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.

J Orthop Sports Phys Ther 2009;39(8):573-585, Epub 24 June 2009. doi:10.2519/jospt.2009.3036

KEY WORDS: iontophoresis, manipulation, mobilization, plantar fasciitis, plantar fasciosis

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.

J Orthop Sports Phys Ther 2009;39(8):593-603. doi:10.2519/jospt.2009.3040

KEY WORDS: ankle, flat foot, medial longitudinal arch, posterior tibialis

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.

J Orthop Sports Phys Ther 2009;39(8):612-617. doi:10.2519/jospt.2009.2961

KEY WORDS: human immunodeficiency virus (HIV), Kaposi’s sarcoma, knee pain, physical therapy

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

KEY WORDS: foot, gait, physical therapy, running, walking

A selection of important abstracts of articles published in other journals.

J Orthop Sports Phys Ther 2009;39(8):636-647.