Prevalence of Pain With Movement in Active Duty US Army Soldiers.

INTRODUCTION: Soldiers must be able to perform a multitude of physically demanding tasks as part of their regular duty, but their physical readiness is often degraded due to pain and musculoskeletal injury (MSKI). The presence of pain with movement has been associated with increased MSKI risk in Soldiers. Improved awareness of the prevalence of painful movements in uninjured Soldiers could help inform Army injury mitigation efforts. The purpose of this study was to identify the prevalence of pain with movement in a population of healthy active duty Soldiers. MATERIALS AND METHODS: The Selective Functional Movement Assessment-Top Tier Movements (SFMA-TTM), active range of motion (AROM) of the hips and shoulders, and the elicitation of pain with movement were measured in 268 healthy US Army Soldiers. Descriptive statistics were generated for the number of painful movements for each measure and inferential statistics; independent t-test and one-way independent analysis of variance (ANOVA) were used for analysis of the other measures. RESULTS: Greater than half (59%) of the participants reported pain with at least 1 movement and more than 41% reported pain with 2 or more movements. Soldiers reported a mean of 1.35 painful movements on the SFMA-TTM assessment and a mean of 1.54 painful AROM movements. CONCLUSIONS: Pain with functional movement patterns was common across a sample of uninjured Soldiers. The presence of pain with movement warrants further evaluation as it may impact a Soldier's physical performance, risk for future injury, and overall quality of life.

The Presence of Hip Joint Effusion on MRI Is Predictive of a Grade 4 Femoral Neck Stress Injury.

INTRODUCTION: One of the most debilitating types of bone stress injuries is those occurring at the femoral neck. This problem occurs in the military population with much higher incidence than in the normal population and is of great concern to military medical providers. Early detection and accurate diagnosis are key in protecting soldiers and recruits from sustaining a potentially career-ending fracture. In a case study, a 16-year-old elite male distance runner presented with hip pain. MRI found hip joint effusion but was unremarkable for marrow edema and a low-signal fracture line. The initial diagnosis was acute arthritis; however, a follow-up radiograph 1 month later, after the patient had been refraining from running, confirmed a significant non-displaced compression-side Grade 4 femoral neck stress injury (FNSI). In light of the case study and our similar clinical experience, we tested the hypothesis that an MRI study positive for an FNSI, combined with the evidence of a hip joint effusion, is indicative of a Grade 4 FNSI, even without visualization of a low-signal intensity fracture line on T1 or short tau inversion recovery images. MATERIALS AND METHODS: Recruits in Army Basic Combat Training were included in the investigation if 1) diagnosed with a unilateral FNSI, 2) had an initial positive MRI for an FNSI, 3) had a positive bone scan for uptake in the femoral neck area (to validate the diagnosis), 4) had no other hip/pelvis injuries, and 5) had a follow-up MRI within 60 days. Hip joint effusion was defined as 1) ≥2-mm measurable difference in the thickness of fluid along the length of the involved femoral neck when compared to the contralateral uninvolved femoral neck on the initial MRI; 2) visibly assessed as a prominent collection of fluid distending the posterior hip joint capsule on the initial MRI coronal short tau inversion recovery sequence (called the "flash sign"). RESULTS: A total of 162 recruits met the study inclusion criteria. For the detection of a Grade 4 FNSI on the first MRI, the sensitivity, specificity, and positive predictive value of the measured joint effusion criteria were 0.52, 0.94, and 0.89, respectively. or the non-measured flash sign, these values were 0.70, 0.83, and 0.80, respectively. CONCLUSIONS: Both the measured hip joint effusion criteria and the non-measured flash sign were predictive of a Grade 4 FNSI and may be useful in clinical evaluation.

Predicting Postoperative Injury and Military Discharge Status After Knee Surgery in the US Army.

BACKGROUND: Researchers have assessed postoperative injury or disability predictors in the military setting but typically focused on 1 type of surgical procedure at a time, used relatively small sample sizes, or investigated mixed cohorts with civilian populations. PURPOSE: To identify the relationship between baseline variables and injury incidence or military discharge status in US Army soldiers after knee surgery. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Data were obtained from a repository containing personnel, performance, and medical records for all active-duty US Army soldiers. Multivariate logistic regressions were used to estimate the effects of numerous variables on postoperative injury or on medical discharge. Variable selection and model validation were conducted using the k-fold method. RESULTS: A total of 7567 soldiers underwent knee surgery between 2017 and 2019. Meniscal procedures were the most common type of surgery (39%), and approximately 71% of the cohort had a postoperative injury. Significant predictors for sustaining a postoperative injury included having a previous nonknee injury (odds ratio [OR], 1.5), female sex (OR, 1.3), and Black race (OR, 1.2). Within 4 years after surgery, 17% of soldiers were discharged from the military because of knee-related disability. Significant predictors for discharge from duty included enlisted rank (OR, 2.3), recent fitness test failure (OR, 1.9), number of previous knee surgeries (OR, 1.7), and having a previous nonknee injury (OR, 1.6). CONCLUSION: After knee surgery, nearly three-fourths of the soldiers in this cohort sustained a postoperative injury and almost one-fifth of soldiers were medically discharged from the military within 4 years. This study identified variables that indicate statistically increased risk for these postoperative outcomes and highlighted potentially modifiable factors.

Timing of Outcomes and Expectations After Knee Surgery in the US Military: A Systematic Review.

CONTEXT: Knee injury and subsequent surgery are widespread in the military setting. Associations between knee surgery and expected outcomes over time have not been consolidated and characterized systematically by procedure type across the body of literature, and the temporal expectations of these outcomes remain unclear. OBJECTIVE: To summarize common postoperative follow-up times and associated outcomes that determine clinical or surgical failure in US service members after elective knee surgery. DATA SOURCES: A systematic search was conducted with 3 bibliographic databases of published research reports from 2010 through 2021. STUDY SELECTION: Studies in US military service members undergoing elective knee surgery, with a minimum of 1-year follow-up, and reporting on a functional/occupational outcome were included. Three reviewers screened all abstracts and full-text articles to determine eligibility. STUDY DESIGN: Systematic review of longitudinal cohort studies. LEVEL OF EVIDENCE: Level 2a. DATA EXTRACTION: Extracted data included military demographics, surgical procedure variables, surveillance period, and outcome measures. The Newcastle-Ottawa Scale and the Grading of Recommendations Assessment, Development, and Evaluation approach were used to determine study quality and risk of bias. RESULTS: A total of 22 studies (mean follow-up time of 40.7 months) met the inclusion criteria. For cruciate ligament repair, approximately one-third of patients required a second surgery or were medically separated from military service by 2 years from surgery; 100% were reinjured by 4 years, and 85% sustained a new injury within 5 years of surgery. For meniscal repair, nearly one-third of patients were medically separated, and half were placed on activity restrictions within 3 years of surgery. For articular cartilage repair, within 5 years, 39% of patients required a second surgery, 30% were placed on activity restrictions, and 36% were medically separated. For patellar repair, 37% of patients were medically separated and over half were placed on activity restrictions within 5 years. CONCLUSION: Common knee surgeries can have long-term implications for military careers that may not become apparent with shorter follow-up periods (<2 years). When longer surveillance periods are used (eg, up to 5 years), additional surgical procedures are more common and the likelihood of being injured or medically separated from military service is higher.

A Population-Level Summary of Health Care Utilization for the Management of Patellar Tendinopathy in the Military Health System.

Patellar tendinopathy (PT) is a common nontraumatic orthopaedic disorder of the knee suffered by many service members. Understanding the make-up of usual care for PT at the system level can better frame current clinical gaps and areas that need improvement. Exercise therapy is recommended as a core treatment for PT, but it is unclear how often it is used as a part of usual care for PT within the Military Health System (MHS). The purpose of the study was to identify interventions used in the management of PT and the timing of these interventions. A secondary purpose was to determine if exercise therapy use was associated with reduced recurrence of knee pain. In total, 4,719 individuals aged 17 to 50 years in the MHS diagnosed with PT between 2010 and 2011 were included. Pharmacological and nonpharmacological interventions, visits to specialty providers, and imaging services were captured. Descriptive statistics were used to report the findings. Interventions were further categorized as being part of initial care (within the first 7 days), the initial episode of care (within the first 60 days), or the 2-year time period after diagnosis. Linear regression assessed the relationship between the number of exercise therapy visits in the initial episode of care and recurrences of knee pain. In total, 50.6% of this cohort had no more than one medical visit total for PT. Exercise therapy (18.2%) and nonsteroidal anti-inflammatory drugs (4.3%) were the two most used interventions in the initial episode of care. Radiographs were ordered for 23.1% of the cohort in the initial episode of care. The number of exercise therapy visits a patient received during the initial episode of care was not associated with recurrences of knee pain. Half of the individuals received no further care beyond an initial visit for the diagnosis of PT. Exercise therapy was the most common intervention used during the initial episode of care, but exercise therapy did not influence the recurrence of knee pain.

Differences in Outcomes between Patellar Dislocations Managed in Emergent versus Non-Emergent Care Settings.

Patellar dislocations occur at a much higher rate in military than civilian populations. Past population-level studies have shown that surgical management is as good as or superior to conservative care and may reduce future reoccurrences. Although in acute cases and in civilian clinics, patellar dislocations are usually managed first in an emergent care setting, previous work suggests this can lead to increased costs. This study compared differences in downstream care type and intensity of services based on whether initial care occurred in emergent or non-emergent care settings. In our sample of 1,523 Military Health System (MHS) beneficiaries with patellar dislocation and 2-year follow-up, we found non-significant differences in costs, intensity of services, and rates of surgical repair regardless of whether the patient was initially seen in an emergent versus non-emergent care setting. Although we found significant increases in the use of imaging, patellar dislocation-related medical visits, and frequency of closed treatment approaches in emergent care settings, these values were very small and likely not clinically significant. These findings, which included all the patellar dislocations reported across the entire MHS in a 24-month period, suggest that neither emergent nor non-emergent care settings are likely to influence the long-term care received by the individual.

Upper Extremity Superficial Vein Thromboses Presenting as Acute Neck Pain in a Young and Healthy Male: A Case Report.

BACKGROUND AND PURPOSE: Neck pain in the United States is pervasive and contributes to disability. While the majority of neck pain in young and healthy individuals is neuromusculoskeletal in nature, screening for red flags is necessary for ruling-out serious medical pathologies. The purpose of this case report is to describe a young and healthy male subject with a primary complaint of acute neck pain with multiple underlying upper extremity superficial vein thromboses (UESVTs). CASE DESCRIPTION: The subject was a 27-year-old male active-duty Soldier referred to physical therapy by his primary care provider (PCP) for acute left-sided neck pain. Prior to physical therapy, the subject had been treated with cyclobenzaprine, oxycodone-acetaminophen, trigger point injection and had undergone a D-dimer to rule out a potential thrombus due to air travel and lower extremity immobilization. OUTCOMES: The subject underwent a D-dimer, Doppler ultrasound, pharmacological treatment of Rivaroxaban, and was referred to hematology/oncology to rule out systemic causes of SVTs. Evidence of subtle increases in blood pressure over the course of three months, a positive D-dimer, and symptoms incongruent with clinical presentation contributed to referral to a hematology/oncology specialist and a diagnosis of multiple UESVTs. The subject was able to return to his previous level of activity by six months and remained free of SVTs at two-year follow-up. DISCUSSION: UESVT events are rare and can be challenging to identify. This case report describes a unique presentation of acute neck pain caused by underlying UESVTs in an otherwise healthy and active young male. LEVEL OF EVIDENCE: Level 4.

Self-Reported Musculoskeletal Injury Healthcare-Seeking Behaviors in US Air Force Special Warfare Personnel.

PURPOSE: This study evaluated the musculoskeletal injury (MSKI) self-reporting behaviors among active-duty Air Force Special Warfare personnel to explore potential limitations of injury surveillance approaches. METHODS: Participants completed a 47-item survey between December 2018 and March 2019 regarding their MSKI history. Participants were asked if they sought medical care for symptoms consistent with MSKIs and reasons they did or did not report their injuries. Injury reporting rates were calculated with descriptive statistics and rank ordering was utilized to determine frequency. RESULTS: A total of 398 airmen reported 1,057 injuries occurring in the previous 12-month period, including 508 (48%) injuries identified as not reported to medical personnel. Approximately 55% (N = 579) of all injuries were described as gradual onset. The most common reason for not reporting injuries (28.8%, N = 62) was "fear of potential impact on future career opportunities." CONCLUSION: Approximately half of MSKIs in this sample of US Air Force Special Warfare personnel were not reported to medical personnel. The underreporting of injuries may pose unknown levels of risk and negatively impact military readiness levels.

Fractures and Chronic Recurrence are Commonly Associated with Ankle Sprains: a 5-year Population-level Cohort of Patients Seen in the U.S. Military Health System.

BACKGROUND: Whereas ankle-foot injuries are ubiquitous and affect ~16% of military service-members, granularity of information pertaining to ankle sprain subgroups and associated variables is lacking. The purpose of this study was to characterize and contextualize the burden of ankle sprain injuries in the U.S. Military Health System. METHODS: This was a retrospective cohort study of beneficiaries seeking care for ankle sprains, utilizing data from the Military Health System Data Repository from 2009 to 2013. Diagnosis and procedural codes were used to identify and categorize ankle sprains as isolated lateral, isolated medial, concomitant medial/lateral, unspecified, or concomitant ankle sprain with a malleolar or fibular fracture. Patient characteristics, frequency of recurrence, operative cases, and injury-related healthcare costs were analyzed. RESULTS: Of 30,910 patients included, 68.4% were diagnosed with unspecified ankle sprains, 22.8% with concomitant fractures, (6.9%) with isolated lateral sprains, (1.7%) with isolated medial sprains and 0.3% with combined medial/lateral sprains. Pertaining to recurrence, 44.2% had at least one recurrence. Sprains with fractures were ~2-4 times more likely to have surgery within one year following injury (36.2% with fractures; 9.7% with unspecified sprains) and had the highest ankle-related downstream costs. CONCLUSION: Fractures were a common comorbidity of ankle sprain (one in five injuries), and operative care occurred in 16.4% of cases. Recurrence in this cohort approximates the 40% previously reported in individuals with first-time ankle sprain who progress to chronic ankle instability. Future epidemiological studies should consider reporting on subcategories of ankle sprain injuries to provide a more granular assessment of the distribution of severity. LEVEL OF EVIDENCE: 3b.

Cervical Fracture With Posterior Ligamentous Injury While Skydiving.

A 46-year-old male soldier reported to an emergency department with severe acute neck pain immediately following a hyperflexion injury during recreational skydiving. He was evaluated in the emergency department, including radiographs, and released with a diagnosis of "acute neck strain." After presenting with continued neck pain, he was sent for consultation with a physical therapist. The physical therapist ordered cervical spine radiographs, which revealed findings consistent with cervical fracture and ligamentous disruption. In addition, the radiologist recommended computed tomography and magnetic resonance imaging, which confirmed bilateral C6 lamina fractures and multiple ligamentous disruption at C5-6. J Orthop Sports Phys Ther 2019;49(2):113. doi:10.2519/jospt.2019.8360.

Surveyed Reasons for Not Seeking Medical Care Regarding Musculoskeletal Injury Symptoms in US Army Trainees.

INTRODUCTION: Musculoskeletal injuries (MSKIs) pose a significant threat to military readiness and are difficult to monitor due to Soldiers' reluctance to seek medical treatment. There is high risk of developing MSKIs while going through initial entry training (IET), many of which go unreported. The purposes of this study were to identify the contributing factors that influence US Army trainees to not seek medical care for self-reported symptoms of musculoskeletal injury (SMSKI) and establish how those factors may differ by sex, training school, and installation site. MATERIALS AND METHODS: Data were collected from 739 trainees (607 males, 132 females) completing IET at either Fort Benning, GA, Fort Sill, OK or Fort Leonard-Wood, MO, USA. Male trainees were in combat arms jobs while female trainees were from both combat arms and other physically demanding jobs. All surveys were completed within 5 weeks of graduation from Advanced Individual Training and One Station Unit Training. Trainees answered a series of questions about SMSKIs sustained during IET that lasted seven or more days. Using a Likert-type scale (1-strongly disagree through 5-strongly agree), trainees rated the influence that each of the following seven statements contributed to their decision not to seek medical care: "graduating on time," "avoiding negative perceptions associated with injuries," "avoiding profile," "inconvenience in seeing a provider," "self-managing the injury based on past experience," "severity of the injury," and "prior negative experiences seeking medical care in the military." Pearson's Chi-square test was used to assess significant relationships among SMSKI reporting across sex, training school and training installation. RESULTS: Overall, SMSKI incidence was 36.1% and 58.3% among IET male and female trainees, respectively (40% overall). Nearly two-thirds (64%) of all trainees injured during IET had a SMSKI that they did not report to leadership or a medical provider. Across sex, female trainees were more likely to report SMSKIs than male trainees (p < 0.01), but there was no difference in SMSKI reporting rates by sex (p = 0.48). There was a difference in SMSKI rates by training school (p < 0.01), where infantry had higher SMSKI rates than field artillery (p < 0.01). There were no differences across training schools in how often trainees sought medical care (p = 0.58). The most common reasons selected for not reporting SMSKIs (i.e., not seeking medical care) included "I wanted to graduate on time" and "I wanted to avoid a profile." "I had prior negative experiences seeking medical care in the military" was consistently rated as the least important reason. Female trainees were more likely to not report SMSKIs in order "to avoid a profile" than male trainees (p < 0.05). CONCLUSION: Over 64% of trainees' did not seek medical care for their SMSKI during IET. As early detection, better reporting and timely treatment may result in reductions in SMSKI severity, reduced IET attrition, and lower medical expenses, trainees should be encouraged to report SMSKIs for proper early stage treatment. These study findings could be used to assist military leadership to create a positive environment for reporting and seeking care for SMSKIs.

Increased Glenoid Retroversion Is Associated With Increased Rotator Cuff Strength in the Shoulder.

BACKGROUND: The rotator cuff muscles are critical secondary stabilizers in the shoulder. Increased glenoid retroversion and rotator cuff strength have been associated with the risk of posterior shoulder instability; however, the effect of increased glenoid retroversion on rotator cuff strength remains unclear. PURPOSE/HYPOTHESIS: The purpose was to examine the association between glenoid version and rotator cuff strength in the shoulder in a young and healthy population with no history of shoulder instability. The hypothesis was that increased glenoid retroversion would be associated with increases in rotator cuff muscle strength. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A prospective cohort study was conducted over a 4-year period within a high-risk population to identify the risk factors for shoulder instability. Analyzed participants included 574 freshmen entering a United States service academy. Baseline data collected upon entry into the study included magnetic resonance imaging measurements of glenoid version. Rotator cuff strength was also assessed at baseline using a handheld dynamometer. Internal and external rotation strength were assessed with the glenohumeral joint positioned in neutral and in 45° of abduction. The current study represents an analysis of the baseline data from this cohort. RESULTS: The mean age, height, and weight of participants was 18.77 ± 0.97 years, 176.81 ± 8.48 cm, and 73.80 ± 12.45 kg, respectively. The mean glenoid version at baseline was 7.79°± 4.85° of retroversion. Univariate linear regression analyses demonstrated that increased glenoid retroversion was associated with increased internal and external rotation strength of the rotator cuff in neutral and 45° of abduction (P < .001). Similar results were observed in multivariable models controlling for important confounding variables. CONCLUSION: The results of this study demonstrate that as glenoid retroversion increases, internal and external rotation strength of the rotator cuff also increase in a young and healthy athletic population. These compensatory changes may contribute to increased glenohumeral dynamic stability in the presence of worse static stability with increasing retroversion.

Changes in deep abdominal muscle thickness during common trunk-strengthening exercises using ultrasound imaging.

STUDY DESIGN: Cross-sectional study design. OBJECTIVES: To characterize changes in muscle thickness in the transversus abdominis (TrA) and internal oblique (IO) muscles during common trunk-strengthening exercises, and to determine whether these changes differ based on age. BACKGROUND: Although trunk-strengthening exercises have been found to be useful in treating those with low back pain (LBP), our understanding of the relative responses of the TrA and IO muscles during different exercises is limited. METHODS AND MEASURES: Six commonly prescribed trunk-strengthening exercises were performed by 120 subjects (40 subjects per age group: 18-30, 31-40, and 41-50 years). Ultrasound imaging was used to measure the thickness of the TrA and IO during the resting and contracted state of each exercise. The average thickness of the muscles while in the contracted position was divided by the thickness values in the resting position for each exercise, based on 2 performances of each exercise. Two 3-by-6 repeated-measures analyses of variance were used to determine significant changes in muscle thickness of the TrA and IO, based on age group and exercise performed. RESULTS: For both muscles, the trunk exercise-by-age interaction effect (TrA, P = .358; IO, P = .217) and the main effect for age (TrA, P = .615; IO, P = .219) were not significant. A significant main effect for trunk exercise for both muscles (P<.001) was found. The horizontal side-support (mean +/- SD contracted-rest thickness ratio: TrA, 1.95 +/- 0.69; IO, 1.88 +/- 0.52) and the abdominal crunch (mean +/- SD contracted-rest thickness ratio: TrA, 1.74 +/- 0.48; IO, 1.63 +/- 0.41) exercises resulted in the greatest change in muscle thickness for both muscles. The abdominal drawing-in maneuver (mean +/- SD contracted-rest thickness ratio: TrA, 1.73 +/- 0.36; IO, 1.14 +/- 0.33) and quadruped opposite upper and lower extremity lift (mean +/- SD contracted-rest thickness ratio: TrA, 1.59 +/- 0.49; IO, 1.25 +/- 0.36) exercises resulted in changes in TrA muscle thickness with minimal changes in IO muscle thickness. CONCLUSION: Changes in TrA and IO muscle thickness differed across 6 commonly prescribed trunk-strengthening exercises among healthy subjects without LBP. These differences did not vary by age. This information may be useful for informing exercise prescription.

DIAGNOSTIC IMAGING IN A DIRECT-ACCESS SPORTS PHYSICAL THERAPY CLINIC: A 2-YEAR RETROSPECTIVE PRACTICE ANALYSIS.

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.

Morel-Lavallée lesion of the lumbar region.

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 low back pain that began the previous day after falling directly onto his back while snowboarding. Given the patient's history of trauma, worsening low back pain, and enlarged soft tissue mass in the lumbar region, the physical therapist ordered magnetic resonance imaging. The findings were consistent with a Morel-Lavallée lesion of the lumbar region.

Treatment of subacute posterior knee pain in an adolescent ballet dancer utilizing trigger point dry needling: a case report.

STUDY DESIGN: Case Report. BACKGROUND AND PURPOSE: Dry needling (DN) is an increasingly popular intervention used by clinicians as a treatment of regional neuromusculoskeletal pain. DN is an invasive procedure that involves insertion of a thin monofilament needle directly into a muscle trigger point (MTP) with the intent of stimulating a local twitch response. Current evidence is somewhat limited, but recent literature supports the use of this intervention in specific neuromusculoskeletal conditions. The purpose of this case report is to present the outcomes of DN as a primary treatment intervention in an adolescent subject with subacute posterior knee pain. CASE DESCRIPTION: The subject was a 16-year-old female competitive ballet dancer referred to physical therapy with a two month history of right posterior knee pain. Palpation identified MTPs which reproduced the patient's primary symptoms. In addition to an exercise program promoting lower extremity flexibility and hip stability, the subject was treated with DN to the right gastrocnemius, soleus, and popliteus muscles. OUTCOMES: The subject reported being pain free on the Numerical Pain Scale and a +7 improvement in perceived change in recovery on the Global Rating of Change at final follow-up. Physical examination demonstrated no observed impairments or functional limitations, including normal mobility, full strength, and unrestricted execution of dance maneuvers. DISCUSSION: The patient was able to return to high level dance training and competition without physical limitations and resumed pre-injury dynamic movement activities including dancing, running, jumping, and pivoting without pain. DN can be an effective and efficient intervention to assist patients in decreasing pain and returning to high intensity physical activity. Additional research is needed to determine if DN is effective for other body regions and has long-term positive outcomes. LEVEL OF EVIDENCE: Level 4.

Diagnosis and expedited surgical intervention of a complete hamstring avulsion in a military combatives athlete: a case report.

BACKGROUND AND PURPOSE: Hamstring injuries are frequent injuries in athletes, with the most common being strains at the musculotendinous junction or within the muscle belly. Conversely, hamstring avulsions are rare and often misdiagnosed leading to delay in appropriate surgical interventions. The purpose of this case report is to describe the history and physical examination findings that led to appropriate diagnostic imaging and the subsequent diagnosis and expedited surgical intervention of a complete avulsion of the hamstring muscle group from the ischium in a military combatives athlete. CASE DESCRIPTION: The patient was a 25 year-old male who sustained a hyperflexion injury to his right hip with knee extension while participating in military combatives, presenting with acute posterior thigh and buttock pain. History and physical examination findings from a physical therapy evaluation prompted an urgent magnetic resonance imaging (MRI) study, which led to the diagnosis of a complete avulsion of the hamstring muscle group off the ischium. OUTCOME: Expedited surgical intervention occurred within 13 days of the injury potentially limiting comorbidities associated with delayed diagnosis. CONCLUSION: Recognition of the avulsion led to prompt surgical evaluation and intervention. Literature has shown that diagnosis of hamstring avulsions are frequently missed or delayed, which results in a myriad of complications. LEVEL OF EVIDENCE: Level 4.

Cysts of the lateral meniscus.

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).

Posterior labral tear with a paralabral cyst causing suprascapular nerve compression.

The patient was a 21-year-old man who was currently enrolled in a military academy. He was seen by a physical therapist in a direct-access capacity for a chief complaint of right shoulder fatigue and discomfort that was present for the past week. Due to marked atrophy and weakness with no history of injury, an orthopaedic surgeon was consulted and diagnostic imaging was requested. Magnetic resonance imaging revealed a posterior labral tear with a large paralabral cyst, likely resulting in significant compression of the suprascapular nerve.

Isolated posterior cruciate ligament injury.

The patient was a 19-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 right knee pain and giving way after falling onto his right knee while snow sledding at a high rate of speed 2 weeks earlier. Knee radiographs were ordered by the physical therapist, which demonstrated a large suprapatellar joint effusion. Due to concern for a posterior cruciate ligament injury and to assess for concomitant injury, magnetic resonance imaging was ordered, which revealed disruption of the posterior cruciate ligament without injury to surrounding tissues.