Efficacy of customised foot orthoses in the treatment of Achilles tendinopathy: study protocol for a randomised trial

Background

Achilles tendinopathy is a common condition that can cause marked pain and disability. Numerous non-surgical treatments have been proposed for the treatment of this condition, but many of these treatments have a poor or non-existent evidence base. The exception to this is eccentric calf muscle exercises, which have become a standard non-surgical intervention for Achilles tendinopathy. Foot orthoses have also been advocated as a treatment for Achilles tendinopathy, but the long-term efficacy of foot orthoses for this condition is unknown. This manuscript describes the design of a randomised trial to evaluate the efficacy of customised foot orthoses to reduce pain and improve function in people with Achilles tendinopathy.

Methods

One hundred and forty community-dwelling men and women aged 18 to 55 years with Achilles tendinopathy (who satisfy inclusion and exclusion criteria) will be recruited. Participants will be randomised, using a computer-generated random number sequence, to either a control group (sham foot orthoses made from compressible ethylene vinyl acetate foam) or an experimental group (customised foot orthoses made from semi-rigid polypropylene). Both groups will be prescribed a calf muscle eccentric exercise program, however, the primary difference between the groups will be that the experimental group receive customised foot orthoses, while the control group receive sham foot orthoses. The participants will be instructed to perform eccentric exercises 2 times per day, 7 days per week, for 12 weeks. The primary outcome measure will be the total score of the Victorian Institute of Sport Assessment - Achilles (VISA-A) questionnaire. The secondary outcome measures will be participant perception of treatment effect, comfort of the foot orthoses, use of co-interventions, frequency and severity of adverse events, level of physical activity and health-related quality of life (assessed using the Short-Form-36 questionnaire - Version two). Data will be collected at baseline, then at 1, 3, 6 and 12 months. Data will be analysed using the intention to treat principle.

Discussion

This study is the first randomised trial to evaluate the long-term efficacy of customised foot orthoses for the treatment of Achilles tendinopathy. The study has been pragmatically designed to ensure that the study findings are generalisable to clinical practice.

Trial registration

Australian New Zealand Clinical Trials Registry Number: ACTRN12609000829213.

Thoracic outlet syndrome part 1: clinical manifestations, differentiation and treatment pathways

Thoracic outlet syndrome (TOS) is a challenging condition to diagnose correctly and manage appropriately. This is the result of a number of factors including the multifaceted contribution to the syndrome, the limitations of current clinical diagnostic tests, the insufficient recognition of the sub-types of TOS and the dearth of research into the optimal treatment approach. This masterclass identifies the subtypes of TOS, highlights the possible factors that contribute to the condition and outlines the clinical examination required to diagnose the presence of TOS.

Prevention and management of osteitis pubis in the Australian Football League: a qualitative analysis

OBJECTIVES

To examine current practices and develop a set of recommendations for the management of osteitis pubis in the Australian Football League (AFL).

DESIGN

A qualitative study using in-depth interviews to gather data and thematic coding to analyze findings.

SETTING

Participants were interviewed in their workplace or at a convenient meeting point.

PARTICIPANTS

Thirty-six medical and fitness staff from the 16 AFL clubs.

RESULTS

Respondents from all clubs viewed osteitis pubis as an overuse injury and recognized that the key to prevention is balancing pelvic integrity and load. Osteitis pubis was described as the end result of a continuum of groin pathology, and recognition of predisposing factors and early detection were identified as the key elements of optimal management. Management strategies included rest, training modification, cross-training, correction of predisposing factors, physical therapy and a progression back to competition. Most clubs also conduct generic prevention and education programs.

CONCLUSIONS

Overall, respondents perceived that awareness and management of osteitis pubis is currently at a high level in the AFL. Management of osteitis pubis requires the balancing of pelvic integrity and mechanical load through the pelvis and the early identification of warning signs.

The influence of second toe and metatarsal length on stress fractures at the base of the second metatarsal in classical dancers

BACKGROUND

Stress fractures at the base of the second metatarsal frequently occur in female classical dancers. There is a strong belief that a foot shape in which the first metatarsal or toe is shorter than the second metatarsal or toe increases the risk of this injury in dancers. However, there is a lack of empirical evidence to support this theory. The objective of this study was to examine the influence of the relative length difference between the first and second metatarsals and first and second toes on the frequency of stress fractures at the base of the second metatarsal in elite, female classical dancers.

METHODS

Both feet of 50 elite female classical dancers were measured for length differences between the first and second toes and first and second metatarsals. Retrospective analysis of dancers' medical histories revealed 17 feet with stress injury and 83 without. The mean of the difference between the metatarsal and toe length for the stress-injury group was compared to that of the control group.

RESULTS

No difference between the groups was identified for first and second toe length difference (p = 0.865) and the relative difference between the ends of the first two metatarsals (p = 0.815).

CONCLUSIONS

Dancers who had a stress injury at the base of the second metatarsal displayed similar variances in the two independent variables as dancers who had not had such an injury.

The relationship between adherence to hand therapy and short-term outcome after distal radius fracture

This study aimed to examine the relationship between adherence to hand therapy and short-term outcome after fracture of the distal radius. Attendance at hand therapy appointments, therapist-rated adherence during appointments, and home-exercise diaries were used to monitor adherence in 15 people undertaking rehabilitation after a wrist fracture. Outcome measures were change in impairment (wrist extension, grip strength, and pain rating) and change in activity (modified Levine questionnaire, Jebsen Test of Hand Function) from initial assessment (after cast removal) to follow-up (six weeks later). Multiple regression analysis found over 50% of variance in wrist extension change, Levine questionnaire change, and change on the simulated feeding item of the Jebsen Test of Hand Function to be predicted by adherence. Home exercise adherence was the most important predictor of the adherence measures. These results highlight the importance of adherence to home exercises prescribed by a hand therapist after fracture of the distal radius.

Effect of physiotherapy attendance on outcome after anterior cruciate ligament reconstruction: a pilot study

BACKGROUND

In many centres patients are routinely referred for physiotherapy after anterior cruciate ligament (ACL) reconstruction. However, to date the role and amount of supervised physiotherapy required has not been clearly established.

OBJECTIVE

To establish whether there was any difference in outcome between a group of patients who attended physiotherapy regularly after ACL reconstruction and a group who attended only infrequently.

METHODS

Ten patients who had attended physiotherapy infrequently (mean 1.9 visits) during the first six months after ACL reconstructive surgery were matched for age, sex, graft type, and activity level and occupation before injury with 10 patients who had attended physiotherapy regularly (mean 26.5 visits). Outcome was assessed at 12 months using the Cincinnati knee rating system and the IKDC form.

RESULTS

Compared with the regular physiotherapy group, patients in the minimal physiotherapy group had fewer symptoms (mean Cincinnati symptom score 46.2 v 43.4, p = 0.045). There was also a trend towards higher overall Cincinnati knee scores in the minimal physiotherapy group (mean 93.7 v 87.3, p = 0.06) but no difference in IKDC ratings.

CONCLUSION

These preliminary results indicate that some patients who choose to attend physiotherapy on a very limited basis after ACL reconstruction can achieve satisfactory, if not better, outcomes than patients who attend physiotherapy regularly.

Nontransitivity of paternity in a bird

In many animals reproductive success is determined after insemination by the interaction of male and female processes. While sperm competition is reasonably well understood in some taxa, other processes, such as cryptic female choice and differential early embryo mortality resulting from genetic incompatibilities, are less well understood. The relative importance of these different factors contributing to reproductive success is difficult to assess. Here we control for male-mediated effects (which are often considerable and can mask more subtle processes) through the artificial insemination of known numbers of sperm in the domestic fowl to reveal that male reproductive success is nontransitive across females: the success of a particular male depends on the background against which his sperm compete for fertilization. Two potential processes could account for this effect: cryptic female choice (sperm choice) or differential early embryo mortality. Regardless of the mechanism, nontransitivity of male reproductive success has important evolutionary consequences, including the maintenance of variation in male fitness.

The sexually-selected sperm hypothesis: sex-biased inheritance and sexual antagonism

When females are inseminated by more than one male (polyandry) sexual selection continues after insemination in the form of sperm competition and cryptic female choice. The sexually-selected sperm hypothesis proposes that, under the risk of sperm competition, additive variation in male traits determining fertilising efficiency will select for female propensity to be polyandrous in order to increase the probability of producing sons with superior fertilising efficiency. Two factors complicate this prediction: sex-biased transmission of male fertilising efficiency traits and sexual antagonism of sex-limited traits, fostered by sex-biased inheritance. Here, we (i) review the evidence that male traits contributing towards fertilising efficiency are heritable through sex-biased mechanisms, and (ii) explore the evolutionary implications for male and female reproductive strategies caused by both sex-biased transmission and sexual antagonism of fertilising efficiency traits. Many male fertilising efficiency traits are heritable through sex-biased mechanisms and may not necessarily increase female fitness. The predictions of the sexually-selected sperm hypothesis change dramatically under these different mechanisms of inheritance of fertilising efficiency traits, and different fitness pay-offs derived by females from the expression of such traits. Both sex-biased control of fertilising efficiency and sexual antagonism may also be important in explaining the maintenance of the genetic variance and selection potential of fertilising efficiency. We propose that a useful approach to test the sexually-selected sperm hypothesis is to combine studies which identify behavioural and physiological mechanisms explaining variation in reproductive success with artificial selection experiments to infer the underlying evolutionary patterns.

Pre- and post-insemination episodes of sexual selection in the fowl, Gallus g. domesticus

Although much attention has been recently directed to sexual selection arising after insemination from sexual promiscuity, little is known about the mechanisms determining reproductive success after insemination, and the way these mechanisms interact with each other and with selective mechanisms occurring before insemination: mate choice and mate acquisition. Here, we briefly review the findings of an on-going study investigating the mechanisms generating variation in reproductive success at both a pre- and a post-insemination stage in the domestic fowl. Female preference consistently favours socially dominant males before and after insemination. However, although social status mediates the number of sperm that a male inseminates into a female, dominant males may inseminate sperm of lower fertilising quality than their subordinates. We argue that mitochondrial genes may contribute to determine sperm quality, and speculate that the maternal control of mitochondrial genes may prevent sexual selection from operating on males, thus explaining both the lack of a positive correlation between social dominance and sperm quality and the maintenance of variation in male quality in the fowl.

Indirect partner choice through manipulation of male behaviour by female fowl, Gallus gallus domesticus

The direct and indirect consequences of female copulatory behaviour for copulation success have seldom been quantified. In feral fowl, most copulations were forced by males and copulation success was determined by two factors. First, female differential resistance and solicitation directly affected copulation success and were displayed non-randomly with respect to male social status. Second, another female copulatory behaviour, the distress call, had an indirect effect on both copulation success and the quality of copulation partners. Distress calls triggered male attention to a copulation, which increased the probability of higher-ranking males than the copulating male disrupting the copulation and inseminating the calling female. Females preferentially uttered distress calls when mounted by low-ranking males. Both copulation resistance and distress calling influenced copulation success, but only distress calling increased the probability of copulation disruption by other males. Consistent with the effect of direct selection, differential distress calling indirectly biased copulation success in favour of dominant males. Female fowl may thus ameliorate the effect of male sexual coercion by manipulating male behaviour.

Female feral fowl eject sperm of subdominant males

Paternity is often determined by competition between the ejaculates of different males. Males can also use particular behaviours or structures to manipulate how females use sperm. However, the ability of females to bias sperm utilization in favour of preferred males independently of male manipulation has not been demonstrated. Females are predicted to respond differentially to the sperm of different males when the reproductive interests of the sexes differ and when females are coerced into copulating. Here we show that in female feral fowl most copulations are coerced, and that females consistently bias sperm retention in favour of the preferred male phenotype. Females prefer to copulate with dominant males, but when sexually coerced by subordinate males, they manipulate the behaviour of dominant males to reduce the likelihood of insemination. If this fails, females differentially eject ejaculates according to male status in the absence of any male manipulation and preferentially retain the sperm of dominant males.