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| Table of Contents: 1. Recurrent Ankle Injury (Lateral Ligament Sprain) 2. Talus 3. Fibula Stuck in Superior Glide 4. Peroneal Tendonitis 5. Research on Motion of the Foot and Ankle 6. Letter to the Editor: Hip Study
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| 1. Recurrent Ankle Injury (Lateral Ligament Sprain) RECURRENT ANKLE INJURY (LAERAL LIGAMENT SPRAIN) Please see my post titled CUBOID SYNDROME as this pattern is very relevant to recurrent ankle injuries. After restoring normal accessory motions, of the foot and ankle as described in CUBOID SYNDROME, it is necessary to reevaluate the integrity of the foot and ankle ligaments. These tests are described in the literature. Prior to moving the client into weight-bearing exercise, I would screen the hip in all directions and then screen the pelvis. I believe that pelvic side-glide restriction is a common compensation for an ankle injury, in which the client reduces weight-bearing on the symptomatic side. Please see case example of pelvic side-glide fixation reflections on recent case. I am not aware of any research that addresses this, but maybe by posting the idea here it can be encouraged. There are some nice studies in the literature addressing hip abductor weakness in response to ankle injuries. I submit that a pelvic side-glide fixation would perpetuate hip abductor weakness and inhibit muscle function. If present, resolving thepelvic side-glide fixation would be a reasonable first step towards restoring hip abductor stength, endurance, firing sequence, etc. As the client moves beyond the acute phase and rehab is appropriate, articles such as the one cited below (abstract) can be useful.
The Effect of a 4-Week Comprehensive Rehabilitation Program on Postural Control and Lower Extremity Function in Individuals With Chronic Ankle Instability
Authors: Sheri A. Hale, Lauren C. Olmsted-Kramer, Jay Hertel
STUDY DESIGN: Prospective, randomized controlled trial. OBJECTIVE: To examine the effects of a 4-week rehabilitation program for chronic ankle instability (CAI) on postural control and lower extremity function. BACKGROUND: CAI is associated with residual symptoms, performance deficits, and reinjury. Managing CAI is challenging and more evidence is needed to guide effective treatment. METHODS AND MEASURES: Subjects with unilateral CAI were randomly assigned to the rehabilitation (CAI-rehab, n=16) or control (CAI-control, n=13) group. Subjects without CAI were assigned to a healthy group (n=19). Baseline testing included the (1) center of pressure velocity (COPV), 2) star excursion balance test (SEBT), and 3) Foot and Ankle Disability Index (FADI) and FADI-Sports Subscale (FADI-Sport). The CAI-rehab group completed 4 weeks of rehabilitation that addressed range of motion, strength, neuromuscular control, and functional tasks. After 4 weeks, all subjects were retested. Nonparametric analyses for group differences and between-group comparisons were performed. RESULTS: Subjects with CAI demonstrated deficits in postural control and SEBT reach tasks in the involved limb compared to the uninvolved limb and reported functional deficits on the involved limb compared to healthy subjects. Following rehabilitation, the CAI-rehab group had greater SEBT reach improvements on the involved limb than the other groups and greater improvements in FADI and FADI-Sport scores. CONCLUSIONS: These results demonstrate postural control and functional limitations exist in individuals with CAI. In addition, rehabilitation appears to improve these functional limitations. Finally, there is evidence to suggest the SEBT may be a good functional measure to monitor change after rehabilitation for CAI.
J Orthop Sports Phys Ther. 2007;37(6):303-311, Epub 16 April 2007. doi:10.2519/jospt.2007.2322
KEY WORDS: ankle sprain, balance, Foot and Ankle Disability Index, star excursion balance test 2. Talus KEY CONCEPT: YOU MUST DRAW THE INFERIOR CLACANEUS ANTERIOIRLY WHEN YOU ARE MOBILIZING THE TALUS POSTERIORLY. THIS WILL ENGAGE THE TALUS AND CALCANEUS AND WILL ENHANCE THE ROTATIONAL ASPECT OF TALAR MOBILITY. YOU CANNOT JUST GLIDE THE TALUS POSTERIORLY, THE TALUS MUST ALSO ROTATE WITH THE CALCANEUS. TALAR POSTERIOR GLIDE/SLIDE ALSO HAS A COMPONENT OF ROLL. ROLL IS ONLY PROVOKED WHEN YOU APPLY AN ANTERIOR DRAWER TO THE CALCANEUS WHILE GLIDING THE ANTERIOR TALUS POSTERIORLY. I WILL POST PICTURES SOON THAT WILL REINFORCE THIS. FURTHERMORE, IT MAXIMIZES CONTACT OF TALUS AND CALCANEUS ALSO CALLED CLOSED-PACK POSITION. NOTE THAT THE DOME OF THE TALUS WHICH ARTICULATES WITH THE TIBIA IS CONVEX. BEING CONVEX MEANS THAT ROTATION IS A VERY RELEVANT MOTION AS OPPOSED TO ONLY GLIDE/SLIDE. I WILL POST PHOTOS LATER. 3. Fibula Stuck in Superior Glide FIBULA STUCK IN SUPERIOR GLIDE: A RARE INJURY This is an unusual and rare injury with a fabulous outcome. I treated my son Gabriel once and shortly thereafter, he was pain free and went on to resume training and 2 months later, won first place in his age group and 9th overall (see link below) in a grueling hill race, the Albuquerque La LUz Run (see 2nd link below). This run was honored as one of the "12 Most Grueling Trail Races in North America" by the fall 2001 issue of Trail Runner Magazine. http://www.laluztrailrun.org/2008/La_Luz_Final_Results_2008.pdf, I am delighted to begin reporting this case study as it involves my son Gabriel Hesch a 24 year old teacher in Albuquerque, New Mexico. He came to visit me in June 2008 and he was having some pain in the area of the superior tibiofibular joint and diffuse foot pain. I noted swelling along the lateral compartment of the lower leg which concerned me. I was fatigued that evening so deferred detailed evaluation and treatment until the following day. He did not have a limp, in fact there was no noticeable gait deviation, however, the eval revealed that he could not hop on that leg due to pain. He also had inhibition of all foot and ankle muscle groups, and reduced unilateral stance balance. The following morning (prior to treatment) he did have reduced swelling and improved muscle function except that his evertors were still inhibited. The improvement was most likely due to rest and reduced swelling from recumbent sleep position. BASIC CONCEPTS 1. This is a rare and unusual injury and there is very little in the literature to describe it. 2. It is basically the opposite of the typical ankle inversion injury, it is a superior glide fixation of the fibula. 3. The injury causes pain because the fibula loses superior and inferior motion and thus the foot and ankle becomes less effective as a shock attenuator and soft tissue pain ensues. 4. The palpatory findings are rather subtle and thus it can be overlooked. There is not much physiological superior glide of the fibula and it seems to be enhanced with abduction and eversion (in dorsiflexion) of the foot and ankle. I cannot perceive any superior glide of my fibula with pure dorsiflexion. Some authors report that superior glide is actually enhanced with adduction of the foot, and I would implicate anatomical variance in the shape of the superior and inferior tibiofibular joints, which has been reported in the literature. 5. The injury seems to be an overuse injury and perhaps due to a large passive force imparted when the foot and ankle are in abduction and eversion (and dorsiflexion) and hill running is perfect for imposing these kinds of motions and forces. 6. Palpation of the fibular head and lateral malleolus will reveal ligamentous tension which is greater than the opposite side. the same is true with regards to the soft tissue especially the tibialis anterior and the peroneal group (now named fibularis). 7. Passive superior and inferior glide applied to the lateral malleolus and fibular head will be blocked. Anterior and posterior glide at both ends of the fibula will be variable; either hypermobile or hypomobile, based on anatomical variation. 8. Treatment is very easy, very straightforward. It involves placin the foot and ankle in maximum inversion (because this is non weight-bearing, you will not cause an inversion ankle sprain). The therapist make purchase on lateral malleolus and the fibular head and tractions the fibula inferiorly with moderate force for 2-3 minutes. 9. Again because the great majority of ankle injuries are inversion injuries and this is essentially the opposite, it is probably overlooked in the patient population. research in the non-responders may reveal a higher incidence of this type of injury I am still researching the literature and intend to fully describe my findings and treatment and provide a video link to show the most relevant part of the evaluation and treatment. I look forward to completing this post in the near future. I will finish the video and provide a link. 4. Peroneal Tendonitis PERONEAL TENDONITIS The peroneal tendons are typically irritated at the lateral ankle and foot as the wrap around the lateral malleolus and traverse the retinacular tunnel. They are also irritated on the lateral and inferior portion of the cuboid where there is an indentation specific to the tendons. Not all persons are gifted with a 3rd peroneal muscle/tendon, some have a 3rd small one called the peroneus tertius. You can look that one up, good topic for a later date. There was a recent change in terminology, the peroneal muscles now named the Fibularis longus, replacing Peroneus Longus, and same first name for the Brevis and Tertius. however, it has not yet made its way into common usage. Let me guess thet the change was somewhere around 2003 and doneby the large international anatomy group, whose name escapes me! This is a very good article by Dr Sammarco. He has published extensively and is well respected. In this population my efforts would be directed at reducing the varus of the calcaneus, which in many clients is a mutable dysfunction. I utilize manual therapy, emphasizing creep (deformation over time) to restore calcaneal abduction, a key to restoring calcaneal valgus. Surprisingly, this can oftentimes be accomplished within 1-2 1-hour visits. Chances are good that these clients have not just excessive (unilateral) varus on the side with peroneal tendonitis, but they also have a Type II "Cuboid Syndrome". I place it in quotations, because the limited cuboid mobility is not necessarily painful. In working to restore calcaneal valgus/eversion, all patterns would be evaluated and treated sequentially. Please see the section on Type II Cuboid Syndrome for a review. Of course, in addition to restoring functional, normative mobility throughout the foot and ankle, in this population, treating the peroneal tendonitis would aslo be performed. This would include transverse friction massage and instruction in performing same at home, ice, compression, education in use of supports, exercise, etc. The retinaculum is like a cover, sleeve, pulley that holds the tendo in place, thus providing mechanical advantage. If it is incompetent and does not heal, or if the tendonitis is severe and does not respond to conservative measures, the followiing article becomes relevant. A more current literature search is also in order. IMAGES OF PERONEAL SUBLUXATION AND RETINACULUM TEAR I must object to the term "foot turns inward", and replace with "foot turns outward"! A worthwhile article on Peroneal Tendonitis. Peroneal tendonitis can lead to tendon rupture Dividing tendons into four zones can aid in diagnosis and surgical treatment. By Dave Levitan
1st on the web (May 20, 2005) (http://www.orthosupersite.com/view.asp?rID=3252) Peroneal tendonitis and tendon ruptures can cause severe pain and immobility if left untreated, while early treatment can help patients avoid ruptures. But expect patients to require surgery when they have full ruptures or fail to respond to conservative treatment. “Peroneal tendonitis is a common cause of lateral ankle pain. It occurs in a system of fiberosseous tunnels at the lateral aspect of the foot and ankle. Commonly it is an overuse condition that responds to conservative treatment, but if it is left untreated it can progress to a complete tendon rupture,” said G. James Sammarco, MD, of the Center for Orthopaedic Care in Cincinnati. He discussed management of peroneal tendon ruptures at the American Orthopaedic Foot and Ankle Society Specialty Day meeting at the American Academy of Orthopaedic Surgeons 72nd Annual Meeting in Washington. Predisposing factors Predisposing factors for peroneal tendonitis and rupture include varus alignment of the hindfoot and peroneal subluxation and dislocation. Participation in certain sports, including downhill skiing, skating, ballet, running and soccer creates higher risk for peroneal tendon tears. “Poorly fitting footwear, particularly ski boots and hockey skates, are often the inciting factors,” Sammarco wrote in his abstract. If caught early, surgeons can treat peroneal tendonitis or instability conservatively with NSAIDs, immobilization and avoidance of exacerbating activities. Once secondary changes in the tendon occur, however, surgical treatment often becomes necessary. Sammarco recommended dividing the course of the tendons into four anatomic zones as follows: 1. Zone A includes the superior peroneal retinaculum and distal fibula; 2. Zone B is the inferior peroneal retinaculum at the level of the peroneal tubercle of the calcaneus; 3. Zone C involves the cuboid notch at the point the peroneus longus tendon enters the osseous groove; and 4. Zone D involves avulsion of the tendons from their insertion at the metatarsal base. “Zone A tears usually involve the peroneus brevis, although both tendons can be involved at this level," Sammarco said. "The treatment is to ... do a side-to-side repair.” He noted the need to address nearby muscles and that sometimes accompanying muscles must be excised. Surgical procedures Surgical procedures for the other zones are similar in the need for a side-to-side repair, but some aspects differ. For Zone B tears, surgeons should remove the peroneal tubercle and take care not to close the peroneal retinaculum too tight over the tendon tear. Generally speaking, surgical treatment in all zones “involves decompression of stenosis, debridement, and side-to-side repair of attritional tears and tendon repair for all cases of complete rupture,” according to the abstract. Varus heel deformity, Sammarco noted, may require a calcaneal osteotomy, because when left untreated it can lead to further tendon problems and ankle instability. “Delayed diagnosis or chronic rupture may require [a] tendon transfer,” he wrote. “Neglected rupture may result in secondary varus foot deformity or first metatarsal elavatus.” Early and comprehensive treatment of any peroneal tendonitis or rupture is key for ensuring a good result and full recovery. For more information: · Sammarco GJ. Surgical technique tip I: managing complete peroneal tendon ruptures. Presented at the American Orthopaedic Foot and Ankle Society Specialty Day Meeting. Feb. 26, 2005. Washington. 5. Research on Motion of the Foot and Ankle Remarkable Research on Motion of Major Joints of Foot and Ankle Gait Posture. 2008 Jul;28(1):93-100. Epub 2007 Dec 21. Links
Invasive in vivo measurement of rear-, mid- and forefoot motion during walking.Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden. The aim of this work was to use bone anchored external markers to describe the kinematics of the tibia, fibula, talus, calcaneus, navicular, cuboid, medial cuneiform, first and fifth metatarsals during gait. Data were collected from six subjects. There was motion at all the joints studied. Movement between the talus and the tibia showed the expected predominance of sagittal plane motion, but the talocalcaneal joint displayed greater variability than expected in its motion. Movement at the talonavicular joint was greater than at the talocalcaneal joint and motion between the medial cuneiform and navicular was far greater than expected. Motion between the first metatarsal and the medial cuneiform was less than motion between the fifth metatarsal and cuboid. Overall the data demonstrated the complexity of the foot and the importance of the joints distal to the rearfoot in its overall dynamic function. Emails I sent to Professor Nester a coauthor of the above cited study. Sent: Tuesday, April 07, 2009 8:59 PM Subject: Re: Lundgren et al
Dear Professor Nester, Thank you for a copy of the brilliant paper. I think it is perhaps the best basic science foot and ankle paper of the decade! I have taken the liberty to share it with a few, trust that is OK? I do have several comments and questions which I will post shortly. I apologize for the delay, but will get to it very soon. Best Regards, Jerry Hesch, MHS, PT Sent: Wednesday, April 08, 2009 3:19 PM Subject: Re: Lundgren et al Dear Professor Nester, Thank you again for sharing your research paper with me. I have read it a few times and have a few comments and questions. I would be very grateful for our shared insight in the issues raised below. Please respond to questions and comments. 1. I look forward to creating a table of the average motions so it will be easy to use and commit these to memory. This being for individual joints and for several joints that make up a particular region. 2. If I understand correctly when motion is describes as for example between the cuboid and 5th metatarsal, it describes motion of BOTH, as opposed to one being fixed? 3. The use of 3 markers per pin is simple - yet brilliant! I can see the advantage over use of just one marker, which I would probably have done without further thought. 4. The motion described is rotation as it is measured in degrees. Is there any way to discern glide/slide in mm? 5. The above question is very relevant as a lot of clinicians describe a posterior glide mobilization to the talus, yet I can't help but wonder about the concept. I believe that glide is actually slight at the tibio-talar joint, but rotation in the sagittal plane is much greater. therefore I mobilize the talus with a posterior glide FORCE with heel of hand on the very small portion of talus that is accessible anteriorly. To that I add an anterior drawer/scoop of the calcaneus which I believe engages the talus and induces the primary motion of rotation of talus on tibia. 6. Any thoughts on the reason for some of the low CMC's? 7. I am very interested in learning about the average amount of motions such as superior and inferior glide of the fibula, distraction/compression of the talus on tibia and calcaneus, etc. 8. I am intrigued that the talonavicular motion exceeded the transverse plane motion at the talo-calcaneal. especially intriguing also was the fact that sagittal plane motion of the medial arch exceeded that of the tibio-talar joint in 5/6. 9. Very intriguing that only 1/3 had calcaneal eversion occurring right at or right after heel strike. 10. I am passionate about joint mobilization of the foot and ankle, and I utilize a series at the major joints. I am intrigued that direct attempts to restore calcaneal valgus/eversion fail, but after performing prepatory mobilization at all other major articulations, valgus/eversion is readily increased by inferior distraction of the calcaneus and then aBducting the calcaneus with moderate force 30 reps. Of course this works with average clients who have lost that motion, but not in those who have developmental lack of valgus/eversion or a traumatic bleed into the joint with dense scar tissue. 11. do you intend to do any clinical research, such as pre and post joint mobilization? 12. Is there any way that I might be able to participate in clinical research? 13. Your comment early in the paper contrasting other approaches of measurement causes me to wonder if the use of stereophotogrammetry of the sacroiliac joint has any limitations? would your approach applied to the sacroiliac have distinct advantages? If so, any chance of pursuing it? Please see: Sturesson B, Uden A, Vleeming A. A radiostereometric analysis of movements of the sacroiliac joints during the standing hip flexion test. Spine. 2000;25:364–368. Sturesson B, Selvik G, Uden A. Movements of the sacroiliac joints: a roentgen stereophotogrammetric analysis. Spine. 1989;14:162–165. Tullberg T, Blomberg S, Branth B, Johnsson R. Manipulation does not alter the position of the sacroiliac joint: a roentgen stereophotogrammetric analysis. Spine. 1998;23:1124–1128; discussion 1129. 14. What are your plans for future studies? Any plan to study motion at the superior tibio-fibular joint? 15. On page 99 2nd column first sentence: "A further comparison of walking with bone pins and walking with markers attached to the skin has recently been reported." A little more elaboration would be welcomed. May I please request a copy of this paper #20, and any others that you deem relevant? 16. I often encounter what I believe to be bizarre statements that require elaboration such as that found at several sources, including orthopedic surgery web sites "as the foot/calcareous dorsiflexed the talus plantarflexes"??????? If they mean that it is "relative and early in the motion before the calcaneus engages the talus...OK! Thank you very much for your kindness in taking the time to address my comments and questions. Best Regards, Jerry Hesch, MHS, PT 1609 Silver slipper Ave Henderson, NV 89002 702-558-6011 Pacific Time cell 702-561-0143 6. Letter to the Editor: Hip Study This letter to the Editor of Journal of Orthopedic and Sports Physical Therapy was sent on September 16, 2008. This is a remarkable issue, every single article; very relevant. I was especially delighted to see a one-page article on slipped capital femoral epiphysis, which typically is missed with usual hip radiographs. In the old days PT Journal had a feature titled "Briefly Noted". Hope this similar type of 1-page article continues. Yes, I will still read the longer ones, but can make a case for the short ones too! Back to the slipped capital femoral epiphysis. It requires a lateral or a frog-leg x-ray view and better yet, an MRI as per the article. Another study on abdominal aneurysm in a 38-year male was rather frightening to contemplate, a very relevant read. Reminds me of a client I treated years ago who essentially had zero musculoskeletal signs and my panic was justified. Well, that will come in a future post. Here's to a great study on the hip, even if preliminary, nestled in an excellent edition of JOSPT. Development of a Clinical Prediction Rule for Diagnosing Hip Osteoarthritis in Individuals With Unilateral Hip Pain. JOSPT 2008:38((9); 542-550 Dear EDITOR-IN-CHIEF Dr. Simoneau, and Dr Sutlive, The study Development of a Clinical Prediction Rule for Diagnosing Hip Osteoarthritis in Individuals With Unilateral Hip Pain. JOSPT 2008:38((9); 542-550 is a very promising preliminary study. It is especially encouraging to see all motions of the hip studied, in contrast to other recent studies that did not directly evaluate hip extension; a very relevant component of human gait and function during ADL's. It is also encouraging to read a study that evaluates end-feel, a very relevant emergent property of all articulations. I am curious to know if there was any relevant difference in the ROM when evaluated passively for the purpose of determining end-feel, as compared to active ROM? It seems to me that active ROM can oftentimes be less than passive ROM, especially in the presence of weakness of the agonist or weakness of proximal stabilizers, especially hip extension, hip abduction and hip flexion (order here is arbitrary). Furthermore, my experience has been that with prodding, additional active hip extension ROM can at times be acquired. Regarding hip extension it seems, perhaps by design, that there is an initial ROM that feels normative, and an additional ROM that is achieved with coaxing. I have frequently noted that in a group of 20 to 30 clients or PT's or PT students, at least one will present with a passive lack of hip extension that typically gives several false positives for so-called sacroiliac joint dysfunction (SIJD). This correlates with patellofemoral compression in which patellar lift is limited. This is probably due to subtle hip and knee flexion (client supine), which at times may be missed on visual screen. Gentle mobilization and stretching easily restores the hip extension to within the norm, resolving false positives for SIJD, resolving patellofemoral compression, and restoring a fluidity to client's subjective experience of gait. I recall one client who was then able to climb stairs pain-free and she was very encouraged. Lastly, one PT student presented with the restriction, but her gait gave no clues whatsoever. A former competitive gymnast, her adaptations and compensations were rather remarkable. Nonetheless, she also felt much improved after a simple 2 minute mobilization and stretch. I am taking the time to briefly describe the above, because to my knowledge it has been described in the literature. It is my hope that you will continue to develop your preliminary prediction rules study, and with a larger population, you might also encounter the above and perhaps shed light on the problem. Thank you very much for the opportunity to share some thoughts. I hope that your very promising preliminary study will continue. I look forward to following your future work. Sincerely Yours, Jerry Hesch, MHS, PT LEG LENGTH STUDIES Association of leg-length inequality with knee osteoarthritis: a cohort study.
Ann Intern Med. 2010 Mar 2;152(5):287-95.
Harvey WF, Yang M, Cooke TD, Segal NA, Lane N, Lewis CE, Felson DT.
Boston University School of Medicine and Tufts Medical Center, Boston, Massachusetts; Queen's University, Kingston, Ontario, Canada; University of Iowa, Iowa City, Iowa; University of California at Davis, Davis, California; and University of Alabama, Birmingham, Alabama.
Background: Leg-length inequality is common in the general population and may accelerate development of knee osteoarthritis.
Objective: To determine whether leg-length inequality is associated with prevalent, incident, and progressive knee osteoarthritis.
Design: Prospective observational cohort study.
Setting: Population samples from Birmingham, Alabama, and Iowa City, Iowa.
Patients: 3026 participants aged 50 to 79 years with or at high risk for knee osteoarthritis.
Measurements: The exposure was leg-length inequality, measured by full-limb radiography. The outcomes were prevalent, incident, and progressive knee osteoarthritis. Radiographic osteoarthritis was defined as Kellgren and Lawrence grade 2 or greater, and symptomatic osteoarthritis was defined as radiographic disease in a consistently painful knee.
Results: Compared with leg-length inequality less than 1 cm, leg-length inequality of 1 cm or more was associated with prevalent radiographic (53% vs. 36%; odds ratio [OR], 1.9 [95% CI, 1.5 to 2.4]) and symptomatic (30% vs. 17%; OR, 2.0 [CI, 1.6 to 2.6]) osteoarthritis in the shorter leg, incident symptomatic osteoarthritis in the shorter leg (15% vs. 9%; OR, 1.7 [CI, 1.2 to 2.4]) and the longer leg (13% vs. 9%; OR, 1.5 [CI, 1.0 to 2.1]), and increased odds of progressive osteoarthritis in the shorter leg (29% vs. 24%; OR, 1.3 [CI, 1.0 to 1.7]).
Limitations: Duration of follow-up may not be long enough to adequately identify cases of incidence and progression. Measurements of leg length, including radiography, are subject to measurement error, which could result in misclassification.
Conclusion: Radiographic leg-length inequality was associated with prevalent, incident symptomatic, and progressive knee osteoarthritis. Leg-length inequality is a potentially modifiable risk factor for knee osteoarthritis. Primary Funding Source: National Institute on Aging.
Symptoms of the knee and hip in individuals with and without limb length inequality.
Osteoarthritis Cartilage. 2009 May;17(5):596-600. Epub 2008 Nov 19.
Golightly YM, Allen KD, Helmick CG, Renner JB, Jordan JM.
Department of Epidemiology, School of Public Health, University of North Carolina, Chapel Hill, NC 27599, USA.
OBJECTIVE: This cross-sectional study examined the association of limb length inequality (LLI) with chronic joint symptoms at the hip and knee in a large, community-based sample, adjusting for the presence of radiographic osteoarthritis (OA) and other confounders.
METHODS: The total study group comprised 3012 participants with complete knee symptoms data, 3007 participants with complete hip symptoms data, and 206 with LLI>or=2 cm. Presence of chronic knee symptoms was defined as report of pain, aching, or stiffness (symptoms) of the knee on most days. Presence of chronic hip symptoms was defined as hip pain, aching, or stiffness on most days or groin pain. Multiple logistic regression models were used to examine the relationship of LLI with knee and hip symptoms, while adjusting for demographic and clinical factors, radiographic knee or hip OA and history of knee or hip problems (joint injury, fracture, surgery, or congenital anomalies).
RESULTS: Participants with LLI were more likely than those without LLI to have knee symptoms (56.8% vs 43.0%, P<0.001), and hip symptoms (49.5% vs 40.0%, P=0.09). In adjusted models, knee symptoms were significantly associated with presence of LLI (adjusted odds ratio [aOR]=1.41, 95% confidence interval, [95% CI] 1.02-1.97), but the relationship between hip symptoms and LLI (aOR=1.20, 95% CI 0.87-1.67) was not statistically significant.
CONCLUSION: LLI was moderately associated with chronic knee symptoms and less strongly associated with hip symptoms. LLI may be a new modifiable risk factor for therapy of people with knee or hip symptoms.
Leg-length inequality is not associated with greater trochanteric pain syndrome.
Arthritis Res Ther. 2008;10(3):R62. Epub 2008 May 29.
Segal NA, Harvey W, Felson DT, Yang M, Torner JC, Curtis JR, Nevitt MC; Multicenter Osteoarthritis Study Group.
Department of Orthopedics & Rehabilitation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 0728 JPP, Iowa City, IA 52242-1088, USA. neil-segal@uiowa.edu
INTRODUCTION: Greater trochanteric pain syndrome (GTPS) is a common condition, the pathogenesis of which is incompletely understood. Although leg-length inequality has been suggested as a potential risk factor for GTPS, this widely held assumption has not been tested.
METHODS: A cross-sectional analysis of greater trochanteric tenderness to palpation was performed in subjects with complaints of hip pain and no signs of hip osteoarthritis or generalized myofascial tenderness. Subjects were recruited from one clinical center of the Multicenter Osteoarthritis Study, a multicenter population-based study of community-dwelling adults aged 50 to 79 years. Diagnosis of GTPS was based on a standardized physical examination performed by trained examiners, and technicians measured leg length on full-limb anteroposterior radiographs.
RESULTS: A total of 1,482 subjects were eligible for analysis of GTPS and leg length. Subjects' mean +/- standard deviation age was 62.4 +/- 8.2 years, and 59.8% were female. A total of 372 lower limbs from 271 subjects met the definition for having GTPS. Leg-length inequality (difference > or = 1 cm) was present in 37 subjects with GTPS and in 163 subjects without GTPS (P = 0.86). Using a variety of definitions of leg-length inequality, including categorical and continuous measures, there was no association of this parameter with the occurrence of GTPS (for example, for > or = 1 cm leg-length inequality, odds ratio = 1.17 (95% confidence interval = 0.79 to 1.73)). In adjusted analyses, female sex was significantly associated with the presence of GTPS, with an adjusted odds ratio of 3.04 (95% confidence interval = 2.07 to 4.47). CONCLUSION: The present study found no evidence to support an association between leg-length inequality and greater trochanteric pain syndrome.
Leg length discrepancy.
Gait Posture. 2002 Apr;15(2):195-206.
Gurney B.
Division of Physical Therapy, School of Medicine, University of New Mexico, Health Sciences and Services, Boulevard 204, Albuquerque, NM 87131-5661, USA. bgurney@salud.unm.edu
The role of leg length discrepancy (LLD) both as a biomechanical impediment and a predisposing factor for associated musculoskeletal disorders has been a source of controversy for some time. LLD has been implicated in affecting gait and running mechanics and economy, standing posture, postural sway, as well as increased incidence of scoliosis, low back pain, osteoarthritis of the hip and spine, aseptic loosening of hip prosthesis, and lower extremity stress fractures. Authors disagree on the extent (if any) to which LLD causes these problems, and what magnitude of LLD is necessary to generate these problems. This paper represents an overview of the classification and etiology of LLD, the controversy of several measurement and treatment protocols, and a consolidation of research addressing the role of LLD on standing posture, standing balance, gait, running, and various pathological conditions. Finally, this paper will attempt to generalize findings regarding indications of treatment for specific populations. | |
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