Manipulative interventions for reducing pulled elbow in young children

BACKGROUND

Pulled elbow (nursemaid's elbow) is a common injury in young children. It results from a sudden pull on the arm, usually by an adult or taller person, which pulls the radius through the annular ligament, resulting in subluxation (partial dislocation) of the radial head. The child experiences sudden acute pain and loss of function in the affected arm. Pulled elbow is usually treated by manual reduction of the subluxed radial head. Various manoeuvres can be applied. Most textbooks recommend supination of the forearm, as opposed to pronation and other approaches. It is unclear which manoeuvre is most successful. This is an update of a Cochrane review first published in 2009.

OBJECTIVES

The objective of this review is to compare the effectiveness and painfulness of the different methods used to manipulate pulled elbow in young children.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, LILACS, PEDro, clinical trial registers and reference lists of articles. Date of last search: July 2011.

SELECTION CRITERIA

Any randomised or quasi-randomised controlled clinical trials evaluating manipulative interventions for pulled elbow were included. Our primary outcome was failure at the first attempt, necessitating further treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently evaluated trials for inclusion and, for the included trials, independently assessed the risk of bias and extracted data.

MAIN RESULTS

One trial with 66 children was newly included in this update. Overall, four trials with 379 children, all younger than seven years old, were included. All four trials compared pronation versus supination. One trial was at high risk of selection bias because allocation was not concealed and all four trials were at high risk of detection bias due to the lack of assessor blinding. Pronation resulted in statistically significantly less failure than supination (21/177 versus 47/181, risk ratio 0.45; 95% confidence interval 0.28 to 0.73). Pain perception was reported by two trials but data were unavailable for pooling. Both studies concluded that the pronation technique was less painful than the supination technique.

AUTHORS' CONCLUSIONS

There is limited evidence from four small low-quality trials that the pronation method might be more effective and less painful than the supination method for manipulating pulled elbow in young children. We recommend that a high quality randomised trial be performed to strengthen the evidence.

Inversion/Eversion strength dysbalance in patients with medial tibial stress syndrome

The main purpose of the study is to investigate the inversion/eversion muscle strength balance of the ankle in patients with medial tibial stress syndrome (MTSS). A dysbalance of these muscles may play a role in the pathophysiology of MTSS. Another aim is to measure the medial longitudinal arch and navicular drop in patients with MTSS. A total of 11 patients diagnosed with MTSS in the outpatient clinic of Ege University School of Medicine Sports Medicine Department were enrolled in this study. The control group consisted of 11 regularly exercising individuals. The mean age of the patient group and the control group was 21. 0 ± 1.9 years (18-23 years) and 23.2 ± 2.9 years (18-27 years), respectively. A detailed exercise questionnaire was administered to all subjects. Isokinetic muscle strength testing was performed at 30°/sec and 120°/sec to assess invertor and evertor muscle strength of the ankle. Photographs of the weight bearing and non-weight bearing foot were taken to measure the medial longitudinal arch deformation and the navicular drop. At 30°/sec, the average eversion concentric strength was significantly higher in the patient group, and the inversion/eversion strength ratio was significantly higher in the control group (p < 0.05). At 120°/sec velocity, average concentric eversion strength was significantly higher in the patient group (p < 0.05). The measurements of pronation indicators did not reveal any statistically significant differences between the two groups (p > 0.05). MTSS may occur without an increase of pronation indicators like medial longitudinal arch deformation or navicular drop. In such cases, one of the predisposing factors may be the strength dysbalance of the invertor/evertor muscles in favour of the evertor muscles. This observation may be of additional value in the prevention and therapy of MTSS. Key pointsAt 30°/sec, the average eversion concentric strength was significantly higher in the MTSS group, and the inversion/eversion strength ratio was significantly higher in the control group.At 120°/sec velocity, average concentric eversion strength was significantly higher in the MTSS group.MTSS may occur without an increase of pronation indicators like medial longitudinal arch deformation or navicular drop. In such cases, one of the predisposing factors may be the strength dysbalance of the invertor/evertor muscles in favour of the evertor muscles.

The navicular position test - a reliable measure of the navicular bone position during rest and loading

BACKGROUND

Lower limb injuries are a large problem in athletes. However, there is a paucity of knowledge on the relationship between alignment of the medial longitudinal arch (MLA) of the foot and development of such injuries. A reliable and valid test to quantify foot type is needed to be able to investigate the relationship between arch type and injury likelihood. Feiss Line is a valid clinical measure of the MLA. However, no study has investigated the reliability of the test.

OBJECTIVES

The purpose was to describe a modified version of the Feiss Line test and to determine the intra- and inter-tester reliability of this new foot alignment test. To emphasize the purpose of the modified test, the authors have named it The Navicular Position Test.

METHODS

Intra- and inter-tester reliability were evaluated of The Navicular Position Test with the use of ICC (interclass correlation coefficient) and Bland-Altman limits of agreement on 43 healthy, young, subjects.

RESULTS

Inter-tester mean difference -0.35 degrees [-1.32; 0.62] p = 0.47. Bland-Altman limits of agreement -6.55 to 5.85 degrees, ICC = 0.94. Intra-tester mean difference 0.47 degrees [-0.57; 1.50] p = 0.37. Bland-Altman limits of agreement -6.15 to 7.08 degrees, ICC = 0.91.

DISCUSSION

The present data support The Navicular Position Test as a reliable test of the navicular bone position during rest and loading measured in a simple test set-up.

CONCLUSION

The Navicular Position Test was shown to have a high intraday-, intra- and inter-tester reliability. When cut off values to categorize the MLA into planus, rectus, or cavus feet, has been determined and presented, the test could be used in prospective observational studies investigating the role of the arch type on the development of various lower limb injuries.

Motor nerve transfers to restore extrinsic median nerve function: case report

Active pronation is important for many activities of daily living. Loss of median nerve function including pronation is a rare sequela of humerus fracture. Tendon transfers to restore pronation are reserved for the obstetrical brachial plexus palsy patient. Transfer of expendable motor nerves is a treatment modality that can be used to restore active pronation. Nerve transfers are advantageous in that they do not require prolonged immobilization postoperatively, avoid operating within the zone of injury, reinnervate muscles in their native location prior to degeneration of the motor end plates, and result in minimal donor deficit. We report a case of lost median nerve function after a humerus fracture. Pronation was restored with transfer of the extensor carpi radialis brevis branch of the radial nerve to the pronator teres branch of the median nerve. Anterior interosseous nerve function was restored with transfer of the supinator branch to the anterior interosseous nerve. Clinically evident motor function was seen at 4 months postoperatively and continued to improve for the following 18 months. The patient has 4+/5 pronator teres, 4+/5 flexor pollicis longus, and 4-/5 index finger flexor digitorum profundus function. The transfer of the extensor carpi radialis brevis branch of the radial nerve to the pronator teres and supinator branch of the radial nerve to the anterior interosseous nerve is a novel, previously unreported method to restore extrinsic median nerve function.

MEDIAL FOOT LOADING ON ANKLE AND KNEE BIOMECHANICS

BACKGROUND: The incidence of anterior cruciate ligament (ACL) injuries among females continues at disproportionate rates compared to males, with research indicating inconclusive multifactorial causality. Data from previous retrospective studies suggest an effect of abnormal foot and ankle biomechanics on pathology at the knee, including the ACL. OBJECTIVE: To determine if a relationship exists between plantar foot loading patterns during normal gait and high risk biomechanics purported to increase risk of ACL injury. METHODS: Dynamic barefoot plantar pressure distribution was measured on 33 female collegiate soccer players. Groups were divided according to their predominant gait loading pattern (medial or lateral). Three dimensional (3-D) motion analysis was conducted during drop vertical jumps to assess vertical ground reaction force and discrete angle and joint moment variables of the lower extremities. RESULTS: No significant differences occured in sagittal or coronal plane knee joint kinematics and kinetics between the medial and lateral loading groups. DISCUSSION: Dynamic foot and ankle biomechanics during gait do not appear to be related to lower extremity kinematics or kinetics during landing in collegiate female soccer players. CONCLUSION: The exact cause of the abnormal differences in female landing biomechanics has not been irrefutably defined. This study suggests no effect of foot and ankle biomechanics exists on the landing mechanics of female soccer players.

Plantar foot pressures after the augmented low dye taping technique

CONTEXT

Taping and orthoses are frequently applied to control excessive foot pronation to treat or prevent musculoskeletal pain and injury of the lower limb. The mechanism(s) by which these devices bring about their clinical effects are at best speculative and require systematic evaluation.

OBJECTIVE

To determine the initial effect of the augmented low Dye taping technique (ALD) on plantar foot pressures during walking and jogging.

DESIGN

Within-subjects, repeated-measures randomized control trial.

SETTING

Gait research laboratory.

PATIENTS OR OTHER PARTICIPANTS

Fifteen women and 7 men with an average age of 28.0 +/- 7.4 years who were asymptomatic.

INTERVENTION(S)

Participants walked and jogged along a 12-m walkway before and after the application of ALD. The untaped side served as the control.

MAIN OUTCOME MEASURE(S)

Peak and mean maximum plantar pressure data were calculated for the medial and lateral areas of the rear and midfoot and the medial, central, and lateral forefoot areas. Thus, a 3-factor model was tested: condition (ALD, control) x time (preapplication, postapplication) x area (medial and lateral rearfoot and midfoot and medial, central, and lateral forefoot).

RESULTS

Significant 3-way interactions were present for both peak and mean maximum plantar pressure during walking (F (6,126) = 9.55, P = .006 and F (6,126) = 11.36, P = .003, respectively) and jogging (F (6,126) = 5.76, P = .026 and F (6,126) = 4.56, P = .045, respectively) tasks. The ALD predominantly increased plantar pressures in the lateral midfoot during walking and jogging. In addition, tape reduced mean maximum pressure at the medial forefoot and at the medial rearfoot during walking.

CONCLUSIONS

The ALD, which has previously been shown to reduce excessive pronation, produced significant increases in lateral midfoot plantar pressures, thereby providing additional information to be considered when the mechanism(s) of action of such a treatment are modeled.

Plantar fasciitis and the windlass mechanism: a biomechanical link to clinical practice

OBJECTIVE

Plantar fasciitis is a prevalent problem, with limited consensus among clinicians regarding the most effective treatment. The purpose of this literature review is to provide a systematic approach to the treatment of plantar fasciitis based on the windlass mechanism model.

DATA SOURCES

We searched MEDLINE, SPORT Discus, and CINAHL from 1966 to 2003 using the key words plantar fasciitis, windlass mechanism, pronation, heel pain, and heel spur.

DATA SYNTHESIS

We offer a biomechanical application for the evaluation and treatment of plantar fasciitis based on a review of the literature for the windlass mechanism model. This model provides a means for describing plantar fasciitis conditions such that clinicians can formulate a potential causal relationship between the conditions and their treatments.

CONCLUSIONS/RECOMMENDATIONS

Clinicians' understanding of the biomechanical causes of plantar fasciitis should guide the decision-making process concerning the evaluation and treatment of heel pain. Use of this approach may improve clinical outcomes because intervention does not merely treat physical symptoms but actively addresses the influences that resulted in the condition. Principles from this approach might also provide a basis for future research investigating the efficacy of plantar fascia treatment.

Metrecom measurement of navicular drop in subjects with anterior cruciate ligament injury

OBJECTIVE

Research suggests that excessive pronation of the foot contributes to the incidence of anterior cruciate ligament (ACL) tears by increasing internal tibial rotation. Studies have documented greater navicular drop values in individuals with a history of an ACL tear using methods that may not accurately follow the motion of underlying bone. The purpose of our investigation was to compare the navicular drop of subjects with a history of ACL tears with healthy controls when measured by a Metrecom.

SUBJECTS

Eighteen subjects previously diagnosed with a torn ACL were matched by age, sex, and limb to noninjured control subjects.

DESIGN AND SETTING

Static group comparisons of navicular drop in subjects with an injured ACL and subjects having no history of ACL injury.

MEASUREMENTS

A single investigator performed the measure of navicular drop. The position of the navicular tuberosity was digitized while the subject stood barefoot on a flat surface in subtalar joint neutral and in relaxed stance. Intrarater reliability was assessed using intraclass correlation coefficient and standard error of the measurement. An independent t test assessed the difference between the amount of navicular drop in the ACL group and the controls.

RESULTS

Analysis of repeated measures, intraclass correlation coefficient (2,1), demonstrated intrarater reliability for the measure of navicular drop to be 0.90; the standard error of measurement was 1.19 mm. The independent t test showed a statistically greater amount of navicular drop in the ACL group.

CONCLUSIONS

Excellent intrarater reliability was demonstrated when using the Metrecom to measure navicular drop. Excessive subtalar joint pronation, measured as navicular drop, was identified as 1 factor that may contribute to ACL injury.

Prevention of injuries in excessive pronators through proper soccer shoe fit

OBJECTIVE

Properly fitting shoes are important in the prevention of injuries. When it involves the lower extremity and pronation, proper fitting of shoes is considered as a treatment for gender variations in shoe fit and excessive pronators. The purpose of the study therefore, is to compare static and dynamic foot tracings in excessive pronators to determine if there were differences between right and left feet of male and female soccer athletes.

DESIGN AND SETTING

Multivariate analysis with static and dynamic foot tracing measurements of foot length, first metatarsal length, fifth metatarsal length, metatarsal width, and heel width as the dependent variables and male and female (gender) as the effect. Interscholastic soccer players who were excessive pronators were used in the study.

SUBJECTS

Volunteers were solicited from a boys and girls interscholastic soccer team (level C to varsity). From this pool of 40 subjects, a group of 20 (10 males and 10 females, n = 40 feet), with excessive pronation were used in the study. Criteria for selection was based on navicular height (? 10 mm) and arch index (? .26).

MEASUREMENTS

Static and dynamic foot tracings were determined. From these tracings, foot length, first metatarsal length, fifth metatarsal length, metatarsal width, and heel width were determined. Multivariate analysis of variance (MANOVA; p < .05), one-way repeated measures analysis of variance (ANOVA; p < .05), and pairwise comparisons (p < .05) were performed to determine significance, as well as intraclass correlation coefficients for intraclass reliability of the measurements.

RESULTS

For between genders, male foot tracings for static and dynamic right and/or left feet were statistically greater in all foot parameters except heel width. Comparison of same side static and dynamic measurements for the right or left foot indicated differences for foot length, metatarsal width, and heel width for males, and foot length, fifth metatarsal width, metatarsal width, and heel width for females. There were no significant differences between static and dynamic foot measurements for either foot between genders and within genders.

CONCLUSIONS

Foot length should not be the only consideration used for determining proper shoe fit. Static and dynamic measurements for the right or left foot, as well as metatarsal width, fifth metatarsal length, and heel width should also be included.