The relationship between pelvic torsion and anatomical leg length inequality: a review of the literature

Robert Cooperstein, Makani Lew

Abstract: Objective: Although it is common to find assertions relating functional leg length inequality (LLI) to pelvic torsion and other states of subluxation, comments and/or data concerning anatomical LLI in this same context are uncommon. This review of the literature synthesizes the evidence on pelvic torsion in relation to anatomical LLI.

Methods: The literature was searched using the PubMed; Manual, Alternative, and Natural Therapy Index System; Allied and Complementary Medicine Database; Cumulative Index to Nursing and Allied Health Literature; and Index to Chiropractic Literature databases for primary studies that related LLI, either artificially created or naturally occurring, to pelvic torsion. Extracted data included natural vs artificial LLI, method of creating or detecting LLI, subject selection, methodology for measuring pelvic torsion, and results.

Results: Nine English-language studies were retrieved published 1936-2004. Seven determined the impact of artificial, transient LLI on pelvic torsion, whereas 2 studied the effect of naturally occurring LLI.

Conclusion: Across varying methodologies for measuring LLI and pelvic torsion, a consistent, dose-related pattern was identified in which the innominate rotates anteriorly on the side of a shorter leg and posteriorly on the side of the longer leg. This finding was contrary to the common assertion that the ilium rotates posteriorly on the side of a short leg and vice versa. Practitioners of manual medicine who derive vectors for intervention based on leg checking procedures should consider the possibility that the direction of pelvic torsion may be variable depending on whether the LLI is of anatomical or functional origin.

Journal of Chiropractic Medicine, Vol 8, Issue 3, Pages 107-118 (September 2009) – abstract

Filed under: Assessment, Hip, Physical examination, Topic review , Ilium, Leg length inequality, Mechanical, Posture, Sacroiliac joint, Torsion

Most clinical tests cannot accurately diagnose rotator cuff pathology: a systematic review.

Hughes PC, Taylor NF, Green RA

Question: Do clinical tests accurately diagnose rotator cuff pathology?

Design: A systematic review of investigations into the diagnostic accuracy of clinical tests for rotator cuff pathology.

Participants: People with shoulder pain who underwent clinical testing in order to diagnose rotator cuff pathology.

Outcome measures: The diagnostic accuracy of clinical tests was determined using likelihood ratios.

Results: Thirteen studies met the inclusion criteria. The 13 studies evaluated 14 clinical tests in 89 separate evaluations of diagnostic accuracy. Only one evaluation, palpation for supraspinatus ruptures, resulted in significant positive and negative likelihood ratios. Eight of the 89 evaluations resulted in either significant positive or negative likelihood ratios. However, none of these eight positive or negative likelihood ratios were found in other studies. Of the 89 evaluations of clinical tests 71 (80%) did not result in either significant positive or negative likelihood ratio evaluations across different studies.

Conclusion: Overall, most tests for rotator cuff pathology were inaccurate and cannot be recommended for clinical use. At best, suspicion of a rotator cuff tear may be heightened by a positive palpation, combined Hawkins/painful arc/infraspinatus test, Napoleon test, lift-off test, belly-press test, or drop-arm test, and it may be reduced by a negative palpation, empty can test or Hawkins-Kennedy test.

Australian Journal of Physiotherapy 54: 159–170 – full text

“The poor accuracy of clinical tests for rotator cuff pathology could be related to a lack of anatomical validity of the tests or it may be that the close relationships of structures in the shoulder may make it difficult to identify specific pathologies with clinical tests.”

Filed under: Assessment, Physical examination, Shoulder , differential, Review, Rotator cuff; Diagnosis

Measurement Properties of the Neck Disability Index: A Systematic Review

JC MacDermid, DM Walton, S Avery, A Blanchard, E Etruw, C McAlpine, CH Goldsmith

STUDY DESIGN: Systematic review of clinical measurement. OBJECTIVE: To find and synthesize evidence on the psychometric properties and usefulness of the neck disability index (NDI). BACKGROUND: The NDI is the most commonly used outcome measure for neck pain, and a synthesis of knowledge should provide a deeper understanding of its use and limitations. METHODS AND MEASURES: Using a standard search strategy (1966 to September 2008) and 4 databases (Medline, CINAHL, Embase, and PsychInfo), a structured search was conducted and supplemented by web and hand searching. In total, 37 published primary studies, 3 reviews, and 1 in-press paper were analyzed. Pairs of raters conducted data extraction and critical appraisal using structured tools. Ranking of quality and descriptive synthesis were performed.

RESULTS: Horizon estimation suggested the potential for 1 missed paper. The agreement between raters on quality assessments was high(kappa = 0.82). Half of the studies reached a quality level greater than 70%. Failures to report clear psychometric objectives/hypotheses or to rationalize the sample size were the most common design flaws. Studies often focused on less clinically applicable properties, like construct validity or group reliability, than transferable data, like known group differences or absolute reliability (standard error of measurement [SEM] or minimum detectable change [MDC]). Most studies suggest that the NDI has acceptable reliability, although intraclass correlation coefficients (ICCs) range from 0.50 to 0.98. Longer test intervals and the definition of stable can influence reliability estimates. A number of high-quality published (Korean, Dutch, Spanish, French, Brazilian Portuguese) and commercially supported translations are available. The NDI is considered a 1-dimensional measure that can be interpreted as an interval scale. Some studies question these assumptions. The MDC is around 5/50 for uncomplicated neck pain and up to 10/50 for cervical radiculopathy. The reported clinically important difference (CID) is inconsistent across different studies ranging from 5/50 to 19/50. The NDI is strongly correlated (>0.70) to a number of similar indices and moderately related to both physical and mental aspects of general health.

CONCLUSION: The NDI has sufficient support and usefulness to retain its current status as the most commonly used self-report measure for neck pain. More studies of CID in different clinical populations and the relationship to subjective/work/function categories are required.

J Orthop Sports Phys Ther 2009;39(5):400-417.- full text PDF

doi:10.2519/jospt.2009.2930

Filed under: Cervical, Outcome measure , Cervical spine, Outcome measure, reliability

Special physical examination tests for superior labrum anterior posterior shoulder tears are clinically limited and invalid: a diagnostic systematic review

Calvert, Chambers, Regan et al

Objective

The diagnosis of a superior labrum anterior posterior (SLAP) lesion through physical examination has been widely reported in the literature. Most of these studies report high sensitivities and specificities, and claim to be accurate, valid, and reliable. The purpose of this study was to critically evaluate these studies to determine if there was sufficient evidence to support the use of the SLAP physical examination tests as valid and reliable diagnostic test procedures.

Study Design and Setting

Strict epidemiologic methodology was used to obtain and collate all relevant articles. Sackett’s guidelines were applied to all articles. Confidence intervals and likelihood ratios were determined.

Results

Fifteen of 29 relevant studies met the criteria for inclusion. Only one article met all of Sackett’s critical appraisal criteria. Confidence intervals for both the positive and negative likelihood ratios contained the value 1.

Conclusion

The current literature being used as a resource for teaching in medical schools and continuing education lacks the validity necessary to be useful. There are no good physical examination tests that exist for effectively diagnosing a SLAP lesion.

Journal of Clinical Epidemiology, Volume 62, Issue 5, May 2009, Pages 558-563 – abstract

doi:10.1016/j.jclinepi.2008.04.010

Filed under: Physical examination, Shoulder, Topic review , Diagnostic accuracy, Physical examination, Sensitivity, Shoulder, Superior labrum anterior posterior (SLAP) lesion, Systematic review

Acetabular Labral Tears

CL Lewis, SA Sahrmann

Anterior hip or groin pain is a common complaint for which people are referred for physical therapy, with the hip region being involved in approximately 5% to 9% of injuries in high school athletes. Although anterior hip pain is known to result from a number of musculoskeletal and systemic pathologies, a tear of the acetabular labrum is a recent addition to the list that is of particular interest to physical therapists. This mechanically induced pathology is thought to result from excessive forces at the hip joint and has been proposed as part of a continuum of hip joint disease that may result in articular cartilage degeneration. Although the number of recent articles in the orthopedic literature identifying acetabular labral tears as a source of hip pain is increasing, labral tears often evade detection, resulting in a long duration of symptoms, greater than 2 years on average, before diagnosis. Studies have shown that 22% of athletes with groin pain and 55% of patients with mechanical hip pain of unknown etiology  were found to have a labral tear upon further evaluation. In order to provide the most appropriate intervention for patients with anterior hip or groin pain, physical therapists should be knowledgeable about all of the possible sources and causes of this pain, including a tear of the acetabular labrum and the possible factors contributing to these tears. Therefore, the purpose of this article is to review the anatomy and function of the acetabular labrum and present current concepts on the etiology, clinical characteristics, diagnosis, and treatment of labral tears.

PHysical Therapy, Vol. 86, No. 1, January 2006, pp. 110-121 – full text

Filed under: Assessment, Conservative therapies, Hip

The accuracy of MRI in the Detection of Lumbar Disc Containment

BK Weiner; R Patel

Background

MRI has proven to be an extremely valuable tool in the assessment of normal and pathological spinal anatomy. Accordingly, it is commonly used to assess containment of discal material by the outer fibers of the anulus fibrosus and posterior longitudinal ligaments. Determination of such containment is important to determine candidacy for intradiscal techniques and has prognostic significance. The accuracy of MRI in detecting containment has been insufficiently documented.

Methods

The MRI’s of fifty consecutive patients undergoing open lumbar microdiscectomy were prospectively evaluated for disc containment by a neuroradiologist and senior spinal surgeon using criteria available in the literature and the classification of Macnab/McCulloch. An independent surgeon then performed the surgery and documented the actual containment status using the same methods. Statistical evaluation of accuracy was undertaken.

Results

MRI was found to be 72% sensitive, 68% specific, and 70% accurate in detecting containment status of lumbar herniated discs.

Conclusion

MRI may be inaccurate in assessing containment status of lumbar disc herniations in 30% of cases. Given the importance of containment for patient selection for indirect discectomy techniques and intradiscal therapies, coupled with prognostic significance; other methods to assess containment should be employed to assess containment when such alternative interventions are being considered.

Journal of Orthopaedic Surgery and Research 2008,3:46 (full text)

doi:10.1186/1749-799X-3-46

Filed under: Assessment, Imaging, Spine

Incidental Meniscal Findings on Knee MRI in Middle-Aged and Elderly Persons

M Englund, A Guermazi, D Gale, DJ Hunter et al.

ABSTRACT

Background – Magnetic resonance imaging (MRI) of the knee is often performed in patients who have knee symptoms of unclear cause. When meniscal tears are found, it is commonly assumed that the symptoms are attributable to them. However, there is a paucity of data regarding the prevalence of meniscal damage in the general population and the association of meniscal tears with knee symptoms and with radiographic evidence of osteoarthritis.

Methods – We studied persons from Framingham, Massachusetts, who were drawn from census-tract data and random-digit telephone dialing. Subjects were 50 to 90 years of age and ambulatory; selection was not made on the basis of knee or other joint problems. We assessed the integrity of the menisci in the right knee on 1.5-tesla MRI scans obtained from 991 subjects (57% of whom were women). Symptoms involving the right knee were evaluated by questionnaire.

Results – The prevalence of a meniscal tear or of meniscal destruction in the right knee as detected on MRI ranged from 19% (95% confidence interval [CI], 15 to 24) among women 50 to 59 years of age to 56% (95% CI, 46 to 66) among men 70 to 90 years of age; prevalences were not materially lower when subjects who had had previous knee surgery were excluded. Among persons with radiographic evidence of osteoarthritis (Kellgren–Lawrence grade 2 or higher, on a scale of 0 to 4, with higher numbers indicating more definite signs of osteoarthritis), the prevalence of a meniscal tear was 63% among those with knee pain, aching, or stiffness on most days and 60% among those without these symptoms. The corresponding prevalences among persons without radiographic evidence of osteoarthritis were 32% and 23%. Sixty-one percent of the subjects who had meniscal tears in their knees had not had any pain, aching, or stiffness during the previous month.

Conclusions – Incidental meniscal findings on MRI of the knee are common in the general population and increase with increasing age

the New England Journal of  Medicine. 2008 Sep 11;359(11):1169-70.

Filed under: Imaging, Knee

Clinical diagnosis of carpal tunnel syndrome: Old tests–new concepts

Yasser El Miedany, Samia Ashour Sally Youssef, Annie Mehanna and Fatma A. Meky

The aim of this study was to examine the relationship between the clinical manifestations of CTS with the outcome of the diagnostic tools (nerve conduction tests and ultrasonography), and its implication for clinical practice. All patients and controls completed a patient oriented questionnaire, were subjected to clinical testing for provocative tests for carpal tunnel syndrome (Tinel’s, Phalen’s, Reverse Phalen’s and carpal tunnel compression tests), nerve conduction testing as well ultrasonographic assessment of the carpal tunnel and median nerve. The results of this study revealed that Tinel’s, Phalen’s, Reverse Phalen’s and carpal tunnel compression tests are more sensitive, as well as being specific tests for the diagnosis of tenosynovitis of the flexor muscles of the hand, rather than being specific tests for carpal tunnel syndrome and can be used as an indicator for medical management of the condition.

Joint Bone Spine, June 2008, article in press

doi:10.1016/j.jbspin.2007.09.014

Link to article

Filed under: Assessment, Wrist