Lower Extremity Review

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COVER

34 HOW MOUNTAIN BIKING IS RESHAPING THE LANDSCAPE OF CYCLING INJURY

Differences in equipment, terrain, riding style, and other risk factors mean different types and prevalence of injuries when riding a mountain bike, compared to a road bike.

By Michael Reeder, DO, and Brent Alumbaugh, MS

GUEST EDITORIAL

9 WE ARE THE HEART OF NATIONAL BIOMECHANICS DAY

The International and American Societies of Biomechanics were founded in 1973 and 1977, respectively. Coincident with the expansion of Biomechanics during the following decades, fitness and health …

By Paul DeVita, PhD

CALL FOR MANUSCRIPTS

10 HERE’S HOW TO SUBMIT YOUR MANUSCRIPT

FEATURES

19 BONE STIMULATION REPRESENTS NEW FRONTIER FOR OPTIMIZING PATIENT OUTCOMES

Limited research into electromagnetic and ultrasound bone stimulation devices complicates efforts to determine efficacy. For the majority of people, lower-limb fractures and fractures in other parts of the body heal well and reliably. However, some people experience complications that…

By Nicole Wetsman

27 MITIGATING THE OPIOID CRISIS WITH PAIN MANAGEMENT REGIMENS IN A MULTIMODAL APPROACH

For help limiting the number of opioid tablets you prescribe—and to still treat postop pain successfully—turn to practice guidelines, evidence from the literature about local and …

By ROBERT G. SMITH, DPM, MSC, RPH, CPED, CPRS

43 TAPE USE TO PREVENT BLISTERS: DOES IT REALLY DO WHAT WE THINK IT DOES?

Taping is a mainstay of preventive foot blister management in athletes and active people. Its use is based on the premise that rubbing causes blisters, and that tape protects the skin from this rubbing and/or provides thermal insulation from the heat generated by rubbing. This commentary highlights…

By Rebecca Rushton, BSc(Pod)

51 THE THERAPEUTIC POWER OF ELASTIC BANDS

Here’s why resistance therapy with these low-tech tools is gaining prominence—for youth soccer players, geriatric patients, and everyone in between. Elastic resistance bands are increasingly popular in physical therapy, as the modality is being used…

By Keith Loria

FROM THE LITERATURE13 • Benefits of a Foot Orthosis During

a Step-descent Task on Kinematics, Kinetics, and Activation of Muscle

• Concurrent Changes in Eccentric Hamstring Strength and Knee-joint Kinematics

• Delayed Charcot Diagnosis Increases Costs, Hospital Days, Amputations

• AFOs for Stroke: Early Use Does Not Limit Long-Term Benefit

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Our Mission:Lower Extremity Review informs healthcare practitioners on current developments in the diagnosis, treatment, and prevention of lower extremity injuries. LER encourages a collaborative multidisciplinary clinical approach with an emphasis on functional outcomes and evidence-based medicine.

Opinions expressed are those of the authors and do not necessarily represent those of Lower Extremity Review, LLC.

LER is published monthly, except for a combined November/December issue and an additional special issue in December, by Lower Extremity Review, LLC. Copyright ©2019 Lower Extremity Review, LLC. All rights reserved. The publication may not be reproduced in any fashion, including electronically, in part or whole, without written consent. LER is a registered trademark of Lower Extremity Review.

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The International and American Societies of

Biomechanics were founded in 1973 and 1977,

respectively. Coincident with the expansion of

Biomechanics during the following decades, fit-

ness and health have moved out from under the

realm of medicine and are rapidly overtaking

the realm of the personal—the personal lifestyle

to be more exact (think yoga, yogurt, and yoga

pants). It is no coincidence that this trend has

mirrored the increasing role of Biomechanics in

our everyday lives as the evolving science has

allowed us to see that sitting is the new smoking

and that movement is our best option to main-

tain or get back to health.

And Biomechanics, the study of human

movement, of how bones, tendons, ligaments,

even cell components all work together, will

inform every step of that journey. The world

of Biomechanics today encompasses a host of

activities that are necessary to keep life moving

smoothly, but also to improve sport perfor-

mance, enhance rehabilitation, correct gait,

stabilize balance… all the pieces and parts of

maintaining a healthy active lifestyle, no matter

what age.

The good news is, biomechanists across the

globe are using today’s latest technology to help

improve patient outcomes and keep athletes

safe. But imagine if more young people were

aware of the field before they got to college?

How much faster would the knowledge base

spread if middle- and high-school students were

made aware of what Biomechanics has to offer?

That was the stimulus behind the first

National Biomechanics Day (NBD) in 2016

(aka, “The Early Year”). It began as a US-based

initiative to expand the impact of Biomechanics

on peoples’ lives. By 2017 (aka, “The Expansion

Year,”), NBD had grown into an international

celebration of Biomechanics. As of this date, 22

countries were expected to participate in NBD

2019. We think that, by introducing Biomechan-

ics to high school students, a population largely

under-exposed to Biomechanics science, we will

be seeding larger numbers of future biome-

chanists and a larger biomechanical impact.

Indeed, because Biomechanics education exists

nearly entirely at universities, any exposure to

younger people would bring new people to the

field. Although it is too early to know if we will

be successful in the long term, we certainly have

created a foundation for success. From 2016 to

2018, NBD excited more than 20,000 young

people and 800 teachers about Biomechanics

science, application, and careers. “That’s a lotta

kids,” as I like to say.

Still, why has NBD become such an as-

tounding success so quickly? Is there some facet

about NBD that entices biomechanists to not

only join the initiative but to thrive in it and to

enjoy it so fully? Certainly, many Biomechanics

labs around the world conduct outreach services

to show children and community leaders their

science. Actually, many university departments

beyond those housing Biomechanics programs

conduct social outreach to the benefit of both

the department and community. The partici-

pating departments benefit by increasing the

popularity of their fields and their particular

programs, and families benefit by learning

about potential career opportunities for their

children. These outreach events are wonderful

for all involved. Yet, these demonstrations and

events lack one element that is central to the

NBD mission. NBD celebrates the broad field

of Biomechanics beyond any individual lab,

program, or university. National Biomechanics

Day is enjoyed around the world because it is

a unifying platform upon which we coalesce

into one grand celebration of our science. NBD

enables biomechanists to unite into a single

synchronized, worldwide Biomechanics party.

It is not any individual person, it is all of us…

together: we all do it together and together

we are the Heart of NBD. The outcome of our

efforts is described by a single phrase, “Through

NBD, there are more smiles on more faces, in

more Biomechanics labs than on any other day.”

Pretty cool.

Our expansion to more biomechanists and

more high schoolers is paralleled by our expan-

sion to more sponsors and supporters. We have

33 sponsors who provide financial assistance

and promotional advertisements. For example,

LER has published two articles on NBD and

numerous photographs showing NBD events

around the world. Our sponsors include many

Biomechanics societies, instrument manufactur-

ers, and commercial entities using Biomechanics

to create their products and services. There is

also an important idea we emphasize about our

sponsors: They are not simply NBD sponsors,

they sponsor nearly all events and activities that

are Biomechanics. They sponsor Biomechanics

societies, Biomechanics conferences, Biome-

chanics outreach events, and, not to be neglect-

ed, they hold their own Biomechanics events.

They are us. Each individual company cannot

sponsor everything Biomechanics, but many of

them sponsor multiple Biomechanics entities.

NBD is extremely grateful to all its sponsors and

to all sponsors of Biomechanics. Without them,

we could not conduct the science of Biomechan-


GUEST EditorialWe Are The Heart of National Biomechanics Day

Continued on page 10

By Paul DeVita, PhD

http://nationalbiomechanicsday.asbweb.org/sponsors/

ics as it is conducted now.

NBD and all NBDers are excited about

the future of Biomechanics. We have from the

start promoted the idea that Biomechanics

will be the breakthrough science of the 21st

century. We explained this position last year,1

but to briefly restate: First, Biomechanics has

great, yet untapped value for society; it can help

many people in many ways. While we know

this, it has yet to make a major, commercial

breakthrough that is fully within the public

consciousness. Second, we also propose that

while Biomechanics is largely unknown outside

of Biomechanics, it is on the verge of great

popularity. Many people know vaguely about 3D

motion capture as the basis for video games and

movies. Biomechanics is seen throughout social

media and television, including regular shows

but also commercials. It is seen in publications

like LER, which increase the awareness of our

science. People are also becoming aware of its

application for improving sport performance.

Still, it remains more unknown than known.

Because Biomechanics will have a major impact

on peoples’ lives and because it is on the verge

of society’s awareness, we propose, through our

efforts, that Biomechanics will be the break-

through science of this century.

We encourage all biomechanists in all Bio-

mechanics fields to join National Biomechanics

Day and help us expand the many beneficial

outcomes of the practice of Biomechanics.

Paul DeVita is one of two Leroy T. Walker

Distinguished Professors or Kinesiology and

Director, Biomechanics Laboratory, Department

of Kinesiology, East Carolina University, Green-

ville, North Carolina. To learn more about NBD,

contact him at [email protected].

Reference

1. DeVita P. Why National Biomechanics Day?

J. Biomech. 2018;71:1-3.

Continued from page 9

CALL FOR MANUSCRIPTSThe Editors of Lower Extremity Review

want to highlight the work of thoughtful,

innovative practitioners who have solved

their patients’ vexing problems. We are

seeking reports of your most intriguing

cases in the following areas:

• Gait analysis

• Drop Foot

• Ankle-foot orthotics

Before you begin to write, query the

Editors about your proposed topic (email is

fine). Doing so ensures that your manu-

script will conform to the mission of the

publication and that the topic does not

duplicate an article already accepted for

publication. Furthermore, a query often

allows the Editors and the publication’s

advisors to make recommendations for

improving the utility of the manuscript for

readers.

Case reports should be no more than 1500 words (not including references, legends, and author biographies). Photos (≤4) are encouraged. Case reports can in-clude a literature review as is appropriate for the topic. (Please note that for HIPPA compliance, photos should be de-identified before sending.)

Manuscripts must be original and not under consideration for publication else-where. Any prior publication of material must be explained in a cover letter.

All authors must be medical professionals in good standing. Students will be consid-ered as first author only when the byline includes a fully licensed professional.

Manuscripts are submitted with the under-standing that they will be reviewed; that revisions of content might be requested; and that the editorial staff will undertake editing, as necessary, aimed at improving

clarity and conciseness and applying con-

formity to style. Authors will have the op-

portunity to review and approve the edited

version of their work before publication.

The Editors reserve the right to reject any

unsolicited or solicited article that does not

meet with editorial approval, including ap-

proval denied following requested revision.

Electronic Submission

Please attach the manuscript as a Mic-

rosoft Word document or plain text file.

Photos, tables, and figures can be embed-

ded in the document, although submission

of individual files is preferred. Figures not

embedded in the main Word document

should be submitted as .jpg files.

Please send queries and submissions to:

[email protected]

We look forward to hearing from you!

Figure 1. NBD 2019 sponsors

10 3.19 lermagazine.com

Benefits of a Foot Orthosis During a Step-descent Task on Kinematics, Kinetics, and Activation of Muscle By Sarah Curran, PhD, FCPodMed

Foot orthoses are considered to work

by controlling internal rotation of

the tibia and eversion of the cal-

caneus, and have been reported to

be effective during weightbearing ac-

tivities such as walking and running.

As a result, they have been shown to

be effective in managing a range of

musculoskeletal conditions—not the

least of which is patellofemoral pain.

Everyday life and activities

place a variety of demands on the

lower extremities; an example is

stair-climbing—in particular, the

stair descent, which can place

increased loading on the patella.

Moreover, the mechanism for

progressing and stepping down a

step uses a toe–toe–heel pattern of

contact, and foot orthoses that incor-

porate forefoot posting can therefore

influence pronation of the foot and

the proximal musculoskeletal chain

of the lower extremities.

This present study set out to

explore the influence of 3 types of

foot orthoses on kinematics, kinet-

ics, and activation of muscle during

a step-down task. Sixteen healthy

volunteers (mean age, 25.7 years)

performed a step-down task from a

height of 20 cm in 3 conditions of

orthosis: a control flat insole, a 5° rearfoot medial wedge, and a 5° rear-

foot and forefoot medial wedge, all while wearing standardized footwear

(Dr Comfort Winner Plus).

The findings showed that both types of wedged foot orthoses

(rearfoot and forefoot) improved kinematics within the foot (metatarsal to

calcaneal rotation), the ankle, and the hip; while knee adduction moment

was increased, the internal rotation moment was reduced, compared to

what was observed with the control insole. Activity of the abductor hallucis

muscle was reduced with the use of the 5° rearfoot medial wedge and a 5°

rearfoot and forefoot medial wedge, compared to the control insole. Only

the 5° rearfoot medial wedge showed a reduction in activity for the tibialis

anterior muscle.

These findings offer further insight into the use of foot orthoses on

musculoskeletal conditions—in particular, patellofemoral pain—through

the role of changing kinematics (internal rotation) and kinetics of the lower

extremities that creates stability. Furthermore, this is the first study to show

the influence of abductor hallucis and tibialis anterior muscles, which had

a reduction in activity with both sets of medial wedged foot orthoses during

the step-down maneuver. This reduction in activity could be due to arch

support and a wedge that acts as a mechanical barrier to minimize foot

pronation; alternatively, it could indicate improved control of foot position

and support from the foot orthosis.

These findings might be of use clinically to patients with patellofem-

oral pain, given the demands placed on the lower limb and knee during

step descent. Although this study explored only the impact of a single step,

further assessment on continuous and cumulative loading of step descent

would provide further insight. From a clinical perspective—particularly

when a patient presents with patellofemoral pain—the clinician should

seek assessment of stair descent in terms of pain and function.

Sarah Curran, PhD, FCPodMed, is Professor of Podiatric Medicine and

Rehabilitation at Cardiff Metropolitan University, Cardiff, Wales.

Source: Bonifácio D, Richards J, Selfe J, Curran S, Trede R. Influence

and benefits of foot orthoses on kinematics, kinetics and muscle activation

during step descent task. Gait Posture. 2018;65:106-111.

Concurrent Changes in Eccentric Hamstring Strength and Knee-joint Kinematics By Matt Greig, MPhil, PhD

Hamstring strain incidence in soccer increases during the latter stages

of match-play, consistent with experimental studies that report reduced

eccentric hamstring strength during soccer-specific fatigue.

The biarticular function of the hamstring is such that fatigue-in-

duced changes in strength are also likely to have an impact on knee-joint

stabilization, with the knee a common site of severe injury in soccer. The

aim of this study was to consider concurrent changes in eccentric ham-

string strength and knee-joint kinematics, with isokinetic testing speed

matched to the kinematic demands of the task. In selecting an appropri-

ate functional task, jump landings and hopping tasks are commonly used

because they replicate the mechanism of knee ligamentous injury.

From the LITERATURE



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Figure 1. Time history of changes in knee varus at touchdown. * Significantly different to

pre-exercise.

2468

1012141618

0 15 30 45 60 75 90 105

Knee

varu

s (º)

Time (min)

Inversion Eversion Neutral

* * *

Figure. Time history of changes in knee varus at touchdown.

* Significantly different to pre-exercise. Used with permission from Elsevier Ltd. All rights reserved.

To investigate the influence of soccer-specific fatigue on concurrent

changes in knee-joint kinematics and hamstring strength, 10 male profes-

sional soccer players completed reactive inversion, eversion, and neutral

hop tasks at 15-minute intervals during a soccer-specific treadmill proto-

col. Knee-joint kinematics in frontal and sagittal planes were calculated

every 15 minutes. In a separate trial, players completed maximal eccentric

knee flexions at 160° s-1 (reflecting average knee angular velocity in the

functional task) at 15-minute intervals, quantifying peak torque.

All trials were characterized by knee flexion and varus at touch-

down. Knee flexion of approximately 30° was maintained throughout the

exercise protocol, but a main effect for task highlighted greater flexion

at touchdown in the inversion trial (P = .01). This task-dependent

observation in the degree of knee flexion at landing most likely indicates

the greater mechanical challenge imposed by this task, with inversion

movements incurring a greater risk of ligamentous injury.

Knee varus at touchdown (Figure) was sensitive to exercise dura-

tion, with approximately 4° greater malalignment elicited over the final

15 minutes of the protocol (P ≤ .05). Although knee flexion at touchdown

serves as a protective mechanism, varus displacement of the knee might

be a risk factor for ligamentous injury. Genu varum in these elite male

players is in marked contrast to the knee valgus commonly observed in

female players, and has been identified as a risk factor for patellofemo-

ral pain syndrome, deterioration of the articular cartilage in the medial

tibiofemoral compartment of the knee, and osteoarthritis.

Peak eccentric hamstring strength was significantly (P = .05)

reduced throughout the second half of the trial, compared to pre-exercise

values. This reduced strength might provide the mechanism for increased

varus displacement because hamstring musculature acts to stabilize the

knee joint during such functional tasks. Conversely, the knee in varus

would increase tension on the biceps femoris, creating an increased risk

of hamstring strain injury with fatigue—a finding that would support

epidemiological observations.

Coincident impairment of eccentric hamstring strength and

increased knee varus at touchdown predisposes the player to injury—

again, supporting epidemiological observations. The association between




strength and joint kinematics implicated in injury risk provides clinical

merit for isokinetic assessments, provided that the isokinetic assessment

has functional relevance to the demands of the sport or the mechanism of

injury (or both). In this study, functional relevance was aligned to speed-

matched analyses of strength and knee-joint motion.

Matt Greig, MPhil, PhD, is Associate Head for Sports Therapy, and

Sports Injuries Research Group Lead at Edge Hill University, Ormskirk,

Lancashire, England. His research focuses on the physical (biomechanical

and physiological) response to soccer-specific activity, with implications for

performance enhancement and injury prevention.

Source: Greig M. Concurrent changes in eccentric hamstring strength and

knee joint kinematics induced by soccer-specific fatigue. Phys Ther Sport.

2019:37:21-26.

Delayed Charcot Diagnosis Increases Costs, Hospital Days, AmputationsBy Jonathan M. Labovitz, DPM, FACFAS, CHCQM

Early recognition and treatment of Charcot neuroarthropathy has been

long considered paramount to optimizing clinical outcomes and deliver-

ing high-quality care. Without this rapid response to control the devastat-

ing effects of Charcot, patients are left with significant deformities;

increased risk of ulcers, infection, and amputations; a reduced quality of

life that often fails to improve; and a higher 5-year mortality rate.

Regrettably, delayed diagnosis occurs frequently due to similar clinical

presentations as many of the other complications of diabetes mellitus.

iStockphoto.com #480156920

Our study looked at public discharge records from acute care hospitals in

California and compared those with a timely diagnosis and those with a

delayed diagnosis of Charcot neuroarthropathy. Our hypothesis was that

a delayed diagnosis of Charcot neuroarthropathy increases cost of care

and healthcare utilization.

We identified 4,363 patients with Charcot neuroarthropathy as one

of the top five discharge diagnoses that were discharged from California

hospitals from 2009-2012. A delayed diagnosis was observed in 13.2% of

the patients. The costs of the acute care stay were 10.8% greater in these

patients and length of stay (LOS) was 0.8 days longer with a delayed

diagnosis, both of which were significantly different from patients with

a diagnosis at the time of admission (P < .05). In addition, there was

a moderate correlation for cost and LOS for both the diagnosis and the

delayed diagnosis groups.

When evaluating potential diagnoses often mistaken for Charcot

neuroarthropathy, only diabetic foot infection resulted in significantly

greater costs despite a significantly higher prevalence of diabetic foot

Data presented as % or mean ± standard deviation. Abbreviations: AMA, against medical advice; LOS, length of stay; SNF, skilled nursing facility.* v<.05 • † p < .01Reprinted with permission from The Journal of Foot and Ankle Surgery, the official journal of the American College of Foot and Ankle Surgeons, published by Elsevier, Inc.

Total acute care cost and usage of healthcare services

Variable Group (%) Cost ($) LOS (days)

Diagnosed Delayed Diagnosis

p Value Diagnosed Delayed Diagnosis p Value Diagnosed Delayed Diagnosis

p Value

Total Disposition 86.3 13.2 $18,347 ± $21,091 $20,334 ± $23,200 .038* 6.6 ± 9.0 7.4 ± 8.8 .042*

Acute care 2.6 2.4 .889 $20,217 ± $27,771 $32,352 ± $25,797 .126 9.5 ± 14.9 10.8 ± 12.9 .757

Discharged to home 48.7 44.4 .06 $15,776 ± $20,548 $16,983 ± $24,355 .39 5.2 ± 8.6 6.2 ± 9.3 .085

Died 0.3 1.2 .011* $30,900 ± $23,731 $47,710 ± $30,503 .184 10.2 ± 8.2 12.4 ± 9.0 .587

Home health service 22.2 23.9 .363 $18,720 ± $18,019 $18,877 ± $15,152 .923 7.6 ± 8.2 7.4 ± 6.4 .785

Left AMA 1.1 1.6 .296 $10,132 ± $7,824 $9,450 ± $10,943 .875 4.6 ± 4.6 4.6 ± 7.1 1

Other hospital care 2.7 3.8 .18 $25,932 ± $29,256 $34,752 ± $28,535 .162 8.4 ± 11.7 12.5 ± 13.3 .148

Residential care/SNF 21.8 22.4 .746 $22,784 ± $21,976 $24,163 ± $14,182 .508 8.0 ± 8.1 8.5 ± 7.3 .509

Change in level of care services needed at discharge versus before admission

More services 42.0 43.5 .527 $15,323 ± $16,941 $17,456 ± $24,826 .085 4.8 ± 6.6 6.1 ± 9.2 .006†

Fewer services 9.3 10.4 .402 $20,616 ± $20,011 $22,075 ± $m21,733 .607 6.6 ± 6.5 7.1 ± 7.0 .586

No change 48.7 46.1 .264 $23,918 ± $36,969 $25,814 ± $19,704 .413 15.4 ± 19.1 14.4 ± 10.5 .403

ulcers, infections, and lower-extremity amputations in the delayed

diagnosis group. A significantly greater number of chronic conditions and

number of procedures performed during the hospital stay also occurred

when there was a delayed diagnosis. Additional procedures strongly

correlated with increased acute care costs, with each supplementary pro-

cedure resulting in additional costs of $4,800 and an increase in LOS by

1.7 days. Potentially most concerning was the 2.8% increase in the total

number of lower-extremity amputations that occurred when there was

a delay in the diagnosis. This resulted in an incremental cost increase

of $7,201 (30.4%) and LOS increased 2.6 days (31.6%) compared to a

timely diagnosis.

Because Charcot neuroarthropathy often poses a diagnostic chal-

lenge due to the clinical presentation similarities with other diabetes-re-

lated complications, a delayed diagnosis often occurs. Despite likely un-

derestimating the total costs to the healthcare system by relying only on

acute care costs, we quantified the costs and resource utilization during

the hospital stay to begin evaluating the consequence of a delayed diag-

nosis in a value-based care system. Over a 4-year period in California, a

delayed diagnosis of Charcot neuroarthropathy resulted in an additional

spending of $1.15 million and 462 additional bed days. As we move to a

value-based system, it is critical we see the impact of delayed diagnosis in

this challenging population has potentially significant negative impact on

cost as well as quality of care.

Source: Labovitz JM, Shapiro JM, Satterfield VK, Smith NT. Excess cost

and healthcare resources associated with delayed diagnosis of Charcot

foot. J Foot Ankle Surg. 2018;57(5):952-956.

AFOs for Stroke: Early Use Does Not Limit Long-Term Benefit


Stroke often impairs walking, particularly by altering foot clearance

during the swing phase. Activity of the tibialis anterior (TA) plays an

important role in foot clearance; clinicians often prescribe an ankle-foot

orthosis (AFO) for post-stroke patients to help with foot clearance. But


LER-Mar2019-half.indd 2 2/27/2019 8:18:14 AM


some commentators worry that providing an AFO too soon after stroke

could in fact impede recovery of foot clearance. To explore this concern,

researchers from the Netherlands looked at early and delayed use of

AFOs in stroke patients to determine whether:

• use of an AFO for 26 weeks affects TA activity

• early or delayed timing of AFO use matters

• AFOs affect TA activity within a single measurement.

This randomized controlled trial analyzed 26 unilateral hemiparetic

patients: 16 assigned to receive the AFO 1 week post-stroke (15 were an-

alyzed) and 17 assigned to receive the AFO 8 weeks post-stroke (11 were

analyzed). In study Weeks 1, 9, 17, and 26, electromyography was used to

measure TA activity.

The researchers found that, compared with walking without an

AFO, use of an AFO significantly reduced TA activity levels during the

swing phase (P = .041). Throughout the 26-week period, they saw no

changes in TA activity without an AFO, neither within groups (P =

.420 [early] and P = 0.282 [delayed]) nor between groups (P = .987).

Furthermore, at the end of 26 weeks, the researcher found no differences

in TA activity between both groups in the swing phase, with (P = .207)

or without an AFO (P = .310).

Use of an AFO for 26 weeks did not affect muscle activity, regard-

less of when the AFO was provided (Week 1 or Week 8). The researchers

did not detect negative effects on activity of the TA with long-term use of

an AFO early after stroke.

To explain their results, the researchers cited studies suggesting that

the possible negative effects of an AFO on muscle activity in a single gait

cycle might be counteracted by the fact that an AFO improves walking in

general. They proposed that an increase in the amount of walking (steps

taken) offsets a decrease in EMG during a single step. They also note that

this work builds on that of others showing:

• positive effects of AFOs on ankle kinematics early after stroke

• no differences in the effects of early or delayed AFO provision on

pelvis, hip, and knee kinematics

• beneficial effects of AFOs on functional levels

• no differences with respect to balance and mobility between early

and delayed provision of AFOs; early provision showed favorable

outcomes in the first 11 to 13 weeks, possibly resulting in earlier

independent and safe walking.

The authors conclude: “For clinical practice, this means that clinicians,

together with the patient, can decide when to start AFO treatment based

on personal priorities and preferences. Early AFO provision is expected to

provide beneficial effects on a functional level in the short-term, without

negatively affecting muscle activity of the TA in the long-term.”

Source: Nikamp C, Buurke J, Schaake L, Van der Palen J, Rietman

J, Hermens H. Effect of long-term use of ankle-foot orthoses on tibialis

anterior muscle electromyography in patients with sub-acute stroke: a

randomized controlled trial. J Rehabil Med. 2019;51(1):11–17.

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“


Limited research into electromagnetic and ultrasound bone stimulation devices complicates efforts to determine efficacy.

By Nicole Wetsman

For the majority of people, lower-limb fractures

and fractures in other parts of the body heal

well and reliably. However, some people expe-

rience complications that may cause significant

harm. Strategies that might help avoid these

complications are appealing to clinicians.

“There’s a lot of interest in trying to find

ways to further optimize patient recovery,” said

Jason Busse, DC, PhD, an associate professor at

McMaster University.

One major complication is nonunion,

which occurs when a broken bone fails to knit

back together. Anywhere from 10% to 20% of

tibial shaft fractures, for example, result in non-

union (Figure 1).1 It can be caused by a variety of

factors, ranging from poor nutrition to old age.

One strategy to treat nonunion has been

the use of bone stimulators, which strap to the

injury location and send pulses of ultrasonic or

electromagnetic energy onto the fracture with

the aim of facilitating healing. Pre-clinical and

model research shows that there are mecha-

nisms by which these devices could encourage

bone healing. However, the clinical data on their

efficacy is mixed, and the studies that have been

conducted have been inconsistent—making it

challenging to form a clear picture of their effi-

cacy and to make treatment recommendations.

Electromagnetic bone stimulators come

in various forms (Figure 2).2 Direct current stim-

ulators are surgically implanted at the fracture

site and therefore require an invasive procedure

to use. While these devices don’t require the

patient to take any action to trigger stimula-

tion, the surgical process comes with risks of

infection.

Other types of electromagnetic devices

are placed on the skin above the fracture site.

Capacitive coupling devices place electrodes on

either side of the limb, forming an electrical field

around the break. Inductive coupling, on the

other hand, places one or two coils directly on

the fracture site. Ultrasound stimulators, which

are non-invasive, are placed directly on the skin

above the fracture site.

“They are very useful,” said Ardeshir Bayat,

PhD, principal investigator in the Division of

Musculoskeletal & Dermatological Sciences at

the University of Manchester. “The problem is

that there are too many modalities in ways to

deliver treatment, and people are very confused

about which tool is the best for which purpose.”

Mechanisms of actionIn bone and in other tissues, mechanical stimu-

lation and movement trigger cellular pathways

that promote healing. Electromagnetic and

ultrasound work in a similar way, said Regis

O’Keefe, MD, PhD, chair of the department of

orthopaedic surgery at Washington University

School of Medicine. “When cells respond to the

stimulation, they activate various signals and

signaling pathways,” he said. “It’s likely these



Bone Stimulation Represents New Frontier for Optimizing Patient Outcomes

Figure 1. An old fracture with nonunion of the fracture fragments. Image use is per Creative Commons Share-Alike Unported license.

“There’s a lot of interest in trying to find ways to further

optimize patient recovery.”



mechanisms work through pathways that are

analogous to mechanical stimulation.”

The protein insulin-like growth factor 2,

for example, is key for bone tissue formation,

and exposing skeletal tissue to electromagnetic

fields increases levels of both the protein and

the protein’s RNA. In one study, published in the

journal Bioelectrochemistry and Bioenergetics,

30 minutes of exposure to magnetic fields

significantly increased levels of IGF-II in human

osteoblasts, which synthesize bone. The protein

was elevated following magnetic field exposure

in rodent models of fractures as well.3

Pulsed electromagnetic fields increase the

expression of bone morphogenic proteins—im-

portant growth factors in the generation of bone

and cartilage—as has been demonstrated in

chick embryos, rat models, and human cells.

They also upregulate transforming growth factor

beta 1, another protein that assists in cell growth

and proliferation.4

In a February 2019 study, researchers

exposed bone-derived human stem cells to

static magnetic fields of varying strengths for 2

weeks and found that the groups of cells under

the magnetic fields had higher expression of

proteins that would promote the differentia-

tion of the stem cells into bone. The team also

examined the effect of static magnetic fields on

rodents with bone defects and found that the

group in the magnetic field condition had more

new bone formation than the control group.5

Stimulation by ultrasound also increases

the expression of growth factors, like insulin

growth factors and transforming growth factors.

In addition, in laboratory studies, ultrasound

stimulation has been shown to improve the in-

tegration of calcium ions into bone. It improves

the formation of callus, which forms across a

fracture preceding full bone repair in rodent

models, likely by improving production of cells

integral to that process.6

However, despite the cell line and rodent

model research into the mechanisms at play

during bone stimulation, there are still gaps in

the scientific understanding of the process. “We

have some ideas, but we don’t really know,”

Bayat said. “Fundamentally, we don’t know the

molecular mechanisms in detail.”

In the clinicIn the United States, both electromagnetic

and ultrasound bone stimulation devices

are approved for use by the Food and Drug

Administration. According to a market analysis,

sales of these devices are increasing, particularly

pulse electromagnetic field stimulators.7 It’s hard

to say how many physicians are actually using

them for treatment, said Busse, though some

surveys have been conducted.

“In prior surveys we’ve done among

surgeons, we really find there are a substantial

group of surgeons advocating for these products,

and a substantial group advocating not. It

almost breaks down 50-50,” he said. In a survey

of Canadian physicians, published in 2004, or-

thopedic surgeons using these devices preferred

electromagnetic and ultrasound stimulation

equally.8

It’s still unclear which group—advocates

or detractors—has the stronger case, as clinical

evidence for the efficacy of these devices is not

only limited, but what is available is mixed.

A 2016 meta-analysis9 of electrical stimu-

lators examined 15 trials that included a total of

1,247 patients. The analysis showed moderate

evidence that the devices led to reduced pain

and reduced rates of fracture nonunion—ac-

cording to the study authors, the data showed

that the devices could prevent 1 nonunion for

every 7 patients treated. It did not find that the

devices have an effect on patient function.

Other reviews of research on these stim-

ulating devices were inconclusive, and a 2011

Cochrane review found that the devices did not

significantly improve union rates. “Though the

available evidence suggests that electromagnet-

ic field stimulation may offer some benefit in

the treatment of delayed union and nonunion

of long bone fractures, it is inconclusive and

Figure 2. The three methods of administering electric stimulation are shown in this diagram. (a) Direct current (DC): A cathode is implanted at the fracture site which is attached to either a subcutaneous power source or an external power source to generate an electric field at the fracture site. (b) Capacitive coupling (CC): Two capacitive coupled electrodes are situated on the skin on either sides of the fracture site. An external power source is then attached to the electrodes, which induces an electric field at the fracture site. (c) Inductive coupling (IC): An electromagnetic current carrying coil is placed on the skin overlying the fracture site, which is attached to an external power source. The coil generates a magnetic field, which induces an electrical field at the fracture site.2 Use is per the Creative Commons Attribution License.

“When cells respond to the stimulation,

they activate various signals and signaling

pathways.” Continued on page 22

insufficient to inform current practice,” wrote the

authors of the Cochrane review.10

Some individual studies of ultrasound de-

vices find evidence that they can assist in bone

healing and functional outcomes. However,

a systematic review of 26 trials conducted by

Busse and published in 2017 determined that

they did not improve patient outcomes. Of the

studies that the authors classified as having a

low risk of bias, the devices did not reduce days

to weight bearing. Overall results that included

studies that had a risk of bias found that the

devices might have a slight reduction in pain

and radiographic healing, as well as a return to

weight bearing.11

“Evidence from higher quality studies sug-

gests no effect on patient-reported outcomes,”

Busse said. “The issue seems to be settled.”

According to Busse, although ultrasound

devices seem to no longer be worth pursuing,

there’s still potential in electromagnetic devices.

“We’re kind of in a situation where we have a

lot of small studies, a number at risk of bias,

and with the vast majority focusing on surrogate

outcomes,” he said. More research is needed

before that determination can be made.

The small number of well-designed studies

and an inconsistency in research methods has

made drawing overarching conclusions about

the devices difficult, researchers said.

Most of the research that has been done

to date on both types of devices looks at the

final scans and radiographs for evidence of

efficacy—not patient results—which makes the

studies less useful, Busse said. “Patients don’t

really care about that outcome; they care about

pain and function,” he said. “We have very little

information on those outcomes.”

Bayat agreed that the varied outcome mea-

sures complicate efforts to draw conclusions. “If

someone talks about bone healing, they might

not also talk about functional outcomes. That

makes it difficult to navigate,” he said.

Researchers also have little understand-

ing of how the devices compare to each other.

“There aren’t many trials that don’t just look at

the same device,” Bayat said. “The regime for

currents can be different from device to device.

How can you judge which is better? One of

the fundamental things we don’t understand is

which is the optimal modality of delivery.” That

might, he said, be one reason some studies don’t

see a result with the treatment.

That argument is less convincing to Busse,

however. “There is always the argument that if

you deliver it in a different way at a different

intensity, it might work better,” he said.

O’Keefe said that there might be other

reasons why both reviews and individual studies

show limited efficacy, and why the devices might

not spur healing in every patient: for example,

the mechanisms likely rely on an intact and

robust periosteum, the layer of tissue that

surrounds bone and contains cells necessary

for regrowth (Figure 3). “If you have a situation

where you don’t have progenitor cell population

that can respond, from aging or other disease,

you might not see as much of an effect,” he said.

Devices that deliver the ultrasound or

electromagnetic currents are commercial prod-

ucts, which adds another layer of complication

to research: many studies are, at least in part,

funded by device manufacturers, who have a

financial stake in the findings and seek greater

control of the messaging around the data.

Busse came across those challenges first-

hand while working with a device company on a

study of ultrasound devices. “We wanted to en-

roll 500 patients and follow them for a year,” he

said. The team wanted to look at functionality as

the primary outcome measure, but the company

wanted to look at radiographic outcomes. The

company also wanted to see unblinded data

from an intermediary point in the study and

then decided to pull the plug on the trial when

the results appeared not to support the efficacy

of the device. Busse’s team continued the study

with its remaining funding and began to put

together a paper with negative results. Out

of more than a dozen subgroup analyses, the

company wanted them to stress the three that

showed some benefits from their devices.

Studies have found that research spon-

sored by companies leads to more favorable

results than research funded by other means.12

O’Keefe said that those conflicts of interest

pose a big challenge in this and other areas of

research. “Conflicts of interest influence the way

that data is presented, and the interpretation of

that data,” he said.

Those conflicts will be important to note as

research on electromagnetic stimulation moves

forward, Busse said. “The evidence we do have



Figure 3. The periosteum forms the outer surface of bone, and the endosteum lines the medullary cavity. Illustration from Anatomy & Physiology, Connexions Website. http://cnx.org/content/col11496/1.6/, Jun 19, 2013. Image use is per Creative Commons 3.0 Share-Alike Unported license.

“Evidence from higher quality studies

suggests no effect on patient-reported

outcomes.”


suggests a potential there, but there really needs

to be a large trial done to understand if it does

have a benefit. Whether or not a company will

choose to do that study, I don’t know. There

are lessons to be learned from our ultrasound

experience.”

Despite the challenges and lack of clarity

around efficacy, Bayat thinks that clinicians and

researchers should continue to consider bone

stimulators a promising treatment approach.

“There is a lot of evidence to suggest that there

is a role for them, and it should spur more

research,” he said.

Nicole Wetsman is a freelance writer based in

New York, New York.

References

1. Hernandez RK, Do TP, Critchlow CW, et al.

Patient-related risk factors for fracture-healing

complications in the United Kingdom Gen-

eral Practice Research Database. Acta Orthop.

2012;83:653-660.

2. Griffin M, Bayat A. Electrical Stimulation in

Bone Healing: Critical Analysis by Evaluating

Levels of Evidence. Eplasty. 2011;11:e34.

3. Ryaby J, Fitzsimmons R, Khin NA, et al.

The role of insulin-like growth factor II in

magnetic field regulation of bone formation.

Bioelectrochem Bioenerg. 1994;35:87:91.

4. Aaron RK, Boyan BD, Ciombor DM, et al.

Stimulation of Growth Factor Synthesis by

Electric and Electromagnetic Fields. Clin. Or-

thop. Relat. Res. 2004;419:30–37.

5. He Y, Yu L, Liu J, et al. Enhanced osteogenic

differentiation of human bone-derived mes-

enchymal stem cells in 3-dimensional printed

porous titanium scaffolds by static magnetic

field through up-regulating Smad4. FASEB J.

2019; doi: 10.1096/fj.201802195R

6. Hannouche D, Petite H, Sedel L. Current

trends in the enhancement of fracture heal-

ing. J Bone Joint Surg Br. 2001;83(2):157-64.

7. Victoria C, Petrisor B, Drew B, et al. Bone

stimulation for fracture healing: What’s all the

fuss? Indian J Orthop. 2009; 4:117–120.

8. Busse JW, Bhandari M. Therapeutic ul-

trasound and fracture healing: a survey of

beliefs and practices. Arch Phys Med Rehabil.

2004;85:1653-6.

9. Aleem IS, Aleem I, Evaniew N et al. Efficacy

of Electrical Stimulators for Bone Healing:

A Meta-Analysis of Randomized Sham-Con-

trolled Trials. Sci Rep. 2016; 19;6:31724.

10. Griffin XL, Costa ML, Parsons N, et al.

Electromagnetic field stimulation for treating

delayed union or non-union of long bone

fractures in adults. Cochrane Database Syst

Rev. 2014:CD008471.

11. Schandelmaier S, Kaushal A, Lytvyn L, et

al. Low intensity pulsed ultrasound for bone

healing: systematic review of randomized

controlled trials. BMJ. 2017;356:j656.

12. Lundh A, Lexchin J, Mintzes B et al. In-

dustry sponsorship and research outcome.

Cochrane Database Syst Rev. 2017; doi:

10.1002/14651858.MR000033.pub3.



https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3145421/



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For help limiting the number of opioid tablets you prescribe—and to still treat postop pain successfully—turn to practice guidelines, evidence from the literature about local and regional anesthesia techniques, and constraints of the law.

By Robert G. Smith, DPM, MSc, RPh,

CPed, CPRS

Opioid abuse is among the most consequential

and preventable public health threats in the

United States1; many of these analgesic medi-

cations are associated with a high likelihood of

physical dependence and a relatively high risk of

addiction. This is a critical problem that needs

to be addressed by all health-care professions.

To manage patients’ pain after invasive

procedures, all practicing clinicians prescribe

medication on occasion; the central theme of

this article is responsible opioid pain manage-

ment by lower-extremity specialists. I’ll describe

prescription opioid strategies for use in alleviat-

ing lower-extremity pain, as well as how modern

clinical-based evidence has led to ethical pre-

scribing standards and legal regulations aimed

at alleviating the widespread crisis we face. My

goals? To have lower-extremity practices estab-

lish 1) procedures to better control and limit

opioid prescriptions and 2) opioid monitoring

strategies to recognize and reduce the risk of

aberrant opioid misuse and abuse,2 and develop

analgesic regimens to treat pain.*

Opioids or non-opioids? Or both?Analgesic opioid therapy has been the corner-

stone of pharmacotherapeutic management of

acute and chronic pain. Ideally, opioid analge-

sics are prescribed by balancing beneficial and

adverse effects. Although often overlooked as a

source of opioid medications, podiatric and or-

thopedic surgical interventions are often painful

postoperatively; therefore, these specialists are

frequent opioid prescribers.5

No single opioid analgesic is perfect, and

no single agent can treat all types of pain.5,8 The

underlying rationale for combination analgesic

strategies involves the availability of individual

agents that induce analgesia through sepa-

rate or overlapping mechanisms or that have

separate adverse effect profiles. The basic goal

of a combination strategy is to amplify desired

effects while decreasing, or at least not equally

increasing, the undesired effects of individual

agents.5, 8

Many treatments are available to manage

pain. Some non-opioid therapies are likely to be

as effective as, or more effective than, opioids,

and, potentially, carry less risk when used

appropriately. Any meaningful effort to improve

pain management will require a basic culture

shift in the nation’s approach to mandating

pain-related education for all health-care profes-

sionals who provide care to people with pain.

Prescribing guidelines may be most effec-

tive when accompanied by education; therefore,

an evidence-based national approach to pain

education that addresses pharmacotherapeutic

and nonpharmacotherapeutic treatments and

includes materials on opioid prescribing, is

needed.2,5,9,10 The appropriate combination of

agents, including opioids and adjunctive medi-




A REVIEW FOR LOWER-EXTREMITY SPECIALISTS

Mitigating the Opioid Crisis with Pain Management Regimens in a Multimodal Approach

*See “For lower-extremity specialists: Key points in opioid analgesic prescribing,” page 29.2,3 Elsewhere,2, 4-7 the author has discussed [within the scope of lower-extremity pain management] the pharmacology, pharmacodynamics, and pharmacokinetics of opioid analgesics, as well as opioid drug–drug interactions and adverse effects.

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cations, can be seen as rational pharmacother-

apy, providing a stable therapeutic platform on

which treatment changes can be based:

• Reassessing the pain score and level

of function, regularly reassessing the

patient, and combining this effort with

corroborative support from family and other

knowledgeable third parties; doing so will

help document the rationale for continuing

or modifying the therapeutic trial.

• Regularly assessing the “4 As” of pain

medicine: routine assessment of Analgesia,

Activity, Adverse effects, and Aberrant

behavior.5,9,10

• Periodically reviewing the pain diagnosis

and comorbid conditions, including

addictive disorders and any underlying

illness. The findings of diagnostic tests

change with time; in the pain and addiction

continuum, it is not uncommon for a patient

to move from a dominance of one disorder

to another. As a result, the treatment focus

might need to change over time.

From the literature: Strategies to reduce the need for opioidsPublished clinical-based evidence has described

the effects of employing local anesthetic prod-

ucts to reduce postoperative pain and reduce the

need for opioid analgesics:

Osteotomy. Kim et al. investigated 30 consecu-

tive patients who underwent bilateral proximal

osteotomy for correction of a hallux valgus

deformity.11 Each patient acted as his (her) own

control: 1 foot received local infiltration of a test

solution made with ropivacaine, morphine, ke-

torolac, and epinephrine; the other foot received

the same amount of normal saline. A visual pain

analogue scale was used to assess pain intensity

4 hours after surgical intervention and through-

out the night of the first postoperative day.

Finding: The difference in visual analogue

scale values between left and right sides was

most notable 8 hours after the operation, then

gradually decreased through the first and second

postoperative days. The investigators concluded

that the local multidrug cocktail was easy to

perform, safe, and effective in reducing pain

and enhancing patient satisfaction after hallux

valgus surgery.

Talar and calcaneal fracture repair. Luiten

et al.12 investigated their hypothesis that a

continuous peripheral-nerve block would reduce

the pain score more effectively than systemic

analgesics, improve recovery, and reduce length

of stay. They retrospectively analyzed 3 years of

data from patients who underwent open reduc-

tion and internal fixation of talar or calcaneal

fracture and received 1) intravenous opioid,

patient-controlled analgesia or 2) continuous

peripheral-nerve block.

Finding: On the first postoperative day,

the patient-controlled analgesia group (which

had unrestricted access to opioids) required

approximately 30-fold more opioids than the

continuous peripheral-nerve block group (which

had to request additional opioids).

Mitchell-Kramer osteotomy. Gadek and Liszka13

evaluated the influence of local anesthetic infil-

tration before hallux valgus surgery on postop-

erative pain and the need for analgesics. Their

study group comprised 134 patients who under-

went chevron or mini-invasive Mitchell-Kramer

osteotomy of the first distal metatarsal. Each

patient was randomized to receive 7 mL of local

anesthetic (4 mL of bupivacaine, 0.25%, and 3

mL of lidocaine, 2%) or normal saline 15 min-

utes prior to skin incision. Each patient’s level of

pain was assessed by the visual analogue scale

at Hours 2, 4, 8, 12, 16, and 24, and again 72

hours after release of the tourniquet.

Finding: The authors concluded that pre-



FOR LOWER-EXTREMITY SPECIALISTS

KEY POINTS IN OPIOID ANALGESIC PRESCRIBING2,3 It is critical that lower-extremity specialists first, understand the underlying issues of opioid prescribing and, second, exercise sound clinical judgment in identifying patients who might have, or develop, physical or psychological dependence on these drugs. Such understanding includes:

• knowing that opioid analgesics should be prescribed by balancing their beneficial and adverse effects2

• managing pain while minimizing abuse potential through careful procedural techniques and use of alternative therapies, by limiting prescriptions to appropriate quantities when opioids are deemed necessary, and by altering the attitudes of patients and physicians2

• providing pain management responsibly in an error-free environment, adhering to state and federal regulations (such as Centers for Disease Control and Prevention guidelines that help providers manage pain effectively amid the opioid crisis)3

• awareness that providers are not insulated from medical errors, medication misfortune, or ethical and legal responsibilities when prescribing opioid medication.

“Opioid abuse is among the most consequential and preventable public

health threats in the United States1 ”


emptive local anesthetic infiltration significantly

decreased pain during the first 24 hours after

hallux valgus surgery.

Foot and ankle surgery. Gupta et al14 investi-

gated the number of narcotic tablets taken by

opioid-naïve patients undergoing outpatient

foot and ankle surgery with regional anesthesia.

Their patient population was 84 patients who

underwent outpatient surgery using spinal

blockade and a long-acting popliteal anesthetic

block.

Patients were given 40 or 60 narcotic

tablets, a 3-day supply of ibuprofen, deep-vein

thrombosis prophylaxis, and an antiemetic. A

survey completed at postop Days 3, 7, 14, and

56 documented whether they were still taking

narcotics, how many pills they consumed,

whether refills were obtained, pain level, and

their reason for stopping opioids, if that was

what they had done.

Finding: Patients consumed a mean of

22.5 tablets (95% confidence interval, 18-27

tablets). Those who received regional anesthe-

sia reported a progressively lower pain score

with low narcotic use, for as long as 56 days

postoperatively.

Foot and ankle surgery. Saini et al15 conducted

a prospective investigation to evaluate utilization

patterns and prescribing guidelines for opioid

consumption after foot and ankle surgery. Their

study population included patients undergoing

outpatient orthopedic foot and ankle proce-

dures who met inclusion criteria. The following

prospective information was collected: patient

demographics, preoperative health history,

patient-reported outcomes, anesthesia type,

procedure type, and opioid prescription and

consumption details. The morphine milligram

equivalent dosage was calculated for each

prescription, then converted to the equivalent of

a 5-mg oxycodone “pill.”

Univariate analyses were performed to

identify variables with a statistically robust

association with opioid consumption, for inclu-

sion in a multivariable linear regression model.

A stepwise backward regression was then

performed to identify independent predictors

of opioid consumption. Postoperative opioid

utilization was reported for 988 patients (mean

age, 49 years).

Finding: Overall, patients consumed a me-

dian of 20 pills; the median number prescribed

was 40. The study revealed that these patients

were overprescribed narcotic medication in an

amount nearly twice what they consumed.

Postop analgesia protocol. Boffeli and Gorman16

recently described creation of a postoperative

pain protocol using a multimodal approach that

involves various medications used in the preop-

erative setting to tackle difficult lower-extremity

pain pathways.

Finding: One year after adopting the pain

protocol, the authors had reduced the amount

of opioids prescribed postoperatively by 30% by

adding non-steroidal anti-inflammatory agents

to the protocol—without an incident of delayed

union or nonunion.

Rescue therapy. Suzuki and Birnbaum17 assert-

ed that opioid medication may have a role as

rescue medications, but only as a last resort for

neuropathic pain.

Reducing opioid use: Challenging, but doableMultimodal analgesia for lower-extremity sur-

gery is widely practiced as a means of reducing

the use of opioids and opioid-related adverse

effects. A multimodal approach is likely to

produce analgesia superior to an opioid-based

approach because multimodal analgesic agents

target a variety of pain pathways. Furthermore,

many non-opioid multimodal agents are inex-

pensive and offer benefit by reducing consump-

tion, and, therefore, adverse effects of opioids.

Lower-extremity providers face the

challenging task of setting appropriate proto-

cols when balancing pain relief and regulatory

guidelines. A clinical evidence base has revealed

that the use of regional local anesthesia tech-

niques during lower-extremity procedures has

decreased consumption of opioids. Using a com-

bination of the clinical evidence base that I’ve

reviewed here, clinical practice guidelines (see

“Suggested reading on pain management using

opioids,” page 33), and state- and federally-leg-

islated opioid limitations, the lower-extremity

clinician can begin to reduce the number of

opioid tablets prescribed to treat acute, chronic,

and postsurgical pain.

Robert G. Smith is in private podiatry practice at

Shoe String Podiatry in Ormond Beach, Florida.

He has been an advisor to the US Food and

Drug Administration and the US Drug Enforce-

ment Administration regarding the rescheduling

of hydrocodone combinations. He has delivered

presentations on the appropriate prescribing of

opioids to avoid drug–drug interactions, adverse

effects of opioids, and avoidance of opioid abuse

disorder at meetings of state, national, and

international professional organizations in 2017

and 2018.

References

1. Manchikanti L, Sanapati J, Benyamin RM, et

al. Reframing the prevention strategies of the

opioid crisis: focusing on prescription opioids,

fentanyl, and heroin epidemic. Pain Physician.

2018;21(4):309-326.

2. Smith RG. Opioid prescribing: podiatric

implications. Podiatry Management.



“Some non-opioid therapies are likely to be as effective as, or more effective than, opioids, and, potentially, carry less risk when used

appropriately.”



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2018;37(5):161-169. http://www.podiatrym.

com/cme/CME618.pdf. Accessed January 20,

2019.

3. Centers for Disease Control and Prevention.

CDC guideline for prescribing opioids for

chronic pain - United States, 2016. MMWR

Recomm Rep. 2016;65(1):1-49. .

4. Smith RG. A review of opioid analgesics fre-

quently prescribed by podiatric physicians. J

Am Podiatr Med Assoc. 2006;96(4):367-373.

5. Smith RG. Using clinical-based evidence as

the sextant to prescribe and navigate through

the opioid crisis. Foot and Ankle Quarterly.

2018;29(3):143-157.

6. Smith RG. Drug interactions and opioids:

what you should know. Podiatry Today.

2018:31(4). www.podiatrytoday.com/drug-in-

teractions-and-opioids-what-you-should-know.

Accessed January 20, 2019.

7. Smith RG. Opioid prescribing and the opi-

oid crisis in the lower extremity. Advance

Research on the Foot and Ankle: ARFA-106.

2018;2018(1):1-7.

8. Raffa RB, Clark-Vetri R, Tallarida RJ, et al.

Combination strategies for pain management.

Expert Opin Pharmacother. 2003;4(10):1697-

1708.

9. Bonnie RJ, Ford MA, Phillips JK, editors;

National Academies of Sciences, Engineering,

and Medicine. Consensus Study Report: Pain

Management and the Opioid Epidemic: Bal-

ancing Societal and Individual Benefits and

Risks of Prescription Opioid Use. Washington,

DC: The National Academies Press; July 12,

2017. https://www.nap.edu/catalog/24781/

pain-management-and-the-opioid-epidem-

ic-balancing-societal-and-individual. Accessed

January 20, 2019.

10. Passik SD, Weinreb HJ. Managing chronic

nonmalignant pain: overcoming obstacles to

the use of opioids. Adv Ther. 2000;17(2):70-

83.

11. Kim BS, Shim DS, Lee JW, et al. Compar-

ison of multi-drug injection versus placebo

after hallux valgus surgery. Foot Ankle Int.

2011;32(9):856-860.

12. Luiten WE, Schepers T, Luitse JS, et al.

Comparison of continuous nerve block versus

patient-controlled analgesia for postoperative

pain and outcome after talar and calcaneal

fractures. Foot Ankle Int. 2014;35(11):1116-

1121.

13. Gdek A, Liszka H. Preemptive local anesthetic

infiltration in hallux valgus one-day surgery.

Przegl Lek 2015;72(1):16-19.

14. Gupta A, Kumar K, Roberts MM, et al. Pain

management after outpatient foot and ankle

surgery. Foot Ankle Int. 2018;39(2):149-154.

15. Saini S, McDonald EL, Shakked R, et al. Pro-

spective evaluation of utilization patterns and

prescribing guidelines of opioid consumption

following orthopedic foot and ankle surgery.

Foot Ankle Int. 2018;39(11):1257-1265.

16. Boffeli T, Gorman C. A guide to postoper-

ative pain management. Podiatry Today.

2018;31(9):48-54.

17. Suzuki K, Birnbaum Z. Pain management and

wound care patients: key principles. Podiatry

Today. 2018;31(12):36-41.




SUGGESTED READING ON PAIN MANAGEMENT USING OPIOIDS

This listing of guidelines for using opioids to manage acute and chronic pain, developed by professional organizations and government agencies, is certainly not

exhaustive and does not necessarily represent the views of the author or Lower Extremity Review.

Guideline for Prescribing Opioids for Chronic Pain – United States 2016

Centers for Disease Control and Prevention: https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.

gov%2Fmmwr%2Fvolumes%2F65%2Frr%2Frr6501e1er.htm

Opioid Prescribing: Acute and Postoperative Pain Management

American Association of Oral and Maxillofacial Surgeons: https://www.aaoms.org/docs/govt_affairs/advocacy_white_papers/opioid_prescribing.pdf

Opioid-Prescribing Guidelines for Common Surgical Procedures: An Expert Panel Consensus

Opioids after Surgery Workgroup of the American College of Surgeons: www.journalacs.org/article/S1072-7515(18)31129-3/fulltext

Oregon Acute Opioid Prescribing Guidelines

Public Health Division, Oregon Health Authority: https://www.oregon.gov/oha/PH/PREVENTIONWELLNESS/SUBSTANCEUSE/OPIOIDS/Documents/Acute-

Prescribing-Guidelines.pdf

Postoperative Opioid Prescribing Guidelines: Background for Surgeons

City of Philadelphia Department of Public Health: www.phila.gov/media/20181219135343/OpioidGuidelines-BackgroundforSurgeons_12_14.pdf

By MICHAEL REEDER, DO, AND BRENT ALUMBAUGH, MS

Over the past several decades, mountain biking has

become remarkably popular as a competitive and recre-

ational activity. Mountain biking is popular international-

ly and can be observed in numerous competitive events;

the most popular are the annual World Cup Series,

Olympic Games, and World Championships. The largest

increase in number of participants, however, has been in

recreational mountain biking. The Outdoor Foundation1

recently reported mountain biking as one of the most

popular outdoor activities in the United States, with

approximately 8.32 million mountain bikers in 2015 (see

“Why so much interest in mountain biking?,” page 40).

Equipment and Technology Has ChangedRecently, there has been a change in bike sales in the

United States: More mountain bikes are now sold than

road bikes.2 More recently, electrical bikes, or e-bikes,

have become popular, including electrical-assist moun-

tain bikes, which might make mountain biking a feasible

option for more of the population. The price of mountain

bikes ranges from a few hundred dollars for an entry-lev-

el bike to more than $10,000 for high-end bikes.

Bicycle manufacturers have improved mountain

bike technology since the first models appeared on the

market in the early 1970’s. There are now different types

of mountain bikes that vary significantly, depending

on the inclination of rider and the intended use. As the

technology of mountain bikes has improved, it’s become

easier for riders to attempt more technical terrain and

ride at higher speeds. Compared to road bikes, mountain

bikes are designed for stability and maneuverability in

technical terrain; they generally have larger tires, lower

bottom brackets, shorter chain stays, and lower head-

tube angles (see annotated image, page 37).

Furthermore, improvements in protective apparel

have made mountain biking safer; however, these im-

provements have likely led to greater rider confidence—

leading, somewhat paradoxically, to higher speeds and

more risk-taking behavior. Despite remarkable improve-

ments in bike technology and the use of protective equip-

ment and clothing, the risk of injury to all parts of the

body is ever-present in mountain biking, as we describe

in detail in this article.

Getting a Handle on Injury in Mountain BikingThe nature of injury rates in mountain biking is not

well-defined. Mountain bikers include competitive and

recreational riders, ranging from adolescents to older

How Mountain Biking Is Reshaping the Landscape of Cycling InjuryDifferences in equipment, terrain, riding style, and other risk factors mean different types and prevalence of injuries when riding a mountain bike, compared to a road bike. Be prepared to see those differences in your practice.


adults—all of whom have different preferences in riding

style. Most older studies of mountain biking injuries are

limited to competition and mountain bike parks, making

the injury rate outside of those settings hard to define,

especially when injuries go unreported.

A study by Gaulrapp et al3 of more than 3800

mountain bikers, most of whom were noncompetitive

recreational bikers, cited a very low rate of significant

injury: 1 injury for every 1000 hours of riding, with 75%

of injuries considered minor. In contrast, Kronisch

et al4 looked at competitive mountain bikers and cited an

injury rate of 3.7 injuries for every 1000 hours of racing

in cross-country biking and 43.4 injuries for every 1000

hours in downhill racing. Similarly, a prospective study

by Becker et al5 of downhill mountain biking injuries

seen in competition is in agreement with Kronisch’s find-

ings,4 showing an increased incidence of injuries: 16.8

injuries for every 1000 hours of downhill racing cycling.

Nelson and Mckenzie6 illustrated the importance

of the age of the rider as it relates to traumatic brain

injury. Reporting on more than 200,000 patients who

suffered a mountain-biking injury and were treated in

an emergency department between 1994 and 2007, the

researchers showed that patients 14 to 19 years of age

sustained the greatest percentage of traumatic brain in-

juries. Similarly, 2 studies7,8 from Canada illustrated the

preponderance of head and neck injury in young male

recreational riders.

What’s behind this preponderance of adolescent

male victims? The popularity and continued develop-

ment of mountain bike parks at ski resorts likely has

contributed to the demographic phenomenon. As resorts

expand ski-lift access and develop terrain that is more

technical, riders are able to spend more time riding

downhill at high speed. During competitive downhill

races, mountain bikers attain speeds approaching 60

mph over uneven, often rocky, terrain.

There is more: In the United States, competitive

high school mountain bike leagues are increasingly pop-

ular, drawing more and more participants. These leagues

are overseen by the National Interscholastic Cycling As-

sociation (NICA; www.nationalmtb.org/), which has de-

veloped appropriate rider safety guidelines. In response

to concerns over safety, NICA, in conjunction with the

University of Utah, recently initiated a study comparing

injury reports among various high school sports and

cycling (www.nationalmtb.org/nica-safety-study/).

A Look at the Scope of Mountain Biking InjuryAs the number of off-road cyclists increases, so has the

number of cycling-related injuries.9 Surveys of mountain

bikers demonstrate that injury is common, but most are

minor and involve soft tissue. The nature of mountain

biking lends itself to injuries to skin, with the most

common types being soft-tissue abrasion, laceration, and

contusion.3,5 After soft-tissue injury, mountain bikers

experience the following injuries in order of prevalence:

fracture of the clavicle, fracture of the ribs, fracture of the

distal radius, and fracture of the scaphoid.5 What follows



“The risk of injury to all parts of the body is ever-present in

mountain biking”

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is a review of mountain biking injury by body

region.

Head and face. Along with soft-tissue injury

and fractures, older literature suggested that

mountain bike riders have a relatively higher

associated rate of maxillofacial trauma com-

pared to road cyclists.10 Gassner10 and Chow11

proposed that conventional cycling helmets were

inadequate for mountain bikers; they recom-

mended adding face guards to mountain bike

helmets secondary to the high rate of maxillofa-

cial trauma.11 Perhaps in response to this recom-

mendation, there has been an increase in hel-

mets that provide greater protection, as shown

in a study by Becker et al,5 which demonstrated

that the great majority of competitive downhill

mountain bikers wear a full-face helmet.

Spine. High speeds and technical terrain

associated with downhill racing increase the

risk of acute spinal injury. As noted, the greatest

occurrence of spinal injury is observed among

younger male riders. Similarly, McLean et al12

reported on spinal injury in mountain bikers

and showed that, principally, young males are at

risk. They recommended mandatory universal

use of protective equipment and appropriate

rider training.

With regard to overuse injury of the spine,

the nature of riding leads to cyclists remaining

in a flexed position on the bike, which can lead

to neck and back pain; such complaints are

frequent in road cyclists. However, the geometry

of a mountain bike allows a more upright riding

position and changes in riding terrain often

require different body positions, which may

decrease the incidence of chronic neck and back

pain in mountain biking, compared to what is

seen in road cycling.

Abdomen. Spleen and liver injuries are the

most frequently reported abdominal injuries;9

some have been associated with using bar ends

on handlebars that allow for additional riding

positions. Nehoda13 reported the relationship

between an increase in liver injury and bar ends

on handlebars in the late 1990’s, which led to

a decrease in the use of bar ends. Recently,

however, there has been a resurgence of shorter

attachments to the handlebars because of per-

ceived improved comfort.

Skin and soft tissue. Skin and soft-tissue

injury is common in mountain biking. Trau-

matic lacerations and abrasions are common

and, likely, underreported. It is probable that

many soft-tissue injuries from mountain biking

are taken care of at home and, therefore, not

reported. For injuries requiring evaluation by a

medical provider, initial management includes

copious irrigation and tetanus immunization if

needed. Proper anesthesia is essential to allow

full wound assessment for foreign bodies and

deeper injuries (to tendons and joints) as well as

appropriate irrigation and debridement.

The anterior lower leg of mountain bikers

frequently sustains soft-tissue trauma, including

injuries from plant undergrowth, teeth of the

chain ring, and sharp edges of flat pedals. Most

such injuries heal well with appropriate wound

care, which might include aggressive irrigation

and debridement. However, these injuries might

also require more significant intervention, as

noted by Patel,14 who reported significant pretib-

ial lacerations from the chain ring when using

quick-release pedals—lacerations that required

debridement under anesthesia and delayed

wound closure or skin grafting.

Trauma in mountain biking can result

in injury to the soft-tissue bursa from a direct

blow, resulting in fluid collection and swelling.

A similar injury to the bursa involves a shearing

force that separates superficial fascia from deep

fascia, resulting in a collection of fluid, known

as a Morel-Lavallée lesion.15 This lesion is most

often seen at the olecranon bursa, the greater

trochanter of the hip, or one of the knee bursa.

Although many of these injuries are treated

with ice and compression, management for a

small percentage of patients includes timely

aspiration.15

The upper extremity. Ulnar and median neu-

ropathies are the most common overuse prob-

lems of the upper extremity in all cyclists. This

problem is related to direct pressure on nerves


TABLE: LOWER-EXTREMITY OVERUSE AND ACCIDENTAL INJURIES IN MOUNTAIN BIKING

Foot numbness

Foot pain

• Metatarsalgia • Morton’s neuroma • Plantar fasciitis • Sesamoiditis

Iliotibial band syndrome

Knee pain

Other

• Bilateral tarsal tunnel syndrome • Lisfranc fracture


at the wrist on the handlebar. Ulnar neuropathy,

or cyclist’s palsy, causes injury to the ulnar nerve

at Guyon’s canal and can produce numbness

and tingling of the fourth and fifth fingers.

Median nerve injury or irritation also occurs

and can present with numbness or tingling of

the thumb, index finger, and middle finger or

with other signs and symptoms of carpal tunnel

syndrome. Initial treatment of ulnar neuropathy

and median nerve injury includes padded gloves

and handlebars, improving rider posture, proper

bike fit, night splints, and other appropriate

strength and stretching therapy for these specific

nerve-compression syndromes.

After such soft-tissue injuries as abrasion

and laceration, fractures of the upper extremity

are the most common reported injuries among

mountain bikers, with fracture of the clavicle

most common. Bush16 performed a study in

the area of the Whistler Mountain Bike Park

in British Columbia, Canada, and reported that

scaphoid, distal radius, and metacarpal fractures

were the most common fractures of the hand,

particularly from landing on an outstretched

arm.

The lower extremity. The 3 principal areas

of contact between cyclist and bike are the

handlebars, saddle, and foot–pedal interface.

That foot–pedal link, which is the connection

to the drive train of the bike and relates to the

kinematics of cycling, is one of the contributors

to overuse injury in cycling (Table, page 37).

Although there is an abundance of literature re-

lated to shoe wear and orthoses in running and

walking, information about shoes and orthoses

in cycling is limited. Specific to mountain biking,

it is more challenging to make observations or

give general recommendations about footwear

because riders use different types of shoes and

flat or clipless pedals.

Knee pain is a common complaint among

cyclists, reported by 20% to 27% of mountain

bikers.17 During an average weekend ride, a

cyclist can flex and extend the knee 15,000

times. With that amount of repetitive motion,

even small inefficiencies can contribute to knee

pain—particularly, anterior pain. The cycling

literature on knee pain generally suggests that

pain occurs due to:

• a sudden increase in mileage and intensity

• impaired hip gluteal and hip abductor

function

• seat position too low or too far forward

• poor patellar mechanics.18

In a systematic review of the literature

regarding knee pain in cyclists, Bini and Bini19

attempted to synthesize previous studies, suggest-

ing that cyclists with knee pain have increased

medial projection of the knee and abnormal

muscular activation. They noted, however, that

research in this area is limited and true biome-

chanical understanding of this injury is lacking.

Interestingly, they concluded that there is little

evidence, based on their review of studies, for

a relationship between saddle height and knee

pain, which conflicts with the theory that decreas-

ing saddle height might increase patellofemoral

pain and pressure, causing anterior knee pain.

Iliotibial band syndrome (ITBS) is a

common overuse injury at the knee in cycling.

Although forces at the iliotibial band at the

knee in a cyclist are markedly less than forces

seen in runners, bike fit and the high amount

of repetition of cycling in the impingement zone

likely play a role in ITBS in cycling. It has been

suggested that a seat set too high and training

errors are the main causes of ITBS in cycling.20

Mountain bikers may present with foot

pain or numbness (or both); this can be related

to type of shoe or pedal, location of the cleats,

and a high amount of repetitive movement.

Traditional cycling shoes with cleats might be

too narrow in the forefoot for mountain biking,

causing compression of the metatarsal phalan-

geal joints and interdigital nerves. Common

diagnoses of foot pain in this group include

metatarsalgia, plantar fasciitis, sesamoiditis, and

Morton’s neuroma (i.e., of an intermetatarsal

plantar nerve).

Initial treatment of foot pain and numb-

ness in a cyclist can include adjustment of

shoe wear, modifying the cleat position (often,

positioning is too far forward), and adding

appropriate footbeds. If the rider uses clipless

pedals, adjusting the cleat might help because

a cleat that is too far forward can increase 1)

pressure on the forefoot and sesamoids of the

first metatarsal phalangeal joint and 2) stress on

the plantar fascia.

Introduction of newer carbon-soled shoes,

which are stiffer than older plastic models,

might decrease some of these foot problems

by distributing forces differently. Conventional

solutions, such as footbeds or orthoses, can be

challenging with many traditional (i.e., narrow)

cycling shoes, where there is a need to be

space-conscious. In addition, there is less re-

search and guidance available to clinicians and



WHY SO MUCH INTEREST IN MOUNTAIN BIKING?The increase in popularity of mountain biking is likely due to a number of contributing factors, including:

• improvements in mountain bike technology

• accessibility to more and more trails

• growing knowledge of associated benefits of cardiovascular exercise with cycling.

Although mountain bikers may have similar reasons for participating in the activity, they are still a highly heterogeneous group, with a wide range of disciplines—ranging from recreational cross-country riding to extreme downhill and free-riding.

Medical providers often encourage mountain biking as a lifetime activity that can improve health. There are potential health benefits to mountain biking compared to road biking because of augmented use of the upper body and increased cognitive effort and decision-making. Although there are clearly health benefits, risk exists for acute and chronic overuse injury in this sport, as this article describes, given the nature of the terrain and the technical nature of the sport. It has been challenging to weigh the risks versus the benefits of mountain biking, however, because, first, there are likely many unreported injuries and, second, it is difficult to study the heterogeneous population that participates in this sport.

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therapists about appropriate use of orthoses and

wedges in mountain biking. Older studies that

looked at performance have evaluated wedges

and orthoses in cycling and have reported im-

provements in power, kinematics, and changes

in forces at the knee;21 however, those studies

are limited and there is a general lack of direc-

tion for providers concerning footwear solutions

for foot and ankle pain in mountain biking.

Making a decision to improve comfort and,

perhaps, safety, many recreational cyclists prefer

flat pedals. They have adopted a stiffer, moun-

tain bike-specific shoe with a wider toe box and

sturdy construction, which might offer improved

protection of the foot from direct trauma.

Last, unusual foot injuries can occur in

mountain biking:

• Lisfranc fracture. A case report described a

fracture dislocation of the tarsometatarsal

joint in a mountain biker. The mechanism

of injury was axial loading of the foot while

attempting to prevent a fall at a high rate

of speed.22

• Bilateral tarsal tunnel syndrome. This

uncommon problem was reported in a

cyclist, caused by a marked increase in

cycling intensity, leading to symptoms of

nerve impingement.23

Risk of Injury Is InherentMountain biking has evolved into a popular out-

door activity with health benefits. However, given

the nature of the terrain and the demographics of

mountain bikers, there remains associated risk to

this sport. Medical providers should be aware of

common associated injuries and some of the dis-

tinctive differences in mountain biking, compared

to other cycling activities.

Michael Reeder, DO, board-certified in emergency

medicine, is Director of the Monfort Family Hu-

man Performance Lab, Colorado Mesa University,

Grand Junction, Colorado. He is Director of

Medical Education for Cycling CME, a provider of

continuing medical education for physicians, PAs,

and other health-care providers (see page 62). Dr.

Reeder holds a Certificate of Added Qualifications

Fellowship in Primary Care Sports Medicine

Brent Alumbaugh, MS, is Clinical Coor-

dinator and Exercise Physiologist at Monfort

Family Human Performance Lab, Colorado Mesa

University.

References

1. Outdoor Foundation. (2017). Out-

door recreation Participation Topline

Report 2017. Available at https://

outdoorindustry.org/wp-content/up-

loads/2017/04/2017-Topline-Report_FINAL.

pdf

2. The NPD Group. U.S. Retail Tracking Ser-

vice, Independent Bicycle Dealers, Dollar

Sales, January-December 2017.

3. Gaulrapp H, Weber A, Rosemeyer B. Inju-

ries in mountain biking. Knee Surg Sports

Traumatol Arthrosc. 2001;9(1):48-53.

4. Kronisch RL, Pfeiffer RP, Chow TK. Acute

injuries in cross-country and downhill off-

road bicycle racing. Med Sci Sports Exerc.

1996;28(11):1351-1355.

5. Becker J, Runer A, Neunhäuserer D, Frick

N, Resch H, Moroder P. A prospective study

of downhill mountain biking injuries. Br J


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Sports Med. 2013; 47(7):458-462.

6. Nelson NG, McKenzie LB. Mountain bik-

ing-related injuries treated in emergency

departments in the Unites States, 1994-2007.

Am J Sports Med. 2011;39(2):404-409.

7. Dodwell ER, Kwon BK, Hughes B, et al. Spi-

nal column and spinal cord injuries in moun-

tain bikers: a 13-year review. Am J Sports

Med. 2010;38(8):1647-1652.

8. Ashwell Z, McKay MP, Brubacher JR, Gareau

A. The epidemiology of mountain bike park

injuries at the Whistler Bike Park, British

Columbia (BC), Canada. Wilderness Environ

Med. 2012;23(2):140-145.

9. Kim PT, Jangra D, Ritchie AH, et al. Moun-

tain biking injuries requiring trauma center

admission: a 10-year regional trauma system

experience. J Trauma. 2006;60(2):312-318.

10. Gassner RJ, Hackl W, Tuli T, Fink C, Wald-

hart E. Differential profile of facial injuries

among mountain bikers compared to bicy-

clists. J Trauma. 1999;47(1):50-54.

11. Chow TK, Corbett SW, Farstad DJ. Do con-

ventional bicycle helmets provide adequate

protection in mountain biking. Wilderness

Environ Med. 1995;6(4):385-390.

12. McLean NJ, Kim PW, Brubacher J, Kel-

ly-Smith C, Simons R. Spine injuries in

mountain bikers: the Vancouver experience.

CJEM. 2006;8(3 Suppl).

13. Nehoda H, Hochleitner BW. Subcap-

sular liver haematomas caused by bar

ends in mountain-bike crashes. Lancet.

1998;351(9099):342.

14. Patel ND. Mountain bike injuries and clipless

pedals: a review of three cases. Br J Sports

Med. 2004;38(3):340-341.

15. Khodaee M, Deu RS, Mathern S, Bravman

JT. Morel-Lavallée lesion in sports. Curr

Sports Med Rep. 2016;15(6):417-422.

16. Bush K, Meredith S, Demsey D. Acute hand

and wrist injuries sustained during recre-

ational mountain biking: a prospective study.

Hand (N Y). 2013;8(4):397-400.

17. Campbell ML, Lebec MT. Etiology and in-

tervention for common overuse syndromes

associated with mountain biking. Ann Sports

Med Research. 2015;2(3):1022.

18. Silberman MR. Bicycling injuries. Curr Sports

Med Rep. 2013;12(5):337-345.

19. Bini RR, Flores Bini A. Potential factors

associated with knee pain in cyclists: a sys-

tematic review. Open Access J Sports Med.

2018;9:99-106.

20. Farrell KC, Reisinger KD, Tillman MD. Force

and repetition in cycling: possible implica-

tions for iliotibial band friction syndrome.

Knee. 2003;10(1):103-109.

21. FitzGibbon S, Vicenzino B, Sisto SA. Inter-

vention at the foot-shoe-pedal interface in

competitive cyclists. Int J Sports Phys Ther.

2016;11(4):637-650.

22. Callaghan MJ, Jane MJ. Fracture dislo-

cation of the tarsometatarsal (Lisfranc’s)

joint by a mountain biker. Phys Ther Sport.

2000;1(1):15-18.

23. Paolasso I, Granata G, Erra C, Coraci D,

Padua L. Bilateral tarsal tunnel syndrome re-

lated to intense cycling activity: proposal of a

multimodal diagnostic approach. Neurol Sci.

2015;36(10):1921-1923.


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By Rebecca Rushton, Bsc(Pod)

Taping is one of the favoured modalities for

preventing blisters in athletic and active patients.

Runners, hikers, tennis players, golfers, and oth-

er athletes frequently use either rigid or flexible

tape, for either treatment or prophylaxis. Taping

is definitely the favoured preventative option at

aid stations of running/walking events as well. At

a guess, taping could make up 80%-90% of all

preventative interventions for blisters.

But how does it work?

Effectiveness of Preventive Blister Taping?Both Brennan1 in 2002 and Richie2 in 2010

state that the scientific evidence behind the use

of adhesive tape for blister prevention is lacking.

“Athletes, athletic trainers and other sports

medicine specialists have anecdotally used these

products with varying degrees of success.” 1

Since then, Lipman et al have published

two papers on the use of paper tape in ultramar-

athon runners. The first in 20143 found it to not

be protective against blisters, while the second, in

2016,4 found it was protective against blisters.

Mechanism of Action?While there is little evidence that taping prevents

foot blisters, there is also little discussion about

how taping might accomplish this.

Most dialogue in both medical and main-

stream literature seems to assume that tape

prevents blisters by protecting the skin from

rubbing. But is rubbing on the skin required for

blister development?

What Causes BlistersBlisters form when shear stress exceeds the shear

strength of the skin, resulting in a separation

within the stratum spinosum of the epidermis.

This was established 40-60 years ago with the

work of Naylor,5 Sulzberger et al,6 Akers and Sul-

zberger 7 and Comaish,8 among others. Consider

this explanation of the mechanics of shear during

gait from Richie:2

“Shear forces are applied to the human

foot during walking and running because of the

mechanics of foot alignment during contact and

propulsion. The foot approaches the ground at a

tangential angle (not a purely vertical angle) and

then pushes off in a similar tangential direction.

The foot [bones] must skid to a stop and then

push into the ground to propel forward. The

skidding will occur in both an anterior-posterior

and medial-lateral direction, depending on the

activity and demands of the sport.”

The force of friction acts in the opposite

direction to bone movement (see Figure 1). It

acts to keep the skin surface stationary (for

longer than the bones). During gait, because

internal tissue layers are structurally connected,

soft tissues between skin and bone undergo

shear distortion. During a shear distortion,

these connected tissue layers move parallel to

one another. If shear occurs to excess, it results

in a “mechanical fatigue” within the layer of

the stratum spinosum of the epidermis.5, 7-9

Presumably this is the layer of cells with the least

resistance to shear. These microscopic tears are

the initial blister injury. The higher the shear

magnitude, the fewer repetitions required to

cause a blister.5,6,8

Rubbing Not RequiredIn spite of experimental blister studies using

rubbing to produce blisters,5-8,10 and in spite of

real-life blister situations often involving rubbing,

skin surface rubbing is not necessary to produce

skin damage such as blisters.3,11,12 In fact, shear

distortions peak in a state of static friction –

the state in which there is no relative motion

between two surfaces. As soon as the transition


Tape Use to Prevent Blisters: Does It Really Do What We Think It Does?


Figure 1. The opposing horizontal forces creating soft tissue shear.

Taping is a mainstay of preventive foot blister management in athletes and active people. Its use is based on the premise that rubbing causes blisters, and that tape protects the skin from this rubbing and/or provides thermal insulation from the heat generated by rubbing. This commentary highlights research that casts doubt on these assumptions and discusses alternative mechanisms of action for preventive blister taping.

to kinetic friction occurs (relative motion between

two surfaces), shear distortions reduce, as seen

in Figure 2. Veijgen et al found static friction

coefficients to be 18% higher than dynamic

friction coefficients.13 This phenomenon can

easily be observed when pushing a heavy piece

of furniture across the floor – the force required

to get the furniture moving is much higher than

that required to keep it moving.14

An easy demonstration of shear on the

human body:

Step 1: The tip of the index finger is pressed

against the back of the opposing hand.

Step 2: Wobbling the finger back and forth

while keeping it in contact with the same patch of

skin results in skin stretching. This is shear, and

it is the true cause of blisters.

Shear might seem to involve rubbing, but it

does not. Notice in the above demonstration that

the fingertip has not moved relative to the skin

of the back of the hand. But the skin on the back

of the hand has moved relative to the underlying

bone – it has undergone shear distortion. Blister

causation is a “duck under water” scenario – be-

low the surface is where the action is occurring!

Blister causation is about stretching (shear), not

rubbing.

Thankfully, the tissues of the feet can tol-

erate a high amount of shear. While blisters will

only form when shear is excessive and repetitive,

the blister-causing threshold will vary between

individuals. This was evident in research by:

• Naylor in 1955 on 19 volunteer British

medical students and doctors.5 He showed

blistering occurred between 27 and 138

repetitions. The middle of the shin was used

in this experiment.

• Sulzberger et al in 1966 conducted on 54

American army personnel.6 Some soldiers

blistered in 3 minutes and others still had

not blistered even after 50 minutes. The

frictional force repetitions were applied to

the palmar skin.

• Hashmi et al in 2013 on 30 volunteers at

the University of Salford.10 They found that

blister onset ranged from between 4 and

32 minutes. The frictional force repetitions

were applied to the back of the heel.

How Might Taping Prevent Blisters?Personal experience and research3 shows a

blister can occur underneath the tape applied to

prevent it. But divergent personal experience and

research4 also shows taping can prevent blisters.

This is why many practitioners use taping on

patients.

With an understanding of what causes

blisters, the following are four potential hypothe-

ses for how preventive taping works:

1. Thermal insulation

Rubbing any two surfaces together causes the

production of heat, and it is no different for the

skin.15-17 Assuming heat is a causative factor in

blister formation, perhaps tape applied to the

skin provides thermal insulation to lessen the

effect of frictional heat. Although plausible,

research to date does not support the theory that

local surface heat generated by rubbing is a sig-

nificant factor in blister formation, as explained

below.

If heat transfer from the surface of the stra-

tum corneum to the stratum spinosum (see Fig-

ure 3) were a major factor in blister development,

one would expect faster rubbing to increase

blister occurrence. Naylor found this not to be

the case.5 In his experimental blister research, he

compared blister rates at two rubbing speeds –

the faster rubbing speed did not cause blisters to

form any more quickly than the slower rubbing

speed. Separately, he compared rubbing with 2

materials that differed in thermoconductivity. No

difference in blistering rate was found.

Hashmi et al produced experimental blisters

at the posterior heel of 30 subjects with an inter-

mittent rubbing force.10 The median temperature

increase at the blister site at the time of blister

formation was 5.1°C (range: 1.7 – 9.9°C) and did

not exceed 35°C.

Li et al demonstrated that rubbing causes

a moderate increase in skin temperature, and

that this warmer area of skin increases sweat

production, which increases skin friction.17 This

perspiration/friction mechanism

[rubbing heat → more perspiration → higher

friction level → blister]

differs from the burn mechanism

[rubbing → heat → burn → blister]

and this distinction should be recognized.

Besides, remembering that the initial blister

injury is within the stratum spinosum of the

epidermis, if heat transfer from the skin surface

to the stratum spinosum were a major factor

in blister development, one would expect the




Figure 2. Shear will peak in a state of static friction (no rubbing). A state of kinetic friction (rubbing) brings about reduced shear strain.

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thicker stratum corneum of the plantar surface to

afford a level of blister protection. The reality is,

a thick corneum is one of the requisites for blister

formation.5-7

Heat is not a requirement for blister for-

mation. Although friction blisters on the feet are

more common in warmer temperatures, blisters

can occur in cold temperatures too.18,19 Griffin et

al18 produced experimental blisters on chilled,

warmed, and “normal” temperature skin and

noted:

• blisters formed more quickly when initial

skin temperature was higher

• blisters took longer to form on chilled skin

(14°C) compared to normal (30°C ) and

warmed skin (46°C )

• when the initial skin temperature was

low, the skin temperature at the time of

blistering was also lower.

Overall, Knape’s review summarizes

it nicely: “Skin temperature appears to be

a minor factor in blister formation. Blisters

form somewhat more rapidly when the

skin temperature is higher but blisters also

occur when the skin temperature is low. In

experimental rubbing studies, local heat is

produced and skin temperatures have been

reported between 41 degrees Celsius and 50

degrees Celsius. However, friction blisters do not

resemble second-degree thermal burns either

clinically or histologically.”20

2. Protection from rubbing

By the admission of sports medicine practitioners

and athletes alike, the most common

understanding of how taping prevents blisters

is “by protecting the skin from rubbing.” But

as explained earlier, rubbing on the skin is not

necessary to cause a blister, and blisters can

occur under tape.3

What does rubbing do? It removes cells

from the skin surface, exposing progressively

deeper and deeper layers. This is not a blister.

This is an abrasion.

So tape does not prevent blisters by

stopping rubbing. Taping protects the skin from

abrasion. But this is abrasion prevention, not

blister prevention.

Consider another blister prevention

strategy: that of lubricants. Lubricants facilitate

rubbing of the sock against the skin to prevent

blisters by way of reducing friction levels (more

below).

3. Reducing friction levels

In-shoe conditions result in high-friction levels.

This is partly by design as materials are chosen

to provide traction for the foot,2,11 and partly

due to the high density of sweat glands and

enclosed environment, because there is minimal

evaporation of moisture when shod.21

It is plausible that tape reduces shear by

lowering friction levels. By replacing the higher

friction skin-sock interface with a lower friction

tape-sock interface, earlier rubbing movement

occurs between the two surfaces. This earlier

state of dynamic friction means shear peak will

be lower, potentially providing blister prevention.

Zhang and Mak articulate this idea well,

stating: “The injurious effects of friction on the

skin and the underlying tissues can be divided

into two classes, those without slip and those

with slip. The former may rupture the epidermis

and occlude blood and interstitial fluid-flows by

stretching or compressing the skin. The latter

adds an abrasion to this damage.”22

Understanding this, Polliack and Scheinberg

gathered a number of blister dressings and tested

their friction properties, observing coefficients of



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Epidermis

Dermis

Dermis

Stratum Basale

Stratum Spinosum

Stratum Granulosum

Stratum Corneum

Hypodermis

Figure 3. Layers of the epidermis. Medical illustration by Chyna LaPorte for LER.

Table 1. Laboratory product comparisons using a custom-made friction-measurement apparatus 23

Product Manufacturer Average CoF† Difference, %‡ Thickness, mm No. of tests

Bursatek bandage Advanced Wound Systems, Newport, OR 0.57 – 6 3

Dr Scholl’s Moleskin Plus Schering-Plough Corp, Kenilworth, NJ 0.69 +21 31 3

Moleskin PPR Inc, Brooklyn, NY 0.94 +64 26 3

Band-Aid Johnson & Johnson, New Brunswick, NJ 1.01 +77 22 3

Band-Aid Plastic Johnson & Johnson 1.03 +80 18 3

2nd Skin Blister Pads Spenco Medical Corp, Waco, TX 1.04 +82 35 3

New-Skin Medtech, Jackson, WY 1.05 +84 9 4

Nexcare Comfort 3M Health Care, St Paul, MN 1.08 +89 35 3

Dr Scholl’s Blister Treatment Schering-Plough Corp 1.20 +110 32 3

Blister Block (Compeed) Johnson & Johnson 1.37 +139 40 3

Tegaderm 3M Health Care 1.54 +169 1.5 3

†CoF indicates coefficient of friction. 237-g normal applied load to end probe. ‡Compared with the Bursatek device. Copyright ©2016 Wilderness Medical Society. Published by Elsevier Inc. Used with permission.


friction ranging from 0.57 to 1.54 (see Table).23

Other in-shoe coefficient of friction data can be found in Carlson,14

including insights into the effect of moisture.

Unfortunately, few of the adhesive tapes used for the prevention of

blisters have had their friction properties tested in any research – only

Moleskin from these charts. What’s more surprising is that we could find

no coefficient of friction data available from the manufacturers for these

tapes! Perhaps this is because most tapes used in blister prevention are

not specifically made for blister prevention. This represents an area for

improving our understanding of this modality’s mechanism of action.

4. Spreading shear load

Cushioning spreads vertical load over a larger area to reduce peak pres-

sure. Does tape spread the tangential shear load over a larger area of skin

to reduce peak shear in a similar way?24

Could it be that without adhesive tape applied, shear peaks at a

certain discrete location? And could it be that with adhesive tape applied

to a wider area of skin, shear is dispersed over that wider area, reducing

the peak? In other words, by spreading the shear load, shear per unit area

of skin may be lessened. If this is the case, a stiffer tape would exert this

effect better than a compliant tape.

ConclusionFor a modality that is arguably the most common blister prevention

strategy used, it is odd that we know so little about how it works. Once a

mechanism is established, more could be understood about which tapes

are best in certain conditions and for certain anatomical regions. Specifics

about application technique could also be identified. The mechanism of

preventing blisters is an area that deserves much more research.

Rebecca Rushton, BSc(Pod), is a podiatrist in private practice at Esperance

Podiatry in Perth, Australia. She is the owner of the foot blister website

blisterprevention.com.au and BlisterPod, which sells blister products.

References

1. Brennan FH. Managing blisters in competitive athletes. Curr Sports

Med Rep. 2002;1(6):319-322.

2. Richie D. How to manage friction blisters. Podiatry Today.

2010;23(6):42-48.

3. Lipman G, Ellis M, Lewis E, et al. A Prospective Randomized Blister

Prevention Trial Assessing Paper Tape in Endurance Distances (Pre-

TAPED). Wilderness Environ Med. 2014;25(4):457-61.

4. Lipman GS, Sharp LJ, Christensen M, et al. Paper Tape Prevents

Foot Blisters: A Randomized Prevention Trial Assessing Paper Tape

in Endurance Distances II (Pre-TAPED II). Clin J Sport Med. 2016

Sep;26(5):362-8.

5. Naylor P. Experimental friction blisters. British J Dermatol.

1955;67:327–342.

6. Sulzberger M, Cortese T, Fishman L, Wiley H. Studies on blisters



produced by friction: I. Results of linear rubbing and twisting technics.

J Invest Dermatol. 1966;47(5):456-465.

7. Akers W, Sulzberger M. The Friction Blister. Mil Med. 1972;137:1-7.

8. Comaish JS. Epidermal Fatigue as a Cause of Friction Blisters. Lancet.

1973;Jan:81-83.

9. Cortese T, Griffin T, Layton L, Hutsell T; Experimental friction blisters

in macaque monkeys. J Invest Dermatol. 1969;53(2):172-177.

10. Hashmi F, Richards B, Forghany S, Hatton A, Nester C. The formation

of friction blisters on the foot: the development of a laboratory-based

blister creation model. Skin Res Technol. 2013;19(1)479-489.

11. Carlson J. Functional limitations from pain caused by repetitive loading

on the skin: A review and discussion for practitioners, with new data

for limiting friction loads. J Prosthet Orthot. 2006;18(4):93-103.

12. Carlson J. The mechanics of soft tissue damage: removing the “teeth”

from the “rub”. The Academy TODAY. 2011;7.1 (Feb):A5-7.

13. Veijgen N, Van der Heide E, Masen M. A multivariable model for pre-

dicting the frictional behaviour and hydration of the human skin. Skin

Res Technol. 2013;19(3):330-338.

14. Carlson J. The friction factor. OrthoKinetic Review 2001;1.7(Nov-

Dec):1-3.

15. Akers WA. Sulzberger on friction blistering. Internat J Dermatol.

1977;16:369-72.

16. El-Shimi AF. In vivo skin friction measurements. J Soc Cosmetic

Chemists 1977;28(Feb):37-51.

17. Li W, Pang Q, Jiang Y, Zhai Z, Zhou Z. Study of physiological parame-

ters and comfort sensations during friction contacts of the human skin.

Tribological Letters. 2012;8:1-12.

18. Griffin C, Cortese T, Layton L, Sulzberger M. Inverse time and tem-

perature relationship in experimental friction blisters. J Invest Derma-

tol. 1969;52:384-401.

19. Knapik J, Reynolds K, Staab J, Vogel JA, Jones B: Injuries associated

with strenuous road marching. Mil Med. 1992;157:64–67.

20. Knapik J, Reynolds K, Duplantis K, Jones B. Friction blisters – patho-

physiology, prevention and treatment. Sports Med. 1995;20(3):136-147.

21. Deng F, Gong T, Jin H, Du S. Research on factors influencing tempera-

ture and relative humidity inside of shoes. College of Resources and

Environments, Shanxi University of Science and Technology. 2009.

Available at https://www.aaqtic.org.ar/congresos/china2009/down-

load/2-6/2-218.pdf. Accessed March 10, 2019.

22. Zhang M, Mak A. In vivo friction properties of human skin. Prosthet

Orthot Internat. 1999;23:135-141.

23. Polliack A, Scheinberg S. A New Technology of Reducing Shear and

Friction Forces on the Skin: Implications for Blister Care in the Wilder-

ness Setting. Wilderness Environ Med. 2006;17:109-119.

24. Carlson J, personal communication, 2013.

https://www.aaqtic.org.ar/congresos/china2009/download/2-6/2-218.pdf

https://www.aaqtic.org.ar/congresos/china2009/download/2-6/2-218.pdf

Here’s why resistance therapy with these low-tech tools is gaining prominence—for youth soccer players, geriatric patients, and everyone in between.By Keith Loria

Elastic resistance bands are increasingly popular

in physical therapy as the modality is being

used to treat a wide number of lower-extremity

problems on a diverse patient population that

covers everyone from youth sports players to

seniors. Experts point to 3 important features

that have contributed to the rise of elastic bands

(here, called simply “bands”) in therapy: They

are inexpensive; don’t take up much storage

space; and are easy to transport.

Furthermore, because of the properties of

bands and because they can be used alone or in

combination with free weights, a range of people

(from the patient to the athlete) can use them.

Keep in mind, however, that it is important to

have a high percentage of total load come from

the bands; otherwise, the benefit of using the

bands will vanish and the effect will instead be

similar to using free weights alone.

A Tool for Loading During Exercise…Vidar Andersen, associate professor of educa-

tion, arts and sports at the Western Norway

University of Applied Sciences, has performed

several studies1,2 examining the effects of elastic

bands on muscle activation, maximal strength,

and explosive parameters.

“In general, our findings show that elastic

bands yield similar effects as more conventional

free weights,” Andersen told LER. “However,

when analyzing different parts of the movement,

elastic bands seem to be more advantageous

in the upper parts of the ascending movement.

This could be useful in both therapy and exer-

cise for those wanting to emphasize these parts

of the movement.”

For example, some patients might have

a problem performing the squat, or similar

exercises, with free weights, due to high torque

at the beginning of the upward movement.

Elastic bands can, in these cases, be a valuable

alternative because they reduce torque in the

early upward phase but still stress muscles in

the upper parts of the movement, when patients

have no problem performing the squat or other

exercises.

Andersen led a 2018 study3 that examined

the effects of full-body elastic resistance band

training in young female team handball players.

In the study, 12 players completed an 11-week

control period, followed by 9 weeks of elastic

resistance band training, during which they per-

formed 6 exercises as part of the team’s standard

training sessions.

All exercises were done with 3 sets of 6 to

10 explosive repetitions. Maximal power output

was tested in squat and bench press, jump

height, throwing velocity and repeated agility

run, before and after control and training peri-

ods. The researchers found that a brief, explo-

sive, full-body elastic resistance band program,

incorporated into regular handball training

sessions for 9 weeks, improved explosive low-

er-limb performance in young female handball

players more than handball training alone.

“I think the elastic bands could be strong

for many injuries and rehab situations,” Ander-


The Therapeutic Power of Elastic Bands


“In general, our findings show that elastic bands yield similar effects as

more conventional free weights…”

iStockPhoto.com # 482982350

sen said. “The elastic bands don’t create a great

torque when going from a descending to an

ascending movement, but more gently increase

the torque as the bands are stretched. Further,

we have performed several interventions with

the elderly performing explosive training and

our experience is that in these situations, the

elastic bands are very useful.”

…and for UnloadingAnother important aspect of the utility of bands

is that they can be used to unload. For example,

if a patient isn’t able to perform a chair rise or

squat because of pain or lack of muscle strength,

bands can be used to reduce some of the body

weight, thus assisting the person in performing

the exercise.

“The research on this topic has increased

in the recent years and I believe the interest

among experts has increased simultaneously,”

Andersen said. “For me, elastic bands have

become more prevalent and will be in the years

to come.

“However, I don’t think we should regard

elastic bands as a replacement for free weights,

but more as an alternative or variation in situ-

ations where the properties of the elastic bands

could be useful.”

A Means to Boost Functional PerformanceEduardo Lusa Cadore, PhD, professor at the

physical education school of the Federal Univer-

sity of Rio Grande do Sul, Porto Alegre, Brazil,

led a study4 that provided evidence that resis-

tance training using elastic bands is an easy,

effective tool for inducing marked functional

performance in older people.

“Specifically, we observed marked improve-

ments in tests that included the ability of sit-to-

stand, walking, dynamic balance, upper-body

muscular endurance and flexibility,” Cadore

explained to LER. “This is an important finding

since elastic bands are easy to carry and may be

used in any space, including at home.”

Cadore described how bands can be used

to treat femoroacetabular impingement (hip

impingement syndrome). For example, patients

can hold the bands at the ankles and perform

exercises for various hip muscles, in an isomet-

ric or dynamic manner (if the syndrome allows

them to exercise dynamically). This approach

has the potential to prevent or delay the need

for surgery and can be used to rehabilitate the

hips postoperatively.

“These bands help, because it is a kind of

resistance that can be used to train, as any kind

of resistance,” Cadore said. “Of course, [a band

has] some upper threshold of resistance, and

one wouldn’t use it for training a competitive

weightlifter. Nevertheless, for people searching

for health and neuromuscular function improve-

ments, it can be used.”

Cadore foresees bands becoming even

more prevalent because the number of studies

using resistance training with elastic bands in

exercise-intervention models is growing.5,6 In

addition, the number of studies validating and

quantifying loads—in each elastic band color

(ie, each color denoting a progressive increase in

resistance), with different initial lengths, and in

various lengths of elastic deformation—is also

increasing. He noted that this is an important

matter because, to prescribe resistance training

using elastic bands, exercise professionals need

to know how to quantify the intensity of the

tool.

“Another important aspect of these bands

is that the workload is always progressive when

bands are deformed,” Cadore said. “In some

joints, [the band] won’t respect the biomechan-

ical characteristic of a muscle group. For exam-

ple, during a knee extension, the internal torque

produced by the knee extensors increases from

90° of knee flexion to full extension, whereas

the band provides progressive resistance. So,

the use of the band in this movement is not

impeditive, but this issue must be taken into

consideration.”

Bands Have Utility in Older PatientsMaurício Krause, PhD, professor in the

department of physiology at the Institute of

Basic Health Sciences, Federal University of

Rio Grande do Sul, recently led a study on

uncomplicated band exercise training for elderly

people.7

“The age-related loss of muscle mass and

function arise from an imbalance between pro-

tein synthesis and protein degradation, resulting

in muscle atrophy and consequent increases in

morbidity and mortality, and can be accelerated

by a combination of factors, which include a

reduced physical activity level and a suboptimal

nutritional profile,” Krause said. “Concerns with

the impact on the healthcare system due to

increased economic and social costs associated

with possible loss of independence with aging

have brought attention to alternative exercise


iStockPhoto.com # 621232042



interventions as an effective way of delaying

the negative effects of aging on functional and

metabolic parameters.”7,8

In this way, physical activity—in particular,

resistance exercise—is an established counter-

measure to attenuate the decline in lean body

mass that occurs with aging. In fact, Krause

said, resistance exercise training can induce

several benefits in older people, including:

• increased muscle strength and power

• improved insulin sensitivity

• enhanced mitochondrial function

• reduced inflammation

• muscle-mass growth.

Krause and colleagues’ study7 sought to

determine the effects of 12 weeks of resistance

exercise training, plus protein supplementation

on body composition, markers of muscle atro-

phy and hypertrophy, and heat-shock response

(a molecular pathway involved in cellular pro-

tection, having an important anti-inflammatory

role) in 38 healthy, older (mean age, 63.5 ± 4.4

years) adults.

“Our group demonstrated that 12-weeks of

traditional [resistance exercise], using profes-

sional gym equipment, in diabetic elderly people

is an effective tool to improve muscle function,

metabolism, and immune system functional-

ity,” Krause said. “However, the use of specific

exercise equipment is not always available.

So, we tested a nontraditional, body weight-

based, elastic-band resistance training to test if

this type of exercise would also be effective to

improve muscle metabolism, body composition,

and muscle function in healthy elderly people.”

To test that hypothesis, the researchers

designed a 12-week training protocol using

only body weight and elastic bands as sources

of resistance. The training was conducted in a

gymnasium on 3 nonconsecutive days a week

by qualified sport and exercise scientists; each

session lasted 45 to 60 minutes and consisted

of a warm-up period, body weight- and elastic

band-based resistance exercise training, and

a cool-down period. Primary exercises used

throughout the program included squats, lunges,

hip abduction, shoulder press, latissimus dorsi

pull-down, bicep curls, calf raises, pushups, tri-

ceps dips, and lumbopelvic stabilization exercises.

“Among the findings were that body weight/

elastic bands-based resistance exercise training

increases muscle mass and function in healthy

elderly people, independently of protein sup-

plementation,” Krause said. “This indicates that

exercise training, using body weight and elastic

bands, is an efficient way to maintain and even

increase muscle mass in elderly people, especially

at the lower limbs.”

Participants in the exercise training also

saw their muscle function-testing scores improve.

When protein supplementation was added to

their diet, additional gains were detected, includ-

ing lower fat mass and changes in skeletal-muscle

signaling (eg, protein synthesis pathways and the

heat-shock response).

State of the Art: Uncomplicated, Under SupervisionKrause summed it up: “The use of elastic

bands and body weight as resistance exercise is



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receiving more attention from exercise experts

because [bands offer] an uncomplicated way

to exercise at any place—home, work, outside,

etc. However, it is important that people receive

an appropriate orientation and supervision on

how to use [bands] correctly, how to choose the

individual load, and how they should progress

with the training.”

Keith Loria is a Washington, DC-based freelance

writer.

References

1. Andersen V, Fimland MS, Kolnes MK, et al.

Elastic bands in combination with free weights

in strength training: neuromuscular effects. J

Strength Cond Res. 2015;29(10):2932-2940.

2. Saeterbakken AH, Andersen V, Kolnes MK,

et al. Effects of replacing free weights with

elastic band resistance in squats on trunk

muscle activation. J Strength Cond Res.

2014;28(11):3056-3062.

3. Andersen V, Fimland MS, Cumming

KT, et al. Explosive resistance training

using elastic bands in young female team

handball players. Sports Med Int Open.

2018;2(6):E171-E178.

4. Cadore EL, Pinto RS, Bottaro M, et al.

Strength and endurance training prescrip-

tion in healthy and frail elderly. Aging Dis.

2014;5(3):183-195.

5. Iversen VM, Mork PJ, Vasseljen O, et al. Mul-

tiple-joint exercises using elastic resistance

bands vs. conventional resistance-training

equipment: A cross-over study. Eur J Sport Sci.

2017;17(8):973-982.

6. Kubo T, Hirayama K, Nakamura N, et al.

Effect of accommodating elastic bands on

mechanical power output during back squats.

Sports (Basel). 2018;6(4):pii:E151.

7. Krause M, Crognale D, Cogan K, et al. The

effects of a combined bodyweight-based and

elastic bands resistance training, with or with-

out protein supplementation, on muscle mass,

signaling and heat shock response in healthy

older people. Exp Gerontol. 2019;115:104-113.

8. de Lemos Muller CH, Rech A, Botton CE, et

al. Heat-induced extracellular HSP72 release

is blunted in elderly diabetic people compared

with healthy middle-aged and older adults, but

it is partially restored by resistance training.

Exp Gerontol. 2018;111:180-187.

LATEST RESEARCH…Resistance Exercise to Forestall Cognitive Decline?“As a preventative tool [for Alzheimer’s disease], resistance exercise improves memory, attention, spatial awareness, reaction time, planning, and information processing. Improvements in cognitive performance following resistance exercise and training may be mediated by peripheral elevations in … physiological biomarkers (ie, neural and vascular).”

Source: Marston KJ, Brown BM, Rainey-Smith SR, Peiffer JJ. Resistance exercise-induced responses in physiological factors linked with cognitive health. J Alzheimers Dis. 2019:68(1):39-64.


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TECHNOLOGY

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PEDIATRIC REHABILITATION

Positive Outcomes for Successful Practitioners

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THE X BRACE ADDED TO MEDI-DYNE PAIN RELIEF SOLUTIONS

Medi-Dyne Healthcare Products has acquired The X Brace. Developed by Joshua P. Eldridge, DC, DACBSP, for relief of heel pain due to plantar fasciitis and Sever’s disease, The X Brace is an easy-to-use foot and heel support product. It provides a comfortable, low-profile, pain-relieving solution for previously hard-to-treat circumstances, such as when wearing flip flops or sandals, or when walking barefoot. Ac-cording to Medi-Dyne, The X Brace has been used effectively by athletes and other sufferers worldwide. Medi-Dyne products, including The X Brace, are made in the US.

Medi-Dyne Healthcare Products800/810-1740medi-dyne.com

UNISA CREATES RECIPE FOR REALISTIC FOOT ULCERSPodiatrists at the University of South Australia (UniSA), Adelaide, have blended icing sugar, chicken stock, and flexible resin to create real-istic-looking foot ulcers as part of a world-first podiatric training initiative. Helen Banwell, DPM, and Ryan Causby, DPM, concocted the mixture, which is being added to 3D-printed feet and is designed to mimic infected and non-infected diabetic foot wounds.

The addition of lifelike ulcers and effects is added by UniSA’s podiatry team and can en-compass anything from dry gangrene to oozing pus. Banwell said the 3D foot models, which

are made from thermoplastic polyurethane, will play a part in teaching fourth-year podiatry students how to treat and manage high-risk foot conditions.

“The most effective way to manage these conditions is to medically remove dead or damaged skin to expose the healthy skin un-derneath and encourage healing,” said Banwell. “The 3D foot models—and the mock injuries with which we enhance them—enable us to provide a realistic but safe learning tool for stu-dents to practice their scalpel skills, before they begin clinical placements, and all without the stress or anxiety of treating a real patient.”

To support the training, ulcer debridement and management videos are being developed.

UniSA is also trialing 3D-printed baby legs in podiatry pediatric teaching sessions to allow students hands-on practice for clubfoot casting.

CMS LAUNCHES “WHAT’S COVERED” APP TO GUIDE BENEFICIARIESThe Centers for Medicare & Medicaid Ser-vices (CMS) launched a new app that gives consumers direct access on a mobile device to some of the most-used content on Medicare.gov. The new “What’s Covered” app lets people with Original Medicare, caregivers, and others quickly see whether Medicare covers a specific medical item or service. The app also provides beneficiaries with access to Blue Button 2.0, an

application programming interface, created by the US Digital Service, that enables beneficia-ries with different needs to grant access to de-velopers who can help them monitor for drug conflicts, refill prescriptions, and track progress toward desired healthcare outcomes.

CMS launched the eMedicare initiative in 2018 to empower beneficiaries with cost and quality information. Other tools in the eMedi-care suite include:

• Enhanced interactive online decision

support to help beneficiaries better

understand and evaluate their Medicare

coverage options and costs between

Medicare and Medicare Advantage.

• A new online service that lets people see

how different coverage choices will affect

their estimated out-of-pocket costs.

• New price transparency tools that let

consumers compare the national average

costs of certain procedures between

settings, so people can see what they’ll

pay for procedures done in a hospital

outpatient department versus an

ambulatory surgical center.

• A new webchat option in the Medicare

Plan Finder.

The What’s Covered app is available for free in Google Play (play.google.com/store/apps/details?id=gov.medicare.coverage) and the Apple App Store (itunes.apple.com/us/app/whats-covered/id1444143600?mt=8).

WOUND HEALING CLINICAL & TRANSLATIONAL RESEARCH TEAM RECEIVES GRANT TO JOIN DIABETIC FOOT CONSORTIUMThe clinical and translational research team at the University of Miami (UM) Miller School of Medicine’s Department of Dermatology and Cutaneous Surgery received a 4-year, $1.7

INDUSTRY SNAPSH TNoteworthy products, association news, and market updates


Photograph of 3D-printed feet, some enhanced with foot ulcers, courtesy of UniSa.

million grant to become 1 of 6 Clinical Re-search Units (CRU) in the US to help improve outcomes for patients with diabetic foot ulcers. This team approach to research is part of the National Institute of Diabetes and Digestive and Kidney Diseases’ Diabetic Foot Consor-tium (DFC) for future clinical study of selected biomarkers.

The objective of the DFC is to establish an organizational framework and infrastructure that will serve as a platform for integrated multidisciplinary experimental clinical and translational research. The UM-CRU will, in conjunction with DFC, develop the research design and study protocol, and establish proto-cols for participant recruitment and follow-up, data collection, quality control, interim data and safety monitoring, final data analysis and interpretation, and publication of results. In addition, UM-CRU and DFC will facilitate procurement, storage, and shipment of the bio-materials (tissue samples, swabs, wound fluid, blood, serum, and/or urine) as a part of the future biomarker studies. It will also establish and maintain a clinical database that will allow overall data analyses of the DFC.

PIEDRO PEDIATRIC ORTHOPEDIC FOOTWEAR

Cascade Orthopedic Supply has expanded its product line with the addition of Piedro Pediat-ric Orthopedic Footwear. The new line of foot-wear features a wider and deeper toe box to ensure a precision fit with orthotic devices. The double stitching and high abrasion-resistant toe cap provide increased durability for children. Piedro Pediatric Orthopedic Footwear features an adjustable depth and a trimmable sole, and is available with either lace or Velcro closures. Color options for the new shoe line include

pink, blue, and black to match any taste. Shoe sizes include Toddler (4–9), Youth (10–13, 1–3), and Adolescent (4–7).

Cascade Orthopedic Supply800/888-0865cascade-usa.com

ICEBREAKER HIKE LIGHT CREW

Suitable for adventure and hiking, Icebreaker’s men’s Hike Light Crew sock is designed to be an ideal sock for year-round comfort on the trail. The sock has double up cushioning for comfort. It is made from breathable, tempera-ture-regulating merino wool (60%); nylon (37%) for durability; and Lycra (3%). Addi-tional design features include Achilles support, reinforced heel and toe, instep support, and a comfort cuff. The overall goal of the adven-ture sock is to keep the wearer’s feet happy to ensure great journeys. The socks come in a twisted-heather color and are available in small, medium, large, and extra-large sizes. The company offers a lifetime guarantee on all of its socks.

Icebreaker877/827-6816icebreaker.com

SIGVARIS IS NOW SIGVARIS GROUP SIGVARIS, Peachtree, Georgia, has changed its corporate name and logo from SIGVARIS to SIGVARIS GROUP. SIGVARIS, a 155-year-

old Swiss company, manufactures medical compression socks and hosiery with a wide assortment of inelastic wraps and lymphedema garments. SIGVARIS GROUP will use this opportunity to build a customer-centric plat-form for innovation and growth, according to a company press release. In the new brand ar-chitecture, products will have their own unique brands to bring more clarity and understanding to product positioning and to differentiate the organization from product brands.

ORTHOTIC STRAP KITS

JMS Plastics Supply has introduced orthotic straps as a new market offering. The exclusive straps are made from reinforced PVC that is welded together with high frequency to make them strong and durable. The straps feature hook-and-loop closures and are available in kits or sold individually. Each kit contains one PVC Chafe, one strap, and one pad. Kits are offered in nine colors and four widths. JMS Plastics’ orthotic straps can also be ordered to feature any company logo.

JMS Plastics Supply800/342-2602jmsplastics.com

INDUSTRY SNAPSHOT


INDUSTRY SNAPSHOT

REVISTIM WEARABLE DC STIMULATOR

Prizm Medical has introduced the ReviStim DC Stimulator, which is described as the world’s first wearable DC stimulation device. The unit’s copyrighted software delivers DC electrotherapeutic energy uniformly over the entire treatment area through hydrogel stick-on electrodes or Prizm’s proprietary Sigma gar-ment electrodes. Sigma garments are soft and comfortable, and they are available in the form of socks, sleeves, and gloves. The ease of use of the products, coupled with the compact size of the ReviStim, allows for nighttime delivery of electrotherapeutic treatment, thereby in-creasing the number of treatments per day and allowing for improved patient compliance.

Prizm Medical770/622-0933woundstim.com

CMS INCLUDES 7 OTS KNEE ORTHOSES IN 2021 COMPETITIVE BIDDING PROGRAMThe Centers for Medicare & Medicaid Ser-vices (CMS) announced that the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bid-ding Program for dates of service beginning January 1, 2021, will include 7 off-the-shelf (OTS) knee orthoses. The affected codes are L1812, L1830, L1833, L1836, L1850, L1851, and L1852. According to CMS, the law requires that OTS orthotics or braces are included in the DMEPOS competitive bidding program, specifically, “orthotics which require minimal

self-adjustment for appropriate use and do not require expertise in trimming, bending, mold-ing, assembling, or customizing to fit to the individual.”

To access the DMEPOS Competitive Bidding Round 2021 Fact Sheet, visit gov/newsroom/fact-sheets/dmepos-competitive-bid-ding-round-2021.

INSIGHTFUL PRODUCTS’ MASTED KNEE BRACE

The Masted Knee Brace (MKB) is the newest design offered by Insightful Products. The MKB was developed primarily to address the common problem of distal migration. This knee orthosis is said to ensure good knee and brace-joint alignment. It has adjustable flexion and extension stops at 15-degree increments and the foot section offers full range of motion for the foot/ankle complex. The posterior calf and thigh sections allow for easy donning. This orthotic solution is indicated for conical limb shapes where suspension is a challenge. Ac-cording to Insightful Products, the MKB is ap-propriate for rehabilitation, post-op, ACL, or to control recurvatum. It can be configured with an integrated Step-Smart Brace for those with foot drop. Videos on the company’s website of-fer more information. HCPCS code L1832.

Insightful Products207/885-0414insightfulproducts.com

$11 MILLION NIH GRANT CREATES NEW CENTER FOR MUSCULOSKELETAL RESEARCH Clemson University, South Carolina, received an $11 million grant from the National In-stitutes of Health’s Center for Biomedical Research Excellence to launch a new research center that will bring together scientists from across the state to change the way musculo-skeletal disorders are diagnosed, treated, and studied. Led by bioengineers at Clemson, the South Carolina Center for Translational Research Improving Musculoskeletal Health combines orthopedics and other clinical exper-tise from the Greenville Health System and the Medical University of South Carolina with computer scientists, computational engineers, biophysicists, and other experts to better understand musculoskeletal disorders and to design and evaluate new devices, interventions, and drug therapies.

RENOWNED ORTHOPEDIC SURGEON TO LEAD FOOT AND ANKLE DIVISION AT NYU LANGONE HEALTHJohn G. Kennedy, MD, renowned for his work in the surgical treat-ment of foot and ankle injuries, has been ap-pointed the new chief of the Foot and Ankle Division in the De-partment of Orthopedic Surgery, and Director of the Foot and Ankle Center at NYU Langone Health. He joined NYU Langone in January, where he holds the title of professor of ortho-pedic surgery at NYU School of Medicine.

Kennedy brings to NYU Langone a spe-cial interest in articular cartilage injury and joint preservation. He has been a leader in minimally invasive, arthroscopic treatments of cartilage injuries of the ankle and smaller joints of the foot. An award-winning researcher, Ken-nedy and his team collaborate on National In-stitutes of Health (NIH) research into cartilage


INDUSTRY SNAPSHOT


regeneration and work with several interna-tional universities, investigating basic science and clinical outcomes in cartilage regenera-tions, tendon healing, and bone growth. These collaborations have resulted in more than 200 publications in medical journals and more than 500 podium presentations worldwide.

Kennedy is an alumnus of the Royal Col-lege of Surgeons in Dublin, Ireland. In 2002, he started the first subspecialty foot and ankle sports injury clinic in New York City. Most recently, Kennedy spent the past 17 years as an assistant professor of orthopedic surgery at Weill Cornell Medical School, and as an assis-tant attending physician at Hospital for Special Surgery, both of which are located in New York City. In addition, Kennedy serves as co-presi-dent of the International Society on Cartilage Repair of the Ankle, which last year established the International Consensus Meeting on Car-tilage Repair of the Ankle to standardize ankle cartilage treatment algorithms.

SAMUEL HUBBARD WOMEN’S CITY ZIPPER BOOT

Slide in. Zip up. Step out. The City Zipper from Samuel Hubbard is designed to wow the wearer’s feet. Comfort engineering is at the heart of how Samuel Hubbard designs and builds its shoes. Meant to be the go-to-boot in any women’s closet, the women’s City Zipper is fabricated from premium European sourced,

tumbled leather soft uppers, and buttery-soft glove leather sock linings for comfort and breathability. The boot features an easy-glide, extra-light EVA custom-designed outsole, and incorporates removable Poron insoles and heel support. The boots are available in size 5½ to 11, including half sizes and medium width. Samuel Hubbard’s footwear is handcrafted in Portugal.

Samuel Hubbard844/482-4800samuelhubbard.com

CORE-SPUN PATTERNED AFO SOCKS BY SMARTKNIT

Knit-Rite has long been a manufacturer of SmartKnit Seamless Socks made for adults and children who use AFOs. SmartKnit Seam-less Socks are soft and comfortable, giving the feeling of a cool second layer of skin between the wearer and the AFO. Knit-Rite now offers Core-Spun Patterned AFO Socks by Smart-Knit. The children’s AFO Socks are available in 2 patterns: thin line (white with grey and purple striping), cheery (black sock with bright blue, doughnut-shaped spots), and halo (3-pack of socks with the same pattern but in 3 different color combinations—white with soft yellow striping, grey with hunter green striping, and black with bright blue striping). For adults, Knit-Rite offers a classic diamond pattern for a professional look.

Knit-Rite800/821-3094knitrite.com

APTA, ACSM FORMALIZE NEW PARTNERSHIPThe American Physical Therapy Association (APTA) has partnered with the American College of Sports Medicine (ACSM), under the APTA Partnerships program, which seeks to enhance relationships and develop mutually beneficial partnerships with other organiza-tions that share common goals. The program allows APTA to extend its reach in advancing the physical therapy profession.

In signing this memorandum of understanding, APTA and ACSM seek to build on existing collaboration to advance their missions and the health of communities and individuals through movement, physical activity, and exercise. APTA and ACSM also hope to work jointly on advocacy efforts as well as to incorporate elements and expand participation of both groups in each other’s events and initiatives.

SPS PROMOTES WEGER TO VP AND GENERAL MANAGERHanger, Inc., Austin, Texas, announced that Regina Weger has been promoted to VP and general manager of its subsidiary SPS, Alpharetta, Georgia. Weger has been with SPS for over 20 years, having started her ca-reer within the customer service function and taking on additional roles and responsibilities throughout the years. For the past 2 years she served as VP of SPS sales and marketing. We-ger will continue reporting to Jay Wendt, pres-ident of Hanger’s Product & Services business segment, in her new role as a member of the Products & Services leadership team.

“This is a well-deserved promotion for Regina, as she has been functioning in a gen-eral manager capacity for us, taking on several additional leadership responsibilities on top of her role as vice president of sales and market-ing,” said Wendt.

ACROSS1 More of these bikes sold than road bikes5 Resort often offers gym facilities7 Common name for diagnostic images pro-

duced by electromagnetic waves9 Dieters fixate on this measurement, abbr.11 In good physical condition12 SSN, for one13 With chamomile, it might alleviate anxiety14 Hits the ground16 Fluid-filled sac is a toe problem for marathon

runners17 ____ manual20 Anatomical sac in the knee21 Almost an eternity23 Often describes timing of a physical exam24 Severe, as pain26 Here are found phalanxes27 Triathlon competitor30 Surgical procedure, abbr.31 __ Capitan, beloved by climbers32 Take it by mouth, abbr34 West Coast city that holds annual marathon35 One type of bone stimulation

DOWN1 Relating to jaws and face; frequent type of

mountain bike injury2 Land of the ACA3 Trials4 Pen point5 Most common type of injury associated with

mountain biking accidents6 The “A” in PAD8 Nutritionist’s intake measure, for short9 Places for experiments10 They are being used to improve bone fracture

healing15 Problem when a bone fails to knit back

together18 Area19 One source of skin Ca, en Espanol22 Made better25 Admit wrongdoing28 Inclined29 Neither’s partner33 Copper symbol

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Test your knowledge of information from this issue of Lower Extremity Review and the world in general with our new crossword puzzle feature. The answer box can be found online at lermagazine.com

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