John J. Fraser

Supervised Rehabilitation Versus Home Exercise in the Treatment of Acute Ankle Sprains: A Systematic Review

In competitive sports medicine, supervised rehabilitation is the standard of care; in the general population, unsupervised home exercise is more common. We systematically reviewed randomized, controlled trials comparing outcomes for supervised rehabilitation versus home exercise programs. Supervised rehabilitation programs resulted in (1) less pain and subjective instability, (2) greater gains in ankle strength and joint position sense, and (3) inconclusive results regarding prevention of recurrent ankle sprains. We recommend supervised rehabilitation over home exercise programs owing to the improved short-term patient-recorded evidence with a strength-of-recommendation taxonomy level of evidence of 2B.

Utilization of Physical Therapy Intervention Among Patients With Plantar Fasciitis in the United States

• STUDY DESIGN: Retrospective observational study. • BACKGROUND: Plantar fasciitis is responsible for 1 million ambulatory patient care visits annually in the United States. Few studies have investigated practice patterns in the treatment of patients with plantar fasciitis. • OBJECTIVE: To assess physical therapist utilization and employment of manual therapy and supervised rehabilitation in the treatment of patients with plantar fasciitis. • METHODS: A retrospective review of the PearlDiver patient record database was used to evaluate physical therapist utilization and use of manual therapy and supervised rehabilitation in patients with plantar fasciitis between 2007 and 2011. An International Classification of Diseases code (728.71) was used to identify plantar fasciitis, and Current Procedural Terminology codes were used to identify evaluations (97001), manual therapy (97140), and rehabilitation services (97110, 97530, 97112). • RESULTS: A total of 819 963 unique patients diagnosed with plantar fasciitis accounted for 5 739 737 visits from 2007 to 2011, comprising 2.7% of all patients in the database. Only 7.1% (95% confidence interval: 7.0%, 7.1%) of patients received a physical therapist evaluation. Of the 57 800 patients evaluated by a physical therapist (59.8% female), 50 382 (87.2% ± 0.4%) received manual therapy, with significant increases in utilization per annum. A large proportion (89.5% ± 0.4%) received rehabilitation following physical therapist evaluation. • CONCLUSION: Despite plantar fasciitis being a frequently occurring musculoskeletal condition, a small proportion of patients with plantar fasciitis were seen by physical therapists. Most patients who were evaluated by a physical therapist received manual therapy and a course of supervised rehabilitation as part of their plan of care. • LEVEL OF EVIDENCE: Treatment, level 2a.

Foot impairments contribute to functional limitation in individuals with ankle sprain and chronic ankle instability

Purpose To investigate the clinical measures of foot posture and morphology, multisegmented joint motion and play, strength, and dynamic balance in recreationally active young adults with and without a history of a lateral ankle sprain (LAS), copers, and chronic ankle instability (CAI). Methods Eighty recreationally active individuals (healthy: n  = 22, coper: n  = 21, LAS: n  = 17, CAI: n  = 20) were included. Foot posture index (FPI), morphologic measures, joint motion (weight-bearing dorsiflexion (WBDF), rearfoot dorsiflexion, plantar flexion, inversion, eversion; forefoot inversion, eversion; hallux flexion, extension), joint play (proximal and distal tibiofibular; talocrural and subtalar, forefoot; 1st tarsometatarsal and metatarsophalangeal), strength (dorsiflexion, plantar flexion, inversion, eversion, hallux flexion, lesser toe flexion), and Star Excursion Balance Test (SEBT) (anterior, posteromedial, posterolateral) were assessed. Results There were no group differences in FPI or morphological measures. LAS and CAI groups had decreased ankle dorsiflexion ( p  = 0.001) and greater frontal plane motion ( p  < 0.001), first MT plantar flexion, and sagittal excursion ( p  < 0.001); increased talocrural glide ( p  = 0.02) and internal rotation ( p  < 0.001) and decreased forefoot inversion joint play ( p  < 0.001); and decreased strength in all measures ( p  < 0.001) except dorsiflexion compared to healthy controls. The LAS group also demonstrated decreased distal tibiofibular ( p  = 0.04) and forefoot general laxity ( p  = 0.05) and SEBT performance (anterior: p  = 0.02; posteromedial: p  < 0.001; posterolateral: p  < 0.001). Conclusion Individuals with LAS or CAI have increased pain, impaired physiologic and accessory joint motion, ligamentous tenderness, and strength in the foot and ankle. Clinicians should assess the multiple segments of the ankle–foot complex when caring for individuals with an LAS or CAI. Level of evidence II.

Mortarmen's Knee: Adult-Onset Tibial Tubercle Exostoses in 2 Infantrymen

Two 20-year-old male patients presented together to a multidisciplinary primary care sports medicine clinic with reports of focal swelling and pain at the left anterior knee just distal to the patella. Both patients enlisted together, chose the same occupational specialty, and trained together, resulting in similar exposure to training loads. Following examination, radiographic imaging was ordered for both patients. Radiographs of both patients revealed exostosis and fragmentation, with multiple ossicles of the tibial tubercle. J Orthop Sports Phys Ther 2018;48(6):510. doi:10.2519/jospt.2018.8005.

Does manual therapy improve pain and function in patients with plantar fasciitis? A systematic review

Abstract Objective: To assess if manual therapy (MT) in the treatment of plantar fasciitis (PF) patients improves pain and function more effectively than other interventions. Methods: A systematic review of all randomized control trials (RCTs) investigating the effects of MT in the treatment of human patients with PF, plantar fasciosis, and heel pain published in English on PubMed, CINAHL, Cochrane, and Web of Science databases was conducted. Research quality was appraised utilizing the PEDro scale. Cohen’s d effect sizes (ES) and associated 95% confidence intervals (CI) were calculated between treatment groups. Results: Seven RCTs were selected that employed MT as a primary independent variable and pain and function as dependent variables. Inclusion of MT in treatment yielded greater improvement in function (6 of 7 studies, CI that did not cross zero in 14 of 25 variables, ES = 0.5–21.5) and algometry (3 of 3 studies, CI that did not cross zero in 9 of 10 variables, ES = 0.7–3.0) from 4 weeks to 6 months when compared to interventions such as stretching, strengthening, or modalities. Though pain improved with the inclusion of MT, ES calculations favored MT in only 2 of 6 studies (3 of 13 variables) and was otherwise equivalent in effectiveness to comparison interventions. Discussion: MT is clearly associated with improved function and may be associated with pain reduction in PF patients. It is recommended that clinicians consider use of both joint and soft tissue mobilization techniques in conjunction with stretching and strengthening when treating patients with PF. Level of Evidence: Treatment, level 1a.

Variability in center of pressure position and muscle activation during walking with chronic ankle instability

Chronic ankle instability (CAI) patients exhibit altered gait mechanics. The objective was to identify differences in stride-to-stride variability in the position of the center of pressure (COP) and muscle activity during walking between individuals with and without CAI. Participants (17 CAI;17 Healthy) walked on a treadmill at 1.3 m/s while surface electromyography (sEMG) of the fibularis longus (FL) and plantar pressure were recorded. The medial-lateral COP position was averaged for each 10% interval of stance and group standard deviations (SD), coefficient of variation (COV), and range for the COP position were compared between groups via independent t-tests. Ensemble curves for sEMG amplitude SD were graphed for the entire stride cycle to determine significant differences. The CAI group had increased COP position variability (SD (CAI = 0.79 ± 0.47 mm, Control = 0.48 ± 0.17 mm), COV (CAI = 1.47 ± 0.87 mm, Control = 0.93 ± 0.33 mm), range (CAI = 2.97 ± 2.07 mm, Control = 1.72 ± 0.33 mm, P < .05 for all analyses)) during the first 10% of stance. The CAI group had lower FL sEMG amplitude variability from 1 to 10% (mean difference = 0.014 ± 0.006), 32-38% (mean difference = 0.013 ± 0.004) and 56-100% (mean difference = 0.026 ± 0.01) of the gait cycle. Increased COP variability at initial contact may increase risk of lateral ankle sprains in CAI patients. Decreased sEMG amplitude variability may indicate a constrained sensorimotor system contributing to an inability to adapt to changing environmental demands.

Preinjury to Postinjury Disablement and Recovery After a Lateral Ankle Sprain: A Case Report

A healthy 19-year-old male college student (height = 177.8 cm, mass = 64.3 kg, body mass index = 20.3 kg/m2, Foot Posture Index = -1) participating in a study sustained a grade 2 inversion lateral ankle sprain 3 days after completing patient-reported outcome measures. A treatment protocol including therapeutic exercises and midfoot mobilizations was provided. Patient-reported outcomes assessing physical health, mental health, and foot-ankle function were completed 3 days preinjury and 1, 3, and 12 weeks postinjury. Substantial postinjury changes in function, physical health, and kinesiophobia reflected functional limitations that improved with treatment and time. This level 3 exploration case report provides a rare opportunity to highlight preinjury-to-postinjury changes in patient-reported physical and psychological measures caused by a lateral ankle sprain.

P31 Gluteal muscle thickness during lateral band walking in individuals with history of ankle sprain

Study Design Cross-sectional. Objectives To compare gluteal muscle thickness changes measured by ultrasound imaging (USI) during lateral band walking with the resistance band positioned around the ankles or the forefeet in individuals with a history of lateral ankle sprain (LAS). Background Evidence suggests proximal neuromuscular adaptations exist in individuals with a history of LAS. Understanding how lateral band walking exercises target the proximal musculature could be beneficial for treatment following LAS. Methods and Measures 18 individuals (Age=22±6 years, Height=168.8±10.5 cm, Mass=74.4±28.7 kg, Previous LAS=4±3) with history of LAS participated. B-mode USI of gluteus maximus (GMax) and gluteus medius (GMed) were collected during lateral band walking. The 8 MHz wireless transducer was secured to participants using an elastic belt. Patients performed 3 trials of 5 lateral steps per band position. Thickness measures were taken from the inferior aspect of the superior muscle border to the superior aspect of the inferior border of each muscle. Images were normalised to quiet standing. The percent activity beyond quiet standing was calculated by taking the exercise muscle thickness divided by quiet muscle thickness. Paired sample t-tests were used to compare each muscle in each band position. Cohen’s d effect sizes (ES) were calculated to determine magnitude of difference. Results The percent activity for GMax (10.63%±7.01% ankle vs. 13.98%±7.21% forefoot, p=0.009, ES=0.48) and GMed (13.61%±18.60% ankle vs. 19.10%±19.30% forefoot, p<0.001, ES=0.30) increased from the ankle position to forefoot position. Conclusion The percent activity increased for both muscles in the forefoot position compared to the ankle position. Placing the resistance band around the forefoot may be a more challenging task for individuals with a history of LAS. During rehabilitation, it may be beneficial to begin with lateral band walks around the ankle and progress to the forefoot position as patients become more proficient at the exercise.