Improved Ankle Dorsiflexion Research Articles

Hindfoot endoscopic release of the posterior ankle capsuloligamentous structures improves ankle dorsiflexion range, function and pain in patients with painful limitation of ankle dorsiflexion

ObjectiveTo evaluate the effect of arthroscopic release of the posterior capsuloligamentous structures on ankle dorsiflexion and function in patients with painful limitation of ankle dorsiflexion.MethodsA prospective consecutive case series of 13 adult patients with painful limitation of ankle dorsiflexion were included. None had clinically relevant gastrocnemius, soleus or Achilles contracture. Patients with anterior bony impingement or ankle degeneration on CT scan were excluded. All patients underwent combined anterior and posterior ankle arthroscopies with resection of posterior capsuloligamentous structures and the posterior fibulotalocalcaneal ligament. Ankle range of motion was assessed 2 years postoperatively. Foot and Ankle Outcome Scores (FAOS) were used to assess functional outcome.ResultsThe median patient age at surgery was 26 years (range 19–44). At 2 years postsurgery, the ankle dorsiflexion range had increased by 15 degrees (range 0–25, p<0.0001). FAOSs completed at a median of 44 months postsurgery (range 26–72) significantly improved. Median improvements were 19 points for pain (range 6–67, p=0.0004), 14 points for symptoms (range 0–36, p=0.0005), 15 points for activities of daily living (range 6–35, p<0.0001), 45 points for sport (range 20–55, p<0.0001) and 50 points for quality of life (range 13–62, p<0.0001).ConclusionsHindfoot endoscopic release of the posterior ankle structures, including the posterior fibulotalocalcaneal ligament, is an effective technique for improving ankle dorsiflexion range in patients with painful limitation of ankle dorsiflexion.Level of evidenceIV.

Syndesmotic Implant Removal: Does It Really Improve Ankle Dorsiflexion Range of Motion?

Category:AnkleIntroduction/Purpose:There is limited evidence that removal of syndesmotic implants is beneficial. Despite this, many surgeons advocate removal based on previous studies suggesting improved ankle dorsiflexion. Methodologic difficulties make the validity and applicability of previous works questionable. The purpose of this study was to examine the effect of ankle dorsiflexion after syndesmotic implant removal using radiographic measurements of ankle dorsiflexion before and after screw removal utilizing a standardized, applied load.Methods:All patients undergoing isolated syndesmotic implant removal were consented for participation. Ankle dorsiflexion was measured radiographically at three different time points: (I) immediately before implant removal intraoperatively, (II) immediately after implant removal intraoperatively and (III) approximately three months after implant removal. A standardized dorsiflexion torque force of 33.4 newton-meter (Nm) was applied to the ankle by a research assistant using a tensiometer at these time points and a perfect lateral radiograph of the ankle was obtained. Four reviewers independently measured ankle dorsiflexion on randomized, deidentified and blinded images using a digital measurement tool. Chi-square tests were used for categorical variables. Paired T-test or analysis of variance (ANOVA) with repeated measures was used for continuous variables. Intra-class correlation coefficients (ICC) were calculated using a 2-way random effects model and the absolute agreement definition.Results:29 patients met inclusion criteria and were enrolled in the study. There were 11 men (38%) and 18 women (62%). The mean, and standard deviation, age was 50.3 ± 16.9 years (range 19-80). The mean ankle dorsiflexion pre-operatively, post-op and at 3 month follow up was 13.7°± 6.6°, 13.3°±7.3° and 11.8°±11.3°, respectively (p=0.466). For subsequent analysis, 5 patients were excluded due to potential cofounding effect of retained suture button devices. Analysis of the remaining 24 patients demonstrated similar results with no statistically significant difference in ankle dorsiflexion at all three time points.Conclusion:Removal of syndesmotic screws does not improve ankle dorsiflexion motion and should not be used as an indication for screw removal.

A Scoping Review of Neuromuscular Electrical Stimulation to Improve Gait in Cerebral Palsy: The Arc of Progress and Future Strategies.

Background: Neuromuscular deficits of children with spastic cerebral palsy (CP) limits mobility, due to muscle weakness, short muscle-tendon unit, spasticity, and impaired selective motor control. Surgical and pharmaceutical strategies have been partially effective but often cause further weakness. Neuromuscular electrical stimulation (NMES) is an evolving technology that can improve neuromuscular physiology, strength, and mobility. This review aims to identify gaps in knowledge to motivate future NMES research.Methods: Research publications from 1990- July 20th 2019 that investigated gait-specific NMES in CP were reviewed using the PubMed and Google Scholar databases. Results were filtered by the National Institute of Neurological Disorder and Stroke common data elements guidelines for CP. The Oxford Centre for Evidence Based Medicine guidelines were used to determine levels of evidence for each outcome. Gait-specific NMES research protocols and trends are described, with implications for future research.Results: Eighteen studies met inclusion criteria, reporting on 212 participants, 162 of whom received NMES while walking, average age of 9.8 years, GMFCS levels I–III. Studies included 4 randomized control trials, 9 cohort studies and 5 case studies. A historical trend emerged that began with experimental multi-channel NMES device development, followed by the commercial development of single-channel devices with inertial sensor-based gait event detection to facilitate ankle dorsiflexion in swing phase. This research reported strong evidence demonstrating improved ankle dorsiflexion kinematics in swing and at initial contact. Improved walking speed, step length, and muscle volume were also reported. However, improvements in global walking scores were not consistently found, motivating a recent return to investigating multi-channel gait-specific NMES applications.Conclusions: Research on single-channel gait-specific NMES found that it improved ankle motion in swing but was insufficient to address more complex gait abnormalities common in CP, such as flexed-knee and stiff-knee gait. Early evidence indicates that multi-channel gait-specific NMES may improve gait patterns in CP, however significantly more research is needed. The conclusions of this review are highly limited by the low level of evidence of the studies available. This review provides a historical record of past work and a technical context, with implications for future research on gait-specific NMES to improve walking patterns and mobility in CP.

The effect of adding TENS to stretch on improvement of ankle range of motion in inactive patients in intensive care units: a pilot trial

BackgroundPatients hospitalized in intensive care units (ICUs) are susceptible to joint contracture and diminished range of motion. This is due to immobility as well as other underlying factors such as brain damage. Joint contracture causes functional disorders thereby diminishing the quality of life of patients following the intensive care period. Recent studies have introduced transcutaneous electrical nerve stimulation (TENS) as a new method for preventing and treating joint contracture. This study was performed to determine the effect of adding TENS to stretch on the range of ankle motion in patients hospitalized in ICUs.MethodsThirty-six patients admitted to the ICU ward of the hospital who were not able to move their legs voluntarily were assigned randomly into experimental (n = 18) and control (n = 18) groups. The intervention group received TENS along with manual stretch in the ankle three times a week for 2 weeks. The control group only received stretch in the ankle for the same time. The extent of dorsiflexion and plantar flexion of the ankle was measured using a standard goniometer. Both groups were evaluated before and one and 2 weeks after the intervention. The obtained data were analyzed by SPSS 21 through analysis of covariance and repeated measures ANOVA tests.ResultsIn both groups, the increase in the ankle range of motion parameters was significant over time (means ranged over 44–48 for plantar flexion and means ranged over 5–11 for dorsiflexion, P < 0.001 for all of time points). The increase in ankle plantar and dorsiflexion in experimental group was significantly more than control group (mean between-group differences ranged over 1.35–3.57 within 95% CI of 1.04 to 4.01, P < 0.001).ConclusionAdding TENS to stretch may provide more improvement in ankle dorsiflexion and plantar flexion.Trial registrationTrial registration: This study was registered in the Iranian Clinical Trial Center with the code IRCT2017010814333N64, registered 20 January 2017.

Botulinum toxin treatment in children with cerebral palsy

Introduction: Botulinum toxin is used for decreasing spasticity, improving gait pattern and preventing secondary deformities and orthopedic surgeries in children with cerebral palsy. Despite its wide use, there is no evidence for the long-term beneficial effect of the toxin. Aim: The authors focused on the short-term effects of the toxin and on the subjective evaluation done by the parents about the botox treatment. Method: First, the calf muscle of 18 children was treated and casting was also performed. In our second patient group, multilevel lower limb injection was done in 12 cases. Joints' range of motion, muscle tone and spasticity were assessed before and 4-6 weeks after treatment. In ambulatory children, gait analysis was done. Side effects were recorded and parental opinion about the treatment was requested. Results: Increased ankle range of motion and decreased muscle tone and spasticity were seen in our first patient group. In the second group, hip flexion contracture became milder and hip abduction and the popliteal angle improved. However, gait analysis results only slightly changed after botox treatment. Occasional mild and transient adverse effects were observed during the pharmacologically active period of the toxin. Associate beneficial effects were also reported such as better comfort, easier movements, improving function of the non-injected upper limb, decreasing dysarthria and dysphagia. Conclusion: Our study strengthens the observation that botox treatment of the spastic calf muscle together with plaster casting can result in improved ankle dorsiflexion. Multilevel botox treatment can improve lower limb joints range of motion, however, gait pattern remains unchanged. The administration of botulinum toxin with respect to the guidelines has no major adverse effects. Further studies are needed to clarify the observed beneficial associate effects of the toxin. Orv Hetil. 2019; 160(28): 1105-1111.

An Investigation of Factors Affecting Dynamic Postural Stability in Collegiate Cross Country Runners

Injury rates for NCAA cross country runners between 2009 and 2014 were 4.7-5.9/1000 athlete exposures. Prevalence of running-related injuries in the general population has been shown to be between 18-92%. Injury could lead to impaired balance which is a common aspect of return-to-sport rehabilitation programs, and various methods of its assessment have been proposed. The Dynamic Postural Stability Index (DPSI) was introduced to measure variability in tri-axial ground reaction forces during specific tasks. DPSI has been shown to be increased in injured runners and predict athletic performance in soccer players. DPSI has been correlated to ankle range of motion and strength in military personnel. These variables have not been measured in healthy collegiate runners. PURPOSE: To investigate how previous injury affects DPSI and explore relationship between ankle range of motion and strength with DPSI in collegiate runners. METHODS: Twenty-seven Division I collegiate cross country athletes (age: 19.8±1.3 years) participated. Those with an injury in the past 3 years were categorized in the injured group (IG). Athletes jumped over a hurdle on to a force plate and landed on a single leg. Three trials were performed on each leg. DPSI was calculated for the first 3s after landing. Ankle range of motion was assessed via active dorsiflexion and gastrocnemius length measurement. Ankle and hip strength were measured using a handheld dynamometer. An independent samples t-test was used to determine differences in DPSI between IG and uninjured group (UG). Pearson’s correlation coefficient was used to determine relationships between DPSI and other variables. RESULTS: No significant difference was found for DPSI on left (IG: 0.30±0.03 vs. UG: 0.32±0.04) and right (IG: 0.30± 0.03 vs. UG: 0.31±0.03) sides. There was a significant moderate negative correlation between dorsiflexion range of motion and DPSI (right side r= -0.605, p= 0.001; left side r= -0.452, p= 0.001). There were no correlations between strength and DPSI except for right inversion strength and right DPSI (r= 0.446, p=0.020). CONCLUSION: DPSI seems to be influenced to a greater extent by ankle dorsiflexion than strength or previous injury in a collegiate running population; therefore, improving ankle dorsiflexion may be used as a rehabilitation strategy to improve DPSI.

Anterior osteophyte resection of the ankle joint to increase range of motion in haemophilic ankle arthropathy.

Haemophilic ankle arthropathy may cause joint bleeding, pain, stiffness, erosion and progressive motion limitations, including a decreased range of motion (ROM) secondary to anterior osteophyte impingement. The purpose of this study was to investigate changes in the ROM and symptoms after synovectomy and anterior osteophyte resection for haemophilic ankle arthropathy. We retrospectively reviewed 41 ankles in 35 patients with haemophilic arthropathy who underwent arthroscopic and/or open synovectomy. The mean follow-up period was 59.5months. Indications for the procedure included a lack of improvement with conservative management, and the presence of haemarthrosis and arthralgia. We assessed radiographic images, ankle joint range of motion, the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score and patients' subjective satisfaction preoperatively and at the last follow-up. Arthroscopic synovectomy was performed in 32 ankles, open synovectomy in 6, and arthroscopic synovectomy with additional mini-open debridement in 3. Ankle dorsiflexion improved from a mean of 2.7° preoperatively to a mean of 7.5° at the final follow-up (P=0.003), whereas plantar flexion improved from a mean of 30.7° preoperatively to a mean of 32.7° at the final follow-up (P=0.276). The AOFAS score improved from 62.2 preoperatively to 79.1 at the final follow-up (P<0.001). Patient satisfaction was "excellent" in 11 ankles, "good" in 22, "fair" in 3 and "poor" in 5. Arthroscopic and/or open synovectomy with anterior osteophyte resection and early rehabilitation in adolescents and adults with haemophilic ankle arthropathy showed improved ankle dorsiflexion and AOFAS scores.

Effect of Syndesmotic Implant Removal on Dorsiflexion

There is limited evidence that syndesmotic implant removal (SIR) is beneficial. However, many surgeons advocate removal based on studies suggesting improved motion. Methodologic difficulties make the validity and applicability of previous works questionable. The purpose of this study was to examine the effect of ankle dorsiflexion after SIR using radiographically measured motion before and after screw removal utilizing a standardized load. All patients undergoing isolated SIR were candidates for inclusion. Dorsiflexion was measured radiographically: (1) immediately before implant removal intraoperatively, (2) immediately after removal intraoperatively, and (3) 3 months after removal. A standardized torque force was applied to the ankle and a perfect lateral radiograph of the ankle was obtained. Four reviewers independently measured dorsiflexion on randomized, deidentified images. A total of 29 patients met inclusion criteria. All syndesmotic injuries were associated with rotational ankle fractures. There were 11 men (38%) and 18 women (62%). The mean, and standard deviation, age was 50.3 ± 16.9 years (range 19-80). The mean ankle dorsiflexion pre-operatively, post-operatively, and at a 3-month follow-up was 13.7 ± 6.6 degrees, 13.3 ± 7.3 degrees and 11.8 ± 11.3 degrees, respectively ( P = .466). For subsequent analysis, 5 patients were excluded because of the potential confounding effect of retained suture button devices. Analysis of the remaining 24 patients (and final analysis of 21 patients who had complete 3-month follow-up) demonstrated similar results with no statistically significant difference in ankle dorsiflexion at all 3 time points. Removal of syndesmotic screws may not improve ankle dorsiflexion motion and should not be used as the sole indication for screw removal. Level II, prospective cohort study.

Speed-adaptive control of functional electrical stimulation for dropfoot correction

BackgroundFunctional electrical stimulation is an important therapy technique for dropfoot correction. In order to achieve natural control, the parameter setting of FES should be associated with the activation of the tibialis anterior.MethodsThis study recruited nine healthy subjects and investigated the relations of walking speed with the onset timing and duration of tibialis anterior activation. Linear models were built for the walking speed with respect to these two parameters. Based on these models, the speed-adaptive onset timing and duration were applied in FES-assisted walking for nine healthy subjects and ten subjects with dropfoot. The kinematic performance of FES-assisted walking triggered by speed-adaptive stimulation were compared with those triggered by the heel-off event, and no-stimulation walking at different walking speeds.ResultsHigher ankle dorsiflexion angle was observed in heel-off stimulation and speed-adaptive stimulation conditions than that in no-stimulation walking condition at all the speeds. For subjects with stroke, the ankle plantarflexion angle in speed-adaptive stimulation condition was similar to that in no-stimulation walking condition, and it was significant larger than that in heel-off stimulation condition at all speeds.ConclusionsThe improvement in ankle dorsiflexion without worsening ankle plantarflexion in speed-adaptive stimulation condition could be attributed to the appropriate stimulation timing and duration. These results provide evidence that the proposed stimulation system with speed-related parameters is more physiologically appropriate in dropfoot correction, and it may have great potential value in future clinical applications.Trial registrationMedical Ethics Committee of Guangdong Work Injury Rehabilitation Center, AF/SC-07/2016.22. Registered 26 May 2016.

Effects of a 4-Week Self-Ankle Mobilization with Movement Intervention on Ankle Passive Range of Motion, Balance, Gait, and Activities of Daily Living in Patients with Chronic Stroke: A Randomized Controlled Study

GoalTo compare the effects of a 4-week self-ankle mobilization with movement training program with those of self-ankle mobilization with movement with a 10° inclined board in patients with chronic stroke. Materials and MethodsA randomized controlled assessor-blind trial was conducted. The patients were randomized into 2 arms. Subjects were 28 chronic stroke patients with hemiplegia. Both arms attended standard rehabilitation therapy for 30 minutes per session. In addition, self-ankle mobilization with movement and self-ankle mobilization with movement with a 10° inclined board trainings were performed 3 times per week for 4 weeks. Ankle dorsiflexion passive range of motion, static balance ability, Berg balance scale, gait parameters (walking speed, cadence, and step length), and activities of daily living were used to assess changes in motor function after training. FindingsAfter 4 weeks of training, all dependent variables were significantly improved in both arms as compared with their baseline values. Furthermore, relative to the self-ankle mobilization with movement arm, the self-ankle mobilization with movement with a 10° inclined board arm demonstrated significantly improved ankle dorsiflexion passive range of motion, static balance ability, gait speed, cadence, and affected-side step length. ConclusionsOur results support the hypothesis that self-ankle mobilization with movement with a 10° inclined board combined with standard rehabilitation was superior to self-ankle mobilization with movement combined with standard rehabilitation with respect to the improvement in motor function in the patients with chronic stroke.

Effect of knee joint angle-based, adaptive functional electrical stimulation of the peroneal nerve in spastic paresis. A case report

Functional electrical stimulation (FES) of the peroneal nerve has long been proposed to improve ankle dorsiflexion during swing phase of gait in hemiparesis. The present study assesses the effect of a knee joint angle-based adaptive FES compared with classical FES and no use of FES on active ankle dorsiflexion during gait. The rationale behind aFES is to amplify dorsiflexor stimulation when it is most needed, to face increased plantar flexor cocontraction as gastrocnemius muscles are stretched by knee re-extension in late swing. Three subjects with chronic hemiparesis (time since stroke, 4 ± 3 years) underwent gait analysis at comfortable speed with shoes in three conditions: without stimulation (control), with classical FES (cFES) using trapezoidal stimulus intensity pattern and with an adaptive FES (aFES), in which stimulus intensity is indexed on the degree of knee flexion (the more re-extended the knee in swing, the higher the intensity). We compared cFES and aFES on the gain in active ankle dorsiflexion from control condition, during three periods of swing phase (T1 [0–42.5%], T2 [42.5–65%], T3 [65–100%], 10 gait cycles analyzed), and on the stimulation intensity delivered. For the three patients pooled, the gain in active dorsiflexion from control condition was +4 ± 2° at T1, +3 ± 1° at T2 and +5 ± 5° at T3 with cFES; and +2 ± 1° at T1, +3 ± 1° at T2 and +5 ± 3° at T3 with aFES. Stimulation intensity was 12 ± 10% lower with aFES compared with cFES. Both classical and adaptive FES increase ankle dorsiflexion during swing phase in hemiparesis. These first case studies suggest higher effect of classical FES compared with adaptive FES in early swing, and similar effects of both FES systems during mid and late swing, while aFES used lower stimulation intensity.

Overtightening of the Syndesmosis Revisited and the Effect of Syndesmotic Malreduction on Ankle Dorsiflexion

Category: Ankle, Trauma Introduction/Purpose: Ankle syndesmotic injuries are a significant source of morbidity and require anatomic reduction to optimize outcomes. Although a previous study concluded that maximal dorsiflexion during syndesmotic fixation was not required, methodologic weaknesses existed and several studies have demonstrated improved ankle dorsiflexion after removal of syndesmotic screws. The purposes of the current investigation are: To assess the effect of syndesmotic screw fixation on ankle dorsiflexion utilizing a controlled load and instrumentation allowing for precise measurement of ankle dorsiflexion. To assess the effect of anterior &amp; posterior syndesmotic malreduction after syndesmotic screw fixation on ankle dorsiflexion. Methods: Fifteen cadaveric leg specimens were utilized for the study. Ankle dorsiflexion was measured utilizing a precise micro- sensor system after application of a consistent load in the intact state, after compression fixation with a syndesmotic screw and after anterior &amp; posterior malreduction of the syndesmosis. Results: Following screw compression of the nondisplaced syndesmosis, dorsiflexion ROM was 99.7±0.87% (mean ± standard error) of baseline ankle ROM. Anterior and posterior displacement of the syndesmosis resulted in dorsiflexion ROM that was 99.1±1.75% and 98.6±1.56% of baseline ankle ROM, respectively. One-way ANOVA was performed showing no statistical significance between groups (p-value =0.88). Two-way ANOVA comparing the groups with respect to both the reduction condition (intact, anatomic reduction, anterior displacement, posterior displacement) and the displacement order (anterior first, posterior first) did not demonstrate a statistically significant effect (p-value= 0.99). Conclusion: Maximal dorsiflexion of the ankle is not required prior to syndesmotic fixation. Anterior or posterior syndesmotic malreduction following syndesmotic screw fixation has no effect on ankle dorsiflexion thus poor patient outcomes after syndesmotic malreduction does not appear to be the result of loss of dorsiflexion due to mechanical block.

Hip and knee effects after implantation of a drop foot stimulator.

An active ankle dorsiflexion is essential for a proper gait pattern. If there is a failure of the foot lifting, considerable impairments occur. The therapeutic effect of an implantable peroneus nerve stimulator (iPNS) for the ankle dorsiflexion is already approved by recent studies. However, possible affection for knee and hip motion after implantation of an iPNS is not well described. The objective of this retrospective study was to examine with a patient cohort whether the use of iPNS induces a lower-extremity flexion withdrawal response in the form of an increased knee and hip flexion during swing phase. Eighteen subjects (12 m/6 w) treated with an iPNS (ActiGait®, Otto Bock, Duderstadt, Germany) were examined in knee and hip motion by gait analysis with motion capture system (Vicon Motion System Ltd®, Oxford, UK) and Plug-in-Gait model after a mean follow up from 12.5 months. The data were evaluated and compared in activated and deactivated iPNS. Only little changes could be documented, as a slight average improvement in peak knee flexion during stand phase from 1.0° to 2.5° and peak hip flexion in stance from 3.1° to 2.1° In contrast, peak knee flexion during swing appeared similar (25.3° to 25.7°) same as peak hip flexion during swing. In comparison with the healthy extremity, a more symmetric course of the knee flexion during stand phase could be shown. No statistical significant improvements or changes in hip and knee joint could be shown in this study. Only a more symmetric knee flexion during stand phase and a less hip flexion during stand phase might be hints for a positive affection of iPNS for knee and hip joint. It seems that the positive effect of iPNS is only based on the improvement in ankle dorsiflexion according to the recent literature.

Gastrocnemius Recession Leads to Increased Ankle Motion and Improved Patient Satisfaction After 2 Years of Follow-Up

The isolated gastrocnemius contracture present in neurologic healthy patients results in a significant limitation of ankle dorsiflexion causing pathologic gait patterns and a greater risk of further foot disorders. Gastrocnemius recession is an established procedure to increase ankle dorsiflexion. However, little evidence is available of the use of gastrocnemius recession in these patients. Complication rates, recurrence of gastrocnemius contracture, and the prevalence of additional foot disorders needs further evaluation. A study group of 64 operated limbs undergoing gastrocnemius recession was evaluated to determine the prevalence of foot disorders, pre- and postoperative ankle dorsiflexion, and incidence of complications. A subgroup of 15 (23.4%) patients without additional operative procedures was examined regarding ankle dorsiflexion, strength (Janda method), sensitivity in the operated limb, and the pre- and postoperative Foot Function Index scores. The prevalence of foot disorders showed pes planus (41%), hallux valgus (38%), metatarsalgia (19%), hammertoe deformity (13%), and symptomatic Haglund exostosis (11%). At 31 months of follow-up, the patients had significantly benefited from increased ankle dorsiflexion of 13.3° ± 7.9° (p < .001). Postoperatively, 16% patients experienced complications. In the subgroup of 15 patients, the follow-up examination after 44 months showed ankle dorsiflexion of 14° ± 7.1°. The plantarflexion strength was 4 of 5 (Janda method). The Foot Function Index score had improved significantly from 65.4 ± 26.5 points to 33.4 ± 19.5 points (p < .001). Patients with isolated gastrocnemius contracture seem to have a high prevalence of symptomatic foot disorders. At a mid-term follow-up examination, gastrocnemius recession (Strayer) was shown to be an effective procedure to significantly improve ankle dorsiflexion, functionality, and pain symptoms. More attention should be given to the development of postoperative complications.

Effects of Anteroposterior Talus Mobilization on Range of Motion, Pain, and Functional Capacity in Participants With Subacute and Chronic Ankle Injuries: A Controlled Trial

ObjectiveThe purpose of this study was to measure the acute (1 session) and chronic effects (6 sessions) and the follow-up (2 weeks) of anteroposterior articular mobilization of the talus, grade III of Maitland, on the dorsiflexion range of motion (ROM), pain, and functional capacity of individuals with subacute and chronic traumatic injuries of the ankle. MethodsThirty-eight volunteers, men and women, with a mean age of 40.8 years, with subacute and chronic ankle injuries participated. The volunteers were blinded to the study purpose and were allocated into the experimental group (EG) or sham group (SG). Dorsiflexion ROM, pain, and functional capacity were measured using the universal goniometer, visual analog scale, and Foot and Ankle Ability Measure, respectively. Measurements were taken on 4 different occasions: (1) baseline, (2) after the first session, (3) after the sixth session, and (4) at follow-up. Articular anteroposterior mobilization of the talus grade III of Maitland was applied to the EG, whereas manual contact was applied to the SG. Three series of 30 seconds each with a 30-second rest interval between the series were conducted. ResultsSignificant increases in ankle dorsiflexion ROM were observed only for the EG after the first (EG: 9.5 ± 1.1; SG: 7.6 ± 1.1) and sixth (EG: 12.8 ± 1.2; SG: 8.4 ± 1.2) sessions and were maintained at follow-up (EG: 13.2 ± 1.1; SG: 9.3 ± 1.3). Decreases in pain and improvements in functional capacity (FC) were identified for both groups after the first and sixth sessions (Pain, EG: 1.3 ± 0.5; SG: 1.8 ± 0.6 and EG: 0.7 ± 0.3; SG: 0.7 ± 0.3; FC, EG: 64.6 ± 3.5; SG: 67.4 ± 4.4 and EG: 79.9 ± 3.3; SG: 86.2 ± 3.3) and remained at follow-up (Pain, EG: 0.3 ± 0.2; SG: 0.5 ± 0.3; FC, EG: 86.8 ± 2.7; SG: 89.8 ± 3.7). ConclusionArticular grade III mobilization improved ankle dorsiflexion ROM, when compared with the SG. Changes in pain and functional capacity were similar in both groups.

Gastrocnemius recession leads to medial shift of gait line, impairment of muscle strength and improved dorsal extension in forefoot overload syndrome

BackgroundGastrocnemius recession (GR) has been introduced for treatment of forefoot overload syndrome (FOS). We questioned if GR leads to an altered forefoot load and weakness of plantarflexors in those patients. Methods26 patients suffering from FOS and gastrocnemius tightness underwent GR. A strength power analysis of plantar flexors and a pedobarography was performed. Clinical outcome was measured by Foot Function Index (FFI). ResultsPlantarflexors are impaired about 40% six weeks and around 10% 24 weeks following GR compared to the contralateral side. Patients experienced a pain relief and an improvement of ankle dorsiflexion from 2° to 15°. An increased contact time of the heel (15%) and a shift of metatarsal plantar pressure from lateral to medial could be demonstrated. ConclusionsThis study suggests that GR leads to pain reduction by an increase in heel contact time and a shift of gait line to medial in patients with a FOS. Despite, a temporary impairment of muscle strength has to be considered.

Overtightening of the syndesmosis revisited and the effect of syndesmotic malreduction on ankle dorsiflexion

BackgroundAnkle syndesmotic injuries are a significant source of morbidity and require anatomic reduction to optimize outcomes. Although a previous study concluded that maximal dorsiflexion during syndesmotic fixation was not required, methodologic weaknesses existed and several studies have demonstrated improved ankle dorsiflexion after removal of syndesmotic screws.The purposes of the current investigation are: (1) To assess the effect of compressive syndesmotic screw fixation on ankle dorsiflexion utilizing a controlled load and instrumentation allowing for precise measurement of motion. (2) To assess the effect of anterior & posterior syndesmotic malreduction after compressive syndesmotic screw fixation on ankle dorsiflexion. Material and methodsFifteen lower limb cadaveric leg specimens were utilized for the study. Ankle dorsiflexion was measured utilizing a precise micro-sensor system after application of a consistent load in the (1) intact state, (2) after compression fixation with a syndesmotic screw and (3) after anterior & (4) posterior malreduction of the syndesmosis. ResultsFollowing screw compression of the nondisplaced syndesmosis, dorsiflexion ROM was 99.7±0.87% (mean±standard error) of baseline ankle ROM. Anterior and posterior malreduction of the syndesmosis resulted in dorsiflexion ROM that was 99.1±1.75% and 98.6±1.56% of baseline ankle ROM, respectively. One-way ANOVA was performed showing no statistical significance between groups (p-value=0.88).Two-way ANOVA comparing the groups with respect to both the reduction condition (intact, anatomic reduction, anterior displacement, posterior displacement) and the displacement order (anterior first, posterior first) did not demonstrate a statistically significant effect (p-value=0.99). ConclusionMaximal dorsiflexion of the ankle is not required prior to syndesmotic fixation as no loss of motion was seen with compressive fixation in our cadaver model. Anterior or posterior syndesmotic malreduction following syndesmotic screw fixation had no effect on ankle dorsiflexion. Poor patient outcomes after syndesmotic malreduction may be due to other factors and not loss of dorsiflexion motion.Level of Evidence: IV

Does a foot-drop implant improve kinetic and kinematic parameters in the foot and ankle?

Unlike the drop foot therapy with ortheses, the therapeutic effect of an implantable peroneus nerve stimulator (iPNS) is not well described. IPNS is a dynamic therapy option which is placed directly to the motoric part of the peroneal nerve and evokes a dorsiflexion of the paralysed foot. This retrospective study evaluates the kinematics and kinetics in drop foot patients who were treated with an iPNS. 18 subjects (mean age 51.3years) with a chronic stroke-related drop foot were treated with an implantable peroneal nerve stimulator. After a mean follow-up from 12.5months, kinematics and kinetics as well as spatiotemporal parameters were evaluated and compared in activated and deactivated iPNS. Therefore, a gait analysis with motion capture system (Vicon Motion System Ltd®, Oxford, UK) and Plug-in-Gait model was performed. The study showed significantly improved results in ankle dorsiflexion from 6.8° to 1.8° at the initial contact and from -7.3° to 0.9° during swing phase (p ≤ 0.004 and p ≤ 0.005, respectively). Likewise, we could measure improved kinetics, i.a. with a statistically significant improvement in vertical ground reaction force at loading response from 99.76 to 106.71N/kg (p = 0.043). Enhanced spatiotemporal results in cadence, douple support, stride length, and walking speed could also be achieved, but without statistical significance (p > 0.05). The results show statistically significant improvement in ankle dorsiflexion and vertical ground reaction forces. These facts indicate a more gait stability and gait efficacy. Therefore, the use of an iPNS appears an encouraging therapeutic option for patients with a stroke-related drop foot.

The Ponseti technique and improved ankle dorsiflexion in children with relapsed clubfoot: a retrospective data analysis.

This study quantifies the change in passive ankle range of motion following modified Ponseti casting in children with relapsed idiopathic clubfoot. Fifty-three cases (feet) were retrospectively reviewed, with 6-month follow-up data available for 72% of participants. The median improvement in dorsiflexion was 15° (95% confidence interval: 12.5°-17.5°, P≤0.05), with 85% achieving dorsiflexion≥10°. At the 6-month follow-up, dorsiflexion remained significantly improved and 12 feet (32%) presented with subsequent relapse. Nine were referred for further casting and three were recommended for extra-articular surgery. Repeat modified Ponseti management clinically and statistically improves passive ankle dorsiflexion in relapsed idiopathic clubfoot.

Ankle Power and Endurance Outcomes Following Isolated Gastrocnemius Recession for Achilles Tendinopathy

Studies have demonstrated improved ankle dorsiflexion and pain reduction following a gastrocnemius recession (GR) procedure. However, changes in muscle performance during functional activities are not known. The purpose of this study was to determine the effect of an isolated GR on ankle power and endurance in patients with Achilles tendinopathy. Fourteen patients with chronic unilateral Achilles tendinopathy and 10 healthy controls participated in this study. Patient group data were collected 18 months following GR. Pain was compared to preoperative values using a 10-cm visual analog scale (VAS). Patient-reported outcomes for activities of daily living (ADL) and sports were assessed using the Foot and Ankle Ability Measure (FAAM). Kinematic and kinetic data were collected during gait, stair ascent (standard and high step), and repetitive single-limb heel raises. Between-group and side-to-side differences in ankle plantarflexor muscle power and endurance were evaluated with appropriate t tests. Compared with preoperative data, VAS pain scores were reduced (pre 6.8, post 1.6, P < .05). Significant differences were observed between GR and Control groups for FAAM scores for both ADL (GR 90.0, Control 98.3, P = .01) and Sports subscales (GR 70.6, Control 94.6, P = .01). When compared to controls, ankle power was reduced in the involved limb of the GR group for all activities (all P < .05). Between-group and side-to-side deficits (GR group only) were also found for ankle endurance. The gastrocnemius recession procedure provided significant pain reduction that was maintained at the 18-month follow-up for patients with chronic Achilles tendinopathy who failed nonoperative interventions. There were good patient-reported outcomes for activities of daily living. However, compared to controls, ankle plantarflexion power and endurance deficits in the GR group were noted. The functional implications of the muscle performance deficits are unclear, but may be reflective of patients' self-reported difficulty during more challenging activities. Level III, comparative study.