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Functional gait development in children is discussed controversially. Differentiated information about the roll- over process of the foot, represented by the "Center of Pressure" (COP), are still missing. The purpose of the study was the validation of the COP-path to quantify the functional gait development of children. Plantar pressure distribution was measured barefoot with an individual speed on a walkway (tartan) - in 255 children aged between 2 and 15 years. The medial and lateral area enclosed between the COP-path and the bisection of plantar angle (A(med), A(lat), Sigma: A(ml)) was calculated from plantar pressure data. Furthermore, the duration of the COP-path in the heel (COPtimeF), midfoot (COPtimeM) and forefoot (COPtimeV) was analysed. The load distribution under the medial and lateral forefoot was also calculated. The variation coefficient (VC) was calculated as a measure of interindividual variability. The medio-lateral divergency of the COP (Aml) initially decreases with advancing age (-20.2%), followed by a continuous increase (+27.2%). No changes in VC (A(med), A(lat), and A(ml)) appeared during age-related development. COPtimeM remains constant in all children over time. In contrast to COPtimeM, Cop(time)F decreases from youngest to oldest children (-31.0%), and COPtimeV increases (+41.7%). After initial descent up to 8 years of age, VC (COPtimeF, COPtimeM, COPtimeV) remains constant. The mediolateral load under the forefoot did not change. The COP-Path is able to characterise the functional gait development of children. VC values indicate high individual variability of gait pattern. In this context, age-based standard values should be critically discussed
HIRSCHMULLER, A., V. FREY, L. KONSTANTINIDIS, H. BAUR, H-H. DICKHUTH, N. P. SUDKAMP, and P. HELWIG. Prognostic Value of Achilles Tendon Doppler Sonography in Asymptomatic Runners. Med. Sci. Sports Exerc., Vol. 44, No. 2, pp. 199-205, 2012. Introduction: Midportion Achilles tendinopathy (MPT) is a common problem in running athletes. Nevertheless, its etiology is not fully understood, and no valid prognostic criterion to predict the development of MPT could be identified to date. The purpose of the present study, therefore, was to evaluate whether power Doppler ultrasonography (PDU) is a suitable method to identify a predisposition to MPT in yet asymptomatic runners. Methods: At 23 major running events, 634 asymptomatic long-distance runners were tested for Achilles tendon thickness, vascularization, and structural abnormalities using a high-resolution PDU device (Toshiba Aplio SSA-770A/80, 12 MHz). In addition, their medical history and anthropometric data were documented. All subjects were contacted 6 and 12 months later and asked about any new symptoms. The collected anamnestic, anthropometric, and ultrasonographic data were subjected to regression analysis to determine their predictive value concerning the manifestation of midportion Achilles tendon complaints (P < 0.05). Results: The highest odds ratio (OR) for manifestation of MPT within 1 yr was found for intratendinous blood flow ("neovascularization,'' OR = 6.9, P < 0.001). An increased risk was also identified for subjects with a positive history of Achilles tendon complaints (OR = 3.8, P < 0.001). A third relevant parameter, just above the level of significance, was a spindle-shaped thickening of the tendon on PDU (Wald chi(2) = 3.42). Conclusions: PDU detection of intratendinous microvessels in the Achilles tendons of healthy runners seems to be a prognostically relevant factor concerning the manifestation of symptomatic MPT. This finding lays the foundation for an early identification of a predisposition to MPT as well as prophylactic intervention in as yet asymptomatic runners.
Background
Foot orthoses are usually assumed to be effective by optimizing mechanically dynamic rearfoot configuration. However, the effect from a foot orthosis on kinematics that has been demonstrated scientifically has only been marginal. The aim of this study was to examine the effect of different heights in medial arch-supported foot orthoses on rear foot motion during gait.
Methods
Nineteen asymptomatic runners (36±11years, 180±5cm, 79±10kg; 41±22km/week) participated in the study. Trials were recorded at 3.1 mph (5 km/h) on a treadmill. Athletes walked barefoot and with 4 different not customized medial arch-supported foot orthoses of various arch heights (N:0 mm, M:30 mm, H:35 mm, E:40mm). Six infrared cameras and the `Oxford Foot Model´ were used to capture motion. The average stride in each condition was calculated from 50 gait cycles per condition. Eversion excursion and internal tibia rotation were analyzed. Descriptive statistics included calculating the mean ± SD and 95% CIs. Group differences by condition were analyzed by one factor (foot orthoses) repeated measures ANOVA (α = 0.05).
Results
Eversion excursion revealed the lowest values for N and highest for H (B:4.6°±2.2°; 95% CI [3.1;6.2]/N:4.0°±1.7°; [2.9;5.2]/M:5.2°±2.6°; [3.6;6.8]/H:6.2°±3.3°; [4.0;8.5]/E:5.1°±3.5°; [2.8;7.5]) (p>0.05). Range of internal tibia rotation was lowest with orthosis H and highest with E (B:13.3°±3.2°; 95% CI [11.0;15.6]/N:14.5°±7.2°; [9.2;19.6]/M:13.8°±5.0°; [10.8;16.8]/H:12.3°±4.3°; [9.0;15.6]/E:14.9°±5.0°; [11.5;18.3]) (p>0.05). Differences between conditions were small and the intrasubject variation high.
Conclusion
Our results indicate that different arch support heights have no systematic effect on eversion excursion or the range of internal tibia rotation and therefore might not exert a crucial influence on rear foot alignment during gait.
Background: Several equipment interventions like optimizing seat position or optimizing shoe/insole/pedal interface are suggested to reduce overuse injury in cycling. Data analyzing clinical or biomechanical effects of those interventions is sparse. Foot orthoses out of carbon fiber are one possibility to alter the interface between foot and pedal. The aim of this study was therefore to analyze plantar pressure distribution in carbon fiber foot orthoses in comparison to standard insoles of commercially available cycling shoes. Materials and Methods: 11 pain-free triathletes (Age: 29 +/- 9, 1.77 +/- 0.04 m, 68 5 kg) were tested on a cycle ergometer at 60 and 90 rotations per minute (rpm) at workloads of 200 and 300 Watts. Subjects wore in randomized order a cycling shoe with its standard insole (control condition CO) or the shoe with carbon fiber foot orthoses (Condition CA). Mean peak pressure out of 30 movement cycles were extracted for the total foot and specific foot regions (rear, mid, fore foot (medial, central, lateral) and toe region). Three-factor ANOVAs (factor foot orthoses, rpm, workload) for repeated measures (alpha = 0.05) were used to analyze the main question of a foot orthoses effect on peak in-shoe plantar pressure. Results: Peak pressures in the total foot were in a range of 70-75 kPa for 200 Watts (W) (300 W: 85-110 kPa). The carbon fiber foot orthoses reduced peak pressures by -4,1% compared to the standard insole (p = 0,10). In the foot regions rear(-16,6%, p<0.001), mid (-20,0%, p<0.001) and fore foot (-5.9%, p < 0.03)CA reduced peak pressure compared to CO. In the toe region, peak pressure was higher in CA (+16,2%) compared to CO (p<0,001). The lateral fore foot showed higher peak pressures in CA (+34%) and CO (+59%) compared to medial and central fore foot. Conclusion: Carbon fiber can serve as a suitable material for foot orthoses manufacturing in cycling. Plantar pressures do not increase due to the stiffness of the carbon. Individual customization may have the potential to reduce peak pressure in certain foot areas.
Achilles (AT) and patellar tendons (PT) are commonly affected by tendinopathy in adult athletes but prevalence of symptoms and morphological changes in adolescents is unclear. The study aimed to determine prevalence of tendinopathy and intratendinous changes in ATs and PTs of adolescent athletes. A total of 760 adolescent athletes (13.0 +/- 1.9 years; 160 +/- 13cm; 50 +/- 14kg) were examined. History, local clinical examination, and longitudinal Doppler ultrasound analysis for both ATs and PTs were performed including identification of intratendinous echoic changes and vascularization. Diagnosis of tendinopathy was complied clinically in case of positive history of tendon pain and tendon pain on palpation. Achilles tendinopathy was diagnosed in 1.8% and patellar tendinopathy in 5.8%. Vascularizations were visible in 3.0% of ATs and 11.4% of PTs, hypoechogenicities in 0.7% and 3.2% as well as hyperechogenicities in 0% and 0.3%, respectively. Vascularizations and hypoechogenicities were statistically significantly more often in males than in females (P0.02). Subjects with patellar tendinopathy had higher prevalence of structural intratendinous changes than those without PT symptoms (P0.001). In adolescent athletes, patellar tendinopathy is three times more frequent compared with Achilles tendinopathy. Longitudinal studies are necessary to investigate physiological or pathological origin of vascularizations and its predictive value in development of tendinopathy.
Rehabilitation after autologous chondrocyte implantation for isolated cartilage defects of the knee
(2017)
Autologous chondrocyte implantation for treatment of isolated cartilage defects of the knee has become well established. Although various publications report technical modifications, clinical results, and cell-related issues, little is known about appropriate and optimal rehabilitation after autologous chondrocyte implantation. This article reviews the literature on rehabilitation after autologous chondrocyte implantation and presents a rehabilitation protocol that has been developed considering the best available evidence and has been successfully used for several years in a large number of patients who underwent autologous chondrocyte implantation for cartilage defects of the knee.
Background
Overweight and obesity are increasing health problems that are not restricted to adults only. Childhood obesity is associated with metabolic, psychological and musculoskeletal comorbidities. However, knowledge about the effect of obesity on the foot function across maturation is lacking. Decreased foot function with disproportional loading characteristics is expected for obese children. The aim of this study was to examine foot loading characteristics during gait of normal-weight, overweight and obese children aged 1-12 years.
Methods
A total of 10382 children aged one to twelve years were enrolled in the study. Finally, 7575 children (m/f: n = 3630/3945; 7.0 +/- 2.9yr; 1.23 +/- 0.19m; 26.6 +/- 10.6kg; BMI: 17.1 +/- 2.4kg/m(2)) were included for (complete case) data analysis. Children were categorized to normalweight (>= 3rd and <90th percentile; n = 6458), overweight (>= 90rd and <97th percentile; n = 746) or obese (>97th percentile; n = 371) according to the German reference system that is based on age and gender-specific body mass indices (BMI). Plantar pressure measurements were assessed during gait on an instrumented walkway. Contact area, arch index (AI), peak pressure (PP) and force time integral (FTI) were calculated for the total, fore-, mid-and hindfoot. Data was analyzed descriptively (mean +/- SD) followed by ANOVA/Welch-test (according to homogeneity of variances: yes/no) for group differences according to BMI categorization (normal-weight, overweight, obesity) and for each age group 1 to 12yrs (post-hoc Tukey Kramer/Dunnett's C; alpha = 0.05).
Results
Mean walking velocity was 0.95 +/- 0.25 m/s with no differences between normal-weight, overweight or obese children (p = 0.0841). Results show higher foot contact area, arch index, peak pressure and force time integral in overweight and obese children (p< 0.001). Obese children showed the 1.48-fold (1 year-old) to 3.49-fold (10 year-old) midfoot loading (FTI) compared to normal-weight.
Conclusion
Additional body mass leads to higher overall load, with disproportional impact on the midfoot area and longitudinal foot arch showing characteristic foot loading patterns. Already the feet of one and two year old children are significantly affected. Childhood overweight and obesity is not compensated by the musculoskeletal system. To avoid excessive foot loading with potential risk of discomfort or pain in childhood, prevention strategies should be developed and validated for children with a high body mass index and functional changes in the midfoot area. The presented plantar pressure values could additionally serve as reference data to identify suspicious foot loading patterns in children.
Fractures of the calcaneus are often associated with serious permanent disability, a considerable reduction in quality of life, and high socio-economic cost. Although some studies have already reported changes in plantar pressure distribution after calcaneal fracture, no investigation has yet focused on the patient's strength and postural control.
Method: 60 patients with unilateral, operatively treated, intra-articular calcaneal fractures were clinically and biomechanically evaluated >1 year postoperatively (physical examination, SF-36, AOFAS score, lower leg isokinetic strength, postural control and gait analysis including plantar pressure distribution). Results were correlated to clinical outcome and preoperative radiological findings (Bohler angle, Zwipp and Sanders Score).
Results: Clinical examination revealed a statistically significant reduction in range of motion at the tibiotalar and the subtalar joint on the affected side. Additionally, there was a statistically significant reduction of plantar flexor peak torque of the injured compared to the uninjured limb (p < 0.001) as well as a reduction in postural control that was also more pronounced on the initially injured side (standing duration 4.2 +/- 2.9 s vs. 7.6 +/- 2.1 s, p < 0.05). Plantar pressure measurements revealed a statistically significant pressure reduction at the hindfoot (p = 0.0007) and a pressure increase at the midfoot (p = 0.0001) and beneath the lateral forefoot (p = 0.037) of the injured foot.
There was only a weak correlation between radiological classifications and clinical outcome but a moderate correlation between strength differences and the clinical questionnaires (CC 0.27-0.4) as well as between standing duration and the clinical questionnaires. Although thigh circumference was also reduced on the injured side, there was no important relationship between changes in lower leg circumference and strength suggesting that measurement of leg circumference may not be a valid assessment of maximum strength deficits. Self-selected walking speed was the parameter that showed the best correlation with clinical outcome (AOFAS score).
Conclusion: Calcaneal fractures are associated with a significant reduction in ankle joint ROM, plantar flexion strength and postural control. These impairments seem to be highly relevant to the patients. Restoration of muscular strength and proprioception should therefore be aggressively addressed in the rehabilitation process after these fractures.
Neuromuscular response of the trunk to sudden gait disturbances: Forward vs. backward perturbation
(2016)
The study aimed to analyse neuromuscular activity of the trunk comparing four different perturbations during gait. Thirteen subjects (28 +/- 3 yrs) walked (1 m/s) on a split-belt treadmill, while 4 (belt) perturbations (F1, F2, B1, B2) were randomly applied. Perturbations differed, related to treadmill belt translation, in direction (forward (F)/backward (B)) and amplitude (20 m/s(2) (1)/40 m/s(2) (2)). Trunk muscle activity was assessed with a 12-lead-EMG. EMG-RMS [%] (0-200 ms after perturbation; normalized to RMS of normal gait) was analyzed for muscles and four trunk areas (ventral left/right; dorsal left/right). Ratio of ventral: dorsal muscles were calculated. Muscle onset [ms] was determined. Data analysis was conducted descriptively, followed by ANOVA (post hoc Tukey-Kramer (alpha = 0.05)). All perturbations lead to an increase in EMG-RMS (428 +/- 289%). F1 showed the lowest and F2 the highest increase for the flexors. B2 showed the highest increase for the extensors. Significant differences between perturbations could be observed for 6 muscles, as well as the 4 trunk areas. Ratio analysis revealed no significant differences (range 1.25 (B1) to 1.71 (F2) between stimuli. Muscle response time (ventral: 87.0 +/- 21.7 ms; dorsal: 88.4 +/- 17.0 ms) between stimuli was only significant (p = 0.005) for the dorsal muscles. Magnitude significantly influences neuromuscular trunk response patterns in healthy adults. Regardless of direction ventral muscles always revealed higher relative increase of activity while compensating the walking perturbations. (C) 2016 Elsevier Ltd. All rights reserved.