WICHITA STATE MBB: Ron Baker Diagnosed with Stress Fracture

WICHITA, Kan. -- Wichita State starting guard Ron Baker will miss approximately six weeks with a stress fracture in his left foot as the third Shocker starter currently injured, Head Basketball Coach Gregg Marshall announced today.

He is the fourth Shocker starter injured since Nov. 21 who will miss significant playing time. The three currently injured players represent 28 season starts.

Coach Marshall announced Monday that senior forward Carl Hall (Cochran, Ga.) will miss four weeks with a broken right thumb, while sophomore guard Evan Wessel (Wichita) is out with a broken right pinky, which could also require surgery.

Seven-foot center Ehimen Orukpe (Lagos, Nigeria) missed three games with a sprained right ankle suffered Nov. 21 against Iowa before he saw seven minutes of limited time off the bench against Tennessee.

Baker, a redshirt freshman from Scott City, averages 7.3 points and 2.6 rebounds through the first 10 games.

Wichita State has 11 players suiting up for practice, including transfer Kadeem Coleby (Nassau, Bahamas/Louisiana-Lafayette), and redshirting freshmen Derail Green (Houston, Texas) and Zach Bush (Wichita).

"The guys who were out there practiced very hard and very well yesterday and today," Marshall said. "I'm assuming these guys are excited about having an opportunity to step into a more prominent role. That's why you use all of your scholarships, but it's not going to make it any easier. Our margin for error is much less than it was approximately a week ago. We've literally got three starters out, and another one banged up. They were starters for a reason."

Wichita State next plays 7 p.m., Thursday at home against Charleston Southern.

"We need quite an atmosphere Thursday night," Marshall said. "At this point the Shocker faithful needs to do what they can to help. It's not on them. It's on us, but anything they can do to rally around this team with noise and support. We've got a few home games before Christmas and we've got the one right after Christmas against Northern Iowa. This place needs to be as loud as it can possibly be. We're 9-1, but we've had our wings clipped a little bit and we've got to use every available resource and that's certainly a big one."

Lower extremity focus helps cut risk of falls

Falls are common, disabling and costly. Causes are multifactorial but include foot disorders, ill-fitting footwear, and poor bal­ance. Recent research supports a multi­dis­ci­plinary approach to falls prevention and indicates that lower extremity practi­tioners can play an important role. Falls in older people are a major public health problem, with one in three people aged 65 years and older falling each year.1 Falls most frequently result in minor injuries such as superficial cuts and abrasions, bruises, and sprains. However, up to 15% of falls result in more serious injury such as head trauma, fractures, dislocations, and lacerations, making falls the leading cause of hospitalization in older people.2 Furthermore, in the US, falls are responsible for two-thirds of deaths from unintentional injury, making falls a larger contributor to mortality in older people than motor vehicle accidents.3 Management of fall-related injury makes a substantial contribution to healthcare expenditure. In the US, it has been estimated that each injurious fall costs an average of $10,749 in treatment costs—a figure that increases to $26,483 if hospitalization is required.4 In 2000, the total cost of treating nonfatal injurious falls in the US was an estimated $19 billion.5 Although substantial, these figures are likely to be an underestimate of the true economic impact of falls, as they focus on direct treatment costs and do not consider loss of productivity, personal costs, and the financial impact on spouses, other family members, and caregivers. What causes falls? Falls are complex multifactorial events that result from both intrinsic (physiological) and extrinsic (environmental) risk factors. Prospective studies have identified major intrinsic risk factors for falls in older people; these include muscle weakness, a previous history of falls, gait disorders, visual impairment, use of psychoactive medications, and cognitive impairment. Extrinsic risk factors include hazards such as stairs, slippery surfaces, throw rugs, and cracked pavements.6 It is now well accepted that environmental hazards alone are not the major cause of most falls. Rather, the interaction between environmental hazards and an older person’s physical abilities plays a key role. For example, an older person with high level of physical functioning may be able to cope in a hazardous environment without falling, while an older person with significant physical impairment may fall in a relatively safe environment. Furthermore, an older person’s perceptions of their own abilities and risk of falling, particularly fear of falling, influences their level of exposure to hazardous situations and subsequent incidence of falls.7 Foot disorders, balance, and falls The foot provides the only source of direct contact with the ground during walking, and contributes to both the absorption of impact after heel contact and the generation of power required for forward momentum. Each of these functions requires the complex interaction of joint motions at specific times to achieve smooth transfer of body weight. It is therefore reasonable to expect that foot dysfunction may interfere with normal progression of the body during walking and may therefore be a contributing factor to falling in older people.8 The first literature reference to the potential link between foot problems and falls, a paper published by De Largy9 in 1958, suggested that structural foot disorders may lead to inactivity and subsequent lower extremity muscle weakness, thereby increasing the risk of falls. In 1966, Helfand suggested a more direct link, arguing that foot disorders impair balance by modifying the base of support during standing and walking.10 In the past decade, a growing body of evidence has emerged to support these early observations. In addition to foot pain, structural factors such as hallux valgus, lesser-toe deformity, limited ankle joint range of motion, and reduced strength of foot and ankle muscles have been shown to impair performance in tests of walking speed, balance, and functional tasks, such as rising from a chair.11-13 Two prospective studies have confirmed that many of these characteristics are also independently associated with falls after established risk factors are considered. Menz et al14 prospectively followed 176 retirement village residents for 12 months to track the incidence of falls and found that, compared with those who did not fall, fallers were more likely to have foot pain and exhibit decreased ankle flexibility, more severe hallux valgus deformity, decreased plantar tactile sensitivity, and decreased toe plantar flexor strength. After adjusting for physiological falls risk and age, decreased toe plantar flexor strength and disabling foot pain remained significantly and independently associated with falls. More recently, a 12-month prospective study of 312 com­munity-dwelling older people by Mickle et al15 concluded that, compared with nonfallers, fallers demonstrated significantly less plantar flexion strength of the hallux and lesser toes and were more likely to have hallux valgus and lesser-toe deformity. Footwear, balance and falls By modifying the interface between the body and the environment during weightbearing, footwear has the potential to influence postural stability, either beneficially or detrimentally. Several studies have reported that many older people wear suboptimal footwear that could potentially increase the risk of falling. Barbieri16 conducted interviews with older people who had fallen while hospitalized, and found that poorly fitting shoes played a role in 51% of cases. Similarly, Finlay17 evaluated footwear in 274 patients admitted to a geriatric outpatient unit, and reported that only 53% were wearing adequate footwear. Finally, Hourihan et al18 reported that 33% of 147 subjects hospitalized for fall-related hip fracture were wearing slippers when they fell. Laboratory-based biomechanical studies have since confirmed that that high heels, narrow heels, and excessively thick and soft soles are detrimental to balance in all adults, while shoes with a low, broad heel and thin, firm midsoles are beneficial.19 However, extrapolating the laboratory findings to falls studies is difficult due to the wide range of other risk factors that need to be considered and the range of different shoes and walking surfaces encountered during normal daily activities. Although prospective studies have shown that shoes with high, narrow heels increase the risk of falls,20 there is also evidence that the role of footwear varies depending on whether the fall takes place outdoors or inside the home, with the risk of indoor falls being increased when older people are barefoot or wearing socks compared with wearing shoes.21,22 Nevertheless, despite the inherent difficulties in identifying the role of footwear in falls, general recommendations regarding footwear have been developed for older people at risk of falling (see Figure 1). Falls prevention interventions Over the past three decades, there has been a sustained research effort to evaluate the effectiveness of a wide range of interventions to prevent falls in older people, resulting in hundreds of trials. This vast body of research has been collated recently into a systematic review published by the Cochrane Collaboration,23 and this provides the best available evidence of what works for falls prevention. For older people living in the community, this review of 111 trials indicates that exercise (including multiple-component group exercise, Tai Chi, and individually prescribed multiple-component home-based exercise), gradual withdrawal of psychoactive medication, the prescription of vitamin D (in people with low vitamin D levels), prescription modification by primary care physicians, the use of pacemakers (in people with carotid sinus hypersensitivity), and first eye cataract surgery are effective for reducing the incidence of falls. The review found that home safety modification was not effective for reducing falls overall, but was effective in people with severe visual impairment and older people at high risk of falling. Foot specialists and falls prevention In response to the emerging evidence that foot problems and inappropriate footwear increase the risk of falls, two recent falls prevention guidelines recommend that older people at risk of falling should have their feet and footwear assessed, and that appropriate treatment should be provided as part of a multifactorial intervention strategy.24,25 Furthermore, several multidisciplinary “falls clinics” have been established in the US, the UK, and Australia that employ podiatrists alongside physical therapists, geriatricians, and occupational therapists.26 However, there is very little guidance in the literature on what type of interventions should be used by lower extremity practitioners to prevent falls. Furthermore, a recent evaluation of podiatry involvement in falls prevention clinics in Australia revealed a high level of variability of podiatry service provision relative to eligibility criteria, assessments undertaken, and interventions provided.26 Based on these observations, it would appear that despite significant potential, lower extremity healthcare currently has a limited and poorly defined role in falls prevention, largely because of a lack of evidence from randomized trials to guide treatment. A multifaceted podiatry intervention To address this substantial gap in the literature, our research group recently conducted, to our knowledge, the first randomized controlled trial of a podiatry intervention specifically designed to improve balance and prevent falls.27 In this study, 305 community dwelling older men and women with disabling foot pain and an increased risk of falling were allocated to either a routine podiatry care control group or a multifaceted podiatry intervention, and were tracked for falls over a 12-month period. The routine podiatry care group received ongoing maintenance treatment only, which typically involved nail care and scalpel debridement of hyperkeratotic lesions (corns and calluses). The multifaceted podiatry intervention group also received routine care in addition to prefabricated foot orthoses (Figure 2), advice on footwear, a cost subsidy to assist in the purchase of new footwear if current footwear was deemed inappropriate, a home-based program of foot and ankle exercises (Table 1), and a falls prevention education booklet. At the completion of the study, researchers had documented 264 falls. Participants in the intervention group experienced 36% fewer falls than participants in the control group. In addition, the intervention group demonstrated significant improvements relative to the control group with regard to strength (ankle eversion), range of motion (ankle dorsiflexion and inversion/eversion), and balance (postural sway on the floor when barefoot and maximum balance range wearing shoes). Adherence to the interventions was good, with 52% of the participants completing 75% or more of the requested three exercise sessions weekly, and 55% of those issued orthoses reporting that they wore them most of the time.28 Given that the interventions are inexpensive and relatively simple to implement, we believe that program could be incorporated into routine podiatry practice or multidisciplinary falls prevention clinics with minimal training. Future directions The findings of our trial suggest that podiatry has an important role to play in preventing falls in older people living in the community. However, whether the same intervention would be effective in residential aged-care settings or in older people without foot pain requires further investigation. Given that older people in residential care are generally older, more frail, and more likely to have cognitive impairment than those living in the community, the intervention may need to be modified to address the needs of this population. Furthermore, the intervention did not target all relevant foot and ankle risk factors for falls. Both hallux valgus and deformity of the lesser toes have been shown to be risk factors for falls, but these conditions generally require surgical treatment. It is likely that surgical treatment of toe deformities is beneficial for balance, but this has yet to be formally evaluated. Finally, we used only a simple prefabricated orthosis in our intervention; future investigations could evaluate the effectiveness of other types of orthoses and braces in improving balance and preventing falls. Conclusion Falls in older people are common, disabling, and costly to the healthcare system. Foot disorders and inappropriate footwear increase the risk of falling. Recent research indicates that a multifaceted podiatry intervention improves foot and ankle strength, range of motion, and balance and reduces the rate of falls by 36%. These findings make a strong case for lower extremity healthcare to play an important role in the multidisciplinary effort to prevent falls in the older population. Hylton B. Menz, PhD, is professor and deputy director of the Musculoskeletal Research Centre at La Trobe University in Melbourne, Australia. Martin J Spink, BPod(Hons), is a podiatrist and PhD candidate in the Department of Podiatry and Musculoskeletal Research Centre at La Trobe University. Disclosure: The trial reported in this article was funded by the National Health and Medical Research Council of Australia and the La Trobe University Central Large Grants Scheme. The foot orthoses were provided by Foot Science International. Professor Menz is funded by a National Health and Medical Research Council of Australia Career Development Award. Neither of the authors has a competing interest to declare. By Hylton B. Menz, PhD, and Martin J. Spink, BPod(Hons)

Heel pain revisited: New guidelines emphasize evidence

The American College of Foot and Ankle Surgeons’ revised guidelines for heel pain treatment reflect lower extremity healthcare’s increasing focus on evidence-based medicine, including hundreds of references as well as helpful diagrams. But evidence has its limitations, and clinical experience is still essential to the therapeutic process.

New practice guidelines for the diagnosis and treatment of heel pain, published on April 30 by the American College of Foot and Ankle Surgeons (ACFAS), continued the trend of basing treatment recommendations on evidence-based medicine.1 But the guidelines also provoked controversy among those most likely to rely on them for clinical decision making.

Heel pain—most commonly plantar fasciitis—is a serious matter for podiatrists, physical therapists, and other lower extremity clinicians. Roughly two million Americans are affected by it each year, and 10% of people experience chronic heel pain at some point in their lives.2

Despite the condition’s prevalence, practitioners disagree about the best treatments for it. Some of this has to do with scope of practice; physical therapists can’t give cortisone injections or perform surgery, of course, and podiatrists are usually less familiar with physical therapy approaches than with the techniques in which they’ve been trained. Some clinicians dismiss the relevance of orthoses, while others consider them the most crucial aspect of treatment. Certain practitioners feel that surgery is inappropriate for fasciitis, while others rely on it to an extent that their colleagues sometimes consider troubling.

Of course, the whole point of guidelines is to delineate the evidence for different approaches and help all practitioners make better decisions. And although there is significant confluence of ideas about best practices, the differences can be telling. The American Physical Therapy Association (APTA) published its own set of heel pain guidelines in 2008 and provided significant evidence for its recommendations.3 And although the APTA recommendations agree in many respects with the ACFAS guidelines, the two documents also diverge in important ways.

Both organizations rank evidence and make recommendations based on the same template, though they differ in the details. Evidence is graded from Level I (the highest, based on randomized controlled trials) to Level IV or V (expert opinion). Grades of recommendation range from grade A (strong evidence, based on Level I or II studies) to grade F (in the case of the APTA guidelines) or grade I (in the ACFAS guidelines, “I” signifies “insufficient evidence to make a recommendation”).

The Word from ACFAS

The new ACFAS guidelines, which evolved from a previous version in 2001,4 classify heel pain in several categories and provide both text and graphic pathways for diagnosing, evaluating, and treating it. The clinician’s first step is to determine the cause of the problem, whether it be neurologic, arthritic, traumatic, or mechanical. This last etiology, which typically presents as plantar heel pain, is the most common.

“What’s really new in these guidelines is they are not just opinion-based; we’ve tried to look at evidence-based medicine and give treatment recommendations based on that,” said James Thomas, DPM, FACFAS, the lead author of the ACFAS guidelines.

Thomas, an associate professor in the department of orthopedics at West Virginia University in Morgantown, noted other improvements over the previous version.

“Newer technology and treatments are available now, such as radiofrequency coblation of the plantar fascia, though at this point it rates only a ‘C’ because it’s so new we don’t have the numbers to support it,” he said. “We will probably see that [literature] grow over the next few years.”

The new guidelines also note a shift in terminology.

“While ‘fasciitis’ describes the most common cause of heel pain, MRI studies are showing us that it is not just a matter of inflammation,” Thomas said. “There are degenerative changes in the fascia which are better described as ‘fasciosis.’ Practitioners recognize this and are starting to use the new term.”

Thomas also pointed out the document’s flowcharts, which provide a succinct visual presentation of the decision trees in the text. In Pathway 2, “Plantar Heel Pain,” for example, clinicians are guided through taking the history (e.g., pain in the morning or after periods of rest); through significant findings (radiographs, pain on palpation, obesity, pronated foot architecture, and the like); through initial treatment options (e.g. stretching, over the counter insoles, cortisone injection, activity limitation, padding, and strapping); and finally to second and third-tier treatments that include night splints, prescription orthoses, repeated injections, and surgery.

Controversy

Some of these recommendations have stirred the pot of controversy, however. For example, corticosteroid injections are given an evidence grade of B in the guidelines’ text and listed as an initial treatment option; by contrast, physical therapy is not listed in any of the protocol’s three tiers (physical therapy received a grade of “I”—insufficient evidence to recommend—from ACFAS).

“I am strongly against cortisone shots as a first intervention,” said Michael Gross, PT, PhD, a professor of physical therapy at the University of North Carolina at Chapel Hill. “They don’t address a single issue that gave the person the problem. Fasciitis is caused by tensile stress from the foot undergoing three-point bending, exacerbated by factors such as weight gain or increases in activity. An injection compromises tissue that is already weak, and it reduces pain that is the only thing telling the patient that something’s wrong. As a result, they’re likely to go out and hurt the tissue more, but they won’t know that until the analgesic wears off, at which point they’re in worse condition than they were originally.”

It’s not only physical therapists who object to this treatment approach.

“I would take exception to corticosteroids being in Tier 1, for a first visit,” said James Clough, DPM, who practices in Great Falls, MT. “There are people who come in with such severe pain that they can’t walk, and maybe there I would occasionally give an injection. But 95% of patients never need that. You’re running the risk of injuring Baxter’s nerve and creating a neuritis, and corticosteroids delay the healing process. Also, some studies have suggested the method of injection is more important than what is actually injected.”

Thomas acknowledged that clinical judgment should be a key factor in such decisions.

“With clinical practice guidelines you have to be inclusive and consider all the different types of presentation you may see,” he responded. “The panel agreed that corticosteroid injections have to be used judiciously, and by no means do we use them now as we did ten years ago, when patients would get a series of three weekly injections. By the same token, we don’t have evidence-based medicine that says, ‘What is the proper time for that?’ An injection in the first appointment would be for the patient who has had problems for a long time and is acutely symptomatic.”


Reprinted with permission from Thomas JL, Christensen JC, Kravitz SR, et al. The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010. J Foot Ankle Surg 2010;49(3 Suppl):S2.

Although Thomas emphasized the importance of examining the guidelines’ text rather than going just by the flowcharts, in fact the text provides no further clarification of the authors’ intent in this matter. It simply reads, “Initial treatment options may include…a corticosteroid injection localized to the area of maximum tenderness.” The guidelines from nine years ago read, “Initial treatment options may include…corticosteroid injections for appropriate patients.”4 It’s difficult to discern the change in approach.

Some research supports concern. For example, a 2005 paper in the Clinical Journal of Sports Medicine found that “existing medical literature does not provide precise estimates for complication rates….Tendon and fascial ruptures are often reported complications of injected corticosteroids.”5

Necessary Surgery?

Clough also expressed concern that the guidelines did not clarify which aspects of orthotic intervention were most likely to affect fasciitis.

“Fasciitis is primarily a mechanical malfunction of the foot, and the orthotic, along with stretching and gait training, is very important in establishing normal function,” he said. “But the ACFAS guidelines don’t expound on what an orthotic approach should be. Almost 100% of my plantar fasciitis patients are not walking correctly, and a lot of that has to do with dysfunction of the first ray. Correcting that with an orthotic modification, then doing the appropriate gait training to get them to use their first ray and engage the windlass mechanism, is a very effective way to treat fasciitis.”

Clough has not had to resort to plantar fascia surgery for fasciitis in his past 15 years of practice, and he is troubled at how often some of his colleagues do.

“I worry that we are going too fast from Tier 1 to Tier 2, then to Tier 3,” he said. “Not all doctors adhere to these tiers. They don’t understand the proper use of orthotics, stretching, and gait training; they view them as just another stepping stone to surgery. This is a mechanically induced problem, and if patients are not responding to mechanical control of the foot, we need to reevaluate and make changes. Watching your patients walk can be very instructive. Perhaps surgery is appropriate for hallux limitus or an extremely unstable flatfoot deformity, but I fail to see the indication for a plantar fasciotomy, no matter how many ways you can think of to do it.”

Thomas agreed that roughly 95% of patients get better without surgery.

“In the algorithms we recommend exhaustive nonoperative care for a minimum of six months,” he said. “Surgery is really the end stage, only if you’ve failed nonoperative approaches. But it is very worthwhile for folks who have gotten to that point and has a high success rate, approaching 90%.”

However, Clough noted a scarcity of studies assessing long-term outcomes following plantar fasciotomy.

“Is there an increase in bunion deformities, in hammer toes, in shin splints? Is there a flattening of the foot?,” he asked. “You look at them after a year and you say, ‘they got better.’ But five years down the line are they still better, or are they coming in with other problems?”

Some research supports Clough’s concerns, including at least one long-term study. In 2009, researchers reviewed 22 years’ worth of studies, then reported in the Journal of the American Podiatric Medical Association that research in cadaver feet suggested that plantar fasciotomy led to loss of integrity of the medial longitudinal arch. They also reviewed in vivo studies, which found satisfactory clinical outcomes but a decrease in medial longitudial arch height and a medial deviation of the center of pressure of the weightbearing foot.6 One long-term study of fasciotomy (4.5- to 15-year follow-up) reported that it was successful (i.e., with good or excellent results) 71% of the time, but that problems included slower recovery and abnormalities of foot function.7

The PT’s Perspective

The authors of the APTA guidelines, not surprisingly, found significant evidence to support the use of physical therapy in treating heel pain and fasciitis (though it should be noted that an MD was among the authors).

Recommendations for the physical exam include palpation, talocural joint dorsiflexion range of motion, the tarsal tunnel syndrome test, the windlass test, and longitudinal arch angle. Interventions include activity limitation, dexamethasone delivered via iontophoresis, manual therapy, stretching of the calf and plantar fascia, night splints, and prefabricated or custom foot orthoses.

“We wanted to review the best current evidence for how one should go about the exam, and also look at interventions that fall within the realm of physical therapy,” said Thomas McPoil, PT, PhD, lead author of the guidelines. McPoil, who is the regents professor of physical therapy and co-director of the Laboratory for Foot and Ankle Research at Northern Arizona University in Flagstaff, added that the authors had hoped to include exercise but ultimately opted not to.

“Most physical therapists feel that exercise is important, for both the muscles of the lower leg and the intrinsic muscles of the foot, but we didn’t have the evidence to substantiate including that,” he said.

A recent randomized clinical trial further bolstered the efficacy of manual therapy, however;2 and Michael Gross explained why stretching the calf actually works.

“When you get a lot of tension in the Achilles, it grabs onto the calcaneus and pulls it slightly posterior, which stretches the plantar fascia,” he said. “And if you have tightness in the calf muscles, it will restrict the motion of the ankle joint and drive it to the other joints of the foot. That, in turn, can cause the arch to collapse and put even more stress on the plantar fascia.”

“What is preventing our patients from doing what they want to do is edema, inflammation of periarticular tissues, muscle weakness, and pain,” McPoil added. “In physical therapy, we have to look more at impairment, functional limitation, and disability rather than trying to come up with a specific diagnosis.”

McPoil’s colleague and coauthor, Mark Cornwall, PT, PhD, CPed, agreed. “Plantar fasciitis is a medical diagnosis, not a physical therapy diagnosis,” Cornwall said. “The physical therapist would say, ‘I know you have fasciitis, but what can you do? What can’t you do? Why can’t you do it?’”

According to McPoil, the feedback from therapists has been positive.

“It’s having an impact,” he said. “Physical therapists like the guidelines because it provides a consensus of the available literature. They can say, here is what we’re doing, and here’s the evidence to support that.”

New studies make it important to update the guidelines every four or five years if possible, McPoil said; the 2008 guidelines are the first set issued by the APTA. He is also more struck by the similarities between the various guidelines than by their differences.

“If you allow for the differences in scope of practice, the new guidelines from ACFAS are very similar to what we published,” he said. “I was glad to see that, because I thought, good—we are pretty much right on.”

Cary Groner is a freelance writer based in the San Francisco Bay area.

References

1. Thomas JL, Christensen JC, Kravitz SR, et al. The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010. J Foot Ankle Surg 2010;49(3 Suppl):S1-19.

2. Cleland JA, Abbott JH, Kidd MO, et al. Manual physical therapy and exercise versus electrophysical agents and exercise in the management of plantar heel pain: a multicenter randomized clinical trial. J Orthop Sports Phys Ther 2009;39(8):573–585.

3. McPoil TG, Martin RL, Cornwall MW, et al. Heel pain—plantar fasciitis: clinical practice guidelines. J Orthop Sports Phys Ther 2008;4(38):A1–18.

4. Thomas JL, Christensen JC, Kravitz SR, et al.The diagnosis and treatment of heel pain. J Foot & Ankle Surg 2001;40(5):329–340.

5. Nichols A. Complications associated with the use of corticosteroids in the treatment of athletic injuries. Clin J Sport Med 2005;15(5):370–375.

6. Tweed JL, Barnes MR, Allen MJ, Campbell JA. Biomechanical consequences of total plantar fasciotomy: a review of the literature. J Am Podiatr Med Assoc 2009;99(5):422–430.

7. Daly P, Kitaoka H, Chao E. Plantar fasciotomy for intractable plantar fasciitis: clinical results and biomechanical evaluation. Foot Ankle 1992;13(4):188–195.

Beyond Bunionectomy: The Role of Physical Therapy

More and more surgeons are embracing the idea that physical therapy after bunion surgery can improve range of motion and other functional outcomes. But some practitioners still aren’t sure it’s right for everyone.

Most surgeons will tell you outcomes of hallux valgus surgery are very good, often quoting a 90% to 100% percent success rate. A survey-based study published in the December 2001 issue of Foot and Ankle International is typically cited as evidence.
But consensus is harder to come by in determining to what degree post-operative physical therapy contributes to functional outcomes. Some doctors send patients home with a self-administered exercise and self-massage routine and nothing more. Others prescribe an extensive, twice-weekly supervised physical therapy protocol that lasts from four to eight weeks on top of home-based exercises. To complicate matters, patients start PT at various times after surgery, depending on the rate of healing and the type of procedure.

Not all practitioners are ready to accept the idea that physical therapy, and not just surgical technique, can have a substantial impact on the success of hallux valgus procedures.

“Some physicians may think if they send a patient for physical therapy after surgery, it reflects poorly on their surgical procedure,” said Juan J. Rivera, DPM, a private practice podiatrist with the Ankle + Foot Center of Tampa Bay, who views physical therapy as complementary. “In actuality, you are helping your patient optimize their ultimate results and overall post-surgical experience.”

In the last year, two studies, one published and one presented at the American College of Foot and Ankle Surgeons’ annual meeting, have revived the debate. They suggest that post-operative physical therapy can significantly improve range of motion and weight bearing outcomes.

Enter new evidence
In the September 2009 issue of Physical Therapy, investigators from the Foot and Ankle Center in Vienna, Austria, analyzed 30 patients who underwent surgical correction of mild to moderate hallux valgus deformity, including 20 Austin osteotomies and 10 Scarf osteotomies. Prior to initiating the study, the researchers had observed that despite favorable clinical results, including pain relief, the ability to wear a wider variety of shoes, and the ability to participate in recreational activities, gait patterns did not spontaneously alter after surgery.
“We noticed that patients who underwent hallux valgus surgery didn’t use their great toe for push off, even though the deformity was corrected sufficiently,” said Reinhard Schuh, MD, a first-year resident in the department of orthopaedic surgery at Innsbruck Medical University and lead author of the study.

“To achieve bony union of the osteotomy, we had to avoid loading for four weeks,” Schuh said. “But we instructed patients to perform passive ROM exercises starting two days after surgery.”

At four weeks, patients began a comprehensive, 45-minute rehabilitation program once a week for four to six weeks. The standard protocol included elevation of the leg, lymphatic drainage, and activation of the muscle pump, and cryotherapy in the first session to reduce swelling. Other modalities, such as scar tissue massage, mobilization, manual therapy, soft tissue techniques, proprioceptive training for the lower leg, strengthening exercises, and gait training, were added progressively over the next four weeks.

Although the researchers did not use a control group, they found that at six months after surgery patients experienced significant improvements in first metatarsophalangeal joint range of motion and function. Weight bearing at the great toe and first metatarsal head, specifically related to maximum force levels and force-time integral, also improved significantly. Participants’ mean functional score on the American Orthopaedic Foot & Ankle Society forefoot scale improved from 60.7 out of 100 before surgery to 94.5 out of 100 at six months. By comparison, previous plantar pressure studies have documented a lack of weight bearing in the medial forefoot and first ray after hallux valgus surgery not followed by physical therapy.

Believe it or not
In the second study, which has been submitted for publication, researchers studied 55 patients who had undergone Scarf procedures at the Weil Foot and Ankle Institute in Des Plaines, IL. The large, 16-office practice in the Chicago area handles 500 bunion surgeries a year. According to Lowell Weil, Jr., DPM, MBA, senior investigator of the study, surgeons in his practice fall into two camps.

“The advent of screws and proper screw fixation eliminated the need for complete immobilization. Patients are able to return to activities and start physical therapy earlier, which has tremendous benefits. We developed physical therapy protocols for patients undergoing these types of procedures,” he said. “Despite that, some doctors in our practice weren’t prescribing physical therapy; they didn’t believe it made a difference.”

So Weil and a few colleagues set out to investigate. Their nonbelieving colleagues’ patients, who did not receive PT, served as a control group.
They studied 44 patients (65 feet) who underwent Scarf osteotomy procedures between 2006 and 2008, followed by a program of once- or twice-weekly physical therapy sessions. The 30 to 45 minute sessions continued for one to six weeks. Another group of 11 patients (14 feet) received no post-operative therapy.

Follow up occurred between November 2009 and January 2010. The physical therapy group significantly outperformed the control group on the Foot Function Index (FFI) and the ACFAS Universal Foot and Ankle Scoring System (see table).

Opinions about post-operative physical therapy in hallux valgus cases are as varied as surgical procedures. For PT proponents, like Michael Loshigian, DPM, a podiatric foot and ankle surgeon in private practice with the Metropolitan Foot Group in New York City, the benefits are indisputable.

“My own experience is fairly clear. Patients who have some sort of formal or informal physical therapy after hallux valgus surgery have better overall results and the progression of healing is more consistent and reliable,” Loshigian said.

Getting a head start
Loshigian, who performs these surgeries at least weekly, says the physical therapy protocol often begins shortly after surgery.

“In a joint fusion case, there should not be any attempt to move the joint, obviously. But in the majority of cases, we’re reorienting the MTP joint, restoring normal range of motion and alignment and function of that joint. In those cases, I have patients start their own range of motion exercises the day after surgery,” he said.

A primary objective is to prevent the soft tissue contracture and joint stiffening that can result from cutting and repositioning of bone.

“It’s easier to maintain good range of motion from the beginning than to attempt to restore it after it has been lost,” he said. “If we give those soft tissues an opportunity to tighten up, movement becomes difficult.”

Loshigian usually starts patients on formal twice-weekly physical therapy two to three weeks after surgery, once he removes the stitches. For most patients, the complete course of therapy lasts six to eight weeks.

At three or four weeks after surgery, patients can start weight bearing without the protection of a post-op shoe; at that point, Loshigian recommends strengthening the muscles and tendons that control the great toe along with continuing ROM exercises and techniques to reduce swelling. The final stage involves strengthening the lower legs and improving patterns of gait, agility, and balance.

Contributing factors
Rivera says many factors influence his decisions about the timing and course of therapy.

“Surgical procedures —MTP joint fusion, arthroplasty, chevron, opening base wedge, closing base wedge, first metatarsal-cuneiform joint fusion—all have various timeframes to stay offloaded, which can lead to disuse atrophy,” he said. “Many patients have such low pain tolerance, they need gait retraining to overcome post-operative pain and swelling and regain joint flexibility. Older patients need more help with loss of balance and proprioception.”

Another issue is the amount of time a patient with an operable deformity has postponed surgery; long delays can lead to compensatory gait patterns that are difficult to unlearn without additional physical therapy.

“A common example for me is the patient who undergoes hallux limitus correction surgery,” he said. “The biomechanical compensation for a painful arthritic great toe joint is to ambulate with the foot in an inverted position. Post surgery, the patient continues to ambulate in that position out of habit, delaying the healing of the foot.”

Not for everyone
Donald R. Bohay, MD, a professor of orthopedic surgery at Michigan State University who is also in private practice at Orthopaedic Associates of Michigan in Grand Rapids, views hallux valgus surgery and its aftermath from a slightly different perspective.

“I’m a believer in physical therapy that can help your patient get better faster,” Bohay said. “But I don’t think we know for sure that the patient who gets physical therapy versus the patient who doesn’t is necessarily better after a year.”

Bohay, who favors tarsometatarsal arthrodesis with a modified McBride procedure, says that his patients wear a post-op splint for two weeks. They then wear a short leg cast with heel weight bearing for six weeks, followed by a weight bearing boot for two to four weeks.

Most of the surgeons interviewed for this article would prescribe supervised physical therapy for a procedure requiring so much healing time and immobilization. However, Bohay instructs most of his patients to do home-based range-of-motion exercises and soft self-massage with vitamin E oil to desensitize the foot. When he considers it necessary, he does prescribe formal physical therapy.

“You get a sense that some patients aren’t going to do the program. Those patients do well by going to PT,” he said. “Then there are patients who have a lot more done, who are very swollen, very stiff. For them, physical therapy helps reestablish control, range of motion, and desensitization.”

The therapist’s perspective
Despite the general consensus among surgeons that PT is a useful tool after bunion correction, at least in certain cases, physical therapists express frustration that surgeons don’t take full advantage of their expertise.

“It’s a misconception that physical therapy is cookie cutter,” said Clarke Brown, PT, DPT, OCS, ATC, who is in private practice in Rochester, NY, and president of the American Physical Therapy Association’s foot and ankle special interest group. “We study these procedures. We develop separate protocols for them, and adapt them for each patient.”

Physical therapy following bunion surgery, Brown said, should extend well above the ankle.

“The most challenging thing about feet is that they radically change what happens all the way up the kinetic chain. The good practitioner looks at the whole system, all the way up to the knee, the hip, and the back. We look at the range of motion in all the joints and the strength of the entire leg,” he said. “Most chronic bunion patients can’t effectively lift the bunion leg in side-lying. The hip muscles atrophy.”

Brown notes that the foot and ankle subspecialty in physical therapy is just developing. Even though it’s not something surgeons have clamored for, those who witness the benefits of specialized therapy are sold, he said.

“We found that the faster we started to move the patient’s foot and toes, the more quickly the swelling went down,” he said. “One podiatrist used to take his sutures out after two weeks. But when we moved aggressively, the incisions would sometimes open up. Now he takes the stitches out at 21 days, saying ‘I’ll leave these in longer so you guys can do more.’ The more we communicate with each other, the better.”

A proactive approach
Stephen Paulseth, PT, DPT, SCS, ATC, who runs a private practice in West Los Angeles, often sees patients who have complications or problems that he believes could have been avoided by introducing physical therapy earlier.

“If doctors would send their patients for prehab, they would be doing so much better,” said Paulseth, who preceded Brown as president of the foot and ankle SIG. “I sometimes see patients six weeks in who haven’t really done much. They’ve been told to ice, strengthen, and do some gentle motion, but they just can’t tolerate it.”

He believes proper therapy and patient training can reduce the progression of bunion surgeries.

“Calf length is number one. Inadequate dorsiflexion of the ankle leads to all kinds of distal forefoot issues, including hallux valgus. Patients should begin calf stretching as soon as possible, and they have to continue calf stretching after they’ve healed,” Paulseth said.

Surgeons contend that most patients who undergo hallux valgus surgeries are happy with the results.

“From my experience, the vast majority of patients who have gone through this procedure are very satisfied with the results and in retrospect would choose to undergo the same procedure again,” Loshigian said. “As for their initial post-op experience, the feedback I get from most patients is that it is less stressful and painful than they anticipated.”

In Brown’s estimation, that already good patient experience could be even better if the relationship between patient, doctor, and physical therapist were more collaborative.

“When patients do better quicker, the word of mouth is more positive for the doctor,” he said. “Everybody wins.”

August 2010 by Linda Weber