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July2015

18 COVER STORYDriving safety: THE EFFECTS OF LOWER EXTREMITY IMPAIRMENT The question of when or if it’s safe for patients to drive after surgery or while wearing alower extremity orthotic device is one practitioners should address. But, in the absenceof formal guidelines, clinicians’ advice is often inconsistent.By Hank Black

IN THE MOMENTgait/13

Speed trap: Slowest seniors have increased mortalityIn children with CP, gait impairment correlates with daily step activity levelStep width, length variables may help predict fall-related risks in older adults

13 35 43

VOLUME 7 NUMBER 7 LERMAGAZINE .COM

features

35 Iliotibial band syndromeand running mechanicsThe mixed findings of several cross-sectional studies seem to suggestthat no specific biomechanical variables are unequivocally associatedwith iliotibial band syndrome in either men or women, which underscoresthe importance of assessing each patient individually.By Eric Foch, PhD

43 Diabetic foot conferenceweighs offloading issuesOffloading was a hot topic at the recent meeting of the InternationalWorking Group on the Diabetic Foot in the Netherlands. Diabetic footexperts in attendance discussed new research on offloading strategiesand updated the organization’s practice recommendations. By Cary Groner

51 Role of early rehab stagesafter ACL reconstructionTraditionally, anterior cruciate ligament reconstruction outcomes havebeen assessed preoperatively and several months postoperatively, butnew research suggests the early postoperative stages of recovery mayalso significantly affect self-reported outcomes.By Caitlin J. Miller, PT, DPT, and Jesse C. Christensen, PT, DPT, SCS

SPECIAL SECTION

Conference Coverage:

2015 ISPO World Congress

27

plus... PUBLISHER’S MEMO / 9

One to grow onWe’ve capped a year of exciting projects byinvesting in editorial growth and launchinga new quarterly publication on foot health.By Richard Dubin

OUT ON A LIMB / 11

The NBA takes on fatigueThe NBA’s new plan for injury preventiondoesn’t directly involve biomechanics.But that’s not necessarily a bad thing.By Jordana Bieze Foster

NEW PRODUCTS / 62The latest in lower extremity devices and technologies

MARKET MECHANICS /65 News from lower extremity companies and organizationsBy Emily Delzell

A NEW PERSPECTIVE ON MOVEMENT3D printed orthotics created using advanced data capture and modeling technology. That means SOLS are custom-engineered for your patient’s foot morphology, body, and lifestyle._

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Publisher Richard Dubin | [email protected]

Editor Jordana Bieze Foster | [email protected]

Senior editorEmily Delzell | [email protected]

Associate editorP.K. Daniel | [email protected]

Operations coordinator Melissa Rosenthal-Dubin | [email protected]

Social media consultant Kaleb S. Dubin | [email protected]

New products editorRikki Lee Travolta | [email protected]

Graphic design & productionChristine Silva | MoonlightDesignsNC.com

Website developmentAnthony Palmeri | PopStart Web [email protected]

CirculationChristopher Wees | Media Automation, Inc

Editorial advisorsCraig R. Bottoni, MD, Jonathan L. Chang, MD, Sarah Curran, PhD, FCPodMed, Stefania Fatone, PhD, BPO,Timothy E. Hewett, PhD, Robert S. Lin, CPO,Jeffrey A. Ross, DPM, MD, Paul R. Scherer, DPM, Erin D. Ward, DPM, Bruce E. Williams, DPM

Our Mission: Lower Extremity Review informs healthcare practitioners on current developments in the diagnosis, treatment, andprevention of lower extremity injuries. LER encourages a collaborative multidisciplinary clinical approach with anemphasis on functional outcomes and evidence-based medicine. LER is published monthly, with the exception of a combined November/ December issue and an additional special issue in December, by Lower Extremity Review, LLC.Subscriptions may be obtained for $38 domestic. and $72 international by writing to: LER, PO Box 390418, Minneapolis, MN, 55439-0418. Copyright©2015 Lower Extremity Review, LLC. All rights reserved. The publication may not be reproduced in any fashion, including electronically, in part or whole, without written consent. LER is a registered trademark of Lower Extremity Review, LLC. POSTMASTER: Please send address changes to LER, PO Box 390418, Minneapolis, MN, 55439-0418.

Lower Extremity Review292 Washington Ave. Ext. #105, Albany, NY 12203518/452-6898

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Another year has passed,

filled with new and exciting

developments for LER.

With all the growth that we

have experienced in the

past year, it was necessary

to expand our editorial

team with promotions to

Emily Delzell and P.K.

Daniel, who are now senior

editor and associate editor,

respectively.

After listening to the market and responding to the requests of

our readers, we are excited to announce the launch of a new

quarterly publication. LER: Foot Health will premiere this month

at the APMA/PFA National Conference in Orlando. This exciting

publication will focus on issues related to foot health, including

footwear, insoles, gait, diabetes, and more. LER: Foot Health will

profile innovative retailers and dispensing clinicians, showcase

new shoe styles, and provide analysis of the latest foot health

research. Based on demand for this type of content and the

perceived void in the market, this will be a print publication with

a microsite component to take full advantage of the LER platform.

LER editor Jordana Bieze Foster, who provided exclusive cover-

age of the recent ACL Research Retreat in Greensboro, NC, has

also been invited to attend the upcoming Patellofemoral Pain

Research Retreat in Manchester, UK. These are two of the most

prominent research events in the world, and we are proud to be

involved with them.

LER: Pediatrics, which we launched at the start of 2014, has been

very well received by readers and advertisers. That positive feed-

back really solidifies the position of this quarterly publication in

the LER portfolio.

This past year, we also developed a second installment of a publi-

cation for SureStep. In Step with Pediatric Hypotonia has been an

overwhelming success with LER readers who treat patients with

hypotonia, and we were very excited to work with such a great

organization once again.

In addition, LER was commissioned to create a publication for the

Charcot-Marie-Tooth Association. This incredible organization was

looking for a partner to develop independent, unbiased content

related to Charcot-Marie-Tooth and orthotic devices. We are grate-

ful that they chose to work with LER. This publication launched

last month and, according to the association’s CEO, is “the single

best project we have ever sponsored.”

As you can see, what differentiates LER is our content! We are

committed to developing the most innovative, informative,

evidence-based content on lower extremity health issues. We

have invested in editorial growth because that is what makes

LER special. I am proud to work with such an incredible team of

editors, writers, and designers. This amazing team continues to

provide the most sophisticated and informative publications

related to lower extremity care.

I am also grateful for LER’s excellent relationships within the

advertising community, many of which involve people and com -

panies I have worked with my entire career. The trust and

belief in what we do day in and day out is greatly appreciated.

Thanks to our readers who continue to embrace the LER platform

and respond to the LER advertisers. Their financial commitment to

LER allows us to provide this publication to you free of charge.

But you, the readers, are the reason we do it.

Richard Dubin, Publisher

Publisher’s memo:One to grow on

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After a season in which too

many of its most market -

able stars spent too much

time in street clothes, the

National Basketball Associ-

ation (NBA) is making a

commitment to injury

prevention. Interesting,

however, the approach

being discussed is only

indirectly related to bio -

mechanics. And that’s not

necessarily a bad thing.

The NBA has partnered with General Electric Healthcare (a major

manufacturer of magnetic resonance imaging systems and other

diagnostic imaging equipment) to promote research on injuries

specific to the sport, particularly musculoskeletal injuries such as

ligament tears and hamstring strains.

But when John DiFiori, MD, chief of the Division of Sports Medi-

cine at University of California, Los Angeles and chair of the

advisory committee that will oversee the new NBA initiative,

spoke with ESPN.com about the program, he didn’t talk about

kinematics, kinetics, strength, flexibility, or neuromuscular training.

He talked about scheduling.

The NBA is famous for its grueling 82-game schedule, filled with

cross-country flights and back-to-back games. The league has

already experimented with shortening the length of each game

from 48 minutes to 44, which was relatively successful during the

2014 preseason, and now will examine the possibility of reducing

the number of consecutive games and sets of four games in five

nights.

Most star players are on the court, running continuously on an

unforgiving surface, for the majority of each game. That in itself is

a significant risk factor for overuse injury, and it seems feasible

that reducing those minutes could reduce injury risk.

The other injury risk factor that could be addressed through

scheduling is fatigue—and that may have an even greater potential

upside.

Multiple studies have demonstrated that athletes are more likely

to sustain musculoskeletal injuries when they’re tired—near the

end of the first or second half of a game, or near the end of a

season. A March 2014 study found that adolescent athletes—who

were not all that much younger than some NBA rookies—were 1.7

times more likely to be injured if they got fewer than eight hours

of sleep per night. One reason for this, which has also been docu-

mented in multiple studies, is that fatigue has a negative effect on

postural control and the biomechanics of running, cutting, and

landing.

And, although no study has yet analyzed the effect of air travel

on injury rates in athletes, a 2014 study found that Australian

rugby players reported more leg tiredness on days of away games

than home games, even when their travel didn’t involve crossing

time zones. It seems safe to assume that jet lag would only com-

pound those effects.

Training athletes to maintain proper mechanics when fatigued

would appear to be a logical approach to this problem. But in

reality, that has turned out to be difficult to do. So, if schedule

changes can reduce fatigue and jet lag, which in turn can reduce

injury risk, that might actually be a much more effective—and

cost-effective—solution.

Convincing NBA players to forgo the club scene for a full night’s

sleep, of course, is another thing entirely. The committee assigned

to that task definitely will have its work cut out for it.

Jordana Bieze Foster, Editor

The NBA’s new plan for injury preventiondoesn’t directly involve biomechanics.But that’s not necessarily a bad thing.

out on a limb:The NBA takes on fatigue


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Speed trapSlowest seniors have increased mortality

Gait speeds less than .6 m/s, a thresholdthat has been recommended as an indica-tor of mobility-related health problems,also confer a significantly increased risk oftwo-year mortality in hospitalized olderpatients, according to a recent prospectivestudy.

Researchers at the University of Texas Medical Branch in Galvestontested gait speed in 289 hospitalized patients older than 65 years(61.6% female, age range 65-103 years), asking them to walk eightfeet at their preferred speed. Participants had been admitted to anacute care for elders (ACE) hospital unit for cardiopulmonary diseaseor respiratory or gastrointestinal diagnoses, which together accountfor 87% of US ACE unit admissions.

The majority, 73.7%, had gait speeds at or below .6 m/s, athreshold below which physical therapists diagnose dismobility. Overthe next two years, 17% (n = 49) of the patients died. All but four

deaths occurred in people with gait speeds less than .6 m/s, whowere two and half times as likely to die as those with faster gaitspeeds.

“Because gait speed reflects the combined functioning of thenervous, sensory, musculoskeletal, and cardiorespiratory systems,its assessment has been recommended as part of a standard in-patient geriatric evaluation,” said Glenn V. Ostir, MD, PhD, lead authorof the study, which was epublished in June by the Archives of PhysicalMedicine and Rehabilitation.

in the moment: gait

In children with CP, gait impairmentcorrelates with daily step activity levelIn children with cerebral palsy(CP), gait impairment has a mod-erate relationship with daily stepcount and high daily activity lev-els, according to research fromthe University of Auckland inAustralia.

The investigators evaluated55 children with CP (age range6-18 years) using the gait devi-ation index (GDI, a score of gaitpathology derived from 3D gaitanalysis), two days of accelero -meter data, and two clinic-basedmeasures of walking capacity,the six-minute walk test (6MWT)and walking speed.

Investigators found a mod-erate correlation between GDIand average daily step count,with up to a third of the variationin daily step count related to

changes in the GDI, whichwasn’t correlated with low step-ping activity time but did have amoderate association with highstepping activity time (>42steps/min). They found lower as-sociations between GDI and6MWT and walking speed.

The findings, which wereepublished June 25 by theArchives of Physical Medicineand Rehabilitation, suggest thatinterventions that improve gaitkinematics may improve chil-dren’s community walking ability,the authors wrote. Source: Wilson NC, Signal N, Naude Y, et al.Gait deviation index correlates withdaily step activity in children with cere-bral palsy. Arch Phys Med Rehabil 2015Jun 25. [Epub ahead of print]

Step width, length variables may help predict fall-related risks in older adultsStep width (SW), step length (SL),and a ratio of the two variablesmay help predict falls and fall-related injuries in older adultswith and without diabetic periph-eral neuropathy (DPN), accord-ing to research from the Univer-sity of Michigan in Ann Arbor.

The investigators used op-toelectronic kinematic tech-niques to assess walking onsmooth and uneven surfaces in27 participants (aged 50-85years, 12 women) with a spec-trum of peripheral nerve func-tion, ranging from normal tomoderately severe DPN (n = 16).

In the following year, 17 in-dividuals (62.9%) fell and 12(44.4%) sustained a fall-relatedinjury. All but one of the individ-uals with DPN sustained a fall.Compared with nonfallers, fallers

demonstrated slower walkingspeed, greater SW, shorter SL,and a greater step width to steplength ratio (SW:SL) on both sur-faces. SW:SL on an uneven sur-face was the strongest predictorof falls and fall-related injuries.

The results were epub-lished in June by the AmericanJournal of Physical Medicine andRehabilitation. The data suggestolder individuals with diabeteswho are at increased fall risksacrifice speed and efficiencyfor stability on uneven surfaces,the authors noted. Source:Zurales K, DeMott TK, Kim H, et al. Gaitefficiency on an uneven surface is as-sociated with falls and injury in oldersubjects with a spectrum of lower limbneuromuscular function: A prospectivestudy. Am J Phys Med Rehabil 2015 Jun5. [Epub ahead of print]

Continued on page 14


By Emily Delzell

istockphoto.com #66889063

in the moment: gaitContinued from page 13

14 07.15 lermagazine.com

In a 2014 Journal of theAmerican Medical Associationreport, a mobility working grouprecommended that cliniciansroutinely test gait speed in olderadults and use the .6 m/s thresh-old as an indicator of mobility-related health problems, whichcould help reveal a wide rangeof disorders.

“Gait speed could comple-ment information traditionallycollected on older patients, es-pecially those who self-report lit-tle or no disability. For example,declines in walking performancehave been associated with lossof independence, increased fallrisk, and death, as well as vari-ables that are more difficult tomeasure but may still impactmedical recovery, such as de-pression, motivation, and socialsupport,” said Ostir, who is a pro-fessor in the University of Mary-

land Department of Epidemiol-ogy & Public Health and directorof its Division of Gerontology inBaltimore.

“Although testing gait speedcan be easily and quickly donein almost all clinical settings, ishighly reproducible, and reliablypicks up small changes in phys-ical function and health, it is nota routine part of health assess-ments in most clinical settings,”he said.

Having an easy-to-remem-ber cut-point (ie, ≤ .6 m/s) couldincrease the clinical visibility ofmobility-related health problemsand serve as a diagnostic mech-anism to activate resources di-rected at resolving potentiallytreatable conditions contributingto declines in health, Ostir said.

“Once a patient is identifiedwith slow gait, added efforts maybe made to identify potential

causes of the problem, and, ifappropriate, treatments initiatedthat could target cardiopul-monary, neurological, or muscu-loskeletal systems, and whichcould extend beyond the periodof hospitalization,” he said.

Using gait speed to stratifyhealth risks may also help per-sonalize treatment goals.

“A diagnosis of dismobilitycould be used by physical ther-apists to develop measureable,meaningful mobility targets inconsultation with the older pa-tient and individualized plans tomaintain those targets after hos-pital discharge,” Ostir said.

Gait speed, unlike manyother health indicators, is oftenmodifiable.

“In acutely ill hospitalizedpatients, each .1 meter per sec-ond increase in gait speed hasbeen strongly linked to shorter

hospital stays, reduced hospitalcosts, and fewer disabilities inactivities of daily living,” he said.“It is not uncommon for olderadults with subacute medicalconditions to visit their primarycare physician when their med-ical symptoms affect their func-tion. Thus, declining or slow gaitspeed may capture unrecog-nized information about theseverity or worsening of under-lying chronic conditions.” Sources: Ostir GV, Berges IM, Ottenbacher KJ, etal. Gait speed and dismobility in olderadults. Arch Phys Med Rehabil 2015Jun 8. [Epub ahead of print]Cummings SR, Studenski S, Ferrucci L.A diagnosis of dismobility—giving mo-bility clinical visibility: a Mobility WorkingGroup recommendation. JAMA 2014;311(20):2061-2062.Purser JL, Weinberger M, Cohen HJ, etal. Gait speed predicts health status andhospital costs for frail elderly male vet-erans. J Rehabil Res Dev 2005;42(4):535-546.

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The entire dressing was applied to cover the the knuckle as well as the wound inorder to help reduce the swelling faster.

Reference:

1. Harrison J. Successful Healing of Digit Wounds with One Dressing. Poster 6130.Wound Ostomy and Continence Nurses Association (WOCN). June 9-13, 2012.Charlotte, NC, USA.

The closing and healing of all wounds involves establishing andmaintaining optimal wound healing conditions. Managingwounds on fingers and toes can be difficult due to the need to

reduce edema without a good way to accomplish the goal.Additionally, a caregiver is often required to apply dressings in a waythat limits the digit’s range of motion, further interfering with thehealing process. Dressings applied to the finger or toe often need tobe changed frequently because they slip off due to movement. Inpatients with vascular or diabetic co-morbidities, digit wounds can beespecially slow to heal and often require multiple medicalinterventions.

A recent poster,1 highlighting four patients with digit wounds on eitherthe hand or foot, demonstrated the use of Ferris Mfg. Corp.’s latestproduct, the PolyMem® Finger/Toe dressing. The dressing wasdeveloped to be easily applied and removed and contains the sameformulation of all PolyMem dressings, helping ensure less pain andmore healing.

Patient 1 was a 78-year-old diabetic male with a below-the-knee rightleg amputation. He bumped his left foot during a transfer from hiswheelchair to the toilet. The trauma resulted in three blood-filledblisters on the second toe of the left foot and swelling of his left lowerextremity became a healing obstacle. Due to increased susceptibilityto infection, the silver version of the PolyMem Finger/Toe dressingwas applied to the blisters. His wife performed the dressing changesand his blisters dried under the dressings in less than two weeks,using only two dressings.

Patient 2 was a 71-year-old diabetic male with a history of poorvascular perfusion, below-the-knee amputation of the right leg, andvenous stasis ulcers. The hook-and-loop fastener of a post-operativeshoe created a friction wound on the top of the toe on his remainingfoot. The periwound skin became edematous and macerated. Usingthe PolyMem Finger/Toe dressing, he was able to do his own dressingchanges and the periwound maceration, swelling and weepingdecreased. The wound, which originally measured 0.5 cm x 0.7 cm x0.1 cm, was closed in 14 days. Only two PolyMem dressings wereused to close this wound.

Patient 3 was a 56-year-old paraplegic female whose shoe came offwhen her foot fell from the wheelchair footrest, resulting in anavulsion of the second toenail of the left foot. The periwound skinbecame slightly erythemic and edematous. Her dressing changeswere performed by home health and the wound closed in only threedays.

Patient 4 was a 56-year-old male who suffered an amputation at theproximal joint of the first finger of his right hand while operating ahydraulic log-splitter. A surgical flap was attempted, but it wasunsuccessful. The periwound skin was swollen, macerated and warmto the touch. He received whirlpool baths to the wound twice weeklyby physical therapy. He changed his own dressings when requiredand when no whirlpool treatments were scheduled. The maceratedperiwound skin resulting from the whirlpools was managed with abarrier cream. The pain during the whirlpool treatments was managedwith oral analgesia. All these wounds healed rapidly using PolyMemFinger/Toe dressings.

PolyMem is a multifunctional polymeric membrane dressing andcontains components that draw and concentrate the body’s naturalhealing substances into the wound bed to promote rapid healing.PolyMem Silver has all the unique properties of the standard pinkPolyMem dressings with the additional antimicrobial propertiesprovided by elemental silver.

The Finger/Toe dressings, like all PolyMem products, help to reduceedema, bruising, pain and inflammation when applied to either openor closed injuries. The dressings help relieve both persistent andprocedural pain that is associated with injury and are effectivethroughout all stages of the healing process. The dressings fitsecurely over the finger or toe while allowing freedom of movement;encouraging range of motion; helping reduce pain, swelling, bruisingand inflammation; and providing cushioning protection.

After application of PolyMem dressings, all these patients experiencedsignificant swelling reduction in the affected digits and saw rapidresolution of any previously present periwound skin complications.Nurses, patients and caregivers found the dressings easy andconvenient to use. Finger/Toe dressings were shown to be costeffective when compared to other approaches as the number ofdressings used was significantly decreased, the time needed fordressing changes was minimal and the home health nurses madefewer visits. PolyMem dressings provided optimal healingenvironments, which resulted in rapid wound resolutions.

The Silver Finger/Toe dressing was easily applied.

The question of when or if it’ssafe for patients to drive

after surgery or whilewearing a lowerextremity orthoticdevice is onepractitioners

should address.But, in the absence

of formal guide lines,clinicians’ advice

is often inconsistent.

There’s a point, said Douglas H. Richie Jr, DPM, whenmost clinicians realize they should have a talk with their patientsabout when it will be safe again to drive after their lower extremitymovement or response time has been impaired as a result of sur-gery or an existing condition. His own such aha! moment came sev-eral years ago after a patient with diabetic neuropathy, who Richiehad just fitted with a short leg walking cast, drove away from Richie’sSeal Beach Podiatry Group in California, and shortly afterwardcrashed through several patio tables at a fast food restaurant.

“Thankfully, no one was outside eating at the time, or there wouldhave been injuries or even fatalities, but that was when it became clearto me that I had a responsibility to warn people of dangers I assumedthey should know intuitively,” Richie said. “When you are wearing acast or tight ankle brace and can’t plantar flex the ankle, or have lossof feeling and lose some fine motor coordination, you likely can’t feelthe difference between the brake and gas pedals.”

The ability to drive is vitally important to many patients.1 Allpractitioners interviewed for this article said the when-to-drive ques-tion is ubiquitous in almost all practices, and recommended that arelevant conversation should definitely take place. They also said,however, that this often does not happen, or that advice is incon-sistent.

Studies back them up. For example, Lewis et al surveyed 100patients after knee arthroscopy and found only 65% of those

responding said their surgeon talked about postoperative driving.In addition, patients reported that the time before patients were al-lowed to drive varied from two days to four weeks.2 Argintar et alsurveyed sports medicine-trained physicians about driving instruc-tions given before patients underwent uncomplicated arthroscopyand found that fewer than 30% said they always had the conversa-tion.3 Fifty-seven percent of physicians reported they brought upthe subject half the time or less.

Studies have not provided the clarity and consistency requiredto spur adoption of formal practice guidelines by medical, trans-portation, government, or other professional groups.3 However, re-cent advances in technology and surgical management may helpanswer the question.

For modern automobiles with automatic transmissions, the legin question is almost always the one that controls the brake and ac-celerator, which in the US is the right limb. Impairment of the leftleg is not problematic once flexibility is regained and narcotic painmedication is not a factor, so most research deals with the rightleg.4,5

Medicolegal landscapeThe question of when it’s safe to drive following surgery is fraughtwith legal and safety considerations.6 Insurance companies put theresponsibility for safe driving on the patient, as do law enforcement

18 07.15 lermagazine.com18 07.15 lermagazine.com

DRIVINGSAFETY:

The effects of

lower extremity

impairment

By Hank Black

agencies. Practitioners in the US have not yet been successfullysued for providing improper return-to-driving instructions,7 but a2007 Massachusetts case produced a precedent for litigation stem-ming from poor advice allegedly given about operating a vehiclewhile using a prescribed narcotic.8 The same state passed legisla-tion in 2010 that extends liability protection to physicians whobreach patient privacy to report impaired drivers.9

A Swiss report10 by Fleury et al noted physicians in that countryare not obligated to report a patient who is unfit to drive, but theyalso are not bound to medical professional secrecy in case theychoose to notify the authorities. Current UK law states that, when apatient operates a vehicle against a doctor’s advice, the doctor hasa professional obligation to notify authorities.11

Clinician awareness of the difficulty in deciding when a patientcan return to driving is driven by the belief that the medicolegal en-vironment is more uncertain today than in the past, the fact that lawsimpacting the issue vary greatly from state to state, the decreasedtime available for practitioners to interact with patients in a clinicvisit, and the growing population of aging patients, many of whomalready are anxious about the prospect of having to stop driving.6

“I believe this patient-driving question absolutely must be cov-ered and noted in the medical record with every patient whose con-dition may impair driving. Rather than just a legal issue, it’s primarilymy moral responsibility to the general society,” Richie said.

Geoffrey S. Marecek, MD, assistant professor of orthopedic sur-gery at the Keck School of Medicine at the University of SouthernCalifornia in Los Angeles, was one of several who agreed.

“Physicians always should have this conversation, even if the pa-tient doesn’t raise the question,” Marecek said. “It definitely doesn’thappen enough.”

He tells patients he can’t write a note that clears them to drive,and he provides a handout that includes his general guide-lines, including the statement (which he also providesverbally): “Remember, there is no such thing as‘clearance’ to drive. Law enforcement andinsurance agencies consider it to beYOUR responsibility to ensureyou can drive safely.”

Marecek coauthor eda 2013 literature reviewon the subject pub-lished in the Journal ofthe American Academyof Orthopaedic Sur-geons.12 In it he encour-aged practitioners totalk with patients abouthow long to wait beforethey might safely drive.

“We generally foundthat, as baseline prereq-uisites, patients shouldnot drive before theyare fully weight bearing,off of narcotic medica-tions, and no longerwearing a protective device, such as a castor boot,” he said.

The National Highway Transportation and Safety Board recom-mends not driving with a splint or immobilization device and statesin its physician guide, “Physicians have an ethical responsibility toassess patients’ physical or mental impairments that might adverselyaffect driving abilities.”13 The American Medical Association alsonotes in its code of medical ethics that physicians have a responsi-bility to assess impairments that can affect driving ability and safety.14

The importance of driving for patients, particularly those whohave no other way to get to follow-up clinic appointments, in-creases the risk of noncompliance with restrictions related to driv-ing and devices and narcotic medications. Orthopedic surgeons inurban practices surveyed their patients and found that up to 25%were still taking their prescribed medication when they returned todriving.1

Fortunate is the patient who lives where public transportationis adequate or who has the resources to pay a taxi or neighbor forthis service.

“In major urban centers like mine, it’s convenient for a largenumber of people to get where they need to go by subway or bus,but elsewhere it presents a problem,” said Erika Schwartz, DPM, ofFoot and Ankle Specialists of the Mid-Atlantic in Washington, DC.

Technological advances are helping to bring transportation toothers, or at least minimizing the inconvenience of not driving, shenoted.

“Increasing use of Uber, Lyft, and other ride-sharing apps forsmartphones might make essential travel cheaper and more wide-spread in some areas, but the biggest beneficial change I’ve seenin recent years is the growing ability of many people to work from

lermagazine.com 07.15 19lermagazine.com 07.15 19

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home via computer,” she said. Many researchers and clinicians interviewed by LER look for-

ward to the day when drivers can depend on their vehicle to do the“driving” itself.

“Self-driving cars are coming at some point in the future, al-though it may be further off than some think,” Marecek said. Andthose futuristic expectations, he added, wouldn’t directly benefitpeople who might not drive due to choice, physical condition, orlack of resources.

Geoffrey H. Westrich, MD, director of research for adult recon-struction and joint replacement at the Hospital for Special Surgeryin New York City, said he looked forward to a car that actively brakesand keeps itself in the correct lane.

“No doubt, cars are getting smarter,” he said.

Driving simulatorsA spate of recent studies is helping bring clarity to this issue. Mostresearch uses bespoke or commercial driving simulators to deter-mine how quickly a driver can move the right leg from the acceler-ator to the brake pedal and apply enough force to stop a vehicle.6

Others use simpler but somewhat equivalent evaluative methods,such as how often in a defined timeframe a patient can perform a

sit-to-stand task or lift the right foot over a block of wood and back.15

Driving simulators cannot take into account all the factors thatgo into driving on the road, and they are not uniform in their com-plexity, according to David Goodwin, MD, a sports medicine fellowat New York University in New York City who coauthored a recentliterature review on driving after orthopedic surgery.6

“They may measure the total braking time and distance fromstimulus to full stop, but there are many other distracting factors in-volved when you’re on the road, such as noise,” Goodwin said.

Goodwin and colleagues noted in their 2013 review of postsur-gical driving recommendations6 that suggested guidelines basedon individual studies vary significantly.

“When to drive may differ for individual patients, so it’s difficultto issue a blanket recommendation for safety,” he said. “In my sportsmedicine practice, for example, it’s hard to rein in younger, moreactive patients. And, depending on the type and location of surgery,who performed it and where, individual differences show up.”

Researchers hope better driving simulation equipment, in tan-dem with more modern surgical techniques, can reduce driverdowntime and provide support for the development of official ratherthan suggested recommendations. Total hip arthroplasty (THA) is

Continued from page 19


Figure 1. A patient poses with thedriving simulator used in a Hospitalfor Special Surgery study of brake re-sponse times after total hip replace-ment.16 Inset shows a schematic ofthe simulator. (Photo by Robin Frank,courtesy of the Hospital for SpecialSurgery.)


one procedure that has benefited from such studies. The suggestedguidelines for return to driving following right THA historically haveranged from six to eight weeks, but results of two recent studiesusing advanced driving simulators purport to show that driving maystart earlier.

Westrich used a fully interactive driving simulator with an Amer-ican Automobile Association automatic brake reaction timer (Figure1) in a study of 100 patients undergoing modern THA.16 The par-ticipants all took a brake reaction-time test before surgery to estab-lish a baseline, then were randomly selected to repeat the test two,three, or four weeks after the operation; the average return to pre-operative baseline timing was about four weeks.

“There are some physically fit or less pain-sensitive patientswho recover more quickly and may drive sooner than four weeks,and some are a bit older and not in as good physical shape whomay not be able to drive that quickly,” he said. “Of course, it’s alwaysgood to err on the side of caution for driving issues.”

Advances in operative technique and materials might reducethe time a patient needs to wait before driving after some surgeries.A group led by Victor H. Hernandez, MD, MS, found patients mightdrive as soon as two weeks postoperatively. Using an advanceddriving simulator to evaluate braking time in 38 patients before sur-gery and at two, four, and six weeks after modern muscle-sparingTHA, Hernandez et al determined that 33 reached their baselinetarget by two weeks. The other five (13%) took four weeks to reachbaseline, but even so were under the nationally recommended safebrake time standard.17

“With advanced techniques, we avoid cutting the muscles un-less necessary and spend time repairing them if we do. Our con-temporary protocol also includes multimodal pain management withminimal use of narcotics, an early mobilization physical therapy pro-tocol, and more stable hip [implants] and other materials,” said Her-nandez, an assistant professor in the Department of OrthopedicSurgery at the University of Miami in Florida.

Immobilizing and adaptive devicesMost practitioners interviewed said they do not allow driving if a pa-tient is still wearing an immobilizing device on the lower extremity,which is routine for many procedures. Their conclusions were basedprimarily on a report by Orr et al.18 Using a driving simulator, Orr et


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al found total brake response time was significantly slower whenvolunteers wore a short leg cast or controlled ankle-motion bootand when they used a driving adapter that allows the left foot topress the accelerator or brake, compared with response times whenthey wore normal footwear.

Several other studies came to similar conclusions regarding im-mobilization appliances.19-21 Murray et al evaluated the emergencybraking times in healthy volunteers wearing a walking cast, a walkingboot, or a running shoe on the right limb.19 Total braking time as as-sessed with an instrumented car was significantly shorter for therunning shoe condition than for either of the immobilizing devices.

Dammerer et al20 assessed brake response time in 64 healthyvolunteers with commonly used knee braces using a custom drivingsimulator. They found that knee braces that restricted range of flex-ion-extension motion were associated with significantly slower brak-ing response time than the no-brace condition, but a patellofemoralrealignment brace, a ligament instability brace, an offloading os-teoarthritis brace, and an elastic knee bandage had no significanteffect on response time.

In a UK study of 23 healthy volunteers and a driving simulator,immobilization of the knee and ankle increased the time it took tomove the foot from the accelerator to the brake pedal.21 An above-knee plaster cast, a below-knee cast, and a knee brace fixed at 0°of flexion were all associated with significantly longer total brakingreaction time than unrestricted braking. The group wearing anabove-knee cast performed worst, with the stopping distance at 30miles per hour increased by almost three meters on average. Theanalysis also showed, unexpectedly, that driver “thinking time” in-creased with the level of restriction. And, in the case of a car acci-dent, Goodwin noted, a driver wearing a brace or cast is less likelyto be given the benefit of the doubt by law enforcement or insur-ance personnel.

“If a patient has had surgery and is seen wearing a restrictivedevice when getting out of the car following a collision, they canexpect that fact to be noted by investigators as well as other partiesand likely will be listed as a contributing cause of the wreck,” hesaid.

Even forefoot dressings are too restrictive for driving, Richiesaid.

“I don’t let patients drive after bunionectomy while there’s adressing on the foot,” he said. “When the dressing is off and the sur-gical site is stable, I let them drive wearing a surgical shoe. If theyare ambulating with the more restrictive walking boot, I get them toremove it and wear a surgical shoe when driving, which protectsthe surgery fairly well.”

Although orthotists are often involved in providing braces andother immobilizing devices, they generally do not consider thequestion of driving when they make clinical decisions on the typeof bracing recommended for an individual, said Phillip Stevens, MEd,CPO, FAAOP, president of the American Academy of Orthotists &Prosthetists, who practices in Salt Lake City, UT.

“We are viewing the orthotic device in the context of affectingthe kinematics of ambulation, sit-to-stand transfers, or navigation ofuneven terrain,” Stevens said. “It is rare that a device is designedspecifically with driving in mind, so patients should always be madeaware of that limitation. When patients ask me if they can safelydrive with an orthosis, I will always defer to their physician for thatbroader discussion of whether they are competent to drive. Many


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of the deficits that might bring patients to us are such that, whether

due to weakness, paralysis or neuropathy, they would affect driving

with or without the use of an orthosis.”

Research to guide clinicians is sketchy in some areas. The usual

recommendation for bunionectomy is primarily based on a study

by Holt et al of patients who had undergone hallux valgus surgery

with a first metatarsal osteotomy.22 The researchers tested 28 such

patients preoperatively and at two and six weeks after surgery and

compared them with a control group of healthy volunteers. Only

25% of operated patients could perform emergency stops at the

two-week mark. At six weeks, brake reaction time had improved sig-

nificantly but still was slower than that of the controls.

General guidelines from recent literature reviews3,6,10 include

the following: simple knee arthroscopy, four weeks; anterior cruciate

ligament repair, four to six weeks; bunionectomy, six weeks; diaphy-

seal fracture, 12 weeks; periarticular fracture, 16 weeks; ankle frac-

ture, nine weeks; total knee arthroplasty, four to eight weeks; and

total hip arthroplasty, six to eight weeks.

Clinicians should also keep in mind that, if a condition is dire

enough to warrant possible surgical intervention, it might already

be compromising the ability to conduct an emergency stop even

before surgery has been performed. In a cross-sectional survey,

Hofmann et al found that osteoarthritis of the right knee or hip could

preoperatively prolong time to make an emergency stop of a vehi-

cle.23 Unexpectedly, while osteoarthritis of the left hip did not pro-

long braking time significantly, osteoarthritis of the left knee did

impair this capability.


Istockphoto.com #1141631


Driver evaluation programsDriver evaluation programs are a resource that many clinicians andpatients may not be aware of.1 Elin Schold Davis, OTR/L, CDRS, adriving rehabilitation specialist with the American OccupationalTherapy Association (AOTA), said, “Any individual with strong cog-nitive abilities can compensate for physical impairment with training,adaptive devices, or vehicular modification. Driver rehabilitation as-sistance is offered by trained specialists, including occupationaltherapists, who have a clinical background, engineers, and drivereducation experts.”

Schold Davis, coordinator of the AOTA’s Older Driver Initiativein Chicago, said that no single test, including driving simulation, candetermine whether a driver needs intervention.

“We seek to work with surgeons and physicians to tailor pro-grams for the specific needs of their clinic population,” she said.“Currently there are people driving scared because they have amedical condition that threatens to take away their ability to drive,and we could help them. Before a driving evaluation, I even sawsomeone relying on a cane to press on the accelerator.”

The AOTA works with a broad range of groups to help educatedrivers who may be impaired. CarFit (car-fit.org), for example, wasstarted by the AOTA, the American Automobile Association, andthe American Association of Retired People to help older adultsadapt to the myriad features of modern automobiles, from bucketseats to back-up camera displays. Schold Davis met recently withthe Transportation Research Board to discuss what will be necessaryto help people use self-driving features and, eventually, self-drivingcars. The board’s membership includes appointees from the Insti-tute of Medicine and the National Academy of Science.

Because of expense and the learning curves involved, vehicularmodifications and driver adaptations may not be the answer for patients who are surgically impaired for only a few weeks. Longer-lasting or permanent problems may call for such interventions, how-ever. Richie cited patients with a long-term drop-foot diagnosis whofound that hand controls for the brake and accelerator allowed saferdriving. “There are too many patients with neuromuscular or otherconditions who are not aware they can safely drive if they take acourse and learn to manage with such adaptations,” he said.

Individual recommendationsStudies give a structure for decision-making, but individualized ap-proaches and patients’ awareness of their own responsibility shouldgo into their choices, Marecek said.

“Guidelines today are not official rules,” he said, “so when I talkwith patients about this, I try to make it personal and give them thegrandkid test: ‘How will you feel if your grandchild chases a ball infront of the car you’re driving—do you feel comfortable being behindthe wheel with that child’s life in your hands?’”

Hank Black is a medical writer in Birmingham, AL.

References are available at lermagazine.com, or by scanning the QR or tag codes at left.

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woman with rheumatoid arthritis, played by a Dutch actress, comesto pick up a pair of custom therapeutic shoes from her practitioner,played by Klaas Postema, MD, PhD, who in real life is the head of theCenter for Rehabilitation at the University of Groningen. Despite hav-ing been involved in choosing the design elements of her new shoes,the patient is disappointed when she actually sees them and hesi-tantly tells the clinician she doesn’t want to wear them. Where thetwo scripts differ is in the clinician’s response to the situation.

Before the viewing, symposium speakers discussed the impor-tance of practitioner-patient communication for maximizing patientcompliance, and touched on some key points to consider when hav-ing those conversations.

“There’s no pill you can give to a patient to guarantee accept-


FRENCH CONNECTIONS: Coverage of the 2015 ISPO World CongressIn orthotics and prosthetics, practitioners increasingly are learning that making personal connec-tions with patients is as important as connecting patients with the right devices. At the June meetingof the International Society for Prosthetics & Orthotics, clinicians and researchers from around theworld met in Lyon, France, to discuss the most effective ways of accomplishing both objectives.

DIABETIC FOOTWEARCinematic symposium exploresperson-centric communicationCannes is the French city most often associated with cinema. Butseveral hundred kilometers to the north, in Lyon, a pair of short filmsdebuted in June that sent a clear message about the most effectiveways for lower extremity practitioners to interact with their patients.

The videos, unveiled at the 2015 International Society of Pros-thetics and Orthotics (ISPO) World Congress, were part of a sympo-sium on person-centered communication related to therapeuticfootwear. But the themes explored could be applied to virtually anyaspect of lower extremity care.

“I think it’s really important for us to think about not just providingthe best possible device, but also all those little bits and pieces thatadd up to a good outcome. We’re talking about footwear today, butI think these skills can be used anywhere,” said symposium speakerAshley Morphet, cOP, a senior orthotist at Northern Health in Mel-bourne, Australia.

The scenario in each of the movies is the same: A 60-year-old



More ISPO coverage:AMPUTATION ..............................................................................28PEDIATRICS ..................................................................................30DROP FOOT..................................................................................30OSTEOARTHRITIS ......................................................................32PROSTHETICS..............................................................................32

By Jordana Bieze Foster


ance,” said Jaap van Netten, PhD, a human movement specialist whois a senior researcher at Ziekenhuisgroep Twente in Almelo, theNetherlands. “You really have to communicate.”

As with any orthotic device that is visible when worn, one issuethat can lead to noncompliance with therapeutic footwear is a reluc-tance to have a disability be so apparent. But footwear is a specialcase, van Netten noted.

“Therapeutic footwear isn’t just something new, it replacessomething that is normally worn. Shoes don’t just solve a problem,they require the patient to get rid of something they like in exchangefor something they like less,” he said.

Such visible evidence of disability also forces a patient to reallyacknowledge his or her disease—something that is difficult for manypatients and can be another driver of noncompliance.

“The patient has to accept not only the shoes, but also the dis-ease that is the reason for the shoes. If you do not accept your illness,you probably will not accept the need for shoes,” van Netten said.

A third factor that can affect compliance with footwear—or anyother device—is a patient’s feeling that his or her concerns aren’tbeing heard or considered by the practitioner.

“The most important point is to make sure the patient is the onemaking the decision, based on your recommendation as a clinician,”Morphet said.

The two films touched on all of these compliance issues.In the first version, the practitioner is all business, his attention

focused on the shoes rather than the patient. When she expresses

disappointment in the shoes’ appearance, he argues with her. “I don’tthink they’re bad, I think they’re lovely,” he says in an accusatory tone.“These aren’t old people shoes, they’re very modern.”

After several rounds of this type of back-and-forth, the clinicianmakes it clear that the discussion is over despite nothing having beenresolved. “Do you want to wear them now?” he asks, although it’sclear she doesn’t. “From my perspective we’re all done.”

The patient leaves, without the shoes and without paying forthem, and the practitioner appears more irritated than concerned asthe film comes to an end. It’s clear that this was an example for cli-nicians of what not to do with regard to communication.

In the second film, things go much differently. As soon as thepatient expresses her disappointment, the clinician sits next to her,looks her in the eye, and appears to be genuinely concerned as theydiscuss the pros and cons of the footwear.

“I can see you’re very disappointed,” he says, without judgment.“And, if you look at these shoes for the first time, especially next tothe more modest shoes that give you so many problems, yes, thesenew shoes would seem very different.”

Gradually, the practitioner refocuses the discussion on the pa-tient’s pain.

“For you, it’s a major drawback how these shoes look,” heagrees. “But what kinds of things could you do in your life if you hadless pain?”

She thinks about that, and ultimately reassesses the situation. “Iguess I just have to accept it,” she says. “Now let me try them on.”

AMPUTATIONPatients cite lack of educationabout partial foot proceduresPatients who have had a partial foot amputation followed by atranstibial amputation on the same limb feel that they were inade-quately educated about what the first procedure would involve, ac-cording to detailed interviews conducted by researchers at LaTrobe University in Melbourne, Australia.

“When we look at conditions like cancer or end-stage renal dis-ease, there’s quite good evidence that education and managing ex-pectations has a positive effect on things like anxiety and depression.But there doesn’t seem to be much specific to partial foot amputa-tion, which is surprising given how common it is,” said Michael Dillon,BP&O(Hons), PhD, a senior lecturer in prosthetics and orthotics atthe university, who presented the findings in June at the 2015 ISPOCongress.

Interviews with three patients at least six months following theirtranstibial surgery were synthesized for the presentation; the re-searchers plan to continue the interviews until no new themesemerge, Dillon said.

The researchers were surprised by patients’ lack of awarenessabout complications associated with partial foot amputation, Dillonsaid, particularly since they typically make multiple clinic visits in themonths preceding the procedure. Patients also said they had beenunprepared for the extent of tissue removed during the surgery.

“The first point of discussion is often about will they walk again.Issues like mortality and complications are often not even on the pa-tient’s radar,” he said.

All patients expressed disappointment in the lack of informationabout treatment alternatives, in particular transtibial amputation,which is typically associated with fewer complications than partialfoot amputation.

“Patients said they would have liked to use their time differentlyin retrospect, given the complications associated with the partial footamputation, especially since many don’t have a lot of years left,” Dil-lon said.

Some patients said they were able to obtain knowledge abouttheir treatment options through unconventional channels, includingchance encounters with allied health professionals and with otherpatients. That knowledge, they said, helped them advocate for thetype of healthcare they wanted, which in some cases involvedtranstibial amputation rather than partial foot amputation.

Patients also told the researchers they would have liked to havehad supplementary written information in addition to verbal discus-sion. Although this finding surprised the researchers, it does makesense, Dillon said, given that patients may be distracted or under theinfluence of strong medications when conversations about surgicalprocedures take place.

“Often at the time they are not in a good position to make deci-sions,” he said. “Many of these people you could have given the bestinformation in the world, and they wouldn’t have been in a positionto process that information.” Source:Ozturk H, Dillon M, Duke E, Kennedy-Jones M. Experience of sequential partial footand transtibial amputation: A narrative enquiry. Presented at the International So-ciety of Prosthetics & Orthotics World Congress, Lyon, France, June 2015.


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PEDIATRICSCP studies assess potential advantages of flexible AFOsThe flexibility of an ankle foot orthosis (AFO) does not necessarilyaffect walking economy in children with cerebral palsy (CP), butmore flexible AFOs may be particularly beneficial for sports activ-ities in higher-performing children with CP, according to researchpresented in June at the 2015 ISPO Congress.

In children with spastic CP and excessive knee flexion duringstance, improvement in gait efficiency achieved with AFOs hasmore to do with kinematic changes than push-off power, Dutch researchers found.

Investigators from Vrije University Medical Center in Amster-dam, the Netherlands, assessed 14 children (mean age 10 ± 2years) with spastic CP and excessive knee flexion during stanceas they walked while wearing shoes only and under three differentAFO conditions. One condition involved wearing a rigid ventral-shell AFO, while the other two conditions involved a spring-hingedventral-shell AFO, a design concept that has been reported to im-prove ankle push-off power and improved walking economy inadults (see “Finding a formula for the optimal AFO,” March 2012,page 22). The spring-hinged AFO, which allowed 20° to 35° ofankle dorsiflexion, was tested under two stiffness settings, with ei-ther a stiff spring or a flexible spring. The children were allowedfour weeks to accommodate to each AFO condition before gaitanalysis was performed.

“We expected that there would be a trade-off between improv-ing knee angle and knee moment during stance and improvingpush-off power,” said Yvette Kerkum, MSc, a doctoral student inthe Department of Rehabilitation Medicine at the university, whopresented the findings at the congress.

All three AFO conditions significantly improved knee angleand knee moment compared to the shoes-only condition, andthere were no significant differences between the AFOs for thosevariables. The rigid AFO was associated with significantly less anklepush-off power than shoes alone, but the two spring-hinged AFOconditions preserved it.

All three AFO conditions were associated with significantly

DROP FOOTBenefits of FES after strokeare maintained at 42 weeksGait speed improvements associated with 30 weeks of functionalelectrical stimulation (FES) in poststroke patients are maintainedat 42 weeks, according to research presented in June at the 2015ISPO World Congress.

In 99 patients who experienced drop foot following a stroke,researchers from the University of Maryland in Baltimore and FESdeveloper Bioness in Valencia, CA, found that gait speed improvedfrom .42 m/s at baseline to .6 m/s after 42 weeks of FES use. In67% of patients, the change was greater than the minimum clini-cally important difference of .1 m/s, and 55% had progressed toa higher Perry Ambulation Category.

lower net energy cost than shoes only, and, surprisingly, there wasno significant differences between conditions. Effects were vari-able, in that some children were more efficient while wearing stifferdevices and others were more efficient with more flexible devices.

“The biomechanical differences between the devices were notnecessarily reflected in the gait efficiency,” Kerkum said. “In chil-dren with cerebral palsy and excess knee flexion, improvement ingait may be defined more by kinematics and less by push-offpower.”

The benefits of flexible AFOs, however, may be more apparentin children with high-level gross motor skills, according to researchfrom McMaster University Children’s Hospital and Advanced Or-thodynamics in Hamilton, Ontario, Canada.

The study included seven children with CP and one with sacralmyelomeningocele (age range 7-14 years), all functioning at GrossMotor Function Classification System levels I or II, all of whom wereunilateral users of molded plastic AFOs at the time of enrollment.Each child was provided a prefabricated dynamic-response carbon-fiber AFO and given one month to accommodate to thedevice.

Compared with a barefoot condition, both types of AFOs wereassociated with significant improvement on a six-minute walk test(6MWT), shuttle run, and Gross Motor Function Measure (GMFM)dimension E (walking, running, jumping); the dynamic-responseAFO was also associated with significant improvement in jumpingdistance. The children’s scores were significantly better in the dynamic-response AFOs than the plastic AFOs for jumping andGMFM-E. Six of the eight children and/or their parents said theypreferred the dynamic-response device.

“The dynamic-response carbon-fiber AFO has the potential to provide enhanced performance of high level gross motor skillsthat are the components of sports and fitness,” said Eric Bapty,CO(C), an orthotist at Advanced Orthodynamics, who presentedthe findings. Sources:Kerkum Y, Brehm M-A, van den Noort J, et al. A spring-hinged ankle foot orthosiscan normalize knee kinematics and kinetics while preserving push-off power in chil-dren with cerebral palsy. Presented at the International Society of Prosthetics & Or-thotics World Congress, Lyon, France, June 2015.Burrow S, Wright M, Bapty E. Effectiveness of carbon (GRF) AFOs for high function-ing children with lower limb disability who require an ankle foot orthosis. Presentedat the International Society of Prosthetics & Orthotics World Congress, Lyon, France,June 2015.

The results are consistent with those found after 30 weeks inthe same population. Those findings were published in the June2013 issue of Stroke; gait speed improvements at 30 weeks weresimilar for the 99 FES users and 98 patients who used ankle footorthoses.

“This doesn’t mean the AFO will go away. There will always becases where patients will benefit from an AFO, but many patientswill do well with FES alone,” said Keith McBride, DPT, chief tech-nology officer for Bioness and an adjunct professor of physicaltherapy and rehabilitation at the University of Maryland, who pre-sented the findings. Source:O’Dell M, Dunning K, Kluding P, McBride K. Efficacy and prediction of improvementfrom 42 weeks of functional electrical stimulation in post-stroke drop foot: Datafrom the FASTEST trial. Presented at the International Society of Prosthetics & Or-thotics World Congress, Lyon, France, June 2015.


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PROSTHETICSFoot strike pattern can affectload in amputee runners tooFoot strike pattern during running affects loading in unilateral lowerlimb amputees, as it does in able-bodied runners, according to re-search from the Chinese University of Hong Kong.

Four unilateral lower limb amputee runners were analyzedwhile running on a treadmill with a forefoot strike or a rearfootstrike pattern in the sound limb. Three of the runners (one below-knee, one above-knee, and one through-knee amputee) were ha-bitual rearfoot strikers, while one below-knee amputee was ahabitual forefoot striker.

of ErgoResearch, who presented the findings.Anecdotally, Boucher said, 75% of the patients were still wear-

ing the brace for six to eight hours per day after 12 months.A third presentation explored the biomechanics of a third or-

thotic approach to knee OA that involves no bracing at the knee. Researchers from the Otto Bock Competence Center in Göt-

tingen, Germany, analyzed the effects of a hinged ankle foot or-thosis (AFO) on knee kinematics and kinetics in 10 healthyindividuals and 12 patients with unilateral knee OA. The AFO wasdesigned to allow unrestricted sagittal plane ankle motion but fea-tured rigid bridging in the frontal plane to limit eversion range ofmotion of the subtalar joint, shifting the body’s center of pressure(COP) laterally and decreasing the lever arm between the groundreaction force vector and the knee.

The investigators found that the AFO was associated with asignificant decrease in first peak varus moment compared with aneutral shoe condition, from .47 to .36 Nm/kg in the healthy indi-viduals and from .73 to .63 Nm/kg in the OA patients. In the OApatients, AFO use was also associated with a significant improve-ment in pain during level walking and stair ascent and descent.

Tibial rotation, an indirect marker of subtalar joint eversion,was significantly reduced with AFO use in both groups, and theCOP shifted laterally by 9.7 mm in the healthy participants and by12.5 mm in the OA patients. These values correlate with lever armreductions of 6.9 and 11 mm.

Because AFOs are more discreet than conventional knee OAbraces and are less vulnerable to migration, patients may be moreaccepting of the distal approach, said Thomas Schmalz, PhD, a re-search biomechanist with Otto Bock, who presented the findings.He noted, however, that a knee orthosis might be a better choicefor patients with knee instability. Sources:Walkay S, Munro W, Buchan M. A clinical outcome study of the varus-valgus stressadjustment knee brace in the management of knee osteoarthritis: A district generalhospital experience in the West of Scotland. Presented at the International Societyof Prosthetics & Orthotics World Congress, Lyon, France, June 2015.Desroisiers L, Boucher D. Clinical and biomechanical efficiency evaluation of anew distraction/rotation knee brace in the treatment of medial knee osteoarthritis.Presented at the International Society of Prosthetics & Orthotics World Congress,Lyon, France, June 2015.Schmalz T, Drewitz H, Stocker K. The use of an AFO as an innovative method withinthe scope of the conservative treatment of osteoarthritis of the knee. Presented atthe International Society of Prosthetics & Orthotics World Congress, Lyon, France,June 2015.

The forefoot strike pattern was associated with significantly lowerimpact peak and loading rate than rearfoot strike running in all fouramputees. The effects on heart rate were more variable; forefootstrike running was associated with a faster heart rate than rearfootstriking in two of the habitual rearfoot strikers (the above-knee andthrough-knee amputees), a slower heart rate in the habitual forefootstriker, and no change in the third habitual rearfoot striker.

The findings were presented as a poster in June at the 2015ISPO World Congress. Source:Choi WC. Effects of footstrike on the loading and heart rate in a group of top am-putee runners with running-specific prosthesis in Hong Kong. Presented at the In-ternational Society of Prosthetics & Orthotics World Congress, Lyon, France, June2015.

OSTEOARTHRITISOrthotic options for knee OAfocus on compliance issuesNew research presented in June at the 2015 ISPO Congress un-derscored the potential long-term benefits of valgus knee bracingfor relief of medial knee osteoarthritis (OA) symptoms when patientcompliance is high, while other ISPO presentations explored alter-native strategies for orthotic management of OA.

Researchers from Inverclyde Royal Hospital in Greenock, Scot-land, analyzed pain and function in 147 patients with medial kneeOA who wore a varus-valgus adjustment stress brace with four-point fixation and a closed frame with a polycentric hinge. A retro-spective assessment included 86 patients and a mean follow-upof 3.4 years; 61 patients were assessed prospectively, with a meanfollow-up of 1.2 years.

Pain levels, measured using a 10-point visual analog scale,significantly improved from 9 to 4 points. Average daily walkingdistance improved from 150 yards to 900 yards.

Patient compliance with brace use was high; only 13 patientsdiscontinued brace use. Eight patients (six in the retrospectivegroup) underwent total knee replacement and two (both in the ret-rospective group) underwent high tibial osteotomy (HTO). The twoHTO patients had experienced improvement with the brace butwere not able to wear it to work, according to S. Walkay, BSc,MRCS, a researcher in the hospital’s department of orthopedics,who presented the findings.

Although few patients discontinued brace wear, most did re-duce the extent of weekly wear over time, Walkay said.

“Once they get used to the brace, they can wear it for lesstime without recurrence of pain,” he said. “At the end of two years,most patients were only wearing the brace two or three days perweek.”

A study from Laval, Quebec, Canada, suggests that a differentapproach to knee OA bracing is also associated with high levelsof patient compliance.

In 24 patients with medial knee OA, a distraction-rotationbrace was associated with a 14% decrease in the second peakknee adduction moment (KAM), an 8.8% decrease in KAM im-pulse, and a 42% improvement in pain after three months, accord-ing to Danielle Boucher, an orthotist-prosthetist and vice president

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Iliotibial band syndromeand running mechanics

The mixed findings of several cross-sectional studies seem to suggest that nospecific biomechanical variables are un-equivocally associated with iliotibial bandsyndrome in either men or women, whichunderscores the importance of assessingeach patient individually.

By Eric Foch, PhD

Running is a popular choice of physical activity among exercisers,as well as germane to the conditioning of athletes and military pop-ulations. Running confers musculoskeletal health benefits,1,2 but thelikelihood of a runner sustaining an overuse injury is high. Previousprospective investigations indicate that the overuse injury rateamong runners during a 12-month period ranges from 56% to85%.3-6 A similar overuse injury rate of 74% was reported in amore recent retrospective investigation in collegiate cross countryrunners.7

The knee is the most commonly injured anatomical location,accounting for 25% to 42% of all reported running-related overuseinjuries.4,8 Iliotibial band syndrome (ITBS) is the most common causeof lateral knee pain and the second most common injury sustainedby runners.8 Furthermore, women are two times more likely to de-velop ITBS than men.8 Gender differences in biomechanics duringrunning have been reported between healthy female runners andmale runners.9,10 Female runners exhibit greater hip adduction,9,10

hip internal rotation,10 and knee abduction9,10 angles than men dur-ing stance. Collectively, throughout the stance phase of running,women demonstrate different lower extremity alignment in thefrontal and transverse planes compared with men. The differencesin movement patterns between genders may suggest the existenceof different etiologies of ITBS for men and women.

Functional anatomy of the iliotibial bandThe iliotibial band functions to stabilize the lateral hip and knee, aswell as limit hip adduction and knee internal rotation.11 Greater hipadduction and knee internal rotation angles during knee flexion andextension may increase the tensile and torsional strain experiencedby the iliotibial band.12 A combination of increased tensile strain, tor-sional strain, or both may damage the iliotibial band over the courseof many miles run.13

Furthermore, increased strain may compress a highly inner-vated fat pad that lies between the iliotibial band and lateral femoral


Reported differences in running movementpatterns between genders may suggest theexistence of different etiologies of iliotibialband syndrome for men and women.


epicondyle. Compression of this fat pad also may be a source ofpain associated with ITBS.12

Kinematics of ITBS in female runnersProspective evidence indicates that female runners who later de-velop ITBS exhibit greater peak hip adduction and knee internal ro-tation angles during stance at baseline, compared with femalerunners who remain uninjured.14 This hip and knee movement pat-tern may contribute to the pain associated with ITBS.

Prospective studies are the gold standard for experimental de-sign, in particular for determining cause and effect relationships be-tween variables. However, conducting a prospective investigationis costly in terms of participant recruitment and adherence.14 Alter-natively, cross-sectional investigations are less time-consuming andcan provide insight into determining associations between biome-chanics during running and ITBS injury status. No ITBS study has in-vestigated whether runners’ biomechanics postinjury are the sameas before their first incidence of ITBS. However, approximately halfof runners who experienced an overuse injury reported a previousinjury to the same anatomical site.15

The results of previous cross-sectional investigations differ withrespect to associations between greater hip adduction or knee rotation and current or previous ITBS in women.16-20 Women withprevious ITBS indeed exhibit greater peak hip adduction and kneeinternal rotation angles compared with controls.16 However, the literature also reports less hip adduction motion in women with pre-

vious ITBS17,19 and current ITBS20 compared with healthy women. Additionally, a 2015 study found that women with current ITBS ex-hibit greater hip external rotation angles in late stance comparedwith healthy women, a finding that has not been reported else-where.20 At the knee, internal rotation angles have been reportedto be similar between healthy runners and those with previousITBS17,19 and current ITBS.20

The current theory that excessive frontal and transverse planehip and knee motion influences iliotibial band mechanics is elegantin its simplicity. However, the equivocal findings in the literature sug-gest that determining how biomechanics during running are relatedto ITBS in women is considerably more complex. Greater peak hipadduction and knee internal rotation angles may be predictors ofITBS in women. But the differences in findings among studies withrespect to excessive peak hip adduction and knee internal rotationangle in women with ITBS may indicate that a female runner’s injurystatus does affect the way she runs.

For example, in women with previous ITBS, decreased hip ad-duction angle may be a compensatory running strategy developedafter ITBS symptoms have abated19 or a way to limit pain while theinjury is current.20 Running with the hip in a less adducted positionmay decrease the tensile strain experienced by the iliotibial band,thereby lessening the pain.12,17,19

Kinematics of ITBS in male runnersRelative to the body of literature that reports biomechanical factorsassociated with ITBS in women, few studies have investigated ITBSin men. Specifically, no prospective ITBS investigations of male run-ners have been reported. Additionally, running biomechanics havebeen compared only between men with current ITBS and healthymale runners,20,21 and men with current ITBS exhibit greater peakhip internal rotation and knee adduction during early stance thancontrols.21 The combination of excessive hip internal rotation andknee adduction may elongate the iliotibial band, increasing iliotibialband strain.

Distal to the iliotibial band, ankle internal rotation is differentbetween male runners with current ITBS and healthy male runners.20

However, since greater ankle internal rotation suggests a decreasein tibial internal rotation relative to the foot, it is unclear how lesstibial internal rotation would negatively affect the iliotibial band. Itmay be a protective mechanism through which male runners withITBS limit iliotibial band strain. These two studies suggest that, formale runners, both proximal and distal kinematic factors may be associated with the etiology of ITBS.

Hip strength and its association with ITBS Researchers have hypothesized that increased hip adduction duringthe stance phase of running may demand greater eccentric activityfrom the gluteal musculature.14,16 This greater eccentric activitywould be reflected in the magnitude of the hip abduction moment.During running, peak hip abduction moment has been reported tobe similar among female runners who later developed ITBS, thosewith current ITBS, those with a history of ITBS, and healthywomen,14,16,18,19 but has not been studied in men with current ITBS.

No difference in hip abduction moment in women with ITBSmay suggest that this population is characterized by differences inthe timing of gluteal muscle activation rather than the magnitude ofthe activity.14 However, the activation of two primary hip abductors,





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the gluteus medius and tensor fasciae latae, have not been directlymeasured in previous ITBS studies.

In healthy female and male runners, there is no difference be-tween genders for peak, average, and onset timing of gluteus mediusmuscle activation during running, even though women demonstratedgreater peak hip adduction than men.9 It was concluded that the tim-ing of gluteal muscle activation likely does not play a significant rolein overuse injuries associated with hip adduction.9

The hip abduction moment during running is a submaximalmeasure of strength. A maximal measure of hip abduction strengthmay provide insight into biomechanical factors associated with ITBSeven if it is not measured during running. Findings in the literatureon this topic are mixed. Maximal isometric hip abductor weaknesshas been reported in groups that consist of both male and femalerunners with current ITBS11,22 and of only male runners with currentITBS.21 However, women with previous ITBS exhibit less isometrichip abductor strength compared with female runners with currentITBS and with healthy runners.19

In the latter study, women with current ITBS flexed the trunkmore toward the stance limb in the frontal plane compared with fe-male runners with previous ITBS and healthy runners. This may rep-resent a compensatory strategy on the part of female runners withcurrent ITBS to reduce the demand on the hip abductors.19 Conse-quently, less hip abductor strength in runners with previous ITBSmay be a residual effect of greater trunk ipsilateral flexion that wasused during running when previously injured.19 Therefore, treatmentfor ITBS should target trunk motion, as well as hip abductor strength,even after the pain associated with ITBS has diminished.

Whereas a handful of studies in the ITBS literature have exam-ined hip abductor strength in runners, only one has investigated hip




external rotation strength.21 The hip external rotators play an impor-tant role in maintaining transverse plane control of the hip.23 Duringrunning, hip external rotator weakness may result in a decreasedability to limit hip internal rotation, thereby increasing iliotibial bandstrain.23 Indeed, male runners with current ITBS who demonstrateincreased hip internal rotation compared with controls also exhibitless isometric hip external rotator strength than healthy men.21

Collectively, these results provide evidence that men andwomen should be considered separately when investigatingstrength differences associated with ITBS. When treating patientswith ITBS, strengthening the lower extremity musculature as a wholethrough multijoint exercises could aid in preventing any new or fur-ther strength deficiencies.

Hip strength training in runnersThe reported findings that excessive hip and knee movement pat-terns during running are associated with ITBS and may play a rolein its etiology suggest that, potentially, runners with ITBS who do ex-hibit greater hip and knee motion than healthy runners may benefitfrom strength training. However, few studies have examined thispossibility.

One study has investigated the effect of strengthening the hipabductors and external rotators in healthy female runners with nohistory of ITBS but who exhibited excessive hip adduction duringrunning.24 After a six-week training program of three sessions perweek, the women significantly increased their hip abductor and ex-ternal rotator strength. However, hip and knee kinematics remainedunchanged following the program.24 These findings indicate that, toimprove form during running, there is not anything to suggest thatincreasing lower extremity strength alone is beneficial.

Gait retrainingRecently, the concept of implementing gait retraining strategies toalter joint kinematics in runners with knee overuse injuries has beenstudied, with promising results.25 Eight women with patellofemoralpain were provided with real-time kinematic feedback on hip ad-duction angle during the stance phase of running for eight sessions.Feedback was gradually removed over the last four sessions. At theone-month follow-up session, the women still demonstrated im-proved lower extremity pelvis and hip alignment during the stancephase of running.25 This improvement in hip mechanics was asso-ciated with a reduction in pain.

Outpatient orthopedic physical therapy clinics often do nothave the luxury of a 3D motion capture system. However, verbal in-structions and feedback can be provided by the clinician to the run-ner; for example, giving the instruction, “attempt to run with yourknee pointing straight ahead,”25 during treadmill running. This maybe an effective and economical feedback measure to alter biome-chanics during running. Additionally, in a 2014 study, healthy maleand female runners were able to decrease peak hip adduction an-gles by landing with their feet on pieces of tape placed along a run-way.26 Instructing a runner to land with her feet wider apart duringrunning may also be a simple yet effective feedback measure to im-prove lower extremity alignment during stance.

ConclusionResearchers have made considerable efforts to understand biome-chanical risk factors associated with overuse running injuries in



order to improve treatment and prevention. However, there hasbeen no significant decrease in injury rates during the past 30years.7 The alterations to biomechanics during running seen in stud-ies of runners with other overuse injuries may also be beneficial torunners with ITBS, and to women in particular. However, the mixedfindings of several cross-sectional ITBS studies seem to suggest thatno specific biomechanical variable are unequivocally associatedwith ITBS in either men or women. For example, not all runners withcurrent or previous ITBS exhibit greater hip adduction during run-ning or hip abductor weakness compared with healthy runners.

Collectively, there is likely not a generalizable gait retraining orrehabilitation intervention for male and female runners with currentITBS. The findings reported in the literature should be used as aguide for clinicians treating patients with ITBS. What the literatureindicates is that hip strength and atypical trunk, hip, and knee move-ment patterns are associated with ITBS. Therefore, when a clinicianis presented with a runner with ITBS symptoms, these biomechani-cal factors should be assessed, and a patient-specific rehabilitationplan can be developed and implemented accordingly.

Eric Foch, PhD, is an assistant professor of biomechanics at Central

Washington University in Ellensburg.



References are available at lermagazine.com, or by scanning the QR or tag codes at left.Istockphoto.com #9913056

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Diabetic foot conferenceweighs offloading issues

Offloading was a hot topic at the recentmeeting of the International WorkingGroup on the Diabetic Foot in the Nether-lands. Diabetic foot experts in attendancediscussed new research on offloadingstrategies and updated the organization’spractice recommendations.

By Cary Groner

The most recent meeting of the International Working Group on theDiabetic Foot (IWGDF) in The Hague in the Netherlands this May il-lustrated how researchers and clinicians are establishing new levelsof collaboration to help clarify the lessons of the lab and apply themin the clinic, particularly with respect to offloading strategies for pa-tients with diabetic foot ulcers.

In addition to research presentations about offloading strate-gies, the organization’s practice recommendations on offloadingwere updated. The full guidelines, as well as the systematic reviewon which they are based, are available at the IWGDF website,iwgdf.org.1,2

Foot ulcers afflict roughly 2% of patients with diabetes annuallyin developed countries.3 They are considered a major complicationand are associated with high morbidity, mortality, and costs.4-6 More-over, recurrence rates can be as high as 40% in the first year.7,8 Asa result, preventing and treating such ulcers is critical, and offloadingis an essential strategy for avoiding recurrence. Although total con-tact casts (TCCs) have long been the gold standard for offloading,they have been plagued historically with extremely low use rates byclinicians and poor patient tolerance,9 leading researchers to seekalternatives. Surgical offloading (including Achilles tendon length-ening, metatarsal head resection, and other approaches)2 is a lastresort when less-invasive tactics fail.

GuidelinesKristien Van Acker, MD, PhD, a Belgian diabetologist who is chairof both the IWGDF and the International Diabetes Federation’s footprogram, told LER it’s important that new guidelines improve patientcare in both developed and less-developed countries.

“You can have guidelines, but you must also have effective im-plementation,” she said.

Van Acker noted, moreover, that the IWGDF’s recommenda-tions have changed to reflect improved research methodologies,which should enhance their practicality and effectiveness.


The IWGDF’s offloading recomendationshave changed to reflect improved researchmethodologies, which should enhance theirpracticality and effectiveness.

“In the early days, most guidelines were based on expert opin-ion,” she explained. “Now the recommendations are updated everyfour years based on a graded literature review. We have an interna-tional panel and have many working groups on prevention,footwear, infection, peripheral arterial disease, diagnosis, therapy,and wound care research.”

One important change related to patients with neuropathic plantarforefoot ulcers absent ischemia or uncontrolled infection is that thenew guidelines call for offloading with a “non-removable knee-high de-vice with an appropriate foot-device interface.” This could mean a TCC,but it could also refer to prefabricated removable walkers that havebeen altered so the patient can’t take them off.

“In the past, the gold standard for ulcer treatment was casting,”Van Acker said. However, the issues with treatment adherence doc-umented in temperate climates are exacerbated in other places.

“When I worked in India, Africa, and Latin America, I found thatit’s much more difficult to use casts because of the heat,” she said.“Another recommendation is for adapted shoes, but people in someplaces can’t afford them. So we feel responsible for finding solutionswhen there is a gap between what the evidence recommends andwhat can be done in reality.”

The guidelines state that if nonremovable devices are contra -indicated (eg, due to severe ischemia or a dangerous infection), orif they are poorly tolerated due to patient preference or local con-ditions, clinicians should switch the patient to a removable knee-high walker, Van Acker said. If that isn’t tolerated, clinicians canconsider a forefoot offloading shoe, cast shoe, or custom temporaryshoe.

Assessing risksBecause comorbidities such as peripheral arterial disease (PAD) affectdecisions about casting and other offloading interventions, the IWGDFhas clarified guidelines pertaining to them, as well. The main point,Van Acker said, is to use noninvasive bedside tests to exclude PAD.

Those with an ankle-brachial index lower than .5 and a pedal pres-sure below 50 mm Hg are at high risk of amputation, Van Acker said.

“If the circulation isn’t good, then of course you’ll have a delayin wound healing. But beyond that, if you put a cast on a high-riskvascular patient, you can do more harm than good,” she said.

Van Acker explained that such cases are relatively common, infact, which is one reason casting is used less often than guidelinesmight suggest.

“If you have to stage an ulcer, it’s always a three-level process,”she said. “Is there a hidden infection such as osteomyelitis? Is therebad circulation? And, if the wound is not healing, did you makeenough efforts to offload it? Controlling infection as soon as possibleis the highest priority, then immediately thereafter looking for vas-cular problems. In daily practice, you have to integrate all that to-gether in each patient, along with the metabolic problems and thepsychosocial context.”

The new recommendations note specifically that offloadingstudies have focused almost exclusively on treating noncomplicatedforefoot plantar ulcers. Little information is available regarding thevalue of offloading complicated plantar ulcers, midfoot and heel ul-cers, and nonplantar ulcers. Moreover, the guidelines noted, manyclinical studies don’t directly measure the degree to which an inter-vention has affected offloading.

“We need to guide researchers to do better,” Van Acker said.To that end, she added, the IWGDF will publish a paper this yearclarifying its recommendations for research protocols, particularlywhere pressure measurement is concerned.

Similarly, the organization’s positions regarding therapeuticfootwear have been modified to reflect improved technology that’savailable for measuring in-shoe plantar pressures.

“Now we know that, if the patient is at high risk, you have tomeasure plantar pressures,” Van Acker said. “There must be thirtypercent peak plantar pressure relief compared to the pressure instandard therapeutic footwear.” The 30% offloading guideline wasbased on unpublished analysis of data from published studies thatquantified plantar pressure reductions associated with recurrentulcer prevention.8,10

Another offloading option noted in the recommendations is theuse of felted foam, applied directly to the foot around the ulcer, incombination with appropriate footwear. Van Acker stressed that thisapproach is primarily for situations in which other methods aren’tavailable.

“If you’re in a less developed country and you can’t use a fullcontact cast, you can use the foams,” she said. “It’s better to do thatthan to do nothing.”

Oral presentationsAs the breadth of conference presentations made clear, ideas aboutoffloading are subject to evolutionary forces; as new forms emerge,only the strong—those provable and repeatable—will survive.

In one study, researchers at the University of Arizona (UA) Collegeof Medicine in Tucson assessed smart insoles (Figure 1) for real-timemonitoring of plantar pressures in 21 patients with diabetic peripheralneuropathy and recently healed foot ulcers.11 Patient dissatisfactionwith the initial devices led to a redesign using a thinner insole and asmartwatch for monitoring in an ongoing follow-up study.

Lead author Bijan Najafi, PhD, an associate professor of surgeryat UA, said that the research is based on evaluating pressure areas




Smart insoles alert patients when a combined threshold value of pressure and dura -tion is exceeded; researchers track how many alerts the patients receive, and whetherthey lead to a reduction in pressure. (Photo courtesy of Bijan Najafi, PhD.)

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over time rather than peak plantar pressure magnitude during walking.One effect of this approach is that the insoles are sensitive to pres-sure buildup during sitting and standing, not just to spikes duringambulation.

“Someone sitting for a long time may transfer pressure to themedial or lateral part of the foot, and this can lead to ulceration,”Najafi explained. In the ongoing study, patients are alerted when acombined threshold value of pressure and duration is exceeded;researchers track how many alerts the patients receive, and whetherthey lead to a reduction in pressure.

“The patient gets instructions through the smartwatch, whichthen checks to see if the alert has been resolved,” he said. “For ex-ample, if the alert happens during sitting, one recommendationwould be for the patient to stand up and walk a few steps. Anotherwould be to offload the foot or change its position.”

When patients get alerts during walking, the watch may suggestcalling the medical office, and Najafi said clinicians will check thehigh-pressure area of the foot at the next appointment.

In a collaborative study between the same UA group and in-vestigators at Hamad Medical College in Doha, Qatar, researchersevaluated patterns of physical activity, and their relationship towound healing, in patients with foot ulcers protected by either re-movable or nonremovable offloading devices.12 They found thathealing proportion was higher at 12 weeks in patients who receivedan instant total contact cast (iTCC) versus those who’d been givena removable cast walker (RCW). Those with the walker were signif-icantly more active than those in the iTCC group, but in the RCWgroup it appeared that standing in particular was associated withdelayed wound healing.

“We found that the only parameter [in the RCW group] that canindependently predict the status of wound healing, when we control

for [hemoglobin] A1C levels and initial wound size, is how muchsubjects stand,” Najafi said. “Standing entails continuous loadingand may be more dangerous than walking. It may be that [when in-structing patients] we placed more emphasis on offloading duringwalking, and that the patients with removable cast walkers stoodwithout wearing them. In the group with nonremovable casts, therewas no association between the standing periods and the speed ofwound healing.”

In another oral session, investigators from the Netherlands re-ported that various types of felted foam products significantly re-duced peak plantar pressures during walking in 16 healthy adultscompared with walking barefoot.13 Mean peak pressure reductionsvaried between 32% and 43% depending on the foam type used,though there was some tendency for pressures to creep back upafter 24 hours. The authors noted that, although the promising re-sults were found in healthy individuals, there was no reason to sus-pect that the effects would be different in patients with diabetes,and suggested that the loss of offloading over time could be ad-dressed by changing the pads daily.

In a presentation on the results of a randomized clinical trial of247 patients with foot ulcers conducted at the University of TexasSouthwestern Medical Center in Dallas,14 significantly more patientswere healed by TCCs (74%) than removable cast boots (RCBs) oriTCCs (45%). The TCCs were also associated with fewer iatrogeniculcers, abrasions, blisters, infections, and serious adverse eventsthan the other offloading devices.

One of that paper’s coauthors, David Armstrong, DPM, MD,PhD, said that because neither the TCCs nor the iTCCs were remov-able, the results were surprising, especially given that they seemed




In a randomized trial of 60 diabetic patients with uninfected, non-ischemic plantar forefoot ulcers, three removable devices—a bivalved TCC (left), a custom-cast removable fiberglass shoe(top right), and a rocker-sole forefoot offloading shoe (bottomright)—didn’t differ significantly in clinical effectiveness. (Photoscourtesy of Jaap Van Netten, PhD.)

“I have successfully incorporated the OWLS program into my diabetic wound practice as a viable alternative to total contact casting in patients with plantar heel and forefoot ulcers. The custom orthoses reduce shear forces to the foot while stabilizing the foot and ankle complex and reducing pressure to the aff ected site.”

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to subvert the new IWGDF guidelines Armstrong helped write. Armstrong, who is a professor of surgery and codirector of theSouthern Arizona Limb Salvage Alliance (SALSA) at the Universityof Arizona College of Medicine, said he suspected the results mighthave been affected by the study design.

“These were intent-to-treat data, so anyone who dropped outwas considered a treatment failure, and more people in the iTCCgroup dropped out than in the TCC group,” he said. “We’re goingto do a per-protocol analysis in the actual manuscript, which maychange things.”

In another randomized trial of 60 diabetic patients with unin-fected, nonischemic plantar forefoot ulcers,15 three removable de-vices—a bivalved TCC, a custom-cast removable fiberglass shoe,and a rocker-sole forefoot offloading shoe (see Figure 2)—didn’t dif-fer significantly in clinical efficacy. The 12-week healing rates were58%, 60%, and 70%, respectively; at 20 weeks, they were 63%,83%, and 80%.

Lead author Jaap Van Netten, PhD, a human movement spe-cialist who is a senior researcher at Ziekenhuisgroep Twente inAlmelo in the Netherlands, credited his coauthors with conceivingand initiating the study. The findings are important to real-worldpractice, he said, partly because of the discrepancy between re-search results and common practice patterns.

“The evidence supports the superiority of the nonremovableTCC,16,17 but in actuality it’s used in a relatively small number of pa-tients,” he continued, explaining that certain practical issues asso-ciated with the devices reduce the frequency with which they’represcribed.

“First, you have to remove the cast if you want to examine ortreat the wound,” he pointed out. “Second, when those with nonre-movable casts see other patients with removable walkers, they wantone too.”

In a nod to the IWGDF recommendations, clinicians at Van Net-ten’s facility now initially prescribe nonremovable TCCs more often.But after a week, they may switch patients to a removable devicewith the caveat that if healing is too slow, they’ll have to go back tothe TCC.

“That way, we do what the guidelines tell us—use nonremovableoffloading,” Van Netten said. “But we also try to accommodate thepatient and give them a little more freedom.”

For patients whose infected ulcers or ischemia make it imper-ative to monitor the wound, the results by Van Netten and his col-leagues shed light on what can be expected with a variety ofremovable devices.

“We didn’t find major differences among them, so you can seewhich device fits the patient best,” he said.

Another oral presentation examined ways to improve compli-ance by reducing the limb-length inequality associated with RCWs,the hypothesis being that, if patients were more comfortable, theywouldn’t remove the walkers so much.18 Investigators at RosalindFranklin University in Chicago evaluated 25 patients at risk for footulcers wearing both short and long RCWs, with and without a con-tralateral lift. They found that the short device reduced gait velocityless than the taller one, and that the lift didn’t significantly affect ve-locity. However, the cast foot was best offloaded in the taller RCW.This raised the obvious question of whether the advantages of abetter offloading device are offset by its increased discomfort andthe resulting potential for lower compliance.

“In the case of removable offloading devices, I suspect the in-creased comfort is likely more important than the decreased of-floading capacity,” said lead author Ryan Crews, MS, CCRP, a clinicalresearch scientist, and assistant professor in the Department of Po-diatric Surgery and Applied Biomechanics, at Rosalind Franklin. “Ifincreased comfort leads to greater offloading adherence, I think theuse of the lift is warranted.”

PostersSeveral of the posters presented at the conference addressed is-sues related to offloading, as well.

In a five-year retrospective analysis,19 Dutch researchers re-ported a healing rate of 88% with custom-cast removable fiberglassshoes, suggesting that the shoe was as effective as a TCC. Theshoes were associated with healing rates of 64% and 85% at 12and 20 weeks, respectively, and effectively treated grade 3 ulcersin addition to grade 1 and 2 ulcers.

In another poster, Panamanian investigators studied an off-the-shelf TCC system in nine patients; the casts and dressings werechanged two to three days after initial application and weekly there-after.20 The authors found that the cast system achieved roughly a50% reduction in ulcer surface area at four weeks; moreover, sixpatients experienced full wound closure at eight weeks.

Dennis Janisse, CPed, presented a literature review showingthat rocker soles are an effective—and often overlooked—means ofoffloading the forefoot and reducing peak plantar pressures.21

Janisse, who is president and chief executive officer of National Pe-dorthic Services and a clinical assistant professor of physical med-icine and rehabilitation at the Medical College of Wisconsin in



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Milwaukee, told LER the review showed that rocker soles could re-duce pressure by 35% to 65% under the heel and centralmetatarsal heads; that rockers don’t negatively affect postural sta-bility in patients with diabetic neuropathy; and that attention to anindividual patient’s pathologies is critical when choosing betweenoffloading device designs.

“Rocker soles can be valuable if they’re carefully designed andfabricated,” Janisse said. “A lot of pedorthic education doesn’t dealwith shoe modification these days, and I think many students com-ing out of school shy away from the technical challenges of it. Butappropriate rockers enhance the effects of the foot orthosis and thefunction of the shoe; they can accomplish so much, but you haveto understand how to prescribe and use them.”

In another study designed to analyze the association betweenthe locations of healed ulcers and peak plantar shear, Texas re-searchers used a custom stress plate that quantified triaxial plantarstresses.22 Of the eight healed ulcer locations (updated from four inthe submitted abstract), three corresponded with peak shear sitesonly, two with the peak pressure site only, one occurred at a sitethat experienced both peak pressure and peak shear, and two didn’toverlap with either peak pressure or peak shear.

The lead author of the abstract, Metin Yavuz, DEng, an engineerand assistant professor of physical therapy at the University of NorthTexas Health Science Center in Fort Worth, said the study exposedhow complicated it can be to evaluate the effects of the forces thataffect the plantar surface of the foot.

“These results should make us rethink ulceration pathomechan-ics,” Yavuz said.

Shear is biphasic, he noted; that is, braking forces occur whenthe foot hits the ground, then at push-off the shear acts in the op-posite direction. Yavuz likens it to breaking a paper clip by bendingit back and forth.

“For us to effectively prevent ulcers, we need to have a betterunderstanding of why they occur, and try to integrate the implica-tions of pressure, shear, temperature, physical activity, skin proper-ties, and even moisture,” he said.

As an example, Yavuz noted that when researchers discussphysical activity, they usually mean the average number of stepstaken in a given day. But such simple measures fail to include walk-ing speed, which affects both pressure and shear stresses. A moresophisticated measure called cumulative daily stress,23 developedby researchers at Washington University in St. Louis, would provideinformation about both the magnitude of stress and how long perstep it was applied to the skin, according to Yavuz.

Yavuz plans to add shear stress to this equation so the meas-urement becomes 3D.

“We live in a three-D world, and we should remember that ul-cers form in that three-D world,” he said. “We need to quantify whatthe tissue experiences and take into account all these time-relatedvariables.”

Cary Groner is a freelance writer in the San Francisco Bay Area.



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Role of early rehab stagesafter ACL reconstruction

Traditionally, anterior cruciate ligament reconstruction outcomes have been as-sessed preoperatively and several monthspostoperatively, but new research suggeststhe early postoperative stages of recoverymay also significantly affect self-reportedoutcomes.

By Caitlin J. Miller, PT, DPT, and Jesse C. Christensen, PT, DPT, SCS

More than 200,000 anterior cruciate ligament (ACL) injuries are es-timated to occur in the US annually, and ACL reconstruction (ACLR)is a commonly performed surgical procedure in active individualswho have expectations of returning to their prior level of function.1-3

Outcomes following ACLR are typically evaluated objectively bysuch methods as clinical examination, assessment of ligamentouslaxity, and radiography. Patients, however, are typically more con-cerned with more subjective outcomes, such as symptom reductionand functional ability.4 Therefore, both objective and subjective out-comes should be paramount in determining the response to recov-ery after ACLR.

Traditionally, these outcome measures have been assessedpreoperatively and several months postoperatively to determine theeffects of ACLR.5-13 However, little is known about the influence theearly postoperative stages of recovery have on self-reported out-comes following surgery.

Preoperative education Patient education throughout postoperative rehabilitation is criticalto a successful outcome following ACLR. However, the process ofa successful recovery can begin well before surgical intervention.One of the most critical first steps in obtaining a successful postop-erative outcome is preparing the involved limb appropriately priorto surgery. Following an ACL injury, the patient should be educatedon the importance of addressing post-traumatic effusion, loss ofrange of motion (ROM), limited quadriceps activation, and alteredgait mechanics.

Other preoperative steps that can help avoid postoperativecomplications and improve rehabilitation include achieving symmet-rical knee ROM, increasing lower extremity strength, and restoringdaily functional mobility. These milestones should be met prior tomoving forward with surgical intervention.14,15 Meeting with a rehab -ilitation clinician (eg, physical therapist or athletic trainer) will providethe necessary interventions to improve in these areas, while


The medical literature has focused largelyon long-term outcomes following ACLR,with less attention to how deficits in theearly phase of recovery affect outcomes.


providing an opportunity to educate patients on the nature of theirinjury and to begin to set expectations for their road to recovery.

It has been shown that patients lacking knee ROM prior to sur-gical intervention have greater difficulty restoring joint mobility post-operatively than those with greater knee ROM.15 Clinicians shouldemphasize not only obtaining neutral extension of the involved kneejoint, but also restoring full symmetric knee hyperextension in theinvolved limb and flexion ROM (Figure 1). Achievement of full kneemotion should serve as a critical milestone prior to patients movingforward with surgical intervention.

Additionally, preoperative rehabilitation should focus on quadri-ceps strengthening, which not only improves short-term functional

mobility, but has also been shown to be predictive of postoperativeoutcomes.16-18 Logerstedt et al10 found that preoperative quadricepsstrength was a significant predictor of International Knee Documen-tation Committee Subjective Knee Evaluation Form (IKDC) scoressix months after surgery. Additionally, de Jong et al16 reported thatpatients with quadriceps strength deficits greater than 20% pre -operatively relative to the contralateral limb demonstrated a signif-icantly lower limb symmetry index at six and nine monthspost operatively than those with lesser preoperative strength deficits.Based on the current evidence, there should be a strong emphasison strengthening prior to surgery without causing increased inflam-mation that may lead to subsequent loss of ROM.



Figure 1. To measure preopera-tive hyperextension knee rangeof motion (ROM), we recom-mend evaluating the patient in aseated position with the heel ofthe foot positioned on a bolsterto demonstrate symmetrical hy-perextension, if it is present. Tomeasure preoperative knee flex-ion ROM, we recommend eval-uating the patient in a seatedposition using a heel slide withassistance to demonstrate sym-metrical knee flexion. Knee ROMshould be measured with a go-niometer.

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Psychosocial factorsRecent studies have also highlighted the role of psychosocial com-ponents with respect to influencing the ability to successfully re-cover from an ACL injury.19-23 Several subjective outcometools—including the ACL Return to Sport after Injury (ACL-RSI), KneeSelf-Efficacy Scale (K-SES), and the Tampa Scale for Kinesiophobia(TSK-11)—are available to help clinicians identify patients with an in-creased risk of not returning to their previous level of function dueto psychosocial ramifications. Although minimal research has beenconducted in this area preoperatively, Thomee et al24 demonstratedthat preoperative K-SES scores can be predictive of patients return-ing to the same intensity and frequency of physical activity 12months after ACLR. Patients who perceived their function as suc-cessful at 12 months postoperatively had scored themselves signif-icantly higher on the K-SES preoperatively.24

In a recent systematic review, Te Wierike et al25 described howpsychosocial factors may affect ACLR recovery. According to Wiese-Bjornstal, the psychosocial responses of injured athletes consist ofcognitive, affective, and behavioral factors.26 It is the interaction ofthese domains that contribute to full recovery following ACL injury.Clinicians may consider incorporating treatment strategies such asrelaxation, imagery, training of self-efficacy, and modeling to addresscognitive and affective deficits.27-29

Additionally, with regard to behavioral factors, the systematicreview25 found a positive association between goal setting and re-habilitation adherence. Patients with higher adherence scores ex-perienced fewer knee symptoms, indicating that adherence to arehabilitation program had a positive effect on recovery afterACLR.30

Further research is needed in this area to identify the potentialinfluence psychosocial factors have on returning patients to priorlevels of function or to identify patients who may require some ofthe aforementioned treatment strategies.

Range of motionDuring the early phase of postoperative rehabilitation, emphasisshould be placed on restoring full symmetric knee ROM. A growingbody of evidence indicates that postoperative knee ROM deficitsare associated with lower subjective outcome scores in the short-and long-term, as well as increased risk of developing knee osteo -arthritis (OA).14,31,32

Traditional postoperative restrictions, such as bracing for im-mobilization and limiting early hyperextension, have been utilizedthroughout rehabilitation, with the intention of preventing excessiveloads on the healing graft.33 Although these are still valid concernsin postoperative management, advancements in surgical techniqueand fixation have warranted a reevaluation of movement restrictionsafter ACLR. Postoperative protocols have been influenced largelyby theories of graft-tunnel healing and graft selection over time, butgathering evidence suggests that restrictions may not be necessary,and early unrestricted ROM has not been associated with adverseeffects on anterior-posterior laxity, ROM deficits, reinjury rate,and/or ability to return to the patient’s previous level of function.31,34

Shelbourne et al35 found that as little as 3° of knee extensionloss relative to the contralateral knee can have a negative effect onsubjective and objective outcomes. It has further been shown thatpatients with less than normal knee motion (relative to the contralat-



eral knee) are 2.4 times more likely than those with normal kneemotion to have radiographic findings of knee OA 10 years followingACLR.31 More recently, at a mean of 10.5 years following ACLR, normal radiographic findings were identified in 71% of patients withnormal symmetrical knee ROM compared with 55% of patients whohad knee flexion and/or extension ROM deficits at final study follow-up.12

Further findings have indicated that early ROM deficits mayhave some influence on patient-reported outcomes following ACLR.In the first month following surgery, deficits in knee flexion ROMhave been shown to be related to lower IKDC scores at the equiv-alent time point.32 This highlights that even subtle ROM deficits maysignificantly impact patients’ perceived functional ability.

Early progressive ROM exercises should begin within the first24 to 48 hours following surgery,33 with a specific emphasis onrestoring symmetrical extension or hyperextension (if present).35

Postoperative functional bracing may interfere with early motiongains and in recent studies has been shown not to offer any signif-icant advantages over no bracing.33,36,37 Wright et al33 conducted asystematic review, concluding that neither a postoperative kneebrace locked in full extension nor an open-hinged brace offered sig-nificant advantages over no bracing with regard to self-reported out-comes, knee laxity, ROM, or strength testing. The literature alsosuggests that emphasis on restoring symmetrical knee ROM relativeto the contralateral knee is critical for avoiding possible complica-tions relative to joint mobility limitations, such as graft impingement,development of arthrofibrosis, and inefficient quadriceps activationfollowing isolated ACLR (Figure 2).14,38

Lower extremity strengthIn conjunction with restoring symmetrical knee ROM, progressivelower extremity strengthening should also be an area of focusacutely following ACLR. Aggressive strengthening not only improvesfunctional mobility in the early phases of rehabilitation, but may alsoimprove the patient’s capacity to return to his or her previous levelof function in the later phases of recovery.

Gerber et al39 found that atrophy of up to 30% in the quadriceps

muscle in the surgical limb is evident just three weeks after ACLR,underscoring the importance of early resistive training immediatelyafter surgery in an effort to mitigate atrophy and weakness. It hasfurther been shown that knee extensor weakness of nearly 20%persists one to six years following surgery.40 Quadriceps weaknessleads to predominant limitations in functional mobility and has beenshown to be the strongest contributor to the strength-function rela-tionship during early recovery after ACLR.41 Initial quadriceps acti-vation and mitigating atrophy can be achieved by allowing fullweight bearing with assistive devices (as needed) immediately aftersurgery. This has been shown to be safe, as well as beneficial, whilealso decreasing potential future risk of patellofemoral pain and likelyimproving functional mobility.33

Lower extremity strength may be difficult to measure objec-tively in the early phase of rehabilitation. However, recent work hasshown that examining peak isometric hip and knee extensorstrength as early as one month following surgery is safe and appro-priate (Figure 3).37 Additionally, the ratio of surgical to nonsurgicallimb isometric force measures at one and two months postsurgeryhas been shown to be significantly associated with one- and two-month IKDC scores.32 This highlights the importance of focusedlower extremity strengthening during the early phase of rehabilita-tion, as this plays a primary role in normalized gait patterns as wellas more demanding tasks such as stair climbing.

Further evidence suggests that neuromuscular electrical stim-ulation (NMES) may play a role in enhancing quadriceps strengthduring the early phase of rehabilitation. Kim et al42 performed a sys-tematic review evaluating the efficacy of NMES for improvingquadriceps strength measures, functional performance measures,and self-reported outcomes. A moderate effect was shown for improved subjective outcome scores on the Knee Outcome Surveyusing NMES in conjunction with postoperative rehabilitation exer-cises relative to exercise alone or electromyography biofeedbackduring the first month following ACLR.43 There is inconclusive evidence to support a significant difference in functional outcomes,




Figure 2. To measure postoperative symmetrical quadriceps activation and hyperextension knee ROM, we recom-mend evaluating the patient in a seated position. Ask the patient to lift the heel off the examination table whilemaintaining the knee in a neutral position (left, center). To measure postoperative symmetrical knee flexion ROM,the patient should be able to kneel and sit back on the heels comfortably (right).

including the anterior reach, lateral step up, and unilateral squat

tests44 when using NMES; however, it appears to be most beneficial

when used at a high intensity in the first few weeks following sur-

gery.45 Future studies with improved methodological quality and

consistent treatment parameters are needed to assess the potential

benefit of NMES in this population.42

KinesiophobiaCriteria for returning patients to their previous level of sports functionfollowing ACLR generally focuses on ligamentous stability, normaliza-tion of knee ROM, restoration of lower extremity strength, improvedbiomechanics, and limb symmetry on functional tests.46,47 Althoughthe physical factors that contribute to a successful recovery are crit-ical, clinicians must also consider the influence of psychological fac-tors in returning patients to their prior level of function. Ardern et al21

reported that only 44% of competitive athletes who were classifiedas having normal or near-normal physical function after ACLR wereable to return to their previous level of competitive sport activity at amean follow-up of 41.5 months. A growing body of literature suggestspatients may not be achieving their desired level of function postop-eratively due to psychological factors, including fear avoidance be-haviors, kinesiophobia (fear of movement/re-injury), or both.21,23,48 Ithas been reported that nearly 20% of patients cited fear of reinjuryat 12 months following ACLR as their reason for not returning to theirprevious level of sport function.21 This highlights a potential area ofrehabilitation that may be overlooked.

Currently, we know that these fear avoidance behaviors arepresent, but further research is needed to determine the most clin-ically effective ways to use kinesiophobia measures and implementpsychological interventions during relevant timeframes followingACLR. The development of novel interventions that address the psy-chological aspect of injury and provide a platform for patients to im-prove in these areas is warranted. These interventions could beimplemented in the early phase of recovery, while providing the




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Figure 3. Single-leg strength testing of unilateral closed-chain peak isometric kneeextension force production, using a horizontal Plyo-Press.

necessary guidance to minimize fear avoidance behaviors through-out rehabilitation and likely increasing patients’ ability to return totheir prior level of function.

Identifying the patients at highest risk for fear avoidance andimplementing interventions specifically in those patients could alsobe beneficial; however, this can be a challenging process due tothe scarcity of subjective outcome tools and currently limited research in this area. The TSK-11 has been adapted for patients following ACLR.49 The TSK-11 is a valid measure of fear of move-ment/re-injury with response items related to somatic sensations(eg, “Pain always means I have injured my body”) and activity avoid-ance (eg, “I’m afraid that I may injure myself if I exercise”). Althoughthis tool showed a strong association with knee function as assessedby IKDC scores at six to 12 months postoperatively, no associationhas been found in the six months following surgery.50 The ACL-RSIscale has also been used to examine psychological readiness to re-turn to sport and recreational activity.19,49,51 Müller et al52 prospec-tively followed ACLR patients and at six months found that theACL-RSI was a strong predictor of patients’ return to sport. Ardernet al also reported that, when assessed in a long-term follow up(mean = 35 months), for every one-point increase on the ACL-RSIoutcome tool, patients had approximately twice the odds of returning to activities.19

ConclusionsThe medical literature has focused largely on long-term postoperativeoutcomes following ACLR, with less attention drawn to how deficits inthe early phase of recovery influence overall outcomes. Normal gait



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mechanics, reduced swelling, and restoration of symmetrical kneeROM should be achieved prior to surgical intervention. Immediate un-restricted knee ROM should be implemented postoperatively to im-prove subjective outcomes and minimize long-term risk of knee OA.Full weight bearing to tolerance and quadriceps strengthening shouldbegin immediately following surgery to minimize lower extremity at-rophy. Patients should be screened for psychosocial deficits and fearavoidance behaviors preoperatively and during early phases of recov-ery to help identify those with risk of factors that may interfere withreturning to their prior level of function.

There are many factors to consider when developing a rehab -ilitation protocol for ACLR. These guidelines serve to highlight keyareas that should be addressed preoperatively and in the early post-operative period to further improve subjective and objective out-comes. Future research is needed to examine how addressing theseearly deficits will affect long-term outcomes following ACLR.

Caitlin J. Miller, PT, DPT, is a practicing physical therapist at The Or-thopedic Specialty Hospital, a division of Intermountain Healthcare,and a graduate student in the MS Clinical Investigation program atthe University of Utah in Salt Lake City. Jesse C. Christensen, PT, DPT,SCS, is a practicing physical therapist at The Orthopedic SpecialtyHospital and a PhD student within the Department of Physical Ther-apy/Orthopaedics at the University of Utah.

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Lems ShoesPrimal2

Lems Shoes are designed tomirror the natural shape of thehuman foot, with a toe box thatallows for maximum room forthe toes to wiggle and spread.The Primal2 is a lightweight (6.9oz), flexible, breathable, flatshoe that is assembled usingno-sew construction, which al-lows the shoe to comfortablyform to the foot. Lightweight microsuede and open-weavemesh provide airflow andbreathability. The low-profile 8-mm LemsRubber sole bringsthe wearer close to the groundfor a more natural stride. TheLemsLast design, with its naturalfoot shape, provides what thecompany calls a “Feelgood Fit.”

Lems Shoes877/321-7836lemsshoes.com

Elite AdjustableNight Splint

Now available from Elite Ortho -paedics is the Premier Ad-justable Night Splint for patientswith plantar fasciitis, Achillestendinitis, and other lower ex-tremity overuse injuries. It fea-tures an angled shell to keepthe foot in a dorsiflexed posi-tion, which can be easily ad-justed using medial and lateralhook and loop straps. A remov-able 5° foam forefoot wedge al-lows for additional stretching.The liner is removable andwashable. Available in sizessmall (fits men’s shoe sizes 4-7,women’s shoe sizes 4-7.5),medium (men’s 7.5-10, wom -en’s 8-10.5), and large (men’s10.5+, women’s 11+). Sug-gested HCPCS code L4397.

Elite Orthopaedics800/284-1688elite-ortho.com

ElectronicTuning Fork

O’Brien Medical announces thecommercial release of its pre-mier product, the ETF128 elec-tronic tuning fork. The medical-grade ETF128 transforms themost valuable features of a con-ventional 128-Hz tuning forkinto a modern electrical config-uration with four vibration am-plitude modes and a simple er-gonomic design. The accuracyand reproducibility of the elec-tronic tuning fork has been com-bined with an integrated timingfunction, which makes possiblethe performance of standard-ized timed vibration testing forthe early diagnosis and trackingof peripheral neuropathy in pa-tients with diabetes.

O’Brien Medical207/290-0719obimed.com

Ped-LiteMaterials

Ped-Lite is proud to announceits new line of fabrication mate-rials to complement its existingproduct lines of custom and pre-fabricated diabetic inserts anddiabetic shoes. The Ped-Lite lineof fabrication materials includesclosed-cell foam sheets, two-and three-layer laminates, corks,top covers, and soling materials.The materials are offered in sev-eral color options and varyingthicknesses, depending on theproduct. The company offersthis satisfaction guarantee: Ifthere is dissatisfaction with aproduct due to the workman-ship or a defect of a material, itwill be corrected or replaced atno additional cost.

Ped-Lite219/756-0901pedlite.com


Visit lermagazine.com/productsfor more products and to submit your new product listing.

ArcopedicoHigh-tops

Arcopedico USA is debutingknit high-top sneaker styles asadditions to its top-selling knitshoe collections. Shocks 5sneaker-style high-tops featurea lace-up front, outer-side logodetails, SanSmell fabric lining,cushioned footbed, and flexibleheel strap. With an MSRP of$120, they are available inblack, gunmetal, black starrynight, brown starry night, andnavy starry night. Nicknamed“Shocks” for their sock-like feel,the machine-washable knitshoes feature flexible, breath-able uppers and Arcopedico’stwin-arch support system for aneven distribution of weight overthe entire foot surface.

Arcopedico USA775/322-0492arcopedicousa.com

Branier Shoes,Boa Closures

Branier Orthopedic, through acollaboration with Click Medical,is now offering the Boa closuresystem for its custom-moldedshoe lines. Adjustable with theuse of a single hand, Boa’s me-chanical reel system works todraw a steel cable through aseries of easy-glide nylonguides. With the capacity toeasily generate tension acrossthe vamp of a shoe that is com-parable to or exceeds the ten-sion achieved with standardlaces, the Boa closure systemoffers a novel solution to pa-tients with limited manual dex-terity who are frustrated by aninability to achieve a snug fit inshoes with conventional closuresystems.

Branier Orthopedic 863/314-0016branier.org

KLM Uniflex 4 Foot Orthosis

KLM Laboratories, a provider oforthotic devices since 1973, of-fers a new addition to the Uni-flex family of functional orthoticdevices, the Uniflex 4. The Uni-flex 4 foot orthosis comes stan-dard with a gray simulatedleather top cover and a semi-rigid polypropylene shell andrearfoot post, but practitionerscan request that the device bemade more rigid or more flexi-ble to match specific patients’needs. The Uniflex 4 insole alsocan be modified with any ofKLM Laboratories’ top covermaterials and accommodations.All Uniflex foot orthoses comewith a lifetime guarantee againstbreakage.

KLM Laboratories800/556-3668klmlabs.com

Kano Sigma-4Exam Chair

The modern, sleek Sigma-4exam chair from Kano Labs fea-tures four independent, low-voltage motors. Like otherSigma exam chairs, the Sigma-4 has a 360° locking ring swivelbase, digital control electronics,surface mounting technology,and computerized testing of theautomated test equipment cardfor fast, silent, and reliablemovement controlled by a footpedal. The upholstery is nonslipand seamless and is availablein 14 colors. The chair has dou-ble-panel, extendable leg rests,a contoured backrest, and isadaptable to a patient’s height,which allows for customized positioning.

Kano Labs208/254-0019kano-labs.com

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new products


Hook & LoopStrap Kits

WBC Industries introduces PVCHook & Loop Strap Kits for useon ankle foot orthoses andknee ankle foot orthoses foradults and children. Each kitcomes with a strap, chafe, pad,and matching rivets and is avail-able in 14 different colors.Straps feature a bullet-shapedhook tip with an easy-lift end.They can be cut to any lengthand are reinforced with durable,easy-to-clean PVC material.Pads are also made from PVC,with a soft cushion foam center.Four rivets in two different sizesare provided in each kit. Sizesinclude a 25-mm width in 300-mm or 500-mm lengths, or a40-mm width in 400-mm or680-mm lengths.

WBC Industries800/818-2932wbcindustries.com

DiabeticFoot Cream

Myfootshop.com introduces Di-abetic Foot Cream, an all-natural,multipurpose cream intendedto address the unique skin careneeds of patients with diabetes,including dry skin, superficialcellulitis, and bacterial and fun-gal infections. Diabetic FootCream is a tea tree oil-basedcream used to treat dry skinand chronic tinea rubrum. Dia-betic Foot Cream is formulatedwith .025% capsicum essentialoil to help reduce the tinglingand burning of diabetic periph-eral neuropathy. Additional in-gredients include shea butter,avocado oil, jojoba oil, lavender,and Epsom salts. The creamcomes in a convenient four-ounce jar.

Myfootshop.com888/859-8901myfootshop.com

Drew Antwerpfor Women

Drew Shoe introduces theAntwerp for women, with astretch fabric upper and a Vel-cro closure. Designed for thosewith common foot ailments, thisslip-on walking shoe featuresDrew’s Proprietary Plus fittingsystem, which includes two removable footbeds for addeddepth to accommodate a rangeof orthotic devices. A soft, moisture-wicking liner helpsfeet stay dry. The removablepoly urethane insole has addi-tional heel and metatarsalpadding and a Dri-Lex topcover. A tempered steel shankenergizes the midfoot, and theextended medial heel stabilizerreduces slippage and providessupport.

Drew Shoe800/837-3739drewshoe.com

Aircast AirHeelwith Stabilizers

Now available from DJO Globalis the Aircast AirHeel with Sta-bilizers, designed to improvepatient compliance by providingactive relief of plantar fasciitis,Achilles tendinitis, and otherheel pain symptoms. Intercon-nected aircells under the archand at the back of the heel apply pulsating compression,while medial-lateral stabilizersare designed to enhance pro-prioception and stability. TheAirHeel with Stabilizers is madeof lightweight, breathable fabricand is simple to apply: the pa-tient slips it on like a sock andadjusts the fit with one strap.Available in small, medium, andlarge sizes.

DJO Global800/336-6569djoglobal.com

NATA inducts its 2015 Hall of Famers The National Athletic Trainers’Association (NATA) on June 25inducted eight individuals into itsHall of Fame at the NATA 66thClinical Symposia and AT Expoin St. Louis, MO.

The 2015 inductees areTina Bonci, MS, ATC, LAT,(posthumously), formerly associ-ate athletics director at the Uni-versity of Texas at Austin; DavidCarrier, MA, ATC, head athletictrainer at Michigan State Univer-sity in East Lansing; Malissa Mar-tin, EdD, ATC, associate viceprovost and graduate programdirector of Athletic Training atRocky Mountain University ofHealth Professions in Provo, UT;Terry Noonan, MS, ATC, LAT,

director of Athletic Training Serv-ices at the University of Iowa inIowa City; Russ Richardson, EdD,ATC, associate professor ofHealth and Human Performanceat the University of MontanaWestern in Dillon; Brian Robin-son, MS, ATC, (retired) head ath-letic trainer at Glenbrook SouthHigh School in Glenview, IL, from1977 to 2014; Sandra Shultz,PhD, ATC, FNATA, professor andchair of the Department of Kine-siology at University of NorthCarolina at Greensboro; andThomas Weidner, PhD, ATC,FNATA, professor of athletictraining and chair of the Schoolof Kinesiology at Ball State Uni-versity in Muncie, IN.

Profoot teams up with NYC FC soccer Brooklyn, NY-based Profoothosted a game viewing party onJuly 7 to celebrate its partner-ship with the New York City FC,which kicked off its inaugural Ma-jor League Soccer season inMarch.

Profoot, the team’s officialfoot care brand, invited soccerfans to watch the US Men’s Na-tional Soccer team face the Hon-duras National Football team

alongside New York City FC mid-fielder Tommy McNamara. TheUS beat Honduras 2-1 in theGold Cup’s Group A opener.

Profoot provided samples ofits products, which include thePlantar Fasciitis Orthotic andTriad Orthotic insole, and willhold giveaways for fans onmatch days at Yankee Stadiumand other special offers through-out the year.

Dralla announces 2015 grant recipients The Rockaway, NJ-based DrallaFoundation on June 10 an-nounced its 2015 grant recipi-ents, who will use their shares ofthe $30,000 in awarded fundsto hold events and programs foradults and children with physicalchallenges.

This year’s grant recipi-ents are: the Bay Area Out-reach & Recreation Program inBerkeley, CA; the ColoradoAdaptive Sports Foundation inDenver; Daring Adventures inPhoenix, AZ; Heroes on the

Water in Allen, TX; Kinetic Kidsin San Antonio, TX; the Reha-bilitation Institute of Chicago;and the Telluride AdaptiveSports Program in MountainVillage, CO.

Allard USA, also headquar-tered in Rockaway, funds theDralla grants by donating a per-centage from each sale of itsToeOff ankle foot orthoses.

Since forming in 2011, theDralla Foundation has awardedalmost $150,000 in grants to or-ganizations across the US.

Therafirm legwear wins retail awardThe VGM Group (named forfounder Van G. Miller) on June17 awarded Kansas City, KS-based Therafirm’s new Easebrand compression legwear itsMost Innovative Retail Product of2015 honor at the VGM Heart-land Conference in Waterloo, IA.

During a presentation of 12competing products, the audi-ence and a panel of judgeswatched as each vendor demon-

strated their items. In the Easedemonstration, Therafirm staffdonned the product to show it’seasier to get on than other com-pression legwear. Judges scoredproducts on features and bene-fits, packaging, merchandising,and marketing tools.

Preggers, a Therafirm brandof maternity compression leg-wear, was also among the 12 fi-nalists.

DonJoy launches retail Performance brandSan Diego-based DJO Global onJune 10 launched DonJoy Per-formance for sale to consumersonline and in select retailers na-tionwide.

The company also unveiled

its consumer website, donjoyperformance .com.

The DonJoy Performanceline includes the Bionic, Web -tech, and Trizone sleeves andbraces.

market mechanicsBy Emily Delzell



AOPA names business award nominees The Washington, DC-basedAmerican Orthotic & ProstheticAssociation (AOPA) announcedon June 9 the contenders for the2015 Hamontree Award.

The contenders are Chris -tina Throndson, web marketingmanager for Waterloo, IA-basedVGM Forbin; Thomas McGovern,managing partner of Baiting Hol-low, NY-based Clinical EducationConcepts; and Tyler Ritchey,

MBC, CP, ACM, Southwest re-gion clinic manager for Hangerin Austin, TX.

AOPA created the Sam E. Ha-montree, CP(E) Business Educa-tion Award to recognize the bestbusiness paper submitted for pres-entation at the AOPA National As-sembly. The contenders will pres-ent their papers at the 2015 AOPANational Assembly in San Antonio,TX, on October 9.

ING Source supports pedorthic education Hickory, NC-based ING Source,which manufactures the Or-thoSleeve line of compressionproducts, announced in July a$60,000 donation to TheRobert M. Palmer, MD, Instituteof Biomechanics (RMPI), basedin Elwood, IN.

The donation will supportthe RMPI capital campaign forpedorthic education, research,and scholarships to advance

foot care product designs byinnovative pedorthic practi-tioners.

Visit the RMPI booth at theAmerican Podiatric Medical As-sociation/Pedorthic FootcareAssociation Symposium in Or-lando, FL, July 23-26. RMPIfounder Pam Haig, CPed, willspeak on applied foot and anklebiomechanics during the con-ference’s opening session.

Remington Products is top workplace Employee engagement researchfirm WorkplaceDynamics onJune 21 named Wadsworth, OH-based Remington ProductsCompany one of NortheastOhio’s Top Workplaces. Reming-ton Products Company, whichmanufactures aftermarket in-soles, is the parent company ofthe Powerstep brand distributedby West Chester, OH-based Sta-ble Step.

Remington Products is anemployee stock owned com-pany (ESOP) with a benefitspackage that includes annual al-locations of company stock, aquarterly discretionary bonusprogram based on companyprofitability, and a workout facilityand wellness program. Work-placeDynamics’ top workplacesare selected based on employeefeedback.

market mechanicsContinued from page 65

I Measure U crowdfunds wearable Auckland, New Zealand-basedI Measure U opened an In-diegogo campaign in June toraise funds for a production runof its I Measure U Run (IMU-Run), a wearable sensor tomeasure and monitor tibial

shock and cumulative load forrunners.

The device fits on runners’ankles and sends data to asmartphone app wearers canuse to evaluate tibial shock un-der various conditions.

NBA commits to player health, wellnessIn response to a 2014-2015season marred by numerous in-juries, the National BasketballAssociation (NBA) has part-nered with General ElectricHealthcare, whose US officesare in Waukesha, WI, to form acommittee that will identify anddesign research projects that

will help prevent injury throughimproved detection and treat-ment programs.

John DiFiori, MD, NBA di-rector of sports medicine, willchair the committee, which willinclude orthopedic surgeons,sports medicine experts, radiol-ogists, and epidemiologists.

Synxsole scores reality show investment Perth, Australia-based insolecompany Synxsole scored a$100,000 investment from Aus-tralian investor Andrew Banksduring the first season of the en-trepreneurial reality show SharkTank Australia, which wrappedup in June.

The two podiatrists who in-vented a customizable prefab-ricated orthosis found theircompany in a three-way bidding

war among the show’s “sharks,”or judges. Banks won, and nowowns 45% of the company,which intends to move its slim-line orthosis into the Australianmarket before spreading intothe US and Europe.

The device has a neutralrearfoot and can be customizedfor pronation or supination,trimmed to fit, and cut to half-length sizes.

Townsend brace alters knee OA loading A study epublished June 25 byProsthetics and Orthotics Inter-national found that use of a de-compressive knee brace fromBakersfield, CA-based Town -send Design significantly re-duced detrimental knee adduc-tion moments in people withknee osteoarthritis (OA).

Researchers performedgait analysis on 15 adults withKellgren-Lawrence grade 2-4unilateral medial knee OA atbaseline and two and eightweeks after fitting with Town -send’s Rebel Reliever brace

The brace significantly re-duced knee adduction impulse

and second peak knee adduc-tion moment at two and eightweeks compared with baseline(36% and 34% reduction inknee adduction impulse, re-spectively, and 26% reductionin second peak knee adductionmoment at both time points).

Participants also walkedfaster with increased knee mo-tion during stance.

The researchers were fromStony Brook University in NewYork; Long Island Orthotics &Prosthetics in West Babylon, NY;and Lenox Hill Hospital in NewYork City.

Nepal quake volunteers call for fundsMany of the more than 18,000individuals injured in the Apriland May earthquakes that struckNepal are in need of mobility de-vices, including prostheses fornew amputees, according to thecharitable group Handicap Inter-national, which now has 19emergency response specialistsin the country providing support,physical therapy, and devices.

The organization reportsthat those interested in helping

new amputees can best do sowith monetary donations ratherthan giving advanced prostheticlimbs, which are hard to alterand replace in the resource-poor nation. Funds can be usedto buy locally made prosthesesthat cost from $10 to $500, farless than most devices used inthe West, according to Handi-cap International.

Go to handicap-international.us to donate.

Delcam 2015 OTFs have record attendance More than 250 delegates at-tended two regional Ortho Tech-nology Forums (OTF) in Canadaand Australia, hosted by Birm-ingham, UK-based Delcam.

About 120 delegates at-tended the North AmericanOTF in Vancouver, Canada,which was held as a presympo-

sium event to the 2015 annualconference of the Pedorthic As-sociation of Canada on April16. Another 130-plus attendeestook part in the Australian OTFon May 7, held as part of the2015 Australasian PodiatryCouncil Conference in GoldCoast.


Spenco sponsors ultra-marathonerWaco, TX-based Spenco an-nounced on June 11 its sponsor-ship of ultra-marathoner Roy Wie-gand, who runs in Spenco insolesand raises awareness and moneyfor a number of charities.

On July 4, Wiegand finisheda 100-mile run from Orange

County to Burbank, CA, in 24hours, raising $25,000 for fami-lies of children with cancer. Heran for the Michael HoefflinFoundation in honor of Christo-pher Wilke, a friend of his son’s,who died at age 12 after battlinga rare form of cancer.

Vicon adds four unis to customer list Oxford, UK-based Vicon an-nounced in June the addition offour new research university cus-tomers for its motion-capturetechnology.

The Department of PhysicalTherapy at Saint Francis Univer-sity in Loretto, PA; Ohio Univer-sity’s School of Rehabilitation and

Communication Sciences inAthens; the Sports Medicine Re-search Laboratory at Universityof North Carolina at Chapel Hill;and the Motion + Media AcrossDisciplines Lab at the Universityof Minnesota Duluth are the mostrecently reported investors in Vi-con systems.

Ottobock introduces K2 bionic knee Austin, TX-based Ottobock onJune 26 introduced its Kenevomicroprocessor knee, designedfor K2 (low mobility potential)amputees, who often have re-duced muscle strength and co-ordination, putting them at highrisk for falls.

Standard practice has beento fit these less active patientswith mechanical knees, but a2014 literature review con-ducted by Ottobock re-searchers and published in the

Journal of Rehabilitation Re-search & Development foundmicroprocessor-controlledknees may significantly reduceuncontrolled falls by up to 80%compared with knees withoutmicroprocessor technology.

The Kenevo knee providessupport for sitting, standing,walking, and stumble recovery,and its microprocessor technol-ogy enables real-time gait andmovement monitoring, accord-ing to an Ottobock release.

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