Stephen F. Reischl

Comparison of Foot Pronation and Lower Extremity Rotation in Persons With and Without Patellofemoral Pain

Abnormal foot pronation and subsequent rotation of the lower extremity has been hypothesized as being contributory to patellofemoral pain (PFP). The purpose of this study was to test the hypothesis that subjects with PFP would exhibit larger degrees of foot pronation, tibia internal rotation, and femoral internal rotation compared to individuals without PFP. Twenty-four female subjects with a diagnosis of PFP and 17 female subjects without PFP participated. Three-dimensional kinematics of the foot, tibia, and femur segments were recorded during self-selected free-walking trials using a six-camera motion analysis system (VICON). No group differences were found with respect to the magnitude and timing of peak foot pronation and tibia rotation. However, the PFP group demonstrated significantly less femur internal rotation compared the comparison group. These results do not support the hypothesis that individuals with PFP demonstrate excessive foot pronation or tibial internal rotation compared to nonpainful individuals. The finding of decreased internal rotation in the PFP group suggests that this motion may be a compensatory strategy to reduce the quadriceps angle.

Trunk Position Influences the Kinematics, Kinetics, and Muscle Activity of the Lead Lower Extremity During the Forward Lunge Exercise

STUDY DESIGN Experimental laboratory study. OBJECTIVES To examine how a change in trunk position influences the kinematics, kinetics, and muscle activity of the lead lower extremity during the forward lunge exercise. BACKGROUND Altering the position of the trunk during the forward lunge exercise is thought to affect the muscular actions of the lead lower extremity. However, no studies have compared the biomechanical differences between the traditional forward lunge and its variations. METHODS AND MEASURES Ten healthy adults (5 males, 5 females; mean age +/- SD, 26.7 +/- 3.2 years) participated. Lower extremity kinematics, kinetics, and surface electromyographic (EMG) data were obtained while subjects performed 3 lunge exercises: normal lunge with the trunk erect (NL), lunge with the trunk forward (LTF), and lunge with trunk extension (LTE). A 1-way analysis of variance with repeated measures was used to compare lower extremity kinematics, joint impulse (area under the moment-time curve), and normalized EMG (highest 1-second window of activity for selected lower extremity muscles) among the 3 lunge conditions. RESULTS During the LTF condition, significant increases were noted in peak hip flexion angle, hip extensor and ankle plantar flexor impulse, as well as gluteus maximus and biceps femoris EMG (P<.015) when compared to the NL condition. During the LTE condition, a significant increase was noted in peak ankle dorsiflexion and a significant decrease was noted in peak hip flexion angle (P<.015) compared to the NL condition. CONCLUSIONS Performing a lunge with the trunk forward increased the hip extensor impulse and the recruitment of the hip extensors. In contrast, performing a forward lunge with the trunk extended did not alter joint impulse or activation of the lower extremity musculature. LEVEL OF EVIDENCE Therapy, level 5.

Achilles Pain, Stiffness, and Muscle Power Deficits: Achilles Tendinitis

The Orthopaedic Section of the American Physical Therapy Association presents this sixth set of clinical practice guidelines on Achilles pain, stiffness, and muscle power deficits that are characteristic of Achilles Tendinitis. These clinical practice guidelines are linked to the International Classification of Functioning, Disability, and Health (ICF). The purpose of these practice guidelines is to describe evidence-based orthopaedic physical therapy clinical practice and provide recommendations for (1) examination and diagnostic classification based on body functions and body structures, activity limitations, and participation restrictions, (2) interventions provided by physical therapists, (3) and assessment of outcome for common musculoskeletal disorders. J Orthop Sports Phys Ther 2010:40(9):A1–A26. doi:10.2519/jospt.2010.0305

Nonsurgical Management of Posterior Tibial Tendon Dysfunction With Orthoses and Resistive Exercise: A Randomized Controlled Trial

Background and Purpose: Tibialis posterior tendinopathy can lead to debilitating dysfunction. This study examined the effectiveness of orthoses and resistance exercise in the early management of tibialis posterior tendinopathy. Subjects: Thirty-six adults with stage I or II tibialis posterior tendinopathy participated in this study. Methods: Participants were randomly assigned to 1 of 3 groups to complete a 12-week program of: (1) orthoses wear and stretching (O group); (2) orthoses wear, stretching, and concentric progressive resistive exercise (OC group); or (3) orthoses wear, stretching, and eccentric progressive resistive exercise (OE group). Pre-intervention and post-intervention data (Foot Functional Index, distance traveled in the 5-Minute Walk Test, and pain immediately after the 5-Minute Walk Test) were collected. Results: Foot Functional Index scores (total, pain, and disability) decreased in all groups after the intervention. The OE group demonstrated the most improvement in each subcategory, and the O group demonstrated the least improvement. Pain immediately after the 5-Minute Walk Test was significantly reduced across all groups after the intervention. Discussion and Conclusion: People with early stages of tibialis posterior tendinopathy benefited from a program of orthoses wear and stretching. Eccentric and concentric progressive resistive exercises further reduced pain and improved perceptions of function.

Heel Pain—Plantar Fasciitis: Revision 2014

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organizations International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to nonarthritic heel pain.

Relationship between foot pronation and rotation of the tibia and femur during walking.

The purpose of this study was to test the hypothesis that the magnitude and timing of peak foot pronation would be predictive of the magnitude and timing of peak rotation of tibia and femur. Thirty subjects who demonstrated a wide range of pronation participated. Three-dimensional kinematics of the foot, tibia, and femur segments were recorded during self-selected free walking trials using a six-camera VICON motion analysis system. Regression analysis demonstrated that the magnitude and timing of peak pronation was not predictive of the magnitude and timing of tibial and femoral rotation. The lack of a relationship between peak foot pronation and the rotation of the tibia and femur is contrary to the clinical hypothesis that increased pronation results in greater lower extremity rotation. It would seem, therefore, that the relationship between foot pronation and rotation of the lower extremity segments should be assessed on a patient-by-patient basis.

Triple arthrodesis in adults with non-paralytic disease a minimum ten-year follow-up study

BACKGROUND The triple arthrodesis was developed to treat sequelae of neurologic disorders affecting the hindfoot. Today, the typical adult patient undergoing this procedure has degenerative disease, usually not related to a neurologic disorder. The purpose of this study was to investigate the long-term outcome of triple arthrodesis in this patient population. METHODS Twenty-seven adult patients (thirty-one feet) who had undergone triple arthrodesis for the treatment of chronic hindfoot pain and had been followed for a minimum of ten years completed an outcomes questionnaire, and twenty-two patients (twenty-six feet) were available for physical examination, radiographs, and functional testing. The mean age of the patients who were examined was forty-five years at the time of the surgery, and the mean duration of follow-up of those patients was fourteen years (range, eleven to eighteen years). RESULTS Twenty-five (93%) of the patients were satisfied with the result of the treatment. However, only eleven (41%) reported that they could perform moderate activity with mild or no pain in the foot and ankle. Twenty patients (74%) reported moderate-to-severe difficulty with, or an inability to negotiate, uneven surfaces. The mean Short Form-36 (SF-36) physical component outcomes score was 35.2 points, well below the mean of 50 points for the United States population. The SF-36 score was significantly lower for patients with systemic inflammatory disease (primarily rheumatoid arthritis). There was an average 12 degrees (27%) loss of plantar flexion but no significant loss of dorsiflexion compared with the untreated foot. Severe arthrosis developed in seven of the twenty-six ankles, in seven naviculocuneiform joints, and in six tarsometatarsal joints. Some patients had severe arthrosis at more than one level, and three patients later required an ankle arthrodesis. There were no nonunions or revisions of the triple arthrodeses. The average patient performances on the six-minute walk and the 3-m up-and-go functional tests were well below the age-controlled means. CONCLUSIONS Triple arthrodesis may provide patients with substantial long-term relief of preoperative symptoms. However, there may also be adverse consequences, particularly degenerative changes in adjacent joints, that may be reasons for orthopaedic surgeons to consider alternatives to triple arthrodesis when feasible. LEVEL OF EVIDENCE Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Effect of foot orthoses on tibialis posterior activation in persons with pes planus.

PURPOSE To examine the influence of footwear on tibialis posterior (TP) activation in persons with pes planus. METHODS Six asymptomatic adults with pes planus (arch index of < or =0.16) participated. Subjects performed a resisted foot adduction with plantar flexion exercise (3 sets of 30 repetitions). The exercise was performed barefoot and shod with foot orthoses. The two testing conditions were separated by a week. Magnetic resonance image signal intensity of the tibialis posterior, tibialis anterior, soleus, medial gastrocnemius, and peroneus longus was measured immediately before and after each exercise. Multivariate analyses of variance followed by paired Students t-test were performed for the signal intensity of each muscle assessed to determine whether TP was selectively activated during the barefoot and shod exercises. RESULTS When barefoot, five of the six subjects activated other lower-leg muscles in addition to TP. When wearing the foot orthoses and shoes, all five participants activated only TP. Additionally, activation of TP was higher when exercises were performed in shoes with orthoses than when barefoot (P = 0.019). CONCLUSION Wearing the foot orthoses and shoes improved selective activation of the TP in persons with flat feet. In cases where selective activation of TP is desirable, such as persons with flat feet or TP tendon dysfunction, use of shoes and an arch supporting foot orthoses may enhance selective activation of the muscle.

Women With Posterior Tibial Tendon Dysfunction Have Diminished Ankle and Hip Muscle Performance

STUDY DESIGN Controlled laboratory study using a cross-sectional design. OBJECTIVES To characterize ankle and hip muscle performance in women with posterior tibial tendon dysfunction (PTTD) and compare them to matched controls. We hypothesized that ankle plantar flexor strength, and hip extensor and abductor strength and endurance, would be diminished in women with PTTD and this impairment would be on the side of dysfunction. BACKGROUND Individuals with PTTD demonstrate impaired walking abilities. Walking gait is strongly dependent on the performance of calf and hip musculature. METHODS Thirty-four middle-aged women (17 with PTTD) participated. Ankle plantar flexor strength was assessed with the single-leg heel raise test. Hip muscle performance, including strength and endurance, were dynamometrically measured. Differences between groups and sides were assessed with a mixed-model analysis of variance. RESULTS Females with PTTD performed significantly fewer single-leg heel raises and repeated sagittal and frontal plane non-weight-bearing leg lifts, and also had lower hip extensor and abductor torques than age-matched controls. There were no differences between sides for hip strength and endurance measures for either group, but differences between sides in ankle strength measures were noted in both groups. CONCLUSION Women with PTTD demonstrated decreased ankle and hip muscle performance bilaterally.

Non-operative management of posterior tibialis tendon dysfunction: design of a randomized clinical trial [NCT00279630]

BackgroundPosterior tibialis tendon dysfunction (PTTD) is a common cause of foot pain and dysfunction in adults. Clinical observations strongly suggest that the condition is progressive. There are currently no controlled studies evaluating the effectiveness of exercise, orthoses, or orthoses and exercise on Stage I or IIA PTTD. Our study will explore the effectiveness of an eccentric versus concentric strengthening intervention to results obtained with the use of orthoses alone. Findings from this study will guide the development of more efficacious PTTD intervention programs and contribute to enhanced function and quality of life in persons with posterior tibialis tendon dysfunction.Methods/designThis paper presents the rationale and design for a randomized clinical trial evaluating the effectiveness of a treatment regime for the non-operative management of Stage I or IIA PTTD.DiscussionWe have presented the rationale and design for an RCT evaluating the effectiveness of a treatment regimen for the non-operative management of Stage I or IIA PTTD. The results of this trial will be presented as soon as they are available.