• "Including a Single Study Multiple Times in a Meta-analysis" and Authors' Response
• "Foot Strike Patterns in Runners" and Authors' Response

The patient was a 20-year-old man who was referred to a physical therapist 6 weeks following an inversion sprain of his right ankle. Radiographs were completed and had been interpreted as normal, but due to continued complaints of instability and marked laxity on examination, ankle stress radiographs were ordered. Talar tilt stress radiographs were suggestive of lateral ligamentous insufficiency of the right ankle.

J Orthop Sports Phys Ther 2012;42(2):145. doi:10.2519/jospt.2012.0403

KEY WORDS: ankle stress radiographs, radiography, talar tilt

STUDY DESIGN: Case report. BACKGROUND: Rehabilitation that includes progressive quadriceps strengthening after total knee arthroplasty (TKA) leads to superior outcomes. Though patients with TKA show marked functional improvement after outpatient physical therapy, they continue to adopt movement asymmetries characterized by reduced knee excursion on the operated limb and excessive loading on the contralateral limb. The purpose of this case report was to describe the functional and biomechanical improvements in a patient who, after TKA, participated in a novel physical therapy protocol that included retraining of symmetrical movement patterns. CASE DESCRIPTION: A 57-year-old female with unilateral knee osteoarthritis was evaluated prior to TKA and at 3 and 10 weeks after surgery. Postoperative rehabilitation included progressive quadriceps strengthening and movement retraining that consisted of visual, verbal, and tactile feedback to promote symmetrical weight bearing during strengthening exercises and functional activities. Outcomes were compared to a historical cohort of patients with TKA. OUTCOMES: Prior to TKA, the patient scored below average on all functional measures and walked with knee biomechanics that were abnormal and asymmetrical. After symmetry retraining, her knee motion and moments were restored to normal levels. The patient also walked with greater magnitude and more symmetrical knee excursion compared to a cohort of similar patients. DISCUSSION: This case report describes the use of a novel rehabilitation protocol intended to improve walking biomechanics and functional outcomes after TKA. Restoration of symmetrical movement patterns could improve long-term outcomes of TKA. Further research is needed to evaluate the effectiveness and implementation of similar rehabilitation strategies in a wide range of patients after TKA. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2012;42(2):135-144. doi:10.2519/jospt.2012.3773

KEY WORDS: motion analysis, osteoarthritis, physical therapy, rehabilitation, total knee replacement

STUDY DESIGN: Randomized clinical trial. OBJECTIVES: To determine whether manipulation of the proximal or distal tibiofibular joint would change ankle dorsiflexion range of motion and functional outcomes over a 3-week period in individuals with chronic ankle instability. BACKGROUND: Altered joint arthrokinematics may play a role in chronic ankle instability dysfunction. Joint mobilization or manipulation may offer the ability to restore normal joint arthrokinematics and improve function. METHODS: Forty-three participants (mean ± SD age, 25.6 ± 7.6 years; height, 174.3 ± 10.2 cm; mass, 74.6 ± 16.7 kg) with chronic ankle instability were randomized to proximal tibiofibular joint manipulation, distal tibiofibular joint manipulation, or a control group. Outcome measures included ankle dorsiflexion range of motion, the single-limb stance on foam component of the Balance Error Scoring System, the step-down test, and the Foot and Ankle Ability Measure sports subscale. Measurements were obtained prior to the intervention (before day 1) and following the intervention (on days 1, 7, 14, and 21). RESULTS: There was no significant change in dorsiflexion between groups across time. When groups were pooled, there was a significant increase (P<.001) in dorsiflexion at each postintervention time interval. No differences were found among the Balance Error Scoring System foam, step-down test, and Foot and Ankle Ability Measure sports subscale scores. CONCLUSIONS: The use of a proximal or distal tibiofibular joint manipulation in isolation did not enhance outcome effects beyond those of the control group. Collectively, all groups demonstrated increases in ankle dorsiflexion range of motion over the 3-week intervention period. These increases might have been due to practice effects associated with repeated testing. LEVEL OF EVIDENCE: Therapy, level 2b–.

J Orthop Sports Phys Ther 2012;42(2):125-134. doi:10.2519/jospt.2012.3729

KEY WORDS: ankle sprain, CAI, manual therapy, mobilization

J Orthop Sports Phys Ther 2012;42(2):95. doi:10.2519/jospt.2012.0502

KEY WORDS: patellofemoral pain syndrome, prevention, quadriceps muscle

STUDY DESIGN: Clinical measurement, longitudinal; multicenter prospective cohort study. OBJECTIVES: To examine the validity, reliability, and responsiveness of the Patient-Specific Functional Scale (PSFS) in patients with musculoskeletal upper extremity problems being treated in physical therapy. BACKGROUND: The clinimetric properties of the PSFS have not been established nor compared with region-specific outcome measures in patients with upper extremity problems. METHODS: Patients completed the PSFS, Upper Extremity Functional Index (UEFI), and numeric pain rating scale (NPRS) at baseline and follow-up, and were categorized as improved, stable, or worsened, using the global rating of change. Construct validity was assessed by comparing the change scores of the stable and improved groups, using independent-samples t tests. Reliability was evaluated using intraclass correlation coefficient (ICC_2,1) with 95% confidence intervals. Bland-Altman plots determined limits of agreement. Responsiveness and minimal important difference (MID) were determined with receiver operator characteristic (ROC) curves. RESULTS: One hundred eighty patients met the inclusion criteria. Construct validity was supported for the PSFS and the UEFI (P<.001). Reliability was moderate to good for the PSFS (ICC_2,1 = 0.713) and UEFI (ICC_2,1 = 0.848). Reported estimates of reliability may be lower than true values because the group of “stable” patients from this cohort had, on average, a small positive change. Bland-Altman plots indicated good agreement. The area under the ROC curve (AUC) was significantly different from the null value of 0.5 for the PSFS (0.887) and the UEFI (0.877), indicating good accuracy in distinguishing improved patients from stable patients. MID was 1.2 for the PSFS (scale, 0-10) and 8.5 for the UEFI (scale, 0-80). CONCLUSION: The PSFS is a valid, reliable, and responsive outcome measure for patients with upper extremity problems.

J Orthop Sports Phys Ther 2012;42(2):56-65. doi:10.2519/jospt.2012.3953

KEY WORDS: clinical measurement, instrument validation, outcome measure, upper limb

The convex-concave rules purportedly help describe the roll-and-slide relationships that naturally occur between moving articular surfaces. There are 2 components of this rule, depending on whether the convex or concave articular member of the joint is considered the moving segment. As a teacher of kinesiology and a physical therapist, I have always respected these rules, primarily because of their ability to assist with the mental imaging of joint motion. Recently, I have been perplexed by questions from experienced physical therapists as to why the convex-concave rules are still being taught in college or continuing education venues, when research has shown that they are flawed. Perhaps I am so hopelessly infatuated with, and blinded by, the educational charm and utility of the convex-concave rules that I fail to realize they are flawed. Are they? I don’t think so, which is the topic of this editorial.

J Orthop Sports Phys Ther 2012;42(2):53-55. doi:10.2519/jospt.2012.0103

KEY WORDS: arthrology, articular surfaces, kinesiology, morphology

The patient was a 72-year-old woman who presented to an emergency department with a chief complaint of severe right thigh pain following a fall. Prior to the fall, the patient reported an 8-month history of worsening right thigh pain. The patient had a 4-year history of alendronate and calcium use to manage her osteoporosis. Dual X-ray absorptiometry (DXA) hip images taken 1 month prior to the patient’s fracture demonstrated lateral cortical thickening in the subtrochanteric region of the femur. In retrospect, this finding was concerning for impending complete fracture.

J Orthop Sports Phys Ther 2012;42(1):44. doi:10.2519/jospt.2012.0402

KEY WORDS: bisphosphonates, bone mineral density, dual X-ray absorptiometry, DXA, radiography, thigh pain

The patient was a 21-year-old man, currently serving in the military, who was referred to a physical therapist for a chief complaint of left lateral ankle pain of 2 months in duration, after an inversion ankle injury sustained while hiking. At the time of the initial evaluation, the physical therapist reviewed computed tomography images and the radiologist’s report, which noted a cystic lesion in the anterior calcaneus, with a small area of communication with the subtalar joint, which was concerning for a pathologic fracture. The patient was diagnosed with a unicameral bone cyst of the calcaneus and subsequently underwent curettage and packing with a multipotential cellular bone matrix containing adult stem cells.

J Orthop Sports Phys Ther 2012;42(1):43. doi:10.2519/jospt.2012.0401

KEY WORDS: computed tomography, multi-potential cellular bone matrix, radiography, stem cells

J Orthop Sports Phys Ther 2012;42(1):21. doi:10.2519/jospt.2012.0501

KEY WORDS: cervical spine, mobilization, spinal manipulation, thoracic spine

Last Fall, JOSPT conducted an extensive environmental survey that attracted 560 respondents. The survey represented the Journal’s many stakeholder groups, including authors, reviewers, editors, Orthopaedic and Sports Sections members, individual and institutional subscribers, and international partners. The Journal also held a strategic planning meeting and adopted a plan for the next 2 years. Among other findings, the survey showed that journals remain the most important means by which professionals stay current in the field of musculoskeletal rehabilitation. The survey also highlighted the technological sea change in publishing today. The expansion of JOSPT’s online features in recent years, the need to select the “right” technologies, the plethora of content delivery options already available, and the growing demand to read and access the Journal anytime, anywhere, dominated the survey’s results. Based on this survey, existing initiatives, and discussion at the planning meeting, JOSPT’s plan for the future has at its heart technology as means of developing and disseminating clinically relevant information to improve patient care. KEY WORDS: media, technology

In Memoriam: Former JOSPT Editor, Dr Richard Paul Di Fabio

Richard Paul Di Fabio, PT, PhD, editor-in-chief of the Journal of Orthopaedic & Sports Physical Therapy from 1999 to 2001, died Friday, December 9, 2011, following a prolonged and private battle with a progressive illness.

J Orthop Sports Phys Ther 2012:42(1):3-4. doi:10.2519/jospt.2012.0102

Musculoskeletal conditions are important contributors to United States healthcare spending and are certain to play an important role in the future as the population continues to age. Almost half of the population of the United States experiences a musculoskeletal condition annually. Meeting the needs of these individuals within a changing healthcare delivery and reimbursement environment prompted a recent Summit sponsored by the United States Bone and Joint Initiative (USBJI). The Summit dealt with a topic critical to the future of healthcare for clinicians, consumers, and payers alike: value. We do not operate within a value-based healthcare system. Our current delivery system continues to reward volumes, not value. Failure to focus on value has had devastating consequences. The challenge of shifting from a volume-based to a value-based system is central to the future of healthcare. Discussion and action will be critical for the physical therapy profession moving into the future.

J Orthop Sports Phys Ther 2012;42(1):1-2. doi:10.2519/jospt.2012.0101

KEY WORDS: cost, musculoskeletal conditions, outcomes, United States healthcare

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

The patient was a 17-year-old female who was referred to a physical therapist by her primary-care physician with a chief complaint of bilateral hip and groin pain. The patient was treated by the physical therapist for 8 weeks, but she was unable to successfully return to playing soccer. The patient was subsequently referred to an orthopaedic surgeon, who ordered a magnetic resonance arthrogram that did not reveal intra-articular pathology. To further evaluate bony morphology, computed tomography with 3-dimensional reconstructions was ordered, which demonstrated findings consistent with cam-type femoroacetabular impingement.

J Orthop Sports Phys Ther 2011;41(12):982. doi:10.2519/jospt.2011.0425

KEY WORDS: computed tomography, hip pain, groin pain, magnetic resonance imaging, radiography

The patient was a 79-year-old man with a chief complaint of neck pain after a fall. Three days following the fall, the patient was seen in the emergency department, where computed tomography imaging of the head and radiographs of the cervical spine were completed. The patient was subsequently referred to a physical therapist. Due to concern for a possible undetected cervical spine fracture, the patient was immediately referred to his physician. Magnetic resonance imaging demonstrated a type II fracture of the odontoid.

J Orthop Sports Phys Ther 2011;41(12):981. doi:10.2519/jospt.2011.0424

KEY WORDS: cervical spine, computed tomography, magnetic resonance imaging, radiography

STUDY DESIGN: Prospective, longitudinal, observational cohort design. OBJECTIVE: The primary aim was to examine the association between changes in psychosocial distress (PD), and functional status (FS) and pain intensity at discharge from physical therapy. BACKGROUND: Patients with lumbar impairments seeking physical therapy commonly demonstrate elevated PD. However, it is not clear if PD changes that occur during physical therapy management are associated with improved clinical outcomes. METHODS: Data from adults (n = 692) with lumbar impairment were analyzed. Patients were screened using the Symptom Checklist Back Pain Prediction Model questionnaire (SCL BPPM) to identify patients at intake and discharge into 3 levels of risk for persistent disability (high, intermediate, or low). SCL BPPM classifications allowed for 5 patterns of change in PD during therapy (decreased, stable low, stable intermediate, stable high, or increased). Associations between PD change patterns and discharge FS and pain intensity were assessed using multivariable linear regression models, controlling for selected risk-adjustment variables. RESULTS: Proportions of patients classified by patterns of PD change for decreased, stable low, stable intermediate, stable high, and increased were 0.34, 0.52, 0.05, 0.06, and 0.03, respectively. Compared to the decreased PD group, (1) increased, stable high, and stable intermediate PD patterns were associated with worse discharge FS scores (–7.9 [95% CI: –13.5, –2.21], –10.9 [95% CI: –15.25, –6.49], and –8.9 [95% CI: –13.65, –4.21] units, respectively), and (2) stable high and stable intermediate PD patterns were associated with higher pain intensity (2.59 [95% CI: 1.81, 3.56] and 2.14 [95% CI: 1.25, 3.04] units, respectively). CONCLUSIONS: Lower FS and higher pain intensity outcomes were associated in similar but not identical patterns with patients whose SCL BPPM classification of PD increased, or remained at high or intermediate levels during physical therapy. Serial assessments of change in PD during rehabilitation are recommended as a possible treatment-monitoring tool.

J Orthop Sports Phys Ther 2011;41(12):969-980. doi:10.2519/jospt.2011.3814

KEY WORDS: computerized adaptive testing, depression, functional and pain outcomes, lumbar spine, psychosocial distress, somatization

STUDY DESIGN: Controlled laboratory testing using a single-group, prospective, repeated-measures design. OBJECTIVES: To compare the material properties of a hyperelastic athletic tape to a conventional tape and to compare the passive ankle support of these tapes before and after exercise. BACKGROUND: The near-linear material properties of conventional athletic tape may interfere with ankle motion, resulting in reduced athletic performance. Conventional athletic tape is also known to lose much of its initial support during exercise. It was assumed that a tape constructed of Kevlar fibers embedded in a silicon matrix would possess hyperelastic material properties that would improve ankle support. METHODS: A tensile testing machine was used to determine the tensile material properties of 11 samples of conventional and hyperelastic tape. The ankles of 11 young, healthy athletes were taped, one ankle with conventional tape and the other ankle with hyperelastic tape. The passive ankle support of each tape was measured with an instrumented linkage (the ankle flexibility tester) before and after 30 minutes of exercise. RESULTS: The composite tape had a significantly higher load to failure than the conventional tape. It had significantly lower initial stiffness and higher late stiffness than conventional tape, thus demonstrating highly hyperelastic behavior. The hyperelastic tape maintained a significantly higher portion of its support during the 30 minutes of exercise than the conventional tape. CONCLUSIONS: Composite athletic tape with highly hyperelastic properties can be constructed and maintains a larger portion of its support during short-duration exercises (less than 30 minutes) than conventional athletic tape.

J Orthop Sports Phys Ther 2011;41(12):961-968. doi:10.2519/jospt.2011.3476

KEY WORDS: anterior talofibular ligament, brace, calcaneofibular ligament, inversion sprain, ligament

STUDY DESIGN: Resident’s case problem. BACKGROUND: A 21-year-old athletic male college student presented to a direct-access physical therapy clinic with complaints of left calf pain 4 days in duration. After initial examination, a working diagnosis of calf strain was formulated. Three days following initial examination, the patient reported 80% improvement in symptoms and was performing activities of daily living pain free. Four weeks later, the patient returned with complaints of reoccurring calf pain. The patient’s signs, symptoms, and history at subsequent follow-up no longer presented a consistent clinical picture of calf strain; therefore, a D-dimer assay was ordered to rule out a deep vein thrombosis (DVT). DIAGNOSIS: The D-dimer was elevated so the patient was admitted to the hospital and started on low-molecular-weight heparin. A compression ultrasound revealed an extensive left superficial femoral and popliteal DVT in this otherwise healthy athlete. DISCUSSION: Lower extremity DVT is a serious and potentially fatal disorder. Physical therapists need to be diagnostically vigilant for vascular pathology in all patients with extremity pain and swelling. Employing the best current evidenced-based screening tools to rule out vascular pathology, such as deep and superficial vein pathology, should be the goal of every clinician. The Wells score is one such screening tool that has proven to be beneficial in this area. This case report presents a dilemma in diagnosis and illustrates the importance of revisiting differential diagnoses with each patient encounter. Clinicians must consider the possibility of a DVT with every patient seen with posterior leg pain. LEVEL OF EVIDENCE: Diagnosis, level 4.

J Orthop Sports Phys Ther 2011;41(12):942-947. doi:10.2519/jospt.2011.3823

KEY WORDS: clinical prediction rule, D-dimer assay, DVT

STUDY DESIGN: Descriptive bibliometric analysis. BACKGROUND: Content and bibliometric studies are useful for describing the publication patterns of a given profession, such as physical therapy, within the medical and allied health fields. However, few studies have conducted these analyses on specialty physical therapy journals. OBJECTIVES: To conduct a content and bibliometric assessment of publications within the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) and report publication and citation trends over multiple years. METHODS: All available JOSPT manuscripts published from 1980 through 2009 were reviewed. Only research reports, topical reviews, and case reports were included in the current analysis. Articles were coded by 2 independent reviewers based on type, participant characteristics, research design, purpose, clinical condition, and intervention. We obtained additional citation information (eg, authors and institutions) from a subset of articles published from 1992 through 2009 using bibliometric software. RESULTS: Of the 2233 available JOSPT publications, 1732 (77.6%) met criteria for inclusion. Of these, 1172 (67.7%) were research reports, 351 (20.3%) topical reviews, and 209 (12.1%) case reports. Over the last 30 years there has been a significant increase in the number of articles published and the percentage of research reports, systematic reviews, articles focused on prognosis, and articles including symptomatic participants. Percentage decreases were observed for topical or nonsystematic reviews and articles focused on anatomy/physiology. Top institutions, authors, and cited papers from 1992 through 2009 were identified in the bibliometric analyses. CONCLUSION: JOSPT has shown publication trends for increased percentage of experimental and clinically relevant research. However, there may be a need for increased publication of randomized controlled trials and studies focused on diagnosis, prognosis, and treatment, if goals of evidence-based practice are to be met.

J Orthop Sports Phys Ther 2011;41(12):920-931. doi:10.2519/jospt.2011.3808

KEY WORDS: citation analysis, publication trends, research

Editor-in-Chief Dr. Guy Simoneau recognizes the authors, associate editors, International Editorial Review Board members, and manuscript and musculoskeletal imaging reviewers who contributed to the various aspects of the Journal over the past 12 months.

J Orthop Sports Phys Ther 2011;41(12):911-913. doi:10.2519/jospt.2011.0112

KEY WORDS: authors, editorial board, reviewers

For physical therapists, modifying technique is not a novel concept; however, our motives are typically focused on symptom and injury reduction rather than purely performance. These specific modifications are based on minimizing tissue load, while still enabling successful completion of the task. Applying this same rationale to running, an activity in which up to 80% of participants are injured annually, would seem to be a good thing. Yet the idea of using gait retraining in patients without neurological injury/pathology is rather uncommon. However, a few researchers have investigated specific walking retraining strategies to reduce knee joint loading, with the goal of applying these techniques to individuals with knee osteoarthritis. This has led some to use the same concept on runners with patellofemoral pain, with a corresponding improvement in gait and symptoms.

J Orthop Sports Phys Ther 2011;41(12):909-910. doi:10.2519/jospt.2011.0111

KEY WORDS: 2012 Olympic Games, running

This month’s issue of JOSPT contains a bibliometric analysis of the publishing history of the Journal of Orthopaedic & Sports Physical Therapy. The results provide an opportunity to reflect on trends at JOSPT and, more generally, in the evidence base of orthopaedic and sports physical therapy practice. Results of the bibliometric review by Coronado and colleagues are encouraging for JOSPT and the profession of physical therapy as a whole. The results indicate an increase in the publication of research articles involving symptomatic subjects, with fewer narrative and nonsystematic review papers. The results also raise an interesting issue about whether we have a sufficient number of randomized controlled trials in our literature and to what extent our future progress should be based on the publication of more randomized trials.

J Orthop Sports Phys Ther 2011;41(12):907-908. doi:10.2519/jospt.2011.0110

KEY WORDS: evidence-based medicine, physical therapy, profession, randomized controlled trials