The patient was a 26-year-old man referred to a physical therapist for a chief complaint of worsening bilateral knee pain in the region of the patellar tendons over the past 3 months that was insidious in onset. In an effort to further evaluate tendon morphology, the physical therapist pursued ultrasound imaging of the bilateral patellar tendons. It was determined that the ultrasound findings were compatible with xanthomatous tendinosis.

J Orthop Sports Phys Ther 2012;42(4):379. doi:10.2519/jospt.2012.0406

KEY WORDS: knee pain, magnetic resonance imaging, patellar tendon, ultrasound

STUDY DESIGN: Controlled laboratory study using a cross-sectional design. OBJECTIVES: To characterize ankle and hip muscle performance in women with posterior tibial tendon dysfunction (PTTD) and compare them to matched controls. We hypothesized that ankle plantar flexor strength, and hip extensor and abductor strength and endurance, would be diminished in women with PTTD and this impairment would be on the side of dysfunction. BACKGROUND: Individuals with PTTD demonstrate impaired walking abilities. Walking gait is strongly dependent on the performance of calf and hip musculature. METHODS: Thirty-four middle-aged women (17 with PTTD) participated. Ankle plantar flexor strength was assessed with the single-leg heel raise test. Hip muscle performance, including strength and endurance, were dynamometrically measured. Differences between groups and sides were assessed with a mixed-model analysis of variance. RESULTS: Females with PTTD performed significantly fewer single-leg heel raises and repeated sagittal and frontal plane non–weight-bearing leg lifts, and also had lower hip extensor and abductor torques than age-matched controls. There were no differences between sides for hip strength and endurance measures for either group, but differences between sides in ankle strength measures were noted in both groups. CONCLUSION: Women with PTTD demonstrated decreased ankle and hip muscle performance bilaterally.

J Orthop Sports Phys Ther 2011;41(9):687-694. doi:10.2519/jospt.2011.3427

KEY WORDS: acquired flatfoot deformity, PTTD, walking

STUDY DESIGN: Controlled laboratory study using a cross-sectional design. OBJECTIVES: To analyze lower extremity kinematics during takeoff of a “saut de chat” (leap) in dancers with and without a history of Achilles tendinopathy (AT). We hypothesized that dancers with AT would demonstrate different kinematic strategies compared to dancers without pathology, and that these differences would be prominent in the transverse and frontal planes. BACKGROUND: AT is a common injury experienced by dancers. Dance leaps such as the saut de chat place a large demand on the Achilles tendon. METHODS: Sixteen female dancers with and without a history of AT (mean ± SD age, 18.8 ± 1.2 years) participated. Three-dimensional kinematics at the hip, knee, and ankle were quantified for the takeoff of the saut de chat, using a motion analysis system. A force platform was used to determine braking and push-off phases of takeoff. Peak sagittal, frontal, and transverse plane joint positions during the braking and push-off phases of the takeoff were examined statistically. Independent samples t tests were used to evaluate group differences (α = .05). RESULTS: The dancers in the tendinopathy group demonstrated significantly higher peak hip adduction during the braking phase of takeoff (mean ± SD, 13.5° ± 6.1° versus 7.7° ± 4.2°; P = .046). During the push-off phase, dancers with AT demonstrated significantly more internal rotation at the knee (13.2° ± 5.2° versus 6.9° ± 4.9°; P = .024). CONCLUSION: Dancers with AT demonstrate increased peak transverse and frontal plane kinematics when performing the takeoff of a saut de chat. These larger displacements may be either causative or compensatory factors in the development of AT.

J Orthop Sports Phys Ther 2011;41(8):606-613, Epub 12 July 2011. doi:10.2519/jospt.2011.3580

KEY WORDS: ankle, biomechanics, dance, hip, leaps, saut de chat, tendon

The patient was a 53-year-old man referred to a physical therapist with a chief complaint of worsening right medial knee pain of 3 months' duration. He had a history of anterior cruciate ligament reconstruction 7 years prior, and recent diagnostic imaging studies had not been performed. Physical examination of the right knee was unremarkable, without reproduction of his chief complaint of medial knee pain. During examination of the right hip, however, combined movements of hip flexion, internal rotation, and adduction, as well as hip distraction and compression, reproduced the patient's knee pain. While radiographs of the right knee were unremarkable, radiographs of the right hip revealed acetabular undercoverage, superolateral joint space narrowing, and subchondral sclerosis. Magnetic resonance imaging of the hip, with and without intra-articular gadolinium, identified developmental dysplasia with marked acetabular undercoverage and moderately advanced degenerative joint disease. The patient did not respond to conservative management and subsequently underwent total hip arthroplasty 9 months after first being seen by the physical therapist, which resulted in complete resolution of his medial knee pain.

J Orthop Sports Phys Ther 2011;41(1):33. doi:10.2519/jospt.2011.0402

KEY WORDS: magnetic resonance imaging, radiography

STUDY DESIGN: Controlled laboratory study using a cross-sectional design. OBJECTIVES: To evaluate knee joint dynamics in elite volleyball players with and without a history of patellar tendinopathy, focusing on mechanical energy absorption and generation. We hypothesized that tendinopathy would be associated with
reduced net joint work and net joint power. BACKGROUND: Patellar tendinopathy is a common, debilitating injury affecting competitive volleyball players. METHODS: Thirteen elite male players with and without a history of patellar tendinopathy (mean ± SD age, 27 ± 7 years) performed maximum-effort volleyball approach jumps. Sagittal plane knee joint kinematics, kinetics, and energetics were quantified in the lead limb, using data obtained from a force platform and an 8-camera motion analysis system. Vertical ground reaction forces and pelvis vertical velocity at takeoff were examined. Independent sample t tests were used to evaluate group differences (α = .05). RESULTS: The tendinopathy group, compared to controls, demonstrated significant reductions (approximately 30%) in net joint work and net joint power during the eccentric phase of the jump, with no differences in the concentric phase. Positive to-negative net joint work and net joint power ratios were significantly higher in the tendinopathy group, which had a net joint work ratio of 1.00 (95% CI: 0.77, 1.24) versus 0.76 (95% CI: 0.64, 0.88) for controls, and a net joint power ratio of 1.62 (95% CI: 1.15, 2.10) versus 1.00 (95% CI: 0.80, 1.21) for controls. There were no significant differences in net joint moment, angular velocity, or range of motion. Peak vertical ground reaction forces were lower for the tendinopathy group, while average vertical ground reaction forces and pelvis vertical velocity were similar. CONCLUSION: Patellar tendinopathy is associated with differences in sagittal plane mechanical energy absorption at the knee during maximum-effort volleyball approach jumps. Net joint work and net joint power may help define underlying mechanisms, adaptive effects, or rehabilitative strategies for individuals with patellar tendinopathy.

J Orthop Sports Phys Ther 2010;40(9):568-576, Epub 27 May 2010. doi:10.2519/jospt.2010.3313

KEY WORDS: biomechanics, eccentric, energetics, joint kinetics, tendon

STUDY DESIGN: Longitudinal single-cohort study. OBJECTIVE: To characterize the time course of performance adaptations during a postsurgical exercise intervention following a single-level microdiscectomy. BACKGROUND: Patients with a recent history of lumbar microdiscectomy are functionally limited, weak, have compromised paraspinal musculature, and benefit from an exercise program. METHODS: Patients (n = 48) with a single-level microdiscectomy participated in a 12-week (36 sessions) comprehensive strength and endurance exercise program starting 4 to 6 weeks postsurgery. Lumbar extensor strength was quantified as the degree from horizontal on a modified Sorensen test procedure. Patients unable to assume the horizontal position were assumed to have strength deficits. Lumbar muscular endurance performance was quantified by the amount of time patients could hold the Sorensen test position at the horizontal. The time rate of lumbar muscular endurance adaptations were analyzed using longitudinal growth curve modeling. RESULTS: The adherence rate of this program was low (67%). Twenty percent of the patients were identified as having strength deficits. These deficits were corrected in all patients within 3 to 9 weeks. Linear mixed-model results suggest an improvement of 5.6 seconds in hold time per week of exercise. Both the initial level of endurance and the rates of improvements were highly individualized. CONCLUSION: The time course of musculoskeletal performance adaptations in persons with a history of lumbar surgery is highly individualized. When compared to normative endurance times, the results of this study indicate that the number of sessions and duration of therapy needed to generate meaningful adaptations of the paraspinal musculature is longer than what is typically provided in the clinic postsurgery. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2010;40(6):336-344, Epub 13 May 2010. doi:10.2519/jospt.2010.3141

KEY WORDS: herniated disc, low back pain, physical endurance, rehabilitation

The patient was a 21-year-old male who was referred to physical therapy with a 1-week history of right knee pain and stiffness following an injury of traumatic onset. While attempting to jump off of both legs to dunk a basketball during a game, the patient heard and felt a pop in his right knee that was associated with an immediate onset of pain and swelling. He was unable to bear weight following the injury and, therefore, immediately went to the emergency department, where radiographs were completed and interpreted as negative for a fracture. However, the patella for the right knee was superiorly displaced. The patient was issued crutches and referred to physical therapy. At the time of the initial physical therapy examination, the patient was still not able to bear full weight on the right lower extremity or actively fully extend his right knee. Due to concern over possible meniscal, medial collateral ligament, or patellar tendon involvement, the patient's physician was contacted and magnetic resonance imaging was ordered. Five days later, the patient presented with decreased knee effusion and the special tests for the medial collateral ligament and meniscus were negative. However, the patient was still not able to actively extend his knee, suggesting a possible rupture of the patellar tendon, which was later confirmed on magnetic resonance imaging. Surgical repair of the patellar tendon was performed 2 weeks later.

J Orthop Sports Phys Ther 2009;39(11):825. doi:10.2519/jospt.2009.0413

KEY WORDS: knee, magnetic resonance imaging 

STUDY DESIGN: A descriptive and exploratory investigation of lumbar extensor performance in persons with a recent history of single-level microdiscectomy. OBJECTIVE: To provide a justification for and outline the procedure of assessing lumbar extensor musculature performance. BACKGROUND: The time of holding an unsupported trunk horizontally, also called the Sorensen Test (ST), is often used to test the lumbar extensor endurance of healthy and patient populations, but may need to be modified for some patients. METHODS AND MEASURES: Sixty-eight participants completed a modified ST procedure, along with several questionnaires and performance measures, approximately 4 to 6 weeks after a single-level microdiscectomy. Participants were classified as either able to complete or unable to complete the final position of the modified ST procedure (trunk horizontal). RESULTS: Fifty-one point five percent of the participants could not attain the final position of the modified ST procedure due to either pain or perceived exertion. Those who could not attain the final position of the modified ST procedure had significantly lower scores (compared to those who could) on most measures. A majority (78.8%) of the participants in this study who were unable to complete the ST were correctly classified using the Fear-Avoidance Belief Questionnaire Work Subscale and a 24-hour activity questionnaire. CONCLUSION: The ability to attain the final position of the modified ST procedure was closely associated with fear-avoidance beliefs and physical activity level, suggesting that this test may be too intense (either real or perceived) for many patients within 4 to 6 weeks following a single-level microdiscectomy.

J Orthop Sports Phys Ther. 2007;37(7):356-363; published online 29 May 2007. doi:10.2519/jospt.2007.2366

KEY WORDS: Fear-Avoidance Belief Questionnaire, lumbar musculoskeletal performance, Sorensen test

J Orthop Sports Phys Ther. 2002; 32(3):114–124.

Key Words: neural entrapment, plantar fasciitis

Study Design: Case study. Objective: To demonstrate the importance of assessment and treatment of the thoracic spine in the management of a patient with signs and symptoms of upper extremity Complex Regional Pain Syndrome Type I (CRPS-I). Background: The patient was a 38-year-old woman who suffered a traumatic injury to her left hand. Five months after injury, she presented with severe pain, immobility of the left arm, and associated dystrophic changes. She was unable to work and needed help in some activities of daily living. Methods and Measures: The patient was treated for 3 months in 36 visits. Initial treatment consisted of cutaneous desensitization, edema management, and gentle therapeutic exercises. However, further examination indicated hypomobility and hypersensitivity of the upper thoracic spine. Joint manipulation of the T3 and T4 segments was implemented. The patient's status was monitored and range of motion, strength, temperature, and skin moisture were measured. Results: Immediately after the vertebral manipulation, there was a significant increase in the left hand's skin temperature and a decrease in hyperhydrosis as measured by palpation. Shoulder range of motion increased from 135-175° and the patient reported reduced pain from 6/10 to 3/10 on a scale from 0 to 10, where 0 represents no pain. The decrease in the patient's dystrophic and allodynic symptoms permitted further progress in functional reeducation. The patient was discharged with full return to independence and initiation of a vocational retraining program. Conclusion: Assessment and treatment of the thoracic spine should be considered in patients with upper extremity CRPS-I.

J Orthop Sports Phys Ther. 2000;30(7):401-409.

Key Words: manipulation, manual therapy, reflex sympathetic dystrophy

Study Design: Case study. Objectives: To discuss the differential diagnosis, the nonsurgical and postoperative management of common accessory bones of the foot. Background: Accessory bones of the foot that are formed during abnormal ossification are commonly found in asymptomatic feet. Two of the most common accessory bones are the accessory navicular and the os peroneum. Their painful presence must be considered in the differential diagnosis of any acute or chronic foot pain. The optimal treatment for the conservative and postoperative management of painful os peroneum and accessory navicular bones remains undefined. Methods and Measures: Therapeutic management of the fractured os peroneum included bracing, taping, and foot orthotics to allow healing of involved tissues, and stretching. The focus of the postoperative management of the accessory navicular was joint mobilization and progressive strengthening. Dependent variables included level of pain with provocation and alleviation tests of joint and soft tissue; girth and sensory tests of the foot and ankle; goniometric measures of foot and ankle; strength of ankle and hip muscles; functional tests; and patient's self-reported pain status. Results: The patient with the fractured os peroneum was treated in 13 visits for 10 weeks. At discharge from physical therapy, the patient had the following outcomes relative to the noninvolved side: 100% return of normal sensation tested by light touch and vibration; pain decreased from 6/10 to 1/10; 100% reduction of swelling with ankle girth to normal; 100% range of motion of ankle and subtalar joints. Strength in plantar flexion and eversion remained 20% impaired (80% return to normal) secondary to pain. Upon discharge, he still reported mild pain when walking but was able to return to previous leisure activities. The second patient with the accessory navicular was treated in 18 visits over 9 weeks. Relative to the uninvolved side, she was discharged with the following: 70% return of range of motion in the foot and ankle, 100% of strength in hip and ankle, and 100% return of balance. She could squat and jump without pain and she returned to full premorbid activity level. Conclusions: Rehabilitative management of both cases addressed specific impairments and was successful in improving the patients' activity limitation. Clinicians should be aware that these accessory bones are possible sources of disability, secondary to foot pain.

J Orthop Sports Phys Ther. 2000;30(10):580-594.

Key Words: accessory bones, accessory navicular, foot pain, neurodynamics, os peroneum, os tibiale externum

Study Design: Single group test-retest repeated measures. Objectives: To determine the effects of lumbar traction with 3 different amounts of force (10%, 30% and 60% body weight) on pain-free mobility of the lower extremity as measured by the straight leg raise (SLR) test. Background: There are several recommendations on how lumbar traction should be performed, but the duration, frequency, force, and type of technique to be applied differ among the sources. Methods and Measures: Ten subjects with subjective complaints of low back pain or radicular symptoms with a positive unilateral SLR test below 45° participated in this study. The pain-free mobility of the lower extremity in the SLR test position was measured prior to and immediately following 5 minutes of static traction in the supine position. Random assignment in the order of the amount of applied traction was implemented. Results: The straight leg raise measurements were found to be significantly greater immediately following 30% and 60% of body weight traction as compared to pretraction and 10% of body weight traction. The mean (SD) SLR measurements were pretraction (24.1° ± 13.0), 10% of body weight traction (27.4° ± 14.5), 30% of body weight traction (34.0° ± 14.3), 60% of body weight traction (36.5° ± 15.8). Conclusions: The results of this study indicate that traction in this group of patients improved the mobility of the lower extremity during the SLR test. Both 30% and 60% of body weight tractions were shown to be effective for increasing motion beyond pretraction levels.

J Orthop Sports Phys Ther. 2000;30(10):595-601.

Key Words: disc pathology, lumbar traction, straight leg raise

Study Design: Cross-sectional. Objective: To investigate the association between lumbar segmental motion and pain response during the application of a posterior-to-anterior (PA) force to the lumbar spinous processes in persons with nonspecific low back pain. Background: Although low back pain is believed to be associated with altered segmental motion of the lumbar spine, the relationship between subjective reports of pain and objective measurements of segmental motion has not been established. Methods and Measures: Thirty-five individuals between 18 and 45 years of age with nonspecific low back pain (less than 3 months’ duration) participated. All subjects participated in 2 separate procedures: (1) segmental motion assessment during a PA force application over the lumbar spinous processes using dynamic magnetic resonance imaging (MRI), and (2) pain assessment during a PA force application procedure outside of the MRI environment. Frequency counts were used to determine the lumbar segments that were most painful, and which functional spinal units had the most and least motion. Fisher exact tests were performed to determine if an association existed between the most painful segment and the functional spinal unit with the most or least motion. Results: L5 was deemed the most painful segment in nearly half of the participants (48.1%). The L1-2 and L3-4 functional spinal units most frequently had the most motion (25.9% each) and the L4-5 functional spinal units most frequently had the least motion (29.6%). No association was found between the most painful segment and the functional spinal units with either the most or least motion. Conclusion: The results of this study indicate that an assumption regarding segmental motion cannot be inferred from the pain response when using a PA force application procedure.

J Orthop Sports Phys Ther. 2005;35(4):203-209. doi:10.2519/jospt.2005.1479

Key Words: lumbar spine, manual therapy, painful segment

Study Design: Randomized multicenter retrospective chart review of medical referral diagnoses and corresponding referral, patient, and physician demographic data. Objective: To examine the information content of medical referral diagnoses provided to outpatient physical therapists with respect to physician and patient characteristics. Background: Previous studies indicate that physicians commonly provide nonspecific referral diagnoses to physical therapists. The effects of patient and physician characteristics on information contained in referral diagnoses are not well elucidated. Methods and Measures: A team of blinded raters categorized the information content of referral diagnoses (n = 2183) using a classification system adapted from a previous study. Results: One third (32%) of analyzed diagnoses were anatomically oriented and reported specific pathology. These specific diagnoses were provided significantly more commonly by specialist physicians (odds ratio [OR], 3.4; 95% confidence interval [CI], 2.7-4.2; P<.001), male physicians (OR, 2.2; 95% CI, 1.6-3.1; P<.001), both early- and late-career physicians (P<.001), and for male patients (OR, 1.3; 95% CI, 1.1-1.6; P<.05). Conclusion: Physicians frequently provide nonspecific referral diagnoses to physical therapists. The practice of evidence-based physical therapy seems challenged by the high rate of nonspecific referral diagnoses. Physical therapists may also have the responsibility to conduct differential diagnosis of pathology more commonly than formally recognized by many state practice acts and third-party payers.

J Orthop Sports Phys Ther. 2005;35(9):572-579. doi:10.2519/jospt.2005.2050

Key Words: differential diagnosis, direct access, primary care

The Guide to Physical Therapist Practice affirms that physical therapists should determine the appropriateness of physical therapy to address a patient's disablement. The decision facing all therapists-during the initial evaluation and every subsequent clinic visit-is whether to treat the patient, refer the patient, or initiate both treatment and referral. This decision is based on whether the patient's clinical presentation is consistent with symptoms and signs of pathology that seem amenable to physical therapy. At minimum, deciding the appropriateness of physical therapy takes confirmation of the pathology suggested in a physician's referral diagnosis, if present. However, anecdotal evidence suggests that more extensive questioning, clinical testing, and referral to other specialists frequently are needed.

J Orthop Sports Phys Ther. 2006; 36(1):1-2. doi:10.2519/jospt.2006.0101

Key Words: diagnosis 

J Orthop Sports Phys Ther. 2002; 32(7):318–326.

Key Words: extension syndrome, manual therapy, thoracic spine