Tanja Nauck

Translation, Cross-Cultural Adaption and Validation of the German Version of the Foot and Ankle Ability Measure for Patients with Chronic Ankle Instability.

Objectives The evaluation of health-related quality of life and physical function is important for determining therapeutic strategies following ankle injuries. The Anglo-American Foot and Ankle Ability Measure (FAAM) is a valid and reliable self-reported measure to detect functional deficits in chronic lateral ankle instability. The purpose of this study was to translate, cross-culturally adapt and validate the FAAM questionnaire for use with German-speaking patients with chronic lateral ankle instability. Patients/Participants Preoperative and conservatively treated patients with chronic lateral ankle instability. Sport students and volleyball athletes served as control groups. Main Outcome Measurements The FAAM was forward and back translated, cross-culturally adapted and validated. The study population completed the FAAM-G questionnaire twice within 3–5 days. Additionally, the patients were scored with the Good ankle laxity classification system. Test–Retest reliability, construct validity and internal consistency were calculated. Results Reliability and validity of the FAAM-G were examined in presurgical chronic ankle instability patients (n=24), conservatively treated chronic ankle instability patients (n=17), university sport students (n=31) and volleyballers (n=37). Test–retest reliability revealed fair, good, or excellent reliability (inter-class correlation coefficient (ICC)=0.590–0.998; ρ=0.528–1.000). Construct validity, tested between the FAAM-G subscores and the Good et al ankle laxity classification system demonstrated strong correlations (ρ = −0.819 to −0.861). Conclusions The original FAAM questionnaire was successfully translated and cross-culturally adapted from English to German. Corresponding to the Anglo-American version, the FAAM-G is a reliable and valid questionnaire for self-reported assessment of pain and disability in German-speaking patients suffering from chronic ankle instability.

Comparison of Radial Versus Focused Extracorporeal Shock Waves in Plantar Fasciitis Using Functional Measures

Background: Recent literature shows evidence for effective treatment for plantar fasciitis using either focused or radial shock waves. Up to now no research has been available which compares these different procedures. We hypothesized (H0 Hypothesis) that for plantar fasciitis, outcomes following focused or radial shock wave treatment were equal. Materials and Methods: For this pilot study, 39 patients suffering from recalcitrant plantar fasciitis were randomized in two groups. Treatment was performed in three sessions. Once a week 2000 impulses of radial (0.17 mJ/mm 2 ) or focused (0.20 mJ/mm 2 ) shock waves were applied. Efficacy was determined by multivariate analysis of eight single variables including changes in Foot Functional Index, neuromuscular performance (Single leg drop and long jump, postural stability, isokinetic testing), and by a composite score from baseline to 12 weeks followup. Multivariate Wilcoxon tests (Wei-Lachin procedure) and formal meta-analytic procedure with adjustment for subgroups was performed to determine the adjusted effect sizes with their corresponding confidence intervals. Results: The overall result (“Crude Pooling”) shows “small” superiority of the focused extracorporeal shock wave therapy (MW = 0.55, LB-CI = 0.4644). Adjusted for age the focused treatment exhibited “more than small” superiority (MW = 0.59, LB-CI > 0.5) and this result is statistically significant (LB-CI = 0.5067, benchmark for equality = 0.5). Conclusion: This study provides some evidence for focused extracorporeal shock wave treatment being superior to radial extracorporeal shock wave therapy for recalcitrant plantar fasciitis. Level of Evidence: I, Prospective Randomized Study

Posterior tibial tendon dislocation: a systematic review of the literature and presentation of a case

Objective In contrast to posterior tibial tendon lesions, dislocations of the posterior tibial tendon are thought to be ‘extremely rare’. Diagnostic criteria for this condition have not yet been established. Methods A systematic literature review revealed 61 published cases with posterior tibial tendon dislocation in 36 reports, including eight (12 patients) in French and five (7 patients) in German. We add one more case, which was complicated by a longitudinal tibial tendon tear and a lateral talar dome osteochondral lesion. Fifty-nine cases were descriptively analysed regarding initial injury, subjective symptoms, clinical presentation and findings on different imaging modalities. Treatment and outcome were additionally evaluated. Results 58.5% of the initial injuries were induced by sport. Initially most cases were misdiagnosed (53.1%). 35.6% of the patients felt a recurrent snapping phenomenon at the medial ankle. Physical examination exhibited a cord-like structure over the medial malleolus in 58.6%, and a posterior tibial tendon (sub)luxation could be provocated in 54.2%. MRI, ultrasound and plain radiography (medial malleolar chip fracture) detected specific findings in 75.0%, 66.7% and 14.7%, respectively. Surgery was done in 83.1% of the patients using varying techniques. The authors judged the treatment result as excellent or asymptomatic in 80%, as good in 12% and as fair or moderate in 8% of the patients. Conclusions Posterior tibial tendon dislocation occurs more frequently than was previously thought. Misdiagnosis can be avoided, if the surgeon is aware of the condition and combines findings from history, physical investigation and imaging modalities.

Comparison of endoscopic and open resection for Haglund tuberosity in a cadaver study.

Background: About half of patients who have Haglund disease may require treatment by surgical resection of the superior portion of the calcaneal tuberosity. Endoscopic techniques have been described as alternatives to open surgery, but only results of uncontrolled retrospective clinical investigations have been reported. Up to now no research is available which compares these different procedures. Methods: A controlled laboratory study was done to evaluate the morphologic appearance of the superior portion of the calcaneal tuberosity after endoscopic or open resection. The tuberosity was resected in 15 isolated fresh-frozen human cadaver lower limb specimens with either open (nine) or endoscopic (six) technique. Outcome was measured radiographically. Iatrogenic soft-tissue lesions of the distal Achilles tendon, plantaris tendon and sural nerve caused by the surgical procedure were evaluated by direct observation after anatomic dissection. Results: Radiographs revealed that the slope of the resection line (osteotomy angle) was steeper (p = 0.017) and the resected protruberance was larger (p = 0.003), while the remaining posterior rim was smaller (p = 0.048) after open resection than after endoscopic resection. Macroscopic analysis indicated that both approaches may damage soft tissues particularly the medial Achilles tendon column and in the plantaris tendon (relative risk = 0.5 in either group). Iatrogenic sural nerve injuries were found after both techniques (relative risk = 0.2 for endoscopic and 0.1 for open resection). Residual bursa tissue was detected only after endoscopy (relative risk = 0.3), while loose bony fragments were present only after open surgery (relative risk = 0.4). Conclusions and clinical relevance: The medial column of the Achilles tendon, the plantaris tendon, and the sural nerve are at risk in both open and endoscopic resection for Haglund disease.

Observer Reliability in Ankle and Calcaneocuboid Stress Radiography

Background Stress radiographic measurements play an important role in assessing the degree of joint instability in scientific investigations and for decision making in treatment. However, their validity and reliability are still a matter of intensive debate. Hypothesis There is no difference regarding interobserver and intraobserver reliability with respect to anterior talar drawer, talar tilt, and calcaneocuboid stress radiographs. Study Design Cohort study (diagnosis); Level of evidence, 4. Methods Eighty-nine anterior talar drawer, 89 talar tilt, and 76 calcaneocuboid stress radiographs were selected. Analyses for anterior talar drawer (1 measurement technique), talar tilt (1 measurement technique), and lateral calcaneocuboid instability (4 measurement techniques) were performed by 4 independent raters. One rater repeated the measurements after 1 month. Intraclass and interclass correlation coefficients (ICCs) with calculated confidence intervals assessed intratester and intertester reliability of each measure. Results Ankle stress radiographic interobserver agreement was ICC = 0.73 to 0.97 for anterior talar drawer test and ICC = 0.78 to 0.97 for talar tilt. Interobserver reliability for calcaneocuboid angle measurement methods was lower (ICC = 0.35–0.91) than for the calcaneocuboid joint-space distance measurements (ICC = 0.81–0.95). Intraobserver ICC varied between 0.78 and 0.97 for ankle stress testing and was 0.67 to 0.94 for calcaneocuboid stress radiography, respectively. Conclusions Ankle stress radiographic measurements were proven to be reliable. Insufficient reproducibility was found for angular calcaneocuboid stress radiography measurements, while lateral calcaneocuboid joint-space distances offered accurate reliability. Clinical Relevance Measurement errors can be avoided using standardized stress radiography and measurement techniques with proven reliability.

Cross-cultural Adaptation and Validation of the VISA-P Questionnaire for German-Speaking Patients With Patellar Tendinopathy

STUDY DESIGN Clinical measurement study. OBJECTIVES To cross-culturally adapt and validate the Victorian Institute of Sports Assessment Patellar Tendinopathy Questionnaire (VISA-P) for German-speaking patients. BACKGROUND Like most questionnaires, the VISA-P was developed for English-speaking patients. There is a need to adapt the scale for German-speaking patients and thereby add to the total body of psychometric evidence relating to this instrument. METHODS The VISA-P questionnaire was translated and cross-culturally adapted into German (VISA-P-G) in 6 steps: translation, synthesis, back translation, expert committee review, pretesting, and advisory committee appraisal. The psychometric properties of the VISA-P-G were determined using 23 patients with patellar tendinopathy and 57 active healthy persons (32 sport students and 25 basketball players). Reliability was evaluated by applying the questionnaire twice within a week to all 80 participants. Known group validity was calculated using a 1-way analysis of variance. Additionally, VISA-P-G results were correlated with the Blazina classification system for patellar tendinopathy, using the Spearman rank correlation coefficient. VISA-P-G ratings from the present study groups were further compared with respective data published in the original English, Dutch, and Swedish versions by a 2-sample t test. Internal consistency for the individual items of the questionnaire was determined within the patient group using a Cronbach alpha. RESULTS Test-retest revealed excellent reliability for the patient and the asymptomatic control group (ICC = 0.88 and 0.87, respectively). Internal consistency for the patients was 0.88. Concurrent validity was almost perfect (ρ = -0.81; P<.001). CONCLUSION The VISA-P-G is a reliable and valid questionnaire for the self-assessment of pain, symptoms, and function in German-speaking patients with patellar tendinopathy. Its psychometric properties are comparable with the original English and international adaptations (Swedish, Dutch, and Italian).

Training effects of two different unstable shoe constructions on postural control in static and dynamic testing situations

OBJECTIVE The aim of this study was to compare training effects on postural control using two different unstable shoe constructions. SUBJECTS AND SETTING Twenty-nine healthy subjects participated in this study and were randomly divided into three groups. Two experimental groups (10 subjects in each group) were assigned to a 6 week training program of specific sensorimotor exercises with unstable shoe constructions, one group using MBT(®) shoes and one group wearing Reflex Control(®) shoes (RC). Subjects in the control group (9 subjects) did not perform balance training. MAIN OUTCOME MEASURES Postural control was measured in one-leg stance in two testing conditions. We recorded postural sway on a force plate (static testing situation) and displacements of a moveable platform (dynamic testing situation) before and after the training period. RESULTS There were no effects of training with unstable shoe constructions on postural sway in the static testing condition (for comparison of groups: p = 0.990 and p = 0.119). However, the RC group showed statistically significant improvements in the dynamic testing situation (p = 0.014 compared to control subjects). In the MBT group improvements were not significantly different in comparison to control group (p = 0.518). CONCLUSIONS Our results indicate that exercises using unstable shoe constructions, particularly the RC, improve postural control only in dynamic conditions.

Augmented periosteal flap repair of the chronically unstable calcaneocuboid joint : A series of six cases

Isolated calcaneocuboid instability is a rarely described clinical entity, but it has been speculated that the number of patients in whom the condition has been unrecognized or misdiagnosed is high1. Up to the present time, the cases of only eight operatively treated ankles have been reported1-5 (Table I). The authors of those reports agreed that initial treatment should be conservative. Besides calcaneocuboid arthrodesis2, a plantaris tendon graft to reconstruct the calcaneocuboid ligament3 has been proposed as operative treatment. Recently, an anatomic repair has been described by one of us (H.L.)5. View this table: TABLE I Review of the Literature on Operative Treatment of Isolated Dorsal Calcaneocuboid Ligament Instability Clear diagnostic criteria for this condition have not been reported. A specific stress radiographic technique for the calcaneocuboid joint has been developed2, and serial sectioning of the calcaneocuboid ligament followed by stress radiography has been performed in five cadaver specimens4. The purpose of the present report was to focus clinical attention on isolated lesions of the dorsal calcaneocuboid ligament, and a diagnostic algorithm was developed. The outcome in a consecutive group of five adolescent female patients (six ankles) who were treated with an augmented anatomic repair is described. ### Diagnostic Procedure Several studies have served to establish the diagnosis of calcaneocuboid instability1,4,5. The patients history reveals an initial inversion-plantar flexion, supination, or twisting injury with subsequent swelling and pain in the lateral aspect of the foot and ankle region distal and inferior to the tip of the fibula. A hematoma is not necessarily present. Most patients report that a minor injury of the lateral ankle ligaments was initially assumed. Subsequently, recurrent giving-way or fear of giving-way develops. Sports and leisure time activities therefore are restricted and painful. Physical examination should …

Mechanical instability destabilises the ankle joint directly in the ankle-sprain mechanism

Background Despite massive research efforts, it remains unclear how mechanical ankle instability (MAI) and functional ankle instability (FAI) affect joint control in the situation of ankle sprain. Thus, the purpose of this study was to evaluate whether individuals with MAI have deficits in stabilising their ankle joint in a close-to-injury situation compared with those with FAI and healthy controls. Methods Ankle-joint control was assessed by means of three-dimensional motion analysis and electromyography in participants with FAI and MAI (n=19), in participants with pure FAI (n=9) and in healthy controls (n=18). Close-to-injury situations were simulated during standing, walking and jumping by means of a custom-made tilt platform. Results Individuals with FAI and MAI displayed significantly greater maximum ankle inversion angles (+5°) and inversion velocities (+50°/s) in the walking and jumping conditions compared to those with pure FAI and controls. Furthermore, individuals in the FAI and MAI group showed a significantly decreased pre-activation of the peroneus longus muscle during jumping compared to those with FAI. No differences between groups were found for plantar flexion and internal rotation, or for muscle activities following tilting of the platform. Conclusions The present study demonstrates that MAI is characterised by impairments of ankle-joint control in close-to-injury situations. This could make these individuals more prone to recurrent ankle sprains, and suggests the need for additional mechanical support such as braces or even surgery. In addition, the study highlights the fact that dynamic experimental test conditions in the acting participant are needed to further unravel the mystery of chronic ankle instability.

Dorsal calcaneocuboid ligament versus lateral ankle ligament repair: a case-control study

Objective: Anatomic reconstruction is the treatment of choice for lateral ankle ligament instability. A similar technique has recently been described for stabilisation of a chronic unstable calcaneocuboid joint as an alternative to the previously proposed tenodesis and arthrodesis procedures. Methods: Five consecutive young females experiencing recurrent giving way of six calcaneocuboid joints were treated operatively during a 4 year period using anatomic ligament repair reinforced by a periosteal flap. Results were compared to five patients who underwent anatomic lateral ankle ligament repair in a case-control design. Outcome was measured using the Foot and Ankle Outcome Score, physical examination, and stress radiographic and MRI (calcaneocuboid group) investigation. Functional neuromuscular performance was evaluated by isokinetic torque measurements, posturometry, single-leg drop jumps, and single-leg long jumps. Results: Outcome scores at follow up (5–61 months after surgery) revealed excellent results for both groups. No relevant difference was found between the affected legs and the non-affected legs or between groups with respect to the outcome measures. MRI exhibited ligament-like structures at the repaired dorsal calcaneocuboid joints in five out of six joints. Conclusions: Results of anatomic repair of unstable lateral ankle and isolated calcaneocuboid joint instability equally lead to excellent results.