The diagnosis and nonoperative management of hip disorders are important clinical issues. Physical therapists can provide an alternative to surgical and pharmacological solutions for patients with lower quarter musculoskeletal complaints with noninvasive, low-risk interventions that are effective for reducing pain and disability. These interventions have none of the health risks associated with medications, surgery, and other invasive treatment options. Although effective low-risk physical therapy interventions exist for these patients, the real question is whether patients know about physical therapy and whether they are afforded an opportunity to access this type of care. Equally important is whether we physical therapists are adequately delivering it.

J Orthop Sports Phys Ther. 2007;37(9):511-513. doi:10.2519/jospt.2007.0108

STUDY DESIGN: Observational, cohort study. OBJECTIVES: To test the hypothesis that patellar alignment and tibiofemoral rotation alignment explain unique portions of variance in patellofemoral joint contact area in individuals with patellofemoral pain (PFP) and in pain-free control subjects. BACKGROUND: PFP has been proposed to result from increased patellofemoral joint stress due to decreased contact area. Patellar malalignment (lateral displacement and tilt) is believed to be the main contributor to decreased contact area. Recent studies suggest that transverse plane rotation of the femur and/or tibia may also contribute to decreased contact area. METHODS AND MEASURES: Twenty-one subjects with PFP (16 female, 5 male) and 21 pain-free subjects (14 female, 7 male) participated. Subjects underwent magnetic resonance imaging (MRI) with the knee in full extension and the quadriceps contracted. Measures of patellofemoral joint contact area, lateral patellar displacement, patellar tilt angle, tibiofemoral rotation angle, and patellar width were obtained. Hierarchical multiple regression analyses were performed for each group using contact area as the dependent variable. The order of independent variables was patellar width, patellar tilt angle, and tibiofemoral rotation angle. To avoid multicolinearity, lateral patellar displacement was not included. RESULTS: In the PFP group, patellar width and tibiofemoral rotation angle explained 46% of the variance in contact area. In pain-free subjects, patellar width was the only predictor of contact area, explaining 31% of its variance. Patellar tilt angle did not predict contact area in either group. CONCLUSION: Addressing factors that control tibiofemoral rotation may be indicated to increase contact area and reduce pain in individuals with PFP. Future studies should investigate the contributions of patellar alignment and tibiofemoral rotation to patellofemoral joint contact area at a variety of knee flexion angles.

J Orthop Sports Phys Ther. 2007;37(9):521-528, published online 12 July 2007. doi:10.2519/jospt.2007.2589

KEY WORDS: biomechanics, knee, MRI

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVES: To identify, analyze, and synthesize the literature to determine which physical examination tests, if any, accurately diagnose a torn tibial meniscus. BACKGROUND: Knee pain has a lifetime prevalence of up to 45% and as many as 31% of individuals with knee pain will consult a general practitioner. Roughly 5% of these individuals will undergo a tibial meniscectomy and many more will undergo partial meniscectomy or meniscus repair. Determining which of these individuals is appropriate for surgical consult depends on clinical examination findings. METHODS AND MEASURES: We searched MEDLINE, CINAHL, and SPORTDiscus from 1966 to August 2006 and extracted all English- and German-language studies that reported the diagnostic accuracy of individual physical examination tests for a torn meniscus. We retrieved data regarding true positives, false positives, true negatives, and false negatives to create 2x2 tables for each article and test. Like tests were then subjected to meta-analysis and subanalysis.  Cochran Q test and the I2 statistic were used to examine for the presence of heterogeneity and the extent of the effect of heterogeneity, respectively. A qualitative analysis was also performed using the QUADAS tool. RESULTS: Eighteen studies qualified for the final analyses. Three physical examination tests (McMurray's, Apley's, and joint line tenderness) were examined in more than 7 studies and had enough data to consider meta-analysis. However, study results were heterogeneous. Pooled sensitivity and specificity were 70% and 71% for McMurray's, 60% and 70% for Apley's, and 63% and 77% for joint line tenderness. Large between-study differences could not be explained by prevalence, study quality, or how well an index test was described. CONCLUSIONS: No single physical examination test appears to accurately diagnose a torn tibial meniscus and the value of history plus physical examination is unknown. Differences between studies in diagnostic performance remain unexplained, presumably due to local differences in the way the tests are defined, performed, and interpreted. We recommend a more standardized approach to performing and interpreting these tests and the development of a clinical prediction rule to aid clinicians in the diagnosis of a torn tibial meniscus.

J Orthop Sports Phys Ther. 2007;37(9):541-550, published online 30 May 2007. doi:10.2519/jospt.2007.2560

KEY WORDS: Apley's, diagnosis, joint line tenderness, McMurray's, primary care, tibiofemoral joint

STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To examine the effect of attentional focus instructions during training on the transfer of a learned balance capability to a more challenging condition among subjects with ankle ligament injury. BACKGROUND: Current evidence suggests that instructions inducing an external focus of attention may be more effective at promoting learning than instructions inducing an internal focus of attention. The effect of attentional direction on transfer has not been tested in populations following a disease or injury, such as lateral ankle sprain, in which postural control is impaired. METHODS AND MEASURES: Participants were 36 male volunteers (mean age 20.9 years, range 19-33 years) who were referred to physical therapy following a grade 1 or 2 ankle sprain. The patients were randomly allocated to 1 of 2 groups, which were instructed to focus attention either internally or externally during postural control training. Three training sessions were conducted on consecutive days and consisted of ten 20-second trials at 2 stability levels, using the Biodex Stability System. Postural control at an untrained, less stable level was assessed before the initial training session and 48 hours following the last session, using the Biodex Stability System. Three measures of stability were used: (1) overall stability, as indicated by the variance in platform displacement in all directions, (2) anterior/posterior variance of platform displacement, and (3) medial/lateral variance of platform displacement. RESULTS: Participants utilizing an external focus of attention improved significantly over the study period in all 3 stability indices, while those utilizing internal focus of attention did not improve significantly. CONCLUSIONS: Our results suggest that an external focus of attention is advantageous for the transfer of learning of a postural control task following an ankle injury. Furthermore, they indicate that using an external focus of attention when training under moderately unstable conditions can significantly improve postural control under less stable conditions.

J Orthop Sports Phys Ther. 2007;37(9):564-569, published online 30 May 2007. doi:10.2519/jospt.2007.2519

KEY WORDS: ankle injuries, attention, learning, postural balance, rehabilitation

Correction to recent citations of a 1991 article published in the JOSPT.  Please see corrected articles:

• Cibulka MT, Threlkeld J. The early clinical diagnosis of osteoarthritis of the hip. J Orthop Sports Phys Ther. 2004; 34(8):461-467.  

• Cliborne AV, Wainner RS, Rhon DI. Clinical hip tests and a functional squat test in patients with knee osteoarthritis: reliability, prevalence of positive test findings, and short-term response to hip mobilization. J Orthop Sports Phys Ther. 2004; 34(11):676-685.

• MacDonald CW, Whitman JM, Cleland JA, Smith M, Hoeksma HL. Clinical outcomes following manual physical therapy and exercise for hip osteoarthritis: a case series. J Orthop Sports Phys Ther. 2006: 36(8):588-599.