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

National Library I * m of Canada Bibliothèque nationale du Canada

Acquisitions and Acquisitions et Bibliographic Services services bibliographiques

395 Wellington Street 395. rue Wellington OttawaON K1AON4 OttawaON K1AON4 Canada Canada

The author has granted a non- exclusive licence allowing the National Library of Canada to reproduce, loan, distribute or seil copies of this thesis in microform, paper or electronic formats.

The author retains ownership of the copyright in this thesis. Neither the thesis nor substantial extracts from it may be printed or othemise reproduced without the author's permission.

Y w r Me Voire refërmw

Our Ne Noire refdrence

L'auteur a accordé une licence non exclusive permettant à la Bibliothèque nationale du Canada de reproduire, prêter, distribuer ou vendre des copies de cette thèse sous la forme de microfiche/film, de reproduction sur papier ou sur format électronique.

L'auteur conserve la propriété du droit d'auteur qui protège cette thèse. Ni la thèse ni des extraits substantiels de celle-ci ne doivent être imprimés ou autrement reproduits sans son autorisation.

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.

REFERENCES

Baker, C. L. (1 992). Acute hemarthrosis of the knee [Review]. Journal of the Medical Association of Georeia 8 1 (6), 3 10-305.

Bendetto, K. P., Spemer, G., & Glotzer, W. (1990). Der Kniegelenkhamarthrosis-differenbddianostische Ulberlegungen zur Planung einer Operation [Knee joint hemarthrosis differential diagnostic considerations for planning an operation]. Orthopade. 19(2), 69-76. (From Medline: UWO database, 1996, Abstract No. 90295264)

Bergfeld, J. A., (1 997, January). Knee: Functional ana tom^ for the Team Phvsician. Presented at the meeting of the American Coliege of Sports Medicine, Jacksonville, Florida.

Bergfeld, J. A., (1 997, January). Knee: Intemal Derangement - Team Phvsicians Course. Presented at the meeting of the American College of Sports Medicine, Jacksonville, Florida.

Bomberg, B. C., & McGinty, J.B. (1990). Acute hemarthrosis of the knee: indications for diagnostic arthroscopy. Arthroscopv. 6(3), 22 1 -225.

Bondeville, J. M., Cordoliani, Y. S., & Hamze, B. (1993). Les ligaments du genou [Ligaments of the knee]. Annales de Radiologie. 3 6(3), 207-2 14. (From Medline: UWO database, 1997, Abstract No. 9405801 1)

Corea, J. R., Moussa, M., al Othman, A. (1994). McMurry's test tested. Knee Surgery. Sports Traumatolow. Arthroscop~. 2(2), 70-72. (From Medline: UWO database, 1997, Abstract No. 96052584)

Craft, M. J., Heick, M., Richards, B., Murray, J., Lathrop, N., & Reed, S. (1992). Program characteristics influencing nurse selection of CE offerings. J o d of Continuine Education in Nursine. 23(6), 245-252.

Dehaven, K. E. (1 980). Diagnosis of acute knee injuries with hemarthosis. American Journal of S~orts Medicine. 8X1), 9-14.

Del Greco, L., & Walop, W. (1987). Questionnaire development: 1. Formulation. Canadian Medical Association Journal. 1 3 6,583-5 85,

Del Greco, L., Walop, W., & McCarthy, R. H. (1 987). Questionnaire development: 2. Validity and reliability. Canadian Medical Association Joumai. 136, 699-700

Del Greco, L., Walop, W., & Eamidge, L. (1987). Questionnaire development: 3. Translation. Canadian Medical Association Journal. 1 36,8 1 7-8 1 8.

Del Greco, L., Walop, W., Eastridge. L., Marchand, B., & Szen~eri , K. (1987). Questionnaire development: 4. Preparation for d y s i s . Canadian Medical Associaton Journal. 136,927-928.

Del Greco, L., & Walop, W. (1987). Questionnaire development: 5. The Pretest. Canadian Medical Association JowaI. 136,1025- 1026.

Fowler, P. J., & Regan, W. D. (1987). The patient with symptomatic chronic anterior cmciate ligament insufficiency. Resdts of minimal arthroscopie surgery and rehabilitation. The American Journal of Sports Medicine. 1 5(4), 32 1 -325.

Glazier, R.H., Dalby, D.M., Badley, E.M., Hawker, G.A., Bell, M.J., & Buchbinder, R. (1996). Deteminans of physician confidence in the primary care management of rnuskuloskeleîal disorders. Journal of Rheumatolorrv. 23,3 5 1-3 56.

Gleb, H. J., Glasgow S. G., Sapega, A. A., & Torg, J. S. (1996). Magnetic resonance imaging of knee disorders. Clin id value and costeffectivness in a sports medicine practice. American Journal of Sports Medicine. 24(1), 99- 1 03.

Godwin, M., Chapman, J., Mowat, D., Racz, W., McBride, J., & Tang, J. (1996). Delisting of drugs in Ontario. How attitudes and prescnbing strategies of family physicians in the Kingston area changed. Canadian Familv Medicine. 42, 1309- 13 16.

Guyatt, G. H., Bombardier, C., & Tugwell, P. X. (1 986). Measuring disease- specific quality of life in chical trials. Canadian Medical Association Journal. 1 34,889- 894.

Hoher, J., Munster, A., Klein, J., Eypasch, E., & Tiling, T. (1995). Validation and application of a subjective knee questionnaire. Knee Sureerv. S ~ o r t s Traumatolow~ Arthroscopv. 3(1), 26-33.

Iovane. A., Midiri, M., Lo Casto, A., De Maria, M., Babiera, F., Mercurio, G., & Lagalla, R. (1 995). Biomeccaaica e semeiotica delle lesioni traumatiche del legamento crociato potenore con Risonanza Magnetica [Biomechanics and semeiotics of traumatic lesions of the posterior cmciate ligament using magnetic resooance]. Radiologia Medica, e4(6), 707-7 14. (From Medline: UWO database, 1996, Abstract No. 96296685)

Johannsen, H. V., & Fruensgaard, S. (1988). Arhroscopy in the diagnosis of the h e e joint. International Ortho~aedics. l2(4), 283- 286. (From Medline: UWO database, 1 996, Abstract No. 89 1 223 69)

Johnson, D. L., & Warner, J. J. (1 993). Diagnosis for anterior cruciate ligament surgery. [Review]. Clinics in Sport Medicine. 12(4), 67 1684.

Kang, B., Du, J. Y., Luo, H. C., & Huang, J. H. (1 994). Sonographic diagnosis of the knee effusion. Joumal of Toni i Medical Universi@. 14(2), 1 05- 1 09. (From Medline: UWO database, 1997, Abstract No. 95055943)

Konig, H., Andresen, R, Radmer, S., Schmidt, M., & Wolf, K. J. (1995). Die konventionell Arthrographie im Vergleich ni Magnetresonanztomographie und Arthroskopie bei Kniegelenkbinnedasionen: Verbleiben Indikationen? [Conventional arthrography in cornparison with magnetic resonance tomography and arthroscopy in interna1 knee joint injuries: are there specific indications?]. Aktuelle Radiologie. 5 (2), 97- 100. (From Medline: W O database, 1997, Abstract No. 95275939)

Kim, S. J., & Kim, H. K. (1995). Reliability of the anterior drawer test, the pivot shift test and the Lachman test. Clinicai Orthooaedics & Related ResearchX3 1 7), 23 7- 242. (From Medline: UWO database, 1997, Abstract No. 9540 1 464)

Kirsch, M. D., Fitzgerald, S. W., Friedman, H., & Rogers, L. F. (1993). Transient lateral patellar dislocation: diagnosis with MR imaging. American Journal of Roentgenoloq. 1 6 1 (1), 109- 1 1 3. (Fonn Medline: UWO database, 1997, Abstract No. 9229745 8)

Kul- T., & Noiklang, P. (1 993). Arthrography and arthrotomy of the knee in sports injuries. British J o d of Sports Medicine. 27(2), 87-89.

Lachin, J. M., (198 1). Introduction to sample size detemination and power analysis for clinical trials. Controlled Clinical TnaIs-Design & Methods. 2,(2), 93- 1 13.

Lipacmon, J. D. (1994). MRI's role in evaiuating knee anatomy and injuries. Radiolomc Technolow. 66(2), 9 1 - 1 03.

M a i , N., Binfield, P. M., King, J. B., & Good, C. J. (1993). Acute haemarthrosis of the knee in athietes. A prospective midy of 106 cases. Journal of Bone and Joint Sur- - British Volume. 75(6), 945-949.

McGuire, D. A., & Grinstead, G. L. (1990). Advaxes in anterior cruciate ligament surgery . Alaska Medicine. 32(3), 10 1 - 105.

Mendelsohn, C. L., & Paiement, G. D. (1996). Physcial examination of the knee. Primary Care: Clinics in Office Practice. 23(2), 32 1-328.

Mendenhall, W., Wackerly, D. D., & ScheafTer, R. L. (1990). Mathematical Statistics With Aoolication (4 editionl PSW-KENT, Boston.

Miller, M. D., Ritchie J. R., Gomez, B. A., Royster, R. M., & DeLee, J. C. (1 995). Meniscal repair. An experimental study in the goat. American Journal of S~orts Medicine. 23(1), 124- 128.

Mïrza, F., Mai, D., & Kirkley, A. (1995). [The National Knee Injury Survey.] Unpublished raw data.

Moonen, C. T., van Zijl, P. C., Frank, J. A., Le Bihan, D., & Becker, E. D. (1 990). Functional magnetic resonance imaging in medicine and physiology. Science, 250(4977), 53-6 1. -

Neumann, A., Schiller K., Witf S., Beîz, A., Kruëger, P., & Schweiberer, L. (1 99 1). Der Kniegelenkshamarthros. Absolute Indkation nir ûperation? [Knee joint hemarthrosis. An absolute indication for operation?]. Unfallchirurrr. 94(11), 560-564. (From Medline: UWO database, 1996, Abstract No. 92124189)

Neumann, R. D. (1992). Traumatic knee injuries. [Review]. Primarv Care Clinics in Office Practice. l9(2), 35 1-376. (From Medline: UWO database, 1997, Abstract No. 92302339)

Nielson, A. B., & Yde, J. (1991). Epidemiology of acute knee injuries. A prospective hospital investigation. Journal of Tramuatolo W . 1 3, 1 644- 1 648.

Noyes, F. R., Bassest, R. W., Grood, E. S., & Butler, D. L. (1 980). Arthroscopy in acute traumatic haemarthrosis of the knee. The Journal of Bone and Joint Sur~erv, 62(5), 687-695. -

Orlander, J. D., & Callahan, C. M. (1 99 1). Fellowship training in acadernic general internal medicine: a curriculum survey. Journal of General Intemal Medicine, 6(5), 460-465. -

Reker, D. M., Fletcher, J. W., Tantana, S., Mahanta, B., Vas, W., & Yoo, R. (1990). Observer reliability in CT and MRI of the abdomen and pelvis. Mametic Resonance Imaeina(5) , 577-582.

Rothenberg, M. H., & Graf, B. K. (1993). Evaluation of acute knee injuries. [Review]. Postm-aduate Medicine. 93(3), 7582,8586. (From Medline: UWO database, 1996, Abstract No. 93 189485)

Rubinstein, R. A. Jr., Shelboume, K. D., McCanoil, J.R., VanMeter, C. D., & Retting, A. C. (1994). The accmcy of the clinical examination in the setting of posterior cruciate ligament injuries. Amencan Journal of Smrts Medicine. 22(4), 550- 557.

Sahn, A., & Slastry, W. (1985). A non-mathematical euide., chpts, 2-5, Statistics Canada.

Sena B. L., & Scott, B. E. (1990). Factors that inDuence residency applicants in the seiection of a specinc program. American Journal of H o s ~ i d Pharmacv. 47(5), 1094-1096. (From Medline: UWO daîabase, 1997, Abstract No. 90247397)

Shirakura, K., Terauchi, M., Kizuki, S., Moro, S., & Kimura, M. (1995). The nahual history of unûeated anterior mciate tears in recreational athletes. Journal of C h i c d ûrtho~aedics (3 1% 227-236.

Simmons, Je, & Gardiner, CC. (Eds.). (1996). Canadian Medicai Directory. Don Mills: Southham Magazine and Information Group.

Smith, B. W., & Green, G. A. (1995). Acute knee injuries: Part 1. History and physical examination. American Familv Phvsician. 5 1 (3), 6 15-62 1.

Smith, L. F e , & Reynolds, J. L. (1995). Factors associated with the decision of family physicians to provide inttapartum care. Canadian Medicd Association Journal, 152(1 l), 1789-1 797. -

Stiell, 1. G., Wells, G. A., McDowell, I., Greenberg, G. H., McKnight, R. D., & Cwinn, A. A. (1 995). Use of radiography in acute loiee injuries: need for clinical decision d e s . Academic Emereency Medicine. 2(1 l), 966-973.

Stiell, 1. G., Greenberg, G. H., Wells, G. A., McDowell, I., Cwinn, A. A., & Smith, N. A. (1996). Prospective validation of a decision d e for the use of radiography in acute knee injuries. JAMA. 275(8), 61 1-61 5.

Stull, M. A., & Nelson, M. C. (1990). nie role of MRI in diagnostic imaging of the injured knee. Amencan Familv Phvsician. 4 l(2) 489-500.

Vahasarja, V., Kinnuen, P., & Serlo, W. (1993). Arthroscopy of the acute traumatic knee in children. Prospective study of 138 cases. Acta Orthoaaedica Scandinavica 64(5), 580-582. (From Medline: UWO Database. 1997, Abstract No. 94055660)

Verhoeven, A. A., Boemra E. J., & Meyboom-de Jong, B. (1 995). Use of information sources by family physicians: a literature survey. Bulletin of the Medical L i b q Association. 83(1), 85-90.

Wacker, F., Boize, X., MeUerowicz, H., & Wolf, K. J. (1995). Abteilung fur

Radiologische Diagnostik und Nuklearrnedizin, Freien Universitat Berlin [Diagnosis of changes in the knee joint of high performance athietes.] [Review]. Radiolee. 3 S(2), 94- 100. (Frorn Medline: UWO database, 1996, Abstract No. 95258596)

Wallace, K. G., Reed, B. A., Pasero, C., & Olsson, G. L. (1995). Staff nurses' perceptions of barriers to effective pain management. Journal of Pain and S-ymptom Management 1 O(3), 204-2 1 3.

Wojtys, E. M. (Eds.). (1991). The ACL Deficient Knee. Rosemont: Amencan Academy of Orthopaedic Surgeons, 4 & 9.

Worker's Compensation Board of Canada (1 982- 199 1). Statisticd Supplement to Annuai Report of 199 1 . (Table No. 6-8). Ottawa, Canada

Zhai, G. H. (1992). Diagnosis of anterior cmciate ligament injury of the knee joint. Chinese Journal of Sureery. 30(1), 10- 13,6 1. (From Medline: UWO database, 1997, Abstract No. 92362426)

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