Lower Extremity Measures Research Articles

Anatomical and Biomechanical Assessments of Medial Tibial Stress Syndrome

Medial tibial stress syndrome is a common overuse injury in weightbearing, physically active individuals and in athletes. Most research associated with this condition is primarily based on static foot and lower-extremity measurements. A cross-sectional design was used to assess a set of static and dynamic measurements to determine which anatomical factors (limb length, ankle dorsiflexion, first metatarsophalangeal joint extension, and arch height) and biomechanical factors (center-of-pressure excursion index, malleolar valgus index, and gait velocity) are associated with medial tibial stress syndrome. One-way analysis of variance models revealed that participants with medial tibial stress syndrome had significantly greater visual analog pain levels and slower gait velocity than noninjured controls (P = .05). No other significant differences were found between the two groups. Further investigation of these and other factors can help health professionals develop better strategies for the prevention and clinical intervention of medial tibial stress syndrome.

Functional and Radiographic Results of Patients with Syndesmotic Screw Fixation: Implications for Screw Removal

Screw fixation of the injured syndesmosis restores stability but may reduce motion. The purpose of this study is to determine whether functional outcomes and radiographic results after ankle fracture are affected by the status of the syndesmosis screw. Retrospective review of a consecutive clinical series. Level 1 academic trauma center. One hundred six adults were reviewed radiographically; mean follow up was 15 months (range, 4-30 months). Seventy-six of the 106 patients completed formal functional testing; mean follow up was 23 +/- 13 months (range, 12-32 months). Open reduction and internal fixation, including fixation of the tibiofibular syndesmosis. Patients with intact, broken or loose, or removed syndesmosis screws were compared. Functional outcomes were measured using the Lower Extremity Measure and the Olerud Molander ankle score. Radiologic review included tibiofibular clear space, tibiofibular overlap, and medial clear space. Functional outcomes were improved in patients with fractured, loosened, or removed screws compared with those with intact screws. The Lower Extremity Measure score for patients with intact screws was 70 +/- 6 compared with 85 +/- 3 for fractured, loosened, or removed screws (P = 0.01). The Olerud Molander ankle score for patients with intact screws was 47 +/- 8.0 compared with 64 +/- 4 for fractured, loosened, or removed screws (P = 0.04). There was no difference in outcome comparing fractured, loosened, and removed screws. The tibiofibular clear space was narrowed in patients with intact screws compared with removed, fractured, or loose screws. The tibiofibular clear space for intact screws was 3.1 +/- 0.2 compared with 4.1 +/- 0.2 for removed, fractured, or loosened screws (P = 0.005). There was no difference in outcome comparing large and small fragment screws. An intact syndesmosis screw was associated with a worse functional outcome compared with loose, fractured, or removed screws. However, there were no differences in functional outcomes comparing loose or fractured screws with removed screws. Screw removal is unlikely to benefit patients with loose or fractured screws but may be indicated in patients with intact syndesmosis screws.

A Prospective Randomized Controlled Trial of a Bioresorbable Calcium Phosphate Paste (α-BSM) in Treatment of Displaced Intra-Articular Calcaneal Fractures

Displaced intra-articular calcaneal fractures are devastating injuries and pose a therapeutic challenge. The purpose of this study was to determine whether open reduction internal fixation (ORIF) plus an injectable bioresorbable calcium phosphate paste (alpha-BSM [bone substitute material]) is superior to ORIF alone in the treatment of calcaneal bone voids encountered after operative treatment of displaced intra-articular calcaneal fractures. We prospectively randomized 47 patients with 52 closed displaced intra-articular fractures necessitating operative fixation to receive ORIF alone (n = 28) or ORIF plus alpha-BSM (n = 24). The maintenance of Böhler's angle was evaluated at follow-up visits for more than 1 year. Secondary outcome measures included the SF-36 and lower extremity measure every 6 months, and the Oral Analog Scale (OAS) score at 2 years. There was no difference between the groups in the degree of collapse of Böhler's angle at 6 weeks and 3 months when compared with initial postoperative values. However, at 6 months, the mean collapse of the alpha-BSM and ORIF group was 5.6 degree (SD, 4.5 degree) and ORIF alone was 9.1 degree (SD, 5.8 degree), which was statistically significant (p = 0.03). Final radiographic evaluation after 1 year revealed a Böhler's angle loss of 6.2 degree (SD 5.9 degree) and 10.4 degree (SD 7.1 degree) in alpha-BSM and ORIF and ORIF alone groups, respectively, (p = 0.05). There was no difference between the two groups in regards to secondary outcome measures of general health, limb specific function, and pain past 2 years. These results support the use of an injectable, in situ hardening calcium phosphate paste to fill the bone void after a displaced intra-articular calcaneal fracture. There was no impact on general health, limb specific function, and pain past 2 years and no associated complications with alpha-BSM use, supporting it safety as an augment to ORIF.

Static and dynamic correlates of the knee adduction moment in healthy knees ranging from normal to varus-aligned

Background Individuals with medial knee osteoarthritis often present with varus knee alignment and ambulate with increased knee adduction moments. Understanding the factors that relate to the knee adduction moment in healthy individuals may provide insight into the development of this disease. Thus, this study aimed to examine the relationships of both static and dynamic lower extremity measures with the knee adduction moment. We hypothesized that the dynamic measures would be more closely related to this moment. Methods Arch height index, hip abduction strength and two static measures of knee alignment were recorded for 37 young asymptomatic knees that varied from normal to varus-aligned. Overground gait analyses were also performed. Correlation coefficients were used to assess the relationships between the static and dynamic variables to the knee adduction moment. Hierarchical regression analyses were then conducted using the static measures, the dynamic measures, and the static and dynamic measures together. Results Among the static measures, the tibial mechanical axis and the distance between the medial knee joint lines were correlated with the knee adduction moment. The best predictive static model ( R 2 = 0.53) included only the tibial mechanical axis. Among the dynamic variables, knee adduction and rearfoot eversion angles were correlated with the knee adduction moment. Knee adduction and rearfoot eversion, together, were the best dynamic model ( R 2 = 0.53). The static and dynamic measures together created the strongest of the three models ( R 2 = 0.59). Conclusions These results suggest that dynamic measures slightly enhance the predictive strength of static measures when explaining variation in the knee adduction moment.

Development of a battery of tests to identify risk of injury to the lower extremity

Introduction: It is believed that poor alignment of the lower extremity (e.g. pes planus [flat feet] or genii valgum [knock knees]) can lead to injury. Data reporting different methods of alignment measurements involving the hips, knees and ankles in runners, football players and the military, have being investigated for decades and consisted of photographs, X-rays, measuring alignment using tractographs or goniometers and visualisation. Method: To develop a battery of tests for a prospective study, a pilot study to investigate the reliability of lower extremity measurements of 10 participants was undertaken.

Results of Femoral Intramedullary Nailing in Patients Who are Obese Versus Those Who are not Obese: A Prospective Multicenter Comparison Study

Antegrade femoral nailing through a piriformis fossa starting point in patients who are obese has been demonstrated to be problematic. Retrograde femoral nailing therefore has been advocated in this patient population, but little data exist to support such a recommendation. The purpose of this study was to evaluate and compare antegrade and retrograde femoral nailing technique in both patients who are and are not obese. Prospective, multicenter, nonrandomized, internal review board (IRB)-approved study. Four Level 1 trauma centers. Patients (151) with a femoral shaft fracture (OTA 32) treated with intramedullary nailing were studied. Thirty-two with a body mass index (BMI) of >or=30 comprised the obese group (OG), and 119 with a BMI of <30 comprised the nonobese group (NOG). Antegrade nailing was performed in 15 patients from the OG and 84 from the NOG. Retrograde nailing was performed in 17 patients from the OG and 35 from the NOG. Reamed intramedullary nailing of a femoral shaft fracture. Patient and fracture characteristics, operative time, fluoroscopy time, healing, complications, and functional outcome based on the lower extremity measure (LEM) were evaluated. Antegrade technique in the OG was associated with a 52% greater average operative time (94 minutes) compared with antegrade nailing in the NOG (62 minutes; P < 0.003). For retrograde nailing technique, there was no difference in the average operative time between the OG (67 minutes) and NOG (62 minutes; P = 0.51). Antegrade technique in the OG was associated with a 79% greater average radiation exposure time (247 seconds) compared with antegrade nailing in the NOG (135 seconds; P < 0.03). For retrograde nailing technique, average fluoroscopy time was similar between the OG (76 seconds) and the NOG (63 seconds; P = 0.44). Within the OG, antegrade nailing required 40% greater average operative time (94 minutes versus 67 minutes, P < 0.02) and more than 3 times more average fluoroscopy time (242 seconds versus 76 seconds, P < 0.002) than retrograde nailing. Thirty-eight patients from the original cohort were not available for follow-up. Of the 113 patients followed (average 9 months, range: 4 to 25 months), healing complications occurred similarly between the 2 groups, with 1 nonunion and 2 delayed unions in the OG (12%), and 3 nonunions and 9 delayed unions in the NOG (14%). This study provides evidence, in the form of decreased operative and radiation exposure times, to support the use of retrograde nailing technique for the treatment of femoral shaft fractures in patients who are obese. Also, antegrade nailing was found to require significantly more operative and radiation exposure time in the patient who is obese as opposed to the patients who is not obese. Although having similar baseline functional scores, patients who are obese recovered at a slower rate and more incompletely than patients who are not obese.

Trochanteric versus Piriformis Entry Portal for the Treatment of Femoral Shaft Fractures

The purpose of this study was to compare results of femoral shaft fracture treatment with nailing through the greater trochanter to nailing through the piriformis fossa with nails specifically designed for each starting point. Prospective cohort study. Four level 1 trauma centers. One-hundred and eight patients treated by 1 of 4 surgeons for a femoral shaft or subtrochanteric fracture with antegrade nailing between January 2001 and April 2003 were included. Four patients who expired early in the postoperative period and 13 with insufficient follow-up were excluded from analysis. Patients were treated with either nailing through a greater trochanter starting point with the Trigen TAN nail (GT group) (n = 38) or through a piriformis fossa starting point with the Trigen FAN nail (PF group) (n = 53). Operative time, fluoroscopy time, fracture alignment, fracture healing, complications, and functional outcome based on the lower-extremity measure (LEM). Thirty-seven of the 38 fractures from the GT group and 52 of the 53 fractures from the PF group healed after the index procedure. One patient from the GT group had external rotation malalignment of 12 degrees. There were no other malalignments or iatrogenic fracture comminution. There were 2 infectious complications, 1 from each group. The average operative time was 75 minutes for piriformis insertion using the FAN nail and 62 minutes for trochanteric insertion using the TAN nail (P = 0.08). The average fluoroscopy time was 61% greater for the PF group (153 seconds) than for the GT group (95 seconds) (P < 0.05). These differences were magnified in patients who were obese (body mass index > 30) where the operative time was 30% greater (P < 0.05) and the fluoroscopy time was 73% higher in the PF group (P < 0.02). Patients from both groups had a similar initial decline and subsequent improvement in function over time (P > 0.05). A femoral nail specially designed for trochanteric insertion resulted in equally high union rates, equally low complication rates, and functional results similar to conventional antegrade femoral nailing through the piriformis fossa. The greater trochanter entry portal coupled with an appropriately designed nail represents a rational alternative for antegrade femoral nailing with the benefit of decreased fluoroscopy time and decreased operative time in patients who are obese.

Subclinical Neuropathy Among Diabetes Control and Complications Trial Participants Without Diagnosable Neuropathy at Trial Completion

We sought to evaluate the prevalence of subclinical neuropathy in intensive and conventional treatment groups at completion of the Diabetes Control and Complications Trial (DCCT). We assessed neuropathy using nerve conduction results obtained at DCCT completion after stratifying the DCCT cohort to exclude subjects with progressively less severe degrees of diagnosable neuropathy. We began with those who had confirmed clinical neuropathy (the primary DCCT end point) and eventually excluded all subjects with any clinical or electrodiagnostic evidence of neuropathy. After excluding subjects with confirmed clinical neuropathy at DCCT completion, 8 of 10 nerve conduction measures (including all lower-extremity measures) were significantly improved in the intensive treatment group (O'Brien rank-sum test across all nerve conduction measures, P < 0.0001). Conduction velocity group differences were substantial, and the peroneal conduction velocity averaged 3.1 m/s faster in the intensive compared with the conventional treatment group (45.1 vs. 42.0 m/s, P < 0.0001). Numerous significant differences in median and peroneal motor conduction velocities favoring the intensive treatment group persisted, regardless of the exclusion criteria applied. Intensive and conventional treatment group subjects without diagnosable neuropathy at DCCT completion had significant differences in electrophysiologic measurements favoring the intensive treatment group. Differences in subsequent incident neuropathy between the original treatment groups may reflect, in part, their levels of subclinical neuropathy at DCCT completion, rather than persistent metabolic effects.

Development of a Clinical Prediction Rule for Classifying Patients With Patellofemoral Pain Syndrome Who Respond to Patellar Taping

Predictive validity/diagnostic test study. To determine the predictive validity and interrater reliability of selected clinical exam items and to develop a clinical prediction rule (CPR) to determine which patients respond successfully to patellar taping. Patellar taping is often used to treat patients with PFPS. However, the characteristics of the patients who respond best to patellar taping intervention have not been identified. Fifty volunteers (27 males, 23 females) with PFPS underwent a standardized clinical examination. Diagnosis of PFPS was based on the complaint of retropatellar pain that was provoked by a partial squat or stair ascent/descent. Subjects performed 3 functional activities and rated their pain during each activity on a numerical rating scale (NPRS). All subjects received treatment with a medial glide patellar-taping technique and repeated the functional activities and pain ratings. An immediate 50% reduction in pain or moderate improvement on a global rating of change (GRC) questionnaire was considered a treatment success. Likelihood ratios (LRs) were calculated to determine which examination items were most predictive of treatment outcome. Logistic regression analysis identified items included in the CPR. Twenty-six subjects (52%) had an immediate successful response to the intervention. Two examination items (positive patellar tilt test or tibial varum greater than 5 degrees, +LR = 4.4) comprised the CPR. Application of the CPR improved the probability of a successful outcome from 52% to 83%. Fifty-eight percent of the lower extremity measures were associated with moderate to good reliability (reliability coefficient range, 0.52-0.84). The reliability coefficients for the items that comprised the CPR were 0.49 (patellar tilt) and 0.66 (tibial varum). A CPR was developed to predict an immediate successful response to a medial glide patellar taping technique. Validation of the CPR in an independent sample is necessary before widespread clinical use can be recommended.

Selected physical capacity norms for Australian football players at the non-elite level

Australian football is a popular male team sport that consists mainly of participants competing at the non-elite level. The main purpose of this study was to compare in non-elite Australian football players competing in sub-elite and community leagues, selected physical capacities recognised as predictors of lower extremity injury in Australian football and/or other sports. Participants were 143 adult (mean age of 22.2 years) male Western Australian footballers from the Western Australian Football League (WAFL) (sub-elite) and the Western Australian Amateur Football League (WAAFL) (community). During the 2005 regular playing season participants completed a questionnaire and a physical measurement testing session. The physical testing session involved the following lower extremity measures: generalised joint laxity, leg length discrepancy, presence of Morton's toe, foot arch, hamstring flexibility and static balance. Football players from the sub-elite and community leagues did not differ significantly in any of the physical testing session measures or in the questionnaire items relating to injury number in the past 12 months and lower limb preventative device use. However, they did differ in some measures with players from the sub-elite league significantly more likely to stretch after a match and training, and to have a designated stretching leader at their club. While players from the community league were significantly more likely to smoke and to participate in sports additional to Australian football. Although the selected physical capacities did not differ between the sub-elite and community players in this study, future research should be aimed at identifying differences for a greater number of physical capacities, including skill and endurance, while utilising a larger sample.

Lower Extremity Measure

Lower Extremity Measure

Change in physical performance over time in older women: the Women's Health and Aging Study.

Although lower and upper extremity performance measures are widely used and represent validated physical function measures in older adults, there is limited information regarding the magnitude of changes in these measures over time. This study (i) assesses prospective changes in physical performance measures, (ii) defines a summary score that demonstrates a significant amount of change over time, and (iii) examines rates of decline according to age and baseline performance levels. Data from the Women's Health and Aging Study (WHAS) were analyzed to assess change in the one third most disabled older women living in the community. Lower extremity function was assessed using walking speed, balance, and chair stands tests. The putting-on-blouse test, the lock and key test, the Purdue Pegboard test, and grip strength were used to gauge upper extremity function. Continuous and categorical summary performance scores were calculated using continuous and categorical data of lower and upper performance measures. After 3 years, lower extremity performance measures declined by 16%-27%, while upper extremity performance measures declined less (7%-24%). For lower extremity function, the continuous summary performance score showed a slightly greater 3-year decline from baseline (decline vs baseline mean: 23%; decline vs SD of the baseline mean: 59%) than the categorical score (22% and 41%, respectively). Older age and intermediate level of baseline performance were associated with the greatest decline, especially for lower extremity function. In moderately to severely disabled women aged 65 or older, lower extremity measures show more change over 3 years than upper extremity measures. Among the lower extremity summary scores, the continuous score changes more over time than the categorical score with respect to the baseline SD. The lower extremity continuous summary performance score may be a useful outcome measure for clinical studies of physical performance in older women.

Surgical rehabilitation of the planovalgus foot in cerebral palsy.

The objectives of this study were to quantitatively determine the effects of subtalar arthrodesis on the planovalgus foot using three-dimensional (3-D) gait analysis and plantar pressure measurements. Twelve children and adolescents with planovalgus foot deformity secondary to spastic cerebral palsy participated in this outcome study. The pediatric population were evaluated preoperatively and following subtalar fusion. Seventeen feet were operated for the correction of the planovalgus foot deformity. A Holter-type microprocessor-based portable in-shoe data acquisition system was used in this study to collect the multistep dynamic plantar pressure history, while a five-camera Vicon-based gait analysis system was used to track the lower extremity joint kinematics. The results obtained from the plantar pressure measurement showed significant increases in mean peak vertical plantar pressures postoperatively at the lateral midfoot and lateral metatarsal heads. Mean contact durations and mean pressure-time integrals were also significantly increased at these plantar locations following foot surgery. This redistribution in pressure metrics suggests the formation of new lateral plantar weight bearing areas. The 3-D gait analysis system, using standardized lower extremity measurements, was unable to reveal any significant changes in joint kinematics, particularly at the foot and ankle where the surgery was performed. This suggests the need for a more refined system to track the complex motion of the pediatric foot and ankle during gait.

Reliability, Validity, and Responsiveness of the Lower Extremity Measure for Patients with a Hip Fracture*

The purpose of this study was to determine whether currently published outcome measures of physical function would be suitable for use for older adults with a hip fracture. The measures that were considered were the Musculoskeletal Function Assessment (MFA) Instrument, the Older Americans' Resources and Services (OARS) Multidimensional Functional Assessment Questionnaire physical function subscale, the Toronto Extremity Salvage Score (TESS), and the Short Form-36 (SF-36). Following suggestions by an expert panel and patient interviews, the MFA was not tested further. The TESS was modified and renamed the Lower Extremity Measure (LEM). Forty-three community-dwelling patients with a hip fracture completed the LEM, OARS, and SF-36 in the hospital so that the prefracture status could be obtained; they were then followed prospectively at six weeks and at six months. All patients were interviewed twice in the hospital to assess the reliability of the LEM (intraclass correlation coefficient = 0.85). To establish criterion validity, the measures were compared with the Timed Up and Go (TUG) test at six weeks. We tested a number of hypotheses to determine construct validity. Only the LEM scores were significantly correlated with the TUG scores (r = -0.53, p = 0.03). The LEM scores were significantly correlated with the SF-36 subscale scores and the OARS scores. Patients with at least one comorbidity had a lower mean prefracture LEM score (90.0 +/- 9.7) than patients with no comorbidity (96.9 +/- 8.1) (p = 0.02). Patients who had used no walking aids before the fracture had a higher mean prefracture LEM score than those who had used a cane (95.5 +/- 5.8 compared with 85.5 +/- 12.7; p = 0.0007). Both the LEM and the SF-36 scores changed significantly between all of the time-periods (p < 0.05). Measures of responsiveness indicated that the LEM was the best measure for detecting changes in physical function. The LEM can detect clinically important changes in physical function over time in patients with a hip fracture and would be most useful for clinical trials or cohort studies. Orthopaedists who are currently utilizing the SF-36 can be reassured that the physical function subscale is a valid measure for patients with a hip fracture.

The relationship between static lower extremity measurements and rearfoot motion during walking.

Despite the fact that clinicians regularly perform static lower extremity measurements on their patients, to date, little research has been published supporting their ability to predict dynamic rearfoot motion. The abilities of static measurements to predict dynamic foot motion could have important implications considering the fact that excessive rearfoot motion has been associated with various injuries of the lower extremity. The purpose of this study, therefore, was to determine if static lower extremity measurements could be used to predict the magnitude of rearfoot motion during walking. Rearfoot motion of each lower extremity was measured from videotape in 27 healthy young adult subjects with a mean age of 26.1 years. In addition, 17 static measurements were measured and recorded bilaterally for each subject. The results of a multiple regression analysis indicated that the only variable that was able to predict maximum rearfoot pronation was the "difference in navicular height" (r2 = .17). None of the 17 measurements were found to predict time to maximum pronation. These results indicate that static measurements of the lower extremity and foot are poor predictors of dynamic rearfoot motion as measured by maximum pronation or time to maximum pronation in healthy individuals without severe foot deformities.

Anterior Knee Pain in Adolescents

The purpose of this study was to determine historical and physical factors associated with anterior knee pain in a cross section of athletic and nonathletic adolescents. We studied 142 high-school students, each of whom answered a questionnaire addressing athletic involvement and a history of knee pain. All subjects underwent a complete knee examination, and measurements of quadriceps girth, Q angle, lower extremity flexibility, and limb length. Forty-five percent of the subjects had a diagnosis of anterior knee pain including patellofemoral pain, patellar tendinitis, or tibial tuberosity pain. Significant correlations were found between anterior knee pain and several historical variables: current pain, pain with exercise, pain with stair climbing, the theater sign, and pain with routine activity. Painful quadriceps “setting” was significantly related to the diagnosis of anterior knee pain. Multiple regression analysis showed that a history of current pain and painful quadriceps setting accounted for 34% of the variance of the diagnosis of anterior knee pain. No other measurement variable, including Q angle, was related to the current diagnosis. We conclude that traditional historical variables associated with anterior knee pain contributed to its diagnosis in a cross section of adolescents. Anterior knee pain could not be predicted from structural measurements of lower extremities.

Relationship between selected static an dynamic lower extremity measures

Twenty-four non-symptomatic subjects were recruited for this study. They were evaluated for foot-type and selected static parameters to determine their influence on kinematic and kinetic variables measured during barefoot overground walking. Foot-type and lower extremity characteristics were examined through the measurement of arch index, range of motion measurements of the ankle, subtalar, first metatarsal and hip joints, and the measurement of the orientation of the calcaneus and tibia. Measurements collected during the support phase of the gait cycle included kinetic measures via a force platform, kinematic measures of the knee joint using a three-dimensional electrogoniometer and kinematic measures of the rearfoot angle using a high speed motion camera. Angle of gait and step parameters were also measured utilizing an inked paper track system. Using the static evaluation measures to predict dynamic gait resulted in significant canonical correlations between first ray mobility and rotational values at the knee, first ray mobility and anteroposterior ground reaction force variables, and static hip internal-external rotation with varus-vaigus motion at the knee. The results suggest that static lower extremity measures have limited value in predicting dynamic lower extremity function to any great degree.

Arch index and kinematic lower extremity measures

Arch index and kinematic lower extremity measures