Differences in Lower Extremity Kinematics Between High School Cross-Country and Young Adult Recreational Runners.

BACKGROUND: While previous research has assessed running kinematics for age-related differences that could increase the risk of a running-related injury, none of these studies have included high school aged runners or assessed running kinematics using 2-dimensional video analysis. PURPOSE: The purpose of this study was to compare sagittal plane kinematics during treadmill running in high school cross-country and young adult recreational runners using 2-dimensional motion analysis techniques. METHODS: Twenty-five high school cross-country runners (13 women, 12 men) and 25 young adult recreational runners (12 women, 13 men) consented to participate in this study. Reflective markers were placed on each lower extremity over multiple anatomical landmarks. After a five-minute acclimation period in which the participants ran on a treadmill at their preferred running speed, video data were recorded at 240 frames per second for all participants while they continued to run on the treadmill. RESULTS: There were no significant differences between left and right extremities. The young adult recreational runners exhibited significantly greater vertical excursion of the center of mass (t = 4.64, p = .0001) compared to the high school runners. There was no significant difference between the two age groups regarding the six other sagittal plane variables. CONCLUSIONS: The young adult recreational runners demonstrated an increased center-of-mass vertical excursion in comparison to high school cross-country runners. In addition, the results obtained in this study for kinematic variables using 2-dimensional motion analysis were similar to previously reported studies using 3-dimensional motion analysis, demonstrating that 2-dimensional motion analysis could be used for analyzing sagittal plane running kinematics in clinical settings. LEVEL OF EVIDENCE: 4, Controlled laboratory study.

Physical therapist decision-making in managing plantar heel pain: cases from a pragmatic randomized clinical trial.

INTRODUCTION: Plantar heel pain (PHP) is a common condition managed by physical therapists that can, at times, be difficult to treat. Management of PHP is complicated by a variety of pathoanatomic features associated with PHP in addition to several treatment approaches with varying efficacy. Although clinical guidelines and clinical trial data support a general approach to management, the current literature is limited in case-specific descriptions of PHP management that addresses unique combinations of pathoanatomical, physical, and psychosocial factors that are associated with PHP. Purpose: The purpose of this case series is to describe physical therapist decision-making of individualized multimodal treatment for PHP cases presenting with varied clinical presentations. Treatment incorporated clinical guidelines and recent evidence including a combination of manual therapy, patient education, stretching, resistance training, and neurodynamic interventions. A common clinical decision-making framework was used to progress individualized treatment from a focus on symptom modulation initially to increased load tolerance of involved tissues and graded activity. In each case, patients met their individual goals and demonstrated clinically meaningful improvements in pain, function, and global rating of change that were maintained at the 1-2-year follow-up. Implications: This case series provides details of physical therapist management of a variety of PHP clinical presentations that can be used to complement clinical practice guidelines in the management of PHP.

Effectiveness of physical therapy treatment in addition to usual podiatry management of plantar heel pain: a randomized clinical trial.

BACKGROUND: Many patients will seek care from a podiatrist for plantar heel pain (PHP), while few of these patients will also be seen by a physical therapist. Physical therapists can provide treatment that is not a part of routine podiatric care for PHP and may provide additional improvement. Therefore, the purpose of this study was to examine the effects of interdisciplinary care for PHP that incorporated physical therapy treatment after initiating podiatric treatment. METHODS: Eligible individuals with PHP that presented to a podiatrist were randomized to receive usual podiatric care (uPOD) or usual podiatric care plus physical therapy treatment (uPOD+PT). The primary outcome was change in foot and ankle ability measure (FAAM) at 6-months. Secondary outcomes included change in numeric pain rating scale (NPRS), patient-reported success, and 6-week and 1-year endpoints. Patient-reported success was defined as the top two global rating of change scale rankings. Primary analysis was intention-to-treat (ITT) using analysis by covariance adjusted to baseline scores, and a secondary per-protocol (PP) analysis was performed analyzing only those who completed treatment. RESULTS: Ninety-five individuals participated and were included in the ITT analysis, and 79 were included in the PP analysis. For the primary outcome of FAAM change from baseline to 6-months, both groups improved significantly (uPOD+PT: 26.8 [95% CI 21.6, 31.9]; uPOD: (20 [15.6, 24.4]), but there was no between-group difference (4.3 [- 1, 9.6]). For secondary outcomes, the uPOD+PT group demonstrated greater improvement in NPRS at 6 weeks (0.9 [0.3, 1.4]) and 1 year (1.5 [0.6, 2.5]) in the ITT analysis. In the PP analysis, the uPOD+PT group demonstrated greater improvement in FAAM at 6 months (7.7 [2.1, 13.3]) and 1 year (5.5 [0.1, 10.8]), NPRS at 6 weeks (0.9 [0.2, 1.6]), 6 months (1.3 [0.6, 2.1]) and 1 year (1.3 [0.6, 2.1]), and in patient-reported success (relative risk [95% CI]) at 6 weeks (2.8 [1.1, 7.1]), 6 months (1.5 [1.1, 2.1]), and 1 year (1.5 [1.1, 1.9]). CONCLUSIONS: There was no significant benefit of uPOD+PT in the primary outcome of FAAM change at 6 months. Secondary outcomes and PP analysis indicated additional benefit of uPOD+PT, mostly observed in individuals who completed treatment. TRIAL REGISTRATION: Prospectively registered May 24, 2013 at www.clinicaltrials.gov (NCT01865734).

Is Excellence in the Cards?

Thomas G. McPoil, PT, PhD, FAPTA, is Emeritus Professor of Physical Therapy at Regis University, Denver, Colorado, and Emeritus Regents' Professor of Physical Therapy at Northern Arizona University. He has served as an Adjunct Honorary Professor in the School of Physiotherapy at the University of Queensland, Brisbane, Australia, and currently serves as a consultant to the Physical Therapy Orthotics Clinic at Denver Health Medical Center, Denver, Colorado. Dr. McPoil is known nationally and internationally for his scholarly contributions that have systematically examined foot and ankle function from both scientific and clinical perspectives. Dr. McPoil is an author or coauthor of 130 publications in peer-reviewed journals, coeditor of 2 books, and coauthor of 6 book chapters. His work reaches beyond the profession of physical therapy, as he served on the editorial boards of Foot and Ankle International, the Journal of Foot and Ankle Research, and Research in Sports Medicine and is currently on the editorial boards of the Journal of the American Podiatric Medical Association and The FOOT. Dr McPoil received his PhD in kinesiology with a specialization in biomechanics from University of Illinois at Urbana-Champaign. He holds an MS in physical education with a specialization in athletic training from Louisiana State University and a BA in physical education from the California State University, Sacramento. During his career, he has held faculty appointments at the University of Illinois at Chicago, Northern Arizona University, and Regis University. Dr McPoil's clinical practice has focused on the management of chronic orthopedic foot and ankle disorders for the past 38 years. Dr McPoil is the founding president of the Foot and Ankle Special Interest Group of the Academy of Orthopaedic Physical Therapy. He has served as Vice President of the Academy of Orthopaedic Physical Therapy and as the Treasurer of the Journal of Orthopaedic and Sports Physical Therapy. He has received numerous teaching awards, including APTA's Dorothy E. Baethke & Eleanor J. Carlin Award for Excellence in Academic Teaching and the Academy of Orthopaedic Physical Therapy's James A. Gould Excellence in Teaching Orthopaedic Physical Therapy Award. He is a recipient of a Fulbright Senior Scholar Award, the William J. Stickel Award for Research in Podiatric Medicine, the Academy of Orthopaedic Physical Therapy's Stanley Paris Distinguished Service Award and was elected a Catherine Worthingham Fellow of APTA in 2007.

USE OF 2-DIMENSIONAL SAGITTAL KINEMATIC VARIABLES TO ESTIMATE GROUND REACTION FORCE DURING RUNNING.

BACKGROUND: Variations in vertical loading rates have been associated with overuse injuries of the lower extremity; however, they are typically collected using 3-dimensional motion capture systems and in-ground force plates not available to most clinicians because of cost and space constraints. PURPOSE: The purpose of this study was to determine if kinetic measures commonly used to describe lower extremity loading characteristics could be estimated from step rate and specific sagittal plane kinematic variables captured using 2-dimensional motion analysis during treadmill running. STUDY DESIGN: Observational Study. METHODS: Ten high school cross-country runners (4 men and 6 women) voluntarily consented to participate in this study. Reflective markers were placed on each lower extremity over multiple anatomical landmarks. Participants were then asked to run on the instrumented treadmill at their preferred running speed. When the participants indicated they were in their typical running pattern, they continued to run at their preferred speed for a minimum of five minutes. After three minutes of running at their preferred running speed, the participant's step rate was counted and after running for four minutes, video and ground reaction force data were recorded for 60 sec. All running motion data were recorded using a single high-speed camera at 240 frames per second and ground reaction force data were sampled at 1000 Hz. RESULTS: Mean kinematic values between the left and right extremities for all 10 participants were not significantly different. Consequently, data for the left and right extremities were grouped for all further analyses. The stepwise forward regression to predict vertical ground reaction force resulted in a five-variable model (step rate and four kinematic variables) with R2 = 0.56. The stepwise forward regression to predict average loading rate also resulted in a five kinematic variable model with R2 = 0.51. CONCLUSIONS: Step rate and sagittal plane kinematic variables measured using a simplified 2-dimensional motion analysis approach with a single high-speed camera can provide the clinician with a reasonable estimate of ground reaction force kinetics during treadmill running. LEVEL OF EVIDENCE: 4, Controlled laboratory study.

Instrument-Assisted Soft-Tissue Mobilization for the Management of Chronic Plantar Heel Pain: A Pilot Study.

BACKGROUND: The purpose of this study was to determine feasibility of further investigation of treatment with instrument-assisted soft-tissue mobilization (IASTM), using the Graston technique, compared with conservative care for treatment of chronic plantar heel pain (CPHP). METHODS: Eleven participants with plantar heel pain lasting 6 weeks to 1 year were randomly assigned to one of two groups, with each group receiving up to eight physical therapy visits. Both groups received the same stretching, exercise, and home program, but the experimental group also received IASTM using the Graston technique. Outcome measures of pain and function were recorded at baseline, after final treatment, and 90 days later. Feasibility of a larger study was determined considering recruitment and retention rates, compliance, successful application of the protocol and estimates of the treatment effect. RESULTS: Both groups demonstrated improvements in current pain (pain at time of survey), pain with the first step in the morning, and function after final treatment and at 90-day follow up. Medium-to-large effect sizes between groups were noted, and sample size estimates demonstrated a need for at least 42 participants to realize a group difference. A larger-scale study was determined to be feasible with modifications including a larger sample size and higher recruitment rate. CONCLUSIONS: This pilot study demonstrates that inclusion of IASTM using the Graston technique for CPHP lasting longer than 6 weeks is a feasible intervention warranting further study. Clinically important changes in the IASTM group and moderate-to-large between-group effect sizes suggest that further research is warranted to determine whether these trends are meaningful.

The effect of manual therapy on gastrocnemius muscle stiffness in healthy individuals.

STUDY DESIGN: Randomized clinical trial. BACKGROUND: Muscle stiffness is a potential complication after injury and has been shown to be a risk factor for injury in healthy individuals. OBJECTIVES: The primary purpose of this study was to assess the short-term effects of manual therapy (MT) on muscle stiffness of the gastrocnemius in both a relaxed and contracted state. The secondary purpose was to assess the reliability of a novel clinical tool (MyotonPRO) to measure muscle stiffness in the gastrocnemius in both a passive and contracted state. METHODS: Eighty-four consecutive healthy individuals were randomized to receive Manual Therapy (MT group) directed at the right-side ankle and foot or no treatment (CONTROL group). Muscle stiffness of the gastrocnemius was assessed bilaterally in all participants at baseline and then immediately after intervention in a relaxed and contracted state. Group (MT vs. CONTROL) by side (ipsilateral vs. contralateral) by time (pre vs. post) effects were compared through a 3-way interaction utilizing mixed model ANOVA. Reliability of the MyotonPRO was assessed with two-way mixed model intraclass correlation coefficients. RESULTS: There was a significant 3-way interaction for muscle stiffness of the gastrocnemius in a relaxed state (p<0.01), but not contracted state (p=0.54). All conditions had increased resting muscle stiffness from pre to post measures except for the ipsilateral limb of the MT group. There was not a significant interaction for muscle stiffness in a contracted state. Reliability estimates (ICC) for muscle stiffness measures ranged between 0.898 and 0.986. CONCLUSION: The change in muscle stiffness of the gastrocnemius in a relaxed state depended upon whether individuals received MT. Muscle stiffness measures were highly reliable based on single measurements. LEVEL OF EVIDENCE: Therapy, level 2.

RELIABILITY OF TWO-DIMENSIONAL VIDEO-BASED RUNNING GAIT ANALYSIS.

BACKGROUND: While two-dimensional (2D) video running analysis is commonly performed in the clinical setting, the reliability of quantitative measurements as well as effect of clinical experience has not been studied. PURPOSE: The purpose of this study was to assess the intra-rater and inter-rater reliability of six different raters using 2D video analysis of sagittal and frontal plane kinematic variables while running on a treadmill. STUDY DESIGN: Cross-sectional Study. METHODS: Running videos from 10 individuals (five female, five male) with a mean age of 22.8 years were selected for analysis. Two raters had over 10 years of experience with running video analysis and the other four raters had no prior experience. Before beginning analyses, the senior investigator conducted two hours of training with all raters to review the measurement procedures and the movement analysis software program. After completing training and one practice analysis, each rater assessed four 60-second video clips for the 10 runners twice (20 total). A minimum of one week separated the two assessments on each runner. The order of the runner analyses were randomly assigned and each rater completed a single analysis within 24 hours. After the rater had completed their initial assessment on all 10 runners, a second analysis was completed one week later with a different order of randomization. Eight sagittal plane (SAG) and four frontal plane (FRT) quantitative variables were measured for the left and right lower extremities on all 10 runners. Intra- and inter-rater reliability was assessed using intraclass correlation coefficients (ICC) and standard error of the measurement (SEM). RESULTS: The intra-rater ICC values for experienced raters ranged from 0.75 to 0.98 for the SAG and 0.45 to 0.96 for FRT variables. The inter-rater ICC values between the experienced raters ranged from 0.76 to 0.99 for the SAG and 0.82 to 0.98 for FRT variables. The intra-rater ICC values for inexperienced raters ranged from 0.54 to 0.99 for the SAG and 0.08 to 0.97 for FRT variables. The inter-rater ICC values between the inexperienced raters ranged from 0.93 to 0.99 for the SAG and 0.79 to 0.98 for FRT variables. Intra-rater SEM values based on average means of all raters ranged from 1 to 47% of the mean values obtained for the SAG and from 6 to 158% for the FRT variables. CONCLUSIONS: The intra-rater and inter-rater reliability levels were higher for SAG quantitative variables assessed in this study in comparison to FRT variables. Experience does not appear to be a factor when consistency is required with repeated analyses on the same runner. LEVEL OF EVIDENCE: 4, Controlled laboratory study.

Timing of initiating manual therapy and therapeutic exercises in the management of patients after hindfoot fractures: a randomized controlled trial.

STUDY DESIGN: Randomized clinical trial. BACKGROUND: Patients with fractures to the talus and calcaneus report decreased functional outcomes and develop long-term functional limitations. Although physical therapy is typically not initiated until six weeks after fixation, there's little research on the optimal time to initiate a formal physical therapy program. OBJECTIVES: To assess whether initiating physical therapy including range of motion (ROM) and manual therapy two weeks post-operatively (EARLY) vs. six weeks post-operatively (LATE) in patients with fixation for hindfoot fractures results in different clinical outcomes. METHODS: Fifty consecutive participants undergoing operative fixation of a hindfoot fracture were randomized to either EARLY or LATE physical therapy. Outcomes, including the American Orthopedic Foot and Ankle Society Hindfoot Scale (AOFAS), the Lower Extremity Functional Scale (LEFS), active ROM, swelling, and pain, were collected at three and six months and analyzed using linear mixed-modeling to examine change over time. Adverse events were tracked for 12 months after surgery. RESULTS: The EARLY group demonstrated significantly larger improvements for the AOFAS (p = .01) and the LEFS (p = .01) compared to the LATE group. Pairwise comparison of the LEFS favors the EARLY group at 6 months [7.5 (95%CI -.01 to 15.0), p = .05]. There were no differences between the groups with regard to ROM, pain, and swelling. The LATE group incurred increased adverse events in this study. CONCLUSION: Initiating early physical therapy may improve long-term outcomes and mitigate complications in patients after hindfoot fractures. LEVEL OF EVIDENCE: Therapy, level 2b.

Use of high speed stereo radiography to assess the foot orthoses effectiveness in controlling midfoot posture during walking: A pilot study.

BACKGROUND: The intent of this pilot study was to determine the feasibility of using high-speed stereo radiography (HSSR) to assess the effectiveness of footwear and foot orthoses in controlling the change in the position of the midfoot during walking in individuals with a flexible pes planus foot type. METHODS: Four individuals (1 female; 3 male) with a mean age of 25 years (range 22-29) and a bilateral flexible pes planus foot type participated in the study. The HSSR system was used to measure 3-dimensional changes in the longitudinal arch angle (LAA) with each participant walking barefoot, shoe only and shoes with orthoses. RESULTS: The HSSR system was found to be highly effective in measuring the change in the position of the midfoot, as measured using the LAA, when wearing footwear with or without foot orthoses. Based on an assessment of mean values, three out of the four participants demonstrated a change in the LAA as a result of using either shoes only or shoes with orthoses. The methodology used in this pilot study for assessing the effect of footwear and foot orthoses on the posture of the midfoot was highly effective with no side-effects noted by any of the study participants. CONCLUSIONS: Future studies using the HSSR will require modifications to participant inclusion criteria as well as alterations to the data collection methodology. The HSSR system used in this study is feasible for use in larger cohort studies assessing footwear and foot orthosis effectiveness with the described modifications.

Hardness and posting of foot orthoses modify plantar contact area, plantar pressure, and perceived comfort when cycling.

OBJECTIVES: To evaluate the effects of hardness and posting of orthoses on plantar profile and perceived comfort and support during cycling. DESIGN: A repeated measures study with randomised order of orthoses, hardness, and posting conditions. METHODS: Twenty-three cyclists cycled at a cadence of 90rpm and a perceived exertion rating of twelve. Contoured soft and hard orthoses with or without a medial forefoot or lateral forefoot post were evaluated. Plantar contact area, mean pressure and peak pressure were measured for nine plantar regions using the pedar®-X system and represented as a percentage of the total (CA%, MP%, and PP% respectively). Perceived comfort and support was rated on a visual analogue scale. RESULTS: The softer orthosis significantly increased CA% (p=0.014) across the midfoot and heel with a decrease in the toe region and forefoot. MP% (p=0.034) and PP% (p=0.012) were significantly increased at the mid and lateral forefoot with reductions in MP% at the midfoot and in PP% at the hallux and toes. Forefoot posting significantly increased CA% (p=0.018) at the toes and forefoot and decreased it at the heel. PP% was significantly altered (p=0.013) based on posting position. Lateral forefoot posting significantly decreased heel comfort (p=0.036). CONCLUSION: When cycling, a soft, contoured orthosis increased contact across the midfoot and heel, modulating forefoot and midfoot plantar pressures but not altering comfort or support. Forefoot postings significantly modified contact areas and plantar pressures and reduced comfort at the heel.

CAN RUNNERS PERCEIVE CHANGES IN HEEL CUSHIONING AS THE SHOE AGES WITH INCREASED MILEAGE?

BACKGROUND: For those runners who utilize footwear and have a rearfoot strike pattern, the durability of the midsole heel region has been shown to deteriorate as shoe mileage increases. PURPOSE: The purpose of this study was threefold: 1) to determine if the runner can self-report changes in heel cushioning properties of the midsole after an extended period of distance running, 2) to determine if force and plantar pressures measured in the heel region of the midsole using a capacitance sensor insole change after running 640 km, and 3) to determine if a durometer could be used clinically to objectively measure changes in the hardness of the material in the heel region of the midsole. STUDY DESIGN: Cross-sectional Study. METHODS: Fifteen recreational runners voluntarily consented to participate and were provided with a new pair of running shoes. Each participant's running style was observed and classified as having a rearfoot strike pattern. Inclusion criteria included running at least 24 km per week, experience running on a treadmill, no history of lower extremity congenital or traumatic deformity, or acute injury six months prior to the start of the study. The ability of each participant to self-perceive changes in shoe cushioning, comfort and fit was assessed using the Footwear Comfort Assessment Tool (FCAT). In-shoe plantar pressures and vertical forces were assessed using a capacitance sensor insole while runners ran over a 42-meter indoor runway. A Shore A durometer was used to measure the hardness of the midsole in the heel region. All measures were completed at baseline (zero km) and after running 160, 320, 480, and 640 km. In addition to descriptive statistics, a repeated measures analysis of variance was used to determine if the FCAT, pressures, forces, or midsole hardness changed because of increased running mileage. RESULT: While plantar pressures and vertical forces were significantly reduced in the midsole heel region, none of the runners self-reported a significant reduction in heel cushioning based on FCAT scores after running 640 km. The use of a durometer provided an objective measure of the changes in the heel region of the midsole that closely matched the reductions observed in pressure and force values. CONCLUSION: The results indicated that runners who have a rearfoot strike pattern will have a 16% to 33% reduction in the amount of cushioning in the heel region of the midsole after running 480 km. Although there were significant reductions in heel cushioning, the experienced recreational runners in this study were not able to self-perceive these changes after running 640 km. In addition, the use of a durometer provides a quick and accurate way to assess changes in the hardness of the heel region of the midsole as running mileage increases. LEVEL OF EVIDENCE: 3, Controlled laboratory study.

The use of a static measure to predict foot posture at midstance during walking.

Previous studies have successfully used the longitudinal arch angle (LAA) to assess foot posture, but the measurement consistency and ability of the LAA to predict dynamic foot posture during activity in a variety of foot types have not been evaluated. The purpose of this study was to determine the reliability of the LAA as well as if the clinical method of assessing the LAA could be used to predict the LAA at midstance during walking for supinated, normal, and pronated foot types. The Arch Height Ratio was used to select 35 participants with 12 supinated, 46 normal, and 12 pronated feet. A standard goniometer was used to measure the LAA (CLINIC_LAA) on both feet while standing. Both feet were then filmed using a high speed camera while walking on a treadmill. The LAA was determined by the angle formed by two lines drawn between the markers placed on the first metatatarsal and medial malleolus with the apex the navicular tuberosity. The LAA in midstance (WALK_LAA) was determined using the mean of five walking trials. The reliability of the CLINIC_LAA assessed on both feet by two raters over two days were excellent. There was no difference between the left and right foot for the CLINIC_LAA. The Pearson correlation between CLINIC_LAA and WALK_LAA for all 70 feet was r=0.96 (r2=0.92). The results indicate the LAA is highly predictive of foot posture at midstance in walking explaining over 90% of the variance for a wide range of foot types.

ACCURACY OF SELF-REPORTED FOOT STRIKE PATTERN IN INTERCOLLEGIATE AND RECREATIONAL RUNNERS DURING SHOD RUNNING.

BACKGROUND: Clinicians are interested in the foot strike pattern (FSP) in runners because of the suggested relationship between the strike pattern and lower extremity injury. PURPOSE: The purpose of this study was to assess the ability of collegiate cross-country runners and recreational runners to self-report their foot strike pattern during running. STUDY DESIGN: Cross-sectional Study. METHODS: Twenty-three collegiate cross-country and 23 recreational runners voluntarily consented to participate. Inclusion criteria included running at least 18 miles per week, experience running on a treadmill, no history of lower extremity congenital or traumatic deformity, or acute injury three months prior to the start of the study. All participants completed a pre-test survey to indicate their typical foot strike pattern during a training run (FSPSurvey). Prior to running, reflective markers were placed on the posterior midsole and the vamp of the running shoe. A high-speed camera was used to film each runner in standing and while running at his or her preferred speed on a treadmill. The angle between the vector formed by the two reflective markers and the superior surface of the treadmill was used to calculate the foot strike angle (FSA). To determine the foot strike pattern from the video data (FSPVideo), the static standing angle was subtracted from the FSA at initial contact of the shoe on the treadmill. In addition to descriptive statistics, percent agreement and Chi square analysis was used to determine distribution differences between the video analysis results and the survey. RESULTS: The results of the chi-square analysis on the distribution of the FSPSurvey in comparison to the FSPVideo were significantly different for both the XCRunners (p < .01; Chi-square = 8.77) and the REC Runners (p < .0002; Chi-square = 16.70). The cross-country and recreational runners could correctly self-identified their foot strike pattern 56.5% and 43.5% of the time, respectively. CONCLUSION: The findings of this study suggest that the clinician cannot depend on an experienced runner to correctly self-identify their FSP. Clinicians interested in knowing the FSP of a runner should consider performing the two-dimensional video analysis described in this paper. LEVEL OF EVIDENCE: 3.

THE USE OF A STATIC MEASURE TO PREDICT FOOT POSTURE AT MIDSUPPORT DURING RUNNING.

BACKGROUND: The posture of the foot has been implicated as a factor in the development of running-related injuries. A static measure of foot posture, such as the longitudinal arch angle (LAA), that can be easily performed and is predictive of the posture of the foot at midsupport while running could provide valuable information to enhance the clinician's overall evaluation of the runner. PURPOSE: The purpose of this study was to determine if the LAA, assessed in relaxed standing, could predict the posture of the foot at midsupport while running on a treadmill. STUDY DESIGN: Cross-sectional Study. METHODS: Forty experienced runners (mean age 26.6 years) voluntarily consented to participate. Inclusion criteria included running at least 18 miles per week, previous experience running on a treadmill, no history of lower extremity congenital or traumatic deformity, or acute injury three months prior to the start of the study. Each runner had markers placed on the medial malleolus, navicular tuberosity, and medial aspect 1(st) metatarsal head of both feet. A high speed camera (240 Hz) was used to film both feet of each runner in standing and while running on a treadmill at their preferred speed. The LAA in standing and at mid-support while running was determined by angle formed by two lines drawn between the three markers with the navicular tuberosity serving as the apex. The LAA in midsupport was determined using the mean of the middle five running trials. RESULTS: The levels of intra-rater and inter-rater reliability for the dynamic LAA were excellent. The results of the t-tests indicated that mean values between the left and right foot were not significantly different for the standing or running LAA. The results of the t-tests between male and female runners were also not significantly different for standing or running LAA. The Pearson correlation between standing and running LAA for all 80 feet was r = 0.95 (r(2) = 0.90). CONCLUSIONS: The standing LAA was found to be highly predictive of the running LAA at midsupport while running. Approximately 90% of the variance associated with foot posture at midsupport in running could be explained by the standing LAA. LEVEL OF EVIDENCE: 4, Controlled laboratory study.

Use of a temporary supramalleolar orthosis to manage foot pain in a patient with rheumatoid arthritis: A case report.

BACKGROUND: Rheumatoid arthritis is a chronic inflammatory condition characterized by joint pain, stiffness, and functional disability. Approximately 90% of patients will report symptoms in the foot or ankle during the course of their disease. CASE DESCRIPTION: A case of a 40-year-old woman with a 12-year history of rheumatoid arthritis referred to outpatient physical therapy with a chief complaint of pain in the lateral rearfoot and forefoot is presented. At the time of the initial examination, the patient reported persistent pain ranging from 3 to 9/10, aggravated when standing and walking during activities of daily living. Treatment consisted of the fabrication of a supramalleolar orthosis that incorporated an in-shoe foot orthosis to address functional limitations and abnormal foot and ankle posture. A home exercise program was prescribed to address potential balance deficits and strength loss following the application of the orthosis. OUTCOMES: Clinically significant improvements were seen in pain, gait speed, and on the Foot Function Index following the implementation of the orthotic device. The patient returned to standing and walking with minimal symptom limitations. DISCUSSION: This case report highlights the short-term clinical outcomes when using a supramalleolar orthosis in conjunction with an in-shoe foot orthosis to manage lateral rearfoot and forefoot pain in a patient with rheumatoid arthritis.

Orthosis-Shaped Sandals Are as Efficacious as In-Shoe Orthoses and Better than Flat Sandals for Plantar Heel Pain: A Randomized Control Trial.

OBJECTIVE: To investigate efficacy of a contoured sandal being marketed for plantar heel pain with comparison to a flat flip-flop and contoured in-shoe insert/orthosis. METHOD: 150 volunteers aged 50 (SD: 12) years with plantar heel pain (>4 weeks) were enrolled after responding to advertisements and eligibility determined by telephone and at first visit. Participants were randomly allocated to receive commercially available contoured sandals (n = 49), flat flip-flops (n = 50) or over the counter, pre-fabricated full-length foot orthotics (n = 51). Primary outcomes were a 15-point Global Rating of Change scale (GROC: 1 = a very great deal worse, 15 = a very great deal better), 13 to 15 representing an improvement and the 20-item Lower Extremity Function Scale (LEFS) on which participants rate 20 common weight bearing activities and activities of daily living on a 5-point scale (0 = extreme difficulty, 4 = no difficulty). Secondary outcomes were worst level of heel pain in the preceding week, and the foot and ankle ability measure. Outcomes were collected blind to allocation. Analyses were done on an intention to treat basis with 12 weeks being the primary outcome time of interest. RESULTS: The contoured sandal was 68% more likely to report improvement in terms of GROC compared to flat flip-flop. On the LEFS the contoured sandal was 61% more likely than flat flip-flop to report improvement. The secondary outcomes in the main reflected the primary outcomes, and there were no differences between contoured sandal and shoe insert. CONCLUSIONS AND RELEVANCE: Physicians can have confidence in supporting a patient's decision to wear contoured sandals or in-shoe orthoses as one of the first and simple strategies to manage their heel pain. TRIAL REGISTRATION: The Australian New Zealand Clinical Trials Registry ACTRN12612000463875.

Plantar Pressure and Gait Symmetry in Individuals with Fractures versus Tendon Injuries to the Hindfoot.

BACKGROUND: The intent of this study was to determine whether differences in function, walking characteristics, and plantar pressures exist in individuals after operative fixation of an intra-articular calcaneal fracture (HFX) compared with individuals with operative repair of an Achilles tendon rupture (ATR). METHODS: Twenty patients (ten with HFXs and ten with ATRs) were recruited approximately 3.5 months after operative intervention. All of the participants completed the Lower Extremity Functional Scale and had their foot posture assessed using the Foot Posture Index. Walking velocity was assessed using a pressure mat system, and plantar pressures were measured using an in-shoe sensor. In addition to between-group comparisons, the involved foot was compared with the uninvolved foot for each participant. RESULTS: There were no differences in age, height, weight, or number of days since surgery between the two groups. The HFX group had lower Lower Extremity Functional Scale scores, slower walking velocities, and different forefoot loading patterns compared with the ATR group. The involved limb of both groups was less pronated. CONCLUSIONS: The results indicate that individuals with an HFX spend more time on their involved limb and walk slower than those with an ATR. Plantar pressures in the HFX group were higher in the lateral forefoot and lower in the medial forefoot and in the ATR group were symmetrically lower in the forefoot.

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 Organization's 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.

The effect of exercise and time on the height and width of the medial longitudinal arch following the modified reverse-6 and the modified augmented low-dye taping procedures.

PURPOSE/BACKGROUND: No evidence exits regarding the magnitude of the change in foot posture following the "modified reverse-6" (MR6) taping procedure, either alone or in combination with the "low-dye" (LD) taping technique. The purpose of this study was to investigate the change in the height and width of the midfoot after application of the MR6 and the MR6 plus the LD (MR6+LD) taping technique and determine how long those changes last. METHODS: Eleven individuals (2 female and 9 male) were recruited for this study and were tested under each of two experimental conditions, the MR6 and the MR6+LD taping technique. The order of testing for the two conditions was randomly determined. For each condition, the height and width of the midfoot at 50% of each subject's foot length was initially measured and then again immediately following the application of the tape. These measurements were repeated four hours later immediately prior to running two miles on a treadmill, again immediately after running, and finally after another four hours. RESULTS: The dorsal arch height increased significantly with both the MR6 and MR6+LD taping, but only the MR6+LD remained statistically greater after four hours, a bout of exercise and again at the end of the day. The mean width of the midfoot significantly decreased with both taping procedures. The change in the width of the midfoot remained significantly decreased in both taping conditions after exercise and throughout the day. CONCLUSIONS: Both taping procedures are able to significantly change the height and width of the medial longitudinal arch of the foot, but the change lasted longer when the two taping procedures were combined. LEVELS OF EVIDENCE: Level 3, Prospective Cohort Study.