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13 33 39 VOLUME 9 NUMBER 4 LERMAGAZINE.COMApril 2017features 25 SPECIAL SECTION Many sports, one goal: 16 COVER STORY Joining forces for injury prevention From prints to prison:33 Protocol helps improve FORENSIC PODIATRY AND GAIT ANALYSIS GAIN GROUNDTKA outcomes, cut costs Increasingly, lower extremity experts are being called on to assist with crime scene investigations byA multidisciplinary joint replacement program is improving patient analyzing footprints, shoe prints, and the gait patterns of shadowy figures on security videos. Foroutcomes, decreasing complications, and shortening hospital stays, members of this fledgling field, as Sherlock Holmes famously said, the game is afoot.which helps to lessen clinical anguish following total knee arthroplasty By Shalmali Palas well as the financial burden on patients and the healthcare system. IN THE MOMENTBy Katie Mullen, SPT; Jon R. Cook, PT, DPT; Meghan Warren, PT, MPH, PhD; and TarangJain, PT, PhD, DPT rehabilitation / 1339 Metatarsal morphology Protecting hip implants: Gait patterns help predict wear rates Hallux valgus angle and pain improve after year of custom toe separator useand injury risk in runners Even in older women, mechanical loading leads to Achilles adaptationAlthough it has not been shown to be a risk factor for stress fracture in plus...traditional running, the presence of Morton’s foot (a second metatarsallonger than the first) alters running mechanics in ways that may OUT ON A LIMB / 11 NEW PRODUCTS / 58exacerbate the risks of forefoot injury associated with alternativerunning styles. Workload roulette in the NFL The latest in lower extremity devices and technologiesBy Brian E. Stoltenberg, DPT, OCS, CSCS; and Donald L Goss, PT, PhD, OCS, ATC Recent findings on NFL running backs and MARKET MECHANICS /61 injury risk will make fantasy football players49 The troublesome triad happy, but may not tell the whole story. News from lower extremity companies and organizationsof diabetic ulcer healing By Jordana Bieze Foster By Emily DelzellUncontrolled deformity, deep infection, and ischemia-hypoxia make upthe troublesome triad of confounders associated with healing challengesin patients with diabetic foot ulcers. Clinical examination and interventionin nonhealing patients should focus on these three elements.By Anna Maria M. Tan, DPM; Michael B. Strauss, MD; and Lientra Q. Lu, BS
Publisher GET INVOLVED AND STAY ttt tt CONNECTED WITH THERichard Dubin | [email protected] GROWING LER SOCIALEditor MEDIA NETWORK!Jordana Bieze Foster | [email protected] Visit lermagazine.com today to stay up to date on critical lower extremity information, subscribe to our monthly e-newsletter, and joinSenior editor the conversation on our vast, ever-expanding social media network.Emily Delzell | [email protected] facebook.com/LowerExtremityReviewAssociate editor 23,494 likesP.K. Daniel | [email protected] @lowerextremityOperations coordinator 3050 followersMelissa Rosenthal-Dubin | [email protected] youtube.com/user/LowerExtremityReviewSocial media consultant 142,000 video viewsKaleb S. Dubin | [email protected] instagram.com/lowerextremity/New products editor 343 followersRikki Lee Travolta | [email protected] pinterest.com/lowerextremity/Graphic design & production 294 followersChristine Silva | MoonlightDesignsNC.comWebsite developmentAnthony Palmeri | PopStart Web [email protected] Wees | Media Automation, IncEditorial advisorsCraig R. Bottoni, MD, Jonathan L. Chang, MD,Sarah Curran, PhD, FCPodMed, Stefania Fatone, PhD, BPO,Timothy E. Hewett, PhD, Robert S. Lin, CPO,Jeffrey A. Ross, DPM, MD, Paul R. Scherer, DPM,Erin D. Ward, DPM, Bruce E. Williams, DPMOur Mission:Lower Extremity Review informs healthcare practitionerson current developments in the diagnosis, treatment, andprevention of lower extremity injuries. LER encouragesa collaborative multidisciplinary clinical approach with anemphasis on functional outcomes and evidence-basedmedicine. LER is published monthly, with the exception ofa combined November/ December issue and an additionalspecial issue in December, by Lower Extremity Review, LLC.Subscriptions may be obtained for $38 domestic. and $72international by writing to: LER, PO Box 390418, Minneapolis,MN, 55439-0418. Copyright©2017 Lower Extremity Review, LLC.All rights reserved. The publication may not be reproduced in anyfashion, including electronically, in part or whole, without writtenconsent. LER is a registered trademark of Lower Extremity Review, LLC.POSTMASTER: Please send address changes to LER, PO Box 390418,Minneapolis, MN, 55439-0418.Lower Extremity Review197 Williamsburg Court, Albany, NY 12203518/452-6898 lermagazine.com 04.17 9
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out on a limb: Workload roulette in the NFL A recent study assignment for that play could easily be just as physical and the reported that National injury risk just as high. It would be interesting to see whether a Football League (NFL) running back’s injury risk is associated with total snap count, running backs with rather than just number of carries. more than 300 carries in a season are not That said, an even more important determinant of injury risk more likely to miss involves not just the previous season’s workload but how that time with an injury the previous season’s workload compares to the athlete’s current following season than workload. As Australian sports scientist Tim Gabbett, PhD, those with consider- discussed in a keynote presentation in Monaco at the recent IOC ably fewer carries. World Conference on Prevention of Illness and Injury in Sport, a For fantasy football growing body of research suggests the ratio of acute-to-chronic players, this is great workload is strongly associated with injury risk in certain athletes. news. But for sports Workload spikes—going from limited activity to high activity within medicine experts, it’s a short period of time—are of particular concern. a reminder that injuryrisk rarely can be boiled down to a single parameter. Recent findings on NFL running backs and injury risk will make fantasy football playersConventional wisdom in football holds that any running back happy, but may not tell the whole story.older than 30 years is a risky proposition, due to the extremelyphysical nature of the position, and many NFL teams are reluctant And another recent study from the UK found that three workload-to sign older running backs to large contracts even if they have related factors were associated with injury risk in rugby players:been consistently productive. a high number of matches in the previous year, a low number of matches in the previous year, and a low-moderate number ofThat’s why the recent study findings, published in February by the matches in previous year followed by intense play in the recentOrthopaedic Journal of Sports Medicine, are somewhat surprising. past.One might assume the running backs with the most carries perseason are those most likely to take a beating over time and, It’s possible that maintaining a high workload over time really iseventually, those most likely to spend some time on the disabled protective against injury in NFL running backs. But until thatlist. But in fact, the study found running backs with 300 carries or theory has been effectively tested, running backs like LeGarrettemore missed fewer games due to injury the following season than Blount (who had 299 carries for the New England Patriots lastrunning backs who carried the ball between 150 and 250 times season) might not want to get too comfortable.(despite similar mean ages for both groups). Jordana Bieze Foster, EditorBut coaches and clinicians who work with football players knowthe number of carries in a season is not necessarily reflective of arunning back’s workload. A running back is often involved in farmore plays than just the ones in which he is given the ball. And,even if a running back doesn’t end up with the ball, his blockinglermagazine.com 04.17 11
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in the moment: rehabilitationProtecting hip implantsGait patterns help predict wear ratesBy Katie BellPatient-specific implant wear rates follow-ing total hip arthroplasty (THA) are morestrongly associated with gait patternsthan component positioning, according toresearch from Chicago that suggests im-plant wear could be reduced with the useof predictive wear models. iStockphoto.com 533552808“This study demonstrates the power of gait as a [mechanical] bio- 27.3 kg/m2. All participants underwent a primary unilateral THA, per-marker,” said study author Markus A. Wimmer, PhD, the Grainger Di- formed a gait test 10 months or more after surgery, and had a seriesrector of the Rush Arthritis & Orthopedics Institute and professor for of standing radiographs taken more than one year after surgery, withresearch in the Department of Orthopedics at Rush University Medical a minimum of three years of clinical follow-up. All received the sameCenter in Chicago. “Knowing the association for a specific patient implant, which featured a 28-mm metal head and a hip cup made ofcould help to define the follow-up period. Those with more wear noncrosslinked polyethylene.should be seen more often. Gait modifications with the help of aphysical therapist could be considered.” Implant wear rates were calculated based on the femoral head’s displacement relative to the cup using a computer-assisted x-ray The study included data on 43 men and 30 women, with an av-erage age of 69 years and an average body mass index (BMI) of Continued on page 14Hallux valgus angle and pain improve Even in older women, mechanicalafter year of custom toe separator use loading leads to Achilles adaptationA custom-molded silicone toe in the intervention group had Fourteen weeks of mechanical tions were done three times perseparator can help reduce hal- decreased by 3.3°, while in the loading is associated with week for the first 14 weeks andlux valgus angle and pain in pa- control group it had increased Achilles tendon adaptations in twice a week thereafter, fortients with hallux valgus, ac- by 1.9°; in both groups, the senior women, according to about 50 minutes per session.cording to research from change from baseline was sta- German findings suggestingThailand. tistically significant. older age should not exclude After 14 weeks of loading, patients from exercise-based the women experienced signifi- Investigators from Siriraj The patients in the inter- Achilles rehabilitation. cantly increased Achilles tendonHospital in Bangkok analyzed vention group also experienced stiffness, hypertrophy, and a79 patients with moderate hal- a significant decrease in hallux Researchers from the Ger- 22% increase in ankle plantarlux valgus who were random- pain between baseline and one man Sport University Cologne flexion moment. However, noized into two groups. Both year. analyzed 34 women (mean age, further improvement was notedgroups received foot care, 65 years) with no history of after 1.5 years.footwear recommendations, The findings were epub- Achilles injury in the previousand pain medications for one lished on March 20 by Prosthet- five years; 21 completed 14 The findings were pub-year; the 40 patients in the in- ics & Orthotics International. weeks of high-strain cyclic load- lished in March by the Journaltervention group also were in- ing exercises, while the remain- of Experimental Biology.structed to wear a toe separa- – Jordana Bieze Foster ing 12 women formed a controltor, custom molded from room- group. Twelve members of the – Jordana Bieze Fostertemperature vulcanization sili- Source: exercise group continued the in-cone, for six hours per night. tervention for 1.5 years. Source: Chadchavalpanichaya N, Prakotmong- Epro G, Mierau A, Doerner J, et al. The After one year, the mean hal- kol V, Polhan N, et al. Effectiveness of Exercises emphasizing iso- Achilles tendon is mechanosensitive inlux valgus angle for the patients custom-mold room temperature vul- metric plantar flexion contrac- older adults: adaptations following 14 canizing silicone toe separator on hal- weeks versus 1.5 years of cyclic strain lux valgus: A prospective, randomized exercise. J Exp Biol 2017;220(Pt 6): single-blinded controlled trial. Prosth 1008-1018. Orthot Int 2017 Mar 20. [Epub ahead of print] lermagazine.com 04.17 13
in the moment: rehabilitation Continued from page 13wear-analysis suite. The investi- biomechanics, implant position- tance of wear predictors [ie, spe- However, because the traumagators established three groups: ing, and wear rate, with the non- cific gait and implant positioning associated with surgery can af-Low wear was classified as less linear model having a higher variables] may differ dependent fect muscle performance andthan .1 mm per year, moderate prediction accuracy. on age.” mobility, Judd suggested that in-wear was between .1 and .2 mm terventions to address THA wearper year, and high wear was Notably, flexion-extension Dana Judd, PT, DPT, PhD, rates be implemented postop-more than .2 mm per year. range of motion and hip mo- an assistant professor in the eratively. ments in the sagittal and trans- Physical Therapy Program at the No group differences were verse planes explained 42% to University of Colorado Anschutz “Interventions might ad-found for positioning and gait, 60% of wear rate. Meanwhile, Medical Campus in Aurora, said dress strength training targetingwith the authors suggesting that positioning factors, including cup the postoperative gait variables the hip and abdominal muscu-different wear rates result from medialization and cup inclination associated with implant wear are lature to stabilize the pelvis, asa combination of factors rather angle, were less predictive, ex- likely reflective of preoperative well as balance and neuromus-than single variables. The find- plaining just 10% to 33% of gait abnormalities and the expe- cular reeducation programs toings were epublished by Clinical wear rate. rience of undergoing surgery promote healthy movement andOrthopaedics and Related Re- rather than a product of any par- stabilization,” she said.search in March. BMI did not emerge as a ticular surgical technique. The wear predictor. Although patient findings also are consistent with Sources: A linear discriminant analy- activity level was not assessed those of a different Chicago re- Ardestani MM, Amenábar Edwards PP,sis model correctly predicted the directly, it should be reflected in search group, in which preop- Wimmer MA. Prediction of polyethylenewear level in 80% of participants the combinations of age and gait erative gait variables were pre- wear rates from gait biomechanics andwith low wear, 87% of those with variables that were analyzed, dictive of clinical response after implant positioning in total hip replace-moderate wear, and 73% of pa- Wimmer said. THA (see “Gait and THA out- ment. Clin Orthop Relat Res 2017 Martients with high wear. For each comes: Hip mechanics have 2. [Epub ahead of print]wear level, multiple linear and “We believe that the results predictive value,” June 2016, Foucher KC. Preoperative gait mechan-nonlinear regression showed of this study are translatable to page 15). ics predict clinical response to total hipstrong associations among gait patients of all age ranges,” Wim- arthroplasty. J Orthop Res 2017;35(2): mer said. “However, the impor- 366-376.14 04.17 lermagazine.com
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INCREASINGLY, lower extremity experts arebeing called on to assist with crime sceneinvestigations by analyzing footprints, shoe prints,and the gait patterns of shadowy figures on securityvideos. For members of this fledgling field, asSherlock Holmes famously said, the game is afoot.By Shalmali Pal “Come, Watson, come!” he cried. “The game is afoot. Not a word! Into your clothes and come!” – Sherlock Holmes, The Adventure of the Abbey GrangeThe in-person diagnosis of lower limb conditions, or assessing foot “The field of foot evidence is relatively new,” said John DiMag-and gait mechanics, is second nature to lower extremity practition- gio, DPM, ASFP, founder and president, and a retired podiatrist whoers. But what happens if the assessment required involves a foot has practiced in Arizona and Oregon. “Forensic podiatry can offerthat isn’t actually in the exam room—say, a shoe print embedded in additional information when a case isn’t conclusive, based onthe mud under a window, a footprint left in blood on a kitchen floor, anatomy, biomechanics, morphology, and pathology. We can offeror closed-circuit television (CCTV) footage of an otherwise uniden- more details about a person and his feet.”tifiable person walking away? ASFP currently has 25 practicing podiatrist members, along What kind of deductions could be made about the absentee with 15 podiatry residents and 70 students, both in podiatry and inowners of those shoes or feet, the way they walk, and—importantly— other disciplines (eg, anthropology, medical examiners), said DiMag-their potential level of involvement in a crime? That’s when forensic gio, who is a coauthor of the second edition of Forensic Podiatry:podiatry and gait analysis enter the scene. Principles and Methods.2 The now-deceased Norman H. Gunn, DPM, of Canada is cred- LER spoke with DiMaggio and other experts in the field aboutited with introducing the concept of forensic podiatry in the early what they do, how forensic podiatry and gait analysis work, and how1970s; about two decades later, an introductory article on the sub- lower extremity practitioners can become involved.ject appeared in the Journal of the American Podiatric Medical As-sociation.1 The Bandon, OR-based American Society of Forensic Footprints and footwearPodiatry (ASFP) was established in 2003, and four years later, aforensic podiatry subcommittee was established by the Hollywood, Although TV shows and mainstream media outlets tend to use theFL-based International Association for Identification (IAI). terms synonymously, there is an important distinction between foot- prints and shoe prints.lermagazine.com 04.17 17
Continued from page 17 court in 1996 because of legal technicalities, Krone was retried and found guilty once again, based on the bite marks but no other physical evidence. WhileFigure 1. A comparison of a footprint with a shoeprint left at the scene Krone was in prison (10 years overall, with two years on death row), his attor-of a crime. (Photo courtesy of John DiMaggio, DPM.) neys began reworking the case to prove his innocence. That’s when DiMaggio got involved. “If you are looking to match a suspect to a shoeprint, the foot examiner is the main person to go to,” ex- A shoe print estimated as coming from a men’s size 10 to 10.5 sneakerplained Michael Nirenberg, DPM, founder of Friendly was found at the crime scene, but this piece of evidence was not included inFootcare in Crown Point, IN, ASFP vice president, and a initial court cases. DiMaggio was called in by the defense attorneys to evaluatecontributing author to the Forensic Podiatry textbook. that shoe print and to make a cast of Krone’s foot. He submitted a report veri-“If you are looking to match a suspect to a potential fying that Krone’s shoe size was an 11 to 11.5 and that his foot could not havefootprint, then the forensic podiatrist is the right person fit into the shoe that left the incriminating print.for that. You need a knowledge of the foot to make thatcomparison.” The forensic podiatry evidence was part of the overall package, including new DNA evidence, that ultimately led to the conviction of the real killer and Footwear examination has become more prevalent brought about Krone’s release in 2002.3in crime scene investigation in the last two decades,and that expertise is typically limited to outsoles, DiMag- “Was the information about Krone’s foot the deciding factor that got hisgio agreed. conviction overturned? I wouldn’t say that,” DiMaggio said. “I think the foot analysis that I performed added to the weight of evidence.” “When I hear the word ‘footprint,’ I think of the footand not the shoe, and that’s where the podiatric expert- A high-tech field?ise lies. As a forensic podiatrist, I can still examine theoutsole, looking for heel wear or wear under the ball of While technologies such as 3D scanning have made inroads in the clinic, theythe foot, but I can also examine the upper of a shoe and haven’t quite caught on in forensic podiatry. That may be because the field issee where the wearer has a bunion deformity. Looking quite small and quite new, DiMaggio noted.only at the shoe’s outsole would not reveal that kind ofinformation.” But technology is part of its founders’ vision. Nirenberg proposed the use of a fiber-optic arthroscopic camera for examining the inside of a shoe. One case that was a win for forensic podiatry wasthe overturned conviction of Ray Krone, of Phoenix, AZ, “The insides of shoes and boots often contain wear patterns and impres-for the 1991 murder of a woman named Kim Ancona sions,” Nirenberg wrote in the Journal of Forensic Identification in 2008.4 “Thesein a local bar. His initial 1992 conviction was based pri- wear marks contribute to individuality and aid in linking a given shoe or boot tomarily on expert testimony that his teeth matched bite a specific person’s foot.”marks on Ancona’s breast and throat.3 Such wear marks may appear on the shoe’s insole or the upper, often in When that conviction was overturned by a state the form of an imprint left by the wearer’s foot. The inside of the footwear may also contain materials (eg, soil or blood) that could help place a suspect at a crime scene, Nirenberg explained. Traditional examination of the inside of footwear involved using a small den- tal mirror or cutting the footwear open—what Nirenberg called a “shoe autopsy.” To examine the inner shoe with an arthroscopic camera, he advised starting at the posterior aspect and working forward to the toebox, noting “the arthroscope will allow the relationship between the foot’s impression on the insole and on the toebox to be clearly seen.” Nirenberg told LER that arthroscopic examination also allows for preserva- tion of the footwear, along with a record of the exam process. “You can see a lot more detail with the fiber-optic camera,” he said. “You also can record the exam process in case the jury wants to see the inside of the shoe before it’s disassembled. The jury can see how you examined the in- side of the shoe and any impressions of the foot.” Going by the gait Gait analysis for forensic purposes is defined as “the analysis, comparison, and evaluation of human gait including the components and features of gait, to assist the process of identification or to answer any other legal question concerning gait,” according to Forensic Podiatry.2 “Gait analysis works with what we call ‘class characteristics.’ These are fea- tures that show consistency and compatibility, but are not unique,” explained Wesley Vernon, OBE, PhD, DPodM, coauthor of Forensic Podiatry and retired head of podiatry services at Sheffield Teaching Hospitals NHS Foundation Trust in England. “As such, gait analysis can be used with varying degrees of certainty to suggest how likely or unlikely it is that the unknown person captured on CCTV is the same [as a potential suspect].” These class characteristics include elements with which all lower extremity Continued on page 2018 04.17 lermagazine.com
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Continued from page 18 foot and ankle joint; neutral varus/valgus knee; and very little pelvic rotation.” Once a suspect was picked up by the police, the gait analysis of the per-Figure 2. The FBI Bureau Reference Scale, developed by the agency’sfootwear examiners, is considered the gold standard for determining petrator on the footage was deemed a positive match with another gait analysissize from an image. (Photo courtesy of John DiMaggio, DPM.) of a suspect by Larsen’s group. The gait analysis was further bolstered by a pos- ture analysis, leading Larsen’s group to conclude “the perpetrator and suspectpractitioners are familiar—the gait cycle, including might well be identical to each other, but we stressed that these methods didstance and swing phases; single- and double-support not constitute identification in terms of...DNA typing or fingerprinting.”phases; and any deviations from a typical gait cycle be-cause of functional anomalies and compensation from That is one of the crucial points to remember with forensic gait analysis:underlying pathologies.1 It’s a tool that can help increase the likelihood of pinpointing a suspect, but it cannot make a definitive identification or offer information beyond the limits of In 2007, Peter K. Larsen, PhD, a researcher in the the lower extremities. For instance, when asked if gait analysis could be usedsection of forensic pathology, department of forensic to corroborate an eyewitness statement regarding a person seen fleeing amedicine, at the University of Copenhangen in Den- scene, potentially confirming or refuting that account, Vernon answered “yes,”mark, and colleagues published a checklist for forensic but cautioned that the witness statement would have to include some descrip-gait analysis in the Journal of Electronic Imaging.5 Lower tion of the suspect’s gait.extremity areas of interest for forensic gait analysis are: “Forensic gait analysis utilizes our knowledge of gait and, as such, a forensic • General: Long or short steps, stiff or relaxed, signs gait analyst would not report on height, weight, etc, with their opinions beingof pathology restricted to areas that fall within their own particular expertise,” he wrote in an email. • Feet/ankle joint: Outward rotation, inversion/ever-sion, degree of “push-off” at toe-off Other researchers offered similar caveats. A 2016 paper in the Journal of Forensic Sciences noted that analysis of gait patterns from CCTV footage, paired • Knee: Varus/valgus, knee flexion during stance with photogrammetry (the science of making measurements from photographs), • Hip/pelvis: Abduction/adduction, rotation, tilt were important but challenging forensic tools. By way of example, the authors These elements are then paired with upper body tested the feasibility of 3D reconstructions for forensic gait analysis, and foundassessments, such as positioning of the shoulder, neck, considerable interobserver variability in data interpretation.6and head. Larsen’s group applied this checklist to help solve Larsen’s group stressed that “in our work, we have both overt and coverta 2004 bank robbery in Noerager, Denmark. They an- recordings of the subject. There might be a potential problem in using overtalyzed CCTV footage of the perpetrator walking in and recordings if the suspect consciously tries to modify the gait pattern duringout of the bank and standing during the robbery. They recording...at present, we do not find it possible to positively identify a perpe-started by evaluating the general characteristics of the trator based on image analysis.”person’s gait and then analyzing each of the joint rota-tions. They noted the person on the footage had a “stiff Ultimately, forensic gait analysis data are only as good as the footage pro-gait with ‘heavy’ feet; marked outward rotation in the vided for that evaluation, the experts agreed. Larsen explained to LER in an email that the frequencies of oscillations during normal walking range up to 6 Hz, so the 12 Hz to 15 Hz frequency that modern CCTV units use should be more than sufficient to clearly capture even the quickest ambulator. In a 2014 study in Science and Justice, Vernon and colleagues showed that CCTV frame rate, which can vary from 25 frames per second to one frame every four seconds, can affect the ability of even the most experienced practitioners to identify gait characteristics on that footage. “Every effort should therefore be made to ensure that CCTV footage likely to be used in criminal proceedings is captured at as high a frame rate as pos- sible,” they noted.7 Vernon acknowledged that new technologies, such as digital media, can be helpful for playing back an image at multiple speeds or looking at multiple images simultaneously on a single screen. “Computer engineers are working on developing approaches that will do automatic gait analyses and comparisons, but these haven’t yet been developed to the point where they can be used in [forensic] practice,” he noted. Data on what does and doesn’t work for forensic gait analysis can be used to inform where cameras are placed in public venues. Larsen’s group found most gait features can be examined using a frontal camera view and another in profile to record joint and segment angles in the sagittal plane. Some venues also have a camera positioned overhead to provide a transverse view of a per- petrator; this view can be helpful for assessing the degree of rotation of the feet and step length, but in general, is not as useful as the frontal view, Larsen said. Vernon added that proper storage of high-resolution footage is always im- portant to maintain the integrity of the evidence and support any related gait analysis. Continued on page 2220 04.17 lermagazine.com
Continued from page 20 On solid footing?Figure 3. A shoeprint compared with a cast of a foot, used to illustrate Where does forensic podiatry fit into the overall landscape of usable or permissiblethat a suspect’s foot was too big to fit into the specific shoes associ- evidence for solving a crime? Ruth Morgan, DPhil, director of the University Collegeated with a crime. (Photo courtesy of John DiMaggio, DPM.) London Centre for Forensic Sciences, specializes in trace evidence dynamics, or “understanding the behavior of trace evidence in different contexts and within dif- ferent environments over space and time,” and the interpretation of evidence.8 “Footprint and gait analysis are most aligned with other pattern-based forms of evidence [like blood pattern analysis, for example],” Morgan told LER by email. “Our trace evidence dynamics work looks at trace evidence [particulates such as soils, gunshot residue, and other traces such as trace DNA] and how it transfers, persists, and is preserved under different environmental conditions.” For instance, Morgan’s group authored a recent study in Forensic Science International that evaluated the generation of footwear marks in blood.9 They re- ported that “footwear tread effects were also dependent on blood type, but the type of flooring did not affect the appearance of the mark.” “The study first looked at whether there was a difference in replicating a case scenario in which a blood mark was purported to have been made by a shoe making contact with a blood drop on the floor,” she explained. “We tested human and animal blood, and the results were not consistent when the other variables remained the same. In comparison, if the same blood type was used, the type of flooring material did not appear to affect the blood pattern.” As with all evidence, data gleaned from forensic podiatry and gait analysis needs to fit into the big picture, Morgan added. “Our interpretation of evidence work looks at the whole forensic science process—from crime scene, to laboratory analysis, to the interpretation of that evidence and its presentation as intelligence [to investigators] or as evidence [in court],” she said. Forensic podiatry has a connection with the US Supreme Court, thanks to the Daubert standard.10 In his chapter in Forensic Podiatry,1 Nirenberg wroteTHE NEW MODULARGAIT ANALYSIS PLATFORM Human Gait Analysis Made Easy! Force & Pressure Data Temporal & Spatial Parameters Track Patient Progress LEARN MORE WWW.TEKSCAN.COM/STRIDEWAY-LER22 04.17 lermagazine.com
that the highest court in the land “explained in Daubert that evi- for validating forensic podiatry as a subspecialty.”dence is admissible under [Federal Rules of Evidence 702: Testi- The case also highlights the fact that lower extremity profes-mony by Expert Witnesses] if ‘it rests on a reliable foundation and isrelevant.’” sionals with an interest in the field cannot rely solely on their med- ical expertise—a knowledge of crime scene investigation tech- In a 2014 case in Mt. Morris, WI, Robert Kasun was found mur- niques, the criminal justice system, and the basics of forensic sci-dered in a hotel room.11 Investigators arrested Travis L. Peterson, ence are essential.who was staying in the room next to Kasun’s, and he was chargedwith first-degree intentional homicide. At the crime scene, blood “Interpreting elements of the foot is not like DNA or a finger-was found near the body, and chemical enhancement revealed a print in terms of how definitive it is,” DiMaggio noted. “It’s importantfootprint. Nirenberg was asked for his expert opinion—could the that podiatrists understand how to interpret evidence within thebloody footprint have been made by Peterson? context of the criminal justice system.” Nirenberg’s forensic podiatry analysis and report showed com- To that end, the ASFP has plans to offer in-person seminars andmonality between Peterson’s foot and the footprint, including the webinars in the future.shape of the toes. Nirenberg noted the bloody footprint exhibited adark ridge on the second and third toes, which matched the mor- “It’s important to have the forensics foundation, and understandphology of Peterson’s actual foot. The pattern made the footprint how forensics do and don’t apply to issues of the foot that we asunique to Peterson, according to Nirenberg. podiatrists are more accustomed to dealing with,” Nirenberg said. The defense attorneys challenged the validity of the forensic po- In the meantime, podiatrists who would like to learn more candiatry findings, so a Daubert hearing was held to determine if the foot- visit the resources library at ASFP, or consider courses givenprint analysis, and Nirenberg’s testimony, was admissible. The judge through the IAI, the American Academy of Forensic Sciences, orin the case green-lighted both, and Nirenberg testified at the Peterson the American Board of Criminalistics. The New York College of Po-trial. Peterson was found guilty and sentenced to life in prison. diatric Medicine in New York City, Temple University School of Po- diatric Medicine in Philadelphia, and Barry University School of “This was the first instance of forensic podiatry being the pri- Podiatric Medicine in Miami Shores, FL, also have set up forensicmary subject of a Daubert hearing,” Nirenberg wrote in a 2016 podiatry groups for their students.Journal of Forensic Sciences case report.12 “The hearing resulted inthe court ordering this evidence admissible. The expert’s testimony “We have very good, dedicated DPM members,” DiMaggiocontributed to the suspect’s conviction. It’s a win for forensic podi- noted. “It’s at the student level that we have to get people interestedatry, because that Daubert hearing showed that the evidence met if we are going to grow this field.”the Supreme Court standards. In that sense, it’s an important step Shalmali Pal is a freelance writer based in Tucson, AZ. References are available at lermagazine.com.lermagazine.com 04.17 23
MANY SPORTS, ONE GOAL: Joining forces for injury prevention Athletes in all sports—from gymnastics to volleyball to running—struggle with injuries, and that means injury prevention is top of mind for the global community of sports medicine researchers and clinicians. In March, those experts convened in Monaco at the IOC World Conference on Prevention of Injury and Illness in Sport to develop strategies for taking sports injury prevention to the next level. LER’s exclusive coverage of this event focuses on lower extremity injuries, from ankle sprains to hamstring strains. All articles by Jordana Bieze FosterShutterstock.com #17162604826 Sports injury prevention experts revisit risk factors and advocate for adherence27 Online counseling helps reduce injuries in highly specialized youth athletes28 Proximal and distal factors may affect 5th met fracture risk in soccer players29 By itself, zero drop in a running shoe does not translate to barefoot-like gait30 Landing biomechanics may contribute to ankle sprain in basketball, volleyball lermagazine.com 04.17 25
Sports injury prevention experts revisitrisk factors and advocate for adherenceDespite strides, gaps between lab and practice remainIt’s an exciting time for clinicians involved researchers presenting their latest findings, Shutterstock.com 39962635in preventing sports injuries. Increasing and attendees commiserating and collabo-numbers of studies are identifying risk fac- rating during coffee breaks. Designing effective interventions basedtors associated with specific injuries and on identified risk factors, it turns out, is notdocumenting the effectiveness of preven- Wrestling with risk factors as straightforward as experts had hoped.tive interventions for reducing injury rates. The reasons for this were explored in an- As most sports medicine professionals are other keynote presentation by Roald Bahr, But in many ways, it’s also a confusing well aware, the model for sports injury pre- MD, PhD, professor in the Department oftime, especially when it comes to designing vention1 introduced by van Mechelen and Sports Medicine at the Norwegian School ofand refining evidence-based interventions. colleagues in 1992 proposes that, after Sport Sciences, chair of the Oslo SportsStudies can identify risk factors associated identifying the need to reduce the risk of Trauma Research Center, and head of thewith an injury, but that doesn’t necessarily a particular injury (step 1), researchers Aspetar Sports Injury & Illness Preventionmean those risk factors actually contribute should identify risk factors and mecha- Programme in Doha, Qatar.to the injury or that targeting those risk fac- nisms that contribute to that injury (step 2),tors will reduce injury rates. Other studies after which they should develop preventive The idea that identified risk factorscan demonstrate a preventive benefit of an interventions (step 3), and rigorously eval- should be used to screen athlete popula-intervention without offering any insight uate the effect of each intervention (step 4). tions for those at the highest risk, and thatinto why it works, or why it works for some interventions should be implementedathletes, but not others. But Willem van Mechelen, MD, PhD, based on risk factor based cutoffs, is par- now a professor of occupational and sports ticularly problematic, Bahr said—echoing Such gaps between the sports injury medicine at Vrije Universiteit in Amster- the theme of a 2016 paper he published inprevention literature and clinical practice dam, opened the conference with a the British Journal of Sports Medicine.2are not as wide as they once were, but still keynote speech noting many ways in whichrepresent significant challenges for re- sports injury prevention has turned out to “Identifying risk factors does not meansearchers and clinicians alike. During the be more complicated than he and his col- we can identify players at risk,” Bahr said.triennial IOC World Conference on Pre- leagues envisioned. For one thing, therevention of Injury and Illness in Sport, held have been far more papers published on As an example, he cited a 2004 studyin Monaco in March, this theme was re- topics related to steps 1 and 2 of the in which athletes with a history of hamstringvisited continually—by keynote speakers, model than those related to steps 3 and 4. injury were 7.42 times more likely to suffer a future hamstring injury than those with no Shutterstock.com 194392007 history.3 Despite the impressive odds ratio, Bahr pointed out, only 10 of the 19 ham- string injuries in that study occurred in ath- letes with a history of injury, so screening based solely on that risk factor would have missed nearly half of the athletes who ended up being injured. “When screening for injury risk, statis- tically significant association is not the same as prediction,” Bahr said.26 04.17 lermagazine.com
In Monaco, this theme was revisited iStockphoto.com 152026009 single-leg drop vertical jumps, single-legmultiple times during oral research presen- hops, and side stepping), but knee flexiontations on risk factors, particularly those re- Moores University in the UK found that angle at initial contact, peak knee abduc-lated to lower extremity injuries. most anterior cruciate ligament (ACL) risk tion moment (KAM), and peak vertical factors are more strongly correlated with ground reaction force had low to moderate In a study of 306 youth basketball and some tasks than others.5 In 41 female ath- correlations.floorball players, researchers from the UKK letes, knee abduction angle at initial con-Institute for Health Promotion in Tampere, tact had moderate to good correlations Continued on page 28Finland, analyzed frontal plane projection across multiple dynamic tasks (bilateral andangle during single-leg stance at baselineand then assessed new time-loss injuriesfor 12 months.4 They found that a frontalplane knee projection angle greater thanone standard deviation above the meanwas associated with a 5.57 times higherrisk of lower extremity injury and a 2.37times higher risk of ankle injury. But first author Anu Raisanen, PT, PhD,project coordinator for the Tampere Re-search Center of Sports Medicine, cautionedconference attendees in Monaco to considerthe findings in light of Bahr’s comments. “As you know, an association does notequal prediction,” Raisanen said. “So wehave to keep that in mind. Most likely, wecan use this [information] in combinationwith other factors.” Although a risk factor that is consistentacross dynamic tasks would be ideal for in-jury prediction, a study from Liverpool JohnOnline counseling helps reduce injuriesin highly specialized youth athletesEarly single-sport specialization in youth ath- ing at an age younger than 12 years, and to Istockphoto.com #465924830letes is associated with increased risk of train for more than eight months of the year.reinjury in addition to primary injury, but on- recommendations to take one day off fromline counseling can help to reduce those “Young athletes were more likely to de- sports per week, and to keep the number ofrisks, according to two studies from Atlanta velop a reinjury at follow-up if they had a hours of sports participation per week topresented at the IOC World Conference on high degree of specialization,” Jayanthi said. less than the athlete’s age. They were leastPrevention of Injury and Illness in Sport, held compliant with the recommendation that thein Monaco in March. In a separate study, also presented by ratio of hours spent in organized sports ver- Jayanthi, the Emory researchers assessed the sus free play should be less than 2:1. Both sets of findings were presented by effectiveness of an online counseling programNeeru Jayanthi, MD, a sports medicine designed to educate youth athletes about as- “We can’t change people’s decisions,”physician at the Emory School of Medicine, sociations between sport specialization and Jayanthi said. “What we try to do is providewho was the first author of a 2015 study that injury risk, as well as provide evidence-based information.”made headlines with its conclusion that in- recommendations to reduce that risk. Ath-jury risk was twice as high for highly special- letes between ages 8 and 17 years were ran- Sources:ized youth athletes than in those who domized to a group that received onlineparticipated in multiple sports. counseling or to a control group; both groups Jayanthi N. Sports specialized risks for reinjury in were monitored for one year. young athletes: A 2+ year clinical prospective evalu- In Monaco, Jayanthi presented three- ation. Br J Sports Med 2017;51(4):333.year follow-up results for the same popula- Injured athletes accounted for similartion, including the finding that nearly 70% of percentages of each group at baseline. At Jayanthi N. The effects of serial sports training risk as-the reported injuries were reinjuries (approx- six months, however, athletes in the inter- sessment and counseling in kids (TRACK). Br J Sportsimately half of which were in the same loca- vention group had a significantly lower injury Med 2017;51(4):333-334.tion as the previous injury). Risk of reinjury rate than those in the control group (27.7%was more than three times higher in youth vs 48%). Jayanthi NA, LaBella CR, Fischer D, et al. Sports-spe-athletes who were highly specialized than in cialized intensive training and the risk of injury intheir more diversified counterparts. Injured “We do think there’s opportunity to do young athletes: A clinical case-control study. Am Jathletes were more likely than uninjured ath- serial online counseling, and we do think it Sports Med 2015;43(4):794-801.letes to be female, to have started specializ- can be as effective as smoking or weight loss counseling,” Jayanthi said. Athletes were most compliant with the lermagazine.com 04.17 27
Continued from page 27 Shutterstock.com 558434407 seem to support the use of multimodal in- terventions, such as the 11+ warm-up pro- “We all think a high load will be a high Multimodal mysteries gram (formerly known as the FIFAload regardless of the task, but we can see 11+)—and, in fact, such programs havethis is not the case,” said Raihana Sharir, a The challenge of making the jump from been associated with reductions in injurydoctoral student in the university’s Institute identifying risk factors to preventive inter- rates, most recently a 4.25-fold decreasefor Sport and Exercise Science, who pre- vention wasn’t the only one mentioned by in ACL injuries in elite male soccer players.8sented the findings in Monaco. “One vari- van Mechelen in his keynote presentation.able can’t tell us everything.” The increasing evidence that few injuries In such situations, however, researchers can be traced to a single risk factor would A second presentation from theFinnish group provided a more detailedanalysis of a study published earlier thisyear, in which stiff landings were associatedwith ACL injury risk in 171 young femalebasketball and floorball players.6 In theMonaco presentation,7 peak hip flexionduring landing from a vertical drop jumpwas negatively associated with noncontactACL injury risk, with a hazard ratio of .6. However, the area under the receiveroperating curve for that risk factor was .54,suggesting that it would be nearly as likely topredict a false positive result as a true positiveresult, said Mari Leppanen, PhD, a researcherin the Tampere Research Center of SportsMedicine and first author of both studies, whopresented the findings in Monaco. “We are nowhere near saying we canpredict ACL injury based on hip flexion,”Leppanen said.Proximal and distal factors may affect5th met fracture risk in soccer playersClinicians looking to prevent fifth meta- Meanwhile, a second study from Ju- Shutterstock.com 206261488tarsal fractures (Jones fractures) in soccer tendo University, also in Tokyo, found sig-players may want to consider proximal as nificantly reduced hip internal rotation— Sources:well as distal factors, according to studies which can also lead to lateralization of Matsuda S, Hirose N, Fukubayashi T. The risk factorsfrom two separate Japanese research plantar loads—in athletes with a history of of fifth metatarsal stress fracture in football players.groups presented at the IOC World Con- fifth metatarsal fracture compared with Br J Sports Med 2017;51(4):357.ference on Prevention of Injury and Illness those with no such history. Saita Y, Nagao M, Kobayashi Y, et al. Restriction inin Sport, held in Monaco in March. hip internal rotation and fifth metatarsal stress frac- Researchers reviewed baseline bio- tures (Jones fracture) in professional football players. A prospective study from Waseda mechanical assessments for 20 profes- Br J Sports Med 2017;51(4):380.University in Tokyo found that fifth sional soccer players who went on tometatarsal fracture was associated with experience a fifth metatarsal fracture andlateralized plantar pressures during a heel 40 players who did not. Hip internal rota-raise and structural variables that also con- tion was significantly more limited in thetribute to load lateralization. injured players than the uninjured players, and in the injured players was also more Investigators prospectively assessed limited in the hip corresponding to the in-310 male collegiate soccer players and jured foot than on the contralateral side.followed them for one year. Those whowent on to suffer a fifth metatarsal fracture The reduced hip internal rotation canwere more likely to load the lateral aspect lead to supination and lateralization ofof both feet during standing weightbearing load in the foot, increasing the risk of fifththan those who were not injured. In addi- metatarsal fracture, said Yoshimoto Saita,tion, the injured foot was associated with MD, PhD, a researcher in the university’smore lateralized plantar pressures during department of orthopedics and sportsheel raises at baseline than the contralat- medicine, who presented his group’s find-eral foot. ings in Monaco.28 04.17 lermagazine.com
often have no way of knowing which as- By itself, zero drop in a running shoepects of such multimodal interventions are does not translate to barefoot-like gaitactually driving the outcomes. And the pic-ture gets even more complicated when iStockphoto.com 511135767 However, methodological aspects ofone considers that, even if an intervention the study may have affected the outcomes,is effective across a group of athletes, there A zero drop is not enough to notably alter he noted.will almost always be some athletes within the biomechanics of running in a cush-that group who respond positively and ioned shoe but may affect injury risk in “We looked at shoe drop influence forsome who do not. some runners, according to research from normally cushioned shoes. It might be dif- Luxembourg presented at the IOC World ferent if the zero-drop shoes were actually This was underscored in Monaco by a Conference on Prevention of Injury and Ill- barefoot-like,” Theisen said. “[Also] this ispresentation from the University of Delaware ness in Sport, held in Monaco in March. not a within-subject comparison for differ-in Newark, in which collegiate women’s soc- ent shoe models; we compared differentcer players performed the 11+ warm up at The findings suggest that, although groups wearing different shoes. This mayleast three times per week for two seasons.9 barefoot running by definition involves a make it more difficult to see results.”On average, peak KAM did not change over zero drop from the heel to the toe, othertime for the intervention group or a control design features may play a bigger role in In addition to the subgroup gait analy-group. However, 14 of 39 players in the 11+ determining the extent to which minimalist sis, the researchers also followed up withgroup did demonstrate a decrease in peak running shoes are associated with bare- all of the study participants with regard toKAM; those athletes had smaller hip flexion foot-like gait. injuries sustained during six months of run-moments and hip adduction moments than ning in the experimental shoes. For thethe nonresponders, said Amelia Arundale, Investigators from the Luxembourg In- group overall, shoe drop was not signifi-PT, DPT, a physical therapist and research as- stitute of Health randomized 553 runners cantly associated with injury risk.sistant at the university who presented the to six months of running while wearing onefindings in Monaco. of three experimental cushioned shoe However, in occasional runners (those styles that differed only in terms of shoe who said they had fewer than six monthsChasing adherence drop: 0, 6, or 10 mm. The zero-drop of regular running practice in the year prior shoes had a 21-mm cushion in both the to the study) shoes with a drop of 0 or 6Of all the challenges involved in sports in- toe and heel. mm were associated with a lower injuryjury prevention, perhaps the most vexing risk than shoes with a 10-mm drop (hazardfor van Mechelen is that even the best in- Gait was assessed in a subset of 59 ratio [HR] = .48). And in those who rantervention will not be effective if athletes participants at baseline and after five months more regularly, the two lowest shoe dropdon’t actually complete it. Too few interven- or 500 km as they ran on a treadmill at a categories were associated with a highertion studies assess athlete adherence, he self-selected speed. Changes from baseline injury risk than the 10-mm shoes (HR =noted—likely because it isn’t easy to docu- did not differ significantly between groups 1.67).ment objectively, and self-reported adher- for any of the gait variables measured ex-ence is likely to be inflated. But there’s no cept for knee abduction angle at midstance, “It seems safe to recommend low-dropquestion that it makes a difference. which decreased by 1° in the zero-drop shoes for occasional runners but not regu- group but increased by 1° in the 6-mm lar runners,” said Laurent Malisoux, PhD, a In a 2011 randomized controlled trial group and by .7° in the 10-mm group. researcher at the institute, who presentedfrom the Netherlands, for example, only the injury risk findings in Monaco.23% of athletes in the intervention group Although the changes over time werewere fully compliant with a neuromuscular statistically significant, they were still very Sources:training program designed to prevent ankle small in magnitude, noted Daniel Theisen,sprain recurrence.10 Although the program PhD, head of the Sports Medicine Re- Malisoux L, Chambon N, Urhausen A, Theisen D. Ishad no effect on the group as a whole, the search Laboratory at the Luxembourg In- shoe drop a key factor for injury prevention in run-relative risk of an ankle sprain was signifi- stitute of Health, who presented the ning? Part 1: An RCT on injury risk. Br J Sports Medcantly lower in those who were adherent biomechanics outcomes in Monaco. 2017;51(4):355.compared with those who were not, as wellas compared with those in the control group. “We have to ask if this [knee abduc- Theisen D, Gette P, Chambon N, et al. Is shoe drop a tion] is clinically meaningful at all, and I’m key factor for injury prevention in running? Part 2: An “We can design interventions, and we not so sure,” Theisen said. RCT on running biomechanics. Br J Sports Medknow they are effective. But typically we 2017;51(4):393-394.have lousy adherence, which affects injuryoutcome,” van Mechelen said. The good news is that a growing num-ber of sports injury prevention studies—including several presented in Monaco—are confirming that better adherence isassociated with better outcomes. Continued on page 30 lermagazine.com 04.17 29
Continued from page 29 Researchers from Waseda University lower extremity injuries. Br J Sports Med 2017;51(4): in Tokyo reported an impressive 89% 375-376. In a study of more than 2400 youth compliance rate among the 189 collegiaterugby players,11 researchers from the Uni- women’s basketball players assigned to an 5. Sharir R, Vanrenterghem J, Robinson M, et al.versity of Bath in the UK found that a pre- education and hip-focused neuromuscular What separates an individual at risk of ACL injury? Aventive exercise program was associated training program designed to reduce ACL first step towards an ACL-risk movement passport. Brwith a 15% reduced risk of match-related injuries.13 The incidence of ACL injury was J Sports Med 2017;51(4):387.injuries compared with controls, which was .08/1000 athlete exposures in the inter-not a statistically significant difference. vention group, compared with .25/1000 in 6. Leppanen M, Pasanen K, Kujala UM, et al. StiffHowever, in players who completed the a control group. landings are associated with increased ACL injury riskprogram at least three times per week, the in young female basketball and floorball players. Amrelative risk of match injury was reduced The high level of adherence, however, J Sports Med 2017;45(2):386-393.by 72%, according to Michael Hislop, MSc, won’t help the Japanese researchers de-a doctoral student at the university who termine whether the intervention’s effec- 7. Leppanen M, Pasanen K, Krosshaug T, et al. Land-presented the findings in Monaco. tiveness was related to changes in ing with less hip flexion is associated with increased biomechanics, since those were not as- risk of ACL injuries in young female team sports play- In analyzing the effectiveness of the sessed, noted Yorikatsu Ohmi, RPT, MS, a ers. Br J Sports Med 2017;51(4):349.11+ warm-up program for reducing injury researcher at the university who presentedrisk in collegiate men’s soccer players, the the findings in Monaco. 8. Silvers-Granelli HJ, Bizzini M, Arundale A, et al.Delaware research group found four teams Does the FIFA 11+ injury prevention program reducehad low compliance (1-19 sessions per sea- Sports injury prevention has evolved con- the incidence of ACL injury in male soccer players?son), 14 teams had moderate compliance siderably since van Mechelen’s model was in- Clin Orthop Relat Res 2017 Apr 7. [Epub ahead of(20-39 sessions), and nine teams had high troduced, but at least one theme has remained print]compliance (40 or more sessions).12 Overall the same: Nothing is ever simple.injury rate was 6.39 per 1000 athlete expo- 9. Arundale A, Silvers-Granelli H, Marmon A, et al.sures in the high compliance group, Sources: Biomechanical changes with FIFA 11+ utilization over8.55/1000 in the moderate group, and 1. Van Mechelen W, Hlobil H, Kemper HC. Incidence, multiple soccer seasons. Br J Sports Med 2017;10.35/1000 in the low group. Differences severity, aetiology, and prevention of sports injuries. 51(4):287.between the groups were statistically signif- A review of concepts. Sports Med 1992;14(2):82-99.icant, according to Holly Silvers-Granelli, 2. Bahr R. Why screening tests to predict injury do 10. Verhagen EA, Hupperets MD, Finch CF, et al. TheMPT, a doctoral student at the university not work – and probably never will…: a critical review. impact of adherence on sports injury prevention ef-who presented the findings in Monaco. Br J Sports Med 2016;50(13):776-780. fect estimates in randomized controlled trials: Look- 3. Arnason A, Sigurdsson SB, Gudmundsson A, et al. ing beyond the CONSORT statement. J Sci Med Sport Risk factors for injuries in football. Am J Sports Med 2011;14(4):287-292. 2004;32:5S-16S. 4. Raisanen A, Pasanen K, Krosshaug T, et al. Asso- 11. Hislop M, Stokes K, Williams S, et al. The efficacy ciation between frontal plane knee control and acute of a movement control exercise program to prevent injuries in youth rugby: A cluster-randomised con- trolled trial. Br J Sports Med 2017;51(4):329-330. 12. Silvers-Granelli H, Bizzini M, Arundale A, et al. Does higher compliance to the FIFA 11+ injury pre- vention program improve overall injury rate in male soccer (football) players? Br J Sports Med 2017;51(4): 388-389. 13. Ohmi Y, Hirose N. Effects of a prevention program focused on hip joint function on the incidence of an- terior cruciate ligament injuries in female basketball players. Br J Sports Med 2017;51(4):366-367.Landing biomechanics may contributeto ankle sprain in basketball, volleyballTwo studies presented at the IOC World researcher who presented the findings in Shutterstock.com 64514659Conference on Prevention of Injury and Ill- Monaco.ness in Sport, held in Monaco in March, ing rehabilitation, we should take into ac-shed light on the complex ways in which In addition, video analysis revealed count knee position as well as ankle posi-aspects of landing contribute to risk of that inversion ankle sprains during landing tion during landing,” said Maria Antonioankle sprain in volleyball and basketball— did not typically occur with the ankle in Castro, PhD, a researcher with the insti-both sports in which ankle sprains often plantar flexion—a finding that runs counter tute, who presented her group’s findingsoccur when one player lands on another’s to popular belief among many ankle in Monaco.foot. sprain experts. Sources: Because ankle sprains occur so “Typically ankle plantar flexion at ini- Skazalski C, Kruczynski J, Bahr MA, et al. Landing re-quickly that patient recall about the mech- tial contact involves relatively neutral in- lated ankle injuries do not occur in plantar flexion asanism of injury is often unreliable, re- version-eversion. As the ankle moves once thought: A video analysis of ankle injuries insearchers from Aspetar Orthopedic and toward dorsiflexion, it rapidly everts. But world-class volleyball from the FIVB injury surveil-Sports Medicine Hospital in Doha, Qatar, the inversion actually does not occur dur- lance system. Br J Sports Med 2017;51(4):389.analyzed video footage of ankle sprains ing plantar flexion,” Skazalski said. Castro MA, Fernandes O, Janeira MA, VencesBritosustained by 24 elite male volleyball play- A. How important is knee position on landing forers for a more detailed analysis by five ex- Researchers from the Polytechnic In- ankle sprain? Br J Sports Med 2017;51(4):303.perts. stitute of Coimbra in Portugal analyzed landing mechanics in basketball players, In most cases, attacking players who jumped onto an unstable surface torather than blockers were to blame for in- simulate landing on another player’s foot.juries—including back row attackers land- Players with a history of ankle spraining their front-row teammates, a situation landed in greater knee extension at initialthat had not been previously reported in contact than those with no history ofrelation to ankle sprains, according to ankle sprain; this difference was particu-Christopher Skazalski, PT, DPT, an Aspetar larly pronounced in women. “Not only for prevention but also dur-30 04.17 lermagazine.com
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Protocol helps improve TKA outcomes, cut costsShutterstock.com 171517952 A multidisciplinary joint replacement pro- As healthcare evolves and patients shop gram is improving patient outcomes, de- for the best outcomes at the lowest cost, multidisciplinary TKA programs will be creasing complications, and shortening positioned to provide results and savings. hospital stays, which helps to lessen clini- cal anguish following total knee arthro- plasty as well as the financial burden on patients and the healthcare system. By Katie Mullen, SPT; Jon R. Cook, PT, DPT; Meghan Warren, PT, MPH, PhD; and Tarang Jain, PT, PhD, DPT Yelling and groaning. Those of us who have ever been in a physical therapy (PT) clinic while a patient’s knee is being stretched following a total knee arthroplasty (TKA) have all heard the sounds that come with such an intensive process, and if you have ever been that pa- tient, you know the pain that comes with it. Although this may make TKA sound like a procedure to avoid, these surgeries have become increasingly popular over the last two decades. The life expectancy of our population continues to in- crease, as does the incidence of degenerative joint diseases and the demand for TKAs from patients, as these procedures have been shown to increase quality of life and decrease pain.1 It is projected that 3.5 million TKAs will be performed annually by 2030.2 As the demand for these surgeries has increased, improve- ments in surgical technique, decreased complications, and earlier rehabilitation have contributed to the increased success of TKAs. But with the increase in success, technology, and demand comes an increase in price, as costs associated with TKA have also risen over the last 20 years.1 Unfortunately for hospitals and healthcare providers, the rise in cost does not always match the rate of reim- bursement. In 2006, the national average charge for total hip and knee arthroplasties was $38,447, but the national average reim- bursement was $11,916. This disparity may lead to a decrease in the number of hospitals offering total joint replacements,3 which will pose a problem to our healthcare system if supply cannot match demand. Therefore, there is an increasing need to make TKAs more cost-effective. Physical ther- apists have a vital role to play in ensuring positive patient outcomes following TKA and in decreasing costs to the healthcare system. Physical therapy and TKA Physical therapists are involved throughout the recovery process following TKA, from acute postoperative care to outpatient dis- charge. The hospital discharge goal is a safe return to the homelermagazine.com 04.17 33
Continued from page 33 The Verde Valley JRP iStockphoto.com 154932354 Physical therapists and other healthcare providers at the Verde Val- ley Medical Center (VVMC) in Cottonwood, AZ, in response to thewith referral to appropriate rehabilitation resources. This requires a variability in TKA rehabilitation and the need for more preoperativepatient to have functional mobility, which is typically gained through education, have developed a joint replacement program (JRP) thatearly mobilization. Aggressive PT following a total joint replacement aims to improve patient outcomes and decrease complications, withhas been proven effective;4 even elderly patients can tolerate and the goal of a safe discharge to the home.3 The JRP involves a multi-achieve increased functional ability through early, aggressive PT. Ad- disciplinary team of healthcare professionals, the patient, and theditionally, PT immediately following a total hip arthroplasty (THA) has patient’s family. The program includes a preoperative class, standardbeen shown to decrease costs and increase the likelihood of a pa- pathways for medical care, comprehensive perioperative pain man-tient being discharged home.4 agement, aggressive PT, and proactive discharge planning.3 However, variability still exists in the initiation and intensity of The preoperative class aims to reduce anxiety and increasePT following such procedures.4 A 2015 systematic review of ran- awareness of postoperative recovery, and includes the patient indomized controlled trials by Artz et al found that following TKA, out- goal setting and hospital discharge planning. Through this class, thepatient exercise therapy was initiated between two and 12 weeks patient learns about details of the procedure, the benefits of thepostsurgery. The evidence supports the short-term effectiveness of aggressive rehabilitation program, appropriate pain managementPT after TKA with regard to decreased pain, improved function, and strategies, exercises provided by the physical therapist, and goalsimproved knee range of motion (ROM). There remains, however, a to be achieved prior to hospital discharge.3need to increase patient education prior to surgery so individualshave a greater awareness of what recovery will entail.5 Research In agreement with evidence supporting the functional benefitssuggests patient expectations are significantly associated with total of early PT following TKA, the JRP includes initiation of PT betweenjoint replacement outcomes.6-9 two and four hours postsurgery. During this visit, the physical ther- apist evaluates the patient and then begins exercises. Rehabilitation first focuses on gait training, bed mobility, balance, closed kinetic chain (CKC) exercises, and ROM, while abiding by precautions. In subacute rehabilitation, exercises are progressed to include increas- ing ROM, isometric and CKC exercises to improve strength, advanc- ing gait training, stationary biking, and walking on the treadmill. Postacute exercises focus on enabling the patient to return to pre- vious activities; this is accomplished by continuing to increase ROM, performing open kinetic chain exercises for strengthening, improv- ing single-leg balance, introducing pool therapy, and employing task-specific movements. Starting the day after surgery, the patient is seen by a physical therapist twice per day in a group setting, and continues to work toward the PT goals of being able to safely trans- fer independently, walk more than 150 feet, and complete a home- exercise program; achieving these goals contributes to the determination of discharge readiness.3 Discharge data Safe discharge to the home is not only a goal of the JRP; in our clin- ical experience, it is also most often the primary goal of patients, and a significant contributor to decreased costs to the healthcare system. El Bitar et al noted that a 1974 study reported the average length of a hospital stay following total joint replacement was 23 days; that number has now decreased to an average in the US of 3.7 days.1 Data we collected from April 2006 to November 2007, which assessed the effectiveness of the JRP at six-month follow-up, showed an even shorter average length of stay for the 74 included patients. Discharge within two days was achieved by 53% of pa- tients, 39% went home within three days, and 7% were discharged within four days. The average length of stay was 2.5 days.3 Discharge to the home compared with discharge to a skilled nursing facility (SNF) has been shown to decrease the odds of hos- pital readmission within 90 days, which also contributes to cost sav- ings.10 In a 2008 study by Bini et al, data extracted from the Kaiser Permanente Total Joint Replacement Registry from April 2001 to Continued on page 3634 04.17 lermagazine.com
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Continued from page 34 similar outcomes in both groups and a shorter recovery time for the outpatient PT group, outpatient PT following TKA may be more cost- iStockphoto.com 177316285 effective than HH.December 2004 showed 15% of patients were discharged to an The JRP helps decrease expenditures through appropriate, di-SNF following TKA.10 In our VVMC study, only three patients (4%) rect referral of patients to outpatient PT. However, it is necessary towere discharged to an SNF following JRP participation.3 emphasize that patients can have similar outcomes postsurgery, even if HH PT is deemed necessary at discharge. These results are Physical therapists play a beneficial role in rehabilitation after encouraging, as this may contribute to the JRP goals of patientTKA, both immediately after surgery and after hospital discharge, safety and decreased complication rates, which still may result inas well, by helping patients continue to improve their ROM, strength, cost savings.11and functional ability. We analyzed data from July 2005 to January2010 from our JRP to assess the program’s impact on functional Future directionsand clinical outcomes of direct referral to outpatient PT comparedwith referral to home health (HH) PT.11 While results from the JRP have been encouraging so far, more re- search is needed for this program to continue to be meaningful for Upon discharge home from the JRP, patients were referred to patient recovery and for the healthcare system. At VVMC we areeither outpatient PT (87 patients), or HH PT prior to outpatient PT currently assessing the association between preoperative functional(22 patients).11 Patients were discharged home and referred to out- characteristics, such as self-reported disability, walking distance, 30-patient PT if the orthopedist, along with the multidisciplinary team, day readmission, and length of hospital stay and recovery followingdetermined the patient had achieved medical stability (ie, no other TKA.2 This data will help the JRP team better understand which as-known conditions that could lead to readmission), wound stability pects of preoperative education and function should be prioritized(ie, no signs of infection), appropriate blood coagulation values, pain before surgery to optimize recovery. Jon Cook, PT, DPT, coordinatorcontrol with oral medications, and progress toward PT goals. If the of the Joint Replacement and Sports Medicine programs at VVMCpatient needed additional medical treatment, was unsafe with mo- and a coauthor of this paper, has noted the future of TKA rehabili-bility, or had transportation issues, he or she was referred to HH PT tation will include “identification of prognostic indicators that mayor another appropriate postacute care center.2 predispose patients to complications…” and the JRP team will utilize research to identify “…plans to resolve these.” Although the number of outpatient visits did not differ betweengroups, patients who went directly to outpatient PT had shorter re- Yelling and groaning: Delayed PT, complications, and lack ofcovery times in terms of days from surgery to PT discharge than mobility all contribute to these grievances and to prolonged recov-those in the HH group. However, there were no significant between- ery following TKA. The JRP at VVMC is achieving improved patientgroup differences in the number of patients who achieved their outcomes, decreased complications, and shortened hospital stays,knee ROM goals or in patients’ walking endurance, self-reported all of which help to lessen the clinical anguish that occurs followingpain, or quality of life at PT discharge. Given that these data show TKA. In addition to decreasing recovery time, the JRP is also con- tributing to decreased financial burden on patients and the health- care system. For patients in need of TKA, awareness of hospitals that use pro- grams like the JRP is important, as this could contribute to a safer, quicker return to home and physical function, with an improved quality of life, at a lower cost, compared with traditional protocols. As our healthcare system evolves, patients are encouraged to shop for the greatest outcomes at the lowest cost, and programs such as this are in a position to provide both results and savings. For physical therapists and other healthcare providers, it is nec- essary to understand the trends of TKA rehabilitation and be a part of the solution to the problems associated with such high proce- dural demand. As the reimbursement system shifts its emphasis to- ward outcomes as opposed to services rendered, all healthcare providers must use programs supported by evidence, like the JRP, to provide appropriate care and increase the value they provide to the healthcare system. Katie Mullen, SPT, is a physical therapy student at Northern Arizona University in Flagstaff. John R. Cook, PT, DPT, is the coordinator of the Joint Replacement and Sports Medicine programs at Verde Val- ley Medical Center in Cottonwood, AZ. Meghan Warren, PT, MPH, PhD, is an associate professor and Tarang Jain, PT, DPT, PhD is an assistant professor in the physical therapy department at Northern Arizona University. References are available at lermagazine.com.36 04.17 lermagazine.com
Shutterstock.com 430967419 Metatarsal morphology and injury risk in runners The question of whether a nonrearfoot strike pattern is a potential risk factor Although it has not been shown to be a for injury in runners with Morton’s foot risk factor for stress fracture in traditional structure deserves consideration. running, the presence of Morton’s foot (a second metatarsal longer than the first) alters running mechanics in ways that may exacerbate the risks of forefoot injury associated with alternative running styles. By Brian E Stoltenberg, DPT, OCS, CSCS; and Donald L Goss, PT, PhD, OCS, ATC With nearly 17 million running event finishers recorded in 2016,1 running remains a popular recreational activity across the US. Un- fortunately, the incidence of lower extremity injuries associated with running can be substantial, ranging from 19% to 79% in published reports.2 It is estimated that 15% to 20% of those injuries come in the form of a stress fracture.3 Stress fracture is the result of repetitive loading to bony tissue that leads to accelerated resorption during an otherwise normal reparative process. This creates cumulative microtrauma that con- tributes to progressive bone injury.4 The running gait cycle involves the transfer of load through the metatarsals as the limb progresses through the stance phase. Mod- eled as cantilevers, the metatarsals are subject to shearing forces and bending strain with each step. It has been suggested that during running the second metatarsal is where these mechanical demands are the greatest.5 This may provide a partial explanation as to why forefoot stress fractures are most commonly sustained across the central (second and third metatarsals) region.6,7 A potential risk factor for second metatarsal stress fracture is the presence of Morton’s foot.6 First introduced in 1935 by Dudley Morton, MD, a foot structure with an abnormally short and hyper- mobile first metatarsal may cause an overloading of the central metatarsals during gait, creating a cortical thickening of the second metatarsal shaft8 (Figure 1). Morton described an “axis of leverage” that, through a normal foot, runs from the calcaneus to a location between the heads of the first and second metatarsals. In the pres- ence of a shortened first metatarsal, this axis is shifted toward the second metatarsal, making it the primary point of leverage.9 In studies conducted since his initial publication, Morton’s the- ories of the pathologic foot have come under scrutiny.9-12 It is pos- sible that the technological limitations of Morton’s era caused him to err in his conclusions, as more recent work has shown a lack of clinical utility with regard to measures of first ray mobility andlermagazine.com 04.17 39
Continued from page 39 resulting forefoot strike pattern has been associated with lower vertical loading rates than heel strike running,2 but the plantar flexed foot po-Figure 1. Characteristics of Morton’s foot structure8 include an abnormally short first sition in forefoot strikers may increase load on the forefoot duringmetatarsal (protruding second ray), hypermobility at the first ray, and resultant cortical stance. For this reason, runners with a history of stress fracture of thethickening of the second metatarsal shaft. foot are often discouraged from attempting to transition to a forefootsecond metatarsal cortical thickening.11,12 One portion of his theory strike pattern.that does still have support, however, is that peak pressure will beelevated under the head of a relatively longer second metatarsal.13 It is estimated that 22% of the population has a Morton’s foot, sometimes called “Morton’s toe” or “Greek foot.”17 Considering this This alteration of mechanics may be worth consideration as the prevalence, the condition likely affects a considerable number offorefoot strike running pattern, often achieved through methods such runners who are seeking to transition to a forefoot strike pattern.as Chi,14 barefoot,15 or Pose16 running, has become more popular. This raises two important questions: First, in the presence of Mor-When runners aim to reduce heel strike at initial foot contact, the ton’s foot, does transitioning to a forefoot strike running pattern magnify the biomechanical demands across the second metatarsal, increasing the potential risk of stress fracture? And second, should this foot type be a screening consideration prior to attempting such a transition? Metatarsal mechanics During normal walking, the heel is the primary loadbearing structure of the foot. Using plantar pressure measurements, Wearing et al18 demonstrated that in healthy, young individuals the calcaneus reaches a peak force of 80% of body weight by approximately 20% of the stance phase of gait. As body weight is translated forward, load is borne equally between the heel and the second and third metatarsals at around 45% of stance. In terminal stance, the hallux sustains the majority of a 22% body-weight force across the digits, but the primary weightbearing structures late in the gait cycle re- main the second and third metatarsals. Wearing et al18 also analyzed temporal relationships among their peak force measurements, demonstrating an interesting inter- action among the medial three metatarsals. In terms of time to max- imum force, the second and third metatarsals were positively correlated with each other (r = .64, p = .01). The time to maximum force for the first metatarsal, however, was negatively correlated with that of the third metatarsal (r = -.63, p = .01). These relation- ships suggest the first and third metatarsals may function to atten- uate force across the less mobile second metatarsal.18 Although these data were collected at a self-selected walking speed without differentiation of foot morphology, they do provide insight about the distribution of forces across the forefoot in terminal stance. Seeking to define these weightbearing forces with respect to the presence of Morton’s foot structure, Rogers and Cavanaugh13 analyzed plantar pressure measurements during gait in a group of 45 individuals. Thirty of these participants had a Morton’s foot struc- ture, as defined by an in-clinic measurement of a second metatarsal longer than the first (8 mm more distally positioned metatarsal head on average). The remaining 15 participants were classified as having normal foot structure. An arch type index, calculated from plantar pressure measurements, did not differ significantly between the groups. Across all participants, mean pressure under the second metatarsal head (294.6 ± 109.4 kPa) was greater than under the first (243.3 ± 83.1 kPa). The statistical significance of this compar- ison was not discussed. In terms of between-group differences, the authors noted that the pressure under the second metatarsal head was more distally positioned in the Morton’s foot structure group than in the control group. Again, the authors did not quantify the potential statistical significance of this comparison. Continued on page 4240 04.17 lermagazine.com
Continued from page 40 is also supported by a recent cadaveric study. Weber et al19 per- formed laboratory-controlled plantar pressure measurements on six A relatively long second metatarsal may feet (without presence of Morton’s foot structure) under a mechan- create two axes at the metatarsal break ically applied force equal to one quarter of body weight. Measure- of the foot, and the second metatarsal ments were conducted under a control condition, then with may function as a hinge between the two. subsequent 2-mm, 4-mm, 6-mm, and 8-mm aluminum spacers ap- plied to the second metatarsal to lengthen it. A significant associa-Morphology and plantar pressure tion was observed between increases in second metatarsal length and increases in peak pressure under the head of the secondThe statistical significance of between-group differences in plantar metatarsal (p <.001). Increases in pressure-time integral (definedpressure magnitude was discussed, however. Participants in the as the product of peak pressure and plantar contact time) under theRogers and Cavanaugh13 cohort with Morton’s foot structure had sig- second metatarsal head were also significantly associated with in-nificantly higher plantar pressures under both the first and second creases in second metatarsal length (p <.001).metatarsal heads than those without the condition; statistical signif-icance was maintained when these values were normalized to body Force and bending strainweight. The authors described a biomechanical model in which arelatively long second metatarsal may create two separate axes at The previously mentioned Gross and Bunch5 model of thethe metatarsal break of the foot (Figure 2). As body weight is borne metatarsals as rigid cantilevers during the stance phase of gait sug-by the forefoot during the latter half of the gait cycle, the second gests the bone shafts are subject to bending strain from the weightmetatarsal may function as a hinge between the two axes, providing of the body. In their study, Gross and Bunch5 collected plantar forcea potential mechanism for the heightened pressures observed at data on 21 healthy male distance runners. Force transducers werethis location. placed on the insoles of the running shoes, corresponding to the lo- cations of the first, second, third, and fifth metatarsal heads, as well The description of increased plantar pressures at the second as the hallux (estimated by palpation). Forces were measured whilemetatarsal head with respect to increased relative metatarsal length the participants ran on a treadmill at 3.58 m/s, and the mean of five foot strikes was recorded. Consistent with previously described observations, the greatest forces were observed at the second and first metatarsal heads (341.1 N and 279.1 N, respectively). After gathering morphologic data from multiple sources (accounting for bone geometry of the ®42 04.17 lermagazine.com
...Innovative Casting Technology # !\" Figure 2. Demonstration of the exaggerated separate axes at the metatarsal break in 04.17 43the presence of Morton’s foot structure. A protruding second ray may be a mechanismfor increased plantar pressure at the second metatarsal as body weight shifts betweenthese two axes during gait.13metatarsals), the investigators calculated bending moments, axialand shear forces, and bending strain for each of the metatarsals. Thegreatest shear force and bending strain were observed in the secondmetatarsal, while the greatest axial load was observed in the firstmetatarsal. Continued on page 44 lermagazine.com
Continued from page 43 Figure 3. Cantilever model of the metatarsals during stance and The authors noted these data are demonstration of the resultingsomewhat paradoxical, as the structure bending strain. Running, shearof the first metatarsal (larger diameter forces, and bending strain haveand relatively shorter length) makes it been calculated to be greatestthe most structurally resistant to bend- across the second metatarsal. 5ing strain. But the first metatarsal sus-tains an estimated 6.9 times less strain in a New Directionduring gait than the second metatarsal,where the smaller diameter and longerrelative length actually make it less re-sistant, suggesting a substantial struc-tural load across the shaft of the bone.The authors proposed this model as apotential mechanism for the incidenceof stress fracture in the second meta-tarsal among distance runners. Although mechanically it’s intuitivethat the presence of a relatively pro-truding second metatarsal would cor-respond to increased structural loadacross the bony structure, there is littlesupport in the literature for an in-creased incidence of metatarsal stressfracture in those with Morton’s footstructure. Drez et al10 analyzed files from 65patients with confirmed metatarsalstress fractures (indiscriminate as to Take a We treat our customers like family 618-288-9297 • 866-798-7463 newsteporthotics.com As a Family owned orthotic lab, the individual attention and Hands on 4225 S. State Rte. 159 (Ste 1)approach we provide make your orthotic experience with us very memorable. Glen Carbon, IL 62034 Give us a call and see what it feels like to be treated like family! DRESS • DIABETIC • SPORTS44 04.17 lermagazine.com
which bone) and compared them with 50 controls who did not have ...Innovative Casting Technologya history of foot injury. Efforts to match the groups with regard toany demographic were not described. Ratios of first-to-second #metatarsal length were calculated from radiographs. No significant !\"differences were observed between the metatarsal length ratios inthe fracture group and the control group. Derived from their de- scriptive data, the authors proposed an objective definition of a “short” first metatarsal: A first-to-second metatarsal length ratio of less than 73% represents the range outside two standard deviations from the mean.Proximal fracture patternsChuckpaiwong et al20 focused their retrospective analysis on differ-ent stress fracture locations along the shaft of the second metatarsaland attempted to identify potential risk factors for the different sites.Nine patients with proximal stress fractures of the second metatarsal(four with bilateral injuries; 13 cases total) were compared with 45age-matched patients with distal fractures of the second metatarsal.All patients reported their injuries were caused or exacerbated bysports. Nearly half (43.1%) were described as having a short firstmetatarsal as measured on radiographs. Presence of a short first metatarsal in this study was associatedwith proximal stress fractures, but not distal stress fractures. Thosewith proximal second metatarsal stress fractures demonstrated afirst-to-second metatarsal length ratio of 80%, while those with dis-tal fractures showed a mean ratio of 95%. Proximal second metatarsal stress fractures are traditionallyconsidered rather unique to ballet dancers, who are routinely sub-jected to weightbearing forces in extreme plantar flexion.21,22 How-ever, in addition to Chuckpaiwong et al20 documenting existence ofthese proximal injuries across recreational sports, Guiliani et al23 de-scribed two cases in which proximal stress fractures occurred invery experienced runners within six weeks after switching from tra-ditional cushioned-heel running shoes to barefoot-simulating shoes(neither runner was analyzed for Morton’s foot). First-to-secondmetatarsal-length ratios were not collected on these cases. Instead,the authors proposed a mismatch between running style andfootwear design. They speculated that, rather than adopting theforefoot strike pattern that is common in habitual barefoot runners,the runners maintained a traditional heel-strike running gait in theirnew footwear. This theory would be supported when considering the obser-vations of Lieberman et al.24 A small group (n = 8) of habitually shodrunners were asked to run across a 25-m track in both shod andbarefoot conditions. Only one naturally transitioned out of a rearfootstrike running pattern during the barefoot trials. In contrast, approx-imately 60% of natural rearfoot strike runners in a larger cohort25(n = 41) immediately adopted a nonrearfoot pattern in a barefootrunning condition without any cues to do so. It is well within reasonthat the two runners in the Guiliani et al23 case series self-selecteda foot strike pattern resulting in increased weightbearing on theanterior aspect of the foot. Particularly if the runners did not mod-erate their mileage during the transition, this may suggest a mech-anism for their injuries, based on the repetitive bending straindescribed previously (Figure 3). The results of Ridge et al26 provide further support for the po-tential of bone stress changes when transitioning to barefoot-simu-lating footwear. Nineteen of 36 individuals were randomly assigned Continued on page 46lermagazine.com 04.17 45
Help Your Patients Continued from page 45A Short Leg Caused By: to make the progressive transition over a 10-week period. The otherHip or Knee Replacement, 17 continued their current footwear and training schedule, servingFracture of Lower Extremity, as controls. Magnetic resonance images of both feet were obtainedOr Other Lower Extremity Issues, pre- and postintervention. Blinded radiologists reported the pres-Can Diminish Their Quality of Life. ence of stress reactive changes or stress injury or fracture in 10 ofOur Products Can Help Them: the 19 that transitioned and only one in the control group. Foot strike pattern in these runners was not discussed. The authors did Rehab Better, state that pain reports were variable (many of the stress changes Walk better, were subclinical) and compliance logs were inconsistent, but their And Feel Better. conclusion should be well received: They recommended the tran- sition to barefoot-simulating footwear should be approached in a prolonged, controlled manner to minimize risk of bone stress injury in the foot. www.gwheellift.comHeel Lift, Inc. 1.800.235.4387LIVE A MORE shutterstock.com 360267020ACTIVE LIFE INNEW COLORS Foot strike and injury riskTRAVERSE SOCKS AND PERFORMANCE SLEEVES Regardless of whether an alternative running style is intentionally sought or naturally self-selected when changing footwear, the ques-SPRING 2017 TO ORDER CALL 800-322-7744 tion of whether a nonrearfoot strike pattern is a potential risk factor OR VISIT www.sigvarisusa.com for injury in runners with Morton’s foot structure deserves consid- eration. Although the literature on foot strike pattern in runners does not typically provide details about metatarsal morphology, study findings related to metatarsal mechanics in general may have im- plications for individuals with Morton’s foot structure. The work of Kernozek et al27 investigated the plantar forces ob- served as runners transitioned from traditional cushioned-heel shoes to barefoot-simulating footwear. Thirty female runners were46 04.17 lermagazine.com
advised to acclimate slowly to the new shoes over four weeks, and ...Innovative Casting Technologythen return for an assessment with an in-shoe pressure sensor. Fif-teen runners demonstrated a nonrearfoot strike pattern after tran- #sitioning. Logically, this pattern yielded reduced pressure at the !\"rearfoot and greater pressure in the forefoot, most noticeably in thecentral metatarsal region. In describing the effect of alternative running styles on foot con- tact pressure, Goss and Gross28 defined pressure as applied force divided by contact area. Barefoot running has been shown to de-crease the contact area of the foot by 25% to 63% compared with 04.17 47conventional shod running,29 due to less rearfoot contact with theground. If the applied force remains constant, this reduction in con-tact area will result in greater pressure. As pressure shifts to theforefoot, the reduction in contact area may counteract the potentialbenefits of the reduced vertical loading rates associated with alter-native running styles. Magee et al30 described how making initial contact with themidfoot during running will concentrate the center of pressure (orMorton’s “axis of leverage”) more anteriorly than a traditional rear-foot strike pattern. Goss and Gross28 suggested this can increasevertical ground reaction impulse stress (force multiplied by time)across the metatarsals, due to the proportionally longer duration offorefoot loading. The advantages of a nonrearfoot strike in runners have becomea recent point of emphasis. This is true in the clinical setting,31 butalso in recreational running as popularized by Runner’s World.32Based on the aforementioned mechanics, it is common to excludethose with a history of foot stress fracture from transitioning to aforefoot strike running style. It is less common, however, to take rel-ative metatarsal lengths into consideration when deciding if the tran-sition is appropriate for a given individual. Although it has not been shown to be a risk factor for stressfracture in traditional running, presence of “Morton’s toe” or “Greekfoot” is a simple clinical observation that may provide informationon potential injury risk to the forefoot prior to adopting an alternativerunning style. Further research on this theory is required to help an-swer two questions that are more specific than the two posed earlierin this paper: First, in the presence of Morton’s toe, does transition-ing to a forefoot strike running pattern magnify the biomechanicaldemands across the second metatarsal, creating a potential risk forstress fracture? And second, should this foot type be a screeningconsideration prior to attempting transition of a runner to a forefootstrike?Brian E. Stoltenberg, DPT, OCS, CSCS, is a sports physical therapy fel-low and Donald L. Goss, PT, PhD, OCS, ATC, is an associate professorand fellowship director at the Baylor University-Keller Army Commu-nity Hospital Division 1 Sports PT Fellowship in West Point, NY.Authors’ note: The opinions or assertions contained herein are the pri-vate views of the authors and are not to be construed as official or asreflecting the views of the US Military Academy or the Department ofDefense.References are available at lermagazine.com. lermagazine.com
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The troublesome triad of diabetic ulcer healingiStockphoto.com 452546761 Uncontrolled deformity, deep infection, Clinicians should recognize and correct the and ischemia-hypoxia make up the trou- troublesome triad before trying to heal diabetic ulcers using other interventions, blesome triad of confounders associated particularly those that are expensive. with healing challenges in patients with diabetic foot ulcers. Clinical examination and intervention in nonhealing patients should focus on these three elements. By Anna Maria M. Tan, DPM; Michael B. Strauss, MD; and Lientra Q. Lu, BS Diabetic foot ulcers (DFUs) are a common cause of morbidity and often require comprehensive multidisciplinary management. The cost of care imposes substantial economic burdens on the health- care system. It adds an additional $9 billion to $13 billion dollars to the annual $245 billion spent for care of patients with diabetes mel- litus in the US.1 DFUs also are a major risk factor for lower extremity amputations.2 The progression from preulcer to ulceration to in- fected nonhealing wound is a common course of events that in about 25% of cases leads to lower limb amputation.3 The majority of DFUs heal uneventfully with management that includes appropriate wound dressings, debridement, and offloading. There are usually identifiable reasons why a DFU does not heal. Often these reasons are multifactorial. We have observed that three confounding factors are responsible for failure of wound healing in more than 90% of cases.4 We term these factors—uncontrolled deformity, deep infection, and ischemia-hypoxia—the “troublesome triad.” Being able to identify these elements of the troublesome triad is essential to the evaluation of diabetic wounds, their management, and determining outcomes. We grade outcomes on all wounds on a 0-to-2 scale as follows: 1) Healed = 2 points 2) Improved (chronic stable wounds, with patients pain-free, able to resume activities, minimal dressing changes, healthy-appear- ing wound base) = 1.5 points 3) No change (not good enough for inpatients but may be ac- ceptable for outpatients) = 1 point 4) Worsening = .5 point 5) Lower limb amputation or death = 0 points We consider healed or improved outcomes to be positive, and no change, worsening, or lower extremity amputation or death to be poor outcomes. A variety of wound-dressing agents are available to help with wound management of diabetic foot ulcers, such as negative pres- sure wound therapy (NWPT), subatmospheric wound dressings,lermagazine.com 04.17 49
Continued from page 49 Figure 1. The troublesome triadbioengineered wound coverings, antimicrobials (including those Total contact casting (TCC) is recommended for outpatientwith silver), medica-grade honey, agents that absorb secretions, or management of diabetic foot ulcers.8 However, Frigg et al found ancombinations of these. However, when elements of the troublesome ulcer recurrence rate of 57% in patients treated with TCC, despitetriad are present, healing is unlikely even if the most advanced ther- healing and compliant use of protective footwear.9 When the ulcersapies are used. Advanced wound therapies such as biologic agents occur in the midfoot and hindfoot, and especially if hospital man-and NPWT should only be used after the confounders of the trou- agement of the deformity is required, TCC is usually not sufficientblesome triad have each been addressed. and surgery is required.9 The elements of the troublesome triad are detailed in Figure 1 Deep infectionand described in more detail below. The second component of the troublesome triad is infection, whichUncontrolled deformity frequently occurs with diabetic foot ulcers. In an Institutional Review Board-approved prospective study of patients hospitalized withFoot deformities can cause plantar pressures to concentrate in a focal DFUs, we found residual deep infection was the most frequent con-area and can create biomechanical stresses, both of which contribute founder, being present in 61.3% of the patients.4to DFUs.5 Soft tissue breakdown follows repetitive cycles of pressureconcentrations, shear stresses, or both, especially in patients with Infections that are pertinent to this component of the troublesomesensory neuropathy.6 Deformities we frequently observe in the dia- triad are those that are deep (ie, involving bursa, cicatrix, and/or bone)betic foot include claw, hammer, and mallet toes; hallux valgus, varus, to the skin and base of the wound and involve bone, bursa, cicatrix,or rigidus; forefoot abduction/adduction; midfoot pronation/supina- or combinations of these. These deep infections typically do not re-tion; plantarward extrusion of midfoot bones; equinus contracture; spond to antibiotics and require surgical debridement to achieve heal-rocker bottom foot; and combinations of these conditions. ing. Failure to adequately debride the tissues affected by deep infection often, in our experience, leads to nonhealing and the need Bony prominences underlying mal perforans ulcers often are a for lower limb amputation.7 Snyder reported in a retrospective studyconsequence of the deformities and are a reason DFUs do not of diabetic patients with forefoot amputations that uncontrolled infec-heal.7 In our experience, deformities can also occur secondary to tion at the amputation site, even when concurrent or previously man-Charcot neuroarthropathy bone destruction, motor components of aged, was the reason 37% of the patients subsequently required aperipheral neuropathy, malunion, cicatrix, and hypertrophic bursa transtibial or above knee amputation.10formation. These complications often overshadow the extent of theunderlying bony spur. We have observed that deep infection includes persistence of infection even when treated with antibiotics and superficial debride- Cicatrix and bursa formation can develop as a type of defense ment; induration and/or maceration around the wound margins; hy-mechanism by the body to provide padding over a deformity.7 In pertrophic granulation tissue and/or recurrent highly keratinizedour experience, this is often self-defeating, with the amount of cic- callus around wound margins; persistent fibrous membranes and/oratrix and/or bursa far exceeding the magnitude of the bone defor- biofilm; a verrucous-cobblestone appearance or pale, atrophic ap-mity. When the mass effect of the cicatrix and hypertrophic bursa pearance of the ulcer base; or combinations of these (Table 1). Theexceeds the protection the padding attempts to provide, an ulcer- hallmark of deep infection is the recurrence of findings at returnation develops. clinic visits even when the wound appears improved after the su- perficial debridement. Often, these DFUs have been managed with If the DFU is superficial, coexisting deformity may be only a me- a variety of advanced therapies before the decision is made to ex-chanical problem and may not contribute to deep infection. In such plore and debride the deep infection associated with bone, bursa,cases, we recommend surgical management of the deformity when or cicatrix.the ulcer persists after a trial of offloading and/or protective footwear,with as much surgical attention being focused on removing the cicatrix Continued on page 52and bursa as on eliminating the underlying bony deformity.50 04.17 lermagazine.com
New!shark-o™ Charcot OrthosisCustom to Cast or Scan from all industry standard le formats. Features: Liner made from ¼\" aliplast foam.Outer shell constructed of polypropylene for maximum control of the foot and ankle complex. Molded copolymeranterior internal shell to limit shear forces and lock the leg in securely. Tri-laminated foot bed consisting of twodensities EVA and one layer of P-Cell® to help protect the foot during treatment.INDICATIONSUsed for the prevention and management Patent pending design allows adjustable volumeof pressure ulcers caused by ischemia, changes of the calf while leaving the foot at a setdirect trauma and/or repetitive stress often volume. This is achieved by overlapping the footfound in persons with: section, locking it in place while at the same time• Diabetes Mellitus smoothly underlapping the calf area allowing the anterior shell to slide easily under the• Charcot deformity posterior.• Decreased sensation and/or paralysis• Foot fractures The “shark-o style” CROW Orthosis is a viable design that makes tting and follow-up of the Charcot foot easier and more e ective. Its design features reduce orthosis weight and pressure to the plantar foot surface as compared to the traditional CROW. This transition is made possible by the notched wedge shaped trim cutout at the ankle/instep. The patient can easily adjust for daily calf volume (edema) changes with simple strap adjustments.©2016 Orthomerica Products, Inc. 877-737-8444 | www.orthomerica.com US & International Patents Pending All Rights Reserved.
Continued from page 50 Table 1: Signs of deep infection SIGN COMMENTS Induration and/or maceration Reflects deep infection and/ around wound margins or production of exudate or transudate Hypertrophic granulation tissue and/or recurrent highly Possible epigenetic influence keratinized callus around from chronic infection on gene wound margins expression that regulates the formation of these tissues Verrucous, cobblestone appearance of wound base Biofilm reflects bioburden in wound; fibrous tissue formation is a body’s response to the infection Medical Shoe Collection Plain x-rays and nuclear medicine scans using a combination of indium and technetium and augmented with computed tomog- Accommodate various foot deformities raphy are useful in identifying the source of a deep infection.11,12 Variety of widths, closures and depths Magnetic resonance imaging (MRI) is helpful in delineating the soft Shapes for Charcot, Edema or Hammer tissue components of the infection, but tends to be over-read, as the interpretation of bone infection is based on bone edema.13 Ease of fit adjustability Edema in bone can arise from inflammation of surrounding tissues Foot protection and wound prevention and be interpreted as osteomyelitis on the MRI. Often, the radiolo- gist will conclude “possible osteomyelitis” and suggest confirmation Billing Code : PDAC A5500 & A5512 with a nuclear medicine study. Apis Footwear Co. Main 1-888-937-2747 (PST) The definitive diagnosis of osteomyelitis is made with culture CA office: 2239 Tyler Ave., South El Monte, CA 91733 and sensitivity of a bone sample.14 Probing to bone has an 85% sen-KY Office: 13024 Forest Centre Court, Louisville, KY 10223 sitivity for osteomyelitis.15 Toll Free 1-888-777-0448 (EST) Surgical management of deep infection requires removal of the infected bone, bursa, and cicatrix. Usually, all three components are www.apisfootwear.com involved when infection is the reason for nonhealing in a diabetic foot ulcer. Following adequate debridement, we recommend anti- biotics be continued for a couple of weeks after surgery to sterilize the soft tissues adjacent to the debrided bone and soft tissues. The use of hyperbaric oxygen (HBO) as an adjunct to manage- ment of deep infection associated with a DFU requires careful con- sideration. If ischemia-hypoxia is evident, it is possible the host factors will not be able to sterilize any residual infection in the bone or soft tissues, as the neutrophil-oxidative killing of bacteria and bone resorption by osteoclasts is highly oxygen-dependent. Hunt et al showed that 30-40 mm Hg oxygen tensions in the wound are required for healing to occur.16 At lesser oxygen tensions, the tis- sues may not die, but will be unable to heal the wound or eliminate the infection.17 HBO should be used as an adjunct to surgical and antibiotic management in such situations. Ischemia-hypoxia Perfusion that is not sufficient to meet oxygen requirements for wound healing and infection control is the third troublesome triad confounder. Pompers et al reported that 50% of patients with dia- betic foot ulcers exhibit a component of ischemia.18 And Apelqvist et al found that the likelihood of wound healing without a major am- putation is inversely related to the severity of underlying peripheral arterial disease (PAD), in addition to the seriousness of the patient’s comorbidities and the complexity of tissue involvement.19 The evaluation for PAD starts with a patient history and checking for symptoms of intermittent claudication and rest pain; these symp- toms, however, may not be apparent because of sensory neuropathy. Components of the physical exam include checking for palpable52 04.17 lermagazine.com
pulses at the hip, knee, and ankle levels, as well as for secondary 04.17 53signs of perfusion such as pedal hair growth, skin quality, coloration,temperature, and toe capillary refill time. In the absence of palpablepulses, wound ischemia-hypoxia can be confirmed with Doppler im-aging.20 Based on clinical signs and symptoms, imaging studies andpossibly transcutaneous oxygen measurements (TCOMs) can bedone to screen for the severity of PAD and provide justification forinterventions. PAD is a prominent risk factor for lower extremity am-putation regardless of etiology.21 When diabetic foot ulcers fail to improve in the context of theclinical findings noted above, angiography is the next step in theevaluation of critical limb ischemia-hypoxia. Comparing juxta-woundTCOMs under normal indoor air conditions and with hyperbaric oxy-gen can provide objective data with which to determine whetherhyperbaric oxygen is needed for wound healing in these situations.If the TCOM readings exceed 40 mm Hg in room air, wound oxy-genation is sufficient for wound healing, and failure to heal is likelydue to one of the other confounders, or an occasional biochemicalproblem (for example, matrix metalloproteins). If the TCOMs arelower than 30 mm Hg, healing is not likely to occur. However, incases where the juxta-wound TCOMs increase to more than 200mm Hg with HBO exposure, regardless of the room air readings,we have observed healing in 88% of our patients,22 and similar find-ings were reported by Fife et al.23 Other interventions to mitigate wound ischemia-hypoxia shouldnot be overlooked in this cohort of patients. These include edemareduction, optimization of cardiac function, and use of medicationsto improve blood rheology. Edema increases the diffusion distanceof oxygen from the capillary to the cell along a gradient.24 Improvingcardiac function increases perfusion to the ischemic tissues. Finally, rheological agents such as aspirin, clopidogrel, warfarin,heparin, pentoxifylline, and dextran improve perfusion through an-ticoagulation, decreasing the sludging of erythrocytes in the micro-circulation, and/or improving red blood cell deformity.25 When usedas the only technique to improve perfusion, in our experience, theywill not likely be adequate to achieve healing in an ischemic-hypoxicwound; consequently, we recommend they be used in conjunctionwith the other methods described.ConclusionsUncontrolled deformity, deep infection, and ischemia-hypoxia arethe three elements that we have labeled the troublesome triad, andthese confounders are associated with healing challenges in pa-tients with DFUs (Table 2). Our prospective study found one or moretroublesome triad confounders in 91.9% of 62 inpatients withDFUs.4 Each confounder has characteristic findings that can be con-firmed with examination and remedied with interventions. These in-clude surgical removal of the deformity and stabilization of the footin a plantigrade position; debridement of infected bone, bursa, andcicatrix; and improving perfusion with revascularization techniques,hyperbaric oxygen, and medical interventions. Our 0-to-2 pointgrading system for wound outcomes is a useful tool to assess theeffectiveness of our interventions to manage these cases. We have observed “good” outcomes in nearly 80% of ourpatients (unpublished data) hospitalized with diabetic foot woundswhen elements of the troublesome triad were addressed. Continued on page 54 lermagazine.com
Continued from page 53Table 2: Characteristics of the troublesome triadCOMPONENT DIAGNOSIS MANAGEMENT COMMENTSDeformity Inspection Offloading The body reacts to deformities by Plain x-rays Surgeries: ostectomies, forming bursa and cicatrix. When osteotomies, resections overwhelmed, ulcerations develop at the apex of the deformityDeep infection Physical exam Exploration and debridement Infection occurs as result of Imaging studies* bacteria tracking through ulcer base to deeper structuresIschemia-hypoxia History, pulses, Doppler, misc.** Revascularization, hyperbaric If ischemia is primary concern, oxygen (HBO), edema reduction, then revascularization should be medications done; if hypoxia, then HBO*Plain x-rays; nuclear medicine scans (SPECT) for osteomyelitis; MRI for suspected cysts, fluid collections, and/or soft tissue lesions**Edema reduction, medications (anticoagulants, antiplatelet, thrombin inhibitors). Local vasodilators (nitroglycerin). We feel it is incumbent on clinicians treating these patients to lows clinicians to manage these chronic stable wounds withrecognize the components of the troublesome triad and to correct glycemic control monitoring and medication.them before trying to achieve wound healing with other interventions,particularly those that are costly, as healing is unlikely to occur and Anna Maria M. Tan, DPM, is chief resident of Podiatric Medicine &persist when these confounders have not been addressed. In partic- Surgery at Long Beach Memorial Medical Center in California.ular, interventions to target the troublesome triad confounders should Michael B. Strauss, MD, is the former director of Hyperbaric Medi-not be ignored or deferred in favor of using advanced wound thera- cine at Long Beach Memorial Medical Center. Lientra Q Lu, BS, is apies. Recognition and management of these confounders can help research coordinator at VA Medical Center Long Beach Healthcareconserve resources when attempting to heal diabetic foot ulcers. System and administrative assistant at the Southern California Insti- tute for Research and Education in Long Beach. In addition, it is important to recognize that not all wounds heal,and in our clinical experience, a patient may live with a chronic sta- References are available at lermagazine.com.ble wound for several years. Addressing the troublesome triad al-&- ,-* * & \"+,*\" -,'* ' THE PREVENTIVE'* -+ \"& ,! '',. * \"& -+,*\" + HIGH HEEL & Antidote +,' # ,!'-+ & + ' , ' !\" +2 1 '.!\" Prevent achy bunions 1 *+#\"&+ and overlapping toes. 1 +! (+#\"&+ 1 (\" +#\"&+ t$0.'035\"#-& 1 .''$+#\"&+ t$045&''&$5*7& 1 $ % +#\"&+ & t&\"4:5064& 1 +- $ ,! * www.my-happyfeet.com | 440-256-1526 \"& '0 &+ ' '$'*+ & ,!\" #& ++ +' * ,! \"& +, )- $\",/ , \"+ '-&, .!'$ + $ (*\" + . , *!'-+ $ ,! * '%54 04.17 lermagazine.com
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newpPartial Foot Astro XO Navy Midtown Noraxon NinoxProsthesis Exoskeleton Socks for Men Camera SystemNew from Custom Composite Astro Medical introduces the The Sigvaris Midtown Microfiber Noraxon USA has released theManufacturing is the Partial Foot Astro XO flexible exoskeleton compression collection for men Ninox camera system, a port-Prosthesis, specifically designed designed to rehabilitate ankle now includes navy socks in two able, USB-powered, high-defin-to accommodate the unique power and forward propulsion compression levels, 15-20 mm ition camera system with inte-needs of Chopart and Lisfranc to treat soft tissue and joint dis- Hg and 20-30 mm Hg. The grated LED light for capturing(transmetatarsal) amputees. The orders (such as plantar fasciitis compression socks are de- and analyzing human move-Partial Foot Prosthesis is de- and Achilles tendinitis) that af- signed to be comfortable and ment data. The camera systemsigned to help restore normal fect gait. The Astro XO includes durable while providing thera- is designed to give biomechan-foot biomechanics and facilitate a knee component, which pro- peutic relief. Constructed from ics researchers and sports sci-the transfer of energy from a vides a proximal anchor point, fine, breathable microfiber ny- entists a way to capture humanrigid lever arm (the anterior and a foot bracket that fits most lon, the socks help manage vari- movement in the lab or in theshell) to a progressive resistance shoes; the two are connected cose veins, leg pain, and leg field. The Ninox cameras capturecarbon footplate that can be by an elastic actuator. In a clini- swelling. The complete Midtown visual data at up to 250 framespaired with a toe filler. The light- cal trial of patients with chronic Microfiber line is available in 15- per second and feature frame-weight, durable, device is cus- plantar fasciitis, the Astro XO 20 mm Hg, 20-30 mm Hg, and by-frame slow-motion playback.tom-fabricated from a cast; it was associated with 71% less 30-40 mm Hg. The men’s line The two models of Ninox cam-comes with a foam liner, Velcro pain and a 38% improvement includes socks, socks with grip- eras (125 or 250 maximum framesstrap, and toe filler. Suggested in ankle dorsiflexion. The Astro tops, and thigh-highs; colors in- per second) are available as aL-codes include L-5020, L- XO is customized to three sim- clude black, tan-khaki, steel stand-alone camera system or5634, L-5654, L-5785, and L- ple patient measurements. gray, and navy. as a part of the myoMetrics5976. portable lab. Astro Medical SigvarisCustom Composite Manufacturing 847/557-0105 800/322-7744 Noraxon USA866/273-2230 astroxo.com sigvarisusa.com 800/364-8985cc-mfg.com noraxon.com58 04.17 lermagazine.com
roductsUpdated Custom FasciaFix Pedoped Insole KinesiologyDiabetic Inserts Sleeve for Load Analysis Taping SocksApex Foot Health Industries The PediFix Footcare Company novel GmbH introduces the Pe- Reset Sport Kinesiology Tapingreintroduces Apex Custom Dia- offers the FasciaFix Plantar doped insole, the latest ad- Socks are designed to facilitatebetic Inserts (CDI) with an en- Fasciitis Relief Sleeve, a new vancement in its load measuring recovery from foot and ankle in-tirely new ScanCast 3D technol- compression sleeve to help re- technology. The product fea- juries and aid in their prevention.ogy application to scan and lieve heel and arch pain related tures one large sensor that cov- By simulating a proprioceptivesubmit orders. Apex ScanCast to plantar fasciitis. By compress- ers the entire surface of the foot neuromuscular strap, the socks3D orders are fabricated to pre- ing and supporting the arch in to accurately measure the nor- provide external support withoutcisely fit Apex footwear, as well two directions, the new plantar mal ground reaction force under restricting normal range of mo-as other brands, with increased fasciitis compression sleeve the foot independent of which tion. The socks are made ofaccuracy and with no practi- helps relieve strain on the fascia part of the foot is being loaded fibers with varied tension levels,tioner adjustments necessary. as it also helps to minimize the (heel, toes, or whole foot). The akin to those found in elasticFoam and plaster casts are also effects of inflammation. The new Pedoped insole technology therapeutic tape; an internal sil-accepted and modifications are plantar fasciitis sleeve is de- includes matchbox-sized elec- icone band at the top of theavailable as needed. Addition- signed to be used in the day- tronics that communicate wire- sock anchors it to the leg to re-ally, the company has made up- time or nighttime, and can be lessly with a smartphone via duce migration. The socks alsodates to its CDI line. The inserts worn over or under socks. It is Bluetooth in real-time. The user feature Innergy technology toare manufactured using genuine available in four sizes (S-XL) and/or patient receives instant- generate a gentle heat. DifferentPlastazote top covers. Apex in- based on the patient’s arch cir- aneous biofeedback about plan- sock models address Achillessert and shoe orders are always cumference. Practitioners can tar loading of the feet via visual, support, tibial stress, ankle sta-bundled and shipped together. order the sleeves singly or in a auditory, or vibratory feedback. bility, and pronation control. 12-pack display.Apex Foot Health Industries novel USA Reset Sport800/323-0024 PediFix Footcare Company 651/221-0505 +34 93 706 50 20apexfoot.com 800/424-5561 novelusa.com resetsport.com pedifix.comVisit lermagazine.com/products for more products and to submit your new product listing. lermagazine.com 04.17 59
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market mechanicsBy Emily DelzellEO2 oxygen delivery device heals DFUs DonJoy introduces TriFit OA knee braceResults of a randomized con- wound closure or for 12 weeks, San Diego-based DJO Global in justment system that pullstrolled trial presented in March whichever was sooner. Patients, March launched the OA Reac- everything together and pro-at the Diabetic Foot Global Con- treating physicians, and inde- tion TriFit Knee brace from Don- vides 3D protection.ference (DFCon) in Houston pendent evaluators were blinded Joy, the company’s latest os-found continuous diffusion of to the study arm. All patients teoarthritis (OA) knee brace DJO Global also announcedoxygen (CDO) with San Anto- received identical offloading, designed to provide pain relief in March that its Exprt Revisionnio-based EO2 Concepts’ Trans dressings, and follow-up. to those with moderate to severe Hip portfolio received marketCu O2 System was more effec- knee OA. clearance from the US Food andtive for treatment of diabetic Mark Q. Niederauer, PhD, Drug Administration. The systemfoot ulcers (DFUs) than stan- COO of EO2, presented the re- TriFit by DonJoy features a offers an anatomically inspireddard approaches. sults, which found significantly Web Tech shock absorber to design that costs 40% to 70% more people healed in the active assist with full knee extension of the price of comparable revi- Investigators for the clinical arm compared with the sham and patellofemoral tracking, sion hip systems and has 80%-trial randomized 100 participants group (46% vs 22%); this rela- Exos Tech for a heat-thermo- 90% fewer instruments, accord-with DFUs (79% male, aged 58.3 tive effect was greater in more formable custom fit that hugs ing to a company release.± 12.1 years) to receive either ac- chronic wounds (42.5% vs the area around the knee, andtive CDO therapy with the wear- 13.5%). Patients using the active Boa Tech, a microtension ad- Visit exprtprecision.com forable TransCu O2 device or an oth- device also had significantly more information.erwise fully operational sham faster closures rates compareddevice that provided moist with the sham group. Paceline buys Orthomerica’s Seal PVA bizwound therapy without deliveringoxygen. The Journal of Diabetes Sci- Matthews, NC-based Paceline in Paceline director of sales, in a ence and Technology published late March acquired Orlando, FL- company release. They followed patients until the study in February. based Orthomerica’s Seal PVA business. Seal PVA item numbers willBOC manager, sales team win Stevies remain, and the only change ef- “The addition of the Seal fective immediately is that allThe Owings Mills, MD-based the Year. The BOC hired Tolson PVA business adds to Paceline’s new orders will now come fromBoard of Certification/Accredita- in 2014 to lead its new business growing portfolio of lamination Paceline.tion (BOC) in March announced development unit; she has products, including closed-endits receipt of awards in two cate- since hired and trained a team PVA [polyvinyl alcohol], resins, Contact Glontz at dglontzgories at the 11th annual Stevie that helped increase the num- carbon, nyglass, FeatherStretch, @paceline.com with any ques-Awards gala, held February 24 ber of BOC-accredited facil- and more,” noted David Glontz, tions about the acquisition or thein Las Vegas by the Fairfax, VA- ities by 10% in a shrinking mar- transition process.based Stevie Awards group. ketplace, according to a BOC release. ABC funds journal issue for AOPA papers Cynthia Tolson, BOC busi-ness development manager, The BOC also won a Bronze The Washington, DC-based The Journal of NeuroEngi-won a Gold Stevie as Business Stevie for Front-Line Customer American Orthotic & Prosthetic neering and Rehabilitation willDevelopment Professional of Service Team of the Year. Association (AOPA) announced publish the Presidential Papers in March that the American as a special supplement, andSigvaris marks North American expansion Board for Certification in Or- ABC will make the research avail- thotics, Prosthetics & Pedorthics able worldwide through the jour-Peachtree City, GA-based Sigvaris office, manufacturing, and ware- (ABC) will sponsor the 2017 nal and accompanying search in-in March celebrated the grand house space and will create AOPA World Congress Presi- dexes such as Medline.opening of its expansion for its more than 70 new jobs over the dential Papers, the top 10 clin-North American headquarters next 10 years, with 18 new em- ical education submissions to ABC will also be an officialwith a ribbon cutting ceremony ployees already hired, according the congress of original re- partner of the 2017 AOPA Worldthat included local city officials, to a company release. search backed by a full manu- Congress, which is scheduled toemployees, and members of the script. be held September 6-9 in Lascompany’s founding family. Sigvaris in March also cele- Vegas. brated the grand opening of its The expansion includes new manufacturing facility in Hol- Ottobock acquires BionX active ankle40,000 square feet of additional land, MI.allardafo.com goes live, tells ToeOff story Austin, TX-based Ottobock the Empower Ankle, which re- HealthCare in March acquired places muscle and tendon func-Rockaway, NJ-based Allard USA a “40 Reasons” section detailing prosthetic foot and ankle maker tion with an actively driven an-announced in late March that its the company’s process from BionX Medical Technologies, kle joint and supports the usernew website, allardafo.com, is live. manufacturing to social respon- headquartered in Boston, MA. by supplying additional energy sibility, and links to Allard suppli- during gait, according to an Ot- The site features the history ers worldwide. BionX Medical Technolo- tobock release.of its ToeOff ankle foot orthosis, gies produces an active pros- thetic foot and ankle solution, Continued on page 62 lermagazine.com 04.17 61
market mechanics Continued from page 61KD, OREF award orthopedic researchers Curbell aids high school prosthetic projectKappa Delta Sorority and the Or- coauthored by Christina Gurnett, Orchard Park, NY-based Curbell many amputees.thopaedic Research and Educa- MD, PhD. Plastics in March provided tech- They reached out to Jefftion Foundation (OREF) in March nical expertise and donatedat the 2017 Annual Meeting of Henrik Malchau, MD, PhD, material to students in the Tech- Wilson, Curbell business devel-the American Academy of Or- professor of orthopaedics at Har- nology and Engineering (STEM) opment manager of Orthotics,thopaedic Surgeons (AAOS) pre- vard Medical School and vice Program at Wilson High School Prosthetics and Podiatry, and hesented four awards of $20,000 chief orthopaedics and codirec- in West Lawn, PA. worked with the students oneach to scientists for conducting tor of the Harris Orthopaedic selecting materials.outstanding musculoskeletal re- Laboratory Massachusetts Gen- The seniors enrolled insearch. The meeting took place eral Hospital in Boston, won the the Wilson Capstone Course Curbell also donated theMarch 14-18 in San Diego. OREF Clinical Research Award in Engineering Design and three blocks of copolymer ac- for his research on the impact Development had to identify etal used to fabricate the pros- Robin Queen, PhD, associ- of arthroplasty implant registries and solve a systemic societal thesis, giving students theate professor of biomedical en- throughout the world. The re- problem, and decided to de- chance to try out 3D modeling,gineering and mechanics at Vir- search was coauthored by velop a transtibial prosthesis 3D printing, computer-aidedginia Polytechnic Institute and Daniel Berry, MD; Charles Brag- that addressed the cost and manufacturing (CAM), and com-State University in Blacksburg, don, PhD; Göran Garellick, MD, comfort issues that plague puter-numerically controlledand associate professor of or- PhD; William H. Harris, MD, (CNC) milling and turning.thopaedic surgery at Virginia ScD; Peter Herberts, MD, PhD;Tech Carilion School of Medicine Johan Kärrholm, MD, PhD; PCL brace reduces peak PFJ pressuresand Research Institute, won the David Lewallen, MD; Lars Lid-Kappa Delta Young Investigator gren, MD, PhD; and Otto Robert- The Journal of Experimental Or- load of 400 N/200 N.Award for her research on the son, MD, PhD. thopaedics on March 31 pub- They then repeated the test-impact of ankle osteoarthritis and lished a study of Foothill Ranch,total ankle replacement on gait Scott W. Wolfe MD, chief CA-based Össur’s Rebound PCL ing after application of the Össurmechanics and balance. emeritus of hand surgery and at- (posterior cruciate ligament) PCL brace. tending orthopaedic surgeon at brace, showing the device sig- Matthew Dobbs, MD, won the Hospital for Special Surgery nificantly reduced peak patello- Brace application signifi-the Kappa Delta Ann Doner in New York City, received the femoral joint (PFJ) pressures in cantly reduced force, total pres-Vaughn Award for his research 2017 Kappa Delta Elizabeth Win- in PCL-deficient knees compared sure, and peak pressures in theon advancing personalized med- ston Lanier Award for research with no brace. PFJ in PCL- and PCL/PLC-defi-icine for clubfoot. Dobbs is the on kinematics of the normal and cient knees, most significantly atDr. Asa C. and Mrs. Dorothy W. injured wrist and the importance Investigators from the Ker- higher degrees of flexion.Jones professor of orthopaedic of the midcarpal joint. The re- lan Jobe Orthopaedic Clinic insurgery at Washington University search was coauthored by Los Angeles tested PFJ pres- Össur in March also openedin St. Louis. The research was Joseph J. Crisco III, PhD. sures and force using a pressure registration for its second Annual mapping system via a lateral Women’s Leadership Confer-HHS data validate KOOS JR. survey arthrotomy at knee flexion an- ence for O&P professionals, gles of 30°, 60°, 90°, and 120° scheduled for September 28-30Investigators from the Hospital replacement bundled payment in intact PCL-deficient and PCL/ at the Össur Academy facility infor Special Surgery (HSS) on program. In the study presented posterolateral corner (PLC)-defi- Orlando, FL.March 14 presented research at the AAOS meeting, HSS re- cient cadaveric knees under aat the 2017 Annual Meeting of searchers looked at the results combined quadriceps/hamstrings Registration is $50 per per-the American Academy of Or- of 314 patients who underwent son and space is limited; getthopaedic Surgeons (AAOS) in revision surgery following total more information and register atSan Diego that confirms a knee replacement between May ossur.com.seven-question survey devel- 2007 and December 2011 andoped at the Manhattan-based completed KOOS JR. patient-re- Tekscan launches gait analysis systemcenter is a valid and efficient ported outcome measure sur-tool for assessing patient out- veys before surgery and two Boston, MA-based Tekscan on ditional tiles, according to acomes following revision total years later. The KOOS JR. meas- April 28 introduced the world- Tekscan release. It also featuresknee replacement. ures proved to be as valid, and wide release of its Strideway a wide active area and flush sur- have as much internal consis- gait analysis system. face to minimize trip hazards The survey, the KOOS JR. tency, external validity, and other and accommodate patients with(Knee Injury and Osteoarthritis measures of reliability in deter- The modular pressure mobility aids or gait dysfunc-Outcome Score), is significantly mining outcomes for these pa- measurement system provides tions.shorter than the older 42-ques- tients as they did in patients who kinetic, temporal, and spatialtion knee replacement survey had primary total knee replace- gait parameters, as well pres- The system made its debutand has already been adopted ments. sure and force data. It’s con- in February at the Americanby Medicare for its primary joint structed by clicking together Physical Therapy Association modular tiles to form a platform, Combined Sections Meeting in making the system easy to set San Antonio. up, move, and store, and cus- tomers can add length with ad- Visit tekscan.com/strideway for more information.62 04.17 lermagazine.com