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

STUDY DESIGN: Prospective single-group cohort study. OBJECTIVES: To identify the effectiveness of a temporary custom foot orthosis (TCFO), followed by a stretching program, for the treatment of plantar fasciitis (PF). BACKGROUND: PF, a common cause of heel pain, often leads to disability. Optimal treatment for this often challenging clinical condition is still unknown. METHODS: Fifteen individuals with PF were recruited from the general public. All participants received a TCFO and were instructed to wear it for 2 weeks while weight bearing. Following the initial 2 weeks, participants were weaned off of the TCFO and instructed to begin a daily stretching program. Follow-up appointments occurred at 2, 4, and 12 weeks. The primary outcome measures included first-step heel pain via numeric pain rating scale (NPRS), the Foot and Ankle Ability Measure activities of daily living subscale (FAAM-A), and the Foot and Ankle Ability Measure sports subscale (FAAM-S). Secondary outcome included the global rating of change (GRC) score. RESULTS: Individuals with a primary complaint of plantar foot pain entered and completed this study. Repeated-measures ANOVAs for the NPRS, FAAM-A, and FAAM-S showed statistically significant changes (P<.001). Post hoc analysis using paired t tests demonstrated statistically and clinically significant change at all follow-up times, compared to the initial intervention (P<.001). Mean GRC scores at 2, 4, and 12 weeks were 4.4, 4.5, and 4.2, respectively. CONCLUSION: In treating PF, a TCFO used for 2 weeks, followed by a stretching program, provided preliminary evidence that first-step heel pain and foot and ankle function improve in the short term and up to 12 weeks. LEVEL OF EVIDENCE: Therapy, level 2b.

J Orthop Sports Phys Ther 2011;41(4):221-231, Epub 2 February 2011. doi:10.2519/jospt.2011.3348

KEY WORDS: foot, heel pain, plantar fascia, shoe inserts

The patient was a 27-year-old male soldier in the United States Army who presented to a physical therapy clinic with a chief complaint of left ankle pain following an inversion ankle sprain during a road march. Observation revealed bilateral pes planus with a nonantalgic gait. Active range of motion measurements of the ankle revealed excessive inversion and decreased dorsiflexion on the left ankle. Ankle radiographs revealed an osteochondral defect of the medial talar dome, and magnetic resonance imaging revealed an abnormality on the medial aspect of the talar dome, with considerable bone marrow edema and depression of a portion of the articular cortex. The patient was referred to an orthopaedic surgeon and underwent left ankle mosaicplasty and medial malleolar osteotomy.

J Orthop Sports Phys Ther 2010;40(4):238. doi:10.2519/jospt.2010.0406

KEY WORDS: ankle, magnetic resonance imaging, radiographs

STUDY DESIGN: Secondary analysis of a randomized clinical trial (RCT). OBJECTIVES: To perform a secondary analysis on the treatment arm of a larger RCT to determine differences in treatment outcomes, adverse reactions, and effect sizes between patients who received cervical thrust manipulation and those who received only nonthrust manipulation as part of an impairment-based, multimodal treatment program of manual physical therapy (MPT) and exercise for patients with mechanical neck pain. BACKGROUND: A treatment regimen of MPT and exercise has been effective in patients with mechanical neck pain. Limited research has compared the effectiveness of cervical thrust manipulations and nonthrust mobilizations for this patient population, and no studies have investigated the added benefit of cervical thrust manipulations as part of an overall MPT treatment plan. METHODS: Treatment outcomes from 47 patients in the treatment arm of a larger RCT, with a primary complaint of mechanical neck pain, were analyzed. Twenty-three patients (49%) received cervical thrust manipulations as part of their MPT treatment, and 24 patients (51%) received only cervical nonthrust mobilizations. All patients received up to 6 clinic sessions, twice weekly for 3 weeks, and a home exercise program. Primary outcome measures were the Neck Disability Index (NDI), 2 visual analog scales for cervical and upper extremity pain, and a 15-point global rating of change scale. Blinded outcome measurements were collected at baseline and at 3-, 6- and 52-week follow-ups. RESULTS: Consistent with the larger RCT, both subgroups in this secondary analysis demonstrated improvement in short- and long-term pain and disability scores. Low statistical power (β≤.28) and the resultant small effect size indices (–0.21 to 0.17) preclude the identification of any between-group differences. No serious adverse reactions were reported by patients in either subgroup. CONCLUSIONS: Clinically meaningful and statistically significant improvements in both subgroups of patients over time suggest that cervical thrust manipulation, as part of the MPT treatment plan, did not influence the results of the treatment arm of the larger RCT from which this study was drawn. Although no between-group differences can be identified, the small observed effect sizes in this study may benefit future studies with sample size estimation for larger RCTs and indicate the need to incorporate clinical prediction rule criteria as a means to improve statistical power. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2010;40(3):133-140, Epub 5 February 2010. doi:10.2519/jospt.2010.3106

A 23-year-old male infantry soldier presented to a direct-access physical therapy clinic with a complaint of persistent left knee pain. Observation revealed mild left quadriceps atrophy and left knee effusion. The patient's gait was mildly antalgic and a small, mobile, hard palpable mass was protruding at the medial joint line during gait. Due to the increased frequency of the patient's left knee giving way and the presence of a palpable mass along the medial joint line of the left knee, knee radiographs were ordered. The radiographs demonstrated abnormal contour of the medial femoral condyle, consistent with an osteochondral defect, and a fabella posterior to the knee. Based on the patient's antalgic gait and radiographic findings, the patient was instructed on the proper use of crutches and referred to an orthopaedic surgeon for appropriate management. While the irregular contour of the medial femoral condyle was readily apparent in this patient's images, radiographs may not always adequately show osteochondral defects. Magnetic resonance imaging is typically the modality of choice for noninvasive imaging and evaluation of osteochondral defects.

J Orthop Sports Phys Ther 2009;39(6):490. doi:10.2519/jospt.2009.0406

KEY WORDS: antalgic gait, knee, radiographs

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

STUDY DESIGN: Prospective cohort/predictive validity study. OBJECTIVE: To determine the diagnostic accuracy of common clinical examination items and to construct a preliminary clinical prediction rule for diagnosing hip osteoarthritis (OA) in individuals with unilateral hip pain. BACKGROUND: The current gold standard for the diagnosis of hip OA is a standing anteroposterior (AP) radiograph of the pelvis. Other than for Altman's criteria, little research has been done to determine the accuracy of clinical examination findings for diagnosing hip OA. METHODS AND MEASURES: Seventy-two subjects completed the study. Each subject received a standardized history, physical examination, and standing AP radiograph of the pelvis. Subjects with a Kellgren and Lawrence score of 2 or higher based on the radiographs were considered to have definitive hip OA. Likelihood ratios (LRs) were computed to determine which clinical examination findings were most diagnostic of hip OA. Potential predictor variables were entered into a logistic regression model to determine the most accurate set of clinical examination items for diagnosing hip OA. RESULTS: Twenty-one (29%) of the 72 subjects had radiographic evidence of hip OA. A clinical prediction rule consisting of 5 examination variables was identified. If at least 4 of 5 variables were present, the positive LR was equal to 24.3 (95% confidence interval: 4.4-142.1), increasing the probability of hip OA to 91%. CONCLUSION: The preliminary clinical prediction rule provides the ability to a priori identify patients with hip pain who are likely to have hip OA. A validation study should be done before the rule can be implemented in routine clinical practice. LEVEL OF EVIDENCE: Diagnosis, level 2b.

J Orthop Sports Phys Ther. 2008;38(9):542-550, published online 14 July 2008. doi:10.2519/jospt.2008.2753

KEYWORDS: arthritis, diagnosis, OA, predictive validity

Study Design: Case series. Objective: To describe an impairment-based physical therapy treatment approach for 4 patients with plantar heel pain. Background: There is limited evidence from clinical trials on which to base treatment decision making for plantar heel pain. Methods and Measures: Four patients completed a course of physical therapy based on an impairment-based model. All patients received manual physical therapy and stretching. Two patients were also treated with custom orthoses, and 1 patient received an additional strengthening program. Outcome measures included a numeric pain rating scale (NPRS) and self-reported functional status. Results: Symptom duration ranged from 6 to 52 weeks (mean duration ± SD, 33 ± 19 weeks). Treatment duration ranged from 8 to 49 days (mean duration ± SD, 23 ± 18 days), with number of treatment sessions ranging from 2 to 7 (mode, 3). All 4 patients reported a decrease in NPRS scores from an average (± SD) of 5.8 ± 2.2 to 0 (out of 10) during previously painful activities. Additionally, all patients returned to prior activity levels. Conclusion: In this case series, patients with plantar heel pain treated with an impairment-based physical therapy approach emphasizing manual therapy demonstrated complete pain relief and full return to activities. Further research is necessary to determine the effectiveness of impairment-based physical therapy interventions for patients with plantar heel pain/plantar fasciitis.

J Orthop Sports Phys Ther. 2004;34(11):725-733. doi:10.2519/jospt.2004.1506

Key Words: ankle, manipulation, mobilization, plantar fasciitis

Study Design: Randomized controlled trial among patients with low back pain (LBP). Objectives: (1) Determine the reliability of real-time ultrasound imaging for assessing activation of the lateral abdominal muscles; (2) characterize the extent to which the abdominal drawing-in maneuver (ADIM) results in preferential activation of the transverse abdominis (TrA); and (3) determine if ultrasound biofeedback improves short-term performance of the ADIM in patients with LBP. Background: Ultrasound imaging is reportedly useful for measuring and training patients to preferentially activate the TrA muscle. However, research to support these claims is limited. Methods and Measures: Thirty patients with LBP referred for lumbar stabilization training were randomized to receive either traditional training (n = 15) or traditional training with biofeedback (n = 15). Ultrasound imaging was used to measure changes in thickness of the lateral abdominal muscles. Differences in preferential changes in muscle thickness of the TrA between groups and across time were assessed using analysis of variance. Results: Intrarater reliability measuring lateral abdominal muscle thickness exceeded 0.93. On average, patients in both groups demonstrated a 2-fold increase in the thickness of the TrA during the ADIM. Performance of the ADIM did not differ between the groups. Conclusion: These data provide construct validity for the notion that the ADIM results in preferential activation of the TrA in patients with LBP. Although, the addition of biofeedback did not enhance the ability to perform the ADIM at a short-term follow-up, our data suggest a possible ceiling effect or an insufficient training stimulus. Further research is necessary to determine if there is a subgroup of patients with LBP who may benefit from biofeedback.

J Orthop Sports Phys Ther. 2005;35(6):346-355. doi:10.2519/jospt.2005.1780

Key Words: lumbar stabilization, real-time ultrasound imaging, therapeutic exercise, transverse abdominis