Custom-made foot orthoses for the treatment of foot pain

An assessment of plantar fascia with ultrasound findings in patients with plantar fasciitis: a systematic review

INTRODUCTION

Plantar fasciitis (PFS) is described by an intense pain over medial tubercle of calcaneus, increased with the first step after waking up, after rest and during weightbearing activity. It is the most common cause of plantar heel pain in adults with the prevalence estimated 10% of the general population. Ultrasound imaging is commonly being used to measure the PF thickness, evaluate the efficacy of different treatments and a guide therapeutic technique in patients with PFS. The objective of this study was to systematically review the studies that were previously published to evaluate the role of ultrasound in the assessment of PF in patients with PFS.

METHODS

A systematic search was carried out over the last 5 years from 2017 to 2022 on basis the following electronic databases: Science Direct, Scopus, Web of Science, Springer and PubMed. The keywords that used in the searching were: ultrasound, sonography, ultrasonography, plantar fasciitis, imaging of plantar fascia, physiotherapy of plantar fasciitis, interventional treatment of plantar fasciitis, randomized controlled trial of plantar fasciitis and interventional ultrasound. The review focused on the assessment of PF in patients with PFS underwent different interventions using B-mode, shear wave elastography (SWE) and color Doppler ultrasound.

RESULTS

During the search process, 1661 were recorded using the proper keywords from 2017 to 2022 in which 666 original articles were found after removing the review and duplicated articles. Of these, thirty articles met the inclusion criteria and included in this review. The articles have assessed the PF in patients with PFS under different conditions using different ultrasound modes. Twenty-six articles evaluated the effectiveness of different treatment on PF in patients with PFS using different ultrasound modes. In 8 of 26 articles, the ultrasound was used as both an assessment tool of PF and guide therapeutic technique in patients with PFS. In 18 articles, the ultrasound was used as only assessment tool to identify the PF thickness and its observation changes in patients with PFS. Four articles compared the PF thickness and its intrafascial changes between patients with PFS and healthy subjects.

CONCLUSION

The ultrasound can be a reliable tool in assessment the effect of different interventions on PF by evaluating its thickness, echogenicity and stiffness changes in patients with PFS. There were different methods and treatments were used among the studies.

Development and Effectiveness Testing of a Novel 3D-Printed Multi-Material Orthosis in Nurses with Plantar Foot Pain

Plantar foot pain is one of the most common musculoskeletal conditions affecting the foot. It is regularly experienced by the population with occupations that require prolonged standing hours, especially in nurses. The etiology of plantar foot pain remains unclear, but it is likely to be multi-factorial, with many associated risk factors including increased hours of standing. Orthoses and insoles are often recommended to plantar foot pain patients, however with minimal scientific advancements and limited customizations. In this study, a novel 3D-printed multi-material customized foot orthosis was developed, and its effectiveness on plantar foot pain reduction and functional ability improvement was studied in the nursing population. A total of thirty-six subjects were recruited and were randomized into two groups. The experimental group received the novel 3D-printed multi-material customized foot orthosis, whereas the control group received the standard-of-care (or traditional) intervention. Pre-test and the post-test scores of pains, functional ability and plantar pressure were observed using SPSS software. Improvements were observed in both of the groups; however, better improvements were seen in the experimental group. Overall, the novel 3D printing-based customized foot orthosis showed significant efficacy in reducing plantar foot pain and pressure, and also in increasing functional ability in the nursing population as compared to the traditional method.

Non-pharmacological treatment in difficult-to-treat rheumatoid arthritis

Although the management of rheumatoid arthritis (RA) has improved remarkably with new pharmacological therapies, there is still a significant part of patients not reaching treatment goals. Difficult-to-treat RA (D2TRA) is a complex entity involving several factors apart from persistent inflammation, thereafter requiring a holistic management approach. As pharmacological treatment options are often limited in D2TRA, the need for non-pharmacological treatments (NPT) is even more pronounced. The mechanism of action of non-pharmacological treatments is not well investigated, NPTs seem to have a complex, holistic effect including the immune, neural and endocrine system, which can have a significant additive benefit together with targeted pharmacotherapies in the treatment of D2TRA. In this review we summarize the current knowledge on different NPT in rheumatoid arthritis, and we propose a NPT plan to follow when managing D2TRA patients.

Effects of Foot Orthoses on Pain and the Prevention of Lower Limb Injuries in Runners: Systematic Review and Meta-Analysis

CONTEXT

A variety of approaches have been proposed to prevent lower limb injuries in runners. However, the evidence for the effectiveness of interventions to reduce lower limb pain and injury after intensive running is very weak.

OBJECTIVE

The authors performed a systematic review to investigate the effects of foot orthoses on pain and the prevention of lower limb injuries in runners.

EVIDENCE ACQUISITION

The authors searched the MEDLINE/PubMed, Physiotherapy Evidence Database, Scielo, and Cochrane Central (from inception to February 2022) databases for randomized controlled trials that evaluated the effects of foot orthoses in runners. The authors then calculated mean differences and 95% confidence intervals from these trials. Heterogeneity was assessed using the I2 test. Furthermore, the authors compared the criteria between runners with foot orthoses and ones with no intervention (control group).

EVIDENCE SYNTHESIS

Twelve studies (5321 runners) met our review criteria. The control and the foot orthoses group sustained 721 (37%) and 238 (24%) injuries, respectively. Compared with the control group, the use of foot orthoses resulted in a significant reduction in lower limb injury risk (risk ratio = 0.6; 95% confidence interval, 0.5-0.7; P = .00001, I2 = 54%; 7 studies, N = 2983: moderate-quality evidence). Moreover, the foot orthoses group corresponded to a 40% reduction in the risk of developing lower limb injuries.

CONCLUSIONS

The use of foot orthoses may help reduce the incidence of lower limb injuries and pain in runners.

The Efficacy of Acupuncture on Foot and Ankle for Pain Intensity, Functional Status, and General Quality of Life in Adults: A Systematic Review

Objective: To assess the effect of acupuncture on foot and ankle pain intensity, functional status, quality of life, and incidence of adverse events in adults. Methods: Randomized controlled trials (RCTs) were obtained from a systematic search of 6 major English databases, and a manual search of relevant systematic reviews using Google Scholar. RCTs that compared acupuncture with various forms of sham acupuncture, nonactive and waitlist controls for pain intensity, functional status, and general quality of life were included. Study screening, data extraction, risk of bias assessment, and quality assessment were all performed independently. A narrative synthesis was performed when quantitative pooling was inappropriate. Results: Four RCTs were included, encompassing a total of 211 participants. Due to clinical heterogeneity for all outcomes, quantitative analysis was not appropriate. Our Grades of Recommendation, Assessment, Development and Evaluation rated all outcomes to have either low or very low quality of evidence. With low-quality evidence, acupuncture was shown to be efficacious for participants with plantar fasciitis for pain relief and functional status improvement at short- and intermediate-term follow-ups. Acupuncture was also shown to be efficacious for participants with Achilles tendinopathy for pain relief at short- and intermediate-term follow-ups. No adverse events were reported. Conclusion: There is some evidence to suggest acupuncture to be a safe and efficacious treatment for relieving pain and improving functional status for the foot and ankle. The results of this systematic review should be interpreted with caution due to the limited evidence. Future research should take into consideration the findings of this systematic review.

A Systematic Review of Systematic Reviews on the Epidemiology, Evaluation, and Treatment of Plantar Fasciitis

The number of systematic review and meta-analyses on plantar fasciitis is expanding. The purpose of this review was to provide a comprehensive summary of reviews on the topic pertaining to plantar fasciitis, identify any conflicting and inconsistent results, and propose future research direction. A qualitative review of all systematic reviews and meta-analyses related to plantar fasciitis up to February 2021 was performed using PubMed, Embase, Web of Science, and the Cochrane Database. A total of 1052 articles were initially identified and 96 met the inclusion criteria. Included articles were summarized and divided into the following topics: epidemiology, diagnosis, and treatment. While the majority of reviews had high level of heterogeneity and included a small number of studies, there was general consensus on certain topics, such as BMI as a risk factor for plantar fasciitis and extracorporeal shockwave therapy as an effective mode of therapy. A qualitative summary of systematic reviews and meta-analyses published on plantar fasciitis provides a single source of updated information for clinicians. Evidence on topics such as the epidemiology, exercise therapy, or cost-effectiveness of treatment options for plantar fasciitis are lacking and warrant future research.

Advanced design and manufacturing of custom orthotics insoles based on hybrid Taguchi-response surface method

Herein, a machining strategy to fabricate custom orthotic insoles with high surface finish and wide fit tolerance is presented. CNC milling was used to machine ethylene-vinyl acetate (EVA) foam for insoles with various surface hardness, and the Taguchi-response surface method (TM-RSM) was adopted to optimize the parameters of the CNC milling process (cutting speed, feed rate, tool path strategy, and step over). EVA foam with varying surface hardness and the tolerance of the wide fit insoles corresponding to the surface roughness were analyzed. Subsequently, a mathematical model was established to determine the optimal CNC milling parameters for a standard milling cutter under dry coolants. The results of the six parameters corresponding to the mean values of surface roughness were initially examined using the signal-to-noise ratio of the Taguchi method (TM). The surface roughness obtained with the TM-RSM was up to 4.13% higher than that obtained with the TM. The EVA foam insole with a surface hardness of 50–60 HRC and a wide fit tolerance of 0.75 mm provided the ideal level of comfort and support for patients with diabetes. The results of this study demonstrated that CNC milling provided a better surface finish of orthotic shoe insoles than other methods, which can serve as guidance in the development of machining strategies for insoles made from EVA foam.

Objective measurement of adherence to wearing foot orthoses using an embedded temperature sensor

The objective of this study was to evaluate the validity of a temperature sensor for the measurement of adherence to wearing foot orthoses. Ten participants were provided with foot orthoses containing an embedded temperature sensor and wore the orthoses for a randomly-determined duration over a five-day period. Sensor-detected wear time was compared to a reference standard (objectively measured wear time using a smart-phone application). Ambient temperature and physical activity were recorded with a temperature gauge and wearable activity tracker, respectively. A simple peak detection algorithm which identified the largest one-minute changes in sensor temperature provided highly accurate wear time values (r = 0.999, coefficient of variation=0.2%). Ambient temperature and physical activity did not significantly influence temperature sensor scores. These findings demonstrate that the temperature sensor provides accurate foot orthosis wear time data and may therefore be a useful tool for documenting adherence in clinical practice and intervention studies.

Shear wave elastography for treatment monitoring of plantar fasciitis

BACKGROUND

Plantar fasciitis is a common cause of heel pain. Monitoring therapy effects is challenging with conventional B-mode ultrasound. Shear wave elastography (SWE) provides important diagnostic information beyond B-mode, with typically lower tissue stiffness in symptomatic plantar fascia. Up to now little is known about SWE features for therapy monitoring in plantar fasciitis. We evaluated the clinical effects of a 3-month physical therapy based treatment and its influence on B-mode and SWE ultrasound findings in patients suffering from plantar fasciitis, correlating ultrasound findings to score-based symptom development.

METHODS

Prospective, IRB-approved clinical study in plantar fasciitis patients undergoing a 3-month physical therapy based treatment. Measurement time points were before (T0), after 1 (T1) and 3 (T2) months of treatment, consisting of clinical orthopedic (FFI, AOFAS-Score) and multimodal radiologic sonographic examinations (B-mode/SWE) using a high-resolution linear 18-MHz probe.

RESULTS

A total of 33 patients with 43 symptomatic plantar fascia were included. We found a significant (P<0.001) clinical score improvement (AOFAS +14, FFI-Pain -21, FFI-Function -18) between T0 and T2. Mean initial thickness (T0) of symptomatic plantar fascia was 4.2 (±1.2) mm, compared to 3.2 (±0.7) mm at the asymptomatic contralateral side (P<0.001). No significant thickness changes were seen at T1 (4.2±1.1 mm) and T2 (4.5±1.3 mm), even though clinical scores improved significantly. Mean initial stiffness (T0) of symptomatic plantar fascia was 59.57 (±43.3) kPa, compared to 83.23 (±47.3) kPa at the asymptomatic contralateral side (P<0.001). In contrast to B-mode ultrasound, SWE values increased significantly between T0 (59.6±43.3 kPa), T1 (82.6±47.3 kPa) and T2 (102.5±47.2 kPa) (P<0.001-0.009), with positive correlations for AOFAS/FFI-Pain/Function scores (r=0.285-0.473, P<0.001-0.002).

CONCLUSIONS

A physical therapy based treatment relieves plantar fasciitis symptoms during a 3-month period. In line with symptom reduction, stiffness (Young's-moduli) of plantar fascia increased significantly, while B-mode ultrasound revealed no measurable changes during the healing process. Shear wave elastography was able to quantify plantar fascia pathologies and their recovery under therapy.

Effect of 3D printed foot orthoses stiffness and design on foot kinematics and plantar pressures in healthy people

BACKGROUND

Foot orthoses (FOs) have been widely prescribed to alter various lower limb disorders. FOs' geometrical design and material properties have been shown to influence their impact on foot biomechanics. New technologies such as 3D printing provide the potential to produce custom shapes and add functionalities to FOs by adding extra-components.

RESEARCH QUESTION

The purpose of this study was to determine the effect of 3D printed FOs stiffness and newly design postings on foot kinematics and plantar pressures in healthy people.

METHODS

Two pairs of ¾ length prefabricated 3D printed FOs were administered to 15 healthy participants with normal foot posture. FOs were of different stiffness and were designed so that extra-components, innovative flat postings, could be inserted at the rearfoot. In-shoe multi-segment foot kinematics as well as plantar pressures were recorded while participants walked on a treadmill. One-way ANOVAs using statistical non-parametric mapping were performed to estimate the effect of FOs stiffness and then the addition of postings during the stance phase of walking.

RESULTS

Increasing FOs stiffness altered frontal and transverse plane foot kinematics, especially by further reducing rearfoot eversion and increasing the rearfoot abduction. Postings had notable effect on rearfoot frontal plane kinematics, by enhancing FOs effect. Looking at plantar pressures, wearing FOs was associated with a shift of the loads from the rearfoot to the midfoot region. Higher peak pressures under the rearfoot and midfoot (up to +31.7 %) were also observed when increasing the stiffness of the FOs.

SIGNIFICANCE

3D printing techniques offer a wide range of possibilities in terms of material properties and design, providing clinicians the opportunity to administer FOs that could be modulated according to pathologies as well as during the treatment by adding extra-components. Further studies including people presenting musculoskeletal disorders are required.

Can short-term effectiveness of anti-pronation taping predict the long-term outcomes of customized foot orthoses: developing predictors to identify characteristics of patients with plantar heel pain likely to benefit from customized foot orthoses

Background

Foot orthoses are widely used to manage plantar heel pain (PHP). However, the evidence concerning the effect of foot orthoses on PHP is not conclusive. The study aims to identify the characteristics of patients with PHP likely to achieve a positive outcome after customized foot orthoses and to verify the concept that patients who respond positively to anti-pronation taping would achieve a positive prognosis after wearing foot orthoses for six months.

Methods

This is a prospective observational cohort study. Seventy-four patients with PHP underwent a baseline examination and received anti-pronation taping to their painful feet. The taping effects on pain and function were assessed at the 7-day follow-up visit. Then, all patients received an intervention for their PHP with customized foot orthoses for six months. Outcome was assessed with a numeric pain rating scale, the patient-specific functional scale, the foot function index, and the global rating of perceived change. Significant reduction of pain, increase of function, and perception of a meaningful improvement were considered a positive response.

Results

Of 74 patients, 49 had a positive response to the customized foot orthosis treatment. Five predictors were identified: (1) the average pain intensity decreased by over 1.5 points with taping, (2) the range of ankle plantarflexion > 54 degrees, (3) the strength of ankle plantarflexors on the symptomatic side was equal to or stronger than that on the other side, (4) the range of hip internal rotation < 39 degrees, and (5) the range of hip external rotation > 45 degrees. The presence of three or more predictors increased the rate of achieving positive outcome from 66 to 89%.

Conclusions

The predictors of customized foot orthosis outcome in patients with PHP are related to several physical measures of a lower extremity. Findings of the study can be used to screen and select patients with PHP for foot orthosis intervention. Moreover, patients who respond positively to anti-pronation taping would also benefit from the customized foot orthoses. However, since there was no control group in the current study, it is inappropriate to draw conclusions about the effectiveness of the foot orthoses treatment.

Trial registration

The trial was retrospectively registered with the Australian and New Zealand Clinical Trials Registry (ACTRN 12617000119392).

Effectiveness of Manual Therapy, Customised Foot Orthoses and Combined Therapy in the Management of Plantar Fasciitis-a RCT

Background: Plantar fasciitis (PF) is one of the most common causes of plantar heel pain. Objective: To evaluate the effectiveness of three different treatment approaches in the management of PF. Methods: Sixty-three patients (44 female, 19 men; 48.4 ± 9.8 years) were randomly assigned into a manual therapy (MT), customised foot orthosis (FO) and a combined therapy (combined) group. The primary outcomes of pain and function were evaluated using the American Orthopaedic Foot and Ankle Society-Ankle Hindfoot Scale (AOFAS-AHS) and the patient reported outcome measure (PROM) Foot Pain and Function Scale (FPFS). Data were evaluated at baseline (T0) and at follow-up sessions after 1 month, 2 months and 3 months (T1–T3). Results: All three treatments showed statistically significant (p < 0.01) improvements in both scales from T0 to T1. However, the MT group showed greater improvements than both other groups (p < 0.01). Conclusion: Manual therapy, customised foot orthoses and combined treatments of PF all reduced pain and function, with the greatest benefits shown by isolated manual therapy.

Effects of a contoured foot orthosis and flat insole on plantar pressure and tibial acceleration while walking in defence boots

This study investigated the effects of a contoured, prefabricated foot orthosis and a flat insole on plantar pressure and tibial acceleration while walking in defence boots. Twenty-eight adults walked along an 8-metre walkway in a: (i) defence boot (control condition), (ii) defence boot with a flat insole, and (iii) defence boot with a contoured foot orthosis. Plantar pressure data were collected using the pedar-X in-shoe system and tibial accelerations were measured with an accelerometer. In relation to plantar pressure under the rearfoot, the contoured foot orthosis, compared to the defence boot, decreased peak pressure and maximum force, and increased contact area. Under the medial midfoot, the contoured foot orthosis and flat insole increased peak pressure, maximum force and contact area. Under the medial forefoot, the contoured foot orthosis and flat insole increased maximum force. Under the lateral forefoot, the contoured foot orthosis and flat insole increased contact area, with the flat insole also increasing maximum force. In relation to tibial acceleration, the contoured foot orthosis, compared to the defence boot, decreased tibial peak positive acceleration. These findings provide novel biomechanical evidence for the effects of contoured foot orthoses in defence boots.

Electrical dry needling as an adjunct to exercise, manual therapy and ultrasound for plantar fasciitis: A multi-center randomized clinical trial

Study Design

Randomized, single-blinded, multi-center, parallel-group trial.

Objectives

To compare the effects of adding electrical dry needling into a program of manual therapy, exercise and ultrasound on pain, function and related-disability in individuals with plantar fasciitis (PF).

Background

The isolated application of electrical dry needling, manual therapy, exercise, and ultrasound has been found to be effective for PF. However, no previous study has investigated the combined effect of these interventions in this population.

Methods

One hundred and eleven participants (n = 111) with plantar fasciitis were randomized to receive electrical dry needling, manual therapy, exercise and ultrasound (n = 58) or manual therapy, exercise and ultrasound (n = 53). The primary outcome was first-step pain in the morning as measured by the Numeric Pain Rating Scale (NPRS). Secondary outcomes included resting foot pain (NPRS), pain during activity (NPRS), the Lower Extremity Functional Scale (LEFS), the Foot Functional Index (FFI), medication intake, and the Global Rating of Change (GROC). The treatment period was 4 weeks with follow-up assessments at 1 week, 4 weeks, and 3 months after the first treatment session. Both groups received 6 sessions of impairment-based manual therapy directed to the lower limb, self-stretching of the plantar fascia and the Achilles tendon, strengthening exercises for the intrinsic muscles of the foot, and therapeutic ultrasound. In addition, the dry needling group also received 6 sessions of electrical dry needling using a standardized 8-point protocol for 20 minutes. The primary aim was examined with a 2-way mixed-model analysis of covariance (ANCOVA) with treatment group as the between-subjects variable and time as the within-subjects variable after adjusting for baseline outcomes.

Results

The 2X4 ANCOVA revealed that individuals with PF who received electrical dry needling, manual therapy, exercise and ultrasound experienced significantly greater improvements in first-step morning pain (F = 22.021; P<0.001), resting foot pain (F = 23.931; P<0.001), pain during activity (F = 7.629; P = 0.007), LEFS (F = 13.081; P<0.001), FFI Pain Subscale (F = 13.547; P<0.001), FFI Disability Subscale (F = 8.746; P = 0.004), and FFI Total Score (F = 10.65; P<0.001) than those who received manual therapy, exercise and ultrasound at 3 months. No differences in FFI Activity Limitation Subscale (F = 2.687; P = 0.104) were observed. Significantly (X² = 9.512; P = 0.023) more patients in the electrical dry needling group completely stopped taking medication for their pain compared to the manual therapy, exercise and ultrasound group at 3 months. Based on the cutoff score of ≥+5 on the GROC, significantly (X² = 45.582; P<0.001) more patients within the electrical dry needling group (n = 45, 78%) achieved a successful outcome compared to the manual therapy, exercise and ultrasound group (n = 11, 21%). Effect sizes ranged from medium to large (0.53<SMD<0.85) at 3 months in favor of the electrical dry needling group.

Conclusion

The inclusion of electrical dry needling into a program of manual therapy, exercise and ultrasound was more effective for improving pain, function and related-disability than the application of manual therapy, exercise and ultrasound alone in individuals with PF at mid-term (3 months).

Level of evidence

Therapy, Level 1b.

Foot orthoses for plantar heel pain: a systematic review and meta-analysis

Objective

To investigate the effectiveness of foot orthoses for pain and function in adults with plantar heel pain.

Design

Systematic review and meta-analysis. The primary outcome was pain or function categorised by duration of follow-up as short (0 to 6 weeks), medium (7 to 12 weeks) or longer term (13 to 52 weeks).

Data sources

Medline, CINAHL, SPORTDiscus, Embase and the Cochrane Library from inception to June 2017.

Eligibility criteria for selecting studies

Studies must have used a randomised parallel-group design and evaluated foot orthoses for plantar heel pain. At least one outcome measure for pain or function must have been reported.

Results

A total of 19 trials (1660 participants) were included. In the short term, there was very low-quality evidence that foot orthoses do not reduce pain or improve function. In the medium term, there was moderate-quality evidence that foot orthoses were more effective than sham foot orthoses at reducing pain (standardised mean difference −0.27 (−0.48 to −0.06)). There was no improvement in function in the medium term. In the longer term, there was very low-quality evidence that foot orthoses do not reduce pain or improve function. A comparison of customised and prefabricated foot orthoses showed no difference at any time point.

Conclusion

There is moderate-quality evidence that foot orthoses are effective at reducing pain in the medium term, however it is uncertain whether this is a clinically important change.

[Forefoot relief with shoe inserts : Effects of different construction strategies]

BACKGROUND

Shoe inserts and shoe modifications are used to reduce plantar peak pressure. The effects of different shoe inserts and shoe construction strategies for relief of the forefoot have not yet been sufficiently evaluated.

PURPOSE

The aim of this study was to analyze the effects of shoe inserts and shoe construction strategies (e.g. metatarsal pad, forefoot cushioning and control) and shoe modifications (e.g. flexible or stiff) on the peak plantar pressure in the forefoot region.

MATERIAL AND METHODS

In this study 15 healthy subjects were recruited. Plantar pressure distribution was measured using an in-shoe system during walking (3.5km∙h^-1) on a treadmill and the average plantar peak pressure (kPa) in the forefoot was calculated. The statistics for testing the hypothesis were carried out using 2‑factorial ANOVA with repeat measurements (factors: shoe, insert; α = 0.05).

RESULTS

The metatarsal pad and forefoot cushioning led to a reduction of peak pressure, which was statistically significant compared to the control condition (p = 0.009). No differences were observed between both shoe inserts (p > 0.05). A comparison between stiff and flexible shoes revealed a statistically significant pressure reduction in favor of stiff shoes (p = 0.0001). The metatarsal pad led to a peak pressure increase in the midfoot of 12% and by 21% compared to control and forefoot cushioning, respectively.

DISCUSSION

A peak pressure reduction in the forefoot can be achieved with a metatarsal pad or with cushioning; however, the metatarsal pad resulted in a subsequent increase in midfoot pressure. Moreover, shoe construction is crucial because a stiff shoe contributes to a better peak pressure reduction compared to a flexible shoe. Prospective clinical studies should be carried out to prove whether this results in beneficial effects for patients with metatarsalgia.

Custom-made foot orthoses: an analysis of prescription characteristics from an Australian commercial orthotic laboratory

BACKGROUND

Foot orthoses are widely used in the prevention and treatment of foot disorders. The aim of this study was to describe characteristics of custom-made foot orthosis prescriptions from a Australian podiatric orthotic laboratory.

METHODS

One thousand consecutive foot orthosis prescription forms were obtained from a commercial prescription foot orthosis laboratory located in Melbourne, Victoria, Australia (Footwork Podiatric Laboratory). Each item from the prescription form was documented in relation to orthosis type, cast correction, arch fill technique, cast modifications, shell material, shell modifications and cover material. Cluster analysis and discriminant function analysis were applied to identify patterns in the prescription data.

RESULTS

Prescriptions were obtained from 178 clinical practices across Australia and Hong Kong, with patients ranging in age from 5 to 92 years. Three broad categories ('clusters') were observed that were indicative of increasing 'control' of rearfoot pronation. A combination of five variables (rearfoot cast correction, cover shape, orthosis type, forefoot cast correction and plantar fascial accommodation) was able to identify these clusters with an accuracy of 70%. Significant differences between clusters were observed in relation to age and sex of the patient and the geographic location of the prescribing clinician.

CONCLUSION

Foot orthosis prescriptions are complex, but can be broadly classified into three categories. Selection of these prescription subtypes appears to be influenced by both patient factors (age and sex) and clinician factors (clinic location).

Corticosteroid injections compared to foot orthoses for plantar heel pain: protocol for the SOOTHE heel pain randomised trial

INTRODUCTION

Corticosteroid injections and foot orthoses are common interventions for plantar heel pain. Previous clinical trials have found that the effectiveness of these interventions differs over time, with corticosteroid injections being more effective in the short-term (i.e. 0-4 weeks) and foot orthoses more effective in the longer-term (i.e. 5-12 weeks). However, some of these trials have methodological weaknesses that could have caused confounding and bias, which may have led to over- or under-estimation of the effectiveness of these interventions. As a result, there is a need to compare the effectiveness of corticosteroid injections and foot orthoses in a robust clinical trial with an appropriate follow-up time.

METHODS

This article describes the protocol for a pragmatic, parallel-group assessor-blinded randomised trial (Steroid injection versus foot orthoses (SOOTHE) heel pain trial). One hundred participants with plantar heel pain will be randomly allocated (i.e. two groups of approximately 50) to receive either an ultrasound-guided corticosteroid injection or prefabricated foot orthoses. Outcome measures will be obtained at baseline, 4, 8 and 12 weeks, with two primary endpoints at 4 and 12 weeks to reflect the hypothesised temporal effects of each intervention. The primary outcome measure will be the foot pain domain of the Foot Health Status Questionnaire.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry number ACTRN12615001266550.

The effect of foot orthoses with forefoot cushioning or metatarsal pad on forefoot peak plantar pressure in running

Background

Foot orthoses are frequently used in sports for the treatment of overuse complaints with sufficient evidence available for certain foot-related overuse pathologies like plantar fasciitis, rheumatoid arthritis and foot pain (e.g., metatarsalgia). One important aim is to reduce plantar pressure under prominent areas like metatarsal heads. For the forefoot region, mainly two common strategies exist: metatarsal pad (MP) and forefoot cushioning (FC). The aim of this study was to evaluate which of these orthosis concepts is superior in reducing plantar pressure in the forefoot during running.

Methods

Twenty-three (13 female, 10 male) asymptomatic runners participated in this cross-sectional experimental trial. Participants ran in a randomised order under the two experimental (MP, FC) conditions and a control (C) condition on a treadmill (2.78 ms⁻¹) for 2 min, respectively. Plantar pressure was measured with the in-shoe plantar pressure measurement device pedar-x®-System and mean peak pressure averaged from ten steps in the forefoot (primary outcome) and total foot was analysed. Insole comfort was measured with the Insole Comfort Index (ICI, sum score 0–100) after each running trial. The primary outcome was tested using the Friedman test (α = 0.05). Secondary outcomes were analysed descriptively (mean ± SD, lower & upper 95%-CI, median and interquartile-range (IQR)).

Results

Peak pressure [kPa] in the forefoot was significantly lower wearing FC (281 ± 80, 95%-CI: 246–315) compared to both C (313 ± 69, 95%-CI: 283–343; p = .003) and MP (315 ± 80, 95%-CI: 280–350; p = .001). No significant difference was found between C and MP (p = .858). Peak pressures under the total foot were: C: 364 ± 82, 95%-CI: 328–399; MP: 357 ± 80, 95%-CI: 326–387; FC: 333 ± 81 95%-CI: 298–368. Median ICI sum scores were: C 50, MP 49, FC 64.

Conclusions

In contrast to the metatarsal pad orthosis, the forefoot cushioning orthosis achieved a significant reduction of peak pressure in the forefoot of recreational runners. Consequently, the use of a prefabricated forefoot cushioning orthosis should be favoured over a prefabricated orthosis with an incorporated metatarsal pad in recreational runners with normal height arches.

Electronic supplementary material

The online version of this article (doi:10.1186/s13047-016-0176-z) contains supplementary material, which is available to authorized users.

Comparability of off the shelf foot orthoses in the redistribution of forces in midfoot osteoarthritis patients

BACKGROUND

Midfoot osteoarthritis (OA) is more prevalent and strongly associated with pain than previously thought. Excessive mechanical loading of the midfoot structures may contribute to midfoot OA and studies suggest that functional foot orthoses (FFO) may relieve pain through improving function. This exploratory study aimed to evaluate the mechanical effect of two off-the-shelf FFOs, compared to a sham orthosis in people with midfoot OA.

METHODS

Thirty-three participants with radiographically confirmed symptomatic midfoot OA were randomly assigned to wear either a commercially available FFO or a sham orthosis. After wearing their assigned orthoses for 12 weeks, plantar pressure measurements were obtained under shoe-only and assigned orthoses conditions. Participants assigned to the sham, were additionally tested wearing a second type of FFO at the end of trial. Descriptive mean change (±95% confidence intervals) in plantar pressure for each orthoses condition, versus a shoe only baseline condition are presented.

FINDINGS

Compared to the shoe only conditions, both FFOs decreased hindfoot and forefoot maximum force and peak pressure, whilst increasing maximum force and contact area under the midfoot. The sham orthosis yielded plantar pressures similar to the shoe-only condition.

INTERPRETATION

Findings suggest that both types of off-the-shelf FFO may provide mechanical benefit, whilst the sham orthoses produced similar findings to the shoe only condition, indicating appropriate sham properties. This paper provides insight into the mechanisms of action underpinning the use of FFOs and sham orthoses, which can inform future definitive RCTs examining the effect of orthoses on midfoot OA.

Physiotherapy for plantar fasciitis: a UK-wide survey of current practice

OBJECTIVES

To identify how United Kingdom (UK) physiotherapists currently diagnose, assess and manage plantar fasciitis in routine practice.

DESIGN

Online questionnaire survey.

PARTICIPANTS

Practising physiotherapists across the UK who treat patients with plantar fasciitis.

METHODS

Physiotherapists were approached via 'interactive Chartered Society of Physiotherapy (CSP)' online networks and an email database of clinical educators in South West England. An online questionnaire was developed by reviewing similar existing physiotherapy surveys and consultation with experienced musculoskeletal researchers/clinicians. Descriptive statistics were used to analyse the data.

RESULTS

285 physiotherapists responded, with 257 complete survey responses. Pain on palpation and early morning pain were the most common diagnostic criteria, with some physiotherapists using no formal test criteria. Advice (237/257, 92%), plantar fasciitis pathology education (207/257, 81%) and general stretching exercises (189/257, 74%) were most routinely used. Prefabricated orthotics, custom made orthotics and night splints were seldom always used. For the manual therapy approach, the most frequently used modalities were massage, myofascial release, specific soft tissue mobilisations and myofascial trigger point therapy. Commonly used outcome measures were pain assessment, functional tests and range of movement.

CONCLUSIONS

Physiotherapists appeared to follow most of the established diagnostic criteria for PF, but have not followed established outcome measure guidelines. Advice as well as education with an emphasis on self-management including calf/hamstring stretching was the most commonly reported treatment approach. There was uncertainty whether this approach accurately reflected clinical practice used throughout the UK, owing to potential response bias/unknown response rate and the low number of patients with PF treated by the respondents.

The STAP-study: The (cost) effectiveness of custom made orthotic insoles in the treatment for plantar fasciopathy in general practice and sports medicine: design of a randomized controlled trial

BACKGROUND

Plantar fasciopathy is a common cause of foot pain, accounting for 11 to 15% of all foot symptoms requiring professional care in adults. Although many patients have complete resolution of symptoms within 12 months, many patients wish to reduce this period as much as possible. Orthotic devices are a frequently applied option of treatment in daily practice, despite a lack of evidence on the effectiveness. Therefore, the objective is to study the (cost)-effectiveness of custom made insoles by a podiatrist, compared to placebo insoles and usual care in patients with plantar fasciopathy in general practice and sports medicine clinics.

METHOD/DESIGN

This study is a multi-center three-armed participant and assessor-blinded randomized controlled trial with 6-months follow-up. Patients with plantar fasciopathy, with a minimum duration of complaints of 2 weeks and aged between 18 and 65, who visit their general practitioner or sport physician are eligible for inclusion. A total of 185 patients will be randomized into three parallel groups. One group will receive usual care by the general practitioner or sports physician alone, one group will be referred to a podiatrist and will receive a custom made insole, and one group will be referred to a podiatrist and will receive a placebo insole. The primary outcome will be the change from baseline to 12 weeks follow-up in pain severity at rest and during activity on a 0-10 numerical rating scale (NRS). Secondary outcomes include foot function (according to the Foot Function Index) at 6, 12 and 26 weeks, recovery (7-point Likert) at 6, 12 and 26 weeks, pain at rest and during activity (NRS) at 6 and 26 weeks and cost-effectiveness of the intervention at 26-weeks. Measurements will take place at baseline and at, 2, 4, 6, 12 and 26 weeks of follow-up.

DISCUSSION

The treatment of plantar fasciopathy is a challenge for health care professionals. Orthotic devices are frequently applied, despite a lack of evidence of the effectiveness on patient reported outcome. The results of this randomized controlled trial will improve the evidence base for treating this troublesome condition in daily practice.

TRIAL REGISTRATION

Dutch Trial Registration: NTR5346 . Date of registration: August 5(th) 2015.

Foot orthoses for the prevention of lower limb overuse injuries in naval recruits: study protocol for a randomised controlled trial

Background

Foot orthoses are frequently used for the prevention of lower limb overuse injuries but evidence for their effectiveness is limited. The primary aim of this study is to determine if prefabricated foot orthoses reduce the incidence of lower limb overuse injuries in naval recruits undertaking 11 weeks of basic training.

Methods

This study is a participant and assessor blinded, parallel-group, randomised controlled trial. The trial will recruit participants undertaking 11 weeks of basic training at the Royal Australian Navy Recruit School, Cerberus, Victoria, Australia. Participants will be randomised to a control group (flat insole) or an intervention group (prefabricated foot orthosis). Over the 11 weeks of basic training, participants will document the presence and location of pain in weekly self-report diaries. The end-point for each participant will be the completion of 11 weeks of basic training. The primary outcome measure will be the combined incidence of four lower limb injuries (medial tibial stress syndrome, patellofemoral pain, Achilles tendinopathy, and plantar fasciitis/plantar heel pain) which are common among defence members. Secondary outcome measures include: (i) overall incidence of lower limb pain, (ii) severity of lower limb pain, (iii) time to injury, (iv) time to drop-out due to injury, (v) adverse events, (vi) number of lost training days, (vii) shoe comfort, and (viii) general health status. Data will be analysed using the intention-to-treat principle.

Discussion

This randomised controlled trial will evaluate the effectiveness of prefabricated foot orthoses for the prevention of common lower limb overuse injuries in naval recruits.

Trial registration

Australian New Zealand Clinical Trials Registry: ACTRN12615000024549.

A study of the immediate effects of glycerine-filled insoles, contoured prefabricated orthoses and flat insoles on single-leg balance, gait patterns and perceived comfort in healthy adults

Background

Footwear interventions are often prescribed to assist with the management of lower limb pain, injury and disease. Commercially available shoe insoles and orthoses are increasingly incorporating novel design features to alleviate foot and lower limb symptoms, but this may be at a cost to optimal functional performance. This study compared the immediate effects of wearing glycerine-filled insoles, contoured prefabricated orthoses, and flat insoles, on balance and gait measures.

Methods

Thirty healthy adults (17 men, 13 women; mean [SD] age: 24.3 [2.5] years) performed tests of single-leg standing with eyes open (Kistler force platform), star excursion balance test, and level-ground walking (GAITRite® walkway system), under three randomised conditions: wearing glycerine-filled insoles, prefabricated orthoses, and flat (control) insoles, within their own footwear. Centre of pressure movement (anterior-posterior and mediolateral range and standard deviation, total path velocity), star excursion balance test reach distance, and temporospatial gait variables were collected. Perceived comfort of the inserts was scored immediately after use on a 100 mm visual analogue rating scale. After trialling all inserts each participant ranked their level of comfort from least to most.

Results

Centre of pressure measures, star excursion balance test reach distance, or temporospatial gait variables did not differ between the three inserts (all P values >0.088). Significant between-condition differences were reported for comfort ranking (P = 0.031), but not rating scores (P = 0.638). Weak to moderate negative correlations (r values ranged between −0.368 and −0.406) were observed between visual analogue scale comfort rating for the flat insoles and prefabricated orthoses, star excursion balance test and gait measures.

Conclusions

Single-leg standing balance, star excursion balance test performance, and level-ground walking patterns in asymptomatic adults do not appear to differ when wearing glycerine-filled insoles, contoured prefabricated orthoses, or flat insoles. Perceived comfort may be related to the biomechanical or clinical effectiveness of novel footwear interventions, and requires further investigation. Importantly, these findings are specific to a healthy population and further research is needed to determine the long-term effects of glycerine-filled insoles in patients with known balance impairments.

Evaluating a standardised tool to explore the nature and extent of foot and ankle injuries in amateur and semi-professional footballers

BACKGROUND

Most studies of football injuries include professional players and data have been collected in without a single validated, standardised tool. We aimed to develop a new standardised questionnaire for assessing injuries among non-professional footballers and pilot its use.

METHOD

A questionnaire was developed using input from footballers, healthcare professionals and triangulation from the literature. The new tool was piloted among players representing amateurs and semi-professionals. Their comments were used iteratively to improve the instrument.

RESULTS

The development phase produced a 33-item questionnaire collecting quantitative and qualitative data. In the pilot phase, 42 questionnaires were distributed, 34 (81%) returned. Respondents reported total of 273 football-related injuries, 114 affecting the foot/ankle (70 at the ankle and 44 at the foot). In total, 44% of respondents had suffered one or more foot/ankle injuries in the past 12 months.

CONCLUSION

We developed a new standardised tool which we found to be well-completed by young male footballers in semi-professional and amateur settings with an excellent response rate. Our results suggested that foot/ankle injuries were common, larger studies in non-professionals are needed to identify risk factors for injury and develop pragmatic advice for prevention.

Plantar fasciitis: a concise review

One challenge in the treatment of plantar fasciitis is that very few high-quality studies exist comparing different treatment modalities to guide evidence-based management. Current literature suggests a change to the way that plantar fasciitis is managed. This article reviews the most current literature on plantar fasciitis and showcases recommended treatment guidelines. This serves to assist physicians in diagnosing and treating heel pain with plantar fasciitis.

A radiographic and anthropometric study of the effect of a contoured sandal and foot orthosis on supporting the medial longitudinal arch

Background

In-shoe foot orthoses improve conditions such as plantar heel pain (fasciitis), probably due to their ability to raise the medial longitudinal arch of the foot and lower the stress on the plantar tissues. Increasingly the arch-profile form of the in-shoe foot orthosis is being incorporated into sandal footwear, providing an alternative footwear option for those who require an orthosis. The purpose of this study was to evaluate if a sandal that incorporates the arch-profile of an in-shoe foot orthosis does indeed raise the medial longitudinal arch.

Methods

Three commercially available non-medical devices (contoured and flat sandal, prefabricated in-shoe orthosis) worn by healthy individuals were studied in two independent experiments, one using radiographic measurements in Australia (n = 11, 6 female, age 26.1 ± 4.3 yrs, BMI 22.0 ± 2.4 kg/m²) and the other utilising anthropometric measures in the USA (n = 10, 6 female, age 26.3 ± 3.8 yrs, BMI 23.5 ± 3.7 kg/m²). A barefoot condition was also measured. Dorsal arch height was measured in both experiments, as well as in subtalar neutral in the anthropometric experiment. One way repeated measures ANOVA with follow up Bonferroni-corrected pairwise comparisons were used to test differences between the conditions (contoured and flat sandal, orthosis, barefoot). Mean difference and 95% confidence intervals (CI) and standardised mean differences (SMD) were also calculated.

Results

The contoured sandal significantly increased dorsal arch height compared to barefoot and flat sandal in both the anthropometric and radiographic experiments with SMD ranging from 0.95 (mean difference 5.1 mm (CI: 0.3, 1.6)) to 1.8 (4.3 mm (1.9, 6.6)). There were small differences between the contoured sandal and orthosis of 1.9 mm (0.6, 3.3) in the radiographic experiment and 1.2 mm (−0.4, 0.9) in the anthropometric experiment. The contoured sandal approximated the subtalar neutral position (0.4 mm (−0.5, 0.7)).

Conclusions

Medial longitudinal arch height is elevated by contoured sandals and approximates subtalar joint neutral position of the foot and that achieved by an orthosis. Practitioners wanting to increase the medial longitudinal arch can do so with either an orthosis or a contoured sandal that includes the raised arch profile form of an orthosis.

Treatment of forefoot problems in older people: a randomized clinical trial comparing podiatric treatment with standardized shoe advice

PURPOSE

Consultations for forefoot pain are frequent in primary care, but scientific support of treatment options is scarce. The purpose of this study is to investigate the effect of podiatric treatment vs standardized advice on proper shoe characteristics and fit of shoes by means of an information leaflet for people aged 50 years and older with forefoot pain in primary care.

METHODS

In this randomized controlled trial, 205 participants aged 50 years and older with hindering nontraumatic forefoot pain have been recruited at their general practitioner's office. Exclusion criteria were treatment of forefoot problem of less than 6 months' duration before inclusion, rheumatoid arthritis, and diabetic neuropathy or having pain considered not to be musculoskeletal (eg, warts). Participants received shoe advice by means of an information leaflet or podiatric care. Foot pain, foot-related dysfunction, general health, and social participation were assessed by means of questionnaires every 3 months for 1 year. Using multilevel analysis, we analyzed results at the level of (1) outcome measures, (2) the individual, and (3) the general practitioner.

RESULTS

No differences were found between the 2 treatment groups. Both intervention groups showed an improvement over time in foot pain and foot-related dysfunction.

CONCLUSION

This study found that shoe advice provided to patients consulting their general practitioner for forefoot pain and symptom relief resulted in outcomes similar to treatment outcomes in patients consulting a podiatrist. Based on these results, primary care physicians should be cautious when referring a patient to a podiatrist; instead, they should start by providing advice on proper characteristics and fit of shoes.

Foot posture, leg length discrepancy and low back pain--their relationship and clinical management using foot orthoses--an overview

Mechanical low back pain (LBP) is a very common, expensive, and significant health issue in the western world. Functional musculoskeletal conditions are widely thought to cause mechanical low back pain. The role of foot posture and leg length discrepancy in contributing to abnormal biomechanics of the lumbopelvic region and low back pain is not sufficiently investigated. This critical review examines the evidence for the association between foot function, particularly pronation, and mechanical LBP. It also explores the evidence for a role for foot orthoses in the treatment of this condition. There is a body of evidence to support the notion that foot posture, particularly hyperpronation, is associated with mechanical low back pain. Mechanisms that have been put forward to account for this finding are based on either mechanical postural changes or alterations in muscular activity in the lumbar and pelvic muscles. More research is needed to explore and quantify the effects of foot orthoses on chronic low back pain, especially their effects on lumbopelvic muscle function and posture. The clinical implications of this work are significant since foot orthoses represent a simple and potentially effective therapeutic measure for a clinical condition of high personal and social burden.

Clinical efficacy and cost-effectiveness of bespoke and prefabricated foot orthoses for plantar heel pain: a prospective cohort study

BACKGROUND

Plantar heel pain is a common reason for referral to podiatric practice, and one of the key interventions is the use of orthoses. The aim of the present study was to compare the clinical efficacy of bespoke, casted foot orthoses and prefabricated foot orthoses for plantar heel pain.

METHODS

People with plantar heel pain were included if, following initial assessment, foot orthoses were indicated and participants received either bespoke, casted foot orthoses or prefabricated semi-rigid orthoses (Powerstep™). Clinical efficacy was assessed at eight weeks using the Manchester Foot Pain and Disability Questionnaire (MFPDQ).

RESULTS

A total of 67 patients completed the trial and at baseline there were no appreciable differences in the two groups of patients in terms of the MFPDQ score; however, at eight weeks post-treatment both had significantly reduced foot pain and disability (both p < 0.0001). There was no significant difference in effectiveness between the bespoke or prefabricated orthoses. However, prefabricated devices were 38% cheaper per patient compared with the average costs of casted devices.

CONCLUSION

For most patients with plantar heel pain, prefabricated semi-rigid insoles such as the Powerstep™ devices used in the present trial provide short-term benefit equivalent to that of bespoke, casted foot orthoses, but at considerably reduced costs.

Mechanism of orthotic therapy for the painful cavus foot deformity

Background

People who have extremely high arched feet or pes cavus often suffer from substantial foot pain. Custom-made foot orthoses (CFO) have been shown to be an effective treatment option, but their specificity is unclear. It is generally thought that one of the primary functions of CFO is redistributing abnormal plantar pressures. This study sought to identify variables associated with pain relief after CFO intervention.

Methods

Plantar pressure data from a randomized controlled trial of 154 participants with painful pes cavus were retrospectively re-analyzed at baseline and three month post CFO intervention. The participants were randomized to a treatment group given CFO or a control group given sham orthoses.

Results

No relationship between change in pressure magnitude and change in symptoms was found in either group. However, redistribution of plantar pressure, measured with the Dynamic Plantar Loading Index, had a significant effect on pain relief (p = 0.001). Our final model predicted 73% of the variance in pain relief from CFO and consisted of initial pain level, BMI, foot alignment, and changes in both Dynamic Plantar Loading Index and pressure–time integral.

Conclusion

Our data suggest that a primary function of effective orthotic therapy with CFO is redistribution of abnormal plantar pressures. Results of this study add to the growing body of literature providing mechanistic support for CFO providing pain relief in painful foot conditions. The proposed model may assist in better designing and assessing orthotic therapy for pain relief in patients suffering painful cavus foot deformity.

Trial registration

Randomized controlled trial: ISRCTN84913516

The use of 'off-the-shelf' foot orthoses in the reduction of foot symptoms in patients with early rheumatoid arthritis

BACKGROUND

Foot pain in patients diagnosed with early rheumatoid arthritis is common.

OBJECTIVES

To investigate effects of off-the-shelf foot orthoses on outcomes of swollen and tender joints, and pain, in patients with early rheumatoid arthritis.

METHODS

Thirty-five patients with painful and swollen foot joints were recruited. None had previously used foot orthoses or had contraindications to their use. Any patients with concomitant musculoskeletal disease, endocrine disorders, and neurological disease, were excluded. At baseline, participants were prescribed a customised off-the-shelf foot orthosis with chair-side modifications. Data was collected at baseline, three and six months. Foot pain (using Visual Analogue Scale) and the number of tender and swollen foot joints was measured.

RESULTS

There was a trend towards a reduction in the number of swollen and tender joints by 3 months with a further improvement by 6 months. Statistically (p<0.05) and clinically significant reductions in pain levels were also noted.

CONCLUSION

Patients diagnosed with early RA may benefit from using off-the-shelf foot orthoses with the majority of their pain reduction occurring within the first 3 months of use, but with some small further symptomatic improvement up to 6 months. There was a tendency to a reduction in swollen and tender joints although more studies are required to substantiate these findings.

The rheumatoid forefoot

Rheumatoid arthritis (RA) manifests itself in a variety of ways, with its effect being seen in around 90 % of sufferers' feet. The foot has been found to be the most common reason for incapacity in patients with RA, with the forefoot the most common area. The foot is second, behind only the hand, as the most common place for manifestation of RA. Pain in the foot is commonly the most debilitating condition, which causes the patient to seek specialist help. As well as pain, foot deformities such as hallux valgus and claw toes are common complaints. These symptoms often arise as a result of continued walking on an unstable foot, leading to painful callosities and dislocation of the metatarsophalangeal joints. Other conditions, such as pannus formation and Morton's neuroma, can be related to RA. This review sets out what we believe to be a successful approach to the rheumatoid forefoot, which aims at the relief of pain and the preservation of ambulation. Key to a successful outcome is appropriate medical control with a multidisciplinary approach that enables close liaison between orthopaedic surgeons, orthotists, and rheumatologists. Combined clinics provide this multidisciplinary care. Those treating RA need to be aware of the high incidence of foot involvement and how early intervention may benefit the patient. The aim of this article is to present current evidence to enable people to develop a treatment algorithm for this condition.

Considerations in footwear and orthotics

This article is based on educating readers and physicians about the use of footwear and orthotics for themselves and their patients, to treat diseases and enhance functionality in sports and daily life.

Additive hindfoot arthrodesis for rheumatoid hindfoot disease: a clinical study of patient outcomes and satisfaction

Advanced rheumatoid hindfoot disease causes significant pain and disability. Hindfoot arthrodesis is a useful procedure but is often overlooked as a treatment option. The objective of this study was to report the improvements in patients' health, pain, functional ability and satisfaction following this procedure. Thirty-seven patients with rheumatoid arthritis (RA) were recruited from the outpatient clinic and underwent 42 hindfoot arthrodesis procedures by a single surgeon. Outcome measures were SF12 score, Manchester-Oxford Foot Questionnaire index score, visual analogue pain score and satisfaction scores, as well as radiographic assessment. Assessment was undertaken at the pre-admission clinic and at 6 and 12 months post-operatively. Statistically significant improvements were seen at 6 and 12 months in all measured outcomes. The union rate was 97.6%. The satisfaction rate was 92.5%. The complication rate was 7.1%. The functional benefit and outcome scores are comparable to those reported following hip and knee replacement in patients with RA. The findings of this study provide evidence that hindfoot arthrodesis should be considered a worthwhile surgical treatment in the rheumatoid patient with advanced hindfoot disease. Healthcare professionals involved in the management of these patients should be aware of the potential benefits of this procedure and refer early to a foot and ankle surgeon specialist when conservative treatment modalities have failed.

The effect of customised and sham foot orthoses on plantar pressures

Background

The effectiveness of foot orthoses has been evaluated in many clinical trials with sham foot orthoses used as the control intervention in at least 10 clinical trials. However, the mechanical effects and credibility of sham orthoses has been rarely quantified. This study aimed to: (i) compare the effects on plantar pressures of three sham foot orthoses to a customised foot orthosis, and (ii) establish the perceived credibility and the expected benefit of each orthotic condition.

Methods

Thirty adults aged between 18 and 51 participated in this study. At 0 and 4 weeks, plantar pressure data were collected for the heel, midfoot and forefoot using the pedar^®-X in-shoe system for the following five randomly assigned conditions: (i) shoe alone, (ii) customised foot orthosis, (iii) contoured polyethylene sham foot orthosis, (iv) contoured EVA sham foot orthosis, and (v) flat EVA sham foot orthosis. At the initial data collection session, each participant completed a Credibility/Expectancy Questionnaire (CEQ) to determine the credibility and expected benefit of each orthotic condition.

Results

Compared to the shoe alone at week 0, the contoured polyethylene sham orthosis was the only condition to not significantly effect peak pressure at any region of the foot. In contrast, the contoured EVA sham orthosis, the flat EVA sham orthosis and the customised orthosis significantly reduced peak pressure at the heel. At the medial midfoot, all sham orthoses provided the same effect as the shoe alone, which corresponded to effects that were significantly different to the customised orthosis. There were no differences in peak pressure between conditions at the other mask regions, the lateral midfoot and forefoot. When the conditions were compared at week 4, the differences between the conditions were generally similar to the findings observed at week 0. With respect to credibility and expected benefit, all orthotic conditions were considered the same with the exception of the contoured polyethylene sham orthosis, which was perceived as being less credible and less likely to provide benefits.

Conclusion

The findings of this study indicate that all of the sham orthoses tested provided the same effect on plantar pressures at the midfoot and forefoot as a shoe alone. However, the contoured EVA sham orthosis and the flat EVA sham orthosis significantly reduced peak pressure under the heel, which was similar to the customised orthosis. In contrast, the contoured polyethylene sham orthosis had no significant effect on plantar pressure and was comparable to the shoe alone at all regions of the foot. Hence, lower plantar pressures were found under the heel with some sham orthoses, but not with others. Importantly, participants perceived the polyethylene sham orthosis – the sham that had no effect on plantar pressure – to be the least credible orthosis and the least likely to provide benefits. This may be critical for the design of future clinical trials as it may introduce confounding effects that produce inaccurate results. These findings provide some evidence for the mechanical effects, treatment credibility and expected benefit of sham foot orthoses, which should be considered when they are used as a control intervention in a clinical trial.

Musculoskeletal conditions of the foot and ankle: assessments and treatment options

Musculoskeletal conditions of the foot and ankle are an important public health challenge due to their increasing incidence combined with their substantial negative impact on patients' quality of life. Non-pharmacological treatments serve as the first line of treatment and are frequently used for patients with musculoskeletal conditions of the foot and ankle. This review provides a summary of the assessments and non-invasive treatment options based upon available evidence. Recent studies show that individuals with foot and ankle pain have multiple co-existing impairments in alignment, motion, load distribution and muscle performance that may be evident in static and/or dynamic tasks. In addition, both clinical and epidemiological studies support the inter-dependence between the foot and proximal joints. For instance, aberrant foot structure has been linked to foot osteoarthritis (OA), as well as OA and pain at the knee and hip. Most recently, advances in motion capture technology and plantar load distribution measurement offer opportunities for precise dynamic assessments of the foot and ankle. In individuals with musculoskeletal conditions of the foot and ankle, the chief objectives of treatment are to afford pain relief, restore mechanics (alignment, motion and/or load distribution) and return the patient to their desired level of activity participation. Given that most patients present with multiple impairments, combinational therapies that target foot-specific as well as global impairments have shown promising results. In particular, in individuals with rheumatoid arthritis and other rheumatic diseases, comprehensive rehabilitation strategies including early detection, foot-based interventions (such as orthoses) and wellness-based approaches for physical activity and self-management have been successful. While significant improvements have been made in the last decade to the assessment and treatment of foot and ankle conditions, few randomised clinical trials specifically have investigated patients with foot or ankle conditions to provide global insights into this area. Consequently, current recommendations vary based upon the scope of studies presented in this review as well as the strength of studies. This review indicates a need for more in-depth investigations into the components of assessment and treatment options for foot and ankle musculoskeletal conditions.

The relationship between foot motion and lumbopelvic-hip function: a review of the literature

Excessive pronation has been implicated in the development of numerous overuse injuries of the lower limb and is suggested to cause more proximal biomechanical dysfunction. Functional foot orthoses (FFO) are frequently prescribed for lower limb injury associated with excessive foot pronation and have been demonstrated to have efficacy with specific conditions. However, the mechanism of action of FFO is largely unknown. Research investigating the kinematic and kinetic changes associated with FFO use is inconclusive. Furthermore there is a growing body of evidence suggesting that changes to muscle activity patterns in response to FFO may be responsible for their therapeutic effect. Additionally, current research suggests dysfunction of musculature of the lumbopelvic-hip complex is involved in lower extremity functional changes and is related to the development some pathologies traditionally attributed to excessive foot pronation. Evidence of temporal coupling between the hip and the foot and changes in hip muscle activity associated with FFO use further suggest a relationship between proximal and distal lower limb function. The aim of this review is to discuss the association between foot and lumbopelvic-hip complex dysfunction and injury, assess the evidence for functional changes to lower limb and lumbopelvic-hip function with FFO use and finally to discuss the potential for changes to hip musculature activation with FFO use to influence distal mechanics and produce a therapeutic benefit.

Room for improvement: patient, parent, and practitioners' perceptions of foot problems and foot care in juvenile idiopathic arthritis

OBJECTIVE

To explore the perceived impact of disease-related foot problems and foot care in juvenile idiopathic arthritis (JIA) from the perspectives of patients, parents, pediatric rheumatologists, and health professionals.

DESIGN

A qualitative study using an interpretative phenomenological approach.

SETTING

Outpatients department, public health service children's hospital.

PARTICIPANTS

Patients (N=15; 4 adult patients, 2 parents of children with JIA, 3 pediatric rheumatologists, and 6 health professionals) from 2 National Health Service rheumatology centers (1 pediatric and 1 adult).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Qualitative outcomes were participants' perceptions elicited using semistructured interviews (telephone or face-to-face) and focus groups using an interpretative phenomenological approach. A data-driven inductive approach to coding and theme development was adopted for transcript analysis.

RESULTS

Participants volunteered to take part in a total of 7 interviews and 2 focus groups. The analysis revealed 6 key themes related to the impact of foot problems and perceptions of foot care from respective groups. These were the following: (1) pain, (2) mobility impairment, (3) reduced ability to perform activities of daily living, (4) footwear difficulties, (5) poor referral pathways/delayed access to care, and (6) lack of evidence in support of conservative foot care.

CONCLUSIONS

Several areas for development of foot care services were identified including a need for improved referral pathways, shorter waiting times for initial consultations, greater attention to patient compliance, and a need for better evidence in support of customized foot orthoses. Several key foot health-related outcomes were identified, which may be of importance for measuring therapeutic response to foot-related interventions.

Metatarsal bars more effective than metatarsal pads in reducing impulse on the second metatarsal head

BACKGROUND

The second metatarsal head is commonly involved in cases of metatarsalgia. As part of the conservative treatment, metatarsal bars and metatarsal pads are often prescribed.

OBJECTIVE

To compare the effectiveness of metatarsal bars and metatarsal pads in reducing impulse on the second metatarsal head.

METHOD

Thirty-five healthy subjects were monitored with an insole scanning system during walking in four different conditions: (a) wearing shoes only, (b) shoes plus metatarsal pads and shoes plus metatarsal bars, placed either (c) perpendicular to the foot axis or (d) oblique to the foot axis. The impulse under the second metatarsal head was measured using the first condition as a control. Both feet were examined in each subject resulting in a total of 840 measurements.

RESULTS

Both metatarsal bars and metatarsal pads were effective in reducing impulse when compared with the control (P<0.01). Metatarsal bars were found to be more effective in reducing impulse as compared to the metatarsal pads (P<0.01), and the oblique position of the bars was more effective than the perpendicular one (P<0.01).

CONCLUSIONS

The greatest reduction of impulse on the second metatarsal head in healthy subjects is achieved with the use of metatarsal bars in an oblique position.