Thomas G. McPoil

Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: randomised clinical trial

Objective To compare the clinical efficacy of foot orthoses in the management of patellofemoral pain syndrome with flat inserts or physiotherapy, and to investigate the effectiveness of foot orthoses plus physiotherapy. Design Prospective, single blind, randomised clinical trial. Setting Single centre trial within a community setting in Brisbane, Australia. Participants 179 participants (100 women) aged 18 to 40 years, with a clinical diagnosis of patellofemoral pain syndrome of greater than six weeks’ duration, who had no previous treatment with foot orthoses or physiotherapy in the preceding 12 months. Interventions Six weeks of physiotherapist intervention with off the shelf foot orthoses, flat inserts, multimodal physiotherapy (patellofemoral joint mobilisation, patellar taping, quadriceps muscle retraining, and education), or foot orthoses plus physiotherapy. Main outcome measures Global improvement, severity of usual and worst pain over the preceding week, anterior knee pain scale, and functional index questionnaire measured at 6, 12, and 52 weeks. Results Foot orthoses produced improvement beyond that of flat inserts in the short term, notably at six weeks (relative risk reduction 0.66, 99% confidence interval 0.05 to 1.17; NNT 4 (99% confidence interval 2 to 51). No significant differences were found between foot orthoses and physiotherapy, or between physiotherapy and physiotherapy plus orthoses. All groups showed clinically meaningful improvements in primary outcomes over 52 weeks. Conclusion While foot orthoses are superior to flat inserts according to participants’ overall perception, they are similar to physiotherapy and do not improve outcomes when added to physiotherapy in the short term management of patellofemoral pain. Given the long term improvement observed in all treatment groups, general practitioners may seek to hasten recovery by prescribing prefabricated orthoses. Trial registration Australian Clinical Trials Registry ACTRN012605000463673 and ClinicalTrials.gov NCT00118521.

Variability of plantar pressure data. A comparison of the two-step and midgait methods

The number of trials required to obtain a reliable representation of the plantar pressure pattern is an important factor in the assessment of people with insensate feet or the use of plantar pressure data as a basis for fabrication of foot orthoses. Traditionally, the midgait method has been used for the collection of pressure data, but the large number of walking trials required by this method can increase the risk of injury to the plantar surface of the insensate foot. As a result, the two-step method of plantar pressure data collection has been advocated. The purpose of this investigation was to determine the degree of variability in regional plantar pressure measurements using the midgait and two-step methods of data collection. Plantar pressure data were collected from ten volunteers (five men and five women) between the ages of 20 and 35 years in 20 trials using both data-collection protocols. The results of the study indicate that three to five walking trials are needed to obtain reliable regional peak pressure and pressure-time integral values when the two-step data-collection protocol is used. Although either method can be used for pressure data collection, one method should be used consistently when repeated assessments are required.

Heel pain--plantar fasciitis: clinical practice guildelines linked to the international classification of function, disability, and health from the orthopaedic section of the American Physical Therapy Association.

The Heel Pain-Plantar Fasciitis Guidelines link the International Classification of Functioning, Disability, and Health (ICF) body structures (Ligaments and fascia of ankle and foot, and Neural structures of lower leg) and the ICF body functions (Pain in lower limb, and Radiating pain in a segment or region) with the World Health Organizations International Statistical Classification of Diseases and Related Health Problems (ICD) health condition (Plantar fascia fibromatosis/Plantar fasciitis). The purpose of these practice guidelines is to describe evidence-based orthopaedic physical therapy clinical practice and provide recommendations for (1) examination and diagnostic classification based on body functions and body structures, activity limitations, and participation restrictions, (2) prognosis, (3) interventions provided by physical therapists, and (4) assessment of outcome for common musculoskeletal disorders.

Motion of the first metatarsophalangeal joint. Reliability and validity of four measurement techniques.

The purpose of this study was to first determine the intra-rater reliability of four different static measurement procedures used to assess first metatarsophalangeal joint extension range of motion and, second, determine which of the four static procedures provided a valid measure of the amount of first metatarsophalangeal joint extension required for normal walking. Twenty healthy adult subjects between the ages of 21 and 43 years participated in the study. Four static techniques were evaluated and dynamic first metatarsophalangeal joint extension was also determined from video recordings during walking. The results indicate that 1) all static measurement techniques were reliable; 2) the degree of first metatarsophalangeal joint extension obtained for each of the four static measurement techniques exceeded the amount of first metatarsophalangeal joint extension required for walking; 3) although each of the static measurement techniques was reliable, they should not be considered interchangeable; and 4) approximately 65 degrees of first metatarsophalangeal joint extension are required for normal walking.

Comparison of three methods for obtaining plantar pressures in nonpathologic subjects.

The purpose of this study was to determine if pressure data, collected after taking one step or two steps, were similar to values obtained by using the traditional midgait method. Ten healthy subjects, with a mean age of 27 years, walked across a sensor platform sampling at 70 Hz. Each subject was randomly assigned to take one step, two steps, or multiple steps (midgait method) across the sensor platform. The results of the study indicate that the two-step method, in comparison with the one-step method, provides pressure data more representative of the midgait method, and different values for pressure and force will be obtained, depending on the method of pressure data collection selected by the clinician.

Relationship Between Neutral Subtalar Joint Position and Pattern of Rearfoot Motion During Walking

The purpose of this study was to determine the relationship between the angle formed by the rearfoot when the subtalar joint is positioned in neutral and the pattern of rearfoot motion during walking. Each lower extremity for 50 healthy young adult subjects (mean age 25.5 years) was videotaped and the pattern of rearfoot motion was assessed using two-dimensional analysis. The results indicate that the rearfoot is slightly inverted before heel strike and that the average time to maximum pronation occurs at approximately 37.9% of the stance phase duration. Contrary to a previously published theory, the “neutral” position of the rearfoot for the typical pattern of rearfoot motion during the walking cycle was found to be resting standing foot posture rather than subtalar joint neutral position.

Foot Orthoses and Gait: A Systematic Review and Meta-analysis of Literature Pertaining to Potential Mechanisms

This article systematically reviews the available literature to improve our understanding of the physiological basis for orthoses under the kinematic, shock attenuation and neuromotor control paradigms. The propositions made under these three paradigms have not been systematically reviewed collectively, and as such, there is no single-point synthesis of this clinically relevant body of evidence and somewhat disparate findings. Our comprehensive search strategy yielded 22 papers. Under each paradigm, the role of orthoses with different design features including combinations of posting, moulding and density was analysed. Where possible, data have been pooled to provide an increased level of confidence in findings. The main findings in the kinematic paradigm were that posted non-moulded orthoses systematically reduced peak rearfoot eversion (2.12° (95% CI 0.72 to 3.53)) and tibial internal rotation (1.33° (0.12 to 2.53)) in non-injured cohorts. In the shock attenuation paradigm, it was found that non-posted moulded and posted moulded orthoses produced large reductions in loading rate and vertical impact force when compared with a control and to a posted non-moulded orthosis. The neuromotor control paradigm seems to be the least conclusive in its outcome. Based on our review, this paper concludes with rudimentary guidelines for the prescription of orthosis, that sports medicine practitioners may use in their clinical decision-making process. The need for further research focusing on the role of injury, particularly in neuromotor control modification and long-term adaptation to orthoses, was highlighted.

Foot Orthoses in Lower Limb Overuse Conditions: A Systematic Review and Meta-Analysis

There is evidence from the meta-analysis to support the use of foot orthoses in the prevention of the first incidence of lower-limb overuse conditions. The inclusion of orthoses in a treatment program for individuals who already have an overuse condition is difficult to support or refute because of the generally poor research base, which has been highlighted by this systematic review. There is evidence from pooled data that there is no difference between the use of custom and prefabricated foot orthoses, inferring that practitioners may use either in the prevention and treatment of lower-limb overuse injuries. Focal points for future research conducted in this area include longer intervention durations, greater consistency with reliable measures, and better consensus in definitions of foot orthoses.

Reliability of ankle goniometric measurements: a literature review.

This article reviews the existing range-of-motion measurement literature related to ankle dorsiflexion and plantarflexion to determine whether the reliability of ankle range-of-motion measurements can be defined, how the characteristics of the study population or clinician affect reliability, and the level of responsiveness for these measures. A MEDLINE search was performed through February 2004, and 11 articles met the inclusion criteria established for this review. Ample evidence was found for intrarater reliability for ankle dorsiflexion and plantarflexion range of motion. Although some evidence for interrater reliability of dorsiflexion was found, little evidence for interrater reliability of plantarflexion range of motion was uncovered. On the basis of the current literature, the responsiveness of ankle joint range-of-motion measurements is uncertain and requires further studies using patient populations.

Reliability and normative values for the foot mobility magnitude: a composite measure of vertical and medial-lateral mobility of the midfoot

BackgroundA study was conducted to determine the reliability and minimal detectable change for a new composite measure of the vertical and medial-lateral mobility of the midfoot called the foot mobility magnitude.MethodsThree hundred and forty-five healthy participants volunteered to take part in the study. The change in dorsal arch height between weight bearing and non-weight bearing as well as the change in midfoot width between weight bearing and non-weight bearing were measured at 50% of total foot length and used to calculate the foot mobility magnitude. The reliability and minimal detectable change for the measurements were then determined based on the assessment of the measurements by three raters with different levels of clinical experience.ResultsThe change in dorsal arch height between weight bearing and non-weight bearing, midfoot width between weight bearing and non-weight bearing, and the foot mobility magnitude were shown to have high levels of intra-rater and inter-rater reliability. Normative data are provided for the left and right feet of both the female (n = 211) and male (n = 134) subjects.ConclusionWhile the measurements of navicular drop and drift have been used as a clinical method to assess both the vertical and medial-lateral mobility of the midfoot, poor to fair levels of inter-rater reliability have been reported. The results of the current study suggest that the foot mobility magnitude provides the clinician and researcher with a highly reliable measure of vertical and medial-lateral midfoot mobility.