SYNOPSIS: Degeneration of the lumbar intervertebral discs (IVDs) is highly prevalent in adults, and is nearly universal in the elderly population. Degenerative changes within, and adjacent to, the IVDs are likely to contribute to a variety of pain syndromes; however, the exact association between these findings and symptoms remains speculative. Recent research has provided new information regarding the etiology, pathophysiology, and clinical relevance of degeneration of the IVD. This information will assist clinicians and researchers in understanding the development and clinical course of lumbar disc degeneration as well as its potential impact upon patients seeking physical therapy care for back pain. The purposes of this clinical commentary are to review the structure and metabolic capacity of the normal and degenerative lumbar IVD, and to discuss factors that influence the onset and progression of disc degeneration. Lumbar magnetic resonance images will be used to illustrate the common findings associated with this condition.

J Orthop Sports Phys Ther., Epub 12 March 2008, doi:10.2519/jospt.2008.2768

KEY WORDS: back pain, lumbar disc, rehabilitation

STUDY DESIGN: Resident's case problem BACKGROUND: Nonossifying fibroma (NOF) is the most common fibrous bone lesion in children. The lesion is usually asymptomatic, and rarely leads to pathological fractures. DIAGNOSIS: We present the case of a 12-year-old boy, who appeared to be normally developed, but who had a pathological insufficiency fracture associated with NOF in the distal femur. He was a member of a track athletics club and he ran more than 5 kilometers every day. Seven weeks prior to the initial evaluation, he felt discomfort in the left distal thigh when running, and felt pain upon knee flexion. The amount of discomfort increased gradually and he began to experience pain while running 4 weeks prior to his initial evaluation. At the time of the initial evaluation, he had tenderness over the distal thigh region and there was increased pain with weight-bearing. Plain radiographs showed an irregular well-defined cortical bone lesion, suggesting NOF, with vague increased density in the bone marrow across the femur and periosteal new bone, suggesting a fracture. Computed tomography confirmed a linear fracture with increased density across the femur leading to the cortical lesion. In the process of differential diagnosis, osteosarcoma or Ewing sarcoma, and bone/joint infection were ruled out using magnetic resonance imaging. The final diagnosis based upon the images and clinical course was pathological insufficiency fracture associated with NOF. The patient was treated with initial avoidance of weight bearing using 2 crutches for ambulation followed by progressive weight-bearing over a period of 5 weeks. Active range of motion of the knee joint was allowed. Three months after onset (5 weeks after the initial evaluation), the patient had normal gait without pain, whereupon the patient resumed his sport activities, beginning with jogging. DISCUSSION: Although pathological fractures secondary to NOF in the femur are rare, NOF can cause pathological insufficiency fractures in athletes, even if the lesion is confined and small. The current case is a reminder of such a possibility. This case also provides a time-course as a reference for the rehabilitation of patients in similar cases.

J Orthop Sports Phys Ther., Epub 12 March 2008, doi:10.2519/jospt.2008.2655

KEY WORDS: athletes, bone lesion, femur, fibroxanthoma

STUDY DESIGN: Systematic literature review. OBJECTIVES:  To conduct a systematic review of case series and clinical trials investigating the diagnostic accuracy of clinical tests for superior labral anterior posterior (SLAP) lesions. BACKGROUND: Primary contact practitioners are often presented with shoulder problems and use a battery of clinical tests to reach a diagnosis. Early detection of SLAP pathology may lead to more optimal interventions and better outcomes for patients. METHODS AND MEASURES: The OVID search interface was utilized with MEDLINE, AHMED, CINAHL, and SPORTDiscus databases searched from 1996-2006. Studies were retrieved that included patients with shoulder pain who underwent at least 1 clinical shoulder test for SLAP lesions. For an article to be included in this review, the results of the clinical tests needed to be compared with findings on arthroscopy. Quality of the manuscripts included in this review were rated using the QUADAS appraisal tool so comparisons could be made across studies. RESULTS: Seventeen published manuscripts fit the inclusion/exclusion criteria and were used for this review. Eight studies were found to be of high quality. Within these 8 studies, Lui et al²⁷ reported high diagnostic accuracy values for the Crank test (sensitivity 91% (95% confidence intervals 76-97), specificity 93% (95% confidence intervals 79-88), + likelihood ratio 13.6 (95% confidence intervals 3.6-52.1), and - likelihood ratio 0.1 (95% confidence intervals 0.0-0.3). The study by Myers et al³⁵ on the Resisted Supination External Rotation Test also scored high on the QUADAS and reported diagnostic accuracy values of 83% (66-92), 82% (52-95), 4.6 (1.3-16.1) and 0.20 (0.1-0.5) respectively. Of significance is the fact that the majority of papers reporting highly accurate clinical diagnostic tests, were of low quality with the results not supported by other authors. CONCLUSION: It appears no single test is sensitive or specific enough to determine the presence of a SLAP lesion accurately. Further research is required to determine whether sub-grouping of patients by mechanism of injury or the type of SLAP lesion, may improve diagnostic accuracy. Determining the diagnostic accuracy of a combination of 2 or more tests is also needed.

J Orthop Sports Phys Ther., Epub 22 February 2008, doi:10.2519/jospt.2008.2676

STUDY DESIGN: A prospective methodological study of interrater reliability. OBJECTIVES: To examine the interrater reliability of a movement impairment-based classification system for patients with chronic low back pain (LBP). BACKGROUND: Movement impairment-based classification for the lumbar spine categorizes LBP based on the findings derived from a patient history and standardized examination. Though many presume this classification to be useful for directing treatment of individuals with LBP, agreement between examiners for assigning a lumbar spine category to a patient has not been studied thoroughly. METHODS AND MEASURES: Two physical therapists independently examined 24 patients  (8 men, 16 women) with chronic LBP (pain duration > 12 weeks). All patients enrolled in the study had been diagnosed with LBP believed to be due to mechanical causes and the duration of their symptoms ranged from 20 to 1,040 weeks. The examiners used a standardized examination to assess patients and then classify them into 1 of 5 lumbar spine categories. Percent agreement and kappa coefficients were calculated between the examiners for the lumbar movement impairment-based classifications. RESULTS: Percent agreement between examiners was 75% and the kappa coefficient was 0.61. The most prevalent lumbar spine categories identified by both examiners were lumbar extension rotation syndrome (41.7% of patients by examiner 1, 37.5% of patients by examiner 2) and lumbar rotation syndrome (41.7% of patients by both examiners). CONCLUSIONS: Interrater reliability between 2 physical therapists classifying patients with chronic LBP patients into 1 of 5 lumbar spine movement impairment categories substantial agreement.

J Orthop Sports Phys Ther., Epub 22 January 2008, doi:10.2519/jospt.2008.2760

KEY WORDS: agreement, diagnostic categories, kappa statistic

STUDY DESIGN: Prospective cohort/predictive validity study. OBJECTIVE: To determine the predictive validity of selected clinical exam items and to develop a clinical prediction rule (CPR) to determine which patients with patellofemoral pain syndrome (PFPS) have a positive immediate response to lumbopelvic manipulation. BACKGROUND: Quadriceps muscle function in patients with PFPS was recently shown to improve following treatment with lumbopelvic manipulation.  No previous study has determined if individuals with PFPS experience symptomatic relief of pain immediately following this manipulation technique. METHODS AND MEASURES:  Fifty subjects (26 male, 24 female; age range: 18 to 45 years) with PFPS underwent a standardized history and physical examination. After the evaluation, each subject performed 3 typically pain-producing functional activities (squatting, stepping up a 20 cm step and stepping down a 20 cm step).  The pain level perceived during each activity was rated on a numerical pain scale (0=no pain, 10=worst possible pain). Following the assessment, all subjects were treated with a lumbopelvic manipulation, which was immediately followed by re-testing the 3 functional activities to determine if there was any change in pain ratings. An immediate overall 50% reduction in pain or moderate improvement on a Global Rating of Change questionnaire was considered a treatment success. Likelihood ratios (LRs) were calculated to determine which examination items were most predictive of treatment outcome. RESULTS: Data for 49 subjects were included in the data analysis, of which 22 (45%) had a successful outcome. Five predictor variables were identified. The most powerful predictor of treatment success was a side-to-side difference in hip internal rotation range of motion greater than 14^º (+LR = 4.9). If this variable was present, the chance of experiencing a successful outcome improved from 45% to 80%. CONCLUSION: A CPR was developed to predict an immediate successful response to lumbopelvic manipulation in patients with PFPS. However, future studies are necessary to validate the CPR rule and in light of a limited sample size and omission of potentially meaningful predictor variables.

J Orthop Sports Phys Ther., Epub 22 January 2008, doi:10.2519/jospt.2008.2669

KEY WORDS: anterior knee pain, physical examination, rehabilitation, spinal manipulation