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1.  MIDSHAFT HUMERAL FRACTURE FOLLOWING A PROXIMAL HUMERAL FRACTURE: A CASE REPORT 
Background and Purpose:
Proximal humeral fractures are relatively uncommon injuries. While previous research has led to effective clinical and diagnostic evaluation and treatment of proximal fractures, less is currently known regarding the typical evaluation and treatment of midshaft humeral fractures. The purpose of this case is to describe the clinical reasoning and utilization of diagnostic imaging in the physical therapy management of a midshaft humeral fracture, sustained during the course of rehabilitation of a proximal humerus fracture.
Case Description:
A 63‐year‐old female recreational tennis player presented to physical therapy, progressing well following a proximal humeral fracture, sustained 18 weeks prior. During the course of care, the patient had a significant regression in range of motion and function, with increased pain, following a seemingly trivial injury. Based on a cluster of subjective and objective flags, the therapist was concerned about a new fracture. The therapist communicated findings with a physician and recommended plain film radiographs before continuing therapy.
Outcomes:
Radiographs showed an oblique displaced fracture extending through the midshaft of the humerus. The patient ultimately underwent surgical plating. At one‐year post injury e‐mail follow up, she had functional mobility of her left arm, and was playing tennis recreationally three times a week.
Discussion:
In this case, a patient who was progressing well following a proximal humeral fracture sustained a separate displaced fracture of the midshaft of the humerus, not associated with therapy. Her reported mechanism was not consistent with a typical injury. This highlights the need for clinicians, specifically physical therapists, to cluster subjective information, objective data, and the patient's medical history when interpreting patient appropriateness for therapy, and to optimize outcomes.
Level of Evidence:
5 (single case report)
PMCID: PMC4275189  PMID: 25540715
clinical reasoning; humeral fracture; radiograph; tennis
2.  LUMBAR MANIPULATION AND EXERCISE IN THE MANAGEMENT OF ANTERIOR KNEE PAIN AND DIMINISHED QUADRICEPS ACTIVATION FOLLOWING ACL RECONSTRUCTION: A CASE REPORT 
Background and Purpose:
Quadriceps weakness is a common finding following knee injuries or surgery, and can be associated with significant functional limitations. This weakness or muscle inhibition may be due to central inhibitory mechanisms, rather than local peripheral dysfunction. Lumbopelvic manipulation has been shown to effect efferent muscle output by altering nociceptive processing. The purpose of this report is to describe the physical therapy management of anterior knee pain and chronic quadriceps weakness utilizing side‐lying rotational lumbar thrust manipulation and therapeutic exercise for an individual eight months status‐post ACL reconstruction
Case Description:
A 20 year‐old male presented to physical therapy eight months following anterior cruciate ligament (ACL) reconstruction of the left knee with primary complaints of residual anterior knee pain and quadriceps weakness. The subject was treated with a multimodal approach using side‐lying rotational lumbar thrust manipulation in addition to therapeutic exercise.
Outcomes:
The subject was seen in physical therapy for eight sessions over eight weeks. Lower Extremity Functional Scale (LEFS) scores improved from 58/80 to 72/80, quadriceps force, measured by hand‐held dynamometry (HHD), was improved from 70.6 lbs to 93.5 lbs and the subject was able to return to pain free participation in recreational sports.
Discussion:
Therapeutic exercises can facilitate improved quadriceps strength, however, in cases where quadriceps weakness persists and there is concurrent pain, other interventions should be considered. In this case, lower quarter stabilization exercise and lumbar thrust manipulation was associated with improved functional outcomes in a subject with anterior knee pain and quadriceps weakness. Side‐lying rotational lumbar thrust manipulation may be a beneficial adjunctive intervention to exercise in subjects with quadriceps weakness.
Level of Evidence:
5, Single case report
PMCID: PMC4275202  PMID: 25540713
ACL; knee; manipulation; manual therapy
3.  ECCENTRIC TRAINING FOR THE REHABILITATION OF A HIGH LEVEL WRESTLER WITH DISTAL BICEPS TENDINOSIS: A CASE REPORT 
Background and Purpose:
Distal biceps brachii tendinosis is a relatively uncommon clinical diagnosis seen by physical therapists. As a result, there is little evidence guiding clinical decisions regarding best practice or effective treatment options to restore individuals to their previous level of function. The purpose of this case report is to describe the use of eccentric training as the primary intervention in the rehabilitation of a patient with distal biceps tendinosis.
Case Description:
A 41-year-old male electrician and collegiate wrestling coach presented to a university outpatient physical therapy clinic with a two month duration of pain in the right antecubital space which occurred when the patient was performing close-grip body weight curl ups for the first time. Sharp pain was noted in the right arm during the lowering phase of the exercise. Following the examination, distal biceps tendinosis appeared to be the likely diagnosis. The patient was educated in eccentric exercise principles and was prescribed eccentric loading exercises for the distal biceps brachii tendon in two different positions of elbow flexion.
Outcomes:
The patient was seen in physical therapy for three visits over the course of four weeks. Following eccentric training, the patient reported decreased pain, demonstrated increased right elbow flexion and forearm supination strength, was no longer tender to palpation of the distal biceps tendon and showed clinically significant improvement in QuickDASH scores.
Discussion:
Given the lack of available research on the rehabilitation of distal biceps tendinosis, eccentric training showing benefits with other upper quarter tendinoses and the positive outcomes in this case, it may be appropriate for physical therapists to employ eccentric training for patients with distal biceps tendinosis.
Level of Evidence:
5 (Single case report)
PMCID: PMC3414073  PMID: 22893861
distal biceps; eccentric exercise; tendinosis

Results 1-3 (3)