The patient was a 41-year-old man who was referred to a physical therapist with a chief complaint of right anterior hip/groin pain. The patient’s symptoms started 6 months earlier after dunking a basketball and were exacerbated while moving boxes 4 months later. The patient reported morning stiffness and constant pain that was exacerbated by squatting and prolonged sitting. Right hip range of motion was limited to 85° of flexion and 0° of internal rotation with a painful “pinching” sensation noted in the groin region at end range of motion; these range-of-motion findings were consistent with a clinical diagnosis of hip osteoarthritis. Given the lack of improvement with conservative measures, the patient was referred to an orthopaedic surgeon. Radiographs revealed decreased offset of the femoral head-neck junction, greater on the right than on the left, which is suggestive of cam-type femoral acetabular impingement. Moderate degenerative osteoarthrosis of the right hip was also noted. The patient’s symptoms improved for 3 weeks following a corticosteroid injection, but then returned to baseline. The patient subsequently underwent a Birmingham hip resurfacing procedure. In this patient, conservative management of his hip osteoarthritis may have been complicated by the presence of femoral acetabular impingement.

J Orthop Sports Phys Ther 2011;41(3):201. doi:10.2519/jospt.2011.0406

KEY WORDS: Birmingham hip resurfacing, radiography

STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To determine if patients who met the clinical prediction rule (CPR) criteria for the success of thoracic spine thrust joint manipulation (TJM) for the treatment of neck pain would have a different outcome if they were treated with a cervical spine TJM. BACKGROUND: A CPR had been proposed to identify patients with neck pain who would likely respond favorably to thoracic spine TJM. Research on validation of that CPR had not been completed when this trial was initiated. In our clinical experience, though many patients with neck pain responded favorably to thoracic spine TJM, they often reported that their symptomatic cervical spine area had not been adequately addressed. METHODS: Twenty-four consecutive patients, who presented to physical therapy with a primary complaint of neck pain and met 4 out of 6 of the CPR criteria for thoracic TJM, were randomly assigned to 1 of 2 treatment groups. The thoracic group received thoracic TJM and a cervical range-of-motion (ROM) exercise for the first 2 sessions, followed by a standardized exercise program for an additional 3 sessions. The cervical group received cervical TJM and the same cervical ROM exercise for the first 2 sessions, and the same exercise program given to the thoracic group for the next 3 sessions. Outcome measures collected at 1 week, 4 weeks, and 6 months from start of treatment included the Neck Disability Index, numeric pain rating scale, and Fear-Avoidance Beliefs Questionnaire. RESULTS: Patients who received cervical TJM demonstrated greater improvements in Neck Disability Index (P≤.001) and numeric pain rating scale (P≤.003) scores at all follow-up times. There was also a statistically significant improvement in the Fear-Avoidance Beliefs Questionnaire physical activity subscale score at all follow-up times for the cervical group (P≤.004). The number needed to treat to avoid an unsuccessful overall outcome was 1.8 at 1 week, 1.6 at 4 weeks, and 1.6 at 6 months. CONCLUSION: Patients with neck pain who met 4 of 6 of the CPR criteria for successful treatment of neck pain with a thoracic spine TJM demonstrated a more favorable response when the TJM was directed to the cervical spine rather than the thoracic spine. Patients receiving cervical TJM also demonstrated fewer transient side-effects. LEVEL OF EVIDENCE: Therapy, level 1b.

J Orthop Sports Phys Ther 2011;41(4):208-220, Epub 18 February 2011. doi:10.2519/jospt.2011.3640

KEY WORDS: clinical prediction rule, manual therapy, mobilization, prognosis

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

• "Manual Magic: The Method Is Not the Trick" and Authors' Response
• "Moving Past Sleight of Hand" and Authors' Response
• "Core Muscle Activation During Swiss Ball and Traditional Abdominal Exercises" and Authors' Response

J Orthop Sports Phys Ther 2010;40(8):535-541. doi:10.2519/jospt.2010.0201

The patient was a 68-year-old man who had undergone a right total hip arthroplasty 3 years prior. He complained of progressively worsening right hip pain. Physical examination findings were consistent with a positive sign of the buttock. A triple-bone scan showed increased radio-pharmaceutical activity, which is consistent with infection. Subsequent aspiration of the right hip revealed infection, which was treated with antibiotics before the patient underwent a revision total hip arthroplasty.

J Orthop Sports Phys Ther 2010;40(6):377. doi:10.2519/jospt.2010.0410

KEY WORDS: computed tomography, hip, triple-phase bone scan

Medical care historically has had a strong association with magic, illusion, and secrecy. Although we profess to be
modern healthcare practitioners, utilizing manual therapy techniques, and strive for evidence-based practice, the reality is that one of the most ubiquitous of all manual therapy techniques, manipulation, is obscured by illusive
and ill-defined terminology. As a first step in moving from magician to modern clinician, we recently proposed a
nomenclature intended to standardize and clarify the terminology used in describing specific manual therapy techniques, recommending the use of 6 key characteristics. The persistent obfuscations appear to be aimed at
obscuring the differentiation of manipulation from mobilization. The time has come for a more precise delineation
between manipulation and mobilization and to move beyond seeing these valuable interventions simply as some sleight-of-hand technique.

J Orthop Sports Phys Ther 2010;40(5):253-255. doi:10.2519/jospt.2010.0105

KEY WORDS: manipulation, mobilization, terminology

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

• Clinical Prediction Rules in Physical Therapy: Coming of Age? J Orthop Sports Phys Ther 2009;39(3):231-232. doi:10.2519/jospt.2009.0201
• Frontal Plane Measurements During a Single-Leg Squat Test in Individuals With Patellofemoral Pain Syndrome and Authors' Response, J Orthop Sports Phys Ther 2009;39(3):233-234. doi:10.2519/jospt.2009.0202
• Management of Patients With Patellofemoral Pain Syndrome Using a Multimodal Approach: A Case Series and Authors' Response, J Orthop Sports Phys Ther 2009;39(3):234-237. doi:10.2519/jospt.2009.0203

A 22-year-old woman presented to a direct-access physical therapy clinic with a 1-week history of right foot pain, following an injury while playing basketball. Unable to bear weight, she went to the emergency department immediately after the injury, where radiographs were taken and interpreted as normal. In the initial physical therapy examination, 7 days after the initial injury, several factors led the authors to suspect a potential tarsometatarsal joint injury. The patient was immediately referred to an orthopaedic surgeon and repeat radiographs were ordered, which revealed widening at the junction of the base of the second metatarsal with the medial and middle cuneiform. The patient was subsequently treated with external fixation.

J Orthop Sports Phys Ther 2009;39(1):28-28. doi:10.2519/jospt.2009.0401

KEY WORDS: radiographs, weight-bearing

J Orthop Sports Phys Ther 2009;39(3):188-200, Epub 24 October 2008. doi:10.2519/jospt.2009.2940

STUDY DESIGN: Resident's case problem. BACKGROUND: The role of premanipulative testing of the cervical spine is an area of controversy, and there are very few data to inform and guide practitioners on the use of ligamentous stability tests when assessing the upper cervical spine. DIAGNOSIS: A 23-year-old female was referred to physical therapy by a neurologist for the management of intractable headaches of possible musculoskeletal origin. Her Neck Disability Index score was 54% and she rated her headache pain from 3/10 to 9/10 on a Numerical Pain Rating Scale. She reported a 2-year history of intermittent lower extremity paresthesias without a known mechanism or current symptoms. She was treated in physical therapy for 11 visits with improvements in cervical range of motion, strength, and intensity of her headaches, but noted no change in the frequency of headaches. She was subsequently referred to the primary author for a second opinion and potential manual therapy interventions. Initial neurological screening examination for upper and lower motor neuron lesions was unremarkable. Assessment of the transverse ligament, using the anterior shear test in supine, brought on paresthesias in both feet and her toes. The paresthesias continued after the cessation of the test. The Sharp-Purser test performed in sitting, immediately after the transverse ligament test, abolished the paresthesias. She was then referred back to her primary care physician for further evaluation. Subsequent radiographs and magnetic resonance imaging revealed that the patient had a C2-C3 Klippel-Feil congenital fusion and os odontoideum. The patient was examined by a neurosurgeon who concluded that she was not a surgical candidate. Her neurological symptoms completely resolved, but she continued to have headaches. DISCUSSION: Os odontoideum is a clinically important condition, given that the mobile dens may render the transverse ligament incompetent, leading to atlantoaxial instability. Both the role and sequencing of upper cervical ligamentous testing is controversial. The results of this case report suggest that physical therapists should be cognizant of this condition and consider screening the upper cervical ligaments prior to manual or mechanical interventions to this region. LEVEL OF EVIDENCE:  Differential diagnosis, level 4.

J Orthop Sports Phys Ther. 2008;38(8):465-475, published online 27 June 2008. doi:10.2519/jospt.2008.2747

KEY WORDS: Klippel-Feil syndrome, manual therapy, neck, transverse ligament, upper cervical instability

SYNOPSIS: We propose describing a manipulative technique using 6 characteristics:

1. Rate of force application: Describe the rate at which the force was applied.
2. Location in range of available movement: Describe whether motion was intended to occur only at the beginning of the available range of movement, towards the middle of the available range of movement, or at the end point of the available range of movement.
3. Direction of force: Describe the direction in which the therapist imparts the force.
4. Target of force: Describe the location to which the therapist intended to apply the force.
5. Relative structural movement: Describe which structure or region was intended to remain stable and which structure or region was intended to move, with the moving structure or region being named first and the stable segment named second, separated by the word "on."
6. Patient position: Describe the position of the patient, for example, supine, prone, recumbent. This would include any premanipulative positioning of a region of the body, such as being positioned in rotation or side bending.

J Orthop Sports Phys Ther. 2008;38(3):A1-A6. doi:10.2519/jospt.2008.0301

STUDY DESIGN: Case report. BACKGROUND: Following total knee arthroplasty (TKA), restoration of normal quadriceps muscle function is rare. One month after surgery, quadriceps torque (force) is only 40% of preoperative values and quadriceps activation is only 82% of preoperative levels, despite initiating postoperative rehabilitation the day after surgery. Early application of neuromuscular electrical stimulation (NMES) offers a possible approach to minimize loss of quadriceps torque more effectively than traditional rehabilitation exercises alone. CASE DESCRIPTION: A 65-year-old female underwent a right, cemented TKA. Isometric quadriceps and hamstrings muscle torque were measured preoperatively and 3, 6, and 12 weeks after TKA. Quadriceps muscle activation was measured using a doublet interpolation technique at the same time points. The patient participated in a traditional TKA rehabilitation program augmented by NMES, which was initiated 48 hours after surgery and continued twice/day for the first 3 weeks, and once daily for 3 additional weeks. OUTCOMES: Preoperatively, the involved quadriceps produced 75% of the torque of the uninvolved side and demonstrated only 72.9% activation. At 3, 6, and 12 weeks after TKA, quadriceps torque was greater than the preoperative values of the involved side by 16%, 40% and 56%, respectively. Similarly, activation improved to 93.4%, 94.6%, and 93.5% at 3, 6, and 12 weeks after TKA. DISCUSSION: Mitigating quadriceps muscle weakness immediately after TKA using early NMES may improve functional outcomes, because quadriceps weakness has been associated with numerous functional limitations and an increased risk for falls. Despite presenting preoperatively with substantial quadriceps torque and activation deficits, the patient in this case demonstrated improvements in quadriceps function at all time points measured, all of which were superior to those reported in the literature.  The patient also made substantial improvements in functional outcomes, including the Knee Injury and Osteoarthritis Outcome Score (KOOS), 6-minute walk test, timed up and go (TUG) test, stair-climbing test, and the SF-36 Physical Component Score. Appropriately controlled clinical trials will be necessary to determine whether such favorable outcomes following TKA are specifically attributable to the addition of NMES to the rehabilitation program. 

J Orthop Sports Phys Ther. 2007, 37(7):364-371, published online 29 May 2007. doi:10.2519/jospt.2007.2541

KEY WORDS: electrical stimulation, knee replacement, muscle activation, rehabilitation