Injuries to the ankle or foot are some of the most common orthopaedic complaints seen in primary care and sports medicine settings, accounting for 5% to 10% of all visits. Physical therapists working in a military setting are frequently the first credentialed providers to evaluate and diagnose patients with musculoskeletal complaints or orthopaedic trauma, using their privileges to order radiographs, bone scans, and electromyographical/nerve conduction study examinations. Because the presenting symptoms of sprains and fractures are often similar, it is imperative that physical therapists are competent and comfortable with their role of evaluating acute traumatic injuries without a physician referral. The validity of physical therapists managing patients with acute musculoskeletal injuries, without physician referral, has been previously established. This important role has enabled US Army orthopaedic surgeons to focus their practice on more complicated trauma or surgical cases. As direct access becomes more prevalent in the civilian profession of physical therapy, it becomes increasingly important that the physical therapist, as the first credentialed provider evaluating the patient, is proficient in distinguishing between ankle sprains and fractures. Even in the absence of direct access, physical therapists should still be able to determine when radiographs are appropriate in the event of a misdiagnosis and referral for an ankle sprain. The Ottawa Ankle Rules and the Buffalo modification are effective clinical decision rules to assist therapists in ruling out a fracture or determining whether radiographs are necessary for acute ankle injuries. We chose to report this case as example of how physical therapists can effectively apply these rules while serving in a direct-access role for the benefit of patients.

J Orthop Sports Phys Ther. 2004;34(4):182-186. doi:10.2519/jospt.2004.1310

Key Words: sprains, fractures, Ottawa Ankle Rules, Buffalo modification, direct-access

Study Design: Nonexperimental, retrospective design. Objectives: This study was designed to compare clinical diagnostic accuracy (CDA) between physical therapists (PTs), orthopaedic surgeons (OSs), and nonorthopaedic providers (NOPs) at Keller Army Community Hospital on patients with musculoskeletal injuries (MSI) referred for magnetic resonance imaging (MRI). Background: US Army PTs are frequently the first credentialed providers privileged to examine and diagnose patients with musculoskeletal injuries. Physical therapists assigned at Keller Army Community Hospital have also been credentialed with privileges to order MRI studies for several years. Methods and Measures: To reduce provider bias, a retrospective analysis was performed on 560 patients referred for MRI over an 18-month period. An electronic review of each patient’s radiological profile was performed to assess agreement between clinical diagnosis and MRI findings. Data analyses were performed through descriptive statistics and contingency tables. Results:Analysis on agreement between clinical diagnosis and MRI findings produced a CDA of 74.5% (108/145) for PTs, 80.8% (139/172) for OSs, and 35.4% (86/243) for NOPs. There was a significant difference in CDA between PTs and NOPs (P<.001), and between OSs and NOPs (P<.001). There was no difference in CDA between PTs and OSs (P>.05). Conclusions: Clinical diagnostic accuracy by PTs and OSs on patients with musculoskeletal injuries was significantly greater than for NOPs, with no difference noted between PTs and OSs.

J Orthop Sports Phys Ther. 2005;35(2):67-71. doi: 10.2519/jospt.2005.1344

Key Words: diagnostic agreement, direct access, primary care

Study Design: Resident’s case problem.
Background: A 19-year-old female, currently enrolled in a military training program, sought medical care for a twisting injury to her right knee. The patient reported her symptoms as similar to an injury she incurred 1 year previously while enrolled in the same military program. The patient’s past medical history included a nondepressed fracture of the medial tibial plateau and complete tear of the deep fibers of the medial collateral ligament.
Diagnosis: Physical exam revealed nonlocalized anterior and medial knee pain without evidence of internal derangement. Initial knee and tibia radiographs were unremarkable. Referral for orthopedic physician evaluation resulted in concurrence with the therapist’s diagnosis and plan of care, and the patient was allowed to continue with limited physical training demands. Despite periods of rest, the patient’s symptoms progressively worsened upon attempts to resume running. The examining therapist referred the patient for magnetic resonance imaging (MRI) due to the patient’s worsening symptoms, normal radiographs, and concern for a proximal tibia stress fracture. MRI revealed a severe proximal tibial metaphysis stress fracture.
Discussion: Stress fractures are commonly encountered injuries in individuals subjected to increased physical training demands. Early evaluation may not yield well-localized findings and may mimic other conditions. Nonmusculoskeletal conditions should be considered in the management of patients with stress fractures. This resident’s case problem illustrates the importance of serial physical examinations and collaboration with other healthcare practitioners in the comprehensive assessment and management of a patient with a severe stress fracture.

J Orthop Sports Phys Ther. 2006;36(7):526-534. doi:10.2519/jospt.2006.2125

Key Words: bone injury, female athlete triad, tibia