Is barefoot regional plantar loading related to self-reported foot pain in patients with midfoot osteoarthritis

Size: px
Start display at page:

Download "Is barefoot regional plantar loading related to self-reported foot pain in patients with midfoot osteoarthritis"

Transcription

1 Osteoarthritis and Cartilage xxx (2011) 1e7 Is barefoot regional plantar loading related to self-reported foot pain in patients with midfoot osteoarthritis S. Rao y *, J.F. Baumhauer z, D.A. Nawoczenski x y Department of Physical Therapy, New York University, NY 10012, USA z Department of Orthopedics, University of Rochester Medical Center, Rochester, NY, USA x Center for Foot and Ankle Research, Department of Physical Therapy, Ithaca College e Rochester Center, Rochester, NY, USA article info summary Article history: Received 19 July 2010 Accepted 16 April 2011 Keywords: Arthritis Midfoot Plantar pressure Objective: While recent evidence suggests that foot pain may be related to mechanical stress, quantitative data elucidating the role of regional plantar loading in foot pain in individuals with midfoot osteoarthritis (OA) are lacking. Therefore the authors objective is to examine regional plantar loading and self-reported foot pain in patients with midfoot OA compared to asymptomatic, matched control subjects. Method: Fifty subjects, 30 patients with midfoot OA and 20 control subjects participated in this study. Self-reported function was assessed using the Foot Function Index e Revised (FFI-R). Plantar loading during barefoot walking at self-selected, monitored walking speed was quantified using an EMED pedobarograph. Between-group differences in FFI-R score and plantar loading were assessed using an independent t-test and the ManneWhitney U-test respectively. The relationship between FFI-R score and plantar loading was assessed using Spearman rank correlation. A k-means cluster analysis was used to identify potential sub-groups of patients through regional plantar loading. Results: The key findings of this study showed that patients with midfoot OA reported significantly higher FFI-R scores, and higher heel and medial midfoot compared to control subjects. Medial midfoot pressureetime integral was positively associated with FFI-R Pain Subscale Score (r ¼ 0.524, P < 0.01). Based on the adequacy index, the two-cluster solution was deemed most appropriate. Conclusion: This study demonstrated that patients with midfoot OA sustain increased magnitude and duration of regional plantar loading during walking compared to matched control subjects. Our findings support the theory that regional mechanical stress may be associated with symptoms in patients with midfoot OA. Future studies should assess whether interventions designed to reduce plantar loading are effective in relieving foot pain, and preventing progression of symptoms in patients with midfoot OA. Ó 2011 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved. Introduction The incidence and progression of osteoarthritis (OA), characterized by progressive loss of articular cartilage and attendant pain and disability, has been linked to mechanical stress sustained during weight-bearing activities of daily living 1,2. Increasing evidence indicates that mechanical stress plays an important role in cartilage homeostasis because chondrocytes function as mechanical transducers and respond to their mechanical milieu by upregulating synthetic activity or increasing the production of inflammatory cytokines and matrix-degrading enzymes 3e5. Progressive cartilage breakdown is accompanied by increasing * Address correspondence and reprint requests to: S. Rao, Department of Physical Therapy, New York University, 380 2nd Ave, 4th Floor, New York, NY 10010, USA. Tel: ; Fax: address: (S. Rao). disease severity 6, pain and disability 7. While the role of mechanical stress and patients self-reported pain and disability has been assessed in patients with OA of the knee joint, few studies have assessed mechanical stress in patients who have arthritis in the joints of the foot. OA of the tarso-metatarsal joints (midfoot) has emerged as a challenging problem due to its high potential for foot pain and chronic secondary disability. Individuals with midfoot OA experience foot pain which limits their participation in walking and weight-bearing activities. Midfoot injuries affect approximately 55,000 people per year 8 and are commonly seen in the athletic population 9. Despite their seemingly low incidence, they are particularly concerning because as many as 20% are missed or misdiagnosed 10. In recent years, these injuries have increased with alarming incidence as a consequence of plantar impact sustained in restrained motor vehicle trauma 11. Additionally, as our population ages, chronic increased joint loads sustained with high heeled /$ e see front matter Ó 2011 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved. doi: /j.joca

2 2 S. Rao et al. / Osteoarthritis and Cartilage xxx (2011) 1e7 footwear may be linked to the development of midfoot OA 12. Irrespective of the mechanism of trauma, midfoot OA has been reported to be inevitable sequelae of significant tarsometatarsal joint disease 11,13. Recent evidence from a variety of clinical populations suggests that foot pain may be related to mechanical stress, quantified as regional plantar loading 14. Mechanical stress, combined with local and central sensitization of neural pathways, may interact with inflammatory mediators and contribute to pain perception in patients with OA 15. Additionally, regional loading may influence net joint reaction forces and moments, and lead to abnormal articular (joint) stress 12,16. Burns et al. (2005) reported a significant positive relationship between total foot pressure time integral and foot pain in patients with rigid high arches secondary to pes cavus foot deformity 17. In patients with acquired flat foot deformity and hindfoot pain, Ellis et al. noted increased lateral midfoot pressure 18 and concomitant degenerative changes at the subtalar joint, following surgical correction of flat foot deformity 19. Compared to asymptomatic control subjects, patients with OA of the first metatarsophalangeal joint (hallux rigidus/limitus), demonstrated higher plantar loads under the great toe region 20,21. Taken together, these studies suggest that increased regional plantar loads may contribute to mechanical overloading and consequently, to foot pain in patients with foot pathology. While growing evidence confirms the presence of elevated regional plantar loading and foot pain in patients with rheumatoid arthritis compared to control subjects, within-group analyses in studies examining the relationship between regional plantar loading and foot pain have reported conflicting results. One recent report found greater lateral forefoot loading in patients with rheumatoid arthritis and higher Health Assessment Questionnaire (HAQ) score (less disability, less pain) compared to patients with lower HAQ score 22. These results may suggest that patients with lower HAQ score (more disability, more pain) may adopt an antalgic loading strategy characterized by lower plantar loading. In contrast, two other studies have reported that elevated plantar loading is associated with increasing foot pain 23,24, in agreement with the premise that foot pain is related to mechanical overloading. These conflicting results may indicate that patients with foot pain may demonstrate either an antalgic strategy (increasing pain associated with lower loading) or a mechanical overloading strategy (increasing pain associated with higher loading), and underscore gaps in current knowledge elucidating the relationship between regional plantar loading and foot pain. Further, while regional plantar loading has been identified as a key determinant in mediating foot pain, previous studies have been limited to patients with neurogenic foot problems or inflammatory arthritis. Midfoot OA differs from neurogenic foot pain and inflammatory arthritis both in the etiology, as well as location of pain. Quantitative data elucidating the role of regional plantar loading in foot pain in individuals with midfoot OA are lacking. Walking has been ranked as the highest priority for improvement by patients seeking specialized care for foot and ankle disorders 25. In order to design the most effective intervention and minimize secondary disability in patients with midfoot OA, investigations that critically evaluate factors contributing to foot pain during functional activities are essential. Based on these data, corrective intervention may be designed and instituted to optimize patients function. The purpose of our study was to examine regional plantar loading and self-reported foot pain in patients with midfoot OA compared to asymptomatic, matched control subjects using between-group comparisons. In addition, we sought to examine the relationship between plantar loading and selfreported foot pain, using linear correlations and within-group analysis of clusters. Methods Subjects The sample comprised 50 subjects, 30 patients with midfoot OA and 20 asymptomatic control subjects, matched in age, sex and body mass index. All procedures were approved by the Institutional Review Boards of Ithaca College and the University of Rochester. Patients were recruited from the Outpatient Orthopedic Clinic at the University of Rochester Medical Center. All data were collected at the Movement Analysis Lab, Center for Foot and Ankle Research, at the Department of Physical Therapy, Ithaca College e Rochester Center, Rochester, NY, USA. Inclusion and exclusion criteria All patients presented with unilateral foot pain localized to the medial tarso-metatarsal region, and aggravated by weight bearing. The diagnosis of isolated midfoot OA was confirmed by radiographic evidence of degenerative changes at one or more tarsometatarsal joints on antero-posterior and lateral weight-bearing radiographs. All patients diagnosed with midfoot OA were invited to participate in this study with the following exclusion criteria: (1) injury or surgery of the lower extremity within the past 6 months, (2) other conditions such as stroke that may affect walking, or (3) use of assistive devices such as a cane or walker. Sixty-eight patients with medial foot pain were screened and 32 met the inclusion criteria. Twenty-five patients had a history of injury or surgery to the index lower extremity over the last 6 months, six patients had diabetes, five patients used an assistive device (cane) during walking. Of the 32 patients who met the inclusion criteria, two refused to participate for logistical reasons (lived more than 2 h away). Since the purpose of this study was to examine regional plantar loading and foot pain in patients with midfoot OA compared to matched control subjects, medial midfoot average pressure served as the primary outcome measure. Based on normative data from previous reports using similar methodology to evaluate medial midfoot 26,27, a priori power analysis indicated that group sizes of 18 and 18 are needed to achieve 81% power to detect a moderate effect size (Cohen s d ¼ 0.55) with a significance level (alpha) of 0.05, using a two-sided ManneWhitney test. Radiographic assessment Degenerative changes were assessed using medial longitudinal arch alignment, quantified as the calcaneal-first metatarsal angle (Fig. 1) on the lateral radiograph 28,29, and Kellgren Lawrence grades Fig. 1. Weight bearing lateral radiograph depicting calcaneal-first metatarsal angle, used to characterize medial longitudinal arch alignment.

3 S. Rao et al. / Osteoarthritis and Cartilage xxx (2011) 1e7 3 Table I Summary of radiographic characteristics in patients with midfoot arthritis Joint Median Kellgren Lawrence grade on lateral radiographs Percent of patients with Kellgren Lawrence grade of 1 and higher Joint Median Kellgren Lawrence grade on anterioreposterior radiographs Tarso-metatarsal first tarso-metatarsal Naviculo-cuneiform second tarso-metatarsal Talo-navicular Inter-tarsal Subtalar Inter-metatarsal Calcaneo-cuboid Percent of patients with Kellgren Lawrence grade of 1 and higher on lateral and anterioreposterior radiographs 30. A single rater obtained all radiographic measurements. Personal identifiers were eliminated from radiographs and three blinded readings (i.e., the rater was not allowed to refer to the previous reading) of each measurement were made. Intra-rater reliability was examined using Intraclass Correlation Coefficient (ICC) (Model (3,3)) 31,32. Excellent intra-rater reliability, reflected in ICC(3,3) of 0.96, 0.95 and 0.93, for calcaneal-first metatarsal angle, lateral and anterioreposterior tarsometatarsal Kellgren Lawrence grade respectively, was noted. Lower arch alignment was noted in patients with midfoot OA. Patients with midfoot OA demonstrated calcaneal-first metatarsal angle of 145 [standard deviation (SD: 8)] compared to normative values of 132 (SD: 11) 28,29. Median Kellgren Lawrence grades and percentage of patients showing degenerative changes at each articulation (Kellgren Lawrence grade 1 and higher) are reported in Table I. Control group Asymptomatic subjects were recruited from the community using fliers, screened by a single trained physical therapist (SR) for lower extremity pain and/or dysfunction, and were matched for age, gender and BMI to patients with midfoot OA. Demographic characteristics of the study and control group are summarized in Table II. Self-reported pain and foot function The Foot Function Index e Revised (FFI-R) was used to assess self-reported pain and foot function. The FFI-R is the revised version 33 of an anatomically-specific outcomes instrument with previously established validity, testeretest reliability, internal consistency and responsiveness 33e37. The FFI-R assesses selfreported foot function the following dimensions: pain, activity limitation, disability and psychosocial issues. Psychometric properties of the FFI-R have been tested using Rasch analysis, and established on a sample of 92 patients, of whom slightly over twothirds (63/92, 69%) reported having degenerative arthritis 33. Given its robust psychometric properties, the FFI-R was selected to assess the subjects in this study. Plantar loading Plantar loading during barefoot walking at self-selected, monitored walking speed was quantified using an EMED pedobarograph (Novel Inc, St Paul, MN). The capacitative pedobarograph was Table II Mean (SD) summary of demographic characteristics Midfoot arthritis Control group P value Age (years) 62 (7) 58 (7) Body mass index (kg/m 2 ) 29.7 (5.7) 29.3 (4.3) Sex (M:F) 2:28 1:19 e Walking speed (m/s) 0.71 (0.20) 0.74 (0.17) embedded flush with the walkway. Plantar loading data were acquired at 50 Hz and at a spatial resolution of four sensors per square centimeter. Patients walked at self-selected speed, monitored to 5% using an infra-red timing system (Brower Inc, UT). Control subjects speed was matched to patients walking speed, because walking speed is known to influence magnitude of plantar loading 38. Prior to data collection, all subjects were encouraged to attempt practice trials to establish walking speed. Subjects were allowed as many practice trials as they needed prior to data collection. Starting position was standardized to avoid targeting and to ensure clean foot contact on the pedobarograph. Using a mid-gait protocol, a minimum of three and maximum of five steps were collected to ensure adequate reliability 39,40. Data were analyzed using Novel Projects software (Novel Inc, St Paul, MN). The foot was divided into the following regions of interest or masks,defined as a percent of foot length and width: heel, medial and lateral midfoot, medial and lateral forefoot, and great toe. Given the location of pain in patients with midfoot OA, loading characteristics at the medial midfoot were the primary focus of analysis. In addition, the heel, medial and lateral forefoot masks were used for a secondary evaluation of comparative regional loading, or load transfer 41. Plantar loading data was analyzed using Novel Win softwareô (St Paul, MN). The following dependent variables were evaluated:, contact time and pressure time integral. Average pressure was defined as the mean of the highest pressures sustained within each mask and expressed in kilopascals (kpa). Contact time was defined as the duration of loading for each mask and expressed in % stance. Pressure time integral was defined as the area under the peak pressure within each mask and expressed in kilopascals.seconds (kpa.s). These definitions of dependent variables used to characterize plantar loading are consistent with definitions used in previous studies 17,42,43. Statistical analysis All dependent variables were assessed for normality, using the KolmogoroveSmirnov test, and variance homogeneity, using Levene s test. Subsequently, independent t-tests, not assuming equal variance, were used to assess statistical significance of differences in FFI-R scores in patients with midfoot OA compared to asymptomatic control subjects. The statistical significance of between-group comparisons in regional plantar loading was assessed using the ManneWhitney U-test. Differences between groups were considered significant if P < Correlations were assessed using Spearman rank correlation. A k-means cluster analysis was used to identify potential clusters (sub-groups of patients) present in the midfoot OA patient cohort. K-means analysis applies an optimization approach to minimize the sum of the squared Euclidean distances between observations and their group mean over multiple features of the dataset 44. K-means cluster analysis is an exploratory data analysis technique and may be valuable in studies that assess plantar loading because k-means analysis allows us to simultaneously

4 4 S. Rao et al. / Osteoarthritis and Cartilage xxx (2011) 1e7 Table III Mean (95% confidence interval) FFI-R scores in patients with midfoot OA and matched control subjects. Higher score indicates worse function explore multiple features (masks) of a dataset. K-means clustering was performed using in each mask: heel, medial and lateral midfoot, medial and lateral forefoot and great toe. Two, three, four and five cluster solutions and analysis of variance (ANOVA) tables were computed. Subsequently, the adequacy index, computed as mean square error between-clusters divided by the mean square error within-clusters, was used to determine the optimum number of clusters in the dataset. The best solution (number of clusters) was the solution that maximized adequacy index 44. Lastly, to understand the implications of cluster membership, FFI-R Pain Subscale Score and in each mask were computed for each of the sub-groups. All statistical testing was performed in SPSS v16 (SPSS, Chicago). Results Midfoot arthritis Control group 95% confidence intervals P value Pain (17,29) <0.001 Disability (18,28) <0.001 Activity limitation (14,31) <0.001 Psychosocial issues (10,21) <0.001 Total score (16,26) <0.001 midfoot. Contact time was higher in the heel, medial and lateral midfoot, and medial forefoot regions in patients with midfoot OA compared to asymptomatic control subjects (Table IV). Pressure time integral was higher in the heel, medial and lateral midfoot, and medial forefoot regions in patients with midfoot OA compared to asymptomatic control subjects (Table IV). Correlations There was a significant positive correlation between medial midfoot pressureetime integral and FFI-R Pain Subscale Score (r ¼ 0.524, P < 0.01) and between medial midfoot and FFI-R Pain Subscale Score (r ¼ 0.448, P < 0.01). However, medial midfoot pressure-time integral and medial midfoot were highly correlated (r ¼ 0.927, P ¼ 0.01). Cluster analysis Based on the adequacy index, the two-cluster solution was deemed most appropriate for this cohort of patients with midfoot OA. Graphical depiction of the adequacy index and bivariate scatter plots of the two-cluster solution are presented in Fig. 2. Mean (SD) FFI-R Pain Subscale Score, and Average Pressure sustained at the Heel, Medial and Lateral Midfoot, Medial and Lateral Forefoot and Self-reported pain and foot function Patients with midfoot OA reported significantly higher FFI-R Total Scores compared to matched control subjects (Table III). An examination of subscale scores revealed that patients with midfoot OA scored significantly higher on all the subscales (Pain, Activity Limitation, Disability and Psychosocial Issues) of the FFI-R compared to matched control subjects (Table III). Plantar loading Average pressure was higher in the heel and medial midfoot regions in patients with midfoot OA compared to asymptomatic control subjects (Table IV). Similar trends were noted at the lateral Table IV Mean (SD), contact time and pressure time integral during barefoot walking, in patients with midfoot arthritis compared to matched asymptomatic control subjects Midfoot arthritis Control group P value Average pressure (kpa) Heel (51.3) 90.0 (30.8) Medial midfoot 32.8 (16.1) 21.6 (16.2) Lateral midfoot 60.4 (33.2) 47.1 (32.0) Medial forefoot (73.2) (62.9) Lateral forefoot (73.9) (77.7) Great toe (98.0) (98.5) Contact time (% stance) Heel 69.5 (9.4) 57.2 (11.5) Medial midfoot 50.8 (18.2) 29.1 (24.2) Lateral midfoot 67.0 (14.9) 53.7 (12.4) Medial forefoot 80.0 (6.9) 77.2 (5.0) Lateral forefoot 86.1 (4.5) 84.2 (3.3) Great toe 73.1 (14.5) 72.8 (15.2) Pressure time integral ((kpa)*s) Heel (103.7) 76.1 (26.2) Medial midfoot 32.8 (18.7) 17.8 (23.0) Lateral midfoot 67.4 (34.8) 41.6 (29.6) Medial forefoot (117.6) (55.0) Lateral forefoot (105.0) (63.2) Great toe (131.7) (82.6) Fig. 2. (Top) Graph depicting adequacy index (ordinate) vs number of clusters (abscissa) indicating that the two-cluster solution is appropriate. (Bottom) Bivariate scatter plots showing two-cluster solution obtained using the following features: in heel (h_avgp), medial midfoot (mmid_avgp), lateral midfoot (lmid_avgp), medial forefoot (mfore_avgp), lateral forefoot (lfo_avgp), great toe (halx_avgp).

5 S. Rao et al. / Osteoarthritis and Cartilage xxx (2011) 1e7 5 Table V Mean (SD) FFI-R Pain Subscale Score, and median Kellgren Lawrence grade in the higher function (n ¼ 10) and lower function (n ¼ 10) clusters Cluster Pain Subscale FFI-R Heel average pressure Medial midfoot Lateral midfoot Medial forefoot Lateral forefoot Great toe Kellgren Lawrence grade n ¼ (13) (26.3) 37.5 (17.0) 61.3 (24.2) (55.0) (79.9) (58.3) 3.1 (0.8) n ¼ (13) (68.8) 24.4 (10.7) 58.9 (47.0) (71.9) (66.3) (69.2) 3.0 (0.6) Great Toe for the two-cluster solution are presented in Table V. K-means clustering identified two subgroups, Cluster 1 (higher medial midfoot group (n ¼ 20)) and Cluster 2 (lower medial midfoot average group (n ¼ 10)). Cluster 1 (n ¼ 20) showed higher medial midfoot, higher FFI-R Pain Subscale scores, and lower heel and forefoot pressure compared to Cluster 2 (n ¼ 10). Discussion Increasing evidence indicates that mechanical stress plays an important role in cartilage breakdown and clinical outcomes in individuals with knee OA. However, limited objective data are available examining the relationship between mechanical stress and self-reported function in patients with arthritis in their foot. The key findings of our study showed that patients with midfoot OA report significant pain and disability, reflected as higher scores on the FFI-R Pain Subscale and Total Scores, compared to asymptomatic control subjects. In addition, patients with midfoot OA demonstrated elevated magnitude and duration of regional plantar loading, evidenced as increased medial midfoot, contact time, and pressure time integral. To our knowledge, these results are the first to support the theory that regional plantar loading is related to symptoms in patients with midfoot OA. These findings emphasize the significant disability experienced by patients with midfoot OA and suggest potential mechanisms by which mechanical stress may contribute to patients clinical symptoms and self-reported pain. Our cohort of patients with midfoot OA reported moderate to severe foot pain in weight-bearing activities of daily living compared to asymptomatic matched controls, evidenced as significantly higher FFI-R Pain Subscale Scores. Consistent with previous reports of foot function in patients with midfoot OA compared to asymptomatic matched controls, our patients also demonstrated significant activity limitation and reduction in overall foot function 45,46. The preponderance of female patients (28/30) in our study, is consistent with previous studies examining patients with midfoot OA as well as other types of arthritis affecting the foot 45,47. Contrary to our expectation that the majority of patients would present with post-traumatic midfoot OA 8, none of our patients recalled a major traumatic event leading to their midfoot symptoms. While our study sample is similar in terms of etiology and patient demographics, to that reported in more recent reports 45,46, the absence of major trauma combined with the gender distribution, may be indicative of the potential role of chronic increased joint loads accompanying poor footwear choices 48 in the development of midfoot OA. The magnitudes of pressure time integral sustained in the control group during barefoot walking are in agreement with previous reports of pressure time integral in asymptomatic subjects 26,27. The magnitude of pressure time integral sustained at the heel and forefoot in patients with midfoot OA is consistent with previous reports of pressure time integral sustained during barefoot walking in asymptomatic subjects 26,27, as well as in subjects with chronic rheumatoid arthritis 24. However, the magnitude of medial midfoot pressure time integral as well as medial midfoot sustained during barefoot walking in patients with midfoot OA was higher than that reported in previous studies 24,26,27. Increased medial midfoot loading in asymptomatic subjects 49 and in individuals with arthritis of the talo-navicular and navicular-first cuneiform joints 50 has been linked with low arch alignment. Increased medial midfoot loading may be related to motion, such as calcaneal pronation, that occurs at proximal joints 51. However, recent evidence does not support this contention 52. Using an in vivo three-dimensional kinematic model of the foot, motion of the first metatarsal and calcaneus was assessed during barefoot walking. No between-group differences were noted in calcaneal eversion in patients with midfoot arthritis compared to matched control subjects 52. In addition to arch alignment and pronation, several reports have suggested that disease severity, quantified using radiographs, is related to midfoot plantar loading. In patients with hindfoot pain, Ellis et al. noted increased lateral midfoot loading 18 and subtalar arthritis 18. In patients with rheumatoid arthritis, increased joint erosion, determined using the Larsen score, was accompanied by increased forefoot plantar loading 23,42. Consistent with the literature, our findings may suggest that increased medial midfoot plantar loading may be linked with pain experienced by patents with midfoot OA. In agreement with the mechanical overloading theory, a modest positive association between medial midfoot plantar loading and patients self-reported pain score was noted. Regional plantar loading explained about 28% of the variance in patients pain. In a study involving patients with painful pes cavus, Burns et al. found that pressure time integral accounted for 24% of the variance in foot pain 17. In patients with rheumatoid arthritis, previous studies have noted that the magnitude of forefoot plantar loading accounts for 10e30% of the variance in patients self-reported pain 14,24. Taken together, the results of our study combined with previous findings, suggest that regional plantar loading may account for approximately one third of the variance in self-reported foot pain, and support the contention that mechanical stress may be related to patients symptoms. In an attempt to identify potential clusters (sub-groups of patients) present in the midfoot OA patient cohort, k-means analysis was used as an exploratory data analysis technique 44. Previous studies evaluating plantar loading in patients with foot pain have assessed one foot region at a time 17,22,24. The chief limitation of this approach (assessing one foot region at a time) is that it does not take into account changes in load distribution that may occur concurrently over multiple regions of the foot. As a novel solution to this problem, we used k-means cluster analysis to simultaneously assess plantar loading in multiple regions of the foot. Using k-means cluster analysis, we discerned two subgroups within our cohort of patients with midfoot OA. Cluster 1 (n ¼ 20) showed higher medial midfoot, higher FFI-R Pain Subscale Scores, and lower heel and forefoot pressure compared to Cluster 2 (n ¼ 10). These clusters are consistent with the regional mechanical overloading theory and may represent different load redistribution strategies. Mechanical stress, through its effect on cartilage homeostasis and breakdown, may contribute to the development and progression of osteoarthritic changes 3.

6 6 S. Rao et al. / Osteoarthritis and Cartilage xxx (2011) 1e7 Shape-based k-means cluster analysis has been previously used to classify subjects based on their plantar loading characteristics, with varying degrees of success in terms of providing clinically meaningful results 53,54. De Cock et al. used forefoot pressure time integral obtained during jogging to classify asymptomatic subjects into four foot types 53. K-means cluster analysis of the peak pressure curve was applied in symptomatic patients with rheumatoid arthritis and indicated the presence of three well-separated subgroups 54. However, classification of patients using k-means cluster analysis did not agree with a HAQ-based clinical classification 54. Whether the inclusion of plantar loading parameters from multiple regions of the foot in k-means analysis will improve agreement remains unknown and requires further study. Our results indicate that the inclusion of multiple regions of the foot is valuable in the assessment of patients with foot pain and pathology. Additionally, alternative multi-variate techniques such as principal components analyses may reduce the dimensionality of plantar loading parameters and may help characterize loading strategies that contribute to patients symptoms. The chief limitations of this study are its relatively small sample size and cross-sectional nature. Prospective studies are indicated to examine the time course of the evolution of foot pain and changes in plantar loading in patients with midfoot OA. Additional studies are indicated to assess whether anatomical subtypes exist within midfoot OA, based on anatomical location of joints affected. We assessed regional plantar loading during barefoot walking to avoid confounding effects due to footwear and shoe inserts. However, in individuals with foot pain, barefoot walking may have limited external validity. Patients with midfoot OA report symptoms during dynamic weight-bearing activities such as walking. For this reason, we assessed midfoot plantar loading during walking. However, normal force (the product of pressure and area) and dynamic loads through the forefoot, particularly during the propulsion phase of gait may also contribute to patients symptoms. Future investigations modeling biomechanical loads at the midfoot are indicated to assess net joint forces and moments at the tarso-metatarsal joints. Additional studies are indicated to quantify the direct relationship between regional plantar loading and articular stress sustained in the joints of the foot during weight-bearing activities. Conclusions This study demonstrated that patients with midfoot OA sustain increased magnitude and duration of regional plantar loading during walking compared to matched control subjects. Future studies should assess whether interventions designed to reduce plantar loading are effective in relieving foot pain and/or preventing progression of symptoms in patients with midfoot OA. Further analysis using k-means cluster analysis distinguished two sub-groups. Prospective studies are indicated to assess disease progression and response to intervention in these two subgroups. Contributions All authors were involved in study design, data analysis and manuscript preparation. The Corresponding Author (Smita Rao) was primarily responsible for seeking consent and collecting data, and is responsible for the integrity of the work as a whole, from inception to finished article. Role of the funding source The study sponsors played no role in the study design; collection; analysis or interpretation of data. Conflict of interest We, the authors of this manuscript, affirm that we have no financial affiliation (including research funding) or involvement with any commercial organization that has a direct financial interest in any matter included in this manuscript except as cited in the manuscript. Acknowledgments We would like to acknowledge funding support from the Arthritis Foundation and the American Orthopaedic Foot and Ankle Society. Supplementary data Supplementary data related to this article can be found online at doi: /j.joca References 1. Segal NA, Anderson DD, Iyer KS, et al. Baseline articular contact stress levels predict incident symptomatic knee osteoarthritis development in the MOST cohort. J Orthop Res 2009;27:1562e8. 2. Andriacchi TP, Mundermann A. The role of ambulatory mechanics in the initiation and progression of knee osteoarthritis. Curr Opin Rheumatol 2006;18:514e8. 3. Abramson SB, Attur M. Developments in the scientific understanding of osteoarthritis. Arthritis Res Ther 2009;11: Goldring MB, Goldring SR. Articular cartilage and subchondral bone in the pathogenesis of osteoarthritis. Ann N Y Acad Sci 2010;1192:230e7. 5. Seedhom BB. Conditioning of cartilage during normal activities is an important factor in the development of osteoarthritis. Rheumatology (Oxford) 2006;45:146e9. 6. Sowers MF, Karvonen-Gutierrez CA, Yosef M, Jannausch M, Jiang Y, Garnero P, et al. Longitudinal changes of serum COMP and urinary CTX-II predict X-ray defined knee osteoarthritis severity and stiffness in women. Osteoarthritis Cartilage 2009;17:1609e Berry PA, Maciewicz RA, Wluka AE, Downey-Jones MD, Forbes A, Hellawell CJ, et al. Relationship of serum markers of cartilage metabolism to imaging and clinical outcome measures of knee joint structure. Ann Rheum Dis 2010;69:1816e Hardcastle PH, Reschauer R, Kutscha-Lissberg E, Schoffmann W. Injuries to the tarsometatarsal joint. Incidence, classification and treatment. J Bone Joint Surg Br 1982;64:349e Curtis MJ, Myerson M, Szura B. Tarsometatarsal joint injuries in the athlete. Am J Sports Med 1993;21:497e Goossens M, De Stoop N. Lisfranc s fracture-dislocations: etiology, radiology, and results of treatment. A review of 20 cases. Clin Orthop Relat Res 1983;176:154e Richter M, Wippermann B, Krettek C, Schratt HE, Hufner T, Therman H. Fractures and fracture dislocations of the midfoot: occurrence, causes and long-term results. Foot Ankle Int 2001;22:392e Yu J, Cheung JT, Fan Y, Zhang Y, Leung AK, Zhang M. Development of a finite element model of female foot for high-heeled shoe design. Clin Biomech (Bristol, Avon) 2008;23(Suppl 1):S31e Teng AL, Pinzur MS, Lomasney L, Mahoney L, Havey R. Functional outcome following anatomic restoration of tarsalemetatarsal fracture dislocation. Foot Ankle Int 2002;23:922e Hodge MC, Bach TM, Carter GM. Orthotic management of plantar pressure and pain in rheumatoid arthritis. Clin Biomech (Bristol, Avon) Oct 1999;14(8):567e75. novel Award First Prize Paper.

7 S. Rao et al. / Osteoarthritis and Cartilage xxx (2011) 1e Hunter DJ, McDougall JJ, Keefe FJ. The symptoms of osteoarthritis and the genesis of pain. Rheum Dis Clin North Am 2008;34:623e Kristen KH, Berger K, Berger C, Kampla W, Anzbock W, Weitzel SH. The first metatarsal bone under loading conditions: a finite element analysis. Foot Ankle Clin 2005;10:1e Burns J, Crosbie J, Hunt A, Ouvrier R. The effect of pes cavus on foot pain and plantar pressure. Clin Biomech (Bristol, Avon) 2005;20:877e Ellis SJ, Yu JC, Johnson AH, Elliott A, O Malley M, Deland J. Plantar pressures in patients with and without lateral foot pain after lateral column lengthening. J Bone Joint Surg Am 2010;92:81e Ellis SJ, Deyer T, Williams BR, Yu JC, Lehto S, Maderazo A, et al. Assessment of lateral hindfoot pain in acquired flatfoot deformity using weightbearing multiplanar imaging. Foot Ankle Int 2010;31:361e Van Gheluwe B, Dananberg HJ, Hagman F, Vanstaen K. Effects of hallux limitus on plantar foot pressure and foot kinematics during walking. J Am Podiatr Med Assoc 2006;96:428e Zammit GV, Menz HB, Munteanu SE, Landorf KB. Plantar pressure distribution in older people with osteoarthritis of the first metatarsophalangeal joint (hallux limitus/rigidus). J Orthop Res 2008;26:1665e Schmiegel A, Rosenbaum D, Schorat A, Hilker A, Gaubitz M. Assessment of foot impairment in rheumatoid arthritis patients by dynamic pedobarography. Gait Posture 2008;27:110e Tuna H, Birtane M, Tastekin N, Kokino S. Pedobarography and its relation to radiologic erosion scores in rheumatoid arthritis. Rheumatol Int 2005;26:42e van der Leeden M, Steultjens M, Dekker JH, Prins AP, Dekker J. Forefoot joint damage, pain and disability in rheumatoid arthritis patients with foot complaints: the role of plantar pressure and gait characteristics. Rheumatology (Oxford) 2006;45:465e Sangeorzan BJ, Beskin JL, Britt SM, Brage M, Holt S, Kadel NJ, et al. Issues of importance to patients seeking care from members of the AOFAS: a preliminary report of the outcomes committee of the AOFAS. Foot Ankle Int 2005;26:638e Bryant AR, Tinley P, Singer KP. Normal values of plantar pressure measurements determined using the EMED-SF system. J Am Podiatr Med Assoc 2000;90:295e Putti AB, Arnold GP, Cochrane LA, Abboud RJ. Normal pressure values and repeatability of the Emed ST4 system. Gait Posture 2008;27:501e Cavanagh PR, Morag E, Boulton AJ, Young MJ, Deffner KT, Pammer SE. The relationship of static foot structure to dynamic foot function. J Biomech 1997;30:243e Saltzman CL, Nawoczenski DA, Talbot KD. Measurement of the medial longitudinal arch. Arch Phys Med Rehabil 1995;76:45e Greisberg J, Hansen Jr ST, Sangeorzan B. Deformity and degeneration in the hindfoot and midfoot joints of the adult acquired flatfoot. Foot Ankle Int Jul 2003;24(7):530e Portney LG, Watkins MP. Foundations of Clinical Research: Applications to Practice. 2nd edn. Upper Saddle River, N.J.: Prentice Hall; Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater reliability. Psychol Bull 1979;86:420e Budiman-Mak E, Conrad K, Stuck R, Matters M. Theoretical model and Rasch analysis to develop a revised foot function index. Foot Ankle Int 2006;27:519e Budiman-Mak E, Conrad KJ, Roach KE. The foot function index: a measure of foot pain and disability. J Clin Epidemiol 1991;44: 561e SooHoo NF, Shuler M, Fleming LL. Evaluation of the validity of the AOFAS clinical rating systems by correlation to the SF-36. Foot Ankle Int 2003;24:50e Agel J, Beskin JL, Brage M, Guyton GP, Kadel NJ, Saltzman CL, et al. Reliability of the foot function index: a report of the AOFAS outcomes committee. Foot Ankle Int 2005;26:962e SooHoo NF, Vyas R, Samimi D. Responsiveness of the foot function index, AOFAS clinical rating systems, and SF-36 after foot and ankle surgery. Foot Ankle Int 2006;27:930e Rosenbaum D, Hautmann S, Gold M, Claes L. Effects of walking speed on plantar pressure patterns and hindfoot angular motion. Gait Posture 1994;2:191e McPoil TG, Cornwall MW, Dupuis L, Cornwell M. Variability of plantar pressure data. A comparison of the two-step and midgait methods. J Am Podiatr Med Assoc 1999;89:495e Meyers-Rice B, Sugars L, McPoil T, Cornwall MW. Comparison of three methods for obtaining plantar pressures in nonpathologic subjects. J Am Podiatr Med Assoc 1994;84:499e Bus SA, Ulbrecht JS, Cavanagh PR. Pressure relief and load redistribution by custom-made insoles in diabetic patients with neuropathy and foot deformity. Clin Biomech (Bristol, Avon) 2004;19:629e Schmiegel A, Vieth V, Gaubitz M, Rosenbaum D. Pedography and radiographic imaging for the detection of foot deformities in rheumatoid arthritis. Clin Biomech (Bristol, Avon) 2008;23: 648e Gurney JK, Kersting UG, Rosenbaum D. Between-day reliability of repeated plantar pressure distribution measurements in a normal population. Gait Posture 2008;27:706e Manly BFJ. Multivariate Statistical Methods: A Primer. 2nd edn. London; New York: Chapman & Hall; Davitt JS, Kadel N, Sangeorzan BJ, Hansen Jr ST, Holt SK, Donaldson-Fletcher E. An association between functional second metatarsal length and midfoot arthrosis. J Bone Joint Surg Am 2005;87:795e Jung HG, Myerson MS, Schon LC. Spectrum of operative treatments and clinical outcomes for atraumatic osteoarthritis of the tarsometatarsal joints. Foot Ankle Int 2007;28:482e de P Magalhaes E, Davitt M, Filho DJ, Battistella LR, Bertolo MB. The effect of foot orthoses in rheumatoid arthritis. Rheumatology (Oxford) 2006;45:449e Yu J, Cheung JT, Fan Y, Zhang Y, Leung AK, Zhang M. Development of a finite element model of female foot for high-heeled shoe design. Clin Biomech (Bristol, Avon) 2008; 23(Suppl 1):S31e Morag E, Cavanagh PR. Structural and functional predictors of regional peak pressures under the foot during walking. J Biomech 1999;32:359e Menz HB, Munteanu SE, Zammit GV, Landorf KB. Foot structure and function in older people with radiographic osteoarthritis of the medial midfoot. Osteoarthritis Cartilage 2010;18: 317e O Sullivan K, Kennedy N, O Neill E, Ni Mhainin U. The effect of low-dye taping on rearfoot motion and plantar pressure during the stance phase of gait. BMC Musculoskelet Disord 2008;9: Rao S, Baumhauer JF, Tome J, Nawoczenski DA. Comparison of in vivo segmental foot motion during walking and step descent in patients with midfoot arthritis and matched asymptomatic control subjects. J Biomech 2009;42:1054e De Cock A, Willems T, Witvrouw E, Vanrenterghem J, De Clercq D. A functional foot type classification with cluster analysis based on plantar pressure distribution during jogging. Gait Posture 2006;23:339e Giacomozzi C, Martelli F, Nagel A, Schmiegel A, Rosenbaum D. Cluster analysis to classify gait alterations in rheumatoid arthritis using peak pressure curves. Gait Posture 2009;29: 220e4.

IN THE NAME OF GOD. Mohammad Ayati,M.D Department of Orthopaedics, Yazd University of Medical Science.

IN THE NAME OF GOD. Mohammad Ayati,M.D Department of Orthopaedics, Yazd University of Medical Science. IN THE NAME OF GOD Mohammad Ayati,M.D Department of Orthopaedics, Yazd University of Medical Science. 1 2 Midfoot arthritis is a common cause of significant pain and disability of foot. Etiology of midfoot

More information

63 Tarsometatarsal arthritis

63 Tarsometatarsal arthritis 63 Tarsometatarsal arthritis Contents Introduction Anatomy Biomechanics Clinical Presentation Pathogenesis Physical Examination Imaging Conservative Treatment Operative Treatment Controversy References

More information

Osteoarthritis progresses slowly and the pain and stiffness it causes worsens over time.

Osteoarthritis progresses slowly and the pain and stiffness it causes worsens over time. Arthritis of the Foot and Ankle Arthritis is the leading cause of disability in the United States. It can occur at any age, and literally means "pain within a joint." As a result, arthritis is a term used

More information

Position Statement: The Use of Total Ankle Replacement for the Treatment of Arthritic Conditions of the Ankle

Position Statement: The Use of Total Ankle Replacement for the Treatment of Arthritic Conditions of the Ankle Position Statement: The Use of Total Ankle Replacement for the Treatment of Arthritic Conditions of the Ankle Position Statement The (AOFAS) endorses the use of total ankle replacement surgery for treatment

More information

E. de P. Magalhães, M. Davitt 1, D. J. Filho 2, L. R. Battistella 2 and M. B. Be rtolo

E. de P. Magalhães, M. Davitt 1, D. J. Filho 2, L. R. Battistella 2 and M. B. Be rtolo Rheumatology 26;45:449 453 Advance Access publication 15 November 25 The effect of foot orthoses in rheumatoid arthritis E. de P. Magalhães, M. Davitt 1, D. J. Filho 2, L. R. Battistella 2 and M. B. Be

More information

Arthritis of the midfoot is a common

Arthritis of the midfoot is a common Review Article Midfoot Arthritis Amar Patel, MD Smita Rao, PT, PhD Deborah Nawoczenski, PT, PhD Adolf S. Flemister, MD Benedict DiGiovanni, MD Judith Baumhauer, MD, MPH Abstract Midfoot arthritis is a

More information

Plantar Heel Pain: The very common and uncommon

Plantar Heel Pain: The very common and uncommon Plantar Heel Pain: The very common and uncommon Plantar Heel Pain Common clinical entity Common across age, activity, body type Treatment program varied, difficult to gage success of each So common, a

More information

Midfoot Arthritis: Nonoperative Options and Decision Making for Fusion

Midfoot Arthritis: Nonoperative Options and Decision Making for Fusion Techniques in Foot & Ankle Surgery 7(3):188 195, 2008 Ó 2008 Lippincott Williams & Wilkins, Philadelphia T E C H N I Q U E Midfoot Arthritis: Nonoperative Options and Decision Making for Fusion Smita Rao,

More information

12. Physical Therapy (PT)

12. Physical Therapy (PT) 1 2. P H Y S I C A L T H E R A P Y ( P T ) 12. Physical Therapy (PT) Clinical presentation Interventions Precautions Activity guidelines Swimming Generally, physical therapy (PT) promotes health with a

More information

A Comparison of Ground Mechanical Axis Deviation and Conventional Mechanical Axis Deviation in Patients Undergoing Total Knee Arthroplasty

A Comparison of Ground Mechanical Axis Deviation and Conventional Mechanical Axis Deviation in Patients Undergoing Total Knee Arthroplasty A Comparison of Ground Mechanical Axis Deviation and Conventional Mechanical Axis Deviation in Patients Undergoing Total Knee Arthroplasty Naven Duggal, M.D. 1 Gabrielle M. Paci, M.D. 2 Ayesha Abdeen,

More information

BACK PAIN FROM THE GROUND UP: THE WINDLASS EFFECT. Dr. Marcus A. Kampfe, CCEP, FAKTR, PSC, PES, CES, GFS

BACK PAIN FROM THE GROUND UP: THE WINDLASS EFFECT. Dr. Marcus A. Kampfe, CCEP, FAKTR, PSC, PES, CES, GFS BACK PAIN FROM THE GROUND UP: THE WINDLASS EFFECT Dr. Marcus A. Kampfe, CCEP, FAKTR, PSC, PES, CES, GFS WINDLASS EFFECT Mech of Gait Heel raise to toe off Supination of the foot, Ext rot of contact leg

More information

.org. Lisfranc (Midfoot) Injury. Anatomy. Description

.org. Lisfranc (Midfoot) Injury. Anatomy. Description Lisfranc (Midfoot) Injury Page ( 1 ) Lisfranc (midfoot) injuries result if bones in the midfoot are broken or ligaments that support the midfoot are torn. The severity of the injury can vary from simple

More information

The Flatfoot. Flatfoot: Terminology, Treatment, & Importance of Cobey View page 1 of 10. Are You Smarter Than a 5 th Grader? Podiatrist?

The Flatfoot. Flatfoot: Terminology, Treatment, & Importance of Cobey View page 1 of 10. Are You Smarter Than a 5 th Grader? Podiatrist? & Importance of Cobey View page 1 of 10 Society of Skeletal Radiology 2010 The Flatfoot Adult PTT Acquired Surgeries Flatfoot Terminology, Treatment, & Importance of Cobey View I have nothing to disclose

More information

ORIGINAL ARTICLES Chiropractic adjustments and orthotics reduced symptoms for standing workers

ORIGINAL ARTICLES Chiropractic adjustments and orthotics reduced symptoms for standing workers ORIGINAL ARTICLES Chiropractic adjustments and orthotics reduced symptoms for standing workers John Zhang, PhD, MD a WINTER 2005 Number 4 Volume 4 a Logan College of Chiropractic, Chesterfield, MO. Submit

More information

Audit on treatment and recovery of ankle sprain

Audit on treatment and recovery of ankle sprain Hong Kong Journal of Emergency Medicine Audit on treatment and recovery of ankle sprain WY Lee Study Objectives: The object of this study is to audit the care of ankle sprain of different severity and

More information

Therapeutic shoes (for individuals with diabetes) and foot (in-shoe) orthotics are reimbursable under Plans administered by QualCare, Inc.

Therapeutic shoes (for individuals with diabetes) and foot (in-shoe) orthotics are reimbursable under Plans administered by QualCare, Inc. Subject: Foot Orthotics and Diabetic Shoes* Effective Date: October 1, 1999 Department(s): Utilization Management Policy: Objective: Procedure: Therapeutic shoes (for individuals with diabetes) and foot

More information

Hogeschool van Amsterdam. Navicular Drop Test. User Guide and Manual. Sabrina Jayne Charlesworth and Stine Magistad Johansen

Hogeschool van Amsterdam. Navicular Drop Test. User Guide and Manual. Sabrina Jayne Charlesworth and Stine Magistad Johansen Hogeschool van Amsterdam Navicular Drop Test User Guide and Manual Sabrina Jayne Charlesworth and Stine Magistad Johansen 2010 Introduction The ND test was first described by Brody (1982) who used it in

More information

Biomechanical Offloading

Biomechanical Offloading Biomechanical Offloading Jeffrey D Lehrman, DPM, FACFAS, FASPS, FAPWH Fellow, American College of Foot & Ankle Surgeons Fellow, American Society of Podiatric Surgeons Fellow, Academy of Physicians in Wound

More information

The Five Most Common Pathomechanical Foot Types (Rearfoot varus, forefoot varus, equinus, plantarflexed first ray, forefoot valgus)

The Five Most Common Pathomechanical Foot Types (Rearfoot varus, forefoot varus, equinus, plantarflexed first ray, forefoot valgus) The Five Most Common Pathomechanical Foot Types (Rearfoot varus, forefoot varus, equinus, plantarflexed first ray, forefoot valgus) Pathomechanical foot types usually refer to structural deformities that

More information

R unning is a high-impact activity. Middle-distance runners

R unning is a high-impact activity. Middle-distance runners ORIGINAL ARTICLE Do you get value for money when you buy an expensive pair of running shoes? Richard Clinghan, Graham P Arnold, Tim S Drew, Lynda A Cochrane, Rami J Abboud... Br J Sports Med 2007;0:1 5.

More information

The Journal of Foot & Ankle Surgery

The Journal of Foot & Ankle Surgery The Journal of Foot & Ankle Surgery 50 (2011) 420 429 Contents lists available at ScienceDirect The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org Validation of the American College of

More information

Integra. Subtalar MBA Implant

Integra. Subtalar MBA Implant Integra Subtalar MBA Implant Patient EDUCATION Overview: What is Flatfoot? Flatfoot is a physical deformity where there is an absence of the arch that runs from the heel of the foot to the toes. A common

More information

Prepared by: Kaitlin MacDonald, MOT, OTR/L 1, Stephanie Ramey, MS, OTR/L 1, Rebecca Martin, OTR/L, OTD 1 and Glendaliz Bosques 1,2, MD

Prepared by: Kaitlin MacDonald, MOT, OTR/L 1, Stephanie Ramey, MS, OTR/L 1, Rebecca Martin, OTR/L, OTD 1 and Glendaliz Bosques 1,2, MD 1 The Relationship between Power and Manual Wheelchair Mobility and Upper Extremity Pain in Youths with Low Level Cervical Spinal Cord Injury Prepared by: Kaitlin MacDonald, MOT, OTR/L 1, Stephanie Ramey,

More information

FORGET ME NOT: The Triple Arthrodesis

FORGET ME NOT: The Triple Arthrodesis C H A P T E R 1 5 FORGET ME NOT: The Triple Arthrodesis Andrea D. Cass, DPM INTRODUCTION The triple arthrodesis is a procedure that is performed much less commonly for the same conditions as it was 20

More information

MASS CUSTOMISATION OF FOOT ORTHOSIS FOR RHEUMATOID ARTHRITIS. Abstract

MASS CUSTOMISATION OF FOOT ORTHOSIS FOR RHEUMATOID ARTHRITIS. Abstract MASS CUSTOMISATION OF FOOT ORTHOSIS FOR RHEUMATOID ARTHRITIS J. H. P. Pallari A, K. W. Dalgarno A, and J. Woodburn B A) School of Mechanical Engineering, University of Leeds, LS2 9JT, United Kingdom, B)

More information

TENS, Electroacupuncture and Ice Massage: Comparison of Treatment for Osteoarthritis of the Knee

TENS, Electroacupuncture and Ice Massage: Comparison of Treatment for Osteoarthritis of the Knee TENS, Electroacupuncture and Ice Massage: Comparison of Treatment for Osteoarthritis of the Knee Merih Yurtkuran, Tuncer Kocagil Uludag University Medical Faculty Department of Physical Therapy and Rehabilitation,

More information

Imaging of Lisfranc Injury

Imaging of Lisfranc Injury November 2011 Imaging of Lisfranc Injury Greg Cvetanovich, Harvard Medical School Year IV Agenda Case Presentation Introduction Anatomy Lisfranc Injury Classification Imaging Treatment 2 Case Presentation

More information

ACFAS Scoring Scale User Guide. The American College of Foot and Ankle Surgeons ACFAS SCORING SCALE

ACFAS Scoring Scale User Guide. The American College of Foot and Ankle Surgeons ACFAS SCORING SCALE ACFAS SCORING SCALE ACFAS Scoring Scale User Guide James L. Thomas, DPM, FACFAS, 1 Jeffrey C. Christensen, DPM, FACFAS, 2 Robert W. Mendicino, DPM, FACFAS, 3 John M. Schuberth, DPM, FACFAS, 4 Lowell Scott

More information

Ankle Arthritis Treatment in Worker Compensation The New Gold Standard ~ Total Ankle Replacement

Ankle Arthritis Treatment in Worker Compensation The New Gold Standard ~ Total Ankle Replacement Ankle Arthritis Treatment in Worker Compensation The New Gold Standard ~ Total Ankle Replacement Aprajita Nakra, DPM, FACFAS Board Certified, Reconstructive Foot & Ankle Surgery Past President, Arizona

More information

PHYSICAL EXAMINATION OF THE FOOT AND ANKLE

PHYSICAL EXAMINATION OF THE FOOT AND ANKLE PHYSICAL EXAMINATION OF THE FOOT AND ANKLE Presenter Dr. Richard Coughlin AOFAS Lecture Series OBJECTIVES 1. ASSESS 2. DIAGNOSE 3. TREAT HISTORY TAKING Take a HISTORY What is the patient s chief complaint?

More information

Plantar fascia. Plantar Fasciitis (pain in the heel of the foot)

Plantar fascia. Plantar Fasciitis (pain in the heel of the foot) ! Plantar fascia Plantar Fasciitis (pain in the heel of the foot) Plantar Fasciitis is the most common foot problem seen in runners and is often associated with an increase in running mileage. Typically

More information

Plantar fasciitis is a common foot problem that occurs in 10%

Plantar fasciitis is a common foot problem that occurs in 10% Review Article Plantar Fasciitis Heel Pain: Part 1 a Practical Management Plantar fasciitis is a common foot problem that occurs in 10% of the population. 1,2 The most involved age group is 40-50 3,4 Actually,

More information

Taking Care of Flat Feet in Children

Taking Care of Flat Feet in Children 1 Contact: Customer Service Foot Levelers, Inc. P.O. Box 12611 Roanoke, VA 24027-2611 (800) 553-4860 Ext. 3189 service@footlevelers.com Taking Care of Flat Feet in Children by Mark N. Charrette, DC Flatfoot

More information

A User's Guide to: Rheumatoid and Arthritis Outcome Score RAOS

A User's Guide to: Rheumatoid and Arthritis Outcome Score RAOS RAOS User's Guide 2004 A User's Guide to: Rheumatoid and Arthritis Outcome Score RAOS RAOS is developed as an instrument to assess the patients opinion about their hips/knees and/or feet and associated

More information

The goals of surgery in ambulatory children with cerebral

The goals of surgery in ambulatory children with cerebral ORIGINAL ARTICLE Changes in Pelvic Rotation After Soft Tissue and Bony Surgery in Ambulatory Children With Cerebral Palsy Robert M. Kay, MD,* Susan Rethlefsen, PT,* Marty Reed, MD, K. Patrick Do, BS,*

More information

Rheumatoid Arthritis of the Foot and Ankle

Rheumatoid Arthritis of the Foot and Ankle Copyright 2011 American Academy of Orthopaedic Surgeons Rheumatoid Arthritis of the Foot and Ankle Rheumatoid arthritis is a chronic disease that attacks multiple joints throughout the body. It most often

More information

INTER-RATER AND INTRA-RATER RELIABILITY OF ACTIVE HIP ABDUCTION TEST FOR STANDING INDUCED LOW BACK PAIN

INTER-RATER AND INTRA-RATER RELIABILITY OF ACTIVE HIP ABDUCTION TEST FOR STANDING INDUCED LOW BACK PAIN Original Article INTER-RATER AND INTRA-RATER RELIABILITY OF ACTIVE HIP ABDUCTION TEST FOR STANDING INDUCED LOW BACK PAIN Mansi Shah * 1, Pravin Aaron 2, Subin Solomen 3. *1 Lecturer, Musculoskeletal Physiotherapy,

More information

Early identification and treatment - the Norwegian perspective. Till Uhlig Dept of Rheumatology Diakonhjemmet Hospital Oslo, Norway

Early identification and treatment - the Norwegian perspective. Till Uhlig Dept of Rheumatology Diakonhjemmet Hospital Oslo, Norway Early identification and treatment - the Norwegian perspective Till Uhlig Dept of Rheumatology Diakonhjemmet Hospital Oslo, Norway Oslo Rheumatoid Arthritis Registry (ORAR) Very early Arthritis Clinic

More information

Posttraumatic medial ankle instability

Posttraumatic medial ankle instability Posttraumatic medial ankle instability Alexej Barg, Markus Knupp, Beat Hintermann Orthopaedic Department University Hospital of Basel, Switzerland Clinic of Orthopaedic Surgery, Kantonsspital Baselland

More information

Hyperpronation and Foot Pain

Hyperpronation and Foot Pain Hyperpronation and Foot Pain Steps Toward Pain-Free Feet Steven D. Stovitz, MD; J. Chris Coetzee, MD THE PHYSICIAN AND SPORTSMEDICINE - VOL 32 - NO. 8 - AUGUST 2004 For CME accreditation information, instructions

More information

Predictors of Physical Therapy Use in Patients with Rheumatoid Arthritis

Predictors of Physical Therapy Use in Patients with Rheumatoid Arthritis Predictors of Physical Therapy Use in Patients with Rheumatoid Arthritis Maura Iversen,, PT, DPT, SD, MPH 1,2,3 Ritu Chhabriya,, MSPT 4 Nancy Shadick, MD 2,3 1 Department of Physical Therapy, Northeastern

More information

Effect of Calcaneal Taping on Peak Plantar Pressure of Forefoot and Rearfoot during Gait

Effect of Calcaneal Taping on Peak Plantar Pressure of Forefoot and Rearfoot during Gait JKPT pissn Vol. 27, No. 6, December 2015 1229-0475 eissn 2287-156X Original Article Effect of Calcaneal Taping on Peak Plantar Pressure of Forefoot and Rearfoot during Gait Jong-Hyuck Weon 1, Goen-Su Kim

More information

world-class orthopedic care right in your own backyard.

world-class orthopedic care right in your own backyard. world-class orthopedic care right in your own backyard. Patient Promise: At Adventist Hinsdale Hospital, our Patient Promise means we strive for continued excellence in everything we do. This means you

More information

Clinical Analysis of Foot Problems

Clinical Analysis of Foot Problems Clinical Analysis of Foot Problems by Karen S. Seale, M.D. Introduction Orthotists are vital members of the foot care team. Their expertise and special interests in materials and biomechanics add a unique

More information

Sports Injuries of the Foot and Ankle. Dr. Travis Kieckbusch August 7, 2014

Sports Injuries of the Foot and Ankle. Dr. Travis Kieckbusch August 7, 2014 Sports Injuries of the Foot and Ankle Dr. Travis Kieckbusch August 7, 2014 Foot and Ankle Injuries in Athletes Lateral ankle sprains Syndesmosis sprains high ankle sprain Achilles tendon injuries Lisfranc

More information

Posterior Tibialis Tendon Dysfunction (PTTD)

Posterior Tibialis Tendon Dysfunction (PTTD) Patient information leaflet Royal Surrey County Hospital NHS Foundation Trust Posterior Tibialis Tendon Dysfunction (PTTD) Physiotherapy This leaflet has been designed to provide information about the

More information

1.0 Abstract. Title: Real Life Evaluation of Rheumatoid Arthritis in Canadians taking HUMIRA. Keywords. Rationale and Background:

1.0 Abstract. Title: Real Life Evaluation of Rheumatoid Arthritis in Canadians taking HUMIRA. Keywords. Rationale and Background: 1.0 Abstract Title: Real Life Evaluation of Rheumatoid Arthritis in Canadians taking HUMIRA Keywords Rationale and Background: This abbreviated clinical study report is based on a clinical surveillance

More information

Segmental foot mobility in individuals with and without diabetes and neuropathy

Segmental foot mobility in individuals with and without diabetes and neuropathy Clinical Biomechanics 22 (2007) 464 471 www.elsevier.com/locate/clinbiomech Segmental foot mobility in individuals with and without diabetes and neuropathy Smita Rao a, *, Charles Saltzman b, H. John Yack

More information

UNILATERAL VS. BILATERAL FIRST RAY SURGERY: A PROSPECTIVE STUDY OF 186 CONSECUTIVE CASES COMPLICATIONS, PATIENT SATISFACTION, AND COST TO SOCIETY

UNILATERAL VS. BILATERAL FIRST RAY SURGERY: A PROSPECTIVE STUDY OF 186 CONSECUTIVE CASES COMPLICATIONS, PATIENT SATISFACTION, AND COST TO SOCIETY UNILATERAL VS. BILATERAL FIRST RAY SURGERY: A PROSPECTIVE STUDY OF 186 CONSECUTIVE CASES COMPLICATIONS, PATIENT SATISFACTION, AND COST TO SOCIETY Robert Fridman DPM, Jarrett Cain DPM, Lowell Weil Jr. DPM,

More information

Foot orthoses are widely. The Effect of Forefoot and Arch Posting Orthotic Designs on First Metatarsophalangeal Joint Kinematics During Gait

Foot orthoses are widely. The Effect of Forefoot and Arch Posting Orthotic Designs on First Metatarsophalangeal Joint Kinematics During Gait The Effect of Forefoot and Arch Posting Orthotic Designs on First Metatarsophalangeal Joint Kinematics During Gait Deborah A. Nawoczenski, PT, PhD 1 Paula M. Ludewig, PT, PhD 2 Study Design: Repeated-measures

More information

WALKING BOOTS WALKING BOOTS. AFO s: Provider vs Prescriber? Provider. Prescriber

WALKING BOOTS WALKING BOOTS. AFO s: Provider vs Prescriber? Provider. Prescriber Douglas H. Richie, Jr., D.P.M. 550 Pacific Coast Highway Suite 209 Seal Beach, California 90740 562.493.2451 phone 562.596.3157 fax DRichieJr@aol.com WALKING BOOTS Definitions: L 4360 (defined by HCPS):

More information

Impact of adhesive capsulitis on quality of life in elderly subjects with diabetes: A cross sectional study

Impact of adhesive capsulitis on quality of life in elderly subjects with diabetes: A cross sectional study Original Article Impact of adhesive capsulitis on quality of life in elderly subjects with diabetes: A cross sectional study Saumen Gupta, Kavitha Raja, Manikandan N Department of Physical Therapy, Manipal

More information

EMERGING TECHNOLOGIES IN THE BATTLE AGAINST KNEE OSTEOARTHRITIS: NEW ANSWERS TO OLD QUESTIONS

EMERGING TECHNOLOGIES IN THE BATTLE AGAINST KNEE OSTEOARTHRITIS: NEW ANSWERS TO OLD QUESTIONS EMERGING TECHNOLOGIES IN THE BATTLE AGAINST KNEE OSTEOARTHRITIS: NEW ANSWERS TO OLD QUESTIONS Dr. Jason Peeler PhD, CAT(C) Department of Human Anatomy & Cell Science, U of M Pan Am Clinic Research Foundation

More information

Predislocation syndrome

Predislocation syndrome Predislocation syndrome Sky Ridge Medical Center, Aspen Building Pre-dislocation syndrome, capsulitis, and metatarsalgia are all similar problems usually at the ball of the foot near the second and third

More information

Basic gait parameters : Reference data for normal subjects, 10-79 years of age

Basic gait parameters : Reference data for normal subjects, 10-79 years of age Journal of Rehabilitation Research and Development Vol. 30 No. 2 1993 Pages 210 223 'V"Ze Department of Veterans Affairs A Technical Note Basic gait parameters : Reference data for normal subjects, 10-79

More information

Arthritis of the Foot and Ankle

Arthritis of the Foot and Ankle Arthritis of the Foot and Ankle Arthritis is inflammation of one or more of your joints. It can cause pain and stiffness in any joint in the body, and is common in the small joints of the foot and ankle.

More information

Current Concepts In Orthotic Therapy For Pes Cavus

Current Concepts In Orthotic Therapy For Pes Cavus Current Concepts In Orthotic Therapy For Pes Cavus http://www.podiatrytoday.com/current-concepts-in-orthotic-therapy-for-pes-cavus Podiatry Today- Volume 21 - Issue 10 - October 2008 Author(s): By Paul

More information

Treatment of Recalcitrant Intermetatarsal Neuroma With 4% Sclerosing Alcohol Injection: A Pilot Study

Treatment of Recalcitrant Intermetatarsal Neuroma With 4% Sclerosing Alcohol Injection: A Pilot Study Treatment of Recalcitrant Intermetatarsal Neuroma With 4% Sclerosing Alcohol Injection: A Pilot Study Christopher F. Hyer, DPM,' Lynette R. Mehl, DPM,2 Alan J. Block, DPM, MS, FACFAS,3 and Robert B. Vancourt,

More information

Al-Eisa E, Egan D, Deluzio K, & Wassersug R (2006). Spine; 31(3): E71-79.

Al-Eisa E, Egan D, Deluzio K, & Wassersug R (2006). Spine; 31(3): E71-79. Effects of Pelvic Skeletal Asymmetry on Trunk Movement: Three-Dimensional Analysis in Healthy Individuals versus Patients with Mechanical Low Back Pain Al-Eisa E, Egan D, Deluzio K, & Wassersug R (2006).

More information

Common Foot & Ankle Sports Injuries

Common Foot & Ankle Sports Injuries Common Foot & Ankle Sports Injuries Symptoms Related to Abnormal Foot Biomechanics & their Differential Diagnosis Daniel Pang BSc (Hon) P&O, Cped Certified Pedorthist (USA) Only 10% of foot having structure

More information

Journal of Experimental and Clinical Medicine

Journal of Experimental and Clinical Medicine J Exp Clin Med 2011;3(5):233e238 Contents lists available at SciVerse ScienceDirect Journal of Experimental and Clinical Medicine journal homepage: http://www.jecm-online.com ORIGINAL ARTICLE Postoperative

More information

Foot Pain. Aching in arch of foot - worse after prolonged weight bearing

Foot Pain. Aching in arch of foot - worse after prolonged weight bearing 1 Foot Pain "Pronatory Disorder" ICD-9-CM: 734 Flat foot (pes planus-acquired) Diagnostic Criteria History: Physical Exam: Aching in arch of foot - worse after prolonged weight bearing Excessive pronation

More information

Lower Back Spinal Fusion & Exercise

Lower Back Spinal Fusion & Exercise & Exercise with Rick Kaselj, MS More FREE Information on Exercise & Injuries $299 Fitness Education Returning the Shoulder Back to Optimal Function Seminar Exercise Modification for the Sensitive Shoulder

More information

Objectives Learn the anatomy of the foot. Identify key terms associated with plantar fasciitis. Determine the causes of plantar fasciitis and understa

Objectives Learn the anatomy of the foot. Identify key terms associated with plantar fasciitis. Determine the causes of plantar fasciitis and understa Plantar Fasciitis Objectives Learn the anatomy of the foot. Identify key terms associated with plantar fasciitis. Determine the causes of plantar fasciitis and understand why it occurs. Recognize the injury

More information

International Cartilage Repair Society

International Cartilage Repair Society OsteoArthritis and Cartilage (25) 13, 582e588 ª 25 Published by Elsevier Ltd on behalf of OsteoArthritis Research Society International. doi:1.116/j.joca.25.3.2 Prolonged clinical benefit from joint distraction

More information

A critical review of foot orthoses in the rheumatoid arthritic foot

A critical review of foot orthoses in the rheumatoid arthritic foot Rheumatology 2006;45:139 145 Advance Access publication 8 November 2005 Review Article A critical review of foot orthoses in the rheumatoid arthritic foot H. Clark, K. Rome, M. Plant 1, K. O Hare y and

More information

Podo Pediatrics Identifying Biomechanical Pathologies

Podo Pediatrics Identifying Biomechanical Pathologies Podo Pediatrics Identifying Biomechanical Pathologies David Lee, D.P.M., D. A.B.P.S. Purpose Identification of mechanical foot and ankle conditions Base treatments Knowing when to refer to a podiatrist

More information

Pattern Characterization of Running and Cutting Maneuvers in Relation to Noncontact

Pattern Characterization of Running and Cutting Maneuvers in Relation to Noncontact Pattern Characterization of Running and Cutting Maneuvers in Relation to Noncontact ACL Injury Brenna Hearn During running and cutting maneuvers, the anterior cruciate ligament (ACL) is commonly injured

More information

Effect of Foot Orthoses as Treatment for Plantar Fasciitis or Heel Pain

Effect of Foot Orthoses as Treatment for Plantar Fasciitis or Heel Pain Journal of Sport Rehabilitation, 2013, 22, 130-136 2013 Human Kinetics, Inc. www.jsr-journal.com CRITICALLY APPRAISED TOPIC Effect of Foot Orthoses as Treatment for Plantar Fasciitis or Heel Pain Jordan

More information

Health Benchmarks Program Clinical Quality Indicator Specification 2013

Health Benchmarks Program Clinical Quality Indicator Specification 2013 Health Benchmarks Program Clinical Quality Indicator Specification 2013 Measure Title USE OF IMAGING STUDIES FOR LOW BACK PAIN Disease State Musculoskeletal Indicator Classification Utilization Strength

More information

Rheumatoid Arthritis: Symptoms, Causes, and Treatments of Rheumatoid Foot and Ankle

Rheumatoid Arthritis: Symptoms, Causes, and Treatments of Rheumatoid Foot and Ankle Rheumatoid arthritis is the most common form of inflammatory arthritis, affecting about two to three million Americans. Rheumatoid arthritis is a symmetric disease, meaning that it will usually involve

More information

Gait recovery pattern of unilateral lower limb amputees during rehabilitation

Gait recovery pattern of unilateral lower limb amputees during rehabilitation Prosthetics and Orthotics International, 1990, 14, 80-84 Gait recovery pattern of unilateral lower limb amputees during rehabilitation P. A. BAKER and S. R. HEWISON Physiotherapy Department, Caulfield

More information

WHEN TO BE CONCERNED: Leg Bowing, Intoeing and Flat Feet.

WHEN TO BE CONCERNED: Leg Bowing, Intoeing and Flat Feet. WHEN TO BE CONCERNED: Leg Bowing, Intoeing and Flat Feet. Understanding normal childhood development and recognizing signs of pathology WHAT IS NORMAL? Very important: the average and normal are not the

More information

In preschool children with flat feet what are the indications of non-surgical treatment? An evidence based case report.

In preschool children with flat feet what are the indications of non-surgical treatment? An evidence based case report. In preschool children with flat feet what are the indications of non-surgical treatment? An evidence based case report. Introduction. The paediatric flat foot is a controversial topic. And although flat

More information

Articular Cartilage Injury to the Knee: Current Concepts in Surgical Techniques and Rehabilitation Management

Articular Cartilage Injury to the Knee: Current Concepts in Surgical Techniques and Rehabilitation Management Articular Cartilage Injury to the Knee: Current Concepts in Surgical Techniques and Rehabilitation Management Combined Sections Meeting 2014 Las Vegas, Nevada, February 3 6, 2014 James L. Carey, MD, MPH

More information

Y O U R S U R G E O N S. choice of. implants F O R Y O U R S U R G E R Y

Y O U R S U R G E O N S. choice of. implants F O R Y O U R S U R G E R Y Y O U R S U R G E O N S choice of implants F O R Y O U R S U R G E R Y Y O U R S U R G E O N S choice of implants F O R Y O U R S U R G E R Y Your Surgeon Has Chosen the C 2 a-taper Acetabular System The

More information

ARTICLE IN PRESS. Journal of Science and Medicine in Sport xxx (2012) xxx xxx. Contents lists available at SciVerse ScienceDirect

ARTICLE IN PRESS. Journal of Science and Medicine in Sport xxx (2012) xxx xxx. Contents lists available at SciVerse ScienceDirect Journal of Science and Medicine in Sport xxx (2012) xxx xxx Contents lists available at SciVerse ScienceDirect Journal of Science and Medicine in Sport journa l h o me p age: www.elsevier.com/locate/jsams

More information

Field Evaluation and Management of Non-Battle Related Knee and Ankle Injuries by the ATP in the

Field Evaluation and Management of Non-Battle Related Knee and Ankle Injuries by the ATP in the Field Evaluation and Management of Non-Battle Related Knee and Ankle Injuries by the ATP in the JF Rick Hammesfahr, MD Editor s Note: Part Three consists of ankle injury evaluation and taping. Part Two

More information

Synopsis of Causation. Pes Planus

Synopsis of Causation. Pes Planus Ministry of Defence Synopsis of Causation Pes Planus Author: Mr Matthew J Wilson, Ninewells Hospital and Medical School, Dundee Validator: Mr William Body, The Hillingdon Hospital, Uxbridge September 2008

More information

Paediatric Flat Feet Why do we treat the way we do? By Kim McArthur and Adam Jones

Paediatric Flat Feet Why do we treat the way we do? By Kim McArthur and Adam Jones Paediatric Flat Feet Why do we treat the way we do? By Kim McArthur and Adam Jones Aims and Objectives As clinicians we regularly make decisions in clinics regarding the orthotic treatment plan of children.

More information

Outline. The Agony of the Foot: Disclosure. Plantar Fasciitis. Top 5 Foot and Ankle Problems in Primary Care. Daniel Thuillier, M.D.

Outline. The Agony of the Foot: Disclosure. Plantar Fasciitis. Top 5 Foot and Ankle Problems in Primary Care. Daniel Thuillier, M.D. The Agony of the Foot: Top 5 Foot and Ankle Problems in Primary Care Daniel Thuillier, M.D. Assistant Professor of Clinical Orthopaedics University of California San Francisco Plantar Fasciitis Achilles

More information

Vectra DA Blood Test for Rheumatoid Arthritis. Original Policy Date January /2014

Vectra DA Blood Test for Rheumatoid Arthritis. Original Policy Date January /2014 MP 2.04.81 Vectra DA Blood Test for Rheumatoid Arthritis Medical Policy Section 2.0 Original Policy Date January /2014 Last Review Status/Date 1/2014 Disclaimer Our medical policies are designed for informational

More information

Determinants of footwear difficulties in people with plantar heel pain

Determinants of footwear difficulties in people with plantar heel pain Sullivan et al. Journal of Foot and Ankle Research (2015) 8:40 DOI 10.1186/s13047-015-0102-9 JOURNAL OF FOOT AND ANKLE RESEARCH RESEARCH Determinants of footwear difficulties in people with plantar heel

More information

Case Series on Chronic Whiplash Related Neck Pain Treated with Intraarticular Zygapophysial Joint Regeneration Injection Therapy

Case Series on Chronic Whiplash Related Neck Pain Treated with Intraarticular Zygapophysial Joint Regeneration Injection Therapy Pain Physician 2007; 10:313-318 ISSN 1533-3159 Case Series Case Series on Chronic Whiplash Related Neck Pain Treated with Intraarticular Zygapophysial Joint Regeneration Injection Therapy R. Allen Hooper

More information

Are You Living with. Hip Pain? MAKOplasty may be the right treatment option for you.

Are You Living with. Hip Pain? MAKOplasty may be the right treatment option for you. Are You Living with Hip Pain? MAKOplasty may be the right treatment option for you. Hip pain shouldn t keep you from doing the things you love. Understanding Common Causes of Hip Pain If you are one of

More information

Rheumatoid Arthritis and Treat-to-Target

Rheumatoid Arthritis and Treat-to-Target Rheumatoid Arthritis and Treat-to-Target A Case of Need Encountering Opportunity Need RA affects approximately 1.5 million adults in the United States 1 20%-30% face permanent work disability if not treated

More information

ORIGINAL ARTICLE. EXCISION OF RETROCALCANEAL SPUR BY A LATERAL APPROACH FOR RELIEF OF HEEL PAIN. Nandivada V.S. Kiran Kumar

ORIGINAL ARTICLE. EXCISION OF RETROCALCANEAL SPUR BY A LATERAL APPROACH FOR RELIEF OF HEEL PAIN. Nandivada V.S. Kiran Kumar EXCISION OF RETROCALCANEAL SPUR BY A LATERAL APPROACH FOR RELIEF OF HEEL PAIN. Nandivada V.S. Kiran Kumar 1. Assistant Professor. Department of Orthopaedics, King George Hospital. Visakhapatnam. CORRESPONDING

More information

A pilot study of the primary care management of knee osteoarthritis in the Northern States of Malaysia.

A pilot study of the primary care management of knee osteoarthritis in the Northern States of Malaysia. A pilot study of the primary care management of knee osteoarthritis in the Northern States of Malaysia. Arshad A and Rashid R Putra Specialist Centre, Alor Setar, Kedah, Malaysia ABSTRACT ORIGINAL ARTICLE

More information

November 2012 Case Study. Authors: Kyle Nagle, MD, MPH; Karl Fry, PT, DPT, OCS; David Bernhardt, MD

November 2012 Case Study. Authors: Kyle Nagle, MD, MPH; Karl Fry, PT, DPT, OCS; David Bernhardt, MD CC: Right foot pain November 2012 Case Study Authors: Kyle Nagle, MD, MPH; Karl Fry, PT, DPT, OCS; David Bernhardt, MD HPI: A 17 year old female cross country runner presents with right foot pain. At a

More information

Static Response of Maximally Pronated and Nonmaximally Pronated Feet to Frontal Plane Wedging of Foot Orthoses

Static Response of Maximally Pronated and Nonmaximally Pronated Feet to Frontal Plane Wedging of Foot Orthoses ORIGINAL ARTICLES Static Response of Maximally Pronated and Nonmaximally Pronated Feet to Frontal Plane Wedging of Foot Orthoses Javier Pascual Huerta, DP* Juan Manuel Ropa Moreno, DP* Kevin A. Kirby,

More information

8 General discussion. Chapter 8: general discussion 95

8 General discussion. Chapter 8: general discussion 95 8 General discussion The major pathologic events characterizing temporomandibular joint osteoarthritis include synovitis and internal derangements, giving rise to pain and restricted mobility of the temporomandibular

More information

14-12-2015. Classification of meniscal tears. Evidence from randomized placebo controlled trials

14-12-2015. Classification of meniscal tears. Evidence from randomized placebo controlled trials 14-12-2015 Treatment for degenerative meniscal tears - surgery, exercise or both? 1 Jonas Bloch Thorlund Associate professor (MSc, PhD) Research Unit for Musculoskeletal Function and Physiotherapy (FOF)

More information

This article appeared in a journal published by Elsevier. The attached copy is furnished to the author for internal non-commercial research and

This article appeared in a journal published by Elsevier. The attached copy is furnished to the author for internal non-commercial research and This article appeared in a journal published by Elsevier. The attached copy is furnished to the author for internal non-commercial research and education use, including for instruction at the authors institution

More information

Clinical performance of endoprosthetic and total hip replacement systems

Clinical performance of endoprosthetic and total hip replacement systems Veterans Administration Journal of Rehabilitation Research and Development Vol. 24 No. 3 Pages 49 56 Clinical performance of endoprosthetic and total hip replacement systems P. M. SANDBORN, B.S. ; S. D.

More information

Orthotic Management for the Foot

Orthotic Management for the Foot Orthotic Definition Orthotic Management for the Foot Michael Barnett Jr., MD Assistant Professor of Orthopaedic Surgery Boonshoft School of Medicine Wright State University Devices placed inside shoe Accommodative

More information

Our feet are much more important to our health than we imagine and giving them the care they deserve will benefit you.

Our feet are much more important to our health than we imagine and giving them the care they deserve will benefit you. Insoles Our feet are much more important to our health than we imagine and giving them the care they deserve will benefit you. Our feet may ache due to different biomechanical problems, anatomical or orthopedic

More information

First Year. PT7040- Clinical Skills and Examination II

First Year. PT7040- Clinical Skills and Examination II First Year Summer PT7010 Anatomical Dissection for Physical Therapists This is a dissection-based, radiographic anatomical study of the spine, lower extremity, and upper extremity as related to physical

More information

Introducing TRUE 3D. Weight Bearing Imaging for Foot & Ankle

Introducing TRUE 3D. Weight Bearing Imaging for Foot & Ankle Introducing TRUE 3D Weight Bearing Imaging for Foot & Ankle You can t know what you don t see. Take a stand for uncompromised vision in foot & ankle diagnosis. The power and precision of pedcat puts optimal

More information

The Use of the Lokomat System in Clinical Research

The Use of the Lokomat System in Clinical Research International Neurorehabilitation Symposium February 12, 2009 The Use of the Lokomat System in Clinical Research Keith Tansey, MD, PhD Director, Spinal Cord Injury Research Crawford Research Institute,

More information