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March2016features26ORTHOTIC DEVICES FOR THE WINPlantar fasciitis: Clinicalconcerns in basketballHighly visible elite athletes with plantar fasciitis are in the news, buthealthcare practitioners need to also focus on those who play recreation-ally for health benefits.By Patricia Pande, MClScPT, CSCS, CPed

29 Running modificationsand reducing injury riskEvidence suggests that no one foot strike style can be expected to decrease injury risk in all runners, and that switching foot strike patterns can have unintended consequences. Using a shorter stridelength, however, can be an effective alternative for some runners. By Elizabeth Boyer, PhD, and Tim Derrick, PhD

37 Strength training: Bonehealth benefits for menMen with low bone mass are much less likely than their female counter-parts to receive treatment. But research suggests that resistance exerciseis a safe and effective way to improve bone mineral density in men and, in turn, reduce the risk of fracture and related complications.By Pamela S. Hinton, PhD

43 Ankle instability rehabemphasizes individualityResearch presented at the most recent International Ankle Symposium indicates that rehabilitation for chronic ankle instability is evolving from a one-size-fits-all approach to an increased focus on matching specificinterventions to the patients who are most likely to benefit.By Lori Roniger

49 Flexible flat foot: Effectsof orthoses during gaitIn this original investigation, researchers analyzed the biomechanical effects of a foot orthosis in patients with flexible flat foot during walkingand the extent to which those functional effects are consistent with proposed theories about the device’s mechanism of action.By Bruce Elliott, PT, DPT, COMT, and Juan Garbalosa, PhD, PT

18 COVER STORYOutcomes after ACL surgery: THE IMPORTANCE OF GRAFT TYPE In an attempt to decrease the risk of re-rupture and revision surgery after anterior cruciate ligament reconstruction, practitioners are refining the decision process regarding which procedure is best for which patient.By Cary Groner

IN THE MOMENTrunning/13

Benefits of balance: YBT is associated with history of injuryTest for lower extremity asymmetry identifies risk in recreational runnersClinically useful 2D measurements predict patellofemoral joint forceOA/15

PFOA prognostication: Sagittal plane factors predict worseningYears after Achilles tear, injured limb demonstrates elevated knee loadingClinical single-leg hop tests can help estimate risk of OA after ACL injury

plus...OUT ON A LIMB / 9

An analgesic assistThe type of analgesia used in ACL surgerycan affect patients' quadriceps strength,which could influence functional outcomes.By Jordana Bieze Foster

NEW PRODUCTS / 58The latest in lower extremity devices and technologies

MARKET MECHANICS /61 News from lower extremity companies and organizationsBy Emily Delzell

29 37 43

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When it comes to improving

outcomes after anterior

cruciate ligament (ACL)

recon struction, lower

extrem ity practitioners need

all the help they can get.

Fortunately, a recent study

suggests they might be able

to get some valuable assis-

tance from their colleagues

in anesthesiology.

Increasing numbers of studies have underscored the importance

of quadriceps strength—and, in particular, quadriceps strength

symmetry between limbs—in determining functional outcomes

after ACL surgery. In fact, a number of orthopedic surgeons say

the need to maximize quadriceps strength after ACL reconstruc-

tion is an important consideration in their choice of graft type,

surgical technique, and rehabilitation protocols (see “Outcomes

after ACL surgery: The importance of graft type,” page 18).

But a smaller body of literature is starting to indicate the type of

analgesia used in ACL reconstruction procedures also affects

postoperative quadriceps strength—which could, in turn, affect

functional outcomes.

Femoral nerve blocks, for example, have been widely reported to

cause immediate postoperative quadriceps weakness, particularly

in patients undergoing total joint arthroplasty, but also in those

undergoing ACL reconstruction. One might not think analgesia-

induced weakness in the first day or two after surgery would have

longer-term implications, especially in athletes, but research from

the Mayo Clinic in Rochester, MN, suggests it might.

The Mayo Clinic team reported last February in the Journal of

Knee Surgery that ACL reconstruction patients who received a

postoperative femoral nerve block (FNB) had significantly weaker

quadriceps at six months than patients who did not receive a

FNB. Vertical jump and single-leg hop performance was also

significantly poorer in the FNB group.

Given the obvious downsides to the conventional FNB approach,

surgeons and their anesthesiologist colleagues have been looking

for alternatives. These include the adductor canal block (ACB), a

more distal block of the femoral nerve, positioned in the midthigh

to preserve quadriceps femoris strength.

Early studies on ACB use in total knee arthroplasty patients have

been positive. And, in a study epublished in early March by Anes-

thesiology, researchers from the University of Toronto in Canada

found that an ACB administered prior to ACL reconstruction was

associated with significantly less quadriceps strength loss than a

preoperative FNB, while providing equal or better pain relief.

Granted, the findings are preliminary, and we can’t connect all the

dots yet. The Toronto study only assessed strength loss preopera-

tively, so we can’t assume those effects would be evident postop-

eratively. The Mayo Clinic results suggest they might, but we can’t

yet assume the findings of that study can be extrapolated beyond

six months, or that they would have any impact on rerupture rates

or cartilage degeneration.

Still, the findings are intriguing enough that lower extremity practi-

tioners should at least be asking questions about analgesia when

planning an ACL reconstruction or a postoperative rehab protocol.

And, when facing a clinical challenge as complicated as an ACL

injury, lower extremity practitioners should also be encouraged to

know that it’s a battle being fought on multiple fronts.

.

Jordana Bieze Foster, Editor

The type of analgesia used in ACL surgerycan affect patients' quadriceps strength,which could influence functional outcomes.

out on a limb:An analgesic assist

lermagazine.com 03.16 9

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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©2016 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.

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Benefits of balanceYBT is associated with history of injury

By P.K. Daniel

Deficits in single-leg balance may con-tribute to the high rate of injuries amongendurance athletes, but hip strength maynot, according to two studies presented inFebruary at the American Physical TherapyAssociation’s annual Combined SectionsMeeting in Anaheim, CA.

Both studies were conducted by researchers at Ironman Sports Med-icine Institute, Memorial Hermann Health System, and Texas Woman’sUniversity, all in Houston, TX.

In the first, researchers found the anterior reach component ofthe Y Balance Test (YBT) differed significantly between enduranceathletes with a history of lower extremity injury in the previous threeyears and healthy participants.

The 71 male and 78 female athletes, who were not seekingmedical attention, were selected from local running clubs and partic-ipants in the Houston marathon and Ironman races. Of the 149

athletes, 61 reported a recent history—within 36 months—of lowerextremity injury.

While medial, lateral, and composite reach scores were not sta-tistically different between limbs for either group, the researchersfound a recent history of lower extremity injury was negatively asso-ciated with anterior reach. The injured athletes also demonstratedsignificantly less mean anterior reach for the involved lower extremity(57 ± 14.5 cm) compared with the uninvolved extremity (63.4 ± 13.1cm) and the uninjured athletes (64.1 ± 14.6 cm).

in the moment: running

Test for lower extremity asymmetry identifies risk in recreational runners Asymmetrical lower extremityneuromuscular control is predic-tive of repetitive stress injury inrecreational runners, accordingto findings presented at the Com-bined Sections Meeting of theAmerican Physical Therapy As-sociation in February in Anaheim.

Researchers from NovaSoutheastern University in Ft.Lauderdale, FL, assessed anthro-pometric variables, proximal anddistal isometric lower extremitymuscle performance, isometriccore muscle endurance, lowerextremity flexibility, and neuro-muscular control in 72 recre-ational runners and followedthem over an 18-week period be-fore a graded marathon trainingprogram. During that time, theathletes experienced 33 repeti-tive stress injuries.

Between-limb asymmetry,based on composite Y BalanceTest scores, was significantlygreater in injured runners than intheir uninjured counterparts, saidSteven Jackson, PT, PhD, OCS, afaculty member for the Universityof Chicago Physical Therapy Or-thopedic Residency Program,who presented the findings. Anasymmetry of 3.6% or greaterpredicted 69.2% of the injuries.

Ankle dorsiflexion with theknee extended also differed signif-icantly between the injured and un-injured runners, but the statisticalanalysis revealed that variable wasnot predictive of injury risk. Source:Jackson S, Cheng MS, Kolber M, SmithAR. An investigation of relationships be-tween physical characteristics of recre-ational runners and lower extremityinjuries. J Orthop Sports Phys Ther2016;46(1):A41.

Clinically useful 2D measurementspredict patellofemoral joint force Researchers from East CarolinaUniversity (ECU) in Greenville,NC, have identified 2D lowerextremity kinematic measure-ments that accurately predictpatellofemoral joint (PFJ) forceduring running and can be usedclinically to identify runners atrisk of injury.

The two-phase study in-volved recreational athletesaged between 18 and 35 years.The researchers first performed3D motion analysis on 56 ath-letes and identified three vari-ables that predicted mean PFJimpulse during the stancephase of running: knee angleat midstance, step length, andvertical excursion of the centerof mass.

The investigators then per-

formed both 2D and 3D kine-matic analyses in 34 athletes,and found that using clinicallyfeasible 2D methods (a videocamera and free video analysissoftware) to assess the threepredictive variables from thefirst phase of the study ac-counted for 70% of the variabil-ity in PFJ impulse.

Jennifer M. Warren, a phys-ical therapy doctoral student atECU, presented the findings atthe Combined Sections Meet-ing of the American PhysicalTherapy Association in Febru-ary in Anaheim. Source:Warren JM, Sanii AR, Huf MD, et al.Clinical prediction of patellofemoraljoint contact force during running. J Or-thop Sports Phys Ther 2016;46(1):A55.

Continued on page 14


Istockphoto.com#63842549

in the moment: runningContinued from page 13

14 03.16 lermagazine.com

“I would say the most inter-esting aspect of the study wasthe dramatic difference in ante-rior reach distance on the in-volved side within the previousinjury group,” said lead authorAndrew J. Nasr, PT, DPT, CSCS,now a staff physical therapistwith the University of TexasSouthwestern Medical Center inDallas, TX, who presented thefindings. “We hypothesized therewould be a difference, but didnot expect such a difference.”

The researchers believetheir study is the first to investi-gate functional performance ina sample of endurance athletesusing testing procedures com-mon to field sports. The findingssuggest that utilization of the YBalance anterior reach test todetect balance deficits may beable to help identify athletes atrisk for lower extremity injury or

to help determine whether anathlete is ready to return tosports.

“While we cannot makesweeping conclusions with thefindings due to the retrospectivenature of the study and inherentlimitations, we do feel that the YBalance can be used as a goodclinical tool to track this athleticpopulation as we rehab themback to sport participation,” Nasrsaid.

Because little is known re-garding endurance athletes’ riskfactors for injury, the same re-searchers conducted a secondstudy involving the same partic-ipants to determine the relation-ship between hip abductionstrength and history of lower ex-tremity injury. For this study, theresearchers also analyzed skilllevel (elite vs recreational) as apossible contributing factor.

The 149 athletes partici-pated in a single session of clin-ical and functional testing. Sur-prisingly, there was nocorrelation between hip abduc-tion strength and history of alower extremity injury in the pre-vious three years.

That lack of correlation wastrue for both skill-level groups.Among the injured recreationalathletes (<25 mi/wk), no differ-ences in hip abduction strengthwere observed between the in-jured (50.6 ± 18.2 lb) and unin-jured limbs (51.9 ± 18.2 lb). Sim-ilarly, no differences were notedfor hip abduction strength be-tween injured (54.9 ± 18.8 lb)and uninjured sides (55 ± 11.7lb) for elite injured athletes.

“Our data didn’t supportour hypothesis that there wouldbe a difference in hip abductionstrength and previous [lower

extremity] injury,” said lead au-thor Caitlyn Lang, PT, DPT, a staffphysical therapist at MemorialHermann Health System, whopresented the findings.

However, the researchersdid find a positive relationshipbetween hip abduction strengthand a top-three placementwithin a competitive event, sug-gesting that hip abductionstrength has a stronger associa-tion with performance than withinjury risk. Sources:Nasr AJ, Lang C, Duncan BR, et al.Deficits in single-leg balance are as-sociated with recent lower extremityinjuries among asymptomatic en-durance athletes currently participat-ing in sport. J Orthop Sports Phys Ther2016;46(1):A46. Lang C, Nasr AJ, Duncan BR, et al.The relationships between hip abduc-tion strength lower extremity injuryhistory & performance in enduranceathletes. J Orthop Sports Phys Ther2016;46(1):A43.

PFOA prognosticationSagittal plane factors predict worsening

By Jordana Bieze Foster

Sagittal plane mechanics and forces dur-ing gait in patients with patellofemoral os-teoarthritis (PFOA) can help identify thosewho are likely to experience worseningpain or cartilage degeneration, accordingto research presented in February at theannual Combined Sections Meeting of theAmerican Physical Therapy Association inAnaheim, CA.

The predictive potential of sagittal plane variables in individuals withPFOA underscores the biomechanical differences between PFOAand tibiofemoral osteoarthritis and the need to manage the two con-ditions differently.

“Sagittal plane mechanics during gait may influence thepatellofemoral load and disease course, while tibiofemoral OA is

more likely to be affected by frontal plane mechanics,” said AlisonChang, PT, DPT, MS, an associate professor of physical therapy andhuman movement sciences at the Northwestern Feinberg School ofMedicine in Chicago.

In one PFOA study, presented at the meeting by Chang, she andher colleagues assessed dynamic joint stiffness—a measure of kneeflexion moment versus knee flexion angle as a percentage of thegait cycle—in 204 patients with OA in any compartment of at leastone knee. They also assessed magnetic resonance imaging (MRI)-based markers for cartilage degeneration; two years later, they re-peated the MRI exams to assess cartilage damage progression.

Tibiofemoral damage progression was detected in 26.5% ofparticipants; patellofemoral damage progression was detected in

in the moment: OA

Years after Achilles tear, injured limbdemonstrates elevated knee loadingA history of Achilles tendon rup-ture is associated with elevatedknee loading during hoppingand running, suggesting an in-creased risk of knee osteoarthri-tis and other overuse kneepathologies, according to re-search from East Carolina Uni-versity in Greenville, NC.

Investigators analyzed 34individuals who had experi-enced a unilateral Achilles teara mean of six years previously,as they jogged at a self-selectedspeed and performed a single-leg hopping task. Peak concen-tric knee power, peak patello -femoral joint reaction force, andpeak tibiofemoral contact forcewere significantly higher in theinjured limb than the uninjuredlimb for both tasks.

The asymmetries were evi-dent despite a high level of self-reported function for the group,a mean of 84 out of 100 on theAchilles Tendon Total RuptureScore.

“Rehabilitation may need toinclude the knee in addition tothe foot and ankle,” said HayleyPowell, a graduate student in theuniversity’s Department of Phys-ical Therapy, who presented thefindings in February at the an-nual Combined Sections Meet-ing of the American PhysicalTherapy Association in Anaheim. Source:Powell H, Silbernagel KG, Brorsson A,et al. Patellofemoral and tibiofemoraljoint loading asymmetries are presentduring running and hopping in individ-uals 5 years post–Achilles tendon rup-ture. J Orthop Sports Phys Ther2016;46(1):A50.

Clinical single-leg hop tests can helpestimate risk of OA after ACL injuryPerformance on single-leg hoptests a few weeks after anteriorcruciate ligament (ACL) injurycan predict the risk of radi-ographic knee osteoarthritis(OA) five years later, accordingto research from the Universityof Delaware in Newark.

In 65 athletes involved incutting or pivoting sports whohad sustained an ACL injury amean of 1.8 months earlier, in-vestigators assessed perform-ance on four single-leg hoppingtests that can easily be admin-istered by clinicians: single,triple, crossover, and 6-m timed.A mean of 5.7 years after theinjury, the investigators identi-fied radiographic evidence ofknee OA in nine of the athletes.

The athletes with evidence

of knee OA at follow-up hadbetter performance than thosewith knee OA on all the base-line hopping tests; the differ-ences were significant for thesingle and triple hop tests. Thetests with the best diagnosticaccuracy, however, were thetriple hop test and the 6-mtimed test.

The findings were pre-sented in February at the an-nual Combined Sections Meet-ing of the American PhysicalTherapy Association in Ana-heim. Source:Wellsandt E, Axe M, Snyder-Mackler L.Single-legged hop tests as a screeningtool for risk of posttraumatic os-teoarthritis after anterior cruciate liga-ment injury. J Orthop Sports Phys Ther2016;46(1): A56.



Istockphoto.com #71687689

in the moment: OAContinued from page 15


13.6%. However, only patello -femoral cartilage damage pro-gression—specifically in the lat-eral aspect of the patella—wasassociated with dynamic jointstiffness at baseline. After ad-justing for demographics anddisease- related covariables, forevery unit increase in dynamicjoint stiffness at baseline, theodds of patellofemoral cartilagedamage progression increased3.5 times.

Although cartilage damageis not always associated withpain in patients with PFOA, in-vestigators from the Universityof California, San Francisco(UCSF) reported in a secondpresentation that peak patello -femoral joint (PFJ) stress duringthe early stance phase of walk-ing in individuals with PFOA ispredictive of pain progressionone year later.

The researchers assessedkinematics and kinetics in 50 in-dividuals with PFOA as theywalked at a self-selected speed,then used those measures to es-timate peak PFJ stress during thefirst and second half of stance.The study participants also com-pleted the pain and symptomssubscales of the Knee Osteo -arthritis Outcomes Score (KOOS)questionnaire at the time of thegait analysis, and again a yearlater.

At one year, 10 participantshad significant pain progression,defined as a KOOS-Pain scoreincrease above a previously re-ported minimum detectablechange score. Those with painprogression had significantlyhigher early stance peak PFJstress at baseline than thosewhose pain did not progress;every one standard-deviation

increase in PFJ stress duringearly stance resulted in nearly asixfold higher chance of painprogression at one year.

The higher peak PFJ levelsin those with pain progressionwere largely due to knee flexionmoment rather than knee flexionangle, according to Hsiang-Ling(Sharon) Teng, PT, PhD, a post-doctoral scholar in the Depart-ment of Radiology at UCSF, whopresented the findings.

Pain progression was alsoassociated with higher peak PFJstress in the second half ofstance; that association was notstatistically significant, but maybe clinically relevant, Teng said.

“Prevention and rehabilita-tion protocols should focus onpatellofemoral joint loading dur-ing the entire stance phase,”she said.

Chang and Teng both em-

phasized the need for PFOA in-terventions to decrease kneeflexion moment, which could in-clude increasing step rate, de-creasing walking speed, or wear-ing flat shoes instead of heels.The Northwestern findings alsosuggest there could be a benefitto increasing knee joint flexionangle during gait, Chang said,but noted that patients may needneuromotor training to learn touse any additional joint range ofmotion they achieve.Sources:Chang AH, Chmiel JS, Almagor O, et al.Baseline knee sagittal dynamic jointstiffness during gait is associated with2-year patellofemoral cartilage dam-age progression in knee osteoarthritis.J Orthop Sports Phys Ther 2016;46(1):A5.Teng H-L, MacLeod TD, Nardo L, et al.Association between patellofemoraljoint stress during gait and sympto-matic progression in people withpatellofemoral joint osteoarthritis. J Or-thop Sports Phys Ther 2016;46(1):A26.

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18 03.16 lermagazine.com18 03.16 lermagazine.com

Thomas Davis made headlines in February by playing in the SuperBowl with a broken left arm, but what’s most impressive about theCarolina Panthers linebacker is his right knee. Davis ended the Jan-uary 17 playoff game against Seattle by fielding the Seahawks’ last-ditch onside kick with a spectacular leaping grab. It would havebeen a great play for anyone, but Davis made his jump on a rightanterior cruciate ligament (ACL) that had been reconstructed threetimes.

Increasingly, people take such heroic athleticism in stride. Butcases like that of Davis, in which patients reinjure the ligament andrequire revision surgery—sometimes more than once—have led ex-perts to try to identify factors that may decrease the risk of subse-quent rupture. The rigors of pro football notwithstanding, theoriesare all over the map. As more data become available, however, aguarded consensus is emerging.

In an attempt todecrease the risk of

re-rupture and revisionsurgery after anterior

cruciate ligamentreconstruction,

practitioners arerefining the decision

process regarding whichprocedure is best for

which patient.

Outcomes afterACL surgery:

The importance of graft type

By Cary Groner

lermagazine.com 03.16 19lermagazine.com 03.16 19



Recent research has helped define the scope of the problem.Reported five-year revision rates after ACL reconstruction havebeen as high as 8.7%, and are significantly higher for patientsyounger than 21 years than for their older counterparts.1

Graft selectionIn ACL reconstruction, surgeons use either autografts (tissue fromthe patient) or allografts (tissue from cadaver donors), and each ap-proach has advantages and disadvantages. Allografts circumventthe problem of donor-site morbid-ity and offer robust tendons, suchas the tibialis anterior, thatcouldn’t be harvested from a liv-ing donor. In one large US study,allografts were used in roughly42% of primary and 79% of revi-sion ACL reconstructions.2 Disad-vantages include the risk ofdisease transmission, slower in-corporation, and strength limita-tions, depending on how thetissue has been processed.3

Autografts include bone–patellar tendon–bone (BPTB) re-construction, in which the graft istaken from the patient’s ipsilat-eral or contralateral knee. Al-though this approach is oftenconsidered the gold standard inthe US, it is associated with a riskof anterior knee pain and otherproblems at the harvest site.3 Asa result, many surgeons haveturned to soft tissue grafts, par-ticularly from the hamstring ten-don; in recent years hamstringreconstruction has become theprimary approach in Scandina-vian countries.4 Recently, a fewsurgeons have begun using thequadriceps tendon, as well, andthe percentage of such surger-ies is expected to grow.5

But as surgery becomes more custom ized, physicians continue to refine the decision process regardingwhich procedure is best for which patient. This affects choicesabout surgical procedure, graft harvest, and rehabilitation.

Not fail-safe“We now know that the use of allografts in young people—particu-larly teenagers or very active people in their twenties and early thir-ties—is associated with a higher risk of graft tearing and revision,”said Steven Singleton, MD, an orthopedic surgeon with the Stead-man Clinic in Vail, CO.

There are various reasons for this, he explained. With allografts,the body recognizes the tissue as non-native, and though it doesn’treject the graft as it might a transplanted organ, it does mount animmune response that retards ligamentation and healing, leaving

the graft weaker for a longer time than an autograft would be. Theresult, particularly in active young people, may be tissue stretchingand breakdown leading to graft failure.

Jonathan Chang, MD, a clinical associate professor of orthope-dics at the University of Southern California in Los Angeles, agreed.

“Graft selection is now influenced by age,” he said. “If you’reroughly twenty-five or younger, you’re usually better off with a patel-lar tendon autograft—though there’s discussion about where thattipping point is, and some put it at age forty or higher. As you getolder, though, you probably have lower activity levels, so there areadvantages to an allograft. The graft failure rates start equalizing at

ages thirty-five to forty, so at thatpoint, unless you’re a profes-sional athlete, you’re likely to dowell with any kind of graft.”

Recent research supportsthis perspective. For example, aKaiser Permanente study of21,304 ACL reconstruction pa-tients found that those youngerthan 40 years had a higher riskof revision after allograft surgerythan those with BPTB autografts;moreover, those younger than 21years with hamstring autograftshad a revision risk 1.6 times thosewho had BPTB autografts.1

“We found that the greatestdifferences occurred in theyounger patients,” said GregoryMaletis, MD, the study’s first au-thor, who is chief of orthopedics atKaiser Permanente in BaldwinBark, CA, and lead physician forthe ACL registry there. “We alsofound that females are a little lesslikely to undergo revision, as arethose with higher BMI [body massindex], who may be less active.”

Maletis told LER that he and hiscolleagues aren’t yet sure why ham-string autografts failed more oftenthan BPTB autografts.

“It may have to do with graft di-ameter; smaller hamstring graftsmay not withstand the loads as well,”

he said. “We didn’t see that in the older patients, so it’s probablybecause the younger ones are doing higher-level sports and puttingtheir knees at the greatest risk.”

Several recent studies have reached conclusions about grafttype and longevity. For example, a 2014 study from Scandinaviafound that patellar tendon autografts had a significantly lower riskof revision (hazard ratio .63) than hamstring autografts.4 A Norwe-gian paper from the same year reported a revision risk 2.3 timeshigher for hamstring grafts than patellar tendon grafts and four timeshigher for younger patients than older ones.6 A 2014 Danish studyfound that hamstring reconstructions were 1.4 times more likely tofail than BPTB ones (the authors also noted that use of hamstring

Continued from page 19



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tendons in Denmark increased from 68% in 2005 to 85% in 2011).7

A long-term randomized trial conducted in military personnelin Hawaii found that, 10 years after reconstructive surgeries with ei-ther a hamstring autograft or a tibialis posterior allograft, more than80% of grafts were intact and stable; however, allografts failed atthree times the rate of autografts (26.5% vs 8.3%).3

Lead author Craig Bottoni, MD, chief of sports medicine in theOrthopedic Surgery Service at Tripler Army Medical Center in Hon-olulu, said surgeons minimized variables by using the same fixationand rehabilitation techniques in all patients.

“Allografts are an acceptable alternative for ACL reconstruction,but some do have a higher risk of failure,” Bottoni said.

ProcessingBottoni emphasized the importance of surgeons knowing as muchas possible about the allograft tissue they use.

“It’s imperative to know what type of graft you’re using, whereit comes from, and how it’s been processed,” he said. “Terminal ra-diation and some types of processing have been found to negativelyalter the biomechanical properties of the allograft.”

Indeed, the Kaiser team concluded that certain factors seemto increase risk of allograft failure, including irradiation greater than1.8 mrad, BioCleanse processing, younger patient age, male gen-der, and BPTB allograft.8

“Nonirradiated, nonprocessed grafts seem to hold up the best,”Maletis said. “There also appears to be a time-dependent relation-ship, in that we may not see failures within the first year or two. Thatmay explain why studies with shorter time frames haven’t shown

such differences with allografts.”The finding that BPTB allografts had a higher risk of revision

than soft tissue allografts (relative risk = 1.8) suggests processingmay also weaken bone tissue, he added. A 2008 meta-analysisfrom the Mayo Clinic supports this finding.9

TechniqueIn a paper from the Steadman Clinic, researchers compared BPTBautografts to BPTB allografts and reported that, while functional out-comes were similar, 14% (n = 11) of allografts were revised by amean of 4.7 years after surgery, whereas no autografts required re-vision. Moreover, patients aged 25 years or younger were 23 timesmore likely to require a revision than older patients.10

Like many surgeons, Singleton uses techniques he hopes willminimize his patients’ revision rates. He prefers BPTB autografts tohamstrings—though he’ll use the latter in patients with a history ofpatellar tendinitis or arthritis—and said that in his practice he seesvery little anterior knee pain after BPTB surgeries.

“We’ve developed a small-incision technique to harvest the graft,”he said. “We also mobilize the patella right away in our rehab program,and I think those things minimize the potential for scarring.”

Jonathan Chang has his own take on the situation.“I take twenty to thirty minutes harvesting the graft, carefully

bone-grafting the harvest sites and doing a layered closure over thetendon without over-straining it,” he said. “If you do that, you’ll haveless postoperative bleeding and better function. If you don’t playclose attention to how you treat that tissue, the patient has a higherrisk of anterior knee pain.”

Donald Shelbourne, MD, who practices at the Shelbourne Knee


PFS


Center at Community Westview Hospital in Indianapolis, favors aBPTB technique that many other surgeons shy away from: He har-vests the graft from the contralateral knee rather than the injuredone, and recently reported the approach was associated with betterpostoperative leg strength in both limbs and better strength sym-metry while minimizing symptoms at the graft harvest site.11

“Back in the eighties, I found that we had trouble rehabbing theACL-injured knee because we’d also taken a patellar tendon fromit,” he said. “You can avoid that problem with cadaver or hamstringgrafts, but I didn’t find those to be as successful—allografts failed,hamstring grafts left the patients weaker. When we started doingcontralateral grafts in revision surgeries, we realized that it was abetter approach because we had two independent rehabs insteadof two rehabs in the same knee. We’ve now done over four thou-sand primary ACL reconstructions that way, and I think it’s the bestanswer. My goal is to give the patient two good knees, and I can dothat more predictably when I take the graft from the opposite knee.”

Shelbourne, who keeps detailed data about his procedures andoutcomes, said his team had collected information about their ACLrepairs in 52 college soccer players. Of those who had ipsilateralBPTB reconstructions, 77% were playing at their previous level ayear later, whereas 91% of those who’d had a contralateral graft re-turned to that level (unpublished data). One reason for the greatersuccess, he said, is that contralateral harvesting leads to better heal-ing at the donor site.

“The two thirds of the tendon we leave grows back to normal,”he said. “We didn’t see that when we took the graft from the sameknee, because we had to rehab the ACL and couldn’t focus on thedonor site. You need high-repetition, low-resistance exercises in the

first month, and you can’t do that when you take the graft from thesame knee that you’ve operated on for the ACL.”

Other surgeons told LER that, though they use contralateralgrafts for revision procedures, they remained reluctant to do so inprimary reconstructions.

Anatomic accuracy of tunnel drilling can also affect outcomes,Singleton said.

“In the original arthroscopies in the late eighties and earlynineties, surgeons used one approach to drill a tunnel in the femurand a second one to drill the tibia, and the graft was anchored inthose tunnels,” he said. “Then, in the mid-nineties, an all-endoscopictechnique was developed in which you drilled the tibial tunnel first,then used that to drill the femoral tunnel. That technique is still usedby many doctors, with reasonable success; the problem is that itdoesn’t allow one to get the [femoral] tunnel in the exact anatomiclocation of the native ACL. Steadman, Shelbourne, and a few othersrecognized this and continued to drill both tunnels independently.What I see clinically is that there is a lower rate of graft re-tears inACLs done with independent tunnel drilling. You want the graft inthe exact location it needs to be in.”

RehabSurgeons and therapists stress the importance of proper rehabilita-tion, though there’s professional disagreement about what consti-tutes it.

“Rehab may be more crucial than the surgery itself,” said CraigBottoni. “You want the patient to get back to activity as soon as pos-sible without compromising the graft. Most of us are big advocates


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of extension, because if you don’t get it back in the early phase, it’sdifficult to get it back later.”

Shelbourne emphasized both extension and delay in loadingthe ACL-injured leg.

“The first week after surgery, it’s too soon for things like ridinga bike and walking,” he said. “Those can just leave the knee moreinflamed and swollen. In terms of long-term rehab, though, we wantto achieve full flexion, full strength, full function, and identical motionwith the contralateral side.”

Shelbourne and his colleagues have documented the impor-tance of achieving full extension, including terminal hyperextensionsymmetric to the opposite knee, and suggest concerns that this mayoverstress the graft are unsubstantiated.12

For Singleton, controlling swelling and regaining full range of mo-tion drive the protocol in the first couple of weeks.

“We teach the patient to elevate the knee so the leg wants tocome straight, and to some extent we’ll use a continuous passive mo-tion machine to prevent adhesions and minimize swelling,” he said.

Rehabilitation should account for graft type, too, according toJonathan Chang.

“When surgeons use allografts, they usually slow the rehabprocess a little to be sure that the incorporation has really taken holdbefore they start pushing the patient,” he said.

Bottoni added that, in general, clinicians are adjusting their ex-pectations about return to sports.

“It used to be six months, but now people are saying that beforenine or twelve months, patients don’t really have their proprioceptionback. Their quadriceps are still weak, so there is a risk for re-tear, especially in elite athletes,” he said.

Other researchers have reported the importance of quadricepsstrength for achieving biomechanical symmetry during rehab, infact.13,14

Clinicians at the University of Delaware in Newark are exploringa new rehab protocol involving a form of neuromuscular work theycall postoperative return-to-sports training.15 The approach uses a se-ries of progressive perturbations on unstable surfaces in both bilateraland unilateral stance, in conjunction with distractions and other tasks.

“People haven’t been using uniform or even very stringentrehab criteria,” said Lynn Snyder-Mackler, PT, ATC, alumni distin-guished professor of physical therapy, and one of the study’s de-signers. “In this approach, we perturb the support surfaces;something unexpected happens, so how do you control your knee?In ten sessions over a couple of weeks, we increase the challengesand they get better at it. You’re trying to incorporate new movementpatterns into sport-specific activities.”

In the clinical trial, all patients will receive quadriceps strength-ening and agility drills, while only some will receive the perturbationtraining. Ideally, results will be published within the next year or two.

“It’s a hard thing to say to a kid, but if all they’re focusedon is getting back on the field, that might be to their detri-ment,” Snyder-Mackler said. “They need to think aboutnot having the second injury, and that might mean wait-

ing a year.”

Cary Groner is a freelance writer in the San FranciscoBay Area.

References are available at lermagazine.com.


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Basketball is associated with a high number of lower extremity in-juries,1,2 often related to footwear and the unique biomechanics andrepetitious motion of the sport. This reflects the evolution of bas-ketball from a refined sport to one of extreme physical contact andleverage. At elite levels of competition, the joint loading that comeswith players’ size also contributes to lower extremity injury risk; largeplayers with large feet frequently have large problems.

The mainstream media has given considerable attention to theloss of playing time associated with plantar fasciitis in highly compen-sated athletes, but recreational players also present a challenge tosports medicine clinics. As many as 45.9% of players in Australia havebeen sidelined for more than a week with lower extremity injuries.3

Definitions The plantar “fascia” is not actually fascia but an aponeurosis withmechanical and histological similarities to surrounding tendons andligaments.4 Plantar heel pain is one of the most common ailmentsin the US, accounting for up to two million annual visits to physiciansand comprising up to 10% of all sports clinic visits.5,6 It presentswith pain with the first step in the morning or after prolonged boutsof sitting.

Repetitive stress can inflame the plantar fascia or lead to de-generative changes, commonly called fasciosis, which explains therecalcitrant nature of the condition. Altered hydrostatic pressure inthe fascia may also impede blood flow.7

Plantar fasciitis in basketball players Although there is a shortage of information about the incidence ofplantar fasciitis in basketball players, plantar fascia rupture associ-ated with basketball has been reported.8 Factors contributing to thehigh incidence of lower extremity and foot and ankle injuries in bas-ketball, and more specifically to plantar fasciitis, include the repeti-tive high loads associated with running,9 as well as jumping, landing,and cutting by players who often are large in frame.1,2 Other factorsthat may contribute to plantar fasciitis risk in basketball includefootwear and fatigue.

Body mass index (BMI). Van Leeuwen et al found a positiveassociation between patients with a high BMI and plantar fasciitis.10

BMI was the only variable that predicted disability in an earlierstudy.11

The average National Basketball Association (NBA) playerweighs 220 lbs and wears a size 14.8 shoe, maxing out at size 20.12

Higher BMI theoretically causes increased vertical force during heelcontact, with a concomitant increase in tissue stress.13 However, re-duction of body weight and lower extremity anthropometrics typi-cally is not feasible for the basketball player.

Plantar loads. Although no studies have examined the associ-ation between plantar loads and plantar fasciitis in basketball play-ers, evidence does suggest that runners with plantar fasciitis havehigher plantar loads and loading rates than healthy runners.9 Be-cause much of basketball involves running—not to mention changesof direction, jumping, and landing on hard and unyielding court surfaces—it seems likely that plantar loads in basketball are at leastas high as in running.

Basketball movements other than running have also been as-sociated with high loads. Cutting movements, which are commonin basketball, have been associated with high plantar pressures atthe heel in other sports.14 Lay ups, free throws, and jump shots areall associated with greater plantar loads than static stance.15 Groundreaction forces (GRF) associated with jump shots in basketball havebeen reported to be more than five times body weight, heighteningthe risk of damage with repetition.16 In fact, ground reaction forcesare higher in basketball players than soccer players.17 Learning howto land softly and on the forefoot or midfoot will reduce landingGRF;16 however, this is an adjustment that recreational players maynot have mastered.

Running volume. There is some evidence that plantar fasciitismay be associated with a faster running pace.18 Basketball involveshigh acceleration and anaerobic bursts of running. Highly effectivebasketball players may run up and down a 90-foot court at highspeed a minimum of 50 times per game, resulting in increasedstrain on the intrinsic muscles of the foot.19

Basketball shoes. The most coveted basketball shoes havetransitioned from being highly structured to being lightweight andflexible. At the most elite levels, basketball players are restricted intheir choice of shoes due to footwear contracts. Colleges often usebasketball shoe brands as a tool in recruiting high school players.20

Most importantly, the shoe must be able to withstand high plan-tar loading without deformation and resist the rotational and cuttingforces that stretch the upper in a very moist environment. Frequent

Sponsored by an educational grant from medi USA.

By Patricia Pande, MClScPT, CSCS, CPed

Plantar fasciitis: Clinicalconcerns in basketball

Plantar fascia corticosteroid injections in athletes may have un-intended adverse effects, with some accounts of rupture after earlyre-entry into play.28 Additionally, surgical management with plantarfasciotomy has only moderately improved patient outcomes in thegeneral population, often resulting in extended recovery time.29,30

The risks of adverse events must be weighed judiciously in anytreatment paradigm.

Orthotic managementAn orthotic device with intrinsic or extrinsic medial wedges was as-sociated with greater soft tissue thickness under the heel, whichmay protect the fat pad (assessed statically) more than no orthosisor an orthosis with arch support only.31 This may have implications

for treatment of plantar fasciitisgiven the condition’s associationwith fat pad atrophy in some pa-tients.32 Further investigation iswarranted.

The diagonal cuts and lateralshuffle cuts in basketball are alsoassociated with elevated forcesunder the metatarsal heads.33,34

Plantar fasciitis interventions to re-distribute plantar pressures musttake care to avoid overloading themetatarsals.35,36

Treatment must mitigate dele-terious forces on the foot with thefollowing orthotic strategies. Or-thoses must:

1. Reduce impact plantar load -ing without inhibiting performanceor excessively increasing load inother areas; accommodative orshock-absorbing inserts are muchbetter tolerated by basketball players;22,37

2. Not elevate the heel ordestab ilize the ankle;7

3. Not hamper the function ofthe abductor hallucis and intrinsicmuscles;

4. Have reduced arch height to minimize pressure shift laterallyand decrease fifth metatarsal head pressure;31 and

5. Not impede blood flow to the foot from excessive pressure.38

Plantar fasciitis in basketball will continue to be a growing con-cern made even more clinically challenging by the lack of specificresearch on foot and ankle biomechanics in this popular and stren-uous sport. Vigilant clinical judgement, informed by the broaderbody of research on the biomechanics of plantar fasciitis, will be es-sential to meeting this challenge.

Patricia Pande, MClScPT, CSCS, CPed, is a physical therapist, pedor-thist, and strength and conditioning specialist based in Durham, NC.She is the founder of FootCentric, an online continuing education com-pany dedicated to comprehensive, multidisciplinary foot treatment.



Sponsored by an educational grant from medi USA.

footwear changes can help reduce midsole fatigue. Shoes havebeen shown to reduce impact forces during unanticipated droplandings in basketball.21

For many basketball players, the shoe is not wide enough, es-pecially with added bulk of high-profile orthoses.22 If the shoedoesn’t have sufficient volume to allow for proper activation of mus-cles (eg, abductor hallucis), this can impair the propulsive functionof the longitudinal arch during walking and running.19,23

Lower extremity clinicians who treat basketball players say thegame has changed since the late 1990s from one played close tothe basket to one played around the perimeter. This switch requiresmore lateral footwork, with more stresses to the ankle and plantarfascia. In response, basketball shoe designs have evolved to rein-force the lateral border to reduceankle sprains and promotequicker directional changes. Thisdesign shift has led to shoes withreduced medial support and am-plified pronatory moments, whichmay increase the risk of plantarfasciitis.

There also has been a tran-sition to lightweight shoes. Inter-estingly, a group of researchers inCalgary found that lighter-weightshoes were associated with im-proved performance of basket-ball tasks, but not when athleteswere blinded to the weight of theshoes, suggesting a psychologi-cal effect.24 There is a need forfurther research on the functionaleffects of lighter footwear, includ-ing foot orthoses.

Sport-specific factors. Al-though basketball originated as anoncontact sport, its physical na-ture has evolved over the yearswith regard to both offense anddefense.25 Rapid braking and ac-celeration (vertical and horizon-tal), along with lateral shifts ofbody weight, are very demanding on the foot and ankle.

Steve Vinson, who coaches girl’s basketball at Ann Arbor HuronHigh School in Michigan, said plantar fasciitis in younger athletes isa growing concern, with competition for scholarships leading tomore aggressive play, and intense schedules leaving little time torecuperate from the stresses associated with the sport.26

Treatment and preventionThe treatment paradigm of rest, cessation of activity, or both is oftennot feasible for high-level athletes. Changes in jumping technique,which can help reduce the risk of knee and ankle injuries,16,27 havenot been studied in cases of plantar fasciitis or fasciopathy. Taylorstressed prevention and proprioception programs to reduce the in-cidence of ankle sprains and lower extremity injuries, but there hasbeen no attempt to study or adapt these programs for the preven-tion of plantar fasciitis.27


Running modificationsand reducing injury risk

Evidence suggests that no one foot strikestyle can be expected to decrease injuryrisk in all runners, and that switching footstrike patterns can have unintended con-sequences. Using a shorter stride length,however, can be an effective alternative forsome runners.

By Elizabeth Boyer, PhD, and Tim Derrick, PhD

Runners struggling with injuries may be curious about barefoot run-ning or running on their toes if they’ve seen other runners doing it,or if they’ve heard it will decrease their risk of injury because it’s“more natural.” Although there is evidence in the medical literaturethat such changes may reduce the risk of some types of injuries insome runners, evidence also suggests injury risk can be reducedusing an alternative running modification that might be easier to implement.

Large-scale epidemiological studies objectively quantifying howrunners run (ie, footwear or foot strike pattern) and how those vari-ables relate to injury risk are nonexistent. A few studies with eithersmall sample sizes or self-reported information about footwear orfoot strike style provide conflicting evidence of injury prevalence inrearfoot, midfoot, and forefoot strikers, and shod versus barefootrunners,1-6 though shod rearfoot strikers might sustain more injuriesthan others.

Beyond foot strikeWe need to be wary of studies using self-reported foot strike,though, because approximately one third of runners misclassify theirfoot strike style.7,8 Additionally, since stride length may slightlyshorten when switching from a rearfoot strike (RFS) pattern to a mid-foot or forefoot strike (FFS) pattern3,9-11 or when switching from shodto barefoot running,12-14 the independent effects of stride length,footwear, and foot strike style appear to be equivocal. For instance,the decreased loading associated with running barefoot versus shodrunning may be primarily attributed to a shorter stride length,15 andmultiple studies have shown that a shortened stride beneficially de-creases loading.16-26 So, in addition to, or in place of, running bare-foot or using a FFS modification, we might be able to decreaseinjury risk by retraining runners to use shorter strides.26,27

In our model, we consider the effects of shorter stride lengthand increased stride frequency to be synonymous. Although thesevariables aren’t perfectly interchangeable, if running velocity is held


A shorter stride seems to decrease certainloading variables as much as switching toa forefoot strike pattern, without thenegative effect of increasing ankle loads.


constant, stride length and stride frequency vary inversely with eachother. In other words, running velocity is equal to the product ofstride length and stride frequency. For example, 3 m/s running ve-locity can be obtained by a stride length of 2.25 m and a stride fre-quency of 1.33 strides/s (or 160 steps/minute). If the same runnershortened his or her stride by 10% (to 2.03 m) but maintained that3 m/s velocity, he or she would have to use a stride frequency of1.48 strides/s (or 178 steps/minute).

ForcesMany studies investigating biomechanical differences between footstrike styles and footwear have focused on the vertical ground re-action force (GRF) and how quickly it changes, or GRF loading rate.Several studies have found that runners with high vertical loadingrates are more likely than those with lower loading rates to sustaina future injury or to report a history of injury, particularly of stressfracture.28-33 Zadpoor and Nikooyan34 summarized 13 studies andfound that higher vertical loading rate (not peak vertical GRF) wasassociated with the risk of stress fractures of the tibia andmetatarsals. Typically, loading rate is higher with a RFS pattern thana FFS pattern,1,3,35,36 which is one reason why FFS running is pur-ported to help reduce injuries.

However, focusing only on vertical forces neglects the smallershear forces. Considering that the leg is relatively perpendicular tothe ground during stance and that muscles can apply force onlythrough shortening, the femur and tibia/fibula are primarily loadedin compression. Bones are most resistant to these compressiveforces and stresses, and less resistant to tensile forces and shearingforces,37 such as those caused by shear GRFs. We found that, whilehabitual rearfoot strikers decreased their peak vertical GRF andloading rate when using a FFS, the shear (posterior and medial)GRFs and loading rates were higher during forefoot striking thanrearfoot striking during impact.38 These higher shear forces orient

the resultant GRF vector more perpendicular to the tibia (Figure 1).We may also want to shift our focus to the resultant GRF and loadingrate (ie, summation of all three orthogonal directions), as that forceis what the body experiences, and it is always equal to or greaterthan the vertical force.

MomentsTaking it a step further, we can look at joint moments (or torques),which are surrogates for the net muscle activity at a joint. Joint mo-ments during running have been fairly well documented for thesagittal plane, which is the plane associated with the largest mo-ments during running. Generally, plantar flexion moment and powerare greater for FFS than RFS patterns,8,11,39-41 knee extension mo-ment and power are greater for RFS than FFS patterns,8,11,39,41,42 andstudies of sagittal plane hip moments have been inconclusive withregard to foot strike.11,41,43 Similar trends have been reported forbarefoot versus shod running.12,15,39,44,45

However, the other planes have been largely neglected. Of thefew variables that have been investigated, knee abduction momentwas higher and ankle external rotation moment was lower for RFSthan FFS.11,43 Compared with habitual midfoot and forefoot strikers,when habitual rearfoot strikers ran with a FFS, they had larger hipabductor and ankle external rotation moments.43 Additionally, ankleinternal rotation moment increased when habitual rearfoot strikersran with a FFS compared with a RFS.43 We have supplementedthese findings and found similar results with a few contradictions.46

Many studies have shown habitual rearfoot strikers can de-crease loading by shortening their stride length,18,19,21,30,35 but canthey decrease it to the same extent as when switching to a FFS pat-tern? Our preliminary data comparing stride shortening and switch-ing from a RFS to FFS pattern suggest they can for several variables,including peak knee extensor moment, hip internal rotation




Figure 1. The resultant ground reaction force vec-tor (red arrow) is larger and oriented more pos-teriorly for forefoot strike running (left) vs rearfootstrike running (right) in the early part of stance(~8% of stance). Adapted from reference 38.

moment, lateral knee contact force, and posterior hip contract

force.46 Therefore, a shorter stride seems to decrease certain load-

ing variables as much as switching to a FFS pattern. Plus, shortening

one’s stride does not increase ankle loads the way a FFS pattern

does.

Net joint moments are limited in that they cannot tell us the ex-

tent to which all muscles are firing. Instead, they just tell us which

muscle group is firing the most. For example, the quadriceps could

be producing a +100-Nm moment while the hamstrings produce a

-80-Nm moment, resulting in a net joint moment of +20 Nm. How-

ever, both of these moments contribute to gross loading at the joint.

Joint contact forces include both joint reaction forces (forces

accounted for in net joint moment calculations) and muscle forces,

which we can estimate using optimization procedures. It is impor-

tant to consider these muscle forces, as they account for more of

the total joint loading than reaction forces.47,48 For instance, peak

ankle joint reaction force might be two times body weight, whereas

muscle forces might be six to eight times body weight. Only a few

studies have reported contact forces for different foot strike styles,

focusing on the axial40 or patellofemoral contact forces.11,42 Again,

we supplemented their findings with data for all three planes.46 In-

terestingly, because co-contraction is ignored in net joint moment

calculations, it is possible that moments may be larger for one foot

strike style, but contact forces could actually be equal or larger for

the other foot strike style, which we observed.46 The take-home

message is that we need to consider muscle forces to get a better

understanding of the actual joint loading during running.



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Offsetting effectsTaken together, the literature suggests that ankle loads are higherfor FFS than RFS patterns, while some knee and hip loads are higherfor RFS than FFS. Some researchers have observed that habitualrearfoot strikers tend to have higher knee and hip loads than habit-ual midfoot and forefoot strikers for both RFS and FFS.43,46,49 Thiscontinuation of more reliance on the knee extensors may be a lin-gering effect of the neuromotor programming associated with a RFSpattern. So, even though knee loads tend to decrease when habitualrearfoot strikers switch to a FFS pattern, if they do not decrease tothe levels seen in habitual midfoot or forefoot strikers, this couldpotentially mute the effect on injury risk. Shortening stride length,however, decreases loading to a similar extent. If tolerated by therunner, this alternative to foot strike modification may be a betterapproach to decreasing injury risk. Additionally, studies have shownthat, despite taking more steps per distance with a shorter stridelength, cumulative loading (ie, the summation of loading from allsteps per distance) remains lower for the shortened stride lengthcondition versus normal stride length.20,25

Although loads may be higher at different joints for certain footstrike styles, bones may adapt so that the actual bone stresses andstrains are unchanged. Our preliminary data and those of othershave shown that tibial stresses, strains, or strain rates are highestduring shod FFS running, moderate for barefoot FFS running, andlowest for shod RFS running.46,50,51 Only shear stress decreasedslightly with a shorter stride length.46 As such, if runners’ bones donot have time to adapt to the greater stresses and strains of FFS andbarefoot running, running in these strike patterns may load the tibiaexcessively. Alternatively, if runners transition slowly to FFS or bare-foot running, these higher loads may make their bones stronger.

In addition to peak joint loads, certain frontal and transverseplane variables have been linked to running-related injuries, suchas patellofemoral pain, iliotibial band syndrome, and tibial stressfractures.32,52-58 We previously investigated how these variableschanged with foot strike style and step length in 42 runners.16 Re-garding beneficial changes, during FFS, contralateral pelvic drop(which has been associated with patellofemoral pain52,58 and iliotib-ial band syndrome54) was reduced. During RFS, step width was in-creased, which is beneficial since a wider step width decreasesfrontal joint moments,59 iliotibial band strain,60 and peak free mo-ment.61 During RFS, peak negative free moment was also reduced,which is beneficial as research has linked larger peak free momentswith risk of tibial stress fractures.30,32 However, variables such aspeak iliotibial band strain and strain rate, hip adduction, rearfooteversion, and positive free moment were not different between RFSand FFS. Therefore, the risk of injuries related to these variables—such as patellofemoral pain, iliotibial band syndrome, and tibialstress fractures—is largely unaffected by foot strike style.

Most variables did, however, slightly decrease as runners usedshorter strides, which may have been associated with their con-comitant wider steps. Adding to the plethora of data supporting thebenefits of shortened stride length, we found shortening one’s stridelength may decrease—or at least not increase—the propensity forrunning injuries based on the variables we measured.16

Clinical implicationsCollectively, study findings suggest that a single foot strike style doesnot appear to explicitly decrease injury risk; rather, different footstrike styles may predispose runners to different types of injuries.



A shorter stride length, however, may be beneficial. So, should runners modify their running style to prevent per-

sistent injuries by running barefoot, on their toes, or taking shortersteps? The evidence suggests none of these modifications univer-sally reduce loading on all structures.

If a runner is experiencing ankle or foot pain (particularly in themetatarsals or plantar fascia), rest is probably indicated, as runningbarefoot or using a midfoot or forefoot strike or both may make theproblem worse. If resting isn’t an option, shortening strides by 10%may reduce loading.

If a runner is experiencing knee or patellofemoral pain causedby excessive loading, either switching to a midfoot or forefoot strike(shod or barefoot) or shortening the stride by about 10% may help.

The benefit of only shortening the stride is that the runner won’t beincreasing loading on different joints or tissues.

If a tibial stress fracture is the concern, neither switching footstrike nor running barefoot will likely decrease tibial stresses, andthe runner may have to use at least a 10% shorter stride length tosignificantly decrease stresses.

If the runner is experiencing hip pain caused by excessive load-ing, he or she may decrease loading more by switching to a midfootor forefoot strike (shod or barefoot) rather than by shortening thestride, though both modifications are options for decreasing load.

It would be logical to consider both running modifications (footstrike and stride length) simultaneously, which researchers have foundto beneficially decrease GRF loading rate.35 Indeed, most habitualrearfoot strike runners instinctively shorten their stride length whenrunning at the same speed with a midfoot or forefoot strike.3,9-11,16

What if runners are not injured and just want to switch footstrike style? They can try it, but should transition very slowly (at least10 weeks or more).6 Because there is no evidence that a shorterstride length leads to injuries, runners wanting to adopt this modifi-cation do not need to transition slowly. As with making any runningregimen change, it is important for runners to listen to their bodiesto help avoid injury.

Elizabeth Boyer, PhD, is a postdoctoral fellow at Gillette Children’sSpecialty Healthcare in St. Paul, MN, studying movement disordersin children and adults. Tim Derrick, PhD, is a professor in the De-partment of Kinesiology at Iowa State University in Ames studyingmusculoskeletal loading during activities of daily living.




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Strength training: Bonehealth benefits for men

Men with low bone mass are much lesslikely than their female counterparts to receive treatment. But research suggeststhat resistance exercise is a safe andeffect ive way to improve bone mineraldensity in men and, in turn, reduce the riskof fracture and related complications

By Pamela S. Hinton, PhD

Osteoporosis, which is defined1 as “low bone mass and micro-architectural deterioration of bone tissue, leading to enhanced bonefragility and a consequent increase in fracture risk,” currently affectsmore than 200 million people worldwide.2 The World Health Organ-ization defines osteoporosis as a bone mineral density (BMD) thatis two and a half standard deviations (SD) or more below the aver-age value for a young adult (T-score < -2.5).3 Osteopenia is charac-terized as low bone mass, and is defined as a BMD that is betweenone and two and a half SDs below the young adult mean (T-scorebetween -1 and -2.5).3

Low BMD is associated with increased risk of nontraumaticfracture; fracture risk is increased 1.5 to three-fold or greater foreach SD decrease in BMD.4 Each year, more than 4.5 million peoplein the US and Europe will suffer a fragility fracture.3 Due to thegrowth of the aging population and the rise in life expectancy in recent years, the incidence of osteoporosis and related fracture isexpected to increase.5

Osteoporosis affects menOsteoporosis affects more than two million men in the US, andnearly 16 million more have low bone mass.6 Men account for ap-proximately 40% of the nine million new osteoporotic fractures thatoccur annually,7 and the lifetime fracture risk in men aged 60 yearsand older is estimated to be as high as 25%.8 Compared withwomen, men have a significantly greater risk for complications aftera hip fracture, including increased morbidity, mortality, loss of inde-pendence, and rate of institutionalization,9,10 yet treatment rates aremuch lower in men than in women.11

Recent estimates from the National Osteoporosis Foundationguidelines indicate that one third of white men older than 65 years,and more than half older than 75 years, should be recommendedpharmacologic treatment for osteoporosis.12 Yet, even after sufferingan osteoporosis-related fracture, more than 90% of men remain un-diagnosed and untreated.13,14 Postfracture, men are less likely than


Resistance training is well tolerated andappears to have a minimal risk of injury or discomfort, which predicts both goodcompliance and practical application.


women to receive follow-up care,15 including calcium and vitaminD supplementation16 and prescription of antiresorptive pharma-cotherapy.11

Physical inactivity Physical inactivity is a modifiable risk factor for osteoporosis, andincreasing physical activity at any point throughout the lifespan pos-itively affects bone health,17-22 while reductions in physical activitycan result in bone loss.23,24 Cross-sectional and longitudinal studieshave shown the skeletal benefits of physical activity during adoles-cence and young adulthood persist into middle age and older adult-hood.25,26 In addition to increasing BMD, bone loading duringadulthood increases bone size, cortical area, and strength,27 and reduces hip fracture risk later in life.20

Exercise can affect bone through multiple mechanisms, includ-ing muscle contraction forces, gravitational loading, and endo -crine/paracrine effects. During physical activity, bone is subjectedto mechanical forces exerted by muscle contraction and gravita-tional loading. At the cellular level, bone cells (osteocytes) perceivethese mechanical forces as cell deformation, changes in extra -cellular fluid shear stress, pressure gradients, and electric fields.28

The osteocytes communicate with osteoblasts and osteoclasts tomodulate bone formation and resorption, thereby changing thebone’s geometry and material properties.29

It is well-accepted that bone adapts to the mechanical de-mands to which it is subjected, and muscle contractions contributea portion of those demands.30,31 The importance of skeletal musclecontraction forces (ie, joint reaction forces) to bone mass is sup-ported by the parallel changes in bone mass and muscle strengththroughout the lifespan.30,32 Similarly, in states of muscular disusethat result in muscle atrophy (eg, disease, inactivity, or paralysis),muscle contraction forces are severely reduced, and site-specificreductions in bone mass and bone strength occur.31

Site-specific relationships between skeletal muscle mass andBMD demonstrate the importance of muscle contraction to thepreservation of bone mass. Studies of tennis players demonstratethat a player’s dominant arm has greater muscle and bone massthan their nondominant arm.32 In the lower extremity, the bones ofthe nondominant limb have greater bone density due to greatermotor neuron excitability and activity of stabilizing muscles of thenondominant side.33 Cross-sectional studies have shown positivesite-specific associations between repetitive muscle contraction andregional BMD, such that resistance training of the upper body is as-sociated with greater BMD of the arms.34 Likewise, changes inskeletal mass following strength training are positively associatedwith changes in BMD.35 Thus, there is considerable evidence thatmuscle contraction forces are important for bone strength.

Resistance training The American College of Sports Medicine recommends weightbear-ing endurance activities, including those that involve jumping andjogging, three to five times per week, and resistance exercise twoto three times per week to preserve bone health during adulthood.36

Resistance training is also recommended by the National Strengthand Conditioning Association to increase BMD or to prevent age-associated reductions in BMD.37 The Surgeon General’s Report onBone Health also recommends progressive resistance training, aswell as daily jump-training and participation in weightbearing recre-ational activities for individuals who can tolerate high-impactactivity.1

The majority of clinical trials of resistance training have beenconducted in women. Exercise that exerts high muscle-contractionor ground reaction forces on the skeleton, such as high-intensity re-sistance training or structured jump-training, respectively, is associ-ated with increased BMD in pre- and postmenopausal women.38-40

However, very few controlled trials have examined the effects of re-sistance training on bone mass in men.22,41-48

Generally, these studies reported positive effects of resistancetraining on BMD. Kukuljan et al found that 12 months of progressiveresistance training and impact exercise (three days per week) wasassociated with increased BMD at the femoral neck and lumbarspine by 1.8% and 1.5%, respectively, in men aged 50 to 79 yearswith normal to below-average BMD at baseline.42 Whole-body BMDincreased by about 1.2% after 12 weeks of resistance training inelderly men and in women with an average age of about 60 years.48

Ryan et al also reported a 2.8% increase in femoral neck BMD afterfour months of resistance training in men with an average agearound 60 years,46 and Menkes et al observed significant increasesin lumbar spine (2%) and femoral neck (3.8%) BMD in men aged55 to 60 years.45 In a study of men and women aged 55 to 74years, some of whom were osteopenic or osteoporotic, Bemben etal found that 40 weeks of resistance training significantly increasedBMD of the spine, trochanter, and total hip by ≤1%.41 However, be-cause these studies included men and women, elderly men, or amixed study population of men who had either normal or low BMD,or because the intervention included a combined exercise protocol(ie, resistance training plus high-impact activity), the effectivenessof resistance training for increasing BMD in men with existing lowbone mass could not be determined.

Clinical trial To answer this clinically relevant question, we conducted a clinicaltrial to determine the effects of 12 months of periodic progressiveresistance training on BMD in apparently healthy men (mean age,44 ± 2 years; median age, 44 years) with osteopenia of the hip orspine.49 This study was conducted in accordance with the Declara-tion of Helsinki and was approved by the local Institutional ReviewBoard. Informed written consent was obtained from each study participant.

Apparently healthy physically active (four or more hours ofleisure time physical activity/week for the past 24 months) menaged 25 to 60 years with low BMD of the lumbar spine or hip (T-score between -2.5 and -1 SD) were eligible to participate in thestudy. Exclusion criteria were: use of medications or supplementsthat affect bone metabolism or prevent exercise; a previous or cur-rent medical condition affecting bone health; osteoporosis of thelumbar spine and/or hip (T-score < -2.5 SD); cardiovascular disease;metal implants; current smoker (ie, within the past six months); cur-rent regular participation in high-intensity resistance training and/orplyometrics; reversed sleep/wake cycle (ie, sleep during the dayand work at night); and consumption of more than three alcoholicdrinks per day.

The participants completed two resistance training sessions perweek under the supervision of study personnel. The resistance train-ing intervention included exercises that load the hip and spine:squats, bent-over-row, modified dead lift, military press, lunges, andcalf raises. Participants were instructed to perform the eccentricphase of each lift in two to three seconds and to perform the con-centric contraction “explosively.” Prior to and every six weeks during




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the intervention, we performed maximal strength testing.50

To minimize risk of injury and to account for strength adapta-tions as a result of strength training improvements, the interventionalso used a progressive intensity design based on a six-week cyclefollowed by a rest week; a total of eight cycles were completed.During the six-week cycle, the intensity progressively increasedevery two weeks based on the strength measured at the end ofeach cycle.

• Weeks one to two were light intensity, consisting of onewarm-up set of 10 repetitions at 20% of the 1-repetition maximum(1RM) and three sets of 10 repetitions at 50% of the 1RM.

• Weeks three and four were moderate intensity, with onewarm-up set of 10 repetitions at 20% of the 1RM, two sets of 10repetitions at 60% of the 1RM, and one set of six to eight repetitionsat 70% to 75% of the 1RM.

• Weeks five to six were high-intensity, starting with one warm-up set of 10 repetitions at 20% of the 1RM, followed by two sets of10 repetitions at 60% of the 1RM, and one set of three to five rep-etitions at 80% to 90% of the 1RM.

At the end of the 12-month intervention, participants significantlyimproved their muscular strength, as evidenced by increases in 1RMfor the squat, lunge, modified deadlift, calf raise, military press, andbent-over row of 79%, 114%, 64%, 79%, 52%, and 44%, respec-tively. Bone mineral density of the whole body, total hip, and lumbarspine, which was measured using dual-energy X-ray absorptiometry,also significantly increased after 12 months of resistance training.There was a positive relationship between percent changes in squat1RM and in left leg BMD (r = .605, p = .042). The increases in BMDobserved in the present study were associated with favorable

alterations in serum bone turnover markers; specifically, there wasa significant reduction in bone resorption and an increase in boneformation.

Biological and clinical significance The biological and clinical significance of these results can be ap-preciated only if one considers that bone loss occurs with normalaging. Young adult and middle-aged men lose BMD at rates ofabout .4% to 1.5% per year.51-53 The results are also important be-cause they suggest that a time-efficient (two to three days per week)resistance training intervention can improve BMD in otherwisehealthy men. We previously observed that physically active adultmen with osteopenia, similar to those in the present study, lost hipBMD at a rate of .8% per year,54 consistent with the literature con-sensus that bone loss occurs with aging. Therefore, the increasesin BMD observed in this and previous exercise-intervention studies,though relatively small (.6% to 1.3%), are biologically significant, inthat exercise reversed the bone loss that occurs with normal aging.

The increases in BMD observed following exercise interven-tions likely have clinical significance, as small increases in BMD re-sult in much larger gains in bone strength. For example, increasingBMD by 5% increased bone strength by 65% in an animal model,55

and, in women with postmenopausal osteoporosis, a 1% increasein spine BMD reduced fracture risk by 8%.56 Similar to the increasein bone formation and decrease in bone resorption observed in ourstudy, others have reported increases in bone formation markersrelative to resorption following high-intensity resistance training inolder men.47,57,58 These data suggest exercise might counteract age-related bone loss in men, which has been attributed primarily to adeficit in bone formation relative to bone resorption.59



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Feasibility of resistance trainingFrom a practical perspective, it is worth noting that, in our study, thetime and equipment required to complete the resistance trainingeach week was minimal, ranging from 60 minutes during a “light”week to 120 minutes for a “heavy” week. If participants missed asession, they were required to make it up. While the training in ourstudy was supervised, it could be done at home without supervision.

These observations, coupled with evidence of long-term com-pliance with voluntary unsupervised high-impact exercise interven-tions in premenopausal women,60 suggests exercise-based inter -ventions might be effective in the real world.

This conclusion is strengthened when one considers the alter-native of pharmacologic treatment. Although antiresorptive medica-tions are a Food and Drug Administration-approved treatment forosteoporosis in men,61 less than 10% of men with osteoporotic frac-tures are treated with bisphosphonates. Enthusiasm for use of thesemedications in men appears to be limited by the relative lack of long-term safety and efficacy studies in men, the especially poor treatmentcompliance in men,62 and data suggesting poor cost-effectiveness ofbisphosphonate treatment in men.63 Drug treatments for osteoporosishave low rates of compliance and persistence, and most patients whostop taking their osteoporosis medication do not restart.64

Safety issuesTo evaluate safety of the resistance training intervention, we as-sessed the self-reported pain and fatigue associated with the exer-cise at each training session. On average, the participants rated theintensity of the pain caused by the training as a score of 10 or lessout of 100, with 100 being the most intense pain imaginable. In ad-dition, the pain ratings decreased from the baseline assessment at

six and 12 months. Participants also rated fatigue associated withthe interventions as less than 30 out of 100, with 100 being themost fatigue imaginable, at all time points. In addition, there wereno injuries reported during any of the approximately 1800 super-vised training sessions.

Thus, the resistance training was well tolerated by the partici-pants and appears to have a minimal risk of injury or discomfort,which predicts both good compliance and practical application. Otherstudies have reported that older adults with low bone mass can safelyperform maximal strength training (squats)65 or jumping.66,67 More-over, a recent review by a panel of experts strongly recommendsmulti component exercise that includes resistance training for individ-uals with osteoporosis. Osteoporosis Canada, the National Osteo-porosis Foundation, and Osteoporosis Australia’s Medical andScientific Advisory Committee endorsed the recommendation thatindividuals with osteoporosis engage in resistance training that targetsall major muscle groups at least twice per week.68

ConclusionIn summary, the existing evidence suggests that resistance traininginterventions are safe and effectively increase BMD in men with lowbone mass. These results have clinical implications, as exercise maybe the appropriate “prescription” for some individuals with low bonemass.

Pamela S. Hinton, PhD, earned in her doctorate in nutrition sciencesfrom the University of Wisconsin-Madison and is currently an asso-ciate professor in the Department of Nutrition & Exercise Physiologyat the University of Missouri-Columbia.



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Ankle instability rehabemphasizes individuality

Research presented at the most recent International Ankle Symposium indicatesthat rehabilitation for chronic ankle insta-bility is evolving from a one-size-fits-all approach to an increased focus on match-ing specific interventions to the patientswho are most likely to benefit.

By Lori Roniger

The future of rehabilitation interventions for chronic ankle instability(CAI) could include combining treatments and personalizing rehabprograms for individual patients and their specific deficits, accordingto new research presented at the 6th International Ankle Sympo-sium in Dublin, Ireland.

“I think the key to successful rehab in people with chronic ankleinstability is matching the treatment to the individual patient, nothaving a protocol applied to all patients,” said Jay Hertel, PhD, ATC,the Joe H. Gieck professor of sports medicine and codirector of theexercise and sports injury lab at the University of Virginia in Char-lottesville. “Matching up the impairments identified in the evaluationshould lead to the treatment they get.”

Hertel gave a keynote lecture on treatment strategies for CAIat the October 2015 symposium and emphasized in a phone inter-view after the event that, while CAI is multifactorial in nature, thisdoesn’t mean every patient is influenced by all the possible factors.In particular, he said, it is important to address those that contributeto a patient’s specific limitations, such as range of motion, mobility,strength, balance, or more functional issues involving gait or cuttingand landing in athletes.

“We need to be treating everyone as an individual,” said ErikWikstrom, PhD, assistant professor of sports medicine at the Uni-versity of North Carolina at Chapel Hill, whose research on CAIrehab was presented at the conference.

Performing a baseline assessment of each patient and his orher impairments is particularly important in patients with CAI as thatpopulation is more heterogeneous than others, Wikstrom said.

Matching the treatment to the patientPatrick McKeon, PhD, ATC, FACSM, assistant professor of exerciseand sports sciences at Ithaca College in New York, has been work-ing with Wikstrom and other researchers to determine which CAIpatients will benefit most from specific interventions that have al-ready been shown to be effective for improving CAI. The result has


A growing body of research suggests thatankle instability threatens quality of life andleads to decreased activity levels, whichcould have long-term implications.


been what the researchers call a sensory-targeted ankle rehabilita-tion strategies (STARS) treatment paradigm.1,2

Their research has examined plantar massage, ankle joint mo-bilization, or calf stretching in CAI patients, and the effect on out-comes such as postural control, ankle joint range of motion, andself-assessed function.1

“All of those interventions improved more or less all of thoseoutcomes,” Wikstrom said.

They found that response to treatment varied for each inter-vention—some individuals had large improvements while some hadonly small improvements—and they sought to determine if theycould predict which interventions were best for which patients, start-ing with plantar massage and ankle joint mobilization.

training with multimodal STARS treatment in CAI patients improvedstatic postural control more than balance training alone. While thispreliminary research did not find a significant difference in staticpostural control between the treatment groups, Wikstrom said theresults, which were based on a relatively small group of 24 patients,suggest that combining the treatments could be effective. He hopesto study this combination treatment in a larger group of patients anddetermine if any variables can predict a positive response to this intervention.

Impairment-based modelLuke Donovan, PhD, ATC, an assistant professor of kinesiology atthe University of Toledo in Ohio, presented research at the anklesymposium on an impairment-based approach to CAI rehab. In thismodel, patients are prescribed interventions to address specific im-pairments (such as sensory issues, decreased proprioception, or al-tered gait kinematics) starting at levels that are challenging for theindividual, instead of giving everyone the same tasks.

A study of his that was epublished in March by the Journal ofAthletic Training examines the effectiveness of a four-week rehabil-itation program in which CAI patients performed exercises whilewearing an ankle destabilization shoe or while on traditional unsta-ble surfaces. The study’s protocol provided patients with challengingexercises throughout the study and focused on range of motion,strength, balance, and functional exercises. After patients were as-sessed, they started exercises at a level that was difficult for them.

“What we found more or less was that both groups progressedsimilarly with clinical measures,” Donovan said. “Everyone’s strengthimproved on average. I would say that these [ankle destabilization]devices are just as effective as unstable surfaces.”

At the symposium he presented the results of a second manu-script stemming from the same data that found impairment-basedrehabilitation incorporating an ankle destabilization device was as-sociated with improvements in dorsiflexion range of motion duringthe stance phase of gait—which is often limited in patients with CAI.The same protocol without the destabilization device had no effecton ankle dorsiflexion.6

He said the patients anecdotally enjoyed participating in thestudy and found the exercises challenging. These studies did notfollow patients over the long term, although Donovan is replicatingthe study using different gait training devices and plans to followpatients over a longer period.

Hertel, one of the study’s authors, emphasized the importanceof using specific interventions to address the altered gait patternsseen in CAI patients.

“If we don’t specifically address the gait mechanics throughrehab, we don’t actually change the gait patterns,” he said. “Patientsreport feeling better but don’t see change in gait without doing spe-cific gait interventions.”

Walk this wayLike other researchers, Donovan is trying to figure out how to bestbring his research into the clinic. He’s been investigating the use ofoff-the-shelf video cameras to look for visual cues that differentiatebetween CAI patients and those who have never sprained their an-kles, and the potential value of this information for CAI rehabilitation.

Donovan has also been studying the effects of an auditorybiofeedback device, worn in a shoe, on gait in CAI patients. Recently




They found that a baseline Foot and Ankle Ability Measure(FAAM) Sport score greater than 70.31% and a single-limb balancetest improvement of at least 1.67 errors after one five-minute plan-tar massage treatment predicted which patients with CAI would improve their postural control after six such sessions over a two-week period, according to preliminary results presented at the anklesymposium.3

“Plantar massage really seems to be beneficial if there is a single-limb balance deficit,” Wikstrom said.

In another pilot study, CAI patients who were responsive to jointmobilization treatment had lower FAAM-ADL (activities of daily liv-ing) scores and higher anterior Star Excursion Balance Test scoresprior to undergoing this intervention than those who did not re-spond.4 The treatment involved six sessions over two weeks; eachsession involved two two-minute sets of Maitland grade-II talocruraltraction and four two-minute sets of Maitland grade-III anterior-to-posterior talocrural joint mobilization.

Mix and matchMcKeon, who has both research and clinical responsibilities atIthaca College, said he enjoys seeing the clinical improvements as-sociated with such interventions; ankle joint mobilization, for exam-ple, can help increase dorsiflexion and self-reported function. Hehas also been developing protocols that he hopes will be practicalin the real world.

While randomized controlled trials conducted for STARS inter-ventions used only one form of treatment on each patient, McKeonand colleagues are now studying a multimodal approach in whichCAI patients receive five minutes of joint mobilization, five minutesof plantar massage, and five minutes of foot core work three timesa week for two weeks.

“After that, I typically introduce some balance activities likestanding on one leg and hopping on one leg,” he said.

Another study5 presented at the International Ankle Symposiumby Wikstrom and colleagues examined whether combining balance

“If we don’t specifically address the gaitmechanics through rehab, we don’tactually change the gait patterns.”

— Jay Hertel, PhD, ATC

published research reported that wearing the device was associatedwith decreased plantar pressure in the lateral column of the footwhile walking on a treadmill.7 Since patients walk differently whenusing the device, he’d like to see if incorporating it into a rehab pro-gram causes lasting and long-term changes, such as altering gait,self-reported function, or incidence of giving way.

“There are pretty effective ways clinicians can measurestrength, balance, or range of motion, but when it comes to func-tional movement patterns, it’s tough to assess,” Donovan said.

He also noted that CAI rehab studies typically have not re-ported long-term results.

Having a visionA new area of research on which Wikstrom, McKeon, Hertel, andothers are collaborating is examining whether CAI patients have anincreased reliance on visual information. Some of them presentedan abstract at the ankle symposium on their systematic review ofthe use of visual information in CAI patients compared with un -injured controls.8

Assessing 11 studies of single-limb stance under eyes-openand eyes-closed conditions in CAI patients, healthy individuals, orboth, they found CAI patients rely more heavily on visual informationduring that task than controls. These sensory weighting differencessuggest there may be a neurophysiological component to the bal-ance deficits associated with CAI, Wikstrom said.

“We want to get a better understanding of the full spectrum ofdeficits associated with sensory reweighting,” he said.

The next step is to determine whether this outcome is treat-able; however, he said, preliminary data from a few of his group’songoing investigations suggest existing interventions may not treatthis issue. If existing interventions don’t adequately address the waypatients use somatosensory versus visual information, that couldexplain why patients with CAI often continue to experience epi -sodes of ankle sprain or giving way despite having gone through afull balance training protocol.

Changes in the brainPhillip Gribble, PhD, ATC, FNATA, who spoke at the conferenceabout CAI as the next injury epidemic, has been trying to documentchanges that CAI may cause in the brain and spinal cord pathwaysand how they may manifest into clinical functional deficits.

“There is a rise in understanding that chronic ankle instabilitycreates some adaptations in the nervous system,” he said.

A study conducted by Gribble and colleagues published earlierthis year found that fibularis longus corticospinal excitability wasgreater in controls than in CAI patients.9 He is currently using trans -cranial magnetic stimulation (TMS), which was used in the previousstudy, to detect differences in the corticospinal excitability of theperipheral muscles between CAI patients and ankle sprain copers(those who have a history of ankle sprain but don’t develop CAI).

“These results may lead to the development of novel rehabtechniques,” he said.

Long-term consequencesGribble noted that a growing body of research, some of it presentedat the ankle symposium, has been finding that CAI threatens qualityof life and leads to a decline in physical activity levels, which couldhave long-term implications.



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A 2015 study by Hubbard-Turner et al found that physical ac-tivity levels were reduced in college students with CAI comparedwith healthy students,10 and another by Houston et al found thatquality of life is reduced in individuals with CAI.11

“Something we all recognize that’s on the horizon is how to mit-igate problems for CAI patients on this path toward long-term con-sequences and ultimately promote a physically active lifestyle inthese patients,” Gribble said.

People are recognizing the long-term consequences of CAI andankle instability, which include ankle osteoarthritis,12-15 as they havepreviously for anterior cruciate ligament (ACL) injuries.

“What we’re seeing with the ankle is clearly mirrored in theknee patient population,” he said.

Future research may investigate how interventions may help toturn CAI patients into copers.

“There has been, to my knowledge, no studies on how any in-terventions impact physical activity levels,” Wikstrom said. “That’sthe next step.”

One challenge is that many patients with CAI come in for treatmentonly when they experience a recurrent ankle sprain or an episode ofgiving way and want treatment for acute symptoms, he noted.

“Generally, those get resolved and those patients disappear,”Wikstrom said.

These patients often don’t think they need rehab and don’t un-derstand they may have residual impairments, he said.

“People don’t respect ankle injuries,” McKeon said.

Compliance and communicationMcKeon talked about the importance of a maintenance program forCAI patients after they have undergone some form of rehabilitation,

such as balance training. “I think it’s really important for them to continue with those

types of activities,” McKeon said. “If you don’t use it, you lose it.”Such maintenance programs could include performing foot

core exercises, foot massage, and trying to balance on one leg.McKeon also recommends that CAI patients get involved an activitythat promotes balance and dynamic movement, such as yoga, Pi-lates, tai chi, or hiking.

“There’s a reason that CAI is such a recalcitrant condition,”McKeon said. “I think compliance seems to be the biggest issue.”

He said he emphasizes to his CAI patients the outcomes andimprovements they’re seeing while working with him. He likes touse self-reported functional scales, such as the FAAM, to show themwhere they have difficulties and where their abilities are improvingthrough rehabilitation.

“Having the patients fill out the form initially is a good way forme to show them what their problems are and then to work throughgoal-setting with them to address those problems,” McKeon said. “Ican then come back to how each intervention we include in theirrehab ties back to the problem they reported. Then as we progressthrough rehabilitation, I have them revisit the FAAM and show themhow they’re shifting their perception of difficulty based on the rehab.It definitely helps with the patients’ perception of why we’re doingwhat we’re doing.”

This approach also makes it easier to link changes in clinical out-comes—such as strength, range of motion, limb girth, and balance—to the subjective outcomes identified on the FAAM, he said.

Lori Roniger is a freelance writer based in San Francisco, CA.



Flexible flat foot: Effectsof orthoses during gait

In this original investigation, researchersanalyzed the biomechanical effects of afoot orthosis in patients with flexible flatfoot during walking and the extent towhich those functional effects are consis-tent with proposed theories about the device’s mechanism of action.

By Bruce Elliott, PT, DPT, COMT, and Juan Garbalosa, PhD, PT

Low arches, or flat feet, are associated with an increased risk of in-jury among physically active people, and it is widely believed thatthis type of foot tends to be more flexible than other foot types, al-lowing a disproportionate amount of pronation during the gait cycle.1,2

Researchers have theorized that flexible flat feet affect the movementand muscular activity patterns of the lower leg, predisposing such in-dividuals to lower extremity musculoskeletal injuries.3-5

Excessive pronation at the subtalar joint and the transversetarsal joint is associated with a flexible flat foot.6,7 It has been sug-gested that this foot type will contribute to a loss of ligamentousand osseous stability, necessitating increased muscular activity inthe lower leg and foot to maintain that stability.8 Additionally, thelack of stability may cause an increase in the magnitude of the stressand shear forces that are transmitted to the soft connective tissues.Excessive pronation is the etiological variable most commonlylinked to overuse injuries, and the subsequent increase in muscularactivity and transmitted forces can ultimately lead to muscular fa-tigue, which is associated with a variety of overuse injuries.5,9

A biomechanical foot orthosis is commonly used for the man-agement of lower extremity injuries that are related to overpronationor flexible flat feet.8,10 According to Root, realigning the posture ofthe foot is considered an effective intervention because abnormalfoot posture is generally considered the cause of a wide variety ofpathological conditions,11 and the flexible flat foot is managed withorthosis intervention more often than other foot types.4,5,9,12-14

Increasingly, foot orthoses have been successfully used as anadjunct treatment for symptoms that are secondary to increasedflexibility. Of 465 podiatric patients reporting various maladies, 62%acknowledged complete resolution of their chief complaint after or-thotic treatment, and an additional 33% gained partial resolution.Similarly, in a retrospective study with both temporary soft orthosesand permanent rigid orthoses, 96% of patients experienced painrelief, while 70% were able to return to previous levels of activity.15,16

Additionally, Nigg et al17 reported that at least 70% of runners


The orthosis did not affect most of thekinematics of the forefoot, first ray, andmedial longitudinal arch, but did affecttransverse movement at the forefoot.

who experience lower extremity musculoskeletal exertional painwill have a reduction in their symptoms with the use of a biome-chanical orthosis. Based on static radiologic data, Bleck andBerzins,18 and later Bordelon and Lusskin,19 reported that significantcorrection of flexible flat foot deformity could be achieved by theuse of orthoses. In contrast, Penneau et al20 and Wenger et al21 sug-gested the use of an orthotic device could not make permanentchanges to a flat foot.

The use of foot orthoses in the treatment of abnormal foot bio-mechanics has been extensively described in the literature, andthose interventions can be grouped into two categories—accom-modative or corrective. Regardless of the orthotic prescription, it isdifficult to judge the scientific merit of the recommendations that



Figure 1. Modified Gib test ranges.

have been generated by these studies because of the conflictingopinions regarding the effectiveness of different orthoses.1,7,14,22

We conducted a study comparing the stance phase mechanicsof symptomatic individuals with flexible flat feet during normal walk-ing in a conventional sandal and in the same sandal with a maximalarch supination stabilization orthosis. The purpose of the study wasto document the effect of the orthosis on the forefoot, medial lon-gitudinal arch, and first ray mechanics of flexible flat feet during nor-mal overland walking at a self-selected speed.

Methods and materialsWe screened a convenience sample of 20 individuals for participa-tion in this study. Thirteen met the inclusion criteria; two were lostto follow-up, and one participant’s data file became unusable. The10 individuals (six women) who completed the study ranged in agefrom 20 to 54 years and reported various complaints of foot, heel,leg, and knee pain. Informed consent and a medical history wereobtained from each participant prior to taking any measurements.Individuals were excluded if they had sustained any lower extremityfractures or injury to the capsular or ligamentous structures of thelower leg or foot within the past 12 months.

The inclusion criteria for the experiment were defined by thenavicular drop test and the modified Gib test. Individuals were in-cluded in the study if they had a navicular drop greater than or equalto 10 mm bilaterally, and if they had at least 60° of frontal forefootor rearfoot passive range of motion (as determined by the modifiedGib test, illustrated in Figure 1)23 in both feet. The modified Gib testis recommended for orthosis prescription by the manufacturer;however, because of the subjective nature and less-than-adequate

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reliability of this test, we also used the navicular drop test to definean individual’s inclusion in the study.

Upon completion of the structural evaluation, participants werecasted for a custom pair of orthoses according to standardized cast-ing procedures of the orthosis manufacturer. One investigator per-formed all of the casting tasks. This sequential process entailed agait-referenced weightbearing foam box casting, which captures themaximal amount of arch that one can comfortably achieve at mid-stance with the heel and forefoot in full contact with the ground (Fig-ure 2). Once accomplished, the casts and orthosis prescription wereshipped to the manufacturer.

At the second visit, approximately two weeks later, proper fit ofthe orthosis was verified and study participants were instructed ontheir break-in and use. The orthosis featured a semirigid thermo-plastic heel cup extending to the base of the metatarsals with a full-length, 1/8-in thick, perforated ethylene vinyl acetate top cover(Figure 3). The individuals used their own footwear during the six-week break-in period and were allowed to take part in normal ac-tivities. The only activity that was restricted prior to the actual datacollection was recreational running with the orthosis in the shoe.

At the end of the accommodation period, all participants at-tended a data collection session. At this session, retro-reflectivemarkers were placed on the pelvis, lower extremities, and feet overspecific bony landmarks (Figure 4). Using an eight-camera videosystem sampling at a rate of 120 Hz, the 3D displacements of theretro-reflective markers were recorded while the participants walkedover level ground at a self-selected walking speed under one of two


Figure 2. Study participant’s foot in the final stage of casting.

Figure 3. Maximal arch supination stabilization orthosis with perforated EVA top cover.


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footwear conditions. The footwear conditions consisted of walkingin a sandal and walking in a sandal with the orthosis, which was se-cured to the sandal with two-sided tape. A modified Teva sandalwas used for the walking trials (Figure 5). To allow for full visibility ofthe foot markers, the sandals were modified by removing the straps(with the exception of the anchoring straps) and replacing them withhalf-inch Velcro straps.

A walking trial consisted of the participant walking continuouslyat a self-selected walking speed within the laboratory setting, mak-ing wide-angle turns at each end of the room. Twelve trials of videodata were collected for each participant (six trials in each footwearcondition). Each individual walked in the sandal-only condition first,followed by walking in the sandal with orthosis.

Data analysisWe used marker displacement data to obtain the 3D angular dis-placements of the rearfoot, forefoot, and first ray, as well as the dy-namic arch index, during the walking trials. We defined dynamicarch index as the vertical distance to the navicular marker from thefloor, divided by the distance from the inferior calcaneal to the firstmetatarsal marker. The stance phase of the walking trials was ex-tracted and time normalized to 100 frames (1 and 100 representingheel strike and toe off, respectively). We obtained maximum, mini-mum, and range (maximum minus minimum) of the rearfoot, fore-foot, and first ray angles and dynamic arch index of five stancephases for each footwear condition.

To determine the effect of condition (orthosis vs no orthosis)we analyzed six dependent variables simultaneously: forefoot kine-matic movement in the sagittal, frontal, and transverse planes; first



Figure 4. The retro-reflective markers,footwear, and or-thoses that wereused in the study.

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ray kinematic movement in the sagittal and transverse planes; andkinematic movement of the medial longitudinal arch (arch index).The level of statistical significance was set at p<.10.

ResultsWe found a significant difference between conditions for maximumforefoot movement in the transverse plane, for both left and rightfeet. There was also a significant difference between conditions forminimum forefoot movement in the transverse plane for right feet.However, we found no range of motion differences between condi-tions for any of the other dependent variables, including the archindex, in either lower extremity.

DiscussionThe orthosis used in this study is typically prescribed for patientswith symptoms associated with flexible flat feet and abnormal prona-tion. The manufacturer states that the orthosis attempts to controlthe subtalar joint indirectly by controlling the amount of medial lon-gitudinal arch deformation through direct and total contact of thearch.23 This is based on the theory that a direct relationship existsbetween arch height and subtalar pronation; therefore, if arch heightis controlled, pronation is also effectively controlled.

An additional claim of the manufacturer is that the orthosis willhypothetically increase first metatarsal plantar flexion by directinga mechanical control over the tarsus of the foot, theoretically creat-ing an indirect force on the calcaneus and talus.23 The purpose ofthis is to increase first metatarsophalangeal (MTP) joint dorsiflexionin an effort to create a more rigid lever through the stance phase ofthe gait cycle.23 The results of this study do not show significant



Figure 5. The modified Teva sandal (top) and the modified Teva sandal with orthosis(bottom).

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differences in the maximum and minimum positions of the first ray

with the use of the orthosis and do not support this claim. The lack

of an effect on first ray motion agrees with the results of Nawoczen-

ski and Ludewig,24 who also failed to identify any significant change

in movement of the first ray during the weightbearing phase of the

gait cycle with orthosis use.

During normal walking, first metatarsal plantar flexion is needed

to allow unrestricted first MTP joint dorsiflexion during the push-off

phase of gait. Nawoczenski and Ludewig compared a forefoot

posted orthosis with a maximal arch supination stabilization orthosis

and assessed the ability of each to alter motion at the first

metatarsal and hallux.24 Neither orthotic design was associated with

significant effects on first MTP joint dorsiflexion, either at midstance

or at push-off. Individual participant responses to the maximal arch

supination stabilization orthosis revealed that 83% of the partici-

pants experienced no change in first MTP joint dorsiflexion; the re-

maining participants were split between having increased dorsi -

flexion and decreased dorsiflexion of the first MTP joint.24

The maximal arch supination stabilization orthosis is calibrated to

deliver a range of forces that overlap the range of downward forces

exerted on the device by the human body.25 The orthosis, which is

fabricated from thermoplastic, applies a corrective force to the plantar

surface of the foot. Depending on the relative flexibility of the orthosis,

there will be a certain amount of movement observed in the trans-

verse plane of the forefoot, a finding we saw in our study.

Anecdotally, all but one participant in our study continued to

wear the orthoses after the study’s completion, and six of the 10

participants reported either a decrease or complete resolution of

their symptoms after several weeks of orthosis use. These phenom-

ena may be attributed to the proprioceptive change the orthosis

provides within the shoe.

The major limitation associated with this study was the use of

a sandal instead of a shoe for the data collection. The heel counter

and upper of a shoe have the ability to improve the fit of the ortho-

sis, prevent movement of the orthosis with respect to the plantar

surface of the foot, and potentially enhance the overall effectiveness

of the orthosis.

ConclusionsThis experiment examined the effectiveness of a clinically recom-

mended orthosis on the joint kinematics of flexible flat feet during

normal self-paced overland walking. Although the orthosis did not

have an effect on most of the joint kinematics of the forefoot, medial

longitudinal arch, and first ray, it did have a significant and consistent

effect on transverse movement at the forefoot.

Bruce Elliott, PT, DPT, COMT, is an assistant professor in the School

of Physical Therapy at MCPHS University in Worcester, MA. Juan

Garbalosa, PhD, PT, is a clinical professor of physical therapy and

the director of the Motion Analysis Laboratory at Quinnipiac Univer-

sity in Hamden, CT.



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AOPA calls for O&P pilot grant RFPs The Alexandria, VA-based Amer-ican Orthotic & Prosthetic Asso-ciation (AOPA) in late Februaryinvited requests for proposals(RFPs) for 2016 O&P researchgrants. This year AOPA will fund

up to four pilot grants for up to$15,000 each.

View the 2016 researchtopics available for funding andfull RFP and application onlineat aopanet.org.

ProtoKinetics launches gait screen at CSMHavertown, PA-based Proto -Kinetics launched its MovementAnalysis Software (PKMAS) Pri-mary Gait Screen on February17 at the Combined SectionsMeeting of the American Phys-ical Therapy Association in Ana-heim, CA.

The PKMAS Primary Gait

Screen (PGS) addresses transi-tional movements in a single test(typically performed in less thanone minute) that requires no edit-ing and is easy to administer, ac-cording to a company release.Data are available immediately.Key gait metrics include efficiency,symmetry, and speed.

OHI funds $120K podiatric ed grant Ronkonkoma, NY-based OHI (Or-thotic Holdings Inc.) and theAmerican College of Foot & AnkleOrthopedics & Medicine (AC-FAOM) on February 10 an-nounced a joint educational part-nership to support the podiatricprofession and advise on the im-pact of shifts in the healthcare in-dustry.

The partnership is builtaround a $120,000 educationand advocacy grant from OHI for

programs that over a four-yearperiod will support biomechanicsand the podiatric profession.

The alliance will enable thedevelopment of consequentialeducational programs and re-sources that will help ACFAOMmembers and all podiatrists pre-pare for the myriad of challengesand opportunities facing them ina fast-evolving healthcare envi-ronment, according to an OHIrelease.

Medicare adopts HSS joint surveysInvestigators from the Manhat-tan, NY-based Hospital for Spe-cial Surgery on February 29epublished data in Clinical Or-thopaedics and Related Re-search validating two new short-ened questionnaires that willreduce time spent collecting pa-tient-reported outcome data forhip and knee replacement sur-geries.

Beginning in April, Medicarewill incentivize hospitals partici-pating in the ComprehensiveCare for Joint Replacementmodel, an initiative supportinghigher-quality care for hip andknee replacement patients, to vol-untarily submit patient-reportedoutcome data. Consumers will beable to access survey results onhealthcare.gov, the first time treat-

ment-specific, patient-reportedoutcomes data will be publiclyavailable.

The Hip disability and Os-teoarthritis Outcome Score(HOOS) JR—a six-question hipsurvey—and the Knee injury andOsteoarthritis Outcome Score(KOOS) JR—a seven-questionknee survey—are abbreviatedversions of the existing HOOSand KOOS surveys. In addition tosaving patient and practitionertime, HSS investigators designedthe new questionnaires to helporthopedic surgeons better iden-tify optimal surgery candidates,improve rehab services, andmore effectively evaluate implantdevices.

The surveys are available athss.com.

market mechanicsBy Emily Delzell



M.J. Markell sells Quikiks Hands-Free shoesNew York, NY-based QuikiksHands-Free Shoes in Februarysigned its first US distributionagreement within the O&P indus-try with M.J. Markell Shoe Com-pany.

M.J. Markell, headquarteredin Yonkers, NY, will distributeQuikiks shoes, which featurehands-free technology calledStep-in-Go that allows wearersto step easily into and fasten

their shoes without bending orusing their hands.

In December Entrepreneurand Canon USA named Quikiksfounder Steve Kaufman thegrand prize winner of the ProjectGrow Challenge, a small busi-ness owner competition. Kauf-man said he will use the$25,000 award to invest in prod-uct improvements and market-ing.

DJO brace addresses lateral knee OAResearch on Vista, CA-based DJOGlobal’s varus unloader bracepublished in February suggeststhe device may improve abnormalknee joint mechanics associatedwith the development and pro-gression of lateral knee osteoarthri-tis (OA) after anterior cruciate lig-ament reconstruction (ACLR).

Investigators conducted 3Dgait analysis on 19 participantswho had undergone primary ACLRfive to 20 years previously andhad symptomatic and radiographiclateral knee OA and valgusmalalignment.

Participants walked underthree conditions: no brace; unad-justed brace (sagittal plane supportwith neutral frontal plane adjust-ment); and adjusted brace (sagittalplane support with varus adjust-

ment). Compared with no brace,the adjusted brace significantlyincreased peak knee flexion angleand adduction angle and reducedpeak internal rotation angle, aswell as peak knee flexion moment,adduction moment, and externalrotation moment. It also significantlyreduced peak hip adduction angleand increased peak hip adductionand external rotation momentscompared with no brace.

There were no significantdifferences between the ad-justed and unadjusted braceconditions except for knee inter-nal rotation angle, which was sig-nificantly reduced with the ad-justed brace.

The American Journal ofSports Medicine epublished thefindings on February 3.

Flexion releases data for new OA injectable Burlington, MA-based FlexionTherapeutics in February re-leased phase 3 data for its leadproduct candidate Zilretta, anovel nonopioid injectable forknee osteoarthritis (OA).

The sustained-release cor-ticosteroid achieved the study’sprimary endpoints, reducing pain50% from baseline at 12 weeksin patients with moderate to se-vere knee OA pain, and reducingpain significantly at weeks onethrough 16 compared withplacebo. It also achieved a sec-ondary measure, statistical sig-nificance against placebo andimmediate-release triamcinolone

acetonide for pain, stiffness, andfunction through week 12.

Flexion plans to present de-tailed results from the phase 3trial at an upcoming scientificmeeting, according to the com-pany.

The Food and Drug Admin-istration fast tracked Zilretta lastyear, and the company’s plannedNDA (new drug application) sub-mission is on track for 2016. Ifapproved, the therapy would bethe first sustained-release corti-costeroid injection for knee OAand the first new injectable ap-proved for the condition in morethan a decade.

market mechanicsContinued from page 61

APTA names outcomes registry panelThe Alexandria, VA-based Amer-ican Physical Therapy Associa-tion (APTA) on February 10 an-nounced the members of aScientific Advisory Panel to over-see its Physical Therapy Out-comes Registry.

The panel members are:James Irrgang, PT, PhD, ATC,FAPTA (director); Kristin Archer,PT, DPT, PhD; Linda Arslanian,PT, DPT, MS; Janet Freburger, PT,PhD; Christopher Hoekstra, PT,DPT, OCS, FAAOMPT; StephenHunter, PT, DPT, OCS; MichaelJohnson, PT, PhD, OCS; ChristineMcDonough, PT, PhD; and LindaWoodhouse, PT, PhD.

The panel will provide di-

rection for the registry on scien-tific integrity, clinical application,quality, public policy, and re-search. It will also oversee theregistry’s research agenda, datamanagement and analysis strate-gies, clinical application, contentdevelopment, and scholarly pub-lications.

Data will guide best practices,help providers meet regulatory re-porting requirements, generatebenchmarking reports, and helpshape payment policy and supportthe physical therapists in currentand future quality and complianceprograms required by payers,such as the Physician Quality Re-porting System.

AAOS supports local playground build The American Academy of Or-thopaedic Surgeons (AAOS) onMarch 1 joined the City ofKissimmee, FL, Central AvenueElementary School, local resi-dents, and organizers from Com-munity Vision and KaBoom! tobuild a new community play-ground at Central Avenue Ele-mentary.

Last December childrenfrom the neighborhood drewtheir dream playgrounds, andmore than 200 volunteers used

a plan based on those drawingsto finish the construction in lessthan six hours.

The new space provides aplace to play for more than 2678Kissimmee children.

Since 2000, the AAOS hassponsored a one-day volunteerbuild to kick-off its annual meet-ing, which was held this year atthe Orange County ConventionCenter in Orlando March 1-5.The playground is the 17th builtby AAOS and KaBoom!

BOC gives $100K for pedorthic research The American Board for Certifica-tion on Orthotics, Prosthetics, andPedorthics (BOC) in Decembergave the Pedorthic Foundation$100,000.

The foundation will use the

funds to support grants for clinicalor laboratory research in prescrip-tion footwear and orthotic and pe-dorthic modifications. For moreinformation on the grants, go topedorthicfoundation.org.

Ottobock opens orthotic business unit Austin, TX-based Ottobock’s cus-tomers in January began gettingsupport from the company’s newbusiness unit and sales organi-zation dedicated to orthotics.

Ottobock’s new orthoticbusiness unit and sales repre-sentatives (formerly called activ-ity and sports medicine [ASM]representatives) support the fullline of its orthotics product and

services, including the C-Brace,Stance Control, WalkOn, modularcomponents, and the full line ofOttobock off-the-shelf bracingproducts.

Ottobock’s prosthetics busi -ness unit (formerly the technicalorthopedics business unit) issupported by the North Ameri -can prosthetics sales organiza-tion.

ConforMis introduces knee system Bedford, MA-based ConforMisundertook the full commerciallaunch of its customized poste-rior-stabilized (PS) knee re-placement system on March 2at the American Academy ofOrthopaedic Surgeons annualmeeting in Orlando, FL.

The customized iTotal PSimplant is customized for eachpatient to avoid overhang, ro-tation, and sizing compromises.

The system also helps re-stores knee curvature and hasa customized cam and spine toprovide stability throughout thefull range of motion.

Primary total knee implants

either retain the patient’s ownposterior cruciate ligament (CR),or substitute for it (PS). PS im-plants use a cam and spine fea-ture that functions as the pos-terior cruciate ligament.

US surgeons in the USmarket show a heavy prefer-ence for the PS, which accountsfor 72% by revenue of all pri-mary total knee replacements,according to a ConforMis re-lease.

The iTotal PS nearly triplesthe available market for Con-forMis, said Philipp Lang, MD,MBA, the company’s CEO andpresident.


Fitness orgs join to check chronic disease The American College of SportsMedicine (ACSM), Medical FitnessAssociation (MFA), and AmericanCouncil on Exercise (ACE) on Feb-ruary 23 announced a major neweffort called the Exercise is Medi-cine (EIM) Solution at NationalPress Club in Washington DC. Theeffort is part of the ongoing EIMglobal initiative the ACSMlaunched in 2008.

With the MFA and the ACEjoining the ACSM, the new pro-gram represents nearly half thefitness professional industry inthe US.

“Much of the illness andearly death related to [many]chronic diseases can be pre-vented by increased physical ac-

tivity. The EIM Solution is an in-novative approach that, througha prescription, links the medicalprofession with physical activityprofessionals and community re-sources” said US Surgeon Gen-eral Regina Benjamin, MD, whodelivered a keynote talk duringthe announcement.

The EIM Solution will in-clude physical activity counsel-ing, as well as prescription andreferral strategies, particularly theinvolvement of health and fitnessprofessionals, an often-missingcomponent of physician-pre-scribed treatment plans, accord-ing to the ACSM.

Go to exerciseismedicine.org for more information.

Justin Blair, ING finalize distribution deal Chicago-based Justin Blair inFebruary completed an exclu-sive distribution agreement withHickory, NC-based ING Source,manufacturer of the Foot Gymand orthopedic compressionproducts, including the Or-thosleeve.

Justin Blair is ING Source’sleading distribution partner forthe Midwest, and the agreementcovers independent pharmacy,home and durable medicalequipment, and foot care retail

channels in 11 states across theregion. Justin Blair has offeredthe full range of the Orthosleevebrand as a standard distributorfor more than four years.

In January, Teaneck, NJ-based Apex Foot Health andJustin Blair finalized an exclusivedistribution agreement allowingthe Chicago-based company tosell Apex footwear to its phar-macy, home medical equipment,and pedorthic shoe store cus-tomers across 17 states.

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