STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To compare the effectiveness of 2 different conservative management approaches in the treatment of plantar heel pain. BACKGROUND: There is insufficient evidence to establish the optimal physical therapy management strategies for patients with heel pain, and little evidence of long-term effects. METHODS: Patients with a primary report of plantar heel pain underwent a standard evaluation and completed a number of patient self-report questionnaires, including the Lower Extremity Functional Scale (LEFS), the Foot and Ankle Ability Measure (FAAM), and the Numeric Pain Rating Scale (NPRS). Patients were randomly assigned to be treated with either an electrophysical agents and exercise (EPAX) or a manual physical therapy and exercise (MTEX) approach. Outcomes ofinterest were captured at baseline and at 4-week and 6-month follow-ups. The primary aim (effects of treatment on pain and disability) was examined with a mixed-model analysis of variance (ANOVA). The hypothesis of interest was the 2-way interaction (group by time). RESULTS: Sixty subjects (mean [SD] age, 48.4 [8.7] years) satisfied the eligibility criteria, agreed to participate, and were randomized into the EPAX (n = 30) or MTEX group (n = 30). The overall group-by-time interaction for the ANOVA was statistically significant for the LEFS (P = .002), FAAM (P = .005), and pain (P = .043). Between-group differences favored the MTEX group at both 4-week (difference in LEFS, 13.5; 95% CI: 6.3, 20.8) and 6-month (9.9; 95% CI: 1.2, 18.6) follow-ups. CONCLUSION: The results of this study provide evidence that MTEX is a superior management approach over an EPAX approach in the management of individuals with plantar heel pain at both the short- and long-term follow-ups. Future studies should examine the contribution of the different components of the exercise and manual physical therapy programs. LEVEL OF EVIDENCE: Therapy, level 1b.
STUDY DESIGN: Clinical measurement, criterion standard. OBJECTIVES: To determine if the clinical measure of femoral anteversion is comparable to measures obtained from magnetic resonance imaging (MRI). An additional purpose of this study was to assess the intertester and intratester reliability of the clinical test. BACKGROUND: Femoral anteversion is commonly assessed as part of the physical examination; however, limited and inconsistent data exist on the validity and reliability of the clinical test. METHODS: Eighteen healthy adults (9 males, 9 females; mean ± SD age, 25.4 ± 3.3 years; body mass index, 22.9 ± 3.4 kg/m2) participated. Each underwent 3 data collection sessions: (1) MRI to measure femoral anteversion, (2) clinical testing of femoral anteversion, measured independently by 2 physical therapists, and (3) repeated clinical testing. Validity and reliability were assessed using intraclass correlation coefficient (ICC2,3) and standard error of measurement (SEM). RESULTS: Moderate agreement was found between the clinical test and MRI measures of femoral anteversion (ICCs of 0.69 and 0.67 for examiners 1 and 2, respectively). The SEM was similar for both examiners (5.8° and 6.0°). Both intratester (ICCs of 0.88 and 0.90 for examiners 1 and 2, respectively) and intertester (ICC = 0.83) reliability was found to be substantial. CONCLUSIONS: In persons with a low body mass index, the clinical test to assess femoral anteversion was shown to exhibit substantial reliability, but only moderate agreement with MRI measurements. When performing the clinical test, one can be 95% confident that the true value of femoral anteversion will fall within 11.8° of the clinically measured value. This relatively wide confidence interval calls into question the clinical utility of the clinical test for assessing femoral anteversion.
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/m2) and 15 controls (mean ± SD age, 56.5 ± 7.7 years; body mass index, 30.6 ± 3.6 kg/m2). Footkinematic 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 [CI]: 5.1° to 9.5°), greater first metatarsal dorsiflexion (mean difference between groups, 9.0°; 95% CI: 3.7° to 14.4°), and less hallux dorsiflexion (mean difference, 6.7°; 95% CI: 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.
STUDY DESIGN: Clinical measurement, reliability study. OBJECTIVES: To investigate the improvements in precision when averaging multiple measurements of percent change in muscle thickness of the transversus abdominis (TrA) and lumbar multifidus (LM) muscles. BACKGROUND: Although the reliability of TrA and LM muscle thickness measurements using rehabilitative ultrasound imaging (RUSI) is good, measurement error is often large relative to mean muscle thickness. Additionally, percent thickness change measures incorporate measurement error from both resting and contracted conditions. METHODS: Thirty volunteers with nonspecific low back pain participated. Thickness measurements of the TrA and LM muscles were obtained using RUSI at rest and during standardized tasks. Percent thickness change was calculated with the formula (thicknesscontracted – thicknessrest/thicknessrest). Standard error of measurement (SEM) quantified precision when using 1 or a mean of 2 to 6 consecutive measurements. RESULTS: Compared to when using a singlemeasurement, SEM of both the TrA and LM decreased by nearly 25% when using a mean of 2 measures, and by 50% when using the mean of 3 measures. Little precision was gained by averaging more than 3 measurements. CONCLUSION: When using RUSI to determine percent change in TrA and LM muscle thickness, intraexaminer measurement precision appears to be optimized by using an average of 3 consecutive measurements.
J Orthop Sport Phys Ther 2009;39(8):604-611 Epub 24 June 2009. doi:10.2519/jospt.2009.3088
STUDY DESIGN: Resident’s case problem. BACKGROUND: Kaposi’s sarcoma (KS) is the most common form of cancer in patients with human immunodeficiency virus (HIV) infection. Although KS is often initially asymptomatic, this neoplasm may progress to affect multiple organ systems, including structures of the musculoskeletal system, which can produce symptoms similar to those associated with common orthopaedic conditions. This resident’s case problem describes the evaluation and differential diagnosis of a 45-year-old male with HIV and KS, referred to physical therapy with an initial diagnosis of radiographic osteoarthritis (OA) and patellofemoral pain syndrome (PFPS) of the left knee. His primary complaint was knee pain during end range knee flexion. DIAGNOSIS: The history, systems review, and examination suggested a source of pain of a nonorthopaedic origin. Differential examination ruled out clinical OA, PFPS, ligament/cartilage derangement, and tendonitis. Avascular necrosis of the medial femoral condyle was also considered as a possible source of pain. Recent blood tests indicated a high viral load and low CD4 count, which might have increased susceptibility to opportunistic infections or KS tumor progression. The patient was referred back to his physician for additional follow-up. Magnetic resonance imaging (MRI) of the knees were consistent with a systemic inflammatory process such as KS. A true-cut biopsy was subsequently scheduled, which confirmed KS lesions at the left knee. DISCUSSION: Physical therapists who manage orthopaedic conditions should be aware of the disablement that may result from acquired immunodeficiency syndrome-related KS. A thorough joint-specific examination, with a broad differential diagnosis, should be employed for patients having known systemic diseases. LEVEL OF EVIDENCE: Differential diagnosis, level 4.
STUDY DESIGN: Controlled laboratory study using a single-group, repeated-measures design. OBJECTIVES: To investigate scapular kinematics during both constrained and functional shoulder movements. BACKGROUND: Abnormal scapulothoracic joint motion has been associated with pathologiessuch as shoulder impingement. Constrained protocols are commonly used in the measurement of shoulder kinematics; however, few studies have measured motion during functional tasks. METHODS: Twenty-five healthy subjects participated in this study. Three-dimensional kinematic data from the scapula and humerus with respect to the thorax were collected with a magnetic tracking system. Functional testing consisted of 6 different tasks representing common activities of daily living. Constrained testing consisted of at least 42 arm elevations in various planes. Two-way analyses of variance with repeated measures were used to compare scapular rotations between constrained and functional movements at the same humeral elevation and plane of elevation angles. Intersubject variability was compared between the overhead tasks andthe constrained humeral elevation in the scapular plane by using the coefficient of multiple correlations. RESULTS: Significant differences between constrained trials and functional tasks were found for all scapular rotations. A similar pattern was observed for scapular rotations variability between overhead tasks and constrained arm elevation in the scapular plane. CONCLUSION: Care needs to be taken when comparing and generalizing scapular kinematic data from constrained humeral movements and applying it to functional humeral movements.
STUDY DESIGN: Controlled laboratory study using a cross-sectional design. OBJECTIVES: To compare the measurements of navicular drop during walking and running to those made clinically during a static position in a group of healthy young adults. BACKGROUND: The navicular drop test is a common clinical measure of foot structure and, more specifically, of talonavicular joint function. Previous work has focused on static measurement to establish the relationship between navicular drop and various overuse injuries. However, loads on foot structure are dramatically increased during gait. Examining navicular drop dynamically is more reflective of the functional demands of the foot when walking and running. METHODS: The navicular drop of 72 healthy runners was evaluated using 2 static methods. Results were used to classify individuals into groups and compared to dynamic measures of navicular drop made during walking and running. Three-dimensional motion capture and an instrumented treadmill were used to assess dynamic navicular mobility. A repeated-measures analysis of variance (ANOVA) was performed to examine differences between measurement conditions. Between-group differences were assessed with independent-samples t test (P<.05). RESULTS: Static measures of navicular drop were not found to be uniformly predictive of dynamic function during walking or running. Functional navicular drop measurements underestimated the dynamic measures in all foot types, while subtalar neutral drop overestimated dynamic measures for individuals with neutral and hypermobile foot types. No differences in navicular drop were found between foot types during walking, and small differences were found in runningonly between the hypomobile and hypermobile foot types. Maximum foot deformation during gait occurs at the time of maximum ground reaction force. Significant differences in navicular drop between foot type groups measured statically become muted when looking at group differences while walking and running. CONCLUSIONS: Differences in navicular mobility between foot type groups during walking and running indicate that factors other than staticalignment affect dynamic foot mobility. Dynamic assessment of navicular mobility may be an effective tool to examine the interplay of how the extrinsic force demands of gait and intrinsic structure and neuromuscular control affect foot function in walking and running.
J Orthop Sport Phys Ther 2009;39(8):628-634, Epub 24 June 2009. doi:10.2519/jospt.2009.2968
The patient was a 24-year-old male with a 1-month history of right knee pain following a twisting injury. The patient was seen by his physician and radiographs of the right knee were taken and interpreted as normal. He was then referred to physical therapy. Magnetic resonance imaging of the right knee was ordered by the physical therapist because of concern over an anterior cruciate ligament (ACL) injury, and revealed a complete tear of the ACL, with the distal aspect of the ACL flipped anteriorly. It was hypothesized that the positioning of the distal segment of the ACL contributed to the loss of full knee extension in this patient. After recognition of the ACL tear, the patient was referred to an orthopaedic surgeon and underwent an ACL reconstruction 2 weeks later.