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A Survey Analyzing the Management of the Acutely Injured Knee By Primary Care Physicians in Ontario
Shawn Alexander Anthony Suprun
Facdty of Kinesiology
mbmitted in partial fulfilment of the requirements for the degree of
Master of Science
Facuity of Graduate Studies
The University of Western Ontario
London, Ontario
May, 1997
Q Shawn A. A. Suprun 1997
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Abstract
The purpose of this study was to characterize the importance of various clinical
fïndings and diagnostic procedures avdable to primary care physicians, in diagnosing an
acute knee injury, and their eEect on subsequent management.
A self-administered survey was mailed to a simple random sample of 600 Ontano
primary care physicians îisted in the Canadia. Medicd Direaory (1996). Two rnailùigs and
a reminder postcard were used to rnaximke response rate. The physician's perceived level
of importance of variables was measured on a 5 point Likert scale.
The overall response rate was 60%. Seventy percent of those surveyed were male
and 30% were female. The average age of respondents was 44 years. Physicians indicated
that the most important items in the routine investigation of an acute knee injury were
history and clinical examination. Specifically, signs of effkion and detemiining the
mechanism of injury were extremely important in making a diagnosis. Of much less
importance was the use of imaging procedures such as radiography, arthrography, magnetic
resonance imaghg, and computerized tomography.
The most important m e n t options for a general knee injury were treatment by the
physician and referral to a physiotherapist. When presented with an ACL injury the most
important treatment option was referral to an orthopaedic surgeon.
The level of musculoskeletal training varied widely throughout the province.
Physicians who had completed a sport medicine fellowship indicated greater preference for
clinical knee ligament stability tests such as the Lachman's and pivot shift, implying a
higher index of suspicion for an ACL injury in the acutely injured knee, as defined by the
iii
survey .
In conclusion, the data gathered during this study indicates that the spectrum of the
current management of the acutely injureci knee is not as diverse as originally suspected. The
most important variables influencing diagnosis and treatment were history , clinical
examination, availability of medical personnel, and muscuioskeietal training. As we 11, in
combination with the low emphasis placed on technology there is a positive statement made
regarding the cost eflectiveness of management of this problem by primary care physicians.
Key words: survey, Likert scale, acute knee injury, primary care physiciaos,
management, treatment, imaging procedures, clinicai tests
Dedication
This thesis is dedicated to my family and fiiends,
for dl their support and encouragement over the years
Tony, Cathy, Aron and Jamie Suprun
Marion Sinden (Nana)
Rebecca Rodger
Acknowledgements
I would like to thank the following people for their help with the completion of this thesis:
Dr. Antonio Cogliano, for his excellent guidance and willingness to always find time for me despite a busy schedule
Dr. Peter Fowler, for his advice and support of this study
Dr. Sandy Kirkley, for her assistance and time in helping design the s w e y
Mr. Steve Dedik, for his help with the statistical analysis
Mrs. Joan Macrow, for ail her support, encouragement, and especially patience
Mrs. Anna Hales for her patience and help in the editing of this thesis
My family, especially my parents and two brothers, for their support and encouragement in helping me complete this study
TABLE OF CONTENTS
TITLE PAGE .................................................................................................. CERTlFIC ATE OF EXAMINATION ............................................................
..... ..... ...................... ABSTRACT ... , DEDICATION ......... ,., .................................................................................... ACKNO WLEDGEMENTS ............................................................................ TABLE OF CONTENTS ................... .... ................................................... LIST OF APPENDICES ............................................................................. LIST OF FIGURES .......................................................................................
CHAPTER ONE . INTRODUCTION ............................................................
Statement of the Problem ........................................................ ..................................................................... Related Research
Diagnostic Methods and Techniques ....................................... Specific Imaging and Diagnodc Procedures .......................... Clhicai Stability Tests ............................................................. History and Clinical Exam ...................................................... Likert Scdes ............................................................................. Purpose ..................................................................................... . . ...................................................... .................... Obj echves ... Hypothesis ................................................................................
Chapter 2 . METHODOLOGY
2.1 Subjects ................ .... ......................................................... . . 2.2 Sample Size Determination ...................................................... 2.3 Design ....................................................................................... 2.4 Measures ................................................................................... 2.5 Procedures ................................................................................
CHAPTER 3 œ RESULTS ................................................................................
CHAPTER 4 O DISCUSSION ............... ... ........................................................
CHAPTER 5 O CONCLUSION .......................................................................
VITAE ..............................................................................................................
vii
LIST OF APPENDICES
Appendix
A
B
C
D
E
Description
Cover letter and S w e y
Questions 1-4, Calculated Results
Demographic Data
Paired t-test, Questions 3 - 4
Exploratory Analysis of Physicians: -Years of Practice -Tirne to Oahopaedic Appointment
Page
52
56
69
80
84
Breakdown of Physicians According to 102 Muscdoskeletal Background
Exploratory Analysis of Physicians: 1 06 -Courses, Conferences, Joumals
Comparing MRI Availability 116
Sample Size Calculations 118
Figures 5 - 15 120
viii
Figure
LIST OF FIGURES
Description Page
Resdts Summary for Question 1 ................... 30
History and Clinicai Examination .................. 32
Clinical Examination (Ligament Stability Tests) 33
Imaging Procedures ........................................
INTRODUCTION
1.1 Sfatement of the Problem
The acute knee injury is a common problem that may have significant health,
lifestyle, and economic implications. Therefore, accurate diagnosis and correct treatment
are essential if the impact of such an injury on the individual is to be kept at a minimum.
Despite the common nature and fiequency of knee injuries, there seems to be considerable
variability in the diagnostic and treatment methods utilized by primary care physicians. As
well, there exists a wide range of possible diagnoses. These factors give nse to concerns
regarding the consistency of care given to the patient with an acutely injured knee. This
study will provide a knowledge of the assessrnent and diagnostic procedures used by
primary care physicians, of the level of importance of different diagnostic tests, and of the
factors which affect individual preferences. This information may influence current
management practices in this area.
1.2 Related Research
The National Knee Injury Survey (Mirza, et al 1996), sweyed approxirnately 700
orthopaedic surgeons across Canada and analyzed their methods of managing an acute
haemarthrosis in generd and anterior cruciate ligament (ACL) insufnciency in particular.
The treatment of the acutely injured knee however, is more iikely to be initiated by a
physician working in an emergency department, a sports injury clinic or a family practice
office. These settings are predomhantly the domain of the primary care physician. Not ail
of these injuries are referred to orthopaedic surgeons, and the tirne from injury to
cod ta t ion often varies.
Knee rur ies are a common medical problem (Mendelsohn & Paiemenb 1996). The
prevalence of signincant knee injuries has been estimated to be 0.3 per 1,000 in the generai
population or approximately 2,400 amually in the population of Ontario (Nielsen & Yde.
199 1). Events that occur during activities, whether occupational or recreational' that may
cause a knee injury include: a direct blow, pivoting or twisting and jumping (Baker, 1992).
In 1985, there were 9398 Worker's Compensation Board cl- made by Canadians
which were related to knee injuries. These amounted to 5.4% of total daims (Statistics
Canada, 1991). Clearly, the economic impact is enormous.
Knee inj laies rank as a major cause of physical disability (Statistics Canada, 1 9 9 1 ).
Patients' cornplaints of physical limitations with activities of daily living (ADL) and/or
sports are possible signs of a lmee injury (Hoher, Munster, Klein, Eypasch, & Tiling, 1995).
Depending on the injury, it may be necessary to modi@ or discontinue specific sporting or
occupational activities. Such injuries may have a profound effect on both the highly
successful athletic career or on the longevity of the work-life of the average labourer. The
correct diagnosis, is therefore extremely important, since inappropriate treamient may lead
to patient morbidity. An example of this type of injury is an ACL rupture. This commody
missed injury causes varying degrees of knee instability and may result in multiple episodes
of knee subluxations with M e r meniscal and cartilage injuries (Shirakura, Terauchi,
Kizuki, Moro, & Kimura, 1995). The treatment ranges fÎom physical therapy and bracing
to reconstmctive surgery in order for patients to r e m to their sport or occupation of choice
(Wojtys, 1994).
There is a wide range of possible diagnoses when the knee is injured acutely.
3 Because of this, many primary care physicim are uncomfortable making a clinicai
diagnosis of the damage fouod in this type of injury (Mendelsohn & Paiement, 1996). This
group should be able to decipher and diagnose such entities as: ligament insufficiency
whether it be ACL' posterior cmciate ligament (PCL), medial collateral ligament (MCL) or
lateral coliateral ligament (LCL); cartilage problems; meniscai tears; bone lesions such as
tibia1 and fernord loose bodies; patello-femoral problems; and aggravation of chronic
injuries (Bergfeld, 1997).
Included in the literahue is a survey of primary care physicians which showed
Continued Medical Education (CME) to be the most important and modifiable variable that
improved management of musculoskeletd disorders (Glazier, Dalby, Badley, Hawker, Bell
& Buchbinder, 1996). A second s w e y analyzed information sources used by family
physicians. It demonstrated that this goup most often consulted coileagues followed by
joumals and books (Verhoeven, Boemra, & Meyboom-de Jong, 1995). In both studies,
several components were analyzed to characterize and weigh the importance of various
elements such as: continued medical education, resources, training and age. These are
examples of factors influencing the management of physical injury.
1 3 Diagnostic Methods
The management of the acutely injured knee which may include the dimption of
various structures, whether iigarnentous or cartilaginous, has always been controvenid
(McGuire, & Griastead, IWO). Over the past 15 years several studies have been performed
to determine the accuracy of such procedures as arthroscopy, magnetic resonance imaging
(MRI), computerkd tomography scan (CT scaa), plain radiography, and arthrography ,
(Bondeville, Cordoliani, & Hamze, 1993). Specific tests such as the Lachman's, the
drawer, the pivot shift and the McMurray's have also been evaluated (Neumann, Schiller:
Witf Betz, Kmeger, & Schweiberer, 1991). The accuracy of both the highly advanced
imaging techniques and simple stress tests seems controvenial. Some physicians rnay
demonstrate a bias for a particular diagnostic procedure while others will have rarely
implemented the same test. More irnportantiy, some studies have s h o w that a particuiar
test or imaging procedure is of great value while others have determined that the same
diagnostic tool is of limited value.
1.4 Specific Imaging and Diagnostic Procedures
Baker (1 992) reported that arthroscopy is not essential in the routine diagnosis of the
acutely injured h e e . He concluded that with a knowledge of the common causes of
haemarthrosis and an understanding of the knee examination, the trained examiner c m make
an accurate diagnosis in 80 to 90% of cases. However, Johannsen & Fruenspaard (1988)
concluded that a more accurate diagnosis can be made with arthroscopy than with clinical
examination alone and is therefore extremely valuable. MaBilli, Binfield, King, and Good
(1 993) conciuded that acute traumatic haemarthrosis indicates a serious ligament injury until
proven otherwise, and arthroscopy is needed to compliment careful history and clinical
examination. If haemarthrosis is conf-ed, urgent admission and arthroscopy are essential.
Vahsarja, Kinnuen, and Serlo (1 993), arthroscopically examined 13 8 children with acute
knee trauma and found that in 37 cases (27%), a correct diagnosis wodd have been missed
without arthroscopy.
Over the past 6-10 years there has been an increase in the number of diagnostic
procedures available. The trend fiom arthroscopy and CT scan to MRI is again a
controveaial one. Stull, and Nelson (1 990) mted that a clinical examination of the acutely
injured knee is kequently augmented by diagnostic imaging and that MRI is rapidly
replacing other techniques such as arthroscopy. Likewise Iovane, and Midiri (1995),
reviewed 458 magnetic resonance examinations of the knee to assess its diagnostic potential.
They concluded that MRI should replace the somewhat outdated arthroscopie procedure.
Reker, Fletcher, Tantana, Mahanta, Vas, and Yoo (1 990) evaluated two sources of enor in
the reliability of the CT scan and M N and found that overall diagnostic agreement was
significantly higher for MRI.
Moonen,Van Zij 1, Frank, Le Bihan, and Becker (1 990) assessed the value of M N in
diagnosing the acute lmee injury. They concluded that it is useful in providing detailed
structural and anatomical information.
ûrthopaedic surgeons such as, Gleb, Glasgow, Sapega, and Torg (1 996), evaluated
the ciinical value of MRI in knee injuries referred to a sports medicine clinic. They found
that in cornparison, clinical evaluation had a sensitivity and specificity of 100%, whereas
MRI rated 95% and 88% respectively. They concluded that MN is overused and is
therefore not cost effective compared to a skilled clinical examiner. They suggested that
clinical assessrnent equals or surpasses the MRI when determining an accurate
diagnosis.
The value of plain radiography when assessing lmee injuries is also questionabie.
Stiell, Wells, McDowell, Greenberg, McKnight, and Cwinn (1995) concluded that
physicians order radiography for most patients, even though in many cases, through proper
discriminatory procedures, they cm expect these to be nomal. Stiell, Greenberg, Wells,
McDowell, Cwinn, and Smith (1996) validated a decision d e for the use of radiography in
patients with acute luxe injury and concluded that this was both reliable and acceptable. As
a result, physicians should Iimit the use of radiography for patients with acute knee injury.
However, in a study by Wacker, Bolze, Mellerowicz, and Wolf (1995), it was stated that
following histo~y and physical examination, radiographs were an absolute necessity for a
more thorough diagnosis. The lack of consensus in the prùnary care field regarding
diagnostic procedures when assessing acute knee injuries is evident.
Knee arthrography has also been used to help iden- stmctures which have been
compromised. Miller, Ritchie, Gomez, Royster, and DeLee (1995) reported that in the
evaluation of meniscal tears, arthrography was 92% accurate and should be used in clinical
practice. However, Konig, Andresen, Radmer, Schmidt, and Wolf (1995), examined 21
patients with çuspected knee joint lesions and used arthroscopie findings as a gold standard
to measure the accuracy and sensitivity of MRI versus arthrography . This study showed that
MRI scored much higher in both categories and concluded that there are no special
indications for arthrography in suspected knee joint lesions. It has also been demonstrated
that clinical examination can obtain an accurate diagnosis in 88.35% of cases compared to
arthrography which accurately diagnosed 76.89% of the identical cases. (Kulthanan &
Noiklang, 1993).
Other important diagnostic tools have been proven effective in assessing the acute
knee injury. Ultrasound can visualize not only a knee effusion, but also abnormalities in the
synovium, menisci and the popliteal fossa (Kang, Du, Luo, and Huang 1994). This provides
an important ba i s for diagnosis and treatment. It has also been shown to be economical,
pain-fiee, and generally more readily avaïiable @ h g et al. 1994).
A study done by Baker (1992) showed that history and clinicd examination should
provide the best opportunity for making an accurate diagnosis. However, Baker aiso stated
that while aspiration of the joint fluid can aid in making the diagnosis, this procedure should
not be used routinely. Maffulli et a1 (1 993) prospectively studied mature male sportsmen
who had sae red an acute haernarthrosis of the knee due to sports related injuries. They
concluded that al1 cases with a tense effusion occurrhg 12 hours post injury require
aspiration.
1.5 Ciinical Stabïlity Tests
In 199 1, a German study found that the degree of severity of a knee joint injury is
estirnated on the bais of the history given by the patient, stabiiity tesàng and haemarthrosis.
A variety of stability tests were used including varus and valgus stress tests, Lachman's test,
anterior drawer and pivot shift test (Neumann et al. 1991). Since there are so many
variables, each prirnary care physician may develop a specifk diagnostic protocol for testing
the acutely inj ured knee.
McGuire & Grinstead (1990) stated that the tests which are most fkequently used
when assessuig the acutely injured knee include the drawer tests, Lachman's test, and the
pivot shifi test.
Kim & Kim (1 995) examined 147 patients with aahroscopically diagnosed injuries
of the ACL. The anterior drawer, the Lachman's, and pivot shift tests were performed on
each patient to determine the sensitivity of each in a clinical setting when analyzing injury
to the ACL. Results showed that the Lachman's test was positive in 98.6% of cases and
therefore was the most sensitive of the three tests. The pivot shift test was also sensitive,
(89.8%), but the authon concluded that it rnay be influenced by many factors. The anterior
drawer test scored the lowest at 79.6%. However, Zhai (1 992), concluded that the anterior
drawer test indicated ACL deficiency, more often than the pivot shift when perfonned on the
sarne ACL deficient knees.
In diagnosing a posterior cmciate ligament injury Rubinstein, Shelboume,
McCarrol, VanMeter, and Retting (1994) concluded that the postenor drawer test was the
most sensitive and specific with an overall accuracy rate of 96%.
Kirsch, Fitzgerald, Freidman, and Rodgers (1 993) stated that patello-femord joint
injury, specificaily transient lateral patellar dislocation, is frequently difficult to assess
properly on the ba is of clinical findings. This study suggested that aspects of transient
lateral patellar dislocation, provide a distinct MR image that can be used to distinguish it
fiom other common knee injuries.
Several stuclies have determined the accuracy of specinc knee stress tests. Bomberg
& McGuity (1 990) found that the Lachman's test was accurate in diagnosing acute complete
tears of the ACL 86% of the time and partial tears 80% of the tirne. Al1 findings were
confinned through arthroscopy.
Benedetto, Spencer & Glotzer (1 990) performed 620 arthroscopies between 1980
and 1988 on patients with acute knee haernarthrosis. Arthroscopies confïrmed that anterior
instability could be detected through clinicai examination, which included a Lachman's
test, combined with a pivot shift test.
Neumann (1992) concluded that when assessing an acute knee injury the history
shouid dinerentiate between contact and non-contact sports. He noted that an audible pop
irnplies an ACL rupture and that the evaluation should include a thorough physical exam and
specifically the Lachman's and pivot shift test.
Smith & Green (1995) aiso reported that an in-depth history and physical
examination were helpful in obtaining an accurate diagnosis and that the Lachman's and the
pivot shift test particularly were useM in the evaluation of the anterior cruciate ligament.
The McMurray7s test and Apley's Grind test were demonstrated to be of use when
diagnosing meniscal injuries.
However, Corea, Moussa, and al Othman (1994) studied the vaiidity of the
McMurray's test for tom meniscus in 93 patients. This was compared to arthrotomy
findings and had a sensitivity of 58.5% and specificity of 93.4%. These researchers
concluded that the McMurray's test is of limited value in curent clinical practice.
1.6 Aistory and Clinical Exam
Since the lmee is one of the most complex joints in the human body (Lipcamon,
1994), it seems legitimate that there are disagreements regarding how it is examined. Al1
of the diagnostic tools are available to help the examiner make the most accurate diagnosis
possible. Much of the related research attempts to prove or disprove that some types of
diagnostic tools are better than others. It can be argued that these procedures are either a
help or a hindrance. However, the majority of the studies conclude that a well trained and
Uiformed examiner is the most important ingredient for a correct diagnosis.
Mendelsohn and Paiement (1 W6), studied the examination styles of p hy sicians
diagnosing acute knee injuries. This study emphasized the importance of a good history to
determine the mechanism of the injury and nanow the diagnostic possibilities. They
concluded that, in more than 90% of al1 knee injuries, an accurate diagnosis can be made
with a good history and a careful physical examination.
Rothenberg and Graf (1993), stated that early, accurate diagnosis and aggressive
treatment are important in retuming a patient with a knee injury to full function. They
concluded that a detailed history and a thorough and knowledgeable exam are the most
significant elements of the evaiuation, and that special tests and imaging are helpful.
Bondevile et al (1993), studied various aspects of the examination of the knee.
Included in this study were topics such as anatomy, mechanisms of injury, clinicai
diagnosis, specific stress tests and types of imaging. An accurate history c m enhance the
physician's ability to determine the mechanism of injury, which in turn can increase the
potential for a correct diagnosis. They concluded that tools such as M N compliment the
clinical examination and therefore should be used concurrently, not independently.
Smith and Green (1 995) stated that no technological advance c m replace a thorough
history and physical exarnination in the evaluation of an acute knee injury. They reported
that these are helpfid in diagnosing meniscal damage, cruciate and collateral ligament
sprains and patellar instability, which are the four major acute knee injuries. Examination
should include passive and active range of motion testing, palpation of the joint line, and
the observance of visual a b n o d t i e s such as swelling. These procedures, combined with
a variety of clinical stress tests, can assist a physician in making a correct diagnosis.
Johnson and Wamer (1993), reviewed the important aspects of the history and
physical examination. They concluded that when an expenenced clinician obtains an in-
depth history, which may include mechanism of injury, stiffhess, and instability, and a
detailed physical exam which incorporates range of motion testing, palpation and speciai
clinical tests, there is a 90% chance that disruptions such as ACL tears can be diagnosed at
the tirne of injury.
1.7 Likert Scales
Likert scales have been used to measure the perceived level of importance of specific
variables. Craft, Heick, Richards, MW, Lathrop, and Reed (1 992) used a Likert scale to
measure the level of importance of program characteristics that influenced decision making
in the selection of continuing education for 238 nurses. The ratings were based on a number
of possible questions which could be rated between levels of high importance and low
importance. In a mailed survey, Orlander & Caliahan (1 991) used a Likert scaie to determine
whether or not current fellowships meet the needs of physicians. In another study, medical
students were asked to provide demographic information and rate the level of importance of
specific rasons for selecting their residency program after medical school (Senst & Scott,
1 990).
Likext scales may range fkom a four point to a ten point rating system and c m be
implemented into various types of studies. Godwin, Chapman, Mowat, Racz, McBride, and
Tang (1 996), used a five point Likert scale, as part of a self-administered sunrey, to m e s s
attitude changes of physicians when drugs were de-listed fkom the Ontario Drug Benefit
formulary. Wallace, Reed, Pasero, and Olsson (1995) used a four point Likert scale to
rneasure stan nurses' response to the adequacy of their knowledge and skills regarding
hospital procedures.
Smith and Reynolds (1 999, used a seven point Likert scde to rneasute the primary
factors related to obstetric care. Finally, a ten point Likert scale was used in a study which
rated the level of confidence primary care physicians placed on their management of MSK
disorders (Glazier et al 1 996).
A 5 point Likert scale was implemented in this study on the advice of Dr. John
Baskervillet Statslab, at the University of Western Ontario.
1.8 Purpose
Because there exists a wide spectrum of management routines for the acutely injured
knee, this survey was designed to characterize the importance of the various clinical
hdings and diagnostic procedures to primary care physicians when diagnosing and treating
the acute knee injury.
1.9 Objectives
1. Primary: To assess the relative importance of salient features included in the
history and physicai investigation of the acutely injured knee to prirnary care physicians.
2. Secondary: To assess the influence of the availability of resources and level of
musculoskeletal training on the management styles of primary care physicians when dealing
with the acutely injured knee.
1.10 Hypothesis
The hypothesis is that medicai resources and level of musculoskeletal training
innuence the physician's management of the acutely injured knee. Since it is suspected that
these factors Vary widely throughout the province, it is anticipated that approaches to the
management of the acutely injured knee will be found to be inconsistent.
Cha~ter #2: METEIODOLOGY
2.1 Subjects
The target population in this shidy was primary care physicians (family physicians,
general practitioners, emergency, walk-in and occupational medicine physicians) dealing
with acute knee injuries in Ontario. The number of physicians in Ontario is approximately
20,500 (Canadian Medical Directory, 1996). Of this population there are approximately
1 1,250 prirnary care physicians. The potential was equal for each physician to be included
for participation in the survey. Selection was not biased as to gender or age. A sampling
frame of 600 physicians was sent a copy of the se&administered survey.
23 Sample Size Determinations and Criterion for Significance
The sarnple size was calculated by the Statslab in the department of actuarial science
at the University of Western Ontario (see appendix 1). Sample size calculations revealed that
600 surveys would have to be circulated to d o w for: (i) estimates of the population's mean
scores to be accurate within plus or minus 0.25 (19 times out of 20) and, (ii) tests
hypothesizing no clifference in the average importance of various management and treatment
options between general and ACL injuries at an overall 5% significance level. A sample
size of 300 physicians would be sufEcient assurning a minimum response rate of between
30 and 50%. (J. Baskerville, personal communication, September, 1996).
Based on a review of the fiterature and anaiysis of these calculations, 600 surveys
were rnailed initially. There were two mailings and one follow-up reminder. With the
follow-up and the reminder combined, the study projected a response rate of between 350
and 400. This number would adequately Mfill the number of surveys required for
23 Design
The Primary Care Physician Acute Knee Injury S w e y was developed at the
University of Western Ontario, by two orthopaedic surgeons, a primary care sport medicine
physician and a Masters of Science *dent. The study was a simple random sample (SRS)
survey of the management of the acutely injured knee with respect to assessrnent by the
primary care physician.
Each physician in the population had an equal chance of k ing included in the sample
frame. The advantage of this type of survey is that it allows generalization f b m sample
statistics to population parameters. Additionaily, the precision of generalization depends
only on the sample size and not the population size. (Sahn & Slastry,ch. 4 1985). A random
numbers program designed by the department of Actuarial Sciences, produced a series of
digits through a random numbers generation process. Each subject was designated a figure
based on the population of 1 1,250. Each number was different fiom and independent of the
others, ensuring that ail numbers couid be selected only once.
2.4 Measures
Primary Care Physician Acute Knee Injury S w e y :
Questions were designed to eiicit a respome fiom the primary Gare physician of the
perceiveci value of important variables, (ie. history, physical exam etc.), when presented with
the acutely injured knee. A general scenario of the acutely injured knee was utilized.
An acute knee injuy was d e h e d as follows:
1. The injury occurred less thm 3 weeks ago
2. Pain or a history of pain in the lmee
3. Swelling or a history of swelling about the knee
4. A traumatic event associated with the onset of the above
(adapted fiom Wojtys, 1994 and Fowler, 1997 personal communication)
Each survey was nurnerically coded to ensure confidentiality and to help protect
against bias (Del Greco, Walop, bstridge, Marchand, & Szentveri , 1987). The importance
of each variable was ranked on a five point Likert scde. Response options varied from
"extremely important" to "not important at dl", with extremely important having a value of
"one" and not important at al1 hwing a value of "five".
Several variables are commonly used to help in the diagnosis of the acute knee
injury. It was apparent however, that not al1 physicians are in agreement as to which of
these should be included or excluded in the assessment. M e r consulting knee injury
experts, the survey was divided into categories according to specific variables. For
example, ciinical and physical examinations. specific imaging procedures and clinical
stability tests were grouped accordingly.
The s w e y was tested to determine if any weaknesses in validity, reiiability and
length existed.
Validity was examllied in three different ways:
1. Content validity determines whether or not the area of focus has been adequately
covered (Del Greco, Walop, and McCarthy 1987). The content of the survey was examined
by colleagues and experts and a pilot study later c o b e d that al1 important variables had
been included.
2. Face validity refers to the appearance of the survey (Del Greco et al. 1 987). Since
professional surveys are more likely to initiate a response, the cover letter incorporated the
logo of the Fowler Kennedy Sport Medicine Chic , a listing of d the physicians who work
at the c h i c and a short summary of the intentions of the survey. The second page, listed
questions which were easy to read and understand on both sides. Following a pilot study
and revisions it was determùied that the survey had face validity.
3. Comtruct valiarty attempts to reveal whether or not the s w e y mesures what it
was designed to measure (Guyatt, Bombardier, & Tugwell 1986). This s w e y was
designed to measure the importance of specfic variables which physicians use in their day-
to-day practice. The Likert scale contained five numbers fiom which to choose. The pilot
study confirmed that the survey could be well understood and that it had the capability to
measure the perceived level of importance of the variables.
Reliability indicates whether the survey is consistent (Del Greco et al. 1987). To
deterrnine if the survey was reliable it was given to 6 physicians at the Fowler Kennedy Sport
Medicine C h i c on 2 occasions at a 2 week intemal. After additions and deletions the
survey was determineci to be reliable.
To maintain the respondent's cornpliance and interest, questions of high relevance
were placed at the beginning and those more sensitive in nature, such as demographics, were
left for the end @el Greco, & Walop 1987).
Questions regarding each topic were clustered to facilitate the physician's memory
@el Greco et al. 1987). For example, topics regarding specific imaging procedures were al1
containeci in question one and statements regarding clinical stability tests were al1 contained
in question two.
Following circulation to experts and colleagues for review and cnticism, the nirvey
was piloted to a random sample of 30 primary care physicians in Ontario. The results of the
pilot shi0y confirmed that the survey was ready for the on@ sampling m e of 600. The
response rate was 60% and al l indications were positive regarding the design of the survey.
The 20 sweys collected fkom the pilot study were included in the main studies response
rate. Question 1 specifically dealt with the importance of items in the physician's routine,
when diagnosing an acute knee injury. History and clinical examination were categonzed
together with specific imaging procedures. Question 2 asked how specific components of
history and physical examination wodd be rated. Included in the history category were
mechanism of injury, swelling and age of patient. The physical examination included such
variables as ability to weight bear, range of motion and specific clinicd stability tests.
Since an acute knee haemarthrosis implies an injured anterior cniciate ligament in
up to 72% of cases (Noyes et al 1980) two questions regarding the management of this
diagnostic entity were utilized. In questions 3 and 4 of the survey, both the general knee
injury and the ACL injury were measured regarding the perceived level of importance of the
management and treatment options routinely used by physicians.
In question 3 referral options were categorized and included various factors such as
sex of patient, time since injury, age, and previously failed treatment. Question 4
determined the level of imporîance of treatment options such as: unlimited or limited
activity, casting, bracing or splinting, and physiotherapy. The demographic questions asked
for information regarding personal backgound, community size, available resources,
musculoskeletal background and type of practice. In this section of the survey, al1 m e r s
were written or circled.
Data was collected according to the first mailing, second mailing and total mailings
received. To determine if differences existed between those a n s w e ~ g the survey in the
fist mailing and those answering the survey in the second mailing, data from each mailing
was analyzed separately. An analysis of the combined data was also perfomed. The
assumption being that if no differences were detected between the physicians' answers on
the first and second mailing, the responses to a thud and f o u . mailing would aiso be the
same.
2.5 Procedures
The survey was printed on two sheet. of eight and a half by eleven inch paper. The
first page consisted of the cover letter, which contained a brief description regarding the
purpose of the survey. Instructions regarding the completion and rehuning of the survey
were then provided. An ethics committee approval regarding this study was not required
(B. Bowein, personal communication, September, 1 996).
The survey contained a dennition of an acute knee injury that would aid the
physician in complethg the questions. The Likert scaie, rating the level of importance, was
provided on each side of the survey.
The survey consisted of two mailings. In the fbst mailing, each physician received
an envelope which contained a copy of the cover letter and the survey (each survey was
numeridly coded). A self-addressed stamped envelope was included which wodd enable
the physician to return the survey conveniently.
A period of 21 to 28 days was allocated for an initial response. A code on each
survey corresponded to a physician on the original mailing list. After 28 days a second
mailing was initiated by means of a follow-up letter to al1 those who did not reply.
Physicians were asked to complete the original survey sent. As a precautionary rneasure
another copy of the survey was forwarded dong with the follow-up letter. A self-
addressed stamped envelope was aiso included in this mailing. A deadline date was then
estaHished for surveys to be returned.
Cha~ter # 3: RESULTS
3.1 Response Rate and Data Collection:
Three hundred and fifty-eight of the 600 physicians responded to the survey,
providing a response rate of 60%. There were 222 responses to the fht mailing. Of these
13 were retunied b1an.k. The second mailing contained 167 responses, with 149 physicians
completing the survey, while 1 8 rehuned blank surveys. The total of 3 1 blank surveys,
were excluded fiom the study.
ï h e anaiysis between the first and second mailing determined that no significant
differences existed between the two groups. As a result, data used in the analysis and
discussion is fiom the two mailings combined.
3.2 Resuits of Questions 1-4
Questions 1 through 4 received mean scores, which were calculated ushg 95%
confidence intervals. Resuits for each question contain the mean score, the confidence
intervals and the standard deviations. The confidence interval enables the variables of each
question to be ranked according to their level of importance. Each interval indicates that
there is a 95% chance that the true mean lies between the two dculated numbers Iocated
in brackets under the mean score in appendix B.
The results of question 1 indicated that history and clinical exam are the most
important items in a physician's routine investigation of an acute knee injury. These two
aspects of the investigation received mean scores of 1.123 and 1.190 respectively. The least
important variables of question 1 were imaging procedures. Specifically MRI and CT scan
were rated with low importance. Each of these procedures received a score of 4.567 and
4.646 respectively. The most important imaging procedure was plain radiography which
scored a 3.2 14 (see appendul B).
Question 2 of the survey was divided into two sections. The first section dealt with
variables in obtaining a proper history. The r d t s indicate that determining the mechanism
of injury is the most important. The mean score for this variable was 1.263. The remaining
variables under history were also rated with high levels of importance with mean scores,
except for age of patient which was rated lower at 1 -642 to 1.950.
The second section of this question dealt with the importance of variables related to
the physical exam. The observation of an effusion upon examination was determined to be
most important, with a mean score of 1.527. The remaining categories, excluding the
clinical stability tests, were also given high levels of importance. Their scores ranged
between 1.750 and 1.904.
There were 6 clinicd stability tests rated. Collateral ligament testing, and drawer
testing were the two most important tests, with mean scores of 1.785 and 2.090
respectively. The McMurray's test was the l e s t important ciinical test with a mean score
of 2.544 (see appendix B).
Questions 3 and 4 contained two columns in which to rate variables. The £ k t
column rated the acute lmee injury in a general sethg and the second column rated an ACL
injury specificall y.
Question 3 rated the level of importance of various management options available
to physicians. The first five response categories asked about the importance of diagnosis and
referrals. For the general acute knee injury, the highest levels of importance were for
variables (a) and (e), "diagnose treat yourself and refer as necessary" and ccnon-surgicai
referral." The mean scores for each were 1 S63 and 2.405 respectively.
For the ACL column, the highest level of importance was indicated for variable (dl,
"orthopaedic surgery r e f e d ' with a mean score of 2.015. The lowest rated Ievel of
importance for both columns was found in variable (c), "refer without determinhg a specific
diagnosis yourself", with mem scores of 4.029 and 3.629 respectively.
The remainder of question 3 dealt with various factors which could affect the
management of an acute knee injury. The mean scores for both columns were almost exactly
the same. The highest level of importance for both columns was received by variable (i),
which asked if the injured structure was importaut for the patient's occupation. The mean
score for both general and ACL colurnns was approxirnately 1.9. The least important
variable was "sex of patient" with a mean score totalling 4.660.
Question 4 rated the level of importance of treatment options. Both columns received
similar scores in each category. The most important variables were letters (b) and (d). For
both general and ACL colurnns, variable @) which asks to lirnit activity: c m brace, splùit,
etc., received mean scores of 2.020 and 1.690 respectively. Variable (d), " re fed to
physiotherapy", received mean scores of 1.953 and 2.085. The other two options received
low Ievels of importance in both columns (see appendix B).
3 3 Dernographies
Demographic data was divided into three sections: first maiiing, second mailing
and both mailings combineci. T'his information was divided into categones which display
the number of responses, mean scores, standard deviations, maximum and minimum answers
and percentages when necessary (dl demographic data is displayed in appendix C).
Since demographic information cm be a sensitive issue, not aU physicians chose to
respond. Gender distribution was 21 1 male and 90 fernale physicians (see figure 5, appendix
J) The average age of the respondents was 44 years, with the youngest physician being 27
and the oldest physician being 93 years of age (see figure 13, appendix 0.
The average number of years in practice was 16, with the shortest time being 6
months and the longest t h e being 60 years. The approximate community population for all
respondents was approximately 452,347 people. The smallest area serviced was 500 and
the Iargest area was 2,200,000.
When referring patients to orthopaedic surgeons, the average distance to the place of
refend was 18.7 kilometres (km). The minimum distance travelled was O km and the
furthest distance travelled was 600 km. The mean score for days to appointment with a
surgeon, was 27.1 days.
When asked if arthroscopy and ACL reconstruction were important in the physician's
decision to refer to an orthopaedic surgeon, 95.3% responded yes IO arthroscopy and 77.1 %
answered yes to ACL reconstruction (see figure 6, appendix J).
Demographics concerning the current availability of resources in each physician's
community indicated that 99.7% of aii physicians had access to plain radiography, 83.1 %
had access to CT scan and 33% had access to MRI (see figure 7, appendix J) In the
personnel category, 80.9% physicians had access to an orthopaedic surgeon in the
comrnunity, 90.6% had access to physiotherapy and 82.3% had access to a doctor of
chiropractie (see figure 8, appendix J).
Musculoskeletal training was divided into three sections: medical training, CME
and related training. In the section regarding medical tmuiing, 75.1 % of physicians took
electives in medical school and 1.7% had completed a sport medicine fellowship. For CME,
the breakdown was as follows: 46.3% respondents had taken courses, 32.9% had attended
conferences and 45.1% had read joumais regarding musculoskeletal topics (see figure 9,
appendix J). The number of physicians with related training was significantIy low, with a
total of 18 having prior experience in physiotherapy, kinesiology or chiropractie.
When asked the number of acute knee injuries seen annuaily, the majority
responded in the 10-20 or 20-50 categories (se figure 10, appendix J). Eighty-one percent
of the physicians indicated that they would diagnose between 1 and 10 ACL injuries per
year (see figure 1 1, appendix 0.
The predominant type of practice was in family practices offices and emergency
room settings. A break-down of this information is provided in appendix C. (see figure 12,
appendix J).
The last option to dl questions in the survey was the "other" category. This
provided an opportunity for physicians to write answers and rate them accordingly. Al1
responses to this variable as well as its rating is provided in appendix C.
3.4 Paired t-Test Resnlts of Question 3 and 4:
The data was subjected to a paired t-test to determine if any significance existed
bebveen the general column and the ACL column (see appendk D). The ACL score was
submted nom the general score and a t-statistic was cdculated. If p-value was less than
0.0030 (the critical value), one column would be significantly more important than the other.
When determining the level of signifïcance for variables in question 3, "diagnosing
and treating yourseif" and a bbnon-surgical re fed ' were statistically more important when
managing a generai knee injury. "Diagnose yourself and refer for treaûnent", "referring
without determining a diagnosis" and "orthopaedic surgery referral" were al1 statistically
more important when presented with an ACL injury specifically.
In question 4, "unlimited activity" and "prescribing an exercise yourself' were more
important when presented with a generd lmee injury and limiteci activity was more important
when treating an ACL injury. The results of the t-tests and the cdculated p-values are
displayed in appendix D.
3.5 Results of Yeats in Practice
Physicians were asked to respond to the number of years they had practiced and
these results were divided into three categories: physicians practicing less than 12 yean,
between 12 and 25 years, and greater than 25 years (see figure 14, appendix 0. The data was
subjected to an d y s i s of variance test (ANOVA) in which p-values and mean scores were
caiculated (see appendix E). This enables the observation and identification of any trends
between groups when analyzhg specific variables.
Al1 chical tests such as: the drawer, Lachman's, and pivot shift decreased in
importance as the number of years pmcticed increased. The most notable difference in the
level of importance was observed for the Lachman's. The under 12 year group had a rnean
score of 1.982, the 12-25 year group scored 2.291 and the over 25 year group scored 2.822.
Question 3 indicated that physicians practicing fm more than 25 years were more
inciined to refer patients to orthopaedic specialists for a general h e e problem and l e s likely
to refer to non surgical specialties.
3.6 Days to Appointment when referring to an Orthopaedic Surgeon
The responses were divided into 3 categories: 0-7 days, 8- 14 days and over 14 days
(see figure 15, appendix J). Since the number of days to an appointment may dictate the
management and treatment of an injury, the data was subjected to an ANOVA test where
p-values and mean scores were caiculated for questions 3 and 4 (see appendix E). Both
general and ACL columns showed, that as days to appointment increased, the level of
importance of determining a diagnosis increased.
3.7 Results of Musculoskeletal Background
Musculoskeletal background was divided into 3 categories. A score of 1 indicated
that a category in medical training or CME was chosen. A score of 2 demonstrated that
the related training category was chosen. Finaüy a score of 3 indicated that the physician had
completed a sports feilowship (see appendut F) The purpose of this d y s i s was to examine
the mean scores for groups related to question 2. Group 1 contained 3 14 physicians, group
2 contained 19 physicians and group 3 contained 6 physicians.
In the history section of question 2, the 6 physicians who indicated they had
completed a sports fellowship, consistentiy rated al1 aspects of history, except for age of
patient, at approximately 1.3. The remaining 2 groups rated ail aspects of history,
exciuding age, approximately half a point higher indicating that history was less important
overall.
Consistent with the resdts in the history section, groups 1 and 2 rated the level of
importance of the physical exam to be approximately equal for al1 variables. The means
calculated for the sport feliowship category, indicated that the Lachrnan's and the pivot shift
tests were more important when diagnosing an acute knee injury.
An examination of the individual aspects of CME provided no statistically
significant information (see appendix G). Examples of CME were provided in the n w e y
to aid physician response and were not included for specific analysis.
3.8 Results for Practice Type versus Number of Knee injuries
Types of practices were compared to the number of acute knee injuries seen and the
number of ACL injuries, diagnosed annually. Regardless of practice type, the number of
acute knee injuries seen annuaily was higher than the number of ACL diagnoses made
annuaily (see figures 6 & 7, appendix J). Specifically when analyring emergency, farnily
and *-in practices, the majority of physicians replied that they would encounter 20 to
50 acute knee injuries annually and diagnose 1 to 10 ACL injuries per year.
3.9 Physicians with Access to MM versus Physicians Without Access to MRI
Physicians with m e s s to MRI in the community were compared to those physicians
without. Each group had mean scores calculated for question 1. A t-test was then
perfonned to detemüne statistical significance. There was no statistical significance
between these 2 groups. The results of this cornparison are located in appendix H.
Cha~ter #4 DISCUSSION
4.1 Anaiysis of Mean Scores: Questions 1-2
A cornparison of the mean scores for question 1, demonstrated that primary care
physicians rate history and clinical exam as being much more important than irnaging
procedures. This corresponds to other studies of important aspects of acute knee injury
diagnosis. Mendelsohn and Paiement (1996), concluded that a correct diagnosis can be
made up to 90% of the tirne if a proper history and physicai examination are conducted.
Rothenberg and Graf (1 993), stated that a detailed history and physical examination are the
most significant elements in determining a diagnosis. Smith and Green (1 999, concluded
that no tecbnological advance c m replace a thorough history and clinical examination. The
results of our study are that history and clinical examination are the most important aspects
of the primary care physician's routine investigation of the acutely injured knee. This is in
keeping with the opinions of the physicians consulted during the design of the survey.
Although plain radiography was the moa important imaging procedure, it was less
important than the history and cl inid examination. Wacker et al (1995), felt that history
and clinical examination are important but should be complemented by radiography for a
more thorough diagnosis. Physicians responding to this survey indicated that radiography
is of limited importance when detennining a diagnosis. Although plain radiography was
rated the most important irnaging procedure, its low level of importance indicated that
physicians tend to use more discretion in this area. Therefore, when physicians selecting
an imaging procedure to assist in making a diagnosis, radiography would iikely be their fim
choice. A practical application of this is presented by Stiell et al (1 999, who concluded
that plain radiographs of the acutely injured knee couid be more cost effective when based
on an appropriate history and physical examination.
Despite the fact that 33% of physicians have access to MRI and 83.1% have access
to CT scan, these imaging procedures were rated with extremely low importance. This is
a positive indication that expensive imaging procedures are used with discretion and do not
replace the more cost effective history and physical examination (see figure 1).
In question 2, history and physical examination were placed in separate categories.
The results indicate that identifying the mechanism of injury is the single most important
aspect of a complete history and that this would lead to an accurate diagnosis. For example,
the incidence of suspicion of an ACL injury is much higher if it has been determined that
the patient nistained a true hyperextension or a forced internai rotation of the knee joint. It
has ken demonstrated that these episodes place the ACL at N k and are therefore important
to document (Wojtys, 1994). This corresponds to studies done by Mendelsohn and
Paiement (1996), and Bondeville et al (1993), which suggest that an accurate history which
specificall y identines the mechanism of injury will enhance the phy sician's chances to
d e t e d e an accurate diagnosis.
Al1 other aspects of history except for patient age were rated with high levels of
importance. A locked or stiff laiee, swelling, and ùistability or giving way were also
considered important. Since history was rated with such high levels of importance in
question 1, it seems logical that the elements of a proper history would also be rated with
hi& importance when analyzed in question 2.
The presence of an effusion was the most important aspect of the physical exam.
This is not surprishg since an effusion, (ie. swelling of the joint), implies a senous injury
such as ACL rupture, meniscal tear, or other internai derangements. Also rated with high
levels of importance were range of motion, the ability to weight bear and the location of
tendemess. The study by Johnson and Wamer (1993), also found it important to perfonn
a detailed physical examination, which included observation of any swelling, tests for range
of motion and palpation for joint line tendemess (see figure 2)
The rnost important clinical stability tests were collateral ligament testing and the
drawer tests. Al1 tests were rated between 1.7 and 2.5 on the Likert scaie. Since the
collateral tests determine the laxity of either the MCL or the LCL and the drawer tests
determine the laxity of the ACL or PCL, this may indicate that there is greater emphasis on
diagnosing a type of structural injury (ie. cruciate ligament) rather than a specific injury (ie.
ACL) (see figure 3).
The distribution of m e r s for the Lachman's and the pivot shift tests, fou& that the
majority of the respondents either found these tests to be very important or not important
at all. There were relaiively few cases in which either test received a mid-range score of 3.
This implies that some physicians are aware of the Lachman's and pivot shift tests while
others may not be familar with either the names of the tests, the techniques invoived or their
indications in the acutely injured k. The fact that severai surveys were either lefi blank
or had question marks in the space provided to rate the Lachman's or the pivot shift tests,
supports this argument.
The Lacbman's and the pivot shift test are specifically used to detemllne the laxity
of the ACL. According to the dennition of an acute knee injury provided by the survey, an
ACL rupture shouid have been suspected when these tests are positive. Fowler (personai
communication) and Regan (1 987) suspected that an acute haemarthrosis of the knee
implies an injured anterior cruciate in approximately 72 to 85% of cases. In our study, the
Figure 3: CLlNlCAL STABlLlTY TESTS
McMURRAY DRAWER CCT LACHMAN PIVOT SHlFT
VARIABLES
antenor drawer was rated as the most important test determining ACL laxity. However. in
a study by Kim and Kim (1 995), the Lachman's, pivot shift and antenor drawer tests were
compared when diagnosing ACL injuries c o b e d by arthroscopy. î h e incidence of a
positive test result was 98.6% for the Lachman's, 89.9% for the pivot shift and 79.6% for
the anterior drawer. Fowler and Regan (1987), indicated that the ACL injuries in their sens
were ofken dismissed as "knee sprains" and that attention should be paid to the fact that 95%
were misdiagnosed. This hplies that some prirnary care physicians either have a low index
of suspicion, or are not aware of the most sensitive and specific tests for an ACL injury.
Of least importance was the McMurray's test which corresponds with the study done by
Corea et a1 (1994), concluding that this test seems to have limited value in curent clinical
practice.
4.2 Analysis of Management Options: General versus ACL
Five management options were rated in question 3. Since these scenarios compared
the management of an acute knee injury in general to that of an ACL injury in particuiar, a
paired t-test was perfonned to determine statistical significance.
When managkig an acute lmee injury in general, physicians felt it was significantly
more important to make a diagnoses and refer to non- surgical hedth care professionals (ie.
physiotherapy, chiropractor, massage therapist). When managing an amte ACL injury, there
was more importance placed on a refend to an orthopaedic surgeon rather than on non-
surgical treatment.
There appeared to be no difference in acute knee injury management when
considering sex, sporting interest, occupation, time since injury, prior failed treatmenk and
age. An ACL injury was more significant in patient management when the level of
premorbid activity was taken into account This seems logical as the performance of certain
activities with a high ACL demand (ie. basketbail, football etc.) would necessitate
appropriate treatment.
Question 4 analyzed treatment options. Physicians are more cornfortable prescribing
an exercise for a general knee problem rather than for an ACL injury. Since it was
demonstated that ACL injuries are likely to be referred to an orthopaedic surgeon, it may be
that prirnary care physicians feel that prescribing an exercise program wodd interfere with,
or delay definitive management for this injury. Physicians also feel that regardless of the
injury, referral to a physiotherapist is more important than prescribing an exercise program.
This indicates that most physicians utilize the medical personnel in their community to the
patient's advantage.
4 3 Analysis of Years Practiced
As the number of years in practice increased, the importance of clinical stability tests
tended to decrease. This indicated that more experienced physicians perceive clinicai
stability tests to be less important than do their Iess experienced colleagues. Years in
practice had no bearing on the level of importance of imaging procedures. However!
expenenced physicians preferred more conservative treatment options such as limited
activity, rest and physiotherapy in treating the acutely injured knee.
4.4 Analysis Comparing the Number of Days to Appointment when Referring to
an Orthopaedic Surgeon
The results indicate that physicians are more likely to determine a diagnosis if there
is little chance that a patient can be assessed by an orthopaedic surgeon in less than 2 weeks.
Rothenberg and Graf (1 999 , stated that early accurate diagnosis is important for a patient
with an acute knee injury to r e m to full fûnction. The results of the survey also suggest
that primary care physicians believe that early accurate diagnosis is important when a knee
injury is sustained.
4.5 Analysis of Musculoskelehl Background
As described in the resdts, musculoskeletal background was divided into the
following groups: (1) CME only, (2) CME and related training (ie. physiotherapy), or (3)
cornpletion of a sport medicine fellowship.
Physicians who completed a sport medicine fellowship rated the mechanism of
injury, a locked knee, swelling, and instability to be more important than physicians whose
musculoskeletal background consisted of CME and related training only. Despite this fact,
ail groups indicated that determining the mechanism of injury was the most important
variable in the diagnosis of an acute knee injury. This is in keeping with the conclusions
made by Mendelsohn and Paiement (1996), that obtaining a good history was the most
important aspect in determining the mechanism of injury.
With respect to the physical examination, physicians who completed a sport
medicine fellowship rated an eaision and the ability to weight bear with more importance
than those physicians without such training. As discussed in section 4.1, this seem
appropriate as such findings are ofien associated with serious injury (Johnson & Wamer,
1993). The same trend was demonstrated by this group when rating the importance of the
Lachman's and pivot shift tests. hterestingiy enough, both of these tests determine an
injury to the ACL, suggesting that there is a higher index of suspicion for this injury in this
group. With the definition of an acute knee injury provided by the survey, such suspicion
is warranted. As well, Dehaven (1980), indicated that an acute haemarthrosis of the knee
joint implies a . injured ACL in up to 72% of such cases.
The Lachman's and the pivot shifi have been proven to be more sensitive when
diagnosing ACL injury than the antenor b e r test (Kùn & Kim 1995). However, the IWO
groups that had not completed sport medicine fellowships indicated that the drawer tests
were more important. This may imply that the musculoskeletai training received by the
latter group has enhanced their knowledge of the most sensitive and specific tests for
detennining ACL injury, as well as the clinical scenarios in which these tests are most
appropriate. This training may also benefit physicians when diagnosing other
musculoskeletal injuries (ie. shoulder or ankie injuries).
It should be noted that while only 6 physicians had completed a sport medicine
fellowship, this still represents approximately 30% of such trained individuals in the
province of Ontario. This is due to the fact that there are ody two training centres in this
relatively new program available annually in Ontario and other provinces. Therefore, the
6 out of a possible 20 responses indicate ùiat the data collected provides an appropriate
representation of this specificdly trained group.
Aside from a sport medicine fellowship, al1 other aspects of musculoskeletal
background (CME and related training) did not appear to Muence the level of importance
of the individual components of the history and physical examination.
4.6 Number of Knee Injuries Seen Annnaily
It was estimated that for every 100 acute knee injuries seen with a history of pain,
swelling and a traumatic event, ody 30 injured ACL's would be diagnosed. This is less then
the 72% incidence reported in the literature (Fowler & Regan, 1987). Therefore, this tends
to be consistent with the previously demibed low index of suspicion for an ACL injury
demonstmted in this suntey.
4.7 Cornparison of Pbysicians With and Without Access MRI
Major centres in Ontario are more likely to have MN. Consequently, 33% of the
physicians surveyed indicated that they had availability to MRI in their community.
Mean scores were calculated for question 1 uidicated no significant differences
between these groups. This suggests that having access to MRI does not predispose
physicians to its oveme. Gleb et al (1996), concluded that MRI is an ovemsed diagnostic
technique when evaluating knee injuries, and therefore is not cost effective when compared
to evaluation by a clinical examiner. Our shidy on the other hand suggested that history
and clinical exam are substantially more important than the use of MM. This is a positive
indication that physicians do not rely on the use of diagnostic imaging equipment to
determine a diagnosis. Therefore, the methods that physicians tend to use are more cost
effective (see figure 4).
4.8 Limitations of the Study
Two hundred and forty-two physicians did not respond to the survey. The
assumption is that the majority of physicians who did respond have a specific interest in
musculoskeletal injuries and orthopaedics. Therefore, the data collected from these 338
physicians may be biased which may explain the insignificant resdts found when
comparing the group with CME to the group with no CME. This is in contrast to severd
other studies that show CME to be the most important variable in improving physician
management of musculoskeletal disorders. This dinerence may be due to a lack of interest
on the part of the non-respondents who did not r e m the survey. Regardless o f CME,
physicians rated ail variables of the history and clinicai examination to be approximately
equal. Only a 100% response rate wodd determine if the interest level of the non-
respondents is significantly different.
Another possible exphnation for the lack of influence of CME in this group, was
that questions regarding this topic were located near the end of the survey in the sensitive
demographic section. It is possible that CME would have had a more significant impact on
physician management if the w e y had been more specifïc with regard to conference type
and course topic. One would expect that a course focusing on the musculoskeletal system
(ie. ACSM team physician course) would have more impact than a general family practice
couse with one topic dedicated to musculoskeletal injuries. Further research, specifically
relating to the physician's level of CME and the implications this may have on the routine
investigation of musculoskeletal injury is needed.
The length of the s w e y may have had an impact on the response rate as 3 1 surveys
were returned completely blank and 21 1 surveys were not retumed at 4. Therefore, if the
survey had asked fewer questions, there may have been a better rate of response.
Chapter #5:
5.1 Clinical Relevance
Knee injuries are a common medical problem for which the direct costs are
enormous. This study indicated that history and cluiical examination tend to be the most
important variables in a physician's routine investigation of an acute knee injury. Expensive
diagnostic imaging techniques were the le& important, regardless of availability. E s
indicates that these techniques are king used with more discretion, thereby minimiring the
burden of health care costs in Ontario.
The responses nom physicians who had completed a sport medicine fellowship
imply that the musculoskeletal training received by this group enhanced their howledge
of the most sensitive and specific tests (ie. Lachman's & pivot shift tests) for determining
an ACL injury. This suggests that a more cost effective overail approach to this problem
is being implemented, and emphasizes the role of important musdoskeletal training.
5.2 Conciusion
The data gathered during this study indicates that the spectrum of the curent
management of the acutely injured knee is not as diverse as originaily assumed. The resuits
regarding the routine investigation of an acute knee injury indicate that prirnary care
physicians consider history and clinical examination to be the most important variables in
determinhg a diagnosis for this injury. SpecificaIly, signs of effusion and deteminhg the
mechanism of injury were selected as the most important variables in making a correct
diagnosis.
It was hypothesized that technological resources may play a role in the diagnosis of
acute hee injuries. In this study, there was no evidence to suggest that the availability of
plain radiography, MRI, CT scan, arthrogram or joint aspiration influences the marner in
which physicians diagnose acute knee injuries.
However, unlike technology, the availability of medical health personnel did affect
the treatment of the acutely injured laiee. In general, physicians preferred to refer to a
physiotherapist for the conservative component of treatment. Physicians aiso indicated that
when referrîng patients to orthopaedic surgeons, it becomes more important to detennine a
diagnosis if the patient can not be seen within two weeks.
The level of muscuioskeletal training of each physician varied widely rhroughout
the province. The physicians who demoll~trated that they had completed a sports medicine
fellowship provided a positive indication that the training they received may have resulted
in a greater awareness of the most sensitive and specific tests for musculoskeletai injury.
Primary care physicians are relatively consistent when maoaging acute knee injuries
and factors such as history, clinical examination, availability of medical personnel, and
rnusculoskeletai kainhg may have some important implications in the diagnosis and
treatment of this type of injury.
In conclusion:
1. History and clinical examination are the most important variables in the routine
investigation of the acute knee injury. Specifically the detennination of the mechanism of
injury and the presence of an effusion.
2. The Ieast important variables in the routine investigation of acute knee injuries are
imaging procedures such as, MM, CT scan and anhrography. If however, an imaging
procedure was going to be used for diagnosis, radiography would likely be the hrst choice.
3. Further musculoskeletal training such as, the completion of a spon medicine
fellowship, impiied that these physicians have a greater preference for the Lachman and
pivot shift test, irnplying a higher index of suspicion for an ACL injury.
4. Due to the relative consistency of reponses to this study the spectrum of the acutely
injured knee is not as diverse as originally suspected.
5. There is a positive indication regarding the cost effective approach to management
of the acutely injured knee by primary care physicians in Ontario.
5.3 Recornmendations for Future Studies
1 . Analyze the management styles of musculoskeletal injuries by cornparhg physicians
praaicing in urban centres to those practicing in rurai areas.
2. A study determinhg the specifics of CME regarding conference type and course
selection and its effects on the management of musculoskeletai injury.
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Appendix A
- Cover Letter - Survey
To : Randomly selected primary care physicians in ontario.
Re: Primary Care Physician Acute Knee Injury Survey
Investigators : P. Fowler, M.D., F.R.C.S.C. A. Kirkley, M.D., F.R.C.S.C. A. Cogliano, M.D., C.C.F.P. S. Supnui, B.A. M.Sc. Candidate
Dear Doctor:
As you may know, there is still much controversy about management of acute knee injuries, both from a surgical and non-surgicd point of view. This n w e y is not intended to assess your knowledge regarding this issue. but rather is intended to be a representation of o u . current practise as primary care physicians in this province.
In order to resolve some of this controversy, a double-sided 2 page . . questionnaire, The Prim- Care Phvsician Acute Knee 1niu-y Survev, was designed at the University of Western Ontario to determine the current state of care for the acutely injured knee by primary care physicians in Ontario.
Recipients of the survey were randomly selected fiom a database of prima y care physicians encompassing aU family Br emergency phy sicians.
Please read the instructions attache& complete the questionnaire and r e m it in the self-addressed, stamped envelope at your earliest convenience. If you cannot complete the survey, we request that you please retum it, even if it is blank, in the envelope provided.
Your time and effort is greatly appreciated. S incerel y,
There are several possible diagnoses for an acute knee injury. We would Iike to know how you deal with this in your practise. For this m e y , we will define an acute knee injury as one that indudes al1 of the foilowing:
A traumatic evea occuring withb three weeks of presentation. * or a history of pain. * SweUHig or a history of swelhg.
For Questions Q# 1 to Q#4, using the foIlowing scale, please choose a m b e r that most accurately depicts the importance of each of the iisted items in your routine. Score in blanks provided. You mav use the same score more than once.
extremely important 1-2--5 not at al1 important
0#1: How important are the following items in your routine (Le. on every patient) inv-ation of the acutely injured h e e .
- a history - b. chical exam - c. plain radiographs - d. arùirogram - e, Magnetic Resonance haging - f. CT Scan - g . Joint Aspiration (Arthrocentesis) - h. Other: (PIease speciQ) - i. Ali investigations depend on the history & clinical exam.
W2: Using the scaie described above, how important are each of the following elements of the historv and phvsical exam in your diagnosis and management of the acutely injured knee.
history:
- a. mechanism of injury - b. locked or stiff h e e on history - c. swelling on history - ci. instability or giving way on history - e. age of patient - f. OTHER important history:
physical d a t i o n :
g. effusion on examination - - h. range of motion on examination - i. ability to weight bear - j. location of tendemess - k. McMiirray's test - 1. drawer test - m. Lachman test - n. pivot shifi test - o. collateral ligament testing - p. patelbfemoral joint testing - q. OTHER important examinations:
extremely important 1-2--5 not at ail important
P#lr How important are the followhg your management of an ngaS! injured I m e , in general (GEN), and for anterior cruciate ligament (ACL) injury?
GEN ACL - a diagnose and treat yourself, and refer as necessary - 6. diagnose yourself, but refer for matment regardles of diagnosis - c. refer without determing a specific diagnosis yourself - d. orthopaedic surgery referal - e. non-surgical refera1 (sport physician, pfiysiotherapy, chiropractor etc.) - f. sex of patient - g. IeveI of activity (ie. nonathletic vs recreaîional vs cornpetitive) - h. type of sport returning to (ie. chosen sport requires injured structure) - i. injured structure important for occupation? - j. tirne since injury - k- previously faited treatment - 1. age (pre-physeal closure, teens, 20-45, +45, etc) - m. patient preference, even if you consider not best choice
0#4: How important are the following treatxnent options m your management of the acutek injured hee, in general (GEN) and for ACL injury?
GEN ACL - - a unlimited activity, rest as necessary - - b. lirnit activity: cas& brace, splint, cmtch, cane - - c. prescribe an exercise yourseif - - d- referral to physiotherapy - - e, OTHER:
Ptease provide the following Demographic Data:
Sex (please circle): Male or Femaie Age: Yean of practice: Approximate Cornmuaity Population (Catchment Area):
If referring your patient to an orthopaedic surgeon, state location: distance (lm) %rn your cornrnunity: time (days) to appointment:
Are these important in your choice of orthopaedic referral? (please circle) - arthroscopy available: Yes or No - ACL reconstruction available: Yes or No
Cumnt avaiia ble resources in community: (please circie al1 th apply) - - .
Imaging: -Y MRI CT Other: Personnel: Onhopaedic surgeon General surgeon that does orthopaedics Physiotheqist Chiropractor
Musculoskeletal Background: (please circle ail tfiat apply) Medical training: electives h medical schooi 1 residency spom feuowship CME: courses conferences jouraals other Related irahing: physiotherapy kinesiology chiropractic other
For each of the foiiowing questions, please circle one: a. acute knee injuries seen annually (none) ( 1-1 0) (1 0-20) (20-50) (50- 100) (> LOO) b. acute ACL injuries diagnosed annaully (none) (1 - 10) (1 0-20) (20-50) (50- 100) (> 1 00)
Practice type: (please circle aiI that apply) (Emergency) (Family Office) (Sport Medicine) (Occupational Medicine) ( Wak-In) (Other: 1-
Appendix B .
- Questions 1-4: Mean Scores - First Mailing Responses - Second Mailing Responses - Total Responses - 95 % Confidence Intervals - Standard Deviations
uestion # 1 : How important are t&e following items in your routine (Le. on every patient) investigation of the acutely injured knee?
Isr Mailing 2nd Mailing TOTAL
1st Mailing 2nd Mailing
TOTAI;
(c) plain radiographs
1st Mailing 2nd Mailing TOTAL
NUMBER OF RESPONSES
209 148 357
NUMBER OF RESPONSES
209 148 357
MEAN SCORE 1.13 1.1 1 1.12
(1.07, 1.18)
MEAN SCORE 125 1.1 1 1.19
(1.13, 1.25)
STANDARD DEVIATION
0.57 0.52 0.55
STANDARD DEVIATION
0.62 0.47 0.56
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
208 3.23 1 .O2 147 3.19 1 .O2 355 3.2 1 1.02
(3.11,3.32)
NUMBER OF RESPONSES
1st Mailing 206 2nd Mailing 147
TOTAL 353
(e) Magnetic Resonance Imaging
NUMBER OF RESPONSES
1st Mailing 206 2nd Mailing 147 TOTAL 353
MEAN SCORE 4.3 9 4 3 3 4.33
(4.23,4.42)
MEAN SCORE 4.53 4.6 1 4.57
(4.49,4.65)
STANDARD DEMATION
0.88 0.95 0.91
STANDARD DEViATION
0.85 0.6 1 0.76
1st Mailing 2nd Mailing
TOTAL
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
206 4.58 0.76 147 4.59 0.68 353 4.58 0.73
(4.51,4.66)
(& Joint Aspiration (Arthrocentesïs)
NUMBER OF RESPONSES MEAN SCORE
1st Mailing 207 3.54 2nd Mailing 147 4.1 1 TOTAL 354 3.77
(3.66,3.88)
NUMIBER OF RESPONSES MEAN SCORE
1st Mailing 1 1 2.27 2nd Mailing h 3 1.50
TOTAL 13 2-15
(i) all imestigations &pend on the history & dinical eram
1st Mailing 2nd Mailing
TOTAL
NUMBER OF RESPONSES MEAN SCORE
193 1.28 145 1.17 338 1.23
(lJS,L31)
STANDARD DEVIATION
1 .O3 1.01 1 .O6
STANDARD DEVIATION
1.19 0.7 1 1.14
STANDARD DEVIATION
0.8 1 0.60 0.73
Ouation # 2 : Using the scale described above, how important are each of the following elements of the hist0t-y and physical exam in your diagnosis and management of the acutely injured knee?
liisloly : (a) rnechunism of injwy
1st Mailing 2nd Mailing TOTAL
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
209 1.32 0.79 148 1.19 0.6 1 357 1.26 0.73
(1-19,134)
(5) iocked or stzyknee on history
NUMBER OF FUSPONSES
1st Mailing 207 2nd Mailing 148 TOTAL 355
NUMBER OF RESPONSES
1st Mailing 208 2nd Mailing 148 TOTAL 356
(4 instabilis, or giving way on history
NUMBER OF RESPONSES
1st Mailing 207 2nd Mailing 148 TOTAL 355
(e) age of patienr
1st Mailing 2nd Mailing TOTAL
CI) other important history
MEAN SCORE 1-63 1.80 1.70
(1.61,1.79)
MEAN SCORE 1.95 1.88 1.92
(1.83,2.01)
MEAN SCORE 1.62 1.67 1.64
(1.56, 1.72)
STANDARD DEVIATION
0.87 0-92 0.89
STANDARD DEVIATION
0.86 0.87 0.87
STANDARD DEVIATION
0.77 0.77 0.77
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
208 2.60 0.98 148 2.30 1.01 356 2.47 1 .O0
(237,2.58)
NUMBER OF RESPONSES
1st Mailing 22 2nd Mailing 8
TOTAL 30
STANDARD MEAN SCORE DEVlATION
1.68 0.65 1.75 0.7 1 1.70 0.65
NUMBER OF RESPONSES
1st Mailing 209 2nd Mailing 148
TOTAL 357
fi) range of motion on eraminution
NUMBER OF RESPONSES
1st Mailing 208 2nd Mailing 148
TOTAL 356
(1) ability to weight bear
1st Mailing 2nd Mailing
TOTAL
0) location of tendemess
1st Mailing 2nd Mailing
TOTAL
Ist Mailing 2nd Mailing TOTAL
1st Mailing 2nd Mailing TOTAL
MEAN SCORE 1.66 1.34 1.53
(1.44, 1.61)
MEAN SCORE 1.81 1.66 1.75
(1.66, 1.84)
STANDARD DEWATION
0.84 0.72 0.81
STANDARD DEVIATION
0.83 0.8 1 0.82
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
208 1.76 0-94 148 1.76 0.75 356 1.76 0.87
(1.67,1.85)
NUMBER OF RESPONSES
208 148 356
NUMBER OF RESPONSES
207 148 355
NUMBER OF RESPONSES
206 148 354
MEAN SCORE 1.9 1 1 .go 1.90
(1.81,2.00)
MEAN SCORE 2.32 2.85 2.54
(2.42,2.67)
MEAN SCORE 2.03 2.17 2.09
(1.98,2.20)
STANDARD DEVIATION
0.92 0.87 0.90
STANDARD DEVIATION
1.13 1-25 1.21
STANDARD DEVIATION
1 .O0 1 .O4 1.02
(m) Lachmm test
NUMBER OF RESPONSES
2 st Mailing 205 2nd Mailing 148
TOTAL 353
(n) pivot sh@ test
NUMBER OF RESPONSES
1st Mailing 206 2nd Mailing 148 TOTAL 354
(O) coIluteral ligament testing
NUMBER OF RESPONSES
Ist Mailing 206 2nd Mailing 148 TOTAL 354
NUMBER OF RESPONSES
1st Mailing 205 2nd Mailing 148 TOTAL 353
NUMBER OF RESPONSES
Ist Mcriling 5 2nd Mailing 1 TOTAL 6
MEAN SCORE 2.29 2.09 2.21
(2.07,234)
MEAN SCORE 2.78 1.99 2.45
(2.30,2.59)
MEAN SCORE 1.75 1-83 1.79
(1.69, f -88)
MEAN SCORE 2.14 2.24 2.18
(2.08,2.28)
MEAN SCORE 220 1 .O0 2.00
STANDARD DEVIATION
128 1.27 1.28
STANDARD DEVIATION
1.37 126 138
STANDARD DEVIATION
0.87 0.87 0.87
STANDARD DEVIATION
0.98 0.97 0.98
STANDARD DEVIATION
0.84
w o n # 3 : How important are the following m your management of an acutely injured knee, in general (GEN), and for anterior cruciate ligament (ACL) injury?
GEN : (a) diagnose and treat yourseK and refer us necessury
NUMBER OF RESPONSES MEAN SCORE
1 st Mailing 202 1.55 2nd Mailing 14 1 1-58
TOTAL 343 1.56 (1.46, 1.67)
fi) diagnose yourseK but rder for ireannent regardas of di4gnosïs
NUMBER OF RESPONSES MEAN SCORE
1st Mailing 200 3.84 2nd Mailing 140 3.61
TOTAL 340 3.74 (3.61,3.87)
(c) refer without detwmining a specific diagnosis yourseif
NUMBER OF RESPONSES MEAN SCORE
1st Mailing 200 4.10 2nd Mailing 14 1 3 -93
TOTAL 341 4.03 (3.91,4.15)
NUMBER OF RESPONSES MEAN SCORE
1st Mailing 198 3 -24 2nd Mailing 14 1 3.64
TOTAL 339 3.41 (3.28,3.53)
(e) non-surgicul rderr~I (sport physician, physiotherapy, chiropractor, etc.)
NUMBER OF RESPONSES MEAN SCORE
1st Mailing 197 2.5 1 2nd Mailing 14 1 226
TOTAL 338 2.41 (2.28,2.54)
STANDARD DEVIATION
0.97 1 .O6 1.00
STANDARD DEVIATION
136 1.15 1.22
STANDARD DEVIATION
1.13 1.18 1.15
STANDARD DEVIATION
1 . 1 1 1.24 1.18
STANDARD DEVIATION
1.20 1.24 1.22
ser of patient
Ist Mailing 2nd Mailing
TOTAL
LYUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
198 4.62 0.85 142 4.68 0.87 340 4.65 0.86
(4.56,4.74)
(g) level of activity (i-e. nomathletic vs. recreational vs. cornpetitive)
NUMBER OF RESPONSES MEAN SC0.RE
1st Mailing 200 2.62 2nd Mailing 142 2.59
TOTAL 342 2.61 (2,48,2.73)
(h) type of sport returning to (i.e. chosen sport requites injured structure)
NUMBER OF RESPONSES MEAN SCORE
1st Mailing 198 2.16 2nd Mailing 142 2.42
TOTAL 340 2.27 (2.15,239)
(i) injuredsnuchcre important for occupation?
h'UMBER OF RESPONSES
1st Mailing 198 2nd Mailing 141
TOTAL 339
NUMBER OF RESPONSES
1st Mailing 199 2nd Mailing 141
TOTAL 340
MEAN SCORE 1.86 2.14 1.98
(1.86,2.09)
MEAN SCORE 2.57 2.57 2.57
(2.47,2.67)
STANDARD DEVIATION
128 1.1 l 1.21
STANDARD DEVIATION
1 .O7 1-03 1.06
STANDARD DEVIATION
1.01 0.92 0.97
1st Mailing 2nd Mailing
TOTAL
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
197 2.40 1 .O0 140 236 0.90 337 2.39 0.96
(2.28,2.49)
(I) age @re-phyd closure, teem, 20-45, +45, etc.)
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
1st Mailing 197 2.39 1 .O5 2nd Mailing 14 1 2.30 0.96
TOTAL 338 235 1.01 (2.24,2.46)
(m) patient preference, even ifyou consikr nos best choice
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
1st Mailing 196 2.80 1-14 2nd Mailing 140 2.36 1.04 TOTAL 336 2.62 1.12
(2.50,2.74)
ACL : (a) diagnose and ireat yourseK and refer as necessary
NUMBER OF RESPONSES MEAN SCORE
1st Mailing 200 2.36 2nd Mailing 140 2.48
TOTAL 340 2.41 (2.24,2.57)
(3) diagnose yourself: but refir for mannent regmaïess of diagnosis
1st Mailing 2nd Mailing
TOTAL
NUMBER OF RlESPONSES MEAN SCORE
200 2.94 141 2.57 341 2.79
(2.61,2.96)
STANDARD DEVIATION
1.49 1-64 1.55
STANDARD DEVIATION
1.62 1.60 1.62
(c) refer without detennining a speclf7c dkgnosis yowself
NUMBER OF RESPONSES MEAN SCORE
1st Mailing 20 1 3.87 2nd Mailing 140 3 -44 TOTAL 341 3.69
(3.54,3.84)
(4 orrhopaedic stugey r e f e d
NUMBER OF RESPONSES MEAN SCORE
1st Mailing 202 1.93 2nd Mailing 141 2-14 TOTAL 343 2.01
(1.87,2.15)
(e) non-wgicd &erra1 (sport physiciun, physiotherapy. chiropractor, etc.)
NUMBER OF RESPONSES MEAN SCORE
1st Mailing 198 2.97 2nd Mailing 140 3.49 TOTAL 338 3.19
(3.04,334)
# sac of patient
NUMBER OF RESPONSES MEAN SCORE
1st Mailing 199 4.6 1 2nd Mailing 142 4.73 TOTAL 341 4.66
(4.57,4.75)
fg) levef of activity (i-e. non-athletic vs. recreational vs. cornpetitive)
NUMBER OF RESPONSES MEAN SCORE
1st Mailing 200 2.40 2nd Mailing 142 2.43
TOTAL 342 2.41 (2.26,2.55)
STANDARD DEVIATION
1.32 1.51 1.41
STAM)ARD DEVIATION
1.25 1.43 1.33
STANDARD DEVIATION
1.42 1.36 1.41
STANDARD DEVIATION
0.86 0.80 0.84
STANDARD DEVIATION
1.44 1.27 137
fi) type of sport returning to (Le. chosen sport requires injwed smchue)
NUMBER OF RESPONSES MEAN SCORE
1st Mailing 199 2.09 2nd Mailing 142 2.18 TOTAL 341 2.13
(t.OO, 2.26)
fi) injwed structure important for occupaiion?
NUMBER OF RESPONSES MEAN SCORE
1st Mailing 199 1.92 2nd Mailing 14 1 1.93 TOTAL 340 1.92
(l.80,2.04)
1st Mailing 2nd Mailing TOTAL
(;k) previously failed rreatmew
NUMBER OF RESPONSES MEAN SCORE
200 2.57 14 1 2.21 341 2.42
(231,2.54)
NUMBER OF RESPONSES MEAN SCORE
Isr Mailing 197 2.39 2nd Mailing 140 2.05 TOTAL 337 2.25
(2.13,2.37)
(I) age (pre-physeal closure, teem, 2045, +45. etc.)
NUMBER OF RESPONSES MEAN SCORE
1st Mailing 199 2.40 2nd Mailing 141 2.13 TOTAL 340 2.29
(2.17,2.41)
(m) patienî preference, even fyou cornider not best choice
NUMBER OF RESPONSES MEAN SCORE
1st Mailing 197 2.82 2nd Mailing 140 2.3 1 TOTAL 337 2.61
(2.48,2.73)
STANDARD DEVIATION
1.26 132 1.24
STANDARD DEVIATlON
1.18 1 .O8 1.14
STANDARD DEVIATION
1-10 1 .O2 1 .O8
STANDARD DEVIATION
1.14 1 .O3 1.10
STANDARD DEVIATION
1.18 1.01 1.12
STANDARD DEVIATION
1 .l9 1 .O7 1.16
Duestion # 4 : How important are the following treatment options in your management of the acutely injured knee, in general (GEN) and for ACL injury?
GEN : (a) wlimited actntiîy, rest as necessaty
NUMBER OF RESPONSES
1st Mailing 20 1 2nd Mailing 1 43 TOTAL 344
(b) limit activity: car , brace, splint, cmtch, cane
NUMBER OF RESPONSES
1st Mailing 20 1 2nd Mailing 143 TOTAL 344
ISZ Mailing 2nd Mailing TOTAL
1st Mailing 2nd Mailing
TOTAL
(e) 0 t h
Ist Mailing 2nd Mailing
TOTAL
NUMBER OF RESPONSES
203 143 346
NUMBER OF RESPONSES
20 1 143 344
NUMBER OF RESPONSES
5 6 11
MEAN SCORE 322 3.87 3.49
(334,3.64)
MEAN SCORE 2.17 1.80 2.02
(1.90,2.14)
MEAN SCORE 3.06 3.38 3.19
(3.05,333)
MEAN SCORE 2.0 1 1.87 1.95
(1.85,2.05)
MEAN SCORE 220 1.50 1-82
STANDARD DEVIATION
1.47 139 1.43
STANDARD DEMATION
1.15 0.97 1 .O9
STANDARD DEVIATION
1.32 1.33 133
STANDARD DEVIATION
0.9 1 0.99 0.94
STANDARD DEVIATION
1.79 0.84 133
ACL : (a) uniimited acrivity, rest as necasary
NUMBER OF RESPONSES
1st Mailing 195 2nd Mailing 143 TOTAL 338
NUMBER OF RESPONSES
1st Mailing 199 2nd Mailing 143
TOTAL 342
MEAN SCORE 3.95 4.25 4.08
(3.95,4.21)
MEAN SCORE 1.73 1.64 1.69
(1.58, 1.80)
STANDARD DEVIATION
1.23 1.14 1.20
STANDARD DEVTATION
0.95 1 .O5 0.99
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
1st Mailing 198 3 -68 1.30 2nd Mailing 142 3.85 1.26 TOTAL 340 3.75 138
(3.61,3.89)
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVLATTON
1st Mailing 198 2.17 1.37 2nd Mailing 142 1.97 1.24
TOTAL 340 2.09 132 (1.95,t.W)
1st Mailing 2nd Mailing
TOTAL
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
9 1 .O0 0.00 7 1 .O0 0.00 16 1 -00 0.00
- Demographic Results: - First Mailing Responses - Second Mailing Responses - Total Responses - Mean Scores and Standard Deviations - Table Indicating the Responses to "Other"
Demoera~hic Section : Sa
MALES 1st Mailing 120
2nd Mailing 91 TOTAL 211 (70.1%)
NUMBER OF RESPONSES MEAN
1st Mailing 153 43 -4 2nd Mailing 135 45.1
TOTAL 288 44.2
Years of Practice
NUMBER OF RESPONSES MEAN
1st Mailing 151 15.6 2nd Mailing 125 16.8
TOTAL 276 16.1
Approximate Cornmunity Population (Catchment Area)
STANDARD DEVKATION
10.9 11.3 11.1
STANDARD DEVLATION
113 10.3 10.8
NUMBER OF STANDARD RESPONSES MEAN DEVIATION
I sr Mailing 146 507236.3 1921339 2nd Mailing 8 7 360235.6 I 159024
TOTAL 233 452347.6 1676381
urefming your patient tu an orthopaedic surgeon, (0 Locarion
Location Amprior Barrie
Belleville Brampton Brantford Burlington
CaIedon
Cambridge Chatham Conningto
Responses 1 7 1 1 2 2 1
1 2 1
Location Grimsby Guelph
Hamilton Hawkesbu Jane Finch Kingston Kitimat
Kitchener Lindsay London
Responses 1 5 18 1 1 8 1
7 1
26
Location Niagara
North Bay N. York Oakville Orillia
Oshawa ûttawa
Perth Peterborou
Prince George
Responses 7 - 3 5 1 1 6 12
1 1 1
TOTAL 177 124 301
Location StCatheri St-Thomas Sudbury
S.S.Marie Timmins Toronto Thunder
Bay Vanier
Waterloo Welland
MAXIMUM 81 93 93
MAXIMUM 55 60 60
Responses 4 1 5 1 6 88 2
1 I 1
Cornwall - 7 Markham 1 Sarnia Downsvie 1 Mississiug 6 Scarborou Etobicoke 4 Newmarke - 3 Stratford
(ii) Distance (km) fiom your cornrnuniîy
NUMBER OF STANDARD RESPONSES MEAN DEVIATION
1st Mailing 143 14.7 29.8 2nd Mailing 1 06 24.1 73 3
TOTAL 249 18.7 52.9
NIMBER OF STANDARD WSPONSES MEAN DEVTATION
Ist Mailing 127 35.1 47.8 2nd Mailing 95 16.5 37.7
TOTAL 222 27.1 44.6
Are these important in your choice of oriliopaedic refend?
ARTHROSCOPY AVAiLABLE
1st Mailing Yes 187 No 13
2nd Mailing Yes 138 No 4
TOTAL Y s 325 (953%) No 16 (4.7%)
C u m r available resources in communiry : (i) Imaging
XRAY MRI 1st Mailing Y a 204 80
No 1 124 2nd Mailing Yes 145 35
No O 110 TOTAL Yes 349 (99.7%) 115 (33.0%)
No 1 (0.3%) 234 (67.0%)
(ii) Personnel
Isr Mailing
6 Windsor 3 13 Woodtock 1
ACL RECONSTRUCTION AVAILABLE
146 50 113 27
259 (77.1 O h )
77 (22.9%)
ORTHO. GENERAL SURGEON SURGEON PHYSIO. CHIRO.
Yes 170 43 184 165 No 35 162 2 1 40
2nd Mazling Yes No
TOTAL Yes No
M11scuIoskeietaf Background : (0 Medical Training
1st Mailing
2nd Mailing
TOTAL
1st Mailing
2nd Mailing
TOTAL
(iii) Related Training
Yes No Yes No Yes No
Yes No Yes No Yes No
Ist Mailing Yes No
2nù Mailing Yes No
TOTAL Yes No
Acute knee injuries seen annualiy
NONE 1st Mailing O
2nd Mailing 3 TOTAL 3
ELECTIVES IN MEDICAL SCHOOL / RESIDENCY SPORTS FELLOWSHIP
143 3 62 202 120 3 25 142
263 (75.1 %) 6 (1.7%) 87 (24.9%) 344 (983%)
COURSES CONFER JOURNALS OTHER 122 74 1 06 3 83 13 1 99 O 40 41 52 3 105 1 04 93 O
162 (16.3%) 115 (32.9%) 158 (45.1%) 6 188 (53.7%) 235 (67.1%) 192 (54.9%) O
PHYSIO. KINESIO. CHIRO. 4 6 1
20 1 199 204 7 - 4 1
143 141 1 44 6 (1.7%) 10 (2.9%) 2 (0.6%)
344 (98.3%) 340 (97.1 %) 348 (99.4%)
OTHER 3 O 1 O 4 O
Rcure ACL injuries diagnosed mmZb
1st Mailing 2nd Mailing
TOTAI:
Practice type
Ist Mailing 2nd Mailing
TOTAL
FAMlLY EMERG. OFFICE
65 186 3 3 132 98 318
SPORT OCCUP. MEDICLNE MEDICINE WALK-IN OTHER
6 3 25 1 O 2 3 28 6 8 6 53 16
onses to uOther" as D lavai on the Suwev
+Note : Numbers in parenthesis indicde the score of the parti& respome.
on # 1 : How important are the following items in your routine (i.e. on every patient) investigation of the acutely injured knee?
other
arthroscopy (3) previous knee pathology (1) orthopaedic / special testing (1) course since injury (2) gait (1) arthroscopie examination (2) bone scan (4) referral(4) consultation (1) referral(3) referral(3) CT scan on second presentation if warranted (1) arthroscopy (2)
uestion # 2 : Using the scaie described above, how important are each of the following elernents of the history and physical exam in your diagnosis and management of the acutely injured knee?
03 other important history
problematic steps going down stairs (2) previous injury (2) medical history of hypermobile joint / various medical conditions leading to disorder in bone metabolism (1) previous injury (2) past history (2) activity, past history of injury (1) previous history (1) praious injury, surgery, family history (1) prior history of trauma or arthntis (2) prior treatment of same or other known injury (1)
previous history (2) prior problems (3) previous history (1)
pain (2) weight bearing (2) being able to take steps at tirne of injury (1) relative strength of qua& (3) prior history of injury (2) previous knee history (1) "pop" sound (2) timing of swelling (i.e. immediate vs. gradual) (2) repetitive injury (1) prior h e e problerns, job I lifestyle of individual (2) previous Mury (1) previous injuries (3) alcoholism, weather (2) type of work at the time of injury (1) "velocity" of swelling : sudden vs. gradual, previous history of knee injury (2) "pop" sound (1) weight bearing after event (2)
(@ other important examinations
CBC(3) person's temp. (2) the rest of the leg (3) power testing (1) calfor popliteal (tendemess or mass) (2) visual cornparison to non-affiected knee (1)
Ouestion # 4 : How important are the foilowing treatment options in your management of the acutely injured hee , in general (GEN) and for ACL injury?
(e) GEN - other
follow-up (1) rest, antünflamatones, slowly increasing activity (1) orthopaedic referral(3) assessing contributhg factors : shoes, abnormal mechanics, muscle tone, weight (1) orthopaedics (5) age of the patient (1) referml to orthopaedics (1)
rest and orthopaedic referral(1) follow-up (3) antiinfiamatories, ice (2) follow-up appointment (1)
(e) ACL - other
foilow-up (1) refer to specialist (1) referral to orthopaedics (1) orthopaedic referrai (1) assessing contributing factors : shoes, abnormal mechanics, muscle tone, weight (1) referrai for orthopaedic surgeon opinion (1) always refer to orthopaedics (1) referral to orthopaedic surgeon (1) orthopaedics (1) refer to orthopaedic surgeon (1) age of the patient (1) referral to orthopaedic surgeon (1) referral to orthopaedic singeon (1) rest and orthopaedic referml(1) orthopaedic referral(1) foliow-up appointment (1)
D e m o e h i c s Section :
pote : Numbers in purenthesis m w indicate whether the partidat respome was repeured more t h one rime.
Ifreferring yourpatient to an orthopaedic surgeon - Location
hospital(13) local (9) same city (4)
City (3) same (3) community (2) in the area same clinic within city
same building close by hospiîal 1 sports clinic c h i c here same area Ontario office KGH metro in t o m my building North Wb Gen. Westminister M o . Century Health C h i c
Ifreferrring yourpafient to an odiopaedc surgeon - Tirne (days) to appointment
depends (10) 3 + (5) rnonths (4) weeks (4) days to weeks (4) 3 + weeks (3) weeks to months (2) weeks + weeks - maybe less for acute lcnee varies 2 + weeks depending on severity of problem depends - elective (6 months), non-elective (sooner) same day to months unknown 4 months + I week to 6 months visiting ortho. 1 2 weeks depends on suspected diagnosis 3 + > 4 days 3 + months 6 > depends on my assessrnent depends on urgency depends - usuaiiy quickly
60 + depends on severity of the problem - 1 day to 3 months 1 month to 2 years referred to junior partner for appointments 5 + depends - days to months 1 week (if lucb) or months varies - days for urgent appointmen& many months for non-urgent appointment as warranted depends on severity of injury a few days dependent on diagnosis - elective referral (severai months), acute referral (discuss on phone and can be seen if necessary) several weeks at least (up to 6 ) 15 + urgent (same day), elective (2 to 4 weeks) few days to months (depends on case)
If refetring your p a t i to <ui orîhopaedic surgeon - Distance&n)fiorn your cornrnuniîy
close (4) <3O km 2 hour drive 120 to 250 km 100 to 200 km O to 130 km 10 IO 15 km < 2 0 b O to 60 km (I work in one teaching and one rurai hospital) 60 to 160 km 1.5 hours O to 100 km very close 0.5 to 1 hoUr
CT avaiiable to specialist whatever we need arthroscopy
M~~culoskeietaf Background - C m
miliîary diploma sport medicine tutonal group volunteer for sports events rehabiIitation general practitioner (G.P.)
M11scuIlokeeletal Background - ReZuted Training
orthopaedics (2) personal interest, very logical and deduction (not comrnon) acupuncture
semi-referral (surgicai assist only, no practice) family practice 1983- 1993, now psychiatry ward University health clinic university health sentice GP / anaesthesia + ER academic family medicine hospital hospital rehab and psychiatrie commdty health ch ic anaesthetics G.P. fbcture clinic at EGH general practice, mostiy genatric addiction genatrics G.P. G.P. psychotherapy
Appendix D
- Results of the Paired t-Test for Questions 3 and 4 - Number of Paired Responses - T - Statistics - P - Values
Results of the Paired t-Test for Questions 3 and 4
Question # 3 (a) diagnose anù neat yourselJ and refer as necessary
NUMBER OF PAIRED T-STATISTIC RESPONSES
338 -10.03 19
01) diagnose yowseg but refer for treatntent regardless of diagnosis
NUMBER OF PAIRED T-STATISTIC RESPONSES
338 10.5057
(c) re f r without determining a specifc diagnosis yoursev
NüMBER OF PGIRED TSTATISTIC RESPONSES
339 6.3273
(4 orthopuedic surgery refrral
NUMBER OF PAiRED T-STATISTIC RESPONSES
337 16.224 1
(e) non-surgical refend (sport physician, physiotherapy, chzropractor, etc.)
NUMBER OF PAIRED T-STATISTIC RESPONSES
335 -8.9938
NUMBER OF PAIRED T-STATISTIC RESPONSES
339 -0.5768
(g) level of acriviry (i-e. nonathlerie vs. recreurionai vs. cornpetitive)
NUMBER OF PAIRED T-STATISTIC RESPONSES
340 4.4928
fi) type of sport returning to (ie. chosen sport requires injured smcfure)
-ER OF PAFRED T-STATISTIC RESPONSES
539 3.0 138
P-VALUE
0.000 1
P-VALUE
0.000 1
P-VALUE
0.000 1
P-VALUE
0.000 1
P-VALUE
0.000 1
P-VALUE
0.5645
P-VALUE
0.000 1
P-VALUE
0.0028
Io iniwed smctwe important for occupation?
NUMBER OF PAIRED TSTATISTIC RESPONSES
338 1.3073
NUMBER OF PAIRED T-ST ATISTIC RESPONSES
339 3.1457
fi) previously failed t remem
NUMBER OF PAIRED T-STATISTIC RESPONSES
335 2.7028
(I) age @te-pkyseal closure, teens. 2035, -35. etc.)
NUMBER OF PAIRED T-ST ATISTIC RESPONSES
337 1.6820
(m) patient preference, men ifyou conrider nor best choice
NUMBER OF PAlRED T-STATISTIC RESPONSES
335 02658
Question # 4
(a) unlimited activiîy, r a t as necessmy
NUMBER OF PAKRED T-STATISTIC RESPONSES
337 -8.9094
(b) limit activity : c m , brace. spiint. crutch, cane
NUMBER OF PAIRED T-STATISTIC RESPONSES
340 6.0027
(c) prescribe an exercise yowself
NUMBER OF P W D T-STATISTIC RESPONSES
340 -8.8686
P-VALUE
O. 1920
P-VALUE
0.00 18
P-VALUE
0.0072
P-VALUE
0.7905
P-VALUE
0.000 1
P-VALUE
0.000 1
P-VALUE
0.000 1
NUMBER OF PAIRED RESPONSES
339
T-ST ATISTIC
-S. 1849
P-VALUE
0.0296
Appendix E
Exploratory Analysis of Physicians According to: Years of Practice for Q. 1-4 Time (Days) to Orthopaedic Appointment for Q. 3-4
Number of Responses Mean Scores and Standard Deviations P - Values
EXPLORATORY ANALYSIS - YEARS OF PRAC77CE
Q#I (a) history
C 12 years 12 to 25 years > 25 years
C IZ years IZ to 25 years > 25 years
< 12 yems I Z to 25 years > 25 years
e#Z (d) arthrogram
< 12 years 12 to 25 years > 25 yems
NUMBER OF STANDGRD RESPONSES MEAN SCORE DEVIATION
110 1.12 0.48 1 17 1.13 0.58 48 1.17 0.63
P-VALUE = 0.8774
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
110 1-16 0.40 117 120 0.62 48 127 0.7 1
P-VALUE = 0.541 7
NUMBER OF RESPONSES
1 IO Il6 47
NUMBER OF RESPONSES
110 116 46
e#I (e) Magnezic Resonance Imaging
< 12 yens I2 to 25 years > 25 yems
NUMBER OF RESPONSES
110 I l 6 46
MEAN SCORE 5-03 3.35 3 -28
MEAN SCORE 4.47 4.28 3.94
MEAN SCORE 4.48 4.6 1 4.50
STANDARD DEVIATION
1 .O0 0.98 0.95
P-VALUE = 0.0405
STANDARD DEVIATION
0.80 0.9 1 1.16
P-VALUE = 0.0040
STANDARD DEVLATION
0.87 0.63 0.9 1
P-VALUE = 0.4255
< 12 years 12 ro 25 years > 25 years
NUMBER OF RESPONSES
110 Il6 46
Q#I (& Joint Aspiration (Arthrocentesis)
< 12 years 12 ro 25 years > 25 years
NUMBER OF RESPONSES
Il0 116 47
MEAN SCORE 4.56 4.6 1 4 -44
MEAN SCORE 3.74 3.84 3.70
e#I (i) d l investigations depena' on the hisroty & clinical eram
c 12 years 12 to ZS years > 25 years
e#2 (a) mechanisrn of injury
< 12 yems 12 to 25 years > 25 years
NUMBER OF RESPONSES MEAN SCORE
1 03 1.18 1 09 1.23 47 1.32
rYUMBER OF RESPONSES
110 117 48
< 12 years 12 ro 25 years > 25 years
< 12 years 12 ro 25 years > 25 years
NUMBER OF RESPONSES
110 116 47
NUMBER OF RESPONSES
110 Il6 48
MEAN SCORE 1.25 1 -24 1.35
MEAN SCORE i.70 1.77 1.75
MEAN SCORE 1-87 1.87
STANDARD DEVIATION
0.77 0.67 0.89
P-VALUE = 0.4010
STANDARD DEVUTION
1 .O9 1.01 1.18
P-VAJAE = 0.6927
STANDARD DEVIATION
0.57 0.69 0.96
P-VALUE = 0.5038
STANDARD DEVIATION
0.62 0.68 1 .O2
P-VALUE = 0.6266
STANDARD DEVIATION
0.85 0.89 f .O7
P-VALUE = 0.8547
STANDARD DEVIATION
0.87 0.87 1 .O0
P-VALUE = 0.1 171
@Y2 (d) instabiidy or giving way on history
< 12 years 12 to 25 years > 25years
Q#2 (e) age of parient
c 12 yems 12 to 25 years > 25yem.s
< 12 years 12 to 25 years > 25 years
NUMBER OF RESPONSES
1 IO Il6 47
NUMBER OF RESPONSES
110 117 47
NUMBER OF RESPONSES
110 1 I7 48
@Y2 fi) range of motion on acaminafion
< 12 years 12 to 25 Yeats > 25year.s
Q#2 (i) ability ro weight bear
< 12 years 12 &O 25 years > 25 yems
@Y2 Cj) location of tenderness
< 12 yems 12 to 25 years > 25 years
NUMBER OF RESPONSES
110 117 47
NUMSER OF RESPONSES
110 117 47
MEAN SCORE 1 -60 1.66 1-60
MEAN SCORE 2.42 3.44 2.79
MEAN SCORE 1.86 1-73 1.70
MEAN SCORE
STANDARD DEVIATION
0.73 0.78 0.85
P-VALUE = 0.7896
STANDARD DEVIATION
0.90 1 .O3 1 22
P-VALUE = 0.0878
STANDARD DEVIATION
0.67 0.80 1.10
P-VALUE = 0.0209
STANDARD DEVLATION
0.83 0.8 1 0.83
P-VALUE = 0.4058
STANDARD DEVIATION
0.79 0.92 0.85
P-VALUE = 0.7150
NUMBER OF STANRARD RESPONSES MEAN SCORE DEVIATION
110 1.72 0.74 117 1 -99 0.94 47 2.06 1.1 1
P-VALUE = 0.0283
@2 (k) M c M w a y 's test
< Id years 12 ro 25 yems > 25 years
< I Z years 12 to 25 years > 25 years
Q#2 (m) Lnchman test
C 12 years 12 ro 25 years > 25 Jeun
e#t (n) pivot shifi test
< ZZ years I2 to 25 years > 25 yems
NUMBER OF RESPONSES
110 Il7 46
NUMBER OF RESPONSES
110 117 45
NUMBER OF RESPONSES
1 IO 117 45
NUMBER OF RESPONSES
110 117 46
Q#2 (O) collateral ligament testing
< 12 years It to 25 years > 25 years
NUMBER OF RESPONSES
110 Il7 46
@Y2 @) puteth-femoral joint testing
C I2 years 12 to 25 years > 25 years
NUMBER OF RESPONSES
110 117 45
MEAN SCORE 2.45 2.63 2.67
STANDARD DEVIATION
1.1 1 121 1.52
P-VALUE = 0.4159
STANDARD MEAN SCORE DEVlATION
1-96 0.85 2.12 1 .O4 2.24 138
P-VALUE = 0.2 197
MEAN SCORE 1.98 3.29 2.82
MEAN SCORE 2.30 3 2 4 2.67
MEAN SCORE 1.65 1.85 1-98
MEAN SCORE 2.17 2.20 2.40
STANDARD DEVIATION
1.10 1.3 1 1.60
P-VALUE = 0.0012
STANDARD DEVIATION
1.22 1.33 1.52
P-VALUE = 0. 1623
STANDARD DEVIATION
0.69 0.95 1.14
P-VALUE = 0.0695
STANDARD DEVIATION
0.93
@3-GEN (a) diagnose and treat yourselfs and refir as necessary
c 12 years 12 to 25 yems > 35 years
NUMBER OF RESPONSES MEAN SCORE
1 08 1.48 110 1.49 45 1.84
e#3-GEN (b) diagnose yourself: but refer for treatmenr regardess of diagrrosis
C 12 years I2 ro 25 years > 25 years
NUMBER OF RESPONSES MEAN SCORE
108 3.71 1 09 3-75 42 3.55
@3-GEN (c) refer without aktermining a speczjic djagnosis yourself
< 12 years 12 to 25 years > Z j years
NUMBER OF RESPONSES MEAN SCORE
1 08 4-14 1 09 4.06 43 3.79
@3-GEN (d) orthopaedic surgery referral
< 12 years /Z to 25 yeurs > 25years
NUMBER OF RESPONSES MEAN SCORE
1 07 3.36 1 09 3.61 43 2.84
STANDARD DEVLATION
0.84 0.97 1.21
P-VALUE = 0.0764
STANDARD DEVIATION
1.18 1.16 1.40
P-VALUE = 0.6428
STANDARD DEWATION
1 .O2 1.12 1.42
P-VALUE = 0.2332
Q#3-GEN (e) non-surgical referral (sport physician, physotherapy. chiropractor. etc.)
STANDARD DEVLATION
1.1 1 1 .O8 1.33
P-VALUE = 0.00 10
< 12 years 12 ro 25 years > 25 years
m3-GEN s a of patient
c z2yeQrs 12 to 25years > 25 years
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
1 O5 2.39 1.12 1 09 2.37 1.18 44 2.86 1.58
P-VALUE = 0.0605
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
1 07 4.75 0.63 110 4.6 1 0.88 43 4.54 1 .O5
P-VALUE = 0.2704
m3-GEIV fg) Ievel of activzty (Xe. non-athietic vs. recreationai vs. cornpetitive)
C 12 years 22 to 25 years > 25 yeurs
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIAnON
107 2.40 1-10 i l 1 2.80 1.18 44 2.9 1 1.34
P-VALUE = 0.0137
QiW3-GEN fi) ppe of sport returning ta (i. e. chosen sport requim injured sirtichue)
C 12 years 12 to 25 yenrs > 25 yems
NUMBER OF RESPONSES MEAN SCORE
1 06 2-09 11 1 2.4 1 43 2.49
P#3-GEN (i) injured snucture important for occupation?
C 22 years 12 to 25 yeurs > 23 years
Q#3-GEIV 0) time since injwy
< 22 years I2 to 25 years > 25 yems
NUMBER OF IRESPONSES MEAN SCORE
1 06 1.79 110 2.17 43 2.05
NUMBER OF RESPONSES MEAN SCORE
1 06 2.38 110 2.67 44 2.52
Q#3-GEN (k) previously failed h.eutrneru
< 12 years 12 to ZS years > 25 years
NUMBER OF RESPONSES MEAN SCORE
1 06 2.43 107 2.37 44 2.41
STANDARD DEVIATION
0.9 1 1.13 1.32
P-VALUE = 0.0396
STANDARD DEVIATION
0.88 1.16 1.29
P-VALUE = 0.0342
STANDARD DEVIATION
0.9 1 1 .O0 0.95
P-VALUE = 0.0773
S T A N D W DEVIATION
0.94 0.94 1.19
P-VALUE = 0.9048
Q#3-GEN (I) age (pre-physeal clusure, teem. 2045, +45, etc.)
< 1-7 yeurs 12 tu 25 yeurs > 25 years
NUMBER OF RESPONSES MEAN SCORE
1 06 2.3 1 108 2.43 44 2.52
Q#3-GEN (m) patient preleence, men o o u consider nor bat choice
< 12 years 22 to 25 years > 25 years
NUMBER OF RESPONSES MEAN SCORE
1 06 2.75 1 07 2.58 43 2.77 .
e#3-RCL (a) diagnose and treat yowseK and refer us necessary
< ZZyears f 2 to 25 years > 25 yeurs
NUMBER OF RESPONSES MEAN SCORE
106 2.36 110 2.40 43 2.54
Q#3-ACL (b) diagnose yourseK but refer for neumenr regardas of diagnosis
< 12 yems 12 to 25 years > 25 years
NUMBER OF RESPONSES MEAN SCORE
1 07 2.69 1 IO 2.7 8 43 2.95
w3-ACL fc) refer without determining a specific diagnosis yowself
< 12 years 12 to 25 years > 25 years
NUMBER OF RESPONSES MEAN SCORE
108 3.84 110 3.63 42 3.41
@3-ACL (d) orthopaedic surgev refrral
NUMBER OF RESPONSES MEAN SCORE
1 06 1.93 I l l 2.08 46 1.85
STANDARD DEVIATION
0.99 1 .OS 1.17
P-VALUE = 0.4992
STANDARD DEVLATION
1 .os 1.12 1 -3 1
P-VALUE = 0.4863
STANDARD DEVIATION
1 -48 1-58 1.76
P-VALUE = 0.8242
STANDARD DEVIATION
1-48 1.67 1.80
P-VALUE = 0.6671
STANDARD DEVIATION
1.29 1.48 1.59
P-VALUE = 0.2 107
STANDARD DEVlATION
1.17 1-36 1.40
P-VALUE = 0.5262
Q#3-ACL (e) non-swgica2 refrraf (sport physician. p?ysiotherqy, chiropructor, etc.)
< Il years 12 to 25 yems > 25 years
Q#3-ACL fl sex of patient
< I l yems 12 to 25 years > 25 yems
NUMBER OF RESPONSES MEAN SCORE
1 06 2.88 110 3.36 42 3.67
NUMBER OF RESPONSES MEAN SCORE
1 07 4.79 11 1 4.60 43 4.49
@3-ACL (&) levef of activiry (i-e. non-athietic vs. recreutionai vs. cornpetitive)
C 12 years 12 to 25 yems > 25 years
NUMBER OF RESPONSES MEAN SCORE
1 07 2.3 1 112 2.60 43 2.5 1
Q#3-ACL (h) type of sport renrrning to (i. e. chosen sport requires injured smcture)
< 12 years 12 to 25 years > 25 yems
NUMBER OF RESPONSES MEAN SCORE
106 1.94 112 2.29 43 2.19
@3-ACL (i) injured sttuchve important for occupation?
< I l years 12 to 25 years > 25 years
< 12 years 2 2 to 25 yems > 25 years
NUMBER OF RESPONSES
1 O6 111 43
NUMBER OF RESPONSES
1 O6 111 44
STANDARD DEVIATION
1.40 1.34 1.5 1
P-VALUE = 0,0030
STANDARD DEVIATION
0.57 0.89 1 .O8
P-VALUE = 0.0834
STANDARD DEVLATION
1 2 7 1.44 1 S O
P-VAL- = 0.2934
STANDARD DEVIATION
1.10 1.31 1.42
P-VALLE = 0.1240
STANDARD MEAN SCORE DEVIATION
1.79 0.99 2.05 1.23 2.00 1.33
P-VALUE = 0.2335
STANDARD MEAN SCORE DEVIATION
2.35 0.96 2 .42 1.17 2.32 1 .O3
P-VALUE = 0.8 1 18
< 12 years 12 to 25 years > 25 yens
NUMBER OF RESPONSES MEAN SCORE
105 2.34 108 2.2 1 44 2.30
@3-ACL 0 age (pre-physeal ciosure. teens, 20-45. W5, etc.)
< I2 years 12 to 25 years > 25 years
NUMBER OF RESPONSES MEAN SCORE
1 06 2.2 1 1 09 2.28 45 2.64
@3-ACL (in) parient preference, men ifyou consider not best choice
< 22 years 12 to 25 years > 2.5 years
NUMBER OF RESPONSES MEAN SCORE
106 2.69 108 2.58 43 2.70
e#4-GEN (a) unlirn ited activiîy, ra t as necessary
< 12 years 22 to 25 years > 25 years
NUMBER OF RESPONSES MEAN SCORE
1 08 3.3 1 113 3.60 45 3.49
@GEN (b) Iimit activity: cast, brace, splint, cnitch, cane
< l 2 years 12 to 25 years > 25 yens
r n E R OF RESPONSES MEAN SCORE
1 09 2.22 112 2.03 45 1.80
P#&GEN (c) prescribe un erercise yourself
< 12years 12 to 25 years > 25 years
NUMBER OF RESPONSES MEAN SCORE
1 09 3 .O6 113 3 .O8 46 3 -54
STANDARD DEVIATION
1 .O8 1.10 1.34
P-VALUE = 0.7039
STANDARD DEVIATION
1 .O6 1.15 1.33
P-VALUE = 0.0950
STANDARD DEVLATION
1.1 1 1.19 1.32
P-VALUE = 0.7693
STANDARD DEVIATION
1.34 1.46 1.59
P-VALUE = 0.3056
STANDARD DEVIATION
1 .O9 1.16 1 .O 1
P-VALUE = 0.0907
STANDARD DEVLATION
1.34 1.36 1-24
P-VALUE = 0.0927
W - G E N (d) refmal to physiotherapy
C 12 yeurs I t ro 25 years > 25 years
NUMBER OF RESPONSES MEAN SCORE
1 08 2.05 112 1.93 46 1.96
QW-ACL (a) unlimited activiîy, resr as necessary
C I Z years I Z zo 25 yens > 25 years
NUMBER OF RESPONSES MEAN SCORE
1 06 3-86 11 1 4.18 43 4.19
W A C L (b) Iimit acrivizy: cast, brace. splint, crutch. cane
< I2 years I 2 CO 25 years > 25 years
NUMBER OF RESPONSES MEAN SCORE
1 O8 1.75 111 1.68 45 1.64
< 12 years I Z to 25 years > 5 years
NUMBER OF RESPONSES MEAN SCORE
1 08 3.70 11 1 3 -62 43 4.02
QWACL (d) refemai to physiotherapy
C IZ years 12 ro 25 years > 25 yems
NUMBER OF RESPONSES MEAN SCORE
1 07 2.12 111 1.99 44 2.43
STANDARD DEVIATION
0.96 0.9 1 1.23
P-VALUE = 0.6671
STANDARD DEVIATION
1.19 1-21 1.26
P-VALUE = 0.1080
STANDARD DEVIATION
0.99 0.96 f -09
P-VALUE = 0.7875
STANDARD DEVIATION
1.28 1-39 1.23
P-VALUE = 0.2151
STANDARD DEVIATION
1.34 1.19 1-69
P-VALUE = 0.1851
Q#3-GEN (a) diagnose and treat yourself, and refer as necessary
Oro 7ahys 8 ro 13 abys over 1 Cf dqys
NUMBER OF RESPONSES MEAN SCORE
73 1.62 64 1.45 82 1.67
@3-GEN (5) diagnose yowselj: but refer for rrearment regurdless of diagnosis
Oro 7aàys 8 ro 14 abys over 14 &YS
NUMBER OF RESPONSES MEAN SCORE
72 3.75 65 3-69 81 3-72
Q#3-GEN (c) refer wwithour determinhg a specrjk diagnosis yutirself
Oro 7aàys 8 t o 14Aays over 14 days
NUMBER OF RESPONSES MEAN SCORE
72 3.5 1 65 3.99 82 4.34
Q#3-CEN (d) orthopuedic surgery referrai
Oro 7~2izys 8 ro 13 days over 14 days
NUMBER OF RESPONSES MEAN SCORE
72 3 -29 64 3 -44 82 3 -45
STANDARD DEVLATION
1.17 0.85 1.01
P-VALUE = 0.4297
STANDARD DEWATION
1.14 1-30 1 -24
P-VALUE = 0.9620
STANDARD DEVIATION
1.27 1.19 0.86
P-VALUE = 0.0001
STANDARD DEVIATION
1 -24 1.10 1.18
P-VALUE = 0.6615
@3-GEN fe) non-swgical refend (sport physiczan, physiotherapy, chiropractor, etc.)
Oro i&s 8 to 14 dàys over II aàys
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
73 2.22 125 64 2.30 1.18 81 2.83 1.19
P-VALUE = 0.0036
Q#3-GEN @ sex of parient
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
72 4.6 1 0.94 64 4.59 0.85 82 4.7 1 0.7 1
P-VALUE = 0.6655
Q#3-GEN (@ level of activiîy (i.e non-athletic vs. recreatiod vs. cornpetitive)
Oro 7-s 8 tu 14 rlays over 14 ahys
NUIMISER OF STANDARD RESPONSES MEAN SCORE DEVIATION
' 73 2.40 0.97 64 2.50 1.14 82 2.53 1.34
P-VALUE = 0.0572
Q#3-GEIV fi) iype of sport returning to (i. e. chosen sport requires injured structure)
O C O 7&ys 8 to 14 ahys over 14 ahys
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
72 2.36 1 .O5 64 2.02 0.93 81 2.3 1 1.21
P-VALUE = 0.1396
m3-GEN (i) injured smctwe important for occupation?
Oto 7&s 8 to 14 uàys over 14 ahp
Q#J-GEN (j) time since injuv
Oro 7-s 8 to 14 ahys over 14 days
!WMBER OF RESPONSES MEAN SCORE
72 2.22 64 1.77 81 1.96
NUMBER OF RESPONSES MEAN SCORE
73 2.53 64 2.44 81 2.68
STArnARD DEVIATION
1.17 0.77 1.13
P-VALUE = 0.0412
STANDARD DEVIATION
0.85 0.87 1 .O7
P-VALUE = 0.3003
Q#3-GEIV (ü) previously failed treament
020 7days 8 to 24 dqys over 14 days
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVLATION
73 239 0.92 64 2.38 0.8 1 8 O 2.3 8 0.99
P-VALUE = 0.80 17
P#3-GEN 0) age (pre-physeal closwe, teens, 20-45, +45, etc-)
Oro 7&s 8 to 14 days over 14 ahys
W E R OF STAMIARD RESPONSES MEAN SCORE DEVIATION
72 2.35 0.92 64 2.27 0.88 80 2.28 1-10
P-VALUE = 0.8631
Q#3-GEIV (m) patient prefirence, men ifyou consider not best choice
Oto 7days 820 I l + over 14 akgs
NUMBER OF STANDARD RESPONSES MEAN SCORE DEMATION
72 2.43 1 .O5 64 2.56 1.11 80 2.79 1.17
P-VALUE = 0.1360
Q#3-ACL (a) diagnose and rreat purself; and refer as necessary
O f 0 7&s 8 to 14 d q s over 14 ahys
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
73 2.18 1.45 65 2.60 1.68 8 1 2.37 1.43
P-VALUE =: 0.2638
Q#3-ACL 0 diagnose yourseK but refer for treatmenl regmdIess of diugnosis
020 7days 8 ro 14 dcrys over 14 days
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
72 2.78 1.71 66 2.65 1.60 82 2.94 1.61
P-VALUE = 0.5656
m3-ACL (c) rejér withour derermining a specrfic diagnosis yourseif
NUMBER OF RESPONSES MEAN SCORE
72 3 -35 66 3 -52 8 1 4.03
@3-ACL (d) orthopaedic surgery refrral
Oro T&s 8 ro Id akys over 14 akys
NUMBER OF RESPONSES MEAN SCORE
73 2.03 65 1 -94 81 2.14 .
STANDARD DEVIATION
1.49 1-40 1.38
P-VALUE = 0.0024
QM-ACL (e) non-surgical r e f e d (sport physician. phyriotherap, chiropractor, etc.)
STANDARD DEVIATION
1-26 1-30 1.39
P-VALUE = 0.6793
O to 7 d q s 8 to II abys over 14 days
Q#3-ACL 0 s a of patient
ut0 7days 8to 14abys over I4 akys
NUMBER OF STANDARD IZESPONSES MEAN SCOlRE DEVIATION
72 3 -28 1.35 65 3.19 1.44 80 3.18 1.51
P-VALUE = 0.8920
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
72 4.64 0.9 1 65 4.68 0.75 82 4.71 0.73
P-VALUE = 0.8688
@3-ACL (a level of activiîy (i.e. non-athletic vs. recreational vs. cornpetifive)
Oto 7 d q s 8 ro I # @ s over 14 &s
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
72 2.24 1.13 65 2.37 1.42 82 2.70 1.5 1
P-VALUE = 0.1025
@#3-ACL fi) vpe of sport reruming to (i. e. chosen sport requires injured structure)
O f 0 7days 8to 1 4 % ~ over 14 Aays
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
72 2.26 1.16 65 1.91 1.17 8 1 2.27 1.40
P-VALUE = 0.1557
@3-ACL 0) injured smcture important for occupation?
oto 77days 8 to 14 afqs over 14 days
O to 7 days 8 to I d h y s over 14 Aays
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
72 2.25 1 -24 65 1.66 0.76 81 2.1 1 1.34
P-VALUE = 0.0095
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
73 2.38 0.98 65 2.00 0.87 81 2.84 1.16
P-VALfiX = 0.0001
@3-ACL (k) previousiy failed treaimenr
Oto 7&ys 8 to 14 aàys over 14 ahys
NUMBER OF RESPONSES MEAN SCORE
73 2.33 65 3.06 80 2.36
@#3-ACL (I) age (pre-physeal closure, teem, 20-45, +4 j , etc.)
Oro 7ahys 8 to 14 chys over 14 a2zys
NUMBER OF RESPONSES MEAN SCORE
73 2.4 1 65 2.12 80 2.3 1
STANDARD DEVIATION
1 .O8 0.92 1.23
P-VALUE = 0.2103
STANDARD DEVIATION
1.10 0.98 1.23
P-VALUE = 0.31 18
W3-ACL (m) patient preference, men ifyou consider not best choice
O f 0 7&s 8 to 13 /lavs over 14 aàys
NLl-hIBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
72 2.43 1.1 1 65 2.54 1.16 80 2.80 1.24
P-VALUE = 0.1375
O ~ O r ~ a y s 8ro 14uhys over II dqs
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
73 3 -64 1 -40 65 3.43 1-41 81 321 1.41
P-VALUE = O. 1634
NIMBER OF RESPONSES MËAN SCORE
Oro 7 W s 72 1.81 8to 14uhys 65 2.28 over 14 dàys 82 220
W G E N (c) prescribe an exercice yourseif
Oro 7days 8 to 14 ahys over 13 days
NUMBER OF RESPONSES MEAN SCORE
73 3 .26 65 3 -02 82 3.10
W G E N (d) r e M d to physiothempy
Oto 7ahys 8to 14ahys over 14 &s
NUMBER OF RESPONSES MEAN SCORE
73 2.00 64 1.88 82 1.95
STANDARD DEVIATION
0.96 1.17 1 .O2
P-VALUE = 0.0179
STANDARD DEVIATION
1.25 1.23 1-27
P-VALUE = 0.5005
STANDARD DEVIATION
1-01 0.97 0.82
P-VALUE = 0.7332
W A C L (a) unlimited actîvity, r a t as necessq
O to 7 days 8 ro 14 &ys over 14 &ys
NUMBER OF RESPONSES MEAN SCORE
71 4.1 1 64 3 -95 80 3 -90
@M-ACL (3) limir activiry: cm, brace. spliw, crutch, cane
Oro 7Aays 8 to 14 abys over 14 dqys
NUMBER OF RESPONSES MEAN SCORE
72 1-50 65 1.71 81 1.79
QiWACL. (c) prescribe an exercke yourself
O to 7 days 8 to I i l dqs over 14 days
NUMBER OF RESPONSES MEAN SCORE
7 1 3 -65 65 3.80 8 1 3.64
W A C L (d) referral ro physiotherapy
O ro 7 days 8 to 14 *s over 14 days
NUMBER OF RESPONSES MEAN SCORE
72 2.13 64 2.14 8 1 2.1 1
STANDARD DEVIATION
1 -26 1.17 1.22
P-VALUE = 0.5468
STANDARD DEVIATION
0.89 1 .Of 0.90
P-VALUE = 0.1488
STANDARD DEVIATION
1.28 1.16 1.31
P-VALUE = 0.7060
STANDARD DEVIATION
1.26 1.37 1.37
P-VALUE = 0.9913
Appendix F
- Breakdown of Physicians According to Musculoskeletal Background
- Number of Responses - Mean Scores & Standard Deviations
1. Electives + CME 2. Related Training 3. Sports Fellowship
hvsicians A c c o r w Muscu Breakdown o f P loskeletal Back~round
Ouestion # 2 : Using the scde described above, how important are each of the following elements of the history and physical exam in your diagnosis and management of the acutety injured knee?
hisloiy : ('a) rnechunism of injury
ElectNes -i any C'ME Related training Sports fellowship
NUMBER OF MEAN SCORE STANDARD RESPONSES DEVIATION
3 13 1 246 0.72 1 19 1 .42 1 1.017 6 1.167 0.408
(b) locked or stlf knee on histos,
NUMBER OF MEAN SCORE STANDARD RESPONSES DEVIATION
Elecrives + any C E 311 1 -704 0.903 Related training 19 1.789 0.976 Sports fellowship 6 1.333 0.816
NUMBER OF MEAN SCORE STANDARD RESPONSES DEVIATION
Electives + any C m 3 12 1.910 0.870 Reluted training 19 1.947 0.848 Sports fello wship 6 1.500 0.548
(4 imrab ility or giwing way on histoty
Electives + any CME Related rraining Sports jëiiowship
(e) age of patient
Electives + any CME Related iraining Sports jëllowship
NUMBER OF MEAN SCORE STANDARD RESPONSES DEVIATION
31 1 1.650 0 -764 19 1.632 1 .O12 6 1.333 0.5 16
NUMBER OF MEAN SCORE STANDARD RESPONSES DEVIATION
3 12 2.429 O -949 19 2.789 1 .O32 6 2.833 0.753
physkai d a r i o n : (g) e m z o n on examinution
NUMBER OF RESPONSES
Electives +- uny CME 3 13 Relared training 19 Sports felrowship 6
01) range of motion on eraminarion
Electives + any CME Related training Sports fellowship
( I ) ability to weigitt bear
Electives + any CME Related training Sports fellowship
0) location of tenderness
Electives + any C m Related iraining Sports fellowship
fi) McMu~ray 's test
Electives + any CME Related training S p o ~ s fellowship
(2) d m e r test
Electives + any CME Related iruining Sports fello wship
NUMBER OF RESPONSES
3 12 19 6
NUMBER OF RESPONSES
3 12 19 6
NUMBER OF RESPONSES
3 12 19 6
NUMBER OF RESPONSES
311 19 6
NUMBER OF RESPONSES
310 19 6
MEAN SCORE
MEAN SCORE
MEAK SCORE
MEAN SCORE
MEAN SCORE
MEAN SCORE
STANDARD DEVIATION
0.809 0.872 0.516
STANDARD DEVLATION
0.833 0.895 0.8 16
STANDARD DEVIATION
0.866 0.96 1 0.516
STANDARD DEVIATION
0.913 0.787 0.894
STANDARD DEVIATION
1.227 1.134 1 .O95
STANDARD DEVIATION
I .O05 1 .O49 1 .O49
(m) Lachman test
Electives + any CME Relared training Sports felowship
fn) pivot sh@ test
NUMBER OF MEAN SCORE STANDARD RESPONSES DEVIATION
3 10 2.194 1378 19 2.316 1.250 6 1.500 0.548
NUMBER OF RESPONSES
Electiues + any C'ME 3 11 Related training 19 Sports fellowship 6
(O) collarerat ligamenr testing
NUMBER OF RESPONSES
Electives + any CME 311 Related training 19 Sports fellowship 6
(p) patellefemoral joim testing
NUMIBER OF RESPONSES
Electives + any CM€ 2 10 Related training 19 Sports fellowship 6
MEAN SCORE
MEAN SCORE
MEAN SCORE:
STANDARD DEVIATION
1.406 1 .O7 1 1.21 1
STANDARD DEVIATION
0.882 0.855 0.548
STANDARD DEVIATION
0.984 0.875 0.632
Appendix G
Exploratory Analysis Courses Conferences Journals
- Number of Responses - Mean Scores & Standard Deviations - P - Values
EXPLORATORY ANALYSE - COURSES
Q#2 (a) rnechanism of injury
cowses - Yes Courses - No
-ER OF RESPONSES
161 188
e#l (b) Iocked or srrflknee on history
NUMBER OF RESPONSES
Cowses - Yes 159 Courses - No 188
@2 (c) sweiling on hisrov
Courses - Yes Courses - No
NUMBER OF RESPONSES
160 188
Q#2 (d) instabilig or giving wqv on history
Courses - Yes Courses - No
@2 (e) age ofpatient
Cow~es - Yes Courses - No
NUMBER OF RESPONSES
159 188
STANDARD MEAN SCORE DEVIATION
1.29 0.79 1.24 0.67
P-VALUE = 0.5549
STANDARD MEAN SCORE DEVIATION
1.57 0.88 1.81 0.9 2
P-VALUE = 0.0105
STANDARD MEAN SCORE DEVLATION
1.93 0.90 1.90 0.85
P-VALUE = 0.8252
STANDARD MEAN SCORE DEVIATXON
1 .S5 0.72 1-70 0.8 1
P-VALIIE = 0.0726
NUMBER OF STGNDARD RESPONSES MEAN SCORE DEVIATION
160 2.56 1 .O3 188 2.36 0.96
P-VALUE = 0.0608
courses - Yes courses - No
NUMBER OF STANDARD RESPOMES MEAN SCORE DEVUTION
161 1.60 0.82 188 1-46 0.80
P-VALUE = 0.0945
Q#2 (h) range of motion on mamination
Courses - Yes Courses - No
Q#2 (0 abiiiry to weight beur
Courses - Yes Courses - No
@?O) location of tenderness
Courses - YRS Courses - No
@2 (k) M c M m a y 's test
Courses - Yes C0urs.e~ - No
Courses - Yes Courses - No
NUMBER OF RESPONSES
160 188
NUMBER OF RESPONSES
160 188
STANDARD MEAN SCORE DEVlATION
1.75 0.76 1-76 0.88
P-VALUE = 0.9052
STANDARD MEAN SCORE DEVLATION
1.72 0.86 1.81 0.88
P-VALUE = 0.3377
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
160 1 -84 0.87 188 1.95 0.93
P-VALUE = 0.2666
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
159 2.28 1 .O7 188 2.76 128
P-VALUE = 0.0003
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
158 2.03 0 -94 188 2.1 I 1 .O6
P-VALUE = 0.492 l
@Y2 (in) Luchman test
Cowses - Yes Courses - No
Q#2 (n) pivot shtj? test
Courses - Yes cowses - fV0
NüMBER OF STANDARD RESPONSES MEAN SCORE DEVLATION
158 2.30 1.30 188 2.12 135
P-VALUE = 0.2040
NUMBER OF RESPONSES
159 188
@2 (O) collateral ligament testing
cowses - Yes Courses - No
NUMBER OF RESPONSES
159 188
Q#2 @) patelfa-fernoral joint testing
Courses - Yes Courses - No
NUMBER OF RESPONSES
158 188
STANDARD MEAN SCORE DEVIATION
2.79 1.40 2.14 1.30
P-VALUE = 0.0001
STANDARD MEAN SCORE DEVIATION
1.69 0.76 1.85 0.95
P-VALUE = 0.0906
STANDARD MEAN SCORE DEMATION
1.99 0.79 2.33 1.10
P-VALUE = 0.0015
Conferences - Yes Conferences - No
NUMBER OF RESPONSES
Il5 234
@2 0) locked or stzrknee on history
Conferences - Yes Conferences - No
Q#2 (c) swelling on histoy
Conferences - Yes Conferences - No
NliMBER OF RESPONSES
114 233
NUMBER OF RESPONSES
114 234
STANDARD MEAN SCORE DEVIATION
1.25 0.80 i .26 0.69
P-VALUE = 0.8780
STANDARD MEAN SCORE DEVFATION
1.61 0.89 1.75 0.9 1
P-VALUE = O. 1697
STANDARD MEAN SCORE DEVIATION
1.75 0.84 1.99 0.88
P-VALUE = 0.0 I7O
e#2 (d) instabiiiry or giving way on history
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVLATION
Conferences - Yes 114 1.58 0.80 Conferences - No 233 1.66 0.75
P-VALUE = 0.3515
e#2 (e) age of patient
Confeences - Yes Conferences - No
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
115 2.50 0.94 233 2.43 1 .O2
P-VALUE = 0.5087
NCTMBER OF RESPONSES
Conferences - Yes 115 Conferences - No 234
Q#2 fi) range ofmotion on examination
NUMBER OF RESPONSES
Conferences- Yes 1 15 Conferences - No 233
Q#2 (i) abilis, to weight bear
Conferences - Yar Conferences - No
Q#2 0) location of tendemess
Conferences - Yes Conferences - No
e#t (k) McMwray S test
NUMBER OF RESPONSES
115 233
NUMBER OF RIESPONSES
Il5 23 3
NUMBER OF RESPONSES
Conferences - Yes 115 Conferences- No 232
STANDARD MEAN SCORE DEVIATION
1.48 0.86 1-55 O -78
P-VALUE = 0.4556
STANDARD MEAN SCORE DEVIATION
1.78 0.90 1.74 0.79
P-VALUE = 0.6716
STANDARD MEAN SCORE DEVIATION
1.70 0.87 1.80 0.87
P-VALUE = 0.3437
MEAN SCORE 1.93 1.89
MEAN SCORE 2.48 2.57
STANDARD DEVLATION
1 .O4 0.83
P-VALUE = 0.6845
STANDARD DEVIATION
1.25 1 -20
P-VALUE = 0.5133
P#2 (I) drawer test
Conferences - Yes Conferences - No
@2 (m) Luchman test
Confetences - Yes Conferences - No
Q#2 (n) pivot shifi test
Conferences - Yes Conferences- No
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVLATION
115 2.10 1 .O8 23 1 2-06 0.97
P-VALUE = 0.7607
NUMBER OF RESPONSES
1 I5 23 1
NUMBER OF RESPONSES
I l5 232
STANDARD MEAN SCORE DEVIATION
2.30 1.40 2.15 . 1.2 1
P-VALUE = 0.2947
STANDARD MEAN SCORE DEVIATION
2.45 1.39 2.43 1.38
P-VALUE = 0.8937
Q#2 (O) collaterd ligament testing
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
Conferences - Yes Il5 1.75 0.96 Conferences - N o 232 1-79 0.83
P-VALUE = 0.6501
Conferences - Yes Conferences - No
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
115 2.17 1.03 22 1 2.18 0.96
P-VALUE = 0.8828
EXPLORATORY ANALYSE - JOURNAU
@2 (a) mechaniSm of injury
NUMBER OF RESPONSES
157 192
@Y2 (c) swelling on history
Jownals - Yes JOWM~S - No
NUMBER OF RESPONSES
156 191
NUMBER OF FtESPONSES
156 192
@2 (d) insrabilip or giving wrs) on hutory
Q#2 (e) age ofpatient
MEAN SCORE 1-28 1 2 4
MEAN SCORE 1.65 1.74
MEAN SCORE 1.90 1.92
STANDARD DEVIATION
0.74 0.72
P-VALUE = 0.6521
STANDARD DEVIATION
0.85 0.94
P-VALUE = 0,3863
STANDARD DEVIATION
0.90 0.85
P-VALUE = 0.848 1
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
156 1.58 0.7 1 191 1-68 0.8 1
P-VALUE = 0.21 18
lMTMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
157 2.49 1 .O0 191 2.42 0.99
P-VALUE = 0.5370
@2 (g) e m i o n on examination
NlfMBER OF RESPONSES
Journuts - Yes 157 Journnls - hi0 192
Q#2 fi) range ofmotion on examinarion
JournaLs - Yes JOWM~S - No
Qü2 (i) abilip to weight bear
Jownuls - Yes
NUMBER OF RESPONSES
157 191
NUMBER OF RESPONSES
157 191
NUMBER OF RESPONSES
157 Journals - No 19 1
Q#2 (k) M c M w r q ~ 's test
J o d s - Yes Journals - No
NUMBER OF RESPONSES
157 I9O
MEAN SCORE 1.56 1.49
MEAN SCORE 1.75 1.76
MEAN SCORE 1.66 1.85
MEAN SCORE 1.92 1.88
MEAN SCORE 2.52 2.56
STANDARD DEWATION
0.80 0.8 1
P-VALUE = 0.4504
STANDARD DEVIATION
0.88 0.78
P-VALUE = 0.9326
STANDARD DEVIATION
0.84 0.89
P-VALUE = 0.0412
STANDARD DEVIATION
0.98 0.84
P-VALUE = 0.6919
STANDARD DEVIATION
1.25 1.19
P-VALUE = 0.7491
Q#r (I) &mer test
Journals - Yes Jownals - No
NUMBER OF STANDARD RESPONSES MEAN SCORE DEVIATION
157 2.15 1.10 189 2.0 1 0.92
P-VALUE = 0.2114
Q#2 (m) Lachman test
Q#r (n) pivot sh~j? test
Journals - Yes Journals - hi0
NUMBER OF RESPONSES
157 189
NUMBER OF RESPONSES
157 190
@2 (o) colheruf ligament resting
NUMBER OF RESPONSES
157 190
@2 @) patello-fmoral joint testing
NUMBER OF RESPONSES
157 189
STANDARD MEAN SCORE DEVIATION
2.33 1.32 2. IO 1.23
P-VALUE = 0.0868
STANDARD MEAN SCORE DEVIATION
2 -46 1.37 2.42 1.40
P-VALUE = 0.80 19
STANDARD MEAN SCORE DEVIATION
1.81 0.97 1.75 0.79
P-VALUE = 0.5509
STANDARD MEAN SCORE DEViATION
2-17 1 .O8 2.18 0.90
P-VALUE = 0.9407
Appendix H
- Comparing Physicians with Access to MRI to those Without - Number of Responses - Means Scores and Standard Deviations - P - Values
2 17
Corn~aring the Availability of MRI to the Investigation of the Acnte Knee Iniurv
Question 1 # of Responses Pvalues Mean Score Standard Deviation
a) history YES 115 0.4004 1.16 0.72 NO 233 1.10 0.45
b) clinical YES 115 0,8760 1.19 0.67 NO 233 1.18 0.49
c) x-ray E S 113 0.659 1 3 -23 1 .O5 NO 232 3.18 1 .O0
d) arthrogram YES 114 0.4826 4.3 6 0.98 NO 23 1 4.29 0.88
e ) YES 114 0.2647 4.49 0.88 NO 23 1 4.59 0.70
f) CT Scan YES 114 0.3860 4.52 0.86 NO 23 1 4.60 0.65
g) Aspiration YES 114 0.33 1 1 3-85 0.99 NO 232 3.74 1.09
- YES - indicates that the physician had access to MRI - NO - indicates that the physician did not have access to MRI
Appendix 1
- Sample Size Calculations
Sample Sue Calculations
(i) Estimation of ~opuiatioo mean scores:
Formula Used : n = z2 d / B'
Z = the percentile of the nomal distribution corresponding to the desired level of confidence
a = the standard deviation of each variable's responses B = the error bound or desired precision of the estimate
Values Used : Z = 1.96 (95% confidence) o = 2 (conservative estimate) B = 0.25 (desired precision)
Sample Size Required : n = 246
Adapted from Mendenhail et al (1 990).
for equaliîy of mean scores in Questions 3 & 4 between GEN & ACL:
Z, - the percentile of the normal distxibution corresponding to the desired level of significance a
Zp = the percentile of the normal distribution corresponding to the desired power of the test 1 -p
o = the standard deviation of the differences d = the minimum difference to be detected
Values Used : Z, = 2.96 (overallS% level of significance) Zg = 1.28 (90% power) o = 2 (conservative estimate) d = 0.5 (minimum difference)
Sample Size Required : n = 288
Adapted fkom Lachin (1 98 1 ).
Appendix J
Figure 5 - Figure 6 - Figure 7 - Figure 8 - Figure 9 - Figure 10 - Figure 11 - Figure 12 - Figure 13 - Figure 14 - Figure 15 -
Gender Distribution Orthopaedic Refemal Choices Imaging Resources in Community Personnel Resources in Community Musculoskeletal Background - CME Acute Knee Injuries Seen Annually Acute ACL Injuries Diagnosed Annually Practice Type Age Distribution Years of Practice Time (days) to Appointment
Figure 5 - Gender Distribution
MALES FEMALES
F b r e 6 - Oithopaedic Refeml Choices
ARTHROSCOPY AVAILABLE
ACL RECONSTRUCTION
AVAILABLE
. YES I NO
Figure 7 - lmaging Resources Available In Community
X-RAY MRI CT OTHER
Figure 8 - Personnel Resources Available In Community
ORTHO. GENERAL PMSIO. CHIRO.
Figure 9 - Musculorkeletal Background - CME
COURSES CONFERENCES JOURNALS OTHER
under 40 40 to 55 over 55
under 12 12 to 25 over 25
Fipre l5 - Tirne (Days) To Appointment
O ta 7days 8 to 14 days aver 14 days
IMAGE EVALUATION TEST TARGET (QA-3)
APPLIED - IMAGE. lnc = 1653 East Main Street - -. - Rochester. NY 14609 USA -- -- Phone: 71 6i482-0300 -- -- - - Fax: 716/288-5989
O 1993. Applied Image. inc.. Ali Rghts ReseFied
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