Does stretching increase ankle dorsiflexion range of motion? A systematic review

Association between Achilles tightness and lower extremity injury in children

BACKGROUND

It is unclear whether isolated gastroc/soleus tightness can increase the risk of lower extremity injury in an otherwise healthy child.

QUESTIONS/PURPOSES

(1) Is there a difference in gastroc/soleus tightness, as represented by ankle dorsiflexion with the knee extended, in children presenting with upper versus lower extremity complaints? (2) Is there a difference in gastroc/soleus tightness in children presenting with atraumatic versus traumatic lower extremity complaints?

METHODS

We performed a cross-sectional study of 206 consecutive walking age children presenting to a county orthopedic clinic with new upper or lower extremity complaints. Passive ankle dorsiflexion was measured based on the lateral border of the foot versus the anterior lower leg with the knee fully extended and the foot in inversion.

RESULTS

Average age was 10.0 ± 4.5 years. In the 117 patients presenting with upper extremity complaints, ankle dorsiflexion was 15.0° ± 11.6°. Of the lower extremity patients, 40 presented without trauma, with dorsiflexion of 11.8° ± 14.5°, while 49 presented with trauma, with dorsiflexion of 6.5° ± 12.0°. Multiple regression analysis found significantly decreased ankle dorsiflexion with increasing age and in the lower extremity trauma group. Twelve percent of upper extremity patients had 0° or less of dorsiflexion, as compared to 25% of lower extremity nontrauma patients and 41% of lower extremity trauma patients.

CONCLUSIONS

Patients presenting with lower extremity trauma had significantly more gastroc/soleus tightness in their well leg than patients presenting with upper extremity complaints. Gastroc/soleus tightness may present a simple target for reducing lower extremity injury rates in children.

The Split Second Effect: The Mechanism of How Equinus Can Damage the Human Foot and Ankle

We are currently in the process of discovering that many, if not the majority, of the non-traumatic acquired adult foot and ankle problems are caused by a singular etiology: non-neuromuscular equinus or the isolated gastrocnemius contracture. There is no question that this biomechanical association exists and in time much more will be uncovered. There are three basic questions that must be answered: why would our calves tighten as we normally age, how does a tight calf, or equinus, actually cause problems remotely in the foot and ankle, and how do the forces produced by equinus cause so many seemingly unrelated pathologies in the foot and ankle? The purpose of this paper is to address the second question: how does a tight calf mechanically cause problems remotely in the foot and ankle? There has been little evidence in the literature addressing the biomechanical mechanisms by which equinus creates damaging forces upon the foot and ankle, and as a result, a precise, convincing mechanism is still lacking. Thus, the mere concept that equinus has anything to do with foot pathology is generally unknown or disregarded. The split second effect, described here, defines exactly how the silent equinus contracture creates incremental and significant damage and injury to the human foot and ankle resulting in a wide variety of pathological conditions. The split second effect is a dissenting theory based on 30 years of clinical and academic orthopedic foot and ankle experience, keen clinical observation along the way, and review of the developing literature, culminating in examination of many hours of slow motion video of normal and abnormal human gait. To my knowledge, no one has ever described the mechanism in detail this precise.

Physiotherapy for plantar fasciitis: a UK-wide survey of current practice

OBJECTIVES

To identify how United Kingdom (UK) physiotherapists currently diagnose, assess and manage plantar fasciitis in routine practice.

DESIGN

Online questionnaire survey.

PARTICIPANTS

Practising physiotherapists across the UK who treat patients with plantar fasciitis.

METHODS

Physiotherapists were approached via 'interactive Chartered Society of Physiotherapy (CSP)' online networks and an email database of clinical educators in South West England. An online questionnaire was developed by reviewing similar existing physiotherapy surveys and consultation with experienced musculoskeletal researchers/clinicians. Descriptive statistics were used to analyse the data.

RESULTS

285 physiotherapists responded, with 257 complete survey responses. Pain on palpation and early morning pain were the most common diagnostic criteria, with some physiotherapists using no formal test criteria. Advice (237/257, 92%), plantar fasciitis pathology education (207/257, 81%) and general stretching exercises (189/257, 74%) were most routinely used. Prefabricated orthotics, custom made orthotics and night splints were seldom always used. For the manual therapy approach, the most frequently used modalities were massage, myofascial release, specific soft tissue mobilisations and myofascial trigger point therapy. Commonly used outcome measures were pain assessment, functional tests and range of movement.

CONCLUSIONS

Physiotherapists appeared to follow most of the established diagnostic criteria for PF, but have not followed established outcome measure guidelines. Advice as well as education with an emphasis on self-management including calf/hamstring stretching was the most commonly reported treatment approach. There was uncertainty whether this approach accurately reflected clinical practice used throughout the UK, owing to potential response bias/unknown response rate and the low number of patients with PF treated by the respondents.

Ankle-Dorsiflexion Range of Motion After Ankle Self-Stretching Using a Strap

CONTEXT

A variety of ankle self-stretching exercises have been recommended to improve ankle-dorsiflexion range of motion (DFROM) in individuals with limited ankle dorsiflexion. A strap can be applied to stabilize the talus and facilitate anterior glide of the distal tibia at the talocrural joint during ankle self-stretching exercises. Novel ankle self-stretching using a strap (SSS) may be a useful method of improving ankle DFROM.

OBJECTIVE

To compare the effects of 2 ankle-stretching techniques (static stretching versus SSS) on ankle DFROM.

DESIGN

Randomized controlled clinical trial.

SETTING

University research laboratory.

PATIENTS OR OTHER PARTICIPANTS

Thirty-two participants with limited active dorsiflexion (<20°) while sitting (14 women and 18 men) were recruited.

MAIN OUTCOME MEASURE(S)

The participants performed 2 ankle self-stretching techniques (static stretching and SSS) for 3 weeks. Active DFROM (ADFROM), passive DFROM (PDFROM), and the lunge angle were measured. An independent t test was used to compare the improvements in these values before and after the 2 stretching interventions. The level of statistical significance was set at α = .05.

RESULTS

Active DFROM and PDFROM were greater in both stretching groups after the 3-week interventions. However, ADFROM, PDFROM, and the lunge angle were greater in the SSS group than in the static-stretching group (P < .05).

CONCLUSIONS

Ankle SSS is recommended to improve ADFROM, PDFROM, and the lunge angle in individuals with limited DFROM.

A comparative efficacy evaluation of ultrasound-guided pulsed radiofrequency treatment in the gastrocnemius in managing plantar heel pain: a randomized and controlled trial

OBJECTIVE

The treatment of plantar heel pain is highly challenging. We report ultrasound-guided pulsed radiofrequency treatment (UG-PRF) in the gastrocnemius to treat plantar heel pain and minimize the safety issues.

DESIGN

This study compared UG-PRF with sham treatment in 100 patients with plantar heel pain. Primary outcome measures include the pain subscale of the Foot Health Status Questionnaire (FHSQ-pain) and "first step" pain as measured on a visual analogue scale (VAS-"first-step" pain). The secondary outcome measures include the FHSQ-foot function and general foot health, and health related quality of life (assessed using the Short Form-36 questionnaire [SF-36]). All outcomes were measured at 3 and 6 months post-treatment.

RESULTS

The results showed the efficacy of UG-PRF in terms of pain management, as reflected by higher FHSQ-pain score (increased by 20.0 (P < 0.0001) and 17.9 (P = 0.001) compared with the sham treatment at 3 or 6 months, respectively) and lower VAS-"first-step" pain (reduced by 26.1 (P < 0.0001) and 14.3 (P = 0.01) compared with the sham group at 3 or 6 months, respectively). The FHSQ-foot function and FHSQ-general foot health were increased by the UG-PRF (P < 0.05, vs sham treatment at 3 or 6 months). The SF-36 physical component score in the sham group was 10.8 (P = 0.042) and 10.4 (P = 0.044) lower than the UG-PRF group at 3 or 6 months, respectively. No severe complications were observed.

CONCLUSIONS

We conclude that the UG-PRF is both safe and efficacious in managing plantar heel pain.

The use of ultrasound to isolate the gastrocnemius-soleus junction prior to gastrocnemius recession

Gastrocnemius recession has become a popular procedure to release isolated gastrocnemius tightness. Using visual anatomic landmarks alone to plan the incision can be deceiving. The use of ultrasound preoperatively has been highly reproducible in isolating the gastrocnemius-soleus junction in the authors' practice. This provides confidence for incision placement, a smaller incision, and isolated release of the gastrocnemius fascia while leaving the underlying soleus undisturbed.

Three-dimensional analysis of foot motion after uphill walking with mobilization with movement using tape applied to the talocrural joint in women with limited ankle dorsiflexion

BACKGROUND

Previous studies that investigated mobilization with movement (MWM) treatment assessed only improvements in passive range of motion (ROM). No information is currently available regarding the efficacy of modified MWM by application of tape. Therefore, we investigated the effect of uphill walking with modified MWM using tape applied to the talocrural joint (uphill walking with MWM taping) in women with limited ankle dorsiflexion.

METHODS

Twelve feet of 12 women with ankle dorsiflexion < 8 degrees were studied. Passive ROM measured using a goniometer was used to select participants. Participants walked on a level walkway under 3 conditions: before exercise, after uphill walking, and after uphill walking with MWM taping. The Oxford Foot Model using 3D motion analysis system was used to examine dynamic foot kinematics, and statistical significance was determined by 1-way repeated-measures analysis of variance.

RESULTS

After uphill walking with MWM taping, peak hindfoot dorsiflexion relative to the tibia was significantly greater than that before exercise and after uphill walking. Furthermore, peak forefoot plantarflexion relative to the hindfoot, peak hindfoot plantarflexion relative to the tibia, and backward tilt of the tibia were greater than those before exercise.

CONCLUSIONS

Uphill walking with MWM taping resulted in an immediate alteration in foot motion during walking, increasing hindfoot dorsiflexion in particular.

CLINICAL RELEVANCE

Further studies are needed to investigate the long-term effects of uphill walking with MWM taping and its potential use in rehabilitation training.

The effect of exercise and time on the height and width of the medial longitudinal arch following the modified reverse-6 and the modified augmented low-dye taping procedures

PURPOSE/BACKGROUND

No evidence exits regarding the magnitude of the change in foot posture following the "modified reverse-6" (MR6) taping procedure, either alone or in combination with the "low-dye" (LD) taping technique. The purpose of this study was to investigate the change in the height and width of the midfoot after application of the MR6 and the MR6 plus the LD (MR6+LD) taping technique and determine how long those changes last.

METHODS

Eleven individuals (2 female and 9 male) were recruited for this study and were tested under each of two experimental conditions, the MR6 and the MR6+LD taping technique. The order of testing for the two conditions was randomly determined. For each condition, the height and width of the midfoot at 50% of each subject's foot length was initially measured and then again immediately following the application of the tape. These measurements were repeated four hours later immediately prior to running two miles on a treadmill, again immediately after running, and finally after another four hours.

RESULTS

The dorsal arch height increased significantly with both the MR6 and MR6+LD taping, but only the MR6+LD remained statistically greater after four hours, a bout of exercise and again at the end of the day. The mean width of the midfoot significantly decreased with both taping procedures. The change in the width of the midfoot remained significantly decreased in both taping conditions after exercise and throughout the day.

CONCLUSIONS

Both taping procedures are able to significantly change the height and width of the medial longitudinal arch of the foot, but the change lasted longer when the two taping procedures were combined.

LEVELS OF EVIDENCE

Level 3, Prospective Cohort Study.

Chronic plantar fasciitis: plantar fasciotomy versus gastrocnemius recession

PURPOSE

The purpose of this study was to compare results of partial proximal fasciotomy (PPF) with proximal medial gastrocnemius release (PMGR) in the treatment of chronic plantar fasciitis (CPF).

METHOD

This retrospective study compares 30 patients with CPF that underwent PPF with 30 that underwent isolated PMGR. Both groups were matched in terms of previous treatments and time from onset of symptoms to surgery. Different standardised evaluation scales (VAS, Likert, AOFASh) were used to evaluate results.

RESULTS

Plantar fasciotomy had satisfactory results in just 60 % of patients, with an average ten weeks needed to resume work and sports. Patient satisfaction in the PMGR group reached 95 %, being back to work and sports at three weeks on average. Functional and pain scores were considerably better for PMGR and fewer complications registered.

CONCLUSION

In our series, isolated PMGR is a simple and reliable procedure to treat patients with CPF. It provides far better results than conventional fasciotomy with less morbidity and better patient satisfaction, and thus has become our surgical procedure of choice in recalcitrant CPF.

Acute effects of 5 min of plantar flexor static stretching on balance and gait in the elderly

[Purpose] The purpose of this study was to examine the acute effects of five minutes of plantar flexor static stretching (PSS) on the balance and gait of the elderly. [Subjects and Methods] Twenty-five subjects aged 65 years and above performed 5 min of PSS in the form of wedge board standing. The sway length of each subject’s center of mass was measured to examine the subject’s static balance. It was measured by one minute of quiet standing with the eyes closed. Functional reach tests (FRTs), timed up and go tests (TUGs), and 10-meter walk tests (10MWTs) were performed to examine dynamic balance and gait before and after PSS. [Results] The outcome showed significant increases in sway distances (6.55 ± 5.03 cm) after stretching. However, in the FRTs, TUGs, and 10MWTs, the reach distance and time did not show any significant changes. [Conclusion] These results suggest that the elderly subjects temporarily experienced difficulties in maintaining balance immediately after the PSS but that their dynamic balance and gait were not adversely affected after a short period of time. Therefore, to prevent falls and perform exercises in a safe way, it is recommended to allow patients to rest after performing PSS.

Treatment of subacute posterior knee pain in an adolescent ballet dancer utilizing trigger point dry needling: a case report

STUDY DESIGN

Case Report.

BACKGROUND AND PURPOSE

Dry needling (DN) is an increasingly popular intervention used by clinicians as a treatment of regional neuromusculoskeletal pain. DN is an invasive procedure that involves insertion of a thin monofilament needle directly into a muscle trigger point (MTP) with the intent of stimulating a local twitch response. Current evidence is somewhat limited, but recent literature supports the use of this intervention in specific neuromusculoskeletal conditions. The purpose of this case report is to present the outcomes of DN as a primary treatment intervention in an adolescent subject with subacute posterior knee pain.

CASE DESCRIPTION

The subject was a 16-year-old female competitive ballet dancer referred to physical therapy with a two month history of right posterior knee pain. Palpation identified MTPs which reproduced the patient's primary symptoms. In addition to an exercise program promoting lower extremity flexibility and hip stability, the subject was treated with DN to the right gastrocnemius, soleus, and popliteus muscles.

OUTCOMES

The subject reported being pain free on the Numerical Pain Scale and a +7 improvement in perceived change in recovery on the Global Rating of Change at final follow-up. Physical examination demonstrated no observed impairments or functional limitations, including normal mobility, full strength, and unrestricted execution of dance maneuvers.

DISCUSSION

The patient was able to return to high level dance training and competition without physical limitations and resumed pre-injury dynamic movement activities including dancing, running, jumping, and pivoting without pain. DN can be an effective and efficient intervention to assist patients in decreasing pain and returning to high intensity physical activity. Additional research is needed to determine if DN is effective for other body regions and has long-term positive outcomes.

LEVEL OF EVIDENCE

Level 4.

Acute decrease in the stiffness of resting muscle belly due to static stretching

The purpose of the study was to examine the acute effect of static stretching exercise on the resting stiffness of gastrocnemius muscle belly. Ten healthy young adults performed standing wall stretching in dorsiflexion for 1 min at a time and repeated five times. Before and after stretching, the shear modulus was measured in medial and lateral heads of the resting gastrocnemius muscle with ultrasound shear-wave elastography. After the stretching, dorsiflexion range of motion (ROM) of the ankle joint increased (P < 0.01) by 3.9° and returned in 20 min. Immediately after stretching, shear modulus decreased (P < 0.01) by 14%, compared with before stretching across muscle heads. The decrease in shear modulus returned in 20 min after stretching. In the comparison group of 10 additional subjects, the standing intervention without stretching had no influence on these measures. There was a negative correlation between dorsiflexion ROM and shear modulus in either head before and after stretching. The results demonstrate the transient decreases in the stiffness of the resting gastrocnemius muscle belly and indicate that joint flexibility is greater in individuals with lower resting stiffness of the muscle belly.

Interventions for increasing ankle joint dorsiflexion: a systematic review and meta-analysis

BACKGROUND

Ankle joint equinus, or restricted dorsiflexion range of motion (ROM), has been linked to a range of pathologies of relevance to clinical practitioners. This systematic review and meta-analysis investigated the effects of conservative interventions on ankle joint ROM in healthy individuals and athletic populations.

METHODS

Keyword searches of Embase, Medline, Cochrane and CINAHL databases were performed with the final search being run in August 2013. Studies were eligible for inclusion if they assessed the effect of a non-surgical intervention on ankle joint dorsiflexion in healthy populations. Studies were quality rated using a standard quality assessment scale. Standardised mean differences (SMDs) and 95% confidence intervals (CIs) were calculated and results were pooled where study methods were homogenous.

RESULTS

Twenty-three studies met eligibility criteria, with a total of 734 study participants. Results suggest that there is some evidence to support the efficacy of static stretching alone (SMDs: range 0.70 to 1.69) and static stretching in combination with ultrasound (SMDs: range 0.91 to 0.95), diathermy (SMD 1.12), diathermy and ice (SMD 1.16), heel raise exercises (SMDs: range 0.70 to 0.77), superficial moist heat (SMDs: range 0.65 to 0.84) and warm up (SMD 0.87) in improving ankle joint dorsiflexion ROM.

CONCLUSIONS

Some evidence exists to support the efficacy of stretching alone and stretching in combination with other therapies in increasing ankle joint ROM in healthy individuals. There is a paucity of quality evidence to support the efficacy of other non-surgical interventions, thus further research in this area is warranted.

Therapeutic interventions for increasing ankle dorsiflexion after ankle sprain: a systematic review

CONTEXT

Clinicians perform therapeutic interventions, such as stretching, manual therapy, electrotherapy, ultrasound, and exercises, to increase ankle dorsiflexion. However, authors of previous studies have not determined which intervention or combination of interventions is most effective.

OBJECTIVE

To determine the magnitude of therapeutic intervention effects on and the most effective therapeutic interventions for restoring normal ankle dorsiflexion after ankle sprain.

DATA SOURCES

We performed a comprehensive literature search in Web of Science and EBSCO HOST from 1965 to May 29, 2011, with 19 search terms related to ankle sprain, dorsiflexion, and intervention and by cross-referencing pertinent articles.

STUDY SELECTION

Eligible studies had to be written in English and include the means and standard deviations of both pretreatment and posttreatment in patients with acute, subacute, or chronic ankle sprains. Outcomes of interest included various joint mobilizations, stretching, local vibration, hyperbaric oxygen therapy, electrical stimulation, and mental-relaxation interventions.

DATA EXTRACTION

We extracted data on dorsiflexion improvements among various therapeutic applications by calculating Cohen d effect sizes with associated 95% confidence intervals (CIs) and evaluated the methodologic quality using the Physiotherapy Evidence Database (PEDro) scale.

DATA SYNTHESIS

In total, 9 studies (PEDro score = 5.22 ± 1.92) met the inclusion criteria. Static-stretching interventions with a home exercise program had the strongest effects on increasing dorsiflexion in patients 2 weeks after acute ankle sprains (Cohen d = 1.06; 95% CI = 0.12, 2.42). The range of effect sizes for movement with mobilization on ankle dorsiflexion among individuals with recurrent ankle sprains was small (Cohen d range = 0.14 to 0.39).

CONCLUSIONS

Static-stretching intervention as a part of standardized care yielded the strongest effects on dorsiflexion after acute ankle sprains. The existing evidence suggests that clinicians need to consider what may be the limiting factor of ankle dorsiflexion to select the most appropriate treatments and interventions. Investigators should examine the relationship between improvements in dorsiflexion and patient progress using measures of patient self-reported functional outcome after therapeutic interventions to determine the most appropriate forms of therapeutic interventions to address ankle-dorsiflexion limitation.

The reliability of the modified reverse-6 taping procedure with elastic tape to alter the height and width of the medial longitudinal arch

PURPOSE/BACKGROUND

Anti-pronation-taping utilizing both inelastic and elastic tape has been advocated to reduce pain and symptoms associated with excessive foot pronation. An important question regarding the use of taping is whether it can be applied consistently from one therapist to the next, from one session to the next or from one day to the next. Thus, the purpose of this study was to determine whether the "modified" Reverse-6 taping procedure using elastic tape could be applied to produce a consistent within-day and between-day change in the height and width of the medial longitudinal arch for a single clinician as well as between clinicians. A second purpose was to determine if the amount of general clinical experience influenced this consistency.

METHODS

Fifteen asymptomatic individuals (10 female and 5 male) with a mean age of 28.7 years were recruited to participate in this study. The height and width of the midfoot at 50% of each subject's foot length was measured in standing using a digital gauge and caliper. These measurements were done twice on the same day, on two different days and again by two clinicians with different levels of experience before and after having their feet taped using the "modified" Reverse-6 taping technique using elastic tape. Both clinicians received a one-hour training session on how to apply the taping technique and were also given a DVD showing the technique that they could review. In addition to descriptive statistics, intra-class correlation coefficients (ICC) were used to assess each clinician's within-day and between-day reliability. Between-clinician reliability was also determined.

RESULTS

The mean dorsal arch height and midfoot width before the application of tape was 62.7 and 78.9 mm. The mean dorsal arch height and width after the application of tape was 66.6 and 78.8 mm. The within-day reliability ICC(2,1) values for the two clinicians ranged from .865 to .991. The between-day reliability ICC(2,1) values for the two clinicians ranged from .874 to .985. The between-clinician reliability ICC(2,1) values ranged from .918 to .993.

CONCLUSIONS

The results of this study indicate that the "modified" Reverse-6 foot taping technique using elastic tape can be used by more than one therapist for the same patient as well as from one session to the next with excellent reliability.

LEVEL OF EVIDENCE

Level 2, Prospective Cohort Study.

Effect of kinesio tape application on calf pain and ankle range of motion in duathletes

The purpose of this study was to examine the effect of the kinesio tape immediately after its application and after a duathlon competition on calf pain and the ankle range of motion in duathletes. A sample of 28 duathletes (age 29.11 ± 10.35 years; body height 172.57 ± 6.17 cm; body mass 66.63 ± 9.01 kg; body mass index 22.29 ± 2.00 kg/m(2)) were recruited from the competitors in a duathlon sprint. The Numerical Pain Rating Scale and ankle dorsiflexion range of motion measures were obtained at baseline, immediately after taping and 10 to 15 minutes after ending the duathlon competition. The kinesio tape was applied on the calf of duathletes 20 to 90 minutes before the competition, only on one of their legs (experimental leg) with the other leg acting as a control (control leg) in a randomized order. According to the between-group comparison, no differences were found immediately after the application of the kinesio tape and after the competition in the ankle range of motion and calf pain. However, a significant difference from baseline to immediately after taping was found in the ankle range of motion in the experimental leg. Applying the kinesio tape on the calf seems to immediately increase ankle dorsiflexion range of motion, but not after a duathlon competition. Applying the kinesio tape on the calf does not reduce muscle pain immediately or after a duathlon competition, but it appears to control an increase in pain.

Use of a static progressive stretch orthosis to treat post-traumatic ankle stiffness

Background

Chronic ankle stiffness can develop for numerous reasons after traumatic injury, and may adversely affect patient gait, mobility, and function. Although standard physical therapeutic techniques typically resolve this stiffness, some cases may be recalcitrant to these measures, making it difficult to restore range-of-motion. The purpose of this study was to evaluate a static progressive stretch orthosis for the treatment of chronic ankle stiffness.

Methods

Twenty-six patients (26 ankles) who had chronic post-traumatic ankle stiffness were studied. The patients began treatment at a mean of 47 weeks (range, 6 to 272 weeks) following their initial injury using a static progressive stretch orthosis. A patient-directed protocol was used for 30 minutes per day, 1 to 3 times per day, until the range-of-motion was considered to have plateaued. Mean treatment time was 10 weeks (range, 3 to 19 weeks). Treatment duration, range-of-motion, and complications with the device were assessed.

Results

The overall mean improvement in motion (combined dorsiflexion and plantar flexion) was 17 degrees (range, 2 to 44 degrees). There was a mean improvement in dorsiflexion of 9 degrees (range, -2 to 20 degrees), and a mean improvement of 8 degrees of plantar flexion (range, -10 to 35 degrees). There were no reports of numbness or skin problems.

Conclusions

The outcomes of this study suggest that a patient-directed treatment protocol using a static progressive stretch orthosis was an effective ancillary method for the treatment of chronic post-traumatic ankle stiffness that was refractory to standard physical therapy techniques.

Outcome measures and rehabilitation treatment in patients affected by Charcot-Marie-Tooth neuropathy: a pilot study

OBJECTIVE

: We evaluated the sensitivity of various rehabilitation and lung function scales to detect differences between people with Charcot-Marie-Tooth (CMT) disease and healthy controls. We also studied whether these measurements are sensitive to disclose changes in patients with CMT disease after rehabilitative treatment.

DESIGN

: Eight patients with different types of CMT participated in the study. Data were gathered at baseline; at the end of the treadmill training, stretching, respiratory, and proprioceptive exercise (TreSPE) treatment period; and after a washout period of 6 mos. The following instruments were used for data collection: Medical Research Council scale for lower limb strength; Tinetti Balance Scale; Physical Performance Battery; ankle angle, oxygen consumption, and lung function tests; peak treadmill velocity and slope; time to walk 6 m; and CMT Neuropathy Score. The participants underwent TreSPE treatment twice every week for 8 wks.

RESULTS

: All rehabilitative measures were significantly worse in subjects with CMT disease than in healthy controls. Lung function was always normal except for the maximum expiratory pressure and maximum inspiratory pressure. No dropouts or worsening in any of the different outcome measures were observed after TreSPE. The ankle angle and the time to walk 6 m were the only measures that significantly improved after treatment.

CONCLUSIONS

: The rehabilitative outcome measures used in this protocol are useful in detecting clinical impairment in people with CMT disease. Lung function tests were confirmed to be minimally abnormal in patients with CMT disease. The TreSPE treatment, besides being safe and well tolerated, induced some training effects in CMT neuropathy, in the absence of lung function amelioration and effort tolerance. Follow-up showed that CMT patients should be treated at least twice every year because a regression of all outcome measures to the baseline state was found after a 6-mo washout period.

American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise

The purpose of this Position Stand is to provide guidance to professionals who counsel and prescribe individualized exercise to apparently healthy adults of all ages. These recommendations also may apply to adults with certain chronic diseases or disabilities, when appropriately evaluated and advised by a health professional. This document supersedes the 1998 American College of Sports Medicine (ACSM) Position Stand, "The Recommended Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory and Muscular Fitness, and Flexibility in Healthy Adults." The scientific evidence demonstrating the beneficial effects of exercise is indisputable, and the benefits of exercise far outweigh the risks in most adults. A program of regular exercise that includes cardiorespiratory, resistance, flexibility, and neuromotor exercise training beyond activities of daily living to improve and maintain physical fitness and health is essential for most adults. The ACSM recommends that most adults engage in moderate-intensity cardiorespiratory exercise training for ≥30 min·d on ≥5 d·wk for a total of ≥150 min·wk, vigorous-intensity cardiorespiratory exercise training for ≥20 min·d on ≥3 d·wk (≥75 min·wk), or a combination of moderate- and vigorous-intensity exercise to achieve a total energy expenditure of ≥500-1000 MET·min·wk. On 2-3 d·wk, adults should also perform resistance exercises for each of the major muscle groups, and neuromotor exercise involving balance, agility, and coordination. Crucial to maintaining joint range of movement, completing a series of flexibility exercises for each the major muscle-tendon groups (a total of 60 s per exercise) on ≥2 d·wk is recommended. The exercise program should be modified according to an individual's habitual physical activity, physical function, health status, exercise responses, and stated goals. Adults who are unable or unwilling to meet the exercise targets outlined here still can benefit from engaging in amounts of exercise less than recommended. In addition to exercising regularly, there are health benefits in concurrently reducing total time engaged in sedentary pursuits and also by interspersing frequent, short bouts of standing and physical activity between periods of sedentary activity, even in physically active adults. Behaviorally based exercise interventions, the use of behavior change strategies, supervision by an experienced fitness instructor, and exercise that is pleasant and enjoyable can improve adoption and adherence to prescribed exercise programs. Educating adults about and screening for signs and symptoms of CHD and gradual progression of exercise intensity and volume may reduce the risks of exercise. Consultations with a medical professional and diagnostic exercise testing for CHD are useful when clinically indicated but are not recommended for universal screening to enhance the safety of exercise.

The epidemiology of foot injuries in professional rugby union players

BACKGROUND

Foot injuries represent a small but important proportion of injuries to professional rugby union players. There are no detailed epidemiological studies regarding these injuries. The aim of this study was to describe the epidemiology of foot injuries sustained by a cohort of professional rugby union players and identify areas that may be targeted for injury prevention in the future.

METHODS

Medical personnel prospectively recorded injuries in professional Premiership rugby union players in England over four seasons. Injuries to the foot were identified and the time away from training and playing was reported.

RESULTS

A total of 147 foot injuries were sustained resulting in 3542 days of absence in total. Acute events accounted for 73% of all foot injuries, with chronic, mostly overuse conditions, accounting for 25% (undiagnosed 2%). Chronic conditions led to proportionately more time away from training and playing (p=<0.001). Specifically, stress fractures in the foot accounted for 8% of the total foot injuries but 22% of the absence. Navicular stress fractures had the longest recovery time with the mean return to training and match play of 188 days.

CONCLUSION

In collision sports such as rugby, some injuries may be inevitable but clinicians should always be seeking ways to minimise their occurrence and impact. This study revealed a high proportion of morbidity associated with chronic and overuse foot injuries in these professional athletes. With greater attention paid to risk factors, some of these injuries, and importantly, recurrent injuries may be avoided.

Viscoelasticity of the muscle-tendon unit is returned more rapidly than range of motion after stretching

The purpose of this study was to clarify the time course of the viscoelasticity of gastrocnemius medialis muscle and tendon after stretching. In 11 male participants, displacement of the myotendinous junction on the gastrocnemius medialis muscle was measured ultrasonographically during the passive dorsiflexion test, in which the ankle was passively dorsiflexed at a speed of 1°/s to the end of the range of motion (ROM). Passive torque, representing resistance to stretch, was also measured using an isokinetic dynamometer. On five different days, passive dorsiflexion tests were performed before and 0, 15, 30, 60 or 90 min after stretching, which consisted of dorsiflexion to end ROM and holding that position for 1 min, five times. As a result, end ROM was significantly increased at 0, 15 and 30 min (P<0.05 each) after stretching as compared with each previous value. Passive torque at end ROM was also significantly increased after stretching. Although the stiffness of the muscle-tendon unit was significantly decreased immediately after stretching (P<0.05), this shift recovered within 15 min. These results showed that the retention time of the effect of stretching on viscoelasticity of the muscle-tendon unit was shorter than the retention time of the effect of stretching on end ROM.

A new device for assessing ankle dorsiflexion motion: reliability and validity

STUDY DESIGN

Clinical measurement.

OBJECTIVE

To determine the validity and reliability of measures obtained using a custom-made device for assessing ankle dorsiflexion motion and stiffness.

BACKGROUND

Limited dorsiflexion has been implicated in the evolution of foot pain in a number of clinical populations. Assessment of ankle dorsiflexion range of motion (ROM) is, therefore, commonly performed as part of a foot and ankle examination. Conventional goniometric assessment methods have demonstrated limited intertester reliability, while alternative methods of measurements are generally more difficult to use. The Iowa ankle range of motion (IAROM) device was designed in an attempt to develop a simple, clinically relevant, and time- and cost-effective tool to measure ankle dorsiflexion range of motion and stiffness.

METHODS

Validity and intertester reliability of dorsiflexion range-of-motion measures using the IAROM device were assessed at 10, 15, 20, and 25 Nm of passively applied dorsiflexion torque, with both the knee extended and flexed approximately 20°. Stiffness (change in torque/change in dorsiflexion angle) values were determined using the angular change obtained between the 15- and 25-Nm torque levels. Convergent validity (n = 12) was assessed through comparison of ankle dorsiflexion angles measured simultaneously with the IAROM device and an optoelectronic motion analysis system. Intertester reliability (n = 17) was assessed by 2 testers who took measurements within the same day.

RESULTS

Validity testing demonstrated excellent agreement (intraclass correlation coefficient [ICC] values ranging from 0.95 to 0.98). Reliability testing demonstrated good to excellent intertester agreement (ICC values ranging from 0.90 to 0.95). The ICCs for ankle joint dorsiflexion stiffness were .71 and .85 for the knee in an extended and flexed position, respectively.

CONCLUSION

The IAROM device provides valid and reliable measurement of ankle dorsiflexion ROM. The IAROM device also allows calculation of stiffness by measuring ROM at multiple torque levels, although the reliability of the measurement is not optimal.

The role of manual therapies in equine pain management

Manual therapy includes a diverse array of techniques, such as touch therapies, massage, physical therapy, osteopathy, and chiropractic, that were originally developed for use in humans and have been gradually applied to horses. All forms of manual therapy have variable reported levels of effectiveness for treating musculoskeletal issues in humans, but mostly only anecdotal evidence exists in horses. This article explores the scientific literature for evidence of efficacy, safety, and common mechanisms of action of the different forms of manual therapies for potential use in managing acute or chronic pain syndromes in horses. Currently, there is limited evidence supporting the effectiveness of spinal mobilization and manipulation in reducing pain and muscle hypertonicity. Further research is needed to assess the efficacy of specific manual therapy techniques and their contribution to multimodal protocols for managing specific somatic pain conditions in horses.

Limited joint mobility (LJM) in elderly subjects with type II diabetes mellitus

LJM is frequently observed in young subjects with insulin-dependent diabetes mellitus (IDDM). Aim of this study was to evaluate whether non-insulin-dependent diabetes mellitus (NIDDM) increases the risk of LJM in elderly subjects. Thirty patients (15 males, 15 females, mean age 73.93 ± 12.72 years) with NIDDM in good glycemic control were compared with thirty non-diabetic elderly, well matched for sex and age (15 males, 15 females, mean age 74.3 ± 4.24 years), and with ten young normal subjects (5 males, 5 females, mean age 26.3 ± 1.56 years). In these subjects, the range of motion (ROM) of ankle, knee, hip, elbow and shoulder were measured with a double-armed goniometer. Moreover, abnormalities of supraspinatus, patellar and Achilles tendons were evaluated with a standardized ultrasound (US) procedure. A significant reduction in the mobility of all joints was found in elderly subjects, compared to younger ones, with exception for the knee and elbow flexion. Elderly patients with diabetes, compared with their age-matched counterpart, showed LJM for ankle dorso- and plantar flexion, hip flexion and adduction, shoulder abduction and flexion. Moreover, tendons sonographic abnormalities were more frequently observed in diabetics. Our data confirm that diabetes worsens the LJM in the elderly, increasing the cross-linking of collagen by the non-enzymatic advanced glycation end products formation.

Physical therapy of the patient with foot and ankle injuries sustained in combat

The rehabilitation of soldiers returning from Operation Iraqi Freedom and Operation Enduring Freedom after combat-related trauma poses significant challenges. Polytrauma from high-energy blasts are common and frequently associated with mangled extremities, axial fractures, and traumatic brain injuries. Current evidence in the physical therapy literature is scant for this population and an empiric approach is often used. This article highlights the challenges encountered and techniques used in the rehabilitation of soldiers with foot and ankle injuries sustained in recent combat operations.

[Aging and physical activity data on which to base recommendations for exercise in older adults]

An abundance of epidemiological research confirms the benefits of physical activity in reducing risk of various age-related morbidities and all-cause mortality. Analysis of the literature focusing on key exercise variables (e.g., intensity, type, and volume) suggests that the requisite beneficial amount of activity is that which engenders improved cardiorespiratory fitness, strength, power, and, indirectly, balance. Age-related declines in these components are such that physical limitations impinge on functional activities of daily living. However, an exercise programme can minimize declines, thus preventing older adults (age 65+ years) from crossing functional thresholds of inability. Cross-sectional and longitudinal data demonstrate that cardiorespiratory fitness is associated with functional capacity and independence; strength and, importantly, power are related to performance and activities of daily living; and balance-mobility in combination with power are important factors in preventing falls. Exercise interventions have documented that older adults can adapt physiologically to exercise training, with gains in functional capacities. The few studies that have explored minimal or optimal activity requirements suggest that a threshold (intensity) within the moderately vigorous domain is needed to achieve and preserve related health benefits. Thus, physical activity and (or) exercise prescriptions should emphasize activities of the specificity and type to improve components related to the maintenance of functional capacity and independence; these will also delay morbidity and mortality. An appropriate recommendation for older adults includes moderately vigorous cardiorespiratory activities (e.g., brisk walking), strength and (or) power training for maintenance of muscle mass and specific muscle-group performance, as well as "balance-mobility practice" and flexibility (stretching) exercise as needed.

A weightbearing technique for the measurement of ankle joint dorsiflexion with the knee extended is reliable

Measurement of ankle joint dorsiflexion is routinely undertaken by clinicians who manage lower limb musculoskeletal pathology. This study aimed to determine the reliability of a technique to measure ankle joint dorsiflexion in a weightbearing position with the knee extended. Four raters with varying clinical experience measured ankle joint dorsiflexion in a weightbearing position with the knee extended on 30 asymptomatic participants. Measurements occurred on two occasions, 1 week apart using (i) a digital inclinometer and (ii) a clear acrylic plate apparatus. Intraclass correlation coefficients (ICCs) and 95% limits of agreement (LOAs) were calculated. Intra-rater reliability of the experienced raters was high for both the digital inclinometer (average ICC=0.88, average 95% LOA=-6.6 degrees to 4.8 degrees ) and the clear acrylic plate apparatus (average ICC=0.89, average 95% LOA=-7.2 degrees to 4.3 degrees ). Intra-rater reliability of the inexperienced rater was good to high for both the digital inclinometer (ICC=0.77, 95% LOA=-9.1 degrees to 8.3 degrees ) and the clear acrylic plate apparatus (ICC=0.89, 95% LOA=-8.1 degrees to 4.6 degrees ). Inter-rater reliability was high for both the digital inclinometer (ICC=0.95, 95% LOA=-5.7 degrees to 5.7 degrees ) and the clear acrylic plate apparatus (ICC=0.97, 95% LOA=-4.7 degrees to 4.7 degrees ). Measurements of ankle dorsiflexion in a weightbearing position with the knee extended can be performed reliably by experienced and inexperienced raters. However, the reliability of this measurement technique needs to be interpreted in the context of the purpose for which the measurement is intended.

Ageing and physical activity: evidence to develop exercise recommendations for older adultsThis article is part of a supplement entitled Advancing physical activity measurement and guidelines in Canada: a scientific review and evidence-based foundation for the future of Canadian physical activity guidelines co-published by Applied Physiology, Nutrition, and Metabolism and the Canadian Journal of Public Health. It may be cited as Appl. Physiol. Nutr. Metab. 32(Suppl. 2E) or as Can. J. Public Health 98(Suppl. 2)

An abundance of epidemiological research confirms the benefits of physical activity in reducing risk of various age-related morbidities and all-cause mortality. Analysis of the literature focusing on key exercise variables (e.g., intensity, type, and volume) suggests that the requisite beneficial amount of activity is that which engenders improved cardiorespiratory fitness, strength, power, and, indirectly, balance. Age-related declines in these components are such that physical limitations impinge on functional activities of daily living. However, an exercise programme can minimize declines, thus preventing older adults (age 65+ years) from crossing functional thresholds of inability. Cross-sectional and longitudinal data demonstrate that cardiorespiratory fitness is associated with functional capacity and independence; strength and, importantly, power are related to performance and activities of daily living; and balance-mobility in combination with power are important factors in preventing falls. Exercise interventions have documented that older adults can adapt physiologically to exercise training, with gains in functional capacities. The few studies that have explored minimal or optimal activity requirements suggest that a threshold (intensity) within the moderately vigorous domain is needed to achieve and preserve related health benefits. Thus, physical activity and (or) exercise prescriptions should emphasize activities of the specificity and type to improve components related to the maintenance of functional capacity and independence; these will also delay morbidity and mortality. An appropriate recommendation for older adults includes moderately vigorous cardiorespiratory activities (e.g., brisk walking), strength and (or) power training for maintenance of muscle mass and specific muscle-group performance, as well as “balance-mobility practice” and flexibility (stretching) exercise as needed.

Asymmetry of the active nonweightbearing foot and ankle range of motion for dorsiflexion-plantar flexion and its coupled movements in adults

Asymmetries in ankle range of motion (ROM) have been reported, but often the uninvolved limb is used as a reference in clinical practice. The study wanted to quantify the intraindividual asymmetries in dorsi-plantar flexion foot and ankle ROM and its coupled foot movements. Active triplanar nonweightbearing ROM of the foot and ankle was recorded in young healthy adults (30 male volunteers, mean age 22.8 years; 35 female volunteers, mean age 23.8 years) using an optoelectronic set-up. The sagittal plane movement (mean ROM female subjects right side 71.3 degrees, left side 71.4 degrees, P > 0.05; mean ROM male subjects right side 69 degrees , left side 68.9 degrees, P > 0.05; sex difference, P < 0.001) was coupled with frontal (mean ROM female subjects right side 16.6 degrees, left side 14.8 degrees, P > 0.05; male subjects right side 17 degrees, left side 15.3 degrees; P > 0.05; no sex difference) and horizontal (mean ROM female subjects right side 19.6 degrees, left side 18.8 degrees, P < 0.001; male subjects right side 17.6 degrees, left side 16.2 degrees, P < 0.001; sex < 0.001) plane motions. Individual fluctuating asymmetries up to 15 degrees (principal movement), and up to 29 degrees (associated movements) were measured. Overall, 20% of female and 34% of male subjects had principal plane asymmetries >5 degrees, and 50% of the subjects had asymmetries >5 degrees in the associated movements. In young adults, individual asymmetries in ankle joint complex dorsi-plantar flexion should be taken into account when using the uninvolved, contralateral limb as a reference for clinical examination.

Effectiveness of calf muscle stretching for the short-term treatment of plantar heel pain: a randomised trial

Background

Plantar heel pain is one of the most common musculoskeletal disorders of the foot and ankle. Treatment of the condition is usually conservative, however the effectiveness of many treatments frequently used in clinical practice, including stretching, has not been established. We performed a participant-blinded randomised trial to assess the effectiveness of calf muscle stretching, a commonly used short-term treatment for plantar heel pain.

Methods

Ninety-two participants with plantar heel pain were recruited from the general public between April and June 2005. Participants were randomly allocated to an intervention group that were prescribed calf muscle stretches and sham ultrasound (n = 46) or a control group who received sham ultrasound alone (n = 46). The intervention period was two weeks. No participants were lost to follow-up. Primary outcome measures were 'first-step' pain (measured on a 100 mm Visual Analogue Scale) and the Foot Health Status Questionnaire domains of foot pain, foot function and general foot health.

Results

Both treatment groups improved over the two week period of follow-up but there were no statistically significant differences in improvement between groups for any of the measured outcomes. For example, the mean improvement for 'first-step' pain (0–100 mm) was -19.8 mm in the stretching group and -13.2 mm in the control group (adjusted mean difference between groups -7.9 mm; 95% CI -18.3 to 2.6). For foot function (0–100 scale), the stretching group improved 16.2 points and the control group improved 8.3 points (adjusted mean difference between groups 7.3; 95% CI -0.1 to 14.8). Ten participants in the stretching group experienced an adverse event, however most events were mild to moderate and short-lived.

Conclusion

When used for the short-term treatment of plantar heel pain, a two-week stretching program provides no statistically significant benefit in 'first-step' pain, foot pain, foot function or general foot health compared to not stretching.