Effects of MLS Laser on pain, function, and disability in chronic non-specific low back pain: A double-blind placebo randomized-controlled trial.

BACKGROUND: Among non-pharmacological interventions, Multiwave Locked System (MLS) Laser therapy has been used in patients with several musculoskeletal pathologies and in combination with other therapeutical interventions. The effects of sole MLS therapy on pain and function in patients with chronic non-specific low-back pain are unknown. OBJECTIVE: The objective of this study was to investigate the effects of MLS Laser therapy on pain, function, and disability in patients with chronic non-specific low back pain in comparison to a placebo treatment group. METHODS: Forty-five patients were randomized into two groups: the MLS Laser group and the Sham Laser group, undergoing 8 sessions of either a MLS Laser therapy or a Sham Laser therapy, respectively. At the beginning of the therapy (T0), at the end of the therapy (T1), and 1 month after the end of therapy (T2) patients were assessed for low back pain (by means of a VAS scale), function (by means of kinematic and electromyographic assessment of a forward bending movement) and self-reported disability (by means of the Roland-Morris and Oswestry Disability questionnaires). RESULTS: There was a significant reduction of pain and disability in both groups at T1 and T2 in comparison with T0. At T2 patients in the MLS group showed a significantly lower pain in comparison with patients in the Sham group (VAS = 2.2 ± 2 vs. 3.6 ± 2.4; p< 0.05). No differences between the two groups were found for function and disability. CONCLUSION: Both MLS Laser and Sham Laser therapies lead to a significant and comparable reduction in pain and disability in patients with chronic non-specific low back pain. However, one month after treatment, MLS Laser therapy has been found to be significantly more effective in reducing pain as compared to sham treatment.

"Transcranial Direct Current Stimulation (tDCS) in managing pain and recovery: A clinical case of radial capitellum fracture".

INTRODUCTION: The management of pain and functional recovery following a radial capitellum fracture poses a significant clinical challenge, especially in individuals whose professions, such as physiotherapy, demand optimal joint functionality. Transcranial Direct Current Stimulation (tDCS) emerges as a potential non-pharmacological intervention for pain management, necessitating exploration in the context of orthopedic injuries. CASE PRESENTATION: A 41-year-old male physiotherapist presented with a MASON 2 radial capitellum fracture following a fall, experiencing notable pain (NPRS 6/7) and functional impairment (DASH 45/100, PRTEE 43/100). Conservative management, involving immobilization and potential surgical consideration, was employed, followed by tDCS for pain management. Post-tDCS, significant improvements were observed in pain and functional scores (NPRS to 0, DASH to 14.2, PRTEE to 7), alongside enhancements in range of motion and muscle strength. CLINICAL DISCUSSION: The application of tDCS showcased notable efficacy in pain reduction and functional improvement, highlighting its potential in augmenting pain management strategies post-fracture. However, the variability in responses and lack of standardized application protocols necessitate further research to optimize its clinical utility. The balance between immobilization for fracture healing and mobilization for preventing stiffness and facilitating recovery was pivotal in managing the fracture and ensuring functional improvement. CONCLUSIONS: This case underscores the potential of tDCS in managing pain and facilitating functional recovery in radial capitellum fractures, warranting further exploration and standardization of its application in clinical practice. The integrated, patient-centric approach, involving interdisciplinary collaboration and personalized care, was crucial in ensuring positive outcomes and provides a framework for managing similar orthopedic cases.

Clinical and multi-segment kinematic analysis of a modified Grice arthrodesis to correct type II adult-acquired flat-foot.

BACKGROUND: Adult acquired flat foot (AAFF) is a symptomatic postural alteration of the foot due to modifications in bony structures and/or soft tissues supporting the medial longitudinal arch. For the most severe cases, when orthotic solutions do not provide enough pain relief, surgery may be necessary. RESEARCH QUESTION: Is it possible to restore a normal medial longitudinal arch and to correct the static and dynamic frontal plane alignment of the rearfoot via a modified Grice surgical procedure in AAFF patients? METHODS: Eleven patients with stage II AAFF were recruited in the study and underwent the Grice procedure. Patients were assessed via gait analysis using a validated multi-segment foot protocol. Double-leg standing static posture and foot joint kinematics during barefoot walking were measured before surgery and at a mean follow-up of 15 ± 8 months. Twenty-seven age-matched healthy subjects without foot morphological alterations were used as control. Patients' feet were clinically assessed via the Foot Function Index and the Foot Posture Index. Wilcoxon signed rank test was used to assess differences in kinematic and spatio-temporal parameters between pre-op and follow-up evaluations. 1D statistical parametric mapping was used to assess differences in temporal profiles of foot joint rotations. RESULTS: The clinical indexes significantly improved at post-op (p < 0.05). No differences in sagittal plane static and dynamic joint rotations were observed between pre-op and post-op. In the frontal plane, metatarsus to calcaneus and midfoot to calcaneus rotation angles significantly improved from pre-op to post-op, with the latter resulting consistent with control data. Range of motion and maximum value of the medial longitudinal arch angle were reduced following surgery. SIGNIFICANCE: The modified Grice procedure restored a good frontal-plane alignment of rearfoot and midfoot, and the clinical scores provided evidence of its effectiveness in significantly reducing pain and improving the quality of daily activities.

3D measurement techniques for the hindfoot alignment angle from weight-bearing CT in a clinical population.

Cone-beam CT (CBCT) scans now enable accurate measurements on foot skeletal structures with the advantage of observing these in 3D and in weight-bearing. Among the most common skeletal deformities, the varus/valgus of the hindfoot is the most complex to be represented, and a number of measure proposals have been published. This study aims to analyze and to compare these measurements from CBCT scans in a real clinical population with large such deformity. Ten patients with severe acquired adult flatfoot and indication for surgery underwent CBCT scans (Carestream, USA) while standing on that leg, before and after surgical correction. Corresponding 3D shape of each bone of the distal shank and hindfoot were defined (Materialise, Belgium). Six different techniques from the literature were used to calculate the varus/valgus deformity, i.e. the inclination of the hindfoot in the frontal plane of the shank. Standard clinical measurements by goniometers were taken for comparison. According to these techniques, and starting from a careful 3D reconstruction of the relevant foot skeletal structures, a large spectrum of measurements was found to represent the same hindfoot alignment angle. Most of them were very different from the traditional clinical measures. The assessment of the pre-operative valgus deformity and of the corresponding post-operative correction varied considerably. CBCT finally allows 3D assessment of foot deformities in weight-bearing. Measurements from the different available techniques do not compare well, as they are based on very different approaches. It is recommended to be aware of the anatomical and functional concepts behind these techniques before clinical and surgical conclusions.

Angular and linear measurements of adult flexible flatfoot via weight-bearing CT scans and 3D bone reconstruction tools.

Acquired adult flatfoot is a frequent deformity which implies multiple, complex and combined 3D modifications of the foot skeletal structure. The difficult thorough evaluation of the degree of severity pre-op and the corresponding assessment post-op can now be overcome by cone-beam (CBCT) technology, which can provide access to the 3D skeletal structure in weight-bearing. This study aims to report flatfoot deformities originally in 3D and in weight-bearing, with measurements taken using two different bone segmentation techniques. 21 such patients, with indication for surgical corrections, underwent CBCT (Carestream, US) while standing on one leg. From these scans, 3D models of each bone of the foot were reconstructed by using two different state-of-the-art segmentation tools: a semi-automatic (Mimics Innovation Suite, Materialise, Belgium), and an automatic (Bonelogic Ortho Foot and Ankle, Disior, Finland). From both reconstructed models, Principal Component Analysis was used to define anatomical reference frames, and original foot and ankle angles and other parameters were calculated mostly based on the longitudinal axis of the bones, in anatomical plane projections and in 3D. Both bone model reconstructions revealed a considerable valgus of the calcareous, plantarflexion and internal rotation of the talus, and typical Meary's angles in the lateral and transverse plane projections. The mean difference from these angles between semi-automatic and automatic segmentations was larger than 3.5 degrees for only 3 of the 32 measurements, and a large number of these differences were not statistically significant. CBCT and the present techniques for bone shape reconstruction finally provide a novel and valuable 3D assessment of complex foot deformities in weight-bearing, eliminating previous limitations associated to unloaded feet and bidimensional measures. Corresponding measurements on the bone models from the two segmentation tools compared well. Other more representative measurements can be defined in the future using CBCT and these techniques.

Correlations between weight-bearing 3D bone architecture and dynamic plantar pressure measurements in the diabetic foot.

BACKGROUND: Measurements of plantar loading reveal foot-to-floor interaction during activity, but information on bone architecture cannot be derived. Recently, cone-beam computer tomography (CBCT) has given visual access to skeletal structures in weight-bearing. The combination of the two measures has the potential to improve clinical understanding and prevention of diabetic foot ulcers. This study explores the correlations between static 3D bone alignment and dynamic plantar loading. METHODS: Sixteen patients with diabetes were enrolled (group ALL): 15 type 1 with (N, 7) and without (D, 8) diabetic neuropathy, and 1 with latent autoimmune diabetes. CBCT foot scans were taken in single-leg upright posture. 3D bone models were obtained by image segmentation and aligned in a foot anatomical reference frame. Absolute inclination and relative orientation angles and heights of the bones were calculated. Pressure patterns were also acquired during barefoot level walking at self-selected speed, from which regional peak pressure and absolute and normalised pressure-time integral were worked out at hallux and at first, central and fifth metatarsals (LOAD variables) as averaged over five trials. Correlations with 3D alignments were searched also with arch index, contact time, age, BMI, years of disease and a neuropathy-related variable. RESULTS: Lateral and 3D angles showed the highest percentage of significant (p < 0.05) correlations with LOAD. These were weak-to-moderate in the ALL group, moderate-to-strong in N and D. LOAD under the central metatarsals showed moderate-to-strong correlation with plantarflexion of the 2nd and 3rd phalanxes in ALL and N. LOAD at the hallux increased with plantarflexion at the 3rd phalanx in ALL, at 1st phalanx in N and at 5th phalanx in D. Arch index correlated with 1st phalanx plantarflexion in ALL and D; contact time showed strong correlation with 2nd and 3rd metatarsals and with 4th phalanx dorsiflexion in D. CONCLUSION: These preliminary original measures reveal that alteration of plantar dynamic loading patterns can be accounted for peculiar structural changes of foot bones. Load under the central metatarsal heads were correlated more with inclination of the corresponding phalanxes than metatarsals. Further analyses shall detect to which extent variables play a role in the many group-specific correlations.

Retrospective comparison between a two- and three-component ankle arthroplasty: clinical and functional evaluation via gait analysis.

BACKGROUND: Total ankle arthroplasty is intended to restore physiological joint function in case of severe ankle arthritis. However, little is known about the functional outcome associated to different prosthesis designs. The aim of this retrospective study was to compare clinical and functional outcomes via gait analysis of two ankle prostheses designed to preserve ankle ligamentous isometry. METHODS: Two groups of twenty patients who underwent ankle arthroplasty using either a three-component or a two-component prosthesis, were clinically evaluated, both pre-operatively and at minimal 2-year follow-up, by means of the AOFAS score. The spatio-temporal parameters, along with the kinetics and kinematics of the lower limb joints were also assessed at follow-up via gait analysis. The non-parametric Kruskal-Wallis test was used to assess differences in functional data between the two patient groups and with respect to those from a control group of 20 healthy subjects. FINDINGS: All AOFAS scores significantly improved from pre-operative to post-operative assessment in both patient groups (P < 0.05). Most spatio-temporal and functional parameters in the patients were worse than those in the control group, but no significant differences were observed between the two arthroplasty groups. INTERPRETATION: Both patient groups showed improved clinical outcome at follow-up, with a few differences in gait parameters. However, neither of the two groups achieved normal locomotion patterns. Since both prostheses were designed to preserve ligamentous isometry, the choice of one implant over the other should be due to preferences in the surgical approach and to other patient-specific factors.

Functional Evaluation of a Shock Absorbing Insole During Military Training in a Group of Soldiers: A Pilot Study.

OBJECTIVE: Soldiers' lower limbs and feet are frequently affected by overload- and overuse-related injuries. In order to prevent or limit the incidence of these injuries, the use of foot orthoses is often recommended. The aim of this study is to assess the effects of shock-absorbing insoles on in-shoe plantar pressure magnitude and distribution in a group of professional infantry soldiers wearing military boots during standard indoor military training. METHODS: Twenty male professional soldiers of the Italian Army (age 35.1 ± 6.1 years; BMI 25.2 ± 2.3 kg/m2) were recruited for this study. Each subject underwent clinical examination to assess possible overuse-related diseases of the lower limb and trunk. Subjects with altered foot morphology according to the Foot Posture Index (FPI) were excluded from this study. Twelve subjects were considered eligible and therefore underwent an indoor training routine comprised of marching, running, jumping inside parallel bars and jumping from different heights. Soldiers repeated the training session twice wearing standard military boots along with two types of insoles: the standard prefabricated insole within the boots (STI), and a special shock-absorbing insole (SAI) featuring an elastic medial arch support. A 99-capacitive sensor insole system was used to record plantar pressure distribution in both feet. Analysis of in-shoe pressure parameters at rearfoot, midfoot and forefoot and in the total foot was performed via a custom-software application developed in MATLAB. Perceived foot comfort (VAS 0-15) was also assessed. RESULTS: Pressure parameters recorded during walking and running were considered suitable for statistical analysis. In the whole foot region, pressure parameters were 18-22% lower in military boots fitted with the SAI during walking and 14-18% lower during running. SAI resulted in better comfort (+25%) with respect to the prefabricated boot orthotics (median comfort: SAI = 15/15; STI = 12/15; p = 0.0039) both during walking and running. CONCLUSIONS: Shock-absorbing insoles can be an effective solution when fitted inside military boots. The present functional evaluation shows that wearing a prefabricated shock-absorbing insole can provide a significant amelioration of perceived foot comfort and plantar pressure parameters. Further studies are now needed with a larger population and more demanding exercises.

Weight-bearing CT Technology in Musculoskeletal Pathologies of the Lower Limbs: Techniques, Initial Applications, and Preliminary Combinations with Gait-Analysis Measurements at the Istituto Ortopedico Rizzoli.

Musculoskeletal radiology has been mostly limited by the option between imaging under load but in two dimensions (i.e., radiographs) and three-dimensional (3D) scans but in unloaded conditions (i.e., computed tomography [CT] and magnetic resonance imaging in a supine position). Cone-beam technology is now also a way to image the extremities with 3D and weight-bearing CT. This article discusses the initial experience over a few studies in progress at an orthopaedic center. The custom design of total ankle replacements, the patellofemoral alignment after medial ligament reconstruction, the overall architecture of the foot bones in the diabetic foot, and the radiographic assessment of the rearfoot after subtalar fusion for correction of severe flat foot have all taken advantage of the 3D and weight-bearing feature of relevant CT scans. To further support these novel assessments, techniques have been developed to obtain 3D models of the bones from the scans and to merge these with state-of-the-art gait analyses.

Functional evaluation of bilateral subtalar arthroereisis for the correction of flexible flatfoot in children: 1-year follow-up.

BACKGROUND: Flexible flatfoot (FFF) is a common alteration of the foot diagnosed in the pediatric population causing pain and decreased quality of life. Surgical treatment via arthroereisis of the subtalar joint can be recommended when non-invasive options do not result in sufficient pain relief. While clinical outcome of subtalar joint arthroereisis is generally positive, no functional evaluation has thus far been reported following surgery. RESEARCH QUESTION: The aim of this study was to assess the effects of two arthroereisis implants for the correction of bilateral FFF on foot and lower limb biomechanics during gait. METHODS: This is a prospective study following 13 children affected by bilateral symptomatic FFF. The patients underwent bilateral subtalar arthroereisis during the same surgery using two types of poly-L-lactide bioabsorbable implants: an expanding endo-orthotic implant, and a calcaneo-stop screw. Radiological parameters and gait analysis were performed preoperatively and at 1 year follow-up and compared to those from an age-matched normal-arched control population. Lower limb and multisegment foot kinematic analysis, along with EMG of the main ankle flexor/extensor muscles, were performed during level walking at comfortable speed. Paired non-parametric Wilcoxon signed-rank test was used to assess differences in radiological and kinematic parameters between pre-op and post-op assessments. RESULTS: All radiological parameters, and frontal-plane orientation of the rearfoot in double-leg standing were improved at 1-year follow-up in both implant groups (e.g calcaneo-stop: pre-op = 15 ±â€¯7 deg; post-op = 6 ±â€¯9 deg; p < 0.01). The endo-orthotic implant group showed significantly lower pronation/supination at the ankle and midtarsal joint. Activation of the tibialis anterior muscle was more physiological after surgery in both groups. SIGNIFICANCE: According to the present analysis, both implants appear effective in restoring physiological alignment of the rearfoot, however the endo-orthotic implant appeared more effective in restoring a more correct frontal-plane mobility of foot joints.

Two-stage surgical treatment for septic non-union of the forearm.

AIM: To investigate the effectiveness of a two-stage surgical procedure for the treatment of septic forearm non-union. METHODS: Septic non-unions are rare complications of forearm fractures. When they occur, they modify the relationship between forearm bones leading to a severe functional impairment. Treatment is challenging and surgery and antibiotic therapy are required to achieve infection resolution. It is even harder to obtain non-union healing with good functional results. The aim of this study is to present a two stages surgical treatment for septic forearm non-union with revision and temporary stabilization of the non-union until infection has cleared and subsequently perform a new synthesis with plate, opposite bone graft strut and intercalary graft. We retrospectively reviewed 18 patients with a mean age at the time of primary injury of 34.5 years (19-57 years) and a mean follow-up of 6 years (2-10 years). All patients presented an atrophic non-union with a mean length of the bone defect of 1.8 cm (1.2-4 cm). Complications and clinical results after surgical treatment were recorded. RESULTS: Mean time to resolution of the infectious process was 8.2 wk (range 4-20 wk) after the first surgery and specific antibiotic therapy. All the non-union healed with an average time of 5 mo (range 2-10 mo) after the second step surgery. Cultures on intraoperative samples were positive in all cases. No major intraoperative complications occurred. Two patients developed minor complications and one needed a second surgical debridement for infection resolution. At the last follow-up functional results were excellent in 5 (27.8%) patients, satisfactory in 10 (55.5%) and unsatisfactory in 3 (16.7%) patients. No activities of daily living (ADLs) limitations were reported by 12 (66.6%) patients, slight by 3 (16.6%) and severe limitation by 3 (16.6%) patients. Mean visual analog scale at the last follow-up was 1 (0-3). CONCLUSION: The two-step technique has proven to be effective to achieve resolution of the infectious process and union with good functional results and low rate of complications.

In shoe pressure measurements during different motor tasks while wearing safety shoes: The effect of custom made insoles vs. prefabricated and off-the-shelf.

Health and safety regulations in many countries require workers at risk to wear safety shoes in a factory environment. These shoes are often heavy, rigid, and uncomfortable. Wearing safety shoes daily leads to foot problems, discomfort and fatigue, resulting also in the loss of numerous working days. Currently, knowledge of the biomechanical effects of insoles in safety shoes, during working activities, is very limited. Seventeen workers from a metalworking factory were selected and clinically examined for any foot conditions. Workers feet were 3D scanned, with regards to their plantar view, and the images used to design 34 custom-insoles, based on foot and safety shoe models. Three insoles were blind-tested by each worker: custom (CUS); prefabricated with the safety-shoe (PSS), and off-the-shelf (OTS). Foot-to-insole pressure distribution was measured in seven motor tasks replicating typical working activities: single and double-leg standing; weight lifting; stair ascending and descending; normal and fast walking. Wearing CUS within safety shoes resulted in a greater uniform pressure distribution across plantar regions for most of the working activities. Peak pressure at the forefoot during normal walking was the lowest in the custom insole (CUS 275.9±55.3kPa; OTS 332.7±75.5kPa; PSS 304.5±54.2kPa). Normal and fast walking were found to be the most demanding activities in terms of peak pressure. Wearing safety shoes results in high pedobarographic parameters in several foot regions. The use of custom insoles designed on the foot morphology helps decrease peak pressure and pressure-time integral compared to prefabricated featureless insoles.

Pedobarographic and kinematic analysis in the functional evaluation of two post-operative forefoot offloading shoes.

BACKGROUND: Forefoot offloading shoes are special orthopaedic footwear designed to protect and unload the injured part of the foot after surgery and for conservative treatments. The offloading action is often achieved by transferring plantar load to the rearfoot via rocker shoes with reduced contact area between shoe and ground. While these shoes are intended to be worn only for short periods, a compromise must be found between functionality and the risk of alterations in gait patterns at the lower limb joints. In this study, the pedobarographic, kinematic and kinetic effects of a traditional half-shoe and a double-rocker full-outsole shoe were compared to those of a comfortable shoe (control). METHODS: Ten healthy female participants (28.2 ± 10.0 years) were asked to walk in three different footwear conditions for the left/right foot: control/half-shoe, control/full-outsole, and control/control. Full gait analysis was obtained in three walking trials for each participant in each condition. Simultaneously a sensor insole system recorded plantar pressure in different foot regions. Normalized root-mean-square error, coefficient of determination, and frame-by-frame statistical analysis were used to assess differences in time-histories of kinematic and kinetic parameters between shoes. RESULTS: The half -shoe group showed the slowest walking speed and the shortest stride length. Forefoot plantar load was significantly reduced in the half-shoe (maximum force as % of Body Weight: half-shoe = 62.1; full-outsole = 86.9; control = 93.5; p < 0.001). At the rearfoot, mean pressure was the highest in the full-outsole shoe. At the ankle, sagittal-plane kinematics in the full-outsole shoe had a pattern more similar to control. CONCLUSIONS: The half-shoe appears significantly more effective in reducing plantar load at the forefoot than a double-rocker full-outsole shoe, which is designed to reduce forefoot loading by using an insole with a thicker profile anteriorly as to maintain the foot in slight dorsiflexion. However, the half-shoe is also associated with altered gait spatio-temporal parameters, more kinematic modifications at the proximal lower limb joints and reduced propulsion in late stance.

Functional and clinical assessment of two ankle arthrodesis techniques.

Isolated tibiotalar fusion is the preferred choice for isolated end-stage arthritis, joint destruction after infection, talar avascular necrosis, Charcot neuroarthropathy, and joint replacement failure. Combined tibiotalar and subtalar joint fusion with an intramedullary nail can achieve better alignment and save patients from prolonged non-weightbearing. The purpose of the present study was to functionally assess using instrumental gait analysis and clinically assess the effect of these 2 surgical techniques. Twelve patients with a mean follow-up duration of 70 (range 55 to 89) months after successful ankle fusion were analyzed, 6 isolated and 6 combined. The main outcome measure was the functional assessment performed using a stereophotogrammetric system and an established multisegment foot kinematics protocol. Standard clinical, imaging, and score systems were also assessed in the 2 groups, including radiographic-based classification of arthritic degeneration at the neighboring foot joints. No significant differences were found between the 2 groups using the scoring systems. Severe arthritic degeneration was found at the subtalar joint in the isolated fusion group and at the talonavicular and Lisfranc joints in the combined fusion group. From the gait analysis, no differences were found in the time-distance parameters; however, significant differences were observed in several joint rotations and planar angles. Isolated tibiotalar fusion allows for motion, however small, at the subtalar joint but can result in severe degeneration. Good clinical and functional results can also be obtained with combined tibiotalar and subtalar fusion, although this can result in degeneration of the adjacent joints of the foot.

Validation of the angular measurements of a new inertial-measurement-unit based rehabilitation system: comparison with state-of-the-art gait analysis.

BACKGROUND: Several rehabilitation systems based on inertial measurement units (IMU) are entering the market for the control of exercises and to measure performance progression, particularly for recovery after lower limb orthopaedic treatments. IMU are easy to wear also by the patient alone, but the extent to which IMU's malpositioning in routine use can affect the accuracy of the measurements is not known. A new such system (Riablo™, CoRehab, Trento, Italy), using audio-visual biofeedback based on videogames, was assessed against state-of-the-art gait analysis as the gold standard. METHODS: The sensitivity of the system to errors in the IMU's position and orientation was measured in 5 healthy subjects performing two hip joint motion exercises. Root mean square deviation was used to assess differences in the system's kinematic output between the erroneous and correct IMU position and orientation.In order to estimate the system's accuracy, thorax and knee joint motion of 17 healthy subjects were tracked during the execution of standard rehabilitation tasks and compared with the corresponding measurements obtained with an established gait protocol using stereophotogrammetry. RESULTS: A maximum mean error of 3.1 ± 1.8 deg and 1.9 ± 0.8 deg from the angle trajectory with correct IMU position was recorded respectively in the medio-lateral malposition and frontal-plane misalignment tests. Across the standard rehabilitation tasks, the mean distance between the IMU and gait analysis systems was on average smaller than 5°. CONCLUSIONS: These findings showed that the tested IMU based system has the necessary accuracy to be safely utilized in rehabilitation programs after orthopaedic treatments of the lower limb.

Effect of trunk sagittal attitude on shoulder, thorax and pelvis three-dimensional kinematics in able-bodied subjects during gait.

It has been shown that an original attitude in forward or backward inclination of the trunk is maintained at gait initiation and during locomotion, and that this affects lower limb loading patterns. However, no studies have shown the extent to which shoulder, thorax and pelvis three-dimensional kinematics are modified during gait due to this sagittal inclination attitude. Thirty young healthy volunteers were analyzed during level walking with video-based motion analysis. Reflecting markers were mounted on anatomical landmarks to form a two-marker shoulder line segment, and a four-marker thorax and pelvis segments. Absolute and relative spatial rotations were calculated, for a total of 11 degrees of freedom. The subjects were divided into two groups of 15 according to the median of mean thorax inclination angle over the gait cycle. Preliminary MANOVA analysis assessed whether gender was an independent variable. Then two-factor nested ANOVA was used to test the possible effect of thorax inclination on body segments, planes of motion and gait periods, separately. There was no significant difference in all anthropometric and spatio-temporal parameters between the two groups, except for subject mass. The three-dimensional kinematics of the thorax and pelvis were not affected by gender. Nested ANOVA revealed group effect in all segment rotations apart those at the pelvis, in the sagittal and frontal planes, and at the push-off. Attitudes in sagittal thorax inclination altered trunk segments kinematics during gait. Subjects with a backward thorax showed less thorax-to-pelvis motion, but more shoulder-to-thorax and thorax-to-laboratory motion, less motion in flexion/extension and in lateral bending, and also less motion during push-off. This contributes to the understanding of forward propulsion and sideways load transfer mechanisms, fundamental for the maintenance of balance and the risk of falling.

Functional recovery after hip resurfacing and rehabilitation.

CONTEXT: Surface replacement of the hip is aimed especially at active patients, and it seems to achieve optimal functional results in a short time if associated with a tailored rehabilitation protocol. OBJECTIVE: To assess the functional outcome in a group of active patients after hip resurfacing. DESIGN: Clinical measurement and controlled laboratory study in a case series. SETTING: Gait-analysis laboratory. PARTICIPANTS: 8 patients and a control group of 10 subjects. INTERVENTIONS: Patients treated with Birmingham hip-resurfacing system and a tailored rehabilitation protocol MAIN OUTCOME MEASURES: Clinical assessment (Harris Hip Score [HHS]) and instrumented gait analysis including muscular electromyographic assessment. Patients were assessed preoperatively and at 3 and 9 mo follow-up after surgery. RESULTS: HHS showed a significant increase from the baseline to 3- (P = .008) and 9-month (P = .014) follow-up; 5 patients returned to sport. Gait pattern in the presented case series of patients improved substantially 3 mo postoperatively, and minimal further changes were present 9 months postoperatively. Residual abnormalities of time-distance and hip-kinematics parameters were consistent with a slow gait. A complete restoration of the muscle-activation pattern during gait was achieved. CONCLUSION: Hip resurfacing associated with a rehabilitation protocol based on the characteristics of the implant provides excellent clinical and functional outcome, especially for very active patients.

Diagnosis of flexible flatfoot in children: a systematic clinical approach.

The goal of this study was to provide measures of symptoms and signs in a consecutive case series of children with flexible flatfoot based on a systematic clinical approach. Fifty-three children (age range, 10-14 years) previously diagnosed with flexible flatfoot were evaluated by a structured interview and clinical assessment. Most patients had foot symptoms (65.3% of feet) and functional limitation (68.3%). Symptoms included a sensation of discomfort (11.3%), such as early tiredness or difficulties during prolonged standing or walking, and pain (54%), mostly located in the plantar aspect of the foot (28.7%) and the medial hindfoot (18.8%). Body mass index was positively correlated to the presence of symptoms and their severity. Even if an enlarged footprint was present in 93.1% of feet, objective assessment evidenced the presence of heel valgus only in 83% of feet. Forefoot adduction was present in 22% of feet. Jack's test provided varus correction in only 54% of feet. Internal knee rotation was the most common associated disalignment, present in 43.6% of limbs. Symptoms were significantly correlated to knee alignment, and functional limitation was correlated to heel valgus. Standing balance on 1 leg was significantly correlated to footprint grading severity. A systematic clinical approach to assess children with flexible flatfoot should always be recommended for the correct diagnosis and the associated treatment management based on symptoms, functional limitation, and foot dysfunction. Functional assessment by specific tests should be included in the examination, as evidence exists that morphology and function are not necessarily related.

Clinicoradiographic assessment of flexible flatfoot in children.

BACKGROUND: Radiographic assessment is still used to evaluate flexible flatfoot in children. METHODS: To find a set of radiologic parameters for assessing this disease, we studied 53 children aged 10 to 14 years. The degree of plantar collapse was measured by Viladot's classification (grades 0-4). The degree of valgus deformity measured in the heel in a standing position, the presence of painful points, and functional limitation during daily-living activities were also reported. The children underwent standard radiography of the foot under load. On the dorsoplantar view, the talocalcaneal, hallux metatarsophalangeal, and first intermetatarsal angles were measured. On the lateral view, the talocalcaneal, Costa Bertani, talometatarsal, talonavicular, and tibiotalar angles were measured. The radiographic measurements were compared with the data reported in the literature and were correlated with the clinical parameters studied (degree of flatfoot, valgus deviation of the heel, pain, and functional limitation). RESULTS: The radiographic measures that resulted increased with respect to the reference values reported in the literature for the Costa Bertani (93.1% of feet), talometatarsal (93.5%), talonavicular (89.1%), and tibiotalar (69.7%) angles, all in the lateral view. Of the angles assessed in the dorsoplantar view, the hallux metatarsophalangeal (11.1%) and first intermetatarsal (24.2%) angles were increased. The degree of flatfoot was correlated with the Costa Bertani angle (P < .0005). In the group with pain, the lateral talocalcaneal (P = .016) and first intermetatarsal (P = .02) angles were increased compared within the group without pain. CONCLUSIONS: Despite technical limitations, we still consider standard radiography of the foot, combined with clinical examination, to be a valid tool for assessing flexible flatfoot in children, especially when surgical treatment is expected and when a basic measure of the structural setup of the foot is necessary.