INTRODU CI NG CA RA CH UKKA BOO TJordana Bieze Foster, Editor Efforts to decrease patients’ joint pain in the short term are inadvertently setting those patients up for chronic pain

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September2017features25Hemophilia, ankle pain,and orthotic managementThe ankle is a frequent site of arthropathy in patients with hemophilia, but orthotic devices and orthopedic shoes can help relieve this pain. New research suggests that carbon fiber ankle foot orthoses and orthopedic shoes also appear to have gait-related advantages in thispatient population.By David Oleson, PT, PCS; Katherine Stribling, PT, DPT, PCS; Jamie Beckwith, PT, DPT;

Laura Fox, PT, DPT, PCS; Felicity Case, PT, DPT, PCS; Nancy Durben, MSPT, PCS; and

Michael Recht, MD, PhD

35 SEBT scores and injuryrisk in collegiate athletesAnterior-direction Star Excursion Balance Test performance may mostappropriately discriminate between collegiate athletes who are and arenot at risk for lower extremity injury, though additional research is neededto determine specific injury cutoff scores for other athletic populations. By Mikel R. Stiffler-Joachim, MS; David R. Bell, ATC, PhD; and Bryan C. Heiderscheit, PT, PhD

43 Soft braces: Experts huntfor potential mechanismsSoft braces are not designed to change lower extremity alignment or joint forces, but research suggests they may influence knee and anklebiomechanics in other ways, including by enhancing proprioception. Thisline of investigation could open the door to new therapeutic opportunities.By Stephanie Kramer

51 Surgery and ulcer healingin patients with equinusAchilles tendon lengthening and gastrocnemius recession both increaseankle joint dorsiflexion and reduce plantar forefoot pressures in patientswith diabetes and equinus deformity, but experts continue to debate whichis best for managing forefoot ulcers and minimizing reulceration.

By Barbara Boughton

16 COVER STORYIn spite of advancements in research and subsequent modifications to runningfootwear design, rates of running-related injuries have not decreased. That maybe because researchers and designers have been focusing on the wrong variables.By Joseph Hamill, PhD, and Gillian Weir, PhD

IN THE MOMENTsports medicine/11

Achilles prophecy: Early heel rise linked to later outcomesOnline education helps reduce injuries in trail runners despite poor complianceNavicular injury in college football players slashes odds of NFL successknee oa/13

OA accelerants: 4 factors help hasten disease progressionStudy suggests strawberry consumption can benefit obese adults with knee OAIntraarticular NSAIDs and opioid meds may contribute to cartilage cell death

plus...OUT ON A LIMB / 9

Of opioids and outcomesEfforts to decrease patients’ joint pain inthe short term are inadvertently settingthose patients up for chronic pain later on.By Jordana Bieze Foster

NEW PRODUCTS / 58The latest in lower extremity devices and technologies

MARKET MECHANICS /61 News from lower extremity companies and organizationsBy Emily Delzell

11 35 51

VOLUME 9 NUMBER 9 LERMAGAZINE .COM

Running shoes and injury risk:RETHINKING THE IMPORTANCE OF CUSHIONING AND PRONATION

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Editor Jordana Bieze Foster | [email protected]

Senior editorEmily Delzell | [email protected]

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New products editorRikki Lee Travolta | [email protected]

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Editorial advisorsCraig R. Bottoni, MD, Jonathan L. Chang, MD, Sarah Curran, PhD, FCPodMed, Stefania Fatone, PhD, BPO,Timothy E. Hewett, PhD, Robert S. Lin, CPO,Jeffrey A. Ross, DPM, MD, Paul R. Scherer, DPM, Erin D. Ward, DPM, Bruce E. Williams, DPM

Our Mission: Lower Extremity Review informs healthcare practitioners on current developments in the diagnosis, treatment, andprevention of lower extremity injuries. LER encourages a collaborative multidisciplinary clinical approach with anemphasis on functional outcomes and evidence-based medicine. LER is published monthly, with the exception of a combined November/ December issue and an additional special issue in December, by Lower Extremity Review, LLC.Subscriptions may be obtained for $38 domestic. and $72 international by writing to: LER, PO Box 390418, Minneapolis, MN, 55439-0418. Copyright©2017 Lower Extremity Review, LLC. All rights reserved. The publication may not be reproduced in any fashion, including electronically, in part or whole, without written consent. LER is a registered trademark of Lower Extremity Review, LLC. POSTMASTER: Please send address changes to LER, PO Box 390418, Minneapolis, MN, 55439-0418.

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Recent efforts to reduce

utilization of opioid pain

medications for lower

extremity joint injuries

and surgical rehabilitation

have mostly focused

on reducing the risk of

addiction. But there’s an-

other important reason to

be concerned about the

use of opioids in these

patients—and other popular

pain medications as well.

A Stanford University study published in September found in

vitro evidence that intraarticular use of the opioid meperidine

(Demerol) is associated with chondrocyte death, which con trib -

utes to the development of osteoarthritis. And although non -

steroidal anti-inflammatory drugs (NSAIDs) are often pro posed as

opioid alternatives for pain relief, the same study found that the

NSAID ketorolac was also associated with in vitro chondro toxicity

(see “Intraarticular NSAIDs and opioid meds may contri bute to

cartilage cell death,” page 13).

Other studies have reported similar findings with other popular

pain medications. The Stanford group found in 2012 that lido-

caine injection was associated with cartilage cell death, and a

2013 study from the University of Connecticut in Farmington

reported chondrotoxic effects of methylprednisone.

Granted, these are in vitro studies, and cartilage cells likely

behave at least somewhat differently in vivo than in a petri dish.

The oral medications typically given to patients after an injury or

surgery also likely behave somewhat differently than intraarticular

injections of the same medication. But the implications are still

pretty scary.

Preliminary evidence suggests cartilage deterioration begins

almost immediately after a joint injury (see “Early warnings: Data

support aggressive intervention,” August, page 11). So, it’s not a

stretch to think that plying patients with potentially chondrotoxic

medications after a joint injury will only exacerbate that degen -

erative process. That leaves us with the sobering possibility that

efforts to improve patients’ quality of life by decreasing their pain

in the short term are inadvertently setting those patients up for

chronic pain in the same joint later in life.

On the positive side, not all pain medications studied by the Stan-

ford group and others have been associated with chondrotoxicity;

these include bupivacaine, ropivacaine, morphine, and fentanyl.

It’s also possible that platelet-rich plasma (PRP) injections can

help offset some chondrotoxic effects: The UConn study found

that cartilage cell viability associated with ketorolac was signifi-

cantly greater than placebo when the NSAID was supplemented

with PRP. However, a 2013 review of basic science research on

PRP and cartilage noted that, although such preliminary findings

are encouraging, not all in vivo studies have found a positive ef-

fect of PRP on cartilage repair after surgery.

Less-invasive therapies also show promise as nondrug analgesic

alternatives; for example, a systematic review and meta-analysis in

the August issue of JAMA found moderate-certainty evidence to

support acupuncture and electrotherapy after total knee arthro-

plasty. Bracing, foot orthoses, and physical therapy have all been

associated with pain relief in various populations and would seem

to be worthy of future study in this context, as well.

The fight against opioid addiction needs all the help it can get.

If lower extremity researchers and clinicians can assist in this

effort while reducing the risk of long-term cartilage damage at

the same time, that definitely seems like a win-win proposition.

Jordana Bieze Foster, Editor

Efforts to decrease patients’ joint pain inthe short term are inadvertently settingthose patients up for chronic pain later on.

out on a limb:Of opioids and outcomes


Achilles prophecyEarly heel rise linked to later outcomes

By Katie Bell

Single-leg standing heel-rise test perform-ance one year after Achilles tendon rup-ture is associated with the long-term re-covery of ankle biomechanics, according toresearch from Gothenburg, Sweden. Thefindings may have implications for rehab -ilitation after Achilles injury, particularlywith regard to relatively demanding activ-ities such as jumping.

The ankle impairments observed six years after injury in the studycould potentially lead to longer-term pathologies, although further re-search is needed to confirm that, said lead author Annelie Brorsson,PT, MSc, an associate researcher in the Department of Orthopaedicsat the University of Gothenburg.

“Theoretically, it is possible that the risk for overload injuries can

increase in some individuals due to the asymmetrical loading in ankleand knee joints during more demanding activities,” Brorsson said.

Brorsson and colleagues assessed 38 patients one year afterAchilles rupture. In 17, heel-rise height for the injured limb was lessthan 15% of the unaffected limb; in the other 17, the side-to-side dif-ference was greater than 30%. A mean of six years after injury, theresearchers assessed ankle biomechanics, tendon length, calf musclerecovery, and patient-reported outcomes.

Standard motion capture procedures were used to analyze anklemechanics during walking, jogging, a single-leg countermovementdrop jump, and hopping. Kinematic variables included plantar flexion,dorsiflexion, eversion, and abduction; kinetic variables included ec-centric and concentric plantar flexion power, peak Achilles tendon

in the moment: sports medicine

Online education helps reduce injuriesin trail runners despite poor complianceAn online program designed toeducate trail runners about in-jury prevention is associatedwith a significant decrease inrunning-related injury rate, evenif runners don’t significantlychange their preventive behav-iors, according to research fromthe Netherlands.

Investigators from VU Uni-versity Medical Center provided232 trail runners with basic ad-vice about preventing running-related injuries. All runners filledout an online questionnaire re-garding their injury status everytwo weeks; those randomized tothe intervention group receivedautomated online advice aboutinjury management, while thosein the control group did not.

After six months, the trailrunners in the intervention grouphad reported 13% fewer running-

related injuries than those in thecontrol group. However, therewas no significant difference be-tween groups in terms of self-reported adherence to the injuryprevention advice provided atbaseline. The authors hypothe-sized that subtle but statisticallyinsignificant improvements insome preventive behaviors mayhave combined for a protectiveeffect in the intervention group.

The findings were epub-lished in late August by theBritish Journal of Sports Medi-cine. –Jordana Bieze FosterSource: Hespanhol LC Jr, van Mechelen W, Ver-hagen E. Effectiveness of online tailoredadvice to prevent running related injuriesand promote preventive behavior inDutch trail runners: a pragmatic random-ized controlled trial. Br J Sports Med2017 Aug 30. [Epub ahead of print]

Navicular injury in college footballplayers slashes odds of NFL successNational Football League (NFL)prospects with a history of nav-icular injury are significantly lesslikely to be successful at the pro-fessional level than those withoutsuch an injury history, accordingto research that underscores theimportance of restoring gait andfunction after a navicular stressinjury in athletes.

Investigators from the Stead-man Philippon Research Institutein Vail, CO, and MassachusettsGeneral Hospital in Boston ana-lyzed 14 players with a history ofnavicular stress injury or fracturewho attended the annual NFLCombine over a seven-year pe-riod. More than half (57%) ofthese players went undrafted,compared with 30.9% of playerswithout a history of navicular in-

jury. Just 28.6% of combine at-tendees with navicular injuryplayed for two years or longer inthe NFL, compared with 69.6%of controls.

Among the 12 players withnavicular injury who underwentradiographs, evidence of talon-avicular arthritis was observedin 75% of injured feet and 60%of contralateral feet.

The findings were pub-lished in August by the Ortho-pedic Journal of Sports Medi-cine.

–Jordana Bieze FosterSource:Vopat B, Beaulieu-Jones BR, WaryaszG, et al. Epidemiology of navicular in-jury at the NFL Combine and their im-pact on an athlete’s prospective NFLcareer. Orthop J Sports Med 2017;5(8):2325967117723285.

Continued on page 12


iStockphoto.com 116922589

in the moment: sports medicineContinued from page 11

12 09.17 lermagazine.com

force, and Achilles impulse. Achilles tendon Total Rup-

ture Score (ATRS), Physical Ac-tivity Scale, and Foot and AnkleOutcome Score were used toevaluate patient-reported symp-toms and physical activity, whileultrasound was used to measuretendon length.

Fifteen patients in the <15%group and 13 patients in the>30% group were included inthe final analysis. At long-termfollow-up, the >30% group hadmore deficits in ankle kineticsduring all activities than the<15% group, with the respectivelimb symmetry indices (LSI) rang-ing from 70% to 149% and 84%to 106%. No between-group dif-ferences were found for anklekinematics.

Additionally, at long-termfollow-up the >30% group wasless symmetrical than the <15%

group for heel-rise height (LSI of72% vs 95%) and heel-rise work(LSI of 58% vs 91%). LSI for ten-don length was also significantlygreater for the >30% group(114% vs 106%).

The authors reported cor-relations between peak ankle ab-duction and tendon length dur-ing walking and jogging, but nocorrelations between tendonlength and any of the kinetic vari-ables. Although a correlation wasfound between one kinematicvariable (peak ankle abduction)and LSI for heel-rise work, sev-eral correlations were noted be-tween LSI for heel-rise work andkinetic variables. Additionally, be-tween-limb difference in tendonlength was correlated negativelywith LSI for heel-rise height. Thestudy found no differences be-tween groups in patient-reportedoutcomes.

The kinetic differences be-tween groups were most notableduring hopping. In addition, theLSI for heel-rise work was corre-lated with all kinetic variables dur-ing hopping, but with only ec-centric plantar flexion powerduring walking. The authors hy-pothesized that a difference instretch-recoil cycle betweengroups might explain this finding.

The authors concluded thatminimizing tendon elongationand regaining heel-rise height during rehabilitation after Achillestendon injury may be importantfor ankle biomechanics recoveryin the long term. The findingswere epublished by The Ameri-can Journal of Sports Medicinein August.

David A Porter, MD, PhD,an orthopedic surgeon atMethodist Sports Medicine in In-dianapolis, IN, recommended

the use of a rehab program thatemphasizes aggressive earlyweightbearing and early rangeof motion—practices that werefirst popularized in Europe butwhich are becoming more com-mon in the US (see “Battles ofAchilles II: How the debate is in-forming clinical practice,” No-vember 2015, page 20).

“Work hard on isolated, sin-gle-leg strengthening. Specifi-cally, work and focus on heelraises in your rehab protocol,”Porter said. “Focus on the bio-mechanics of walking and run-ning that emphasize midfootstriking to encourage more nor-mal pushoff and improved gas-trocnemius-soleus function.” Source:Brorsson A, Willy RW, Tranberg R, Grä-vare Silbernagel K. Heel-rise heightdeficit 1 year after Achilles tendon rup-ture relates to changes in ankle biome-chanics 6 years after injury. Am J SportsMed 2017 Aug 1. [Epub ahead of print]

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OA accelerants4 factors help hasten disease progression

By Chris Klingenberg

Age and body mass index (BMI)—as well astheir interactions with glucose concentra-tion and static femorotibial alignment—contribute to increased risk of acceleratedknee osteoarthritis (OA), according to re-search from Tufts University School ofMedicine in Boston that could have impli-cations for early diagnosis and interven-tion in this population.

People who develop knee OA earlier than expected and in whom thedisease progresses very quickly are said to have “accelerated” kneeOA; because the window of opportunity for early intervention in thesepatients is very small, the ability to screen for potential risk factors iseven more critical than in the typical knee OA population (see “Theclinical implications of accelerated knee OA,” April 2016, page 43).

“This study is a nice reminder that there can be complex interplayamong risk factors for things like accelerated knee osteoarthritis,”said Jeffrey Driban, PhD, ATC, CSCS, who is an assistant professor inthe Division of Rheumatology at Tufts University School of Medicineand also on the scientific staff at Tufts Medical Center. “This interplay is

in the moment: knee OA

Study suggests strawberry consumptioncan benefit obese adults with knee OAThe old adage about an applea day keeping the doctor awaymay need to be expanded toinclude other fruits, in light ofnew findings that a high levelof daily strawberry consumptioncan relieve pain and reducemarkers of disease progressionin obese adults with knee os-teoarthritis (OA).

The study, conducted atOklahoma State University inOklahoma City, included 17obese adults (mean body massindex of 39.1 kg/m2) and radi-ographic evidence of mild tomoderate knee OA.

All participants consumedtwo beverages per day madefrom one of two nutritional pow-ders reconstituted in water. One12-week trial period involved a

powder containing 50 g of re-constituted freeze-dried straw-berries per serving, and theother 12-week trial period in-volved a control powder. Theorder of the two beverage typeswas randomized.

Compared with the controlpowder, the strawberry-basedpowder was associated withsignificantly greater reductionsin pain as well as serum bio-markers for inflammation andcartilage degradation. The find-ings were published in an Augustspecial issue of Nutrients.

–Jordana Bieze FosterSource:Schell J, Scofield RH, Barrett JR, et al.Strawberries improve pain and inflam-mation in obese adults with radio -graphic evidence of knee osteo arthritis.Nutrients 2017;9(9):949.

Intraarticular NSAIDs and opioid meds may contribute to cartilage cell deathTreating lower extremity jointpain with intraarticular non -steroidal anti-inflammatory drugs(NSAIDs) and opioid medica-tions may contribute to cartilagecell death, which could acceler-ate the progression of osteo -arthritis, according to an in vitrostudy from Stanford Universityin California.

Investigators arthroscopicallyharvested human cartilage fromthe intercondylar notch of the fe-mur and replicated it in vitro. Cul-tured chondrocytes were then ex-posed to four types of painmedication solutions (ketorolactromethamine, morphine sulfate,meperidine hydrochloride, andfentanyl citrate) at various single-dose equivalent concentrations;the chondrocytes were also ex-posed to saline as a control.

All concentrations of theNSAID ketorolac and the opioidmeperidine were associated withsignificantly greater chondrocytedeath than the saline condition,and a dose-response relationshipwas also observed for those twomedications. Chondrocyte mor-tality associated with morphineand fentanyl, however, did notdiffer significantly from that asso-ciated with the control condition,even after an additional twoweeks of exposure.

The findings were epub-lished in September by theAmerican Journal of SportsMedicine.

–Jordana Bieze FosterSource:Abrams GD, Chang W, Dragoo JL. Invitro chondrotoxicity of nonsteroidalanti-inflammatory drugs and opioidmedications. Am J Sports Med Sept 13.[Epub ahead of print]




in the moment: knee OAContinued from page 13


important because it may helpidentify high-risk groups of adultsand may eventually lead to tar-geted prevention strategies.”

Driban and colleagues con-ducted a case-control study thatused data and images frombaseline and the first four yearsof follow-up in the OsteoarthritisInitiative, a longitudinal multicen-ter observational study of adultswith or at risk for knee OA. TheTufts study population included54 patients diagnosed with ac-celerated knee OA (defined asadvanced-stage OA onset withinfour years) and two controlgroups, each with 54 individuals;one control group included pa-tients with typically developingknee OA, and the second con-trol group included individualswithout knee OA.

The authors then used aclassification and regression tree

analysis to assess eight risk fac-tors for typically developingknee OA in terms of their asso-ciation with accelerated kneeOA: serum concentrations for C-reactive protein, glycated serumprotein, and glucose; age; sex;BMI; coronal tibial slope; andfemorotibial alignment.

Age and BMI were both in-dependently associated with ac-celerated knee OA. Age may bethe most important factor forclassifying those at high risk, thestudy found—but with some ex-ceptions. Individuals youngerthan 63.5 years were unlikely todevelop accelerated knee OAunless they were obese (BMI ≥33.9 kg/m2). Individuals olderthan 63.5 years were classifiedas being at risk for acceleratedknee OA except when they hadelevated fasting glucose concen-trations (> 81.98 mg/dl) and no

varus malalignment (femor otibialangle ≥ 2.31°); BMI did not seemto play a role in the older group.The findings were epublished inAugust by the Journal of Or-thopaedic Research.

However, Driban noted thatthe four contributing factors iden-tified in the study—age, BMI, glu-cose level, and femorotibial align-ment—only accounted for 31%of the variance in the analysis.

“Our analysis suggests we’remissing a lot of information thatmay help classify people at riskfor accelerated knee OA,” hesaid. “For example, injuries arelikely an important factor. Ourpreliminary findings suggest thatinjuries that compromise thesubchondral bone or the func-tion of the meniscus are espe-cially concerning.”

Abbey Thomas-Fenwick,PhD, ATC, an assistant professor

in the Department of Kinesiol-ogy at the University of NorthCarolina at Charlotte, noted thatfactors other than those exam-ined in the Tufts study also canplay a role in typically develop-ing knee OA.

“Knee joint injury repre-sents an important risk factor forknee OA, leading to what isknown as posttraumatic OA. Thisphenotype of the disease tendsto present in younger individualsfollowing injury to the joint,” shesaid. “Genetics may also play arole, as some individuals are in-herently susceptible to OA de-velopment.” Source:Driban JB, McAlindon TE, Amin M, et al.Risk factors can classify individuals whodevelop accelerated knee osteoarthri-tis: data from the osteoarthritis initiative.J Orthop Res 2017 Aug 4. [Epub aheadof print]

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16 09.17 lermagazine.com16 09.17 lermagazine.com

Rethinking the importance of

RUNNING SHOES AND INJURY RISK:


lermagazine.com 09.17 17lermagazine.com 09.17 17

In spite of advancements in research andsubsequent modifications to runningfootwear design, rates of running-relatedinjuries have not decreased. That may bebecause researchers and designers havebeen focusing on the wrong variables.

By Joseph Hamill, PhD, and Gillian Weir, PhD

cushioning and pronation


The explosion in the popularity of running and physical activitybegan in the 1970s. Along with this interest in physical activity camethe development of sport-specific shoes with an emphasis on thebiomechanics of footwear. Since this interest in physical activitybegan, the evaluation of running footwear has focused on two guid-ing principles for footwear design: 1) decreasing the risk of running-related injuries, and 2) improving performance.

The purpose of this paper is to present an overview of the pa-rameters used to evaluate footwear in order to reduce the risk ofinjury; performance enhancement will not be addressed at this time.This paper will present the parameters investigated by mostfootwear scientists in the early years of footwear research and whywe sought to link these parameters to injury. Lastly, this paper willattempt to look into the future and suggest some different parame-ters and methods for footwear design that may be helpful in effortsto reduce running-related injuries.

Footwear evaluationIn terms of reducing the probability of running footwear as a riskfactor for running-related injuries through footwear design, two fociwere studied extensively: reducing the load on the body from thefoot/ground collision (ie, cushioning the shoe), and increasingmedio lateral stability (ie, controlling rearfoot calcaneal eversion orpronation). However, in spite of advancements in research and sub-sequent improvements in running footwear design over the years,the rates of running-related injuries have not decreased.1

Cushioning. The measurement of external loads applied to thebody, and the attenuation of these loads through footwear, has pri-marily focused on ground reaction force (GRF) data. More specifi-cally, running research has primarily investigated the first peak forceand the loading rate of the vertical component of the GRF. It wasthought these parameters were critical factors in reducing the riskof impact-type overuse injuries.2

In the early period of footwear biomechanists’ involvement inrunning shoe design, it was surmised that the way to reduce impact

forces was to make the midsole of the shoe much softer. However,it was determined that softer materials did not necessarily result inbetter cushioning, based strictly on the impact loading as measuredusing the vertical GRF.3 The soft midsole of a running shoe could,in fact, collapse to the point at which the vertical GRF was similarto a firmer midsole. This may be due to individuals adapting to themagnitude of the force when running.3

Figure 1a shows differences in the peak acceleration associ-ated with midsoles of varying hardnesses, assessed using an im-pact-testing device. Figure 1b illustrates that the impact peak differsvery little among the same three insoles. It can be inferred thatsofter materials do not necessarily result in better cushioning, and,subsequently, that softer materials do not necessarily reduce theexternal forces applied to the runner.

The concept of a relationship between impact forces and injurywas initially derived from animal studies in which the joints of ani-mals were subjected to numerous repeated impacts.4 In a study byRadin and colleagues,4 joints were significantly degraded, suggest-ing the repeated impulsive impacts were deleterious.

More recent evidence, however, suggests high-impact loadingis not necessarily linked to running injuries. For example, several stud-ies have reported that knee osteoarthritis was found in equal fre-quency in runners and nonrunners,5,6 despite runners experiencingmore foot-ground contacts. Further, in a recent publication, Miller re-ported joint loading in runners does not initiate knee osteo arthritis.7

It appears that, unlike previous thinking, high impact peaks nor highloading rates do not relate to injury.8 However, in the biomechanicsliterature, a number of researchers continue to cite studies that sup-port a relationship between vertical GRF parameters and injury.

Pronation. Pronation is a naturally occurring movement of thefoot and was considered a major factor in the etiology of lower ex-tremity soft tissue.9,10 There has been a substantial amount of re-search on the injury risk associated with rearfoot pronation, withparticular focus on the measurement of rearfoot eversion. The

Continued from page 17




theory of rearfoot instability as a risk factor involved the couplingand timing of calcaneal eversion, tibial internal rotation, and kneeflexion during support.8 It was postulated that too much eversion(ie, “excessive” pronation) and extraneous rearfoot movements in-creased the risk of injury, particularly to the knee.

Neither of the assumptions concerning too much eversion andextraneous rearfoot movement has been shown to be true.8,11 Forexample, in a one-year epidemiological observational prospectivecohort study with 927 novice runners, Nielsen et al found footpronation was not associated with increased injury risk.11 Nigg sug-gested footwear designs make little difference in the degree ofpronation.8 Our own unpublished data with 10 participants suggestconsiderable midsole variations result in little difference in maxi-mum pronation value during running (see Figure 2). The footwearin Figure 2 had different midsole densities and different degrees ofposting, resulting in different midsole variations that should have af-fected rearfoot pronation, but did not.

Current evaluation of footwearThe current state of footwear evaluation has not changed the focusof footwear research or footwear design. Many researchers and

footwear manufacturers are still using the cushioning or rearfootstability paradigm as a basis of injury risk reduction. A large numberof these studies have contributed to interesting and beneficialfootwear technologies, such as gels, encapsulated gases, and high-density plastics. But the ultimate goal of reducing injury risk throughimproving footwear design has still not been achieved.

Modern instruments and methodologies have allowed signifi-cant questions to be addressed, but these questions are still basedon previously used paradigms. Today, researchers use 3D kinemat-ics and kinetics, electromyography, magnetic resonance imaging,optimization, forward dynamics, and more to analyze footwear.However, at the 2015 Footwear Biomechanics Symposium of theInternational Society of Biomechanics Footwear BiomechanicsGroup held in Liverpool, UK, keynote speaker Darren Stefanyshyn,PhD, suggested that, quite possibly, biomechanists have been look-ing at the “wrong measures” in the evaluation of footwear. In the fu-ture, new measures or new paradigms must be adopted if the goalof reducing the risk of injury is to be achieved.

Future possibilities In his 2010 book, The Biomechanics of Sport Shoes,12 biomechanistBenno Nigg, PhD, suggested we rethink our notions of cushioningand pronation as risk factors for running-related injuries. Nigg’s al-ternative paradigm was what he termed the “preferred movementpath.” He suggested there is a subject-specific and task-specific pre-ferred locomotion pattern determined by many factors (eg, muscles,tendon, ligaments, bone structure) and that this preference for aparticular motion path may explain why shoes have only a small ormoderate effect on lower extremity kinematics. This new paradigmhas given researchers food for thought, and may lead to new as-sessment goals, such as how footwear may affect the determinationof a runner’s deviation from his or her preferred path.

A runner’s preferred movement path may be interpreted inmany different ways, one of which relates to the movement of thewhole body as a system rather than the movement of a single joint.Multiple joints and segments of the lower extremity interact to pro-duce a smooth and efficient movement path. Thus, if each individualhas a unique preferred movement path, deviations from the idealpath would result in significant muscle adaptations. Analysis tech-niques based on dynamical systems theory13 may be appropriate



Figure 1: a) Midsole durometertested on an impact machine. b)Midsole durometer tested on partic-ipants running across a force plat-form with no statistical differencesamong footwear midsoles (unpub-lished data).

Figure 2: Rearfoot angles for four footwear types with large differences in midsoleconstruction but with little difference in maximum pronation (unpublished data).

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for assessing these types of coordinated body movements duringrunning, and could lead to a more fruitful evaluation of runningfootwear than what has been used in the past.

As an example, Taunton and his group1 identified the knee as themost prevalent injury location in runners. It may be that focusing on asingle parameter such as calcaneal eversion is too narrow a view,which would help explain why previous literature has produced mixedresults. Rather than footwear affecting the knee directly, it may be thatthe hip or ankle are affected by footwear, and alterations in these jointscause deviations at the knee that can lead to injury.

Analyzing how the knee interacts with other joints using a ho-listic or coordination analysis may help us better understand the ac-tual mechanisms underlying the many knee injuries that occur inrunners. Then, in turn, we may be better equipped to answer thequestion: Can footwear reduce the risk of these injuries? The holisticanalyses may also help reveal functional groups of runners, someof which may be more or less susceptible to injury.

It is very difficult to ascertain and quantify a runner’s preferredmovement path. Rather, it may be easier to determine their habitualpath or the path they commonly use. One footwear company hasconducted research to develop a paradigm relating the choice offootwear to their habitual path, or their habitual joint motion path(HJMP). To begin, it was determined the knee should be the focusof the paradigm, since the largest number of running-related injuriesinvolve the knee.1 In an unpublished cadaveric study, it was foundthat knee motion was highly repeatable within an individual but notbetween cadaver limbs from different individuals (see Figure 3).

To determine the HJMP path at the knee, 3D lower extremitykinematics were assessed as runners performed a squat to a des-ignated position and as they ran in a shoe with a minimal midsole.The difference between the squat knee position and the knee po-sition during running was determined to create a deviation value.

This deviation value allows runners to be classified as low de-viators or high deviators. In the case of the low deviator, a neutralshoe would suffice. However, in high deviators, depending on howor in what direction the deviation occurred, a shoe to return themto their HJMP could be recommended. Such an analysis is currentlybeing used in many technical running stores across the US and Eu-rope to evaluate runners for footwear recommendations.


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Other directions for the evaluation of running footwear alsoshow promise. The concepts of the “eversion buffer”14,15 (ie, thepronation angle relative to the passive range of motion) or the pro-longed loading bone stress16 have been used to illustrate differ-ences in injury risk between groups and between shoes. Rodrigueset al15 reported individuals with a smaller buffer would be at agreater injury risk, while Firminger and Edwards16 suggested minimalistrunning shoes would show greater bone stress over a lesser cumula-tive distance. Other suggestions include using in-shoe sensors to

evaluate footwear during both steady state and fatigued conditions,which could also help generate large quantities of data for population-based analysis of running parameters in multiple environments.

Lastly, great strides have been made in the development ofanalysis techniques for evaluating footwear. Techniques such asprincipal components analysis,17 functional data analysis,18 and dy-namical systems analysis13 can be used with large quantities of datato evaluate footwear.

ConclusionsWhile running footwear can be a risk factor for injury, it is not themain or most significant factor. Research conducted in the past hasproduced excellent footwear, but we cannot state definitively thatfootwear has reduced the risk of running injuries. From the currentresearch, it may be ascertained that the traditional parameters (ie,cushioning and pronation) used to define injury risk have not pro-duced footwear that has actually minimized that risk, as observedby the lack of change in injury rates in runners.

This suggests new paradigms must be evaluated. Nigg’s pre-ferred movement path and the concept of the habitual joint motionpath are suggested as future areas of research. These paradigmsand others could be valuable tools in the future for evaluating run-ning footwear.

Joseph Hamill, PhD, is professor emeritus and Gillian Weir, PhD, is

a postdoctoral fellow in the Biomechanics Laboratory of the Depart-

ment of Kinesiology at the University of Massachusetts Amherst.

References are available at lermagazine.com.

Figure 3: A 3D plot of the forced knee motion of different cadaver legs over five flexioncycles, illustrating the within-leg consistency and the between-leg differences. Eachcolored line represents a cadaveric limb from a different individual.

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Hemophilia, ankle pain,and orthotic management

The ankle is a frequent site of arthropathyin patients with hemophilia, but orthoticdevices and orthopedic shoes can help re-lieve this pain. New research suggests thatcarbon fiber ankle foot orthoses and ortho-pedic shoes also appear to have gait-related advantages in this patient population.

By David Oleson, PT, PCS; Katherine Stribling, PT, DPT, PCS; Jamie Beck-

with, PT, DPT; Laura Fox, PT, DPT, PCS; Felicity Case, PT, DPT, PCS; Nancy

Durben, MSPT, PCS; and Michael Recht, MD, PhD

Hemophilia is a genetic disorder characterized by less than normalamounts of coagulation factors VIII (FVIII) and IX (FIX). The clinicalfeatures of FVIII and FIX deficiencies are identical. Persons with lessthan 1% FVIII or FIX are said to have severe hemophilia and mostcommonly bleed into their joints, causing synovial inflammation, irondeposition, cartilage destruction, and bony changes.1,2 Thesearthritic changes are painful and alter movement.1 In boys witharthropathy, reported changes from controls include increases inswing time, stance time, double support, single support, and baseof support. Decreases from controls include step length and nor-malized velocity.2

Treatment of hemophilia primarily involves replacement of themissing factors by infusion. The standard of care is to infuse pro-phylactically to prevent bleeding. Despite prophylaxis, arthropathyremains common.1,3 In particular, the ankle is a frequent site ofbleeding in hemophilia.3 Pain relief in this population is elusive, andpromotion of activity and participation in daily life and desired ac-tivities are common physical therapy goals.4

In our treatment center, the Hemophilia Center at OregonHealth & Science University in Portland, we have investigated anklearthropathy from multiple perspectives. We have studied the effectof two different types of bracing on gait parameters and pain relief,as well as the effect of orthotic device use on pain, activity, and par-ticipation of persons with ankle arthropathy.

Bracing, gait, and ankle painBracing to relieve ankle pain from hemophilic arthropathy has longbeen used, but the effects of these devices on gait had never beenanalyzed. In our study, we chose to compare the gait parametersassociated with a carbon fiber floor reaction ankle foot orthosis(AFO) and a fracture boot.5


Qualitative data suggest that respect forpatients’ individuality, knowledge, andexperience should be considered whenmanaging hemophilic ankle arthropathy.


Fracture boots and AFOs both restrict ankle range of motionto relieve pain during gait caused by joint destruction and loss ofjoint space. Fracture boots absorb weightbearing through their rigidwalls and mimic normal propulsion during walking with a curvedsole.6,7 AFOs relieve pain similarly. For patients with hemophilia andankle arthropathy, they are typically custom fabricated of thermo-plastic material, are rigid, and are worn inside the shoe; this typicallyrequires the patient to wear a larger shoe size than usual. In addi-tion, both types of devices can be hot and uncomfortable to wear.7

In our clinical experience, people with hemophilia and anklearthropathy shun the use of these types of devices.

For our study, we used a fracture boot with a pneumatic linerand a carbon fiber AFO.

Carbon fiber floor reaction AFOs are lighter than fracture bootsbut are equally able to absorb the forces of walking. They have asingle strut on the lateral side. Unlike typical AFOs, they do not re-quire a larger shoe, are easy to put on and take off, and are not hotto wear. These braces were much more acceptable to our patientsduring early trials.

We studied the gait parameters of 17 people with severe he-mophilia and unilateral ankle arthropathy using a 14-foot electronicsensor-embedded walkway. Participants walked at self-determinedspeed four times in each of three conditions: with shoes bilaterallyand no brace, with a shoe on the unaffected foot and a fracture booton the affected foot, and with a shoe on the unaffected foot and acarbon fiber AFO and shoe on the affected foot.

Pain was assessed using an 11-point (0-10) numerical rating8

scale and was assessed before and after each walking trial. Painscores were divided into three categories (0 = no pain, .5 – 2 =moderate pain, > 2 = severe pain).

FindingsPain relief and gait-related effects of bracing the painful ankle werestudied on both the braced and nonbraced sides. Each participantserved as their own control. Pain was relieved significantly (p < .05)




Figure 2. Summary of mean (± 1 standard error) pain scores reported by patientswearing shoes only, a fracture boot, or a carbon fiber AFO. *Indicates difference atp < .05 level, pairwise comparison with multiple testing adjustment.

with both devices compared with the shoes-only (no brace) condi-tion. There was no difference in pain reduction between the fractureboot and carbon fiber AFO treatments (p = .999). (Figure 1.)

Compared with the nonbraced condition, we found use of afracture boot on the involved ankle decreased the number of stepstaken per unit of time (cadence) and increased step time (timeneeded for one foot-to-next-foot contact), swing time (time the footis in the air), and cycle time (time needed between one foot contactand the next foot contact of the same foot). (Figure 2.)

Step time, swing time, and cycle time parameters tell us aboutthe dynamic effects of bracing. The treatment effects associated withthese gait parameters may be due to the differences in size and weightof the two braces. This may also be responsible for the changes notedin cadence, as the heavier fracture boot may require the limb to movemore slowly, so fewer steps per minute would be generated.

We also found static effects of bracing. These changes may bedue to the greater size and weight of a fracture boot compared witha carbon fiber AFO. Our findings suggest walking with a fracture booton one limb requires a longer swing time on the braced side to allowthe boot to advance, which, in turn, necessitates a longer stance timeon the nonbraced side. Both of these findings are shown.

A fracture boot is not only heavier but also longer than a shoe




Figure 2: Summary of mean (± 1 standard error) gait parameters associated withthree treatment conditions (no brace [0], fracture boot [1], and carbon fiber AFO [2]).*, ** Indicate between-group differences at p < .05 level, pairwise comparison withmultiple testing adjustment.

alone, and therefore longer and heavier than a shoe with a carbonfiber AFO. Advancing of the limb wearing a fracture boot may re-quire greater energy and may explain the increases in swing, cycle,and step times noted when compared with the no-brace condition.This added weight and length of the fracture boot may also explainthe differences noted in swing time of the uninvolved limb when afracture boot is worn on the involved limb.

There were no significant differences for any of the gait param-eters between the nonbraced (shoes-only) condition and the carbonfiber AFO condition. This finding, coupled with the significant differ-ences observed between the fracture boot and the carbon fiberAFO, suggest the AFO helps to preserve a more typical and efficientgait pattern in patients with hemophilia and ankle arthropathy.

The implications of this study involve better management ofpain relief, preservation of gait, and increase in participation. Ourresults indicate both devices were equally effective in relieving pain.

What are the effects of these devices on gait? Observation anddiscussion with our patients greatly informed this question. Peoplewho had tried fracture boots for their ankle pain said they felt un-stable, possibly because of the boot’s different height and weight,and chose not to use a fracture boot despite good pain relief, whilethose who had tried carbon fiber AFOs uniformly liked and ac-cepted them. Our results suggest using a fracture boot on a painfulankle negatively affected the dynamic aspects of gait on both thebraced side and the nonbraced side. The carbon fiber AFO, how-ever, did not affect gait parameters and relieved pain equally. Sub-jective comments of our study participants indicated a much greateracceptance of the carbon fiber AFO than the fracture boot.

Can we use this information to improve participation? Of ourpatients, those who are currently using a carbon fiber AFO are wear-ing it on an as-needed basis. Some wear it at work only, some wearit when they know they will be doing a specific activity that neces-sitates more walking than usual. Anecdotally, they all report theycan do what they need to do longer and with less pain when usinga carbon fiber AFO compared with shoes only. Of the patients inour study, only one is using a carbon fiber AFO and uses it asneeded, and none are using a fracture boot.

Bracing is not for everyone, and personal preference must berespected. In our experience, persons with hemophilia tend to beresistant to bracing, and may not be comfortable even with a bracethat is lighter, cooler, and lower-profile than a typical device.

Orthotic useJoint damage from hemarthroses result in painful bony changes thatcan be exacerbated during weightbearing. Because of this, foot or-thoses have long been a component of treating patients with he-mophilic arthropathy of the ankle.6,9,10

Some studies have addressed the impairments and activity limi-tations associated with hemophilia, but only a few have looked at par-ticipation, and most have focused on children and adolescents.11-17

One study18 used 3D gait analysis and the Revised Foot Func-tion Index (FFI-R)19,20 to compare the effect on hemophilic anklearthropathy of custom-fabricated orthopedic shoes and custom-fabricated orthopedic inserts. The FFI-R asks questions about footfunction in five domains: pain, stiffness, difficulty, activity limitation,and social and emotional outcomes. In this study, FFI-R scores sug-gest both orthopedic shoes and orthopedic inserts provide pain



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relief. The gait analysis results showed the orthopedic shoes wereassociated with improved propulsive function at the ankle, while theorthopedic inserts had only a limited effect on gait.18

To study the effects of orthotic use on participation, we sur-veyed 16 men with moderate and severe factors VIII and IX defi-ciencies and ankle pain using the Foot Function Index (FFI).21 TheFFI is a Likert-type scale that includes questions related to pain, dis-ability, and activity level.22,23 We also asked participants subsequentquestions about how satisfied they were with their activity with andwithout orthotics.21 Comparison of mean scores showed no differ-ences in pain levels but significant improvements in activity (disabil-ity on the FFI) and participation (subsequent questions) with orthoticdevice use compared with no orthotic use.21

These results prompted an ongoing qualitative study to identifycommon themes and perspectives related to ankle function and or-thotic device use. Study participants also completed the FFI-R in anattempt to look at associations between qualitative findings and ob-jective data. The FFI-R was chosen due to its comprehensive rangeof domains.22,23

In this ongoing study,24 17 interviews involving men with mod-erate to severe factor VIII and IX deficiencies have been transcribedand coded. To date, themes identified include impact of pain ondaily life, individualization of management, self-advocacy, uniquepsychosocial challenges, the role of learning from others with he-mophilia, and the desire for respectful acknowledgment by health-care professionals of their experience dealing with their bleedingdisorder. Interviews are still being conducted.

Pilot data from the FFI-R show a positive trend in participation(eg, a lower score for activity limitation) for orthotic device users.Data trends also suggest fewer social issues among those using or-thotic devices. There were no trends associated with age. However,this study is ongoing; data are still being collected and analyzed,and should not be taken as conclusive at this point.24

SummarySeparate studies show ankle pain can be relieved with bracing,5 aswell as with foot orthoses and orthopedic shoes.18 The same studiessuggest carbon fiber AFOs do not alter the gait cycle, whereas frac-ture boots do,5 and that orthopedic shoes are associated with im-proved gait while foot orthoses have a limited effect.18

The FFI-R appears to be a sensitive tool to evaluate the effectsof foot orthoses and participation in persons with hemophilia.18,24

Qualitative data suggest individuality and respect for personalknowledge and experience need to be taken into account in themanagement of hemophilic ankle arthropathy.24

David Oleson, PT, PCS, and Nancy Durben, MSPT, PCS, are physicaltherapists at The Hemophilia Center at Oregon Health & ScienceUniversity (OHSU) in Portland. Katherine Stribling, PT, DPT, PCS;Jamie Beckwith, PT, DPT; Laura Fox, PT, DPT, PCS; and Felicity Case,PT, DPT, PCS, contributed to this paper as pediatric physical therapyresidents at OHSU. Stribling and Beckwith are currently participatingin hemophilia research at OHSU as coinvestigators. Michael Recht,MD, PhD, is medical director of The Hemophilia Center at OHSU.




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SEBT scores and injuryrisk in collegiate athletes

Anterior-direction Star Excursion BalanceTest performance may most appropriatelydiscriminate between collegiate athleteswho are and are not at risk for lower ex-tremity injury, though additional researchis needed to determine specific injury cut-off scores for other athletic populations.

By Mikel R. Stiffler-Joachim, MS; David R. Bell, ATC, PhD; and Bryan C. Hei-

derscheit, PT, PhD

Prevention of sports-related injuries is an area of interest for sportsmedicine researchers, clinicians, and coaches. Consequently, de-velopment of screening tests that can identify athletes who are atrisk for a lower extremity injury has become the subject of many re-search investigations.1-6

In particular, the Star Excursion Balance Test (SEBT) was devel-oped as an efficient and inexpensive test of dynamic balance toscreen for injury risk. Initially designed with eight reach directions,7

the test has since been simplified to three directions: anterior (ANT),posterolateral (PL), and posteromedial (PM).8 To perform the SEBT,the participant stands on one leg with hands on hips and reachesas far as possible with the free lower limb in each of the directions(Figure 1). The reach is deemed invalid if the individual loses bal-ance completely or moves the stance foot, removes the hands fromthe hips, or transfers weight to the reach foot. The reach distanceis recorded as the maximal distance reached by the great toe.

Although SEBT performance has been repeatedly associatedwith both injury risk and injury recovery,6,9-11 the specific measure-ment (eg, reach distance, side-to-side asymmetry) most associatedwith injury risk remains inconsistent across studies. Therefore, ourresearch group aimed to summarize the literature involving SEBTperformance and injury, determine expected SEBT performancewithin our population of interest (National Collegiate Athletic Asso-ciation Division I collegiate athletes), and assess SEBT performanceand injury risk while controlling for secondary variables known toinfluence injury risk.

Normative dataSEBT scores can be compared to population-specific reference val-ues, such as expected reach distances or typical side-to-side asym-metries. Although numerous investigations have aimed to developinjury cutoff scores, few studies have reported normative values, anddifferences in SEBT performance between sexes are varied.12-14 As a


Practitioners should take care to applypublished SEBT cutoff scores for lowerextremity injury risk only to the populationfor which the scores were developed.

result, our research group characterized SEBT performance forhealthy Division I collegiate athletes to evaluate the effect of sexand sport.

Our records review involved SEBT data for 393 Division I col-legiate athletes from a single university who were healthy at the timeof testing. Reach distances in the ANT, PL, and PM directions werenormalized to leg length, and the composite (COMP) score was sub-sequently calculated. Side-to-side asymmetry in reach distance wasalso calculated for each direction and COMP score. Across allsports, average normalized reach distances ranged from 62% to69%, 84% to 97%, and 99% to 113% of leg length in the ANT, PL,and PM directions, respectively (Table 1).11 Reach distance asym-metry ranged from 2 to 4 cm, 3 to 7 cm, and 3 to 6 cm in the ANT,PL, and PM directions, respectively (Table 2).11

Our primary finding was that SEBT performance is sport-spe-cific in all directions and in COMP score. Among women’s teams,there were significant team differences in the PL and PM directionsand COMP score, with women’s ice hockey athletes reaching far-ther than athletes on all other teams in the PL and PM directions.11

Women’s soccer athletes also reached farther than softball athletesin the PM direction and COMP score. Among men’s teams, signifi-cant team differences were observed in all directions.11 Men’s icehockey athletes reached farther distances than athletes on all otherteams in the PL direction and all other teams except wrestling inthe ANT and PM directions and COMP score. These findings suggest

an individual’s performance should be compared to normative val-ues derived specific to his or her sport.11

Performance in the ANT direction alone demonstrated a sig-nificant interaction between sport and sex. Women achieved similarnormalized reach distances to men participating in the same sport,except for those participating in soccer. Among soccer athletes,women were able to reach significantly farther than men. Interest-ingly, neither absolute nor normalized asymmetry in each of theSEBT directions was sport-specific and demonstrated no interactioneffects.

In addition to reporting side-to-side asymmetry in reach dis-tance in absolute terms, our study was also one of the first investi-gations to report normalized asymmetry (% leg length). Normalizedreach distance asymmetry ranged from 3% to 4%, 5% to 8%, and5% to 6% in the ANT, PL, and PM directions, respectively.11

Because limb lengths in our population of collegiate athletesaveraged approximately 100 cm, our absolute asymmetry was verysimilar to our normalized asymmetry (eg, 4 cm of asymmetry = 4%asymmetry). However, among populations with shorter limb lengths,a 4-cm asymmetry may represent a much greater side-to-side dif-ference when normalized to limb length, and therefore may be in-dicative of more asymmetrical performance between limbs. Ifproviding normalized asymmetry data becomes standard for re-search in this area, that may enable comparisons to be more easilydrawn across studies with regard to expected asymmetry within agiven population and may also allow for more robust injury cutoffsto be developed.

Injury cutoff measuresUtilization of the SEBT as an injury screening tool has led to a varietyof injury cutoff scores being proposed. For example, previous re-search determined that among recreationally active college stu-dents, PL direction reach distances less than 80% of limb lengthwere associated with a 48% increase in ankle sprain injury risk.15

Alternatively, a cutoff of 4 cm of asymmetry in the ANT directionidentified both high school basketball players6 and Division I colle-giate football players16 who were and were not at risk for a lowerextremity injury.

In a sample of Division III collegiate football players, Y-balancetest (YBT; an instrumented version of the SEBT) COMP score sym-metry below 89.6% identified athletes who were at risk for a non-contact lower extremity injury.17 However, among a sample of bothhigh school and collegiate football players, reduced ANT directionreach distances on the SEBT, not asymmetry, were associated withinjury risk.18

Additional considerations for injury riskSeveral factors known to influence both SEBT performance and in-jury risk may help explain the inconsistencies between previousstudies. For example, sport, sex, and athletic exposure (eg, level ofcompetition, starting status) have all been shown to influence SEBTperformance.19,20 These same factors also affect injury rates.

For example, noncontact knee and ankle injury rates are typi-cally highest among football and basketball players.21,22 Additionally,women frequently demonstrate higher knee injury rates thanmen,22,23 and starters in college football are at greater risk for non-contact injuries than nonstarters.24 Consideration of these additionalvariables is needed to advance the SEBT as a robust screening test




Figure 1. Star Excursion Balance Test setup, with the anterior reach demonstrated.

and ensure it is valid across a variety of populations. To this end, we aimed to assess the relationship between SEBT

performance and injury status while controlling for sport, sex, andathletic exposure, measured via starting status.11 We first identifieda cohort of healthy athletes from a single academic year who hadno history of lower extremity surgery and were cleared for full par-ticipation at their preseason testing time point. Based on medicalrecords, we then identified individuals who either remained healthyover the course of their competitive season (n = 118) or went on tosustain a noncontact knee or ankle injury (n = 29).

For each athlete, SEBT reach distances in the ANT, PL, and PMdirections were compiled for both limbs and normalized to limblength. We calculated a normalized COMP score, as well as absolute(cm) and normalized (% limb length) side-to-side asymmetries.Reach distances and COMP score were compared between thehealthy and injured groups for the dominant limb (limb used to kicka ball for maximal distance) and nondominant limb, as well as forside-to-side asymmetry. Dominant-limb normalized ANT reach dis-tance and COMP score; nondominant-limb normalized ANT, PL, andPM reach distance and COMP score; and both absolute and nor-malized ANT asymmetry were significantly different between thosewho did and did not sustain a noncontact knee or ankle injury.These eight variables were then entered into separate multivariableregression models to predict injury status while controlling for sport,sex, and starting status.

Our multivariable regression models indicated both absoluteand normalized ANT side-to-side asymmetries best identified ath-letes who did and did not sustain a noncontact knee or ankle injury.Athletes who sustained an injury demonstrated approximately 1.8cm (1.9% limb length) greater ANT side-to-side asymmetry thanthose who did not.11 However, given that the smallest detectabledifference for the ANT direction of the SEBT has been reported as6.9% to 9%,25,26 this difference may not be clinically meaningful.Therefore, we also calculated receiver operating characteristiccurves to assess the efficacy of our multivariable models. Both mod-els (absolute and normalized asymmetry) demonstrated area-under-the-curve values greater than .82, with approximately 88% optimalsensitivity and 67% optimal specificity.11

Although our study was the first to assess the relationship be-tween SEBT performance and injury while controlling for variablesinfluencing injury risk, our results are similar to previous investiga-tions that have found ANT direction asymmetry to be most stronglyrelated to injury risk. However, the degree of ANT asymmetry thatindicates an athlete has an elevated risk of injury remains varied.Our investigation was unable to calculate a threshold or cutoff scoreas a result of our multivariable analyses, but application of the pre-viously proposed 4-cm cutoff to our study sample would only cor-rectly categorize 48% of the injured athletes and 73% of healthy




*Values represent the left and right limbs averaged together as no significant differences were observed between limbs. †Values represent the right limb only as no significant differences were observed between limbs. ‡Right limb values are reported in the dominant limb columns, left limb values are reported in the nondominant limb columns.

Women

Men

Menand

Women

athletes in our study. As injury risk differs by sport and level of competition, so too

may the SEBT thresholds that help identify if an athlete is at risk forinjury. Consequently, we recommend that injury cutoffs be utilizedonly in the population for which they were developed, until cross-validation of the cutoff score has occurred in other populations.

Inconsistencies in methodologyThough the SEBT has been extensively studied, inconsistencies inmethodology remain prevalent, such as stance foot alignment, handplacement, and direction identification.

Previously employed foot alignments have included: centeringthe foot at the intersection of the reach directions (origin),27,28 align-ing the most distal portion of the great toe with the origin for all di-rections,3,11,20 and aligning the great toe with the origin for anteriordirections and the heel to the origin for posterior directions (Figure2).26,29,30

In our studies, athletes aligned their great toe with the originfor all directions. When comparing our normative values to studiesthat aligned the heel with the origin,26 our values were approxi-mately 10% and 17% greater in the PL and PM directions, respec-tively.20 A recent study comparing foot position during the SEBTreported similar reductions of 17% and 6% in the PL and PM direc-tions, respectively.31 Standardization of stance-foot placement dur-ing the SEBT would greatly improve the ability to compare resultsacross studies and determine if true performance differences existacross populations.

Another area of inconsistency among SEBT research is handplacement. Athletes at our institution are required to maintain handson hips for the duration of the reach to standardize trunk movement,as recommended by previous investigations.3 Other studies haveallowed hands to be free from the hips and used for balance,26,32

which may facilitate better balance maintenance during the test33

and also be more reflective of an individual’s actual balancecapabilities during sport (eg, hands are rarely restrained when an

athlete needs to maintain balance in a sporting event). When com-paring hand position (free vs fixed) with the great toe aligned withthe origin, significantly greater reach distances were observed in alldirections in the hands-free condition compared with the hands-fixed condition.31 Differences in hand position between studies willclearly influence the findings and make it difficult to summarize cu-mulative SEBT results and injury cutoffs across populations whenmethodologies between the studies differ.

Lastly, studies often identify the PL and PM directions differently.In early SEBT research, the PL direction was identified as reachingto the lateral side of the stance limb, such that the reach limbcrossed behind the stance limb, and the PM direction was identifiedas reaching away from the medial side of the stance limb. However,a few recent investigations have defined the PL and PM directionsin the opposite manner of the initial description of the SEBT.15,18,25,34

In instances in which the directions are explicitly described or a fig-ure with directions labeled is available, comparisons may still bemade across studies. However, the directions are often not explicitlydescribed in the methods and a figure of the reach directions is pro-



TABLE 2. Side-to-side reach distance asymmetries on the Star Excursion Balance Test. Values are mean ± SD.

Gender SportNormalized reach distance asymmetry (% limb length)* Absolute reach distance asymmetry (cm)

Anterior Posterolateral Posteromedial Composite Anterior Posterolateral Posteromedial

Composite

Women

Basketball 4.3 ± 2.7 5.2 ± 3.2 5.2 ± 3.2 4.9 ± 2.1 3.5 ± 2.9 4.6 ± 3.3 4.5 ± 3.7 4.2 ± 2.4

Golf 2.8 ± 1.4 5.1 ± 2.8 5.3 ± 3.2 4.4 ± 1.8 2 ± 1.6 3.4 ± 2.9 4.5 ± 2.7 3.3 ± 1.5

Hockey 3.4 ± 2.5 6.3 ± 4 6 ± 3.8 5.2 ± 1.8 2.5 ± 2.2 5.1 ± 4 4.6 ± 4 4.1 ± 1.7

Soccer 3.1 ± 1.9 6 ± 5.1 5 ± 2.5 4.7 ± 2.1 2.4 ± 1.9 4.6 ± 4.8 4.1 ± 2.7 3.7 ± 2

Softball 2.9 ± 2 8 ± 5.3 5.7 ± 5.7 5.5 ± 3.6 2.3 ± 1.8 6.6 ± 5 4.6 ± 5 4.5 ± 3.1

Volleyball 4.2 ± 2.3 6.3 ± 2.9 5 ± 2 5.1 ± 1.7 3.1 ± 2.6 5.6 ± 3.5 3.2 ± 2.6 4 ± 1.9

Men

Basketball 3.7 ± 2.5 6.9 ± 4.3 4.6 ± 2.7 5 ± 2 3.3 ± 2.7 6.7 ± 5.4 4.2 ± 3.3 4.7 ± 2.3

Golf 4.2 ± 2.9 7.1 ± 5.4 6.2 ± 3.4 5.8 ± 2.5 4 ± 2.9 6.2 ± 5.7 5.9 ± 3.4 5.3 ± 2.2

Hockey 2.8 ± 1.9 6.2 ± 4 5.1 ± 4 4.7 ± 2.4 2.4 ± 2.2 5.3 ± 4.6 4.4 ± 3.9 4 ± 2.6

Soccer 2.9 ± 1.8 5.9 ± 3.8 4.5 ± 2.7 4.4 ± 1.7 2.2 ± 1.8 5.1 ± 3.6 3.5 ± 2.9 3.6 ± 1.6

Football 4 ± 2.9 6.6 ± 4.8 5.3 ± 3 5.3 ± 2.2 3.8 ± 3 5.7 ± 5.5 4.7 ± 3.5 4.7 ± 2.4

Wrestling 3.7 ± 3.2 6 ± 3.5 5 ± 2.8 4.9 ± 2.1 2.9 ± 3.2 4.3 ± 3.5 3.8 ± 3 3.7 ± 2.2

Women

CompositePosterolateralAnteriorComposite PosteromedialPosterolateralAnterior Posteromedial

Men

Figure 2. Star Excursion Balance Test foot position variations, with A) toes aligned tothe origin, B) foot centered on the origin, and C) heel aligned to the origin.

vided infrequently as familiarity with the SEBT has increased, whichcan make it difficult to summarize collective findings from multipleSEBT investigations.

A final consideration when comparing normative and injury cut-offs values for the SEBT is the specific testing setup used. The YBTis an instrumented device used by many to perform the SEBT,35

which has led to the two tests often being viewed as interchange-able. Previous research comparing the two setups has shown YBTperformance in the ANT direction is 3% less than SEBT perform-ance in the ANT direction, with no significant differences observedbetween testing methods for the other directions.36

Given that the ANT direction has been the parameter most fre-quently associated with injury risk in previous SEBT investigations,it is possible the ANT direction on the YBT may also be the most in-formative regarding injury risk. However, due to the difference inANT direction performance, the specific cutoff scores developedusing the SEBT are likely not applicable to testing with the YBT ap-paratus. As a result, normative values and injury cutoff scores shouldcontinue to be developed separately for the SEBT and YBT.

ConclusionThe overall body of research on the SEBT to this point suggestsANT-direction SEBT performance may most appropriately discrimi-nate between those who are and are not at risk for injury, thoughadditional research is needed to determine population-specific in-jury cutoff scores.

To further the development of the SEBT as a screening test,both clinicians and researchers should aim to be more consistentin their methodologies with regard to the aforementioned areas ofconcern: foot alignment, hand placement, and directional labelling.Although the SEBT can be a useful screening tool, previously pub-lished injury cutoff scores have not been cross-validated, and careshould be taken to apply injury cutoff scores only to the populationfor which the scores were developed.

Future investigations should continue to develop normativedata for noncollegiate athletes and non-Division I collegiate athletes,determine injury cutoff scores for sports not currently representedin the literature, and cross-validate injury cutoff scores to ensurethey are robust and valid.

Mikel R. Stiffler-Joachim, MS, is a research specialist in the Depart-

ment of Orthopedics and Rehabilitation at the University of Wiscon-

sin-Madison (UWM). David R. Bell, ATC, PhD, is an assistant

professor in the Department of Kinesiology at UWM. Bryan C. Hei-

derscheit, PT, PhD, is professor in the Doctor of Physical Therapy

program at UWM.



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Clinicians and researchers should aim tobe more consistent in their methodologieswith regard to SEBT foot alignment, handplacement, and directional labelling.

Soft braces: Experts huntfor potential mechanisms

Soft braces are not designed to changelower extremity alignment or joint forces,but research suggests they may influenceknee and ankle biomechanics in otherways, including by enhancing propriocep-tion. This line of investigation could openthe door to new therapeutic opportunities.

By Stephanie Kramer

Soft braces are widely used at the knee and ankle for relieving painand preventing injury. Although they do not address joint issues me-chanically, the number of studies documenting their association withpain relief is growing, and researchers are also inching toward anunderstanding of the underlying mechanisms responsible for sucheffects.

“We take soft braces for granted,” said Nerrolyn Ramstrand,PhD, BP&O, an associate professor of prosthetics and orthotics atJönköping University in Sweden. “A soft brace is a quick solutionthat we can offer patients. They’re relatively simple, but we don’tknow enough about the underlying mechanisms that are facilitatingfunction.”

Soft bracing is a common approach for management of kneeosteoarthritis (OA), patellofemoral pain (PFP), and the chronic ankleinstability that can lead to ankle osteoarthritis, so it’s an importantissue.1-4

In one oft-cited study in support of soft bracing, researchersfrom the University of Southern California (USC) in Los Angelesfound a soft brace was associated with increased patellofemoraljoint contact area as well as with decreased pain in women withPFP, despite having no effect on patellar alignment.5

“People have shown soft braces do reduce pain. The questionis what is the mechanism?” said first author Christopher Powers, PT,PhD, director of the Program in Biokinesiology and codirector of theMusculoskeletal Biomechanics Research Lab at USC.

An intriguing possibility to emerge from current research andclinical discussions is that soft braces, which are not designed tochange alignment or joint forces, may influence biomechanics inother ways, including by enhancing proprioception. This line of in-vestigation could open the door to new therapeutic opportunities.

Potential mechanisms As reported in this magazine in June, researchers presented newfindings on soft braces at the 2017 International Society for


Patients who feel a rigid brace is too bulkyand uncomfortable may be more willing towear a softer one, but even a soft brace canbe difficult to apply and fit correctly.


Prosthetics and Orthotics (ISPO) World Congress in Cape Town,South Africa (see “Sleeves showcase softer side of knee pain man-agement,” June, page 30).

In one study, researchers at the University of Central Lancashirein Preston, UK, evaluated four people with mild to moderate kneeOA and 10 controls during a step-down task, with or without brac-ing.6 In both groups, bracing led to biomechanical changes, includ-ing a significant reduction in transverse plane range of motion. KneeOA patients also reported improvement on the Knee Injury and Osteoarthritis Outcome Score (KOOS).

“If you have improvements in knee movement, particularly inthe transverse plane, there will be improved stability and the pa-tient’s symptoms will improve,” said James Richards, PhD, a profes-sor of biomechanics at the university, who presented the findings.“A soft brace makes the knee more stable, possibly not through me-chanical effects, but through proprioceptive effects.”

A recent paper in the Archives of Physical Medicine and Rehab -ilitation supports these findings.3 The meta-analysis of 11 studies onknee OA patients concluded soft bracing improved symptoms andjoint functioning. The review authors speculated that knee sleevesmay enhance proprioception by stimulating skin mechano receptors,leading to improved muscle activity. Theoretically, this could de-crease loading and improve knee joint stability. Other potentialmechanisms include better biomechanical balance7 or lower jointcontact forces due to reduced cocontraction of the muscles.8,9

“We found that wearing a soft brace can improve pain in theimmediate term and improve physical function in the long term,”said study leader Tomasz Cudejko, a PhD fellow at VU University

Medical Center Amsterdam in the Netherlands. “This is contradic-tory to the belief that a brace is a temporary treatment measure.”

In the USC study mentioned earlier,5 Powers and colleaguesused axial magnetic resonance imaging (MRI) to assess changes tojoint contact area and patellar displacement during 0°, 20°, 40°, and60° of knee flexion with or without a brace. The authors concludedincreased joint contact area, not improved tracking, was associatedwith reduced pain.

“A lot of research on soft braces shows that neoprene bracesdon’t affect tracking per se.10,11 Their influence is more subtle,” Pow-ers said. “They don’t control how the patella tracks. That’s the myth.We think it’s more that it’s a compressive effect.”

A 2010 study suggests wearing a knee sleeve may influencebrain activity. Using functional MRI, scientists demonstrated alteredactivity in the sensorimotor cortex in 13 female volunteers duringknee flexion and extension while wearing a knee sleeve, comparedwith no sleeve.12

Soft braces and subgroups A clearer understanding of what soft braces can achieve—and whatmakes them effective—is crucial for determining which subgroupsof patients may be helped by a softer approach, Richards said.

“Knee bracing may not work on all patients all the time,” he said. The key is to identify which patients may benefit, Richards said.

For example, one subgroup of patients with knee OA are those whodevelop an accelerated form of the disease (see “The implicationsof accelerated knee OA,” April 2016, page 43). Richards and





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colleagues have been developing a detailed classification systemfor subgroups of patients with PFP,13 which they described in theJanuary issue of LER (see “Patellofemoral pain subgroups: A criticalfirst step toward personalized clinical intervention,” January, page18).

At the ISPO Congress, Richards presented a paper on soft brac-ing for one of the three PFP subgroups his team has identified.14

The 20 recreational athletes with PFP in that study were all mem-bers of the “strong” subgroup, meaning they did not have weaknessin the hip abductors or quadriceps muscles. The researchers foundwearing a soft brace during run-and-cut movements was associatedwith significantly decreased peak patellofemoral forces, patello -femoral pressure, and loading rate, along with improved pain, com-pared with no brace.

ProprioceptionAs with the Central Lancashire group’s findings in patients with kneeOA, Richards believes soft bracing in patients with PFP also has pro-prioceptive effects, which—at least in one subgroup—may also im-prove stability and functional performance as well as pain.

“There were hand-in-hand changes. Patients experienced im-provements in both knee stability and KOOS scores,” Richards said.“Improvements in movement control can lead to improvements instability, and this in turn can improve symptoms and people’s abilityto play sports.”

Similarly, a Belgian study published in the Clinical Journal ofSports Medicine in 2008 explored the proprioceptive effects of a neo-prene knee sleeve in military recruits, about 30% of whom have beenpreviously reported to develop PFP after six weeks of basic training.15

Sixty-four healthy adults underwent four consecutive tests ofactive joint repositioning before and after a fatigue protocol and withor without a knee sleeve on one limb. The authors found joint

repositioning was more accurate acutely after application of theknee sleeve than with no sleeve; after the fatigue protocol, position-ing errors increased in the control limb but were similar to prefa-tigue error levels in the braced limb. After the knee sleeve wasremoved postfatigue, error levels were similar in both limbs.

“It’s probably not a mechanical effect, but a neurophysiologicalone,” said lead author Damien Van Tiggelen, PhD, visiting professorin the Department of Rehabilitation Sciences at Ghent Universityand head physical therapist at the Military Hospital Queen Astrid inBrussels. “Once you remove the brace and do a test of reposition,the effect is immediately gone.”

The Belgian findings are consistent with those of researchersfrom the University of Western Ontario in London, Canada,16,17 whoreported small but significant improvement in joint position senseassociated with the use of a neoprene knee sleeve—but, interest-ingly, also suggested that some individuals may experience greaterproprioceptive benefit from a knee sleeve than others, which sup-ports the subgroup theory discussed earlier.

A later randomized clinical trial from the Fowler Kennedy SportMedicine Clinic in London, Canada, reported use of a neopreneknee sleeve after anterior cruciate ligament (ACL) reconstructiondid not differ from use of a functional knee brace with regard to an-terior tibial translation, the single-limb forward hop test, or TegnerActivity Scale.18

The findings of a 2017 paper from the University of Central Lan-cashire19 may help explain the Canadian results. In 13 healthy malerecreational athletes, a prophylactic knee sleeve was associatedwith significantly lower ACL loading rates during cutting and single-leg hop tests compared with no sleeve; however, loading rates didnot differ between the two conditions during running.





“The prophylactic knee sleeve significantly reduced the rate atwhich the ACL experienced loading during the more dynamic cut-and-hop movements,” said lead author Jonathan Sinclair, PhD, anassociate lecturer at the School of Sport and Wellbeing at the Uni-versity of Central Lancashire.

Anecdotally, soft braces also can be associated with improvedproprioception at the ankle, Ramstrand said.

“People who have had ankle problems and thus decreased pro-prioception sometimes use a soft brace as a prophylactic measure,”she said. “It may help reduce the incidence of ankle sprains.”

Soft brace designA current line of investigation related to the potential benefits of softbracing involves the extent to which brace design may play a role.

One hypothesis is that the amount of pressure a knee braceapplies affects proprioception.

In a paper presented at the ISPO Congress, Ramstrand and col-leagues compared the effects of two braces in 20 healthy men andwomen.20 Participants wore either a neoprene sleeve or a bracewith rigid joints. The researchers found that, though the rigid braceapplied greater pressure than the sleeve, more rigid bracing wasalso associated with a poorer sense of passive motion.

“If you apply large amounts of pressure—a stiffer orthosis withmaximum flexion—in healthy individuals, proprioception decreases.This suggests there is a threshold,” Ramstrand said. “The flipside isthere is no orthosis on the market that addresses that.”

Although it was a significant finding, these were test conditionsand may not apply to normal walking, she added.

Other research presented in Cape Town suggested the tight-ness of a soft brace had no significant influence on pain or functionin 44 patients with knee OA. Cudejko and colleagues reported nodifference between a properly fitted soft brace and a looser onewith regard to pain, activity limitations, or knee confidence duringperturbed treadmill walking.21

According to Ramstrand, the effectiveness of soft bracing mayinvolve a combination of factors, including the material’s rigidity, itseffects against the skin, and pressure.

“Even a Band-Aid can affect skin stretching,” she said. “If [thesleeve material] is stiffer and there is more pressure, then thestretching of the skin is also greater.”

The type of interface material used—silicone versus gel, for ex-ample—may also make a difference, Ramstrand said.

“The design of the knee brace is important, but no one haslooked at that,” she said.

Similarly, Richards said brace characteristics could contribute toimproved pain and function, partly by activating receptors in the skin.

“The skin sensation sends information to the sensory part ofthe brain, and the motor cortex sends signals to the muscles whichcontrol the biomechanics at the joint,” he said. For example, the useof 3D knitting could produce different tensions over the patella, in-fluencing proprioception.

However, Van Tiggelen suggested that specific design featuresmay not be critical.

“I think it’s just the wrapping and compression on the skin that’simportant. It doesn’t matter if it’s elastic or neoprene,” he said,though he noted he hasn’t yet investigated the effects of differentbraces on proprioception.

Other practical issues for clinicians include whether the effectsof soft bracing are time-limited.

“Is it an immediate effect? Or is it long-lasting? We don’t knowthe answer to that yet,” Ramstrand said.

Another concern is that even a cloth brace can be a challengeto apply and fit correctly. Ramstrand noted that in their study pre-sented in Cape Town, two assistants helped patients properly posi-tion the brace. This is important, she said, not only for healing butfor maximizing compliance.

Practice pointers Clinical decisions about bracing, experts noted, are primarily deter-mined by the indication and the goal of treatment.

“It depends on what the clinician is trying to achieve,” Powerssaid. “A rigid brace would provide more structural support for thejoint. It would be more effective at preventing unwanted motion. Asoft brace would not affect rotation or restrict movement to anygreat degree.”

For example, the use of a rigid brace may make sense for shortperiods of time, such as in the period shortly after surgery.

“If the patient has true mechanical instability, such as after ananterior cruciate ligament repair where you want to protect the graft,a more rigid bracing would be a safer bet,” Richards said. “If youwant to improve control, then soft bracing could work.”

Yet many patients may not realize they have impaired proprio-ception. In a second study22 on the same 64 reportedly healthy mil-itary recruits from the aforementioned Belgian study, about half hada joint position sense error of more than 5° on each side at baseline,Van Tiggelen said. In those with poor proprioception at baseline, aneoprene knee sleeve was associated with significantly improvedjoint position sense before and after a fatigue protocol; in those withgood proprioception at baseline, the sleeve was associated withpostfatigue improvement only.

This has implications for therapy, Van Tiggelen said. “Any patient with poor proprioception should wear a brace dur-

ing training or rehabilitation,” said Van Tiggelen. “If you can identifylacking proprioception, you can add a tool that is immediately help-ful to them.”

Athletes who fear reinjury, as well as older patients, may feel




more confident with knee or ankle bracing, Ramstrand said.“A soft brace can give balance confidence in elderly people,”

she said, adding that clinicians should ask patients what it is theywant to do and whether they are able to do it.

Yet adherence with any type of bracing can be an issue in clin-ical practice.

“Patient compliance can be really low,” Van Tiggelen said.“Clients are absolutely not motivated to wear a brace.”

However, many patients who don’t want to wear a rigid bracebecause it’s bulky and uncomfortable may be more willing to weara softer one.

“Soft braces are relatively comfortable and are easier to put on,especially for elderly patients,” Ramstrand said. “They cost less, too.And people can buy them at a sports shop—they don’t need to see

a clinician.” Athletes are often worried that wearing a brace could weaken

their muscles; Van Tiggelen said such concerns are misplaced, butalso noted patients should avoid relying on a brace if possible.

“You can also improve proprioception by training,” he said.“The brace is just a helpful tool.”

Powers also cautioned against using as a brace as long-termmeasure.

“They don’t necessarily fix what’s causing the pain,” he said.“When the brace comes off you haven’t fixed anything.”

Stephanie Kramer is a freelance medical writer based in Berlin, Germany.



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Surgery and ulcer healingin patients with equinus

Achilles tendon lengthening and gastroc-nemius recession both increase ankle jointdorsiflexion and reduce plantar forefootpressures in patients with diabetes andequinus deformity, but experts continueto debate which is best for managing fore-foot ulcers and minimizing reulceration.

By Barbara Boughton

Although total contact casting is the gold standard for healing andpreventing diabetic foot ulcers, practitioners have increasinglyturned to surgery—specifically gastrocnemius recession andAchilles tendon lengthening—for more effective long-term manage-ment. Both Achilles tendon lengthening and gastrocnemius reces-sion increase ankle joint dorsiflexion in patients with diabetesequinus deformity, and reduce plantar forefoot pressures. Althoughboth these surgeries are effective, there continues to be debateover whether gastrocnemius recession or Achilles tendon length-ening is best for diabetic patients who have forefoot ulcers or a highrisk for ulceration.

One of the first papers on these surgeries1 compared Achillestendon lengthening to total contact casting, and found the surgerywas significantly more effective than casting at reducing recurrenceof neuropathic ulceration on the plantar aspect of the forefoot. In a2003 study by Mueller et al,1 researchers at Washington University inSt. Louis compared immobilization in a total contact cast alone withtotal contact casting combined with percutaneous Achilles tendonlengthening in 64 patients with neuropathic plantar forefoot ulcers.

They found 88% of ulcers healed in the total contact castinggroup after a mean of 41 days, while 100% of ulcers healed in theAchilles tendon lengthening group after a mean of 58 days. Thegroup treated with Achilles tendon lengthening demonstratedgreater dorsiflexion right after surgery and at seven months afterthe procedure compared with the total contact casting group. Com-pared with those who underwent total contact casting, patients inthe Achilles tendon lengthening group also had a 75% lower riskfor ulcer recurrence at seven months and a 52% lower risk at twoyears from baseline.

“Although total contact casting may be adequate to heal simpleulcers, it’s more likely that a patient will need a surgical approachas his or her diabetes progresses,” noted Paul J. Kim, DPM, directorof research and associate professor in the Department of PlasticSurgery at Georgetown University Hospital in Washington, DC.


Research suggests Achilles lengthening isassociated with greater ankle dorsiflexion,but also higher rates of complication andrerupture, than gastrocnemius recession.

and drawbacks of each of these surgeries. While Achilles tendonlengthening has long been the standard for alleviating equinus de-formity, an increasing number of studies have begun to establishthe benefits of gastrocnemius recession.

In 2015,3 researchers performed a systematic review of 18studies on gastrocnemius recession, including five in which the pro-cedure was the primary treatment for diabetic ulcers on the plantarmidfoot and forefoot. With clinical enthusiasm for gastrocnemius re-cession increasing, the researchers aimed to find scientific supportfor this treatment, according to Christopher DiGiovanni, MD, a re-view author. They concluded there was growing evidence and sci-entific support for using isolated gastrocnemius recession as aneffective treatment strategy for midfoot or forefoot ulcers, but notedmore carefully controlled investigations were needed to define thetrue efficacy of the surgery.

“The evidence for gastrocnemius recession continues tomount, although the quality of the evidence is not as good as itshould be,” said DiGiovanni, who is chief of the Division of Foot andAnkle Surgery at Massachusetts General Hospital in Boston and atNewton Wellesley Hospital.

Pros and consGastrocnemius recession achieves a less powerful correction to ankledorsiflexion than Achilles tendon lengthening, increasing ankle jointrange of motion by up to 18° versus 30° or more with Achilles tendonlengthening, according to recent studies.4,5 However, because theAchilles tendon has poor blood supply, lengthening of this tendon isalso associated with a risk for rupture.5 It also has a higher incidenceof wound complications than gastrocnemius recession due to thefragility and thinness of the skin over the tendon, according to RobertSantrock, MD, associate professor and chief of foot and ankle surgeryat West Virginia University in Morgantown.

Often clinicians will try a total contact cast first to heal and off -load a diabetic forefoot ulcer, since it is a conservative measurewithout the risks of surgery, said John Steinberg, DPM, a professorin the Department of Plastic Surgery at Georgetown. Although totalcontact casting does have a high success rate for wound healing,there are two important problems with this modality, Steinbergnoted. Although a cast may allow the ulcer to heal, it doesn’t ad-dress any underlying equinus deformity that may contribute to re-current ulceration.

“It’s also hard for many patients to accept a nonremovable,bulky cast that they have to wear even while sleeping. Patients reallydislike it,” Steinberg added.

Literature reviewsMore recent studies have also validated the effectiveness of surgicalapproaches to healing and preventing diabetic foot ulcers comparedwith total contact casting. In a review published in the Journal of Footand Ankle Research in 2015, Australian researchers performed ameta-analysis of randomized controlled trials that assessed outcomesof Achilles tendon lengthening, gastrocnemius recession, and totalcontact casting in patients with diabetic ulcers on the forefoot or mid-foot.2 All Achilles tendon lengthening and gastrocnemius recessionsurgeries included in the meta-analysis were performed to addresslimited ankle joint dorsiflexion or equinus deformity.

The analysis of 11 studies (614 participants) indicated the timeto ulcer healing and the rate of healed ulcers was similar amongpatients who had surgery and those who wore a total contact cast.But the rate of ulcer recurrence was significantly lower in those whohad surgery—either Achilles tendon lengthening or gastrocnemiusrecession—than with total contact casting, the authors noted.

In the Australian study, researchers did not separate the resultsachieved with Achilles tendon lengthening versus gastrocnemiusrecession, but other studies have attempted to tease out the benefits




Photos illustrate intraoperative Achilles tendon lengthening procedure. Limited ankle dorsiflexion is evident prior to the procedure (far left) and significantly improved afterward(far right). (Photos provided by David Armstrong, DPM, MD, PhD.)

Achilles tendon lengthening surgery is also associated with agreater risk of overlengthening than gastrocnemius recession, andas a result, calcaneal gait can occur,2 according to David Armstrong,DPM, MD, PhD, professor of surgery and director of the Southwest-ern Academic Limb Salvage Alliance at the University of SouthernCalifornia in Los Angeles.

“Gastrocnemius recession has a lower risk for complications,6

but the amount of correction you get is also less,” Armstrong said. Armstrong prefers to perform Achilles tendon lengthening pro-

cedures for equinus deformities in diabetic patients because hefinds it is easier to achieve optimal results with this procedure thanwith gastrocnemius recession, he said. But gastrocnemius recessionis currently more popular than Achilles tendon lengthening, partlydue to the lower risk for complications with this surgery, accordingto Santrock.

In one of the largest studies on gastrocnemius recession, pub-lished in 2006,6 researchers retrospectively reviewed the morbidityassociated with this surgery in 126 patients. Ten patients underwentisolated gastrocnemius recession, while the rest had the surgerywith an additional foot and ankle procedure. Patients were followedfor a mean of 19 months to assess postoperative complications.Postoperative complications developed in only 6% of patients; themost common were scar problems in four patients (4%) and nerveproblems in three patients (2%). No patient had a limp or gait dis-turbance afterward, and none developed persistent decreases inmuscle strength or calcaneal gait.

“The most prevalent complication with gastrocnemius reces-sion is weakness, and there is less weakness after these surgeriesthan with an Achilles tendon lengthening,” said Monroe Laborde,MD, assistant professor of orthopedic surgery and director of thefoot clinic and at Louisiana State University in New Orleans.

Gastroc-soleus recessionLaborde said he prefers to use a gastrocnemius-soleus recessionin diabetic patients with equinus. This type of gastrocnemius reces-sion also includes intramuscular lengthening of the soleus muscle.

“Gastroc-soleus recession provides additional lengtheningcompared to gastrocnemius recession alone, so it’s helpful whenmore correction is needed,” Laborde said. “But a gastrocnemius recession alone will also cause less weakness afterward than a gastrocnemius-soleus recession.”

Laborde has authored a number of studies on gastrocnemius-soleus recession,7-9 and has found these surgeries result in effectiveoutcomes but lower complication rates than Achilles tendon length-ening. Although transfer ulcers or heel ulcers are rare after all thesesurgeries, they can occur, as the surgeries redistribute plantar pres-sures from the forefoot to the heel. Yet there are fewer transfer ulcers after gastrocnemius recession than after Achilles tendonlengthening, Laborde said.

In a 2008 study of 16 patients with 19 ulcers, for instance,Laborde and fellow researchers found that 18 of 19 ulcers healedand three of 18 ulcers recurred after gastrocnemius-soleus reces-sion. In addition to an amputation, the complications included oneheel ulcer, two toe ulcers, and one toe dislocation at 45 months follow-up.7,8 In a review of studies on gastrocnemius recession andAchilles tendon lengthening, published in 2010,7 however, Labordeand fellow researchers found Achilles tendon lengthening resultedin more complications than those gastrocnemius recession. In one

paper published in 2004, for instance, Achilles tendon lengtheningin 68 patients resulted in healing of 68 of 75 ulcers, but complica-tions included two amputations, 11 heel ulcers, and seven Achillestendon ruptures after one year of follow-up.9

Postoperative considerationsRecovery after a gastrocnemius recession is also quicker and lessonerous than after an Achilles tendon lengthening procedures, ac-cording to clinicians interviewed by LER. Most patients who havegastrocnemius recession can bear weight in an orthopedic walkingboot the same day as the surgery, can walk without a boot withinfour weeks, and can run at six to seven months after surgery, ac-cording to Laborde. After an Achilles tendon lengthening, however,the patient will spend at least four to six weeks in a cast or splintand then a walking boot.

The challenge with such a recovery is patient compliance, aspatients who remove their brace or splint are at risk for an Achillestendon rupture or tear.

“We aim to enhance patient compliance after an Achilles ten-don lengthening procedure by doing a lot of education preopera-tively,” Steinberg said.

Achilles tendon lengthening can now be performed as an opensurgery or percutaneously. Lin, who does Achilles tendon length-ening surgeries primarily for equinus deformities, favors the percu-taneous approach because he finds it a more controlled, reliabletechnique. Triple hemisectioning of the Achilles tendon through apercutaneous approach is a popular technique because it’s a rela-tively simple surgery and can provide 3° to 12° of increased ankledorsiflexion for each centimeter of lengthening, according to Kimand other researchers.10,11 However, an open Achilles tendonlengthening procedure does offer better visualization of the tendonduring surgery.5

Most surgeons agree both Achilles tendon lengthening andgastrocnemius recession are fairly safe, even for patients with comorbidities. The standard for selecting the type of surgery is theSilfverskiöld test, which assesses ankle dorsiflexion range of motion.If there is limited dorsiflexion in the gastrocnemius muscle alone,then a gastrocnemius recession is the preferred surgery. However,if there is limited dorsiflexion in both the gastrocnemius and soleusmuscles, then an Achilles tendon lengthening is the right procedure,according to DiGiovanni.

Yet, even this test is controversial. Some surgeons questionwhether it is truly useful in a diabetic population, and others find itmore helpful to base their surgical decision on the amount of cor-rection they hope to obtain.

“We do use the test, but we generally still perform the Achillestendon lengthening in our highest-risk patients because we havefound that we get a more durable correction with this surgery in ei-ther gastroc or gastroc-soleus equinus,” Armstrong said. “Some-times the choice of surgery will come down to the individualsurgeon’s preference.”

Physical therapy and orthosesBoth surgeries improve gait, but the associated offloading of theforefoot also can affect balance, according to Steinberg.

“Patients can have the sensation that they are falling forward,”Steinberg said, adding this is why physical therapy, including gaittraining, is important.




As well as working on exercises that improve gait, it’s crucialfor physical therapy to provide stretching and tensioning ofstretches in the muscles involved in the surgery, according to ClarkeBrowne, PT, DPT, athletic trainer and owner of BrownStone PhysicalTherapy in Macedon, NY.

“Since both Achilles tendon lengthening and gastrocnemius re-cession make the distance from the knee to the calcaneus longer,we want to apply significant stretches to the gastrocnemius andsoleus so that the muscles do not contract again,” he added.

Yet there are challenges to physical therapy after both gastroc-nemius recession and Achilles tendon lengthening, according toBrowne. If the foot is still tender, it can be difficult for a patient tohook a towel or strap around the foot to stretch. Thus, physical ther-apists often prescribe gentle exercises that can be done while wear-ing diabetic footwear.

“We also lighten the intensity of exercise, but lengthen the du-ration,” Browne said.

The exercises used to recover from both surgeries includepulling up and contracting the tibialis anterior muscle. Standing calfstretches are also used. Patients are given range-of-motion exer-cises to aid their recovery, and are encouraged to ride stationarybikes with light tension, as long as they are wearing protectivefootwear, Browne said.

Orthotic devices can also aid patient recovery. “An orthotic with the right amount of cushioning can help the

diabetic foot feel comfortable after surgery and reduce pressure onthe foot,” Browne said.

He often incorporates a heel lift into orthotic devices, so it is

easier for patients to walk around and exercise.

“Once the calf muscles are sufficiently stretched out with phys-

ical therapy, we take the heel lift out,” he said.

Compression stockingsTo prevent vascular problems and alleviate swelling after surgery,

Browne also prescribes compression stockings for his patients who

undergo Achilles tendon lengthening and gastrocnemius recession.

“Compression stockings can help with poor circulation, and by

using them, wound healing after these surgeries can be hastened,”

he said. “Both activity and compression stockings aid blood circu-

lation, and compression stockings help move the blood toward the

heart. As a result, compression stockings can prevent the blood

from collecting in the lower leg.”

There are definite differences in recovery time and potential

complications between gastrocnemius recession and Achilles ten-

don lengthening, and controversy about which procedure is asso-

ciated with the best outcomes in which patients. But the literature

strongly suggests these procedures often have benefits for diabetic

patients with equinus who are at risk for ulceration.

“They can be tremendous procedures because they provide

diabetic patients with the ability to have an active lifestyle that can

be free of recurrent ulcers,” Steinberg said.

Barbara Boughton is a freelance writer based in the San Francisco

Bay Area.




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Dr. ComfortCara Chukka

New from Dr. Comfort, thewomen’s Cara chukka boot fea-tures a roomy, protective toebox to help prevent skin irrita-tion and toe stubbing. With afirm heel counter, this stylishlace-up ankle bootie providesextra medial and lateral supportand stability. Natural suedeleather material helps to regu-late heat and keep feet cool anddry. Like the Ruk boot for men,the Cara is a therapeutic shoe—it qualifies for Medicare reim-bursement using HCPCS codeA5500—that doesn’t compro-mise on style. Easy to put onand adjust, the Cara is a time-less boot available in black andbrown and a variety of widthsand sizes.

Dr. Comfort800/728-9917drcomfort.com

OPTP JointDistractor

OPTP has introduced a newproduct for use as an adjunctto manual therapy methods: theOPTP Joint Distractor. The prod-uct’s hook-and-loop strap de-sign fastens a patient’s ankle se-curely in place, allowing forcomplete isodynamic joint dis-traction for the lower extremi-ties. Physical therapists, athletictrainers, and fitness trainers canuse the unit to provide comfort-able axis distraction therapy thathelps promote joint health fortheir patients and clients. Indi-cations include postoperativejoint rehabilitation; knee, hip, orankle osteoarthritis; ankle sprainrehabilitation; and restoration ofscar tissue following injury.

OPTP800/367-7393optp.com

SilhouetteWound Imaging

Aranz Medical has announcedthe availability of Silhouette ver-sion 3.19, a camera and softwarepackage for lower extremitywound imaging, 3D measure -ment, and documentation. Thethree-part Silhouette packageincludes SilhouetteStar (a light-weight image capture device),SilhouetteConnect (the softwareapplication), and Silhouette Cen-tral (a database for long-termstorage). The new version of thesoftware includes tissue typeclassification and measure-ments, improving the ability ofresearchers and clinicians to ac-curately and efficiently analyzetissue types and record detailedchanges to wounds over time.

Aranz Medical866/467-0934aranzmedical.com

FillauerAllPro Foot

The AllPro prosthetic foot fromFillauer crosses all boundaries,combining high flexibility anddynamic performance to allowthe user to work and play like apro. This “do-it-all” foot easilytransitions from the gym to ten-nis and basketball courts, as wellas soccer, football, and lacrossefields. The AllPro is designed formultiaxial needs, whether thoseinvolve walking on a flat surfaceor traversing steep hills. It fea-tures excellent plantar flexionand dorsiflexion, a carbon com-posite design for dynamic re-sponse, a rocker toe for easyand smooth rollover, and a Re-versable Pyramid Insert adapterfor optimal alignment.

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Visit lermagazine.com/productsfor more products and to submit your new product listing.

Pediatric TripleAction Joint

Developed by Becker Orthope-dic, the Pediatric Triple ActionAnkle Joint is designed to pro-vide control of the lower limbthrough all phases of gait. Thisadvanced orthotic ankle joint isengineered to keep pace withactive patients—particularly thosewho may benefit from precisetuning of ankle and knee supportfor each phase of the gait cycle—improving performance and re-ducing component mainte-nance. The component is small,lightweight, and durable. It maybe used unilaterally, paired witha free motion companion joint,or used in a double upright ther-moplastic design for larger pa-tients or those with high tone.

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SaeboStepFoot Drop Brace

The SaeboStep is a lightweightbrace designed to provide footdrop patients with convenience,comfort, optimum foot clear-ance, and support during gait.The SaeboStep brace can beworn comfortably with mostshoe styles. The Boa lift dial onthe ankle strap allows users toquickly and easily customize thelift angle, or release the tensionas needed, with a simple turnof the dial. The thin and durableSpectra Cord attaches to ashoe’s eyelets to lift the footquickly and easily; small hookattachments are positioned onthe shoe to secure the SpectraCord. An accessory kit enablesmodification of shoes withouteyelets.

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ProtecTozzCleat Guard

New to the market is the Pro-tecTozz Cleat Guard, developedand field-tested over five yearsby Mark Tozzi, DPM, and his sonMichael Tozzi, former captain ofthe John Carroll University foot-ball team in University Heights,OH. Made of polycarbonate ma-terial, the ProtecTozz is light-weight (1.5 oz) and easily at-taches to and detaches from alldetachable cleat brands andsizes. It is designed to protect afootball player from the force ofgetting stepped on by a 300-plus pound lineman, withoutnegatively affecting speed ormobility. The device can becolor-matched to a team’s colorsand decaled with a team logo.

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TayCoAnkle Brace

The TayCo ankle brace is an ex-ternal, over-the-shoe ankle footorthosis for adults and teens.Developed by a University ofNotre Dame team physician andtrainer, it is an easy-to-use alter-native to walking boots or in-shoe AFOs. In addition to pro-viding increased stability andperformance, it is lightweight(typically 12 oz) and can be wornwith other foot orthotic devices.The TayCo is designed to facili-tate immediate functional recov-ery, allowing injured patients toreturn to driving, work, home,or the playing field with confi-dence. Brace models includemedical, worker, and athletic(low profile or high profile).

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roducts

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MaverickFiberglass Feet

Freedom Innovations has re-leased the complete portfolio ofits Maverick fiberglass prostheticfeet, showcasing the durabilityand flexibility of fiberglass. Theseinclude the Maverick Xtremeand Xtreme AT feet for use in ex-treme activities, such as runningand jumping, and the MaverickComfort AT, an everyday walkingfoot. The Maverick Xtreme andXtreme AT feet offer an averagebuild height of 6.7", while theMaverick Comfort AT at 4.6" inheight can accommodate thosewith clearance challenges. BothAT models feature a split keeland 32°of coronal motion forenhanced ground complianceand stability.

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VenodolAnalgesic

Caretta Therapeutics is intro -ducing Venodol, a nonaddictivealternative to opioid and steroi -dal analgesics for patients withmoderate to severe chronicpain associated with inflamma-tion. Indications for Venodol in-clude joint pain, inflammatoryarthritis pain, tendinitis, andstubborn aches. With cobravenom as its active ingredient,the easy-to-use analgesic roll-on does not contain acetamin-ophen, aspirin, naprox en sodi -um, or ibuprofen. Venodol usersare instructed to apply the anal-gesic to the affected area threeto four times per day for up totwo weeks. A 2-oz topical roll-on applicator sells for $19.95.

Caretta Therapeutics 877/323-9184venodol.com

Feetz3D-Printed Shoes

Feetz is a shoe company thatleverages advanced technologyto produce a full 3D-printed,wearable shoe using a cus-tomized app. Clients can cus-tomize the color and arch sup-port on any available Feetzstyles. Feetz men’s and wom -en’s styles include walkingshoes, casual loafers, sandals,and wedge heels. The orderprocess is simple. Customersdownload the company’s appand take three photos of eachfoot to create a 3D foot modeland SizeMe ID. Next, the cus-tomer chooses a shoe style. Fi-nally, Feetz robots custom-sizeand 3D print the shoe compo-nents, which are then assem-bled by humans.

Feetz800/503-8823feetz.com

Unloader OneLite Brace

Össur has launched its Un-loader One Lite Brace, for pa-tients suffering from mild tomoderate knee pain associatedwith osteoarthritis and degen-erative meniscal tears. The Un-loader One Lite is based on thetechnology behind the originalUnloader brace, including the3-Points of Leverage design withdual Dynamic Force straps, butthe new device features a sleek,low-profile design and is 6 ozlighter than its predecessor. Thenew Unloader One Lite is in-tended for younger, more phys-ically active patients who arestarting to experience earlysymptoms of knee osteoarthritisor degenerative meniscal tears.

Össur800/233-6263 ossur.com

Lower extremity orgs help hurricane victims Lower extremity organizationsand business stepped up to do-nate resources and funds to vic-tims of September’s devastatinghurricanes, Harvey and Irma.

Rockford, MI-based Wolver-ine Worldwide partnered with theAmerican Red Cross, foot wear in-dustry charity Two Ten FootwearFoundation (donate at twoten.org),and others pledged more than$2.6 million in aid. Wolverine alsosent more than 35,000 units offootwear and apparel items tostorm victims and first responders.

Others giving resources andfunds include: the Alexandria, VA-based American Orthotic andProsthetic Association, which do-nated about $12,500; Dallas, TX-based Roma Boot, donated 500

pairs of rain boots; Twisted X, lo-cated in Decatur, TX, partneredwith Nashville, TN-based non-profit Soles4Souls to donate10,500 pairs of shoes and workboots (go to soles4 souls.org tocontribute); Greensboro, NC-based legwear manufacturerKayser-Roth, donated more than60,000 pairs of socks; and Birm-ingham, AL-based Hanger Clinicdonated $31,700 to the Ameri-can Red Cross for Hurricane Har-vey relief and was matching do-nations up to $10,000 forHurricane Irma recovery (go toredcross.org/donate/cm/hanger-inc-emp to donate).

Look for additional cover-age of hurricane relief efforts inthe October issue of LER.

Amgen drug beats osteoporosis standard The New England Journal ofMedicine on September 11epublished the results of a trialof more than 4000 postmeno -pausal women with osteoporosisand a previous fragility fracture,in which a monoclonal antibodymade by Thousand Oaks, CA-based Amgen outperformed acommonly used and effectiveosteoporosis medication in pre-venting new fractures.

Investigators at the Univer-sity of Alabama at Birmingham(UAB) randomly assigned thewomen to two groups. One (n =2046) received injections of theinvestigational drug romoso -zumab, which increases bone for-mation by binding to and inhibit-ing sclerostin, a protein thatinhibits bone formation. The othergroup (n = 2047) received weeklyoral alendronate for 12 months.Both groups then took alen-dronate for another 12 months.

At 24 months investigators

observed 127 new vertebral frac-tures (6.2%) in the romoso -zumab group, while the alen-dronate group had 243 newfractures (11.9%), a 48% lowervertebral fracture risk for the ro-mosozumab group. The risk ofnonvertebral fractures and hipfractures in the romosozumabgroup were 19% and 38%lower, respectively. Patients re-ceiving romosozumab also hadgreater gains in bone mineraldensity than those taking alen-dronate alone.

Adverse events in the twogroups were balanced overall,though investigators found morefrequent serious cardiovascularadverse events in the ro-mosozumab group (not a statis-tically significant difference), afinding that hadn’t been seen inprior studies of romosozumab,according to a UAB release.

Dr. Comfort prototype improves balanceBMC Geriatrics on September 11epublished a study examining theeffects of prototype footwearmade by Mequon, WI-based Dr.Comfort used with textured in-soles on balance in older women.

Investigators at La TrobeUniversity in Melbourne, Aus-tralia, measured balance abilityand gait patterns in 30 womenaged 65 to 83 years under threefootwear conditions: their ownfootwear, flexible footwear, andprototype footwear and insolesdesigned to improve dynamicbalance. The participants docu-mented their perceptions of thefootwear in a structured ques-tionnaire.

The researchers selectedthe Dr. Comfort shoe for its firmrubber sole, laces plus Velcrofastening, high collar, and firmheel counter and modified theoutsole to optimize slip resist-ance. They constructed a tex-

tured insole from 4-mm thickethylene vinyl acetate and withdome-shaped projections acrossthe forefoot and along the lateralborder, extending to the heel.

When wearing the proto-type shoe, participants had a sig-nificantly narrower step widthand end sway during a tandemwalking test compared with theother two footwear conditions.Postural sway, limits of stability,and gait patterns did not differamong footwear conditions. Par-ticipants said their own footwearwas more attractive, comfort-able, well-fitted, and easier todon and doff than the prototype,though 60% said they wouldconsider wearing the prototypeto reduce their risk of falling.

Dr. Comfort has the rightsto commercialize the footwear ifit’s proven effective.

market mechanicsBy Emily Delzell



AAOS offers Pain Awareness Month tips The Rosemont, IL-based Ameri-can Academy of OrthopaedicSurgeons (AAOS) is marking Sep-tember as Pain Awareness Monthby offering comprehensive tipsfor safe and effective pain reliefand safe disposal of prescription

pain medications to help mini-mize opioid use and misuse.

Go to orthoinfo.org for ad-vice on managing pain and pre-scription safety and to aaos.orgfor a physician toolkit on painrelief.

G&W Heel Lift celebrates half centuryFamily owned G&W Heel Lift inAugust celebrated 50 years ofsupplying custom heel and footlifts to its customers. Based inCuba, MO, the company’s sig-nature product is its cork heellift, designed to address compli-cations from issues such as al-tered gait, Achilles tendinitis, andAchilles tendon repair.

“The design of our producthas not changed through the

years,” said cofounder ArthurGross, DC. “We are proud tohave provided relief for so manypeople over the years and willcontinue our commitment toserving our customers for yearsto come.”

G&W Heel Lifts products aremade in the US and distributedto customers worldwide. Go togwheellift.com for more informa-tion or call 800/235-4387.

Diabetes Council issues shoe guideline The Diabetes Council, an educa-tional website for people with type2 diabetes run by healthcare pro-fessionals, in August published aguide to buying therapeutic shoesfor people with diabetes.

Online at diabetescouncil.com, the guide offers detailedinformation on how therapeuticshoes help prevent foot ulcers,shoe selection, insurance cover-age, and more.

market mechanicsContinued from page 61

HP, Superfeet pilot 3D retail platformPalo Alto, CA-based HewlettPackard (HP) in September an-nounced Ferndale, WA-basedSuperfeet is piloting in selectstores its new retail foot scan-ning platform that performs dy-namic gait analysis of cus-tomers’ feet with a combinationof 3D scanning and pressureplate technology

FitStation powered by HP isa hardware and software plat-form that captures 3D scans ofthe foot, foot pressure measure-ments, and gait analysis and pro-duces details for custom shoes

with polyurethane-injected mid-soles that vary in density basedon customer needs. Customerscan create a profile, get person-alized off-the-shelf insole andshoe recommendations, orderfully customized 3D printed in-soles, and design their own cus-tom footwear.

Kirchheimbolanden, Ger-many-based safety shoe manu-facturer Steitz Secura will use Fit-Station to aid in its focus oncomfort, preventive health, andsafety, according to an HP re-lease.


Ottobock develops pediatric knee joint Austin, TX-based Ottobock Health-Care in September reported it hasdeveloped the first everyday pros-thesis with hydraulic swing phasecontrol specifically for children.

The 3R67 prosthetic kneejoint is designed to support chil-dren aged 6 to 12 years during avariety of activities, including walk-ing and running at different speeds,intuitive kneeling with a flexion an-gle of up to 150°, and frequent

changes of pace while riding a bikeor scooter.

The polycentric four-axisgeometry of the joint, whichweighs 18 oz, ensures stancephase stability and safety, and theprosthesis can be extended asthe child grows. Scope of deliveryincludes a tube clamp adapter,designed to increase in length byup to 2 cm without a newadapter.

NBA, GE give bone injury grants to HSSThe National Basketball Associ-ation (NBA) and GE HealthcareOrthopedics and Sports Medi-cine Collaboration announced inSeptember they were awardingalmost $400,000 for the studyof bone stress injuries to two re-search teams at the Hospital forSpecial Surgery (HSS) in Man-hattan.

A team led by HSS primarycare sports medicine physicianBrett Toresdahl, MD, received agrant of nearly $300,000 for inves-tigating the use of ultrasound im-aging to monitor healing and guidereadiness of return to play in ath-

letes with bone stress injuries. HSS foot and ankle surgeon

Martin O’Malley, MD, won a$100,000 grant for his team toassess risk factors and interven-tion strategies for fifth metatarsalstress fractures using screeningdata from collegiate and profes-sional basketball players.

NBA and GE Healthcarebegan this partnership in 2015to collaborate with leading clin-ical researchers on prevention,diagnosis, and treatment ofmusculoskeletal injuries affect-ing NBA players and recre-ational athletes.

Rand study backs advanced device use The Santa Monica, CA-based non-profit Rand Health in Septemberepublished a study showing ad-vanced prostheses used by trans-femoral amputees produce sig-nificant improvements in physicalfunction and significant reductionsin the incidence of falls and os-teoarthritis (OA) in the contralat-eral limb compared with less-advanced devices (see, “Knee OAin amputees: Biomechanical andtechnological considerations,”March, page 18).

The authors did a literaturereview of the clinical and eco-nomic impacts of microproces-sor-controlled knees (MPK) andnon-MPKs, convened technicalexpert panel meetings, compiledthe input parameters required,and constructed and imple-mented a simulation model overa 10-year period for unilateraltransfemoral amputees with aMedicare Functional Classifica-tion Level of 3 and 4.

The study found 26% of pa-tients who received MPKs willfall per year compared with 82%of patients receiving non-MPKlimbs. Of these, 10.4% are med-ical falls with a range of meancosts: 7% result in death($27,338); 40% result in majorinjuries with inpatient and/orskilled nursing facility treatment($23,363); and the remaining

53% have minor injuries($1091).

There are 22 fall-relateddeaths per 10,000 patient yearsfor the non-MPK amputees, andfour fall-related deaths per10,000 patient years for theMPK amputees. Simulation datashow 66 injurious falls withMPKs, and 289 with non-MPKs.MPK-wearing amputees have alower incidence of OA due tolower vertical ground force (14%for MPK vs 20% for non-MPK).

MPK users gain about .09life years per person over 10years compared with non-MPKusers, but about .91 quality-ad-justed life years per person. Be-cause of the higher cost of MPKdevices, overall annual cost is$15,083 per MPK patient and$13,382 per NMPK patient, a netincrease of $1702 based on cur-rent payment levels for devicesand repair services.

The economic benefits ofMPKs are comparable to thoseof total knee replacement andbetter than the implantable car-dioverter defibrillator, the authorswrote. They concluded MPKsprovide good value for moneyfrom a societal perspective.

The study, which was fund -ed by the American Orthotic andProsthetic Association, is avail-able at rand.org.

AOPA awards Zahedi, others at congress The Alexandria, VA-based Amer-ican Orthotic and Prosthetic As-sociation (AOPA) honored SaeedZahedi, OBE, FREng, BSc, PhD,FIMechE, CEng, RDI, with its Life-time Achievement Award at itsSeptember World Congress inLas Vegas.

Zahedi is a prolific authorand inventor and helped de-velop the Linx, the first fully in-tegrated microprocessor-con-trolled lower limb system,according to AOPA. Zahedi istechnical director at Chas A.Blatchford and Sons in Bas-ingstoke, UK, and visiting profes-sor at the Bournemouth Univer-sity Design Simulation ResearchCenter in Poole, UK. Queen Eliz-abeth II knighted him this year“for services to engineering andinnovation.”

AOPA gave Inventor Awards

to Van Phillips for Reykjavik, Ice-land-based Össur’s Flex-Foot;Martin “Marty” Carlson, CPO(E),FAAOP, for Minneapolis, MN-based Tamarack HabilitationTechnologies’ Flexure Joint; M.E.“Bill” Miller, CO, for Avon, MA-based Boston O&P’s thoraco-lumbo-sacral-orthosis; and KellyJames, PEng, for Austin, TX-based Ottobock’s C-Leg.

Thranhardt Lecture Series“best in show” winners are ShenanHoppe-Ludwig, CPO, of the Re-habilitation Institute of Chicago,for a report on microprocessor-controlled orthoses, and An-drea Giovanni Cutti, MEng, PhD,of the Budrio, Italy-based Na-tional Institute for InsuranceAgainst Accidents at Work, forwork on gait rehabilitation ref-erence values for lower limbamputees.

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INTRODU CI NG CA RA CH UKKA BOO TJordana Bieze Foster, Editor Efforts to decrease patients’ joint pain in the short term are inadvertently setting those patients up for chronic pain