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Effectiveness of customised foot orthoses for the treatment of Achilles tendinopathy: Preliminary findings of a randomised controlled trial
2013 ASICS Conference / Journal of Science and Medicine in Sport 16S (2013) e2–e38
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Effectiveness of customised foot orthoses for the treatment of Achilles tendinopathy: Preliminary findings of a randomised controlled trial
Diagnostic accuracy of clinical tests for ankle syndesmosis injury
S. Munteanu 1,2,∗ , L. Munteanu 1,2 , K. Landorf 1,2 , D. Bonanno 1,2 , T. Pizzari 1,3 , J. Cook 4 , H. Menz 1 1 Lower Extremity and Gait Studies Program, Faculty of Health Sciences, La Trobe University, Australia 2 Department of Podiatry, Faculty of Health Sciences, La Trobe University, Australia 3 Department of Physiotherapy, Faculty of Health Sciences, La Trobe University, Australia 4 Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia
Introduction: Foot orthoses are commonly recommended for the management of mid-portion Achilles tendinopathy (AT), but the evidence relating to their effectiveness is equivocal. This study aimed to evaluate the effectiveness of customised foot orthoses for chronic AT in people who were also undergoing a calf muscle eccentric exercise program. Methods: One hundred and forty community-dwelling men and women aged 18–55 years with AT (mean [SD] age = 43.6 [7.9] years) were randomly allocated to either a control group (sham foot orthoses) or an experimental group (customised foot orthoses). Both groups were also prescribed a standard 12-week calf muscle eccentric exercise program. Participants were blinded to group allocation. The primary outcome measure was the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire. Secondary outcome measures included participant perception of treatment effect (dichotomised as effective or ineffective change in symptoms), level of physical activity (assessed using the 7-day Physical Activity Recall questionnaire), and health-related quality of life (assessed using the Short-Form-36 questionnaire – Version 2). Data were collected at baseline, then at 1, 3, and 6 months. Results: There were clinically significant improvements in VISAA questionnaire scores across time in both groups. However, there were no statistically significant differences between groups in scores of the VISA-A questionnaire at 1, 3, or 6 months (VISA-A at 3 months adjusted mean difference = 2.1 points, 95% CI −4.1 to 8.2, p = 0.506). Furthermore, there were no significant differences between groups for the perception of treatment effect (risk ratio at 3 months = 1.08, 95% CI = 0.89–1.31), or health-related quality of life at any time point. Discussion: Customised foot orthoses are no more effective than sham foot orthoses in reducing symptoms and improving function and activity in people with AT undergoing a calf muscle eccentric exercise program. http://dx.doi.org/10.1016/j.jsams.2013.10.065
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A. Sman 1,∗ , C. Hiller 2 , K. Rae 2 , J. Linklater 3 , D. Black 1 , L. Nicholson 1 , J. Burns 1 , K. Refshauge 1 1
Faculty of Health Sciences, University of Sydney, Australia 2 Sports Clinic, University of Sydney, Australia 3 Castlereagh Imaging, St Leonards, Australia Introduction: Ankle syndesmosis injury is clinically difficult to identify. Although clinical diagnostic tests form a critical part of the diagnostic triage for ankle syndesmosis injury, the usefulness of these tests has not been adequately researched. The aim was to investigate diagnostic accuracy of four common clinical diagnostic tests, and common features of clinical presentation to identify ankle syndesmosis injury. Methods: Patients aged 16–60 years with an ankle sprain injury presenting to a participating clinic were invited to participate. A clinical history was taken and the four clinical diagnostic tests for ankle syndesmosis injury were performed prior to the acquisition of the MRI. The MRIs were performed within 2 weeks of injury and reported on by a blinded radiologist with extensive experience in musculoskeletal imaging. Diagnostic tests were evaluated using sensitivity, specificity values and likelihood ratios (LR), with 95% confidence intervals. A backwards stepwise Cox regression model was used to determine clinical value. Results: Eighty-seven participants (69 male) aged 24.6 ± 6.5 years (mean ± SD) enrolled, of whom 38 had MRI-confirmed syndesmosis injury. The regression model, which correctly classified 69% of cases, showed that an injury was almost four times more likely to be an ankle syndesmosis injury in the presence of positive ankle syndesmosis ligament tenderness (OR 4.04, p = 0.048) and a positive dorsiflexion/external rotation stress test (OR 3.9, p = 0.004). As individual tests, the squeeze test had highest specificity (0.88, 95% CI 0.76–0.94) and the dorsiflexion/external rotation stress test had the highest combination of sensitivity (0.71, 95% CI 0.55 to 0.83) and specificity (0.63, 95% CI 0.49–0.75). Other factors, such as the inability to perform a single leg hop and the clinical presentation of inability to walk immediately after injury had the highest sensitivity (both 0.89, 95% CI 0.76–0.96). Pain out of proportion to the apparent injury had the best combination of sensitivity (0.65, 95% CI 0.49–0.78) and specificity (0.79, 95% CI 0.65–0.88). Discussion: In this first study to compare diagnostic accuracy of clinical tests with MRI, we found no single test with sufficiently high values to accurately diagnose ankle syndesmosis injury. We recommend that clinicians use a combination of tests of high sensitivity to rule out or high specificity to diagnose (rule in) ankle syndesmosis injury. We recommend that future studies concentrate on prediction models that include combinations of factors such as clinical signs and symptoms and clinical diagnostic tests. http://dx.doi.org/10.1016/j.jsams.2013.10.066
61
62
Effectiveness of customised foot orthoses for the treatment of Achilles tendinopathy: Preliminary findings of a randomised controlled trial
Diagnostic accuracy of clinical tests for ankle syndesmosis injury
S. Munteanu 1,2,∗ , L. Munteanu 1,2 , K. Landorf 1,2 , D. Bonanno 1,2 , T. Pizzari 1,3 , J. Cook 4 , H. Menz 1 1 Lower Extremity and Gait Studies Program, Faculty of Health Sciences, La Trobe University, Australia 2 Department of Podiatry, Faculty of Health Sciences, La Trobe University, Australia 3 Department of Physiotherapy, Faculty of Health Sciences, La Trobe University, Australia 4 Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia
Introduction: Foot orthoses are commonly recommended for the management of mid-portion Achilles tendinopathy (AT), but the evidence relating to their effectiveness is equivocal. This study aimed to evaluate the effectiveness of customised foot orthoses for chronic AT in people who were also undergoing a calf muscle eccentric exercise program. Methods: One hundred and forty community-dwelling men and women aged 18–55 years with AT (mean [SD] age = 43.6 [7.9] years) were randomly allocated to either a control group (sham foot orthoses) or an experimental group (customised foot orthoses). Both groups were also prescribed a standard 12-week calf muscle eccentric exercise program. Participants were blinded to group allocation. The primary outcome measure was the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire. Secondary outcome measures included participant perception of treatment effect (dichotomised as effective or ineffective change in symptoms), level of physical activity (assessed using the 7-day Physical Activity Recall questionnaire), and health-related quality of life (assessed using the Short-Form-36 questionnaire – Version 2). Data were collected at baseline, then at 1, 3, and 6 months. Results: There were clinically significant improvements in VISAA questionnaire scores across time in both groups. However, there were no statistically significant differences between groups in scores of the VISA-A questionnaire at 1, 3, or 6 months (VISA-A at 3 months adjusted mean difference = 2.1 points, 95% CI −4.1 to 8.2, p = 0.506). Furthermore, there were no significant differences between groups for the perception of treatment effect (risk ratio at 3 months = 1.08, 95% CI = 0.89–1.31), or health-related quality of life at any time point. Discussion: Customised foot orthoses are no more effective than sham foot orthoses in reducing symptoms and improving function and activity in people with AT undergoing a calf muscle eccentric exercise program. http://dx.doi.org/10.1016/j.jsams.2013.10.065
e27
A. Sman 1,∗ , C. Hiller 2 , K. Rae 2 , J. Linklater 3 , D. Black 1 , L. Nicholson 1 , J. Burns 1 , K. Refshauge 1 1
Faculty of Health Sciences, University of Sydney, Australia 2 Sports Clinic, University of Sydney, Australia 3 Castlereagh Imaging, St Leonards, Australia Introduction: Ankle syndesmosis injury is clinically difficult to identify. Although clinical diagnostic tests form a critical part of the diagnostic triage for ankle syndesmosis injury, the usefulness of these tests has not been adequately researched. The aim was to investigate diagnostic accuracy of four common clinical diagnostic tests, and common features of clinical presentation to identify ankle syndesmosis injury. Methods: Patients aged 16–60 years with an ankle sprain injury presenting to a participating clinic were invited to participate. A clinical history was taken and the four clinical diagnostic tests for ankle syndesmosis injury were performed prior to the acquisition of the MRI. The MRIs were performed within 2 weeks of injury and reported on by a blinded radiologist with extensive experience in musculoskeletal imaging. Diagnostic tests were evaluated using sensitivity, specificity values and likelihood ratios (LR), with 95% confidence intervals. A backwards stepwise Cox regression model was used to determine clinical value. Results: Eighty-seven participants (69 male) aged 24.6 ± 6.5 years (mean ± SD) enrolled, of whom 38 had MRI-confirmed syndesmosis injury. The regression model, which correctly classified 69% of cases, showed that an injury was almost four times more likely to be an ankle syndesmosis injury in the presence of positive ankle syndesmosis ligament tenderness (OR 4.04, p = 0.048) and a positive dorsiflexion/external rotation stress test (OR 3.9, p = 0.004). As individual tests, the squeeze test had highest specificity (0.88, 95% CI 0.76–0.94) and the dorsiflexion/external rotation stress test had the highest combination of sensitivity (0.71, 95% CI 0.55 to 0.83) and specificity (0.63, 95% CI 0.49–0.75). Other factors, such as the inability to perform a single leg hop and the clinical presentation of inability to walk immediately after injury had the highest sensitivity (both 0.89, 95% CI 0.76–0.96). Pain out of proportion to the apparent injury had the best combination of sensitivity (0.65, 95% CI 0.49–0.78) and specificity (0.79, 95% CI 0.65–0.88). Discussion: In this first study to compare diagnostic accuracy of clinical tests with MRI, we found no single test with sufficiently high values to accurately diagnose ankle syndesmosis injury. We recommend that clinicians use a combination of tests of high sensitivity to rule out or high specificity to diagnose (rule in) ankle syndesmosis injury. We recommend that future studies concentrate on prediction models that include combinations of factors such as clinical signs and symptoms and clinical diagnostic tests. http://dx.doi.org/10.1016/j.jsams.2013.10.066