Demonstration and Evaluation of Physical Examination Techniques Intended to Identify Proximal Femoral Bone Stress Injuries.

Purpose: Proximal femoral bone stress injuries (BSI), especially those involving the femoral neck (FNBSI), pose a risk to military medical readiness. There is currently no optimal physical examination technique or test item cluster that substantially influences the clinical diagnosis of FNBSI. Consequently, a lower threshold to order diagnostic imaging is employed by clinicians who manage military populations at risk for FNBSI. A viable physical examination technique or cluster of techniques is needed to better inform this clinical decision process and reduce the associated diagnostic imaging burden. This project assessed the perceived clinical utility of several novel physical examination techniques intended to identify proximal femoral bone stress injuries.

Methods: Thirteen FNBSI-specific physical examination techniques were evaluated using standardized grading criteria, evaluating safety, reliability, and credibility. Based on group consensus, two weight-bearing techniques- forward lunge and tap (FLT), rear lunge reach and tap (RLRT)-and three non-weight-bearing techniques- proximal femoral shear test, 45-degree compress and percuss, and the side-lying scissor test-were each determined to possess a parsimonious cluster of desirable examination properties. A one-hour, multimedia presentation accompanied by live demonstrations was presented to 13 clinicians. Each clinician rated the physical examination techniques based on the following five criteria: patient safety, likely to identify only bone pathology, accuracy regardless of symptom duration or acuity, performed in the mid-range of available motion, and reliability. These criteria were individually weighted from 1 (strongly disagree) to 5 (strongly agree), yielding a possible maximum score of 25. Each physical examination technique was also given a yes or no rating for overall credibility. The minimum acceptable value was set a priori at 80% yes votes.

Results: All clinicians in attendance were physical therapists with an average of 5.9 (SD: 4.4) years of experience managing patients with FNBSI. All attendees either agreed or strongly agreed all techniques would be safe to use with patients suspected of having a FNBSI. The highest overall scoring test based on the five criteria was the FLT with a score of 21. The only two tests to exceed the 80% benchmark for overall credibility were the FLT (92.3%) and the RLRT (83.3%). There were no overall statistically significant differences within each individual criterion except for the safety criterion. However, post hoc pairwise comparisons revealed no statistically significant differences.

Conclusions: A minimum of two of the novel physical examination techniques (FLT, RLRT) appear to have sufficient credibility to warrant further evaluation based on voting results from an experienced group of clinicians. A concurrent criterion validity study to assess the diagnostic accuracy properties associated with these techniques is now indicated.

Clinical relevance: This line of research may assist future clinicians to determine the need for diagnostic imaging procedures in patients with a suspected FNBSI.