Deborah A. Nawoczenski

Abnormal scapular kinematics and associated muscle function presumably contribute to shoulder pain and pathology. An understanding of scapular kinematic and electromyographic profiles in asymptomatic individuals can provide a basis for evaluation of pathology. The purpose of this study was to describe normal three-dimensional scapular orientation and associated muscle activity during humeral elevation. Twenty-five asymptomatic subjects, 19-37 years old, were evaluated. Digitized coordinate data and surface electromyographic signals from the trapezius (upper and lower), levator scapulae, and serratus anterior were collected at static positions of 0, 90, and 140 degrees of humeral elevation in the scapular plane. The scapula demonstrated a pattern of progressive upward rotation, decreased internal rotation, and movement from an anteriorly to a posteriorly tipped position as humeral elevation angle increased. Electromyographic activity of all muscles studied increased with increased humeral elevation angles. Differences between mean values at all elevation angles for all variables were significant (p < .05), except for the lower trapezius between the 90 and 140 degrees humeral angles. The results of this study suggest assessment of scapular tipping and internal rotation as well as upward rotation may be necessary to understand pathologies of the shoulder that are related to abnormal scapular kinematics.

BACKGROUND: Approximately 10% of patients with plantar fasciitis have development of persistent and often disabling symptoms. A poor response to treatment may be due, in part, to inappropriate and nonspecific stretching techniques. We hypothesized that patients with chronic plantar fasciitis who are managed with the structure-specific plantar fascia-stretching program for eight weeks have a better functional outcome than do patients managed with a standard Achilles tendon-stretching protocol. METHODS: One hundred and one patients who had chronic proximal plantar fasciitis for a duration of at least ten months were randomized into one of two treatment groups. The mean age was forty-six years. All patients received prefabricated soft insoles and a three-week course of celecoxib, and they also viewed an educational video on plantar fasciitis. The patients received instructions for either a plantar fascia tissue-stretching program (Group A) or an Achilles tendon-stretching program (Group B). All patients completed the pain subscale of the Foot Function Index and a subject-relevant outcome survey that incorporated generic and condition-specific outcome measures related to pain, function, and satisfaction with treatment outcome. The patients were reevaluated after eight weeks. RESULTS: Eighty-two patients returned for follow-up evaluation. With the exception of the duration of symptoms (p < 0.01), covariates for baseline measures revealed no significant differences between the groups. The pain subscale scores of the Foot Function Index showed significantly better results for the patients managed with the plantar fascia-stretching program with respect to item 1 (worst pain; p = 0.02) and item 2 (first steps in the morning; p = 0.006). Analysis of the response rates to the outcome measures also revealed significant differences with respect to pain, activity limitations, and patient satisfaction, with greater improvement seen in the group managed with the plantar fascia-stretching program. CONCLUSIONS: A program of non-weight-bearing stretching exercises specific to the plantar fascia is superior to the standard program of weight-bearing Achilles tendon-stretching exercises for the treatment of symptoms of proximal plantar fasciitis. These findings provide an alternative option to the present standard of care in the nonoperative treatment of patients with chronic, disabling plantar heel pain.

BACKGROUND: In a previous investigation, eighty-two patients with chronic proximal plantar fasciitis for a duration of more than ten months completed a randomized, prospective clinical trial. The patients received instructions for either a plantar fascia-stretching protocol or an Achilles tendon-stretching protocol and were evaluated after eight weeks. Substantial differences were noted in favor of the group managed with the plantar fascia-stretching program. The goal of this two-year follow-up study was to evaluate the long-term outcomes of the plantar fascia-stretching protocol in patients with chronic plantar fasciitis. METHODS: Phase one of the clinical trial concluded at eight weeks. At the eight-week follow-up evaluation, all patients were instructed in the plantar fascia-stretching protocol. At the two-year follow-up evaluation, a questionnaire consisting of the pain subscale of the Foot Function Index and an outcome survey related to pain, function, and satisfaction with treatment was mailed to the eighty-two subjects who had completed the initial clinical trial. Data were analyzed with use of a mixed-model analysis of covariance for each outcome of interest. RESULTS: Complete data sets were obtained from sixty-six patients. The two-year follow-up results showed marked improvement for all patients after implementation of the plantar fascia-stretching exercises, with an especially high rate of improvement for those in the original group treated with the Achilles tendon-stretching program. In contrast to the eight-week results, the two-year results showed no significant differences between the groups with regard to the worst pain or pain with first steps in the morning. Descriptive analysis of the data showed that 92% (sixty-one) of the sixty-six patients reported total satisfaction or satisfaction with minor reservations. Fifty-one patients (77%) reported no limitation in recreational activities, and sixty-two (94%) reported a decrease in pain. Only sixteen of the sixty-six patients reported the need to seek treatment by a clinician. CONCLUSIONS: This study supports the use of the tissue-specific plantar fascia-stretching protocol as the key component of treatment for chronic plantar fasciitis. Long-term benefits of the stretch include a marked decrease in pain and functional limitations and a high rate of satisfaction. This approach can provide the health-care practitioner with an effective, inexpensive, and straightforward treatment protocol.

Foot orthotics have been used successfully in the treatment of musculoskeletal symptoms associated with structural variations of the foot. Their effectiveness has been primarily addressed through two-dimensional, frontal plane motion studies of the subtalar joint in individuals considered "clinical pronators." Recent evidence suggests that assessment of tibial axial rotation in combination with frontal plane analysis of calcaneal inversion/eversion may provide improved understanding of subtalar joint function. The purpose of this study was to examine the effects of semi-rigid foot orthotics on three-dimensional lower limb kinematics in 20 recreational runners presenting with distinct structural foot characteristics. Radiographic measurements were used to classify subjects into a low or high rearfoot profile group. The results of the kinematic analysis showed a significant orthotic effect for rotations occurring from heel contact to peak tibial internal rotation, as well as in the coupling relationship between tibial axial rotation and calcaneal inversion/eversion. Both groups responded similarly with a mean reduction of 2 degrees in tibial internal rotation. No differences were found for the frontal plane rotations for either group when orthotics were worn. The findings suggest that the maximum effect of orthotics may be realized in the first 50% of stance and related to the changes in tibial axial rotation.