STUDY DESIGN: Systematic literature review and meta-analysis. OBJECTIVES: To evaluate the diagnostic accuracy of clinical tests to identify stress fractures in the lower limb. BACKGROUND: Stress fractures are a bone-related overuse injury primarily occurring in the lower limb and commonly affecting running athletes and military personnel. Physical examination procedures and clinical tests are suggested for diagnosing stress fractures; however, data on the diagnostic accuracy of these tests have not been investigated through a systematic review of the literature. METHODS: A systematic review was conducted in 8 electronic databases to identify diagnostic accuracy studies, published between January 1950 and June 2011, that evaluated clinical tests against a radiological diagnosis of lower-limb stress fracture. Retrieved articles were evaluated using the Quality Assessment of Diagnostic Accuracy Studies tool, and a meta-analysis was performed where appropriate. RESULTS: Nine articles investigating 2 clinical procedures, therapeutic ultrasound (n = 7) and tuning fork testing (n = 2), met the study inclusion criteria. Meta-analysis was used to statistically analyze the data extracted from the ultrasound articles and demonstrated a pooled sensitivity of 64% (95% confidence interval [CI]: 55%, 73%), specificity of 63% (95% CI: 54%, 71%), positive likelihood ratio of 2.1 (95% CI: 1.1, 3.5), and negative likelihood ratio of 0.3 (95% CI: 0.1, 0.9). Tuning fork test data could not be pooled; however, sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio ranged from 35% to 92%, 19% to 83%, 0.6 to 3.0, and 0.4 to 1.6, respectively. CONCLUSION: The results of this systematic review do not support the specific use of ultrasound or tuning forks as standalone diagnostic tests for lower-limb stress fractures. As the overall diagnostic accuracy of the tests investigated is not strong, based on the calculated likelihood ratios, it is recommended that radiological imaging should continue to be used for the confirmation and diagnosis of stress fractures of the lower limb. LEVEL OF EVIDENCE: Diagnosis, level 1a–.

J Orthop Sports Phys Ther 2012;42(9):760-771, Epub 19 July 2012. doi:10.2519/jospt.2012.4000

KEY WORDS: diagnosis, lower limb, tuning fork, ultrasound, validity

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

• "Early Prognostic Factors in Patients With Whiplash" and Author's Response
• "Staying Current in the Use of Ultrasound Imaging" and Author's Response
• "Differentiating the Soleus From the Gastrocnemius With the Heel Raise Test" and Author's Response

J Orthop Sports Phys Ther 2011;41(12):983-987. doi:10.2519/jospt.2011.0202

STUDY DESIGN: Controlled laboratory study, using a repeated-measures, counterbalanced design. OBJECTIVES: To provide estimates on the average knee angle maintained, absolute knee angle error, and total repetitions performed during 2 versions of the heel raise test. BACKGROUND: The heel raise test is performed in knee extension (EHRT) to assess gastrocnemius and knee flexion (FHRT) for soleus. However, it has not yet been determined whether select knee angles are maintained or whether total repetitions differ between the clinical versions of the heel raise test. METHODS: Seventeen healthy males and females performed maximal heel raise repetitions in 0° (EHRT) and 30° (FHRT) of desired knee flexion. The average angle maintained and absolute error at the knee during the 2 versions, and total heel raise repetitions, were measured using motion analysis. Participants’ kinematic measures were fitted into a generalized estimation equation model to provide estimates on EHRT and FHRT performance applicable to the general population. RESULTS: The model estimates that average angles of 2.2° and 30.7° will be maintained at the knee by the general population during the EHRT and the FHRT, with an absolute angle error of 3.4° and 2.5°, respectively. In both versions, 40 repetitions should be completed. However, the average angles maintained by participants ranged from –6.3° to 21.6° during the EHRT and from 22.0° to 43.0° during the FHRT, with the highest absolute errors in knee position being 25.9° and 33.5°, respectively. CONCLUSION: On average, select knee angles will be maintained by the general population during the select heel raise test versions, but individualized performance is variable and total repetitions do not distinguish between versions. Clinicians should, therefore, interpret select heel raise test outcomes with caution when used to respectively assess and rehabilitate soleus and gastrocnemius function.

J Orthop Sports Phys Ther 2011;41(7):505-513, Epub 18 February 2011. doi:10.2519/jospt.2011.3489

KEY WORDS: Achilles tendon, ankle, triceps surae

STUDY DESIGN: Cross-sectional, controlled laboratory study. OBJECTIVES: To determine whether thigh muscle isokinetic torque patterns and activity, measured by electromyography (EMG), of individuals with hamstring injury differ from control individuals. BACKGROUND: Neuromuscular control during thigh muscle strength assessment following hamstring injuries has not been reported. METHODS: Fifteen athletes with prior hamstring injury (hamstring-injured group [HG]) were compared to 15 uninjured athletes (control group [CG]). The injuries were incurred 6 weeks to 12 months prior to participation, and all injured athletes had returned to at least partial training. Participants performed 5 isokinetic concentric extensor, concentric flexor, and eccentric flexor torque tests at 60°/s in the seated position. Peak torque was determined for each contraction type, as well as average torque for each of 4 time-based movement quartiles. EMG root-mean-squares were calculated in these movement quartiles for the biceps femoris and medial hamstrings. RESULTS: No significant differences were found for peak torque for all contractions, when comparing HG injured and uninjured sides to CG bilateral averages. The HG injured limb eccentric flexor torque was significantly lower in the fourth quartile (approximately 25° to 5° knee flexion, hamstring lengthened range) compared to the CG bilateral average (P = .025). Eccentric flexor biceps femoris and hamstrings EMG root-mean-squares of the HG injured and the uninjured sides were significantly lower in the second to fourth quartiles (towards the lengthened range), compared to the CG bilateral averages (P<.05). CONCLUSION: Decreased strength and EMG activation in a lengthened hamstrings range for the athletes with prior hamstring injury suggested a change in neuromuscular control. Lengthened range assessment of isokinetic eccentric flexor torque may be useful for the assessment of athletes with a prior injury; however, results should be confirmed with prospective studies.

J Orthop Sports Phys Ther 2011;41(5):354-363, Epub 2 February 2011. doi:10.2519/jospt.2011.3268

KEY WORDS: dynamometry, EMG, electromyography, strain

The validity and reliability of hand-held dynamometry and Cybex dynamometry were investigated using maximal isometric contractions of the external rotators of the shoulder in 14 healthy male subjects. Three maximum voluntary contractions were recorded from each subject by a hand-held dynamometer and a Cybex isokinetic dynamometer at two testing sessions approximately 1 week apart. Analysis of variance did not reveal any significant differences between the mean peak torques obtained with either instrument or between days. The intrarater reliability was clearly established for both the hand-held dynamometer (r = 0.986) and Cybex dynamometer (r = 0.993). Within-day correlations between the two instruments accounted for 27% (day 1) and 60% (day 2) of the explainable variance. This suggests that although both techniques produced identical peak torque values and measured the same element of performance-strength, they did so in a slightly different manner. The possible nature of these differences is discussed.

J Orthop Sports Phys Ther 1988;10(6):213-217.

The purpose of this study was to investigate the effects of massage on neuromuscular excitability, as measured by changes in Hoffmann reflex (H-reflex) amplitudes. Nine healthy subjects (= 25.2 years; 2 males, 7 females), with no history of neurological disease, participated in the study. H-reflexes were elicited from the right soleus muscle by delivering square wave impulses (Grass S48 stimulator) of 1 msec duration to the posterior tibial nerve of the same leg. H-reflex peak to peak amplitudes were measured at 10 sec intervals, and a total of 10 recordings were made during each of five separate conditions (C1, C2, MASS, C3, and C4). Two pretreatment control (C1 and C2) conditions, separated by a 5-minute pause in the recordings, were immediately followed by the massage condition (MASS). H-reflex recordings were also made during the first 2 minutes of a 3-minute massage application to the right triceps surae muscle group. One post-treatment control (C3) condition was introduced immediately following the termination of the massage, and a second (C4) after a 5 minute delay. A one-way repeated measures analysis of variance revealed a significant difference among conditions (F_4,32 = 32.26, p < 0.01) for individual means. Newman Keuls post hoc procedures for pair-wise comparisons revealed that all massage-control pairings were statistically different (p < 0.01). No other pairings (control-control) were significantly different. A 71% decrease in H-reflex amplitudes was observed during the massage, followed by a return to baseline levels immediately following the termination of the massage. These results suggest the use of massage as an alternative to other therapeutic modalities such as passive muscle stretching and tendon pressure to decrease spinal motoneuron excitability.

J Orthop Sports Phys Ther 1990;12(2):55-59.

J Orthop Sports Phys Ther 1992;15(5):229-235.

Key Words: ankle taping, muscle strength, ankle orthotics