This is the first of a series of evidence-based practice guidelines that are being developed using the International Classification of Functioning, Disability, and Health (ICF) as the basis for describing and classifying care provided by physical therapists to patients with a variety of musculoskeletal conditions. The practice guidelines being developed by the Orthopaedic Section of the American Physical Therapy Association will focus primarily on the structures related to movement and the neuromusculoskeletal and movement-related functions and sensory functions and pain categories within the ICF. These body structures and body functions will be linked with their associated health conditions from the World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD).

J Orthop Sports Phys Ther. 2008;38(4):167-168. doi:10.2519/jospt.2008.0105

KEY WORDS: heel pain, ICF, Orthopaedic Section, plantar fasciitis, practice guidelines

DESIGN: Case-control study. OBJECTIVE: To analyze the differences in muscle size and shape of cervical multifidus between patients with bilateral chronic neck pain and healthy subjects. BACKGROUND: Researchers have demonstrated atrophy of lumbar multifidus in patients presenting with low back pain; however, there are only few published reports on cervical multifidus muscle size in individuals with chronic neck pain. METHODS AND MEASURES: Bilateral ultrasound images of multifidus muscle from the third to sixth cervical vertebrae (C3 to C6) were taken in 20 women with bilateral chronic neck pain and 20 healthy women. Cross-sectional area (CSA [cm²]) and muscle shape ratio (ratio between lateral [Lat] and anterior-posterior [AP] dimensions, [Lat/AP]) were measured without knowledge of group assignment. Two separate 3-way (4 x 2 x 2) mixed-model analyses of variance (ANOVAs) with cervical level (C3 to C6) and side (right, left) as within-subject factors and group (patient, control) as the between-subject factor, were used to evaluate differences in CSA and muscle shape ratio between groups, sides, and cervical levels. RESULTS: The ANOVA for CSA indicated a significant effect for cervical level (F = 6.81, P<.001) and group (F = 20.27, P<.001), but not for side (F = 1.26, P = .36). There were no significant interactions among the variables (P>.5). Post hoc analysis showed that the CSA of the C3 multifidus was smaller than the CSA of the C4 (P = .025), C5 (P<.001) or C6 (P<.01) multifidus. There was no significant difference between C4, C5, and C6 multifidus CSA (P>.05). The patients with neck pain had a smaller CSA of the cervical multifidus at all levels compared to controls (P<.001). The ANOVA for muscle shape ratio indicated a significant effect for level (F = 7.84, P<.001) and group (F = 12.501, P<.001), but not for side (F = 0.654, P = .58). There was a significant interaction between level and group (F = 3.651, P = .01). Patients had a wider ovoid shape (greater values in muscle shape ratio) of the C3 (P<.001) and C6 (P<.01) cervical multifidus compared to controls. Further, the C4 multifidus had a smaller shape ratio compared to C6 (P<.001), but was not significantly different than the shape ratio of the C3 and C5 (P>.05) multifidus. CONCLUSIONS: Females with bilateral chronic neck pain had generalized smaller CSA of the cervical multifidus muscles compared to healthy females. LEVEL OF EVIDENCE: Diagnosis, level 5.

J Orthop Sports Phys Ther. 2008;38(4):175-180, published online 7 December 2007. doi:10.2519/jospt.2008.2598

KEY WORDS: cervical spine, rehabilitative ultrasound imaging, ultrasonography

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

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

The original article was corrected in October 2008, and the amended article PDF is provided here. Please see: October 2008 Errata

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