Table 1 Questions with corresponding ChatGPT and guideline-based responses

What are the intrinsic risk factors for carpal tunnel syndrome?

The intrinsic risk factors with the strongest link to carpal tunnel syndrome are obesity, age, and female sex. The risk increases linearly with body mass index and age. The risk doubles in individuals with a body mass index greater than 30 kg/m² and in those over the age of 50. Female sex increases the risk by 1.5 to 4 times. Intrinsic risk factors linked to carpal tunnel syndrome, but to a lesser extent include diabetes mellitus, osteoarthrit previous musculoskeletal disorders, estrogen replacement therapy, cardiovascular disease risk factors, hypothyroidism, family history of carpal tunnel syndrome, lack of physical activity, wrist ratio greater than 0.70, wrist-palm ratio greater than 0.39, a short, wide hand, and short stature [21].

Intrinsic risk factors for carpal tunnel syndrome (CTS) include anatomical variations (e.g., a smaller carpal tunnel), female sex (due to generally narrower carpal tunnels), obesity, hormonal changes (such as during pregnancy or menopause), and certain medical conditions like diabetes, hypothyroidism, and rheumatoid arthritis. These factors may increase pressure within the carpal tunnel or make the median nerve more susceptible to compression.

How is neck pain classified based on clinical presentation?

Neck pain is classified as neck pain with limited mobility, neck pain with movement coordination disorders, neck pain with headache, and neck pain with radiating pain [22].

Neck pain is commonly classified into four categories based on clinical presentation:

1. Neck pain with mobility deficits – Characterized by limited range of motion and localized neck pain, often linked to mechanical dysfunction or poor posture.

2. Neck pain with movement coordination impairments – Includes whiplash-associated disorders, often with instability, motor control deficits, and hypersensitivity.

3. Neck pain with headaches (cervicogenic) – Associated with headaches triggered by neck movements or sustained postures, often linked to upper cervical dysfunction.

4. Neck pain with radiating pain - Involves radicular symptoms such as pain, numbness, or weakness radiating into the arm, often due to nerve root compression.

What are the common characteristics, symptoms, and recurrence rates of a hamstring strain injury (HSI)?

An hamstring strain injur can occur anywhere along the length of the muscle, but occurs most frequently in the proximal biceps femoris at the musculotendinous junction. At the time of injury, an individual experiences a sudden, sharp pain in the posterior thigh. Additionally, an audible or palpable popping sensation often occurs during an activity that overloads and/or overstretches the hamstring muscle. The individual may stop the event or activity due to the pain and limited function. The recurrence rate of HSI ranges between 13.9% and 63.3% when followed over the same and subsequent seasons. Also, injuries with more extensive myofascial damage extending into the tendon are more prone to reinjury and delayed return to play [23].

Hamstring strain injuries are characterized by sudden onset pain in the posterior thigh, often occurring during activities involving rapid acceleration or deceleration, such as sprinting or kicking. Symptoms include localized tenderness, swelling, bruising, and reduced strength or flexibility. There are two main types: sprint-related strains (more severe, affecting the long head of the biceps femoris) and stretch-related strains (associated with slower movements like high kicks). Recurrence rates are high, ranging from 12–63%, often due to inadequate rehabilitation, poor neuromuscular control, or returning to activity prematurely. Strength imbalances and previous injury are key risk factors.

What are the risk factors for hip fractures in older individuals?

Individual risk factors for hip fracture in individuals 65 yearsof age and older have been extensively explored. In addition to reduced bone mineral density, a range of other factors have been identified, including older age, female sex, low body mass index, ethnicity, being postmenopausal without estrogen replacement therapy, femoral geometry, previous hip fracture, smoking, vitamin D deficiency, low dietary calcium intake, and hypervitaminosis A, among many others [24].

Risk factors for hip fractures in older individuals include osteoporosis (weakened bone density), advanced age (due to decreased bone mass and muscle strength), and female sex (postmenopausal bone loss). Other factors include poor balance and reduced mobility, which increase fall risk, as well as chronic conditions like arthritis, diabetes, or neurological disorders. Medications that cause dizziness or sedation, nutritional deficiencies (e.g., calcium and vitamin D), and lifestyle factors like sedentary behavior or smoking also contribute. Environmental hazards, such as loose rugs or poor lighting, further increase the risk of falls leading to hip fractures.

What are the risk factors for achilles tendon disorder?

Risk factors are commonly classified as those that are intrinsic or extrinsic to the individual. Intrinsic risk factors that have been associated with Achilles tendon disorders include abnormal ankle dorsiflexion range of motion, abnormal subtalar joint range of motion, decreased ankle plantar flexion strength, increased foot pronation, and associated diseases. Extrinsic risk factors that have been associated with Achilles tendinopathy include training errors, environmental factors, and faulty equipment [25].

Risk factors for Achilles tendon disorders include intrinsic factors such as reduced flexibility, poor ankle dorsiflexion, decreased calf muscle strength, and abnormal foot biomechanics (e.g., overpronation). Extrinsic factors include sudden increases in activity level, repetitive overuse from high-impact sports like running or jumping, and wearing inappropriate footwear. Other contributing factors include age-related tendon degeneration, male sex, obesity, and systemic conditions like diabetes or inflammatory arthritis. Certain medications, such as fluoroquinolones or corticosteroids, are also associated with increased risk of tendon disorders.

Assessment

What provocative tests are used to evaluate people with carpal tunnel syndrome?

Provocative tests used to evaluate carpal tunnel syndrome are the Phalen Test, Tinel Sign, Carpal Compression Test, Reverse Phalen Test, Upper Extremity Neurodynamic Test and Scratch-Collapse test [21].

Common provocative tests used to evaluate carpal tunnel syndrome (CTS) include:

1. Phalen’s Test: The patient flexes their wrists to 90 degrees and holds the position for 60 s. A positive test reproduces symptoms like tingling or numbness in the median nerve distribution.

2. Tinel’s Sign: Gentle tapping over the carpal tunnel elicits tingling or “electric shock” sensations in the median nerve distribution.

3. Durkan’s Compression Test: Direct pressure is applied over the carpal tunnel for up to 30 s. Symptom reproduction indicates a positive result.

4. Hand Elevation Test: Raising both hands above the head for one to two minutes may provoke symptoms.

These tests help confirm median nerve compression but should be combined with history and diagnostic imaging for accuracy.

What key historical and physical examination findings are most indicative of lumbar disc herniation with associated radiculopathy?

Manual muscle testing, sensory testing, supine straight leg raise, Lasegue sign, and crossed Lasegue sign are suggested for use with recommendation grade A in the diagnosis of lumbar disc herniation with radiculopathy.

The supine straight leg raise is suggested for use with recommendation grade B in diagnosing of lumbar disc herniation with radiculopathy.

There is an insufficient evidence to make a recommenda-tion for or against the use of the cough impulse test, Bell test, hyperextension test, femoral nerve stretch test, slump test, lumbar range of motion, or absence of reflexes in diagnosing lumbar disc herniation with radiculopathy [26].

In lumbar disc herniation with radiculopathy, the history typically includes low back pain radiating into the leg along a dermatomal pattern, often described as sharp, burning, or electric-like. Pain is often exacerbated by activities that increase intradiscal pressure, such as sitting, bending, coughing, or sneezing. Patients may also report numbness, tingling, or weakness in the affected leg.

On physical examination, findings may include:

• Positive straight leg raise (SLR) test: Pain radiates down the leg when the affected leg is raised.

• Decreased reflexes: Commonly in the Achilles (S1) or patellar (L4) reflexes.

• Sensory deficits: Numbness in dermatomal patterns (e.g., L5 or S1).

• Motor weakness: Weakness in ankle dorsiflexion (L5) or plantarflexion (S1).

• Antalgic posture or gait: To reduce nerve root tension.

These findings correlate with the affected nerve root and guide diagnosis.

Which conditions should physiotherapists consider in the differential diagnosis of lateral elbow pain?

The conditions to consider with a differential diagnosis of lateral elbow pain, although not all-inclusive, include the following:

• Cervical radiculopathy

• Radial tunnel syndrome

• Posterior interosseous syndrome

• Plica syndrome

• Radio-capitellar chondromalacia

In the differential diagnosis of lateral elbow pain, physical therapists should consider lateral epicondylalgia (tennis elbow) as the most common cause, but also evaluate for radial tunnel syndrome (nerve entrapment causing pain without significant weakness), posterior interosseous nerve syndrome (with motor deficits), cervical radiculopathy (referred pain from C5-C6), osteoarthritis of the elbow, ligamentous injuries (e.g., lateral collateral ligament sprain),

• Posterolateral rotatory instability

• Myofascial trigger points in the wrist extensors

[27]

and intra-articular pathology (e.g., synovitis or loose bodies). Additionally, systemic conditions like rheumatoid arthritis or referred pain from the shoulder should be considered if the presentation is atypical.

What diagnostic criteria should clinicians use to identify patellofemoral pain?

Clinicians should use criteria such as the presence of retropatellar or peripatellar pain, recurrence of retropatellar or peripatellar pain with squatting, climbing stairs, sitting for prolonged periods, or other functional activities that load the patellofemoral joint in a flexed position, and exclusion of all other conditions that may cause anterior knee pain, including tibiofemoral pathologies. Additionally, clinicians may use patellar tilt testing in the presence of hypomobility to support the diagnosis of patellofemoral pain [28].

Clinicians should diagnose patellofemoral pain based on the following criteria:

1. Anterior knee pain: Pain localized to the peripatellar or retropatellar region, often described as dull or aching.

2. Activity-related symptoms: Pain is exacerbated by activities that load the patellofemoral joint, such as squatting, running, climbing stairs, prolonged sitting (the “theater sign”), or jumping.

3. Absence of other specific knee pathology: Ruling out conditions like ligament tears, meniscal injuries, or patellar instability through clinical evaluation and imaging if necessary.

4. Physical examination findings:

o Pain during patellar compression or palpation of the patellar facets.

o Positive Clark’s test (patellar grind test) or pain during resisted quadriceps contraction.

o Possible maltracking or poor patellar alignment during movement.

These criteria emphasize pain location, activity provocation, and exclusion of differential diagnoses.

How should physical therapists diagnose the International Classification of Disease (ICD) category of plantar fasciitis and the associated International Classification of Functioning, Disability and Health (ICF) impairment-based category of heel pain using the patient’s history and physical examination findings?

• Plantar medial heel pain: most noticeable with initial steps after a period of inactivity, but also worse following prolonged weight-bearing

• Heel pain precipitated by a recent increase in weight-bearing activity

• Pain with palpation of the proximal insertion of the plantar fascia

• Positive windlass test

• Negative tarsal tunnel tests

• Limited active and passive talocrural joint dorsiflexion range of motion (ROM)

• Abnormal Foot Posture-6 (FPI-6) score

• High body mass index in nonathletic individuals

[29]

Patient History:

1. Location of pain: Pain is usually at the medial plantar heel, often at the insertion of the plantar fascia.

2. Onset and progression: Symptoms often develop gradually and are worse with the first steps in the morning or after prolonged inactivity (post-static dyskinesia).

3. Aggravating factors: Pain increases with prolonged standing, walking, or running and improves with rest.

4. Risk factors: History of recent changes in activity levels, inappropriate footwear, or prolonged weight-bearing activities.

Physical Examination:

1. Palpation: Localized tenderness at the medial calcaneal tubercle or along the plantar fascia.

2. Windlass test: Pain reproduced during dorsiflexion of the great toe, which stretches the plantar fascia.

3. Passive dorsiflexion: Limited dorsiflexion of the ankle, often associated with tightness in the gastrocnemius or soleus muscles.

Exclusion of other causes: No signs of systemic conditions (e.g., rheumatoid arthritis or infection) or neural involvement (e.g., tarsal tunnel syndrome).

Rehabilitation

What are the strength and motor control training recommendations in the rehabilitation program after anterior cruciate ligament (ACL) reconstruction?

Strength and motor control training recommendations in the rehabilitation program are plyometric and agility training, motor control training, isotonic and isokinetic training, concentric and eccentric training, open and closed kinetic chain exercises, core stability and aquatic therapy [30].

ACL reconstruction, strength and motor control training should focus on progressive, structured exercises tailored to recovery stages. In the early phase (0–6 weeks), emphasize quadriceps activation (e.g., isometric exercises) and restoring normal gait. In the intermediate phase (6–12 weeks), incorporate progressive resistance training targeting quadriceps, hamstrings, and hip musculature, along with neuromuscular control exercises (e.g., balance and proprioceptive training). In the late phase (12+ weeks), focus on sport-specific drills, dynamic stability, and plyometric exercises to improve strength, motor control, and functional performance. Progressions should consider pain, swelling, and achieving symmetry between limbs to reduce re-injury risk.

Which interventions can be used in the treatment of patients with hip osteoarthritis?

Flexibility, strengthening, endurance exercises, and manual therapy can be used in the treatment of patients with hip osteoarthritis with evidence grade A.

Additionally, modalities and patient education combined with exercises can be used at level B evidence, while functional, gait and balance training and weight loss can be used at level C evidence [31].

Treatment for hip osteoarthritis includes a combination of exercise therapy, manual therapy, and patient education. Strengthening exercises targeting the hip abductors, extensors, and flexors, along with aerobic and flexibility training, are essential to improve joint stability and mobility. Manual therapy techniques, such as joint mobilizations and soft tissue release, can reduce pain and improve range of motion. Patient education should focus on weight management, activity modification, and joint protection strategies. Additionally, assistive devices (e.g., canes) and modalities like heat or ultrasound may provide symptomatic relief. Advanced cases may require referral for pharmacological or surgical interventions.

Which interventions are performed in patients with neck pain and limitation of movement?

The timing of the introduction of shoulder ROM exercises by physical therapists may be delayed up to 4 weeks without negatively impacting patient-reported outcomes in patients with glenohumeral osteoarthritis who have undergone total shoulder arthroplasty (Moderate quality of evidence) [32].

In the acute phase, clinicians should provide thoracic manipulation, a program of neck ROM exercises, and scapulothoracic and upper extremity strengthening to increase compliance with the program. Additionaly, clinicians may provide cervical manipulation and/or mobilization.

In the subacute phase, clinicians should provide neck and shoulder girdle endurance exercises and thoracic manipulation and cervical manipulation and/or mobilization.

In the chronic phase, clinicians should provide a multimodal approach of the following: thoracic manipulation and cervical manipulation or mobilization, mixed exercise for cervical/scapulothoracic regions: neuromuscular exercise (eg, coordination, proprioception, and postural training), stretching, strengthening, endurance training, aerobic conditioning, and cognitive affective elements.

Additionaly, dry needling, laser, or intermittent mechanical/manual traction may be used [22].

When should range of motion exercises begin for patients with glenohumeral osteoarthritis following total shoulder arthroplasty?

The timing of the introduction of shoulder ROM exercises by physical therapists may be delayed up to 4 weeks without negatively impacting patient-reported outcomes in patients with glenohumeral osteoarthritis who have undergone total shoulder arthroplasty (Moderate quality of evidence) [32].

ROM exercises for patients with glenohumeral osteoarthritis following total shoulder arthroplasty typically begin within the first week post-surgery, as long as the surgical approach and healing allow. In the early phase (0–4 weeks), passive ROM exercises are prioritized to protect the joint and soft tissues while preventing stiffness. Progression to active-assisted and active ROM exercises usually occurs in the intermediate phase (4–6 weeks), depending on patient tolerance and surgeon guidelines. Careful monitoring is essential to avoid overloading the joint or compromising the surgical repair.

Which interventions can be used for Heel Pain – Plantar Fasciitis?

Manual therapy (A), stretching (A), taping (A), foot orthoses (B-C), night splints (A), ultrasound (A), low level laser therapy (B), phonophoresis (C), electrotherapy (D), education and counseling for weight loss (E), therapeutic exercise and neuromuscular re-education (B), dry needling (B) [29].

Interventions for heel pain from plantar fasciitis focus on reducing pain, improving flexibility, and restoring function. Stretching exercises targeting the plantar fascia and calf muscles are highly effective. Strengthening exercises, particularly for the intrinsic foot muscles, can improve arch support. Manual therapy, including myofascial release and joint mobilizations, helps reduce stiffness and pain. Additional interventions include night splints, orthotics to offload the plantar fascia, and taping for short-term symptom relief. Patients should also be educated on activity modification, appropriate footwear, and gradual return to activity. For persistent cases, shockwave therapy or corticosteroid injections may be considered.

What should be the patient education strategies of physiotherapists in the management of patients with adhesive capsulitis?

Clinicians may utilize patient education that describes natural course of the disease, promotes activity modification to encourage functional, pain-free ROM, and matches the intensity of stretching to the patient’s current level or irritability [33].

Patient education for adhesive capsulitis should focus on explaining the condition’s phases (freezing, frozen, and thawing) to set realistic expectations for recovery, which can take months to years. Reassure patients that the condition is self-limiting and improves over time, but emphasize the importance of staying active within pain-free limits to maintain joint mobility. Educate on gentle stretching and avoiding aggressive movements that may worsen pain. Discuss the role of pain management strategies, such as heat or cold therapy, and the potential benefits of corticosteroid injections if recommended by their physician. Encourage adherence to home exercise programs and emphasize patience and consistency in rehabilitation.

What are the joint mobilization/manipulation interventions used for Lateral Elbow Tendinopathy (LET)?

A preponderance of level 2 evidence demonstrates that lateral glide MWM technique to the elbow, Mill’s manipulation technique, or regional mobilization techniques all demonstrate a positive effect compared with a placebo or control group on pain, pain-free grip strength, and function in the short term. Clinicians should use local elbow joint manipulation or mobilization techniques to reduce pain and increase pain-free grip strength in individuals with LET, as a stand-alone or adjunctive treatment in improving short-term outcomes for those who can tolerate the specific technique (B). Clinicians may use manipulation or mobilization techniques directed at the cervical spine, thoracic spine, and/or wrist as an adjunct to local treatment for short-term pain relief in individuals with LET when impairments in those regions are identified (C).

Gaps in Knowledge

The current literature does not address which type of joint mobilization technique is superior to others. The midterm and long-term outcomes of joint mobilization on outcomes in LET are unknown. Joint mobilizations/manipulations may contribute to diminishing pain and improving motor function via neurophysiologic mechanisms. Although these mechanisms are not completely understood, joint mobilizations/manipulations may involve reflex inhibition of pain mediated through joint mechanoreceptors [27].

Joint mobilization and manipulation for lateral elbow tendinopathy aim to reduce pain, improve joint mobility, and promote tissue healing. Common interventions include:

1. Lateral glide mobilization: A sustained or oscillatory lateral glide of the humeroulnar joint, often combined with gripping exercises to enhance pain-free grip strength.

2. Radial head mobilization: Anterior or posterior mobilizations of the radial head to address stiffness and improve forearm movement.

3. Cervical and thoracic mobilizations or manipulations: Techniques targeting the cervical spine (e.g., C5-C6) and thoracic spine to address referred pain and improve overall upper extremity mechanics.

4. Soft tissue mobilization: Targeting the extensor muscle group and common extensor tendon to reduce tension and pain.

These techniques are often integrated into a broader rehabilitation program including strengthening and neuromuscular retraining.

When should rehabilitation begin for patients with distal radius fractures (DRF)?

Clinicians should initiate early therapy that consists of hand, wrist, and shoulder active range of motion (AROM) exercises along with light daily activity within the first 3 weeks after a surgically repaired DRF to improve short-term (up to 3 months) outcomes for pain, wrist AROM, grip strength, and functional, and long-term (≥6 months) outcomes for wrist AROM and grip strength (A). Clinicians should initiate submaximal progressive strengthening, such as towel and putty squeezing and light-load gripping exercises at 2 weeks following a surgically repaired DRF or during the second week of cast immobilization (only the uncomplicated individuals with stable DRF, satisfactory radius-ulna articular alignment, and no ulnar-sided pain) to improve short-term (up to 6 months) outcomes for pain, wrist AROM, grip strength, and functional capacity with negligible risk of compromising proper fracture healing (B) [34].

Rehabilitation for patients with distal radius fractures should typically begin as soon as the acute inflammatory phase subsides, usually within 1–2 weeks after injury or surgical fixation, provided the fracture is stable. Early rehabilitation focuses on reducing pain and swelling through gentle range-of-motion exercises for the fingers, wrist, and forearm to prevent stiffness. For immobilized fractures, therapy starts after cast or splint removal (4–6 weeks), emphasizing gradual wrist and forearm mobility, strength, and functional use. Early intervention is critical for optimal outcomes but must respect fracture healing timelines and surgeon recommendations.

What should be the patient education strategies of physiotherapists in the management of patients with low back pain (LBP)?

Physical therapists may use active education strategies rather than passive strategies (i.e., providing access to educational materials only). Active education strategies include one-on-one education on the biopsychosocial contributors to pain and self-management techniques, such as remaining active, pacing strategies, and back-protection techniques. Physical therapists may also incorporate counseling on the favorable natural history of acute LBP as part of the education strategy (B) [35].

Patient education for managing low back pain should focus on reassurance, promoting active recovery, and addressing misconceptions. Physiotherapists should educate patients about the benign and often self-limiting nature of most low back pain, emphasizing the importance of staying active and avoiding prolonged bed rest. They should explain the role of posture, ergonomics, and regular exercise in prevention and management while encouraging gradual return to normal activities. Addressing fears and beliefs about pain and movement (e.g., fear of harm) is crucial to reduce kinesiophobia. Providing strategies for managing acute flare-ups, such as pacing and relaxation techniques, is also beneficial.

Which interventions can be performed for an ankle ligament sprain?

For acute/protected motion phase;

Early weight bearing with support (A), manual therapy (A), cryotherapy (A), diathermy (C), electrotherapy (D), low- level laser therapy (D), and therapeutic exercises (A).

For progressive loading/sensorimotor training phase;

Manual therapy (A), therapeutic exercise and activities (C), and sport - related activity training (C) [36].

Interventions for an ankle ligament sprain focus on reducing pain and swelling, restoring mobility and strength, and preventing recurrence. In the acute phase, use the RICE protocol (Rest, Ice, Compression, Elevation) alongside protected weight-bearing with braces or taping if needed. Gentle range-of-motion exercises, such as ankle circles or dorsiflexion-plantarflexion movements, should be introduced early. In the subacute phase, progress to strengthening exercises (e.g., resistance bands) and proprioceptive training, such as balance exercises on unstable surfaces. The rehabilitation phase includes functional activities like hopping, agility drills, and sport-specific movements to restore full performance. Education on proper footwear and prevention strategies is essential.