STUDY DESIGN: Resident’s case problem. BACKGROUND: Abdominal pain is a common symptom, but not a common diagnosis, of patients referred to physical therapists for examination and intervention. For patients with primary symptoms of abdominal pain, a thorough evaluation must be performed to determine if symptoms are musculoskeletal in nature or of a nonmusculoskeletal origin that would warrant a referral to a different healthcare provider. This report describes the management of 3 adults with primary complaints of abdominal pain who were referred for physical therapy evaluation and treatment. DIAGNOSIS: Two of the patients had secondary symptoms of hip and/or low back pain and had previously undergone extensive medical testing for their chronic abdominal pain, without a definitive diagnosis having been determined. A physical therapy evaluation was conducted, and treatment, including manual physical therapy and exercise, was administered to address all relative impairments, once the physical therapist had determined that the patients’ symptoms were of musculoskeletal origin. The third patient included in this series was referred to a physical therapist with a diagnosis of greater trochanteric versus iliopsoas bursitis. However, the patient had abdominal pain that was more acute in nature and a history and physical examination findings that were concerning for abdominal pain of nonmusculoskeletal origin. Both patients with abdominal pain of musculoskeletal origin showed marked improvement in pain and disability after 7 treatment sessions. The third patient was referred to her primary care physician, and ultrasound examination of the abdomen revealed several intrauterine masses that were consistent with uterine fibroids. Following uterine fibroid embolization, the patient was symptom free. DISCUSSION: Although not routinely managed by physical therapists, abdominal pain is a relatively common patient symptom that can have several causes, both musculoskeletal and nonmusculoskeletal. This paper emphasizes the importance of physical therapists having the necessary differential diagnostic skills to determine if patients with primary symptoms of abdominal pain require physician referral or physical therapist intervention. LEVEL OF EVIDENCE: Differential diagnosis, level 4.

J Orthop Sports Phys Ther 2013;43(2):44-53. Epub 14 January 2013. doi:10.2519/jospt.2013.4408

KEY WORDS: abdominal examination, differential diagnosis, hip, low back pain, manual physical therapy

References in the text and in the reference section were amended in the March 2013 Erratum, and the article PDF with the Erratum page included is provided here. Please see: March 2013 Erratum

STUDY DESIGN: Descriptive. BACKGROUND: An important role for physical therapists in the healthcare delivery system is to recognize when patient referral to a physician or other healthcare provider is indicated. Few studies exist describing physical therapists' evaluative and diagnostic processes leading to patient referral to a physician. OBJECTIVE: To summarize published patient case reports that described physical therapist/patient episodes of care that resulted in the referral of the patient to a physician and a subsequent diagnosis of medical disease. METHODS: A literature search identified 78 case reports describing physical therapist referral of patients to physicians with subsequent diagnosis of a medical condition. Two evaluators reviewed the cases and summarized (1) how and when patients accessed physical therapy services, (2) timing of patient referral to a physician, (3) resultant medical diagnoses, (4) physical therapists' role in referral of patients for diagnostic testing, and (5) relevant patient symptom description, health history, review of systems, and physical examination findings. RESULTS: Fifty-eight (74.4%) of 78 patients had been referred to a physical therapist by their physician, while the remaining 20 patients accessed physical therapy services via direct access. The patients' primary presenting symptoms included pain (n = 60), weakness (n = 4), tingling/numbness (n = 2), or a combination (n = 12). Patient referrals to a physician occurred at the initial physical therapy session in 58 (74.4%) of 78 cases. A majority of patient referrals to a physician (n = 65) were related to primary presenting symptoms, including manifestations inconsistent with physician diagnosis, recent worsening without cause, unusual accompanying symptoms such as fatigue and/or weakness, and inadequate response to treatment. Resultant diagnoses included neuromusculoskeletal disorders (n = 53; fractures and tumors most common), visceral disorders (n = 14; cardiovascular involvement most common), and medication-related disorders (n = 3). CONCLUSIONS: This review of published patient case reports provides numerous examples of physical therapists using effective multifactorial screening strategies for referred and direct-access patients, leading to timely patient referrals to physicians. The therapist-initiated patient referral to a physician led to subsequent diagnosis of a wide range of conditions and pathological processes.

J Orthop Sports Phys Ther 2012;42(5):446-454, Epub 25 January 2012. doi:10.2519/jospt.2012.3890

KEY WORDS: differential diagnosis, direct access, examination, imaging, physical therapy, screening

The patient was a 45-year-old man who was referred to a physical therapist with a chief complaint of posterior right ankle pain for the past 2 weeks. The physical therapist requested radiographs, which demonstrated obliteration of Kager's fat pad, a finding highly suspicious for an Achilles tendon rupture. Based upon history, physical examination, and radiographic findings, the physical therapist ordered magnetic resonance imaging which confirmed the diagnosis of Achilles tendon rupture.

J Orthop Sports Phys Ther 2011;41(11):904. doi:10.2519/jospt.2011.0422

KEY WORDS: ankle, Kager's fat pad, magnetic resonance imaging, radiography

SYNOPSIS: For healthcare providers involved in the management of patients with musculoskeletal disorders, the ability to order diagnostic imaging is a beneficial adjunct to screening for medical referral and differential diagnosis. A trial of conservative treatment, such as physical therapy, is often recommended prior to the use of imaging in many treatment guidelines for the management of musculoskeletal conditions. In the United States, physical therapists are becoming more autonomous and can practice some degree of direct access in 48 states and Washington, DC. Referral for imaging privileges could increase the effectiveness and efficiency of healthcare delivery, particularly in combination with direct access management. This clinical commentary proposes that, given the American Physical Therapy Association's goal to have physical therapists as primary care musculoskeletal specialists of choice, it would be beneficial for physical therapists to have imaging privileges in their practice. The purpose of this commentary is 3-fold: (1) to make a case for the use of imaging privileges by physical therapists, using a historical perspective; (2) to discuss the barriers preventing physical therapists from having this privilege; and (3) to offer suggestions on strategies and guidelines to facilitate the appropriate inclusion of referral for imaging privileges in physical therapist practice.

J Orthop Sports Phys Ther 2011;41(11):829-837. doi:10.2519/jospt.2011.3556

KEY WORDS: diagnosis, direct access, MRI, radiology, x-ray

The physical therapy profession has long recognized the importance of physical therapists determining whether a need for a patient referral to another healthcare practitioner exists. This clinical decision is based on physical therapists recognizing patient history and physical examination red flag findings consistent with pathology that requires physician consultation and examination. The challenge to physical therapists is the current lack of evidence describing what red flag findings are representative of specific pathological conditions.

J Orthop Sports Phys Ther 2010;40(11):682-684. doi:10.2519/jospt.2010.0109

KEY WORDS: low back pain, pathology

The patient was an 87-year-old woman referred to a physical therapist for right buttock and lateral calf pain of insidious onset that had been present for the past 3 weeks. She also complained of a 5-day history of right anterior hip/groin pain. Due to concern for a recent fracture of the right hip or pelvis, based on prior radiographs and the patient's medical history, radiographs were ordered that demonstrated new superior and inferior right pubic rami fractures. An orthopaedic surgeon was immediately consulted who diagnosed the patient with insufficiency fractures of the right pubic rami. The patient was instructed on toe touch weight bearing with a walker for the right lower extremity, and the orthopaedic surgeon recommended treatment by the physical therapist, as well as a reevaluation of the current management strategies for the patient's osteoporosis.

J Orthop Sports Phys Ther 2010;40(10):666. doi:10.2519/jospt.2010.0416

KEY WORDS: hip, osteoporosis, pelvis, radiographs

The patient was a 23-year-old woman referred to physical therapy for the primary treatment of knee pain which began 4 months prior following a twisting injury. During the patient interview, the patient also complained of neck pain and numbness and tingling in her bilateral hands and feet which began 6 weeks earlier after jumping into a 2 meter pool head first and striking her head on the floor of the pool. Due to concern over a serious cervical spine injury, the physical therapist focused his initial physical examination on the patient's cervical spine. Physical examination findings were remarkable for midline cervical spine tenderness and decreased sensation throughout both hands and feet. Cervical spine radiographs were ordered, which revealed a cortical irregularity along the anterior aspect of the superior endplate of the C7 vertebral body, which was concerning for an anterior-superior compression fracture. Computed tomography scanning was completed for further evaluate the area of injury and revealed minimally displaced anterior compression fractures within the C7, T1, T2, and T3 vertebral bodies. Due to the paresthesias in the upper and lower extremities, magnetic resonance imaging was completed, which demonstrated no evidence for significant central canal or foraminal stenoses. The patient was referred to a neurosurgeon who recommended conservative management.

J Orthop Sports Phys Ther 2010;40(3):189. doi:10.2519/jospt.2010.0405

KEY WORDS: computed tomography, magnetic resonance imaging, neck pain, radiographs

The patient was a 64-year-old woman who reported a sudden onset of neck pain and headaches following a fall 2.5 months prior to her initial physical therapy visit. Cervical spine radiographs, which were ordered by the referring physician, revealed extensive degenerative disc disease of the lower cervical spine. At her initial physical therapy evaluation, cervical spine range of motion was within functional limits except for bilateral rotation, which was limited to 45° due to pain and stiffness. The patient's headache symptoms were abolished with the Sharp-Purser test. Although assessment of symptoms was not the intent of the Sharp-Purser test, a reduction of symptoms during the test would warrant further evaluation. Therefore, the physical therapist ordered cervical spine flexion-extension radiographic views to assess for atlantoaxial instability. The radiologist's report noted a stable atlantodens interval that did not change with cervical flexion and extension and a course of physical therapy was initiated. At the time of discharge from physical therapy, the patient reported no neck pain and only very mild occasional headaches, which she believed she could manage on her own. 

J Orthop Sports Phys Ther 2009;39(5):418. doi:10.2519/jospt.2009.0405

KEY WORDS: atlantoaxial instability, cervical spine, radiographs

The patient was a 22-year-old male with progressively worsening left hip pain for the past 5 days. He had been evaluated by a physician and diagnosed with an inguinal hernia and an adductor strain. Radiographs were not ordered, but he was given crutches due to an antalgic gait. At his initial physical therapy evaluation, 5 days after onset of pain, the patient was unable to bear weight on his left lower extremity. Based on the patient's history and physical examination, the physical therapist was concerned about the possibility of a hip fracture. Pelvic anterior-posterior and lateral frog leg radiographs were ordered, and the radiologist's report was significant for a displaced left femoral neck fracture. The patient was referred to an orthopaedic surgeon and underwent open reduction internal fixation on his left hip the next day. In this case, despite the recent history of pain and the insensitivity of radiographs to the early changes associated with a stress fracture, the fracture was visible on radiographs and it did not require further imaging.

J Orthop Sports Phys Ther. 2008;38(9):578-578. doi:10.2519/jospt.2008.0409

KEY WORDS: hip, lower extremity, radiograph

STUDY DESIGN: Resident's case problem. BACKGROUND: The purpose of this paper is to provide the examination of and decision-making process for a patient referred to physical therapy for the treatment of neck pain following trauma. She was found to have an underlying odontoid fracture that precluded physical therapy intervention. DIAGNOSIS: This case involved a 73-year-old woman who had a sudden onset of neck and left upper extremity pain after a fall 15 days prior to her initial physical therapy visit. Conventional cervical spine radiographs completed 1 day prior to her initial physical therapy visit were negative for a fracture. However, several components of this patient's history and physical examination were consistent with a condition for which physical therapy intervention would not be indicated until more definitive cervical spine diagnostic imaging had been completed; more specifically, the physical therapist was primarily concerned about the possibility of an undetected fracture. The referring physician was contacted and immediate magnetic resonance imaging was requested, which revealed a type II fracture of the odontoid. Thirty-four days after her fall, the patient underwent a C1-C2 fusion. DISCUSSION: When evaluating patients with neck pain who have a history of cervical spine trauma, it is important that physical therapists understand the clinical findings associated with cervical spine fractures, as these findings provide guidance for the use of cervical spine diagnostic imaging and medical referral prior to implementing physical therapy interventions. LEVEL OF EVIDENCE: Diagnosis, level 4.

J Orthop Sports Phys Ther. 2008;38(7):418-424, published online 3 June 2008. doi:10.2519/jospt.2008.2687

KEY WORDS: cervical spine, dens fracture, diagnostic imaging, differential diagnosis

A 55-year-old man was referred to physical therapy because of constant mid-back pain of 1 month's duration. Because of the strong suspicion for a fracture, thoracic spine anterior-posterior and lateral radiographs were ordered, which revealed compression deformities of the T6, T8, T9, and T12 vertebral bodies. An interventional radiologist ordered magnetic resonance imaging and believed the patient was a candidate for vertebroplasty, a technique in which medical grade cement is injected into a painful fractured vertebral body in an effort to stabilize the fracture. At 1 week following his vertebroplasty the patient was pain free. Further medical evaluation indicated that the patient had underlying osteoporosis, and treatment was initiated. At 1 and 2 years after vertebroplasty, the patient reported being symptom free. However, a history of osteoporosis and multiple compression fractures led to further medical evaluation 2 years after vertebroplasty and the patient was eventually diagnosed with multiple myeloma for which treated was initiated.

J Orthop Sports Phys Ther. 2008;38(4):214. doi:10.2519/jospt.2008.0404

KEY WORDS: back pain, fracture, magnetic resonance imaging, vertebroplasty

Letters to the Editor-in-Chief of the JOSPT as follows:

• Regional Interdependence: A Musculoskeletal Examination Model Whose Time Has Come. J Orthop Sports Phys Ther. 2008;38(3):159-161. doi:10.2519/jospt.2008.0201
• Authors' response. J Orthop Sports Phys Ther. 2008;38(3):159-161. doi:10.2519/jospt.2008.0202
• Slipped Capital Femoral Epiphysis in a Patient Referred to Physical Therapy for Knee Pain. J Orthop Sports Phys Ther. 2008;38(3):159-161. doi:10.2519/jospt.2008.0203
• Authors' response. J Orthop Sports Phys Ther. 2008;38(3):159-161. doi:10.2519/jospt.2008.0204

The radiographs of this patient, an 11-year-old female with progressively worsening right knee pain, were significant for a right slipped capital femoral epiphysis (SCFE). The patient was referred to the orthopaedic surgeon on-call and underwent surgical fixation of her SCFE on the day of diagnosis.

J Orthop Sports Phys Ther. 2008;38(1):26. doi:10.2519/jospt.2008.0401

KEY WORDS: musculoskeletal imaging, hip radiographs, slipped capital femoral ephiphysis

Girth measures are commonly used to assess muscle atrophy or joint effusion. Little is known, however, regarding girth measurement changes following knee injury and subsequent surgery. Therefore, the purpose of this study was to compare the thigh and calf girth measurements of involved and noninvolved extremities prior to and following knee surgery for subjects with acute and chronic knee injuries. Of the 40 subjects that were studied, 22 subjects were placed in the acute group (less than 6 months from time of injury to presurgery measurement) and 18 subjects were placed in the chronic group (greater than 6 months from time of injury to presurgery measurement). Thigh and calf girth measurements were taken prior to surgery and then prior to the initiation of outpatient rehabilitation following surgery. For the acute and chronic groups, a 3-way analysis of variance (ANOVA) with repeated measures on the extremity, muscle, and time factors was used to analyze the data. For each group, the 3-way ANOVA revealed a significant 2-way interaction between the extremity and time factors. Post hoc analysis revealed significant differences between involved and noninvolved extremities at both the pre- and postsurgery time periods for the acute and chronic groups. While thigh and calf girth measurement differences existed between the involved and noninvolved extremities prior to and after surgery, the bulk of the girth measurement differences existed prior to surgery for both groups. Based upon the results of this study, the assessment and rehabilitation of the thigh and calf following knee injury and surgery are recommended.

J Orthop Sports Phys Ther. 1998;27(1):9-15.

Key Words: knee, surgery, thigh girth, calf girth

The lateral step-up test is often utilized by clinicians to assess lower extremity performance capabilities. Reliability of the lateral step-up test, however, is not available. Therefore, the purpose of this study was to determine the test-retest reliability of a 15-sec and a 50-repetition lateral step-up test on a .15-m (6-inch) and .2-m (8-inch) step. For each of the 15-sec lateral step-up tests, subjects were asked to perform as many repetitions as possible during the 15-sec time frame, while for each of the 50-repetition lateral step-up tests, subjects were asked to perform 50 repetitions as quickly as possible. Eighteen healthy subjects were studied. Data were analyzed through a repeated measures analysis of variance, intraclass correlation coefficients (ICC) (2,1), and standard errors of measurement. The ICC values were .90 and .94 for the .15-m and .2-m 15-sec lateral step-up tests and .91 and .96 for the .15-m and .2-m 50-repetition lateral step-up tests, respectively, revealing test-retest reliability to be high for each of the tests. Significant differences, however, were noted between the testing days for each of the 50-repetition lateral step-up tests, indicating that the measures may not be stable. No significant differences were seen between testing days for either of the 15-sec lateral step-up tests. While the results support the use of each of the 15-sec lateral step-up tests as reliable, stable measures of lower extremity performance, caution should be used when interpreting the results of either of the 50-repetition lateral step-up tests if used as demonstrated in this study.

J Orthop Sports Phys Ther.1997;25(2):128-132.

Key Words: lateral step-up test, lower extremity, reliability

Study Design: Resident’s case problem. Background: This paper describes the clinical course of a patient with low back pain (LBP) and left lower extremity pain and tingling, and how the physical therapist used clinical examination findings and a lack of improvement with conservative measures to initiate further medical evaluation. This evaluation resulted in a diagnosis of cancer as the primary cause of the patient’s low back and hip pain. Diagnosis: A 45-year-old man with chief complaints of left-sided LBP, left posterior thigh pain, and tingling along the anterolateral aspect of his left lower extremity was initially seen by a physical therapist in a direct access setting. Several components of the patient’s history and physical examination were consistent with a mechanical neuromusculoskeletal dysfunction. However, there were signs and symptoms present that may have been suggestive of more serious underlying disease. Specifically, the patient’s most intense pain was in the evening and into the night and an atypical pattern of restricted motion at the left hip was noted. Therefore, the physical therapist recommended that the patient schedule an appointment with his physician for medical evaluation. A short-term course of physical therapy treatment was also undertaken to address neuromusculoskeletal impairments. Despite 5 physical therapy visits over the course of a month, while the patient waited for his scheduled physician appointment, the patient’s condition gradually worsened. After medical evaluation, the patient was eventually diagnosed with small cell carcinoma of the lung, with metastases to the spine and pelvis. Despite 2 cycles of chemotherapy, the patient succumbed to the cancer 5 months after he was first seen in physical therapy. Discussion: It is important that physical therapists have an understanding of the clinical findings associated with the presence of serious underlying diseases causing LBP, as this information provides guidance as to when communication with the patient’s physician is warranted.

J Orthop Sports Phys Ther. 2005;35(10):651-658. doi:10.2519/jospt.2005.2105 

Key Words: carcinoma, diagnostic imaging, lumbar spine