STUDY DESIGN: Case Report. BACKGROUND: The healing response procedure is a minimally invasive arthroscopic surgical technique used to stimulate healing in the treatment of partial cruciate ligament tears. The purpose of this report was to provide information on the surgical procedure, the post-operative rehabilitation, and the overall functional results in a patient who underwent such a procedure. CASE DESCRIPTION: A 15-year-old male who sustained a partial tear of both the anterior cruciate and posterior cruciate ligament while playing football underwent arthroscopic surgical management utilizing a healing response technique. Precautions concerning range of motion and resisted activities were followed post-operatively to protect the healing cruciate ligaments. The post-operative protocol consisted of 3 phases culminating in return to sport training. Treatment incorporated cardiovascular, proprioceptive, strength, power, plyometric, and sport specific activities. Treatment was progressed based on specific criteria emphasizing proper movement patterns and eccentric control during functional activities. OUTCOMES: The patient attended 31 physical therapy sessions over 17 weeks. Strength improved from 3/5 to 5/5, knee range of motion returned to normal, Lower Extremity Functional Scale (LEFS) scores improved from 21/80 to 80/80, and successful outcomes on functional return to sport testing allowed the patient to return to competitive athletics. DISCUSSION: Primary repair of cruciate ligament tears has yielded poor results and partial cruciate ligament tears may not require complete surgical reconstruction. The healing response technique offers a possible solution for the treatment of partial cruciate ligament tears. A criterion-based post-operative protocol was derived based on current evidence regarding rehabilitation following cruciate ligament reconstruction and evidence regarding lower extremity rehabilitation principles and injury prevention. LEVEL OF EVIDENCE: Therapy, Level 4.

J Orthop Sports Phys Ther, Epub 12 March 2010. doi:10.2519/jospt.2010.3162

KEY WORDS: ACL, anterior cruciate ligament, healing response, physical therapy, PCL, posterior cruciate ligament

STUDY DESIGN: Validity and test-retest reliability of questionnaires related to the Fear-Avoidance Model (FAM). OBJECTIVE: To investigate test-retest reliability, construct redundancy, and criterion validity for 4 commonly used FAM measures. BACKGROUND: Few studies have reported psychometric properties for more than 2 FAM measures within the same cohort making it difficult to determine which specific measures should be implemented in outpatient physical therapy settings. METHODS: 53 consecutive patients (mean age = 44.3 years ± 18.5) with chronic low back pain (LBP) participated in this study. Data collected included validated measures for FAM constructs including the Fear-Avoidance Beliefs Questionnaire (FABQ), Fear of Pain Questionnaire (FPQ-9), Tampa Scale for Kinesiophobia (TSK-11), and Pain Catastrophizing Scale (PCS). Validated measures were used to investigate criterion validity of the FAM measures including the Patient Health Questionnaire (PHQ) for depression, Numerical Rating Scale (NRS) for pain intensity, Physical Impairment Scale (PIS) for physical impairment, and the Oswestry Disability Questionnaire (ODQ) for self-report of disability. Test-retest reliability of the FAM measures was determined with intraclass correlation coefficients (ICC [2,1]) for total questionnaire scores at baseline and 48 hours later. Construct redundancy was determined with Pearson correlation coefficients for FAM measures. Criterion validity was assessed by 4 separate multiple regression models that included age, sex, and employment status as covariates. Depression, pain intensity, physical impairment, and disability were the dependent variables for these analyses. RESULTS: Test-retest ICC coefficients ranged from 0.90 to 0.97 for all FAM questionnaires. The FAM measures were significantly correlated with each other, with the only exception being that the FPQ was not correlated with the FABQ - work scale. In the multiple regression models the PCS contributed additional variance to depression. The FABQ - physical activity scale contributed additional variance to pain intensity and disability. The FABQ - work scale contributed additional variance to physical impairment and disability. No other FAM measures contributed to these regression models. CONCLUSION: These data suggest 4 commonly used FAM measures have similar test-retest with varying amounts of construct redundancy. The criterion validity analyses suggest that measurement of fear-avoidance constructs for patients seeking outpatient physical therapy with chronic LBP should include the PCS and the FABQ.

J Orthop Sports Phys Ther, Epub 12 March 2010. doi:10.2519/jospt.2010.3298

KEY WORDS: chronic pain, lumbar spine, pain catastrophizing

STUDY DESIGN: Controlled laboratory study using a cross-sectional design. OBJECTIVE: To compare patellofemoral joint kinematics, femoral rotation, and patella rotation between females with patellofemoral pain (PFP) and pain-free controls using weight-bearing kinematic magnetic resonance imaging (MRI). BACKGROUND: Recently, it has been recognized that patellofemoral malalignment may be the result of femoral motion as opposed to patella motion. METHODS: Fifteen females with PFP and 15 pain-free females between the ages of 18 and 45 years participated in this study. Kinematic imaging of the patellofemoral joint was performed using a vertically open MRI system. Axial-oblique images were obtained using a fast gradient-echo (Fast-GRE) pulse sequence. Images were acquired at a rate of 1 image per second while subjects performed a single limb squat. Measures of femur and patella rotation (relative to the image field of view), lateral patella tilt, and lateral patella displacement were made from images obtained at 45°, 30°, 15°, and 0° of knee flexion. Group differences were assessed using a mixed-model analysis of variance (ANOVA) with repeated measures. RESULTS: When compared to the control group, females with PFP demonstrated significantly greater lateral patella displacement at all angles evaluated and significantly greater lateral patella tilt at 30°, 15° and 0° of knee flexion. Similarly, greater medial femoral rotation was observed in the PFP group at 45°, 15° and 0° of knee flexion when compared to the control group. No group differences in patella rotation were found. CONCLUSION: Altered patellofemoral joint kinematics in females with PFP appears to be related to excessive medial femoral rotation as opposed to lateral patella rotation. Our results suggest that the control of femur rotation may be important in restoring normal patellofemoral joint kinematics.

J Orthop Sports Phys Ther, Epub 12 March 2010. doi:10.2519/jospt.2010.3215

KEY WORDS: biomechanics (lower extremity), hip, knee, medical imaging, MRI

STUDY DESIGN: Single-subject with repeated measures. OBJECTIVES: To determine if runners can use real-time visual feedback from an accelerometer to achieve immediate reductions in tibial acceleration and vertical force loading rates. BACKGROUND: Stress fractures are a common injury among runners. Previous studies suggest that runners with higher than normal tibial acceleration and vertical force loading rates are at increased risk for tibial stress fractures. If these runners can be trained to reduce the loading on their lower extremities, it may reduce their risk of stress fractures. METHODS: Five subjects participated in this study. All subjects ran on a treadmill, instrumented with force transducers, during a single 30-minute session that was divided into warm-up, feedback, no-feedback, and cool-down periods. During running, the subjects also wore an accelerometer taped to their distal right tibia. Peak positive acceleration of the tibia, vertical force impact peak, and average and instantaneous vertical force loading rates were assessed at the end of the warm-up, feedback, and no-feedback periods. RESULTS: Single-subject analysis revealed that 4 of the 5 subjects had significant reductions in their peak positive acceleration at the end of the no-feedback period compared to the warm-up. In addition, all of the subjects had significant decreases in impact peak and vertical ground reaction force loading rates at the end of the no-feedback period. CONCLUSION: In a single session of training with real-time visual feedback, it appears that most runners can reduce the types of lower extremity loading associated with stress fractures. This may lead to training programs that reduce the risk of stress fractures for runners.

J Orthop Sports Phys Ther, Epub 12 March 2010. doi:10.2519/jospt.2010.3166

KEY WORDS: accelerometer, gait retraining, ground reaction forces, stress fracture, tibia

STUDY DESIGN: Clinical Measurement, validity and intra-rater reliability study. OBJECTIVES: (1) To confirm the validity and assess between-day test-retest reliability of cervical spine motion measurements made with the cervical range of motion (CROM) device in flexion, extension, bilateral rotation, and bilateral side flexion; (2) To provide meaningful information to clinicians about the standard error of measurement (SEM) and the minimal detectable change (MDC) for the CROM device. BACKGROUND: Range of motion (ROM) is a common outcome measure used in the assessment of the cervical spine. The CROM device is one of the tools used to measure cervical ROM in the clinical setting. However, its psychometric properties are not well established, especially for measurements taken on separate days. METHODS: Quasi-experimental design with 1 group comparison. Twenty healthy adults (9 men and 11 women) participated in this study. Cervical ROM was simultaneously recorded with the CROM device and the Fastrak® motion analysis system for all 6 cervical movements mentioned above. The CROM device was placed on the participant's head consistent with standard clinical procedures. Two Fastrak® sensors were positioned, 1 on the forehead and 1 over the spinous process of the T6 vertebra. Test-retest reliability of measurements made with the CROM device was assessed, as well as its SEM and MDC, with measures taken on 2 separate days spaced 48 hours. RESULTS: Values obtained by the 2 measuring devices yielded Pearson correlation coefficients ranging between 0.93 and 0.98. Test-retest reliability of measurements of cervical ROM using the CROM was found to be good, with ICCs ranging between 0.89 and 0.98. The SEMs across the 6 movements ranged from 1.6° to 2.8° and the MDCs across the 6 movements ranged from 3.6° to 6.5°. CONCLUSIONS: The measurements made with the CROM were shown to be reliable in all movement directions.

J Orthop Sports Phys Ther, Epub 12 March 2010. doi:10.2519/jospt.2010.3180

KEY WORDS: cervical ROM measurement, clinical tool, psychometrics, SEM, MDC