STUDY DESIGN: Controlled laboratory study using a single cohort design. OBJECTIVES: To determine if balance in older adults could be significantly improved with foot orthotic intervention. BACKGROUND:  Poor balance has been associated with risk for falls. Limited evidence exists indicating that foot orthoses influence balance. METHODS: Thirteen individuals older than 65 who reported at least 1 unexplained fall during the past year and who demonstrated poor balance participated in the study.  Subjects were tested for one-leg stance, tandem stance, tandem gait, and alternating step tests during the first (SCREEN) and second (PRE) sessions prior to foot orthotic intervention. Tests were repeated during the second testing session immediately after custom foot orthotic intervention (POST), and 2 weeks following foot orthotic use (FU).  SCREEN and PRE measures were compared for stability using absolute difference computations and Friedman's rank test.  PRE, POST, and FU data were analyzed using the Friedman's rank test (alpha = 0.05) with Bonferroni correction for multiple post-hoc comparisons. RESULTS: Each balance measure was statistically equivalent between the SCREEN and PRE measurements.  One-leg stance times for PRE were significantly less than POST (P = .002) and FU (P = .013) measurements.  Tandem stance times for PRE were significantly less than POST (P = .013) and FU (P = .013) measurements.  Steps taken for the tandem gait test during the PRE measurements were significantly fewer than steps taken for the FU test (P = .007).  Steps taken during the alternating step test for the PRE test were significantly fewer than steps taken during the POST (P = .002) and FU (P =.001) tests.  POST and FU measurements were not significantly different for any of the 4 outcome measures. CONCLUSIONS: The results provide preliminary evidence that foot orthoses can effect improvement in balance measures for older adults.

J Orthop Sports Phys Ther, Epub 25 January 2012. doi:10.2519/jospt.2012.3944

KEY WORDS: falls, geriatrics, orthoses, postural control, stability

J Orthop Sports Phys Ther 1987;9(1):33-39.

The purposes of this project were to evaluate the reliability of a method for quantitative assessment of contact thermograms; and to test the null hypotheses of no difference in temperature distribution patterns between dominant and nondominant patellar tendon sites and between dominant and nondominant common wrist extensor tendon sites. Both tendon sites were evaluated for 17 normal subjects using contact thermography. A mean temperature was calculated over each tendon site in each subject. Inter-rater reliability for eight pairs of mean temperature calculations by two investigators was r = 0.88. Paired t-tests indicated no statistically significant difference (α = 0.05) between dominant and nondominant extremities for either of the tendon sites. The method of thermogram analysis presented in this paper can be used reliably to quantify the assessment of contact thermograms. Clinicians who detect temperature asymmetry at either of the two tendon sites analyzed should attribute this asymmetry to unilateral pathology and not to differences in temperature distribution caused by dominance.

J Orthop Sports Phys Ther 1989;10(10):412-417.

The purpose of this study was to compare the effectiveness of the Johnson Anti-Shear Accessory (JASA) and the standard dynamometer accessory (SDA) in controlling tibial translation for isometric knee flexion and extension exercise on the Cybex^® II. The subject was a 26-year-old male with known anterior cruciate ligament (ACL) deficiency of the left knee. The subject performed maximum isometric muscle contractions for JASA and SDA conditions. Medial-lateral roentgenograms were obtained while the subject maintained isometric knee flexion and extension muscle contractions at three positions of knee flexion. JASA and SDA trials were analyzed for one extension position and one flexion position. The authors compared JASA and SDA conditions for magnitude of contact pad force and for degree of tibial translation evidenced on the roentgenograms. Tibial translation was greater and contact pad force was less for the SDA condition than the JASA condition. The results suggest the JASA is useful in protecting ACL surgical reconstructions, the partially torn ACL, and secondary supporting structures of the knee as patients perform isometric exercise on Cybex instrumentation.

J Orthop Sports Phys Ther 1990;11(11):547-553.

The purpose of this study was to compare the effectiveness of Swede-O-Universal^® Ankle Support and Aircast^® Sport-Stirrup^TM orthoses and ankle tape in restricting eversion-inversion before and after exercise. Subjects were eight males and eight females with no history of ankle injury during the six months prior to testing, neurological condition, lower extremity arthritis, lower extremity fracture, cardiac condition, or balance problems. A Biodex dynamometer and computer were used to impose passive moments and to measure eversion and inversion of an ankle support system prior to application, following application, and following 10 minutes of figure-of-eight running and 20 unilateral toe raises. Both ankles of each subject were assessed for each of the three ankle support systems. All support systems significantly reduced eversion and inversion following application and following exercise. Eversion increased significantly following exercise for all support systems, and inversion increased significantly for the tape system. Eversion measurements did not differ among the support systems following exercise. Inversion measurements following exercise were less for the tape and Aircast systems than the Swede-O-Universal system. The authors discuss additional factors involved in selecting an ankle support system. The results should assist clinicians in selecting ankle support systems designed to protect against initial and recurrent ankle sprain injuries.

 J Orthop Sports Phys Ther 1991;13(1):11-19.

The purpose of this study was to assess intramachine and intermachine reliability of the Biodex and Cybex^® II. Subjects were 10 healthy volunteers between ages 21 and 40. Both legs of each subject were tested twice on each isokinetic device for concentric knee flexion and extension peak torque and angular work at 60°/sec and 180°/sec. The approximate knee range of motion (ROM) for both machines was 0 to 150° flexion. The intraclass correlation coefficient (ICC) was used to assess reliability for: 1) raw data from each instrument, and 2) windowed data from ranges of motion that were common to all subjects and that excluded Cybex II impact artifact data. Repeated measures ANOVA procedures were used to test for differences among the four testing sessions for the windowed data. Intramachine reliability using raw data was 0.38 to 0.89 for the Cybex II and 0.67 to 0.97 for the Biodex. Intramachine reliability using windowed data was 0.90 to 0.96 for the Cybex II and 0.89 to 0.97 for the Biodex. Intermachine reliability was 0.41 to 0.93 using raw data and 0.79 to 0.95 using windowed data. Significant differences were detected between measurements on the two devices for six of the eight dependent variables. The results suggest clinicians can improve reliability of isokinetic measurement on the Biodex and Cybex II by assessing data within the middle segments of ROM on each device and by excluding Cybex II impact artifact data. The results also indicate that measurements on one of the two devices tested in this study may not be generalized to the other device.

J Orthop Sports Phys Ther 1991;13(6):329-335.

Selected quadriceps muscle action may influence the movement path of the patella in the malaligned patellofemoral joint. The purpose of this study was to investigate the effects of arc of motion, angular velocity, and contraction type on the vastus medialis obliques:vastus lateralis (VMO:VL) absolute averaged electromyographic (AAEMG) ratio. Thirty healthy subjects performed maximum concentric and eccentric isokinetic quadriceps muscle contractions on the Kin-Com^® dynamometer at velocities of 60 and 120°/sec. Electromyography data from the VMO and the VL were acquired, and a VMO:VL AAEMG ratio was calculated for all combinations of the three independent variables. The results indicate that the VMO:VL AAEMG ratio for the 60°-85° arc was significantly greater than the ratio for the 35°-60° arc (p < 0.05), the ratio for the 60°-85° arc was significantly greater than the ratio for the 10°-35° arc (p < 0.05), and the ratio for the 35°-60° arc was significantly greater than the ratio for the 10°-35° arc (p < 0.05). The VMO:VL AAEMG ratio for concentric contraction at 120°/sec was significantly greater than the ratio for concentric contraction at 60°/sec (p < 0.05) and was significantly greater than the ratio for eccentric contraction at 120°/sec (p < 0.05). The results indicate that the VMO:VL AAEMG ratio is affected by isokinetic exercise parameters. The use of isokinetic exercise parameters that produce a greater VMO:VL AAEMG ratio may be effective in altering muscular imbalance between the VMO and VL.

J Orthop Sports Phys Ther 1991;14(6):256-262.

Key Words: electromyography, muscular imbalance, patellofemoral dysfunction

J Orthop Sports Phys Ther 1992;15(1):24-31.

Key Words: ankle muscle strength, anthropometric measures, modeling

Clinicians are often faced with the task of selecting ankle orthoses for patients who have incurred an ankle sprain injury. The purpose of this study was to compare the effectiveness of the DonJoy^® Ankle Ligament Protector and the Aircast^® Sport-Stirrup^TM in limiting foot and ankle motion before and after exercise. Subjects were eight males and eight females with no history of ankle injury during the 6 months prior to testing, neurological condition, lower extremity arthritis, lower extremity fracture, or cardiac or balance problems. A Biodex dynamometer and computer were used to impose passive moments and to measure eversion and inversion prior to application of the ankle orthoses, following application, and following 10 minutes of figure-of-eight running and 20 unilateral toe raises. Both ankles of each subject were assessed for each ankle orthosis. Subjects also rated the orthoses for comfort, stability, and cosmetic acceptability. Both ankle orthoses significantly reduced eversion and inversion following application and following exercise compared to preapplication measurements. Eversion measurements increased significantly following exercise for both ankle orthoses. Eversion measurements for the two orthoses did not differ following exercise. Inversion measurements following application and following exercise were less for the DonJoy Ankle Ligament Protector orthosis than for the Aircast Sport-Stirrup orthosis. The results of this study may assist clinicians in selecting either of these orthoses for use in protection against ankle sprain injury.

J Orthop Sports Phys Ther 1992;16(2):60-67.

Key Words: ankle, sprain, exercise, orthoses

Chronic tendinitis is a common and debilitating musculoskeletal pathology that can be particularly recalcitrant to treatment. Details of the composition and structure of tendon are presented, enabling clinicians to understand the mechanical function of tendon under different loading conditions and the various mechanisms of tendinitis injury. The effects of exercise, disuse, the incidence of injury, and tendinitis terminology are discussed. Other purposes of this paper are to describe the natural course of tendon healing, the clinical assessment of tendinitis, and suggested treatments for chronic tendinitis. The paper concludes with two case studies. Information in this paper should assist the clinician in treating chronic tendinitis more successfully.

J Orthop Sports Phys Ther 1992;16(6):248-261.

Key Words: tendinitis, injury, rehabilitation

J Orthop Sports Phys Ther 1993;17(3):133-143.

Key Words: biomechanics, rehabilitation, roentgenogram

STUDY DESIGN: Preassessment and postassessment of treatment intervention. OBJECTIVE: To determine the changes in pain and disability secondary to shoe lift intervention for subjects with chronic low back pain (LBP) who have a limb length inequality (LLI). BACKGROUND: Previous reports have suggested that LLI may be a cause of LBP. Most prior studies of lift therapy for management of LLI in patients with LBP have lacked clear guidelines for clinicians regarding the implementation of shoe lift intervention. METHODS AND MEASURES: Twelve subjects (6 male, 6 female) between the ages of 19 and 62 years with LLI (6.4-22.2 mm) and chronic LBP (1-30 years) participated. Visual analog scale (VAS) pain ratings and disability questionnaire scores were acquired before and after lift intervention. Subjects determined their lift height based on resolution of LBP symptoms. RESULTS: Subjects experienced relief of general pain symptoms (P = .0006) and pain associated with standing (P = .002) following lift intervention, with minimally clinically important (MCID) reductions in general pain for 9 of 12 subjects and MCID reductions in standing pain for 8 of 10 subjects.   Subjects also had less disability on the disability questionnaire (P = .001) following the intervention, with 9 of 12 subjects experiencing MCID reductions in disability. CONCLUSION: Shoe lifts may reduce LBP and improve function for patients who have chronic LBP and an LLI. Randomized controlled trials are needed to assess the efficacy of this intervention. 

J Orthop Sports Phys Ther. 2007;37(7):380-388, published online 29 May 2007. doi:10.2519/jospt.2007.2429

KEY WORDS:  leg length inequality, low back pain, rehabilitation

J Orthop Sports Phys Ther. 2007;37(4):186-191. doi:10.2519/jospt.2007.2327

J Orthop Sports Phys Ther. 2006; 36(12):942-953. doi:10.2519/jospt.2006.2336 

Key Words: balance, feet, pronation, supination

Objective:To determine the impact of custom semirigid foot orthotics on pain and disability for individuals with plantar fasciitis.

Background: Few studies have examined the efficacy of foot orthotics for plantar fasciitis, and no single study has yet examined the effects of semirigid foot orthotics on an established quality-of-life instrument.

Methods and Measures: Eight men and 7 women (mean ages 44.7 ± 9.0 years) who reported having plantar fasciitis symptoms for an average of 21.3 ± 23.7 months participated in the study. Subjects were timed for a 100-m walk at a self-selected speed, then they rated the pain they experienced during the walk using a 10-cm visual analog scale. Subjects also completed the pain and disability subsections of the Foot Function Index questionnaire. All measures were acquired before the fabrication of custom semirigid foot orthotics and 12 to 17 days following onset of foot orthotic use.

Results: Postorthotic 100-m walk times were not significantly different (t = 0.39, P = 0.70) than preorthotic values. Postorthotic pain ratings (mean = 0.7 ± 0.7) for the 100-m walk were significantly less than (Wilcoxon t =1,P < 0.005) preorthotic pain ratings (mean = 3.0 ± 1.7). Postorthotic Foot Function Index pain subsection ratings (Wilcoxon t = 0, P < 0.005) were significantly less than preorthotic ratings, demonstrating a 66% reduction in pain ratings. Postorthotic Foot Function Index disability subsection ratings (Wilcoxon t =0,P < 0.005) were significantly less than preorthotic ratings, demonstrating a 75% reduction in disability ratings.

Conclusion: Custom semirigid foot orthotics may significantly reduce pain experienced during walking and may reduce more global measures of pain and disability for patients with chronic plantar fasciitis.

J Orthop Sports Phys Ther. 2002; 32(4):149–157.

Key Words: heel pain, orthotics, plantar fasciitis

Objectives: To determine the reliability of the one-arm hop test and the effects of upper-extremity dominance on test scores for 2 athletic groups.

Background: Limited information is available regarding functional performance tests of the upper extremity that involve axial loading. Methods and Measures: Thirteen male collegiate wrestlers (mean age, 20.3 ± 1.6 years) and 13 male collegiate football players (mean age, 20.0 ± 1.7 years) without upper-extremity pathology participated in the study. Subjects were trained to perform the one-arm hop test, starting from a one-arm push-up position and then hopping as quickly as possible onto and off of a 10.2-cm platform 5 times. Subjects returned to the test site 1 to 2 days later and were timed for 2 trials of the one-arm hop test for each upper extremity.

Results: Within-session ICC2,1 reliability values were 0.78 for the football players and 0.81 for the wrestlers. Mean absolute differences between trials were 0.64 seconds for the football players and 0.47 seconds for the wrestlers. Trial 2 performance times were significantly faster than trial 1 times for the wrestlers. Although performance time for the nondominant side was on average 4.4% slower than that of the dominant side, performance times for the dominant side were not significantly different from those of the nondominant upper extremities.

Conclusions: The results provide preliminary evidence that the one-arm hop test may be a reliable upper-extremity functional performance test with sufficient training of the subject. Uninjured upper-extremity performance for the one-arm hop test may be useful as a basis for comparing performance of an injured contralateral upper extremity.

J Orthop Sports Phys Ther. 2002; 32(3):98–103.

Key Words: functional performance test, upper extremity

The purpose of this paper is to review relevant literature concerning limb length inequalities in adults and to make recommendations for assessment and intervention based on the literature and our own clinical experience. Literature searches were conducted in the MEDLINE, PubMed, and CINAHL databases. Limb length inequality and common classification criteria are defined and etiological factors are presented. Common methods of detecting limb length inequality include direct (tape measure methods), indirect (pelvic leveling), and radiological techniques. Interventions include shoe inserts or external shoe lift therapy for mild cases. Surgery may be appropriate in severe cases. Little agreement exists regarding the prevalence of limb length inequality, the degree of limb length inequality that is considered clinically significant, and the reliability and validity of assessment methods. Based on correlational studies, the relationship between limb length inequality and orthopaedic pathologies is questionable. Stronger support for the link between low back pain (LBP) and limb length inequality is provided by intervention studies. Methods involving palpation of pelvic landmarks with block correction have the most support for clinical assessment of limb length inequality. Standing radiographs are suggested when clinical assessment methods are unsatisfactory. Clinicians should exercise caution when undertaking intervention strategies for limb length inequality of less than 5 mm when limb length inequality has been identified with clinical techniques. Recommendations are provided regarding intervention strategies.

J Orthop Sports Phys Ther. 2003;33(5):221-234.

Key Words: assessment, leg length discrepancy, leg length inequality, treatment, unequal leg lengths

Study Design: Cross-sectional study. Objective: To determine if a difference exists in toe flexors strength and passive extension range of motion of the first metatarsophalangeal joint between individuals with unilateral plantar fasciitis and control subjects. Background: Weakness of the dynamic longitudinal arch supporters and shortening of the plantar fascia have been suggested as etiologic factors for plantar fasciitis. Methods and Measures: Twenty subjects with unilateral plantar fasciitis participated in the study. Subjects had had symptoms for an average (±SD) of 19.9 ± 33.2 months prior to participating in the study. Twenty control subjects matched for sex and age were also tested. Each subject was measured bilaterally for passive extension range of motion of the first metatarsophalangeal joint and peak resistance force observed during an isometric test of toe flexors strength. Results: Subjects with unilateral plantar fasciitis demonstrated weaker toe flexors (P<.05) than the control subjects. A significant main effect for feet also indicated that the toe flexors for the involved feet were significantly weaker than the uninvolved feet (P<.05) of subjects with unilateral plantar fasciitis. Passive extension range of motion of the first metatarsophalangeal joint was not significantly different between the involved and the uninvolved feet for subjects with plantar fasciitis. Conclusion: Results for our subjects indicate that the extensibility of soft tissues influencing extension of the first metatarsophalangeal joint was not related to the presence of plantar fasciitis. Additional research is needed to determine if toe flexors weakness is a cause or a result of plantar fasciitis and if strengthening regimes for the toe flexors are effective interventions for plantar fasciitis.

J Orthop Sports Phys Ther. 2003;33(8):468-478.

Key Words: biomechanics, foot, mobility, muscle strength

Lateral ankle sprains are one of the most common injuries incurred in recreational and competitive athletics. These injuries have a significant impact in terms of cost, athletic participation, and activities of daily living. Prophylactic ankle braces are often used to reduce the risk of injury recurrence when individuals return to athletic participation. The purpose of this clinical commentary is to review the literature and provide our own experience relative to the use of prophylactic ankle bracing. Relatively high incidence rates of ankle sprain injury have been reported for basketball and soccer athletes, military trainees, and individuals with a previous history of ankle sprain injury. Semirigid and laced ankle braces have significantly reduced the incidence of initial and recurrent ankle sprain injuries in athletic and military samples. With few exceptions, these braces do not appear to affect functional performance adversely. The prophylactic use of semirigid ankle braces appears warranted to reduce the incidence of initial and, in particular, recurrent ankle sprain injuries for individuals who participate in activities that have the highest risk for these injuries. Additional research is needed to evaluate the many new braces that are available and in use and their influence on the incidence of ankle sprain injury and functional performance.

J Orthop Sport Phys Ther. 2003;33(10):572-577.

Key Words: brace, compliance, incidence, injury, orthosis, performance

Foot orthoses often are prescribed for patients with patellofemoral pain. The purpose of this clinical commentary is to review the theoretical and research basis that might support this intervention and to provide our own clinical experience in providing foot orthoses for these patients. Literature is reviewed regarding (1) the effects of foot orthoses on pain and function, (2) the relationship between foot and lower-extremity/patellofemoral joint mechanics, (3) the effects of foot orthoses on lower-extremity mechanics, and (4) the effects of foot orthoses on patellofemoral joint position. The literature and our own clinical experience suggest that patients with patellofemoral pain may benefit from foot orthoses if they also demonstrate signs of excessive foot pronation and/or a lower-extremity alignment profile that includes excessive lower-extremity internal rotation during weight bearing and increased Q angle. The mechanism for foot orthoses having a positive effect on pain and function for these patients may include (1) a reduction in internal rotation of the lower extremity; (2) a reduction in Q angle; (3) reduced laterally-directed soft tissue forces from the patellar tendon, the quadriceps tendon, and the iliotibial band; and (4) reduced patellofemoral contact pressures and altered patellofemoral contact pressure mapping. Foot orthoses may be a valuable adjunct to other intervention strategies for patients who present with the previously stated structural alignment profile.

J Orthop Phys Ther. 2003;33(11):661-670.
 

Key Words: function, kinematics, knee pain, lower extremity, patella

Study Design: Repeated-measures analysis of intervention. Objectives: To determine the effects of foot orthoses on quality of life for individuals with patellofemoral pain who demonstrate excessive foot pronation. Background: Foot orthoses are a common intervention for patients with patellofemoral pain. Limited information is available, however, regarding the effects of foot orthoses on quality of life for these patients. Methods and Measures: Sixteen subjects with patellofemoral pain who also exhibited signs of excessive foot pronation were studied. Subjects underwent a 2-week period of baseline study followed by custom foot orthotic intervention. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was administered to subjects at the time of screening, just prior to foot orthotic intervention, and at 2 weeks and 3 months following foot orthotic intervention. Results: Wilcoxon matched-pairs signed-rank test results indicated statistically significant improvements in the pain and stiffness subscales 2 weeks following the start of foot orthotic intervention. All WOMAC subscale scores were significantly improved at 3 months compared with preintervention measurements. Conclusions: Custom-fitted foot orthoses may improve patellofemoral pain symptoms for patients who demonstrate excessive foot pronation.

J Orthop Sports Phys Ther. 2004;34(8):440-448. doi:10.2519/jospt.2004.1384

Key Words: biomechanics, knee pain, physical function, stiffness

Study Design: A mixed design for kinetic comparison of 2 types of one-handed backhand strokes and 2 skill levels in tennis. Objectives: To develop and evaluate a model to estimate the impact force on the racquet during tennis stroke, and to compare the peak impact force between one-handed backhand stroke with a long backswing and one-handed backhand stroke with a short backswing and between the beginning and advanced players. Background: A one-handed backhand stroke is commonly used in tennis and may be associated with many upper extremity over-use injuries. An understanding of kinetics of the backhand stroke is essential for understanding injury mechanisms and prevention. Methods and Measures: Five male advanced tennis players and 4 male and 1 female beginning tennis players participated. Mean age was 32.2 ± 7.0 years. Each subject was instructed to use the 2 types of one-handed backhand strokes to hit balls from a tennis ball machine. Three-dimensional coordinates of critical body and racquet landmarks were obtained. A mathematical model was developed to estimate the contact duration and the peak impact force during a stroke. Results: The estimated peak impact forces were reproducible and comparable to those reported in the literature from direct measurements. A one-handed backhand stroke with a short backswing had a significantly shorter contact duration (0.008 ± 0.003 seconds) and a greater peak resultant impact force (330.0 ± 140.7) than that with a long backswing (0.016 ± 0.004 seconds and 180.8 ± 49.1 N). Skill level did not significantly affect the peak resultant impact force. Conclusion: A long backswing in a one-handed backhand stroke may reduce the load on the upper extremity and may assist in reducing the risks of tennis-related upper extremity over-use injuries.

J Orthop Sports Phys Ther. 2001;31(5):247-254.

Key Words: over-use injury, tennis, upper extremity load

Study Design: Prospective analysis of relationship between lifting capacity and multiple anthropometric variables. Objectives: To determine the relationship between lifting capacity and anthropometric variables and to model this relationship quantitatively. Background: Low-back injuries commonly occur in individuals who perform lifting tasks. Objective data are needed to determine preinjury lifting capacity that, in turn, might be used to guide decisions during rehabilitation of these injuries. Methods and Measures: We recorded age and sex and measured the following variables for 35 men and 23 women between the ages of 22 and 40: height, weight, percentage of body fat, torso height, pelvic width, pelvic girth, arm length, thigh girth, and calf girth. Variables were selected for the study on the basis of theoretical modeling or previous research regarding the relationship between study variables and lifting capacity. Subjects also were tested to determine their maximum lifting capacity by using a lordotic lumbar spine lifting technique. Results: Stepwise regression analysis indicated that the combination of sex, age, thigh girth, pelvic girth, and percentage body fat was significantly related to maximum lift capacity (multiple R2 = 0.76). The mean absolute difference (± SD) between lifted amount predicted by the regression model and the actual amount lifted was 118.6 ± 86 N (26 ± 19.3 lb), which corresponded to an average absolute error of 16% (SD = 14%) of the actual weight lifted. Conclusion: The results may be useful in estimating 1 aspect of preinjury lifting capacity. Similar studies are needed to model the requirements of frequency of lift, duration of lifting efforts, variety of hand-object coupling, and combined lifting and reaching.

J Orthop Sports Phys Ther. 2000;30(5):237-247, 258-262.

Key Words: lifting, modeling, strength

Study Design: Repeated measures analysis of intervention. Objectives: To determine the effects of foot orthotics and shoe wear on calcaneal eversion for standing and treadmill walking. Background: Foot orthotics are commonly used as an intervention for treating lower extremity musculoskeletal pathology. Qualitative research regarding the benefit of foot orthotics tends to be favorable, while the results of quantitative studies often conflict. Methods and Measures: Eight men (mean age = 35.8 ± 12.7 years) and 5 women (mean age = 30.4 ± 10.6 years), who demonstrated abnormal pronation, walked quickly (average velocity = 1.9 m/s) on a treadmill with and without foot orthotics. Subjects were filmed using a 2-dimensional video system and plastic molds designed to indicate calcaneal position inside the shoe during static standing and treadmill walking. Results: Paired t tests indicated that foot orthotics significantly reduced the mean maximum calcaneal eversion angle by 2.2° and the mean calcaneal eversion angle at heel rise by 2.1° during fast walking. Orthotic and nonorthotic conditions did not differ significantly for the remaining kinematic variables. A one-way ANOVA indicated that calcaneal eversion in standing was significantly greater for barefoot standing compared with standing in shoes with or without orthotics. ANOVA also indicated that the plastic molds provided reliable measures of calcaneal position. Conclusions: Foot orthotics have a significant effect on calcaneal eversion and shoes also should be considered in conjunction with foot orthotic prescription.

J Orthop Sports Phys Ther. 2000;30(11):664-675.

Key Words: calcaneal eversion, kinematics, orthotics, rearfoot

Study Design: Repeated measures analysis of the effects of foot wedges on quadriceps muscle function. Objectives: To investigate the relationship between foot position and 2 quadriceps muscle activation conditions: maximum voluntary isometric quadriceps muscle contractions with the knee extended and 1-leg short squats with a knee flexion range of motion of 0° to 50°. Background: Abnormal foot position has been suggested as an important factor that may lead to patellofemoral malalignment. No previous studies have examined the effects of foot position on activation of the vastus medialis oblique (VMO) and vastus lateralis (VL) muscles using weight-bearing exercises. Methods and Measures: Sixteen healthy volunteers performed the 2 exercises under 3 foot conditions: level surface, a 10° medial wedge, and a 10° lateral wedge. Subjects' electromyographic data for the VMO and VL were analyzed using ANOVA. Results: The normalized VMO/VL ratio was significantly greater during the short squat than during the maximum voluntary isometric muscle contractions, but no significant differences were identified across the 3 foot positions. Conclusions: Clinicians should understand that the benefit of using a foot orthotic to correct a pronated or supinated foot might not result from a change in quadriceps muscle activation intensity but from other mechanical factors.

J Orthop Sports Phys Ther. 1999;29(2):93-105.

Key Words: patellofemerol, quadriceps muscle, weight-bearing

Clinicians commonly include an assessment of leg length inequality (LLI) as a component of a musculoskeletal examination. Little research is available, however, documenting reliability and validity of clinical methods for assessing LLI. The purpose of this study was to determine the reliability and validity of assessing functional LLI using a pelvic leveling device. Subjects were 19 women and 13 men between the ages of 18 and 55 who reported having a diagnosed or suspected LLI. Clinical determination of LLI was made by placing rigid lifts under the suspected shorter lower extremity until the leveling device indicated that the iliac crests were level. This measurement was made twice by one investigator and once by a second investigator. Standing radiographic measurements of LLI using rigid lifts were used to establish validity of the clinical method. Intraclass correlation coefficients [ICC(2, 1)] and absolute difference values were computed to assess reliability and validity. The mean absolute difference between the 2 clinical measurements of LLI by the same investigator was 0.29 cm (± 0.52), with an ICC = 0.84. The mean absolute difference between clinical measurements of LLI by the 2 investigators was 0.49 cm (± 0.46), with an ICC = 0.77. The ICC and mean absolute difference reflecting agreement between radiographic measurements and clinical measurements of LLI was 0.64 and 0.58 cm (± 0.58), respectively, for one investigator and 0.76 and 0.55 cm (± 0.37), respectively, for the second investigator. The intratester reliability, intertester reliability, and validity assessments included instances in which paired observations disagreed regarding which lower extremity was the shorter lower extremity. Factors that may be associated with the unacceptable reliability and validity of the clinical assessment method include asymmetric positioning of the ilia, body composition of the patient, and design of the clinical instrument. The authors discuss clinical implications related to assessment of LLI.

J Orthop Sports Phys Ther. 1998;27(4):285-294.

Key Words: method, lower extremity, leg length, measurement

Functional turnout for each of the 5 classical ballet positions involves lower extremity motion that occurs primarily through hip external rotation. Ballet dancers often attempt to increase turnout angle through excessive motions at the foot or knee that may be associated with the development of musculoskeletal pathology. The purpose of this study was to further the understanding of turnout by identifying the relationship between available hip external rotation and functional turnout for the 5 classical ballet positions. Subjects were 20 female ballet dancers between the ages of 11 and 14. The investigators measured hip external rotation as the sum of passive external rotation available at both hips of each subject. Functional turnout angle was measured for each subject as the subject stood in each of the 5 classical ballet positions. A repeated measures analysis of variance and Tukey Honestly Significant Difference test indicated that hip external rotation was significantly less than functional turnout for the 5 classical ballet positions. No significant differences in functional turnout angle were present among the 5 ballet positions. Regression analyses demonstrated weak relationships between hip external rotation and functional turnout angle for each of the 5 ballet positions. Hip external rotation should not be used to predict functional turnout for the 5 classical ballet positions. Turnout in first position may be useful as a guide for functional turnout for the crossed foot positions: third, fourth, and fifth.

J Orthop Sports Phys Ther. 1998;27(5):339-347.

Key Words: ballet, injury prevention, turnout

Current literature recommends incorporating push-up progressions into upper extremity rehabilitation for advanced training of the scapular stabilizers. No documentation exists to demonstrate changes in the level of muscle activation when push-up progressions are performed. The purpose of this study was to determine the effect of difficulty level for push-ups on electrical activity of the scapular stabilizing synergists. Sixteen subjects performed 5 repetitions for each of the 3 conditions in a push-up progression. Electromyographic data collected on the serratus anterior, upper trapezius, and lower trapezius revealed a statistically significant interaction effect between the serratus anterior and upper trapezius and push-up condition when the feet were elevated. No significant interaction was found between push-up condition and the lower trapezius. This study supports the clinical use of push-up progressions to facilitate activation of the serratus anterior and the upper trapezius during upper extremity rehabilitation.

J Orthop Sports Phys Ther. 1998;28(3):146-157.

Key Words: push-up progression, scapular stabilizers, electromyography

Back testing devices are frequently utilized in the clinic to assess function and return to work readiness in place of the job task, yet little research on their validity has been reported. This study was conducted to determine if correlations exist between squat lifting and isoinertial and isometric trunk extensor strength, torso length and isoinertial and isometric trunk extensor strength, and body weight and isoinertial and isometric trunk extensor strength. Twenty-eight subjects participated in 2 sessions involving B200 testing and 30.5 cm to knuckle lifting ability. Regression and correlations were performed. The results indicate that body weight and torso length do not demonstrate a relationship with trunk extensor strength, and isometric and isoinertial trunk extensor strength cannot be used accurately to estimate one's 30.5 cm to knuckle lifting ability. In conclusion, other anthropometric measures should be investigated if anthropometrics are used to estimate strength, and functional testing should be used to evaluate function.

J Orthop Sports Phys Ther. 1997;25(2):137-144.

Key Words: squat lift, trunk strength

Ankle orthoses are commonly used for protection against initial ankle sprain injuries and for protection against reinjury. The purpose of this study was to compare the effects of the DonJoy® Ankle Ligament Protector (ALP) and the Aircast® Sport-Stirrup™ (AS) on the functional performance tasks of a 40-meter sprint, a figure-of-eight run, and standing vertical jump. Subjects were 14 males and 9 females who reported a history of 2 or more lateral ankle sprains of the same ankle and no sprains of the contralateral ankle. Each subject performed all functional tasks on the first test day with both ankles unbraced and with the recurrently sprained ankle braced with 1 of the 2 orthoses. Each subject returned for testing on a second day and performed all tasks with both ankles unbraced and with the other orthoses on the recurrently sprained ankle. Subjects also rated the orthoses for comfort and support. Analysis of variance indicated that braced data were not significantly different than unbraced data and that data for the 2 orthoses did not differ significantly for any of the functional performance tasks. Seventy-four percent of the subjects reported the AS was more comfortable than the ALP, and 61% of the subjects indicated that the AS provided more support than the ALP. Neither orthosis had an effect on functional performance. The results may assist clinicians in selecting either of these orthoses for use in protection against ankle sprain injury.

J Orthop Sports Phys Ther. 1997;25(4):245-252.

Key Words: ankle, brace, injury, rehabilitation

Physical therapists, athletic trainers, and other health care professionals commonly evaluate static postures and dynamic motions in patients with skeletal malalignments of the lower extremity. Accurate clinical evaluation of these malalignments depends on reliable and valid measures as well as established normal values. The purpose of this study was to document the intraexaminer and interexaminer reliability and mean values for 9 static lower extremity skeletal measures in healthy Naval midshipmen. The measures studied were femoral torsion, ankle dorsiflexion, tibial length, leg length discrepancy, genu varus/valgus, medial talonavicular joint bulge, rearfoot angle, arch angle, and foot type classification. Intraexaminer and interexaminer reliability ICCs ranged between .65 and .97, and percentage agreements ranged between 88.8% and 94.4%. Mean absolute difference values all were within acceptable limits for clinical measurement. A foot type classification scheme was suggested. The results of this study indicate that the measures investigated are reliable when conducted on healthy Naval midshipmen by experienced examiners. Suggestions for further research are offered.

J Orthop Sports Phys Ther. 1997;25(4):253-263.

Key Words: skeletal measures, reliability, naval midshipmen

Skeletal malalignments of the lower quarter, deformities within a bone or at a joint, may be the primary cause of musculoskeletal patient problems. Skeletal malalignments also may sustain the presence of a musculoskeletal patient problem that has some other causal mechanism. A screening exam for skeletal alignment of the lower quarter may assist clinicians in identifying skeletal malalignments that are associated with a musculoskeletal complaint. The purposes of this paper are to: 1) describe components for a skeletal alignment screening exam, 2) analyze how lower quarter malalignments may influence lower quarter function and contribute to the development of musculoskeletal pathology, and 3) suggest general characteristics of foot orthoses and shoes that may assist in the management of musculoskeletal patient problems of the lower quarter.

J Orthop Sports Phys Ther. 1995;21(6):389-405.

Key Words: lower extremity, biomechanics, rehabilitation

Clinicians often must select an appropriate prophylactic ankle support system for their patients from a variety of ankle orthoses and ankle taping configurations. The purpose of this study was to compare the effectiveness of the DonJoy® Ankle Ligament Protector and a newly developed ankle taping procedure in restricting foot and ankle motion before and after exercise. Subjects were 8 males and 8 females who reported no history of ankle injury during the 6 months prior to testing, neurological condition, lower extremity arthritis, lower extremity fracture, or cardiac or balance problems. A Biodex dynamometer and computer were used to impose passive moments and to measure eversion and inversion prior to application of the ankle support systems, following application, and following 10 minutes of figure-of-eight running and 20 unilateral toe raises. Both ankles of each subject were assessed for each ankle support system. Subjects also compared the support systems for comfort, stability, and cosmetic acceptability. Both ankle support systems significantly reduced eversion and inversion following application and following exercise compared with preapplication measurements. Eversion measurements increased significantly following exercise for both ankle support systems compared with postapplication measurements. Inversion displacement following application was greater for the Ankle Ligament Protector than the ankle taping system. The 2 ankle support systems did not differ significantly following exercise for eversion or inversion measurements. The results may assist clinicians in selecting either of these ankle support systems for use in protection against ankle sprain injury.

J Orthop Sports Phys Ther. 1994;19(1):33-41.

Key Words: ankle, taping, brace

Clinicians often are faced with the task of selecting an ankle orthosis that will provide protection against ankle sprain injury and will not have a deleterious effect on functional performance. The purpose of this study was to compare the effects of the DonJoy® Ankle Ligament Protector (ALP) and the Aircast® Sport-Stirrup™ (AS) on 3 functional performance tasks: the 40-m sprint run, the figure-of-eight run, and the standing vertical jump. Subjects were 8 males and 8 females who reported no history of ankle injury during the 6 months prior to testing, neurological condition, lower extremity surgery or pathology, or cardiac, pulmonary, vascular, or balance problems. Each subject performed all functional tasks on the first test day with both ankles unbraced and with one randomly selected ankle braced with 1 of the 2 orthoses. Each subject returned for testing on a second day and performed all tasks with both ankles unbraced and with the other orthosis on the previously selected ankle. Subjects also rated the orthoses for comfort and support. An ANOVA indicated that braced data were not significantly different than unbraced data and that data for the 2 orthoses did not differ significantly for any of the functional performance tasks. Seventy-five percent of the subjects reported the AS was more comfortable than the ALP, and 63% of the subjects indicated that the ALP provided more support than the AS. Neither orthosis had a deleterious effect on functional performance. The results may assist clinicians in selecting either of these orthoses for use in protection against ankle sprain injury.

J Orthop Sports Phys Ther. 1994;19(3):150-156.

Key Words: ankle, orthotics, injury