Comparison of in vivo segmental foot motion during walking and step descent in patients with midfoot arthritis and matched asymptomatic control subjects

Evaluating plantar biomechanics while descending a single step with different heights

Objective

This study aims to investigate the plantar biomechanics of healthy young males as they descend a single transition step from varying heights.

Methods

Thirty healthy young males participated the experiment using the F-scan insole plantar pressure system in which participants made single transition steps descent from four step heights (5, 15, 25, and 35 cm), leading with their dominant or non-dominant foot. Plantar pressure data were collected for 5 s during the period between landing touchdown and standing on the ground. Landing at each step height was repeated three times, with a five-minute rest between different height trials.

Results

At 5 cm and 15 cm steps, participants demonstrated a rearfoot landing strategy on both sides. However, forefoot contact was observed at heights of 25 cm and 35 cm. Parameters related to center of plantar pressure (COP) of the leading foot were significantly larger compared to the trailing foot (P < 0.001), increased with higher step heights. Vertical ground reaction forces for the biped, leading and trailing feet decreased with increasing step height (all P < 0.05). The leading foot had a higher proportion of overall and forefoot loads, and a lower proportion of rearfoot load compared to the trailing foot (P < 0.001). The overall load on the dominant side was lower than that on the non-dominant side for both the leading and trailing feet (P < 0.001). For the trailing foot, forefoot load on the dominant side was lower than that on the non-dominant side, however, the opposite result appeared in rearfoot load (P < 0.001). Upon the leading foot landing, forefoot load exceeded the rearfoot load for the dominant (P < 0.001) and non-dominant sides (P < 0.001). Upon the trailing foot landing, forefoot load was lower than the rearfoot load for the dominant (P < 0.001) and non-dominant sides (P = 0.019).

Conclusion

When the characteristics of biomechanical stability are compromised by step height, landing foot, and footedness factors - due to altered foot landing strategies, changing COP, or uneven force distribution - ability to control motion efficiently and respond adaptively to the forces experienced during movement is challenged, increasing the likelihood of loss of dynamic balance, with a consequent increased risk of ankle sprains and falls.

The influence of women's age and fall history on foot and lower limb kinematics during transition step descent

Falls are a major public health concern, with older women being at the greatest risk to experience a fall. Step descent increases the likelihood of a fall injury, yet the influence of age and fall history on lower extremity kinematics have not been extensively studied. The purpose of this study was to examine lower extremity and foot kinematics of women with and without a fall history during single step descent. Hip, knee, and foot kinematics of young women (n = 15, age = 22.6 ± 3.2 years), older women with no recent falls (n = 15, age = 71.6 ± 4.4 years), and older women with a fall history (n = 15, age = 71.5 ± 5.0 years) as they descended a 17 cm step were examined. Differences in initial contact angles and ROM during landing were examined with between group MANOVA tests. Distal foot initial contact angles were not significant between groups. For range of motion, both older groups went through greater hip extension (p = 0.003, partial η2 = 0.25), but less hip adduction (p = 0.002, partial η2 = 0.27) and less lateral midfoot dorsiflexion (p = 0.001, partial η2 = 0.28) than the younger women. The older fall group had reduced knee flexion (p = 0.004, partial η2 = 0.23) than the younger group, and the older non-fallers slightly plantarflexed at the medial midfoot (p = 0.005, partial η2 = 0.23) while the young women dorsiflexed. Thelanding phase ROMdifferences exhibited by the older adult groupsmayincrease the likelihood of a misstep, which may result in a fall.

Structural Foot Characteristics in People With Midfoot Osteoarthritis: Cross-Sectional Findings From the Clinical Assessment Study of the Foot

OBJECTIVE

This study compared radiographic measures of foot structure between people with and without symptomatic radiographic midfoot osteoarthritis (OA).

METHODS

This was a cross-sectional study of adults aged 50 years and older registered with four UK general practices who reported foot pain in the past year. Bilateral weightbearing dorsoplantar and lateral radiographs were obtained. Symptomatic radiographic midfoot OA was defined as midfoot pain in the last 4 weeks, combined with radiographic OA in one or more midfoot joints (first cuneometatarsal, second cuneometatarsal, navicular-first cuneiform, and talonavicular). Midfoot OA cases were matched 1:1 for sex and age to controls with a 5-year age tolerance. Eleven radiographic measures were extracted and compared between the groups using independent sample t-tests and effect sizes (Cohen's d).

RESULTS

We identified 63 midfoot OA cases (mean ± SD age was 66.8 ± 8.0 years, with 32 male and 31 female participants) and matched these to 63 controls (mean ± SD age was 65.9 ± 7.8 years). There were no differences in metatarsal lengths between the groups. However, those with midfoot OA had a higher calcaneal-first metatarsal angle (d = 0.43, small effect size, P = 0.018) and lower calcaneal inclination angle (d = 0.46, small effect size, P = 0.011) compared with controls.

CONCLUSIONS

People with midfoot OA have a flatter foot posture compared with controls. Although caution is required when inferring causation from cross-sectional data, these findings are consistent with a pathomechanical pathway linking foot structure to the development of midfoot OA. Prospective studies are required to determine the temporal relationships between foot structure, function, and the development of this common and disabling condition.

International Foot and Ankle Osteoarthritis Consortium review and research agenda for diagnosis, epidemiology, burden, outcome assessment and treatment

OBJECTIVE

To summarise the available evidence relating to the diagnosis, epidemiology, burden, outcome assessment and treatment of foot and ankle osteoarthritis (OA) and to develop an agenda to guide future research.

METHOD

Members of the International Foot and Ankle Osteoarthritis Consortium compiled a narrative summary of the literature which formed the basis of an interactive discussion at the Osteoarthritis Research Society International World Congress in 2021, during which a list of 24 research agenda items were generated. Following the meeting, delegates were asked to rank the research agenda items on a 0 to 100 visual analogue rating scale (0 = not at all important to 100 = extremely important). Items scoring a mean of 70 or above were selected for inclusion.

RESULTS

Of the 45 delegates who attended the meeting, 31 contributed to the agenda item scoring. Nineteen research agenda items met the required threshold: three related to diagnosis, four to epidemiology, four to burden, three to outcome assessment and five to treatment.

CONCLUSIONS

Key knowledge gaps related to foot and ankle OA were identified, and a comprehensive agenda to guide future research planning was developed. Implementation of this agenda will assist in improving the understanding and clinical management of this common and disabling, yet relatively overlooked condition.

Ankle plantar flexor muscle performance and patient reported outcomes in people following total ankle arthroplasty

BACKGROUND

The purpose of this study was to prospectively evaluate ankle power generation during gait in people with total ankle arthroplasty, and examine the relationships between postoperative plantar flexor strength, ankle power, and patient outcomes.

METHODS

Nineteen people with end-stage ankle arthritis who received a total ankle arthroplasty and 19 healthy matched controls participated in this case-control study. Patient reported outcomes included a region specific measure of foot function and a generic measure of physical function. Gait speed was recorded with the 6-min walk test. Isokinetic plantar flexor strength was measured with an instrumented dynamometer. Motion capture and force plate data were used to calculate peak ankle power generation during walking. Paired or independent t-tests were used to compare ankle power across time and between groups, respectively. Bivariate correlations were performed to examine the interplay of postoperative strength, ankle power, gait speed, and patient reported outcomes.

FINDINGS

Ankle power was not different between the preoperative and 6-month postoperative time points (d = 0.20). Six-month postoperative ankle power was less than controls (d = 1.32). Strength, ankle power, and gait speed were directly correlated in the patient group 6-months postoperatively (r or ρ ≥ 0.47). Six-month postoperative strength and ankle power were directly correlated to select 2-year patient reported outcomes (both ρ = 0.54).

INTERPRETATION

Lower than normal 6-month postoperative ankle power, which was correlated to strength, gait speed, and longer-term patient reported outcomes, suggests efforts toward improving ankle plantar flexor muscle performance may improve patient outcomes.

Midfoot Function Before and After Total Ankle Arthroplasty

BACKGROUND

Information regarding the effect of total ankle arthroplasty (TAA) on midfoot function is extremely limited. The purpose of this study was to characterize midfoot region motion and power during walking in people before and after TAA.

METHODS

This was a prospective cohort study of 19 patients with end-stage ankle arthritis who received a TAA and 19 healthy control group participants. A motion capture and force plate system was used to record sagittal and transverse plane first metatarsal and lateral forefoot with respect to hindfoot motion, as well as sagittal plane midfoot region positive and negative peak power during walking. Parametric or nonparametric tests to examine differences and equivalence across time were conducted. Comparisons to examine differences between postoperative TAA group and control group foot function were also performed.

RESULTS

Involved-limb midfoot function was not different between the preoperative and 6-month postoperative time point in the TAA group (all P ≥ .17). Equivalence testing revealed similarity in all midfoot function variables across time (all P < .05). Decreased first metatarsal and lateral forefoot motion, as well as positive peak power generation, were noted in the TAA group postoperative involved limb in comparison to the control group (all P ≤ .01).

CONCLUSION

The similarity of midfoot function across time, along with differences in midfoot function in comparison to controls, suggests that TAA does not change midfoot deficits by 6 months postoperation.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Foot structure and lower limb function in individuals with midfoot osteoarthritis: a systematic review

OBJECTIVE

To determine how foot structure and lower limb function differ between individuals with and without midfoot osteoarthritis (OA).

DESIGN

Electronic databases were searched from inception until May 2020. To be eligible, studies needed to (1) include participants with radiographically confirmed midfoot OA, with or without midfoot symptoms, (2) include a control group of participants without radiographic midfoot OA or without midfoot symptoms, and (3) report outcomes of foot structure, alignment, range of motion or any measures of lower limb function during walking. Screening and data extraction were performed by two independent assessors, with disagreements resolved by a third independent assessor. The methodological quality of included studies was assessed using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies.

RESULTS

A total of 1,550 records were screened by title and abstract and 11 met the inclusion criteria. Quantitative synthesis indicated that individuals who had midfoot OA had a more pronated foot posture, greater first ray mobility, less range of motion in the subtalar joint and first metatarsophalangeal joints, longer central metatarsals and increased peak plantar pressures, pressure time integrals and contact times in the heel and midfoot during walking. Meta-analysis could not be performed as the data were not sufficiently homogenous.

CONCLUSIONS

There are several differences in foot structure and lower limb function between individuals with and without midfoot OA. Future research with more consistent case definitions and detailed biomechanical models would further our understanding of potential mechanisms underlying the development of midfoot OA.

Patient reported outcomes and ankle plantarflexor muscle performance following gastrocnemius recession for Achilles tendinopathy: A prospective case-control study

BACKGROUND

Prospective studies to guide the application of a gastrocnemius recession for Achilles tendinopathy are limited. Our aim was to prospectively evaluate patient reported outcomes and muscle performance.

METHODS

Patients with unilateral recalcitrant Achilles tendinopathy who received an isolated gastrocnemius recession (n=8) and a healthy control group (n=8) were included. Patient reported outcomes, ankle power during walking and stair ascent, and the heel rise limb symmetry index (total work) were collected.

RESULTS

Improvements in pain and self-reported function were observed (six months and two years). Sport participation scores reached 92% by two years. Patients demonstrated lower ankle power during stair ascent and decreased limb symmetry during heel rise six months following treatment (p≤.02).

CONCLUSIONS

Study findings regarding long-term improvements in patient pain, self-reported function and sport participation, and early preservation of ankle function during walking, can help refine patient selection, anticipated outcomes, and rehabilitation strategies.

Foot and Leg Muscle Weakness in People With Midfoot Osteoarthritis

OBJECTIVE

To compare foot and leg muscle strength in people with symptomatic midfoot osteoarthritis (OA) with asymptomatic controls, and to determine the association between muscle strength, foot pain, and disability.

METHODS

Participants with symptomatic midfoot OA and asymptomatic controls were recruited for this cross-sectional study from general practices and community health clinics. The maximum isometric muscle strength of the ankle plantarflexors, dorsiflexors, invertors and evertors, and the hallux and lesser toe plantarflexors was measured using hand-held dynamometry. Self-reported foot pain and foot-related disability were assessed with the Manchester Foot Pain and Disability Index. Differences in muscle strength were compared between groups. Multivariable regression was used to determine the association between muscle strength, foot pain, and disability after adjusting for covariates.

RESULTS

People with midfoot OA (n = 52) exhibited strength deficits in all muscle groups, ranging from 19% (dorsiflexors) to 30% (invertors) relative to the control group (n = 36), with effect sizes of 0.6-1.1 (P < 0.001). In those with midfoot OA, ankle invertor muscle strength was negatively and independently associated with foot pain (β = -0.026 [95% confidence interval (95% CI) -0.051, -0.001]; P = 0.045). Invertor muscle strength was negatively associated with foot-related disability, although not after adjustment for depressive symptoms (β = -0.023 [95% CI -0.063, 0.017]; P = 0.250).

CONCLUSION

People with symptomatic midfoot OA demonstrate weakness in the foot and leg muscles compared to asymptomatic controls. Preliminary indications from this study suggest that strengthening of the foot and leg muscles may offer potential to reduce pain and improve function in people with midfoot OA.

Ankle and Midfoot Power During Single-Limb Heel Rise in Healthy Adults

Although the midfoot is recognized to have an important role in the successful performance of a single-limb heel rise, healthy heel rise performance remains primarily characterized by ankle function. The purpose of this study was to examine the contribution of midfoot region power to single-limb heel rise in healthy adults. Participants (N = 12) performed 20 single-limb heel rises. An electromagnetic motion capture system and a force plate were used to record 3-segment foot motion and ground reaction forces. Inverse dynamic calculations were performed to obtain ankle and midfoot region powers. These data were evaluated with descriptive statistics. A correlation was performed to evaluate the contribution of midfoot region power to heel height, as heel height is a clinical measure of heel-rise performance. The midfoot contributed power during single-limb heel rise (peak positive power: 0.5 [0.2] W·kg-1). Furthermore, midfoot peak power accounted for 36% of the variance in heel height (P = .04). As energy generating internal mechanisms, such as muscle activity, are attributed to power generation, midfoot tissue loading and muscle performance should be considered during clinical and modeling applications of the heel-rise task.

Multisegment Foot Models and Clinical Application After Foot and Ankle Trauma: A Review

Since the end of the 1990s, several multisegment foot models (MSFMs) have been developed. Several models were used to describe foot and ankle kinematics in patients with foot and ankle pathologies; however, the diagnostic value for clinical practice of these models is not known. This review searched in the literature for studies describing kinematics in patients after foot and ankle trauma using an MSFM. The diagnostic value of the MSFMs in patients after foot and ankle trauma was also investigated. A search was performed on the databases PubMed/MEDLINE, Embase, and Cochrane Library. To investigate the diagnostic value of MSFMs in patients after foot and ankle trauma, studies were classified and analyzed following the diagnostic research questions formulated by Knottnerus and Buntinx. This review was based on 7 articles. All studies were published between 2010 and 2015. Five studies were retrospective studies, and 2 used an intervention. Three studies described foot and ankle kinematics in patients after fractures. Four studies described foot and ankle kinematics in patients after ankle sprain. In all included studies, altered foot and ankle kinematics were found compared with healthy subjects. No results on patient outcome using MSFMs and costs were found. Seven studies were found reporting foot and ankle kinematics in patients after foot and ankle trauma using an MSFM. Results show altered kinematics compared with healthy subjects, which cannot be seen by other diagnostic tests and add valuable data to the present literature; therefore, MSFMs seem to be promising diagnostic tools for evaluating foot and ankle kinematics. More research is needed to find the additional value for MSFMs regarding patient outcome and costs.

Midfoot osteoarthritis: potential phenotypes and their associations with demographic, symptomatic and clinical characteristics

OBJECTIVE

To investigate the demographic, symptomatic, clinical and structural foot characteristics associated with potential phenotypes of midfoot osteoarthritis (OA).

DESIGN

Cross-sectional study of 533 community-dwelling adults aged ≥50 years with foot pain in the past year. Health questionnaires and clinical assessments of symptoms, foot structure and function were undertaken. Potential midfoot OA phenotypes were defined by the pattern of radiographic joint involvement affecting either the medial midfoot (talonavicular, navicular-1^st cuneiform, or cuneiform-1^st metatarsal joint), central midfoot (2^nd cuneiform-metatarsal joint), or both medial and central midfoot joints. Multivariable regression models with generalised estimating equations were used to investigate the associations between patterns of midfoot joint involvement and symptomatic, clinical and structural characteristics compared to those with no or minimal midfoot OA.

RESULTS

Of 879 eligible feet, 168 had medial midfoot OA, 103 central midfoot OA, 76 both medial and central midfoot OA and 532 no/minimal OA. Having both medial and central midfoot OA was associated with higher pain scores, dorsally-located midfoot pain (OR 2.54, 95%CI 1.45, 4.45), hallux valgus (OR 1.76, 95%CI 1.02, 3.05), flatter foot posture (β 0.44, 95%CI 0.12, 0.77), lower medial arch height (β 0.02, 95%CI 0.01, 0.03) and less subtalar inversion and 1^st MTPJ dorsiflexion. Isolated medial midfoot OA and central midfoot OA had few distinguishing clinical characteristics.

CONCLUSIONS

Distinct phenotypes of midfoot OA appear challenging to identify, with substantial overlap in symptoms and clinical characteristics. Phenotypic differences in symptoms, foot posture and function were apparent in this study only when both the medial and central midfoot were involved.

Multi-segment foot models and their use in clinical populations

BACKGROUND

Many multi-segment foot models based on skin-markers have been proposed for in-vivo kinematic analysis of foot joints. It remains unclear whether these models have developed far enough to be useful in clinical populations. The present paper aims at reviewing these models, by discussing major methodological issues, and analyzing relevant clinical applications.

RESEARCH QUESTION

Can multi-segment foot models be used in clinical populations?

METHODS

Pubmed and Google Scholar were used as the main search engines to perform an extensive literature search of papers reporting definition, validation or application studies of multi-segment foot models. The search keywords were the following: 'multisegment'; 'foot'; 'model'; 'kinematics', 'joints' and 'gait'.

RESULTS

More than 100 papers published between 1991 and 2018 were identified and included in the review. These studies either described a technique or reported a clinical application of one of nearly 40 models which differed according to the number of segments, bony landmarks, marker set, definition of anatomical frames, and convention for calculation of joint rotations. Only a few of these models have undergone robust validation studies. Clinical application papers divided by type of assessment revealed that the large majority of studies were a cross-sectional comparison of a pathological group to a control population.

SIGNIFICANCE

This review suggests that there is sufficient evidence that multi-segment foot models may be successfully applied in clinical populations. Analysis of the currently available models allows users to better identify the most suitable protocol for specific clinical applications. However new models require thorough validation and assessment before being used to support clinical decisions.

Ankle and Midfoot Power During Walking and Stair Ascent in Healthy Adults

Ankle power dominates forward propulsion of gait, but midfoot power generation is also important for successful push-off. However, it is unclear if midfoot power generation increases or stays the same in response to propulsive activities that induce larger external loads and require greater ankle power. The purpose of this study was to examine ankle and midfoot power in healthy adults during progressively more demanding functional tasks. Multisegment foot motion (tibia, calcaneus, and forefoot) and ground reaction forces were recorded as participants (N = 12) walked, ascended a standard step, and ascended a high step. Ankle and midfoot positive peak power and positive total power, and the proportion of midfoot to ankle positive total power were calculated. One-way repeated-measures analyses of variance were conducted to evaluate differences across tasks. Main effects were found for ankle and midfoot peak and total powers (all Ps < .01), but not for the proportion of midfoot-to-ankle total power (P = .33). Ankle and midfoot power significantly increased across each task. Midfoot power increased in proportion to ankle power and in congruence to the external load of a task. Study findings may serve to inform multisegment foot modeling applications and internal mechanistic theories of normal and pathological foot function.

Foot and Ankle Kinematics During Descent From Varying Step Heights

In the general population, one-third of incidences during step negotiation occur during the transition to level walking. Furthermore, falls during curb negotiation are a common cause of injury in older adults. Distal foot kinematics may be an important factor in determining injury risk associated with transition step negotiation. The purpose of this study was to identify foot and ankle kinematics of uninjured individuals during descent from varying step heights. A 7-segment foot model was used to quantify kinematics as participants walked on a level walkway, stepped down a single step (heights: 5 cm, 15 cm, 25 cm), and continued walking. As step height increased, landing strategy transitioned from the rearfoot to the forefoot, and the rearfoot, lateral and medial midfoot, and medial forefoot became more plantar flexed. During weight acceptance, sagittal plane range of motion of the rearfoot, lateral midfoot, and medial and lateral forefoot increased as step height increased. The changes in landing strategy and distal foot function suggest a less stable ankle position at initial contact and increased demand on the distal foot at initial contact and through the weight acceptance phase of transition step negotiation as step height increases.

Effect of Full-Length Carbon Fiber Insoles on Lower Limb Kinetics in Patients With Midfoot Osteoarthritis: A Pilot Study

OBJECTIVES

We investigated the effects of full-length carbon fiber (FCF) insoles on gait, muscle activity, kinetics, and pain in patients with midfoot osteoarthritis (OA).

DESIGN

We enrolled 13 patients with unilateral midfoot OA (mild: Visual Analog Scale [VAS] range, 1-3; moderate, VAS range, 4-7) and healthy controls. All participants were asked to walk under two conditions: with and without FCF insole. The outcome measures were ground reaction force, quantitative gait parameters, electromyography activities and pain severity (VAS).

RESULTS

In the patients with moderate midfoot OA, significantly longer gait cycle and higher muscle activity of lower limb during loading-response phase were observed while walking without FCF insoles. In the mild midfoot OA group, there was no significant difference in VAS score (without, 2.0 ± 1.0 vs. with, 2.0 ± 0.5) with FCF insole use. However, significantly reduced VAS score (without, 5.5 ± 1.4 vs. with, 2.0 ± 0.5) and muscle activity of the tibialis anterior and increased muscle activity of gastrocnemius were observed in the moderate midfoot OA group by using an FCF insole (P < 0.05).

CONCLUSIONS

Full-length carbon fiber insoles can improve pain in individuals with moderate midfoot OA, which might be associated with changes in the kinetics and muscle activities of the lower limb. Taken together, the results of the present study suggest that FCF insoles may be used as a helpful option for midfoot OA.

Ankle Power and Endurance Outcomes Following Isolated Gastrocnemius Recession for Achilles Tendinopathy

BACKGROUND

Studies have demonstrated improved ankle dorsiflexion and pain reduction following a gastrocnemius recession (GR) procedure. However, changes in muscle performance during functional activities are not known. The purpose of this study was to determine the effect of an isolated GR on ankle power and endurance in patients with Achilles tendinopathy.

METHODS

Fourteen patients with chronic unilateral Achilles tendinopathy and 10 healthy controls participated in this study. Patient group data were collected 18 months following GR. Pain was compared to preoperative values using a 10-cm visual analog scale (VAS). Patient-reported outcomes for activities of daily living (ADL) and sports were assessed using the Foot and Ankle Ability Measure (FAAM). Kinematic and kinetic data were collected during gait, stair ascent (standard and high step), and repetitive single-limb heel raises. Between-group and side-to-side differences in ankle plantarflexor muscle power and endurance were evaluated with appropriate t tests.

RESULTS

Compared with preoperative data, VAS pain scores were reduced (pre 6.8, post 1.6, P < .05). Significant differences were observed between GR and Control groups for FAAM scores for both ADL (GR 90.0, Control 98.3, P = .01) and Sports subscales (GR 70.6, Control 94.6, P = .01). When compared to controls, ankle power was reduced in the involved limb of the GR group for all activities (all P < .05). Between-group and side-to-side deficits (GR group only) were also found for ankle endurance.

CONCLUSION

The gastrocnemius recession procedure provided significant pain reduction that was maintained at the 18-month follow-up for patients with chronic Achilles tendinopathy who failed nonoperative interventions. There were good patient-reported outcomes for activities of daily living. However, compared to controls, ankle plantarflexion power and endurance deficits in the GR group were noted. The functional implications of the muscle performance deficits are unclear, but may be reflective of patients' self-reported difficulty during more challenging activities.

LEVEL OF EVIDENCE

Level III, comparative study.

Midfoot and forefoot osteoarthritis

BACKGROUND

Foot osteoarthritis (OA) is linked with chronic foot pain and functional impairment.

OBJECTIVE

To review the current knowledge on midfoot and forefoot OA.

METHODS

PubMed, CINAHL, PEDro, and the ISI Web of Science databases (1950-2013) were searched for keywords: foot OA, midfoot OA, forefoot OA and metatarsal OA. The search was limited to reports in human subjects and English language. Published cohort, cross-sectional studies and clinical trials relating to epidemiology, clinical features, functional impairment, risk factors and treatment were included.

RESULTS

We found heterogeneity in the design, radiographic views and grading systems used among studies. Most of the literature focused on radiographic OA, being the prevalence between 0.1% and 61%, depending on gender, age and joint evaluated. The age and female gender were the main associated factors, whereas structural (bone length) and mechanical factors (hypermobility, altered tarso-metatarsal stress, etc.) seemed to be related. Various treatments are widely used, i.e. physical therapy, orthotics, steroid injection, analgesics and arthrodesis. However, scarce research supports their efficacy.

CONCLUSION

Most of the current knowledge comes from observational and small case-control studies. Future population-based studies as well as controlled studies are essential to understand the risk factors and to evaluate the effectiveness of treatment options.

Reliability and relevance of radiographic measures of metatarsus primus elevatus and arch alignment in individuals with midfoot arthritis and controls

BACKGROUND

Low arch alignment and metatarsus primus elevatus (MPE) have been postulated to increase dorsal compressive stresses in the joints of the medial column of the foot and to contribute to the development of degenerative changes. The primary purposes of this study were (1) to examine the relationship between radiographic measures of arch alignment and MPE and (2) to assess arch alignment and MPE in individuals with midfoot arthritis and in asymptomatic controls. The secondary aim was to examine the reliability of radiographic measures of arch alignment and MPE.

METHODS

Radiographic measures of arch height and MPE were quantified on 28 individuals with midfoot arthritis and 22 individuals in a control group. Reliability was assessed using the intraclass correlation coefficient (ICC). The Pearson product moment correlation (r) was used to assess the relationship between arch alignment and MPE. Between-group differences were assessed using a two-sample t test (α = 0.05).

RESULTS

Good to excellent reliability was noted for measures of arch height (ICC[2,3] = 0.919-0.994) as well as MPE (ICC[2,3] = 0.891-0.882). A modest positive association was noted between normalized cortical elevation and normalized navicular height (r = 0.274, P = .030) and calcaneal inclination angle (r = 0.263, P = .035). Individuals with midfoot arthritis demonstrated lower arch alignment, reflected in a significantly higher calcaneal-first metatarsal angle (P = .002), lower calcaneal inclination angle (P = .004), and lower normalized navicular height (P < .001) compared with controls. No evidence was found to support between-group differences in lateral intermetatarsal angle (P = .495) and normalized cortical elevation (P = .146).

CONCLUSIONS

These findings provide objective data establishing the reliability of measures of MPE and arch alignment and their potential clinical significance.

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.

Regional plantar pressure during walking, stair ascent and descent

Regional plantar pressures during stair walking may be injurious in at risk populations. However, limited data are available examining the reliability of plantar pressure data collected during stair walking. The aims of this study were three fold; to assess the reliability of the plantar pressure data recorded during stair walking, to assess the effects of level ground and stair walking on plantar loading, and to develop regression equations to predict regional plantar pressures in stair walking from those collected on level ground. Fifteen subjects without conditions affecting their ability to walk on level surfaces or stairs were recruited. Each participant performed at least 10 steps in level ground and stair walking while plantar pressure data were recorded in six foot regions. Reliability was assessed using Intraclass Correlation Coefficient. A repeated measures ANOVA was used to assess the effect of activity on plantar pressure, and a linear regression was used to predict forefoot loading during stair walking. A reliability of 0.9 was achieved within 10 steps in all foot regions, with the forefoot requiring fewer steps. Plantar pressures were influenced by both, foot region and activity, with the heel and forefoot regions generally experiencing lower peak pressures and maximal forces during stair walking than level ground walking. The regression equations predicting peak pressure during stair walking accounted for between 37% and 70% of the variance of the stair walking data. These findings establish the reliability of plantar pressure data collected during stair walking. Future studies should investigate these parameters in clinical populations.

Is barefoot regional plantar loading related to self-reported foot pain in patients with midfoot osteoarthritis

OBJECTIVE

While recent evidence suggests that foot pain may be related to mechanical stress, quantitative data elucidating the role of regional plantar loading in foot pain in individuals with midfoot osteoarthritis (OA) are lacking. Therefore the authors' objective is to examine regional plantar loading and self-reported foot pain in patients with midfoot OA compared to asymptomatic, matched control subjects.

METHOD

Fifty subjects, 30 patients with midfoot OA and 20 control subjects participated in this study. Self-reported function was assessed using the Foot Function Index-Revised (FFI-R). Plantar loading during barefoot walking at self-selected, monitored walking speed was quantified using an EMED pedobarograph. Between-group differences in FFI-R score and plantar loading were assessed using an independent t-test and the Mann-Whitney U-test respectively. The relationship between FFI-R score and plantar loading was assessed using Spearman rank correlation. A k-means cluster analysis was used to identify potential sub-groups of patients through regional plantar loading.

RESULTS

The key findings of this study showed that patients with midfoot OA reported significantly higher FFI-R scores, and higher heel and medial midfoot average pressure compared to control subjects. Medial midfoot pressure-time integral was positively associated with FFI-R Pain Subscale Score (r=0.524, P<0.01). Based on the adequacy index, the two-cluster solution was deemed most appropriate.

CONCLUSION

This study demonstrated that patients with midfoot OA sustain increased magnitude and duration of regional plantar loading during walking compared to matched control subjects. Our findings support the theory that regional mechanical stress may be associated with symptoms in patients with midfoot OA. Future studies should assess whether interventions designed to reduce plantar loading are effective in relieving foot pain, and preventing progression of symptoms in patients with midfoot OA.

Body of evidence supporting the clinical use of 3D multisegment foot models: a systematic review

BACKGROUND

A critical component in the characterization of foot mechanics during clinical gait analysis is the quantitative measurement of foot kinematics. Currently, the use of 3D multisegment foot models (3DMFMs) is popular in gait laboratories as it would seem to be an adequate tool for the in vivo analysis of dynamic foot kinematics. This systematic review identifies and evaluates current evidence for the use of 3DMFMs in clinical gait analysis.

METHODS

A targeted search strategy traced full papers that fulfilled the inclusion and exclusion criteria. The papers were classified and evaluated for quality using a custom made quality appraisal form.

FINDINGS

Forty-one manuscripts were included yielding a total number of fifteen 3DMFMs. Generally, study procedures and sample selection were adequately described; however, the methodological quality varied widely. Evidence regarding the repeatability of the identified models also varied widely. Models facing the highest level of scientific credibility were characterized by adequate repeatability indices obtained from between-trial, between-day and between and within assessor studies. Generally, the highest reliability indices were found for the sagittal plane kinematics. Within-subject variability was found to be the lowest, contrarily, between-subject and between-day variabilities were found to be highest.

INTERPRETATION

Reported repeatability indices such as the coefficient of multiple correlation, standard deviation and standard error of measurement provide evidence for the continued use of 3DMFMs. While a number of published models exist, there is no adequate evidence available to support their clinical use. More reliability and validity studies are needed to confirm adequate measurement properties of 3DMFMs.

Midfoot arthritis

Midfoot arthritis is a common cause of significant pain and disability. Although the medial tarsometatarsal (TMT) joints provide < 7 degrees of sagittal plane motion, the more mobile lateral fourth and fifth TMT joints provide balance and accommodation on uneven ground. These small constrained TMT joints also provide stability and translate the forward propulsion motion of the hindfoot and ankle joint to the forefoot metatarsophalangeal joints from heel rise to toe-off. Posttraumatic degeneration is the primary cause of midfoot arthritis, although primary degeneration and inflammatory conditions can also affect this area. The result is a painful midfoot that can no longer effectively transmit load from the hindfoot to the forefoot. Shoe modifications and orthotic inserts are the mainstay of nonsurgical management. Successful management of midfoot arthritis with orthoses is predicated on achieving adequate joint stabilization while still allowing function. Surgical intervention typically involves arthrodesis of the medial midfoot, although the best treatment of the more mobile lateral column is a subject of debate.

The use of gait analysis in the treatment of pediatric foot and ankle disorders

Assessment of foot pathology during walking should form an integral part of the clinical evaluation of children. Simple observation and video recording have limitations and are not quantifiable. Three-dimensional analysis of foot motion during walking can provide invaluable information on the dynamic function of the foot and can contribute to clinical decision making. As motion analysis technology advances, the accuracy and reliability of the dynamic assessment of the foot during walking will increase further, allowing clinicians to rely confidently on this information during patient assessment and the study of treatment outcomes. It is logical to expect that objective and quantifiable assessment of gait should be undertaken before and after treatment that sets gait improvement as one of its aims.

Orthoses alter in vivo segmental foot kinematics during walking in patients with midfoot arthritis

OBJECTIVE

To assess the effect of a 4-week intervention with a full-length carbon graphite (FL) orthosis on pain and function in patients with midfoot arthritis, and to identify alterations in in vivo foot kinematics accompanying FL use in patients with midfoot arthritis. These results have immediate application for enhancing patient care through effective orthotic recommendations.

DESIGN

Experimental laboratory study supplemented by a case series.

SETTING

University based clinical research laboratory.

PARTICIPANTS

Patients (n=30) with midfoot arthritis and age-, sex-, and body mass index-matched control subjects (n=20).

INTERVENTION

Four-week intervention with FL orthoses.

MAIN OUTCOME MEASURES

Pain and function were assessed using the Foot Function Index-Revised (FFI-R). In vivo foot kinematics were quantified as peak and total range of calcaneal eversion, forefoot abduction, first metatarsal plantarflexion, and first metatarsophalangeal joint dorsiflexion during walking in 2 conditions: with FL orthoses and with shoes only. A paired t test and repeated-measures analysis of variance were used to assess statistical significance (alpha=.05) of change in FFI-R score and in vivo foot kinematics, respectively.

RESULTS

Significant improvements in pain and function, discerned as lower FFI-R scores (P<.001), were noted after the 4-week intervention with FL orthoses. During walking, FL orthosis use resulted in decreased first metatarsophalangeal joint dorsiflexion (P=.024) and first metatarsal plantarflexion range of motion (P=.038), compared with the shoe-only condition.

CONCLUSIONS

Orthotic intervention emphasizing a "stiffening" strategy of the first metatarsal and first metatarsophalangeal joint may be valuable in patients with midfoot arthritis and early degenerative changes.