STUDY DESIGN: Controlled laboratory study. OBJECTIVES: To determine the effect of the modified scapular assistance test (SAT) on 3-dimensional shoulder kinematics, strength, and linear measures of subacromial space in patients with subacromial impingement syndrome (SAIS). BACKGROUND: Abnormal scapular kinematics have been identified in patients with SAIS. Increased scapular upward rotation and posterior tilt, as induced with manual assistance using the SAT, have been theorized to increase subacromial space and may alter shoulder strength. METHODS: Forty-two subjects (21 with SAIS and 21 controls) participated in this study. The anterior outlet of the subacromial space, measured via the acromiohumeral distance on ultrasound images, and 3-dimensional scapular kinematics, measured using motion analysis, were determined with the arm at rest, and at 45° and 90° of active elevation with and without the SAT. A dynamometer was used to measure isometric shoulder strength. Full factorial mixed-model analyses of variance evaluated the effects of the SAT on variables between groups. RESULTS: There was an increase in scapular posterior tilt at all angles, upward rotation at rest and 45° of elevation, and acromiohumeral distance at 45° and at 90° with the SAT. The SAT did not alter normalized isometric strength. There were no differences in response to the SAT between the SAIS and control groups. CONCLUSIONS: Manual scapular assistance using the SAT influences factors associated with SAIS, such as subacromial space and potentially scapular orientation during static arm elevation, but not more so in individuals with SAIS than in healthy individuals. The SAT performed statically may be a way to identify potential subgroups of individuals with SAIS for whom subacromial space narrowing may be a contributing factor.

J Orthop Sports Phys Ther 2012;42(5):400-412, Epub 27 January 2012. doi:10.2519/jospt.2012.3579

KEY WORDS: acromiohumeral distance, examination, rotator cuff disease, shoulder, ultrasound imaging

STUDY DESIGN: Case report. BACKGROUND: Symptomatic accessory navicular can be a source of pain and disability. The treatment considerations for accessory navicular in dancers may differ due to increased demands on the foot, the repetitive nature of the movements, and the specific footwear required. The purpose of this report is to describe the management (1 conservative and 1 postoperative) of 2 adolescent dancers with symptomatic accessory navicular. CASE DESCRIPTIONS: Case 1 was an 11-year-old female who underwent surgical excision of a symptomatic accessory navicular. Case 2 was a 15-year-old female who, following a traumatic injury that caused pain judged to be related to her accessory navicular, was managed nonsurgically. Treatment included pain management, range-of-motion exercises, trunk and lower extremity strengthening, balance and proprioception training, orthoses, crosstraining, and a guided return-to-dance progression. OUTCOMES: Both patients had improved pain, dance technique, strength, and patient-reported outcome scores that allowed a full return to dance. DISCUSSION: The 2 dancers presented here had foot pain believed to be related to a symptomatic accessory navicular. In both cases, treatment targeted specific impairments to improve function and disability. The guided progression of activities was intended to facilitate a return to dance that protected healing tissues and prevented a recurrence of symptoms. Clinicians should be aware of the effect of a symptomatic accessory navicular in the young dancer and potentially effective nonsurgical treatment options for this condition. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2012;42(5):465-473, Epub 25 January 2012. doi:10.2519/jospt.2012.3809

KEY WORDS: ballet, dance, foot

STUDY DESIGN: Controlled laboratory study. OBJECTIVES: To analyze the vertical and anteroposterior components of the ground reaction force during stationary running performed in water and on dry land, focusing on the effect of gender, level of immersion, and cadence. BACKGROUND: Stationary running, as a fundamental component of aquatic rehabilitation and training protocols, is little explored in the literature with regard to biomechanical variables, which makes it difficult to determine and control the mechanical load acting on the individuals. METHODS: Twenty-two subjects performed 1 minute of stationary running on land, immersed to the hip, and immersed to the chest at 3 different cadences: 90 steps per minute, 110 steps per minute, and 130 steps per minute. Force data were acquired with a force plate, and the variables were vertical peak (Fy), loading rate (LR), anterior peak (Fx anterior), and posterior peak (Fx posterior). Data were normalized to subjects' body weight (BW) and analyzed using repeated-measures analysis of variance. RESULTS: Fy ranged from 0.98 to 2.11 BW, LR ranged from 5.38 to 11.52 BW/s, Fx anterior ranged from 0.07 to 0.14 BW, and Fx posterior ranged from 0.06 to 0.09 BW. The gender factor had no effect on the variables analyzed. A significant interaction between level of immersion and cadence was observed for Fy, Fx anterior, and Fx posterior. On dry land, Fy increased with increasing cadence, whereas in water this effect was seen only between 90 steps per minute and the 2 higher cadences. The higher the level of immersion, the lower the magnitude of Fy. LR was reduced under both water conditions and increased with increasing cadence, regardless of the level of immersion. CONCLUSION: Ground reaction forces during stationary running are similar between genders. Fy and LR are lower in water, though the values are increased at higher cadences.

J Orthop Sports Phys Ther 2012;42(5):437-443, Epub 8 March 2012. doi:10.2519/jospt.2012.3572

KEY WORDS: aquatic exercises, biomechanics, hydrotherapy, kinetics

STUDY DESIGN: Descriptive. BACKGROUND: An important role for physical therapists in the healthcare delivery system is to recognize when patient referral to a physician or other healthcare provider is indicated. Few studies exist describing physical therapists' evaluative and diagnostic processes leading to patient referral to a physician. OBJECTIVE: To summarize published patient case reports that described physical therapist/patient episodes of care that resulted in the referral of the patient to a physician and a subsequent diagnosis of medical disease. METHODS: A literature search identified 78 case reports describing physical therapist referral of patients to physicians with subsequent diagnosis of a medical condition. Two evaluators reviewed the cases and summarized (1) how and when patients accessed physical therapy services, (2) timing of patient referral to a physician, (3) resultant medical diagnoses, (4) physical therapists' role in referral of patients for diagnostic testing, and (5) relevant patient symptom description, health history, review of systems, and physical examination findings. RESULTS: Fifty-eight (74.4%) of 78 patients had been referred to a physical therapist by their physician, while the remaining 20 patients accessed physical therapy services via direct access. The patients' primary presenting symptoms included pain (n = 60), weakness (n = 4), tingling/numbness (n = 2), or a combination (n = 12). Patient referrals to a physician occurred at the initial physical therapy session in 58 (74.4%) of 78 cases. A majority of patient referrals to a physician (n = 65) were related to primary presenting symptoms, including manifestations inconsistent with physician diagnosis, recent worsening without cause, unusual accompanying symptoms such as fatigue and/or weakness, and inadequate response to treatment. Resultant diagnoses included neuromusculoskeletal disorders (n = 53; fractures and tumors most common), visceral disorders (n = 14; cardiovascular involvement most common), and medication-related disorders (n = 3). CONCLUSIONS: This review of published patient case reports provides numerous examples of physical therapists using effective multifactorial screening strategies for referred and direct-access patients, leading to timely patient referrals to physicians. The therapist-initiated patient referral to a physician led to subsequent diagnosis of a wide range of conditions and pathological processes.

J Orthop Sports Phys Ther 2012;42(5):446-454, Epub 25 January 2012. doi:10.2519/jospt.2012.3890

KEY WORDS: differential diagnosis, direct access, examination, imaging, physical therapy, screening

STUDY DESIGN: Controlled laboratory study using a cross-sectional design. OBJECTIVES: To compare lower extremity force applications during a sit-to-stand (STS) task with and without upper extremity assistance in older individuals post–hip fracture to those of age-matched controls. BACKGROUND: A recent study documented the dependence on upper extremity assistance and the uninvolved lower limb during an STS task in individuals post–hip fracture. This study extends this work by examining the effect of upper extremity assistance on symmetry of lower extremity force applications. METHODS: Twenty-eight community-dwelling elderly subjects, 14 who had recovered from a hip fracture and 14 controls, participated in the study. All participants were independent ambulators. Four force plates were used to determine lower extremity force applications during an STS task with and without upper extremity assistance. The summed vertical ground reaction forces (vGRFs) of both limbs were used to determine STS phases (preparation/rising). The lower extremity force applications were assessed statistically using analysis of variance models. RESULTS: During the preparation phase, side-to-side symmetry of the rate of force development was significantly lower for the hip fracture group for both STS tasks (P<.001). During the rising phase, the vGRF impulse of the involved limb was significantly lower for the hip fracture group for both STS tasks (P = .045). The vGRF impulse for the uninvolved limb was significantly increased when participants with hip fracture did not use upper extremity assistance compared to elderly controls (P = .002). This resulted in a significantly lower vGRF symmetry for the hip fracture group during both STS tasks (P<.001). CONCLUSION: Participants with hip fracture who were discharged from rehabilitative care demonstrated decreased side-to-side symmetry of lower extremity loading during an STS task, irrespective of whether upper extremity assistance was provided. These findings suggest that learned motor control strategies may influence movement patterns post–hip fracture.

J Orthop Sports Phys Ther 2012;42(5):474-481. doi:10.2519/jospt.2012.3562

KEY WORDS: biomechanics, chair, ground reaction forces

The patient was a 25-year-old woman who was referred to a physical therapist for a chief complaint of pain at the base of the occiput and left upper quarter region, as well as bilateral hand paresthesias. The findings of the history and physical examination were discussed with the patient's physician, who then ordered magnetic resonance imaging of the cervical spine, which revealed protrusion of the cerebellar tonsils 1 cm below the foramen magnum, consistent with a type 1 Chiari malformation.

J Orthop Sports Phys Ther 2012;42(5):483. doi:10.2519/jospt.2012.0409

KEY WORDS: cervical spine, magnetic resonance imaging, neck pain