The Orthopaedic Section of the American Physical Therapy Association presents this sixth set of clinical practice guidelines on Achilles pain, stiffness, and muscle power deficits that are characteristic of Achilles Tendinitis. These clinical practice guidelines are linked to the International Classification of Functioning, Disability, and Health (ICF). The purpose of these practice guidelines is to describe evidence-based orthopaedic physical therapy clinical practice and provide recommendations for (1) examination and diagnostic classification based on body functions and body structures, activity limitations, and participation restrictions, (2) interventions provided by physical therapists, (3) and assessment of outcome for common musculoskeletal disorders.

J Orthop Sports Phys Ther. 2010:40(9):A1-A26. doi:10.2519/jospt.2010.0305

KEY WORDS: APTA, clinical practice guidelines, ICD, ICF, Orthopaedic Section

STUDY DESIGN: Case report. BACKGROUND: No head-to-head comparisons of different orthoses for patients with stage II posterior tibial tendon dysfunction (PTTD) have been performed to date. Additionally, the cost of orthoses varies considerably, thus choosing an effective orthosis that is affordable to the patient is largely a trial-and-error process. CASE DESCRIPTION: A 77-year-old woman was seen with complaints of abnormal foot posture ('my foot is out'), minimal medial foot and ankle pain, and a 3-year history of conservatively managed stage II PTTD. The patient was not able to complete 1 single-limb heel rise on the involved side, while she could complete 3 on the uninvolved side. Ankle strength testing revealed a mild to moderate loss of plantar flexor strength (20%-31% deficit on the involved side), combined with a 22% deficit in isometric ankle inversion and forefoot adduction strength. To assist this patient in managing her flatfoot posture and PTTD, 3 orthoses were considered: an off-the-shelf ankle-foot orthosis (AFO), a custom solid AFO, and a custom articulated AFO. The patient's chief complaint was partly cosmetic (ìmy foot is outî). As decreasing flatfoot kinematics may unload the tibialis posterior muscle, thus prevent the progression of foot deformity, the primary goal of orthotic intervention was to improve flatfoot kinematics. Given the difficulties in clinical approaches to evaluating flatfoot kinematics, a quantitative gait analysis, using a multisegment foot model, was used. OUTCOMES: In the frontal plane, all 3 orthoses were associated with small changes toward hindfoot inversion. In the sagittal plane, between 2.7° and 6.1°, greater forefoot plantar flexion (raising the medial longitudinal arch) occurred. There were no differences among the orthoses on hindfoot inversion and forefoot plantar flexion. In the transverse plane, the off-the-shelf design was associated with forefoot abduction, the custom solid orthosis was associated with no change, and the custom articulated orthosis was associated with forefoot adduction. DISCUSSION: Based on gait analysis, the higher-cost custom articulated orthosis was chosen as optimal for the patient. This custom articulated orthosis was associated with the greatest change in flatfoot deformity, assessed using gait analysis. The patient felt it produced the greatest correction in foot deformity. Reducing flatfoot deformity while allowing ankle movement may limit progression of stage II PTTD. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2009;39(11):816-824, Epub 15 October 2009. doi:10.2519/jospt.2009.3107

KEY WORDS: biomechanics, PTTD, tendinopathy

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

J Orthop Sports Phys Ther 2009;39(3):201-209, Epub 2 February 2009. doi:10.2519/jospt.2009.2908

J Orthop Sports Phys Ther 2007;37(11):661-669, published online 12 July 2007. doi:10.2519/jospt.2007.2539

KEY WORDS:  foot kinematics, pronation, tendinopathy, walking

STUDY DESIGN: Two-factor, mixed experimental design. OBJECTIVES: To compare movement patterns of subjects who are anterior cruciate ligament (ACL) deficient and classified as noncopers to controls during early stance of anticipated and unanticipated straight and cutting tasks. BACKGROUND: Altered neuromuscular control of subjects that are ACL deficient and noncoper theoretically influences movement patterns during unanticipated tasks. METHODS AND MEASURES: The study included 16 subjects who are ACL deficient, classified as noncopers, and 20 healthy controls. Data were collected using an Optotrak Motion Analysis System and force plate integrated with Motion Monitor Software to generate knee joint angles, moments, and power. Each testing session included anticipated tasks, straight walking task (ST), and 45° side-step cutting tasks (SSC), followed by a set of unexpected straight walking (STU) and unexpected sidestep cutting (SSCU) tasks in a random order. For all tasks speed was maintained at 2 m/s. Peak knee angle, moment, and power variables during early stance were compared using 2- way mixed-effects ANOVA models. RESULTS: For both the straight and sidestep tasks, the noncoper group did not show a dependence on whether the task was anticipated or unanticipated (group-by-condition interaction) for the knee angle (straight, P = .067; side-step cutting, P = .103), moment (straight, P = .079; side-step cutting, P = .996), and powers (straight, P = .181; side-step cutting, P = .183) during the loading response phase. However, during both straight and side-step cutting tasks, the subjects in the noncoper group used significantly lower knee flexion angles (straight, P = .002; side-step cutting, P = .019), knee moments (straight, P = .005; sidestep cutting, P<.001), and knee powers (straight, P = .013; side-step cutting, P<.001). CONCLUSIONS: This study suggests subjects that are ACL deficient and classified as noncopers use a common abnormal movement pattern of lower knee extensor loading even during unanticipated tasks.  

J Orthop Sports Phys Ther. 2007;37(2):56-64. doi:10.2519/jospt.2007.2292 

KEY WORDS: anterior cruciate ligament, cutting task, knee instability, neuromuscular control

J Orthop Sports Phys Ther. 2003;33(5):273-287.

Key Words: anterior cruciate ligament, biomechanics, kinematics, knee instability

Study Design: Case study. Objective: To compare knee kinematics and moments of nongiving way trials to a giving way trial during a combined stepping and crossover cutting activity. Background: The knee kinematics and moments associated with giving way episodes suggest motor control strategies that lead to instability and recovery of stability during movement. Methods and Measures: A 27-year-old woman with anterior cruciate ligament deficiency reported giving way while performing a combined stepping and crossover cutting activity. A motion analysis system recorded motion of the pelvis, femur, tibia, and foot using 3 infrared emitting diodes placed on each segment at 60 Hz. Force plate recordings at 300 Hz were combined with limb inertial properties and position data to estimate net knee joint moments. The stance time, foot progression angle, and cutting angle were also included to evaluate performance between trials. Results: Knee internal rotation during the giving way trial increased 3.2° at 54% of stance relative to the nongiving way trials. Knee flexion during the giving way trial increased to 33.1° at 66% of stance, and the knee moment switched from a nominal flexor moment to a knee extensor moment at 64% of stance. The knee abductor moment and external rotation moment during the giving way trial deviated in early stance. Conclusions: The observed response to the giving way event suggests that increasing knee flexion may enhance knee stability for this subject. The transverse and frontal plane moments appear important in contributing to the giving way event. Further research that assists clinicians in understanding how interventions can impact control of movements in these planes is necessary.

J Orthop Sports Phys Ther. 2001;31(9):481-495.

Key Words: anterior cruciate ligament deficiency, kinematics, knee kinetics

Study Design: Two-factor mixed-design study, with factors including group (control and noncoper) and task (sidestep, crossover, and straight). Objectives: To compare the knee and hip joint angles and moments of control subjects and subjects with an anterior cruciate ligament (ACL) deficient knee classified as noncopers, during a sidestep, crossover, and straight-ahead task. Background: Subjects with ACL deficiency primarily note difficulty with cutting tasks as opposed to straight-ahead tasks. Yet, previous studies have primarily focused on straight-ahead tasks. Methods and Measures: Fifteen subjects with ACL deficiency classified as noncopers, based on the number of giving-way episodes (>1) and global question of knee function (<60%), were included in this study. These subjects (10 male, 5 female; age range, 18-49 years) were compared to a healthy control group (7 male, 7 female; age range, 19-47 years). Position data collected at 60 Hz were combined with anthropometric and ground reaction force data collected at 420 Hz to estimate 3-dimensional knee and hip joint angles and moments. All subjects performed 3 tasks including a step and 45° sidestep cut, step and 45° crossover cut, and step and proceed straight. Two-way mixed-model ANOVAs were used to compare peak angle and moment variables between 10% to 30% of stance. Results: The ACL-deficient noncoper group had 1.8° to 5.7° less knee flexion angle compared to the control group across tasks (P<.043). The ACL-deficient noncoper group used 22% to 27% lower knee extensor moment during weight acceptance compared to the control group (P<.001). The sagittal plane hip extensor moments were 34% to 39% higher in the ACL-deficient noncoper group compared to the control group (P<.025). Hip frontal (P<.037) and transverse plane (P<.04) moments also distinguished the ACL-deficient noncoper from the control group. Conclusions: This study suggests that individuals who do not cope well after ACL injury rely on a hip control strategy during cutting tasks.

J Orthop Sports Phys Ther. 2005;35(8):531-540. doi:10.2519/jospt.2005.1763

Key Words: ACL, biomechanics, knee stability

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