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: Test-retest reliability and validity. Objective: To determine the validity and reliability of the Palpation Meter (PALM). Background: Leg length discrepancy (LLD) has been associated with a variety of musculoskeletal disorders. Therefore, the clinical measurement of LLD has become a routine and important part of the physical examination. The PALM is an instrument that was recently developed to indirectly measure LLD, but little is known about its measurement properties. Methods and Measures: Fifteen healthy and 15 symptomatic subjects with suspected LLD participated in this study. Measurements of pelvic crest height difference (PD) were obtained by 2 examiners using the PALM. A standing antero-posterior (AP) radiograph of each subject's pelvis was taken, and PD and LLD (femoral head height difference) were determined from the radiograph for comparison with the PALM values. Intraclass correlation coefficients (ICCs) were calculated to determine the validity and reliability estimates of the PALM. Results: For all subjects, the validity estimates (ICC2, 3) of the PALM for PD were excellent (0.90 for rater 1 and 0.92 for rater 2) when compared with the standing AP radiograph of the pelvis. The PALM was less accurate (ICC2,3 of 0.76 and 0.78 for rater 1 and 2, respectively) as an indirect estimate of LLD. Intrarater reliability for each rater was excellent (ICC3,3 = 0.97 and 0.98) and interrater reliability was very good (ICC2,3 = 0.88). Conclusion: The PALM is a reliable and valid instrument for measuring PD. Clinicians should consider this convenient, cost-effective clinical tool as an alternative to radiographic measurement of pelvic crest height difference.

J Orthop Sports Phys Ther. 2003;33(6):319-325.

Key Words: leg length inequality, measurement, pelvic obliquity, reliability, validity

Study Design: Retrospective resident's case reports. Background: In today's healthcare setting, it is important for physical therapists to recognize when diagnostic imaging is necessary-as well as know how to interpret the results of these tests-to assist in the clinical decision-making process. Two cases are presented that illustrate how a physical therapist, credentialed to request and review diagnostic imaging, effectively and efficiently utilized multiple forms of diagnostic imaging to assist in his differential diagnosis and clinical decision making. Diagnosis: The first case report describes the differential diagnostic process for a 33-year-old active duty military paratrooper who had sustained trauma to his neck. His history was consistent with a C6 radiculopathy, which was confirmed by a neurological screening examination. Radiographs requested by the physical therapist revealed an anterolithesis of C5 on C6, with a possible fracture. An orthopedic surgeon was consulted and further diagnostic testing via magnetic resonance imaging revealed a large disc herniation at C5-6, with spinal cord compression, as well as a C5 vertebral body fracture with nearly perched facets at C5 on C6. The patient was subsequently referred to a neurosurgeon and underwent an emergency C5-6 fusion that afternoon. The second case report describes the differential diagnosis of a 20-year-old active-duty soldier referred for rehabilitation with a diagnosis of a distal fibula stress fracture. Previous treatment by the referring provider included 3 months of rest and anti-inflammatory medications. Physical examination of the patient revealed a marked decrease in ankle inversion with a firm end feel. This was not consistent with the diagnosis established by the referring provider. Subsequent radiographs requested by the physical therapist and a computed tomography scan requested by a podiatrist revealed synostosis of the middle facet of the talocalcaneal joint with an apparent fracture line. The patient subsequently underwent a subtalar arthrodesis. Discussion: In these cases the physical therapist requested imaging needed for appropriate management, despite the patient having previously seen a primary care provider. In both examples, the physical therapist successfully identified abnormalities prior to a radiologist or other physician reviewing the results. This avoided delay in definitive management of the patients' problems. It is imperative that physical therapists understand when diagnostic imaging is necessary to assist in the differential diagnosis of patients. Likewise, it is important for physical therapists to be competent in interpreting the results of these tests. When not in a direct access physical therapy environment, a physical therapist should understand when diagnostic imaging tests are indicated. This facilitates working with the entire health care team to acquire necessary tests in an appropriate timeframe.

J Orthop Sports Phys Ther. 2005;35(11):745-754. doi:10.2519/jospt.2005.2087

Key Words: anterolisthesis, disc herniation, neurosurgery, stress fracture

Study Design: Predictive validity/diagnostic test study.
Objective: To determine the predictive validity and interrater reliability of selected clinical exam items and to develop a clinical prediction rule (CPR) to determine which patients respond successfully to patellar taping.
Background: Patellar taping is often used to treat patients with PFPS. However, the characteristics of the patients who respond best to patellar taping intervention have not been identified.
Methods and Measures: Fifty volunteers (27 males, 23 females) with PFPS underwent a standardized clinical examination. Diagnosis of PFPS was based on the complaint of retropatellar pain that was provoked by a partial squat or stair ascent/descent. Subjects performed 3 functional activities and rated their pain during each activity on a numerical rating scale (NPRS). All subjects received treatment with a medial glide patellar-taping technique and repeated the functional activities and pain ratings. An immediate 50% reduction in pain or moderate improvement on a global rating of change (GRC) questionnaire was considered a treatment success. Likelihood ratios (LRs) were calculated to determine which examination items were most predictive of treatment outcome. Logistic regression analysis identified items included in the CPR.
Results: Twenty-six subjects (52%) had an immediate successful response to the intervention. Two examination items (positive patellar tilt test or tibial varum greater than 5°, +LR = 4.4) comprised the CPR. Application of the CPR improved the probability of a successful outcome from 52% to 83%. Fifty-eight percent of the lower extremity measures were associated with moderate to good reliability (reliability coefficient range, 0.52-0.84). The reliability coefficients for the items that comprised the CPR were 0.49 (patellar tilt) and 0.66 (tibial varum).
Conclusion: A CPR was developed to predict an immediate successful response to a medial glide patellar taping technique. Validation of the CPR in an independent sample is necessary before widespread clinical use can be recommended.

J Orthop Sports Phys Ther. 2006; 36(11):854-866. doi:10.2519/jospt.2006.2208

Key Words: bracing, knee pain, physical examination, physical therapy, rehabilitation