The patient was a 39-year-old man who self-referred to a physical therapist with a chief complaint of right wrist pain after falling backward onto an outstretched right hand the previous day. Based on the suspicion of a fracture, right wrist radiographs (posterior-toanterior, lateral, and oblique views) were completed, which revealed a comminuted dorsal triquetrum fracture. The patient was referred to an orthopaedic surgeon who recommended nonoperative management.

J Orthop Sports Phys Ther 2012;42(4):380. doi:10.2519/jospt.2012.0407

KEY WORDS: radiography, wrist

STUDY DESIGN: Resident’s case problem. BACKGROUND: A 21-year-old athletic male college student presented to a direct-access physical therapy clinic with complaints of left calf pain 4 days in duration. After initial examination, a working diagnosis of calf strain was formulated. Three days following initial examination, the patient reported 80% improvement in symptoms and was performing activities of daily living pain free. Four weeks later, the patient returned with complaints of reoccurring calf pain. The patient’s signs, symptoms, and history at subsequent follow-up no longer presented a consistent clinical picture of calf strain; therefore, a D-dimer assay was ordered to rule out a deep vein thrombosis (DVT). DIAGNOSIS: The D-dimer was elevated so the patient was admitted to the hospital and started on low-molecular-weight heparin. A compression ultrasound revealed an extensive left superficial femoral and popliteal DVT in this otherwise healthy athlete. DISCUSSION: Lower extremity DVT is a serious and potentially fatal disorder. Physical therapists need to be diagnostically vigilant for vascular pathology in all patients with extremity pain and swelling. Employing the best current evidenced-based screening tools to rule out vascular pathology, such as deep and superficial vein pathology, should be the goal of every clinician. The Wells score is one such screening tool that has proven to be beneficial in this area. This case report presents a dilemma in diagnosis and illustrates the importance of revisiting differential diagnoses with each patient encounter. Clinicians must consider the possibility of a DVT with every patient seen with posterior leg pain. LEVEL OF EVIDENCE: Diagnosis, level 4.

J Orthop Sports Phys Ther 2011;41(12):942-947. doi:10.2519/jospt.2011.3823

KEY WORDS: clinical prediction rule, D-dimer assay, DVT

The patient was an 18-year-old male military trainee who presented to a physical therapist with a chief complaint of right ankle pain following a combined plantar flexion-eversion ankle injury 3 days earlier. Based on the suspicion of a fracture, ankle radiographs were ordered by the physical therapist. On the lateral radiographic view, a longitudinal nondisplaced fracture of the posterior aspect of the distal tibia was appreciated.

J Orthop Sports Phys Ther 2011;41(8):615. doi:10.2519/jospt.2011.0417

KEY WORDS: ankle, radiography, tibia

A 19-year-old male presented to a direct access physical therapy clinic with a complaint of left ankle pain after "rolling it" multiple times on uneven terrain. The physical therapist, having imaging privileges, ordered ankle radiographs due to the patient's severe tenderness and difficulty with weight bearing. Except for medial soft tissue swelling, the radiographs were interpreted as normal by the radiologist. The physical therapist, however, observed a radiographic lucency within the talar neck and ordered magnetic resonance imaging to further evaluate the area of concern. Magnetic resonance imaging revealed a 2.3 x 1.1 x 1.4-cm mass on the anterior aspect of the medial talus, producing a well-defined, 8-mm-diameter erosion into the talar neck. The patient was diagnosed with pigmented villonodular synovitis. The patient was referred to an orthopaedic surgeon. Treatment included excision of the mass followed by thorough curettage and treatment of the talar lesion. The patient subsequently returned to full activity.

J Orthop Sports Phys Ther 2009;39(4):296. doi:10.2519/jospt.2009.0404

KEY WORDS: magnetic resonance imaging, radiographs, talar lesion

STUDY DESIGN: Randomized, matched design. BACKGROUND: Optimal rehabilitation following anterior cruciate ligament reconstruction (ACLR) requires safe and effective interventions. Negative work exercise (via eccentric muscle activity) has the potential to be highly effective at producing large quadriceps size and strength gains early after ACL-R. The purpose of this investigation was to evaluate the short-term safety and efficacy of adding a progressive negative work exercise program via eccentric (ECC) ergometry early after ACL-R. METHODS AND MEASURES: Beginning 3 weeks after ACL-R, 32 participants were randomly assigned into either a 12-week traditional (TRAD) or ECC exercise program. Safety was assessed by measuring knee pain, thigh pain, knee effusion, and knee stability prior to surgery and at 3, 15, and 26 weeks after surgery. Efficacy was assessed by measuring negative work output during the 12-week training program and by measuring functional ability (ie, quadriceps peak torque, hopping distance, self-reported functional ability and activity level scales) prior to surgery and 26 weeks after ACL-R. RESULTS: There were no significant differences between groups in measures of knee and thigh pain, effusion, or stability at any period after surgery. Negative work output increased systematically throughout training, while knee and thigh pain remained at relatively low levels. A significant group-by-time interaction was observed for quadriceps peak torque, hopping distance, and activity level (P≤.02). Quadriceps strength and hopping distance of the involved limb improved by a significantly greater amount in the ECC group compared to the TRAD group (P<.01). Activity level decreasedto a lesser extent in the ECC group compared to the TRAD group (P = .02). CONCLUSIONS: Negative work via an ECC intervention was implemented safely after ACLR. The addition of negative work exercise also induced superior short-term results in strength, performance, and activity level after surgery. 

J Orthop Sports Phys Ther. 2007;37(1):10-18. doi:10.2519/jospt.2007.2362 

KEY WORDS: ACL, knee, rehabilitation

Study Design: Case report.

Objectives: To present a progressively increasing negative-work exercise program via eccentric ergometry early after anterior cruciate ligament reconstruction (ACL-R) and to suggest the potential of negative work to amplify the return of quadriceps size and strength.

Case Description: The patient was a 26-year-old highly active recreational athlete who sustained an ACL tear while skiing in January 2004 and then again while skiing in February 2005. This individual underwent an arthroscopically assisted ACL-R with a double-loop semitendinosusgracilis autograft initially, then a patellar tendon autograft following his ACL graft rupture. Beginning within 3 weeks after surgery, a progressive negative-work exercise program was initiated using an eccentric ergometer. The patient completed 31 training sessions of 5 to 30 minutes in duration over a 12-week period following the ACL-R and 33 training sessions of the same frequency and duration following the ACL revision.

Outcomes: Following ACL-R, quadriceps volume increased 28% (involved lower extremity) and 14% (uninvolved lower extremity) during the 12-week training program. Following revision, quadriceps volume returned to similar levels at the same postoperative period as those achieved after the initial surgery (2% less on the involved side and 2% greater on the uninvolved side). Quadriceps strength, 15 weeks after ACL-R, exceeded preoperative measures by an average of 20% (involved) and 14% (uninvolved). Quadriceps strength after ACL revision exceeded all previous measures.

Discussion: This case report suggests that if gradually and progressively applied, negative work via eccentric ergometry can be both safe and efficacious early after ACL-R. Eccentric exercise may mitigate the prevalent muscle size and strength deficits commonly observed after ACL-R. The results of this case suggest a need for continued research with early negative work interventions following ACL-R. J Orthop Phys Ther. 2006;36(5):298-307. doi:10.2519/jospt.2006.2197

Key Words: ACL, knee, muscle physiology, skiing