Military Rehabilitation

Special Issue

Clinical Reasoning and Advanced

D.I. Rhön, PT, DPT, DSc, OCS,
FAAOMPT, Department of Physi-
cal Medicine & Rehabilitation,
Madigan Army Medical Center,
Fort Lewis, Washington. Mailing
address: Department of Physical
Medicine & Rehabilitation, Madi-
gan Army Medical Center, Build-
ing 9040, Jackson Ave, Tacoma,
WA 98431 (USA). Address all cor-
respondence to Dr Rhön at:
daniel.rhon@us.army.mil.
CD. Deyle, PT, DPT, DSc, OCS,
FAAOMPT, US Army-Baylor Uni-
versity Doctoral Fellowship in
Orthopaedic Manual Physical
Therapy, San Antonio Military
Medical Center, Fort Sam Hous-
ton, Texas.
N.W. Gill, PT, DSc, OCS,
FAAOMPT, US Army-Baylor Uni-
versity Doctor of Physical Therapy
Program, Fort Sam Houston,
Texas.
[Rhön DI, Deyle GD, Gill NW. Clin-
ical reasoning and advanced prac-
tice privileges enable physical
therapist point-of-care decisions
in the military health care system:
3 clinical cases, i^hys Ther.
201 3;93:1234-1243.]
© 2013 American Physical Therapy
Association
Practice Privileges Enable Physical
Therapist Point-of-Care Decisions in
the Military Health Care System:
3 Clinical Cases
Daniel I. Rhön, Gail D. Deyle, Norman W. Gill
Background and Purpose. Physical therapists frequently make itnportatit
poitit-of-care decisions for musculoskeletal injuries and conditions. In the Military
Health System (MHS), these decisions may occur while therapists are deployed in
support of combat troops, as well as in a more traditional hospital setting. Proficiency
with the musculoskeletal examination, including aftindamentalunderstanding of the
diagnostic role of musculoskeletal imaging, is an important competency for physical
therapists. The purpose of this article is to present 3 cases managed by physical
therapists in unique MHS settings, highlighting relevant challenges and clinical
decision making.
Case Description. Three cases are presented involving conditions where the
physical therapist was significantly involved in the diagnosis and clinical management
plan. The physical therapist's clinical privileges, including the ability to order appro-
priate musculoskeletal imaging procedures, were helpful in making clinical decisions
that facilitate timely management. The cases involve patients with an ankle sprain and
Maisonneuve fracture, a radial head fracture, and a pelvic neoplasm referred through
medical channels as knee pain.
Outcomes. CUnical pathways from point of care are discussed, as well as the
reasoning that led to decisions affecting definitive care for each of these patients. In
each case, emergent treatment and important combat evacuation decisions were
based on a combination of examination and management decisions.
Discussion. Physical therapists can provide important contributions to the pri-
mary management of patients with musculoskeletal conditions in a variety of settings
within the MHS. In the cases described, advanced clinical privileges contributed to
the success in this role.

Published Ahead of Print:

February 7, 2013
Accepted: February 4, 2013
Submitted: March 30, 2012

Post a Rapid Response to

this article at:
ptjournal. opta, org

1234 m Physical Therapy Volume 93 Number 9 September 201 3

 Physical Therapist Point-of-Care Decisions in the Military Health Care System

P
hysical therapists often are posi- disrupt joint surfaces or produce role in guiding the diagnostic pro-
tioned to make point-of-care instability, such as Lisfranc or ankle cess and ultimate management of
management decisions within syndesmosis injuries, have a better these patients.^
their area of specialty training, most prognosis w^ith timely recognition
often musculoskeletal conditions.'"^ and early appropriate manage- In the forward operating base, the
In the Military Health System (MHS), ment."^-i** Although very uncom- front-lines environment was austere,
these management decisions can mon, neoplasms also can masquer- with limited medical resources, and
occur -while the physical therapist is ade as musculoskeletal pathology, asthe only imaging medium available
deployed in a combat support the skeletal system is a common sitewas a small mobile radiography sys-
role,'''^'^ in addition to the more tra- of metastasis for various primary tem. A computed tomography scan-
ditional hospital settings.»•"' Physicalcancers.13-23 ner w^as available in the Combat Sup-
therapists in the MHS are often the port Hospital a short fiight away,
first credentialed providers to exam- The purpose of this article is to pres- where the closest surgeon was
ine and diagnose patients with mus- ent 3 cases where physical therapists located.^'* The medical personnel in
culoskeletal conditions.*' Formal clin- in the MHS played roles in the diag- the forward operating base included
ical privileges to order basic nosis and clinical management and 2 physicians (internal medicine and
laboratory and diagnostic imaging provide insight into their decision- family medicine specialties), a phys-
studies and refer patients to the making and clinical reasoning pro- ical therapist, 2 physician's assis-
appropriate specialty clinic may
cesses. Each case illustrates a focus tants, a dentist, a nurse, and a mental
facilitate timely and cost-effective
on clinical decisions, including health provider. Although there
management of musculoskeletal inju-
ordering diagnostic musculoskeletal were trauma, mass casualty, and
ries and conditions.^'"-12
images and implementing appropri- evacuation protocols that were prac-
ate subsequent care. ticed by the medical team, none
Strong patient interview and physi- existed for the standard management
cal examination skills also can facili- of musculoskeletal injuries and con-
tate timely and accurate decisions Therapist and Environment ditions. Additionally, leaving the con-
regarding necessary additional Characteristics fines of the forward operating base
screening. Physical therapists should The physical therapist providing for a convoy to the Combat Support
carefully formulate or select each care for the first 2 patients had a Hospital was a dangerous and poten-
interview question or diagnostic test master's degree in physical therapy, tially life-threatening course of
that may provide valuable informa- 4 years of outpatient orthopedic action and had to be weighed
tion to help rule in or nile out a experience in direct access settings, accordingly in the management deci-
clinical hypothesis. 1' Most clinical and formal credentials for advanced sions. Two of these cases were cho-
decision tools used for screening and clinical privileges, including order- sen from afileof cases brought back
diagnosis have not been studied in ing musculoskeletal imaging and from a combat deployment,^ based
combat settings. Keeping this per- basic laboratory studies. These cases on their musculoskeletal imaging
spective, a blend of current best evi- occurred during a 12-month combat application.
dence and clinical experience is deployment while serving in a for-
helpftil to identify and appropriately ward operating base in Iraq, where
channel patients w^ith injuries and the physical therapist served as the
conditions requiring treatment out- musculoskeletal asset attached to a Available With
side a physical therapist's scope of mechanized infantry brigade and This Article at
practice. Examples of pathology a saw 309 unique patients (1,362 total ptjournal.apta.org
physical therapist may encounter visits) during that time frame.^ The
include tumors, infections, aortic last case was seen in a large military Listen to a special Craikcast on
abdominal aneurysnis, fractures, dis- medical treatment facility by a phys- the Military Rehabilitation Special
locations, and a variety of other sys- ical therapist with a master's degree Issue with editors John Childs and
Alice Aiken.
temic diseases. Additionally, condi- in physical therapy, 20 years of gen-
tions such as cauda equina eral and orthopedic physical therapy Audio Podcast: "Advancing the
syndrome, stress fractures of the experience, and similar clinical priv- Evidence Base in Rehabilitation
femoral neck, or compartment syn- ileges. In each of these cases, the for Military Personnel and
Veterans" symposium recorded at
drome''' may require emergent sur- physical therapist played a helpful
APTA Conference 201 3, |une 28,
gical intervention. 14 15 Injuries that 2013, in Salt Lake City, Utah.

September 2013 Volume 93 Number 9 Physical Therapy m 1235

Physical Therapist Point-of-Care Decisions in the Military Health Care System

larities and verified neurovascular

integrity. A radiographie study of the
ankle (Fig. 1) was ordered in the
trauma triage room and read verba-
tim as a "possible avulsion of medial
malleolus but otherwise unremark-
able." It was unknown whether the
Ottawa Clinical Decision Rule^^ -^^g,
used before ordering the radiograph.
He was provided crutches, a com-
pression wrap, and instmctions to
ice and elevate the ankle. Two days
later, after the swelling had slightly
subsided, he came in to see the phys-
ical therapist for additional care.

Clinical impression 1. The other-

wise healthy patient was using
crutches, tolerating partial but not
full weight bearing. Moderate joint
effusion and ecchymosis over the lat-
eral ankle were still present. The
¡physical therapist's plan was to rule
out a fracture, and if a fracture
existed, to determine whether surgi-
cal stabilization was required (w^hich
would require an evacuation out of
the country). The physical thera-

m
l")ist's differential diagnosis included
medial collateral (deltoid) or lateral
collateral ligament ankle sprain, rear-
foot or midfoot sprain (Lisfranc or
Charcot), and high ankle (syndesmo-
Figure 1. sis) sprain (Table). Unique consider-
Initial radiographs (lateral and anterior-posterior oblique/mortise views) taken of the ations for prognosis included the
ankle. Note the exposed area on the radiograph was below the proximal fibula. The need to ambulate on rocky terrain
hairline fracture can be seen on the medial malleolus in this image, but it is not easy to while wearing body armor (~8 kg).
detect.
The decision to consult with an
orthopedic surgeon would not be
trivial, as it required an escorted car-
Case Descriptions base for further evaluation by medi- avan of vehicles on a hostile route.
Case 1 (Maisonneuve Fracture) cal staff. He denied any low back, This patient case demonstrates some
Patient history and systems hip, or knee pain, and all of his vital unique considerations of managing a
review. A 38-year-old Hispanic signs were normal. He was not cur- patient with a musculoskeletal injury
male physician's assistant reported rently on other medications. He was in a combat environment, including
that he was on a combat foot patrol able to take 4 steps with some an assessment of resources and
in Iraq when he "stepped wrong" weight distributed on his right lower implications of clinical decisions on
and twisted his right ankle. He extremity, although he winced from ftirther care and prognosis.
reported immediate pain that pain. Upon removal of his boots,
increased with weight bearing, but there was obvious ankle effusion on Examination. The physical thera-
he was able to continue the patrol. the right compared with the left. Tlie pist used the Ottawa Ankle Rule-' to
After 30 minutes, due to increasing attending physician in the trauma screen the patient for a fracture,
pain, he was placed in a vehicle and room cleared the foot and ankle for even though a radiograph had
returned to the forward operating lacerations, "wounds, or other irregu- already been taken. The rules indi-

1236 • Physical Therapy Volume 93 Number 9 September 201 3

 Physical Therapist Point-of-Care Decisions in the Military Health Care System

Table.
Clinical Reasoning Summary for All Cases

Case Differential Diagnosis Differentiation Point" Management Pian Outcome

Maisonneuve 1. Lateral collateral ligament Mechanism of injury. Sharp pain Discussion with orthopedic After 2 weeks of immobilization.
fracture ankle sprain on medial malleolus and surgeon in remote and based on minimal pain
2. Syndesmosis (high ankle) proximal fibula with location. Surgical and minimal widening with
sprain palpation. Inability to fully intervention usually proper stress views of the
3. Proximal fibula fracture bear weight in single-limb required for this ankle, the decision was made
stance due to pain. condition. Patient was to manage the fracture
evacuated out of theater nonsurgically. The patient
for surgical consideration. returned to the combat
theater 4 months later.

Radial head 1. Elbow contusion
fracture 2. Radial collateral ligament
sprain
3. Radial head dislocation
4. Olecranon fracture
Mechanism of injury, joint
effusion, fracture-quality pain.
and inability to fully extend
the elbow. Fat pad sign seen
on radiograph.
Discussed with orthopedic
surgeon the nature of
the fracture (articular
surface). Based on age
and work demands.
recommendation was
made to evacuate patient
out of theater for surgical
fixation.
Based on status and function of
patient on further evaluation.
decision was made to
manage the fracture
nonsurgically. Patient was
able to return to theater
because the physical therapist
was able to manage him
there. By 14 weeks, patient
was able to do 10 push-ups
pain-free.

Hip neoplasm 1. Tumor: malignant or Gait indicating impaired hip Screening radiographs Same-day evaluation by
benign function with no mechanism ordered by physical orthopedic oncologist
2. Infection of injury. therapist at initial visit initiated plan for differential
3. Pelvic inflammatory Red flags: revealed aggressive diagnosis and definitive care.
disease 1. Night pain malignant process.
4. Fracture: hip or pelvis 2. Early satiation
3. Bowel changes
4. Bladder changes
5. Menstrual irregularity
Palpable fullness in the right
anterior pelvic region

" Differentiation point marks critical aspects from the examination leading to the decision to order diagnostic imaging. The results could have a significant
impact on determining the intervention plan.

cate that radiographs are necessary
only if there is any pain in the mal-
leolar zone along with the presence
of at least 1 of these 3 factors: (1)
bone tenderness along the distal 6
cm of the posterior edge of the tibia
or tip of the medial malleolus, (2)
bone tenderness along the distal 6
cm of the posterior edge of the fibula
or lateral malleolus, or (3) inability to
bear weight both immediately after
the injury and for at least 4 steps in
the emergency department. The sen-
sitivity for ruling out a fracture with-
out the need of a radiograph if these
factors are not present is 100%2'5;
however, these rtiles have not been
validated in a combat setting. The
patient was putting partial body-
weight on his foot, but it caused sig-
nificant pain and discomfort. Tender-
ness was elicited with palpation of
the lateral malleolus. Gentle ligamen- the forefoot and mid-foot joints did
tous stress tests (talar tilt and ante-not reproduce any pain. The Achilles
rior drawer) were inconclusive due tendon was intact, and resisted
to pain. Additionally, their value as straight plantar flexion was not pain-
conclusive diagnostic tests for liga- ftil. A mild forced external rotation
ment disruption is questionable due force'^ to the leg and foot repro-
to poor duced pain in the medial and lateral
ankle, in addition to the proximal
In order to provide a thorough eval- lateral leg. The medial malleolous
uation, the entirefibulawas carefully also was tender. The physical thera-
palpated for a possible fracture and pist evaluated the radiographs taken
compressed against the tibia as a pro- 2 days prior, but the proximal fibula
vocative assessment of the syndes- was not visualized in that particular
mosis, suggestive of a positive test image (Fig. 1). The differential at this
for syndesmotic injury (kappa= point included a syndesmosis sprain
0.50),-» although it should not be versus a proximal fibula fracture,
relied on alone for the diagnosis.^** with the potential for a concurrent
This intervention reproduced the medial ankle sprain or fracture. He
patient's pain.'" Palpation to the placed the patient non-weight bear-
proximal fibula produced sharp ing on crutches with an immobilizer
pain, even without a provocative boot and ordered repeat radiographs
squeeze. Joint mobility assessment of

September 2013 Volume 93 Number 9 Physical Therapy • 1237

Physical Therapist Point of-Care Decisions in the Military Health Care System

ankle injuries should include assess-

ment of adjacent joints,^^ in this
case, careful palpation of the fib-
ula*'-^* and the bones of the foot,^*
in addition to the malleoli. The areas
above and below the area of primary
symptoms should be assessed for
less obvious injury and potentially
related or referred pain. Maison-
neuve fractures occur as a result of
an external rotation injury to the
ankle (often causing medial malleo-
lus pathology) whose force is trans-
mitted up through the interosseous
membrane, ultimately resulting in a
fracture of the proximal fibula. The
proximal fibular fracture, in isola-
tion, can in many cases be managed
nonsurgically.^"^ However, some
medial malleolar fractures and del-
toid ligament sprains may result in
Figure 2. significant ankle instability, requiring
The combination of a proximal fibular fracture (often indicating injury to the syndes- surgical fixation.^^••*'' Because of
mosis) and medial malleolus fracture can predispose the talocrural joint to significant these possible complications and the
instability and often requires surgical fixation. (A) The fracture of the medial malleolus austere medical setting, the physical
was more evident on anterior-posterior view than In the oblique (mortise) view in Figure
1. (B) Exposure of the entire leg revealed a fracture of the proximal diaphysis of the
therapist decided to have the patient
fibula. medically evacuated. Once back in
the United States, the orthopedic
surgeon decided that due to optimal
initial management and good joint
to include the proximal leg and knee of this nature without proper treat- stability, the best option was to con-
region. ment could result in greater disabil- tinue treating the fracture conserva-
ity. The diagnosis may have been tively with immobilization. Had the
Clinical impression 2. The physi- missed without the additional radio- fracture been missed originally, the
cal therapist evaluated the new graphic images of the knee and prox- patient may have displaced his frac-
images and visualized a spiral frac- imal fibula. After several weeks of ture, creating greater instability and
ture of the proximal fibula in addi- rest and proper immobilization dur- a need for surgery, leading to a lon-
tion to a fracture of the medial mal- ing the transition back to the United ger period of disability. In this case,
leolus (Fig. 2). These findings were States, the injury showed early callus optimal early management by the
consistent with the clinical examina- formation and minimal widening of physical therapist may have contrib-
tion and the diagnosis of a Maison- the mortise with proper stress imag- uted to the surgeon's decision to
neuve fracture.'* ing (radiographs and fluoroscopy). forgo surgery and return the soldier
The surgeon decided to treat the to the combat theater later that year.
Outcome. The injury had been well-positioned fracture conserva-
assessed as thoroughly as permitted tively with a short leg cast in a non- Case 2 (Radial Head Fracture)
in that clinical setting. The decision weight-bearing status for 6 additional Patient history and systems
was made to medically evacuate the weeks. review. A 21-year-old Caucasian
patient to the United States for fur- male soldier was seen by the physi-
ther evaluation by an orthopedic sur- Discussion. Maisonneuve frac- cal therapist with a complaint of
geon at a large Army hospital. The tures are easy to misdiagnose."*"•*' A right elbow pain after a fall sustained
decision, based on the rocky terrain comprehensive clinical examination while playing basketball several
and instability of the ankle from the that assesses areas above and below hours earlier. The pain was primarily
Maisonneuve fracture, was in the the area of symptoms can make mis- in the posterior-lateral elbow, and
best interest of the patient. An injury diagnosis less likely. Examination of the patient was unable to ftilly

1238 • Physical Therapy Volume 93 Number 9 September 2013

 Physical Therapist Point-of-Care Decisions in the Military Health Care System

extend his elbow because of the

pain. The patient denied any symp-
toms in the neck, shoulder, or hand,
other medical issues, or prior history
of elbow injury. The soldier was 3
months into his 1-year deployment
in Iraq, hoping to remain in theater
with his unit. After initial triage in
the trauma room to rule out other
injuries, the patient was sent to the
physical therapist for a thorough
evaluation of the elbow.

Clinical impression 1. The soldier

presented with his arm in a sUng, and
he wasftiUyalert and oriented to the Figure 3.
situation. He denied hitting Ws head Mason grade II fracture: (A) anterior-posterior view with forearm in supination, (B)
or any symptoms in the wrist, shoul- anterior-posterior view with forearm in pronation, (C) lateral view. Note the value in this
der, or neck but reported his lateral case of obtaining pronation and supination views of the forearm. The views in images
elbow pain as 9/10 on the numeric B and C appear unremarkable at first glance, and the fracture is difficult to visualize. The
view in supination (A) reveals the extent of the fracture coursing across articular surface
pain rating scale. Despite the swell- of the radial head.
ing, he w^as willing to take liis arm
out of the sling, but guarded his
elbow against full elbow extension.
diminish before casting or splinting apist placed the patient in a plaster-
Examination. Gentle palpation the elbow. fabricated long-arm cast in elbow
produced intense pain on the poste- flexion and full forearm supitiation.
rior lateral aspect of the elbow. Clinical impression 2. In the
There was visible elbow effusion, absence of a radiologist or orthope- Outcome. Due to the nature of
and pain limited full elbow exten- dist, the physical therapist initially the fracture involving the articular
sion. There was neurovascular integ- evaluated the radiographs. A radial surface, the physical therapist pre-
rity of the distal forearm and hand. head fracture, later categorized as a sented the case to an orthopedic sur-
Shoulder range of motion was full Mason grade II, was identified span- geon at a larger Combat Support
and pain-free. The physical therapist ning through the articular surface Hospital using e-mail to send him the
decided to order a set of anterior- and coursing the length of the radial radiograpliic images. In this particu-
posterior and lateral view radio- head (Fig. 3).^** *' The Mason classi- lar case, the surgeon felt that surgical
graphs of the elbow in order to rule fication system for radial head frac- evaluation was appropriate; there-
out a fracture. The inability to ftilly tures is: (1) type I—nondisplaced fore, the patient was evacuated to a
extend the elbow (elbow extension fracture of the radial head; (2) type hospital outside the combat theater.
test) has been associated with a 50% II—marginal radial head fracture Ultimately, because the fracture was
likelihood of fracture.^^ Alternately, with minimal displacement, depres- minimally displaced and the patient
ftiU extension of the elbow can rule sion, or angulation; and (3) type Ill- was already showing promising signs
out a fracture with a sensitivity of comminuted radial head fracture.''" of recovery, the fracture was man-
98.4% (negative likelihood ratio of Although the reliability of the classi- aged nonsurgically in a long-arm
0.03).^^ The patient was instmcted fication system has been called into cast. The patient requested to return
to continue wearing the sling, mon- question,^y it has been shown to be to the combat theater, despite med-
itor his neurovascular status, use ice, one of the more reproducible classi- ical evacuation orders stating,
elevate the upper extremity, and fication systems (intrarater "Patient will need conservative treat-
report back the next day. The phys- kappa=0.58, interrater kappa= ment unavailable in theater due to
ical therapist reasoned that even if a 0.43-0.56).^' The patient returned his job." Subsequently, the soldier's
fracture were present (Table), it after 72 hours, reporting decreased case manager contacted the physical
would be better to wait at least 24 to pain of 0/10 at rest and 3/10 when therapist on the base in Iraq to deter-
48 hours to allow the effusion to moving the elbow. The effusion had mine whether the patient could
decreased substantially, and the ther- receive conservative care there. The

September 2013 Volume 93 Number 9 Physical Therapy • 1239

Physical Therapist Point-of-Care Decisions in the Military Health Care System

athletic activity, a specific mecha-

PI: Constant,slightly nism of injury, or a change in her
variable, fatiguing, work-related duties. She had been
deep ache to sharp
8-10/10 seen in the medical center adoles-
cent clinic on 3 occasions during the
previous month for right hip and
knee pain. The prescribed naproxen
did not provide appreciable symp-
tom relief. A contrast bowel study
performed due to her recent history
of difficult bowel movements was
unremarkable. No imaging of the pel-
P2: Intermittent intense vis, hip, or thigh had been obtained.
tingling
The referral diagnosis from the phy-
sician in the adolescent clinic was
patellar tendinitis. Her primary com-
plaint was a constant, slightly vari-
able ache to sharp pain (10/10 at
Figure 4. worst) with intermittent intense tin-
Body chart or map of patient-reported symptoms. PI represents the worst or most
gling that extended from the anterior
severe area of symptom reported by the patient. Cleared areas were determined by pelvic region distally to the anterior
touching the area and asking the patient whether she was experiencing any symptoms knee (Fig. 4). The symptoms were
in this location. Check marks indicate symptom-free areas. severe enough to keep her from get-
ting more than 1 hour of sleep per
night. Her pain was most intense
physical therapist confirmed that the range-of-motion exercises in the when squatting, lifting her leg to get
soldier's fracture could be managed physical therapy clinic. By 14 weeks, out of the car or show^er, moving her
there, and the soldier was able to there was adequate union, and the leg for braking while driving, and
return to Iraq. patient was able to complete 10 while standing to operate the cash
push-ups without pain. Ultimately, register at work. During health
Discussion. The articular surface the soldier was able to finish his screening, she indicated that she was
involvement of the radial head frac- entire deployment in Iraq. experiencing a decreased capacity
ture required evaluation by an ortho- for food, urgency and frequency of
pedic surgeon. Management of this Case 3 (Tumor Case) urination, difficulty initiating bowel
type of fracture can be conserva- Patient history and systems movements, and menstrtial irregular-
tive'*2 or surgical, depending on age review. A 21-year-old African ity. She also indicated general health
or functional demands of the American female college student changes of fatigue and malaise.
patient.''* The outcome often can be with right knee, thigh, and hip
favorable without surgery.^'' Evi- region symptoms was referred to a Clinical impression 1. The
dence for surgical versus nonsurgical physical therapist at a large MHS aca- patient/client history indicated that
care for a Mason type II radial head demic medical center. Although the injury or overuse influencing the
fracture remains inconclusive. A patient had received prior medical musculoskeletal system was not
recent systematic review showed attention for a variety of signs and likely. The onset, progression,
there was insufficient evidence from symptoms associated with her con- behavior, and severity of symptoms
which to draw firm conclusions.'" dition, the physical therapist's diag- were atypical for a musculoskeletal
After the surgeon decided on non- nostic hypothesis shifted the focus condition. Additionally, the "red
surgical treatment, the physical ther- to examining structures of the hip flags" of early satiation,^'^ consistent
apist was able to help manage the and pelvic region, inckiding radio- difficulty with bowel movements,
patient in the combat theater. At 6 graphic studies, which revealed an urinary urgency,"^ changes in men-
weeks, radiographs revealed incom- aggressive malignant neoplasm. strual regularity,**'' and general health
plete healing, so the physical thera- changes suggested the possibility of
pist transitioned to partial immobili- The patient attended college and pathology outside the musculoskele-
zation by fabricating a splint that worked nights in a convenience tal system and possibly within the
could be removed for active-assisted store. She denied regular physical or genitourinary or lower gastrointesti-

1240 • Physical Therapy Volume 93 Number 9 September 2013

 Physical Therapist Point-of-Care Decisions in the Military Health Care System

nal system (Table). The physical

therapist planned a careftil examina-
tion of the pelvic region, hip, thigh,
and knee.

Examination. Her pain at rest in a

standing position was 8/10. The
patient's gait was antalgic, and she
walked on her forefoot on the pain-
ftil side with a fiexed hip and knee.
Active attempts to straighten the hip
and knee in a standing position
increased the pain to 10/10. During
supine examination, the knee could Figure 5.
Imaging of the pelvic neoplasm. (A) An anterior-posterior view radiograph of the pelvis
reach full passive extension when reveals an aggressive destructive lesion involving the right superior pubic ramus (blue
the hip was slightly flexed without arrow) and acetabulum. A Codman's reactive triangle of bone is present along the
increasing her knee pain. Knee flex- medial surface of the right ilium (yellow arrow). Residual contrast material from previous
ion was equal to the contralateral bowel study is apparent (green arrow). (B) Coronal magnetic resonance image of the
side and did not increase her pain if pelvis revealing large soft tissue tumor (black arrows), displaced bladder (orange arrow),
and femoral head (red arrow).
the hip was held stable. No ligamen-
tous instability was noted at the
knee. There were no typical signs of
infrapatellar tendinitis such as swell- ical therapist ordered an anterior- tum likely accounted for the bowel
ing or crepitus, but there was vague posterior and lateral view radio- and bladder changes and early satia-
palpation tenderness over the ante- graphic study of the pelvis, which tion the patient had experienced.
rior aspect of the infrapatellar ten- also would reveal hip structures. Ultimately, upon receiving definitive
don. By disrobing the patient to her cancer treatment, the diagnosis was
undergarments and carefully palpat- Outcome. A highly aggressive, a malignant peripheral nerve sheath
ing the pelvic region,'*^'*'^ fullness in
destructive lesion was identified on tumor,5^ a class of sarcoma.
the right anterior lateral pelvic the radiographie images involving
region was appreciated, with pain the right superior pubic ramus and Discussion. This patient presenta-
over the superior pubic ramus and right acetabulum (Fig. 5A). The mus- tion was identified as atypical by a
anterior ipsilateral hip. Hip passive culoskeletal radiologist's report physical therapist who routinely
range of motion was limited by pain stated that a Codman's triangle (a examines patients with musculoskel-
in all directions. Resisted strength triangular periosteal bone forma- etal problems. Accurately complet-
tests of the foot and ankle were 5/5, tion)" was present along the medial ing the body chart or symptom map
but those of the hip and thigh were surface of the right ilium with aggres- helped focus the examination to the
weak and painftil. sive periosteal reaction. This finding hip and pelvic region (Fig. 4). The
has been reported in other tumors of patient interview helped identify red
Clinical impression 2. Due to the the pelvis.^- The radiologist's initial fiags and changes associated with 2
atypical history, including several differential diagnosis included tel- major body systems. Tenderness at
redflags,and the abnormal examina- angietatic osteosarcoma'* and infec- the knee was most likely referred
tion findings in the pelvic and hip tion. The radiologist contacted the pain from the involved somatic struc-
region, the physical therapist physical therapist recommending a tures in the pelvic region, a well-
decided additional screening was magnetic resonance imaging (MRI) documented phenomenon.''"''"'' The
indicated. She selected an initial scan and a bone scan. The physical intense tingling may have been
screening strategy of plainfilmradio- therapist immediately notified the caused by the peripheral nerve
graphs to be followed as necessary orthopedic oncologist on call, who sheath pathology. The physical ther-
by the appropriate screening labora- contacted the patient. The subse- apist facilitated the diagnosis with a
tory studies such as an erythrocyte quent MRI study revealed a lytic thorough examination ofthe patient,
sedimentation rate<'^ and complete bone lesion that had completely including an appropriate imaging
blood cell count'" and advanced destroyed the right superior pubic screening strategy. The physical
imaging. The thigh and knee seemed ramus (Fig. 5B). A large necrotic soft therapist's credentials to order the
to be minimally involved. The phys- mass displacing the bladder and rec- appropriate musculoskeletal imaging

September 2013 Volume 93 Number 9 Physical Therapy • 1241

Physical Therapist Point-of-Care Decisions in the Military Health Care System

helped facilitate a more timely privileges, and they add to the body
diagnosis. of literature describing progressive
clinical practice patterns of physical
Outcomes therapists.
The 3 cases in this report describe
select patient management pro-
All authors provided concept/idea/project
cesses in these various clinical set- design and writing. Dr Rhön and Dr Deyle
tings within the MHS. Point-of-care provided the patient cases. Dr Deyle and Dr
clinical decision pathways and rele- Gill provided consultation (including review
vant clinical reasoning affected of manuscript before submission).
definitive care for each of these The views expressed are those of the authors
patients (Table). Urgent intervention and do not reflect the official policy of the
and important medical evacuation Department of the Army, the Department of
decisions in these cases were possi- Defense, or the US Government.
ble, in part, because of the physical DOI: 10.2522/ptj.20120148
therapists'ftillscope of relevant clin-
ical privileges. The value of an appro- References
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Number 9 Physical Therapy • 1243
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