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