Journal of Orthopaedic & Sports Physical Therapy - April 2007 Volume 37, No. 4

Consider the Alternative

Teaching is a great skill that underlies many hands-on professions and is grounded by effective communication. One quality of successful teachers is the ability to impart to the student the need to consider the weight of evidence and to see the possibility of alternative explanations for what we observe on a daily basis. The physical therapy profession has many individuals who posess these attributes as teachers, clinicians, and researchers. Individuals who are new to the profession should strive to keep up with the latest and best theories and yet always be willing to examine the potential of alternative explanations. It is this type of reasoning that will further the individual and the profession reflected in great teaching, quality clinical practice, and research breakthroughs.

J Orthop Sports Phys Ther. 1007; 37(4):153-154. doi:10.2519/jospt.2007.0104

A Controlled Trial of Weight-Bearing Versus Non�Weight-Bearing Exercises for Patellofemoral Pain

Lee Herrington, Abdullah Al-Sherhi
STUDY DESIGN: Randomized controlled trial, pretest-posttest design. OBJECTIVES: To compare the efficacy of non-weight-bearing single-joint quadriceps exercise (SJNWBE) versus weight-bearing multiple-joint quadriceps exercise (MJWBE) for individuals with patellofemoral pain syndrome (PFPS). BACKGROUND: PFPS is a common ailment of the knee. Both weight-bearing and non-weight bearing exercises are considered appropriate for strengthening the quadriceps, a key element in the treatment of this condition. METHODS AND MEASURES: Forty-five male subjects with PFPS between 18 and 35 years of age were randomized into 1 of 3 groups. Group 1 (SJNWBE) performed knee extension exercises, group 2 (MJWBE) performed seated leg press exercises, and group 3 (control group) received no treatment. Subjective symptoms, knee extensor muscle strength, and functional performance were evaluated at the time of the initial examination and at the end of the 6-week treatment period. RESULTS: Individuals in both exercise groups demonstrated a statistically significant decrease in pain and an increase in muscle strength and functional performance, as compared to the control group (P<.05). All measures showed no significant differences in outcome between the 2 exercise groups (P>.05). CONCLUSION: This study demonstrates that both weight-bearing and non-weight-bearing quadriceps exercises can significantly improve subjective and clinical outcomes in patients with PFPS.

J Orthop Sports Phys Ther. 2007;37(4):155-160. doi:10.2519/jospt.2007.2433

KEY WORDS: anterior knee pain, chondromalacia, knee, patellofemoral joint

Sensitivity and Specificity of the Blankenship FCE System’s Indicators of Submaximal Effort

Perry N. Brubaker, Frank J. Fearon, Stephen M. Smith, Richard J. McKibben, James Alday, Stacie S. Andrews, Everald Clarke, George L. Shaw, Jr
STUDY DESIGN: Single-blinded, randomized, posttest only design. OBJECTIVE: To help contribute to the body of evidence in defining the validity of functional capacity evaluations. BACKGROUND: Functional capacity evaluations (FCEs) are tests used to help determine an individual's readiness to return to work. Most FCEs incorporate indicators of effort within the evaluation. Published evidence validating the use of these indicators is limited. METHODS AND MEASURES: Forty-nine injured and noninjured individuals 18 to 65 years of age participated in this study. The participants were randomly assigned to 1 of 2 groups: 100% effort or 50% effort. Raters were blinded to participant group. The Blankenship Version 6.0 software was used to analyze the data and a Blankenship FCE validity profile was scored. A score of 70% or greater was deemed a valid FCE as adopted by the Blankenship protocol. RESULTS: The sensitivity of the FCE components tested was demonstrated to be 80% and specificity was 84.2%. The positive likelihood ratio was 5 and the negative likelihood ratio was 0.2. A receiver operating characteristic (ROC) curve demonstrated the 70% cut-off value for scoring the FCE was optimal. CONCLUSION: Four components of the Blankenship FCE system demonstrated good sensitivity and specificity for detecting submaximal effort. However, clinicians should note that false positives (maximum effort identified as submaximal effort) may occur and scores of "equivocal" are not scored in the "criteria passed" category. The rater should be aware that this method of scoring could potentially influence a client's overall FCE score.

J Orthop Sports Phys Ther. 2007;37(4):161-168. doi:10.2519/jospt.2007.2261

KEY WORDS: ergonomics, false positives, functional capacity evaluation, sincerity of effort, work-related injuries

Does the Evidence Support the Existence of Lumbar Spine Coupled Motion? A Critical Review of the Literature

Susan L. Edmond, Owen Legaspi
STUDY DESIGN: Literature review. OBJECTIVES: To synthesize the current literature addressing coupled motion between side bending and rotation in the lumbar spine to determine if a consistent pattern exists across articles. BACKGROUND: Low back pain is one of the most common conditions seen in outpatient physical therapy clinics. This condition is often treated with manual therapy techniques. Many approaches to manual therapy incorporate the concept of coupled motion. METHODS AND MEASURES: Using OVID databases, we reviewed and categorized articles published between 1982 and 2006 that addressed coupled motion between side bending and rotation in the lumbar spine. We identified 24 articles in which 32 analyses addressed our clinical question. RESULTS: Seventeen of the 24 articles identified concluded that some form of coupled motion exists; however, there was little agreement across articles as to the specific characteristics of coupled motion. CONCLUSIONS: The inconsistency in reported patterns of coupled motion suggests that physical therapists should use caution when applying concepts of coupled motion to the evaluation and treatment of patients with low back pain.

J Orthop Sports Phys Ther. 2007;37(4):169-178. doi:10.2519/jospt.2007.2300

KEY WORDS: coupled movements, lumbar biomechanics, lumbar motion

Proximity of Collateral Ligament Origin to the Axis of Rotation of the Proximal Interphalangeal Joint of the Finger

Peter V. Loubert, Thomas J. Masterson, Matthew S. Schroeder, Aaron M. Mazza
STUDY DESIGN: Descriptive anatomical study. OBJECTIVE: To determine the proximity of proximal interphalangeal (PIP) joint collateral ligament origin to the axis of rotation (AOR) of the joint. BACKGROUND: Normal function of the PIP joints of the hands requires competent collateral ligaments. Studies of the collateral ligaments of the PIP joint have led to a hypothesis that the collateral ligaments of the PIP joints originate at the joint AOR. However, no studies have yet provided quantitative evidence to support this assertion. METHODS AND MEASURES: A total of 30 collateral ligament specimens were prepared from the radial and ulnar halves of 16 fingers (digits 2 through 5) from the right hands of 5 formalin-embalmed cadavers. A geometric method was employed to estimate the PIP joint AOR. The proximity of collateral ligament origins to the estimated AOR of the PIP joint was determined. RESULTS: Collateral ligaments were found to have their proximal attachment an average of 0.02 mm distal and 0.24 mm palmar to the PIP joint AOR. For 90% of specimens the center of the collateral ligament origin was within 1.00 mm of the joint AOR. CONCLUSIONS: These results support the hypothesis that PIP joint collateral ligaments originate at the joint AOR. This finding predicts that the linear distance between the attachments should remain constant as the PIP joint moves through its range of motion. The modest changes in PIP collateral ligament length described in other studies can be attributed primarily to travel of the ligament across a small condylar tubercle at approximately 15° to 20° of PIP joint flexion. The practice of immobilizing the PIP joint in 15° to 20° of flexion is supported by these findings.

J Orthop Sports Phys Ther. 2007;37(4):179-185. doi:10.2519/jospt.2007.2476

KEY WORDS: arthrokinematics, hinge mechanics, joint biomechanics, ligament attachment, PIP

Effects of Wearing Foot Orthosis With Medial Arch Support on the Fifth Metatarsal Loading and Ankle Inversion Angle in Selected Basketball Tasks

Michael T. Gross, Bing Yu, Jennifer J. Preston, Robin M. Queen, Ian R. Byram, W. Mack Hardaker, J. Marc Davis, Timothy N. Taft, William E. Garrett
STUDY DESIGN: Preintervention and postintervention, repeated-measures experimental design. OBJECTIVES: The objective was to investigate the effects of foot orthoses with medial arch support on ankle inversion angle and plantar forces and pressures on the fifth metatarsal during landing for a basketball lay-up and during the stance phase of a shuttle run. BACKGROUND: Proximal fractures of the fifth metatarsal, specifically the Jones fracture, are common in sports. Wearing foot orthoses with medial arch support could increase the ankle inversion angle and the plantar forces and pressure on the fifth metatarsal that may increase the risk for fifth metatarsal fracture. METHODS AND MEASURES: Three-dimensional (3-D) videographic, force plate, and in-shoe plantar force and pressure data were collected during landing after a basketball lay-up and during the stance phase of a shuttle run with and without foot orthoses with medial arch support for 14 male subjects. Two-way ANOVAs with repeated measures were performed to compare ankle inversion angle, maximum forces, and pressure on the fifth metatarsal head and base between conditions and between tasks. RESULTS: The maximum ankle inversion angle and maximum plantar force and pressure on the base of the fifth metatarsal during both tasks as well as the maximum plantar force and pressure on the head of the fifth metatarsal during the stance of the shuttle run were significantly increased (P<.026) when wearing foot orthoses. No significant differences were found in the maximum vertical ground reaction forces between foot orthotic conditions. CONCLUSION: Generic use of off-the-shelf foot orthoses with medial arch support causes increased plantar forces and pressures on the fifth metatarsal and may increase the risk for proximal fracture of the fifth metatarsal. Future studies are needed to investigate this risk, acknowledging that the differences noted in our study were small in magnitude and the foot type was not measured.

J Orthop Sports Phys Ther. 2007;37(4):186-191. doi:10.2519/jospt.2007.2327

KEY WORDS: fifth metatarsal fractures, foot orthoses, in-shoe pressure, Jones fracture

Prolonged Immobilization in Abduction and Neutral Rotation for a First-Episode Anterior Shoulder Dislocation

Kathryn L. Nagel, Gail D. Deyle
STUDY DESIGN: Case report. BACKGROUND: Patients who sustain first-episode anterior glenohumeral dislocations are at risk to develop chronic glenohumeral instability. Current treatment options after an initial anterior glenohumeral dislocation include immediate surgery, delayed surgery, or conservative interventions such as immobilization and strengthening exercises. Duration of immobilization is variable among formal studies. Recent research suggests that typical immobilization positions may not allow adequate healing and in fact may promote glenohumeral joint instability. CASE DESCRIPTION: The patient was a 19-year-old male who sustained a first-episode anterior glenohumeral dislocation during athletic activity. Physical therapy management included a longer-than-typical period of immobilization and protected activity to allow for more complete healing. The shoulder abduction and neutral rotation immobilization position used with this patient may increase healing of structures that influence stability of the shoulder. OUTCOMES: At 13 weeks after the dislocation, the patient had full active and passive range of motion, near normal strength, and no complaints of pain or instability. At a 20-month follow-up the patient had resumed full activities of daily living including recreational sports without symptoms of instability. DISCUSSION: Conservative intervention options for first-episode anterior shoulder dislocations need further study. Immobilization and protected activity periods should be adequate to allow for complete healing. The optimal positions for immobilization should be determined and implemented.

J Orthop Sports Phys Ther. 2007:37(4):192-198. doi:10.2519/jospt.2007.2393

KEY WORDS: Bankart lesion, glenohumeral joint, shoulder instability

Reliability and Minimal Detectable Change for the Figure-of-Eight-20 Method of Measurement of Ankle Edema

Manuela Rohner-Spengler, Anne F. Mannion, Reto Babst
STUDY DESIGN: Single-session, repeated-measures design, with 3 raters. OBJECTIVES: To determine the intrarater and interrater reliability and the minimal detectable change score for a modified version of the figure-of-eight method of measurement of ankle edema (figure-of-eight-20) developed for patients with severe injuries. BACKGROUND: The precise quantification of ankle edema is necessary to determine the relative effectiveness of interventions aimed at reducing swelling, and to monitor individual progress during treatment. METHODS AND MEASURES: Thirty subjects (mean ± SD age, 46 ± 16 years; 9 female and 21 male) with ankle edema following surgery for malleolar fracture took part in the study. Each of 3 raters performed 3 measurements of the affected ankle without marking landmarks and 3 measurements of both ankles using skin markings. The order of the raters was randomized and the raters were blinded to each other's results. RESULTS: The figure-of-eight-20 method showed high intrarater and interrater reliability (intraclass correlation coefficients greater than .99). The minimal detectable change (MDC_95%) for the swollen ankle was 9.6 mm when measured without skin marks and 7.3 mm with marks. The difference in circumference of the affected and unaffected ankle (mean ± SD, 33.8 ± 12.1 mm) consistently exceeded the MDC_95%, even in patients with only mild edema. CONCLUSIONS: The standardized figure-of-eight-20 offers a good option for reliably measuring ankle circumference in patients with severe ankle trauma. In repeated assessments, greater accuracy is likely to be obtained when the landmarks for measurement are marked and the same rater carries out the measurements.

J Orthop Sports Phys Ther. 2007;37(4):199-205. doi:10.2519/jospt.2007.2371

KEY WORDS: ankle swelling, circumference measurements, tape measure

Abstracts

A selection of important abstracts of articles published in other journals.

J Orthop Sports Phys Ther. 2007; 37(4):206-213.