Randomized Controlled Trial Comparing Orthosis Augmented by Either Stretching or Stretching and Strengthening for Stage II Tibialis Posterior Tendon Dysfunction

Background: The value of strengthening and stretching exercises combined with orthosis treatment in a home-based program has not been evaluated. The purpose of this study was to compare the effects of augmenting orthosis treatment with either stretching or a combination of stretching and strengthening in participants with stage II tibialis posterior tendon dysfunction (TPTD). Methods: Participants included 39 patients with stage II TPTD who were recruited from a medical center and then randomly assigned to a strengthening or stretching treatment group. Excluding 3 dropouts, there were 19 participants in the strengthening group and 17 in the stretching group. The stretching treatment consisted of a prefabricated orthosis used in conjunction with stretching exercises. The strengthening treatment consisted of a prefabricated orthosis used in conjunction with the stretching and strengthening exercises. The main outcome measures were self-report (ie, Foot Function Index and Short Musculoskeletal Function Assessment) and isometric deep posterior compartment strength. Two-way analysis of variance was used to test for differences between groups at 6 and 12 weeks after starting the exercise programs. Results: Both groups significantly improved in pain and function over the 12-week trial period. The self-report measures showed minimal differences between the treatment groups. There were no differences in isometric deep posterior compartment strength. Conclusions: A moderate-intensity, home-based exercise program was minimally effective in augmenting orthosis wear alone in participants with stage II TPTD. Level of Evidence: Level I, prospective randomized study

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

Comparison of changes in posterior tibialis muscle length between subjects with posterior tibial tendon dysfunction and healthy controls during walking

Fisheye STUDY DESIGN: Case control study. Fisheye OBJECTIVE: To compare posterior tibialis (PT) length between subjects with stage II posterior tibial tendon dysfunction (PTTD) and healthy controls during the stance phase of gait. Fisheye BACKGROUND: The abnormal kinematics demonstrated by subjects with stage II PTTD are presumed to be associated with a lengthened PT musculotendon, but this relationship has not been fully explored. Fisheye METHODS: Seventeen subjects with stage II PTTD and 10 healthy controls volunteered for this study. Subject-specific foot kinematics were collected using 3-D motion analysis techniques for input into a general model of PT musculotendon length (PTLength). The kinematic inputs included hindfoot eversion/inversion (HF Ev/Inv), forefoot abduction/adduction (FF Ab/Add), forefoot plantar flexion/dorsiflexion (FF Pf/Df), and ankle plantar flexion/dorsiflexion (Ankle Pf/Df). To estimate the change in PTLength from neutral the following model was used: PTLength = 0.401(HF Ev/Inv) + 0.270(FF Ab/Add) + 0.137(FF Pf/Df) + 0.057(Ankle Pf/Df). Positive values indicated lengthening from the subtalar neutral (STN) position, while negative values indicated shortening relative to the STN position. A 2-way analysis of variance (ANOVA) model was used to compare PTLength between groups across the stance phases of walking (loading response, midstance, terminal stance, and pre-swing). Also, a 2-way ANOVA was used to assess the foot kinematics that contributed to alterations in PTLength. The Short Musculoskeletal Functional Assessment Index and Mobility subscale were used to compare function and mobility. Fisheye RESULTS: PTLength was significantly greater (lengthened) relative to the STN position in the PTTD group compared to the control group across all phases of stance, with the greatest between-group difference in PTLength occurring during preswing. The greater PTLength in subjects with PTTD compared to controls was principally attributed to significantly greater HF Ev/Inv during loading response (P = .014) and midstance (P = .015). During terminal stance and preswing, each kinematic input to estimate PTLength contributed to lengthening (main effect, P = .03 and P = .01, respectively). Subjects with PTTD with abnormally greater PTLength reported significantly lower function (P = .04) and mobility (P = .03) compared to subjects with PTTD with normal PTLength during walking. Fisheye CONCLUSIONS: The greater PTLength, as determined from foot kinematics, suggests that the PT musculotendon is lengthened in subjects with stage II PTTD, compared to healthy controls. The amount of lengthening is not dependent on the phase of gait; however, different foot kinematics contribute to PTLength across the stance phase. Targeting these foot kinematics may limit lengthening of the PT musculotendon. Subjects with excessive PT lengthening experience a decrease in function

Comparison of foot kinematics between subjects with posterior tibialis tendon dysfunction and healthy controls

Study Design: A 2 × 4 mixed-design ANOVA with a fixed factor of group (posterior tibialis tendon dysfunction [PTTD] and asymptomatic controls), and a repeated factor of phase of stance (loading response, midstance, terminal stance, and preswing). Objective: To compare 3-dimensional stance period kinematics (rearfoot eversion/inversion, medial longitudinal arch [MLA] angle, and forefoot abduction) of subjects with stage 11 PTTD to asymptomatic controls. Background: Abnormal foot postures in subjects with stage 11 PTTD are clinical indicators of disease progression, yet dynamic investigations of forefoot, midfoot, and rearfoot kinematic deviations in this population are lacking. Methods: Fourteen subjects with stage 11 PTTD were compared to 10 control subjects with normal arch index values. Subjects were matched for age, gender, and body mass index. A 5-segment, kinematic model of the leg and foot was tracked using an Optotrak Motion Analysis System. The dependent kinematic variables were rearfoot inversion/eversion, forefoot abduction/adduction, and the MLA angle. An ANOVA model was used to compare kinematic variables between groups across 4 phases of stance. Results: Subjects with PTTD demonstrated significantly greater rearfoot eversion (P = .042), MLA angle (P = .008) and forefoot abduction angles (P\u3c.005) during specific phases of stance. Subjects with PTTD demonstrated significantly greater rearfoot eversion (P\u3c.004) and MLA angles (P\u3c.009) by 6.2° and 8.0°, respectively, during loading response when compared to controls. During preswing, the subjects with PTTD demonstrated a significantly greater MLA angle (P\u3c.002) and a forefoot abduction angle (P\u3c.001) which exceeded that of the controls by 10.0°. Conclusions: The abnormal kinematics observed at the rearfoot, midfoot, and forefoot across all phases of stance implicate a failure of compensatory muscle and secondary ligamentous support to control foot kinematics in subjects with stage 11 PTTD

Foot kinematics during a bilateral heel rise test in participants with stage II posterior tibial tendon dysfunction

STUDY DESIGN: Experimental laboratory study using a cross-sectional design. OBJECTIVES: To compare foot kinematics, using 3-dimensional tracking methods, during a bilateral heel rise between participants with posterior tibial tendon dysfunction (PTTD) and participants with a normal medial longitudinal arch (MLA). BACKGROUND: The bilateral heel rise test is commonly used to assess patients with PTTD; however, information about foot kinematics during the test is lacking. METHODS: Forty-five individuals volunteered to participate, including 30 patients diagnosed with unilateral stage II PTTD (mean ± SD age, 59.8 ± 11.1 years; body mass index, 29.9 ± 4.8 kg/ m ) and 15 controls (mean ± SD age, 56.5 ± 7.7 years; body mass index, 30.6 ± 3.6 kg/m ). Foot kinematic data were collected during a bilateral heel rise task from the calcaneus (hindfoot), first metatarsal, and hallux, using an Optotrak motion analysis system and Motion Monitor software. A 2-way mixed-effects analysis of variance model, with normalized heel height as a covariate, was used to test for significant differences between the normal MLA and PTTD groups. RESULTS: The patients in the PTTD group exhibited significantly greater ankle plantar flexion (mean difference between groups, 7.3°; 95% confidence interval [Cl]: 5.1° to 9.5°), greater first metatarsal dorsiflexion (mean difference between groups, 9.0°; 95% Cl: 3.7° to 14.4°), and less hallux dorsiflexion (mean difference, 6.7°; 95% Cl; 1.7° to 11.8°) compared to controls. At peak heel rise, hindfoot inversion was similar (P = .130) between the PTTD and control groups. CONCLUSION: Except for hindfoot eversion/ inversion, the differences in foot kinematics in participants with stage II PTTD, when compared to the control group, mainly occur as an offset, not an alteration in shape, of the kinematic patterns. 2

Comparison of in vivo segmental foot motion during walking and step descent in patients with midfoot arthritis and matched asymptomatic control subjects

The purpose of this study was to compare in vivo segmental foot motion during walking and step descent in patients with midfoot arthritis and asymptomatic control subjects. Segmental foot motion during walking and step descent was assessed using a multi-segment foot model in 30 patients with midfoot arthritis and 20 age, gender and BMI matched controls. Peak and total range of motion (ROM), referenced to subtalar neutral, were examined for each of the following dependent variables: 1st metatarso-phalangeal (MTP1) dorsiflexion, 1st metatarsal (MT1) plantarflexion, ankle dorsiflexion, calcaneal eversion and forefoot abduction. The results showed that, compared to level walking, step descent required greater MTP1 dorsiflexion (p\u3c0.01), MPT1 plantarflexion (p\u3c0.01), ankle dorsiflexion (p\u3c0.01), calcaneus eversion (p=0.03) and forefoot abduction (p=0.01), in all subjects. In addition, step descent also necessitated greater MTP1 dorsiflexion (p\u3c0.01), ankle dorsiflexion (p\u3c0.01) and forefoot abduction (p=0.02) excursion compared to walking. Patients with midfoot arthritis responded differently to the step task compared to control subjects in terms of MT1 and calcaneus eversion excursion. During walking, patients with midfoot arthritis showed significantly less MT1 plantarflexion excursion compared to control subjects (p=0.03). However, during step descent, both groups showed similar MT1 plantarflexion excursion. During walking, patients with midfoot arthritis showed similar calcaneus eversion excursion compared to control subjects. However, during step descent, patients with midfoot arthritis showed significantly greater calcaneus eversion excursion compared to control subjects (p=0.03). Independently or in combination, these motions may contribute to articular stress and consequently to symptoms in patients with midfoot arthritis. © 2009 Elsevier Ltd. All rights reserved

Orthoses Alter In Vivo Segmental Foot Kinematics During Walking in Patients With Midfoot Arthritis

Rao S, Baumhauer JF, Tome J, Nawoczenski DA. Orthoses alter in vivo segmental foot kinematics during walking in patients with midfoot arthritis. Objective: To assess the effect of a 4-week intervention with a full-length carbon graphite (FL) orthosis on pain and function in patients with midfoot arthritis, and to identify alterations in in vivo foot kinematics accompanying FL use in patients with midfoot arthritis. These results have immediate application for enhancing patient care through effective orthotic recommendations. Design: Experimental laboratory study supplemented by a case series. Setting: University based clinical research laboratory. Participants: Patients (n=30) with midfoot arthritis and age-, sex-, and body mass index-matched control subjects (n=20). Intervention: Four-week intervention with FL orthoses. Main Outcome Measures: Pain and function were assessed using the Foot Function Index-Revised (FFI-R). In vivo foot kinematics were quantified as peak and total range of calcaneal eversion, forefoot abduction, first metatarsal plantarflexion, and first metatarsophalangeal joint dorsiflexion during walking in 2 conditions: with FL orthoses and with shoes only. A paired t test and repeated-measures analysis of variance were used to assess statistical significance (α=.05) of change in FFI-R score and in vivo foot kinematics, respectively. Results: Significant improvements in pain and function, discerned as lower FFI-R scores (P\u3c.001), were noted after the 4-week intervention with FL orthoses. During walking, FL orthosis use resulted in decreased first metatarsophalangeal joint dorsiflexion (P=.024) and first metatarsal plantarflexion range of motion (P=.038), compared with the shoe-only condition. Conclusions: Orthotic intervention emphasizing a stiffening strategy of the first metatarsal and first metatarsophalangeal joint may be valuable in patients with midfoot arthritis and early degenerative changes. © 2010 American Congress of Rehabilitation Medicine

Use of time-to-boundary to assess postural instability and predict functional mobility in people with diabetes mellitus and peripheral neuropathy

© 2020 Elsevier B.V. Background: People with diabetes mellitus and peripheral neuropathy (DMPN) often have balance and mobility deficits. Time-to-boundary (TTB) is a parameter of postural control that combines position and velocity center of pressure data. While not previously investigated, assessment of TTB may provide new insight regarding postural control in people with DMPN. Research question: Is TTB reduced and related to a measure of mobility in people with DMPN? Methods: Thirteen people with DMPN without fall history and 13 healthy matched controls participated in this case-control study. Participants stood in double-limb stance on a force plate. The anterior-posterior and medial-lateral center of pressure position and velocity relative to the boundaries of the base of support were used to calculate TTB (s). Lower values indicate less postural control. Time-to-failure during single-limb stance was a secondary measure of postural control. Time to complete the Timed Up and Go (TUG) was our measure of mobility. Longer TUG times correspond to decreased mobility, strength, and balance. Independent t-tests or Mann-Whitney U tests were conducted to assess group differences. Bivariate correlations between task outcomes were conducted. Results: Anterior-posterior TTB and single-limb stance times were shorter in people with DMPN (p ≤ 0.04). TUG times were longer in the DMPN group (p = 0.04). In the DMPN group, inverse relationships were observed between TTB and TUG (anterior-posterior R2 = .34; medial-lateral R2 = .49; both p = 0.01), but not between single-limb stance times and TTB or TUG. Significance: TTB was a sensitive measure of postural control in people with DMPN. The detected relationship between TTB and TUG newly establishes TTB as a clinically meaningful indicator of balance and function. Study findings may serve to further guide balance screening and rehabilitation efforts in people with DMPN

Ankle and foot kinematics associated with stage II PTTD during stance

Background: Subjects with stage II posterior tibial tendon dysfunction (PTTD) exhibit abnormal foot kinematics; however, how individual segment kinematics (hindfoot (HF) or first metatarsal (first MET) segments) influence global foot kinematics is unclear. The purpose of this study was to compare foot and ankle kinematics and sagittal plane HF and first MET segment kinematics between stage II PTTD and controls. Materials and Methods: Thirty patients with stage II PTTD and 15 healthy controls were evaluated. Kinematic data from the tibia, calcaneus, and first MET were collected during walking using three dimensional motion analysis techniques. A three-segment foot model (HF, calcaneus; first MET, first metatarsal, and tibia) was used to calculate relative angles (ankle, HF relative to tibia; midfoot, first MET relative to HF) and segment angles (HF and first MET relative to the global). A mixed effect ANOVA model was utilized to compare angles between groups for each variable. Results: Patients with PTTD showed greater ankle plantarflexion (p = 0.02) by 6.8 degrees to 8.4 degrees prior to or at 74% of stance; greater HF eversion (p \u3c 0.01) across stance (mean difference = 4.5 degrees); and greater first MET dorsiflexion (p \u3c 0.01) across stance (mean difference = 8.8 degrees). HF and first MET segment angles revealed greater HF dorsiflexion (p = 0.01) during early stance and greater first MET dorsiflexion (p = 0.001) across stance. Conclusion: Abnormal HF and first MET segment kinematics separately influence both ankle and midfoot movement during walking in subjects with stage II PTTD. Clinical Relevance: These abnormal kinematics may serve as another measure of response to clinical treatment and/or guide for clinical strategies (exercise, orthotics, and surgery) seeking to improve foot kinematics. Copyright © 2009 by the American Orthopaedic Foot & Ankle Society