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Objective The goal of this study is to compare the subvastus method to the usual medial parapatellar technique for total knee replacement in patients with osteoarthritis who present to a tertiary care centre, based on quadriceps function recovery in days after surgery. Materials and methods We retrospectively reviewed case notes of 76 patients with osteoarthritis who had total knee replacements in a tertiary care hospital over the course of a year from August 2019 to August 2020. We divided them into two groups: group A received TKR via the subvastus approach, and group B received TKR via the medial parapatellar approach. Preoperative quadriceps strength, BMI, and baseline demographics were all recorded from their initial pre-operative workup case notes. Starting on the first postoperative day, patients recorded first unassisted straight leg raise (SLR) was kept as the main determinant for muscle function. The data were evaluated to determine the quadriceps muscle function post TKR. Results When compared to the medial parapatellar approach, the quadriceps muscle function returns sooner with the subvastus technique. Patients in their sixties showed the highest improvement. Preoperative quadriceps strength has a major impact on muscle recovery after surgery. Conclusion The subvastus method to total knee replacement is linked to a faster recovery of quadriceps muscle strength, resulting in a shorter hospital stay and postoperative therapy., Highlights • Knee osteoarthritis (OA) is a major public health concern and a primary cause of functional disability and reduced quality of life in the elderly. • The subvastus technique to the knee joint includes removing the vastus medialis muscle from its femur origin before dislocating the patella laterally 8, leaving the quadriceps mechanism intact. • Goal of this study is to compare the subvastus method to the usual medial parapatellar technique for total knee replacement. • We retrospectively reviewed case notes of 76 patients with osteoarthritis who had total knee replacements in a tertiary care hospital. • The subvastus method to total knee replacement is linked to a faster recovery of quadriceps muscle strength.

Study design: A controlled radiologic follow-up study. Objective: The aim of this study was to ascertain whether changes in cord excursion with straight leg raise test (SLR) at 1.5-year follow- up time accompany changes in clinical symptoms. Summary of background data: Lumbar intervertebral disc herniation (LIDH) is known to be a key cause of sciatica. Previously, we found that a significant limitation of neural displacement (66.6%) was evident with the SLR on the symptomatic side of patients with subacute single level posterolateral LIDH. Methods: Fourteen patients with significant sciatic symptoms due to a subacute single-level posterolateral LIDH were reassessed clinically and radiologically at 1.5 years follow-up with a 1.5T MRI scanner. Displacement of the conus medullaris during the unilateral and bilateral SLR was quantified reliably with a randomized procedure and compared between SLRs and to data from baseline. Multivariate regression models and backward variable selection method were employed to identify variables more strongly associated with a decrease in low back pain (LBP) and radicular symptoms. Results: Compared with previously presented baseline values, the data showed a significant increase in neural sliding in all the quantified maneuvers (P ≤ 0.01), and particularly of 2.52 mm (P ≤ 0.001) with the symptomatic SLR.Increase in neural sliding correlated significantly with decrease of both radicular symptoms (Pearson = -0.719, P ≤ 0.001) and LBP (Pearson = -0.693, P ≤ 0.001). Multivariate regression models and backward variable selection method confirmed the improvement of neural sliding effects (P ≤ 0.004) as the main variable being associated with improvement of self- reported clinical symptoms. Conclusion: To our knowledge, these are the first noninvasive data to objectively support the association between increase in magnitude of neural adaptive movement and resolution of both radicular and LBP symptoms in in vivo and structurally intact human subjects. Level of evidence: 2.

BACKGROUND: Pregnancy and childbirth are associated with lumbopelvic pain and instability. Fatigability of the lumbopelvic stabilizing muscles after childbirth is unknown, and no clinical tests exist to assess this important metric of muscle function. OBJECTIVES: To compare fatigability of the lumbopelvic stabilizing muscles in postpartum and nulligravid (control) women using the Active Straight Leg Raise (ASLR) Fatigue Task, and to determine if fatigability is associated with inter-recti distance (IRD), physical function, and pain/disability. STUDY DESIGN: Longitudinal case-control study METHODS: Twenty-nine nulligravid (25.4 ± 9.1 years) and 31 postpartum women (31.4 ± 5.2 years; vaginal delivery n=18) were tested at two time points, 16 weeks apart (postpartum women tested at 8–10 and 24–26 weeks postpartum). Muscular function was assessed with manual muscle testing (MMT), the ASLR Test, and a new ASLR Fatigue Task. Other measures included IRD, rectus abdominis thickness, physical activity, and six-minute walk distance. RESULTS: Postpartum women were 23% more fatigable (p=0.028) and were weaker (MMT) (p

Rationale: Herpes zoster frequently causes dermatomal vesicular rash accompanied by severe neuralgia, and reaching a differential diagnosis may be challenging before the appearance of the vesicular rash. Patient concerns: A 40-year-old male patient visited the emergency department with a complaint of sudden onset motor weakness and ipsilateral radiating neuralgia to the Lt. thigh. He had suffered from chickenpox during childhood. Diagnoses: No skin lesion was present at the initial visit. The reverse Straight Leg Raise test was negative. Magnetic resonance imaging showed asymmetrically swollen dorsal root ganglion with Gadolinium enhancement. The vesicular rash that appeared on the sixth day after the symptom onset led to the diagnosis of herpes zoster. Interventions: Antiviral agent of valacyclovir (1000 mg t.i.d.) was administered for 7 days. Outcomes: The patient recovered from motor weaknesses by 2 weeks from the onset of the symptom. Mild degree post-herpetic neuralgia recovered by 2 months. Lessons: A high index of suspicion is necessary to differentiate early herpes zoster radiculitis before the appearance of vesicular rash from compressive radiculopathy. In L2–3 ipsilateral radiating pain along the dermatome or myotome, the absence of reverse Straight Leg Raise sign may be a possible factor in differentiating herpes zoster radiculitis from compressive radiculopathy.

Observational study.Are there deviations in the thickness of abdominal muscles at rest in individuals with adolescent idiopathic scoliosis (AIS)? Are there deviations in abdominal muscular activity in people with AIS during the active straight leg raise (ASLR) test?Ultrasound imaging can be used to assess the lateral abdominal muscle. Some authors suggest that scoliosis develops through a weakness or improper functioning of the abdominal muscles that cannot provide adequate support to the spinal segments. However, the literature lacks studies on the functioning of the abdominal muscles in individuals with spinal deviations. This study focuses on the evaluation of the thickness of the external oblique (EO), internal oblique (IO), and transversus abdominalis (TrA) muscles of individuals with AIS.Seventy-one healthy adolescents and 71 patients with AIS, all aged 10-16 years, were studied. The thickness of the muscles at rest was measured at the end of normal exhalation in millimeters. Muscular activity during the ASLR test was measured in the final position, and the standards were normalized with the thickness produced at rest. Muscular activity during the ASLR test was represented as a percentage change in the muscle thickness.The AIS group demonstrated a smaller resting thickness of all tested muscles of both sides (P0.01). All the muscles on the right side of the body showed higher activity in the AIS group during the ASLR test (P0.01).Patients with AIS had thinner EO, IO, and TrA at rest in the supine position. During the ASLR test, the AIS patients displayed higher activity of the EO, IO, and TrA muscles on the right side.

Screening for primary musculoskeletal injury (MSK-I) is costly and time-consuming. Both the Functional Movement Screen (FMS) and the Y-Balance Test (YBT) have been shown to predict future MSK-I. With a goal of optimizing the efficiency of primary MSK-I screening, we studied associations between performance on the FMS and YBT and whether history of MSK-I influenced FMS and YBT scores. In total, 365 deploying Marines performed the FMS and YBT as prescribed. Composite and individual scores were each categorized as high risk or low risk using published injury thresholds: High-risk FMS included composite scores ≤14 and right-to-left (R/L) asymmetry for Shoulder Mobility, In-Line Lunge, Straight Leg Raise, Hurdle Step, or Rotary Stability. High-risk YBT consisted of anterior, posteromedial, and/or posterolateral R/L differences >4 cm and/or composite differences ≥12 cm. Pearson's χ tests evaluated associations between: (a) all FMS and YBT risk groups and (b) previous MSK-I and all FMS and YBT risk groups. Marines with high-risk FMS were twice as likely to have high-risk YBT posteromedial scores (χ = 10.2, p = 0.001; odds ratio [OR] = 2.1, 95% confidence interval [CI] = 1.3-3.2). History of any MSK-I was not associated with high-risk FMS or high-risk YBT. However, previous lower extremity MSK-I was associated with In-Line Lunge asymmetries (χ = 9.8, p = 0.002, OR = 2.2, 95% CI = 1.3-3.6). Overall, we found limited overlap in FMS and YBT risk. Because both methods seem to assess different risk factors for injury, we recommend FMS and YBT continue to be used together in combination with a thorough injury history until their predictive capacities are further established.

The factor structure and internal consistency of the Functional Movement Screen (FMS) have not been examined in a general healthcare population. Replicating the factor structure of the FMS is important because it illustrates the interdependence between each of the subtests, enabling the strength and conditioning professional to better interpret and act on an individual's FMS score. Anthropometric data and FMS scores were collected from 1,113 clients of a multidisciplinary healthcare clinic in Vancouver, BC The mean (SD) ages were 53.4 (11.1) for men (n = 656) and 49.3 (12.3) for women (n = 457). The mean FMS Summary Score was 13.7 (2.9) and was significantly negatively correlated with both age (r = -0.25; p < 0.001) and body mass index (r = -0.37; p < 0.001). The internal consistency of the FMS scale, which was assessed with both ordinal and Cronbach's alpha, was 0.73 and 0.64, respectively. Polychoric correlations between individual movements ranged from 0.03 to 0.59. Exploratory and confirmatory factor analyses (CFA) revealed that the FMS showed 2 main factors, a basic movement factor (shoulder mobility and active straight leg raise) and a complex movement factor (squat, hurdle step, inline lunge, and the trunk stability push-up). Rotary stability loaded onto both factors in the CFA, and its exclusion from the model had little effect. The findings of this study broadly replicated the intended factor structure of the FMS, as the individual movements aligned well with the intended factors.

Background Adolescent patients undergoing anterior cruciate ligament (ACL) reconstruction may not adequately recover safe movement patterns before returning to sport participation. The aims of this study were to assess functional movement and dynamic balance 9 months after primary ACL reconstruction in adolescent patients, and to assess for any maturity-specific differences that may guide rehabilitation strategies. Methods A series of 39 adolescent patients who underwent primary, anatomic, transphyseal ACL reconstruction using hamstrings autograft from October 2009 to January 2013 were identified from a research database: 17 skeletally immature (SI) patients (mean age 13.6±1.6 y) and 22 skeletally mature (SM) patients (mean age 16.6±1.2 y). An adult reference population of 16 primary ACL reconstruction patients (mean age 27.4±4.0 y) was also identified. All patients followed a standardized operative and rehabilitation protocol. The 3 patient groups were compared 9 months postoperatively using the Functional Movement Screen (FMS) to assess movement competency and the Lower Quarter Y-Balance Test (LQYBT) to assess single-limb dynamic balance. Results Nine months postoperatively, the FMS scores for all 3 groups indicated an increased risk for lower extremity injury (total score ≤14). With respect to specific movement patterns, the SI group displayed inferior active straight leg raise score (P=0.006) despite a lower incidence of pain with this movement. With the LQYBT, there was no significant difference in mean anterior (P=0.987), posterolateral (P=0.349), or posteromedial (P=0.870) reach asymmetry between the 3 groups; however, the adolescent groups demonstrated wider ranges of anterior reach asymmetry than the adult group indicating an increased risk for injury. Conclusions Adolescent patients undergoing primary ACL reconstruction do not consistently recover adequate functional movement patterns by 9 months postoperatively to permit a safe return to sport. We have identified unique functional movement deficits in SI and SM adolescents, which highlight the need for maturity-specific rehabilitation strategies for adolescent patients undergoing ACL reconstruction. Level of evidence Level IV—retrospective cohort

The purpose of this study was to investigate whether the functional movement screen (FMS) could predict running injuries in competitive runners. Eighty-four competitive male runners (average age = 20.0 ± 1.1 years) participated. Each subject performed the FMS, which consisted of 7 movement tests (each score range: 0-3, total score range: 0-21), during the preseason. The incidence of running injuries (time lost because of injury ≤ 4 weeks) was investigated through a follow-up survey during the 6-month season. Mann-Whitney U-tests were used to investigate which movement tests were significantly associated with running injuries. The receiver-operator characteristic (ROC) analysis was used to determine the cutoff. The mean FMS composite score was 14.1 ± 2.3. The ROC analysis determined the cutoff at 14/15 (sensitivity = 0.73, specificity = 0.54), suggesting that the composite score had a low predictability for running injuries. However, the total scores (0-6) from the deep squat (DS) and active straight leg raise (ASLR) tests (DS and ASLR), which were significant with the U-test, had relatively high predictability at the cutoff of 3/4 (sensitivity = 0.73, specificity = 0.74). Furthermore, the multivariate logistic regression analysis revealed that the DS and ASLR scores of ≤3 significantly influenced the incidence of running injuries after adjusting for subjects' characteristics (odds ratio = 9.7, 95% confidence interval = 2.1-44.4). Thus, the current study identified the DS and ASLR score as a more effective method than the composite score to screen the risk of running injuries in competitive male runners.

Synovial cysts of the lumbar spine result from degeneration of the facet capsule, and their prevalence may be as high as 10% in symptomatic patients. Although conservative management is possible, the majority of patients will require resection. Traditional procedures for resection use an ipsilateral approach requiring partial or complete resection of the ipsilateral facet complex, possibly leading to further destabilization. A contralateral technique using minimally invasive tubular retractors for synovial cyst resection avoids facet disruption, minimizes soft-tissue trauma, and limits disruption of the ligamentous and bony structures. Additionally, by approaching contralateral, the cyst/dura interface is better visualized especially at the depths of the lateral recess. Seeing the full extent of this interface from an ipsilateral approach is very difficult without decompressing the cyst, which, in turn, makes dissecting and separating the remaining cyst wall more difficult and increases the risk of durotomies.1,2 We report the case of a 53-yr-old female who presented with persistent left leg pain in an L5 distribution that was associated with some mild lower back pain. She was refractory to conservative management that included physical therapy along with a series of epidural steroid injections. She was noted to have some weakness with dorsiflexion on the left side and as absent a straight leg raise. Given the predominance of her leg over her back symptoms along with the patient's age, a minimally invasive contralateral approach for resection of the synovial cyst was offered as opposed to more traditional decompression and fusion. Institutional Review Board approval and patient consent for solitary case reports are not needed at our institution.

OBJECTIVES The active straight leg raise (ASLR) test is widely used clinically to assess severity of lumbopelvic pain due to decreased stability of the sacroiliac joint (SIJ). This study aimed to bypass the influence of decreased SIJ stability on the ASLR test by investigating the effect of experimental pelvic pain and hyperalgesia on the outcome of the ASLR test. METHODS Thirty-four healthy participants took part in this randomized crossover study. Pelvic pain was induced by injecting hypertonic saline into the long posterior sacroiliac ligament. Isotonic saline was injected on the contralateral side as control. Pain intensity was assessed on an electronic visual analogue scale. The Likert scores of difficulty performing the ASLR test and simultaneous electromyography of trunk and thigh muscles were recorded before, during, and postpain. Pressure pain thresholds were assessed bilaterally in the pelvic area and lower limb. RESULTS Compared with the control condition and baseline, hypertonic saline injections caused (P

STUDY DESIGN Controlled radiological study. OBJECTIVE Ascertain if a difference exists in the mechanical effects on the cord between the unilateral and bilateral straight leg raise (SLR) and to verify whether the effect on the spinal cord may be cumulative between the two. SUMMARY OF BACKGROUND DATA To the authors' knowledge these are the first data on noninvasive, in vivo, normative measurement of spinal cord displacement with bilateral SLR test. METHODS Sixteen asymptomatic volunteers were scanned with 1.5-T magnetic resonance scanner (Siemens Avanto, Erlangen, Germany) using T2-weighted turbo spin-echo fat-saturation sequence. The displacement of the medullar cone relative to the vertebral endplate of the adjacent vertebra during the passive bilateral SLR was quantified and compared with the position of the conus in the neutral (anatomic) position and with unilateral SLR. Each movement was performed twice for evaluation of reproducibility. The measurements were repeated by 2 observers. Four practitioners performed the maneuvers in a random sequence to avoid series effects. RESULTS Compared with the neutral (anatomic) position, the medullar cone displaced caudally in the spinal canal by 2.33 ± 1.2 mm (μ ± SD) with unilateral (P ≤ 0.001) and 4.58 ± 1.48 mm with bilateral SLR (P ≤ 0.001). Statistical significance was also reached for bilateral versus unilateral SLR (P ≤ 0.001). Spearman correlations proved higher than 0.99 for intra and interobserver reliability, and 0.984 for results reproducibility in bilateral SLR. CONCLUSION The caudal displacement of the medullar cone was significantly greater (almost double) with the bilateral SLR than the unilateral SLR. We hypothesize that this greater movement may be because more force was transmitted to the cord through a larger number nerve roots with the bilateral than unilateral SLR. The high correlation values in this study show that these movements are consistent and reproducible. This study offers baseline measurements on which further studies in diagnosis and treatment of lumbar disc protrusion and radiculopathy may be developed.

The purpose of this study was to determine if passive muscle-tendon properties of the posterior muscles of the hip and thigh and lower-body muscle power could discriminate between athletic status in division I female soccer athletes and nonathlete controls. Ten athletes (mean ± SE, age = 18.70 ± 0.34 years; mass = 64.61 ± 2.16 kg; height = 165.99 ± 1.46 cm; thigh muscle cross-sectional area = 94.08 ± 2.58 cm) and 11 nonathletes (mean ± SE, age = 19.64 ± 0.51 years; mass = 62.81 ± 2.60 kg; height = 162.44 ± 2.20 cm; thigh muscle cross-sectional area = 86.33 ± 2.81 cm) performed 2 instrumented straight-leg raise (iSLR) assessments using an isokinetic dynamometer programmed in passive mode to move the foot toward the head at 5°·s. During each iSLR, passive stiffness was calculated from the slopes of the initial (phase 1) and final (phase 2) portions of the angle-torque curve, and maximum range of motion (ROM) was determined as the point of discomfort but not pain, as indicated by the participant. Lower-body power characteristics were assessed through a countermovement vertical jump (CMJ) test. The results indicated that phase 1 and 2 slopes, CMJ height, and peak power (Pmax) were significantly higher (p = 0.004-0.036) for the athletes compared with the nonathletes; however, maximum ROM was not different (p = 0.601) between groups. Significant relationships were also observed between phase 1 and 2 slopes, and CMJ height and Pmax (r = 0.483-0.827; p ≤ 0.001-0.027). These findings suggest that in addition to traditional power characteristics, passive stiffness may also be a sensitive and effective measure for discriminating athletes from nonathletes. Coaches and practitioners may use these findings when designing training programs aimed at increasing musculotendinous stiffness of the posterior hip and thigh muscles and to help identify athletes with high overall athletic potential.

The aims of this study were (a) to determine and compare the concurrent hamstring criterion-related validity of the sit-and-reach (SR) and toe-touch (TT) tests in different athletes (tennis players, kayakers, canoeists, and cyclists); (b) to determine the criterion-related validity of the pelvic tilt assessed by the Spinal Mouse system as a measure of hamstring flexibility in athletes; and (c) to evaluate the influence of spinal posture, pelvic tilt, and hamstring muscle flexibility in the SR and TT scores. Twenty-four tennis players, 30 canoeists, 43 kayakers, and 44 cyclists were recruited. Passive straight leg raise (PSLR), SR, and TT tests were randomly performed. Spinal curvatures and pelvic tilt were evaluated with a Spinal Mouse system when the maximal trunk flexion was achieved in the SR and TT tests. Tennis players and cyclists showed moderate correlations between PSLR with respect to SR (β = 0.78 and β = 0.76, respectively) and TT (β = 0.77 and β = 0.74, respectively). Correlations were slightly lower in canoeists (SR, β = 0.64; TT, β = 0.75). Kayakers showed the lowest correlation values (SR, β = 0.53; TT, β = 0.57). Correlation values between PSLR and pelvic tilt angle in both the SR and TT tests were β < 0.70 in all the groups of athletes. Stepwise multiple regression analysis showed a high variance explained from pelvic tilt and lumbar spine in the SR score. In conclusion, the SR and TT tests can be appropriate measures to determine spine flexibility and pelvic tilt range of motion but not to evaluate the hamstring muscle flexibility in tennis players, canoeists, kayakers, and cyclists.

Static stretching is widely applied in various disciplines. However, the acute effects of different durations of stretching are unclear. Therefore, this study was designed to investigate the acute effects of different stretching durations on muscle function and flexibility, and provide an insight into the optimal duration of static stretching. This randomized crossover trial included 24 healthy students (17 men and 7 women) who stretched their right hamstrings for durations of 20, 60, 180, and 300 seconds in a random order. The following outcomes were assessed using an isokinetic dynamometer as markers of lower-limb function and flexibility: static passive torque (SPT), dynamic passive torque (DPT), stiffness, straight leg raise (SLR), and isometric muscle force. Static passive torque was significantly decreased after all stretching durations (p < 0.05). Static passive torque was significantly lower after 60, 180, and 300 seconds of stretching compared with that after 20-second stretching, and stiffness decreased significantly after 180- and 300-second stretching (p < 0.05). In addition, DPT and stiffness were significantly lower after 300 seconds than after 20-second stretching (p < 0.05), and SLR increased significantly after all stretching durations (p < 0.05). Straight leg raise was higher after 180- and 300-second stretching than after 20-second stretching and higher after 300-second stretching than after 60-second stretching (p < 0.05). Isometric muscle force significantly decreased after all stretching durations (p < 0.05). Therefore, increased duration of stretching is associated with a decrease in SPT but an increase in SLR. Over 180 seconds of stretching was required to decrease DPT and stiffness, but isometric muscle force decreased regardless of the stretching duration. In conclusion, these results indicate that longer durations of stretching are needed to provide better flexibility.

Lumbopelvic injuries are often refractory to treatment and can limit return to sport. Research shows that 50 Newtons (N) of force applied transversely to the pelvis improves lumbopelvic stability and pain. This study applies transverse and diagonal forces to the pelvis in athletes with lumbopelvic pain, and investigates effects on pain and function.To investigate the effects of transverse and diagonal compressive forces applied to the pelvis of athletes with lumbopelvic painA randomized, repeated measures design using 20 athletes with lumbopelvic pain.No belt and four pelvic belt configurations (50 N force) were tested. Outcome measures were: resting pain, pain on active straight leg raise (ASLR), resisted hip adduction force and pain on 1-metre broad jump. Force on the adduction test was determined via load cell.Data were analyzed using repeated measures ANOVA. Squeeze test showed significant effect of condition F (4, 76) = 2.7, P0.05. On ASLR ipsilateral to the side of pain, pain decreased across conditions (F (4, 76) = 2.5 P = 0.05).Results suggest application of diagonal forces towards the site of pain may have additional benefits in improving pain and function. Such information may inform the development of an orthosis. Clinical relevance The results may be used clinically to determine the effectiveness of different belt placements (with belts or straps) in managing athletic lumbopelvic pain. The results offer an alternative to the application of transverse belts, and may inform new approaches in the development of orthotics.

The purpose of this study was to test sex differences in sagittal plane thoracic (T), lumbar (L), and pelvic (P) angles measured during the sit-and-reach (SR) test and hip joint angle during a passive straight leg raise (SLR) test in men and women matched for SR scores. Thirty-five men and 35 women performed a standard SR and SLR test. Among the 70 subjects, 25 male and female pairs were identified using

OBJECTIVE The objective of this study was to use finite element model (FEM) simulations and experimental testing to study the relationship between lower limb positioning for surgeries of the spine and changes in sagittal curves. METHODS Four volunteers underwent lower limb flexibility and range of motion testing before being placed prone on a new surgical frame where lateral radiographs of their spines were taken in positions of hip flexion (average 48 degrees) and extension (average 13 degrees). Personalized FEMs were created representing each volunteer's spine, rib cage, pelvis, and lower limbs. Optimization of model behavior was performed by adjustment of lower limb muscle initial strains. The FEMs were exploited to examine the impact of more extreme and intermediate lower limb positions; 30 degrees of hip extension to 90 degrees of flexion at intervals of 20 degrees. RESULTS With increased hip flexion, lordosis and kyphosis decreased to an average of 52% (35 degrees) and 16% (6 degrees), respectively. Personalization of the 4 FEMs allowed reproduction of the experimental results within 5 degrees and their subsequent exploitation showed the linear changes in lordosis and kyphosis between extreme positions decreasing an average of 84% (59 degrees) and 34% (13 degrees) with increased hip flexion. A strong correlation was found between experimental change in lordosis and individual hamstring flexibilities (R=-0.93) which allowed for the development of a predictive equation for lordosis in terms of hip flexion which factors straight leg raise test results. CONCLUSIONS Knowledge gained through this study can be used to improve intraoperative control of sagittal curves through lower limb positioning.

The purpose of this study was to determine the relationship between core stability, functional movement, and performance. Twenty-eight healthy individuals (age = 24.4 ± 3.9 yr, height = 168.8 ± 12.5 cm, mass = 70.2 ± 14.9 kg) performed several tests in 3 categories: core stability (flexion [FLEX], extension [EXT], right and left lateral [LATr/LATl]), functional movement screen (FMS) (deep squat [DS], trunk-stability push-up [PU], right and left hurdle step [HSr/HSl], in-line lunge [ILLr/ILLl], shoulder mobility [SMr/SMl], active straight leg raise [ASLRr/ASLRl], and rotary stability [RSr/RSl]), and performance tests (backward medicine ball throw [BOMB], T-run [TR], and single leg squat [SLS]). Statistical significance was set at p ≤ 0.05. There were significant correlations between SLS and FLEX (r = 0.500), LATr (r = 0.495), and LATl (r = 0.498). The TR correlated significantly with both LATr (r = 0.383) and LATl (r = 0.448). Of the FMS, BOMB was significantly correlated with HSr (r = 0.415), SMr (r = 0.388), PU (r = 0.407), and RSr (r = 0.391). The TR was significantly related with HSr (r = 0.518), ILLl (r = 0.462) and SMr (r = 0.392). The SLS only correlated significantly with SMr (r = 0.446). There were no significant correlations between core stability and FMS. Moderate to weak correlations identified suggest core stability and FMS are not strong predictors of performance. In addition, existent assessments do not satisfactorily confirm the importance of core stability on functional movement. Despite the emphasis fitness professionals have placed on functional movement and core training for increased performance, our results suggest otherwise. Although training for core and functional movement are important to include in a fitness program, especially for injury prevention, they should not be the primary emphasis of any training program.

The active manual straight leg raise (ASLR) and passive manual straight leg raise (MSLR) tests are commonly used in clinical settings to assess hamstring tightness. However, to our knowledge, the validity and sensitivity of these tests have not been compared with the instrumental straight leg raise (ISLR). The aim of the present study was to assess the intrarater reproducibility of the ISLR and compare the sensitivity of the ASLR, MSLR, and ISLR to change. Twelve men with hamstring tightness underwent the ASLR, MSLR, and ISLR tests at baseline and after a 4-week home-based right leg stretching program with the left leg serving as a control. The ISLR measurements were repeated consecutively at baseline to assess reproducibility. The intraclass correlation coefficient for the ISLR was 0.94, and the coefficient of reproducibility was 6. Significant differences in the range of motion emerged between all testing methods (p0.05). In the stretched legs, the mean +/- SD increases were 17 +/- 5 degrees for ISLR, 10 +/- 8 degrees for ASLR, and 6 +/- 5 degrees for MSLR, whereas the control legs showed a significant mean change only for ASLR (5 +/- 4 degrees ). The mean standard response with the ASLR and MSLR tests did not differentiate between the treated and control legs, but it was almost 10-fold higher in the treated leg than the control leg for the ISLR, clearly differentiating between them. The ISLR had good reproducibility and sensitivity to changes, whereas ASLR and MSLR showed a poor ability to detect changes. Thus, the ISLR test is recommended for use in research evaluating the effectiveness of stretching.

The aim of this study was to analyze the influence of hamstring muscle extensibility on the hamstring criterion-related validity of the sit-and-reach (SR) and toe-touch (TT) tests. Two hundred forty young adults (mean age: 22.9 +/- 3.6 years) participated in this study. Three trials of straight leg raise (SLR) (left and right), SR, and TT tests were performed in a random order. The subjects were dichotomized into group A (subjects with an SLR angle75 degrees ) or group B (subjects with an SLR angle/= 75 degrees ). The correlation values between SLR angle and SR and TT scores were calculated and compared between both groups. Group B elicited higher mean SR and TT scores than group A (p0.001). Group A showed low associations between SLR with respect to the SR (r = 0.31-0.41) and TT (r = 0.28-0.40) tests. Group B showed moderate values for both SR (r = 0.55) and TT (r = 0.60-0.61) tests. The hamstring criterion-related validity of the SR and TT tests is influenced by hamstring muscle extensibility. From the results of this investigation, we find that the SR and TT tests are not valid measures of hamstring extensibility for subjects with reduced hamstring muscle extensibility.

An informal review of literature on the use of postisometric relaxation (PIR) type proprioceptive neuromuscular facilitation (PNF) indicates that the force of contraction requested from the athlete ranges from 10 to 100% of maximum voluntary isometric contraction (MVIC). The purpose of this study was therefore to determine if an optimal contraction intensity to elicit maximum positive change in range of motion (DeltaROM) exists. This research question was tested across a convenience sample of 56 (37 male and 19 female) university athletes. Target contractions during PNF interventions were set at 20, 50, and 100% MVIC. Pre- and post-PNF intervention hip flexion range of motion (ROM) was measured on a unilateral straight leg raise. The target MVIC of 20, 50, and 100% elicited mean pre-post intervention DeltaROM of 8.4, 12.9, and 11.6 degrees , respectively (all p < or = 0.0001). Differences in pre-post intervention DeltaROM between target contraction intensities were also significant (p = 0.016 to < or = 0.0001). A peak DeltaROM of 13.3 degrees was found at a PNF contraction intensity of 64.3% MVIC. Where optimizing increased ROM in healthy athletes is the desired outcome of PIR-PNF application, coaches and trainers should elicit contraction intensities of approximately 65% MVIC.

Objective To investigate whether abdominal muscle thickness in athletes with long-standing adduction-related groin pain (LAGP) differs between subgroups with a positive or no response to a pelvic belt. The response to a pelvic belt is defined positive in case of a decrease > or = 1 on a Likert pain scale (0-10) during the squeeze test (SQT) or a decrease > or = 1 on the active straight leg raise (ASLR) test score (0-10). Design Cross-sectional study. Setting Physical therapy practice. Patients Fifty athletes with LAGP. Independent variables Squeeze test and ASLR test. Main outcome measures First, the effect of a pelvic belt on pain during the SQT and the ASLR test score was evaluated. Then, thickness of m. transversus abdominis (TA) and m. obliquus internus (OI) was measured using ultrasound during rest, ASLR left and right, and SQT. Results Of the 50 participants, 25 (50%) experienced a decrease in pain during the SQT when wearing a pelvic belt and 10 (20%) improved in ASLR performance with a pelvic belt. Thickness of TA and OI at rest (both cases P > .08) and relative thickness compared with rest during tasks (in all cases P > .12) revealed no significant difference when comparing the 2 subgroups based on the belt response during the SQT or ASLR. Conclusions Using these methods, abdominal muscle thickness behavior in athletes with LAGP did not differ between the subgroups based on a positive or no response to a pelvic belt. However, the ultrasound method used may not have been sensitive enough to reveal differences between groups.

Background: To date there has been no study using robust surface electromyographic methods to compare the effect of sub-vastus and mid-vastus approaches to total knee arthroplasty on quadriceps activity. This study was done to ascertain if the sub-vastus technique would result in greater postoperative muscle activity than a vastus splitting approach as measured by electromyography and an earlier achievement of a straight leg raise. Methods: This was a prospective comparative study of the sub-vastus and mid-vastus approaches on vastus medialis and vastus lateralis muscle activity measured by electromyography and time to straight leg raise in 18 patients (7 men and 11 women) after a primary total knee arthroplasty. Results: A statistically significant difference in the number of days taken to achieve straight leg was noted between the mid-vastus and sub-vastus groups (mid-vastus = 2.0 days, 95% CI, 1.43 to 2.56; sub-vastus = 1.25 days, 95% CI, 0.93 to 1.57; P = 0.045). There were no statistical differences (P > 0.05) between the two techniques in electromyography or any of the secondary outcomes at 5 days, 6 weeks and 3 months after surgery. There was no significant correlation (P > 0.05) between the earlier return of straight leg raise in the sub-vastus technique and increased quadriceps activation. Conclusions: This study did not find any statistically significant differences in electromyographic data between the two approaches, suggesting no evidence of denervation of the vastus medialis, although the sub-vastus technique led to an earlier single-leg raise. (C) 2009 Lippincott Williams & Wilkins, Inc

Study design Diagnostic study. Objective To assess the construct validity of the flip test as a sign of nerve root tension. Summary of background data The flip test is commonly performed in patients with sciatica to confirm or otherwise nerve root tension evidenced by a restricted supine straight leg raise (SLR). Passive extension of the knee with the patient in the erect position and the hip flexed is reported to cause a sudden falling or flipping back of the trunk. Although widely known there are no research articles validating this test. Methods Sixty-seven patients with sciatica and magnetic resonance imaging scans confirming disc protrusion and nerve root compression underwent the flip test. The response of the patient was recorded, compared with the supine SLR, and subjected to statistical analysis. Results Thirty-three percent of patients felt no pain, 39% felt pain on full extension of the knee, and 28% resisted full extension of the knee due to pain. Only one-third of patients demonstrated a "flip." The response was related to the supine SLR, such that patients with high SLRs tended not to show a painful reaction whereas all patients with a supine SLR below 45 degrees showed a painful response. Conclusion We consider that the flip test has been substantially misinterpreted in the past. However, it remains a useful check of nerve root tension but only for patients with supine SLRs below 45 degrees . The most reliable response was not a flip but the demonstration of pain on extension of the knee. We would recommend the term "sitting SLR test," as a more accurate and less misleading name.

Study design Repeated measures. Objective To investigate motor control (MC) patterns in chronic pelvic girdle pain (PGP) subjects during an active straight leg raise (ASLR). Summary of background data The ASLR is a test used to assess load transference through the pelvis. Altered MC patterns have been reported in subjects with chronic PGP during this test. These patterns may impede efficient load transfer, while having the potential to impinge on respiratory function and/or to adversely affect the control of continence. Methods Twelve female subjects with chronic PGP were examined. Electromyography of the anterior abdominal wall, right chest wall and the scalene, intraabdominal pressure, intrathoracic pressure, respiratory rate, pelvic floor kinematics, and downward leg pressure of the nonlifted leg were compared between an ASLR lifting the leg on the affected side of the body versus the nonaffected side. Results Performing an ASLR lifting the leg on the affected side of the body resulted in a predominant MC pattern of bracing through the abdominal wall and the chest wall. This was associated with increased baseline shift in intraabdominal pressure and depression of the pelvic floor when compared with an ASLR lifting the leg on the nonaffected side. Conclusion This MC pattern, identified during an ASLR on the affected side of the body, has the potential to be a primary mechanism driving ongoing pain and disability in chronic PGP subjects.

This study compared the efficacy of 4 different hamstring-stretching techniques. Flexibility can be achieved by a variety of stretching techniques, yet little research has been performed on the most effective method. The 2 basic types include active stretching, in which range of motion is increased through voluntary contraction, and passive stretching, in which range of motion is increased through external assistance. The 2 types of active stretching include neuromobilization and proprioceptive neuromuscular facilitation (PNF). Our study aims to determine which type of stretching technique is most effective in improving hamstring length. One hundred subjects between the ages of 21 and 57 were enrolled in the study. Intrarater reliability of hamstring length measurement was performed using 10 subjects. All 100 subjects were included in a randomized controlled trial of 5 different groups comparing different hamstring-stretching techniques. Outcome measures, including hamstring length and perceived level of hamstring tightness, were recorded on all subjects initially, at 4 weeks, and at 8 weeks. After 4 weeks of stretching, there was a statistically significant improvement in hamstring length (p < 0.05) using active stretches as compared with passive stretches. From weeks 4 through 8, hamstring length for the active stretching groups decreased. After 8 weeks of stretching, the straight leg raise (SLR) passive stretch group had the greatest improvement in hamstring length. There was no correlation between hamstring flexibility and age, initial tightness, or frequency of exercise per week. Improvement in hamstring flexibility was greatest for the SLR passive stretch. Also, using PNF in the 90/90 active stretch provided better knee range-of-motion improvements than the 90/90 passive methods did.

Study Design. A randomized, double-blind, placebo-controlled trial of patients with radicular low back pain who present to an emergency department (ED) within 1 week of pain onset. Objective. We hypothesized that a single intramuscular 160 mg dose of methylprednisolone acetate would improve pain and functional outcomes 1 month after ED discharge if the corticosteroid were administered early in disease symptomotology. Summary of Background Data. Parenteral corticosteroids are not recommended for acute, radicular low back pain, though their role in this disease process is ill-defined. To date, this medication class has only been studied in a highly selected group of patients requiring hospitalization. Methods. Adults between the ages of 21 and 50 who presented to an ED with low back pain and a positive straight leg raise test were enrolled. The primary outcome was change in pain intensity on an 11 point numerical rating scale 1 month after ED visit. Secondary outcomes 1 month after ED discharge included analgesic use, functional disability, and adverse medication effects. Results. Six hundred thirty-seven patients were approached for participation, 133 were eligible, and 82 were randomized. Baseline characteristics were comparable between the groups. The primary outcome, a comparison of the mean improvement in pain intensity, favored methylprednisolone by 1.3 (P = 0.10). Some secondary outcomes favored methylprednisolone, such as use of analgesic medication within the previous 24 hours (22% vs. 43%, 95% CI for difference of 20%: 0%–40%) and functional disability (19% vs. 49%, 95% CI for difference of 29%: 9%–49%). Adverse medication effects 1 week after ED discharge were reported by 32% of methylprednisolone and 24% of placebo patients (95% CI for difference of 9%: −12% to 30%). Conclusion. This study was a negative study, though there was a suggestion of benefit of methylprednisolone acetate in a population of young adults with acute radicular low back pain. Further work with a larger sample of patients is needed.

Patellar fractures in children are uncommon and represent 1% of all pediatric fractures1-3. Of all patellar fractures, less than 2% occur in the skeletally immature patient2. Intra-articular dislocation of the patella is also a rare occurrence. Sleeve fractures represent the most common type of patellar fracture in children2, with most reported cases involving sleeve fractures of the inferior patellar pole. To our knowledge, only two cases of sleeve fractures of the superior pole have been reported in the English-language literature4,5 and the association of a sleeve fracture of the superior patellar pole with an intra-articular dislocation of the patella has not been previously reported. Our patient and his family were informed that data concerning the case would be submitted for publication, and they consented. A fourteen-year-old boy presented to our institution after sustaining a direct blow to the suprapatellar area of the right knee. The injury occurred as a result of the knee striking a concrete block while the patient was swinging on a rope. Following the injury, the boy was unable to walk and could not move the right knee. Examination revealed bruising of the anterior aspect of the knee and an unusual shape of the patella. The patient could neither perform a straight leg raise nor flex the knee. Radiographs of the knee revealed an intra-articular dislocation of the patella (Figs. 1-A and 1-B). In the lateral projection (Fig. 1-B), the patella was seen to be lying in a transverse position, with the articular surface facing in a distal direction. Fig. 1-A Fig. 1-B Preoperative anteroposterior (Fig. 1-A) and lateral (Fig. 1-B) radiographs of the knee, showing the transverse orientation of the patella with the articular surface facing in a distal direction. With the patient under intravenous morphine sedation, the patella …

Study design Descriptive study. Objective To compare clinical decision rules in low back pain guidelines for identification of neurologic involvement. Summary of background data Low back pain guidelines have been developed in a number of countries. Guideline recommendations for assessment of patients with low back pain in primary care include clinical decision rules for identification of neurologic involvement. Broad variation in recommended clinical assessments has previously been identified. More specific investigation of these clinical assessments seems warranted given that guidelines have an important role in facilitating accurate and timely identification of neurologic involvement in patients with low back pain presenting in primary care. Methods Guidelines were included that met the following criteria: the guideline included clinical decision rules for low back pain assessments; recommendations were for clinical management of low back pain in primary care; and the guideline was available in English. Results Three categories of neurologic involvement were identified in the guidelines: cauda equina syndrome; nerve root syndrome; and spinal stenosis. However, only cauda equina syndrome was included in all guidelines. Spinal stenosis or both nerve root syndrome and spinal stenosis categories were omitted from some guidelines. Decision factors for assignment to categories were: generally consistent for cauda equina syndrome; agreed to be conduction block in sensory and motor nerves and pain on straight leg raise for nerve root syndrome; and agreed to be reduced walking distance resulting from pseudoclaudication for spinal stenosis. Disagreement related to postural factors for nerve root syndrome and spinal stenosis categories. Conclusion This study has identified differences between the guidelines in the clinical decision rules for identification of neurologic involvement including omission of categories. Decision-making that employs all 3 categories of neurologic involvement will arguably facilitate accurate and timely identification of patients with low back pain so affected in primary care.

Study design Experimental, biomechanical study to determine the kinetics of the lumbar spine and hips during sit-to-stand and stand-to-sit. Objective To investigate the effects of back pain, with and without limitation in straight leg raise, on the joint moment and power of the lumbar and hips during sit-to-stand and stand-to-sit. Summary of background data Movements of the lumbar spine and hips, and their coordination have been reported to be affected by the presence of low back pain (LBP), especially in those with a positive straight leg raise. However, the literature has no information concerning moment and power characteristics of the lumbar spine and hips during sit-to-stand and stand-to-sit in such patients. Methods Twenty asymptomatic subjects, 20 LBP patients, and 20 patients with LBP and a positive straight leg raise sign were requested to perform the sit-to-stand and stand-to-sit activities. Electromagnetic sensors were attached to the body segments to measure their kinematics while 2 nonconductive force plates gathered ground reaction force data. Biomechanical models were used to determine the muscle moments and power at the lumbosacral (L5/S1) joint and hips. Results Muscle moments acting at the lumbar spine and hip in the sagittal plane were found to decrease in subjects with LBP, but there were significant increases in moments in other planes of motion. The power patterns of the spine and hips were also significantly altered, particularly in subjects with a positive straight leg raise sign. Conclusions Back pain subjects exhibit compensatory movements and altered load sharing strategies during the sit-to-stand and stand-to-sit activities. Exercise therapy should take account of these changes so that the normal kinematic and kinetic characteristics of the spine and hips can be restored.

Limb lengthening procedures can be associated with loss of range of knee movement, although the amount of knee flexion lost varies markedly between patients. The exact aetiology of this problem is not fully understood. This study investigates whether the amount of joint range that is lost during limb lengthening might be affected by the inherent passive compliance and length of the patients' soft tissues determined preoperatively. A simple mathematical model has been developed to calculate the inherent length and 'spare' length of the hamstring and quadriceps muscle groups in 28 patients undergoing limb lengthening procedures. The range of knee motion was recorded preoperatively and loss of movement recorded during follow-up. The results show a strong correlation between predicted 'spare' length of quadriceps and loss of knee flexion. An association was noted between loss of knee extension and the straight leg raise and correlation of knee extension and the spare length of the hamstrings. The straight leg raise test, and calculation of spare quadriceps length using our formula, as part of the preoperative assessment, can help predict which patient is at risk of a reduced range of motion of the knee.

Long-standing groin pain is a persistent problem that is commonly difficult to rehabilitate. Theoretical rationale indicates a relationship between the motor control of the pelvis and long-standing groin pain; however, this link has not been investigated.The current experiment aimed to evaluate motor control of the abdominal muscles in a group of Australian football players with and without long-standing groin pain.Ten participants with long-standing groin pain and 12 asymptomatic controls were recruited for the study. Participants were elite or subelite Australian football players. Fine-wire and surface electromyography electrodes were used to record the activity of the selected abdominal and leg muscles during a visual choice reaction-time task (active straight leg raising).When the asymptomatic controls completed the active straight leg raise (ASLR) task, the transversus abdominus contracted in a feed-forward manner. However, when individuals with long-standing groin pain completed the ASLR task, the onset of transversus abdominus was delayed (P0.05) compared with the control group. There were no differences between groups for the onset of activity of internal oblique, external oblique, and rectus abdominus (all P0.05).The finding that the onset of transversus abdominus is delayed in individuals with long-standing groin pain is important, as it demonstrates an association between long-standing groin pain and transversus abdominus activation.

The tibial tubercle osteotomy is gaining popularity for revision total knee arthroplasty; however, the potential for tubercle displacement has been a concern. This study compared the mechanical behavior of the tibial tubercle osteotomy after screw and cerclage wire fixation. Tibial tubercle osteotomy was done on 40 tibias from cadavers with equal numbers fixed by either screws or wires. Specimens were loaded cyclically to simulate straight leg raises and then loaded to failure with the patellar tendon oriented 0 degrees or 25 degrees from the tibial axis. Tibial tubercle osteotomy cyclic displacement was greater for wire constructs at 25 degrees than all other constructs. Failure loads were greater for screw constructs at 25 degrees than both wire constructs. Screw constructs failed at 1429 +/- 348 N (0 degrees) and at 1925 +/- 982 N (25 degrees). Wire constructs failed at 1072 +/- 260 N (0 degrees) and at 893 +/- 293 N (25 degrees). Bone mineral density correlated positively with failure loads. Straight leg raise (400 N) and knee extension (250 N) against gravity during rehabilitation should be feasible with either screw or wire fixation after tibial tubercle osteotomy. Special care should be taken for the large patient and patients with decreased bone density.

UNLABELLED Labor analgesia initiated with intrathecal bupivacaine and fentanyl, without a local anesthetic epidural test dose, provides effective analgesia and allows ambulation. In this study, we sought to determine the effect of a lidocaine-epinephrine test dose administered immediately after the initiation of combined spinal-epidural (CSE) analgesia with bupivacaine 2.5 mg and fentanyl 25 micro g on parturients' hemodynamic stability, posterior column function, motor strength, and subjective ability to walk. Parturients (n = 153) were randomized to receive either 3 mL of epidural saline or lidocaine 1.5% with epinephrine 1:200,000. Hemodynamic variables, proprioception, straight leg raise, and the modified Bromage score were analyzed in 110 parturients who completed the study protocol and were not different between groups. Vibratory sense, the ability to perform a partial deep knee bend and to step up on a stool, and the subjective ability to walk were impaired in a larger number of parturients in the lidocaine-epinephrine group at 30 min (P < 0.05). At 60 min, there were no differences between the groups except that fewer parturients in the lidocaine-epinephrine group could step up on a stool. The straight leg raise against resistance and the modified Bromage scale did not correlate well with other tests of motor strength (Spearman's rho, 0.273-0.405). These data suggest that the test dose should be avoided immediately after initiation of CSE analgesia when early ambulation is desired. IMPLICATIONS A lidocaine-epinephrine epidural test dose (3 mL of lidocaine 1.5% with epinephrine 1:200,000), injected immediately after the initiation of combined spinal-epidural labor analgesia with bupivacaine 2.5 mg and fentanyl 25 microg, may interfere with the ability to perform simple tests of motor function and ambulation.

Study design An experimental study of respiratory function and kinematics of the diaphragm and pelvic floor in subjects with a clinical diagnosis of sacroiliac joint pain and in a comparable pain-free subject group was conducted. Objective To gain insight into the motor control strategies of subjects with sacroiliac joint pain and the resultant effect on breathing pattern. Summary of background data The active straight-leg-raise test has been proposed as a clinical test for the assessment of load transfer through the pelvis. Clinical observations show that patients with sacroiliac joint pain have suboptimal motor control strategies and alterations in respiratory function when performing low-load tasks such as an active straight leg raise. Methods In this study, 13 participants with a clinical diagnosis of sacroiliac joint pain and 13 matched control subjects in the supine resting position were tested with the active straight leg raise and the active straight leg raise with manual compression through the ilia. Respiratory patterns were recorded using spirometry, and minute ventilation was calculated. Diaphragmatic excursion and pelvic floor descent were measured using ultrasonography. Results The participants with sacroiliac joint pain exhibited increased minute ventilation, decreased diaphragmatic excursion, and increased pelvic floor descent, as compared with pain-free subjects. Considerable variation was observed in respiratory patterns. Enhancement of pelvis stability via manual compression through the ilia reversed these differences. Conclusions The study findings formally identified altered motor control strategies and alterations of respiratory function in subjects with sacroiliac joint pain. The changes observed appear to represent a compensatory strategy of the neuromuscular system to enhance force closure of the pelvis where stability has been compromised by injury.

Study design The study measured the reliability of the passive straight leg raise (SLR) test and lumbar range of motion (LROM) tests measured as continuous variables embedded within a comprehensive physical examination. Objectives To determine the reliability of the SLR and LROM test scores when they are measured with a Cybex electronic inclinometer (Lumex, Inc., New York, NY) within a physical examination. Summary of background data Good published empirical reliability exists for the Cybex and for SLR and LROM tests when the measurements are taken in isolation from other physical examination procedures. Reliability of the Cybex for continuous SLR and LROM measurement within a physical examination has not been assessed, however. Methods Forty-five participants were seen by one of two physician/physiotherapist teams. Participants were examined by both team members. The first examiner conducted the first tests and retested 1 week later (intrarater reliability). The second examined the participants the day after their first appointment (inter-rater reliability). Results Only two scores showed substantial reliability (defined as r > or = 0.60). These scores were left (r = 0.81) and right (r = 0.79) SLR intrarater reliability. All other scores fell below the specified cutoff. Conclusions SLR and LROM scores used clinically are collected during comprehensive physical examinations. Most scores gathered under these conditions were not reliable. These findings have implications for the use of clinically derived SLR and LROM scores.

This is a case report of a unique presentation of a mild form of osteogenesis imperfecta (OI) (type IA) in a 9-year-old African-American boy who presented with simultaneous bilateral tibial tubercle avulsion fractures. The boy presented to the authors' emergency room complaining of acute bilateral knee pain. He could not perform a straight leg raise. Other than his orthopaedic examination, significant findings included blue sclera and irregular teeth. Radiographs and magnetic resonance imaging (MRI) confirmed bilateral tibia tubercle avulsion fractures. The patient underwent open reduction and internal fixation of his fractures, and postoperative genetic testing confirmed that the patient was heterozygous for OI. The authors present the fourth reported case of simultaneous bilateral tibial tubercle fractures. To their knowledge this is the first case of OI presenting with these fractures, the youngest reported case, and the first case with MRI documentation.

STUDY DESIGN: The value of adherence to selection criteria for laser disc decompression (LDD) was evaluated. A total of 204 patients who underwent LDDs were identified. Follow-up information could be obtained for 164 (80.8%) patients. Results were compared based on the selection criteria. SUMMARY OF BACKGROUND DATA: Laser disc decompression is a relatively new procedure. Few reports concerning outcome of LDD exist; and none deal specifically with patient selection. OBJECTIVE: This study compared the results of LDD performed among patients who met appropriate selection criteria with those who did not. Also, the value of discography in patient selection for LDD was investigated. METHODS: Two independent reviewers extracted data from patient charts. From this information, each patient was assigned to one of three groups: 1) those who met all selection criteria for LDD (leg pain, positive physical examination finding such motor, sensory, or reflex deficits, and/or straight leg raise, contained disc herniation confirmed by discography); 2) those who did not meet the selection criteria (had a normal physical examination, the presence of stenosis, spondylolisthesis, extruded disc fragment, leakage of discographic dye from the outer annulus, multiple prior lumbar surgeries); or 3) those who could not be assigned to either of the first two groups for reasons such as discography not being performed or inadequate physical examination data recorded in the chart. At 1 year follow-up, each patient was sent a questionnaire assessing outcome. Successful outcome was defined to be no subsequent lumbar surgery, the patient felt that LDD had helped, and if the patient was working before symptom onset, he was able to work at the time of follow-up. RESULTS: Among the 41 patients who met all selection criteria, the success rate was 70.7% (29/41); among patients who did not meet all the criteria, the success rate was only 28.6% (12/42); significantly less than in the first group (P < 0.005). Among patients who could not be assigned definitively to either of the first two groups, the success rate was 55.6% (45/81). Also, the success rate among patients with discographic confirmation of a contained disc herniation was significantly greater than among those who either did not have discography performed or extravasation of contrast was noted (70.7% vs. 44.4%, P < 0.035). CONCLUSIONS: These results emphasize the importance of strict adherence to appropriate selection criteria to obtain satisfactory results from LDD.

Fifty-eight back pain patients and 21 entry-level Postal Service workers without low-back pain were evaluated using a variety of lumbar function measures. Isolated trunk strength and full lifting strength were gauged with isokinetic and isometric methods. Lumbar range-of-motion was computed using toe-touch and goniometers. Conventional clinical techniques such as toe touch and straight leg raise were effective in distinguishing back-injured from normal subjects. Isometric and isokinetic peak force and torque tests failed to show significant differences between low-back pain and job applicant groups. When compared with published norms, our job applicant group was significantly deconditioned. Our data suggest that asymptomatic, deconditioned subjects could be mistaken for back-impaired patients or symptom magnifiers.

The diurnal height change reported to occur in young adults was investigated to characterize changes in the lumbar range of motion, spinal profile, and range of motion of the back. Twelve subjects aged 18-22 years were measured using stereophotography and standard clinical examinations in the evening and after a minimum of 8 hours of complete bed rest. The average increase in height was 20 mm. Forty percent of the height increase took place in the lumbar spine without change in the depth of the lordosis, and forty percent took place in the thoracic curve with a decrease in the kyphosis. The remaining 20% of the height increase was not located, but no measurements were taken of the cervical spine. Range of motion studies revealed that lumbar flexion, as measured using the lumbar flexion increment, was decreased in the morning, and straight leg raise was decreased when measured clinically but not when measured photographically. Extension, rotation, and femoral stretch test were not affected. The authors conclude that stereophotogrammetry offers an accurate, noninvasive way to study spinal profiles. Further work is needed to assess and quantify the relative motion of the skin and the underlying structures.

Acute compartment syndrome is defined as an increased pressure within a closed fascial space leading to reduced capillary perfusion that is inadequate for tissue viability1. Compartment syndrome of the lower leg can be classified by location (lateral, anterior, deep posterior, or superficial posterior), chronicity (acute or chronic), and etiology (traumatic or exertional). Exertional compartment syndrome has been well described in the orthopaedic literature; it is usually chronic in nature and does not present emergently2,3. Typically, acute compartment syndrome of the lower leg affects the anterior compartment and is caused by trauma; it rarely occurs bilaterally4-8. We present a unique case of acute exertional compartment syndrome with a delayed presentation of four days after the inciting event. The patient was informed that data concerning this case would be submitted for publication, and he provided consent. A forty-three-year-old man presented to the emergency department (ED) with severe bilateral lower-extremity (BLE) pain, approximately twenty-four hours after a two-mile run. Midway through the run, he had experienced “shooting pains” along the lateral calves that radiated up the thighs to both buttocks, with resulting tightness, warmth, swelling, and erythema of both lower extremities. He denied any trauma, twisting, or falling. All of the symptoms were worse on the left side, but both legs were symptomatic. The treating ED physicians found that the patient had no pain with passive range of motion of either lower extremity at the foot, ankle, knee, and hip; had minimal paresthesias on the dorsum of the left foot; and had a positive bilateral straight leg raise test. The patient was diagnosed with sciatica and was discharged. The patient returned to the ED twenty-four hours later with worsening pain, increased bilateral foot swelling, and inability to walk. On examination, the blood pressure …

The medial parapatellar approach and the midvastus approach are the two most commonly used surgical approaches in total knee replacement. This study compared surgical and clinical parameters associated with both surgical approaches in primary total knee replacement. One hundred nine patients who underwent bilateral primary total knee replacements had a medial parapatellar approach to one knee and a midvastus approach to the opposite knee. The prosthetic design and physical therapy were identical in all 109 patients. The patients and physical therapists were blinded to the type of approach used on each knee. The comparison included the surgical parameters of difficulty of exposure, surgical time, incidence of lateral retinacular release, and total blood loss. The clinical parameters of pain, range of motion, ability to perform a straight leg raise, and complications were compared at 8 days, 6 weeks and 6 months. The comparison between the two surgical approaches showed a statistically significant difference in four parameters, all of which favored the midvastus approach. The patients who had the midvastus approach required fewer lateral retinacular releases, had less pain at 8 days, had less pain at 6 weeks, and had a higher incidence of ability to straight leg raise at 8 days. There was no statistical difference between the two surgical approaches in all other surgical and clinical parameters. There was no increased difficulty of exposure using the midvastus approach when compared with the medial parapatellar approach even in patients with severe varus or valgus deformities. Notably, all clinical parameters were equal at 6 months. From a clinical standpoint, the midvastus approach had an advantage over the medial parapatellar approach because the patients had significantly less pain and had the ability to straight leg raise at 8 days. Because the managed care environment dictates a shorter hospital stay, patients who have the midvastus surgical approach have less pain and earlier control of the operative leg, and may be discharged from the hospital earlier. However, the clinical results at 6 months based on the patient's pain relief, range of motion, and ability to straight legraise were identical between the two surgical approaches.