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VOLUME 11 NUMBER 3 LERMAGAZINE.COM contents

COVER FEATURES

19 BONE STIMULATION 51 THE THERAPEUTIC POWER REPRESENTS NEW FRONTIER OF ELASTIC BANDS FOR OPTIMIZING PATIENT Here’s why resistance therapy OUTCOMES with these low-tech tools is Limited research into gaining prominence—for youth electromagnetic and ultrasound soccer players, geriatric patients, bone stimulation devices and everyone in between. Elastic 34 HOW MOUNTAIN BIKING IS complicates efforts to determine resistance bands are increasingly popular in RESHAPING THE LANDSCAPE efficacy. For the majority of physical therapy, as the modality is being used… OF CYCLING INJURY people, lower-limb fractures and fractures in other By Keith Loria Differences in equipment, terrain, riding style, parts of the body heal well and reliably. However, and other risk factors mean different types and some people experience complications that… prevalence of injuries when riding a mountain bike, FROM THE LITERATURE By Nicole Wetsman compared to a road bike. 27 MITIGATING THE OPIOID 13 • Benefits of a Foot Orthosis During By Michael Reeder, DO, and a Step-descent Task on Kinematics, Brent Alumbaugh, MS CRISIS WITH PAIN Kinetics, and Activation of Muscle MANAGEMENT REGIMENS IN A MULTIMODAL APPROACH • Concurrent Changes in Eccentric GUEST EDITORIAL For help limiting the number of Hamstring Strength and Knee-joint opioid tablets you prescribe— Kinematics 9 WE ARE THE HEART OF and to still treat postop pain • Delayed Charcot Diagnosis Increases NATIONAL BIOMECHANICS successfully—turn to practice Costs, Hospital Days, Amputations DAY guidelines, evidence from the • AFOs for Stroke: Early Use Does Not The International and American literature about local and … Limit Long-Term Benefit Societies of Biomechanics were By ROBERT G. SMITH, DPM, MSC, RPH, founded in 1973 and 1977, CPED, CPRS AD INDEX respectively. Coincident with the expansion of Biomechanics during the following decades, fitness and 43 TAPE USE TO PREVENT 57 GET CONTACT INFO FOR ALL health … BLISTERS: DOES IT REALLY OF OUR ADVERTISERS By Paul DeVita, PhD DO WHAT WE THINK IT DOES? Taping is a mainstay of preventive INDUSTRY SNAPSHOT CALL FOR MANUSCRIPTS foot blister management in athletes and active people. Its 58 PRODUCTS, ASSOCIATION 10 HERE’S HOW TO SUBMIT use is based on the premise that NEWS & MARKET UPDATES YOUR MANUSCRIPT rubbing causes blisters, and that tape protects the skin from this rubbing and/or provides thermal insulation from the heat generated CROSSWORD PUZZLE by rubbing. This commentary highlights… 62 TEST YOUR KNOWLEDGE OF By Rebecca Rushton, BSc(Pod) INFORMATION FROM THIS ISSUE

The views and opinions expressed here are those of the authors and do not necessarily reflect the official policy or position of Lower Extremity Review. New! Skin Saver! 4 Ways SoreSpot® Silicone Tape Will Help Soothe & Heal Your Patients Foot Care — Skin Care — Wound Care — Scar Care A new, better alternative to paper and cloth tape wound dressings • Shields Blisters, Corns & Irritations • Reduces Friction & Skin Damage • Gently Secures Bandages & Dressings • Helps Improve the Appearance of Scars • Creates an Occlusive Barrier for Faster Penetration of Topical Wart Treatments New • More! 12 Roll Safe & Easy Release for Painless Clinic Pack Removal Without Skin Damage Thin, Self-adhering, Waterproof, Reusable, Hypoallergenic Save skin with Sorespot® Silicone Tape — the new skin protectant and topical ® bandage option Medical Footcare

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19108-Silicone Tape Full-Page Ad LER419.indd 1 4/9/19 3:23 PM EDITORIAL ADVISORY BOARD Craig R. Bottoni, MD Geza Kogler, PhD, CO Chief, Sports Medicine Service Director, Clinical Biomechanics Laboratory Orthopaedic Surgery Service School of Biological Sciences Tripler Army Medical Center Georgia Institute of Technology Honolulu, Hawaii Atlanta, Georgia

Jonathan Chang, MD Robert S. Lin, CPO PUBLISHER AND CHIEF EXECUTIVE OFFICER Orthopaedic Surgery Managing Partner, Adaptive Prosthetics & University of Southern California Orthotics Richard Dubin School of Medicine Residency Coordinator, New England Orthotic and [email protected] | 518.221.4042 Alhambra, California Prosthetic Systems, LLC Wethersfield, Connecticut EDITORIAL STAFF Robert Conenello, DPM Editor Orangetown Podiatry Antonio Robustelli, CSCS Janice T. Radak | [email protected] Clinical Director, NJ Special Olympics Sports Performance Consultant Senior editor - Pediatrics NYPD Honorary Surgeon Applied Sport Scientist/Technologist Emily Delzell | [email protected] Greater New York City Area, New York Strength & Conditioning Specialist Senior editor Salerno, Italy Karen Hentry |[email protected] Sarah Curran, PhD, FCPodMed Professor, Podiatric Medicine & Rehabilitation Jarrod Shapiro, MD Associate editor Laura Fonda Hochnadel | [email protected] Cardiff Metropolitan University Vice Chair, Department of Podiatric Medicine, Cardiff, United Kingdom Surgery & Biomechanics New products editor Associate Professor of Podiatric Medicine, Surgery Rikki Lee Travolta | [email protected] Stefania Fatone, PhD, BPO & Biomechanics Consulting editor Professor, Physical Medicine & Rehabilitation Western University of Health Sciences John Baranowski | [email protected] Northwestern University ACFAOM Liaison Operations coordinator Chicago, Illinois Pomona, California Melissa Rosenthal-Dubin | [email protected] Timothy E. Hewett, PhD Bruce E. Williams, DPM Graphic design & website development Director, Biomechanics Laboratories & Sports Anthony Palmeri | PopStart Web Dev Medical Director [email protected] Medicine Research Center Go4-D Mayo Clinic Chicago, Illinois Audience development Minneapolis, Minnesota Christopher Wees | Media Automation, Inc.

Our Mission: Lower Extremity Review informs healthcare practitioners on current developments in the diagnosis, treatment, and prevention of lower extremity injuries. LER encourages a collaborative multidisciplinary clinical approach with an emphasis on functional outcomes and INFORMATION FOR AUTHORS evidence-based medicine. LER encourages a collaborative multidisciplinary clinical Opinions expressed are those of the authors and do not necessarily approach to the care of the lower extremity with an represent those of Lower Extremity Review, LLC. emphasis on functional outcomes using evidence- based medicine. We welcome manuscripts (1000- LER is published monthly, except for a combined November/ 2000 words) that cross the clinical spectrum, December issue and an additional special issue in December, by including podiatry, orthopedics, physical medicine Lower Extremity Review, LLC. Copyright ©2019 Lower Extremity Review, LLC. All rights reserved. The publication may not be and rehabilitation, biomechanics, obesity, wound reproduced in any fashion, including electronically, in part or whole, management, physical and occupational therapy, athletic without written consent. LER is a registered trademark of Lower training, orthotics and prosthetics, and pedorthics. Extremity Review. See detailed Author Guidelines at lermagazine.com – click the Editorial tab Subscriptions may be obtained for $38 domestic and $72 on the homepage. international by writing to: LER, PO Box 390418 Minneapolis, MN 55439-0418. POSTMASTER: Please send address changes to LER, ELECTRONIC SUBMISSIONS PO Box 390418, Minneapolis, MN 55439-0418. Please attach manuscript as an MS Word file or plain text. Tables may be included in the main document, but figures should be submitted as separate LOWER EXTREMITY REVIEW 41 State St. • Suite 604-16 • Albany, NY 12207 jpg attachments. Send to: [email protected] 518.452.6898

lermagazine.com 3.19 7 Call now for a free Temporal Spatial Gait Analysis Interpretation 610.449.4879 Guide! protoKinetics.com/rehab [email protected] GUEST Editorial We Are The Heart of National Biomechanics Day

safe. But imagine if more young people were children. These outreach events are wonderful aware of the field before they got to college? for all involved. Yet, these demonstrations and How much faster would the knowledge base events lack one element that is central to the spread if middle- and high-school students were NBD mission. NBD celebrates the broad field made aware of what Biomechanics has to offer? of Biomechanics beyond any individual lab, That was the stimulus behind the first program, or university. National Biomechanics National Biomechanics Day (NBD) in 2016 Day is enjoyed around the world because it is (aka, “The Early Year”). It began as a US-based a unifying platform upon which we coalesce initiative to expand the impact of Biomechanics into one grand celebration of our science. NBD on peoples’ lives. By 2017 (aka, “The Expansion enables biomechanists to unite into a single Year,”), NBD had grown into an international synchronized, worldwide Biomechanics party. celebration of Biomechanics. As of this date, 22 It is not any individual person, it is all of us… countries were expected to participate in NBD together: we all do it together and together By Paul DeVita, PhD 2019. We think that, by introducing Biomechan- we are the Heart of NBD. The outcome of our ics to high school students, a population largely efforts is described by a single phrase, “Through The International and American Societies of under-exposed to Biomechanics science, we will NBD, there are more smiles on more faces, in Biomechanics were founded in 1973 and 1977, be seeding larger numbers of future biome- more Biomechanics labs than on any other day.” respectively. Coincident with the expansion of chanists and a larger biomechanical impact. Pretty cool. Biomechanics during the following decades, fit- Indeed, because Biomechanics education exists Our expansion to more biomechanists and ness and health have moved out from under the nearly entirely at universities, any exposure to more high schoolers is paralleled by our expan- realm of medicine and are rapidly overtaking younger people would bring new people to the sion to more sponsors and supporters. We have the realm of the personal—the personal lifestyle field. Although it is too early to know if we will 33 sponsors who provide financial assistance to be more exact (think yoga, yogurt, and yoga be successful in the long term, we certainly have and promotional advertisements. For example, pants). It is no coincidence that this trend has created a foundation for success. From 2016 to LER has published two articles on NBD and mirrored the increasing role of Biomechanics in 2018, NBD excited more than 20,000 young numerous photographs showing NBD events our everyday lives as the evolving science has people and 800 teachers about Biomechanics around the world. Our sponsors include many allowed us to see that sitting is the new smoking science, application, and careers. “That’s a lotta Biomechanics societies, instrument manufactur- and that movement is our best option to main- kids,” as I like to say. ers, and commercial entities using Biomechanics tain or get back to health. Still, why has NBD become such an as- to create their products and services. There is And Biomechanics, the study of human tounding success so quickly? Is there some facet also an important idea we emphasize about our movement, of how bones, tendons, ligaments, about NBD that entices biomechanists to not sponsors: They are not simply NBD sponsors, even cell components all work together, will only join the initiative but to thrive in it and to they sponsor nearly all events and activities that inform every step of that journey. The world enjoy it so fully? Certainly, many Biomechanics are Biomechanics. They sponsor Biomechanics of Biomechanics today encompasses a host of labs around the world conduct outreach services societies, Biomechanics conferences, Biome- activities that are necessary to keep life moving to show children and community leaders their chanics outreach events, and, not to be neglect- smoothly, but also to improve sport perfor- science. Actually, many university departments ed, they hold their own Biomechanics events. mance, enhance rehabilitation, correct gait, beyond those housing Biomechanics programs They are us. Each individual company cannot stabilize balance… all the pieces and parts of conduct social outreach to the benefit of both sponsor everything Biomechanics, but many of maintaining a healthy active lifestyle, no matter the department and community. The partici- them sponsor multiple Biomechanics entities. what age. pating departments benefit by increasing the NBD is extremely grateful to all its sponsors and The good news is, biomechanists across the popularity of their fields and their particular to all sponsors of Biomechanics. Without them, globe are using today’s latest technology to help programs, and families benefit by learning we could not conduct the science of Biomechan- improve patient outcomes and keep athletes about potential career opportunities for their Continued on page 10

lermagazine.com 3.19 9 Continued from page 9 of Biomechanics, it is on the verge of great We encourage all biomechanists in all Bio- ics as it is conducted now. popularity. Many people know vaguely about 3D mechanics fields to join National Biomechanics NBD and all NBDers are excited about motion capture as the basis for video games and Day and help us expand the many beneficial the future of Biomechanics. We have from the movies. Biomechanics is seen throughout social outcomes of the practice of Biomechanics. start promoted the idea that Biomechanics media and television, including regular shows but also commercials. It is seen in publications Paul DeVita is one of two Leroy T. Walker will be the breakthrough science of the 21st like LER, which increase the awareness of our Distinguished Professors or Kinesiology and century. We explained this position last year,1 science. People are also becoming aware of its Director, Biomechanics Laboratory, Department but to briefly restate: First, Biomechanics has application for improving sport performance. of Kinesiology, East Carolina University, Green- great, yet untapped value for society; it can help Still, it remains more unknown than known. ville, North Carolina. To learn more about NBD, many people in many ways. While we know Because Biomechanics will have a major impact contact him at [email protected]. this, it has yet to make a major, commercial on peoples’ lives and because it is on the verge breakthrough that is fully within the public of society’s awareness, we propose, through our Reference consciousness. Second, we also propose that efforts, that Biomechanics will be the break- 1. DeVita P. Why National Biomechanics Day? while Biomechanics is largely unknown outside through science of this century. J. Biomech. 2018;71:1-3.

Figure 1. NBD 2019 sponsors

CALL FOR MANUSCRIPTS

The Editors of Lower Extremity Review Case reports should be no more than clarity and conciseness and applying con- want to highlight the work of thoughtful, 1500 words (not including references, formity to style. Authors will have the op- innovative practitioners who have solved legends, and author biographies). Photos portunity to review and approve the edited their patients’ vexing problems. We are (≤4) are encouraged. Case reports can inversion of their work before publication. seeking reports of your most intriguing clude a literature review as is appropriate The Editors reserve the right to reject any cases in the following areas: for the topic. (Please note that for HIPPA unsolicited or solicited article that does not compliance, photos should be de-identified • Gait analysis before sending.) meet with editorial approval, including ap- • Drop Foot proval denied following requested revision. Manuscripts must be original and not • Ankle-foot orthotics under consideration for publication else- Electronic Submission where. Any prior publication of material Before you begin to write, query the Please attach the manuscript as a Mic- must be explained in a cover letter. Editors about your proposed topic (email is rosoft Word document or plain text file. fine). Doing so ensures that your manu- All authors must be medical professionals Photos, tables, and figures can be embed- script will conform to the mission of the in good standing. Students will be consid- ded in the document, although submission ered as first author only when the byline publication and that the topic does not of individual files is preferred. Figures not includes a fully licensed professional. duplicate an article already accepted for embedded in the main Word document publication. Furthermore, a query often Manuscripts are submitted with the under- should be submitted as .jpg files. allows the Editors and the publication’s standing that they will be reviewed; that Please send queries and submissions to: advisors to make recommendations for revisions of content might be requested; [email protected] improving the utility of the manuscript for and that the editorial staff will undertake readers. editing, as necessary, aimed at improving We look forward to hearing from you!

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Benefits of a Foot Orthosis what was observed with the control insole. Activity of the abductor hallucis muscle was reduced with the use of the 5° rearfoot medial wedge and a 5° During a Step-descent Task rearfoot and forefoot medial wedge, compared to the control insole. Only on Kinematics, Kinetics, and the 5° rearfoot medial wedge showed a reduction in activity for the tibialis Activation of Muscle anterior muscle. These findings offer further insight into the use of foot orthoses on By Sarah Curran, PhD, FCPodMed musculoskeletal conditions—in particular, patellofemoral pain—through Foot orthoses are considered to work the role of changing kinematics (internal rotation) and kinetics of the lower by controlling internal rotation of extremities that creates stability. Furthermore, this is the first study to show the tibia and eversion of the cal- the influence of abductor hallucis and tibialis anterior muscles, which had caneus, and have been reported to a reduction in activity with both sets of medial wedged foot orthoses during be effective during weightbearing ac- the step-down maneuver. This reduction in activity could be due to arch tivities such as walking and running. support and a wedge that acts as a mechanical barrier to minimize foot As a result, they have been shown to pronation; alternatively, it could indicate improved control of foot position be effective in managing a range of and support from the foot orthosis. musculoskeletal conditions—not the These findings might be of use clinically to patients with patellofem- least of which is patellofemoral pain. oral pain, given the demands placed on the lower limb and knee during Everyday life and activities step descent. Although this study explored only the impact of a single step, place a variety of demands on the further assessment on continuous and cumulative loading of step descent lower extremities; an example is would provide further insight. From a clinical perspective—particularly stair-climbing—in particular, the when a patient presents with patellofemoral pain—the clinician should stair descent, which can place seek assessment of stair descent in terms of pain and function. increased loading on the patella. Sarah Curran, PhD, FCPodMed, is Professor of Podiatric Medicine and Moreover, the mechanism for Rehabilitation at Cardiff Metropolitan University, Cardiff, Wales. progressing and stepping down a step uses a toe–toe–heel pattern of Source: Bonifácio D, Richards J, Selfe J, Curran S, Trede R. Influence contact, and foot orthoses that incor- and benefits of foot orthoses on kinematics, kinetics and muscle activation porate forefoot posting can therefore during step descent task. Gait Posture. 2018;65:106-111. influence pronation of the foot and the proximal musculoskeletal chain Concurrent Changes in Eccentric of the lower extremities. Hamstring Strength and Knee- This presentFrom study set out to the LITERATURE explore the influence of 3 types of joint Kinematics foot orthoses on kinematics, kinet- By Matt Greig, MPhil, PhD ics, and activation of muscle during Hamstring strain incidence in soccer increases during the latter stages a step-down task. Sixteen healthy of match-play, consistent with experimental studies that report reduced volunteers (mean age, 25.7 years) Tibialis anterior muscle diagram. eccentric hamstring strength during soccer-specific fatigue. performed a step-down task from a Originally in Gray’s Anatonmy. The biarticular function of the hamstring is such that fatigue-in- height of 20 cm in 3 conditions of duced changes in strength are also likely to have an impact on knee-joint orthosis: a control flat insole, a 5° rearfoot medial wedge, and a 5° rear- stabilization, with the knee a common site of severe injury in soccer. The foot and forefoot medial wedge, all while wearing standardized footwear aim of this study was to consider concurrent changes in eccentric ham- (Dr Comfort Winner Plus). string strength and knee-joint kinematics, with isokinetic testing speed The findings showed that both types of wedged foot orthoses matched to the kinematic demands of the task. In selecting an appropri- (rearfoot and forefoot) improved kinematics within the foot (metatarsal to ate functional task, jump landings and hopping tasks are commonly used calcaneal rotation), the ankle, and the hip; while knee adduction moment because they replicate the mechanism of knee ligamentous injury. was increased, the internal rotation moment was reduced, compared to Continued on page 14

lermagazine.com 3.19 13 Figure 1. Time history of changes in knee varus at touchdown. * Significantly different to

pre-exercise. Continued from page 13

Now Available Inversion Eversion Neutral 18 16 * * * JMS Cotton Stockinettes 14 º ) 12 10 8

Knee varus( 6 4 2 0 15 30 45 60 75 90 105 Time (min)

Figure. Time history of changes in knee varus at touchdown.

To investigate the influence of soccer-specific fatigue on concurrent changes in knee-joint kinematics and hamstring strength, 10 male profes- Premium Materials at Economic Pricing sional soccer players completed reactive inversion, eversion, and neutral hop tasks at 15-minute intervals during a soccer-specific treadmill protocol. Knee-joint kinematics in frontal and sagittal planes were calculated For more information every 15 minutes. In a separate trial, players completed maximal eccentric call 800-342-2602 knee flexions at 160° s-1 (reflecting average knee angular velocity in the or visit us at jmsplastics.com! functional task) at 15-minute intervals, quantifying peak torque. All trials were characterized by knee flexion and varus at touchdown. Knee flexion of approximately 30° was maintained throughout the exercise protocol, but a main effect for task highlighted greater flexion at touchdown in the inversion trial (P = .01). This task-dependent observation in the degree of knee flexion at landing most likely indicates the greater mechanical challenge imposed by this task, with inversion ® COMPREFLEX LITE movements incurring a greater risk of ligamentous injury. Knee varus at touchdown (Figure) was sensitive to exercise dura- tion, with approximately 4° greater malalignment elicited over the final FOR MANAGEMENT OF 15 minutes of the protocol (P ≤ .05). Although knee flexion at touchdown CVI & LYMPHEDEMA serves as a protective mechanism, varus displacement of the knee might be a risk factor for ligamentous injury. Genu varum in these elite male 20–50mmHg of gradient, players is in marked contrast to the knee valgus commonly observed in short-stretch compression female players, and has been identified as a risk factor for patellofemo- Billable for ulcers ral pain syndrome, deterioration of the articular cartilage in the medial under Code A6545-AW tibiofemoral compartment of the knee, and osteoarthritis. Easily worn under Peak eccentric hamstring strength was significantly (P = .05) standard footwear reduced throughout the second half of the trial, compared to pre-exercise Soft, conforming values. This reduced strength might provide the mechanism for increased Breathe-O-Prene® material varus displacement because hamstring musculature acts to stabilize the creates a comfortable fit. knee joint during such functional tasks. Conversely, the knee in varus would increase tension on the biceps femoris, creating an increased risk of hamstring strain injury with fatigue—a finding that would support 1.800.322.7744 | sigvarisusa.com epidemiological observations. SIGVARIS and COMPREFLEX are registered trademarks of SIGVARIS, CH-9014 St.Gallen/Switzerland, in many countries worldwide. Breathe-O-Prene is a registered trademark of Accumed Innovative Technologies, Coincident impairment of eccentric hamstring strength and LLC. All Rights Reserved. © Copyright 2019 SIGVARIS, Inc. increased knee varus at touchdown predisposes the player to injury— again, supporting epidemiological observations. The association between

14 3.19 lermagazine.com HomeCareMagazine_0119.indd 1 1/18/19 3:22 PM strength and joint kinematics implicated in injury risk provides clinical merit for isokinetic assessments, provided that the isokinetic assessment has functional relevance to the demands of the sport or the mechanism of injury (or both). In this study, functional relevance was aligned to speed- matched analyses of strength and knee-joint motion.

Matt Greig, MPhil, PhD, is Associate Head for Sports Therapy, and Sports Injuries Research Group Lead at Edge Hill University, Ormskirk, Lancashire, England. His research focuses on the physical (biomechanical and physiological) response to soccer-specific activity, with implications for performance enhancement and injury prevention. iStockphoto.com #480156920 Source: Greig M. Concurrent changes in eccentric hamstring strength and knee joint kinematics induced by soccer-specific fatigue. Phys Ther Sport. Our study looked at public discharge records from acute care hospitals in 2019:37:21-26. California and compared those with a timely diagnosis and those with a delayed diagnosis of Charcot neuroarthropathy. Our hypothesis was that Delayed Charcot Diagnosis a delayed diagnosis of Charcot neuroarthropathy increases cost of care and healthcare utilization. Increases Costs, Hospital Days, We identified 4,363 patients with Charcot neuroarthropathy as one Amputations of the top five discharge diagnoses that were discharged from California hospitals from 2009-2012. A delayed diagnosis was observed in 13.2% of By Jonathan M. Labovitz, DPM, FACFAS, CHCQM the patients. The costs of the acute care stay were 10.8% greater in these Early recognition and treatment of Charcot neuroarthropathy has been patients and length of stay (LOS) was 0.8 days longer with a delayed long considered paramount to optimizing clinical outcomes and deliver- diagnosis, both of which were significantly different from patients with ing high-quality care. Without this rapid response to control the devastat- a diagnosis at the time of admission (P < .05). In addition, there was ing effects of Charcot, patients are left with significant deformities; a moderate correlation for cost and LOS for both the diagnosis and the increased risk of ulcers, infection, and amputations; a reduced quality of delayed diagnosis groups. life that often fails to improve; and a higher 5-year mortality rate. When evaluating potential diagnoses often mistaken for Charcot Regrettably, delayed diagnosis occurs frequently due to similar clinical neuroarthropathy, only diabetic foot infection resulted in significantly presentations as many of the other complications of diabetes mellitus. greater costs despite a significantly higher prevalence of diabetic foot

Total acute care cost and usage of healthcare services

Variable Group (%) Cost ($) LOS (days)

Diagnosed Delayed p Value Diagnosed Delayed Diagnosis p Value Diagnosed Delayed p Value Diagnosis Diagnosis

Total Disposition 86.3 13.2 $18,347 ± $21,091 $20,334 ± $23,200 .038* 6.6 ± 9.0 7.4 ± 8.8 .042*

Acute care 2.6 2.4 .889 $20,217 ± $27,771 $32,352 ± $25,797 .126 9.5 ± 14.9 10.8 ± 12.9 .757

Discharged to home 48.7 44.4 .06 $15,776 ± $20,548 $16,983 ± $24,355 .39 5.2 ± 8.6 6.2 ± 9.3 .085

Died 0.3 1.2 .011* $30,900 ± $23,731 $47,710 ± $30,503 .184 10.2 ± 8.2 12.4 ± 9.0 .587

Home health service 22.2 23.9 .363 $18,720 ± $18,019 $18,877 ± $15,152 .923 7.6 ± 8.2 7.4 ± 6.4 .785

Left AMA 1.1 1.6 .296 $10,132 ± $7,824 $9,450 ± $10,943 .875 4.6 ± 4.6 4.6 ± 7.1 1

Other hospital care 2.7 3.8 .18 $25,932 ± $29,256 $34,752 ± $28,535 .162 8.4 ± 11.7 12.5 ± 13.3 .148

Residential care/SNF 21.8 22.4 .746 $22,784 ± $21,976 $24,163 ± $14,182 .508 8.0 ± 8.1 8.5 ± 7.3 .509

Change in level of care services needed at discharge versus before admission

More services 42.0 43.5 .527 $15,323 ± $16,941 $17,456 ± $24,826 .085 4.8 ± 6.6 6.1 ± 9.2 .006†

Fewer services 9.3 10.4 .402 $20,616 ± $20,011 $22,075 ± $m21,733 .607 6.6 ± 6.5 7.1 ± 7.0 .586

No change 48.7 46.1 .264 $23,918 ± $36,969 $25,814 ± $19,704 .413 15.4 ± 19.1 14.4 ± 10.5 .403

Data presented as % or mean ± standard deviation. Abbreviations: AMA, against medical advice; LOS, length of stay; SNF, skilled nursing facility. * v<.05 • † p < .01 Reprinted with permission from The Journal of Foot and Ankle Surgery, the official journal of the American College of Foot and Ankle Surgeons, published by Elsevier, Inc. Continued on page 16

lermagazine.com 3.19 15 Continued from page 15 Source: Labovitz JM, Shapiro JM, Satterfield VK, Smith NT. Excess cost ulcers, infections, and lower-extremity amputations in the delayed and healthcare resources associated with delayed diagnosis of Charcot diagnosis group. A significantly greater number of chronic conditions and foot. J Foot Ankle Surg. 2018;57(5):952-956. number of procedures performed during the hospital stay also occurred when there was a delayed diagnosis. Additional procedures strongly AFOs for Stroke: Early Use Does correlated with increased acute care costs, with each supplementary pro- Not Limit Long-Term Benefit cedure resulting in additional costs of $4,800 and an increase in LOS by 1.7 days. Potentially most concerning was the 2.8% increase in the total number of lower-extremity amputations that occurred when there was a delay in the diagnosis. This resulted in an incremental cost increase of $7,201 (30.4%) and LOS increased 2.6 days (31.6%) compared to a timely diagnosis. Because Charcot neuroarthropathy often poses a diagnostic challenge due to the clinical presentation similarities with other diabetes-related complications, a delayed diagnosis often occurs. Despite likely un- derestimating the total costs to the healthcare system by relying only on acute care costs, we quantified the costs and resource utilization during the hospital stay to begin evaluating the consequence of a delayed diagnosis in a value-based care system. Over a 4-year period in California, a iStockphoto.com #992705780 delayed diagnosis of Charcot neuroarthropathy resulted in an additional Stroke often impairs walking, particularly by altering foot clearance spending of $1.15 million and 462 additional bed days. As we move to a during the swing phase. Activity of the tibialis anterior (TA) plays an value-based system, it is critical we see the impact of delayed diagnosis in important role in foot clearance; clinicians often prescribe an ankle-foot this challenging population has potentially significant negative impact on orthosis (AFO) for post-stroke patients to help with foot clearance. But cost as well as quality of care.

LER-Mar2019-half.indd 2 2/27/2019 8:18:14 AM 16 3.19 lermagazine.com some commentators worry that providing an AFO too soon after stroke To explain their results, the researchers cited studies suggesting that could in fact impede recovery of foot clearance. To explore this concern, the possible negative effects of an AFO on muscle activity in a single gait researchers from the Netherlands looked at early and delayed use of cycle might be counteracted by the fact that an AFO improves walking in AFOs in stroke patients to determine whether: general. They proposed that an increase in the amount of walking (steps • use of an AFO for 26 weeks affects TA activity taken) offsets a decrease in EMG during a single step. They also note that • early or delayed timing of AFO use matters this work builds on that of others showing: • positive effects of AFOs on ankle kinematics early after stroke • AFOs affect TA activity within a single measurement. • no differences in the effects of early or delayed AFO provision on This randomized controlled trial analyzed 26 unilateral hemiparetic pelvis, hip, and knee kinematics patients: 16 assigned to receive the AFO 1 week post-stroke (15 were analyzed) and 17 assigned to receive the AFO 8 weeks post-stroke (11 were • beneficial effects of AFOs on functional levels analyzed). In study Weeks 1, 9, 17, and 26, electromyography was used to • no differences with respect to balance and mobility between early measure TA activity. and delayed provision of AFOs; early provision showed favorable The researchers found that, compared with walking without an outcomes in the first 11 to 13 weeks, possibly resulting in earlier AFO, use of an AFO significantly reduced TA activity levels during the independent and safe walking. swing phase (P = .041). Throughout the 26-week period, they saw no The authors conclude: “For clinical practice, this means that clinicians, changes in TA activity without an AFO, neither within groups (P = together with the patient, can decide when to start AFO treatment based .420 [early] and P = 0.282 [delayed]) nor between groups (P = .987). on personal priorities and preferences. Early AFO provision is expected to Furthermore, at the end of 26 weeks, the researcher found no differences provide beneficial effects on a functional level in the short-term, without in TA activity between both groups in the swing phase, with (P = .207) negatively affecting muscle activity of the TA in the long-term.” or without an AFO (P = .310). Use of an AFO for 26 weeks did not affect muscle activity, regard- Source: Nikamp C, Buurke J, Schaake L, Van der Palen J, Rietman less of when the AFO was provided (Week 1 or Week 8). The researchers J, Hermens H. Effect of long-term use of ankle-foot orthoses on tibialis did not detect negative effects on activity of the TA with long-term use of anterior muscle electromyography in patients with sub-acute stroke: a an AFO early after stroke. randomized controlled trial. J Rehabil Med. 2019;51(1):11–17. Recreate Natural Gait Help patients walk safely and efficiently

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Bone Stimulation Represents New Frontier for Optimizing Patient Outcomes

Limited research into electromagnetic and ultrasound bone stimulation devices complicates efforts to determine efficacy.

By Nicole Wetsman

For the majority of people, lower-limb fractures and fractures in other parts of the body heal well and reliably. However, some people experience complications that may cause significant harm. Strategies that might help avoid these complications are appealing to clinicians. “There’s a lot of interest in trying to find ways to further optimize patient recovery,” said Jason Busse, DC, PhD, an associate professor at McMaster University. One major complication is nonunion, which occurs when a broken bone fails to knit Figure 1. An old fracture with nonunion of the fracture fragments. Image use is per Creative Commons Share-Alike Unported license. back together. Anywhere from 10% to 20% of tibial shaft fractures, for example, result in non- patient to take any action to trigger stimula- are non-invasive, are placed directly on the skin union (Figure 1).1 It can be caused by a variety of tion, the surgical process comes with risks of above the fracture site. factors, ranging from poor nutrition to old age. infection. “They are very useful,” said Ardeshir Bayat, One strategy to treat nonunion has been Other types of electromagnetic devices PhD, principal investigator in the Division of the use of bone stimulators, which strap to the are placed on the skin above the fracture site. Musculoskeletal & Dermatological Sciences at injury location and send pulses of ultrasonic or Capacitive coupling devices place electrodes on the University of Manchester. “The problem is electromagnetic energy onto the fracture with either side of the limb, forming an electrical field that there are too many modalities in ways to the aim of facilitating healing. Pre-clinical and around the break. Inductive coupling, on the deliver treatment, and people are very confused model research shows that there are mecha- other hand, places one or two coils directly on about which tool is the best for which purpose.” nisms by which these devices could encourage the fracture site. Ultrasound stimulators, which bone healing. However, the clinical data on their Mechanisms of action efficacy is mixed, and the studies that have been In bone and in other tissues, mechanical stimu- conducted have been inconsistent—making it “There’s a lot of lation and movement trigger cellular pathways challenging to form a clear picture of their effi- that promote healing. Electromagnetic and cacy and to make treatment recommendations. interest in trying to ultrasound work in a similar way, said Regis Electromagnetic bone stimulators come O’Keefe, MD, PhD, chair of the department of orthopaedic surgery at Washington University in various forms (Figure 2).2 Direct current stim- find ways to further School of Medicine. “When cells respond to the ulators are surgically implanted at the fracture optimize patient stimulation, they activate various signals and site and therefore require an invasive procedure signaling pathways,” he said. “It’s likely these to use. While these devices don’t require the recovery.” Continued on page 21

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Continued from page 19 mechanisms work through pathways that are analogous to mechanical stimulation.” The protein insulin-like growth factor 2, for example, is key for bone tissue formation, and exposing skeletal tissue to electromagnetic fields increases levels of both the protein and the protein’s RNA. In one study, published in the journal Bioelectrochemistry and Bioenergetics, 30 minutes of exposure to magnetic fields significantly increased levels of IGF-II in human osteoblasts, which synthesize bone. The protein was elevated following magnetic field exposure in rodent models of fractures as well.3 Pulsed electromagnetic fields increase the expression of bone morphogenic proteins—important growth factors in the generation of bone and cartilage—as has been demonstrated in Figure 2. The three methods of administering electric stimulation are shown in this diagram. (a) Direct current (DC): A cathode is implanted at the fracture site which is attached to either a subcutaneous power source or an external power source to generate an chick embryos, rat models, and human cells. electric field at the fracture site. (b) Capacitive coupling (CC): Two capacitive coupled electrodes are situated on the skin on either sides of the fracture site. An external power source is then attached to the electrodes, which induces an electric field at the fracture They also upregulate transforming growth factor site. (c) Inductive coupling (IC): An electromagnetic current carrying coil is placed on the skin overlying the fracture site, which is beta 1, another protein that assists in cell growth attached to an external power source. The coil generates a magnetic field, which induces an electrical field at the fracture site.2 Use is per the Creative Commons Attribution License. and proliferation.4 In a February 2019 study, researchers molecular mechanisms in detail.” almost breaks down 50-50,” he said. In a survey exposed bone-derived human stem cells to of Canadian physicians, published in 2004, or- static magnetic fields of varying strengths for 2 In the clinic thopedic surgeons using these devices preferred weeks and found that the groups of cells under In the United States, both electromagnetic electromagnetic and ultrasound stimulation the magnetic fields had higher expression of and ultrasound bone stimulation devices equally.8 proteins that would promote the differentia- are approved for use by the Food and Drug It’s still unclear which group—advocates tion of the stem cells into bone. The team also Administration. According to a market analysis, or detractors—has the stronger case, as clinical examined the effect of static magnetic fields on sales of these devices are increasing, particularly evidence for the efficacy of these devices is not rodents with bone defects and found that the pulse electromagnetic field stimulators.7 It’s hard only limited, but what is available is mixed. group in the magnetic field condition had more 9 to say how many physicians are actually using A 2016 meta-analysis of electrical stimu- new bone formation than the control group.5 them for treatment, said Busse, though some lators examined 15 trials that included a total of Stimulation by ultrasound also increases surveys have been conducted. 1,247 patients. The analysis showed moderate the expression of growth factors, like insulin evidence that the devices led to reduced pain growth factors and transforming growth factors. “In prior surveys we’ve done among and reduced rates of fracture nonunion—ac- In addition, in laboratory studies, ultrasound surgeons, we really find there are a substantial cording to the study authors, the data showed stimulation has been shown to improve the in- group of surgeons advocating for these products, that the devices could prevent 1 nonunion for tegration of calcium ions into bone. It improves and a substantial group advocating not. It every 7 patients treated. It did not find that the the formation of callus, which forms across a devices have an effect on patient function. fracture preceding full bone repair in rodent Other reviews of research on these stim- models, likely by improving production of cells “When cells respond ulating devices were inconclusive, and a 2011 integral to that process.6 Cochrane review found that the devices did not However, despite the cell line and rodent to the stimulation, significantly improve union rates. “Though the model research into the mechanisms at play available evidence suggests that electromagnet- during bone stimulation, there are still gaps in they activate various ic field stimulation may offer some benefit in the scientific understanding of the process. “We signals and signaling the treatment of delayed union and nonunion have some ideas, but we don’t really know,” of long bone fractures, it is inconclusive and Bayat said. “Fundamentally, we don’t know the pathways.” Continued on page 22

lermagazine.com 3.19 21 Continued from page 21 insufficient to inform current practice,” wrote the authors of the Cochrane review.10 Some individual studies of ultrasound devices find evidence that they can assist in bone healing and functional outcomes. However, a systematic review of 26 trials conducted by Busse and published in 2017 determined that they did not improve patient outcomes. Of the studies that the authors classified as having a low risk of bias, the devices did not reduce days to weight bearing. Overall results that included studies that had a risk of bias found that the devices might have a slight reduction in pain and radiographic healing, as well as a return to Figure 3. The periosteum forms the outer surface of bone, and the endosteum lines the medullary cavity. Illustration from Anatomy & Physiology, Connexions Website. http://cnx.org/content/col11496/1.6/, Jun 19, 2013. Image use is per Creative Commons 3.0 weight bearing.11 Share-Alike Unported license. “Evidence from higher quality studies suggests no effect on patient-reported outcomes,” the fundamental things we don’t understand is to research: many studies are, at least in part, Busse said. “The issue seems to be settled.” which is the optimal modality of delivery.” That funded by device manufacturers, who have a According to Busse, although ultrasound might, he said, be one reason some studies don’t financial stake in the findings and seek greater devices seem to no longer be worth pursuing, see a result with the treatment. control of the messaging around the data. there’s still potential in electromagnetic devices. That argument is less convincing to Busse, Busse came across those challenges first- “We’re kind of in a situation where we have a however. “There is always the argument that if hand while working with a device company on a lot of small studies, a number at risk of bias, you deliver it in a different way at a different study of ultrasound devices. “We wanted to en- and with the vast majority focusing on surrogate intensity, it might work better,” he said. roll 500 patients and follow them for a year,” he outcomes,” he said. More research is needed O’Keefe said that there might be other said. The team wanted to look at functionality as before that determination can be made. reasons why both reviews and individual studies the primary outcome measure, but the company The small number of well-designed studies show limited efficacy, and why the devices might wanted to look at radiographic outcomes. The company also wanted to see unblinded data and an inconsistency in research methods has not spur healing in every patient: for example, from an intermediary point in the study and made drawing overarching conclusions about the mechanisms likely rely on an intact and then decided to pull the plug on the trial when the devices difficult, researchers said. robust periosteum, the layer of tissue that Most of the research that has been done the results appeared not to support the efficacy surrounds bone and contains cells necessary to date on both types of devices looks at the of the device. Busse’s team continued the study for regrowth (Figure 3). “If you have a situation final scans and radiographs for evidence of with its remaining funding and began to put where you don’t have progenitor cell population efficacy—not patient results—which makes the together a paper with negative results. Out that can respond, from aging or other disease, studies less useful, Busse said. “Patients don’t of more than a dozen subgroup analyses, the you might not see as much of an effect,” he said. really care about that outcome; they care about company wanted them to stress the three that Devices that deliver the ultrasound or pain and function,” he said. “We have very little showed some benefits from their devices. electromagnetic currents are commercial prod- information on those outcomes.” Studies have found that research spon- ucts, which adds another layer of complication Bayat agreed that the varied outcome mea- sored by companies leads to more favorable sures complicate efforts to draw conclusions. “If results than research funded by other means.12 someone talks about bone healing, they might O’Keefe said that those conflicts of interest not also talk about functional outcomes. That “Evidence from pose a big challenge in this and other areas of makes it difficult to navigate,” he said. research. “Conflicts of interest influence the way Researchers also have little understand- higher quality studies that data is presented, and the interpretation of ing of how the devices compare to each other. that data,” he said. “There aren’t many trials that don’t just look at suggests no effect Those conflicts will be important to note as the same device,” Bayat said. “The regime for on patient-reported research on electromagnetic stimulation moves currents can be different from device to device. forward, Busse said. “The evidence we do have How can you judge which is better? One of outcomes.” Continued on page 24

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Continued from page 22 suggests a potential there, but there really needs 2. Griffin M, Bayat A. Electrical Stimulation in fuss? Indian J Orthop. 2009; 4:117–120. to be a large trial done to understand if it does Bone Healing: Critical Analysis by Evaluating 8. Busse JW, Bhandari M. Therapeutic ul- have a benefit. Whether or not a company will Levels of Evidence. Eplasty. 2011;11:e34. trasound and fracture healing: a survey of choose to do that study, I don’t know. There 3. Ryaby J, Fitzsimmons R, Khin NA, et al. beliefs and practices. Arch Phys Med Rehabil. are lessons to be learned from our ultrasound The role of insulin-like growth factor II in 2004;85:1653-6. experience.” magnetic field regulation of bone formation. 9. Aleem IS, Aleem I, Evaniew N et al. Efficacy Despite the challenges and lack of clarity Bioelectrochem Bioenerg. 1994;35:87:91. of Electrical Stimulators for Bone Healing: around efficacy, Bayat thinks that clinicians and 4. Aaron RK, Boyan BD, Ciombor DM, et al. A Meta-Analysis of Randomized Sham-Con- researchers should continue to consider bone Stimulation of Growth Factor Synthesis by trolled Trials. Sci Rep. 2016; 19;6:31724. stimulators a promising treatment approach. Electric and Electromagnetic Fields. Clin. Or- 10. Griffin XL, Costa ML, Parsons N, et al. “There is a lot of evidence to suggest that there thop. Relat. Res. 2004;419:30–37. Electromagnetic field stimulation for treating is a role for them, and it should spur more 5. He Y, Yu L, Liu J, et al. Enhanced osteogenic delayed union or non-union of long bone research,” he said. differentiation of human bone-derived mes- fractures in adults. Cochrane Database Syst enchymal stem cells in 3-dimensional printed Rev. 2014:CD008471. Nicole Wetsman is a freelance writer based in porous titanium scaffolds by static magnetic New York, New York. 11. Schandelmaier S, Kaushal A, Lytvyn L, et field through up-regulating Smad4. FASEB J. al. Low intensity pulsed ultrasound for bone References 2019; doi: 10.1096/fj.201802195R healing: systematic review of randomized 1. Hernandez RK, Do TP, Critchlow CW, et al. 6. Hannouche D, Petite H, Sedel L. Current controlled trials. BMJ. 2017;356:j656. Patient-related risk factors for fracture-healing trends in the enhancement of fracture heal- 12. Lundh A, Lexchin J, Mintzes B et al. In- complications in the United Kingdom Gen- ing. J Bone Joint Surg Br. 2001;83(2):157-64. dustry sponsorship and research outcome. eral Practice Research Database. Acta Orthop. 7. Victoria C, Petrisor B, Drew B, et al. Bone Cochrane Database Syst Rev. 2017; doi: 2012;83:653-660. stimulation for fracture healing: What’s all the 10.1002/14651858.MR000033.pub3.

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A REVIEW FOR LOWER-EXTREMITY SPECIALISTS Mitigating the Opioid Crisis with Pain Management Regimens in a Multimodal Approach

For help limiting the number of opioid tablets you prescribe—and to still treat postop pain successfully—turn to practice guidelines, evidence from the literature about local and regional anesthesia techniques, and constraints of the law.

By Robert G. Smith, DPM, MSc, RPh, CPed, CPRS iStockphoto.com #900309188

Opioid abuse is among the most consequential scribing standards and legal regulations aimed agents that induce analgesia through sepa- and preventable public health threats in the at alleviating the widespread crisis we face. My rate or overlapping mechanisms or that have United States1; many of these analgesic medi- goals? To have lower-extremity practices estab- separate adverse effect profiles. The basic goal cations are associated with a high likelihood of lish 1) procedures to better control and limit of a combination strategy is to amplify desired physical dependence and a relatively high risk of opioid prescriptions and 2) opioid monitoring effects while decreasing, or at least not equally addiction. This is a critical problem that needs strategies to recognize and reduce the risk of increasing, the undesired effects of individual to be addressed by all health-care professions. aberrant opioid misuse and abuse,2 and develop agents.5, 8 To manage patients’ pain after invasive analgesic regimens to treat pain.* Many treatments are available to manage procedures, all practicing clinicians prescribe pain. Some non-opioid therapies are likely to be medication on occasion; the central theme of Opioids or non-opioids? as effective as, or more effective than, opioids, this article is responsible opioid pain manage- Or both? and, potentially, carry less risk when used ment by lower-extremity specialists. I’ll describe Analgesic opioid therapy has been the corner- appropriately. Any meaningful effort to improve prescription opioid strategies for use in alleviat- stone of pharmacotherapeutic management of pain management will require a basic culture ing lower-extremity pain, as well as how modern acute and chronic pain. Ideally, opioid analge- shift in the nation’s approach to mandating clinical-based evidence has led to ethical pre- sics are prescribed by balancing beneficial and pain-related education for all health-care professionals who provide care to people with pain. adverse effects. Although often overlooked as a Prescribing guidelines may be most effec- *See “For lower-extremity specialists: Key points source of opioid medications, podiatric and or- in opioid analgesic prescribing,” page 29.2,3 tive when accompanied by education; therefore, thopedic surgical interventions are often painful Elsewhere,2, 4-7 the author has discussed [within an evidence-based national approach to pain postoperatively; therefore, these specialists are the scope of lower-extremity pain management] education that addresses pharmacotherapeutic frequent opioid prescribers.5 the pharmacology, pharmacodynamics, and and nonpharmacotherapeutic treatments and No single opioid analgesic is perfect, and pharmacokinetics of opioid analgesics, as well includes materials on opioid prescribing, is as opioid drug–drug interactions and adverse no single agent can treat all types of pain.5,8 The needed.2,5,9,10 The appropriate combination of effects. underlying rationale for combination analgesic agents, including opioids and adjunctive medi- strategies involves the availability of individual Continued on page 29

lermagazine.com 3.19 27 Finally... an effective and affordable scanning solution for foot orthotics. CONVENIENT EFFICIENT PORTABLE

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1-800-564-LEVY (5389) LevyandRappel.com 339 10th Street Saddle Brook, NJ 07663 Continued from page 27 evaluated the influence of local anesthetic infil- cations, can be seen as rational pharmacother- “Opioid abuse is among tration before hallux valgus surgery on postop- apy, providing a stable therapeutic platform on erative pain and the need for analgesics. Their which treatment changes can be based: the most consequential Finally... an effective and study group comprised 134 patients who under- • Reassessing the pain score and level and preventable public of function, regularly reassessing the went chevron or mini-invasive Mitchell-Kramer affordable scanning solution patient, and combining this effort with health threats in the osteotomy of the first distal metatarsal. Each corroborative support from family and other patient was randomized to receive 7 mL of local 1 knowledgeable third parties; doing so will United States ” anesthetic (4 mL of bupivacaine, 0.25%, and 3 for foot orthotics. help document the rationale for continuing mL of lidocaine, 2%) or normal saline 15 min- or modifying the therapeutic trial. utes prior to skin incision. Each patient’s level of • Regularly assessing the “4 As” of pain tive patients who underwent bilateral proximal pain was assessed by the visual analogue scale CONVENIENT medicine: routine assessment of Analgesia, osteotomy for correction of a hallux valgus at Hours 2, 4, 8, 12, 16, and 24, and again 72 Activity, Adverse effects, and Aberrant deformity.11 Each patient acted as his (her) own hours after release of the tourniquet. behavior.5,9,10 control: 1 foot received local infiltration of a test Finding: The authors concluded that pre- EFFICIENT Periodically reviewing the pain diagnosis solution made with ropivacaine, morphine, ke- • and comorbid conditions, including torolac, and epinephrine; the other foot received FOR LOWER-EXTREMITY SPECIALISTS addictive disorders and any underlying the same amount of normal saline. A visual pain PORTABLE illness. The findings of diagnostic tests analogue scale was used to assess pain intensity KEY POINTS IN change with time; in the pain and addiction 4 hours after surgical intervention and throughout the night of the first postoperative day. OPIOID ANALGESIC continuum, it is not uncommon for a patient 2,3 to move from a dominance of one disorder Finding: The difference in visual analogue PRESCRIBING to another. As a result, the treatment focus scale values between left and right sides was It is critical that lower-extremity specialists might need to change over time. most notable 8 hours after the operation, then first, understand the underlying issues of opioid gradually decreased through the first and second prescribing and, second, exercise sound clinical From the literature: postoperative days. The investigators concluded judgment in identifying patients who might have, Strategies to reduce the that the local multidrug cocktail was easy to or develop, physical or psychological dependence need for opioids perform, safe, and effective in reducing pain on these drugs. Such understanding includes: and enhancing patient satisfaction after hallux Published clinical-based evidence has described • knowing that opioid analgesics should be valgus surgery. the effects of employing local anesthetic prod- prescribed by balancing their beneficial and 2 ucts to reduce postoperative pain and reduce the Talar and calcaneal fracture repair. Luiten adverse effects need for opioid analgesics: et al.12 investigated their hypothesis that a • managing pain while minimizing abuse continuous peripheral-nerve block would reduce potential through careful procedural The Levy ® iPad scanner Osteotomy. Kim et al. investigated 30 consecu- the pain score more effectively than systemic techniques and use of alternative therapies, by limiting prescriptions to appropriate offers clinicians a quick, easy analgesics, improve recovery, and reduce length quantities when opioids are deemed of stay. They retrospectively analyzed 3 years of and accurate scanning necessary, and by altering the attitudes of data from patients who underwent open reduc- patients and physicians2 method for foot orthotics. tion and internal fixation of talar or calcaneal • providing pain management responsibly in fracture and received 1) intravenous opioid, an error-free environment, adhering to state patient-controlled analgesia or 2) continuous and federal regulations (such as Centers for The intuitive software gives you the power, precision and control to include modifications and peripheral-nerve block. Disease Control and Prevention guidelines Finding: On the first postoperative day, that help providers manage pain effectively select the device you prescribe from our complete catalog of products. the patient-controlled analgesia group (which amid the opioid crisis)3 had unrestricted access to opioids) required • awareness that providers are not insulated approximately 30-fold more opioids than the from medical errors, medication misfortune, 1-800-564-LEVY (5389) continuous peripheral-nerve block group (which or ethical and legal responsibilities when prescribing opioid medication. LevyandRappel.com had to request additional opioids). iStockphoto.com #936318564 13 339 10th Street Mitchell-Kramer osteotomy. Gadek and Liszka Continued on page 30 Saddle Brook, NJ 07663 lermagazine.com 3.19 29 Continued from page 29 utilization was reported for 988 patients (mean emptive local anesthetic infiltration significantly age, 49 years). decreased pain during the first 24 hours after Finding: Overall, patients consumed a me- hallux valgus surgery. dian of 20 pills; the median number prescribed was 40. The study revealed that these patients Foot and ankle surgery. Gupta et al14 investi- were overprescribed narcotic medication in an gated the number of narcotic tablets taken by amount nearly twice what they consumed. opioid-naïve patients undergoing outpatient foot and ankle surgery with regional anesthesia. Postop analgesia protocol. Boffeli and Gorman16 Their patient population was 84 patients who recently described creation of a postoperative iStockphoto.com #155132832 underwent outpatient surgery using spinal pain protocol using a multimodal approach that blockade and a long-acting popliteal anesthetic involves various medications used in the preop- tion, and, therefore, adverse effects of opioids. block. erative setting to tackle difficult lower-extremity Lower-extremity providers face the Patients were given 40 or 60 narcotic pain pathways. challenging task of setting appropriate proto- tablets, a 3-day supply of ibuprofen, deep-vein Finding: One year after adopting the pain cols when balancing pain relief and regulatory thrombosis prophylaxis, and an antiemetic. A protocol, the authors had reduced the amount guidelines. A clinical evidence base has revealed survey completed at postop Days 3, 7, 14, and of opioids prescribed postoperatively by 30% by that the use of regional local anesthesia tech- 56 documented whether they were still taking adding non-steroidal anti-inflammatory agents niques during lower-extremity procedures has narcotics, how many pills they consumed, to the protocol—without an incident of delayed decreased consumption of opioids. Using a com- whether refills were obtained, pain level, and union or nonunion. bination of the clinical evidence base that I’ve their reason for stopping opioids, if that was reviewed here, clinical practice guidelines (see what they had done. Rescue therapy. Suzuki and Birnbaum17 assert- “Suggested reading on pain management using Finding: Patients consumed a mean of ed that opioid medication may have a role as opioids,” page 33), and state- and federally-leg- 22.5 tablets (95% confidence interval, 18-27 rescue medications, but only as a last resort for islated opioid limitations, the lower-extremity tablets). Those who received regional anesthe- neuropathic pain. sia reported a progressively lower pain score clinician can begin to reduce the number of with low narcotic use, for as long as 56 days Reducing opioid use: opioid tablets prescribed to treat acute, chronic, postoperatively. Challenging, but doable and postsurgical pain. Multimodal analgesia for lower-extremity sur- Foot and ankle surgery. Saini et al15 conducted Robert G. Smith is in private podiatry practice at gery is widely practiced as a means of reducing a prospective investigation to evaluate utilization Shoe String Podiatry in Ormond Beach, Florida. the use of opioids and opioid-related adverse patterns and prescribing guidelines for opioid He has been an advisor to the US Food and effects. A multimodal approach is likely to consumption after foot and ankle surgery. Their Drug Administration and the US Drug Enforce- produce analgesia superior to an opioid-based study population included patients undergoing ment Administration regarding the rescheduling approach because multimodal analgesic agents outpatient orthopedic foot and ankle proce- of hydrocodone combinations. He has delivered target a variety of pain pathways. Furthermore, dures who met inclusion criteria. The following presentations on the appropriate prescribing of many non-opioid multimodal agents are inex- prospective information was collected: patient opioids to avoid drug–drug interactions, adverse pensive and offer benefit by reducing consump- demographics, preoperative health history, effects of opioids, and avoidance of opioid abuse patient-reported outcomes, anesthesia type, disorder at meetings of state, national, and procedure type, and opioid prescription and international professional organizations in 2017 consumption details. The morphine milligram “Some non-opioid and 2018. equivalent dosage was calculated for each References prescription, then converted to the equivalent of therapies are likely to be a 5-mg oxycodone “pill.” as effective as, or more 1. Manchikanti L, Sanapati J, Benyamin RM, et Univariate analyses were performed to al. Reframing the prevention strategies of the identify variables with a statistically robust effective than, opioids, opioid crisis: focusing on prescription opioids, association with opioid consumption, for inclu- fentanyl, and heroin epidemic. Pain Physician. sion in a multivariable linear regression model. and, potentially, carry 2018;21(4):309-326. A stepwise backward regression was then less risk when used 2. Smith RG. Opioid prescribing: podiatric performed to identify independent predictors implications. Podiatry Management. of opioid consumption. Postoperative opioid appropriately.” Continued on page 32

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Continued from page 30 8. Raffa RB, Clark-Vetri R, Tallarida RJ, et al. Comparison of continuous nerve block versus 2018;37(5):161-169. http://www.podiatrym. Combination strategies for pain management. patient-controlled analgesia for postoperative com/cme/CME618.pdf. Accessed January 20, Expert Opin Pharmacother. 2003;4(10):1697- pain and outcome after talar and calcaneal 2019. 1708. fractures. Foot Ankle Int. 2014;35(11):1116- 3. Centers for Disease Control and Prevention. 9. Bonnie RJ, Ford MA, Phillips JK, editors; 1121. CDC guideline for prescribing opioids for National Academies of Sciences, Engineering, chronic pain - United States, 2016. MMWR 13. Gdek A, Liszka H. Preemptive local anesthetic and Medicine. Consensus Study Report: Pain Recomm Rep. 2016;65(1):1-49. . infiltration in hallux valgus one-day surgery. Management and the Opioid Epidemic: Bal- Przegl Lek 2015;72(1):16-19. 4. Smith RG. A review of opioid analgesics fre- ancing Societal and Individual Benefits and quently prescribed by podiatric physicians. J Risks of Prescription Opioid Use. Washington, 14. Gupta A, Kumar K, Roberts MM, et al. Pain Am Podiatr Med Assoc. 2006;96(4):367-373. DC: The National Academies Press; July 12, management after outpatient foot and ankle 5. Smith RG. Using clinical-based evidence as 2017. https://www.nap.edu/catalog/24781/ surgery. Foot Ankle Int. 2018;39(2):149-154. pain-management-and-the-opioid-epidem- the sextant to prescribe and navigate through 15. Saini S, McDonald EL, Shakked R, et al. Pro- ic-balancing-societal-and-individual. Accessed the opioid crisis. Foot and Ankle Quarterly. spective evaluation of utilization patterns and 2018;29(3):143-157. January 20, 2019. prescribing guidelines of opioid consumption 10. Passik SD, Weinreb HJ. Managing chronic 6. Smith RG. Drug interactions and opioids: following orthopedic foot and ankle surgery. nonmalignant pain: overcoming obstacles to what you should know. Podiatry Today. Foot Ankle Int. 2018;39(11):1257-1265. 2018:31(4). www.podiatrytoday.com/drug-in- the use of opioids. Adv Ther. 2000;17(2):70- 16. Boffeli T, Gorman C. A guide to postoper- teractions-and-opioids-what-you-should-know. 83. Accessed January 20, 2019. 11. Kim BS, Shim DS, Lee JW, et al. Compar- ative pain management. Podiatry Today. 2018;31(9):48-54. 7. Smith RG. Opioid prescribing and the opi- ison of multi-drug injection versus placebo oid crisis in the lower extremity. Advance after hallux valgus surgery. Foot Ankle Int. 17. Suzuki K, Birnbaum Z. Pain management and Research on the Foot and Ankle: ARFA-106. 2011;32(9):856-860. wound care patients: key principles. Podiatry 2018;2018(1):1-7. 12. Luiten WE, Schepers T, Luitse JS, et al. Today. 2018;31(12):36-41.

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32 3.19 lermagazine.com SUGGESTED READING ON PAIN MANAGEMENT USING OPIOIDS This listing of guidelines for using opioids to manage acute and chronic pain, developed by professional organizations and government agencies, is certainly not exhaustive and does not necessarily represent the views of the author or Lower Extremity Review.

Guideline for Prescribing Opioids for Chronic Pain – United States 2016 Centers for Disease Control and Prevention: https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc. gov%2Fmmwr%2Fvolumes%2F65%2Frr%2Frr6501e1er.htm

Opioid Prescribing: Acute and Postoperative Pain Management American Association of Oral and Maxillofacial Surgeons: https://www.aaoms.org/docs/govt_affairs/advocacy_white_papers/opioid_prescribing.pdf

Opioid-Prescribing Guidelines for Common Surgical Procedures: An Expert Panel Consensus Opioids after Surgery Workgroup of the American College of Surgeons: www.journalacs.org/article/S1072-7515(18)31129-3/fulltext

Oregon Acute Opioid Prescribing Guidelines Public Health Division, Oregon Health Authority: https://www.oregon.gov/oha/PH/PREVENTIONWELLNESS/SUBSTANCEUSE/OPIOIDS/Documents/Acute- Prescribing-Guidelines.pdf

Postoperative Opioid Prescribing Guidelines: Background for Surgeons City of Philadelphia Department of Public Health: www.phila.gov/media/20181219135343/OpioidGuidelines-BackgroundforSurgeons_12_14.pdf

lermagazine.com 3.19 33 How Mountain Biking Is Reshaping the Landscape of Cycling Injury Differences in equipment, terrain, riding style, and other risk factors mean different types and prevalence of injuries when riding a mountain bike, compared to a road bike. Be prepared to see those differences in your practice.

By MICHAEL REEDER, DO, AND BRENT ALUMBAUGH, MS

Over the past several decades, mountain biking has market in the early 1970’s. There are now different types become remarkably popular as a competitive and recre- of mountain bikes that vary significantly, depending ational activity. Mountain biking is popular international- on the inclination of rider and the intended use. As the ly and can be observed in numerous competitive events; technology of mountain bikes has improved, it’s become the most popular are the annual World Cup Series, easier for riders to attempt more technical terrain and Olympic Games, and World Championships. The largest ride at higher speeds. Compared to road bikes, mountain increase in number of participants, however, has been in bikes are designed for stability and maneuverability in recreational mountain biking. The Outdoor Foundation1 technical terrain; they generally have larger tires, lower recently reported mountain biking as one of the most bottom brackets, shorter chain stays, and lower head- popular outdoor activities in the United States, with tube angles (see annotated image, page 37). approximately 8.32 million mountain bikers in 2015 (see Furthermore, improvements in protective apparel “Why so much interest in mountain biking?,” page 40). have made mountain biking safer; however, these improvements have likely led to greater rider confidence— Equipment and Technology leading, somewhat paradoxically, to higher speeds and Has Changed more risk-taking behavior. Despite remarkable improve- Recently, there has been a change in bike sales in the ments in bike technology and the use of protective equip- United States: More mountain bikes are now sold than ment and clothing, the risk of injury to all parts of the road bikes.2 More recently, electrical bikes, or e-bikes, body is ever-present in mountain biking, as we describe have become popular, including electrical-assist moun- in detail in this article. tain bikes, which might make mountain biking a feasible option for more of the population. The price of mountain Getting a Handle on Injury in bikes ranges from a few hundred dollars for an entry-lev- Mountain Biking el bike to more than $10,000 for high-end bikes. The nature of injury rates in mountain biking is not Bicycle manufacturers have improved mountain well-defined. Mountain bikers include competitive and bike technology since the first models appeared on the recreational riders, ranging from adolescents to older

34 3.19 lermagazine.com “The risk of injury to all parts of the body is ever-present in mountain biking”

adults—all of whom have different preferences in riding contributed to the demographic phenomenon. As resorts style. Most older studies of mountain biking injuries are expand ski-lift access and develop terrain that is more limited to competition and mountain bike parks, making technical, riders are able to spend more time riding the injury rate outside of those settings hard to define, downhill at high speed. During competitive downhill especially when injuries go unreported. races, mountain bikers attain speeds approaching 60 A study by Gaulrapp et al3 of more than 3800 mph over uneven, often rocky, terrain. mountain bikers, most of whom were noncompetitive There is more: In the United States, competitive recreational bikers, cited a very low rate of significant high school mountain bike leagues are increasingly pop- injury: 1 injury for every 1000 hours of riding, with 75% ular, drawing more and more participants. These leagues of injuries considered minor. In contrast, Kronisch are overseen by the National Interscholastic Cycling As- et al4 looked at competitive mountain bikers and cited an sociation (NICA; www.nationalmtb.org/), which has de- injury rate of 3.7 injuries for every 1000 hours of racing veloped appropriate rider safety guidelines. In response in cross-country biking and 43.4 injuries for every 1000 to concerns over safety, NICA, in conjunction with the hours in downhill racing. Similarly, a prospective study University of Utah, recently initiated a study comparing by Becker et al5 of downhill mountain biking injuries injury reports among various high school sports and seen in competition is in agreement with Kronisch’s find- cycling (www.nationalmtb.org/nica-safety-study/). ings,4 showing an increased incidence of injuries: 16.8 injuries for every 1000 hours of downhill racing cycling. A Look at the Scope of Mountain Nelson and Mckenzie6 illustrated the importance Biking Injury of the age of the rider as it relates to traumatic brain As the number of off-road cyclists increases, so has the injury. Reporting on more than 200,000 patients who number of cycling-related injuries.9 Surveys of mountain suffered a mountain-biking injury and were treated in bikers demonstrate that injury is common, but most are an emergency department between 1994 and 2007, the minor and involve soft tissue. The nature of mountain researchers showed that patients 14 to 19 years of age biking lends itself to injuries to skin, with the most sustained the greatest percentage of traumatic brain in- common types being soft-tissue abrasion, laceration, and juries. Similarly, 2 studies7,8 from Canada illustrated the contusion.3,5 After soft-tissue injury, mountain bikers preponderance of head and neck injury in young male experience the following injuries in order of prevalence: recreational riders. fracture of the clavicle, fracture of the ribs, fracture of the What’s behind this preponderance of adolescent distal radius, and fracture of the scaphoid.5 What follows male victims? The popularity and continued development of mountain bike parks at ski resorts likely has Continued on page 37

lermagazine.com 3.19 35 The new C-Brace® Step into the future.

Meet the world’s first mechatronic stance and swing phase control orthosis system (SSCO®), which controls both the stance and swing phase with microprocessor sensor technology. For patients with neurological conditions affecting their legs, C-Brace supports the user during the entire gait cycle and adapts to everyday situations in real-time. It’s time to step into the future.

• Request a C-Brace Trial at professionals.ottobockus.com/c-brace 3/19 ©2019 Ottobock HealthCare, LP, All rights reserved. 3/19 ©2019 Ottobock HealthCare, LP, Continued from page 35 is a review of mountain biking injury by body region.

Head and face. Along with soft-tissue injury and fractures, older literature suggested that mountain bike riders have a relatively higher associated rate of maxillofacial trauma compared to road cyclists.10 Gassner10 and Chow11 proposed that conventional cycling helmets were inadequate for mountain bikers; they recommended adding face guards to mountain bike The new C-Brace® helmets secondary to the high rate of maxillofacial trauma.11 Perhaps in response to this recom- Step into the future. mendation, there has been an increase in helmets that provide greater protection, as shown Meet the world’s first mechatronic stance and in a study by Becker et al,5 which demonstrated swing phase control orthosis system (SSCO®), that the great majority of competitive downhill in a flexed position on the bike, which can lead appropriate irrigation and debridement. which controls both the stance and swing phase mountain bikers wear a full-face helmet. to neck and back pain; such complaints are The anterior lower leg of mountain bikers with microprocessor sensor technology. For patients frequent in road cyclists. However, the geometry frequently sustains soft-tissue trauma, including with neurological conditions affecting their legs, Spine. High speeds and technical terrain of a mountain bike allows a more upright riding injuries from plant undergrowth, teeth of the C-Brace supports the user during the entire gait associated with downhill racing increase the position and changes in riding terrain often chain ring, and sharp edges of flat pedals. Most cycle and adapts to everyday situations in real-time. risk of acute spinal injury. As noted, the greatest require different body positions, which may such injuries heal well with appropriate wound It’s time to step into the future. occurrence of spinal injury is observed among decrease the incidence of chronic neck and back care, which might include aggressive irrigation younger male riders. Similarly, McLean et al12 pain in mountain biking, compared to what is and debridement. However, these injuries might Request a C-Brace Trial at reported on spinal injury in mountain bikers • seen in road cycling. also require more significant intervention, as professionals.ottobockus.com/c-brace and showed that, principally, young males are at noted by Patel,14 who reported significant pretib- risk. They recommended mandatory universal Abdomen. Spleen and liver injuries are the ial lacerations from the chain ring when using use of protective equipment and appropriate most frequently reported abdominal injuries;9 quick-release pedals—lacerations that required rider training. some have been associated with using bar ends debridement under anesthesia and delayed With regard to overuse injury of the spine, on handlebars that allow for additional riding wound closure or skin grafting. the nature of riding leads to cyclists remaining positions. Nehoda13 reported the relationship Trauma in mountain biking can result between an increase in liver injury and bar ends in injury to the soft-tissue bursa from a direct on handlebars in the late 1990’s, which led to blow, resulting in fluid collection and swelling. TABLE: LOWER-EXTREMITY a decrease in the use of bar ends. Recently, A similar injury to the bursa involves a shearing OVERUSE AND ACCIDENTAL however, there has been a resurgence of shorter force that separates superficial fascia from deep INJURIES IN MOUNTAIN BIKING attachments to the handlebars because of per- fascia, resulting in a collection of fluid, known Foot numbness ceived improved comfort. as a Morel-Lavallée lesion.15 This lesion is most Foot pain Skin and soft tissue. Skin and soft-tissue often seen at the olecranon bursa, the greater • Metatarsalgia injury is common in mountain biking. Trau- trochanter of the hip, or one of the knee bursa. • Morton’s neuroma matic lacerations and abrasions are common Although many of these injuries are treated • Plantar fasciitis and, likely, underreported. It is probable that with ice and compression, management for a • Sesamoiditis many soft-tissue injuries from mountain biking small percentage of patients includes timely Iliotibial band syndrome are taken care of at home and, therefore, not aspiration.15 Knee pain reported. For injuries requiring evaluation by a The upper extremity. Ulnar and median neu- medical provider, initial management includes Other ropathies are the most common overuse prob- copious irrigation and tetanus immunization if • Bilateral tarsal tunnel syndrome needed. Proper anesthesia is essential to allow lems of the upper extremity in all cyclists. This • Lisfranc fracture full wound assessment for foreign bodies and problem is related to direct pressure on nerves

deeper injuries (to tendons and joints) as well as Continued on page 38

lermagazine.com 3.19 37 3/19 ©2019 Ottobock HealthCare, LP, All rights reserved. 3/19 ©2019 Ottobock HealthCare, LP, Continued from page 37 at the wrist on the handlebar. Ulnar neuropathy, pain occurs due to: pressure on the forefoot and sesamoids of the or cyclist’s palsy, causes injury to the ulnar nerve • a sudden increase in mileage and intensity first metatarsal phalangeal joint and 2) stress on at Guyon’s canal and can produce numbness • impaired hip gluteal and hip abductor the plantar fascia. and tingling of the fourth and fifth fingers. function Introduction of newer carbon-soled shoes, Median nerve injury or irritation also occurs which are stiffer than older plastic models, • seat position too low or too far forward and can present with numbness or tingling of might decrease some of these foot problems • poor patellar mechanics.18 the thumb, index finger, and middle finger or by distributing forces differently. Conventional with other signs and symptoms of carpal tunnel In a systematic review of the literature solutions, such as footbeds or orthoses, can be 19 syndrome. Initial treatment of ulnar neuropathy regarding knee pain in cyclists, Bini and Bini challenging with many traditional (i.e., narrow) and median nerve injury includes padded gloves attempted to synthesize previous studies, suggest- cycling shoes, where there is a need to be ing that cyclists with knee pain have increased and handlebars, improving rider posture, proper space-conscious. In addition, there is less re- medial projection of the knee and abnormal bike fit, night splints, and other appropriate search and guidance available to clinicians and strength and stretching therapy for these specific muscular activation. They noted, however, that nerve-compression syndromes. research in this area is limited and true biomechanical understanding of this injury is lacking. After such soft-tissue injuries as abrasion WHY SO MUCH INTEREST Interestingly, they concluded that there is little and laceration, fractures of the upper extremity evidence, based on their review of studies, for IN MOUNTAIN BIKING? are the most common reported injuries among a relationship between saddle height and knee The increase in popularity of mountain biking is mountain bikers, with fracture of the clavicle pain, which conflicts with the theory that decreas- likely due to a number of contributing factors, most common. Bush16 performed a study in ing saddle height might increase patellofemoral including: the area of the Whistler Mountain Bike Park pain and pressure, causing anterior knee pain. in British Columbia, Canada, and reported that • improvements in mountain bike technology Iliotibial band syndrome (ITBS) is a scaphoid, distal radius, and metacarpal fractures • accessibility to more and more trails common overuse injury at the knee in cycling. were the most common fractures of the hand, • growing knowledge of associated benefits Although forces at the iliotibial band at the particularly from landing on an outstretched of cardiovascular exercise with cycling. knee in a cyclist are markedly less than forces arm. seen in runners, bike fit and the high amount Although mountain bikers may have similar The lower extremity. The 3 principal areas of repetition of cycling in the impingement zone reasons for participating in the activity, they are of contact between cyclist and bike are the likely play a role in ITBS in cycling. It has been still a highly heterogeneous group, with a wide handlebars, saddle, and foot–pedal interface. suggested that a seat set too high and training range of disciplines—ranging from recreational That foot–pedal link, which is the connection errors are the main causes of ITBS in cycling.20 cross-country riding to extreme downhill and to the drive train of the bike and relates to the Mountain bikers may present with foot free-riding. kinematics of cycling, is one of the contributors pain or numbness (or both); this can be related Medical providers often encourage mountain to overuse injury in cycling (Table, page 37). to type of shoe or pedal, location of the cleats, biking as a lifetime activity that can improve Although there is an abundance of literature re- and a high amount of repetitive movement. health. There are potential health benefits lated to shoe wear and orthoses in running and Traditional cycling shoes with cleats might be to mountain biking compared to road biking walking, information about shoes and orthoses too narrow in the forefoot for mountain biking, because of augmented use of the upper body in cycling is limited. Specific to mountain biking, causing compression of the metatarsal phalan- and increased cognitive effort and decision- it is more challenging to make observations or geal joints and interdigital nerves. Common making. Although there are clearly health give general recommendations about footwear diagnoses of foot pain in this group include benefits, risk exists for acute and chronic because riders use different types of shoes and metatarsalgia, plantar fasciitis, sesamoiditis, and overuse injury in this sport, as this article flat or clipless pedals. Morton’s neuroma (i.e., of an intermetatarsal describes, given the nature of the terrain and the technical nature of the sport. It has Knee pain is a common complaint among plantar nerve). been challenging to weigh the risks versus cyclists, reported by 20% to 27% of mountain Initial treatment of foot pain and numb- the benefits of mountain biking, however, bikers.17 During an average weekend ride, a ness in a cyclist can include adjustment of because, first, there are likely many unreported cyclist can flex and extend the knee 15,000 shoe wear, modifying the cleat position (often, injuries and, second, it is difficult to study the times. With that amount of repetitive motion, positioning is too far forward), and adding heterogeneous population that participates in even small inefficiencies can contribute to knee appropriate footbeds. If the rider uses clipless this sport. pain—particularly, anterior pain. The cycling pedals, adjusting the cleat might help because literature on knee pain generally suggests that a cleat that is too far forward can increase 1) Continued on page 40

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Go 4-D is the North American healthcare distributor of FitStation powered by HP and manufacturer of 3D printed custom orthotics. Recommended by the NFL Medical Committee Continued from page 38 • Bilateral tarsal tunnel syndrome. This Brent Alumbaugh, MS, is Clinical Coor- uncommon problem was reported in a dinator and Exercise Physiologist at Monfort therapists about appropriate use of orthoses and cyclist, caused by a marked increase in Family Human Performance Lab, Colorado Mesa wedges in mountain biking. Older studies that cycling intensity, leading to symptoms of University. looked at performance have evaluated wedges nerve impingement.23 and orthoses in cycling and have reported im- References provements in power, kinematics, and changes 1. Outdoor Foundation. (2017). Out- in forces at the knee;21 however, those studies Risk of Injury Is Inherent door recreation Participation Topline Mountain biking has evolved into a popular out- are limited and there is a general lack of direc- Report 2017. Available at https:// door activity with health benefits. However, given tion for providers concerning footwear solutions outdoorindustry.org/wp-content/up- the nature of the terrain and the demographics of for foot and ankle pain in mountain biking. loads/2017/04/2017-Topline-Report_FINAL. Making a decision to improve comfort and, mountain bikers, there remains associated risk to pdf this sport. Medical providers should be aware of perhaps, safety, many recreational cyclists prefer 2. The NPD Group. U.S. Retail Tracking Ser- common associated injuries and some of the dis- flat pedals. They have adopted a stiffer, moun- vice, Independent Bicycle Dealers, Dollar tinctive differences in mountain biking, compared tain bike-specific shoe with a wider toe box and Sales, January-December 2017. sturdy construction, which might offer improved to other cycling activities. 3. Gaulrapp H, Weber A, Rosemeyer B. Inju- protection of the foot from direct trauma. Michael Reeder, DO, board-certified in emergency ries in mountain biking. Knee Surg Sports Last, unusual foot injuries can occur in medicine, is Director of the Monfort Family Hu- Traumatol Arthrosc. 2001;9(1):48-53. mountain biking: man Performance Lab, Colorado Mesa University, 4. Kronisch RL, Pfeiffer RP, Chow TK. Acute • Lisfranc fracture. A case report described a Grand Junction, Colorado. He is Director of injuries in cross-country and downhill off- fracture dislocation of the tarsometatarsal Medical Education for Cycling CME, a provider of road bicycle racing. Med Sci Sports Exerc. joint in a mountain biker. The mechanism continuing medical education for physicians, PAs, 1996;28(11):1351-1355. of injury was axial loading of the foot while and other health-care providers (see page 62). Dr. 5. Becker J, Runer A, Neunhäuserer D, Frick attempting to prevent a fall at a high rate Reeder holds a Certificate of Added Qualifications N, Resch H, Moroder P. A prospective study of speed.22 Fellowship in Primary Care Sports Medicine of downhill mountain biking injuries. Br J

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40 3.19 lermagazine.com Sports Med. 2013; 47(7):458-462. protection in mountain biking. Wilderness 18. Silberman MR. Bicycling injuries. Curr Sports 6. Nelson NG, McKenzie LB. Mountain bik- Environ Med. 1995;6(4):385-390. Med Rep. 2013;12(5):337-345. ing-related injuries treated in emergency 12. McLean NJ, Kim PW, Brubacher J, Kel- 19. Bini RR, Flores Bini A. Potential factors departments in the Unites States, 1994-2007. ly-Smith C, Simons R. Spine injuries in associated with knee pain in cyclists: a sys- Am J Sports Med. 2011;39(2):404-409. mountain bikers: the Vancouver experience. tematic review. Open Access J Sports Med. 7. Dodwell ER, Kwon BK, Hughes B, et al. Spi- CJEM. 2006;8(3 Suppl). 2018;9:99-106. nal column and spinal cord injuries in moun- 13. Nehoda H, Hochleitner BW. Subcap- 20. Farrell KC, Reisinger KD, Tillman MD. Force tain bikers: a 13-year review. Am J Sports sular liver haematomas caused by bar and repetition in cycling: possible implica- Med. 2010;38(8):1647-1652. ends in mountain-bike crashes. Lancet. tions for iliotibial band friction syndrome. 1998;351(9099):342. 8. Ashwell Z, McKay MP, Brubacher JR, Gareau Knee. 2003;10(1):103-109. A. The epidemiology of mountain bike park 14. Patel ND. Mountain bike injuries and clipless 21. FitzGibbon S, Vicenzino B, Sisto SA. Inter- injuries at the Whistler Bike Park, British pedals: a review of three cases. Br J Sports vention at the foot-shoe-pedal interface in Columbia (BC), Canada. Wilderness Environ Med. 2004;38(3):340-341. competitive cyclists. Int J Sports Phys Ther. Med. 2012;23(2):140-145. 15. Khodaee M, Deu RS, Mathern S, Bravman 2016;11(4):637-650. 9. Kim PT, Jangra D, Ritchie AH, et al. Moun- JT. Morel-Lavallée lesion in sports. Curr tain biking injuries requiring trauma center Sports Med Rep. 2016;15(6):417-422. 22. Callaghan MJ, Jane MJ. Fracture dislocation of the tarsometatarsal (Lisfranc’s) admission: a 10-year regional trauma system 16. Bush K, Meredith S, Demsey D. Acute hand joint by a mountain biker. Phys Ther Sport. experience. J Trauma. 2006;60(2):312-318. and wrist injuries sustained during recre- 10. Gassner RJ, Hackl W, Tuli T, Fink C, Wald- ational mountain biking: a prospective study. 2000;1(1):15-18. hart E. Differential profile of facial injuries Hand (N Y). 2013;8(4):397-400. 23. Paolasso I, Granata G, Erra C, Coraci D, among mountain bikers compared to bicy- 17. Campbell ML, Lebec MT. Etiology and in- Padua L. Bilateral tarsal tunnel syndrome re- clists. J Trauma. 1999;47(1):50-54. tervention for common overuse syndromes lated to intense cycling activity: proposal of a 11. Chow TK, Corbett SW, Farstad DJ. Do con- associated with mountain biking. Ann Sports multimodal diagnostic approach. Neurol Sci. ventional bicycle helmets provide adequate Med Research. 2015;2(3):1022. 2015;36(10):1921-1923.

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FAI/LER Acquire Ad.indd 1 4/12/19 11:32 AM Tape Use to Prevent Blisters: Does It Really Do What We Think It Does?

Taping is a mainstay of preventive foot blister management in athletes and active people. Its use is based on the premise that rubbing causes blisters, and that tape protects the skin from this rubbing and/or provides thermal insulation from the heat generated by rubbing. This commentary highlights research that casts doubt on these assumptions and discusses alternative mechanisms of action for preventive blister taping.

By Rebecca Rushton, Bsc(Pod) foot blisters, there is also little discussion about how taping might accomplish this. Figure 1. The opposing horizontal forces creating soft Taping is one of the favoured modalities for Most dialogue in both medical and main- tissue shear. preventing blisters in athletic and active patients. stream literature seems to assume that tape Runners, hikers, tennis players, golfers, and oth- direction to bone movement (see Figure 1). It prevents blisters by protecting the skin from er athletes frequently use either rigid or flexible acts to keep the skin surface stationary (for rubbing. But is rubbing on the skin required for tape, for either treatment or prophylaxis. Taping longer than the bones). During gait, because blister development? is definitely the favoured preventative option at internal tissue layers are structurally connected, aid stations of running/walking events as well. At What Causes Blisters soft tissues between skin and bone undergo a guess, taping could make up 80%-90% of all shear distortion. During a shear distortion, Blisters form when shear stress exceeds the shear preventative interventions for blisters. these connected tissue layers move parallel to strength of the skin, resulting in a separation one another. If shear occurs to excess, it results within the stratum spinosum of the epidermis. But how does it work? in a “mechanical fatigue” within the layer of This was established 40-60 years ago with the the stratum spinosum of the epidermis.5, 7-9 5 6 Effectiveness of Preventive work of Naylor, Sulzberger et al, Akers and Sul- Presumably this is the layer of cells with the least 7 8 Blister Taping? zberger and Comaish, among others. Consider resistance to shear. These microscopic tears are Both Brennan1 in 2002 and Richie 2 in 2010 this explanation of the mechanics of shear during the initial blister injury. The higher the shear 2 state that the scientific evidence behind the use gait from Richie: magnitude, the fewer repetitions required to of adhesive tape for blister prevention is lacking. “Shear forces are applied to the human cause a blister.5,6,8 “Athletes, athletic trainers and other sports foot during walking and running because of the medicine specialists have anecdotally used these mechanics of foot alignment during contact and Rubbing Not Required products with varying degrees of success.” 1 propulsion. The foot approaches the ground at a In spite of experimental blister studies using Since then, Lipman et al have published tangential angle (not a purely vertical angle) and rubbing to produce blisters,5-8,10 and in spite of two papers on the use of paper tape in ultramar- then pushes off in a similar tangential direction. real-life blister situations often involving rubbing, athon runners. The first in 20143 found it to not The foot [bones] must skid to a stop and then skin surface rubbing is not necessary to produce be protective against blisters, while the second, in push into the ground to propel forward. The skin damage such as blisters.3,11,12 In fact, shear 2016,4 found it was protective against blisters. skidding will occur in both an anterior-posterior distortions peak in a state of static friction – and medial-lateral direction, depending on the the state in which there is no relative motion Mechanism of Action? activity and demands of the sport.” between two surfaces. As soon as the transition While there is little evidence that taping prevents The force of friction acts in the opposite Continued on page 44

lermagazine.com 3.19 43 Continued from page 43 to kinetic friction occurs (relative motion between two surfaces), shear distortions reduce, as seen in Figure 2. Veijgen et al found static friction coefficients to be 18% higher than dynamic friction coefficients.13 This phenomenon can easily be observed when pushing a heavy piece of furniture across the floor – the force required to get the furniture moving is much higher than that required to keep it moving.14 An easy demonstration of shear on the human body: Step 1: The tip of the index finger is pressed against the back of the opposing hand. Step 2: Wobbling the finger back and forth while keeping it in contact with the same patch of skin results in skin stretching. This is shear, and it is the true cause of blisters. Shear might seem to involve rubbing, but it Figure 2. Shear will peak in a state of static friction (no rubbing). A state of kinetic friction (rubbing) brings about reduced shear strain. does not. Notice in the above demonstration that the fingertip has not moved relative to the skin How Might Taping Prevent the faster rubbing speed did not cause blisters to of the back of the hand. But the skin on the back Blisters? form any more quickly than the slower rubbing of the hand has moved relative to the underlying speed. Separately, he compared rubbing with 2 Personal experience and research3 shows a bone – it has undergone shear distortion. Blister materials that differed in thermoconductivity. No blister can occur underneath the tape applied to causation is a “duck under water” scenario – be- difference in blistering rate was found. prevent it. But divergent personal experience and low the surface is where the action is occurring! Hashmi et al produced experimental blisters research4 also shows taping can prevent blisters. Blister causation is about stretching (shear), not at the posterior heel of 30 subjects with an inter- This is why many practitioners use taping on rubbing. mittent rubbing force.10 The median temperature patients. Thankfully, the tissues of the feet can tol- increase at the blister site at the time of blister With an understanding of what causes erate a high amount of shear. While blisters will formation was 5.1°C (range: 1.7 – 9.9°C) and did blisters, the following are four potential hypothe- only form when shear is excessive and repetitive, not exceed 35°C. ses for how preventive taping works: the blister-causing threshold will vary between Li et al demonstrated that rubbing causes individuals. This was evident in research by: 1. Thermal insulation a moderate increase in skin temperature, and • Naylor in 1955 on 19 volunteer British Rubbing any two surfaces together causes the that this warmer area of skin increases sweat 5 production of heat, and it is no different for the medical students and doctors. He showed production, which increases skin friction.17 This skin.15-17 Assuming heat is a causative factor in blistering occurred between 27 and 138 perspiration/friction mechanism repetitions. The middle of the shin was used blister formation, perhaps tape applied to the [rubbing heat → more perspiration → higher in this experiment. skin provides thermal insulation to lessen the effect of frictional heat. Although plausible, friction level → blister] • Sulzberger et al in 1966 conducted on 54 research to date does not support the theory that American army personnel.6 Some soldiers differs from the burn mechanism local surface heat generated by rubbing is a sig- blistered in 3 minutes and others still had nificant factor in blister formation, as explained [rubbing → heat → burn → blister] not blistered even after 50 minutes. The below. frictional force repetitions were applied to and this distinction should be recognized. If heat transfer from the surface of the stra- the palmar skin. Besides, remembering that the initial blister tum corneum to the stratum spinosum (see Fig- injury is within the stratum spinosum of the • Hashmi et al in 2013 on 30 volunteers at ure 3) were a major factor in blister development, epidermis, if heat transfer from the skin surface the University of Salford.10 They found that one would expect faster rubbing to increase to the stratum spinosum were a major factor blister onset ranged from between 4 and blister occurrence. Naylor found this not to be in blister development, one would expect the 32 minutes. The frictional force repetitions the case.5 In his experimental blister research, he were applied to the back of the heel. compared blister rates at two rubbing speeds – Continued on page 47

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thicker stratum corneum of the plantar surface to Epidermis Stratum Corneum afford a level of blister protection. The reality is, a thick corneum is one of the requisites for blister Stratum Granulosum formation.5-7 Dermis Stratum Spinosum Heat is not a requirement for blister for- Stratum Basale EXPLORE mation. Although friction blisters on the feet are Hypodermis Dermis more common in warmer temperatures, blisters can occur in cold temperatures too.18,19 Griffin et al18 produced experimental blisters on chilled, Figure 3. Layers of the epidermis. Medical illustration by Chyna LaPorte for LER. warmed, and “normal” temperature skin and 2. Protection from rubbing This is partly by design as materials are chosen noted: By the admission of sports medicine practitioners to provide traction for the foot,2,11 and partly MORE • blisters formed more quickly when initial and athletes alike, the most common due to the high density of sweat glands and skin temperature was higher understanding of how taping prevents blisters enclosed environment, because there is minimal • blisters took longer to form on chilled skin is “by protecting the skin from rubbing.” But evaporation of moisture when shod.21 (14°C) compared to normal (30°C ) and as explained earlier, rubbing on the skin is not It is plausible that tape reduces shear by warmed skin (46°C ) necessary to cause a blister, and blisters can lowering friction levels. By replacing the higher occur under tape.3 friction skin-sock interface with a lower friction • when the initial skin temperature was What does rubbing do? It removes cells tape-sock interface, earlier rubbing movement low, the skin temperature at the time of from the skin surface, exposing progressively occurs between the two surfaces. This earlier blistering was also lower. deeper and deeper layers. This is not a blister. state of dynamic friction means shear peak will Overall, Knape’s review summarizes This is an abrasion. be lower, potentially providing blister prevention. it nicely: “Skin temperature appears to be So tape does not prevent blisters by Zhang and Mak articulate this idea well, a minor factor in blister formation. Blisters stopping rubbing. Taping protects the skin from stating: “The injurious effects of friction on the form somewhat more rapidly when the abrasion. But this is abrasion prevention, not skin and the underlying tissues can be divided skin temperature is higher but blisters also blister prevention. into two classes, those without slip and those occur when the skin temperature is low. In Consider another blister prevention with slip. The former may rupture the epidermis experimental rubbing studies, local heat is strategy: that of lubricants. Lubricants facilitate and occlude blood and interstitial fluid-flows by produced and skin temperatures have been rubbing of the sock against the skin to prevent stretching or compressing the skin. The latter Soft and flexible, yet tough on impact, reported between 41 degrees Celsius and 50 blisters by way of reducing friction levels (more adds an abrasion to this damage.”22 the super shock-absorbing midlayer degrees Celsius. However, friction blisters do not below). Understanding this, Polliack and Scheinberg XRD® Technology is lightweight, thin, resemble second-degree thermal burns either 3. Reducing friction levels gathered a number of blister dressings and tested and engineered for repeated impact. clinically or histologically.”20 In-shoe conditions result in high-friction levels. their friction properties, observing coefficients of

Table 1. Laboratory product comparisons using a custom-made friction-measurement apparatus 23

Product Manufacturer Average CoF† Difference, %‡ Thickness, mm No. of tests Bursatek bandage Advanced Wound Systems, Newport, OR 0.57 – 6 3 Dr Scholl’s Moleskin Plus Schering-Plough Corp, Kenilworth, NJ 0.69 +21 31 3 Moleskin PPR Inc, Brooklyn, NY 0.94 +64 26 3 Breathable top cover helps Band-Aid Johnson & Johnson, New Brunswick, NJ 1.01 +77 22 3 Band-Aid Plastic Johnson & Johnson 1.03 +80 18 3 eliminate odor and is anti-microbial 2nd Skin Blister Pads Spenco Medical Corp, Waco, TX 1.04 +82 35 3 New-Skin Medtech, Jackson, WY 1.05 +84 9 4 Nexcare Comfort 3M Health Care, St Paul, MN 1.08 +89 35 3 Dr Scholl’s Blister Treatment Schering-Plough Corp 1.20 +110 32 3 Blister Block (Compeed) Johnson & Johnson 1.37 +139 40 3 Call us for more information Tegaderm 3M Health Care 1.54 +169 1.5 3 †CoF indicates coefficient of friction. 237-g normal applied load to end probe. ‡Compared with the Bursatek device. Footmaxx.com F | L Copyright ©2016 Wilderness Medical Society. Published by Elsevier Inc. Used with permission. 1.800.779.3668 Continued on page 48 lermagazine.com 3.19 47

FAI/LER Ad.indd 1 4/4/19 1:39 PM Continued from page 47 friction ranging from 0.57 to 1.54 (see Table).23 Other in-shoe coefficient of friction data can be found in Carlson,14 including insights into the effect of moisture. Unfortunately, few of the adhesive tapes used for the prevention of blisters have had their friction properties tested in any research – only Moleskin from these charts. What’s more surprising is that we could find no coefficient of friction data available from the manufacturers for these tapes! Perhaps this is because most tapes used in blister prevention are not specifically made for blister prevention. This represents an area for improving our understanding of this modality’s mechanism of action.

4. Spreading shear load Cushioning spreads vertical load over a larger area to reduce peak pressure. Does tape spread the tangential shear load over a larger area of skin to reduce peak shear in a similar way?24 Could it be that without adhesive tape applied, shear peaks at a certain discrete location? And could it be that with adhesive tape applied to a wider area of skin, shear is dispersed over that wider area, reducing the peak? In other words, by spreading the shear load, shear per unit area of skin may be lessened. If this is the case, a stiffer tape would exert this effect better than a compliant tape. Conclusion For a modality that is arguably the most common blister prevention strategy used, it is odd that we know so little about how it works. Once a mechanism is established, more could be understood about which tapes are best in certain conditions and for certain anatomical regions. Specifics about application technique could also be identified. The mechanism of preventing blisters is an area that deserves much more research.

Rebecca Rushton, BSc(Pod), is a podiatrist in private practice at Esperance Podiatry in Perth, Australia. She is the owner of the foot blister website blisterprevention.com.au and BlisterPod, which sells blister products.

References 1. Brennan FH. Managing blisters in competitive athletes. Curr Sports Med Rep. 2002;1(6):319-322. 2. Richie D. How to manage friction blisters. Podiatry Today. 2010;23(6):42-48. 3. Lipman G, Ellis M, Lewis E, et al. A Prospective Randomized Blister Prevention Trial Assessing Paper Tape in Endurance Distances (Pre- TAPED). Wilderness Environ Med. 2014;25(4):457-61. 4. Lipman GS, Sharp LJ, Christensen M, et al. Paper Tape Prevents Foot Blisters: A Randomized Prevention Trial Assessing Paper Tape in Endurance Distances II (Pre-TAPED II). Clin J Sport Med. 2016 Sep;26(5):362-8. 5. Naylor P. Experimental friction blisters. British J Dermatol. 1955;67:327–342. 6. Sulzberger M, Cortese T, Fishman L, Wiley H. Studies on blisters

48 3.19 lermagazine.com produced by friction: I. Results of linear rubbing and twisting technics. J Invest Dermatol. 1966;47(5):456-465. 7. Akers W, Sulzberger M. The Friction Blister. Mil Med. 1972;137:1-7. 8. Comaish JS. Epidermal Fatigue as a Cause of Friction Blisters. Lancet. 1973;Jan:81-83. 9. Cortese T, Griffin T, Layton L, Hutsell T; Experimental friction blisters in macaque monkeys. J Invest Dermatol. 1969;53(2):172-177. 10. Hashmi F, Richards B, Forghany S, Hatton A, Nester C. The formation of friction blisters on the foot: the development of a laboratory-based blister creation model. Skin Res Technol. 2013;19(1)479-489. 11. Carlson J. Functional limitations from pain caused by repetitive loading on the skin: A review and discussion for practitioners, with new data for limiting friction loads. J Prosthet Orthot. 2006;18(4):93-103. 12. Carlson J. The mechanics of soft tissue damage: removing the “teeth” from the “rub”. The Academy TODAY. 2011;7.1 (Feb):A5-7. 13. Veijgen N, Van der Heide E, Masen M. A multivariable model for pre- dicting the frictional behaviour and hydration of the human skin. Skin Res Technol. 2013;19(3):330-338. 14. Carlson J. The friction factor. OrthoKinetic Review 2001;1.7(Nov- Dec):1-3. 15. Akers WA. Sulzberger on friction blistering. Internat J Dermatol. 1977;16:369-72. 16. El-Shimi AF. In vivo skin friction measurements. J Soc Cosmetic Chemists 1977;28(Feb):37-51. 17. Li W, Pang Q, Jiang Y, Zhai Z, Zhou Z. Study of physiological parameters and comfort sensations during friction contacts of the human skin. Tribological Letters. 2012;8:1-12. 18. Griffin C, Cortese T, Layton L, Sulzberger M. Inverse time and temperature relationship in experimental friction blisters. J Invest Derma- tol. 1969;52:384-401. 19. Knapik J, Reynolds K, Staab J, Vogel JA, Jones B: Injuries associated with strenuous road marching. Mil Med. 1992;157:64–67. 20. Knapik J, Reynolds K, Duplantis K, Jones B. Friction blisters – patho- physiology, prevention and treatment. Sports Med. 1995;20(3):136-147. 21. Deng F, Gong T, Jin H, Du S. Research on factors influencing temperature and relative humidity inside of shoes. College of Resources and Environments, Shanxi University of Science and Technology. 2009. Available at https://www.aaqtic.org.ar/congresos/china2009/download/2-6/2-218.pdf. Accessed March 10, 2019. 22. Zhang M, Mak A. In vivo friction properties of human skin. Prosthet Orthot Internat. 1999;23:135-141. 23. Polliack A, Scheinberg S. A New Technology of Reducing Shear and Friction Forces on the Skin: Implications for Blister Care in the Wilder- ness Setting. Wilderness Environ Med. 2006;17:109-119. 24. Carlson J, personal communication, 2013.

lermagazine.com 3.19 49

The Therapeutic Power of Elastic Bands

Here’s why resistance therapy with these low- tech tools is gaining prominence—for youth soccer players, geriatric patients, and everyone in between.

By Keith Loria

Elastic resistance bands are increasingly popular in physical therapy as the modality is being used to treat a wide number of lower-extremity problems on a diverse patient population that covers everyone from youth sports players to seniors. Experts point to 3 important features iStockPhoto.com # 482982350 that have contributed to the rise of elastic bands (here, called simply “bands”) in therapy: They are inexpensive; don’t take up much storage elastic bands seem to be more advantageous the upper parts of the movement, when patients space; and are easy to transport. in the upper parts of the ascending movement. have no problem performing the squat or other Furthermore, because of the properties of This could be useful in both therapy and exer- exercises. 3 bands and because they can be used alone or in cise for those wanting to emphasize these parts Andersen led a 2018 study that examined combination with free weights, a range of people of the movement.” the effects of full-body elastic resistance band (from the patient to the athlete) can use them. For example, some patients might have training in young female team handball players. Keep in mind, however, that it is important to a problem performing the squat, or similar In the study, 12 players completed an 11-week have a high percentage of total load come from exercises, with free weights, due to high torque control period, followed by 9 weeks of elastic the bands; otherwise, the benefit of using the at the beginning of the upward movement. resistance band training, during which they per- bands will vanish and the effect will instead be Elastic bands can, in these cases, be a valuable formed 6 exercises as part of the team’s standard similar to using free weights alone. alternative because they reduce torque in the training sessions. early upward phase but still stress muscles in All exercises were done with 3 sets of 6 to A Tool for Loading During 10 explosive repetitions. Maximal power output Exercise… was tested in squat and bench press, jump Vidar Andersen, associate professor of educa- “In general, our height, throwing velocity and repeated agility tion, arts and sports at the Western Norway run, before and after control and training peri- University of Applied Sciences, has performed findings show that ods. The researchers found that a brief, explo- several studies1,2 examining the effects of elastic sive, full-body elastic resistance band program, bands on muscle activation, maximal strength, elastic bands yield incorporated into regular handball training and explosive parameters. sessions for 9 weeks, improved explosive low- “In general, our findings show that elastic similar effects as er-limb performance in young female handball bands yield similar effects as more conventional more conventional players more than handball training alone. free weights,” Andersen told LER. “However, “I think the elastic bands could be strong when analyzing different parts of the movement, free weights…” for many injuries and rehab situations,” Ander- Continued on page 52

lermagazine.com 3.19 51 Continued from page 51 sen said. “The elastic bands don’t create a great torque when going from a descending to an ascending movement, but more gently increase the torque as the bands are stretched. Further, we have performed several interventions with the elderly performing explosive training and our experience is that in these situations, the elastic bands are very useful.” …and for Unloading Another important aspect of the utility of bands is that they can be used to unload. For example, if a patient isn’t able to perform a chair rise or squat because of pain or lack of muscle strength, bands can be used to reduce some of the body weight, thus assisting the person in performing iStockPhoto.com # 621232042 the exercise. “The research on this topic has increased in the recent years and I believe the interest exercises for various hip muscles, in an isomet- joints, [the band] won’t respect the biomechan- among experts has increased simultaneously,” ric or dynamic manner (if the syndrome allows ical characteristic of a muscle group. For exam- Andersen said. “For me, elastic bands have them to exercise dynamically). This approach ple, during a knee extension, the internal torque become more prevalent and will be in the years has the potential to prevent or delay the need produced by the knee extensors increases from to come. for surgery and can be used to rehabilitate the 90° of knee flexion to full extension, whereas “However, I don’t think we should regard hips postoperatively. the band provides progressive resistance. So, elastic bands as a replacement for free weights, “These bands help, because it is a kind of the use of the band in this movement is not but more as an alternative or variation in situ- resistance that can be used to train, as any kind impeditive, but this issue must be taken into ations where the properties of the elastic bands of resistance,” Cadore said. “Of course, [a band consideration.” could be useful.” has] some upper threshold of resistance, and one wouldn’t use it for training a competitive Bands Have Utility in Older A Means to Boost Functional weightlifter. Nevertheless, for people searching Patients Performance for health and neuromuscular function improve- Maurício Krause, PhD, professor in the Eduardo Lusa Cadore, PhD, professor at the ments, it can be used.” department of physiology at the Institute of physical education school of the Federal Univer- Cadore foresees bands becoming even Basic Health Sciences, Federal University of sity of Rio Grande do Sul, Porto Alegre, Brazil, more prevalent because the number of studies Rio Grande do Sul, recently led a study on led a study4 that provided evidence that resis- using resistance training with elastic bands in uncomplicated band exercise training for elderly 5,6 tance training using elastic bands is an easy, exercise-intervention models is growing. In people.7 effective tool for inducing marked functional addition, the number of studies validating and “The age-related loss of muscle mass and performance in older people. quantifying loads—in each elastic band color function arise from an imbalance between pro- “Specifically, we observed marked improve- (ie, each color denoting a progressive increase in tein synthesis and protein degradation, resulting ments in tests that included the ability of sit-to- resistance), with different initial lengths, and in in muscle atrophy and consequent increases in stand, walking, dynamic balance, upper-body various lengths of elastic deformation—is also morbidity and mortality, and can be accelerated muscular endurance and flexibility,” Cadore increasing. He noted that this is an important by a combination of factors, which include a explained to LER. “This is an important finding matter because, to prescribe resistance training reduced physical activity level and a suboptimal since elastic bands are easy to carry and may be using elastic bands, exercise professionals need nutritional profile,” Krause said. “Concerns with used in any space, including at home.” to know how to quantify the intensity of the the impact on the healthcare system due to Cadore described how bands can be used tool. increased economic and social costs associated to treat femoroacetabular impingement (hip “Another important aspect of these bands with possible loss of independence with aging impingement syndrome). For example, patients is that the workload is always progressive when have brought attention to alternative exercise can hold the bands at the ankles and perform bands are deformed,” Cadore said. “In some Continued on page 55

52 3.19 lermagazine.com

Continued from page 52 years) adults. pull-down, bicep curls, calf raises, pushups, tri- interventions as an effective way of delaying “Our group demonstrated that 12-weeks of ceps dips, and lumbopelvic stabilization exercises. the negative effects of aging on functional and traditional [resistance exercise], using profes- “Among the findings were that body weight/ metabolic parameters.”7,8 sional gym equipment, in diabetic elderly people elastic bands-based resistance exercise training In this way, physical activity—in particular, is an effective tool to improve muscle function, increases muscle mass and function in healthy resistance exercise—is an established counter- metabolism, and immune system functional- elderly people, independently of protein sup- measure to attenuate the decline in lean body ity,” Krause said. “However, the use of specific plementation,” Krause said. “This indicates that mass that occurs with aging. In fact, Krause exercise equipment is not always available. exercise training, using body weight and elastic So, we tested a nontraditional, body weight- said, resistance exercise training can induce bands, is an efficient way to maintain and even based, elastic-band resistance training to test if several benefits in older people, including: increase muscle mass in elderly people, especially this type of exercise would also be effective to • increased muscle strength and power at the lower limbs.” improve muscle metabolism, body composition, Participants in the exercise training also • improved insulin sensitivity and muscle function in healthy elderly people.” saw their muscle function-testing scores improve. • enhanced mitochondrial function To test that hypothesis, the researchers When protein supplementation was added to designed a 12-week training protocol using • reduced inflammation their diet, additional gains were detected, includ- only body weight and elastic bands as sources • muscle-mass growth. ing lower fat mass and changes in skeletal-muscle of resistance. The training was conducted in a 7 signaling (eg, protein synthesis pathways and the Krause and colleagues’ study sought to gymnasium on 3 nonconsecutive days a week heat-shock response). determine the effects of 12 weeks of resistance by qualified sport and exercise scientists; each exercise training, plus protein supplementation session lasted 45 to 60 minutes and consisted State of the Art: on body composition, markers of muscle atro- of a warm-up period, body weight- and elastic Uncomplicated, Under phy and hypertrophy, and heat-shock response band-based resistance exercise training, and (a molecular pathway involved in cellular pro- a cool-down period. Primary exercises used Supervision tection, having an important anti-inflammatory throughout the program included squats, lunges, Krause summed it up: “The use of elastic role) in 38 healthy, older (mean age, 63.5 ± 4.4 hip abduction, shoulder press, latissimus dorsi bands and body weight as resistance exercise is

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54 3.19 lermagazine.com receiving more attention from exercise experts using elastic bands in young female team al. Heat-induced extracellular HSP72 release because [bands offer] an uncomplicated way handball players. Sports Med Int Open. is blunted in elderly diabetic people compared to exercise at any place—home, work, outside, 2018;2(6):E171-E178. with healthy middle-aged and older adults, but etc. However, it is important that people receive 4. Cadore EL, Pinto RS, Bottaro M, et al. it is partially restored by resistance training. an appropriate orientation and supervision on Strength and endurance training prescrip- Exp Gerontol. 2018;111:180-187. how to use [bands] correctly, how to choose the tion in healthy and frail elderly. Aging Dis. individual load, and how they should progress 2014;5(3):183-195. LATEST RESEARCH… with the training.” 5. Iversen VM, Mork PJ, Vasseljen O, et al. Mul- Resistance Exercise to Forestall Keith Loria is a Washington, DC-based freelance tiple-joint exercises using elastic resistance Cognitive Decline? bands vs. conventional resistance-training writer. “As a preventative tool [for Alzheimer’s equipment: A cross-over study. Eur J Sport Sci. disease], resistance exercise improves References 2017;17(8):973-982. memory, attention, spatial awareness, reaction 1. Andersen V, Fimland MS, Kolnes MK, et al. 6. Kubo T, Hirayama K, Nakamura N, et al. time, planning, and information processing. Elastic bands in combination with free weights Effect of accommodating elastic bands on Improvements in cognitive performance in strength training: neuromuscular effects. J mechanical power output during back squats. following resistance exercise and training Strength Cond Res. 2015;29(10):2932-2940. Sports (Basel). 2018;6(4):pii:E151. may be mediated by peripheral elevations in … physiological biomarkers (ie, neural and 2. Saeterbakken AH, Andersen V, Kolnes MK, 7. Krause M, Crognale D, Cogan K, et al. The vascular).” et al. Effects of replacing free weights with effects of a combined bodyweight-based and elastic band resistance in squats on trunk elastic bands resistance training, with or with- Source: Marston KJ, Brown BM, Rainey-Smith SR, Peiffer JJ. Resistance exercise-induced muscle activation. J Strength Cond Res. out protein supplementation, on muscle mass, responses in physiological factors linked 2014;28(11):3056-3062. signaling and heat shock response in healthy with cognitive health. J Alzheimers Dis. 3. Andersen V, Fimland MS, Cumming older people. Exp Gerontol. 2019;115:104-113. 2019:68(1):39-64. KT, et al. Explosive resistance training 8. de Lemos Muller CH, Rech A, Botton CE, et

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LER04-17_LER 4/18/17 5:53 PM Page 1 lermagazine.com LER02-16_LER 2/9/16 4:20 PM Page 1 resourceLER07-17V64_LER 7/21/17 11:12 AM Page 1 LER06-17_LER 6/19/17 3:33 PM Page 1 LER10-16_LER 10/13/16 5:35 PM Page 1 guide 2017

TECHNOLOGY ANKLE PROSTHETICS FOOT

KNEE

FABRICATION PEDIATRIC REHABILITATION

Positive Outcomes for Successful Practitioners

lermagazine.com 3.19 57 INDUSTRY SNAPSH T Noteworthy products, association news, and market updates

THE X BRACE ADDED TO application programming interface, created by the US Digital Service, that enables beneficia- MEDI-DYNE PAIN RELIEF ries with different needs to grant access to de- SOLUTIONS velopers who can help them monitor for drug conflicts, refill prescriptions, and track progress toward desired healthcare outcomes. CMS launched the eMedicare initiative in 2018 to empower beneficiaries with cost and quality information. Other tools in the eMedi- care suite include:

Photograph of 3D-printed feet, some enhanced with foot • Enhanced interactive online decision ulcers, courtesy of UniSa. support to help beneficiaries better understand and evaluate their Medicare Medi-Dyne Healthcare Products has acquired are made from thermoplastic polyurethane, coverage options and costs between The X Brace. Developed by Joshua P. Eldridge, will play a part in teaching fourth-year podiatry Medicare and Medicare Advantage. DC, DACBSP, for relief of heel pain due to students how to treat and manage high-risk plantar fasciitis and Sever’s disease, The X foot conditions. • A new online service that lets people see Brace is an easy-to-use foot and heel support “The most effective way to manage these how different coverage choices will affect product. It provides a comfortable, low-profile, conditions is to medically remove dead or their estimated out-of-pocket costs. damaged skin to expose the healthy skin un- pain-relieving solution for previously hard-to- • New price transparency tools that let derneath and encourage healing,” said Banwell. treat circumstances, such as when wearing flip consumers compare the national average “The 3D foot models—and the mock injuries flops or sandals, or when walking barefoot. Ac- costs of certain procedures between with which we enhance them—enable us to cording to Medi-Dyne, The X Brace has been settings, so people can see what they’ll used effectively by athletes and other sufferers provide a realistic but safe learning tool for stu- pay for procedures done in a hospital worldwide. Medi-Dyne products, including The dents to practice their scalpel skills, before they outpatient department versus an X Brace, are made in the US. begin clinical placements, and all without the stress or anxiety of treating a real patient.” ambulatory surgical center. Medi-Dyne Healthcare Products To support the training, ulcer debridement • A new webchat option in the Medicare 800/810-1740 and management videos are being developed. Plan Finder. medi-dyne.com UniSA is also trialing 3D-printed baby The What’s Covered app is available for legs in podiatry pediatric teaching sessions to free in Google Play (play.google.com/store/ allow students hands-on practice for clubfoot apps/details?id=gov.medicare.coverage) and casting. UNISA CREATES RECIPE the Apple App Store (itunes.apple.com/us/ FOR REALISTIC FOOT app/whats-covered/id1444143600?mt=8). ULCERS CMS LAUNCHES Podiatrists at the University of South Australia “WHAT’S COVERED” (UniSA), Adelaide, have blended icing sugar, WOUND HEALING chicken stock, and flexible resin to create real- APP TO GUIDE CLINICAL & istic-looking foot ulcers as part of a world-first BENEFICIARIES TRANSLATIONAL podiatric training initiative. Helen Banwell, The Centers for Medicare & Medicaid Ser- RESEARCH TEAM DPM, and Ryan Causby, DPM, concocted the vices (CMS) launched a new app that gives RECEIVES GRANT TO mixture, which is being added to 3D-printed consumers direct access on a mobile device to feet and is designed to mimic infected and some of the most-used content on Medicare. JOIN DIABETIC FOOT non-infected diabetic foot wounds. gov. The new “What’s Covered” app lets people CONSORTIUM The addition of lifelike ulcers and effects with Original Medicare, caregivers, and others The clinical and translational research team at is added by UniSA’s podiatry team and can en- quickly see whether Medicare covers a specific the University of Miami (UM) Miller School compass anything from dry gangrene to oozing medical item or service. The app also provides of Medicine’s Department of Dermatology and pus. Banwell said the 3D foot models, which beneficiaries with access to Blue Button 2.0, an Cutaneous Surgery received a 4-year, $1.7

58 3.19 lermagazine.com INDUSTRY SNAPSHOT million grant to become 1 of 6 Clinical Re- pink, blue, and black to match any taste. Shoe old Swiss company, manufactures medical search Units (CRU) in the US to help improve sizes include Toddler (4–9), Youth (10–13, compression socks and hosiery with a wide outcomes for patients with diabetic foot ulcers. 1–3), and Adolescent (4–7). assortment of inelastic wraps and lymphedema This team approach to research is part of the garments. SIGVARIS GROUP will use this Cascade Orthopedic Supply National Institute of Diabetes and Digestive opportunity to build a customer-centric plat- 800/888-0865 and Kidney Diseases’ Diabetic Foot Consor- form for innovation and growth, according to cascade-usa.com tium (DFC) for future clinical study of selected a company press release. In the new brand ar- biomarkers. chitecture, products will have their own unique The objective of the DFC is to establish an brands to bring more clarity and understanding organizational framework and infrastructure ICEBREAKER HIKE LIGHT to product positioning and to differentiate the that will serve as a platform for integrated CREW organization from product brands. multidisciplinary experimental clinical and translational research. The UM-CRU will, in conjunction with DFC, develop the research ORTHOTIC STRAP KITS design and study protocol, and establish proto- cols for participant recruitment and follow-up, data collection, quality control, interim data and safety monitoring, final data analysis and interpretation, and publication of results. In addition, UM-CRU and DFC will facilitate procurement, storage, and shipment of the bio- materials (tissue samples, swabs, wound fluid, blood, serum, and/or urine) as a part of the future biomarker studies. It will also establish and maintain a clinical database that will allow overall data analyses of the DFC. Suitable for adventure and hiking, Icebreaker’s men’s Hike Light Crew sock is designed to be an ideal sock for year-round comfort on the PIEDRO PEDIATRIC trail. The sock has double up cushioning for ORTHOPEDIC FOOTWEAR comfort. It is made from breathable, temperature-regulating merino wool (60%); nylon (37%) for durability; and Lycra (3%). Addi- tional design features include Achilles support, reinforced heel and toe, instep support, and a comfort cuff. The overall goal of the adventure sock is to keep the wearer’s feet happy to ensure great journeys. The socks come in a twisted-heather color and are available in JMS Plastics Supply has introduced orthotic small, medium, large, and extra-large sizes. straps as a new market offering. The exclusive The company offers a lifetime guarantee on all straps are made from reinforced PVC that is of its socks. welded together with high frequency to make Cascade Orthopedic Supply has expanded its Icebreaker them strong and durable. The straps feature product line with the addition of Piedro Pediat- 877/827-6816 hook-and-loop closures and are available in ric Orthopedic Footwear. The new line of foot- icebreaker.com kits or sold individually. Each kit contains one wear features a wider and deeper toe box to PVC Chafe, one strap, and one pad. Kits are ensure a precision fit with orthotic devices. The offered in nine colors and four widths. JMS double stitching and high abrasion-resistant toe SIGVARIS IS NOW Plastics’ orthotic straps can also be ordered to cap provide increased durability for children. feature any company logo. Piedro Pediatric Orthopedic Footwear features SIGVARIS GROUP an adjustable depth and a trimmable sole, and SIGVARIS, Peachtree, Georgia, has changed JMS Plastics Supply is available with either lace or Velcro closures. its corporate name and logo from SIGVARIS 800/342-2602 Color options for the new shoe line include to SIGVARIS GROUP. SIGVARIS, a 155-year- jmsplastics.com

lermagazine.com 3.19 59 INDUSTRY SNAPSHOT REVISTIM WEARABLE DC self-adjustment for appropriate use and do not $11 MILLION NIH GRANT STIMULATOR require expertise in trimming, bending, mold- CREATES NEW CENTER ing, assembling, or customizing to fit to the individual.” FOR MUSCULOSKELETAL To access the DMEPOS Competitive RESEARCH Bidding Round 2021 Fact Sheet, visit gov/ Clemson University, South Carolina, received newsroom/fact-sheets/dmepos-competitive-bid- an $11 million grant from the National In- ding-round-2021. stitutes of Health’s Center for Biomedical Research Excellence to launch a new research center that will bring together scientists from INSIGHTFUL PRODUCTS’ across the state to change the way musculo- MASTED KNEE BRACE skeletal disorders are diagnosed, treated, and studied. Led by bioengineers at Clemson, the South Carolina Center for Translational Research Improving Musculoskeletal Health Prizm Medical has introduced the ReviStim combines orthopedics and other clinical exper- DC Stimulator, which is described as the tise from the Greenville Health System and world’s first wearable DC stimulation device. the Medical University of South Carolina with The unit’s copyrighted software delivers DC computer scientists, computational engineers, electrotherapeutic energy uniformly over the biophysicists, and other experts to better entire treatment area through hydrogel stick-on understand musculoskeletal disorders and to electrodes or Prizm’s proprietary Sigma gar- design and evaluate new devices, interventions, ment electrodes. Sigma garments are soft and and drug therapies. comfortable, and they are available in the form of socks, sleeves, and gloves. The ease of use of the products, coupled with the compact size of the ReviStim, allows for nighttime delivery RENOWNED of electrotherapeutic treatment, thereby in- ORTHOPEDIC SURGEON creasing the number of treatments per day and TO LEAD FOOT AND allowing for improved patient compliance. ANKLE DIVISION AT NYU

Prizm Medical The Masted Knee Brace (MKB) is the newest LANGONE HEALTH 770/622-0933 design offered by Insightful Products. The John G. Kennedy, MD, woundstim.com MKB was developed primarily to address the renowned for his work common problem of distal migration. This in the surgical treat- knee orthosis is said to ensure good knee and ment of foot and ankle CMS INCLUDES 7 OTS brace-joint alignment. It has adjustable flexion injuries, has been ap- KNEE ORTHOSES IN and extension stops at 15-degree increments pointed the new chief 2021 COMPETITIVE and the foot section offers full range of motion of the Foot and Ankle for the foot/ankle complex. The posterior calf Division in the De- BIDDING PROGRAM and thigh sections allow for easy donning. This partment of Orthopedic Surgery, and Director The Centers for Medicare & Medicaid Ser- orthotic solution is indicated for conical limb of the Foot and Ankle Center at NYU Langone vices (CMS) announced that the Durable shapes where suspension is a challenge. Ac- Health. He joined NYU Langone in January, Medical Equipment, Prosthetics, Orthotics, cording to Insightful Products, the MKB is ap- where he holds the title of professor of ortho- and Supplies (DMEPOS) Competitive Bid- propriate for rehabilitation, post-op, ACL, or to pedic surgery at NYU School of Medicine. ding Program for dates of service beginning control recurvatum. It can be configured with Kennedy brings to NYU Langone a spe- January 1, 2021, will include 7 off-the-shelf an integrated Step-Smart Brace for those with cial interest in articular cartilage injury and (OTS) knee orthoses. The affected codes are foot drop. Videos on the company’s website of- joint preservation. He has been a leader in L1812, L1830, L1833, L1836, L1850, L1851, fer more information. HCPCS code L1832. minimally invasive, arthroscopic treatments of and L1852. According to CMS, the law requires cartilage injuries of the ankle and smaller joints that OTS orthotics or braces are included in Insightful Products of the foot. An award-winning researcher, Ken- the DMEPOS competitive bidding program, 207/885-0414 nedy and his team collaborate on National In- specifically, “orthotics which require minimal insightfulproducts.com stitutes of Health (NIH) research into cartilage

60 3.19 lermagazine.com INDUSTRY SNAPSHOT regeneration and work with several interna- tumbled leather soft uppers, and buttery-soft APTA, ACSM FORMALIZE tional universities, investigating basic science glove leather sock linings for comfort and NEW PARTNERSHIP and clinical outcomes in cartilage regenera- breathability. The boot features an easy-glide, tions, tendon healing, and bone growth. These extra-light EVA custom-designed outsole, and The American Physical Therapy Association collaborations have resulted in more than 200 incorporates removable Poron insoles and heel (APTA) has partnered with the American publications in medical journals and more than support. The boots are available in size 5½ College of Sports Medicine (ACSM), under the 500 podium presentations worldwide. to 11, including half sizes and medium width. APTA Partnerships program, which seeks to enhance relationships and develop mutually Kennedy is an alumnus of the Royal Col- Samuel Hubbard’s footwear is handcrafted in beneficial partnerships with other organiza- lege of Surgeons in Dublin, Ireland. In 2002, Portugal. he started the first subspecialty foot and ankle tions that share common goals. The program sports injury clinic in New York City. Most Samuel Hubbard allows APTA to extend its reach in advancing recently, Kennedy spent the past 17 years as 844/482-4800 the physical therapy profession. an assistant professor of orthopedic surgery at samuelhubbard.com In signing this memorandum of Weill Cornell Medical School, and as an assis- understanding, APTA and ACSM seek to tant attending physician at Hospital for Special build on existing collaboration to advance Surgery, both of which are located in New York CORE-SPUN PATTERNED their missions and the health of communities City. In addition, Kennedy serves as co-presi- AFO SOCKS BY and individuals through movement, physical dent of the International Society on Cartilage activity, and exercise. APTA and ACSM also Repair of the Ankle, which last year established SMARTKNIT hope to work jointly on advocacy efforts as the International Consensus Meeting on Car- well as to incorporate elements and expand tilage Repair of the Ankle to standardize ankle participation of both groups in each other’s cartilage treatment algorithms. events and initiatives.

SAMUEL HUBBARD SPS PROMOTES WEGER WOMEN’S CITY ZIPPER TO VP AND GENERAL BOOT MANAGER Hanger, Inc., Austin, Texas, announced that Regina Weger has been promoted to VP Knit-Rite has long been a manufacturer of and general manager SmartKnit Seamless Socks made for adults of its subsidiary SPS, and children who use AFOs. SmartKnit Seam- Alpharetta, Georgia. less Socks are soft and comfortable, giving the Weger has been with feeling of a cool second layer of skin between SPS for over 20 years, having started her ca- the wearer and the AFO. Knit-Rite now offers reer within the customer service function and Core-Spun Patterned AFO Socks by Smart- taking on additional roles and responsibilities Knit. The children’s AFO Socks are available throughout the years. For the past 2 years she in 2 patterns: thin line (white with grey and served as VP of SPS sales and marketing. We- purple striping), cheery (black sock with bright ger will continue reporting to Jay Wendt, pres- blue, doughnut-shaped spots), and halo (3- ident of Hanger’s Product & Services business pack of socks with the same pattern but in 3 segment, in her new role as a member of the different color combinations—white with soft Products & Services leadership team. yellow striping, grey with hunter green striping, “This is a well-deserved promotion for Slide in. Zip up. Step out. The City Zipper and black with bright blue striping). For adults, Regina, as she has been functioning in a gen- from Samuel Hubbard is designed to wow the Knit-Rite offers a classic diamond pattern for a eral manager capacity for us, taking on several wearer’s feet. Comfort engineering is at the professional look. additional leadership responsibilities on top of heart of how Samuel Hubbard designs and her role as vice president of sales and market- builds its shoes. Meant to be the go-to-boot in Knit-Rite ing,” said Wendt. any women’s closet, the women’s City Zipper is 800/821-3094 fabricated from premium European sourced, knitrite.com

lermagazine.com 3.19 61 Test your knowledge of information from this issue of How Well Did You Lower Extremity Review and the world in general with our new crossword puzzle feature. The answer box can Read This Issue? be found online at lermagazine.com

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