STUDY DESIGN: Experimental laboratory study supplemented by a case series. OBJECTIVES: (1) To assess the effect of a 4-week intervention with a full-length insert on functional outcomes in patients with midfoot arthritis; (2) to examine the effect of the custom molded three-quarter-length (3Q) and full-length (FL) carbon graphite insert on plantar loading in patients with midfoot arthritis. BACKGROUND: Given the coexistence of pain and lower-arched foot alignment in patients with midfoot arthritis, arch-restoring orthotic devices such as the 3Q insert are frequently recommended. However, patients continue to report foot pain despite using the 3Q insert. The FL insert has been proposed as an alternative, but objective data examining its efficacy are lacking. METHODS: Twenty female patients with midfoot arthritis participated in the study. Functional outcomes were assessed using the Foot Function Index-Revised (FFI-R). Plantar loading during walking was measured in the following conditions: shoe only, shoe with 3Q insert, and shoe with FL insert. Repeated-measures analyses of variance with post hoc analyses were used for statistical analysis. RESULTS: FL insert use for 4 weeks resulted in a 12% improvement in total FFI-R score (mean ± SD before, 35.6 ± 10.9; after, 31.1 ± 9.8 [P = .03]). FL insert use resulted in a 20% reduction in medial midfoot average pressure loading (mean ± SD, 64.8 ± 20.4 and 51.0 ± 15.4 kPa, with 3Q and FL insert respectively [P = .015]) and an 8.5% reduction in medial midfoot contact time (mean ± SD, 84.9% ± 6.4% and 76.4% ± 7.1% of stance, with 3Q and FL insert respectively [P<.01]), compared to the 3Q insert. No differences in plantar loading were discerned between the shoe-only and FL conditions. CONCLUSION: Symptomatic improvement in patients with midfoot arthritis treated with a FL insert was accompanied by reduced magnitude and duration of loading under the medial midfoot. These preliminary outcomes suggest that the FL insert may be a viable alternative in the conservative management of patients with midfoot arthritis. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2009;39(7):522-531. doi:10.2519/jospt.2009.2900

KEY WORDS: Lisfranc, orthoses, tarsometatarsal

J Orthop Sports Phys Ther 1985;7(3):107-109.

J Orthop Sports Phys Ther 1987;9(5):190-193.

The purpose of this study was to determine if differences exist in peak torque and total work performed when the Johnson Anti-Shear Device was utilized as compared to the standard shin adapter during knee extension. The Cybex II, in conjunction with the HUMAC computer system was used in this study. Twenty-seven healthy subjects, with no history of knee pathology, were tested on successive days at speeds of 60°/sec and 180°/sec. Results demonstrated a significant decrease (p < 0.05) in peak torque at low speeds as well as total work performed at high speeds when using the anti-shear device. The findings indicate that the clinician/researcher must be consistent with the choice of shin pad in order to ensure valid, reliable data.

J Orthop Sports Phys Ther 1988;9(8):284-286.

Study Design: Repeated-measures analysis of variance. Objective: To examine the effect of 2 different orthotic posting designs on first metatarsophalangeal (first MTP) joint kinematics during gait. Background: Common orthotic designs used to control abnormal pronation incorporate the use of a medial post in the forefoot and/or rearfoot locations. Although this design may favorably alter rearfoot and lower-limb kinematics, the incorporation of a forefoot post has been theorized to negatively impact first MTP joint function by limiting hallux dorsiflexion during push off. An alternative design that has been proposed to be more favorable for function of the hallux and first metatarsal is the medial arch support. Methods and Measures: Eighteen subjects with a mean age of 28.2 years (SD, 8.3 years) completed the study. All subjects were judged to have excessive pronation based on a clinical orthopaedic examination. Two different pairs of orthoses were custom molded for each subject. One design incorporated an extrinsic rearfoot and forefoot post and the second design had a high medial longitudinal arch in combination with an extrinsic rearfoot post. The "Flock of Birds" electromagnetic tracking device was used to collect 3-dimensional position and orientation data of 3 body segments (hallux, first metatarsal, and calcaneus) during the stance phase of walking for 3 conditions (no orthosis and each of the 2 different orthotic designs). A repeated-measures analysis of variance was used to assess differences in first MTP joint dorsiflexion at midstance and during the push-off period of gait, as well as metatarsal declination angle changes during relaxed stance. An exploratory regression analysis was used to investigate factors that related to the change in peak dorsiflexion for the orthotic conditions. Results: Peak first MTP joint dorsiflexion averaged between 38° and 40° across all conditions. Although slight increases in first MTP joint dorsiflexion values were noted with both types of orthotic designs, these differences were not significant at either phase of the stance cycle (P = .50). The metatarsal declination angle in relaxed stance significantly increased (P = .001) under both orthotic conditions. Considerable individual variability was present. For the rearfoot-forefoot posted orthosis, a change in the declination angle of the first metatarsal during relaxed stance with the orthosis was a significant nonlinear predictor of change in peak dorsiflexion during push off. Conclusions: Foot orthoses that incorporate a medial forefoot post do not have a consistent negative effect of reducing first MTP joint dorsiflexion during walking.

J Orthop Sports Phys Ther. 2004;34(6):317-327. doi:10.2519/jospt.2004.1246

Key Words: arch support, first metatarsal joint, hallux, medial orthotic posts

Study Design: Case study of the management of an individual with hallux rigidus deformity. Objective: To describe the outcome of nonoperative and operative treatment, including kinematic and kinetic changes following cheilectomy surgery, for an individual with hallux rigidus deformity. Background: Hallux rigidus is a common disorder of the first metatarsophalangeal joint characterized by progressive limitation of hallux dorsiflexion, prominent dorsal osteophyte formation, and pain. Surgery may be considered when nonoperative management strategies have proven unsuccessful. Kinematic and plantar pressure changes during dynamic activities have not been previously described following cheilectomy surgery for hallux rigidus deformity. Methods and Measures: The patient was a 54-year-old man who sustained a traumatic injury to the great toe. Conservative treatment included nonsteroidal anti-inflammatory drugs, custom insole fabrication, and footwear outersole modification. Because of continued pain, loss of motion, and restrictions in daily activities, the patient elected to have surgery, and a cheilectomy procedure was done. Presurgical and postsurgical kinematic data of first metatarsophalangeal joint motion were collected using an electromagnetic tracking device during clinical motion tests and walking. Peak plantar pressures were assessed during gait. The patient was evaluated preoperatively, at 6 months, and again at 18 months following surgery. Results: The outcome of surgery proved favorable, both subjectively and objectively. Peak dorsiflexion increased significantly (a minimum of 20°) for all clinical tests and walking trials at the first metatarsophalangeal joint when compared with preoperative measurements. Peak plantar pressures also increased over the medial forefoot (68%) and hallux (247%) between preoperative testing and follow-up, indicating increased loading to this region of the foot. Conclusions: Restrictions in motion and daily activities and persistent pain may warrant surgical intervention for individuals with hallux rigidus deformity. A successful outcome, as measured by the patient's self-reported pain, return to recreational activities, and kinematic and plantar pressure changes at the follow-up examination, was demonstrated in this case study.

J Orthop Sports Phys Ther. 1999;29(12):727-735.

Key Words: cheilectomy, electromagnetic device, first metatarsophalangeal joint

Foot orthotics have been used successfully in the treatment of musculoskeletal symptoms associated with structural variations of the foot. Their effectiveness has been primarily addressed through 2-dimensional, frontal plane motion studies of the subtalar joint in individuals considered "clinical pronators. " Recent evidence suggests that assessment of tibial axial rotation in combination with frontal plane analysis of calcaneal inversion/eversion may provide improved understanding of subtalar joint function. The purpose of this study was to examine the effects of semi-rigid foot orthotics on 3-dimensional lower limb kinematics in 20 recreational runners presenting with distinct structural foot characteristics. Radiographic measurements were used to classify subjects into a low or high rearfoot profile group. The results of the kinematic analysis showed a significant orthotic effect for rotations occurring from heel contact to peak tibial internal rotation, as well as in the coupling relationship between tibial axial rotation and calcaneal inversion/eversion. Both groups responded similarly with a mean reduction of 2° in tibial internal rotation. No differences were found for the frontal plane rotations for either group when orthotics were worn. The findings suggest that the maximum effect of orthotics may be realized in the first 50% of stance and related to the changes in tibial axial rotation.

J Orthop Sports Phys Ther. 1995;21(6):317-327.

Key Words: running, kinematics, foot orthotics

The human foot is a unique structure in the animal kingdom, as it is capable of supporting sustained bipedal gait. The foot facilitates upright walking in several ways: 1) load bearing, 2) leverage, 3) shock absorption, 4) balance, and 5) protection. In this article, we discuss the specialized architecture that enables the foot to accomplish these functions.

J Orthop Sports Phys Ther. 1995:21(6):354-360.

Key Words: foot, structure, function

Abnormal scapular kinematics and associated muscle function presumably contribute to shoulder pain and pathology. An understanding of scapular kinematic and electromyographic profiles in asymptomatic individuals can provide a basis for evaluation of pathology. The purpose of this study was to describe normal 3-dimensional scapular orientation and associated muscle activity during humeral elevation. Twenty-five asymptomatic subjects, 19-37 years old, were evaluated. Digitized coordinate data and surface electromyographic signals from the trapezius (upper and lower), levator scapulae, and serratus anterior were collected at static positions of 0°, 90°, and 140° of humeral elevation in the scapular plane. The scapula demonstrated a pattern of progressive upward rotation, decreased internal rotation, and movement from an anteriorly to a posteriorly tipped position as humeral elevation angle increased. Electromyographic activity of all muscles studied increased with increased humeral elevation angles. Differences between mean values at all elevation angles for all variables were significant (p < .05), except for the lower trapezius between the 90° and 140° humeral angles. The results of this study suggest assessment of scapular tipping and internal rotation as well as upward rotation may be necessary to understand pathologies of the shoulder that are related to abnormal scapular kinematics.

J Orthop Sports Phys Ther. 1996;24(2):57-65.

Key Words: scapula, electromyography, shoulder joint

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 II PTTD to asymptomatic controls.
Background: Abnormal foot postures in subjects with stage II 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 II 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<.005) during specific phases of stance. Subjects with PTTD demonstrated significantly greater rearfoot eversion (P<.004) and MLA angles (P<.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<.002) and a forefoot abduction angle (P<.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 II PTTD.

J Orthop Sports Phys Ther. 2006;36(9):635-644. doi:10.2519/jospt.2006.2293

Key Words: biomechanics, foot kinematics, tendinopathy, tendonitis