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29 37 43

VOLUME 8 NUMBER 3 LERMAGAZINE.COM

March 201 6 fea tures 26 ORTHOTIC DEVICES FOR THE WIN Plantar fasciitis: Clinical concerns in basketball Highly visible elite athletes with plantar fasciitis are in the news, but healthcare practitioners need to also focus on those who play recreation - ally for health benefits. By Patricia Pande, MClScPT, CSCS, CPed COVER STORY 29 Running modifications 18 and reducing injury risk Evidence suggests that no one foot strike style can be expected to Outcomes after ACL surgery: decrease injury risk in all runners, and that switching foot strike patterns can have unintended consequences. Using a shorter stride THE IMPORTANCE OF GRAFT TYPE length, however, can be an effective alternative for some runners. In an attempt to decrease the risk of re-rupture and revision surgery after anterior By Elizabeth Boyer, PhD, and Tim Derrick, PhD cruciate ligament reconstruction, practitioners are refining the decision process regarding which procedure is best for which patient. 37 Strength training: Bone By Cary Groner health benefits for men IN THE MOMENT Men with low bone mass are much less likely than their female counter - running /13 parts to receive treatment. But research suggests that resistance exercise is a safe and effective way to improve bone mineral density in men and, Benefits of balance: YBT is associated with history of injury in turn, reduce the risk of fracture and related complications. Test for lower extremity asymmetry identifies risk in recreational runners By Pamela S. Hinton, PhD Clinically useful 2D measurements predict patellofemoral joint force OA /15 43 Ankle instability rehab emphasizes individuality PFOA prognostication: Sagittal plane factors predict worsening Years after Achilles tear, injured limb demonstrates elevated knee loading Research presented at the most recent International Ankle Symposium indicates that rehabilitation for chronic ankle instability is evolving from Clinical single-leg hop tests can help estimate risk of OA after ACL injury a one-size-fits-all approach to an increased focus on matching specific interventions to the patients who are most likely to benefit. By Lori Roniger plus ... 49 Flexible flat foot: Effects of orthoses during gait OUT ON A LIMB / 9 NEW PRODUCTS / 58 In this original investigation, researchers analyzed the biomechanical An analgesic assist The latest in lower extremity devices and technologies effects of a foot orthosis in patients with flexible flat foot during walking The type of analgesia used in ACL surgery and the extent to which those functional effects are consistent with can affect patients' quadriceps strength, MARKET MECHANICS /61 proposed theories about the device’s mechanism of action. which could influence functional outcomes. News from lower extremity companies and organizations By Bruce Elliott, PT, DPT, COMT, and Juan Garbalosa, PhD, PT By Jordana Bieze Foster By Emily Delzell Custom AFO Gauntlets 

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When it comes to improving Given the obvious downsides to the conventional FNB approach, outcomes after anterior surgeons and their anesthesiologist colleagues have been looking cruciate ligament (ACL) for alternatives. These include the adductor canal block (ACB), a recon struction, lower more distal block of the femoral nerve, positioned in the midthigh extrem ity practitioners need to preserve quadriceps femoris strength. all the help they can get. Early studies on ACB use in total knee arthroplasty patients have Fortunately, a recent study been positive. And, in a study epublished in early March by Anes - suggests they might be able thesiology , researchers from the University of Toronto in Canada to get some valuable assis - found that an ACB administered prior to ACL reconstruction was tance from their colleagues associated with significantly less quadriceps strength loss than a in anesthesiology. preoperative FNB, while providing equal or better pain relief. Increasing numbers of studies have underscored the importance of quadriceps strength—and, in particular, quadriceps strength symmetry between limbs—in determining functional outcomes after ACL surgery. In fact, a number of orthopedic surgeons say The type of analgesia used in ACL surgery the need to maximize quadriceps strength after ACL reconstruc - can affect patients' quadriceps strength, tion is an important consideration in their choice of graft type, which could influence functional outcomes. surgical technique, and rehabilitation protocols (see “Outcomes after ACL surgery: The importance of graft type,” page 18).

But a smaller body of literature is starting to indicate the type of analgesia used in ACL reconstruction procedures also affects Granted, the findings are preliminary, and we can’t connect all the postoperative quadriceps strength—which could, in turn, affect dots yet. The Toronto study only assessed strength loss preopera - functional outcomes. tively, so we can’t assume those effects would be evident postop - eratively. The Mayo Clinic results suggest they might, but we can’t Femoral nerve blocks, for example, have been widely reported to yet assume the findings of that study can be extrapolated beyond cause immediate postoperative quadriceps weakness, particularly six months, or that they would have any impact on rerupture rates in patients undergoing total joint arthroplasty, but also in those or cartilage degeneration. undergoing ACL reconstruction. One might not think analgesia- induced weakness in the first day or two after surgery would have Still, the findings are intriguing enough that lower extremity practi - longer-term implications, especially in athletes, but research from tioners should at least be asking questions about analgesia when the Mayo Clinic in Rochester, MN, suggests it might. planning an ACL reconstruction or a postoperative rehab protocol.

The Mayo Clinic team reported last February in the Journal of And, when facing a clinical challenge as complicated as an ACL Knee Surgery that ACL reconstruction patients who received a injury, lower extremity practitioners should also be encouraged to postoperative femoral nerve block (FNB) had significantly weaker know that it’s a battle being fought on multiple fronts. quadriceps at six months than patients who did not receive a . FNB. Vertical jump and single-leg hop performance was also significantly poorer in the FNB group. Jordana Bieze Foster, Editor

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TM in the moment: running

Benefits of balance YBT is associated with history of injury

By P.K. Daniel

Deficits in single-leg balance may con - tribute to the high rate of injuries among endurance athletes, but hip strength may not, according to two studies presented in February at the American Physical Therapy Association’s annual Combined Sections Meeting in Anaheim, CA. Istockphoto.com#63842549

athletes, 61 reported a recent history—within 36 months—of lower Both studies were conducted by researchers at Ironman Sports Med - extremity injury. icine Institute, Memorial Hermann Health System, and Texas Woman’s While medial, lateral, and composite reach scores were not sta - University, all in Houston, TX. tistically different between limbs for either group, the researchers In the first, researchers found the anterior reach component of found a recent history of lower extremity injury was negatively asso - the Y Balance Test (YBT) differed significantly between endurance ciated with anterior reach. The injured athletes also demonstrated athletes with a history of lower extremity injury in the previous three significantly less mean anterior reach for the involved lower extremity years and healthy participants. (57 ± 14.5 cm) compared with the uninvolved extremity (63.4 ± 13.1 The 71 male and 78 female athletes, who were not seeking cm) and the uninjured athletes (64.1 ± 14.6 cm). medical attention, were selected from local running clubs and partic - ipants in the Houston marathon and Ironman races. Of the 149 Continued on page 14 Test for lower extremity asymmetry Clinically useful 2D measurements identifies risk in recreational runners predict patellofemoral joint force Asymmetrical lower extremity Between-limb asymmetry, Researchers from East Carolina formed both 2D and 3D kine - neuromuscular control is predic - based on composite Y Balance University (ECU) in Greenville, matic analyses in 34 athletes, tive of repetitive stress injury in Test scores, was significantly NC, have identified 2D lower and found that using clinically recreational runners, according greater in injured runners than in extremity kinematic measure - feasible 2D methods (a video to findings presented at the Com - their uninjured counterparts, said ments that accurately predict camera and free video analysis bined Sections Meeting of the Steven Jackson, PT, PhD, OCS, a patellofemoral joint (PFJ) force software) to assess the three American Physical Therapy As - faculty member for the University during running and can be used predictive variables from the sociation in February in Anaheim. of Chicago Physical Therapy Or - clinically to identify runners at thopedic Residency Program, first phase of the study ac - Researchers from Nova risk of injury. Southeastern University in Ft. who presented the findings. An counted for 70% of the variabil - The two-phase study in - Lauderdale, FL, assessed anthro - asymmetry of 3.6% or greater ity in PFJ impulse. volved recreational athletes pometric variables, proximal and predicted 69.2% of the injuries. Jennifer M. Warren, a phys - aged between 18 and 35 years. distal isometric lower extremity Ankle dorsiflexion with the ical therapy doctoral student at The researchers first performed muscle performance, isometric knee extended also differed signif - ECU, presented the findings at 3D motion analysis on 56 ath - core muscle endurance, lower icantly between the injured and un - the Combined Sections Meet - letes and identified three vari - extremity flexibility, and neuro - injured runners, but the statistical ing of the American Physical analysis revealed that variable was ables that predicted mean PFJ muscular control in 72 recre - Therapy Association in Febru - ational runners and followed not predictive of injury risk. impulse during the stance ary in Anaheim. them over an 18-week period be - Source: phase of running: knee angle fore a graded marathon training Jackson S, Cheng MS, Kolber M, Smith at midstance, step length, and Source: AR. An investigation of relationships be - program. During that time, the vertical excursion of the center Warren JM, Sanii AR, Huf MD, et al. tween physical characteristics of recre - Clinical prediction of patellofemoral athletes experienced 33 repeti - ational runners and lower extremity of mass. injuries. J Orthop Sports Phys Ther joint contact force during running. J Or - tive stress injuries. 2016;46(1):A41. The investigators then per - thop Sports Phys Ther 2016;46(1):A55.

lermagazine.com 03.16 13 in the moment: running

Continued from page 13

“I would say the most inter - to help determine whether an The 149 athletes partici - extremity] injury,” said lead au - esting aspect of the study was athlete is ready to return to pated in a single session of clin - thor Caitlyn Lang, PT, DPT, a staff the dramatic difference in ante - sports. ical and functional testing. Sur - physical therapist at Memorial rior reach distance on the in - “While we cannot make prisingly, there was no Hermann Health System, who volved side within the previous sweeping conclusions with the correlation between hip abduc - presented the findings. injury group,” said lead author findings due to the retrospective tion strength and history of a However, the researchers Andrew J. Nasr, PT, DPT, CSCS, nature of the study and inherent lower extremity injury in the pre - did find a positive relationship now a staff physical therapist limitations, we do feel that the Y vious three years. between hip abduction strength with the University of Texas Balance can be used as a good That lack of correlation was and a top-three placement Southwestern Medical Center in clinical tool to track this athletic true for both skill-level groups. within a competitive event, sug - Dallas, TX, who presented the population as we rehab them Among the injured recreational gesting that hip abduction findings. “We hypothesized there back to sport participation,” Nasr athletes (<25 mi/wk), no differ - strength has a stronger associa - would be a difference, but did said. ences in hip abduction strength tion with performance than with not expect such a difference.” Because little is known re - were observed between the in - injury risk. The researchers believe garding endurance athletes’ risk jured (50.6 ± 18.2 lb) and unin - Sources: their study is the first to investi - factors for injury, the same re - jured limbs (51.9 ± 18.2 lb). Sim - Nasr AJ, Lang C, Duncan BR, et al. gate functional performance in searchers conducted a second ilarly, no differences were noted Deficits in single-leg balance are as - sociated with recent lower extremity a sample of endurance athletes study involving the same partic - for hip abduction strength be - injuries among asymptomatic en - using testing procedures com - ipants to determine the relation - tween injured (54.9 ± 18.8 lb) durance athletes currently participat - mon to field sports. The findings ship between hip abduction and uninjured sides (55 ± 11.7 ing in sport. J Orthop Sports Phys Ther 2016;46(1):A46. suggest that utilization of the Y strength and history of lower ex - lb) for elite injured athletes. Lang C, Nasr AJ, Duncan BR, et al. Balance anterior reach test to tremity injury. For this study, the “Our data didn’t support The relationships between hip abduc - detect balance deficits may be researchers also analyzed skill our hypothesis that there would tion strength lower extremity injury history & performance in endurance able to help identify athletes at level (elite vs recreational) as a be a difference in hip abduction athletes. J Orthop Sports Phys Ther risk for lower extremity injury or possible contributing factor. strength and previous [lower 2016;46(1):A43.

14 03.16 lermagazine.com in the moment: OA

PFOA prognostication Sagittal plane factors predict worsening

By Jordana Bieze Foster

Sagittal plane mechanics and forces dur - ing gait in patients with patellofemoral os - teoarthritis (PFOA) can help identify those who are likely to experience worsening pain or cartilage degeneration, according Istockphoto.com #71687689 to research presented in February at the more likely to be affected by frontal plane mechanics,” said Alison Chang, PT, DPT, MS, an associate professor of physical therapy and annual Combined Sections Meeting of the human movement sciences at the Northwestern Feinberg School of American Physical Therapy Association in Medicine in Chicago. In one PFOA study, presented at the meeting by Chang, she and Anaheim, CA. her colleagues assessed dynamic joint stiffness—a measure of knee flexion moment versus knee flexion angle as a percentage of the gait cycle—in 204 patients with OA in any compartment of at least The predictive potential of sagittal plane variables in individuals with one knee. They also assessed magnetic resonance imaging (MRI)- PFOA underscores the biomechanical differences between PFOA based markers for cartilage degeneration; two years later, they re - and tibiofemoral osteoarthritis and the need to manage the two con - peated the MRI exams to assess cartilage damage progression. ditions differently. Tibiofemoral damage progression was detected in 26.5% of “Sagittal plane mechanics during gait may influence the participants; patellofemoral damage progression was detected in patellofemoral load and disease course, while tibiofemoral OA is Continued on page 16 Years after Achilles tear, injured limb Clinical single-leg hop tests can help demonstrates elevated knee loading estimate risk of OA after ACL injury A history of Achilles tendon rup - The asymmetries were evi - Performance on single-leg hop of knee OA at follow-up had ture is associated with elevated dent despite a high level of self- tests a few weeks after anterior better performance than those knee loading during hopping reported function for the group, cruciate ligament (ACL) injury with knee OA on all the base - and running, suggesting an in - a mean of 84 out of 100 on the can predict the risk of radi - line hopping tests; the differ - creased risk of knee osteoarthri - Achilles Tendon Total Rupture ographic knee osteoarthritis ences were significant for the tis and other overuse knee Score. (OA) five years later, according single and triple hop tests. The pathologies, according to re - “Rehabilitation may need to to research from the University tests with the best diagnostic search from East Carolina Uni - include the knee in addition to of Delaware in Newark. accuracy, however, were the versity in Greenville, NC. the foot and ankle,” said Hayley In 65 athletes involved in triple hop test and the 6-m Investigators analyzed 34 Powell, a graduate student in the cutting or pivoting sports who timed test. individuals who had experi - university’s Department of Phys - had sustained an ACL injury a The findings were pre - enced a unilateral Achilles tear ical Therapy, who presented the mean of 1.8 months earlier, in - sented in February at the an - findings in February at the an - a mean of six years previously, vestigators assessed perform - nual Combined Sections Meet - nual Combined Sections Meet - as they jogged at a self-selected ance on four single-leg hopping ing of the American Physical ing of the American Physical speed and performed a single- tests that can easily be admin - Therapy Association in Ana - Therapy Association in Anaheim. leg hopping task. Peak concen - istered by clinicians: single, heim. Source: tric knee power, peak patello - triple, crossover, and 6-m timed. Source: femoral joint reaction force, and Powell H, Silbernagel KG, Brorsson A, A mean of 5.7 years after the et al. Patellofemoral and tibiofemoral Wellsandt E, Axe M, Snyder-Mackler L. peak tibiofemoral contact force joint loading asymmetries are present injury, the investigators identi - Single-legged hop tests as a screening were significantly higher in the during running and hopping in individ - fied radiographic evidence of tool for risk of posttraumatic os - uals 5 years post–Achilles tendon rup - teoarthritis after anterior cruciate liga - injured limb than the uninjured ture. J Orthop Sports Phys Ther knee OA in nine of the athletes. ment injury. J Orthop Sports Phys Ther limb for both tasks. 2016;46(1):A50. The athletes with evidence 2016;46(1): A56.

lermagazine.com 03.16 15 in the moment: OA

Continued from page 15

13.6%. However, only patello- The researchers assessed increase in PFJ stress during phasized the need for PFOA in - femoral cartilage damage pro - kinematics and kinetics in 50 in - early stance resulted in nearly a terventions to decrease knee gression—specifically in the lat - dividuals with PFOA as they sixfold higher chance of pain flexion moment, which could in - eral aspect of the patella—was walked at a self-selected speed, progression at one year. clude increasing step rate, de - associated with dynamic joint then used those measures to es - The higher peak PFJ levels creasing walking speed, or wear - stiffness at baseline. After ad - timate peak PFJ stress during the in those with pain progression ing flat shoes instead of heels. justing for demographics and first and second half of stance. were largely due to knee flexion The Northwestern findings also disease- related covariables, for The study participants also com - moment rather than knee flexion suggest there could be a benefit every unit increase in dynamic pleted the pain and symptoms angle, according to Hsiang-Ling to increasing knee joint flexion joint sti ffness at baseline, the subscales of the Knee Osteo- (Sharon) Teng, PT, PhD, a post - angle during gait, Chang said, odds of patellofemoral cartilage arthritis Outcomes Score (KOOS) doctoral scholar in the Depart - but noted that patients may need damage progression increased questionnaire at the time of the ment of Radiology at UCSF, who neuromotor training to learn to 3.5 times. gait analysis, and again a year presented the findings. use any additional joint range of Although cartilage damage later. Pain progression was also motion they achieve. is not always associated with At one year, 10 participants associated with higher peak PFJ Sources: pain in patients with PFOA, in - had significant pain progression, stress in the second half of Chang AH, Chmiel JS, Almagor O, et al. vestigators from the University defined as a KOOS-Pain score stance; that association was not Baseline knee sagittal dynamic joint stiffness during gait is associated with of California, San Francisco increase above a previously re - statistically significant, but may 2-year patellofemoral cartilage dam - (UCSF) reported in a second ported minimum detectable be clinically relevant, Teng said. age progression in knee osteoarthritis. presentation that peak patello - change score. Those with pain “Prevention and rehabilita - J Orthop Sports Phys Ther 2016; 46(1):A5. femoral joint (PFJ) stress during progression had significantly tion protocols should focus on Teng H-L, MacLeod TD, Nardo L, et al. the early stance phase of walk - higher early stance peak PFJ patellofemoral joint loading dur - Association between patellofemoral ing in individuals with PFOA is stress at baseline than those ing the entire stance phase,” joint stress during gait and sympto - matic progression in people with predictive of pain progression whose pain did not progress; she said. patellofemoral joint osteoarthritis. J Or - one year later. every one standard-deviation Chang and Teng both em - thop Sports Phys Ther 2016;46(1):A26.

                 

   


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16 03.16 lermagazine.com

Outcomes after ACL surgery: The importance of graft type

By Cary Groner

In an attempt to decrease the risk of re-rupture and revision surgery after anterior cruciate ligament reconstruction, practitioners are refining the decision process regarding which procedure is best for which patient.

Thomas Davis made headlines in February by playing in the Super Bowl with a broken left arm, but what’s most impressive about the Carolina Panthers linebacker is his right knee. Davis ended the Jan - uary 17 playoff game against Seattle by fielding the Seahawks’ last- ditch onside kick with a spectacular leaping grab. It would have been a great play for anyone, but Davis made his jump on a right anterior cruciate ligament (ACL) that had been reconstructed three times. Increasingly, people take such heroic athleticism in stride. But cases like that of Davis, in which patients reinjure the ligament and require revision surgery—sometimes more than once—have led ex - perts to try to identify factors that may decrease the risk of subse - quent rupture. The rigors of pro football notwithstanding, theories are all over the map. As more data become available, however, a guarded consensus is emerging.

18 03.16 lermagazine.com Istockphoto.com #16884945

lermagazine.com 03.16 19 Continued from page 19 the graft weaker for a longer time than an autograft would be. The Recent research has helped define the scope of the problem. result, particularly in active young people, may be tissue stretching Reported five-year revision rates after ACL reconstruction have and breakdown leading to graft failure. been as high as 8.7%, and are significantly higher for patients Jonathan Chang, MD, a clinical associate professor of orthope - younger than 21 years than for their older counterparts. 1 dics at the University of Southern California in Los Angeles, agreed. “Graft selection is now influenced by age,” he said. “If you’re Graft selection roughly twenty-five or younger, you’re usually better off with a patel - lar tendon autograft—though there’s discussion about where that In ACL reconstruction, surgeons use either autografts (tissue from tipping point is, and some put it at age forty or higher. As you get the patient) or allografts (tissue from cadaver donors), and each ap - older, though, you probably have lower activity levels, so there are proach has advantages and disadvantages. Allografts circumvent advantages to an allograft. The graft failure rates start equalizing at the problem of donor-site morbid - ages thirty-five to forty, so at that ity and offer robust tendons, such point, unless you’re a profes - as the tibialis anterior, that sional athlete, you’re likely to do couldn’t be harvested from a liv - well with any kind of graft.” ing donor. In one large US study, Recent research supports allografts were used in roughly this perspective. For example, a 42% of primary and 79% of revi - Kaiser Permanente study of sion ACL reconstructions. 2 Disad - 21,304 ACL reconstruction pa - vantages include the risk of tients found that those younger disease transmission, slower in - than 40 years had a higher risk corporation, and strength limita - of revision after allograft surgery tions, depending on how the than those with BPTB autografts; tissue has been processed. 3 moreover, those younger than 21 Autografts include bone– years with hamstring autografts patellar tendon–bone (BPTB) re - had a revision risk 1.6 times those construction, in which the graft is who had BPTB autografts. 1 taken from the patient’s ipsilat - “We found that the greatest eral or contralateral knee. Al - differences occurred in the though this approach is often younger patients,” said Gregory considered the gold standard in Maletis, MD, the study’s first au - the US, it is associated with a risk thor, who is chief of orthopedics at of anterior knee pain and other Kaiser Permanente in Baldwin problems at the harvest site. 3 As Bark, CA, and lead physician for a result, many surgeons have the ACL registry there. “We also turned to soft tissue grafts, par - found that females are a little less ticularly from the hamstring ten - likely to undergo revision, as are don; in recent years hamstring those with higher BMI [body mass reconstruction has become the index], who may be less active.” primary approach in Scandina - Maletis told that he and his vian countries. 4 Recently, a few LER colleagues aren’t yet sure why ham - surgeons have begun using the string autografts failed more often quadriceps tendon, as well, and than BPTB autografts. the percentage of such surger - Istockphoto .com #16885127 “It may have to do with graft di - ies is expected to grow. 5 ameter; smaller hamstring grafts But as surgery becomes more custom ized, may not withstand the loads as well,” physicians continue to refine the decision process regarding he said. “We didn’t see that in the older patients, so it’s probably which procedure is best for which patient. This affects choices because the younger ones are doing higher-level sports and putting about surgical procedure, graft harvest, and rehabilitation. their knees at the greatest risk.” Not fail-safe Several recent studies have reached conclusions about graft type and longevity. For example, a 2014 study from Scandinavia “We now know that the use of allografts in young people—particu - found that patellar tendon autografts had a significantly lower risk larly teenagers or very active people in their twenties and early thir - of revision (hazard ratio .63) than hamstring autografts. 4 A Norwe - ties—is associated with a higher risk of graft tearing and revision,” gian paper from the same year reported a revision risk 2.3 times said Steven Singleton, MD, an orthopedic surgeon with the Stead - higher for hamstring grafts than patellar tendon grafts and four times man Clinic in Vail, CO. higher for younger patients than older ones. 6 A 2014 Danish study There are various reasons for this, he explained. With allografts, found that hamstring reconstructions were 1.4 times more likely to the body recognizes the tissue as non-native, and though it doesn’t fail than BPTB ones (the authors also noted that use of hamstring reject the graft as it might a transplanted organ, it does mount an immune response that retards ligamentation and healing, leaving Continued on page 22

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US & International Patents Pending © 2016 Orthomerica Products, Inc. 877-737-8444 | www.orthomerica.com All Rights Reserved. Continued from page 20 such differences with allografts.” tendons in Denmark increased from 68% in 2005 to 85% in 2011). 7 The finding that BPTB allografts had a higher risk of revision A long-term randomized trial conducted in military personnel than soft tissue allografts (relative risk = 1.8) suggests processing in Hawaii found that, 10 years after reconstructive surgeries with ei - may also weaken bone tissue, he added. A 2008 meta-analysis 9 ther a hamstring autograft or a tibialis posterior allograft, more than from the Mayo Clinic supports this finding. 80% of grafts were intact and stable; however, allografts failed at three times the rate of autografts (26.5% vs 8.3%). 3 Technique Lead author Craig Bottoni, MD, chief of sports medicine in the In a paper from the Steadman Clinic, researchers compared BPTB Orthopedic Surgery Service at Tripler Army Medical Center in Hon - autografts to BPTB allografts and reported that, while functional out - olulu, said surgeons minimized variables by using the same fixation comes were similar, 14% (n = 11) of allografts were revised by a and rehabilitation techniques in all patients. mean of 4.7 years after surgery, whereas no autografts required re - “Allografts are an acceptable alternative for ACL reconstruction, vision. Moreover, patients aged 25 years or younger were 23 times but some do have a higher risk of failure,” Bottoni said. more likely to require a revision than older patients. 10 Like many surgeons, Singleton uses techniques he hopes will Processing minimize his patients’ revision rates. He prefers BPTB autografts to Bottoni emphasized the importance of surgeons knowing as much hamstrings—though he’ll use the latter in patients with a history of as possible about the allograft tissue they use. patellar tendinitis or arthritis—and said that in his practice he sees “It’s imperative to know what type of graft you’re using, where very little anterior knee pain after BPTB surgeries. it comes from, and how it’s been processed,” he said. “Terminal ra - “We’ve developed a small-incision technique to harvest the graft,” diation and some types of processing have been found to negatively he said. “We also mobilize the patella right away in our rehab program, alter the biomechanical properties of the allograft.” and I think those things minimize the potential for scarring.” Indeed, the Kaiser team concluded that certain factors seem Jonathan Chang has his own take on the situation. to increase risk of allograft failure, including irradiation greater than “I take twenty to thirty minutes harvesting the graft, carefully 1.8 mrad, BioCleanse processing, younger patient age, male gen - bone-grafting the harvest sites and doing a layered closure over the der, and BPTB allograft. 8 tendon without over-straining it,” he said. “If you do that, you’ll have “Nonirradiated, nonprocessed grafts seem to hold up the best,” less postoperative bleeding and better function. If you don’t play Maletis said. “There also appears to be a time-dependent relation - close attention to how you treat that tissue, the patient has a higher ship, in that we may not see failures within the first year or two. That risk of anterior knee pain.” may explain why studies with shorter time frames haven’t shown Donald Shelbourne, MD, who practices at the Shelbourne Knee

PFS

22 03.16 lermagazine.com Center at Community Westview Hospital in Indianapolis, favors a first month, and you can’t do that when you take the graft from the BPTB technique that many other surgeons shy away from: He har - same knee that you’ve operated on for the ACL.” vests the graft from the contralateral knee rather than the injured Other surgeons told LER that, though they use contralateral one, and recently reported the approach was associated with better grafts for revision procedures, they remained reluctant to do so in postoperative leg strength in both limbs and better strength sym - primary reconstructions. metry while minimizing symptoms at the graft harvest site. 11 Anatomic accuracy of tunnel drilling can also affect outcomes, “Back in the eighties, I found that we had trouble rehabbing the Singleton said. ACL-injured knee because we’d also taken a patellar tendon from “In the original arthroscopies in the late eighties and early it,” he said. “You can avoid that problem with cadaver or hamstring nineties, surgeons used one approach to drill a tunnel in the femur grafts, but I didn’t find those to be as successful—allografts failed, and a second one to drill the tibia, and the graft was anchored in hamstring grafts left the patients weaker. When we started doing those tunnels,” he said. “Then, in the mid-nineties, an all-endoscopic contralateral grafts in revision surgeries, we realized that it was a technique was developed in which you drilled the tibial tunnel first, better approach because we had two independent rehabs instead then used that to drill the femoral tunnel. That technique is still used of two rehabs in the same knee. We’ve now done over four thou - by many doctors, with reasonable success; the problem is that it sand primary ACL reconstructions that way, and I think it’s the best doesn’t allow one to get the [femoral] tunnel in the exact anatomic answer. My goal is to give the patient two good knees, and I can do location of the native ACL. Steadman, Shelbourne, and a few others that more predictably when I take the graft from the opposite knee.” recognized this and continued to drill both tunnels independently. Shelbourne, who keeps detailed data about his procedures and What I see clinically is that there is a lower rate of graft re-tears in outcomes, said his team had collected information about their ACL ACLs done with independent tunnel drilling. You want the graft in repairs in 52 college soccer players. Of those who had ipsilateral the exact location it needs to be in.” BPTB reconstructions, 77% were playing at their previous level a year later, whereas 91% of those who’d had a contralateral graft re - Rehab turned to that level (unpublished data). One reason for the greater Surgeons and therapists stress the importance of proper rehabilita - success, he said, is that contralateral harvesting leads to better heal - tion, though there’s professional disagreement about what consti - ing at the donor site. tutes it. “The two thirds of the tendon we leave grows back to normal,” “Rehab may be more crucial than the surgery itself,” said Craig he said. “We didn’t see that when we took the graft from the same Bottoni. “You want the patient to get back to activity as soon as pos - knee, because we had to rehab the ACL and couldn’t focus on the sible without compromising the graft. Most of us are big advocates donor site. You need high-repetition, low-resistance exercises in the Continued on page 24

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lermagazine.com 03.16 23 Continued from page 23

of extension, because if you don’t get it back in the early phase, it’s difficult to get it back later.” The Noodle TA AFO Shelbourne emphasized both extension and delay in loading the ACL-injured leg. $GYDQFHG&DUERQ)LEHU%UDFH “The first week after surgery, it’s too soon for things like riding a bike and walking,” he said. “Those can just leave the knee more inflamed and swollen. In terms of long-term rehab, though, we want to achieve full flexion, full strength, full function, and identical motion with the contralateral side.” Shelbourne and his colleagues have documented the impor - $YDLODEOH tance of achieving full extension, including terminal hyperextension symmetric to the opposite knee, and suggest concerns that this may 2IIWKH6KHOI overstress the graft are unsubstantiated. 12 %XLOGWR2UGHU For Singleton, controlling swelling and regaining full range of mo - tion drive the protocol in the first couple of weeks. &XVWRPIURP&DVW “We teach the patient to elevate the knee so the leg wants to come straight, and to some extent we’ll use a continuous passive mo - tion machine to prevent adhesions and minimize swelling,” he said. Rehabilitation should account for graft type, too, according to Jonathan Chang. ĸ&KRLFHRIĸ&KRLFHRIStrut “When surgeons use allografts, they usually slow the rehab /DWHUDORU0HGLDO process a little to be sure that the incorporation has really taken hold before they start pushing the patient,” he said. Bottoni added that, in general, clinicians are adjusting their ex - pectations about return to sports. “It used to be six months, but now people are saying that before nine or twelve months, patients don’t really have their proprioception back. Their quadriceps are still weak, so there is a risk for re-tear, especially in elite athletes,” he said. Other researchers have reported the importance of quadriceps strength for achieving biomechanical symmetry during rehab, in fact. 13,14 Clinicians at the University of Delaware in Newark are exploring a new rehab protocol involving a form of neuromuscular work they call postoperative return-to-sports training. 15 The approach uses a se - ries of progressive perturbations on unstable surfaces in both bilateral Medicare and unilateral stance, in conjunction with distractions and other tasks. +DQGFUDIWHG Code “People haven’t been using uniform or even very stringent PCS L19 LQWKH86$ HC 32 rehab criteria,” said Lynn Snyder-Mackler, PT, ATC, alumni distin - guished professor of physical therapy, and one of the study’s de - signers. “In this approach, we perturb the support surfaces; 'D\8QFRQGLWLRQDO*XDUDQWHH something unexpected happens, so how do you control your knee? If for any reason during the initial 30 day trial period the In ten sessions over a couple of weeks, we increase the challenges practitioner or wearer is not completely satisfied with and they get better at it. You’re trying to incorporate new movement The Noodle TA AFO it may be returned for a refund. patterns into sport-specific activities.” In the clinical trial, all patients will receive quadriceps strength - )81&7,2167

Carbon Fiber Specialists Cary Groner is a freelance writer in the San Francisco 800-919-3668 Bay Area. www.KineticResearch.com References are available at lermagazine.com.

24 03.16 lermagazine.com

Plantar fasciitis: Clinical concerns in basketball

By Patricia Pande, MClScPT, CSCS, CPed

Basketball is associated with a high number of lower extremity in - The average National Basketball Association (NBA) player juries, 1,2 often related to footwear and the unique biomechanics and weighs 220 lbs and wears a size 14.8 shoe, maxing out at size 20. 12 repetitious motion of the sport. This reflects the evolution of bas - Higher BMI theoretically causes increased vertical force during heel ketball from a refined sport to one of extreme physical contact and contact, with a concomitant increase in tissue stress. 13 However, re - leverage. At elite levels of competition, the joint loading that comes duction of body weight and lower extremity anthropometrics typi - with players’ size also contributes to lower extremity injury risk; large cally is not feasible for the basketball player. players with large feet frequently have large problems. Plantar loads. Although no studies have examined the associ - The mainstream media has given considerable attention to the ation between plantar loads and plantar fasciitis in basketball play - loss of playing time associated with plantar fasciitis in highly compen - ers, evidence does suggest that runners with plantar fasciitis have sated athletes, but recreational players also present a challenge to higher plantar loads and loading rates than healthy runners. 9 Be - sports medicine clinics. As many as 45.9% of players in Australia have cause much of basketball involves running—not to mention changes been sidelined for more than a week with lower extremity injuries. 3 of direction, jumping, and landing on hard and unyielding court surfaces—it seems likely that plantar loads in basketball are at least Definitions as high as in running. The plantar “fascia” is not actually fascia but an aponeurosis with Basketball movements other than running have also been as - mechanical and histological similarities to surrounding tendons and sociated with high loads. Cutting movements, which are common ligaments. 4 Plantar heel pain is one of the most common ailments in basketball, have been associated with high plantar pressures at in the US, accounting for up to two million annual visits to physicians the heel in other sports. 14 Lay ups, free throws, and jump shots are and comprising up to 10% of all sports clinic visits. 5,6 It presents all associated with greater plantar loads than static stance. 15 Ground with pain with the first step in the morning or after prolonged bouts reaction forces (GRF) associated with jump shots in basketball have of sitting. been reported to be more than five times body weight, heightening Repetitive stress can inflame the plantar fascia or lead to de - the risk of damage with repetition. 16 In fact, ground reaction forces generative changes, commonly called fasciosis, which explains the are higher in basketball players than soccer players. 17 Learning how recalcitrant nature of the condition. Altered hydrostatic pressure in to land softly and on the forefoot or midfoot will reduce landing the fascia may also impede blood flow. 7 GRF; 16 however, this is an adjustment that recreational players may not have mastered. Plantar fasciitis in basketball players Running volume. There is some evidence that plantar fasciitis Although there is a shortage of information about the incidence of may be associated with a faster running pace. 18 Basketball involves plantar fasciitis in basketball players, plantar fascia rupture associ - high acceleration and anaerobic bursts of running. Highly effective ated with basketball has been reported. 8 Factors contributing to the basketball players may run up and down a 90-foot court at high high incidence of lower extremity and foot and ankle injuries in bas - speed a minimum of 50 times per game, resulting in increased ketball, and more specifically to plantar fasciitis, include the repeti - strain on the intrinsic muscles of the foot. 19 tive high loads associated with running, 9 as well as jumping, landing, Basketball shoes. The most coveted basketball shoes have and cutting by players who often are large in frame. 1,2 Other factors transitioned from being highly structured to being lightweight and that may contribute to plantar fasciitis risk in basketball include flexible. At the most elite levels, basketball players are restricted in footwear and fatigue. their choice of shoes due to footwear contracts. Colleges often use Body mass index (BMI). Van Leeuwen et al found a positive basketball shoe brands as a tool in recruiting high school players. 20 association between patients with a high BMI and plantar fasciitis. 10 Most importantly, the shoe must be able to withstand high plan - BMI was the only variable that predicted disability in an earlier tar loading without deformation and resist the rotational and cutting study. 11 forces that stretch the upper in a very moist environment. Frequent Sponsored by an educational grant from medi USA.

26 03.16 lermagazine.com footwear changes can help reduce midsole fatigue. Shoes have Plantar fascia corticosteroid injections in athletes may have un - been shown to reduce impact forces during unanticipated drop intended adverse effects, with some accounts of rupture after early landings in basketball. 21 re-entry into play. 28 Additionally, surgical management with plantar For many basketball players, the shoe is not wide enough, es - fasciotomy has only moderately improved patient outcomes in the pecially with added bulk of high-profile orthoses. 22 If the shoe general population, often resulting in extended recovery time. 29,30 doesn’t have sufficient volume to allow for proper activation of mus - The risks of adverse events must be weighed judiciously in any cles (eg, abductor hallucis), this can impair the propulsive function treatment paradigm. of the longitudinal arch during walking and running. 19,23 Lower extremity clinicians who treat basketball players say the Orthotic management game has changed since the late 1990s from one played close to An orthotic device with intrinsic or extrinsic medial wedges was as - the basket to one played around the perimeter. This switch requires sociated with greater soft tissue thickness under the heel, which more lateral footwork, with more stresses to the ankle and plantar may protect the fat pad (assessed statically) more than no orthosis fascia. In response, basketball shoe designs have evolved to rein - or an orthosis with arch support only. 31 This may have implications force the lateral border to reduce for treatment of plantar fasciitis ankle sprains and promote given the condition’s association quicker directional changes. This with fat pad atrophy in some pa - design shift has led to shoes with tients. 32 Further investigation is reduced medial support and am - warranted. plified pronatory moments, which The diagonal cuts and lateral may increase the risk of plantar shuffle cuts in basketball are also fasciitis. associated with elevated forces There also has been a tran - under the metatarsal heads. 33,34 sition to lightweight shoes. Inter - Plantar fasciitis interventions to re - estingly, a group of researchers in distribute plantar pressures must Calgary found that lighter-weight take care to avoid overloading the shoes were associated with im - metatarsals. 35,36 proved performance of basket - Treatment must mitigate dele - ball tasks, but not when athletes terious forces on the foot with the were blinded to the weight of the following orthotic strategies. Or - shoes, suggesting a psychologi - thoses must: cal effect. 24 There is a need for 1. Reduce impact plantar load - further research on the functional ing without inhibiting performance effects of lighter footwear, includ - or excessively increasing load in ing foot orthoses. othe r areas; accommodative or Sport-specific factors. Al - shock-absorbing inserts are much though basketball originated as a better tolerated by basketball noncontact sport, its physical na - players; 22,37 ture has evolved over the years 2. Not elevate the heel or with regard to both offense and destab ilize the ankle; 7 defense. 25 Rapid braking and ac - 3. Not hamper the function of Istockphoto.com #61283072 celeration (vertical and horizon - the abductor hallucis and intrinsic tal), along with lateral shifts of muscles; body weight, are very demanding on the foot and ankle. 4. Have reduced arch height to minimize pressure shift laterally Steve Vinson, who coaches girl’s basketball at Ann Arbor Huron and decrease fifth metatarsal head pressure; 31 and High School in Michigan, said plantar fasciitis in younger athletes is 5. Not impede blood flow to the foot from excessive pressure. 38 a growing concern, with competition for scholarships leading to more aggressive play, and intense schedules leaving little time to Plantar fasciitis in basketball will continue to be a growing con - recuperate from the stresses associated with the sport. 26 cern made even more clinically challenging by the lack of specific research on foot and ankle biomechanics in this popular and stren - Treatment and prevention uous sport. Vigilant clinical judgement, informed by the broader The treatment paradigm of rest, cessation of activity, or both is often body of research on the biomechanics of plantar fasciitis, will be es - not feasible for high-level athletes. Changes in jumping technique, sential to meeting this challenge. 16,27 which can help reduce the risk of knee and ankle injuries, have Patricia Pande, MClScPT, CSCS, CPed, is a physical therapist, pedor - not been studied in cases of plantar fasciitis or fasciopathy. Taylor thist, and strength and conditioning specialist based in Durham, NC. stressed prevention and proprioception programs to reduce the in - She is the founder of FootCentric, an online continuing education com - cidence of ankle sprains and lower extremity injuries, but there has pany dedicated to comprehensive, multidisciplinary foot treatment. been no attempt to study or adapt these programs for the preven - tion of plantar fasciitis. 27 References are available at lermagazine.com.

Sponsored by an educational grant from medi USA.

lermagazine.com 03.16 27

Running modifications and reducing injury risk

Evidence suggests that no one foot strike style can be expected to decrease injury risk in all runners, and that switching foot strike patterns can have unintended con - sequences. Using a shorter stride length, however, can be an effective alternative for some runners.

By Elizabeth Boyer, PhD, and Tim Derrick, PhD

Runners struggling with injuries may be curious about barefoot run - ning or running on their toes if they’ve seen other runners doing it, or if they’ve heard it will decrease their risk of injury because it’s “more natural.” Although there is evidence in the medical literature that such changes may reduce the risk of some types of injuries in some runners, evidence also suggests injury risk can be reduced using an alternative running modification that might be easier to implement. Large-scale epidemiological studies objectively quantifying how runners run (ie, footwear or foot strike pattern) and how those vari - ables relate to injury risk are nonexistent. A few studies with either small sample sizes or self-reported information about footwear or foot strike style provide conflicting evidence of injury prevalence in rearfoot, midfoot, and forefoot strikers, and shod versus barefoot runners, 1-6 though shod rearfoot strikers might sustain more injuries than others. Beyond foot strike We need to be wary of studies using self-reported foot strike, Istockphoto.com #41130854 though, because approximately one third of runners misclassify their foot strike style. 7,8 Additionally, since stride length may slightly shorten when switching from a rearfoot strike (RFS) pattern to a mid - foot or forefoot strike (FFS) pattern 3,9-11 or when switching from shod to barefoot running, 12-14 the independent effects of stride length, footwear, and foot strike style appear to be equivocal. For instance, the decreased loading associated with running barefoot versus shod running may be primarily attributed to a shorter stride length, 15 and A shorter stride seems to decrease certain multiple studies have shown that a shortened stride beneficially de - creases loading. 16-26 So, in addition to, or in place of, running bare - loading variables as much as switching to foot or using a FFS modification, we might be able to decrease a forefoot strike pattern, without the injury risk by retraining runners to use shorter strides. 26,27 negative effect of increasing ankle loads. In our model, we consider the effects of shorter stride length and increased stride frequency to be synonymous. Although these variables aren’t perfectly interchangeable, if running velocity is held

lermagazine.com 03.16 29 Continued from page 29

Figure 1. The resultant ground reaction force vec - tor (red arrow) is larger and oriented more pos - teriorly for forefoot strike running (left) vs rearfoot strike running (right) in the early part of stance (~8% of stance). Adapted from reference 38.

constant, stride length and stride frequency vary inversely with each the resultant GRF vector more perpendicular to the tibia (Figure 1). other. In other words, running velocity is equal to the product of We may also want to shift our focus to the resultant GRF and loading stride length and stride frequency. For example, 3 m/s running ve - rate (ie, summation of all three orthogonal directions), as that force locity can be obtained by a stride length of 2.25 m and a stride fre - is what the body experiences, and it is always equal to or greater quency of 1.33 strides/s (or 160 steps/minute). If the same runner than the vertical force. shortened his or her stride by 10% (to 2.03 m) but maintained that 3 m/s velocity, he or she would have to use a stride frequency of Moments 1.48 strides/s (or 178 steps/minute). Taking it a step further, we can look at joint moments (or torques), which are surrogates for the net muscle activity at a joint. Joint mo - Forces ments during running have been fairly well documented for the Many studies investigating biomechanical differences between foot sagittal plane, which is the plane associated with the largest mo - strike styles and footwear have focused on the vertical ground re - ments during running. Generally, plantar flexion moment and power action force (GRF) and how quickly it changes, or GRF loading rate. are greater for FFS than RFS patterns, 8,11,39-41 knee extension mo - Several studies have found that runners with high vertical loading ment and power are greater for RFS than FFS patterns, 8,11,39,41,42 and rates are more likely than those with lower loading rates to sustain studies of sagittal plane hip moments have been inconclusive with a future injury or to report a history of injury, particularly of stress regard to foot strike. 11,41,43 Similar trends have been reported for fracture. 28-33 Zadpoor and Nikooyan 34 summarized 13 studies and barefoot versus shod running. 12,15,39,44,45 found that higher vertical loading rate (not peak vertical GRF) was However, the other planes have been largely neglected. Of the associated with the risk of stress fractures of the tibia and few variables that have been investigated, knee abduction moment metatarsals. Typically, loading rate is higher with a RFS pattern than was higher and ankle external rotation moment was lower for RFS a FFS pattern, 1,3,35,36 which is one reason why FFS running is pur - than FFS. 11,43 Compared with habitual midfoot and forefoot strikers, ported to help reduce injuries. when habitual rearfoot strikers ran with a FFS, they had larger hip However, focusing only on vertical forces neglects the smaller abductor and ankle external rotation moments. 43 Additionally, ankle shear forces. Considering that the leg is relatively perpendicular to internal rotation moment increased when habitual rearfoot strikers the ground during stance and that muscles can apply force only ran with a FFS compared with a RFS. 43 We have supplemented through shortening, the femur and tibia/fibula are primarily loaded these findings and found similar results with a few contradictions. 46 in compression. Bones are most resistant to these compressive Many studies have shown habitual rearfoot strikers can de - 18,19,21,30,35 forces and stresses, and less resistant to tensile forces and shearing crease loading by shortening their stride length, but can forces, 37 such as those caused by shear GRFs. We found that, while they decrease it to the same extent as when switching to a FFS pat - habitual rearfoot strikers decreased their peak vertical GRF and tern? Our preliminary data comparing stride shortening and switch - loading rate when using a FFS, the shear (posterior and medial) ing from a RFS to FFS pattern suggest they can for several variables, GRFs and loading rates were higher during forefoot striking than including peak knee extensor moment, hip internal rotation rearfoot striking during impact. 38 These higher shear forces orient Continued on page 32

30 03.16 lermagazine.com

Continued from page 30 moment, lateral knee contact force, and posterior hip contract force. 46 Therefore, a shorter stride seems to decrease certain load - ing variables as much as switching to a FFS pattern. Plus, shortening one’s stride does not increase ankle loads the way a FFS pattern does. Net joint moments are limited in that they cannot tell us the ex - tent to which all muscles are firing. Instead, they just tell us which muscle group is firing the most. For example, the quadriceps could be producing a +100-Nm moment while the hamstrings produce a -80-Nm moment, resulting in a net joint moment of +20 Nm. How - ever, both of these moments contribute to gross loading at the joint. Joint contact forces include both joint reaction forces (forces accounted for in net joint moment calculations) and muscle forces, which we can estimate using optimization procedures. It is impor - tant to consider these muscle forces, as they account for more of the total joint loading than reaction forces. 47,48 For instance, peak ankle joint reaction force might be two times body weight, whereas muscle forces might be six to eight times body weight. Only a few studies have reported contact forces for different foot strike styles, focusing on the axial 40 or patellofemoral contact forces. 11,42 Again, we supplemented their findings with data for all three planes. 46 In - terestingly, because co-contraction is ignored in net joint moment calculations, it is possible that moments may be larger for one foot strike style, but contact forces could actually be equal or larger for the other foot strike style, which we observed. 46 The take-home

Istockphoto.com #22720678 message is that we need to consider muscle forces to get a better understanding of the actual joint loading during running.

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32 03.16 lermagazine.com Offsetting effects In addition to peak joint loads, certain frontal and transverse plane variables have been linked to running-related injuries, such Taken together, the literature suggests that ankle loads are higher as patellofemoral pain, iliotibial band syndrome, and tibial stress for FFS than RFS patterns, while some knee and hip loads are higher fractures. 32,52-58 We previously investigated how these variables for RFS than FFS. Some researchers have observed that habitual changed with foot strike style and step length in 42 runners. 16 Re - rearfoot strikers tend to have higher knee and hip loads than habit - garding beneficial changes, during FFS, contralateral pelvic drop ual midfoot and forefoot strikers for both RFS and FFS. 43,46,49 This (which has been associated with patellofemoral pain 52,58 and iliotib - continuation of more reliance on the knee extensors may be a lin - ial band syndrome 54 ) was reduced. During RFS, step width was in - gering effect of the neuromotor programming associated with a RFS creased, which is beneficial since a wider step width decreases pattern. So, even though knee loads tend to decrease when habitual frontal joint moments, 59 iliotibial band strain, 60 and peak free mo - rearfoot strikers switch to a FFS pattern, if they do not decrease to ment. 61 During RFS, peak negative free moment was also reduced, the levels seen in habitual midfoot or forefoot strikers, this could which is beneficial as research has linked larger peak free moments potentially mute the effect on injury risk. Shortening stride length, with risk of tibial stress fractures. 30,32 However, variables such as however, decreases loading to a similar extent. If tolerated by the peak iliotibial band strain and strain rate, hip adduction, rearfoot runner, this alternative to foot strike modification may be a better eversion, and positive free moment were not different between RFS approach to decreasing injury risk. Additionally, studies have shown and FFS. Therefore, the risk of injuries related to these variables— that, despite taking more steps per distance with a shorter stride such as patellofemoral pain, iliotibial band syndrome, and tibial length, cumulative loading (ie, the summation of loading from all stress fractures—is largely unaffected by foot strike style. steps per distance) remains lower for the shortened stride length Most variables did, however, slightly decrease as runners used condition versus normal stride length. 20,25 shorter strides, which may have been associated with their con - Although loads may be higher at different joints for certain foot comitant wider steps. Adding to the plethora of data supporting the strike styles, bones may adapt so that the actual bone stresses and benefits of shortened stride length, we found shortening one’s stride strains are unchanged. Our preliminary data and those of others length may decrease—or at least not increase—the propensity for have shown that tibial stresses, strains, or strain rates are highest running injuries based on the variables we measured. 16 during shod FFS running, moderate for barefoot FFS running, and lowest for shod RFS running. 46,50,51 Only shear stress decreased slightly with a shorter stride length. 46 As such, if runners’ bones do Clinical implications not have time to adapt to the greater stresses and strains of FFS and Collectively, study findings suggest that a single foot strike style does barefoot running, running in these strike patterns may load the tibia not appear to explicitly decrease injury risk; rather, different foot excessively. Alternatively, if runners transition slowly to FFS or bare - strike styles may predispose runners to different types of injuries. foot running, these higher loads may make their bones stronger. Continued on page 34

lermagazine.com 03.16 33 Continued from page 33 The benefit of only shortening the stride is that the runner won’t be increasing loading on different joints or tissues. If a tibial stress fracture is the concern, neither switching foot strike nor running barefoot will likely decrease tibial stresses, and the runner may have to use at least a 10% shorter stride length to significantly decrease stresses. If the runner is experiencing hip pain caused by excessive load - ing, he or she may decrease loading more by switching to a midfoot or forefoot strike (shod or barefoot) rather than by shortening the stride, though both modifications are options for decreasing load. It would be logical to consider both running modifications (foot strike and stride length) simultaneously, which researchers have found to beneficially decrease GRF loading rate. 35 Indeed, most habitual rearfoot strike runners instinctively shorten their stride length when running at the same speed with a midfoot or forefoot strike. 3,9-11,16 Istockphogo.com #79746661 What if runners are not injured and just want to switch foot A shorter stride length, however, may be beneficial. strike style? They can try it, but should transition very slowly (at least 6 So, should runners modify their running style to prevent per - 10 weeks or more). Because there is no evidence that a shorter sistent injuries by running barefoot, on their toes, or taking shorter stride length leads to injuries, runners wanting to adopt this modifi - steps? The evidence suggests none of these modifications univer - cation do not need to transition slowly. As with making any running sally reduce loading on all structures. regimen change, it is important for runners to listen to their bodies If a runner is experiencing ankle or foot pain (particularly in the to help avoid injury. metatarsals or plantar fascia), rest is probably indicated, as running Elizabeth Boyer, PhD, is a postdoctoral fellow at Gillette Children’s barefoot or using a midfoot or forefoot strike or both may make the Specialty Healthcare in St. Paul, MN, studying movement disorders problem worse. If resting isn’t an option, shortening strides by 10% in children and adults. Tim Derrick, PhD, is a professor in the De - may reduce loading. partment of Kinesiology at Iowa State University in Ames studying If a runner is experiencing knee or patellofemoral pain caused musculoskeletal loading during activities of daily living. by excessive loading, either switching to a midfoot or forefoot strike (shod or barefoot) or shortening the stride by about 10% may help. References are available at lermagazine.com.

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Strength training: Bone health benefits for men

Men with low bone mass are much less likely than their female counterparts to receive treatment. But research suggests that resistance exercise is a safe and effect ive way to improve bone mineral density in men and, in turn, reduce the risk of fracture and related complications

By Pamela S. Hinton, PhD

Osteoporosis, which is defined 1 as “low bone mass and micro- architectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk,” currently affects more than 200 million people worldwide. 2 The World Health Organ - ization defines osteoporosis as a bone mineral density (BMD) that is two and a half standard deviations (SD) or more below the aver - age value for a young adult (T-score < -2.5). 3 Osteopenia is charac - terized as low bone mass, and is defined as a BMD that is between one and two and a half SDs below the young adult mean (T-score between -1 and -2.5). 3 Low BMD is associated with increased risk of nontraumatic fracture; fracture risk is increased 1.5 to three-fold or greater for each SD decrease in BMD. 4 Each year, more than 4.5 million people in the US and Europe will suffer a fragility fracture. 3 Due to the growth of the aging population and the rise in life expectancy in recent years, the incidence of osteoporosis and related fracture is expected to increase. 5 Osteoporosis affects men Istockphoto.com #86982231 Osteoporosis affects more than two million men in the US, and nearly 16 million more have low bone mass. 6 Men account for ap - proximately 40% of the nine million new osteoporotic fractures that occur annually, 7 and the lifetime fracture risk in men aged 60 years and older is estimated to be as high as 25%. 8 Compared with women, men have a significantly greater risk for complications after a hip fracture, including increased morbidity, mortality, loss of inde - pendence, and rate of institutionalization, 9,10 yet treatment rates are 11 Resistance training is well tolerated and much lower in men than in women. Recent estimates from the National Osteoporosis Foundation appears to have a minimal risk of injury guidelines indicate that one third of white men older than 65 years, or discomfort, which predicts both good and more than half older than 75 years, should be recommended compliance and practical application. pharmacologic treatment for osteoporosis. 12 Yet, even after suffering an osteoporosis-related fracture, more than 90% of men remain un - diagnosed and untreated. 13,14 Postfracture, men are less likely than

lermagazine.com 03.16 37 Continued from page 37 The majority of clinical trials of resistance training have been conducted in women. Exercise that exerts high muscle-contraction women to receive follow-up care, 15 including calcium and vitamin or ground reaction forces on the skeleton, such as high-intensity re - D supplementation 16 and prescription of antiresorptive pharma - sistance training or structured jump-training, respectively, is associ - cotherapy. 11 ated with increased BMD in pre- and postmenopausal women. 38-40 Physical inactivity However, very few controlled trials have examined the effects of re - sistance training on bone mass in men. 22,41-48 Physical inactivity is a modifiable risk factor for osteoporosis, and Generally, these studies reported positive effects of resistance increasing physical activity at any point throughout the lifespan pos - training on BMD. Kukuljan et al found that 12 months of progressive itively affects bone health, 17-22 while reductions in physical activity resistance training and impact exercise (three days per week) was can result in bone loss. 23,24 Cross-sectional and longitudinal studies associated with increased BMD at the femoral neck and lumbar have shown the skeletal benefits of physical activity during adoles - spine by 1.8% and 1.5%, respectively, in men aged 50 to 79 years cence and young adulthood persist into middle age and older adult - with normal to below-average BMD at baseline. 42 Whole-body BMD hood. 25,26 In addition to increasing BMD, bone loading during increased by about 1.2% after 12 weeks of resistance training in adulthood increases bone size, cortical area, and strength, 27 and 48 reduces hip fracture risk later in life. 20 elderly men and in women with an average age of about 60 years. Exercise can affect bone through multiple mechanisms, includ - Ryan et al also reported a 2.8% increase in femoral neck BMD after ing muscle contraction forces, gravitational loading, and endo - four months of resistance training in men with an average age 46 crine/paracrine effects. During physical activity, bone is subjected around 60 years, and Menkes et al observed significant increases to mechanical forces exerted by muscle contraction and gravita - in lumbar spine (2%) and femoral neck (3.8%) BMD in men aged 45 tional loading. At the cellular level, bone cells (osteocytes) perceive 55 to 60 years. In a study of men and women aged 55 to 74 these mechanical forces as cell deformation, changes in extra - years, some of whom were osteopenic or osteoporotic, Bemben et cellular fluid shear stress, pressure gradients, and electric fields. 28 al found that 40 weeks of resistance training significantly increased The osteocytes communicate with osteoblasts and osteoclasts to BMD of the spine, trochanter, and total hip by ≤1%. 41 However, be - modulate bone formation and resorption, thereby changing the cause these studies included men and women, elderly men, or a bone’s geometry and material properties. 29 mixed study population of men who had either normal or low BMD, It is well-accepted that bone adapts to the mechanical de - or because the intervention included a combined exercise protocol mands to which it is subjected, and muscle contractions contribute (ie, resistance training plus high-impact activity), the effectiveness a portion of those demands. 30,31 The importance of skeletal muscle of resistance training for increasing BMD in men with existing low contraction forces (ie, joint reaction forces) to bone mass is sup - bone mass could not be determined. ported by the parallel changes in bone mass and muscle strength throughout the lifespan. 30,32 Similarly, in states of muscular disuse Clinical trial that result in muscle atrophy (eg, disease, inactivity, or paralysis), To answer this clinically relevant question, we conducted a clinical muscle contraction forces are severely reduced, and site-specific trial to determine the effects of 12 months of periodic progressive reductions in bone mass and bone strength occur. 31 resistance training on BMD in apparently healthy men (mean age, Site-specific relationships between skeletal muscle mass and 44 ± 2 years; median age, 44 years) with osteopenia of the hip or BMD demonstrate the importance of muscle contraction to the spine. 49 This study was conducted in accordance with the Declara - preservation of bone mass. Studies of tennis players demonstrate tion of Helsinki and was approved by the local Institutional Review that a player’s dominant arm has greater muscle and bone mass Board. Informed written consent was obtained from each study than their nondominant arm. 32 In the lower extremity, the bones of participant. the nondominant limb have greater bone density due to greater Apparently healthy physically active (four or more hours of motor neuron excitability and activity of stabilizing muscles of the leisure time physical activity/week for the past 24 months) men 33 nondominant side. Cross-sectional studies have shown positive aged 25 to 60 years with low BMD of the lumbar spine or hip (T- site-specific associations between repetitive muscle contraction and score between -2.5 and -1 SD) were eligible to participate in the regional BMD, such that resistance training of the upper body is as - study. Exclusion criteria were: use of medications or supplements 34 sociated with greater BMD of the arms. Likewise, changes in that affect bone metabolism or prevent exercise; a previous or cur - skeletal mass following strength training are positively associated rent medical condition affecting bone health; osteoporosis of the with changes in BMD. 35 Thus, there is considerable evidence that lumbar spine and/or hip (T-score < -2.5 SD); cardiovascular disease; muscle contraction forces are important for bone strength. metal implants; current smoker (ie, within the past six months); cur - Resistance training rent regular participation in high-intensity resistance training and/or plyometrics; reversed sleep/wake cycle (ie, sleep during the day The American College of Sports Medicine recommends weightbear - and work at night); and consumption of more than three alcoholic ing endurance activities, including those that involve jumping and drinks per day. jogging, three to five times per week, and resistance exercise two The participants completed two resistance training sessions per to three times per week to preserve bone health during adulthood. 36 week under the supervision of study personnel. The resistance train - Resistance training is also recommended by the National Strength ing intervention included exercises that load the hip and spine: and Conditioning Association to increase BMD or to prevent age- squats, bent-over-row, modified dead lift, military press, lunges, and associated reductions in BMD. 37 The Surgeon General’s Report on Bone Health also recommends progressive resistance training, as calf raises. Participants were instructed to perform the eccentric well as daily jump-training and participation in weightbearing recre - phase of each lift in two to three seconds and to perform the con - ational activities for individuals who can tolerate high-impact centric contraction “explosively.” Prior to and every six weeks during activity. 1 Continued on page 40

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800/564-LEVY (5389) www.levyandrappel.com Continued from page 38 alterations in serum bone turnover markers; specifically, there was a significant reduction in bone resorption and an increase in bone the intervention, we performed maximal strength testing. 50 To minimize risk of injury and to account for strength adapta - formation. tions as a result of strength training improvements, the intervention also used a progressive intensity design based on a six-week cycle Biological and clinical significance followed by a rest week; a total of eight cycles were completed. The biological and clinical significance of these results can be ap - During the six-week cycle, the intensity progressively increased preciated only if one considers that bone loss occurs with normal every two weeks based on the strength measured at the end of aging. Young adult and middle-aged men lose BMD at rates of 51-53 each cycle. about .4% to 1.5% per year. The results are also important be - • Weeks one to two were light intensity, consisting of one cause they suggest that a time-efficient (two to three days per week) warm-up set of 10 repetitions at 20% of the 1-repetition maximum resistance training intervention can improve BMD in otherwise (1RM) and three sets of 10 repetitions at 50% of the 1RM. healthy men. We previously observed that physically active adult • Weeks three and four were moderate intensity, with one men with osteopenia, similar to those in the present study, lost hip warm-up set of 10 repetitions at 20% of the 1RM, two sets of 10 BMD at a rate of .8% per year, 54 consistent with the literature con - repetitions at 60% of the 1RM, and one set of six to eight repetitions sensus that bone loss occurs with aging. Therefore, the increases at 70% to 75% of the 1RM. in BMD observed in this and previous exercise-intervention studies, • Weeks five to six were high-intensity, starting with one warm- though relatively small (.6% to 1.3%), are biologically significant, in up set of 10 repetitions at 20% of the 1RM, followed by two sets of that exercise reversed the bone loss that occurs with normal aging. 10 repetitions at 60% of the 1RM, and one set of three to five rep - The increases in BMD observed following exercise interven - etitions at 80% to 90% of the 1RM. tions likely have clinical significance, as small increases in BMD re - At the end of the 12-month intervention, participants significantly sult in much larger gains in bone strength. For example, increasing improved their muscular strength, as evidenced by increases in 1RM BMD by 5% increased bone strength by 65% in an animal model, 55 for the squat, lunge, modified deadlift, calf raise, military press, and and, in women with postmenopausal osteoporosis, a 1% increase bent-over row of 79%, 114%, 64%, 79%, 52%, and 44%, respec - in spine BMD reduced fracture risk by 8%. 56 Similar to the increase tively. Bone mineral density of the whole body, total hip, and lumbar in bone formation and decrease in bone resorption observed in our spine, which was measured using dual-energy X-ray absorptiometry, study, others have reported increases in bone formation markers also significantly increased after 12 months of resistance training. relative to resorption following high-intensity resistance training in There was a positive relationship between percent changes in squat older men. 47,57,58 These data suggest exercise might counteract age- 1RM and in left leg BMD (r = .605, p = .042). The increases in BMD related bone loss in men, which has been attributed primarily to a observed in the present study were associated with favorable deficit in bone formation relative to bone resorption. 59

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40 03.16 lermagazine.com Feasibility of resistance training six and 12 months. Participants also rated fatigue associated with the interventions as less than 30 out of 100, with 100 being the From a practical perspective, it is worth noting that, in our study, the most fatigue imaginable, at all time points. In addition, there were time and equipment required to complete the resistance training no injuries reported during any of the approximately 1800 super - each week was minimal, ranging from 60 minutes during a “light” vised training sessions. week to 120 minutes for a “heavy” week. If participants missed a Thus, the resistance training was well tolerated by the partici - session, they were required to make it up. While the training in our pants and appears to have a minimal risk of injury or discomfort, study was supervised, it could be done at home without supervision. which predicts both good compliance and practical application. Other These observations, coupled with evidence of long-term com - studies have reported that older adults with low bone mass can safely pliance with voluntary unsupervised high-impact exercise interven - perform maximal strength training (squats) 65 or jumping. 66,67 More - tions in premenopausal women, 60 suggests exercise-based inter - over, a recent review by a panel of experts strongly recommends ventions might be effective in the real world. multi component exercise that includes resistance training for individ - This conclusion is strengthened when one considers the alter - uals with osteoporosis. Osteoporosis Canada, the National Osteo - native of pharmacologic treatment. Although antiresorptive medica - porosis Foundation, and Osteoporosis Australia’s Medical and tions are a Food and Drug Administration-approved treatment for Scientific Advisory Committee endorsed the recommendation that osteoporosis in men, 61 less than 10% of men with osteoporotic frac - individuals with osteoporosis engage in resistance training that targets tures are treated with bisphosphonates. Enthusiasm for use of these 68 medications in men appears to be limited by the relative lack of long- all major muscle groups at least twice per week. term safety and efficacy studies in men, the especially poor treatment compliance in men, 62 and data suggesting poor cost-effectiveness of Conclusion bisphosphonate treatment in men. 63 Drug treatments for osteoporosis In summary, the existing evidence suggests that resistance training have low rates of compliance and persistence, and most patients who interventions are safe and effectively increase BMD in men with low stop taking their osteoporosis medication do not restart. 64 bone mass. These results have clinical implications, as exercise may be the appropriate “prescription” for some individuals with low bone Safety issues mass. To evaluate safety of the resistance training intervention, we as - Pamela S. Hinton, PhD, earned in her doctorate in nutrition sciences sessed the self-reported pain and fatigue associated with the exer - from the University of Wisconsin-Madison and is currently an asso - cise at each training session. On average, the participants rated the ciate professor in the Department of Nutrition & Exercise Physiology intensity of the pain caused by the training as a score of 10 or less at the University of Missouri-Columbia. out of 100, with 100 being the most intense pain imaginable. In ad - dition, the pain ratings decreased from the baseline assessment at References are available at lermagazine.com.

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TM Ankle instability rehab emphasizes individuality

Research presented at the most recent International Ankle Symposium indicates that rehabilitation for chronic ankle insta - bility is evolving from a one-size-fits-all approach to an increased focus on match - ing specific interventions to the patients who are most likely to benefit.

By Lori Roniger

The future of rehabilitation interventions for chronic ankle instability (CAI) could include combining treatments and personalizing rehab programs for individual patients and their specific deficits, according to new research presented at the 6th International Ankle Sympo - sium in Dublin, Ireland. “I think the key to successful rehab in people with chronic ankle instability is matching the treatment to the individual patient, not having a protocol applied to all patients,” said Jay Hertel, PhD, ATC, the Joe H. Gieck professor of sports medicine and codirector of the exercise and sports injury lab at the University of Virginia in Char - lottesville. “Matching up the impairments identified in the evaluation should lead to the treatment they get.” Hertel gave a keynote lecture on treatment strategies for CAI at the October 2015 symposium and emphasized in a phone inter - view after the event that, while CAI is multifactorial in nature, this doesn’t mean every patient is influenced by all the possible factors. In particular, he said, it is important to address those that contribute to a patient’s specific limitations, such as range of motion, mobility, strength, balance, or more functional issues involving gait or cutting Istockphoto.com #64994205 and landing in athletes. “We need to be treating everyone as an individual,” said Erik Wikstrom, PhD, assistant professor of sports medicine at the Uni - versity of North Carolina at Chapel Hill, whose research on CAI rehab was presented at the conference. Performing a baseline assessment of each patient and his or her impairments is particularly important in patients with CAI as that population is more heterogeneous than others, Wikstrom said. A growing body of research suggests that Matching the treatment to the patient ankle instability threatens quality of life and Patrick McKeon, PhD, ATC, FACSM, assistant professor of exercise leads to decreased activity levels, which and sports sciences at Ithaca College in New York, has been work - could have long-term implications. ing with Wikstrom and other researchers to determine which CAI patients will benefit most from specific interventions that have al - ready been shown to be effective for improving CAI. The result has

lermagazine.com 03.16 43 Continued from page 43 training with multimodal STARS treatment in CAI patients improved been what the researchers call a sensory-targeted ankle rehabilita - static postural control more than balance training alone. While this preliminary research did not find a significant difference in static tion strategies (STARS) treatment paradigm. 1,2 postural control between the treatment groups, Wikstrom said the Their research has examined plantar massage, ankle joint mo - results, which were based on a relatively small group of 24 patients, bilization, or calf stretching in CAI patients, and the effect on out - suggest that combining the treatments could be effective. He hopes comes such as postural control, ankle joint range of motion, and to study this combination treatment in a larger group of patients and 1 self-assessed function. determine if any variables can predict a positive response to this “All of those interventions improved more or less all of those intervention. outcomes,” Wikstrom said. They found that response to treatment varied for each inter - Impairment-based model vention—some individuals had large improvements while some had Luke Donovan, PhD, ATC, an assistant professor of kinesiology at only small improvements—and they sought to determine if they the University of Toledo in Ohio, presented research at the ankle could predict which interventions were best for which patients, start - symposium on an impairment-based approach to CAI rehab. In this ing with plantar massage and ankle joint mobilization. model, patients are prescribed interventions to address specific im - pairments (such as sensory issues, decreased proprioception, or al - tered gait kinematics) starting at levels that are challenging for the “If we don’t specifically address the gait individual, instead of giving everyone the same tasks. mechanics through rehab, we don’t A study of his that was epublished in March by the Journal of Athletic Training examines the effectiveness of a four-week rehabil - actually change the gait patterns.” itation program in which CAI patients performed exercises while — Jay Hertel, PhD, ATC wearing an ankle destabilization shoe or while on traditional unsta - ble surfaces. The study’s protocol provided patients with challenging exercises throughout the study and focused on range of motion, They found that a baseline Foot and Ankle Ability Measure strength, balance, and functional exercises. After patients were as - (FAAM) Sport score greater than 70.31% and a single-limb balance sessed, they started exercises at a level that was difficult for them. test improvement of at least 1.67 errors after one five-minute plan - “What we found more or less was that both groups progressed tar massage treatment predicted which patients with CAI would similarly with clinical measures,” Donovan said. “Everyone’s strength improve their postural control after six such sessions over a two- improved on average. I would say that these [ankle destabilization] week period, according to preliminary results presented at the ankle devices are just as effective as unstable surfaces.” symposium. 3 At the symposium he presented the results of a second manu - “Plantar massage really seems to be beneficial if there is a script stemming from the same data that found impairment-based single-limb balance deficit,” Wikstrom said. rehabilitation incorporating an ankle destabilization device was as - In another pilot study, CAI patients who were responsive to joint sociated with improvements in dorsiflexion range of motion during mobilization treatment had lower FAAM-ADL (activities of daily liv - the stance phase of gait—which is often limited in patients with CAI. ing) scores and higher anterior Star Excursion Balance Test scores The same protocol without the destabilization device had no effect prior to undergoing this intervention than those who did not re - on ankle dorsiflexion. 6 spond. 4 The treatment involved six sessions over two weeks; each He said the patients anecdotally enjoyed participating in the session involved two two-minute sets of Maitland grade-II talocrural study and found the exercises challenging. These studies did not traction and four two-minute sets of Maitland grade-III anterior-to- follow patients over the long term, although Donovan is replicating posterior talocrural joint mobilization. the study using different gait training devices and plans to follow patients over a longer period. Mix and match Hertel, one of the study’s authors, emphasized the importance McKeon, who has both research and clinical responsibilities at of using specific interventions to address the altered gait patterns Ithaca College, said he enjoys seeing the clinical improvements as - seen in CAI patients. sociated with such interventions; ankle joint mobilization, for exam - “If we don’t specifically address the gait mechanics through ple, can help increase dorsiflexion and self-reported function. He rehab, we don’t actually change the gait patterns,” he said. “Patients has also been developing protocols that he hopes will be practical report feeling better but don’t see change in gait without doing spe - in the real world. cific gait interventions.” While randomized controlled trials conducted for STARS inter - ventions used only one form of treatment on each patient, McKeon Walk this way and colleagues are now studying a multimodal approach in which Like other researchers, Donovan is trying to figure out how to best CAI patients receive five minutes of joint mobilization, five minutes bring his research into the clinic. He’s been investigating the use of of plantar massage, and five minutes of foot core work three times off-the-shelf video cameras to look for visual cues that differentiate a week for two weeks. between CAI patients and those who have never sprained their an - “After that, I typically introduce some balance activities like kles, and the potential value of this information for CAI rehabilitation. standing on one leg and hopping on one leg,” he said. Donovan has also been studying the effects of an auditory Another study 5 presented at the International Ankle Symposium biofeedback device, worn in a shoe, on gait in CAI patients. Recently by Wikstrom and colleagues examined whether combining balance Continued on page 46

44 03.16 lermagazine.com

Continued from page 44

published research reported that wearing the device was associated with decreased plantar pressure in the lateral column of the foot while walking on a treadmill. 7 Since patients walk differently when using the device, he’d like to see if incorporating it into a rehab pro - gram causes lasting and long-term changes, such as altering gait, self-reported function, or incidence of giving way. “There are pretty effective ways clinicians can measure strength, balance, or range of motion, but when it comes to func - tional movement patterns, it’s tough to assess,” Donovan said. He also noted that CAI rehab studies typically have not re - ported long-term results. Having a vision A new area of research on which Wikstrom, McKeon, Hertel, and others are collaborating is examining whether CAI patients have an increased reliance on visual information. Some of them presented an abstract at the ankle symposium on their systematic review of the use of visual information in CAI patients compared with un - 8 XcelTrax ™ is an affordable and injured controls. Assessing 11 studies of single-limb stance under eyes-open comprehensive family of Walking Braces and eyes-closed conditions in CAI patients, healthy individuals, or providing ideal support and comfort to help both, they found CAI patients rely more heavily on visual information during that task than controls. These sensory weighting differences promote healing for patients with mild to suggest there may be a neurophysiological component to the bal - moderate foot and ankle injuries. ance deficits associated with CAI, Wikstrom said. “We want to get a better understanding of the full spectrum of The lightweight design and unique deficits associated with sensory reweighting,” he said. pre-shaped ergonomic frame help modify The next step is to determine whether this outcome is treat - able; however, he said, preliminary data from a few of his group’s the level of pressure on the injury, plus the ongoing investigations suggest existing interventions may not treat built-in shock absorbing outer sole helps this issue. If existing interventions don’t adequately address the way patients use somatosensory versus visual information, that could maximize comfort during ambulation. explain why patients with CAI often continue to experience epi - sodes of ankle sprain or giving way despite having gone through a full balance training protocol. Changes in the brain Phillip Gribble, PhD, ATC, FNATA, who spoke at the conference about CAI as the next injury epidemic, has been trying to document changes that CAI may cause in the brain and spinal cord pathways and how they may manifest into clinical functional deficits. “There is a rise in understanding that chronic ankle instability creates some adaptations in the nervous system,” he said. A study conducted by Gribble and colleagues published earlier this year found that fibularis longus corticospinal excitability was ™ greater in controls than in CAI patients. 9 He is currently using trans - XCEL TRAX cranial magnetic stimulation (TMS), which was used in the previous study, to detect differences in the corticospinal excitability of the Walking Braces peripheral muscles between CAI patients and ankle sprain copers To Step Up to Value, call 800.336.6569 (those who have a history of ankle sprain but don’t develop CAI). “These results may lead to the development of novel rehab or visit DJOglobal.com/procare techniques,” he said. Long-term consequences Gribble noted that a growing body of research, some of it presented at the ankle symposium, has been finding that CAI threatens quality of life and leads to a decline in physical activity levels, which could have long-term implications.

46 03.16 lermagazine.com A 2015 study by Hubbard-Turner et al found that physical ac - such as balance training. tivity levels were reduced in college students with CAI compared “I think it’s really important for them to continue with those with healthy students, 10 and another by Houston et al found that types of activities,” McKeon said. “If you don’t use it, you lose it.” quality of life is reduced in individuals with CAI. 11 Such maintenance programs could include performing foot “Something we all recognize that’s on the horizon is how to mit - core exercises, foot massage, and trying to balance on one leg. igate problems for CAI patients on this path toward long-term con - McKeon also recommends that CAI patients get involved an activity sequences and ultimately promote a physically active lifestyle in that promotes balance and dynamic movement, such as yoga, Pi - these patients,” Gribble said. lates, tai chi, or hiking. People are recognizing the long-term consequences of CAI and “There’s a reason that CAI is such a recalcitrant condition,” ankle instability, which include ankle osteoarthritis, 12-15 as they have McKeon said. “I think compliance seems to be the biggest issue.” previously for anterior cruciate ligament (ACL) injuries. He said he emphasizes to his CAI patients the outcomes and “What we’re seeing with the ankle is clearly mirrored in the improvements they’re seeing while working with him. He likes to knee patient population,” he said. use self-reported functional scales, such as the FAAM, to show them Future research may investigate how interventions may help to where they have difficulties and where their abilities are improving turn CAI patients into copers. through rehabilitation. “There has been, to my knowledge, no studies on how any in - “Having the patients fill out the form initially is a good way for terventions impact physical activity levels,” Wikstrom said. “That’s me to show them what their problems are and then to work through the next step.” goal-setting with them to address those problems,” McKeon said. “I One challenge is that many patients with CAI come in for treatment can then come back to how each intervention we include in their only when they experience a recurrent ankle sprain or an episode of rehab ties back to the problem they reported. Then as we progress giving way and want treatment for acute symptoms, he noted. through rehabilitation, I have them revisit the FAAM and show them “Generally, those get resolved and those patients disappear,” how they’re shifting their perception of difficulty based on the rehab. Wikstrom said. It definitely helps with the patients’ perception of why we’re doing These patients often don’t think they need rehab and don’t un - what we’re doing.” derstand they may have residual impairments, he said. This approach also makes it easier to link changes in clinical out - “People don’t respect ankle injuries,” McKeon said. comes—such as strength, range of motion, limb girth, and balance— to the subjective outcomes identified on the FAAM, he said. Compliance and communication Lori Roniger is a freelance writer based in San Francisco, CA. McKeon talked about the importance of a maintenance program for CAI patients after they have undergone some form of rehabilitation, References are available at lermagazine.com.

lermagazine.com 03.16 47

Flexible flat foot: Effects of orthoses during gait

In this original investigation, researchers analyzed the biomechanical effects of a foot orthosis in patients with flexible flat foot during walking and the extent to which those functional effects are consis - tent with proposed theories about the device’s mechanism of action.

By Bruce Elliott, PT, DPT, COMT, and Juan Garbalosa, PhD, PT

Low arches, or flat feet, are associated with an increased risk of in - jury among physically active people, and it is widely believed that this type of foot tends to be more flexible than other foot types, al - lowing a disproportionate amount of pronation during the gait cycle. 1,2 Researchers have theorized that flexible flat feet affect the movement and muscular activity patterns of the lower leg, predisposing such in - dividuals to lower extremity musculoskeletal injuries. 3- 5 Excessive pronation at the subtalar joint and the transverse tarsal joint is associated with a flexible flat foot. 6,7 It has been sug - gested that this foot type will contribute to a loss of ligamentous and osseous stability, necessitating increased muscular activity in the lower leg and foot to maintain that stability. 8 Additionally, the lack of stability may cause an increase in the magnitude of the stress and shear forces that are transmitted to the soft connective tissues. Excessive pronation is the etiological variable most commonly linked to overuse injuries, and the subsequent increase in muscular activity and transmitted forces can ultimately lead to muscular fa - tigue, which is associated with a variety of overuse injuries. 5,9 A biomechanical foot orthosis is commonly used for the man - agement of lower extremity injuries that are related to overpronation or flexible flat feet. 8,10 According to Root, realigning the posture of the foot is considered an effective intervention because abnormal foot posture is generally considered the cause of a wide variety of pathological conditions, 11 and the flexible flat foot is managed with orthosis intervention more often than other foot types. 4,5,9,12-14 Increasingly, foot orthoses have been successfully used as an adjunct treatment for symptoms that are secondary to increased The orthosis did not affect most of the flexibility. Of 465 podiatric patients reporting various maladies, 62% acknowledged complete resolution of their chief complaint after or - kinematics of the forefoot, first ray, and thotic treatment, and an additional 33% gained partial resolution. medial longitudinal arch, but did affect Similarly, in a retrospective study with both temporary soft orthoses transverse movement at the forefoot. and permanent rigid orthoses, 96% of patients experienced pain relief, while 70% were able to return to previous levels of activity. 15,16 Additionally, Nigg et al 17 reported that at least 70% of runners

lermagazine.com 03.16 49 Continued from page 49 have been generated by these studies because of the conflicting opinions regarding the effectiveness of different orthoses. 1,7,14,22 We conducted a study comparing the stance phase mechanics of symptomatic individuals with flexible flat feet during normal walk - ing in a conventional sandal and in the same sandal with a maximal arch supination stabilization orthosis. The purpose of the study was to document the effect of the orthosis on the forefoot, medial lon - gitudinal arch, and first ray mechanics of flexible flat feet during nor - mal overland walking at a self-selected speed. Methods and materials We screened a convenience sample of 20 individuals for participa - tion in this study. Thirteen met the inclusion criteria; two were lost to follow-up, and one participant’s data file became unusable. The Figure 1. Modified Gib test ranges. 10 individuals (six women) who completed the study ranged in age from 20 to 54 years and reported various complaints of foot, heel, who experience lower extremity musculoskeletal exertional pain leg, and knee pain. Informed consent and a medical history were will have a reduction in their symptoms with the use of a biome - obtained from each participant prior to taking any measurements. chanical orthosis. Based on static radiologic data, Bleck and Individuals were excluded if they had sustained any lower extremity 18 19 Berzins, and later Bordelon and Lusskin, reported that significant fractures or injury to the capsular or ligamentous structures of the correction of flexible flat foot deformity could be achieved by the lower leg or foot within the past 12 months. 20 21 use of orthoses. In contrast, Penneau et al and Wenger et al sug - The inclusion criteria for the experiment were defined by the gested the use of an orthotic device could not make permanent navicular drop test and the modified Gib test. Individuals were in - changes to a flat foot. cluded in the study if they had a navicular drop greater than or equal The use of foot orthoses in the treatment of abnormal foot bio - to 10 mm bilaterally, and if they had at least 60° of frontal forefoot mechanics has been extensively described in the literature, and or rearfoot passive range of motion (as determined by the modified those interventions can be grouped into two categories—accom - Gib test, illustrated in Figure 1) 23 in both feet. The modified Gib test modative or corrective. Regardless of the orthotic prescription, it is is recommended for orthosis prescription by the manufacturer; difficult to judge the scientific merit of the recommendations that however, because of the subjective nature and less-than-adequate

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50 03.16 lermagazine.com FOOTWEAR • ORTHOSES • BRACES “We Want Your Most Di,cult Cases”

   


Figure 2. Study participant’s foot in the final stage of casting. reliability of this test, we also used the navicular drop test to define an individual’s inclusion in the study. Upon completion of the structural evaluation, participants were casted for a custom pair of orthoses according to standardized cast - ing procedures of the orthosis manufacturer. One investigator per - SEBRING BRACE formed all of the casting tasks. This sequential process entailed a gait-referenced weightbearing foam box casting, which captures the maximal amount of arch that one can comfortably achieve at mid - stance with the heel and forefoot in full contact with the ground (Fig - ’s ure 2). Once accomplished, the casts and orthosis prescription were AFO shipped to the manufacturer. At the second visit, approximately two weeks later, proper fit of the orthosis was verified and study participants were instructed on their break-in and use. The orthosis featured a semirigid thermo - plastic heel cup extending to the base of the metatarsals with a full- length, 1/8-in thick, perforated ethylene vinyl acetate top cover (Figure 3). The individuals used their own footwear during the six- week break-in period and were allowed to take part in normal ac - tivities. The only activity that was restricted prior to the actual data collection was recreational running with the orthosis in the shoe. At the end of the accommodation period, all participants at - tended a data collection session. At this session, retro-reflective markers were placed on the pelvis, lower extremities, and feet over specific bony landmarks (Figure 4). Using an eight-camera video system sampling at a rate of 120 Hz, the 3D displacements of the retro-reflective markers were recorded while the participants walked Made in over level ground at a self-selected walking speed under one of two the USA

Trusted Quality for over 25 Years

Figure 3. Maximal arch supination stabilization orthosis with perforated EVA top cover. Continued on page 52 877-524-0639 • Branier.com

lermagazine.com 03.16 51 Continued from page 51

Justin Blair & Company | Chicago, IL 60623 www.justinblairco.com | (800) 566-0664

Figure 4. The retro- A TRUSTED AND TIME TESTED BRAND reflective markers, footwear, and or - thoses that were used in the study.

SUPERIOR PRODUC T FOR A SUPERIOR OUT COME footwear conditions. The footwear conditions consisted of walking in a sandal and walking in a sandal with the orthosis, which was se - Our G enuine Ther moC or k is a hea t f or mable cured to the sandal with two-sided tape. A modified Teva sandal cor k c omposit e tha t pr ovides str ength, was used for the walking trials (Figure 5). To allow for full visibility of the foot markers, the sandals were modified by removing the straps Gr ea t f or shock absor ption, ev en under (with the exception of the anchoring straps) and replacing them with sev er e str ess . half-inch Velcro straps. A walking trial consisted of the participant walking continuously at a self-selected walking speed within the laboratory setting, mak - ing wide-angle turns at each end of the room. Twelve trials of video ThermoCork produced in 1/8”, 3/16”, 1/4” & 3/8” sheets. data were collected for each participant (six trials in each footwear Contact us today to receive a free sample condition). Each individual walked in the sandal-only condition first, followed by walking in the sandal with orthosis. Genuine ThermoCork is available through your preferred distributor of choice. Data analysis We used marker displacement data to obtain the 3D angular dis - Ask for our 2016 M Guide to learn about all the materials placements of the rearfoot, forefoot, and first ray, as well as the dy - oŽered by Justin Blair’s Material Division namic arch index, during the walking trials. We defined dynamic arch index as the vertical distance to the navicular marker from the floor, divided by the distance from the inferior calcaneal to the first FABRICATING CAPABILITIES metatarsal marker. The stance phase of the walking trials was ex - tracted and time normalized to 100 frames (1 and 100 representing heel strike and toe off, respectively). We obtained maximum, mini - BLOCKERS PADS DIE-CUTTING WEDGES SHEETS LAMINATES mum, and range (maximum minus minimum) of the rearfoot, fore - foot, and first ray angles and dynamic arch index of five stance phases for each footwear condition. 'RLQJEXVLQHVVPDGHHDV\ To determine the effect of condition (orthosis vs no orthosis) we analyzed six dependent variables simultaneously: forefoot kine - ThermoCork® is a registered trademarks of Aetrex Worldwide, Inc. matic movement in the sagittal, frontal, and transverse planes; first

52 03.16 lermagazine.com ray kinematic movement in the sagittal and transverse planes; and kinematic movement of the medial longitudinal arch (arch index). FOOTWEAR • ORTHOSES • BRACES The level of statistical significance was set at p<.10. Results “We Want Your Most We found a significant difference between conditions for maximum forefoot movement in the transverse plane, for both left and right Di/cult Cases” feet. There was also a significant difference between conditions for minimum forefoot movement in the transverse plane for right feet.    
 However, we found no range of motion differences between condi - tions for any of the other dependent variables, including the arch index, in either lower extremity. Discussion The orthosis used in this study is typically prescribed for patients with symptoms associated with flexible flat feet and abnormal prona - tion. The manufacturer states that the orthosis attempts to control the subtalar joint indirectly by controlling the amount of medial lon - gitudinal arch deformation through direct and total contact of the arch. 23 This is based on the theory that a direct relationship exists between arch height and subtalar pronation; therefore, if arch height is controlled, pronation is also effectively controlled. An additional claim of the manufacturer is that the orthosis will hypothetically increase first metatarsal plantar flexion by directing CUSTOM ORTHOSES a mechanical control over the tarsus of the foot, theoretically creat - 23 ing an indirect force on the calcaneus and talus. The purpose of FREE this is to increase first metatarsophalangeal (MTP) joint dorsiflexion Impression Box in an effort to create a more rigid lever through the stance phase of SES the gait cycle. 23 The results of this study do not show significant THO OR FREE Shipping

Figure 5. The modified Teva sandal (top) and the modified Teva sandal with orthosis Made in (bottom). the USA

Trusted Quality for over 25 Years

877-524-0639 • Branier.com Continued on page 55

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www.matplusinc.com Continued from page 53 differences in the maximum and minimum positions of the first ray FOOTWEAR • ORTHOSES • BRACES with the use of the orthosis and do not support this claim. The lack of an effect on first ray motion agrees with the results of Nawoczen - “We Want Your Most ski and Ludewig, 24 who also failed to identify any significant change in movement of the first ray during the weightbearing phase of the Di*cult Cases” gait cycle with orthosis use. During normal walking, first metatarsal plantar flexion is needed    
 to allow unrestricted first MTP joint dorsiflexion during the push-off phase of gait. Nawoczenski and Ludewig compared a forefoot posted orthosis with a maximal arch supination stabilization orthosis and assessed the ability of each to alter motion at the first metatarsal and hallux. 24 Neither orthotic design was associated with significant effects on first MTP joint dorsiflexion, either at midstance or at push-off. Individual participant responses to the maximal arch supination stabilization orthosis revealed that 83% of the partici - pants experienced no change in first MTP joint dorsiflexion; the re - maining participants were split between having increased dorsi - flexion and decreased dorsiflexion of the first MTP joint. 24 The maximal arch supination stabilization orthosis is calibrated to deliver a range of forces that overlap the range of downward forces exerted on the device by the human body. 25 The orthosis, which is CUSTOM FOOTWEAR fabricated from thermoplastic, applies a corrective force to the plantar surface of the foot. Depending on the relative flexibility of the orthosis, there will be a certain amount of movement observed in the trans - SH verse plane of the forefoot, a finding we saw in our study. OES Anecdotally, all but one participant in our study continued to wear the orthoses after the study’s completion, and six of the 10 participants reported either a decrease or complete resolution of their symptoms after several weeks of orthosis use. These phenom - ena may be attributed to the proprioceptive change the orthosis provides within the shoe. The major limitation associated with this study was the use of a sandal instead of a shoe for the data collection. The heel counter and upper of a shoe have the ability to improve the fit of the ortho - sis, prevent movement of the orthosis with respect to the plantar surface of the foot, and potentially enhance the overall effectiveness of the orthosis. Made in Conclusions the USA This experiment examined the effectiveness of a clinically recom - mended orthosis on the joint kinematics of flexible flat feet during normal self-paced overland walking. Although the orthosis did not have an effect on most of the joint kinematics of the forefoot, medial longitudinal arch, and first ray, it did have a significant and consistent Trusted Quality for over 25 Years effect on transverse movement at the forefoot.

Bruce Elliott, PT, DPT, COMT, is an assistant professor in the School of Physical Therapy at MCPHS University in Worcester, MA. Juan Garbalosa, PhD, PT, is a clinical professor of physical therapy and the director of the Motion Analysis Laboratory at Quinnipiac Univer - sity in Hamden, CT. 877-524-0639 • Branier.com References are available at lermagazine.com.

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lermagazine.com 03.16 57 new p r

Bunionette SuperFlex Ankle Compression Hose Nomad Lite Bootie Foot Orthosis In Larger Sizes Outdoor Shoe

New from Bunion Bootie, a New York OMC introduces Su - Based on requests from pa - In response to customer de - comfortable and practical treat - perFlex, a new flexible, molded, tients and physicians, Sigvaris mand, Spenco is unveiling a ment option is available for pa - integrated ankle foot orthosis has introduced six new calf- lightweight performance ver - tients with tailor’s bunions (oth - designed to promote dynamic length sizes and two new thigh- sion of its Nomad Moc, the erwise known as bunionettes). biomechanical function. Fea - high sizes to its Select Comfort company’s most rugged out - The Bunionette Bootie soothes tures include an outer layer of line of compression hosiery to door shoe. Offered in an ex - and restores feet by helping to durable vegetable-dyed leather, accommodate patients with panded color palette, the No - separate and support the first a full-interface lining to protect larger legs (calf circumferences mad Lite features a combination and fifth toes, which in turn can fragile skin, a pretibial leather up to 24 inches, and thigh cir - of water-resistant fabric and improve standing balance and lace closure, a medial arch bal - cumferences up to 32 inches). lightweight, water-resistant nu - dynamic stability. A soft, thin, anced with 30-shore durometer The durable Select Comfort line, buck leather, soft shell fabric dual-layer barrier helps protect EVA (ethylene vinyl acetate) for designed for easy donning and and technical mesh lining for against blisters, rubbing, and ten - extra stability, and extra Poron doffing, comes in closed-toe better breathability, a molded derness. The Bunionette Bootie padding at both ankles. A styles for women and in open- rubber toe, and a lug outsole provides longitudinal and trans - choice of closures—lace, Velcro, toe styles for both men and of rubber and EVA (ethylene verse arch support to help re - boot hooks, or a combination— women. The hosiery is available vinyl acetate) for traction. Like duce fatigue while walking and facilitates easy donning and in 20-30 mm Hg and 30-40 its predecessor, the Nomad Lite standing for long periods. It is doffing. Available in black or mm Hg of compression. Colors comes with a removable Spenco available in small, medium , and natural color with a choice of vary by style and include natu - Total Support Insole designed large sizes. three foot-plate lengths. ral, suntan, crispa, and black. for foot align ment, motion con - Bunion Bootie New York OMC Sigvaris trol, and cushioning. 877/208-4540 718/618-7292 800/322-7744 Spenco Medical Corporation bunionbootie.com newyorkomc.com sigvarisusa.com 800/877-3626 spenco.com

58 03.16 lermagazine.com roduc ts

Sharp Shape Rebound Dual Strap Pilates Reformulated Scanning Package Knee Brace Book, 2nd Ed Relief Cream

The newest addition to the Össur has launched the Re - A second edition of Stretch Out Relief topical analgesic from AOMS (Automated Orthotic bound Dual, a malleable, com - Strap Pilates Essentials has Corganics has a new and im - Manufacturing System) family of fortable knee brace for people been published by OPTP and proved formulation, with more products from Sharp Shape is with ligament issues, including certified Stott Pilates instructor menthol than in the original (3% the TOT (Transformation of ligament instabilities, and knee Angela Kneale. The book shows vs 2.5%) for increased effec - Technology) package, designed osteoarthritis. The Rebound Dual participants how to enhance Pi - tiveness and an improved pre - to lower practitioner scanner brace is suitable for people who lates movements by effectively servative system designed to costs. The AOMS TOT package participate in low-to-high impact using the Stretch Out Strap, a ensure a three-year shelf life. includes an iPad, a small 3D activities, including sliding tool that features multiple loops The analgesic cream features a sensor called the Structure Sen - sports. Its lightweight alu minum for deep, personalized self- synergistic blend of essential sor, a Sharp Shape customized frame can be easily adjusted for stretching. Readers learn dy - oils (menthol, peppermint, eu - iPad app, and a specially de - varus/valgus alignment and pa - namic exercises for use with the calyptus, lavender, palmarosa, signed Windows processing tient height. The easy off-and-on strap, including exercises for and sweet orange) along with program. The AOMS TOT app adjustable strapping allows pa - the lower extremities, that both aloe, vitamin E, and L-arginine. allows practitioners to take 3D tients to avoid the cumbersome lengthen and strengthen while Relief has a refreshing scent, is images of the plantar surface of “step-through” approach. A doe - challenging core stability and nonsticky, absorbs quickly, and the foot, positive and negative skin thigh liner helps enhance control. Additional benefits of does not burn or dry skin or plaster-casts, and foam boxes. comfort, while a breathable Ac - the exercises include increased stain skin or clothing. Available The images can then be sent tiveGrip calf liner helps the brac e flexibility, improved range of in a 4-oz tube, 3-oz roll-on, 16- to participating labs to create remain in place. motion, and injury prevention. oz pump, or one-gallon pump. orthotic devices. Össur OPTP Corganics Sharp Shape 800/233-6263 800/367-7393 866/939-9541 408/871-1798 ossur.com optp.com reliefcream.com sharpshape.com

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lermagazine.com 03.16 59 new products

College Park Mephisto Exercise Plan Coral Mag Fizz Sidekicks Maryse Sandal Software Supplement

Introducing College Park’s Side - New to the Mobils by Mephisto PhysioTools software makes Coral Mag Fizz is a beverage kicks, the first multi-axial stubbie line of comfort footwear is the creating exercise programs enhancer designed to boost the feet for foreshortened prosthe - Maryse sandal for women, a quick and easy. Select exer - body’s ability to perform and re - ses. Used in pairs, the feet en - slingback wedge sandal with a cises, customize the text, and cover by utilizing magnesium courage muscle activity to assist polyurethane outsole, nubuck then email or print the resulting and potassium, an essential bilateral transfemoral amputees upper, and three adjustable Vel - handout. The new app can be mineral duo reported to help with rehabilitation, especially cro straps. A key feature of all used to send exercise plans to relieve muscle cramps by im - when the goal is a transition to Mobils footwear is the all-over a smartphone or tablet. Each proving muscle and nerve func - microprocessor knees. The flex - soft padding—cushioning be - exercise includes clearly written tion and regulating the body’s ible platform and anatomical an - tween the lining and the soft instructions, color photographs water balance. When added to kle motion promote ground leather upper that is designed and/or drawings, and often drinking water, the effervescent, compliance for stability and bal - to pillow the feet. Mobils foot - videos. Modules of interest to lemon-lime flavored supple - ance, and the molded tread wear also features soft-air tech - lower extremity practitioners in - ment delivers 300 mg of mag - provides traction and durability. nology in the midsole to mini - clude Lower Extremity Basic nesium and 500 mg of potas - The gait-matched, natural ankle mize shock, which has benefits Exercises, JEMS (Joanne El - sium. The recommended dose motion also helps reduce for the more proximal muscu - phinston Movement Systems) is 6 g of Coral Mag Fizz per 4-6 socket forces and unwanted loskeletal structures in addition Dyn amic Movement Progres - oz of water, once or twice daily. torque. Sidekicks are also sold to the feet. The Maryse sandal sions for Trunk and Lower Body, The beverage supplement has singly for unilateral amputees is available in dark taupe, in and Corrective Exercises for a suggested retail price of involved in adaptive sports. sizes 5-12 (whole sizes only). Movement System Impairment. $19.95 for a 6.4-oz container. College Park Industries Mephisto USA PhysioTools Coral 800/728-7950 800/775-7852 888/449-2338 800/882-9577 college-park.com mephistousa.com physiotools.com coralcalcium.com

60 03.16 lermagazine.com market mechanics By Emily Delzell

DJO brace addresses lateral knee OA Medicare adopts HSS joint surveys Research on Vista, CA-based DJO ment). Compared with no brace, Investigators from the Manhat - ment-specific, patient-reported Global’s varus unloader brace the adjusted brace significantly tan, NY-based Hospital for Spe - outcomes data will be publicly published in February suggests increased peak knee flexion angle cial Surgery on February 29 available. the device may improve abnormal and adduction angle and reduced epublished data in Clinical Or - The Hip disability and Os - knee joint mechanics associated peak internal rotation angle, as thopaedics and Related Re - teoarthritis Outcome Score with the development and pro - well as peak knee flexion moment, search validating two new short - (HOOS) JR—a six-question hip gression of lateral knee osteoarthri - adduction moment, and external ened questionnaires that will survey—and the Knee injury and tis (OA) after anterior cruciate lig - rotation moment. It also significantly reduce time spent collecting pa - Osteoarthritis Outcome Score ament reconstruction (ACLR). reduced peak hip adduction angle tient-reported outcome data for (KOOS) JR—a seven-question Investigators conducted 3D and increased peak hip adduction hip and knee replacement sur - knee survey—are abbreviated gait analysis on 19 participants and external rotation moments geries. versions of the existing HOOS who had undergone primary ACLR compared with no brace. Beginning in April, Medicare and KOOS surveys. In addition to five to 20 years previously and There were no significant will incentivize hospitals partici - saving patient and practitioner had symptomatic and radiographic differences between the ad - pating in the Comprehensive time, HSS investigators designed lateral knee OA and valgus justed and unadjusted brace Care for Joint Replacement the new questionnaires to help malalignment. conditions except for knee inter - model, an initiative supporting orthopedic surgeons better iden - Participants walked under nal rotation angle, which was sig - higher-quality care for hip and tify optimal surgery candidates, three conditions: no brace; unad - nificantly reduced with the ad - knee replacement patients, to vol - improve rehab services, and justed brace (sagittal plane support justed brace. untarily submit patient-reported more effectively evaluate implant with neutral frontal plane adjust - The American Journal of outcome data. Consumers will be devices. ment); and adjusted brace (sagittal Sports Medicine epublished the able to access survey results on The surveys are available at plane support with varus adjust - findings on February 3. healthcare.gov, the first time treat - hss.com. Flexion releases data for new OA injectable OHI funds $120K podiatric ed grant Ronkonkoma, NY-based OHI (Or - programs that over a four-year Burlington, MA-based Flexion acetonide for pain, stiffness, and thotic Holdings Inc.) and the period will support biomechanics Therapeutics in February re - function through week 12. American College of Foot & Ankle and the podiatric profession. leased phase 3 data for its lead Flexion plans to present de - Orthopedics & Medicine (AC - The alliance will enable the product candidate Zilretta, a tailed results from the phase 3 FAOM) on February 10 an - development of consequential novel nonopioid injectable for trial at an upcoming scientific nounced a joint educational part - educational programs and re - knee osteoarthritis (OA). meeting, according to the com - nership to support the podiatric sources that will help ACFAOM The sustained-release cor - pany. profession and advise on the im - members and all podiatrists pre - ticosteroid achieved the study’s The Food and Drug Admin - pact of shifts in the healthcare in - pare for the myriad of challenges primary endpoints, reducing pain istration fast tracked Zilretta last dustry. and opportunities facing them in 50% from baseline at 12 weeks year, and the company’s planned The partnership is built a fast-evolving healthcare envi - in patients with moderate to se - NDA (new drug application) sub - around a $120,000 education ronment, according to an OHI vere knee OA pain, and reducing mission is on track for 2016. If and advocacy grant from OHI for release. pain significantly at weeks one approved, the therapy would be through 16 compared with the first sustained-release corti - placebo. It also achieved a sec - costeroid injection for knee OA AOPA calls for O&P pilot grant RFPs ondary measure, statistical sig - and the first new injectable ap - The Alexandria, VA-based Amer - up to four pilot grants for up to nificance against placebo and proved for the condition in more ican Orthotic & Prosthetic Asso - $15,000 each. immediate-release triamcinolone than a decade. ciation (AOPA) in late February View the 2016 research invited requests for proposals topics available for funding and (RFPs) for 2016 O&P research full RFP and application online M.J. Markell sells Quikiks Hands-Free shoes grants. This year AOPA will fund at aopanet.org. New York, NY-based Quikiks their shoes without bending or Hands-Free Shoes in February using their hands. ProtoKinetics launches gait screen at CSM signed its first US distribution In December Entrepreneur Havertown, PA-based Proto- Screen (PGS) addresses transi - agreement within the O&P indus - and Canon USA named Quikiks Kinetics launched its Movement tional movements in a single test try with M.J. Markell Shoe Com - founder Steve Kaufman the Analysis Software (PKMAS) Pri - (typically performed in less than pany. grand prize winner of the Project mary Gait Screen on February one minute) that requires no edit - M.J. Markell, headquartered Grow Challenge, a small busi - 17 at the Combined Sections ing and is easy to administer, ac - in Yonkers, NY, will distribute ness owner competition. Kauf - Meeting of the American Phys - cording to a company release. Quikiks shoes, which feature man said he will use the ical Therapy Association in Ana - Data are available immediately. hands-free technology called $25,000 award to invest in prod - heim, CA. Key gait metrics include efficiency, Step-in-Go that allows wearers uct improvements and market - The PKMAS Primary Gait symmetry, and speed. to step easily into and fasten ing. Continued on page 62

lermagazine.com 03.16 61 market mechanics

Continued from page 61

APTA names outcomes registry panel ConforMis introduces knee system The Alexandria, VA-based Amer - rection for the registry on scien - Bedford, MA-based ConforMis either retain the patient’s own ican Physical Therapy Associa - tific integrity, clinical application, undertook the full commercial posterior cruciate ligament (CR), tion (APTA) on February 10 an - quality, public policy, and re - launch of its customized poste - or substitute for it (PS). PS im - nounced the members of a search. It will also oversee the rior-stabilized (PS) knee re - plants use a cam and spine fea - Scientific Advisory Panel to over - registry’s research agenda, data placement system on March 2 ture that functions as the pos - see its Physical Therapy Out - management and analysis strate - at the American Academy of terior cruciate ligament. comes Registry. gies, clinical application, content Orthopaedic Surgeons annual US surgeons in the US The panel members are: development, and scholarly pub - meeting in Orlando, FL. market show a heavy prefer - James Irrgang, PT, PhD, ATC, lications. The customized iTotal PS ence for the PS, which accounts FAPTA (director); Kristin Archer, Data will guide best practices, implant is customized for each for 72% by revenue of all pri - PT, DPT, PhD; Linda Arslanian, help providers meet regulatory re - patient to avoid overhang, ro - mary total knee replacements, PT, DPT, MS; Janet Freburger, PT, porting requirements, generate tation, and sizing compromises. according to a ConforMis re - PhD; Christopher Hoekstra, PT, benchmarking reports, and help The system also helps re - lease. DPT, OCS, FAAOMPT; Stephen shape payment policy and support stores knee curvature and has The iTotal PS nearly triples Hunter, PT, DPT, OCS; Michael the physical therapists in current a customized cam and spine to the available market for Con - Johnson, PT, PhD, OCS; Christine and future quality and compliance provide stability throughout the forMis, said Philipp Lang, MD, McDonough, PT, PhD; and Linda programs required by payers, full range of motion. MBA, the company’s CEO and Woodhouse, PT, PhD. such as the Physician Quality Re - Primary total knee implants president. The panel will provide di - porting System. Justin Blair, ING finalize distribution deal AAOS supports local playground build Chicago-based Justin Blair in channels in 11 states across the The American Academy of Or - a plan based on those drawings February completed an exclu - region. Justin Blair has offered thopaedic Surgeons (AAOS) on to finish the construction in less sive distribution agreement with the full range of the Orthosleeve March 1 joined the City of than six hours. Hickory, NC-based ING Source, brand as a standard distributor Kissimmee, FL, Central Avenue The new space provides a manufacturer of the Foot Gym for more than four years. Elementary School, local resi - place to play for more than 2678 and orthopedic compression In January, Teaneck, NJ- dents, and organizers from Com - Kissimmee children. products, including the Or - based Apex Foot Health and munity Vision and KaBoom! to Since 2000, the AAOS has thosleeve. Justin Blair finalized an exclusive build a new community play - sponsored a one-day volunteer Justin Blair is ING Source’s distribution agreement allowing ground at Central Avenue Ele - build to kick-off its annual meet - leading distribution partner for the Chicago-based company to mentary. ing, which was held this year at the Midwest, and the agreement sell Apex footwear to its phar - Last December children the Orange County Convention covers independent pharmacy, macy, home medical equipment, from the neighborhood drew Center in Orlando March 1-5. home and durable medical and pedorthic shoe store cus - their dream playgrounds, and The playground is the 17th built equipment, and foot care retail tomers across 17 states. more than 200 volunteers used by AAOS and KaBoom! Fitness orgs join to check chronic disease BOC gives $100K for pedorthic research The American College of Sports tivity. The EIM Solution is an in - The American Board for Certifica - funds to support grants for clinical Medicine (ACSM), Medical Fitness novative approach that, through tion on Orthotics, Prosthetics, and or laboratory research in prescrip - Association (MFA), and American a prescription, links the medical Pedorthics (BOC) in December tion footwear and orthotic and pe - Council on Exercise (ACE) on Feb - profession with physical activity gave the Pedorthic Foundation dorthic modifications. For more ruary 23 announced a major new professionals and community re - $100,000. information on the grants, go to effort called the Exercise is Medi - sources” said US Surgeon Gen - The foundation will use the pedorthicfoundation.org. cine (EIM) Solution at National eral Regina Benjamin, MD, who Press Club in Washington DC. The delivered a keynote talk during effort is part of the ongoing EIM the announcement. Ottobock opens orthotic business unit global initiative the ACSM The EIM Solution will in - Austin, TX-based Ottobock’s cus - services, including the C-Brace, launched in 2008. clude physical activity counsel - tomers in January began getting Stance Control, WalkOn, modular With the MFA and the ACE ing, as well as prescription and support from the company’s new components, and the full line of joining the ACSM, the new pro - referral strategies, particularly the business unit and sales organi - Ottobock off-the-shelf bracing gram represents nearly half the involvement of health and fitness zation dedicated to orthotics. products. fitness professional industry in professionals, an often-missing Ottobock’s new orthotic Ottobock’s prosthetics busi - the US. component of physician-pre - business unit and sales repre - ness unit (formerly the technical “Much of the illness and scribed treatment plans, accord - sentatives (formerly called activ - orthopedics business unit) is early death related to [many] ing to the ACSM. ity and sports medicine [ASM] supported by the North Ameri - chronic diseases can be pre - Go to exerciseismedicine representatives) support the full can prosthetics sales organiza - vented by increased physical ac - .org for more information. line of its orthotics product and tion.

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