J Orthop Sports Phys Ther 2013;43(5):351. doi:10.2519/jospt.2013.0503

KEY WORDS: adhesive capsulitis, clinical practice guidelines

The patient was a 48-year-old man serving in a deployed combat setting, who was referred to a physical therapist for evaluation of progressively worsening left hip and left wrist pain. Due to concern for hip and wrist fractures, the physical therapist ordered radiographs of the left hip and left wrist. The radiographs revealed comminuted fractures of the midneck to distal neck of the left femur and left scaphoid.

J Orthop Sports Phys Ther 2013;43(5):350. doi:10.2519/jospt.2013.0409

KEY WORDS: hip, radiography, wrist

The patient was an 8-year-old girl who was referred to a physical therapist by her pediatrician for a chief complaint of worsening proximal right calf pain and progressive right-sided toe walking for the past 6 weeks. Due to concern that the patient's symptoms were nonmusculoskeletal in nature, the physical therapist discussed the history and physical examination findings with the patient's pediatrician and an orthopaedic surgeon. Subsequent magnetic resonance imaging and percutaneous biopsy led to a diagnosis of a low-flow venolymphatic malformation of the proximal gastrocnemius muscle.

J Orthop Sports Phys Ther 2013;43(5):349. doi:10.2519/jospt.2013.0408

KEY WORDS: calf, magnetic resonance imaging, radiography

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these clinical practice guidelines is to describe the peer-reviewed literature and make recommendations related to adhesive capsulitis.

J Orthop Sports Phys Ther 2013;43(5):A1-A31. doi:10.2519/jospt.2013.0302

KEY WORDS: clinical practice guidelines, frozen shoulder, ICD, ICF, Orthopaedic Section

In this issue of JOSPT, the Orthopaedic Section of the American Physical Therapy Association introduces the first of its shoulder clinical practice guidelines (CPGs), titled "Shoulder Pain and Mobility Deficits: Adhesive Capsulitis." This CPG, as well as the collection of Orthopaedic Section CPGs previously published in JOSPT, use long diagnostic labels to identify the underlying clinical conditions. Author Paula M. Ludewig discusses the merits of using these movement system diagnostic labels rather than shorter pathoanatomic labels, which create a disconnect between diagnostic and treatment processes.

J Orthop Sports Phys Ther 2013;43(5):280-283. doi:10.2519/jospt.2013.0104

KEY WORDS: clinical practice guidelines, diagnostic labels, ICF, Orthopaedic Section

JOSPT offers invited reviews of current titles. The April 2013 column includes 5 reviews of the following books: Diagnosis for Physical Therapists: A Symptom-Based Approach; FIMS Sports Medicine Manual: Event Planning and Emergency Care; Brunnstrom's Clinical Kinesiology: 6th Edition; Atlas of Anatomy: 2nd Edition; and Anatomy & Physiology Revealed.

J Orthop Sports Phys Ther 2013;43(4):276-279. doi:10.2519/jospt.2013.43.4.276

The patient was a 19-year-old woman who recently completed a military basic training program. She was evaluated by a physical therapist in a direct-access capacity for a chief complaint of anterior right hip pain that limited her ability to run. Due to the limited sensitivity of radiographs, magnetic resonance imaging of the right hip was obtained, which revealed a stress fracture of the right distal femoral neck.

J Orthop Sports Phys Ther 2013;43(4):275. doi:10.2519/jospt.2013.0407

KEY WORDS: hip, magnetic resonance imaging, radiography

STUDY DESIGN: Clinical measurement study. OBJECTIVES: To cross-culturally adapt the Anterior Knee Pain Scale (AKPS), the Functional Index Questionnaire (FIQ), and the Pain Severity Scale (PSS) for patellofemoral pain syndrome (PFPS) into Brazilian Portuguese. This study also aimed to test the measurement properties of the AKPS, the FIQ, and the PSS, and the existing Brazilian Portuguese versions of the numeric pain rating scale (NPRS) and the Global Perceived Effect scale in a group with PFPS. BACKGROUND: PFPS is a common condition. Therefore, translated, culturally adapted, and clinimetrically tested instruments for measuring PFPS are needed. METHODS: The AKPS, FIQ, and PSS instruments were cross-culturally adapted into Brazilian Portuguese. The measurement properties of the AKPS, FIQ, PSS, NPRS, and Global Perceived Effect scale (internal consistency, ceiling and floor effects, and construct validity) were tested in 83 patients with PFPS. The reproducibility and responsiveness were tested in 52 patients with PFPS in a test-retest design, with follow-up testing at 48 to 72 hours and at 4 weeks after baseline. RESULTS: The AKPS, the FIQ, and the PSS yielded adequate internal consistency (Cronbach alpha ranging from .75 to .87) and excellent reliability (intraclass correlation coefficients [model 2,1] ranging from 0.90 to 0.97). The AKPS and the PSS yielded very good agreement (standard error of measurement, 2.9% and 3.5%, respectively). The highest correlations were observed among the AKPS, the FIQ, and the PSS (Pearson r>0.60, P<.05). No floor or ceiling effects were observed for any of the instruments. Effect sizes used for measuring internal responsiveness ranged from moderate to high for all measures. The NPRS and the AKPS were the measures with the highest external responsiveness. CONCLUSION: The Brazilian Portuguese versions of the AKPS, FIQ, PSS, NPRS, and Global Perceived Effect scale have acceptable measurement properties.

J Orthop Sports Phys Ther 2013;43(5):332-339. Epub 13 March 2013. doi:10.2519/jospt.2013.4228

KEY WORDS: anterior knee pain syndrome, knee, measurement properties, questionnaires

STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To compare the effects of thrust and nonthrust manipulation and exercises with and without the addition of myofascial therapy for the treatment of acute inversion ankle sprain. BACKGROUND: Studies have reported that thrust and nonthrust manipulations of the ankle joint are effective for the management of patients post–ankle sprain. However, it is not known whether the inclusion of soft tissue myofascial therapy could further improve clinical and functional outcomes. METHODS: Fifty patients (37 men and 13 women; mean ± SD age, 33 ± 10 years) post–acute inversion ankle sprain were randomly assigned to 2 groups: a comparison group that received a thrust and nonthrust manipulation and exercise intervention, and an experimental group that received the same protocol and myofascial therapy. The primary outcomes were ankle pain at rest and functional ability. Additionally, ankle mobility and pressure pain threshold over the ankle were assessed by a clinician who was blinded to the treatment allocation. Outcomes of interest were captured at baseline, immediately after the treatment period, and at a 1-month follow-up. The primary analysis was the group-by-time interaction. RESULTS: The 2-by-3 mixed-model analyses of variance revealed a significant group-by-time interaction for ankle pain (P<.001) and functional score (P = .002), with the patients who received the combination of nonthrust and thrust manipulation and myofascial intervention experiencing a greater improvement in pain and function than those who received the nonthrust and thrust manipulation intervention alone. Significant group-by-time interactions were also observed for ankle mobility (P<.001) and pressure pain thresholds (all, P<.01), with those in the experimental group experiencing greater increases in ankle mobility and pressure pain thresholds. Between-group effect sizes were large (d>0.85) for all outcomes. CONCLUSION: This study provides evidence that, in the treatment of individuals post–inversion ankle sprain, the addition of myofascial therapy to a plan of care consisting of thrust and nonthrust manipulation and exercise may further improve outcomes compared to a plan of care solely consisting of thrust and nonthrust manipulation and exercise. However, though statistically significant, the difference in improvement in the primary outcome between groups was not greater than what would be considered a minimal clinically important difference. Future studies should examine the long-term effects of these interventions in this population. LEVEL OF EVIDENCE: Therapy, level 1b–.

J Orthop Sports Phys Ther 2013;43(5):300-309. Epub 13 March 2013. doi:10.2519/jospt.2013.4467

KEY WORDS: manual therapy, pressure pain threshold, triceps surae

STUDY DESIGN: Case series. OBJECTIVES: To evaluate the feasibility of an active rehabilitation program for patients with knee full-thickness articular cartilage lesions. BACKGROUND: No studies have yet evaluated the effect of active rehabilitation in patients with knee full-thickness articular cartilage lesions or compared the effects of active rehabilitation to those of surgical interventions. As an initial step, the feasibility of such a program needs to be described. METHODS: Forty-eight patients with a knee full-thickness articular cartilage lesion and a Lysholm score below 75 participated in a 3-month active rehabilitation program consisting of cardiovascular training, knee and hip progressive resistance training, and neuromuscular training. Feasibility was determined by monitoring adherence to the program, clinical changes in knee function, load progression, and adverse events. Patients were tested before and after completing the rehabilitation program by using patient-reported outcomes (Knee injury and Osteoarthritis Outcome Score, International Knee Documentation Committee Subjective Knee Evaluation Form 2000) and isokinetic muscle strength and hop tests. To monitor adherence, load progression, and adverse events, patients responded to an online survey and kept training diaries. RESULTS: The average adherence rate to the rehabilitation program was 83%. Four patients (9%) showed adverse events, as they could not perform the exercises due to pain and effusion. Significant and clinically meaningful improvement was found, based on changes on the International Knee Documentation Committee Subjective Knee Evaluation Form 2000, the Knee injury and Osteoarthritis Outcome Score quality of life subscale, isokinetic muscle strength, and hop performance (P<.05), with small to large effect sizes (standardized response mean, 0.3-1.22). CONCLUSION: The combination of a high adherence rate, clinically meaningful changes, and positive load progression and the occurrence of only a few adverse events support the potential usefulness of this program for patients with knee full-thickness cartilage lesions. This study was registered with the public trial registry ClinicalTrials.gov (NCT00885729). LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2013;43(5):310-324. Epub 13 March 2013. doi:10.2519/jospt.2013.4354

KEY WORDS: chondral injury, neuromuscular exercises, strength exercises, tibiofemoral joint

STUDY DESIGN: Case series. OBJECTIVES: To use blood oxygenation level–dependent functional magnetic resonance imaging (fMRI) to determine if supraspinal activation in response to noxious mechanical stimuli varies pre– and post–thrust manipulation to the thoracic spine. BACKGROUND: Recent studies have demonstrated the effectiveness of thoracic thrust manipulation in reducing pain and improving function in some individuals with neck and shoulder pain. However, the mechanisms by which manipulation exerts such effects remain largely unexplained. The use of fMRI in the animal model has revealed a decrease in cortical activity in response to noxious stimuli following manual joint mobilization. Supraspinal mediation contributing to hypoalgesia in humans may be triggered following spinal manipulation. METHODS: Ten healthy volunteers (5 women, 5 men) between the ages of 23 and 48 years (mean, 31.2 years) were recruited. Subjects underwent fMRI scanning while receiving noxious stimuli applied to the cuticle of the index finger at a rate of 1 Hz for periods of 15 seconds, alternating with periods of 15 seconds without stimuli, for a total duration of 5 minutes. Subjects then received a supine thrust manipulation directed to the midthoracic spine and were immediately returned to the scanner for reimaging with a second delivery of noxious stimuli. An 11-point numeric pain rating scale was administered immediately after the application of noxious stimuli, premanipulation and postmanipulation. Blood oxygenation level–dependent fMRI recorded the cerebral hemodynamic response to the painful stimuli premanipulation and postmanipulation. RESULTS: The data indicated a significant reduction in subjects’ perception of pain (P<.01), as well as a reduction in cerebral blood flow as measured by the blood oxygenation level–dependent response following manipulation to areas associated with the pain matrix (P<.05). There was a significant relationship between reduced activation in the insular cortex and decreased subjective pain ratings on the numeric pain rating scale (r = 0.59, P<.05). CONCLUSION: This study provides preliminary evidence that suggests that supraspinal mechanisms may be associated with thoracic thrust manipulation and hypoalgesia. However, because the study lacked a control group, the results do not allow for the discernment of the causative effects of manipulation, which may also be related to changes in levels of subjects’ fear, anxiety, or expectation of successful outcomes with manipulation. Future investigations should strive to elicit more conclusive findings in the form of randomized clinical trials.

J Orthop Sports Phys Ther 2013;43(5):340-348. Epub 13 March 2013. doi:10.2519/jospt.2013.4631

KEY WORDS: fMRI, manipulation, neuroscience, pain

STUDY DESIGN: Within-subject, repeated-measures design. OBJECTIVES: To determine the influence of pelvis position and hip angle on activation of the hip abductors while performing the clam exercise. BACKGROUND: Therapeutic exercises are regularly employed to strengthen the hip abductors to improve lower-limb and pelvis stability. While previous studies primarily have compared the activity of hip abductor muscles between various exercises, few studies have examined the influence of varying the techniques of particular exercises on the relative activation of hip abductor muscles. Such information could be used to facilitate appropriate exercise instruction. METHODS: Muscle activation in 17 healthy, asymptomatic volunteers during 6 variations of the clam exercise was analyzed with surface electromyography. Electromyographic signals were recorded from the gluteus maximus, gluteus medius, and tensor fasciae latae. Normalized data were examined using 2-way, repeated-measures analyses of variance. RESULTS: The magnitude of gluteus maximus and gluteus medius activation was significantly greater when the pelvis was in neutral rather than reclined. Furthermore, gluteus medius activation was greatest when the hip was flexed to 60°. Activation of the tensor fasciae latae was not influenced by pelvis position or hip angle. CONCLUSION: A neutral pelvis position is advocated to optimize recruitment of the gluteus maximus and gluteus medius during the clam exercise. Increasing the hip flexion angle increases activation of the gluteus medius. Tensor fasciae latae activity was relatively low and generally unaffected by variations of the clam exercise.

J Orthop Sports Phys Ther 2013;43(5):325-331. Epub 13 March 2013. doi:10.2519/jospt.2013.4004

KEY WORDS: clam exercise, EMG, gluteus maximus, gluteus medius, tensor fasciae latae

STUDY DESIGN: Randomized, double-blind, parallel-group clinical trial. OBJECTIVES: To assess differences between a progressive agility and trunk stabilization rehabilitation program and a progressive running and eccentric strengthening rehabilitation program in recovery characteristics following an acute hamstring injury, as measured via physical examination and magnetic resonance imaging (MRI). BACKGROUND: Determining the type of rehabilitation program that most effectively promotes muscle and functional recovery is essential to minimize reinjury risk and to optimize athlete performance. METHODS: Individuals who sustained a recent hamstring strain injury were randomly assigned to 1 of 2 rehabilitation programs: (1) progressive agility and trunk stabilization or (2) progressive running and eccentric strengthening. MRI and physical examinations were conducted before and after completion of rehabilitation. RESULTS: Thirty-one subjects were enrolled, 29 began rehabilitation, and 25 completed rehabilitation. There were few differences in clinical or morphological outcome measures between rehabilitation groups across time, and reinjury rates were low for both rehabilitation groups after return to sport (4 of 29 subjects had reinjuries). Greater craniocaudal length of injury, as measured on MRI before the start of rehabilitation, was positively correlated with longer return-to-sport time. At the time of return to sport, although all subjects showed a near-complete resolution of pain and return of muscle strength, no subject showed complete resolution of injury as assessed on MRI. CONCLUSION: The 2 rehabilitation programs employed in this study yielded similar results with respect to hamstring muscle recovery and function at the time of return to sport. Evidence of continuing muscular healing is present after completion of rehabilitation, despite the appearance of normal physical strength and function on clinical examination. LEVEL OF EVIDENCE: Therapy, level 1b–.

J Orthop Sports Phys Ther 2013;43(5):284-299. Epub 13 March 2013. doi:10.2519/jospt.2013.4452

KEY WORDS: MRI, muscle, return-to-sport criteria

STUDY DESIGN: Prospective cohort study. OBJECTIVE: To evaluate the internal consistency, concurrent construct validity, longitudinal validity, sensitivity to change, and factor structure of the Patient-Rated Elbow Evaluation form (PREE), the patient-reported form of the American Shoulder and Elbow Surgeons Elbow Questionnaire (pASES-e), and the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) in a diverse group of patients who had surgery for various elbow pathologies. BACKGROUND: Measuring functional outcomes after surgical procedures of the elbow requires valid patient-reported pain and disability questionnaires. The PREE, the pASES-e, and the DASH are commonly used questionnaires. There is, however, insufficient evidence available concerning their validity and sensitivity to change. METHODS: Data were prospectively collected from 128 patients (mean ± SD age, 46.5 ± 12.8 years) post–elbow surgery. Patients completed the PREE, the pASES-e, the DASH, and the Medical Outcomes Study 36-Item Short-Form Health Survey at baseline (first visit after surgery) and 6 months postsurgery. Concurrent construct validity, longitudinal validity, sensitivity to change, and factor structure were analyzed. RESULTS: Concurrent construct validity was demonstrated by confirmation of expected relationships; the strongest correlations were observed between the PREE pain score, the PREE total score, the pASES-e pain score, and the DASH score (r = 0.73-0.87). The pASES-e function score correlated the least with other constructs. Longitudinal validity demonstrated similar findings: the pASES-e pain change score and PREE change score were most strongly correlated, and the pASES-e function change score and DASH change score were moderately to weakly correlated. All 3 patient-reported questionnaires demonstrated a large effect size and standardized response means greater than 1.0. Structural validity was supported for the PREE (R² = 77.2%, 4 factors) and the pASES-e (R² = 74.4%, 4 factors), but not for the DASH (R² = 71.3%, 5 factors). CONCLUSION: The PREE, the pASES-e, and the DASH have acceptable validity and sensitivity to change. The pASES-e function subscale is the least sensitive to change and is less correlated to other measures.

J Orthop Sports Phys Ther 2013;43(4):263-274. Epub 13 March 2013. doi:10.2519/jospt.2013.4029

KEY WORDS: DASH, elbow questionnaires, outcome measures, pASES-e, PREE, quality of life, SF-36

STUDY DESIGN: Double-blind, randomized controlled trial. OBJECTIVE: To examine the effectiveness of a manual therapy and exercise approach relative to a placebo intervention in individuals with carpometacarpal (CMC) joint osteoarthritis (OA). BACKGROUND: Recent studies have reported the outcomes of exercise, joint mobilization, and neural mobilization interventions used in isolation in patients with CMC joint OA. However, it is not known if using a combination of these interventions as a multimodal approach to treatment would further improve outcomes in this patient population. METHODS: Sixty patients, 90% female (mean ± SD age, 82 ± 6 years), with CMC joint OA were randomly assigned to receive a multimodal manual treatment approach that included joint mobilization, neural mobilization, and exercise, or a sham intervention, for 12 sessions over 4 weeks. The primary outcome measure was pain. Secondary outcome measures included pressure pain threshold over the first CMC joint, scaphoid, and hamate, as well as pinch and strength measurements. All outcome measures were collected at baseline, immediately following the intervention, and at 1 and 2 months following the end of the intervention. Mixed-model analyses of variance were used to examine the effects of the interventions on each outcome, with group as the between-subject variable and time as the within-subject variable. RESULTS: The mixed-model analysis of variance revealed a group-by-time interaction (F = 47.58, P<.001) for pain intensity, with the patients receiving the multimodal intervention experiencing a greater reduction in pain compared to those receiving the placebo intervention at the end of the intervention, as well as at 1 and 2 months after the intervention (P<.001; all group differences greater than 3.0 cm, which is greater than the minimal clinically important difference of 2.0 cm). A significant group-by-time interaction (F = 3.19, P = .025) was found for pressure pain threshold over the hamate bone immediately after the intervention; however, the interaction was no longer significant at 1 and 2 months postintervention. CONCLUSION: This clinical trial provides evidence that a combination of joint mobilization, neural mobilization, and exercise is more beneficial in treating pain than a sham intervention in patients with CMC joint OA. However, the treatment approach has limited value in improving pressure pain thresholds, as well as pinch and grip strength. Future studies should include several therapists, a measure of function, and long-term outcomes. Trial registration: Current Controlled Trials ISRCTN37143779. LEVEL OF EVIDENCE: Therapy, level 1b.

J Orthop Sports Phys Ther 2013;43(4):204-213. Epub 13 March 2013. doi:10.2519/jospt.2013.4524

KEY WORDS: arthritis, CMC, joint mobilization, neural mobilization

STUDY DESIGN: Reliability study. OBJECTIVES: To determine the feasibility and reliability of using transcranial magnetic stimulation (TMS) to assess corticomotor excitability (CE) of the gluteus maximus. BACKGROUND: Sport-specific skill training targeting greater utilization of the gluteus maximus has been proposed as a method to reduce the incidence of noncontact knee injuries. The use of TMS to assess changes in CE may help to determine training-induced central mechanisms associated with gluteus maximus activation. METHODS: Within- and between-day reliability was measured in 10 healthy adults. The CE was measured by stimulating the gluteus maximus ìhotspotî at 120% and 150% of motor threshold, while subjects performed a double-leg bridge. An intraclass correlation coefficient (model 2,1), standard error of measurement, and minimal detectable change were calculated to determine the within- and between-day reliability for the following TMS variables: peak-to-peak motor-evoked potential (MEP) amplitudes, cortical silent period, and MEP latency. RESULTS: It is feasible to measure the CE of the gluteus maximus with TMS. The intraclass correlation coefficients for all TMS outcome measures ranged from 0.73 to 0.97. The ranges of minimal detectable change, with respect to mean values for each TMS variable, were larger for MEP amplitude (304.7-585.4 µV) compared to those for cortical silent period duration (25.3-40.8 milliseconds) and MEP latency (1.1-2.1 milliseconds). CONCLUSION: The present study demonstrated a feasible method for using TMS to measure CE of the gluteus maximus. Small minimal detectable change values for the cortical silent period and MEP latency provide a reference for future studies.

J Orthop Sports Phys Ther 2013;43(4):214-221. Epub 13 March 2013. doi:10.2519/jospt.2013.4188

KEY WORDS: corticomotor excitability, reliability, transcranial magnetic stimulation

KEY WORDS: collaboration, JBJS, orthopaedic surgeons, patient outcomes, physical therapists

We hope you enjoy reading this Special Report and would appreciate your feedback about it. Please take a few moments to access an online survey at https://www.surveymonkey.com/s/ITTAKESATEAMJOSPT

J Orthop Sports Phys Ther 2013;43(3):197-198.

The Fifth International Ankle Symposium (IAS5), a multidisciplinary conference focused predominantly on ankle injury evaluation, rehabilitation, and prevention, was held in Lexington, KY in October 2012. IAS5 brought together over 90 clinicians and scientists from disciplines such as athletic training, physical therapy, sports medicine, orthopaedics, and biomechanics. In this supplement, you will find a summary statement, keynote addresses from invited lectures and workshops, a program schedule, and the abstracts of the original research, both podium and poster presentations, from IAS5.

J Orthop Sports Phys Ther 2013;43(3):A1-A27. doi:10.2519/jospt.2013.0301

KEY WORDS: ankle injury, IAS5

Rodeghero JR, Denninger TR, Ross MD. Abdominal Pain in Physical Therapy Practice: 3 Patient Cases. J Orthop Sports Phys Ther 2013;43(2):44-53. Epub 14 January 2013. doi:10.2519/jospt.2013.4408

J Orthop Sports Phys Ther 2013;43(3):196.

The patient was a 17-year-old adolescent male who was referred to a physical therapist for a chief complaint of anterior right hip pain. The physical therapist reviewed the patient's radiographs, which had been completed and interpreted as normal prior to referral, and determined that there were radiographic signs present that may be concerning for an avulsion fracture. Further evaluation through magnetic resonance imaging confirmed the presence of an avulsion fracture at the right anterior superior iliac spine.

J Orthop Sports Phys Ther 2013;43(3):195. doi:10.2519/jospt.2013.0406

KEY WORDS: hip, magnetic resonance imaging, radiography, running

The patient was a 15-year-old adolescent male who was referred to a physical therapist for a chief complaint of worsening right medial foot pain. Given the worsening nature of the patient’s right medial foot pain, palpatory findings, and a prior recommendation for computed tomography from a radiologist, the patient was referred to his physician. Subsequent computed tomography imaging of the right foot revealed a nondisplaced fracture through the dorsal-medial aspect of the navicular.

J Orthop Sports Phys Ther 2013;43(3):194. doi:10.2519/jospt.2013.0405

KEY WORDS: computed tomography, magnetic resonance imaging, navicular

J Orthop Sports Phys Ther 2013;43(3):128. doi:10.2519/jospt.2013.0502

KEY WORDS: cervical spine, manipulation, manipulative therapy, mechanical neck pain, mobilization, thoracic spine

Published jointly by JOSPT and The Journal of Bone & Joint Surgery (JBJS), “It Takes a Team: Working Together Works for Patients” is a first-of-its-kind publication that describes how collaboration among orthopaedic surgeons, physical therapists, and other healthcare clinicians working in a variety of clinical settings has improved patient outcomes. This Special Report is available as a free download from JOSPT's website at the following link: It Takes a Team: Working Together Works for Patients

J Orthop Sports Phys Ther 2013;43(3):117. doi:10.2519/jospt.2013.0103

KEY WORDS: collaboration, JBJS, orthopaedic surgeons, patient outcomes, physical therapists

We hope you enjoy reading this Special Report and would appreciate your feedback about it. Please take a few moments to access an online survey at https://www.surveymonkey.com/s/ITTAKESATEAMJOSPT

During the American Physical Therapy Association’s Combined Sections Meeting in San Diego in January 2013, JOSPT recognized the authors of the most outstanding research and clinical practice manuscripts published in JOSPT during the 2012 calendar year. The 2012 JOSPT Excellence in Research Award was presented to Ivan Mulligan, Mark Boland, and Justin Payette for their paper titled “Prevalence of Neurocognitive and Balance Deficits in Collegiate Football Players Without Clinically Diagnosed Concussion.” The 2012 George J. Davies–James A. Gould Excellence in Clinical Inquiry Award was presented to Richard B. Souza, Thomas Baum, Samuel Wu, Brian T. Feeley,  Nancy Kadel, Xiaojuan Li, Thomas M. Link, and Sharmila Majumdar for their work titled “Effects of Unloading on Knee Articular Cartilage T1rho and T2 Magnetic Resonance Imaging Relaxation Times: A Case Series.”

J Orthop Sports Phys Ther 2013;43(3):115-116. doi: 10.2519/jospt.2013.0102

KEY WORDS: JOSPT awards

STUDY DESIGN: Case report. BACKGROUND: Traumatic glenohumeral dislocations with concomitant rotator cuff and capsular injuries present a unique and challenging surgical and rehabilitative condition, particularly in the overhead-throwing athlete. Multiple injuries of the shoulder complex create the potential for complications in the course of recovery and place a full return to high-level sport at risk. The purpose of this case report is to present the multiphased rehabilitation approach of an elite professional quarterback after an acute 330° capsulolabral reconstruction and rotator cuff repair as a result of a luxatio erecta injury. CASE DESCRIPTION: A 26-year-old male professional football player, a quarterback, sustained a right luxatio erecta shoulder dislocation while trying to recover a fumble during a regular-season game. The injury occurred when he was hit in the back of his throwing shoulder, which was in an abducted and externally rotated position, while lying on the ground. Five days postinjury, he underwent a 330° capsulolabral repair, with concomitant rotator cuff repair and subacromial decompression. He completed 28 weeks of a multiphased rehabilitation program. OUTCOMES: The patient returned to play in the National Football League (NFL) 8 months later, for the start of the next season, during which he had his most productive year as a professional quarterback, leading the league in passing yards and finishing third in the league for the number of touchdowns. Since the injury, the patient has played 6 consecutive seasons, starting over 96 consecutive, regular-season games and maintaining a very high level of play. DISCUSSION: This case report highlights the clinical decision-making process and management of this rare, severe injury. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2013;43(3):142-153. Epub 12 February 2013. doi:10.2519/jospt.2013.3726

KEY WORDS: dislocation, luxatio erecta, shoulder, SLAP

SYNOPSIS: Ice hockey goaltenders, especially those who employ the butterfly technique, are a specialized population of athletes because of the unique physical demands that the position places on their lower extremities, specifically at the hip. It is no surprise that hip injuries are a common occurrence among goalies. A review of the biomechanical literature has demonstrated that stresses on the hip while in flexion and end-range internal rotation, the position goaltenders commonly use, put the hip at risk for injury and are likely a major contributing factor to overuse hip injuries. The stress on a goaltender’s hip can potentially be further intensified by the presence of bony deformities, such as cam- or pincer-type femoroacetabular impingement, which can lead to chondrolabral junction and articular cartilage injuries. There have been few published reports of goaltenders’ functional outcomes following femoroacetabular impingement surgery, and, to our knowledge, no studies have yet identified the specific challenges presented in the rehabilitation of goaltenders following femoroacetabular impingement surgery. The present clinical commentary describes a 6-phase return-to-skating program developed as part of a rehabilitation protocol to aid hockey goaltenders recovering from surgery. LEVEL OF EVIDENCE: Therapy, level 5.

J Orthop Sports Phys Ther 2013;43(3):129-141. Epub 12 February 2013. doi:10.2519/jospt.2013.4430

KEY WORDS: butterfly position, FAI, impingement, injury, return to play, skating

The patient was an 11-year-old boy who was referred to a physical therapist for a chief complaint of left anterior/lateral hip pain. Prior to referral to the physical therapist, radiographs were completed and interpreted as normal. Initially, his hip pain did not limit his participation in athletic activities; however, following a prescription of an exercise program, the patient reported worsening left hip pain that caused an inability to participate in lacrosse, as well as 2 episodes of severe night pain. The patient was immediately referred to his physician, where magnetic resonance imaging revealed signs most concerning for an infectious process/osteomyelitis in the region of the proximal femur and greater trochanter.

J Orthop Sports Phys Ther 2013;43(2):106. doi:10.2519/jospt.2013.0404

KEY WORDS: magnetic resonance imaging, osteomyelitis, radiography

The patient was a 30-year-old man who was referred to a physical therapist for a chief complaint of a painful, swollen left lower leg that had caused difficulty with walking in the previous 3 weeks. Prior to physical therapist referral, the patient’s primary care provider ordered radiographs of the left ankle, which were interpreted as normal. Due to history and physical examination findings that were concerning for an Achilles tendon rupture, the physical therapist immediately referred the patient to an orthopaedic surgeon. Magnetic resonance imaging confirmed the presence of a complete rupture of the Achilles tendon.

J Orthop Sports Phys Ther 2013;43(2):105. doi:10.2519/jospt.2013.0403

KEY WORDS: ankle, lower leg, magnetic resonance imaging, radiography

J Orthop Sports Phys Ther 2013;43(2):65. doi:10.2519/jospt.2013.0501

KEY WORDS: buttock muscles, gluteus maximus, gluteus medius, tensor fascia lata

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVE: To update a previous review and meta-analysis on risk factors for persistent problems following whiplash secondary to a motor vehicle accident. BACKGROUND: Prognosis in whiplash-associated disorder (WAD) has become an active area of research, perhaps owing to the difficulty of treating chronic problems. A previously published review and meta-analysis of prognostic factors included primary sources up to May 2007. Since that time, more research has become available, and an update to that original review is warranted. METHODS: A systematic search of international databases was conducted, with rigorous inclusion criteria focusing on studies published between May 2007 and May 2012. Articles were scored, and data were extracted and pooled to estimate the odds ratio for any factor that had at least 3 independent data points in the literature. RESULTS: Four new cohorts (n = 1121) were identified. In combination with findings of a previous review, 12 variables were found to be significant predictors of poor outcome following whiplash, 9 of which were new (n = 2) or revised (n = 7) as a result of additional data. The significant variables included high baseline pain intensity (greater than 5.5/10), report of headache at inception, less than postsecondary education, no seatbelt in use during the accident, report of low back pain at inception, high Neck Disability Index score (greater than 14.5/50), preinjury neck pain, report of neck pain at inception (regardless of intensity), high catastrophizing, female sex, WAD grade 2 or 3, and WAD grade 3 alone. Those variables robust to publication bias included high pain intensity, female sex, report of headache at inception, less than postsecondary education, high Neck Disability Index score, and WAD grade 2 or 3. Three existing variables (preaccident history of headache, rear-end collision, older age) and 1 additional novel variable (collision severity) were refined or added in this updated review but showed no significant predictive value. CONCLUSION: This review identified 2 additional prognostic factors and refined the estimates of 7 previously identified factors, bringing the total number of significant predictors across the 2 reviews to 12. These factors can be easily identified in a clinical setting to provide estimates of prognosis following whiplash. LEVEL OF EVIDENCE: Prognosis, level 1a.

J Orthop Sports Phys Ther 2013;43(2):31-43. Epub 14 January 2013. doi:10.2519/jospt.2013.4507

KEY WORDS: cervical spine, neck, prognosis, WAD

STUDY DESIGN: Within-subject and between-subject cross-sectional study. OBJECTIVES: To investigate symmetry in hop-test performance, strength, and lower extremity kinematics 6 to 9 months following anterior cruciate ligament reconstruction (ACLR). BACKGROUND: Despite the extensive body of literature involving persons following ACLR, no study has comprehensively evaluated measures of strength, lower extremity kinematics, and functional performance of functional hop tests in this population. METHODS: The subjects were 22 men (mean ± SD age, 28.8 ± 11.2 years) who had ACLR using a bone-patellar tendon-bone autograft 6 to 9 (7.01 ± 0.93) months previously and 22 healthy male controls (age, 24.8 ± 9.1 years). Participants completed a self-report questionnaire and underwent isokinetic strength testing and functional and kinematic assessment of the single-, triple-, and crossover-hop tests. Two-way analyses of variance were used to test for differences between the ACLR group and the control group, and between the 2 lower extremities of the ACLR group. RESULTS: Compared to the control group, the ACLR group had greater isokinetic knee extension torque deficits at all speeds (P≤.001) and greater performance asymmetry for all 3 hop tests (P<.001). Compared to the noninvolved lower extremity, the involved lower extremity of the ACLR group exhibited less ankle dorsiflexion and knee flexion in the phases of propulsion (P≤.014) and landing (P≤.032). When compared to the control group, the involved lower extremity exhibited less ankle dorsiflexion in the propulsion phase (P<.001) but higher hip flexion in the landing phase (P = .014). CONCLUSION: Six to 9 months following ACLR, patients continue to demonstrate functional hop and isokinetic knee extension deficits, as well as kinematic differences, during the propulsion and landing phases of the hop tests.

J Orthop Sports Phys Ther 2013;43(3):154-162. Epub 14 January 2013. doi:10.2519/jospt.2013.3967

KEY WORDS: anterior cruciate ligament reconstruction, hop tests, isokinetics, kinematics, knee

STUDY DESIGN: Resident’s case problem. BACKGROUND: Abdominal pain is a common symptom, but not a common diagnosis, of patients referred to physical therapists for examination and intervention. For patients with primary symptoms of abdominal pain, a thorough evaluation must be performed to determine if symptoms are musculoskeletal in nature or of a nonmusculoskeletal origin that would warrant a referral to a different healthcare provider. This report describes the management of 3 adults with primary complaints of abdominal pain who were referred for physical therapy evaluation and treatment. DIAGNOSIS: Two of the patients had secondary symptoms of hip and/or low back pain and had previously undergone extensive medical testing for their chronic abdominal pain, without a definitive diagnosis having been determined. A physical therapy evaluation was conducted, and treatment, including manual physical therapy and exercise, was administered to address all relative impairments, once the physical therapist had determined that the patients’ symptoms were of musculoskeletal origin. The third patient included in this series was referred to a physical therapist with a diagnosis of greater trochanteric versus iliopsoas bursitis. However, the patient had abdominal pain that was more acute in nature and a history and physical examination findings that were concerning for abdominal pain of nonmusculoskeletal origin. Both patients with abdominal pain of musculoskeletal origin showed marked improvement in pain and disability after 7 treatment sessions. The third patient was referred to her primary care physician, and ultrasound examination of the abdomen revealed several intrauterine masses that were consistent with uterine fibroids. Following uterine fibroid embolization, the patient was symptom free. DISCUSSION: Although not routinely managed by physical therapists, abdominal pain is a relatively common patient symptom that can have several causes, both musculoskeletal and nonmusculoskeletal. This paper emphasizes the importance of physical therapists having the necessary differential diagnostic skills to determine if patients with primary symptoms of abdominal pain require physician referral or physical therapist intervention. LEVEL OF EVIDENCE: Differential diagnosis, level 4.

J Orthop Sports Phys Ther 2013;43(2):44-53. Epub 14 January 2013. doi:10.2519/jospt.2013.4408

KEY WORDS: abdominal examination, differential diagnosis, hip, low back pain, manual physical therapy

References in the text and in the reference section were amended in the March 2013 Erratum, and the article PDF with the Erratum page included is provided here. Please see: March 2013 Erratum

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To evaluate falls among elective orthopaedic inpatients at a musculoskeletal hospital. BACKGROUND: Falls are the most commonly reported hospital incidents. Approximately 30% of in-hospital falls result in minor injury, and up to 8% of falls result in moderate to severe injury. Given the projected rise in elective orthopaedic procedures, it is important to better understand fall patterns in this population. METHODS: A retrospective review of electronic medical records and patient charts (2000-2009) was conducted to identify falls in patients admitted for elective orthopaedic procedures. RESULTS: There were 868 falls among orthopaedic patients older than 18 years. The fall rate was 0.9% of admissions, or 2.0 falls per 1000 inpatient days. The average age of the patients who had fallen was 68 years, and 57.6% were women. Knee replacements (38.2%), spine procedures (18.5%), and hip replacements (14.7%) were the procedures most commonly associated with falls. Three hundred eighty-six falls (45.8%) involved bathroom usage. One hundred ten first falls (13.1%) resulted in injuries. Twenty-eight falls (3.3%) resulted in serious events, including 5 returns to the operating room, 3 transfers to a higher level of care, 14 prosthesis dislocations, 6 fractures, 2 intracranial bleeds, and 1 hemorrhage. Patients with serious injuries were more likely to fall earlier (mean postoperative days, 2.7 versus 4.1; mean difference, 1.4 days; 95% confidence interval: 0.51, 2.3; P = .003) and to have had hip replacement (odds ratio = 3.7; 95% confidence interval: 1.7, 8.2). Serious injuries were not associated with body mass index, age, gender, hospital location, day, or fall history. CONCLUSION: Falls are avoidable events that are poorly described among orthopaedic patients having elective procedures. This large series identifies hip replacement patients as being at almost 4-fold risk of having a serious adverse event after falling. Larger prospective trials are needed to confirm results and to inform prevention strategies.

J Orthop Sports Phys Ther 2013;43(2):91-96. Epub 14 January 2013. doi:10.2519/jospt.2013.4349

KEY WORDS: adverse event, fear-avoidance, hip replacement, injury, inpatient care, postoperative risk

STUDY DESIGN: Systematic literature review. OBJECTIVE: To evaluate the quality of systematic reviews (SRs) on specific stabilization exercises for chronic low back pain (LBP). BACKGROUND: Multiple SRs regarding the effectiveness of lumbar stabilization exercises for people with chronic LBP have been published. As more SRs are published, the more it is recognized that, like other forms of research, methodological quality affects the validity of, and conclusions drawn from, the data. METHODS: A search of MEDLINE, CINAHL, and Embase was completed. Additionally, the PEDro database was screened and hand searching was completed. Included SRs had to contain randomized controlled trials examining a specific stabilization exercise program for the treatment of chronic LBP. Additionally, the assessed outcome measures had to include pain and/or disability measures. Literature reviews and clinical practice guidelines were excluded. Three reviewers independently assessed each SR for methodological quality. RESULTS: The search produced 665 SRs for review, of which 8 fulfilled the inclusion criteria. Consensus quality assessment scores ranged from 13/26 to 26/26, with an average of 20.7 points. Percent agreement and kappa values for individual criteria scores ranged from 50% to 92% and 0.25 to 0.85, respectively. Agreement was moderate to substantial across individual items, except for criterion 1. The intraclass correlation coefficient for overall score was 0.98 (95% confidence interval: 0.96, 0.99). CONCLUSION: This review of SRs identified several high-quality reviews that indicated some benefit of specific stabilization exercise programs for patients with nonspecific chronic LBP. LEVEL OF EVIDENCE: Therapy, level 1a.

J Orthop Sports Phys Ther 2013;43(4):242-250. Epub 14 January 2013. doi:10.2519/jospt.2013.4346

KEY WORDS: chronic low back pain, spinal stabilization exercise, systematic review

STUDY DESIGN: Systematic literature review. BACKGROUND: The diagnosis of a hamstring injury has traditionally relied on various clinical measures (eg, palpation, swelling, manual resistance), as well as the use of diagnostic imaging. But a few studies have suggested the use of specific clinical tests that may be helpful for the diagnostic process. OBJECTIVE: To summarize the current literature on the diagnostic accuracy of orthopaedic special tests for hamstring injuries and to determine their clinical utility. METHODS: A computer-assisted literature search of the MEDLINE, CINAHL, and Embase databases (along with a manual search of grey literature) was conducted using key words related to diagnostic accuracy of hamstring injuries. To be considered for inclusion in the review, the study required (1) patients with hamstring or posterior thigh pain; (2) a cohort, case-control, or cross-sectional design; (3) inclusion of at least 1 clinical examination test used to evaluate hamstring pathology; (4) comparison against an acceptable reference standard; (5) reporting of diagnostic accuracy of the measures (sensitivity [SN], specificity [SP], or likelihood ratios); and (6) publication in English. SN, SP, and positive and negative likelihood ratios were calculated for each diagnostic test. RESULTS: The search strategy identified 602 potential articles, of which only 3 articles met the inclusion criteria, with only 1 of these 3 articles being of high quality. Two of the studies investigated a single special test, whereas the third article examined a composite clinical assessment employing various special tests. The SN values ranged from 0.55 (95% confidence interval [CI]: 0.46, 0.69) for the active range-of-motion test to 1.00 (95% CI: 0.97, 1.00) for the taking-off-the-shoe test. The SP values ranged from 0.03 (95% CI: 0.00, 0.22) for the composite clinical assessment to 1.00 (95% CI: 0.97, 1.00) for the taking-off-the-shoe test, active range-of-motion test, passive range-of-motion test, and resisted range-of-motion test. The use of a single special test demonstrated stronger SP than SN properties, whereas the composite clinical assessment demonstrated stronger SN than SP properties. CONCLUSION: Very few studies have investigated the utilization of clinical special tests for the diagnosis of hamstring injuries. Further studies of higher quality design are suggested prior to advocating independent clinical utilization of these special tests. LEVEL OF EVIDENCE: Diagnosis, level 3b.

J Orthop Sports Phys Ther 2013;43(4):222-231. Epub 14 January 2013. doi:10.2519/jospt.2013.4343

KEY WORDS: diagnosis, sensitivity, specificity, strain

STUDY DESIGN: Interrater reliability. OBJECTIVES: (1) To examine the interrater reliability of an existing clinical prediction rule (CPR) to predict the success of lumbar stabilization exercises (LSE), and (2) to examine the interrater reliability of 4 clinical tests that may be useful in determining the need for LSE. BACKGROUND: Physical therapists commonly use LSE to manage patients with low back pain. The clinical efficacy of LSE is unclear. A CPR has been previously suggested to identify patients most likely to benefit from LSE. The passive lumbar extension test, lumbar extension load test, active straight leg raise test, and active hip abduction test are 4 clinical tests that may also suggest the need for LSE. The reliability of these tests has not been established sufficiently. METHODS: Thirty patients with low back pain, who participated in a larger randomized clinical trial, underwent all tests by 2 independent examiners. Kappa coefficients with 95% confidence intervals (CIs) were calculated to establish the interrater reliability of the CPR and individual tests. RESULTS: The interrater reliability of the CPR was excellent (κ = 0.86; 95% CI: 0.65, 1.00). The interrater reliability of the individual items making up the CPR, as well as that of the passive lumbar extension test, was substantial (κ = 0.64-0.73 and κ = 0.76, respectively; 95% CI: 0.46, 1.00). The interrater reliability of the active straight leg raise test (κ = 0.53; 95% CI: 0.20, 0.84) and lumbar extension load test (κ = 0.47; 95% CI: 0.14, 0.78) was moderate. The interrater reliability of the active hip abduction test was poor (κ = –0.09; 95% CI; –0.35, 0.27). CONCLUSION: With the exception of the active hip abduction test, all other clinical tests can be considered sufficiently reliable for clinical use. The relatively small sample size likely contributed to the fairly wide confidence intervals around some of the reliability indices.

J Orthop Sports Phys Ther 2013;43(2):83-90. Epub 14 January 2013. doi:10.2519/jospt.2013.4310

KEY WORDS: clinical prediction rule, low back pain, lumbar segmental instability

STUDY DESIGN: Clinical measurement. OBJECTIVES: To translate, adapt, and test the measurement properties of the Brazilian Portuguese version of the Victorian Institute of Sport Assessment-Patella (VISA-P) questionnaire. BACKGROUND: It is important to objectively measure symptoms and functional limitations related to patellar tendinopathy using outcome measures that have been validated in the language of the target population. Cross-cultural adaptations are also useful to enhance the understanding of the measurement properties of an assessment tool, regardless of the target language. METHODS: The VISA-P questionnaire was translated into Brazilian Portuguese, culturally adapted, and titled VISA-P Brazil. It was then administered on 2 occasions with a 24- to 48-hour interval between them, and a third time after a month of physical therapy treatment. The following measurement properties were analyzed: internal consistency, test-retest reliability, agreement, construct validity, floor and ceiling effects, and responsiveness. RESULTS: The VISA-P Brazil had high internal consistency (Cronbach α = .76; if item deleted, Cronbach α = .69-.78), excellent reliability and agreement (intraclass correlation coefficient = 0.91; 95% confidence interval: 0.85, 0.95; standard error of measurement, 5.2 points; minimal detectable change at the 90% confidence level, 12.2 points), and good construct validity (Pearson r = 0.60 compared to Lysholm). No ceiling and floor effects were detected for the VISA-P Brazil, and the responsiveness, based on 32 patients receiving physical therapy intervention for 1 month, demonstrated a large effect size of 0.97 (95% confidence interval: 0.68, 1.25). CONCLUSION: The VISA-P Brazil is a reproducible and responsive tool and can be used in clinical practice and research to assess the severity of pain and disability of patients with patellar tendinopathy.

J Orthop Sports Phys Ther 2013;43(3):163-171. Epub 14 January 2013. doi:10.2519/jospt.2013.4287

KEY WORDS: Brazil, knee, patellar tendinopathy, questionnaire, tendinopathy

STUDY DESIGN: Block-counterbalanced, repeated-measures crossover study. OBJECTIVES: To assess scapular upward rotation positional adaptations to experimentally induced subacromial pain. BACKGROUND: Existing subacromial pathology is often related to altered scapular kinematics during humeral elevation, such as decreased upward rotation and posterior tilting. These changes have the potential to limit subacromial space and mechanically impinge subacromial structures. Yet, it is unknown whether these changes are the cause or result of injury and what the acute effects of subacromial pain on scapular upward rotation may be. METHODS: Subacromial pain was induced via hypertonic saline injection in 20 participants, aged 18 to 31 years. Scapular upward rotation was measured with a digital inclinometer at rest and at 30°, 60°, 90°, and 120° of humeral elevation during a painful condition and a pain-free condition. Repeated-measures analyses of variance were conducted for scapular upward rotation position, based on condition (pain or control) and humeral position. Post hoc testing was conducted with paired t tests as appropriate. RESULTS: Scapular upward rotation during the pain condition was significantly increased (range of average increase, 3.5°-7.7°) compared to the control condition at all angles of humeral elevation tested. CONCLUSION: Acute subacromial pain elicited an increase in scapular upward rotation at all angles of humeral elevation tested. This adaptation to acute experimental pain may provide protective compensation to subacromial structures during humeral elevation.

J Orthop Sports Phys Ther 2013;43(4):199-203. Epub 14 January 2013. doi:10.2519/jospt.2013.4276

KEY WORDS: experimental shoulder pain, impingement syndrome, rotator cuff

STUDY DESIGN: Workplace-simulation study using a crossover design. OBJECTIVES: To evaluate the effect of lift teams on trunk and upper extremity kinematics and muscle activity among bricklayers. BACKGROUND: Healthcare practitioners often instruct individuals with work-related musculoskeletal disorders in proper lifting techniques. Bricklayers are especially affected by lifting-related musculoskeletal disorders. Lift teams are a possible intervention for reducing exposure to heavy lifting. METHODS: Eighteen apprentice bricklayers constructed walls with concrete blocks alone (1 person) and in 2-person lift teams. Peak shoulder and trunk kinematics and normalized mean surface electromyography of the upper trapezius, lumbar paraspinals, and flexor forearm muscles were collected bilaterally. Differences between construction methods and rows 1, 3, and 6 of the wall were calculated with repeated-measures analyses of variance. RESULTS: Working in lift teams required less trunk flexion (P = .008) at row 1 but more sidebending at row 6 (P<.001) than working alone. Dominant-side lumbar paraspinal activity was lower at row 3 (P = .008) among lift-team workers. Lift-team peak shoulder flexion was lower at row 3 (P = .002), whereas abduction was higher at rows 1 (P = .007) and 6 (P<.001). Concomitantly, nondominant upper trapezius activity and flexor forearm activity were significantly higher for lift teams at row 6 (P<.001 and P = .007). Block moment arm was significantly greater for lift teams at all rows (P≤.002). CONCLUSION: Working in lift teams may be a beneficial intervention for reducing trunk flexion and lumbar paraspinal activity when bricklayers work at heights between the knees and waist, but lift teams are not recommended at higher working heights.

J Orthop Sports Phys Ther 2013;43(4):232-241. Epub 14 January 2013. doi:10.2519/jospt.2013.4249

KEY WORDS: biomechanics, electromyography, ergonomics, exposure assessment, intervention effectiveness, lifting

J Orthop Sports Phys Ther 2013;43(1):A126-A143.

KEY WORDS: Combined Sections Meeting, CSM

J Orthop Sports Phys Ther 2013;43(1):A64-A125.

KEY WORDS: Combined Sections Meeting, CSM

J Orthop Sports Phys Ther 2013;43(1):A43-A63.

KEY WORDS: Combined Sections Meeting, CSM

J Orthop Sports Phys Ther 2013;43(1):A16-A42.

KEY WORDS: Combined Sections Meeting, CSM

J Orthop Sports Phys Ther 2013;43(1):A1-A15.

KEY WORDS: Combined Sections Meeting, CSM

The patient was a 23-year-old man, currently serving in a military airborne operations unit. During a jump training exercise, the patient’s right lower extremity became entangled in his parachute equipment upon exiting the aircraft, which caused hyperextension and valgus forces upon his right knee. Due to concern for a fracture, the patient was transported to an emergency department, where conventional radiographs were completed and interpreted by a radiologist as negative for a fracture. Following further physical examination by a physical therapist, magnetic resonance imaging of the right knee was ordered, revealing ruptures of the anterior cruciate ligament and medial collateral ligament.

J Orthop Sports Phys Ther 2013;43(1):30. doi:10.2519/jospt.2013.0402

KEY WORDS: anterior cruciate ligament, magnetic resonance imaging, medial collateral ligament, radiography

The patient was a 15-year-old adolescent male who was referred to a physical therapist for a chief complaint of bilateral posterolateral lower-leg pain, which was worse in the right lower extremity than in the left. Due to findings that were concerning for a stress fracture, the patient was referred to a pediatric sports medicine physician. Subsequent radiographs revealed findings that were concerning for a stress fracture along the medial aspect of the midshaft of the right fibula.

J Orthop Sports Phys Ther 2013;43(1):29. doi:10.2519/jospt.2013.0401

KEY WORDS: lower leg, radiography

For the last several years, the Journal of Orthopaedic & Sports Physical Therapy has made a concerted effort to provide information that fosters evidence-based practice not only in the United States, JOSPT’s home base, but also around the world. We have sought to reach new audiences through partnerships with professional organizations in other countries and to deliver greater value to all our readers through the Journal’s website. In 2013, we will continue to pursue these goals and describe a few of our initiatives briefly in this editor's note.

J Orthop Sports Phys Ther 2013;43(1):1-2. doi:10.2519/jospt.2013.0101

KEY WORDS: international partners, technology, website

STUDY DESIGN: Reliability study. OBJECTIVES: To compare the within- and between-day intrarater reliability of rehabilitative ultrasound imaging (RUSI) using static images (static RUSI) and video clips (video RUSI) to quantify multifidus muscle thickness at rest and while contracted. Secondary objectives were to compare the measurement precision of averaging multiple measures and to estimate reliability in individuals with and without low back pain (LBP). BACKGROUND: Although intrarater reliability of static RUSI in measuring multifidus thickness has been established, using video RUSI may improve reliability estimates, as it allows examiners to select the optimal image from a video clip. Further, multiple measurements and LBP status may affect RUSI reliability estimates. METHODS: Static RUSI and video RUSI were used to quantify multifidus muscle thickness at rest and during contraction and percent thickness change in 27 volunteers (13 without LBP and 14 with LBP). Three static RUSI images and 3 video RUSI video clips were collected in each of 2 sessions 1 to 4 days apart. Reliability and precision were assessed using intraclass correlation coefficients, standard error of measurement, minimal detectable change, bias, and 95% limits of agreement. RESULTS: Using an average of 2 measures yielded optimal measurement precision for static RUSI and video RUSI. Based on the average of 2 measures obtained under the same circumstance, there was no significant difference in the reliability estimates between static RUSI and video RUSI across all testing conditions. Reliability point estimates (intraclass correlation coefficient model 3,2) of multifidus thickness were 0.99 for within-day comparisons and ranged from 0.93 to 0.98 for between-day comparisons. The within- and between-day intraclass correlation coefficients (model 3,2) of percent thickness change ranged from 0.97 to 0.99 and from 0.80 to 0.90, respectively. The exploratory analysis showed no significant difference in the reliability estimates between asymptomatic and LBP participants across most testing conditions. CONCLUSION: Both RUSI methods yielded high reliability estimates for multifidus muscle measurements. Using an average of 2 measures obtained optimal measurement precision. Overall, video RUSI is a reliable surrogate for static RUSI for multifidus muscle measurements and has the additional advantage of requiring shorter data collection time.

J Orthop Sports Phys Ther 2013;43(4):251-262. Epub 7 December 2012. doi:10.2519/jospt.2013.4478

KEY WORDS: low back pain, lumbar multifidus, reproducibility, RUSI, ultrasonography

STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To investigate the short-term effects of thoracic spine thrust manipulation combined with cervical spine nonthrust manipulation (experimental group) versus cervical spine nonthrust manipulation alone (comparison group) in individuals with mechanical neck pain. BACKGROUND: Research has demonstrated improved outcomes with both nonthrust manipulation directed at the cervical spine and thrust manipulation directed at the thoracic spine in patients with neck pain. Previous studies have not determined if thoracic spine thrust manipulation may increase benefits beyond those provided by cervical nonthrust manipulation alone. METHODS: Sixty-four participants with mechanical neck pain were randomized into 1 of 2 groups, an experimental or comparison group. Both groups received 2 treatment sessions of cervical spine nonthrust manipulation and a home exercise program consisting of active range-of-motion exercises, and the experimental group received additional thoracic spine thrust manipulations. Outcome measures were collected at baseline and at a 1-week follow-up, and included the numeric pain rating scale, the Neck Disability Index, and the global rating of change. RESULTS: Participants in the experimental group demonstrated significantly greater improvements (P<.001) on both the numeric pain rating scale and Neck Disability Index at the 1-week follow-up compared to those in the comparison group. In addition, 31 of 33 (94%) participants in the experimental group, compared to 11 of 31 participants (35%) in the comparison group, indicated a global rating of change score of +4 or higher at the 1-week follow-up, with an associated number needed to treat of 2. CONCLUSION: Individuals with neck pain who received a combination of thoracic spine thrust manipulation and cervical spine nonthrust manipulation plus exercise demonstrated better overall short-term outcomes on the numeric pain rating scale, the Neck Disability Index, and the global rating of change. LEVEL OF EVIDENCE: Therapy, level 1b.

J Orthop Sports Phys Ther 2013;43(3):118-127. Epub 7 December 2012. doi:10.2519/jospt.2013.4221

KEY WORDS: manipulative therapy, manual therapy, mobilization