForLower-Extremity StressFracture InjuriesCameron KL, Peck KY, OwensBD, Svoboda SJ, Padua DA,DiStefano LJ, Beutler AI, Yau R,Marshall SW: Keller ArmyHospital, United States MilitaryAcademy, West Point, NY;University of North Carolina atChapel Hill, Chapel Hill, NC;University of Connecticut, Storrs,CT; Uniformed Services Universityof Health Sciences, Bethesda, MD

Context: Stress fracture injuriesdisproportionately affect athletes andmilitary service members and little isknown about the modifiablebiomechanical risk factors associatedwith these injuries. Objective: Thepurpose of this study was toprospectively examine the associationbetween biomechanical factors uponentry to military service and thesubsequent incidence rate of lower-extremity stress fracture duringfollow-up. Design: Prospectivecohort study. Setting: We analyzeddata from the JUMP-ACL cohort, anexisting prospective cohort of militarycadets. Patients or Participants: Allparticipants were college freshmenentering a U.S. Service Academy.There were 1895 participants availablefor analysis. Fifty-two participantsreported a history of stress fracture atbaseline and were excluded fromfurther analysis leaving 1843participants. Interventions: Detailedmotion analysis was conducted at theinitiation of each subject’s militarycareer. Kinematic data were collectedfrom the subject’s dominant leg duringthree jump-landing trials. A Flock ofBirds® (Ascension Technologies,Inc., Burlington, VT) electromagneticmotion analysis system controlled byMotion Monitor® (Innovative SportsTraining, Inc. Chicago, IL) data

acquisition computer software wasused to collect three-dimensionalcoordinates of selected anatomicallandmarks at a sampling rate of 144 Hz.Primary Outcome Measures: Theprimary outcome of interest was theincidence rate of lower-extremitystress fracture during the follow-upperiod. The electronic medicalrecords of each potential incident casewere reviewed and each case wasconfirmed by an adjudicationcommittee consisting of two sportsmedicine fellowship trainedorthopaedic surgeons. The associationbetween incident stress fracture andsagittal, frontal, and transverse planehip and knee kinematics during thejump-landing task were examined atinitial contact (IC), 15%(T15),50%(T50), 85%(T85) and 100%(T100) of stance phase. We usedunivariate and multivariable Poissonregression models to analyze the data.Results: Overall, 94 (5.1%, 95%CI:4.14, 6.21) subjects sustained anincident stress fracture during thefollow-up period. Compared to thosewith greater than 5° of knee valgus,subjects with neutral or varus kneealignment exhibited incidence ratesfor stress fracture that were 43%-53%lower at IC (IRR=0.57, 95%CI: 0.29,1.11, p=0.10), T50 (IRR=0.47,95%CI=0.23, 1.00, p=0.05), and T85(IRR=0.53, 95%CI: 0.29, 0.98,p=0.04). Subjects with greater than 5°of internal knee rotation exhibitedrates for stress fracture that were 2-4times higher at T15 (IRR=2.31,95%CI: 1.01, 5.27, p=0.05), T50(IRR=3.98, 95%CI: 0.99, 16.00,p=0.05), and T85 (IRR=2.31, 95%CI:0.86, 6.23, p=0.10), when comparedto those with neutral or external kneerotation. Conclusions: Knee valgusand internal rotation during a jumplanding task at baseline appear to beassociated with a 2-4 fold increase

in the incidence rate of lower-extremity stress fracture injuriesduring follow-up. Future researchshould examine the role of injuryprevention programs in decreasingstress fracture incidence by targetinghigh-risk movement patterns.

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Optimal Rehabilitation Protocolsfor the Treatment ofPatellofemoral Pain Syndrome:an Outcome-Based RCT StudyFerber R, Bolgla L, Earl-Boehm J,Emery CA, Hamstra-Wright KL:Faculty of Kinesiology, Universityof Calgary, Calgary, Canada;Department of Physical Therapy,Medical College of Georgia,Augusta, GA; Department ofHuman Movement Sciences,University of Wisconsin-Milwaukee, Milwaukee, WI;Department of Kinesiology &Nutrition, University of Illinois-Chicago, Chicago, IL

Context: Patellofemoral painsyndrome (PFPS) is the most commoninjury in running and jumping sports.The gold standard for PFPSrehabilitation has traditionally beenstrengthening the muscles surroundingthe knee (KNEE). More recently, it hasbeen suggested the aetiology of PFPSis related to reduced hip and corestrength (HIP). However, norandomized controlled trial (RCT)studies have determined the optimalrehabilitation for PFPS. Objective:To compare pain and function betweenKNEE and HIP rehabilitationprotocols using an RCT approach. Wehypothesized greater improvements invisual analog scale (VAS) and AnteriorKnee Pain Scale (AKPS) scores forHIP as compared to KNEE. Design:Single-blind RCT multi-centeredstudy. Setting: Four clinical researchlaboratories across North America.Patients or Other Participants: 202PFPS patients, assessed by an AT andmeeting inclusion criteria based onBoling et al. (2006), volunteered toparticipate (67 males, 135 females:age=29.36±7.33 years; mass= 69.46±14.17kg; height= 170.86±9.48cm).Interventions: PFPS patients wererandomly assigned to a treatmentprotocol: KNEE vs. HIP. Each subject

visited an AT 3 times per week over a6-week period for rehabilitationprogression. Main OutcomeMeasures: VAS and AKPS werecollected at baseline and one time perweek over 6-weeks. Treatmentsuccess was a priori defined as adecrease in VAS by 3cm and/or anincrease in AKPS of 8 points. Datawere analyzed using an intent-to-treatbasis. We calculated the mean changescores within groups, and differencesin change scores between groups, with95% confidence intervals (CI) andperformed 2x2 ANOVAs (group xtime; P<0.05) on the VAS and AKPSscores. Results: At baseline, nodifferences (F

1,199=0.92; P=0.54) in

VAS were observed between HIP(5.12±1.65cm; CI: 5.50-4.73cm) andKNEE (4.97±1.61cm; CI: 5.35-4.60cm) and no differences(F

1,199=0.78; P=0.66) in AKPS were

observed between HIP (75.00±9.74;CI: 77.28-72.72) and KNEE(75.62±9.81; CI: 77.91-73.34). 23patients dropped out after baselinetesting, 141 PFPS reported asuccessful outcome, and 38 wereunsuccessful. Of the 141 successfuloutcomes, 70 were HIP and 71 wereKNEE and no differences in either VAS(F

1,138=0.77; P=0.69) or AKPS

(F1,138

=0.91; P=0.57) were measuredbetween groups. HIP exhibited anaverage decrease of 3.58±1.94cm inVAS (CI: 1.38-2.16) and 17.62±9.46increase in AKPS (CI: 90.37-93.68)while KNEE demonstrated an averagedecrease of 3.65±1.74cm in VAS (CI:1.19-1.79) and 18.91±12.69 increasein AKPS (CI: 90.69-93.79).Conclusions: With ATs as the primaryinterventionists, this RCT studydemonstrated significant improve-ments in pain and function for one ofthe most common musculoskeletalinjuries. Both KNEE and HIPprotocols improved patient-centeredoutcome scores after 6-weeks oftherapeutic strengthening. This is thefirst RCT study investigating KNEE vs.

HIP protocols for patients withPFPS. Funded by the NATA REF:808OUT003R and Alber taInnova tes : Hea l th So lu t ions .

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Patient-Centered And ClinicalOutcomes Associated WithGrade II Lateral Ankle Sprains:A Case SeriesMulligan RP, Mutchler J, Hoch MC,Van Lunen BL: Old DominionUniversity, Norfolk, VA

Background: The purpose of thiscase series is to describe the clinicaland patient-centered outcomes of 5collegiate athletes who presented totheir respective athletic trainingfacilities with grade II lateral anklesprains. These patients (2 female, 3male; age=19.4±0.8years) wereparticipating in NCAA athletics(lacrosse, track, soccer and baseball)and sustained a lateral ankle sprainassociated with an inversionmechanism while running or landing.Four patients reported no previoushistory of ankle sprain. All patientsexhibited mild-to-moderate instabilitywith manual stress tests (anteriordrawer and talar tilt), point tendernessover the lateral ankle ligaments,limited ROM compared to thecontralateral ankle, pain with weight-bearing, and sudden onset of edemawithin 72 hours of injury. All patientswere monitored over the course oftreatment using objective clinicalmeasures (OCM) including pain, theglobal rating of change scale (GROC),and active dorsiflexion range ofmotion (DROM) along with self-reported measures of health includingthe Foot and Ankle Ability Measure(FAAM), the FAAM-Sport, theCumberland Ankle Instability Tool(CAIT), and the Tampa Scale ofKinesiophobia-11 (TSK-11). Whilethe FAAM, FAAM-Sport, and CAIT arepatient reported outcomes (PRO)focusing on regional measures ofhealth associated with the foot andankle, the TSK-11 describes the fearof movement. Treatment: Treatmentand rehabilitation protocols for eachpatient were dependent upon thediscretion of their respective athletictrainer. Patients completed PRO and

OCM one day post-injury (Day1), oneweek post-injury (Week1), and atreturn to play (RTP)(19.6±5.86days).Active DROM was measured indegrees with the patient in proneposition with the knee extended. Painwas measured in centimeters using avisual analog scale (VAS) and changesin self-reported injury status weremeasured using the GROC. The FAAMcontains 21 items related to activitiesof daily living (highest score=100%),the FAAM-Sport contains 8 itemsrelated to sport-specific activity(highest score=100%), and the CAITcontains nine items pertaining toinstability during activity (highestscore=30). All items on the FAAM,FAAM-Sport, and CAIT are graded ona Likert scale with higher scoresindicating greater self-reportedfunction. The TSK-11 is an 11-itemquestionnaire graded on a 4-pointLikert scale (total=44, lowest=11)with higher scores indicating greaterfear of movement. Results: Allpatients demonstrated improvementsin OCM as indicated by changes inDROM (Day1=6.6±8.47°; Week1=10.6±5.32°), pain on the VAS( D a y 1 = 5 . 2 8 ± 2 . 4 1 c m ;Week1=1.5±1.19cm) andhe GROC(Day1=-0.02±2.0; Week1=2.8±0.83).The improvements in OCMcorresponded to improvements inoverall health status as indicated bychanges in PRO measures for theFAAM (Day1= 55.50±20.00%;Week1=79.00±23.50%), the FAAM-Sport (Day1=11.87±3.56%; Week1=27.50±6.38%), the CAIT (Day1=8.20±7.43; Week1 =13.60 ±7.43)and the TSK-11 (Day1=26.80±3.27;Week1=22.20±3.03). The GROCcontinued to improve at RTP(4.5±0.55) while pain (0.06±0.09cm)and DROM (10.6±7.13°) did notchange. Upon RTP, all patientsdemonstrated high levels of functionon each PRO measure (FAAM=98.50±2.05%; FAAM-Sport=96.25±5.59%; CAIT=24.60±3.21;TSK-11=16.00±2.34) indicating

minimal functional loss. Uniqueness:There is a lack of evidence supportingthe use of PRO and OCM to track theprogress during rehabilitation of lateralankle sprains. This case seriesdemonstrates how patient-centeredmeasures of function can be used toenhance patient evaluation and trackrehabilitation progress when combinedwith traditional clinical indicators offunction. Conclusions: Followinglateral ankle sprain, patientsdemonstrated decreases in pain,increases in DROM, andimprovements in perceived injurystatus which corresponded withimprovements in self-reportedmeasures of health assessed throughPRO instruments. All patientsdemonstrated improvements in OCMand PRO at RTP regardless of theirrehabilitation plan. However, PROinstruments continued to identifyimprovements at RTP despite a plateauin certain OCM. This demonstrates thebenefit of combining OCM and PROfor tracking the rehabilitation progressfor patients with lateral ankle sprains.

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Treatment Characteristics AndEstimated Direct Costs Of CareProvided By Athletic TrainersFor Upper Extremity Disorders:A Report From The AthleticTraining Practice-BasedResearch NetworkSauers EL, Bliven K, Lam KC: A.T. Still University, Mesa, AZ

Context: Data regarding the treatmentcharacteristics and estimated directcosts of care (DCC) for athletictraining services (ATS) providedoutside of the Centers for Medicareand Medicaid Services (CMS) systemare limited. To appropriately value ATSoccurring in traditional practicesettings, it is important to describe thetreatment characteristics andestimated DCC for ATS as if thoseservices were reimbursed by CMS.Objective: Describe treatmentcharacteristics and estimated DCC forATS for upper extremity disorders(UED). Design: A retrospectiveanalysis of electronic medical records.Setting: Athletic Training Practice-Based Research Network (AT-PBRN).Patients or Other Participants:Medical records of 951 patients(male=648, female=303, age=17.1±2.0 yrs, height=171.7±12.0 cm,mass=71.7±16.1 kg) diagnosed with anUED by an athletic trainer (AT)within the AT-PBRN. Interventions:Medical records of patients whoreceived ATS between October 2009-October 2012 from 65 clinicalpractice sites within the AT-PBRNwere reviewed. All medical recordswere created by an AT utilizing a web-based electronic medical record(EMR). Each UED was defined as aunique case and identified utilizingUED-specific diagnostic codes(ICD-9). Main OutcomeMeasures: Summary statistics werecalculated for patient and UEDdemographics. Treatment character-

istics included duration of care[initial evaluation to last documentedepisode of care (EOC)], EOC’s(number of documented patientencounters), type of ATS provided(CPT codes). DCC were estimatedby applying the 2012 CMS PhysicianFee Schedule (MPFS) nationalpayment amount. The MPFS onlinedatabase was utilized to determinethe non-facility (i.e., non-hospital)price for each CPT code. Codes werepriced in accordance with thenumber of units recordedand theDCC for each EOC were estimated.Results: The most frequent regionofupper extremity injury was theshoulder (43.4%) followed by thewrist (12.1%). Sprain/strain of hand/finger (ICD9: 842.10) was the mostfrequent UED diagnosis overall(12.5%). Subluxation/dislocation(ICD9: 831.00) was the mostcommon shoulderdiagnosis (14.5%of all shoulder injuries) and sprain/strain (ICD9: 842.00) was the mostcommon wrist diagnosis (53.0% ofall wrist injuries). The mostfrequently utilized treatments werehot or cold pack [CPT 97010(33.0%)], therapeutic exercise[CPT97110 (21.9%)], manualtherapy [CPT 97140 (8.3%)],electrical stimulation [CPT97032(6.8%)], and ultrasound [CPT97035 (5.9%)]. The average durationof care was12.0±30.4 days and theaverage number of EOC’s was2.71±3.7 per UED. The averagenumber of treatments provided perEOC was 1.94±1.01. The averagetotal cost of carewas $188.34±316.67 per UED and the averagecost per EOC was $67.52±33.30.Conclusions: These dataprovide important information aboutthe treatmentcharacteristics andestimated DCC for ATS providedoutside of the CMS system.Thesedata speak to the value of ATSand potential cost savings to the

healthcare system when ATS areprovided in a population-basedpractice model outside of CMS.

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Free Communications, Oral Presentations: Concussion Education and PolicyThursday, June 27, 2013, 3:00PM-5:00PM; Palm C; Moderator: Tricia Kasamatsu, MA, ATC1 3 0 9 6 F O S P

Changes In Athlete Self-Reported SymptomatologyOver Time Following Sport-Related Concussion: Are WeOverly Optimistic?Bay RC, Valovich McLeod TC: A.T.Still University, Mesa, AZ

Context: The decision to return anathlete to play following concussionrelies, in large part, on athlete self-report of symptomatology. Currentguidelines suggest that athletes shouldnever return-to-play followingconcussion if they have ANYsymptoms. Objective: To assesschanges in high school athlete self-reported symptoms and health-relatedquality of life (HRQOL), following aconcussion. Design: Cohort.Setting: High school athletic trainingfacilities. Patients or OtherParticipants: A convenience sampleof 147 adolescent athletes (118 males,29 females, age=16.0±1.1; grade=9.4±1.0) who suffered a sport-relatedconcussion diagnosed by an athletictrainer. Interventions: Theindependent variable was time sinceconcussion. Participants completedthe Sport Concussion AssessmentTool-2 (SCAT2) symptom evaluationduring a pre-season baseline (BL), atDay of Injury (D0), Day 3 (D3), Day10 (D10) and Day 30 (D30) post-injury. Two measures of HRQOL, thePediatric Quality of Life Inventory(PedsQL) and MultidimensionalFatigue Scale (MFS) were completedat BL, D3, D10 and D30. MainOutcome Measures: Dependentvariables included scores from theSCAT2 symptom scale, PedsQL Totaland MFS General Fatigue subscale.Two summary scores were calculatedfrom the 22-item SCAT2 symptomscale: Total Symptom Score (TSS) andTotal Symptoms Endorsed (TSE).Lower scores indicate lower symptomseverity (TSS) and fewer endorsedsymptoms (TSE). The PedsQL andMFS are valid and reliable measures

of HRQOL in pediatric patients. Lowerscores indicate lower HRQOL. Ageneralized estimating equationsapproach was used to assess changeover time. Bonferroni-adjustedcomparisons evaluated pairwisedifferences (p<.05, two-tailed).Results: 147 athletes completed theSCAT2 symptom evaluation at BL, D0,D3, D10 and D30. A subset of theseathletes (n=121, 82%) completed thePedsQL and MFS at BL, D3, D10 andD30. The TSS and TSE both showedsignificant increases from BL (TSS:9.5±12.5; TSE:4.4±4.8) at D0 (TSS:27.2±20.6, TSE: 10.7±5.8 and D3(TSS: 17.4±19.3, TSE: 7.5±6.5),p<0.001. Average scores for bothreturned to BL by D10, p=1.0.However, at D30, both weresignificantly lower (TSS: 2.6±4.5,TSE: 1.8±3.1) than BL, p<0.001. Asimilar pattern was noted for thePedsQL and MFS scales: Scores werelower at D3 than BL (p<0.001), butexceeded BL at D10 and D30,p<0.001. Conclusions: Athlete self-report of symptomatology must beconsidered in making a return-to-playdecision; however, concussionmanagement models may offer aperverse incentive; they may leadto unintended and undesirableconsequences. Concussed athletes knowthey must be “symptom-free” to return-to-play. Our data suggest that athletesreport significantly fewer and lesssevere symptoms at D30 than at BL.Likewise, by D10, their HRQOLsignificantly exceeds BL. We suspectthat concussion does not decreasesymptomatology or increase HRQOLfrom baseline measures a few days post-concussion. Alternatively, self-report ofboth may be overly optimistic anddriven by the desire to return-to-play.Funded by a grant from the NationalOperating Committee on Standardsfor Athletic Equipment (NOCSAE).

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The Relationship Between TheTime In Each Step Within AReturn To Play Guideline ForSports-Related ConcussionAmong High School Student-AthletesShimizu A, Furutani T, Kocher M,Wahl T, Oshiro RS, Tamura K,Murata N: Department ofKinesiology and RehabilitationScience, University of Hawaii atManoa, Honolulu, HI, and State ofHawaii Department of Education,Honolulu, HI

Context: Assessment and manage-ment in sport related concussion hasbeen studied from various aspects.Current research demonstrated theimportance of creating a return to playguideline for concussed athletes toreturn to play in the safest manner.Objective: To investigate therelationship between the numbers ofdays from concussion onset to fullreturn to sports participation using theState of Hawaii return to play (RTP)protocol among high school student-athletes. Design: Retrospective casereview of concussions reportedbetween 2010 and 2012. Setting: TheState of Hawaii has implemented acomprehensive RTP protocol thattracks step wise cognitive rest periodsand physical exertion periods ofconcussion recovery. Certifiedathletic trainers from 64 high schoolsin the State of Hawaii participated inthe Concussion Management Program.They were instructed to complete aconcussion log for each concussedathlete. Participants: De-identifieddata from 375 were concussionsaccurately reported with patientscompleting the RTP protocol during2010-2012. 229 male (mean age ± SD= 15.56 ± 1.18) and 138 females(mean age ± SD = 15.29 ± 1.16) wereincluded. Interventions: Thecompletion date of each step wasrecorded as follows: Step 1 =cognitive rest, Step 2 = return to

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school full time, Step 3 = Lightexercise, Step 4 = Running, Step 5 =Non-contact drills, Step 6 = Fullcontact practice, and Step 7 = norestrictions. Each step was separatedby at least a 24 hour period. MainOutcome Measures: Correlationanalysis and multiple regressionanalysis were conducted to analyze therelationship among the steps in theprotocol. Days between each step andthe total days each concussed athletespent to complete the protocol servedas the primary outcome measures.Results: Days between Step 2 and 3had the strongest correlation with thetotal days missed in the protocol (p <0.01, r = 0.84). With multipleregression analysis, the time betweenStep 2 and 3 remained significantpredictor of the total days missed (Rsquare = 0.70). Conclusions: 70% ofthe total days missed in the protocolwere accounted for the days betweenStep 2 and 3. In other words, the longerthe concussed athlete took to completethe light exercise phase without anyreoccurring symptoms, the moresevere the concussion was. Possiblereasons for the concussed athleteswhose Step 2 to 3 were prolongedmight be due to two reasons: Theircognitive rest period was too short, andno formal school accommodationsplans administered. Future studiesshould investigate the symptoms andneurocognitive scores reported duringeach step of the RTP protocol. Also,the effect of implementing schoolaccommodations to recover fromconcussion should be investigated.

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Return To Play ProgressionFollowing Concussion UsingStandardized Exercise AndIntensityLake AW, Cruickshank JA, BrooksKL: Cleveland Clinic, Cleveland,OH

Background: This case series followsnine high school football playersthrough a return to play progressionfollowing a concussion. The athletes’average age was 16.22 years andaverage grade in school was 10.89,average height and weight were 70.97inches and 201.11 poundsrespectively. Six athletes werefollowed after their first documentedconcussion. Three had at least oneprevious concussive injury with themost recent for each occurring duringthe previous football season. Sixinjuries occurred in practice and threeduring game play. All athletes wereevaluated by an athletic trainer orphysician within 24 hours anddetermined to have sustained aconcussion. Treatment: The athletesparticipated in a six phase return toplay progression where phase oneconsisted of rest, resolution ofsymptoms, a full day of school withoutthe return of symptoms andneurocognitive testing showingrecovery. Phases two through fourconsisted of exercise controlled foractivity and intensity level. Exerciseintensity was monitored using the BorgRating of Perceived Exertion Scale(RPE) and/or heart rate monitoring.Criterion for progression to each newstep of these phases was remainingasymptomatic before, during and afterexercise, monitored with a gradedsymptom checklist, and at least 24hours between steps. In phase two ofthe program, athletes completed 15minutes of stationary cycling at anintensity of 8 to 11 on the RPE scale.In phase three, athletes completed fourexercise circuits alternatingcardiovascular stress with upper body,lower body, core, and balance activity.

Tasks were changed every 30 to 60seconds, depending on fitness level andexertion, and a two minute rest wasgiven between each circuit. Exerciseintensity for phase three was keptbetween 11 and 14 on the RPE scale.Phase four also used four exercisecircuits with the addition of change ofdirection and plyometric tasks to thecomponents of the phase threecircuits. Exercise intensity for phasefour fell between 14 and 18 on theRPE scale. Phase four also includednon-contact sports specific drills aspart of practice following completionof the exercise circuits. Phase fiveconsisted of a full-contact practiceand phase six entailed participation ina game. Results: The average amountof time for return to play for athleteswithout previous concussion was 22days (range 15 to 29). For those withprevious history of concussion thiswas 21.33 days (range 17 to 23).Overall the time elapsed between theconcussion incident and initiation ofexercise was on average 11.67 days(range 5 to 16). For the athletes withprevious concussion this was 13.33days (range 8 to 16), and for thosewithout history of concussion this was10.83 days (range 5 to14). For athleteswithout history of concussion phasestwo, three, four, and five occurred at10.83, 14, 16.5, and 18.17 daysrespectively. For the athletes withprevious history of concussion thoseaverages were 13.33, 15, 17, and 18.67days respectively. Average timeelapsed between the initiation ofexercise and full return to game playfor all athletes was 10.78 days (range7 to 16). For athletes without previousconcussion this was 11.17 days (range7 to 16) and 10 days (range 8 to13)for those with a previous concussionhistory. Uniqueness: This case isunique in that exercise and intensitywere controlled and standardized usingthe RPE scale and/or heart ratemonitoring during each phase of thereturn to play progression.

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Conclusions: Certified AthleticTrainers were able to successfullyreturn multiple athletes to high schoolfootball utilizing a return to playprogression that controlled for bothexercise type and level of exertionthroughout the return to play process.

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Self-Reported ConcussionManagement Practices AmongSecondary School AthleticTrainersWeber ML, Mayfield RM, McCartyCW, Parsons JT, Valovich McLeodTC: A.T. Still University, Mesa, AZ

Context: The evaluation of sport-related concussion by athletic trainers(AT) is essential in ensuring propermanagement and safely returning anathlete to play. Currentrecommendations suggest a writtenpolicy and multifaceted approach toassessment and managementconstitute best practices, however it isunclear how secondary school ATs arepracticing. Objective: To describe theconcussion management practicesamong secondary school ATs. Design:Cross-sectional design. Setting: Self-reported online survey. Patients orOther Participants: 851 clinicians(25.9% response rate) from aconvenience sample of ATs that werecurrently practicing in the secondaryschool setting (308 males, 376females, 167 missing, age= 37.9±22.3). Interventions: Participantswere solicited via email to completethe Athletic Trainers’ Beliefs,Attitudes, and Knowledge ofPediatric Athletes with Concussions(BAKPAC-AT) survey. The BAKPAC-AT consisted of several multipartquestions to assess ATs’ currentconcussion management practicesregarding policy, standing orders,baseline and follow-up testing andclearing athletes to return-to-play.Main Outcome Measures: Thedependent variables were participants’responses to the concussionmanagement questions. Descriptivestatics were used to evaluate the useand types of baseline and follow upassessment tools. Separate forwardstepwise binary logistic regressionanalyses (p<.05) were used todetermine whether any personal (yearscertified, experience in secondaryschool setting) or school (enrollment,

type, presence of football)demographic predicted the use ofbaseline or follow-up assessments andwhether the AT clears athletes toreturn-to-play. Results: The majorityof ATs indicated they had a writtenconcussion policy (82.4%, n=701)and standing orders approved by theirdirecting physician (67.3%, n=573).Baseline testing was used by 75.1%(n=639), with the majority usingcomputerized neurocognitive tests(71.2%, n=606) and fewer usingbalance assessments (9.2%, n=78) anda symptom scale (11.4%, n=97).Follow-up concussion testing wasemployed by 81.8% (n=696) withcomputerized neurocognitive testingbeing employed by 68.5% (n=583),balance testing by 23.5% (n=200),symptom scales by 35.5% (n=302)and sideline assessments (eg. SCAT2)by 40.5% (n=345). Approximately70% (n=603) of ATs indicated theyclear athletes following return-to-playprotocols. The regression analysesfound that years of certification(p=.049) and type of secondary school(p=.033) predicted the use of baselinetesting with ATs practicing 3-5 yearsmore likely to baseline test comparedto those practicing less than 2 yearsand public charter school affiliationmore likely to test than public schools.There were no significant predictorsof follow-up testing. Conclusions:Most ATs surveyed were engaged inmanagement protocol involvingbaseline and follow-up testing. In bothinstances, neurocognitive testing wasmost often utilized. Ideally, amultifaceted approach that alsoincludes balance testing and symptomassessment should all be administeredat baseline and follow-up.Demographic information regardingyears certified and location of practicecan aid educational efforts to ensureall ATs are using best practicesin concussion management.

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Comparison Of ConcussionManagement Programs OnReturn To ParticipationOutcomes Of Concussed HighSchool Student-Athletes During2011-12Kanaoka T, Goeckeritz LM, UyenoRK, Oshiro RS, Furutani TM, WahlTP, Kocher MH, Murata NM: Stateof Hawaii Department ofEducation, University of HawaiiHonolulu Community College,Honolulu, HI, and Department ofKinesiology and RehabilitationScience, University of Hawaii atManoa, Honolulu, HI

Context: A multifaceted approach forthe management of sport-relatedconcussion that includes a clinicalexamination, graded symptom checklist, postural stability testing,neurocognitive testing, and a GradualReturn to Play Protocol (GRPP) hasbeen recommended by severalconcussion consensus statements andposition papers. Healthcareprofessionals caring for concussedstudent-athletes across the UnitedStates may not be following theseguidelines and therefore allowingstudent-athletes to return toparticipation (RTP) prematurely.Objective: To investigate how theduration of RTP and GRPP forconcussed high school student-athletes was influenced by the type ofConcussion Management Program(CMP), which incorporated twodifferent neuropsychological testingbatteries for RTP decision-making.Design: Retrospective cross-sectional investigation. Setting: Twodifferent neurocognitive tests wereutilized within the CMP of 37 publichigh schools and 3 private high schoolsin the State of Hawaii. Patients orOther Participants: Concussedstudent-athletes (n=390, between theages of 13 to 18) received baseline andpost-concussion neurocognitivetesting during school year (SY) 2011-

12. Interventions: Two differentneurocognitive tests used in a CMPwere compared: 19 schools utilizedthe Immediate Post-ConcussionAssessment and Cognitive Testing(ImPACT) and 21 schools utilizedStandard Assessment of Concussion(SAC). Main Outcome Measures:The difference in means between twodifferent neurocognitive tests used inthe CMP (ImPACT n=225, SACn=165) were compared using anindependent samples t-test. Days ofrestricted participation post-concussion and duration of the GRPPuntil return to unrestrictedparticipation, mean, standard deviation(SD), and 95% confidence intervals(CI) were reported. The duration of theGRPP was defined as the number ofdays of the rehabilitation period,starting from light aerobic exercise tofull-contact practice. The GRPPconsisted of five steps, each separatedby a minimum of 24 hours. Results: Asignificant (F1=2.865, p=.033)difference was found betweenrestricted participation post-concussion for ImPACT=26.25±18.99(CI= 23.76 – 28.75) days comparedto SAC=22.50±14.17 (CI= 20.32 –24.67) days. No significant (F1=.728,p=.870) difference was found for theaverage duration of the GRPPincorporating ImPACT=10.30±7.06(CI=9.38 – 11.25) days compared toSAC=10.18±7.37 (CI=9.05 – 11.31)days. Conclusions: The duration ofGRPP for concussed student-athleteswas not significantly different;however, the days of restrictedparticipation post-concussion wassignificantly different when using thetwo different neurocognitive testingbatteries (SAC or ImPACT) within theCMPs. The schools that utilizedImPACT in the CMP had a significantlylonger number of days restricted thanthe schools that utilized SAC in theCMP. This result indicates a moreconservative approach to RTPdecision-making by Athletic Trainerswho utilized the CMP incorporating

ImPACT. The two testing batteries usedin this study are just one part ofthe multifaceted nature of RTPdecision-making within acomprehensive CMP. Thus, utilizingadditional clinical examinations isvital to prevent the premature releaseof concussed student-athletes.

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Concussion ManagementProtocols In The Military AndThe Role Of The AthleticTrainer: A Systematic ReviewBergens BL-F, Kasamatsu TM,Cleary MA: Athletic TrainingEducation Program, ChapmanUniversity, Orange, CA

Context: Athletic trainers are on theforefront of managing mild traumaticbrain injury or concussions in thephysically active population.However, in the various militarysettings, other health careprofessionals tend to fill the role ofconcussion management. Incidencerates are increasing in theaters(combat) such as Operation IraqiFreedom and Operation EnduringFreedom largely due to increasedsymptom awareness and increased useof improvised explosive devices.Many of the concussion managementprotocols in the military have beendeveloped from sport-relatedconcussion research, with onedifference being the small number ofathletic trainers working with soldiersin garrison (domestic base).Objective: To critically analyze theconcussion management protocols ofthe military and determine thepotential role athletic trainers couldfulfill while working in this emergingpractice setting. Data Sources: Acomputerized search for relevantarticles was performed using thedatabases PubMed, Military andGovernment Collection, SPORTDiscus, and Health Source: Nursing/Academic edition from 2000-2012.The search was conducted using thekeywords: concussion managementand military, sport concussionepidemiology, sport-relatedconcussion, and WARCAT. Limitswere: published in peer reviewedjournals, full text available, English,and humans. Study Selection:Articles were selected by reading theabstract, scanning headings and titlesfor relevance to concussion injuries in

the military, sport-related concussion,management protocols, duties ofhealthcare professionals and athletictrainers. Data Extraction: Full-textof 22 articles was reviewed, wesummarized major findings in aspreadsheet and scored each article onthe Strength of RecommendationTaxonomy (SORT) or if the articlecontained human subjects we scoredit using the Physiotherapy EvidenceDatabase (PEDro) scale. DataSynthesis: Data were synthesized bycategorizing the SORT levels ofevidence and summing the frequencyof each level of evidence (1 through3). We found that 86.4% (19/22) ofthe articles were not human subjectsand were scored as SORT Levels ofEvidence 3 and 13.6% (3/22) werescored 2. For the 22.7% (5/22) ofarticles that included human subjects,the PEDro score was 5±0 points.Conclusions: The militaryrecognizes the importance ofconcussion management andimplements current research intotheir management protocols. TheMilitary Acute ConcussionEvaluation was adapted from theStandardized Assessment ofConcussions and is used to diagnoseand help guide a safe return to duty.Neuropsychological batteries such asImPACT have been validated andimplemented in garrison and intheater. As opposed to in garrison,concussion management in theater iscomplicated by access to medicalresources, remote locations, andduration of missions. Athletictrainers’ understanding ofconcussion management andcoordination with military personnelmay positively impact the soldier’sstandard of care upon return fromtheater. Concussion management ingarrison needs continuedinvestigation and development whichmay be where athletic trainers canmake the greatest contribution.

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An Investigation Of ConcussionEducation Content AndEffectivenessHildenbrand KJ, Pietz KM;Washington State University,Pullman, WA

Context: Since 2009, bothWashington and Idaho have enactedconcussion laws requiring formaleducation of athletes and coaches. Ourprimary focus was to determine theeffectiveness of currently providededucation methods regardingconcussion knowledge withinWashington and Idaho high schools (9th

-12th grade). Objective: The proposedproject is designed to identify andassess effectiveness of the variety ofconcussion education instructionaldelivery methods currently used.Design: The study used contentanalysis to understand existingeducation methods, includingcomparisons between the content ofthe various identified methods. A pre-survey was administered to bothcoaches and student athletes prior todissemination of the currentconcussion education program utilizedby each school. Following the athleticseason a post-survey was conducted toassess retention of knowledge. Setting: Surveys were administered ina classroom or gymnasium locationduring both the pre-education surveyand post-season survey. Patients orOther Participants: Participantswere high school football and girls’soccer athletes and coaches fromWashington and Idaho. The schoolswere selected based on proximity tothe area, availability of an athletictrainer at the location and variousalumni connections. Fourteen highschools participated, including 14football programs and 6 soccer teams.Interventions: Surveys wereadministered in a paper and pencilformat by an athletic trainer or coach.The survey was based on a combinationof multiple existing surveys regardingconcussion knowledge. The survey

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was used to examine the currentlyprovided program from each school.Main Outcome Measures: Therewere several outcomes in this studyincluding (a) identify concussioneducation methods utilized to meetrequirements of the concussion laws,(b) detail current curriculum andconduct a literature search todetermine optimal instructionaldelivery, (c) statistically compare theimpact of methods of education, and(d) disseminate informationconcerning optimal concussioneducation interventions and methods.Results: The content analysis is on-going as fall sports seasons areconcluding. Initial results of pre-season surveys demonstrate thatstudent athletes still struggle withbasic concussion applicationquestions. Most students answeredincorrectly that LOC must occur for aconcussion to be present. Athletesalso struggled to answer correctlywhen an athlete should be removedfrom play, or allowed to return basedon initial symptoms. This survey wasbefore the education program wasadministered, so results will need tobe compared to post educationsurveys. Once the content analysis iscomplete comparing pre and postseason surveys, results will determineareas of weakness in currentlydelivered concussion knowledgeamong coaches and student athletes. Conclusions: Through assessingeffectiveness of current concussioneducation programs in Washington andIdaho, awareness of gaps in knowledgeand delivery methods is exposed.Results allow for development of aneffective concussion education modelto be established and promotedstatewide .

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A Content Analysis Of Trends InState Sport ConcussionManagement LegislationParsons JT, Mayfield RM, ValovichMcLeod TC: A.T. Still University,Mesa, AZ

Context: Since 2009, 40 states havepassed sport-concussion management(SCM) legislation. With the exceptionof NFL influence, most statutesreflect the nuances of local statepolitics. Therefore, little is knownabout the collective managementtrends emerging from these initiatives,nor is there a complete understandingof the impact of these statutes onathletic training (AT) practice.Objective: To identify the componentsof state SCM legislation and thefrequency with which they areimplemented. Design: A descriptive,content analytic study. Setting: Textof approved state SCM statutes.Patients or Other Participants: Thetext of all enacted state SCM statuteswas secured from state legislativewebsites. When necessary, secondarypolicy documents created by otherstated agencies and referred to by SCMstatutes were secured. DataCollection and Analysis: All textswere subjected to an inductive contentanalytic process based on anestablished coding scheme. Thisproduced 39 variables in six clustersrepresenting key statutorycomponents: 1) descriptives, 2)education, 3) patient management, 4)provider decision-making authority, 5)return-to-play (RTP) procedures, and6) liability protections. The leadauthor completed all coding, followinga coding scheme approved by an expertpanel, which also resolved codingproblems. Results: Descriptives:Thirty-nine states and D.C. (n=40;78.4%) passed SCM statutes; five(9.8%) are pending; 6(11.8%) havenone. Education variable cluster: All(n=40; 100%) require distribution ofconcussion education, but only24(47.1%) require focused trainingfor coaches; surprisingly, 8(15.7%)

states mandate AT training and 4(7.8%)physician training. Thirty-four(62.7%) require signed informedconsent before participation. Patientmanagement cluster: All (n=40;100%) require removal from play ifconcussion is suspected, but only14(27.5%) prohibit same-day return;no states require baselineneurocognitive testing, but 2(3.9%)require it post-injury. Providerdecision-making authority cluster:All (n=40; 100%) require clearancebefore RTP, and 9(17.6%) restrictclearance authority to physicians;17(33.3%) give clearance authorityto undefined “licensed health careproviders”, while 28(54.9%) requirethe provider to have “trainingin concussion evaluation andmanagement”; the most commonlyauthorized providers are physicians(n=40; 100%), ATs and physicianassistants (n=11; 21.6%), nursepractitioners (n=10; 19.6%)and neuropsychologists (n =7; 13.7%).Return to play cluster: Only 5(9.8%)and 8(15.7%) mention, but donot mandate, academic accommo-dation or graduated return-to-activity,respectively. Liability protectionscluster: 8(15.7%) provide immunity toschools, 7(13.7%) to schoolemployees, and 9 (17.6%) tovolunteer providers. Conclusions:This study reveals the rapidlyemerging policy trends in SCM.It finds an inconsistent, and sometimesinefficient, national legal framework.It also demonstrates a contradictorylegal standing for ATs whoare frequently authorized to makeclearance decision, but whoare sometimes required to receiveremedial concussion educationand training. Future researchmust incorporate regulatory andscope of practice analysis tomore accurately account forprovider clearance authorization.

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Free Communications, Oral Presentations: Patient Related Outcome,Correlation to Clinical or Lab MeasuresTuesday, June 25, 2013, 8:00AM-9:15AM; Palm D; Moderator:13F01MONEA Comparison Of Self-ReportedDisability And Dynamic PosturalControl Between Patients WithChronic Ankle Instability, AnkleCopers, And Healthy ControlsBoley HA, Carey SE, RullestadEA, Terada M, Quinlevan ME,Gribble PA: University of Toledo,Toledo, OH

Context: Diminished dynamic posturalcontrol assessed by the star excursionbalance test (SEBT) and decreasedself-reported function assessed by theFoot and Ankle Ability Measure(FAAM) and FAAM-sport has beendemonstrated in individuals withchronic ankle instability (CAI)compared to healthy controls.However, limited comparisons havebeen made between CAI patients andankle sprain copers who have sprainedtheir ankles but did not develop CAI.Additionally, it is unclear if there is acorrelation between the SEBT andFAAM measures. Understanding thedifferences between these measuresamong these groups may provideinsight into the consequence andinterventions for CAI. Objective: Tocompare SEBT performance, and self-reported disability among individualswith CAI, copers, and healthy controls;and to determine if there is acorrelation between the selectedoutcome measures. Design: Case-control study. Setting: Researchlaboratory. Patients or OtherParticipants: Fourteen ankle coperparticipants (7M,7F; 20.2±1.9yrs;168.7±9.5cm; 70.3±13.3kg), 9participants with CAI (4M,5F; 20.7±2.2yrs; 170.5±9.9cm; 76.1±15.6kg),and 8 healthy control participants (8F;20.6±1.1yrs; 162.9±4.1cm; 59.0±6.8kg) volunteered. Interventions:Participants completed the FAAM andFAAM-sport, and performed theanterior reach of the SEBT (A-SEBT).Main Outcomes: Three trials of the A-SEBT (cm) were reported as a

percentage of limb length (cm) of theparticipant (%MAXD). Scores on theFAAM and FAAM-Sport arerepresented as a percentage. Groupmeans and standard deviations of theA-SEBT trials, FAAM, and FAAM-Sport were used for analysis. Separateone-way ANOVA’s were used tocompare the group means and standarddeviations of the A-SEBT, FAAM, andFAAM-Sport. A Tukey’s post-hoc testwas applied in the event of statisticalsignificance. Pearson product momentcorrelations were used to determinethe relationship among dependentvariables. Significance was set a prioriat P<.05. Results: Significant groupdifferences were observed for%MAXD (F2,29=11.03, P<0.01),FAAM (F2,29=25.18, P<0.01), andFAAM-sport (F2,29=24.62, P<0.01)scores. For %MAXD, CAI patients(CAI=58.80%±6.05) performedworse than copers (67.79%±4.73,P<0.001) and controls (67.22%±2.47,P=0.03). For the FAAM, CAI scores(87.16%±5.61) were lower thancopers (97.77%±2.39, P<0.001) andcontrols (98.66%±3.78, P<0.001).For the FAAM-Sport, CAI scores(74.63%±8.17) were lower thancopers (93.08%±7.27, P<0.001) andcontrols (97.65%±6.62, P<0.001).%MAXD was significantly andmoderately correlated with the FAAM(r=0.50, P<0.01) and FAAM-sport(r=0.44, P<0.01). Conclusion:Participants with CAI demonstrateddecreased dynamic postural control onthe A-SEBT and increased self-reported disability compared to copersand healthy controls. Furthermore, weobserved a moderate correlationbetween self-reported disabilitymeasures and anterior reach of theSEBT, suggesting that participants withlower perceived ankle function mayexhibit less dynamic postural control.Future research should identify themechanism by which copers are ableto retain these higher levels of

function compared to patients withCAI. This project was supported by aNATAREF Osternig Masters Grant.

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13309UONERelationship BetweenFunctional Hop Tests AndPatient-Orientated OutcomesAfter Anterior CruciateLigament ReconstructionVeasley SJ, Martinez JC, BellDR, Pennuto AP, Meyer J, Rubino T, Soontararak M, TrojianTH, Joseph MF, DiStefano LJ:University of Connecticut, Storrs,CT, and University of Wisconsin,Madison, WI

Context: Individuals following ananterior cruciate ligament (ACL)reconstruction have a high risk of re-injury and problems with activities ofdaily living. Functional performancemeasures, such as the unilateral single-hop test, are frequently used in return-to-play decisions after ACLreconstructions. Minimal research hasbeen done to evaluate if hop tests arerelated to an individual’s pain andability to perform normal activities ofdaily living. Objective: To evaluate ifunilateral single-hop and triple-hoptests are associated with patient-oriented outcomes and if the hop testscan discriminate between injured anduninjured limbs. Design: Case SeriesSetting: Laboratory Patients orOther Participants: 52 participants(14 males, 38 females, age: 21±3,height: 170.9±7.0 cm, mass:71.5±11.9 kg) with a history of at leastone ACL reconstruction and currentlywithout any physical activityrestrictions in sports that involvecutting and landing volunteered toparticipate. Interventions: Partici-pants completed a baselinedemographic questionnaire and theInternational Knee DocumentationCommittee (IKDC 2000) question-naire prior to testing. Participantsperformed two trials of the unilateralsingle-hop for distance followed bythe unilateral triple-hop for distanceon both injured and uninjured limbs.Main Outcome Measures: TheIKDC is a valid patient-orientedoutcomes questionnaire to evaluate

ranging from 1.65-6.65. Participantsalso completed self-reportedmeasures of health including the Footand Ankle Ability Measure-Sport(FAAM-Sport), Tampa Scale ofKinesiophobia-11 (TSK-11), andDisablement in the Physically ActiveScale (DPA). The self-reportednumber of previous ankle sprains(PAS) and episodes of giving way(EGW) in the past three months werealso recorded. Main OutcomeMeasures: Lower SWM detectionthresholds represented greatersensitivity while higher FAAM-Sport,lower TSK-11, and lower DPA scoresrepresented greater levels of self-reported health. Five separate PearsonProduct Moment correlations (r) wereperformed and squared (r2) todetermine the relationship betweenplantar cutaneous sensation andmeasures of self-reported health, PAS,and EGW. Descriptive statistics werereported as mean±standard deviation.Alpha level was set a priori at p<0.05for all analyses. Results: There was asignificant correlation between SWMdetection threshold (4.3±0.2) and PAS(5.9±4.1,r=0.66,r2=0.44,p=0.03).There were no significant correlationsbetween SWM detection threshold andthe TSK-11 (18.8±4.9, r=0.50,r2=0.25,p=0.14), the DPA (13.6±5.5,r=0.34,r2=0.12,p=0.33), the FAAM-Sport (24.3±14.6, r=-0.13, r2= 0.02,p=0.72), or EGW (8.1±8.1, r=-0.35,r2=0.12,p=0.32). Conclusions:Individuals with CAI reporting agreater number of PAS exhibitedhigher SWM detection thresholdsindicating decreased sensitivity.Although plantar sensation was notsignificantly correlated to measures ofself-reported health, SWM detectionthreshold did explain 25% of thevariance in TSK-11 scores. Thissuggests the relationship betweenplantar sensation and kinesiophobiawarrants further investigation.

13418MONECorrelation Between PlantarCutaneous Sensation And Self-Reported Health In IndividualsWith Chronic Ankle InstabilityPowden CJ, Houston MN, PowellMP, Hoch MC: Old DominionUniversity, Norfolk, VA

Context: Individuals with chronicankle instability (CAI) havedemonstrated decreased sensation onthe plantar aspect of the foot comparedto healthy individuals. It is unclear ifthis sensory deficit is related todecrements in self-reported measuresof health or the injury characteristicsoften used to quantify the magnitudeof CAI. Objective: To determine ifplantar cutaneous sensation iscorrelated to self-reported measuresof health or injury characteristics inindividuals with CAI. Design:Correlational investigation. Setting:Laboratory. Participants or otherParticipants: Ten participants with CAI(2 male, 8 female, age=22.5±2.9years,height=171.6±10.1cm, weight= 71.4±13.2kg) were included. Inclusioncriteria consisted of a history of oneor more ankle sprains, two or moreepisodes of giving way in the previousthree months, and answering “yes” tofive or more questions on the AnkleInstability Instrument. Interventions:Participants reported to the laboratoryfor a single session. Sensation wasassessed using Semmes-WeinsteinMonofilaments (SWM) on three sitesof the plantar surface (heel, base of the5th metatarsal, head of the1stmetatarsal). SWM were appliedperpendicular to the skin for 1-2seconds. Based on the participant’sperceptual response, a heavier orlighter weight SWM was applied forthe subsequent stimulus. An adaptedstaircase algorithm determined thelightest weight SWM which could beidentified, representing the detectionthreshold. The detection thresholdfrom all three sites was averaged foreach participant and used for analysis.SWM are reported as an index value

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13270DOBIThere Is No RelationshipBetween Dynamic Balance AndKnee Health Related Quality OfLife In ACL ReconstructedPatientsPennuto AP, Stiffler MR, SmithMD, DiStefano LJ, Martinez JC,Bell DR: University of Wisconsin-Madison, Madison, WI, andUniversity of Connecticut, Storrs,CT

Context: Knee health related qualityof life (HRQOL) is an importantindicator of recovery after severe kneeinjury such as rupture to the AnteriorCruciate Ligament (ACL). Clinicalassessments of dynamic balance areoften used during the rehabilitationprocess and to assist with return tosport decision making. However, therelationship between dynamic balanceand knee HRQOL has not beenexamined. Objective: To determine ifdynamic balance is related to kneeHRQOL and if dynamic balance differsbetween reconstructed and healthylimbs. Design: Cross-sectional.Setting: Laboratory. Patients orOther Participants: Forty-ninepatients with a history of unilateralACL reconstruction volunteered toparticipate (14 males, 35 females,Height: 170.9±6.9cm, Mass:75.2±23.8kg, Age: 20.7±2.9yrs,Average time from surgery=45months). Patients were cleared toreturn to activity from their personalphysician. Interventions: Dynamicbalance was assessed via the starexcursion balance test in threedirections: anterior (ANT),posteromedial (PM), and posterol-ateral (PL). All individuals completed4 practice and 3 recorded trials on thehealthy and reconstructed limbs.Subjects were instructed to reach asfar as possible whilst keeping theirhands on their hips. Patients alsocompleted a knee HRQOLquestionnaire (IKDC 2000 SubjectiveForm). Main Outcome Measures:Reach distances were measured in

patients’ pain, symptoms, and functionof the knee post-surgically. The 2 trialsfrom each jump were averagedtogether and normalized for bodyheight. An asymmetry index wascreated for both hop tests (injured/uninjured). Pearson correlationcoefficients were calculated toevaluate the relationship between hoptest performance (single-hop, triple-hop, single-hop index, triple-hopindex) and IKDC score. Paired t-testsevaluated the difference betweeninjured and uninjured limbperformance on the hop tests.Results: Neither hop test variable wassignificantly correlated with IKDCscore (Mean±SD: 84.07± 10.85)(P>0.05). Both hop tests were able todetect differences between injured anduninjured limbs (Single-hop:Injured=0.88±0.15 % Body Height(BW), Uninjured =0.92 ±0.16%BH,P=0.004; Triple-hop: Injured=2.61±0.59%BH, Uninjured =2.74±0.49%BH, P=0.02). Conclusion:Individuals after an ACLreconstruction continue todemonstrate deficits in functional hopperformance after they havecompleted rehabilitation and areparticipating fully in physical activity.However, performance on functionalhop tests does not appear to be aneffective tool to measure current kneefunction and pain. Clinicians shouldevaluate both patient-orientedoutcomes and functional performance.

centimeters (cm) and normalized toleg length (%) in each direction. Acomposite score (CS) for each limbwas also calculated by adding reachdistances in each direction anddividing by three times the limb length.Relationships were examined bycalculating pearson correlationcoefficients between IKDC scoresand SEBT composite scores andindividual reach measurements. Pairedt-tests were used to examine reachdistances between healthy andreconstructed limbs (P<.05). Results:No significant relationships wereobserved between IKDC score andreach distances in the reconstructedlimb (ANT: 81.8±20.4%, r = -0.18,P=0.21; PM: 89.5±14.3%, r = -0.07,P=0.61; PL: 86.4±17.3%, r = -0.03,P=0.83; CS: 85.9±15.6%, r = -0.11,P=0.44). However, the reconstructedlimb did have deficits in reach distancein the ANT direction (Injured:80.7±20.6%, Uninjured: 82.4±20.9%,t = -2.5, P=0.02). All other findingswere not significant (P>0.05).Conclusions: Deficits in dynamicbalance exist after ACL reconstruction.However, there is no relationshipbetween dynamic balance and kneeHRQOL in individuals with ACLreconstruction. Clinical assessmentsof dynamic balance may still holdpromise for assisting with return tosport but may not be a good indicatorof knee HRQOL. Additional researchis needed to develop theserelationships. Studies should examinethese variables in reconstructedindividuals at similar time framesfollowing surgery and after their returnto activity. Supported by the UWSports Medicine Foundation.

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responses (p< 0.05) in SANE andIKDC was assessed by repeatedmeasures ANOVA (RM-ANOVA).MCID was calculated for SANE usingknown IKDC MCID values as ananchor. Logistic regression modelsusing improved status as the dependentvariable and change from baseline ofSANE as the independent variablewere developed. MCID for SANE ateach time point was the value thatmaximized the sensitivity andspecificity of the receiver operatingcharacteristic (ROC) curve from thelogistic model. Results: Moderate tostrong correlations were seen betweenSANE and IKDC (0.65-0.83). SANE,on average, was 2.7 (95% CI: 1.5, 3.9;p-value < 0.001) units greater thanIKDC over all time points. At baseline(p=0.005), 3 months (p=0.010), and12 months (p=0.031) SANE wasstatistically significantly higher thanIKDC. The MCID for SANE at 6months was calculated to be 7 (sn89.7%, spc 67.9%). The MCID forSANE at 12 months was calculated tobe 19 (sn 87.4%, spc 72.5).Conclusions: SANE and IKDC scoreswere strongly correlated across alltime points from pre-injury to 12month follow-up. The ability tocalculate the MCID gives addedmeaning to the SANE score and allowsfor greater clinical application for arange of knee injuries. Providingclinicians with patient-orientedoutcome measures that can beobtained with little clinician and patientburden may allow for greateracceptance and use of outcomemeasures in clinical settings.

13264FOINComparison Of IKDC AndSANE Outcome MeasuresAnd Establishing MCIDFollowing Knee Injury InActive FemalesWinterstein AP, McGuine TA,Hetzel SJ, Carr KE: University ofWisconsin-Madison, Madison, WI

Context: Knee injury among youngactive females remains a pressingpublic health issue. Clinicians arebeing called upon to pay greaterattention to patient-orientedoutcomes to better evaluate the impactof these knee injuries. Little agreementexists on which outcome measures arebest and clinicians cite several barriersto their clinical use. SingleAssessment Numerical Evaluation(SANE) may provide meaningfuloutcome information while lesseningthe time burden associated with otherpatientoriented knee measures.Objective: The purposes of this studywere to determine the correlationbetween a SANE assessment and the2000 International KneeDocumentation Committee (IKDC)questionnaire and to determine theminimal clinically importantdifference (MCID) for the SANEscore in a population of active youngfemales following knee injury frompre-injury through one year follow-up.Design: Observational prospectivecohort. Setting: Data were collectedat a sports medicine clinic anduniversity health service. Participants:A convenience sample of 263 highschool and college females (age = 17.8±1.6 years) who were diagnosed by aphysician with a knee injury that was aresult of participation in sport orregular fitness activities.Interventions: Knee function wasassessed using IKDC and SANE at pre-injury, by recall, at diagnosis, 3, 6, and12 months post-injury. Main OutcomeMeasures: Pearson’s correlationcoefficients (95%CI) were calculatedto assess relationship and strength ofassociation. Comparison of mean

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Free Communications, Oral Presentations: Stumped: Differential Diagnosis inAthletic Training (Case Studies)Tuesday, June 25, 2013, 9:30AM-10:45AM; Palm D; Moderator:13035MCMorel-Lavallee Lesion In A MaleHigh School Soccer PlayerYounger R, Mazoué C, Pollack M:University of South Carolina,Columbia, SC

Background: A male, 18 year old, highschool soccer player presented withedema over the VMO and jointstiffness of the right knee. Additionalsymptoms included a description offeeling a ‘weight’ on the knee with aburning sensation when in contact withfabric. The patient reported amechanism of the right knee slidingwith anterior medial contact on theground, causing a sheering forcebetween the dermal layers andunderlying structures. The patientreported a feeling that the patella wasstationary in contact with the groundwhile the medial tibiofemoral jointcontinued. Two initial evaluations at thetime of the MOI, by differentphysicians found a structurally soundknee examination and no reason tocease activity. The patient continued toplay for the 4-month period beforeseeing the current primary physician.Upon evaluation, the physician againfound a structurally sound knee withminimal tenderness over thequadriceps tendon and pes anserineburse with edema over the VMO area.Differential Diagnosis: Differentialdiagnoses were a ruptured bursa withnerve damage, bone contusion,quadriceps tendonitis, and pes anserinebursitis. Treatment: X-rays werenegative and the patient was treated withan injection into the pes anserine bursaof lidocaine and dexamethason. Followup care instructions included the useof GameReady, Voltaren creame, aDonJoy reaction knee brace andphysical therapy. During the firstphysical therapy session, the edemasignificantly increased. Drainage of 30cc of serous fluid were aspirated fromthe VMO area and sclerosing agentswere injected, followed again by the

use of a GameReady. An increase inthe effusion presented six days later.Blood-tinged joint fluid was removedand an MRI was ordered.The MRIrevealed subtle marrow edema at themedial femoral condyle with no jointeffusion. A large fluid collection,termed a Morel-Lavellee lesion(MLL), in the anteromedial softtissues peripheral to the medialretinaculum measuring 10 cm inlength in a crescent configuration wasfound. Surgery was performed withinthe following month. A fibrousmembrane measuring 15 cm proximal/distal, 8 cm medial/lateral wasremoved, the area was irrigated withbacitracin-impregnated saline, aWound VAC on continuous suctionand knee immobilizer were put inplace. Six days later an irrigation anddebridement with the delayed primaryclosure and removal of the WoundVAC took place. The patient was givena Kneehab XP and remained in theknee immobilizer for another fourweeks. The patient continues withrehabilitation and treatmentmaintenance. Reappearance ofsymptoms have been controlled withinthe past month and progression toreturn to play has begun. Uniqueness:MLL, is simply defined as a closeddegloving injury caused by a shearingforce to the skin. Pseudocysts format the site, causing reoccurring fluidaccumulation consisting of blood,lymph, and necrotic fat. It commonlyoccurs in the greater trochanter, lowerback and gluteal regions due to theirgreater propensity to shearing forces.It is very rare for a MLL to occur inthe knee/quadriceps region. Due to theseparation of the dermal layers andsubcutaneous tissue from theunderlying fascia, proper healing andpreventing reoccurrence is difficult.Conclusions: A MLL of the knee is arare injury. Due to the infrequency,recognition is challenging for allhealth care providers. Size and

location help differ MLL from a bursainjury. As an athletic trainer,witnessing the shearing mechanism ofinjury and, recognizing the primarysymptom of recurrent edemaassociated with a MLL may prevent apatient from progressing to surgery.Gradual progression in exercises andreturn to play are needed to prevent thereoccurrence of fluid accumulationduring conservative treatment as wellas after surgical removal.

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13115FCA Case Of Benign ParoxysmalPositional Vertigo In A HighSchool Football AthleteSnyder MM, Barry KE, WilliamsKN, Millward MJ: AshlandUniversity, Ashland, OH; OhioUniversity, Athens, OH; AustinPeay State University, Clarksville,TN; MedCental Health System,Shelby, OH

Background: An 18 year old malehigh school football centerexperienced benign paroxysmalpositional vertigo (BPPV) duringsummer football camp and through thehigh school football season. The firstepisode occurred during football campin the summer. The patient wasoriginally seen by his family physicianwho diagnosed him with BPPV. Carewas transferred to the athletic trainerworking with his high school footballteam. Symptoms included severenystagmus, nausea, migraines anddizziness. Patient had a positive Dix-Hallpike maneuver test. Dix-Hallpikemaneuver test involves moving thepatient from an upright position to asupine position with the head at 45degrees rotation in cervical extension.Torsional upbeating nystagmusindicates a positive test. DifferentialDiagnosis: Concussion, tinnitus,central nervous system disease,vestibular neuritis, motion sickness,vestibular migraines, or méniére’sdisease No diagnostic imaging wasperformed. Treatment: BPPV wasdiagnosed based on the patient’ssymptoms and positive Dix-Hallpikemaneuver test. Treatments included theEpley maneuver and Semont maneuver.The maneuvers were performed on thesidelines, the athletic training room orin a doctor’s office. Both treatmentsinvolved displacing the patients headin order to dislodge the otholiths(calcium crystals lodged in thesemicircular canals) to allow theendolymph (fluid of the inner ear)movement in order to establish theequilibrium of the athlete. The Epleymaneuver was performed by turning

the head of the patient to the affectedside and placing the neck in as muchcervical extension as possible. Theathletic trainer waited for thenystagmus to stop then rotate the headto the opposite side, waiting fornystagmus to subside and then rotatethe athlete to their side. After twominutes, the patient sat up in normalposition. The Semont maneuver wasexecuted if the episode continued. TheSemont maneuver was performed byturning the patient to the unaffectedside and putting the patient in a proneposition until the nystagmus subsides.When the nystagmus subsided thepatient was then forcefully thrown tothe opposite end of the table to asupine position. This process wasrepeated twice and the patient was thenreturned to a sitting position. If neitherof these treatments worked, the patientwas not allowed to compete untilsymptoms subsided. Many times theEpley maneuver resolved thesymptoms. However, occasionallyboth treatments were used andunsuccessful. Signs and symptomssubsided one week after footballconcluded. He is currentlyparticipating in football at thecollegiate level with no recurrence ofsymptoms. Uniqueness: In about 50-70% of BPPV no specific cause isfound. The incidence’s of BPPVoccurring in males and in a populationunder 55 is rare. Mean age of patientssuffering from BPPV has beenreported as 51-57.2 years. This patienthad no true onset or triggers for hisepisodes. The onset of symptomsoccurred on the bus, after a hit to thehelmet, or upon standing. There weredays that he did not have any symptomsand days when he couldn’t functionbecause the symptoms were severe.Conclusions: A high school playerexperienced vertigo and was able tocontinue playing football. The Epleyand Semont maneuvers wereperformed to treat the patient. Vertigois believed to be an older adult illnessleading to the lack of knowledge in theathletic population. Several factors can

be overlooked with an injury like thisbecause of its uniqueness and lack ofawareness in our field. Even thoughthe injury is not life threatening, it is aserious condition of the inner ear andimmediate treatment is crucial toprevent the condition from gettingworse.

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13192SCKienböck’s Disease In ACollegiate Softball Player: ACase ReportBenson SB, Norte GE, Ristic S:State University of New York atNew Paltz, New Paltz, NY; St.Anne’s-Belfield School,Charlottesville, VA; Universityof Virginia, Charlottesville, VA;Orthopedic Associates ofDutchess County, Poughkeepsie,NY

Background: A 20 year-oldcollegiate softball pitcher presentedwith diffuse, intermittent pain in hernon-dominant wrist during pre-season,which she explained had occurred forone year at the collegiate level and fouryears prior. Pain varied with asystematic progression noted duringpre-season training. The athlete notedpain on physical examination withactive wrist extension and flexion andlocalized tenderness to palpation overthe dorsal and volar radiocarpal joint.Symptoms appeared to be idiopathic,as the athlete denied history of traumaor known mechanism of injury. Theathlete had a history of type I diabetes.Differential Diagnosis: Extensortenosynovitis, scapholunate instability,lunotriquetral instability, triangularfibrocartilage complex tear, scaphoidfracture, Kienböck’s disease, ganglioncyst, pisiform pathology, avascularnecrosis of the capitate, and posteriorinterosseous nerve compressionsyndrome were considered.Treatment: The athlete’s painresponded positively to a conservativeregimen of bracing and strengtheningfor one year and was able to maintainfull sport participation. Pain increasedduring the following fall off-seasontraining, and she was subsequentlyreferred to an orthopedic handspecialist. Plain film radiographs andMRI revealed avascular necrosis of thelunate (Stage II Kienböck’s disease).Repeat radiographs following 6 weeksof conservative management(immobilization) revealed no changein bone healing, and pain persisted;

therefore, a radial osteotomy toreduce pressure on the lunate wasperformed. Surgery was postponed for6 months due to the athlete’s inabilityto control her blood glucose levels.Upon clearance from her treatingendocrinologist, pre-surgeryradiographs demonstrated Stage IIIprogression with beginning stages oflunate collapse. At this time, a 2 mmradial shortening osteotomy wasperformed, 7 months after the initialorthopedic examination. The athletewas immobilized immediatelyfollowing surgery for 6 weeks andunderwent a subsequent 6-week boutof physical therapy to restore range ofmotion at the wrist. She is currently 6months post surgery, and pain free withfull active range of motion, but hasbeen advised to cease competitivesoftball due to the progressivedegeneration of the disease.Uniqueness: Kienböck’s disease ismost commonly found in malepatients ages 20-40 years, with malestwice as likely to develop the disease.The etiology is unknown, but is oftenassociated with repetitive microtraumaand commonly found in manualworkers. Kienböck’s disease has beenreported infrequently in the adolescentathletic population, but has been seenin those with prior trauma or repetitivestress, such as weight bearing ingymnastics. This case involves anathlete’s non-dominant wrist, with nohistory of trauma, but moderaterepetitive stresses from utilizing theipsilateral hand to catch in softball.Additionally, the athlete had advancedstages of the disease, but did notdemonstrate the normal progressionof loss of flexion and extension, norsteadily increasing pain, which madethis case particularly difficult todetect promptly. Prognosis is likelytime dependent, and the delay ofsurgical intervention due to poormanagement of her type I diabetes mayhave contributed to the allowedprogression of the disease.Conclusions: Younger patients withKienböck’s disease yield positive

outcomes from surgical interventionif detected early. As the diseaseprogresses, individuals are moresusceptible to irreversible arthriticdamage, which may yield long-termdisability. Early detection and referralis essential in reducing the sequelaeof injury associated with Kienböck’sdisease, and its presence should beconsidered in the differentialdiagnosis of individuals presentingwith increasing chronic wrist pain.

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13280FCPaget-Schrotter Syndrome InA Collegiate Volleyball Player:A Case StudyNakajima MA, Brandt MS,Johnson KM: California StateUniversity, Long Beach, LongBeach, CA

Background: A 20-year-old Division Imale volleyball player presented witha swollen, discolored right arm thatwas cold to touch before a fall pre-season training session. He had noprevious upper extremity injuries, andthere were no family history ofvascular disease. The athletic trainerperformed shoulder and upperextremity evaluations and no structuraldamage was noted. He then proceededwith clinical tests to determinethoracic outlet syndrome (TOS) whichwere positive. Differential Diagnosis:Neurologic thoracic outlet syndrome(nTOS); venous thoracic outletsyndrome (vTOS) otherwise known asPaget-Schrotte Syndrome (PSS);arterial thoracic outlet syndrome(aTOS); deep vein thrombosis (DVT);brachial plexus injury, thoracicdiscogenic pain dyndrome, cervicaldiscogenic pain syndrome. Treatment:Athlete was referred to the teamphysician, who ordered diagnosticimages to confirm TOS. Initialultrasound (12/7/11) was inconclusivefor TOS. Follow-up MRI (12/13/11)and MRA (12/14/11) was performedof the right shoulder, which showedDVT in the right subclavian vein. Theday after the test, a thrombolysis wasperformed (12/15/11). Athlete wasgiven clearance to return to activitywhen spring season practice started,which was two weeks post procedure.After one week of practice, symptomsstarted to return in the athlete’s rightarm accompanied with pain (1/5/12).This time, athlete was referred to avascular surgeon, who ordered anotherMRA (1/13/12) and a CT scan (2/27/12) of the right shoulder and the chest.The athletic trainers worked with theathlete in effort to relieve the external

pressure caused by the tightmusculature surrounding the vein.Myofascial release, massage,stretching, and postural rehabilitationto correct the rounded shoulder wereperformed. When symptoms did notimprove, athlete was seen by anothervascular surgeon who recommendedsurgical intervention. (4/18/12).During surgery (5/3/12), it was notedthat subclavius and middle scalene washypertrophied two-times the normalsize, and the anterior scalene musclewas three-times the normal size.Therefore, subtotal resection ofsubclavius, anterior, and middlescalene muscles were performed,along with resection of the first rib onthe athlete’s right side through theaxilla. Two weeks post-surgery,athlete was given clearance to beginrehabilitation without restrictions. Avenogram procedure was performedtwo weeks post-surgery (5/23/12) andfindings showed normal blood flowrestoration. The athlete was givenclearance to begin volleyball activityonce strength and range of motion wasbilaterally equal (6/6/12). Today,athlete is fully recovered andparticipating in NCAA Division I men’svolleyball team. Uniqueness:Approximately 95% of the cases ofTOS are called the neurologic type, inwhich the brachial plexus arecompressed by surrounding tissues.The PSS is a venous type TOS, in whichthe vein is obstructed causingspontaneous axillosubclavian veinthrombosis. It accounts forapproximately 3-4% of TOS. Theetiology is similar, in which both casesare seen in patients who participate inexcessive upper extremity activitieswith prolonged hyperabduction andexternal rotation of the shoulder.However, in PSS patients, the straincauses microtraumatization of thevenous intima that result in localcoagulation and formation of venousthrombosis. It is not know why certainindividuals develop one form of TOSover another. Conclusions: Although

rare, PSS should be considered in thedifferential diagnosis for upperextremity conditions. Early correctdiagnosis and prompt care is crucialto the speedy recovery of the patient.Although rare, incidence of pulmonaryembolism associated with PSS hasbeen reported in as high as 30% of thecases. Athletic trainers shouldfamiliarize themselves with thedifferent TOS conditions, as well astreatment options for each of the threeconditions. For PSS, thrombolysisfollowed by 1st rib resection seems tobe the standard of care for PSS andacute subclavian vein thrombosis.

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13340SCKlippel-Feil Deformity In A HighSchool Football PlayerIannetta T, Smith J: ClevelandClinic, Cleveland, OH

Background: This is a 16 year-olddefensive back playing football whopresented to the athletic training roomthe morning following the previousnight’s football game. His chiefcomplaint was bilateral neck andtrapezius pain with left being greaterthan right. He admitted that he may havesustained a “stinger” in the game whilemaking a tackle which he did not reportto the medical staff. Physical exam bythe ATC demonstrated full cervical andshoulder active range of motion withno radicular symptoms bilaterally.Negative Spurlings and brachial plexustest. Cervical and shoulder strength 5/5. Treatment consisted of rest, ice,gentle range of motion and flexibilityexercises. The athlete completed theremainder of the season with noreported reoccurrence. Uponcompletion of the football season, hereturned to the athletic training roomcomplaining of pain at the base of hisneck and a headache after performinga military press and bench press duringa weight training class. He denied anyradiating pain at this time. The athletewas referred for further evaluation anddiagnostic testing. DifferentialDiagnosis: Cervical sprain, cervicalstrain, brachial plexus lesion, cervicalfacet syndrome, herniated cervicaldisc, concussion, exertional headache,Klippel-Feil deformity. Treatment:Physician workup for concussion-likesymptoms was negative. Evaluationshowed mild suboccipital tenderness,no midline cervical tenderness, andfull cervical range of motion with painupon flexion, left lateral side bend androtation. Upper extremity strength was5/5 and symmetric. Reflexes weresymmetric at biceps, triceps andbrachioradialis. No sensory loss in theupper extremities. Negative Spurlingsmaneuver. X-rays were ordered andshowed rudimentary C6-C7 disc space

with fusion of C6-C7, unfused C7spinous process, pseudosubluxation atC3-C4, C4-C5, C5-C6. A MRI wasalso ordered and results were fusionof the C6-C7 vertebral bodies with arudimentary intervening vertebral disc.The right lamina of C7 is deficient.Partial fusion of the left C6-C7 laminaand spinous process. The canal andneural foramina are widely patent fromC1-2 to C7-T1. The final workingdiagnosis is that of Klippel-Feildeformity. Recommendation to theathlete and his parents was todiscontinue football due to hiscongenital fusion. This would put himat a greater risk for a cervical spinalcord injury. The athlete was thenreferred to a spine specialist who hadthe same recommendations afterexamining and reviewing the athlete’sx-rays and MRI. Uniqueness: Brachialplexus injuries and cervical sprains andstrains are not uncommon in the sportof football. This athlete had a singlereported incident of a possiblebrachial plexus injury which resolvedquickly. However, other symptomswere reported after starting weighttraining which necessitated furtherevaluation. Although, these symptomscould have been something as commonas cervical strain or exertionalheadache other abnormalities neededto be ruled out. Klippel-Feil deformityis usually associated with otherdisorders such as defects in otherorgans including the inner ear, spinalcord, heart and genitourinary tract.This athlete did not present with anyof these defects. Conclusion: Thisathlete was unable to continuecollision sports such as football dueto the risk of a cervical spinal cordinjury. However, through rehabilitationto maintain his range of motion,flexibility and strength, he was allowedto play baseball. He had a verysuccessful season without any furtherexacerbation of his condition.

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Free Communications, Oral Presentations: Prehospital Care of the InjuredAthleteTuesday, June 25, 2013, 11:00AM-11:45AM; Palm D; Moderator: Julianne Schmidt, MA, ATC13368MOEMFacemask Removal OfCommonly Worn LacrosseHelmetsRyan C, Paden A, Tierney RT,Bright N, Higgins M: TempleUniversity, Philadelphia, PA, andTowson University, Towson, MD

Context: In the event of a head or neckinjury in equipment-laden sports, it hasbeen recommended to remove thefacemask rather than the entire helmetfor access to the airway. Researchsurrounding facemask removal,however, has focused primarily onfootball helmets, which arestructurally different than lacrossehelmets. To date, there has beenlimited published research regardingmen’s lacrosse helmet facemaskremoval. Objective: To determine theeffect of lacrosse helmet type onfacemask removal time and rate ofperceived exertion (RPE). Design: Asingle factor repeated measure design.Setting: Controlled laboratorysetting. Participants: Eight certifiedathletic trainers (male = 4, female =4; age = 24.13 ± 2.17 yr, experience =1.75 ± .71 yr). No exclusionary criteriaexisted. Interventions: Each subjectparticipated in a familiarizationsession and testing session for eachhelmet. The familiarization sessionconsisted of watching a videodemonstrating the removal techniquefollowed by two successful facemaskremovals for each helmet. Within aweek, each subject returned for atesting session in which theyparticipated in a timed facemaskremoval and reported the RPEafterwards. All facemasks wererequired to be removed within a four-minute time limit to be consideredsuccessful. The independent variablewas helmet type (Warrior Venom(WV), Cascade CPX-R (CC), CascadePro7 (CP), and Riddell Revolution(RR)). Main Outcome Measures:The dependent variables were facemaskremoval time (seconds) and RPE

(Borg Scale 0-10). Two one-way (1x4)repeated measures analyses ofvariance (ANOVA) and paired samplest-tests were used to analyze significantdifferences (p < .05) in removal timeand RPE between helmet types.Results: The ANOVAs revealedstatistically significant differences forremoval time, F(3,21) = 43.22, p <.001, and RPE, F(3,21) = 6.96, p =.002. The CP (63.3 sec) facemask took61%, 93%, and 108% longer to removethan the WV (39.3 sec; p = .001), CC(32.7 sec; p = .001), and RR (30.5 sec;p = .001), respectively. The WVfacemask took 29% longer to removecompared with the RR (p = .002). Theparticipants found the CP (3.4) to be59%, 100%, and 199% more difficultthan the WV (2.1; p = .049), RR (1.7;p = .022), and CC (1.1; p = .005),respectively. There were no otherstatistically significant differencesidentified. Conclusion: The CPfacemask was the most timeconsuming and difficult to removelikely due to having five removal sitesversus three removal sites on theremaining three helmets. All of thefacemasks, however, weresuccessfully removed well within thefour-minute time limit for removal.These data suggest that lacrossefacemask removal for these helmetsis a viable option for lacrosse athleteairway access.

13254OOEMThe Effects Of EquipmentDesign On Cervical SpineMotion, Removal Time, AndDifficulty During FootballShoulder Pad RemovalBric JD, Swartz EE, Al-DarrajiSJ, Decoster LC, Mihalik JP:University of New Hampshire,Durham, NH; New HampshireMusculoskeletal Institute,Manchester, NH; University ofNorth Carolina, Chapel Hill, NC

Context: Football equipment designscontinue to evolve, providing betterprotection for athletes participating incollision sports, including Americanfootball. Recent shoulder padequipment designs departconsiderably from the traditionalequipment many football athletictrainers (ATs) are familiar with. Theseevolutions may affect cervical spineinjury management, when ATs arerequired to intervene quickly and safelyto provide resuscitation and advancedcardiovascular care. Objective: Tocompare the amount of headmovement, time to task completion,and perceived difficulty during removalof traditional and quick-releaseshoulder pads. Design: Quasi-experimental. Setting: Researchlaboratory. Patients or OtherParticipants: Forty ATs free ofphysical pathology preventing themfrom completing the required taskswere recruited (males=21; females=19; age=33.7±11.2 yrs; mass=80.7±17.1 kg; height= 173.1±9.2 cm;AT experience =10.6±10.4 yrs).Interventions: The independentvariable was shoulder pad design(Traditional or Riddell RipKordTM).After familiarization, participantsworking in pairs conducted 8successful trials in random orderwhereby they removed traditional(using the flat torso technique) orRipKordTM shoulder pads from a livemodel (4 trials of each). An eight-camera three-dimensional motion

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system and two three-point segmentmarker sets (head and torso) were usedto capture head motion. Total time wasrecorded with a digital stopwatch. Thedifficulty for the task by the participantwas recorded after each trial using amodified Borg CR-10 scale. MainOutcome Measures: Dependentvariables included head excursion indegrees (computed by subtractingminimum position from maximumposition) in each of the three planes(sagittal, frontal, transverse) duringshoulder pad removal, time to taskcompletion, and difficulty rating.Trials for each team were ensembleaveraged. Paired-samples t-tests wereemployed to evaluate differencesbetween the two levels of ourindependent variable for eachdependent variable. Results: Athletictrainers required significantly lesstime to remove the RipKordTM

shoulder pads (21.96 ± 3.08 s) thantraditional shoulder pads (29.22 ± 4.45s) in our study (t

19 = 9.80; P<0.001).

There were no significant differencesin sagittal (t

19 = 1.63; P=0.119), frontal

(t19

= 0.80; P=0.435), or transverse (t19

= 1.10; P=0.285) cervical spinemotion resulting from shoulder padremoval between the two designs.There were no differences in difficultyreported by the ATs in removing thetwo shoulder pad designs (t

19 = -0.80;

P=0.435). Conclusions: Our datasuggest that the new RipKordTM designallows ATs to remove shoulder padsmore quickly, without compromisingcervical spine motion or introducingadditional difficulty to the task. Theseresults can only be generalized to theflat torso technique of shoulder padremoval at this time. Future researchshould examine the efficacy of suchshoulder pad designs in allowing foreffective access to the chest as wouldbe needed in cardiovascularemergencies. Incorporating theseequipment advances to other sportsshould be considered. This study wasfunded by the Eastern AthleticTrainers’ Association.

13007OOEMAthletic Training ServicesAssociated With EmergencyPreparedness & Planning In SCHigh School AthleticsWham GS, Saunders RP, MenschJW: University of South Carolina,Columbia, SC, and LexingtonSchool District 1, Lexington, SC

Context: Recent research suggestsSouth Carolina(SC) schools with ATservices provide higher levels ofmedical care; however, no research hasexamined the relationship between ATservices and components ofemergency planning/preparedness.Objective: To examine therelationship between existence of ATservices in a school and compliancewith recommendations for emergencyplanning/preparedness identified in theAppropriate Medical Care forSecondary School-aged Athlete(AMCSSAA) Consensus Statement/Monograph. Design: Cross-sectionalstudy. Setting: Mailed/emailedsurvey. Participants: 63% (166/263)of SC high schools. Intervention(s):SC high schools were surveyedregarding existence of ATservices(independent variable) andexistence of components ofappropriate medical care related toemergency planning/preparedness.After pilot-testing, data were collectedvia a systematic, modified-Dillmanapproach. Test-retest reliability wasstrong (r=.89). Main OutcomeMeasure(s): AMCSSAA Monographrecommendations related tocomponents of emergency planning/preparedness were identified,summarized, re-phrased as policies orpractices, and included as survey items.Items were scored 3, 2, 1, or 0 on a 4-point scale. Higher scores indicatedmore favorable provision of medicalcare. Each component served as adependent variable: Existence ofEmergency Action Plan(EEAP), EAPReviewed Annually(EAPRA), EAPReviewed Post-emergency(EAPRP),EAP Posted in Facilities(EAPPF),Coaches CPR/AED certified(CCAC),

Coaches First-aid certified(CFAC),Vacuum Splints Available(VSA), SpineBoard Available(SBA), Cervical CollarAvailable(CCA), Facemask RemovalDevice Available(FRDA), AEDAvailable(AEDA), CPR MaskAvailable(CPRMA), Shoulder SlingAvailable(SSA), Crutches Available(CA), Blood Pressure Cuff/Stethoscope Available(BPSA), Latex/nitrile Gloves Available(LNGA), IceBags Available(IBA), and First-aid KitAvailable(FAKA). SPSS was used tocalculate descriptive statistics andmultiple comparison tests. Results:Significant differences existedbetween schools with AT services andthose without AT services for thefollowing components of emergencyplanning/preparedness: EEAP [AT2.48(.78) and no AT 2.11(1.02),F=5.5,p<.02], EAPRA [AT 1.88(1.06) and noAT 1.46(1.09),F=4.27,p<.04], EAPRP[AT 1.85(1.03) and no AT 1.33(1.08),F=7.32,p<.01], VSA [AT2.13(1.05) and no AT .86(1.05),F=41.71,p<.0001], SBA [AT1.65(1.23) and No AT .70(.93),F=18.98,p<.001], CCA [AT 1.77(1.20)and No AT 1.04(.17), F=12.46,P<.001], FRDA [AT 2.51(.91)and No AT 1.75(1.25),F=16.83,P<.001], CPRMA [AT 2.54(.82) and NoAT 1.41(1.17),F=44.46,P<.001], SSA[AT 2.54(.82) and No AT.80(.98),F=25.57,P<.001], CA [AT2.59(.74) and No AT 1.54(1.23),F=41.39,P<.001], BPCSA [AT2.36(1.01) and No AT 1.18(1.24),F=35.41,P<.001], LNGA [AT 2.88(.37)and No AT 2.42(1.01), F=17.91,P<.001]. No significantdifferences were identified betweenschools with AT services and schoolswithout AT services for: CCAC, CFAC,EAPPF, AEDA, IIBA, and FAKA.Conclusions: In SC high schools,schools without AT services werefound to lack many componentsrequired to provide appropriatemedical care related to emergencyplanning/preparedness. These resultsprovide guidance for decision-makers(school administrators and

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legislators) and those who influencedecision-makers (parents and athletes)in improving medical care providedfor interscholastic athletes.

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Spine Evidence-Based ForumTuesday, June 25, 2013, 12:00PM-1:00PM, Palm D; Moderator:

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Free Communications, Oral Presentations: Emergent Conditions in Athletes(Case Study)Tuesday, June 25, 2013, 1:15PM-2:30PM; Palm D; Moderator:13080DCSRetrospective Clinical CaseSeries Of Sudden DeathDuring Physical Activity InThe Collegiate Setting:July 2011 – June 2012Adams WM, Pryor RR, PagnottaKD, Vandermark LW, Stearns RL,Casa DJ: Korey Stringer Institute;University of Connecticut, Storrs,CT

Background: We sought toinvestigate all cases of sudden deathduring National Collegiate AthleticAssociation (NCAA) sanctionedsporting events from July 1, 2011-June30, 2012. An online LexisNexis andsubsequent media search resulted infour student athletes, all of whom weremale (2 basketball players, 1 footballplayer, and 1 baseball player;Mean±SD: age=20±1y, height= 187±7cm, weight=97±15kg), who diedwhile participating in their respectivesport. A 22-year-old CaucasianDivision III football player (athlete A)collapsed during an August footballpractice while being escorted off thefield by the athletic training staff. Hewas complaining of a headache from ahelmet-to-helmet collision. A 21-year-old Division II African Americanbasketball player (athlete B) collapsedduring an early September men’sbasketball conditioning session andlater died at the hospital. A 19-year-old Division III African Americanbasketball player (athlete C) collapsedduring preseason basketball practicethat took place at the end of September.The fourth student athlete was aDivision I Caucasian baseball player(athlete D) who collapsed during anoffseason conditioning session in lateOctober, 2011 with seasonably warmtemperatures (high of 64°F) that day.Treatment: Athlete A was beingevaluated by one of the school’s staffathletic trainers and upon collapse wasrushed to the hospital where heunderwent emergency surgery to

relieve swelling in his brain. Coachesperformed cardiopulmonary resusci-tation (CPR) on athlete B before hewas rushed to the hospital. Athlete Ccollapsed after complaining of visionproblems and cramps. He was rushedto the hospital with an extremelyelevated body temperature. Afterathlete D collapsed, he was taken to alocal hospital where his core bodytemperature was initially recorded as105.9°F and peaked at 107.9°F. He wastreated for exertional heat stroke oncehe arrived at the hospital and latertreated for multi-organ failure.Throughout treatment, he had to beresuscitated five times and surgeonshad to remove his right lung. Results:Athlete A died due to complicationsfrom a traumatic brain injury. Thecause of death for athlete B remainsunknown but is speculated to be theresult of cardiac arrest. Lab resultswere positive for the chemical JWH-018 in athlete C, which is used to makesynthetic marijuana. He died four daysafter being admitted to the hospital.Official cause of death is listed as drugtoxicity due to the presence of thesynthetic chemical but it is speculatedthat the athlete either died of exertionalsickling or exertional heat stroke.Three days after being admitted to thehospital and treated for exertional heatstroke and the resulting multi-organfailure, athlete D died due to resultingcomplications. The official cause ofdeath is inconclusive but is speculatedto be from exertional heat stroke.Uniqueness: Of the four-presentedcases, three of the deaths occurredduring conditioning sessions prior tothe start of their NCAA sport season.None of the deaths occurred duringgame participation. Similar to previousresearch, the majority (or all) deathswere males, conversely, the deathswere evenly distributed betweenCaucasian and African Americanathletes. Conclusions: The four casesof death in the NCAA level from July

1, 2011-June 30, 2012 occurredduring the fall of 2011. Three of thefour deaths occurred during offseasonor preseason conditioning sessionswhere medical staff was not present (anathletic trainer was only present at thefootball practice of athlete A with nomedical coverage during theconditioning sessions of athletes B, C,and D). The health and safety ofcollegiate athletes during offseasonconditioning sessions should befurther investigated.

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13056OCSudden Collapse Of A MiddleSchool Baseball PlayerWilliams SJ, Kamp A: University ofKentucky Orthopaedic Surgeryand Sports Medicine andUniversity of Kentucky Departmentof Cardiology, Lexington, KY

Background: A 14 year old middleschool baseball player with nocontributory medical history suddenlycollapsed following 30 minutes ofdrills at high school baseballconditioning. He fell face first to theground and did not move. The athletictrainer was called. When she arrived,the athlete had agonal breathing.Carotid pulses were checked and theathletic trainer began cardiopulmonaryresuscitation (CPR). The coachesactivated the emergency action plan,calling 911 and getting the automatedexternal defibrillator (AED). Theathletic trainer administered CPR andused the AED during the 6 minutesbefore paramedics arrived. Thedefibrillation detected a rhythm ofventricular tachycardia. It is believedthat the patient did regain a pulse. EMSarrived shortly thereafter and thepatient was again in ventriculartachycardia and received two moredefibrillations. CPR administered bythe Lewis device was continued inprogress to the emergency departmentwhere the patient had a pulse intact.Differential Diagnosis: Hyper-trophic cardiomyopathy (HCM),myocarditis, catechol-aminergicpolymorphic ventricular tachycardia(CPVT), drug or supplement use,sudden cardiac arrest withindeterminate cause. Treatment:Once at the emergency department, theathlete continued to be in sinustachycardia with a good carotid pulse.EKG performed showed evidence ofnonspecific ST and T wave changes.His drug test was negative. He wasadmitted to Pediatric Cardiology in thePediatric Intensive Care Unit.Subsequent head CT was unremarkableand echocardiogram showed no HCMbut a decreased filling of the left

ventricle. The athlete was taken offintubation and awoke the next day. Hisrepeat EKG was normal sinus rhythmand no delta wave. On the third day, theathlete experienced some delirium andwas combative. He was unable to havea cardiac MRI performed due to hismental status. Daily EKGs werecontinued with no abnormalities.Electroencephalography (EEG) wasperformed and found to be normal. Theathlete was then transferred to theProgressive Care Unit (PCU). Afterthe cardiac MRI was performed, theresults were within normal limits. Itwas then recommended to have anepinephrine push to elicit CPVT.Cardiac catheterization was performedand coronary artery origins andcourses were normal. Endomyocardialbiopsy results were normal andadenosine administration demon-strated no evidence of Wolff-Parkinson-White syndrome. Follow-ing exhaustive testing that wasinconclusive, an implantablecardioverter-defibrillator (ICD) wasplaced to detect any future cardiacarrhythmia and to correct thearrhythmia with a shock. The athletewas discharged from the hospital 12days after collapse. Uniqueness: Theathlete had no personal or familialmedical history to predispose him toa cardiac event. Allowing patients withICDs to participate in sports has longbeen contra-indicated. Recentresearch is showing that athletes withICDs have no more risks during sportsthan patients who do not participate inmoderate activities. Conclusions: A14 year old athlete’s sudden collapseduring a low intensity workout isuncommon. Athletic trainers shouldunderstand how to first deal with asudden cardiac arrest, and alsounderstand the benefits and risksassociated with having an athlete whoparticipates in competitive sports withan ICD. Currently this athlete hasdecided to discontinue playingbaseball and has begun to play golf. Heis also involved in the ROTC programat his high school. Genetic testing was

completed and detected a mutatedabnormality in a gene with no knowncorrelation. It is unclear if a diagnosiswill ever be determined.

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13214MCSudden Myocardial Infarction InA 19-year-old Division I FootballLineman With No PriorIndicatorsWard BL, Hanley M, Lopez R:East Carolina University,Greenville, NC, and University ofSouth Florida, Tampa, FL

Background: In this case, a 19-year-old African American male footballplayer (6’7”, 326.8 lbs.) with nosignificant previous medical historyreported having chest pain associatedwith nausea, diaphoresis, shortness ofbreath, and a severe cough after awinter evening workout. The initialevaluation consisted of a standing/resting pulse, heart rate, andtemperature. The immediate diagnosiswas that the pain experienced waslikely attributed to extreme physicalexertion further aggravated by aprevious upper respiratory infection.The athlete denied any family historyof cardiac conditions. The athletictrainer instructed the athlete to go tohis dorm room to rest, and to call himimmediately should his symptomspersist, or if he experienced any painand/or numbness in his upperextremities. The athlete’s painfluctuated for about four hours, afterwhich he started having numbness inhis extremities and back pain. Theathlete subsequently drove himself tostudent health services, where he wasmet by the athletic trainer and drivento the hospital. DifferentialDiagnosis: Viral illness, exertionalsickling, hyperlipidemia, musclestrain, myocardial infarction, systemicdisease. Treatment: Upon arriving atthe emergency room, the athletereceived nitroglycerin sublingually,which relieved his pain completely.Testing revealed the athlete hadabnormally high cardiac enzymes,troponin’s (149.5), CK’s (3,410) andCK-MB (270.7). Also, the patient’sEKG on admission showed STelevation. A 2-D echocardiogramrevealed hypokinesis (50%-55%) withthe left anterior descending artery

(LAD) wall motion, resulting in adiagnosis of a myocardial infarction(MI). The athlete underwent a cardiaccatheterization where a thrombus wasdetected in the LAD with mild leftventricular systolic dysfunction; thiswas cleared using an AngioJet device,which left the athlete stable.Hematology was consulted forhypercoaguability workup, and theathlete was found to haveheterozygous Factor V Leidenabnormality (evidence of lupusanticoagulant), elevated serumhomocysteine level, hyper-triglyceridemia, low HDL, elevatedLDL, and elevated lipoprotein. Theathlete was hospitalized for three days.Following his initial hospital stay, theathlete was placed on anti-coagulantsand underwent an exercise Cardioliteat three months after his initial illness,a Multi-Gated Acquisition Scan(MUGA) at five months, and wasadministered a Holter Test at sixmonths, all of which were withoutsignificant abnormalities. Elevenmonths after the MI, the athlete had hisfinal hematology evaluation and thephysician believed the dyslipidemiaand homocysteinemia were resolved.The athletic training staff required asecond opinion, which concurred thatthe athlete could return to activity withall appropriate risk factors andsymptoms being monitored. Theathlete returned to competitivefootball and remained asymptomaticwhile under increased care for theremainder of his collegiate career.Presently the athlete is doing well withno complications, but is still onmedication for his condition.Uniqueness: To our knowledge, thereis no other report of a young, eliteAfrican-American male athlete havingFactor V Lieden and having sufferedan anterior ST elevation myocardialinfarction. This case was unique tocare for due to the lack of standardizedmanagement recommendations forathletic trainers. MI’s are rare in thisage group, especially with no clearetiology, and in an elite athlete who was

cleared to continue playingcompetitive football at the collegiatelevel. Conclusions: To better preparefor MI’s in young athletes, athletictrainers should pay careful attention tothe patient’s personal and familymedical histories with an anticipatorymindset in diagnosing anomalies notcommonly attributed to this age group.Although return to play guidelines forathletes with an MI should beindividualized, it is imperative forathletic trainers to be knowledgeableof the guidelines for athleticparticipation in order to reduce therisk of arrhythmia-related morbidityor mortality.

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13404SCBlunt Abdominal Injury In ACollegiate Male Lacrosse PlayerSesma AR, Rooks Y: University ofMaryland, College Park, MD

A twenty year-old male Division 1collegiate lacrosse player was hit inthe abdomen by a defensive player atthe beginning of practice but continuedto play for 90 minutes. He reportedto the ATC at the end of practice thathe was having rib pain from the hit andsome trouble breathing. On fieldassessment revealed tenderness overthe lower left ribs with no reboundtenderness over the abdomen. Ribcompression test was painful on theleft side. Upon further evaluation in theathletic training room he reportedsome pain with deep breathing and withforceful expiration. BP and pulse wereWNL. Kerr’s sign was inconclusivesecondary to labral repair surgery onhis left shoulder 1 year prior andreporting always feeling “achy” afterpractice. He was still point tender overthe left 8-10th ribs and had somerebound tenderness over the abdomen.Differential Diagnosis: Rib contusion,rib fracture, liver contusion orlaceration, spleen laceration or ruptureTreatment: He was monitored in theATR for 30 minutes and symptomswere unchanged. He was allowed togo home and he and his roommateswere instructed to call the ATC if hissymptoms worsened or if heexperienced any nausea, vomiting,dizziness, or increased difficultybreathing. About 1 hour later, hisroommates called and said he had beentrying to vomit and appeared to be pale.The athlete spoke with the ATC and saidhe felt extremely nauseous and hadincreased abdominal pain. He wasbrought to the ER within 15 minutes.A chest/abdominal x-ray was negativeand discharge from the ER wasconsidered, however upon an increasein symptoms an abdominal CT scanwas ordered and revealed a grade IIIlaceration of the spleen involving theanterior/inferior aspect with

surrounding hemorrhage. He wasadmitted to the ICU at 1 am. Around 9am, physicians met to discuss thepossibility of removing the spleen butdecided to continue to monitor hishemoglobin/hematocrit over 48-72hours. After 36 hours, he was movedout of the ICU and was discharged after72 hours with a stable hemodynamicstatus. The trauma surgeon instructedhim to rest completely for 4 weekswith follow-up CT scan at 6 weeks. At4 weeks he was allowed to start lightjogging and lifting. A CT scan at 6weeks showed ongoing resolution ofthe hematoma. He was cleared toreturn to all non-contact activityincluding stick drills and conditioning.An abdominal ultrasound wasperformed at 10 weeks post injury,which showed that the hematoma hadresolved completely. The athlete wasallowed to return to full contact drillsand competition with a specializedprotective abdominal shirt. He playedin his first collegiate game 10 dayslater and did not have any symptomsfor the remainder of the season.Uniqueness: There are no evidencebased return-to-play guidelinesregarding splenic injuries. A numberof case reports show return-to-play inas little as 3 weeks followingsplenectomy or 8-12 weeks followinglaceration in football or hockeyplayers but few cases involvinglacrosse players. Some literaturesuggests diagnostic ultrasound mayprovide a low cost and low radiationalternative to CT for serial monitoringof hematoma resolution. Conclusions:Early recognition of abdominalinjuries is vital. They may appear stablebut symptoms can worsen in a shortamount of time making it imperativeto give student-athletes and the peoplearound them detailed instructions.Given the limited informationavailable regarding return-to-playguidelines, decisions must be made ona case-by-case basis with carefulcollaboration by the sports medicineteam. Considerations include

equipment modification andappropriate monitoring of signs andsymptoms during activity progression.

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13024FCBlunt Trauma Carotid ArteryInjury Resulting In Death In ACollegiate Male LacrossePlayer: A Case ReportStavinski-Ciocco MM, Zawadzki-Brzoska A: King’s College, Wilkes-Barre, PA

Background: A 19 year old maledivision III collegiate lacrosse athletewas struck on the left lateral neck witha thrown lacrosse ball during practice.The patient had a whiplash likemechanism when struck and initiallycomplained that his “body went numb”and he fell to the ground in a seatedposition. He was able to walk off theplaying field and into the athletictraining room with the help of ateammate. At that time, the patientcomplained of pain with swallowing,trouble with swallowing, the taste ofblood in his mouth, headache,dizziness, nausea, fatigue, neck pain atthe site of impact and blurred vision.The patient’s neurological status wasevaluated and his cervical dermatomesand myotomes were normal at the timeof the exam, but the patientcomplained of intermittent decreasedsensation in his right arm and hand.The patient had a past medical historyof concussion and post- concussionsyndrome, but with no current issuesrelated to this. The patient wasbecoming increasingly confused as theevaluation continued. The patientpresented with concussion-like signsand symptoms. He was not orientedto time and place and had memorydeficits, not even being able torecognize his teammates or coach. Thepatient was sent to the EmergencyRoom (ER) and initially diagnosed witha concussion and sent home. Within24 hours, the patient suffered a strokeand was transported back to the ER forfurther evaluation. The patient wasthen diagnosed with a carotid arterydissection. He was referred to atrauma hospital where his symptomsprogressed to death within one week.Differential Diagnosis: Closed head

injury, basilar skull fracture, facialfracture, spinal fracture, seizure,vasovagal syncope, carotid arteryinjury, subarachnoid hemorrhage,cluster headaches, migraines, horner’ssyndrome, stroke, syncope, andcervicoephalic arterial dissections.Treatment: Referral to ER by theCertified Athletic Trainer (AT). Acomputed tomography (CT) scan ofthe head was performed at the ER andwas read as negative. Because of thepatient’s decreased neurological andmental status, and the normal readingof the head CT scan, a diagnosis ofconcussion was made. The patient wasthen released from the ER that sameevening. The patient suffered a strokethe following day and was re-admitted.A second CT was performed andshowed carotid artery dissection. Thecause of the stroke was a blood clotfrom the dissected area. The patientwas taken to a trauma hospital where astent was inserted to control theswelling. Increased swelling causedbrain stem herniation resulting inclinical brain death. The patient wasremoved from life support five dayspost injury and died shortly thereafter.Uniqueness: The patient presentedwith concussion-like signs andsymptoms and was initially sent homefrom the ER diagnosed with aconcussion. Within 24 hours, hesuffered a stroke resulting from a clotformed from a carotid arterydissection. The patient’s symptomswere exacerbated to death within 1week. Conclusions: A 19 year old maledivision III lacrosse player presentedwith concussion-like signs andsymptoms after being struck in theneck with a thrown lacrosse ball. Eventhough proper referral was made in thiscase, blunt carotid artery injuries canresult in death if unrecognized oruntreated in a timely manner by furtheradvanced personnel. Diagnosis is oftendelayed due to a failure to suspectserious injury caused by trauma or adelay in symptom manifestation,especially neurological deficits. Early

recognition of the exact mechanism ofinjury and subsequent symptoms,combined with accurate diagnosis andtreatment are the key to patientsurvival. ATs need to be aware of carotidartery injuries and their severity whichcan result in death.

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Free Communications, Oral Presentations: Assessment of the Throwing AthleteTuesday, June 25, 2013, 2:45PM-3:45PM; Palm D; Moderator: Steve Tucker, PhD, ATC

13006OODIReliability And Validity OfMusculoskeletal Ultrasound ForIdentification Of HumeroradialJoint Chondral LesionsLohman CM, Smith MP, DedrickGS, Jarman NF, Atkins LT, BrisméeJM: Texas Tech University HealthSciences Center, Lubbock, TX ;The Sage Colleges, Troy, NY;Campbell University, Buies Creek,NC

Context: Epicondylalgia is a commoncondition with pain generatingstructures including tendon, neural andchondral tissue. Current non-invasivereference standard for identifyingchondral lesions is MagneticResonance Imaging (MRI).Musculoskeletal Ultrasound (MUS)may be an inexpensive and effectivealternative. Objective: Examine thereliability and validity of an athletictrainer utilizing MUS foridentification of chondral lesions inthe humeroradial joint (HRJ). Design:Cross-sectional study. Setting:Clinical anatomy research laboratory.Patients or Other Participants:Twenty-eight embalmed cadavers(mean age=79.5±8.5 years, 14 males).Intervention(s): An athletic trainerwith two years of hands-on MUSexperience but no formal MUS trainingperformed MUS evaluation of eachanterior and distal-posteriorcapitellum and radial head to identifychondral lesions. The examiner wasblinded during analysis of the MUSimages. Each elbow was then dissectedof all soft tissues and disarticulated forgross macroscopic examination of thearticular surfaces of the HRJ. Thereference standard was identificationof chondral lesions by grossmacroscopic examination. A chondrallesion was confirmed and graded byvisualization of ulceration oreburnation. Main OutcomeMeasure(s): Intra-rater reliability forreproducing an image was calculatedusing intraclass correlation coefficient

[ICC (3,k)] for the average of threemeasurements representing the sizeof the articular surface of two imagesrepresenting the same location. Intra-rater reliability was calculated usingCohen’s Kappa for the agreement ofthe presence of chondral lesions on asingle image. Validity values werecalculated of sensitivity, specificity,positive likelihood ratio (+LR) andnegative likelihood ratio (-LR) usingthe agreement of MUS images andgross macroscopic examination.Results: The data indicated high intra-rater reliability for reproducing animage (ICC=0.88 [95% confidenceinterval {CI}, 0.77, 0.94]) andexcellent agreement for evaluating asingle image (Kappa=0.93 [95% CI,0.80, 1.06]). Identification of chondrallesions on all HRJ surfaces with MUSdisplayed: sensitivity=0.93,specificity=0.28, +LR=1.28 and -LR=0.27. The low specificity and +LRdemonstrated that this method maynot be ideal for ruling-in a chondrallesion with a positive examination.However, the high sensitivity and low-LR indicated that MUS couldaccurately rule out HRJ chondrallesions with a negative examination.These values vary with differentsurfaces and different grades ofchondral lesions. Of interest are thesensitivities and -LRs for the radialhead (0.94, 0.07), anterior surface ofthe radial head and capitellum (0.94,0.18) and grade 4 lesions (1.00, 0.00).This indicates a negative examinationwith MUS in these areas shouldprovide confidence in ruling out thepresence of a chondral lesion.Conclusions: Musculoskeletalultrasound is a reliable and sensitivetool for a clinician to rule out HRJchondral lesions with relatively littleexperience and training. These resultsmay assist with clinical assessmentand decision-making in patients withlateral epicondylalgia to rule out HRJchondral lesions.

13456FODIBlood Flow Of The BrachialArtery: A Bilateral ComparisonAmong Baseball Pitchers AndPosition PlayersSelkow NM, Laudner K, Lynall R,Meister K: Illinois State University,Normal, IL, and Texas MetroplexInstitute for Sports Medicine andOrthopedics, Arlington, TX

Context: Vascular pathologies, suchas thoracic outlet syndrome and deepvein thrombosis, are of a growingconcern among baseball players,particularly pitchers. Adaptivechanges to the musculoskeletalsystem overtime may increase the riskof vascular pathologies and thesubsequent time lost fromcompetition. Objective: To measurebrachial artery blood flow between thedominant and non-dominant arm ofprofessional baseball pitchers andposition players. Design: Cross-sectional. Setting: Professionalbaseball athletic training room.Patients or Other Participants:Twenty-six professional baseballpitchers (Age: 21.0±1.8 years; Height:172.5±8.3 cm; Weight: 72.6±12.0 kg)and 29 position players (Age: 20.4±1.8years; Height: 169.1±8.1 cm; Weight:67.8±11.5 kg) participated.Interventions: Pitchers and positionplayers who reported for springtraining had their bilateral brachialartery blood flow measured, usingdiagnostic ultrasound, while in twoseparate shoulder positions. The firstposition was at rest with the player’sarm by his side. For the secondposition an investigator passivelymoved the test shoulder into 90° ofabduction, which was monitored withthe use of a digital inclinometer, andend range external rotation. Thisposition was chosen due to thesimilarity to the late cocking phase ofthe throwing motion. While in each ofthese positions a second investigatorused an ultrasound probe to find thebrachial artery, while a third

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investigator recorded blood flowvolume and peak flow using theultrasound software. Main OutcomeMeasures: Brachial artery blood flowvolume (ml/min) and peak flow (cm/sec) were measured once for eachposition. Separate 1-way analyses ofcovariance for blood flow volume andpeak flow were conducted. Effectsizes were calculated to provide anindication of clinical meaningfulnessResults: Pitchers had significantlyless blood flow volume (p=0.02,effect size=0.73) and peak flow(p=0.03, effect size=0.78) when in theabducted and externally rotatedposition of the dominant arm(5.7±0.43 ml/min and 16.8±4.3 cm/sec) compared to the non-dominantarm (7.3±2.2 ml/min and 20.1±4.3 cm/sec). The position players did not haveany bilateral difference in blood flowvolume (p=0.85, effect size=0.03) orpeak flow (p=0.70, effect size=0.11)(8.6±2.9 ml/min and 16.8±4.3 cm/secfor the dominant arm and 8.7±2.9 ml/min and 17.0±4.6 cm/sec for the non-dominant arm). Conclusions: Bloodflow volume and peak flow in thedominant arm of pitchers wassignificantly less than the non-dominant arm when placed in passiveshoulder abduction and externalrotation. Our results suggest thatadaptations from pitching mayincrease the risk of vascularpathologies in the throwing arm. Theseresults may help explain theoccurrence of “dead arm syndrome” inpitchers, which has been described asarm fatigue, decreased ball velocityand decreased ball control whilethrowing. Clinicians should considerincorporating therapeutic exercise andstretching to decrease risk ofdeveloping vascular pathologies.

13283FOMUDominant Vs. Non-DominantShoulder And Elbow Range-Of-Motion Differences In SoftballPitchersMcDonald LM, Kaminski TW,Werner SL: University ofEvansville, Evansville, IN;University of Delaware, Newark,DE; Sport Science Unlimited,Arlington, TX

Context: Shoulder and elbow range-of-motion in softball pitchers are notwell documented. Side-to-sidecomparisons of baseball pitchers havedemonstrated glenohumeral internalrotation deficits (GIRD) withconcurrent increases in externalrotation, as well as changes at theelbow. Rehabilitative strategies aretypically implemented to preventrelated pathology in these athletes.Despite softball pitchers deliveringthe ball underhand, range-of-motiondifferences may exist that can drivepreventative or rehabilitative treatmentdecisions for clinicians. Objective:Compare dominant and non-dominantpassive range of motion (PROM) forshoulder internal rotation (SIR),shoulder external rotation (SER),elbow extension (EEX), and elbowcarrying angle (ECA) in softballpitchers. We hypothesized nodifferences between sides. Design:Within-subjects comparison. Setting:Climate-controlled biomechanicslaboratory. Patients or OtherParticipants: Forty-three femalesoftball pitchers (17.2±2.1 yrs.;164.7±6.7 cm; 65.6±11.4 kg) wererecruited to participate. All subjectswere injury free at time of collection.Two pitchers were left-handed.Interventions: PROM was assessedusing a standard goniometer. SER andSIR were measured supine with thehumerus abducted to 90° and theelbow flexed 90°. Start position (0°)was defined as the forearmperpendicular to the table. For bothmeasurements, the humerus wasmoved passively to the subject’s endrange-of-motion. End range was

determined when the subject’s scapulabegan to aid humeral motion or a firmend-feel was achieved. For EEX, thegoniometer was placed with the axisat the lateral epicondyle as the elbowwas moved to the subject’s extensionend range-of-motion. ECA wasmeasured with the subject standing,arms relaxed at side, and axis of thegoniometer at the cubital fossa. MainOutcome Measures: Three trialswere performed for each range-of-motion and averaged to obtain a finalvalue in degrees. Paired t-tests wereconducted to compare dominant andnon-dominant sides for eachmeasurement. Results: At theshoulder, SER demonstratedsignificance (p<.001) between thedominant (84.5°±7.4°) and non-dominant (78.9°±6.8°) shoulders. SIRwas also significantly different(p=.012) between the dominant(71.3°±12.3°) and non-dominant(77.5°±8.9°) sides. At the elbow, ECAwas significant (p=.002) between sides(dominant: 8.4°±2.5; non-dominant:10.3°±2.8°). Conclusions: Thoughsoftball pitchers are not typicallyassociated with the same pathologiesthat occur in baseball pitchers, theseresults suggest that side-to-sidedifferences in shoulder and elbowrange-of-motion exist. Unlikebaseball, a softball pitcher may playother positions. Further research isnecessary to determine if these range-of-motion differences manifest as aresult of underhand pitching or theoverhand throwing necessary in fieldpositions. Regardless of the source, itis important for clinicians to becognizant of side-to-side range-of-motion differences in softball pitchersand consider implementing injuryprevention strategies as they wouldwith a baseball pitcher.

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13381DOINThe Effect Of IntrinsicMusculoskeletal CharacteristicsOn Shoulder Complex Injury InCollegiate Baseball And SoftballPlayersVarnell MS, McFate DA, KeenanKA, Heebner NR, Salesi T, CsonkaJ, Kido Y, Schreppel B, Sell TC:Neuromuscular ResearchLaboratory, Department of SportsMedicine and Nutrition, School ofHealth and RehabilitationSciences, University of Pittsburgh,Pittsburgh, PA; Department ofAthletics, University of Pittsburgh,Pittsburgh, PA

Context: Preventable shouldercomplex injuries (SCI) are a persistentand principal health concern forcollegiate baseball and softballathletes and the clinicians who care forthem. Multiple epidemiologicalstudies have been conducted in thispopulation; however, there is a lack ofprospective studies examiningmodifiable musculoskeletal riskfactors for SCI. Objective: Toprospectively identify intrinsic riskfactors for SCI in collegiate baseballand softball players. Design:Prospective cohort study. Setting:Athletic Training Room Participants:Data were collected on thirteencollegiate baseball (age:19.7±0.9years, height: 72.8± 2.8in,mass:89.2±9.1kg) and ten collegiatesoftball (age: 19.8± 1.5years, height:65.1±1.9in, mass:69.8±11.9kg)players. All athletes were cleared forfull participation and had no history ofshoulder injury in the past month.Interventions: All tests wereperformed preseason. Strengthassessments were performedbilaterally using isometric “maketests” (5 seconds) in standard grade 5manual muscle testing positions usinghand-held dynamometry. Musclestested included: biceps, triceps,glenohumeral internal and externalrotators (IR, ER), pectoralis major(upper, lower fibers), trapezius (upper,middle, lower), rhomboids, serratus

anterior, and supraspinatus. Range ofmotion (ROM), flexibility, andpostural variables included:glenohumeral IR and ER, pectoralismajor flexibility, pectoralis minorlength, posterior shoulder tightness(PST), and forward head (FHP) andforward shoulder posture (FSP). Theaverage of three trials was used foranalysis. Participants were followedfor a single season for SCI asdocumented and reported by eachteam’s Certified Athletic Trainer.Mann-Whitney U tests were used tocompare injured (Inj) and uninjured(NInj) athletes by sport. Statisticalsignificance was set at p<0.05 apriori. Main Outcome Measures:Mean peak force normalized to bodyweight (%BW) for isometric strengthmeasurements. Mean values in degreesfor glenohumeral IR/ER rotation, PST,FHP and FSP. Mean values inmillimeters were analyzed forpectoralis minor length. Results: Overthe season, two baseball players (15%)and five softball players (50%)sustained a SCI, with all injuries exceptone sustained on the dominantshoulder. No athlete incurred morethan one injury. All injuries reportedwere classified as overuse, with fivesustained through a throwingmechanism and two the result ofrepetitively diving while fielding. Nosignificant differences in strengthwere demonstrated between Inj andNInj groups in either team. Injuredbaseball players demonstratedsignificantly greater bilateralglenohumeral external rotation ROM(dominant ER: Inj=120°±1.9°;NInj=104°±10.7°; p=0.026 and non-dominant ER: Inj=119°±3.7°;NInj=101°±6.6°; p=0.026). However,Inj softball players demonstratedsignificantly greater dominant PST(Inj=119°±7.9; NInj=105°±4.9;p=0.032) and less non-dominantpectoralis minor length( I n j = 5 9 . 5 m m ± 3 . 6 m m ;NInj=73mm±6.7mm; p=0.008).Conclusions: Based on the findingsof this study in a small cohort, SCI risk

factors may differ between baseballand softball. In addition, flexibility maybe a better indicator of SCI risk thanstrength. Future research shouldexplore if these results can bereplicated with large sample size andother populations.

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Free Communications, Oral Presentations: Manual TherapyWednesday, June 26, 2013, 8:00AM-9:00AM; Palm D; Moderator: Tricia Hubbard Turner, PhD, ATC

13424FOTEEffect Of A 1-Week Mobilization-With-Movement InterventionOn Range Of Motion, DynamicBalance, And Self-ReportedFunction In Those With ChronicAnkle InstabilityHoch MC, Gilbreath JP, GavenSL, Van Lunen BL: Old DominionUniversity, Norfolk, VA

Context: A single talocruralmobilization-with-movement (MWM)treatment has increased dorsiflexionrange of motion (ROM) in individualswith chronic ankle instability (CAI).Examining the effects of multipleMWM treatments on dorsiflexionROM and other aspects of functionwould further elucidate the clinicalapplications of using MWM for CAIrehabilitation. Objective: To examinethe effects of a one-week talocruralMWM intervention on dorsiflexionROM, dynamic balance, and self-reported function in adults with CAI.Design: Repeated-measures. Setting:Laboratory. Participants: Elevenadults (5 males, 6 females; age=20.8±1.2 years; height=179.4±4.9 cm;mass=87.3±14.9 kg) with CAIvolunteered to participate. Participantsreported a history of at least one anklesprain, two episodes of the ankle“giving way” in the past three months,and a Cumberland Ankle InstabilityTool score of d”25. Intervention: TheMWM intervention consisted of threetreatment sessions performed withinone week by the same clinician. TheMWM treatment was performed byapplying posterior-to-anterior glidesof the tibia over the talus with theparticipant in a kneeling lunge positionwith the involved limb in a weight-bearing stance. Each treatmentconsisted of two sets of four glides.Each glide was sustained for 30seconds at the point of maximaldorsiflexion ROM. Main OutcomeMeasures: Dorsiflexion ROM wasmeasured using the weight-bearing

lunge test, dynamic balance wasmeasured using the anterior directionof the Star Excursion Balance Test, andself-reported function was measuredusing the Foot and Ankle AbilityMeasure-Sport (FAAM-Sport). Theseassessments were measured one weekbefore the intervention (baseline),prior to the first treatment (pre-intervention), and 24 hours followingthe final treatment (post-intervention).Separate one-way ANOVAs examinedchanges in dorsiflexion ROM (cm),normalized anterior reach distance(%), and the FAAM-Sport (%). Theindependent variable was time(baseline, pre-intervention, post-intervention). Post-hoc paired t-testswere calculated in the presence ofsignificant time effects. Alpha levelwas set at pd”0.05 for all analyses.Results: No significant time effectswere detected for dorsiflexion ROM(baseline: 7.39±2.38, pre-inter-vention: 7.48±2.54, post-inter-vention:7.77±2.57; p=0.69) oranterior reach distance (baseline:71.36±7.88, pre-intervention: 71.55±7.19, post-intervention:71.54±7.15;p=0.99). A significant time effect wasdetected for the FAAM-Sport(p=0.01). FAAM-Sport scores weresignificantly greater post-intervention(86.82±9.18) compared to baseline(77.27±11.09; p=0.01) and pre-intervention (79.82±13.45; p=0.04)but no difference was present betweenbaseline and pre-intervention(p=0.20). Conclusion: The one-weektalocrural MWM intervention whichtargeted the posterior noncontractilestructures of the ankle did not improvedorsiflexion ROM or dynamic balancein individuals with CAI. However, theMWM intervention did have a positiveeffect on self-reported function asmeasured by the FAAM-Sport.Therefore, it appears three treatmentsof MWM had a positive impact onpatient-centered aspects of functionbut the effects of this intervention on

clinical measures of function requiresfurther investigation.

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13240DOBIIncreasing Ankle DorsiflexionRange Of Motion Does Not AlterLower Extremity KinematicsDuring A Single Leg SquatBegalle RL, Dill KE, Frank BS,Zinder SM, Padua DA: SportsMedicine Research Laboratory,University of North Carolina atChapel Hill, Chapel Hill, NC, andDepartment of Orthopedics,University of South Florida,Tampa, FL

Context: Limited ankle dorsiflexionrange of motion (DF ROM) isassociated with altered lowerextremity kinematics and increasedrisk of a variety of lower extremityinjuries. Interventions to increase DFROM may alter lower extremitykinematics and ultimately reduce therisk of lower extremity injury in thosewith limited DF ROM. However,research has not addressed thisquestion. Objective: To determine ifankle DF ROM and lower extremitykinematics during a single leg squat arealtered following a flexibilityintervention in individuals with limitedDF ROM. Design: RandomizedControl Trial Setting: Researchlaboratory. Patients or OtherParticipants: Twenty physicallyactive participants were randomized tothe stretching (n=10, 19.40±1.84years, 171.10±6.89 cm, 72.08±14.34kg) or control (n=10, 19.50±0.85years, 171.13±10.46 cm, 68.76±10.86kg) group. All participants had limitedDF ROM, which was defined as DFROM d”5° (assessed with kneeextended). Interventions: Gonio-metric assessments of passive ankledorsiflexion with the knee extended(DF

EXT) and knee flexed (DF

FLX) were

recorded pre- and post- intervention.In addition, electromagnetic motion-capture recorded lower extremitykinematics on the dominant limbduring the single leg squat at both timepoints. The stretching groupperformed a single 5-minute sessionof foam rolling over the triceps suraemuscles with the knee extended (2-

minutes), triceps surae stretchingusing a slant board with the kneeextended and flexed (2-minutes), andrepeated foam rolling (1-minute). Thecontrol group sat in a chair for thesame duration of time (5-minutes)prior to post-testing. Main OutcomeMeasures: The averages of three trialswere used for DF

EXT and DF

FLX

measures. Joint displacements werecalculated for sagittal plane ankle andthree-dimensional knee and hip jointsas the difference between peak jointangles and the joint angles at theinitiation of movement. Separate 2x2(time x group) mixed model, repeatedmeasures ANOVA were performed.Tukey’s post-hoc testing wasperformed to identify location ofsignificance. Results: We observed asignificant main effect of Time forDF

FLX (F

(1, 18)=19.08, P<0.001,

Pre=8.52, Post=9.80) and a significantTime x Group interaction for DF

EXT

(F(1, 18)

=7.65, P=0.013, Control:Pre=1.33±2.98, Post=1.93±4.34,Stretching: Pre=1.93±2.23, Post=4.60±1.93). Post-hoc analysis of theTime x Group interaction for DF

EXT

indicated the stretching group hadsignificantly greater increases inmotion than the control group. Nosignificant main effects orinteractions for time or group wereobserved for any kinematicdisplacement variables (P>0.05).Conclusions: An isolated stretchingapproach was effective in improvingankle DF ROM in healthy individualswith restrictions, but did not alterlower extremity kinematics during thesingle leg squat. Implications of thesefindings suggest isolated acute DFROM increases do not promotechanges in movement patterns. Futureresearch should investigate a longerduration or integrated interventionapproach to influence these changes.

13F05MONEImmediate Effects Of A PosteriorTalar Joint Mobilization OnSpinal-Reflexive AndCorticospinal Excitability InIndividuals With Chronic AnkleInstabilityHarkey MS, Wells AM, McLeodMM, Tevald MA, Gribble PA,Pietrosimone BG: University ofToledo, Toledo, OH

Context: Neuromuscular function isaltered in people with chronic ankleinstability (CAI). One hypothesis isthat decreased dorsiflexion,potentially caused by aberrant anklearthrokinematics from an anteriorlydisplaced talus, affects neuromuscularcontrol of stabilizing muscles aroundthe ankle. Joint mobilizations areindicated for restoring properarthrokinematics and restoring rangeof motion; yet, it remains unknown ifmobilization will alter neuromuscularexcitability around the ankle.Objective: Determine the immediateeffects of a grade III posterior talarmobilization on spinal-reflexive andcorticospinal excitability in thefibularis longus(FL) and soleus(SOL),as well as ankle dorsiflexion range ofmotion (DF) in patients with CAI.Design: Single-blinded, randomizedcontrol trial. Setting: Researchlaboratory. Patients or OtherParticipants: Fourteen participantswith CAI were randomized into themobilization group (11M/3F;21.3±3.6years; 175.6±7.6 cm;80.0±13.8kg; FADI:77.6±15.7;FADIs:60.6±17.4) and fifteenparticipants served as controls (3M/12F; 21.1±2.1years; 168.6±8.8cm;68.9±20.9kg; FADI:82.7±8.4; FADIs:62.3±17.8). Interventions: Follow-ing baseline measurements, themobilization group received 3, 60-second Maitland grade III posteriortalar mobilizations from a certifiedathletic trainer, while the control groupsat quietly for 5 minutes. Outcomemeasures were conducted by a blindedinvestigator prior to and immediatelyfollowing the intervention. Main

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Outcome Measures: Peripheralelectrical stimulation of the sciaticnerve was used to elicit Hoffmannreflexes (H-reflex) and maximalmuscle responses (M-response) of thefibularis longus and soleus muscles.Spinal-reflexive excitability wasdefined as the maximum H-reflexnormalized to the maximum M-response (H:M ratio). Corticospinalexcitability was evaluated bymeasuring active motor thresholds(AMT) using Transcranial MagneticStimulation (TMS). AMTs weredetermined by finding the lowest TMSintensity that elicited measurablemotor evoked potentials (MEPs>100μV) in five out of ten consecutivetrials. Active DF range of motion wasmeasured with the patient positionedsupine with an inclinometer. Separate2x2 repeated measures ANOVAs wereperformed to investigate thedifferences between groups and time(pre, post) for all outcomes measures.Dependent t-tests were used toevaluate individual group differencesover time in the presence of asignificant interaction. Alpha level wasset a priori at P<0.05. Results: Therewere no significant differences inspinal-reflexive or corticospinalexcitability for either muscle in themobilization or control group(P>0.05). There was a significantinteraction effect for DF (F

1,27=4.10,

P=0.05), with the t-test revealing anincrease in DF immediately followingthe joint mobilization (PreDF:16.4±5.3º, Post DF:19.1±5.6º; t=-2.15, P=0.05) while no difference wasfound for controls (Pre DF:18.2±5.6º,Post DF:17.8±4.1º; t=0.39, P=0.70).Conclusions: A single jointmobilization treatment was efficaciousat restoring DF range of motion inparticipants with CAI, but excitability ofspinal-reflexive and corticospinalpathways at the ankle were unaffected.Future research should evaluate theeffect of mobilizations over multipletreatment sessions to determine its trueneuromuscular therapeutic capabilities.

13166MOTEThe Effects Of The GrastonTechnique® On Knee ExtensionAngleToepper BW, Docherty CL,Donahue M, Kingma J, SchraderJ: Indiana University, Bloomington,IN

Context: Hamstring dysfunction mayincrease the likelihood of injury andpresent with symptoms not associatedwith the hamstring muscles;interventions designed to lengthen thehamstrings can decrease likelihood ofinjury and resolve many associatedsymptoms. Objective: To evaluate theeffects of an instrument assisted softtissue mobilization technique on kneeextension angle. Design: Cohortstudy. Setting: Research laboratory.Patients or Other Participants: 32physically active males with limitedhamstring flexibility (21.6±2.2yo; 1.8± 0.7m; 80.8±11.6kg) volunteered toparticipate in this study. Participantshad no acute lower extremity injury inthe last 12 months, no current low backpain, no history of diabetes, and werenot taking anticoagulant medication.Interventions: All participants werepre-tested using the passive kneeextension test. To conduct this test,subjects were asked to lay supine, flexthe hip to 90p and allow a standardizedweight to slowly extend the knee. Adigital inclinometer (ACUMARDatacapture 5.0 Digital Inclinometer,Lafayette Instrument Co., Lafayette,IN) was placed on the shaft of the tibiato record maximal knee extensionangle. Three trials were completed.Instrument assisted soft tissuemobilization treatment was employedusing the Graston Technique® (GT).This technique utilizes stainless steelinstruments to assess and treat softtissue adhesions. A standard GTprotocol was followed, which includedan active warm-up, soft tissuemobilization using the instruments,low load high repetition exercises, andstretching. Participants wererandomly assigned to one of threetreatment groups: Global Graston

Technique(G-GT), Local GrastonTechnique(L-GT), and a control group.The G-GT group received the standardGT protocol with specificmobilization over the posterior thigh,leg, and plantar surface of the foot. TheL-GT group received the standard GTprotocol with specific mobilizationonly over the posterior thigh. Thecontrol group received a 15-minutesham electrical stimulation treatment.For each group, treatment occurred onfour separate days with a minimum of48 hours between treatments. Post-testing occurred in the same manneras the pre-test at the end of the fourtreatment sessions. A RMANOVA wascalculated to determine differencesbetween the groups. Tukey post hoctests were completed on anysignificant findings. Alpha level wasset at P<.05. Main OutcomeMeasures: Knee Extension Angle(°).Results: A significant test by groupinteraction was identified (F

(2,21)=4.16,

p=0.01). Specifically, the G-GT grouphad improved range of motionfollowing treatment (pretest=156.3°±10.7°, posttest= 163.0°±11.0°, mean difference=6.8°),however, neither the L-GT group(pretest=156.8°±7.0°, posttest=160.6°±10.0°, mean difference=3.8°)or the control group (pretest=155.5°±9.6°, posttest= 154.5°±13.8°, mean difference=1.0°) resultedin significant improvements.Conclusions: The use of the GrastonTechnique® can improve kneeextension angle when the treatmentarea includes the entire posteriorthigh, leg, and plantar surface of thefoot. This evidence may support thecurrent concepts of fascial slingssuggested by Thomas Myers.

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Free Communications, Oral Presentations: What Cryotherapy Cannot DoWednesday, June 26, 2013, 9:15AM-10:15AM; Palm D; Moderator:13252MOTEComparing Interventions ForDelayed Onset Muscle SorenessIn College Aged Subjects:Nintendo® Wii Boxing, Ice AndLight Concentric ExerciseChang SD, Naugle KM, Parr JJ,Naugle KE: University of Florida,Gainesville, FL

Context: Delayed-onset musclesoreness (DOMS) induced byeccentric exercise occurs in athletesand causes discomfort and potentiallya decline in physical performance orloss of practice time. Modalities suchas ice and massage exist to combat thisdiscomfort and pain, but outcomes varyin effectiveness. Active gaming hasbecome a trendy rehabilitation tool inathletic training facilities; however, nostudies have investigated whetheractive gaming for sore muscles issuperior to commonly used treatmentsfor DOMS. Objective: The purpose ofthis study was to compare theeffectiveness of active gaming,specifically Wii boxing, compared tostandardized light concentric exercise,and ice bag treatment in alleviatingDOMS. Design: Randomized-controlled trial. Setting: Controlledresearch laboratory. Patients orOther Participants: Twenty-eightcollege-aged volunteers (19.52±0.79yrs). Interventions: Partici-pants performed an eccentric exerciseprotocol of the non-dominant elbowflexors to induce DOMS. Participantswere randomized into one of fourconditions: Wii Boxing (n=7), lightconcentric exercise (LCE; n=8)consisting of elbow flexion andextension with minimal weightresistance, ice bag treatment (n=5), orcontrol group (natural history; n=8).On follow-up Days 1 and 2,participants completed 20 minutes oftheir selected intervention. MainOutcome Measures: Measurementswere taken on Day 0 prior to DOMSand pre and post intervention on Day 1and 2: total active (TA) ROM during

elbow flexion and extension, pain usingthe Brief Pain Inventory (BPI: scale 1-10), muscle tenderness using pressurepain thresholds (PPTs), and functionaldisability (QuickDASH). Changescores (post-pre) were created foreach measure and analyzed withbetween-subjects 1-way ANOVAs.Results: On Day 1, the Wii group[M=1.52o(SE=.83); 95% confidenceintervals (CI): -0.25,3.29] exhibitedimprovements in TA ROM duringelbow flexion compared to the LCE[p=.021; M=-1.23o(SE=.73); 95% CI:-2.75,0.29] and control group [p=.008;M=-1.47o(SE=.73); 95%CI: -2.99,0.56]. On Day 2, the ice group [M=-9.09(SE=4.31); 95%CI: -21.06,2.88]reported improvements in functionaldisability compared to the Wii[p=.011; M=1.29(SE=2.15); 95%CI:-3.97,6.56], LCE [p=.021; M=0.16(SE=0.80); 95%CI: -1.79,2.12]and control group [p=.012;M=0.85(SE=2.46); 95%CI: -4.97,6.68]. On Day 2, the ice group [M=-1.2(SE=.58); 95% CI: -2.82,0.42]reported greater reductions in paincompared to the Wii [p=.021;M=0.43(SE=0.37); 95%CI: -0.47,1.33], LCE [p=.008; M=0.71(SE=0.61); 95%CI: -0.77,2.20] andcontrol group [p=.049; M=0.13(SE=0.13); 95%CI: -0.17,0.42]. Alsoon Day 2, the ice group [M=0.72(SE=.12); 95% CI: 0.44, 1.00]exhibited reduced muscle tendernesscompared to the Wii [p=.004; M=-.02(SE=0.10); 95%CI: -0.33,0.30],LCE [p<.001; M=-0.25(SE=0.15);95%CI: -0.62,0.12] and control group[p=.002; M=-0.09(SE=0.19); 95%CI:-0.56,0.39]. Conclusions: Theseresults suggest that light exerciseusing Wii Boxing temporarilyimproves ROM following an inducedbout of DOMS. However, ice bagtreatment was superior in improvingpain, functional disability, and muscletenderness compared to all otherconditions. Clinically, this suggests amultiple intervention strategy to

rehabilitation should be used foroptimal outcomes.

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13032DOTHCryotherapy Does Not AlterPassive Dorsiflexion Range OfMotion And PlantarflexorMusculotendinous StiffnessAkehi K, Long BC, Conchola EC,Palmer TB: Oklahoma StateUniversity, Stillwater, OK

Context: Cryotherapy is commonlyused in health care. Its influences ontissue extensibility, elasticity, and jointrange of motion (ROM), however, arenot well understood. Objective: Thepurpose of the study was to determineif a 20-minute crushed ice bagapplication to the plantarflexor musclegroup influenced passive ankledorsiflexion ROM, passiveplantarflexor torque (PPT), and passivemusculotendinous stiffness (MTS) at4 joint angles (˜

1,2,3,&4). Design:

Randomized controlled study.Setting: Controlled laboratorysetting. Participants: Twentyrecreationally active college-agedparticipants (male: n=9, age=21.63±2.00yrs, ht=178.31±6.72cm,mass=78.54±32.89kg; and female:n=11, age=19.5±0.52yrs, ht= 166.46±9.41cm, mass= 67.58± 8.31kg) withno known lower extremity injuries inthe 6 months prior to data collectionvolunteered. Interventions: A2x2x2x5 cross-over measure wasconducted on all factors. Independentvariables were treatment (a 2-kgcrushed ice bag or nothing), gender(male and female), day (1st and 2nd),and time (pre-treatment, immediatepost-, 10, 20, & 30 minutes post-treatment). Subjects were randomlyassigned to a treatment order aftersigning the IRB approved informedconsent. On the first day, we obtainedsubject demographics and conductedthe familiarization session. On thesecond and third day, subjects warmedup on a stationary cycle for 5 minutes.Subjects were then positioned on thechair of an isokinetic dynamometer forpassive ankle dorsiflexion and passivetorque measures. Passive dorsiflexionmeasures were taken twice at 5°/s,starting at 20° of plantarflexion. The

13328FOTHBetter Together Or Apart:Effects Of Simultaneous AndIndividual Application OfTherapeutic Cold & ESTIM OnPain PerceptionTsang KKW, Cordova MM, KueiCY: California State UniversityFullerton, Fullerton, CA

Context: The therapeutic effects ofcold modalities and electricalstimulation (ESTIM) as individualtreatments in the management ofmusculoskeletal injury are welldocumented in the research literatureand commonplace practice in theclinical setting. Although thesimultaneous application of bothmodalities is empirically accepted andpracticed, the effects of thesetreatments have not been demonstratedin the research literature. Objective:The purpose of this study was toexamine if these therapeuticmodalities are more effective whenapplied simultaneously or singularly inthe treatment of pain. Design:Crossover study. Setting: Researchlaboratory. Patients or OtherParticipants: 21 participants (9 males,12 females) (mean: age = 22.3 ±2.8years; height = 171.5 ±9.6 cm; mass =68.5 ±13.6 kg) with no history ofcurrent or recent musculoskeletalinjury. Interventions: Independentvariable was treatment mode: cold pack(CP), electrical stimulation (IFS), andelectrical stimulation/cold pack (IC).Operational definitions: IFS(interferential stimulation: carrierfrequency 4000 Hz, beat frequency 80/150 Hz) (Intelect Legend XT,Chattanooga Group, Vista, CA), CP(Moji, Glenview, IL). A repeatedmeasures design was utilized, eachparticipant completed three treatmentsessions over a three-day period. Theorder of treatment mode wasrandomized for each participant. Amodified pneumatic tourniquet wasused to induce perceived pain duringeach session. A baseline pain thresholdwas established at a pressure level

(mmHg) at which each subjectindicated a perceived pain rating of “6”on a Visual Analog Scale (VAS). VASwas used to assess pain level at varioustime periods over a twenty-minutetreatment application and twenty-minute post-application. MainOutcome Measures: Dependentvariable was VAS score (mm). Separaterepeated measures ANOVA was usedto assess differences betweentreatment mode on VAS score atvarious time points (minute 0, 6, 10,20, 26, 40). The level was set a prioriat .05, interactions were analyzedusing post-hoc testing. Results: Allvalues presented as mean ±SD (mm).Analysis revealed no differencesbetween treatment mode at any giventime period: minute 0 (P = .81), CP(54.23 ±6.8), IFS (53.42 ±8.4), IC(54.52 ±9.4); minute 6 (P = .08), CP(46.05 ±16.1), IFS (51.71 ±18.9), IC(42.19 ±16.8); minute 10 (P = .06),CP (45.23 ±20.7), IFS (48.95 ±18.8),IC (39.28 ±19.1); minute 20 (P = .18),CP (42.47 ±24.4), IFS (43.23 ±20.7),IC (36.28 ±24.6); minute 26 (P = .41),CP (45.33 ±24.7), IFS (45.33 ±23.2),IC (41.28 ±23.3); minute 40 (P = .21),CP (50.66 ±23.6), IFS (49.0 ±26.2),IC (45.33 ±26.4). Conclusions: Ourresults indicate the simultaneousapplication of ESTIM and coldmodality does not provide better painrelief than separate applications. Theclinical practice of combinedmodalities application should berevisited for considerations ofevidence-based practice and effectiveresource management.

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pre-determined treatment was thenapplied for 20 minutes. Post-treatment measures were takenimmediately and at 10, 20, and 30minutes after both treatments. PassiveMTS was examined based on passiveangle-torque curves. We alsomeasured surface interfacetemperature every minute in pre-,during, and post-treatment measures.Main Outcome Measures: Weassessed maximum passive ankledorsiflexion ROM, maximum PPT,and passive MTS at 4 joint angles (˜

1-

4) separated by 5° on 5 different time

and 2 different days. Results: Asexpected, cryotherapy decreasedsurface temperature at each post-treatment measure (Pre: 29.68±1.10°C, Post: 8.52±3.37°C, 10

post:

21.02±1.57°C, 20post

: 23.25± 1.84°C,and 30

post: 24.21± 1.50°C; Tukey-

Kramer, P<.01). Control group andambient air temperature fluctuated lessthan 2°C. Cryotherapy did notinfluence ROM (Ice

male: 33.89±4.55°,

Controlmale

: 32.60±5.20°, Icefemale

:32.36±10.86°, Control

female:

33.35±

9.91°; Tukey-Kramer, P>.85). Therewas no main effect difference betweentimes for ROM, PPT, or MTS for eachtreatment (Tukey-Kramer, P>.05).Males, however, had higher PPT (Ice:76.91±20.28Nm, Control: 74.01±15.42Nm; F

1,360=718.72, P<.01)

compared to female PPT (Ice:26.46±10.18Nm, Control: 30.46±12.92Nm). This was also true at eachof the MTS˜

1-4 (Tukey-Kramer,

P<.05). Conclusions: Decreasingplantarflexion temperature with a 20-minute crushed ice bag does not appearto influence passive ankle dorsiflexionROM, maximum PPT, or passive MTS.Regardless of cryotherapy application,males had greater passive PPT andMTS than female.

c13034MOTHEffect Of Different CompositionsOf Ice Bags On Circulation InThe Femoral Artery In HealthyMalesTeblum JB, Boucher TM,Greenwood LD: Baylor University,Waco, TX; University of Louisianaat Monroe, Monroe, LA; TexasA&M University, College Station,TX

Context: Many studies haveinvestigated the effectiveness ofdifferent cryotherapy agents, includingdifferent compositions of ice bags, inlowering tissue temperatures.However, there is no current researchthat has investigated the effect of icebag composition on blood flowvelocity. Objective: To investigatedifferent compositions of ice bags onblood flow velocity in the femoralartery. Design: A repeated-measurescounterbalanced design. Setting:University Laboratory Setting.Patients or Other Participants:Male subjects 18 to 35 years old wererecruited on a volunteer basis from thesurrounding area. Fifteen healthy maleparticipants (age = 20.3 ± 1.2 years,height = 181.3 ± 7.9 cm, mass = 75.3± 13.9 kg) with no circulatoryconditions or current lower extremityinjuries completed the study.Interventions: Ice bags made withcrushed, cubed, wet crushed, or wetcubed ice were prepared withstandardized procedures and applied tothe right upper thigh for 15 minutes.The wet bag composition simulatedmelting that often occurs clinicallyprior to application. The icecomposition selection was randomlyassigned and administered on fourseparate test sessions, with at least 24hours in between sessions. The bloodflow (cm/sec) was measured viaspectral Doppler ultrasonography(SonoSite M-Turbo, SonoSite, Inc.,Bothell, WA). Main OutcomeMeasures: Blood flow velocity of theright femoral artery was measuredprior to ice application and every 5

minutes for 30 minutes followingtreatment removal. A mixed designrepeated measure analysis of variance(ANOVA) compared blood velocitybetween the different ice bagcompositions across the time points.Four separate repeated measuresANOVA’s were performed testingeach individual ice bag composition’seffect on blood flow in relation to timeelapsed. Results: Among the fourdifferent types of ice bagcompositions there was not anysignificant difference in blood flowvelocity (P = .63). Individually, therewas no significant difference in bloodvelocity over the eight time points forthe wet crushed (57.9 to 62.67 cm/sec,P = 0.66), cubed (60.4 to 59.9 cm/sec,P = 0.72), and wet cubed ice bags (65.1to 63.0 cm/sec, P = 0.64). However,there was a significant decrease inblood velocity (74.2 to 62.8 cm/sec)relative to time with the crushed icebag (P = .006) and pairwise comparisonrevealed the significant differencebetween pre-application baseline andall post ice application velocities. Thissignificant difference was attributed tothe average pretreatment blood flowvelocity for this group beingsignificantly different from the otherthree. Conclusions: Ice bagcomposition and the influence of amelted ice state do not affect bloodflow velocity and are an equallyeffective application of cryotherapy tobe used clinically.

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Modalities Evidence-Based ForumWednesday, June 26, 2013, 10:30AM-11:30AM; Palm D; Moderators:

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Free Communications, Oral Presentations: Taping/Bracing/Orthotic InterventionsThursday, June 27, 2013, 8:00AM-9:30AM; Palm D; Moderator: Mitchell Cordova, PhD, ATC

13170MONEEffect Of Lace-Up Ankle BracesOn Electromyography MeasuresDuring Walking In SubjectsWith Chronic Ankle InstabilityBarlow G, Donovan L, Hart JM,Hertel J: University of Virginia,Charlottesville, VA

Context: Injuries to the ankle are oneof the most common musculoskeletalinjuries in athletics with a high rate ofrecurrence and prolonged dysfunction.Previous studies have shown areduction in ankle sprains among thosewith previous ankle injury whilebraced, however, ankle braces have notbeen shown to decrease the severityof injury, It may thus be implie that themechanism by which a brace decreasesinjury risk goes beyond restrictingrange of motion and may also affectthe neuromuscular control of theankle. Objective: To determine theeffect of a lace-up ankle brace onlower extremity muscle function insubjects with chronic ankle instability(CAI). Design: Crossover. Setting:Laboratory. Patients or OtherParticipants: Fifteen adults with CAI(height=173±11cm, mass=72±14kg,age=23±4, sex=M:5 F:10) parti-cipated. Intervention(s): Conditionorder was randomly allocated tocondition order (lace-up brace or nobrace). Surface EMG electrodes wereplaced over the anterior tibialis (AT),peroneus longus (PL), lateralgastrocnemius (LG), rectus femoris(RF), biceps femoris (BF) and gluteusmedius (GM). The protocol consistedof 30 seconds of treadmill walking at3 mph during each condition. MainOutcome Measures: NormalizedEMG amplitude 100ms pre- and200ms post initial contact, time ofactivation relative to initial contact,and percent of activation across thestride cycle were calculated for eachmuscle across 9 steps. Muscleactivation was determined for eachmuscle if the amplitude was 10 SD over

the mean amplitude during quietstanding. A negative value for time ofonset represents muscle activationprior to initial contact. Percent ofactivation was calculated as theproportion of the total time across thestride cycle that the amplitude wasgreater than the previously describedthreshold. Paired t-tests wereperformed for each dependent variableto compare groups. The level ofsignificance was set a priori atPd”0.05 for all analyses. Results: Thepre-contact amplitude of the PL wassignificantly lower in the bracedcondition (0.16±0.08) when comparedto the shod condition (0.20±0.10mV,p=0.01). The AT, PL, RF, and GM wereactivated significantly later relative tocontact in the braced condition whencompared to the shod condition (AT: -0.32±0.02 vs. -0.36±0.16ms, p=0.02;PL: 0.02±0.12 vs. -0.07±0.10ms,p=0.02; RF: -0.07±0.06 vs. -0.14±0.15ms, p=0.03; GM: 050±.082 vs. -0.08±0.10ms, p=0.009, respectively).The PL and RF were activated for asignificantly shorter percentage acrossthe stride cycle in the braced conditionwhen compared to the shod condition(PL: 28.67±9.35 vs. 36.04±10.26%,p=0.002; RF: 30.79±18.86 vs.36.90±24.52%, p=0.05, respectively).Conclusions: Lace-up ankle bracescaused an alteration in lower extremitymuscle activation in individuals withCAI. These alteration in muscleactivation due to bracing maycontribute to the decrease therecurrence of ankle sprains in peoplewith CAI by providing a more efficientmuscle activation patterns.

13091SOBIEffect Of Over-The-CounterFoot Orthotic Devices On Multi-Segment Foot BiomechanicsKimmel W, Hettinga BA, Ferber R:Faculty of Kinesiology, Universityof Calgary, Calgary, Canada

Context: Over-the-counter (OTC)foot orthoses are thought to be a cost-effective alternative to custom-madedevices. However, few studies havecompared OTC devices and mostbiomechanical research involvingorthoses has focused on rearfootbiomechanics. Objective: Todetermine changes in multi-segmentfoot biomechanics during shodwalking in three commerciallyavailable OTC devices: SOLE,SuperFeet (SF), and Powerstep (PS)compared to no orthotic (NO). Basedon a previous SOLE study, andconstruction of the OTCs, wehypothesized significantly reducedplantar fascia strain (PFS) for SOLEand SF compared to NO. We alsohypothesized that SF and PF wouldsignificantly reduce rearfoot eversion(RFEV), tibial internal rotation (ROT),and medial longitudinal archdeformation (MLAD) compared toNO. Design: Crossover, repeatedmeasures. Setting: Clinical researchlaboratory. Patients or OtherParticipants: Eleven healthyindividuals (3 males, 8 females: age=31.3 ±6.7yrs, height= 167.5±8.4cm,mass= 65.1±12.8kg) volunteeredthrough informed consent.Interventions: Retroreflectivemarkers were placed on the right limbto represent forefoot, midfoot,rearfoot and shank segments. 3Dkinematics were recorded using 8-cameras (Vicon, Oxford, UK: 120Hz)placed around a treadmill whilesubjects walked in a neutral shoe at 1.1m/s. The order of the 4 conditions wasrandomized. Main OutcomeMeasures: 3D marker trajectorieswere calculated using custom-written

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13234FOPREffect Of Prophylactic AnkleSupport On Actual AndPerceived Dynamic BalanceGear WS, Bookhout JL, SolyntjesAL: University of Minnesota-Duluth, Duluth, MN, and MarywoodUniversity, Scranton, PA

Context: Ankle injuries are the mostcommon injury associated with sportsparticipation. Taping and bracing arecommonly used measures to preventankle injury. Patients often report afeeling of increased stability due toProphylactic Ankle Support, howeverprevious studies have producedconflicting results. Objective: Thepurpose of this study was to examinethe actual and perceived effect oftaping and bracing on dynamic stability.Design: Repeated measures design.Setting: Controlled laboratorysetting. Patients or OtherParticipants: 21 physically activesubjects [12 females (age = 20.33 ±1.44 years, height = 165 ± 0.05 cm,mass = 68.76 ± 12.69 kg), and 9 males(age = 21.33 ± 1.66 years, height =180 ± 0.10 cm, mass = 86.54 ± 9.46kg)]. Interventions: Dynamicstability and perception of stabilitywere assessed barefoot and with theankle taped and braced. The taped anklecondition used a standard preventivetape application including two anchors,three stirrups, close downs,horseshoes, two heel locks per sideand two figures’ of eight. During thebraced condition, participants werefitted with a Swede-O Inner Lok 8ankle brace per manufacturerguidelines. Main OutcomeMeasures: The Biodex BalanceSystem SD was used to measuremedial-lateral and anterior-posteriorstability. Dynamic balance wasassessed in a single leg stance duringthree 20-second trials at stability level4. A 30 second rest period wasprovided between trials. Perception ofstability was assessed using a 4-pointLikert scale (1 = very unstable, 2 =unstable, 3 = stable, 4 = very stable)after each test session. Independent

variables were counter-balanced tominimize the effects of fatigueassociated with the testing procedures.A Repeated measures ANOVA wasused to analyze the difference betweenbarefoot, ankle tape, and ankle bracefor medial-lateral and anterior-posterior dynamic stability indices andperception of stability. All tests ofsignificance were carried out at analpha level = 0.05. The Bonferronipost hoc test was used for all pairedcomparisons. Results: Significantdifferences were not found for medial-lateral stability (Barefoot = 1.24 ±0.63, Taped = 1.21 ± 0.72, Braced =1.38 ± 0.71) nor anterior-posteriorstability (Barefoot = 1.70 ± 1.07,Taped = 1.50 ± 0.89, Braced = 1.47 ±0.74). Significant differences werefound for perception of stability(Barefoot = 2.57 ± 0.60, Taped = 3.32± 0.67, Braced = 2.90 ± 0.76; p =0.000). The taped condition wassignificantly different from bothbarefoot and braced conditions (p =0.000 and p = 0.021 respectively).Conclusions: The use of ankle tapingand bracing had no influence ondynamic stability measures in thisstudy. Ankle taping did cause anincreased perception of stabilitysuggesting that ankle taping may havemore of a placebo effect in uninjuredankles.

Matlab software (Natick, USA). RFEV,MLAD, and ROT were measured indegrees. PFS (unitless) is calculatedby approximating the plantar fasciaspanning between the first metatarsalhead and calcaneus and determined aschange in relative marker position.Between-condition differences weredetermined using 1 (group) x 4(condition) repeated measuresANOVAs and a priori post-hoc testing(P<0.05). Results: There were nosignificant differences in peak RFEVfor any OTC (SOLE: F

1,7=2.11;

10.60±4.63deg; P=0.11, SF:F

1,7=3.01; 10.10±5.64deg; P=0.09,

PS: F1,7

=1.87; 11.72±5.30deg;P=0.24) compared to NO (13.31±5.19deg). There were no significantdifferences in peak ROT for any OTC(SOLE: F

1,7=0.99; 0.28±7.37deg;

P=0.42, SF: F1,7

=1.79; -1.26± 5.14deg; P=0.29, PS: F

1,7=1.81; -1.67

±5.76deg; P=0.24) compared to NO(-0.21±3.43deg). There were nosignificant differences in peak MLADfor any OTC (SOLE: F

1,7=0.97;

155.55±7.46deg; P=0.41, SF:F

1,7=1.01; 158.04±8.25deg; P=0.30,

PS: F1,7

=0.99; 154.88±7.47deg;P=0.33) compared to NO (156.25±7.03deg). There were no significantdifferences in PFS for PS (F

1,7=1.78;

0.008±0.004; P=0.29) compared toNO (0.009±0.001). Significantdecreases in PFS were measured forSOLE (F

1,7=7.65; 0.001±0.009;

P=0.02) and SF (F1,7

=3.55;0.004±0.007; P=0.05) compared toNO. Conclusions: Supporting thehypotheses, a SOLE OTC orthoticdoes not control RFEV or MLAD butdoes reduce PFS compared to walkingwithout an orthotic device. Partiallysupporting the hypotheses, SF alsoreduces PFS. Contrary to thehypotheses, PS and SF do not controlrearfoot or tibial kinematics nor reduceMLAD. SOLE and Powerstep donatedtheir devices. Funded by SOLE andAlberta Innovates: Health Solutions.

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13348DOPRPlantar Flexion Motion AllowedBy Different Ankle TapingCombinations Assessed ByThe Taguchi MethodBoscolo MS, Zhu W: Universityof Illinois at Urbana Champaign,Urbana, IL

Context: There are many tapingtechniques used by athletic trainers,but it is yet unknown if one tapingtechnique is better than another. Tapingtechnique can be broken down intocomponents and these components canbe systematically varied (i.e., one orthree layers thick of tape) and studiedfor effectiveness. No ankle tapingstudies have systematically exploredsystematic optimization of tappingtechniques. Objective: To determinethe optimal ankle taping combinationfor reducing plantar flexion using theTaguchi Method (TM) model. Design:A repeated measures design was usedwhere each participant was tested ineach of the four ankle tapingcombinations. Setting: Researchlaboratory. Patients or OtherParticipants: Thirty-five femaleparticipants (aged=24.7±4.91 years;160.17±11.93 cm; 61.62±5.83 kg)with no ankle injury in the past yearvolunteered for this study.Interventions: Ankle taping factorsWeight (W), Tape Height (H) and pre-wrap Thickness (T) weresystematically varied. Each parameterhad two levels: W1 = one tape layerthick; W2 = three tape layers thick; H1= 20% of fibular height; H2 = 35% offibular height; T1 = one pre-wrap layerthick; T2 = three pre-wrap layers thick.2” Crammer Underwrap™ and 1.5”Coach™ athletic tape was applieddown to the middle of the arch using apredefined technique. Tapingcombination order was randomizedfor each participant. The Inman anklemachine, with an attached wirelessinclinometer, was used to measureplantar flexion and has been foundreliable and valid in previous studies.Main Outcome Measures: A one wayANOVA was used to analyze the

degrees of plantar flexion allowed byselect ankle taping combinationswhich were selected using a TMorthogonal array 4. Alpha was set at<0.05. Using TM procedures lowcontributing factors were pooled tobecome error variance and ANOVAwas rerun. The optimal combinationwas determined based on the signal tonoise ratio (S/N) Smaller is Better, andthen confirmed with collected data.Results: In the traditional meansanalysis W (F

1,136 = 23.36; p=0.001),

H (F1,136

= 6.61; p=0.01) were foundto be significance, but T (F

1,136 = 0.94;

p=0.33) was not. In the initial S/N ratioanalysis W accounted for 74.45%, H20.70% and T 5.85% of the variance.After T was pooled error varianceaccounted for 5.85%, W 73.45% andHeight 20.70% of the variance. Theoptimal combination (W2-H2)estimation was 40.11 ± 11.77 º ofallowed plantar flexion. Confirmatoryanalysis on n=35 participants showsthe average results for allcombinations containing W2-H2 was40.97 º which is within the 95% CI.Conclusions: The results provideevidence of the optimal ankle tapingcombinations for limiting ankleplantar flexion. Further research isneeded to determine what effectexercise has on the variouscombinations used in this study.

13090FOPRThe Effects Of Load Range AndBrace Support In Ankle ComplexStabilityKovaleski JE, Gurchiek LR,Heitman RJ, Liu W, Mitchell SM,Hollis JM: University of SouthAlabama, Mobile, AL

Context: Stabilization against aninversion injury is a major function ofan ankle brace. No comprehensiveanalysis concerning the effectivenessof brace support on ankle-complexbehavior across a load range has beenreported. Objective: To evaluate theeffect of different types of bracesupport on ankle-complex inversionrotation and stiffness. Design: Cross-sectional. Setting: Researchlaboratory. Participants: Thedominant ankle of 22 femalecollegiate athletes (20.7±1.2 years,70.2±8.7 kg, 173.2±9.0 cm).Interventions: Maximal inversionload-displacement curves werecollected using a six degrees-of-freedom linkage-instrumented anklearthrometer. With the subject wearingher own low-top athletic shoe allankles underwent loading at 15°plantar-flexion (PF), which wasdefined as the zero-load/zero-momentunloaded position. Main OutcomeMeasurements: Inversion ROM wasmeasured from zero to 4-Nm with theloading portion of the moment-angulardisplacement curve divided into low-load (0-2 Nm) and high-load (2-4 Nm)segments. Rotation was measured andsecant stiffness for each load-rangecalculated. Repeated measure ANOVAwas used to compare rotation valuesamong the no brace and braced ankles(soft-shell [Zoom™]; lace-up[ASO™]; rigid [Active Ankle T2™]) at4-Nm. Separate t-tests compareddifferences in rotation and stiffnessbetween low-load and high-loadranges. Significance was set a prioriat P < .05. Results: At the 4-Nm load,bracing (soft-shell: 21.5±4.9°; rigid:22.3±6.7°; lace-up 24.5±7.6°)produced a significant reduction inROM when compared to the no brace

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trial (47.1±9.7°; P<.001), with noROM differences between bracedconditions (P>.05). Across the twoload ranges, bracing restricted ROMmore in the 0-2 Nm load range than inthe 2-4 Nm load range [soft-shell(8.7±2.7°,12.8±3.0°; P<.001), rigid(8.1±3.5°,14.2±3.9°; P<.001), lace-up (9.6±4.5°,14.9±3.9°; P<.001).Whereas, in the NB condition, greaterROM occurred between the 0-2 Nmload range than in the 2-4 Nm loadrange (33.0±9.1°,14.1±2.2°, P<.001).Bracing produced greater stiffness inthe 0-2 Nm load range than in the 2-4Nm load range [soft-shell (.259±.11Nm/°, .165±.04 Nm/°; P<.001), rigid(.303±.16 Nm/°, .151±.04 Nm/°;P<.001), lace-up (.299±.22 Nm/°,.145±.05 Nm/°; P=.001). Whereas, inthe NB condition, less inversionstiffness was found in the 0-2 Nm loadrange (.066±.02 Nm/°) than the 2-4Nm load range .145±.02 Nm/°,P<.001). Conclusions: The braces wetested lead to a significant reductionin maximal inversion rotation. Thelargest effects of the braces oninversion ROM of the ankle complexoccurred in the low-load range. Therelative contribution of the brace tototal stiffness in this region was high.However, towards the extremes ofmotion, the ankle becomes greatlystiffer than in its neutral zone.Therefore, the relative contribution ofthe brace to the total stiffness in thisregion is diminished. Objectiveinformation on the amount and natureof passive support may assist athletictrainers when recommending braces totheir patients.

13163MOPRAnkle Bracing EnhancesMediolateral Postural Stability InThose With And Without AHistory Of Ankle SprainsGoodrich ME, Oyama S, Goto S,Myers JB, McKeon PO, ZinderSM: Department of Exercise andSport Science, University of NorthCarolina at Chapel Hill, Chapel Hill,NC

Context: Ankle braces have beenshown to reduce the risk of both first-time and recurrent sprains. Sincedeficits in postural stability have beenlinked to an underlying mechanism forincreased ankle sprain risk, it istheorized that the effectiveness ofankle braces in reducing ankle sprainrisk is attributed to its ability toimprove postural stability. However,the effects of ankle bracing on posturalstability have been inconclusive,especially in those with a history ofankle sprain. Time to boundary (TTB)is a relatively new method to assessspatiotemporal postural stability.Assessing balance performance usingTTB may elucidate the effects of anklebraces on postural stability.Objective: To examine the effects ofankle bracing on single limb balancein individuals with and without a historyof ankle sprain using TTB measures.Design: Matched crossover design.Setting: Research laboratory.Patients or Other Participants:Nineteen individuals with a history ofankle sprain (AS) (20.4±1.9yrs,170.2±7.0cm, 74.7±13.6kg), and 19age-, height-, and gender-matchedcontrol subjects (20.8±2.0yrs,169.5±6.4cm, 75.6±15.9 kg)participated. Interventions: Eachparticipant attended two testingsessions. Balance was assessed whilewearing an ASO® brace in one sessionand without brace in the other. Theorder of testing was counterbalancedwithin each group. All participantsperformed 3 10-second trials ofsingle-leg balance on their affectedlimb with eyes closed. MainOutcome Measures: TTB in anterior-

posterior (AP) and medial-lateral (ML)directions were calculated based onthe center of pressure position andvelocity in relation to the boundariesof the foot. The mean and standarddeviation of TTBML and TTBAP werecompared using separate group (AS/control) by condition (brace/no-brace)mixed-model ANOVAs. Alpha levelwas set a priori at p<0.05. Results:There were no significant group bycondition interactions for any TTBvariables. There were significantcondition main effects in which allparticipants exhibited significantlyincreased mean TTBML (meandifference=0.29±0.74, 95%CI: 0.04-0.53, p=0.02), and standard deviationof TTBML (mean difference=0.51±1.16, 95%CI: 0.12-0.89,p=0.01) during the braced condition,regardless of group. No significantgroup main effects were found for anyof the TTB measures. Conclusions:The increased mean TTBML in thebraced condition reflects an improvedability to maintain single limb balance.An increase in the TTBML standarddeviation reflects a less constrainedsensorimotor system and an enhancedability to adapt to ML balanceperturbations. These improvementscan potentially be attributed toenhanced mechanical support in themediolateral direction as well asaugmented proprioceptive feedbackfrom cutaneous mechanoreceptorswhile wearing the brace. Therefore,regardless of a history of ankle sprain,use of an ankle brace has a potential toimprove balance performance. Thismay be one of the underlyingmechanisms for the prophylacticbenefit of ankle bracing for new and/or recurring ankle injuries.

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Free Communications, Oral Presentations: Elbow Injury CaseThursday, June 27, 2013, 12:00pm-12:45pm; Palm D; Moderator: Ned Bergert, ATC, PTA/

13183SCOsteochondral Lesion Of TheElbow Trochlea In CollegiateBasketball PlayerYeargin BE, Rettig LA, YearginSW: Drayer Physical Therapy,Columbia, SC; Methodist SportsMedicine, Indianapolis, IN;University of South Carolina,Columbia, SC

Background: A 19yo Division Icollegiate basketball point guardpresented with a 4 month history ofincreasing elbow pain during thecompetitive season. Pain was insidiousin nature and occurred with forcedterminal extension involving the right-dominate shooting arm. Outside ofbasketball, pain occurred duringweight lifting while loaded in elbowflexion > 90 degrees (e.g. bench press,hang cleans) as well as with heavysingle arm rows. Examinationdemonstrated loss of terminal elbowextension with reproducible pain alongthe posterolateral joint line.Tenderness and pocket effusion wereevident over the same region. Theathlete described an occasional“catching” sensation. There was novisual deformity or incongruence ofanatomical landmarks. The cubitalcarrying angle was normal for a maleand there was no previous elbow, norshoulder, trauma. Collateralligamentous tests were negative.Neurological screen was normal.Within the first month of painpresentation, the athlete was evaluatedby the team orthopedist. Although anosteochondral injury was suspected,xrays taken at the time wereunremarkable. After educating theathlete about the suspected injury, hedecided to treat conservatively and re-evaluate after the season. During the 4months of conservative treatment,attempts to manage symptoms weremade with modalities and weight roommodifications. DifferentialDiagnosis: Valgus ExtensionOverload Syndrome, Posterolateral

Rotatary Instability, Olecranon StressFracture, Triceps Tendonitis,Ostechondral lesion. Treatment:Athlete was referred back to the teamorthopedist for follow up evaluationafter the competitive basketballseason. X-rays were obtained andshowed chondral changes within thetrochlea. An MRI scan of the elbowidentified small loose bodies alongwith chondral changes involving theposterior trochlea of the humerus. Thepatient underwent arthroscopicdebridement of the osteochondrallesion with microfracture and removalof loose bodies. Athlete was placed ina removable elbow brace for fourweeks. Rehabilitation included elbowactive ROM exercises at day 1 post opand Scapulothoracic stabilizationexercises. Athlete was progressed toelbow specific strengthening exercisesat 6 weeks. He regained full range ofmotion and strength by 8 weeksfollowing the arthroscopic procedure.At 3 months post-op, the patientreturned to full court participation.Clinical evaluation at two years post-op, demonstrated maintenance of fullrange of motion of the elbow withoutpain or effusion. Final follow-upradiographs were unremarkable.Uniqueness: Osteochondral injuriesinvolving the elbow are mostcommonly identified within thecapitellum. Trochlear osteochondraldefects are uncommon. The area ishypovascular due to lack of arteryanastomosis. Previous case studiestypically involve males but occurearlier in adolescence. Predisposingfactors in the current case wereminimal, with only repetitive extension

as the primary factor. Additionally,ligament laxity has been speculated inprevious literature but was not relevantin the current case. Conclusions:Terminal extension pain, a “catching”sensation and lack of resolution withconservative treatment are keyindicators for a chondral injury.Previous literature indicates thepossibility of increased range ofmotion losses when diagnosis isdelayed. This was prevented in thecurrent case with follow upevaluations and imaging resulting in adiagnosis. Arthroscopic debridementand microfracture of the trochlea maybe a viable option in these rare lesionsand increase the likelihood of longterm success.

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Chronic Elbow Injury inIntercollegiate Baseball PitcherWhetstone JM, Felton SD,Mullaney KP, Albritton, DL: FloridaGulf Coast University, Fort Myers,FL

Background: A 20-year-oldcollegiate left handed baseball pitcherpresented at beginning of academicyear to Certified Athletic Trainer(ATC) stating he suffered a coronoidstress fracture during summer leagueparticipation. ATC evaluation revealedno edema, full active ROM comparedbi-laterally; however, athlete presentedwith a 10 degree extension lag. Athletehad full strength with no reportedneurological or circulatory issuesnoted. Valgus and Varus Stress testswere (-) with solid endpoints, (+)Valgus Extension Overload test. Inconsultation with Team Physician,rehabilitation program was initiated.Differential Diagnosis: LateralEpicondylitis, OsteochondritisDissecans, Valgus ExtensionOverload, Olecrannon Stress Fracture,Process Stress Fracture. Treatment:Initial treatment included six weeks ofnon-activity. During this time, anextensive and detailed rehabilitationfocused on ROM and strengtheningexercises. Exercises included wristflexion/extension, pronation/supination, grip strength, and elbowflexion/extension exercises steadilyprogressing resistance each week.Shoulder exercises included scapularstabilization, proprioception, androtator cuff exercises with weeklyprogression. After six weeks of painfree rehabilitation, he was cleared forthe interval throwing program (ITP)and light strength training. Aftercompleting ITP, no edema or painnoted. ROM and strength were WNLand was granted full clearance. Whilescrimmaging one week later, hereported similar pain as initial injuryto ATC were examination revealedposterolateral pain with extension.Athlete referred to Team Physician

who ordered an MRI which revealedmarrow edema, with a coronoidprocess fracture. Conservativetreatment was initiated withoutsuccess; thus, Team Physicianproceeded with surgical intervention.Surgery identified coronoid as anintact structure and threemicrofractures were drilled intocoronoid to initiate a healing process.Following surgery he was immobilizedfor 10 days, with restriction fromactive biceps activities for 1 month. Hebegan rehabilitation, restoring ROMand strength. Approximately 3.5months post-surgery, he was clearedfor throwing. Athlete completed ITPand was granted full clearance. He hada successful fall and spring training,and started second game of the season,but felt pain in his elbow. ATCexamination revealed swelling overposterior elbow, pain with ROM,AROM 30-100 degrees, (-)ligamentous stress tests. Athletereferred to Team Physician whoordered MRI revealing marrow edemainvolving coronoid process. He waswithheld from participation for 6weeks and began another rehabilitationprogram. After 6 weeks, athlete had fullelbow ROM and strength. ATC couldnot elicit pain with special tests. At thistime, he began ITP, reporting minimalsoreness. Athlete returned for lastgame of season pitching successfully.However following game, athletereported to ATC complaining ofsimilar pain as initial evaluation.Uniqueness: Coronoid fractures aretypically associated with posteriorelbow joint dislocations with anoccurrence rate of approximately10%. Through an extensive literaturesearch, a coronoid stress fracture isextremely rare and data supportingtheir occurrence is limited. This casehighlights the challenges of a coronoidstress fracture in an elite throwingathlete when applying conventionalstress fracture protocols. Athletewould respond well to rehabilitationuntil his scheduled return to

competitive pitching. Conclusions:This case highlights extensivetreatment and rehabilitation of anathlete suffering from chronic stressfractures of the coronoid process. Thiscase is extremely unique due to thelow incidence of initial and recurringcoronoid process stress fractures. Thiscase exhausted both conservative andsurgical treatment options withminimal success. The casedemonstrates need for ATCs toappreciate complexity of injuriesassociated with elite throwing athletesand understand that althoughconventional rehabilitation would besuccessful with most athleticpopulations, the demands of the sportultimately played an essential role indetermining final outcome of this case.Athlete was unable to continue sportsparticipation and efforts were focusedon maintaining activities of dailyliving.

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13043FCDynamic Ulnar ImpactionSyndrome In A CollegiateBaseball Player: A Case ReportBaer DJ: University of Pittsburgh,Pittsburgh, PA, and West ChesterUniversity, West Chester, PA

Background: A 20-year-old NCAADivision-I male baseball playerreported a gradual onset of dorsalulnar-sided left wrist pain in the spring2007 baseball season. Chiefcomplaints included pain withpronation, supination, and ulnardeviation, as well as increased pain withbatting, due to the excessive andforceful ulnar deviation during thismotion. Strength and range of motion(ROM) were equal bilaterally. An MRIrevealed soft tissue edema near thebase of the third metacarpal and bonemarrow edema at the triquetrum andlunate. There was no radiographicevidence of a triangular fibrocartilagecomplex (TFCC) tear. Followingunsuccessful conservative treatment,the patient opted for exploratory wristarthroscopy in which a large chondraldefect was found and debrided fromthe lunate. Following rehabilitation andfull return to play, the patientcontinued to experience persistentulnar-sided left wrist pain with wristflexion, ulnar deviation, and forearmpronation during batting and fielding.Fourteen weeks after the first surgery,a second exploratory wrist arthroscopyrevealed that the proximal articularsurface of the lunate had healed, butthe new hyaline cartilage had alreadyfrayed and required debridement. Alarge type I-B (dorsal ulnar) TFCC tearwas also found and repaired using anoutside-in technique. Following agradual activity progression and returnto functional activities, the patientagain complained of dorsal ulnar-sidedleft wrist pain, despite having fullstrength and full ROM. DifferentialDiagnosis: TFCC tear, lunotriquetralligament sprain, extensor carpi ulnaristendinopathy, chondromalacia of thelunate or ulna, Kienböck’s disease,ulnar impaction syndrome, dynamic

ulnar impaction syndrome.Treatment: Six months after thesecond arthroscopic surgery, anotherMRI revealed grade 4 chondrosis ofthe proximal lunate. Because allprevious X-rays had shown normalulnar variance with the forearm in aneutral rotation, a pronated grip X-raywas also taken, revealing a positiveulnar variance in that position. Toavoid compromising the integrity ofthe distal radioulnar joint (DRUJ) andthe TFCC with another arthroscopicsurgery, an extra-articular procedurecalled an ulnar shortening osteotomywas performed to decompress theulnocarpal joint and tighten theextrinsic ulnocarpal ligaments toprovide additional stability to theDRUJ. After this third surgery, thepatient was able to return to fullparticipation in baseball practice andtraining until a knee injury preventedhis return to competition.Uniqueness: Using traditional X-raywith the wrist and forearm in a neutralposition, the patient showed noindication of positive ulnar variance,which is usually an underlying causeof ulnar impaction. Although positiveulnar variance is often congenital, thiscase presents strong evidence that itcan also occur during functional ordynamic tasks, as the space betweenthe distal ulna and the carpal bonesdiminishes with pronation andgripping. X-rays taken in this prone,gripping position were important inconfirming the diagnosis of “dynamic”ulnar impaction syndrome because thebaseball player’s grip of the bat ismimicked, and when ulnar deviation isadded during the baseball swing, thealready decreased space between theulna and carpal bones becomes evensmaller as the structures in this spaceare impinged. Conclusions: Becauseof the variety of pathologies that canoccur at the wrist, differentialdiagnosis of patients with idiopathicwrist pain can often be difficult. Evenin individuals who do not present witha positive ulnar variance on traditionalradiography, a diagnosis of ulnar

impaction syndrome should beconsidered in patients with ulnar-sidedwrist pain, especially in athletes whoparticipate in club or racquet sports.Recognition and understanding ofulnar impaction syndrome and dynamiculnar impaction syndrome may lead tomore effective treatment and diagnosisof patients who suffer from ulnar-sided wrist pain.

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Free Communications, Oral Presentations: Non-Mechanical Factors Associatedwith InjuryThursday, June 27, 2013, 3:15pm-4:30pm; Palm D: Moderator: Reed Ferber, PhD, ATC13068SOINEpidemiology Of Basketball,Soccer And Volleyball InjuriesAt The Middle School LevelBarber Foss KD, Myer GD, HewettTE: Cincinnati Children’s HospitalMedical Center, Cincinnati, OH

Context: There are an estimated 30million school aged kids participatingin sports in the United States. Thisrepresents a greater than 20% increaseover the past decade. Of these 30million participants, 34% of middleschool aged participants becomeinjured and seek medical treatment atan annual cost of close to $2 billion.Middle School athletics showincreasing need for services providedby a certified athletic trainer (ATC).Objective: To describe theepidemiology of injuries documentedin the middle school setting over thecourse of three sport seasons. Design:Cohort Study. Setting: Middle Schooland Controlled Laboratory. Patients orOther Participants: Female basketball,soccer and volleyball players wererecruited from a single county publicschool district in Kentucky consistingof five middle schools. A total of 268subjects (162 basketball, 26 soccer and80 volleyball) participated as entireteams, resulting greater than 95%recruitment and data monitoring.Interventions: Athletes were monitoredfor sports related injury by an ATCduring each sports season. Injury wasoperationally defined as causingcessation of participation in thecurrent game or practice and preventedreturn to that session or the dayfollowing and any fracture, even if theathlete did not miss a session. Athleteexposures were recorded on a weeklybasis. Exposure data was submitted bythe coach into the SISS (Sports InjurySurveillance System). Injuries wererecorded in SIMS (Sports InjuryMonitoring System). Main OutcomeMeasures: Athlete risk of injury was

calculated for each sport and across allsports. Injury rate was calculated forspecific types of injuries within eachsport. Results: A total of 134 injurieswere recorded by the ATC over thethree sport seasons. Basketball had themost reported injuries at 84 (52%risk), followed by Volleyball with 38(47.5%) and then soccer with 12(46.1%). The overall rate of injury forbasketball was 4.20 per 1000 AE forgames and 2.24 per 1000 AE inpractice. Soccer game rate was 9.05per 1000 AE and 5.27 per 1000 AE inpractice. The injury rate in volleyballwas higher for practice (5.55 per 1000AE) than for games (0.75 per 1000 AE).The relative risk of injury was morethan twice as high in soccer comparedto basketball. Injuries to the knee werethe most common (99 injuries out of134 or 73.9%) of which PFD (31.3%),OSD (10.4%) and SLJ/patellatendonosis (9%) had the greatestincidence. Ankle was the second mostcommonly injured body partaccounting for 16.4% of all injuries.Conclusions: Middle school agedathletes displayed comparable injurypatterns to those seen in their highschool counterparts. Future work iswarranted to determine the potentialfor improved outcomes in middleschool populations with access to ATCservices.

13027FOINPatients With OsteoarthritisAnd A History Of SportParticipation Consume MoreMedication And Supplement ForManaging Joint Symptoms ThanPatients With OsteoarthritisAnd No History Of SportParticipation: A Cross-sectionalStudyDriban JB, Boehret SA,Balasubramanian E, Cattano NM,Glutting J, Sitler MR: Tufts MedicalCenter, Boston, MA; TempleUniversity, Philadelphia, PA;Temple University Hospital,Philadelphia, PA; West ChesterUniversity, West Chester, PA;University of Delaware, Newark,DE

Context: Osteoarthritis is prevalentamong athletes with a history of jointtrauma or participation in high-risksports. To provide better care for thispatient population we need tounderstand how patients with andwithout a history of sport participation(HxSP) manage joint symptoms.Objective: The purpose of theseanalyses was to determine if patientswith and without a HxSP consumemedications/supplements differentlyto manage joint symptoms. Design:Secondary analysis of a cross-sectional study (Driban et al., BMCMusculoskelet Disord. 2012). Setting:Urban hospital-based outpatientorthopedic practice. Patients: Werecruited a convenience sample of 184patients with a primary complaint ofhip or knee osteoarthritis (22 patientswere excluded or declined toparticipate). Hence, 162 patients wereincluded. The sample included 70(43%) patients without a HxSP: 79%female, 77% African descent, 58±10years old, body mass index=34.7±7.2kg/m2, 36% less than a high school orequivalent education, and 51%reported a diagnosis of arthritis at

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multiple joints. Additionally, 92 (57%)patients had a HxSP: 58% female,70% African descent, 61±11 years old,body mass index=35.7±8.2 kg/m2,21% less than a high school orequivalent education, and 63%reported a diagnosis of arthritis atmultiple joints. Most HxSP patientscompeted at the recreational (35%) orhigh school (47%) level.Interventions: One trained investigatoradministered four interview-basedquestionnaires to obtain informationabout the participant’s health history,sport participation, and pharma-cological/supplemental use. Thequestionnaires were developed by theresearch team and reviewed by twostatisticians. Main OutcomeMeasures: The questionnaires were anitem-by-item design where eachquestion could be scored individually.We used Fisher Exact Tests andlogistic regression models todetermine if a HxSP was associatedwith patterns of medication/supplement use. Odds ratios (OR) and95% confidence intervals (CI) werecalculated. Results: Patients with aHxSP (49%) more often consumed >2medications/supplements for theirjoint symptoms than patients withouta HxSP (29%; OR=2.4, 95%CI=1.3 to4.6). This was true even after adjustingfor gender, education, ethnicity, orreported diagnosis of arthritis atmultiple joints. Both groupsoccasionally or never consumed theirmedication consistently (withHxSP=44%, without HxSP =44%;p=1.00). Finally, patients with andwithout a HxSP (15%, 18%;respectively) had a similar frequencyof patients reporting their medicationas ineffective or required a strongermedication to manage joint symptoms.Conclusions: Similar to findings thatcurrent and retired football playersmay misuse analgesic medications wefound that patients with a HxSP mayconsume more medications to managetheir joint symptoms than patientswithout a HxSP. To promote safer and

more efficacious treatments forpatients with a HxSP we need to findnew strategies to better educate andcommunicate with HxSP patientsabout safe medication use.

Sleep Quantity, Sleep Qualityand Daytime SleepinessAssessment in CollegiateAthletesDettl MG, Ragan BG: OhioUniversity, Division of AthleticTraining, Athens, OH

Context: Sleep is an importantcomponent of health and can affectnormal psychological andphysiological function. Poor sleep hasbeen associated with suboptimalathletic performance therefore it isimportant for athletic trainers toassess sleep in patients. There are 3main characteristics associated withsleep assessment: quality, quantity, anddaytime sleepiness. Currently, there isscant research in athletic trainingexamining the relationship betweenthese characteristics in collegiateathletes. Objective: To examine therelationship between the 3characteristics of sleep in femalecollegiate athletes. Design: Cross-sectional. Setting: Clinical athletictraining setting at a NCAA Division Iinstitution. Participants: A total of 43female student athletes (Age: mean ±SD: 19.57 yrs ± 0.86) volunteered forthis study. Power analysis for acorrelation of 0.3 with a power 0 of0.80 indicated a sample size of 42.Intervention: Participants wore anaccelerometer to assess sleep quantityon their wrists while sleeping for 7consecutive nights. At the end of thedata collection period, participantscompleted computer adaptivePROMIS sleep-related impairment(SRI: daytime sleepiness) and sleepdisturbance (SD: sleep quality)instruments. Validity of these sleepmeasures has been well established inother disease populations. MainOutcome Measures: The dependentvariables were T scores from the SRI,SD, and the 6 accelerometry variables.Using the ActiLife5 software, theSadeh algorithm was used because ofthe age of the population. Thealgorithm produced the 7-day average

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13310MOTERelationship BetweenRehabilitation Related MentalToughness, Mood, And AnxietyAfter InjuryCaswell A, Ragan BG, Snook EM:University of MassachusettsAmherst, Amherst, MA; OhioUniversity, Athens, OH; DatalysCenter for Sports Injury Researchand Prevention, Indianapolis, IN

Context: Many elite athletesexperience mood disturbances (e.g.,depression) and stress after beinginjured during practice or competition.These negative psychologicalreactions to injury can reduceadherence to rehabilitation protocolsimpacting recovery outcomes. Mentaltoughness has been shown to beassociated with better adherence torehabilitation protocols, however therelationship between mentaltoughness and psychological variablesafter an injury has occurred has yet tobe examined. Objective: To determinethe relationships among mentaltoughness, mood state, and anxiety ininjured collegiate athletes. Design:Cross-sectional. Setting: NCAADivision I athletes at a publicuniversity. Patients or OtherParticipants: Thirty-four (n = 15females) collegiate athletes (20.0 ±1.6 years of age) from 8 varsity sportsinjured during practice or competition.Interventions: Injured athletesprovided informed consent and thencompleted the study surveys on alaptop in the athletic training room.The surveys completed assessedmental toughness (Mental, Emotional,and Bodily Toughness Inventory forRehabilitation [MeBRecover]), mooddisturbance (Profile of Mood States),and perceived stress (Perceived StressScale). Main Outcome Measures:Pearson product-moment correlationcoefficients (r) were calculatedamong the total scores from thesurveys to determine if mentaltoughness was associated with post-

injury mood disturbance and perceivedstress. Results: Mean ± SD for thesurveys are as follows: Profile ofMood States total mood disturbance(27.27 ± 1 3.52), Perceived StressScale (17.59 ± 7.13), andMeBRecover (130.78 ± 13.08).Mental toughness levels weresignificantly correlated with totalmood disturbance (r = -.47, p = .007)and perceived stress (r = -.52, p =.002), indicating that higher levels ofmental toughness were associated withless mood disturbance and stress afterinjury. Conclusions: This researchprovides evidence of relationshipbetween mood disturbances, stress,and mental toughness after injury.Mental toughness is a potentiallymodifiable variable. The results of thisresearch suggest that an interventionaimed at modifying mental toughnessmay have a positive impact onpsychological responses to injury andpotentially improve rehabilitationadherence and outcomes.

of the six key accelerometry sleepvariables: latency (L), total sleep time(TS), time awake (TA), number ofawakenings (A), average awakenings(AA), and sleep efficiency (SE).Relationships between the 3characteristics were examined usingSpearman Rho correlations. ThePROMIS scores were expected to havenegative correlations with SE and TSand to have positive correlations withA, AA, TA, and L. Alpha was set at 0.05.Results: There were significantcorrelations between SRI and SD (r =.42; P<0.05) and SD and TS (r = -0.31;P<0.05). There were no othersignificant correlations. The sleepquantity scores (mean ± SD) were: L= 9.56 ± 9.24 min, TS = 391.67 ± 56.02min, TA = 95.34 ± 10.26 min, A =19.48 ± 5.16 times, AA = 3.65 ± 1.31min per time, and SE = 85 ± 5.69percent. SRI mean score (T score) was56.1 ± 5.76 and SD was 51.88 ± 7.19.Conclusion: Our results indicate thatthe three important characteristics ofsleep in a collegiate population areindependent of each other and need tobe assessed individually. Athletictrainers should be aware that sleepquality, sleep quantity, and daytimesleepiness should be assessed andPROMIS adaptive instruments andaccelerometry together provide aclinically useful and easy way ofmeasuring sleep.

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13382FOINReturn-To-Play ProbabilityEstimates Are Affected ByWhich Knee Ligament Is InjuredMedina McKeon JM, Adkins SG,Bush HM, Comstock RD:University of Kentucky, Lexington,KY, and Research Institute atNationwide Children’s Hospital,Columbus, OH

Context: Knee sprains are the secondmost common sports-related injury;tissue damage alone is not a preciseindicator of when an athlete willreturn-to-play (RTP). Objective,evidence-based estimates of RTPfollowing a knee sprain are needed.Objective: To determine RTPprobability timelines amongst the 4major ligaments of the knee followinga sprain. Design: Observational,epidemiological. Setting: Secondarydata analysis of High School RIO™database. Patients or OtherParticipants: High school athleteswith knee sprains sustained duringschool-sanctioned athletic partici-pation (mean±SD: age=16.0 ±1.2yrs,height =177.3±10.2cm; mass= 77.5±18.7kg). Interventions: New kneesprains were classified by whichligament was documented as injured:anterior cruciate (ACL), posteriorcruciate (PCL), medial collateral(MCL), lateral collateral (LCL). Onlysingle-ligament injuries wereconsidered for analysis. A new injurywas defined as an acute knee sprainwith no prior history of that sameinjury. Main Outcome Measures:Kaplan-Meier(KM) estimators[censored data] were stratified byligament damaged and used tostatistically compare the probability oftime until RTP (T-RTP) after new kneesprain for each ligament. Cases forwhich the athlete did not RTP (medicaldisqualification or season endedbefore the athlete was released) wereconsidered censored. For theestimators, each knee sprain wasanalyzed based on RTP status (return,no return) at specified timeframe

intervals (1-2 day return, 3-6 days, 7-9 days, 10-21 days, > 22-days, noreturn [censored]). Alpha levels wereset at p<.05. Results: A total of 1,332new, single-ligament knee sprains wereconsidered for analysis (ACL=340[227 censored], PCL=35 [12censored], MCL=799 [168 censored],LCL=158 [31 censored]). There wasa significant difference in median T-RTP amongst each ligament(P<.0001). The median T-RTP forACL=22 days (IQR=22,22); PCL=10days (IQR=3,22); MCL=10 days(IQR=3,22); LCL=7 days (IQR=3,22). Selected results are presentedto highlight characteristics of the KMcurves generated. The T-RTPprobability [exact 95% confidenceintervals] of return by 7-9 days for aninjury to the ACL=8.3% [5.8,11.8];PCL=31.7% [18.9,49.9]; MCL=39.3% [36.0,42.8]; LCL=51.9%[44.4,59.9]. The probability of returnby 10-21 days for an injury to theACL=15.5% [12.1,19.1]; PCL=52.5% [37.0,69.7]; MCL =65.4%[62.1,68.7]; LCL=72.0% [64.9,78.9].The lowest probability of return atevery timepoint was due to ACL injury.Curves for the MCL and LCL indicatedthe highest probabilities of return atall time points. Conclusions: RTPafter a single ligament injury isaffected by which ligament wasdamaged. As expected, ACL injurieshad the highest proportion of censoredcases, and the least likelihood to RTPat all time points following injury. Thelikelihood of RTP following MCL orLCL injuries was far higher than thatof the cruciate ligaments. RTPprobabilities can assist clinicians withproviding accurate prognoses forathletes, in particular when surgery isnot likely to be indicated. Further time-to-event analysis of combination-ligament injuries is warranted.

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Free Communications, Poster Presentations: Undergraduate Poster AwardFinalists1 3 2 1 2 U O P R

The Effects Of Ankle KinesioTaping On Muscle ActivityDuring A Drop LandingManeuverFayson SD, Needle AR, Kaminski TW: University ofDelaware, Newark, DE

Context: Kinesio tape (KT) hasrecently gained popularity in theprevention and treatment of athleticinjuries, specifically in the lowerextremity. Previous research hassupported increases in ankle stiffnesswith use of KT; however, it is unclearwhether this is a result of increasedmuscle activation or the mechanicalproperties of the tape. Objective: Toexamine the immediate and prolongedeffects of KT application at the ankleon lower-leg muscle activity during adrop landing. Design: Single grouppre-test, post-test. Setting: Climate-controlled biomechanics laboratory.Patients or Other Participants:Twenty-two subjects (20.0±1.4yrs;72.0±9.8kg; 170.0±14.9cm) with nohistory of ankle pathology volunteeredfor this study. Interventions: Subjectswere asked to jump from a 35cm boxon to an in-ground forceplate andimmediately jump to a height equal to50 percent of their maximum verticaljump. Surface electromyography(EMG) was collected from the tibialisanterior (TA), peroneus longus (PL)and lateral gastrocnemius (LG)muscles and synchronized at 1000Hzwith forceplate data. Five trials werecollected under each of 3 conditions:prior to ankle KT application (BL),immediately after tape application of(KT-I), and following 24-hours of use(KT-24). Kinesio tape applicationfollowed techniques reported inprevious research, using an anteriorstrip applied distal to proximal, astirrup applied from medial to lateral,and transverse strip applied over the

anterior ankle. Main OutcomeMeasures: Peak force (N) fromlanding was compared with a repeated-measures ANOVA with one within-subject factor (Condition). AverageEMG (% ensemble peak) wascalculated 250ms prior to landing(PRE), 0-250ms (POST-1) and 250-500ms (POST-2) after forceplatecontact. EMG measures werecompared with a 3-way ANOVA wihthree within-subject factors(Condition, Muscle, Time). Results:No significant differences wereobserved for peak force(F2,40=1.349, BL=1809.5±824.6N,KT-I=1758.0±784.5N , KT-24=1911.6±1060.0N , p=0.27). Asignificant interaction effect foraverage EMG was observed betweencondition, muscle, and time(F8,160=4.19, p<0.001). Pairwisecomparisons revealed TA activity atPOST-1 decreased from BL(62.2±14.1%) to KT-I (48.1±24.5%,p=0.027), and trended toward adecrease at KT-24 (47.7±26.2%,p=0.054). Furthermore, PL activity atPOST-2 decreased from BL(46.9±23.5%) to KT-24 (27.3±23.5%,p=0.022). Conclusions: Our datademonstrate a decrease in TA and PLmuscle activity with KT application.While this effect appears undesirable,as no changes in peak force wereobserved, these results could suggestthat individuals were able to maintainperformance level with less muscleactivity. While previous research hasreported both muscle facilitationand inhibition following KT use, fewhave studied these variables with ameasure of performance or jointmechanics. To investigate whether thismuscle inhibition is beneficialor detrimental, future studies mighttest the effect of KT on muscleactivation and performance during amore complex landing task.

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Comparison Of Gluteus MediusActivation Between WeightBearing And Non-WeightBearing Limbs During AFunctional Assessment OfHip Abduction StrengthBaellow AL, Nguyen A, BolingMC: High Point University, HighPoint, NC, and University of NorthFlorida, Jacksonville, FL

Context: Decreased function of thegluteus medius (G

med) leading to

dynamic lower extremitymalalignments has been suggested toincrease the risk of knee injuries.However, the relationship betweenG

med function and dynamic lower

extremity motion remains unclear.This may be attributed to themeasurement methods of hipabduction function that are commonlyperformed in side lying, non-weightbearing positions, which may notaccurately reflect G

med function during

weight bearing, functional activities.Assessing

G

med function in a functional

position may require greater activationto stabilize the pelvis in a single limbstance. Objective: To examine thedifferences in G

med activation between

the weight bearing (WB) and non-weight bearing (NWB) limb during afunctional assessment of hip abductionstrength. Design: Descriptivelaboratory study. Setting: Researchlaboratory. Patients or OtherParticipants: Twenty (10 males, 10females) healthy collegiate agedparticipants (24.9±3.9 yrs, 171.7±7.9cm, 71.6±14.9 kg) volunteered for thisstudy. Interventions: Gluteus mediussurface electromyography signals(sEMG) of the WB and NWB limbwere measured as participantsperformed 3 standing hip abductionmaximum voluntary isometriccontractions (MVIC) of the right andleft limbs (hip abducted 5°) on anisokinetic dynamometer. Excellent

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day-to-day reliability of torqueproduction was previouslydemonstrated for this standingmeasure (ICC

2,k=0.91, SEM=0.03

Nm·kg-1). Main Outcome Measures:The maximum root mean squaredamplitudes (volts) of the WB andNWB G

med across 3 trials were used

for analysis. Paired samples t-testsdetermined the difference betweenG

med activation of the WB and NWB

limbs. Results: The maximum rootmean square amplitudes during righthip abduction MVIC for the WB andNWB G

med were 0.369±0.205 and

0.275±0.155 volts, respectively. Themaximum root mean squareamplitudes during left hip abductionMVIC for the WB and NWB G

med were

0.375±0.216 and 0.262±0.183 volts,respectively. The maximum root meansquare amplitudes of the WB G

med was

significantly higher than the NWB Gmed

during both right (paired difference =0.090 volts, P<0.001) and left (paireddifference = 0.097 volts, P<0.001)hip abduction MVIC. Conclusions:Activation of the G

med was greater on

the WB compared to the NWB limbwhen assessing hip abduction MVIC ina functional, WB position. In order forthe NWB limb to produce an abductionforce, greater activation of the WBG

med may be necessary to meet the

increased demand to stabilize thepelvis and trunk. Assessing hipabduction MVIC in a more function-al position may be a more accuraterepresentation of G

med function when

examining the role of the hipabductors in controlling lowerextremity motion during dynamicactivities and their contribution to theincreased risk of knee injuries.

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Metabolic Disorder In ACollegiate Football PlayerPeters J, Rothbard M, NelsonC: Southern Connecticut StateUniversity, New Haven, CT

Background: A 17 year-old African-American male (179.8cm, 79.4kg)presented to the athletic trainer withthirst, fatigue, shortness of breath,dizziness, muscle pain, cramping, andweakness shortly after completingsprints during an Augustintercollegiate football practice. On-site evaluation by the athletic traineridentified confusion, tachycardia,respiratory distress, significant loss ofextremity motion, and inability to self-ambulate. The patient’s medical historywas significant for a cramping andvomiting episode associated withsummer football camp at age 15, andsickle cell trait. DifferentialDiagnosis: Exertional heat stroke,rhabdomyolysis, sickle cell crisis,McArdle disease, Tarui disease, andmalignant hyperthermia. Treatment:After initial evaluation, an immediateattempt to orally rehydrate and rapidlycool the patient was performed by theathletic training staff. EMS wasactivated and administered on-site IVfluids and transported the patient to theemergency department. Upon arrival atthe hospital, blood tests were ordered,revealing changes in electrolyte levelsand blood chemistry. Creatine kinase(CK) levels were significantly elevated(2540 U/L). At the hospital, the patientwas stabilized, prescribed Dantrium®

for two weeks, instructed to follow upwith his health care provider, andreleased. After following up with theathletic trainer, the patient was referredto the team physician who orderedadditional blood tests and restrictedthe patient from athletic participationwhile awaiting results. Status-post twodays, CK levels remained elevated(1710 U/L) and the patient wassubsequently referred to a neurologist,nephrologist, and cardiologist. Allexaminations and additional diagnostictesting was inconclusive. The team

physician further disqualified thepatient and instructed the athletictraining staff to monitor his condition.Status-post 11 weeks, blood testsrevealed that the patient’s CK levelsremained elevated (914U/L). Thepatient was diagnosed with non-anesthesia malignant hyperthermiabecause he continued to demonstratehyper-CK-emia for which the etiologyremained unclear. The absence of amuscle biopsy and subsequent caffeinehalothane contracture test, which isonly offered at five centers in the US,created an inability to identify theetiology of the case and prevented adefinitive diagnosis. The patient wascleared for unrestricted activity by theteam physician and was instructed toreport any changes in health status tothe athletic training staff. Uniqueness:Malignant hyperthermia is rare,although its prevalence has not beenestablished due to a lack of universalreporting. This case is unique becausethe presence of the hematological andmetabolic conditions that manifested,in conjunction with the inability toobtain the necessary diagnostictesting, made the definitive diagnosis,management, and return to activityclearance complex. Also, blood CKlevels normally range from 22 to 198U/L, depending on gender, activitylevel, and ethnicity. This patient’s CKlevels were 23 times normal and hecontinued to demonstrate hyper-CK-emia status-post 11 weeks, for whichthe etiology remained unclear. A lackof research exists about the safety ofathletic participation and clinicalinterventions associated withmalignant hyperthermia. Conclusion:Malignant hyperthermia is a rare,life-threatening, inherited hyper-metabolism syndrome characterizedby muscle abnormality triggered byanesthesia, muscle relaxants, intenseexercise, and/or hyperthermia. In non-anesthetic malignant hyperthermiacases such as this, an abnormalryanodine receptor in skeletal muscleaffects function when until exposed to

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intense exercise or hyperthermia. Abiochemical chain reaction begins thatcauses abnormal release of calciumfrom the sarcoplasmic reticulum. Thisthen results in excessive calcium inskeletal muscles, leading to sustainedmuscle contractions and an increase inmuscular metabolism. ATP depletionis then followed by rhabdomyolyses,which causes the release of potassiumand myoglobin into the blood stream.Ultimately cardiac abnormalities andrenal dysfunction result. Such cardiacand renal complications includemetabolic and respiratory acidosis,heat production, sympathetic nervoussystem activation, hyperkalemia, andblood coagulation irregularity.

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Determination Of MicrobialPopulations In A SyntheticTurf SystemHintze D, Bass J, Oberg C:Weber State University, Ogden,UT

Context: There is growing concernregarding the contribution of infilledturf fields on athlete infections.Abrasions that occur on these fieldscreate a portal of entry for pathogenssuch as Staphylococcus aureus .Objective: This study compared theoccurrence of microbial populationson two infilled turf fields (year old turfin stadium vs. 6 year old turf in practicefield) in three locations on each field.It was hypothesized that the older turffield will contain higher microbialpopulations, therefore, presentinggreater risk. Design: Infill materialfrom both fields was sampled weeklyat each site for 5 months through thefootball season with microbialenumeration done on three selectivemedia. Setting: Sites sampled includethe sideline, the middle of the field,and the end of the field on both fields.Interventions: Tryptic Soy Agar willbe used to determine total microbialload, Mannitol Salt Agar for S. aureus,and Eosin Methylene Blue Agar todetermine the number of coliformssuch as Escherichia coli. MainOutcome Measures: A comparisonwas done between the two fields at eachsite to determine differences betweenmicrobial loads. Means at each sitewere determined and compared bothfor each sample time and over the testperiod. Results: Higher microbialpopulations were found on the olderturf field (as much as a 1E+04 increase

over similar locations on the newerturf), as well as in areas of high trafficsuch as the sidelines. This suggestsmicrobial populations can accumulatein synthetic turf infill from year toyear. When comparing the bacterialload on different areas of the field, thesideline has the highest counts with anaverage of 1.60E+08 CFUs per gramof rubber infill on the older turf. Onthe new turf, the area with the highestnumber of total microorganisms wasthe end of the field rather than thesideline, with an average of 3.09E+05CFUs per gram of infill. This isprobably due to practices held on thestadium turf field rather than actualgame play. A high number of salt-tolerant, mannitol fermenting bacteria(indicators of S. aureus) were alsofound, an average of 3.25E+02 CFUsper gram on the new turf and 2.73E+03 CFUs per gram on the older turf.Escherichia coli was isolated usingEMB agar on the newer turf, in anarea of high usage. Conclusions:These results indicate that infillmaterial can serve as a source forthe spread of pathogens amongathletes and that these organisms seemto accumulate over time posinga greater risk if proper cleaningis not routinely performed.

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dimensional motion system with two,three-point segment marker sets (headand torso) were used in capturing headand torso motion. Kintrak 6.0 and Eva-RT 5.0 (Motion Analysis, Inc.)software was used to digitize motiontrials and process the outcomevariables. Main Outcome Measures:Dependent variables involvedintegrated velocity and integratedacceleration of the head in each of thethree planes (sagittal, frontal,transverse). Trials for each pair wereensemble averaged. Due to ourparticipant pairing, our analyses werebased on a sample of n=20. Six pairedsamples t-tests compared means ineach plane (Pd”0.05). Results:Removing traditional shoulder padsresulted in significantly lessacceleration compared to removingRipKordTM shoulder pads in thesagittal [(t

19 = -4.404,P<.001) Trad

=1964.53 ±639.01 m/s2, Rip=2915.47±780.02 m/s2], and frontal[(t

19= -2.620, P=.017) Trad=

842.32±336.22 m/s2, Rip=1255.55±566.91 m/s2] planes. Removingtraditional shoulder pads also resultedin significantly less velocity in allthree planes [[(t

19= -4.194, P<.00)

Trad=94.63±23.44m/s, Rip= 136.07±38.49 m/s; (t

19= -3.822, P=.001)

Trad=35.60 ±8.22 m/s, Rip=49.30±15.01 m/s; (t

19= -2.632,

P=.016) Trad= 55.83±16.74 m/s,Rip=70.60±20.55 m/s]. Conclusions:Our hypotheses were rejected in thatthe data presented suggest that whenusing the flat torso technique, atraditional style of shoulder pads willresult in lower velocity andacceleration of the head compared tothe RipKord TM shoulder pads. Thisdata does not reflect the amount ofmotion experienced in the cervicalspine at time of removal. Futureresearch should investigate thesevariables in different styles ofshoulder pads using other removaltechniques (i.e., full body levitation,torso lift). This study was funded

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Velocity And Acceleration OfThe Head During EmergencyShoulder Pad RemovalHall BT, Swartz EE, Al-Darraji SJ,Bric JD, Decoster LC, Mihalik JP:University of New Hampshire,Durham, NC; New HampshireMusculoskeletal Institute,Manchester, NH; University ofNorth Carolina, Chapel Hill, NC

Context: As American footballequipment designs introduce newtechnology to improve safety,evidence-based techniques for theiremergent removal must coincide.Previous research in emergencyremoval of shoulder pads hasinvestigated the time for removal andthe induced motion within the cervicalspine. Velocities and accelerations ofthe head and cervical spine duringthese interventions are importantconsiderations that have not beenextensively studied. Objective: Toexamine head velocity andacceleration when removing twostyles of football shoulder pads. Wehypothesized that a new quick releasestyle of shoulder pads would result inless acceleration and velocity at thehead during shoulder pad removal.Design: Quasi-experimental. Setting:Research laboratory. Patients orOther Participants: Forty certifiedathletic trainers (ATs) free of physicalpathology preventing them fromcompleting the required tasks wererecruited (males=21; females=19;age=33.7±11.2 yrs; mass=80.7±17.1kg; height=173.1±9.2 cm; ATexperience=10.6±10.4 yrs). Inter-ventions: The independent variablewas the shoulder pad design(Traditional or Riddell RipKordTM).After practicing and familiarizingthemselves, paired participantsconducted 8 successful, randomizedtrials where they removed traditional(Trad) shoulder pads (using the flattorso technique) or RipKordTM (Rip)shoulder pads from a live model (4trials of each). An eight-camera three-

by the Eastern Athletic Trainers’Association and the Hamel Centerfor Undergraduate Research.

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Free Communications, Poster Presentations: Master’s Poster Award Finalists1 3 4 1 7 M O H E

Career And Family AspirationsOf Female Athletic TrainersEmployed In The NCAA DivisionI SettingClines SH, Mazerolle SM, FerraroEM, Barone CM, Goodman A:University of Connecticut, Storrs,CT

Context: Evidence suggests thatfemale athletic trainers (FAT) departthe profession of athletic training afterthe age of 28. Factors influencingdeparture are theoretical, but includeburnout, job dissatisfaction, andmotherhood. Professional demands,particularly at the collegiate setting,have also been at the forefront ofanecdotal discussion on departurefactors. Objective: Gain a betterunderstanding of the career and familyintentions of FATs employed in thecollegiate setting. Design: Structured,online asynchronous interviews viaQuestionPro™ Setting: NCAADivision I Collegiate Setting.Patients or Other Participants: 26FATs (single=14; married=6; marriedwith children=6) employed in theNCAA Division I setting volunteered.Average age of the participants was 34± 8. All were full-time BOC certifiedwith an average 11 ± 7 years of clinicalexperience. All FATs were on 12 monthcontracts, were responsible formedical coverage for an average of 2± 1 teams, and worked on average 59± 18hours a week. Data Collectionand Analysis: All FATs responded toa series of open-ended questions viareflective journaling. Data was storedon QuestionPro™ a secure datatracking website and the study waspiloted prior to data collection. Datawas analyzed borrowing from theprinciples of general inductiveapproach. Trustworthiness wasestablished by peer review, memberinterpretive review, and multipleanalyst triangulation. Results: Ourparticipants indicated a strong desireto focus on family or to start a familyas part of their personal aspirations.

Professionally, many FATs wereunsure of their longevity within thecollegiate setting or even theprofession itself, the major stimuliincluded job demands and time. Only3 FATs indicated a professional goalthat included persisting at the DivisionI setting regardless of their family ormarital status. Six FATs plan to departthe profession entirely due to conflictswith motherhood and the role of theathletic trainer. The remaining 17 FATsindicated a plan to make a settingchange to balance the roles of motherand athletic trainer because theDivision I setting was not conduciveto parenting. All participants indicatedthat no formal policies were in placeto help FATs balance their roles asboth a mother and collegiate athletictrainer. Conclusions: Our resultssubstantiate previous research, whichindicates the Division I setting can beproblematic for FATs and stimulatesdeparture from the setting and even theprofession. Only a small few indicatedan intention to remain in the collegiatesetting long-term due to constraintsrelated to the role of the athletictrainer in the collegiate setting and itsimpact on being a good mother. Thosewho intended to persist were reliant onpersonal and work support networks,common work life balance strategies.Future research may investigate therole of mentorship on the retention ofFATs who are also mothers.

Patient-Centered And ClinicalOutcomes Associated WithGrade II Lateral Ankle Sprains:A Case SeriesMulligan RP, Mutchler J, HochMC, Van Lunen BL: Old DominionUniversity, Norfolk, VA

Background: The purpose of this caseseries is to describe the clinical andpatient-centered outcomes of 5collegiate athletes who presented totheir respective athletic trainingfacilities with grade II lateral anklesprains. These patients (2 female, 3male; age=19.4±0.8years) wereparticipating in NCAA athletics(lacrosse, track, soccer and baseball)and sustained a lateral ankle sprainassociated with an inversionmechanism while running or landing.Four patients reported no previoushistory of ankle sprain. All patientsexhibited mild-to-moderate instabilitywith manual stress tests (anteriordrawer and talar tilt), point tendernessover the lateral ankle ligaments,limited ROM compared to thecontralateral ankle, pain with weight-bearing, and sudden onset of edemawithin 72 hours of injury. All patientswere monitored over the course oftreatment using objective clinicalmeasures (OCM) including pain, theglobal rating of change scale (GROC),and active dorsiflexion range ofmotion (DROM) along with self-reported measures of health includingthe Foot and Ankle Ability Measure(FAAM), the FAAM-Sport, theCumberland Ankle Instability Tool(CAIT), and the Tampa Scale ofKinesiophobia-11 (TSK-11). Whilethe FAAM, FAAM-Sport, and CAIT arepatient reported outcomes (PRO)focusing on regional measures ofhealth associated with the foot andankle, the TSK-11 describes the fearof movement. Treatment: Treatmentand rehabilitation protocols for eachpatient were dependent upon thediscretion of their respective athletictrainer. Patients completed PRO and

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Multiple Joint InflammationWithin A Division IA FootballDefensive TackleWall A, Uhl TL, Amponsah G:University of Kentucky. Lexington,KY

Background: The individual is a 21year old African American division IAfootball athlete. The athlete is a 330pound defensive lineman with a historyof arthritis within his right shoulderand both knees. After playing in a gamethe athlete presented with a fever of100.9 degrees. He reported someminor joint pain in his right wrist andright great toe but the fever was hismain complaint. The athlete’s wristand great toe were found to have fullrange of motion and no pain limitingmotion. The athlete was treated for hisfever with fluids, ibuprofen, and coldrelief medication. The following daythe fever subsided but the pain in theathlete’s great toe and wrist increased.The joints were re-evaluated andimmobilized due to limited motionand pain. Athlete was referred to ateam physician for further evaluation.Differential Diagnosis: Turf Toe,Tenosynovitis of the wrist,Inflammatory arthritis Treatment:The team physician ordered X-rays forboth joints which were negative forfracture in both joints. After one dayof being immobilized in a walkingboot, a large amount of swelling andpain developed in his left knee. Theathlete admitted himself to theemergency room due to his increasedswelling and pain. The following dayafter being released from ER, theathlete had a MRI of his wrist and kneex-ray as ordered by the team physician.MRI results of the wrist showedtenosynovitis of the extensordigitorum tendon and the knee x-raywas negative for fracture. The teamphysician aspirated 120cc of murkyyellowish fluid removed from hisknee. After seeing the appearance ofthe aspirated fluid, the teamorthopedists ordered laboratory tests

OCM one day post-injury (Day1), oneweek post-injury (Week1), and atreturn to play (RTP)(19.6±5.86days).Active DROM was measured indegrees with the patient in proneposition with the knee extended. Painwas measured in centimeters using avisual analog scale (VAS) and changesin self-reported injury status weremeasured using the GROC. The FAAMcontains 21 items related to activitiesof daily living (highest score=100%),the FAAM-Sport contains 8 itemsrelated to sport-specific activity(highest score=100%), and the CAITcontains nine items pertaining toinstability during activity (highestscore=30). All items on the FAAM,FAAM-Sport, and CAIT are graded ona Likert scale with higher scoresindicating greater self-reportedfunction. The TSK-11 is an 11-itemquestionnaire graded on a 4-pointLikert scale (total=44, lowest=11)with higher scores indicating greaterfear of movement. Results: Allpatients demonstrated improvementsin OCM as indicated by changes inDROM (Day1=6.6±8.47°; Week1=10.6±5.32°), pain on the VAS(Day1=5.28±2.41cm; Week1 =1.5±1.19cm) and the GROC (Day1= -0.02±2.0; Week1=2.8±0.83). Theimprovements in OCM correspondedto improvements in overall healthstatus as indicated by changes in PROmeasures for the FAAM (Day1=55.50±20.00%; Week1 =79.00±23.50%), the FAAM-Sport (Day1=11.87±3.56%; Week1 =27.50±6.38%), the CAIT (Day1=8.20±7.43; Week1= 13.60± 7.43) andthe TSK-11 (Day1=26.80±3.27;Week1=22.20±3.03). The GROCcontinued to improve at RTP(4.5±0.55) while pain (0.06±0.09cm)and DROM (10.6±7.13°) did notchange. Upon RTP, all patientsdemonstrated high levels of functionon each PRO measure (FAAM=98.50±2.05%; FAAM-Sport= 96.25±5.59%; CAIT=24.60±3.21; TSK-

11=16.00±2.34) indicating minimalfunctional loss. Uniqueness: There isa lack of evidence supporting the useof PRO and OCM to track the progressduring rehabilitation of lateral anklesprains. This case series demonstrateshow patient-centered measures offunction can be used to enhance patientevaluation and track rehabilitationprogress when combined withtraditional clinical indicators offunction. Conclusions: Followinglateral ankle sprain, patientsdemonstrated decreases in pain,increases in DROM, andimprovements in perceived injurystatus which corresponded withimprovements in self-reportedmeasures of health assessed throughPRO instruments. All patientsdemonstrated improvements in OCMand PRO at RTP regardless of theirrehabilitation plan. However, PROinstruments continued to identifyimprovements at RTP despite a plateauin certain OCM. This demonstrates thebenefit of combining OCM and PROfor tracking the rehabilitation progressfor patients with lateral ankle sprains.

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The Landing Error ScoringSystem: Do Jump-LandingPatterns Differ Based On Sport?Kulow SM, Valovich McLeod TC,Lam KC: A.T. Still University, Mesa,AZ

Context: The Landing Error ScoringSystem (LESS) is a clinical screeningtool used to assess jump-landingpatterns and identify individuals whomay be at-risk for an anterior cruciateligament (ACL) injury. While previousinvestigations have identified sex andage differences in jump-landingpatterns, it is unclear whether othergroup differences exist. Objective:To determine whether jump-landingpatterns, as assessed by the LESS,differ based on sport. Design: Cross-sectional. Setting: Athletic trainingfacilities. Patients or OtherParticipants: Two-hundred and fifteenintercollegiate athletes were groupedby high-risk (basketball, soccer,volleyball) (male=37, female=62,age=19.8±1.5 years, height=173.3±10.0 cm, weight=68.7±10.2 kg)and low-risk (baseball, softball, trackand field, cross-country, wrestling)(male=79, female=37, age=19.4±1.5years, height=176.0±10.3 cm,weight=72.6±12.3 kg) sports for ACLinjury. Interventions: Independentvariables included risk group and sex.Participants were videotaped from thefrontal and sagittal views whileperforming three trials of a jump-landing task. Videos were later scoredusing the LESS, a reliable and valid 17-item binary scoring system that countsthe number of errors (eg, knee valgusangle) an individual commits at initialground contact (IGC) and maximumknee flexion (MKF) during the jump-landing task. Each trial produces a trialscore, and the mean of all trial scoresrepresents an overall score (OS), withhigher scores indicating poorer jump-landing patterns. Errors for eachscoring item were summed acrosstrials for an item score (IS) and errorsfor all frontal and sagittal items were

to be conducted on the fluid. Theresults showed that the cell count withdifferential demonstrated elevatedWBC count. Due to the elevated WBC,the team physician was worried aboutthe possibility of infection in theathlete’s knee. The team physicianordered the athlete to be admitted tothe hospital for further evaluation andhe was given I.V. antibiotics for twodays. Infectious disease doctors fromthe hospital ER diagnosed the athletewith having either inflammatoryarthritis or disseminated gonococcalarthritis pending the athlete’s labresults. The athlete was dischargedfrom the hospital by the team physicianwith a prescription of Suprax to taketwice a day for two weeks. Suprax isan antibiotic prescribed to treatbacterial infections.The athlete wasmonitored closely by the athletictraining staff over the next two weeksto ensure the athlete was compliantwith taking his medication. Over thecourse of the two weeks the athlete’ssymptoms subsided. The athlete wasgradually returned to play and able tofinish the remainder of the footballseason without a reoccurrence.Uniqueness: This case was unique dueto the rapid onset of symptoms theathlete experienced within a short timeperiod. The staff believed that all ofthe injuries were correlated to theinflammatory arthritis that attackedseveral joints in the athlete’s body. Theathlete had typical presentation ofinflammatory arthritis although thiscondition is normally seen within anolder age group of adults. Theincidence rate of this kind ofinflammatory arthritis is very rare inathletic populations. Conclusions:This case is important because athletictrainers must be mindful of septicand inflammatory arthritis in athleteswith sudden onset of swelling and painwithin multiple joints. Given theresults of the laboratory tests,the medical staff diagnosed thisathlete with inflammatory arthritiswhich was treated with appropriate

medicine and allowed return to fullparticipation in sixteen days.

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1 3 2 0 3 M O E X

The Reliability Of CommonlyUsed Wet Bulb GlobeTemperature DevicesCurry PR, Miles JD, Rosen AB,Ko JP, Cooper ER, GrundsteinAJ, Ferrara MS: University ofGeorgia, Athens, GA

Context: Wet Bulb GlobeTemperature (WBGT) is a compositeenvironmental measure used toestimate the effect of ambienttemperature, humidity and radiation.WBGT measures are used in a varietyof settings including the workplace,military and athletics. The GeorgiaHigh School Association has adoptedspecific rules for practice based on theWBGT reading. Objective: To assessthe reliability of commonly usedWBGT devices on different surfaces.Design: Observational field study.Setting: Artificial field turf and grasspractice fields in Athens, Ga.Equipment: The Extech Heat StressMeter, General Heat Index Checker,Kestrel 4400 Heat Stress Tracker,Kyoto Electronics WBGT 103 HeatStress Checker, Quest Temp 34 andReed Heat Index WBGT meter wereassessed. The reference unit wasdesigned to meet specifications for aWBGT monitor determined by ISOstandard 7243 (ISORU). Inter-ventions: WBGT devices weresimultaneously tested against theISORU for two sessions. The firstsession was on field turf and thesecond session was on grass. MainOutcome Measures: Data wererecorded for two, 2-hour afternoonsessions, at 2 minute intervals. Datawere then averaged over 14 minuteperiods for analysis. Mean absoluteerror (MAE), root mean square error(RMSE), and Pearson’s correlationcoefficient (r) were used to quantifyinstrument performance relative to thereference unit. Results: The overallmean and standard deviation for theISORU was 27.20ºC and 2.07ºC. Themean and (average mean differencefrom the ISORU) was lowest in the

Quest Temp 34 27.37ºC (0.17ºC) andExtech Heat Stress Meter 26.90ºC(0.30ºC), followed by the Reed HeatIndex WBGT monitor 26.83ºC(0.37ºC) and Kyoto ElectronicsWBGT 103 Heat Stress Checker26.45ºC (0.75ºC). The Kestrel 440028.23ºC (1.03ºC) and General HeatIndex Checker 25.83ºC (1.37ºC) werethe farthest from the ISORU. All unitsdemonstrated excellent correlation(r>0.96) compared to the ISORU. TheQuest Temp 34 and Extech Heat StressMeter units performed the best withthe lowest MAE (RMSE) values of0.19ºC (0.27ºC) and 0.46ºC (0.56ºC)respectively, followed by the ReedHeat Index WBGT meter and KyotoElectronics WBGT103 units withvalues of 0.81ºC (0.93ºC) and 0.64º C(0.85ºC). The Kestrel 4400 andGeneral Heat Index Checker units hadthe largest MAE and RMSE values of1.05ºC (1.02ºC) and 1.37º C (1.42ºC),respectively. Conclusions: All sixunits tested performed well comparedto the ISORU. Overall the Quest Temp34 performed best with the lowestMAE and RMSE of the units assessed.However, all six units had excellentcorrelations (r>0.96) and were within1.42 ºC of the ISORU. We conclude theunits are each reliable devicesfor monitoring WBGT on bothartificial and grass surfaces. Athletictrainers should evaluate each unit todetermine the best unit based on theirindividual psychometric properties.

summed for a frontal total error (FTE)and sagittal total error (STE) score,respectively. Main OutcomeMeasures: Dependent variables werethe OS, 17 ISs, FTE and STE.Generalized linear models with twofactors (risk group, sex) were utilizedfor group comparisons. Groupdifferences were further analyzedusing pairwise comparisons(Bonferroni), p<0.05. Results:Significant interaction effects werereported for three ISs (toe out at MKF[p=0.048], knee valgus at MKF[p=0.017], overall frontal planedisplacement [p=0.021]) and for FTE(p=0.011), with high-risk femalesgenerally committing more errorsthan other groups. Significant maineffects of risk group were reported forOS (p=0.009; high-risk=5.51±0.39,low-risk=4.97±0.24), three ISs (footasymmetry at IGC [p=0.024; high-risk=0.71±0.10, low-risk=0.39±0.94], limited hip flexion at MFK[p=0.030; high-risk=0.94±0.11, low-risk=0.59±0.11], overall sagittal jointdisplacement [p=0.001; high-risk=2.93±0.18, low-risk=2.11±0.17]) and STE (p=0.033; high-risk=7.72±0.49, low-risk=6.26±0.47), with the high-risk groupcommitting more errors than the low-risk group. Significant main effectsof sex were reported for knee valgusat IGC (p<0.001; females=1.25±0.12;males=0.57±0.11). Conclusions:Our findings suggest that high-risksport athletes, particularly females,tend to demonstrate poorer jump-landing patterns than low-risk sportathletes. This is surprising given thathigh-risk sport athletes are likely morefamiliar with the movement pattern ofa jumping-landing task than their low-risk counterparts. Future studiesshould determine if these differencesare clinically significant (eg, increasesrisk for lower extremity injury).

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Free Communications, Poster Presentations: Doctoral Poster Award Finalists1 3 0 6 4 D O S P

The Validity Of Head ImpactIndicators To Positively PredictConcussionLynall RC, Mihalik JP, GuskiewiczKM, Marshall SW: University ofNorth Carolina, Chapel Hill, NC

Context: Commercially availablehelmet- and chinstrap-based headimpact indicators purportedly measureresultant linear head acceleration(RLHA), measured in gravities (g), orthe Head Injury Criterion (HIC), andalert coaches and athletes when headimpacts exceeding predeterminedtolerance thresholds are sustainedduring sports participation. Thesethresholds vary among currentlyavailable head impact indicators andare widely unsupported by the researchliterature. Objective: To determinethe sensitivity, specificity, and positivepredictive value (PV+) of head impactindicators. We hypothesized variablesensitivity, high specificity, and poorPV+ of head impact indicators.Design: Prospective cohort. Setting:Field setting. Patients or OtherParticipants: Convenience sample of184 male (age=19.2±1.4yrs) footballplayers representing all playingpositions recruited from one DivisionI program. Interventions: Headimpact biomechanics for 283,348impacts were collected using HeadImpact Telemetry Systeminstrumentation during practices andcompetitions over an 8-year period(preseason, fall, and spring seasons).During this time, a team of physicians,athletic trainers, and clinicalresearchers made concussiondiagnoses based on a comprehensivemulti-faceted concussion managementprogram (n=24). We dichotomizedeach impact based on concussiondiagnosis (yes=24/no=283,324). Wealso dichotomized RLHA and HICbased on whether thresholds employedby commercially available head impactindicators were exceeded: RLHA of 50g, 75 g, or 100 g; and HIC value of 240.

We used frequency analyses tocompute the sensitivity, specificity,and PV+. Main Outcome Measures:Frequencies of dichotomized injurydiagnosis, RLHA and HIC. Results:Based on our independent head impactbiomechanical data, head impactindicators employing a 50 g impactthreshold would be 95.8% (95%CI:79.8–99.3) sensitive based on 24injuries and 90.4% (95%CI: 90.3–90.5) specific, but possess 0.1% PV+based on 27,148 impacts >50 g. At a75 g threshold, we observed 75.0%sensitivity (95%CI: 55.1–88.0) and97.0% specificity (95%CI: 96.9–97.0), but only 0.2% PV+. Employinga 100 g threshold, we observed 45.8%sensitivity (95%CI: 27.9–64.9) and99.0% specificity (95%CI: 99.0–99.1), with a 0.4% PV+. Lastly, headimpact indicators would be 20.8%(95%CI: 9.2–40.5) sensitive and99.3% (95%CI: 99.3–99.4) specific,with a 0.3% PV+ if a HIC of 240 wereto be employed as an impact indicatorthreshold. Conclusions: Whilespecificity appears high using theseindicator thresholds, clinicians shouldconsider the very low PV+ and variablesensitivities associated with utilizingtheoretical impact thresholds forremoval from play. Our findingssuggest that conducting anexamination based on head impactindicators alone would result inan extremely high number ofunnecessary athlete evaluations. Weonly studied the thresholds employedby commercially available head impactindicators as a means of exploringwhether the concept has any clinicalutility for athletic trainers. Futurestudies investigating head impactindicators’ actual measurement validityshould be pursued. Study funded in partby the Centers for Disease Controland Prevention and the NationalOperating Committee on Standardsfor Athletic Equipment.

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Kinesiophobia And Fear-Avoidance Beliefs Are GreaterIn Those With Chronic AnkleInstabilityHouston MN, Van Lunen BL, Hoch MC: Old DominionUniversity, Norfolk, VA

Context: Individuals with chronicankle instability (CAI) have exhibiteddecreased health-related quality of lifebased on regional and global measuresof health. Despite these findings, theextent to which these individualsdisplay deviations in mental aspects offunction such as kinesiophobia andfear-avoidance belief is unknown.Objective: To determine if measuresof kinesiophobia and fear-avoidancebelief differ between individuals withand without CAI and correlate withinjury characteristics that quantify themagnitude of CAI. Design: Case-control. Setting: Laboratory. Patientsor Other Participants: Sixteenparticipants with CAI (3 males, 13females, age=21.9±2.6 years,h e i g h t = 1 7 0 . 8 ± 9 . 8 c m ,mass=70.1±13.3kg) were gender andage matched to sixteen healthyparticipants with no history of anklesprain (3 males, 13 females,age=22.6±1.7 years, height= 166.4±8.9cm, mass= 63.8±12.1kg).Participants were included in the CAIgroup if they reported at least oneankle sprain, two episodes of “givingway” in the past three months, andanswered “yes” to five or morequestions on the Ankle InstabilityInstrument. Interventions: Partici-pants reported to the laboratory for asingle testing session. Participants inboth groups completed the TampaScale of Kinesiophobia-11 (TSK-11)and Fear-Avoidance BeliefsQuestionnaire (FABQ). The TSK-11contains 11 items with 4-point likertscales. The FABQ contains a total of11 items with 6-point likert scales.Individuals in the CAI group alsoreported the number of previous ankle

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sprains (PAS), the number of episodesof “giving way” in the past 3 months(EGW), and completed the 8-itemFoot and Ankle Ability Measure-Sport(FAAM-Sport). Main OutcomeMeasures: TSK-11 scores range from11-44 with higher scores indicating agreater level of kinesiophobia. FABQscores range from 0-66 with higherscores indicating increased fear-avoidance belief. Dependent variablesincluded the TSK-11 and FABQ scoresand the independent variable was group(CAI, healthy). Independent samples t-tests were used to examine groupdifferences in TSK-11 and FABQscores. Pearson-product momentcorrelations (r) were calculated todetermine if TSK-11 and FABQ scoreswere related to PAS, EGW, or FAAM-Sport scores (%) in the CAI group.Alpha level was set a priori at p<0.05for all analyses. Results: Significantgroup differences were identified forthe TSK-11 (CAI=18.1±4.0,Control=13.5±3.0, p=0.004) andFABQ (CAI=17.9±9.7, Control=1.5±2.6, p<0.001). Within the CAIgroup, TSK-11 scores weresignificantly correlated to PAS(4.5±3.8; r=0.52, p=0.04), but notEGW (7.2±7.4; r=-0.49, p=0.054)or FAAM-Sport scores (76.2±18.1%;r=-0.13, p=0.62). The FABQ was notsignificantly correlated to PAS(r=0.01, p=0.98), EGW (r=0.08,p=0.77) or FAAM-Sport scores (r=-0.18, p=0.51). Conclusions:Individuals with CAI experiencegreater kinesiophobia and fear-avoidance beliefs compared tohealthy controls. Also, individuals withCAI with a greater number of sprainsreport increased levels ofkinesiophobia. These findings suggestthat measures of kinesiophobia andfear-avoidance belief should beexamined during the rehabilitationprocess of individuals with CAI.

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Increase In HumeralRetrotorsion Accounts For Age-Related Increase InGlenohumeral Internal RotationDeficit In Youth/AdolescentBaseball PlayersHibberd EE, Oyama S, Myers JB:University of North Carolina atChapel Hill, Chapel Hill, NC, andUniversity of Texas San Antonio,San Antonio, TX

Context: Glenohumeral internalrotation deficit (GIRD) of the throwinglimb relative to the non-throwing limbhas been linked to shoulder and elbowinjury in baseball players. While it hasbeen demonstrated that GIRDincreases during adolescence, itremains unclear whether this changeis due to increases in humeralretrotorsion (osseous) or soft tissuetightness of the throwing limb.Measuring humeral retrotorsion alongwith shoulder internal rotation rangeof motion (IRROM) allows us todifferentiate osseous vs. soft tissuecontribution to GIRD in baseball playersof different ages, as well as compareGIRD between age groups once it hasbeen corrected for humeral retrotorsion.Objective: The purpose of this study wasto evaluate the influence of age groupon GIRD, humeral retrotorsion, andcorrected-GIRD in baseball players.Design: Cross-Sectional. Setting:Field Laboratory. Patients or OtherParticipants: Four groups of baseballplayers (n=287) participated: 1) youth(6-10 year olds) (n=52, age= 8.3±1.3yrs,h e i g h t = 1 3 3 . 7 ± 1 1 . 1 c m ,mass=33.6±8.6kg), 2) junior high (11-13 year olds (JH)) (n=52, age=11.9±0.9yrs, height=149.9±17.8cm,mass=47.2±9.7kg), 3) junior varsity(14-15 year olds (JV)) (n=70,age=14.6±0.5yrs, height =176.3±5.7cm, mass=69.6±12.9kg), and 4)varsity (16-18 year olds) (n=113,age=16.9±0.8yrs, height =180.3±6.6cm, mass=78.0±11.4kg). Inter-ventions: IRROM and humeral torsionwere measured bilaterally using a digitalinclinometer and diagnostic ultrasound,

respectively. Main Outcome Measure:A 3-trial mean was calculated for IRROMand humeral torsion measures.Corrected-IRROM was calculated as theamount of available IRROM oncehumeral torsion was accounted for.GIRD and corrected-GIRD side-to-sidedifferences were calculated as theangular difference in IRROM andcorrected-IRROM. Three separate one-way ANOVAs were used to compareGIRD, humeral retrotorsion, andcorrected-GIRD between age groups.Results: There were significant groupdifference in GIRD (F

3,284=8.957,

p<0.001) and humeral torsion side-to-side difference (F

3,284=9.688, p<0.001),

but not in Corrected-GIRD(F

3,284=1.136, p=0.335). GIRD was

greater in varsity participants comparedto youth (mean difference (md)=5.05°,p=0.002) and JH (md=4.95°, p=0.002)participants, and in JV participantscompared to JH (md=5.36°, p=0.002)and youth (md=5.47°, p=0.002)participants. Humeral torsion was greaterin varsity participants compared to youth(md=8.79°, p<0.001) and JH(md=5.52°, p=0.014) and JV comparedto youth participants (md=7.88°,p=0.001). Conclusions: Asdemonstrated previously, GIRDincreased with age in youth/adolescent baseball players. We alsoobserved that humeral retrotorsionincreased with age, while the torsioncorrected GIRD remainedunchanged. This result indicates thatthe age-related increase in GIRD isprimarily attributed to increase inhumeral retrotorsion, and not softtissue tightness. Our study suggeststhat the most significant alterationsin torsional side-to-side differencesoccur between youth and JVparticipants (6-16), suggesting thatthis period of physical maturationshould be further investigated inrelation to the development of riskfactors for shoulder and elbow injury.Acknowledgements: Funding providedby NIH-NIAMS:R03AR055262.

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Effect Of Strength-TrainingProtocols On Strength AndDynamic Balance In ParticipantsWith FAIHall EA, Docherty CL, Simon JE,Kingma J, Klossner JC: IndianaUniversity, Bloomington, IN

Context: While lateral ankle sprainsare common in sport and can often leadto functional ankle instability (FAI),strength-training rehabilitationprotocols may improve the deficits ofFAI. Purpose: To determine theeffects of strength-training protocolson strength and dynamic balance inparticipants with FAI. Design: Arandomized controlled clinical trial.Setting: University Athletic TrainingResearch Laboratory. Patients andOther Participants: Thirty-nineparticipants (17 males, 22 females,19.72±1.96 years, 173.54±9.21 cm,70.68±12.89 kg) with FAI volunteeredto participate in the study. The AnkleInstability Instrument determined thepresence of FAI and subjects wereexcluded if they had a history of lowerextremity fracture/surgery or a balancedisorder. Interventions: Participantswere pre-tested for strength anddynamic balance. Strength wasassessed isometrically using a handhelddynamometer (Lafayette ManualMuscle Tester, Lafayette InstrumentsCo) in four directions: dorsiflexion,plantarflexion, inversion, and eversion.Three trials of each direction wereperformed. Dynamic balance wasassessed using the Y-balance test kit(Functional Movement Systems, Inc).Participants completed three reachtrials in each direction: anterior,posterolateral and posteromedial.Participants were then randomlyassigned to either the resistance bandprotocol (RBP), ProprioceptiveNeuromuscular Facilitation strengthprotocol (PNF), or control group(CON). Participants in the RBP andPNF groups completed their respectiveprotocols 3x/week for 6 weeks.Participants in the CON group did notattend rehabilitation sessions. All

subjects were post-tested at the endof six weeks in the same manner asthe pre-test. Main OutcomeMeasures: Dorsiflexion, plantar-flexion, inversion, and eversionisometric strength (kg) and Y-balancetest (composite score of threedirections standardized to limb lengthin cm). Maximum values were usedfor statistical analysis. SeparateRMANOVA was completed for eachdependent variable and Bonferronipost hoc test was conducted on anysignificant findings. Alpha level wasset a p<0.05. Results: Both the RBPand PNF groups significantlyimproved between pretest and posttestin isometric strength. In the RBPgroup, dorsiflexion improved by 23%(F

2,36=3.43, p=0.043) and plantar-

flexion improved by 15% (F2,36

= 3.48,p=0.041) over the training period.For inversion strength, the RBP groupimproved by 29% and the PNF groupimproved by 28% following training(F

2,36=6.14, p=0.005). Similarly for

eversion strength, the RBP groupimproved by 28% and the PNF groupimproved by 31% (F

2,36=7.44,

p=0.002). There were no significantstrength improvements in the CONgroup between the pretest and posttest(p>.05). There were no significantdifferences in Y-balance testperformance (p=0.08) in any group.Conclusion: Both rehabilitationprotocols were effective atimproving isometric ankle strengthfollowing the six weeks. Neitherrehabilitation protocol created animprovement in dynamic balance.

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Shoulder Flexion Torque IsAugmented By A VolitionalAbdominal ContractionCacolice PA, Carcia CR, Scibek JS: DuquesneUniversity, Pittsburgh, PA

Context: Increased activation of theabdominal musculature increasesactive stiffness of the trunk andenhances core stability. A strong andstable core is associated withdecreased injury and improvements inperformance. Further, a stable coreprovides a solid base therebytheoretically enhancing extremityfunction. Contraction of the abdominalmusculature during functionalactivities however generally occursautomatically at a subconscious level.It is unclear if an individual is able toproduce a greater amount of extremitytorque while performing asuperimposed volitional contractionof the abdominals. Objective: Todetermine if shoulder torque valueswere different when subjectsperformed a maximal voluntaryisometric contraction (MVIC) of theshoulder flexors with and without avolitional isometric contraction of theabdominals. We hypothesizedparticipants would be able to generatea greater amount of isometric shoulderflexion torque (ISFT) when theabdominals were consciouslyactivated. Design: Quasi-experimental repeated measures.Setting: Research laboratory.Patients or Other Participants: Aconvenience sample of 30 healthy,recreationally active college agedstudents (age=21.9±1.2years; weight=75.2±16.3kg; height= 174.7±9.4cm)participated. Interventions: Partici-pants completed a 5-minute warm upon an upper body ergometer (Monark;Vansbro, Sweden) at a self-selectedpace. Next, using a standardized andpreviously reported protocol, surfaceEMG (sEMG) was captured from theright and left rectus abdominis (RA)using a telemetry system (Noraxon;

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Scottsdale, AZ) that was interfacedwith a commercially available softwareacquisition system (Run Technologies;Laguna Hills, CA) and personalcomputer (Dell; Austin, TX).Collection of RA sEMG was essentialto determine if RA percent activationwas different between test conditions.Subjects then completed threerepetitions of an isometric abdominalcrunch to establish an MVIC of the RAfor normalization. Then in acounterbalanced order using theirdominant upper extremity, subjectscompleted three trials of maximalisometric shoulder flexion at 90degrees using an isokineticdynamometer (Biodex; Shirley, NY)with and without a volitionalcontraction of the abdominals. MainOutcome Measures: Dependentvariables included RA percentactivation and ISFT. We used paired t-tests to determine if RA percentactivation and ISFT values differedbetween conditions (contracted;relaxed). Results: Percent activationof the RA was greater when subjectsvolitionally contracted theirabdominals (15.8±12.7%) comparedto the relaxed condition (6.3±4.8%)(Pd”0.001). ISFT was greater when theabdominals were actively contracted(44.6±18.9N*m) compared to ISFTwhen the abdominals were recruitedsubconsciously (30.7±15.7N*m)(Pd”0.001). Conclusions: Subjectsare able to volitionally recruit greateramounts of RA sEMG compared tothe percent activation thatautomatically occurs while performingan upper extremity task. ISFT valuesat 90 degrees of flexion are greaterwhen a subject volitionallysuperimposes a contraction of theabdominals when compared to ISFTwhen the abdominals are solelyrecruited in a subconscious fashion.

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Free Communications, Poster Presentations: Lower Extremity Neuromechanics1 3 2 6 7 F O B I

Double Legged SquatMechanics Influence MedialKnee DisplacementBell DR, Pennuto AP, Stiffler MR,Smith MD, Olson ME: University ofWisconsin-Madison. Madison, WI

Context: Dynamic knee valgus ormedial knee displacement (MKD) is atheorized risk factor for chronic andacute knee injuries. MKD is the medialcollapse of the knee and is acombination of tibial and femoralmotions. However, it is unclear whatspecific kinematic componentsspecifically contribute to MKD duringthe double legged squat (DLS). Thisinformation could be valuable toclinicians as they design interventionstrategies to improve performance anddecrease injury risk. Objective: Thepurpose of this investigation was toexamine how kinematics of the lowerextremity influence MKD during theDLS. Design: Cross-sectional.Setting: Laboratory. Patients orOther Participants: Eighty threevolunteers with no history of lowerextremity injury (171.3±9.2cm,69.2±12.2kg, 20.3±1.5yrs, 21 Males,62 Females) completed this study.Interventions: All individualscompleted five trials of a DLS from astandardized start position: feet shouldwidth apart, toes straight ahead, withthe hands over the head. Subjects wereinstructed to squat like they weresitting in a chair to a deep butcomfortable depth and in a controlledmanner. The dominant limb was usedfor testing which was defined as thelimb used to kick a ball maximaldistances. Main OutcomeMeasures: Peak kinematicsassociated with ACL loading of the hip(flexion, adduction, and internalrotation), knee (flexion, valgus, andinternal rotation), and trunk flexionwere used as predictor variables whileMKD during the DLS was used as acriterion variable. MKD was

calculated using the electromagnetictracking system and was defined asdisplacement of the knee center in thefrontal plane (cm). Peak values wereobtained for each trial and the averagewas used in the analyses. Separateforward stepwise regressions wereperformed for each gender todetermine the influence of lowerextremity kinematics on MKD. Allstatistical analyses were performed inSPSS with significance set a priori atP < 0.05. Results: In females, peak hipadduction angle (5.1±4.4°) and peakknee valgus angle (-8.4±9.1°)explained 29% of the variance in MKD(1.1±1.1 cm, R2=0.29, P<0.001). Inmales, 22% of the variance in MDKwas explained by peak hip flexion angle(-115.2±11.1°) during the DSL(1.0±1.0 cm, R2=0.22, P=0.03).Conclusions: Kinematics contribut-ing to MKD differed by gender. MKDappears to be related to frontal planehip control in females; however,sagittal plane hip control influencesMKD in males. Clinicians shouldconsider these relationships whendesigning interventions to reduceMKD. Other factors not assessed inthis study most likely account forsome of the unexplained variance inthe position of MKD including rangeof motion restrictions or staticpostural alignment. Funding: VirginiaHorne Henry Fund and the WisconsinAthletic Trainers’ Association.

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Interactive Effects Of BodyPosition And Resistance OnMuscle Activation AndCardiorespiratory ResponseDuring Spinning®Rendos NK, Musto A, Signorile J:University of Miami, Coral Gables,FL

Context: Spinning® is used duringrehabilitation to maintaincardiorespiratory fitness and musclefunction. Intensity is the major factoraffecting these variables and iscontrolled by body position (POS) andperceived resistance level (RES).Objective: To examine the effect of3 POS and 4 RES on muscle activityof the vastus lateralis (VL) andcardiorespiratory response duringSpinning®. Design: Within-subjectsrepeated measures design. Setting:Laboratory of NeuromuscularResearch and Active Aging Patientsor Other Participants: Elevenhealthy, recreational athletes with atleast 6 months Spinning® experience(height=1.68±.09 m, mass=65.8±11.3kg, age=24.4±6.3 years). Inter-ventions: Following and 8h fast,electromyographical normalized rootmean square (nRMS) of the right VLand breath-by-breath data wererecorded during 12 (3POS x 4RES)three-minute randomly assignedSpinning® conditions on four testingdays. POS included seated, running,and standing climb (SC), and RES used4 ranges of the 15-point BorgPerceived Exertion Scale (RPE 6-9,10-13, 14-6, 17-20). RMS wasnormalized for each testing sessionusing maximal voluntary isometric legextensions (hip and knee at 90° offlexion). Main Outcome Measures:Dependent variables included nRMS,heart rate (HR), VO

2 relative to body

weight (VO2rel

), and respiratoryexchange ratio (RER) during eachcondition. A 3(POS) x 4(RES) within-

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subjects ANOVA with Bonferroni post-hoc analysis was performed for eachvariable. Results: A significant POSx RES interaction was observed fornRMS (p=.034). For the seatedposition, RPE 10-13 (0.26±0.08), 14-16 (0.39±0.15), and 17-20(0.51±0.14) were significantly greaterthan RPE 6-9 (0.09±0.08) and RPE17-20 was significantly greater thanRPE 10-13. For running and SC, RPE17-20 (0.50±0.15 and 0.49±0.13) wassignificantly greater than RPE 6-9(0.23± 0.08 and 0.20±0.07) and 10-13 (0.25±0.06 and 0.27±0.08).Additionally for SC, RPE 14-16(0.37±0.15) was greater than RPE 6-9. When the post-hoc analysis wasperformed across RPE levels, the onlysignificant difference detected wasbetween the running and seatedconditions at RPE 6-9. A significantmain effect was observed for POS andRES for VO

2rel (p<.02). VO

2rel was

greater for the running (28.9±2.2ml•kg-1•min-1) and standing climbpositions (26.8±1.7 ml•kg-1•min-1)than for the seated POS(23.5±2.0 ml•kg-1•min-1) and greater for RPE14-16 and 17-20 (31.2±2.4 and34.9±2.6 ml•kg-1•min-1) than RPE 6-9and 10-13 (16.5±1.8 and 22.9±1.9 ml•kg-1•min-1) and RPE 10-13 wassignificantly greater than 6-9 (p<.01).RER was affected by RES only(p<.001), while a significantPOSxRES interaction was observedfor HR (p=.024) where HRpatterns did not match VO

2rel patterns.

Conclusions: VL activity patternsconsistently increased withRES regardless of POS. The SCand running POS can be expectedto produce higher cardiorespiratoryresponses than seated acrossRES levels. HR appears to beineffective as a monitoring methodfor cardiovascular effort.

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A Comparison Of Body Fat,Lean Muscle Mass And MaxVertical Jump Height InOlympic Level AthletesMoore MT, Daniels EJ, DixonJB: Northern Michigan University,Marquette, MI, and MarquetteGeneral – A Duke Life PointHospital, Marquette, MI

Context: Anecdotal evidence amongcoaches suggests a relationshipbetween body composition andperformance despite little researchexamining this connection. Athleticperformance is often contextuallylinked to body fat and lean musclemass scores, particularly when scoresmay be subjective and associated withvisual appeal. Body fat is oftenmeasured using skin fold calipers, andis prevalent in sports that areconsidered aesthetic or have weightcategories. The reliability of bodymass index (BMI) in elite athletes islow due to athletes’ higher percentagesof lean muscle mass. However, Dual-Energy X-ray absorptiometry (DEXA)has been shown to provide an accurateassessment of body composition.Objective: The objectives were twofold 1) Determine if a three trial, threesite pinch caliper test and DEXA yieldsimilar results. 2) Determine if leanmuscle mass and percent body fat iscorrelated with max vertical jumpheight (measure of power output).Design: Cross-sectional Setting:Outpatient Orthopedic Clinic.Patients or Other Participants: 25Olympic level athletes (ages 18-27)volunteered that participated inOlympic weight lifting (men andwomen), Greco-Roman (men) orfreestyle wrestling (women), shorttrack speed skating (men and women).Males (N=12) mean height was164.17cm+5.08 and weight was69.1kg+15.9. Females (N=13) meanheight 172.76cm+9.53, and weightwas 82.83kg+17.57. Interventions:The independent variable was level of

athlete participation. Body fatpercentages calculated usingLohman’s validated method included abody fat caliper three trial three sitepinch (abdominal, subscapular andtriceps) and was compared to DEXAmeasures. All body fats were measuredon the right side and by the sameexaminer. Vertical jump scores wererecorded for the best of three maxattempts using the Vertec followingvalidated standardized warm-upprocedures. Main OutcomeMeasures: The dependent variableswere body fat percentages via caliperand DEXA, body mass index (BMI) andmaximum vertical jump. Analysesincluded a paired t-test and Pearsoncorrelations with a priori alpha levelset at P=.05. Results: A paired t-testshowed no significant differencebetween DEXA (mean 20.64+10.74)and caliper (mean 20.03+7.96) testing(P=.559). Pearson Correlationsrevealed lean muscle mass wasstrongly correlated with DEXA (mean60.87+14.75) and caliper calculations(mean 60.87+14.75). BMI (26.52+4.03) was low to moderatelycorrelated with DEXA percent body fat(P=.089, r=.347). DEXA percent bodyfat was moderately inverselycorrelated with jump height (P=.004,r=-.565) and moderately correlatedwith lean muscle mass (P=.013,r=.501). Conclusions: Body fatcalipers are an accurate substitute forDEXA measures, while BMI was notsignificantly correlated with DEXA inthis population. Individuals who hadlower body fat scores, and more leanmuscle mass were more likely to scorehigher on the max vertical jump.

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Lower Extremity FunctionalContributions To DynamicPostural ControlGrooms D, Beisner A, Bowman J,Borchers J, Miller M, SchroederM, Schussler E, Onate J: TheOhio State University, Columbus,OH

Context: A lack of standardizedclinical tools exists formusculoskeletal injury risk andfunctional performance assessment.The single leg anterior reach (SLAR)component of the star excursionbalance test is a commonly utilizedclinical option to assess dynamicpostural control and ankle sprain injuryrisk. However, the contributions ofankle joint range of motion and singleleg dynamic function to SLAR posturalcontrol is unknown. Objective: Todetermine the relationship betweenvarious aspects of functionalperformance and dynamic posturalcontrol and the best predictors ofdynamic postural control. Design:Descriptive laboratory study Setting:Biomechanics research laboratoryParticipants: 41 male NCAADivision I lacrosse athletes (19.6±1.17years, 1.83±0.08 m, and 84.7±8.6 kg)Interventions: A comprehensivefunctional performance assessmentwas completed prior to the regularseason consisting of left and rightSLAR for dynamic balance, single leghop (SLHOP) for single leg power andlanding control, two measurements ofdorsiflexion range of motion (lungeand kneeling), trunk endurance(backextension and side bridges for time)and hip strength (isometric flexion,extension, abduction, adduction).Main Outcome Measures: Pearsoncorrelations were performed to assessthe relationship between SLAR andSLHOP, dorsiflexion, trunk enduranceand hip strength with an alpha level setat .05. A regression model wascompleted to determine the bestpredictors of SLAR performance.Results: Left SLAR was correlated

with left SLHOP (.322, p=.04), lungedorsiflexion (.565, p<.001) andkneeling dorsiflexion (.647, p<.001).Right SLAR was correlated with rightsingle leg hop distance (.426, p<.006),lunge dorsiflexion (.655, p<.001) andkneeling dorsiflexion (.717, p<.001).Trunk endurance and hip strength werenot correlated with SLARperformance. The best regressionmodel to predict SLAR performanceincluded kneeling dorsiflexion andSLHOP as significant predictors(Right: r² .50, p<.001, Left: r² .55,p<.001). The regression modelindicated that the variance of SLARperformance is explained heavily bykneeling dorsiflexion (Right: r² .42,p<.001, Left: r² .51, p<.001). Theinclusion of the additional lungedorsiflexion measure did not add to themodel as the correlation betweenthese two measures was very high(Right: .903, p<.001, Left: .889,p<.001). Trunk endurance and hipstrength were not significantpredictors in the model. Conclusions:The results of this study show thatSLAR performance is highly related tokneeling weight bearing dorsiflexionand lunge dorsiflexion range of motionand moderately related to SLHOPperformance. This indicates that theSLAR clinical assessment of posturalcontrol is moderately dependenton closed chain dorsiflexion rangeof motion. Clinicians assessingdynamic balance should considerdorsiflexion range of motion as apossible limiting factor. Othervariables such as postural control andeccentric muscle strength may alsoplay a role in SLAR performance thatis not captured with dorsiflexionmotion or hop performance.

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Effect Of Diminished PlantarCutaneous Sensation And FootType On Static Postural ControlKang TK, Lee SC, Lee HD, LeeSY: Yonsei University, Departmentof Physical Education, Seoul,Korea

Context: Plantar cutaneous sensationand different foot types may influencethe regulation of postural control.However, it is unclear whetherdifferent foot types are associated withvariances in postural control beforeand after removal of plantar cutaneoussensation. Objective: To determine ifdifferent structural foot typesinfluence postural control afterdiminished plantar cutaneoussensation. Design: Case controlledstudy. Setting: Laboratory. Patients orOther Participants: A total of 39healthy, young adults (age: 24.67±2.39years; height: 173.17±8.57 cm;weight: 69.05±13.78 kg) wererecruited. There were 18 pronated, 35neutral, and 25 supinated feet.Interventions: We classified foot typeas pronated (e”10mm), neutral (5-9mm), or supinated (d”4mm) bynavicular drop test measures. Subjectsplaced the plantar surface of both feetin an ice bath for 10 minutes. Beforeand after ice-immersion, subjectsperformed three trials of a 10 secondssingle-leg stance balance test withtheir eyes closed while standing on topof an Acusway forceplate (AMTI INC,Watertown, MA). Main Outcomemeasures: Center of pressure x range(RangeX); y range(RangeY); xvelocity(VelocityX); y velocity(VelocityY); x standard deviation(SDx); y standard deviation(SDy); xtime to boundary (TTBx); y time toboundary(TTBy); x mean time toboundary(mean TTBx); y mean time toboundary(mean TTBy); x standarddeviation time to boundary(SD TTBx);and y standard deviation time toboundary(SD TTBy) were measured toquantify postural control. Group (foottype) by time (plantar sensation) mixed

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model two-way repeated measures ofANOVA was used to analyzedifferences between foot types andplantar cutaneous sensation. Results:A significant main effect for time wasfound in SDy (F

1,75=9.57; P=.00). Post

hoc analysis showed that diminishedplantar cutaneous sensation resulted inincreased standard deviation (SD) ofcenter of pressure (CoP) in A-Pdirection (pre: 1.13±.28; post:1.22±.29; P=.00). A significant maineffect for time was found in RangeY(F

1,75=9.07; P=.00). Also diminished

plantar cutaneous sensation resulted inincreased range of CoP in the A-Pdirection (pre: 5.53±1.34; post:5.97±1.44; P=.00). A significant maineffect for time was found in VelX(F

1,75=4.00; P=.05). Diminished

plantar cutaneous sensation alsoresulted in decreased velocity of CoPin M-L direction (pre: 5.11±1.18;post: 4.96±1.22; P=.05). Interestingly,the main effect for foot typeand interaction did not revealsignificant differences and all time toboundary variables did not havesignificant differences. Conclusions:After plantar cutaneous de-sensitization, there was a deficit in A-P directional postural control andimprovement in M-L directionalpostural control. This indicates thatmechanoreceptors located in the deepplantar surface of the foot play animportant role to control posture.

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Postural Control DifferencesBetween Adolescent AndCollegiate Male Athletes UsingThe Stability Examination TestRice T, Mayfield RM, Lam KC,Valovich McLeod TC: AthleticTraining Program, A.T. StillUniversity, Mesa, AZ

Context: Postural control is anessential component of athleticparticipation and has roles in bothmusculoskeletal rehabilitation andconcussion evaluation. The StabilityExamination Test (SET) aims toobjectively analyze an athlete’sbalance and postural control throughmeasurement of sway velocity (SV) ona portable force platform. To date theSET has been primarily used incollegiate athletes, however thedevelopment of postural controlprogresses into adolescence, due tocontinued neural development,strength gains, and muscle activation.Objective: To determine whetherpostural control differences existbetween adolescent and collegiatepopulations using the SET protocol.Design: Cross-sectional. Setting:High school and collegiate athletictraining facilities and a researchlaboratory. Patients or OtherParticipants: Convenience sample of35 adolescent (age=11.1±2.1 years,height=149.7±15.7cm) and 133collegiate (age=19.4±1.3 years,height=181.3±9.0cm) male athletes.Interventions: The independentvariable was group; adolescent (9-15years) vs. college (18-22 years). Allparticipants completed the SET, whichinvolved 6 20-second balance testswith eyes closed, under the followingconditions: double-leg firm (DFi),single-leg firm (SFi), tandem firm,(TFi), double-leg foam (DFo), single-leg foam (SFo), and tandem foam(TFo). Main Outcome Measures:The dependent variable was swayvelocity (SV) for each of the 6 SETconditions. A composite SET SVvariable was also analyzed. SV (deg/

sec) is defined as the ratio of thedistance traveled by the center ofgravity to the time of the trial. A higherscore indicates poorer balance. A 2(group) by 6 (condition) repeatedmeasures analysis of variance was usedto evaluate differences in SV. Anindependent t-test assesseddifferences in the composite SVvariable. Results: The interaction forSV was significant (P=.028) and therewere significant main effects for group(P=.001) and condition (P<.001). Thecomposite SV was significantly higher(P=.023) in the adolescents(3.29±1.21 deg/sec) compared to thecollege athletes (2.79±0.60 deg/sec).Post-hoc analysis of the interactionrevealed that the adolescents hadsignificantly higher SV for the single-firm (3.22±1.78 vs. 2.16±.90 deg/sec)and single-foam (5.25±1.99 vs.4.44±1.25 deg/sec) conditions, withno significant differences among theother conditions. The significant maineffect for condition revealeddifferences between all 6 conditionswith DFi (0.75±0.22 deg/sec) < TFi(1.78±0.97 deg/sec) < SFi (2.367±1.17 deg/sec) < DFo (2.84±0.88 deg/sec) < SFo (4.85±1.47 deg/sec) < TFo(5.19±2.26 deg/sec). Conclusions:Our results indicate that the adolescentpopulation had an overall highercomposite SV, indicating decreasedpostural control. The differences weremore profound on the conditions thatrequired a single-limb stance, perhapsresulting from a lack of lower limbstrength, in addition to posturalinstability. Future studies shouldevaluate whether these differencesexist in females and at what age doadolescents resemble adults with thismeasure of postural control.

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Normally-Occurring AnkleRange Of Motion And DynamicPostural Control AsymmetriesIn Healthy Collegiate Cross-Country RunnersMcNulty MB, McKeon PO:University of Kentucky,Lexington, KY

Context: Cross-country runningrequires participants to constantlyadapt to changing surfaces over thecourse of training and racing. Lowerextremity injuries are widespread inthis sport. Side-to-side asymmetriesin ankle dorsiflexion (DFROM) andthe anterior reach distance of the StarExcursion Balance Test (ANTSEBT)have been identified as risk factors forlower extremity injury in other sports,but no evidence exists about thenormally occurring asymmetries inthese measures for collegiate cross-country runners. By examining thenormally occurring DFROM andANTSEBT asymmetries, we can builda better understanding of their utilityas screening tools in this population.Objective: To determine the normallyoccurring DFROM and ANTSEBTasymmetries in healthy collegiatecross-country runners. Design:Cross-sectional design. Setting:Athletic Training Room. Parti-cipants: 25 healthy Division Icollegiate cross-country runners (11Females, 14 Males, Age: 19.9±1.5 yrs,Height: 1.7±0.4m, Mass: 64.1±13.0kg) who were free from any lowerextremity injury for at least 6 weeksparticipated. Interventions: Alltesting procedures were performed onboth limbs of each participant.Participants performed 3 trials ofmaximum reach in the ANTSEBT oneach limb. The weight-bearing lungetest was used to measure DFROM.Subjects performed 3 trials of theWBLT in which they kept their test heelfirmly planted on the floor while theyflexed their knee to the wall.Maximum dorsiflexion was defined asthe distance from the great toe to thewall based on the furthest distance thefoot was able to be placed without heel-

lift while the knee was able to touchthe wall. Each participant performed4 practice trials of the ANTSEBT and1 for the WBLT for each limb.ANTSEBT reach distance and WBLTdistance were recorded in cm. MainOutcome Measures: The mean ofthe 3 trials for each variable wascalculated for each limb. Limits ofagreement analysis (LoA) assessed thelevel of asymmetry between limbs forthe ANTSEBT and DFROM. Pearsoncorrelation determined therelationship between asymmetries onthese two measures. Alpha level wasset a priori at p<0.05. Results: ForDFROM (right: 11.4±3.0 cm, left:11.7±4.0 cm), the LoA indicated therewas an average mean difference of0.3±2.2cm between limbs. The 95%confidence limits around the meandifference revealed DFROMasymmetries up to 4.3 cm bilaterally.For the ANTSEBT (right: 68.2±7.0cm,left: 68.2±7.4 cm) there was an averagemean difference of 0.0±5.3 cmbetween limbs with the 95%confidence limits of ANTSEBTasymmetries up to 10.4cm bilaterally.There was a significant relationshipbetween the asymmetry of WBLTand ANTSEBT (r=0.51, r2=0.26,p=0.01). Conclusion: There arenormally occurring asymmetriesin DFROM and ANTSEBT incollegiate cross-country runners.Differences beyond 4.3 cm ofDFROM or 10.4 cm on the ANTSEBTmay be indicative of pathologicalasymmetries in this population.

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Effect Of Body Composition OnChanges In Biomechanics AndPerformance During AnExercise ChallengeTritsch AJ, Montgomery MM, Cone JC, Schmitz RJ, ShultzSJ: University of North Carolinaat Greensboro, Greensboro, NC,and California State University,Northridge, Northridge, CA

Context: During intermittent exercisedecrease in neuromuscular control isthought to contribute to an increasedrisk of injury as exercise progresses.As individuals with less lean body massper total body mass (LBM:TBM)require greater muscle activation tocontrol the same body weightcompared to those with higherLBM:TBM, it has been hypothesizedthat greater lean mass may provideprotection to the joint during dynamictasks. However, whether greaterLBM:TBM protects against thefatigue-induced biomechanicalchanges has not been directlyexamined. Objective: To compareindividuals stratified into aboveaverage and below average LBM:TBMon performance and landingbiomechanics during an intermittentexercise protocol (IEP). Design:Descriptive cohort. Setting:Research laboratory. Participants:Fifty-nine (29F, 30M;20.4±2.2yrs,173.3± 9.0cm, 68.7±10.5kg) healthy,active participants. Interventions:Males and females were equallystratified into above and below averageLBM:TBM and participated in anindividualized 90 minute IEP thatincluded 7 varying running intensities.Performance measures andbiomechanical data were assessedduring a 45cm drop jump (DJ) landingprotocol performed before exercise(Pre) and immediately after two 45-minute bouts of running (Post45 andPost90). Main Outcome Measures:Performance was monitored via arating of perceived exertion (RPE)scale, counter-movement jump heightin meters (CMJ), and sprint speed in

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m/s (SS). To assess biomechanicalchanges, kinetic and kinematic datawere collected and used to calculatehip, knee, and ankle energy absorption(JxBW(N)-1xHt(m)-1) from footcontact until peak knee flexion.Separate 2 (group) x 3 (time) repeatedmeasures ANOVA’s examineddifferences in CMJ, RPE, SS, andenergy absorption. Results: RPEincreased [Pre (10.09± 2.11)<Post45(13.98±2.06)<Post90(14.96±2.39);P<0.001] and SS decreased [Pre(4.80±0.36)>Post45(4.68±0.42)>Post90(4.57± 0.44); P<0.001] at each timepoint regardless of group. Energyabsorption at the knee decreased forboth groups at the Post45 and Post90compared to Pre [Pre(-0.090±0.020)>Post45(-0.085± 0.022),Post90(-0.086± 0.022); P=0.018].While those with greater LBM:TBMreported less exertion (12.3 vs. 13.6;P=0.004), jumped higher (0.38 vs.0.31 m; P=0.003), and sprinted faster(4.80 vs. 4.57 m/s; P=0.024) therewere no group differences by time (P-value range: 0.51–0.93). Hip, knee, orankle energy absorption did not differby group (P-value range: 0.14-0.75) orgroup by time (P-value range: 0.46–0.77). There was no main effect orinteraction for CMJ (P>0.05).Conclusions: Regardless ofLBM:TBM, RPE increased, SSdecreased, CMJ did not change, andenergy absorption at the kneedecreased after 45 minutes ofexercise, where it remained after 90minutes. While those having greaterLBM:TBM reported lower RPE, andwere able to jump higher and sprintfaster throughout the IEP, LBM:TBMhad no effect on the degradation oflower extremity energy absorptionwith fatiguing exercise. Therefore,while overall performance may bedependent on body composition, bodycomposition was not a factor in one’sability to maintain their performanceor lower extremity biomechanics asfatigue ensued. Acknowledgements:Supported by NFL Charities

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Changes In Time-To-peakKinetics After NeuromuscularFatigueMcGrath ML, Stergiou N,Blackburn JT, Lewek MD, GiulianiC, Padua DA: University of NorthCarolina, Chapel Hill, NC, andUniversity of Nebraska at Omaha,Omaha, NE

Context: Neuromuscular fatigue isone likely factor for increased anteriorcruciate ligament (ACL) injury ratesat the end of halves or games.Researchers have found altered lowerextremity kinetics post-fatigue that areprospectively linked to greater risk ofACL injury. However, no studies haveexamined how the rate of loading,measured via time-to-peak forces ormoments, may be impacted by fatigueor the presence of interventions likeverbal feedback. Objective: Toquantify the effects of fatigue andverbal feedback on the rate of kneejoint loading during an unanticipatedsidestep cut. Design: Cross-sectional.Setting: Research laboratory.Patients or Other Participants:Fifty-nine club-sport athletes (31M,28F; 19.8±1.6yrs, 176.7±9.2cm,71.2±10.0kg) were randomly assignedto either receive verbal feedback (FB)or no feedback (NFB) post-fatigue.Interventions: The unanticipatedsidestep cutting task involved a jumpover a hurdle, triggering a randomizeddirectional cue. The participant landedwith the dominant foot on a forceplatform and cut 60° in the indicateddirection. Participants then performedan intense, intermittent fatigueprotocol involving multi-directionalsprints and broad jumps. Testingprocedures were repeated post-fatigue, but the FB group receivedinstructions to “land softly, keep yourknee over your toes, and make themovement ‘smooth’”. The NFB groupreceived no instruction. MainOutcome Measures: A 7-cameramotion capture system and forceplatform collected kinematics andkinetics. The length of the stance phase

(initial contact:toe-off) was measuredin milliseconds (ms). Time-to-peak(TTP) kinetics [vertical groundreaction force (VGRF), posteriorground reaction force (PGRF), kneeextension moment (KEM), knee valgusmoment (KVM), and anterior tibialshear force (ATSF)] were calculatedpre- and post-fatigue from initialcontact to the peak value during thefirst 40% of the stance phase. Thesekinetics were specifically chosen asthey correlate with ACL strain in-vivo.Comparisons were made betweengroups and fatigue using mixed-modelANOVA’s with Bonferroni post-hoctests (a<0.05). Results: A significantfatigue x group interaction wasobserved for TTP VGRF (F

1,53=7.242,

P=0.01). The NFB group decreasedTTP VGRF post-fatigue (pre-fatigue:52±21ms, post-fatigue: 41±15ms),whereas the FB group had no change(pre-fatigue: 43±14ms, post-fatigue:41±11ms) (t=4.193, P<0.001).Significant fatigue main effects werefound for TTP ATSF (pre-fatigue:136±180ms, post-fatigue: 76±137ms,F

1,53=8.859, P=0.004) and total stance

time (pre-fatigue: 995±281ms, post-fatigue: 1106±324ms, F

1,53=12.139,

P<0.001). Conclusions: In general,fatigue appears to increase the rate ofloading on the knee joint via shorterTTP VGRF and ATSF, despite a longerstance phase. However, feedback waseffective at preserving TTP VGRF.Prior research using identical methodsfound fatigue increased the magnitudeof ATSF and VGRF, which combinedwith lower TTP VGRF and ATSF wouldlikely increase the strain on the ACL.Therefore, feedback may be onemethod to protect the ACL from injuryunder fatigued conditions.

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Hip Abduction Torque BetweenNon-Specific Low Back PainAnd Healthy Individuals WithRepeated ExerciseSutherlin MA, Hart JM: Universityof Virginia, Charlottesville, VA

Context: Low back pain (LBP) is aprevalent condition that can lead tomuscle weakness and adaptations.People with LBP have weaker coremusculature potentially leading toinstability. Weakness or poorendurance in the gluteus medius maybe an easily treatable deficiency inpatients with LBP. Objective: Tocompare isometric hip abductiontorque of the gluteus medius musclein healthy individuals to those withNSLBP following a repeatedisometric side-lying hip abductiontask. Design: Descriptive laboratorystudy Setting: Laboratory Patients orOther Participants: 24 subjects, 12with a history of NSLBP (5M/7F,age=24±4, body mass index=25.19±3.44, Oswestry low back painscale=8.67±5.61, pain=1.06±0.88,Fear and Avoidance Beliefquestionnaire=18.00±8.07) and 12healthy controls (3M/9F, age 22±3,body mass index=21.28±2.40,Oswestry low back pain scale=0.67±1.23, pain=0±0, Fear andAvoidance Belief questionnaire 0±0).I n t e r v e n t i o n s : P a r t i c i p a n t scompleted a total of five repeatedisometric side-lying hip abductiontrials of 30 seconds durations with 30seconds rest between trials. Subjectswere side-lying with the testing legsecured to an isokinetic dynamometer,and the back stabilized with foam rollsduring testing. Testing of the oppositelimb was conducted 20 minutes aftercompletion of the first leg to reducethe effects of fatigue. Main OutcomeMeasures: Mean hip abductiontorques of the dominant and non-dominant limb were recorded at 2second intervals during the second tofourth seconds and the twenty-six totwenty-eighth seconds during eachtrial. Torque values were averaged

between limbs, and normalized to bodymass. A 2 x 2 ANOVA with repeatedmeasures compared the averagenormalized hip abduction torque at thebeginning of the first fatigue trial andthe end of the last fatigue trial betweengroups. Results: There was nodifference between groups(F

(1,23)=0.207, p=0.653) at the onset

(NSLBP=1.52±0.42 Nm/kg, Healthy=1.62±0.30 Nm/kg) or following therepeated fatiguing exercise (NSLBP=1.10±0.42 Nm/kg, Healthy=1.13±0.30 Nm/kg) for normalized hipabduction torque. There was asignificant main effect of time withingroups (F

(1,22)=71.120, p<0.001)

following fatigue (Prefatigue= 1.57±0.36 Nm/kg, Postfatigue= 1.12±0.36 Nm/kg), but no groupby time interaction (F

(1,22)=0.535,

p=0.472). Conclusions Averagednormalized hip abduction torquedecreases following fatigue, howeverno differences were observed betweengroups. An isometric side-lyinghip abduction task is sensitiveto changes in torque followingprolonged exercise, howeverwe are unable to discriminatebetween those with NSLBP likely toexperience reoccurrences and thosewho do not have NSLBP.

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Effects Of Hip Abductor FatigueOn Kinematics Of The Footduring Walking GaitColdiron GR, Tufaro VJ, BambergSJM, Switzler CL, Hicks-Little CA:University of Utah, Salt Lake City,UT

Context: Multiple studies have foundthat control at the hip is essential forproper function throughout the distallower extremity. Research has shownthat hip function can affect function atthe knee and ankle; but it is onlyassumed that there could be similareffects into the foot. Paucity in theliterature currently exists regardingthe effects hip fatigue or weakness hason foot mechanics during gait.Objective: The purpose of this studywas to determine if there is a directrelationship between hip abductorfatigue and amount of subtalarpronation or supination during walkinggait. Our hypothesis was that hipabductor fatigue will directly affectkinematics of the foot during walkinggait on both the fatigued and non-fatigued legs. Design: A repeatedmeasures design. Setting: SportsMedicine Research Laboratory.Patients: Seventeen healthyvolunteers (10 men and 7 women) age:22.17 ± 2.45 years, height: 174.0 ± 9.0cm, weight: 170.59 ± 32.08 lbs wererecruited to participate in the study. Allparticipants were right foot dominant.Interventions: Participantscompleted five walking trials both preand post completion of a hip abductorfatigue intervention on the dominantleg. Subjects wore a customized footpressure system and 3D lowerextremity reflective markers duringthe walking trials. The hip abductorfatigue protocol involved completinga side lying hip abduction movementto a pre-determined height with a 5lbweight attached to the lower leg of thedominant leg of all participants. Hipabduction movement was continueduntil failure. At that time, participantsimmediately performed the post

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fatigue walking trial measures. MainOutcome Measures: Mean jointposition during gait, maximal subtalarpronation and maximal subtalarsupination in degrees; and mean centerof pressure in millimeters duringwalking gait. A repeated measuresANOVA was utilized with alpha set apriori at d•0.05. Results: Significantdifferences were found for mean jointposition (P=.048) and maximalsupination (P=.019) between thefatigued and non-fatigued legs.Specifically, participants spent alonger time in a pronated position inthe fatigued leg versus a supinatedposition in the non-fatigued leg.Further, the non-fatigued leg presentedwith a maximal supination angle of12.6° compared to 4.9° for thefatigued leg. However, no statisticallysignificant differences were found formaximal pronation (P=.074) or meancenter of pressure (P=.186).Conclusions: Our results revealedthat there is a relationship between hipabductor fatigue and foot kinematics.The significant differences found inour results suggest that compensatoryactions occur between limbs whichmay potentially place athletes at agreater risk for lower extremity injuryif hip abductor weakness or fatigue ispresent. Further research is neededto explore the effect hip abductorstrengthening programs have on footmechanics and the prevention oflower extremity injury.

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The Effect Of Equalizing TaskDemands According To SexDifferences In Lower ExtremityLean Mass During LandingMontgomery MM, Shultz SJ,Schmitz RJ: California StateUniversity, Northridge, Northridge,CA, and The University of NorthCarolina at Greensboro,Greensboro, NC

Context: Females possess less relativelower extremity lean mass (LELM)and strength than males. Less LELMin females has been suggested as afactor influencing sex differences inlower extremity (LE) landingbiomechanics, particularly greaterrelative energy absorption (EA) aboutthe knee, which may lend towards theirgreater risk of ACL injury. However,sex comparisons in biomechanics maybe biased as the majority of studiesutilize experimental procedures inwhich males and females performequivalent tasks (i.e. same dropheight), thus requiring females toperform a task which is relatively moredifficult. Objective: To determine theeffect of equalizing task demands onrelative LE joint energetics during adrop jump (DJ) according todifferences in LELM between malesand females. We expected sexdifferences in EA to decrease whentask demands were equalized.Design: Descriptive Cohort. Setting:Controlled Laboratory. Patients orOther Participants: 35 female (1.67±0.1m, 65.3±6.6kg, 21.6±3.6yrs) and35 male (1.78±0.1m, 74.7±8.9kg,20.9±2.9yrs) athletes. Interventions:Participants were enrolled in male-female pairs, matched by similar bodymass index. LELM was measured viadual-energy x-ray absorptiometry. LEbiomechanics were assessed during aDJ from a standardized height(Height

STD) and after equalizing the

task demands based on the differencein LELM within each pair (Height

EQU).

Main Outcome Measures: LELMwas normalized to body mass (%).

Normalized EA (J*N-1*m-1) for thehip, knee, and ankle were calculatedfrom the kinematic and kinetic dataduring the initial deceleration phaseof the DJ landing and expressedrelative to total EA (%). SeparateANOVAs compared males and femaleson joint EA before and after equalizingtask demands. Results: LELM(Mean±SD) for females comparedto males: 23.6±2.9 vs. 29.1±2.3%.During the Height

STD condition

(0.45±0.0m), males absorbed a greaterproportion of total EA than femalesabout the hip: 18.1±8.4% vs.22.4±9.6% (p=0.05), with nodifferences at the knee: 60.5±10.8% vs. 56.0±10.6% (p=0.08) orankle: 21.3±9.3% vs. 21.6±7.0%(p=0.88). During the Height

EQU

condition (0.57±0.07m), malescontinued to absorb a greaterproportion of energy about the hip:18.1±8.4% vs. 23.1±9.5% (p=0.02),with no differences observed atthe knee: 60.5±10.8% vs.56.0±10.6% (p=0.08) or ankle:21.3±9.3% vs. 20.8±7.0% (p=0.81).Conclus ions: Equal iz ing taskd i f f icu l ty accord ing to sexdifferences in LELM had no effecton the relative joint contributionsto EA, which suggests that it is notjust task demand driving the sexdi f fe rences in b iomechanics .These resu l t s may a l so po in ttowards an inadequacy in thecurrent methods for equalizingtask demands according to LELM;there may be other factors thatmore accura te ly charac te r izere la t ive t ask demands whencompar ing males and females .Future work should examine a morefunctional factor, such as strength,for equalizing task demands withthe larger goal of making unbiasedsex compar i sons in fu tureinvestigations. Supported by NATAF o u n d a t i o n .

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Pubertal Maturation Effects OnLower Extremity Kinetics AndKinematics Of Adolescent MaleAthletes During A Stop-JumpTaskTurn KK, Greska EK, McCartyCW, Waters B, Van Lunen BL:Old Dominion University, Norfolk,VA; University of West Florida,Pensacola, FL; A.T. Still University,Mesa, AZ

Context: There has been extensiveresearch on the incidence of anteriorcruciate ligament (ACL) injuries in thehigh school and collegiate population.However, ACL injuries have becomeincreasingly common in theadolescent population, and there hasbeen limited research investigating thecause. It has been suggested thatchanges experienced during pubertalmaturation may affect lower extremitykinetics and kinematics during athleticmaneuvers. Objective: To determineif pubertal maturation has an effect onlower extremity biomechanics ofhealthy adolescent male athletesduring a stop-jump task. Design: Non-randomized cross-sectional study.Setting: Biomechanics laboratory.Patients or Other Participants:Thirty-three healthy male adolescentathletes between the ages of 9 and 14(11.52±1.54 years, 1.53±0.14m,44.22±11.37kg) volunteered toparticipate. Participants were placedinto three maturational categories[pre-pubescent (PRE), early-pubescent (PUB), post-pubescent(POST)] based on the PubertalMaturation Observational Scale thatwas completed by the participants’parent or legal guardian prior toparticipation. All participants were freeof lower extremity injury during thetime of the study. Intervention:Participants lower extremities weremarked with 42 reflective markersprior to performing 5 trials each of ananticipated side-step cut and runningstop-jump, followed by 5 trials eachof an unanticipated side-step cutand an unanticipated stop-jump.

Data were collected using eight high-speed Vicon motion analysis camerasand two Bertec force plates. Kineticand kinematic data were measuredand analyzed during the unanticipatedstop-jump only. Main OutcomeMeasures: The independent variablewas maturation stage(3), and thedependent variables were knee flexion(KF), knee abduction (KA), hip flexion(HF), hip abduction (HA), knee flexionmoment (KFM), knee abductionmoment (KAM), hip flexion moment(HFM), and hip abduction moment(HAM). All dependent variables weremeasured at initial contact (IC), peakknee flexion (PKF), peak verticalground reaction force (PVGRF), andpeak posterior ground reaction force(PPGRF). A one-way MANOVA wasperformed for each dependent variableacross all time instances, with aBonferroni adjustment set at Pd”.01.Results: For HA, PRE subjectsdemonstrated significantly greaterangles than PUB subjects (IC: PRE-8.64±5.06, PUB -1.00±4.33, P=.002;PPGRF: PRE -8.34±5.20, PUB-0.40±4.80, P=.001; PVGRF:PRE -8.30±5.82, PUB -0.01±5.11,P=.002; PKF: PRE -7.00±6.75, PUB0.74±5.30, P=.01). No significantdifferences (P>.01) were notedbetween maturation stages forall kinetic measures, KF, KA,and HF across all time instances.Conclusions: As a decrease inHA has been noted as a possible ACLinjury risk factor, the differencesdemonstrated between pre-pubescentand post-pubescent malesduring the stop-jump may be acontributing factor to the rise in injuryoccurrence across maturation. Hipstrengthening and other aspects of ACLprevention programs may decrease therisk of a non-contact ACL tear. Moreresearch is needed to furtherinvestigate the effects of maturationstage on lower extremitybiomechanics in adolescent athletes.

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Hip Abductor Induced FatigueAnd Lower Extremity JointAngles During Unilateral DropLandings In Males And FemalesKim CY, Lee SC, Lee HD, Lee SY:Yonsei University, Department ofPhysical Education, Seoul, Korea

Context: Fatigue of abductor musclesof the hip may cause increased frontalplane knee motion leading to increasedrisk of knee valgus collapse. However,comparing landing mechanismsbetween males and females before andafter lower extremity fatigue has notyet been investigated. Objective: Theobjective of this study was to assessgender differences in unilaterallanding before and after hip abductormuscle fatigue. Design: Casecontrolled study. Setting: LaboratoryPatients or Other Participants:Fifteen healthy male (age: 29.6±2.07yrs; weight: 75.4±5.12 kg; height:177.6±5.70 cm) and female (age:22.6±3.29 yrs; weight: 57.9±5.68 kg;height: 163.4±4.64 cm) subjects wererecruited for this study. Intervention:A continuous side lying hip abductionexercise was performed to inducefatigue until subjects were unable totouch target angle which was 35°. Inorder to confirm muscle fatigue, thegluteus medius muscle medianfrequency (MDF) was collected duringexercise using a Delsys wireless EMGsystem (Delsys Inc, Boston, MA).Main Outcome Measures:Independent variables of this studywere gender and fatigue status.Landing data were collected using aVicon motion analysis system (ViconInc, LA, CA) during landing at 200 Hz.Since ACL injuries occur near 30° ofknee flexion, all 3-D joint kinematicsat the hip, knee, and ankle wereanalyzed in this specific angle. Agender by time mixed model two-wayrepeated measures of ANOVA wereperformed to analyze meandifferences. Alpha level was set apriori at .05 for all analysis. Results:A significant main effect for fatiguewas found in hip adduction/abduction

at 30° knee flexion (F1,27

=6.39;P=0.00). Post hoc analysis showed thatfatigue protocol resulted in decreasedhip abduction angle at 30° of kneeflexion (Pre: -8.06°±3.52°; Post:-6.19°±4.19°). A significant maineffect for fatigue was also found inknee varus/valgus angles at 30° of kneeflexion (F

1,27=30.83; P=0.00). Post

hoc analysis showed that fatigueprotocol increased knee valgus anglesat 30° of knee flexion (Pre: -0.09°±4.23°; Post: -2.32°±4.58°).Other kinematic variables did not showsignificant main and interaction effect.Conclusions: Fatigue-inducedchanges in the lower extremitykinematics during unilateral landingmay lead to lower extremity motionsthat are characteristic of ACLmechanisms of injury. However, therewere no differences between genderwhich indicated that only fatigue doplay an important role in controllingknee motion regardless of sex.Therefore, it may be necessary toenhance hip abductor muscle strengthand resistance to fatigue in an effortto ensure safe maneuvering such as insudden changes or unilateral landingwhich are common during sport events.

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The Relationship BetweenMusculoskeletal Strength,Physiological CharacteristicsAnd Knee Kinesthesia FollowingFatiguing ExerciseAllison KF, Sell TC, Abt JP, BealsK, Nagle EF, Lovalekar MT,Lephart SM: NeuromuscularResearch Laboratory, Departmentof Sports Medicine and Nutrition,School of Health and RehabilitationSciences, University of Pittsburgh,Pittsburgh, PA

Context: Fatiguing exercise mayresult in impaired functional jointstability and increased risk ofmusculoskeletal injury. While thereare several musculoskeletal andphysiological characteristics relatedto fatigue onset, their relationship withproprioceptive changes followingfatigue has not been examined.Objective: To establish therelationship between musculoskeletaland physiological characteristics andchanges in knee proprioceptionfollowing fatigue. Design: Cross-sectional, correlational study design.Setting: Research laboratory.Participants: Twenty healthy,physically active females participated(age: 28.7±5.6 years, height:165.6±4.3 cm, weight: 61.8±8.0 kg,BF: 23.3±5.4%). Subjects were freefrom lower extremity injury within thepast year, surgery within the past 5years, and had no history ofligamentous injury to the knee.Interventions: During Visit 1,subjects underwent threshold to detectpassive motion familiarization(TTDPM, passive mode, 0.25°/s, 3repetitions each for knee extension/flexion). In addition, isokinetic kneeflexion/extension strength testing(60°/s, 5 repetitions each) and peakoxygen uptake (VO

2peak)/lactate

threshold (LT) assessments wereperformed (treadmill protocol).During Visit 2, subjects completedTTDPM testing and isometric kneeflexion/extension strength testing (5-

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s, 3 repetitions each) immediatelybefore and after a fatiguing exerciseprotocol designed to elicit upper/lower body, core, and general fatigue.Strength and TTDPM testing wereperformed on the dominant limb,defined as the limb used to maximallykick a ball. Wilcoxon signed rank testsdetermined TTDPM and isometricknee strength changes from pre- topost- fatigue. Spearman’s rhocorrelation coefficients determinedthe relationship between isokineticstrength and physiological variableswith pre- to post-fatigue changes inTTDPM and with pre-fatigue and post-fatigue TTDPM in extension andflexion (˜=0.05). Main OutcomeMeasures: Strength was reported asaverage peak torque normalized tobody weight, VO

2peak as highest 15-

s averaged O2 uptake normalized to

body weight, and LT as %VO2peak.

Mean absolute error from pre- topost-fatigue was calculated forTTDPM. Results: No significantdifferences were demonstrated inTTDPM from pre- to post-fatiguedespite a significant decrease inisometric knee flexion strength(P<0.01) and flexion/extension ratio(P<0.05). No significant correla-tions were observed betweenstrength or physiological variablesand changes in TTDPM from pre- topost-fatigue. Isokinetic flexion/extension ratio was significantlynegatively correlated with pre-fatigue TTDPM into extension (r=-0.231, P<0.05) and VO

2peak was

significantly negatively correlatedwith pre-fatigue (r=-0.500, P<0.01)and post-fatigue (r=-0.520, P<0.05)TTDPM into extension. Con-clusions: No significantrelationships were demonstratedbetween musculoskeletal andphysiological characteristics andchanges in TTDPM followingfatigue, which may be related to thehigh fitness level of these subjects.However, higher strength ratio andVO

2peak were associated with better

proprioception pre- and post-fatigue.

Future studies should considerdifferent subject populations, othermusculoskeletal strength character-istics, and different modalities ofproprioception to determine themost important contributions toproprioceptive changes followingfatigue. Supported by Freddie H. Fu,MD Graduate Research Award.

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There Is A Relationship BetweenKnee And Hip Kinematics AndThe Reduction Of VerticalGround Reaction Forces InYouth Soccer AthletesStephenson LJ, DiStefano LJ,Padua DA: University of NorthCarolina, Chapel Hill, NC; StonyBrook University, Stony Brook,NY; University of Connecticut,Storrs, CT

Context: It has been shown in adultpopulations that vertical groundreaction forces (VGRF) are absorbedprimarily through altering kneekinematics and secondarily throughchanges in ankle angles in females andhip angles in males. As youth athletesdemonstrate different landingbiomechanics than that of adults it isprudent to assess their energyabsorption strategies so that anteriorcruciate ligament (ACL) injuryprevention programs can address thesechanges in lower extremity kinematicsto decrease forces at the knee.Objective: To identify relationshipsbetween decreased VGRF and kneeand hip kinematic variables during ajump-landing task and determine howVGRF is being absorbed in youthsoccer athletes. Design: Cross-sectional. Setting: Researchlaboratory. Participants: Twenty-ninehealthy soccer athletes (females:n=12, age=10±1 years, height=141.68±4.51cm, mass= 33.28±4.40kg; males: n=17, age=10±1 years,h e i g h t = 1 4 1 . 5 9 ± 6 . 0 6 c m ,mass=32.59±3,73kg) volunteered toparticipate. Interventions: Two setsof three jump-landing trials wereperformed during a single testingsession. Participants were providedwith instructions regarding properlanding technique prior to each trial ofthe second set of landings. The taskrequired participants to jump forwardfrom a 30cm high box placed adistance of half their height away froma force plate, land with their dominantfoot on the force plate, andimmediately jump for maximal vertical

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height. An optical three-dimensionalmotion analysis system and a forceplate measured lower extremitykinematics and kinetics. MainOutcome Measures: Dependentvariables included sagittal and frontalplane knee and hip angles at initialcontact and peak values over the stancephase and peak VGRF which wasnormalized to body weight. Bivariatecorrelations were analyzed assessingthe relationship between VGRF and allkinematic variables and wereadditionally analyzed by sex (d”.05).Results: Analysis of all participantsrevealed significant moderate positivecorrelations between VGRF and hipflexion at intial contact (HFIC)(r

(27)=.404, p<.05) and between VGRF

and peak hip flexion (HFP) (r(27)

=.442,p<.05). When analyzed by sex nosignificant correlations were foundbetween VGRF and the kinematicvariables for males, and femalesdemonstrated a moderately strongsignificant negative correlationbetween VGRF and peak knee flexion(r

(10)=-0.578, p<.05). Correlations

between VGRF and knee flexion atinitial contact (r

(10)=.-0.573, p=.051)

and peak knee valgus (r(10)

=.-0.206,p=.052) were approachingsignificance. Conclusion: In orderto decrease VGRF youth soccerathletes alter hip flexion. Thislanding strategy is in contrastto their adult counterparts who favorchanges in knee kinematics asa strategy in decreasing VGRF. Thefemales in this study demonstratedlanding in a more erect posture withincreased hip extension followedby increases in peak knee flexionto absorb VGRF; this is concurrentwith the l i terature on landingstrategies in adult females.By understanding these forceabsorption strategies we canconstruct a more comprehensiveACL injury prevention programfor these young athletes.

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Frontal Plane Knee Laxity IsPredictive Of MeasuresAssociated With Medial KneeLoading During GaitSchmitz RJ, Shultz SJ, WangHM, Copple TJ, Rhea CK: TheUniversity of North Carolina atGreensboro, Greensboro, NC

Context: Knee osteoarthritis (OA)onset and progression is related to gaitbiomechanics characteristic of medialknee loading. While frontal plane kneejoint laxity has been associated withOA progression, it is unknown iffrontal plane knee joint laxity is relatedto gait biomechanics commonlyassociated with medial joint loadingand OA initiation. Objective:Determine if frontal plane knee laxityis related to frontal plane gaitmechanics commonly associated withOA onset and progression afteraccounting for pertinent anatomy.Design: Cross-sectional. Setting:Controlled Laboratory. Participants:Forty healthy participants (20 females;1.64±0.04m, 65.1±11.1kg, 21.7±3.1yrs; 20 males: 1.79±0.09m, 83.2±17.2kg, 25.1±3.6yrs) with no currentorthopedic injury or history of surgeryin left limb. Interventions: On asingle day participants underwentgoniometric assessment of lower limbalignment, frontal plane knee laxitytesting using the Vermont Knee LaxityDevice, and 10 trials of over groundwalking at a self-selected pace. Alltesting was performed on the left limb.Main Outcome Measures:Tibiofemoral angle (TFA) representedthe angle formed in the frontal planeby the anatomical axes of the femurand tibia. Varus and valgus knee laxitywere determined at ±10Nm using theVermont Knee Laxity Device. Lowerextremity joint biomechanics duringthe stance phase of gait werenormalized to 100 points andensemble averaged over the 10 trials.Peak hip and knee adduction angles andpeak external hip and knee adductionmoments were extracted from thefirst 50% of stance phase. Separate

linear regressions examined the extentto which absolute (varus) and relative(varus/valgus) knee laxity predicted thepeak biomechanical measures, afteraccounting for TFA and sex. Results:After accounting for TFA (11.8±3.1°)and sex, lesser absolute (3.5±1.2°) andrelative (0.77±.25) varus laxitypredicted greater peak knee adductionangle (5.1±3.4°) (R2"=17.5%,P”=0.014) and greater peak kneeexternal adduction moment (0.039±0.010 Nm*bw-1*ht-1 x10-2) (R2"=13.3%, P”=0.032). Laxity measureswere not significantly predictive ofpeak hip adduction angle (5.8±4.2°)(R2"=12.8%, P”=0.072) or peakexternal hip adduction moment(0.0570±0.011 Nm*bw-1*ht-1 x10-2)(R2"=13.7%, P”=0.070). Con-clusions: After accounting for bonyalignment and sex, lesser absolute andrelative varus laxity predict kneebiomechanics commonly associatedwith greater medial knee loading inhealthy individuals. Mechanicalrestraints to frontal plane knee motionhave the potential to affect chronicknee loading patterns that maypredispose one to knee OA. Futurework needs to further understand thepredictive role of knee joint laxity inOA onset and progression.

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Hip Abductor And ExternalRotator Strength Is Not RelatedTo Medial Knee Displacement InPost-Pubescent FemalesBarry MA, Martinez JC, TrojianTH, Joseph MF, Denegar CR,DiStefano LJ: University ofConnecticut, Storrs, CT

Context: Anterior cruciate ligament(ACL) injuries are frequently seenduring cutting and single leg landingmovements. Excessive medial kneedisplacement (MKD) is theorized tobe a risk factor for ACL injuries.Post-pubescent females demon-strate greater MKD and have a higherrisk of ACL injury compared to theirmale counterparts. There isconflicting evidence regarding therole of hip strength in controllingMKD specifically in a high-riskpopulation. Objective: To evaluatethe relationship between hip abductorand hip external rotator strengthwith medial knee displacement(MKD) in post-pubescent highschool female athletes. Design :Cross-sectional. Setting: ResearchLaboratory. Patients or OtherParticipants : Twenty-five post-pubescent high school femaleathletes (age= 16 ±1 years, mass=58.6±7.4 kg, height= 166±8 cm)volunteered to participate in thisstudy. Interventions : Maximalisometric hip abduction and externalrotation strength were measuredduring two trials using a hand-helddynamometer. MKD was assessedduring three trials of a standardizedjump-landing task using three-dimensional motion analysis. Thejump-landing task requiredparticipants to jump forward froma 30-cm high box a distance ofhalf their height jump for maximumvertical height immediately uponlanding. Main Outcome Measures:MKD was calculated as thedisplacement of the knee jointcenter between initial groundcontact (ground reaction

force>10N) and maximum kneeflexion. The average value for MKDand strength were used for analyses.Separate Pearson correlationcoefficients were calculatedto evaluate the relationship betweenhip abductor strength and hipexternal rotator strength with MKD.A linear regression was performedto evaluate if hip abduction and/orhip external rotator strengthsignificantly predicted MKD.Results: Neither hip abduction (r=-0.24, p=0.26) nor hip externalrotation (r=-0.007, p=0.97) strengthwere significantly correlatedwith MKD or significantly predictedMKD (R2=0.11, p=0.28) in post-pubescent females. Conclusions:These results suggest that increasinghip strength alone may beinsufficient to control MKD andprevent ACL and other lowerextremity injuries in this high riskpopulation. Strength training of thehip musculature may still need tobe addressed in preventionand rehabilitation programs, butshould also be combined withteaching proper neuromuscularcontrol through balance, plyometrics,and sport-specific exercises.

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Hip External Rotation StrengthImpacts Frontal Plane HipMotion During UnanticipatedLanding Activities In CollegiateFemale Soccer PlayersMeinerz CM, Kipp K, Wood CM,Geiser CF: Marquette University,Milwaukee, WI

Context: A number of lower extremityinjuries have been linked to hip muscleweakness in both cross-sectionalstudies and theoretical papers.However, studies on the link betweenhip muscle strength measures andkinematic variables have beeninconclusive or inconsistent.Objective: To examine the associationbetween hip strength measures andlanding kinematics during athletic-liketasks. Design: Cross-sectionalcorrelation. Setting: Biomechanicslaboratory Participants: Twenty-three healthy collegiate female soccerplayers (Age: 19.6+1.3 yrs, Height:1.69+0.06 m, Mass: 63.3+6.6 kg)Interventions: A Lafayette manualmuscle testing system™ was usedwith a standardized protocol tomeasure hip abduction and externalrotation strengths. Participantsperformed three tasks while three-dimensional kinematic data of thelower extremity were collected. Foreach task, participants had to strideforward off of a platform, and land ona force plate with a single leg.Platform height and stride distancewere normalized to the participant’svertical jump height and stride length,respectively. While in the air,participants were given one of threevisual signals on a video screen, whichwould indicate one of three actionsafter landing; continue running forward(RUN), stop and balance on the landingleg (STOP), or cut to the side awayfrom the landing leg (CUT). Visual 3Dwas used to process kinematic dataduring the landing phase, which wasidentified using vertical groundreaction force and corresponded toapproximately the first 30% of total

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ground contact time. Hip excursionwas calculated as the differencebetween maximum and touchdownangle. Hip strength measures werenormalized to body mass and segmentlengths. Both normalized hip strengthmeasures were simultaneously enteredinto three regression models with hipexcursions as the outcome variables.Main Outcome Measures: Hipexcursion (degrees) in each cardinalplane. Results: Hip External Rotationstrength was significantly associatedwith hip excursion during landing in theFrontal plane during all three tasks(Stop R2

Adj=0.243, B=0.768,

t(20)=3.025, p=0.006; CutR2

Adj=0.476, B=0.889, t(20)=4.021,

p=0.001; Run R2Adj

=0.0.283, B=0.808,t(20)=3.267, p=0.004), but not in thesagittal or transverse planes. HipAbduction strength was not associatedsignificantly with any hip excursionmeasures. Conclusions: Regressioncoefficients demonstrate a positiveassociation between hip ExternalRotation isometric strength and hipexcursion in the frontal plane duringunanticipated landing tasks. In thefrontal plane, the stronger the hipexternal rotators were isometrically,the greater frontal plane hip excursionthey demonstrated duringunanticipated tasks. The associationwas greatest for the cutting task, whichis a frontal plane activity whencompared to the more sagittal planetasks of stopping and running.

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Understanding The Role Of HipMuscle Activation In ControllingLower Extremity Motion DuringFunctional TasksNguyen A, Baellow AL, BolingMC: High Point University, HighPoint, NC, and University ofNorth Florida, Jacksonville, FL

Context: Weakness of the hipmusculature has been suggested tocontribute to an increased risk of kneeinjuries due to decreased control of thehip. However, the relationship betweenhip strength and dynamic hip motionremains unclear, as many studies havenot accounted for activation of the hipmusculature during dynamic activities.Objective: To determine the role ofhip torque and muscle activation inpredicting hip kinematics during adrop-landing and single leg hop (SLH).Design: Descriptive laboratory study.Setting: Research laboratory.Patients or Other Participants:Seventy-eight (39 males, 39 females)healthy participants (22.1±3.5 yrs,169.9±10.2 cm, 71.2±15.8 kg)volunteered for this study.Interventions: All measures wereperformed on the dominant stancelimb. Hip abduction (standing, hipabducted 5°) and extension (supine, hipflexed 90°) torques were measuredduring maximal isometric voluntarycontractions (MVIC) using anisokinetic dynamometer. Three-dimensional hip kinematics, gluteusmedius (G

med) muscle activation and

gluteus maximus (Gmax

) muscleactivation were assessed duringbilateral drop-landings (height=45cm)and SLH trials (hop distance=40% ofheight, minimal vertical height=5”).The highest peak torque over 3 trialsfor each strength measure, and theaverage hip angle at initial contact (IC),peak angle, total excursion, andaverage G

med and G

max pre-activation

(250ms prior to IC) and post-activation (IC to maximum kneeflexion) over 5 drop-landing and SLHtrials were used for analyses. Separate

step-wise linear regressionsdetermined the extent to which hipmuscle activation and hip torquepredicted hip kinematics during a drop-landing and SLH. Main OutcomeMeasures: Hip torque was measuredin Newton-meters and normalized tobody mass (Nm•kg-1). Frontal andtransverse plane hip angles (°) at IC,peak angle during the landing (IC tomaximum knee flexion), and jointexcursion (peak minus IC angle) wereextracted. The average root meansquare (RMS) amplitude of the G

med

and Gmax

during the drop-landing andSLH were normalized to the peak RMSvalue during MVIC for each muscle(%MVIC). Results: In females, lessG

med pre-activation (0.32±0.15%

MVIC) predicted less hip internalrotation at IC (0.53±6.07°) during adrop-landing (R2=0.145, P=0.017)and less peak hip internal rotation (-4.42±7.79°) during a SLH (R2=0.115,P=0.038). In males, less G

med post-

activation (0.932±0.658%MVIC)predicted less peak hip internalrotation (-10.79±7.45°) during a drop-landing (R2=0.210, P=0.005) whileless hip extension torque (3.52±0.80Nm•kg-1) predicted greater hip internalrotation excursion (-3.13±3.18°)during a SLH (R2=0.248, P=0.016).Hip muscle activation and torques werenot significant predictors of other hipkinematics (P>0.05). Conclusions:While hip torque was associated withhip internal rotation excursion inmales, activation of the G

med was a

consistent predictor of hip kinematicsduring dynamic tasks. Future studiesshould account for hip muscle activationwhen investigating neuromuscularcontrol of lower extremity motion andrisk factors for knee injuries.

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Understanding The Role Of HipMuscle Activation In ControllingLower Extremity Motion DuringFunctional TasksNguyen A, Baellow AL, BolingMC: High Point University, HighPoint, NC, and University ofNorth Florida, Jacksonville, FL

Context: Weakness of the hipmusculature has been suggested tocontribute to an increased risk of kneeinjuries due to decreased control of thehip. However, the relationship betweenhip strength and dynamic hip motionremains unclear, as many studies havenot accounted for activation of the hipmusculature during dynamic activities.Objective: To determine the role ofhip torque and muscle activation inpredicting hip kinematics during adrop-landing and single leg hop (SLH).Design: Descriptive laboratory study.Setting: Research laboratory.Patients or Other Participants:Seventy-eight (39 males, 39 females)healthy participants (22.1±3.5 yrs,169.9±10.2 cm, 71.2±15.8 kg)volunteered for this study.Interventions: All measures wereperformed on the dominant stancelimb. Hip abduction (standing, hipabducted 5°) and extension (supine, hipflexed 90°) torques were measuredduring maximal isometric voluntarycontractions (MVIC) using anisokinetic dynamometer. Three-dimensional hip kinematics, gluteusmedius (G

med) muscle activation and

gluteus maximus (Gmax

) muscleactivation were assessed duringbilateral drop-landings (height=45cm)and SLH trials (hop distance=40% ofheight, minimal vertical height=5”).The highest peak torque over 3 trialsfor each strength measure, and theaverage hip angle at initial contact (IC),peak angle, total excursion, andaverage G

med and G

max pre-activation

(250ms prior to IC) and post-activation (IC to maximum kneeflexion) over 5 drop-landing and SLHtrials were used for analyses. Separate

step-wise linear regressionsdetermined the extent to which hipmuscle activation and hip torquepredicted hip kinematics during a drop-landing and SLH. Main OutcomeMeasures: Hip torque was measuredin Newton-meters and normalized tobody mass (Nm•kg-1). Frontal andtransverse plane hip angles (°) at IC,peak angle during the landing (IC tomaximum knee flexion), and jointexcursion (peak minus IC angle) wereextracted. The average root meansquare (RMS) amplitude of the G

med

and Gmax

during the drop-landing andSLH were normalized to the peak RMSvalue during MVIC for each muscle(%MVIC). Results: In females, lessG

med pre-activation (0.32± 0.15%

MVIC) predicted less hip internalrotation at IC (0.53±6.07°) during adrop-landing (R2=0.145, P=0.017)and less peak hip internal rotation(-4.42±7.79°) during a SLH (R2

=0.115, P=0.038). In males, less Gmed

post-activation (0.932± 0.658%MVIC) predicted less peak hip internalrotation (-10.79±7.45°) during a drop-landing (R2=0.210, P=0.005) whileless hip extension torque (3.52±0.80Nm•kg-1) predicted greater hip internalrotation excursion (-3.13±3.18°)during a SLH (R2=0.248, P=0.016).Hip muscle activation and torques werenot significant predictors of other hipkinematics (P>0.05). Conclusions:While hip torque was associated withhip internal rotation excursion inmales, activation of the G

med was

a consistent predictor of hipkinematics during dynamic tasks.Future studies should account forhip muscle activation wheninvestigating neuromuscular controlof lower extremity motion and riskfactors for knee injuries.

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Knee Joint Stiffness DiffersAmong Athletes With VaryingConditioning HistoriesOates DC, Needle AR, KaminskiTW, Swanik CB: University ofDelaware, Newark, DE. andCampbell University, BuiesCreek, NC

Context: Maintaining functional jointperformance and stability is dependenton the ability to optimally regulatestiffness while preparing and reactingto the onset of loads. However,previous research is unclear withrespect to the types of training orconditioning histories that maypromote different optimal jointstiffness levels. Training with lowrepetitions and high weight (power), aswell as training with high repetitionsand low weight (endurance) are bothrelated to several neurophysiologicaladaptations; however, it is unclear howthese conditioning histories affectjoint stiffness. Objective: To assessthe effect of conditioning history onknee joint stiffness under variousreactive conditions. Design: Post-testonly. Setting: Biomechanicslaboratory. Patients or OtherParticipants: Forty-two malecollegiate athletes (20.1±1.3yrs,73.0±12.0kg, 176.4±6.2cm) with nohistory of knee injury volunteered forthis study. Subjects included enduranceathletes (END, 15 cross-countryrunners), power-trained athletes(PWR, 12 sprinters), and 15recreational athletes (CON).Interventions: Subjects were testedon a customized stiffness assessmentdevice that generated a rapid 40°flexion perturbation to the knee (30°to 70° flexion arc). Perturbations wererandomly applied in 5 differentconditions: passively (no musclecontraction, PS), actively contracted(85% effort, AS), relaxed withsubjects reactively stiffening the joint(PRS), pre-contracted (85% effort)with subjects reactively stiffening thejoint (ARS), and pre-contracted (85%effort) with subjects asked to

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reactively deactivate and relax (DS).Main Outcome Measures:Normalized knee joint stiffness(˜torque/˜position, Nm/°/kg) wascalculated at the short-range (0-4°),and for the total perturbation (0-40°).Differences were assessed using a 3-way analysis of variance to compareacross groups (3-levels), conditions(5-levels), and stiffness ranges (2-levels). Results: A significant 3-wayinteraction effect was observed(F8,156=2.52,p=0.013). Pairwisecomparisons revealed short-rangestiffness was greater in END(0.0569±0.0028 Nm/°/kg) than CON(0.0474±0.0028 Nm/°/kg, p=0.021)under the passive condition. Totalstiffness was higher in PWR (0.0020Nm/°/kg ±0.003) than END(0.0009±0.0002 Nm/°/kg, p=0.016)in the passive condition. Additionally,for ARS, END (0.0507±0.004 Nm/°/kg) had higher total stiffness than CON(0.0289±0.004 Nm/°/kg, p=0.001) orPWR (0.0372±0.005 Nm/°/kg,p=0.044) groups. Conclusions: Ourresults indicate conditioning historychanges stiffness regulation strategiesin response to knee perturbations.Higher joint stiffness was observed inpower-trained athletes under thepassive condition, indicating apotential alteration in the fusimotorreflexes while at rest. Furthermore,our results found that endurance-trained athletes had higher knee jointstiffness during the reactive trials witha larger range of motion. As thisperturbation condition is morerepresentative of a functional task, itsuggests that training with low-loadand high repetitions may be morebeneficial for achieving greater jointstiffness when necessary.

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Force Sense Does Not DifferBetween Power And EnduranceTrained Collegiate AthletesAn YW, Oates DC, Needle AR,Kaminski TW, Swanik CB:University of Delaware, Newark,DE, and Campbell University,Buies Creek, NC

Context: Recent studies have linkeddeficits in the early detection of jointloading to recurrent episodes ofinstability. Force sense (FS) is aperception influenced by adaptationsto Golgi Tendon Organs (GTO) andmuscle spindles, which play animportant role in regulating jointstiffness and responding to injuriousloads. Enhancing force sense throughspecific types of conditioningprograms may be desirable duringprevention and rehabilitation, but it isunclear whether power or endurancetraining would convey any advantages.Objective: To determine ifconditioning history influences FSperception. Design: Case-controlstudy. Setting: Biomechanicslaboratory. Patients or OtherParticipants: Forty-two male athletes(20.1±1.3yrs, 73.0±12.0kg, 176.4±6.2cm) with no history of knee injuryvolunteered for this study. Subjectsincluded endurance athletes (END, 15cross-country runners), power-trainedathletes (PWR, 12 sprinters), and 15recreational athletes (CON).Interventions: Subjects were testedfor quadriceps and hamstrings FS at30% of their maximum voluntaryisometric contraction on a custom-built assessment device. Subjects wereallowed practice with visual feedbackof force prior to the first trial but nofeedback was provided between trials.Subjects were instructed to exert theirtarget torque and depress a hand-heldswitch. A period of 500ms fromdepression of the switch was used todetermine matched force. Order oftesting was randomized. MainOutcome Measures: The independentvariables were group (END, PWR,

CON) and muscle (hamstrings andquadriceps). Dependent variablesincluded relative error (RE, %),coefficient of variation over the500ms match (CV, %), and time-to-matched torque (sec). Separaterepeated-measures analysis ofvariance was used to determinedifferences between muscles (2levels) and groups (3 levels). Results:The main effect for conditioninghistory (group) was not significant forRE (F2,39=0.220, p=0.803), CV(F2,39=1.068, p=0.353), or time-to-matched torque (F2,39=0.674,p=0.515). Mean ± SDs of RE for thehamstrings were END= 26.37±18.17%, PWR= 33.44± 18.33%,CON= 33.74±20.53%, and thequadriceps were END=37.62±30.29%, PWR=33.08±16.97%,CON=25.2±18.34%. Mean ± SDs oftime-to-matched torque for thehamstrings were END=2.72±1.21 sec,PWR=2.45± .88 sec, CON=2.4±1.02sec, and for the quadriceps wereEND=3.14±1.18 sec, PWR=2.99±1.22 sec, CON=2.54±1.29 sec,respectively. The main effect formuscle was not significant for RE(F1,39=0.030, p=0.864) or CV(F1,39=0.162, p=0.690). Mean ± SDsof RE for the hamstrings andquadriceps were 31.18±2.96% and31.97±3.58%, respectively. However,the main effect for muscle for time-to-matched torque was significant(F1,39=11.12, p=0.002). Time-to-matched torque for the hamstrings(2.52±0.17 sec) was faster thanquadriceps (2.89±0.19 sec).Conclusions: Our findings revealedthat conditioning history does notaffect FS and that the time-to-matchedtorque was faster for the hamstringscompared to the quadricepsin healthy subjects. FS does notappear sensitive to differences inphysical conditioning among healthysubjects; therefore future studies mayexplore whether FS deficits existingin injured populations may benefitfrom conditioning programs.

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Hip Abductor Peak Torque As APredictor Of Rapid ForceProduction And StrengthEnduranceKollock RO, Van Lunen B, RinglebSI, Oñate JA: Auburn University,Auburn, AL; Old DominionUniversity, Norfolk, VA; The OhioState University, Columbus, OH

Context: Lower extremity muscularstrength deficits may increase anathlete’s susceptibility to injury. Manyhave proposed the inclusion ofmaximum strength evaluations intopre-participation screening exams.However, strength consists of threeparameters (maximum strength, rapidforce production and strengthendurance) and there is minimalevidence indicating maximum strengthas a predictor of these other qualities.Objective: To determine the extent towhich maximum strength predictsother qualities of strength. Design:Within-subjects correlational study.Setting: Research Laboratory.Patients and Other Participants:Thirty-three recreationally activefemales (20.94±2.86 yrs,168.75±7.58 cm, 67.75±13.72 kg).Interventions: The investigatorscollected isometric maximumstrength (i.e. peak torque) and rateof torque development datasimultaneously from the hipabductors in a standing positionusing a load cell and data acquisitionsystem at 1 kHz. To calculate the rateof torque development from 0-50and 0-200 milliseconds, theinvestigators used the initial 200millisecond after the contraction.Isometric rate of torquedevelopment test consisted of three5-second trials with a 60-second restbetween trials. Following a 10-minute rest , the participantunderwent isometric strengthendurance testing, which consistedof two 30-second isometriccontractions separated by a two-minute rest . Main Outcome

Measures: Hip abduction peaktorque (Nm), rate of torquedevelopment (Nms-1) from 0-50 and0-200 milliseconds and strengthendurance were calculated as apercent fatigue using a fatigue index(FI): FI = [1 – (area under the torque-time curve 0-30 seconds /maximumforce 0-5 seconds x 30)] x 100. Toaddress the research question of thepresent study the investigators usedthree simple l inear regressionanalyses. Results: The M+SD forpeak torque and strength endurancewas 112.60±31.66 Nm and29.99±7.34 percent, respectively.The M+SD for rate of torquedevelopment at 0-50 and 0-200milliseconds was 1838.73±588.84Nm”s-1 and 455.78±144.60 Nm”s-1, respectively. Peak torque wasa significant predictor of rate oftorque development from 0-50milliseconds [F(1, 31) = 433.19,p < .001, R2 adjusted = .93] andfrom 0-200 milliseconds, [F(1, 31)= 233.09, p < .001, R2 adjusted =.88]. Peak torque was not asignificant predictor of strengthendurance, [F(1, 31) = 2.50, p =.117, R2 adjusted = .05].Conclusions: Although, isometricabductor peak torque is a predictorof rate of torque development from0-50 and 0-200 milliseconds theseresults suggest peak torque does notpredict an individual’s ability tosustain (i .e. endurance) forceisometrically at the abductors.

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Lower Extremity Muscle ActivityWhile Wear A Functional KneeBraceMelinchak M, Donovan L, HertelJ, Hart JM: University of Virginia,Charlottesville, VA

Context: The use of functional kneebraces among athletes to preventinjury is common. However, theapplication of knee braces can alter theelectromyographic amplitude andtiming characteristics of thighmusculature. There is little researchthat evaluates the effects of afunctional knee brace on trunk, hip andcrural musculature. Objective: Tocompare lower extremityelectromyographic muscle activityduring a drop landing task with andwithout functional knee braces.Design: Randomized, controlledcross over design. Setting:Laboratory. Patients or OtherParticipants: Twenty-four younghealthy adults (height= 172±9cm,mass= 69.65±1.4kg, age= 21.63±4.4yrs sex=M:8 F:16). Inter-ventions: Each participant performed10 drop landing tasks in both thebraced and non-braced conditions, inrandom order. The brace was placedon the dominant leg (leg used whenkicking). The drop landing taskconsisted of jumping off a 30.5cm boxlanding on both feet and immediatelyperforming a maximum vertical jump.Main Outcome Measures: SurfaceEMG was collected from the lumbarparaspinals, gluteus medius, vastuslateralis, biceps femoris, medialgastrocnemius, peroneus brevis, andtibialis anterior. Normalized surfaceEMG mean amplitude (50msimmediately prior to contact (pre-contact 1), 50ms immediatelyfollowing initial contact (post-contact1), 50 ms prior to vertical jump (toe-off), 50ms immediately prior to thesecond initial contact (pre-contact 2)and 50ms following the second contact(post-contact 2)), time to activationrelative to first contact, and percent

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activation across total foot contacttime. Muscle activation threshold wasreached if the amplitude exceeded 10standard-deviations above that of quietstanding. Percent of activation wascalculated as the total time across thestride cycle that the amplitudeexceeded activation threshold. Non-normally distributed data werecompared between bracing conditionsusing Wilcoxon signed-ranked test foreach dependent variables. Alpha levelwas d”0.05. Results: The pre-contact1 amplitude of the tibialis anterior wassignificantly lower in the bracecondition when compared to the non-braced condition (31.36±29.57 vs.32.56±34.95, p=0.007). The medialgastrocnemius was activatedsignificantly earlier relative to initialcontact in the braced condition whencompared to the non-braced condition(-0.109±0.102 vs. -0.073±0.13ms,p=0.05). The medial gastrocnemiusand gluteus medius were activated fora significantly longer percentageacross total foot contact time in thebraced condition when compared tothe non-braced condition (MG:57.3±24.8 vs. 52.7±23.6%, p=0.03;GM: 48.0±32.4 vs. 40.8±30.2,p=0.03). Conclusions: A functionalknee brace alters the activation ofthe tibialis anterior and the timingcharacteristics of the medialgastrocnemius and gluteus medius inhealthy young adults. It is not clearwhether these changes wouldinfluence performance or injury risk.

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Knee Stiffness Regulation AfterThe Startle Response AndHormonal ChangesDeAngelis AI, Needle AR, RoyerT, Knight CA, Kaminski TW,Swanik CB: University ofDelaware, Newark, DE, andDelaware State University,Dover, DE

Context: Growing evidence suggeststhe nervous system has a significantrole in the high rate of non-contactanterior cruciate ligament injuries.Females are the most susceptible, butevidence for a hormonal role isconflicting. The startle reflex isuniversal across animals and stiffenslimb muscles after sudden,unanticipated events. No studies haveinvestigated how hormonal changesduring the menstrual cycle mayinteract within the nervous system toalter the startle response and kneestiffness regulation among males andfemales. Objective: To assess ifreactive knee joint stiffening strategiesare affected differently in males andfemales during an acoustic startle.Design: Post-test only with repeatedmeasures. Setting: Universitylaboratory Patients or OtherParticipants: 16 males (21.3±2.0 yrs,82.8±15.8 kg, 179.5±6.9 cm) and 16females (20.9±2.0 yrs, 61.8±7.6 kg,164.4±6.8 cm) with no previous kneeinjury participated in this study. Allfemales were tested at 2 points in themenstrual cycle to form 3 groups:Males (M), Female-Follicular (FF),and Female-Ovulation (FO).Interventions: Subjects were seatedon a custom stiffness device thatgenerated a rapid 40° flexionperturbation to the knee (30° to 70°flexion arc). Subjects remainedrelaxed prior to the perturbation, andwere instructed to react with maximalextension force as quickly as possiblewhen the perturbation was sensed. Atotal of 6 trials were performed, withan acoustic startle (50ms, 1000Hz,100dB) applied 100ms prior to the

perturbation on 3 randomly selectedtrials. Main Outcome Measures:Normalized knee stiffness (˜torque/˜position, Nm/°/kg) was calculated atthe short-range (0-4°) and for the totalperturbation (0-40°). The average ofthe control (CON) and startle trial (ST)were used for analysis. Repeated-measures analyses of variancecomparing gender (M, FF, FO) andstartle condition (CON, ST) were usedfor analysis at both short-range andtotal range. Results: The startlesignificantly increased short-rangestiffness (F=4.24, p=0.04), anddecreased total (F=11.25, p<0.001)stiffness. Pairwise comparisonsrevealed that at short-range, STdisplayed a significantly greaterstiffness of 0.047±0.002Nm/°/kg,(p=0.003) compared to the CON(0.043±0.003Nm/°/kg). However, fortotal stiffness, the startle responsecaused significantly less total stiffness(0.028±0.002Nm/°/kg) than the CON(0.037±0.002Nm/°/kg, p=0.004)condition. No significant gender ormenstrual cycle phase differenceswere observed for stiffness values.Conclusions: This is the first studyto indicate that the startle response cansignificantly disrupt the normal kneestiffness regulation strategies that arerequired to maintain joint stability, andthis effect may occur equally in malesand females. Gender and menstrualcycle phase do not appear to affectknee stiffness or negatively interactwith the startle response. Furtherstudies should explore the potentialrole of startle responses in accidentsand unintentional non-contact injuries.

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1 3 4 5 2 D O N E

Muscle Activity Of The VastusMedialis And Vastus MedialisOblique Are DifferentiallyModulated By The MenstrualCycleTenan MS, Lam A, Hackney AC,Griffin L: University of Texas atAustin, Austin, TX, and Universityof North Carolina at Chapel Hill,Chapel Hill, NC

Context: Patellofemoral painincidence is more than twice as highin females than in males. This may bedue to differences in the activation ofthe muscles that stabilize the patella.In vitro and in vivo evidence suggestthat sex hormones can modulate motorneuron activity. Objective: Toexamine the differences in motor unit(MU) recruitment patterns of thevastus medialis (VM) and the vastusmedialis oblique (VMO) musclesacross the menstrual cycle and inmales. We hypothesized that MUrecruitment would be delayed andinitial firing rate would be lower in theVMO compared to the VM in theovulatory and luteal phases of themenstrual cycle due to elevated sexhormones. Design : The data isconsidered cross-sectional sincedifferent MUs were presumablysampled on each testing date.Setting : Controlled laboratory.Patients or Other Participants: 11males (24.6±5.1 yr) and 7eumenorrheic females (24.9±4.3 yr)participated. From these participants,510 MUs were analyzed.Interventions: Using basal bodytemperature mapping, 5 menstrualphases were determined for datacollection. Males attended only onesession. All sessions consisted of anisometric ramp knee extension up to30% maximal force. Before thecontraction, intramuscularelectrodes were inserted into theVMO and VM. Individual MUs wereidentified based upon shape anddischarge timing. MU recruitment

threshold was defined as the force atwhich 4 consecutive dischargesoccurred. The initial firing rate wasthe average of these intervals,converted to hertz. ANCOVAanalysis was performed with VM/VMO comparisons at each menstrualphase and males to determine ifinitial firing rate was different aftercontrolling for recruitmentthreshold. A Wilcoxon rank-sum testwas used to determine if the VM andVMO had different recruitmentthreshold distributions. MainOutcome Measures: The dependentvariables were initial firing rate,which is continuous, and recruitmentthreshold, which is a boundedmeasure with a right-skeweddistribution. Results: Similar VMand VMO recruitment thresholddistributions were observed in theearly follicular phase (p=0.728;VMO median=8.7%; VM median=8.7%) and there were nodifferences observed in the otherphases or males (p>0.05). The initialfiring rate was significantly lower inthe VMO than in the VM at theovulatory (p=0.007; VMO= 8.0±0.4Hz; VM= 9.1±0.4 Hz) and mid luteal(p=0.007; VMO= 7.9±0.4 Hz; VM=9.1±0.4 Hz) phases. No differencesbetween the muscles occurred at theother phases or in males (p>0.05).Conclusions: The initial MU firingrate of the VMO is lower than inthe VM at the ovulatory and midluteal phases. The lower activation ofthe VMO compared to VM dueto hormonal oscillations mayincrease lateral glide of the patellaand predispose females to a higherincidence of patellofemoralpain compared to males.

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Sex, Hormones, And UseOf Contraceptives OnNeuromuscular FunctionRuss AC, Yingling VR, StearneDJ, Anastasio SM, Tierney RT,Moffit DM: Biokinetics ResearchLaboratory, Temple University,Philadelphia, PA; West ChesterUniversity, West Chester, PA;Idaho State University, Pocatello,ID

Context: Fluctuating hormones of themenstrual cycle may influence the rateof non-contact anterior cruciateligament (ACL) injuries, withincreased risk prior to ovulation whenestrogen levels peak. Females haveshown increased strength and alteredneuromuscular activation prior toovulation. These findings have not beenreplicated in females using oralcontraceptives, which prevent themenstrual cycle. Objective: Todetermine the effect of sex, hormones,and contraceptive use on kneeneuromuscular function at three pointscoinciding with the menstrual cycle.Design: Decroptive cohort.Settings: Controlled laboratory.Participants: Thirty healthyphysically active college-age studentsvolunteered (10 males [M],height=182.40 ± 8.47cm, mass=76.41± 11.33kg; 10 female OC [FOC],height=169.33 ± 7.47cm, mass=71.34± 17.83 kg; 10 female non-OC[FNOC], height= 72.80 ± 5.12cm,mass=68.78 ± 10.57cm). Inter-ventions: Participants completedthree testing sessions (1/follicular, 2/ovulatory, 3/luteal). FOC testingsessions were scheduled based oncontraceptive pill day, FNOC werescheduled around self-report and apositive ovulation test. A standardizedtesting protocol was followed.Participants completed 3 drop jumpsoff a 46-cm box, landing on a forceplate. Data from areaelectromyography (EMG [%maximum voluntary isometriccontraction]) of the rectus femoris

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(RF) and biceps femoris (BF) werecollected 250ms pre- and post-land.Force plate data were used to calculatevertical leg stiffness (VLS) during theeccentric phase of landing andnormalized with a liner regression-based correlation using body weight.Main Outcome Measures:Neuromuscular activation (RF, BF) bygroup (M, FOC, FNOC), testingsession (1/follicular, 2/ovulatory, 3/luteal), and time period (pre, post); andVLS by group (M, FOC, FNOC) andtesting session (1/follicular, 2/ovulatory, 3/luteal). A multipleanalysis of variance was used toanalyze EMG data, while an analysisof variance was used to analyze VLS(pd”.05). Results: Post-land, EMGarea of RF (pre=19.71 ± 1.46%,post=46.23 ± 25.36%) and BF(pre=9.40 ± 6.18%, post = 19.69 ±14.71%) were significantly greaterthan pre-land across groups and testingsessions (F=3.71, p<.001). No othersignificant interactions or maineffects for EMG data were observed.A significant difference existedbetween groups with respect to VLS(F=4.66, p=.012). Males (88.15 ±51.86kN/m) and FOC (81.09 ±55.53kN/m) had significantly greaterVLS than FNOC (52.66 ± 26.53).Conclusion: Neuromuscularactivation was not affected by sex,hormones, or contraceptive use.Lower extremity stiffness wasaffected by sex and contraceptive use.Males and FOC experienced greaterlevels of stiffness than the FNOCgroup. Higher levels of stiffness aretheorized to be more protective of theACL. There was no evidence thatvariation within the menstrual cycleaffected neuromuscular function.Future research should explore therelationship between neuromuscularactivation, stiffness, and hormones inrelation to ACL injury. A smaller timeframe is needed to examine EMGactivation as it relates to stiffness.

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Free Communications, Poster Presentations: Psychometrics1 3 F 1 2 D O I N

Development Of A Patient-ATTrust Instrument Using A FocusGroupDavid SD, Price EA, Ragan BG:Division of Athletic Training, OhioUniversity, Athens, OH

Context: Patient care has had aparadigm shift from the disease-centric to the patient-centered focus,making the patient the centered of thehealth care plan. This changeemphasizes that patients and caregiverscommunicate effectively so patientscan actively participate in theirhealthcare decision process. Patienttrust is an important factor in thiscommunication. It has been linked toincreased adherence and ultimatelybetter treatment outcomes. Despitethe positive benefits the definition andfactors of trust have varied acrosshealthcare settings with little attentionto the application in athletic training.The long-term purpose of this multi-phased project is to develop aninstrument to quantify trust in ATthrough a mixed methods approach andpsychometric testing standards.Objective: The purpose of this study(phase 1) was to understand keycomponents of trust in the athletictraining (AT) setting through qualitativeinquiry. Design: A qualitative focusgroup was completed using groundedtheory techniques. Setting: A quietclassroom. Participants: A typical,stratified purposeful sample of sixcollege-aged Division I student-athletes (5 females; 1 male; 20±1.6yrs) from a variety of sports (fieldhockey, wrestling, and volleyball)participated in a focus group. DataCollection and Analysis: Focusgroup questions were targeted tobetter understand the definition andfactors of trust related to AT. We usedinitial data collected in the AT settingfrom a modified psychotherapy trustscale to provide participants with

background information and a conceptof trust to help facilitate discussion ofideas. We were able to provide relativeitem difficulty of initial trust items thatwere calibrated using Rasch RatingScale Model, which places items andpeople on a common metric.Trustworthiness of the data wasensured using an external auditor,member checks, and methodstriangulation. Results: The focusgroup revealed seven themes: fidelity(decision making with the patient’sbest interest in mind), education,competence, confidentiali ty,reliability, time/availability, andcommunication. Each theme wasfurther classified into one of twocategories: personal attributes orpersonalization. Personal attributeswere personal characteristics of theathletic trainer while personalizationwas making the treatment approachindividualized with the patient at thecenter of the health care. Personalattributes were: time/availability,communication, confidence, andknowledge while personalizationthemes were: fidelity, education, andconfidentiali ty. Conclusion:Results from the two maincategories provide a framework fortrust in the AT sett ing. Thethemes from this qualitative studyprovide a blueprint for i temdevelopment to ensure each themeis adequately represented. Thiswill ult imately lead to thedevelopment of a psychometricallysound AT trust instrument.

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Reliability Of Bony AnatomicLandmark Assessment In TheLumbopelvic RegionSchultz SM, Jacobs MM, GorgosKS, Wasylyk NT, Van Lunen BL:Old Dominion University, Norfolk,VA

Context: The ability to palpate bonylandmarks within the lumbopelvicregion is considered to be a basic skillneeded for application of treatmenttechniques and assessment of patientprogress. Assessment of athletictrainers(ATCs) accuracy of thismeasurement has not been examined.Objective: To examine intra- andinter-tester reliability of four ATCsfor identification of the L4 spinousprocess and the right and left posteriorsuperior iliac spine(PSIS) compared toexpert raters. Design: Cross-sectional reliability. Setting:Laboratory Participants: Sixteenphysically active adults (age=22.56+2.67yrs, ht= 172.0+ 9.38cm,mass= 67.39+ 9.73kg, BMI= 22.8+1.97) volunteered to participate. Fournovice ATCs (certified<1yr) served asthe testers of interest. Intervention:The subjects were placed in a proneposition and two expert ATCs(certified>12yrs) agreed upon eachbony landmark and transferred theexpert markings to contact paper. Thecontact paper and skin of theparticipant were aligned via permanentmarkings, which were also used toalign the tester contact paper whentransferring markings. Each testerpalpated the landmarks twice within thesame test session by utilizing invisiblepens and ultraviolet light. Testersrotated between subjects after onemarking trial. Testers transferred theirown markings and removed themarkings with alcohol wipes, prior totesting the next subject. Expert markswere transposed over the tester marksvia transparency on which the contact

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paper was attached. Main OutcomeMeasurements: The independentvariables were tester(T1,T2,T3,T4)and time(Trial 1,Trial 2) and thedependent variables included distancefrom the expert marking inmillimeters(mm) for L4 and PSISpalpations, and agreement as towhether marks landed within oroutside of a designated area for the L4spinous process. The predeterminedarea included a rectangular boxtransposed over the expert markings asdetermined by previous research.Intraclass correlation coefficients(ICC

2,1) and standard error of

measurement(SEM) were calculatedto determine the intra- and inter-testerreliability for all objectiveassessments. Percent agreement wasalso calculated for each tester(between expert and novice) for L4markings. Results: Intra-testerICC

2,1’s for L4 ranged from ICC

2,1=-

0.14(SEM=2.49mm) to ICC2,1

=0.83(SEM=4.62mm). Inter-tester ICC

2,1’s

for L4 were ICC2,1

=0.16 (SEM=7.02mm) for Trial 1 andICC

2,1=0.26(SEM=6.1mm) for Trial 2.

Percent agreement between expertand testers ranged from 13-56% forL4. Intra-tester ICC

2,1’s for right PSIS

ranged from ICC2,1

=-0.15(SEM=4.03mm) to ICC

2,1=0.77 (SEM=

3.21mm) and left PSIS ranged fromICC

2,1=-0.17(SEM=6.44mm) to

ICC2,1

=0.74(SEM=3.81mm). Inter-tester ICC

2,1’s for right PSIS were

ICC2,1

=0.17(SEM=4.36mm) for Trial1 and ICC

2,1=-0.001(SEM=4.86) for

Trial 2. Inter-tester ICC2,1

’s for leftPSIS were ICC

2,1=0.15 (SEM=

4.76mm) for Trial 1 and ICC2,1

=-0.05(SEM=5.57mm) for Trial 2.Conclusion: Our results indicatepoor to moderate intra-testerreliability for palpation of bonylandmarks in the lumbopelvic regionfor newly credentialed ATCs, as wellas poor inter-tester reliability and

agreement. Competency in palpationskills throughout professionaleducation should be confirmedin order to ensure proper treatmentapplication and pathology assessmentwithin clinical practice.

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Reliability And Validity Of AStanding Hip IsometricEndurance Test For GeneratingMuscle FatigueMutchler J, Weinhandl J, HochMC, Van Lunen BL: Old DominionUniversity, Norfolk, VA

Context: Muscle fatigue is a commonconsideration when evaluating andrehabilitating athletic injuries. Currentassessments of hip muscle fatigue areperformed in seated and/or lyingpositions. Research has notdetermined if a prolonged isometrictest in a standing position is a reliableand valid technique for generatingmuscular fatigue of the hip. Objective:To determine the reliability andvalidity of a standing hip isometricendurance test to generate musclefatigue. Design: Cross-sectionaldesign. Setting: Laboratory. Patientsor Other Participants: Twentyhealthy recreationally activeindividuals(10 male, 10 female;age=25.2±3.3years; height= 175.1± 11 . 6 c m ; m a s s = 7 0 . 6 ± 1 5 . 4 k g )participated. Participants wereexcluded if they scored above 9.33 onthe Disablement in the PhysicallyActive Scale, had a lower extremityinjury within 4 months, or did notpartake in physical activity for at least30 minutes, 3 times per week.Intervention: Participants completedtwo sessions of testing within the sameday. The second session beganapproximately 30 minutes after thefirstsession. Electromyographic(EMG) surface electrodes were placedon the rectus femoris(RF), bicepsfemoris(BF), gluteus maximus(GMax), gluteus medius (GMed) andadductor longus(ADD) of thedominant limb. Endurance testing wasconducted through a single 60-secondhip flexion, extension, adduction, andabduction Maximum VoluntaryIsometric Contraction on an isokineticdynamometer in a standing position.

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Two minutes of rest was providedbetween trials and the order of hipaction was counterbalanced. MainOutcome Measures: Medianfrequency(MF), interpreted as therate of conduction of muscle fibers,was used to quantify fatigue. MF wasexamined from the EMG signal of theprimary muscle of each hip action(Flexion=RF, Extension=BF andGMax, Adduction=ADD, Abduction=GMed) for the first and last 15s ofeach trial through power spectralanalysis (Hz). Intra-sessionreliability was assessed for eachaction using intraclass correlationcoefficients (ICC[3,1]). Facevalidity of the endurance test wasexamined through paired t-tests foreach action between the two timeintervals(0-15s,46-60s) of the datacollected in the second session.Decreases in MF represented fatigueof fast twitch muscle fibers, leavingslow twitch fibers to sustain activity.Descriptive statistics werecalculated as mean±standard error.Alpha level was set at pd”0.05.Results: The ICC[3,1] values forintra-session reliability were good-to-excellent for both timeintervals(0-15s,46-60s) of eachaction (Flexion=0.95,0.84; Ex-tension

BF =0.92,0.95; Ex-tension

GMax

= 0.64,0.84; Adduction =0.79,0.90;Abduction= 0.91,0.62). Significantdecreases in MF were detected overtime for Flexion(0-15sec= 83.66±1.72Hz;46-60s=74.22 ±3.74Hz;p<0.001), Extension

BF(0-15s=

8 3 . 7 5 ± 3 . 7 4 H z ; 4 6 - 6 0 s =7 4 . 3 7 ± 3 . 8 2 H z ; p < 0 . 0 0 1 ) ,Extension

GMax(0-15s= 57.72 ±4.10

Hz;46-60s= 48.29± 2.26Hz;p=0.001), and Adduction(0-15s=61.03 ±1.40 Hz;46-60s= 49.97±1.95Hz; p<0.001). Although MFdecreased during Abduction,statistical significance was notreached(0-15s =75.36 ±3.90Hz;46-60s= 69.59 ±3.03Hz; p=0.132).

Conclusion: The MF associatedwith the 0-15s and 46-60s timeintervals of the 60-second standinghip isometric endurance testdisplayed suitable intra-sessionreliability for all hip actions. Thedecrease in MF over time indicatesthis protocol generates fatigue forall hip actions, except abduction.Therefore, the endurance test used inthis study is a reliable and valid techniqueto generate muscular fatigue for hipflexion, extension, and adduction.

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Reliable Change Index OfScapular Upward RotationIngram RL, Munkasy BA, TuckerWS, Buckley TA: GeorgiaSouthern University, Statesboro,GA, and University of CentralArkansas, Conway, AR

Context: Recently, the importance ofscapular upward rotation in relation tochronic shoulder pathology has beenhighlighted. However, a reliablechange index (RCI) of scapular upwardrotation has not been established tohelp identify true difference asopposed to the result of randomvariation in measurements. Theestablishment of RCIs will assist withthe interpretation of both statisticallyand clinically significant changes inscapular upward rotationmeasurements. Jacobson proposedthat change should reflect more thanfluctuations of a potentially imprecisemeasuring instrument. Objective: Todetermine the RCI for scapular upwardrotation at four commonly assessedshoulder angles. Design: Prospectivetest-retest. Setting: Biomechanicsresearch laboratory. Patients orOther Participants: Twenty-sixmales with no history of shoulderinjury participated in this study: (age:22.2±2.6 years, height: 1.77+0.07 m,weight:76.9+10.9 kg). Interventions:Static scapular upward rotation wasmeasured on the throwing dominantarm with a digital protractor whilesubjects were at rest and at 60ˆ, 90and 120 of humeral elevation in thescapular plane on two consecutivedays. The root of the scapular spine andthe posterolateral acromion werepalpated and used as landmarks for themeasurements. Three trials wereperformed at each position with a 30second rest period between each trial.Order of position was randomizedduring each of the two days. The threeupward rotation measurements at eachposition were averaged for each day.Main Outcome Measures: The RCI

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was calculated according to theJacobson method of quantifyingclinically significant change bydividing the change in measurementsbetween test days on the outcomemeasure by the standard error ofdifference score. Intraclasscorrelation coefficients (ICC) wereneeded to complete the RCIcalculation. An RCI was calculated forthe four positions of humeral elevation(rest, 60°, 90°, and 120°). Results:The mean scapular upward rotation atrest was 0.04 + 2.46° with an ICC of0.97 and an RCI of 3.84°. At 60°, themean was 7.72 + 4.42° with an ICC of0.89 and an RCI of 0.92°. At 90°, themean was 18.57 + 4.69° with an ICCof 0.92 and an RCI of 6.31°. At 120°,the mean was 31.84 + 5.17° with anICC of 0.95 and an RCI of 3.77°.Conclusions: The results of thisstudy provide clinicians withbaseline values for normal scapularupward rotation, reliabili ty ofthe measurements and RCIs toidentify clinically significantchanges. These measurements mayprovide clinicians with referencevalues to identify potentiallypathological shoulder movements inorder to distinguish true differencesfrom slight variation normallyassociated with a repeatedmeasurement. Future researchshould compare these results topatients with scapular dysfunctionand intervention protocols used totreat scapular dyskinesis.

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A Modified Digital InclinometerIs A Valid Instrument ForMeasuring Scapular Anterior-Posterior Tilt In ShoulderInjured SubjectsScibek JS, Gatti JM, Carcia CR,Vomer R: Duquesne University,Pittsburgh, PA

Context: Using electromagnetictracking systems, investigators havebeen able to quantify tri-planarscapular kinematics in healthy andshoulder injured subjects. Modifieddigital inclinometers have beenvalidated for the assessment ofscapular upward rotation. Whileevidence suggests that scapularanterior-posterior (AP) tilt is also animportant factor to consider whentreating shoulder injured patients, noclinical instruments have beenvalidated for this purpose. Objective:The purpose of this study was to testthe hypothesis that measurements ofscapular AP tilt obtained using amodified digital inclinometer wouldproduce valid results when comparedto measures acquired using anelectromagnetic tracking system inshoulder injured subjects. Design:Quasi-experimental, correlationaldesign. Setting: Controlledlaboratory environment. Patients orOther Participants: Nineteenvolunteers (20.42 + 1.92 years; 1.77+ 0.09 meters; 85.13 + 23.11 kg; 10males, 9 females), with either a currentor a history of shoulder injury (43.89+ 31.18 months, ranging from 1 to 96months). All subjects underwent anevaluation to confirm shoulder injurystatus. Intervention: Shoulderkinematic data were collected usingthe MotionStar electromagnetictracking system (AscensionTechnology, Burlington, VT), andMotion Monitor software (InnovativeSports Training, Chicago, IL).Anatomic and reference coordinatesystems approved by the InternationalSociety of Biomechanics were used to

calculate position, orientation anddisplacement of the scapula. ScapularAP tilt was measured using a modifieddigital inclinometer that has beenvalidated (r = 0.63 - 0.86) and in whichintra-rater (ICC

(3,2)= 0.86 – 0.99) and

inter-rater reliability (ICC(2,2)

= 0.83 -0.92) have been previously establishedfor healthy shoulders. All datacollection involved the injuredshoulder. Subjects performed threetrials of 0o, 30o, 45o, 60o, 90o, and 120o

of humeral elevation in the scapularplane in a randomized fashion. MainOutcome Measures: The dependentvariable was scapular AP tilt.Criterion-related validity of theinclinometer was assessed via PearsonProduct Moment correlations. SPSSversion 17.0 was used for thestatistical analyses. An a = 0.05 wasset a priori. Results: Correlationanalyses revealed significant moderateto good correlations (r = 0.68 - 0.76,p < 0.001) for clinically relevantcombinations of humeral elevation.The coefficients of determinationrevealed that 45-58% of the errorvariance could be accounted for bycommon factors involving the twodevices. Conclusions: The results ofthis study indicate that the modifieddigital inclinometer is a valid methodfor assessing scapular AP tilt inshoulder injured patients. Use ofthe modified digital inclinometer willenhance our ability to affordablymonitor in-vivo scapular AP tilt in theclinical environment. Furthermodifications to the inclinometer maybe warranted to address the errorbetween the devices. This study wasfully funded by the Eastern AthleticTrainers’ Association, Inc.

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Mechanical Laxity Testing InThose With Chronic AnkleInstability: An Evidence BasedApproachRosen AB, Ko JP, Brown CN:University of Georgia, Athens, GA

Context: Chronic ankle instability(CAI) commonly develops followinglateral ankle sprain. There is limitedconsensus concerning the rolemechanical laxity plays in those withCAI. Additionally, it has not beenestablished if clinical orthopedic testsare comparable to instrumentedarthrometry. Objective: To determineif instrumented and manual talar tilttests have diagnostic utility in CAIpopulations. Design: Cross-sectional.Setting: Biomechanics ResearchLaboratory. Patients or OtherParticipants: Seventy-fourrecreationally active participants withvarying degrees of ankle function (41females, 33 males, mean age±standarddeviation 21.0±2.4years, height169.57±9.97cm, mass 69.86±13.60kg). Interventions: In a singletest session participants completed theCumberland Ankle Instability Tool(CAIT) and an ankle injury historyquestionnaire. Mechanical laxitytesting consisted of instrumentedarthrometer inversion talar tilt tests(ML) and manual medial talar tilt stresstests for laxity (TT). Sensitivity,specificity, positive likelihood ratio(LR+) and negative likelihood ratio(LR-) were calculated to assess theability of both laxity tests to correctlydiagnose CAI. Main OutcomeMeasures: A CAI group was identifiedas those with history of lateral anklesprain, e”2 reported episodes of ankleinstability in the last 12 months, and aCAIT score d”26. The non-CAI groupwas those with a CAIT score e”28 andno history of instability in the past 12months Based on previous literature,hypermobility was denoted with ML of>29.4°. For TT, a scale of 1-5 wasused; scores of 4 and 5 were labeledhypermobile. Sensitivity, specificity,

LR+ and LR- were calculated for bothML and TT in those diagnosed with CAIand non-CAI participants via theaforementioned criteria. Results:Non-CAI participants (N=37) hadCAIT scores of 29.6±0.7, while CAIparticipants (N=37) had 19.9±5.2. ForML, non-CAI participants had16.47°±10.37° and CAI participantshad 22.94°±11.16° inversion. For MLsensitivity=0.33 (95%CI: 0.20, 0.50),specificity=0.86 (95%CI: 0.72, 0.94),LR+=2.45 (95%CI: 0.97, 6.30) andLR-=0.77 (95%CI: 0.59, 1.00). ForTT, sensitivity=0.50 (95%CI: 0.34,0.66), specificity=0.81 (95%CI:0.66, 0.90), LR+=2.64 (95%CI:1.26, 5.55) and LR-=0.62 (95%CI:0.43, 0.89). Conclusions: The resultsindicate mechanical laxity testing hassome diagnostic value for evaluatingCAI. The high specificity revealed apositive laxity test suggests a highdegree of likelihood that one has CAI.The results also indicate clinicians caneffectively identify participants’ laxitythrough manual testing. This finding isimportant in clinical settings due tolimited access to instrumentedarthrometers. Currently, the “goldstandard” for evaluating CAI is limitedto self-report questionnaires and pastmedical history. Objective measures ofCAI may be necessary for researchersto increase homogeneity among groupmembership. The few false positives inboth mechanical laxity tests implyclinical usefulness and it is suggestedCAI be evaluated through a wide rangeof quantitative and qualitative tools.

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Identifying Clinically ImportantObserved Gait AbnormalitiesSamson CO, Kuntzelman KS,Ragan BG: Ohio University,Division of Athletic Training,Athens, OH

Context: Gait assessment is animportant component of manyevaluations. There are multiplemethods available for clinicians to usefor gait assessment. The most commonmethod relies on observation ofpatients while walking or runningrather than the more expensive use offorce plates and 3D cameras. Becausemethods and philosophical approachesto assessment vary greatly, there is aneed for standardized gait assessment.Objective: To identify observed gaitabnormalities perceived as clinicallyimportant and the correspondingassessment parameters commonlyused by clinicians for each. Design:Survey. Setting: An online survey wasadministered through Patient ReportedOutcomes Measurement InformationSystem (PROMIS). Participants:Fourteen licensed and currentlypracticing athletic trainers (mean±SD:age = 26 ± 9.1 yrs; 6 male, 8 female;experience = 4 ± 12.2 yrs) volunteeredto serve as content experts (CE). Fortool development, 10-15 CE aretypically needed. Interventions: TheGait Abnormalities: ClinicalImportance Survey (GACIS) wasdeveloped based on 60 gaitabnormalities identified in theliterature. Twenty of the 60abnormalities were eliminatedprimarily due to repetitive definitionsusing varied nomenclature and a fewwere considered unfeasible. Theremaining 40 abnormalities wereidentified for GACIS and pilot testedfor readability. Prior to the completionof GACIS, definitions of each phasewere provided. CE were asked to ratethe clinical importance of each gaitabnormality on a scale of 1 to 5 (leastto most clinical importance).

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Subsequently, CE identified the planeof view (anterior, posterior, or lateral)and gait velocity (walking, jogging, orrunning) used to observe eachabnormality. Main OutcomeMeasures: The variables evaluated inthe survey include clinical importance,plane of view, and gait velocity for eachof the 40 abnormalities. A mean of 3.5or greater was used to determineabnormalities with perceived clinicalimportance. A consensus of at least 75percent among CE was used todetermine the consistency of the planeof view and gait velocity observationparameters. Results: Twenty-two ofthe 40 gait abnormalities wereconsidered to be clinically important.CE varied in their opinions of whichplane of view should be observed for18/22 clinically importantabnormalities, agreeing on only 4/22abnormalities. CE agreed that 11/22abnormalities should be observedwhile the patient is walking; opinionsvaried for the type of velocity thatshould be used to observe theremaining 11/22 abnormalities.Conclusions: CE agreed upon 22 gaitabnormalities that are clinicallyimportant when conducting gaitassessment, but had varied opinions ofwhich plane of view and gait velocitywere optimal to observe theseabnormalities. This lack of consensuscreates a challenge for testing theinter-rater and intra-rater reliability ofclinicians in the assessment of gaitabnormalities for the development ofa gait assessment screening tool.

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Reliability Of Injury RiskPrediction Algorithm AcrossThree Different Institutions:Implications For Multi-CenterBiomechanical AndEpidemiological ResearchMyer GD, Wordeman SC,Sugimoto D, Bates NA, RoewerBD, Medina McKeon JM,Dicesare CA, Di Stasi SL, BarberFoss KD, Thomas SM, Hewett TE:Cincinnati Children’s HospitalMedical Center, Sports MedicineBiodynamics Center and HumanPerformance Laboratory,Cincinnati, OH; Division of AthleticTraining, College of HealthSciences, University of Kentucky,Lexington, KY; Departments ofAthletic Training, SportsOrthopaedics, and PediatricScience Rocky MountainUniversity of Health Professions,Prove, UT; Departments ofPediatrics and OrthopaedicSurgery, College of Medicine,University of Cincinnati,Cincinnati, OH; Department ofBiomedical Engineering, Collegeof Engineering and AppliedSciences, University of Cincinnati,Cincinnati, OH; Sports Medicine,The Sports Health & PerformanceInstitute, Departments ofPhysiology & Cell Biology,Orthopaedic Surgery FamilyMedicine and BiomedicalEngineering, The Ohio StateUniversity, Columbus, OH; AthleticTraining Division, School of AlliedMedical Professions, The OhioState University, Columbus, OH

Context: Multi-center collaborationsfor prospective, longitudinalinvestigations provide an appealingalternative to single-center studies. Amulti-center approach has the capacityto generate large sample sizes and thusgenerate more generalizable andstatistically powerful results. Studiesthat investigate difficult or rarephenomena as their primary outcome

of interest, such as ACL injury, mayparticularly benefit from thisapproach. The biomechanical variablesthat contribute to a predictivenomogram for knee injury have beenvalidated and established as reliable ata single center. However, the utility andtranslatability of these tests acrossmultiple institutions has not beenassessed. Objective: To assess thewithin- and between-center reliabilityof an affordable, clinically-based riskfactors that utilize two-dimensional(2D), camcorder-based methods toscreen young athletes for high risk ofknee injury at three institutions. Wehypothesized that the 2D screeningmethods would provide good-to-excellent reliability within andbetween institutions for frontal andsagittal plane biomechanics andvariables that contribute to nomogram-predicted high knee abduction loads.Design: Multi-center laboratoryreliability study. Setting: School andControlled laboratory. Patients orOther Participants: Nineteen (19)female, varsity and junior varsity levelhigh school volleyball playersparticipated in this study (Mean age ±SD, 15.27 ± 1.0 years; height, 1.69 ±0.42 m; mass, 61.08 ± 7.9 kg)..Interventions: 2D motion capturetechniques were used to collectkinematics of the lower extremityduring a drop vertical jump task. Thesubjects were tested as a group at eachtesting center on separate dates withina three week period. Main OutcomeMeasures: Within-center andbetween-center reliability wereassessed with intra-class and inter-class correlation coefficients (ICCs).Results: Within-center reliability ofthe variables that comprise the clinicalnomogram was consistently classifiedas excellent, but between-centerreliability was classified as fair-to-good. The within-center ICCs for allnomogram variables combined was0.98 (ICC range 0.95-0.99), whilecombined between-center ICC was0.63 (ICC range 0.51-0.78). The

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average typical error for frontal planeknee excursion was 2.3 cm for within-center comparisons and 2.5 cm forbetween-center comparisons, with nodiscernible side-to-side differences.The average typical error for kneeflexion range of motion was 5.9° forwithin-center comparisons and 6.7°for between-center comparisons.Conclusions: The risk screeningprotocols were reliable within centersand repeatable between centers.Additional efforts to increasebetween-center investigator trainingand further standardize methodologiesmay reduce between-center errorduring biomechanical assessments,and further enhance reliability. Thecurrent results demonstrate thefeasibility of multi-site biomechanicalstudies and establish a framework forthe further dissemination of injury riskscreening algorithms for youngathletes. Specifically, the proposedmulti-center studies may allow forvalidation and optimization of readilyaccessible and inexpensive 2Dcamcorder based screening tools toidentify young and underserved femaleathletes at high risk for knee injury.

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Reliability And Validity Of Hand-Held Dynamometry AssessmentOf Hip Abduction Strength InHealthy, Young AdultsBoland SA, Quinlevan ME, DodgeEB, Gribble PA: University ofToledo, Toledo, OH

Context: Hip musculature weakness,specifically of the hip abductors(HABD), has been associated withnumerous musculoskeletalpathologies. Screening of hip strengthduring pre-participation examinationmay be important in the prevention oflower extremity injury. Hand-helddynamometers (HHD) are aconvenient and relatively inexpensiveclinical tool that can estimate musclestrength. In addition, a strap to stabilizethe HHD and address bias associatedwith tester strength has been utilizedin recent investigations. Limited dataexists on the accuracy of HHDassessment compared to the goldstandard of isokinetic dynamometry(ID). Objective: To determine theintersession and interrater reliability,as well as the validity of the HHD inmeasuring HA strength in sidelying(SL) and supine (S) positions, bothwith (SLW, SW) and without a stabilitystrap (SLWO, SWO). Design:Controlled laboratory. Setting:Research laboratory. Participants:Fourteen healthy, young adults (4M,19.25±2.5yrs; 178.44±6cm, 70.31±7.64kg; 10F, 23.6±2.01yrs;166.88±5.62cm, 65.14±11.05kg).Intervention: Participantsvolunteered and reported for twosessions one week apart. At eachsession, two raters, both certifiedathletic trainers, performedassessments in SL and S positions.During the no strap condition the ratersperformed a manual muscle testholding the HHD. During the strapcondition, the volunteer pushed againstthe HHD secured with a strap. Four,5-second trials were performed duringeach condition, with appropriate restbetween trials, conditions, and raters.

Additionally, at the first session,HABD strength was also measuredusing the ID, utilizing the sameprotocol as the HHD for trials and rest.Main Outcome Measures: Rawforce values were converted to torquevalues using the appropriate momentarms and reported in Nm. ICC

2,2

models were calculated for interraterand intersession reliability for eachcondition. Pearson Correlationcoefficients were calculated forvalidity between each HHD conditionand the ID measure. Results: Therewas strong interrater reliability for theSW (ICC

2,2=0.989; 95%CI:0.965-

0.996), SWO (ICC2,2

=0.929;95%CI:0.778-0.977), SLW (ICC

2,2

=.986; 95%CI:0.956-0.995), SLWOconditions (ICC

2,2=0.963; 95%CI:

0.884-0.988). Additionally, there wasstrong intersession reliability for theSW (ICC

2,2=0.958; 95%CI:0.870-

0.987), SWO (ICC2,2

=0.964;95%CI:0.889-0.989), SLW (ICC

2,2=

0.983; 95%CI:0.948-0.995), andSLWO conditions (ICC

2,2=0.967;

95%CI:0.896-0.989).There werestrong, positive correlations betweenthe HHD and SW (r=0.921,p<.01),SWO (r=0.917,p<.01), SLW(r=0.882,p<.01), and SLWOconditions (r=0.852,p<.01).Conclusion: The HHD had stronginterrater and intersession reliabilityfor HABD strength assessment in twotesting positions, both with and withouta strap. Additionally, there was a strongcorrelation between the ID and HHDfor HABD strength. The HHD appearsto be a valid and reliable tool forclinicians in assessing HABD strength.

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Reliability And Validity Of M-Mode Ultrasound MeasurementsOf Quadriceps FemorisContractile TimeBoucher T, La Bounty PM, RigbyR, Arnold E: Baylor University,Waco, TX; Texas A&M University,College Station, TX; BaylorUniversity, Waco, TX

Context: Recruitment and timing ofthe quadriceps femoris (QF) muscleis often impaired with kneedysfunction. Real time ultrasoundimaging (RTUS) is a non-invasiverehabilitative technology to assessskeletal muscle and its contractileperformance. Objective: Todetermine the reliability and validityof RTUS M-mode temporalmeasurements of QF contractile time(CT). Design: Reliability andconcurrent validity design. Setting:Outcome measures were assessed ina university research laboratory.Participants: Twenty healthyparticipants (Eleven female, nine male,age=22.6±4.5, height =168.5±7.5 cm,mass=70±7 kg) were assessed forreliability. Nineteen healthyparticipants (fifteen female, four male,age=20.9±1.5, height=170.8±7.8 cm,mass= 71.5±11.7 kg) were assessedfor concurrent validity. Interventions:RTUS M-mode intra-rater, inter-rater,and test-retest reliability of isometricQF CT by two different investigatorswas compared during two testingsessions 4-7 days apart. RTUS M-mode concurrent validity of isometricQF CT was correlated to isometrictime to peak torque on anelectromechanical dynamometer inanother session. Main OutcomeMeasures: M-mode RTUS was usedto measure longitudinal musclethickness of the distal vastus medialisoblique (VMO), rectus femoris/vastusintermedius together (RF-VI), andvastus lateralis (VL). CT was the timeinterval from muscle thickness at restto the muscle thickness in a maximalvoluntary isometric contraction.

Three trials were assessed for eachlocation of each reliability measure inknee extension and each correlation oftime to peak torque at 60° kneeflexion. Intraclass correlationcoefficients (ICC) were used tomeasure reliability and Pearsoncorrelation coefficients ( = 0.01) wereused to analyze time to peak torquerelationships. Results: The measure-ment method had excellent intra-raterreliability for the VMO (ICC

2,12 rater

1=0.95, 95% CI=0.90-0.98; rater2=0.91, 95% CI=0.84-0.96), RF-VI(ICC

2,12 rater 1=0.97, 95% CI=0.95-

0.99; rater 2=0.91, 95% CI=0.83-0.96), and VL (ICC

2,12 rater 1=0.96,

95% CI=0.93-0.98; rater 2=0.94, 95%CI=0.89-0.97); excellent inter-raterreliability for the VMO (ICC

3,6 session

1=0.95, 95% CI=0.91-0.98; session2=0.92, 95% CI=0.86-0.96), RF-VI(ICC

3,6 session 1=0.94, 95% CI=0.89-

0.97; session 2=0.96, 95% CI=0.93-0.98), and VL (ICC

3,6 session 1=0.95,

95% CI=0.90-0.98; session 2=0.96,95% CI=0.93-0.98); and excellenttest-retest reliability for the VMO(ICC

2,24=0.96, 95% CI=0.93-0.98),

RF-VI (ICC2,24

=0.97, 95% CI=0.95-0.99), and VL (ICC

2,24=0.97, 95%

CI=0.95-0.99). Mean reliability CT ofthe VMO=70 ms, RF-VI=68 ms, andVL=72 ms. A strong correlationbetween VMO RTUS CT and time topeak torque was significant(r(43)=0.62, P<0.001). A strongcorrelation between RF-VI RTUS CTand time to peak torque was significant(r(38)=0.61, P<0.001). A mediumcorrelation between VL RTUS CT andtime to peak torque was significant(r(53)=0.42, P=0.001). Mean validityRTUS CT of the VMO=92 ms, RF-VI=92 ms, and VL=93 ms. Meanvalidity time to peak torque of theVMO=290 ms, RF-VI=300 ms, andVL=310 ms. Conclusions: Thisstudy describes a new reliable and validalternative measurement method of QFtiming with M-mode RTUS.

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sEMG Onset Method SelectionAffects Reliability Estimates AndStatistical OutcomesLippa NM, Krzeminski DE, PilandSG, Rawlins JW, Gould TE: TheUniversity of Southern Mississippi,Hattiesburg, MS

Context: Methods to determinesurface electromyography (sEMG)onset criterion scores are susceptibleto measurement error which can affectstatistical outcomes. Limited peer-reviewed data examines thedependence of outcomes andsubsequent inferences on onsetmethod selection. Objective: Toquantify reliability estimates of, anddetermine how statistical outcomesand inferences are affected by, threeliterature-based methods fordetermining sEMG pre-activationonset. Design: Repeated measures.Setting: Research laboratory.Patients or Other Participants: Aconvenience sample of active females(n=10, 24±2.3 yrs, mass 65±10 kg,height 165±6.3 cm) without pregnancyor illness affecting balancevolunteered to participate.Interventions: Participants steppeddown from a standardized height (7.5”)onto impact-resistant polyurethanefoams of pre-determined thicknesses(independent variable; 0”, ¼”, ½”, 1”,2”). sEMG data were collected (1kHz,BIOPAC Systems) in tibialis anterior(TA), lateral gastrocnemius (LG), andvastus medialis (VM) muscles. Eachof the five conditions was repeated 10times, ensemble averaged, and root-mean squared. Pre-activation onsetwas determined by the followingmethods: (1) regression line (RL), (2)visual inspection (V), and (3) threestandard deviation threshold method(TH). Main Outcome Measures:Calculated reliability estimates forsEMG onset time included coefficientof variation (CV), intraclasscorrelation coefficient (ICC(2,1) and(2,k)), as well as standard error ofmeasurement (SEM) (ICC and SEM

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for 0” only). The continuous dependentoutcomes, sEMG pre-activationduration (ms) and mean amplitude(mV), were determined for eachmethod-muscle combination. Six (3muscles x 2 outcomes) separatemultivariate one-way repeatedmeasure analyses of variance wereperformed. Alpha was set at p<.05.Results: In terms of reliability, CVranged from CV

RL=18-69%

(35±11%), CVV=24-37% (29±4%),

and CVTh

=18-47% (27±11%), non-uniformly across muscles orthicknesses. ICC(2,1) values rangedfrom R

RL =.130-.547(.378±.2), R

V

=.531-.688(.594±.1), and RTH

=.471-.995(.804±.3). ICC(2,k) comparingthe three onset methods yieldedR

TA=.077, R

LG=.754 and R

VM=.766.

SEM values ranged from SEMRL

=84-99 ms (89±10 ms), SEM

V=51-72 ms

(61±10 ms), and SEMTh

=7-66 ms(30±30 ms). As for statisticaloutcomes, RL produced a statisticallysignificant decreasing trend in LG meanamplitude with increasing thickness(p=.017). V indicated a decreasing trendin LG mean amplitude (p=.022), as wellas a within effect (p=.042) and anincreasing trend (p=.017) in duration.There were no significant differencesfor TH. Conclusions: Comparing RL,V, and TH, the magnitude of CV rangewas equivocal; however, the reliabilityestimates (i.e. SEM, ICC(2,1)) were lowfor RL and between methods (ICC(2,k)).Statistical outcomes and inferencesregarding the relationship between foamthickness and sEMG variables wereinfluenced by onset determinationmethod. Even when reliability wassimilar (LG: ICC(2,1)) betweenmethods, each of the three methodsprovided unique outcomes for a givenmuscle-thickness combination andinterpretation varied. Therefore, withoutrobust estimates of reliability for arelevant muscle and movement task, theuse of any onset method is cautioned.

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Assessment Of QuadricepsActivation Via BurstSuperimposition In A ClosedChain Position: A NovelApproachNorte GE, Kuenze C, Roberts D,Hart JM: University of Virginia,Charlottesville, VA

Context: Central activation ratio(CAR) is used to estimate volitionalquadriceps activation during a maximalvoluntary isometric contraction(MVIC). CAR values are typicallycalculated from force data during anopen-kinetic-chain knee extensiontask. Variability in CAR values existsbased on the technique used forperforming MVIC. Assessingquadriceps activation in a closed-kinetic-chain (CKC) position is a novelapproach. Objective: The primaryobjective was to determine the test-retest reliability of the quadricepsCAR in a closed-kinetic-chainposition. Design: Crossover,controlled laboratory study. Setting:Research laboratory. Patients orOther Participants: 25 healthyparticipants (13 men, 12 women; age= 23.8 ± 3 years; height = 72.7 ± 14.5cm; mass = 175.3 ± 9.6 kg)volunteered. Interventions:Participants completed two sessionswith a minimum of 48 hours between,in a test-retest fashion. Burstsuperimposition (SIB) testing wasperformed bilaterally in a CKCposition. Verbal technique-basedinstruction was given, directing theparticipant to focus on quadricepscontraction, maintain upright posturewith appropriate contact between trunkand back of the chair, and exhale whilecontracting with arms across chest.Participants were firmly secured to adynamometer during testing. MainOutcome Measures: QuadricepsCAR via the SIB technique and kneeextension MVIC torque were theprimary outcome measures ofinterest. CAR was measured via theSIB technique, and calculated as

(MVIC/SIB)*100. Mean MVIC andSIB torque were normalized to bodymass. The intra-class correlationcoefficient (ICC

2,k) and Bland-Altman

plot were used to assess inter-sessionreliability and agreement amongquadriceps CAR in a CKC positionbetween sessions. Two separate pairedsamples t-tests were used to evaluatedifferences between sessions for CARand MVIC torque. Results: Inter-session reliability was moderate forquadriceps CAR (ICC

2,k) = 0.68, (F

21,22

= 3.12, P = 0.005). CAR did notsignificantly differ between sessions(Session 1: 81.4 ± 11.5%, Session 2:84.2 ± 8.5%; t

21,.975 = -1.13, P = 0.27).

Bland-Altman plots revealed a meanCAR difference between sessions of-2.5 ± 10.3% (LOA -23.1 to 18.1%).Knee extension MVIC torque wassignificantly greater on Session 2(Session 1: 1.28 ± 0.40 Nm/kg;Session 2: 1.48 ± 0.44 Nm/kg; t

21 = -

2.21, P = 0.038). Conclusions: CARcalculated via burst superimposition ismoderately reliable in a closed-kinetic-chain position with technique-based instruction. Observeddifferences in knee extension torquein the absence of CAR differencesmay indicate a learned effect betweensessions, as technique-basedinstruction was provided. QuadricepsCAR calculated in a CKC position mayprovide a more accurate representationof muscle activity during function.Further consideration should be givento determine the reliability over agreater period of time to account forthe possibility of a learning effect.

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Contractile Impulse DifferencesBetween The Sexes During TimeCritical PeriodsJohnson ST, Norcross MF,Doeringer JR, Pollard CD,Hoffman MA: Oregon StateUniversity, Corvallis, OR,and Oregon State University-Cascades, Bend, OR

Context: Contractile impulse, the areaunder the torque-time curve, is animportant strength measure because,unlike many other strength measures,it incorporates the time history of acontraction. During time criticalsituations, which present the potentialfor injury such as the initial 50 and/or100 ms following ground contact,rapid torque development is likelynecessary to control joint motion andto provide dynamic joint stabilization.Despite its importance and relevanceto lower extremity injury, littleinformation regarding contractileimpulse differences between thesexes exists. Objective: To compareisometric contractile impulsesbetween the sexes. Design: Cross-sectional. Setting: Researchlaboratory. Patients or OtherParticipants: Twenty-one healthy,physically active volunteers (12Males, 9 Females, Age: 20.91 ± 1.55years, Height: 1.70 ± 0.10 m, Mass:72.76 ± 11.31 kg). Interventions:Isometric plantarflexion torque-timecurves of the dominant limb wererecorded using a Biodex System 3dynamometer in terfaced with a BiopacMP100 data collection system.Testing position was standardized sothat all participants were seatedrecumbently, the foot secured to afootplate attached to the dynamometer,and the ankle and knee jointspositioned in neutral and 60º offlexion, respectively. Participantswere instructed to isometricallyplantarflex as hard and fast against thefootplate as possible following thepresentation of a light stimulus. Threetrials with 60 seconds of rest between

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Development Of The Self-Efficacy Of Balance Scale(SEBS) For Young ActiveIndividualsBaker CS, Capilouto G, Usher E,Uhl T, Mattacola CG, McKeon PO,Medina McKeon JM: Universityof Tennessee at Chattanooga,Chattanooga, TN, and Universityof Kentucky, Lexington, KY

Context: Research suggests that injuryrisk reduction is not feasible withoutbehavioral change. Neuromuscularassessment techniques used to identifybalance deficits associated with therisk of lower extremity(LE) injuriesexist; however tools to assesspsychological risk factors for LEinjuries are not currently available.Self-efficacy of balance, apsychological characteristic, mayprovide information regardingpsychological risk factors for LEinjury. Validated instruments to assessself-efficacy of balance do notcurrently exist. Objective:Determine the face and content validityof the Self-Efficacy of BalanceScale(SEBS) for an adolescentpopulation. Design: Cross sectionalSetting: Conducted survey viaelectronic questionnaires. Patientsor Other Participants: Elevencontent experts participated (10athletic trainers(ATs) with clinical andresearch expertise of LE injuries, 1expert in self-efficacy research wereassigned to 2 panels). Interventions:Panel 1 (5 ATs, 1 self-efficacy expert)assessed 17 items for face validity todetermine if each item accuratelyassessed an adolescent individual’sconfidence in the ability to balanceduring athletic activities. The panelalso had the opportunity to add, delete,or suggest edits for wording or clarity.The scale was edited to reflect Panel1 recommendations, including addingthree items. Items suggested fordeletion were flagged for potentialremoval. Panel 2 was instructed toassess content validity by determining

whether each item on the new scalewas ‘essential,’ ‘useful, but notessential,’ or ‘not necessary’ to theperformance of assessing self-efficacy of balance. Main OutcomeMeasures: Feedback from Panel 1was used to evaluate face validity,meaning each item was perceived totest confidence in balance in a young,active population. Responses obtainedfrom Panel 2 were used to assesscontent validity by calculating aContent Validity Ratio(CVR) andContent Validity Index(CVI), the meanfor all retained items. Items with aCVR<0, (majority of panelists did notagree the item was essential) or aCVR=0 (only half of the panel agreedthe item was essential) were flaggedfor potential removal. Results: Theoriginal 17-item scale was revised to21 items, reflecting suggestions madeby Panel 1. Assessment of contentvalidity revealed 16 items reached apositive CVR agreement (majority ofpanelists rated the item to be‘essential’). A CVR of 0 was indicatedfor five items. The CVI was 0.46.Items that reached a positive CVR wereretained and items with a CVR of 0were flagged for further testing.Conclusions: Face validity of theSEBS has been established.Furthermore, panelists were able tovalidate the content of the SEBS.Further analyses are necessary todetermine construct and convergentvalidity, resulting in an objectivepsychological measure for balance.Future use of the SEBS may provideimportant insights into how balanceself-efficacy in young, activeindividuals affects risk of LE injury.

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trials were performed. MainOutcome Measures: Contractileimpulse was calculated by integratingthe area under the torque-time curveduring the initial 50ms (CI-50) and100ms (CI-100) following torqueonset. Onset was defined as the instantwhen the torque signal exceeded 2.5%of the recorded peak torque. The meanvalues across trials for each subjectwere normalized to the product of bodymass and height (BM*Ht).Differences in the CI-50 and CI-100between sexes were assessed usingone-tailed, independent t-tests (d•0.05). Results: Males demonstratedsignificantly greater CI-50 (Males:0.0030 ± 0.0011 Nm0s*(BM*Ht)-1vs. Females: 0.0021 ± 0.0011Nm0s*(BM*Ht)-1; p=0.049) and CI-100 (Males: 0.0123 ± 0.0043Nm0s*(BM*Ht)-1 vs. Females0.0087 ± 0.0045 Nm0s*(BM*Ht)-1;p=0.041) than females. Conclusions:Previous reports have suggested peaktorque and rate of torque developmentdifferences between the sexes. Thecurrent results suggest sex differencesin joint work capability during timecritical periods in which controlof joint motion and dynamicstabilization are essential. As such, theassessment of CI may be useful forcharacterizing neuromuscular functionover short timeframes likely pertinentto injury. Further research is neededto determine if these results holdtrue in other muscle groups.

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Free Communications, Poster Presentations: Concussion1 3 0 0 4 F O S P

An Investigation Of Concussion-Related Neuroproteins InCollegiate Athletes: AComparison Of GenderDifferences In High-Risk SportsHamson-Utley JJ, Schulte S,Hansen RA, Rink D, Glodowskk C,Donahue MS, Bass JA, Podlog L,Scharmann S, Schmolesky M,Fowler L, Ashley A: Weber StateUniversity, Ogden, UT; Universityof Utah, Salt Lake City, UT; PorterFamily Clinic, Ogden, UT

Context: In the United States, morethan 1.6 million sport-relatedconcussion injuries occur annually,with the majority resulting fromcontact sports such as football andsoccer; research reports the highestincidence for female athletes in thesport of soccer. Neuropsychologicalevidence-based guidelines stand to aidin diagnosis of severity and return toplay (RTP) decisions. In addition,sport-concussion in early-adulthoodhas been correlated withneurodegeneration resulting inimpaired movement and memory laterin life. Objective: To identify ifphysiological biomarkers (neuro-proteins) associated with concussionand sub-concussive blows due toparticipation in high-risk sports offootball and soccer differ based ongender. Design: Longitudinal repeatedmeasures, mixed design. Setting:Controlled laboratory environment.Patients or Other Participants:Volunteer sample of collegiateathletes (age = 19.45 ± 1.51 years,years in college sport = 2.18 ± 1.47;N=100, 76% male, 24% female),including football (n=76) and soccerathletes (n= 24) were recruitedthrough sport team meetings to gatherbaseline blood neuroproteins anddemographic information. Inter-ventions: Blood was drawn into twored top vacutainers from veins in thecubital fossa at 1500 hours on threeseparate week days. The blood was

allowed to clot and was spun down toseparate plasma from serum. A pipettetransferred serum and plasma into fivesets of cryovials and stored at -80°F.Samples were kept frozen until sent tothe lab for testing. Data gathered wereanalyzed using One-way ANOVA anddescriptive analyses. Main OutcomeMeasures: The following neuro-proteins were measured in the bloodsamples: ANGF-2, FGF-Basic, HGF,IL-8, PDGF-BB, TIMP-1, TIMP-2,TNFa, and VEG-F. These markers werechosen as the literature suggests theyrelate to inflammation andneurological tissue damage. One-wayANOVA compared theses biomarkersby gender. Results: One-way ANOVAanalyses produced a significantdifference in PDGF-BB [F

(1,98)=8.81,

p=.004, ˜ 2=.369] between males(M=1420.04 ± 483.04) and females(M=1114.47 ± 250.70). Conclusions:Our analyses revealed a significantdifference in PDGF-BB with malefootball athletes having increasedlevels in comparison to female soccerathletes. PDGF-BB, platelet-derivedgrowth factor, is a protein thatregulates cell growth and division.Athletes in the current sampleparticipated in high-risk contact sportand were likely to have experiencedunreported concussion or multiplesub-concussive events during sportparticipation. While yet in the novelstages, the identification of higherlevels of DGF-BB in males should beexamined further to solidify therelationship between concussiveevents and brain healing acrossgenders. In addition, the exploration ofdiagnostic biomarkers could provevital to understanding immediate anddelayed neural damage associated withconcussion and is promising for thefield of athletic training.

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Comparisons of PerformanceOn A Clinical Test Of ReactionTime Between Sport And SexSheldon AM, Montgomery MM:California State University,Northridge, Northridge, CA

Context: Recently, much attention hasbeen given to the importance of properevaluation of concussions in order tocombat the short- and long-termeffects on neurocognitive andpsychomotor function. Using a batteryof tests has been suggested to be mosteffective for diagnosing concussionand guiding return to play decisions.Sex differences in pre- and post-concussion assessments have beenreported for several tests. Recently, anovel test for assessing clinicalreaction time (RTclin) (Eckner et al,2010) was presented as a simple andclinician-friendly test to evaluatepsychomotor function. However, asthis work was primarily performed withfootball players, it is unknown whethernormative data from this group isaccurately representative of a broaderpopulation of athletes. Further, it isunknown whether sex differencesexist in the performance of this test.Objective: To examine performanceof RTclin across multiple sports andto explore potential sex differences inRTclin in healthy collegiate athletes.Design: Descriptive Cohort. Setting:Controlled Laboratory. Patients orOther Participants: 68 football(1.9±0.7m, 94.9±15.8kg, 19.1±1.6yrs), 96 soccer (46F: 1.6±0.6m,60.3±10.9kg, 19.1±1.2yrs; 50M:1.8±0.7m, 71.3±8.4kg, 19.8±1.8yrs),and 29 basketball (12F: 1.8±0.1m,70.7±23.7kg, 19.2±1.0yrs; 17M:1.9±0.9m, 87.6±12.7kg, 19.4±1.0yrs)NCAA Division I and CommunityCollege athletes with no currentconcussion symptoms or injury to thedominant upper extremity.Interventions: While sitting in astandardized position with theirdominant forearm resting on a table,

subjects performed 6 trials of apreseason baseline test of RTclin(Eckner et al., 2010) by catching ameasuring apparatus as quickly aspossible after it was unexpectedlydropped by a researcher. The distancethe apparatus fell before being caughtwas measured (cm). Main OutcomeMeasures: The average distance (cm)across the middle four trials wasconverted to RTclin (ms). A one-wayANOVA compared RTclin between allsports. Independent t-tests thencompared soccer and basketball malesand females on RTclin. Results: Therewere no differences in RTclin(F2,191= 1.41, p=0.25) betweenfootball (197.2±7.9ms), soccer(199.2±7.9ms) or basketball(198.2±5.1ms) athletes. Femalesdisplayed significantly faster (t123=-2.2, p=0.03) RTclin than males(197.4±6.1ms vs. 200.3±8.1ms).Conclusions: Current findingsindicate that performance during abaseline test of RTclin is similar acrosssports, which may aid in futureinterpretability of existing normativedata. When stratifying by sex, itappears that females performed betterthan males. However, the clinicalsignificance of this finding (i.e. 3msdifference) remains unclear. Overall,the findings point positively to thepotential utility of this test. Given itssimplicity, this test may be mostvaluable for AT ˆ s with limitedresources and time. Further work isneeded to validate this test againstother established testing protocols andalso to investigate this test in ayounger population. Futureinvestigations should also evaluatepotential sex differences in RTclinduring post-concussion follow-ups.

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Evaluation Of SupplementalFootball Helmet ProtectionKrzeminski DE, Lippa NM, GouldTE, Rawlins JW, Piland SG:University of Southern Mississippi,Hattiesburg, MS

Context: Efforts to reduce theincidence of sports-relatedconcussion have elicited aftermarket,supplemental protection for helmets.Products claim substantial additiveeffects to football helmetperformance parameters which arepurported to reduce the brain injuryof concussion. However, neitherproduct systems nor the componentshave been validated by peer-reviewedliterature. Objective: To characterizeand evaluate the impact attenuationof a supplemental helmet protectionsystem. Design: Post-test onlycontrol group design. Setting:Research laboratory. Patients/OtherParticipants: Kevlar® fiber mesh,polyurethane-based foam system(Kevlar-PUFoam) (n=6), Kevlarfiber mesh component (Kevlar) (n=6),and polyurethane-based foamcomponent (PUFoam) (n=6).Interventions: Impact tests wereperformed against (1) a flat steelanvil (Anvil) or (2) with the additionof a helmet surrogate plaque-foamsystem (PF) comprised of a stackedinjection molded 1/8” helmet outershell-grade material plaque atop 1”VN600 foam using an instrumenteddrop tower (Dynatup 9250HV,Instron, Norwood, MA) at 5.5 m/secwith a 4.9 kg drop weight containinga rounded polyurethane dart (150M,Lixie Hammers, Central Falls, RI).For impact setups 1 and 2, foursample conditions were evaluated:A) Control, B) Kevlar, C) PUFoam,and D) Kevlar-PUFoam. The controlcondition was devoid ofsupplemental technology. Twoseparate one-way ANOVAs wereperformed with post-hoc Tukey HSDtests, where alpha was set a priori to˜=.05. Main Outcome Measures:

Peak impact force (PIF) and percentchange in severity index comparedto control condition (%SI). Results:For setup 1, mean PIF were: Anvil

A

(13975 N ±245), AnvilB (13345

N ±205), AnvilC (12779 N ± 181), and

AnvilD (12624 N ± 145). Significant

main effects were observed for PIF(F

3,8=28.86, p<.01, f=3.28). Anvil

A

was greater than AnvilB, Anvil

C,

and AnvilD (p=.019, p<.001, p<.001),

respectively. AnvilB was greater

than AnvilC (p=.033) and Anvil

D

(p=.009). For setup 2, mean PIF were:PF

A (5340 N ±47), PF

B (5093 N ±89),

PFC (4835 N ±41), and PF

D (4798 N

±38). Significant main effects wereobserved for PIF (F

3,8=42.79, p<

.01, f=3.99). PFA was greater than PF

B,

PF C

, and PFD (p=.008, p<.001,

p<.001), respectively. PFB was greater

than PFC (p=.006) and PF

D (p=.003).

Mean %SI were calculated to bePF

B (-4.2%), PF

C (-7.0%), and PF

D

(-7.2%). Conclusions: Addition ofthe Kevlar-PUFoam product toa helmet surrogate statisticallyreduced PIF and subsequentlydecreased SI, which providedsupport to the impact protectionproduct claims. However, nodifferences between the Kevlar-PUFoam and the PUFoamcomponent suggested that thepolyurethane-based foam providedthe primary linear, compressiveimpact management mechanism.Finally, supplemental protectionto the inner liner of a helmet shouldlower PIF and better SI, but cliniciansshould be cautious whenrecommending such systemsas no scientific information isavailable to address the clinicalsignificance of these products.

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Forward Head PostureIncreases The Risk Of Crown OfThe Head Impacts In FootballSchmidt JD, Guskiewicz KM,Mihalik JP: The University ofNorth Carolina, Chapel Hill, NC

Context: Forward head posture (FHP)is the anterior translation of the headin the sagittal plane relative to thetrunk. Football athletes with FHP maybe less able to resist the draw ofgravity causing them to have a tendencyto lower the head prior to contact.Objective: 1) To compare the risk ofsustaining impacts to the back, front,side, and top of the head betweenathletes with and without FHP. 2) Tocompare the risk of sustaining mild,moderate, and severe head impactsbetween athletes with and without FHP.Design: Prospective quasi-experimental. Setting: Clinic/On-field.Patients or Other Participants: Thirty-three high school football playerswere categorized into either the non-FHP group (n=18; height=180.2±7.4cm; mass=94.0±20.6 kg) or the non-FHP group (n=15; height=180.5±7.4cm; mass=77.8±12.9 kg) based onpreviously published FHP cutoffs.Interventions: Participants stood infront of a leveled marker, marchedin place five times, squatted once,and were instructed to stand lookingstraight ahead in a natural restingposition. Three sagittal still imageswere captured for each player from200 cm distance. Images were leveledand digitized. Forward head angle wasmeasured as the angle betweena reflective marker placed over C7,the tragus, and the horizontal. We usedthe Head Impact Telemetry Systemto record head impact biomechanicsat all practices and games (FHP:n=8,079; Non-FHP: n=6,035 headimpacts). Main Outcome Measures: 1)We identified the location (back, front,side, top) using measures of elevationand azimuth captured for eachhead impact. Relative risks forsustaining impacts to the back, front,

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side, and top of head were computedfor the FHP group relative to theNon-FHP group. 2) Using previouslypublished values, the linear androtational acceleration of each headimpact was categorized as mild (d•66g;d•4600 rad/s2), moderate (>66g or<106g; 4600> or <7900 rad/s2), orsevere (e”106g; e”7900 rad/s2) .Relative risks of sustaining mild,moderate, and severe head impactswere computed for the FHP grouprelative to the Non-FHP group.Results: Players with FHP were atan increased risk of sustainingimpacts to the top of the head(RR=1.76, 95%CI:1.61-1.92)and,conse-quently, a reduced risk ofsustaining impacts to the back(RR=0.82, 95%CI:0.77-0.87) andfront (RR=0.91, 95%CI:0.87-0.94)of the head. Players with a FHP wereat a reduced risk of sustaining bothmoderate (RR=0.64, 95%CI:0.53-0.78) and severe (RR=0.55,95%CI:0.32-0.95) rotational headimpacts. Conclusions: High schoolfootball players with FHP may havea propensity to lower the head priorto collision rather than utilizing aheads-up tackling technique. Loadingthrough the spine may reduce resultantrotational acceleration of the head, butposes a serious threat to the cervicalvertebrae if in a flexed position. Footballplayers may benefit from interventionsaimed at correcting posture.

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Effect Of Ball Speed DuringSoccer Heading On ConcussionAssessment ScoresHoogeveen AM, Tierney RT,McDevitt JK, Dorminy ML, Higgins M: Temple University,Philadelphia, PA, and TowsonUniversity, Towson, MD

Context: Due to the increasingpopularity of soccer in the US, thenumbers of brain injury due torepetitive head impact have alsoincreased. Certified athletic trainershave used sideline concussion tests toindicate whether or not an athlete hasimpairments that can be indicative ofa concussion. Soccer heading ballspeeds may influence injury risk, buthave not been evaluated in a controlled,yet functional, setting. Objective: Todetermine the influence of soccerheading ball speed on concussionsideline assessment scores. Design:Pre-test post-test repeated measuresresearch design. Setting: Athletictraining laboratory and gymnasium.Participants: Sixteen current divisionone collegiate soccer players (age=20.4 ± .96; M = 10; F = 6) with nohistory of head or neck injury in 6months prior to testing, no braces ontheir teeth, and at least 5 years ofsoccer heading experienceparticipated. Intervention: Theindependent variables were ball speed(30, 40, and 50mph; randomized) andtime (pretest vs. posttest). Ball speedwas a between-subjects factor (30mphn = 5, 40mph n = 5, 50mph n = 6) andtime was a repeated-measure. Soccerballs were projected from a JUGSsoccer machine at 30, 40 and 50 mph.Subjects performed at least 5 standingheaders at their respective ball speeds.Concussion assessments wereperformed approximately 1 week priorto and immediately post soccerheadings. Main Outcome Measures:Sideline concussion assessmentsincluded the Standard ConcussionAssessment Tool 2 (SCAT2), BalanceError Scoring System Score (BESS),

and King Devick Test (KDT). Group(3) by time (2) MANOVAs andANOVAs with repeated measures ontime were performed using SPSS v19,p < .05. Results: There were nostatistically significant differencesbetween ball speed groups on anyconcussion assessment measures overtime. There was a statisticallysignificant main effect, F(1,13) =9.08, p = .010, in KDT for time wherethe posttest KDT time (37.6 + 6.8 sec)was lower than the pretest (40.0 + 5.1sec). Slight symptoms (1 of 6 severityendorsed), such as headache, pressurein the head, neck pain, and fatigue,were elicited post-heading in someplayers during the SCAT2 evaluation.Conclusions: Heading a soccer ballat 30, 40, 50 mph did not causestatistically significant increases inconcussion assessment scores. TheKDT significant result in overall timecould be attributed to a learning effect.Although no statistically significantresults were identified in theconcussion assessments over time,slight symptoms were elicited in someplayers post heading. These transientslight symptoms following high-speedhead impacts in sports are common,but their significance is not wellunderstood. Sports medicine healthcare professionals need to remainproactive and conservative in theirconcussion management strategies.

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Balance And CognitivePerformance Under A DividedAttention Task Prior To AndFollowing Two Different 4-WeekTraining Interventions:Preliminary Implications ForConcussion RehabilitationRegister-Mihalik JK, Ingriselli JM,Schmidt JD, Littleton AC, MihalikJP, Giovanello K, Marshall SW, DeMaio VJ, : WakeMed Health andHospitals, Raleigh, NC, andUniversity of North Carolina,Chapel Hill, NC

Context: Concussion rehabilitationhas emerged as a priority amongclinicians tasked with caring for brain-injured athletes. Little evidence existson the utility and feasibility ofconcussion rehabilitation paradigms.Objective: To examine differences incognitive and balance performanceunder a divided attention paradigmprior to and following a dual-task or asingle-task training intervention inhealthy individuals. We hypothesizedthat the dual-task group would havegreater improvements in dividedattention performance following theintervention. Design: Prospectivecohort with stratified (gender),randomized intervention groupassignment (dual-task or single-task).Setting: Clinical research center.Patients or Other Participants: Aconvenience sample of 30 healthy,recreational athletes (15 male, 15female; 15 dual-task, 15 single task)served as participants (age=20.3±1.9yrs; height=1.7±0.2 m; mass=68.3±13.8 kg). Interventions:Intervention group (dual-task vs. singletask) and test-session (pre-intervention vs. post-intervention)served as independent variables. Allparticipants completed a dividedattention assessment including aconcurrent balance and cognitive examprior to and following theinterventions. Both groups completeda 4-week mass progression

intervention program (3x per weekincluding 1 home session). Individualsin the dual-task group performedbalance and cognitive activitiesconcurrently (e.g. concentration taskwhile performing a single leg balancetask) during training sessions whilethe single-task group performedactivit ies separately. MainOutcome Measures : Outcomesincluded Sensory Organization Test(SOT) eyes-open equilibrium scores(conditions 1, 3, 4, and 6) andcomplex attention reaction timesfor correct responses on anincongruent Stroop task assessedindividually and under a dividedattention paradigm. All outcomeswere assessed pre- and post-intervention (time betweenassessments=34.0±4.2 days). Mixedmodel ANOVAs were used toexamine all measures (˜=0.05 apriori). Results: Followingintervention, divided attention reactiontimes were faster (F

1,26=5.03;

P=0.033) in the single-task group(pre=643.6±60.7 ms; post= 611.7±64.5 ms) and slower in the dual-taskgroup (pre= 569.4±198.6 ms;post=612.4 ±212.1 ms). Dividedattention balance scores improvedbetween pre- and post-intervention forall four SOT condition equilibriumscores in both groups (Condition 1:pre=89.8±6.3 vs. post=92.8±3.1,P=0.011; Condition 3: pre=89.3±3.9vs. post=91.4±3.3, P=0.005;Condition 4: pre=81.9±8.4 vs.post=85.9±6.2, P<0.001; Condition 6:pre=71.0±12.9 vs. post=74.2±6.2,P=0.045). No test-session effect wasobserved for divided attention reactiontime (P=0.477). No group orinteraction effects were observed forany of the SOT condition scores. Nocost differences to balance orcognitive performance under thedivided attention task compared to thesingle task were observed. Participantswere able to comply with theinterventions. Conclusions: Dividedattention balance performance

improved regardless of interventiongroup. Single task complex attentiontraining appears to lead to greaterimprovements during a dividedattention task. Both paradigms maybe feasible for rehabili tationprograms. Future research shouldaddress applications of moreadvanced dual-task rehabilitationparadigms aqnd the effects on dividedattention in the management ofconcussed individuals. This study wasfunded by NCTraCS. The NCTraCSInstitute is supported by grantsUL1TR000083, KL2TR000084,TL1TR000085 from the NationalCenter for Advancing TranslationalSciences, National Institutes of Health.

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A Descriptive Analysis OfClinical Findings At DischargeFollowing Sport-RelatedConcussion: A Report FromThe Athletic Training Practice-Based Research NetworkBaker R, Anderson B, Lam KC,Valovich McLeod TC: A. T. StillUniversity, Mesa, AZ

Context: With many concussion statelaws, the return-to-play decision (RTP)is restricted to qualified healthcareproviders, including athletic trainers(ATs). While ATs are educated andtrained to manage concussive injuries,it is unknown whether ATs arefollowing current recommended RTPguidelines in clinical practice.Objective: To describe the course ofclinical recovery and the rationale ofRTP decision-making at dischargefollowing a sport-related concussion.Design: Retrospective analysis ofelectronic medical records (EMR).Setting: Athletic Training Practice-Based Research Network (AT-PBRN).Patients or Other Participants:Discharge records of 188 patients(141 males, 47 females, age=16.7±1.7) diagnosed with aconcussion by an AT. Interventions:Patient records from the period ofOctober 2009-October 2012 werereviewed. All records were created byan AT utilizing a web-based EMRwithin the AT-PBRN. Concussedpatients were identified byconcussion-specific diagnostic codes(ICD-9: 850.0, 850.5, 850.9). MainOutcome Measures: Frequency anddescriptive statistics were calculatedfor each variable of interest from thedischarge form: diagnostic code,recovery time, delayed onset ofsymptoms, course of recovery, timeloss, primary decision-maker,concussion classification system, andcriteria guiding return-to-playdecisions. Results: The majority ofcases were coded as 850.9-Concussion (77.1%, n=145) withfewer being coded as 850.0-

Concussion mental confusion withoutloss of consciousness (20.2%, n=38),and 850.5-Concussion with loss ofconsciousness (2.7%, n=5). Themajority occurred in football (63.6%n=119) and soccer (12.2%, n=23).Only 11.7% (n=22) were considerednormal within 15 minutes and 26.1%(n=49) reported delayed onset ofsymptoms after the concussion. Most(97.8%, n=184) were not allowed toRTP on the day of injury. While themajority of concussions recoveredgradually (symptoms present for 1-7days) (51.1%, n=96), recovery in othercases was rapid (symptoms present <1day) (13.3%, n=25), prolonged(symptoms present for >7 days)(31.9%, n=60), or with persistentsymptoms (symptoms present at endof season) (3.2%, n=6). Time lost fromcompetition was 14.5±17.6 days andpatients were symptom free for7.8±10.3 days prior to returning tocompetition. Eight percent (n=15) ofpatients were disqualified for theremainder of the season. The athletictrainer served as the primary decision-maker for the patient in 69.7%(n=131) of cases and the majority ofcases (70.2%, n=132) were not gradedwith a classification system. RTPguidelines were used in 77.1%(n=145) of cases, with the Zurichprogression (36.2%, n=68) cited mostfrequently. Conclusions: The vastmajority of concussed patients did notRTP on the day of the injury, followingcurrent recommendations and manystate laws. The majority of cases hadsymptom resolution within 7 days,indicating a relatively quick recovery.The decisions by the majority of ATsto not grade the concussion and to usea RTP progression concur with currentrecommendations, suggesting ATs arefollowing best practices.

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Decreased Sport-RelatedConcussion Incident RatesFollowing Intervention At TheMiddle School Football Level:Case SeriesWerner JL, Uhl TL: University ofKentucky, Lexington, KY

Background: Sport-related con-cussions have the highest incidence infootball. According to injurysurveillance study from 2005-2006,practice and competition injury ratesof concussions at the high schoolfootball level are 2.54 and 12.09 rateof injury per 1000-athlete exposures,respectively. The prevalence of sport-related concussions has not beendefined at the middle school footballlevel. In this case series, four middleschool football players (age range 11-12 years old, all males) sustainedsport-related concussions duringpractice (n=3) and at competition(n=1). No loss of consciousnessoccurred; all athletes were given an on-field concussion evaluation by theathletic trainer and then referred forfurther evaluation by a physician, basedon NATA Position Statement:Management of Sport-RelatedConcussions. The mechanism of allfour concussions was the same witheither head-to-head or head-to-personcontact; specifically all tackles leadwith the head. Common chiefcomplaints were headache, nausea, anddizziness, lasting on average four days.Treatment: All cases receivedphysician clearance at one week andsuccessfully progressed through areturn to play protocol following aconcussion and were able to return tofull completion two weeks followingonset. Recognizing the commonalitybetween these three cases, covering aperiod of one week, and observing inpractice that athletes were leading withthe head during tackles, the AthleticTrainer advised proper hittingmechanics should be taught. Theathletic trainer approached the first-year middle school head coach

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regarding the need to correct theimproper hitting mechanics, especiallyin those of the younger athletes. Thefootball coach expressed disbelief andstated if the athletic trainer felt such,she could make the changes herself.All three levels (6th-8th grade) werespoken to as a group regarding theseverity and implications ofconcussions by the Athletic Trainer.The Athletic Trainer then explained anddemonstrated proper hittingmechanics – athletic position, leadingwith the facemask looking at thenumbers of the opponent, wrap up,keep the feet moving and tackle theopponent. The coach divided the teamby grade level and furtherdemonstrated proper hittingmechanics. Following thedemonstration, athletes beganpracticing supervised hitting, 6.25athletes to 1 coach. The AthleticTrainer floated around to assistcoaches. Two days of practice (3 hourstotal) were devoted to specific hittingand tacking drills, progressing fromone-on-one to live play, emphasizingthe basics. Results: Three sport-related concussions were sustainedwithin the first five days of full-padspractice. Following the intervention,the incident rate dropped from 8.33 to0.434 per 1000-athlete exposuresover a course of two-months.Uniqueness: The role of an athletictrainer has been well defined atassessing and treating athletic injuries,as well as preventing them. This caseseries illustrates the importance of thisrole in recognizing potential athleticinjuries and implementing anintervention. This case demonstratesthe coach and Athletic Trainer can worktogether to reduce injury rates.Conclusions: Although the incidencerate of concussions is not known at themiddle school level it obviouslyoccurs. This series demonstratesteamwork between a coach and theAthletic Trainer to emphasize properhitting mechanics. Although the coachinitially did not believe there was a

problem, the effort and enthusiasmdisplayed by the Athletic Trainerinfluenced the coach to dedicate asignificant amount of practice toimprove hitting technique. Althoughconcussions are acknowledged at thenational level, further emphasis on therisks and severity of concussions needsto be done at the fundamental level.The incidence of sport-relatedconcussions in this case series wasdecreased after the Athletic Traineridentified the improper hittingmechanics and worked with thecoaches to address a problem with apositive result of reduced incidence.

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No Factorial Validity SupportFor Revised Baseline AndInjured Factor Structures OfResponse To PCSSPiland SG, Byon KK, Gould TE,Curry PR, Miles JD, Ferrara MS:University of Southern Mississippi,Hattiesburg, MS, and TheUniversity of Georgia, Athens, GA

Context: A recent study published in2012, provided “revised” factorstructures for both non-injured(baseline) and injured (concussed)responses to the 22-item, ImPACT©

Post Concussion Symptom Scale(PCSS). Employing ExploratoryFactor Analysis (EFA), the studysuggested that both samples ofresponses maintained four symptom-clusters. However, the symptom-clusters and construct definitions notonly varied from previously reportedfactor structures, but also betweenbaseline and concussed responses. Thestrength of inferences drawn fromcomposite scores depends upon thequality and quantity of available validityevidence. Such evidence to support theproposed use of the PCSS compositescores is minimal. However, 4-factormeasurement models have beensuggested by a few studies employingEFA methods (e.g., PCA). Thus, morerigorous confirmation is warranted.Objective: To confirm the factorialvalidity of the 4-factor responsestructures of both non-concussed andconcussed athlete responses to thePCSS found within the ImPACT©

computerized neurocognitive exam.Design: Retrospective AnalysisSettings: University Laboratory.Participants: Non-concussed(N=908) and concussed athletes(N=146) enrolled at a southeasternDivision I institution. Interventions:Baseline and concussed responses tothe 22-item PCSS instrument. MainOutcome Measures: Two separateConfirmatory Factor Analyses (CFAs)(i.e., one CFA with baseline data set andthe other CFA with injured sample)

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were performed to fit the specifiedPCSS model, for which the baselinewas hypothesized as 4-factor with 20/22 items (i.e., Cognitive-Sensory,Affective, Vestibular-Somatic, andSleep-Arousal) and the injured sampleas 4-factor with 17/22 items (i.e.,C o g n i t i v e - M i g r a i n e - F a t i g u e ,Affective, Somatic, and Sleep). Severalmodel fit indexes were employed,including ̃ 2, ˜ 2/df, CFI, and RMSEA.Results: The first data set (N = 908)with baseline was subject to a CFA.Goodness of fit indices revealed thatthe 4-factor model did not fit the datawell (˜ 2 = 2350.04; ˜ 2/df = .164; CFI= .670; RMSEA = .600). Goodness offit indices for the injured sample(N=146) revealed that the injuredresponses to the 4-factor PCSSmodel also did not fit the data well(˜ 2 = 369.03; ˜ 2/df = .113; CFI =.809; RMSEA = .12). Conclusion:Responses of both non-concussedand concussed athletes failed tosupport the posited 4-factormeasurement model of the PCSS.Such evidence severely reduces thestrength of inferences that can bedrawn from the clinical use of thefour symptom clusters within thePCSS. Clinicians should becautioned before using a compositescore from the 22-item PCSS or itsconstituent clusters in prognosis.

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A Comparison Of EmergencyFacemask And Helmet RemovalEffectiveness With VariousFootball Helmets And FacemaskAttachment SystemsAl-Darraji SJ, Swartz EE, BricJD, Decoster LC, Mihalik JP:University of New Hampshire,Durham, NC; New HampshireMusculoskeletal Institute,Manchester, NH; University ofNorth Carolina, Chapel Hill, NC

Context: The National AthleticTrainers’ Association recommendsfacemask removal (FMR) foremergency access to football players’airways with limited researchcomparing helmet removal (HR) andFMR. Recent changes in footballhelmet and facemask designs haveimplemented quick-release systemsaimed at reducing FMR time.Comparing the relative efficacy ofthese two new systems to access theairway during FMR and HR tasks hasnot yet been investigated. Objective:To compare the amount of headmovement, time to task completion,and perceived difficulty during FMRand HR across two different helmetdesigns. We hypothesized that FMRwould result in less motion, time totask completion, and perceiveddifficulty than HR. Design: Quasi-experimental. Setting: Researchlaboratory. Patients or OtherParticipants: Forty athletic trainers(ATs) free of physical pathologypreventing them from completing therequired tasks were recruited(males=21; females=19; age=33.7±11.2 yrs; mass=80.7±17.1 kg;height=173.1±9.2 cm; AT experience=10.6±10.4 yrs). Interventions:Independent variables consisted ofhelmet (Riddell Speed 360—RS360—or Schutt ION 4D—ION4D)and technique (facemask removal vs.helmet removal). After familiarization,paired participants conducted 4successful trials in random order foreach of four helmet-technique

conditions (RS360-FMR; RS360-HR;ION4D-FMR; ION4D-HR). An eight-camera three-dimensional motionsystem and two, three-point segmentmarker sets (head and torso) were usedto record head motion in a live modelwearing properly fitted helmets andshoulder pads. Total time was recordedwith a digital stopwatch. The difficultyfor the task reported by the participantwas recorded after each trial using amodified Borg CR-10 scale. MainOutcome Measures: Dependentvariables included motion, total timeand perceived difficulty. A 2x2 (helmetx technique) within-subjects repeatedmeasures ANOVA was employed foreach dependent variable (Pd•0.05).Due to our participant pairing, ouranalyses were based on a sample ofn=20. Results: We observed asignificant helmet-by-techniqueinteraction (F

1,19=349.12; P=0.001);

RS360-FMR took longer (31.22±7.89s) than ION4D-FMR (20.45±3.57 s)or ION4D-HR (26.40±6.29). Helmetremoval (sagittal: 14.88±2.48ˆ;frontal: 7.00±1.14ˆ; transverse:7.00±1.08ˆ) resulted in greatermotion than FMR (sagittal:7.04±1.80ˆ; frontal: 4.73±1.14ˆ;transverse: 4.49±0.89ˆ) in all threeplanes of motion (sagittal:F

1,19=187.27; frontal: F

1,19=65.34;

transverse: F1,19

=68.36; P<0.001 forall). Our ATs reported equal taskdifficulty across both helmet designsand airway access techniques(F

1,19=0.56; P=0.462). Conclusions:

As hypothesized, FMR induced lessmotion than HR when accessingthe airway, validating current clinicalrecommendations. Quick-releaseloop straps allow FMR to becompleted in clinically acceptabletimes with less motion in all planes.Future research should continue toexamine the effects of helmet designson emergency airway access. Thisstudy was funded by the EasternAthletic Trainers’ Association.

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Head And Trunk AccelerationDuring Intermediate TransportOn Medical Utility VehiclesSwartz EE, Tucker WS, HornorSD: University of CentralArkansas, Conway, AR, andUniversity of New Hampshire,Durham, NH

Context: Medical utility vehicles areused for intermediate transport ofathletes with suspected catastrophicneck injuries from the field to anambulance. Various vehicles differ intheir axle suspension systems, axlelocation relative to patient position,and bi-axle distance. Objective: Toanalyze and compare neck motionduring transport on two differentmedical utility vehicles. Design:Within subject. Setting: Controlledlaboratory. Patients or OtherParticipants: Nineteen males(21.8±1.4 years, 176.5±5.5 cm,90.3±16.1 kg) with no previous historyof injury to the spinal column.Interventions: Participants weresecured to a spine board and stretcherusing standard protocols and loadedonto one of two medical utilityvehicles: Husqvarna HUV 4421DXLambulance (HUV) or modified JohnDeere Gator TH (Gator). Vehicleswere driven 60 yards; consisting of 30yards of artificial turf transitioning toconcrete slab (Interval 1) then 30 yardsof concrete slab transitioning tonatural grass (Interval 2). Subjectscompleted three counterbalancedtrials for each vehicle. Vehicle speedwas standardized (6.46-7.22 mph)using an infrared timing system.During the trials, three-dimensionalaccelerometers (Noraxon USA Inc.,Scottsdale, AZ) recorded peak headand trunk acceleration data in thesagittal, frontal and transverse planes.For each plane, absolute peakacceleration of the trunk wassubtracted from the absolute peakacceleration of the head to yield peakacceleration differences. For eachvehicle, the peak acceleration

differences for the three trials wereaveraged. The independent variableswere the vehicle (HUV and Gator) andinterval (Interval 1 and Interval 2).Main Outcome Measures: Thedependent variables were the averagepeak acceleration differences in thethree planes (sagittal, frontal andtransverse). The influence of vehicleand interval on the average peakacceleration differences wascompared using a two-within factorsANOVA (Pd”0.05). Tukey post hoctesting was applied in the event of asignificant interaction. Results: Maineffects were detected in the frontalplane for vehicle (F

1,36=4.93;

P=0.033) and interval (F1,36

=20.27;P<0.001); in that the Gator(6.55±3.46m/s/s) was greater than theHUV (4.80±3.52m/s/s) and Interval 2(7.16±4.2m/s/s) was greater thanInterval 1 (4.19±1.94m/s/s). A maineffect was detected in the transverseplane for interval (F

1,36=4.1; P=0.05)

in which Interval 1 (4.08±2.2m/s/s)was greater than Interval 2(3.23±2.00m/s/s). There was aninteraction for the transverse plane(F

1,36=18.01; P<0.001) in which the

HUV during Interval 1 (5.27±2.32m/s/s) was greater than the Gator duringInterval 1 (2.90±1.30m/s/s) and HUVduring Interval 2 (2.63±1.76m/s/s).There were no main effects for thesagittal plane. Conclusions:Differences in relative accelerationsexist in the frontal and transverseplanes in healthy spine-boardedparticipants who are securedto different intermediate transportvehicles. This suggests differences insurface-type and vehicle specificationscreate lateral and vertical perturbationsthat may be conveyed to the patient.

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The Influence Of Mood StateOn ImPACT Baseline TestPerformanceResch JE, Brown CN,Baumgartner TA, Walpert K,Macciocchi SN, Ferrara MS:The University of Texas atArlington, Arlington, TX; TheUniversity of Georgia, Athens,GA; Georgia NeurologicalAssociates, Athens, GA; TheShepherd Center, Atlanta, GA

Context: Baseline assessments usingcomputerized neuropsychological(CNP) testing has been advocated forthe management of sport concussion.ImPACT is a commonly used CNP testused in sport concussion managementprotocols. A potential extraneousvariable which may influence baselineImPACT test performance is mood.Sources of random error such as moodmay limit the clinical utility of thebaseline ImPACT assessmentfollowing sport concussion.Objective: To examine the effect ofmood state on ImPACT performancein a healthy collegiate sample.Design: Repeated Measures. Setting:Research laboratory. Patients orOther Participants: One hundred andfour (32 males and 72 females) healthycollege students aged 20.9 + 1.45years participated in this study.Interventions: Participantscompleted the Profile of Mood StatesBrief Form (POMS-B) prior tocompleting ImPACT at three clinicallyrelevant time points (days 1, 45, and50). The Green’s Word Memory Test(WMT) was also delivered to assesseffort. Main Outcome Measure:Pearson correlation coefficients werecalculated for each of the sevenPOMS-B factors (fatigue-inertia,vigor-activity, tension-anxiety,depression-dejection, confusion-bewilderment, anger-hostility and totalmood disturbance) and ImPACTcomposite and symptom scores.Repeated measures analysis ofvariance (ANOVA) was used to

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determine significant differencesacross time in regards to POMS-B,ImPACT, and Green’s WMT compositescores. Greenhouse-Geissercorrections were used to correct forviolations of sphericity. Post-hocanalyses were performed usingdependent t tests. All analyses wereperformed with = .05. Results: Ouranalyses revealed significantdifferences across time for compositeImPACT verbal memory (Wilk’s =.824, F

(2,214) = 10.86, p < .001) and

visual motor speed (Wilk’s = .867F

(2,214) = 7.80, p = .001). Post hoc

analyses revealed significantimprovements between day 1 and day45 (t

(103) = -4.0, p < .001) and day 1and

day 50 (t(103)

= -4.39, p < .001).Significant improvements were alsoobserved for visual motor speedbetween day 1 and day 45 (t

(103) = -2.00,

p = .05), day 1 and day 50 (t(103)

= -3.965, p < .001) and between day 45and 50 (t

(103) = -2.378, p = .02). At time

point 1 ImPACT impulse control wassignificantly correlated to POMS-Bfatigue-inertia (-.228, p = .02).ImPACT’s total symptom score wasmost consistently correlated tomultiple POMS-B factors withcorrelations coefficients ranging from-.23 to .57. No additional significantcorrelations were observed betweenthe remaining ImPACT compositescores and the varying mood states.Conclusions: Our results suggest thatalthough mood factors as measured bythe POMS-B were significantlycorrelated to total symptom score ofImPACT, performance remained eitherconsistent or improved over time.Future research is needed in acollegiate athlete sample to determineif potentially higher mood state valuesinfluence computerizedneuropsychological test results.

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Baseline SCAT2 Scores InMiddle And Secondary SchoolStudent-AthletesGlaviano NR, Benson S, GoodkinHP, Broshek DK, Saliba S:University of Virginia,Charlottesville VA, and SaintAnne’s Belfield School,Charlottesville, VA

Context: The Sport and ConcussionAssessment Tool 2 (SCAT2) isrecommended to assess postconcussion neurocognitive andbalance ability. The components ofthe SCAT2 have demonstrated face andcontent validity, but the use hasprimarily been incorporated intocollege and adult populations. SCAT2has been suggested for use in childrenas young as 10 years old.Representative baseline scores haveonly been reported for high-school andcollege-aged student-athletes. To datethere are no published data onrepresentative baseline scores in themiddle-school level. Objective: Todetermine normal baseline SCAT2scores for middle school athletes andcompare scores by age and gender.Design: Cross sectional. Setting:Single private high-school and middle-school (grades 7-12). Participants:324 student-athletes (170 males, 154females, age=14.44±1.74) completedthe SCAT2 as a part of pre-participation screening. Inter-vention: Baseline SCAT2 scores wereindividually obtained in a quiet setting.Scores were grouped by age (12-18years old) at the time of the test androunded to the nearest whole year.Descriptive statistics were reported byage and gender using separate ANOVAs(p<0.05) and Tukey’s post hoc testingwere reported used to identifydifferences between age. MainOutcome Measures: Maximumscores are: SCAT2 (100) symptomscore (22), sign score (2), GSC (15),BESS (30), coordination (1) and totalSAC (30) as well as its four individual

subcomponents (orientation (5),immediate memory (15),concentration (5), delayed recall (5)).Points are awarded for correctresponses or deducted for symptomscores (22 minus number ofsymptoms) or poor GCS responses.Results: There were no statisticaldifferences on gender between SCAT2scores (F=0.0326, p=0.569,females=91.9±4.9, males=91.6±4.5.All subjects scored 100% for GCS andthe subcomponent sign score. Femalesreported more symptoms (F=12.56,p<0.000, female= 19.6±3.2, males=20.7±2)(lower scores=moresymptoms), higher BESS scores(F=6.89, p=0.009, females=27.3±2.2,males=26.5±3.1), and higher SACimmediate recall scores (F=9.705,p=0.002, females=14.6±0.9, males=14.2±1.3). Comparison by ageidentified a significant difference(F=2.77, p=0.012) in theconcentration subscale. Tukey’s PostHoc testing reported 12 year olds(3.2±1.3) scored lower than 15 yearolds (3.8±1.0) and 16 year olds(3.9±1.1) (p=0.048 and p=0.043respectively). Conclusion: TheSCAT2 test is a widely usedconcussion assessment tool that hasbeen recommended for children asyoung as 10 year old. Subcomponentsof the SCAT2 test show differencesbetween gender and age.Consideration should be given fordemographic differences in middleschool athletes, with baseline testingbeing conducted annually. Additionaldata from multiple sites is needed todetermine normalized values for boththe SCAT2 test and thesubcomponents. SCAT2 tests shouldbe used in conjunction with other testsin scholastic age student-athletes tomake return to play decisions.

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An Examination Of Risk FactorsFor Sport Related ConcussionIn High School Football PlayersMcGuine TA, Brooks MA, HetzelS, Rasmussen J, McCrea M:University of Wisconsin, Madison,WI

Context: Approximately 40,000 SportRelated Concussions (SRC) occurannually in high school football. Todate, most epidemiologic studies ofSRC have not reported variables thatmay be associated with increased riskof SRC in this population. Objective:Determine the association of variousintrinsic and demographic factors withthe incidence of SRC in high schoolfootball players. Design: Prospectivecohort. Setting: Data were collectedby Athletic Trainers (ATCs) at 36public and private high schools inWisconsin during the 2012 footballseason. Participants: A conveniencesample of 1,332 football players(grades 9 – 12, age: 15.9 + 1.8 yrs,BMI: 24.3 + 4.3, with 4.1 + 1.0 yearsof football experience) enrolled in thisstudy. Interventions: During the pre-season, subjects completed aquestionnaire to measure age, height,weight, year in school, level ofcompetition, years of footballexperience and SRC history. ATCs ateach school recorded the incidence ofSRC throughout the season. MainOutcome Measures: Dependentvariables included the incidence ofSRC. T-tests were used to compare theincidence of SRC for age and BMI.Chi-square tests were used to comparethe incidence of SRC among grade,competition levels, years experience,and history of SRC. Relative Risks[RR, 95% CI] were calculated forvariables with significant tests (p<.05). Results: A total of 115 (8.6%)players sustained 116 SRCs. Nodifferences were found in the age (p =0.587) and BMI (p = 0.490) of playerswho sustained an SRC compared totheir non-injured peers. There was nodifference in the rate of SRC (%, 95%

CI) by year in school [p = 0.896],(freshmen (8.4, 5.9 -11.9),sophomores (8.8, 6.0-12.5), juniors(9.5, 6.7-13.2) and seniors (7.8, 5.1-11.6), or competition level [p =0.768], (freshmen (8.8, 6.1 -12.5),junior varsity (9.4, 6.7-13.0) andvarsity (8.1, 6.2-10.6), or previousplaying experience [p = 0.205], (0 to2 years (9.7, 6.6 -14.1), 3 to 5 years(9.5, 7.4 -12.0) and 6 to 8 years (6.6,4.5 -9.6). The rate of SRC was higher[RR = 2.21, 1.54 – 3.17] in playerswith a history of SRC (15.5, 11.4 -20.8) than players without a history ofSRC (7.0, 5.6-8.8), [p < 0.001].Conclusion: Increased risk of SRCwas not associated with a player’s age,BMI, grade in school, level ofcompetition or years of footballexperience. However, players witha history of SRC were twice as likelyto sustain an SRC compared to playerswithout a history of SRC. ATCs needto screen for SRC history to identifythose high school football playersat increased risk of SRC.

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Prior Concussion History AndNewly Diagnosed ConcussionsAre Elevated Among StudentsWith Self-Reported LearningDisability And Attention DeficitHyperactivity DisorderShepherd LI, Bay RC, ValovichMcLeod TC: A. T. Still University,Mesa, AZ

Context: Concussion managementrelies on clinical judgment exercisedon an individualized basis. Clinicaljudgment includes considering thepatient’s personal and medical history.Learning disabilities (LD) andattention deficit hyperactivity disorder(ADHD) have both been identified aspotential modifying factors thatwarrant consideration when assessingan athlete with a concussion. However,little research exists regarding thepotential impact of LD and ADHD onthe likelihood of sustaining aconcussion.Objective: To investigatethe relationship between self-reportedlearning disability (LD) or attentiondeficit hyperactivity disorder (ADHD)and self-reported history ofconcussion and sustaining a diagnosedconcussion. Design: Prospectivecohort. Setting: High school athletictraining facilities. Patients or OtherParticipants: A convenience sampleof 8811 adolescent athletes (2809females, 6002 males, age=15.7±1.2years, grade=9.3±1.1 level)participating in interscholastic contactsports. Interventions: All subjectscompleted the Immediate Post-Concussion Assessment and CognitiveTesting (ImPACT), as part of aconcussion baseline assessmentprotocol. Independent variablesincluded self-reported LD or ADHD,as determined by the participants’responses to questions about LD andADHD within the ImPACTdemographic section. Any participantsustaining a concussion during this 2-year prospective study completedImPACT within 48 hours of theconcussion and serially during

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recovery as indicated by theirrespective athletic trainer. MainOutcome Measures: Dependentvariables included the self-reportedhistory of prior concussion asdocumented in the ImPACTdemographic section and anysubsequent concussion diagnosed byan athletic trainer that resulted in theparticipant completing at least onepost-injury ImPACT test. Therelationship between each independentand dependent variable was evaluatedwith separate Chi-Square analyses(P<.05). Results: A total of 158participants (1.8%) indicated they hadLDs; 375 (4.3%) noted they had beendiagnosed with ADHD, and 1583(18.0%) reported a prior history ofconcussion. A total of 632concussions (incidence=7.2%) werediagnosed during the 2-year studyperiod. Self-reported LD wassignificantly associated with a higherreport of prior concussions (p<.001,31.6% vs. 17.7%) and diagnosedconcussions (p<.001, 14.6% vs.7.0%). Likewise, participants withself-reported ADHD were more likelyto report a prior history ofconcussions (p<.001, 27.7% vs.17.5%) and sustain a newly diagnosedconcussion (p<.001, 12.8% vs. 6.9%).Conclusions : These findingssuggest that self-reported LD andADHD are both associated with ahigher rate of prior concussion andnewly, athletic trainer-diagnosedconcussion. Athletic trainers shouldask about and document thesecomorbid factors as part of the pre-participation examination andconsider them in assessing thepotential for concussion, and themanagement of concussed athletes.Future studies should investigate themechanisms underlying theincreased rate of concussionassociated with LD and ADHD.Funded by a grant from the NationalOperating Committee on Standardsfor Athletic Equipment (NOCSAE).

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Increasing The InterpretabilityOf Patient-Rated OutcomeMeasures For EvaluatingConcussed PatientsRodriguez J, Michener LA, BayRC, Valovich McLeod TC, SnyderValier AR: A.T. Still University,Mesa, AZ

Context: A limitation of using patient-rated outcome instruments (PROMs)with injured athlete populations, suchas those suffering concussion, is lackof information to guide interpretationof scores. Scores indicative ofimprovement have not been defined forthe PedsQL, MFS, and HIT-6 PROMs,limiting the ability to accuratelyinterpret scores as patients recoverfrom injury. Identifying a scorecutpoint that defines athletes asimproved or unimproved in the daysfollowing concussion would increasePROMs’ clinical utility. Objective: Toestimate a score for concussionPROMs that accurately classifiesathletes as improved or unimproved atdays 3 (D3) and 10 (D10) post-concussion. Design: Pre-post, within-subject. Setting: Secondary schoolathletic training facilities. Patients orOther Participants: 218 adolescentathletes who sustained a concussiondiagnosed by their athletic trainer (184males, 34 females, age=15.7±1.1years, grade=10.0±1.0 level).Interventions: Patients completed thePediatric Quality of Life Inventory(PedsQL), PedsQL MultidimensionalFatigue Scale (MFS), Headache ImpactTest (HIT-6), and Global Rating ofChange (GROC) on D3 and D10 post-concussion. Main OutcomeMeasures: Dependent variablesinclude the PedsQL total score, 3subscale scores of the MFS [general(MFS-GF), sleep (MFS-SLF), andcognitive (MFS-CF) fatigue], and theHIT-6 total score. Higher scores onHIT-6 and lower scores on PedsQL andMFS indicate lower HRQOL. TheGROC, scored as 1=very much worse;15= very much better, was used to

ascertain the patient-perceivedmagnitude of change in health statussince concussion. Patients weredichotomized as improved (GROC‘much better’ or higher) or unimproved(GROC less than ‘much better’) on D3and D10. Improvement was determinedthrough receiver operatorcharacteristic curves by identifying thepoint of maximum sensitivity and 1-specificity. Area under the curve(AUC) determined discriminativeability of the improvement cutpoint,with values >0.70 consideredsatisfactory. Means and standarddeviations are reported for PROMs.Cutpoint data are presented as(cutpoint, AUC). Results: At D3, 106patients were classified as improved(PedsQL total=92.7±8.3; MFS-GF=88.0±14.1; MFS-SLF= 82.8±18.1; MFS-CF=84.8±16.0; HIT-6total=56.0±7.7) and 110 asunimproved (PedsQL total= 79.8±12.1; MFS-GF=62.5±23.0; MFS-SLF=60.6±24.1; MFS-CF=61.9±23.7; HIT-6 total=46.6±7.4). PROMcutpoints and AUC values at D3 were:PedsQL total=89, .83; MFS-GF=73,.83; MFS-SLF=77, .78; MFS-CF=77,.78; and HIT-6 total=51, .81. At D10,187 patients were defined as improved(PedsQL total=94.4±8.2; MFS-GF=91.7±14.4; MFS-SLF=89.1±14.2; MFS-CF=89.1±15.7; HIT-6total=46.0±8.6) and 25 as unimproved(PedsQL total=79.0±13.4; MFS-GF=69.0±24.7; MFS-SLF=70.8±18.8; MFS-CF=64.7±25.2; HIT-6total=59.0±6.6). PROM cutpoints andAUC values at D10 were: PedsQLtotal=92, .86; MFS-GF=85, .79; MFS-SLF=90, .79; MFS-CF= 85, .82; andHIT-6 total=53, .87. Conclusions:Our results define PedsQL, MFS, andHIT-6 scores as they relate toimprovement following concussiveinjuries. All cutpoints suggest greaterthan 70% probability of correctlyclassifying concussed patients asimproved as demonstrated by greaterthan satisfactory AUC values. Thesecutpoints should help clinicians better

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interpret concussion PROMs andmanage concussed patients overtime.

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Closed Traumatic Head Injury InA High School Football AthleteFrymyer JL, Felton SD, Cox SJ:Naples Community Hospital,Naples, FL, and Florida Gulf CoastUniversity, Fort Myers, FL

Background: Athlete is a 17 year-oldCaucasian male high school footballlinebacker. The athlete’s medicalhistory revealed an episode of acutepancreatitis within the past year.Athlete was on punt return team whenhe made helmet to helmet contact andfell to the ground creating a secondhead impact. Athlete walked off thefield on his own volition. Athletereported to Certified Athletic Trainer(ATC) complaining of headache anddizziness. He denied any nausea orother symptoms. ATC began side-lineexamination which consisted ofclearing any neck pathologies throughpalpations and evaluations of extremitymyotomes and dermatomes. Inaddition, he was assessed for aconcussion and vital signs weremonitored. Within concussionassessment, ATC noted cranial nervefunction WNL, StandardizedAssessment of Concussion (SAC) test21/30, and Balance Error ScoringSystem (BESS) revealed balancedeficits. Athlete was removed fromcompetition with clinical examinationleading to diagnosis of concussion.Immediate plan of care was discussedwith parent and educational materialsdescribing potential signs andsymptoms requiring immediatereferral were provided to the parent forfurther monitoring. ATC continued tomonitor the athlete for changes instatus throughout the competition.During the half-time, athlete reportedto ATC and admitted that he hadimmediately vomited after initial headtrauma. With the updated athletehistory of vomiting, the ATC, inconsultation with his parent,immediately referred the athlete to theER. Differential Diagnosis: CervicalNeck Pathology, Transient Brian

Injury, Concussion, SubduralHematoma Treatment: Athletereported to ER and attending physicianordered a CT scan. CT Scan revealeda left periventricular hemorrhage. Theathlete was admitted to the hospital forovernight observations. Athlete hadfollow-up CT scan the next day whichdemonstrated no exacerbation of focalbleed; thus, released from hospital.Athlete was scheduled for follow-upappointment two weeks followingthe release from hospital. Athletereturned to school following theweekend and completed post-concussion assessment including,SAC test, BESS, and Immediate Post-Concussion Assessment andCognitive Test (ImPACT) whichrevealed a statistically significantdeviation from baseline. Athletereported daily to ATC formonitoring, completion of symptomcards, and updates on his status. Theathlete’s symptoms includeddizziness, sensitivity to light, andnausea lasting five days in duration.Athlete continued to be withheldfrom competition. At the subsequent2 week follow-up with neurologist,repeat CT Scan revealed that theperiventricular hemorrhage had re-absorbed and thus cleared to fullparticipation by the neurologist. ATCadministered follow-up ImPACT testwhere athlete was at baseline and perDistrict School policy, athlete wasallowed to begin four-dayprogressive return to play protocol(RTP) as described in the NATAposition statement on managementof concussions. The athleteproceeded through the 4 day RTPwith no complications orreoccurrences of signs or symptoms.Eighteen days after initial injury theathlete was cleared by theneurologist and RTP protocol.Uniqueness: Periventricularhemorrhages are an extremelycommon type of brain bleeds foundin pre-term infants. In adults, acuteperiventricular hemorrhages have

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been linked to vicious head injuriessuch as skull fractures, falling froma height, or accelerated backwardfalls. However, a search of theliterature found no cases ofperiventricular hemorrhage with anassociated athletic concussion.Conclusions: This case highlightsthe diagnosis of an athlete with aperiventricular hemorrhage resultingfrom a sports-related coup andcounter-coup concussion. This caseis extremely unique due to no similardocumented sport-related casesfound through a literature review.This case highlights the need forproper evaluation, recognition ofatypical head injuries, referral, andneed for individualized plans ofcare. The athlete made a full returnto participation three weekspost injury and has had nofurther problems or complaints.

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Establishing 3-Day And 7-DaySymptom Clusters For HawaiiHigh School Student AthletesDuring The First Week Of ASport-Related ConcussionOshiro JY, Oshiro RS, Uyeno RK,Tamura K, Furutani TM, Wahl TP,Kocher MH, Murata NM:Department of Kinesiology andRehabilitation Science, Universityof Hawaii at Manoa, Honolulu, HI;State of Hawaii Department ofEducation, Honolulu HI; Universityof Hawaii Honolulu CommunityCollege, Honolulu, HI

Context: Post concussion symptomreports are useful for assessing sport-related concussions. The Post-Concussion Symptom Scale (PCSS)allows clinicians an objectivemeasurement of subjective symptoms.Previous studies have used the 22-itemPCSS to group the symptoms intorelated factor structures; these studieshave been limited to specificpopulations. Objective: The purposeof this study was to examine factorstructures of high school athletes’symptoms during the acute stage ofsport-related concussions. Design: Aretrospective analysis was conductedusing data from the State of HawaiiDepartment of Education’s (DOE)records of Immediate Post-Concussion Assessment and CognitiveTest (ImPACT) from School Years2010-2012. Setting: High schoolathletes participating in interscholasticathletics were prospectively recruitedfor the current study. Participants:Participants were participating in 11sports who sustained a concussionwere diagnosed, treated, and followeduntil return to full participation by thehigh school athletic trainer.Participants where divided into twogroups: group one (N=437,males=292, females=145, mean age15.49 ± 1.33yrs) who were given thePCSS within 3 days (mean days 1.88±0.91) of injury and group two (N=231,males=139, females=92, mean age

15.55 ± 1.33yrs) who were given thePCSS within 4-7 days (mean days5.16± 1.31) of injury. Interventions:All athletic trainers were required tofollow a standardized concussionmanagement protocol including postinjury assessment utilizing ImPACT.The PCSS within the ImPACT wereextracted. Main Outcome Measures:Exploratory Factor Analysis (EFA) wasapplied to the PCSS of both groups.Factors were extracted using theprincipal component analysis withorthogonal rotation (Varimax withKaiser normalization). Results: AnEFA provided two 4-factor structuremodels containing cognitive-migraine, emotional, somatic andsleep clusters. The factors explained57.08% of variance for group one and66.01% for group two. Conclusions:The cognitive-migraine clusterbetween the two groups differed insymptoms loading. Group onesymptoms included headache,vomiting, dizziness, fatigue anddifficulty remembering. Group twosymptoms included trouble fallingasleep, sensitivity to light, difficultyremembering and feeling mentallyfoggy. The changes in cognitive-migraine cluster during the acutephase of a concussion suggestdifferent accommodations shouldbe considered during 0-3 day and 4-7 days. Identifying how symptomclusters change during the acutephase of a concussion, will allowathletic trainers to make the mostbeneficial accommodation forathletes during the first week ofa sport-related concussion.

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The Relationship BetweenCoping, NeurocognitivePerformance, And ConcussionSymptoms In High School AndCollegiate AthletesCovassin T, Elbin RJ, Crutcher B,Burkhart S, Kontos A: MichiganState University, East Lansing, MI,and UPMC Sports MedicineConcussion Program, Universityof Pittsburgh School of Medicine,Pittsburgh, PA

Context: The inconsistentpresentation of concussive symptomsin conjunction with the uncertainty ofprognosis (i.e., return to play) canresult in a difficult and frustrating timefor the injured athlete. Althoughprevious researchers have reported thateffective coping efforts are linked toimproved outcomes followingmusculoskeletal sports injuries, therelationship between coping effortsand concussion is unclear. Objective:The purpose of the study was to explorethe relationship of neurocognitiveperformance and symptoms to copingresponses at 3 and 8 days post-concussion. Design: Prospectivecohort study Setting: This study wasperformed in a controlled laboratoryand field setting. Patients or OtherParticipants: A total of 104concussed athletes volunteered toparticipate in the study (73 males: age= 16.26 + 2.07 years, mass = 77.2 +16.8 kg, height = 178.4 + 8.15 cm, 31female: age = 16.77 + 2.45 years,mass = 62.03 + 7.82 kg, height = 166.7+ 7.57 cm). Interventions: Theindependent variable in this study wastime (baseline, 3, and 8 days post-concussion). Participants completedthe Immediate Post-concussionAssessment and Cognitive Test(ImPACT), Post-concussion SymptomScale (PCSS), and Brief COPE atbaseline; and at 3 and 8 days post-concussion. A series of multipleregressions were performed with eachof the three coping response factorsas the outcome variables and the four

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The Relationship BetweenConcussion History AndPostural Control ImpairmentsBuckley TA, Munkasy BA, Tapia-Lover TG, Krazeize DA, IngramRL: Georgia Southern University,Statesboro, GA, and StetsonUniversity, Deland, FL

Context: Impairments in dynamicpostural control are a knownconsequence of an acute concussion.Some evidence suggests that a historyof 3 or more concussions predisposean individual to long term neurologicalsequela. Objective: The purpose ofthis study was to investigateimpairments in dynamic posturalcontrol between individuals followingan acute concussion and those with ahistory of at least three concussions.Design: Cross sectional. Setting:Biomechanics laboratory. Patients orOther Participants: There were atotal of 45 participants divided intothree groups, 15 participants (8Female, Age: 20.4+1.6 years, Height:1.74+0.15m, Weight: 70.6+18.9kg)tested within 24 hours of a concussion(Acute), 15 participants (8 Male, Age:20.0+1.5 years, Height: 1.78+0.12m,Weight: 83.6+23.0kg) with a historyof at least 3 documented concussions(Multiple), and 15 healthy student-athletes (8 Female, Age: 19.9+1.3years, Height: 1.75+0.09m, Weight:74.2+10.9kg) who denied aconcussion history (Control).Interventions: All participantscompleted 5 trials of self-paced cuedgait initiation (GI). Participants beganeach trial standing on two forceplatesand initiated gait in response to a verbalcue, stepped onto a third forceplate,and continued down a 4.9m walkway.Main Outcome Measures: Thedisplacement of the center of pressure(COP), both posterior and lateral,during the anticipatory posturaladjustment (APA) phase of GI and theinitial step length and velocity werecompared between groups with a one-way ANOVA and tukey post-hoc when

appropriate. Results: There was asignificant main effect for all fourdependent variables. Post-hoc testingidentified a continuum ofperformance whereby the controlsperformed best, the multiple group wasin the middle, and the acute groupperformed worst. The posterior COPdisplacement during the APA wassignificant between all three groups(6.4+1.1cm, 5.0+1.2cm, and 2.3+1.0cm respectively, p<0.001 for Acute vsControl and Multiple, p=0.002 forControl vs Multiple). The lateral COPdisplacement during the APA wassignificant between Acute and Control(2.6+1.2 and 6.4+2.2cm, p<0.001)and Acute vs Multiple (5.8+1.2cm,p<0.001), but not different betweenControl and Multiple. Step length wasonly different between Acute andControl (0.57+0.09m and 0.71+0.11m, p<0.001). Step velocitydiffered between Control and Acute(0.75+0.13m/s and 0.56+0.09m/s,p<0.001) and Control vs Multiple(0.64+0.08m/s, p=0.021). Con-clusion: These results indicate apotential continuum of performancewhereby acute concussiondemonstrates the greatest impair-ments in postural control. Individualswith 3 or more concussionsdemonstrated impairments, comparedto healthy controls, in the posteriordisplacement of the COP and the initialstep velocity with their results beingsimilar to what is commonly seen inhealthy elderly studies. Recentposition and consensus statementsagree there is no magic number linkingconcussions and later-lifeneurological impairments; however,these results add to the growing bodyof literature suggesting 3 or moreconcussions may be a risk factor.This study was funded, in part, by agrant from the National Institute ofHealth/Neurological Disorders andStroke: 1R15NS070744–01A1.

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neurocognitive composite scores andtotal symptoms as predictors. A seriesof repeated measures (RM) analysis ofcovariance (ANCOVA) wereperformed on the Brief COPEsubscales and three coping responsefactors. History of concussion wasused as the covariate for all ANCOVAs.Main Outcome Measures:Dependent variables included ImPACTcomposite scores (verbal/ visualmemory, reaction time, processingspeed), PCSS, and Brief Copeindividual and three coping responsefactors (approach, avoidance, social).RM ANCOVAs with Bonferronicorrection and post-hoc meanscomparisons were performed usingTukey’s HSD. Statistical significancewas set at apior at p<0.05. Results:Concussed athletes reported morefrequent use of self-distraction(M=3.34+1.49: 3.16+1.56, p=.046),behavioral disengagement (M=2.29+.90: 2.14+.51, p=.039), religion(M=2.58+1.38: 2.48+1.27, p=.014), and self-blame (M=2.48+.97:2.27+.69, p=.001) at 3 days post-concussion compared to 8 days post-concussion. Concussed athletesreported more use of avoidancecoping behavior at 3 days than 8 days(F

[1, 100] =4.71, p=.032) post-injury.

Total symptoms was a significant(p=.001) predictor of avoidancecoping at 3 days post-concussion anddecreased performance on visualmemory was associated withincreased avoidance coping (p= .03)at 8 days post-injury. Conclusion:Time since injury likely plays arole between neurocognitive perfor-mance, symptom reports, and coping.Clinicians should be aware ofpatients who report higher symptomsearly in the course of recoveryand have lingering visual memorydeficits 1 week post-injury as they mayuse more potentially maladaptiveavoidance coping following concussion.

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Gait Stepping CharacteristicsAre Not Impaired In IndividualsWith Multiple ConcussionsKrazeise DA, Munkasy BA,Joyner AB, Buckley TA: StetsonUniversity, DeLand, FL, andGeorgia Southern University,Statesboro, GA

Context: Recent evidence hassuggested that a history of multipleconcussions, typically defined as threeor more, may result in long-termneurological impairments. Theinfluence of multiple concussions hastypically been evaluated usingcognitive or neuropsychologicaltesting with limited investigations onpostural control in this population.Further, there have been limitedexaminations on otherwise healthyyoung adults with a history of multipleconcussions. Objective: The purposeof this study was to investigatekinematic stepping characteristics inindividuals with a self-reported historyof three or more concussions. Wehypothesized that individuals with ahistory of multiple concussions woulddemonstrate a conservative gaitstrategy evidenced by reductions ingait velocity, step length, and time insingle support. Design : Crosssectional study. Setting :Biomechanics research laboratory.Patients or Other Participants:Ten individuals, current or recentstudent-athletes with a history of atleast three self-reportedconcussions (6M/4F, age: 20.6 + 1.2years, height: 1.77 + 0.12m, weight:83.8 + 23.9kg, 3.5 + 1.0 previousconcussions, range: 3 – 6) (Multiple)were closely matched to 10 currentstudent-athletes (6M/4F, age: 20.5 +1.6, height: 1.76 + 0.11m, weight:83.6 + 23.0 kg) (Control) of the samesport with no self-reported history ofconcussion or concussion symptoms;direct or indirect head impactsassociated with loss of consciousness,post-traumatic amnesia, or similar.Interventions: Both groups

performed 10 trials of self-selectedpaced gait along a 4.9m instrumentedwalkway. The walkway has beenpreviously established as both validand reliable. Main OutcomeMeasures: The mean gait velocity,step length, and percentage of the gaitcycle in single support were calculatedby the instrumented walkway based onfootfall kinematics. Dependentvariables were compared betweengroups with one-way ANOVAs.Results: There were no betweengroup differences in anthropometriccharacteristics. There were also nodifferences between Multiple andControl groups for gait velocity (1.29+ 0.09m/s and 1.31 + 0.09m/s,p=0.715), step length (0.67 + 0.03mand 0.67 + 0.04m, p=0.982) or thepercentage of the gait cycle in singlesupport (38.2 + 1.0% and 38.3 + 1.1%,p=0.977). Conclusion: The results ofthis study suggest that a history of atleast three concussions does not alterkinematic stepping characteristicsduring level over ground gait. Whilerecent evidence supports somesupraspinal control of gait; level overground walking is generallyconsidered to be regulated by thecentral pattern generators located inthe spinal cord; thus offering apotential rationale why gait would notbe adversely influenced by potentialsupraspinal impairments. Further,these otherwise healthy young adultsmay have sufficient compensatorymechanisms to adapt to any potentialpostural challenges. Future studiesshould investigate either greaterchallenges to the postural controlsystems or additional cognitivedua l t ask cha l lenges .

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Health-Related Quality Of Life InPediatric Patients FollowingMild Traumatic Brain Injury: ASystematic ReviewPurdoff MJ, Snyder Valier AR,Valovich McLeod TC: A.T. StillUniversity, Mesa, AZ

Context: Pediatric patients arecommonly affected by mild traumaticbrain injury (mTBI), withapproximately 475,000 children underthe age of 14 suffering from mTBIannually. Studies in adults havereported that mTBI causes a widevariety of changes in health-relatedquality of life (HRQoL), includingemotional status, neurobehavioraldisturbances, and cognitiveimpairments. However, it is unclearwhether the same HRQoL deficitsoccur in younger patients and whetherany deficits are consistent acrossstudies among the pediatricpopulation. Objective: Tosystematically evaluate the evidenceregarding HRQoL in pediatric patientsfollowing mTBI. We hypothesized thatfollowing mTBI pediatric patientswould demonstrate decreasedHRQoL, specifically in physical,psychosocial, and social domains.Data Sources: A systematic search ofcomputerized bibliographic databaseswas performed using PubMed,CINAHL, ERIC, and OVID. StudySelection: Studies were included ifthey focused on human subjects,pediatric mTBI patients, measuredHRQoL or related components ofHRQoL, included a full abstract, andwere peer reviewed. Keywords used inthe search included mTBI, concussion,pediatric, child, adolescent, HRQoL,quality of life, emotional,psychosocial, social, cognitive,school, and physical. Search termswere combined with the AND Booleanterm. The link-out feature of PubMedwas used to search for related articlesand a hand search of references fromretrieved articles was performed. DataExtraction: Each study was

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Gait Variability Following ASports-Related ConcussionHunter LA, Joyner AB, MunkasyBA, Buckley TA: Georgia SouthernUniversity, Statesboro, GA

Context: Impaired postural control isa cardinal post-concussion symptom.Traditional clinical measures of post-concussion postural control are staticstances; however, some studies haveinvestigated changes in gait steppingcharacteristics. Gait variability ispotentially a more sensitive measureof postural control and hassuccessfully identified impairments inpopulations with central neuro-physiological disorders. Objective:The purpose of this study was toexamine gait variability following aconcussion. We hypothesized thatthose with concussions woulddemonstrate increased gait variabilitycompared to healthy subjects.Design: Prospective longitudinal.Setting: Biomechanics laboratory.Participants: Ten participants (6Female, age: 18.9 + 1.1 years old,height: 1.75 + 0.05m, weight: 77.7 +18.8kg; 10% LOC rate, 40% PTA rate,all Grade II concussions on the Canturevised grading scale) who sufferedsports-related concussions duringintercollegiate athletic participationwere matched to ten healthy controlparticipants based on gender andheight. Interventions: Both groupsperformed 10 trials of self-selectedpaced gait along a 4.9m instrumentedwalkway. The walkway has beenpreviously established as both validand reliable. The concussionparticipants baseline testing wasperformed during pre-participationphysicals prior to participation inintercollegiate athletics and theirsecond testing session was within 24hours of suffering a sports-relatedconcussion. The control participantswere tested on two separate occasions.Main Outcome Measures: Thedependent variables of interestincluded step length variability, step

width variability, and step timevariability. These variables wereexpressed using a coefficient ofvariation which is (standard deviation/mean) *100. Dependent variables ofinterest were compared with three 2x2(group x day) repeated measuresANOVAs. Results: There was nogroup by time interaction (p=0.964,p=0.779) or main effects for time(p=0.757, p=0.226) for step lengthgait variability (Concussion baseline:2.65 + 0.29, post-injury: 2.94 + 0.67;Control baseline: 2.68 + 0.57, day 1:2.98 + 0.37) or step width variability(Concussion baseline: 3.08 + 0.67,post-injury: 3.17 + 0.69; Controlbaseline: 2.32 + 0.71, day 1: 2.51 +0.37). There was no interaction(p=0.824), but there was a main effectfor time (p=0.004) for step timevariability (Concussion baseline: 2.65+ 0.29, post-injury: 2.94 + 0.67;Control baseline: 2.68 + 0.57, day 1:2.98 + 0.37). Conclusions: Theresults of this study suggest thatathletes suffering from sports-relatedconcussion do not display altered gaitvariability compared to healthycontrols. This is surprising as previousstudies have identified differences instepping characteristics and center ofmass sway, suggesting a conservativegait strategy had been adopted.Potentially, these results indicate thatotherwise healthy post-concussionstudent-athletes have sufficientcompensatory mechanisms and/orstrategies to reduce gait variability.Reductions in postural variability havepreviously been hypothesized in staticpostural stability studies which utilizedapproximate entropy measures. Thisstudy was funded, in part, by a grantfrom the National Institute of Health/Neurological Disorders and Stroke:1 R 1 5 N S 0 7 0 7 4 4 – 0 1 A 1 .

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independently evaluated by twoinvestigators using the STROBEChecklist and articles were assessedfor relevance, completeness ofinformation, and methodologicalquality. Data extracted included thenumber of patients, age, length of timepost-mTBI, outcomes instrumentused, subscales of outcomesinstrument, inclusion of a controlgroup, and HRQoL outcomes. DataSynthesis: 582 studies were foundwith 33 studies relevant to theinclusion criteria and included in thereview. These studies used 88 differentoutcomes instruments. Four studiesevaluated symptoms and foundheadache as the most commonlyreported symptom. Two studiesevaluated sleep-related HRQoL, withsleep problems occurring more oftenin the first 6 months following injury.Behavior was evaluated in 20 studies,with 5 studies reporting worseningbehavior in mTBI patients and the other15 finding no differences in behaviorwhen compared to a control group.Studies evaluating interactions withfamily and friends reported no issueswith reintegration into these socialenvironments. Conclusions: Resultsindicate that mTBI may impact HRQoLin pediatric patients, with lingeringsymptoms and behavioral problemsmost commonly reported. However,the variety of outcomes measuresused, varied age groups assessed, andinconsistent follow-up time pointsmake it difficult to determine theexact nature and extent of HRQoLdeficits in this population. Futurestudies are needed to evaluate the mostmeaningful of current outcome toolsand to recommend a specific tool thatshould be used when evaluating theHRQoL of concussed adolescents.

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The Effects Of Cognitive FatigueOn Balance In A ModeratelyActive PopulationSheaffer AE, Greenwood LD,Boucher TM: Baylor University,Waco, TX, and Texas A&MUniversity, College Station, TX

Context: Balance is an integral partof activity and plays a key role in injuryprevention. Because student-athletesare expected to meet certain academicstandards while also excelling in theirrespective sports, it is necessary todetermine if they are at greater riskfor balance disturbances due tocognitive fatigue. Objective: Todiscover the relationship betweencognitive fatigue and balance. Design:Randomized Controlled Trial withCrossover Study Design. Setting:University Laboratory. Patients orOther Participants: Eighteenhealthy, college-aged students (5 men,13 women; age = 20.94 ± 2.07 years;height = 170.60 ± 11.17 cm; mass =63.84 ± 11.85 kg). Interventions:Cognitive fatigue and measures ofbalance were assessed before and afterboth a cognitive fatigue task andcontrol task completed two to fourdays apart. The cognitive fatigue taskconsisted of two hours of the PacedAuditory Serial Addition Test (PASAT),and the control task consisted ofwatching a two-hour PBS documentaryon train travel. Main OutcomeMeasures: A 2 (treatment groups) x 2(time: pretest, posttest) repeatedmeasures ANOVA was used todetermine if there were anydifferences between all pre-task andpost-task balance assessments andcognitive fatigue surveys. Measures ofbalance data were collected on theNeuroCom Smart Equitest System®using the Limits of Stability Test(LOS) and Sensory Organization Test(SOT). Cognitive fatigue was assessedusing the Fatigue Assessment Scale(10 questions) and theMultidimensional Fatigue SymptomInventory-Short Form (30 questions).

The three trials of each condition ofthe SOT were averaged together tocreate one score for each of the sixconditions. Reaction time, movementvelocity, and directional control fromthe LOS, the averages of the sixconditions of the SOT, and thecognitive fatigue surveys weremeasured and compared. Results: Asignificant difference was foundbetween control and cognitive fatigueconditions in the LOS testmeasurement for reaction time incondition three; right forward (pre-control: .69 ± .15 s; post-control: .78± .23 s; pre-fatigue: .8 ± .25 s; post-fatigue: .94 ± .32 s; p = .033) and inthe LOS test measurement formovement velocity in condition two;right forward diagonal (pre control:7.83 ± 1.67 m/s; post-control: 7.34 ±2.37 m/s; pre-fatigue: 6.71 ± 2.54 m/s; post-fatigue: 5.79 ± 2.21 m/s; p =.044). There were no significantdifferences found between conditionsfor the SOT (p e•.05). All questions ofthe cognitive fatigue survey wereanalyzed and 13 had significantdifferences between conditionsindicating increased cognitive fatigue(p d•.05). Conclusions: Reduction instatic balance performance on certainmeasurements was demonstrated withcognitive fatigue. Further research isneeded to determine if cognitivefatigue has an affect on dynamicbalance or balance in other populationssuch as highly trained athletes.

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Free Communications, Poster Presentations: Ankle Instability1 3 1 6 1 D C

Examining MorphologicalChanges Of The AnteriorTalofibular Ligament In AFemale Collegiate VolleyballPlayer Following A SevereLateral Ankle SprainLiu K, Butterworth C, GustavsenG, Kaminski TW: University ofDelaware, Newark, DE, andUniversity of Evansville,Evansville, IN

Background: This case involves a 20year-old female collegiate volleyballplayer withno prior history of an anklesprain. The athlete jumped up at the netto block a spike,landed on the foot ofthe opposing player, and collapsed tothe ground. She complainedof pain (8/10), immediate swelling, and neededto be assisted off the court.Uponinspection, the athletic trainerdetermined a positive anterior drawerand talar tilt test.Range of motion andstrength test were not conducted dueto pain. Differential Diagnosis:Anterior talofibular ligament (ATFL)sprain, calcaneofibular ligamentsprain,distal tibia-fibula fracture, highankle sprain, metatarsal sprain.Treatment: The athlete’sankle wasimmediately iced, wrapped, andelevated. The athlete’s ankle wastapedovernight with a horseshoe andgiven a walking boot and crutches withan initial noweight bearing status. Dueto the severity of the swelling andecchymosis, an MRI wasordered,revealing a complete tear of the ATFL,sprained calcaneofibular ligament,bonebruise on the medial neck of talus,strain of peroneus longus, and a smallsplit tear ofthe peroneus brevis. Twelvedays post-injury, the athlete wastransitioned from thewalking boot toan Aircast. Twenty days post-injury, theathlete was transitioned out oftheAircast to full weight bearing status.The athlete was released to jog 1 monthpostinjury. The athlete sought out afoot and ankle specialist and was

instructed to reduce activity to allowmore time for healing. The athletereturned to sport-specific activities 3months post-injury. With continuingrehabilitation and taping of the ankle,the athlete has returned to fullparticipation but still complains ofpain, instability, and weakness.Uniqueness: Musculoskeletalultrasound (MSUS) images of theathlete’s ATFL were obtained pre andpost injury. During preseasonscreening, a MSUS image wasacquired prior to injury. After theinjury, MSUS images were taken 6days, 1 month, 3 months, and 7 monthspost-injury. These images were usedto track the healing process of theligament after a complete tear to theATFL. Prior to injury, the MSUS imageof the ATFL showed a clean, paralleledfibrous nature of the ligament. TheMSUS image 6 days post-injuryrevealed large pockets of edemaaround the ankle joint and a detachedATFL. The MSUS image 1 month post-injury still presented with edema in thearea and a detached ATFL, though partsof the ATFL can now be seen in theimage. The MSUS image 3 monthspost-injury displayed the form of theATFL but a gap within the ligamentindicated that complete healing had notoccurred yet. Despite the expectedhealing time of the ATFL, the MSUSimage 7 months post-injury stillexhibited abnormalities in theligament. Conclusions: Though theinjury presented in this clinical casedoesn’t involve a unique injury, thedistinctive nature of this study involvesvisual images of the healing processof the ATFL through ultrasoundimaging techniques. Since MRI’s areexpensive with particularcontraindications, they are notnormally ordered for ankle sprains.MSUS, which is much safer and cost-effective, can provide quality imagesthat can identify a torn ATFL. One ofthe roles of an athletic trainer is to

return the athlete back to sport asefficiently as possible. In this case,even with 3 months of rest from sport-specific activities, the athlete stillcurrently complains of substantialresidual symptoms. In severe anklesprains such as this case,understanding the healing process ofthe ligaments of the ankle throughMSUS may assist in the progressionof rehabilitation to prevent furtherdamage or residual symptoms that mayoccur after the initial injury.

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Relationship Between WeightBearing Lunge And Non-WeightBearing Dorsiflexion Range OfMotion MeasuresHankemeier DA, Thrasher AB:Ball State University, Muncie, IN

Context: The weight bearing lunge(WBL) is a reliable method ofassessing dorsiflexion range of motion(ROM) in a more functional positionthan traditional open kinetic chainmethods. While the WBL is morefunctional, little research has beenconducted to determine therelationship between the WBL and thelong-sit (LS) or short-sit (SS)measures of dorsiflexion ROM.Objective: To determine therelationship between WBL and non-weight bearing SS and LS dorsiflexionROM measures while establishingnormative values for the WBL measurein a young adult population. Design:Descriptive cohort study. Setting:Research laboratory. Patients orOther Participants: 107 healthycollege-aged participants (57 females,50 males; 20.52±1.92 years;172.10±1.46 cm; 72.52±15.99 kg)free of current ankle or lowerextremity injuries volunteered for thisstudy. Interventions: An experiencedexaminer performed the assessment oneach participant in a single session.Dorsiflexion ROM was measured intwo different positions (LS and SS)with a long axis goniometer. For bothmeasures, the examiner placed theparticipant in 90° of dorsiflexion withthe goniometer fulcrum on the lateralmalleolus and aligned the arms with thefibular head and parallel to the 5th

metatarsal. The WBL was assessed byasking the participant to stand facing awall with the great toe on a tapemeasure six inches from the wall.Participants then lunged forward in anattempt to touch the anterior aspect oftheir knee to the wall while keepingtheir heel in full contact with theground. Participants continued tomove their foot away from the wall

until they could no longer maintaincontact with the anterior knee or theheel. Once the maximal distance (cm)was obtained, a measure of distancefrom the wall was collected. Measureswere taken bilaterally on allparticipants and all ROM measureswere counterbalanced to improveinternal validity. Main OutcomeMeasures: Pearson correlationcoefficient (r) (d”.05) was used todetermine the relationship betweenmeasures. Means and standarddeviations were used to reportnormative data. Results: A moderatepositive correlation was shownbetween the WBL and LS on both theright (r=.671,P<.001) and left(r=.643,P<.001) limbs. The SS andWBL measures also demonstrated amoderate positive correlation for theright (r=.722,P<.001) and left(r=.690,P<.001) limbs. WBL meanvalues reported for males (right=10.91±4.10 cm, left=11.10±4.31cm) and females (right=11.35±2.89cm, left=11.40±3.6 cm).Conclusions: While the WBL hasgained popularity, the relationshipbetween the WBL and the goniometricmeasures of ROM are not strongenough to use these methodsinterchangeably. The WBL could beused to assess a patients’ functionaldorsiflexion ROM more effectivelyunless weight bearing is contra-indicated. Normative values for theWBL can be used as a reference forclinicians as they implement the WBLwith a collegiate population.

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Weight-Bearing DorsiflexionRestrictions Are Present OnThe Self-Reported Worse LimbIn Those With Chronic AnkleInstabilityMcKeon PO, Wikstrom EA:University of Kentucky,Lexington, KY, and University ofNorth Carolina at Charlotte, NC

Context: Chronic ankle instability(CAI) is a self-reported condition inwhich those who sustain an anklesprain go on to have residualsymptoms and episodes of giving way.One of the potential contributingfactors to CAI is a dorsiflexion rangeof motion (DFROM) restriction. It iscurrently unclear whether DFROMrestrictions contribute to self-reported functional limitationsassociated with CAI. Objective: Todetermine whether dorsiflexion isreduced in the self-reported worselimb relative to the self-reported betterlimb in subjects with CAI. Design:Cross-sectional study. Setting:Laboratory. Participants: 41participants with self-reported CAI(18 males, 23 females; age: 23.7±5.1yrs; height: 1.7±0.9 m; mass:75.9±15.4 kg) participated. Allsubjects had a history of at least 1ankle sprain with current symptoms ofCAI on at least 1 side includingrecurrent episodes of giving way at theankle. Interventions: Eachparticipant self-identified which anklewas considered to be the morefunctionally limited by using the AnkleInstability Instrument (AII). A scoreof e”5 on the AII was considered as anankle with CAI. All subjects alsocompleted the Foot and Ankle AbilityMeasure (FAAM) Activities of DailyLiving (ADL) and FAAM Sport scalesfor the right and left ankles. Thesescales provide information about aparticipant’s perception of disability,associated with ADL and sportactivities respectively within the pastweek due to their ankle instability. Theweight-bearing lunge test (WBLT) was

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used to measure DFROM. Subjectsperformed 3 trials of the WBLT inwhich they kept their test heel firmlyplanted on the floor while they flexedtheir knee to the wall. Maximumdorsiflexion was defined as thedistance from the great toe to the wallbased on the furthest distance the footwas able to be placed without the heellifting. Main Outcome Measures:The independent variable was side(self-reported worse vs. self-reportedbetter). The dependent variables werethe FAAM-ADL (%), FAAM-Sport(%), and the mean WBLT distance(cm). Paired t-tests were used tocompare the dependent variablesbetween sides. Alpha was set a prioriat p<0.05. Results: The self-reportedworse ankles had higher AII scores(6.7±1.2) compared to the self-reported better ankles (2.9±2.75,p<0.001). There were significantdeficits in the FAAM-ADL and FAAM-Sport when comparing the self-reported worse (FAAM-ADL:80.0±11.7%; FAAM-Sport: 64.9±13.3%) to the self-reported better side(FAAM-ADL: 93.4±11.2%, p<0.001;FAAM-Sport: 86.7±17.5%, p<0.001).The self-reported worse ankle(9.2±3.9 cm) also had significantDFROM deficits compared to the self-reported better ankle (10.9±4.03 cm,p=0.002). Conclusion: Significantfunctional limitations associated withADL and sport activities on the self-reported worse side were found inconjunction with significant DFROMdeficits on the worse side. Thesefindings indicate that DFROMrestrictions potentially contribute tofunctional limitations in ADL and sportactivities in those with CAI.

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Subjects With Chronic AnkleInstability Present With AlteredProximal Kinematics DuringShod Gait On A TreadmillChinn L, Dicharry J, Hart J,Saliba S, Wilder R, Hertel J:Kent State University, Kent, OH;Rebound Physical Therapy,Bend, OR; University of Virginia,Charlottesville, VA

Context: Ankle kinematic differenceshave been found between individualswith chronic ankle instability (CAI)compared to healthy controls.However, there is limited researchcomparing more proximal jointkinematics. Because distal kinematicdifferences between groups have beenidentified, it is important to evaluatekinematics up the kinetic change topotentially elucidate adaptations madeby individuals with CAI. Objective: Todetermine if there are knee or hipkinematic differences, in the sagittaland frontal planes, in subjects with CAIcompared to controls while walkingand jogging on a treadmill in shoes.Design: Descriptive laboratory studySetting: Motion analysis laboratoryPatient or Participants: Twenty-seven subjects with self-reported CAI(9 males, 18 females; age = 24.56±5.37 years; mass = 71.44±11.93kgs;height = 170.93±8.37m; Foot andAnkle Ability (FAAM) score =89.8±8.1; FAAM-Sport score =73.1±12.9; number of previous sprains= 4.89±3.20), and 27 healthy controls(11 males, 16 females; age = 22.56±3.49 years; mass = 65.80±13.72kgs;height = 167.51±15.44m; FAAM score= 100.0±0.0; FAAM-Sport score =100.0±0.0) participated. . Inter-ventions: Subjects walked (speed=1.34 m/s) and jogged (speed=2.68 m/s) on a treadmill with embedded forceplates while a 12-camera motionanalysis system captured 3-D lowerextremity kinematics. One 15-secondperiod of gait (average walkingstrides=10; average joggingstrides=20) was captured at eachspeed for analysis. Each stride of the

gait cycle was normalized to 100increments. Sagittal and frontal planeknee and hip angles were calculated ateach increment. Group means andassociated 90% confidence intervals(CIs) were calculated in each planeacross the entire gait cycle. Toidentify significant differences,increments where the CI bands for thetwo groups did not cross each otherwere identified. Mean differences andstandard deviations were calculated forincrements in which the CI bands didnot cross. Main Outcome Measures:Sagittal and frontal kinematics at theknee and hip were measuredthroughout the entire gait cycle.Results: During shod walking,individuals with CAI presented withless knee flexion compared to healthycontrols (mean difference =3.32±0.06°) from mid-stance to toeoff (49-54% of gait cycle).Whilejogging, the CAI group presented withmore hip flexion (mean difference =6.34±0.27°) from loading to toe off(12-34% of gait cycle) and more kneeflexion than controls (meandifference 7.52±1.36°) during swing(77-91% of gait cycle). No frontalplane differences were noted at eitherjoint at either speed. Conclusions:Proximal kinematic alterations frommid-stance to toe off as well as duringswing varied between individuals withand without CAI. These changes mayhelp explain the perceptions ofinstability and the recurrent sprainsthat occur in individuals with CAI.

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Balance Training ChangesCenter Of Pressure LocationDuring Unipedal Standing InSubjects With Chronic AnkleInstabilityMettler A, Chinn L, McKeon PO,Saliba S, Hertel J: University ofVirginia, Charlottesville VA; KentState University, Kent OH;University of Kentucky, Lexington,KY

Context: Individuals with chronicankle instability (CAI) demonstratealtered postural control and utilize amore anterolateral center of pressure(COP) location during unipedal quietstanding compared to healthyindividuals. Postural control can beimproved after balance training, but themechanism of this improvement isunknown. Changes in the spatiallocation of COP location followingbalance training are a potentialmechanism of improved posturalcontrol. Objective: To determine if a4-week balance training programchanges the location of COP duringunipedal stance in subjects with CAI.Design: Randomized control trial.Setting: Laboratory. Patients orOther Participants: 31 individualswith self-reported CAI were randomlyassigned to a balance training group (6males, 10 females; age=22.2±4.5years; height=168.9±7.7cm; mass=63.0±8.1kg; previous sprains =6.3±7.1; Foot and Ankle Disability(FADI)=85.5 ± 8.4%; FADI-Sport=69.9±12.1%) or a control group (6males, 9 females; age=19.6±1.3 years;h e i g h t = 1 7 3 . 3 ± 9 . 8 c m ;mass=67.7±13.7 kg; previoussprains=4.6± 2.5; FADI=82.9 ± 7.4%;F A D I - S p o r t = 6 6 . 5 ± 9 . 8 % ) .Interventions: The balance traininggroup performed a 4-week supervisedbalance program that was progressedin an individualized manner. Exercisesincluded static and dynamic singlelimb balancing tasks. The control groupdid not perform any balance trainingand was asked to maintain their normal

activity levels across the study period.Main Outcome Measures: Allsubjects performed three successful10-second single limb balancing trialson a force plate with eyes open andclosed before and following the 4week intervention. COP data wascollected at 50 Hz resulting in 500 datapoints in each trial. Each subject’s footwas modeled as a rectangle into fourquadrants. Additionally, the foot wasalso divided into anterior and posteriorhalves and medial and lateral halves.The frequency of COP data pointlocation in each region was recordedacross the length of each trial andserved as the dependent variable. Theindependent variables were group(balance training, control) and time(pre, post). For each region, separate2x2 ANOVAS with repeated measureswere computed for eyes open and eyesclosed data. Alpha was set a priori atp<0.05. Results: Changes in COPlocation following balance trainingwere seen in the anterior-posteriordirection, but not in the medial-lateraldirection. After the intervention, COPlocation in the balance training groupshifted from a more anterior to lessanterior in both eyes open(pre=319.1±165.4, post= 160.5±149.5; p=.004) and eyes closed trials(pre=387.9±123.8, post= 189.4±102.9; p<.001) while the non-balancetraining group did not shiftsubstantially in the eyes open( p r e = 2 1 4 . 1 ± 1 9 3 . 3 ,post=230.0±176.3) or eyes closedtrials (pre=326.9±134.3, post=338.2±126.1). Conclusions: Thebalance training program resulted in aCOP location shifted from a moreanterolateral position to a moreposterolateral one which more closelyresembles healthy subjects. This maybe due to behavioral changes as a resultof a more optimally functioning andless constrained sensorimotor system.

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Preparatory Movement PatternsDuring A Laboratory RecordedAnkle SprainTerada M, Thomas AC,Pietrosimone BG, Gribble PA:University of Toledo, Toledo, OH

Context: Establishing the injurymechanisms of recurrent ankle sprainsis a critical step in developingpreventative interventions. In theresearch laboratory, it is unethical toproduce an injury for the examinationof biomechanics during a realrecurrent ankle sprain. However, weobserved an accidental acute anklesprain in a participant with chronicankle instability (CAI) duringbiomechanical testing in an ongoingresearch study. Altered feed-forwardsensorimotor control has beensuggested as a consequence of CAI. Amore definitive description of feed-forward movement patterns of anactual ankle sprain case would improvethe understanding of recurrent ankleinjury mechanisms and may contributeto the development of preventionstrategies for recurrent ankle sprains.Objective: Present preparatorymovement patterns of an acute anklesprain during a stop-jump task.Design: Single-subject descriptivelaboratory. Setting: Researchlaboratory. Patients or OtherParticipants: A recreationally activemale (180.34cm, 79.45kg, 20yrs) withunilateral CAI [Foot and AnkleDisability Index (FADI)=28.85%,FADI sports=15.63%] volunteered foran IRB-approved case-control studyinvestigating the effect of CAI on thelocation of center of mass (COM)during a bilateral stop-jump task.Interventions: The participantexperienced a mild recurrent rightankle sprain during the third of fivetrials of the stop-jump task.Kinematics and kinetics were recordedwith a motion capture systeminterfaced with two force platforms.Main Outcomes: The location ofCOM and sagittal-and frontal-plane

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kinematics for the knee and ankle jointwere calculated during a preparatoryphase that was defined as the timeinterval of 200ms before initialcontact with the force platforms. Theinjury trial was compared with theensemble average of the two non-injury trials performed by thisparticipant. Due to the nature of theobserved data from a single trial froma single participant, data are presentedwithout statistical comparisons.Results: During the injury trial, therewas greater average ankle plantarflexion (18.1°), ankle inversion(9.4°), and knee adduction (4.1°), aswell as less knee flexion (22.9°)during the 200ms preparatory phasecompared to mean values from the200ms preparatory phase of theensemble curves of the two non-injurytrials (plantar flexion=7.5°,inversion=0.01°, knee adduction=1.1°, knee flexion=25.5°). In the injurytrial, COM was located 2cm higher(1.35m) and shifted 4 cm morecontralaterally (0.61m) toward thenon-involved side during thepreparatory phase compared to thenon-injury trials (height=1.33m,side=0.57m). Conclusion: Weobserved differences in preparatorymovement patterns at the knee andankle during a trial in which a recurrentankle injury occurred. These data maycontribute to understanding the injurymechanisms of recurrent ankle sprainsand provide an insight into how todevelop more effective preventativeinterventions for recurrent ankle sprains.

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Functional Performance TestsIn A Recreationally ActivePopulation With Chronic AnkleInstability And A Healthy ControlGroupKo JP, Rosen AB, Brown CN:University of Georgia, Athens, GA

Context: Functional performancedeficits may be present in a populationwith chronic ankle instability (CAI).However, few clinical tools have beenable to differentiate betweenperformance ability in a CAI anduninjured population. Objective: Todetermine if there are differences infunctional performance between a CAIand control group in a recreationallyactive population. Design: Cross-sectional. Setting: BiomechanicsLaboratory. Patients or OtherParticipants: Fifty volunteers weredivided into two groups of 25 each.The CAI group (6 male, 19 female;age=20.60 ± 1.47yrs; height=166.22± 8.52cm; mass=67.33 ± 11.93kg) hadat least 1 moderate-severe anklesprain, 2 episodes of giving way at theankle and a Cumberland AnkleInstability Tool (CAIT) score d”26indicating poor function. The controlgroup (11 Male, 14 female; age=20.16± 1.25yrs; height=167.47 ± 8.94cm;mass=65.22 ± 11.67kg) had no historyof ankle injury and a CAIT score e”28indicating good function.Interventions: In a single testingsession participants completed theCAIT questionnaire and performed theStar Excursion Balance Test (SEBT) inthe posteromedial direction, SingleLeg Hop Test (SLHT), and Time inBalance Test (TIB) in a randomizedorder. The SLHT and TIB werevideotaped. After testing, a single rater,with reliability > 0.80, watched thevideo and recorded the time tocomplete SLHT and the length of timethe participant maintained the testingposition for TIB. Independent sampleT-tests were performed with ˜<0.05.Main Outcome Measures: CAITscores were calculated for the test

limb. The average SEBT reach distanceof 3 trials was normalized to % leglength, with higher % indicating betterfunction. Both SLHT and TIB werereported as time in seconds, and theaverage of 2 trials and 3 trials,respectively, were calculated. Shortertimes indicated better performance.Group means were compared viaindependent samples T-tests. Results:The CAI group had CAIT scores of20.84 ± 4.45, while the control grouphad 29.72 ± 0.54. SEBT reach distancewas significantly different betweencontrol (93.67 ± 10.15%) and CAIgroups (85.30 ± 7.54%) (p=0.002).SLHT was also significantly differentbetween control (15.32 ± 5.01sec) andCAI groups (18.64 ± 5.57sec)(p=0.031). TIB was not significantlydifferent between control (44.46 ±14.42sec) and CAI groups (41.02 ±14.22sec) (p=0.40). Conclusions:These results suggest that participantswith greater perceived instabilityin their ankle (lower CAIT scores)also tended to exhibit performancedeficits on the SEBT and SLHT whencompared to healthy controls.Conversely, there was no significantdifference between groups on TIB.The SEBT and SLHT may provideclinicians cost and time-effectiveclinical tools for screeningand rehabilitation purposes.

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Plantar Cutaneous SensoryDeficits Are Present In ThoseWith Chronic Ankle InstabilityPowell MR, Houston MN, PowdenCJ, Hoch MC: Old DominionUniversity, Norfolk, VA

Context: Sensory deficits have beenidentified on the plantar aspect of thefoot in individuals with chronic ankleinstability (CAI). While these deficitshave been identified using custom-designed laboratory instruments, it isunclear if plantar cutaneoussomatosensory alterations can bedetected using common clinicaltechniques for assessing sensationsuch as Semmes-WeinsteinMonofilaments (SWM) in theseindividuals. Objective: To compareplantar cutaneous detection thresholdsbetween individuals with and withoutCAI using SWM. Design: Case-controlstudy. Setting: Laboratory. Patients orOther Participants: Ten participantswith CAI (2 males, 8 females,age=22.4±2.7 years, height=171.6±10.1cm, mass=71.4±13.2kg,Foot and Ankle Ability Measure-Sport=75.93±19.6%) were gender andside matched to ten healthyparticipants (age=22.4±1.7 years,h e i g h t = 1 6 6 . 9 ± 9 . 3 c m ,mass=65.9±13.6kg, Foot and AnkleAbility Measure-Sport=100.0±0.0%).Participants in the CAI group reportedat least one ankle sprain, two episodesof giving way in the past three months,and answered “yes” to at least fiveitems on the Ankle InstabilityInstrument. Interventions: Eachparticipant reported to the laboratoryon a single occasion. Three sites onthe foot sole were assessed in acounterbalanced order including thehead of the first metatarsal (1st-met),the base of the fifth metatarsal (5th-met), and the center of the heel.Cutaneous sensation of the foot solewas assessed using a 20-pen SWM kit.SWM were applied perpendicular tothe skin, pressed until themonofilament formed a ‘C’ shape, and

held in place for 1-2 seconds. Basedon the perceptual response of theparticipant, a heavier or lighter weightSWM was presented for thesubsequent stimulus. An adaptedstaircase algorithm was used todetermine the lightest weight SWMwhich could be identified, representingthe detection threshold. SWMdetection thresholds are reported as anindex value ranging from 1.65-6.65.Main Outcome Measures: Thedependent variables were the SWMdetection threshold at each site (1st-met, 5th-met, and heel), while theindependent variable was group (CAI,healthy). Detection thresholdsassociated with greater SWM weightsrepresented lesser sensitivity, whilelower SWM weights representedgreater sensitivity. Separate Mann-Whitney U tests were used to examinegroup differences for each site.Descriptive statistics were reported asmean±standard deviation. Alpha levelwas set a priori at p<0.05 for allanalyses. Results: Significantdifferences were identified betweengroups for detection thresholds atthe1st-met (CAI=4.19±0.44, Healthy=3.57±0.46; p=0.01), the 5th-met(CAI=4.31±0.26, Healthy= 3.73±0.40; p<0.001), and the heel(CAI=4.52±0.30, Healthy=4.10±0.27;p=0.009). Conclusions: The mainfinding of this study is that those withCAI have decreased cutaneoussensation at the1st-met, 5th-met andheel compared to healthy individualswhen examined with clinical measuresof sensation. These somatosensorydeficits may be related tosensorimotor alterations demon-strated by those with CAI such asdeviations in gait and postural control.Plantar cutaneous sensation should bea consideration in the rehabilitationstrategy for patients with CAI.

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Does Previous History Of AnkleSprain Alter Muscle StrengthAnd Hip Kinematics During AJump-Landing Task In AnAdolescent PopulationMartinez JC, Kerner M, Crowley E, Matteau E, TrojianTH, DiStefano LJ: Universityof Connecticut, Storrs, CT

Context: Ankle sprains are among themost common injuries sustained in anactive population. Previous researchhas identified an association betweenprevious history of an ankle sprain andhip abductor weakness. It is not knownif this weakness affects movementpatterns in adolescents with a historyof ankle sprain. Objective: To identifyif differences in hip kinematics duringa jump-landing task and hip muscularstrength are present in adolescentswith a history of ankle sprain and theirnon-injured peers. Design: Cohortstudy Setting: High School SettingPatients or Other Participants: 61healthy, active local high schoolstudents (32 males, 29 females, Age:15.98+1.35years; Mass: 63.45+11.77kg; Height: 170.52+10.0cm)were placed in either the uninjured(UNI) group (n=48) or injured (INJ)group (n=13) based on previoushistory of an ankle sprain.Interventions: Subject’s isometricstrength of the hip musculature wasassessed using a handheld dynamotor.Each strength test utilized two trialsand all strength data were normalizedto body mass. Subjects completedthree trials of a jump-landing taskwhere they were asked to jump forwardfrom a 30-cm high box a distance ofhalf their body height. The trials wererecorded using an electromagneticmotion analysis system. MainOutcome Measures: Normalizedpeak isometric strength of the hipextensors, hip abductors, hip internalrotators, and hip external rotators weremeasured. Three-dimensional hipkinematics at initial ground contact andpeak angles (normalized to

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bodyweight and height) werecalculated using the average of thethree trials. Independent t-tests wereused to compare kinematic and hipstrength measurements between theUNI and INJ groups (d”.05) Results:The only significant differencebetween INJ and UNI hip kinematicswas hip adduction at initial contact(p=. 049; INJ= -18.73+7.24; UNI=-13.95+7.71). This indicates that INJlanded in significantly more hipabduction at initial contact than UNI.Although it was not significant therewas a trend for INJ to have higherpeak hip adduction (p=.051; INJ=-9.21+ 8.98; UNI=-3.94+8.24)indicating that INJ go through morehip abduction throughout thejump-landing task. There were noother significant differences foundfor hip strength measurements ofthe UNI and INJ groups.Conclusions: Although we did notfind a significant difference in hipabductor strength it is still importantto note that a difference wasobserved in the movement patternof adolescents with a history ofan ankle sprain. Further researchshould be conducted to identifypotential contributing factors tothis change in movement pattern.As a result, clinicians should assessand address any changes in frontalplane hip motion when treatingpatients with ankle sprains.

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Noise-Enhanced Center OfPressure Complexity InIndividuals With Chronic AnkleInstabilityGlass SM, Rhea CK, Arnold BL,Ross SE: University of NorthCarolina at Greensboro,Greensboro, NC, and VirginiaCommonwealth University,Richmond, VA

Context: Chronic Ankle Instability(CAI) has been shown to impairbalance in single-leg, but not double-leg, quiet stance. However, nonlinearmeasures of center-of-pressure (CoP)signal complexity may be sensitive fordetecting bipedal impairments.Furthermore, if bipedal balancedeficits exist, then a therapy such asstochastic resonance stimulation(SRS) may enhance balance by makingpostural control less constrained.Objective: (1) Examine CoPcomplexity to determine if CAIinfluences balance in double-leg quietstance (group effect) and (2)determine whether SRS influencesCoP complexity in CAI subjects(condition effect). Design: A cross-over design with two groups (CAI andNo CAI) and two treatments (SRS

on,

SRSoff

). Setting: Research Laboratory.Patients or Other Participants:Fifteen subjects presenting with CAI(171.7±8.2 cm, 66.5±10.5 kg,22.7±2.6 yrs) and fifteen healthysubjects without CAI (169.6±7.7 cm,63.8±11.1 kg, 23.1±3.8 yrs). Inclusioncriteria for the CAI group includedfeelings of “giving way” at the ankle(0.57±0.54 “give-ways” per week) andrepeated sprains during activity(3.2±2.5 sprains per subject).Interventions: Quiet double legstance trials without vision or shoeswere collected on a force plate at 50Hz for 20 seconds in a controlcondition (SRS

off) and an optimal SRS

intensity condition (SRSon

). The SRSsignal was applied through vibratingtactors placed on the skin over theperoneus longus, anterior and

posterior tibialis, and gastrocnemiusmuscles of the leg with CAI or amatched test leg. Testing order was ablock randomized design. MainOutcome Measures: Sample Entropy(SampEn) of the Anterior/Posterior(AP) and Medial/Lateral (ML) COPdisplacement time series (unitless).Lower values indicate moreconstrained balance. Plannedcomparisons were performed withone-tailed independent t-tests for: (1)group differences during SRS

off and (2)

CAI SRSon

versus No CAI SRSoff

(alphalevel=0.05). Results: During SRS

off,

AP SampEn was significantly lower inthe CAI group (CAI=0.51±0.08, NoCAI group 0.58±0.09; t

(28)=-2.09,

P=0.02). AP SampEn (0.53±0.13) inthe CAI group during the SRS

on

condition was not different than APSampEn of the No CAI group duringthe SRS

off condition (t

(28)=1.21,

P=0.12). No significant differenceswere observed in the plannedcomparisons for the ML SampEndata (P>0.05). Conclusions: Thepresent findings suggest thatSampEn may be used to identifydifferences in bipedal CoPcomplexity between CAI and NoCAI groups. Lower SampEn valuesin the CAI group indicate a lossof complexity and suggest thatpostural control in this group isoverly constrained and less adaptive.CoP dynamics in the CAI groupduring SRS

on were no different than

in the No CAI group during SRSoff

,which may reflect the relaxation ofsystem constraints with SRStreatment. Future research should bedirected at identifying theseconstraints and the mechanisms bywhich SRS may reduce them.

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Ankle Copers DemonstrateAltered Muscle ActivationStrategies For MaintainingJoint StiffnessSwanik CB, Needle AR: Universityof Delaware, Newark, DE

Context: The prevention ofligamentous injury is dependent on theability to regulate joint stiffness bypreparing for and responding topotentially harmful loads. Whilestudies have identified changes in jointstiffness and laxity in patients withrecurrent instability versus thosewithout symptoms (copers); nostudies have investigatedneuromuscular factors that mayregulate joint stiffness among thissubset of patients. Objective: Toinvestigate muscle activationstrategies from the lower leg duringan ankle perturbation betweenpatients with ankle instabili ty,healthy controls, and copers.Design: Post-test only with controlgroup. Setting: Biomechanicslaboratory. Patients or OtherParticipants: Fifty-eight subjects(22.6±3.3yrs; 171.0±9.7cm;71.8±18.0kg) were stratified usingthe Cumberland Ankle InstabilityTool into healthy control (CON,n=19), functionally unstable (UNS,n=19), and coper (COP, n=20)groups. Interventions: Subjectswere tested on a custom-builtstiffness device with the hip and kneeflexed and the ankle secured to a footplate. Surface electromyography(EMG) was collected from tibialisanterior (TA), peroneus longus (PL),and soleus (SOL) muscles. Aftercollecting maximal voluntarycontractions (MVC) for all muscles,subjects were asked to pronate theankle (30% effort) as a rapidinversion (20°) perturbation wasapplied to the joint at a random point.Subjects were instructed to hold thecontraction through the perturbation.Joint position and EMG activity werecollected in custom software at

2400Hz. Main OutcomeMeasures: Mean EMG (%MVC)was calculated for 250ms prior to(PRE), 250ms following (POST-1),and 250-500ms following (POST-2)the perturbation. Differencesbetween groups were tested with arepeated-measures ANOVA with 2within-subjects factors (Time, 3levels; Muscle, 3 levels) and 1between-subject factor (Group, 3levels). Results: A significant Timeby Group interaction effect(F4,94=3.78, p=0.007) wasobserved. No other group effect wassignificant. Pairwise comparisonsrevealed the pooled average ofmuscle activity was lowest in thecoper group following theperturbation (POST-1: COP= 0.11±0.02, CON=0.14±0.02, UNS=0.16±0.02; POST-2: COP=0.10±0.02,CON=0.13±0.02, UNS=0.16±0.02). Conclusions: Previous datahas suggested that ankle copers mayhave a higher degree of joint stiffnessmeasured both passively andreactively. Our data suggests thatcopers may be able to achieve thisoptimal joint stiffness regulation byusing a decreased amount of overallmuscle activity. Further analysis mayreveal more complex selectiverecruitment and/or coactivationstrategies to explain thisphenomenon. This highlights apotential adaptation following injurythat may prevent subsequentinstability, and future research mayattempt to identify interventions thatmay optimize joint stiffeningstrategies following injury. Asprevious studies have suggestedstiffness of the passive structuresare decreased among ankle copers,future research may investigatethe relationship between stiffnessof the capsuloligamentousstructures, selected muscleactivation and co-contraction.

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Altered Ankle Kinematics DuringGait Following ProlongedExercise In Subjects WithChronic Ankle InstabilityPodell JT, Chinn L, Hart JM, HertelJ: University of Virginia,Charlottesville, VA, and Kent StateUniversity, Kent, OH

Context: Kinematic differences ingait have been shown betweenindividuals with chronic ankleinstability (CAI) and healthy controls.Specifically, individuals with CAI tendto be more plantar flexed and invertedbefore, at, and post initial contact.However, it is unknown if thesekinematic differences are exacerbatedafter exercise, which may increasesports-related re-injury risk.Objective: To compare anklekinematics during walking and joggingon a treadmill between subjects withCAI and healthy controls following aprolonged period of exercise. Design:Descriptive laboratory study. Setting:Motion analysis laboratory. Patientsor Other Participants: 15 physicallyactive young adults with self-reportedCAI (5 male, 10 female; age=23.6±4.2years; height=171.8±9.9 cm;mass=72.9±12.6 kg; Foot and AnkleAbility Measure (FAAM)=86.9±8.2%;FAAM-Sport (FAAMS)=69.6±9.6%)and 15 healthy controls (5 male, 10female; age=21.8±1.8 years; height=166.1±8.1cm; mass=64.1±11.8kg;FAAM=100.0 ± 0.0%; FAAMS=100.0±0.0%) participated. Inter-ventions: Subjects walked (3.0mph)and then jogged (6.0mph) while shodon a treadmill after a 36-minuteexercise protocol. The exerciseprotocol consisted of six 6-minutecycles that included 5 minutes ofinclined treadmill walking (3.0mph)followed by 1 minute of anaerobicjumping activities. As subjectsambulated on an instrumentedtreadmill with embedded force plates,a 12-camera motion analysis systemcaptured 3-D ankle kinematics duringone 15-second trial of walking and

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another of jogging (average walkingstrides=10; average joggingstrides=20). For each trial, individualstrides were normalized to 100increments. Main OutcomeMeasures: Frontal and sagittal planeankle kinematics were recordedthroughout the entire gait cycle foreach speed. Group means andassociated 90% confidence intervals(CI) were calculated for each group.Significant differences in the gaitcycle were determined by identifyingincrements where the CI bands for thetwo groups did not cross each other.Mean differences and standarddeviations between groups werecalculated for these significantintervals. Results: While walking, theCAI group was less dorsiflexed thanthe control group from 33 to 52% ofthe gait cycle (mean difference=3.34±0.19ˆ) and more plantarflexed from 65 to 77% of the gaitcycle (mean difference=5.22±0.72ˆ).While jogging, CAI subjects were lessdorsiflexed than the control groupfrom 5 to 14% of the gait cycle (meandifference=5.65±0.53ˆ). Nosignificant differences were found inthe frontal plane between groups ateither speed. Conclusions: Followinga prolonged period of exercise,individuals with CAI tended to be ina more plantar flexed position duringgait compared to healthy controls.These kinematic changes maypredispose patients with CAIto increased re-injury risk afterprolonged physical exertion. To ourknowledge, this is the first studythat has examined gait kinematicsin individuals with CAI followingprolonged exercise.

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Ankle Joint Coupling DuringJogging With Chronic AnkleInstabilityHerb CC, McKeon PO, HertelJ: University of Virginia,Charlottesville, VA, andUniversity of Kentucky,Lexington, KY

Context: Altered joint couplingpatterns between tibial internal/external rotation and rearfootinversion/eversion during gait may playa role in chronic ankle instability(CAI). Objective: To identifydifferences in the shank-rearfootcoupling magnitude (m) and direction(theta) throughout the gait cyclebetween CAI and healthy controlgroups during barefoot and shodjogging. Design: Case-control.Setting: Motion analysis laboratory.Patients or Other Participants:Twenty-eight young adults (CAI: n=15,#previous ankle sprains=4.9±2.5;Control, n=13, #previous anklesprains=0±0) participated. The Footand Ankle Ability Measure (FAAM)and FAAM-Sport (FAAM-S) were usedto identify the level of self-reportedfunction of CAI subjects compared tocontrols (CAI: FAAM=92.1±5.8%,FAAM-S=74.8±13.3%, Control,FAAM =100±0.0%, FAAM-S=100±0.0%). Interventions: Subjectsjogged (2.68m/s) for 5 minutes on aninstrumented treadmill in bothbarefoot and shod conditions. MainOutcome Measures: Using a 12camera motion analysis system, shankrotation and rearfoot inversion/eversion kinematic data were collected.Theta and m values were calculatedthroughout the entire gait cycle for 3consecutive strides using the Tepavacmethod of vector coding analysis forjoint coupling. This method estimatesthe coupling behavior between the twocoupled segments (in our case, shankrotation and rearfoot inversion/eversion) at each pair of consecutivedata points throughout the stride cycle.Theta represents the vector codingangle between the two segments

indicating the relative direction of thecoupled motions, while m representsthe magnitude of relative motionbetween the two segments. Each stridecycle was normalized to 100 datapoints representing the full gait cycle.At each point in the stride cycle, theaverage values for m and theta acrossthe three strides were calculated foreach individual and used for statisticalanalysis. Means and 90% confidenceintervals for each group werecalculated at each of the 100 points ofthe stride cycle. Group differenceswere determined by identifyingperiods in the gait cycle where theconfidence intervals did not overlap.Group means (+SD) were calculatedacross these intervals and arepresented as descriptive statistics.Results: In shod jogging, groupdifferences in theta were found duringmid-stance (18-21%, control=60.27±4.09º, CAI=47.22±3.47º),early-swing (72-75%, control=51.31±2.24º, CAI=39.35±2.26º) andlate-swing (84-87%, control=61.83±2.26º, CAI=52.82±3.57º)between CAI and controls. Nodifferences in m were found in joggingshod. In barefoot jogging, thetadifferences were found during mid-stance (40-43%, control= 69.80±7.15º, CAI=59.72 ±4.71º), and mid-swing (81-84%, control=76.51±0.65º, CAI=65.89±3.13º)phase of gait. Differences in m werefound in mid-swing (76-84%,control=2.77±0.17º, CAI= 1.33±0.41º), and late-swing (97-100%,control=2.48±0.31º, CAI= 2.95±0.01º). Conclusion: Differences inthe direction and magnitude of theintersegmental joint coupling offrontal plane rearfoot and transverseplane shank motion indicate thatindividuals with CAI exhibit alterationsin movement coordination during gait.These altered movement patternsassociated with CAI may revealinformation on the internalconstraints associated with CAI.

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Lower Extremity SurfaceElectromyography MeasuresDuring Walking In SubjectsWith And Without Chronic AnkleInstabilityFeger M, Donovan L, Hart JM,Hertel J: University of Virginia,Charlottesville, VA

Context: Ankle sprains are among themost common musculoskeletalinjuries and many patients developchronic ankle instability (CAI)following an initial sprain. Individualswith CAI exhibit proprioceptive andpostural control deficits as well asaltered osteokinematics during gait.Neuromuscular activity is theorized toplay a pivotal role in CAI but deficitsduring walking are currently unclear.Objective: To compare neuro-muscular activity in terms of time ofactivation and percent of activationtime as demonstrated by surfaceelectromyography (sEMG) amplitudesduring walking between CAI andmatched controls. Design:Descriptive laboratory study. Setting:Laboratory. Patients or OtherParticipants: 15 adults with CAI(height=173±11cm, mass=72±14kg,age=23±4, sex=M:5 F:10) and 15matched controls (height=173±9cm,mass=71±18kg, age=23±3, sex=M:5F:10) participated. Intervention(s):Subjects walked on a treadmill at 4.83km/h as sEMG signals were recordedfrom the tibialis anterior (TA),peroneus longus (PL), lateralgastrocnemius (LG), rectus femoris(RF), biceps femoris (BF), and gluteusmedius (GM). Stride time wasdetermined with footswitches. MainOutcome Measures: Time ofactivation relative to initial contact andpercent of activation time across thestride cycle were calculated for eachmuscle. Muscle activation wasdetermined for each muscle if theamplitude was 10 SD over the meanamplitude during quiet standing. Anegative value for time to activationrepresents muscle activation prior toinitial contact. Percent of activation

was calculated as the proportion of thetotal time across the stride cycle thatthe amplitude was greater than thepreviously described threshold.Independent t-tests were performedfor each dependent variable to comparegroups. The level of significance wasset a priori at pd”0.05 for all analyses.Results: The PL and RF were activatedsignificantly earlier in the CAI groupcompared to the controls (PL: CAI=-66±98ms, Control=158±165ms,p<.001; RF: CAI=-144±147ms,Control=-36±111ms, p=.03). No othersignificant differences were notedbetween groups for time of activation(AT: CAI=-359±156ms, Control=-285±180ms, p=.24; LG: CAI=179±136ms, Control=247±133ms,p=.17; BF: CAI=-225±98ms,Control=-180±80ms, p=.18; GM:CAI=-80±99ms, Control=-60±124ms, p=.63). The PL was activatedsignificantly more time across thestride cycle (p=.05) in the CAI group(36±10%) compared to the controlgroup (23±22%). No other significantdifferences were noted betweengroups for measures of percent ofactivation time across the stride cycle(AT: CAI=53±27%, Control=53±25%, p=.96; LG: CAI=21±19%,Control=19±12%, p=.58; RF:CAI=37±25%, Control=27±22%,p=.24; BF: CAI=29±20%, Control=28±18%, p=.81; GM: CAI= 27±25%, Control+23±22%, p=.62).Conclusions: Activating the peroneuslongus for a greater duration mayincrease fatigability and pre-activatingprior to initial contact may decreaseavailable motor units capable ofprotecting against inversion momentsduring episodes of anklehyperinversion. Collectively, thedemonstrated coping strategy in theCAI group may be physiologicallyinefficient when compared to healthycounterparts. Targeted therapeuticinterventions for CAI may need tofocus on restoring normalneuromuscular function during gait.

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Individuals With FAI DisplayDecreased Fibularis ReflexResponse During DynamicInversion PerturbationsDonahue M, Docherty CL, RileyZ: Indiana University, Bloomington,IN

Context: Symptoms of FunctionalAnkle Instability(FAI) typicallypresent during dynamic activities.However, neuromuscular deficits inparticipants with FAI are ofteninvestigated during static, standingconditions. In order to create a moreaccurate model, individuals with FAIshould be investigated during moredynamic movement patterns.Objective: Investigate reflexresponses in muscles throughout thelower limb and low back during suddeninversion perturbations in individualswith and without FAI while walking.Design: Cohort Setting: ResearchLaboratory Participants: Fortysubjects (Control Group [n=20,1.7m±1.1, 65.6kg±12.9, 20yo±2] FAIGroup [n=20, 1.7m±1.3, 74.9kg±16.1,22yo±3]) participated in the study.Subjects with no history of previousankle sprains were placed in the controlgroup, while subjects who scored lessthan 27 on the Cumberland AnkleInstability Tool and answered ‘yes’ toat least 5 questions on the AnkleInstability Instrument were placed inthe FAI group. Subjects were excludedif they had a history of bilateral anklesprains, previous lower extremitysurgery, neurological disorders of thelower-limb, or other balance-affectingdisorders. Interventions: SurfaceEMG data were obtained from thefibularis(FIB), gluteus medius(GM),and erector spinae(ES) of the injured/matched side as well as thefibularis(FIB_CLS), gluteus medius(GM_CLS), and erector spinae(ES_CLS) of the uninjured/matchedcontralateral side. All data werecollected as subjects walked down acustom-built 7.2-meter long walkway.For each trial a random segment of the

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ANOVA with Tukey post-hoc testingwas utilized with ˜ =0.05. MainOutcome Measures: CAIT scoreswere calculated and the maximum talartilt angle was recorded and averagedacross 3 trials. Group means werecompared via one-way ANOVA.Results: Groups were not different inage or mass (Pe”0.09). The copergroup was taller than the controls(P=0.003). The CAI group (20.6±5.6)had significantly lower CAIT scores(P<0.001) than the control (29.8±0.5)and coper (29.3±0.9) groups indicatingdecreased function. The CAI group(26.6°±8.4°) demonstrated greatertalar tilt inversion than the control(16.2°±11.0°) and coper (16.9°±9.8°)(P=0.003). Conclusions: The CAIgroup appeared to demonstratedecreased self-reported ankle functionand increased mechanical laxity in thelateral ligaments as measured byinstrumented talar tilt compared to thecontrol and coper groups. There wereno differences in laxity betweencontrols and copers. In thisrecreationally active population,mechanical laxity may be a factor indecreased ankle function. Copers, whohad an injury, may have reported betterfunction because they were not lax andwere comparable to controls. Weattribute the group difference in heightto unequal gender distribution. Futureresearch should clarify the role ofmechanical laxity in contributing to CAI.

walkway would open to 30° causing theankle to invert. EMG signals wererecorded with a BIOPAC Systems MP150 telemetry system(BIOPACSystems Inc, Goleta, CA) at 2kHZ,hardware filtered(500Hz) andrectified. Short-latency reflex (SLR)onset was calculated from dooropening until EMG activation.Amplitude of SLR and long-latencyreflex (LLR) were calculated andnormalized using z-scores. For eachdependent variable, group differenceswere evaluated using independentsample t-test’s. Main OutcomeMeasures: Onset of the SLR andnormalized SLR and LLR amplitudesof 6 muscles (GM,FIB, ES,GM_CLS,FIB_CLS,ES_CLS). Results: Theonset of the SLR of the FIB wassignificantly later in the injured sideof the FAI individuals (46.5 ± 6.8ms)when compared to the controlgroup(41.8±3.7ms; P=0.009). Boththe SLR and LLR amplitude weresignificantly smaller in the FIBmuscle in the FAI group than in thecontrol group([SLR: 3.95±2.08msvs. 7.99±4.01; P< 0.001] [LLR:3.99± 2.27ms vs. 6.98 ± 4.18;P<0.008]). No significantdifferences in latency or amplitudereflex responses were identifiedbetween the two groups in theGM, ES, FIB_CLS, GM_CLS,or ES_CLS (P>.05). Conclusions:The results of this investigationindicate that during a dynamicperturbation task individuals withFAI demonstrate longer fibularismuscle latencies on the injured sidebut display no significant changes inthe proximal muscle groups.Additionally, short and long latencyreflex amplitudes were significantlydecreased in the FAI group.

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Mechanical Laxity Is Greater InAn Unstable Ankle PopulationCompared To Copers AndControlsBrown CN, Rosen AB, Ko JP:University of Georgia, Athens, GA

Context: Chronic ankle instability(CAI) commonly develops followinglateral ankle sprain and appears to bemultifactorial in nature. It is unclearto what extent mechanical laxity ispresent in a CAI population.Objective: To determine if there aredifferences in inversion talar tilt laxitymeasures between recreationalathletes with CAI, a coper group witha history of ankle injury, and a controlgroup with no history of ankle injury.We hypothesized the CAI group woulddemonstrate significantly greater talartilt laxity. Design: Cross-sectional.Setting: Biomechanics Laboratory.Patients or Other Participants:Fifty-six volunteer recreationalathletes divided into 3 groups. CAI: 8males, 11 females, age 20.7±1.5 years,height 169.9±9.0 cm, mass 72.0±17.0kg; Copers: 12 males, 3 females, age22.2±4.3 years, height 176.7±10.8 cm,mass 74.6±13.1 kg; Controls: 6 males,16 females, age 20.4±1.4 years, height166.0.1±8.0 cm, mass 64.9±11.5 kg.CAI and coper groups reported historyof previous moderate-severe anklesprain. CAI group reported e”2episodes of ankle instability in the last12 months while copers and controlshad none. CAI group had CumberlandAnkle Instability Tool (CAIT) scored”26, indicating poor function. Copersand controls scored e”28, indicatinggood function. Interventions: In asingle test session, participantscompleted the CAIT and underwentlateral ankle ligament instrumentedarthrometry for inversion talar tilt. Arater, with established reliability>0.80, performed the arthrometry.Participants’ were positioned with theankle in neutral and the knee slightlyflexed while a 15dN force was applied.Three trials were collected. A one-way

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Plantar Pressure DistributionDifferences In Physically ActiveIndividuals With And WithoutFunctional Ankle InstabilityDuring A Side Cut ManeuverPittman J, Gaven SL, Cortes N,Walker ML, Hoch MC, Van LunenBL: Old Dominion University,Norfolk, VA, and George MasonUniversity, Fairfax, VA

Context: Functional ankle instability(FAI) is a common condition in thephysically active population.Individuals with FAI exhibit alterationsin plantar pressure during gait whencompared to healthy individuals;however, it is unknown if individualswith FAI demonstrate deviations inplantar pressure distribution whileperforming a side cut task. Objective:To assess differences in plantarpressure distributions whilecompleting a side cut task inindividuals with and without FAI.Design: Case-control. Setting:Outdoor FieldTurf and laboratory.Participants: Twenty physicallyactive individuals with FAI(21.4±2.62yrs; 69.67±8.66kg;167.2±4.93 cm; Cumberland AnkleInstabili ty Tool (CAIT) Score=23.95±3.41; Foot Posture Index(FPI) Score=2.0±3.18) and 20individuals without FAI (22.40±3.13yrs; 69.5±10.5kg; 169.6±6.18m;CAIT Score=29.25±0.78; FPIScore= 2.4±2.28). Main OutcomeMeasure(s): All participants filledout the CAIT to determine thepresence of FAI. Foot type wasassessed using the FPI and used formatching. Subjects ran at a self-selected pace for 10 meters and thenperformed a side cut task of 45degrees on FieldTurf. Two trialswere collected. Peak pressure (PP-kPa) and force-time integral (FTI-%bw/s) were measured using thePEDAR-x plantar pressure system(Novel, Inc., Munich) through a six-part mask [lateral (LF) and medialforefoot (MF),lateral (LM) and

medial midfoot (MM), lateral(LR)and medial rearfoot (MR)].Both measures were normalized tobody weight. Separate 2(group) x6(masks) repeated measuresANOVAs were used to assessdifferences for each dependentvariable (PP and FTI) (˜<0.05). Posthoc analyses were conducted usingT-tests with a Bonferroni correction.Results: For FTI a main effect wasdetected for mask(P<0.001) (LF=5.52+1.63%bw/s, MF= 14.01 ±3.78%bw/s, LM=2.17±1.10%bw/s,MM=3.35±1.38%bw/s, LR= 3.19±1.74%bw/s, MR=3.54±1.79%bw/s)with MF> LF,LM,MM, LR,MR(P<.001), LF>LM,MM, LR,MR(P<.001), and LF<MF,LM,MM,LR,MR(P<.001). A main effect wasdetected for group(P=0.015) withFAI individuals(5.69+0.2.05%bw/s)being higher than controls(4.89+1.60%bw/s). A significantmask by group interaction (P=0.033)was detected for FTI. The FAI group(6.11 +1.91%bw/s) had increasedFTI in the LF compared to the controlgroup(4.93+1.04%bw/s)(P=.003).There were no other significantcomparisons (P range = .18-.65).For PP, there was a main effect formask(p<0.001) (LF= 221.15+72.16kPa, MF=462.77+93.04kPa,L M = 1 1 4 . 8 9 + 4 0 . 8 4 k P a ,M M = 1 6 2 . 8 9 + 4 3 . 8 6 k P a ,L R = 2 9 3 . 4 7 + 1 3 6 . 7 5 k P a ,MR=313.38+129.96kPa) with allmasks being different (P<.001)except for LR and MR (P=.99), andLR and LF (P=.103). There was nomain effect for group (FAI:263.96+91.87kPa; Control:258.89 +79.90kPa;P=0.75). There was nomask by group interaction(P=0.36).Conclusions: When performing aside cut task, individuals with FAIspend more time over the lateralforefoot when compared to healthyindividuals. The increase in FTI overthe lateral forefoot may enhancethe chance of an inversion injurymechanism in individuals with

FAI. Alterations in movementpatterns identified by plantarpressure may be useful for futureresearch in understandingcontributing factors to FAI.

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The Relationship Between JointLaxity And Physical ActivityLevelsHubbard-Turner T, Turner MJ:University of North Carolina atCharlotte, Charlotte, NC

Context: Ankle sprains remain one ofthe most common musculoskeletalpathologies. Objective: To determineif there is a relationship between anklejoint laxity and physical activity levelsin those with chronic ankle instability(CAI). Design: Case Control Study.Setting: Controlled, researchlaboratory. Participants: Fifteensubjects with unilateral CAI (6 malesand 9 females, age=21.2± 1.9yr.,mass=71.9±11.7kg, ht=174.3±6.9cm)and fifteen healthy subjects (6 malesand 9 females, age=20.4±2.1yr.,mass=73.1±13.4kg, ht= 172.1±5.5cm) participated in the study.Interventions: Mechanical jointstabili ty was measured with aninstrumented ankle arthrometer. Thearthrometer measured ankle jointmotion for anterior/posteriortranslation and inversion/eversionangular displacement. All subjectsalso filled out the foot and ankleability measure (FAAM) and theFAAM sports subscale. After initialtesting, all subjects were providedwith a Digi-Walker SW-200pedometer (New Lifestyles, Inc.,Lees Summit, Missouri).Participants were instructed to wearthe pedometer everyday for sevendays and complete the daily step log.Bivariate correlations using PearsonProduct Moments were madebetween all dependent variablestaken on the CAI and health ankles.The level of significance was set apriori at p < 0.05 for all analyses.Main Outcome Measures:Anterior displacement (mm),posterior displacement (mm),inversion rotation (°), eversionrotation (°), and average daily stepcount. Results: Subjects with CAIhad significantly less steps (p=.04)

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Postural Modulation OfHoffmann Reflex StronglyCorrelates With PosturalControl In Patients WithChronic Ankle InstabilityKim KM, Hart JM, Saliba SA,Weltman AL, Hertel J: TexasState University, San Marcos,TX, and University of Virginia,Charlottesville, VA

Context: Decreased modulation ofHoffmann reflex (H-reflex) of theankle stabilizing muscles duringchanges in body positions has beenfound in patients with chronic ankleinstability (CAI) suggesting that neuralalterations may be an underlyingneurophysiological mechanism ofpostural control deficits associatedwith CAI. However, it is currentlyunknown whether this modulation isrelated to postural control measuresin patients with CAI. Objective: Todetermine relationships between theH-reflex modulation of the soleus andfibularis longus and postural controlmeasures in an upright position inpatients with and without CAI. Design:Descriptive. Setting: Laboratory.Patients or Other Participants:Fifteen subjects with CAI (9 males, 6females; age=23±5.8 years; height=174.7± 8.1cm; mass=74.9±12.8kg)and 15 controls without any history ofankle sprains (9 males, 6 females; age24±5.8 years; height=171.9±9.9 cm;mass=68.9±15.5 kg) participated.Interventions: Maximum H-reflexes(H-max) and motor waves (M-max)from the soleus and fibularis longusof the CAI-involved or side-matchedlimbs were recorded while subjectslied prone and then stood in bipedal andunipedal stances. Postural tasks ofquiet bipedal and unipedal standingwith eyes closed for 10 seconds wereassessed with a forceplate. MainOutcome Measures: H-max wasnormalized to M-max to obtainH

max:M

max ratios for the three

positions. For each muscle, H-reflex

modulation was quantified with thepercent change scores in H

max:M

max

ratios calculated between: prone-to-bipedal (P-Bi) and bipedal-to-unipedal(Bi-Uni). Center of pressure (COP)data were used to compute 10 specificCOP parameters including standarddeviation, range, velocity, area, andtime-to-boundary (TTB) minima.Pearson correlation coefficients (r)were calculated between H-reflexmodulation and postural controlmeasures. Results: There were 5strong correlations (all Pd”0.05)between P-Bi modulation and bipedalCOP measures found only in the CAIgroup with a range of r=-.639 to -.725for 3 traditional COP measures andr=.588 to .608 for 2 TTB measures.Lower traditional COP and greaterTTB measures reflect better posturalstability, thus indicating that as H-reflex was more down-regulated,postural control measures improved.When pooling the data from bothgroups, there were 9 moderaterelationships found in a range ofr= -.374 to -.465 for 7 traditional COPmeasures and r=.490 to .493 for 2 TTBmeasures. For relationships betweenBi-Uni modulation and unipedal COPmeasures, there were 3 strongcorrelations found in the CAI group ina range of r=-.606 to -.690 for3 traditional COP measures, and 1strong relationship (r=-.759) foundin the healthy group. When combininggroup data, there were 7 moderateto strong correlations found in a rangeof r=-.394 to -.554 for 7 traditionalCOP measures. Conclusions: Theresults indicate that as H-reflexamplitude in a more challengingposition is more down-modulated,the corresponding postural stabilityimproves. This relationship wasmore evident in the CAI group.

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compared to the healthy group. Theaverage daily step count for the CAIgroup was 8,694.47+1,603.35 andfor the healthy group 9,831.01+2,290.01. Subjects with CAI hadsignificantly more (p = .001) anteriordisplacement (14.2mm + 2.7)compared to the healthy ankles(10.6mm + 1.8). There were nosignificant differences for posteriordisplacement or inversion/eversionrotation. Several significant bi-variate correlations were identified.The strongest relationship wasbetween anterior laxity and averagedaily step count (r = -.84, p < .02).As anterior displacement increasedaverage daily step count decreased.There was also a significantrelationship with inversion rotationand average daily step count (r = -.78, p< .047). As inversion rotationincreased average daily step countdecreased. Conclusions : Theresults of this study indicateincreased laxity in those with CAImay contribute to the decreasedphysical activity levels of thesesubjects. I t is unknown if thedecreased step count is due solelyto increased joint laxity orpotentially the correspondingchanges in neuromuscular controlthat occur with joint instability.Decreased physical activity levelsin this population is a concern, andinterventions need to be designedto improve ankle stabili ty andneuromuscular control to ensuresubjects can participate in physicalactivity/exercise programs.

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Free Communications, Poster Presentations: Lower Extremity Injury1 3 3 7 8 U C

Posterior Hip Dislocation WithAcetabular Wall And FemoralHead Fractures: A Case ReportYim DW, Gildard M, Powers ME:Marist College, Poughkeepsie, NY

Background: We present the case ofa posterior hip dislocation complicatedby a posterior acetabular wall fractureand a femoral head fracture. A healthytwenty-two year old male division I clubrugby athlete was running with the ballwhen he was tackled by two opposingplayers. During the tackle, his left kneedirectly impacted the ground while in aflexed and fixed position while historso was forced anteriorly. The patientimmediately complained of severe painin the area of his hip and thigh and wasunable to move his left leg. Duringphysical examination his hip was foundto be in a position of flexion, adductionand internal rotation. The patient wasdiagnosed on the field as having aposterior hip dislocation. An on-fieldreduction was not attempted. Instead,he was immediately immobilized to aspine board in a position of comfort andtransported to the local emergencydepartment. Differential Diagnosis:Pelvic ring fracture, acetabularfracture, femoral head or neck fracture,acetabular labral tear, sciatic nerveinjury. Treatment: Radiographs takenat the emergency department revealeda posterior hip dislocation withposterior acetabular wall and medialfemoral head fractures. Following aclosed reduction, radiographsconfirmed alignment of the femoralhead however a fracture fragment wasnoted at the inferior aspect of theacetabulum. The patient wasimmediately referred to anotherhospital where an orthopedic surgeonperformed an open arthrotomy with aposterior approach to remove thefragments. The procedure requiredsurgical dislocation of the femoral headto obtain a clear view of all fragments.Post-surgery computed tomography(CT) scan and radiographs revealed a

successful procedure with the hipcomplex in a concentric position. Thepatient was discharged six days post-surgery. Uniqueness: Hipdislocations are relatively uncommonduring athletic events. When they dooccur, they are usually associated withhigh-energy impact events likefootball and rugby. Dislocationscomplicated by fractures of both theacetabulum and femur are even moreuncommon. These injuries generallyrequire open reduction and internalfixation because of the instabilitycreated by the acetabular wall defect.This was not indicated for our patienthowever, as he was managed with aclosed reduction only. Conclusion:Posterior hip dislocations withposterior acetabular wall and femoralhead fractures are rare injuries thatresult from high-trauma mechanisms.When these injuries occur, earlyreduction procedures are indicated toreduce the risk of long-termcomplications such as avascularnecrosis and degenerative jointdisease. Post reduction imaging is thenrequired to rule out associatedfractures and intra-articular loosebodies. If loose bodies are found, asin the current case, surgical removalis necessary to prevent abrasive wearof the articular cartilage. Upondischarge, patient education regardingpotential complications such asosteonecrosis of the femoral head,posttraumatic osteoarthritis andrecurrent dislocation is alsoimportant. The acetabular and femoralhead fractures increase the risk ofposttraumatic osteoarthritis and othercomplications. At one year post-surgery our patient has progressedthrough rehabilitation and is nowparticipating in lower extremityresistance training. However, he isstill prohibited from running andparticipating in any contact sports.

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Hip Injury In A Youth FootballPlayerWaugh AM, Hosey RG, WrightRD, Howard JS: University ofKentucky, Department ofOrthopaedic Surgery andSports Medicine, Lexington, KY

Background: A 10yo football playerwith no past history of lower extremityinjury was running the football whenhe was brought to the ground andlanded under multiple players. Theathlete experienced immediate painand difficulty bearing weight but wasable to ambulate with a limp from thefield. He was removed from play. Painwas diffuse about the hip, ROM waslimited secondarily to pain. Hereported no numbness or radiating painfollowing the injury. DifferentialDiagnosis: Contusion, slipped capitalfemoral epiphysis (SCFE), Legg-Calvé-Perthes disease, labral tear,avulsion fracture, or hip dislocation.Treatment: Athlete was referred tothe local emergency department forevaluation. No abnormalities werenoted on plain radiographs. Athlete wassent home on crutches and told tofollow-up with his pediatrician. Uponseeing his pediatrician he wasdiagnosed with a contusion andinstructed to remain on crutches untilhe could walk without a limp. Twenty-seven days post injury he was referredto a primary care sports medicinephysician for further evaluation. At thistime the athlete’s primary complaintwas pain mostly in the groin region withsome pain in the lateral hip. He had fullROM with flexion and extension of thehip, knee and back, limited ROM withinternal and external rotation of thehip. These deficits were further notedwith the hip in a flexed position.Manual muscle testing for strength was5/5 at the hip, knee and ankle. Straightleg raise test was negative bilaterallyand he reported mild discomfort withlogrolling of his left hip. Plain

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radiographs again revealed no bonyabnormalities. Given the patient’sdecreased hip motion and continuedpain, he was referred for an MRI. Thisrevealed a displaced posterior wallacetabular fracture, labrum avulsion aswell as a subchondral fracture of themedial femoral head. The patient wasthen referred to a trauma surgeon forpossible acetabular repair. Thirty dayspost injury the athlete was seen intrauma clinic. Exam was essentiallyunchanged from 3 days prior. Patientwas diagnosed with a posterior wallacetabular fracture secondary to hipposterior dislocation with spontaneousreduction. Surgical repair of thefracture was determined to be the bestoption to return this patient to highlevel function given his age and riskfor instability if not repaired. Surgerywas performed 37 days post injury. Anopen posterior approach was used anda pelvic reconstruction plate wasutilized to secure the posterior wallpieces. The patient was released 3 dayss/p procedure with home exerciseprogram and instructions to be toetouch weight bearing for 6 weeks post-surgery. At last follow-up the patientwas healing well, hip rotational profilewas symmetric, and all lower extremitymuscles were firing appropriately.Patient will continue long-termfollow-up with repeat radiographs tomonitor for avascular necrosis but isexpected to return to full function.Uniqueness: Hip dislocations inathletics are rare. Less than 5% oftraumatic hip dislocations occur inindividuals under age 15 and most areassociated with high impact vehiculartrauma. Pelvic fractures in adolescentsare rare and only 10% of thesefractures involve the acetabulum. Ininstances where spontaneousreduction occurs, diagnosis can bechallenging, particularly whenradiographs are normal. Conclusion:While hip dislocations are rare in theathletic population it is important forathletic trainers to be aware of the

signs and symptoms of a severe hipinjury. These injuries can gomisdiagnosed if symptoms such asreduced rotational ROM are ignoredand further assessment is not pursued.

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Unicameral Bone Cysts Of TheProximal Femur WithSubsequent PathologicalFracture: A Case ReportSchmidt RMS, Companioni GR

,

Lopez RM: Tampa OrthopedicClinic, Tampa, FL, and Universityof South Florida, Tampa, FL

Background: An 18 year-oldphysically active female (5’7”, 120pounds), presented with left hip painof approximately three weeksduration, progressively worsening.She reported pain with hip flexion,external rotation and weight-bearing.There was no acute trauma or specificinjury that could be determined. Theinitial examination by an athletictrainer demonstrated reduced range ofmotion secondary to pain duringflexion, adduction, and externalrotation, the presence of a rightwardantalgic gait, and pain during weight-bearing. The patient was givencrutches, instructed to be non-weightbearing (NWB), and was referred to anorthopedic surgeon due to loss offunction and pain level. X-rays of theleft femur and pelvis demonstratedmultiple lucencies. Physicalexamination demonstrated continuedpain with hip flexion, external rotation,and weight-bearing. DifferentialDiagnosis: Hip sprain/strain, muscletear, fracture, unicameral bone cysts,sarcoma, osteomyelitis, leukemia,osteoporosis. Treatment: Immediatereferral for an MRI, CT scan, and anevaluation by a musculoskeletaloncologist were ordered. Themusculoskeletal oncologistconfirmed the diagnosis as multiplebenign neoplasms of the proximalfemur. Following the two specialists’evaluations, the athlete continuedNWB status while awaiting outpatientsurgery, approximately 2 weeks later.The initial surgery for unicameral bonecysts of the femoral neck and lessertrochanter and pathological fracture ofthe femoral neck consisted of

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curettage and packing of the lesion withOsteoSet Pellets, a synthetic bonegraft. The patient was NWB untilapproximately two weeks status-postsurgery when sutures were removedand formal physical therapy wasinitiated. Gentle progression frompartial weight-bearing to full weight-bearing was achieved over a period offour weeks. X-rays were repeatedat each post-operative visit atapproximately six week intervals.Once discharged from physicaltherapy, the patient continued a homeexercise program (HEP). The athletewas advised that she could returnto participation in recreational and/or competitive sport as long as shewas pain-free. Almost two years aftersurgery, the athlete still complainedof occasional pain and x-raysrevealed that the synthetic graft didnot satisfactorily obliterate thelesions as well as desired by thesurgeon, and an open-reductioninternal fixation (ORIF) wasrecommended in anticipation of thepatient’s start of a potentiallyphysically strenuous program ofstudy. An ORIF with curettage andpacking of the lesion with boneallograft was performed nearly 2years following the initial surgery.The patient was NWB forapproximately two weeks status-postsurgery when sutures were removed.Only two to three visits of formalphysical therapy were ordered andthen the patient was directedto repeat the HEP as previouslyprescribed on the initial surgery. Thepatient was permanently restrictedfrom high-impact sports.Uniqueness: Unicameral bone cysts(UBCs) or simple bone cysts (SBCs)are of an unknown etiology, thoughit is suspected that venousobstruction elevates interosseouspressure, leading to cyst formation.These cysts are often asymptomaticand found incidentally on imaging forseparate complaints. They arereported to be self-l imited,

stabilizing or spontaneouslyresolving following skeletalmaturity. These lesions can causesevere, performance-limiting painin young adults during strenuousactivity but minimal to no painduring sedentary activit ies.Conclusions: Athletic trainersshould consider the possibili tyof oncology-related diagnoses whenevaluating young athletes fororthopedic injuries as theymay present similar to commonsprains/strains and joint aches.Radiographic imaging shouldbe obtained to rule out commondiagnoses, such as fracture oravulsions, and to rule out oncology-related diagnoses, such as UBCs, SBCs,or other benign tumors of the bone.

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The Evaluation And TreatmentOf A FemoroacetabularImpingement In A Young SoccerPlayer: A Case ReportRoss RG, Neefe HI, Lopez RM:All Children’s Hospital, St.Petersburg, FL, and Universityof South Florida, Tampa, FL

Background: This case involves amale, 15-year-old avid soccer player(5’6”, 118.8 lbs); he is a right-footdominant defensive right back. Theathlete presented with left anteriorhip, groin, and buttock pain for over ayear while playing competitive soccer.No specific incident of trauma ormechanism of injury was reported. Hissymptoms progressively worsenedcausing an abnormal walking gait. Thefamily scheduled a consultation witha pediatric orthopedic physician due torestricted movements, uncomfortablepain and declining athleticperformance. Differential Diag-nosis: Adductor or flexor strain,apophysitis, internal or externalsnapping hip, athletic pubalgia, slippedcapital femoral epiphysis, and labraltear. Treatment: Upon initialevaluation the physician immediatelyordered magnetic resonance imaging(MRI) of the pelvis and hip magneticresonance arthrogram (MRA) thatsame day due to a positive hip scouringand anterior impingement test. Clinicalimpression of the pelvis MRI producedabnormal morphology of both hips ina fairly symmetric behavior. Next, aleft hip MRA was performed usingguided fluoroscopy. The results wereremarkable and compatible withfemoroacetabular impingement (FAI)both cam and pincer lesions bilaterallyalong with a left labral tear. Togetherthe family chose arthroscopic surgeryof the FAI for debridement of theosseous prominence, acetabularovergrowth, and to repair the left labraldefect of the hip in order to continueplaying at the elite level. Surgery wasscheduled 6 weeks after the evaluationand diagnostic assessments. The

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surgeon used a Smith and Nephewdistraction table and applied threeknotless Smith and Nephew raptureanchors (2.9 cm) to repair the labrum,then, proceeded with theacetabuloplasty and femoroplasty.Rehabilitation was prescribed withrestrictions, including NWB for 6weeks and TTWB to PWB for anadditional 2 weeks. The protocoladvised for no hip adduction for 6weeks and included AROM limitationsof hip flexion, extension, and externalrotation. Rehabilitation began with hipisometrics and progressed to fullAROM with NWB core exercises. Hebegan biking when hip flexion wastolerable. After week 8, he beganshuttle press, balance andproprioception exercises. Jogging wasintroduced at week 10 using ahydrotrack, with normal progressiverunning at 3 months. The final phasebegan at 4 months and included soccerspecific drills, plyometrics and agilitypatterns. The athlete was cleared toplay at 5 months and finished the entireclub soccer season without setbacks.Uniqueness: FAI is less common inadolescent athletes. Previous researchsuggests that FAI in males typicallyproduces only the cam lesion, makingthis a rare case due to the athlete’s age,sex and morphological mixture ofosseous impingements (both cam andpincer lesions). In addition, thetimeframe between initial symptomsand medical treatment is remarkablesince no signs of degenerative changeswithin the left hip were reported.Conclusions: FAI leads to restrictedhip motion, progressive damage to thelabrum and degenerative intra-articularchanges. Most reported adolescentcases present with either the cam orpincer lesion and not a combination ofboth. It is important to understand theetiology of FAI in order to stop furtherdamage of intra-articular structures.Due to the underlying structures FAIcan be difficult to diagnose. Athletictrainers need to be aware of theetiology involved with hip pathologies

in order to make sure our athletescontinue to play their respected sportwithout causing further damage.Future research should focus on FAIin the adolescent athlete since thereis limited literature readily available.

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Alterations In BiomarkersFollowing Anterior CruciateLigament Injury: A SystematicReviewLuc BA, Thomas AC, Driban JB,Pietrosimone BG: University ofToledo, Toledo, OH, and TuftsMedical Center, Boston, MA

Context: Anterior cruciate ligament(ACL) ruptures occur in approximately250,000 Americans each year, withthese patients experiencing an 8-10fold increase in risk of developingknee osteoarthritis. Osteoarthritis isprimarily diagnosed radiographically,but by the time radiographic changesappear, considerable damage hasoccurred and treatment is challenging.Biochemical markers (biomarkers) ofcartilage degradation may bedetectable early following ACL injurybefore radiographic osteoarthritis hasdeveloped. Objective: Systematicallyreview the literature to determine themagnitude of differences in biomarkerconcentrations following injury andACL reconstruction (ACL-R)compared to healthy controls.Sources: Web of Science wassearched from 1960 throughNovember 9, 2012 with the searchterms “anterior cruciate ligamentinjury” and an exhaustive list ofclassifications of biomarkers.Bibliographies of pertinent studieswere cross-referenced for additionalrelevant studies. Study Selection:Five studies assessed biomarkerconcentrations in either ACL-deficient (ACL-D) or ACL-R patientscompared to healthy controls. Weexcluded studies if: treatments outsideof standard physical rehabilitationwere given in attempt to alterbiomarker concentrations; a controlgroup was not used for comparison;means and standard deviations were notpresented; or studies used animalmodels. Data Extraction: Means andstandard deviations were extractedfrom each study to compare biomarkerconcentrations in ACL-R and ACL-D

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patients to healthy controls. Cohen’seffect sizes (d=treatment–control/pooled standard deviation) with 95%confidence intervals (CI) werecalculated for each biomarker to allowfor comparisons between groups. DataSynthesis: For ACL-D patients, thestrongest effect was found at 12months following injury for serumchondroitin sulfate epitope (WF-6;d=7.57,CI=6.43-8.60). A strongeffect for synovial fluid (SF)glycosaminoglycan (GAG) con-centration was seen immediatelyfollowing injury (d=1.06, CI=0.26-1.81), and moderate effects werefound at 5.4 and 388.4 weeks post-injury (d=0.69,CI=-0.22-1.54; d=-0.56,CI=-1.32-0.23, respectively).Weak effects were found for SFconcentrations of aggrecan at all timepoints (0.7weeks:d=0.26,CI=-0.05-0.99; 5.4weeks:d=0.35,CI=-0.52-1.20; 67.3weeks:-0.14,CI=-0.98-0.70; 388.4weeks:d=-0.13,CI=-0.88-0.64), as well as serum levels ofhyaluronic acid at 12 months in ACL-D patients (d=-0.30,CI=-0.70-0.12).SF GAG concentrations at 67.3 weeksin ACL-D patients were weak (d=-0.39,CI=-1.22-0.47). Following ACL-R, weak effects at all time points wereobserved for urine levels of C-telopeptide fragments of type IIcollagen (CTX-II) followingreconstruction (4weeks:d=0.15,CI=-0.38-0.67; 8weeks:d=0.11,CI=-0.41-0.64; 12weeks:d=0.09,CI=-0.44-0.61; 16weeks:d=0.01,CI=-0.52-0.53), however moderate effects wereseen for SF CTX-II one year followinginjury in ACL-D patients (d=0.53,CI=0.04-1.02). Conclusion:Alterations in biomarker con-centrations are present following ACLinjury in both ACL-R and ACL-Dpatients, suggesting the process ofdegeneration may begin immediatelyfollowing injury. The strongest effectswere found in ACL-D patients in serumlevels of WF-6 one year followinginjury and GAG concentrationsimmediately following injury. Future

studies should aim to determine whichbiomarkers are the strongestpredictors of osteoarthritisdevelopment following ACL injury andACL-R, ultimately allowing for earlydetection of cartilage degeneration.

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Elevated Biomarkers OfCartilage Catabolism AndInflammation In Athletes WithFemoroacetabular ImpingementMendias CL, Gumucio JP, LynchEB, Sibilsky Enselman ER, BediA: University of Michigan, AnnArbor, MI

Context: Femoroacetabularimpingement (FAI) is a common hipcondition in athletes that leads to thedevelopment of early cartilage andlabral damage in the non-dysplastic hip.While FAI surgery improves thekinematics after surgical correction ofFAI, no specific prognostic indicatorsof osteoarthritis that correlate withjoint injury or assess the efficacy ofhip preservation surgery have beenreported to-date. Cartilage oligomericmatrix protein (COMP) is anextracellular matrix protein that is anestablished marker of cartilagecatabolism, and C-reactive protein(CRP) plays an important role ininitiating inflammatory processes andis commonly used as a biomarker ofinflammation.Objective: Todetermine if athletes with FAI haveelevated biomarkers of cartilagemetabolism and inflammation, wemeasured COMP and CRP levels inasymptomatic athletes with FAI andcompared these to matchedasymptomatic athletes without hipdeformity. We hypothesized thatathletes with FAI would have elevatedlevels of COMP and CRP. Design:Cohort study. Setting: Researchlaboratory. Patients or OtherParticipants: Male athletes withradiographically confirmed FAI(N=10, mean age 23.1±6.4, TegnerActivity Level 7.3±2.9, BMI 26.5±3.5)were compared to age and activitymatched males athletes withradiographically confirmed absence ofFAI or dysplasia (N=19, mean age22.3±3.4, Tegner Activity Level7.7±1.0, BMI 26.2±6.5). This study hadIRB approval. Interventions:Radiographs were taken of subjects

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and a board certified, fellowshiptrained musculoskeletal radiologistdetermined the presence or absence ofFAI. Plasma was prepared from bloodthat was drawn from an antecubitalvein. Main Outcome Measures:Circulating levels of COMP (R&DSystems) and CRP (Calbiotech) weremeasured using ELISAs. Subjects alsocompleted SF-12 and Hip disabilityand Osteoarthritis Outcome Score(HOOS) surveys. Differences betweengroups were tested with t-tests(P<0.05). Results: Compared withcontrol athletes, athletes with FAIhad a 24% increase in COMP levels(P<0.05) and a 376% increase in CRPlevels (P<0.05), as well as a 22%decrease in SF-12 physical componentscores (P<0.05), and decreases inall of the HOOS subscale scores(P<0.05). Conclusions: This is thefirst study to-date that demonstratessignificant increases in the levels ofcirculating biomarkers ofinflammation and chondral injury inathletes with FAI compared to controlathletes. These results demonstratethat chondral injury secondary tothe repetitive microtrauma of FAIcan be reliably detected, and offerfuture promise for the use thesebiomarkers as tools to identify at-riskathletes and assess the efficacy oftherapeutic interventions such aship preservation surgery in reducinginflammation, cartilage degeneration,and reducing the likelihoodof developing osteoarthritis.

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ACL Volume And Width AreCorrelated With Anterior-Posterior Knee LaxityWang HM, Schmitz RJ, Shultz SJ:The University of North Carolina atGreensboro, Greensboro, NC

Context: Greater knee joint laxity hasbeen associated with an increased riskof ACL injury. Mechanistically,multiple factors have been attributedto the magnitude of joint laxity. It isunknown if knee joint laxity is relatedto bony joint structure and ACLgeometry. Objective: To determinethe relationship between ACL andfemoral notch geometry obtained viamagnetic resonance (MR) imagingwith anterior (AKL) and posterior(PKL) knee joint laxity. Design:Cross-sectional. Setting: ControlledLaboratory. Participants: Twenty-two recreationally active females(1.67±0.7m, 65±12.1kg, 21.4±3.07yrs). Interventions: MR scans ofthe knee were performed and AKL andPKL were obtained via a commercialjoint arthrometer. Main OutcomeMeasures: The entire ACL wassegmented and manually traced acrossmultiple slices from which ACLvolume was calculated. ACL width wascalculated as the width of a line drawnperpendicular to Blumensaat’s line atthe notch outlet that transected theACL. Notch angle was measured as theangle formed by the intersection of theline parallel to the posterior cortex ofthe femur and Blumensaat’s line. Tenparticpants’ MR data were assessed ontwo separate occasions to establishmeasurement reliability and precision.Joint laxity was measured as theanterior and posterior displacement ofthe tibia relative to the femur (mm) at130N and 89N of force, respectively.Pearson correlations examinedrelationships among variables.Results: Strong measurementconsistency (ICC

2,1) and precision

(±SEM) were established for ACLvolume (0.97±36.1mm3); ACL width(0.98±0.3mm); and notch angle

(0.97±1.1°). Mean ACL volume =1320.6±183.5mm3; mean ACL width =5.9±1.3mm; mean notch angle =37.1±6.2°; mean AKL = 7.2 ± 1.9;mean PKL = -1.7± 0.3. ACL volumewas significantly correlated with ACLwidth (r= .907, P=.001), AKL (r= -.676, P=.032), and PKL (r=.789,P=.007). Smaller, but significantcorrelations were noted between ACLwidth with AKL (r=. -.466, P=.029)and PKL (r=.434, P=.049). There wereno correlations between notch angleand AKL or PKL (P>.05).Conclusions: Greater AKL and PKLwere associated with an ACL that wassmaller and thinner. Collectively, thiswork suggests that clinically availablemeasures of knee laxity are indicativeof ACL geometry measures. A betterunderstanding of the relationshipbetween ACL geometry and knee laxitymay advance prevention efforts. Futurework should determine whetheralteration of ACL geometry as a resultfrom repetitive loading can bemeasured via simple clinicalmeasurement such as joint laxity.

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Relationships Between ACL-Injury Related Knee MechanicsDuring Double-Leg JumpLandings And Side-Step CutsNorcross MF, Pollard CD, JohnsonST, Doeringer JR, Hoffman MA:Oregon State University, Corvallis,OR, and Oregon State University-Cascades, Bend, OR

Context: One limitation of currentanterior cruciate ligament (ACL)injury research is that knee mechanicsrelated to ACL-injury risk are oftenevaluated during different types ofmovement tasks (e.g., landing vs. side-step cut, double-leg vs. single-leg).Two commonly used tasks are thedouble-leg jump landing and the side-step cut. However, it is currentlyunknown whether an individual’s kneebiomechanics during these tasks arerelated; and consequently, whetherfindings from studies utilizing thesedifferent tasks can be directlycompared. Objective: To evaluaterelationships between ACL-injuryrelated knee biomechanics inparticipants performing double-legjump landings (DLJL) and side-stepcuts (SSC). Design: Cross-sectional.Setting: Research laboratory.Patients or Other Participants:Twenty-one healthy, physically activevolunteers (12 Males, 9 Females, Age:20.9±1.5 years, Height: 1.70±0.10 m,Mass: 72.76±11.31 kg). Inter-ventions: Lower extremitybiomechanics of the dominant limbwere assessed via an optical motioncapture system interfaced with twoforce plates as participants completedfive DLJL from a 30 cm high boxpositioned 50% of their height behindthe force plates; and five 45 SSC onthe dominant limb. Main OutcomeMeasures: Sagittal and frontal planeknee angles at initial contact (IC) andpeak knee valgus angle during theloading phase (IC to peak knee flexion)were identified. Internal net jointmoments were calculated usingstandard inverse dynamics procedures,

and the peak knee extension (pKEM)and knee varus (pKVM) momentsduring the initial 20% of the loadingphase were identified. Therelationships between the mean valuesfor each biomechanical measureduring the two movement tasks wereassessed via Pearson correlationcoefficients ( d•0.05). Results:Greater IC (1.74±2.88°) and peak (-2.43±4.47°) knee valgus angles duringDLJL were associated with greater IC(0.11±3.45°) and peak (-2.51±3.28°)knee valgus angles during SSC (IC: r =0.710, p < 0.001; Peak: r = 0.778, p <0.001). Though not statisticallysignificant, there was also a trend forgreater pKEM during DLJL(159.79±40.22 Nm) to be associatedwith greater pKEM during SSC(106.99±32.65 Nm; r = 0.418, p =0.059). However, no relationshipsbetween IC knee flexion angles(DLJL: 21.60±4.60°; SSC:25.97±6.81°; r = 0.181, p = 0.432) orpKVM (DLJL: 25.50±15.04 Nm;SSC: 56.34±26.66 Nm; r = 0.110, p =0.635) during DLJL and SSC wereidentified. Conclusions: Participantsexhibiting higher-risk frontal planeknee positions do so during both DLJLand SSC; but the magnitudes of IC kneeflexion angle during these tasks appearto be unrelated. Conversely, whilethere was a trend for participants toexhibit greater pKEM during bothtasks, we failed to identify arelationship between the magnitude ofpKVM during DLJL and SSC. As such,caution should be exercised whenevaluating IC knee flexion and pKVMresults from studies utilizing thesedifferent movement tasks.

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The Relationship BetweenPerformance On ClinicalBalance Tests After AnteriorCruciate LigamentReconstructionMeyer JD, Martinez JC,Soontararak M, Rubino T, Trojian TH, Joseph MF, VeasleySJ, DiStefano LJ: University ofConnecticut, Storrs, CT

Context: Balance deficits have beenreported in individuals after anteriorcruciate ligament (ACL) injury. TheBalance Error Scoring System (BESS)test and the Star Excursion BalanceTest (SEBT) are common clinicalbalance assessment tools. There arelimited data comparing performanceon these tests after an ACLreconstruction. Objective: Todetermine if there is a correlationbetween the BESS and the SEBT testsin individuals who have had an ACLreconstruction. Design: Correlationstudy Setting: Laboratory Patients orOther Participants: 18 healthy andactive participants (10 females, 8males, Age: 21.8±4.4 years, Mass:75.2±10.43 kg, Height: 172.8±7.6cm) with a history of ACLreconstruction volunteered toparticipate in this study. Inter-ventions: Participants completed theBESS test and SEBT on their injured(most recent reconstructed ACL) anduninjured limbs in a randomized order.Participants were videotaped whilethey balanced in 3 different stances(Double-limb, Single-limb, Tandem)on two surfaces (flat or unstable) forthe BESS test. A single rater, blindedto limb, recorded the errors from thevideotape. A single rater measured theparticipants’ reach distance of twotrials in three directions (anteriorly,posteromedially, posterolaterally) forthe SEBT. Main Outcome Measures:The BESS test and SEBT are valid andreliable tools for measuring balance.The errors from each stance andsurface were summed to calculate aTotal BESS score. The average

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distances for each direction weresummed into a composite SEBT scorenormalized by leg length. Pearsoncorrelation coefficients werecalculated to evaluate the relationshipbetween BESS test and SEBT onboth limbs (˜<.05). Results: Therewas no significant correlation betweenthe BESS test (Injured BESSTotal=6.7±2.9, Uninjured BESSTotal=6.5±3.1) and the SEBT (InjuredSEBT Total=0.48 ±0.10, UninjuredSEBT Total=0.49±0.10) for injuredlimb (r=0.26, P=0.30) or for uninjuredlimb (r=0.13, P=0.62). Conclusions:The BESS test and SEBT appearto measure different aspects of balanceand function. Therefore, these clinicalbalance tests should not be usedinterchangeably in individuals afteran ACL reconstruction. Cliniciansmay consider using both tests toevaluate balance deficiencies and assistreturn to play decisions.

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Lower Extremity BiomechanicsIn Individuals With And WithoutAnterior Knee Pain During ASingle Leg Drop Landing TaskGaven SL, Glass MJ, Van LunenBL, Weinhandl J: Old DominionUniversity, Norfolk, VA

Context: Individuals with anteriorknee pain (AKP) experienceperipatellar pain during repetitive kneeflexion associated with weight-bearingactivities. Differences in lowerextremity(LE) kinematics duringjumping tasks have been demonstrated,however information on landingutilizing a single leg drop does notexist for AKP individuals. Objective:To examine differences in LEkinematics in individuals with AKPcompared to healthy individuals duringsingle leg drop landings. Design:Case-Control Setting: LaboratoryParticipants: Twenty-two physicallyactive adults age 18-30 (11AKP;169.72+7.0cm; 67.08+15.81kg;Kujala:70.73+8.68) (11 Control;170.23+7.24cm; 67.28+12.62kg) whoexercised a minimum of 3x/week forat least 30 minutes volunteered for thisstudy. AKP participants had pain for aminimum of 3 weeks, during physicalactivity, prolonged sitting, jumping,and/or squatting, and the control groupwas free of LE injury and had nohistory of AKP. Intervention: Eachsubject performed five trials of asingle leg drop landing task from threedifferent heights during one testingsession. The task required theparticipant to perform a single legdrop landing from a 20, 30, and 40centimeter(cm) high box placed 10cmbehind a force plate and remain on theforce plate for ~2 seconds. Three-dimensional kinematics of the LEwere obtained using an 8 cameramotion capture system. MainOutcome Measurements: Inde-pendent variables were group [AKP,Control(Con)] and box height (20, 30,and 40cm). Dependent variablesincluded sagittal and frontal plane

transverse plane knee and hip anglesat initial contact(IC) and maximumknee flexion(MaxKF). Separate 2x3ANOVAs were performed for eachvariable. In the event of a significant(d”.05) interaction or main effect,Fisher’s LSD post-hoc tests wereperformed on all pairwisecomparisons. Results: At IC there wasa main effect for box height for ankledorsiflexion(P=0.012) with differ-ences between 20cm(-17.85+1 1.26o)and 30cm(-21.05+8 .44o)(P= 0.027),and 20cm(-17.85+11.26o) and 40cm(-21.06+7.22o)(P=0.03), and hipabduction(P=0.001) between 20cm(-6.42+10.78o) and 30cm(-8.58+

12.94o) (P=0.007), 20cm(-6.42+

10.78o) and 40cm(-9.4+ 14.45o)(P=0.009). At MaxKF there was a maineffect for box height (P=0.001) atknee flexion (KFL) between 20cm(-49.81+7.08o) and 30cm(-52.13+

6.24o)(P=0.001), 20cm(-49.81+7.08o)and 40cm(-55.36+9.15o)(P=0.001),30cm(-52.13 +6.24o)vs. 40cm(-55.36+

9.15o) (P= 0.005) and hip flexion(HFL) (P=0.002) between 20cm(23.13 +25.14o) and 40cm(28.02+25.33o) (P=0.002), and 30cm(23.8+23.21o) and 40cm (28.02+25.33o)(P=0.008). There was a maineffect for group for KFL(AKP:-48.43+7.16o;Con: 56.43 +7.16o)(P=0.017). No other significantfindings were present. There were nosignificant group x height interactionsfor any measure(P>0.05).Conclusion: Individuals with AKPdemonstrate biomechanicaldifferences in KFL at theinstance of MaxKF during asingle leg drop landing compared tohealthy individuals. The AKP groupdemonstrated less KFL at MaxKFsuggesting that they employ a stifferlanding pattern and may not attenuatethe forces imposed on the LE aswell as a healthy individual. Thedecrease in KFL may serve as acoping mechanism for theindividuals with AKP to reduce painduring landing activities.

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Combined Effect Of StaticAnd Dynamic Posture May BePredisposition To Medial TibialStress SyndromeLee SY, Hertel J: YonseiUniversity, Seoul, Korea,and University of Virginia,Charlottesville, VA

Context: Characteristics of multiplestatic postural measures among thosewith Medial Tibial Stress Syndrome(MTSS) have not been examined.Furthermore the difference ofdynamic postural measures betweenMTSS patients with and without staticpostural malalignments may providebetter information to understand theimportance of dynamic posturalmeasures that may elicit MTSS.Objective: To identify multiple staticpostural characteristics of MTSS andinvestigate the dynamic posturalcharacteristics of MTSS patients withand without static malalignments.Design: Case controlled study.Setting: Laboratory. Patients orOther Participants: A total of 74recreational and competitive runners[37 normal (23.9±.4 years), 37 MTSSinjured (24.0±.3 years)] wererecruited. Interventions: Sevenalignments (standing rearfoot angle,navicular drop, pelvic tilt, tibialtorsion, tibial varum, femoralanteversion, weight-bearing Q-angle)were measured and entered into ahierarchical and K-means clusteranalysis to identify the cluster whichcontained the majority of MTSSsubjects. A total of three clusters wereidentified. Seven [MTSS withoutmalalignment (MTSS

dyn) out of 16

subjects (the rest of 9 subjects werenormal group) had MTSS in clusterone. Twenty-seven [MTSS with staticmalalignment (MTSS

mal)] out of 36

subjects [the remaining 9 subjects wereno MTSS with static malalignment(noMTSS

mal) had MTSS in cluster two.

Three (MTSSdyn

) out of 22 subjects(the rest of 19 subjects were normal)had MTSS in cluster three. Therefore,a total number of subject in four

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Comparison Of Triceps SuraeMusculotendinous Stiffness,Geometry, And Architecture InMale Runners With And WithoutA History Of Tibial StressFracturePamukoff DN, Blackburn JT:Neuromuscular ResearchLaboratory, University of NorthCarolina at Chapel Hill, ChapelHill, NC

Context: Previous research hasidentified greater lower extremityjoint stiffness in runners compared tonon-runners, and in runners with ahistory of tibial stress fracture (TSF)compared to healthy runners. Whilemusculotendinous stiffness (MTS) isthe largest contributor to jointstiffness, it is unclear what factorscontribute to greater MTS in runnerswith a history of TSF. Objective: Tocompare triceps surae MTS, andmuscle architecture and geometrybetween runners with and without ahistory of TSF. We hypothesized thatpreviously injured runners wouldhave greater MTS comparedto healthy runners and differ inmedial gastrocnemius (MG)architecture and geometrydemonstrated by greater cross-sectional area (CSA), musclethickness (MT), fascicle length (FL),and pennation angle (PA). Design:Cross-sectional. Patients or OtherParticipants: Eight healthy malerunners (age = 20.8 ± 2.6 years;mass = 66.5 ± 9.4 kg; weekly runningamount = 86.4 ± 31.8 km) and eightmale runners with a history ofTSF (age = 21.9 ± 3.0 years; mass =65.6 ± 5.4 kg; weekly runningamount = 78.9 ± 22.2 km) wererecruited from community runninggroups and the university’s varsityand club cross-country teams. Injurystatus was determined via self-report. Interventions: Triceps suraeMTS was estimated from the dampedfrequency of oscillatory motionabout the ankle followingperturbation under loading

equivalent to 45% of maximalvoluntary isometric contraction(MVIC) of the plantarflexors.Ultrasound imaging was used tomeasure architecture and geometryof the MG. Main OutcomeMeasures: Geometric andarchitectural properties of the MGincluded CSA,MT, FL, and PA. MGstrength was estimated viaplantarflexion MVIC. Triceps suraeMTS was standardized to body mass.All outcome measures werecompared between groups viaseparate one-way analyses ofvariance. Results : Previouslyinjured runners had greaternormalized triceps surae MTScompared to healthy runners (178.4± 45.3 N/cm/kg vs. 112.7 ± 38.5 N/cm/kg; p = 0.007). No differenceswere found in CSA (680.5 ± 131.1mm2 vs. 619.8 ± 105.4 mm2;p=0.325), MT (18.3 ± 2.3 mm vs.17.1 ± 3.0 mm, p=0.0.382), FL (58.4± 11.4 mm vs. 53.0 ± 8.0 mm;p=0.292), PA (25.3 ± 4.0° vs. 24.8 ±3.9°, p=0.810) or MVIC (51.5 ± 8.5kg vs. 47.4 ± 15.2 kg; p = 0.518)between previously injured andhealthy runners. Conclusion: MTSis a modifiable characteristic, andreducing triceps surae MTSmay reduce the risk of TSF in malerunners. Muscle crossbridgeformation at a given percentageof MVIC, muscle architecture, andmuscle geometry did not varybetween groups. Therefore, thedifference in MTS betweenpreviously injured and healthyrunners is l ikely attributableto differences in tendon stiffness.Future research is requiredto determine the contribution oftendon stiffness to MTS inthe lower extremity.

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groups were as follows: MTSSmal

(n=27), MTSSdyn

(n=10), noMTSSmal

(n=9), and normal (n=28) groups.Main Outcome Measures:Maximum 3-D joint kinematics werecollected with Vicon motion analysissystem while jogging (2.65m/s,120Hz). In order to confirm thecharacteristics of three clusters, a one-way ANOVA was performed to examinegroup (cluster) differences of staticpostural measures. One-way ANOVAtests were performed to examinedifferences across the 4 groups ofdynamic postural measures assessedduring jogging. Results: Thecharacteristics of cluster two weregreater valgus standing rearfoot angle(cluster1: 5.60°±2.49°; cluster2:7.14°±3.06°; cluster3: 5.14°±2.71;P=.026), anteverted femoral head(cluster1: -6.75°±2.98°; cluster2:7.08°±3.22°; cluster3: 4.45°±4.16°;P<.001), valgus WB Q-angle(cluster1: 18°±4.29°; cluster2:19.53°±4.45°; cluster3: 11.52°± 3.98°;P<.001), and externally rotated tibia(cluster 1: 24.13°± 7.34°; cluster2:30.42°±4.66°; cluster3: 17.64°± 5.18°;P<.001). MTSS

mal (2.74°±.60°) showed

significantly higher max eversion(F3,70=5.95; P<.001) as compared withnormal (-.51°±2.47°); MTSS(2.40°±.96°) showed significantlyhigher max eversion as compared withnormal (-.51°±2.47°); MTSS

mal

(14.67°±.78°) showed significantlyhigher max hip adduction (F3,70=3.32;P=.025) as compared with normal(11.91°±.72°); and MTSS

mal

(11.05°±1.56°) showed significantlyhigher max knee internal rotation(F3,70=383.00; P=.00) as comparedwith normal (2.12°±1.45°).Conclusions: Individuals with staticpostural measures such as increasedstanding rearfoot angle, femoral ante-verion,WB Q-angle, and externalrotation of tibia may be predis-posed condition for MTSS incombination with joint kinematics suchas rearfoot everion, hip abduction,and knee internal rotation.

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Hamstring Strain Injury HistoryAnd Muscle Strength, Volume,And Flexibility In IntercollegiateSprinters And JumpersKramer N, Herb CC, Kuenze C,Fiorentino N, Blemker S, Hart JM,Hertel J: University of Virginia,Charlottesville, VA

Context: Sprinters and jumpers havea high incidence hamstring straininjury, but limited research has beenperformed investigating long-termeffects of hamstring injury on musclecharacteristics. Objective: Tocompare side-to-side symmetry inmeasures of thigh muscle strength,volume, and flexibility inintercollegiate sprinters and jumperswith and without a history of unilateralhamstring strain injury. Design:Descriptive laboratory study. Setting:NCAA Division I university. Patientsor Other Participants: 21intercollegiate sprinters and jumpers(12 males, 9 females; age=19.1±1.3years; height=1.8±0.1 m; mass=70.2±9.0 kg) participated. Seven (5males, 2 females) had a history ofunilateral hamstring injury while 14 (7males, 7 females) reported no historyof hamstring injury. Individualsreporting bilateral hamstring injuryhistory were excluded fromparticipation. Interventions:Isometric, concentric, and eccentrichamstring and quadriceps strength wascollected using an isokineticdynamometer. Maximal isometriccontractions were performed at 60°knee flexion, while concentric andeccentric isokinetic testing wasperformed at 180°/s. Peak torqueswere normalized to body mass. Musclevolumes of the semimembranosus,semitendinosus, biceps femoris longhead, biceps femoris short head, totalhamstrings, and total quadriceps werecalculated from magnetic resonanceimages using an establishedsegmentation routine. Muscle volumemeasures were normalized to a productof subject mass and height. Hamstringflexibility was assessed with a 90/90

test and hip flexor flexibility wasassessed with the Thomas test withmeasures taken of both the shank andthigh. Main Outcome Measures: Inthe injured group, limb-to-limbsymmetry ratios of the injured touninjured limb were calculated for allmeasures. In the control group, amatching routine was used to assigneach subject with a “sham” injuredlimb prior to computation of symmetryratios. Independent t-tests were usedto compare the symmetry ratiosbetween groups. Results: Thepreviously injured group demonstrateddecreased total quadriceps volumecompared to the non-injured group(injured=.96±.04, healthy=1.0±.04,p=.04). No significant symmetry ratiodifferences were found in any othermeasures (semimembranosus volume:injured=.96±.09, control=1.03±.10,p=.13; semitendinosus volume:injured=1.01±.10, control=.96±.12,p=.34; biceps femoris long head:injured=.97±.13, control=1.02±.09,p=.39; biceps femoris short head:injured=.99±.08, control=1.03±.16,p=.51; total hamstrings volume:injured=.98±.04, control=1.01±.06,p=.31; isometric quadriceps: injured=1.15±.35, control=1.12±.46, p=.89;isometric hamstrings: injured=1.14±.46, control=1.05±.54, p=.72;concentric quadriceps: injured=1.12±.47, control=1.07±.25, p=.74;concentric hamstrings: injured=1.04±.27, control=1.00±.18, p=.68;eccentric quadriceps: injured=.88±.22, control=1.07±.48, p=.32;eccentric hamstrings: injured=.95±.20, control=.90±.23, p=.60; 90/90 test: injured=1.03±.08, control=1.0±.07, p=.38; isometric quadriceps:injured=1.15±.35, control=1.12±.46,p=.89; Thomas test-thigh: injured=.58±.83, control=1.69±.2.42, p=.26;Thomas test-shank: injured=.88±.28,control=.89±..24, p=.94). Con-clusions: Quadriceps volume wasdecreased by approximately 4% on theinvolved limb in sprinters and jumperswith a history of unilateral hamstringstrain; however there were no

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90 degrees and held in place by a strapattached to a treatment table. The withingroup change was analyzed using apaired T-test. The between group datawere analyzed by MANOVA. The alphalevel was set at .05. Main OutcomeMeasures: The dependent variableswere the Achilles tendon thickness andcross sectional area at 8 cm superiorto the plantar surface of the heel.Results: There were significantdecreases in tendon thickness of 7.4%(p<.0001) and cross-sectional area of9.6% (p<.0001) following the 4-milerun by the cross-country runners. Therewere no significant decreases intendon thickness (p=.470) and cross-sectional area (p=.349) in the non-runners following the 30 minuteperiod of non-exercise. There weresignificant differences between therunners and non-runners in the changein Achilles tendon thickness (p=.008)and cross-sectional area (p=.004)between the pre and postmeasurements. Conclusions: Thereappears to be a thinning of thetendon due to running. It is not knownif the magnitude of thinning or lackof thinning or difference in the rate ofthinning is associated with the riskof Achilles tendon injury in runners.Further research should be undertakento investigate correlations betweenAchilles tendon thickness andthe type of workout (e.g. hilly versusflat), foot-strike pattern, and runningseason (i.e. cross-country versustrack) and risk of injury.

symmetry deficits identified inmeasures of hamstring muscle volume,quadriceps or hamstring strength, orflexibility. The diminished quadricepsvolume may represent an adaptivemechanism acquired post-injury.

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A 4-Mile Run Decreases AchillesTendon Thickness And Cross-Sectional Area In CollegiateFemale Cross-Country RunnersMyrer JW, Neves KA, JohnsonAW, Hunter I, Neves C, Bridges J:Brigham Young University, Provo,UT

Context: Recently, there has beeninterest in using ultrasound imaging oftendons and muscles to assess injuryand recovery. In runners, the Achillestendon is the most frequently rupturedtendon. Individuals suffering Achillestendon rupture are often physicallyactive with high rates of sportsparticipation pre-injury. It is importantto understand the effects of running onAchilles tendon thickness to betterunderstand injury risk and to developtraining protocols. Objective: Toinvestigate acute changes in Achillestendon thickness and cross-sectionalarea in female cross-country runnersafter a 4-mile run compared to agematched non-runners. Design:Observational study. Setting: HumanPerformance Research Center.Participants: 12 female collegiatecross-country runners (age:19.3±1.5yrs, height:168.4±4.8 cm, weight:55.2±4.8 kg) and 7 non-running femalevolunteers (age:22.1±2.3 yrs,height:167.6±5.6 cm, weight: 67.1±13.3 kg). Intervention: The Achillestendon of 12 female collegiate cross-country runners and 7 non-runnerswere measured 8 cm from the plantarsurface of the calcaneus usingultrasound imaging (GE Logic e). Bothlongitudinal and transverse imageswere taken before and after a 4-miletraining run in the case of the crosscountry athletes and before and after a30-minute period in the non-runners.The non-runners refrained fromphysical activity during the periodbetween measurements. A mark wasplaced on the skin to ensure the sameportion of tendon was measured preand post-test. The ankle of the runnerswas maintained at a fixed position of

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Changes In Lower ExtremityBiomechanics During Single-Limb Forward Land FollowingConcussion In CollegiateFootball PlayersDuBose DF, Herman D, ConradBP, Tillman SM, Jones DL, PassAN, Moser MW, Farmer KW,Dominguez JA, Chmielewski TL:University of Florida, Gainesville,FL

Context: More than 300,000 sports-related concussions occur annually inthe United States. Alteredbiomechanics observed in gaitfollowing concussion may also existduring jump landings, which mayincrease risk of lower extremity injury.Objective: To examine changes inlower extremity biomechanics duringa jump landing in football players whosustain a concussion. We hypothesizedthat kinetics during a jump landingwould be negatively altered afterconcussion. Design: Pre-test/post-test study. Setting: Testing occurredin the Biomechanics and MotionAnalysis Laboratory at the UF&ShandsOrthaepedics and Sports MedicineInstitute. Patients or OtherParticipants: 13 male Division Ifootball players (age 20.4 ±1.3 years)that sustained a concussion during thecompetitive season. Interventions:Subjects performed a single-limbforward land on each side duringtesting sessions before and after thecompetitive season. Subjects jumpedfrom a 25.4 cm step, landed on a forceplate and held their position for 3seconds. Main Outcome Measures:Concussion history was collectedfrom athletic training records.Variables measured during the single-limb forward land included peakvertical ground reaction force(PVGRF), anterior-posterior stabilityindex (APSI, a measure of fluctuationsaround a 0 point along the sagittal axisof the force plate), time to peak force,and loading rate (PVGRF/time to

PVGRF). All variables except for timeto peak force were normalized to bodyweight (BW). Values from the right andleft limbs were averaged to obtain onemeasure per variable, per subject.Paired-samples t-tests were used todetermine differences in values of thepre- and post-season measures.Significance level was set at ˜=0.05.Results: Average time fromconcussion to post-season testing was75 ± 50.5 days. The APSI showeda significant increase (0.065 ± .004.versus 0.071 ± 0.007; p =0.026)and the time to PVGRF showeda significant decrease (67.5 ± 5.4ms versus 63.5 ± 6.6 ms; p = 0.005)from pre- to post-season testing.No statistical differences were foundbetween pre- and post-season valuesin PVGRF (3.5 ± 0.3 BW, 3.5 ±0.3 BW, respectively; p =0.572) orin loading rate (55.78 ± 7.25 BW/sec,52.7 ± 5.63 BW/sec, respectively;p=0.179). Conclusions: Followingconcussion Division I collegiatemale football players demonstratedan increase in anterior-posterior swayand a decrease in time to PVGRFduring a single limb forward land task.These results indicate poor posturalstability and reduced time to absorbimpact loading, which may increaserisk for lower extremity injury.Clinicians may need to incorporateneuromuscular training intoconcussion rehabilitation protocols.

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Comparison Of Trunk And HipStrength And FlexibilityBetween Pilots With AndWithout A Self-Reported HistoryOf Low Back PainNagai T, Abt JP, Sell TC, KeenanKA, Smalley BW, Wirt MD,Lephart SM: NeuromuscularResearch Laboratory, Universityof Pittsburgh, Pittsburgh, PA; USArmy School of Aviation Medicine,Fort Rucker, AL; Blanchfield ArmyCommunity Hospital, FortCampbell, KY

Context: Low back pain (LBP) is oneof the most common musculoskeletalissues facing military personnel, witha high prevalence reported inhelicopter pilots. Although several riskfactors (age, history of LBP, totalflight-hours, total night-vision goggleflight-hours) have been previouslyidentified, modifiable musculo-skeletal characteristics have not beeninvestigated in this population. Lesstrunk and hip strength and flexibilityhave been previously observed inindividual with LBP in civilian studies.Objective: To compare trunk and hipmuscular strength and flexibility inpilots with and without a history ofLBP. It was hypothesized that pilotswith a history of LBP would exhibitless trunk and hip strength andflexibility than pilots without a history.Design: A cross-sectional design.Setting: University sports medicinelaboratory. Patients or OtherParticipants: A total of 62 pilots withat least 100 flight-hours (previous 12months), no current LBP, and nophysical training restrictions on theday of testing participated in this study.The 31 pilots (aircrafts: AH64=8,UH60=10, CH47=3, OH58=10) withLBP history (29 males/2 females, Age:31.5±5.9years, HT: 177.1±6.3cm, WT:84.4±11.3kg, total flight-hours:1293±1317hrs) were matched ongender, age (±5yrs), and total-flighthours (±500hrs) with pilots (aircrafts:AH64=8, UH60=11, CH47=3,

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1 3 1 6 5 D O N E

Effects of Arthrogenic MuscleInhibition On Sagittal PlaneKinetics And Kinematics DuringStair DescentMurray AM, Lepley AS, BahhurNO, Thomas AC, PietrosimoneBG: University of Toledo, Toledo,OH

Context: Arthrogenic muscleinhibition (AMI) is commonfollowing knee injury, resulting indecreased quadriceps activation andstrength. As a result, performingactivities that require increased demandon the quadriceps, such as stair descent,in the presence of AMI may lead toaltered lower extremity joint loading andchronic knee injury. The consequencesof AMI on joint loading and movementpatterns during stair ambulation have notbeen investigated. Objective:Investigate the effects of simulated AMIon knee biomechanics during stairdescent. Setting: Motion AnalysisResearch Laboratory. Design:Descriptive laboratory study. Patientsor Other Participants: Eighteenhealthy individuals (11M/7F;22.3±2.4yrs; 174.1±6.8cm; 71.8±8.1kg) participated. Interventions:Participants were outfitted with 26retroreflective markers and performedthree trials of stair descent at a self-selected pace on a custom built staircaseinstrumented with a force plate.Following baseline testing, 60mL ofsterile saline was injected into the kneejoint capsule of each participant throughan area supralateral to the patella. Tenminutes following effusion, participantsperformed posttest measurements.Voluntary quadriceps activation wasevaluated before and after effusion withthe central activation ratio (CAR) usingthe burst superimposition technique withthe knee in 90° of knee flexion toconfirm the presence of AMI. MainOutcome Measures: Peak internalknee extension moments (KEM),vertical ground reaction force (vGRF)and knee flexion angle (KFA) were

OH58=9) without LBP history (29males/2 females, Age: 31.5±5.9years,HT: 176.9±8.8cm, WT: 82.9±14.6kg,total flight-hours: 1291±1312hrs).Interventions: An isokineticdynamometer was used to evaluateisometric hip abduction and isokineticconcentric trunk flexion, extension,and rotation strength. A digitalinclinometer was used to measurepassive hip internal/external rotationand active lumbar spine flexion/extension, lateral flexion, and rotationflexibility. Paired t-tests or Wilcoxontests were used to compare betweentwo groups (p<0.05). Main OutcomeMeasures: Hip abduction and trunkflexion, extension, and rotationaverage peak torque were normalizedto body weight (%BW). The averageof three measures was recorded for hipinternal/external rotation and lumbarspine flexion/extension, lateralflexion, and rotation (°). Results: TheLBP group demonstrated significantlyweaker trunk extension strength (LBP:345.5±78.1%BW, non-LBP: 404.5±66.0%BW, p=0.004). The LBP grouphad significantly less trunk lateralflexion right (LBP: 21.5±4.1°, non-LBP: 26.4±4.6°, p<0.001) and left(LBP: 23.0±4.4°, non-LBP: 26.8±4.7°, p=0.005) and right rotationflexibility (LBP: 9.4±3.2°, non-LBP:11.4±3.9°, p=0.043). Conclusions:The current investigation revealedmusculoskeletal characteristics thatare associated with pilots with a self-reported history of LBP. For alliedhealth professionals working with amilitary population, identifyingmodifiable musculoskeletalcharacteristics associated withindividuals with LBP is essential fortreatment and prevention of LBP.Future studies are needed to confirmif these characteristics are predictiveof LBP and loss of duty days due tomedical leave. Additionally, furtherresearch on other modifiableneuromuscular factors (e.g. trunkproprioception, posture, and balance)

is warranted. Supported byUSAMRMC #W81XWH-11-2-0097

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collected through 3-dimensional motionanalysis and extracted from the first50% of stance phase, which wasinitiated once vGRF exceeded 10N. Allvariables were averaged across trialswith KEM normalized to participantbody (mass*height) and vGRFnormalized to participant body mass.Dependent t-tests were performed toassess the effects of AMI on peak KEM,vGRF and KFA. Alpha level was set apriori at Pd”0.05. Results: The presenceof AMI was confirmed with reduction inCAR following effusion (pre: 0.93±0.07; post: 0.88±0.10; t(17)=2.29,P=0.035). KEM (pre: 0.46±0.17Nm/kgm; post: 0.39±0.13Nm/kgm; t(17)=2.78, P=0.013) and vGRF (pre:12.16±1.67N/kg; post: 10.99 ± 1.42N/kg; t(17)=3.62, P=0.002) weresignificantly lower following effusionwhile KFA did not change (pre: 24.7±6.8°; post: 25.9±5.6°; t17=0.842,P=0.412). Conclusions: In thepresence of AMI, quadriceps activationis decreased and subsequently KEM andvGRF are lower during stair descent.These kinetic changes may be indicativeof participants attempting to decreaseloading of the effused knee secondaryto decreased quadriceps control. Thoughunexpected, it appears participantswere able to overcome quadricepsAMI and avoid po ten t ia l lyhazardous loading of the kneejoint. Future investigations maybenefit from inclusion of hip andankle biomechanics to betterunderstand these compensatorystrategies. Supported by funding throughthe Great Lakes Athletic Trainers’A s s o c i a t i o n .

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Free Communications, Poster Presentations: Education1 3 1 4 8 F O P E

Effects Of ContinuingProfessional Education OnEntry-Level CompetenceAmong Athletic TrainersBerry DC, Penny JM: SaginawValley State University, UniversityCenter, MI, and UniversityResearch Associates,Greensboro, NC

Context: To maintain the ATC®credential athletic trainers (AT) arerequired to complete mandatorycontinuing education (CE) within adefined time period because CE isconsidered vital to insuring clinicalcompetence and preventing outdatedpractice. Unfortunately, there is apaucity of evidence examiningwhether the accumulation of CEUsmaintains minimal professionalcompetency as determined by theoriginal Board of Certification (BOC)certification process. Objective: Todetermine whether mandatory CEmaintains entry-level competenceamong certified athletic trainers.Design: Prospective, cross-sectional,observational study. Setting: ATpractice settings. Participants:Convenience sample of 1,025 ATsfrom a solicitation of 9,789 who re-certified in 2010 and 196 ATs whosecertification lapsed (overall responserate was 10.3%). Participants werepredominantly female (61%) andCaucasian (91%). Average yearspracticing as AT was 10.2 years (±7.4);72% held a masters degree or higher.Interventions: An e-mail invitationwas sent to ATs recertifying in 2010and those who allowed theircertification to lapse. The invitationexplained the research project andasked participants to complete an on-line recertification assessmentadministered by Castle Worldwide(Raleigh, NC). The recertificationassessment was a retired form of theBOC Certification Exam used during2010-2011 published by CastleWorldwide under the BOC Role

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Variability In Clinical IntegrationAchieved By Athletic TrainingStudents Across DifferentClinical Sport AssignmentsDodge TM, Mazerolle SM,Bowman TG: Springfield College,Springfield, MA; University ofConnecticut, Storrs, CT; Lynch-burg College, Lynchburg, VA

Context: Clinical integration, definedas assimilation into the clinical portionof entry-level education, has beenshown to impact athletic trainingstudents’ (ATSs) professionaldevelopment, motivation andpersistence. However, research hasyet to elucidate the manner in whichdifferent clinical placements caninfluence clinical integration.Objective: Examine differences in thelevels of clinical integration achievedby ATSs across various clinical sportassignments. Design: Cross-sectional design utilizing aquestionnaire for data collectionpurposes. Setting: Thirteenundergraduate Athletic TrainingEducation Programs (ATEPs) in thesoutheastern United States located atNCAA division I institutions. Patientsor Other Participants: Question-naires were administered to 169 ATSsengaged in clinical educationexperiences. 129 ATSs completed thequestionnaire for a response rate of76.33%. The ATSs had completed anaverage of 4 ± 2 clinical rotations.Interventions: The 12-item clinicalintegration scale was developed by theresearchers following a review ofathletic training and other healthprofessions education literatureconcerned with clinical education andstudent retention. The questionnairewas reviewed by a panel of experiencedathletic training educators and piloted ona group of 11 recent ATEP graduates.The questionnaire was administered viaa combination of in-person and on-linemethods. Responses were scored on a6-point Likert scale (1 stronglydisagree-6 strongly agree). Participants

completed the 12-item questionnaire,rating clinical integration for each oftheir previous clinical rotations. MainOutcome Measures: Descriptivestatistics, including mean clinicalintegration scores (potential minimumscore of 12, maximum score of 72)were calculated for each clinicalplacement. One-way analysis ofvariance (ANOVA) was used to identifydifferences in clinical integrationachieved across clinical placements.Results: One-way ANOVA revealeddifferences in clinical integrationlevels achieved across various clinicalassignments F(19,415)=3.486,p<0.001. Students completing arotation with NCAA division I footballachieved the lowest levels of clinicalintegration (46.9±9.1). Other divisionI sports rated higher with averagesranging from 51.6±10.1 (baseball) to57.8±4.5 (lacrosse) with less anxietyand time wasting reported thanfootball. The high school rotationrated highly as well (54.7±6.4) withhigher levels of learning reported andfewer concerns about anxiety,excessive hours and wasting time.Conclusions: There were cleardifferences in clinical integrationachieved among sites. In particular,ATSs completing clinical rotationswith NCAA division I football reportedthe lowest levels of clinicalintegration. These low levels ofintegration stemmed from feelingsof wasting time during clinicaleducation, completing menial tasks,excessive hours and anxiety associatedwith the educational experience. Asclinical integration is relatedto student motivation and eventualpersistence, matching students toappropriate clinical sites seemsas important as matching ATS andpreceptor characteristics. Futureresearch should continue to focuson identifying clinical site specificcharacteristics that not onlyhinder integration but also thosethat facilitate integration.

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Delineation Study 5th Edition. Ashortened version of the original 175-item exam, the assessment contained125 scored, multiple-choice items andnot the 50 field test items normallyincluded. Castle conducted arecertification assessment standardsetting meeting where nine panelists(ATs) set two passing levels (proficient,advanced) for the recertificationassessment. One-way ANOVAs (˜=0.005 to control experiment-wise error)were performed to investigate betweengroup assessment scores. MainOutcome Measures: Inde-pendentvariables included highest degree androle. Dependent variables includedrecertification exam scores, individualdomain scores and items considered tobe predominantly measuring recall,application, and synthesis. Results:Recertification assessment scoresranged from 15-117; mean was 88.6(±12.7). Converted to percentagecorrect, the average was 70.9% (range12%-94%). Twenty-nine percent of ATscompleting the assessment passed at theproficient level, 4% at the advancedlevel. Significant differences(F

4,965=21.46, P<0.001) existed between

ATs with a doctorate (94.92±9.59) andATs with a Masters in athletic training(92.48±11.28) versus all othereducational levels: ATs with a non-ATMasters (88.50±12.51), ATs with aBachelors-non-AT major (83.25±14.33), and ATs with a Bachelors-ATmajor (83.77±11.76). Significantdifferences (F

2,568=18.40, P<0.001)

existed between educators (97.75±11.39), practicing ATs (88.62±11.47), andadministrators (83.64±15.38). Conclu-sions: Results suggest that many ATs arenot maintaining a “proficient” level ofcompetence as measured by thisassessment. A paradigm shift may bewarranted to address how CE isdelivered and measured. Shifting fromattendance (seat-time) based CE toimproved pre-defined learningoutcomes with post-testing and/orassessment of patient outcomes usingnewly learned skills might be options.

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The Relationship BetweenCandidate PsychologicalFactors And First-Attempt PassRate On The Board OfCertification ExaminationBreitbach AP, Downey DL, FragerA: Saint Louis University, St.Louis, MO, and Austin HighSchool, Austin, MO

Context: Success on the Board ofCertification (BOC) examination isnecessary for persons who wish toobtain the Certified Athletic Trainer(ATC) credential. BOC exam firstattempt pass rates have historicallybeen an issue in athletic training (AT).Objective: The purpose of this studyis to examine the impact of coping,locus of control and academic worryon first attempt passing rates of theBOC exam. Study strategies for theBOC exam were also addressed in thestudy. Design: Cross-sectionalSurvey-based Design. Setting:Subjects were recruited through emailssent to CAATE Accredited Entry-LevelProgram Directors, which wereforwarded to recent programgraduates who accessed the surveyinstrument on-line. Participants: Theresearch sample consisted of 145newly graduated AT students, whoreported they took the BOCexamination from April to October,2010. Interventions: The surveyinstrument included three sections ofitems used to measure the elements oflocus of control, method of coping andacademic worry. Analysis wasperformed showing the relationshipsbetween the scores on these factorsand first attempt pass rate on the BOCexam. Main Outcome Measures:The dependent variable for this studywas the first-attempt pass rate on theBOC exam. Participants were asked toself-report if they passed and howmany attempts they had on the BOCexam. Independent variables in thestudy include coping, locus of controland academic worry. Results:Emotion focus coping scores

significantly correlate with locus ofcontrol (r= -.262, P = .001) andacademic worry scores (r= .307, P <.001). Academic worry had asignificant relationship with emotionfocus coping scores (r= .307, P <.001) and locus of control (r= -.229,P = .006). Locus of control correlatedwith emotion focus coping (r= -.262,P = .001) and academic worry (r=-.229, P = .006). The results of thelogistic regression analysis suggeststhat the full model significantlypredicted passing on the first attempt(˜2 (4) =15.346, p=.004). The resultsof the t-tests indicate that comparedto those who pass the test on the firstattempt, those who did not pass on thefirst attempt had significantly differentscores on the Emotion-FocusedCoping Scale (p= 0.024), locus ofcontrol (p= 0.002), and AcademicWorry (p= 0.026). Conclusions: Datafrom this study suggests thatpsychological factors such as highacademic worry, emotion focusedcoping and an external locus of controlhave a lower first attempt pass rateon the BOC examination. These dataalso suggest that students who passon the first attempt are more likely touse multiple strategies to prepare forthe exam. Professional preparationshould address psychological issuessuch as academic worry, locus ofcontrol and coping skills along withmultiple study strategies andstructured preparation activities.

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Learning Styles OfUndergraduate Athletic TrainingStudents In A CAATE-AccreditedAthletic Training EducationProgramReyes AD, Swanik CB, Knight CA,Kaminski TW: The University ofDelaware, Newark, DE

Context: Assessing preferences andperceptions about the athletic training(AT) learning environment may assistprogram directors to enhance theirstudent’s educational experience andoverall retention of knowledge.Objective: The purpose of this studywas to identify and evaluate learningstyles of undergraduate AT students anddetermine if there is a learning styleprofile that translates into admissionacceptance and success on the Boardof Certification (BOC) examinationfor athletic trainers. Design:Prospective, cohort. Setting:Classroom. Participants: Threehundred and fifteen (110M, 205F)college students (18-25yrs.) between2004-2012 were tested. All studentswere enrolled (or seeking enrollment)in a CAATE accredited athletic trainingeducation program (ATEP) at a mid-sized Division-I institution.Interventions: The Kolb LearningStyles Inventory (LSI) is a 12 questionsurvey that describes the way we learnand deal with day-to-day situations.Athletic training interest (ATI)students are administered the LSI aspart of their orientation activitiesannually. Students who are acceptedinto the ATEP and matriculate throughthe program repeat the LSI during theFall semester of their final year. Pass/fail rates from the BOC exam werederived as students completed theATEP. Main Outcome Measures:Concrete experience (CE), activeexperimentation (AE), reflectiveobservation (RO), and abstractconceptualization (AC) cycles oflearning were analyzed and used tocompute an overall learning style(accommodator, diverger, converger,

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Civic Professionalism: TheImpact Of Service Learning OnThe Professional DevelopmentAnd Values Of First Year AthleticTraining StudentsKlossner J, Tarzon M, DochertyCL, Grove KA: Indiana University,Bloomington, IN

Context: While research supports thevalue of service learning (SL) in highereducation including health careprofessional preparation programs,research specific to the efficacy of SLin athletic training education islacking. Furthermore, the value ofcivic professionalism is discussed innursing and medicine, yet there hasbeen no such discourse in athletictraining. Objective: The purpose ofthis study was to identify ways in whichdirect service learning influenced theprofessional development and valuesof first year athletic training students(ATS) through a framework of civicprofessionalism. Specifically,research questions included: 1) In whatways do ATS view civic responsibilitybefore and after a direct servicelearning experience? 2) What specificinteractions and/or experiencesinfluence the professionaldevelopment and values of ATS? 3) Inwhat ways do ATS develop a growingsense of civic professionalism or otherprofessional values? Design: Basicqualitative content analysis based onScholarship of Teaching and Learningmethodological framework. Setting:Undergraduate athletic trainingclassroom as well as service learningwithin a community-based free clinic.Patients or Other Participants:Undergraduate ATS (sophomore level;n=19) enrolled in A283 – GeneralMedical Issues in Athletic Trainingwere purposively recruited. All of thestudents, 9 male and 10 females,volunteered to participate. Participantages ranged from 20-25. DataCollection and Analysis: Datacollection included reflective groupinterviews, semi-structured cohort

interviews and individual pre, mid andpost-service reflective journals. Wecollected and analyzed data throughconstant comparative analysis. Wealso used methodologicaltriangulation, member checks and peerdebriefing to ensure trustworthiness.Results: Themes such as civicprofessionalism and social awarenessemerged as ATS interacted withpatients of various socioeconomicbackgrounds and recognized the rolethey could play to help the community.Direct SL experiences also facilitatedprofessional socialization asinteractions with health careprofessionals reinforced studentvalues and professional behavior. Inaddition, authentic experiencesfacilitated self-efficacy in the ATS’developing professional role. Roleconfusion existed in some instancesas roles and responsibilities in theservice setting were not consistentwith duties of the athletic trainer asstudents understood them.Conclusions: Service learning isbeneficial to the development of ATS.Findings suggest Athletic TrainingPrograms (ATP) should emphasizeservice learning and civicprofessionalism within theircurriculum. ATP may wish to exploredifferent service settings whichare more consistent with rolesand responsibilities of athletic trainersand/or integrate the value of servicelearning throughout the ATPcurriculum so students more fullyappreciate the value of civicprofessionalism. Further researchshould also explore perceptionsof the community partner, differentservice learning models, and thevalue the profession placeson community service.

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assimilator). Learning styles from thefirst year were compared to programadmission status (yes/no), whilelearning styles from the final year werecompared to success on the BOC exam(pass/fail) using chi-square analysis.Results: To determine learning style,combined scores from the cycles oflearning are plotted on a grid.Combined learning ability scores(means±SD) for the first year oftesting were, AE-RO (7.3±10.8) andAC-CE (2.9±9.9); while those scoresin the final year were AE-RO(8.8±10.0) and AC-CE (7.2±10.1).The dominant learning style was anaccommodator (31%) for the firstyear and a converger (39%) for thefinal year. There was a significantassociation between learning style andacceptance into the program (X2(3,n=281) =12.057, p=0.0072). Theodds of a converger being acceptedwere 2.44 times higher than any otherlearning style. There was not asignificant association betweenlearning style type and success on theBOC exam (X2(3, n=92) =5.525,p=0.137). Conclusions: A convergeris defined as a learner who focuses onAE and AC cycles of learning andtherefore prefers practicalapplications of knowledge. As ATstudents progress in ATEPs, practicalapplications of their classroomexperiences become crucial forachieving success. Enhancing ways tostrengthen these students’ learningexperience in the clinical setting mayprepare them more effectively forsuccess in the profession as entry-level athletic trainers. Finally, BOCexam success does not appear to belearning style dependent.

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Mental Health Issues inIntercollegiate Athletes: ClinicalAnd Educational ImplicationsLaRue MJ: University ofWisconsin-Eau Claire, EauClaire, WI

Context: Currently, limited statisticsare available regarding the incidence,recognition and treatment ofpsychiatric conditions in collegestudent-athletes1. A University ofMinnesota study2 indicated that 25.1%of college students had been diagnosedwith a mental health condition in theirlifetime; therefore, it is probable thatstudent-athletes are experiencing theseconditions at similar rates. This studyexplored what mental health issuescertified athletic trainers encounteredin student-athletes with whom theywork and how the referral process wasmanaged. It also explored whethercertified athletic trainers felt theireducational background prepared themto manage these conditions. Design:An interpretive phenomenologicalanalysis was conducted. Setting:Participants were employed in theuniversity setting and currently workedwith intercollegiate athletes.Participants: Popcorn sampling of 18certified athletic trainers with aminimum of five years’ experience inthe intercollegiate setting wereinterviewed. Eight females and tenmales representing all regions of thecountry and all NCAA divisionsparticipated. Data saturation guided thetotal number of participants chosen forthis study. Data collection andAnalysis: Semi-structured interviewswere conducted and transcribedverbatim. Interview guides wereutilized and additional probingquestions were posed as conceptsemerged. Analysis was conductedusing NVivo software. Trustworthinesswas established via credibility,transferability, dependability andconfirmability through prolongedengagement, persistent observation,member-checking, peer debriefing and

an audit trail. Results: Positive factorsimpacting referral were performancedeclines, personal experiences,knowledge of comorbidity,convenience of Division I resources,cost and convenience of campuscounseling centers, confidentiality andsupportive coaches’ influence.Negative factors which hinderedrecognition and referral were lack ofconfidence, coaches’ detrimentalinfluence, Division III resources,campus counseling location,confidentiality and emotional impact.Participants encountered mentalhealth issues in their student-athletesranging from anxiety and depressionto substance abuse and disorderedeating. Referral resources rangedfrom team physicians andneuropsychologists to emergencyroom physicians. Certified athletictrainers felt their educationalbackground did very little to preparethem to recognize and refer mentalhealth issues in their student-athletes,however practical experiencesassisted them in gaining thisknowledge. Conclusions: Educationalimplications should includeincorporation of mental healthintervention and referral discussionsthroughout the curriculum. Speakerssuch as student-athletes, psychiatrists,psychologists and other mental healthprofessionals should be utilized inrelevant courses. Clinically, athletictraining staffs should develop contactlists of area mental healthprofessionals and facilities andincorporate a psychosocial componentto pre-participation exams. Mentalhealth professionals should beeducated on the intricacies ofintercollegiate student-athletes andthe role of athletic trainers. Staffsshould also have in-service training onintervention and referral techniques,as well as setting proper boundaries.

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Post-Professional GraduateStudents’ PerceptionsConcerning The CompetenciesWithin The Commission OnAccreditation Of AthleticTraining Education ProgramsVan Lunen BL, McCarty CW,Hankemeier DA, Bay RC: OldDominion University, Norfolk, VA;A.T. Still University, Mesa, AZ; BallState University, Muncie, IN

Context: Post-Professional athletictraining (PPAT) programs will beimplementing six competencieswithin their programming, which arecurrently assessed within otherhealthcare professions. Students’ levelof ability in these competencies needsto be assessed. Objective: Todetermine PPAT students’ perceivedabilities, importance, andpreparedness to implement conceptsof the six educational competencieswithin their clinical practice. Design:Cross-sectional design. Setting: Self-reported paper survey. Participants:202 of 258 PPAT students (78.29%)completed the survey (74 males, 128females, age=23.32±2.10yrs).Participants included 95 first-yearstudents, 91 second-year students, and16 students from a one-yearprogram.Interventions: Participantscompleted the survey in the Fall of2012. The survey consisted of threesections for each identifiededucational competency: qualityimprovement(QI), professionalism(PROF), healthcare informatics(HCI),interdisciplinary collaboration(IDC),evidence-based practice(EBP), andpatient-centered care(PCC). Threescales were used for eachcompetency: 1) participants rated theirability to incorporate concepts of eachcompetency within clinical practice,2) participants identified howimportant they perceived each conceptto be for implementation within theirclinical practice, and 3) participantsreported how well they perceived theirprofessional undergraduate athletic

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Student Athletes Have PoorerSleep Compared To StudentsAt The Same UniversityChicoine N, Onofrio MC, DoverGC: Concordia University,Montreal, QC

Context: Sleep is important forathletes and students and can affecttheir performance while attendinguniversity. However, there is a paucityof information on objective sleepmeasures in athletes. Objective: Tocompare subjective and objectivesleep measures of student athletes andstudents enrolled at the sameuniversity. Design: Two groups,repeated measures design. Setting: Allsleep measurements occurred at eachsubject’s residence. Participants:Thirteen healthy students from theuniversity population (5 males and 8females, height = 171.9 ± 9.1 cm, mass= 69.5 ± 9.2 kg, age = 21.3 ± 1.9 years)and 36 healthy male athletes from theuniversity population (12 hockeyplayers, 24 football players, height= 183.3 ± 5.8cm, mass = 95.2 ± 17.7kg, age = 21.3 ± 1.9 years)volunteered for this study.Interventions: All subjectscompleted a self report evaluation onsleep including the: SF-12,Pittsburgh Sleep Quality Index(PSQI), Epworth Sleepiness Scale(ESS), and received the Pittsburghsleep diary and Actiwatch Score(AS). All athletes wore the ActiwatchScore during a 5-day period in thecompetitive season and studentswore the AS during the semester.Both groups completed the sleepdiary every night before going to bedand every morning upon awakeningrecording bed and wake times andsubjective sleep information. One-way ANOVA’s and paired sample t-tests were used to analyze sleepefficiency (SE), total sleep time(TST), wake after sleep onset(WASO), sleep quality, fatigue uponawakening, and alertness uponawakening ( ˜=0 .05) . Main

Outcome Measures: Objectivesleep measures were calculated fromthe raw actigraph data and subjectivesleep measures were recorded fromthe diary. Results: There was asignificant difference betweengroups for sleep efficiency (SEathletes= 79.3%± 5.9; students=88.2% ± 3.0; p< .001) and WASO(WASO athletes= 105.9 min ± 36.3;students= 56.2 min ± 17.2; p< .001).There was no change in total sleeptime between the athletes andstudents. In addition, there was asignificant difference in bed timevariability between football playersand students (football players = 74min± 33min; students= 40min ±32min; p=.023). Moreover, therewas a significant difference in waketime between football players andstudents (football= 09:18:47 am±01:07:52; students= 08:00:00 am±00:45:35; p< .001). In addition,athletes had a higher ESS scorecompared to students indicating theyhave more daytime sleepiness(athletes= 7.9±3.6; student=4.8±2.7; p= .029). Conclusions:Athletes have poorer sleep com-pared to students at the sameuniversity. The variability in theathletes’ bed time suggests thatthe full schedule of the studentathlete might compromise theirability to get the proper amount ofsleep. Considering the amount ofresources spent on coaching andconditioning, more studies areneeded to address athletes sleepsince it could affect performance.

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training program (ATEP) had preparedthem for each concept. Each conceptdescribed an ability that was related tothe definition of the competency.Reliability for each scale was found tobe extremely high: ˜

ability=.955,

˜importance

=.967, ˜preparedness

=.971. MainOutcomes Measures: The surveyconsisted of Likert-scale items(range1-4) and the number of conceptstatements ranged from 8-18 for eachcompetency. Composite ability,importance, and preparedness Likert-scale scores were achieved bytabulating all values and then averagingthe scores back to the Likert scale.Higher scores indicated thatparticipants perceived themselves tohave greater ability, that the conceptswere more important forimplementation in clinical practice,and that they perceived themselves tobe more prepared. Descriptivestatistics (means, standard deviations,percentages) were reported andbetween-group differences werecalculated using Mann-Whitney Utests (P<.05). Results: Overall,participants reported they “agree” theywere able to implement the conceptsof the competencies into their dailypractice (QI=3.28/4.0±0.32, PROF=3.46/4.0±0.29, HCI=2.92/4.0±0.43,IDC=3.15/4.0±0.44, EBP=3.32/4.0±0.35, and PCC=3.20/4.0±0.37),and perceived the concepts involved inthe QI(3.66/4.0±0.29), PROF(3.75/4.0±0.28), HCI(3.41/4.0±0.44),IDC(3.65/4.0±0.34), EBP(3.64/4.0±0.36), and PCC(3.61/4.0±0.36)competencies to be “moderatelyimportant” to “extremely important”for implementation. While theyperceived their professional ATEPs“moderately prepared” them for theQI(3.18/4.0±0.41), PROF(3.36/4.0±0.39), IDC(3.13/4.0±0.53),EBP(3.18/4.0±0.49), and PCC(3.14/4.0±0.49) competencies, 57% ofparticipants reported they felt“minimally prepared” regarding HCI.Second-year students perceivedthemselves to have greater ability

regarding the PROF(M1styear

=3.41/4.0±0.29, M

2ndyear=3.53/4.0±0.27,

U=3331, p=.007) and EBP(M

1styear=3.26/4.0±0.31, M

2ndyear=3.40/

4.0±0.37, U=3244, p=.006)competencies than first-year students.Conclusions: Although PPAT studentsare implementing the sixcompetencies within their clinicalpractice, improvement occurs whileenrolled in PPAT programs. Furtherresearch is needed to determine whichfactors affect changes in competencyimprovement within professional andpost-professional programming.

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Perceptions Of Athletic TrainersAnd Athletic DirectorsRegarding UIL Anabolic SteroidTestingCreinin K, Vela L, McDonald J,Awoniyi S: Texas State University,San Marcos, TX, and EdgewaterHigh School, Orlando, FL

Context: Texas Senate Bill (SB) 8mandates random anabolic steroidtesting of high school athletes toimprove athlete health and safety whilecosting the state $500,000 to 1million dollars a year. No knownresearch has been conducted on theperceptions of the program by keypersonnel enforcing the policy.Objective: To assess the perceptionsof Texas athletic trainers (ATs) andathletic directors (ADs) regarding thepurpose, effectiveness, and necessityof the current program. Design: Crosssectional survey. Setting: An internet-based survey with a six-week windowand a 2-week and 4-week invitationreminder. Participants: We randomlyselected 900 ATs and 1,020 ADs toparticipate. ATs were all certified orassociate members of D6 employed inhigh school or clinic outreach settings.ADs were identified from the 2011-2012 Texas Sports Guide of HighSchools and Colleges. Interventions:A survey with 24 Likert-style and 8demographic questions was developedwith 2 content-matter experts (anexpert in health legislation and aresearcher of anabolic steroid useamong adolescents). Three ATs andthree ADs were interviewed to assessface validity. The survey addressedperceptions in four areas: 1.) purposeof mandatory anabolic steroid testing,2.) effectiveness of mandatoryanabolic steroid testing and anabolicsteroid education programs, 3.)necessity of state regulated mandatoryanabolic steroid testing, and 4.)knowledge of Senate Bill 8. MainOutcome Measures: Dependentvariables were the endorsements forthe questions, which were classified as

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endorsed when the participant selecteda rating of “agree” or “strongly agree”.Results: 140 (15.6% response rate)ATs (87 males, 53 females) and 187(18.3% response rate) ADs (178males, 9 females) responded to thesurvey. ADs were fairly distributedthroughout Texas geographic locationsand school sizes. ATs were fairlydistributed throughout Texasgeographic locations, however mostrespondents were employed at a 3A orlarger school. A small number of ATs(21.5%) and ADs (31.6%) believe thatanabolic steroid testing, in general,is effective. A smaller number of ATs(19.3%) and ADs (28.6%) believedthat Texas mandated anabolic steroidtesting prevents anabolic steroid useamong high school athletes. Agreater number of ATs (49.3%) andADs (65.6%) believed adult lededucation programs were effective indeterring anabolic steroid use. Onlya small number of ATs (3.6%) andADs (2.7%) believe that the TexasLegislature should be responsible forregulating testing or educationprograms in high school athletics.Conclusions: ATs and ADs perceivethat anabolic steroid educationprograms are a more effectivedeterrent than random anabolicsteroid testing and recent researchevidence concurs with theirperceptions. Given recent researchfindings and ATs/ADs perceptions,SB 8 should be re-evaluated.Changes could increase thepracticality and effectiveness of asteroid prevention program byredirecting funding to evidence-based steroid education programs.

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Free Communications, Poster Presentations: Therapeutic Intervention1 3 3 1 8 F O N E

Graded Talocrural JointMobilization Does Not AlterCortical Motor Excitability OfThe Soleus In Individuals WithChronic Ankle InstabilityGrindstaff TL, Morton SK, DolanN, Pietrosimone BG: CreightonUniversity, Omaha, NE, andUniversity of Toledo, Toledo, OH

Context: Ankle joint mobilization caninfluence lower extremity spinalreflex excitability in individuals withchronic ankle instability (CAI). It ispossible that changes in cortical motorexcitability occur in conjunction withchanges in spinal reflex excitability. Itis unknown if a higher intensity jointmanipulation (Grade V) has a moreprofound effect at altering corticalmotor excitability than a lowerintensity mobilizations (Grade IV).Objective: To determine the effectsof talocrural joint manipulation ormobilization on cortical motorexcitability of the soleus in individualswith CAI. We hypothesize that theGrade V mobilization will result in agreater increase in cortical motorexcitability than the Grade IVmobilization and there will be nochange following a sham intervention.Design: Randomized crossoverdesign. Setting: University researchlaboratory. Patients or OtherParticipants: Twenty-eight parti-cipants (age=22.7±2.9 y, height=173.9±9.1 cm, mass= 72.6±14.0 kg)volunteered for this study. Allparticipants had CAI which was definedas repetitive episodes of instabilityand quantified by scoring less than85% on the Foot and Ankle MobilityMeasure Sport subscale or at least 3on the Ankle Instability Instrument.Participants also demonstrated at leasta 5° deficit in ankle dorsiflexioncompared to the contralateral ankle.Interventions: Participants receivedeach of the following interventions, ina randomized order, with at least 48hours between testing sessions;

talocrural joint manipulation (Grade V;maximum of 2 attempts), talocruraljoint anterior to posteriormobilization (Grade IV; 3 sets, 60oscillations), and a sham intervention(positioning similar to Grade IV).Cortical motor excitability of thesoleus was determined by measuringthe amplitude of a motor evokedpotential (MEP) following transcranialmagnetic stimulation. The intensitywas set at 120% active motorthreshold with five MEPs obtained.Maximal muscle response (M

max) was

determined by delivering apercutaneous electrical stimulus, withincremental increasing intensity, to thetibial nerve and measuring the maximalpeak-to-peak amplitude of the muscleresponse with three measures obtained.Main Outcome Measures: Theaverage peak-to-peak amplitude of theMEP normalized to M

max (MEP/M

max

ratio) and expressed as a percentagewas used for data analysis. A two-waymixed model ANOVA was used tocompare changes in soleus MEP/M

max

ratio between interventions over time(pre/post intervention). Results:There were no significant differencesbetween groups when examiningchanges in soleus MEP/M

max ratio

(F2,58

=0.16, P= .86) (Grade V Pre=2.71±1.10%, Post= 2.64±1.34%;Grade IV Pre= 2.83±1.37%, Post=2.52±0.98%; Sham Pre= 2.65±1.19%,Post= 2.44±0.94%). Conclusions:Talocrural joint mobilization (Grade Vand IV) did not alter cortical motorexcitability of the soleus individualswith CAI. Although talocrural jointmobilization has previously beenreported to improve outcomesassociated with CAI, the mechanism ofeffectiveness may not involve changesin cortical motor excitability.

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Shoulder Kinematics In EliteVolleyball Players Following AFull Season Of PlayBrewer ME, Tucker WS:University of Central Arkansas,Conway, AR, and SMART SportsMedicine Center, Cheyenne, WY

Context: Changes to the shouldercomplex, such as postural impairment,muscle length and scapular dyskinesis,have been associated with shoulderinjuries in overhead athletes. It isunknown if changes in scapularkinematics are normal as a result ofparticipating in a full season of anoverhead sport regardless of thepresence of shoulder injury.Objective: To compare pre-seasonand post-season scapular upwardrotation (SUR), anterior scapularposition (ASP), glenohumeral internalrotation (IR) and glenohumeralexternal rotation (ER) in elitevolleyball players. Design: Withinsubject. Setting: Controlledlaboratory. Patients or OtherParticipants: Sixteen femalecollegiate volleyball athletes wererecruited. Fourteen (18.9±1.1 y,174.9±5.8 cm, 70.7±10.2 kg)completed a full volleyball season andwere included in the study.Interventions: Static SUR wasmeasured at rest, 60ˆ, 90 and 120 ofhumeral elevation in the scapular planewith an electrical inclinometer.Anterior scapular position wasmeasured using the pectoralis minorlength test. With the participant in asupine position, the distance incentimeters from the table to theposterior aspect of the acromionprocess was measured with a modifiedtriangle. For IR and ER, participantslaid in a supine position with theshoulder abducted to 90 and the elbowflexed to 90ˆ. Maximum passive IRand ER were measured with a digitalprotractor placed in-line with theolecranon process and ulnar styloidprocess. For each kinematicassessment, three trials were

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were randomized and disinfected usingone of three treatments (dishdetergent/cold water, Colgate Total®toothpaste, UVC-light). Thedisinfected devices were swabbed,planted (SBA), and incubated for 24hours. In phase-4, the two sets of 30plates were evaluated for colonycounts and appearance. Theindependent variable was treatmentgroup. Bacterial colony growth andcount were dependent variables. MainOutcome Measures: Colony growthstoo numerous to count (TNTC) weredefaulted to the minimal thresholdlevel of 300. Data was analyzed withdescriptive statistics, and a repeatedmeasures ANOVA (group X time[initial, post-24, post-disinfectedswab]) set a priori at 0.05 using SPSS20.0 Results: A repeated measuresANOVA revealed a significant maineffect for time (F

2,54=23.8, P < 0.001)

on normal mouth flora colony counts.All groups decreased bacterial growthfrom initial swab (260.0±103.7), topost-24 (168.3±139.2), to post-disinfected (100.8±110.4). Resultsrevealed no significant interaction orgroup main effect. In post-disinfectedswabbings, 100% of toothpaste, 81.8%dish detergent/cold water, and 77.8%UVC-light had growth. Majority oforganisms were normal flora; however,opportunistic bacteria accounted for50%, 33.3%, and 18.2% of the growthin the toothpaste, UVC-light, and dishdetergent/cold water treatment groups,respectively. Conclusions: If un-sanitized, mouthguards may be apossible vector for bacterial growth.Of the three interventions, dishdetergent/cold water appeared to bethe more effective in reducing theopportunistic bacterial growth.However, more research is warrantedon a larger sample size.

performed and averaged on theserving dominant arm prior to thestart of the pre-season (pretest) andrepeated within one week after thefinal match (posttest). The order ofkinematic assessments wasrandomized. The independentvariable was time (pretest andposttest) . Main OutcomeMeasures: The dependent variableswere the mean measurements forSUR at rest, 60ˆ, 90 and 120ˆ, ASP,IR and ER. The influence of time foreach dependent variable wascompared using paired samples t-tests with an adjusted alpha level(p<0.007). Results: There were nosignificant differences for SUR atrest (t

13=0.270; P=0.791) within the

pretest (3.1±3.9°) and posttest(2.9±3.9°), 60 ( t

13=-1.326; P=

0.208) within the pretest (9.1±3.6°)and posttest (10.3±4.9°), 90 (t

13=-

1.426; P=0.177) within the pretest(22.1±4.6°) and posttest (23.8±4.4°)a n d 1 2 0 ˆ ( t

13=-0.859; P=0.406)

within the pretest (36.7±6.8°) andposttest (37.9±5.0°). There were nosignificant differences for ASP( t

13=1.760; P=0.102) within the

pretest (5.8±1.1cm) and posttest(5.5±1.3cm), IR ( t

13=-1.117;

P=0.284) within the pretest(67.3±8.2°) and posttest(69.1±10.9°) and ER (t

13=-1.921;

P=0.077) within the pretest(136.1±10.7°) and posttest(139.7±9.1°). Conclusions:Participation in a full volleyballseason does not appear to changeSUR, ASP, IR and ER in eli tevolleyball players. Clinicians shouldconsider these results whencomparing physical examfindings before, during and after aseason. Future research shouldinvestigate the shoulder kinematicsof overhead athletes over thecourse of multiple seasons.

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Effectiveness Of Three-Sanitation Techniques OnBacterial Growth On AthleticMouthguards After ActivityMcLeod RL, Katch RK, ReinboldKE, Taylor ST, Berry DC, CastilloKH: Saginaw Valley StateUniversity, University Center, MI

Context: Observations during sportingevents suggest that athleticmouthguards (device) are commonlydropped in the dirt/mud, storedimproperly in dark, warmenvironments, and placed in areas onthe body and equipment that areunhygienic. These potentially “dirty”devices are then placed directly backinto the athlete’s mouth. Objective:Determine the degree ofcontamination on athletic mouthguardsafter routine use, and to evaluate theefficacy of three different disinfectingmethods in reducing bacterialexposure to collegiate athletes.Design: Cross-sectional, repeatedmeasures. Setting: Football practicesetting and microbiology laboratory.Participants: A convenience sampleof 30 collegiate male football players(age=20.4±1.4; height =187.6cm±9.5cm; mass= 109.2kg±21.9) freeof recent history of oral/dentaltrauma. Interventions: The studyconsisted of four phases. Phase-1,participants fabricated a “boil and bite”mouthguard following manufacturerecommendations, and then wore thedevice for one 2 1/2 hour practice.Phase-2, devices were collected post-practice, placed in labeled, quart-plastic bags (preventing crosscontamination), and delivered to themicrobiology lab. The devices wereaseptically swabbed and planted onsheep blood agar (SBA) plates, andincubated at 37ˆC for 24 hours.Devices were returned to the plasticbag, placed in a “sports” bag, and storedat 23°C for 24 hours. After 24 hours,the devices were again swabbed,planted (SBA), and incubated for 24hours to begin phase-3. The devices

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Prevalence Of StaphylococcusAureus And MRSA In AndAround A Therapeutic WhirlpoolIn College Athletic TrainingRoomKahanov L, Eberman LE, YoungK: Indiana State University TerreHaute, IN

Context: Community-associatedmethicillin resistant Staphylococcusaureus (CA-MRSA) has become aleading cause of skin and soft tissueinfection in the non-hospitalizedcommunity. Care for the athletes inathletic training rooms (ATR) isspecifically designed with equipmenttailored to the health care needs of theathletes; yet recent studies indicatethat CA-MRSA is still prevalent inathletic facilities and that cleaningmethods may not be optimal.Objective: To assess Staphy-lococcus aureus and CA-MRSAprevalence in and around whirlpoolsin the ATR. Design: Observation.Setting: Division I MidwesternUniversity. Parti-cipants: Student-athletes (n=109) consisting of 46men (42%) and 63 women (58%)from 6 sports, participated in thestudy. Main Outcome Measures:The study assessed the presence ofMRSA and Staphylococcus aureusin and around the whirlpoolstructures relative to the sports andnumber of athletes using thewhirlpools. Results: We identifiedStaphy-lococcus aureus in 22%(n=52/240) of the samples andMRSA in 0.8% (n=2/240) samples.Thirteen (22%) samples testedpositive for Staphylococcus aureusin the opening shift, seven (11%)from the pre-practice shift, and 32(28%) from the post-practice shift.Two (1.7%) samples tested positivefor CA-MRSA in the post-practiceshift from the drain and water. Overthe course of 15 days, we identifiedStaphylococcus aureus from drainson two days (13%), from the agitatorhead and turbine switch on one day

(7%), from the wood steps on 11days (73%), from the neoprene toecaps on 13 days (87%), from thewater on eight days (53%). We alsoidentified Staphylococcus aureusfrom drain and water on two ofthe days (13%). A statist icallysignificant difference existedbetween the number of athletes usingthe whirlpool and the presence ofStaphylococcus aureus in andaround the whirlpools (F

2,238=2.445,

p=0.007). However, Staphylococcusaureus was identified regardlessof the number of athletes usingthe whirlpool. We did not identifya significant relationship between thenumber of athletes whirlpool andStaphylococcus aureus/MRSAdensity (p=0.134). Conclusions:The identification of Staphylococcusaureus and MRSA throughout theday and 24 hours after closingcleaning procedures suggestswhirlpools and related structuresshould be cleaned and disinfectedregardless of number of athletesusing a whirlpool and on a routinebasis throughout the day. Accordingto CDC guidelines for environ-mental infection control in healthcare facilities-hydrotherapy tanksand pools, draining and cleaning ofthe whirlpool after each patient’s usewith EPA-registered products arerecommended. However, drainingand cleaning of whirlpools after eachpatient did not occur during datacollection, nor is i t traditionalpractice in a collegiate ATR.Transmission of the bacteria can bereduced by following the Center forDisease Control and Preventionrecommended cleaning anddisinfecting protocols. AthleticTrainers should use regis tereddisinfectants to sanitize sanitation allwhi r lpools be tween uses . KeyWords: C lean ing , Cente r fo rDisease Control and PreventionRecommendations, Sanitizing, Infection

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Using Implement Soft TissueMobilization Technique AndLaser To Treat LateralEpicondylitisDemchak TJ, Steppe E: IndianaState University, Terre Haute, IN

Background: A 42 year old femalesurgical technology studentcomplained of pain in her elbow aftercompleting surgical technologyexternship. Patient spent 6-10 hoursper day gripping instruments forsurgery. The patient reported pain overleft lateral epicondyle and noneurological symptoms in the hand orforearm. Palpation over lateralepicondyle increased pain as well asresisted wrist extension and ulnardeviation. Grip strength was 20 poundsfor the left hand and 40 pounds for theright hand; pinch strength was 25pounds bilaterally. DifferentialDiagnosis: Lateral epicondylitis, wristextensor strain. Treatment: Physiciandiagnosed patient with lateralepicondylitis. During the initialtreatment (8/7/2012) the patient‘sforearm and elbow were heated withan electric heating pad set at 126o Ffor 10 minutes. After heating thepatient receive Implement Soft TissueMobilization Technique (IASTM)treatment using three instruments for10 minutes over the flexor andextensor muscle groups and tendons,pronator terres, and around the rightelbow. Four strokes were usedincluding sweeping and fanning thearea to detect and treat fascialrestrictions, framing around the boneystructures and light brushing was usedover the lateral epicondyle to decreasepain. Fascial restrictions were mainlyfound in the flexor muscle group andpronator terres. After the treatment,the patient completed wrist flexion andextension stretches 3 x 30 secondswith arm fully extended. The patientwas then treated with Laser-stimulationset at super pulsed 25 W laser (905nm) 5-1000 Hz, 4 Infrared (660nm),

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Clinical Outcomes Of PlateletRich Plasma Injection InPatients With PatellarTendinopathy Following ACLReconstructionTaggart KE, Wilson JJ, Baer GS,McGuine TA: University ofWisconsin-Madison, Madison, WI

Context: Anterior Cruciate Ligament(ACL) reconstruction utilizing apatellar tendon autograft can causePatellar Tendinopathy (PT) in patients,leading to decreased function, inabilityto return to prior levels of activity, andreduced patient satisfaction post-operatively. In situations whereconservative treatment has notprovided pain relief, platelet-richplasma (PRP) injection has beenproposed as an additional treatment tohelp augment patellar tendon healingto alleviate pain and improve function.To date, little data exists thatdocuments changes in knee functionfollowing PRP injection for PTfollowing ACL reconstruction.Objective: Document changes in self-reported knee pain and function forpatients treated with singleintratendinous PRP injection for PTfollowing ACL reconstruction.Design: Prospective case series.Setting: Sports medicine clinic.Patients or Other Participants:Eleven patients (9 females, 2 males;average age = 19 ± 2.19 years) withchronic PT recalcitrant to multipleconservative treatments (physicaltherapy, NSAIDS, rest, iontophoresis)following an ACL reconstructionutilizing a patellar tendon autograft.Interventions: Each patient wasdiagnosed with PT and received anintratendinous PRP injection of theproximal patellar tendon. Injectionswere performed 34.8 ± 17.1 weekspost-ACL reconstruction. Each patientcompleted the 2000 InternationalKnee Documentation Committee(IKDC) at pre-injection and at 29.5 ±17.7 weeks post-PRP injection. MainOutcome Measures: The primary

outcome variable was the paireddifferences of IKDC scores (pre-injection to post-injection) for eachpatient assessed with the WilcoxonSigned-Rank Test (pd”0.05) andreported as the median (inter-quartile ranges [IQR]: 25th and 75th).A difference of 12 points in anindividual subject’s IKDC scoreindicates a significant change.Results: IKDC pre-injection valueswere (48.3 [44.3, 60.3) while post-injection values were (74.7 [52.9,82.8]). The post-injection scoreswere significantly higher (13.8 [1.1,33.0]) (p = 0.02). Seven (64%)patients showed significantimprovement in their IKDC scores,while four (36%) patients showed nosignificant change. Conclusions:PRP injection may be a viabletreatment option for patients with PTfollowing ACL reconstruction witha patellar tendon autograft .

for 5 minutes over the lateralepicondyle and forearm and 50 Hz for5 minutes over the cubital fossa toincrease blood flow to the elbow. Thepatient was instructed to perform wristflexion and extension stretches athome and ice as needed. During thesecond visit, two weeks later (8/23/2012), the patient reported pain haddecreased for 2 days after the firsttreatment, but had returned. The secondtreatment was the same as the firstheat, IASTM technique and stretching,however, the Laser treatment waschanged. The Laser treatment utilizedthe LASER Shower consisting of six50W Laser diodes (905 nm) and four25W Infrared diode (660nm)and thesettings were 5-250 Hz ( anti-inflammatory effects ) for 5 minutesover the lateral epicondyle and 50 Hzfor 5 minutes over the cubital fossa.The patient report her pain haddecreased when she left the clinic.Upon arriving at her third treatment (8/28/2012), the patient reported pain wasonly a 3/10. The patient received thesame treatment as last visit, and added50 repetitions of the followingexercises, wrist flexion and extensionwith 2 pounds and supination andpronation with a green flex bar. Anaddition laser treatment to decrease painwas added (1000 Hz for 5 minutes overthe C5-C6 nerve root). The patient wasiced using a commercial ice pack for 10minutes post exercise. The patientreported that she was pain free when sheleft. The patient came to her last visit on8/30/2012 and reported her elbow waspain free. She was treated with heat, wristflexion and extension stretches,exercises, and laser treatment asdescribed for the previous visit. Thepatient self discharged at the end of thevisit, therefore final grip strengthmeasures were not obtained.Uniqueness: Patient was pain free afteronly three treatments utilizing thecombination of IASTM and lasertreatments. Conclusions: Thecombination of IASTM and Laser areeffective in treating lateral epicondylitis.

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Osteo Chondral DefectSuccessfully Treated WithLASERSteppe E, Demchak TJ: IndianaState University. Terre Haute, IN

Background: A forty year oldfemale house wife presented to thefree rehabili tation cliniccomplaining right anterior medialknee pain. The patient was unable todetermine mechanism of injury. Painstarted one month prior to evaluationand increased with stair climbing andwashing the floors. The patient worea compression wrap for 1 monthprior to appointment, but it did nothelp. Pain level was 7/10 during theinitial evaluation. Palpation:Tenderness was noted anterior andmedial knee and thigh around theVMO insertion and medial femoralcondyle. Observation: No swellingin knee was observed. Knee ActiveRange Of Mot ion was wi th innormal l imi t s . Res i s ted rangemotion – Right knee Flexion 4/5pain; Extension- 4/5 pain, Leftknee Flexion 5/5, extension 5/5.The following ligamentous testswere nega t ive : Lachman’s ;Pos te r io r Drawer ; and Varus /Valgus . Wi l sons t es t fo rosterchondral defects of the kneewas positive and Thessaly’s testfor a meniscus tear was negative.Different ial Diagnosis: OsteoChondra l Defec t ; Subchondra lCys t . Treatment: X-Rayimpressions were a subchondralcyst versus osteochondral defectmedial femoral condyle; physiciand iagnosed as os teochondra ldefect. The patient was treatedfour times with low level laserover a 5 week period. The low levellase r used a LASER Showercons i s t ing of s ix 50W Laserdiodes (905 nm) and four 25WInfrared diode (660nm). Each daythe patient was seated on edge oftreatment table with her knee bentto 90o of flexion. She received a

5 minute treatment at 5-1000 Hzover the medial condyle and a 5minute 50 Hz treatment over thepopliteal fossa to increase bloodflow to the knee. Treatment 1 (7-10-12) Laser t rea tment p luscommerc ia l i ce pack for 10’ ;Trea tment 2 (7-17-12) Pa t ien treported her knee felt better for 2-3 days after initial laser treatment.However, the patient reported shere-injured her knee closing a dooron 7-16-12. Pain was great enoughto have the knee buckle (9/10). Thepatient reported a pain decreasedimmediately after laser treatment(6/10). Treatment 3 (8-7-12) Thepatient reported she only had painin the knee when she was notwearing the compression wrap,otherwise pain 0/10. Palpation ofmedial condyle did not elicit pain.Treatment 4 (8-14-12) The patientrepor ted knee Pa in 0 /10 evenwithout knee wrap. She stated thatthere was a s l igh t ache .Immedia te ly a f te r the l ase rtreatment the patient reported nopain or ache in the knee . Thepatient reported she was able toperform a l l ac t iv i t ies of da i lyl iv ing wi thout knee wrapped .Wilson’s test was negative andknee f lex ion and ex tens ionstrength was 5/5 bi-laterally. Thepatient discharged herself at thist ime . Uniqueness : Pa in l eve ldecreased significantly after onelaser treatment and was completelya l lev ia ted wi th jus t four lasertreatments over five weeks. Icewas applied during the initial visit,but not thereafter. Conclusions:LASER is a viable non-invasivet rea tment to reduce pa in andincrease function in patients withan os teo chondra l defec t .

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Deep And SuperficialQuadriceps Heating UsingContinuous ShortwaveDiathermy At Two Different DutyCyclesTrowbridge CA: The University ofTexas at Arlington, Arlington, TX

Context: Shortwave diathermy (SWD)has traditionally been delivered via adrum and large machine; however, newtechnology uses circumferentialsleeves and portable units to deliverenergy. SWD is used for heating deeptissue for pain relief, spasm reduction,and/or improvement in tissuecompliance; however, we still lack dataregarding the relationship of intensityand duration to treatment outcomes.Objective: To investigate the heatingof two continuous SWD (50% and100%) settings on both superficial anddeep tissue heating. Design: Withinrepeated measure crossover design.Setting: Controlled laboratorysetting. Participants: Twenty-fivemales (n=14) and females (n=11) (age= 25±5 years, mass = 80±16 kg, height= 174± 9cm, distal thigh skinfold =15.8±9mm) volunteered for study. Allhad no current injury involving theirthighs or knees. Interventions:Thermocouples were inserted intoboth distal and proximal vastus lateralismuscles using a 1.16 in and 1.88in 20gcatheter needle, respectively. Theproximal thermocouple was insertedto an absolute depth of ~4 cm from theskin surface (4.0±0.1cm) and the distalthermocouple was inserted 1.5 cmbelow the subcutaneous adipose layer(~2.3±0.4cm depth). The thermo-couple was interfaced through anIsothermex®. Two counterbalancedconditions using theRebound™continuous shortwave diathermy(CSWD) unit were comparedincluding (1) 50% duty cycle/35minutes and (2) 100% duty cycle/35minutes. The CSWD was delivered at13.1 MHz using standard thigh sleeve.Main Outcome Measures: Baseline

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Effects Of Applied Pressure OnIntramuscular TemperatureDuring Ultrasound TreatmentsKrasinski D, Thrasher A, MillerMG, Holcomb WR: WesternMichigan University, Kalamazoo,MI, and The University of SouthernMississippi, Hattiesburg, MS

Context: The magnitude ofintramuscular temperature increaseduring therapeutic ultrasound isdependent upon depth, frequency, andintensity. These variables have beenstudied widely. Another potentialvariable that could affect the rate oftemperature elevation is the pressurethat is applied to the transducer headduring application. Added pressurecould compress the tissue affectingdensity and the transmission ofultrasound energy. Little research hasbeen completed to determine theeffects of the amount of pressureapplied during therapeutic ultrasound.Objective: To determine the effectsof different applied transducerpressures on intramusculartemperature during an ultrasoundtreatment within the left triceps surae.Design: Crossover Clinical Trial.Setting: Human PerformanceResearch Laboratory. Participants:Convenience sample of thirteenhealthy, college-aged students (M=5,F=7, Height: 170.03±9.86 cm, Mass:71.96±16.2 kg, Skinfold: 12.79±5.5mm, Calf circumference: 35.5±6.9cm) free of lower leg injury for theprevious six months and no knowncontraindications to ultrasoundvolunteered to participate.Interventions: Three separate 3MHz,1.0W/cm2 ultrasound treatments wereadministered to the triceps surae,using weights on the transducer headof: 200 g, 600 g and 800 g. Treatmentswere within subjects and order wascounter-balanced. The independentvariable was pressure applied by thetransducer head. The dependentvariable was time required to raisetemperature 0.5, 1.0, 1.5 and 2oC at a

depth of 1.5 cm below the surface ofthe skin. Main Outcome Measures:Intramuscular temperature probeswere used to measure triceps suraetemperature and the time required toincrease temperature to the fourtemperature intervals was determined.A two within repeated measuresanalysis of variance (RM-ANOVA) wasused to analyze the differences in timefor each pressure (200 g, 600 g, and800 g) that it took to reach criticaltemperature points (baseline, 0.5oC,1.0oC, 1.5oC and 2.0oC). Results:There was no significant interactionbetween time and pressure(F(8,96)=1.494, P=.169). The timerequired to raise temperature 2oC was209.1± 104.3s with 200 g, 181.5±123.7s with 600 g, and 194.9± 90.9swith 800 g. Conclusions: Under theconditions of this study, the amount ofpressure applied with the ultrasoundtransducer head during an ultrasoundtreatment does not ultimately affectthe rate of tissue heating.

(TB), skin surface (TSKIN),superficial and deep intramuscular(SupTIM; DeepTIM) temperatures(°C). Two separate 2 x 11 (condition xtime) repeated measures ANOVAs witheleven levels of time (Start, 5, 10, 15,20, 25, 30, 35, post5, post10, post15minutes) investigated changes in skinsurface and both SupTIM andDeepTIM. Alpha wasset apriori at 0.05.Results: There was no difference(p>0.05) in TB at each temperaturesite between conditions (Skin:32.1±0.2°C; Superficial: 35±0.1°C;Deep:36.6 ±0.1°C). There was acondition x time interaction for TSKIN(p<0.001) and SupTIM (p<0.001), butno interaction or main effect forDeepTIM. Both TSKIN and SupTIMincreased significantlyover treatmenttime. The 95% CIs were 38.3-38.9°C(Skin), 38.3-38.8°C (SupTIM), 37.2-37.8°C (Deep TIM) after 35 minutesof treatment using 100% duty cycle.The 95% CIswere 36.5-37.2°C (Skin),36.8-37.4°C (SupTIM), 36.9-37.3°C(Deep TIM) after 35 minutes oftreatment using 50% duty cycle.Conclusions: Intensity of energy doesdetermine amount of heat transfer andoverall tissue heating when usingCSWD. Both 50% and 100% settingswere effective in heating skin and thesuperficial muscle above baselinelevels as early as 5 minutes aftertreatment began. Therapeutic levels ofheating wereachieved at both skinsurface and superficial muscle sites asincreases greater 1°Cwere seen atthese sites across both duty cycles.

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Effect of LidocainePhonophoresis With HydrogelDressing On CutaneousAnesthesia After VaryingTreatment TimesHix RI, Rupp KA, Saliba SA, HertelJ: University of Virginia,Charlottesville, VA

Context: Phonophoresis is atherapeutic modality used to treat softtissue injuries by combiningtherapeutic ultrasound with a topicallyapplied medication preparation.Application of a thin hydrogel dressingover the topical medicationpreparation may allow for bettermedication absorption through theskin. Additionally, alterations inintervention dosage may affectintervention efficacy. Objective: Todetermine changes in skin anesthesiaon the anterior forearm after 3different phonophoresis interventionsusing 2% lidocaine hydrochlorideaqueous gel covered with a hydrogeldressing. Design: Randomized,double-blind, crossover study.Setting: Laboratory. Patients orOther Participants: 15 healthysubjects (9 females, 6 males; age:21.8±2.9 years; height: 170.8±7.2 cm;mass: 72.7±18.2 kg) volunteered toparticipate. Interventions: Allsubjects received 3 interventions over3 sessions separated by at least 24hours. Interventions includedcontinuous phonophoresis: 1 MHz,1.0 W/cm2, 5 minutes, continuous dutycycle (100%); pulsed phonophoresis:1 MHz, 1.0 W/cm2, 25 minutes, pulsedduty cycle (20%); sham: 0 MHz, 0.0W/cm2, 25 minutes. All 3 interventionsused 2 cc of 2% lidocainehydrochloride gel covered with ahydrogel dressing for the duration ofintervention. Interventions wererandomly assigned, and both theassessor and patient were blinded tointervention order. Clinician 1 markedthe treatment area, cleaned the skin,and recorded pre-intervention skinsensation using Semmes-Weinstein

Monofilaments (SWM). Clinician 2administered the assigned interventionbefore clinician 1 returned tocomplete follow-up skin sensationmeasurements at 0-, 15-, and 30-minutes post-intervention. MainOutcome Measures: Skinanaesthesia (grams) measured withSWM (larger force values indicatedecreased skin sensation). SWMforce is presented as mean ± standarddeviation. Wilcoxon Signed Rankstests were used to compare skinanesthesia by group and by time.Results are presented as median(interquartile range). Results: Pulsedphonophoresis caused significantlydecreased sensation immediatelypost-intervention [0.70 g (0.41, 1.19),P=.007], 15-minutes post-inter-vention: [0.70 g (0.41, 1.19), P=.001],and 30-minutes post-intervention:[0.70 g (0.41, 0.70), P=.005]compared to baseline [0.41 g (0.17,0.70)]. Continuous phonophoresiscaused significantly decreased skinsensation immediately post-intervention [0.70 g (0.41, 1.19,P=.011] and 30-minutes post-intervention [0.70 g (0.41, 1.19),P=.027] compared to baseline [.0.41g (0.17, 0.70)]. Sham phonophoresiscaused significantly diminished skinsensation 15-minutes post-intervention [0.70 g (0.41, 1.19,P=.003], and 30-minutes post-intervention [0.70 g (0.41, 1.19),P=.005] compared to baseline [0.41 g(0.17, 0.41)]. Conclusions: While all3 treatments reduced skin sensationpost-intervention, there were nosignificant differences between the3 interventions at any time point.The continuous motion of thetransducer head simulating a massagemay be responsible for the reductionin skin sensation. When a clinicalapplication for using phonophoresisis needed to decrease skin sensation,the continuous treatment is moreclinically applicable and as effectiveas the pulsed and sham treatment.

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NCAA Division I Soccer Players’Use Of Over-The-Counter PainRelieversLins LAB, Plos JM, Polubinsky RL,Wigglesworth JK: Western IllinoisUniversity, Macomb, IL

Context: Athletes regularly use over-the-counter (OTC) pain relievers inaddressing pain. The use of painrelievers by professional soccerplayers has been studied; however, theprevalence, attitudes, and behaviorsrelated to the use of pain relievers bycollegiate soccer players are unknown.Objective: To examine the attitudesand behaviors of NCAA Division Icollegiate soccer players regardingtheir use of pain relievers. Design:Cross-sectional study. Setting:Emailed survey. Patients or OtherParticipants: Fifty-one Division Isoccer players from 7 of 16 SummitLeague Conference teams responded(29%). Interventions: Participantscompleted a 24-item survey withmultiple subsets of questions. Thesurvey was a modified version of the“Over-the-Counter Drug Screen forAthletes Survey” (Wolf, 2006) and hada Cronbach’s Alpha of 0.699. MainOutcome Measures: Frequenciesand chi-square (X2) analyses were usedto assess current attitudes, behaviors,and relationships between factors. Themain outcome measures includedknowledge of drug classifications,knowledge of drug effects, labelreading, use of recommended dosage,origin of decision for use, reasons foruse, and communication on properuse. Results: Drug classificationknowledge was minimal regardingibuprofen (41%), naproxen sodium(28%), aspirin (26%), andacetaminophen (22%). Knowledge ofdrug effects was moderate-highregarding use of pain relievers withalcohol (80%), taking higher dosesthan recommended (78%), and largerathletes requiring higher doses forsame effects (65%). Label readingwas minimally practiced with 21%

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reading labels every time painrelievers were used, 28% readinglabels before the first use only, and15% never reading label directions.Use of recommended dosageidentified 64% using therecommended dose or less, 32%taking more than the recommendeddose, and 4% being unaware ofrecommended doses. A significantcorrelation (X2 (4) =11.66, p=0.02)between reading label directions andtaking more than the recommendeddose was indicated. Origin of decisionfor use revealed self (77%), athletictrainer (11%), parents (9%), andphysician/pharmacist (4%) as thedetermining source. Reasons for useindicated sports-related pain (81%),anticipation of pain (66%), and toavoid missing a practice/game (40%).Communication on proper use wasprovided by the athletic trainer everytime (53%), sometimes (22%), firsttime only (19%) and never (6%) whenproviding the athlete a pain reliever.Conclusions: There is evident misuseand lack of knowledge regarding OTCpain relievers and proper usageamongst collegiate soccer players.Based on these results, the health ofathletes must be addressed as itpertains to use of OTC pain relievers.It is recommended that educationalopportunities be established to informathletes about the effects and properusage of OTC pain relievers.

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The Use Of Biofeedback InIndividuals With Low Back PainPartner SL, Acocello S, SutherlinMA, Saliba SA, Hart JM:University of Virginia,Charlottesville VA

Context: Patients with recurrent non-specific low back pain (NSLBP) oftenhave difficulty activating thetransversus abdominus (TrA) andmultifidus (MF). Patients may benefitfrom clinician-derived biofeedbackincluding verbal, visual, and tactilecues while performing exercises.Objective: To compare TrA and MFpreferential activation ratio (PAR) inindividuals with NSLBP before andafter directed exercises whileproviding visual, verbal and/or tactilebiofeedback. Design: Controlled,randomized study Setting: LaboratoryPatients or Other Participants:Twenty, asymptomatic subjects withhistory of recurrent NSLBPparticipated (11M/9F, age 23±4 years,height 165.26±12.90 cm, mass74.74±15.84 kg, current Oswestry lowback pain scale=11.35±4.00).Interventions: Subjects wererandomly allocated to one session ofdirected exercises with verbalinstructions (exercise only: n=10) orverbal instructions while patientsobserved muscle thickness changesusing real-time ultrasound (US) andpressure cuff biofeedback (exercisewith biofeedback: n=10). Verbalinstructions included cueing toperform a supine abdominal drawing-in maneuver for TrA and lifting thetailbone to the ceiling while prone fora MF contraction. Main OutcomeMeasures: We calculated as thethickness ratio for the TrA relative tothe abdominal wall (TrA+external andinternal obliques) in the rested andcontracted states using real-timeultrasound. We also calculated thethickness ratio of the deep portion ofthe MF relative to the entire MF inboth the contracted and rested states.The PAR was calculated for each

muscle as the (contracted ratio –resting rato )/resting ratio. Data werenot normally distributed thereforewere used Mann-Whitney U tests tocompare groups at baseline and afterexercise. Wilcoxon-signed rankedtests were used to compare baselinewith post-exercise for each group.Results: There were no TrA PARdifferences between groups at baseline(exercise only 0.02±0.07, exercisewith biofeedback 0.06±0.05, p=0.29)or after exercise (exercise 0.08±0.17,exercise with biofeedback 0.12±0.06,p=0.33). The TrA PAR increased preto post test following exercise withbiofeedback (pre 0.06±0.05, post0.11±0.06, p=0.03), but not afterexercise only (pre 0.02±0.07, post0.08±0.17, p=0.24) There were no MFPAR differences at baseline(exercise 0.06±0.05, exercise withbiofeedback 0.10±0.09, p=0.36) orafter exercise (exercise 0.09±0.06,exercise with biofeedback0.09±0.06, p=0.76). There were nochanges from baseline to postexercise with biofeedback (pre0.08±0.07 post 0.09±0.06, p=0.46).Conclusions: TrA PAR increasedafter a session of directed exerciseswith verbal cueing. The additionof tactile and visual biofeedbacktechniques did not have an additiveeffect. MF activation did notimprove after a session of directedexercises. Verbal biofeedbackmay improve TrA contractions inindividuals with NSLBP.

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Athletes’ Attitudes OnTreatment Seeking, InjuryReporting, And Severity Of AndPlaying With InjuriesGranquist MD: University of LaVerne, La Verne, CA

Context: Athletes’ reporting andseeking treatment for injuriesinfluences the care athletic trainerscan provide. Sport ethic and the cultureof risk associated with sports mayinfluence these behaviors (Nixon,1994). Objective: The objective ofthis study was to explore athletes’attitudes related to reporting of andseeking treatment for injuries, ondetermination of severity of injuries,and on decisions to cease play due toinjury. To meet this objective,participants were asked questions infour categories: 1) treatment seeking,2) injury reporting, 3) injury severitydetermination, 4) ceasing play.Design: Cross-sectional, mixed-methods. Setting: NCAA DIIIUniversity. Patients or OtherParticipants: Student-athletes in fall/winter sports were recruited asparticipants; 142 student-athletes (90men, 52 women; mean age 19.7 years)from soccer, basketball, volleyball,and football provided responses.Thirteen participants reported noprevious injury, 79 reported sustaininga minor injury, 56 a moderate injury,and 21 a severe injury (participantsmay have reported multiple injuries).Data Collection and Analysis:Following IRB approval and informedconsent, participants provided writtenresponses in a classroom settingduring pre-season. Descriptive andinferential statistics were calculatedfor quantitative items; hierarchicalcontent analyses were conducted forqualitative items. Hierarchical contentanalyses proceeded through the use ofinductive and deductive techniques inorder to group meaningful textsegments (i.e., quotes) into rawthemes, and more general abstract (i.e.,higher order) themes through

intercoder agreement as described byMason (2002). Results : Nostatistically significant differenceswere found between men and womenon quantitative items. 1) Do youalways seek treatment for your sportinjuries? [yes = 103 (72.5%), no = 39(27.5%)]; themes: optimalperformance, injury healing, advice/clearance from medical staff, playingtime, injury severity. 2) When injured,do you report the injury to medicalstaff? [(yes = 125 (88%), no = 17(12%)]; themes: pain/injury severity,optimal performance. 3) Does theseverity of the injury determine if youreport it to medical staff? [(yes = 117(82.4%), no = 23 (16.2%), no report= 2]; themes: pain, optimalperformance, previous injuryexperience. 4) The following themesemerged related to being too injuredto play: pain, optimal performance,advice/clearance from medical staff.Conclusions : Participants weregenerally comfortable reporting andseeking treatment for injuries,specifically to athletic trainers.Participants who were reluctantto report or seek treatmentidentified factors related to playingtime. Interestingly, participantsbased their reporting and theirseeking treatment on lack of optimalperformance. Based on thesefindings, athletic trainers shouldcontinue to build positive rapportwith their athletes, and shouldtake care to educate athletes aboutpain and injury related to athleticperformance. Future investigationsshould explore psychosocialfactors related to injury reportingand treatment seeking, so thatstrategies can be implementedto enhance athlete care.

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Athletic Trainer’s PerspectivesOn Health Care Access BarriersOf Injured/Ill Adolescent AthletesHardy A, Vela LI: Texas StateUniversity, San Marcos, TX, andChannelview ISD, Channelview,TX

Context: The health care accessbarriers (HCAB) model has been usedto identify community factorsaffecting individual’s health careaccess (financial, structural andcognitive), but little research has beendocumented on ways to modify healthcare access barriers and their impactsin adolescent athletes. Objective: Tounderstand possible HCABs and theirimpacts on injured/ill adolescentathletes from the perspectives ofathletic trainers. Design: Qualitativemethodology. Semi-structured focusgroup interviews were conducted toidentify athletic trainer’s perspectivesand personal experiences withadolescent athletes with HCABs tocreate a descriptive model. Setting:The first focus group took place in aconfidential meeting room at the PIsinstitution while the second and thirdoccurred at a regional athletic trainingconference. Patients or OtherParticipants: Twenty-two licensedand/or certified Texas athletic trainers(12 males, 10 females; experience =12.9±9.8 years; range, 3-32 years)with full-time positions employed asan athletic trainer in a middle schoolor high school and at least 3 years ofadministrative work experience werepurposively sampled to participate inone of three focus group interviews.Focus groups were completed untildata saturation occurred. Five athletictrainers (4 males, 1 female; experience= 19±13.1 years; range, 3-32 years)participated in the member-checkindividual interviews to establishtrustworthiness. Data Collection andAnalysis: Focus group interviewswere conducted by the principalinvestigator face-to-face and wereaudio-taped and transcribed verbatim.The HCAB model was used to derive

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the interview guide questions and we(AH & LV) individually analyzedinterviews using a framework analysis.Trustworthiness was established usingmember checks and analysttriangulation. Results: We confirmedthe presence and impacts of the 3barriers, financial, cognitive, andstructural, in the HCAB model.Financial barriers were represented bylimitations with general insurance,issues with uninsured athletes, andrestrictions specific to state/government/school funded insurance.Structural barriers were problems withtransportation, parent availability andcommunication problems, andhealthcare infrastructure constraints.Cognitive barriers related to problemswith understanding insurance policies,knowledge about condition/injury andprevention, and language barriers andliteracy. A new barrier, socioculturalbeliefs and expectations, wasdiscovered from the interviews whenproblems with obligation beliefs, fearof deportation, and health care systembeliefs were noted. All barriers wereassociated with negative impacts:changes in source of care, time ofpresentation, quality of care, andprevention. A new modified model, theHCAB-AT model was generated fromthe findings. Conclusions: Our resultswill help athletic trainers and otherhealth care providers find possiblesolutions for barriers to minimize theeffects of the barriers on athletes and/or families. Future researchers canexamine health care outcomesdisparities of adolescent athletes and/or families and experimentallyunderstand how the impacts candeleteriously affect them.

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M1 Macrophages Are Active AsEarly As Six Hours FollowingEccentric Exercise: A PilotStudyWaters-Banker C, Swann W,Butterfield TA: University ofKentucky, Lexington, KY

Context: Recent studies have exposedpotential influences of massage at thecellular level however, a lack of soundscientific data to support the efficacyof massage remains. Objective:Assess the effects of massage on thetemporal inflammatory responsefollowing damaging eccentric exercise(EEX). Design: Cross-over controlstudy. Setting: Performed in acontrolled laboratory environment.Subjects: Four maleWistar rats,divided into two groups: 6-hour(n=2) and 24-hour (n=2). Inter-ventions:Nerve cuff electrodeswere surgically implanted on theperoneal nerve of each limb. Animalswere provided one-week of recoverytime to reduce any confoundinginflammatory effects of the surgery.Each limb underwent a single bout ofeccentric exercise. Immediatelyfollowing exercise, the right limb ofeach animal received a 30- min boutof massage using a customizedcyclic compressive loading device(massage memetic). Rats weresacrificed based on respective grouptime point (i .e. 6hrs or 24hrs).Tibialis Anterior muscles wereharvested and cryogenicallypreserved for tissue analysis. Cellscounted using random stereologicalpoint counting. Main Out-comeMeasures: Identify cellularinfiltration of neutrophils, M1, andM2 macrophages util izingimmunohistochemistry techniques.Quantify general cellular infiltrationutilizing H&Estaining. Results: Themost notable result from this pilotinvestigation was theidentificationof M1 macro-phages at 6hrsfollowing EEX and EEX+Massage inall limbs the 6hr group (0.75±0.75

per 0.60mm2 and 5.25± 1.25 per0.60mm2 respectively). Generalcellular infiltration measured byH&E was significantly higher in the6hr compared to the 24hr group(43.0±6.0 and 16.13±2.88respectively, p=0.04). Conclusions:Traditional models of muscleregeneration util ize supra-physiologic means of muscle injury(e.g. freeze injury or cardiotoxininjection). These models havepredominantly shaped our view ofthe time course associated with theinflammatory response. The influxof M1 macrophages has largely beenreported to take place at 12hrs postinjury, however our pilot data showselective fiber infil tration/damagemediated by M1ˆs as earlyas 6hrs. Macrophages are incrediblyplastic cells, influenced by the localmicro-environment, and have theability to transition phenotypesbetween anti- and pro-inflammatorymediators. Our unique in vivo modelmost closely resembles muscleinjury, and allows for the carefultemporal analysis of the immuneresponse inregards to variousimmuno-modulatory treatments likemassage. Although small groupnumbers prevented inferencesbased on statistical analysis at thistime, this observationin geneticallyidentical animals is likely accurate.Therefore, M1 macrophageactivation as early as 6hrsfollowing injury, is an importantfinding that may shape thecurrent dogma associated withmacrophage action, theinflammatory response, and growthand regeneration of skeletal muscle.

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Feasibility Of Conducting AWeb-Based Survey Of PatientReported Outcomes AndRehabilitation ProgressMeade AR, Mattacola CG, Toonstra JL, Howard JS:Cedarville University, Cedarville,OH, and University of Kentucky,Lexington, KY

Context: Patient reportedoutcomes(PROs) have become thestandard for collecting Health RelatedQuality of Life data(HRQOL). PROsprovide clinicians insight into patients’experiences during treatment. There iscurrently a need to develop moreefficient means to incorporateHRQOL assessments into clinicalpractice. Collecting surveys onmultiple occasions throughouttreatment or rehabilitation capturespatient perceptions and behaviorsthroughout the entire treatmentprocess. Web-based surveys providea means to track data over time moreefficiently as they do not rely on thepatient returning to the clinic or theuse of clinician time for thecompletion of additional paperwork.Objective: Our purpose was todetermine the feasibility of utilizingweb-based surveys to longitudinallycapture compliance and self-reportedoutcomes among postoperativeorthopedic patients. Setting:Orthopedic clinic Design:Prospective longitudinal cohort.Patients: Surgical knee patients wererecruited for study participation duringtheir first post-operative clinic visit(n=34, 17 males, 16 females; 34±11.7years of age). Interventions:Following intake questionnaire,patients with internet access, anavailable email address and willingnessto participate in web-based surveyswere counter-balanced into groups toreceive surveys either every 2 or 4weeks for 24 weeks post-surgery.Patients were sent a web-link and log-in for each survey via recurring emails.Reminders via email or phone were

1 3 3 9 1 F O T E

Acute Response Of High-Intensity And TraditionalResistance Exercise OnAnaerobic PowerPettitt RW, Austad MA, Gay CR,Murray SR, Sexton PJ: MinnesotaState University, Mankato, MN, andMayo Clinic Health System-Mankato, Mankato, MN

Context: Quantifying the maximalwork capacity (W’) above the aerobiccritical power (CP) has emerged as amethod for estimating anaerobic workcapacity. Slower cadence, lower-loadresistance training (RT), colloquiallyreferred to as high-intensity training(HIT). HIT consists of slowercadence, lower-load resistance, ascommonly used in rehabilitation andreconditioning, and is purported as abetter metabolic stressor than fastercadence, higher-load RT. To date thisbelief has not been substantiated byresearch. Objective: We comparedthe acute effects of HIT and traditionalRT bouts on average power within a150-second time period (P

150 s), CP

and W’, as measured from a 3-minuteall-out exercise test using cyclingergometry (3 MT). Design: Acrossover design was used. Setting:Data were collected in a researchlaboratory. Patients or OtherParticipants: Eight recreationallyactive males (mean ± SD: age 22 ± 2y, body mass 85 kg ± 14 kg, and height183 cm ± 9 cm) volunteered.Interventions: Baseline 3 MT, 10repetition maximum testing on leg-press and leg-extension machines, andpost-bout 3 MTs following a HIT (4:2second cadence) or traditional RT bout(1:1 second cadence) were collected.Previous reported reliability of the 3MT for CP is TE = 15 W, CV = 7%,ICC = 0.93 and for W’ is TE = 2.8 kJ,CV = 28%, ICC = 0.76, where TE istypical error, CV is coefficient ofvariation, and ICC is intraclasscorrelation coefficient. MainOutcome Measures: P

150 s, CP, and

W’ served as the dependent variables

and were evaluated using one-wayANOVA with repeated measures (i.e.,baseline, post-HIT, and post-traditional RT bouts). Results:Neither HIT (269.2 ± 51.3 W) nortraditional RT (275.1 ± 51.3 W)evoked depreciations (P > 0.05) inP

150 s from the baseline (275.1 ± 45.4

W). Moreover, estimates of W’ at thebaseline (8.3 ± 3.2 kJ) wereunaffected (P > 0.05) either by theHIT (7.6 ± 2.3 kJ) or the traditionalRT (8.3 ± 1.3 kJ) bouts. Measures ofCP were similar pre to post-intervention for HIT (TE = 8.7 W, CV= 4.1%, ICC = 0.96) and traditionalRT (TE = 7.2 W, CV = 3.7%, ICC =0.98), respectively. Anaerobic workcapacity, as estimated by W’, wasmore variable for the traditionalRT trial (TE = 1.87 kJ, CV = 36.0%,ICC = 0.45) in comparison to theHIT trial (TE = 1.72 kJ, CV = 34.3%,ICC = 0.62). Conclusions: Thesedata indicate that the 4:2 cadenceis insufficient to exhaust a person’scapacity for high-intensity work.Longer RT durations, eitherby slower cadences or by multiplesets, are necessary to evokesubstantive declines on W’, andshould be investigated.

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provided at regular intervals if surveyswere not completed. The surveysincluded questions related torehabilitation compliance andattendance and also incorporatedquestions from the Lysholm KneeScale, IKDC, and modified CincinnatiKnee Scale. Main OutcomeMeasures: Outcome measuresincluded recruitment rate (number ofparticipants consented/number ofpatients approached for studyparticipation), eligibility (participantswith available email//participantsconsented), willingness (participantswilling to receive web-based surveys/participants eligible), and responserate (percentage of surveys completedby willing participants). Variables wereanalyzed using frequencies andpercentages. Independent t-tests wereused to compare response ratesbetween the 2 and 4 week groups.Results: Overall 35 patients wereapproached regarding participation.Recruitment rate was 97%(n=33).Eligibility was 91%(n=30); onepatient did not have internet accessand 2 did not have email address. Twopatients were not will ing toparticipatein surveys (willingness=93%, n=28). The average responserate was 45±36% among allparticipants. There was no differencein response rates between the 2week(49±35%) and 4 weekgroups(42±39%; p=.651). Of all 34patients that were approached toparticipate in the study, 47%(16/34)had at least good compliance(>50%response rate) in the surveys.Conclusions: This is one of the firststudies to examine the feasibility ofweb-based surveys in an orthopedicpopulation. Our results demonstrateresponse rates that are at or aboveaccepted standards for surveyresearch; however, response rateswith the current methodology werewell below the minimum follow-uprate of 85% recommended forclinical outcomes research.

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Hip Kinematics, Strength, AndPain, In Female Runners WithPatellofemoral Pain Before AndAfter A Short-Term InterventionQuinlevan, ME, Norberg JD,Phegley A, Fleming A, MahaffeyS, Mattacola CG, Uhl TL, NoehrenB: University of Kentucky,Lexington, KY, and University ofToledo, Toledo, OH

Context: Patellofemoral Pain (PFP)is associated with abnormal hipkinematics and decreased strength.Nevertheless, few interventions havebeen developed to simultaneouslyimprove both kinematics and strength.Objective: To evaluate theeffectiveness of a short-termintervention that focused on muscleawareness exercises and verbalfeedback during running to improve hipkinematics, strength, and pain infemale runners with PFP. Design: Asingle group, longitudinal study.Setting: Laboratory setting.Participants: Five female runnerswith PFP (25.67±6.68 yrs, 1.64±.06m, 59±11.89 kg) participated. Allsubjects met inclusion criteria andwere used for analysis. Participants hadno other injury affecting the lowerextremity, nor any previous kneesurgeries. PFP was diagnosed by alicensed medical professional usingpreviously established criterion.Intervention: Subjects participated inan initial pre-intervention session(Pre), 4 treatment sessions and twopost intervention sessions(immediately Post, and 2wks Post).During the initial data collectionsession, the subjects ran for thirtyminutes on an instrumented treadmill.Average peak hip internal rotation(HIR) and hip adduction (HADD)during stance phase were thencalculated. During the run, pain wasrecorded every minute using a 1 to10pain verbal analog scale (VAS). Hipstrength was measured with a hand helddynamometer and recorded as apercentage of torque normalized to

body weight * height. Four interventionsessions consisted of performing threespecific gluteal muscle exercises forno more than 20 repetitions with 3minutes of treadmill runningimmediately following each exercisewith verbal feedback. This exercise-run intervention was repeated 3 timesat each training session. Recoveryafter each session was 48-72 hours.The final two sessions were identicalto the initial session, with the finalsession occurring approximately twoweeks following the post-trainingsession. Main Outcome Measures:Independent variable was Time (Pre,Post, 2wks Post), and the dependentvariables were peak HADD and peakHIR during stance phase, VASmaximum pain level during running andmaximum hip external rotation peaktorque. Separate Freidman’s tests wereutilized for each dependent variable,with Wilcoxon signed-rank test forpost hoc analysis. Results: Weobserved a significant reduction inpain from Pre (4.2±1.1) to 2wks Post(1.6±1.8) (p=.042) time points. Hipexternal rotation strength increasedfrom Pre (4.1±1%) to Post testing(4.8±.7%) (p=.03). There were nosignificant changes across time inaverage peak HADD (Pre 19.4±5.3°,Post 20.5.3±5.8°, 2wks Post18.7±3.7°) (p=.513) and HIR (Pre9.5±4.3°, Post 13.3±9.1°, 2wks Post16.4±8.3°) (p=.846). Conclusions:Following a two week short-termintervention utilizing awarenessexercises targeting glutealmusculature, and verbal feedbackduring running, there was asignificant decrease in pain andincrease in strength in femalerunners with PFP. A longerintervention, traditionally 6-8 weeks,may be necessary to see kinematicchanges. Acknowledgement: Thisproject was supported by a 2010NATAREF Osternig Masters Grant.

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higher NMT volume, precisely morethan 30 minutes per week, todemonstrate greater prophylacticeffect of NMT to reduce ACLinjuries in female athletes.

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Dosage Effects ofNeuromuscular TrainingInterventions To ReduceAnterior Cruciate LigamentInjury In Female Athletes:Meta-And Sub-Group AnalysesSugimoto D, Myer GD, BarberFoss KD, Hewett TE: CincinnatiChildren’s Hospital MedicalCenter, Cincinnati, OH; Universityof Kentucky, Lexington, KY; OhioState University, Sports Health &Performance Institute, Columbus,OH

Context: Consistent increases innumber of anterior cruciateligament(ACL) injuries and theirassociated long-term physical impacthave resulted in the development anduse of neuromuscular training(NMT)as a prophylactic intervention. Recentmeta-analysis reports demonstrate theeffectiveness of NMT to reduce ACLinjury in female athletic population.However, among reviewed studiesdisparity of ACL injury reduction wasobserved, which may stem fromdifferences in NMT duration andfrequency. Thus, a series of sub-groupanalyses was performed to delineatethe potential effects of training volumerelative to the prophylacticeffectiveness of NMT on ACL injury.Objective: To systematically reviewand synthesize previously publishedstudies to evaluate dosage effects ofNMT on reduction of ACL injury inyoung female athletes. Data Sources:A computerized search was performedusing PubMed, CINHAL, Medline,SPORT Discus, (1995-2012) in May,2012. Key words were “anteriorcruciate ligament”, “ACL”,“prospective”, “neuromuscular”,“training”, “female”, and “prevention”.Abstracts and unpublished data wereexcluded. Study Selection: Criteriafor inclusion required that 1)numberof ACL injuries were reported, 2)NMTprogram was utilized, 3)females wereincluded as participants, 4)studies usedprospective, controlled trials, and

5)NMT duration and frequency weredocumented. Data Extraction: Studyquality was assessed with the PEDroscale. Extracted data included thenumber of ACL injuries and thenumber of subjects in the NMTintervention and control groups. Theextracted data were further classifiedby NMT duration (Short=Less than 20minutes per session vs. Long=Morethan 20 minutes per session),frequency (Single=One NMT sessionper week vs. Multi=At least two NMTsession per week) and volume(Low=Up to 15 minutes per weekduring in-season vs. Moderate=15-30minutes per week during in-season, vs.High=More than 30 minutes per weekduring in-season). Odds ratios(OR)were used to compare a ratio of ACLinjuries between intervention andcontrol groups among thedichotomized and tertile analyses.The quality of evidence was assessedusing the Strength ofRecommendation Taxonomy (SORT)– Levels of Evidence. DataSynthesis: Fourteen studies metinclusion and yielded average PEDroscore of 4.8/10(range: 2 to 7).Results are presented as OR[95%Confidence Intervals]. FewerACL injuries were documented inLong(OR 0.35: [0.23,0.53]) thanShort(OR 0.61: [0.41,0.90])duration. Also, fewer ACL injurieswere recorded in Multi(OR 0.35:[0.23,0.53]) compared to Single(OR0.62: [0.41,0.94]) frequency. Thetertiary analysis indicatedstatistically fewer ACL injuries inHigh(OR 0.32: [0.19, 0.52])compared to Moderate(OR 0.46:[0.21,1.03]) and Low(OR 0.66:[0.43,0.99]) volume. The SORTreached evidence level A.Conclusions: Results of thedichotomized analyses revealeddosage effects in NMT duration andfrequency on ACL injury. The inversedose-response relationship observedin the tertile analysis recommend

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Combined Landing, Core, AndJump Training Modifies LowerExtremity Energetics DuringSingle-Leg Landing In CollegeHandball Players: ImplicationsFor Anterior Cruciate LigamentInjury PreventionShimokochi Y, Igawa T, WatanabeY, Uota S, Kusumoto S: OsakaUniversity of Health and SportSciences, Osaka, Japan

Context: Non-contact anteriorcruciate ligament (ACL) injuries areknown to be more common in femalethan in male athletes, such as handballplayers who frequently performsudden deceleration–accelerationmotions; these athletes are at high riskfor such injuries. Objectives: Toexamine the effects of combinedlanding, core, and jump training onlower extremity energy absorptionduring single-leg landing and todetermine the risk of non-contact ACLinjury in female handball players.Design: Intervention Settings:Training facilities and laboratories.Patients or Other Participants:Twenty-three Japanese female divisionI college handball players(age, 20.0 ±0.8years;height, 162.4 ± 4.9cm, andweight, 59.1 ± 5.7kg). Intervention:The subjects participated in a 5-monthtraining program of core and jump-landing training for 1 month and high-intensity core, jump-landing, and jumptraining for 4 months. Before and afterthe training period, 3-dimensionalbiomechanical data were collectedusing electromagnetic motion trackingsystem and a force plate while subjectsperformed single-leg landings from a30-cm box. Main OutcomeMeasures: Biomechanical data werecollected from non-takeoff (NTOL)and takeoff legs (TOL) when shootinga handball. The negative work (J) of thesagittal plane hip(HW), knee(KW), andankle joint(AW)during the descendingphase of single-leg landings werecalculated. A two-way (joint × training)repeated measures ANOVA examined

differences before and after training.If a significant interaction wasobserved, a paired sample t-test wasused to determine the difference inwork for each joint. Results: TheANOVA revealed a significant increasein the negative work performed by eachjoint (pre-training vs post-training:NTOL=-60.2±54.0 vs.-68.2±33.5,p<0.05; TOL=-62.4±39.6 vs.-72.3±24.9, p<0.01) and interactionsfor both legs(p < 0.01). The pairedsample t-test revealed a significantincrease in HW(NTOL=-3.4±16.5 vs.-52.4±28.1, p<0.01; TOL=-23.1±21.0vs.-67.8±24.8, p < 0.01)and areduction in KW(NTOL=-123.2±29.1vs.-103.6±20.4, p=0.01; TOL=-101.8±23.1 vs.-86.0±20.2, p<0.05)for both legs. No significant changesin AW were observed (NTOL=-54.0±17.4 vs.-48.5±17.0; TOL=-66.7±20.6 vs.-62.0±19.3, bothp>0.05) Conclusions: HW waslowest and KW greatest during single-leg landing before training. However,a significant increase in HW anddecrease in KW were observed aftertraining. Thus, combined training maydecrease the possibility of excessivequadriceps muscle activations withouthamstring muscle co-activationsduring decelerating moves such assingle-leg landing, which have beensuggested to reduce knee stability andincrease ACL strain and injury risk.

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Strength Changes FollowingQuadriceps Or Hip FocusedRehabilitation In Patients WithPFP: An Outcome-Based RCTStudyEarl-Boehm J, Bolgla L, EmeryCA, Hamstra-Wright KL, FerberR: Department of Kinesiology,University of Wisconsin-Milwaukee, Milwaukee, WI;Department of Physical Therapy,Georgia Health SciencesUniversity, Augusta, GA;Department of Kinesiology &Nutrition, University of Illinois atChicago, Chicago, IL; Faculty ofKinesiology, University of Calgary,Calgary, Canada

Context: Patellofemoral painsyndrome (PFPS) is the most commoninjury experienced by running- andjumping-based athletes. Traditionally,the gold standard for PFPSrehabilitation has been strengtheningthe knee musculature. More recently,the etiology of PFPS has beensuggested to be related to reduced hipand core strength. However, no large-scale randomized controlled trials(RCT) have been conducted todetermine the optimal rehabilitationfor PFPS. Objective: To comparestrength changes in knee extension(KEXT), hip abduction (HABD), hipexternal rotation (HER), and hipextension (HEX) before and after a 6-week treatment protocol focused onthe knee (KNEE) or hip/core (HIP)musculature in physically active PFPSpatients . Comparing strength changesin those who had a successfultreatment outcome was a secondaryobjective. Design: Single-blind RCTmulti-centered study. Setting: Fourclinical research laboratories acrossNorth America. Patients or OtherParticipants: 202 PFPS patients,assessed by an AT and meetinginclusion criteria based on Boling etal. (2006), volunteered to participate,135 patients had complete strengthmeasure data (43 males, 92 females:

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1 3 F 0 4 F O T E

Pain, Function, And StrengthOutcomes For Males AndFemales With PatellofemoralPain Who Participate In EitherA Hip- Or Knee-BasedRehabilitation ProgramBolgla LA, Earl-Boehm J, EmeryCA, Hamstra-Wright KL, Ferber R:Department of Physical Therapy,Georgia Health SciencesUniversity, Augusta, GA;Department of Human MovementSciences, University ofWisconsin-Milwaukee, Milwaukee,WI; Faculty of Kinesiology,University of Calgary, Calgary,Canada Department ofKinesiology & Nutrition, Universityof Illinois at Chicago, Chicago, IL;

Context: Patellofemoral pain (PFP)is a common pathology experienced byindividuals who participate in runningand jumping-based sports. Whilequadriceps exercise is the goldstandard intervention, evidence existsregarding the importance of hip/core(HIP) strength. Moreover, researchershave shown that, unlike males, femalesexhibit altered landing and runningmechanics, possibly from reduced HIPstrength, that contribute to PFP. Thus,females with PFP may respond morefavorably to a HIP rehabilitationprotocol than a knee-focused (KNEE)program. However, no study to datehas investigated this hypothesis.Identification of these differencescould help clinicians implement sex-specific interventions for patients withPFP. Objective: To compareimprovements in pain, function, andstrength between males and femaleswith PFP who participated in a HIP orKNEE rehabilitation program. Wehypothesized that no sex differenceswould exist in visual analog scale(VAS), Anterior Knee Pain Scale(AKPS), or hip and knee strengthmeasures. Design: Single-blindrandomized controlled trial multi-centered study. Setting: Four clinicalresearch laboratories across North

age= 20.0±7.1 years; mass=67.6±13.5; height=170.4±9.4cm).Interventions: PFPS patients wererandomly assigned to a treatmentprotocol: KNEE vs. HIP. Each subjectvisited an AT 3 times per week over a6-week period for rehabilitationprogression. Main OutcomeMeasures: Isometric peak strengthwas recorded using a forcedynamometer for KEXT, HABD,HER, and HEX. Peak force wasnormalized to body weight (N/Kg) andused as the dependent variables.Treatment success was a priori definedas a decrease in VAS by 3cm and/or anincrease in AKPS of 8 points (SUC vsUNSUC). Data were analyzed usingan intent-to-treat basis. We performeda 2x2x2 ANOVA (rehab group x time xsuccess; P<0.05) on the dependentvariables. Results: Multivariateanalyses indicated no significantinteractions among rehab group, time,and success (F=.96-1.7; P=.14-.726).There was a significant multivariateeffect for TIME (F=6.28, P<.005).Regardless of rehab group or treatmentsuccess, HABD(F=12.38,p=.001),HER(F=12.66, P=.001), HEXT(F=.6.6, P=.011), and KEXT(F=8.3,P=.005) strength significantlyincreased following the 6-weekintervention HABD(Pre:3.38±1.17,Post:3.63±1.19), HER(Pre:1.19±.43,Post:1.32±.42), HEXT (Pre:2.44±1.05, Post:2.76±1.22), KEXT(Pre:3.95±1.54, Post:4.40±1.48).There were no other significant maineffects for rehab group or treatmentsuccess. Conclusions: Both theKNEE- and HIP-focused rehabilitationprograms resulted in significantstrength gains in all of the musclegroups. It is possible that the exercisesperformed, regardless of group,caused enough muscle activation toproduce strength gains, even if theexercises were not thought to targetone particular muscle. The clinicalapplication of these findings are thatboth quadriceps and hip focusedstrengthening seem to be equally

effective for producing strength gains,and should be prescribed based onindividual patient impairments. Fundedby the NATA REF: 808OUT003R andAlberta Innovates: Health Solutions.

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America. Patients or OtherParticipants: 185 patients with PFP,who met inclusion criteria (Boling etal., 2006), participated (60 males:age=29.9±7.5 years, mass=79.6.8±11.4 kg, height=178.6±6.6cm; 125 females: age=29.1±7.4 years;mass=63.6±11.7 kg; height= 166.6±7.7 cm). Interventions: Patients wererandomly assigned to a HIP or KNEErehabilitation program. Each subjectvisited an AT up to 3 times per weekover the 6-week period forrehabilitation progression. MainOutcome Measures: VAS and AKPSscores as well as hip abductor(HABD), hip external rotator (HER),hip extensor (HEXT), and kneeextensor (KE) isometric strengthmeasures were collected before andafter subjects participated in a 6-week rehabilitation program. Datawere analyzed using an intent-to-treat basis. Separate mixed-model2X2X2 ANOVAs (sex x group xtime; P<0.05) with repeatedmeasures were used to determinedifferences in all dependentmeasures. Results: Regardless ofsex or rehabili tation group, asignificant reduction in VAS (meandifference=-2.6+0.2 cm; F

1,181=

201.1; P<.0001) and improvement inAKPS (mean difference=11.0+0.9points; F

1,181=155.0; P<.0001)

scores occurred. Similar improve-ments existed for HABD (meandifference=0.17+0.1 N/kg; F

1,181=

8.4; P=.004), HER (mean difference=0.10+0.0 N/kg; F

1,181=15.1;

P<.0001), HEXT (mean difference=0.23+0.1 N/kg; F

1,181=15.9;

P<.0001), and KE (mean difference=0.30+0.1 N/kg; F

1,181=12.4;

P=.001) strength. Although notsignificant, females demonstratedmodest improvements in HABD (5.4vs. 4.5%; P=.617), HEXT (11.3 vs.7.4%; P=.825), and KE (8.0 vs.6.8%; P=.998) strength than maleswhile males exhibited greaterimprovement (10.5 vs. 5.8%;

P=.210) in HER strength.Conclusions: Regardless of sex,subjects with PFP benefitted from aHIP- or KNEE-based rehabilitationprogram. The fact that males andfemales had relatively similarimprovements in HABD and KEstrength supports the importance ofexercises targeting these musclesfor all patients with PFP. However,clinicians should considerprescribing exercises thatspecifically target the HEXT forfemales and HER for males.Fundedby the NATA REF: 808OUT003R.

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Whole Body Vibration ReducesQuadriceps Arthrogenic MuscleInhibition Induced ByExperimental Knee JointEffusionBlackburn T, Pamukoff DN, SakrM, Vaughan AJ, Berkoff DJ:Neuromuscular ResearchLaboratory, University of NorthCarolina at Chapel Hill, ChapelHill, NC

Context: Quadriceps arthrogenicmuscle inhibition (QAMI) is acommon symptom following kneeinjury which impedes rehabilitationand may increase the risk ofsubsequent injury and osteoarthritis.Whole body vibration (WBV)facilitates quadriceps function andmay minimize QAMI. However, theeffects of WBV on QAMI areunknown. Objective: To evaluate theeffects of WBV on QAMI followingexperimental knee effusion. Design:Randomized controlled trial. Setting:Research laboratory. Patients orOther Participants: Seventeenhealthy volunteers were randomlyassigned to WBV (n = 9; Mass = 71.5± 13.9kg; Height = 1.7 ± 0.1m Age =21.0 ± 1.2 years) or Control (n = 8;Mass = 71.2 ± 19.5kg; Height = 1.7 ±0.1m Age = 22.0 ± 3.5 years) groups.Interventions: QAMI was induced byultrasound-guided injection of 60mLof saline into the knee joint space.Both groups performed the sameintervention on a WBV device (6 one-minute repetitions of an isometricsquat), but only the WBV groupreceived the vibratory stimulus (30Hz,2.6g). Quadriceps function wasassessed at baseline, post-effusion, andpost-intervention. Main OutcomeMeasures: Quadriceps function wasevaluated via peak torque (PT), rate oftorque development (RTD), andCentral Activation Ratio (CAR,resulting from a superimposedelectrical stimulus) during maximalvoluntary isometric knee extension.PT and RTD were normalized to body

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epicondyle of the femur, the anteriorsuperior iliac crest, and the spinousprocess of the seventh cervicalvertebrae. Main Outcome Measures:Acceleration (g) in the vertical planeat the four locations was collected. Arepeated measures ANOVA was usedto compare the four body points acrossvariables. Results: In the verticalplane, acceleration measured at thefoot and knee were affected by theinteraction of displacement andfrequency. At the foot the variables hada significant effect (F=62.17,p<0.001), such that the 2mm15hz(0.8904±0.44) < 4mm15hz <2mm30hz < 4mm30hz (3.11±0.44).At the knee the 2mm30hz((1.39±0.44)< 2mm15hz < 4mm30hz< 4mm15hz (2.90±0.55) (F=35.75,p<0.001). However, there were nointeractions of main effects acrossvariables at the hip (F=0.89, P =0.372)or cervical vertebrae (F=0.313,p=0.578). Main effects were seen atthe ankle with an effect of frequency(30Hz > 15Hz, (F=315.42 , p<0.001))and at the knee with an effect ofdisplacement 4mm > 2mm (F=56.02,P<0.001)). Conclusions: Thetransmission of vibration doesattenuate through the body asmeasured by acceleration at differentanatomical points in this study. Thelevel of attenuation is not eventhroughout the body as theacceleration at the hip and cervicalareas are negligible. As well, theeffects of displacement and frequencyon acceleration at the ankle and kneeshould lead practitioners to considerboth the frequency and displacementwhen establishing WBV protocols.

mass. These variables were evaluatedvia 2(Group) x 3(Test) mixed-modelrepeated-measures ANOVA, andsignificant interaction effects wereevaluated post hoc via Bonferroni’sprocedure. Results: The interactioneffect for PT was significant (p =0.048). PT decreased similarly in theWBV ( = -22.2 ± 16.6%; p = 0.003)and Control ( = -15.0 ± 15.0%; p =0.004) groups following effusion.However, WBV increased PT ( = 28.6± 21.4%; p = 0.002), but the Controlgroup did not change ( = 0.0 ± 11.8%;p = 0.263). The interaction effect forCAR approached significance (p =0.077; Power = 0.65). Exploratorypost hoc analyses indicated that whileeffusion decreased CAR similarly inboth groups (WBV = -10.2 ± 11.9%,p = 0.017; Control = -9.4 ± 5.6%, p= 0.001), WBV increased CAR ( =12.5 ± 13.0%; p = 0.010), but theControl group did not change ( = 0.9± 13.0%; p = 0.417). Thougheffusion decreased RTD in bothgroups (-51.2% vs. -46.7%), thisdecrement and the associatedimprovements post-intervention(54.8% vs. 60.4%) were similarbetween groups (interaction effect p= 0.898). Conclusions: WBVappears to be an effectivemechanism for minimizing QAMI.Quadriceps strengthening followingknee pathology is often limited dueto QAMI. As such, WBV may beused to facilitate quadriceps functionand enhance quadricepsstrengthening, thus enhancing theefficacy of rehabili tation andpotentially mediating the risk ofsubsequent injury and osteoarthritis.

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Acceleration Through The BodyDuring Whole-Body Vibration IsAffected By VibrationParametersDeMont RG, Rakeja S, Saade N:Department of Exercise Scienceand Department of MechanicalEngineering, ConcordiaUniversity, Montreal, QC

Context: Whole-body vibration(WBV) platforms have been usedwidely under various parameters mostof which indicate benefits to a varietyof physiological measures. However,studies using WBV do not followspecific protocols for determiningwhat parameters are used, and few havemeasured the transmission of vibrationthought the body. Analyzing the effectsof WBV throughout the body could beuseful information in determiningeffective dosage parameters in trainingwith this modality. Objective: Todetermine the vertical planeacceleration transmission through thebody as measured at the foot, knee, hip,and cervical vertebra. Our hypothesiswas that attenuation of the vibrationwould occur from the foot through tothe cervical vertebrae. Design:Counterbalanced control trial.Setting: Engineering andbiomechanics research laboratory.Patients or Other Participants: 30healthy young females (age = 21.7 ±3.1 years, height = 65.7 ± 3.1 inches,weight = 137.3 ± 19.8 pounds) volun-teered. Interventions: Participantsperformed 4 one-legged squat at 40degrees of knee flexion on anoscillating WBV platform (VibraFlex600). Trials were separated by 5minutes of rest and repeated withinsubjects. Participants were exposed tofour 15-second bouts of vibrationconsisting of two displacements (2mmand 4mm) and two vibrationfrequencies (15Hz and 30Hz). Trialswere presented in a counterbalancedorder. Three-axis accelerometers(Sparkfun electronics) were placed atthe medial malleolus, the medial

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Acceleration Through The AnkleDuring Whole-Body VibrationAffected By Footwear ConditionIn FemalesSaade N, Rakheja S, DeMont RG:Department of Exercise Scienceand Department of MechanicalEngineering, ConcordiaUniversity, Montreal, QC

Context: No guidelines exist forselecting between shoe wearing (SW)and being barefoot (BF) while usingwhole-body vibration (WBV)machines. Understanding thetransmission patterns of vibrationthrough the foot in SW or BFconditions may play a role forappropriate selection of footwearduring the use of WBV. Objective Todetermine whether acceleration ofWBV is significantly reduced throughthe ankle in the vertical, coronal andsagittal planes by being barefoot orwearing a shoe. Design: Counter-balanced controlled trial. Setting:Engineering and biomechanicsresearch laboratory. Patients orOther Participants: 30 healthyyoung females (age = 21.7 ± 3.1 years,height = 65.7 ± 3.1 inches, weight =137.3 ± 19.8 pounds) volunteered.Interventions: Participants per-formed a one legged squat at 40degrees of knee flexion on anoscillating WBV platform (VibraFlex600). The SW and BF trials wereseparated by 5 minutes of rest andrepeated within subjects. Participantswere exposed to four settings(2mm15hz, 2mm30hz, 4mm15hz,4mm30hz) for 15 seconds each in acounterbalanced order. Acceleration atthe medial malleolus was recordedusing a 3-axis accelerometer(SparkFun Electronics). MainOutcome Measures: Acceleration (g)was recorded in the vertical, coronaland sagittal axes at the medialmalleolus for SW and BF conditions.The means were compared usingrepeated measure ANOVA todetermine differences between

conditions. Results: Vibration at theankle was lower in SW compared toBF in the vertical-axis at all settings[2mm15hz (SW= 0.742±0.225, BF1.039±0.317, F

1, 56 = 17.445, P =

0.001), 2mm30hz (SW= 2.355±0.619, BF 3.160±0.564, F

1, 56 =

27.751, P < 0.001), 4mm15hz (SW=1.788±0.371, BF 2.040±0.256, F

1, 56

= 9.409, P = 0.003), 4mm30hz (SW=2.911±0.522, BF 3.299±0.227, F

1, 56

= 13.865, P < 0.001)].Vibration at theankle was higher in SW then BF in thecoronal-axis [2mm15hz (SW=1.674±0.316, BF 1.329±0.339, F

1, 56

= 16.663, P < 0.001), 2mm30hz (SW=3.079±0.501, BF 2.199±0.706, F

1, 56

= 30.988 , P < 0.001), 4mm15hz(SW= 2.299±0.335, BF 2.029±0.312,F

1, 56 = 10.425, P = 0.002)] but was not

significant at 4mm30hz. Vibration atthe ankle in the sagittal-axis was notsignificant between groups andinconsistently varied in response toSW or BF conditions. Conclusions:The SW condition influences themedial/lateral ankle displacementmore than BF and should beconsidered when using WBV onindividuals with ankle pathology.Further work is needed to determinethe interest of using WBV during rehabexercises for ankle sprains. The BFcondition increases vertical loading atthe ankle compared to SW which isimportant when using WBV toincrease bone density.

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Pre- And Post-ActivityStretching Practices OfCollegiate Athletic TrainersPopp JK, Judge LW: Ball StateUniversity, Muncie, IN

Context: Current research suggeststhe benefits of pre-activity dynamicstretching include an increase in sport-specific flexibility, strength, power,agility, and sprint performance. On theother hand, recent evidencedemonstrates that pre-activity staticstretching may actually decreaseathletic performance, and is alternatelyrecommended as a component of apost-activity cool-down routine.Objective: To investigate theknowledge and practices of collegiatecertified athletic trainers (ATs) todetermine if stretching practicesutilized are in line with the currentresearch. Design: Cross-sectionalstudy. Setting: A population-basedquestionnaire administered via emailwith a hyperlink to the survey was usedto conduct the data collection.Participants: A total of 2839 ATs, whoare members of the National AthleticTrainers’ Association and indicated thecollegiate setting as the primary placeof employment were emailed andinvited to participate. A total of 500participants (17.6%; 252 male, 248female) completed the survey.Interventions: The “Pre- and Post-Activity Practices in Athletic TrainingQuestionnaire” was administeredelectronically as each subject wascontacted via email, with a briefdescription of the survey purpose andthe hyperlink to the web-based survey.The survey consisted of demographiccharacteristics and multiple choiceitems related to athletic trainers’knowledge and use of pre-activitywarm-up, pre-activity stretching, post-activity cool-down, and post-activitystretching. In previous studies, thesurvey demonstrated constructvalidity, ˜ = .722. Main OutcomeMeasures: Descriptive statistics werecomputed for all items. Pearson chi-

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contraction EMG activity. Whilecontracting, the Achilles tendon wasstimulated 50 times (rectangularpulses, 75 mA, 100 μs duration, 2-sinterpulse interval). Pre, during, andpost-stimulus EMG activity for the 50trials at each measurement time werefiltered, full-wave rectified, andaveraged. An algorithm (implementedusing MatLab software) identifiedinhibitory points and calculated themain outcome measures. MainOutcome Measures: Inhibition area(mV*ms-1), inhibition maximum (mV),and inhibition duration (ms). Outcomemeasures were normalized using 100ms of pre-stimulus EMG activity.Repeated measures ANOVAs withGeisser-Greenhouse corrections wereused to analyze data (˜=0.05, NCSSv.2007). Data are reported as means ±SD. Results: Inhibition area wasunaffected by stretching at any time(F

1,14=1.5, P=0.25; pre-stretch

=0.07±0.09 mV*ms-1, immediatelypost-stretching= 0.07±0.10 mV*ms-1,5 min post-stretching=0.06±0.08mV*ms-1, 10 min post-stretching=0.05±0.04 mV*ms-1, 15 minutespost-stretching=0.05±0.04 mV*ms-1,30 minutes post-stretching=0.05±0.05 mV*ms-1). Inhibitionmaximum was also unaffected bystretching over time (F

1,14=0.2,

P=0.72; pre-stretch= 0.0008±0.0009mV, immediately post-stretching =0.0008 ±0.0008 mV, 5 min post-stretching= 0.0008 ±0.0007 mV, 10min post-stretching=0.0008±0.0007mV, 15 minutes post-stretching=0.0008± 0.0007 mV, 30 minutes post-stretching=0.0008±0.0008 mV).Stretching also did not affect inhibitionduration over time (F

1,14=1.5, P=0.24;

pre-stretch=3.5±2.8 ms, immediatelypost-stretching=3.3±2.8 ms, 5 minpost-stretching=3.3±2.5 ms, 10 minpost-stretching=2.8±1.6 ms, 15minutes post-stretching=2.7±1.7 ms,30 minutes post-stretching=2.7±1.8ms). Conclusions: A single bout ofstatic stretching had no impact on GTOinhibition. Single bouts of static

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Acute Static Stretching DoesNot Affect Golgi Tendon OrganReflex InhibitionMiller KC, Burne JA: North DakotaState University, Fargo, ND, andSchool of Medical Sciences,Sydney Medical School, Universityof Sydney, New South Wales,Australia

Context: Golgi tendon organ (GTO)disinhibition is thought to contributeto exercise-associated muscle cramp(EAMC) genesis. Despite limitedevidence of efficacy, acute staticstretching is often prescribed toprevent EAMC based on the belief thatstretching activates GTOs.Gastrocnemius GTO inhibition ishighest when the gastrocnemius is ina lengthened position, but no researchhas examined the effect of acutestretching on GTO inhibition.Objectives: We asked: Does a singlebout of acute static stretching increasegastrocnemius GTO inhibition? If so,how long does GTO inhibition stayelevated post-stretching? Wehypothesized GTO inhibition wouldincrease post-stretching but wouldreturn to pre-stretching levels within5 minutes. Design: Repeatedmeasures, cross-sectional. Setting:Laboratory. Patients or OtherParticipants: Six men (age=26±3 y;ht=179.5±4.1 cm; mass=81.8±13.4kg) and six women (age=27±7 y;ht=163.4±4.9 cm; mass=64.4±9.6kg). Interventions: Subjects’dominant limb medial gastrocnemiusGTO inhibition was tested before,immediately after, and 5, 10, 15, and30 minutes post-stretching. Withsubjects long sitting, the investigatorsapplied three, 1-minute bouts (1minute of rest separating each bout)of static stretching to thegastrocnemius by placing the ankle intomaximum dorsiflexion. To measureinhibition at each selected timeinterval, subjects maintained medialgastrocnemius contraction intensity at5% of their maximum voluntary

square test was used to evaluategoodness of fit, and kappa wascalculated to measure agreementbetween the subjects. Results: 32.2%of collegiate ATs recommendeddynamic stretching pre-activity,whereas 42.2% recommended acombination of static and dynamicstretching. However, post-activity,60.6% of collegiate ATs recommendedstatic stretching, while only 27.9%recommended a combination of staticand dynamic stretching. There was amoderate level of agreement that ofthe collegiate ATs who recommenddynamic stretching pre-activity, 21%of athletes are actually performingdynamic stretching (K=.582, P<.001).Post-activity, there was a substantialagreement that of the ATs whorecommend static stretching, 61.0%of athletes are actually performingstatic stretching (K=.761, P<.001).Conclusions: Collegiate ATs areemploying practices that are not in linewith current research, whichrecommends dynamic stretching beincorporated pre-activity as a meansto prepare the musculoskeletalsystem for sports activity. There is alow percentage of collegiate ATs whoare recommending, as well asathletes who are performing,dynamic stretching pre-activity. Inaddition, there is a great deal ofcollegiate ATs who arerecommending a combinationof pre-activity static and dynamicstretching. However, collegiateathletic trainers are emphasizingstatic stretching post-activity, andathletes are performing itpost-activity, which is in l inewith the current research.

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stretching are unlikely to preventEAMC assuming the theory that GTOdisinhibition contributes to EAMCgenesis. The effect of chronicstretching programs on GTOinhibition warrants future examination.

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Free Communications, Poster Presentations: Case Studies1 3 2 3 6 U C

Rehabilitation Program ToIncrease Knee ROM And MuscleGirth Following A 1-YearAbsence From ACL Post-Operative RehabilitationSnyder B, Smith S, Fricker D,Tomchuk D, Ross K: MissouriValley College, Marshall, MO, andMarshall Orthopedics and SportsMedicine, Marshall, MO†

Background: An 18 year old malecollegiate soccer signee reportshaving difficulty playing soccer forextended periods of time to theathletic trainer. The athlete couldperform activities of daily living;however, his left thigh and kneebecome tight and painful duringprolonged soccer drills andscrimmages. The athlete is 14 monthspost-ACL reconstruction (cadavergraft) with medial and lateral meniscusrepairs on his left knee. Rehabilitationwas initiated day 1 post-surgery.Rehabilitation consisted of knee rangeof motion (ROM) and strengtheningexercises, moist heat, cryotherapy, andmuscle stimulation 3 times a week for3 months until he was able to walkwithout discomfort. At that time theathlete discontinued all rehabilitation.The injury, surgery, and initialrehabilitation were performed beforethe athlete signed with his collegeteam. Differential Diagnosis: Post-operative arthrofibrosis, infrapatellarcontraction syndrome, patellaentrapment syndrome, cyclops lesion,and myositis ossificans. Treatment:Goniometer measurements revealed110° of flexion and 7° of extension inhis injured knee vs. 125° flexion and -1° in his uninjured knee. Thigh and calfgirth measurements on both limbs 5cmand 15cm superior and inferior to thepatella revealed a deficit on his injuredside (thigh - 45.5cm and 61cm vs.48cm and 64cm; calf - 40.5cm and38cm vs. 38.5 and 40cm). Uponconsultation with an orthopedicsurgeon an aggressive rehabilitation

program was implemented to increaseboth the patients’ knee ROM and girthbefore considering surgicalintervention. Knee extension wasdeemed most important and arehabilitation protocol of moist-heat(20 minutes) and thermal ultrasound(7 minutes, 1 Mhz at 1.5 intensity)while the athlete remained in anextended knee position began on thedistal hamstring. This was followed bydeep tissue massage on the hamstringand patella, stretching, and ice withexternal compression in an extendedknee position for 20 minutes.Hamstring curls, balance/proprioception exercises, hipextensions, TKE’s, straight-leg raises,and calf raises were implemented 1week later. After 6 weeks, the athletes’knee extension and flexion improvedby 3° and 4° respectively resulting insquat-oriented exercises such as: wallsits, wall squats, lunges, and slide boardbeing introduced. Heat, ultrasound,massage, and stretching on the athletes’quadriceps was introduced at this time.At week 10, quadriceps extensions,stool scoots, general running/cuttingdrills, and team soccer practice wereadded as the athletes’ ROM and girthcontinued to improve. Twelve weeksinto rehabilitation, ROM wasreevaluated revealing 117° of flexionand 2° of extension in his injured knee.Girth measurements for the thigh(47.5cm and 63cm) and calf (40.5 and38.5) also improved. The ROM andgirth measurements on the uninjuredleg remained constant. The athlete wasinstructed to continue exercises andplay soccer during summer vacation.Upon reporting for fall camp theathletes’ ROM and muscle girthmeasurements were identical as whenhe departed. The athlete was able topractice and compete during the fallat a higher level with decreaseddiscomfort compared to the spring.Uniqueness: Completing arehabilitation program is vital for asuccessful outcome following ACL

reconstruction. By discontinuingrehabilitation after 3 months, thispatient demonstrated the pitfalls of notcompleting a properly designed andsupervised program. Our protocoldemonstrates that improvements inknee ROM and muscle girth arepossible after a 1-year absence andsurgical intervention is not alwaysnecessary. Conclusion: Delayed ACLrehabilitation can create significantscar tissue buildup resulting indecreased knee ROM, strength,athletic performance, and quality oflife. Completing a properly designedand supervised rehabilitation programprevents deficits in knee ROM andmuscle girth. Athletic trainers shouldeducate their patients on theimportance of adhering to andcompleting their rehabilitationprogram to prevent complications.

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Case Study Report: PectoralisTendon Repair In A CollegiateFootball PlayerWilliams EM: Mississippi StateUniversity, Starkville, MS

Background: The patient is a 20-year-old male Division-I FootballPlayer. He was involved in a motorizedvehicle accident one weekend duringthe summer. Two days later, hereported to the Athletic Training Room,complaining of pain in the rightpectoralis major. He informed theAthletic Trainer about the accident, buthe could not remember an exactmechanism of injury. He onlyremembered being expelled from thevehicle onto the ground. Immediatelyfollowing the accident he did not feelany pain. However, later that day hestarted to experience extreme pain andwas unable to use his right arm toperform any activities of daily living.Physical examination by the AthleticTrainer revealed a lack of musclefunction and contraction in the rightchest/shoulder as well as pain withshoulder abduction and externalrotation. Differential Diagnosis:Possible diagnoses included pectoralisminor strain and labrum tear.Treatment: The patient was seen by aphysician that day and a MagneticResonance Image (MRI) was orderedand conducted that afternoon. Physicalfindings included pectoralis majorweakness and a palpable knot in themedial portion of the muscle. TheMRI revealed a complete tear of theright pectoralis major tendon from itshumeral attachment. Surgery to repairthe muscle was scheduled for two dayslater. Cryotherapy alone was thetreatment course for about the firstweek. The patient was also instructedto wear a sling with a pillow at alltimes. Nine days post-operative, thepatient had a follow-up with theoperating physician. His staples andthe pillow were removed. He wascleared to begin passive range ofmotion (PROM) external rotation

(ER) at 0 degrees to 90 degrees,PROM abduction to 60 degrees, aswell as putty exercises to strengthenhis hand and forearm musculature. Twoweeks post-operative he was clearedto begin PROM abduction to 90degrees, PROM forward flexion to120 degrees, and light forearm weightsto increase grip strength. Four weekspost-operative, he was cleared to beginsome ER and internal rotation (IR)Thera-Band exercises, underwatertreadmill jogging, and leg workouts inthe weight room as long as they did notinvolve his arms. The goal of thisphase was to achieve all full range ofmotion but the last 10 degrees ofabduction external rotation at the 90-90 position. Five weeks post-operative, the patient was cleared tobegin biceps and triceps strengtheningvia dumbbells (high repetitions and lowweight) as long as the pectoralis majorwas not stressed. He was also clearedto begin lateral raises and runningoutside in a straight line. Eight weekspost-operative, he was cleared to beginall pectoralis major strengtheningexercises with high repetitions and lowweight. Progression was as tolerated.He also began catching balls atpractice. Nine weeks post-operative,the patient was cleared to begin lightplyometric exercise. He also beganrunning some routes and catchingmore balls at practice. Ten weeks post-operative, he was cleared to beginmore strenuous plyometric exercise.He also began limited non-contactpracticing. Twelve weeks post-operative, he began full non-contactpracticing. Thirteen weeks post-operative, the patient was cleared forfull-contact practicing and to play inthe football game that week.Uniqueness: This case is uniquebecause most pectoralis majorrehabilitations take about 6 months fornon-athletes to return to full activities.It is rare for an athlete to return to ahigh-contact sport in just 13 weeks.Conclusions: This injury typicallyrequires a long-term recovery.

However, having a highly motivatedathlete and athletic training stafffactored heavily into an optimaloutcome for this patient to return toplay as quickly and safely as possible.

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Use Of Exos Splints In A MiddleSchool PopulationGravelin EM, Brownell EH,Butterfield TA: University ofKentucky, Lexington, KY

Background: A 14 year-old middleschool volleyball athlete with no pastmedical history of hand injuries wasparticipating in a “punch for punch”game with a football athlete on 8/30/12 when she punched his occiput,feeling a pop in her right hand.Evaluation by the athletic trainerrevealed pain and swelling over thehead of the fifth metacarpal, withlimited active and passive range ofmotion (ROM). The patient was givenice and instructed to follow-up with aphysician the next morning.Differential Diagnosis: Boxer’sfracture, hand contusion. Treatment:Physician’s exam of the right handrevealed pain and swelling at the dorsalaspect of the hand over the fifthmetacarpal. ROM was limited at thefifth metacarpalphalengeal joint, butnormal at the proximal phalangeal anddistal phalangeal joints, with norotational abnormalities. Uponreviewing the radiographs, attendingfellow and physician agreed on thefinal diagnosis of a right boxer’s andfifth metacarpal neck fracture. She wasplaced in an Exos ulnar gutter splintwith instructions to remove the splintdaily only to wash her hand. On 9/18/12, subsequent exam and follow-upradiographs revealed the fracture to bemildly healed. The patient was placedin the Exos for an additional twoweeks, with instructions to wash herhand daily and work on gentle ROMwhen out of the splint. On 10/2/12,four weeks from fracture, follow-upradiographs still revealed mild intervalhealing of the fracture. Examinationrevealed pain and swelling over thefifth metacarpal, ecchymosis over thedorsum of the hand, but normal ROMat the wrist, PIP and DIP joints. Thepatient was fitted for a larger size Exos

splint to decrease irritation, but lockedin due to the patient’s previousnoncompliance. On 10/8/12, thepatient returned to the cliniccomplaining of skin irritation, and wasadvised to remove the splint at nightand apply an anti-fungal cream. A castwas applied after no decrease in skinirritation on 10/10/12, withinstructions to follow up as necessaryuntil her next scheduled appointment.No problems were reported afterapplication of the cast, and followingits removal, she successfullycompleted a home exercise program.Uniqueness: New to the healthcarefield, Exos splints are the world’sfirst modifiable, waterproof,antimicrobial bracing system. Whenheated, the foam brace is molded andcustomized to the patient. Theoptional locking feature safeguardsagainst unwarranted removal with itslock and key feature. Exos splintsensure a sawless removal and no needfor removal during radiographs, dueto radiolucent properties. Prior toskin irritation, this patient’s boxer’sfracture was successfully treatedwith an Exos ulnar gutter splint,allowing her to shower, as well asperform gentle ROM exercises todecrease risk of hypomobilityfollowing fracture healing. It isunknown if this patient’s skinirritation is correlated to use of theExos splint. Conclusion: Exossplints can be used to stabilize avariety of upper extremity injuries.The splints allow for basic humannecessities and rehabilitation, andguarantee against removal innoncompliant and adolescentpatients. However, the lockingfeature is only successful ifenforced. In this case study, the lackof parental enforcement led toinsufficient healing and the eventualapplication of a cast. There is alsocurrently no literature to support orconfute Exos use. This gap in theliterature can be closed through case

series studies that examine the useof Exos technology. Given theadvertised benefits, it is importantthat Exos splints are recognized asan option for upper extremityfractures, but situationally used.

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Functional PostoperativeRehabilitation Of A Division 1SwimmerFrancis C, Johnston T, Poole D:Clemson University, Clemson, SC

Background: Athlete is a 21 year oldmale swimmer. He is a breaststrokespecialist. After 33 days of practicethe athlete began complaining ofbilateral anterior medial knee pain. Hewas tender to palpate on the patellatendons of both knees. No joint linepain. No previous history of knee pain.Limited ROM due to pain in all kneemotions. Manual Muscle Test 4/5 withpain in all knee motions. DifferentialDiagnosis: Meniscal and ligamentouspathology were originally suspected aswas patella tendinitis. This wasreinforced by the relief of pain whenusing a patella strap. Also consideredsubpatellar bursitis, that was ruled outas well due to area of pain. Treatment:MRI and Xray were both negative.Athlete was diagnosed by the teamphysician with bilateral knee synovitis.He was treated conservatively duringthe season without surgery. He wastreated daily with the focus onincreasing strength without pain anddecreasing the swelling within the kneejoint. He was immediately limitedduring team strength training, andbreaststroke during practice. A patellarstrap was used on the patella tendonbecause it decreased pain. A dailymaintenance rehab plan was put inplace. 3 days a week he completed awarm up on the stationary bike, tableslides, prone quad sets, 4 way straightleg raises, step ups, terminal kneeextensions, mini-squats, weighted kneeextension and flexion, calf raises, andproprioception exercises. During offdays the rehabilitation was focused onpain management through the use ofcold and electric stimulationmodalities. After the season wascompleted he had arthroscopicsurgery on both knees. During theprocedure, the meniscus appeared

intact, scar tissue was removed fromthe joint, and the synovial lining of thejoint was surgically excised. The firstfour days post surgery he used coldmodalities, and completed ROMexercises. Five days post,strengthening exercises began. As soonas he was cleared to enter the water,he began rehab in the therapy pool.Freestyle was the only stroke used thefirst week in the pool. He then beganprogressing into breaststroke. He useda kick board to isolate the kick. Jetspeed was adjusted to slow down hiskick and focus on a pain free functionalrange of motion. Once achieved, thejet speed was increased and aresistance cord was added to helpstrengthen. Focus was then placed onthe deep knee flexion associated withpushing off the wall. Athlete returnedto competition the following seasonwith personal best times in his firstmeet back. Uniqueness: A nonsurgicaltreatment was taken during the seasonin order to keep him competing. Theunique aspect is the functionalrehabilitation that was performed usingan underwater treadmill andunderwater jet resistance training. Toisolate each phase of the stroke in acontrolled tank was a uniqueopportunity to make sure that theswimmer was rehabilitating withoutaffecting his stroke mechanics. Thesize of the pool used also provides theclinician a unique chance to changespecific aspects of the rehabilitationto advance the treatment and make therehabilitation as functional as possible.Video recordings were taking in orderto give the athlete appropriatefeedback on his progress.Conclusions: Although most sportshave a generally accepted method forfunctional rehabilitation, swimmingdoes not. The inclusion of an isolatedtank with resistance jets into the rehabadds to the functional application ofthe exercises and hopefully a hastenedreturn to play. This method was alsoused to rehabilitate a 21 yr old

swimmer post shoulder arthroscopyand a 20 year old swimmer post repairof a compound femur fracture.

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Upper Extremity Paresthesia InA Collegiate SwimmerAyotte J, Rothbard M, Morin G:Southern Connecticut StateUniversity, New Haven, CT

Background: A 20 year-old maleindividual medley and backstrokerpresented with idiopathic persistentcervical spine pain and paresthesia inthe upper extremities and jaw.Reported symptoms started four yearsago bilaterally, but recently becamemore prevalent on the right side. Hereported being able to perform sportactivities on a self-limiting basis.Symptoms increased throughout theday and decreased with lying down. Thepatient’s medical history was notsignificant for traumatic injuries to thespine or surrounding area. Visualobservation revealed increasedcervical lordosis with forward carriageof the head and chin protraction alongwith thoracic kyphosis and associatedrounded shoulders. Physicalexamination elicited bilateral diffusecervical spine tenderness, uppercervical extensor muscular spasms,and normal skin temperature. AROMtesting revealed lower cervical andupper thoracic spine hypomobility andinduced symptomatic increases withbilateral cervical extension, lateralflexion, and rotation. PROM testingrevealed sternocleidoid, trapezius,levator scapulae, and pectoralis majorand minor tightness. MMT eliciteddeep anterior cervical, serratusanterior, and scapular retractorweakness. Cervical compression,cervical distraction, Spurling’s, Roos,and military brace tests were positive;however, valsalva maneuver andAdson’s and Allen tests were negative.Neurologic testing revealedsignificant bilateral sensory and motordeficits over the entire right upperquarter. Differential Diagnosis:Rheumatoid arthritis, multiplesclerosis, tumor, cervicalspondylolysis, degenerative

osteoarthritis, spinal stenosis, cervicaldisk herniation, clinical cervicalinstability, facet joint dysfunction,degenerated facet joint, and cervicalradiculopathy. Treatment: The patientwas referred to the team orthopedistand removed from athleticparticipation. Following initialconsultation he was referred to aneurologist who ordered blood testsand an MRI of the brain and cervicalspine. Blood tests were normal. TheMRI of the cervical spine revealedmild asymmetric right-sideduncovertebral hypertrophy at C2-C3and C3-C4 with mild-to-moderateneuroforaminal stenosis. A mild masseffect on the left axillary sleeve at theC3-C4 segment was noted. A smallsubannular fissure and left central/subarticular disc protrusionencroaching on the left axillary sleeveand neural foramen at C5-C6 wasobserved. The neurologist diagnosedthe patient with polyradiculopathysecondary to C2-C6 neuroforaminalspinal stenosis and was prescribedCarbamazepine ER for abnormal nervesensations, Voltaren for inflammation,and rehabilitation to facilitate recoveryand function. The rehabilitationprogram involved an integratedapproach and was designed to controlinflammation, provide symptomaticrelief for radicular pain and muscularspasms, and to decrease cervical nerveroot compressive forces. It consistedof physical agents, postural retraining,manual therapy, kinesiotaping toencourage correct posture, andtherapeutic exercises to release tightstructures and strengthen posturalmuscles. Status post four months hissymptoms improved, but did notcompletely resolve. Participation wasself-regulated and related to pain levelsand neurologic deficits. Status-postsix months his symptoms completelyresolved. He was cleared forunrestricted activity. His return toswimming did not elicit any pain orneurologic deficits. Uniqueness:

Most common clinical symptoms ofpolyradiculopathy are neck pain andunilateral arm pain accompanied bymotor and sensory deficits. Theprevalence of polyradiculopathysecondary to spinal stenosis increaseswith age and most commonly occursat C6-C7 and in adults over 30-40.Furthermore, the patient is a post-pubescent athlete who developed earlyonset cervical spinal stenosis. Finally,only 2% of all cervical radiculopathiesoccur at C4-C5 or above.Conclusions:. Polyradiculopathyrefers to compression or damage ofmore than one spinal nerve root thatproduces pain and neurologic deficits.This occurs when the spinal columnnarrows and places pressure onmultiple nerve roots. The lowercervical nerve roots (C5-C8) are mostcommonly involved. Variousetiologies can result in pressure on oneor more cervical nerve roots. In thiscase, the pathology was caused byneuroforaminal spinal stenosissecondary to overactivity.

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Chronic Upper ExtremityNeurological Symptoms In AHigh School Football AthleteHenderson K, Frymyer JL, FeltonSD, Bloom KL: Florida Gulf CoastUniversity, Fort Myers, FL, andNaples Community Hospital,Naples, FL

Background: Athlete is a 17 year-oldmale high school football linebacker.The athlete presented to CertifiedAthletic Trainer (ATC) during hisjunior football season after prolongedhistory of chronic bilateral stingers.Athlete noted he had been examinedby orthopedic physician as well astreated by other allied healthcareprofessionals including ATCs and PTs.The ATC conducted orthopedicexamination and a full bio-mechanical upper extremityexamination. Biomechanicalexamination revealed athlete wasexperiencing bilateral scapulardyskinesis. Specifically bio-mechanical examination revealedforward head posture (FHP),increased kyphosis, and hypertonicupper trapezius and sterno-cleidomastoid musculature (SCM).He also presented with hypomobilefirst rib as well hypomobile lowercervical and upper thoracicvertebrae. Athlete continued todemonstrate full range of motion(ROM) which revealed decreasedrotator cuff strength; bilateralsensation, reflexes, and shoulderROM WNL. ATC presented currentfindings to Team Physician whereMRI was ordered to rule out anycervical neck pathologies. MRIrevealed uncovertebral jointspurring, and no other significantfindings. Differential Diagnosis:Soft Tissue Contusion, Subluxation,Cervical Neck Pathology, AC Sprain,Transient Brachial Plexopathy(Stinger) Treatment: The athletewas treated conservatively with theATC initiating a detailedrehabilitation plan addressing the

scapular dyskinesis. Specificscapular stabilization exercises werefocused on re-education andpromoting proper scapula humeralrhythm utilizing PNF patterns for thescapula. Hypomobility of the firstrib, upper thoracic and lower cervicalvertebrae were addressed withgraded joint mobilizations to restorenormal arthrokinematic movement.Soft t issue mobilization andmyofascial techniques wereadministered to the soft t issueimpairments including the SCM,upper trapezius and pectoralis major/minor. Athlete was an activeparticipant in his treatment processmaking ergogenic changes at homeand school for completingschoolwork and sleeping postures.Athlete responded well to treatmentas evidenced by decreased scapulardyskinesis and improved forwardhead posture and was able to returnto participation. However, duringthe post-season, athlete wasparticipating in physical educationcourse and experienced a subsequentstinger resulting from non-traumaticmechanism of injury. Athletereported to ATC and in consultationwith Team Physician elected to referathlete to a Neurologist for furtherevaluation. Neurologist conductedEMG. EMG revealed normal testing.Athlete, with prescribedrehabilitation program, has been ableto complete senior year of footballcompetition absolved fromreoccurring stingers. Uniqueness:Stingers are a frequent pathologydiagnosed and treated by ATCs withup to 65% of college footballathletes having experienced abrachial plexus injury during theirathletic careers. Most stingersresolve with conservative treatmentof symptoms and generalstrengthening exercises with lowincidence of re-occurrence. There iscurrently limited research on therehabili tation for brachialplexopathy. This case highlights a

thorough biomechanical evaluationto identify all impairments/dysfunctions. These discoveriesallowed a detailed rehabilitationprogram to address and changeathlete’s biomechanics allowingbetter positioning andarthrokinematics, which whentreated eliminated his chronicstingers. Conclusions: This casehighlights the treatment of chronicbi-lateral transient brachialplexopathy. The athlete respondedwell to treatment and was able toreturn to full football competitionand had had no episodes of stingersduring his final season.Furthermore, this case highlights theimportance of conducting a thoroughbiomechanical examination involvingthe entire kinetic chain anddeveloping a rehabilitation plan thataddresses t issue specificimpairments. No current researchexplores the FHP/rounded shoulderposture in association with chronicstingers. This case demonstratessuggestion of a connection with theinflamed brachial plexus in thedecreased space anteriorly with FHP.Increasing this space throughaddressing postural impair-ments assisted in relieving futurebrachial plexus injury. It alsodemonstrates that the use ofdiagnostic imaging is important, butATCs need to continue to conduct athorough clinical examination.

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Upper Extremity Deep VeinThrombosis In A CollegeBaseball Player: A Case StudyPatton TS, Peer KS: Kent StateUniversity, Kent, OH

Background: A twenty-year oldCaucasian, male, height 6’2, weight185lbs, varsity athlete who is a right-handed pitcher on a division 1 baseballteam reports with shoulder and armpain. The athlete has been playingbaseball since he was six year old andhas no documented history of priorshoulder injuries or upper armconditions, until two months prior tothe manifestation of this conditionwhen he strained his right pectoral. Hehas no known medical history ofillness or acute injuries and patient’sfamily history reflects no genetic,terminal or chronic illnesses. Thepatient’s injury occurred during thepreseason of his sophomore year. Thepatient’s parents became concernedabout their son after they noticed anobvious hypertrophy in his right armonly. When asked, the patientmentioned having shoulder fatigue,tightness and “weird” sensations attimes. During inspection the patientpresented with noticeable tautness ofthe skin and edema in the right bicepand triceps region and slight edema andtautness in the forearm. The patient hadfull range of motion in the shoulderand elbow, as well as full strength basedon manual muscle tests and activerange of motion tests. The patienttested negative for Thoracic outletsyndrome and was referred to aphysician the next day. DifferentialDiagnoses: Thoracic OutletSyndrome (TOS) and ChronicExertional Upper Arm CompartmentSyndrome (CECS) were considered asdifferential diagnoses. Both of theseconditions mimic signs and symptomsexhibited by the patient. The patienttested negative for Thoracic OutletSyndrome yet was never tested forChronic Exertional Upper Arm

Compartment Syndrome although hereported arm tightness, swelling, andsome paresthesia of the fingers. Agross protrusion of a small artery inhis right arm was noticed during aphysician visit that warranted furtherimmediate investigation. Treatment:The physician determined the patienthad a possible Deep Vein Thrombosis(DVT). The patient was immediatelysent to a local Emergency Room for aDoppler Ultrasound to rule out DVT.Upon receiving a Doppler Ultrasoundat the local ER, the patient wasdetermined to have a Deep VeinThrombosis. The recommendedtreatment was a right para-clavicularthoracic outlet decompressionincluding anterior and middlescalenectomy, brachial plexusneurolysis, and complete resection ofthe first rib; external venolysis of thesubclavian vein; and an intraoperativeupper extremity venography. Post-operatively, the patient was placed onanticoagulants and was allowed to startrehabilitation exercises. The patienthad a full recovery and has completedhis return to play program within sevenmonths post-operatively. Uniqueness:UEDVT occurs in 2 out of every100,000 people per year afterstrenuous activity like wrestling,rowing or pitching and is usually intheir dominant arm. Incidence ratesshow that males are at a much greaterrisk for developing DVT than theirfemale counterparts and their riskincreases with their age. This patienthad no predisposing factors forUEDVT other than gender and thiscondition manifested over time ratherthan acutely. Conclusion: Upperextremity deep vein thrombosis is acondition that usually affects thedominant arm of overhead athletes.This disorder should be suspected inathletes and patients performingrepetitive overhead activities whodevelop acute-onset swelling.Treatment of this condition varies asdoes the underlying etiologies that

cause this condition. Early detectionand treatment of patients with UEDVTis important to successful treatmentand progression to return to play. Asathletic trainers, we are the first lineof detection and referral of UEDVT inour upper extremity athletes.

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Bilateral Neural ForaminalStenosis Associated WithSchmorl’s Nodes In AnAdolescent Football AthleteOrapello NS, Gildard M, Powers ME: Marist College,Poughkeepsie, NY

Background: We present the case ofan otherwise healthy sixteen year-oldhigh school football athlete who hadbeen experiencing intermittent lowerback pain for approximately two years.Although he could not identify a singletraumatic episode during football orany other sport activity, he did suffer afall while riding an all-terrain vehicle(ATV) just prior to symptomatic onset.He reported landing directly on thesacral area after falling off of themoving ATV, however he did not seekmedical care at that time. Physicalexamination revealed normal lumberlordosis and minimal tightness of thelower lumbar paraspinals. Weight-bearing lumbar extension exacerbatedpain while seated positions and lumbarflexion relieved symptoms. All testswere negative for radicular pain. Deeptendon reflexes, muscle strength andrange of motion were all found to bewithin normal limits, while all sensorytests were negative. DifferentialDiagnosis: Zygapophyseal jointsyndrome, spondylolysis, spondylo-listhesis, lumbar degenerative discdisease, disc herniation, spina bifidaocculta. Treatment: Upon referralradiographs were negative for vertebralmalalignment, bone and jointabnormalities, and spina bifida occulta.Magnetic resonance imaging (MRI)revealed a Schmorl’s node at the T12-L1 level. The MRI also revealed abilateral neural foraminal stenosis fromL3 to L5. A congenitally narrow centralspinal canal with mild annular diskbulging was observed at the L3 throughL5 levels and a decreased disc spaceheight with mild annular disc bulging wasobserved at the L5 and S1 level. Due tothe patient’s age and severity ofsymptoms, he was treated conservatively

with physical therapy. This consistedprimarily of Williams flexion exercisesand core strengthening. Uniqueness:Lumbar spinal stenosis is commonlydiagnosed after middle age andsecondary to years of degeneration,however those with a congenitally narrowcentral canal are more likely to developsymptoms at an earlier age. Our patient’ssymptoms began at age fourteen, whichis considered extremely early for thiscondition. Foraminal stenosis is oftenassociated with severe and radicular legpain because the decreased space in theneural foramin causing impingement ofthe dorsal root ganglion. Our patientfailed to report this, as his only symptomwas intermittent localized lumbar pain.Conclusions: The diagnosis offoraminal stenosis is heavily dependenton both an in-depth patient history andbody positioning during assessment.Symptomatic relief during rest andprovocation during activities indicate thedynamic component of foraminalstenosis. Narrowing of this area caneven occur with normal lateral flexionand extension motions in asymptomaticpatients. Typically, patients presentingwith lumbar stenosis will complain oflocalized back pain as well as radicularpain in the lower extremity uponstanding. Symptoms are normallyexacerbated by walking and otheractivity. While surgery is not uncommon,conservative treatment can providesuccessful outcomes. In the currentcase, the patient’s symptoms havefollowed the desired course ofregression following diagnosis andconservative treatment and he continuesto participate in recreational sportswithout limitation. While cases oflumbar foraminal stenosis are rare in anathletic population, the symptoms of maypresent similar to lumbar pathologiesseen more commonly in athleticpopulations. This emphasizes the needfor a very thorough clinical examination.

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Incidence Of AutoimmuneNeuromuscular Hyper-excitability In A Division ICollegiate AthleteTrotter N, Benson A: TheUniversity of Arkansas,Fayetteville, AR, and TroyUniversity, Troy, AL

Background: A 19 year old femalefreshman Division I collegiatebasketball player with a history of bi-lateral shoulder multi-directionalinstability presented to the athletictraining room in March her freshmanyear complaining of spasms in her neckand trapezius. The patient had recentlyreturned to activity following her thirdSLAP repair and thermalcapsulorrhaphy. Increase in activityresulted in more spasm. The AthleticTrainer (ATC) referred the patient tothe team physician, and she begantaking Zanaflex. One month later theathlete complained of a tight righttrapezius. The ATC performed a lightstretch of the trapezius, and thenapplied electrical stimulation and ice.After five minutes the patientcomplained of discomfort and the ATCnoted that the patients forearm andwrist were visibly contracted. Theelectrical stimulation wasimmediately discontinued. Thepatient’s scapula was visiblydepressed, her face appeared to havepartial paralysis and she had slurredspeech. The athlete was taken to theurgent care then transferred to theemergency room where blood workand a CT scan were performed. Theresults were normal and the athletewas diagnosed with Bell’s palsy and aninfection of the radial nerve. Duringthe fall of her sophomore year, thepatient was running sprints when shelost all motor control resulting in acollapse. Initial evaluation by the ATCnoted nystagmus, abdominal rigidityand the athlete complained of not beingable to move her legs or breathe. Uponrelaxation, the symptoms resolved andshe was referred to the team physician

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and then a neurologist. Both of thedoctors’ findings were inconclusiveand she was released. Later in theseason the patient experienced similarissues in her left shoulder includingdislocations and spasm. An episode ofsyncope and spasms occurred duringa game and the athlete was taken to theemergency room. Altitude and elevatedgallbladder enzymes were credited tothe patient’s episode. The patient wasthen referred to a second neurologist.Differential Diagnosis: Pinchedcervical nerve, Viral infection of theradial nerve, Bell’s Palsy, partialseizures, cervical dystonia, early onsettorsion dystonia, Autoimmuneneuromuscular hyper-excitabilitydisease (Stiff persons syndrome),Neuromyotonia, Paroxysmal nonKinesigenic Dyskinesia, andRheumatologic disease with CNSmanifestations. Treatment: Uponreferral to the second neurologist,diagnostic imaging was performedincluding an MRI, MRI Arthrogram,and a CT scan. Blood work screenedher thyroid levels and ceruloplasminantibodies. Screenings wereperformed to rule out: Wilson’sDisease and Neuromyotonia. Inaddition, an EMG/NCV, EEG, andspinal tap were performed. The ATCalso provided video footage to theneurologist to illustrate the severity ofthe spasms when they occurred. Thevideo and results of the test confirmedthat the patient suffered fromautoimmune neuromuscular hyper-excitability disease. The patient wastreated with Baclefen and allowed toreturn to full activity with follow-upcare as needed. Uniqueness: This isconsidered a rare disease and its exactcause is unknown; however the causeis thought to be acquired,paraneoplastic or heredity. It can oftenbe mistaken for ALS thereforeinstances within the athletic populationare unheard of. This is a treatabledisease with proper diagnosis and thesymptoms may fluctuate in severity

and frequency. Conclusions: ATCsneed to continue to broaden theirscope of knowledge related to variousmedical conditions. Symptoms canoften be misleading however the ATCneeds to continue to be an advocate forthe patient and gather as much data aspossible in order to ensure that aproper diagnosis can be made. Eventhough patients appear young andhealthy, the possibility of uniquediseases should never be ignored.

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Cervical Spine Anomaly In ACollegiate Football PlayerJacobs MM, Hoch JM, BradleyMH: Old Dominion University,Norfolk, VA

Background: A 21 year old maleDivision I-AA wide receiver sustaineda neck injury during a football game.The collision was helmet to helmetwith a tucked chin, resulting in an axialload with subsequent hyperextension.He walked off the field and reportedto the athletic training staff withcomplaints of neck pain in the leftsuboccipital neck region. Uponexamination the athletic training staffnoted no radiculopathy, no UEweakness, no cracking sounds/sensations with movement, and noswelling or deformity. Pain increasedwith PROM: contralateral flexion,bilateral rotation, and extension. Anyattempt of AROM could not beperformed due to pain. The patient hadprevious history of neck pain on rightside after being tackled in a game theprevious season. DifferentialDiagnoses: Neck fracture, musclestrain, ligament sprain. Treatment:The orthopedic physician ordered x-rays to rule out any bony pathology.Radiographs were taken at the gameusing a portable device. The orthopedicphysician deemed the x-rays abnormaland requested they be reviewed by aradiologist. The radiologist reportedthe x-rays to be negative. The patientwas placed in a c-spine collar andunderwent conservative modalitytreatment. During this time, the patientwas monitored to determine if furthertesting was necessary. Two days afterthe initial injury, neck stiffness andpain persisted with manual axial load.Therefore, it was determined thatfurther diagnostic testing wasnecessary and a CT scan was scheduled.The results of the CT scan revealed acongenital C1 anterior and posteriorneural arch defect. An appointmentwith the team spine specialist was madefor the following week to discuss

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prognosis. The patient continuedtreatment with modalities and the useof a c-spine collar until hisappointment with the spine specialist.During the appointment, the patient’sCT scan was examined and x-rays inneck flexion and extension were takento determine if there was anymovement of the C1 vertebrae. Nomovement of the C1 vertebrae wasnoted. The spine specialist confirmedthat the non-union of the anterior andposterior neural arch of C1 was acongenital anomaly. The initialrecommendation by the spinespecialist was to discontinueparticipation in football. However,further consideration was givenregarding the lack of C1 movement andthe physician cleared the athlete toreturn to football activities. However,the patient and his family chose todiscontinue participation in football.Uniqueness: The literature reportsthat C1 anomalies occur in only 2%of patients, with combined anteriorand posterior non-unions being therarest. Most congenital C1 anomaliesare asymptomatic, but can besymptomatic following trauma, suchas the direct blow sustained in thiscase. It has been reported that thesymptoms and appearance of a C1anomaly can be similar to thoseexhibited with an acute fracture.Correctly diagnosing the C1 injury isimportant because the treatment of aC1 anomaly versus acute fracture isdifferent. Furthermore, excessmovement must be measured in theseindividuals via flexion and extensionx-rays in order to determine thestability of the non-union arches. Inthis case, no movement was detectedin the patient’s flexion and extensionx-rays. Conclusions: This patientsustained an axial load andhyperextension to his cervical spineresulting in the discovery of a C1anomaly. His mechanism of injurysuggested a cervical spine fracture buthis ability to walk off the field and hislack of radiculopathy clouded the

diagnosis. Athletic trainers need to becautious when dealing with suspectedc-spine injuries and continue tomonitor associated symptoms. Spineanomalies are often difficult toidentify on x-rays therefore a CT scanand/or MRI may be necessary.

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Delayed Onset CompartmentSyndrome Secondary To AThigh Contusion In A Division 1Men’s Hockey Athlete: A CaseStudyCastrejana TC, Lago MJ, KrawiecCJ, Thomas AC: NortheasternUniversity, Boston, MA, andHarvard University, Cambridge,MA

Background: The patient was atwenty-year-old collegiate Division1men’s ice hockey athlete, 75 inches inheight and weighing 205 pounds. Thepatient’s significant medical historyinvolved a Total Anomalous PulmonaryVenous Return at 11 months old,however this did not give suspicion tohis injury. After he was hit with anopponent’s knee and received acontusion to the left anterolateralthigh, this athlete had a severe increasein pain and edema, three days post-injury. Treatments applied to theathlete, during that time, included ice,compression wrap, stretching, deeposcillation therapy and pneumaticsequential compression. The athletealso took Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), againstmedical advice. The athletic trainermeasured his left thigh girth at 56 cmat 6 cm above the patella while theright was at 54 cm. The athlete’s thighwas elevated 45° and his distalsensation and circulation wasmonitored with no noticeable changein either. Differential Diagnosis:While the initial concern wascompartment syndrome, differentialdiagnoses considered were deep veinthrombosis, hematoma, acuteischemia, rhabdomyolysis, quadricepscontusion, femoral nerve injury, andmyositis ossificans. Treatment: Thephysician, on site, noted the increasein swelling, severe pain, and inabilityto flex the left knee. The physician,concerned about compartmentsyndrome, took the patient formeasurement of compartmentpressures. His quadriceps

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compartment pressure was measuredat 23 mmHg and he was kept overnightfor observation. The following daythe patient had a sharp increase insymptoms and was taken to an urbanlevel 1 trauma center. The pressurein the patient’s quadriceps readbetween 55-60 mmHg with adiastolic blood pressure of 70mmHg. The athlete was diagnosedwith delayed onset compartmentsyndrome of his left thigh and anurgent fasciotomy was ordered todecrease the compartmentalpressure. The fascia was releasedthrough an incision proximally anddistally, significantly decreasingpressure throughout the thigh. Twodays post-operation, due to anadditional increase in pain andswelling, the fasciotomy wasextended roughly 10 cm proximallyand distally. The vastus lateralis wassplit along the femur and a largehematoma was completely removed.97 days after the patient’s initialinjury, with rehabilitation from thesports medicine staff, he was able toreturn to Division 1 hockey.Uniqueness: The mechanism ofinjury and the development ofsymptoms are intriguing factors inthis case. Although contusions arecommon in sports, delayed onsetthigh compartment syndromesecondary to a contusion is rare.Compartment syndrome in theanterolateral compartment of thethigh is usually the result of blunttrauma in the form of femoralfractures and car accidents, ratherthan from a contusion. This patientalso had a reduction of edema andpain after the initial injury, and thena sudden resurgence of both aspectsthree days post injury. Conclusions:Three days after receiving acontusion to the left anterolateralthigh, the patient had a spontaneousincrease in pain and swelling. Thenext day, when the compartmentpressure reached 55-60 mmHg, athigh fasciotomy was performed.

Two days post-operation, it wasextended due to resurgence insymptoms. This case goes to showthat delayed onset compartmentsyndrome can occur from acontusion to the thigh, thereforeclinicians need to possess a highindex of suspicion for this injurywhen blunt trauma is involved.Furthermore, the effects ofpneumatic sequential compressionand NSAIDs on the vascular systemneed to be taken into considerationwhen treating contusions. Morestudies are also needed on theeffects of these treatmentsin relation to compartmentsyndrome. Further research isneeded on the factors that influenceclinical outcomes to determineproper treatment protocols .

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Anterior Fibular Dislocation InA Collegiate Baseball Player: ACase StudyChelette CJ, Greis PE, PetronDJ,Yochem EM, Hicks-Little CA:University of Utah, Salt Lake City,UT

Background: A 23 year old healthymale division one baseball athlete withno previous history of lower legpathology sustained an injury to hisleft knee during a practice session onthe turf in the indoor practice facility.The athlete was running to home baseand stepped on the plate. Since thiswas in the indoor facility the plate wasnot secured to the ground and thereforeslid causing the athlete’s knee tohyperextend upon contact with theplate. The Athletic Trainer immediate-ly evaluated the injury and found theathlete was complaining ofanterolateral knee pain. Uponpalpation it was noted that the fibularhead was not in its correct anatomicalposition. The Athletic Trainercarefully raised the pant leg to furtherexamine the athlete’s knee. Thisrevealed a large protrusion on theanterior aspect of the athlete’s kneejust lateral to the tibial tuberosity. Itwas suspected that the athlete’s fibularhead had dislocated anteriorly. Theathlete was rushed to the UniversityOrthopaedic Center for furtherevaluation by the team physician.Differential Diagnosis: Fibular headdislocation, Lateral collateralligament sprain, Fractured Fibula,Posterior tibiofibular ligament sprain,Anterior tibiofibular ligament sprain.Treatment: The athlete was seenimmediately by an OrthopedicSpecialist. X-rays and a MRI revealeda dislocated fibular head. Thephysician tried but was unsuccessfulat reducing the dislocation. The athletewas therefore scheduled to be reducedunder anesthesia the next morning.The athlete was placed in animmobilizer, provided crutches andtransported home. That evening the

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athlete accidently slipped on hisstaircase and unknown to himselfreduced his fibular head. X-rays weretaken the following morning prior tohis scheduled reduction which showednormal fibular alignment. The athletewas again placed in a straight legimmobilizer and provided crutches.The day after self-reduction, theathlete was point tender over thefibular head as well was the bicepsfemoris tendon. For the first weekof rehabili tation the athletecompleted quad sets, ankle pumps,and received Gameready treatment.The second week of rehabilitationconsisted of a light resistance bikeprogram and basic uniplanar lowerextremity exercises. Further, theathlete discontinued the use of thecrutches and began to fully bareweight. During week three theathlete was cleared to return to playas tolerated. The athlete began to hitballs off the tee, and field groundballs delivered straight towards him.During week four the athlete workedon ground balls directed away fromhim, started hitting live pitches andperforming the following functionalactivities; running, sliding, andcutting. The athlete returned to playwith no restrictions 35 days after theinitial injury and finished the seasonwith no complications. Unique-ness: Anterior fibular headdislocations are the most commontype of fibular head dislocationshowever, the uniqueness of this casewas in the mechanism of injury.Commonly, the fibular head isdislocated when falling on a flexedknee. In this case, the athletedescribed a hyperextension of hisknee before the fibular headdislocated and relocated the fibularhead by falling on a flexed knee.Conclusion: A 23 year old healthymale baseball athlete dislocated hisfibula while running bases duringpractice. The athlete self-reduced byfalling on a set of stairs. The athleteunderwent rehabilitation for 35 day

before returning to play. This caseis important because it providesa base for rehabili tation fordislocated fibular heads. Further, ithighlights the importance forathletic trainers to look beyond themechanism of injury in theirevaluation and differential diagnosis.

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Compartment SyndromeFollowing Anterior CruciateLigament ReconstructionMacDonald A, Johnson D, CoatesA, Lattermann C: University ofKentucky Orthopaedic Surgery &Sports Medicine, Lexington, KY

Background: An eighteen year oldmale high school senior presentedclinically with a left knee AnteriorCruciate Ligament (ACL) tear, themechanism of which was reportedlyunknown by the patient. The patient’smedical history included a previousleft knee ACL tear which had beensurgically repaired approximately 9months previous to this currentincident. The initial tear was duringclub soccer season in the summer. Thepatient’s initial surgery and rehab wereconsidered a success as he was able toreturn for the final half of his seniorsoccer season. Two weeks after theinitial visit the patient underwent ACLrevision surgery. Post operatively thepatient was given an electric coolingdevice and instructions for usage anda prescription for narcotics to use PRNduring the initial post-operativerecovery process. The patient wasinstructed to begin therapy four dayspost-operatively. Two weeks post-surgery the patient presented in ourclinic for his second post-operativevisit. The patient presented with a mildknee effusion as well as calf swelling.He complained of intense pain in hisknee and lower leg. He wasimmediately transferred to a localemergency department for furtherevaluation. Differential diagnosis:deep vein thrombosis (DVT),compartment syndrome. Treatment:An ultrasound was performed at a localemergency department for a suspectedDVT. The ultrasound was negative forDVT. Intracompartmental pressure wastaken which showed an increase inpressure consistent with compartmentsyndrome in a single compartment. Alateral release was performed. Thepatient was admitted to the hospital for

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continued care and monitoring. Heremained in the hospital for 3 days postlateral release with no recurrence ofsymptoms. Prior to hospital dischargethe wound was closed and the patientwas instructed to follow up with hissurgeon in 3 weeks for both lateralrelease and ACL care. It was laterrevealed to orthopeadic staff that thepatient had used the electric coolingdevice on a constant basis for 24 plushours. We believe that this constantusages lead to a rebound phenomenonin the patient, leading directly to thecompartment syndrome. Uniqueness:To our knowledge there are no othercases similar to this in the literature.There are no cases of reboundphenomenon in orthopeadic journals.There are cases that appear to besimilar but the causes of compartmentsyndrome were attributed to eitherimproper tourniquet usage duringsurgery or 1st degree frostbite causedby direct-to-skin contact of a coolingdevice. Conclusion: This case, whileincreidibly unique, illustrates theimportance of following themanufacturer’s recommendationswhen using an electronic coolingdevice. Electric cooling devices arebecoming more and more common inathletic training rooms as well as usefor in home for post-operativeswelling and pain reduction. It alsodemonstrates the importance ofcommunication following surgery andgiving explicit instructions for post-operative treatment. After a lengthyphysical therapy process in which thepatient was relatively non-compliant,the patient regained full use of his footand is now walking with a normal gait.

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Traumatic Eye Injury In A HighSchool Female Soccer AthleteFelton SD, Frymyer JL, AndrewsCA: Florida Gulf Coast University,Fort Myers, FL, and NaplesCommunity Hospital, Naples, FL

Background: Athlete is an 18-year-old Hispanic female soccer goalie.Athlete had no previous history ofconcussion, eye injuries, or othersignificant medical history; however,athlete does wear corrective contactlenses while participating. The athlete,competing at an away competition, wasdefending the goal when she was struckin the left eye from an opponent’s shoton goal from a distance ofapproximately 7 yards. CertifiedAthletic Trainer (ATC) was summonedonto the field for on-the-fieldassessment. Athlete presented with anepistaxis, but no cervical tenderness orpathology and was alert and orientedtimes 3. Further side-line examinationrevealed athlete complaining oftransient oculus sinister vision thatresolved by the completion of theexamination. Concussion assessmentincluding vitals, cranial nerveassessment, Standardized Assessmentof Concussion (SAC) test, and BalanceError Scoring System (BESS) WNL.Host ATC educated athlete andguardian on potential signs andsymptoms that would constitute theneed for immediate referral andinstructed the athlete to follow up withthe ATC at her school the next day.During the follow-up exam completedthe next day by ATC, the athletepresented with no signs or symptomsof a concussion, normal visualtracking, and PEARLA normal. Athletecomplained of intermittent gray spotsand blurry vision while looking down.ATC, in consultation with guardianreferred athlete to an Optometristwhich was further referred to anOphthalmologist. DifferentialDiagnosis: Concussion, CranialNerve Pathology, Corneal Abrasion,

Eye Orbit Contusion, RetinalDetachment Treatment: TheOphthalmologist completedcomprehensive eye examination anddiagnosed athlete with an atrophic holewithin the left retina and commotioretinae. Athlete was withheld from allsport participation to limit increasesin vitreous pressure which could leakto cause retinal detachment and wasscheduled for Ophthalmologistfollow-up appoint-ment in 5 weeks. At5-week follow-up, athlete’s signs andsymptoms persisted, and as resultunderwent in-office Panretinal LaserSurgery (PRP). The PRP surgeryproduces scar formations to decreasethe likelihood of the atrophic holeprogressing to a retinal detachment.The PRP surgery ultimately correctedthe athlete’s symptoms. Athlete did notparticipate in spring sports or activityand had follow-up withophthalmologist for spring pre-participation physical clearance. Atthat time, ophthal-mologist clearedathlete with no restrictions.Uniqueness: Acute traumatic atrophicretinal holes are extremelyuncommon. Through an extensiveliterature review, most atrophic retinalholes are a result of chronicdegeneration seen commonly inpatients with diabetes and peripheralvascular disease. The atrophic holesoccur in patients due to the vitreoushumorous changing consistencycausing a traction force which resultsin thinning of the retinal tissue. Theathlete did experience commotioretinae, a common sign associated withcountercoup eye injuries. Althoughcommotio retinae does not directlyproduce inner eye swelling, it is acontributing factor for periretinalswelling which may have created thetraction force required for theformation of the atrophic hole.Conclusions: This case highlights thediagnosis of an athlete with a traumaticatrophic retinal hole resulting from ablow to the ipsilateral side of the head.

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The case is extremely unique sinceatrophic retinal holes are typically aresult of age or diseases whichcontributes to thinning of the retina.This case highlights the need for theATC to complete a thorough clinicalexamination. In this case, a head injurywas able to be ruled out because of thecomprehensive concussion evaluationbeing negative, but the ATC needed tocontinue to examine to explore causesfor the visual disturbances that werepresented. Case also highlights theprompt referral and management of acondition with unexplained clinicalpresentation. The athlete has made afull recovery and has not had anyfurther problems or complaints.

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Exertional Rhabdomyolysis InA High School AthleteMichelini KJ, Plos JM, MartinGM: Western Illinois University,Macomb, IL, and LaSalle PeruHigh School, LaSalle, IL

Background: A 17-year-old, male, highschool athlete reported to the athletictrainer (AT) two days afterparticipating in a Physical Education(PE) class in which maximum weightsand repetitions were completed. Theathlete complained of severe bilateralarm pain, generalized body soreness,inability to sleep or fully extend hisarms, and dark urine. The athlete waswell-conditioned, had no previoushistory of injuries, surgeries, or othermedical illnesses and denied use ofpower drinks, caffeine, stimulants,steroids, or supplements. The AT’sexamination indicated tenderness onthe biceps brachii and forearms withlimited elbow motion in both flexion(~90 degrees) and extension (~160-170 degrees). All other tests werenegative; therefore the AT attemptedmassage, which did not diminish thepain or increase motion. DifferentialDx: Delayed-onset muscle soreness,dehydration, exertional rhabdo-myolysis, muscle strain. Treatment:Suspecting exertional rhabdo-myolysis, the AT contacted theathlete’s physician for consultation andexam. Physical findings noted: limitedelbow extension (160-165 degrees atright elbow; 170 degrees at left elbow)and flexion (<90 degrees at rightelbow; 80 degrees at left elbow);severe point tenderness on the anteriorand lower portion of the biceps and thevolar surface of the forearmsbilaterally; normal grip strength;normal pulses at the wrist; intactsensation, normal strength; and noswelling or discoloration. Blood testsrevealed creatine kinase (CK) levels>4500 u/L (normal range 33-145 u/L),confirming exertional rhabdo-myolysis. The athlete was admitted to

the hospital for intravenous fluids (IV)for hydration and IV fluid withbicarbonate for urine alkalization.After 3 days, the athlete wasdischarged with an acid-free fluidtreatment plan and disqualified fromall activities for the next 48 hours.Seven days post-injury, the athlete wasallowed to participate in restrictedbasketball practice, but wasdisqualified from the PE class. After14 days, the athlete was allowed toreturn to full practice with dailyprogressive 30 minute timeallotments, but was still restrictedfrom weight training. Three weekspost-injury, the athlete returned to fullparticipation and was released forunrestricted weight training. Nophysical complications resulted fromthe exertional rhabdomyolysis.Uniqueness: Cases of exertionalrhabdomyolysis in college athleteshave been frequently reported over thelast decade and continue to make theheadlines as larger numbers of teammembers fall victim to thispreventable condition. Cases ofexertional rhabdomyolysis in highschool athletes have just begun to bereported and have resulted frompunishment drills or extreme trainingsessions. This case is unique given thatthe athlete was participating in a PEclass that incorporated regular weighttraining sessions prior to this incident.In addition, the athlete’s two youngerbrothers were in the same class andparticipated in the maximum weightsand repetitions activity, but did notexperience exertional rhabdo-myolysis. Conclusions: Exertionalrhabdomyolysis is the breakdown ofmuscle caused by excessive strenuousexercise. Exertional rhabdomyolysiscan occur in individuals of any age, anyfitness level, and while participating inany maximal exercise activity. Thecondition can mimic the muscle painand limited range of motion associatedwith delayed-onset muscle soreness,making it easy to overlook. Exertional

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rhabdomyolysis can be fatal if thesymptoms are not reported by theathlete or if missed by the AT. Thekey signs and symptoms for earlyrecognition and referral are darkcolored urine and severe musclepain a day or two after exercise.Elevated CK levels assist inthe diagnosis. With this condition onthe rise, the AT must continue toeducate athletes, coaches, andphysical educators about exertionalrhabdomyolysis, exercise protocolsand other factors that tendto contribute to the condition,the associated signs and symptoms,proper immediate care, andthe potential complications.

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Facial Pain In A CollegiateFootball PlayerTravers E, Rothbard M, Nelson C:Southern Connecticut StateUniversity, New Haven, CT

Background: An 18 year-old malefootball player with no previous relatedhistory presented to the athletic trainerwith acute, severe, sharp mandibularpain accompanied by loss of function,malocclusion, and mild headachesecondary to a direct blow. The patientwas running while holding a 45lbrubberized weight during a springseason workout when he tripped andfell forward, dropping the weight whichbounced off the floor and made directmandibular contact. Pain quotient wasdescribed as a 9/10 with most of thediscomfort being felt inside the mouth.Visual inspection revealed immediatesevere swelling, moderate bleedingfrom a lip laceration, and grossdeformity to the TMJ and mandiblewhich appeared to be shifted to theright. Physical inspection elicitedmoderate point tenderness anddeformity over the left TMJ and alongthe mandibular body without crepitus.The patient was unable to perform TMJelevation, depression, or lateraldeviation due to pain. No cervical painor ROM limitations were reported.Differential Diagnosis: TMJdislocation, closed head injury, toothfracture, trismus, and mandibularfracture. Treatment: Direct pressurewas applied to the laceration to controlbleeding, a rigid cervical collar wasapplied for immobilization, and hisairway was stabilized by the athletictraining staff. EMS was summoned fortransport to the emergencydepartment. After initial consultationwith the emergency medicinephysician, he was referred to amaxillofacial surgeon. Maxillofacialradiographs revealed five fracture sitesand the patient was subsequentlydefinitively diagnosed with multipleunstable mandibular fractures on thebody and condyles causing the TMJ to

appear dislocated. Status-post threedays, the patient underwentmaxillomandibular fixation with wireosteosynthesis and braces to keep histeeth from shifting. He was placed ona strict liquid diet for two weeks, thenpermitted to progress to soft foods,and finally advanced to solid foods astolerated. Two months post-maxillomandibular fixation, thepatient was cleared for non-contactactivity and resumed conditioning.Three months status-post, the patientmade a full recovery and was expectedto be medically cleared forunrestricted participation; however, hewas ruled ineligible and is no longerparticipating in intercollegiateathletics. Uniqueness: Commonetiologies of mandibular fracturesinclude motor vehicle accidents andassaults, rather than sports, whichaccount for less than 4% of reportedcases. Mandibular fractures occur withan average of 1.5 to 1.8 fracture sitesdepending upon the mechanism;however, the incidence of four or morefracture sites is reported in less than.01% of cases. In addition to thenumber of fracture sites, themechanism and location of the fracturesites make this case unique. The speedand angle of force with which the 45lbplate made contact with the mandiblecaused unique and multiplecombination fractures along both thebody and the condyles. Commonfracture combinations include theangle and the body or condyle and thecondyles and the symphysis. A finalunique aspect of this case is that noneof the fractures sustained were locatedunder the third molar, which is themost common site. Conclusion:Mandible fractures occur as a resultof the prominent position, distinctiveshape, and lack of support of the bone.Patients suffering from mandibularfractures require airway stabilizationand examination to rule out pathologiesto the spine, brain, face, and teeth priorto maxillomandibular fixation and are

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Second Toe Swan NeckDeformity In NCAA MensBasketball PlayerClack SF, Christie SR, ErwinJR: Georgia Southern University,Statesboro, GA

Background: The subject was a 20year old male NCAA Division Ibasketball player. The subject had anunremarkable history of a lowerextremity phalangeal pathology. The6’10” power forward reported to theCertified Athletic Trainer (ATC)complaining of severe pain over theventral aspect of his right second toeduring a basketball game. Initialevaluation revealed that during the pushoff phase of an attempt to “dunk” thebasketball, the subject stepped on theposterior portion of a teammate’s heel,hyperextending his right toes as heforced himself vertically. The subjectfelt an initial “pop” accompanied withsharp, severe pain in the involved toe.Initial observation revealed an obviousproximal interphalangeal (PIP)hyperextension deformity in the rightsecond toe accompanied with slightdistal interphalangeal (DIP) jointflexion. The subject was incapable ofactive flexion at the PIP joint (0degrees). The subject was tender topalpation over the plantar aspect of thesecond toe. The ATC attempted toreduce an assumed PIP jointdislocation, which resulted in thereposition of the toe in the originaldeformed “swan neck” position. Thesubject was splinted and referred to anorthopedic surgeon. The orthopedicsurgeon evaluated the subject, placedin a walking book and referred thesubject to foot specialist for furtherinspection and imaging. DifferentialDiagnosis: Right second toe PIPdislocation; Right second toephalangeal fracture; Right second toeflexor digitorum longus tendonrupture. Treatment: The x-raysdisplayed a swan neck deformity of the

second toe. No notated signs of a PIPdislocation and a phalangeal fracture.The subject was diagnosed with aruptured flexor digitorum tendon ofthe second toe. A phalangeal pinningprocedure was proposed and executedby the foot specialist. Underfleuroscopic guidance, a 0.045 K wirepin was surgically implanted across theDIP and PIP joints of the second toeextending down into the base of theproximal second phalanx in attempt topromote bone healing at the plantarplate. The pin was secured and the righttoe and ankle were immobilized usinga custom toe splint and walking boot.The subject was non weight bearing forthree weeks. The subject began lowerextremity range of motion exercisesand strengthening as part of arehabilitation program three days post-surgery. In order to control and reducethe amount of muscular atrophy due toimmobilization, the subject was placedon a maintenance based rehabilitationprogram focusing on right ankle, knee,and hip strengthening. The pin wasremoved three weeks followingsurgery. The subject’s shoe was fittedwith a custom orthotic featuring a rigidtoe box to limit range of motion of thephalanges. The custom orthotic wasworn throughout the remainder of therehabilitation program and duringreturn to play. Uniqueness:Traditionally, a flexor tendon rupture,known as a swan neck deformity is seenin the upper extremity phalangesrather than in the lower extremityphalanges. A swan neck deformity ofthe lower extremity phalanges is ararity. To date, there are no casereports of a swan neck deformity tophalanges of the lower extremity. Thisextremely unusual toe hyperextensioninjury may be attributed to theuncommon forceful mechanism ofinjury. Conclusion: This case hasdemonstrated that a flexor digitorumtendon rupture can occur to the lowerextremity phalanges, which may beoverlooked in athletics because ATC’s

normally permitted to return to activitysix to eight weeks post injury. Patientsplaced on liquid diets should beclosely supervised and offeredcommercial meal replacements toensure proper nutritional balance andsufficient caloric intake. In this case,the maxillomandibular fixationhindered the patient’s nutritional statusand oxygen consumption required byathletic participation which slightlydelayed his anticipated return.

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and physicians are not familiar withthis injury occurring to the lowerextremity phalanges. It should not beassume that a swan neck deformity canonly occur to the upper extremityphalanges. The injury can besuccessfully treated and allow thesubject to return to play.

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Ruptured Soleus Tendon InMiddle-aged RunnerRidgeway J, Jagger J: Universityof Kentucky Orthopaedic Surgeryand Sports Medicine, Lexington,KY

Background: The athlete is a 48 yearold female who runs on a frequentschedule for half marathons. Shestated that she felt a pop in herposterior lateral right calf with animmediate onset of pain while running2 weeks prior. The athlete stated thatthe muscle balled up with additionalswelling, but no bruising. She said hercurrent pain level is a 2 out of 10,which is gradually improving daily, andonly takes naproxen as needed. She hashad no previous injury or surgery tothat area. Differential Diagnosis:Grastroc-soleus myotendinous strain,gastroc-soleus myotendinous rupture,mid-shaft fibula stress fracture,peroneal strain, peroneal ruptureTreatment: The athlete was examinedto have full strength and range ofmotion at the ankle and knee. She wastender along the lateral border of thegastroc-soleus musculotendinousjunction. Upon palpation, the right calfhas a fuller mass effect in comparisonto the left. X-rays of the tibia andfibula revealed no fractures or jointdislocations with the soft tissue beingwithin normal limits. The athlete wasdiagnosed with a possible tear of thegastroc-soleus musculotendionousjunction. A MRI was ordered toconfirm the diagnosis at her follow upappointment. In the interim, she wasallowed to continue activities astolerated due to the age of the injury.At her one week follow up, the resultsof the MRI confirmed a full thicknesstear of her soleus at the myotendinousjunction of the fibular sided tendonwith surrounding edema and a mildstrain of the medial head of thegastrocnemius. Upon examination, alump can still be palpable at the injurysite. Her edema and pain have bothbeen reduced while retaining full

strength and range of motion of theankle and knee. She was instructed tostart physical therapy for hernonoperative treatment, but did notreturn to clinic after this visit. Shewas contacted and verified that all herpain and edema had resolved, and wasback to running again. Uniqueness:With only an incident rate of 0.7%of all gasctroc-soleus myotendinousjunction injuries, an isolated soleustendon rupture is a rare occurrencethat could be easily misdiagnosedand ultimately mistreated.Conclusion : As seen with thisrunner, an out of the ordinary popcan lead to an uncommon injury,such as her soleus tendon rupture.With the help of advanced imagining,this injury can be correctlydiagnosed, so that the correctcorresponding treatment canbe enacted. In her case, nonoperativephysical therapy was the optimumcourse of action. Ultimately, withany athletic injury, anatomicaland functional assessments witha thorough history allow an athletictrainer to confidently evaluate andtreat an injury, even if the injuryis uncommon and mimics othermore common injuries.

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Non-Contact Fibular HeadFracture In A Division IIICollegiate Men’s BasketballPlayerHarris AM: Endicott CollegeBeverly, MA

Background: A twenty year old NCAAdivision III men’s basketball playerreports with a non-contact fibular headfracture and associated LCL injurywhile attempting a break-away layup ina game; jumping from two feet with adeceleration, varus, and slight twistingmotion to the knee. The athlete fell tothe floor in immediate pain. Athletewas assisted off the court via 1 personcarry and was evaluated. The athletepresented with immediate swelling andextreme tenderness to palpation overlateral aspect of knee extending to thefibular head. Patient was braced andsent to team orthopedic MD. Theathlete denied history of knee injuries.Athlete also denied inversionmechanism at the ankle consistent withMaisonneuve type injury. DifferentialDiagnosis: Possible diagnosis basedon location of pain included fibularhead fracture, fibular head subluxation,LCL tear, lateral meniscus tear.Possible diagnosis based onmechanism of injury included ACLtear, PCL tear, acute meniscal tear,LCL tear. Assessment given prior toimaging was LCL tear with fibular headsubluxation. Treatment: Orthopedicassessment along with radiographicimaging showed non-displaced fibularhead fracture of the left leg. Patientwas placed in CAM walking boot whileperforming low impact cross trainingfor six weeks as well as treatment withnon-thermal ultrasound and ice perMD protocol. Imaging received sixweeks post injury revealed full healingof bony structure. Patient was thenable to return to activity, progressingto full participation with no additionalcomplications. Uniqueness: Fibularhead fractures represent a small partof reported injuries sustained to theleg, with an even smaller percent of

those being fractures. Mostdocumentation and research hasrevolved around stress fracturesto the fibula rather than occultfractures. The more common offibular fractures reported arethose of an avulsive type injury dueto an outside varus force acting atthe knee with or without a fibularhead subluxation. There is noavailable literature on a fibularhead fracture associated with anon-contact type mechanism that hasonly mild complications withthe LCL. Conclusions: While a non-contact fibular head fracture isnot common, it is possible that thiscan occur. Practitioners can usethis case as a guideline if evercoming across a situation as uniquein their clinical practice.

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Rupture Of The PeronealRetinaculum In A CollegiateHurdlerWebster KJ, McNulty MB,Lawrence SJ, Uhl TL: Universityof Kentucky, Lexington, KY

Background: A 20 year old male trackand field athlete, who competes in 60msprint, and 60m hurdle events, with nohistory of ankle injury reported to theathletic training room after landinginverted of his left ankle when jumpinga hurdle during practice. He had minorswelling around the posterior aspectof his lateral malleolus. He was ableto walk into the athletic training roomwith a significant antalgic gait. Hecomplained of a sharp poppingsensation when landing after clearingthe hurdle. Upon observation he hadminimal swelling but significant painover his distal lateral fibula. He hadsignificant subluxation of his peronealtendons with dorsiflexion andplantarflexion, and described a poppingsensation with these movements.Strength, and range of motion were fairfor all directions both being limited bypain, Differential Diagnosis: Lateralankle sprain, peroneal muscle strain,and subluxation of peroneal tendons.Treatment: The team Orthopedist wason campus and evaluated him withinthirty minutes and diagnosed him witha ruptured peroneal retinaculum. Theathlete insisted on trying to competein the conference championship meetin two weeks. The Physician waswilling to allow him to try andcompete, knowing he could do nofurther damage. He was placed in ahigh tide walking boot on crutches nonweight bearing for 10 days at all timesand prescribed a Medrol dose pack tocontrol inflammation. Treatmentsconsisted of cryotherapy,compression, and interferentialcurrent electrical stimulation, tocontrol swelling and pain. Nostrengthening or range of motionexercises were implemented. For thefunctional test and meet the athletic

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training staff and Physician developeda way to stabilize the peroneal tendonsin the retromalleolar groove. Theathlete was taped using therabandtubing placed along the lateral fibula,to act as a bumper to preventsubluxation. Next we tape the distalthird of the tibiofibular joint using acircular pattern with leukotape, whichwas applied with as much force as theathlete could tolerate. Lastly the anklewas taped in a standard way to providesupport. He performed and passed afunctional test two days before themeet consisting of hurdle-take offs andstarting block take offs. He reportedsome pain but no subluxation orpopping and was determined to try torun in the meet. The athlete ran in thepreliminaries, and had a recurrentsubluxation, but qualified for finals.During the final race he felt a sharp popagain, but was able to finish the race andplaced 7th in the conference. Two weeksafter the meet he under went a Peronealretinaculoplasty surgery to repair theruptured retinaculum. After 5 weeks in aposterior splint, athlete beganrehabilitation, focusing on range ofmotion and strength. He started joggingat eight weeks, and hurdling at thirteenweeks and was cleared for fullparticipation at 20 weeks post-op.Uniqueness: This is a unique casebecause there is limited literature todescribe a conservative treatmenttechnique that allows an athlete toparticipate for a short period of timeprior to surgery. Using the three pillarsof evaluation, anatomy, physiology, andbiomechanics, along with patient valuesand our clinical expertise, we were ableto make up for the lack of literature andwe were able to develop an interventionthat allowed our athlete to accomplishhis goal of competing in the meet.Conclusions: This case demonstratedthat this innovative taping techniquecould allow an athlete to achieve theirgoal of competing without adverselyaffecting the long-term outcome.

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Navicular Avulsion Fracture In ADivision I Field Hockey Player: ACase ReportThornton AL, Hoch JM: OldDominion University, Norfolk, VA

Background: A 20-year old femaleDivision-I field hockey player, whowas undergoing treatment for tibialisanterior tendonopathy, suffered anacute foot injury while performing acutting maneuver during practice.The patient finished the drill andwalked off with severely antalgicgait. The patient reported feeling a“pop” in her foot and immediate,severe pain over the entire foot andankle region. Init ial physicalexamination (PE) revealed no grossdeformity, no edema, no ecchymosis,normal neurovascular screen, andgeneralized tenderness to palpation(TTP) over the foot and ankle regionwith moderate-to-severe TTP overthe first tarsometatarsal joint. ROMtests revealed painful passivedorsiflexion and plantar flexionROM. AROM was painful and limitedin all directions, especiallydorsiflexion. RROM was notassessed due to pain. The patient wasiced for the remainder of practice.Following ice removal the patientwas unable to WB without severepain. Repeat PE revealed mild edemaover the anteromedial foot region,continued TTP over the firsttarsometatarsal joint, moderate TTPover the navicular tuberosity, firstmetatarsal, medial talar dome, andtibialis anterior tendon. ROM testsand neurovascular screen remainedunchanged. Long bone compressiontest of first and second ray werenegative, transverse arch squeeze testwas negative, intermetatarsaldistraction caused pain and torsiontest was positive for pain,specifically combined pronation andeversion. Differential Diagnosis:Midfoot sprain, navicular fracture,metatarsal fracture, tibialis anteriorstrain, intrinsic foot muscle strain.Treatment: After 20minutes of

cryotherapy, a compression wrap wasapplied to the foot and ankle and thepatient was placed NWB on crutchesand instructed to ice and elevate. Oneday post-injury the patient reporteddecreased pain but the PE remainedunchanged. Rehabili tation wasinitiated with mild AROM andintrinsic foot strengtheningexercises. Two days post-injury thepatient was evaluated by the teamphysician who ordered x-rays whichrevealed a small navicular avulsionfracture. The patient was placed in along leg cast and instructed to beNWB. Following one week of painfree NWB the patient was given acast-shoe to begin walking in thecast. After two weeks additional x-rays were obtained and a bone growthstimulator was provided to wearwhile sleeping. The six weeks post-injury x-ray examination revealedfull fracture healing and the cast wasremoved. The patient was given ashort walking boot for 4-7 days whileregaining strength. The patientprogressed through a rehabilitationprogram to restore mobility,strength, neuromuscular control andpower. Two weeks into therehabilitation program, the patientexperienced abnormal pain along thefirst ray. An x-ray revealed intactbone and a walking boot wasprescribed until the pain subsided.After two days the patient wasprogressed out of the boot and re-initiated rehabilitation. The patientprogressed to the functional phase ofrehabili tation with no majorcomplications, but has continued toreport intermittent pain of varyingseverity. No specific cause of thepain can be identified. The patient isset to follow-up with an orthopedicfoot specialist to explore the causeof her continued pain. Uniqueness:Navicular avulsion fractures arerelatively rare injuries. This caseinvolves a small avulsion of thedorsal portion from the dorsaltalonavicular ligament that wastreated conservatively. Con-

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Non-Contact Patellar FractureIn A Collegiate Football PlayerFollowing ACL ReconstructionWasylyk NT, Antinarelli MK, HochJM, Shall LM: Old DominionUniversity, Norfolk VA; NorfolkState University, Norfolk, VA;Atlantic Orthopaedic Specialists,Virginia Beach, VA

Background: A 22-year-old collegiateoffensive lineman sustained a non-contact knee injury during a preseasonfootball practice. The patient reportedthat he stepped backwards,experienced a pop, and that it felt likesomeone kicked him in the knee. Uponinitial evaluation by the athletictraining staff diffuse swelling waspresent along with loss of active kneeextension. The patient reported an 8/10 pain. Palpation findings indicatedpoint tenderness over the anterioraspect of the knee and two separatebony prominences at the level of thepatella. No knee special tests wereperformed due to the diffuse swelling,extreme tenderness, and deformityover the anterior knee. The patient wasbraced in full extension andimmediately referred to the teamphysician for further evaluation. Thepatient’s medical history wassignificant for an ACL injuryapproximately 9 months previously inwhich he was able to complete theseason. Once the football season wascomplete he underwent ACLreconstruction utilizing a quadricepstendon autograft. Following astructured rehabilitation program andfunctional return to football relatedactivities the athlete was cleared toreturn to full activity approximately 7months post-ACL reconstruction.Differential Diagnosis: Patellartendon rupture, quadriceps tendonrupture, patellar fracture, tibialtubercle avulsion. Treatment:Following physician evaluation, x-rayswere ordered. Results of the x-rays

showed evidence of a transversefracture along the equator of thepatellar. The fracture was at the levelof the bony defect resultant from theACL reconstruction. One dayfollowing initial injury, the patientunderwent an open reduction internalfixation procedure to repair thefracture. Four pins were insertedparallel to one another from thefracture distally and reinforcementwires were placed around the pins in acrisscross fashion. The initial post-operative treatment consisted ofwound management and the patient wasbraced in full extension and allowedto weight-bear as tolerated withcrutches. One week post-operative, atherapeutic exercise program wasinitiated to decrease pain, edema, andrestore ROM. Active quadricepscontractions were not permittedduring post-operative weeks 2-4,however assisted hip strengthening andROM exercises were performed. Twoweeks post-operative the staples wereremoved and exercises to decreasepain, edema, and restore ROM werecontinued. Following two weeks ofimmobilization in full knee extension,with crutch use, the patient wasprogressed out of the brace andcrutches over the next six weeks. Fourweeks post-operative a repeatradiograph showed no evidence ofdistraction of the patella and at thistime quadriceps strengthening andknee ROM exercises were initiated.Eight weeks post-operative the patientwas out of the brace and began activeROM exercises. Ten weeks post-operative treatment focused onquadriceps muscle strengthening. Thepatient is currently fourteen weeks outand is continuing to improve; currenttreatment focuses on lower extremitystrengthening and increasing function.It is expected the patient will have thehardware removed once the fracturesite has healed, and return to fullactivities of daily living six monthspostoperatively. Uniqueness:

clusions: Mid-foot injuries canlead to long-term activity limitationsand participation restrictionsif not diagnosed and treated properly.Conservative treatment is usuallysufficient for full recovery butoperative treatment may benecessary for optimal outcomesin certain cases. In this case,conservative management anda graduated rehabilitation programproduced satisfactory results andthe patient is currently progress-ing to full participation. D

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According to the literature, patellafractures are rare but not uncommonfollowing ACL reconstructionutilizing quadriceps tendon graft.This case is unique because thefracture occurred as a result of atensile force at the knee and notdirect contact, which is a commonmechanism for acute patellarfracture in an athletic population.Additionally, the fracture was at thelevel of the bony defect resultantfrom the ACL reconstruction.Conclusions: In this case theindividual sustained a noncontactpatellar fracture approximately 7months post-ACL reconstructionusing quadriceps tendon autograft. Inaddition to integrity of the graft, thepatient’s strength, ROM andfunction; graft site healing should betaken into consideration whenreturning patients to full activity.

<file #>13364UCIsolated Grade II PosterolateralCorner Injury In A High SchoolFootball PlayerCreedon D, Gildard M, PowersME: Marist College,Poughkeepsie, NY

Background: We present the case ofa conservatively treated isolated gradeII posterolateral corner (PLC) injuryin a high school football player. Apreviously healthy sixteen year oldvarsity running back with no priorhistory of lower extremity injury wastackled during a preseason scrimmage.When the tackle occurred, his rightfoot was planted on the ground,resulting in an external rotation andvalgus force at the right knee. Theathlete was able to limp off the fieldunder his own power, however hepresented to the certified athletictrainer with complaints of deep andaching pain (6/10) over theposterolateral aspect of his right knee.Physical examination revealed a mildjoint effusion, decreased knee flexion,and point tenderness over the lateraltibial plateau, fibular head, and lateralcollateral ligament. The patient’s painincreased with flexion, varus stress,and weight bearing. Moderate (2+)laxity was noted with the varus stresstest at 30° of knee flexion, andincreased external rotation was notedwith the Dial test at 30° of knee flexion.Differential Diagnosis: Lateralcollateral ligament sprain, PLC injury,lateral meniscus tear, anterior/posterior cruciate ligament sprain,avulsion fracture of the fibular head,tibial plateau fracture. Treatment: Thepatient was managed on site with iceand compression. He was placed in astraight leg immobilizer and was givencrutches for non-weight bearingambulation. The patient was evaluatedby an orthopedic surgeon two daysafter the initial injury. Radiographswere negative for fracture, whilemagnetic resonance imaging (MRI)revealed a grade II sprain of the lateral

collateral ligament and popliteofibularligament, as well as a bone contusionwithin the posteromedial tibial plateau.The orthopedic surgeon recommendedconservative treatment which includedpartial weight bearing for four weeksin a DonJoy T-ROM brace allowing for30°-70° of knee flexion followed bya five week course of physical therapywith the goal of regaining normal rangeof motion, strength, andneuromuscular control. Uniqueness:PLC injuries are relatively rare whencompared to the other capsulo-ligamentous structures of the knee.These injuries are also rarely isolated(1.6%), and often occur withconcomitant tibial plateau fractures(Segond fracture), avulsion fracturesof the fibular head (arcuate sign),anterior and posterior cruciateligament tears, peroneal nerve injuries,distal tears of the biceps femoristendon, tears to the lateral head of thegastrocnemius, IT-Band tears, and kneedislocations. Injuries to the PLC arealso commonly missed upon bothphysical examination and imaging,especially in the presence ofconcomitant injuries. Furthermore,although conservative treatment isoften recommended for grade II PLCinjuries, there is little publishedinformation on the long-term naturalhistory, and there are no known reportson the natural history of isolated injuryof individual components of theposterolateral complex. Conclusions:It is crucial that clinicians proceedwith a high degree of suspicion whendealing with possible PLC injuries,especially in the case of grade IIIinjuries. After 2-3 weeks the tissuebecomes necrotic, and a primary acuterepair is no longer possible.Additionally, unrecognized injuries tothe PLC have been associated with ahigh incidence of ACL and PCL graftfailures, and chronic injury can resultin a high degree of disability. In thiscase the patient was cleared to returnto full participation approximately

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three months after the initial injury.He progressed through the start ofbasketball season withoutrecurrence and only minimalsymptoms. However, he still ex-hibits mild residual laxity withtibial external rotation. Althoughlong term follow up is needed tofully assess the outcome, it appearsthat in this case, conservativetreatment was successful in treatingan isolated grade II PLC injury.

<file #>13437SC

Median Arcuate LigamentSyndrome In A CollegiateFemale RowerStubblefield ZS, Mooney CH:Nova Southeastern University,Ft. Lauderdale, FL

Background: We present a case of amedian arcuate ligament syndrome(MALS) in a 20-year-old collegiatefemale rower. The purpose of this casereport was to emphasize the diagnosisand treatment of this rare vasculardisorder, in which the celiac artery wascompressed by the median arcuateligament as it passes through thediaphragm. The initial athletic trainingexamination, after a race in March2011, revealed severe lowerabdominal pain and cramping,accompanied by nausea andlightheadedness. The athlete had nohistory of abdominal pain and her vitalsigns recovered normally followingthe race. At first, her symptoms wereonly triggered by racing, but afterseveral months, even submaximalexercise provoked the symptoms. Dueto the incapacitating severity of thesymptoms, the athletic trainer referredher to the team physician.Differential Diagnosis: The athletictrainer ’s differential diagnosesincluded hypoglycemia, exertionalheat illness, illiopsoas spasm, andpossible ovarian cysts. Treatment: InApril of 2011, within a week of theonset of her symptoms, the athlete wasexamined by her team physician. Acomprehensive blood panel andurinalysis yielded normal results. Twoweeks later, a CT angiograph revealedonly a small ovarian cyst. The athletewas referred to a GI specialist whoprescribed omeprazole and ordered anultrasound of the liver and gall bladder.The ultrasound was unremarkable so hereferred the athlete for a cardiacevaluation to rule out vasovagalsyncope. The cardiac evaluationincluded an electrocardiogram,echocardiogram, and stress

electrocardiograph, which revealed abenign mitral valve prolapse. At afollow-up visit with the GI specialistin July 2011, a duplex scan of theceliac and mesenteric arteries wasunremarkable. An upper endoscopy,with biopsy, was also negative for H.Pylori. A magnetic resonanceangiogram (MRA) of the abdomenrevealed moderate narrowing of celiacartery, most likely related tocompression by the arcuate ligamentof the diaphragm. When the athletereported for August physical exams,the team physician cleared her toparticipate as tolerated, but referredher to a vascular surgeon for aconsultation. In December 2011, afterreviewing her records and performingan examination, the vascular surgeondeemed the athlete a candidate for alaparoscopic release of the medianarcuate ligament. In January 2012, theprocedure was performed and thepatient was released from the hospitalthe following day. The teamnutritionist, athletic trainer, andsurgeon educated the athlete onoptimal food choices before, duringand after exercise. During the fourweeks post-operative, the athletictrainer guided her through a gradualreturn to rowing. For the first 2 weekspost-operative, she was restricted tosubmaximal, low-impact cardio-vascular exercise. For the next twoweeks, she performed higher-impactcardiovascular exercise and begansubmaximal weight-lifting. After 4weeks, she began gradual progressionon the rowing ergometer, increasingexercise duration before increasingintensity. The athlete returned toracing 8 weeks after the surgery. Ourathlete has had to withhold herselffrom several races since the surgery,but is currently able to race withoutrecurrence of symptoms.Uniqueness: In 10-24% of people,the median arcuate ligament cancompress the celiac artery. CTangiography and MRA is able todiagnose the compression of the

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celiac artery. The significance of thiscompression is a source ofcontroversy in the literature,especially given the high incidence ofthis finding in otherwise asymptomaticindividuals. Conclusions: Athletictrainers often evaluate abdominal pain,nausea and lightheadedness. Weshould be aware that MALS can be asource of these symptoms. Athletictrainers are qualified to guide anathlete through a gradual return to playfollowing laparoscopic release of themedian arcuate ligament.

<file #>13278OC

Recurrent Anterior CruciateLigament Deficiency In TheVarus Aligned Knee Of A Multi-Sport AthleteStanislawski VM, Hackett TR,Ashton J: The Steadman Clinic,Vail, CO

Background: A 33 year old malerecreational athlete presented with leftknee instability in February 2011.Patient’s history involved multipleanterior cruciate ligament (ACL)injuries initially from a snowboardingaccident approximately twelve yearsprior. In 2001 he underwent primaryACL reconstruction with patellartendon autograft and partial medialmeniscectomy. A revision ACLreconstruction with patellar tendonallograft was performed 4years later.Both procedures were performed atoutside facilities. In February 2011,he presented with a chief complaint ofpopping, catching, and instabilityfollowing a work-related injury. Thepatient ambulated with antalgic gaitassisted by a custom hinged kneebrace. Focal exam revealed nodeformity, lesions, erythema orecchymosis. Patient was non-tenderto palpation and presented with equalpatellar mobility and range of motionof 0/0/125 degrees. Patient hadpositive Lachman and anterior drawertesting with negative meniscalfindings. After initial evaluation, arevision ACL reconstruction wasperformed. At 7months, he returnedto full activity with a functional ACLbrace. Approximately 10months aftersurgery, the patient experienced leftknee instability followed by a “pop”sensation. The patient returned forevaluation where physical examfindings, included left knee effusionwith positive Lachman and anteriordrawer tests, consistent with an ACLtear. Differential Diagnosis: ACLgraft insufficiency, graft tunnelmisplacement, lack of graftincorporation, meniscal pathology,varus alignment. Treatment: Initial

radiographic imaging including AP/Lateral/Sunrise views revealed goodjoint space and alignment and evidenceof two previous ACL reconstructionswith tunnels and screws. Outsidemagnetic resonance imaging(MRI)dated February 2011 revealed ACLrepair with graft failure, probable post-meniscectomy without tearing of theroot of the medial meniscus,degenerative joint disease of medialand patellofemoral compartments, andsmall flap tear of central trochleargroove. Initial surgical interventioninvolved revision ACL reconstructionwith Achilles tendon allograft, tunnelbone grafting and removal of hardware.Following re-injury, longstandingradiographs demonstrated varusalignment of left lower extremity.Diagnosis included failed ACLreconstruction secondary to varusalignment of the left lower extremitywarranting additional surgicalintervention. A staged procedureinvolving chondroplasty, hardwareremoval, allograft bone grafting, andopening wedge high tibialosteotomy(HTO) was performed tocorrect alignment, to be followed byrevision ACL reconstruction withallograft approximately 6months later.Uniqueness: A direct relationship hasbeen found to exist between lowerextremity varus alignment and anteriorcruciate ligament tension. It isrecommended that varus alignment beexamined in patients, especially withrecurrent ACL failures, as tensionacross a malaligned knee may causegraft stretching and failure regardlessof graft choice. Conclusions: Thisathletic patient underwent multiple leftknee procedures to reconstruct theintegrity of his ACL. He experiencedthree failed reconstructions prior toassessment of varus alignment. At5months status post HTO procedure tocorrect alignment the patient isprogressing through physical therapywith no complications. He continuesto demonstrate positive findings for

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ACL deficiency and is scheduled toproceed with revision ACLreconstruction. Recognition andcorrection of varus alignmentis crucial prior to proceeding witha ligament reconstruction, inparticular in a young athleticpopulation where varus alignmentcombined with ACL deficiencycan be a common finding. With thecombination of this stagedprocedure, the sports medicineteam hopes to return the patientto regular athletic activities andprevent the need for further surgicalintervention. It is for these reasonsthat sports medicine professionalsshould be aware of the reasonsfor primary ACL reconstructionfailure and be able to provide afull examination includingradiographic assessment to addresspotential malalignment.

<file #>13088UC

Athletic Training ConsiderationsIn A Below The Knee Amputee InFootball And Wrestling: A CaseReportHorne D, Charles-Liscombe R,Guffey J, Lesperance M:Greensboro College, Greensboro,NC; College of Mount St. Joseph,Cincinnati, OH; Southern GuilfordHigh School, Greensboro, NC

Background: A 15-year-old male witha right below the knee amputation(BKA) presented to the AT staff toparticipate in junior varsity footballand wrestling. The patient hadpreviously participated in youth sportswith few to no limitations. At the startof the academic year, the AT staff wererequired to assess the Americans withDisabilities Act (ADA) guidelines andthe North Carolina High SchoolAthletics Association (NCHSAA)rules and regulations regarding athleticparticipation for individuals withprosthetics. Care and management ofthe prosthetic appliance and limb werealso investigated. DifferentialDiagnosis: Choke syndrome, ContactDermatitis, Epidermal Cyst,Maceration, Tinea Infection.Treatment: The patient was able toparticipate throughout theinterscholastic football and wrestlingseasons with minimal complications.At the start of each footballcompetition, the AT staff provided theofficiating team with NCHSAArequired documentation of medicalnecessity and demonstrated adequatepadding for the rigid metal hinge andpost at the leg and foot interface. Priorto and during the wrestling season, thepatient was required to comply withNCHSAA weight certificationstandards with and without theprosthetic appliance. In activeindividuals with prosthetic lowerlimbs, several dermal conditions mayalso present and require treatmentfrom the AT. Complications such aschoke syndrome, contact dermatitis,

tinea infections, and skin macerationoften occur as are result of excessivecompression, moisture, friction, andinfection. Uniqueness: It is estimatedthat among the 21 million athletes withdisabilities, 5-10% have a physicaldisability or physical impairment inwhich Athletic Trainers must be ableto provide sideline care. As athletictrainers broaden their employmentsettings, the possibility for an athletictrainer working with a patient with aprosthetic is more common. Similarly,as large numbers of military veteransreturn from combat operations abroadwith amputations, these individualswill seek out opportunities forcompetitive participation and physicalactivity. ATs should be able to provideeach patient with the necessary careand recognize when referral isnecessary. ADA and NCHSAAregulations provide guidance to thepracticing AT on how to care forthese unique patients. Conclusions:It is important as an athletic trainerto provide compassionate andappropriate care to all athletes. Foran athlete who has a BKA prostheticor any other prostheses i t isimportant to know the ADAregulations and accommodations,understand how a prosthetic isdesigned, fit, and how to repairissues. The athletic trainer must alsobe able to recognize potentialcomplications for prosthetic use.Finally, the athletic trainer mustestablish relationships with thepatient, parent, coaches, primary caregiver, and the prosthetist .

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<file #>13099MCLeft Anterior Knee Pain In ACollegiate Women’s Track AndField 400-m HurdlerArredondo JA, Joseph CJ:University of Central Florida,Orlando, FL

Background: A 19-year-old femalecollegiate 400-m hurdler presentedwith left anterior knee pain over a twoweek period following the end of herfreshmen year of competition. Shecomplained of pain and swellingsubsequent to intense workouts duringthe peak of her outdoor season. For thepast five years, she has experiencedintermittent knee pain over herpatellar tendon throughout the courseof her training and competitions.Differential Diagnosis: Patellartendinitis, patellar tendon strain, tibialosteochondral defect, arthritis, medialmeniscal tear, inferior patellarcalcification. Treatment: Followingher season, the athlete was referred tothe team orthopedic physician.Radiographs were negative forfractures and no evidence of arthritiswas found. The physician’s diagnosiswas mild patellar tendinitis. The athletewas administered a course of oral anti-inflammatories with continued rest andrehabilitation for three months. Twoweeks into her return to fall pre-seasontraining, she continued to experiencesignificant anterior knee pain and wasreferred for diagnostic musculo-skeletal ultrasound images. Ultrasoundimages revealed two significant tearsin her patellar tendon. Due tocontinued pain and failed conservativetreatment, she was referred forplatelet-rich plasma (PRP) treatment.Three weeks later the athlete had herfirst PRP treatment administered.Following the injection, she was non-weight bearing for the first forty-eighthours. For the initial four weeks, nonon-steroidal anti-inflammatory drugs(NSAID’s) were ingested, and ice wasonly applied for ten minutes every hourto reduce the risk of impeding thehealing process. She progressed

through range of motion and stretchingexercises for the initial two weeks thenbegan to swim and bike. By week fourstrengthening exercises wereimplemented. At week five,prescription NSAID’s wereadministered and strengtheningexercises were progressed. At the startof the indoor season, additionalultrasound images confirmed markedimprovement with one of the two tears;however the other tear was stillpresent. As a result, her second PRPtreatment was administered. The samepost treatment protocol was followed.At week four, physical therapy (PT)was ordered three times per week forten weeks with the team physicaltherapist. Two months after PT, MRIand ultrasound images showedcomplete resolution and she has sincereturned to full participation.Uniqueness: This case is uniquebecause the athlete had significantintermittent knee pain for five years.Current literature suggests thatfollowing multiple PRP injections fortendinopathies, individuals return tofull activity within three to six months.This athlete returned to a highlytrained, collegiate level within tenmonths and is currently asymptomatic.The majority of studies have suggestedthat PRP treatments are beneficial andhave a positive influence in thetreatment of patellar tendinopathies.This case is unique because PRPevidence based research is still in itsinfancy and is a topic of interest in themedical field. This case providesadditional evidence to support the useof PRP treatment for patellartendinopathies. Conclusions: Acollegiate female 400-m hurdlerpresented with anterior knee pain at theend of her freshmen season ofcompetition. Ultrasound imagesconfirmed two significant tears in herpatellar tendon. The compromisedpatellar tendon was treated with twoplatelet-rich plasma treatments,NSAID’s, and PT. This case is

significant because in less than tenmonths the athlete is completelyasymptomatic and has returned to fullteam participation, despite beingsymptomatic for the previous fiveyears. More research is still needed todetermine an appropriate number oftreatments to be administered, the timeframe in which the treatments shouldbe administered, and the long termefficacy of PRP therapy.

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<file #>13114MC

Medial Knee Pain In An In-Season Collegiate Men’sSoccer PlayerWhisenant DJ, Joseph CJ:University of Central Florida,Orlando, FL

Background: A 21 year old malecollegiate soccer player presentedwith left knee pain following a game.His initial pain was felt after changingdirection from forward to backwardrunning. He complained of pain alongthe medial joint line and posteriormedial aspect of his knee with forcedknee flexion. Clinical examinationyielded a positive McMurray andbounce home test. The athlete had noprior history of left knee injuries.Differential Diagnosis: Medialmeniscal tear, Medial CollateralLigament sprain, femoral bonecontusion, tibial plateau contusion,femoral osteochondral defect (OCD).Treatment: Possible meniscalpathology was confirmed by the teamphysician and the athlete was referredfor diagnostic imaging. MRI resultsrevealed loose chondral fragments and1 x 1.5 cm acute lateral femoral OCDof the left knee. The loose bodies wereremoved arthroscopically and theOCD was repaired. Microfractureswere performed on the lateralfemoral condyle to promote healingof the OCD. Following surgery, theathlete was strictly non-weightbearing for one week. Range ofmotion and open chain strengtheningexercises were implementedimmediately following surgery. Theathlete began partial weight bearingin week two, and reached full weightbearing very quickly. Sport specificactivities were performed after fourweeks. The athlete reached fullparticipation five weeks post-surgery. Rehabili tation andtreatments were continued throughthe end of his season. He was able tocomplete the remainder of hiscompetitive season with minimalsymptoms. Uniqueness: The athletepresented with medial knee pain, yet

the injury occurred on the lateralaspect of the knee. Initial findingsindicated meniscal symptoms;however the injury occurred to thelateral femoral condyle. This case isalso unique because of the timelineto full participation. The patient wasable to return to full athleticcompetition in five weeks. Currentresearch has suggested that typicalreturn to competition in high-levelmale soccer athletes followingmicrofracture repair of a 2 cm2 OCDis eight months. The fact that hisOCD was relatively small, and thatonly a few microfractures wereperformed is the cause for hisuniquely quick recovery. Currentresearch has also suggested thatfrequency of OCD on the lateralfemoral condyle is fairly low (7-20%). This poses the question ofwhether size or location of an OCDrepaired with microfracture is moreimportant to recovery time.Conclusions : A collegiate malesoccer player who presented withpossible medial meniscus pathologywas found to have loose chondralfragments and a lateral femoral OCDof the left knee. The injury wasrepaired arthroscopically andrehabilitation began immediately. Hewas able to complete the remainderof his competit ive season withminimal symptoms; however,following the season, the athleteexperienced lateral knee pain. Thisis consistent with research thatsuggests microfracture repairmay cause clinical deterioration overtime. This case is significant becauseof the presentation of init ialsymptoms, and despite sufferinga potentially season ending injury,a high-level athlete returned tocompetition during the same season.He completed his collegiate careerand has now continued withrecreational participation.

<file #>13419SC

Osteochondroma Of TheScapula: An Unusual Cause OfUnilateral Scapular Winging InAn Overhead AthletePorter PA, Ismaeli Z, Renehan E,Johnson DC, Johnson TS:National Sports Medicine Institute,Lansdowne, VA

Background: A 15-year-old male highschool overhead athlete reported to hiscertified athletic trainer with a chiefcomplaint of left periscapular pain anddeformity. He was a two sport athlete,playing basketball and footballquarterback. He reported no incidentof injury or known history of upperextremity or back injury. The athletewas aware of the mass for several yearsbut noted a recent increase in size andirritation. He started having pain withweight training activities, such asoverhead press, lat pull downs andshoulder shrugs. He denied recentillness or constitutional symptoms.He complained of pain that is sharp inquality and intermittent in nature,occurring with reaching and overheadactivities. Range of motion was fullwith some scapular crepitus. Anevaluation revealed unilateral scapulawinging with a palpable mass on theleft side. The athlete was referred toteam physician for further evaluation.Differential Diagnosis: Differentialdiagnosis includes: brachialplexopathy, long thoracic nerve palsy,spinal accessory nerve palsy,Parsonage-Turner syndrome, cervicalradiculopathy, neoplasm. Treatment:Physical examination by physicianrevealed severe scapula winging on theleft and a palpable left shoulder massthat was supple and non-adherent to thethoracic ribs. There was no axillarylymphadenopathy. Diagnostic x-raysconfirmed an abnormal calcificationof the left thoracic. An MRI wasordered and consultation withorthopaedic tumor specialist wasobtained to rule out malignancy. MRIscan revealed a well circumscribed2cm x 2cm exostosis on the anterior

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aspect of the lower body of thescapula. The lesion was determined tobe an osteochondroma with a largemulti-septated cystic collection withprominent subscapular bursa thatmeasures 12cm X 7.5cm x 18cm.Treatment options were discussedwith parents and athlete with surgicalexcision encouraged. Surgicalexcision was carried out with anincision over the medial scapula withlower trapezius, latissimus dorsi, andrhomboids dissected. The medialscapula was retracted and the mass wassharply excised. Rehabilitation beganat one month status post and focusedon periscapular and rotator cuffstrengthening. Return to play criteriaincluding pain-free overhead ROM ofmotion, periscapula and rotator cuffstrengthening was met at four months.A scapulothoracic stabilization brace(used for proper scapular retraction toimprove posture alignment, scapularfunction, and reduce pain) wasprescribed for early return to play. Theathlete has made a full recovery andhas returned to full athletic activity,playing at starting quarterback positionin the fall. Uniqueness: Scapulawinging is a common finding in theevaluation of an overhead athlete withshoulder pain. The finding of unilateralscapular winging should alert thepractitioner/clinician to a differentialdiagnosis of neuropraxia, trauma, andneoplasm. Conclusions: This caseoutlines a rare cause of unilateralscapula winging in an overheadathlete. Osteochondromas are benignlesions that usually form on longbones. Osteochondromas are themost common benign lesion on thescapula and although rare (3-5% ofall cases), should be considered incases of unilateral scapula wingingwhen there is no definitivemechanism of injury. Full recoveryand return to competitive overheadsports can be achieved after successfulsurgical excision and rehabilitation ofthe periscapular musculature.

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Os Acromiale In DominantShoulder Of An OverheadAthleteMaguire MC, Petron DJ, Toth R,Lorens K, Hicks-Little CA:University of Utah, Salt Lake City,UT

Background: An 18 year old, female,freshmen Division 1 softball catcherwith no previous history of injury toeither shoulder prior to enteringcollege reports to the athletic trainerwith complaints of anterior shoulderpain. Due to the increases in activityfrom high school to collegiateathletics the athlete began toexperience anterior shoulder pain onher dominant (right) shoulder. Theathlete reported increased pain uponthrowing, especially long distances.Examination revealed tenderness topalpation over the right acromionprocess. The acromioclavicularcompression test as well as theHawkins sign were both positive forpain. Internal and external rotationshoulder range of motion was limiteddue to pain. When asked to rate herpain on a scale from 1 to 10, the athletereported a 7 out of 10. All other rangeof motion, special tests, and manualmuscle tests were within normallimits. Differential Diagnosis:Impingement syndrome, rotator cuffpathology, acromioclavicular jointsprain, biceps brachii pathology,scapular dyskinesis, labral pathology,clavicle fracture, thoracic outletsyndrome, directional instability, orbony pathology. Treatment: Theathlete was referred to the teamphysician where an evaluation resultedin the diagnosis of impingementsyndrome. The team physicianhowever, ordered an x-ray to rule outany other pathology. The x-rayrevealed an os acromiale. Osacromiale is found when one or moreof the three growth plates in theacromion process have not closed. Theathlete was given non-steroidal anti-inflammatory drugs (NSAIDs) and a

corticosteroid injection in order todecrease the pain and inflammationpresent in the area. The injection wasgiven at the site of pain which waslocated at the acromioclavicular joint.After 4 days of rest the athlete wasprescribed a shoulder rehabilitationprogram. The program focused onscapular muscle strengthening as wellas an overall shoulder muscleflexibility program in an effort to takethe pressure off the anterior aspect ofher shoulder. The shoulder programconsisted of multidirectional bandwork, horizontal flies, internal andexternal rotation exercises, raises inthe scapular plane, and scapularsqueezes. Additionally, modalitiessuch as ice, compression, ultrasound,and electric stimulation wereprescribed. Although this particularathlete was allowed to rest while theinjection took effect, she was neverfully with held from play. The athletewas instructed to decrease the weightshe was lifting to her tolerance and hernumber of throws in practice werelimited. As her strength increased andpain decreased, the amount she wasallowed to lifted and throw increasedaccordingly. The athlete was fully ableto return to play pain free after 3months. Uniqueness: Os acromialeis only present in eight percent of thepopulation and within that eightpercent, 33 percent have bilateral osacromiale. It is also reported to bemore prevalent in males than females.Although it is unknown if this athletehas bilateral os acromiale, the smallpercentage of female athletes thatpresent with this pathology providesevidence to the uniqueness of this case.Conclusion: According to currentresearch, the majority of anteriorshoulder pathologies can be treated bycorrecting scapula deficiencies. In thisparticular case, using NSAIDs and acortisone injection provided theathlete with significant pain reliefwhich enabled her to participate inrehabilitation. Within a month ofdiagnosis, the strength of the athletes’

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posterior musculature had increasedand her anterior shoulder pain hadsignificantly decreased. This caseprovides further support that even witha bony deformity, such as osacromiale, that results in significantanterior shoulder pain, implementinga scapular strengthening program aidsin rehabilitating the athlete back topain free return to play.

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Left Shoulder Pain In HighSchool AthleteLeast B, Johnson J, Hosey R:University 0f Kentucky, Lexington,KY, and Henry Clay High School,Lexington, KY

Background: A 17 year old righthanded high school football playerpresented to the athletic training roomwith diffuse left shoulder pain. Henoted discomfort superior to hisclavicle with radiation into his uppertrapezius and deltoid. He could notrecall a specific mechanism of injurybut stated discomfort began duringtackling drills. Due to the significantpain, the athlete noted difficultyraising his arm above shoulder leveland taking a deep breath. He deniedprevious history of injury to theshoulder, numbness, tingling, or neckpain. On examination the patient wastender superior to the proximal leftclavicle and within the mid-belly of thetrapezius and sternocleidomastoid.Shoulder ROM was limited to 90forward flexion and 90 abductionsecondary to pain. Neck ROM wasantalgic to left lateral bending butotherwise full. Strength within theshoulder was antalgic but full and hehad preserved strength and sensationthroughout the remainder of the leftupper extremity. DifferentialDiagnoses: Soft tissue contusion,clavicle fracture/ contusion,acromioclavicular sprain, shouldercapsular sprain, rib fracture.Treatment: Init ial treatmentconsisted of symptom management.The athlete was restricted from sportspecific activities, utilized over thecounter anti-inflammatory medi-cations for pain relief andextensively iced the shoulder. Witha lack of improvement, he was seenby the team physician. Plainradiographs were pertinent for a non-displaced fracture of the left first rib.The athlete was placed in a sling withinstructions for non-weight bearingof the left upper extremity andrestricted ROM. He was held out of

all contact activit ies for ananticipated 10-12 weeks. Physicaltherapy was initiated after 6 weeksof restricted motion and non-weightbearing. The athlete was seen every2 weeks for repeat rib radiographs.Callus formation was noted after 1month and healing progressedthereafter. At 6 weeks the patientbegan conditioning activit ies,progressed to weight lifting after 8weeks and released for full contactafter 10 weeks. At that time, he hadfull pain free ROM and strength.Therapy was continued forprogressive strengthening. Thepatient missed the remainder of thefootball season but was cleared forwrestling activities. Uniqueness:The case denoted a rare presentationof a first rib fracture with symptomsthat mimicked a clavicle or AC jointinjury. The patient’s symptoms werenon-specific, and without a givenmechanism of injury, could havebeen attributed to numerous softtissue and bony shoulder pathology.Conclusion: The athlete respondedwell to conservative management.He returned to wrestling activitiesinitially at full participation butactivity level had to be scaled backdue to pain recurrence. He will begradually progressed through painfree activity with a return to fullparticipation in another 2 weeks. Hedenied additional acute injury andrepeat radiographs noted acompletely healed left f irst r ibfracture with adequate callusformation. Final evaluationindicated a non-tender shoulder withsymmetric ROM and strengthbetween the uninvolved dominantand involved non-dominantextremity. Although rare, thediagnosis of a first rib fracturerequires a heightened suspicion frommedical professionals. Prolongedconservative management can yieldsatisfactory results and return toprevious level of activit ies.

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2013 season. Uniqueness: This caseis unique because the diagnosis ofsuprascapular neuropathy associatedwith repetitive overhead throwing isuncommon, and easily misdiagnosed.This can lead to improperrehabilitation, which may exacerbatethe problem. Conclusions :Evidence suggests that suprascapularneuropathies in overhead throwerscan be complex and potentiallymisdiagnosed due to a similarpresentation as common rotatorcuff tendonopathies. Cliniciansshould be aware that atrophy ofthe infraspinatus may be caused bya compression of the suprascapularnerve. This case study hopes toimprove the effectiveness ofclinicians in diagnosing and treatingsuprascapular neuropathies.

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Suprascapular Neuropathy In ACollegiate Baseball Pitcher: ACase StudyKlass SE, Chelette CJ, YochemEM, Burks RT, Petron DJ, Hicks-Little CA: New York University,New York, NY, and University ofUtah, Salt Lake City, UT

Background: A healthy 19-year-oldmale in his first year as an NCAADivision I baseball pitcher complainedof pain in his right anterior andposterior shoulder that he rated as a7-8/10. Pain occurred on 5/11/10after pitching 4 innings. The athletictrainer’s initial physical examinationrevealed point tenderness over therotator cuff musculature, full AROM,and weakness (4/5) with manualmuscle testing in flexion, adductionand external rotation. Resistedexternal rotation specificallyreproduced the pain. DifferentialDiagnosis: Rotator cuff pathology,suprascapular neuropathy, labralpathology, subacromial impingement,brachial plexopathy, C5-6radiculopathy, quadrilateral spacesyndrome, and space occupying lesion.Treatment: The team physician’sexamination on 5/12/10 identifiedsevere atrophy of the infraspinatuswith scapular dyskinesis. The atrophywas attributed to a suprascapular nervecompression in the spinoglenoidregion, which was thought to be froma ganglion cyst. An x-ray showed noabnormalities, and an MRI revealed nospace occupying lesion, rotator cuff orlabral pathology. A decreasedneuromotor signal in the suprascapularnerve was confirmed by anElectromyography (EMG) test.Surgeons who specialize in baseballinjuries were consulted on the case, andthey collectively recommended a 6month period of rest, rehabilitation,and a slow throwing progression. Theathlete improved steadily, and wascleared for full participation on 12/7/10 after an improved EMG test andsuccessful bouts of pain free pitchingat full strength. During the spring

season, pain and atrophy returned,which was confirmed by EMG testingon 3/18/11. At this time surgery wasrecommended, but the athlete opted totry Accelerated RecoveryPerformance (ARP) wave treatmentinstead. After 5 weeks of treatment, thesymptoms remained unresolved, andon 5/10/11 the athlete underwentsurgery to decompress thesuprascapular nerve. Nine months ofrehabilitation, including scapularcorrection, eccentric exercise, andthrowing followed the surgery, and hereturned to pitching and all teamactivities on 1/9/12. After 7 weeks ofsuccessful pitching, complaints ofscapular tightness began. Prolongedtightness led to a follow up shoulderMRI on 3/24/11, which was deemednormal. Acupuncture, suction cup, andmassage therapy were attempted torelieve the tightness with limitedsuccess. Lack of relief led to a CTscan of the right shoulder on 4/6/12to rule out quadrilateral spacesyndrome. The scan revealed apossible occlusion of thesuprascapular artery, potentiallycausing thoracic outlet syndromeduring throwing. Upon consulting avascular specialist, it was concludedthat thoracic outlet syndrome was notthe cause of the symptoms. Referralto a physician with several yearsexperience in major league baseballdid not uncover any new evidence. Torule out a cervical radiculopathy, aneck MRI was performed on 4/23/12 that showed no irregularities.Symptoms again improved with rest,and a throwing program was initiatedthe following fall on 6/18/12. Thisirritated the athlete’s right latissimusdorsi muscle. As a result the athleteconsulted a chiropractor, who addedsupplemental K-Laser treatments tothe existing rehabilitation exercises.By slowing the athlete’s progressionand modifying mechanics, hecontinues to improve with minorsetbacks. To date the athlete is onschedule to participate in the 2012-

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Wrist Pain In A FemaleIntercollegiate Javelin ThrowerBrodeur A, Rothbard M, Davis C:Southern Connecticut StateUniversity, New Haven, CT

Background: A 20 year-old, 64cm,72.6kg female javelin throwerpresented with right, dull, radiatingmid-forearm pain with crepitussecondary to repetitive stress. Shereported being able to perform ADL,but unable to perform unrestrictedsport activities. Pain quotient was 5/10 at rest, 8/10 with activity, and 6/10after activity. Pain was alleviated byrest and aggravated by wrist flexion andextension. Initial examination revealedposterolateral wrist and forearmswelling and palpabable tenderness.ROM was WNL, but forearmpronation and wrist and thumbextension were painful. MMT revealedpronation and wrist and thumbextension at 4/5. Special testsdemonstrated no ligamentous,vascular, or neurological pathology.The patient’s previous medical historywas significant for right wrist sprainsat 11 and 14 years old, and a fracturedright ulna at 13 years old. At age 18,she reported dull pain, crepitus, andswelling in her wrist, and a noticeableforearm deformity, but was non-compliant to treatment. Relatedhistory also included an unknownelbow and forearm pathology withsimilar symptoms in the forearm,which were treated with rest,cryotherapy, and therapeutic exercises.The elbow pathology resolved, but theforearm pain persisted. The patientself referred to a chiropractor twiceper week and was treated with Grastontools, which caused swelling, bruising,and pain. She was referred from thechiropractor to an orthopedist whoordered radiographs, which wereunremarkable, and a corticosteroidinjection that did not provide relief.Differential Diagnosis: inflamedextensor reticulum, radial stressfracture, radial neuritis, extensor carpi

ulnaris tendinopathy, pronator terestendinopathy, De Quervaintenosynovitis, and intersectionsyndrome. Treatment: After initialevaluation, the patient receivedconservative treatment encompassingmassage and a wrist orthosis limitingwrist and thumb extension and wasreferred to the team orthopedist. Theteam orthopedist definitivelydiagnosed the patient with intersectionsyndrome. Based on his clinicalexamination, he recommended sheremain in the orthoses and take twomonths off from throwing. He alsoprescribed cryotherapy, compression,elevation, and NSAID therapy forseven days. Status-post one week, thepatient began a rehabilitation programemphasizing further pain and swellingreduction and restoring soft tissuemobility and strength of the wrist andthumb. The rehabilitation programconsisted of physical agents todecrease inflammation and therapeuticexercises focusing on fine motorcontrol and dexterity, and eccentricstrengthening to increase grip andtwisting strength. Status-post eightweeks, the patient was cleared forconference championships and wasable to throw with minimal discomfort.She continues to manage any post-activity inflammation withcryotherapy. Uniqueness: Inter-section syndrome is unusual with anincidence rate of less than 1% of allforearm, wrist, and hand injuries. Thecondition is primarily seen inindividuals who perform repetitivewrist actions during occupationalactivities such as raking and shovelingwhere excessive grasping, wringing,and twisting of the wrist occur.Intersection syndrome is rarelystudied in athletic training educationcurricula. Conclusions: Intersectionsyndrome is an inflammatorycondition that occurs at theintersection or crossover point of thefirst extensor (extensor pollicis brevis,extensor carpi radialis longus) and the

second extensor (extensor carpiradialis longus, brevis) compartmentand can easily be clinicallymisdiagnosed. The condition is causedby excessive friction between the twocompartments or entrapment fromstenosis. It presents with pain,swelling, and creptius in the distaldorsoradial forearm. Intersectionsyndrome responds favorably toconservative management within eightweeks. This includes modifying sportactivities to decrease stress on thewrist and forearm, physical agents, andtherapeutic exercises to reduce painand swelling, which improve tendongliding between compartments.

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lesion. Conclusion: Circus athleteshave extreme flexibility makingthe assessment difficult. Some ofthe performances require weightbearing activities and may not beeasily recognized as typicalmechanisms of injury. More studiesare needed on this type of athlete andnon-operative treatment forosteolysis and ALPSA lesions.

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Conservative Treatment ForOsteolysis Of The DistalClavicle And An ALPSA lesion InA National Circus School AthleteRondeau V, Dover GC: ConcordiaUniversity, Montreal, QC

Background: We are presenting thecase of a 24 year old male circusstudent from l’École Nationale deCirque with a history ofcoracobrachialis tendonitis. Thestudent majors in straps which is anacrobatic specialty consisting of twothin parallel straps several meters inlength, which he rolls and unrolls usingthe wrists and arms to execute heldposes, while being suspended. Theathlete started to feel pain at aparticular performance where he waslifting people onto the shoulders ofother performers. During thisperformance the tower is not stable andthe weight is not distributed evenly.The athlete was standing with kneesfully flexed, holding another artistsleg, one hand at the end of his calf andthe other just below his knee. Hiselbows were flexed and abducted dueto the lack of space. He was assessedwith having biceps tendonitis andprescribed rest. After 6 weeks of restthere was no change in pain. His firstassessment back revealed poor postureincluding rounded shoulders. Rightshoulder ROM; extension 60° with 1/10 rating for pain, flexion 185° (2/10),ABD 185° pain-free, ADD 0° (3/10),internal rotation 95° (4/10) andexternal Rotation 80° pain-free.Manual muscle testing of the mid andlower traps, rhomboids, and rotatorCuff were weak (3/5) and pain-free.Coracobrachialis had 5/5 strength with1/10 for pain. Special Tests;impingement and speed’s test werepositive. After two weeks ofstrengthening exercises, lasertreatments, and decreased activitythere was limited success. He was thenreferred to a sports doctor whorecommended x-rays and an arthro-MRI. Differential diagnosis: Biceps

long head tendonitis, supraspinatustear, rotator cuff impingement.Treatment: The MRI resultsindicated the distal end of the clavicleand to a lesser extent, the medialacromion were irregular from boneresorption indicating a post traumaticosteolysis. In addition there was a softtissue mass at the AC joint. Moreoverthere was a high signal intensity of thebone marrow suggesting edmaformation of the distal clavicle. Also,the antero-inferior labrum appeareddetached from the bone of the glenoidbut remains attached distally to theperiosteum indicating an AnteriorLabral Ligamentous Periosteal SleeveAvulsion (ALPSA) Lesion. We startedconservative treatment by addressinghis poor posture including scapularstability exercises and strengtheningexercises (trapezius, rhomboids, androtator Cuff). We released tightmuscles (trapezius, rhomboids, rotatorcuff), and performed AP gleno-humeral glides. We used K-tape tomaintain his scapulae in a retractedposition, which the athlete indicatedwas effective in reducing his pain. After3 weeks of moderate success, theathlete received a cortisone injectionand felt significantly better.Uniqueness: Trauma and repetitiveinjuries are often the cause of post-traumatic osteolysis of the distalclavicle, and often occurs inweightlifters with pain during shoulderelevation and adduction. This caseinvolved a similar mechanism in acircus performer who performed hisstraps routine with his body weight.ALPSA lesions were first described in1993 as detached capsulolabralcomplexes which healed medially onthe scapular neck. A history of multipledislocations is usually present inALPSA lesions, but not in this case.When conservative treatments fail,operative treatments are oftenconsidered however, the prognosticimplications of arthroscopic repair areunclear. Additionally, the recurrenceof instability after repair for an ALPSAlesion is twice as high as therecurrence after repair of a Bankart

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Left Upper Extremity SwellingIn A Collegiate Football PunterHarkins TW, Harkins KR, FullerJD: Marshall University,Huntington, WV

Background: A 22 yr old male,Division I collegiate football punter(5’8’, 191 lbs), reported to the athletictraining staff on Monday following agame. The athlete was not a memberof the travel squad and had participatedin a non-travel training session on theprevious Friday. Athlete reportedfeeling an “unusual tightness” in hisleft upper extremity during themilitary press which had not subsided.The athlete had no previous history ofupper extremity trauma and no relevantmedical history. Physical examinationrevealed slight edema about theentirety of the left arm with mildhyperemia but no true ecchymosis. Hereported no discomfort. The skin ofthe left upper extremity was free oflesions and completely intact, butclearly distended. Neurologicalevaluation revealed slightly reducedsensation about the entire left upperextremity but no myotomal weakness.He had normal and equal pulsesbilaterally, and no lymphadenopathy.Differential Diagnosis: Thoracicoutlet syndrome (TOS), deep veinthrombosis (DVT) or embolism,arterial or venous aneurysm,superficial thrombophlebitis,infection, musculotendinous rupture.Treatment: The athlete was evaluatedby a team physician who ordered an X-ray to rule out rib-implicated TOS,which it did. He was referred for anultrasound the next day whichdemonstrated no evidence of DVT. AnMRI was obtained which demonstratedno evidence of DVT. During this time,the athlete reported an increase in hisupper extremity tightness. Additionalphysical examination revealed strengthdeficits and noticeable discoloration(“mild purplish hue”) about the arm.Due to the persistence of his

symptoms, an MR arthrogram wasobtained. The MRA was unremarkable,but was documented as “inconclusive”due to the fact that the subclavian veinwas not evident. A venogram was thenordered which revealed a 5-7 cm fixedocclusion of a segment of thesubclavian vein with collateralformation beginning and reconstitutingthe brachiocephalic vein indicating thatthe occlusion had been present for atleast one month. Treatment wasinitiated the same day and consisted ofthrombolysis via interventionalradiology with Heparin and TPAinfusion at 1 mg/hour for 24 hours. Thenext day a 10 cm x 4 cm balloon wasinserted into the subclavian vein whichyielded an excellent final angiographicresult. However, it was noted that thevein was likely to re-occlude due tofirst rib pathology. The athlete wasprescribed a regimen of Coumadin andLovenox. Due to the likelihood ofrecurrence, the athlete was referredfor left transaxillary rib resection. Theathlete was cleared for full activityapproximately 5 weeks following therib resection, at which point theCoumadin was discontinued. Theathlete had no incidence related to thepathology upon returning to his normalactivity regimen. Uniqueness: Paget-Schroetter Syndrome (PSS) is a rarepresentation of upper-extremity DVT,occurring in approximately 1-2/100,000 persons per year. As in thiscase, patients are commonly withoutpreviously recognized pro-thromboticrisk factors. PSS typically manifestsin the dominant extremity of thepatient, which was not true in this case.Based on the amount of collateralcirculation that had developed, itappears that the occlusion had beenpresent for a minimum of one month.The ability of the athlete to lift weightswith the same intensity over the courseof the season without symptomsmakes this case unique. It is alsointeresting that numerous diagnostictests did not reveal the pathology.

Conclusions: Although a rarepathology, PSS carries the potentialof significant morbidity andpotentially fatal complications suchas post-thrombotic syndrome andpulmonary embolism. Therefore, itis imperative that athletic trainersrecognize the signs and symptoms ofPSS to facilitate appropriate andtimely referrals, and remain diligentuntil a pathology is detected.

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Author Index

AAbdenour TE, S-62Abt JP, S-64, S-89, S-166, S-231Acocello S, S-17, S-33, S-248Adams JD, S-11Adams WM, S-119Adkins SG, S-144Akehi K, S-131Akins JS, S-89Al-Darraji SJ, S-115, S-148, S-195Alberts JL, S-55Albritton, DL, S-139Allison KF, S-166alovich McLeod TC, S-160, S-199Aminaka N, S-93Amponsah G, S-150Anastasio SM, S-175Anderson B, S-13, S-25, S-193Anderson BL, S-27Andrews CA, S-273Apicella JM, S-20Armour Smith J, S-66Armstrong LE, S-22Arnold BL, S-77, S-212Arnold E, S-184Ashley A, S-188Ashton J, S-283Ashton JM, S-43Atkins LT, S-124Austad MA, S-251Awoniyi S, S-239Ayotte J, S-265

BBaellow AL, S-145, S-170, S-171Baer DJ, S-140Baer GS, S-244Bailey B, S-22Baker CS, S-186Baker R, S-193Balasubramanian E, S-141Ballard K, S-22Bamberg SJM, S-163Barber Foss KD, S-141, S-182, S-253Barlow G, S-134Barone CM, S-59, S-61, S-149Barry KE, S-111Barry MA, S-169Bass J, S-147Bass JA, S-188Bates NA, S-182Baumeister J, S-16Baumgartner TA, S-196Bay RC, S-76, S-100, S-198, S-199, S-238Bazett-Jones DM, S-93Beals K, S-166Bedi A, S-224Beese ME, S-29Begalle RL, S-27, S-128Beidler E, S-33Beisner A, S-159Bell DR, S-107, S-108, S-157Bennett CC, S-24Benson A, S-268Benson S, S-197Bergens BL-F, S-104

Berkoff DJ, S-256Berry DC, S-24, S-52, S-53, S-234, S-242Beutler AI, S-37, S-65, S-92, S-96Blackburn JT, S-27, S-37, S-50, S-162, S-228Blackburn T, S-256Blemker S, S-229Bliven K, S-99Boehret SA, S-141Boland SA, S-183Boley HA, S-106Bolgla L, S-93, S-94, S-97, S-254Bolgla LA, S-255Boling MC, S-92, S-145, S-170, S-171Bonacci JB, S-11Bookhout JL, S-135Borchers J, S-159Boscolo MS, S-136Boucher T, S-184Boucher TM, S-132, S-205Bowman J, S-159Bowman TG, S-34, S-234Bradley MH, S-269Bradney DA, S-34Brandt MS, S-113Braun PA, S-14Breitbach AP, S-235Brewer ME, S-241Bric JD, S-115, S-148, S-195Bridges J, S-230Bright N, S-68, S-115Bright NB, S-68Brismée JM, S-124Brodeur A, S-290Broglio SP, S-17Brooks KL, S-101Brooks MA, S-198Broshek D, S-17Broshek DK, S-33, S-197Brown CN, S-181, S-196, S-210, S-216Brownell EH, S-263Buckley TA, S-179, S-202, S-203, S-204Buening BJ, S-11Burgess MJ, S-70Burkhart S, S-202Burks RT, S-289Burne JA, S-259Bush HM, S-42, S-144Butterfield TA, S-250, S-263Butterworth C, S-206Byon KK, S-194

CCaccese JB, S-90Cacolice PA, S-155Cameron KL, S-48, S-65, S-92, S-96Campbell SE, S-48Capilouto G, S-186Carcia CR, S-155, S-180Carey SE, S-106Carr KE, S-109Casa D, S-83Casa DJ, S-19, S-20, S-22, S-83, S-119Castillo KH, S-242Caswell A, S-143Cattano NM, S-141Chang EW, S-40Chang SD, S-130Charles-Liscombe R, S-284Chelette CJ, S-271, S-289Chicoine N, S-238

Chinn L, S-208, S-209, S-213Chmielewski TL, S-231Christie SR, S-276Clack SF, S-276Cleary MA, S-104Clements AE, S-12, S-36Clines SH, S-149Coates A, S-272Coldiron GR, S-163Comstock RD, S-83Conchola EC, S-131Cone JC, S-161Conrad BP, S-231Cooke A, S-17Cooper E, S-85Cooper ER, S-83, S-84, S-85, S-152Copple TJ, S-168Cordova MM, S-131Cortes N, S-217Covassin T, S-202Cowden NE, S-34Cox SJ, S-200Cram TR, S-27Creedon D, S-281Creighton BC, S-20Creinin K, S-239Crowley E, S-211Cruickshank JA, S-101Crutcher B, S-202Csonka J, S-126Curry PJ, S-84, S-85Curry PR, S-83, S-85, S-152, S-194

DDaniels EJ, S-158David SD, S-177David SL, S-52, S-56Davis B, S-89Davis C, S-290de la Motte SJ, S-65De Maio VJ, S-192DeAngelis AI, S-174Decoster LC, S-115, S-148, S-195Dedrick GS, S-124DeMartini JK, S-19, S-20, S-22Demchak TJ, S-243, S-245DeMont RG, S-257, S-258Denegar CR, S-169Dettl MG, S-142Di Stasi SL, S-182Dicesare CA, S-182Dicharry J, S-208Dill KE, S-128DiStefano LJ, S-28, S-65, S-96, S-107, S-108,

S-167, S-169, S-211, S-226Dixon JB, S-158Docherty CL, S-75, S-129, S-155, S-215, S-236Dodge EB, S-183Dodge TM, S-234Doeringer JR, S-186, S-226Dolan N, S-241Dominguez JA, S-231Donahue M, S-129, S-215Donahue MS, S-188Donovan L, S-15, S-134, S-173, S-215Dorminy ML, S-191Dover GC, S-238, S-291Downey DL, S-235Driban JB, S-141, S-223DuBose DF, S-231

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EEarl-Boehm J, S-93, S-94, S-97, S-254, S-255Eberman LE, S-61, S-243Elbin RJ, S-202Eley DM, S-24, S-52, S-53Emerson CC, S-21, S-22, S-23Emery CA, S-93, S-94, S-97, S-254, S-255Ericksen HM, S-12, S-36Erickson SM, S-20Erwin JR, S-276

FFarmer KW, S-231Farnsworth JL, S-56Fayson SD, S-145Feger M, S-215Felton SD, S-139, S-200, S-273Ferber R, S-93, S-94, S-97, S-134, S-254, S-255Ferrara MS, S-83, S-84, S-85, S-152, S-194, S-196Ferraro EM, S-59, S-61, S-149Filep EM, S-81Fiorentino N, S-229Ford A, S-25Fowler L, S-188Frager A, S-235Francis C, S-264Frank BF, S-28, S-40Frank BS, S-27, S-128Fricker D, S-261Frymyer JL, S-200, S-273Fuller JD, S-292Furutani T, S-100Furutani TM, S-103, S-201

GGanio MS, S-11Gatti JM, S-180Gaven SL, S-127, S-217, S-227Gay CR, S-251Gear WS, S-135Geiger A, S-80Geiser CF, S-169Gilbreath JP, S-127Gildard M, S-220, S-268, S-281Gilsdorf CM, S-40Giovanello K, S-192Giuliani C, S-162Glass MJ, S-227Glass SM, S-212Glaviano NR, S-197Glodowskk C, S-188Glutting J, S-141Goeckeritz LM, S-103Goerger BM, S-37, S-40Goetschius J, S-39Gonzalez L, S-42Goodkin HP, S-197Goodman A, S-59, S-60, S-61, S-149Goodrich ME, S-137Gorgos KS, S-177Goto S, S-15, S-30, S-137Gould TE, S-184, S-190, S-194Graber DK, S-55Granquist MD, S-249Gravelin EM, S-263Gray KA, S-11Greenwood LD, S-132, S-205Greis PE, S-271

Greska EK, S-165Gribble P, S-93Gribble PA, S-12, S-25, S-36, S-75, S-106, S-128,

S-183, S-209Griebert MC, S-90Griffin L, S-175Grindstaff TL, S-241Groff D, S-30Grooms D, S-159Grove KA, S-236Gruber DM, S-44Grundstein A, S-83, S-84, S-85Grundstein AJ, S-85, S-152Guffey J, S-284Gumucio JP, S-224Gurchiek LR, S-136Guskiewicz KM, S-30, S-34, S-153, S-190Gustavsen G, S-206

HHackett TR, S-43, S-283Hackney AC, S-175Hafner R, S-75Haley JT, S-35Hall BT, S-148Hall EA, S-155Hamson-Utley JJ, S-188Hamstra-Wright KL, S-93, S-94, S-97, S-254,

S-255Hankemeier DA, S-63, S-207, S-238Hanley M, S-121Hanline VL, S-54Hansen RA, S-188Hardy A, S-249Harkey MS, S-75, S-128Harkins KR, S-292Harkins TW, S-292Harris AM, S-278Hart J, S-208Hart JM, S-15, S-38, S-39, S-40, S-89, S-134,

S-163, S-173, S-185, S-213, S-215, S-218,S-229, S-248

Heebner NR, S-126Heitman RJ, S-136Herb CC, S-214, S-229Herman D, S-231Hertel J, S-15, S-33, S-38, S-40, S-89, S-134,

S-173, S-208, S-209, S-213, S-214, S-215,S-218, S-229, S-247

Hettinga BA, S-134Hetzel S, S-198Hetzel SJ, S-109Hewett TE, S-42, S-51, S-141, S-182, S-253Hibberd EE, S-154Hicks-Little CA, S-29, S-163, S-271, S-287, S-289Higgins M, S-115, S-191Higginson JS, S-16Hildenbrand KJ, S-104Hintze D, S-147Hirsch JR, S-55Hirth CJ, S-27Hix RI, S-247Hoch JM, S-42, S-269, S-279Hoch MC, S-98, S-107, S-127, S-149, S-153,

S-178, S-211, S-217Hoffman MA, S-186, S-226Holcomb WR, S-246Hollis JM, S-136Hoogeveen AM, S-191

Horne D, S-284Hornor SD, S-196Hosey R, S-288Hosey RG, S-220Houston MN, S-107, S-153, S-211Howard JS, S-45, S-220, S-251Howell D, S-51Hubbard-Turner T, S-218Hudson SR, S-17Huggins RA, S-19, S-20Hunter I, S-230Hunter LA, S-204Huxel Bliven KC, S-27

IIannetta T, S-114Igawa T, S-254Ingram RL, S-179, S-202Ingriselli JM, S-192Ismaeli Z, S-286

JJackson MJ, S-54Jacobs MM, S-177, S-269Jagger J, S-277Jarman NF, S-124Jarvis DN, S-66Jensen K, S-22Johnson AW, S-230Johnson D, S-272Johnson DC, S-286Johnson J, S-288Johnson KM, S-113Johnson ST, S-186, S-226Johnson TS, S-286Johnston T, S-264Jones DL, S-231Joseph CJ, S-286Joseph MF, S-107, S-169, S-226Joy EA, S-29Joyner AB, S-203, S-204Judge LW, S-258Juzeszyn LS, S-61

KKahanov L, S-61, S-243Kaminski TW, S-14, S-88, S-90, S-125, S-145,

S-171, S-172, S-174, S-206, S-236Kamp A, S-120Kana DE, S-55Kanaoka T, S-103Kang M, S-35, S-56Kang TK, S-159Kasamatsu TM, S-104Katch RK, S-242Kavouras SA, S-11Keenan KA, S-89, S-126, S-231Kerner M, S-211Kerr ZY, S-83Kido Y, S-126Kim CY, S-166Kim KM, S-40, S-89, S-218Kim Y, S-56Kimmel W, S-134Kingma J, S-129, S-155Kipp K, S-169Klass SE, S-289Klossner J, S-236

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Klossner JC, S-155Knight CA, S-14, S-174, S-236Ko JP, S-152, S-181, S-210, S-216Kocher M, S-100Kocher MH, S-103, S-201Kollock RO, S-173Komaroff E, S-68Kontos A, S-202Kostishak N, S-13Kovaleski JE, S-136Kramer N, S-229Krasinski D, S-246Krazeise DA, S-203Krazeize DA, S-202Krzeminski DE, S-184, S-190Kuei CY, S-131Kuenze C, S-38, S-39, S-185, S-229Kulig K, S-66Kulow SM, S-77, S-151Kuntzelman KS, S-181Kupchak B, S-22Kupchak BR, S-19Kusumoto S, S-254

LLa Bounty PM, S-184LaFevor ME, S-32Laidlaw CR, S-70Lake AW, S-101Lam A, S-175Lam KC, S-13, S-76, S-77, S-99, S-151, S-160, S-

193LaRue MJ, S-237Lattermann C, S-42, S-45, S-272Laudner K, S-49, S-124Least B, S-288Lee E, S-22Lee HD, S-159, S-166Lee SC, S-159, S-166Lee SY, S-159, S-166Lephart SM, S-64, S-89, S-166, S-231Lepley AS, S-12, S-36Lepley LK, S-37Lesperance M, S-284Letendre MA, S-20Levine JW, S-12, S-36Lewek MD, S-162Li L, S-50Linder SM, S-55Linens SW, S-77Lins LAB, S-247Lippa NM, S-184, S-190Littleton AC, S-34, S-192Liu K, S-206Liu W, S-136Lohman CM, S-124Long BC, S-131Lopez R, S-121Lopez RM, S-22, S-81, S-222Lorens K, S-287Lovalekar MT, S-89, S-166Luc BA, S-223Lynall R, S-49, S-124Lynall RC, S-153Lynch EB, S-224

MMacciocchi SN, S-196MacDonald A, S-272Maguire MC, S-287Maresh CM, S-19, S-22Marshall SW, S-37, S-65, S-83, S-92, S-96, S-153,

S-192Martin GM, S-274Martinez JC, S-107, S-108, S-169, S-211, S-226Martini DN, S-17Mattacola CG, S-42, S-45, S-51, S-186, S-251Matteau E, S-211Matthews A, S-11Mauntel TC, S-27Mayfield RM, S-67, S-69, S-102, S-105, S-160Mazerolle SM, S-59, S-60, S-61, S-62, S-149,

S-234Mazoué C, S-110Mc Elhiney D, S-56Mc Elhiney DS, S-31, S-35McCarty CW, S-26, S-67, S-69, S-70, S-102,

S-165, S-238McCrea M, S-198McDermott BP, S-11, S-20McDevitt J, S-68McDevitt JK, S-68, S-191McDonald J, S-239McDonald LM, S-125McElhiney DS, S-32, S-56McFate DA, S-64, S-126McGrath ML, S-162McGuine TA, S-109, S-198, S-244McKeon PO, S-137, S-161, S-186, S-207, S-209,

S-214McLeod MM, S-75, S-128McLeod RL, S-242McNulty MB, S-161, S-278Meade AR, S-251Medel, M, S-54Medina McKeon JM, S-42, S-144, S-182, S-186Meinerz CM, S-169Meister K, S-49, S-124Melinchak M, S-173Mendias CL, S-224Mensch JW, S-116Mettler A, S-209Meyer J, S-107Meyer JD, S-226Michelini KJ, S-274Michener LA, S-199Mihalik J, S-195Mihalik JP, S-115, S-148, S-153, S-190, S-192Miles JD, S-83, S-84, S-85, S-152, S-194Miller KC, S-259Miller M, S-159Miller MG, S-246Millward MJ, S-111Minton DM, S-21, S-22, S-23Mitchell SM, S-136Moffit DM, S-175Monfreda AM, S-25Montgomery MM, S-161, S-164, S-189Mooney C, S-282Moore MT, S-158Morin G, S-265Morrell M, S-25Morton SK, S-241Moser MW, S-231

Mullaney KP, S-139Mulligan RP, S-98, S-149Munkasy BA, S-179, S-202, S-203, S-204Munõz CX, S-19Muñoz CX, S-20Murata N, S-100Murata NM, S-103, S-201Murray SR, S-251Musto A, S-157Mutchler J, S-98, S-149, S-178Myer GD, S-141, S-182, S-253Myers JB, S-50, S-137, S-154Myrer JW, S-230

NNagai T, S-64, S-231Nagle EF, S-166Nakajima MA, S-113Naugle KE, S-130Naugle KM, S-130Needle AR, S-16, S-88, S-90, S-145, S-171, S-174,

S-213Neefe HI, S-222Nelson C, S-146, S-275Neumann M, S-25, S-27Neves C, S-230Neves KA, S-230Nguyen A, S-92, S-145, S-170, S-171Norcross MF, S-186, S-226Norte GE, S-185

OOates DC, S-171Oberg C, S-147Olson BL, S-54Olson ME, S-157omstock RD, S-144Onate J, S-159Oñate JA, S-173Onofrio MC, S-238Onuki T, S-49Orapello NS, S-268Oshiro JY, S-201Oshiro RS, S-100, S-103, S-201Ostrowski JL, S-70Owens BD, S-48, S-96Oyama S, S-50, S-137, S-154

PPaden A, S-115Padua DA, S-15, S-27, S-28, S-37, S-40, S-50,

S-65, S-92, S-96, S-128, S-162, S-167Pagnotta K, S-22Pagnotta KD, S-19, S-119Palmer TB, S-131Palmer TG, S-51Palmieri-Smith RM, S-37Pamukoff DN, S-228, S-256Paper S, S-21, S-22Parr JJ, S-130Parsons JT, S-67, S-69, S-102, S-105Partner SL, S-248Pass AN, S-231Paszkewicz JR, S-26Patton TS, S-267Peck KY, S-48, S-65, S-96Peer KS, S-267Pennuto AP, S-107, S-108, S-157

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Penny JM, S-234Peters J, S-146Peterson K, S-44Petron DJ, S-271, S-287, S-289Pettitt RW, S-251Pietrosimone BG, S-12, S-25, S-36, S-75, S-93,

S-128, S-209, S-223, S-241Pietz KM, S-104Piland SG, S-184, S-190, S-194Pitney WA, S-59, S-60, S-61, S-62, S-63Pittman J, S-217Plos JM, S-247, S-274Podell JT, S-213Podlog L, S-188Pollack M, S-110Pollard CD, S-186, S-226Polubinsky RL, S-247Poole D, S-264Popp JK, S-258Porter PA, S-286Pouliot S, S-80Powden CJ, S-107, S-211Powell JP, S-83Powell MP, S-107Powell MR, S-211Power ME, S-31Powers ME, S-220, S-268, S-281Prentice WE, S-40Price EA, S-177Pryor RR, S-119Purdoff MJ, S-204Pye ML, S-65

QQuinlevan ME, S-106, S-183

RRagan BG, S-11, S-31, S-32, S-35, S-52, S-54,

S-56, S-142, S-143, S-177, S-181Rakeja S, S-257Rakheja S, S-258Rasmussen J, S-198Rawlins JW, S-184, S-190Register-Mihalik JK, S-30, S-192Reinbold KE, S-242Reinecke K, S-16Rendos NK, S-157Renehan E, S-286Resch JE, S-196Rettig LA, S-138Reyes AD, S-236Rhea CK, S-168, S-212Rice T, S-160Ridgeway J, S-277Rigby R, S-184Riley Z, S-215Ringleb SI, S-173Rink D, S-188Roberts D, S-185Rodriguez J, S-199Roewer BD, S-182Rondeau V, S-291Rooks Y, S-122Rose WC, S-88Rosehart S, S-21, S-22Rosen AB, S-152, S-181, S-210, S-216Ross K, S-261Ross RG, S-222

Ross SE, S-65, S-77, S-212Rothbard M, S-80, S-146, S-265, S-275, S-290Roti M, S-22Royer T, S-174Rubino T, S-107, S-226Rullestad EA, S-106Rupp KA, S-247Russ AC, S-175Ryan C, S-115

SSaade N, S-257, S-258Sakr M, S-256Salesi T, S-126Saliba S, S-17, S-33, S-39, S-197, S-208, S-209Saliba SA, S-218, S-247, S-248Samson CO, S-181Sauers EL, S-99Saunders RP, S-116Scharmann S, S-188Schindler DD, S-55Schmidt JD, S-30, S-190, S-192Schmitz RJ, S-65, S-161, S-164, S-168, S-225Schmolesky M, S-188Schrader J, S-129Schrader JW, S-75Schreppel B, S-126Schroeder M, S-159Schubert M, S-16Schulte S, S-188Schultz SM, S-177Schussler E, S-159Scibek JS, S-155, S-180Scott SM, S-17Sefcik N, S-44Selkow NM, S-124Sell TC, S-64, S-89, S-126, S-166, S-231Sesma AR, S-122Sexton PJ, S-251Sheaffer AE, S-205Sheldon AM, S-189Shepherd LI, S-198Shields C, S-88Shimizu A, S-100Shimokochi Y, S-254Shultz SJ, S-65, S-161, S-164, S-168, S-225Sibilsky Enselman ER, S-224Signorile J, S-157Simon J, S-75Simon JE, S-155Sinha G, S-54Sitler MR, S-141Slone SW, S-48Smalley BW, S-64, S-231Smith DH, S-34Smith J, S-114Smith MD, S-108, S-157Smith MP, S-124Smith S, S-261Snook EM, S-143Snyder B, S-261Snyder MM, S-111Snyder Valier AR, S-199, S-204Sohn DH, S-12, S-36Solyntjes AL, S-135Soontararak M, S-107, S-226Sroufe AM, S-20Stanislawski VM, S-283

Starkey C, S-11Stavinski-Ciocco MM, S-123Stearne DJ, S-175Stearns RL, S-19, S-20, S-22, S-119Stephenson LJ, S-167Steppe E, S-243, S-245Stergiou N, S-162Stiffler MR, S-108, S-157Stollery JC, S-81Stubblefield ZS, S-282Sugimoto D, S-182, S-253Sutherlin MA, S-163, S-248Sutton K, S-21, S-22Svoboda SJ, S-96Swanik CB, S-14, S-16, S-88, S-171, S-172, S-174,

S-213, S-236Swann W, S-250Swartz EE, S-115, S-148, S-195, S-196Switzler CL, S-29, S-163

TTaggart KE, S-244Tamura K, S-100, S-201Tanen LM, S-75Tapia-Lover TG, S-202Tarzon M, S-236Taylor ST, S-242Teblum JB, S-132Tenan MS, S-175Terada M, S-106, S-209Tevald MA, S-128Thomas AC, S-209, S-223Thomas SM, S-182Thornton AL, S-279Thrasher A, S-246Thrasher AB, S-63, S-72, S-207Tierney RT, S-68, S-115, S-175, S-191Tillman SM, S-231Toepper BW, S-129Tomchuk D, S-261Tomczyk, KM, S-52, S-53Toonstra JL, S-251Torres-McGehee TM, S-21, S-22, S-23Toth R, S-287Travers E, S-275Trinidad KJ, S-30Tritsch AJ, S-161Trojian TH, S-107, S-169, S-211, S-226Trotter N, S-268Trowbridge CA, S-245Tsang KKW, S-131Tucker MA, S-11Tucker WS, S-48, S-179, S-196, S-241Tufaro VJ, S-163Turn KK, S-165Turner MJ, S-218

UUhl T, S-186Uhl TL, S-51, S-150, S-193Uota S, S-254Usher E, S-186Uyeno RK, S-103, S-201

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VValovich McLeod TC, S-13, S-25, S-67, S-69,

S-77, S-100, S-102, S-105, S-151, S-193,S-198, S-204

Van Der Pol BJ, S-75Van Lunen B, S-173Van Lunen BL, S-26, S-70, S-98, S-127, S-149,

S-153, S-165, S-177, S-178, S-217, S-227,S-238

Vandermark LW, S-119Varnell MS, S-89, S-126Vaughan AJ, S-256Veasley SJ, S-107, S-226Vela L, S-239Vela LI, S-249Viele K, S-51Volk BM, S-19, S-22Vomer R, S-180

WWahl T, S-100Wahl TP, S-103, S-201Walker ML, S-217Walker SE, S-63, S-72Wall A, S-150Walpert K, S-196Wang HM, S-168, S-225Ward BL, S-121Warner KD, S-52Wasylyk NT, S-177Watanabe Y, S-254Waters B, S-165Waters-Banker C, S-250Waugh AM, S-220Weber ML, S-102Webster KJ, S-278Weindorf JH, S-17Weinhandl J, S-178, S-227Wells AM, S-128Wells KA, S-56Weltman AL, S-218Werner JL, S-193Werner SL, S-125Westrick RB, S-48Wham GS, S-116Whetstone JM, S-139Whisenant DJ, S-286Whittington E, S-21, S-22Wigglesworth JK, S-247Wikstrom EA, S-207Wilckens JH, S-37Wilder R, S-208Wilkinson RD, S-71Williams EM, S-262Williams KN, S-111Williams SJ, S-120Williams TA, S-77Wilson JJ, S-244Winterstein AP, S-109Wirt MD, S-64, S-231Wong R, S-49Wood CM, S-169Wood JM, S-43Wordeman SC, S-182Wright RD, S-220

YYamamoto LM, S-22Yau R, S-96Yeargin BE, S-138Yeargin SW, S-21, S-22, S-23, S-138Yim DW, S-220Yingling VR, S-175Yochem E, S-271Yochem EM, S-289Young K, S-243Younger R, S-110Yu B, S-50

ZZawadzki-Brzoska A, S-123Zhu W, S-136Zinder SM, S-128, S-137

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