STUDY DESIGN: Secondary analysis, pretreatment-posttreatment observational study. OBJECTIVE: To compare the reliability and responsiveness of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Knee Outcome Survey activities of daily living subscale (KOS-ADL), and the Lower Extremity Functional Scale (LEFS) in individuals with knee osteoarthritis (OA). BACKGROUND: The WOMAC is the current standard in patient-reported measures of function in patients with knee OA. The KOS-ADL and LEFS were designed for potential use in patients with knee OA. If the KOS-ADL and LEFS are to be considered viable alternatives to the WOMAC for measuring patient-reported function in individuals with knee OA, they should have measurement properties comparable to the WOMAC. It would also be important to determine whether either of these instruments may be superior to the WOMAC in terms of reliability or responsiveness in this population. METHODS: Data from 168 subjects with knee OA, who participated in a rehabilitation program, were used in the analyses. Reliability and responsiveness of each outcome measure were estimated at follow-ups of 2, 6, and 12 months. Reliability was estimated by calculating the intraclass correlation coefficient (ICC_2,1) for subjects who were unchanged in status from baseline at each follow-up time, based on a global rating of change score. To examine responsiveness, the standard error of the measurement, minimal detectable change, minimal clinically important difference, and the Guyatt responsiveness index were calculated for each outcome measure at each follow-up time. RESULTS: All 3 outcome measures demonstrated reasonable reliability and responsiveness to change. Reliability and responsiveness tended to decrease somewhat with increasing follow-up time. There were no substantial differences between outcome measures for reliability or any of the 3 measures of responsiveness at any follow-up time. CONCLUSION: The results do not indicate that one outcome measure is more reliable or responsive than another when applied to subjects with knee OA. We believe that all 3 instruments are appropriate outcome measures to examine change in functional status of patients with knee OA.

J Orthop Sports Phys Ther 2012;42(8):716-723, Epub 8 March 2012. doi:10.2519/jospt.2012.4038

KEY WORDS: clinimetrics, function, measurement, physical therapy, psychometrics

SYNOPSIS: The goal of every orthopaedic surgeon should be to restore anatomy as close as possible to normal. Intense research on reconstruction of the anterior cruciate ligament (ACL) and an advancing knowledge of the anatomy and function of the 2 primary bundles of the ACL have led to techniques of ACL reconstruction that more closely restore normal anatomy. Restoring the ACL footprint is one of the most important goals of the surgery, and the choice between anatomic single-bundle and double-bundle ACL reconstruction is determined by the anatomical features of each patient. After reconstruction, the graft undergoes a complex, lengthy process of remodeling; therefore, inappropriate (early), aggressive rehabilitation can lead to graft failure and compromise the patient’s outcome. The purpose of this article is to provide an overview of the anatomy and function of the ACL, the methods for anatomic single-bundle and double-bundle ACL reconstruction, and our recommendations for postoperative rehabilitation.

J Orthop Sports Phys Ther 2012;42(3):184-195. doi:10.2519/jospt.2012.3783

KEY WORDS: ACL, knee, surgery

STUDY DESIGN: Case report. BACKGROUND: Patellar fracture is a rare but significant complication following anterior cruciate ligament (ACL) reconstruction when using a bone-patellar tendon-bone (BPTB) autograft. The purpose of these case reports is to describe 2 cases in which patellar fracture occurred during rehabilitation after ACL reconstruction using a BPTB. CASE DESCRIPTION: Both patients were 23-year-old males referred for rehabilitation after ACL reconstruction using a BPTB autograft. They were both progressing satisfactorily in rehabilitation until sustaining a fracture of the patella. One fracture occurred during the performance of the eccentric phase of a knee extension exercise during the sixth week of rehabilitation (7 weeks postsurgery), whereas the other fracture occurred during testing of the patientís quadriceps maximum voluntary isometric contraction in the ninth week of rehabilitation (10 weeks postsurgery). Both patients were subsequently treated with open reduction and internal fixation of the patella. DISCUSSION: During rehabilitation following ACL reconstruction using BPTB autograft, clinicians should consider the need to balance the sometimes-competing goals of improving quadriceps strength while providing protection to the healing graft, minimization of patellofemoral pain, and protection of the patellar donor site. LEVEL OF EVIDENCE: Harm, level 4.

J Orthop Sports Phys Ther 2009;39(4):278-286, Epub 15 December 2008. doi:10.2519/jospt.2009.2864

KEY WORDS: ACL, failure, knee, load, strain

J Orthop Sports Phys Ther 1990;11(8):372-373.

J Orthop Sports Phys Ther 1992;15(6):270-278.

Key Words: anterior cruciate ligament reconstruction, basic science, biomechanics

J Orthop Sports Phys Ther 1992;16(4):174-181.

Key Words: ACL insufficient, assessment, function

Shoulder pain secondary to impingement of the rotator cuff tendons underneath the coracoacromial arch is a common problem seen in athletes who perform repetitive overhead activities. Shoulder impingement has been classified into primary and secondary types. Several factors contribute to impingement, including rotator cuff weakness, posterior capsule tightness, and subacromial crowding. Recently, it has been proposed that scapulothoracic muscle weakness could be a factor that contributes to impingement. Traditional rehabilitation protocols for shoulder impingement syndrome stress individualized rotator cuff strengthening. The authors propose that individualized scapulothoracic muscle strengthening should be a part of any protocol for nonoperative treatment of secondary shoulder impingement syndrome.

J Orthop Sports Phys Ther 1993;17(5):212-224.

Key Words: scapulothoracic muscles, shoulder impingement syndrome, rehabilitation

The Heel Pain-Plantar Fasciitis Guidelines link the International Classification of Functioning, Disability, and Health (ICF) body structures (Ligaments and fascia of ankle and foot, and Neural structures of lower leg) and the ICF body functions (Pain in lower limb, and Radiating pain in a segment or region) with the World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD) health condition (Plantar fascia fibromatosis/Plantar fasciitis). The purpose of these practice guidelines is to describe evidence-based orthopaedic physical therapy clinical practice and provide recommendations for (1) examination and diagnostic classification based on body functions and body structures, activity limitations, and participation restrictions, (2) prognosis, (3) interventions provided by physical therapists, and (4) assessment of outcome for common musculoskeletal disorders.

J Orthop Sports Phys Ther. 2008;38(4):A1-A18. doi:10.2519/jospt.2008.0302

The original article was corrected in October 2008, and the amended article PDF is provided here. Please see: October 2008 Errata

KEY WORDS: APTA, clinical practice guidelines, ICD, ICF, Orthopaedic Section

This is the first of a series of evidence-based practice guidelines that are being developed using the International Classification of Functioning, Disability, and Health (ICF) as the basis for describing and classifying care provided by physical therapists to patients with a variety of musculoskeletal conditions. The practice guidelines being developed by the Orthopaedic Section of the American Physical Therapy Association will focus primarily on the structures related to movement and the neuromusculoskeletal and movement-related functions and sensory functions and pain categories within the ICF. These body structures and body functions will be linked with their associated health conditions from the World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD).

J Orthop Sports Phys Ther. 2008;38(4):167-168. doi:10.2519/jospt.2008.0105

KEY WORDS: heel pain, ICF, Orthopaedic Section, plantar fasciitis, practice guidelines

The information acquired from self-reported outcome instruments is useful only if there is evidence to support the interpretation of obtained scores. To properly interpret scores, there should be evidence for content validity, construct validity, reliability, and responsive­ness. Evidence regarding score interpretation must also contain a description of the applica­ble test conditions, including information about the characteristics of subjects, timing of data collection, and construct of change. The objec­tive of this review was to identify self-reported outcome instruments that have evidence to support their usefulness for assessing the ef­fect of treatment directed at individuals with foot and ankle-related pathologic conditions in an orthopaedic physical therapy setting. In ad­dition, we provide specific information that will allow clinicians and researchers to select an appropriate instrument and properly interpret the obtained scores. Fourteen self-reported outcome instruments that met the objective of this review were identified. Five instruments, the Foot and Ankle Ability Measure, Foot Func­tion Index, Foot Health Status Questionnaire, Lower Extremity Function Scale, and Sports Ankle Rating System quality of life measure, satisfied all 4 categories of evidence (content validity, construct validity, reliability, and re­sponsiveness) outlined herein. 

J Orthop Sports Phys Ther. 2007;37(2):72-84. doi:10.2519/jospt.2007.2403

KEY WORDS: ankle, foot, outcome instru­ments, reliability, responsiveness, validity

Study Design: Randomized clinical trial, single-masked. Objectives: To determine the effectiveness of using a modified neuromuscular electrical stimulation (NMES) training program as an adjunct treatment for improving quadriceps strength and physical function in rehabilitation following anterior cruciate ligament reconstruction (ACLR). Background: NMES training for quadriceps strengthening has previously been shown to be an effective adjunct treatment following ACLR when performed against isometric resistance using a dynamometer with the knee positioned in flexion. We developed a modified version of published NMES protocol because some patients have difficulty tolerating the existing protocol and many clinics may not have instrumented dynamometers. There is a need to determine the effectiveness of this modified protocol. Methods and Measures: Forty-three subjects who had undergone ACLR were randomly assigned to either a group that received (NMES group) or did not receive (comparison group) the NMES treatment in conjunction with their rehabilitation. Group means for quadriceps strength and self-reported measures of knee function were compared after 12 and 16 weeks of rehabilitation. The proportion of subjects in each group achieving clinical criteria to initiate ambulation without crutches, treadmill running, and agility training at selected times during rehabilitation were also compared. Results: The NMES group demonstrated moderately greater quadriceps strength at 12 weeks (effect size, 0.48), and moderately higher levels of self-reported knee function at both 12 (effect size, 0.72) and 16 (effect size, 0.65) weeks of rehabilitation compared to the comparison group. A greater proportion of subjects in the NMES group achieved clinical criteria for advancing to agility training at 16 weeks. Conclusions: The modified NMES quadriceps training protocol can be a useful adjunct to ACLR rehabilitation programs, but the treatment effect is smaller than what has been reported in previous studies.

J Orthop Sports Phys Ther. 2003;33(9):492-501.

Key Words: ACL, clinical trial, knee, strengthening, training

Imbalances in the firing pattern and contraction intensity of the vastus medialis oblique (VMO) and the vastus lateralis (VL) have been considered important factors contributing to patellofemoral joint dysfunction. Vastus medialis oblique and vastus lateralis electromyographic (EMG) activity were measured for 15 individuals without patellofemoral pain (asymptomatic group) and 13 subjects with patellofemoral pain (symptomatic group) while ascending and descending steps. The peak VMO/VL ratios of EMG activity and the difference in peak VMO and VL onset times were measured. Two-way mixed-model analyses of variance (ANOVA) were used to determine the main effects of group (asymptomatic and symptomatic), phase (concentric phase ascending and 2 eccentric phases descending stairs), and the interaction between group and phase. The ANOVAs indicated no difference between groups for the peak VMO/VL EMG ratio or for the onset timing between peak VMO and VL muscle activity. Combining groups, the peak VMO/VL EMG ratio was less for the eccentric weight acceptance phase of descent compared with the concentric phase of ascent. These findings suggest no differences between asymptomatic and symptomatic individuals, but differences may exist between concentric and eccentric VMO/VL ratios. Further research is needed to determine if VMO and VL muscle imbalances contribute to patellofemoral dysfunction.

J Orthop Sports Phys Ther. 1998;27(6):423-429.

Key Words: patellofemoral, electromyography, kinetic chain

Knowledge of the structure and function of articular cartilage is important when considering rehabilitation following surgical procedures for articular cartilage lesions of the knee. Articular cartilage is avascular and derives its nutrition primarily from synovial fluid, resulting in a limited potential for regeneration. Basic science evidence has demonstrated that compressive loading may have a positive impact on articular cartilage healing; however, excessive shear loading may be detrimental. Rehabilitation following surgical procedures for articular cartilage lesions should include controlled range of motion exercises. Exercises to enhance muscle function must be done in a manner that minimizes shear loading of the joint surfaces in the area of the lesion. A period of protected weight bearing is often necessary and should be followed by progressive loading of the joint. This article will: 1) provide a brief review of the structure and function of articular cartilage lesions as it relates to rehabilitation; 2) describe common surgical procedures to address articular cartilage lesions; and 3) provide guidelines for rehabilitation following surgical management of articular cartilage lesions.

J Orthop Sports Phys Ther. 1998;28(4):232-240.

Key Words: articular cartilage, knee surgery, rehabilitation

There is a dearth of reliable and valid instrumentation that measures disability following injury and/or surgery of the knee joint that is responsive to clinically significant changes over time. The purpose of this investigation was to determine whether performance-based or patient-reported measures of function are more effective in estimating disability in individuals with an anterior-cruciate-ligament (ACL)-deficient knee. Subjective rating of knee function was used as the criterion measure for disability, and selected performance-based and patient-reported measures were used as estimation variables. Twenty-nine individuals with an ACL-deficient knee participated in this investigation. Step-wise regression analysis revealed that the Cincinnati Knee Scale, Lysholm Knee Scale, and hop index were the most effective estimates of disability. The results demonstrate that patient-reported measures are more related to the patient's level of disability in individuals with an ACL-deficient knee. More research is necessary to substantiate these findings.

J Orthop Sports Phys Ther. 1998;28(6):392-399.

Key Words: functional disability, anterior cruciate ligament deficiency, knee, assessment

Little research is available on the muscle activity patterns of the lower extremity muscles during dynamic closed chain squatting activities. The purpose of this study was to examine the effect of lower extremity position during an Olympic squat on the muscle activity patterns of the vastus medialis, vastus lateralis, semimembranosus/semitendinosus, and biceps femoris. Twenty-five healthy, untrained subjects, 18-35 years old, were randomly assigned initial squatting positions of either self-selected neutral or 30° of lower extremity turn-out from the self-selected neutral position. Surface electromyography and motion analysis data were collected simultaneously in 10° intervals and analyzed from 10-60° of knee flexion in both the ascending and descending phases of the squat. A 4-way analysis of variance indicated that the main effects of lower extremity position and the interaction of extremity position and knee joint angles were not found to cause significant changes in muscle activity patterns. Significant changes in muscle activity did occur with changes in knee flexion angles in the vastus medialis and vastus lateralis but not in the semimembranosus/semitendinosus or biceps femoris.

J Orthop Sports Phys Ther. 1997;25(5):307-315.

Key Words: squat, electromyography, joint motion, lower extremity

Shoulder kinesthesia has not been extensively studied in upper extremity athletes. The purpose of this study was to determine if there were differences in threshold to detection of passive motion between dominant and nondominant shoulders of healthy overhead athletes in 2 positions, 0° and 75° of external rotation. In addition, the study attempted to determine if there was a relationship between the range of external rotation (ER) and internal rotation (IR) and the threshold to detection of passive motion values. Shoulder kinesthesia was assessed in the dominant and nondominant shoulders of 20 collegiate athletes participating in unilateral upper extremity sports. A proprioceptive testing device passively moved the shoulder into internal and external rotation. The dominant shoulder had a significantly greater difficulty detecting motion compared with the nondominant arm at both 0° and 75° of external rotation. Both shoulders exhibited enhanced kinesthesia (lower threshold to detection of passive motion scores) at 75° of external rotation compared with 0°, where the glenohumeral joint capsule is relatively taut. The results of this study suggest that healthy upper extremity athletes may have kinesthetic deficits in their throwing shoulder compared with their nondominant shoulder.

J Orthop Sports Phys Ther. 1995;21(4):220-226.

Key Words: shoulder, kinesthesia, athletics

Treatment of meniscal injuries in the knee has evolved over the past 3 decades. New research regarding the functional roles of the menisci has increased emphasis on the preservation of meniscal tissue. Meniscal transplantation has developed as a surgical technique for individuals whose menisci have been compromised through trauma or previous meniscectomy. The purpose of this article is to review the current literature regarding meniscal function, the deleterious effects of meniscectomy, and the development of transplantation of allograft menisci as a surgical technique. A case study of a 28-year-old male undergoing medial meniscus transplantation is presented, with emphasis on the development of postoperative rehabilitation guidelines.

J Orthop Sports Phys Ther. 1996;24(2):98-106.

Key Words: meniscus, transplantation, rehabilitation

Swimming has become a popular recreational activity as well as a highly competitive sport in the United States. The repetitive nature of swimming can predispose the shoulder to mechanical impingement and microtrauma, which may lead to laxity, rotator cuff fatigue, and subsequent secondary impingement. Improper stroke mechanics can place the swimmer's shoulder at further risk. The purpose of this paper is to describe the pathology of secondary impingement in freestyle swimmers and to discuss the clinical implications for rehabilitation of swimmers with the pathology. A thorough subjective and objective evaluation is necessary to design a successful rehabilitation program. The rehabilitation program for swimmers with secondary impingement includes modification of training, flexibility, range of motion, strengthening, and mobilization as indicated. Functional and proprioceptive training may also be useful techniques in the rehabilitation of a swimmer's shoulder. Improper stroke mechanics can also have clinical implications on a swimmer's shoulders with secondary impingement. The clinical implication of secondary impingement in freestyle swimmers suggests that the primary goal of rehabilitation is to promote equilibrium of the shoulder complex while accounting for the demands of the sport.

J Orthop Sports Phys Ther. 1994;20(6):307-318.

Key Words: swimming, shoulder impingement and instability, rehabilitation

Study Design: Test-retest reliability study.
Objective: To determine interrater reliability of the modified scapular assistance test (SAT). The modified SAT is designed to assess the contribution of scapular motion to shoulder pain.
Background: Abnormal scapular motion has been implicated in different shoulder disorders. However, there is a lack of clinical evaluation tools to assess the scapular component of shoulder dysfunction.
Methods and Measures: Forty-six subjects who were referred to physical therapy for treatment of various shoulder pathologies were recruited for this study. The modified SAT was performed on each participant by 2 different examiners. Percent agreement and kappa coefficient were utilized to determine interrater reliability of the modified SAT.
Results: The kappa coefficient and percent agreement were 0.53 and 77%, respectively, when the test was performed in the scapular plane, and 0.62 and 91%, respectively, when the test was performed in the sagittal plane.
Conclusions: The modified SAT possesses acceptable interrater reliability for clinical use.

 J Orthop Sports Phys Ther. 2006;36(9):653-660. doi:10.2519/jospt.2006.2234

Key Words: measurement, scapula, shoulder