Search

Objectives:. The time course and magnitude of atrophic remodeling and the effects of an acute rehabilitation program on muscle atrophy are unclear. We sought to characterize bed rest–induced leg muscle atrophy and evaluate the safety and efficacy of an acute rehabilitation program. Design:. Prespecified analysis of a randomized controlled trial. Setting:. Single-center urban hospital. Patients:. Adults (24–55 yr) randomized to 70 days of sedentary bed rest. Interventions:. The 11-day post-bed rest rehabilitation program consisted of low intensity exercise and progressed to increased aerobic exercise duration, plyometric exercises, and higher intensity resistance exercise. Measurements and Main Results:. Upper (rectus femoris, vastus lateralis, quadriceps, hamstrings, adductors) and lower leg (medial gastrocnemius, lateral gastrocnemius, and soleus) MRI scans were obtained once before, nine times during, and three times after bed rest to assess muscle cross-sectional area. The magnitude and rate of muscle atrophy and recovery were determined for each muscle. Nine participants completed 70 days of sedentary bed rest and an 11-day rehabilitation program. A total of 11,588 muscle cross-sectional area images were quantified. Across all muscles except the rectus femoris (no change), there was a linear decline during bed rest, with the highest atrophic rate occurring in the soleus (–0.33%/d). Following rehabilitation, there was rapid recovery in all muscles; however, the quadriceps (–3.74 cm2; 95% CI, –7.36 to –0.12; p = 0.04), hamstrings (–2.30 cm2; 95% CI, –4.07 to –0.54; p = 0.01), medial gastrocnemius (–0.62 cm2; 95% CI, –1.10 to –0.14; p = 0.01), and soleus (–1.85 cm2; 95% CI, –2.90 to –0.81; p < 0.01) remained significantly lower than baseline. Conclusions:. Bed rest results in upper and lower leg muscle atrophy in a linear pattern, and an 11-day rehabilitation program was safe and effective in initiating a rapid trajectory of muscle recovery. These findings provide important information regarding the design and refinement of rehabilitation programs following bed rest.

STUDY DESIGN: Resident's case problem. BACKGROUND: Cauda equina syndrome (CES) is a rare, potentially devastating, disorder and is considered a true neurologic emergency. CES often has a rapid clinical progression, making timely recognition and immediate surgical referral essential. DIAGNOSIS: A 32-year-old male presented to a medical aid station in Iraq with a history of 4 weeks of insidious onset and recent worsening of low back, left buttock, and posterior left thigh pain. He denied symptoms distal to the knee, paresthesias, saddle anesthesia, or bowel and bladder function changes. At the initial examination, the patient was neurologically intact throughout all lumbosacral levels with negative straight-leg raises. He also presented with severely limited lumbar flexion active range of motion, and reduction of symptoms occurred with repeated lumbar extension. At the follow-up visit, 10 days later, he reported a new, sudden onset of saddle anesthesia, constipation, and urinary hesitancy, with physical exam findings of right plantar flexion weakness, absent right ankle reflex, and decreased anal sphincter tone. No advanced medical imaging capabilities were available locally. Due to suspected CES, the patient was medically evacuated to a neurosurgeon and within 48 hours underwent an emergent L4-5 laminectomy/decompression. He returned to full military duty 18 weeks after surgery without back or lower extremity symptoms or neurological deficit. DISCUSSION: This case demonstrates the importance of continual medical screening for physical therapists throughout the patient management cycle. It further demonstrates the importance of immediate referral to surgical specialists when CES is suspected, as rapid intervention offers the best prognosis for recovery. LEVEL OF EVIDENCE: Differential diagnosis, level 4. J Orthop Sports Phys Ther 2009;39(7):541-549, Epub 24 February 2009. doi: 10.2519/jospt.2009.2999. [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Prospective cohort/predictive validity study. OBJECTIVE: To determine the predictive validity of selected clinical exam items and to develop a clinical prediction rule (CPR) to determine which patients with patellofemoral pain syndrome (PFPS) have a positive immediate response to lumbopelvic manipulation. BACKGROUND: Quadriceps muscle function in patients with PFPS was recently shown to improve following treatment with lumbopelvic manipulation. No previous study has determined if individuals with PFPS experience symptomatic relief of activity-related pain immediately following this manipulation technique. METHODS AND MEASURES: Fifty subjects (26 male, 24 female; age range, 18-45 years) with PFPS underwent a standardized history and physical examination. After the evaluation, each subject performed 3 typically pain-producing functional activities (squatting, stepping up a 20-cm step, and stepping down a 20-cm step). The pain level perceived during each activity was rated on a numerical pain scale (0 representing no pain and 10 the worst possible pain). Following the assessment, all subjects were treated with a lumbopelvic manipulation, which was immediately followed by retesting the 3 functional activities to determine if there was any change in pain ratings. An immediate overall 50% or greater reduction in pain, or moderate or greater improvement on a global rating of change questionnaire, was considered a treatment success. Likelihood ratios (LRs) were calculated to determine which examination items were most predictive of treatment outcome. RESULTS: Data for 49 subjects were included in the data analysis, of which 22 (45%) had a successful outcome. Five predictor variables were identified. The most powerful predictor of treatment success was a side-to-side difference in hip internal rotation range of motion greater than 14 masculine (+LR, 4.9). If this variable was present, the chance of experiencing a successful outcome improved from 45% to 80%. CONCLUSION: A CPR was developed to predict an immediate successful response to lumbopelvic manipulation in patients with PFPS. However, in light of a limited sample size and omission of potentially meaningful predictor variables, future studies are necessary to validate the CPR. LEVEL OF EVIDENCE: Prognosis, level 2b.This article features an invited commentary by Christopher M. Powers, PT, PhD, as well as an authors' response.J Orthop Sports Phys Ther. 2008;38(6):297-312, published online 22 January 2008. doi:10.2519/jospt.2008.2669. [ABSTRACT FROM AUTHOR]

The patient was a 27-year-old male pilot referred to a physical therapist for a suspected left acromioclavicular joint injury following a fall 3 weeks prior. Physical examination revealed decreased active shoulder flexion, decreased supraspinatus strength, and a positive Hawkins test. Radiographs were ordered and the anterior-posterior radiographic view showed an incomplete nondisplaced fracture in the superior aspect of the greater tuberosity. The patient was placed in a sling for 4 weeks and performed passive range-of-motion exercises to maintain shoulder mobility. Radiographs at 7 weeks following the injury revealed a healed greater tuberosity fracture.J Orthop Sports Phys Ther 2010;40(7):447. doi:10.2519/jospt.2010.0411. [ABSTRACT FROM AUTHOR]

Background: After an anterior cruciate ligament reconstruction (ACLR), only 47% of military members return to full duty, possibly due to persistent neuromuscular asymmetries. Psychological factors may also contribute to reduced return to duty in military members., Hypothesis: Psychological factors and time since surgery would be associated negatively with neuromuscular asymmetries, asymmetries would be greater in cadets postsurgery when compared with healthy controls, and asymmetries would be greater at earlier timepoints after ACLR., Study Design: Case control., Level of Evidence: Level 4., Methods: This study examined the relationship between psychological factors and time since surgery with neuromuscular asymmetry, compared neuromuscular asymmetries between cadets with and without a history of ACLR, and explored differences in neuromuscular asymmetries at different timepoints in cadets with a history of ACLR. A total of 37 cadets post-ACLR (18.3 ± 9 months) and 28 controls participated. Psychological factors were assessed using the Tampa Scale of Kinesiophobia and Anterior Cruciate Ligament-Return to Sport after Injury scale (ACL-RSI). Participants performed a drop-jump landing, joint positioning sense (JPS), and isometric quadriceps strength testing. Peak vertical ground-reaction forces (vGRF), absolute angle of replication, peak quadriceps torque, rate of torque development (RTD), and RTD time torque interval 200 ms (TTI 200 ) were analyzed., Results: The ACL-RSI score was significantly related to limb symmetry index (LSI) peak quadriceps torque ( r = 0.617, P < 0.01), LSI RTD (r = 0.367, P = 0.05), and LSI TTI 200 (r = 0.0489, P < 0.01), but not time since surgery, JPS, or LSI peak vGRF. Cadets with a history of ACLR had significantly lesser ACL-RSI scores and greater asymmetries compared with controls., Conclusion: Reduced psychological readiness was associated with increased neuromuscular asymmetries after ACLR., Clinical Relevance: Clinicians should assess psychological readiness during rehabilitation after ACLR., Competing Interests: The following author declared potential conflicts of interest: K.L.C. has received research grants from Department of Defense CDMRP and royalties from Springer.

Introduction: Shoulder stabilization surgery is common among military personnel, causing severe acute postoperative pain that may contribute to the development of chronic pain, thereby reducing military readiness. Battlefield Acupuncture (BFA) has shown promise as a non-pharmaceutical intervention for acute postoperative pain. The purpose of this study was to determine the effectiveness of BFA combined with standard physical therapy on pain, self-reported mood, self-reported improvement, and medication use in patients after shoulder stabilization surgery., Materials and Methods: The study design was a single-blind, randomized clinical trial, approved by the Naval Medical Center Portsmouth Institutional Review Board and registered with ClinicalTrials.gov (NCT04094246). Ninety-five participants were recruited after shoulder stabilization surgery. Participants were randomized via concealed allocation into a standard physical therapy (PT) group or a group receiving standard PT and BFA. Both groups received standard postoperative pain medication. The BFA intervention followed a standard protocol with the insertion of gold aiguille d'acupuncture emiermanente needles at 5 specific points in the ear. At 4 time points (baseline [24-48 hours], 72 hours, 1 week, and 4 weeks post-surgery), participants reported worst and average pain using a Visual Analog Scale (VAS), self-reported mood using the Profile of Mood States (POMS), self-recorded medication intake between study visits, and self-reported improvement in symptoms using a Global Rating of Change (GROC) Scale. Outcome assessors were blinded to treatment allocation. An alpha level of 0.05 was set a priori. For pain, a mixed-model analysis of variance was used to analyze the interaction effect between group and time. Differences in baseline data, total opioid usage, and pain change scores between groups were analyzed using independent t-tests., Results: Of the 95 participants enrolled, 7 failed to provide complete study visits after the baseline, leaving 88 patients (43 BFA, 45 control, mean age 21.8 (2.1) years, 23% female). There were no significant group-by-time interactions for VAS worst pain (F = 0.70, P = .54), VAS average pain (F = 0.99, P = .39), the POMS (F = 1.04, P = .37), or GROC (F = 0.43, P = 0.63). There was a significant main effect of time for VAS worst pain (F = 159.7, P < .001), VAS average pain (F = 122.4, P < .001), the POMS (F = 11.4, P < .001), and the GROC (F = 78.5, P < .001). While both groups demonstrated statistically significant and clinically meaningful improvements in pain and self-reported mood over time, BFA did not provide any additional benefit compared to standard physical therapy alone. There was no significant difference in opioid usage between groups at 4 weeks (t = 0.49, P = .63). Finally, both groups also demonstrated statistically significant and clinically meaningful self-reported improvements in function, but again, there was no additional benefit when adding BFA to standard physical therapy., Conclusion: The results of this study do not support the effectiveness of BFA for postsurgical pain management as there were no significant differences in pain, self-reported mood, self-reported improvement, and medication use between participants who received BFA and those who did not. As this is the only known study of BFA in postsurgical participants, continued research is needed to determine if BFA is effective for pain reduction in that setting., Clinical Trial Registration: ClinicalTrials.gov, NCT04094246. Registered September 16, 2019, http://clinicaltrials.gov/NCT04094246., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2025. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Background: The United States military strives to prepare soldiers physically and mentally for war while preventing injury and attrition. Previous research has focused on physical injury risk factors but has not prospectively examined psychological risk factors., Purpose: This study's purpose was to investigate whether self-efficacy is a risk factor for musculoskeletal injury in an initial military training environment and compare it to other known risk factors., Study Design: Prospective, Longitudinal Cohort Study., Materials and Methods: Shortly after starting cadet basic training, new cadets rated self-efficacy by an 11-point questionnaire. Other risk factor data including injury history, sex, height, weight, body mass index, age, aerobic fitness, upper body muscular endurance, core muscular endurance and previous military experience were collected by self-report questionnaire and military fitness testing. The primary dependent variable was musculoskeletal injury that originated during the seven-week course. Independent variables were compared between participants who were and were not injured using Chi-squared test, t-tests, Cox regression analysis and time to injury was evaluated using Kaplan-Meyer survival analyses., Results: Seven hundred eighty-one (65.1%) new cadets were eligible and consented to participate. Injured cadets had significantly lower self-efficacy scores (p=0.003 and p=<0.001), shorter height (p=<0.001), lower weight (p=0.036), lower push-up and plank performance (p=<0.001), slower two-mile run performance (p=<0.001), and females sustained a proportionally higher number of injuries than males (p=<0.001). Cadets with low self-efficacy, shorter height, lower hand release push-up performance, lower plank performance and slower two-mile run performance were at greater risk for musculoskeletal injury. Cadets with less self-efficacy were also less likely to continue uninjured throughout cadet basic training according to a Kaplan-Meier survival analysis (log rank test<0.002). Multivariable Cox regression revealed that only aerobic fitness predicted musculoskeletal injury (HR=1.005 [1.003-1.006], p=<0.001)., Conclusions: Participants with less self-efficacy sustained injuries earlier and more often than those with greater self-efficacy. However, aerobic fitness alone predicted future injury after controlling for all risk factors. Resolved prior injury was not a risk factor for future injury., Level of Evidence 2b: Individual cohort study., (© The Author(s).)

Background: In-clinic gait retraining has been effective in modifying suspected biomechanical risk factors for running injury, but its feasibility is often limited by multiple clinic visits. This randomized clinical trial investigated the effects of a telehealth-based gait retraining intervention on running biomechanics, pain, and function in previously injured runners., Methods: Twenty-three participants recovering from lower extremity injuries were randomized to a control or intervention group. The intervention group completed 4 to 6 telehealth gait retraining sessions over 8 to 10 weeks, consisting of visual and verbal cues to transition to a non-rearfoot strike pattern and increase step rate. The control group received standard physical therapy. Biomechanics, pain, and function were assessed pre- and post-intervention using a 2 × 2 mixed model analysis of variance., Findings: Half of the participants (55 %) in the intervention group successfully transitioned to a non-rearfoot strike pattern. No significant differences were observed between groups in step rate, biomechanics, or function. A significant group-by-time interaction for pain was observed (F = 10.55, P = 0.004), with the intervention group reporting greater reductions in pain compared to the control group (mean difference 2.52, 95 % CI 0.91 to 4.12)., Interpretation: Despite only half of participants adopting the desired gait pattern, telehealth gait retraining may offer a low-risk, accessible, and convenient alternative for select patients who lack in-person care options or have not responded to other pain reduction methods when returning to running from a lower extremity injury., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier Ltd.)

Background: Traumatic shoulder instability is a common injury in the general population and the military. Surgical stabilization surgery reduces recurrence rates compared with nonsurgical management. Time since surgery is generally the primary measure of return to sport. There is a gap in knowledge on psychological variables and time since surgery and their relationship to rotator cuff strength and functional performance., Hypothesis: It was hypothesized that, after shoulder stabilization surgery, psychological factors and time since surgery will be associated positively with objective physical performance tests, that physical performance will differ significantly between postsurgery cadets and healthy controls, and that surgical stabilization of the nondominant arm will demonstrate greater range of motion deficits than surgical intervention on the dominant arm., Study Design: Case-control study., Level of Evidence: Level 4., Methods: The 52 participants (26 postsurgical [6-24 months after surgery] and 26 healthy controls) were all military cadets. Outcome measures were patient-reported outcomes, range of motion, isometric strength, and functional performance., Results: No significant relationships existed between time since surgery and psychological factors to rotator cuff strength or functional performance. Significant differences were found between groups in self-reported outcomes, including the Shoulder Instability Return to Sport After Injury scale, Single Assessment Numeric Evaluation, Numeric Pain Rating Scale, quickDASH, flexion and external rotation (ER), and ER limb symmetry. Those who received dominant-sided shoulder surgery demonstrated a greater mean active range of motion deficit than those who received nondominant-sided surgery. Both groups demonstrated a significant loss in ER, but dominant-sided surgical participants also demonstrated significant flexion loss., Conclusion: Time since surgery and psychological variables did not demonstrate a relationship to rotator cuff strength and functional performance. Significant differences existed between the stabilization surgical participants and healthy controls in all patient-reported outcomes. Surgical participants with dominant-sided shoulder surgery demonstrated a greater mean motion deficit when compared with those who received nondominant-sided surgery., Competing Interests: The authors report no potential conflicts of interest in the development and publication of this article.

Abstract: Scott, KM, Kreisel, BR, Florkiewicz, EM, Crowell, MS, Morris, JB, McHenry, PA, and Benedict, TM. The effect of cautionary versus resiliency spine education on maximum deadlift performance and back beliefs: A randomized control trial. J Strength Cond Res 38(7): e341-e348, 2024-The purpose of this study was to determine the effect of cautionary information about the spine vs. a message of spine resiliency on maximum deadlift (MDL) performance and beliefs regarding the vulnerability of the spine. This cluster randomized control trial involved 903 military new cadets (n = 903) during their mandatory fitness test in cadet basic training (mean age 18.3 years, body mass index 23.8 kg·m-2, 22% female). Subjects were cluster randomized to 3 groups. The cautionary group received a message warning them to protect their backs while deadlifting, the resiliency group received a message encouraging confidence while deadlifting, and the control group received the standardized Army deadlift education only. The outcome measures were MDL weight lifted and perceived spine vulnerability. Significance was set at alpha ≤0.05. There were no between-group differences in weight lifted (p=0.40). Most subjects believed that the spine is vulnerable to injury. Three times as many subjects who received the resiliency education improved their beliefs about the vulnerability of their spines compared with those receiving the cautionary education (p<0.001). This study demonstrated the potential for brief resiliency education to positively influence beliefs about spine vulnerability, whereas cautionary education did not impair performance., (Copyright © 2024 National Strength and Conditioning Association.)

Background: Static balance is often impaired in patients after ankle sprains. The ability to identify static balance impairments is dependent on an effective balance assessment tool. The Sway Balance Mobile Application (SWAY App) (Sway Medical, Tulsa, OK) uses a smart phone or tablet to assess postural sway during a modified Balance Error Scoring System (mBESS) assessment and shows promise as an accessible method to quantify changes in static balance after injury., Purpose: The primary purposes of this study were to determine the ability to differentiate between those with ankle sprain versus controls (construct validity) and ability to detect change over time (responsiveness) of a mBESS assessment using a mobile device application to evaluate static balance after an acute ankle sprain., Study Design: Case-control study., Methods: Twenty-two military academy Cadets with an acute ankle sprain and 20 healthy Cadets were enrolled in the study. All participants completed an assessment measuring self-reported function, ankle dorsiflexion range of motion (via the weightbearing lunge), dynamic balance, and static balance. Static balance measured with the mBESS using the SWAY App was validated against laboratory-based measures. Cadets with ankle sprains completed their assessment twice: once within two weeks of injury (baseline) and again after four weeks of rehabilitation that included balance training. Independent and paired t-tests were utilized to analyze differences over time and between groups. Effect sizes were calculated and relationships explored using Pearson's correlation coefficients., Results: The mBESS scores measured by the SWAY App were lower in participants with acute ankle sprains than healthy Cadets ( t = 3.15, p = 0.004). Injured participants improved their mBESS score measured by SWAY at four weeks following their initial assessments ( t = 3.31, p = 0.004; Baseline: 74.2 +/- 16.1, 4-weeks: 82.7 +/- 9.5). The mBESS measured by the SWAY App demonstrated moderate to good correlation with a laboratory measure of static balance ( r = -0.59, p \< 0.001)., Conclusion: The mBESS assessed with a mobile device application is a valid and responsive clinical tool for evaluating static balance. The tool demonstrated construct (known groups) validity detecting balance differences between a healthy and injured group, concurrent validity demonstrating moderate to good correlation with established laboratory measures, and responsiveness to changes in static balance in military Cadets during recovery from an acute ankle sprain., Level of Evidence: Level 3., Competing Interests: The authors report no conflicts of interest., (© The Author(s).)

Background: Concussions are often accompanied by balance disturbances. Clinically accurate evaluation systems are often expensive, large, and inaccessible to most clinicians. The Sway Balance Mobile Application (SWAY) is an accessible method to quantify balance changes., Purpose: To determine the known groups and convergent validity of the SWAY to assess balance after a concussion., Study Design: Case-Control Study., Methods: Twenty participants with acute concussion and twenty controls were recruited. At initial, one-week, and final return to activity (RTA) evaluations, all participants completed the Sports Concussion Assessment Tool (SCAT-5), and balance control measured by SWAY mBESS and NeuroCom Balance Master Sensory Organization Test (SOT). Mixed model ANOVAs were used to detect differences in SWAY mBESS and NeuroCom SOT scores with time (initial, one-week, final RTA) as the within-subjects factor and group (concussed, healthy) as the between-subjects factor. Spearman's Rho correlations explored the associations between NeuroCom SOT scores, SWAY scores, SCAT-5 symptom scores, and time in days to final RTA., Results: The sampled population was predominantly male and age (20 ± 1), and BMI differences were insignificant between groups. The SWAY did not detect differences between healthy and concussed participants and did not detect change over time [F(2,40) = .114, p = 0.89; F(2,40)= .276, p =0.60]. When assessing the relationship between the SWAY and the SOT, no correlation was found at any time point (r = -0.317 to -0.062, p > 0.05). Time to RTA demonstrated a moderate correlation with both SCAT-5 symptom severity score (r = .693, p < 0.01) and SCAT-5 total symptom score (r = .611, p < 0.01) at the one-week follow-up., Conclusion: The SWAY mBESS does not appear to be a valid balance assessment for the concussed patient. The SWAY mBESS in patients with concussion failed to demonstrate convergent validity and did not demonstrate an ability to validate known groups. When assessing the time to final RTA, the one-week post-initial assessment SCAT-5 symptom severity and total scores may help determine the length of recovery in this population., Level of Evidence: Level 3., Competing Interests: The authors declare no conflicts of interest. This work was funded by the Telemedicine and Advanced Technology Research Center (TATRC) at the U.S. Army Medical Research and Development Command through the Advanced Medical Technology Initiative (AMTI). The views, opinions and/or findings contained in this research/presentation/publication are those of the author(s)/company and do not necessarily reflect the views of the Department of Defense and should not be construed as an official DoD/Army position, policy or decision unless so designated by other documentation. No official endorsement should be made. Reference herein to any specific commercial products, process, or service by trade name, trademark, manufacturer, or otherwise, does not necessarily constitute or imply its endorsement, recommendation, or favoring by the U.S. Government., (© The Author(s).)

Introduction: Running is the most common cardiovascular exercise in the military. However, there is a high incidence of running-related overuse injuries that reduces military readiness. Gait retraining is a common intervention to treat running-related injuries, but the high cost of equipment and lack of clinician expertise and availability reduces utilization. Gait retraining intervention in a telehealth format might improve feasibility. The purpose of this randomized clinical trial is to determine the effectiveness of a telehealth gait retraining intervention on pain, self-reported function, and biomechanical risk factors for injury in service members who present to a Military Health System physical therapy clinic with an overuse knee injury., Methods: This is a parallel, two-arm, single-blind randomized clinical trial. The two independent variables are intervention (2 levels: telehealth gait retraining intervention with standard of care or only standard of care) and time (3 levels: baseline, 10 weeks or post-intervention, 14 weeks). Participants between the ages of 18 to 60 years will be included if they report knee pain during and/or after running to be anywhere from a 3 to a 7 on the numerical pain rating scale and demonstrate a rearfoot strike pattern. The primary dependent variables are as follows: (1) pain (worst pain during and/or after running) and (2) foot strike pattern (conversion rate from rearfoot to non-rearfoot foot strike pattern during running). Secondary outcomes include patient self-reported function and running biomechanics., Discussion: The effectiveness of a telehealth gait retraining intervention to reduce pain and modify foot strike pattern is not known. The results of this study may help determine the effectiveness and feasibility of a telehealth gait retraining intervention to reduce pain, change foot strike, improve function, and improve running gait biomechanics., Trial Registration: ClinicalTrials.gov, NCT04269473 . Registered 05 February 2020., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Military physical therapists practicing direct-access routinely utilize diagnostic imaging and numerous published case reports demonstrate the ability of physical therapists to diagnose and appropriately disposition patients with foot/ankle and wrist/hand fractures. However, no larger cohort studies have explored the utilization of diagnostic imaging by physical therapists to detect fractures., Hypothesis/purpose: To describe the utilization of diagnostic imaging in foot/ankle and wrist/hand injuries by physical therapists in a direct-access sports physical therapy clinic., Study Design: Retrospective cohort study., Methods: The Agfa Impax Client 6 image viewing software (IMPAX) was searched from 2014 to 2018 for patients with diagnostic imaging ordered for foot/ankle and wrist/hand injuries. The Armed Forces Health Longitudinal Technology Application (AHLTA) electronic medical record was independently reviewed by the principal and co-investigator physical therapists. Data extracted were demographics and elements from the patient history and physical examination., Results: In foot/ankle injuries, physical therapists diagnosed a fracture in 16% of the 177 cases and waited for an average of 3.9 days and 1.3 visits before ordering imaging. In wrist/hand injuries, physical therapists diagnosed a fracture in 24% of the 178 cases and waited for an average of 3.7 days and 1.2 visits before ordering imaging. The time to definitive care from the initial physical therapy evaluation was significantly different (p = 0.04) for foot/ankle fractures (0.6 days) compared to wrist/hand fractures (5.0 days). The Ottawa Ankle Rules demonstrated a negative likelihood ratio (-LR) of 0.11 (0.02, 0.72) and a positive likelihood ratio (+LR) of 1.99 (1.62, 2.44) for the diagnosis of foot/ankle fracture., Conclusions: Physical therapists utilizing diagnostic imaging in a direct-access sports physical therapy clinic diagnosed fractures in similar proportions for foot/ankle and wrist/hand injuries and quickly dispositioned patients to definitive care for those fractures. The diagnostic accuracy of the Ottawa Ankle Rules was similar to previously reported values., Level of Evidence: Level 3.

Background: Traumatic shoulder instability is a common injury in athletes and military personnel. Surgical stabilization reduces recurrence, but athletes often return to sport before recovering upper extremity rotational strength and sport-specific abilities. Blood flow restriction (BFR) may stimulate muscle growth without the need for heavy resistance training post-surgically., Hypothesis/purpose: To observe changes in shoulder strength, self-reported function, upper extremity performance, and range of motion (ROM) in military cadets recovering from shoulder stabilization surgery who completed a standard rehabilitation program with six weeks of BFR training., Study Design: Prospective case series., Methods: Military cadets who underwent shoulder stabilization surgery completed six weeks of upper extremity BFR training, beginning post-op week six. Primary outcomes were shoulder isometric strength and patient-reported function assessed at 6-weeks, 12-weeks, and 6-months postoperatively. Secondary outcomes included shoulder ROM assessed at each timepoint and the Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST), the Upper Extremity Y-Balance Test (UQYBT), and the Unilateral Seated Shotput Test (USPT) assessed at the six-month follow-up., Results: Twenty cadets performed an average 10.9 BFR training sessions over six weeks. Statistically significant and clinically meaningful increases in surgical extremity external rotation strength ( p < 0.001; mean difference, .049; 95% CI: .021, .077), abduction strength ( p < 0.001; mean difference, .079; 95% CI: .050, .108), and internal rotation strength ( p < 0.001; mean difference, .060; CI: .028, .093) occurred from six to 12 weeks postoperatively. Statistically significant and clinically meaningful improvements were reported on the Single Assessment Numeric Evaluation ( p < 0.001; mean difference, 17.7; CI: 9.4, 25.9) and Shoulder Pain and Disability Index ( p < 0.001; mean difference, -31.1; CI: -44.2, -18.0) from six to 12 weeks postoperatively. Additionally, over 70 percent of participants met reference values on two to three performance tests at 6-months., Conclusion: While the degree of improvement attributable to the addition of BFR is unknown, the clinically meaningful improvements in shoulder strength, self-reported function, and upper extremity performance warrant further exploration of BFR during upper extremity rehabilitation., Level of Evidence: 4, Case Series., Competing Interests: The authors have no relevant or material financial interests that relate to this study. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the United States Army or Department of Defense.

Background: Overutilization of diagnostic imaging is associated with poor outcomes and increased costs. Physical therapists demonstrate the ability to order diagnostic imaging safely and appropriately, and early access to physical therapy reduces unnecessary imaging, lowers healthcare costs, and improves outcomes., Hypothesis/purpose: The primary purpose of this study was to compare rates of compliance with the National Committee for Quality Assurance - Healthcare Effectiveness Data and Information Set (HEDIS) recommendations for diagnostic imaging in low back pain between physical therapists and primary care providers in young, athletic patients., Study Design: Retrospective cohort study., Methods: Military Health System Data Repository (MDR) data from January 2019 to May 2020 was reviewed for compliance with the low back pain HEDIS recommendation. The low back pain imaging HEDIS measure identifies the percentage of patients who did not have an imaging study (plain X-ray, MRI, CT Scan) ordered on the first encounter with a diagnosis of low back pain or in the 28 days following that first diagnosis. Chi-square tests compared HEDIS compliance rates, with α = 0.05 set a priori., Results: From January 2019 to May 2020, in patients age 18-24, the MDR database identified 1,845 total visits for LBP identified in the Physical Therapy Clinic and 467 total visits for LBP in the Primary Care Clinic. In the Physical Therapy Clinic, 96.7% of encounters did not have imaging ordered within the first 28 days of onset of symptoms, compared with 82.0% in the Primary Care Clinic (p < .001)., Conclusions: Utilizing data from a national standardized healthcare performance measure, physical therapists practicing in a direct-access setting were significantly more likely than primary care providers to adhere to guidelines for low back pain imaging in young, athletic patients., Level of Evidence: Level 3., Competing Interests: The authors have no relevant or material financial interests that relate to this study. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the United States Army or Department of Defense.

Context: Recently, blood flow restriction (BFR) training has gained popularity as an alternative to high-load resistance training for improving muscle strength and hypertrophy. Previous BFR studies have reported positive treatment effects; however, clinical benefits to using BFR following meniscal repair or chondral surgery are unknown. The purpose of this study was to determine the effect of resistance exercises with BFR training versus exercises alone on self-reported knee function, thigh circumference, and knee flexor/extensor strength postmeniscal or cartilage surgery., Design: Single-blinded randomized controlled trial in an outpatient military hospital setting. Twenty participants were randomized into 2 groups: BFR group (n = 11) and control group (n = 9)., Methods: Participants completed 12 weeks of postoperative thigh strengthening. The BFR group performed each exercise with the addition of BFR. Both groups continued with the prescribed exercises without BFR from 12 weeks until discharged from therapy. Thigh circumference and self-reported knee function were measured at 1, 6, 12, and 24 weeks postoperatively along with knee extensor and flexor strength at 12 and 24 weeks. Change scores between time points were calculated for knee function. Limb symmetry indices (LSI) were computed for thigh circumference and knee strength variables., Results: Seventeen participants were included in the final analyses (BFR = 8 and control = 9) due to COVID-19 restrictions. There were no interactions or main effects for group. Time main effects were established for change in knee function scores, thigh circumference LSI, and knee extensor strength LSI. However, knee flexor strength LSI had no main effect for time., Conclusion: The outcomes of this trial suggest that resistance exercises with and without BFR training may result in similar changes to function, thigh atrophy, and knee extensor strength postmeniscus repair/chondral restoration, though further study with larger sample sizes is needed.

Introduction: Running-related musculoskeletal injury (RRI) among U.S. military service members continues to negatively impact force readiness. There is a paucity of evidence supporting the use of RRI interventions, such as gait retraining, in military populations. Gait retraining has demonstrated effectiveness in altering running biomechanics and reducing running load. The purpose of this pilot study was to investigate the clinical effect of a gait retraining intervention on a military cadet population recovering from a lower-extremity RRI., Materials and Methods: The study design is a pilot study. Before study initiation, institutional approval was granted by the Keller Army Community Hospital Office of Human Research Protections. Nine rearfoot strike (RFS) runners recovering from a lower-extremity RRI at the U.S. Military Academy were prospectively enrolled and completed a gait retraining intervention. Participants followed-up with their assigned medical provider 6 times over 10 weeks for a clinical evaluation and running gait retraining. Gait retraining was provided utilizing verbal, visual, and audio feedback to facilitate a change in running foot strike pattern from RFS to non-rearfoot strike (NRFS) and increase preferred running step rate. At pre-intervention and post-intervention running ground reaction forces (GRF) [average vertical loading rate (AVLR), peak vertical GRF], kinematic (foot strike pattern) and temporospatial (step rate, contact time) data were collected. Participants self-reported their level of function via the Single Assessment Numeric Evaluation, Patient-Specific Functional Scale, and total weekly running minutes. Paired samples t-tests and Wilcoxon signed rank tests were used to compare pre- and post-intervention measures of interest. Values of P < .05 were considered statistically significant., Results: Nine patients completed the 10-week intervention (age, 20.3 ± 2.2 years; height, 170.7 ± 13.8 cm; mass, 71.7 ± 14.9 kg; duration of injury symptoms, 192.4 ± 345.5 days; running speed, 2.8 ± 0.38 m/s). All nine runners (100%) transitioned from RFS to NRFS. Left AVLR significantly decreased from 60.3 ± 17.0 bodyweight per second (BW/s) before intervention to 25.9 ± 9.1 BW/s after intervention (P = 0.008; effect size (d) = 2.5). Right AVLR significantly decreased from 60.5 ± 15.7 BW/s to 32.3 ± 12.5 BW/s (P < .001; d = 2.0). Similarly, step rate increased from 169.9 ± 10.0 steps per minute (steps/min) before intervention to 180.5 ± 6.5 steps/min following intervention (P = .005; d = 1.3). Single Assessment Numeric Evaluation scores improved significantly from 75 ± 23 to 100 ± 8 (P = .008; d = 1.5) and Patient-Specific Functional Scale values significantly improved from 6 ± 2.3 to 9.5 ± 1.6 (P = .007; d = 1.8) after intervention. Peak vertical GRF (left, P = .127, d = 0.42; right, P = .052, d = 0.53), contact time (left, P = 0.127, d = 0.42; right, P = 0.052, d = 0.53), and total weekly continuous running minutes (P = 0.095, d = 0.80) remained unchanged at post-intervention. All 9 patients remained injury free upon a 6-month medical record review., Conclusions: In 9 military service members with a RRI, a 10-week NRFS gait retraining intervention was effective in improving running mechanics and measures of function. Patients remained injury-free 6 months following enrollment. The outcomes of this pilot study suggest that individuals recovering from certain lower-extremity RRIs may benefit from transitioning to an NRFS running pattern., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: There is a large incidence of shoulder instability among active young athletes and military personnel. Shoulder stabilization surgery is the commonly employed intervention for treating individuals with instability. Following surgery, a substantial proportion of individuals experience acute post-operative pain, which is usually managed with opioid pain medications. Unfortunately, the extended use of opioid medications can have adverse effects that impair function and reduce military operational readiness, but there are currently few alternatives. However, battlefield acupuncture (BFA) is a minimally invasive therapy demonstrating promise as a non-pharmaceutical intervention for managing acute post-operative pain., Methods: This is a parallel, two-arm, single-blind randomized clinical trial. The two independent variables are intervention (2 levels, standard physical therapy and standard physical therapy plus battlefield acupuncture) and time (5 levels, 24 h, 48 h, 72 h, 1 week, and 4 weeks post shoulder stabilization surgery). The primary dependent variables are worst and average pain as measured on the visual analog scale. Secondary outcomes include medication usage, Profile of Mood States, and Global Rating of Change., Discussion: The magnitude of the effect of BFA is uncertain; current studies report confidence intervals of between-group differences that include minimal clinically important differences between intervention and control groups. The results of this study may help determine if BFA is an effective adjunct to physical therapy in reducing pain and opioid usage in acute pain conditions., Trial Registration: ClinicalTrials.gov NCT04094246 . Registered on 16 September 2019.

An 18-year-old military cadet presented to a direct-access physical therapy clinic 3 days after sustaining a lateral patellar dislocation that self-reduced with extension of the knee. Suspecting a loose body, the physical therapist ordered radiographs, which did not demonstrate any associated fractures. Rapid disposition was required to determine her potential to participate in mandatory Army field training, so the patient was referred to an orthopaedic surgeon, who ordered magnetic resonance imaging to assess for intra-articular pathology. Magnetic resonance imaging demonstrated a full-thickness defect in the patellar cartilage at the medial facet, with a loose fragment in the suprapatellar pouch. J Orthop Sports Phys Ther 2019;49(1):36. doi:10.2519/jospt.2019.7599.

Objectives: Posterior cruciate ligament (PCL) injuries are relatively common injuries associated with athletic activities and high-energy trauma. Posterolateral corner (PLC) injuries frequently accompany injury to the PCL. Diagnosis can be challenging and requires a comprehensive history and physical examination. Patients frequently report vague, nonspecific symptoms and the mechanism of injury is often useful in localizing injured structures. Two of the more common mechanisms for PCL injury include a direct blow to the proximal anterior tibia with the knee flexed, as well as a significant knee hyperextension injury. With a PCL tear, patients rarely describe an audible "pop" that is commonly reported in ACL injuries. On physical exam, a frequent finding in PCL tears is a loss of 10 to 20° of knee flexion. Although the most common clinical tests for PCL tears include the posterior drawer test, the posterior sag sign, and the quadriceps active test, there is a lack of high-quality diagnostic accuracy studies., Materials and Methods: Two cases of U.S. Military Academy Cadets who sustained PCL injuries while removing combat boots during military survival swim training are presented. The results of the clinical examination are accompanied by magnetic resonance imaging results and intraoperative arthroscopic images to highlight key findings., Results: Both patients were evaluated and diagnosed with PCL injures within 10 days of their injuries. Each reported feeling/hearing a "pop," which is atypical in PCL tears. Both patients demonstrated a lack of active and passive knee flexion, which is a commonly reported impairment. One patient was managed nonsurgically with physical therapy and eventually returned to full duty without limitations 9 months after his injury. The other patient, who sustained a combined PCL-PLC injury, underwent a PCL reconstruction and PLC repair and reconstruction 8 weeks after his injury. He returned all training, with the exception of contact/collision sports, 9 months after surgery. Both patient's rehabilitation programs consisted of a progression of exercises to improve range of motion, muscle strength/endurance, motor control, and muscular power., Conclusion: Military and sports medicine professionals should be aware of the potential for PCL injury with this unusual, and previously unreported, mechanism of injury during survival swim training. Prompt diagnosis and appropriate treatment is essential to prevent long-term disability., (Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.)

Background: While advanced diagnostic imaging is a large contributor to the growth in health care costs, direct-access to physical therapy is associated with decreased rates of diagnostic imaging. No study has systematically evaluated with evidence-based criteria the appropriateness of advanced diagnostic imaging, including magnetic resonance imaging (MRI), when ordered by physical therapists. The primary purpose of this study was to describe the appropriateness of magnetic resonance imaging (MRI) or magnetic resonance arthrogram (MRA) exams ordered by physical therapists in a direct-access sports physical therapy clinic., Study Design: Retrospective observational study of practice., Hypothesis: Greater than 80% of advanced diagnostic imaging orders would have an American College of Radiology (ACR) Appropriateness Criteria rating of greater than 6, indicating an imaging order that is usually appropriate., Methods: A 2-year retrospective analysis identified 108 MRI/MRA examination orders from four physical therapists. A board-certified radiologist determined the appropriateness of each order based on ACR appropriateness criteria. The principal investigator and co-investigator radiologist assessed agreement between the clinical diagnosis and MRI/surgical findings., Results: Knee (31%) and shoulder (25%) injuries were the most common. Overall, 55% of injuries were acute. The mean ACR rating was 7.7; scores from six to nine have been considered appropriate orders and higher ratings are better. The percentage of orders complying with ACR appropriateness criteria was 83.2%. Physical therapist's clinical diagnosis was confirmed by MRI/MRA findings in 64.8% of cases and was confirmed by surgical findings in 90% of cases., Conclusions: Physical therapists providing musculoskeletal primary care in a direct-access sports physical therapy clinic appropriately ordered advanced diagnostic imaging in over 80% of cases. Future research should prospectively compare physical therapist appropriateness and utilization to other groups of providers and explore the effects of physical therapist imaging privileging on outcomes., Level of Evidence: Diagnosis, Level 3.

Objectives: Severe lower extremity trauma accounts for large healthcare costs and often results in elective amputation and poor long-term outcomes. The purpose of this case series is to describe an orthopedic manual physical therapy (OMPT) approach combined with a return to run (RTR) clinical pathway consisting of high-intensity functional rehabilitation with a custom energy-storing orthosis., Methods: Three consecutive male patients, aged 21-23 years, with severe lower extremity musculoskeletal injuries were treated with a combined intervention that included a mean (SD) of 12 (2·1) OMPT sessions and 24 (8·7) functional rehabilitation sessions over a mean of 6 weeks (1·0). Additional training with a custom energy-storing orthosis consisted of a mean of 15 (1·2) additional sessions over 4 weeks. Patient self-report outcome measures and a variety of physical performance tests captured change in function., Results: Baseline lower extremity functional scale (LEFS) and foot and ankle ability measure activities of daily living subscale (FAAM-ADL) scores indicated severe disability. All patients exceeded the minimal clinically important difference (MCID) in at least one self-report outcome or physical performance test without a brace. Two of three patients exceeded the MCID for at least two physical performance tests after training with and utilizing a custom energy-storing orthosis., Discussion: Clinically meaningful changes in self-reported function or physical performance were observed in all patients. A multi-modal approach, including manual therapy and functional exercise, may address the entire spectrum of impairments in patients with severe lower extremity trauma, resulting in improvements in both braced and un-braced function.

The patient was a 21-year-old male cadet at a military academy who was evaluated by a physical therapist in a direct-access capacity for a chief complaint of left wrist pain that began 1 day after injuring his wrist while performing a bench-press exercise. Due to concern for a scaphoid fracture and because radiographic imaging was not immediately available, a physical therapist credentialed to utilize fluoroscopy evaluated the left wrist. Radiographs were subsequently ordered, which confirmed a mid-waist, nondisplaced scaphoid fracture.

Study Design: Case report., Background: Comprehensive treatment strategies are needed for individuals with glenohumeral joint osteoarthritis (OA), especially when they are young and active. Prior dislocation, with or without subsequent shoulder stabilization surgery, complicates the clinical presentation and increases the risk of OA progression. The purpose of this case report was to describe an orthopaedic manual physical therapy approach used in a patient with glenohumeral joint OA who presented with shoulder pain and impaired movement. CASE DESCRIPTION A 38-year-old male military officer presented with left-shoulder pain of 2 months in duration that was unrelieved with a subacromial injection. He reported a history of anterior-inferior dislocation with subsequent stabilization surgery 15 years prior and arthroscopic subacromial decompression 2 years prior. Physical examination demonstrated painful limitations in shoulder elevation and internal/external rotation movements, stiffness with testing using accessory glides, and rotator cuff and scapular musculature weakness associated with pain., Outcomes: Treatment consisted of 5 sessions provided over 4 weeks. The plan of care included manual physical therapy, exercises, and progressive functional activities specifically tailored to the patient's clinical presentation. Shoulder Pain and Disability Index scores decreased from 43% to 17%, and the Patient-Specific Functional Scale average score improved from 3.0 to 7.3 out of 10. After 4 additional weeks of a home exercise program, the Shoulder Pain and Disability Index score was 4% and Patient-Specific Functional Scale average score was 9.0. Improvements in self-reported function were maintained at 6 months. Four "booster" treatment sessions were administered at 9 months, contributing to sustained outcomes through 1 year., Discussion: In a young, active patient with glenohumeral joint OA, clinically meaningful short-term improvements in self-reported function and pain, maintained at 1 year, were observed with manual physical therapy and exercise., Level of Evidence: Therapy, level 4.

The patient was a 34-year-old woman who was referred to a physical therapist for a chief complaint of progressively worsening right buttock pain with paresthesias of the right posterior thigh and calf. Prior magnetic resonance imaging of the patient's lumbar spine revealed a large left paracentral disc extrusion at L5-S1. Following physical therapist intervention, the patient reported a new onset of left posterior thigh pain, with paresthesias of the dorsolateral aspect of the left foot. Repeat magnetic resonance imaging of the patient's lumbar spine revealed an increase in the size of the disc extrusion at L5-S1.

Unlabelled: Accurate diagnosis and management of knee pain with or without mechanical symptoms challenges the physical therapist's clinical reasoning skills. Meniscal cysts are one relatively rare disorder of the knee that can cause both pain and mechanical symptoms and are frequently associated with a meniscal tear. In patients with suspected meniscal cysts, systematic differential diagnosis and sound clinical reasoning encourages appropriate integration of the clinical examination with diagnostic imaging. These case reports describe two different presentations of lateral parameniscal cysts where integration of the clinical examination with appropriate imaging allowed the physical therapist to provide a timely and appropriate intervention. In both cases, the diagnostic process is described along with the subsequent interventions that lead to positive outcomes., Level of Evidence: 5 (Case Report).

Synopsis: Physical therapists frequently encounter situations that require complex differential-diagnosis decisions and the ability to consistently screen for serious pathology that may mimic a musculoskeletal complaint. By applying the evidence-based-practice process to diagnosis, screening, and referral, physical therapists can identify diagnostic and screening strategies that positively influence clinical decisions. A critically appraised topic document (a standard 1-page summary of the literature appraisal and clinical relevance in response to a specific clinical question) is a valuable tool in evidence-based practice. The creation of a critically appraised topic makes the educational process cumulative instead of duplicative, allowing the individual clinician to assimilate and consolidate knowledge after a search effort and improving search and appraisal skills. The purpose of this clinical commentary is as follows: (1) to describe the clinical reasoning process of 3 orthopaedic physical therapists that led to the development of specific clinical questions related to screening for nonmusculoskeletal pathology, (2) to describe the search and triage strategy that led each physical therapist to the current best evidence needed to rule out nonmusculoskeletal pathology in the patient, and (3) to discuss the advantages and disadvantages of a critically appraised topic, the implementation of this process, and the tailoring of search strategies to find diagnostic and screening strategies.

Objectives: A recent clinical prediction rule (CPR) identified characteristics that may predict an immediate reduction in pain following lumbopelvic manipulation in patients with patellofemoral pain syndrome. The purpose of this single-arm cohort study was to replicate the proposed CPR in a different population and investigate changes in self-reported pain, hip range of motion, strength, and function immediately following lumbopelvic manipulation., Methods: Forty-four subjects (63·6% female; mean age 27·4 years) met inclusion criteria. Hip internal rotation range of motion, lower extremity strength using a handheld dynamometer, and single/triple hop tests were assessed prior to and immediately following a spinal manipulation. A global rating of change questionnaire was administered after testing and telephonically at 1 week. Paired t-tests compared pre- and post-manipulation range of motion, strength, and hop test limb symmetry indices (α = 0·05)., Results: Fifty-seven percent of subjects had a successful outcome measured by the numerical pain rating scale immediately following manipulation. Twenty-five of subjects experienced a successful outcome as measured by the global rating of change questionnaire at 1 week. No single individual or combination of predictor variables predicted a positive outcome immediately following the lumbopelvic manipulation (+likelihood ratio 0·7 with three of five predictor variables present). Statistically significant differences (P<0·05) were found in hip extension and abduction strength and hip internal rotation symmetry post-manipulation, but do not appear to be clinically meaningful., Discussion: The previously identified CPR was not able to be replicated and no clinically meaningful changes in range of motion, strength, or function were apparent. Future research should focus on a comprehensive impairment-based treatment approach in patients with patellofemoral pain syndrome.