Judith F. Baumhauer

A Prospective Study of Ankle Injury Risk Factors

Many factors are thought to cause ankle ligament in juries. The purpose of this study was to examine injury risk factors prospectively and determine if an abnor mality in any one or a combination of factors identifies an individual, or an ankle, at risk for subsequent inver sion ankle injury. We examined 145 college-aged ath letes before the athletic season and measured gener alized joint laxity, anatomic foot and ankle alignment, ankle ligament stability, and isokinetic strength. These athletes were monitored throughout the season. Fifteen athletes incurred inversion ankle injuries. Statistical analyses were performed using both within-group (un injured versus injured groups) data and within-subject (injured versus uninjured ankles) data. No significant differences were found between the injured (N = 15) and uninjured (N = 130) groups in any of the param eters measured. However, the eversion-to-inversion strength ratio was significantly greater for the injured group compared with the uninjured group. Analysis of the within-subject data demonstrated that plantar flex ion strength and the ratio of dorsiflexion to plantar flex ion strength was significantly different for the injured ankle compared with the contralateral uninjured ankle. Individuals with a muscle strength imbalance as meas ured by an elevated eversion-to-inversion ratio exhib ited a higher incidence of inversion ankle sprains. Ankles with greater plantar flexion strength and a smaller dorsiflexion-to-plantar flexion ratio also had a higher incidence of inversion ankle sprains.

Ankle ligament injury risk factors: a prospective study of college athletes

Over two million individuals suffer ankle ligament trauma each year in the United States, more than half of these injuries are severe ligament sprains; however, very little is known about the factors that predispose individuals to these injuries. The purpose of this study was to determine the risk factors associated with ankle injury. We performed a prospective study of 118 Division I collegiate athletes who participated in soccer, lacrosse, or field hockey. Prior to the start of the athletic season, potential ankle injury risk factors were measured, subjects were monitored during the athletic season, and injuries documented. The number of ankle injuries per 1000 person‐days of exposure to sports was 1.6 for the men and 2.2 for the women. There were 13 injuries among the 68 women (19%) and seven injuries among the 50 men (13%), but these proportions were not significantly different. Women who played soccer had a higher incidence of ankle injury than those who played field hockey or lacrosse. Among men, there was no relationship between type of sport and incidence of injury. Factors associated with ankle ligament injury differ for men relative to women. Women with increased tibial varum and calcaneal eversion range of motion are at greater risk of suffering ankle ligament trauma, while men with increased talar tilt are at greater risk. Generalized joint laxity, strength, postural stability, and muscle reaction time were unrelated to injury.

Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study.

Background: Approximately 10% of patients with plantar fasciitis have development of persistent and often disabling symptoms. A poor response to treatment may be due, in part, to inappropriate and nonspecific stretching techniques. We hypothesized that patients with chronic plantar fasciitis who are managed with the structure-specific plantar fascia-stretching program for eight weeks have a better functional outcome than do patients managed with a standard Achilles tendon-stretching protocol. Methods: One hundred and one patients who had chronic proximal plantar fasciitis for a duration of at least ten months were randomized into one of two treatment groups. The mean age was forty-six years. All patients received prefabricated soft insoles and a three-week course of celecoxib, and they also viewed an educational video on plantar fasciitis. The patients received instructions for either a plantar fascia tissue-stretching program (Group A) or an Achilles tendon-stretching program (Group B). All patients completed the pain subscale of the Foot Function Index and a subject-relevant outcome survey that incorporated generic and condition-specific outcome measures related to pain, function, and satisfaction with treatment outcome. The patients were reevaluated after eight weeks. Results: Eighty-two patients returned for follow-up evaluation. With the exception of the duration of symptoms (p < 0.01), covariates for baseline measures revealed no significant differences between the groups. The pain subscale scores of the Foot Function Index showed significantly better results for the patients managed with the plantar fascia-stretching program with respect to item 1 (worst pain; p = 0.02) and item 2 (first steps in the morning; p = 0.006). Analysis of the response rates to the outcome measures also revealed significant differences with respect to pain, activity limitations, and patient satisfaction, with greater improvement seen in the group managed with the plantar fascia-stretching program. Conclusions: A program of non-weight-bearing stretching exercises specific to the plantar fascia is superior to the standard program of weight-bearing Achilles tendon-stretching exercises for the treatment of symptoms of proximal plantar fasciitis. These findings provide an alternative option to the present standard of care in the nonoperative treatment of patients with chronic, disabling plantar heel pain. Level of Evidence: Therapeutic study, Level I-1a (randomized controlled trial [significant difference]). See Instructions to Authors for a complete description of levels of evidence.

Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up

BACKGROUND In a previous investigation, eighty-two patients with chronic proximal plantar fasciitis for a duration of more than ten months completed a randomized, prospective clinical trial. The patients received instructions for either a plantar fascia-stretching protocol or an Achilles tendon-stretching protocol and were evaluated after eight weeks. Substantial differences were noted in favor of the group managed with the plantar fascia-stretching program. The goal of this two-year follow-up study was to evaluate the long-term outcomes of the plantar fascia-stretching protocol in patients with chronic plantar fasciitis. METHODS Phase one of the clinical trial concluded at eight weeks. At the eight-week follow-up evaluation, all patients were instructed in the plantar fascia-stretching protocol. At the two-year follow-up evaluation, a questionnaire consisting of the pain subscale of the Foot Function Index and an outcome survey related to pain, function, and satisfaction with treatment was mailed to the eighty-two subjects who had completed the initial clinical trial. Data were analyzed with use of a mixed-model analysis of covariance for each outcome of interest. RESULTS Complete data sets were obtained from sixty-six patients. The two-year follow-up results showed marked improvement for all patients after implementation of the plantar fascia-stretching exercises, with an especially high rate of improvement for those in the original group treated with the Achilles tendon-stretching program. In contrast to the eight-week results, the two-year results showed no significant differences between the groups with regard to the worst pain or pain with first steps in the morning. Descriptive analysis of the data showed that 92% (sixty-one) of the sixty-six patients reported total satisfaction or satisfaction with minor reservations. Fifty-one patients (77%) reported no limitation in recreational activities, and sixty-two (94%) reported a decrease in pain. Only sixteen of the sixty-six patients reported the need to seek treatment by a clinician. CONCLUSIONS This study supports the use of the tissue-specific plantar fascia-stretching protocol as the key component of treatment for chronic plantar fasciitis. Long-term benefits of the stretch include a marked decrease in pain and functional limitations and a high rate of satisfaction. This approach can provide the health-care practitioner with an effective, inexpensive, and straightforward treatment protocol.

Current Concepts Review - Hallux Rigidus and Osteoarthrosis of the First Metatarsophalangeal Joint*

Hallux rigidus is characterized by restriction of motion at the first metatarsophalangeal joint8,11. It is a common disorder that has been reported to affect one in forty-five individuals who are more than fifty years of age19. There is a generalized decrease in motion with particular limitation of dorsiflexion8,27,35,51. Hallux rigidus is often associated with a mechanical block to dorsiflexion caused by periarticular osteophytes, with an impingement exostosis of the first metatarsal head against an osteophyte at the base of the proximal phalanx13,15,16,37,41. The natural course of this disorder is typical of degenerative processes, with progression of the osteoarthrotic changes leading to limitation of motion and interference with function of the metatarsophalangeal joint3,13,27,41. Other terms that have been used to describe this clinical entity include hallux limitus5,22,32,66, dorsal bunion37,41, and localized arthrosis32. When there is a large dorsal osteophyte, the great toe is in a position of flexion, which has led to use of the term hallux flexus43. As the position of the great toe becomes even more plantar, the metatarsal becomes elevated, which has led to use of the term metatarsus elevatus50. Hallux rigidus has been attributed to various causes, including trauma2,11,15,41,66, metabolic disorders4,15,16,35, and congenital disorders3,4,9,15,27,28,35,42,51. These disease processes result in degenerative changes within the joint, including loss of articular cartilage, narrowing of …

Relationship between clinical measurements and motion of the first metatarsophalangeal joint during gait.

BACKGROUND The range of joint motion is a commonly reported outcome measure in assessment of the great toe. Although motion of the first metatarsophalangeal joint during gait is of primary functional importance, clinicians rely on relatively static clinical measures to assess this joint. The relationship between the results of commonly used clinical tests of motion of the first metatarsophalangeal joint and motion of this joint during gait was assessed in a study of thirty-three subjects who had no history of a pathological condition of the foot or ankle. METHODS An electromagnetic tracking device was used to acquire three-dimensional orientation data on the hallux with respect to the first metatarsal. Receivers were secured to the skin overlying the proximal phalanx of the hallux, the first metatarsal, and the medial aspect of the calcaneus. Measurements were recorded during four clinical tests. These tests assessed the active range of motion of the first metatarsophalangeal joint with the subject weight-bearing, the passive range of motion with the subject weight-bearing, the passive range of motion with the subject non-weight-bearing, and the motion during a heel-rise. The data collected with these tests were compared with motion of the first metatarsophalangeal joint during walking. The focus of the analysis was the dorsiflexion component of rotation. RESULTS With the exception of the passive range of motion with the subject weight-bearing, the ranges of motion measured during all of the clinical tests exceeded the motion of the first metatarsal joint that is required during normal walking. The motion measured during heel-rise (r = 0.87, p < 0.001) and the active range of motion with the subject weight-bearing (r = 0.80, p < 0.001) had the strongest correlations with motion of the first metatarsophalangeal joint during gait. The mean dorsiflexion during the test of the active range of motion (44 degrees) was closer to the mean dorsiflexion during gait (42 degrees) than was the mean value measured during the heel-rise test (58 degrees). This study also demonstrated that the clinical tests are not interchangeable as their mean results differed by as much as 21 degrees. CONCLUSIONS The selection of a reliable and valid clinical test and an understanding of the relationship of the results of this test to the motion requirements during normal gait will help to standardize reporting techniques and will improve the ability of the clinician to determine the outcomes of treatment. This study showed that measurement of the active range of motion with the subject weight-bearing was a reliable and valid test and that the results were strongly correlated with motion of the first metatarsophalangeal joint during gait.

A Comparison Study of Plantar Foot Pressure in a Standardized Shoe, Total Contact Cast, and Prefabricated Pneumatic Walking Brace

Total contact casting is the current recommended treatment for Wagner Stage 1 and 2 neuropathic plantar ulcers. The rationale for this treatment includes the equalization of plantar foot pressures and generalized unweighting of the foot through a total contact fit at the calf. Total contact casting requires meticulous technique and multiple cast applications to avoid complications before ulcer healing. An alternative to total contact casting is the use of a prefabricated brace designed to maintain a total contact fit. This study compares plantar foot pressure metrics in a standardized shoe (SS), total contact cast (TCC), and prefabricated pneumatic walking brace (PPWB). Five plantar foot sensors (Interlink Electronics, Santa Barbara, CA) were placed at the first, third, and fifth metatarsal heads, fifth metatarsal base, and midplantar heel of 10 healthy male subjects. Each subject walked at a constant speed over a distance of 280 meters in a SS, PPWB, and TCC. A custom-made portable microprocessor-based system, with demonstrated accuracy and reliability, was used to acquire the data. No significant differences in peak pressure or contact duration were found between the initial and repeat SS trials (P > 0.05). Peak pressures were reduced in the PPWB as compared to the SS for all sensor locations (P < 0.05). Similarly, peak pressures were reduced in the TCC compared to the SS for all sensor locations (P < 0.05) with the exception of the fifth metatarsal base (P = 0.45). Our results are summarized as follows: (1) the methods used in the current study were found to be reliable through a test-retest analysis; (2) the PPWB decreased peak plantar foot pressures to an equal or greater degree than the TCC in all tested locations of the forefoot, midfoot, and hindfoot; (3) compared to a SS, contact durations were increased in both the TCC and PPWB for most sensor locations; and (4) the relationship of peak pressure over time, the pressure-time integral, is lower in the brace compared to the shoe at the majority of sensor locations. The values are not significantly different between the cast and shoe. These findings suggest an unweighting of the plantar foot and equalization of plantar foot pressures with both the PPWB and TCC. Based on these findings, the PPWB may be useful in the treatment of neuropathic plantar ulcerations of the foot.

Acute ankle injury and chronic lateral instability in the athlete.

Ankle injuries occur frequently in sports. The lateral ligamentous complex, specifically the anterior talofibular and calcaneofibular ligaments, are most commonly injured. In acute lateral ligament injuries, a functional ankle rehabilitation program is the mainstay of treatment. Chronic ankle instability develops in a minority of patients. Surgical procedures are broadly classified into anatomic ligament repairs versus reconstructive tenodeses. Commonly performed techniques include the Brostrom-Gould procedure,the modified Brostrum-Evans procedure, and the Chrisman-Snook procedure.

Cytokine-induced osteoclastic bone resorption in charcot arthropathy: an immunohistochemical study.

Background: Charcot arthropathy is a chronic, progressive destructive process affecting bone architecture and joint alignment in people lacking protective sensation. The etiologic factors leading to progressive bone resorption have not been elucidated. The purpose of this study was to histologically examine surgical specimens with Charcot arthropathy for cell type and immunoreactivity of known cytokine mediators of bone resorption. Methods: Tissue samples of 20 specimens with known Charcot arthropathy were stained for Hematoxylin and Eosin (H&E) to quantify cell type. Nine of the specimens were stained with interleukin-1 (IL-1) antibody, nine with tumor necrosis factor (TNF) alpha antibody, and nine with interleukin-6 (IL-6) antibody. Distribution of staining was graded as focal (less than 10% of cells), moderate (10% to 50% of cells), and diffuse (more than 50% of cells) by two independent investigators. Inflammatory cells in tissue sections of rheumatoid synovium served as a positive control. Results: Osteoclasts were seen in excessive numbers lining the resorptive bone lacunae. There was a disproportionate increase in osteoclasts to osteoblasts in the Charcot-reactive bone. In each case, osteoclasts demonstrated immunoreactivity for IL-1, IL-6 and TNF-alpha with a grade of moderate or diffuse reactivity. Conclusion: The findings of excessive osteoclastic activity in the environment of cytokine mediators of bone resorption (IL-1, IL-6, and TNF-alpha) suggest enhanced bone resorption through the stimulation of osteoclastic progenitor cells as well as mature osteoclasts. Alteration in the synthesis, secretion, or activity of these important regulatory molecules through the use of pharmacologic agents may, in turn, alter bone remodeling and loss and lead to accelerated healing without collapse or malalignment.

Reliability of AOFAS diabetic foot questionnaire in Charcot arthropathy: stability, internal consistency, and measurable difference.

Background: The development of Charcot changes is known to be associated with a high rate of recurrent ulceration and amputation. Unfortunately, the effect of Charcot arthropathy on quality of life in diabetic patients has not been systematically studied because of a lack of a disease-specific instrument. The purpose of this study was to develop and test an instrument to evaluate the health-related quality of life of diabetic foot disease. Methods: Subjects diagnosed with Charcot arthropathy completed a patient self-administered questionnaire, and clinicians completed an accompanying observational survey. The patient self-administered questionnaire was organized into five general sections: demographics, general health, diabetes-related symptoms, comorbidities, and satisfaction. The scales measured the effect in six health domains: 1) general health, 2) care, 3) worry, 4) sleep, 5) emotion, and 6) physicality. The psychometric properties of the scales were evaluated and the summary scores for the Short-Form Health Survey (SF-36) were compared to published norms for other major medical illnesses. Results: Of the 89 enrolled patients, 57 who completed the questionnaire on enrollment returned a second completed form at 3-month followup. Over the 3-month followup period most of the patients showed an improvement in the Eichenholtz staging. The internal consistency of most was moderate to high and, in general, the scale scores were stable over 3 months. However, several of the scales suffered from low-ceiling or high-floor effects. Patients with Charcot arthropathy had a much lower physical component score on enrollment than the reported norms for other disease conditions, including diabetes. Conclusions: Quality of life represents an important set of outcomes when evaluating the effectiveness of treatment for patients with Charcot arthropathy. This study represents an initial attempt to develop a standardized survey for use with this patient population. Further studies need to be done with larger groups of patients to refine the tool and to begin the validation process. The instrument developed could be used for comparing treatment strategies for Charcot arthropathy.