The Influence of Two Different Types of Foot Orthoses on First Metatarsophalangeal Joint Kinematics During Gait in a Single Subject

Analysis of Static Plantar Pressures in School-Age Children with and without Functional Hallux Limitus: A Case-Control Study

BACKGROUND

The presence of hallux limitus in adulthood is frequently encountered in clinical practice, generating other biomechanical, structural, and functional compensations in dynamics secondary to blockage of the main pivot in the sagittal plane, the first metatarsophalangeal joint. In addition, the presence of functional hallux limitus (FHL) in school-age children is also increasing. Currently, there is a lack of scientific literature about this condition in the pediatric population, and early diagnosis is necessary to reduce future biomechanical disorders and avoid the development of foot arthritis. The purpose of this research was to identify static plantar pressures in school-age children with and without hallux limitus.

METHODS

A total sample of 106 children aged between six and twelve years old was divided into two groups: the case group (53 subjects with functional hallux limitus) and the control group (53 subjects without functional hallux limitus). Data were acquired with the participants in a standing barefoot position on the pressure platform, and the hallux limitus functional test was performed in a sitting position to classify the individuals into the determined study group. The variables analyzed in the research were: plantar pressure, bilateral forefoot and rearfoot surface area, bilateral forefoot and rearfoot ground reaction forces, bilateral forefoot and rearfoot distribution of body weight, total left and right surface area, maximum pressure of the left foot and right foot, medium pressure of the left foot and right foot, ground reaction forces of the left foot and right foot, and the weight of each foot.

RESULTS

Age was the only descriptive quantitative variable that showed a significant difference between the two study groups, with a p-value of 0.031. No statistically significant differences were found between groups in the bilateral forefoot and rearfoot surface area, ground reaction forces, distribution of body weight, or maximum and medium plantar pressure in the left and right foot.

CONCLUSIONS

Changes in the location of the maximum pressure were observed, particularly in older participants with FHL, but these results were not significant. The findings of this study did not show significant differences between the static plantar pressures of school-age individuals with and without functional hallux limitus.

The Impact of Foot Orthoses and Exercises on Pain and Navicular Drop for Adult Flatfoot: A Network Meta-Analysis

Background: Adult flatfoot leads to injury and decreased quality of life. The most widely applied noninvasive approaches are wearing foot orthoses or exercising. Both interventions raise controversy about reducing pain and neutralizing foot posture. This study investigated the impact of foot orthoses and exercise on pain and navicular drop (present for foot posture). Methods: Four databases were used: MEDLINE, PubMed, Web of Science, and Cochrane, from the earliest records to November 2020. Randomized controlled studies focused on adult flatfoot that evaluated the effect of exercise and foot orthoses on pain and navicular drop were extracted. We used data analysis to estimate the relative effect of heterogeneity using I² and publication bias using funnel plots. Results: Ten studies were identified through to November 2020. Active interventions (AIs) were exercise and exercise combined with foot orthoses; passive interventions (PIs) were foot orthoses and added stretching. Both AIs and PIs decreased pain significantly (SMD −0.94, 95% CI −1.35, −0.54 and SMD −1.4, 95% CI −1.87, −0.92). The AIs reduced pain level better than PIs. Controversially, no treatment was found to affect navicular drop. Conclusion: Both exercise and foot orthoses can reduce pain but not realign foot posture. Exercise alone or combined with foot orthoses showed a better effect on adult flatfoot than only wearing foot orthoses. Active intervention was shown to have better efficacy in reducing pain than passive intervention.

Hypermobility of the First Ray: the Cinderella of the measurements conventionally assessed for correction of Hallux Valgus

Background and aim of the work:

hypermobility of the first ray (FRH) began to be considered as a pathological entity from Morton’s studies and was associated as a primary cause of hallux valgus (HV). Currently, this relationship is in discussion, and various authors consider FRH as a consequence of the deformity. The purpose of this narrative review is to summarise the most influential publications relating to First Ray Mobility (FRM) to increase knowledge and promote its conventional assessment during clinical practice.

Methods:

papers of the last century were selected to obtain a homogeneous and up-to-date overview of I-MTCJ mobility and HV, as well as their relationship and management.

Results:

in recent years, FRH was studied from a biomechanical and pathophysiologic point of view. There is still not enough data regarding the aetiology of FRM. The higher rate of instability found in HV lacks an explanation of which is the cause and which is the effect. However, the Lapidus arthrodesis is still a valid method in cases of FRH and HV, even if is not rigorously indicated to treat both. When approaching FRH, radiographic or clinical findings are mandatory for the right diagnosis.

Conclusions:

FRM is an important factor that must be considered in routine clinical practice and prior and post HV surgery, as much as the conventional parameters assessed. Surgeons should consider performing I-MTCJ arthrodesis only if strictly necessary, also paying attention to soft tissue balancing. Improving the measurement of FRH could be useful to determine if it is a cause or effect of the HV deformity. (www.actabiomedica.it)

Measurement of Dorsal First Ray Mobility: A Topical Historical Review and Commentary

Despite evidence that instability of the first ray (first metatarsal and medial cuneiform) alters the loading mechanics of the foot, surprisingly few studies have linked the condition with disorders of the foot. A factor limiting this research is the difficulty associated with measuring first ray mobility (FRM). To quantify dorsal FRM, clinicians and researchers have devised a variety of methods that impose a dorsally directed load, and record displacement. The methods include manual examination, radiographs, mechanical devices, and handheld rulers. Since different methods yield different results; each of these methods is worthy of scrutiny. This article reviews the methods used to quantify dorsal FRM and offers commentary on how the testing procedures could be standardized. The measurement of dorsal FRM informs surgical decisions, orthotic prescriptions, and research design strategies mostly as it pertains to the identification and treatment of first ray hypermobility. This review found sufficient support to recommend continued use of radiographs and mechanical devices for quantifying dorsal displacement, whereas measurements acquired with handheld rulers are prone to the same subjective error attributed to manual examination procedures. Since measures made with radiographs and existing mechanical devices have their own drawbacks, the commentary recommends ideas for standardizing the testing procedure and calls for the development of a next-generation device to measure dorsal FRM. This future device could be modeled after arthrometers that exist and are used to quantify stability at the knee and ankle. Level of Evidence: Level V, expert opinion.

Effectiveness of Foot Orthoses Versus Rocker-Sole Footwear for First Metatarsophalangeal Joint Osteoarthritis: Randomized Trial

Objective

To compare the effectiveness of prefabricated foot orthoses to rocker‐sole footwear in reducing foot pain in people with first metatarsophalangeal (MTP) joint osteoarthritis (OA).

Methods

Participants (n = 102) with first MTP joint OA were randomly allocated to receive individualized, prefabricated foot orthoses or rocker‐sole footwear. The primary outcome measure was the pain subscale on the Foot Health Status Questionnaire (FHSQ) at 12 weeks. Secondary outcome measures included the function, footwear, and general foot health subscales of the FHSQ; the Foot Function Index; severity of pain and stiffness at the first MTP joint; perception of global improvement; general health status; use of rescue medication and co‐interventions to relieve pain; physical activity; and the frequency of self‐reported adverse events.

Results

The FHSQ pain subscale scores improved in both groups, but no statistically significant difference between the groups was observed (adjusted mean difference 2.05 points, 95% confidence interval [95% CI] −3.61, 7.71; P = 0.477). However, the footwear group exhibited lower adherence (mean ± SD total hours worn 287 ± 193 versus 448 ± 234; P < 0.001), were less likely to report global improvement in symptoms (39% versus 62%; relative risk [RR] 0.63, 95% CI 0.41, 0.99; P = 0.043), and were more likely to experience adverse events (39% versus 16%; RR 2.47, 95% CI 1.12, 5.44; P = 0.024) compared to the orthoses group.

Conclusion

Prefabricated foot orthoses and rocker‐sole footwear are similarly effective at reducing foot pain in people with first MTP joint OA. However, prefabricated foot orthoses may be the intervention of choice due to greater adherence and fewer associated adverse events.

Biomechanical Effects of Prefabricated Foot Orthoses and Rocker-Sole Footwear in Individuals With First Metatarsophalangeal Joint Osteoarthritis

Objective

To evaluate the effects of prefabricated foot orthoses and rocker‐sole footwear on spatiotemporal parameters, hip and knee kinematics, and plantar pressures in people with first metatarsophalangeal (MTP) joint osteoarthritis (OA). Methods. A total of 102 people with first MTP joint OA were randomly allocated to receive prefabricated foot orthoses or rocker‐sole footwear. The immediate biomechanical effects of the interventions (compared to usual footwear) were examined using a wearable sensor motion analysis system and an in‐shoe plantar pressure measurement system.

Results

Spatiotemporal/kinematic and plantar pressure data were available from 88 and 87 participants, respectively. The orthoses had minimal effect on spatiotemporal or kinematic parameters, while the rocker‐sole footwear resulted in reduced cadence, percentage of the gait cycle spent in stance phase, and sagittal plane hip range of motion. The orthoses increased peak pressure under the midfoot and lesser toes. Both interventions significantly reduced peak pressure under the first MTP joint, and the rocker‐sole shoes also reduced peak pressure under the second through fifth MTP joints and heel. When the effects of the orthoses and rocker‐sole shoes were directly compared, there was no difference in peak pressure under the hallux, first MTP joint, or heel; however, the rocker‐sole shoes exhibited lower peak pressure under the lesser toes, second through fifth MTP joints, and midfoot.

Conclusion

Prefabricated foot orthoses and rocker‐sole footwear are effective at reducing peak pressure under the first MTP joint in people with first MTP joint OA, but achieve this through different mechanisms. Further research is required to determine whether these biomechanical changes result in improvements in symptoms.

Clinical improvement in functional hallux limitus using a cut-out orthosis

BACKGROUND

Functional hallux limitus (FHL) has been implicated in the development of metatarsophalangeal joint osteoarthritis.

OBJECTIVES

To determine whether cut-out orthosis treatment increases plantarflexion of the first metatarsal by increasing its declination angle.

STUDY DESIGN

Cross-sectional study.

METHODS

A total of 46 female volunteers with an average age of 25.66 ± 5.70 years (range: 19-42 years) and FHL participated in the study. We assessed the degrees of movement of the first metatarsal and proximal phalanx bones at the first metatarsophalangeal joint without and while wearing the cut-out orthosis using the 3Space Fastrak® via sensors.

RESULTS

The movement of the plantarflexión declination angle of the first metatarsal bone was higher using the orthosis 29.84° ± 5.98° versus without orthosis 27.69° ± 5.91° (p < 0.031°). Use of sandals may have minimized the magnitude of movement changes associated with orthosis versus non-orthosis use.

CONCLUSION

The cut-out orthosis demonstrated a beneficial effect on non-fixed first metatarsophalangeal and metatarsal cuneiform joints affected by FHL, significantly increasing the declination of the metatarsal angle. Furthermore, use of the cut-out orthosis significantly reduced adduction movement of the first metatarsal bone in the transverse plane.

CLINICAL RELEVANCE

The cut-out orthosis demonstrated a beneficial effect on non-fixed first metatarsophalangeal and metatarsal cuneiform joints affected by FHL, significantly increasing the declination of the metatarsal angle. Furthermore, use of the cut-out orthosis significantly reduced adduction movement of the first metatarsal bone in the transverse plane.

Biomechanical comparison of first metatarsophalangeal joint arthrodeses using triple-threaded headless screws versus partially threaded lag screws

BACKGROUND

Triple-threaded, cannulated headless screws of varying thread diameters and pitch are designed to maintain thread length across the arthrodesis plane, provide joint compression, and reduce countersinking. This study tested the biomechanical fixation strength of conventional partially threaded lag screws compared to triple-threaded headless screws in first metatarsophalangeal joint arthrodesis.

METHODS

First metatarsophalangeal joint arthrodesis using a crossed screw technique was performed on 11 paired, preserved cadaver first rays with two 4.0-mm triple-threaded, cannulated headless screws or two 4.0-mm partially threaded, cannulated lag screws. The constructs were tested to failure through dorsally directed cantilever bending.

RESULTS

The triple-threaded, cannulated headless screws displayed significantly greater bending stiffness (p=0.017) and failure load (p=0.040) during load-to-failure testing compared to the partially threaded, cannulated lag screws.

CONCLUSIONS

Triple-threaded, cannulated headless screws may be a viable alternative to partially threaded lag screws in first metatarsophalangeal arthrodesis.

How effective is orthotic treatment in patients with recurrent diabetic foot ulcers?

BACKGROUND

We assessed the efficacy of customized foot orthotic therapy by comparing reulceration rates, minor amputation rates, and work and daily living activities before and after therapy. Peak plantar pressures and peak plantar impulses were compared with the patients not wearing and wearing their prescribed footwear.

METHODS

One hundred seventeen patients with diabetes were prescribed therapeutic insoles and footwear based on the results of a detailed biomechanical study and were followed for 2 years. All of the patients had a history of foot ulcers, but none had undergone previous orthotic therapy.

RESULTS

Before treatment, the reulceration rate was 79% and the amputation rate was 54%. Two years after the start of orthotic therapy, the reulceration rate was 15% and the amputation rate was 6%. Orthotic therapy reduced peak plantar pressures in patients with reulcerations and in those without (P < .05), although a significant decrease in peak plantar impulses was achieved only in patients not experiencing reulceration. Sick leave was reduced from 100% to 26%.

CONCLUSIONS

Personalized orthotic therapy targeted at reducing plantar pressures by off-loading protects high-risk patients against reulceration. Treatment reduced the reulceration rate and peak plantar pressures, leading to patients' return to work or other activities.

Rocker-sole footwear versus prefabricated foot orthoses for the treatment of pain associated with first metatarsophalangeal joint osteoarthritis: study protocol for a randomised trial

BACKGROUND

Osteoarthritis affecting the first metatarsophalangeal joint of the foot is a common condition which results in pain, stiffness and impaired ambulation. Footwear modifications and foot orthoses are widely used in clinical practice to treat this condition, but their effectiveness has not been rigorously evaluated. This article describes the design of a randomised trial comparing the effectiveness of rocker-sole footwear and individualised prefabricated foot orthoses in reducing pain associated with first metatarsophalangeal joint osteoarthritis.

METHODS

Eighty people with first metatarsophalangeal joint osteoarthritis will be randomly allocated to receive either a pair of rocker-sole shoes (MBT® Matwa, Masai Barefoot Technology, Switzerland) or a pair of individualised, prefabricated foot orthoses (Vasyli Customs, Vasyli Medical™, Queensland, Australia). At baseline, the biomechanical effects of the interventions will be examined using a wireless wearable sensor motion analysis system (LEGSys™, BioSensics, Boston, MA, USA) and an in-shoe plantar pressure system (Pedar®, Novel GmbH, Munich, Germany). The primary outcome measure will be the pain subscale of the Foot Health Status Questionnaire (FHSQ), measured at baseline and 4, 8 and 12 weeks. Secondary outcome measures will include the function, footwear and general foot health subscales of the FHSQ, severity of pain and stiffness at the first metatarsophalangeal joint (measured using 100 mm visual analog scales), global change in symptoms (using a 15-point Likert scale), health status (using the Short-Form-12® Version 2.0 questionnaire), use of rescue medication and co-interventions to relieve pain, the frequency and type of self-reported adverse events and physical activity levels (using the Incidental and Planned Activity Questionnaire). Data will be analysed using the intention to treat principle.

DISCUSSION

This study is the first randomised trial to compare the effectiveness of rocker-sole footwear and individualised prefabricated foot orthoses in reducing pain associated with osteoarthritis of the first metatarsophalangeal joint, and only the third randomised trial ever conducted for this condition. The study has been pragmatically designed to ensure that the findings can be implemented into clinical practice if the interventions are found to be effective, and the baseline biomechanical analysis will provide useful insights into their mechanism of action.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12613001245785.

A case-series study to explore the efficacy of foot orthoses in treating first metatarsophalangeal joint pain

Background

First metatarsophalangeal (MTP) joint pain is a common foot complaint which is often considered to be a consequence of altered mechanics. Foot orthoses are often prescribed to reduce 1^st MTP joint pain with the aim of altering dorsiflexion at propulsion. This study explores changes in 1^st MTP joint pain and kinematics following the use of foot orthoses.

Methods

The effect of modified, pre-fabricated foot orthoses (X-line^®) were evaluated in thirty-two patients with 1^st MTP joint pain of mechanical origin. The primary outcome was pain measured at baseline and 24 weeks using the pain subscale of the foot function index (FFI). In a small sub-group of patients (n = 9), the relationship between pain and kinematic variables was explored with and without their orthoses, using an electromagnetic motion tracking (EMT) system.

Results

A significant reduction in pain was observed between baseline (median = 48 mm) and the 24 week endpoint (median = 14.50 mm, z = -4.88, p < 0.001). In the sub-group analysis, we found no relationship between pain reduction and 1^st MTP joint motion, and no significant differences were found between the 1^st MTP joint maximum dorsiflexion or ankle/subtalar complex maximum eversion, with and without the orthoses.

Conclusions

This observational study demonstrated a significant decrease in 1^st MTP joint pain associated with the use of foot orthoses. Change in pain was not shown to be associated with 1^st MTP joint dorsiflexion nor with altered ankle/subtalar complex eversion. Further research into the effect of foot orthoses on foot function is indicated.

Dynamic kinematic and plantar pressure changes following cheilectomy for hallux rigidus: a mid-term followup

BACKGROUND

Hallux rigidus leads to significant loss of first metatarsophalangeal (MTP) joint motion. Cheilectomy surgery aims to increase motion, decrease pain, and facilitate a return to activity. Limited data exist regarding restoration of dynamic kinematics and loading responses following cheilectomy. This prospective study assessed three-dimensional in vivo first MTP joint kinematics and loading characteristics following cheilectomy.

MATERIALS AND METHODS

Twenty patients were evaluated prior to undergoing cheilectomy for hallux rigidus. Fifteen subjects returned for mid-term followup at 1.7 years. Eleven subjects were surveyed at 6 years. Plantar pressure data were acquired during barefoot walking. Comparisons of average pressures were determined for 4 different regions of the foot. Pressure differences were compared within, and between symptomatic and asymptomatic feet. First MTP joint dorsiflexion and abduction were assessed during standing, active motion and gait.

RESULTS

Only four out of 15 patients showed increased lateral metatarsal loading preoperatively. Pressures shifted medially following surgery. Significant increases in dorsiflexion were found for active motion (pre-op = 13.3 +/- 12.7 degrees; post-op = 21.7 +/- 14.7 degrees, p = 0.005) and dorsiflexion during gait (pre-op = 19.3 +/- 12 degrees; post-op = 30.8 +/- 14.8 degrees, p = 0.01). Hallux abduction also increased. During standing, the hallux remained in plantarflexion relative to the first metatarsal.

CONCLUSION

Cheilectomy was effective in maintaining balanced plantar loading. First MTP motion increased but dorsiflexion was still less than normative values. The magnitude of dorsiflexion relative to abduction favorably improved during gait. These findings suggest that kinematics continue to be altered and may lead to further degenerative joint changes. Exploration of alternative surgical techniques is warranted.