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 activity-related pain immediately following this manipulation technique. METHODS AND MEASURES:  Fifty subjects (26 male, 24 female; age range, 18-45 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 representing no pain and 10 the worst possible pain). Following the assessment, all subjects were treated with a lumbopelvic manipulation, which was immediately followed by retesting the 3 functional activities to determine if there was any change in pain ratings. An immediate overall 50% or greater reduction in pain, or moderate or greater 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, in light of a limited sample size and omission of potentially meaningful predictor variables, future studies are necessary to validate the CPR. LEVEL OF EVIDENCE: Prognosis, level 2b.

This article features an invited commentary by Christopher M. Powers, PT, PhD, as well as an authors' response.

J Orthop Sports Phys Ther. 2008;38(6):297-312, published online 22 January 2008. doi:10.2519/jospt.2008.2669

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

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

Patients are frequently referred to physical therapy for musculoskeletal injuries. These injuries range from muscle strains to ligament ruptures and bone avulsion fractures. On occasion, what first may appear to be a common musculoskeletal injury can actually develop unexpected sequellae. It is imperative that the physical therapist continue to treat the patient while observing for signs and symptoms that would indicate changes to the initial diagnosis. Reevaluations include examining the progress of the patient and modifying or redirecting interventions.

This is a case report of a patient referred from his primary care physician to physical therapy 6 weeks after suffering a common musculoskeletal injury (diagnosed by the physician as a hamstring muscle contusion). The patient was later determined by a neurologist, and confirmed by a neurosurgeon, to have developed a saphenous neuropathy. Saphenous neuropathy is an uncommon syndrome, accounting for less than 1% of adult patients presenting with lower-extremity pain. True diagnosis is often delayed due to the rarity of the syndrome and the reliance on clinical presentation. Optimal treatment is not known but usually requires injection of local anesthetics with steroids or a surgical nerve release/decompression.

It is important for physical therapists to understand and recognize the signs and symptoms of a saphenous neuropathy. This syndrome is not reported often and can be overlooked or misdiagnosed as it develops. It is equally important for physical therapists to understand their involvement in the primary care team. In that capacity, physical therapists have the opportunity to interact with and refer to other providers. It is important to assimilate the findings of these other care providers as well as the information gathered during initial and follow-up evaluations in the clinic.

J Orthop Sports Phys Ther. 2004; 34(6):328-334. doi:10.2519/jospt.2004.1269

Key Words: saphenous neuropathy, knee, primary care

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

Study Design: Resident's case problem. Background: Although femoral shaft stress fractures in the general population are rare, they are more common among endurance athletes and military recruits. Such individuals presenting with a complaint of hip, thigh, or knee pain should raise suspicion for femoral shaft stress injury. A US Military Academy cadet presented to West Point's Physical Therapy-Sports Medicine clinic with a complaint of thigh pain related to training with the local marathon team. A second cadet presented to the same clinic during Cadet Basic Training with a complaint of vague but increasing hip, thigh, and knee pain. Diagnosis: Both cadets were suspected of having femoral stress injuries, based on clinical exams, and both diagnoses were confirmed with diagnostic imaging. The 2 cadets were both treated conservatively with progressive rehabilitation once healing was confirmed with radiographs. They both responded favorably to conservative management and returned to full athletic activity at approximately 12 weeks. Discussion: Symptoms from a femoral shaft stress fracture can be vague and mimic those of other etiologies. Providers should consider a broad differential diagnosis, to include femoral shaft stress fracture, when treating endurance athletes and military recruits with anterior hip, thigh, or knee pain. Proper imaging confirms the diagnosis and sequential radiographs assist in rehabilitation planning.

J Orthop Sports Phys Ther. 2005;35(10):665-673. doi:10.2519/jospt.2005.2180

Key Words: differential diagnosis, femur, overuse injury, stress fracture

Study Design: Nonexperimental, retrospective, descriptive design. Objectives: This study was designed to ascertain whether direct access to physical therapy placed military health care beneficiaries at risk for adverse events related to their management. Background: Military health care beneficiaries have the option at most US military hospitals and clinics to first enter the health care system through physical therapy by direct access, without referral from another privileged health care provider. This level of autonomous practice incurs broad responsibilities and raises concern regarding the delivery of safe, competent, and appropriate patient care administered by physical therapists (PTs) when patients are not first examined and then referred by a physician or other privileged health care provider. While military PTs practice autonomously in a variety of health care settings, they do not work independently within any facility. Military PTs and physicians rely on one another for sharing and collaboration of information regarding patient care and clinical research as warranted. Additionally, physicians indirectly supervise military PTs. Methods and Measures: To reduce provider bias, a retrospective analysis was performed at 25 military health care sites (6 Army, 11 Navy, and 8 Air Force) on patients seen in physical therapy from October 1999 through January 2003. During this 40-month period, 95 PTs (88 military and 7 civilian) were credentialed to provide care throughout the various medical sites. Descriptive statistics were analyzed for total workload, number of new patients seen with and without referral, documented patient adverse events reported to each facility’s Risk Management Office, and any disciplinary or legal action against a physical therapist. Results: During the 40-month observation period, 472 013 patient visits were recorded. Of these, 112 653 (23.9%) were new patients, with 50 799 (45.1%) of the new patients seen through direct access without physician referral. Throughout the 40-month data collection period, there were no reported adverse events resulting from the PTs’ diagnoses or management, regardless of how patients accessed physical therapy services. Additionally, none of the PTs had their credentials or state licenses modified or revoked for disciplinary action. There also had been no litigation cases filed against the US Government involving PTs during the same period. Conclusions: The findings from this preliminary study clearly demonstrate that patients seen in military health care facilities are at minimal risk for gross negligent care when evaluated and managed by PTs, with or without physician referral. The significance of these findings with respect to direct access is important for not only our beneficiaries but also our profession and the facilities in which we practice.

J Orthop Sports Phys Ther. 2005;35(10):674-678. doi:10.2519/jospt.2005.2141

Key Words: adverse effect, adverse event, liability, primary care

Study Design: Resident’s case problem.
Background: A 19-year-old female, currently enrolled in a military training program, sought medical care for a twisting injury to her right knee. The patient reported her symptoms as similar to an injury she incurred 1 year previously while enrolled in the same military program. The patient’s past medical history included a nondepressed fracture of the medial tibial plateau and complete tear of the deep fibers of the medial collateral ligament.
Diagnosis: Physical exam revealed nonlocalized anterior and medial knee pain without evidence of internal derangement. Initial knee and tibia radiographs were unremarkable. Referral for orthopedic physician evaluation resulted in concurrence with the therapist’s diagnosis and plan of care, and the patient was allowed to continue with limited physical training demands. Despite periods of rest, the patient’s symptoms progressively worsened upon attempts to resume running. The examining therapist referred the patient for magnetic resonance imaging (MRI) due to the patient’s worsening symptoms, normal radiographs, and concern for a proximal tibia stress fracture. MRI revealed a severe proximal tibial metaphysis stress fracture.
Discussion: Stress fractures are commonly encountered injuries in individuals subjected to increased physical training demands. Early evaluation may not yield well-localized findings and may mimic other conditions. Nonmusculoskeletal conditions should be considered in the management of patients with stress fractures. This resident’s case problem illustrates the importance of serial physical examinations and collaboration with other healthcare practitioners in the comprehensive assessment and management of a patient with a severe stress fracture.

J Orthop Sports Phys Ther. 2006;36(7):526-534. doi:10.2519/jospt.2006.2125

Key Words: bone injury, female athlete triad, tibia

J Orthop Sports Phys Ther. 2003;33(1):40-47.

Keywords: abdominal muscular fitness, curl-up, strength training