Foot orthoses in lower limb overuse conditions: a systematic review and meta-analysis

Effects of foot orthoses on running kinetics and kinematics: A systematic review and meta-analysis

BACKGROUND

Foot orthoses (FOs) are often prescribed by clinicians to treat foot and ankle conditions, prevent running injuries, and enhance performance. However, the lack of higher-order synthesis of clinical trials makes it challenging for clinicians to adopt an evidence-based approach to FOs' prescriptions.

RESEARCH QUESTION

Do FOs with different modifications alter lower extremity running kinematics and kinetics?

METHODS

A systematic search of seven databases was conducted from inception to February 2023. The analysis was restricted to healthy adults without foot musculoskeletal impairments and studies that compared the FOs effects with the controls. The methodological quality of the 35 studies that met the eligibility criteria was evaluated using the modified Downs and Black checklist. The random effects model estimated the standardized mean difference (SMD) with 95% confidence intervals and effect sizes. Sub-group analyses based on FOs type were performed to assess the potential effects of the intervention.

RESULTS

Our findings indicated that both custom and off-the-shelf arch-support FOs reduced peak plantar pressure at the medial heel (SMD=-0.35, and SMD=-1.03), lateral heel (SMD=-0.50, and SMD=-0.53), and medial forefoot (SMD=-0.20, and SMD=-0.27), but increased plantar pressure at the mid-foot (SMD=0.30, and SMD=0.56). Compared with the controls, significant increases (SMD=0.36) in perceived comfort were found with custom FOs. A reduction (SMD=-0.58) in initial ankle inversion was found when a raised heel cup was integrated with arch-support FOs. A medial post integrated with arch support exhibited a reduced ankle (SMD=-1.66) and tibial (SMD=-0.63) range of motion. Custom FOs, however, unfavorably affected the running economy (SMD=-0.25) and perceived exertion (SMD=0.20).

SIGNIFICANCE

Although FOs have been reported to have some positive biomechanical effects in healthy populations without musculoskeletal impairments or running-related issues, they need to be optimized and generalized to achieve better running performance and prevent injury.

Orthotic Devices for the Foot and Ankle

Millions of Americans wear ankle-foot orthotic devices for protection, pain relief, and deformity correction. Inquiries about off-the-shelf and custom devices are a common reason for evaluation with a foot and ankle surgeon or general orthopaedic surgeon. Despite limited high-quality evidence for their use, these devices can have a notable clinical impact on physical function. An up-to-date understanding of orthotic device options and their appropriate use in managing musculoskeletal pathologies applies to all orthopaedic providers. This review aims to categorize orthosis types and provide specific device recommendations for common adult conditions such as flatfoot, cavovarus foot, and ankle instability. Collaboration with a certified orthotist can help patients achieve functional and recreational goals with the use of appropriately designed and applied orthoses.

Does orthotics use improve comfort, speed, and injury rate during running? A randomised control trial

BACKGROUND

Running is a hugely popular sport. Unfortunately, running-related injury (RRI) rates are high, particularly amongst amateur and recreational runners. Finding ways to reduce RRI rates and maximise comfort and performance for runners is important. Evidence regarding whether orthotics can successfully improve these parameters is limited and contradicting. Further research is required to provide runners with clearer guidance on the usefulness of orthotics.

AIM

To investigate the effect of Aetrex Orthotics on comfort, speed and RRI rates during recreational running.

METHODS

One hundred and six recreational runners were recruited on a voluntary basis via running clubs and social media pages and randomised into either the intervention or control group. Participants in the intervention group ran with Aetrex L700 Speed Orthotics inserted in their usual running shoes, whilst participants in the control group ran in their usual running shoes with no orthotics. The study ran for an 8-wk period. Participants provided data relating to running comfort, distance, and time during weeks 3-6. Participants provided data relating to any RRIs they sustained during all 8 wks. Running distance and time were used to calculate running speed in miles per hour (mph). For each outcome variable, 95% confidence intervals and P values were calculated to assess the statistical significance between the groups. For comfort and speed data, univariate multi-level analysis was performed, and for outcome variables with significant between group differences, multi-level multivariate analysis was performed to evaluate any confounding effects of gender and age.

RESULTS

Ninety-four participants were included in the final analysis (drop-out rate = 11%). Comfort and speed from 940 runs and 978 injury data reports were analysed. Participants who ran with orthotics reported, on average, speeds 0.30 mph faster (P = 0.20) and comfort scores 1.27 points higher (P ≤ 0.001) than participants who ran with no orthotics. They were also 2.22 times less likely to sustain an injury (P = 0.08) than participants who ran with no orthotics. However, findings were only significant for comfort and not for speed or injury rates. Age and gender were found to be significant predictors of comfort. However, the improvements in comfort reported by participants who ran with orthotics were still significant after adjusting for age and gender.

CONCLUSION

This study found orthotics to improve comfort and speed and prevent RRIs whilst running. However, these findings were only statistically significant for comfort.

Foot orthoses for flexible flatfeet in children and adults: a systematic review and meta-analysis of patient-reported outcomes

BACKGROUND

This systematic review and meta-analysis examined the effectiveness of orthoses for flexible flatfeet in terms of patient-reported outcomes in children and adults.

METHODS

EMBASE, Medline (OvidSP), Web-of-Science, Scopus, CINAHL, Cochrane Central Register of Controlled Clinical Trials, i.e., Cochrane Central and Pubmed were searched to identify relevant studies since their inception up to February 2021. We included randomized controlled trials (RCT) and prospective studies in which patient reported outcomes at baseline and follow-up in an orthoses group were compared with a no orthoses or sham sole group. Methodological quality of the studies was assessed using the Revised Cochrane risk-of-bias tool for randomized trials (RoB 2) and the Risk Of Bias In Non-Randomized Studies of Interventions (ROBINS-I). A meta-analysis was performed where there were multiple studies with the same outcome measures, which was the case for the Visual Analogue Scale (VAS) for pain in adults.

RESULTS

In total nine studies were included: four RCT in children (N = 353) and four RCT and one prospective study in adults (N = 268) were included. There was considerable heterogeneity between studies. A meta-analysis demonstrated that pain reduction between baseline and follow-up was significantly larger in the orthoses (N = 167) than in the control groups in adults (N = 157; - 4.76, 95% CI [- 9.46, - 0.06], p0.05).

CONCLUSION

Due to heterogeneity in study designs, we cannot conclude that foot orthoses are useful for flexible flatfoot in children and adults. However, based on the meta-analysis orthoses might be useful in decreasing pain in adults. The authors did not receive support from any organization for the submitted work.

Pressure Properties of Three Different Types of Prefabricated Insoles Related to Plantar Pressure in Asymptomatic Men

BACKGROUND

In clinical fields, many types of insoles are used to not only realign movement patterns, but also treat pressure-related foot diseases. However, the characteristics of and plantar pressure in each type of insole are still unclear. Therefore, the aim of this study was to validate the plantar pressure-relieving effect of three representative types of insoles (metatarsal padding insole [MPI], lateral heel wedge insole [LHI], and arch support insole [ASI]) in asymptomatic men.

METHODS

A total of 35 feet of 35 asymptomatic men with a mean age of 23.4 ± 2.0 years were included. Pedobarographic data were evaluated by dividing the foot into eight designated regions to compare the three types of insoles. Peak plantar pressure (PPP) and pressure time integral (PTI) were assessed using the Pedar-X system. A repeated measures analysis of variance was used for statistical analyses.

RESULTS

In the hallux region, there was no statistically significant difference. MPI showed highest pressure in the 2nd-5th toe and midfoot region, but lowest in the central and lateral forefoot regions. Meanwhile, ASI showed highest pressure in the medial forefoot region but lowest in the lateral heel region. Lastly, pressure in the lateral heel region was highest in LHI. Overall, results of PTI were similar to those of PPP.

CONCLUSIONS

This study demonstrated that the three types of insole each could reduce and redistribute pressure of specific part of the foot to help select an appropriate insole for each purpose.

The effects of foot orthoses and sensory facilitation on lower limb electromyography: A scoping review

Foot orthoses (FO) are used as a treatment for biomechanical abnormalities, overuse injuries, and neuropathologies, but study of their mechanism remains inconclusive. The neuromotor paradigm has proposed that FOs may manipulate sensory input from foot sole skin to reduce muscle activity for movement optimization. This review argues that a FO likely alters the incoming mechanical stimuli transmitted via cutaneous mechanoreceptors and nociceptors as the foot sole interfaces with the surface of the orthotic. Thus, all FOs with or without intentional sensory facilitation, likely changes sensory information from foot sole cutaneous afferents. Additionally, in light of understanding and applying knowledge pertaining to the cutaneous reflex loop circuitry, FO's increasing sensory input to the motorneuron pool can change EMG to either reflex sign (increase or decrease). The purpose of this scoping review was to synthesize FO and sensory augmentation literature and summarize how FO designs can capitalize on foot sole skin to modulate lower limb electromyography (EMG). Six database searches resulted in 30 FO studies and 22 sensory studies that included EMG as an outcome measure. Results revealed task and phase specific responses with some consistencies in EMG outcomes between testing modalities, however many inconsistencies remain. Electrical stimulation reflex research provides support for a likely sensory-to-motor factor contributing to muscle activity modulation when wearing FOs. The discussion divides trends in FO treatment modalities by desired increase or decrease in each compartment musculature. The results of this review provides a benchmark for future academics and clinicians to advance literature in support of a revised neuromotor paradigm while highlighting the importance of foot sole skin in FO design.

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.

Effects of orthopedic insoles on postural balance in patients with chronic stroke: A randomized crossover study

BACKGROUND

Orthopedic insoles (OIs) with medial arch support and heel cushion are widely used to manage lower extremity injuries, but their effects on postural balance in patients with chronic stroke have not been adequately explored.

METHODS

Design: Double-blinded, sham-controlled, randomized crossover trial.

PARTICIPANTS

A total of 32 ambulatory patients (20 men and 12 women, aged between 30 and 76 years) with more than 6 months since stroke onset.

INTERVENTIONS

All participants received one assessment session wearing OIs and one session wearing sham insole (SI) in a random order with a 1-day interval.

OUTCOMES

Our primary outcome was the Berg Balance Scale score. Secondary outcomes included the Functional Reach Test, Timed Up and Go test, and computerized posturography. All were performed in both sessions. Subgroup analyses regarding demographic and functional variables were conducted to identify potential responders.

RESULTS

Significant between-insole differences favoring OIs were seen in all clinical tests (P < 0.05), but were seen only in the static medial-lateral sway in computerized posturography assessment (P = 0.04). An approximate 2-point difference in the BBS score favoring OIs was observed in all subgroups, not reaching the minimal clinically important difference.

CONCLUSION

The use of OIs generated small but significant positive effects on improving postural balance among patients with chronic stroke. Additional biomechanical and clinical studies are required to evaluate their potential for routine clinical use.

TRIAL REGISTRATION

NCT03194282.

Immediate effects of foot orthoses on gait biomechanics in individuals with persistent patellofemoral pain

BACKGROUND

The efficacy of foot orthoses in reducing patellofemoral pain (PFP) is well documented; however, the mechanisms by which foot orthoses modulate pain and function are poorly understood.

RESEARCH QUESTION

This within-subject study investigated the immediate effects of foot orthoses on lower limb kinematics and angular impulses during level walking and stair ambulation in individuals with persistent PFP.

METHODS

Forty-two participants with persistent PFP (≥3 months duration) underwent quantitative gait analysis during level walking, stair ascent and stair descent while using: (i) standard running sandals (control); and (ii) standard running sandals fitted with prefabricated foot orthoses. Hip, knee, and ankle joint kinematics and angular impulses were calculated and statistically analyzed using paired t-tests (p < 0.05).

RESULTS

Relative to the control condition, foot orthoses use was associated with small but significant decreases in maximum ankle inversion angles during walking (mean difference [95% confidence interval]: -1.00° [-1.48 to -0.53]), stair ascent (-1.06° [-1.66 to -0.45]) and stair decent (-0.94° [-1.40 to -0.49]). Foot orthoses were also associated with decreased ankle eversion impulse during walking (-9.8Nms/kg [-12.7 to -6.8]), and decreased ankle dorsiflexion and eversion impulse during stair ascent (-67.6Nms/kg [-100.7 to -34.6] and -17.5Nms/kg [-23.6 to -11.4], respectively) and descent (-50.4Nms/kg [-77.2 to -23.6] and -11.6Nms/kg [-15.6 to -7.5], respectively). Ankle internal rotation impulse decreased when participants ascended stairs with foot orthoses (-3.3Nms/kg [-5.4 to -1.3]). Limited changes were observed at the knee and hip.

SIGNIFICANCE

In individuals with persistent PFP, small immediate changes in kinematics and angular impulses - primarily at the ankle - were observed when foot orthoses were worn during walking or stair ambulation. The clinical implications of these small changes, as well as the longer-term effects of foot orthoses on lower limb biomechanics, are yet to be determined.

Biomechanical Evaluation and Strength Test of 3D-Printed Foot Orthoses

Foot orthoses (FOs) are commonly used as interventions for individuals with flatfoot. Advances in technologies such as three-dimensional (3D) scanning and 3D printing have facilitated the fabrication of custom FOs. However, few studies have been conducted on the mechanical properties and biomechanical effects of 3D-printed FOs. The purposes of this study were to evaluate the mechanical properties of 3D-printed FOs and determine their biomechanical effects in individuals with flexible flatfoot. During mechanical testing, a total of 18 FO samples with three orientations (0°, 45°, and 90°) were fabricated and tested. The maximum compressive load and stiffness were calculated. During a motion capture experiment, 12 individuals with flatfoot were enrolled, and the 3D-printed FOs were used as interventions. Kinematic and kinetic data were collected during walking by using an optical motion capture system. A one-way analysis of variance was performed to compare the mechanical parameters among the three build orientations. A paired t-test was conducted to compare the biomechanical variables under two conditions: walking in standard shoes (Shoe) and walking in shoes embedded with FOs (Shoe+FO). The results indicated that the 45° build orientation produced the strongest FOs. In addition, the maximum ankle evertor and external rotator moments under the Shoe+FO condition were significantly reduced by 35% and 16%, respectively, but the maximum ankle plantar flexor moments increased by 3%, compared with the Shoe condition. No significant difference in ground reaction force was observed between the two conditions. This study demonstrated that 3D-printed FOs could alter the ankle joint moments during gait.

The effect of foot orthoses and insoles on running economy and performance in distance runners: A systematic review and meta-analysis

Foot orthoses and insoles are prescribed to runners, however their impact on running economy and performance is uncertain. The aim of this systematic review and meta-analysis was to determine the effect of foot orthoses and insoles on running economy and performance in distance runners. Seven electronic databases were searched from inception until June 2018. Eligible studies investigated the effect of foot orthoses or insoles on running economy (using indirect calorimetry) or running performance. Standardised mean differences (SMDs) were computed and meta-analyses were conducted using random effects models. Methodological quality was assessed using the Quality Index. Nine studies met the criteria and were included: five studies investigated the effect of foot orthoses on running economy and four investigated insoles. Foot orthoses were associated with small negative effects on running economy compared to no orthoses (SMD 0.42 [95% CI 0.17,0.72] p = 0.007). Shock absorbing insoles were also associated with negative effects on running economy, but an imprecise estimate (SMD 0.26 [95% CI -0.33,0.84] p = 0.83). Quality Index scores ranged from 4 to 15 out of 17. Foot orthoses and shock absorbing insoles may adversely affect running economy in distance runners. Future research should consider their potential effects on running performance.

Efficacy of different techniques of AFO construction for hemiplegia patients: A systematic review

Background: Ankle foot orthoses (AFOs) are frequently prescribed to improve gait deviation and normalize walking pattern in patients with drop foot hemiplegia disorder. This study was to review the efficacy of different techniques of AFO construction and biomechanics parameters of AFOs. Furthermore, this study aimed to provide a guideline for researchers in detail and help them choose a sufficient measurement instrument.

Methods: Information sources included MEDLINE, CINAHL, Scopus, PubMed, and the Full Cochrane Library up to December 25, 2015. The inclusion criteria include: (1) type and method of controlled clinical trial studies; (2) age of hemiplegia groups (3); AFOs as an intervention; and (4) kinetic and kinematic parameters, and energy expenditure as an intervention of gait performance.

Results: Considering eligibility criteria such as study design, setting, time frame and Language 9 papers with Pedro scores of 5 to 8 for methodological quality were included in the review.

Conclusion: The findings of this review can help to develop guidelines for the best AFO reporting as an intervention and to prevent vagueness of results in the different types of AFOs.

Athletes Rated as Poor Single-Leg Squat Performers Display Measurable Differences in Single-Leg Squat Biomechanics Compared With Good Performers

Context: It is important to validate single-leg squat visual rating criteria used in clinical practice and research. Foot orthoses may improve single-leg squat performance in those who demonstrate biomechanics associated with increased risk of lower limb injury. Objective: Validate visual rating criteria proposed by Crossley et al, by determining whether athletes rated as poor single-leg squat performers display different single-leg squat biomechanics than good performers; and evaluate immediate effects of foot orthoses on single-leg squat biomechanics in poor performers. Design: Comparative cross-sectional study. Setting: University laboratory. Participants: 79 asymptomatic athletes underwent video classification of single-leg squat performance based on established visual rating criteria (overall impression, trunk posture, pelvis “in space,” hip movement, and knee movement), and were rated as good (n = 23), fair (n = 41), or poor (n = 15) performers. Intervention: A subset of good (n = 16) and poor (n = 12) performers underwent biomechanical assessment, completing 5 continuous single-leg squats on their dominant limb while 3-dimensional motion analysis and ground reaction force data were recorded. Poor performers repeated the task standing on prefabricated foot orthoses. Main Outcome Measures: Peak external knee adduction moment (KAM) and peak angles for the trunk, hip, knee, and ankle. Results: Compared with good performers, poor performers had a significantly lower peak KAM (mean difference = 0.11 Nm/kg, 95% confidence interval = 0.02 to 0.2 Nm/kg), higher peak hip adduction angle (−4.3°, −7.6° to −0.9°), and higher peak trunk axial rotation toward their stance limb (3.8°, 0.4° to 7.2°). Foot orthoses significantly increased the peak KAM in poor performers (−0.06 Nm/kg, −0.1 to −0.01 Nm/kg), with values approximating those observed in good performers. Conclusions: Findings validate Crossley et al’s visual rating criteria for single-leg squat performance in asymptomatic athletes, and suggest that “off-the-shelf” foot orthoses may be a simple intervention for poor performers to normalize the magnitude of the external KAM during single-leg squat.

The long-term use of foot orthoses affects walking kinematics and kinetics of children with flexible flat feet: A randomized controlled trial

Background

Due to inconclusive evidence on the effects of foot orthoses treatment on lower limb kinematics and kinetics in children, studies are needed that particularly evaluate the long-term use of foot orthoses on lower limb alignment during walking. Thus, the main objective of this study was to evaluate the effects of long-term treatment with arch support foot orthoses versus a sham condition on lower extremity kinematics and kinetics during walking in children with flexible flat feet.

Methods

Thirty boys aged 8–12 years with flexible flat feet participated in this study. While the experimental group (n = 15) used medial arch support foot orthoses during everyday activities over a period of four months, the control group (n = 15) received flat 2-mm-thick insoles (i.e., sham condition) for the same time period. Before and after the intervention period, walking kinematics and ground reaction forces were collected.

Results

Significant group by time interactions were observed during walking at preferred gait speed for maximum ankle eversion, maximum ankle internal rotation angle, minimum knee abduction angle, maximum knee abduction angle, maximum knee external rotation angle, maximum knee internal rotation angle, maximum hip extension angle, and maximum hip external rotation angle in favor of the foot orthoses group. In addition, statistically significant group by time interactions were detected for maximum posterior, and vertical ground reaction forces in favor of the foot orthoses group.

Conclusions

The long-term use of arch support foot orthoses proved to be feasible and effective in boys with flexible flat feet to improve lower limb alignment during walking.

Effect of Different Insole Materials on Kinetic and Kinematic Variables of the Walking Gait in Healthy People

BACKGROUND

There is a lack of data that could address the effects of off-the-shelf insoles on gait variables in healthy people.

METHODS

Thirty-three healthy volunteers ranging in age from 18 to 35 years were included to this study. Kinematic and kinetic data were obtained in barefoot, shoe-only, steel insole, silicone insole, and polyurethane insole conditions using an optoelectronic three-dimensional motion analysis system. A repeated measures analysis of variance test was used to identify statistically significant differences between insole conditions. The alpha level was set at P < .05.

RESULTS

Maximum knee flexion was higher in the steel insole condition (P < .0001) compared with the silicone insole (P = .001) and shoe-only conditions (P = .032). Reduced maximum knee flexion was recorded in the polyurethane insole condition compared with the shoe-only condition (P = .031). Maximum knee flexion measured in the steel insole condition was higher compared to the barefoot condition (P = .020). Higher maximum ankle dorsiflexion was observed in the barefoot condition, and there were significant differences between the polyurethane insole (P < .0001), silicone insole (P = .001), steel insole (P = .002), and shoe conditions (P = .004). Least and highest maximum ankle plantarflexion were detected in the steel insole and silicone insole conditions, respectively. Maximum ankle plantarflexion in the barefoot and steel insole conditions (P = .014) and the barefoot and polyurethane insole conditions (P = .035) were significant. There was no significant difference between conditions for ground reaction force or joint moments.

CONCLUSIONS

Insoles made by different materials affect maximum knee flexion, maximum ankle dorsiflexion, and maximum ankle plantarflexion. This may be helpful during the decision-making process when selecting the insole material for any pathological conditions that require insole prescription.

Influence and benefits of foot orthoses on kinematics, kinetics and muscle activation during step descent task

BACKGROUND

Medial wedged foot orthoses are frequently prescribed to reduce retropatellar stress in patients with patellofemoral pain (PFP) by controlling calcaneal eversion and internal rotation of the tibia. During activities of daily living, the highest patella loads occur during stair descent, but the effect of foot orthoses during stair descent remains unclear.

RESEARCH QUESTION

The purpose of this study was to compare the kinematics, kinetics and muscle activation during a step descent task in healthy volunteers using three designs of foot orthoses (insoles).

METHODS

Sixteen healthy subjects with a mean age of 25.7 years, BMI of 23.3, and +5 Foot Posture Index were recruited. Subjects performed a step down task from 20 cm using a 5o rearfoot medial wedge (R), a 5o rearfoot and forefoot medial wedge (R/F), and a control flat insole (C).

RESULTS

Significant improvements in control were seen in the R and R/F insoles over the C insole in the foot and at the ankle and hip kinematics. The R and R/F insoles increased the knee adduction moments, but reduced knee internal rotation moment compared to the C insole. Abductor hallucis (AH) activity was reduced with both insoles, whereas tibialis anterior (TA) activity was reduced with the R insole only.

SIGNIFICANCE

Foot orthoses can change joint mechanics in the foot and lower limbs providing greater stability and less work done by AH and TA muscles. This data supports the use of foot orthoses to provide functional benefits during step descent, which may benefit patients with PFP.

Predictors of the Biomechanical Effects of Customized Foot Orthoses in Adults With Flat-Arched Feet

OBJECTIVE

To determine the potential presence and characteristics of biomechanical responders to customized foot orthoses during walking in adults with flat-arched feet.

DESIGN

Experimental, repeated-measures.

SETTING

University clinic and laboratory.

PARTICIPANTS

Eighteen symptom-free adults with flat-arched feet.

INTERVENTIONS

Customized foot orthoses.

MAIN OUTCOME MEASURES

In-shoe foot biomechanics were measured during walking with and without customized foot orthoses using 3D analysis. Selected kinematic and kinetic variables during baseline walking were compared between subgroups who displayed reductions in calcaneal eversion with foot orthoses to those with no change or increases.

RESULTS

Biomechanical responders displayed significantly greater peak calcaneal eversion (+2.2 degrees, P = 0.009). Time to peak calcaneal eversion (-11%, P = 0.006), peak dorsiflexion of the hallux (-6 degrees, P = 0.001), and medial-lateral excursion of the center of pressure during loading response were all reduced in the responder subgroup (-2 mm, P ≤ 0.001). Variables significantly different between subgroups were moderately associated with the response to foot orthoses (canonical correlation = 0.687, effect size = 0.47, P = 0.063).

CONCLUSIONS

Individuals with increased dynamic foot pronation were more likely to show a favorable biomechanical response to customized foot orthoses, providing preliminary evidence to support the stratified use of foot orthoses to optimize their effectiveness.

2018 Consensus statement on exercise therapy and physical interventions (orthoses, taping and manual therapy) to treat patellofemoral pain: recommendations from the 5th International Patellofemoral Pain Research Retreat, Gold Coast, Australia, 2017

Patellofemoral pain affects a large proportion of the population, from adolescents to older adults, and carries a substantial personal and societal burden. An international group of scientists and clinicians meets biennially at the International Patellofemoral Research Retreat to share research findings related to patellofemoral pain conditions and develop consensus statements using best practice methods. This consensus statement, from the 5th International Patellofemoral Research Retreat held in Australia in July 2017, focuses on exercise therapy and physical interventions (eg, orthoses, taping and manual therapy) for patellofemoral pain. Literature searches were conducted to identify new systematic reviews and randomised controlled trials (RCTs) published since the 2016 Consensus Statement. The methodological quality of included systematic reviews and RCTs was graded using AMSTAR and PEDro, respectively. Evidence-based statements were developed from included papers and presented to a panel of 41 patellofemoral pain experts for consensus discussion and voting. Recommendations from the expert panel support the use of exercise therapy (especially the combination of hip-focused and knee-focused exercises), combined interventions and foot orthoses to improve pain and/or function in people with patellofemoral pain. The use of patellofemoral, knee or lumbar mobilisations in isolation, or electrophysical agents, is not recommended. There is uncertainty regarding the use of patellar taping/bracing, acupuncture/dry needling, manual soft tissue techniques, blood flow restriction training and gait retraining in patients with patellofemoral pain. In 2017, we launched the International Patellofemoral Research Network (www.ipfrn.org) to consolidate and grow our patellofemoral research community, facilitate collaboration and disseminate patellofemoral pain knowledge to clinicians and the general public. The 6th International Patellofemoral Research Retreat will be held in Milwaukee, Wisconsin, USA, in October 2019.

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.

Nicotine effects on exercise performance and physiological responses in nicotine-naïve individuals: a systematic review

The purpose of this systematic review was to evaluate the effects of smokeless forms of nicotine on physiological responses and exercise performance. Methodology and reporting were based on the PRISMA statement. The intervention was defined as any product containing nicotine that did not require smoking. Searches were conducted across two electronic databases with supplementary approaches utilized. Studies were selected following set inclusion and exclusion criteria and checked by two independent authors. A modified PEDro scale was utilized to rate study quality with studies averaging 9·3/13. Six studies assessed exercise performance with endurance-based parameters reported as significantly improved with nicotine in one study, while anaerobic parameters were unaffected or decreased compared to placebo except in one study which reported enhanced leg extensor torque but no effect on countermovement jump or Wingate anaerobic capacity. Sixteen of 28 studies investigating physiological responses reported that nicotine significantly increased heart rate compared to placebo or control. Blood pressure and blood flow were also reported as significantly increased in multiple studies. While there is strong evidence of nicotine-induced changes in physiological function that would benefit physical performance, beneficial effects have only been reported on leg extensor torque and endurance performance by one study each. Subsequently, there is need for more research with strong methodological quality to definitively evaluate nicotine's potential as an ergogenic aid.

Incidence and Epidemiology of Foot and Ankle Injuries in Elite Collegiate Athletes

BACKGROUND

Foot and ankle injuries are increasing in competitive professional and collegiate athletics. Many of these injuries result in considerable missed time from sports and often require surgical intervention. To develop and implement effective practice participation strategies, return-to-play protocols, and injury prevention programs, an understanding of injury trends and epidemiology is vital.

PURPOSE

This study aimed to evaluate the incidence of foot and ankle injuries in elite athletes participating in 37 sports at a single National Collegiate Athletics Association (NCAA) Division 1 institution.

STUDY DESIGN

Descriptive epidemiological study.

METHODS

We evaluated the injury records of all varsity sports at a single NCAA Division 1 athletics program, including 1076 athletes participating in 37 sports. Detailed injury data were prospectively collected in a secure electronic database over a 2-year period. We reviewed the database for all foot/ankle injuries. Inclusion criteria were any foot/ankle injury that was sustained during an NCAA-sanctioned event and subsequently received medical treatment. Independent variables included athlete and injury demographics, missed days, physician visits, imaging results, and whether the injury required surgery. Injury incidence, relative frequency distributions, and sample proportions were dependent metrics for this investigation.

RESULTS

During the study period, a total of 3861 total musculoskeletal injuries were recorded. There were 1035 foot/ankle injuries (27%). Of all foot/ankle injuries, 21% (218 of 1035) caused the athlete to miss at least 1 day of participation, with an average of 12.3 days of time loss from sport. Furthermore, 27% of athletes with foot/ankle injuries were referred for office evaluation by a physician, and 84% of these required radiologic imaging. The overall injury incidence rate was 3.80 per 1000 athlete-exposures (AEs). The 4 sports with the highest incidence rate (>75th percentile) were women's gymnastics, women's cross-country, women's soccer, and men's cross country. The most frequently occurring foot/ankle injuries were ankle ligament injuries, tendinopathies or fasciopathies, and bone stress injuries.

CONCLUSION

The prevalence of foot/ankle injury in a large NCAA Division 1 athletics program was 27% of total musculoskeletal injuries over a 2-year period, with 21% of these injuries resulting in missed time. There were significantly higher foot and ankle injury incidence rates and more missed time in female athletes and women's sports.

Effectiveness of foot orthoses and shock-absorbing insoles for the prevention of injury: a systematic review and meta-analysis

OBJECTIVE

To investigate the evidence relating to the effectiveness of foot orthoses and shock-absorbing insoles for the prevention of musculoskeletal injury.

DESIGN

Systematic review and meta-analysis.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Clinical trials evaluating the effectiveness of foot orthoses and shock-absorbing insoles for the prevention of injury.

DATA SOURCES

Cochrane Library, CINAHL, EMBASE, MEDLINE and SPORTDiscus from their inception up to the first week of June 2016.

RESULTS

11 trials that had evaluated foot orthoses and 7 trials that had evaluated shock-absorbing insoles were included. The median Physiotherapy Evidence Database (PEDro) score for trials that had evaluated foot orthoses and shock-absorbing insoles was 5 (range 3-8/10) and 3 (range 1-7/10), respectively. Meta-analysis found that foot orthoses were effective for preventing overall injuries (risk ratio (RR) 0.72, 95% CI 0.55 to 0.94) and stress fractures (RR 0.59, 95% CI 0.45 to 0.76), but not soft-tissue injuries (RR 0.79, 95% CI 0.55 to 1.14). In contrast, shock-absorbing insoles were not effective for preventing overall injuries (RR 0.92, 95% CI 0.73 to 1.16), stress fractures (RR 1.15, 95% CI 0.57 to 2.32) or soft-tissue injuries (RR 0.92, 95% CI 0.74 to 1.15).

CONCLUSIONS

Foot orthoses were found to be effective for preventing overall injuries and stress fractures but not soft-tissue injuries, while shock-absorbing insoles were not found to be effective for preventing any injury. However, further well-designed trials will assist the accuracy and precision of the estimates of risk reduction as the quality of the included trials varied greatly.

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.

The Influence of a Prefabricated Foot Orthosis on Lower Extremity Mechanics During Running in Individuals With Varying Dynamic Foot Motion

Study Design Controlled laboratory study, cross-sectional. Background Orthotic prescription is often based on the premise that the mechanical effects will be more prominent in individuals with greater calcaneal eversion. Objective To compare the effects of a prefabricated foot orthosis on lower extremity kinematics and kinetics between recreational athletes with high and low calcaneal eversion during running. Methods Thirty-one recreational athletes were included in this study. Three-dimensional kinematic and kinetic data were collected while running with and without a foot orthosis. Participants were grouped based on the degree of calcaneal eversion during the running trials relative to a standing trial (dynamic foot motion). The effects of the orthosis on the frontal and transverse plane angles and moments of the hip and knee were compared between the 10 participants with the greatest and least amount of dynamic foot motion. Results There were no significant interactions (group by orthotic condition) for any of the kinematic or kinetic variables of interest. Conclusion The effects of an orthosis on the mechanics of the hip and knee do not appear to be dependent on an individual's dynamic foot motion. J Orthop Sports Phys Ther 2016;46(9):749-755. Epub 5 Aug 2016. doi:10.2519/jospt.2016.6253.

The Effect of Different Foot Orthosis Inverted Angles on Plantar Pressure in Children with Flexible Flatfeet

Although orthotic modification using the inverted technique is available for the treatment of flatfoot, empirical evidence for the biomechanical effects of inverted-angle foot orthoses (FOs) is lacking. The aim of this study was to evaluate the effects of different FO inversion angles on plantar pressure during gait in children with flatfoot. Twenty-one children with flexible flatfeet (mean age 9.9 years) were enrolled in this study. The plantar pressures were measured for the rearfoot; medial and lateral midfoot; and medial, central, and lateral forefoot as participants walked on a treadmill while wearing shoes only and shoes with the following 3 orthotic conditions: (i) orthosis with no inverted angle, (ii) orthosis with a 15° inverted angle, and (iii) orthosis with a 30° inverted angle. A one-way repeated measures analysis of variance (ANOVA) with the Bonferroni-adjusted post-hoc test was used to compare the mean values of each orthotic condition. Compared with the shoe only condition, the peak pressure decreased significantly under the medial forefoot and rearfoot with all FOs (p <0.05). However, no significant differences in the peak pressure under the medial forefoot and rearfoot were observed between the FOs. The peak pressure under the medial midfoot increased significantly with all FOs, and a maximal increase in the peak pressure was obtained with a 30° inverted angle orthosis. Furthermore, the contact area under the medial midfoot and rearfoot increased significantly with all FOs, compared with the shoe only condition (p <0.05). Again, no significant differences were observed between the FOs. For plantar pressure redistribution, a FO with a low inverted angle could be effective, accommodative, and convenient for children with flatfoot.

Comparison of Two Types of Insoles on Musculoskeletal Symptoms and Plantar Pressure Distribution in a Work Environment: A Randomized Clinical Trial

BACKGROUND

The aim of the present study was to assess plantar pressure distribution and musculoskeletal symptoms following the use of customized insoles among female assembly line workers.

METHODS

The study included 29 female assembly line workers (age, 29.76 ± 5.79 years; weight, 63.79 ± 12.11 kg) with musculoskeletal symptoms who work predominantly while standing. The Nordic Musculoskeletal Questionnaire was administered to the study population. Plantar pressure was determined using a computerized plantar pressure feedback system. A control group (n=13) used ethylvinylacetate insoles (Podaly®) that were individually heat molded and heat glued. The intervention group (n=14) also used the insoles and a strip of the same material was added to the site of greatest plantar pressure as determined by the electronic feedback device. After five weeks, the plantar pressure data were collected again and the questionnaire was administered a second time.

RESULTS

There was no significant difference between groups with regard to pain in any anatomic site. However, within each group the lumbar region exhibited a reduction in symptoms in the intervention group (P<0.05), and the feet exhibited a reduction in symptoms in both groups (P<0.05). Mean plantar pressure increased and plantar surface decreased in the intervention group (P<0.05).

CONCLUSION

Insoles increased foot comfort in both groups. However, the added strip did not significantly modify either plantar pressure or other symptoms in female workers.

Foot orthotics for low back pain: The state of our understanding and recommendations for future research

PURPOSE

The purpose of the article is to evaluate the literature on the use of foot orthotics for low back pain and to make specific recommendations for future research.

METHODS

Database searches were conducted using PubMed, EBSCO, GALE, Google Scholar, and clinicaltrials.gov. The biomedical literature was reviewed to determine the current state of knowledge on the benefits of foot orthotics for low back pain related to biomechanical mechanisms and clinical outcomes.

RESULTS

It may be argued that foot orthotics are experimental, investigational, or unproven for low back pain due to lack of sufficient evidence for their clinical effectiveness. This conclusion is based upon lack of high quality randomized controlled trials (RCTs). However, there is extensive research on biomechanical mechanisms underlying the benefits of orthotics that may be used to address this gap. Additionally, promising pilot studies are beginning to emerge in the literature and ongoing large-scale RCTs are addressing effects of foot orthotics on chronic low back pain.

CONCLUSIONS

Based upon the critical evaluation of the current research on foot orthotics related to biomechanical mechanisms and clinical outcomes, recommendations for future research to address the evidence-practice gaps on the use of foot orthotics for low back pain are presented.

Physical Examination Variables Predict Response to Conservative Treatment of Nonchronic Plantar Fasciitis: Secondary Analysis of a Randomized, Placebo-Controlled Footwear Study

BACKGROUND

Plantar fasciitis is a common, disabling condition, and the prognosis of conservative treatment is difficult to predict.

OBJECTIVE

To determine whether initial clinical findings could help predict patient response to conservative treatment that primarily consisted of supportive footwear and stretching.

SETTING

Patients were recruited and seen at 2 outpatient podiatric clinics in the Chicago, Illinois, metropolitan area.

PATIENTS

Seventy-seven patients with nonchronic plantar fasciitis were recruited. Patients were excluded if they had a heel injection in the previous 6 months or were currently using custom foot orthoses at the time of screening. Sixty-nine patients completed the final follow-up visit 3 months after receiving the footwear intervention.

METHODS

Treatment failure was considered a <50% reduction in heel pain at 3 month follow-up. Logistic regression models evaluated the possible association between more than 30 clinical and physical examination findings prospectively assessed at enrollment, and treatment response.

RESULTS

Inability to dorsiflex the ankle past -5° (odds ratio [OR] 3.9, P = .024), nonsevere (≤7 on ordinal scale) first-step pain (OR 3.8, P = .021), and heel valgus in relaxed stance (OR 4.0, P = .014) each predicted treatment failure in multivariable analysis (receiver operating characteristic area under the curve = .769). Limited ankle dorsiflexion also correlated with greater heel pain severity at initial presentation (r = - 0.312, P = .006).

CONCLUSIONS

Patients with severe ankle equinus were nearly 4 times more likely to experience a favorable response to treatment centered on home Achilles tendon stretching and supportive therapy. Thus, earlier use of more advanced therapies may be most appropriate in those presenting without severe ankle equinus or without severe first step pain. The findings from our study may not be clinically intuitive because patients with less severe equinus and less severe pain at presentation did worse with conservative care.

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.

Effects of the site and extent of plantar cutaneous stimulation on dynamic balance and muscle activity while walking

BACKGROUND

Previous studies have demonstrated that stimulating the cutaneous plantar sensory receptors of the foot through textured insoles improves human balance and walking. This study investigated the effect of medial and lateral zoned textured insoles using tibialis anterior/peroneus longus surface electromyographic activity and Centre-of-Pressure as indicators of postural stability while walking.

METHODS

15 asymptomatic subjects were tested using a within-subject randomised repeated measures design. The effect of lateral and medial zoned insoles of varying heights (control, 2, 4 and 6mm) on stability while walking under normal and impaired visual conditions was assessed.

RESULTS

Impaired vision resulted in an increase in foot CoP variability while walking (p<0.05). The laterally zoned insole was associated with a significant (repeated measures ANOVA p<0.05) increase in the rate of medial-lateral CoP change.

CONCLUSION

These findings suggest that the site of stimulation of the plantar foot cutaneous receptors may increase postural instability during walking. This should be considered in the design of insoles that aim to improve balance and reduce falls risk. The importance of vision in balance control has been highlighted and using impaired vision may serve as a way of trialling clinical products in the healthy population.

Adults with flexible pes planus and the approach to the prescription of customised foot orthoses in clinical practice: A clinical records audit

A clinical records audit of the University of South Australia's podiatry clinic clients attending in 2010 was undertaken to determine prevalence of symptomatic flexible pes planus, presenting reasons and treatment options most frequently used. Analysis of rearfoot measures (resting calcaneal stance position, subtalar joint range of motion) between those prescribed a vertical (heel) or inverted (heel) cast pour and a medial heel (Kirby) skive was undertaken. Of 223 clinical records audited, 50% (111/223) of clients were assessed with flexible pes planus, 77% (86/111) of clients with pes planus presented with back or lower limb pain and 58% (64/111) were prescribed customised foot orthoses. Of 42 prescriptions for customised foot orthoses audited; 64% (27/42) were prescribed a vertical (heel) cast pour, 36% (15/42) an inverted (heel) cast pour and 19% (8/42) received a medial heel (Kirby) skive. Those prescribed a medial heel (Kirby) skive had a more everted resting calcaneal stance position than those that were not (mean -8.6±2.8° vs. -5.5±3.4°, p=0.02). Those prescribed an inverted (heel) cast pour had a greater range of subtalar joint motion than those prescribed a vertical (heel) cast pour (median 36.0±10.0° vs. 29.0±5.0°, p=0.01).

Hip arthroscopy in the setting of hip osteoarthritis: systematic review of outcomes and progression to hip arthroplasty

BACKGROUND

Hip arthroscopy is now commonly used to treat hip pain and pathology, including osteoarthritis (OA). Despite this, little is known about the effect of hip arthroscopy on outcomes of pain and function and progression to total hip arthroplasty (THA) in hip OA.

QUESTIONS/PURPOSES

This systematic review aimed to (1) determine pain and function outcomes after hip arthroscopy in people with hip OA; (2) compare the outcome after hip arthroscopy between people with and without hip OA; and (3) report the likelihood of progression to THA in patients with hip OA after hip arthroscopy.

METHODS

This review was conducted in accordance with the PRISMA statement. The Downs and Black checklist was used for quality appraisal. Studies scoring positively on at least 50% of items were included in final analyses. Standardized mean differences (SMDs) were calculated where possible or study conclusions are presented.

RESULTS

Twenty-two studies were included in the final analyses. Methodological quality and followup time varied widely. Moderate to large SMDs were reported for people with and without hip OA; however, the positive effects of the intervention were smaller for people with hip OA. Greater severity of hip OA and older age each predicted more rapid progression to THA.

CONCLUSIONS

Patients with hip OA report positive outcomes from hip arthroscopy, although observed positive effects may be inflated as a result of methodological limitations of the included studies. Patients with hip OA had inferior results compared with those who did not. Chondropathy severity and patient age were associated with a higher risk and more rapid progression to THA. High-quality comparative studies are required to confirm the effects of hip arthroscopy on symptoms and structural change in people with hip OA.

Dynamic foot function as a risk factor for lower limb overuse injury: a systematic review

Background

Dynamic foot function is considered a risk factor for lower limb overuse injuries including Achilles tendinopathy, shin pain, patellofemoral pain and stress fractures. However, no single source has systematically appraised and summarised the literature to evaluate this proposed relationship. The aim of this systematic review was to investigate dynamic foot function as a risk factor for lower limb overuse injury.

Methods

A systematic search was performed using Medline, CINAHL, Embase and SportDiscus in April 2014 to identify prospective cohort studies that utilised dynamic methods of foot assessment. Included studies underwent methodological quality appraisal by two independent reviewers using an adapted version of the Epidemiological Appraisal Instrument (EAI). Effects were expressed as standardised mean differences (SMD) for continuous scaled data, and risk ratios (RR) for nominal scaled data.

Results

Twelve studies were included (total n = 3,773; EAI 0.44 to 1.20 out of 2.00, representing low to moderate quality). There was limited to very limited evidence for forefoot, midfoot and rearfoot plantar loading variables (SMD 0.47 to 0.85) and rearfoot kinematic variables (RR 2.67 to 3.43) as risk factors for patellofemoral pain; and plantar loading variables (forefoot, midfoot, rearfoot) as risk factors for Achilles tendinopathy (SMD 0.81 to 1.08). While there were significant findings from individual studies for plantar loading variables (SMD 0.3 to 0.84) and rearfoot kinematic variables (SMD 0.29 to 0.62) as risk factors for ‘non-specific lower limb overuse injuries’, these were often conflicting regarding different anatomical regions of the foot. Findings from three studies indicated no evidence that dynamic foot function is a risk factor for iliotibial band syndrome or lower limb stress fractures.

Conclusion

This systematic review identified very limited evidence that dynamic foot function during walking and running is a risk factor for patellofemoral pain, Achilles tendinopathy, and non-specific lower limb overuse injuries. It is unclear whether these risk factors can be identified clinically (without sophisticated equipment), or modified to prevent or manage these injuries. Future prospective cohort studies should address methodological limitations, avoid grouping different lower limb overuse injuries, and explore clinically meaningful representations of dynamic foot function.

Electronic supplementary material

The online version of this article (doi:10.1186/s13047-014-0053-6) contains supplementary material, which is available to authorized users.

Consensus-based recommendations of Australian podiatrists for the prescription of foot orthoses for symptomatic flexible pes planus in adults

BACKGROUND

Foot orthoses are commonly used for symptomatic flexible pes planus in adults. However, there are no clinical guidelines for the prescription of customised foot orthoses that are specific to this population. The aim of this study was to investigate prescription habits of Australian podiatrists for customised foot orthoses for symptomatic flexible pes planus in adults and to develop consensus-based practice recommendations for the prescription of these foot orthoses.

METHODS

A four round Delphi survey was undertaken with 24 podiatric experts to establish current use and rationale for individual prescription variables of customised foot orthoses for symptomatic flexible pes planus in adults. Round one determined prescription use (consensus) and rounds two, three and four determined the rationale for use (agreement) of prescription variables across the rearfoot, midfoot, forefoot, as well as accommodation and materials used. For consensus and agreement to be accepted, 70% of the respondents were required to use or agree on the rationale for use of individual prescription variables.

RESULTS

Consensus was reached in round one for two variables, choice of shell material (polyolefin) and when to prescribe a forefoot post balanced to perpendicular. In rounds two, three and four, agreement was reached for 52 statements related to the rationale for use of individual prescription variables, including when to prescribe: an inverted cast pour [heel in an inverted position], an inverted rearfoot post, a medial heel (Kirby) skive, minimal/maximum arch fill, a medial flange, a forefoot post and common orthotic accommodations.

CONCLUSION

This study found consensus or agreement for the use of several prescription variables for customised foot orthoses for symptomatic flexible pes planus in adults. The findings were used to develop the Foot orthosis Prescription Recommendations for symptOmatic flexible Pes planus in adults (FootPROP) proforma, to guide clinicians and researchers in the prescription of customised foot orthoses for this population.

Interventions to prevent sports related injuries: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

The effects of methods to prevent injuries have been studied in several systematic reviews. However, no meta-analysis taking into account all randomised controlled intervention trials aiming at the prevention of sports injuries has been published.

OBJECTIVE

To summarise the effects of sports injury prevention interventions.

DESIGN

Systematic review and meta-analysis of randomised controlled trials.

DATA SOURCES

PubMed, MEDLINE, SPORTDiscus, the Cochrane Central Register of Controlled Trials, CINAHL, PEDro, and Web of Science, searched in September 2013. The reference lists of retrieved articles and reviews were hand searched.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

To be selected articles had to examine the effects of any preventive intervention on sports injuries, be randomised/quasi-randomised and controlled trials, published in a peer-reviewed journal. The outcome of the trial had to be injury rate or the number of injured individuals.

RESULTS

Of the 5580 articles retrieved after a search of databases and the relevant bibliography, 68 randomised controlled trials were included in the systematic review and 60 trials were included in the meta-analysis. Insoles (OR 0.51, 95% CI 0.32-0.81), external joint supports (OR 0.40, 95% CI 0.30-0.53), and specific training programmes (OR 0.55, 95% CI 0.46-0.66) appeared to be effective in reducing the risk of sports injuries. Stretching (OR 0.92, 95% CI 0.80-1.06), modified shoes (OR 1.23, 95% CI 0.81-1.87), and preventive videos (OR 0.86, 95% CI 0.44-1.68) seemed not to be effective.

CONCLUSIONS

This meta-analysis showed that certain interventions can reduce the risk of sports injuries. There were limitations regarding the quality of the trials, generalisability of the results, and heterogeneity of the study designs. In future, the mechanisms behind effective methods and the most beneficial elements of preventive training programmes need to be clarified.

Heel pain-plantar fasciitis: revision 2014

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to nonarthritic heel pain.

Foot orthoses for adults with flexible pes planus: a systematic review

BACKGROUND

Foot orthoses are widely used in the management of flexible pes planus, yet the evidence to support this intervention has not been clearly defined. This systematic review aimed to critically appraise the evidence for the use of foot orthoses for flexible pes planus in adults.

METHODS

Electronic databases (Medline, CINAHL, Cochrane, Web of science, SportDiscus, Embase) were systematically searched in June 2013 for randomised controlled, controlled clinical and repeated measure trials where participants had identified flexible pes planus using a validated and reliable measure of pes planus and the intervention was a rigid or semi-rigid orthoses with the comparison being a no-orthoses (shoes alone or flat non-posted insert) condition. Outcomes of interest were foot pain, rearfoot kinematics, foot kinetics and physical function.

RESULTS

Of the 2,211 articles identified by the searches, 13 studies met the inclusion criteria; two were randomised controlled trials, one was a controlled trial and 10 were repeated measure studies. Across the included studies, 59 relevant outcome measures were reported with 17 calculated as statistically significant large or medium effects observed with use of foot orthoses compared to the no orthoses condition (SMD range 1.13 to -4.11).

CONCLUSIONS

No high level evidence supported the use of foot orthoses for flexible pes planus. There is good to moderate level evidence that foot orthoses improve physical function (medial-lateral sway in standing (level II) and energy cost during walking (level III)). There is low level evidence (level IV) that foot orthoses improve pain, reduce rearfoot eversion, alter loading and impact forces; and reduce rearfoot inversion and eversion moments in flexible pes planus. Well-designed randomised controlled trials that include appropriate sample sizes, clinical cohorts and involve a measure of symptom change are required to determine the efficacy of foot orthoses to manage adult flexible pes planus.

Assessment of gait characteristics and orthotic management in children with Developmental Coordination Disorder: preliminary findings to inform multidisciplinary care

Developmental Coordination Disorder (DCD) is a neurodevelopmental disorder characterised by impaired motor co-ordination and awkward gait. Despite self-reported findings of pes planus and joint hypermobility in children with DCD, there is little objective evidence regarding the clinical management of the foot in children with DCD. The aims of this research were to report clinical findings of foot posture and lower limb hypermobility in children with DCD and to evaluate the impact of foot orthoses on spatio-temporal gait parameters. Children with DCD were recruited into the study. Participants were randomly assigned to an intervention group who received foot orthoses at the start of their rehabilitation programme or to a second group who received foot orthoses at the end of their intervention programme. Foot posture was assessed with the Foot Posture Index and lower limb hypermobility assessed with the Lower Limb Assessment Score. The effect of foot orthoses was evaluated through assessment of spatio-temporal gait characteristics at baseline and post-rehabilitation programme. Fourteen children were recruited (mdn age 7.5 years) with nine children assigned to the group receiving orthoses early (mdn age 8 years) and five children assigned to the post-rehabilitation orthoses group (mdn age 6.5 years). A pes planus foot posture (FPI score=8) and lower limb hypermobility (LLAS score=11) were observed. Changes in spatio-temporal gait parameters failed to reach significance (p>.012) following orthotic invention but demonstrated a trend towards a decreased cadence and increased double support duration. Despite non-significant findings this work offers preliminary support for podiatric intervention in the rehabilitation of children with DCD. Further work is required to understand the biomechanics of gait in children with DCD and appreciate the role of podiatry as a component of multidisciplinary care.

The short-term effect of custom-made foot orthoses in subjects with excessive foot pronation and lower back pain: a randomized, double-blinded, clinical trial

STUDY DESIGN

randomized, double-blinded, clinical trial.

BACKGROUND

Low back pain is one of the commonest disorders affecting the back. The literature reflects how over time excessive pronation of the foot has become to be recognized as linked to chronic low back pain, and how the problem can evolve for the better with the use of compensating foot orthoses.

OBJECTIVES

The main objective of this study is to answer the question of whether the use of a certain type of custom-made foot orthosis alleviates low back pain.

MATERIAL AND METHODS

In a sample of 51 participants with excessive subtalar pronation and chronic low back pain (43 women and 8 men), the effect of custom-made foot orthoses in low back pain was studied. The study design was a randomized, double-blinded, clinical trial with two groups: experimental, treated with the custom-made foot orthoses, and control, treated with a placebo. Low back pain was evaluated by a visual analog scale for pain and Oswestry's Disability Index Questionnaire for lower back pain at two moments--on the day of inclusion in the study and after 4 weeks of treatment.

RESULTS

The evolution of the low back pain showed significant differences in the experimental group, showing a significant reduction of pain and disability (p < 0.001, visual analog scale; p < 0.001, Oswestry's Index).

CONCLUSIONS

In the sample studied, the use of custom-made foot orthoses to control foot pronation had a short-term effect in reduction of perceived low back pain.