Journal of Orthopaedic & Sports Physical Therapy - Susan R. Mercer, BPhty (Hons), MSc ,PhD

Lateral Hip Pain: Findings from Magnetic Resonance Imaging and Clinical Examination

Stephanie J. Woodley, Helen D. Nicholson, Vicki Livingstone, Terence C. Doyle, Grant R. Meikle, Janet E. Macintosh, Susan R. Mercer

STUDY DESIGN: Prospective cross-sectional study. OBJECTIVES: To examine the radiological and physical therapy diagnoses of lateral hip pain (LHP), and determine the validity of selected clinical variables for predicting gluteal tendon pathology. BACKGROUND: LHP is frequently encountered by clinicians. Further investigation is required to establish the specific pathologies implicated in the cause of LHP, and which clinical tests are useful in the assessment of this problem. METHODS AND MEASURES: Forty patients with unilateral LHP underwent a physical therapy examination followed by magnetic resonance imaging (MRI) studies. Three radiologists analyzed the images of both hips for signs of pathology. Interobserver reliability of the image analyses, the agreement between the physical therapy and radiological diagnoses, and the validity of the clinical tests were examined. RESULTS: Gluteus medius tendon pathology, bursitis, osteoarthritis and gluteal muscle atrophy (predominantly affecting gluteus minimus) were all implicated in the imaging report of LHP. While prevalent in symptomatic hips, abnormalities were also identified in asymptomatic hips, particularly relating to the diagnosis of bursitis. The strength of agreement between radiologists was variable and little agreement existed between the physical therapy and radiological diagnoses of pathology. Nine of the 26 clinical variables examined in relation to gluteal tendon pathology had likelihood ratios above 2.0 or below 0.5, but the associated 95% confidence intervals were large. CONCLUSIONS: The diagnosis of LHP is challenging and our results highlight some problems associated with the use of MRI as a diagnostic reference standard. This factor, together with the imprecise point estimates of the likelihood ratios, means that no firm conclusions can be made regarding the diagnostic utility of the clinical tests used in the assessment of gluteal tendon pathology. LEVEL OF EVIDENCE: Diagnosis, level 4.

J Orthop Sports Phys Ther. 2008;38(6):313-328, published online 22 February 2008. doi:10.2519/jospt.2008.2685

KEY WORDS: bursitis, gluteal, muscle atrophy, reliability, tendon pathology, validity

Joints of the Cervical Vertebral Column

Nikolai Bogduk, Richard E. Erhard, Susan R. Mercer
The developing understanding of the morphology of the cervical spine has revealed the complexity of the system. A review of selected literature reported that a number of the joints have an unusual nature and exhibit complicated and even paradoxical motions. For the practicing therapist, the significance of these observations is that assessment and treatment procedures of the cervical spine must be very carefully analyzed. There are significant differing behaviors of some of the cervical joints in response to small changes in movement patterns or initial positioning. Therefore it is not possible to broadly classify results of assessment procedures as normal or pathological without a clear and detailed understanding of the underlying morphology. J Orthop Sports Phys Ther. 2OO1;31(4):174-182. Key Words: atlas, axis, cervical vertebrae, kinematics

Neck Retractions, Cervical Root Decompression, and Radicular Pain

Sami S. Abdulwahab, Susan R. Mercer, Mohamed A. Sabbahi
Study Design: Two-group repeated measures. Objectives: To evaluate the changes in the flexor carpi radialis H reflex after reading and neck retraction exercises and to correlate reflex changes with the intensity of radicular pain. Background: Repeated neck retraction movements have been routinely prescribed for patients with neck pain. Methods and Measures: Ten nonimpaired subjects (mean age, 27 � 4 years) and 13 patients (mean age, 35 � 9 years) with C7 radiculopathy volunteered for the study. The flexor carpi radialis H reflex was elicited by electrical stimulation of the median nerve at the cubital fossa before and after 20 minutes of reading and after 20 repetitive neck retractions. Subjective intensity of the radicular pain was reported before and after each condition using an analog scale. Results: For patients with radiculopathy, a repeated-measures analysis of variance showed a significant decrease in the H reflex amplitude (from 0.81 � 0.4 to 0.69 � 0.39 mV), an increase in radicular symptoms after reading (from 4.2 � 1.3 to 5.6 � 1.4 on the visual analog scale), an increase in the H reflex amplitude (from 0.69 � 0.39 to 1.01 � 0.49 mV), and a decrease in pain intensity (from 5.6 � 1.4 to 1.5 � 1.3) after repeated neck retractions. There was an association between cervical root compression (smaller H reflexes) and increased pain during reading and between cervical root decompression (larger H reflex) and reduced pain (r = -0.86 to -0.60). Exacerbation of symptoms was found with a reading posture. There were no significant changes in the H reflex amplitude in the nonimpaired group. No changes were found in reflex latency for either group. Conclusions: Neck retractions appeared to alter H reflex amplitude. These exercises might promote cervical root decompression and reduce radicular pain in patients with C7 radiculopathy. The opposite effect (an exacerbation of symptoms) was found with the reading posture. J Orthop Sports Phys Ther. 2000;30(1):4-12. Key Words: electromyography, H reflex, neck pain, posture