STUDY DESIGN: Case-control and reliability study. OBJECTIVES: To compare foot and ankle characteristics between individuals with and without patellofemoral pain syndrome (PFPS) and to identify reliable weight-bearing foot and ankle measurements for use in future research on PFPS. BACKGROUND: PFPS is a common presentation to sports medicine and orthopaedic clinics. Characteristics of the foot and ankle are often linked with PFPS development, although evidence to support this link is equivocal and there is a lack of consensus on how best to evaluate these characteristics. METHODS: A variety of weight-bearing foot and ankle measurements were evaluated by 3 raters of varying experience in 20 individuals with PFPS and 20 controls matched by age, sex, height, and body mass. Between-group comparisons were made for each measurement using data from an experienced podiatrist blinded to group assignment of the participants. Intrarater and interrater reliability was compared between all measurements using the first 15 participants from each group. RESULTS: Between-group comparisons showed that the individuals in the PFPS group had a more pronated foot posture when assessed by the foot posture index and longitudinal arch angle, and for all measurements relative to subtalar joint neutral. Foot posture index, normalized navicular drop, and calcaneal angle relative to subtalar joint neutral measurements also possessed high reliability in both groups when used by experienced raters. Reliability was not influenced by rater experience or the presence of PFPS for relaxed-stance foot posture measurements. Both tester inexperience and the presence of PFPS reduced reliability for all measurements of foot posture relative to subtalar joint neutral and measurement of weight-bearing ankle dorsiflexion. CONCLUSION: The foot posture index, normalized navicular drop, and calcaneal angle relative to subtalar joint neutral are all reliable and sensitive to group differences when used in a population with PFPS. Individuals with PFPS possess a more pronated foot posture and increased foot mobility compared to controls. Prospective evaluation of these measurements is now required to determine whether they contribute to the development of PFPS.

J Orthop Sports Phys Ther 2010;40(5):286-296, Epub 12 April 2010. doi:10.2519/jospt.2010.3227

KEY WORDS: aetiology, chondromalacia, knee, posture

STUDY DESIGN: Systematic review of case control studies. OBJECTIVES: To identify and analyze demographic and structural factors associated with hallux limitus/rigidus. METHODS: A literature search was conducted across several electronic databases (Medline, EMBASE, CINAHL, and PubMed) using the following terms: hallux limitus, hallux rigidus, metatarsophalangeal joint, and big toe. Methodological quality of included studies was evaluated using the Quality Index. To evaluate the magnitude of differences between cases and controls, odds ratios were calculated for dichotomous variables and effect sizes (Cohen d) were calculated for continuous variables. RESULTS: The methodological quality of the 7 included studies was moderate, with Quality Index scores ranging from 6 to 11 out of a possible score of 14. The overall mean age for the case group was 44.8 years (mean range, 23.4-54.9 years) and for the control group was 39.6 years (mean range, 23.4-58.8 years). There was a similar distribution of males and females across case and control groups. All studies used plain film radiography to assess foot structure. Cases were found to have a dorsiflexed first metatarsal relative to the second metatarsal, a plantar flexed forefoot on the rearfoot, reduced first metatarsophalangeal joint range of motion, a longer proximal phalanx, distal phalanx, medial sesamoid, and lateral sesamoid, and a wider first metatarsal and proximal phalanx. Measures of foot posture and arch height were not found to substantially differ between cases and controls. CONCLUSIONS: This review of case control studies indicates that several variables pertaining to the structure of the first metatarsophalangeal joint may be associated with hallux limitus/rigidus. These findings have implications for the conservative and surgical treatment of the condition. LEVEL OF EVIDENCE: Prognosis, level 2a–.

J Orthop Sports Phys Ther 2009;39(10):733-742. doi:10.2519/jospt.2009.3003

KEY WORDS: arthritis, foot, hallux limitus, hallux rigidus, podiatry, risk factor

STUDY DESIGN: Systematic literature review. OBJECTIVE: To evaluate the quality and scope of recently published systematic reviews on the topic of patellofemoral pain syndrome (PFPS) and to provide an overview of their findings. BACKGROUND: PFPS is a commonly treated condition. There is a large body of literature on conservative nonpharmacological interventions for PFPS, including multiple systematic reviews, which require critiquing and summarizing. METHODS AND MEASURES: A systematic review of systematic reviews on conservative nonpharmacological treatment strategies for PFPS was performed. Published systematic reviews were identified by searching MEDLINE, EMBASE, CINAHL, SPORTDISCUS, Current Contents, The Cochrane Library, and PEDro electronic databases from the year 2000 until May 2007. Cited reference searches of each author in the Web of Science complemented this search. Review quality was evaluated by a specifically designed scale and only high-quality reviews were retained to validate and summarize reported findings. RESULTS: Ten reviews met the inclusion criteria. Among them, only 3 were considered to be high quality, covering exercise, foot and knee orthoses, and ultrasound intervention for PFPS. None of the 3 reviews included literature published after the year 2001. Some limited evidence for the use of exercise, exercise combined with taping, and exercise combined with the use of a Protonics brace was found for treatment of individuals with PFPS. CONCLUSION: Published systematic reviews and clinical trials need to be conducted with more rigorous methodological design. There are no up-to-date, high-quality systematic reviews covering conservative nonpharmacological treatments for individuals with PFPS, which indicates that updates in all areas are needed. LEVEL OF EVIDENCE: Therapy, level 1a.

J Orthop Sports Phys Ther. 2008;38(9):529-541, published online 3 June 2008. doi:10.2519/jospt.2008.2861

KEY WORDS: exercise, literature, orthoses, physical therapy, ultrasound

One of the most fundamental requirements of many statistical analysis procedures is that each data point must represent an independent observation. However, researchers in the field of musculoskeletal therapy are often faced with the dilemma of how to manage measurements obtained from both limbs of the same participant. In this situation, do we have a sample size of 30 participants, or 60 limbs? Similar problems are encountered in podiatry, where it is not uncommon for researchers to measure both feet, and ophthalmology, where measurements are frequently performed on both eyes. Failing to address the conceptual and statistical issues associated with paired data is common in musculoskeletal research and has the potential to seriously distort research findings.

J Orthop Sports Phys Ther. 2005; 35(8):477-478. doi:10.2519/jospt.2005.0108

Key Words: paired data, research, statistics

Study Design: Concurrent validity study. Objectives: To determine the validity of 3 clinical methods for assessing static foot posture in older people. Background: Variations in the structure of the medial longitudinal arch are thought to influence lower extremity function; however, the validity of clinical measurements has not been fully established. Methods and Measures: Clinical measurements of arch index (AI), navicular height (NH), and Foot Posture Index (FPI) were performed on 95 subjects (31 men and 64 women), aged 62 to 94 years (mean ± SD, 78.6 ± 6.5 years). These clinical measurements were then correlated with 3 arch-related measurements from radiographs: navicular height (NHr), calcaneal inclination angle (CIA), and calcaneal first metatarsal angle (C1MA). Results: All 3 clinical measures demonstrated significant associations with each of the radiographic parameters (P<.01). NH was highly correlated with NHr (Pearson r = 0.79), followed by C1MA (r = –0.53), and CIA (r = 0.44). The AI was highly correlated with the C1MA (r = 0.71) and CIA (r = –0.68), but only moderately correlated with NHr (r = 0.52). The FPI demonstrated weaker correlations with the radiographic parameters (NHr, r = 0.59; CIA, r = 0.36; C1MA, r = 0.42). Conclusion: Clinical measurements of AI, NH, and FPI provide valid information regarding the structure of the medial longitudinal arch; however, each test may reflect different aspects of arch structure. NH would appear to be the most useful clinical measure, as it is simple to perform and provides an accurate representation of the skeletal alignment of the medial longitudinal arch. Further refinement of the clinical measurement of NH is now required to improve its moderate intratester and intertester reliability.

J Orthop Sports Phys Ther. 2005;35(8):479-486. doi:10.2519/jospt.2005.2048

Key Words: aged, arch, clinical measurement, radiographic