Effect of heel lift insertion on gait function in a patient with total hip arthroplasty with patient-perceived leg length difference: a case report.

[Purpose] The effect of heel lift insertion on gait in patients who have undergone total hip arthroplasty (THA) with patient-perceived leg length difference is seldom referenced in the literature. We used an AB design to investigate the alterations of gait function before and after inserting a heel lift on the non-operative side. [Participant and Methods] The participant had a patient-perceived leg length difference after THA and presented with gait disturbance. The survey phase was 10 days (phase A: normal physiotherapy for five days, and phase B: normal physiotherapy and heel lift insertion for another five days) from the 17th day following THA. The ambulatory task was conducted at a self-determined, comfortable pace and objectively assessed using an inertial sensor. [Results] The insertion of a heel lift partially improved the gait symmetry and the ratio of lumbar acceleration in three directions; it also corrected the patient-perceived leg length difference. [Conclusion] An investigation was carried out to examine the impact of a heel lift on gait in a single case of THA with patient-reported leg length difference. The application of a heel lift may enhance the relationship between the patient-perceived leg length difference, gait symmetry, and the ratio of lumbar acceleration in three dimensions.

Controlled trial to compare the Achilles tendon load during running in flatfeet participants using a customized arch support orthoses vs an orthotic heel lift.

BACKGROUND: Achilles tendinopathy is one of the most common overuse injuries in running, and forefoot pronation, seen in flatfeet participants, has been proposed to cause additional loading across the Achilles tendon. Foot orthoses are one of the common and effective conservative treatment prescribed for Achilles tendinopathy, it works by correcting the biomechanical malalignment and reducing tendon load. Previous studies have shown reduction of Achilles Tendon load (ATL) during running by using customized arch support orthosis (CASO) or an orthotic heel lift (HL). However, there are still little biomechanical evidence and comparative studies to guide orthotic prescriptions for Achilles tendinopathy management. Therefore, this study seeks to investigate the two currently employed orthotic treatment options for Achilles tendinopathy: CASO and HL for the reduction of ATL and Achilles tendon loading rate (ATLR) in recreational runners with flatfeet. METHODS: Twelve participants were recruited and run along the runway in the laboratory for three conditions: (1) without orthoses, (2) with CASO (3) with HL. Kinematic and kinetic data were recorded by 3D motion capturing system and force platform. Ankle joint moments and ATL were computed and compared within the three conditions. RESULTS: Participants who ran with CASO (p = 0.001, d = 0.43) or HL (p = 0.001, d = 0.48) associated with a significant reduction in ATL when compared to without orthotics while there was no significant difference between the two types of orthoses, the mean peak ATL of CASO was slightly lower than HL. Regarding the ATLR, both orthoses, CASO (p = 0.003, d = 0.93) and HL (p = 0.004, d = 0.78), exhibited significant lower value than the control but similarly, no significant difference was noted between them in which the use of CASO yielded a slightly lower loading rate than that of HL. CONCLUSIONS: Both CASO and HL were able to cause a significant reduction in peak ATL and ATLR comparing to without orthotics condition. There were subtle but no statistically significant differences in the biomechanical effects between the two types of orthoses. The findings help to quantify the effect of CASO and HL on load reduction of Achilles tendon and suggests that foot orthoses may serve to prevent the incidence of Achilles tendon pathologies. TRIAL REGISTRATION: NCT04003870 on clinicaltrials.gov 1 July 2019.

Efficacy of heel lifts for mid-portion Achilles tendinopathy (the LIFT trial): study protocol for a randomised controlled trial.

BACKGROUND: Mid-portion Achilles tendinopathy is a common condition, characterised by localised Achilles tendon load-related pain and dysfunction. Numerous non-surgical treatments have been proposed for the treatment of this condition, but many of these treatments have a poor or non-existent evidence base. Heel lifts have also been advocated as a treatment for Achilles tendinopathy, but the efficacy and mechanism of action of this intervention is unclear. This proposal describes a randomised controlled trial comparing the effectiveness of heel lifts versus sham heel lifts for reducing pain associated with mid-portion Achilles tendinopathy, with an embedded biomechanical analysis. METHODS: One hundred and eight men and women aged 18 to 65 years with mid-portion Achilles tendinopathy (who satisfy the inclusion and exclusion criteria) will be recruited. Participants will be randomised, using the website Sealed Envelope, to either a control group (sham heel lifts) or an experimental group (heel lifts). Both groups will be provided with education regarding acceptable pain levels to ensure all participants receive some form of treatment. The participants will be instructed to use their allocated intervention for at least 8 h every day for 12 weeks. The primary outcome measure will be pain intensity (numerical rating scale) at its worst over the previous week. The secondary outcome measures will be additional measures of Achilles tendon pain and disability, participant-perceived global ratings of change, function, level of physical activity and health-related quality of life. Data will be collected at baseline and the primary endpoint (week 12). Data will be analysed using the intention-to-treat principle. In addition, the acute kinetic and kinematic effects of the interventions will be examined at baseline in a subpopulation of the participants (n = 40) while walking and running using three-dimensional motion analysis. DISCUSSION: The LIFT trial (efficacy of heeL lIfts For mid-portion Achilles Tendinopathy) will be the first randomised trial to compare the efficacy of heel lifts to a sham intervention in reducing pain and disability in people with Achilles tendinopathy. The biomechanical analysis will provide useful insights into the mechanism of action of heel lifts. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12623000627651 . Registered 7 June 2023.

Scoliosis and Lower Limb Inequality: To Lift or Not to Lift, That Is the Question.

In subjects with scoliotic alterations of the spine, asymmetrical lengths of the lower limbs are frequently observed, a condition commonly referred to as leg length inequality (LLI) or discrepancy (LLD). This asymmetry can induce pelvic misalignments, manifested by an asymmetric height of the iliac crests, and consequently an alteration of the spine's axis. Although correcting this discrepancy might appear to be a straightforward solution, further investigation may reveal other indications. The purpose of this article is to aid clinicians confronted with the decision of whether to compensate for an LLI in individuals with scoliosis, encompassing both adolescents and adults. It presents a literature review on the incidence of LLIs in the general population, distinguishing between structural LLI (sLLI) and functional LLI (fLLI) types of LLIs, and quantifying their magnitude with clinical and instrumental evaluation. Additionally, it links these two types of LLIs to the type of scoliosis (structural or functional). From a clinical perspective, it also examines the compensatory mechanisms employed by the pelvis in the presence of structural or functional LLIs in order to draw useful indications for therapeutic decisions. Moreover, it proposes an additional evaluation parameter in the coronal plane, namely the central sacral vertical line (CSVL), to aid in the decision-making process regarding LLI compensation. Although this parameter has been documented in the literature, it has been little associated with LLIs. The findings indicate that scoliotic discrepancies should be compensated (conservatively or surgically) only when the imbalance of the femoral heads is on the same side as the imbalance of the sacrum and the iliac crests; this corrective action should result in a reduction of the overhang in the coronal plane.

Effect of heel lifts in elderly individuals with spinal kyphosis.

BACKGROUND: The present study aimed to elucidate the effects of heel lifts on spinal alignment, walking, and foot pressure pattern in elderly individuals with spinal kyphosis. METHODS: The spinal alignment, walking speed, step length and foot pressure of 33 community-dwelling elderly individuals with spinal kyphosis (3 men, 30 women; mean age 77.3 years) were examined before and after the application of 10-mm moderately elastic heel lifts. FINDINGS: Spinal alignment of total inclination (mean value 6.9°vs 4.5°) and thoracic angle (43.6°vs 36.2°) were significantly lower after the application of heel lifts than before the application. The lumbar angle (7.3°vs 10.0°) was significantly higher after the application than before the application. Walking speed (0.78 vs 0.88 m/s) and step length (0.42 m vs 0.45 m) were significantly higher after the application. The partial foot pressure as a percentage of body weight of the hallux (6.7% vs 9.0%) and lateral toes (6.5% vs 9.0%) was significantly higher after the application of heel lifts than before the application. The partial foot pressure as a percentage of body weight of the heel (68.9% vs 57.5%) was significantly lower after the application than before the application. INTERPRETATION: In conclusion, heel lifts influenced the sagittal spinal alignment of elderly individuals. Walking speed and step length increased after the application of these devices. Increase in foot pressure in the hallux and lateral toe areas was probably related to these improvements in walking parameters.

Muscle Activity of the Triceps Surae With Novel Propulsion Heel-Lift Orthotics in Recreational Runners.

BACKGROUND: The triceps surae muscle has been identified with propulsion during running gait, and typical heel-lift orthotics (THOs) have been used to treat some sports injuries of this structural-biomechanical unit. The effects of a novel propulsion heel-lift orthotic (PHO) on surface electromyography (EMG) activity of the gastrocnemius during a full cycle of running have yet to be tested. PURPOSE/HYPOTHESIS: We aimed to assess EMG changes in gastrocnemius medialis and lateralis muscle activity when wearing THOs, PHOs, or neutral sports shoes only (SO) during running. We hypothesized that EMG activity of the triceps surae muscle would be lower for PHOs than THOs or SO during running. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 26 healthy, regular recreational runners of both sexes (mean age, 33.58 ± 6.02 years) with a neutral Foot Posture Index and rearfoot strike pattern were recruited to run on a treadmill at 9 km/h using aleatory THOs of 6 and 9 mm, PHOs, and SO while EMG activity of the gastrocnemius medialis and lateralis muscles was recorded over a 30-second period. Intraclass correlation coefficients were calculated to assess reliability. RESULTS: The intraclass correlation coefficient values indicated near perfect reliability, ranging from 0.801 for 6-mm THOs to 0.959 for SO in the gastrocnemius lateralis muscle. EMG activity of the gastrocnemius lateralis muscle was greater for PHOs (25.516 ± 4.780 mV) than for SO (23.140 ± 4.150 mV) (P < .05), but EMG activity of the gastrocnemius medialis muscle did not show any statistically significant difference between conditions (23.130 ± 2.980 mV vs 26.315 ± 2.930 mV, respectively) (P = .3). CONCLUSION: A novel PHO may increase muscle activity of the gastrocnemius lateralis during a full cycle of running gait; consequently, its prescription to treat triceps surae muscle injuries is cautioned. CLINICAL RELEVANCE: The prescription of novel PHOs could increase EMG activity, which has not been previously described.

The effect of increasing heel height on lower limb symmetry during the back squat in trained and novice lifters.

BACKGROUND: Symmetry during lifting is considered critical for allowing balanced power production and avoidance of injury. This investigation assessed the influence of elevating the heels on bilateral lower limb symmetry during loaded (50% of body weight) high-bar back squats. METHODS: Ten novice (mass 67.6 ± 12.4 kg, height 1.73 ± 0.10 m) and ten regular weight trainers (mass 66.0 ± 10.7 kg, height 1.71 ± 0.09 m) were assessed while standing on both the flat level floor and on an inclined board. Data collection used infra-red motion capture procedures and two force platforms to record bilateral vertical ground reaction force (GRFvert) and ankle, knee and hip joint kinematic and kinetic data. Paired t-tests and statistical parametric mapping (SPM1D) procedures were used to assess differences in discrete and continuous bilateral symmetry data across conditions. RESULTS: Although discrete joint kinematic and joint moment symmetry data were largely unaffected by raising the heels, the regular weight trainers presented greater bilateral asymmetry in these data than the novices. The one significant finding in these discrete data showed that raising the heels significantly reduced maximum knee extension moment asymmetry (P = 0.02), but in the novice group only. Time-series analyses indicated significant bilateral asymmetries in both GRFvert and knee extension moments mid-way though the eccentric phase for the novice group, with the latter unaffected by heel lift condition. There were no significant bilateral asymmetries in time series data within the regular weight training group. CONCLUSIONS: This investigation highlights that although a degree of bilateral lower limb asymmetry is common in individuals performing back squats, the degree of this symmetry is largely unaffected by raising the heels. Differences in results for discrete and time-series symmetry analyses also highlight a key issue associated with relying solely on discrete data techniques to assess bilateral symmetry during tasks such as the back squat.

THE INFLUENCE OF HEEL HEIGHT ON MUSCLE ELECTROMYOGRAPHY OF THE LOWER EXTREMITY DURING LANDING TASKS IN RECREATIONALLY ACTIVE FEMALES: A WITHIN SUBJECTS RANDOMIZED TRIAL.

BACKGROUND: An increased risk of ACL injury has been shown in female athletes who land from jumping maneuvers with knee angles close to extension and in those who demonstrate a hamstring-to-quadriceps muscle recruitment imbalance. HYPOTHESIS/PURPOSE: The purpose of this study was to determine if added heel lift height would alter electromyography (EMG) magnitude and timing of the quadriceps (vastus medialis, vastus lateralis), hamstrings (semitendinosus, biceps femoris) and gastroc (medial gastroc, lateral gastroc) musculature during forward jump and drop-rebound jump landing tasks in females. The authors hypothesized increased heel lift height would promote recruitment of the hamstring and gastrocnemius muscles and increase the time to peak muscle activity in the quadriceps muscles. STUDY DESIGN: Prospective randomized trial. METHODS: 60 recreationally active females participated. Participants performed five repetitions of forward jump and drop-rebound jump landing tasks while wearing different heel lifts heights (0, 12, 18, 24 mm) placed on the under-side of an athletic shoe. Task order and heel lift height were randomized. Dependent measures were average magnitude of muscle recruitment (AMR), peak magnitude of muscle recruitment (PMR), and time to reach PMR for six lower extremity muscle groups as measured by surface EMG. RESULTS: Repeated measures ANOVAs were used to determine the influence of heel lift height on the dependent measures. There were no signficant differences in the AMR, PMR, or time to reach PMR with the four different heel heights during the landing maneuvers, with one exception. A significant difference was found in the time to achieve PMR in the semitendinosis muscle during a forward jump landing (p = .024). Post hoc analysis found significant differences with both the 18mm and 24mm heel lift height compared to 0mm. CONCLUSIONS: Utilization of larger heel lifts (18mm and 24mm) to influence landing biomechanics may be of potential benefit; however, only when performing forward jump landing tasks. Further investigation into the protective effects of a quicker onset of semitendinosis peak magnitude is warranted. LEVEL OF EVIDENCE: 2.

Efficacy of heel lifts versus calf muscle eccentric exercise for mid-portion Achilles tendinopathy (the HEALTHY trial): study protocol for a randomised trial.

BACKGROUND: Mid-portion Achilles tendinopathy is a common musculoskeletal condition characterised by degeneration of the Achilles tendon, which causes pain and disability. Multiple non-surgical treatments have been advocated for this condition including calf muscle eccentric exercise and in-shoe heel lifts. Although adherence is challenging, there is evidence to suggest that calf muscle eccentric exercise is effective in decreasing pain and improving function in people with Achilles tendinopathy. Heel lifts reduce ankle joint dorsiflexion and Achilles tendon strain, however their efficacy in the management of Achilles tendinopathy is unclear. This article describes the design of a parallel-group randomised trial comparing the efficacy of heel lifts to calf muscle eccentric exercise for Achilles tendinopathy. METHODS: Ninety-two participants with Achilles tendinopathy will be randomised to one of two groups: (i) a heel lift group that will receive pre-fabricated 12 mm in-shoe heel lifts (Clearly Adjustable®), or (ii) an exercise group that will be advised to carry out a calf muscle eccentric exercise program (twice a day, 7 days a week, for 12 weeks). Outcome measures will be obtained at baseline, 2, 6 and 12 weeks; the primary endpoint for assessing efficacy being 12 weeks. The primary outcome measure will be the total score of the Victorian Institute of Sport Assessment - Achilles (VISA-A) questionnaire. Secondary outcome measures will include thickness and integrity of the Achilles tendon (using ultrasound tissue characterisation [UTC]), participant perception of treatment effect on pain and function (using the 7-point Patient Global Impression of Change scale), severity of pain at the Achilles tendon (using a 100 mm visual analogue scale) in the previous week, health status (using the EuroQol-5D-5L™ questionnaire), physical activity levels (using the 7-day Recall Physical Activity Questionnaire) and calf muscle function (using the standing heel rise test). Data will be analysed using the intention to treat principle. DISCUSSION: The HEALTHY trial (Heel lifts versus calf muscle eccentric Exercise for AchiLles TendinopatHY) is the first randomised trial to compare the efficacy of heel lifts to calf muscle eccentric exercise in reducing pain and improving function in people with Achilles tendinopathy. A pragmatically designed trial was developed to ensure that if the interventions are found to be effective, the findings can be readily implemented in clinical practice. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12617001225303. Registered on August 22nd, 2017.

Insertional achilles tendinopathy associated with altered transverse compressive and axial tensile strain during ankle dorsiflexion.

The purposes of this case-control study (N = 20) were to examine the effects of insertional Achilles tendinopathy (IAT) and tendon region on tendon strain in patients with IAT compared to a control group without tendinopathy. An ultrasound transducer was positioned over the Achilles tendon insertion during dorsiflexion tasks, which included standing and partial squat. A non-rigid image registration-based algorithm was used to estimate transverse compressive and axial tensile strains of the tendon from radiofrequency ultrasound images, which was segmented into two regions (superficial tendon and deep). For transverse compressive strain, two-way mixed effects ANOVAs demonstrated that there were interaction effects between group and tendon region for both dorsiflexion tasks (Heel lowering, p = 0.004; Partial squat, p = 0.008). For axial tensile strain, the IAT group demonstrated a main effect of lower tensile strain than the control group (Standing, p = 0.001; Partial squat, p = 0.033). There was also a main effect of greater tensile strain in the superficial region of the tendon compared to the deep during standing (p = 0.002), but not during partial squat (p = 0.603). Reduced transverse compressive and axial tensile strains in the IAT group indicate altered mechanical properties specific to the region of IAT pathology. Additionally, patterns of compressive strain are consistent with the theory of calcaneal impingement contributing to IAT pathology. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:910-915, 2017.

Adding an arch support to a heel lift improves stability and comfort during gait.

Heel lifts have been widely used as a conservative treatment for some musculoskeletal problems and complaints. However, the heel rise caused by heel lifts may also affect the plantar pressure distribution and stability during walking. This study aimed to test whether adding an arch support to a heel lift would improve its stability and comfort through comparing the center of pressure (COP) during walking and subjective ratings between heel lifts with and without an arch support. Fifteen healthy male participants were asked to walk along an 8m walkway while wearing high-cut footwear with the control heel lifts and the heel lifts with an arch support. A Footscan pressure plate was used to measure the COP during walking. Subjective ratings including medial-lateral control, dynamic foot/shoe fitting and overall comfort were assessed for each participant. The results showed that compared to the control condition, the COP trajectory was medially shifted during stance phase of gait in the arch support condition. The maximum displacements and velocity of medial-lateral COP in the forefoot contact phase were smaller in the arch support condition than in the control condition. Adding an arch support to a heel lift also significantly improved the subjective ratings in terms of the medial-lateral control, dynamic foot/shoe fitting and overall comfort. The findings of this study suggest that adding an arch support to a heel lift could improve its stability and comfort during walking.

Evaluation of the effect of heel lift on postural stability and symmetry of muscle activity.

BACKGROUND: Although a leg length inequality (LLI) has the effect on the performed movement, more complex indices for the evaluation of kinematic variables of postural stability and a symmetry of a muscle activity during standing in subjects with the LLI were never used before. OBJECTIVE: The objective is to present appropriate parameters for an evaluation of kinematic variables of postural stability and muscle activity during standing, i.e. to consider EMG signals, in patients with LLI. METHODS: New indices are offered, such as a sway velocity (i.e. the mCTSIB method) and a modified symmetry index (SI), for a quantitative evaluation of EMG signals. The set of data for evaluating the effect of a heel lift was measured on patients with the LLI and healthy volunteers. RESULTS: Prior to the heel lift application, significant statistic differences were found between the mCTSIB of patients and the CG. These differences were no longer statistically significant after the heel lift was applied. As for the SI, the lowest values were found in the CG, while the greatest values were collected among patients before applying the heel lift. CONCLUSIONS: The results point out the benefits of using the newly applied indices in patients with the LLI. Both methods may become useful tools for the evaluation of the physical state of patients with the LLI in a medical practice.

Ultrasound strain mapping of Achilles tendon compressive strain patterns during dorsiflexion.

Heel lifts are commonly prescribed to patients with Achilles tendinopathy, yet little is known about the effect on tendon compressive strain. The purposes of the current study were to (1) develop a valid and reliable ultrasound elastography technique and algorithm to measure compressive strain of human Achilles tendon in vivo, (2) examine the effects of ankle dorsiflexion (lowering via controlled removal of a heel lift and partial squat) on compressive strain of the Achilles tendon insertion and (3) examine the relative compressive strain between the deep and superficial regions of the Achilles tendon insertion. All tasks started in a position equivalent to standing with a 30mm heel lift. An ultrasound transducer positioned over the Achilles tendon insertion was used to capture radiofrequency images. A non-rigid image registration-based algorithm was used to estimate compressive strain of the tendon, which was divided into 2 regions (superficial, deep). The bland-Altman test and intraclass correlation coefficient were used to test validity and reliability. One-way repeated measures ANOVA was used to compare compressive strain between regions and across tasks. Compressive strain was accurately and reliably (ICC>0.75) quantified. There was greater compressive strain during the combined task of lowering and partial squat compared to the lowering (P=.001) and partial squat (P<.001) tasks separately. There was greater compressive strain in the deep region of the tendon compared to the superficial for all tasks (P=.001). While these findings need to be examined in a pathological population, heel lifts may reduce tendon compressive strain during daily activities.

An optimized design of in-shoe heel lifts reduces plantar pressure of healthy males.

Conventional heel lift with a flat surface increases the risk of foot problems related to higher plantar pressure and decreased stability. In this study, an optimized design of in-shoe heel lifts developed to maintain the midfoot function was tested to investigate if the plantar pressure distribution was improved. The design was based on three dimensional foot plantar contour which was captured by an Infoot 3D scanning system while the heel was elevated by a heel wedge. To facilitate midfoot function, an arch support was designed to support the lateral longitudinal arch, while allowing functional movement of the medial longitudinal arch. Twenty healthy male subjects were asked to walk along an 8m walkway while wearing high-cut footwear with and without the optimized heel lift. Peak pressure, contact area and force-time integral were measured using the Pedar insole system. Range and velocity of medial-lateral center of pressure during forefoot contact phase and foot flat phase were collected using a Footscan pressure plate. Compared to the shoe only condition, peak pressure under the rearfoot decreased with the optimized heel lift, while no increase of peak pressure was observed under the forefoot and midfoot regions, indicating improved plantar pressure distribution. The findings of this study suggest that this optimized heel lift has better biomechanical performance than a conventional flat heel lift. Results from this study may have implications for insole and shoe last design, especially for people who need additional heel height without sacrificing midfoot function.

Concurrent validity and reliability of using ground reaction force and center of pressure parameters in the determination of leg movement initiation during single leg lift.

Postural adjustment evaluations during single leg lift requires the initiation of heel lift (T1) identification. T1 measured by means of motion analyses system is the most reliable approach. However, this method involves considerable workspace, expensive cameras, and time processing data and setting up laboratory. The use of ground reaction forces (GRF) and centre of pressure (COP) data is an alternative method as its data processing and setting up is less time consuming. Further, kinetic data is normally collected using frequency samples higher than 1000Hz whereas kinematic data are commonly captured using 50-200Hz. This study describes the concurrent-validity and reliability of GRF and COP measurements in determining T1, using a motion analysis system as reference standard. Kinematic and kinetic data during single leg lift were collected from ten participants. GRF and COP data were collected using one and two force plates. Displacement of a single heel marker was captured by means of ten Vicon(©) cameras. Kinetic and kinematic data were collected using a sample frequency of 1000Hz. Data were analysed in two stages: identification of key events in the kinetic data, and assessing concurrent validity of T1 based on the chosen key events with T1 provided by the kinematic data. The key event presenting the least systematic bias, along with a narrow 95% CI and limits of agreement against the reference standard T1, was the Baseline COPy event. Baseline COPy event was obtained using one force plate and presented excellent between-tester reliability.

The Effectiveness of Specific Exercise Approach or Modifiable Heel Lift in the Treatment of Functional Leg Length Discrepancy in Early Post-surgery Inpatients after Total Hip Arthroplasty: A Randomized Controlled Trial with a PROBE design.

OBJECTIVE: This study investigated the effectiveness of a specific exercise approach (SEA) or modifiable heel lift (MHL) to improve functional leg length discrepancy (LLD) after total hip arthroplasty (THA). METHODS: The study was a randomized controlled trial with a PROBE (prospective, randomized, open, blinded-endpoint) design trial. Patients (n=33) with both functional and perceived LLDs, 1 week after THA, were randomized to the SEA, MHL, or control groups. Patients in the SEA group performed 2 weeks of exercises to improve hip contracture and lumbar scoliosis. Patients in the MHL group used an insole-type heel lift to correct functional LLD. The control group received normal postoperative care, comprising standard rehabilitation after THA. The primary outcomes were functional LLD, measured by a block test, and patient-perceived LLD at 3 weeks after the surgery. Secondary outcomes included the visual analog scale (VAS) for pain, the Timed Up and Go (TUG) test, and the Western Ontario and McMaster Universities Osteoarthritis index (WOMAC) at 3 weeks after the surgery. RESULTS: The functional LLDs (mean ± SD) for the SEA (3.3 ± 3.1 mm) and MHL (2.2 ± 2.1 mm) groups were significantly smaller than for the control group (6.4 ± 4.0 mm). The degree of patient-perceived LLD differed significantly between the SEA and the control groups (p=.005). CONCLUSIONS: SEA and MHL use, during early post-operative recovery, can produce relevant changes in functional LLD after THA.

The use of orthoses and gait analysis in children with AMC.

PURPOSE: Arthrogryposis multiplex congenita (AMC) can be described as a complex condition characterized by deformed joints with an intact sensory system. Consequences of muscle weakness and joint contractures in the lower limbs influence walking ability. With orthoses most children achieve functional ambulation. Based on four studies, the aim of this article was to describe gait pattern wearing habitual orthoses, to quantify quiet standing, to test and describe a new orthosis and compare gait differences with regular orthoses, in children with AMC. METHODS: In total 83 children, of which 35 with AMC took part in the studies. All children had underwent clinical examination. Based on joint range of motion and muscle strength they had been prescribed various orthosis types, ranging from insoles to knee-ankle-foot orthoses with locked knee joints. 3D gait and motion analysis was performed during standing and walking with 34 reflective markers aligned with anatomical landmarks. RESULTS: The findings are presented with respect to each of the included studies. CONCLUSIONS: According to the positive subjective impressions from parents and children, the clinical experiences of our research group, and the objective results from the gait assessments, continuously wearing of orthoses in persons with AMC is recommended.

Influence of in-shoe heel lifts on plantar pressure and center of pressure in the medial-lateral direction during walking.

The aim of this study was to investigate how the height and material of in-shoe heel lifts affect plantar pressure and center of pressure (COP) trajectory in the medial-lateral direction during walking. Seventeen healthy young male adults were asked to walk along an 8m walkway while wearing a high-cut flat shoe and 5 different heel lifts. Peak pressure (PP), pressure-time integral (PTI) and contact area (CA) were measured by Pedar insole system for three foot regions: forefoot, midfoot and heel. Range and velocity of medial-lateral (ML) COP during forefoot contact phase (FFCP) and foot flat phase (FFP) were collected using Footscan pressure plate. Forefoot pressure and ML-COP parameters increased as the heel was elevated. Statistically significant attenuation of heel peak plantar pressure was provided by all heel lifts except for the hard lift. Post hoc tests suggest that material had a greater influence on the range and velocity of ML-COP during FFCP than heel height, while during FFP, heel height seemed to affect these parameters more. The findings from this study suggest that thick heel lifts should be used with caution, and that a heel lift made of materials with good support and elastic properties might be more appropriate to improve footwear comfort and medial-lateral motion control.

The influence of heel height on vertical ground reaction force during landing tasks in recreationally active and athletic collegiate females.

PURPOSE: To determine if heel height alters vertical ground reaction forces (vGRF) when landing from a forward hop or drop landing. BACKGROUND: Increased vGRF during landing are theorized to increase ACL injury risk in female athletes. METHODS: Fifty collegiate females performed two single-limb landing tasks while wearing heel lifts of three different sizes (0, 12 & 24 mm) attached to the bottom of a athletic shoe. Using a force plate, peak vGRF at landing was examined. Repeated measures ANOVAs were used to determine the influence of heel height on the dependent measures. RESULTS: Forward hop task- Peak vGRF (normalized for body mass) with 0 mm, 12 mm, and 24 mm lifts were 2.613±0.498, 2.616±0.497 and 2.495±0.518% BW, respectively. Significant differences were noted between 0 and 24 mm lift (p<.001) and 12 and 24 mm lifts (p=.004), but not between the 0 and 12 mm conditions (p=.927). Jump-landing task- No significant differences were found in peak vGRF (p=.192) between any of the heel lift conditions. CONCLUSIONS: The addition of a 24 mm heel lift to the bottom of a sneaker significantly alters peak vGRF upon landing from a unilateral forward hop but not from a jumping maneuver.

Effects of heel lifting on transtibial amputee gait before and after treadmill walking: a case study.

BACKGROUND: Prosthetic alignment is usually unchanged once optimized. However, a previous study indicated that long-distance walking significantly altered gait patterns, suggesting some alignment adjustments after walking are required. This study investigated the effects of alignment changes (by inserting a heel lift) on gait of a transtibial amputee before and after treadmill walking. CASE DESCRIPTION AND METHODS: The subject walked, without heel lifts, on a treadmill until perception of fatigue. Gait changes upon heel lifting at the prosthetic side were studied before and after the treadmill walking FINDINGS AND OUTCOMES: For this subject before the treadmill walking, heel lifting induced drop-off with increased prosthetic-side knee flexion at mid-stance and pre-swing. The sound limb outreached to stabilize the gait. After the treadmill walking, the same heel lift did not induce drop-off. It reduced the plantar flexor power generation, potentially delaying its fatigue. CONCLUSION: After walking prosthetic-side heel lifting could be beneficial. CLINICAL RELEVANCE: Many lower-limb amputees have difficulties in long-distance walking due to muscle fatigue. This case study proposes that appropriate alignment changes after some walking potentially relieve fatigue and encourage them to walk longer distances.