Diagnosis of Ewing's Sarcoma After a Fall.

A 21-year-old male Army basic trainee was evaluated in a direct-access physical therapy clinic for left-sided low back pain. Following examination, radiographs and a bone scan were ordered. The findings prompted referral for a computed tomography scan of the pelvis, which characterized an infiltrative soft tissue mass. The therapist immediately contacted an orthopaedic surgeon, who recommended that the physical therapist order immediate magnetic resonance imaging (STAT MRI). The patient underwent a tissue biopsy and subsequently was diagnosed with Ewing's sarcoma. J Orthop Sports Phys Ther 2020;50(5):276. doi:10.2519/jospt.2020.9109.

Trainees With Displaced Hip Fractures Present to Physical Therapy With Primary Complaint of Knee Pain.

Stress fractures of the femoral neck are career-threatening and life-altering injuries that occur frequently in Initial Entry Training (IET) Soldiers. Because of the severity of these injuries, military clinics that serve IET Soldiers have implemented guidelines to direct providers in the management of Soldiers with signs of symptoms of stress fracture. These guidelines focus on Soldiers presenting with a primary complaint of hip pain. The cases described here show two Soldiers who had displaced hip fractures despite having primary complaints of knee pain and no self-reported hip pain. In the first case, the patient was ambulatory with a slight limp and lateral knee pain that he rated as 3 out of 10. His physical therapist noted a significant gross leg length discrepancy on physical examination. Leg length X-rays identified a displaced fracture of the femoral neck. In the second case, the Soldier had severe (7/10) lateral knee pain with no complaints of hip pain. He presented to the Emergency Department where he received knee X-rays, which were normal. The next day in physical therapy, he continued to complain of severe knee pain. A femur X-ray demonstrated that he had a displaced hip fracture. Throughout their examination and diagnostic workup, neither of these patients ever experienced any hip pain. The implication of these cases is that clinicians must remain vigilant in examining the joints above and below the primary complaint. This may be more important when evaluating trainees who have a uniquely high risk of severe bone stress injury. Clinicians who work primarily with trainees should consider updating clinical management guidelines to include basic hip screening on patients who present with primary complaints of knee pain. Because of cases like these and the known connection between knee pain and hip pathology, we recommend that clinicians in IET clinics consider screening procedures to rule out hip pathology in trainees with primary complaints of knee pain.

Risk of Lower Extremity Injury in a Military Cadet Population After a Supervised Injury-Prevention Program.

CONTEXT: Specific movement patterns have been identified as possible risk factors for noncontact lower extremity injuries. The Dynamic Integrated Movement Enhancement (DIME) was developed to modify these movement patterns to decrease injury risk. OBJECTIVE: To determine if the DIME is effective for preventing lower extremity injuries in US Military Academy (USMA) cadets. DESIGN: Cluster-randomized controlled trial. SETTING: Cadet Basic Training at USMA. PATIENTS OR OTHER PARTICIPANTS: Participants were 1313 cadets (1070 men, 243 women). INTERVENTION(S): Participants were cluster randomized to 3 groups. The active warm-up (AWU) group performed standard Army warm-up exercises. The DIME groups were assigned to a DIME cadre-supervised (DCS) group or a DIME expert-supervised (DES) group; the former consisted of cadet supervision and the latter combined cadet and health professional supervision. Groups performed exercises 3 times weekly for 6 weeks. MAIN OUTCOME MEASURE(S): Cumulative risk of lower extremity injury was the primary outcome. We gathered data during Cadet Basic Training and for 9 months during the subsequent academic year. Risk ratios and 95% confidence intervals (CIs) were calculated to compare groups. RESULTS: No differences were seen between the AWU and the combined DIME (DCS and DES) groups during Cadet Basic Training or the academic year. During the academic year, lower extremity injury risk in the DES group decreased 41% (relative risk [RR] = 0.59; 95% CI = 0.38, 0.93; P = .02) compared with the DCS group; a nonsignificant 25% (RR = 0.75; 95% CI = 0.49, 1.14; P = .18) decrease occurred in the DES group compared with the AWU group. Finally, there was a nonsignificant 27% (RR = 1.27; 95% CI = 0.90, 1.78; P = .17) increase in injury risk during the academic year in the DCS group compared with the AWU group. CONCLUSIONS: We observed no differences in lower extremity injury risk between the AWU and combined DIME groups. However, the magnitude and direction of the risk ratios in the DES group compared with the AWU group, although not statistically significant, indicate that professional supervision may be a factor in the success of injury-prevention programs.

Osteochondroma fracture at the distal medial femur.

The patient was a 27-year-old man currently serving in the military who was evaluated by a physical therapist in a direct-access mode of care for a chief complaint of worsening left distal medial thigh pain. Given the traumatic mechanism of injury, worsening symptoms, and the presence of a painful, firm mass in the left distal medial thigh region, the physical therapist ordered radiographs of the left femur, which demonstrated a fracture at the base of an 8.5-cm osteochondroma located at the distal medial femur.

Fracture of the lateral femoral condyle.

The patient was a 25-year-old man who was currently enrolled in a military basic-training program. He was evaluated by a physical therapist in a direct-access capacity for a chief complaint of right knee pain and swelling after his knee buckled and gave way during a training exercise on an obstacle course. The patient was evaluated by the physical therapist 2 days after his injury. Because the patient was unable to bear weight on his right lower extremity or flex his right knee to 90°, the physical therapist ordered radiographs of the right knee, which demonstrated a fracture of the lateral femoral condyle posteriorly.

Exploration of the y-balance test for assessment of upper quarter closed kinetic chain performance.

BACKGROUND: Although upper extremity (UE) closed kinetic chain (CKC) exercises have become commonplace in most rehabilitation programs, a clinically meaningful UE CKC functional test of unilateral ability has continued to be elusive. OBJECTIVES: To examine reliability of the Upper Quarter Y-Balance Test (UQYBT), evaluate the effects of arm dominance on UQYBT performance, and to determine how the UQYBT is related to specific components of the test (trunk rotation, core stability and UE function and performance) in a college-aged population. METHODS: A sample of healthy college students performed the UQYBT and a series of 6 additional dynamic tests designed to assess trunk rotation, core stability, and UE performance. The relationship of these tests compared to the UQYBT was assessed. The effect of upper limb dominance for the UQYBT was also explored. Finally, test re-test reliability was established for the UQYBT. RESULTS: Thirty subjects (24 males, 6 females, mean ages 19.5 6 1.2 and 18.8 6 0.8 years) were assessed during the study. The test re-test reliability was excellent for UQYBT measurements (intraclass correlation coefficient > 0.9). A significant (p <0.05) fair to moderate association was observed between the UQYBT and several core stability and UE functional tests. There was no significant difference in UQYBT performance between dominant and non-dominant limbs. DISCUSSION: The UQYBT is a reliable UE CKC test that can be used to assess unilateral UE function in a closed chain manner. The UQYBT appears to be most related to dynamic tests involving core stability and UE performance. Similarity on the UQYBT between dominant and non-dominant limbs indicates that performance on this test using a non-injured UE may serve as a reasonable measure for "normal" when testing an injured UE. Future research is needed to determine the clinical applicability of the UQYBT. LEVEL OF EVIDENCE: 2b.

Development of a clinical prediction rule to identify patients with knee pain and clinical evidence of knee osteoarthritis who demonstrate a favorable short-term response to hip mobilization.

BACKGROUND AND PURPOSE: The primary purpose of this study was to develop a clinical prediction rule (CPR) for identifying patients with knee pain and clinical evidence of knee osteoarthritis (OA) with favorable short-term response to hip mobilizations. The secondary purpose was to determine the predictive validity of individual clinical tests for identifying these same patients. SUBJECTS AND METHODS: Sixty subjects with knee OA, aged 51 to 79 years, completed self-report questionnaires, a clinical examination of the hip and knee, and functional tests and were treated with 4 hip mobilizations. Follow-up testing was completed 2 days later. The reference criterion for determining a favorable response was either (1) a decrease of at least 30% on composite Numerical Pain Rating Scale score obtained during functional tests or (2) a Global Rating of Change Scale score of at least 3. RESULTS: The CPR developed in this study comprised 5 variables: (1) hip or groin pain or paresthesia, (2) anterior thigh pain, (3) passive knee flexion less than 122 degrees, (4) passive hip medial (internal) rotation less than 17 degrees, and (5) pain with hip distraction. Based on the pretest probability of success (68%), the presence of one variable had a positive likelihood ratio of 5.1 and increased the probability of a successful response to 92% at 48-hour follow-up. If 2 variables were present, the positive likelihood ratio was 12.9 and the probability of success increased to 97%. DISCUSSION AND CONCLUSION: The results suggest that the CPR developed in this study could improve clinicians' decision making and efficiency in examining and treating patients with knee OA.