STUDY DESIGN: Descriptive, correlational, anatomical laboratory study. OBJECTIVES: To investigate the association between the morphology of the vastus medialis obliquus (VMO) and patellar alignment in patients with patellofemoral pain syndrome (PFPS). BACKGROUND: It has long been presumed that PFPS results from patellar malalignment. Strengthening of the VMO has been suggested as an intervention to treat individuals with PFPS, through correction of abnormal patellar tracking. However, the exact role of the VMO in the etiology and treatment of PFPS is not clear. METHODS AND MEASURES: This study included 58 patients with PFPS, of which 31 had bilateral involvement. A total of 89 knees were imaged with a Merchant's view radiograph at 45° of knee flexion to measure patellar alignment consisting of patellar tilt and congruence angles. Those 89 knees were also examined with sonography with the knee in full extension and quadriceps relaxed to measure VMO morphology and additional characteristics such as insertion level, insertion ratio, fiber angle, and volume. The level of association between radiographic and sonographic measurements was explored to determine any relationship between patellar alignment and morphology of the VMO. RESULTS: The patellar tilt angle was negatively correlated with the VMO insertion level (r = –.58, P<.05), insertion ratio (r= –.52, P<.05), and volume (r = –.45, P<.05). In addition, the patellar congruence angle was negatively correlated with the VMO fibers angle (r = –.23, P<.05). CONCLUSIONS: This study showed that some aspects of VMO morphology, measured in full knee extension with the quadriceps relaxed, were associated with patellar alignment measured with the knee at 45° of flexion. Whether or not VMO morphology serves as a predictor of patella alignment with the knee extended should be the focus of future investigations.

J Orthop Sports Phys Ther. 2008;38(4):196-202, published online 21 November 2007. doi:10.2519/jospt.2008.2568

STUDY DESIGN: Case report. BACKGROUND: Selecting the most effective conservative treatment for knee pain continues to be a challenge. An understanding of the underlying movement system impairment that is thought to contribute to the knee pain may assist in determining the most effective treatment. Our case report describes the treatment and outcomes of a patient with the proposed movement system impairment (MSI) diagnosis of tibiofemoral rotation. CASE DESCRIPTION: The patient was a 50-year-old female with a 3-month history of left anteromedial knee pain. Her knee pain was aggravated with sitting, standing, and descending stairs. A standardized clinical examination was performed and the MSI diagnosis of tibiofemoral rotation was determined. The patient consistently reported an increase in pain with activities that produced abnormal motions or alignments of the lower extremity in the frontal and transverse planes. The patient was educated to modify symptom-provoking functional activities by restricting the abnormal motions and alignments of the lower extremity. Exercises were prescribed to address impairments of muscle length, muscle strength, and motor control proposed to contribute to the tibiofemoral rotation. Tape also was applied to the knee in an attempt to restrict tibiofemoral rotation. OUTCOMES: The patient reported a cessation of pain and an improvement in her functional activities that occurred with correction of her knee alignment and movement pattern. Pain intensity was 2/10 at 1 week. At 10 weeks, pain intensity was 0/10 and the patient reported no limitations in sitting, standing, or descending stairs. The patient's score on the activities of daily living scale increased from 73% at the initial visit to 86% at 10 weeks and 96% at 1 year after therapy was discontinued. DISCUSSION: This case report presented a patient with knee pain and an MSI diagnosis of tibiofemoral rotation. Diagnosis-specific treatment resulted in a cessation of the patient's pain and an improved ability to perform functional activities. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther. 2008;38(4):203-213, published online 21 November 2007. doi:10.2519/jospt.2008.2584

KEY WORDS: classification, functional activities, rehabilitation

The Heel Pain-Plantar Fasciitis Guidelines link the International Classification of Functioning, Disability, and Health (ICF) body structures (Ligaments and fascia of ankle and foot, and Neural structures of lower leg) and the ICF body functions (Pain in lower limb, and Radiating pain in a segment or region) with the World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD) health condition (Plantar fascia fibromatosis/Plantar fasciitis). The purpose of these practice guidelines is to describe evidence-based orthopaedic physical therapy clinical practice and provide recommendations for (1) examination and diagnostic classification based on body functions and body structures, activity limitations, and participation restrictions, (2) prognosis, (3) interventions provided by physical therapists, and (4) assessment of outcome for common musculoskeletal disorders.

J Orthop Sports Phys Ther. 2008;38(4):A1-A18. doi:10.2519/jospt.2008.0302

KEY WORDS: clinical practice guidelines, ICD, ICF, Orthopaedic Section

STUDY DESIGN: Case report. BACKGROUND: Determining the cause of painful snapping on the lateral aspect of the knee can be a challenge. The differential diagnosis includes iliotibial band friction syndrome, lateral meniscus tear, intra-articular loose body, discoid lateral meniscus, snapping biceps femoris tendon, degenerative joint disease, proximal tibiofibular joint instability, and snapping popliteus tendon. CASE DESCRIPTION: A 21-year-old female presented with a 7-year history of a painful snapping on the lateral aspect of her left knee. She reported the snapping occurred with all activities involving knee flexion and extension, including running and walking. With a diagnosis of snapping iliotibial band, she had received a variety of physical therapy interventions, including various lower extremity stretching and strengthening exercises. Nonsteroidal anti-inflammatory medications were also prescribed by her physician. Conservative and pharmoclogical interventions were unsuccessful in improving her symptoms. Similarly, our attempt with conservative treatment consisting of ice, taping, and a short period of immobilization was not successful. OUTCOMES: The patient underwent a surgical procedure consisting of removal of a prominent tubercle on the lateral femoral condyle and tenodesis of the popliteus tendon to the proximal aspect of the fibular (lateral) collateral ligament, followed by a postoperative program of physical therapy including range-of-motion and progressive strengthening exercises. At 6 weeks following surgery, the patient had returned to all activities with complete resolution of her symptoms. DISCUSSION: Painful snapping at the lateral aspect of the knee may be caused by a variety of disorders, including the popliteus tendon. Clinical diagnosis is challenging. Clinical suspicion of a snapping popliteus tendon as a source of the signs and symptoms of the condition is important for inclusion in the differential diagnosis. LEVEL OF EVIDENCE: Differential diagnosis, level 4.

J Orthop Sports Phys Ther. 2008;38(4):191-195, published online 14 December 2007. doi:10.2519/jospt.2008.2698

A 55-year-old man was referred to physical therapy because of constant mid-back pain of 1 month's duration. Because of the strong suspicion for a fracture, thoracic spine anterior-posterior and lateral radiographs were ordered, which revealed compression deformities of the T6, T8, T9, and T12 vertebral bodies. An interventional radiologist ordered magnetic resonance imaging and believed the patient was a candidate for vertebroplasty, a technique in which medical grade cement is injected into a painful fractured vertebral body in an effort to stabilize the fracture. At 1 week following his vertebroplasty the patient was pain free. Further medical evaluation indicated that the patient had underlying osteoporosis, and treatment was initiated. At 1 and 2 years after vertebroplasty, the patient reported being symptom free. However, a history of osteoporosis and multiple compression fractures led to further medical evaluation 2 years after vertebroplasty and the patient was eventually diagnosed with multiple myeloma for which treated was initiated.

J Orthop Sports Phys Ther. 2008;38(4):214. doi:10.2519/jospt.2008.0404

KEY WORDS: back pain, fracture, magnetic resonance imaging, vertebroplasty