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Dynamic Splinting for Contracture Reduction: A Review

Posted on December 1, 2012 | Comments Off on Dynamic Splinting for Contracture Reduction: A Review

by Buck F. Willis MBB,S PhD1emailsm and Sarah A. Curran PhD, BSc(Hons), FCPodMed, FFPM RCPS(Glas)FHEA2pdflrg

The Foot and Ankle Online Journal 5 (12): 1

Background: Contracture is molecular shortening of connective tissue(s) which arise from orthopedic, neural, and idiopathic origin. It affects the joints from tempro mandibular to metatarsophalangeal joints, affecting over 250,000 new patients globally each year.
Objectives: The purpose of this literature review was to examine studies on contracture reduction of the knee, ankle and toe, with descriptions of the biomechanics of the Dynasplint systems biomechanics.
Methods: A literature review of Dynamic Splinting and knee, ankle, toe was completed to examine the most recent and pertinent studies on contracture reduction, published since 2007.
Discussion: Dynamic Splinting employs prolonged, passive stretching with dynamic forces to achieve increased time at end-range of motion. The literature reviewed has shown efficacy of this treatment protocol in treating contracture. The biomechanics of this modality have been thoroughly reviewed and justified.
Conclusion: Dynamic splinting should be included in standard of care for contracture reduction of the lower extremity.

Key words: Connective Tissue, Dynasplint, and Range of motion

Accepted: November, 2012

Published: December, 2012

ISSN 1941-6806
doi: 10.3827/faoj.2012.0512.0001

Contracture is a molecular shortening of connective tissue[1-20] which includes realignment of elastin polypeptide chains along the collagen triple helix.[1-4] (Fig. 1) Contracture is caused by joint positioning (immobilization), arthrofibrosis, neural injury or disease, obstruction/impingement (osteocytes) and idiopathic origin. Conditions such as Dupuytren’s contracture, adhesive capsulitis and toe walking can be examples of such idiopathic pathologies. (Fig. 2) The purpose of this literature review was to examine studies on contracture reduction of the knee, ankle and toe, with descriptions of the biomechanics of the Dynasplint systems biomechanics.

Dynamic splinting can deliver various stretching options (prolonged or short duration with high or low intensity of force to counteract the contracture. One keystone experiment to determine which combinations were the most effective was conducted by Usuba, et al.

DynRevFig1

Figure 1 Collagen and elastin polypeptide.

This randomized trial surgically immobilized 66 rat knees (-30º extension) and measured contracture following 40 days of immobilization (mean -45° extension) to determine the difference between combinations of stretching protocols for increasing the range of motion(ROM).[1] The rats were separated into different groups for varied stretching protocols (prolonged vs. short duration and high vs. low torque, force), and the stretching phase lasted for a 4-week period. All protocols showed improved ROM and the only significant difference between protocols was from the combination of prolonged duration of stretching with low-torque of force.[1]

Numerous other studies have examined clinical efficacy of passive stretching[5-9] including a systemic review by Harvey, et al.,[6] which showed efficacy in prolonged, passive stretching for increasing ROM (although limited power did not allow a meta analysis). Studies employing prolonged durations of stretching have enlightened clinicians and allowed surgeons to avoid manipulation under anesthetics to surgically reduce contracture. Patients with neural pathologies or injuries often acquire contracture secondary to unmanaged hypertonicity frequently from damage to the dorsal root ganglia.[7-10]

DynRevFig2

Figure 2. Shortened connective tissue.

Plaster serial casting has long been used in contracture reduction. Singer et al examined serial casting in patients who have suffered traumatic brain injuries (TBI). This study showed that following an 18 month period, none of the patients’ contracture had completely reduced and that 18% of patients began losing the regained ROM within weeks after the final cast was removed.[7] While the duration of prolonged stretching required to prevent or reduce contracture is unknown, Dr. Singer hypothesized that the duration required for reduction equates to the duration of development and “It remains to be seen whether a more proactive approach to the amelioration of dystonic muscle overactivity and maintenance of muscle length and soft tissue extensibility can prevent the development of ankle deformity”.[8]

Glasgow, et al., questioned whether static serial splinting (like serial casting), or static progressive sprinting or dynamic splinting would be the most effective. Their literature review concluded that prolonged duration of end-range stretching is optimal for contracture reduction because “Dynamic splints may have greater potential to maximize the time that the joint is actually held at optimal end range, promoting greater tissue growth and subsequent contracture resolution”.[9] Ada, et al., completed a study examining prolonged positioning for prevention of contracture of the shoulder in stroke patients.

DynRevFig3

Figure 3 Knee Extension Dynasplint.

Their randomized study showed that prolonged positioning (30 minutes per day for six weeks) was effective in maintaining maximal external rotation in experimental subjects.[10]

Lai, et al., examined dynamic splinting in a controlled, cross-over study treating both TBI and stroke patients. All patients in this study began as control subjects being treated only with manual therapy (2/wk for 3 months) and selected patients were crossed-over for treatment with the Ankle Dorsiflexion Dynasplint (AFD; Dynasplint Systems Inc, Severna Park MD, USA). The cross-over patients were treated with AFD for an additional 90 days showed a mean improvement in maximal dorsiflexion of 19º vs. the control patients lost ROM with a mean -8° change after the total 180 day study.[11] This difference was attributed to the duration of total end range stretching which exceeded 620 hours for the experimental patients treated with the AFD vs. less than 25 total hours of stretching (control) when treated with manual therapy alone.

Methods

A literature search was performed through Medline and PubMed using a combination of subject heading and text word search strategy to retrieve manuscripts published addressing the use of dynamic splinting and contracture reduction in joints of the lower extremity. A secondary search was performed to acquiesce similar manuscripts in contracture reduction, published since 2000.

Mechanics of Dynasplint Systems

The mechanics employed by Dynasplint systems are most clearly seen in the Knee Extension Dynasplint system (KED). (Fig. 3) The low load, prolonged duration of end-range stretching is accomplished through a biomechanically correct application of force and counter force. A bilateral, spring loaded tension system applies an equal amount of force across the joint line and maintains proper anatomical alignment even as the tension is increased. This force is measurable, replicable and sequentially increased to adapt to changes in end range of motion.

Hypoallergenic straps secure the KED to each patient’s leg and the initial fitting is accomplished by a Dynasplint specialist who also trains the patient on donning and doffing the modality and how to accomplish the sequential tension changes every two weeks. Patients are instructed to wear the KED for 6-8 hours continuously while sleeping. Patient compliance is typically high because the unit is comfortable and patients quickly feel the benefit in their activities of daily living (ADL). A case reported by Finger and Willis showed such compliance.12

Knee Extension Dynasplint

A 61 year-old male underwent a total knee arthroplasty (TKA) and post-operatively his maximal ROM was -20º of knee extension. This is attributed to post-operative arthrofibrosis.1,3,6,12-15 After 20 of 28 physical therapy sessions (scheduled over two months), the patient reached a plateau of -12º knee extension. Following two additional months with KED (100% compliance), the patient regained full ROM (0°) in knee extension.[12] A retrospective study by Armstrong and Willis questioned the initial time required in a KED to see a significant change in ROM. Studying 107 patients showed a statistically significant change after one month (p< 0.001 and mean Δ 8°).[13] All but 5 of these patients regained full extension and none of the patients in the retrospective study required manipulation under anesthetics which is commonly used to treat a significant number the 40% contracture seen following TKA. Prolonged stretching of dynamic splinting has also been used proactively to prevent the expected contracture following knee surgery.[14,15]

Ankle Dorsiflexion Dynasplint

Ankle contracture is common from similar causes of immobilization, arthrofibrosis, neural onset and idiopathic origin.[3,6-8,11-19] Malleolar fractures are treated with immobilization and/or surgery which show a significant occurrence of contracture. Curran and Willis[16] examined patients who had chronic contracture (more than 12 months) following ankle fractures before being treated with the Ankle Dorsiflexion Dynasplint (AFD). (Fig. 4) Even though other treatment methods had been exhausted for these patients, use of the AFD for low load, prolonged duration of passive stretching accomplished a mean 23.4º improvement in 16 weeks with incremental tension changes every two weeks.

DynRevFig4

Figure 4 Ankle Dorsiflexion Dynasplint.

Ankle equinus is defined as a 10° deficit in dorsiflexion during the stance phase of gait, and it is common secondary to diabetes mellitus. Whilst there is a range of methods for treating ankle equinus, many findings remain inconclusive.[16, 17] It can be argued that the only proven method for reducing this contracture is surgical tendon lengthening. Lopez, et al., conducted a study of AFD treatment for reducing this contracture which affects patients’ gait pattern, injuries, infection and ultimately effects limb preservation in diabetic patients. Durations of treatment varied in this retrospective study (1-6 months) so the first month was examined for uniformity. In the first month patients regained a mean 9° in dorsiflexion which was a significant change for these 48 patients, (p< 0.0001).[17]

Plantar fasciopathy (PF) is considered the most frequent cause of acute heel pain in the United States. It was hypothesized that prolonged passive, end range stretching would benefit this condition.[18] Sixty patients (76 feet) diagnosed with PF (acute heel pain worsening upon rising, paresthesia after non weightbearing, etc) were enrolled in the multi-centre trial conducted by Sheridan et al. Exclusion criteria included calcaneal bursitis, stress fractures, tarsal tunnel syndrome and other related pathologies. The duration of this trial was 12 weeks and the experimental patients fit with the AFD had a mean 33 point reduction in the 100 point ADL Plantar Fasciitis pain scale vs. the control patients who displayed a mean 2 point rise in pain scale scores). (t56 = -8.734, p< 0.001)[18]

Metatarsal Dynasplints

Hallux limitus is a pathologic condition of limited range of motion that leads to degenerative arthritis. Hallux limitus is commonly seen following bunionectomy and cheilectomy procedures of the first metatarsal joint (MTJ). The biomechanical apparatus of dynamic splinting for contracture reduction of the MTJ is similar with force, counter force and measurable dynamic tension, but the Metatarsal Dynasplint (MDS) employs shorter treatment duration.

John, et al., completed a randomized, controlled trial examining reduction of hallux limitus originating secondary to cheilectomy and bunionectomy.[21] (Fig. 5) The current standard of care for hallux limitus includes analgesic and non-steroidal anti-inflammatory drugs (NSAIDs), orthotics (shoe inserts) and home stretching exercises. All patients received these treatments, and in addition, experimental patients were also treated with the MTJ Extension (while seated) 60 minutes, three times per day. The dependent variable in this study was change in maximal active range of motion (AROM) in extension (after eight weeks treatment). The results showed a significant difference between change in AROM between Experimental vs. Control (p<0.0001, t = 4.224, n = 48, df = 47; range -10° to +60°). Experimental patients displayed a 32° improvement in maximal extension compared to only 10° improvement for control patients. No significant difference was shown between bunionectomy vs. cheilectomy patients.[21]

Fig5

Figure 5 Metatarsal Dynasplint extension and flexion.

To see how gait is affected by runner’s toe, John, et al., demonstrated in a case report with gait analysis of an international marathon runner suffering from chronic extension contracture of the MTJ. The patient, a 47 year-old, Caucasian male, had been a competitive runner for 30 years. It was hypothesized that repeated, micro-trauma contusions were the cause of his hallux rigidus. Before treatment with the MDS, his maximal AROM in flexion was 0º compared to 55º flexion in the asymptomatic great toe. The MDS treatment for this patient lasted four months, (60 minutes, three times per day) and gait testing (pre/post) was accomplished with VICON MX system (workstation, polygon, Butterworth filter, and force plate) (Vicon UK, Oxford, England). Following treatment with MDS, beneficial changes were seen in cadence, time aloft, external ankle rotation and ROM of the MTJ. The static, maximal AROM of the symptomatic toe improved from 0º of flexion to 50º flexion after four months in the MDS.[22]

Kalish and Willis wished to see the effect of hallux limitus reduction on a broader population and to determine if there were different initial changes between hallux limitus of bunionectomy vs. cheilectomy vs. contusion. They conducted a retrospective cohort study of 61 hallux limitus patients from multiple sites with a dependent variable of change in AROM with independent variables of categories: bunionectomy vs. cheilectomy vs. contusion. A significant change was seen in all patients (n=61, p0.05).[23]

Patients regained a mean 73% (increase) in dorsiflexion at the first MTJ of the hallux in just one month. MDS utilizes a biomechanical adaptation to achieve a physiological change in contracture reduction of the connective tissue.

Discussion

These studies have shown a conclusive benefit from applying prolonged duration of passive stretching with a low load, measurable dynamic force in contracture reduction. A leading textbook for doctoral physical therapy students, Therapeutic Exercise, Moving Toward Function, 3rd Ed. (Brody and Hall) discussed use of dynamic splinting as a therapeutic adjunct for treating contracture.[20] This text specifically describes how contracture occurs following prolonged immobility and that Dynasplint Systems “Low-torque, long-duration stretching produced better outcomes than short-duration, high-torque activities.”

Serial casting has been a mainstay for contracture reduction but even after 18 continuous months in ankle casts, patients’ regained ROM began deteriorating within weeks of the cast removal.7 This shows that while serial casting may only have short term efficacy. In comparison, the retrospective KED study of patients following TKA showed that 98% of the patients regained full restoration of knee extension and in 12 months following TKA, none of the 107 patients required manipulation under anesthetics to reduce contracture.[13]

Molecular development of contracture is similar despite the causing pathology or injury and reduction of contracture can be equally effective using joint specific dynamic splinting. Dynasplint Systems deliver a low load, prolonged duration of passive stretching with measurable dynamic tension and this should be included in the standard of care in contracture reduction.

Competing Interests

Sarah A. Curran is the Chief Editor and Buck F. Willis is the Associate Editor-in-Chief of the Foot and Ankle Online Journal and were removed from the peer review process and editorial decision for this manuscript. Buck F. Willis is employed by the parent company of Dynasplint Systems, Inc, but has no stock or ownership in either company and receives no compensation for this publication. Sarah A. Curran has no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

References

1. Usuba M, Akai M, Shirasaki Y, Miyakawa S. Experimental joint contracture correction with low torque, long duration repeated stretching. Clin Orthop Relat Res 2007456: 70-78. [PubMed]
2. Abellaneda S, Guissard N, Duchateau J. The relative lengthening of the myotendinous structures in the medial gastrocnemius during passive stretching differs among individuals. J Appl Physiol 2009 106: 169-177. [PubMed]
3. Willis B. Effective Orthopedic Rehab: Seven Steps to Complete Recovery, Trafford publishing, Victoria BC, Canada, 2003. [Website]
4.  Guo C, Kaufman LJ.  Flow and magnetic field induced collagen alignment.  Biomaterials 2007 28: 1105-1114. [PubMed]
5.  Lentell G, Hetherington T, Eagan J, Morgan M. The use of thermal agents to influence the effectiveness of a low-load prolonged stretch. J Orthop Sports Phys Ther 1992 16: 200-207. [PubMed]
6. Harvey L, Herbert R, Crosbie J. Does stretching induce lasting increases in joint ROM? A systematic review. Physiother Res Int 2002 7: 1-13. [PubMed]
7. Singer BJ, Jegasothy GM, Singer KP, Allison GT. Evaluation of serial casting to correct equinovarus deformity of the ankle after acquired. Brain injury in adults. Arch Phys Med Rehabil 2003 84: 483-491. [PubMed]
8. Singer BJ, Jegasothy GM, Singer KP, Allison GT, Dunne JW. Incidence of ankle contracture after moderate to severe acquired brain injury. Arch Phys Med Rehabil  2004 85: 1465-1469. [PubMed]
9. Glasgow C, Tooth L, Fleming J. Which splint? Dynamic versus static progressive splinting to mobilise stiff joints in the hand.  British Jour Hand Therapy 2008 (Winter) 13: 104-110. [Website]
10. Ada L, Goddard E, McCully J, Stavrinos T, Bampton J. Thirty minutes of positioning reduces the development of shoulder external rotation contracture after stroke: a randomized controlled trial. Arch Phys Med Rehabil 2005 86: 230-234. [PubMed]
11. Lai J, Jones M, Willis B. Effect of Dynamic Splinting on Excessive Plantar Flexion Tone/Contracture: A Controlled, Cross-Over study. Proceedings of the 16th European Congress of Physical and Rehabilitation Medicine. Minerva Medica pubs, Italy, August 2008, pg 106-109. [Website]
12. Finger E, Willis FB.  Dynamic splinting after total knee arthroplasty: a case report. Cases Journal 2008 1:421 [PubMed]
13. Armstrong DL, Willis FB. Contracture Reduction Following Total Knee Arthroplasty, a Case Series of 107 Patients. Open Orthopaedics. (In-Press).
14. Freiling D, Lobenhoffer P. The surgical treatment of chronic extension deficits of the knee. Oper Orthop Traumatol 2009 21(6):545-556. (German) [PubMed]
15.  Cook JR, Warren M, Ganley KJ, Prefontaine P, Wylie JW. A comprehensive joint replacement program for total knee arthroplasty: a descriptive study. BMC Musculoskelet Disord. 2008 19: 154. [PubMed]
16.  Curran SA, Willis FB. Chronic ankle contracture reduced: a case series. Foot Ankle Online J4 (7): 2.  [Website]
17. Lopez AA, Kalish SR, John MM, Willis FB. Reduction of ankle equinus contracture secondary to diabetes mellitus with dynamic splinting. Foot Ankle Online J2010 3(3): 2. [Website]
18. Sheridan L, Lopez AL, Perez A, John MM, Willis FB,Shanmugam R. Plantar fasciopathy treated with dynamic splinting: a randomized controlled trial.JAMPA  2010 100: 161-165. [PubMed]
19.  Lundequam P, Willis FB. Dynamic splinting as home therapy for toe walking: a case report.  Cases Journal  2009 10: 188. [PubMed]
20. Thein-Brody L, Hall CM. Therapeutic Exercise, Moving Toward Function.  3rd Edition (Brody and Hall) Chapter 7 “Impaired Range of Motion and Joint Mobility,” pages 143-144, 2010.
21. John MM, Kalish SR, Perns SV, Willis FB.  Dynamic splinting for hallux limitus: a randomized controlled trial. JAPMA 2011 101: 285-288. [PubMed]
22. John MM, Willis FB, Portillo A.  Runner’s hallux rigidus reduction and gait analysis. JAPMA 2009 99: 367-370. [PubMed]
23. Kalish SA, Willis FB. Hallux limitus and dynamic splinting: a retrospective series. Foot Ankle Online J2009 2(4): 1. [Website]

Address correspondence to: 1Buck F. Willis, Assistant Professor, McMurry University, Box 188, Abilene, Texas, USA79697. Email: willis.buck@mcm.edu Phone: 325-793-4993.

2Sarah A. Curran, Senior Lecturer, Wales Centre for Podiatric Studies, Cardiff Metropolitan University, UK.

© The Foot and Ankle Online Journal, 2012

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Chronic Ankle Contracture Reduced: A case series

Posted on July 1, 2011 | Comments Off on Chronic Ankle Contracture Reduced: A case series

by Sarah A. Curran,PhD, BSc(Hons), FCPodMed, FHEA1 , F. Buck Willis, PhD2 

Background: Contracture is molecular shortening of connective tissue that frequently occurs from arthrofibrosis following malleolar fractures, causing plantarflexion contracture. The purpose of this case series was to examine reduction of chronic contracture of ankle fracture patients with treatment of dynamic splinting which delivers prolonged durations of low-load stretching at end range (s) of motion.
Method: Eighteen patients (mean age 46, range 29 – 65 years, 9 females, 9 males) with a prior history of medial malleolar fracture, surgical fixation and contracture of more than one year took part. Dynamic splinting was prescribed for wear each night, achieving 6 to 8 hours of passive end-range stretching. The tension of the Dynasplint was changed twice a month to optimize the stretch at end range of motion.
Results: The mean duration was 16 weeks (range 12-22 weeks) and the patients mean wear was 784 hours (range 660 – 960) in end-range therapy from dynamic splinting. Maximal dorsiflexion was measured at baseline (enrolment) and at four months. The mean maximal change in dorsiflexion was 23.4º (SD=14.1).
Discussion and Conclusion: Contracture reduction is thought to require comparable amounts of time equaling the duration of contracture development. Low force, prolonged, passive stretching is considered to have the most beneficial effect in contracture reduction due to its ability to facilitate permanent changes in connective tissue elongation. The 60% change in maximal dorsiflexion noted in this study can be directly related to the duration of treatment as home therapy. A larger controlled trial should be conducted to measure empirical efficacy of dynamic splinting for contracture reduction following malleolar fractures.

The Foot and Ankle Online Journal 4 (7): 2

Accepted: June, 2011
Published: July, 2011

ISSN 1941-6806
doi: 10.3827/faoj.2011.0407.0002

Ankle fractures are commonly treated with surgical intervention and/or immobilization. Plantarflexion contracture however is seen frequently following both of these treatment options. [1-7] Nightingale, et al.,[1] tracked the reduction of contracture in patients following fracture immobilization and noted that even with manual therapy, recovery was incomplete after three months for both maximal active range of motion (AROM) and passive range of motion (PROM). In an earlier study, Moseley, et al., [2] examined efficacy of passive stretching on plantarflexion contracture following immobilization for fractures. Patients were grouped into “short duration” passive stretching for 6 minutes per day and a second group for 30 minutes per day, called “long-duration” passive stretching. They found no significant difference in the 4week or 3 month testing durations. The “longer duration” in this study however, was only 7% of the “Prolonged Durations” of passive stretching shown effective in numerous studies that employed low torque and prolonged stretching. [8-12]

The premise behind the protocol of dynamic splinting is that greater durations at end-range (of motion) will elongate the connective tissue with hypothetical realignment of elastin polypeptide bonds on collagen trihedral structures. [8,10,15] A study in contracture reduction compared high versus. (vs.) low torque and short vs. prolonged durations of stretching on surgically induced contracture in rats.8 The findings only showed a significant difference between the combined protocols for the low torque with prolonged duration of stretching. This findings is also supported in recent studies on low torque, prolonged end-range stretching have shown efficacy in contracture reduction in the jaw, shoulder, elbow, carpal tunnel, knee, ankle, foot, and toe. [9-20]

One example of this protocol is in the treatment of plantar fasciopathy with prolonged stretching in dorsiflexion. Plantar fasciopathy, also known a plantar fasciitis is a common problem worldwide and can be attributed to contracture of the plantar fascia. In a randomized, multicentre trial, Sheriden, et al., [21] examined the efficacy of dynamic splinting in 60 patients (76 feet) with plantar fasciopathy. After a physical examination and testing for differential diagnosis, patients were administered the Plantar Fasciitis Pain Scale which is a 100-point survey that measures frequency and intensity of pain in activities of daily living. Experimental patients wore the dynamic splinting devices each night to produce prolonged, low-load, dynamic tension. These patients wore the dynamic splint device for 6 to 8 continual hours (while sleeping) for 12 weeks. On completion, it was noted that the experimental patients had a mean 33 point improvement (reduction) in pain scale scores, compared to only 3 point change for the control patients (p

This case series sought to examine the reduction of chronic contracture of ankle fracture patients using dynamic splinting which delivers prolonged durations of low-load stretching at end-range(s) of motion.

Method

The case series consisted of eighteen patients who had suffered a malleolar fracture and received surgical internal fixation of more than one year. Informed consent was taken from each patient, but formal Institutional Review Board review was not accomplished because there was not a control arm or anything deviating from Standard of Care in reducing contracture. All patients presented with a plantarflexion contracture which had been unresolved for more than one year. Maximal active range of motion in dorsiflexion was the dependent variable in this study and was measured upon enrolment and at four months. This measurement was obtained using a standard goniometer while the patient was seated and the knee flexed to 90°.

Intervention

Patients were prescribed Dynasplint ® for nightly wear, achieving six to eight hours of stretching each night and the tension was increased every two weeks. The tension was increased twice a month to keep stretching at the optimal end range of motion. After an Ankle dorsiflexion Dynasplint® was prescribed, a Dynasplint® specialist custom fit the modality to each patient’s foot. Modifications for length and girth were made to each patient as required. (Dynasplint® Systems, Inc. Severna Park, MD, USA). (Fig. 1)

Figure 1 Dynasplint® for ankle joint dorsiflexion. (with permission from Dynasplint® Systems, Severna Park, MD, USA)

Patients were then instructed how to remove and apply the unit properly, as well as adjust the tension for planned increases in tension every two weeks The incremental changes in tension was based on patient tolerance. Tracking was accomplished to ensure compliance with a monthly diary. Each patient wrote the duration and tension level for each night’s wear and was asked to note any discomfort (i.e. yes or no).

Results

This case series consisted of 9 females and 9 males with a mean age of 46.4 years (standard deviation [SD] 11.8, range 29 – 65 years). The mean duration of wear was 16 weeks (SD 2.9, range 12 – 22 weeks) and the patients averaged a mean 784 hours (SD 94.5, range 960 – 660 hours) in end-range therapy from dynamic splinting. Maximal ankle dorsiflexion measured upon enrolment (baseline) and four months showed a mean change of 23.4º. The range of difference was 5 – 54º, with only three of the patients showing a 5º increase in maximum dorsiflexion from baseline to follow-up. The remainder of the patients (n = 15) had an improvement over beyond 10º. None of the patients reported any discomfort during the period of wear.

Discussion

Tension of gastrocnemius is seen to be a causative factor that contributes to contracture. [22] Whilst DiGiovanni, et al., noted a significant difference in maximal dorsiflexion for ankle equinus patients versus control in full knee extension. [22] No significant difference was observed in maximal dorsiflexion when measured in the seated position (p=0.09). Stretching protocols for contracture have been documented as effective in reduction and it is suggested that the total duration of time at end-range of motion is the integral variable for the greatest success. [8,9,11,12] Mosely, et al., tested passive stretching, but their total durations of stretching in the four week study were 2.8 hours (short duration group stretching 6 min/day) and 15 hours (long duration stretching 30 minutes per day). [2] This supports the evidence that “prolonged passive stretching” (6-8 continuous hours) is required for contracture reduction. [8-14,16-21 ]

The patients in this case series achieved a mean 784 hours of end-range stretching in four months. Therefore, 196 hours of end-range stretching in the first month accounts for the different findings. This prolonged duration of passive, end-range stretching supports the findings by Usuba, et al., when comparing durations of stretching. [8] Moreover, evidence from previous studies on dynamic splinting show empirical efficacy in prolonged duration of stretching at end-range stretching. [9-20] More specifically, these benefits compare favorably with Lai, et al., who observed neurological patients with chronic contracture1 [4], as well as the observations made in this case series.

Range of maximum ankle joint dorsiflexion was a key outcome measure used in this case study, and whilst a 60% increase in range of motion is acknowledged, the authors are aware of the error of measurement associated with clinical goniometric measurements. For example, the standard error of measurement (SEM) for ankle joint dorsiflexion has been reported as 2.1º. [23] Although the lowest change of 5º was noted in three patients, this value can still be considered as clinically significant. The role of the SEM however becomes less crucial with the remaining fifteen patients as motion improved by >10º which comfortably supersedes the SEM and further strengthens the actual improvement in range of motion. Whilst no causal inferences can be established about the relationship between the intervention (i.e. Dyansplint®) and outcome, it has provided the foundation for exploring this form of modality further using studies which have more methodological rigor (i.e. randomized controlled trials).

Conclusion

The benefits of this case series serves as a means of initially reporting on the intervention of dynamic splinting for chronic ankle contracture. The next step is to therefore examine the efficacy of dynamic splinting with a superior methodological rigor. This will therefore examine the true efficacy of dynamic splinting against another testing mechanism such as a balance platform.

Competing interests

SAC is the Chief Editor and FBW is the Associate Editor-in-Chief of the Foot and Ankle Online Journal and were removed from the peer review process and editorial decision for this manuscript.

References

1. Nightingale EJ, Moseley AM, Herbert RD. Passive dorsiflexion flexibility after cast immobilization for ankle fracture. Clin Orthop Relat Res 2007 456: 65-69.
2. Moseley AM, Herbert RD, Nightingale EJ, Taylor DA, Evans TM, Robertson GJ, Gupta SK, Penn J. Passive stretching does not enhance outcomes in patients with plantarflexion contracture after cast immobilization for ankle fracture: a randomized controlled trial. Arch Phys Med Rehabil 2005 86:1118-126.
3. Koval KJ, Zhou W, Sparks MJ, Cantu RV, Hecht P, Lurie J.et al. Complications after ankle fracture in elderly patients. Foot Ankle Int 2007 28: 1249-1255.
4. Barrett MO, Wade AM, Della Rocca GJ, Crist BD, Anglen JO. The safety of forefoot metatarsal pins in external fixation of the lower extremity. JBJS 2008 90A: 560-564.
5. Lui TH, Chan KB, Kong CC, Ngai WK. Ankle stiffness after Bosworth fracture dislocation of the ankle. Arch Orthop Trauma Surg 2008 128: 49-53.
6. Heybeli N, Ozcan M, Yalniz E. Ankle stiffness and osteoarthritis in fracture-dislocation: an avoidable complication or natural history. Arch Orthop Trauma Surg 2008 128: 639-640.
7. De Vries G, Roy K, Chester V. Using three-dimensional gait data for foot/ankle orthopaedic surgery. Open Orthop J 2009 3: 89-95.
8. Usuba M, Akai M, Shirasaki Y, Miyakawa S. Experimental joint contracture correction with low torque–long duration repeated stretching. Clin Orthop Relat Res 2007 456: 70-78.
9. Stubblefield MD, Manfield L, Riedel ER. A preliminary report on the efficacy of a dynamic jaw opening device (dynasplint trismus system) as part of the multimodal treatment of trismus in patients with head and neck cancer. Arch Phys Med Rehabil 2010 91: 1278-1282.
10. Gaspar PD, Willis FB. Adhesive capsulitis and dynamic splinting: a controlled, cohort study. BMC Musculoskelet Dis 2009 10:111.
11. Berner SH, Willis FB. Dynamic splinting in wrist extension following distal radius fractures. J Orthop Surg Res 2010 5: 53.
12. Berner SH, Willis FB, Shanmugan R. Pain from carpal tunnel syndrome reduced with dynamic splinting: a retrospective study of 156 patients. J Clin Med Res 2009 1:22-25.
13. Berner SH, Willis FB, Martinez J. Treatment of carpal tunnel syndrome with dynasplint: a randomized, controlled trial. J Medicine 2008 1: 1-5.
14. Lai J, Jones M, Willis B. Effect of dynamic splinting on excessive plantar flexion tone/contracture: A controlled, cross-over study. Proceedings of the 16th European Congress of Physical and Rehabilitation Medicine. Minerva Medica pubs, Italy, August 2008, 106-109.
15. Anderson DS, Willis FB. Contracture reduction following total knee arthroplasty, a cohort series of 107 patients. Clin Rehab (In-Press).
16. Sheridan L, Lopez AL, Perez A, John MM, Willis FB, Shanmugam R. Plantar fasciopathy treated with dynamic splinting: a randomized, controlled, trial. JAPMA 2010 100:161-165.
17. Lopez AA, Kalish SR, John MM, Willis FB. Reduction of ankle equinus contracture secondary to diabetes mellitus with Dynamic Splinting. FAOJ 2010 3: 3.
18. John MM, Willis FB, Portillo A. Runner’s hallux rigidus reduction and gait analysis. JAPMA 2009 99:367-370.
19. Kalish SA, Willis FB. Hallux limitus and dynamic splinting: a retrospective series. FAOJ 2009 2:4.
20. John MM, Kalish SR, Perns SV, Willis, FB. Dynamic splinting for hallux limitus: a randomized, controlled trial. JAPMA (In-Press).
21. Willis FB, Lopez AL, Perez A, Sheridan L, Kalish SA. Pain scale for plantar fasciopathy. FAOJ 2009 2: 5.
22. DiGiovanni CW, Kuo R, Tejwani N, Price R, Hansen ST Jr, Cziernecki J, Sangeorzan BJ. Isolated gastrocnemius tightness. JBJS 2002 84A: 962-970.
23. Van Gheluwe B, Kirby KA, Roosen P, Phillips RD. Reliability and accuracy of biomechanical measurements of the lower extremities. JAPMA 2002 92: 317-326 .

Address correspondence to: Address correspondence to: Sarah A. Curran, PhD, BSc(Hons), FCPodMed, FHEA. Email: scurran@uwic.ac.uk

1  Senior Lecturer, Wales Centre for Podiatric Studies, University of Wales Institute, Cardiff, Western Avenue, Cardiff, CF5 2YB, UK. Phone +44 (0) 29 2041 7221.
2  Clinical Research Director, Landmark Medical, Dynasplint Systems, PO Box 1735 San Marcos TX, USA. Phone: +1 78667 (512) 297 1833.

© The Foot and Ankle Online Journal, 2011

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Reduction of Ankle Equinus Contracture Secondary to Diabetes Mellitus with Dynamic Splinting

Posted on March 1, 2010 | Comments Off on Reduction of Ankle Equinus Contracture Secondary to Diabetes Mellitus with Dynamic Splinting

by Angel L. Lopez, DPM1, Stanley R. Kalish, DPM2, Mathew M John, DPM3, F. Buck Willis, PhD4

The Foot and Ankle Online Journal 3 (3): 2

Introduction: Ankle equinus is a hereditary or acquired contracture of the triceps surae or shortening of the connective tissue causing inability of the foot to dorsiflex during gait. For the patient population with diabetes mellitus, this high plantar pressure from contracture often results in ulceration. This is frequently treated by Achilles tendon lengthening which helps to avoid infection and amputation. The purpose of this study is to examine the effect of dynamic splinting in reduction of ankle equinus contracture for patients with diabetes mellitus.
Methods: A retrospective analysis was accomplished by reviewing the history of 48 patients following treatment with an ankle dorsiflexion dynamic splint. This dynamic splinting modality delivers low-load prolonged duration stretching while one sleeps. In this home therapy study, dynamic splinting was used for a mean 240 hours in the first month (5 weeks).
Results: Patients showed a statistically significant change in maximal ankle dorsiflexion (P < 0.0001).  The patients mean, maximal active range of motion in dorsiflexion increased by 9º in the first month.
Conclusion: This modality proved effective as home therapy and should be examined in further research so that it may be employed as standard of care in treating ankle equinus contracture.

Key words: Bilateral tension, Dynasplint, Home therapy, Rehabilitation.

Accepted: February, 2010
Published: March, 2010

ISSN 1941-6806
doi: 10.3827/faoj.2010.0303.0002

Ankle equinus is defined as the failure to achieve 10° of dorsiflexion during the gait cycle. [1-10] This disability is the result of contracture and has a significant prevalence in patients who have also been diagnosed with Diabetes Mellitus (DM), both Type 1 and Type 2. [1-4]

Contracture by definition is the molecular shortening of connective tissue and is considered to be the underlying cause of this equinus. [2,3] Contracture of connective tissue is also evident in other pathologies causing other limitations in active range of motion (AROM). [13-19]

Diabetic neuropathy is an underlying neurological condition of ankle equinus contracture when the peroneal nerve is involved. Peroneal nerve atrophy allows the posterior muscle group to overpower the weakened anterior muscles. [3]

In addition, plantar nerve neuropraxia or neurotemesis affecting the posterior tibial nerve (medial and lateral plantar nerves) causes a severe muscle imbalance between the larger and more powerful leg muscles and the intrinsic foot muscles. This contributes to the Lisfranc’s dislocation typically seen in the Charcot diabetic foot. This is similar to the neuromuscular hypertonicity following a stroke which is commonly treated with Botulinium Toxin-A (tone management) and dynamic splinting (for contracture reduction). [13]

A study by Van Gils and Roeder showed the incidence of equinus deformity was present in 91% of patients with DM (n = 151, ages 51-95),1 and a study of 1,666 DM patients by Lavery, et. al., showed 50.3% incidence of ankle equinus (All male; mean age 69 +/- 11 years). [2] National estimates from the American Diabetes Association list the current population of both diagnosed and undiagnosed DM to be 23.7 million Americans and the current “Diabetes-related spending” is $133 billion dollars in the USA. [20]

The current standard of care in treating ankle equinus includes shoe modification,1 ankle mobilization therapy including passive stretching [1-4] and surgery (Achilles tendon lengthening, gastrocnemius recession, or tendon advancement procedures). [1,5,6,11]

The goal of all of these treatments is to prevent the need for amputation following uncontrollable infection from ulceration. The purpose of this study is to examine the effect of dynamic splinting in reduction of ankle equinus contracture for patients with DM.

The Ankle Dorsiflexion Dynasplint® (AFD) (Dynasplint Systems, Inc., Maryland, USA) achieves a low-load, prolonged stretch to reduce contracture through increased time at end range (of motion). [13-19] The Dynasplint® units are worn at night (for 6-8 hours of continuous wear) while sleeping. The Dynasplint® modality has bilateral tension rods that allow for a tissue specific stretch. The device permits dynamic tension settings to be changed, which allow tension to be increased as the end range progresses and the deformity is reduced The AFD used in this study has been shown effective for treating excessive plantar flexion in stroke patients [13] and has shown similar efficacy for treating other conditions requiring contracture reduction. [14-19]

Methods

Records of patients with diagnosed ankle equinus, secondary to DM were used for this retrospective study. Patients’ records who were treated with AFD were retrieved from multiple ankle and foot clinics in Georgia, Texas, and California. Maximal ankle dorsiflexion measurements were the dependent variable and these measurements taken with goniometry while the patient was lying supine with the knee fully extended. The 48 enrolled patients included 25 females and 23 males (mean age of 66 ± Standard deviation 11). The ethnic distribution included 7 African Americans, 4 Asians, 27 Caucasians, and 10 Hispanic patients.

Patients’ initial introduction to the AFD, included customized fitting with consideration for the patient’s foot size and varying degrees of edema which may be present. Patient training was instituted by the technician trained on the Dynasplint systems. Verbal and written instructions were provided throughout the duration of treatment for safety, general wear and care, and tension setting goals based on patient tolerance. (Fig. 1)

Figure 1  Ankle Dorsiflexion Dynasplint®.

Each patient was instructed to start by wearing the AFD for a few hours before sleeping for one day, and then for 6-8 hours while sleeping using an initial tension setting of #1 (2.0 foot pound of torque). This initial frequency, intensity, and duration are used for patient acclimatization to the system. The patients were then instructed to increase the tension one increment every two weeks as tolerated. If the new tension gave the patient “prolonged soreness or pain” (defined as greater soreness than would occur after one hour of intense manual therapy), the patient was instructed to reduce the tension one half increment for a few days before returning to the new setting.

The duration for this study was five weeks. This period was selected to ensure 100% patient compliance and to avoid what one study reported as “difficult (prolonged) follow up.” [4] However the AFD is routinely prescribed for six or more months in treating this condition.

Data Analysis

A paired t-test was calculated to determine if a statistically significant difference existed between the initial, maximal AROM and the final, maximal AROM. The calculations were done independently by an outside biostatistician, Dr Ram Shanmugam from Texas State University, San Marcos, TX.

Results

There was a statistically significant difference in the pre vs. post measurements of patients’ maximal, AROM in dorsiflexion, (p< 0.0001, t = 6.469, df = 47, n = 48). The mean improvement was 20% in just one month. (Fig. 2)

Figure 2  Mean change in active range of motion.

Discussion

The purpose of this study is to examine the effect of dynamic splinting in reduction of ankle equinus contracture for patients with diabetes mellitus. Burke, et al., described hypomobility and diabetic ulcers saying “plantar-flexed first ray deformity (contracture) has been shown to increase pressure on the first metatarsal head and is associated with ulceration.” [5] The AFD used in this trial reduced contracture using passive stretching similar to one component used in the study by Danaberg, et al. The Danaberg study included manual therapy “Mobilization” and passive stretching or “assisted stretching”. The findings show an instant 4.9º improvement in maximal dorsiflexion. [4] Comparable passive stretching was delivered by the AFD but for substantially longer durations as it was worn for 6-8 hours wear during sleep. The AFD wear averaged 6.9 hours per night equaling a total of 241 hours of end range stretching. AROM measurements were taken several hours after awakening which showed stable improvement in contracture reduction.

Literature has shown a direct relationship between mechanical stress (positioning), foot ulceration, and surgery. [3,4,9] Research has also described connective tissue elongation from prolonged stretching [22] and sarcomere changes from limb lengthening. [23] The current standard of care, surgical resolution of ankle equinus contracture, has been established. [1-12] However, use of a modality like the AFD could prevent the need for surgery in a significant number of patients. A previous protocol of using serial casting has been discontinued for DM patients due to the great frequency of skin breakdown and ulcerations from the casting itself. There were no incidences of skin breakdown reported in this retrospective AFD study.

The limitations on this study include lack of a control group, but this study did have high external validity due to the retrospective design which recruited patient records completed before initialization of the study. [21] The study was also limited by its short duration. However, the study by Danaberg, et al., described that a shorter duration study was more likely to display results from the highest patient compliance. This five week study had 100% compliance in wear and tracking of this modality. [4]

Conclusion

Use of the biomechanically correct AFD® with bilateral, dynamic tension has proven effective in this study achieving a mean 9º increase in maximal, active range of motion in one month. This treatment method of dynamic splinting as a home therapy should be considered before surgery is implemented to reduce ankle equinus contracture. In addition, awareness by the physician of these potential damaging equinus factors would suggest early and immediate use of the device for prophylaxis. The normal prescription of this system is six months. A future experiment measuring changes from six month duration in a randomized, controlled trial would prove the efficacy of this modality.

References

1. Van Gils CC, Roeder B. The effect of ankle equinus upon the diabetic foot. Clin Pod Med Surg 2002 Jul; 19(3): 391-409.
2. Lavery LA, Armstrong DG, Boulton AJM. Ankle equinus deformity and its relationship to high plantar pressure in a large population with diabetes mellitus. JAPMA 2002 92: 479-482.
3. Frykberg RG. The high risk foot in diabetes mellitus. New York: Churchill Livingstone, 1991.
4. Dananberg HJ, Shearstone J, Guillano M. Manipulation method for the treatment of ankle equinus. JAPMA 2000 90: 385-389.
5. Birke JA, Patout CA, Foto JG. Factors associated with ulceration and amputation in the neuropathic foot. JOSPT 2000 30(2): 91-97.
6. Menz HB, Dananberg HJ. Manipulation method for the treatment of ankle equinus. JAPMA 2001 91: 105-106.
7. Wallny T, Brackmann H, Kraft C, Nicolay C, Pennekamp P. Achilles tendon lengthening for ankle equinus deformity in hemophiliacs: 23 patients followed for 1-24 years. Acta Orthop 2006 Feb;77(1):164-168.
8. Grady JF, Saxena A. Effects of stretching the gastrocnemius muscle. J Foot Surg 1991 Sep-Oct; 30(5): 465-469.
9. Bowers AL, Castro MD. The mechanics behind the image: foot and ankle pathology associated with gastrocnemius contracture. Semin Musculoskelet Radiol 2007 Mar; 11(1): 83-90.
10. Mullaney MJ, McHugh MP, Tyler TF, Nicholas SJ, Lee SJ. Weakness in end-range plantar flexion after Achilles tendon repair. Am J Sports Med 2006 Jul; 34(7): 1120-1125.
11. Chen L, Greisberg J. Achilles lengthening procedures. Foot Ankle Clin 2009 Dec; 14(4): 627-637.
12. Orendurff MS, Rohr ES, Sangeorzan BJ, Weaver K, Czerniecki JM. An equinus deformity of the ankle accounts for only a small amount of the increased forefoot plantar pressure in patients with diabetes. JBJS 2006 Jan; 88B (1): 65-68.
13. Lai J, Jones M, Willis B. Effect of Dynamic splinting on excessive plantar flexion tone/contracture: A controlled, cross-over study. Proceedings of the 16th European Congress of Physical and Rehabilitation Medicine. Minerva Medica pubs, Italy. 2008 August: 106-109.
14. John MM, Willis FB, Portillo A. Runner’s hallux rigidus reduction and gait analysis, JAPMA 2009 99(4): 367-370.
15. Lundequam P, Willis FB. Dynamic splinting as home therapy for toe walking: A case report. Cases J 2009 Nov 2: 188.
16. Willis FB, John MM, Perez A. Plantar fasciopathy treated with dynamic splinting. PM&R 2009 Sep 1; 9: S169.
17. Sheridan L, Lopez AL, Perez A, John MM, Willis FB. Plantar fasciopathy treated with dynamic splinting: A randomized controlled trial. JAPMA In press.
18. John MM, Kalish SR, Perns SV, Willis, FB. Dynamic splinting for hallux limitus: A randomized controlled trial. JAPMA. In press.
19. Kalish SA, Willis FB. Hallux limitus and dynamic splinting: a retrospective series. The Foot & Ankle Online Journal 2009 Apr; 2 (4): 1.
20. Huang ES, Basu A, O’Grady M, Capretta CJ. Projecting the future diabetes population size and related costs for the U.S. Diabetes Care 2009 Dec; 32 (12): 2225-2229.
21. Kooistra B, Dijkman B, Einhorn TA, Bhandari M. How to design a good case series. JBJS 2009 May; 91A Suppl 3: 21-26.
22. Usuba M, Akai M, Shirasaki Y, Miyakawa S. Experimental joint contracture correction with low torque-long duration repeated stretching. Clin Orthop Relat Res 2007 Mar; 456: 70-78.
23. Makarov M, Birch J, Samchukov M. The role of variable muscle adaptation to limb lengthening in the development of joint contractures: an experimental study in the goat. J Pediatr Orthop 2009 Mar; 29(2):175-181.

Address correspondence to: F. Buck Willis, PhD University of Phoenix: Axia College, Adjunct Professor of Health Sciences, and Dynasplint Systems, Inc. PO Box 1735 San Marcos TX 78667 (512) 297-1833

1  Podiatry; Ft Worth, Texas 910 W North Side Dr Ft Worth, TX 76164. (817) 625-1103 .
2  Atlanta Foot and Leg Clinic, P.A. 6911 Tara Blvd #A Jonesboro, GA 30236-1548 (770) 477-9535
3  Ankle & Foot Centers 2790 Sandy Point Rd. #300 Marietta, GA 30066 (770) 977-3668
4  University of Phoenix: Axia College, Adjunct Professor of Health Sciences, and Dynasplint Systems, Inc. PO Box 1735 San Marcos TX 78667 (512) 297-1833

© The Foot and Ankle Online Journal, 2010

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Dynamic Splinting for Hallux Valgus and Hallux Varus: A Pilot Study

Posted on January 1, 2010 | Comments Off on Dynamic Splinting for Hallux Valgus and Hallux Varus: A Pilot Study

by Mathew M. John, DPM1, F. Buck Willis, PhD2

The Foot and Ankle Online Journal 3 (1): 1

Background: Hallux Abductovalgus (HAV) is a deformity causing excessive angulation of the great toe towards the second toe, and this condition affects over 3.6 million Americans. Conversely hallux varus is excessive medial deviation and this pathology occurs secondary to procedures correcting hallux valgus and as a pediatric/congenital anomaly. The purpose of this pilot study was to report the benefits that Dynamic Splinting (DS) had on reducing contracture in hallux varus and hallux valgus.
Methods: Ten patients treated with DS were examined and these patients included six diagnosed with HAV and four patients diagnosed with hallux varus. The outcome measures reported include changes in maximal, active range of motion (AROM) and resting alignment.
Results: The patients treated for HAV regained a mean 10° active range of motion (AROM) in one month. The patients treated for hallux varus regained a mean 9° AROM in 3 months.
Conclusions: Dynamic splinting was beneficial for all patients in this study. The HAV patients regained a mean 10° of AROM (mean duration 1 month) and the hallux varus patients gained a mean 9° (mean duration 2 months). The modality which delivered low-torque stretching for prolonged durations was effective in reducing these conditions without requiring surgery.

 

Key words: Contracture reduction, Dynasplint, home therapy, rehabilitation.

Accepted: December, 2009
Published: January, 2010

ISSN 1941-6806
doi: 10.3827/faoj.2010.0301.0001

Hallux Abductovalgus (HAV) is a bunion deformity causing abnormal angulation of the great toe towards the second toe. The incidence rate of HAV is 1% of all Americans[1-4] and this includes 9% of women over the age of 60 years old. This pathology causes pain, inflammation, and reduced or impaired functioning of the hallux in ambulation.

The current standard of care in treating this condition includes nonsurgical treatment such as shoe modification followed by surgical management. [5-8] Complications of surgical treatment are not without risk though. Osteotomies of the first metatarsal such as the Lapidus and distal chevron procedure have caused significant incidence of hallux varus.

Hallux varus refers to excessive medial deviation of the great toe. In addition to the frequent iatrogenic postoperative variety, hallux varus occurs as a pediatric/congenital pathology and as a rheumatic or posttraumatic condition. [9,10] This connective tissue pathology is also currently only treated with surgical procedures. [3-6,11]

Similar pathologies have symptomatic contracture which is defined as the molecular shortening of the connective tissue and these pathologies occur from postoperative or posttraumatic arthrofibrosis [12-14], immobilization [15,16], or occur secondarily to excessive neuromuscular tone. [16,17] A study by Usuba, et. al., examined nonsurgical, therapeutic treatments for contracture that was caused by surgical immobilization in rats. [15] After 40 days of surgical immobilization the mean rat knee flexion contracture was -125° (n = 60). Usuba, et. al., then tested the interaction of four protocols: Stretching with high vs. low torque and stretching of prolonged duration vs. short duration. The only statistically significant difference seen between treatment protocols was found with combined protocols of low-torque stretching for prolonged durations.

This combination of low-torque stretching for prolonged durations is exactly what was used in the Dynasplint systems. A study by John, et. al., examined efficacy of the Dynasplint modality for reduction of contracture causing Hallux Limitus (HL). [14] In this study, 50 patients were enrolled after diagnosis of HL which occurred following a bunionectomy or cheilectomy.

The duration of this randomized study was eight weeks, and experimental patients received low-torque, prolonged stretching in the metatarsal joint Dynasplint (MTD) for 60 minutes, three times per day.

The dependent variable in Dr. John’s study was change in Active Range of Motion (AROM) and there was a significant change for the experimental patients following use of this home therapy modality (P < 0.001, T = 4.224). Experimental patients in this study regained a mean 32° change in AROM, extension compared to only a mean 10° change in AROM for control patients. Dr John’s randomized, controlled trial showed conclusive efficacy of the MTD modality.14 A retrospective study (N = 61) by Kalish and Willis showed comparable results in patients’ regaining 73% dorsiflexion at the metatarsal joint after 4 weeks. [13] The purpose of this pilot study was to report the benefits that Dynamic Splinting (DS) had on reducing contracture in hallux varus and hallux valgus.

Methods

Ten patients’ were treated with Dynamic Splinting (DS) in this report, (six with HAV and four with hallux varus). The modality can be seen in Figure 1AB and this unit delivers force and counter force to achieve elongation of connective tissue for contracture reduction. The same unit may be used for both lateral and medial stretching and this alteration is analogous to the Metatarsal Dynasplint that stretches both in plantarflexion[12] and dorsiflexion. [13,14]

Figure 1A and 1B  Hallux valgus (A) and hallux varus (B) Dynasplint.

The initial fitting for patients included customization of the unit (patient’s foot length, girth, and varying degrees of hallux edema), and training on donning and doffing of the devices. Patients also received instruction on safety, general wear and care, and standardized tension setting goals. Dynamic splinting employs the protocol of low-load stretching for contracture reduction through an appropriate biomechanical device which increases the joint’s time at end range (of motion). [12-14,16,17]

Each patient was instructed to wear the DS initially for 10 minutes, three times a day (tid) while seated, with an initial tension setting of #1 (0.10 foot pound of torque). Patients were instructed to sequentially increase the wearing time until they were comfortable wearing the unit for 60 minutes, tid. This lowest intensity was used for becoming accustomed to the system, and the patients were instructed to increase tension on increment every two weeks after they were comfortable wearing the unit for 60 minutes, tid.

Results

The outcome measurements in this study included changes in maximal AROM for all patients and changes in hallux alignment measured in resting, weight bearing position. The patients treated for HAV regained a mean 10° AROM (one month) and the patients treated for hallux varus regained a mean 9° AROM in 3 months. Measurement of hallux alignment was taken while resting (weight bearing). This variable yielded comparable gains of Hallux abduction 10° (HAV) and 9° for adduction (hallux varus).

Conclusion

The purpose of this study was to report the benefits that dynamic splinting had on reducing contracture in hallux varus and hallux valgus. This examination of the new modality for contracture reduction was beneficial in restoring AROM and achieving a more optimal hallux alignment. The DS employed a proven protocol in using low-torque, prolonged stretching to reduce contracture without surgery. [13-17] While surgical resolution of hallux varus and HAV are the current standard of care, therapeutic endeavors have been prescribed effectively for treatment of post operative rehabilitation [18], and the DS used in this study answered the call for therapeutic treatment for hallux contracture pathologies. [3,6,12-14,18]

The use of dynamic splinting in this pilot study caused no adverse events, and a future randomized, controlled trial would determine if this new modality is effective in separate populations of patients with hallux abducto valgus and hallux varus.

References

1. Shima H, Okuda R, Yasuda T, Jotoku T, Kitano N, Kinoshita M: Radiographic measurements in patients with hallux valgus before and after proximal crescentic osteotomy. J Bone Joint Surg 91A (6): 1369 – 1376, 2009.
2. Selner AJ, Selner MD, Cyr RP, Noiwangmuang W: Revisional Am Podiatr Med Assoc 4(4): 341 – 346, 2004.
3. Miller JW: Acquired hallux varus: a preventable and correctable disorder. J Bone Joint Surg 57A (2):183 – 188, 1975.
4. Lui TH: Technique tip: minimally invasive approach of tendon transfer for correction of hallux varus. Foot Ankle Int 30(10): 1018 – 1021, 2009.
5. Miller RJ, Rattan N, Sorto L: The geriatric bunion: correction of metatarsus primus varus and hallux valgus with the Swanson total joint implant. J Foot Surg 22 (3):263 – 270, 1983.
6. Vanore JV, Christensen JC, Kravitz SR, Schuberth JM, Thomas JL, Weil LS, Zlotoff HJ, Mendicino RW, Couture SD; [Clinical Practice Guideline First Metatarsophalangeal Joint Disorders Panel of the American College of Foot and Ankle Surgeons]: Diagnosis and treatment of first metatarsophalangeal joint disorders. Section 3: Hallux varus. J Foot Ankle Surg 42 (3): 137 – 142, 2003.
7. Orzechowski W, Dragan S, Romaszkiewicz P, Krawczyk A, Kulej M, Morasiewicz L: Evaluation of follow-up results of McBride operative treatment for hallux valgus deformity. Ortop Traumatol Rehabil 10(3): 261 – 273, 2008.
8. Jahss MH: Disorders of the hallux and first ray. Disorders of the Foot and Ankle: Medical and Surgical Management. 2nd ed. Philadelphia, Pa: WB Saunders Co, 1084 – 1089, 1991.
9. Trnka HJ, Hofstaetter SG, Easley ME: Intermediate-term results of the Ludloff osteotomy in one hundred and eleven feet. Surgical technique. J Bone Joint Surg 91A (Suppl 2 Pt 1): 156 – 168, 2009.
10. Oloff LM, Bocko AP: Application of distal metaphyseal osteotomy for treatment of high intermetatarsal angle bunion deformities. J Foot Ankle Surg 37(6): 481 – 489, 1998.
11. Bilotti MA, Caprioli R, Testa J, Cournoyer R Jr, Esposito FJ: Reverse Austin osteotomy for correction of hallux varus. J Foot Surg 26 (1): 51 – 55, 1987.
12. John MM, Willis FB, Portillo A: Dynamic splinting for runner’s toe: a case report with gait analysis. J Am Podiatric Med Assoc 99(4): 367 – 370, 2009.
13. Kalish SA, Willis FB: Hallux limitus and dynamic splinting: a retrospective series. The Foot & Ankle Online Journal 2 (4): 1, 2009.
14. John MM, Kalish SR, Perns SV, Willis, FB. Dynamic Splinting for Hallux Limitus: a Randomized, Controlled Trial. Journal American Podiatric Medical Assoc (In-Press)
15. Usuba M, Akai M, Shirasaki Y, Miyakawa S: Experimental joint contracture correction with low torque -long duration repeated stretching. Clin Orthop Relat Res 456: 70 – 88, 2007.
16. Willis FB: Post-TBI Gait rehabilitation. Applied Neurol 3(7): 25 – 26, 2007.
17. Lai J, Jones M, Willis B: Effect of dynamic splinting on excessive plantar flexion tone/contracture: A controlled, cross-over study. Proceedings of the 16th European Congress of Physical and Rehabilitation Medicine. Minerva Medica pubs, Italy, 106 – 109, August, 2008.
18. Schuh R, Hofstaetter SG, Adams SB Jr, Pichler F, Kristen KH, Trnka HJ: Rehabilitation after hallux valgus surgery: importance of physical therapy to restore weight bearing of the first ray during the stance phase. Phys Ther 89(9): 934 – 945, 2009.

Address correspondence to: University of Phoenix: Axia College, Adjunct Professor Health Sciences and Dynasplint Systems, Clinical Research Director.
Email: BuckPhD@yahoo.com

1  Ankle & Foot Centers 2790 Sandy Point Rd. #300 Marietta GA, 30066. (770) 977-3668.
2  University of Phoenix: Axia College, Adjunct Professor Health Sciences, Dynasplint Systems, Clinical Research Director , PO Box 1735 San Marcos TX 78667 (512) 297-1833

© The Foot and Ankle Online Journal, 2010

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