Exercise Therapy in the Management of Musculoskeletal Disorders ( PDFDrive )

The Knee 185 trial (FAST). Journal of the American Medical Association, Mandelbaum, B.R., Silvers, H.J., Watanabe, D.S., Knarr, J.F., 277, 32–37. Thomas, S.D., Griffin, L.Y., Kirkendall, D.T. and Garrett, Evcik, D. and Sonel, B. (2002) Effectiveness of a home-based W. (2005) Effectiveness of a neuromuscular and proprio- exercise therapy and walking programme on osteoarthritis ceptive training program in preventing anterior cruciate of the knee. Rheumatology International, 22, 103–106. ligament injuries in female athletes. American Journal of Eyigor, S. (2004) A comparison of muscle training methods Sports Medicine, 33, 1003–1010. in patients with knee osteoarthritis. Clinical Rheumatology, 23, 109–115. Manninen, P., Riihimaki, H., Heliovaara, M. and Fransen, M., Mc Connell, S. and Bell, M. (2001) Exercise for Suomalainen, O. (2001) Physical exercise and the risk of osteoarthritis of the hip or knee (review). Cochrane severe knee osteoarthritis requiring arthroplasty. Database of Systematic Reviews, 2, CD004376. Rheumatology, 40, 432–437. Fredberg, U., Bolvig, L. and Andersen, N.T. (2008) Prophylactic training in asymptomatic soccer players with Mason, D. L., Dickens, V. and Vail, A. (2007) Rehabilitation ultrasonographic abnormalities in Achilles and patellar for hamstring injuries (review). Cochrane Database of tendons: the Danish Super League Study. American Journal Systematic Reviews, 1, CD004575. of Sports Medicine, 36, 451–460. Gilchrist J., Mandelbaum, B.R., Melancon, H., Ryan, G.W., McConnell, J. (1996) Management of patellofemoral prob- Silvers, H.J., Griffin, L.Y., Watanabe, D.S., Dick, R.W. and lems. Manual Therapy, 1, 60–66. Dvorak, J. (2008) A randomised controlled trial to prevent noncontact anterior cruciate ligament injury in female col- Neptune, R.R. and Kautz, S.A. (2000) Knee joint loading in legiate soccer players. American Journal of Sports Medicine, forward versus backward pedalling: implications for reha- 36, 1476–1483. bilitation strategies. Clinical Biomechanics, 15, 528– Grodski, M. and Marks, R. (2008) Exercises following ante- 535. rior cruciate ligament reconstructive surgery: biomechani- cal considerations and efficacy of current approaches. Ng, G.Y.F. and Wong, P.Y.K. (2009) Patellar taping affects Research in Sports Medicine, 16, 75–96. vastus medialis obliquus activation in subjects with patel- Hassan, B.S., Mockett, S. and Doherty, M. (2001). Static lofemoral pain before and after quadriceps muscle fatigue. postural sway, proprioception and maximal voluntary Clinical Rehabilitation, 23, 705–713. quadriceps contraction in patients with knee osteoarthritis and normal control subjects. Annals of Rheumatic O’Reilly, S.C., Muir, K.R. and Doherty, M. (1999) Diseases, 60, 612–618. Effectiveness of home exercise on pain and disability from Heintjes, E., Berger, M.Y., Bierma-Zeinstra, S.M.A., Bernsen, osteoarthritis of the knee: a randomised controlled trial. R.M.D., Verhaar, J.A.N. and Koes, B.W. (2003) Exercise Annals of Rheumatic Diseases, 58, 15–19. therapy for patellofemoral pain syndrome (review). Cochrane Database of Systematic Reviews, 4, CD003472. O’Sullivan, S.P. (2005) Activation of vastus medialis obliquus Herrington, L. and Al-Sherhi, A. (2007) A controlled trial of among individuals with patellofemoral pain syndrome. weight-bearing versus non-weight-bearing exercises for Journal of Strength and Conditioning Research, 19, patellofemoral pain. Journal of Orthopaedic and Sports 302–304. Physical Therapy, 37, 155–60. Houghum, P. (2005) Therapeutic Exercises for the Pai, Y.C., Rymer, W.Z., Chang, R.W. and Sharma, L. (1997) Musculoskeletal Injuries, 2nd edn. Human Kinetics, Effect of age and osteoarthritis on knee proprioception. Champaign, Illinois. Arthritis and Rheumatism, 40, 2260–2265. Jan, M.H., Lin, J.J., Liau, J.J., Lin, Y.F. and Lin, D.H. (2008) Investigation of clinical effects of high and low resistance Panics, G., Tallay, A., Pavlik, A. and Berkes, I. (2008) Effect training for patients with knee osteoarthritis: a randomised of proprioception training on knee joint position sense in controlled trial. Physical Therapy, 88, 427–436. female team handball players. British Journal of Sports Jonsson, P. and Alfredson, H. (2005) Superior results with Medicine, 42, 472–476. eccentric compared to concentric quadriceps training in patients with jumper’s knee: a prospective randomised Peccin, M.S., Almeida, G.J.M., Amaro, J., Cohen, M., Soares, study. British Journal of Sports Medicine, 39, 847–850. B.G.O. and Atallah, A.N. (2005) Interventions for treating Koralewicz, L.M. and Engh, G.A. (2000) Comparison of posterior cruciate ligament injuries of the knee in adults. proprioception in arthritic and age-matched normal knees. Cochrane Database of Systemic Reviews, 3, CD002939. Journal of Bone and Joint Surgery, American Volume, 82, 1582–1588. Pennix, B.W., Messier, S.P., Rejeski, W.J., Williamson, J.D., Lewek, M.D., Rudolph, K.S. and Snyder-Mackler, L. (2004) DiBari, M., Cavazzini, C., Applegate, W.B. and Pahor, M. Quadriceps femoris muscle weakness and activation failure (2001) Physical exercise and the prevention of disability in in patients with symptomatic knee osteoarthritis. Journal activities of daily living in older persons with osteoarthri- of Orthopaedic Research, 22, 110–115. tis. Archives of Internal Medicine, 161, 2309–2316. Purdam, C., R., Johnsson, P., Alfredson, H., Lorentzon, R., Cook, J.L. and Khan, K.M. (2004) A pilot study of the eccentric decline squat in the management of painful chronic patellar tendinopathy. British Journal of Sports Medicine, 38, 395–397. Reider, B., Arcand, M.A., Diehl, L.H., Mroczek, K., Abulencia, A., Stroud, C.C., Palm, M., Gilbertson, J. and Staszak, P. (2003) Arthroscopy. Journal of Arthroscopic and Related Surgery, 19, 2–12. Rogind, H., Bibow-Nielsen, B., Jensen, B., Moller, H.C., Frimodt-Moller and Bliddal, H. (1998) The effects of a

186 Exercise Therapy in the Management of Musculoskeletal Disorders physical training programme on patients with osteoarthri- combination with collateral ligament and meniscal damage tis of the knees. Archives of Physical Medicine and of the knee in adults. Cochrane Database of Systematic Rehabilitation, 79, 1421–1427. Reviews, Issue 3. Art No.: CD005961. DOI:10.1002/ Sevick, M.A., Bradham, D.D., Muender, M., Chen, J., 14651858.CD005961. Enarson, C., Dailey, M. and Ettinger, W.H. (2000) Cost Tsauo, J.Y., Cheung, P-F. and Yang, R.S. (2008) The effects effectiveness of aerobic and resistance exercise in seniors of sensorimotor training on knee proprioception and func- with knee osteoarthritis. Medicine and Science in Sports tion for patients with knee osteoarthritis: a preliminary and Exercise, 32, 1534–1540. report. Clinical Rehabilitation, 22, 448–457. Silva, L.E., Valim, V., Pessanha, A.P.C., Oliviera, L.M., Vagan, V. and Hunt, E. (2008) Patellofemoral pain syn- Myamoto, S., Jones, A. and Natour, J. (2008) Hydrother- drome: a review on the associated neuromuscular deficits apy versus conventional land based exercise for the and current treatment options. British Journal of Sports management of patients with osteoarthritis of the knee: Medicine, 42, 789–795. A randomised clinical trial. Physical Therapy, 88, Van Baar, M.E., Assendelft, W.J.J., Dekker, J., Oostendorp, 12–21. R.A.B. and Bijlsma, J.W.J. (1999) Effectiveness of exercise Slemenda, C., Brandt, K.D., Heilman, D.K., Mazzuca, S., therapy in patients with osteoarthritis of the hip or knee. Braunstein, E.M., Katz, B.P. and Wolinsky, F.D. (1997) Arthritis and Rheumatism, 42, 1361–1369. Quadriceps weakness and osteoarthritis of the knee. Visnes, H. and Bahr, R. (2007) The evolution of eccentric Annals of Internal Medicine, 127, 94–104. training as treatment for patellar tendinopathy (jumper’s Syme, G., Rowe, P., Martin, D. and Daly, G. (2008) Disability knee): a critical review of exercise programmes. British in patients with chronic patellofemoral pain syndrome. A Journal of Sports Medicine, 41, 217–223. randomised controlled trial of VMO training versus Witvrouw, E., Danneels, L., Van Tiggelen, D., Willems T.M. general quadriceps strengthening. Manual Therapy, 14, and Cambier, D. (2004) Open versus closed kinetic chain 252–263. exercises in patellofemoral pain: a 5-year prospective ran- Tagesson, S., Oberg, B., Good, L. and Kvist, J. (2008) A domized study. American Journal of Sports Medicine, 32, comprehensive rehabilitation programme with quadriceps 1122–1130. strengthening in closed versus open kinetic chain exercise Wright, R.W., Preston, E., Fleming, B.C., Amendola, A., in patients with anterior cruciate ligament deficiency. Andrish, J.T., Bergfeld, J.A., Dunn, W.R., Kaeding, C., American Journal of Sports Medicine, 36, 298–307. Kuhn, J.E., Marx, R.G., McCarty, E.C., Parker, R.C., Trees, A.H., Howe, T.E., Dixon, J. and White, L. (2005) Spindler, K.P., Wolcott, M., Wolf, B.R. and Williams, G.N. Exercise for treating isolated anterior cruciate ligament (2008) A systematic review of anterior cruciate ligament injuries in adults. Cochrane Database of Systematic reconstruction rehabilitation: part II: open versus closed Reviews, 4, CD005316. kinetic chain exercises, neuromuscular electrical stimula- Trees, A.H., Howe, T.E., Grant, M. and Gray, H.G. (2007) tion, accelerated rehabilitation, and miscellaneous topics. Exercise for treating anterior cruciate ligament injuries in Journal of Knee Surgery, 21, 225–234.

12The Foot and Ankle Complex Ruth Magee SECTION 1: INTRODUCTION included in the review had methodological limita- AND BACKGROUND tions, some conclusions were drawn. Co-ordination training using ankle discs in those with a prior The treatment of the foot and ankle complex is history of ankle sprain demonstrated a decreased multifactorial, requiring the clinician to use many risk of ankle sprain in the intervention group com- treatment approaches for the successful manage- pared with controls in a number of studies. Some ment of both acute and chronic injuries. However, evidence was also presented indicating that a super- the emphasis in this chapter is on basic exercise vised physiotherapy programme that emphasised rehabilitation of the foot and ankle, although it is balance reduced risk or re-injury when compared important that the therapist considers all the other with controls. The review found good evidence for variables which affect the foot and ankle complex. the use of external ankle supports to prevent liga- ment injuries of the ankle but concluded that further Evidence for the use of exercise in the research was needed to be conclusive regarding rehabilitation of foot and ankle injuries exercise therapy. Evidence which supports treatment interventions to A more recent Cochrane review conducted by the foot and ankle is limited overall, and there has Kerkhoffs et al. (2007) examined surgical versus been a large emphasis in the research on the ankle conservative treatment for acute injuries of the and rearfoot complex, with little on the midfoot lateral ligament complex of the ankle in adults. Of and forefoot. Much of the research has focused on the 20 trials that were included, the authors sug- a small number of conditions, notably anterior tal- gested that all had methodological flaws that could ofibular ligament (ATFL) sprain. have affected their results and the overall conclu- sion was that there was not enough evidence to say Handoll et al. (2001) conducted a review of if surgery or conservative treatment, including exer- research under the Cochrane Collaboration. Studies cise therapy, was the optimal treatment for ankle which examined various interventions for the pre- sprains. De Fries et al. (2006) reviewed studies vention of ankle ligament injuries were included. which examined interventions, including exercise Although a large number of studies that were therapy, for treating chronic ankle instability. Again, methodological flaws were highlighted in many studies and the authors were unable to con- clude if any specific intervention was optimal for Exercise Therapy in the Management of Musculoskeletal Disorders, First Edition. Edited by Fiona Wilson, John Gormley and Juliette Hussey. © 2011 Blackwell Publishing Ltd

188 Exercise Therapy in the Management of Musculoskeletal Disorders treating ankle instability. However, it was found and Tyler et al. (2006) showed that a high body that following surgical construction, early func- mass index, which is frequently related to poor tional rehabilitation, or exercise therapy was supe- cardio-respiratory endurance, was also a risk factor rior to immobilisation regarding time to return to for the same injury. Valderrabano et al. (2006) work and sports. Zoch et al. (2003) reviewed showed that patients who were more ‘sports active’ studies that examined rehabilitation of ligamentous showed better functional results following total ankle injuries, concluding that a combination of ankle replacement compared with patients who isokinetic strength training with proprioceptive were inactive. Although Xu et al. (2004) showed training shortens rehabilitation and serves as a sec- that tai chi had a significant effect on improving ondary prophylaxis. proprioception in the ankle, it is unclear if such exercise involves aerobic conditioning. Hubley- Karatosun et al. (2008) compared intra-articular Kozey et al. (1995) evaluated the effects of a general injection therapy to exercise therapy in the manage- exercise programme on the passive ROM of the ment of osteoarthritis of the ankle and found that lower limb joints including the ankle in elderly both provided functional improvement, although women. The programme included aerobic exercise, the authors concluded that larger trials were neces- stretching and muscular strength and endurance sary to compare individual efficacies more accu- exercise and the authors found that ROM improved rately. Van der Wees et al. (2006) conducted a review in all joints lower limb joints following the pro- of trials which examined the effectiveness of exer- gramme. As there was a stretching component to the cise therapy and manual mobilisation in acute ankle programme it is therefore unclear if the aerobic sprain and found that exercise therapy was effective exercise contributed to the improvements. in reducing the risk of recurrent sprains and func- tional instability although the effects of manual Part of the reason for lack of research may be mobilisation were limited to having an (initial) related to the difficulties of loading the cardio- effect on dorsiflexion range of motion (ROM). respiratory system when the foot and ankle are dysfunctional, leaving limited options such as More recently, Loudon et al. (2008) reviewed swimming and non-weight-bearing programmes for studies which examined the effectiveness of active aerobic exercise. However, those studies which exercise as an intervention for functional ankle examined the role of aerobic exercise in the man- instability. Results were positive for the inclusion of agement of multi-joint osteoarthritis should be con- exercise therapy in management of ankle instability sidered at this point and have been discussed in and the authors concluded that conservative treat- earlier chapters. ment interventions including balance, propriocep- tive and muscle strengthening exercise were effective Muscle strength and endurance in decreasing ‘giving way’ episodes, improving balance stability and improving function. Thus, For many clinicians, the early focus of rehabilita- while there is some clear evidence for the positive tion of any foot or ankle disorders will be muscle benefits of exercise in the management of ankle strengthening exercise. Hartsell and Spaulding ligament sprain and some evidence in the manage- (1999) showed that chronic ankle instability and ment of ankle OA, there is a demand for further muscle weakness do co-exist and Willems et al. trials which are of robust methodology to support (2005a) identified decreased dorsiflexion strength this approach. as a risk factor for ankle inversion sprain. Konradsen et al. (1998) showed that eversion strength is Aerobic exercise reduced (compared with the non-injured joint) 3 weeks following acute ankle inversion injuries and There is little evidence to support the use of aerobic Munn et al. (2003) found that eccentric inversion exercise in the treatment of foot and ankle dysfunc- strength was reduced in ankle instability. Despite tions and the author was unable to source any trials these findings, there is a paucity of research into which examined the role of an aerobic exercise pro- strengthening exercise as rehabilitation following gramme specifically for foot and ankle disorders. ankle joint injury. However, Willems et al. (2005a) showed that poor cardio-respiratory endurance was a risk factor for Much of the focus of strengthening exercise in the inversion ankle sprain in a study of male subjects management of foot and ankle disorders has been

The Foot and Ankle Complex 189 on rehabilitation of Achilles tendinopathy. Alfredson cises. Willems et al. (2005a) found that lack of ankle et al. (1998) were one of the first groups to pros- dorsiflexion was a strong predictor of ankle injury, pectively study the effect of a 12-week, heavy stating that poor dorsiflexion is associated with 2.5 load, eccentric calf muscle training programme on times the risk of injury. If there was excessive dorsi- individuals with chronic Achilles tendinopathy flexion, and a hypermobile ankle, the risk increased compared with a control group that received con- to eight times. However, Willems et al. (2005b) ventional treatment during the same period of found that a greater ROM, in this case in the first time (rest, non-steroidal anti-inflammatory drugs metatarsophalangeal (MTP) joint, was a risk factor (NSAIDs), orthoses, physiotherapy and ‘ordinary’ for ankle inversion sprain in females. Beedle and training programmes). While the control group Mann (2007) determined that the optimal stretch to showed no improvement in symptoms, the subjects increase ROM at the ankle joint was a static stretch in the intervention group were all able to return to following a warm-up, which was superior to bal- full function (running) following the programme. listic stretching following a warm-up. While this was a moderately small study with some methodological flaws, similar findings were pre- There is a lack of consensus regarding the immo- sented by Mafi et al. (2001) with a similar interven- bilisation of acute ankle inversion injuries. Boyce tion and the overall clinical outcome was much et al. (2005) advocated a return to immobilisation, better for eccentric calf training that a concentric but on a temporary basis and recommended the use programme (Niesen-Vertommen et al., 1992; Mafi of an ankle brace for grade 2 and 3 lateral ligament et al., 2001). Alfredson et al. (2008) suggested that sprains. Immobilisation was shown to result in sig- eccentric exercise involves muscle activation com- nificant improvement in ankle joint range of move- bined with muscle-tendon unit lengthening and it is ment at both 10 days and 1 month, when compared likely to affect the dampening characteristics of the with an elastic support. calf muscle and change the type 1 collagen produc- tion and tendon volume, which will increase the Flanigan et al. (2007) examined the effect of tendon tensile strength over time. plantar fascia stretching on plantar fascia pain. Previous studies had demonstrated that specific In further support of an eccentric strengthening stretching of the plantar fascia was superior to protocol, Kingma et al. (2007) conducted a system- standard weight-bearing Achilles tendon stretching atic review of studies with such a programme in exercises and had a significant effect in reducing pain management of Achilles tendinopathy. The authors and functional limitations in subjects with chronic concluded that although further studies are war- plantar fasciitis (Digiovanni et al. 2006). Flanigan et ranted, results to date are promising and support al. (2007) concluded that a stretch which included eccentric overload training in the management of both MTP and ankle joint dorsiflexion was superior Achilles tendinopathy. More recently, similar find- to ankle joint or MTP joint alone, having positive ings were presented in a systematic review by effects in the management of plantar fasciitis. Magnussen et al. (2009), who analysed 16 quality trials, which concluded that eccentric exercises have Balance and proprioception the most evidence of effectiveness in the manage- ment of mid-portion Achilles tendinopathy. Recent research has placed great emphasis on func- tional control of the foot and ankle in rehabilitation Many of the studies on strengthening exercise and the influence of proprioceptive exercise has and the foot and ankle have also looked at proprio- received focus in a number of studies. The single ceptive training and will be discussed in the follow- leg stand test is probably the most useful clinical ing sections. test in identifying proprioceptive and/or balance dysfunction following foot and ankle disorders. Range of motion and flexibility Trojian and McKeag (2006) state that the single Restoring full range of movement to the ankle and leg balance test is a reliable and valid test for pre- foot is essential for the correct movement patterns dicting ankle sprains and that the association and biomechanical alignment of the foot and ankle. between a poor single leg stand test and ankle This can be done using joint mobilisation tech- sprain is significant. Javed et al. (1999) demon- niques, tissue massage and stretching or ROM exer- strated longer reaction time in the peroneus longus muscles of patients who presented with chronic or

190 Exercise Therapy in the Management of Musculoskeletal Disorders acute functional instability when compared with when compared with the soccer players. It was controls. Further, they examined the effects of concluded that a rock climbing type of exercise may either surgical stabilisation or proprioceptive exer- be of value in the treatment of ankle instability. cise on peroneal reaction time and found that only the exercise group showed improvement. Thus although the evidence supporting the use of exercise in the management of foot and ankle dis- Evidence from a number of studies supports the orders is limited in some areas, there is clear support use of wobble boards to improve proprioception in for the use of certain protocols, particularly in the the ankle following inversion injuries (Clark and areas of strengthening and proprioception. Such Burden, 2005). Clark and Burden (2005) noted a exercises will be discussed practically in Section 2. significant decrease in muscle onset latency and a significant improvement of their perception of func- Common conditions tional instability when a group followed a 4-week wobble board training programme for 10 minutes, Ankle inversion injury three times per week. However, there has been a recent trend among clinicians not to use wobble Often an ankle inversion injury is thought to be the boards as they are not considered a functional exer- same as a lateral ligament sprain; however, this is cise, and it is thought that it is better to focus on a not always the case. An ankle inversion injury may land-based functional programme instead. Delahunt affect multiple structures beyond the lateral liga- (2007) noted that subjects who have functional ment and can cause problems such as a fracture at instability in the ankle, exhibit feed-forward control the fibular head, an osteochondral fracture of the deficits to the peroneus longus during dynamic dome of the talus or subluxation of the peroneal activities. Delahunt suggests that rehabilitation tendons – all of which can be very subtle and dif- strategies should include exercises that produce ficult to diagnose. The patient may present with sudden unexpected changes in joint movement, as symptoms very similar to a straightforward lateral this will facilitate unconscious joint stabilization. ligament sprain. It is essential that the therapist The need to rehabilitate the feed-forward mecha- diagnoses the ankle dysfunction correctly and bears nism suggests that the use of wobble boards, foam in mind the other possible diagnoses. For the pur- blocks, foam rollers and trampolines will all aid in poses of this chapter, a lateral ligament sprain will the rehabilitation of the functionally unstable ankle, be discussed, and it is important to remember that as it will produce sudden unexpected change. an inadequately rehabilitated ankle will lead to pro- longed symptoms, a high risk of recurrence and A number of studies have noted that introduction reduced function. of a balance training programme is effective in reducing the risk of ankle sprains. McHugh et al. A lateral ligament injury is usually caused by a (2007) showed that including a balance training plantar flexion/inversion movement, and the most intervention in training for high school football commonly injured portion is the ATFL. Depending players reduced the incidence of non-contact ankle on the severity of the injury (grades 1–3 ligament sprains; Mohammadi (2007) found similar results sprain), the person may need to stop their activity with the same kind of intervention in soccer players. immediately, or can continue with limitations. The McGuine and Keene (2006) showed that a balance swelling may be immediate or may develop within training programme reduced the risk of ankle a few hours. In a grade 1 tear, there is no ligament sprains in high school athletes. Schweizer et al. laxity; in a grade 2 tear there is some ligament (2005) attempted to include variation in balance laxity but a firm end point and in a grade 3, there and co-ordination demands by examining stability is gross laxity with a complete ligament rupture and and co-ordination in the ankles of rock climbers no end point when testing. Often grade 3 injuries compared with soccer players. The authors sug- are the least painful, but it is important to get the gested that rock climbing demands slow, well- diagnosis correct as this will dictate the rate of controlled movements of the foot and ankle with recovery and also the rate of rehabilitation. The the tibiotalar and subtalar joints in varying posi- management principles for all three grades are the tions. The study found that the rock climbers exhib- same: control swelling; reduce pain ± immobilisa- ited significantly better results in stabilometry testing and greater maximum strength in the ankle

The Foot and Ankle Complex 191 tion with a brace, taping or crutches; restore range which can cause torsion of the plantar fascia and of movement; restore muscle strength; propriocep- the Achilles’ tendon. The author’s experience is that tive exercises, and implement a functional sports or planus must be treated if there is a varus or valgus work specific programme. dysfunction at the subtalar joint causing poor bio- mechanics; this is particularly important in the Ankle sprains account for 20% of all sports inju- childhood/adolescent population. If the patient has ries (Price et al., 2004). Disability from ankle a stable subtalar joint, but is genetically flat footed, sprains can be severe with 40% of the population they would appear to have a low risk or predisposi- having dysfunction that persists for as long as 6 tion to injury. Overuse injuries are associated with months after the injury (Gerber et al., 1998) and excessive pronation and it is important to fully athletes with multiple ankle sprains have signifi- rehabilitate not only the long and short intrinsic cantly reduced proprioception and kinaesthetic foot muscles, but also soleus, gastrocnemius and awareness (Garn and Newton, 1998). Ankle sprains tibialis posterior, as these are likely to absorb shock are the most common injury with an incidence rate and reduce the impact on the plantar fascia and of 80% in athletic populations and a recurrence midfoot region (O’Connor and Hamill, 2003). rate of 73% (Yeung et al., 1994). The successful rehabilitation of ankle injuries is crucial in prevent- Plantar fasciitis is thought to be due to irritation ing high recurrence rates. Those at risk of an ankle of the proximal plantar fascia with or without a inversion injury include those with a mobile foot history of trauma. Pain typically presents under the type, a more pronated foot, a longer total foot plantar heel and is worse on weight-bearing contact time, lateral pressure in the forefoot at push although may ease with exercise. There is usually off phase in the gait cycle and those with delayed tenderness at the proximal plantar fascia. Magnetic knee flexion (Willems et al., 2005a). Willems et al. resonance imaging (MRI) may be useful in distin- (2005b) advocate that the therapist attends to gait guishing from a stress fracture. Optimal treatment patterns and addresses foot biomechanics to prevent requires a stretching programme for the gastrocne- inversion injuries. Proprioception is disturbed after mius, soleus, plantar fascia, orthoses, NSAIDs and an ankle sprain (Hartsell, 2000), thus highlighting in worse cases, surgery (Berkson et al., 2007). the importance of adequate rehabilitation. Often rehabilitation is combined with ankle bracing or Hallux valgus of the first MTP joint is also taping, as this has been shown to reduce the inci- known as a bunion, and can have a genetic or bio- dence of re-spraining (Surve et al., 1994). mechanical cause or a combination of both. A hallux valgus diagnosis is given when there is 10° Chronic pain following an ankle inversion injury valgus or greater at the first MTP joint, and it is may be due to a number of factors including: lateral usually associated with a pes planus. This causes or deltoid ligament instability; impingement lesion; the forces at the toe off phase of the gait cycle to osteochondral lesion of the talus; syndesmotic pass through the medial aspect of the first ray, thus instability; or fracture. pushing the ray even further across. Rehabilitation of the foot and ankle may prevent the progression Pes Planus, plantar fasciosis of this condition, but there is a need for further and hallux valgus research in this area, particularly in the adolescent population. Pes planus (flat feet) and pain in the region of the plantar fascia (plantar fasciitis or fasciosis) are Achilles’ tendinopathy often seen together, so are being discussed together rather than as separate entities for the purposes of Achilles’ tendinopathies involve pain in the region this chapter. Clinically, it is very common to see one of the Achilles’ tendon. They can be extremely condition with the other. The plantar fascia is the chronic and difficult to treat and can be very major stabiliser of the longitudinal arch, particu- frustrating for the patient, both athlete and non- larly during the mid stance phase of the gait cycle. athlete alike. Until recently it was assumed that Pes planus, whether rigid or flexible can lead to overuse of the tendon caused inflammation and injury. The navicular is dropped and the longitudi- thus pain, requiring regular use of NSAIDs. nal arch remains pronated during the gait cycle, However, more recent research has demonstrated

192 Exercise Therapy in the Management of Musculoskeletal Disorders that the pain of tendinopathy may be due to SECTION 2: PRACTICAL unidentified biochemical factors that activate peri- USE OF EXERCISE tendinous nociceptors without inflammation. Pathological studies have shown that Achilles’ tend- The evidence supporting the use of exercise therapy inopathy is a degenerative process with an absence in the management of foot and ankle disorders is of inflammatory cells (Smith and Sands, 2007). very condition specific and so this chapter will discuss rehabilitation with reference to chosen Achilles’ tendon functions eccentrically to lower pathologies or disorders. the heel to the ground when landing from a jump and it works hard when walking and running Ankle inversion injury uphill. It is usually a chronic overuse injury, of insidious onset, with no specific event to trigger it. Early rehabilitation However, on further questioning of the patient, it generally becomes obvious that it is associated with Aerobic exercise excessive stress and either slow or sudden overload on the Achilles’ tendon, which can be caused by The primary concern when prescribing aerobic poor and excessive training methods, poor biome- exercise following an inversion injury is the stability chanics of the lower limb and in particular foot of the ankle. In the acute stage, single leg cycling pronation, a change in footwear or training pro- with the unaffected leg will allow the cardiovascu- grammes, poor balance within the training pro- lar system to be challenged without compromising gramme, which can lead to joint and muscle the affected joint. The patient may then progress to imbalances causing weakness and lack of flexibility cycling with the affected leg with the clinician not only of the calf but also of the lumbo-pelvic ensuring that the ankle is maintained in a close region and leg. The pain can be both in the mid packed, dorsiflexed position by keeping the heel section of the Achilles tendon and can also be at its rather than the toe at the front of the pedal. insertion into the calcaneum. The latter is much Swimming is also suitable, particularly front and harder to treat and takes a lot longer to settle, so back crawl. Breast stroke may be tried with the the patient should be aware of the different prog- ankle in dorsiflexion, although avoid the ‘whip nosis, and it is important that the therapist diag- kick’ in as this can be painful. If the ankle is too noses it correctly. Tendinopathy frequently occurs painful with any leg kicking movement, the patient in the mid-substance of the tendon in the area of may put a float between the legs and concentrate hypovascularity. Patients will complain of pain on arm movement only. when rising from a resting position. Examination reveals thickening of the mid-substance of the ROM and flexibility tendon with local tenderness. A programme that includes range of movement Optimal rehabilitation requires exercise therapy exercises and alphabet drawing with the foot is and biomechanical considerations. As it is now suitable to rehabilitate ROM. Progress the pro- known that this disorder is not defined by inflam- gramme to weight transfer and knee bending in mation, traditional anti-inflammatories approaches, standing with support, and gait re-education focus- such as NSAIDs, should be avoided. The greatest ing on heel strike, foot flat and toe off. The patient advance in the management of this condition over may not be able to weight-bear more than 25% of the past 20 years has been in the use of eccentric their body weight at this stage onto the affected leg, exercise therapy with a number of quality trials but they should slowly try to progress their percent- demonstrating its efficacy (Rees et al., 2009). The age body weight onto this leg until they can do a evidence for use of eccentric exercise is strong for single leg stand with comfort. the management of mid portion Achilles’ tendin- opathy but less robust in the management of inser- See Figures 12.1 and 12.2 for progression of tional Achilles’ tendinopathy although recent work dorsiflexion from non-weight-bearing to weight- has demonstrated increased efficacy of eccentric bearing. See Figure 12.3 for plantar flexion home exercise in insertional pathology when the exercise does not move beyond plantigrade (Jonsson et al., 2008). Section 2 outlines practical implementation of the eccentric exercise programme.

The Foot and Ankle Complex 193 (a) (b) Figure 12.1 (a) Long-sitting, straight leg dorsiflexion, targeting gastrocnemius. (b) Long sitting, bent knee dorsiflexion, targeting soleus. (a) (b) Figure 12.2 (a) Dorsiflexion. (b) Dorsiflexion in weight-bearing. exercise progression in standing and sitting. It is a bent knee for the soleus, while using the belt to important that full ROM in all directions are dorsiflex the foot and try the exercise in both long restored to the ankle, particularly dorsiflexion, as sitting (Fig. 12.1) or in a straight leg raise position this is the movement required not only for gait, but with knee extension or flexion in supine (Fig. 12.4). also for the stairs and landing from jumps. It is important that a clinical reasoning approach is used in prescription of every exercise. There is no After an ankle inversion injury, the patient often point in prioritising the exercise in the straight loses the ability to dorsiflex the ankle, and with leg raise position if neurodynamic tests are that, the gastrocnemius and soleus muscles tighten. abnormal. It is very important to start a flexibility programme early for the calf muscles and to identify the other There are many different ways to stretch the calf muscle groups that may also be tight, particularly muscles but the most common way to stretch the the peroneals, as these are often overstretched gastrocnemius is to start on a flat surface and then during the injury and subsequently have increased progress to a book or a slope (Fig. 12.5) and note tone and spasm at rest. the different foot positions available. Starting with the foot in a central position will give a general calf It is possible to start the calf stretches in long stretch; turning the foot medially can give a sitting using a belt, if the patient is unable to weight- more lateral gastrocnemius stretch (Fig. 12.6) and bear, if there is too much pain or if there are positive turning the foot laterally (Fig. 12.7) can give a more neurodynamics in the form of a straight leg raise. medial head stretch. It is important to ‘chase’ the Maintain a straight leg for the gastrocnemius, and

194 Exercise Therapy in the Management of Musculoskeletal Disorders (a) (b) Figure 12.3 Plantar flexion in: (a) standing and (b) sitting. (a) (b) Figure 12.4 (a) Gastrocnemius stretch. (b) Soleus stretch. stretch – the patient focuses on the tightest and Muscle strength and endurance most restricting position. It is also important that the patient does not roll the foot in, and maintains There is much crossover between the exercises for an optimal arch profile by keeping the knee moving muscle strengthening and proprioception/co-ordi- over the third metatarsal. If the patient cannot do nation. The outline and divisions of this chapter are this, the clinician can place a book along the longi- more for academic reasons, but it is important to tudinal arch to stop it collapsing inwards. They can bear in mind, that if a patient is doing a single progress the stretch in standing by asking the leg stand on toes for balance, they are also patient to stand with both feet on an incline board, doing a concentric strengthening exercise for the aiming to keep the legs straight while moving the gastrocnemius/soleus complex. To turn the same pelvis forwards (Fig. 12.8). exercise into a strengthening exercise will mean that the patient repeats a heel lift and lower 20–30 times To focus the stretch on soleus, perform the stretch rather than a sustained hold of 30–60 seconds for as for gastrocnemius (above), but flex the knee, balance. ensuring that the knee moves over the third meta- tarsal. This can be progressed to a bilateral soleus Start with the basic isotonic exercises using squat ensuring that both heels remain on the ground Thera-Band® or free weights and do the entire and that the knees move forward over the feet ankle movements with both knee flexion and knee ensuring ankle dorsiflexion (Fig. 12.9). extension (Fig. 12.10). If isotonic exercises are too

Figure 12.7 Medial gastrocnemius stretch with the foot turned laterally. Figure 12.5 Stretch to the gastrocnemius using a block. Figure 12.8 Stretch on an incline board. Figure 12.6 Lateral gastrocnemius stretch with the foot turned medially. (a) (b) Figure 12.9 Bilateral soleus squat.

196 Exercise Therapy in the Management of Musculoskeletal Disorders (a) (b) (c) (d) (e) (f) Figure 12.10 (a) Resisted plantar flexion in knee extension. (b) Resisted dorsiflexion in knee extension. (c) Resisted dorsiflexion in knee flexion. (d) Resisted plantar flexion in knee flexion. (e) Resisted eversion in knee flexion. (f) Resisted inversion in knee flexion.

The Foot and Ankle Complex 197 Figure 12.11 Dorsiflexion against resistance of the other Figure 12.13 Step-over. foot. Figure 12.12 Step-up, emphasising dorsiflexion and push up with the right foot. The patient stands on the ball of the left foot to prevent pushing with this side. painful, start with basic isometrics, where the Figure 12.14 Multi-directional task with resistance. The patient pushes against their other foot for resistance patient jumps forwards and backwards and left and right. The (Fig. 12.11). height and distance are gradually increased. Progress the subject to a weight-bearing pro- ance as needed (Fig. 12.14). As the patient progresses, gramme as quickly as possible, and always consider start to increase both the distance and the height. the kinetic chain when doing these exercises. Ensure Adapt the hopping patterns to suit the patient’s that there is excellent control around the hip and needs and design as many hopping patterns as pos- trunk, and that the patient is not compensating by sible. This may include focusing on sideways or dipping the pelvis/hip or flexing the trunk forwards. backwards hopping more than forwards. Include The progression of the rehabilitation will depend the trampette – double foot jump, single foot jump, on the presenting patient and their functional and jumping on and off (Fig. 12.15). demands or sport. Progress the jumping activity, by asking the Start with the basic step-up and step-down (Fig. patient to jump forwards, backwards and sideways 12.12) or step-over (Fig. 12.13). This exercise covers many issues. It helps regain dorsiflexion, but more importantly, it works the gluteus medius and pelvic stabilisers. Ensure that the patient can start to hop, and include multi-directional tasks and add resist-

198 Exercise Therapy in the Management of Musculoskeletal Disorders (a) (b) Figure 12.15 (a) Trampette jumps. (b) Single foot trampette jumps. over an object of varying heights on two feet and one foot (Figs 12.16 and 12.17). Include skipping, shuttle runs (forwards, backwards, and sideways) and figure-of-eights forwards and backwards. Proprioception Figure 12.16 Single hop forwards and backwards. The basic approach to restoring balance is to start Progress the single leg stand in flat foot position the patient standing on one leg. (See Fig. 12.18 for to standing on toes on two feet and one foot with the correct technique.) Refer to Figure 12.19 for a straight legs and then onto toes on two feet and one poor technique and excessive weight transference. foot with a bent knee (Fig. 12.20). It is important Although this may be difficult to see in the figure, that the patient keeps the heels high as they bend ‘Trendelenburg’s’ or ‘compensatory Trendelenburg’s’ are very common clinical presentations. If the patient is having difficulties with weight transfer- ence and has a large pelvic shift, start in standing, with a narrow base of support, and start with a heel lift, progressing on to a heel and toe lift. Progress the exercise by widening the stance. Progress the single leg stand exercise with knee flexion on the standing leg. Ensure that, again the patient does not cheat by dipping the pelvis/hip and the only body part to change position is the knee, and that continues to track out over the third meta- tarsal. If the knee rolls inwards and falls over the first, this will have a pronatory effect on the longi- tudinal arch and will reduce the work of the intrin- sic muscles.

The Foot and Ankle Complex 199 Figure 12.17 Double hop sideways. Figure 12.18 Correct technique for single leg stand. (a) (b) Figure 12.19 (a) Poor one leg standing technique with (b) ‘compensatory Trendelenburg’.

200 Exercise Therapy in the Management of Musculoskeletal Disorders (a) (b) Figure 12.20 (a) Heel lift exercise, two feet. (b) Heel lift on one foot. (c) Balance (c) exercise on wobble board. the knee and that the knee continues to move out patient is pain free, has full ROM and good muscle over the third metatarsal. If the patient can com- strength and proprioception. It is important to fortably do these exercises, they can then try to remember that inadequate rehabilitation and early perform them with their eyes closed, and then return to sport will increase the chances of re-injury, throwing a ball. The clinician can then progress all so it is essential that the patient completes a func- the above exercises to the wobble board, foam tional programme and the sooner the clinician can block and foam roller (Fig. 12.20c). The progres- commence this, the more successful will be the sion of the patient will depend on many things rehabilitation. Re-train the movement patterns including their motivation to continue with exer- rather than just focusing on the individual muscles cise, their functional ability and prognosis, and also at this stage, and ensure that all the variables of their sporting level. functional training are considered, including load progression, range of movement, base of support, Functional and late rehabilitation speed and, most importantly, multi-directional activity, by including exercises that challenge the Functional exercises as outlined above (hopping, sagittal, transverse and frontal planes. Include jumping, shuttle runs) should be applied when the squats, dips and plyometric exercises that use dif- ferent arm positions and different directions to not

The Foot and Ankle Complex 201 (a) (b) (c) Figure 12.21 (a) Squat with arm raise. (b) Double leg squat with trunk rotation. (c) Single leg squat with trunk rotation. only challenge the ankle joint but also the whole spiky ball and progress to a golf ball as able. kinetic chain (Fig. 12.21). Progress the massage treatment to massage of the calf muscles in standing, which will create a wind- Planus and plantar fasciosis up effect of the myofascia and can give very good and hallux valgus release of the muscles restricting the normal move- ment. The therapist must restore full range of Rehabilitation movement to the ankle (as outlined earlier), but must also correct the hallux valgus and restore full Aerobic exercise MTP extension. This can be done in standing (Fig. 12.22a) as well as in sitting (Fig. 12.22b), but the All the aerobic exercises described above for ankle patient must ensure that they abduct the toe before inversion injury are appropriate for the manage- extending it, and ensure that they fixate the MTP ment of plantar fasciosis. Activities which are not joint before extending the hallux. fully weight-bearing such as rowing are suitable and weight-bearing activities which do not promote It is also very important to restore normal move- constant pronation may be tried. In general, pain is ment and function to the toes. Toes, when chal- a good indicator of an inappropriate exercise. If the lenged, can be almost as dexterous as fingers. The patient has been prescribed orthoses they should be effect of a rigid foot, may not only lead to pain, but worn during the activity and the prescribing clini- it may also reduce the shock absorbing capabilities cian should constantly monitor biomechanics of the of both the foot and the lower leg. The foot foot and ankle, correcting as appropriate. strengthening programme, for both the foot intrin- sics and extrinsics can be trained quite easily with the following exercises. ROM and flexibility The toe spread (Fig. 12.23) Start by reducing the pain in the plantar fascia See if the patient is able to spread their toes (in the region; this can be done by massaging the sole of same way as they can spread their fingers) and use the foot and the calf muscles, and also by giving a the interossei muscles without moving the heel or home exercise of massage or trigger pointing on a lifting the foot. A progression of this exercise is to

202 Exercise Therapy in the Management of Musculoskeletal Disorders (a) (b) Figure 12.22 (a) Hallux extension stretch in standing. (b) Hallux extension stretch in sitting. Figure 12.23 Toe spread. Figure 12.24 Towel exercise. then ‘toe spread and dome’. In this exercise, the It is also important to include some stretches of patient uses the short intrinsics muscles, and it is not only the calf muscles, as previously demon- important that they do not curl the toes, but still strated, but also of the plantar fascia. This can be have a slight ‘doming effect’ where the arch lifts up. difficult for the individual who cannot get enough MTP extension, and if that is the case, they may The towel exercise (Fig. 12.24) need to do the stretch while keeping the first MTP free. Ensure that the arch profile is maintained This exercise involves the long toe flexors and also throughout the stretch. helps with the arch lift and requires the patient to spread the toes, placing them on the towel and then Muscle strength and endurance scrunching the towel up, until they have managed to pull the whole towel in without moving the heel. There are also some specific foot strengthening A progression of this exercise is to place the towel exercises that should be included. Include walking on a carpet rather than a wooden floor to add more on toes with the heels kept high and a straight leg resistance, or place a weight on the towel. Finally, to work the gastrocnemius. Repeat with a bent the patient should pick up objects using all the toe knee, ‘the soleus walk’, both of which will help to flexors, e.g. pencils, markers, buttons, marbles. control the rearfoot. Walking on the heels (Fig. Ensure that they do not cheat by just using their 12.25) will help use the tibialis anterior to control big toe. the arch position. With this exercise, ensure that the

The Foot and Ankle Complex 203 Achilles’ tendinopathy The main aim of treatment is to restore the ankle range of movement, particularly dorsiflexion, lengthen the calf muscles as outlined previously, and start the patient on an eccentric training pro- gramme for the gastrocnemius and soleus. Management of this condition should be based on a symptom-related approach. Figure 12.25 Walking on heels. Aerobic exercise Aerobic exercise will generally be non-weight-bear- ing in the acute phase of Achilles tendinopathy. Aerobic exercise described in the management of ankle inversion injury is appropriate. Progression to weight-bearing activities should be with caution and as pain allows and low impact exercise should be prescribed. Late stage of rehabilitation should encourage activities such as plyometrics, skipping and bouncing on a trampette to challenge the tissues of the Achilles’ tendon. Figure 12.26 Walking on outside of feet. Range of motion and flexibility patient does not cheat by using their toe extensors The exercise programme described to address ROM or by failing to lift their foot up enough into dor- in the management of plantar fasciosis, as described siflexion. Walking on the outsides of the feet (Fig. above, should be applied in the rehabilitation of 12.26) encourages use of tibialis anterior again and Achilles’ tendinopathy. the arch drop and lift off the edge of a step works the tibialis posterior tendon eccentrically. The tibia- Muscle strength and endurance lis posterior tendon is the main dynamic stabiliser of the foot and works to invert the subtalar joint The programme should commence with the patient and stabilise the arch. performing heel drops over the edge of a step, with both a straight leg and a bent knee (Fig. 12.27). Proprioception Start without any weight and then gradually increase the patient’s load by performing the heel This part of rehabilitation should include the pro- drops with a backpack filled with weights on their prioception programme as outlined earlier with shoulders. Again the weight can be gradually specific attention to maintaining the arch profile increased, as can the repetitions. Alfredson et al. throughout the exercises without losing rear- or (1998) recommend three sets of 15 repetitions, midfoot control. The clinician must also ensure that performed twice a day, 7 days a week. This pro- the patient uses the correct movement patterns and gramme should be maintained for 12 weeks. The is not overusing the long toe extensors or flexors. patient must ensure that they do not load the They must also avoid toe clawing or extending. affected calf concentrically as they move into plantar flexion but must use their non-affected leg to push themselves back up. The patient should be

204 Exercise Therapy in the Management of Musculoskeletal Disorders (a) (b) Figure 12.27 Heel drop with (a) knee extension and (b) knee flexion. warned that the exercises may cause discomfort, exercises, including Figure 12.20, and ensure that particularly in the early stages of the programme, the end-range rehabilitation plan includes func- but must stop if the pain becomes disabling. If the tional exercises such as uphill walking and walking patient can do the exercises in the early stages of downstairs. Step-down exercise will work the calf the programme in bare feet, this allows them to not muscles eccentrically and will also work the hip and only focus on their alignment and foot position, leg muscles. particularly of the longitudinal arch, but it also ensures that the foot intrinsic muscles have to work It is very important to address the orthoses issue, harder. However, if the patient has very poor foot ensuring that the patient not only has orthoses that and ankle alignment/biomechanics, or if the step they will wear, but that will also give enough rear- has no carpet on it, this can be too uncomfortable and midfoot control and will act as good shock on the sole of the foot and will place too much of absorbers. Advice on footwear is essential; ensure a valgus stress on the ankle and midfoot, and will that the footwear has a good heel counter, which require the patient to wear training shoes. helps control the calcaneum and also has good shock absorbency. Often clinicians recommend Proprioception excellent training shoes, with good shock attenua- tion, and then suggest that the patient wear a rigid As discussed previously, it is important to include orthotic device, which will counteract any shock a good proprioceptive programme, see the above absorbency benefits of the shoes. It is important that the clinician understands the kind of shoe and device required and for what effect. SECTION 3: CASE STUDIES AND STUDENT QUESTIONS Case study 1 A 32-year-old female presents to the clinician with and told that she had no fracture but to weight- an acute right ankle inversion injury 3 days after bear as able. She has been applying the PRICEM inverting her ankle while wearing high heels. She (protection, rest, ice compression, elevation, med- attended the accident and emergency room, was ication) principles since injury, and complains of X-rayed and was given a Tubigrip and crutches lateral ankle pain, ‘tightness’ in the forefoot and

The Foot and Ankle Complex 205 Case study 1—cont’d weight transference with or without crutches. Soft tissue work on the peroneus muscles, gastrocne- marked spasm/pain in the peroneus muscles and, mius and soleus muscles may enhance recovery. just today, a feeling of tightness in the calf. Active ROM exercise of the ankle may be per- Assessment reveals marked swelling and discol- formed and repeated in a straight leg raise posi- ouration of the lateral ankle and forefoot; marked tion if neurodynamic tests are positive. ROM pain with palpation over the fibula head, all the exercise may be performed passively with acces- lateral ankle structures, particularly the ATFL, sory movements added with particular attention and muscle spasm and pain in the peroneus to the inferior tibiofibular joint. Aerobic exercise muscles. ROM is reduced and painful in all direc- at this stage could include swimming with a kick- tions – 30° plantar flexion,–10° dorsiflexion, 5° board or one leg cycling. Strengthening exercise inversion, 5° eversion. Ankle strength cannot be at this stage would be fulfilled by the performance assessed accurately due to pain and lack of move- of the balance programme. ment. Instability tests suggest a grade 2 ATFL sprain. She is afraid to weight-bear on the ankle The middle to late phase of rehabilitation not only because of pain but also because of the requires a progression to functional activities. fear that her ankle may ‘give way’. Single leg stand with knee flexion and extension should be performed as well as ‘toe stands’ to Management enhance proprioceptive and build strength. Stair climbing and gait activities with an emphasis on The emphasis in the early stage of management of good pelvis control are good functional activities. this patient should be to reduce swelling and pain The patient should perform ROM exercises in to allow an increase in function. If the pain is functional positions such as squatting in standing. severe, the ankle should be initially immobilised The final stage of rehabilitation should include a in a brace and the patient should use crutches. At full functional programme such as plyometrics this stage, gait should be re-educated progressing and trampette work which includes all compo- from partial weight-bearing with the crutches to nents of fitness. The emphasis at this stage is to fully weight-bearing as pain allows. Early exercise include multi-directional activities. Taping may will include a balance programme comprising provide a psychological and proprioceptive aid in the final stage of management. Case study 2 Clinical examination reveals a right early hallux valgus, approximately 10°, bilateral rearfoot A 14-year-old girl, who is a competitive dancer, varus and compensatory pronation bilaterally. complains of right heel and arch pain since 8 She also has very weak foot intrinsic muscles and weeks. Her dance teacher tells her that she has flat is unable to toe spread or dorsiflex in standing feet and that she is not lifting her heels high (heel walk). The dancer is able to stand on one enough when she dances. The dancer feels that foot with the eyes open, but is poor with the eyes her dancing has deteriorated over the past several closed and is unable to stand on her toes on two months, as she cannot jump as high as she used feet or one foot without significant pronation and to, and she now has to really use her arms when heel drop. She has a very poor jump, with little she jumps to achieve height. Her mother states power coming from her calf muscles or her core. that she dances four times a week and that she has noticed that her daughter has become ‘heavier There is a loss of end-range ankle dorsiflexion, on her feet’ and has had quite a significant recent MTP 1 extension is 40° with a poor movement growth spurt.

206 Exercise Therapy in the Management of Musculoskeletal Disorders Case study 2—cont’d stretched position may aid progress. The intrinsic foot programme (described in text above) should pattern and the right hip has lost end of range commence early and other issues to correct bio- external rotation. Palpation shows marked ten- mechanics should be addressed at an early stage. derness of the right plantar fascia at the calca- Proprioception work in the early stage for this neum and also along the longitudinal arch with patient should include toe standing on one leg multiple trigger points in the deep intrinsics. demonstrating good control of the whole limb and the ability to prevent the rearfoot from drop- Management ping. The middle to late stage of rehabilitation should progress to jumping and trampette work, The aim of management of this patient is to take teaching the patient to jump correctly by control- a global approach, i.e. to address foot dysfunction ling from the hip. This patient should be encour- as well as performance issues. The working diag- aged to jump with hands behind her back to nosis of this patient is plantar fasciosis. facilitate lift with the lower limb and good ‘core’ Rehabilitation should commence with ROM activity. Jumping and trampette work will chal- activities to include intensive stretching of the lenge the proprioceptive, aerobic and strengthen- plantar fascia, gastrocnemius and soleus, as well ing systems. The patient may be further helped by as mobilisation of the first MTP joint. Soft tissue prescription of correct functional foot orthoses or work such as massage with the muscle in a corrective taping. Case study 3 unable to dorsiflex the right ankle more than 5° in standing, without marked compensatory pro- A 40-year-old male office worker, who plays nation. The patient is able to do a single leg heel tennis once per week and likes to walk daily to raise without pain, but five single leg hops on the and from work, complains of pain in the mid- spot provoke his pain, while two hops forwards portion of his right Achilles’ tendon. The pain has provoke the pain. There is marked tenderness of been gradually worsening over the past 3 months, Achilles’, both with the squeeze test of the tendon and it is particularly stiff first thing in the morning and with direct postero-anterior pressure on the getting out of bed. This stiffness tends to last tendon. 10–15 minutes and eases as the patient gets moving. He likes to walk, and has pain at the Management beginning of the walk, which eases as the walk progresses, but if he overdoes it, the pain will In the early stage of rehabilitation of this patient, return and he will start to limp. The pain can then aerobic activities may be continued within the last the rest of the day and evening, although eases confines of pain. If weight-bearing exercise is with the application of a heat pack. He also painful then non-weight-bearing exercise such as notices pain walking downstairs. The patient swimming may be acceptable. ROM exercise states that he always wears soft slip on leather early in management should emphasise recovery shoes, and has not changed his running shoes for of full ankle dorsiflexion and first MTP ROM. about 5 years. He also used to wear orthoses, but Gait re-education should emphasis, in particular, found that they were too cumbersome and did not good heel strike and mid stance. The eccentric fit into his work footwear, so he stopped wearing them about 3 years ago. Clinical findings show marked tightness in the right soleus and gastrocnemius, with the patient

The Foot and Ankle Complex 207 Case study 3—cont’d position such as uphill lunges should be per- formed. Multidirectional activities such as ‘figure- programme described in the text above should be of-eights’ and stop/start exercise should challenge started as soon as possible, noting that discomfort the patient more at this stage. At all times it is likely to be experienced during these exercises. should be ensured that the patient has good foot Proprioception such as single leg stands should and ankle positioning during exercise, particularly also be commenced as early as possible. The in dorsiflexion. As this patient has been prescribed middle to late stage requires progression of activi- orthoses that are not used, this should be investi- ties described above with increased duration and gated. It is better to compromise with a softer, loading. The eccentric exercise programme should slimmer device that will be worn continually than see increased repetitions and the addition of to have no orthoses when poor biomechanics are loading with the use of backpack weights by the compromising recovery. patient. Ballistic activity should be introduced and exercises which work the Achilles’ in a lengthened Student questions treatment of chronic Achilles tendinosis. American Journal of Sports Medicine, 26(3), 360–366. (1) Design three functional exercises for a painter Beedle, B.B. and Mann, C.L. (2007) A comparison of two who complains of Achilles’ pain each time he warm-ups on joint range of motion. Journal of Strength goes up and down the ladder. and Conditioning Research, 21, 776–779. Berkson, E.M., Greisberg, J. and Theodore, G.H. (2007) (2) What are your goals for the first three days Heel pain. In: Di Giovanni, C. and Greisberg, J. (eds) Foot after an acute ankle inversion? & Ankle, Core Knowledge of Orthopaedics, pp. 195–199. Elsevier/Mosby, New York, USA. (3) Describe three different ways to stretch the Boyce, S.H., Quigley, M.A. and Campbell, S. (2005) gastrocnemius. Management of ankle sprains: a randomised controlled trial of the treatment of inversion injuries using an elastic (4) Develop two new proprioceptive exercises for support bandage or an Aircast ankle brace. British Journal the elite level gymnast. of Sport Medicine, 39, 91–96. Clark, V.M. and Burden, A.M. (2005) A 4-week wobble (5) Why would you give a patient a concentric board exercise programme improved muscle onset latency Achilles’ programme as against the recom- and perceived stability in individuals with a functionally mended eccentric programme? unstable ankle. Physical Therapy in Sport, 6, 181–187. De Fries, J.S., Krips, R., Sierevelt, I.N., Blankevoort, L. and (6) List the benefits of good footwear. Van Dijk, C.N. (2006) Interventions for treating chronic (7) Why do therapists use wobble boards to train ankle instability. Cochrane Database of Systematic Reviews, 4, CD004124. proprioception, a wobble board is not consid- Delahunt, E. (2007) Peroneal reflex contribution to the devel- ered a functional exercise? What is the neuro- opment of functional instability of the ankle joint. Physical physiological benefit to training on unstable Therapy in Sport, 8, 98–104. surfaces? Digiovanni, B.F., Nawoczenski, D.A., Malay, D.P., Graci, (8) Develop a strengthening programme for the P.A., Williams, T.T., Wilding, G.E. and Baumhauer, J.F. foot with a tibialis posterior tendinopathy. (2006) Plantar fascia specific stretching exercise improves (9) When would it be appropriate to select a rigid outcomes in patients with chronic plantar fasciitis. A pro- orthotic device for a patient? spective clinical trial with two year follow up. Journal of (10) Design two new home exercises to improve Bone and Joint Surgery, American Volume, 88, ankle plantar flexion. 1775–1781. Flanigan, R.M., Nawoczenski, D.A., Chen, L., Wu, H. and References Digiovanni, B.F. (2007) The influence of foot position on stretching of the plantar fascia. Foot and Ankle Alfredson, H., Pietila, T., Jonsson, P. and Lorentzon, R. International, 28, 815–822. (1998) Heavy-load eccentric calf muscle training for the Garn, S. and Newton, R. (1998) Kinaesthetic awareness in subjects with multiple ankle sprains. Physical Therapy, 68, 166–171.

208 Exercise Therapy in the Management of Musculoskeletal Disorders Gerber, J.P., Williams G.N., Scoville, C.R., Arciero, R.A. and Tendinopathy: a systematic review. Clinical Journal of Taylor, D.C. (1998) Persistent disability associated with Sports Medicine, 19, 54–64. ankle sprains: a prospective examination of an athletic McGuine, T.A. and Keene, J.S. (2006) The effect of a balance population. Foot and Ankle International, 19, 653– training program on the risk of ankle sprains in high school 660. athletes. American Journal of Sports Medicine, 34, 1103–1111. Handoll, H.H.G., Rowe, B.H., Quinn, K.M. and de Bie R. McHugh, M., Tyler, T., Mirabella, M.R., Mullaney, M.J. (2001) Interventions for preventing ankle ligament injuries and Nicholas, S.J. (2007) The effectiveness of a balance (Review). Cochrane Database of Systematic Reviews, 3, training intervention in reducing the incidence of non- CD000018. contact ankle sprains in high school football players. American Journal of Sports Medicine, 8, 1289– Hartsell, H.D. (2000) The effects of external bracing on joint 1294. position sense awareness for the chronically unstable Mohammadi, F. (2007) Comparison of 3 preventive methods ankle. Journal of Sports Rehabilitation, 9, 279–289. to reduce the recurrence of ankle inversion sprains in male soccer players. American Journal of Sports Medicine, 35, Hartsell, H.D. and Spaulding, S.J. (1999) Eccentric/concentric 922–926. ratios at selected velocities for the invertor and evertor Munn, J., Beard, D.J, Refshauge, K. and Raymond, Y.W. muscles of the chronically unstable ankle. British Journal (2003) Eccentric muscle strength in functional instability. of Sports Medicine, 33, 255–258. Medicine and Science in Sports and Exercise, 35, 245–250. Hubley-Kozey, C.L., Wall, J.C. and Hogan, D.B. (1995) Niesen-Vertommen, S.L., Taunton, J.E., Clement, D.B. and Effects of a general exercise programme on passive hip, Mosher, R.E. (1992) The effect of eccentric versus concen- knee and ankle range of motion of older women. Topics tric exercise in the management of Achilles tendonitis. in Geriatric Rehabilitation, 10, 33–44. Clinical Journal of Sport Medicine, 2, 109–113. O’Connor, K. and Hamill, J. (2003) The role of selected Javed, A., Walsh, H.P.J. and Lees, A. (1999) Peroneal reac- extrinsic foot muscles during running. Clinical tion time in treated functional instability of the ankle. Foot Biomechanics, 19, 71–77. and Ankle Surgery, 5, 159–166. Price, R.J., Hawkins R.D., Hulse, M.A. and Hodson, A. (2004) The Football Association medical research pro- Jonsson, P., Alfredson, H., Sunding, K., Fahlstrom, M. and gramme: an audit of injuries in academy youth football. Cook, J., (2008) New regimen for eccentric calf muscle British Journal of Sports Medicine, 38, 466–471. training in patients with chronic insertional Achilles tendi- Rees, J.D., Maffulli, N. and Cook, J. (2009) Management of nopathy: results of a pilot study. British Journal of Sports tendinopathy. American Journal of Sports Medicine, 37, Medicine, 42, 746–749. 1855–1867. Schweizer, A., Bircher, H.P., Kaelin, X. and Ochsner, P.E. Karatosun, V., Unver, B., Ozden, A., Ozay, Z. and Gunal, I. (2005) Functional ankle control of rock climbers. British (2008) Intra-articular hyaluronic acid compared to exer- Journal of Sports Medicine, 39, 429–431. cise therapy on osteoarthritis of the ankle. A prospective Smith, A. and Sands, A. (2007) Achilles tendon problems. In: randomised trial with long term follow up. Clinical Di Giovanni, C. and Greisberg, J. (eds) Foot & Ankle, Experimental Rheumatology, 26, 288–294. Core Knowledge of Orthopaedics, pp. 200–208. Elsevier/ Mosby, New York, USA. Kerkhoffs, G.M.M.J., Struijs, P.A.A., Marti R.K., Assendelft Surve, I., Schwellnus, M.P., Noakes, T. and Lombard, C. W.J.J., Blankevoort, L., Dijk Van, C.N. and The Cochrane (1994) A fivefold reduction in the incidence of recurrent Collaboration. (2007) Different functional treatment strat- ankle sprains in soccer players using the Sport-Stirrup egies for acute lateral ankle ligament injuries in adults orthosis. American Journal of Sports Medicine, 22, (review). John Wiley and Sons Ltd., Chichester. 601–606. Trojian, T.H. and McKeag, D.B. (2006) Single leg balance Kingma, J.J., de Knikker, R., Wittink, H.M. and Takken, T. test to identify risk of ankle sprains. British Journal of (2007) Eccentric overload training in patients with chronic Sports Medicine, 40, 610–613. Achilles tendinopathy: a systematic review. British Journal Tyler, T.F., McHugh, M.P., Mirabella, M.R., Mullaney, M.J. of Sports Medicine, 41, e3. and Nicholas, S.J. (2006) Risk factors for noncontact ankle sprains in High School football players. American Journal Konradsen, L., Olesen, S. and Hansen, H.M. (1998) Ankle of Sports Medicine, 34, 471–475. sensorimotor control and eversion strength after acute Valderrabano, V., Pagenstert, G., Horisberger, M., Knupp, ankle inversion injuries. American Journal of Sports M. and Hintermann, B. (2006) Sports and recreation activ- Medicine, 26, 72–77. ity of ankle arthritis patients before and after total ankle replacement. American Journal of Sports Medicine, 34, Loudon, J.K., Santos, M.J., Franks, L. and Liu, W. (2008) 993–999. The effectiveness of active exercise as an intervention for functional ankle instability: a systematic review. Sports Medicine, 38, 553–563. Mafi, N., Lorentzon, R. and Alfredson, H. (2001) Superior short-term results with eccentric calf-muscle training com- pared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendi- nosis. Knee Surgery, Sports Traumatology, Arthroscopy, 9, 42–47. Magnussen, R.A., Dunn, W.R. and Thomson, A.B. (2009) Nonoperative treatment of midportion Achilles

The Foot and Ankle Complex 209 Van der Wees, P.J., Lenssen, A.F., Hendriks, E., Stomp, D., Xu, D., Hong, Y., Li, J. and Chan, K. (2004) Effect of tai chi Dekker, J. and de Bie, R.A. (2006) Effectiveness of exercise exercise on proprioception of ankle and knee joints in old therapy and manual mobilisation in acute ankle sprain and people. British Journal of Sports Medicine, 38, 50–54. functional instability: A systematic review. Australian Journal of Physiotherapy, 52, 27–37. Yeung, M.S., Chan, K.M., So, C.H. and Yuan, W.Y. (1994) An epidemiological survey on ankle sprain. British Journal Willems, T., Witvrouw, E., Delbaere, K., DeCock, A. and of Sports Medicine, 28, 112–116. DeClercq, D. (2005a) Relationship between gait biome- chanics and inversion sprains: a prospective study of risk Zoch, C., Fialka-Moser, V. and Quittan, M. (2003) factors. Gait Posture, 21, 379–387. Rehabilitation of ligamentous ankle injuries: a review of recent studies. British Journal of Sports Medicine, 37, Willems, T.M., Witrvrouw, E., Delbaere, K., Mahieu, N., De 291–295. Bourdeaudhuij, I. and De Clercq, D. (2005b) Intrinsic risk factors for inversion ankle sprains in male subjects. American Journal of Sports Medicine, 33, 415–423.



Exercise Therapy in Special 3Populations



Musculoskeletal Disorders 13in the Developing Child Juliette Hussey and Mandy Johnson Physical activity in children – health disease risk factors in children and adolescents; benefits and guidelines these include the Bogalusa Heart Study, the Amsterdam Growth and Health Longitudinal Health benefits of physical Study, the Northern Ireland Young Hearts Project, activity in childhood the Cardiovascular Risk in Young Finns Study and the European Youth Heart Study (EYHS). While There are a number of health benefits of physical end points have not been reached in these studies activity, many of which have been discussed in pre- they have highlighted the importance of physical vious chapters. The benefits of regular activity in activity and fitness in the prevention of cardiovas- early adulthood were first investigated in the cular risk factors. These and other related studies Harvard Alumni Health Study where activity levels have produced considerable evidence for the bene- in 16 396 men aged 35–74 years were investigated. fits of activity and fitness on insulin sensitivity An inverse dose relationship between physical (Raitakari et al., 1994b; Schmitz et al., 2002), activity and all-cause mortality was found blood lipid profiles (Suter and Hawes, 1993; (Paffenbarger et al., 1986). Raitakari et al., 1994a), flow mediated dilation of the brachial artery (Abbott, 2002) and multiple risk Other studies (Morris et al., 1966; Lee et al., factors including the metabolic syndrome (Bouziotas 1999; Bucksch, 2005) have added further to the et al., 2004; Brage et al., 2004; Ribeiro et al., 2004). evidence for the health benefits of regular activity in adults. The evidence for the effects of physical Physical activity guidelines in children activity on morbidity and mortality in children is not available at present. The paucity of evidence Young children tend to be active if given sufficient may in part be due to a lack of studies that have opportunity and space. The activity they engage in reached a conclusion, or studies that have not been tends to be short bursts of intense activity inter- of sufficient length to examine such a relationship. spersed with less intense periods. Unlike adults, Currently there are a number of population studies children tend not to engage in long periods of sus- investigating the prevalence of cardiovascular Exercise Therapy in the Management of Musculoskeletal Disorders, First Edition. Edited by Fiona Wilson, John Gormley and Juliette Hussey. © 2011 Blackwell Publishing Ltd

214 Exercise Therapy in the Management of Musculoskeletal Disorders tained activity. As the child gets older he or she children, while almost all achieved such a level, yet commences engaging in more sustained periods of a percentage were overweight (20.7% of boys and activity generally associated with sport or walking/ 20.2% of girls) (Hussey et al., 2007). Similar find- cycling as a means of transport. ings were those of a EYHS study where among children aged 9 years, 97.4% of boys and 97.6% of Activity guidelines for children have changed girls were meeting the recommendations, and again over the last number of years. Physical activity a number were overweight (Riddoch et al., 2004). guidelines for children were first presented by the The idea that there is a need for both genders to American College of Sports Medicine (ACSM) in have a higher level of physical activity is supported 1998. The guidelines were based on those of adults by Andersen et al. (2006), who found a higher level and the recommendation was that children should of activity was needed to prevent clustering of car- achieve 20–30 minutes of vigorous activity per day. diovascular disease risk factors. In addition to a The general ACSM guidelines for physical activity higher level of activity required for children it has were that adults should accumulate at least 30 also been proposed that boys need to do more activ- minutes of moderate intensity activity on most, and ity for a given level of body composition. Tudor- preferably all days of the week (ACSM, 1990). In Locke et al. (2004) recommended different amounts 1994 the International Consensus Conference on of activity for boys and girls based on data on activ- Physical Activity Guidelines for Adolescents recom- ity levels collected by pedometer and cut off points mended that ‘all adolescents are physically active for normal weight and overweight/obesity. The daily, or nearly every day, as part of play, games, selected cut-off points for 6–12 year old children sports, work, transportation, recreation, physical would equate to approximately 120 minutes of education, or planned exercise, in the context of activity per day for girls and 150 minutes per day family, school and community activities’ and that for boys. Therefore it may be that requirements for ‘adolescents engage in three or more sessions per boys and girls not only need to be higher but need week of activities that last 20 minutes or more at a to be different, due to inherent physiological or time that require moderate to vigorous levels of behavioural differences in the genders. exertion (Sallis and Patrick, 1994). More recently in the USA, an expert panel was set up by the To the authors’ knowledge, there are no long- Divisions of Nutrition and Physical Activity and term longitudinal studies on activity and bone Adolescent and School Health of the Centers for health in children, but there have been a number of Disease Control and Prevention to review and eval- studies that have investigated activity over a few uate the evidence on the influence of physical activ- years and retrospective studies that have compared ity on several health and behavioural outcomes in adult bone health with activity performed as a children aged 6–18 years, and to develop evidence- child. Both exercise and nutrition are independently based recommendations (Strong et al., 2005). A recognised as factors essential for optimal bone total of 850 articles were reviewed, and the areas health during growth. Regular weight-bearing exer- included adiposity, cardiovascular health, asthma, cise is well recognised as important in bone mineral mental health, injury associated with physical activ- content and bone mineral density during childhood ity and musculoskeletal health. Most of the inter- and growth. vention studies reviewed included supervised programmes of 30–45 minutes of moderate to vig- The ASCM recommends that to augment bone orous activity on 3–5 days per week. The panel mineral accrual in children and adolescents they recommended that ‘school aged youth should par- should engage in impact activities (gymnastics, ticipate in 60 minutes or more of moderate to vigor- plyometrics and jumping) and moderate intensity ous physical activity that is developmentally resistance training. Participation in sports that appropriate, enjoyable, and involves a variety of involve running and jumping (soccer, basketball) is activities’. likely to be of benefit. The intensity should be high in terms of bone loading forces but resistance train- The strength of the evidence base for the exercise ing should be <60% of 1 RM (repetition maximum). recommendations by Strong et al. (2005) could be The frequency should be at least 3 days per week questioned. It could be argued that a minimum of and the duration 10–20 minutes. 60 minutes of moderate to vigorous activity per day is too low, given that, in a study on 7–10 year old In a review on the evidence in this area Daly (2007) concludes that the structural response of

Musculoskeletal Disorders in the Developing Child 215 bone to exercise during growth is maturity depend- defined until after birth. Bone tissue is different ent and gender specific. Before puberty exercise again as all three processes of hyperplasia, hyper- appears to increase apposition in both genders but trophy and accretion occur in bone growth, which during puberty and late in puberty, exercise appears can continue into late teens or early twenties. to result in periosteal expansion in boys but endo- cortical contraction in girls. While it is accepted Maturation occurs in all the various body that the nature of exercise programmes should be systems, skeletal, sexual, physiological, neurologi- predominately weight-bearing and variable in cal, and morphological, etc., but the timing of the nature the optimal dose range has yet to emerge. process differs with each body system (Malina This is echoed by Macdonald et al. (2007) who et al., 2004a). The maturation of the neurological examined the effect of a daily program of physical system occurs around the age of 7 years, sexual activity on tibial bone strength in pre or early maturation or the ability to reproduce usually pubertal children at baseline. The programme occurs in early teenage years, with girls approxi- included daily jumping and 15 minutes of physical mately 2 years ahead of boys. Skeletal maturation activity in addition to the normal physical educa- is said to have occurred when full skeletal ossifica- tion classes. Pre-pubertal boys had a significant tion has taken place, and also occurs earlier in girls. increase in bone strength index but there was no difference in girls between the intervention and Monitoring and measuring growth control subjects. The authors concluded by suggest- ing the need for a dose response trial for those past The measurement of growth is termed anthropom- the pre-pubertal stage. etry and is used in various ways in both clinical practice and the sporting environment to monitor Growth and maturation the development of children. The monitoring of children’s growth is well established in paediatric During childhood and adolescence there is consid- health care, as poor or slow growth can be due to, erable growth in terms of height and weight, and among other things, poor nutrition, social or eco- growth spurts can result in changes in the ratios of nomic status or various genetic and/or hormonal muscle strength to limb length and in stress on the deficiencies (Hall, 2000; Hermanussen et al., 2001; related soft tissues. Limb growth affects the muscle Cole et al., 2002). Regular monitoring of growth forces that are required for movement and growth can often pre-empt problems and can be carried out also affects the strength of the tendon, apophysis, at a specific chronological age and compared with ligaments and bone (Hawkins and Metheny, 2001). population reference standards usually in the form Muscles and tendons have to lengthen with a of growth charts. Measurements can be taken at growth spurt but if they do not hypertrophy until one moment in time and compared with the charts after the growth spurt, then the increased mass of but that will only give the information of whether the limb will require the muscle to generate a the child at that particular time is small or tall, greater percentage of their maximum force to which if only taken once is clinically meaningless produce a movement. This increased force may lead (Zeferino et al., 2003). Usually, measurements are to increased stress on the tendons. taken at set points over a period of time giving longitudinal data and growth velocity or tempo Different types of tissues grow at different rates (Cole et al., 2002). It is accepted that children grow and at some point go through a process of hyper- at irregular rates at different chronological ages, plasia (an increase in cell number), hypertrophy (an which can lead to difficulties in interpreting the increase in cell size) and accretion (an increase in results in a meaningful way. Height and weight are intercellular substance). Hyperplasia usually occurs the two most commonly used measures to monitor before birth whereas hypertrophy occurs after growth, with weight more relevant in infancy and birth, but this does depend on the tissue type height more relevant after infancy (Cole et al., (Malina et al., 2004a; Stratton et al., 2004). Neural 2002). tissue is essentially defined at the pre-natal stage of development but the amount of muscle tissue is not Growth charts are used to monitor the changes that take place longitudinally in a child and were first developed for British children in the early

216 Exercise Therapy in the Management of Musculoskeletal Disorders sixties by J.M. Tanner and R.H. Whitehouse, and al., 1997; Jones et al., 2000). This information is these charts (in a modified form) are still used along needed by coaches so they may plan sessions to with Freeman charts and the Buckler-Tanner charts apply the correct training loads in boys of the same (Wright et al., 2002). Different countries use refer- chronological age who are at various levels of phys- ence data collected from their own national popula- iological development and therefore have different tions which makes it very difficult to compare performance abilities. Differences in maturity and studies across countries due to the differences in development can be as much as 3–4 years for boys ethnic groups. These differences in ethnicity are of the same chronological age (Hägg and Taranger, beginning to create problems in countries with 1991; Beunen et al., 1992; Iuliano-Burns et al., growing ethnic minorities as the growth charts used 2001). This difference often results in the early for a specific population are not representative of maturing boys being in an advantageous position these different groups (Cole et al., 2002). In most for performance purposes (Malina et al., 2000, sporting environments growth is monitored usually 2004b) and often means that late-maturing boys by regular measurements of height and weight. are deselected, even though research has shown that ultimately the late-maturing boys will catch up in The adolescent growth spurt all dimensions when they reach adulthood (Philippaerts et al., 2006). During adolescence there is a sudden increase in the velocity of growth, which is called ‘the adolescent Peak height velocity growth spurt’. During this time there is an increase in the growth rate that peaks and then gradually When the adolescent growth spurt occurs the rate slows down until full maturity is reached. The ado- of the change in height accelerates and then gradu- lescent growth spurt is used in sport to identify the ally decelerates. Peak height velocity (PHV) is a stage of maturation that has been reached by the somatic biological maturity indicator and records athlete and whether they are early, normal or late the moment of maximum velocity of growth during developers as compared with others in the same age adolescence. PHV has been used in number of group. The onset of the adolescent growth spurt is studies as a non-invasive method of assessing the highly individual and occurs at different chrono- maturation status of players and athletes (Hägg and logical and skeletal ages. The adolescent growth Taranger, 1991; Beunen et al., 1992; Malina, 1994; spurt in girls occurs at approximately 9–10 years Philippaerts et al., 2006). PHV normally precedes of age and can continue until 14–16 years of age; all other peak velocities for other tissue growth and in boys it commences approximately 2 years later the point of time at which this occurs is highly and does not finish until 18 years of age and in individual and there can be considerable variation some cases even later (Malina et al., 2004a). The among children (Iuliano-Burns et al., 2001). PHV adolescent growth spurt has been identified as a will occur on average between 11.3 and 12.2 years particularly vulnerable stage in a young athlete’s of age in girls and 13.3 and 14.1 years of age in development. There appears to be an increase in the boys (Malina, 1994) with the average PHV occur- rate of injury during this time including the risk of ring up to 2 years earlier in girls than it does in boys fracture. This is thought to be due to the rapid (Hägg et al., 1991; Iuliano-Burns et al., 2001). PHV skeletal growth with a delay in bone mineralisation can only be determined in a longitudinal study in in the cortical bone (Blimkie et al., 1993). which regular height measures are taken and then plotted to determine the growth velocity over time. The age of onset of puberty can occur between 8 and 19 years (Baxter-Jones et al., 1995). The Methods of establishing maturity assessment of the biological status of young elite performers is becoming more critical as the demands There are a number of non-invasive methods used for success grow. Chronological age is a poor indi- to assess maturation. Various maturity indicators cator of biological status (Mirwald et al., 2002) and can be used including the development of sexual it has been shown that physical performance can characteristics or morphological age although some depend on the stage of biological maturity and development that has been reached (Katzmarzyk et

Musculoskeletal Disorders in the Developing Child 217 critics would argue that maturity cannot be meas- training sessions, and many injuries are of a minor ured by anthropometrical data as body size in itself nature which may not be reported. is not a maturity indicator (Malina et al., 2004a). Age of menarche is used for the maturity assess- Generally, overuse injuries in children include ment of girls as is the age at PHV for both girls and tendon injury and traction apophysitis, stress frac- boys; but both these methods can only be used tures, bursitis, and joint disorders. They arise due towards full maturity and not prior to the onset of to highly repetitive activities. Children are vulner- puberty. PHV is limited due to the fact that serial able as their apophyseal growth plates are active data needs to be taken for at least 4 years (Roche and even minor injuries to tendons or growth plates et al., 1988) at least twice a year (Stratton et al., should lead to restriction in activity until the symp- 2004), rendering accuracy and availability of the toms resolve. Many studies have described the child over a length of time questionable. important part that growth and development play in overuse injuries in youth athletes (Krivickas and Assessing secondary sexual characteristics is Feinberg, 1996; Marsh and Daigneault, 1999; probably the most commonly used method in clini- Oeppen and Jaramillo, 2003). All these studies cal practice to evaluate maturity status. Criteria acknowledge the fact that longitudinal growth of have been established for each change in sexual bone is the primary event and the surrounding soft characteristics such as the development of pubic tissue of joint tendons, ligaments, tendons and hair, breasts and genitalia, but this system is obvi- muscles elongate as a secondary response. In the ously limited to the pubertal stage of growth. short term, this results in an increased tension in the surrounding soft tissues which leads to relative The only measure of biological maturity from inflexibility and muscle imbalance and consequently birth to full maturity is the measurement of skeletal weakness. This leaves the athlete vulnerable to age. Skeletal age has been described as being the injury particularly during repetitive overload which single best maturational index (Mirwald et al., occurs during regular training (Micheli and Klein 2002). Skeletal age can be assessed using a number 1991; Krivickas, 1997; Di Fiori, 1999; Oeppen and of techniques ranging from plain X-rays to ultra- Jaramillo, 2003). Biomechanical imbalances are sound, magnetic resonance imaging and dual energy due to the speed of growth in the skeletal tissue X-ray absorptiometry (DXA). The hand/wrist is the compared with the period of time it takes for the most commonly used area for assessment of skeletal surrounding soft tissues to adapt (Marsh and maturity for a number of reasons. There is minimal Daigneault, 1999; Hawkins and Metheny, 2001; exposure to radiation, approximately 0.0017 mSv, Oeppen and Jaramillo, 2003). which is the equivalent to approximately 1 hour of background radiation in a city centre such as in Prevention strategies include improving flexibil- Manchester. The wrist/hand is easily positioned and ity, strength and general fitness in addition to there are a large number of bones in a small area matching children by size rather than chronological that can be assessed. age, adherence to the rules, improved playing con- ditions and the compulsory wearing of protective Musculoskeletal disorders in children clothing implements such as shin pads (Schmidt- Olsen et al., 1985; Drawer and Fuller, 2002; Olsen Movement is an essential part of learning for the et al., 2004). child. The most common musculoskeletal problems in children are due to trauma, and fractures of the In the immature athlete, muscle and tendon upper limbs are more common than those of the strains and ligament sprains are not as common as lower limbs. Children engaged in sporting activities in fully mature athletes because the soft tissue tends are susceptible to overuse injuries for a number of to be stronger than the bone to which it is attached. reasons. At a competitive level, children will be The resulting injury therefore, is usually an avulsion engaged in regular competitive training as well as of the muscle, ligament or tendon from its bony weekly competition. Many of these injuries can be attachment (Bruns and Maffulli, 2000). Overuse prevented by incorporating specific techniques into injuries, in youth athletes are usually reported by the player when he or she is no longer able to train comfortably rather than when the symptoms are first felt. All types of injury, if incorrectly treated, can have ramifications in the future with regards to

218 Exercise Therapy in the Management of Musculoskeletal Disorders the players’ balance and proprioception abilities racquet sports (Blohm et al., 1999). For both of being affected (Emery, 2003). these conditions, maintenance of joint range of motion (ROM), strength and proprioception should Specific musculoskeletal be emphasised, within limits of pain, for the patient. disorders in children The preceding chapters on the knee and ankle should be reviewed for specific detail. The conditions described below are specific to chil- dren although management of these conditions Scheuermann’s disease should involve application of the same exercise principles described for each joint in the appropri- Scheuermann’s disease is an osteochondrosis of the ate preceding chapters. spine that mainly occurs in adolescents, usually boys, in their last 2–3 years of growth. It is a dis- Traction apophysitis conditions turbance in the normal growth of the vertebral epiphyseal ring (Williams, 1979). If the compressive Osgood–Schlatter’s syndrome is a traction apo- forces in the spine are sufficient it may cause a physitis of the tibial tubercle due to repeated stress wedge deformity in the vertebral body causing a on the secondary ossification centre of the tibial kyphosis of the thoracic spine and an associated tuberosity. This condition presents in growing chil- increase in lumbar lordosis. Small disc herniations dren usually between 8 and 12 years in girls and in the vertebral end plate called Schmorl’s nodes are between 12 and 15 years in boys. The symptoms sometimes identified on X-ray. The condition often include pain, swelling and tenderness over the tibial remains asymptomatic but can become painful after tuberosity. On X-ray, changes seen include irregu- activity. Treatment would usually consist of mod- larity of the apophysis with separation from the eration of activities to minimise repetitive flexion tibial tuberosity in the early stages and fragmenta- and extension movements of the spine but with an tion in the later stages (Gholve et al., 2007). The active exercise programme. See Chapters 5 and6, tibial tubercle is the site of insertion of the quadri- which discuss exercise in the thoracic and lumbar ceps tendon and activities involving strong contrac- spine areas, for specific details of appropriate tions of the quadriceps, e.g. football, running and exercise. basketball are associated with this injury. In adoles- cents this area is a growth plate and repeated vigor- Spondylolysis and spondylolisthesis ous activity causes traction on the growth plate, which leads to the inflammation and pain. As the The conditions of spondylolysis and spondylolisthe- tubercle is pulled forward by the quadriceps, con- sis are commonly found in adolescent athletes tracting bone forms behind and the tubercle can (Standaert et al., 2000; Gregory et al., 2004; become very prominent. This may in turn lead to Iwamoto et al., 2004). Both conditions are described pain when kneeling. The condition settles once the as stress fractures of the pars interarticularis of the growth plate fuses to the tibia. Treatment is aimed lumbar spine. Spondylolysis is when there is a at reducing the pain and swelling. Ice packs will fracture on only one side of the spine; spondy- provide pain relief, and non-steroidal anti- lolisthesis is when the stress fractures are bilateral inflammatories may be recommended. A knee brace (Standaert et al., 2000; Gregory et al., 2004; may help to reduce strain on the tibial tubercle. Iwamoto et al., 2004). The most common cause of Generally symptoms disappear after the growth spondylolysis in the immature athlete seems to be spurt is complete and only in rare cases is there a repetitive loading of the lumbar spine which creates need for surgical management such tibial tuber- a stress reaction (Gregory et al., 2004). It can be cleplasty (Weiss et al., 2007). both symptomatic and asymptomatic, which is only established on routine radiographs (Standaert et al., Sever’s disease affects the calcaneal attachment of 2000). The treatment is more commonly conserva- the gastrocnemius/soleus musculature (Kaeding and tive, with spontaneous healing occurring in 87.5% Whitehead, 1998). Other traction apophysitis of all cases of spondylolysis. (Iwamoto et al., 2004). include the elbow region which may be seen in Spondylolisthesis is more complex because with a baseball players or more rarely in those playing bilateral fracture there may be some spinal instabil-

Musculoskeletal Disorders in the Developing Child 219 ity and spinal fusion surgery is not uncommon and rotation. The child may require crutches for (Iwamoto et al., 2004). Soler and Calderón (2000) mobilisation. Casts may be used to maintain the hip state that spondylolysis is as common in adolescent in a good position (abduction). Surgical treatment athletes as a ‘lumbar sprain’ and that it is said to realigns the head of the femur within the acetabu- be 3–4 times more common in athletes than in the lum and the alignment is maintained with screws general adolescent population. Low back sprains and plates. The child is kept in a plaster cast for and strains are said to be very common in athletes 6–8 weeks post operatively. (Keene, 1983). Rehabilitation would include a sta- bility programme discussed in Chapter 6 on the In both these conditions, when surgery is lumbar spine. required, the general principles of exercise therapy in management of hip pathologies should be applied Stress fractures can be commonly experienced in in post-operative rehabilitation. The reader is other areas in the adolescent athlete including the referred to Chapter 10 for details. foot, tibia and fibula (Oeppen and Jaramillo, 2003), and less commonly – but not unusual – in the tarsal Scoliosis bones and clavicle. Scoliosis is a curvature of the spine in the lateral Slipped upper femoral epiphysis plane accompanied by rotation. The muscles on the side of the convexity are at a mechanical disadvan- A slipped upper femoral epiphysis (SUFE) is where tage. Scoliosis can be idiopathic or as the result of the growth plate at the upper end of the femur is a neuromuscular condition such as Duchenne’s weakened and the head of the femur moves down- muscular dystrophy, spina bifida or cerebral palsy. wards and backwards, thus affecting the move- Treatment aims at reducing or halting the progres- ments at the hip joint. The exact cause is unknown sion of the deformity by splinting or surgery. In and early diagnosis is important. The child com- terms of exercise the focus should be on maintain- plains of pain in the groin, hip, thigh or knee and ing mobility in the spine and overall musculoskel- has limited movement in the hip joint. The child etal system and a level of fitness. Swimming is may walk with a limp and there may be slight recommended to maintain fitness, muscle strength shortening of the affected leg. Treatment depends and respiratory function. Prescription of exercise on the severity and is guided by X-rays and scans. should refer to the principles discussed in Chapters Surgery may be required to stabilise the hip. Metal 4–6, which discuss the spine. screws are inserted into the head of the femur and removed once the growth plate has closed. Post General considerations in the exercise operatively the child will be non-weight-bearing for management of children about 6 weeks. The ability to physically perform at any stage is Perthes’ disease reflected in a child’s progress in growth, maturity and development. A potential exists in all children Perthes’ disease is a condition characterised by a that follow normal developmental pathways, to loss (temporary) of blood supply to the hip. The learn basic performance skills and movement pat- area around the head of the femur becomes terns, which become refined with practice and rep- inflamed. It is usually seen in children between 4 etition to form a basic movement framework used and 10 years of age and is five times more common in any sport. in boys. Symptoms generally commence with a limp and pain, which may be intermittent over a few The peak bone mass that develops during child- months. Pain is brought on by movements of the hood is an important risk factor in osteoporosis. In hip and relieved by rest. Diagnosis is confirmed children who are physically active higher bone mass with X-rays. Treatment may be conservative or sur- is seen (Slemendra et al., 1991). Therefore it is gical. Anti-inflammatory medication is used to important that clinicians encourage and promote reduce the inflammation around the joint. Stretching health-enhancing physical activity from an early exercises are prescribed to increase range of move- ment and the particular focus is on hip abduction

220 Exercise Therapy in the Management of Musculoskeletal Disorders age. As clinicians are involved in the ongoing man- Blimkie, C., Lefevre, J., Beunen, G.P., Renson, R., agement of children with disorders affecting mobil- Dequeker, J. and Van Damme, P. (1993) Fractures, physical ity it is essential that weight-bearing activities are activity, and growth velocity in adolescent Belgian boys. encouraged to optimise bone mass. In children with Medicine and Science in Sports and Exercise, 25, 801– specific paediatric conditions, exercise management 808. may need to be modified to meet particular require- ments associated with their overall management. In Blohm, D., Kaalund, S. and Jakobsen, B.W. (1999) ‘Little children with cystic fibrosis, exercise will improve league elbow’ – acute traction apophysitis in an adolescent mucociliary clearance, strengthen respiratory badminton player. Scandinavian Journal of Medicine and muscles and improve bone density, whereas for chil- Science in Sports, 9, 245–247. dren with muscular dystrophy the aim may be to increase muscle strength and endurance and thereby Bouziotas, C., Koutedakis, Y., Nevill, A., Ageli, E., Tsigilis, prolong the time the child is ambulant. In those N., Nikolaou, A. and Nakou, A. (2004) Greek adolescents, with spina bifida the primary aim will be upper fitness, fatness, fat intake, activity, and coronary heart limb strength and control of body mass and max- disease risk. Archives of Disease in Childhood, 89, imising aerobic power. Specific exercise programmes 41–44. may need to be devised taking into account the limitations associated with movement in the child Brage, S., Wedderkopp, N., Ekelund, U., Franks, P.W, with neuromuscular disorders. Wareham, N.J., Andersen, L.B. and Froberg, K. (2004) Features of the metabolic syndrome are associated with References objectively measured physical activity and fitness in Danish children. Diabetes Care, 27, 2141–2148. Abbott, R. (2002) Correlation of habitual physical activity levels with flow-mediated dilation of the brachial artery in Bruns, W. and Maffulli, N. (2000) Lower limb injuries in 5–10 year old children. Atherosclerosis, 160(1), 233–239 children in sports. Clinics in Sports Medicine, 19, 637–662. American College of Sports Medicine (ACSM). (1990) The recommended quantity and quality of exercise for develop- Bucksch, J. (2005) Physical activity of moderate intensity in ing and maintaining cardiorespiratory and muscular fitness leisure time and the risk of all cause mortality. British in healthy adults. Medicine and Science in Sports and Journal of Sports Medicine, 39, 632–638. Exercise, 22, 265–274. Cole, D.A., Tram, J.M., Martin, J.M., Hoffman, K.B., Ruiz, American College of Sports Medicine (ACSM). (1998) M.D., Jacquez, F.M. and Maschman, T.L. (2002) Individual American College of Sports Medicine Position Stand. The differences in the emergence of depressive symptoms in recommended quantity and quality of exercise for develop- children and adolescents: a longitudinal investigation of ing and maintaining cardiorespiratory and muscular fitness parent and child reports. Journal of Abnormal Psychology, and flexibility in healthy adults. Medicine and Science in 111, 156–165. Sports and Exercise, 30, 975–991. Daly, R.M. (2007) The effect of exercise on bone mass and Andersen, L., Harro, M., Sardinha, L., Froberg, K., Ekelund, structural geometry during growth. Medicine and Sports U., Brage, S. and Anderssen, S. (2006) Physical activity and Science, 51, 33–49. clustered cardiovascular risk in children: a cross-sectional study (The European Youth Heart Study). Lancet, 368, Di Fiori, J.P. (1999) Stress fracture of the proximal fibula in 299–304. a young soccer player: a case report and a review of the literature. Medicine and Science in Sports and Exercise, 31, Baxter-Jones, A.D., Helms, P., Maffulli, N., Baines-Preece, 925–928. J.C. and Preece, M. (1995) Growth and development of male gymnasts, swimmers, soccer and tennis players: a Drawer, S. and Fuller, C.W. (2002) Evaluating the level of longitudinal study. Annals of Human Biology, 22, injury in English professional football using a risk based 381–394. assessment process. British Journal of Sports Medicine, 36, 446–451. Beunen, G.P., Malina, R.M., Renson, R., Simons, J., Ostyn, M. and Lefevre, J. (1992) Physical activity and growth, Emery, C.A. (2003) Risk factors for injury in child and ado- maturation and performance: a longitudinal study. lescent sport: a systematic review of the literature. Clinical Medicine and Science in Sports and Exercise, 24, Journal of Sports Medicine, 13, 256–268. 576–585. Gholve, P.A., Scher, D.M., Khakharia, S., Widermann, R.F. and Green, D.W. (2007) Osgood Schlatter syndrome. Current Opinion in Paediatrics, 19, 44–50. Gregory, P.L., Batt, M.E. and Kerslake, R.W. (2004) Comparing spondylolysis in cricketers and soccer players. British Journal of Sports Medicine, 38, 737–742. Hägg, U. and Taranger, J. (1991) Height and height velocity in early, average and late maturers followed to the age of 25: a prospective longitudinal study of Swedish urban chil- dren from birth to adulthood. Annals of Human Biology, 18, 47–56. Hall, D. (2000) Growth monitoring. Archives of Disease in Childhood, 82, 10–15.

Musculoskeletal Disorders in the Developing Child 221 Hawkins, D. and Metheny, J. (2001) Overuse injuries in growth and functional capacities of youth football (soccer) youth sports: biomechanical considerations. Medicine and players 13–15 years. European Journal of Applied Science in Sports and Exercise, 33, 1701–1707. Physiology, 91, 555–562. Malina, R.M., Reyes, M.E.P., Eisenmann, J.C., Horta, Hermanussen, M., Lange, S. and Grasedyck, L. (2001). L., Rodrigues, J. and Miller, R. (2000) Height, mass Growth tracks in early childhood. Acta Paediatrica, 90, and skeletal maturity of elite Portuguese soccer players 381–386. aged 11–16 years. Journal of Sports Sciences, 18, 685–693. Hussey, J., Bell, C., Bennett, K., O’Dwyer, J. and Gormley, J. Marsh, J.S. and Daigneault, J.P. (1999) The young athlete. (2007) Relationship between the intensity of physical Current Opinions in Pediatrics, 11, 84–88. activity, inactivity, cardiorespiratory fitness and body com- Micheli, L.J. and Klein, J.D. (1991) Sporting injuries in chil- position in 7–10-year-old Dublin children. British Journal dren and adolescents. British Journal of Sports Medicine, of Sports Medicine, 41, 311–316. 25, 6–9. Mirwald, R.L., Baxter-Jones, A.D., Bailey, D.A. and Beunen, Iuliano-Burns, S., Mirwald, R.L. and Bailey, D.A. (2001) G.P. (2002) An assessment of maturity form anthropomet- Timing and magnitude of peak height velocity and peak ric measurements. Medicine and Science in Sports and tissue velocities for early, average, and late maturing boys Exercise, 34, 689–694. and girls. American Journal of Human Biology, 13, Morris, J.N., Kagan, A., Pattison, D.C. and Gardner, M.J. 1–8. (1966) Incidence and prediction of ischaemic heart disease in London busmen. Lancet, 2, 533–539. Iwamoto, J., Takeda, T. and Wakano, K. (2004) Returning Oeppen, R.S. and Jaramillo, D. (2003) Sports injuries in the athletes with severe low back pain and spondylolysis to young athlete. Topics in Magnetic Resonance Imaging, 14, original sporting activities with conservative treatment. 199–208. Scandinavian Journal of Medicine and Science in Sports, Olsen, L., Scanlan, A., MacKay, M., Babul, S., Reid, D., 14, 346–351. Clark, M. and Raina, P. (2004) Strategies for prevention of soccer related injuries: a systematic review. British Jones, M.A., Hitchen, P.J. and Stratton, G. (2000) The impor- Journal of Sports Medicine, 38, 89–94. tance of considering biological maturity when assessing Paffenbarger, R.S., Hyde, R.T., Wing, A.L. and Hsieh, C.C. physical fitness measures in girls and boys aged 10 to 16 (1986) Physical activity, all-cause mortality, and longevity years. Annals of Human Biology, 27, 57–65. of college alumni. New England Journal of Medicine, 314, 605–613. Kaeding, C.C., Whitehead, R. (1998) Musculoskeletal inju- Philippaerts, R.M., Vaeyens, R., Janssens, M., Van ries in adolescents. Journal of Primary Care, 25, 211– Renterghem, B., Matthys, D., Craen, R., Bourgois, J., 23. Vrijens, J., Beunen, G. and Malina, R.M. (2006) The rela- tionship between peak height velocity and physical per- Katzmarzyk, P.T., Malina, R.M. and Beunen, G.P. (1997) The formance in youth soccer players. Journal of Sports contribution of biological maturation to the strength and Science, 24, 221–230. motor fitness of children. Annals of Human Biology, 24, Raitakari, O.T., Porkka, K.V., Räsänen, L., Rönnemaa, T. 493–505. and Viikari, J.S. (1994a) Clustering and six year cluster- tracking of serum total cholesterol, HDL-cholesterol and Keene, J.S. (1983) Low back pain in the athlete. From spond- diastolic blood pressure in children and young adults. The ylogenic injury during recreation or competition. Cardiovascular Risk in Young Finns Study. Journal of Postgraduate Medicine, 74, 209–217. Clinical Epidemiology, 47, 1085–1093. Raitakari, O.T., Porkka, K.V., Räsänen, L. and Viikari, J.S. Krivickas, L.S. (1997) Anatomical factors associated with (1994b) Relations of life-style with lipids, blood pressure overuse sports injuries. Sports Medicine, 24, 132–146. and insulin in adolescents and young adults. The Cardiovascular Risk in Young Finns Study. Atherosclerosis, Krivickas, L.S. and Feinberg, J.H. (1996) Lower extremity 111, 237–246. injuries in college athletes: relation between ligamentous Ribeiro, J.C., Guerra, S., Oliveira, J., Andersen, L.B., Duarte, laxity and lower extremity muscle tightness. Archives of J.A. and Mota, J. (2004) Body fatness and clustering of Physical Medicine and Rehabilitation, 77, 1139–1143. cardiovascular disease risk factors in portuguese children and adolescents. American Journal of Human Biology, 15, Lee, C.D., Blair, S.N. and Jackson, A.S. (1999) 556–562. Cardiorespiratory fitness, body composition, and all cause Riddoch, C., Andersen, L.B., Wedderkopp, N., Harro, M., mortality in men. American Journal of Clinical Nutrition, Klasson-Heggebo, L., Sardinha, L., Cooper, A. and 69, 373–80. Ekelund, U. (2004) Physical activity levels and patterns of 9- and 15-yr-old european children. Medicine and Science Macdonald, H.M., Kontulainen, S.A., Khan, K.M. and in Sports and Exercise, 36, 86–92. McKay, H.A. (2007) Is a school-based physical activity intervention effective for increasing tibial bone strength in boys and girls? Journal of Bone and Mineral Research, 22, 434–446. Malina, R.M. (1994) Physical growth and biological matura- tion of young athletes. Exercise and Sports Sciences Reviews, 22, 389–433. Malina, R.M., Bouchard, C. and Bar-Or, O. (2004a) Growth, Maturation, and Physical Activity, 2nd edn. Human Kinetics, Champaign. Malina, R.M., Eisenmann, J.C., Cumming, S.P., Ribeiro, B. and Aroso, J. (2004b) Maturity-associated variation in the

222 Exercise Therapy in the Management of Musculoskeletal Disorders Roche, A.F., Guo, S.M., Baumgartner, R.N. and Falls, R.A. Strong, W., Malina, R., Blimkie, C., Daniels, S., Dishman, (1988) The measurement of stature. American Journal of R., Gutin, B., Hergenroeder, A., Must, A., Nixon, P. and Clinical Nutrition, 47, 922. Pivarnik, J. (2005) Evidence based physical activity for school-age youth. Journal of Pediatrics, 146, 732–737. Sallis, J.F. and Patrick, K. (1994) Overview of the interna- tional consensus conference on physical activity guidelines Suter, E. and Hawes, M.R. (1993) Relationship of physical for adolescents. Pediatric Exercise Science, 6, 299–301. activity, body fat, diet, and blood lipid profile in youths 10–15 yr. Medicine and Science in Sports and Exercise, 25, Schmidt-Olsen, S., Bünemann, L.K., Lade, V. and Brassøe, 748–754. J.O. (1985) Soccer injuries of youth. British Journal of Sports Medicine, 19, 161–164. Tudor-Locke, C., Pangrazi, R.P., Corbin, C.B., Rutherford, W.J., Vincent, S.D., Anders Raustorp, A., Tomson, L.M. Schmitz, K.H., Jacobs, D.R., Hong C.P., Steinberger, J., and Cuddihy, T.F. (2004) BMI-referenced standards for Moran, A. and Sinaiko, A.R. (2002) Association of physi- recommended pedometer-determined steps/day in children. cal activity with insulin sensitivity in children. International Preventive Medicine, 38, 857–864. Journal of Obesity, 26, 1310–1316. Weiss, J.M., Jordan, S.S., Andersen, J.S., Lee, B.M. and Slemendra, C.W., Miller, J.Z., Hui, S.L., Reister, T.K. and Kocher, M. (2007). Surgical treatment of unresolved Johnston, C.C. (1991) Role of physical activity in the Osgood Schlatter disease: ossicle resection with tibial development of skeletal mass in children. Journal of Bone tubercleplasty. Journal of Pediatric Orthopedics, 27, and Mineral Research, 6, 1227–1233. 844–847. Soler, T. and Calderón, C. (2000) The prevalence of spondy- Williams, J.G. (1979) Sports injuries. Nursing (London), 4, lolysis in the Spanish elite athlete. American Journal of 158–162. Sports Medicine, 28, 57–62. Wright, C.M., Booth, I.W., Buckler, J.M., Cameron, N., Cole, Standaert, C.J., Herring, S.A., Halpern, B. and King, O. T.J., Healy, M.J., Hulse, J.A., Preece, M.A., Reilly, J.J. and (2000) Spondylolysis. Physical Medicine and Rehabilitation Williams, A.F. (2002) Growth reference charts for use in Clinics of North America, 11, 785–803. the United Kingdom. Archives of Disease in Childhood, 86, 11–14. Stratton, G., Jones, M., Fox, K.R., Tolfrey, K., Harris, J., Maffulli, N., Lee, M. and Frostick, S.P. (2004) BASES Zeferino, A., Filho, A.A.B., Bettiol, H. and Barbieri, M.A. position statement on guidelines for resistance exercise (2003) Monitoring growth. Journal of Pediatrics, 79 in young people. Journal of Sports Sciences, 22, (Suppl. 1), S23–S32. 383–390.

Musculoskeletal Disorders in the 14Cardiac and Respiratory Patient Juliette Hussey Introduction inflammatory disorder of the airways with airway obstruction that is reversible either spontaneously The aim of this chapter is to highlight the range of or with treatment (British Thoracic Society (BTS), musculoskeletal disorders associated with respira- 2001). Symptoms include wheeze, shortness of tory and cardiac disease, so the musculoskeletal breath and cough. The symptoms may be provoked abnormalities associated with conditions such as by a number of triggers including exercise. The chronic obstructive pulmonary disease (COPD), paradoxical relationship with exercise is that exer- asthma, cystic fibrosis and heart failure will be con- cise induces broncho-constriction in many asth- sidered. In addition, the musculoskeletal changes matic people, but exercise is recommended as part that the patient may experience after cardiac or of the overall management of the condition. Cystic thoracic surgery will be presented. The evidence for fibrosis is a disorder of the exocrine glands and is the management of these conditions with exercise characterised by excessive mucus secretion. Exercise therapy will be discussed. Comprehensive details of is recognised as an important part of the manage- both cardiac and pulmonary rehabilitation may be ment of this condition due to its beneficial effects found in a previous publication by the authors on mucociliary clearance, lung function, aerobic (Gormley and Hussey, 2005) and will not be dis- capacity and bone health. cussed in detail in this chapter. Musculoskeletal disorders in COPD is characterised by airflow limitation. It is respiratory disease progressive and is associated with cough, sputum production and shortness of breath (Global Strategy Limitations in physical functioning in for the Diagnosis, Management and Prevention of patient with respiratory disease COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2007) and diagnosis is con- Patients with respiratory disease face a number of firmed by spirometry. Exercise capacity is gradually musculoskeletal problems. These include: postural decreased in these patients due the associated dys- abnormalities, muscle wasting and dysfunction, pnoea. One of the goals of pulmonary rehabilita- tion is to address this limitation. Asthma is an Exercise Therapy in the Management of Musculoskeletal Disorders, First Edition. Edited by Fiona Wilson, John Gormley and Juliette Hussey. © 2011 Blackwell Publishing Ltd

224 Exercise Therapy in the Management of Musculoskeletal Disorders osteoporosis, and reduced range of movement in both in patients with mild and severe disease (BTS, the thoracic cage due to airflow limitation and 2001). Pulmonary rehabilitation includes practical hyperinflation. These changes are probably due to exercise classes and education of exercise training, a number of factors in addition to the disease secretion clearance techniques, nutritional support, process and these include: physical inactivity, mal- smoking cessation and advice on breathing control. nutrition, systemic inflammation, corticosteroid Musculoskeletal assessment in these patients should treatment and hypoxaemia. include observation of posture, measurements of joint range of motion, muscle activity and strength. Exercise tolerance is limited in patients with It should also include documentation of any pain COPD due to hyperinflation and respiratory muscle on rest or movement. Questioning about the use of fatigue (Roussos et al., 1976). Maximal inspiratory long-term steroids is required in patients with pressure has been found to be a predictor of exer- chronic respiratory disease, as this treatment may cise capacity (Dillard et al., 1989) and in patients lead to reduced bone density. Chapters 5 and 7–9, with COPD maximal inspiratory and expiratory which discuss exercise in the management of the pressures have been found to be 50% and 39% of thoracic spine and upper limb conditions, should predicted (Montes de Oca et al., 1996). In these be consulted for practical examples of appropriate patients the diaphragm may be already carrying an exercises. extra load at rest and therefore the accessory muscles of respiration are required early (Montes Range of movement and de Oca et al., 1996). Lung hyperinflation reduces respiratory disease the strength of the respiratory muscles and is one of the pathophysiological mechanisms of dyspnoea The range of movement in the spine and shoulder in these patients. girdle needs to be evaluated prior to specific exercise prescription in the patient with respiratory disease. In patients with respiratory disease physical Posture in sitting needs to be examined; typical deconditioning occurs due to disease progression. abnormalities in patients with cystic fibrosis include The result of dyspnoea associated with many respi- forward head posture, tight suboccipital and cervi- ratory diseases is such that the patient restricts their cal extensors, scapulae the abducted and protracted, activity in order to avoid becoming breathless and an increase thoracic kyphosis and a reduced lumbar this adds to the rapid deconditioning, low confi- lordosis. The range of movement in the thoracic dence and further reduced functioning. Exercise region is dependent on the movement at the apophy- training encourages the patient with respiratory seal, costovertebral, costotransverse joints and ribs, disease to acknowledge that breathlessness can be and the length of the intercostals, pectoralis and controlled through breathing techniques and thus latissimus dorsi. A thoracic kyphosis may be the helps to break the vicious cycle of increasing dysp- result of limited range in the upper thoracic spine. noea with time and progression of lung disease. Thoracic rotation and lateral flexion occur in the mid-thoracic spine and any restriction here or short- Comprehensive pulmonary rehabilitation pro- ening of the latissimus dorsi or teres major will limit grammes aim to restore the patient to the highest the range of shoulder elevation. The range of rota- degree of physical functioning by means of exercise tion in the glenohumeral joint may also be affected therapy and education. The American Thoracic by the tightness in the anterior and posterior shoul- Society and European Respiratory Society have der capsule and related muscles. Shoulder move- adopted the following definition of pulmonary ments and scapulohumeral rhythm need to be rehabilitation in a position paper in 2006: observed. ‘Pulmonary rehabilitation is an evidence-based, multidisciplinary, and comprehensive intervention Muscle function and for patients with chronic respiratory diseases who respiratory disease are symptomatic and often have decreased daily life activities’. Integrated into the individualized treat- Both peripheral muscle strength and respiratory ment of the patient, pulmonary rehabilitation is muscle strength are affected in patients with respi- designed to reduce symptoms, optimise functional status, increase participation, and reduce health care costs through stabilising or reversing systemic manifestations of the disease. The benefits of pul- monary rehabilitation have been demonstrated

Musculoskeletal Disorders in the Cardiac and Respiratory Patient 225 ratory disorders. Respiratory muscle function may tory pressure, higher systemic interleukin-6 levels be affected by a number of factors including and higher C-reactive protein levels than those who hypoxia, hypercapnia, acidaemia and malnutrition had normal lung function measures. Higher systemic (Tobin, 1988). The combination of steroids, levels of interleukin-6 were found to be associated decreased exercise tolerance and chronic inflamma- with reduced forced expiratory volume in 1 second tion may lead to respiratory muscle weakness. (FEV1), quadriceps strength and exercise capacity. Function may also be affected by biomechanical changes associated with hyperinflation of the lungs, Reduced levels of growth hormone and testoster- which leads to flattening of the diaphragm so it is one may contribute to muscle wasting. Van Vliet at a disadvantageous position in terms of the length et al. (2005) compared circulating levels of hor- tension curve. mones of the pituitary-gonadotrophic axis of men with COPD and age matched controls. The rela- In addition to the respiratory muscles, the periph- tionship between muscle force, exercise tolerance, eral muscles are also affected with generally a inflammatory markers and hypogonadism was also greater decrease in the strength of the lower limb explored. The hormonal differences were signifi- muscles (a decrease of 20–30% in quadriceps cantly higher for follicle-stimulating hormone and strength has been reported) and relative preserva- luteinising hormone, and lower testosterone in sub- tion of upper limb strength (Decramer et al., 1994; jects with COPD. Low testosterone was signifi- Gosselink et al., 1996). Within the upper limbs, cantly related to quadriceps weakness (r = 0.48) proximal muscle strength has been found to be and C-reactive protein (r − 0.39) but not to exercise more impaired than distal strength in patients with tolerance as measured by the 6-minute walk test. stable COPD (Gosselink et al., 2000). Structural and biochemical abnormalities have been found Many patients with chronic respiratory disease along with a reduction in the percentage of type 1 will have a combination of these factors, all muscle fibres. Metabolic abnormalities are proba- of which contribute to the decrease in muscle bly due to hypoxaemia and inactivity. Lactic acido- strength and have to be considered in exercise sis occurs at lower work rates in COPD patients management. when compared with controls and this is associated with impaired exercise tolerance. Bone health and respiratory disease Muscle function in patients with respiratory Patients with obstructive lung disease have many disease may also be limited by disuse, malnutrition, risk factors that can predispose them to low bone inflammatory markers, low levels of sex hormones, density. In those with severe disease, the risk of or prolonged use of systemic corticosteroids. osteoporosis increases as patients become more Malnutrition may contribute to the muscle wasting immobile, malnourished and more dependent on and the patient with COPD may experience weight drug therapy. Sin et al. (2003) analysed data from loss and an associated decrease in fat-free mass. the Third National Health and Nutrition Nutritional supplementation for 3 months was Examination Survey and found that airflow obstruc- found to have a positive effect on maximal skeletal tion was associated with increased odds of oste- muscle strength (respiratory muscles and handgrip) oporosis compared with those without airflow in addition to body weight, mid-arm circumference obstruction (odds ratio (OR) 1.9; 95% CI 1.4 to and triceps skinfold thickness (Efthimiou et al., 2.5). Those with severe airflow obstruction were at 1988) in patients with COPD who received sup- an increased risk (OR 2.4; 95% CI 1.3 to 4.4). The plemental oral nutrition compared with controls. authors concluded by highlighting the need for Respiratory muscle strength and hand grip strength bone mineral density (BMD) evaluation in these improved alongside nutritional status. patients to inform related management. Treatment of emphysema by lung volume reduction surgery Many respiratory conditions are associated with has been found to result in an improvement in systemic inflammation (Gan et al., 2004). Yende BMD (Mineo et al., 2005). The increase in BMD et al. (2006) examined the association between correlated with residual volume, diffusing capacity inflammatory markers and ventilatory limitation, of the lung for carbon monoxide and fat-free mass, muscle strength and exercise capacity in elderly suggesting that the improvement was related to patients, both with and without obstructive lung improved respiration and nutritional status. disease. Those with obstructive lung disease had lower quadriceps strength, lower maximum inspira-

226 Exercise Therapy in the Management of Musculoskeletal Disorders Oral glucocorticoids are frequently used in Figure 14.1 Patient performing step-ups. asthma. Inhaled glucocorticosteroids are used in asthma to reduce symptoms and theoretically perform extension and rotation with assistance if should have low systemic effects but even in those required to gain an increase in range. Home exer- on low-dose inhaled corticosteroids, BMD has been cises need to be explained and the use of a mirror found to be lower than controls (El et al., 2005). may help provide visual feedback to the patient. In this latter study on 45 female subjects, no cor- relation was found between disease duration, Typical exercises to increase range of movement inhaled steroid treatment duration, cumulative in the cervical and thoracic spine and shoulder joint inhaled dose and BMD measurements. include active-assisted rotation for the cervical and thoracic spine with the patient sitting on a chair, In subjects with cystic fibrosis, osteopenia and active thoracic spine lateral flexion with the patient osteoporosis are seen and may be related to factors in standing, and passive stretch of the anterior such as malnutrition and chronic use of corticoster- shoulder muscles. Figures 14.1–14.4 show exam- oids (Hardin et al., 2001). Total body bone mineral ples of exercises that are performed in pulmonary content in children with cystic fibrosis has been rehabilitation and which benefit the musculoskele- found to be significantly less than in age- and tal system. Exercises to maintain range of move- gender-matched controls (Hardin et al., 2001). In ment, in particular, in the shoulder and thoracic children with non-cystic fibrosis bronchiectasis, regions are included as part of the warm-up and osteopenia has been found to be more common exercise session. Examples of these are shoulder compared with controls (Guran et al., 2008). The circles in each direction, trunk rotation and flexion risk increased with age but BMD was not related and push-ups with hands against the wall at shoul- to the severity of lung disease, calcium intake or der height. steroid use. Muscle strengthening as part of rehabilitation for Exercise management of patients with patients with COPD is recommended. In addition respiratory disease to lower limb exercises, upper extremity training is also recommended to help performance in daily The exercise component of the pulmonary rehabili- activities. Subjects with reduced exercise capacity tation programme generally comprises aerobic, who experience less ventilatory limitation to exer- strength and flexibility exercises. Either continuous cise and more reduced respiratory and peripheral or interval aerobic training in the form of walking muscle strength have been found to be more likely or cycling is a key component and is carried into to respond well to exercise training (Troosters et the home programme. Extremity conditioning exer- al., 2001). At this stage there is insufficient evidence cises are used to improve maximum oxygen uptake, to advocate high-intensity exercise and there is a strength, endurance and co-ordination (Ries, 1994; Siebens 1996). The type of exercise indicated is of low resistance and high repetition which can be tolerated by the patient. Patients are assessed prior to commencing reha- bilitation and an individual training programme is devised. Patients may need postural correction with the goal of obtaining a position so that the spine, pelvis and shoulder girdle are in a neutral position to permit optimal muscle function. The manage- ment of joint restriction includes the use of passive mobilisations followed by exercises. Upper limb flexion and spinal extension may be performed with breathing exercises. In sitting the patient can

Musculoskeletal Disorders in the Cardiac and Respiratory Patient 227 Figure 14.2 Patient using hand weights. Figure 14.4 Patient exercising upper and lower limbs. (Enright et al., 2004) and healthy subjects, at 80% of maximal effort (Enright et al., 2006). A Cochrane systematic review by Ram et al. (2008) identified five randomised controlled trials in which respira- tory muscle training was investigated. The pooled results showed a significant effect of inspiratory muscle training. Figure 14.3 Shoulder exercises using hand weights. Cardiac disease and musculoskeletal dysfunction need for studies to investigate the results of varying intensities of exercise. Low-intensity peripheral Limitations in physical functioning muscle conditioning, in the form of 10 different in patients after cardiac surgery and exercises, each performed for 30 seconds, has been in those with cardiac disease shown to be well tolerated and led to improved muscle performance in patients with COPD (Clark The causes of musculoskeletal problems post et al., 1996). cardiac surgery may be the result of sternal retrac- tion, positioning of the patient during the surgery The effects of inspiratory muscle training have (which lasts a number of hours), cannulation of the been extensively studied with varying results. internal jugular vein and the relative devascularisa- However, an 8-week programme of high-intensity tion of the sternum due to harvesting of the internal inspiratory muscle training resulted in a significant mammary artery (El-Ansary et al., 2000). Retracting increase in inspiratory muscle function, increased the sternum involves the eversion of the upper ribs thickness of the diaphragm, improved lung volumes and this may be one explanation for pain in the and work capacity in subjects with cystic fibrosis anterior chest wall and thoracic joint dysfunction. The results of the alterations in the chest wall can be seen for at least 3 months post operatively, with

228 Exercise Therapy in the Management of Musculoskeletal Disorders pulmonary function demonstrating a restrictive culoskeletal problems, cerebrovascular disease and pattern (Kristjansdottir et al., 2004). After cardiac respiratory disease, and such may influence func- surgery involving a median sternotomy there may tion and activity (Lien et al., 2002). The presence be limitation of movement in the shoulder girdle of osteoarthritis needs to be taken into account and upper back as well as pain over wound sites when rehabilitating these patients as heart failure (LaPier and Schenk, 2002). The pain may be due may be exacerbated by the use of over-the-counter to direct surgical trauma, and swollen and inflamed non-steroidal anti-inflammatory drugs (Page and areas may lead to mid or lower cervical root irrita- Henry, 2000; Van der Wel et al., 2007). tion causing referred pain to the scapula or upper limb. Posture may also be affected and a flexed Heart failure is associated with changes in muscle posture with forward head position may lead to mass, cellular structure, energy metabolism and shortening of some muscles and lengthening of blood flow. These are associated with decreased others. exercise capacity and are improved with exercise training (Warburton et al., 2007). In post-thoracotomy or -sternotomy patients, passive movements of the shoulder joint may be Exercise management of limited as the patient may hold the upper limb musculoskeletal conditions in immobile due to fear of pain. In the weeks follow- patients with cardiac disease ing surgery the patient may be limited in forward bending or backward extension due to approxima- Cardiac rehabilitation has been defined as ‘the sum tion of the incisional area or stretching of the area. of activity required to ensure cardiac patients the Exercises prescribed need to considered in light of best possible physical, mental and social conditions overall activity recommendations for patients and so that they may by their own efforts regain as gradually increased. Despite current management normal as possible a place in the community and aimed at regaining range of movement in the imme- lead a normal life’ (WHO, 1993). Exercise is a diate post-operative period, a number of patients major component of all phases of cardiac rehabili- (approximately 30%) will develop musculoskeletal tation. It commences with walking in phase 1 and complications that affect comfort and/or function 2 and is increased to circuits in phase 3 in outpa- after cardiac surgery (Stiller et al., 1997). tient, exercise-based cardiac rehabilitation gener- Complications after harvesting the radial artery are ally for 8–12 weeks. Patients are then expected to rare other than persistent cutaneous paraesthesia in continue incorporating exercise into daily life a small percentage of patients (Budillon et al., (phase 4). The exercise components are aerobic- 2003). In patients on long-term ventilation, restric- type activities and resistance training is generally tions in joint range may occur, and where possible, reserved for low- to moderate-risk cardiac patients. passive or assisted movements of the upper and Patients with cardiac disease may have other co- lower limbs should be performed. morbidities that may affect their ability to exercise. Cardiac rehabilitation is part of the overall man- agement of patients post surgery and/or stenting, In patients early post cardiac surgery, exercises and in more recent years is prescribed for those need to be performed to prevent the risk of the with heart failure. In patients with heart failure patient developing a frozen shoulder (Tucker et al., there appear to be peripheral muscle changes with 1996). The scapula can be moved with the patient exercise training. Muscle mass and endurance are in side lying and active upper limb exercises encour- decreased in patients with heart failure, and on aged. While Stiller et al. (1997) found that routine biopsy a decrease in type 1 fibres with an increase range of movement exercises did not lead to a in type 11b fibres is seen (Sullivan et al., 1988). change in the incidence of musculoskeletal prob- Patients with heart failure have been found to have lems at 8–10 weeks post operatively, upper limb lower BMD than age-matched controls (Kenny and trunk exercises are advised to help anterior et al., 2006) and therefore interventions to increase chest wall discomfort (El-Ansary et al., 2000) and physical activity are important in their manage- stretching exercises when the sternum is stable. ment. Heart failure in elderly patients is often accompanied by other co-morbidities such as mus-

Musculoskeletal Disorders in the Cardiac and Respiratory Patient 229 If a patient has osteoarthritis in any of the lower artery bypass grafting: our experience. Surgery, 133, limb joints this will interfere with exercise perform- 283–287. ance. Therefore, the physiotherapist needs to Clark, C.J., Cochrane, L. and Mackay, E. (1996) Low inten- address the limitations to movement including pain sity peripheral muscle conditioning improves exercise tol- and may need to prescribe more non-weight-bear- erance and breathlessness in COPD. Respiratory Journal, ing exercise so that the patient may experience the 9, 2590–2596. benefits associated with exercise rehabilitation. Decramer, M., Lacquet, L.M., Fagard, R. and Rogiers, P. Weight loss may also help in symptoms of osteoar- (1994) Corticosteroids contribute to muscle weakness in thritis and facilitate exercise uptake. chronic airflow obstruction. American Journal of Respiratory and Critical Care Medicine, 150, 11–16. Patients with heart failure have also been found Dillard, T.A., Piantadosi, S. and Rajagopal, K.R. (1989) to benefit from exercise rehabilitation and specifi- Determinant of maximum exercise capacity inpatients with cally muscle strengthening. A 12-week quadriceps chronic airflow obstruction. Chest, 96, 267–271. resistance training programme in New York Heart El-Ansary, D., Adams, R. and Ghandi, A. (2000) Association (NYHA) class III patients led to Musculoskeletal and neurological complications following improvements in muscle strength (P < 0.01), exer- coronary artery bypass graft surgery: A comparison cise capacity (P < 0.01), clinical status (P < 0.01) between saphenous vein and internal mammary artery and quality of life (P < 0.05) (Jankowska et al., grafting. Australian Journal of Physiotherapy, 46, 19–25. 2008). The training programme was performed El, O., Gulbahar, S., Ceylan, E., Ergor, G., Sahin, E., Senocak, three times per week and consisted of resistance O., Oncel, S. and Cimrin, A. (2005) Bone mineral density exercises of several exercise circuits of 10 repeated in asthmatic patients using low dose inhaled glucocorticos- quadriceps resistance exercises. The weight lifted teroids. Journal of Investigational Allergology and Clinical commenced at 35% of maximal weight. Bartlo Immunology, 15, 57–62. (2007) analysed data from a number of trials on Enright, S., Chatham, K., Ionescu, A.A., Unnithan, V.B. and aerobic and strength training in subjects with con- Shale, D.J. (2004) Inspiratory muscle training improves gestive heart failure. Aerobic exercise was found to lung function and exercise capacity in adults with cystic have a significant beneficial effect on dyspnoea, fibrosis. Chest, 126, 405–411. work capacity and ventricular function (P < 0.01) Enright, S., Unnithan, V.B., Heward, C., Withnall, L. and and strength training increased muscle strength Davies, D.H. (2006) Effect of high-intensity inspiratory (P < 0.05) and endurance (P < 0.001) and left ven- muscle training on lung volumes, diaphragm thickness, tricular function (P < 0.01). and exercise capacity in subjects who are healthy. Physical Therapy, 86, 345–354. In conclusion, while the exercise management of Efthimiou, J., Fleming, J., Gomes, C. and Spiro, S.G. (1988) patients with cardiac or pulmonary disease focuses The effect of supplementary oral nutrition in poorly nour- on increasing aerobic capacity it is important for ished patients with chronic obstructive pulmonary disease. the physiotherapist to recognise the limitations to American Review of Respiratory Diseases, 137, exercise and pain, and limitation of movement that 1075–1082. may result from musculoskeletal concerns. Gan, W.Q., Man, S.F., Senthilselvan, A. and Sin, D.D. (2004) Association between chronic obstructive pulmonary References disease and systemic inflammation: a systematic review and a meta-analysis. Thorax, 59, 574–580. Bartlo, P. (2007) Evidence-based application of aerobic and Global Strategy for the Diagnosis, Management and resistance training in patients with congestive heart failure. Prevention of COPD, Global Initiative for Chronic Journal of Cardiopulmonary Rehabilitation and Prevention, Obstructive Lung Disease (GOLD). (2007) Available at: 27, 368–375. www.goldcopd.org (accessed 2009). Gormley, J. and Hussey, J. (2005) Exercise Therapy: In British Thoracic Society Statement (2001) Pulmonary reha- Prevention and Treatment of Disease. Blackwell, Oxford. bilitation. Thorax, 56, 827–834. Gosselink, R., Troosters, T. and Decramer, M. (1996) Peripheral muscle weakness contributes to exercise limita- Budillon, A.M., Nicolini, F., Agostinelli, A., Beghi, C., Pavesi, tion in COPD. American Journal of Respiratory and G., Fragnito, C., Busi, M. and Gherli, T. (2003) Critical Care Medicine, 153, 976–980. Complications after radial artery harvesting for coronary Gosselink, R., Troosters, T. and Decramer, M. (2000) Distribution of muscle weakness in patients with stable chronic obstructive pulmonary disease. Journal of Cardiopulmonary Rehabilitation, 20, 353–360. Guran, T., Turan, S., Karadag, B., Ersu, R., Karakoc, F., Bereket, A. and Dagli, E. (2008) Bone mineral density in

230 Exercise Therapy in the Management of Musculoskeletal Disorders children with non-cystic fibrosis bronchiectasis. Respiration, Sin, D.D., Man, J.P. and Man, S.F. (2003) The risk of oste- 75, 432–436. oporosis in Caucasian men and women with obstructive Hardin, D.S., Arumugam, R., Seilheimer, D.K., LeBlanc, A. airways disease. American Journal of Medicine, 114, and Ellis, K.J. (2001) Normal bone mineral density in 10–14. cystic fibrosis. Archives of Disease in Childhood, 84, 363–368. Stiller, K., McInnes, M., Huff, N. and Hall, B. (1997) Do Jankowska, E.A., Wegrzynowska, K., Superlak, M., exercises prevent musculoskeletal complications after Nowakowska, K., Lazorczyk, M., Biel, B., Kustrzycka- cardiac surgery? Physiotherapy Theory and Practice, 13, Kratochwil, D., Piotrowska, K., Banasiak, W., Wozniewski, 117–126. M. and Ponikowski, P. (2008) The 12-week progressive quadriceps resistance training improves muscle strength, Sullivan, M.J., Higginbotham, M.B. and Cobb, F.R. (1988) exercise capacity and quality of life in patients with stable Exercise training in patients with severe left ventricular chronic heart failure. International Journal of Cardiology, dysfunction. Hemodynamic and metabolic effects. 130, 36–43. Circulation, 78, 506–515. Kenny, A.M., Boxer, R., Walsh, S., Hager, W.D. and Raisz, L.G. (2006) Femoral bone mineral density in patients with Tobin, M.J. (1988) Respiratory muscles in disease. Clinics in heart failure. Osteoporosis International, 17, Chest Medicine, 9, 263–286. 1420–1427. Kristjansdottir, A., Ragnarsdottir, M., Hannesson, P., Beck, Troosters, T., Gosselink, R. and Decramer, M. (2001) H.J. and Torfason, B. (2004) Respiratory movements are Exercise training in COPD: how to distinguish responders altered three months and one year following cardiac from nonresponders. Journal of Cardiopulmonary surgery. Scandinavian Cardiovascular Journal, 38, Rehabilitation, 21, 10–17. 98–103. LaPier, T. and Schenk, R. (2002) Thoracic musculoskeletal Tucker, B., Jenkins, S., Davies, K., McGann, R., Waddell, J., considerations following open heart surgery. King, R., Kirby, V. and Lloyd, C. (1996) The physiotherapy Cardiopulmonary Physical Therapy, 13, 16–20. management of patients undergoing coronary artery Lien, C.T.C., Gillespie, N.D., Struthers, A.D. and McMurdo, surgery: A questionnaire survey. Australian Journal of M.E.T. (2002) Heart failure in frail elderly patients: diag- Physiotherapy, 42, 129–137. nostic difficulties, co-morbidities, polypharmacy and treat- ment dilemmas. European Journal of Heart Failure, 4, Van der Wel, M.C., Jansen, R.W., Bakx, J.C., Bor, H.H., 91–98. Olderikkert, M.G. and van Weel, C. (2007) Non- Mineo, T.C., Ambrogi, V., Mineo, D., Fabbri, A., Fabbrini, cardiovascular co-morbidity in elderly patients with heart E., Massoud, R. (2005) Bone mineral density improvement failure outnumbers cardiovascular co-morbidity. European after lung volume reduction surgery for severe emphysema. Journal of Heart Failure, 9, 709–715. Chest, 127, 1960–1966. Montes de Oca, M., Rassulo, J. and Celli, B.R. (1996) Van Vliet, M., Spruit, M.A., Verleden, G., Kasran, A., Van Respiratory muscle and cardiopulmonary function during Herck, E., Pitta, F., Bouillon, R. and Decramer, M. (2005) exercise in very severe COPD. American Journal of Hypogonadism, quadriceps weakness, and exercise intoler- Respiratory and Critical Medicine, 154, 1284–1289. ance in chronic obstructive pulmonary disease. American Page, J. and Henry, D. (2000) Consumption of NSAIDs and Journal of Respiratory and Critical Care Medicine, 172, the development of congestive heart failure in elderly 1105–1111. patients. Archives of Internal Medicine, 160, 777–784. Ram, F.S.F., Wellington, S.R. and Barnes, N.C. (2008) Warburton, D.E., Taylor, A., Bredin, S.S., Esch, B.T., Inspiratory muscle training for asthma. Cochrane Database Scott, J.M. and Haykowsky, M.J. (2007) Central of Systematic Reviews, 3, CD003792. haemodynamics and peripheral muscle function during Ries, A.L. (1994) The importance of exercise in pulmonary exercise in patients with chronic heart failure. rehabilitation. Clinics in Chest Medicine 15, 327–337. Applied Physiology, Nutrition and Metabolism, 32, 318– Roussos, C.S., Fixley, M.S., Gross, D. and Macklem, P.T. 331. (1976) Respiratory muscle fatigue in man at FRC and higher lung volumes. Physiologist, 19, 345–349. World Health Organization. (1993) Rehabilitation after car- Siebens, H. (1996). The role of exercise in the rehabilitation diovascular diseases, with special emphasis on developing of patients with chronic obstructive pulmonary disease. countries. Report of a WHO Expert Committee. World Physical Medicine and Rehabilitation Clinics of North Health Organization Technical Report Series, 831, America, 7, 299–314. 1–122. Yende, S., Waterer, G.W., Tolley, E.A., Newman, A.B., Bauer, D.C., Taaffe, D.R., Jensen, R., Crapo, R., Rubin, S., Nevitt, M., Simonsick, E.M., Satterfield, S., Harris, T. and Kritchevsky, S.B. (2006) Inflammatory markers are associ- ated with ventilatory limitation and muscle dysfunction in obstructive lung disease in well functioning elderly sub- jects. Thorax, 61, 10–16.

15Musculoskeletal Disorders in Obesity Grace O’Malley Introduction donitis (Werner et al., 2005), frozen shoulder, peripheral nerve entrapment (Descatha et al., 2004) A positive relationship exists between musculoskel- and diabetes-related disorders. etal fitness and general health status. Previous research has demonstrated impairments of the mus- Pain and discomfort can act as barriers to physi- culoskeletal system in individuals who are over- cal activity, and physiotherapists and other health weight, and to date, it is unknown whether these clinicians can help improve the health and func- impairments occur as a consequence of obesity or tional independence of obese individuals by reduc- whether they independently impart an increased ing pain and discomfort. The positive relationship risk of weight gain. In the USA between 1988 and between musculoskeletal fitness (MSF) and weight 2004 the level of functional impairment associated status is mediated by physical activity, as those indi- with obesity increased and a greater burden of dis- viduals with high levels of physical activity are seen ability may be seen in the obese population of the to have better musculoskeletal health (Huang and future (Alley and Chang, 2007). In adults, osteoar- Malina, 2002). Physiotherapists have vast experi- thritis is the condition best documented to be associ- ence in the rehabilitation of individuals with mul- ated with obesity; however recent research describes tiple pathologies and are very often the key other musculoskeletal disorders. Common disor- professionals to motivate change, improve attitude ders that may present to physiotherapists working and build self-efficacy. As such, when an individual with overweight and obese individuals include: dis- who is obese presents to a therapist with muscu- orders of the lower limb such as foot pain; osteoar- loskeletal complaints, efforts to improve the global thritis of the knee (Felson et al., 1988); recurrent health of the client should be made, and might ankle injury (Timm et al., 2005); low back pain furthermore, be considered not only ethical but also (Leboeuf-Yde et al., 2005) and slipped upper part of the duty of care. femoral epiphyses (Loder, 1996). Musculoskeletal disorders in the upper body of overweight individu- In an effort to individualize the management of als include: neck pain, headaches, rotator cuff ten- overweight and obesity, the physiotherapist must first be able to assess the degree of overweight, second examine the general physical condition of the individual and third, in agreement with the Exercise Therapy in the Management of Musculoskeletal Disorders, First Edition. Edited by Fiona Wilson, John Gormley and Juliette Hussey. © 2011 Blackwell Publishing Ltd

232 Exercise Therapy in the Management of Musculoskeletal Disorders patient, define goal-oriented methods of improving client’s body segments. As such, the manual han- the functional independence and quality of life of dling risk associated with certain tests should be the client. considered. Musculoskeletal assessment Physical effects associated with obesity In assessing the general health of an overweight Clinically, limitations of the physical system are client, the physiotherapist should complete a global easily observed in the overweight population and examination of musculoskeletal fitness. This exami- recently, research has begun to describe these. In nation should include measures for joint range of addition, many overweight individuals will present movement and muscle flexibility, muscle strength with diabetes mellitus as a co-morbidity and this and endurance, standing balance, pain, posture and condition is independently associated with muscu- gait. Collecting accurate measures for joint range loskeletal symptoms. of movement can be a challenge due to the difficulty in identifying bony landmarks and as such, the use Impaired joint range of of functional measures may be more appropriate. movement and flexibility In addition to assessment of the musculoskeletal Bony structure determines the primary degree of system, the physiotherapist should detail the client’s joint freedom of movement and is influenced by the medical history, the level of overweight with which extensibility of soft tissue structures. Range of the client presents and the level of both physical movement parameters are commonly used in clini- activity and sedentary pursuits in which the patient cal practice and have been utilised as indicators and engages. Body composition can be assessed by predictors of physical function (Koman et al., measuring height, weight, waist circumference and 2000). Overweight and obese individuals may by calculating the body mass index (BMI; weight present with a reduction in joint range of motion (cm)/ height (kg)2). Subjective measures of physical (ROM). This may be due to increased subcutaneous activity such as the Baeke Questionnaire, the adipose tissue blocking joint excursion, localised International Physical Activity Questionnaire or a oedema, abnormal bony torsion or decreased 7-day activity recall can be useful in clinical prac- muscle length. Regardless of the underlying cause, tice. Similarly, time spent in sedentary activity can it can be assumed that limited joint ROM may lead be calculated by summing the number of hours to subsequent reductions in flexibility and subopti- spent using a computer, playing video games and mal postural alignment. Reduced muscle flexibility watching television. is commonly associated with musculoskeletal con- ditions (Hertling and Kessler, 1996) and may Furthermore, assessing cardio-respiratory fitness predict the presence of musculoskeletal symptoms is useful to gain a greater understanding of the in adulthood (Mikkelsson et al., 2006). Research general fitness of the patient and can provide a reli- suggests that those who are physically active have able client-specific outcome measure. In many cases better muscle flexibility than those who are not medical clearance may be required prior to testing (Huang and Malina, 2002). cardio-respiratory fitness, however, measures such as a 10-m walk test, the 6-minute walk test or a Increased body weight has been shown to be shuttle test can used in appropriate clients. inversely associated with lower limb range of Regardless of the age of the client, a holistic assess- motion and impaired hip ROM is described as a ment will enhance the therapist’s understanding of risk factor in recurrent non-specific low back pain the impairments associated with the client’s health (LBP) (Jones et al., 2005). In a cyclical process, it status, which will in turn, guide him/her on how is hypothesised that poor hip mobility increases best to reduce limitations to activity and enhance spinal strain leading to LBP which, in turn can lead participation. to reduced levels of physical activity, thus possibly increasing the BMI and subsequently increasing the During a musculoskeletal examination, the ther- strain on spinal structures. apist should be aware that palpation and provoca- tive testing can be difficult to complete due to excess subcutaneous tissue and the inertia of the

Musculoskeletal Disorders in Obesity 233 Reduced ankle dorsiflexion ROM and the result- age (Colledge et al., 1994), physical activity level ant equinus gait pattern has been observed to cause (Hahn et al., 1999), previous lower limb injury abnormal pronation of the subtalar joint, which (Emery et al., 2005) and height and weight may increase stress on the plantar fascia (Hill, (Odenrick and Sandstedt, 1984). Balance may be 1995). Furthermore, both obesity and excessive reduced in overweight clients due to muscle weak- subtalar pronation have been highlighted as risk ness, limited range of movement and low levels of factors for the development of chronic plantar heel physical activity. Research has shown that increased pain and repetitive strain injuries (Irving et al., body weight is correlated with an anterior displace- 2007). ment of the centre of mass, which places obese individuals closer to their boundaries of stability Tight quadriceps and hamstrings may increase and at greater risk of falling when exposed to daily compression of the patellofemoral joint, causing postural stress (Hue et al., 2007). Weight loss in the pain (Hertling and Kessler, 1996), and reduced obese cohort has proven to incur significant hamstring and quadriceps length has been described improvements in balance capabilities (Teasdale in obese persons. Impaired hamstring length can et al., 2007). affect pelvic tilt, drawing the pelvis posteriorly (Józwiak et al., 1997). Thus, hamstring tightness Furthermore, limited joint range influences stand- may affect posture, gait and low back discomfort, ing balance (Lowes et al., 2004). Reduced knee and and evidence suggests that impaired hamstring flex- ankle range of movement can increase postural ibility is a risk factor for LBP in both adults (Esola sway (Potter et al., 1990) and also impede the et al., 1996) and adolescents (Salminen et al., 1992; implementation of the ankle strategy for postural Sjolie, 2004). adjustment (Mecagni et al., 2000). Reductions in joint range of movement can also affect standing Oedema balance through the alteration of muscle length/ tension curves, leading to inefficient gait and stance Many obese clients have underlying conditions that (Damiano et al., 2001). may induce joint and soft-tissue swelling. The ther- apist should be aware of conditions such as lym- Appropriate measures of balance should be phoedema and lipidaemia (a disorder of abnormal chosen depending on the patient’s age and general fat deposition) to ensure appropriate management physical condition. Standardised tests such as the for affected patients. Lymph drainage requires Berg balance scale, the timed up and go and timed intermittent changes in local pressure from exercise single leg stance tests are useful; however, at all and movement and as such, sedentary overweight times the clinician should use the tests with caution, individuals may develop dermatological symptoms particularly if the client is morbidly obese or has a (Garcia, 2002). Lymphoedema results from accu- significant fear of falling. mulation of protein-rich lymph in tissues and is caused by inadequate lymph drainage. Conservative Reduced muscle and bone strength management is initially recommended, such as lym- phatic massage therapy, limb mobility exercises, use Muscle strength is an integral part of physical of compression garments and limb elevation fitness and relates to the ability of a muscle to gen- (Weston and Clay, 2007). The clinician should bear erate force at a given speed. Inadequate muscular in mind that local tissue swelling post injury may strength can predispose individuals to an increased be difficult to appreciate secondary to the large bulk risk of musculoskeletal fatigue and injury (Riddiford- of adipose tissue surrounding the joints. Harland et al., 2006). Impaired muscle strength is commonly due to advanced ageing, systemic illness, Impaired balance and postural stability degenerative disease, injury and obesity (Miyatake et al., 2000). A positive relationship exists between Balance is described as the ability of the body to muscle strength and physical activity (Neder et al., maintain a centre of gravity over its base of support 1999) and a negative relationship has been observed with minimal sway and maximal steadiness. Factors between strength and obesity (Riddiford-Harland that have been shown to influence balance include: et al., 2006). It is thought that in overweight individuals, the dampening and decelerating capability of lower

234 Exercise Therapy in the Management of Musculoskeletal Disorders limb musculature is impaired secondary to muscle dramatic weight loss such as that induced by the weakness and the resistance offered by the body’s roux-en-Y gastric bypass and gastric banding is also weight, thus increasing the rate of joint loading associated with significant bone resorption and loss (Mikesky et al., 2000). Functional tasks such (Berarducci, 2007; Carrasco et al., 2009). Efforts as rising from a chair have been shown to be should be made to ensure that weight loss interven- adversely affected by obesity (Riddiford-Harland et tions aim to minimise bone loss by including aerobic al., 2006). In addition, weakness of muscles such and resistance-training protocols. as the gluteals and posterior tibialis (which eccentri- cally control loading during the stance phase of Finally, particular attention should be given to gait) may also lead to hyperpronation and associ- weight loss initiatives targeting elderly people, as ated injury (Cornwall and McPoil, 2000). In order the health benefits of weight loss in this cohort are to improve postural muscle co-ordination and uncertain. Weight loss in this cohort may accelerate enhance balance capacity, strengthening of ankle the loss of muscle mass which, correlates negatively dorsiflexors, ankle plantar flexors and both hip with functional capacity for independent living. and knee extensors should be encouraged (Lowes The co-existence of reduced lean mass and increased et al., 2004). fat mass is defined by ‘sarcopenic obesity’, and characterises a group of individuals with high It is uncertain to date as to what role reduced risk of functional impairment (Miller and Wolfe, muscle strength plays in the development of muscu- 2008). loskeletal impairments. It is clear, however, that reduced muscle strength in children impairs the Altered biomechanics and gait development of bone strength, and that inadequate bone strength at the peak growth stage may increase In adults, links have been made between obesity the risk of sustaining fractures (Goulding et al., and musculoskeletal conditions such as osteoarthri- 2000b). Strong developing muscle has a positive tis and chronic back pain (Visscher and Seidell, effect on the accrual of bone mass both in puberty 2001). Knee osteoarthritis is more common in over- and in adolescence (Gustavsson et al., 2003). weight individuals, especially women, with external Engaging in physical exercise incurs loading forces knee adduction moments cited as the most impor- upon bone by exercising muscle, which in turn, tant load factors in generating articular injury increases bone mineral content and density. (Hurwitz et al., 1998; Sharma et al., 1998). A recent study investigating risk factors for lumbar In the physically active obese child, greater body disc degeneration found that there was a strong mass requires larger muscle force to move the body association (95% CI 1.3 to 14.3) between disc in space and as such will lead to greater bone degeneration at follow-up and persistent over- strength (Slemenda et al., 1997). However, inactive weight, classified as BMI ≥25 kg/m2 at age 25 and obese children with weaker muscles can have a 40–45 years (Liuke et al., 2005). A causal link reduction in bone strength and thus may become between obesity and low back pain is yet to be osteopenic, increasing the risk of fracture. In addi- described, as epidemiological studies report contra- tion, studies of inactive overweight children have dictory results (Leboeuf-Yde et al., 2005; Lee et al., suggested that high BMI, adiposity and associated 2005). low bone density increase the risk of fracture when members of this group sustain a traumatic fall Recent work has described greater ground reac- (Goulding et al., 1998, 2000a; Molgaard et al., tion forces and knee-joint loading in those who are 1998). obese compared with those who are not (Browning and Kram, 2007). Furthermore, Messier et al. In the morbidly obese, it is evident that there is (2005) reported that for every pound of weight lost, bone loss and increased skeletal fragility following there is resultant four-fold reduction in the load weight loss. More significant increases in bone fra- exerted on the knee for each step taking during gility are seen where weight is lost during a rela- daily activities. tively short period of time, such as 3–4 months (Van Loan et al., 1998; Fogelholm et al., 2001), Regarding gait, individuals who are obese may whereas moderate weight loss over a longer period present with a shorter stride length and slower (6 months) results in little or no bone loss (Ramsdale cadence, and spend more time in stance phase and and Bassey, 1994; Shapses et al., 2001). Similarly,