Posts in Physical Therapy Exam
Timing of Physical Therapy and Patient Outcomes

Currently in the United States the majority of citizens can access their Physical Therapist without a prescription from their physician.  As shown in the map above, arbitrary restrictions on this access has been put in place through state legislatures with strong influences from special interest groups.  In Colorado, patients can access their Physical Therapist without restriction allowing them to enjoy the improved outcomes and decreased cost associated with this healthcare pathway.  On average these patients will save $1000 per episode of care and avoid the unnecessary and high risk pathway including medications, procedures, and surgery.  In addition to these benefits, research is now highlighting how this pathway can improve outcomes for patients with musculoskeletal problems.    

The majority of the musculoskeletal aches and pains are best treated early allowing the Physical Therapist to maximize outcomes in fewer visits.  A recent review article in the Journal of Sports and Orthopedic Physical Therapy highlights the importance of early vs. late access to Physical Therapy services (Ojha et al. 2016).  The authors reviewed 14 research articles to examine the impact of early Physical Therapy on health care outcomes.  Consistent with prior business and research articles, early Physical Therapy was associated with decreased costs and future health care utilization.  Patients who receive early Physical Therapy are likely to require fewer physician visits and avoid unnecessary and costly interventions including surgery.  

Patients are encouraged to round out their health care team of a physician and dentist by adding a Physical Therapist.  Seek out a local, knowledgeable Physical Therapist (early) for advice, questions, and treatment of your next ache or pain.     

Impact of Communication on Patient Outcomes
communication-listening-healthcare-physical therapy

William Osler, M.D., considered by many to be the father of modern medicine once said "listen to the patient he is telling you the diagnosis".  Others in the medical field have similar quotes including "listen to the patient long enough and they will tell you the diagnosis, listen longer and they will tell you the treatment".  Hampton et al. confirmed Osler's thoughts by reporting up to 83% of medical diagnoses are made through the subjective history alone (BMJ, 1975).  Indeed, our prior blog post reports on the power of the subjective history to rule out non musculoskeletal sources of pain.  This interview with the patient is a crucial component of any medical encounter and allows the clinician to begin their initial hypothesis generation on what brings the patient into their office.  Unfortunately, on average patients are interrupted 18 seconds into their opening statement, but given the chance to talk they finish their statement in under 3 minutes (Beckman, H. Ann Int Med. 1984).

One of the main reasons we started Mend was to create a one on one environment where our clinicians have 60 minutes of uninterrupted time with each patient at each visit.  This gives the clinician ample time to conduct a thorough history focused on a patient's individual complaints and symptoms.  Starting the initial evaluation with this line of questioning focuses our Physical Therapy examination and treatment.  We find the simple art of listening has helped accelerate our patient's outcomes in fewer visits by providing optimal treatments at each Physical Therapy session.  To experience the difference, contact the experts at Mend. 

Subjective Examination and Low Back Pain

Introduction

Low back pain (LBP) is a common, disabling condition with both musculoskeletal and non musculoskeletal contributions. It has been reported that greater than 80% of individuals will experience LBP within their lifetime and 20-30% of individuals are affected with these symptoms at any point in time[1]. Katz et al. reported the cumulative cost to manage this condition is greater than 100 billion dollars per year[2]. Given the high economic costs associated with LBP it is imperative for the clinician to obtain the necessary information needed to determine the appropriate plan of care, either outside referral or Physical Therapy treatment, for their patient. Matching appropriate interventions based on a patient’s symptoms has been shown to decrease healthcare costs in patients with LBP[3][4]. 

The patient interview is the first opportunity for the clinician to gather information regarding the patient’s condition. Information gathered during the subjective history can increase the clinician’s confidence in either ruling in or ruling out a suspected condition through the utilization of likelihood ratios (LR) to determine the probability of a condition’s presence or absence. After determining the condition responsible for a patient’s LBP symptoms, the subjective examination may help determine which referral or intervention is warranted. 

Subjective Examination

A thorough and detailed subjective history and review of systems allows the clinician to gather information regarding the location, quality, severity, irritability, and behavior of a patient’s symptoms. This information is then assimilated to identify patients appropriate for Physical Therapy and those who require a referral to an outside healthcare provider. The subjective examination facilitates this decision by providing a strong diagnostic resource given the patient’s presenting symptoms. Hampton, et al. reported the subjective history alone assisted in the medical diagnosis of 83% of patients seen in a primary care practice[5]. Specifically, 4 subjective examination questions have demonstrated a sensitivity of 1.0 in screening for cancer in patients with LBP[6]. Despite its importance authors have reported the average time given to a patient to explain their symptoms without interruption is 18 seconds and once interrupted patients often do not return to their previous complaints[7]. In contrast, an uninterrupted patient only needs 150 seconds to fully express their concerns[7]. 

Based on the information gathered from the subjective examination, the clinician will determine which tests to perform designed to confirm or refute their hypothesis on the source of a patient’s symptoms. A selection of the most appropriate questions, with the highest diagnostic utility, will increase the clinician’s confidence in ruling in or out sinister disorders. The following paragraphs will describe questions demonstrating the strongest shifts in probability of a condition being present (+ LR) or absent (-LR). These shifts in probability provide an excellent resource to the clinician treating patients with LBP. 

Risk Factors

The symptoms reported by patients collected through the intake paperwork, review of systems, and subjective examination can assist in clinical hypothesis generation and identification of risk factors shown to influence the prognosis of a patient with LBP. A recent review of the evidence and epidemiological data reports risk factors for LBP include advancing age with first onset between 30-40, sedentary lifestyle, history of back surgery, occupational demands, smoking, depression, corticosteroid use, and obesity[8][9][10][11]. Many of these variables have been correlated with an increased risk of developing LBP in population based studies. Further, studies have identified features that are associated with chronicity of symptoms, such as lower extremity radiating pain, low expectations for recovery, elevated initial pain score, coping style, fear, and psychosocial stress[12][11]. 

Yellow Flags

Due to the multiple factors associated with pain and their relationship with behavior and personal beliefs, it is necessary to review additional details related to this interaction. Kendall defined yellow flags as factors which increase the risk of developing, or perpetuating long term disability and work loss associated with low back pain[9] including depression, pain catastrophizing, and elevated fear avoidance beliefs. Arroll et al. reported two questions, “During the past month have you been feeling down, depressed or hopeless?” and “During the past month have you been bothered by having little interest or pleasure in doing things?”, although lacking diagnostic properties (Specificity (Sp) .57-.67), improve our ability to screen (Sensitivity (Sn) .96-.97) for the presence of depression in patients with LBP[13]. In addition, asking patients when they would like assistance with these questions can help identify those patients benefiting from help today ((+) Likelihood ratio (LR) 17.5) or help in the future ((+) LR 7.9) for their depression. 

Elevated fear avoidance scores associated with the fear avoidance beliefs questionnaire (FABQ) have been associated with an exaggerated perception of pain and an elevated risk for chronic LBP symptoms[8]. Specifically, a FABQ Work score >34 and work score <29 produces a (+) LR 3.33 and (-) LR 0.08, respectively, for the development of chronic LBP symptoms. Calley et al. reported the utilization of a two question screen for fear avoidance behaviors including “Are you afraid physical activity will cause an increase in your LBP?” and “Are you afraid that moving your back will be harmful to you?” can be effective for identifying patients requiring further education on their LBP symptoms[14]. An education session devoted to improving a patient’s understanding of pain neurophysiology including nociception and central sensitization, as well as, understanding their thoughts and beliefs regarding their symptoms can improve outcomes in these patients[15][16][17][18][19]. Clinician’s should aim to reduce a patient’s focus on the patho-anatomical sources of their LBP (ex. herniated disc), educate the patient on the resiliency of the spine and limitations of imaging in LBP, and improve a patient’s self efficacy for management of their symptoms. 

Red Flags

Although uncommon, non musculoskeletal conditions may present as LBP in approximately 5% of patients presenting to primary care offices (see table)[20][21]. Within this 5%, 1% are attributed to non mechanical disorders including cancer, infection, and inflammatory arthropathies; 1-2% are attributed to the viscera (abdominal aortic aneurysm (AAA), pelvic, renal, GI); and 2-3% are attributed to other diseases (Paget’s disease, parathyroid disease). 

Estimated 5% of LBP is caused by serious disease
1% Non mechanical spine disorders (cancer, infection, seronegative spondyloarthritides) 
1-2% Visceral disease (Pelvic, renal, aortic aneurysm, GI) 
2-3% Other Disease (Paget's disease, parathyroid disease, hemoglobinopathies)

Cauda Equina Syndrome

Cauda Equina Syndrome (CES) commonly involves a large midline lumbar disc herniation at L4/5, L5/S1, or less commonly L3/4 which impairs lumbosacral nerve function[22]. This disorder is most frequently seen in individuals aged 40-60 with a prevalence estimated at .04% of the population[22]. Up to 70% of patients with this disorder will complain of a chronic history of LBP and may report symptoms including incontinence, loss of sphincter tone, saddle anesthesia, gait disturbances, unilateral or bilateral sciatica, and urinary retention depending on the severity and duration of symptoms. Early identification of CES is important considering surgical decompression is most successful in patients < 72 hours since onset[22]. Each of these reported symptoms provide the clinician with additional information necessary to rule in or out this condition. Specifically, saddle anesthesia (Sn .75) and unilateral or bilateral sciatica (Sn. 80) may assist in the screening of this patient[23]. More importantly, the presence (Sp .95, +LR 9.9) or absence (Sn. 90, –LR .11) of urinary retention offers the greatest diagnostic utility for CES [20][23].

Cancer

The prevalence of cancer within the LBP population is estimated at 0.7%[20][21] and although this condition is rare clinicians can increase their confidence in screening for this pathology by following the evidence supported in the literature. Henschke, N. et al.[24] conducted a systematic review on 6 studies of 5,097 patients and found a prevalence ranging from .1 to 3.5%. A previous history of cancer (+LR 23) and clinician judgment consistent with cancer (+ 12.1) offered the best shift in post test probability of cancer being present. Conversely, a patient younger than 50 years of age demonstrated a (-) LR of .34 for the presence of cancer. See Table. Further, Deyo, R. et al.[6]demonstrated a four item cluster of age >50 years old, unexplained weight changes, a previous history of cancer, and no improvement with conservative care offered the best screening utility for cancer in patients with LBP (Sn 1.0, -LR .06 (0.0-.91)). In short, if a patient answers no to these historical items we can have increased confidence in our ability to rule out cancer as the source of a patient’s LBP symptoms. 

TABLE - Henschke, N. et al. Screening for malignancy in low back pain patients: 
a systematic review. Eur Spine J. 2007. 16:1673–1679.

Clinical Response Post Test Probability given 1% pre test probability Post test probability given 5% pre test probability
No relief with bed rest 1.7 8.3
Age > 50 years 2.2 10.4
Duration > 1 month 2.5 12.1
No improvement at 1 month 2.9 13.7
Previous history of cancer 19.2 55.7

[Radiograph findings of AS]
Radiograph findings of AS
Ankylosing Spondylitis

Ankylosing Spondylitis (AS) is an inflammatory arthropathy most commonly occurring in males in their 20s and 30s with an estimated prevalence of 3%[20][21]. Radiographic evidence of ankylosis may not be present until several years following initial onset of back pain or stiffness[25]. Given these findings a thorough history and subjective examination may help in early detection of AS. A past medical history significant for irritable bowel syndrome, crohn’s disease, psoriatic arthritis, and reactive arthritis are often found in patients with AS[26]. Inflammatory back pain (IBP) is a common sign associated with AS. Diagnostic variables of IBP include age < 40 years, > 3 month onset of symptoms, insidious onset, morning stiffness lasting at least 30 min, and improvement with exercise. These variables demonstrated a sensitivity of .95 and specificity of .85 if 4 of the 5 criteria were met[25]. 

Specifically, patients with AS may complain of pain and stiffness longer than 3 months, morning stiffness lasting at least 30 minutes, no improvement of back pain with rest, awakening in the second half of the night because of back pain, and alternating buttock pain. If 3 of these 4 criteria are met then there is a (+) LR of 12.4 of AS being present[27]. See Table 1. In addition, Gran, J. et al.17 reported 5 questions with diagnostic value: age < 40 years old, morning stiffness, improvement of symptoms with exercise, a gradual onset, and duration of symptoms > 3 months, offer small shifts in the probability of this condition being present. See Table 2. 

TABLE 1 – Rudaweit, M. et al. Inflammatory back pain in ankylosing spondylitis: a reassessment of the clinical history for application as classification and diagnostic criteria. Arthritis Rheum. 2006. 54;569-578.

Sn Sp (+) LR (-) LR
2/4 Positive .70 .81 3.7
3/4 Positive .33 .98 12.4

 TABLE 2 - Gran JY. et al. An epidemiological survey of the signs and symptoms of ankylosing spondylitis. Clin Rheum. 1985;4:161-9.

Sn Sp (+) LR (-)LR
Positive 4/5 Questions .23 .82 1.3 .94
> 40 years old 1.0 .07 1.1 0.0
No relief in supine .80 .07 1.6 .41
Morning stiffness .64 .59 1.6 .41
> 3 months of pain .09 .99 9.0 .92

Lumbar Stenosis

Lumbar spine stenosis (LSS) is estimated to represent 3% of patients with LBP and is most commonly found in older adults[20][21]. Compression of neurologic structures within the spine can occur from soft tissue (disc, ligament) or bone structures. Up to 20% of asymptomatic individuals over 60 years old may demonstrate pathology on imaging. Symptoms of back pain and leg pain associated with lumbar stenosis must be differentiated from vascular claudication within this population. A patient reporting a minimal duration of rest required for symptoms to ease following activity may indicate a vascular versus neurological claudication. In a previous study, Katz, J. et al.[28] reported on the diagnostic utility of historical items within the subjective examination (see table) with age >65 years old and severe leg pain offering the best screening utility for lumbar stenosis while the best diagnostic properties were found with relief of symptoms with sitting. 

TABLE - Katz JN, Dalgas M, Stucki G, Katz NP, Bayley J, Fossel AH, et al. Degenerative lumbar spinal stenosis. Diagnostic value of the history and physical examination. Arthritis Rheum. 1995;38:1236-41. 

Sn Sp (+) LR (-) LR
> 65 years old .77 .69 2.5 .33
Severe LE pain .65 .67 2.0 .52
No pain with sitting .46 .93 6.6 .58
Worse with walking .71 .30 1.0 .97
Pain better with sitting .52 .83 3.1 .58
Numbness .63 .59 1.5 .63
Weakness .47 .78 2.1 .68

[Sagital view of L5/S1 HNP on MRI]
Lumbar Disc Herniations

A herniated lumbar disc is estimated to have a prevalence of 4% in the LBP population occurring most frequently in patients aged 30-55 years old[20][21]. 95% of these herniations occur at the L4/5 and L5/S1 levels involving the L5 and S1 nerve roots, respectively. Commonly patients will report an acute onset of pain radiating below the knee. Vroomen, P. et al.[29] and Lauder, T. et al.[30] reported on the diagnostic utility of historical examination items in patients with suspected lumbosacral nerve root symptoms. See Tables 1 and 2. The absence of sciatica, lower extremity pain not greater than back pain, and an absence of dermatomal pain offered the greatest value for screening for this pathology. 

TABLE 1 - Vroomen, P. et al. Diagnostic value of history and physical examination in patients suspected of lumbosacral nerve root compression. J Neurol Neurosurg Psychiatry 2002;72:630–634

Sn Sp (+) LR (-) LR
Sciatica .95
Leg pain > back pain .82 .54 1.74 .33
Dermatomal pain .89 .31 1.3 .34

TABLE 2 - Lauder, T. et al. Effect of history and exam in predicting electrodiagnostic outcome among patients with suspected lumbosacral radiculopathy. Am J Phys Med. 2000. 79:60-68.

(+) LR (-) LR
Weakness 1.2 .73
Numbness 1.0 9.4

[L4 compression fracture on radiograph]
Vertebral Frature

Spinal fractures are most common in older, white females occurring with a prevalence of 4% with less than 1% occurring secondary to trauma[20][21]. This prevalence may be underestimated secondary to the asymptomatic nature of many osteoporotic fractures. 

The clinician’s ability to improve the probability of this pathology being present is supported by the literature from Henschke, N. et al. who reported moderate to high shifts in probability if a patient’s pain is associated with major trauma or pain and tenderness within the spine. See table. Further evidence[20][21] suggests a positive history of corticosteroid use may suggest the presence of vertebral fracture (Sp .95, (+) LR 12.0). 

TABLE - Henschke, N. et al. A systematic review identifies five red flags to screen for vertebral fracture. J Clin Epidemiology. 2008. 61:110-118.

Sn Sp (+) LR (-) LR
History of major trauma .65 .95 12.8 .37

Pain and tenderness .60 .91 6.7 .44
Age < 50 years .79 .64 2.2 .34
Female .47 .80 2.3 .67
Corticosteroid use .06 .995 12.0 .94

Spinal Infection

Infections in the spine including osteomyelitis, septic discitis, abscess, and shingles most commonly present secondary to a previous infection elsewhere in the body. Infections known to cause spinal infection include IV drug use, skin infection, urinary tract infection, and skin infection occurring with an estimated prevalence of .01%[20][21]. Symptoms of fever (>100 degrees), chills, malaise, and fatigue may be present concurrent with a patient’s LBP. These infections in the spine are also commonly found in patients with a current or past medical history of immunosuppresion. Waldvogel, F. et al.[31] reported on the diagnostic utility of the subjective examination in this patient population, of note is the lack of screening utility of the presence of fever in this population. See Table. One exception is for infective spondylitis with a positive response for fever offering a sensitivity of .98 and specificity of .50. 

TABLE - Waldvogel FA. et al. Osteomyelitis: the past decade. N Engl J Med. 1980. 303:360-70

Sn Sp (+) LR (-) LR
Concurrent infection or drug use .40
Spinal tenderness to percussion .86 .60 2.1 .23
Fever .27-.83

[CT AAA]
Abdominal Aortic Aneurysm

Abdominal aortic aneurysms (AAA) are included within the visceral prevalence estimates for LBP. This disorder is responsible for 9000/deaths per year with men having 5-6 times the risk of females[32][33]. Interestingly, 75% of patients are asymptomatic at the time of diagnosis [32][33]. The generation of LBP in this pathology is thought to occur from the blood vessels or the pressure of the AAA on the vertebral bodies in the lumbar spine. This pain is typically present in the midline of the spine, hip, buttock, or abdomen described as throbbing or pulsing. Patients may have concurrent symptoms including early satiety, nausea, and weight changes. Lederle et al. reported risk factors include smoking (Odds Ratio (OR) 3-5), family history of AAA or vascular disease (OR 1.28-1.84), and an OR of 1.71 for each 7 year increase in age over 65 years old[32][33]. 

Low Back Pain Classification System

After screening for risk factors, as well as, yellow and red flags the clinician may utilize the subjective history to assist in the classification of a patient with LBP to an indicated treatment group. The utilization of this classification system has demonstrated improvements in pain, disability, and a reduction in cost at 4 weeks and one year compared to Agency for Healthcare Policy and Research guidelines in patients with acute LBP[34]. Further patients correctly treated within their appropriate sub group demonstrated reduced disability up to one year compared to those patients given treatments not consistent with their sub group classification[3]. The table below reports historical and subjective history items which can improve clinician’s ability to match patients to appropriate sub groups of treatment. 

LBP Classification Sub Group Subjective Report
Manipulation Acute onset, symptoms above knee, FABQ work subscale <16
Direction Specific Exercise Strong subjective preference for sitting, walking or standing, report of peripheralization with positioning
Stabilization Training Younger age, previous history of LBP episodes
Traction Symptoms of nerve root compression, lack of centralization with positioning

Conclusion

The subjective examination is one of most powerful tools a clinician can utilize in the examination and treatment of patients with LBP. The questions utilized during this process can improve the clinician’s confidence in identification of sinister pathology warranting outside referral, screening for yellow flags which may interfere with PT interventions, and assist in matching PT interventions with a patient’s symptoms.

References

↑ Freburger JK, Holmes GM, et al. The rising prevalence of chronic LBP. Arch Intern Med. 2009. 169(3):251-8.
↑ Katz, J. et al. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. J Bone Joint Surg Am. 2006. 88(2):21-4.
↑ 3.0 3.1 Brennan, G. et al. Identifying Subgroups of Patients With Acute/Sub acute “Nonspecific” Low Back Pain: Results of a Randomized Clinical Trial. Spine. 2006.
↑ Fritz, J. et al. Subgrouping Patients With Low Back Pain: Evolution of a Classification Approach to Physical Therapy. JOSPT. 2007. 37(6):290-302.
↑ Hampton, J. et al. Relative Contributions of History-taking, Physical Examination, and Laboratory Investigation to Diagnosis and Management of Medical Outpatients. BMJ. 1975. 2:486-489.
↑ 6.0 6.1 Deyo, R. et al. Cancer as a cause of low back pain. J Gen Int Med. 1988. 3:230-239.
↑ 7.0 7.1 Beckman HB, Frankel RM. The use of videotape in internal medicine training. J Gen Intern Med. 1994 Sep;9(9):517-21.
↑ 8.0 8.1 Fritz, J. et al. Identifying psychosocial variables in patients with acute work-related low back pain: the importance of fear-avoidance beliefs. Phys Ther. 2002 Oct;82(10):973-83.
↑ 9.0 9.1 Hill, J. et al. Psychosocial influences on low back pain, disability, and response to treatment. Phys Ther. 2011. 91(5):712-21
↑ Shiri, R. et al. The association between obesity and low back pain: a meta analysis. Am J. Epidemiology. 2010. 171(2):135-154.
↑ 11.0 11.1 Shiri, R. et al. The association between smoking and low back pain: a metal analysis. Am J Med. 2010. 123(1):87. e7-35.
↑ Koes, B. et al. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J. 2010. 19(12):2075-94
↑ Arroll, B. et al. Effect of the addition of a "help" question to two screening questions on specificity for diagnosis of depression in general practice: diagnostic validity study. BMJ. 2005. 15. 331(7521):884.
↑ Calley, D. et al. Identifying Patient Fear-Avoidance Beliefs by Physical Therapists Managing Patients With Low Back Pain. JOSPT. 2010. 40(12):774-783.
↑ Main, C. et al. Psychologically Informed Practice for Management of Low Back Pain: Future Directions in Practice and Research. PT. 2011. 91:820-824.
↑ Moreley, S. Efficacy and effectiveness of cognitive behaviour therapy for chronic pain: Progress and some challenges. Pain. 2011. 152:S99–S106.
↑ Moseley GL. Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain. European Journal of Pain. 2004. 8:39-45.
↑ Moseley GL, Nicholas MK, Hodges PW. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clinical Journal of Pain. 2004. 20:324-30
↑ Smeets, R. et al. Reduction of Pain Catastrophizing Mediates the Outcome of Both Physical and Cognitive-Behavioral Treatment in Chronic Low Back Pain. The J Pain. 2006. 7(4):261-271
↑ 20.0 20.1 20.2 20.3 20.4 20.5 20.6 20.7 20.8 Deyo, R. et al. What Can the History and Physical Examination Tell Us About Low Back Pain? JAMA. 1992. 268(6):760-766.
↑ 21.0 21.1 21.2 21.3 21.4 21.5 21.6 21.7 Jarvik, J. et al. Diagnostic Evaluation of Low Back Pain with Emphasis on Imaging. Ann Intern Med. 2002;137:586-597.
↑ 22.0 22.1 22.2 Small, S. et al. Orthopedic pitfalls: cauda equina syndrome. American Journal of Emergency Medicine (2005) 23, 159–163
↑ 23.0 23.1 Kostuik, J. et al. Cauda equina syndrome and lumbar disc herniation. Bone Joint Surg Am. 1986 Mar;68(3):386-91.
↑ Henschke, N. et al. Screening for malignancy in low back pain patients: a systematic review. Eur Spine J. 2007. 16:1673–1679.
↑ 25.0 25.1 Khan MA, van der Linden SM, Kushner I, Valkenburg HA, Cats A. Spondylitic disease without radiological evidence of sacroiliitis in relatives of HLA B27 positive patients. Arthritis Rheum 1985;28:40–3.
↑ Coronado R. et al. Spondyloarthritis in a patient with unilateral buttock pain and history of Crohn disease. PT. 2010. 90:784-792.
↑ Rudwaleit M, Metter A, Listing J, et al. Inflammatory back pain in ankylosing spondylitis: a reassessment of the clinical history for application as classification and diagnostic criteria. Arthritis Rheum 2006;54:569–78.
↑ Katz JN, Dalgas M, Stucki G, Katz NP, Bayley J, Fossel AH, et al. Degenerative lumbar spinal stenosis. Diagnostic value of the history and physical examination. Arthritis Rheum. 1995;38:1236-41.
↑ Vroomen, P. et al. Diagnostic value of history and physical examination in patients suspected of lumbosacral nerve root compression. J Neurol Neurosurg Psychiatry 2002;72:630–634
↑ Lauder, T. et al. Effect of history and exam in predicting electrodiagnostic outcome among patients with suspected lumbosacral radiculopathy. Am J Phys Med. 2000. 79:60-68.
↑ Waldvogel FA. et al. Osteomyelitis: the past decade. N Engl J Med. 1980. 303:360-70
↑ 32.0 32.1 32.2 Lederle FA, et al. Selective screening for abdominal aortic aneurysms with physical examination and ultrasound. Arch Intern Med. 1988;148:1753-1756.
↑ 33.0 33.1 33.2 Lederle, F. et al. The aneurysm detection and management study screening program: validation cohort and final results. Aneurysm Detection and Management Veterans Affairs Cooperative Study Investigators. Arch Intern Med. 2000 May 22;160(10):1425-30.
↑ Fritz, J. Delitto, A. et al. Comparison of Classification-Based Physical Therapy With Therapy Based on Clinical Practice Guidelines for Patients with Acute Low Back Pain. A Randomized Clinical Trial. Spine. 2003;1363-1372.

Predicting Injury in Runners from the Physical Therapy Exam

We have previously written about the functional movement screen (FMS) and its' ability to predict injury although more recent research has called its' predictive ability into question.  The highest quality research on the FMS has occurred in NFL athletes or those training for the NFL combine.  The research demonstrates the predictive value of these tests may be less powerful in endurance athletes.  As the diagnostic utility of these 7 tests falls it requires the clinician to incorporate other data from the subjective and objective examination to determine an athlete's injury risk.  An important aspect of the FMS that should not be overlooked, regardless of an athlete's sport, is their emphasis on movement quality.  Poor movement patterns may be secondary to a loss of joint mobility, strength, coordination, or balance and can lead to injury if not corrected.  In a runner, a poor movement examination on the treadmill may indicate the need for gait retraining by a Physical Therapist.  

A recent article by Hotta et al. examined the ability of the FMS to predict injuries in 18-24 year old competitive male runners (J Strength Cond Res. 2015).  Each athlete was scored on the 7 examination items during the preseason then followed through the running season to determine the predictive ability of these 7 tests on the development of future injury.  Prior authors have reported a score of less than 14 indicating poor movement patterns is predictive of future injury.  Hotta et al. found this composite score had a low predictability for running injuries.  Conversely, two tests including the active straight leg raise and deep squat had high predictability for running injuries.  A runner with a poor score of these tests had a 10 times greater risk of injury during the season.  

This article continues on prior research indicating the complete 7 tests may not be appropriate for all sports and athletes.  Instead, specific examination tools like the overhead squat can be combined with gait analysis and other running specific examination tests for a more predictive injury screening.  

Preventing Recurrence of Achilles Tendinopathy and Return to Sport

In prior posts we described risk factors for an initial episode of achilles tendinopathy including muscle imbalances, calf weakness (concentric and eccentric), and loss of mobility within the foot and ankle.  Once the tendinopathy is established, patients demonstrate significant deficits in range of motion, strength, balance, endurance, and jumping ability (Silbernagel et al. 2006).  These impairments and the duration of symptoms until complete tendon healing, 12 months, create obstacles for the athlete looking to return to sport following an episode of achilles tendinopathy.  At Mend Physical Therapy we often see patients who describe a recurrent nature of symptoms including pain, stiffness, and an inability to return to their sport.  These athletes are not alone with re injury rates ranging from 20-44% based on the literature (Gajhede-Knudsen et al. 2013).  Common risk factors for re injury include inadequate rehabilitation, short recovery periods, and those who were not given guidance/assistance in their return to play (Hagglund et al. 2007).  To reduce risk patients should seek the advice of a Physical Therapist to advise the patient on the proper tendon loading schedule.  

boulder physical therapy eccentric exercises, achilles tendinopathy


Authors have reported up to a 90% success rate with return to sport after a rehabilitation program (Silbernagel et al. 2015).  We know exercise is essential for promoting healing of the injured tendon, as well as, preparing the tendon and lower extremity for the demands of a patient's sport. The key question remains the prescription of exercise volume (loading type, amount, duration, intensity, frequency, rest periods) to train the tendon the meet the demands of the sport.  In running alone, the tendon must be able to handle 6-12 times the body weight of the patient (Fukashiro et al. 1995).  Silbernagel et al. recommends consideration of a patient's symptoms with activity, stage of tendon healing, recovery of impairments including range of motion, strength, endurance, and balance, as well as, the demands of the patient's individual sport.  

boulder physical therapy, return to sport, achilles tendinopathy

We would encourage those who have a history of achilles tendinopathy to seek the evaluation and guidance of a Physical Therapist to assure lower quarter impairments have been treated, as well as, to receive a game plan for their return to sport.  If left up to the patient or athlete, this condition may return.  

How Important is Imaging for Tendon Pain and Injury?

Our prior posts on tendon injuries have described the structural changes that take place with chronic symptomatic tendinopathies.  The disorganization of tendon fibers and the body's attempts to heal the injured tendon are best viewed on ultrasound or MRI imaging.  MRI is a very sensitive tool, but lacks specificity meaning a positive finding may or may not be contributing to a patient's presentation and symptoms.  Further, we often see positive findings in asymptomatic individuals.  Rio et al. described the presence of positive findings (tendinosis) in asymptomatic and active individuals and also the lack of impact of some findings on a patient's presentation (Sports Med. 2014).  The MRI and ultrasound images document both normal and abnormal imaging findings.  Images courtesy of Docking et al. JOSPT. 2015.

achilles tendon, ultrasound, boulder physical therapy
abnormal achilles tendon, MRI, boulder physical therapy

In the pictures above, we can observe healthy tendon alignment primarily in parallel to resist and absorb tensile forces across the ankle joint, as well as, a high water and protein content reducing friction through the tendon.  Conversely, a tendon with features of tendinosis demonstrates a disorganized tendon structure where tendon cells (tenocytes) are in higher numbers and have a more rounded appearance.  This appearance makes the tendon less resisted to traditional tensile forces since the tendon is not arranged in a parallel alignment.  Finally, there is an ingrowth of nerve fibers and blood vessels which likely contribute to the increased pain and symptoms noted in the achilles as well as in other structures within the body (central sensitization).  If a tendinosis progresses in nature, partial tears in the tendon can also be noted on MRI.  The accuracy of these changes on MRI explaining a patient's symptoms is described as diagnostic utility.  

MRI and ultrasounds greatest limitation on accuracy may be the lack of agreed upon gold standard in the literature.  In a review of the literature Docking et al. reports the specificity for diagnosis with MRI (.68-.70) and ultrasound (.63-.83) for tendinopathies.  Up to 59% of asymptomatic individuals will document some change within the tendon on imaging.  These numbers show a degree of false positives making the clinical examination an essential part of any clinical diagnosis.   This is consistent with the majority of musculoskeletal problems.  If we rely solely on the MRI findings we run the risk of being incorrect in both our diagnosis and treatment.  This will lead to higher healthcare costs and a longer duration of care for the patient.

In short, imaging can be a helpful component of our clinical diagnosis but only if we can use our subjective and objective examination to distinguish between asymptomatic tendinosis or symptomatic tendinopathy.  In addition, an image rarely is helpful in determining how to use manual therapy and exercise to appropriately treat the patient.