The patient was a 38-year-old man evaluated by a physical therapist 14 weeks after repair of the left patellar tendon. The physical therapist requested radiographs, which revealed findings consistent with a patellar tendon retear. The radiologist recommended further evaluation with magnetic resonance imaging, which showed a left patellar tendon tear.

J Orthop Sports Phys Ther 2012;42(8):738. doi:10.2519/jospt.2012.0414

KEY WORDS: knee, lower extremity, patella, magnetic resonance imaging, radiography

SYNOPSIS: Physical therapists frequently encounter situations that require complex differential-diagnosis decisions and the ability to consistently screen for serious pathology that may mimic a musculoskeletal complaint. By applying the evidence-based-practice process to diagnosis, screening, and referral, physical therapists can identify diagnostic and screening strategies that positively influence clinical decisions. A critically appraised topic document (a standard 1-page summary of the literature appraisal and clinical relevance in response to a specific clinical question) is a valuable tool in evidence-based practice. The creation of a critically appraised topic makes the educational process cumulative instead of duplicative, allowing the individual clinician to assimilate and consolidate knowledge after a search effort and improving search and appraisal skills. The purpose of this clinical commentary is as follows: (1) to describe the clinical reasoning process of 3 orthopaedic physical therapists that led to the development of specific clinical questions related to screening for nonmusculoskeletal pathology, (2) to describe the search and triage strategy that led each physical therapist to the current best evidence needed to rule out nonmusculoskeletal pathology in the patient, and (3) to discuss the advantages and disadvantages of a critically appraised topic, the implementation of this process, and the tailoring of search strategies to find diagnostic and screening strategies. LEVEL OF EVIDENCE: Diagnosis, level 5.

J Orthop Sports Phys Ther 2012;42(10):870-879, Epub 19 July 2012. doi:10.2519/jospt.2012.4265

KEY WORDS: critically appraised topic,evidence-based practice, screening

STUDY DESIGN: Prospective single-cohort study. OBJECTIVES: To determine and document changes in pain and disability in patients with primary, nonacute acromioclavicular joint (ACJ) pain treated with a manual therapy approach. BACKGROUND: To our knowledge, there are no published studies on the physical therapy management of nonacute ACJ pain. Manual physical therapy has been successful in the treatment of other shoulder conditions. METHODS: The chief inclusion criterion was greater than 50% pain relief with an ACJ diagnostic injection. Patients were excluded if they had sustained an ACJ injury within the previous 12 months. Treatment was conducted utilizing a manual physical therapy approach that addressed all associated impairments in the shoulder girdle and cervicothoracic spine. The primary outcome measure was the Shoulder Pain and Disability Index. Secondary measures were the American Shoulder and Elbow Surgeon and global rating of change scales. Outcomes were collected at baseline, 4 weeks, and 6 months. The Shoulder Pain and Disability Index and American Shoulder and Elbow Surgeon scale values were analyzed with a repeated-measures analysis of variance. RESULTS: Thirteen patients (11 male; mean ± SD age, 41.1 ± 9.6 years) completed treatment consisting of an average of 6.4 sessions. Compared to baseline, there was a statistically significant and clinically meaningful improvement for the Shoulder Pain and Disability Index at 4 weeks (P = .001; mean, 25.9 points; 95% confidence interval [CI]: 11.9, 39.8) and 6 months (P<.001; mean, 29.8 points; 95% CI: 16.5, 43.0), and the American Shoulder and Elbow Surgeon scale at 4 weeks (P<.001; mean, 27.9 points; 95% CI: 14.7, 41.1) and 6 months (P<.001; mean, 32.6 points; 95% CI: 21.2, 43.9). CONCLUSION: Statistically significant and clinically meaningful improvements were observed in all outcome measures at 4 weeks and 6 months, following a short series of manual therapy interventions. These results, in a small cohort of patients, suggest the efficacy of this treatment approach but need to be verified by a randomized controlled trial. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2012:42(2):66-80, Epub 25 October 2011. doi:10.2519/jospt.2012.3866

KEY WORDS: distal clavicle excision, manipulation, mobilization, Mumford, shoulder

The patient was a 33-year-old man who was referred to a physical therapist following a right ankle sprain. While the patient reported decreased pain and improved function of his right ankle over the course of care, he complained of a new insidious onset of right anterior hip pain. Radiographs of the hip were negative. The patient was treated by the physical therapist 4 times over the next month with manual therapy and therapeutic exercises, which resulted in moderate but temporary relief. Given the lack of response to conservative management and the poor sensitivity of conventional radiographs for early stage pathology, the physical therapist ordered a bone scan, which revealed increased radiopharmaceutical uptake in the lesser trochanteric region of the hip. A computed axial tomography scan revealed a lytic lesion in the proximal right medial femur corresponding to the area of increased uptake on the bone scan, and magnetic resonance imaging demonstrated an intramedullary lesion of the proximal femur. Following a needle biopsy, the patient was diagnosed with eosinophilic granuloma.

J Orthop Sports Phys Ther 2011;41(2):119. doi:10.2519/jospt.2011.0404

KEY WORDS: computed tomography, femur, magnetic resonance imaging, radiography

The patient was an 85-year-old man with multiple medical comorbidities, who was admitted to a hospital inpatient setting for further evaluation after a fall at home earlier that day. The fall resulted in a right acetabular fracture. Radiographs, which indicated an acetabular fracture and protrusio acetabuli, were obtained 2 weeks after his initial injury. Subsequent computed tomography images revealed a comminuted acetabular fracture, with clear protrusion of the femoral head.The availability of diagnostic imaging to the physical therapist and a clear understanding of the nature of the patient's condition were important in this case, as any forces that could potentially increase the protrusion would have to be strictly limited. The patient was eventually transferred to a long-term care facility to convalesce and determine eligibility for operative management.

J Orthop Sports Phys Ther 2009;39(9):703. doi:10.2519/jospt.2009.0410

KEY WORDS: computed tomography, hip, pelvis, radiographs 

A 46-year-old avid female runner was referred to physical therapy for left ankle pain following an inversion injury sustained 1 month earlier while running. The patient had a history of breast cancer, but her health screening was otherwise unremarkable. The patient presented with a normal ankle examination, except for localized tenderness to palpation proximal to the distal tip of the left fibula. The physical therapist was concerned about the possibility of a fibular fracture and ordered ankle radiographs, which were read as normal by the radiologist. The physical therapist, however, observed a slight cortical irregularity of the distal fibula on the anterior-posterior radiograph that corresponded with the site of palpation tenderness, and consequently ordered a bone scan to differentiate active versus old pathology. The bone scan revealed an area of increased metabolic activity at the site of the cortical irregularity, so the physical therapist ordered magnetic resonance imaging, which revealed an incomplete nondisplaced distal fibular stress fracture. Subsequently, the patient was referred to orthopedics for fracture management. The patient's history of a primary cancer required advanced imaging to assist in ruling out metastatic disease; symptomatic management of a suspected stress fracture without advanced imaging may be appropriate in a patient without a history of primary cancer.

J Orthop Sports Phys Ther 2009;39(3):230. doi:10.2519/jospt.2009.0403

KEY WORDS: ankle, distal fibular stress fracture, magnetic resonance imaging, radiographs

J Orthop Sports Phys Ther. 2007:37(4):192-198. doi:10.2519/jospt.2007.2393

Study Design: This study utilized a quasi-experimental design in which subjects served as their own controls. Objective: To determine whether heart rate, pain threshold velocity, and pain perception varied in patients running on a soft-belt treadmill versus a standard hard-belt treadmill. Background: According to promotional literature, the relatively new Orbiter soft-belt treadmill produces a greater increase in heart rate at a given velocity as well as a higher velocity tolerance while walking or running. The manufacturer also asserts that decreased forces transmitted through the lower extremity should decrease pain levels while exercising on the soft-belt treadmill. Methods and Measures: Twenty-seven subjects walked or ran on each of 2 treadmills at incrementally increasing velocities until they experienced either the onset of pain or an increase in pain from baseline levels. Locomotion continued for 2 minutes after that, during which time heart rate and pain level on a visual analog scale (VAS) were recorded. Results: Two univariate paired t tests and a Wilcoxon’s signed rank test revealed a greater heart rate and pain threshold velocity when using the soft-belt treadmill with no statistical difference in the pain reported between the 2 treadmills. Conclusion: Our study revealed a 10% higher heart rate and a 14.5% higher pain threshold velocity with the soft-belt treadmill compared to a hard-belt treadmill. These differences are considered clinically meaningful.

J Orthop Sports Phys Ther. 2003;33(9):532-537.

Key Words: ambulation, running, walking

Study Design: A prospective randomized clinical trial. Objective: To compare the effectiveness of 2 physical therapy treatment approaches for impingement syndrome of the shoulder. Background: Manual physical therapy combined with exercise is a commonly applied but currently unproven clinical treatment for impingement syndrome of the shoulder. Methods and Measures: Thirty men and 22 women (age 43 years ± 9.1) diagnosed with shoulder impingement syndrome were randomly assigned to 1 of 2 treatment groups. The exercise group performed supervised flexibility and strengthening exercises. The manual therapy group performed the same program and received manual physical therapy treatment. Both groups received the selected intervention 6 times over a 3-week period. The testers, who were blinded to group assignment, measured strength, pain, and function before treatment and after 6 physical therapy visits. Strength was a composite score of isometric strength tests for internal rotation, external rotation, and abduction. Pain was a composite score of visual analog scale measures during resisted break tests, active abduction, and functional activities. Function was measured with a functional assessment questionnaire. The visual analog scale used to measure pain with functional activities and the functional assessment questionnaire were also measured 2 months after the initiation of treatment. Results: Subjects in both groups experienced significant decreases in pain and increases in function, but there was significantly more improvement in the manual therapy group compared to the exercise group. For example, pain in the manual therapy group was reduced from a pretreatment mean (±SD) of 575.8 (±220.0) to a posttreatment mean of 174.4 (±183.1). In contrast, pain in the exercise group was reduced from a pretreatment mean of 557.1 (±237.2) to a posttreatment mean of 360.6 (±272.3). Strength in the manual therapy group improved significantly while strength in the exercise group did not. Conclusion: Manual physical therapy applied by experienced physical therapists combined with supervised exercise in a brief clinical trial is better than exercise alone for increasing strength, decreasing pain, and improving function in patients with shoulder impingement syndrome.

J Orthop Sports Phys Ther. 2000;30(3):126-137.

Key Words: exercise, manual physical therapy, shoulder impingement syndrome

This article presents an overview of current concepts of evidence-based diagnosis using a variety of imaging modalities for a broad spectrum of musculoskeletal conditions and syndromes. There is limited but increasing evidence that physical therapists appropriately use diagnostic studies in clinical practice. Pathology revealed by diagnostic studies must be viewed in the context of the complete examination, as pathology is common in the asymptomatic population. Special diagnostic challenges are presented by patients with areas of referred pain, multiple injuries or multiple areas of pathology, neoplasms, and infections. Plain film radiographs have been overused in the clinical management of many conditions, including low back pain. Clinical decision rules provide simple evidence-based guidelines for the appropriate use of imaging studies.

J Orthop Sports Phys Ther. 2005;35(11):708-721. doi:10.2519/jospt.2005.2034

Key Words: clinical decision rule, diagnosis, diagnostic imaging

The risk from either diagnosis or intervention from a physical therapist is extraordinarily low, with the possibility of substantial benefit. This optimal combination of substantial benefit, with little or no risk, is relatively rare in the healthcare field and therefore represents an attractive healthcare investment. While higher-risk, more-invasive interventions have a role in select situations, the general public should have the option to seek conservative care through direct access to physical therapy services.

J Orthop Sports Phys Ther. 2006; 36(9):632-634. doi:10.2519/jospt.2006.0110