The patient was a 25-year-old man who sustained a traumatic left anterior shoulder dislocation. After self-reducing the first time, as well as in subsequent repeated dislocations over the following 2-day period, the patient reported his injury to the medical staff, who sent him to the physical therapist for evaluation. Anterior-posterior, scapular outlet, and axillary radiographic views demonstrated a bony glenoid lesion consistent with a bony Bankart lesion, which was best seen on the scapular outlet view. A 3-dimensional computed tomography scan was performed to assess the size and displacement of the bony Bankart lesion. Six days following injury, the patient underwent operative fixation of the bony Bankart lesion. Following surgery, the patient completed 5 months of physical therapy and subsequently returned to high-demand upper body activities. At 3 years following surgery, the patient reported full functional ability without shoulder instability or pain.

J Orthop Sports Phys Ther 2009;39(10):765. doi:10.2519/jospt.2009.0411

KEY WORDS: computed tomography, dislocation, radiograph, shoulder 

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