Patient Factors in the Selection of Operative Versus Nonoperative Treatment for Posterior Tibial Tendon Dysfunction

Background: The influence of demographic, medical history, and treatment variables on the maintenance of nonoperative care or progression to operative intervention in Posterior Tibial Tendon Dysfuction (PTTD) was explored. This retrospective study compared demographic, medical history and treatment variables between operative and nonoperative care in subjects with PTTD. Materials and Methods: Charts with the ICD-9 codes (726.72, 726.90) and brace distribution records for 2005 and 2006 were used to identify subjects. From these, 166 of 606 charts included documentation of PTTD. Variables were grouped into three categories including demographics (Age, body mass index, gender and working status), medical (stage, symptom duration, pain at initial evaluation, and past treatments) and treatment (initial brace, length of care episode, and brace change). Statistical comparisons between subjects treated nonoperatively and operatively were made. Significant variables were entered into a logistic regression analysis. Accuracy (sensitivity/specificity) was assessed by examining the success of predicting which subjects were treated operatively or nonoperatively. Results: Of the 166 subjects, 125 (75.4%) received nonoperative care and 41 (24.6%) operative care. Nine variables distinguished the operative from the nonoperative group (p \u3c 0.05): including BMI, work status, stage, symptom duration, prior orthotic use, prior injection, custom brace, brace changes, and length of care episode. The logistic regression model identified BMI, symptom duration, prior cortisone injections, and prior orthotic use as significant and resulted in a specificity of 95.4% and sensitivity of 38.2%. Conclusion: This retrospective analysis provides a patient profile of factors in the success of nonoperative care in PTTD

Pilot Data: Are Vertical and Lateral Hop Tests Appropriate for Patients Post-Ankle Fracture?

Ankle fractures effect 5 out of 10,000 individuals (van Staa, 2001). A recent study shows rapid functional gains over the first 6 months after an ankle fracture, but there are little or no gains 18-24 months into the recovery cycle (Beckenkamp, 2014). Similarly, other studies have shown that ankle fracture patients are categorized as having good recovery outcomes on popular measures such as the modified Olerud Molander scale (Egol, 2006), yet are unable to return to previous level of sport (Hong, 2013), indicating there may be persisting higher level performance deficits. This brings up the issue of whether there are performance based tests that would be appropriate for ankle fracture patients to determine return to sport or higher level activity without risk of injury. The purpose of this project is to determine the biomechanical load and side to side comparisons of vertical and lateral hopping tests that may be used in ankle fracture patients

Knee and Hip Angle and Moment Adaptations During Cutting Tasks in Subjects With Anterior Cruciate Ligament Deficiency Classified as Noncopers

Study Design: Two-factor mixed-design study, with factors including group (control and noncoper) and task (sidestep, crossover, and straight). Objectives: To compare the knee and hip joint angles and moments of control subjects and subjects with an anterior cruciate ligament (ACL) deficient knee classified as noncopers, during a sidestep, crossover, and straight-ahead task. Background: Subjects with ACL deficiency primarily note difficulty with cutting tasks as opposed to straight-ahead tasks. Yet, previous studies have primarily focused on straight-ahead tasks. Methods and Measures: Fifteen subjects with ACL deficiency classified as noncopers, based on the number of giving-way episodes (1) and global question of knee function (60%), were included in this study. These subjects (10 male, 5 female; age range, 18-47 years). Position data collected at 60 Hz were combined with anthropometric and ground reaction force data collected at 420 Hz to estimate 3- dimensional knee and hip joint angles and moments. All subjects performed 3 tasks including a step and 45 degree sidestep cut, step and 45 degree crossover cut, and step and proceed straight. Two-way mixed model ANOVAs were used to compare peak angle and moment variables between 10% and 30% stance. Results: The ACL-deficient noncoper group had 1.8 degree to 5.7 degree less knee flexion angle compared to the control group across tasks (P.043). The ACL-deficient noncoper group used 22% to 27% lower knee extensor moment during weight acceptance compared to the control group (P.001). The sagittal plane hip extensor moments were 34% to 39% highter in the ACL-deficient noncoper group compared to the control group (P.025). Hip frontal (P.037) and transverse plane (P.04) moments also distinguished the ACL-deficient noncoper from the control group. Conclusions: This study suggests that individuals who do not cope well after ACL injury rely on a hip control strategy during cutting tasks

Influence of Anticipation on Movement Patterns in Subjects with ACL Deficiency Classified as Noncopers

Study Design: Two-factor, mixed experimental design. Objectives: To compare movement patterns of subjects who are anterior cruciate ligament (ACL) deficient and classified as noncopers to controls during early stance of anticipated and unanticipated straight and cutting tasks. Background: Altered neuromuscular control of subjects that are ACL deficient and noncoper theoretically influences movement patterns during unanticipated tasks. Methods and Measures: The study included 16 subjects who are ACL deficient, classified as noncopers, and 20 healthy controls. Data were collected using an Optotrak Motion Analysis System and force plate integrated with Motion Monitor Software to generate knee joint angles, moments, and power. Each testing session included anticipated tasks, straight walking task (ST), and 45° side-step cutting tasks (SSC), followed by a set of unexpected straight walking (STU) and unexpected sidestep cutting (SSCU) tasks in a random order. For all tasks speed was maintained at 2 m/s. Peak knee angle, moment, and power variables during early stance were compared using 2- way mixed-effects ANOVA models. Results: For both the straight and sidestep tasks, the noncoper group did not show a dependence on whether the task was anticipated or unanticipated (group-by-condition interaction) for the knee angle (straight, P = .067; side-step cutting, P = .103), moment (straight, P = .079; side-step cutting, P = .996), and powers (straight, P = .181; side-step cutting, P = .183) during the loading response phase. However, during both straight and side-step cutting tasks, the subjects in the noncoper group used significantly lower knee flexion angles (straight, P = .002; side-step cutting, P = .019), knee moments (straight, P = .005; sidestep cutting, P,.001), and knee powers (straight, P = .013; side-step cutting, P,.001). Conclusions: This study suggests subjects that are ACL deficient and classified as noncopers use a common abnormal movement pattern of lower knee extensor loading even during unanticipated tasks

Comparison of Frontal Plane Trunk Kinematics and Hip and Knee Moments during Anticipated and Unanticipated Walking and Side Step Cutting Tasks

Background: Frontal plane trunk and lower extremity adjustments during unanticipated tasks are hypothesized to influence hip and knee neuromuscular control, and therefore, contribute to anterior cruciate ligament (ACL) injury risk. The aims of this study were to examine frontal plane trunk/hip kinematics and hip and knee moments (measures of neuromuscular control) during unanticipated straight and side step cut tasks. Methods: Kinematic and kinetic variables were collected while subjects performed two anticipated tasks, including walking straight (ST) and side step cutting (SS), and two unanticipated tasks (STU and SSU). Foot placement, thorax–pelvis–hip kinematic variables and hip and knee moments were calculated over the first 30% of stance. Findings: Hip abduction angles and knee moments were significantly affected by task and anticipation. Hip abduction angles decreased, by 4.0–7.68, when comparing the SSU task to the ST, STU and SS tasks. The hip abduction angles were associated with foot placement and lateral trunk orientation. Interpretation: Hip abduction angles and foot placement, not lateral trunk flexion influence trunk orientation. Anticipation influences hip and knee neuromuscular control and therefore may guide the development of ACL prevention strategies

Analysis of Vertical Ground Reaction Force Variables during a Sit to Stand Task in Participants Recovering from a Hip Fracture

Background: A Sit to Stand task following a hip fracture may be achieved through compensations (e.g. bilateral arms and uninvolved lower extremity), not restoration of movement strategies of the involved lower extremity. The primary purpose was to compare upper and lower extremity movement strategies using the vertical ground reaction force during a Sit to Stand task in participants recovering from a hip fracture to control participants. The secondary purpose was to evaluate the correlation between vertical ground reaction force variables and validated functional measures. Methods: Twenty eight community dwelling older adults, 14 who had a hip fracture and 14 control participants completed the Sit to Stand task on an instrumented chair designed to measure vertical ground reaction force, performance based tests (Timed up and go, Berg Balance Scale and Gait Speed) and a self report Lower Extremity Measure. A MANOVA was used to compare functional scales and vertical ground reaction force variables between groups. Bivariate correlations were assessed using Pearson Product Moment correlations. Findings: The vertical ground reaction force variables showed significantly higher bilateral arm force, higher uninvolved side peak force and asymmetry between the involved and uninvolved sides for the participants recovering from a hip fracture (Wilks\u27 Lambda=3.16, P=0.019). Significant correlations existed between the vertical ground reaction force variables and validated functional measures. Interpretation: Participants recovering from a hip fracture compensated using their arms and the uninvolved side to perform a Sit to Stand. Lower extremity movement strategies captured during a Sit to Stand task were correlated to scales used to assess function, balance and falls risk

Weight-Bearing Asymmetry in Individuals Post-Hip Fracture During the Sit to Stand Task

Background: Individuals post hip fracture decrease force on the involved limb during sit to stand tasks, creating an asymmetry in vertical ground reaction force. Joint specific differences that underlie asymmetry of the vertical ground reaction force are unknown. The purpose of this study was to compare differences in vertical ground reaction force variables and joint kinetics at the hip and knee in participants post-hip fracture, who were recently discharged from home care physical therapy to controls. Methods: Forty-four community-dwelling older adults, 29 who had a hip fracture and 15 elderly control participant’s completed the sit to stand task on an instrumented chair with 3 force plates. T-tests were used to compare clinical tests (Berg Balance Scale, activity balance confidence and gait speed, isokinetic knee strength) and vertical ground reaction force variables. Two-way analyses of variance compared vertical ground reaction force variables and kinetics at the hip and knee between hip fracture and elderly control groups. Pearson correlation coefficients were used to determine correlations between clinical and vertical ground reaction force variables. Findings: Vertical ground reaction force variables were significantly lower on the involved side for the hip fracture group compared to the uninvolved side and controls. Lower involved side hip and knee moments and power contributed to lower involved side vertical ground reaction force. Vertical ground reaction force variables and strength had moderate to high correlations with clinical measures. Interpretation: Uninvolved side knee movements and powers were the largest contributors to asymmetrical vertical ground reaction force in participants post-hip fracture. The association of vertical ground reaction force variables and clinical measures of function suggesting reducing vertical ground reaction force asymmetry may contribute to higher levels of function post-hip fracture. Functional and strength training should target the involved knee to reduce vertical ground reaction force asymmetry. Background Individuals post hip fracture decrease force on the involved limb during sit to stand tasks, creating an asymmetry in vertical ground reaction force. Joint specific differences that underlie asymmetry of the vertical ground reaction force are unknown. The purpose of this study was to compare differences in vertical ground reaction force variables and joint kinetics at the hip and knee in participants post-hip fracture, who were recently discharged from homecare physical therapy to controls. Methods Forty-four community-dwelling older adults, 29 who had a hip fracture and 15 elderly control participant’s completed the sit to stand task on an instrumented chair with 3 force plates. T-tests were used to compare clinical tests (Berg Balance Scale, activity balance confidence and gait speed, isokinetic knee strength) and vertical ground reaction force variables. Two-way analyses of variance compared vertical ground reaction force variables and kinetics at the hip and knee between hip fracture and elderly control groups. Pearson correlation coefficients were used to determine correlations between clinical and vertical ground reaction force variables. Findings Vertical ground reaction force variables were significantly lower on the involved side for the hip fracture group compared to the uninvolved side and controls. Lower involved side hip and knee moments and power contributed to lower involved side vertical ground reaction force. Vertical ground reaction force variables and strength had moderate to high correlations with clinical measures. Interpretation Uninvolved side knee moments and powers were the largest contributors to asymmetrical vertical ground reaction force in participants post-hip fracture. The association of vertical ground reaction force variables and clinical measures of function suggesting reducing vertical ground reaction force asymmetry may contribute to higher levels of function post-hip fracture. Functional and strength training should target the involved knee to reduce vertical ground reaction force asymmetry

Responsiveness of the PROMIS and its Concurrent Validity with Other Region- and Condition-specific PROMs in Patients Undergoing Carpal Tunnel Release

Background The Patient-reported Outcome Measurement Information System (PROMIS) continues to be an important universal patient-reported outcomes measure (PROM) in orthopaedic surgery. However, there is concern about the performance of the PROMIS as a general health questionnaire in hand surgery compared with the performance of region- and condition-specific PROMs such as the Michigan Hand Questionnaire (MHQ) and the Boston Carpal Tunnel Questionnaire (BCTQ), respectively. To ensure that PROMIS domains capture patient-reported outcomes to the same degree as region- and condition-specific PROMs do, comparing PROM performance is necessary. Questions/purposes (1) Which PROMs demonstrate high responsiveness among patients undergoing carpal tunnel release (CTR)? (2) Which of the PROMIS domains (Physical Function [PF], Upper Extremity [UE], and Pain Interference [PI]) demonstrate concurrent validity with the HHQ and BCTQ domains? Methods In this prospective study, between November 2014 and October 2016, patients with carpal tunnel syndrome visiting a single surgeon who elected to undergo CTR completed the BCTQ, MHQ, and PROMIS UE, PF, and PI domains at each visit. A total of 101 patients agreed to participate. Of these, 31 patients (31%) did not return for a followup visit at least 6 weeks after CTR and were excluded, leaving a final sample of 70 patients (69%). We compared the PROMIS against region- and condition-specific PROMs in terms of responsiveness and concurrent validity. Responsiveness was determined using Cohen’s d or the effect-size index (ESI). The larger the absolute value of the ESI, the greater the effect size. Using the ESI allows surgeons to better quantify the impact of CTR, with a medium ESI (that is, 0.5) representing a visible clinical change to a careful observer. Concurrent validity was determined using Spearman’s correlation coefficient with correlation strengths categorized as excellent (\u3e 0.7), excellent-good (0.61-0.70), good (0.4-0.6), and poor (\u3c 0.4). Significance was set a priori at p \u3c 0.05. Results Among PROMIS domains, the PI demonstrated the best responsiveness (ESI = 0.74; 95% CI, 0.39-1.08), followed by the UE (ESI = -0.66; 95% CI, -1.00 to -0.31). For the MHQ, the Satisfaction domain had the largest effect size (ESI = -1.48; 95% CI, -1.85 to -1.09), while for the BCTQ, the Symptom Severity domain had the best responsiveness (ESI = 1.54; 95% CI, 1.14-1.91). The PROMIS UE and PI domains demonstrated excellent-good to excellent correlations to the total MHQ and BCTQ–Functional Status scores (preoperative UE to MHQ: ρ = 0.68; PI to MHQ: ρ = 0.74; UE to BCTQ–Functional Status: ρ = 0.74; PI to BCTQ–Functional Status: ρ = 0.67; all p \u3c 0.001), while the PROMIS PF demonstrated poor correlations with the same domains (preoperative PF to MHQ; ρ = 0.33; UE to BCTQ–Functional Status: ρ = 0.39; both p \u3c 0.01). Conclusions The PROMIS UE and PI domains demonstrated slightly worse responsiveness than the MHQ and BCTQ domains that was nonetheless acceptable. The PROMIS PF domain was unresponsive. All three PROMIS domains correlated with the MHQ and BCTQ, but the PROMIS UE and PI domains had notably stronger correlations to the MHQ and BCTQ domains than the PF domain did. We feel that the PROMIS UE and PI can be used to evaluate the clinical outcomes of patients undergoing CTR, while also providing more robust insight into overall health status because they are general PROMs. However, we do not recommend the PROMIS PF for evaluating patients undergoing CTR. Level of Evidence Level II, diagnostic study

Influence of Upper Extremity Assistance on Lower Extremity Force Application Symmetry in Individuals Post–Hip Fracture During the Sit-to-Stand Task

STUDY DESIGN: Controlled laboratory study using a cross-sectional design. OBJECTIVES: To compare lower extremity force applications during a sit-to-stand (STS) task with and without upper extremity assistance in older individuals post–hip fracture to those of age matched controls. BACKGROUND: A recent study documented the dependence on upper extremity assistance and the uninvolved lower limb during an STS task in individuals post–hip fracture. This study extends this work by examining the effect of upper extremity assistance on symmetry of lower extremity force applications. METHODS: Twenty-eight community-dwelling elderly subjects, 14 who had recovered from a hip fracture and 14 controls, participated in the study. All participants were independent ambulators. Four force plates were used to determine lower extremity force applications during an STS task with and without upper extremity assistance. The summed vertical ground reaction forces (vGRFs) of both limbs were used to determine STS phases (preparation/rising). The lower extremity force applications were assessed statistically using analysis of variance models. RESULTS: During the preparation phase, sideto-side symmetry of the rate of force development was significantly lower for the hip fracture group for both STS tasks (P\u3c.001). During the rising phase, the vGRF impulse of the involved limb was significantly lower for the hip fracture group for both STS tasks (P = .045). The vGRF impulse for the uninvolved limb was significantly increased when participants with hip fracture did not use upper extremity assistance compared to elderly controls (P = .002). This resulted in a significantly lower vGRF symmetry for the hip fracture group during both STS tasks (P\u3c.001). CONCLUSION: Participants with hip fracture who were discharged from rehabilitative care demonstrated decreased side-to-side symmetry of lower extremity loading during an STS task, irrespective of whether upper extremity assistance was provided. These findings suggest that learned motor control strategies may influence movement patterns post–hip fracture

Utility of Ultrasound for Imaging Osteophytes in Patients with Insertional Achilles Tendinopathy

Objectives: To examine (1) the validity of ultrasound imaging to measure osteophytes and (2) the association between osteophytes and insertional Achilles tendinopathy (IAT). Design: Case-control study. Setting: Academic medical center. Participants: Persons with chronic unilateral IAT (n=20; mean age, 58.7±8.3y; 10 [50%] women) and age- and sex-matched controls (n=20; mean age, 57.4±9.8y; 10 [50%] women) participated in this case-control study (N=40). Interventions: Not applicable. Main Outcome Measures: Symptom severity was assessed using the Foot and Ankle Ability Measure, the Victorian Institute of Sport Assessment-Achilles questionnaire, and the numerical rating scale. Length of osteophytes was measured bilaterally in both groups using ultrasound imaging, as well as on the symptomatic side of the IAT group using radiography. The intraclass correlation coefficient was used to examine the agreement between ultrasound and radiograph measures. McNemar, Wilcoxon signed-rank, and Fisher exact tests were used to compare the frequency and length of osteophytes between sides and groups. Pearson correlation was used to examine the association between osteophyte length and symptom severity. Results: There was good agreement (intraclass correlation coefficient, ≥.75) between ultrasound and radiograph osteophyte measures. There were no statistically significant differences (P\u3e.05) in the frequency of osteophytes between sides or groups. Osteophytes were larger on the symptomatic side of the IAT group than on the asymptomatic side (P=.01) and on the left side of controls (P=.03). There was no association between osteophyte length and symptom severity. Conclusions: Ultrasound imaging is a valid measure of osteophyte length, which is associated with IAT. Although a larger osteophyte indicates tendinopathy, it does not indicate more severe IAT symptoms