Study Design: Retrospective descriptive study. Objectives: To examine compliance in wearing heel lifts during 8 weeks of military training in cadets identified with limb length inequalities. Background: Lack of compliance can be blamed for countless poor outcomes in the medical community. Reported compliance with intervention protocols has been reported to range from 11% to 95%. All 1100 new cadets in the class of 2005 were screened for a limb length inequality. One hundred ninety-eight out of 1100 cadets were identified to have a limb length inequality on physical exam and volunteered to participate. Cadets were randomly assigned to a heel lift or control group. Cadets in the heel lift group were instructed to wear a heel lift at all times throughout cadet basic training to attempt to prevent overuse injuries. There was no difference (P>.05) between the heel lift group and the control group on injury rate or excusal days. Methods and Measures: In an attempt to discern whether the preventive intervention was ineffective by design or if noncompliance was to blame, investigators asked cadets via electronic mail survey to report compliance with heel lift wear as a percentage (0%-100%). Results: Seventy-six out of 99 (76.8%) cadets in the heel lift group responded to the electronic mail survey. Mean reported compliance was 38%. Eighteen cadets reported between 70% and 100% compliance. The remaining 58 cadets reported less than 70% compliance. Conclusions: Cadet compliance was poor with the use of a heel lift. Physical therapists throughout the military often prescribe heel lifts, therapeutic exercises, or medication and assume good to excellent compliance. This study reminds providers that good compliance should not be assumed in any setting.

J Orthop Sports Phys Ther. 2004;34(3):126-131. doi:10.2519/jospt.2004.1284

Key Words: footwear, lower extremity, orthosis, prevention

Injuries to the ankle or foot are some of the most common orthopaedic complaints seen in primary care and sports medicine settings, accounting for 5% to 10% of all visits. Physical therapists working in a military setting are frequently the first credentialed providers to evaluate and diagnose patients with musculoskeletal complaints or orthopaedic trauma, using their privileges to order radiographs, bone scans, and electromyographical/nerve conduction study examinations. Because the presenting symptoms of sprains and fractures are often similar, it is imperative that physical therapists are competent and comfortable with their role of evaluating acute traumatic injuries without a physician referral. The validity of physical therapists managing patients with acute musculoskeletal injuries, without physician referral, has been previously established. This important role has enabled US Army orthopaedic surgeons to focus their practice on more complicated trauma or surgical cases. As direct access becomes more prevalent in the civilian profession of physical therapy, it becomes increasingly important that the physical therapist, as the first credentialed provider evaluating the patient, is proficient in distinguishing between ankle sprains and fractures. Even in the absence of direct access, physical therapists should still be able to determine when radiographs are appropriate in the event of a misdiagnosis and referral for an ankle sprain. The Ottawa Ankle Rules and the Buffalo modification are effective clinical decision rules to assist therapists in ruling out a fracture or determining whether radiographs are necessary for acute ankle injuries. We chose to report this case as example of how physical therapists can effectively apply these rules while serving in a direct-access role for the benefit of patients.

J Orthop Sports Phys Ther. 2004;34(4):182-186. doi:10.2519/jospt.2004.1310

Key Words: sprains, fractures, Ottawa Ankle Rules, Buffalo modification, direct-access

Study Design: Nonexperimental, retrospective design. Objectives: This study was designed to compare clinical diagnostic accuracy (CDA) between physical therapists (PTs), orthopaedic surgeons (OSs), and nonorthopaedic providers (NOPs) at Keller Army Community Hospital on patients with musculoskeletal injuries (MSI) referred for magnetic resonance imaging (MRI). Background: US Army PTs are frequently the first credentialed providers privileged to examine and diagnose patients with musculoskeletal injuries. Physical therapists assigned at Keller Army Community Hospital have also been credentialed with privileges to order MRI studies for several years. Methods and Measures: To reduce provider bias, a retrospective analysis was performed on 560 patients referred for MRI over an 18-month period. An electronic review of each patient’s radiological profile was performed to assess agreement between clinical diagnosis and MRI findings. Data analyses were performed through descriptive statistics and contingency tables. Results:Analysis on agreement between clinical diagnosis and MRI findings produced a CDA of 74.5% (108/145) for PTs, 80.8% (139/172) for OSs, and 35.4% (86/243) for NOPs. There was a significant difference in CDA between PTs and NOPs (P<.001), and between OSs and NOPs (P<.001). There was no difference in CDA between PTs and OSs (P>.05). Conclusions: Clinical diagnostic accuracy by PTs and OSs on patients with musculoskeletal injuries was significantly greater than for NOPs, with no difference noted between PTs and OSs.

J Orthop Sports Phys Ther. 2005;35(2):67-71. doi: 10.2519/jospt.2005.1344

Key Words: diagnostic agreement, direct access, primary care