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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 7. Letter to the Editor: Talus
8. Letter to the Editor: Hip Study 9. Letter to the Editor: Trochanteric Bursitis | |
| 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. 7. Letter to the Editor: Talus Talus (Talocrural Joint) Mobilization not published, I never completed it, so did not submit in a timely manner
RE: Landrum E, Kelln Cdr B.M., Parente W. R., Ingersoll C. D., Hertel J. Immediate Effects of Anterior-Posterior Talocrural Joint Mobilization After Prolonged Ankle Immobilization: A Preliminary Study. J Man & Manip Ther 16(2):100-105.
Dear Editor,
RE: Landrum E, Kelln Cdr B.M., Parente W. R., Ingersoll C. D., Hertel J. Immediate Effects of Anterior-Posterior Talocrural Joint Mobilization After Prolonged Ankle Immobilization: A Preliminary Study. J Man & Manip Ther 16(2):100-105.
This study is very encouraging for a variety of reasons. I am delighted that it is a preliminary study, as there is so much potential for enhancements with future studies. While I am not a researcher, I do enthuse about the topic of the study.
Future study with the use of a control group that receives only the instrumented ankle arthrometer (IAA) would allow determination of whether or not the IAA had a treatment effect in enhancing ankle dorsiflexion.
The IAA could be applied to the posterior calcaneus only, in order to tease out some data on the role of anterior glide of the calcaneus. It is my belief that anterior glide of the calcaneus is a very important part of the procedure used to restore posterior glide of the talus with the end result of increased ankle dorsiflexion. It appears to add a sagittal rotational element to the calcaneus and therefore the talus.
The IAA seems to be a relevant tool that can be applied to many structures throughout the body to research appropriate forces for optimal joint mobilization. It might also be used to evaluate joint laxity and hypomobility throughout the body.
The treatment applied to the talus is described as Anterior to Posterior Glide of the Talus (APGT). It is referenced in 6 studies mentioned in the above article. I have recently struggled over this terminology. The term APGT seems appropriate if one is describing what they are performing directly to the talus alone. Yes, the specific force I apply to the talus is appropriately called APGT. It also seems appropriate when one looks at the anatomy of the distal tibia, which articulates with the dome of the talus. In the sagittal plane, the distal tibia is fairly flat, having only a mild anterior-posterior concavity. I am hard pressed to find an adequate picture demonstrating that, having looked in several clinical textbooks. I easily find pictures that demonstrate the significant convexity of the dome of the talus. My anatomical model came to the rescue and it demonstrates that the dome of the talus makes only a relatively small amount of contact with the distal tibia*, and that the contact points on each bone changes throughout the range of dorsiflexion and plantarflexion. At present, A-P or P-A glide of the talus is a theoretical construct lacking hard data. Perhaps glide and roll would be more appropriate. In time I hope to pursue this question via literature research. I submit that mobilizing the distal tibia on the talus can be described as a glide, when the force is A-P or P-A.
*Neumann made this point in a brief general statement comparing contact surface areas for the ankle, knee and hip.
Sincerely Yours, Jerry Hesch
8. Letter to the Editor: Hip Study POSTERIOR GLIDE OF HIP STUDY (ABSTRACT FOLLOWS LETTER BELOW) Letter not accepted for publication Hesch Seminars - Jerry Hesch, PT
8228 Willow Cabin St www.HeschMethod.com Las Vegas, Nevada 89131-1438 email:Jerryhesch@Ivcm.com
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Letter not accepted for publication April 3, 2003 Guy G. Simoneau, PT, PhD, ATC Editor-in-Chief J of Orthopedic & Sports Physical Therapy
1111 N. Fairfax St. Suite 100Alexandria, VA 22314-1436 RE: Linn Harding, Mary F. Barbe, Amy Marks, Raymond Ajai, Jennifer Lardiere, Heather Sweringa, Katherine Shepard Posterior-Anterior Glide of the Femoral Head in the Acetabulum: A Cadaver Study J Orthop Sports Phys Ther. 2003;33:118-125. Dear Editor-in-Chief, I would like to express my appreciation to the authors of the above study. As a former manual therapy clinician and a manual therapy educator, I find the study to be very relevant. In November I was teaching a seminar n the sacroiliac joint pelvis, and lumbar spine. I demonstrated how a client can present with a significant reduction of hip extension with concommitant positive tests for sacroiliac dysfunction. This includes altered pelvic landmarks in standing, a positive March test, and a positive Standing Flexion Test; yet the crux of the problem is in the hip. I made the comment that this pattern presents as though the head of the femur were stuck in flexion and posterior glide, yet I could not envision the hip as having much posterior glide available, based on my understanding of the joint. However, anterior glide passive motion testing revealed hypomobility, in addition to-the loss of active and-passive hip extension. A generalization can be made stating that the shaft of the femur is a bowed structure in the sagittal plane, and is convex anteriorly. In supine' a client with a purported posterior glide fixation will present with the hip in some degree of flexion, such that the greatest portion of the femur appears to more anterior than the contralateral femur, except at the most superior portion. The correction involves anterior glide and gentle stretch into extension, typically with the client in prone, with the knee flexed. This treatment is often very effective in a short period of time, typically 2-3 minutes. The standing pelvic landmarks are then much improved and the standing sacroiliac motion screening tests are typically rendered negative; hence, they were previously false positive. This study is relevant because manual therapists evaluate anterior and posterior glide of the femur, and alteration of those accessory motions, along with reduced hip extension, can be associated with false positive sacroiliac screening tests. Recent studies have suggested that these standing sacroiliac motion tests do not actually provoke any significant motion within the sacroiliac joints, and other structures are implicated.1, 2 Perhaps this is simply a pattern of maintained shortening of the hip flexors, and treatment via anterior glide of the hip may be unnecessary. I look forward to evaluating this possibility. The authors dedicated more than a full page to the section titled: Limitations of Study and Recommendations for Future Research. I believe that they did an excellent job of utilizing objective thinking in this section and it may be very useful for future studies. I was surprised at the degree of excursion of the femoral head with distraction in loose pack position. I believe that there are clinical ramifications worthy of further study. I was also surprised at the amount of force utilized in the study (up to 356 Newtons). I have described up to 176 Newtons for spring testing the ilium, and lesser forces at the sacrum, ischium and symphysis pubis.' If further study on hip mobilization is performed on living subjects, I believe that pilot testing will reveal that much smaller forces are necessary, in order to avoid pain provocation. Again, I believe that the research and the article were very well executed, and are very relevant to manual therapists. Thank you. Sincerely Yours, Jerry Hesch, PT The Hesch Method Sacroiliac Seminars 1. Sturesson B, Uden A, Vleeming A. A radiostereometric analysis of movements of the sacroiliac joints during the standing hip flexion test. Spine. 2000;25(3):364-368. 2. Egan D, Cole J, Twomey L. The standing forward flexion test: an inaccurate determinant of sacroiliac joint dysfunction. Physio.1996;82(4):236-242. 3. Hesch J. The most common patterns of sacroiliac joint dysfunction. In: Movement, Stability & Low Back Pain: the Essential Role of the Pelvis. Vleeming A, Mooney V, Dorman T, Snijders C, Stoeckart R, eds. New York, NY: Churchill Livingstone; 1997. Posterior-Anterior Glide of the Femoral Head in the Acetabulum: A Cadaver Study Linn Harding, Mary F. Barbe, Amy Marks, Raymond Ajai, Jennifer Lardiere, Heather Sweringa, Katherine Shepard Study Design: Descriptive study employing cadaver dissection and measurement of posterior-anterior (PA) glide of the femoral head in the acetabulum. Objective: To quantify PA glide of the femoral head in the acetabulum in a cadaveric sample. Background: Posterior-anterior glide of the femoral head within the acetabulum is a joint mobilization procedure described in orthopaedic physical therapy texts, yet there is no published evidence that the joint structures of the hip allow such movement. This study attempted to quantify PA glide of the femoral head in the hip joints of embalmed cadavers. Methods: Twelve hips, 3 male and 9 female, from 8 embalmed cadavers were employed in this study. Hips were dissected to the level of the joint capsule and a metal rod inserted through the femoral neck served as a mobilizing handle. A load cell was installed into this handle so that mobilizing forces could be monitored. A dial gauge, which recorded displacement of the femoral head, was mounted to the pelvis via bone pins and an external fixator. Results: Using mobilizing forces of 89, 178, 267, and 356 N, mean femoral head displacements of 0.57, 0.93, 1.20, and 1.52 mm were recorded. Within the 89-N trials, PA displacement ranged from a minimum of 0.04 mm to a maximum of 1.54 mm. Within the 356-N trials, PA displacement of the femoral head ranged from a minimum of 0.25 mm to a maximum of 2.90 mm. Conclusion: In an embalmed cadaveric model, measurable PA glide of the femoral head within the acetabulum does exist and it is highly variable between individuals. J Orthop Sports Phys Ther. 2003;33:118-125. Key Words: accessory movement, cadaver hip joint, joint mobilization, posterior-anterior glide 9. Letter to the Editor: Trochanteric Bursitis TROCHANTERIC BURSITIS PROTONICS Published in J of the Section on Women’s Health 27:3, December 2003 Letter to the Editor
Dear Editor, This letter is in response to the article titled "Management of a Woman Diagnosed with Trochanteric Bursitis With the Use of a Protonics® Neuromuscular System" from Volume 2, 1:12-16, April 2003 issue of JSOWH. The stated purpose was to describe a woman with trochanteric bursitis who had 3 physical therapy visits which focused on achieving neutral pelvic position via unilateral hamstring recruitment using a Protonic® Neuromuscular System. The authors are to be commended in significantly reducing the signs and symptoms in 2 visits which were 6 weeks apart. The next visit a year later revealed that the client was significantly improved from the symptoms that had plagued her for 2 years. In the conclusion they state: "Attention to pelvic positioning using the Protonics® resulted in successful outcomes for this woman with trochanteric bursitis." This is such an important case report because it raises many issues. I appreciated the author's theoretical development of the problem of trochanteric bursitis in the introduction section of the article. In the section titled Purpose the authors' state that "The theory behind the case was that the trochanteric bursa was irritated and compressed by the ITB because of the asymmetrical pelvic position and restoring a position of symmetry would abolish the symptoms." A detailed evaluation was performed and I will focus on several positive findings. Hip rotation was measured in sitting and the difference noted was 5° (20 left versus 25° of external rotation). Assuming a possible standard 5% error rate the actual difference might actually be 2.5°. In addition to observing a possible functionally shortened left lower extremity, 6 special tests were pictured and described as "being used to assess pelvic femoral position." The tests are: the Ober Test (bilaterally positive, more so left), and Modified Ober, Thomas Test and Modified Thomas Test (positive left), and supine Left and Right Lower Trunk Rotation (restricted to the left). These findings were purported to suggest a left anteriorly rotated inominate (ilium). The focus of the case was stated, which was "to correct faulty mechanics through the kinetic chain by correcting the pelvic asymmetry to a neutral position." An alternate explanation could be that the limitation of left lower trunk rotation could be due to limited left hip abduction/flexion/external rotation or the opposite motion in the right hip, or both instead of the lower trunk, though it was not discerned. It is certainly surprising and perhaps controversial, that no attempt was made to directly evaluate the strength and endurance or facilitation/inhibition of the muscle group that was targeted for strengthening or recruitment. No attempt was made to compare it to the asymptomatic side prior to and after intervention. I struggle with the author's conclusion of an anterior left ilium based on the hip and trunk tests mentioned. Several of the books referenced in the article contain chapters detailing evaluation of the sacroiliac (SIJ/SIJs), hips, and pelvis (as a unit). In this study, there was no observation of the pelvic posture, which is typically performed anteriorly and posteriorly in the following postures: standing, sitting, supine, and prone. I believe that confusion has surrounded the pelvic structure and a brief survey of the writings in our own profession and in others will affirm this. The SIJ joint has 5/6 synovial characteristics and therefore should be evaluated in the same manner as other synovial joints. Many passive motion tests (spring tests) have been developed or adopted and modified for grading passive accessory motion of SIJ joints and symphysis pubis, and thettraditional palpatory evaluation has also been expanded upon.' The pelvic evaluation described in the article literally shies away from direct palpation, direct observation, and direct motion testing of the pelvis and SIJ, instead utilizing rather indirect hip and lower trunk motion, and hip muscle length tests. The author's did state that these tests were "thought to suggest an anteriorly tilted, forwardly rotated, left l inominate and a left femur that moved with it into passive internal rotation." Since this is a distinct departure from the norm of SIJ/pelvic evaluation, additional details explaining the rationale are certainly warranted. On that basis I reviewed the only study from the article that addressed this issue via research.' This was a student project with a sample of 10 measuring pelvic angle with an inclinometer before and after intervention with the Protonics® strengthening device. The mean anterior pelvic tilt was 19.9° (SD=6.9). Five subjects experienced a change of 3.2° (SD=5.3) of unilateral pelvic tilt and 2 subjects experienced worsening of anterior ilium and the 3 remaining were unchanged. While changes were determined to be significant, it is important to interpret these results in terms of clinical practice and ask if 3.6° of change is clinically relevant. The study might be judged as weak on this basis along with the small sample size. Unfortunately, pilot testing was not performed to determine the degree of intratester reliability, thus the measurements are in question. The authors brought this relevant topic to the forefront, by performing a relevant first study and these issues can be addressed in a future study. Perhaps this nondirect approach may stem from the fact that. multiple studies since the mid 1980s have shown poor inter and intra-tester reliability with respect to palpation and with gross motion testing of the SIJ via the traditional paradigm. Further-more, recent studies have shown that the standing motion tests and manipulation do not actually induce any significant motion in the SIJ joint itself, though no doubt the pelvis itself may move as a unit in tri-dimensional space.''' These studies may be discouraging to clinicians who only use the traditional motion tests and do not utilize direct passive motion testing. Fortunately, there is an approach that appears to be an improvement over the traditional approach. This approach utilizes a few additional land-marks for palpation which is performed in stable postures and also utilizes passive motion testing to grade mobility on a 6-point scale.5.6 The findings with palpation and passive motion testing when Anterior Ilium is present; are not subtle. Furthermore, in the presence of Anterior Ilium, several directions of motion would present as distinctly hypo mobile and the opposite directions would present as hyper mobile. Anterior Ilium is a motion dysfunction that occurs in all 3 planes of the body and evaluation and treatment must address all 3 planes. Motion does occur in the SIJs with passive motion testing as demonstrated with fluoroscopy.' Additionally, recent research demonstrates greater than 70% intratester agreement with most of the palpatory and passive motion tests taught by the new paradigm.' This approach acknowledges the probability that SIJ motion restriction is often due to an external restrictor such as posture of the pelvis or deep muscle guarding; which restricts movement from going through the joint, as opposed to motion restriction occurring only within the joint. The authors in the case study used a Protonics® device to strengthen the hamstrings in order to address the pelvic posture. While studies have shown that the hamstring muscle can restrict motion in the SIJ, it typically occurs at end range, such as with straight leg raising.' In performing the literature review of the Protonics® device the authors reviewed several impressive studies that used the device for patellofemoral pain. However, without detailing any statements from the studies regarding improved pelvic position, the following conclusion was made: "From these 2 studies, the Protonics® System appears to be beneficial in managing patients with patellofemoral syndrome via repositioning of the pelvis and femur Pelvic and femur repositioning may have application for individuals having trochanteric bursitis." If the studies which were referenced reached these conclusions, it was not evident from reading the article. It would be ideal to reference the studies with more detail in order to adequately under gird the conclusions. I reviewed Timm's impressive study (referenced in case study) on patellofemoral pain."' While there was statistically significant improvement in patellar alignment and a decrease in pain, there was no speculation whatsoever regarding ilium position. It is also possible that repositioning of the patella itself, or repositioning of only the femur, or both, excluding the ilium; could also be implicated. It is intriguing indeed that at the end of the 1st visit 3 special tests were rendered negative. In future studies it would be interesting to deter-mine how long these benefits are maintained. It would appear that the results achieved in the first 6 weeks may be due to the intervention; of course this retrospective case study could not by its very nature, be rigidly controlled. It is very difficult, however, to ascribe all or even the majority of benefits between 6 weeks and 52 weeks to the treatment paradigm, as there are simply too many confounding variables. Additional details on the presence or absence of potential intervening variables and control thereof would strengthen the case study. Nonetheless, the case report is not to be discounted and certainly gives direction for future study. As a disabled PT with former episodes of SIJ dysfunction, I would require any treating clinician (especially Physical Therapists) to directly evaluate position and mobility of the pelvic structure rather than rely only on tests that have a greater emphasis on hip mobility and hip muscle length. I would require that the structure be evaluated in neutral, and at end range flexion and extension of the lumbar spine and hips. I would also require that strength, endurance, facilitation, and inhibition be evaluated in the involved side and be compared to the non-symptomatic side before purchasing a strengthening device. I compliment the authors for addressing pain and function and passive motion tests of the hip and in publishing their case report so that debate can occur. I am motivated to learn more about the Protonics® brace and how it can be appropriately utilized in our profession, especially with regards to patellofemoral pain. Thank you for allowing me to share my thoughts and concerns.
Sincerely yours, Jerry Hesch, PT Founder, the Hesch Method of Treating SIJ Dysfunction http://www.heschmethod.com REFERENCES 1. Hesch J. Evaluating sacroiliac joint play with spring tests. J Ob Gyn PT. 1996;20 (3) :4-7. 2. Antoun N, Kerns K, Kramer A, et al. The influence of the Protonics® knee brace on pelvic position. Research Reports 2000. Loma Linda, Calif: School of Allied Health Professionals; 2000:21-36. 3. Tullberg T, Blomberg S, Branth B, et al. Manipulation does not alter the position of the sacroiliac joint. Spine. 1998;23(10): 1124-1129. 4. Sturesson B, Uden A, Vleeming A, et al. A radiosterometric analysis of movements of the sacroiliac joints during the hip flexion test. Spine. 2000;23 (3) :364-368. 5. Hesch J. The Hesch Method of Treating Sacroiliac Joint Dysfunction. Course workbook. Las Vegas, NV: 2002. 6. Hesch J. Evaluation and treatment of the most common pattern of sacroiliac joint dysfunction. In: Movement, Stability and Low Back Pain: the Essential Role of the Pelvis. Vleeming A, Mooney V, Dorman T, et al. London: Churchill Livingston; 1997:535-545. 7. Bernard T. The sacroiliac joint as a source of low back pain: an orthopedic perspective. Video presentation.. Presented at The First Interdisciplinary World Congress on Low Back Pain and the Sacroiliac Joint. November 6, 1992, San Diego, CA. 8. Olson L, Kramer T. Establishing the reliability of the hesch method's spring and positional tests in patients with low back pain. Presented at World Physical Therapy Congress. June 8, 2003, Barcelona, Spain. 9. Vleeming A, Stoeckart R, Snijders CJ. The sacrotuberous ligament: a conceptual approach toits dynamic role in stabilizing the sacroiliac joint. Clin Biomec. 1989; 4:201-203. 10. Timm KE. Randomized controlled trial of Protonics7 on patell,tr pain, position, and function. Med Sci Sports Exercise 1998; 30(5):665-670.
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