Hayley Uden

Plantar fasciitis – to jab or to support? A systematic review of the current best evidence

Background: Plantar fasciitis is a common condition routinely managed by podiatrists in the community and is widely treated conservatively. Two commonly used treatments for plantar fasciitis are customized functional foot orthoses and corticosteroid injections. While common to clinical practice, the evidence base underpinning these treatment strategies is unknown. Therefore, the aim of this systematic review was to assess the effectiveness and safety of customized functional foot orthoses and corticosteroid injections in the treatment of plantar fasciitis. Methods: A systematic literature search was conducted. Experimental studies, in English, from 1998 to 2010 were accepted for inclusion in this review. The PEDro quality assessment tool and the National Health and Medical Research Council’s hierarchy of evidence were used to assess the quality of the included studies. Results: Six randomized controlled trials which met the selection criteria were included in this review. Four reported on customized functional foot orthoses and 2 on corticosteroid injections. Current best available evidence highlights that both customized functional foot orthoses and corticosteroid injections can lead to a decrease in pain associated with plantar fasciitis. Additionally, customized functional foot orthoses may also provide an additional benefit in terms of increased functional ability in patients with plantar fasciitis. Corticosteroid injections may have side effects, especially pain (from the injection). Conclusion: Both customized functional foot orthoses and corticosteroid injections can lead to reduction in pain associated with plantar fasciitis. While customized functional foot orthoses may increase the functional outcomes in patients with plantar fasciitis, corticosteroid injections may have side effects (especially pain as a result of the injection), which may limit its acceptability.

Non-surgical management of a pediatric "intoed" gait pattern - a systematic review of the current best evidence.

Background An intoed gait pattern is one of the most common referrals for children to an orthopedic consultation. Parental concern as to the aesthetics of the child’s gait pattern and/or its symptomatic nature will primarily drive these referrals during a child’s early developmental years. Whilst some of these referrals prove to be the result of a normal growth variant, some children will present with a symptomatic intoed gait pattern. Various treatments, both conservative and surgical, have been proposed including: braces, wedges, stretches and exercises, shoe modifications, and surgical procedures. However, which treatments are effective and justified in the management of this condition is not clear within the literature. The aim of this systematic review was to therefore identify and critique the best available evidence for the non-surgical management of an intoed gait pattern in a pediatric population. Method A systematic review was conducted of which only experimental studies investigating a management option for an intoeing gait pattern were included. Studies needed to be written in English, pertaining to a human pediatric population, and published within a peer reviewed journal. Electronic databases were searched: Ovid (Medline), EMBASE, AMED, PubMed, SportDiscus, CINAHL, and Cochrane Library. The National Health and Medical Research Council’s designation of levels of hierarchy and the Critical Appraisal Skills Programme cohort studies critical appraisal tool were used. Results Five level IV studies were found. The studies were of varied quality and with mixed results. Gait plates, physiologic/standardized shoes, and orthotic devices (with gate plate extension) were shown to produce a statistically significant improvement to an intoed gait pattern. Shoe wedges, torqheels, and a leather counter splint were not able to reduce an intoed gait pattern. Conclusion There is limited evidence to inform the non-surgical management of a pediatric intoed gait pattern. The body of evidence that does exist is small (n = 5) and of varied quality, which means recommendations arising from this evidence base should be interpreted with caution. There is generally weak evidence that suggests that gait plates and orthotic devices with a gait plate extension may assist in the management of a pediatric intoed gait pattern.

The typically developing paediatric foot: how flat should it be? A systematic review

BackgroundAll typically developing children are born with flexible flat feet, progressively developing a medial longitudinal arch during the first decade of their lives. Whilst the child’s foot is expected to be flat, there is currently no consensus as to how flat this foot should be. Furthermore, whilst feet are observed to decrease in flatness with increasing age, it is not known how flat they should be at each age increment. The objective of this systematic review is to define the postural characteristics of the ‘typically’ developing paediatric foot.MethodsThe PRISMA protocol was applied to compare all data currently published describing the typical development of the paediatric foot. The Epidemiological Appraisal Instrument (EAI) was used to assess the risk of bias of the included studies.ResultsThirty four epidemiological papers pertaining to the development of the paediatric foot were graphically compared. Sixteen different foot posture assessments were identified of which footprint based measures were the most reported outcome.ConclusionFirstly, the use of the term normal in relation to foot posture is misleading in the categorisation of the paediatric foot, as indeed a flat foot posture is a normal finding at specific ages. Secondly, the foot posture of the developing child is indeed age dependent and has been shown to change over time. Thirdly, no firm conclusion could be reached as to which age the foot posture of children ceases to develop further, as no two foot measures are comparable, therefore future research needs to consider the development of consensus recommendations as to the measurement of the paediatric foot, using valid and reliable assessment tools.

The effect of footwear and foot orthoses on transverse plane knee motion during running – A pilot study

OBJECTIVES This study aimed to determine the immediate effects of footwear and foot orthoses on transverse plane rotation of the knee joint during the stance phase of jogging gait. DESIGN An experimental, within subjects, repeated measures design. METHODS Three-dimensional knee kinematics were estimated in the transverse plane by surface-mounted markers as 14 asymptomatic participants ran in four randomised conditions; neutral shoe, neutral shoe with customised orthoses, neutral shoe with prefabricated orthoses, and a stability shoe. Peak internal/external rotation joint angles and ranges of motion (ROM) during loading response, midstance and propulsion were determined. Immediate subjective comfort was also recorded for each condition using a 100 mm visual analogue scale. RESULTS Significant main effects of condition were observed for all outcomes except transverse plane knee ROM during loading response (p < 0.05). All significant differences occurred between the stability shoe and another condition, with less knee internal rotation in the stability shoe (mean differences ranged between 1.7° and 6.1°) (p < 0.05). The neutral shoe with prefabricated orthoses was reported as more uncomfortable than all other testing conditions. CONCLUSIONS The stability shoe reduced peak knee internal rotation throughout stance phase of jogging more than any other condition. Importantly, it was subjectively as comfortable as the other conditions. These results identify the ability for footwear alone to induce immediate proximal kinematic effects. The use of the kinematic theory behind foot orthoses therapy is also questioned.

When, why and how foot orthoses (FOs) should be prescribed for children with flexible pes planus: a Delphi survey of podiatrists

Background Flexible pes planus (flat feet) in children is a common reason parents and caregivers seek health professionals consult and a frequent reason podiatrists prescribe foot orthoses. Yet no universal agreement exists on the diagnosis of this condition, or when and how foot orthoses should be prescribed. The aim of this study was to garner consensus and agreement among podiatrists on the use of FOs for paediatric flexible pes planus. Methods A three round Delphi consensus survey was undertaken with 15 podiatry experts from Australia, New Zealand and the United Kingdom. Round One gathered consensus on the diagnosis and intervention into paediatric pes planus with specific questions on types of FOs and prescription variables used. Round Two and Three were based on answers from Round One and gathered agreement (rationale for choices) on a five point Likert scale. 70% of respondents had to agree to a statement for it to be accepted as consensus or agreement. Results Consensus and agreement was achieved for 83 statements directing the diagnosis of pes planus (using FPI-6 and/or rearfoot measures), common signs and symptoms (e.g., pain, fatigue, abnormal gait and other functional concerns) that direct when to intervene into paediatric flexible pes planus. Prefabricated orthoses were the preferred intervention where adequate control is gained with their use. When customised orthoses are prescribed, a vertical [heel] cast pour (71.4%) and minimal arch fill (76.9%) are the prescription variables of choice, plus or minus additional variables (i.e., medial heel (Kirby) skive, the use of a University of California Biomechanical Laboratory device or a medial flange) dependent on level of disorder and plane of excessive motion. Conclusions This study identified consensus and agreement on a series of diagnosis methods and interventions for the paediatric flexible pes planus. A clinical protocol was developed from the resultant consensus statements which provides clinicians with a series of evidenced-informed statements to better guide them on when, how and why FOs are used specific to this population.

The effectiveness of non-surgical intervention (Foot Orthoses) for paediatric flexible pes planus: A systematic review: Update

Background Flexible pes planus (flat feet) in children is a common presenting condition in clinical practice due to concerns amongst parents and caregivers. While Foot Orthoses (FOs) are a popular intervention, their effectiveness remains unclear. Thus, the aim of this systematic review was to update the current evidence base for the effectiveness of FOs for paediatric flexible pes planus. Methods A systematic search of electronic databases (Cochrane, Medline, AMED, EMBASE, CINHAL, SportDiscus, Scopus and PEDro) was conducted from January 2011 to July 2017. Studies of children (0–18 years) diagnosed with flexible pes planus and intervention to be any type of Foot Orthoses (FOs) were included. This review was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. McMaster critical review form for quantitative studies, was used to assess the methodological quality of the included studies. Given the heterogeneity of the included studies, a descriptive synthesis of the included studies was undertaken. Results Out of 606 articles identified, 11 studies (three RCTs; two case-controls; five case-series and one single case study) met the inclusion criteria. A diverse range of pre-fabricated and customised FOs were utilised and effectiveness measured through a plethora of outcomes. Summarised findings from the heterogeneous evidence base indicated that FOs may have a positive impact across a range of outcomes including pain, foot posture, gait, function and structural and kinetic measures. Despite these consistent positive outcomes reported in several studies, the current evidence base lacks clarity and uniformity in terms of diagnostic criteria, interventions delivered and outcomes measured for paediatric flexible pes planus. Conclusion There continues to remain uncertainty on the effectiveness of FOs for paediatric flexible pes planus. Despite a number of methodological limitations, FOs show potential as a treatment method for children with flexible pes planus. PROSPERO registration number CRD42017057310.

Tibiofemoral kinematics: the effect of footwear and foot orthoses during running

Background The knee is the most common site of running related injuries (42.1% of all injuries). Orthoses are thought to manage knee pain by reducing internal tibial rotation as the subtalar joint pronates. However, the influence of the footwear that orthoses are placed in is often ignored. This study aimed to determine the immediate effects of footwear and foot orthoses on transverse plane rotation of the tibiofemoral joint during the stance phase of running.

The relationship between body mass and peak and mean plantar pressure

Background The correlation between foot and ankle pathologies and plantar pressure variables has previously been documented in the literature. One of the premises underlying this correlation is the role of increasing body mass on the magnitude of forces acting upon the foot in locomotion, such as the normal force measurable with plantar pressure equipment. Previously, only a limited number of studies have investigated this relationship in the form of plantar pressure variables such as peak and mean pressure in nonpathological adult populations during walking. This study aimed to investigate the effect of increasing body mass added at known intervals on peak and mean plantar pressure variables in healthy adult subjects during walking.