Abstract
Study Design:
Case Report
Background and Purpose:
The purpose of this case report is to describe the clinical reasoning process involved with the differential diagnosis and management of a 69 year‐old male runner reporting a six month history of insidious onset of left sided low back and buttock pain of low to medium degree of irritability. The case presented describes the utilization of clinical reasoning by a clinician in fellowship training when a patient with atypical adverse neurodynamic dysfunction related to running was encountered.
Case Description:
The patient’s physical examination was relatively unremarkable. Assessment of the patient’s subjective history, self‐report measures [Oswestry Disability Index (ODI), global rating of change scale (GROC)], objective findings, and tests and measures led to a working diagnosis of atypical adverse peripheral neurodynamic dysfunction. The lumbar spine, sacroiliac joint, hip joint and lower extremity were ruled out by a comprehensive subjective and objective examination. The diagnosis of adverse neurodynamic dysfunction became a diagnosis of exclusion.
Outcomes:
Returning two and a half weeks after initial evaluation the patient reported no pain with running. Twelve weeks after the initiation of physical therapy, the patient was contacted via email. He was sent, and asked to fill out an ODI. The patient demonstrated an improvement in ODI from 10% to 2%. He also reported that he continued to run after treatment without pain.
Discussion:
Determining the source of a patient complaint can occasionally be an arduous undertaking. Pathological sources of a patient’s symptoms may not be easily determined. Development of differential diagnosis and clinical reasoning skills is imperative. Improving clinical reasoning skills requires deliberate practice through reflective thinking before, during, and after patient interactions. Refinement of these skills leads to the primary goal of identifying the patient’s clinical presentation, thus matching it with the most effective treatment approach.
Level of evidence:
Level 4
Keywords: Differential diagnosis, nerve tension, physical therapy
BACKGROUND/PURPOSE:
Physical therapists must conduct a thorough examination and evaluation, develop a hypothesis relating to the patients presentation, and select appropriate intervention(s) in order to provide optimal patient outcomes. The process of developing an accurate diagnosis involves sound clinical decision‐making. A broad view of clinical decision‐making can be viewed as being right or being wrong. Current clinical decision making models suggest that there is no right and wrong, rather that there are variations in the correctness of a clinician’s clinical decision‐making.1-3
Clinical reasoning is the process in which the clinician, structures meaning, goals, and health management strategies based on clinical data, patient choices, and professional judgment and knowledge.1 A definitive definition of clinical reasoning can be difficult, becaues it is a complicated and multifaceted process. In fact, no one definition captures the subtlety of how therapists think in the midst of practice.4
Clinical presentations encountered on a daily basis can range from well defined to multifactorial, which can be treated with simple or complex solutions. During each individual patient interaction, components of the clinical examination, including, but not limited to, subjective history, outcome measures, objective examination, and special testing, are assessments with their own ability to shift probability of a particular diagnosis. This is especially true of patients with pain in the lumbo‐pelvic region, an area of suggested symptom convergence.5
The potential for symptom convergence in the lumbo‐pelvic region may be due to the anatomical complexity and the potential numerous sources of pain in this region.6,7 A comprehensive assessment of any patient presenting with complaints of low back pain (LBP) and leg symptoms requires examination of both non‐ neural and neural tissues. Differentiating between mechanical versus nerve related structures can prove difficult as the extent of neural movements are commonly proportional to the extent of the surrounding tissue movement.8 An alteration in neurodynamics will clinically present as adverse neural tension. Therefore, any changes in neural physiology or mobility may result in the development of patient’s symptoms.9
Neurodynamics is a concept that describes the dynamic interaction of the biomechanical, physiological, and morphological functions of the nervous system.10 Recognizing the neurophysiological mechanisms involved in a patient’s pain state often proves challenging, even for expert clinicians. Therefore, examination of the nervous system requires a systematic clinical reasoning approach.
The purpose of this case study is twofold: First, to describe, evaluate, and discuss the clinical reasoning process utilized by a developing practitioner enrolled in a post professional fellowship when encountering an atypical patient presentation. Second, to present the examination and treatment of a patient presenting with atypical adverse neural dynamics related to running.
Case Description
Patient History
The patient was referred from a local orthopedic surgeon for the diagnosis of LBP and sciatica. The patient was a 69 year‐old male reporting a six‐month history of insidious onset of left sided low back and buttock pain of low to medium degree of irritability. Initial pain level reported by the patient was a 0/10, except for 5/10 with running and driving. The ODI was the primary patient reported outcome used in this case report. The patient’s initial score was 10%. The ODI is scored from 0 to 100%. Zero equates to no disability and 100 indicates maximum disability. Secondary outcome measures included a 15‐point global rating of change scale (GROC). His main complaint at the initial visit was aching left lower extremity posterior medial knee pain during running and left buttock/ left posterior medial knee pain while driving. The patient was an avid runner, running four to five times per week, two to three miles per run. The patient had attempted to run 10 days previous to the examination, but the pain began after running one half mile. He had not been able to run since. Ibuprofen helped decrease pain to a 0/10 when present after running or driving. No history of medical problems, past surgeries, or allergies was reported. Anterior‐posterior and lateral radiographs of the lumbar spine revealed mild multilevel degenerative changes at the levels of L3 to S1 with slight retrolisthesis of L2 on L3 and mild lower lumbar facet sclerosis. No evidence of scoliosis, spondylolisthesis, or other pathology was described on imaging report.
Clinical Impression #1(Table 1)
Table 1.
Differential diagnosis following subjective history, self‐report measures and diagnostic imaging.
| Symptoms | Hypothesis | Supporting Evidence | Negating Evidence |
|---|---|---|---|
| R posterior buttock/ posterior medial knee | Lumbar Stenosis | ||
| Lumbar intervertebral disc herniation |
|
||
| Adverse neural dynamics (peripheral nerve entrapment) |
|
||
| Hamstring tendinopathy |
|
||
| Hip osteoarthritis |
|
|
|
| SI joint | |||
| Vertebral fracture |
|
||
Visceral
|
|
|
|
Non‐mechanical
|
|
|
(‐)=negative; LBP=low back pain; SI=sacroiliac; R/O=rule out
Assessment of the patient’s subjective history, self‐report measures, and diagnostic imaging led to the primary working hypotheses of lumbar stenosis, lumbar intervertebral disc herniation, and/or adverse neurodynamic presentation. Hip osteoarthritis, hamstring tendinopathy, and sacroiliac (SI) joint dysfunction were considered other possible sources of the patient’s pain. A thorough subjective history aided the therapist to rule out potential pathological conditions (Table 1). Through appropriate questioning the patient provided descriptions of the type of pain experienced and behavior of symptoms thus assisting in differentiating mechanical musculoskeletal dysfunction from pathological disorders.11 Plain film radiographs were unremarkable for fracture and the patient reported no history of trauma making the likelihood of fracture pathology improbable. The patient did not present with any signs and symptoms of cancer or visceral dysfunction and these conditions were also considered unlikely.
Examination
The examination included a postural assessment, lower extremity neurological screen, active and passive range of motion (ROM) assessments, manual muscle testing, lumbar/hip passive accessory testing, palpation of the hip and lumbar regions, and select special tests. Postural assessment revealed slightly rounded shoulders, increased thoracic kyphosis, and a forward head position. Gait assessment revealed a bilateral reciprocal, non‐antalgic pattern without apparent dysfunction. The patient was able to perform a deep squat without reproduction of pain. He was able to get his thighs parallel to the floor and shins parallel to his trunk with this assessment. Lumbar flexion/extension, side bending, combined movements, and repeated lumbar flexion/extension ROM were all assessed and were negative for symptom reproduction. Lumbar ROM was within normal limits in all directions and over pressure was negative for symptom reproduction. Spinal mobility (as assessed with posterior‐anterior passive accessory testing) did not reproduce the patient’s concordant pain and/or symptoms. Slump test elicited discordant pain, pain not similar to the patient’s pain complaint, in the lower back/pelvis region on the involved left side, as well as the uninvolved right side. Myotome and dermatome testing for bilateral lower extremities was normal. Deep tendon reflexes were normal and symmetrical. Upper motor neuron examination was deferred due to no suggestion that this type of testing was required. Bilateral hip joints demonstrated symmetrical and normal ROM, normal end‐feel, and no symptom reproduction with over pressure in all planes. Palpation of the ischial tuberosity, greater trochanter, gluteus medius, illiotibial band, hamstrings, and SI joint was negative. Hip scour test was negative. Bilateral hamstring strength was 5/5 in prone at knee flexion angles of 40, 60, 90, 120 degrees. Straight leg raise (SLR) testing was 50 degrees bilaterally without symptoms. Straight leg raise testing with variations for peroneal, sural, and tibial nerves was negative bilaterally as well. The cervical spine was flexed during each variation of the SLR test to further sensitize (bias) the nervous system, but was negative in all variations. The thigh thrust test was negative bilaterally. Concordant pain was elicited with active hamstring stretching with the hip flexed at 90 degrees and foot dorsiflexed (Figure 1).10 A formal running assessment was not employed during the initial visit due to patient not having proper running clothing. The patient was advised to bring proper attire to the following visit.
Figure 1.
Active knee extension/dorisflexion bias lower extremity neural assessment
Clinical Impression #2 (Table 2)
Table 2.
Differential diagnosis after objective clinical examination
| Symptoms | Hypothesis | Supporting Evidence | Negating Evidence |
|---|---|---|---|
| R posterior buttock/ posterior medial knee | Adverse neural dynamics (peripheral nerve entrapment) |
|
|
| Lumbar intervertebral disc herniation |
|
||
| Lumbar stenosis | |||
| SI joint | |||
| Hip osteoarthritis |
|
||
| Hamstring tendinopathy |
|
|
(‐)=negative; SLR=straight leg raise; AROM=active range‐of‐motion; SI=sacroiliac; LE=lower extremity; LBP=low back pain; IR=internal rotation
A plethora of diagnostic hypotheses were still present, resulting in the need for continued in‐depth examination. Since lumbar neuro‐musculoskeletal dysfunction was expected, the clinician began with a lower quarter screen. The early objective examination led to a low likelihood that the source of the symptoms was from lumbar stenosis or intervertebral disc herniation as the patient reported no increase or decrease of symptoms with sitting (except with sitting while driving), standing, or walking,12,13 demonstrated normal lumbar AROM in all planes including the lumbar quadrants14 with and without overpressure, and no pain with repeated lumbar motions.15,16
At this point in the examination, it was believed that the neural system should be examined in order to determine if the patient’s concordant sign, the activity or motion that reproduced the patient’s symptoms,17 could be replicated. Slump testing was assessed, eliciting discordant LBP that was comparable on the involved and non‐involved sides and was not affected by a distant component.10,18 Slump testing was deemed negative due to not reproducing concordant pain and meeting the requirements for positive neural tension testing.18 With the finding of discordant pain during slump testing, further assessment of the nervous system was determined to be appropriate. Neurological testing (myotome/dermatome/reflex testing) was performed while in sitting. Findings were normal and symmetrical, providing further evidence to rule out intervertebral disc pathology and stenosis.18,19
Neural testing in supine was assessed due to the patient’s discordant pain during slump testing. Straight leg raise testing as described by Butler10 was performed and found to be negative. Frequently used sensitizing maneuvers, as described in the examination section, were initiated at the ankle and also assessed as negative. Due to the high sensitivity of this test it appeared adverse neural dynamics was of low likelihood.
Possible hypotheses that had not been completely ruled out were hip osteoarthritis, hamstring tendinopathy, and SI joint dysfunction. After further examination hip osteoarthritis, hamstring tendinopathy and SI joint dysfunction were considered of low likelihood due to normal pain free hip ROM,20-22 negative bilateral scour testing, pain free and normal hamstring resistive and special testing,23-26 painfree hamstring palpation, bilateral negative thigh thrust,27,28 negative Fortin finger testing,29-31 and pain free SI joint palpation.32
Unable to distinctly reproduce the patients symptoms up to this point in the examination, and unable to assess running due to limitations in attire, the clinician decided to investigate the neural system further with expansion on foundational neurodynamic testing.10 Testing began with adding hip movements in various sequences, beginning with hip flexion, to SLR testing. According to Butler10 a commonly performed test is to flex the hip to end range and then add knee extension (and ankle dorsiflexion if necessary). Adding hip flexion was selected as the first movement to assess because of the patients functional complaints. Subjectively, the patient reported pain during the eccentric phase of knee extension while running when the hip was in a flexed position. This test elicited the patient’s concordant sign with the addition of ankle dorsiflexion, and was different on the involved compared to the non‐involved side. Therefore this test was assessed as positive. Ankle dorsiflexion was added prior to extending the knee. The patient’s symptoms were further increased with this sensitizing procedure. Performing additional repetitions decreased the intensity of symptoms at end range.
Assessment of the patient’s subjective history, self‐report measures, objective findings, and tests and measures led to a working diagnosis of atypical adverse peripheral neurodynamics. The clinical reasoning that led this working diagnosis considered ruling out other structures as the source of the patient’s symptoms. The likelihood that the patient’s symptoms were originating from the lumbar spine, SI joint, hip joint or lower extremity was ruled less likely by a comprehensive and meticulous subjective and objective examination. In this case, adverse neurodynamics was a diagnosis of exclusion.
Intervention (Table 3)
TABLE 3.
Interventions utilized in case report.
| Visit | Between Session Change | Intervention | Within Session Change |
|---|---|---|---|
| 1 | Active SLR 3 x 10 2‐3x per day Instruction of jog (1 min)/walk (2 min) program Desk ergonomics with specific focus on seated posture Use of lumbar support when sitting | Re‐assessment sign: Active SLR Decrease in intensity of symptoms at end range | |
| 2 (2.5 weeks later) | Patient reports no pain in L buttock at this time with running. | HEP/ergonomic review | N/A |
SLR= straight leg raise; HEP=home exercise program; L=left; min=minute; N/A=not applicable
After differentiating neural versus non‐neural tissue as the pain generator, tensioning techniques were employed.10 Tensioning techniques are used to provide tension to the nervous tissue by pulling at both ends. The testing position that reproduced the patient’s concordant sign was used as the treatment position. The patient was instructed to lie supine and flex the hip past 90 degrees. Once in this position he was instructed to extend his knee and dorsiflex the ankle to the point of concordant pain. This position was held for two to three seconds and repeated as described in Table 3. Since this was the only finding reproducing his pain, this was also instructed as his home exercise program (HEP). Clinical judgment led to the decision to employ tensioning versus gliding techniques secondary to the hypothesis that the neural system was unable to accept tension and the low degree of symptom irritability. The patient was advised to monitor for worsening of symptoms with HEP. If symptoms worsened, the patient was advised to decrease the intensity of the exercise. If symptoms continued to worsen, the patient was advised to discontinue the activity. Additional instructions given are presented in Table 3. Secondary to a demanding work schedule it was decided that the patient would schedule a follow up visit for two to three weeks from the day of the initial evaluation. The treatment plan for the follow up visit was to assess the patient’s response to his HEP as well as perform a running assessment.
The patient attended a follow up visit two and one half weeks after the initial evaluation. The patient reported compliance with his HEP and that his pain level had decreased allowing him to return to running. The patient wanted to review his HEP. He again stated that he did not bring running attire and did not think that it was necessary for a running or functional assessment to be performed since he had returned to running with no limitations and was satisfied with his outcomes.
Outcomes
Twelve weeks after the initiation of physical therapy, the patient was contacted via email. He was sent, and asked to fill out an ODI. The patient demonstrated an improvement in ODI from 10% to 2%, a minimal clinically important difference (MCID) of 8. The patient scored a +7 (a great deal better) on the GROC. Through email the patient reported that he continued to run without pain and that he was able to resume running the same distances he could prior to the onset of pain. He also reported no pain while driving. He could independently manage his symptoms and he was discharged with advice to continue with his independent HEP (Table 3). The patient was instructed and educated to call to schedule an appointment if his symptoms returned or any problems arose. (Table 4)
Table 4.
Outcomes scores for case report
| Oswestry Disability Index | Global rating of change scale | Global rating of function | |
|---|---|---|---|
| Initial | 10% | N/A | 90% |
| Follow up (12 weeks later) | 2% | +7 | 100% |
N/A=not applicable
Discussion
This case report describes the utilization of clinical reasoning by a clinician in fellowship training examining and treating a patient with atypical adverse neurodynamics related to running. The clinician utilized a systematic, logical method of clinical reasoning when attempting to arrive at a differential diagnosis, based on reproduction of the patient’s concordant pain. While the subjective history can be used to determine up to 76% to 83% of diagnoses,33,34 encountering a patient who presents with signs and symptoms not clearly delineating a specific pain generator renders clinical reasoning and differential diagnosis essential. The foundation of clinical reasoning is the ability of the clinician to recognize relevant cues and how they relate to one another. The patient’s subjective and objective examination may make it possible to easily exclude potential diagnoses, but other diagnoses may require more detailed examination.
In this case, the subjective examination aided in ruling out potential pathologic conditions but did not clearly delineate a pain generator. Therefore, the clinicians reasoning processes were modified. This was demonstrated with the use of a progressive clinical examination. Steps were taken to sequentially rule out possible pain generators in the lumbo‐pelvic region.
Clinical reasoning is dependent on two processes: 1) the analytic method, hypothetical deductive reasoning, and 2) the non‐analytic method, pattern recognition. Integration of both processes allows for efficient and accurate clinical decision making.35 Pattern recognition should be considered a necessary building block in the development of clinical reasoning skills. Expert clinicians regularly use pattern recognition for common patient problems and hypothetico‐deductive reasoning for complex problems. Expert clinical reasoning and differential diagnosis is an evolving process that involves identifying working interpretations and repeated hypothesis generation. Deletion and refinement of these interpretations and hypotheses allows health professionals to develop an understanding of patient problems.2,36 A refinement of these skills with reflective thinking leads to achieving the primary goal of identifying the patient’s clinical presentation and matching it with the most effective treatment approach.37
In this case, pattern recognition suggested pain generation from the lumbar spine or pelvis, which was not reproduced with clinical examination. Reflective thinking led to employing further sensitive testing to the neural system. Sensitizing maneuvers, as described by Butler, are used during neural tissue provocation tests and can assist clinicians in differentiating between non‐neural and neural tension related to musculoskeletal pathologies. Sensitizing maneuvers helped to rule in adverse neural tension but not before efficiently ruling out other musculoskeletal sources of pain.
Neural tissue is able to tolerate mechanical forces generated during movements associated with every day and sport activities.10 Peripheral neuropathic pain is a term that is used to describe what occurs when nerve roots or peripheral nerve trunks have been injured by mechanical or chemical stimuli.10 Peripheral neuropathic mechanisms can present similarly to other common musculoskeletal syndromes, such as lateral epicondyligia,38 achilles tendinosis,39 heel pain,40,41 inversion ankle sprains,42 and hamstring tendinosis.43
Interventions for this patient were selected in order to address his concordant sign and functional limitations found during the initial evaluation. The use of tensioning neurodynamic exercise was the focus of the treatment. Currently, there is limited evidence to support the use of neural mobilization in patients presenting with adverse neural tension,44 or even pathology in general.45 Low quality studies have demonstrated that a treatment focusing on movement of neural tissue can be safely implemented to promote recovery for patients with peripheral neuropathic pain.46,47 This case report discusses patient education regarding neural mechanics and their role in the patient’s pathology was imperative in order to improve compliance to the home exercise program.
While it might be argued that the patient initially had limited disability, and may have improved on his own, one independently guided treatment was both objectively and anecdotally successful. As demonstrated through subjective reports of improvement, decreasing pain levels (MCID of 2),48,49 improved ODI (MCID of 30% from baseline score),50 maximum improvement on GROC score (+7), and a return to pain free running, this patient responded well to the selected treatments. Additionally, these significant results were after six months of symptoms that had not improved on their own and the patient continued to be significantly improved 12 weeks after intervention.
Limitations of the case report include lack of any type of functional testing, a formal running assessment, knee examination, and objective assessment during the follow up visit. At the follow up visit the plan was to evaluate running mechanics and perform further functional testing but the patient presented to the visit without running attire, reporting satisfaction with his outcomes at that time. High‐level patient satisfaction has been shown with optimizing aspects of the patient‐therapist interaction, the process of care, and performing a well‐organized evaluation and treatment.51
Conclusion
Ascertaining the pain generator in complex patient presentations requires a diligent, systematic examination approach based on replication of the patients concordant pain. The development of differential diagnosis and clinical reasoning skills is important. Improving clinical reasoning skills requires deliberate practice and routinely engaging in reflective thinking before, during, and after each patient interaction. This case report is a description of utilizing the reasoning process in attempts of providing optimal outcomes in a patient.
REFERENCES
- 1.Jones MA Clinical reasoning in manual therapy. Phys Ther. 1992;72(12):875‐884. [DOI] [PubMed] [Google Scholar]
- 2.Kassirer JP Teaching clinical reasoning: case‐based and coached. Acad Med. 2010;85(7):1118‐1124. [DOI] [PubMed] [Google Scholar]
- 3.Elstein AS Schwartz A Clinical problem solving and diagnostic decision making: selective review of the cognitive literature. BMJ. 2002;324(7339):729‐732. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Mattingly C Flemming MH Clinical Reasoning: Forms of Inquiry in a Therapeutic Practice Philadelphia, PA: FA Davis Company; 1994. [Google Scholar]
- 5.Bogduk N The causes of low back pain. Med J Aust. 1992;156(3):151‐153. [PubMed] [Google Scholar]
- 6.Sizer PS Jr. Brismee JM Cook C Medical screening for red flags in the diagnosis and management of musculoskeletal spine pain. Pain pract. 2007;7(1):53‐71. [DOI] [PubMed] [Google Scholar]
- 7.Sizer PS Jr. Phelps V Dedrick G Matthijs O Differential diagnosis and management of spinal nerve root‐related pain. Pain pract. 2002;2(2):98‐121. [DOI] [PubMed] [Google Scholar]
- 8.Di Fabio RP Neural Mobilization: The Impossible. J Orthop Sports Phys Ther. 2001;31(5):224‐225. [Google Scholar]
- 9.Walsh MT Upper limb neural tension testing and mobilization. Fact, fiction, and a practical approach. J Hand Ther. 2005;18(2):241‐258. [DOI] [PubMed] [Google Scholar]
- 10.Butler DA Mobilisation of the Nervous System. Melbourne: Churchille Livingstone; 1991. [Google Scholar]
- 11.Boissonnault WG Bass C Pathological origins of trunk and neck pain: part I ‐ pelvic and abdominal visceral disorders. J Orthop Sports Phys Ther. 1990;12(5):1‐207. [PubMed] [Google Scholar]
- 12.Katz JN Dalgas M Stucki G, et al. Degenerative lumbar spinal stenosis. Diagnostic value of the history and physical examination. Arthritis Rheum. 1995;38(9):1236‐1241. [DOI] [PubMed] [Google Scholar]
- 13.Cook C Brown C Michael K, et al. The clinical value of a cluster of patient history and observational findings as a diagnostic support tool for lumbar spine stenosis. Physiother Res Int. 2010. [DOI] [PubMed] [Google Scholar]
- 14.Lyle MA Manes S McGuinness M Ziaei S Iversen MD Relationship of physical examination findings and self‐reported symptom severity and physical function in patients with degenerative lumbar conditions. Phys Ther. 2005;85(2):120‐133. [PubMed] [Google Scholar]
- 15.Donelson R Aprill C Medcalf R Grant W A prospective study of centralization of lumbar and referred pain. A predictor of symptomatic discs and anular competence. Spine (Phila Pa 1976). 1997;22(10):1115‐1122. [DOI] [PubMed] [Google Scholar]
- 16.Laslett M Oberg B Aprill CN McDonald B Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. Spine J. 2005;5(4):370‐380. [DOI] [PubMed] [Google Scholar]
- 17.Cook CE Hegedus EJ Orthopedic Physical Examination Tests: An Evidence‐Based Approach: Pearson Prentice Hall; 2008. [Google Scholar]
- 18.Stankovic R Johnell O Maly P Willner S Use of lumbar extension, slump test, physical and neurological examination in the evaluation of patients with suspected herniated nucleus pulposus. A prospective clinical study. Man Ther. 1999;4(1):25‐32. [DOI] [PubMed] [Google Scholar]
- 19.Kerr RS Cadoux‐Hudson TA Adams CB The value of accurate clinical assessment in the surgical management of the lumbar disc protrusion. J Neurol Neurosurg Psychiatry. 1988;51(2):169‐173. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Altman R Alarcon G Appelrouth D, et al. The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hip. Arthritis Rheum. 1991;34(5):505‐514. [DOI] [PubMed] [Google Scholar]
- 21.Birrell F Croft P Cooper C Hosie G Macfarlane G Silman A Predicting radiographic hip osteoarthritis from range of movement. Rheumatology (Oxford). 2001;40(5):506‐512. [DOI] [PubMed] [Google Scholar]
- 22.Brown MD Gomez‐Marin O Brookfield KF Li PS Differential diagnosis of hip disease versus spine disease. Clin Orthop Relat Res. 2004(419):280‐284. [DOI] [PubMed] [Google Scholar]
- 23.Cacchio A Borra F Severini G, et al. Reliability and validity of three pain provocation tests used for the diagnosis of chronic proximal hamstring tendinopathy. Br J Sports Med. 2012. [DOI] [PubMed] [Google Scholar]
- 24.Zeren B Oztekin HH A new self‐diagnostic test for biceps femoris muscle strains. Clin J Sport Med. 2006;16(2):166‐169. [DOI] [PubMed] [Google Scholar]
- 25.Schneider‐Kolsky ME Hoving JL Warren P Connell DA A comparison between clinical assessment and magnetic resonance imaging of acute hamstring injuries. Am J Sports Med. 2006;34(6):1008‐1015. [DOI] [PubMed] [Google Scholar]
- 26.Cook JL Purdam CR The challenge of managing tendinopathy in competing athletes. Br J Sports Med. 2014;48(7):506‐509. [DOI] [PubMed] [Google Scholar]
- 27.Laslett M Aprill CN McDonald B Young SB Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Man Ther. 2005;10(3):207‐218. [DOI] [PubMed] [Google Scholar]
- 28.Laslett M Aprill CN McDonald B Provocation sacroiliac joint tests have validity in the diagnosis of sacroiliac joint pain. Arch Phys Med Rehabil. 2006;87(6):874; author reply 874‐875. [DOI] [PubMed] [Google Scholar]
- 29.Fortin JD Aprill CN Ponthieux B Pier J Sacroiliac joint: pain referral maps upon applying a new injection/arthrography technique. Part II: Clinical evaluation. Spine (Phila Pa 1976). 1994;19(13):1483‐1489. [PubMed] [Google Scholar]
- 30.Fortin JD Falco FJ The Fortin finger test: an indicator of sacroiliac pain. Am J Orthop (Belle Mead NJ). 1997;26(7):477‐480. [PubMed] [Google Scholar]
- 31.Dreyfuss P Michaelsen M Pauza K McLarty J Bogduk N The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine (Phila Pa 1976). 1996;21(22):2594‐2602. [DOI] [PubMed] [Google Scholar]
- 32.Dreyfuss P Dryer S Griffin J Hoffman J Walsh N Positive sacroiliac screening tests in asymptomatic adults. Spine (Phila Pa 1976). 1994;19(10):1138‐1143. [DOI] [PubMed] [Google Scholar]
- 33.Hampton JR Harrison MJ Mitchell JR Prichard JS Seymour C Relative contributions of history‐taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients. Br Med J. 1975;2(5969):486‐489. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Peterson MC Holbrook JH Von Hales D Smith NL Staker LV Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses. West J Med. 1992;156(2):163‐165. [PMC free article] [PubMed] [Google Scholar]
- 35.Eva KW What every teacher needs to know about clinical reasoning. Med Educ. 2005;39(1):98‐106. [DOI] [PubMed] [Google Scholar]
- 36.Epstein RM Hundert EM Defining and assessing professional competence. JAMA. 2002;287(2):226‐235. [DOI] [PubMed] [Google Scholar]
- 37.Wainwright SF Shepard KF Harman LB Stephens J Novice and experienced physical therapist clinicians: a comparison of how reflection is used to inform the clinical decision‐making process. Phys Ther. 2010;90(1):75‐88. [DOI] [PubMed] [Google Scholar]
- 38.Yaxley GA Jull GA Adverse tension in the neural system. A preliminary study of tennis elbow. Australian Physiotherapy. 1993;39(1):15‐22. [DOI] [PubMed] [Google Scholar]
- 39.McCrory P Bell S Bradshaw C Nerve entrapments of the lower leg, ankle and foot in sport. Sports Med. 2002;32(6):371‐391. [DOI] [PubMed] [Google Scholar]
- 40.Schon LC Glennon TP Baxter DE Heel pain syndrome: electrodiagnostic support for nerve entrapment. Foot Ankle. 1993;14(3):129‐135. [DOI] [PubMed] [Google Scholar]
- 41.Meyer J Kulig K Landel R Differential diagnosis and treatment of subcalcaneal heel pain: a case report. J Orthop Sports Phys Ther. 2002;32(3):114‐122; discussion 122‐114. [DOI] [PubMed] [Google Scholar]
- 42.Pahor S Toppenberg R An investigation of neural tissue involvement in ankle inversion sprains. Man Ther. 1996;1(4):192‐197. [DOI] [PubMed] [Google Scholar]
- 43.Turl SE George KP Adverse neural tension: a factor in repetitive hamstring strain? J Orthop Sports Phys Ther. 1998;27(1):16‐21. [DOI] [PubMed] [Google Scholar]
- 44.Tal‐Akabi A Rushton A An investigation to compare the effectiveness of carpal bone mobilisation and neurodynamic mobilisation as methods of treatment for carpal tunnel syndrome. Man Ther. 2000;5(4):214‐222. [DOI] [PubMed] [Google Scholar]
- 45.Ellis RF Hing WA Neural mobilization: a systematic review of randomized controlled trials with an analysis of therapeutic efficacy. J Man Manip Ther. 2008;16(1):8‐22. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 46.Coppieters MW Butler DS Do ‘sliders’ slide and ‘tensioners’ tension? An analysis of neurodynamic techniques and considerations regarding their application. Man Ther. 2008;13(3):213‐221. [DOI] [PubMed] [Google Scholar]
- 47.Cleland JA Childs JD Palmer JA Eberhart S Slump stretching in the management of non‐radicular low back pain: a pilot clinical trial. Man Ther. 2006;11(4):279‐286. [DOI] [PubMed] [Google Scholar]
- 48.Farrar JT Berlin JA Strom BL Clinically important changes in acute pain outcome measures: a validation study. J Pain Symptom Manage. 2003;25(5):406‐411. [DOI] [PubMed] [Google Scholar]
- 49.Farrar JT Portenoy RK Berlin JA Kinman JL Strom BL Defining the clinically important difference in pain outcome measures. Pain. 2000;88(3):287‐294. [DOI] [PubMed] [Google Scholar]
- 50.Ostelo RW Deyo RA Stratford P, et al. Interpreting change scores for pain and functional status in low back pain: towards international consensus regarding minimal important change. Spine (Phila Pa 1976). 2008;33(1):90‐94. [DOI] [PubMed] [Google Scholar]
- 51.Hush JM Cameron K Mackey M Patient satisfaction with musculoskeletal physical therapy care: a systematic review. Phys Ther. 2011;91(1):25‐36. [DOI] [PubMed] [Google Scholar]
- 52.Kellgren JH Lawrence JS Radiological assessment of osteo‐arthrosis. Ann Rheum Dis. 1957;16(4):494‐502. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 53.Fritz JM Erhard RE Delitto A Welch WC Nowakowski PE Preliminary results of the use of a two‐stage treadmill test as a clinical diagnostic tool in the differential diagnosis of lumbar spinal stenosis. J Spinal Disord. 1997;10(5):410‐416. [PubMed] [Google Scholar]
- 54.Dammers R Koehler PJ Lumbar disc herniation: level increases with age. Surg Neurol. 2002;58(3‐4):209‐212; discussion 212‐203. [DOI] [PubMed] [Google Scholar]
- 55.Deyo RA Rainville J Kent DL What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760‐765. [PubMed] [Google Scholar]
- 56.Askling C Saartok T Thorstensson A Type of acute hamstring strain affects flexibility, strength, and time to return to pre‐injury level. Br J Sports Med. 2006;40(1):40‐44. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 57.Askling CM Tengvar M Saartok T Thorstensson A Acute first‐time hamstring strains during high‐speed running: a longitudinal study including clinical and magnetic resonance imaging findings. Am J Sports Med. 2007;35(2):197‐206. [DOI] [PubMed] [Google Scholar]
- 58.Ferrar L Jiang G Adams J Eastell R Identification of vertebral fractures: an update. Osteoporos Int. 2005;16(7):717‐728. [DOI] [PubMed] [Google Scholar]
- 59.Langdon J Way A Heaton S Bernard J Molloy S Vertebral compression fractures‐‐new clinical signs to aid diagnosis. Ann R Coll Surg Engl. 2010;92(2):163‐166. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 60.Deyo RA Diehl AK Cancer as a cause of back pain: frequency, clinical presentation, and diagnostic strategies. J Gen Intern Med. 1988;3(3):230‐238. [DOI] [PubMed] [Google Scholar]
- 61.Fritz JM Piva SR Childs JD Accuracy of the clinical examination to predict radiographic instability of the lumbar spine. Eur Spine J. 2005;14(8):743‐750. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 62.Majlesi J Togay H Unalan H Toprak S The sensitivity and specificity of the Slump and the Straight Leg Raising tests in patients with lumbar disc herniation. J Clin Rheumatol. 2008;14(2):87‐91. [DOI] [PubMed] [Google Scholar]
- 63.van der Windt DA Simons E Riphagen II, et al. Physical examination for lumbar radiculopathy due to disc herniation in patients with low‐back pain. Cochrane Database Syst Rev. 2010(2):CD007431. [DOI] [PubMed] [Google Scholar]
- 64.Deville WL van der Windt DA Dzaferagic A Bezemer PD Bouter LM The test of Lasegue: systematic review of the accuracy in diagnosing herniated discs. Spine (Phila Pa 1976). 2000;25(9):1140‐1147. [DOI] [PubMed] [Google Scholar]
- 65.Askling CM Tengvar M Saartok T Thorstensson A Proximal hamstring strains of stretching type in different sports: injury situations, clinical and magnetic resonance imaging characteristics, and return to sport. Am J Sports Med. 2008;36(9):1799‐1804. [DOI] [PubMed] [Google Scholar]