Effect of a task's postural demands on medial longitudinal arch deformation and activation of foot intrinsic and extrinsic musculatur.

PURPOSE: It is not well established how motion and muscle activation of the medial longitudinal arch (MLA) of the foot vary under different loading conditions. Intrinsic and extrinsic foot muscles may play a role in postural control, which may be investigated by comparing loading tasks with differing postural demands. The objective of this study was to investigate the interaction of MLA flexibility and loading task on muscle activation. METHODS: Twenty healthy adults completed two instrumented single-foot loading tasks: controlled external load of 50% body weight while sitting and bilateral standing. Fine-wire intramuscular and surface electromyography collected flexor hallucis brevis, abductor hallucis, tibialis posterior, flexor hallucis longus, tibialis anterior, and peroneus longus activation. MLA deformation was measured as a percent change in navicular height with loading. RESULTS: During seated external loading, greater MLA deformation was associated with greater muscle activation for all instrumented muscles (R² = 0.224-0.303, p < 0.05) except for tibialis anterior. During bilateral stance, there were no correlations between MLA deformation and muscle activation. Activation of all extrinsic muscles except for tibialis anterior were greater during bilateral standing than during external loading ( p = 0.002-0.013), indicating activation of these muscles was caused by postural demands of the standing task, not simply load. CONCLUSIONS: MLA deformation and muscle activation are strongly task-dependent.

Physical therapists' role in prevention and management of patellar tendinopathy injuries in youth, collegiate, and middle-aged indoor volleyball athletes.

Patellar tendinopathy is highly prevalent in all ages and skill levels of volleyball athletes. To illustrate this, we discuss the clinical, biomechanical, and ultrasound imaging presentation and the intervention strategies of three volleyball athletes at different stages of their athletic career: youth, middle-aged, and collegiate. We present our examination strategies and interpret the data collected, including visual movement analysis and dynamics, relating these findings to the probable causes of their pain and dysfunction. Using the framework of the EdUReP concept, incorporating Education, Unloading, Reloading, and Prevention, we propose intervention strategies that target each athlete's specific issues in terms of education, rehabilitation, training, and return to sport. This framework can be generalized to manage patellar tendinopathy in other sports requiring jumping, from youth to middle age, and from recreational to elite competitive levels.

Physical therapists' role in prevention and management of patellar tendinopathy injuries in youth, collegiate, and middle-aged indoor volleyball athletes

ABSTRACTPatellar tendinopathy is highly prevalent in all ages and skill levels of volleyball athletes. To illustrate this, we discuss the clinical, biomechanical, and ultrasound imaging presentation and the intervention strategies of three volleyball athletes at different stages of their athletic career: youth, middle-aged, and collegiate. We present our examination strategies and interpret the data collected, including visual movement analysis and dynamics, relating these findings to the probable causes of their pain and dysfunction. Using the framework of the EdUReP concept, incorporating Education, Unloading, Reloading, and Prevention, we propose intervention strategies that target each athlete's specific issues in terms of education, rehabilitation, training, and return to sport. This framework can be generalized to manage patellar tendinopathy in other sports requiring jumping, from youth to middle age, and from recreational to elite competitive levels.

Effect of posterior tibial tendon dysfunction on unipedal standing balance test.

BACKGROUND: Foot pain and diminished functional capacity are characteristics of tibialis posterior tendon dysfunction (TPTD). This study tested the hypotheses that women with TPTD would have impaired performance of a unipedal standing balance test (USBT) and that balance performance would be related to the number of single limb heel raises (SLHR). METHODS: Thirty-nine middle-aged women, 19 with early stage TPTD (stage I and II), were instructed to perform 2 tasks; a USBT and repeated SLHR. Balance success was defined as a 10-second stance. For those who were successful, center of pressure (COP) data in anterior-posterior (AP) and medial-lateral (ML) directions were recorded as a measure of postural sway. SLHR performance was divided into 3 bins (≤2; 3-9 and > 10 repetitions). The between-balance success on performing the SLHR test was analyzed using the Fisher's exact test (2 × 3). Independent t tests were used to compare between-group differences in postural sway. Relationship of postural sway to the number of heel raises was assessed using Spearman's rho. RESULTS: The success rate of the USBT was significantly lower in women with TPTD than the controls (47% vs 85%, P = .041). In addition, women with TPTD who completed the USBT exhibited increased AP COP displacement (14.0 ± 7.4 vs 8.4 ± 1.3 mm, P = .008), and a strong trend of increased ML COP displacement (8.3 ± 4.5 vs 6.1 ± 1.2 mm, P = .050). The success rate of USBT was correlated with the number of SLHR (P = .01). The AP and ML COP displacement were correlated with SLHR (r = -.538 and .495), respectively. CONCLUSIONS: Women with TPTD have difficulty in performing the USBT. Performance of the USBT and SLHR are highly correlated and predictive of each other. CLINICAL RELEVANCE: A unipedal balance test may be used as a proxy TPTD assessment tool to the heel raising test when pain prevents performance. LEVEL OF EVIDENCE: Level III, case control study.

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.

Persistent medial foot pain in an adolescent athlete.

The patient was a 15-year-old adolescent male who was referred to a physical therapist for a chief complaint of worsening right medial foot pain. Given the worsening nature of the patient's right medial foot pain, palpatory findings, and a prior recommendation for computed tomography from a radiologist, the patient was referred to his physician. Subsequent computed tomography imaging of the right foot revealed a nondisplaced fracture through the dorsal-medial aspect of the navicular.

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.

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.

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.

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

BACKGROUND: Posterior 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/DESIGN: This 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. DISCUSSION: We 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.

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 Student's 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.

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.

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.