Phillip S. Sizer

Relationships between clinical measures of static foot posture and plantar pressure during static standing and walking

BACKGROUND Information is limited about the relationships between clinical measures of static foot posture and peak plantar pressures under the medial column of the foot. The purpose was to examine these relationships during static standing and walking. METHODS A single-group exploratory design using correlation and regression was used to determine relationships. Ninety-two healthy volunteers participated. Clinical measures of static foot posture including arch index, navicular drop and navicular drift were obtained during static standing. Peak plantar pressures under the hallux, medial forefoot, medial midfoot, and medial rearfoot were obtained during standing and walking. FINDINGS Static foot posture was related to peak plantar pressures during standing and walking, but the strengths of relationships ranged from poor to fair. During standing, navicular drop was correlated (P≤0.05) with hallux (r=0.29) and medial forefoot (r=-0.17) pressures, while arch index (r=-0.17) and navicular drift (r=0.25) were correlated (P≤0.05) with hallux pressure. During walking, arch index, navicular drop and navicular drift were correlated (P≤0.05) with hallux and medial forefoot pressures (r range -0.30 to 0.41), while arch index (r=-0.15) and navicular drop (r=0.16) were correlated (P≤0.05) with medial midfoot pressure. Regression models predicted (P≤0.05) hallux (R(2)=0.08) and medial midfoot (R(2)=0.05) pressures during standing, and hallux (R(2)=0.18), medial forefoot (R(2)=0.07), and medial rearfoot (R(2)=0.05) pressures during walking. INTERPRETATION In healthy participants, lower arch foot postures are associated with greater pressures under the hallux and medial mid-foot and lower pressures under the medial forefoot, but the strength of these relationships may be only poor to fair.

Medical screening for red flags in the diagnosis and management of musculoskeletal spine pain.

Abstract:  When a patient presents with pain in the different regions of the spine, the clinician executes a region‐appropriate basic examination that includes appropriate historical cues and specific physical examination tests that can be used to identify red flags. The clinical tests include a specific examination of the sensory and motor systems. Test outcomes are best interpreted in context with the entire examination profile, where the sensitivity and specificity of these tests can influence their utility in uncovering red flags. These red flags can be categorized based on the nature and severity or the specific elements of the patient’s presentation. Many general red flags can be observed in any region of the spine, while specific red flags must be categorized and discussed for each spinal region. This categorization can guide the clinician in the direction of management, whether that management is aimed at redirecting the patient’s care to another specialist, reconsidering the presentation and observing for clusters of findings that may suggest red flags, or managing the patient within the clinician’s specialty in context with the severity of the patient’s presentation.

Chronic female pelvic pain--part 1: clinical pathoanatomy and examination of the pelvic region.

Abstract:  Chronic pelvic pain is defined as the presence of pain in the pelvic girdle region for over a 6‐month period and can arise from the gynecologic, urologic, gastrointestinal, and musculoskeletal systems. As 15% of women experience pelvic pain at some time in their lives with yearly direct medical costs estimated at

Gender differences among sagittal plane knee kinematic and ground reaction force characteristics during a rapid sprint and cut maneuver.

2.8 billion, effective evaluation and management strategies of this condition are necessary. This merits a thorough discussion of a systematic approach to the evaluation of chronic pelvic pain conditions, including a careful history‐taking and clinical examination. The challenge of accurately diagnosing chronic pelvic pain resides in the degree of peripheral and central sensitization of the nervous system associated with the chronicity of the symptoms, as well as the potential influence of the affective and biopsychosocial factors on symptom development as persistence. Once the musculoskeletal origin of the symptoms is identified, a clinical examination schema that is based on the location of primary onset of symptoms (lumbosacral, coccygeal, sacroiliac, pelvic floor, groin or abdominal region) can be followed to establish a basis for managing the specific pain generator(s) and manage tissue dysfunction.

Thoracic outlet syndrome: a controversial clinical condition. Part 1: anatomy, and clinical examination/diagnosis.

Abstract Women are more prone to anterior cruciate ligament (ACL) injury during cutting sports than men. The purpose of this study was to examine knee kinematic and ground reaction forces (GRF) differences between genders during cutting. Male and female athletes performed cutting trials while force platform and video data were recorded (180 Hz). Differences (p ≤ .05) were observed between groups for knee flexion at contact and GRF at maximum knee flexion. Women averaged 5.8° less flexion at contact and 1.0 N·(kg·m·s1)−1 greater GRF at maximum flexion. Knee range of motion and peak GRF variables were not significantly different, but women had greater values. Women exhibited technique characteristics believed to increase ACL injury risk, but men exhibiting similar characteristics were also observed and could also be at risk.

2006 Young Investigator Award Winner: lumbosacral nerve root displacement and strain: part 2. A comparison of 2 straight leg raise conditions in unembalmed cadavers.

Abstract Thoracic outlet syndrome (TOS) is a frequently overlooked peripheral nerve compression or tension event that creates difficulties for the clinician regarding diagnosis and management. Investigators have categorized this condition as vascular versus neurogenic, where vascular TOS can be subcategorized as either arterial or venous and neurogenic TOS can subcategorized as either true or disputed. The thoracic outlet anatomical container presents with several key regional components, each capable of compromising the neurovascular structures coursing within. Bony and soft tissue abnormalities, along with mechanical dysfunctions, may contribute to neurovascular compromise. Diagnosing TOS can be challenging because the symptoms vary greatly amongst patients with the disorder, thus lending to other conditions including a double crush syndrome. A careful history and thorough clinical examination are the most important components in establishing the diagnosis of TOS. Specific clinical tests, whose accuracy has been documented, can be used to support a clinical diagnosis, especially when a cluster of positive tests are witnessed.

2006 young investigator award winner : Lumbosacral nerve root displacement and strain Part 1. A novel measurement technique during straight leg raise in unembalmed cadavers

Study Design. An inferential cadaveric study. Objectives. To compare the displacement and strain of the lumbosacral nerve roots during different conditions of straight leg raise (SLR) with intact foraminal ligaments. Summary of Background Data. Clinicians use sensitizing movements such as dorsiflexion during neurodynamic testing, assuming that these prepositions influence the displacement or strain to the lumbosacral nerve roots. Little is known about the effect of these prepositions on neurodynamic behavior. Methods. Lower limbs and associated nerve roots of 5 unembalmed cadavers (n = 10) were used to evaluate the displacement and strain of the L4, L5, and S1 roots during 2 different SLR conditions. Fluoroscopic images of intraneural metal markers were digitized to evaluate displacement and strain during SLR with no preposition (SLR NPP) of the ankle and SLR with dorsiflexion preposition (SLR DF) of the ankle, respectively. Results. SLR NPP produced larger distal displacement at L5 and S1, (P < 0.001) when compared with SLR DF. Displacement comparisons at L4 were nonsignificant (P = 0.051). While nonsignificant, medium to large effect sizes (0.60–0.96) suggest that SLR DF may produce more strain than the SLR NPP condition. Conclusions. Prepositions of the SLR test alter the displacement and possibly the strain of the lumbosacral nerve roots in the lateral recess.

The effects of neurodynamic mobilization on fluid dispersion within the tibial nerve at the ankle: an unembalmed cadaveric study

Study Design. A descriptive cadaveric study incorporating a novel nerve root marking technique. Objectives. To describe the displacement and strain of the lumbosacral nerve roots in the lateral recess during straight leg raise (SLR) without disrupting the foraminal ligaments. Summary of Background Data. Previous studies document 2 to 8 mm of lumbosacral nerve root displacement during SLR. Prior dissection methods incorporated laminectomy and facetectomy. Methods. Lower limbs and associated nerve roots of 5 unembalmed cadavers (n = 10) were studied. Metal markers were inserted intraneurally within the lateral recess of L4, L5, and S1 with a modified spinal needle. Fluoroscopic images were digitized to evaluate displacement and strain during SLR. Results. The lumbosacral nerve roots in the lateral recess moved less and experienced less strain during SLR than described in previously published reports. Statistically significant distal displacement occurred at hip positions greater than 60° of flexion at all nerve root levels (P < 0.01). Conclusions. The lumbosacral nerve roots (L4, L5, S1) moved less and underwent less strain during SLR testing than previously reported and may require hip motion greater than 60° to produce substantive displacement in the lateral recess. Additional research is needed to examine the effects of prepositioning during SLR.

Differential Diagnosis and Management of Spinal Nerve Root-related Pain

Abstract Objective: To evaluate the effects of neurodynamic mobilization on the fluid dynamics of the tibial nerve in cadavers. Background: Evidence showing patients benefit from neural mobilization is limited. Mechanisms responsible for changes in patient symptoms are unclear. Methods: Bilateral lower limbs of six unembalmed cadavers (n = 12) were randomized into matched pairs and dissected to expose the tibial nerve proximal to the ankle. Dye composed of Toulidine blue and plasma was injected into the nerve. The longitudinal dye spread was measured pre‐ and post‐mobilization. The experimental group received the intervention consisting of 30 repetitions of passive ankle range of motion over the course of 1 minute. The matched control limb received no mobilization. Data were analysed using a 2×2 repeated measures ANOVA with subsequent t‐tests for pairwise comparisons. Results: Mean dye spread was 23·8±10·2 mm, a change of 5·4±4·7% in the experimental limb as compared to 20·7±6·0 mm, a change of −1·5±3·9% in the control limb. The ANOVA was significant (P⩽0·02) for interaction between group (experimental/control) and time (pre‐mobilization/post‐mobilization). t‐test results were significant between pre‐ and post‐mobilization of the experimental leg (P = 0·01), and between control and experimental limbs post‐mobilization (P⩽0·02). Conclusion: Passive neural mobilization induces dispersion of intraneural fluid. This may be clinically significant in the presence of intraneural edema found in pathological nerves such as those found in compression syndromes.

Changes in Transversus Abdominis Thickness With Use of the Abdominal Drawing-In Maneuver During a Functional Task

Abstract: Pain originating from spinal nerve roots demonstrates multiple pathogeneses. Distinctions in the patho‐anatomy, biomechanics, and pathophysiology of spinal nerve roots contribute to pathology, diagnosis, and management of root‐related pain. Root‐related pain can emerge from the tension events in the dura mater and nerve tissue associated with primary disc related disorders. Conversely, secondary disc‐related degeneration can produce compression on the nerve roots. This compression can result in chemical and mechanical consequences imposed on the nervous tissue within the spinal canal, lateral recess, intervertebral foramina, and extraforminal regions. Differences in root‐related pathology can be observed between lumbar, thoracic, and cervical spinal levels, meriting the implementation of different diagnostic tools and management strategies.