STUDY DESIGN:  Cross-sectional study. OBJECTIVES: To determine whether the distribution of those with and without dynamic knee stability after anterior cruciate ligament (ACL) rupture differs by age, gender, and contact versus non-contact injury mechanisms. BACKGROUND: There is a differential return to preinjury activities after ACL rupture. It is unknown if there are specific patient groups who are more or less likely to experience good dynamic knee stability after ACL rupture. METHODS AND MEASURES: The study sample consisted of 345 consecutive, highly active patients with complete, isolated ACL insufficiency. Based on the results of a screening examination, patients were categorized as having either good (potential coper) or poor (noncoper) dynamic knee stability. Descriptive and chi-square statistics were calculated to describe patient characteristics and identify the proportion of potential copers and noncopers based on age, gender, and injury mechanism. RESULTS: The groups with the greatest proportion of noncopers were women (P=0.002), mid-aged adults (35-44 years old) (P<0.001), and individuals who sustained a noncontact ACL injury (P=0.011). CONCLUSIONS: Women who sustain an ACL rupture, and those who sustain an ACL rupture via a noncontact mechanism frequently experience dynamic knee instability. A profile of demographic characteristics of those most likely to experience knee instability after ACL rupture may facilitate improved patient outcomes. LEVEL OF EVIDENCE: Prognosis, Level 2b.

J Orthop Sports Phys Ther. 2008;38(2):36-41, published online 7 September 2007. doi:10.2519/jospt.2008.2609

STUDY DESIGN: Secondary analysis. OBJECTIVE: To investigate the Fear-Avoidance Beliefs Questionnaire (FABQ) for its ability to predict 6-month outcomes for patients with low back pain (LBP) participating in physical therapy clinical trials. BACKGROUND: Consistent evidence suggests that fear-avoidance beliefs are predictive of short-term outcomes for patients with LBP. However, proposed cut-off scores have not been widely investigated for longer-term outcomes in samples of patients receiving physical therapy. METHODS AND MEASURES: Subjects (n = 160) were participants in 2 separate randomized trials that used standard methodology and investigated the efficacy of physical therapy interventions for LBP. Subjects completed baseline measures of pain, disability, fear-avoidance beliefs, and physical impairment. They completed 4 weeks of randomly assigned physical therapy and were reassessed at 6 months with standard examination techniques. The accuracy of previously proposed cut-offs for elevated FABQ scores were determined by independent t tests and chi-square analysis on raw 6-month Oswestry Disability Questionnaire (ODQ) scores, 6-month ODQ change scores, and minimally clinical important difference (MCID) in ODQ scores (6 points). Next, a hierarchical regression model determined which FABQ scale better predicted 6-month ODQ scores after controlling for previously reported prognostic factors and relevant treatment parameters. Last, receiver operating characteristic curve analyses were planned to generate a range of FABQ cut-off scores that predicted 6-month MCID in the ODQ. RESULTS:  The previously reported cut-off score for the FABQ physical activity scale (>14) resulted in 111 (69.4%) of 160 patients being classified as having elevated baseline scores, while the previously reported cut-off score for the FABQ work scale (>29) resulted in 19 (11.9%) of 160 patients being classified as having elevated baseline scores. Patients with elevated FABQ physical activity scale scores (>14) had no significant differences in 6-month ODQ outcomes. Patients with elevated FABQ work scale (>29) scores reported higher 6-month ODQ scores and were more likely to have reported no improvement in ODQ score. The final regression model explained 24.4% of the variance in 6-month ODQ scores, with only manipulation and exercise and the FABQ work scale as unique predictors. Fifteen of the subjects (12.7%) had a 6-month change in ODQ that indicated no improvement. The area under the receiver operating characteristic curve for the FABQ physical activity scale predicting this outcome was 0.562 (95% CI: 0.415-0.710) and for the FABQ work scale was 0.694 (95% CI: 0.542-0.846). Cut-off scores were explored for the FABQ work scale only, with positive likelihood ratios that ranged from 1.19 to 5.15 and negative likelihood ratios that ranged from 0.30 to 0.83. CONCLUSIONS:  The FABQ work scale was the better predictor of self-report of disability in this sample of patients participating in physical therapy clinical trials. Future studies are necessary to further test and refine the FABQ work scale as a screening tool alone, and in combination with other examination findings. LEVEL OF EVIDENCE: Prognosis, Level 2b.

J Orthop Sports Phys Ther. 2008;38(2):50-58, published online 22 January 2008. doi:10.2519/jospt.2008.2647

KEY WORDS:  disability, FABQ, Owestry, prognosis

STUDY DESIGN: Resident's case problem. BACKGROUND: Chronic anterior hip and groin pain is a growing concern among high-performance athletes. This manuscript enforces the need for physical therapists to remain current with its complex differential diagnosis, as it can be debilitating for the athlete and equally frustrating for the sports medicine team. This resident's case problem details the account of an 18-year-old high-school wrestler who presented to the high-school sports medicine team without physician referral. His chief complaint was chronic right anterior hip and groin pain, which had been variable in frequency and intensity for 3 years. DIAGNOSIS: A screening examination for serious underlying pathology was negative. After physical examination, it was determined that this individual had signs and symptoms consistent with a sports hernia. He was referred to a general surgeon who diagnosed him with a symptomatic inguinal hernia and later performed laparoscopic evaluation and treatment. The patient had a moderate-size indirect inguinal hernia sac, which was carefully dissected away from the remaining contents of the spermatic cord and was repaired with a Parietex mesh. At a 2-week postoperation follow-up, the patient was asymptomatic and cleared to return to wrestling and baseball without limitations. DISCUSSION: This resident's case problem demonstrates the debilitating and often elusive nature of a sports hernia. It suggests that the diagnosis is not well understood and emphasizes the importance of a robust medical foundation for each member of the sports medicine team conducting athletic evaluations. LEVEL OF EVIDENCE: Diagnosis, Level 4. 

J Orthop Sports Phys Ther. 2008;38(2):63-70, published online 7 September 2007. doi:10.2519/jospt.2008.2626

STUDY DESIGN: Retrospective case series. BACKGROUND: Spinal accessory nerve palsy (SANP) is common following neck dissection surgery and can occur with blunt or penetrating trauma to the lateral neck region and cervical stretch injuries. Early detection of SANP remains a clinical challenge and the condition is often misdiagnosed. The purpose of this case series is to describe the associated history, signs, and symptoms related to SANP and increase awareness of the scapular flip sign as a clinical sign associated with SANP. CASE SERIES DESCRIPTION: Twenty subjects (13 male, 7 female) presented with pain and decreased shoulder function following head and neck surgery or posttrauma. All patients were thoroughly examined and the scapular flip sign was assessed. All patients presented with a cluster of signs and symptoms including trapezius atrophy, shoulder girdle depression, limited active shoulder abduction to less than 90°, shoulder pain, and shoulder weakness. A positive scapular flip sign was present in all cases. The middle and lower trapezius were rated as 0/5, based on manual muscle testing, indicating no identifiable muscle activation against resistance. DISCUSSION: A typical history and consistent signs and symptoms were found related to SANP. A strong relationship appeared between the presence of the scapular flip sign and SANP. The suspected mechanism for the scapular flip sign is the unopposed pull of the humeral external rotators by the inactive middle and lower trapezius. Early identification of SANP can assist with the prognosis, explain persistent impairments and functional deficits, motivate appropriate diagnostic testing and interventions, and help maximize outcome. Further research to validate the scapular flip sign and establish a clinical prediction rule for the diagnosis of SANP should be performed. LEVEL OF EVIDENCE: Diagnosis, Level 4.

J Orthop Sports Phys Ther. 2008;38(2):78-86, published online 7 September 2007. doi:10.2519/jospt.2008.2454

KEY WORDS: examination, neck, shoulder, trapezius