J Orthop Sports Phys Ther 1993;17(4):172-176.

Key Words: sacroiliac joint, hip pain, joint manipulation

Letters to the Editor-in-Chief published in the December 2006 issue of the Journal.

J Orthop Sports Phys Ther. 2006;36(12):963-967. doi:10.2519/jospt.2006.0202

Osteoarthritis of the hip is a common condition physical therapists see in the clinic. The fundamental radiological and pathological characteristic of osteoarthritis of the hip is joint space loss. Consequently, the best radiological criterion used to detect osteoarthritis of the hip is by measuring joint space width. Because most physical therapists do not have immediate access to radiographs and do not have the ability to order radiographs, they must either rely on a physician to order a hip radiograph or rely on a clinical method to diagnose osteoarthritis of the hip. Radiographs, though usually helpful in the diagnosis of severe hip osteoarthritis, are not always beneficial in the diagnosis of mild or moderate hip osteoarthritis. In patients with severe hip osteoarthritis, radiographs usually show joint space narrowing, subchondral sclerosis, or osteophytes. However, patients with early osteoarthritis often do not show these kind of radiographic changes. Thus, relying only on radiographs to determine osteoarthritis of the hip, especially in patients with early or mild hip osteoarthritis, can result in false-negative diagnosis. Using the clinical presentation (signs and symptoms) along with imaging findings will likely improve the diagnosis of osteoarthritis of the hip. The ability to clinically determine osteoarthritis of the hip without a radiograph, especially in early cases, would be valuable to many clinicians, not just physical therapists. Finding a clinical method to detect osteoarthritis of the hip would give physical therapists an opportunity for early intervention. Early intervention may improve the chance of clinical success. A number of studies have suggested using a clinical method to diagnose hip osteoarthritis. Studies by Altman et al, Birrell et al, and Bierma-Zienstra et al have recommended using clinical variables, such as pain location or duration, hip range of motion, age, or aggravating movement. Among the different clinical criteria, diminished hip range of motion is the most common component used to indicate the presence of hip joint osteoarthritis. Using hip motion to diagnose hip problems is not new. Many studies have shown the relationship between different hip conditions and diminished hip motion. For example, osteoarthritis of the hip has been linked to patients with femoral neck retroversion, where hip external rotation is increased while hip internal rotation is limited. In osteoarthritis of the hip, the first 2 motions that are diminished are usually hip internal rotation and hip flexion. The purpose of this paper is to describe how we made a clinical diagnosis of osteoarthritis of the hip in a patient with diminished hip range of motion and hip pain.

J Orthop Sports Phys Ther. 2004;34(8):461-467. doi:10.2519/jospt.2004.1313  

The original article was corrected in September 2007, and the amended article PDF is provided here. Please see Correction: Altman's criteria for osteoarthritis of the hip and knee. J Orthop Sports Phys Ther. 2007; 37(9):573.

Key Words: osteoarthritis, hip motion, hip pain, radiograph

Using the evidence-based practice (EBP) approach to find the best evidence from science significantly increases a clinician's probability of making the right diagnosis and selecting the best intervention. The EBP approach is different from the differential diagnosis method that is taught in many schools. Using the differential diagnosis method, the first step is to develop a list of possible causes that may explain the signs and symptoms. Next, using data from the history, clinical examination, imaging, or lab results, the diagnosis is developed through deductive reasoning. Several different strategies are used to help refine the examiner's thought processes when making the diagnosis. For example, when using the anatomic method, each specific tissue is tested or stressed to determine its response. Although widely taught and used by clinicians, the principal caveat to this approach is that the diagnostic tests and interventions are not chosen in an unbiased fashion. Conversely, when using the EBP approach, evidence is gathered in a systematic, unbiased method when selecting and interpreting diagnostic tests and assessing potential interventions. This resident's case problem describes the use of the EBP approach in making an unbiased diagnosis and selecting an intervention for 3 different patients, each with a different cluster of signs and symptoms of low back pain.

J Orthop Sports Phys Ther 2001;31(12):678-695.

Key Words: evidence-based practice, differential diagnosis

Study Design: Case study. Objective: To describe a treatment approach for a patient with recurrent low back pain who also had asymmetry in hip rotation between the left and right sides. Background: The patient's chief complaint was dull, intermittent unilateral low back pain during the past 3 years. Methods and Measures: The patient was a 35-year-old man with recurrent unilateral low back pain. The findings of the physical therapy examination suggested sacroiliac joint dysfunction. Also, evaluation later showed evidence of unilateral excessive foot pronation on the same side of the excessive hip lateral rotation. The finding of excessive hip lateral rotation and excessive foot pronation on the same side of the unilateral low back pain suggested a possible connection between low back symptoms, hip, and lower extremity dysfunction. Results: The treatment of the hip and the subtalar joint of the foot eliminated the reoccurrence of the patient’s signs and symptoms of sacroiliac joint dysfunction. Conclusions: This case report demonstrates the successful treatment of a patient with low back pain who exhibited multiple impairments in the sacroiliac, hip, and subtalar joints.

J Orthop Sports Phys Ther. 1999;29(10):595-601.

Key Words: foot pronation, hip rotation, low back pain, sacroiliac joint

Study Design: Observation to examine the clinical usefulness of a cluster of sacroiliac joint tests. Objectives: To find the sensitivity, specificity, and positive and negative predictive values (4 commonly used epidemiologic measures) for a cluster of sacroiliac joint tests in a group of subjects with and without low back pain. Background: Sacroiliac joint testing is commonly used by orthopaedic physical therapists in the evaluation of patients with low back pain. Methods and Measures: Two hundred nineteen patients who either were being treated for low back pain or were being treated for some other condition not related to the low back participated in the study. The diagnosis of low back pain was obtained from the physician's prescription, which included low back strain, low back pain, or sacroiliac joint dysfunction, and the patient's pain drawing. Results: The results were a finding of 0.82 for sensitivity, 0.88 for specificity, 0.86 for positive predictive value of a test, and 0.84 for negative predictive value of the cluster of tests. Conclusions: The results of this study show that using a cluster of sacroiliac joint tests can be useful in identifying sacroiliac joint dysfunction in patients with low back pain.

J Orthop Sports Phys Ther. 1999;29(2):83-92.

Key Words: epidemiology, diagnosis, sacroiliac joint dysfunction

Many athletes develop shin splints after athletic activity. The purpose of this case report is to describe the treatment of a patient with posteromedial tibial pain (shin splints) who habitually ran with a forefoot contact running style. The 20-year-old male patient, who played volleyball and basketball about 7 hours a week, complained of pain in the middle one-third of the posteromedial tibia after an acute but prolonged episode of running. Routine observational analysis and in-shoe pressure analysis of the patient's running style showed that he habitually ran on his toes with an absence of heelstrike (forefoot contact running). After instructing the patient on heel-toe running, he no longer complained of posteromedial tibial bone pain. Several possible reasons are proposed for the reduction of leg pain following cessation of forefoot contact running. This case report proposes forefoot contact running as a possible contributor to posteromedial shin splints and that a change in running style may be the optimal treatment for some patients.

J Orthop Sports Phys Ther. 1994;20(2):98-102.

Key Words: shin splints, overuse injury, running