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First metatarsophalangeal joint (MTP) joint osteoarthritis (OA) is prevalent, although the pathology of this condition is poorly understood. This study aimed to determine if there were differences in magnetic resonance imaging (MRI) characteristics of the first MTP joint between individuals with and without first MTP joint OA. This cross-sectional study compared 22 participants with first MTP joint OA to 22 control participants without first MTP joint OA (matched for age, sex, and body mass index). Participants underwent MRI of their first MTP joint and osteophytes, bone marrow lesions, subchondral cysts, effusion-synovitis, joint space narrowing, and cartilage loss were documented using an atlas of first MTP joint OA. Associations of MRI characteristics with the presence of first MTP joint OA were then determined. The presence of first MTP joint OA was associated with increased severity of osteophytes (dorsal metatarsal head, plantar metatarsal head, and dorsal proximal phalanx), bone marrow lesions (metatarsal head and proximal phalanx), cysts of the metatarsal head, effusion-synovitis (dorsal aspect), joint space narrowing (metatarsal-proximal phalanx; metatarsal-sesamoids), and cartilage loss. In contrast, there were no statistically significant associations for bone marrow lesions of the sesamoids, cysts of the proximal phalanx, or effusion-synovitis (plantar aspect). Osteophytes, bone marrow lesions, subchondral cysts, effusion-synovitis, joint space narrowing, and cartilage loss are characteristic MRI features of first MTP joint OA. First MTP joint OA is a disease of multiple joint tissues and this has implications for the assessment and management of this condition.

Objective To describe the management of hallux valgus by general practitioners (GPs) in Australia. Methods We analyzed data from the Bettering the Evaluation and Care of Health program from April 2000 to March 2016. Patient and GP encounter characteristics were extracted. Hallux valgus encounters were identified using the International Classification of Primary Care, Version 2 Plus terms hallux valgus and bunion. Data were summarized using descriptive statistics and 95% confidence intervals around point estimates. Results The data set included 1,568,100 patient-encounter records among which hallux valgus was managed 658 times (4.2 management occasions per 10,000 encounters). This management rate extrapolates to an estimated 60,000 GP-patient encounters across Australia in the most recent year data were available (from 2015 to 2016). The management rate was 3 times higher in female compared to male patients and was most frequent among patients ages 45-64 years. Hallux valgus was most frequently managed by referral to orthopedic surgeons (28 per 100 management occasions), counseling or advice (25 per 100), and referral to podiatrists (16 per 100). Pharmacologic management was also frequently used (20 per 100) and primarily involved prescription of nonsteroidal antiinflammatory drugs (7 per 100). Conclusion Hallux valgus is a commonly encountered problem in Australian general practice and is mostly managed by provision of advice and referral to orthopedic surgeons and podiatrists. Further research is required to examine the factors that influence the selection of surgical and nonsurgical treatment pathways by GPs and their comparative effectiveness.

Objective(s)To compare the efficacy of in-shoe heel lifts to calf muscle eccentric exercise in reducing pain and improving function in mid-portion Achilles tendinopathy.MethodsThis was a parallel-group randomised superiority trial at a single centre (La Trobe University Health Sciences Clinic, Discipline of Podiatry, Melbourne, Victoria, Australia). One hundred participants (52 women and 48 men, mean age 45.9, SD 9.4 years) with clinically diagnosed and ultrasonographically confirmed mid-portion Achilles tendinopathy were randomly allocated to either a (1) heel lifts (n=50) or (2) eccentric exercise (n=50) group. The primary outcome measure was the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire at 12 weeks. Differences between groups were analysed using intention to treat with analysis of covariance.ResultsThere was 80% follow-up of participants (n=40 per group) at 12 weeks. The mean VISA-A score improved by 26.0 points (95% CI 19.6 to 32.4) in the heel lifts group and by 17.4 points (95% CI 9.5 to 25.3) in the eccentric exercise group. On average, there was a between-group difference in favour of the heel lifts for the VISA-A (adjusted mean difference 9.6, 95% CI 1.8 to 17.4, p=0.016), which approximated, but did not meet our predetermined minimum important difference of 10 points.ConclusionIn adults with mid-portion Achilles tendinopathy, heel lifts were more effective than calf muscle eccentric exercise in reducing pain and improving function at 12 weeks. However, there is uncertainty in the estimate of effect for this outcome and patients may not experience a clinically worthwhile difference between interventions.Trial registration numberACTRN12617001225303.

Background Osteoarthritis of the first metatarsophalangeal joint (1st MTP joint OA) is a common and disabling condition that results in pain and limited joint range of motion. There is inconsistent evidence regarding the relationship between clinical measurement of 1st MTP joint maximum dorsiflexion and dynamic function of the joint during level walking. Therefore, the aim of this study was to examine the association between passive non-weightbearing (NWB) 1st MTP joint maximum dorsiflexion and sagittal plane kinematics in individuals with radiographically confirmed 1st MTP joint OA. Methods Forty-eight individuals with radiographically confirmed 1st MTP joint OA (24 males and 24 females; mean age 57.8 years, standard deviation 10.5) underwent clinical measurement of passive NWB 1st MTP joint maximum dorsiflexion and gait analysis during level walking using a 10-camera infrared Vicon motion analysis system. Sagittal plane kinematics of the 1st MTP, ankle, knee, and hip joints were calculated. Associations between passive NWB 1st MTP joint maximum dorsiflexion and kinematic variables were explored using Pearson’s r correlation coefficients. Results Passive NWB 1st MTP joint maximum dorsiflexion was significantly associated with maximum 1st MTPJ dorsiflexion (r = 0.486, p r = 0.383, p = 0.007), and ankle joint excursion (r = 0.399, p = 0.005) during gait. There were no significant associations between passive NWB 1st MTP joint maximum dorsiflexion and sagittal plane kinematics of the knee or hip joints. Conclusions These findings suggest that clinical measurement of 1st MTP joint maximum dorsiflexion provides useful insights into the dynamic function of the foot and ankle during the propulsive phase of gait in this population.

Foot posture and ankle joint dorsiflexion have long been proposed to be risk factors for plantar heel pain, however body mass may be a confounder when investigating these factors. The aim of this study was to determine if clinical measures of foot posture and ankle joint dorsiflexion differ in adults with and without plantar heel pain after accounting for body mass. This was a cross-sectional observational study that compared 50 participants with plantar heel pain to 25 control participants without plantar heel pain who were matched for age, sex and body mass index. Foot posture was assessed using the Foot Posture Index and the Arch Index. Ankle joint dorsiflexion was assessed with a weightbearing lunge test with the knee extended and with the knee flexed. No significant differences (P

Background Plantar calcaneal spurs are common, however their pathophysiology is poorly understood. This study aimed to evaluate the prevalence and correlates of plantar calcaneal spurs in a large sample of older people. Methods Weightbearing lateral foot radiographs of 216 people (140 women and 76 men) aged 62 to 94 years (mean age 75.9, SD 6.6) were examined for plantar calcaneal and Achilles tendon spurs. Associations between the presence of spurs and sex, body mass index, radiographic measures of foot posture, self-reported co-morbidities and current or previous heel pain were then explored. Results Of the 216 participants, 119 (55%) had at least one plantar calcaneal spur and 103 (48%) had at least one Achilles tendon spur. Those with plantar calcaneal spurs were more likely to have Achilles tendon spurs (odds ratio [OR] = 2.0, 95% confidence interval [CI] 1.2 to 3.5). Prevalence of spurs did not differ according to sex. Participants with plantar calcaneal spurs were more likely to be obese (OR = 7.9, 95% CI 3.6 to 17.0), report osteoarthritis (OR = 2.6, 95% CI 1.6 to 4.8) and have current or previous heel pain (OR = 4.6, 95% CI 2.3 to 9.4). No relationship was found between the presence of calcaneal spurs and radiographic measures of foot posture. Conclusion Calcaneal spurs are common in older men and women and are related to obesity, osteoarthritis and current or previous heel pain, but are unrelated to radiographic measurements of foot posture. These findings support the theory that plantar calcaneal spurs may be an adaptive response to vertical compression of the heel rather than longitudinal traction at the calcaneal enthesis.

Background Corticosteroid injection is frequently used for plantar heel pain (plantar fasciitis), although there is limited high-quality evidence to support this treatment. Therefore, this study reviewed randomised trials to estimate the effectiveness of corticosteroid injection for plantar heel pain. Methods A systematic review and meta-analysis of randomised trials that compared corticosteroid injection to any comparator. Primary outcomes were pain and function, categorised as short (0 to 6 weeks), medium (7 to 12 weeks) or longer term (13 to 52 weeks). Results A total of 47 trials (2989 participants) were included. For reducing pain in the short term, corticosteroid injection was more effective than autologous blood injection (SMD -0.56; 95% CI, − 0.86 to − 0.26) and foot orthoses (SMD -0.91; 95% CI, − 1.69 to − 0.13). There were no significant findings in the medium term. In the longer term, corticosteroid injection was less effective than dry needling (SMD 1.45; 95% CI, 0.70 to 2.19) and platelet-rich plasma injection (SMD 0.61; 95% CI, 0.16 to 1.06). Notably, corticosteroid injection was found to have similar effectiveness to placebo injection for reducing pain in the short (SMD -0.98; 95% CI, − 2.06, 0.11) and medium terms (SMD -0.86; 95% CI, − 1.90 to 0.19). For improving function, corticosteroid injection was more effective than physical therapy in the short term (SMD -0.69; 95% CI, − 1.31 to − 0.07). When trials considered to have high risk of bias were excluded, there were no significant findings. Conclusions Based on the findings of this review, corticosteroid injection is more effective than some comparators for the reduction of pain and the improvement of function in people with plantar heel pain. However, corticosteroid injection is not more effective than placebo injection for reducing pain or improving function. Further trials that are of low risk of bias will strengthen this evidence. Registration PROSPERO registration number CRD42016053216. Electronic supplementary material The online version of this article (10.1186/s12891-019-2749-z) contains supplementary material, which is available to authorized users.

Background Studies have described general practitioner (GP) management of plantar heel pain from some countries; however, there is limited information from Australian general practice. Objectives To describe patient and GP characteristics, and management actions for plantar heel pain in Australian general practice. Design Secondary analysis of data from the Bettering the Evaluation and Care of Health (BEACH) dataset. Methods Data were summarised using descriptive analysis and robust 95% confidence intervals (CIs) were calculated around point estimates. Multivariate logistic regression identified predictors of plantar heel pain management. Results From 1,568,100 encounters between April 2000 and March 2016, plantar heel pain was managed at 3007 encounters. GPs manage plantar heel pain approximately once every 500 encounters, which extrapolates to 271,100 encounters in 2015-2016. Patient factors independently associated with plantar heel pain encounters included female sex (OR 1.27, 95% CI 1.17-1.34 cf. males), being aged 45-64 (OR 3.44, 95% CI 2.94-4.01 cf. aged 75+) and patients from a non-English speaking background (OR 1.22, 95% CI 1.07-1.39). Plantar heel pain was frequently managed using medication (45.1 per 100), with non-steroidal anti-inflammatory drugs the most common (22.8 per 100). GPs also commonly provided counselling/advice/education (32.4 per 100), and referrals for diagnostic imaging (19.1 per 100) and to podiatrists (12.0 per 100). Conclusions Plantar heel pain is a frequently managed foot condition in Australian general practice. GPs use medication, counselling and education, diagnostic imaging and referral to podiatrists for management. Further research is required to understand the drivers of these management actions and whether they are effective.

This study compared the differences in foot dimensions between children with and without Down syndrome using three-dimensional (3D) foot scans.51 children with and 51 children without Down syndrome had a 3D scan taken of their right foot to compare the absolute and normalised (for height or foot length) measurements.Normalised foot length was shorter in children with Down syndrome (MD -11.62 mm, 95% CI -15.06 to -8.18,Children with Down syndrome have shorter, wider feet with greater girth and fifthtoe height measurements relative to children without Down syndrome. These findings have implications for footwear fit and the manufacturing of population-specific footwear.IMPLICATIONS FOR REHABILITATIONFootwear-fitting issues arise as a result of the unique foot shape of children with Down syndrome.There are substantial variations in the foot shape of children with and without Down syndrome.Children with Down syndrome require wider, deeper footwear at a given length to accommodate their foot dimensions.These findings have implications for the manufacturing of population-specific footwear.

Background Offloading plantar pressure is a key strategy for the prevention or healing of neuropathic plantar ulcers in diabetes. Non-removable walking casts, such as total contact casts, are currently considered the gold-standard for offloading this type of wound. However, alternative methods for offloading that are more cost effective and easier to use are continually being sought. The aim of this study was to evaluate the capacity of the DH Pressure Relief Shoe™ to offload high pressure areas under the neuropathic foot in diabetes. Methods A within-subjects, repeated measures design was used. Sixteen participants with diabetic peripheral neuropathy were recruited and three footwear conditions were evaluated in a randomised order: a canvas shoe (the control), the participants’ own standard shoe, and the DH Pressure Relief Shoe™. The primary outcome was peak plantar pressure, measured using the pedar-X® mobile in-shoe system between the three conditions. Results Data analysis was conducted on 14 out of the 16 participants because two participants could not complete data collection. The mean peak pressure values in kPa (±SD) for each condition were: control shoe 315.9 (±140.7), participants’ standard shoe 273.0 (±127.1) and DH Pressure Relief Shoe™ 155.4 (±89.9). There was a statistically significant difference in peak plantar pressure between the DH Pressure Relief Shoe™ compared to both the control shoe (p = 0.002) and participants’ standard shoe (p = 0.001). The DH Pressure Relief Shoe™ decreased plantar pressures by 51% compared to the control shoe and by 43% compared to participants’ standard shoe. Importantly, for a couple of study participants, the DH Pressure Relief Shoe™ appeared unsuitable for day-to-day wearing. Conclusions The DH Pressure Relief Shoe™ reduced plantar pressures more than the other two shoe conditions. The DH Pressure Relief Shoe™ may be a useful alternative to current offloading modalities used in clinical management of diabetic foot ulceration. However, clinical trials are needed to test their effectiveness for ulcer healing and to ensure they are useable and safe for patients in everyday activities.

Background Some studies have found that flat-arched foot posture is related to altered lower limb muscle function compared to normal- or high-arched feet. However, the results from these studies were based on highly selected populations such as those with rheumatoid arthritis. Therefore, the objective of this study was to compare lower limb muscle function of normal and flat-arched feet in people without pain or disease. Methods Sixty adults aged 18 to 47 years were recruited to this study. Of these, 30 had normal-arched feet (15 male and 15 female) and 30 had flat-arched feet (15 male and 15 female). Foot posture was classified using two clinical measurements (the arch index and navicular height) and four skeletal alignment measurements from weightbearing foot x-rays. Intramuscular fine-wire electrodes were inserted into tibialis posterior and peroneus longus under ultrasound guidance, and surface EMG activity was recorded from tibialis anterior and medial gastrocnemius while participants walked barefoot at their self-selected comfortable walking speed. Time of peak amplitude, peak and root mean square (RMS) amplitude were assessed from stance phase EMG data. Independent samples t-tests were performed to assess for significant differences between the normal- and flat-arched foot posture groups. Results During contact phase, the flat-arched group exhibited increased activity of tibialis anterior (peak amplitude; 65 versus 46% of maximum voluntary isometric contraction) and decreased activity of peroneus longus (peak amplitude; 24 versus 37% of maximum voluntary isometric contraction). During midstance/propulsion, the flat-arched group exhibited increased activity of tibialis posterior (peak amplitude; 86 versus 60% of maximum voluntary isometric contraction) and decreased activity of peroneus longus (RMS amplitude; 25 versus 39% of maximum voluntary isometric contraction). Effect sizes for these significant findings ranged from 0.48 to 1.3, representing moderate to large differences in muscle activity between normal-arched and flat-arched feet. Conclusion Differences in muscle activity in people with flat-arched feet may reflect neuromuscular compensation to reduce overload of the medial longitudinal arch. Further research is required to determine whether these differences in muscle function are associated with injury.

Background Foot orthoses and corticosteroid injection are common interventions used for plantar heel pain, however few studies have investigated the variables that predict response to these interventions. Methods Baseline variables (age, weight, height, body mass index (BMI), sex, education, foot pain, foot function, fear-avoidance beliefs and feelings, foot posture, weightbearing ankle dorsiflexion, plantar fascia thickness, and treatment preference) from a randomised trial in which participants received either foot orthoses or corticosteroid injection were used to predict change in the Foot Health Status Questionnaire foot pain and foot function subscales, and first-step pain measured using a visual analogue scale. Multivariable linear regression models were generated for different dependent variables (i.e. foot pain, foot function and first-step pain), for each intervention (i.e. foot orthoses and corticosteroid injection), and at different timepoints (i.e. weeks 4 and 12). Results For foot orthoses at week 4, greater ankle dorsiflexion with the knee extended predicted reduction in foot pain (adjusted R2 = 0.16, p = 0.034), and lower fear-avoidance beliefs and feelings predicted improvement in foot function (adjusted R2 = 0.43, p = 0.001). At week 12, lower BMI predicted reduction in foot pain (adjusted R2 = 0.33, p R2 = 0.37, p R2 0.19, p = 0.011). For corticosteroid injection at week 4, there were no significant predictors for change in foot pain or foot function. At week 12, less weightbearing hours predicted reduction in foot pain (adjusted R2 = 0.25, p = 0.004) and lower baseline foot pain predicted improvement in foot function (adjusted R2 = 0.38, p Conclusions People with plantar heel pain who use foot orthoses experience reduced foot pain if they have greater ankle dorsiflexion and lower BMI, while they experience improved foot function if they have lower fear-avoidance beliefs and lower BMI. People who receive a corticosteroid injection experience reduced foot pain if they weightbear for fewer hours, while they experience improved foot function if they have less baseline foot pain.

OBJECTIVE: To evaluate the efficacy of carbon-fibre shoe-stiffening inserts in individuals with first metatarsophalangeal joint osteoarthritis. \ud \ud DESIGN: This was a randomised, sham-controlled, participant- and assessor-blinded trial. One hundred participants with first metatarsophalangeal joint osteoarthritis received rehabilitation therapy and were randomised to receive either carbon fibre shoe-stiffening inserts (n = 49) or sham inserts (n = 51). The primary outcome measure was the Foot Health Status Questionnaire (FHSQ) pain domain assessed at 12 weeks. \ud \ud RESULTS: All 100 randomised participants (mean age 57.5 (SD 10.3) years; 55 (55%) women) were included in the analysis of the primary outcome. At the 12 week primary endpoint, there were 13 drop-outs (7 in the sham insert group and 6 in the shoe-stiffening insert group), giving completion rates of 86 and 88%, respectively. Both groups demonstrated improvements in the FHSQ pain domain score at each follow-up period, and there was a significant between-group difference in favour of the shoe-stiffening insert group (adjusted mean difference of 6.66 points, 95% CI 0.65 to 12.67, P = 0.030). There were no between-group differences for the secondary outcomes, although global improvement was more common in the shoe-stiffening insert group compared to the sham insert group (61 vs 34%, RR 1.73, 95% CI 1.05 to 2.88, P = 0.033; number needed to treat 4, 95% CI 2 to 16). \ud \ud CONCLUSION: Carbon-fibre shoe-stiffening inserts were more effective at reducing foot pain than sham inserts at 12 weeks. These results support the use of shoe-stiffening inserts for the management of this condition, although due to the uncertainty around the effect on the primary outcome, some individuals may not experience a clinically worthwhile improvement.

In British Journal of Sports Medicine , Rasenberg and colleagues1 report the findings of the Soles as Treatment Against Pain in feet (STAP) randomised trial comparing the effectiveness of usual general practitioner (GP) care to referral to a podiatrist for custom insoles or sham insoles in 185 people with plantar heel pain.1 After 12 weeks, the usual GP care group reported less pain during activity compared with the custom insole group (assessed using an 11-point Numerical Rating Scale), although this difference was small (less than one point) and did not meet the minimal clinically important difference for this outcome measure. Secondary outcomes favoured the GP group but were mostly small in magnitude. The authors concluded that referral to a podiatrist for custom insoles does not lead to better outcomes compared with usual GP care, and as such, healthcare providers should be ‘reserved’ in prescribing custom insoles for the treatment of plantar heel pain. This is a generally well-designed pragmatic trial and the first to be undertaken in a primary care …

Background Children and adolescents with Down syndrome have a distinctive foot shape (such as wide and flat feet) that often leads to difficulty with footwear fitting. 3-dimensional (3D) scanning can accurately measure the foot dimensions of individuals with Down syndrome, which may assist shoe fit. However, the reproducibility of measuring foot dimensions using 3D scans in children and adolescents with Down syndrome is unknown. The aim of this study was to determine the intra- and inter-rater reproducibility of measuring foot dimensions of children and adolescents with Down syndrome using 3D scanning. Methods 3D foot scans of 30 participants with Down syndrome aged 5 to 17 years were obtained using the FotoScan 3D scanner. Foot dimensions assessed were foot length, ball of foot length, outside ball of foot length, diagonal foot width, horizontal foot width, heel width, ball girth, instep girth, first and fifth toe height, and instep height. Additionally, the Wesjflog Index and forefoot shape were determined. Measurements were completed by two raters independently on two separate occasions, 2 weeks apart. Intra- and inter-rater reliability were assessed using intra-class coefficients (ICCs) and Gwet’s AC1 statistics with 95% confidence intervals. Agreement was determined by calculating limits of agreement (LOA) and percentage agreement. Results Eighteen participants were female and 12 were male (mean age 10.6 [3.9] years). Intra-rater reproducibility (ICCs ranged from 0.74 to 0.99, 95% LOA from − 13.7 mm to 16.3 mm) and inter-rater reproducibility (ICCs ranging from 0.73 to 0.99, 95% LOA from − 18.8 mm to 12.7 mm) was good to excellent, although some measurements (ball of foot length, outside ball of foot length, heel width and girth measurements) displayed wider LOAs indicating relatively poorer agreement. Forefoot shape displayed substantial to almost perfect reliability (Gwet’s AC1 0.68 to 0.85) and percentage agreement ranged from 73 to 87%, indicating acceptable agreement. Conclusions The measurement of specific foot dimensions of children and adolescents with Down syndrome using 3D scans is reproducible. Findings of this study may be used to support future research measuring specific foot dimensions of children and adolescents with Down syndrome using 3D foot scans.

Background Forefoot pads such as metatarsal domes are commonly used in clinical practice for the treatment of pressure-related forefoot pain, however evidence for their effects is inconsistent. This study aimed to evaluate the effects on plantar pressures of metatarsal domes in different positions relative to the metatarsal heads. Methods Participants in this study included 36 community-dwelling adults aged 65 or older with a history of forefoot pain. Standardised footwear was used and plantar pressures were measured using the pedar®-X in-shoe plantar pressure measurement system. Peak pressure, maximum force and contact area were analysed using an anatomically-based masking protocol that included three forefoot mask sub-areas (proximal to, beneath, and distal to the metatarsal heads). Data were collected for two different types of prefabricated metatarsal domes of different densities (Emsold metatarsal dome and Langer PPT metatarsal pad) in three different positions relative to the metatarsal heads. Seven conditions were tested in this study: (i) control (no pad) condition, (ii) Emsold metatarsal dome positioned 5 mm proximal to the metatarsal heads, (iii) Emsold metatarsal dome positioned in-line with the metatarsal heads, (iv), Emsold metatarsal dome positioned 5 mm distal to the metatarsal heads, (v) Langer PPT metatarsal pad positioned 5 mm proximal to the metatarsal heads, (vi) Langer PPT metatarsal pad positioned in-line with the metatarsal heads, and (vii) Langer PPT metatarsal pad positioned 5 mm distal to the metatarsal heads. Results When analysed with the mask that was distal to the metatarsal heads, where the plantar pressure readings were at their highest, all metatarsal dome conditions led to significant reductions in plantar pressure at the forefoot compared to the control (no pad) condition (F3.9, 135.6 = 8.125, p Conclusions Metatarsal domes reduce plantar pressure in the forefoot in older people with a history of forefoot pain. All metatarsal dome conditions significantly reduced peak pressure in the forefoot, however metatarsal domes that were positioned 5 mm proximal to the metatarsal heads provided the best balance of reducing plantar pressure distal to the metatarsal heads, where the pressure is at its greatest, but not adversely increasing plantar pressure proximally, where the bulk of the pad is positioned. In this proximal position, the Emsold metatarsal dome was more effective than the Langer PPT metatarsal pad and we cautiously recommend this forefoot pad for alleviating forefoot pressure in older people with forefoot pain.

Background Plantar heel pain is a common source of pain and disability. Evidence-based treatment decisions for people with plantar heel pain should be guided by the best available evidence, expert clinical reasoning, and consider the needs of the patient. Education is a key component of care for any patient and needs to be tailored to the patient and their condition. However, no previous work has identified, far less evaluated, the approaches and content required for optimal education for people with plantar heel pain. The aim of this study was to gather the patients’ perspective regarding their lived experience, attitudes and educational needs in order to inform the content and provision of meaningful education delivery approaches. Methods Using a qualitative descriptive design, semi-structured interviews were conducted with participants with a clinical diagnosis of plantar heel pain. A topic guide was utilised that focused on the experience of living with plantar heel pain and attitudes regarding treatment and educational needs. Interviews were audio recorded, transcribed verbatim and analysed using the Framework approach. Each transcription, and the initial findings, were reported back to participants to invite respondent validation. Results Eighteen people with plantar heel pain were interviewed. Descriptive analysis revealed eight themes including perceptions of plantar heel pain, impact on self, dealing with plantar heel pain, source of information, patient needs, patient unmet needs, advice to others and interest in online education. Participants revealed doubt about the cause, treatment and prognosis of plantar heel pain. They also expressed a desire to have their pain eliminated and education individually tailored to their condition and needs. Respondent validation revealed that the transcripts were accurate, and participants were able to recognise their own experiences in the synthesised themes. Conclusion Plantar heel pain has a negative impact on health-related quality of life. Participants wanted their pain eliminated and reported that their expectations and needs were frequently unmet. Health professionals have an important role to be responsive to the needs of the patient to improve their knowledge and influence pain and behaviour. Our study informs the content needed to help educate people with plantar heel pain.

Background People with intellectual disabilities (ID) often do not meet recommended guidelines for physical activity. The aim of this study was to systematically review available evidence that evaluated the effectiveness of interventions to increase physical activity in individuals with ID. Method Five electronic databases (MEDLINE, CINAHL, EMBASE, SPORTDiscus and Cochrane Central Register of Controlled Trials) were searched from inception of the database to July 2017 to identify randomised controlled trials that evaluated the effectiveness of interventions to improve physical activity among people with ID. Trials were included if they measured at least one objective measure of physical activity. Quality appraisal was completed by two independent reviewers using the Cochrane Risk of Bias Tool. The magnitude of treatment effect was estimated for each intervention by calculating the standardised mean difference (SMD) and associated 95% confidence interval. Results Nine randomised controlled trials (976 participants, 501 women, age range 9 months to 83 years) were included. Four trials evaluated unimodal interventions and five trials evaluated multimodal health promotion programmes based on using supportive environments to enable sustained behavioural changes in physical activity. None of the trials were rated as low risk of bias as all had at least one item on the Cochrane Risk of Bias Tool that was considered to be high risk. No trials were able to implement participant blinding. Three trials found statistically significant beneficial effects of interventions for increasing physical activity. Results showed that a 10-week progressive resistance training programme led to maintenance of physical activity levels at 24 weeks in adolescents with Down syndrome (SMD 0.78, 95% CI 0.17 to 1.40). Additionally, a 12- to 16-month multicomponent diet and physical activity programme produced improvement in physical activity at programme completion in adults with ID (reported effect size of 0.29). Finally, an 8-month physical activity and fitness programme increased physical activity at 8 months in adults with ID (SMD 0.91, 95% CI 0.20 to 1.60). Findings regarding other interventions were inconclusive with small effects that were not statistically significant. Conclusions There is inconsistent evidence of the effects of interventions for improving physical activity levels in individuals with ID. A progressive resistance training programme was found to maintain physical activity levels in adolescents with Down syndrome, while a multicomponent diet and physical activity programme and a physical activity and fitness programme were found to improve physical activity levels in adults with ID. Future trials using rigorous research designs are required to confirm these findings and establish whether other interventions designed to increase physical activity in people with ID are effective.

Background Foot orthoses are frequently used but little is known about which types are used in contemporary practice. This study aimed to explore the types of foot orthoses currently used by podiatrists and the prescription variations in a range of conditions. Methods A web-based, cross-sectional survey was distributed through professional bodies in the United Kingdom (UK), Australia, and New Zealand. Questions focussed on foot orthosis prescription habits in relation to 26 conditions affecting the back and lower limb. Results Two hundred and sixty-four podiatrists practising in 19 different countries completed the survey; the majority practised in the UK (47%, n = 124), Australia (30%, n = 79) and New Zealand (12%, n = 32). Respondents qualified between 1968 and 2016, and 147 (56%) were female. Respondents worked in different healthcare sectors and this varied between countries: 42 (34%) respondents in the UK worked solely in the public sector, compared to 3 (4%) in Australia and 2 (6%) in New Zealand. Forty-four (35%) respondents in the UK worked solely in private practice, compared to 64 (81%) in Australia and 14 (44%) in New Zealand. UK respondents prescribed more prefabricated orthoses per week (mean 5.5 pairs) than simple insole-type devices (±2.7) and customised devices (±2.9). Similarly, respondents in New Zealand prescribed more prefabricated orthoses per week (±7.7) than simple (±1.4) and customised (±2.8) devices. In contrast, those in Australia prescribed more customised orthoses per week (±4.4) than simple (±0.8) and prefabricated (±1.9) orthoses. Differences in the types of orthoses prescribed were observed between country of practice, working sector, and the condition targeted. Generally, prefabricated orthoses were commonly prescribed for the 26 highlighted conditions in the UK and New Zealand. Australian podiatrists prescribed far fewer devices overall, but when they did prescribe, they were more likely to prescribe custom devices. Respondents in all three countries were more likely to prescribe customised orthoses for people with diabetes complicated by peripheral neuropathy than for diabetes without this complication. Conclusions Foot orthosis prescription habits vary between countries. Prefabricated orthoses were frequently prescribed in the UK and New Zealand, and customised orthoses in Australia. Prescriptions for people with diabetes differed depending on the presence of neuropathy, despite a lack of robust evidence supporting these decisions. This study provides new insight into contemporary practice. Electronic supplementary material The online version of this article (10.1186/s13047-018-0304-z) contains supplementary material, which is available to authorized users.

IntroductionThis study aimed to identify risk factors associated with the development of common lower limb injuries during initial defence training in naval recruits who were enrolled in a randomised trial.MethodsThree-hundred and six naval recruits were randomly allocated flat insoles (n=153) or foot orthoses (n=153) while undertaking 11 weeks of initial training. Participant characteristics (including anthropometrics, general health, physical activity, fitness and foot characteristics) were collected at the baseline assessment and injuries were documented prospectively. Injury was defined as the combined incidence of participants with medial tibial stress syndrome, patellofemoral pain, Achilles tendinopathy and plantar fasciitis/plantar heel pain throughout the 11 weeks of training. A discriminant function analysis was used to explore the ability of baseline measures to predict injury.ResultsOverall, 67 (21.9%) participants developed an injury. Discriminant function analysis revealed that participants who sustained an injury were slightly younger (mean 21.4±SD 4.1 vs 22.5±5.0 years) and were less likely to be allocated to the foot orthosis group (40% vs 53%) compared with those who remained uninjured. The accuracy of these baseline variables to predict injury was moderate (78.1%).ConclusionsLower limb injury was not accurately predicted from health questionnaires, fitness results and clinical assessments in naval recruits undertaking initial defence training. However, although not reaching statistical significance, the use of foot orthoses may be protective against common lower limb injuries.Trial registration numberACTRN12615000024549; Post-results.

Background\ud There is a well-recognised relationship between body weight, plantar pressures and foot pain, but the temporal association between these factors is unknown. The aim of this study was to investigate the relationships between increasing weight, plantar pressures and foot pain over a two-year period.\ud \ud Methods\ud Fifty-one participants (33 women and 18 men) completed the two-year longitudinal cohort study. The sample had a mean (standard deviation (SD)) age of 52.6 (8.5) years. At baseline and follow-up, participants completed the Manchester Foot Pain and Disability Index questionnaire, and underwent anthropometric measures, including body weight, body mass index, and dynamic plantar pressures. Within-group analyses examined differences in body weight, foot pain and plantar pressures between baseline and follow up, and multivariate regression analysis examined associations between change in body weight, foot pain and plantar pressure. Path analysis assessed the total impact of both the direct and indirect effects of change in body weight on plantar pressure and pain variables.\ud \ud Results\ud Mean (SD) body weight increased from 80.3 (19.3), to 82.3 (20.6) kg, p = 0.016 from baseline to follow up. The change in body weight ranged from −16.1 to 12.7 kg. The heel was the only site to exhibit increased peak plantar pressures between baseline and follow up. After adjustment for age, gender and change in contact time (where appropriate), there were significant associations between: (i) change in body weight and changes in midfoot plantar pressure (B = 4.648, p = 0.038) and functional limitation (B = 0.409, p = 0.010), (ii) plantar pressure change in the heel and both functional limitation (B = 4.054, p = 0.013) and pain intensity (B = 1.831, p = 0.006), (iii) plantar pressure change in the midfoot and both functional limitation (B = 4.505, p = 0.018) and pain intensity (B = 1.913, p = 0.015). Path analysis indicated that the effect of increasing body weight on foot-related functional limitation and foot pain intensity may be mediated by increased plantar pressure in the midfoot.\ud \ud Conclusions\ud These findings suggest that as body weight and plantar pressure increase, foot pain increases, and that the midfoot may be the most vulnerable site for pressure-related pain.

Background Foot orthoses are widely used in the prevention and treatment of foot disorders. The aim of this study was to describe characteristics of custom-made foot orthosis prescriptions from a Australian podiatric orthotic laboratory. Methods One thousand consecutive foot orthosis prescription forms were obtained from a commercial prescription foot orthosis laboratory located in Melbourne, Victoria, Australia (Footwork Podiatric Laboratory). Each item from the prescription form was documented in relation to orthosis type, cast correction, arch fill technique, cast modifications, shell material, shell modifications and cover material. Cluster analysis and discriminant function analysis were applied to identify patterns in the prescription data. Results Prescriptions were obtained from 178 clinical practices across Australia and Hong Kong, with patients ranging in age from 5 to 92 years. Three broad categories (‘clusters’) were observed that were indicative of increasing ‘control’ of rearfoot pronation. A combination of five variables (rearfoot cast correction, cover shape, orthosis type, forefoot cast correction and plantar fascial accommodation) was able to identify these clusters with an accuracy of 70%. Significant differences between clusters were observed in relation to age and sex of the patient and the geographic location of the prescribing clinician. Conclusion Foot orthosis prescriptions are complex, but can be broadly classified into three categories. Selection of these prescription subtypes appears to be influenced by both patient factors (age and sex) and clinician factors (clinic location). Electronic supplementary material The online version of this article (doi:10.1186/s13047-017-0204-7) contains supplementary material, which is available to authorized users.

IntroductionCorticosteroid injections and foot orthoses are common interventions for plantar heel pain. Previous clinical trials have found that the effectiveness of these interventions differs over time, with corticosteroid injections being more effective in the short-term (i.e. 0–4 weeks) and foot orthoses more effective in the longer-term (i.e. 5–12 weeks). However, some of these trials have methodological weaknesses that could have caused confounding and bias, which may have led to over- or under-estimation of the effectiveness of these interventions. As a result, there is a need to compare the effectiveness of corticosteroid injections and foot orthoses in a robust clinical trial with an appropriate follow-up time.MethodsThis article describes the protocol for a pragmatic, parallel-group assessor-blinded randomised trial (Steroid injection versus foot orthoses (SOOTHE) heel pain trial). One hundred participants with plantar heel pain will be randomly allocated (i.e. two groups of approximately 50) to receive either an ultrasound-guided corticosteroid injection or prefabricated foot orthoses. Outcome measures will be obtained at baseline, 4, 8 and 12 weeks, with two primary endpoints at 4 and 12 weeks to reflect the hypothesised temporal effects of each intervention. The primary outcome measure will be the foot pain domain of the Foot Health Status Questionnaire.Trial registrationAustralian and New Zealand Clinical Trials Registry number ACTRN12615001266550.

Plantar heel pain is a common condition, but little is known about the relationship between muscle strength and plantar heel pain.To review the evidence relating to muscle strength in those with and without plantar heel pain.We systematically reviewed the literature by searching key databases. Included studies assessed muscle strength (or endurance or size as proxies) in those with and without plantar heel pain. A modified Downs-Black quality index was used to assess study quality and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool was used to evaluate the strength of the evidence. Meta-analysis was performed where possible.Seven studies met the eligibility criteria. Hallux plantar flexion, lesser toe plantar flexion, ankle dorsiflexion, ankle inversion, and ankle eversion strength values were reduced in those with heel pain compared to those without; however, there was inconsistency in the findings between studies. No difference was found in calf muscle endurance between those with and without plantar heel pain (standardized mean difference, 0.01; 95% confidence interval: -0.56, 0.59). Generally, foot muscle volume was smaller in people with plantar heel pain compared to those without. The quality of individual studies was generally high (score range, 11-16/17 on the modified Downs-Black quality index); however, the GRADE ratings suggest the strength of this evidence to be very low.People with plantar heel pain have reduced strength and volume of the foot muscles, but there is no discernible difference in calf muscle endurance. These findings should be interpreted with respect to the very low GRADE ratings and are likely to change with further research. Accordingly, the role of muscle strength in plantar heel pain is worthy of further investigation.

Plantar heel pain is a common foot complaint that causes significant disability and poorer health-related quality of life. Foot orthoses and corticosteroid injection are effective treatments for plantar heel pain; however, it is unclear whether one is more effective than the other.The aim of this trial was to compare the effectiveness of foot orthoses and corticosteroid injection for plantar heel pain.In this parallel-group, assessor-blinded, randomized clinical trial, participants received prefabricated, arch-contouring foot orthoses or a single ultrasound-guided corticosteroid injection. The primary outcome measure was the foot pain subscale of the Foot Health Status Questionnaire at 4 and 12 weeks.One hundred three participants aged 21 to 72 years (63 female) with plantar heel pain were recruited from the community and received an intervention. For the primary outcome of foot pain, corticosteroid injection was more effective at week 4 (adjusted mean difference, 8.2 points; 95% confidence interval: 0.6, 15.8 points). However, foot orthoses were more effective at week 12 (adjusted mean difference, 8.5 points; 95% confidence interval: 0.2, 16.8 points). Although these findings were statistically significant, the differences between the interventions did not meet the previously calculated minimal important difference value of 12.5 points.Corticosteroid injection is more effective than foot orthoses at week 4, but this effect does not last; and appropriately contoured foot orthoses are more effective than corticosteroid injection at week 12. However, patients may not notice a clinically worthwhile difference between the interventions.Therapy, level 1b.

Background Mid-portion Achilles tendinopathy is a common musculoskeletal condition characterised by degeneration of the Achilles tendon, which causes pain and disability. Multiple non-surgical treatments have been advocated for this condition including calf muscle eccentric exercise and in-shoe heel lifts. Although adherence is challenging, there is evidence to suggest that calf muscle eccentric exercise is effective in decreasing pain and improving function in people with Achilles tendinopathy. Heel lifts reduce ankle joint dorsiflexion and Achilles tendon strain, however their efficacy in the management of Achilles tendinopathy is unclear. This article describes the design of a parallel-group randomised trial comparing the efficacy of heel lifts to calf muscle eccentric exercise for Achilles tendinopathy. Methods Ninety-two participants with Achilles tendinopathy will be randomised to one of two groups: (i) a heel lift group that will receive pre-fabricated 12 mm in-shoe heel lifts (Clearly Adjustable®), or (ii) an exercise group that will be advised to carry out a calf muscle eccentric exercise program (twice a day, 7 days a week, for 12 weeks). Outcome measures will be obtained at baseline, 2, 6 and 12 weeks; the primary endpoint for assessing efficacy being 12 weeks. The primary outcome measure will be the total score of the Victorian Institute of Sport Assessment – Achilles (VISA–A) questionnaire. Secondary outcome measures will include thickness and integrity of the Achilles tendon (using ultrasound tissue characterisation [UTC]), participant perception of treatment effect on pain and function (using the 7-point Patient Global Impression of Change scale), severity of pain at the Achilles tendon (using a 100 mm visual analogue scale) in the previous week, health status (using the EuroQol-5D-5L™ questionnaire), physical activity levels (using the 7-day Recall Physical Activity Questionnaire) and calf muscle function (using the standing heel rise test). Data will be analysed using the intention to treat principle. Discussion The HEALTHY trial (Heel lifts versus calf muscle eccentric Exercise for AchiLles TendinopatHY) is the first randomised trial to compare the efficacy of heel lifts to calf muscle eccentric exercise in reducing pain and improving function in people with Achilles tendinopathy. A pragmatically designed trial was developed to ensure that if the interventions are found to be effective, the findings can be readily implemented in clinical practice. Trial registration Australian New Zealand Clinical Trials Registry: ACTRN12617001225303. Registered on August 22nd, 2017. Electronic supplementary material The online version of this article (10.1186/s13047-019-0325-2) contains supplementary material, which is available to authorized users.

This chapter covers soft-tissue disorders, a common occurrence in rheumatology. There is a brief overview of 10 of the most common soft-tissue disorders of the foot in rheumatology, including Achilles tendinopathy, ankle sprains, retrocalcaneal bursitis, tarsal tunnel syndrome, peroneal tendinopathy, tibialis posterior tendinopathy, plantar heel pain, and more. For each disorder, presentation, signs, and management are discussed.

Background Guidelines recommend foot orthoses for people with both early (

Objective.Foot pain is a common complaint in adults. Evidence suggests that body composition is involved in the development of foot pain. However, whether this is the case in men remains unclear because previous studies mainly examined women. The aim of this cross-sectional study was to determine the relationship between body composition and foot pain in men while accounting for important risk factors.Methods.Among 978 men (median age 60 yrs, range 24–98) from the Geelong Osteoporosis Study who participated in a followup study in 2006 to 2011, 796 provided responses to questions on health status and foot pain. Foot pain was determined using the Manchester Foot Pain and Disability Index, and body composition was measured using dual-energy x-ray absorptiometry.Results.Of the 796 respondents, 177 (22%) had foot pain. Risk factors for foot pain were age (OR 1.03, 95% CI 1.02–1.04), self-reported depression (OR 2.05, 95% CI 1.30–3.20), decreased mobility (OR 1.54, 95% CI 1.05–2.24), and lower education (OR 1.47, 95% CI 1.03–2.09). Foot pain was associated with body mass index (OR 1.05, 95% CI 1.00–1.10), fat mass (OR 1.02, 95% CI 1.03–1.05), and fat mass index (OR 1.08, 95% CI 1.01–1.15), but not fat-free mass (OR 1.01, 95% CI 0.98–1.04) or fat-free mass index (OR 1.05, 95% CI 0.95–1.15) after appropriate adjustments were made.Conclusion.Fat mass is associated with foot pain in men. These findings complement those in studies that have mainly examined women, and provide further evidence for the relationship between obesity and foot pain.

Background Plantar heel pain is one of the most common conditions affecting the foot in adults, with prevalence estimates between 4% and 7%.1,2 Corticosteroid injection is a common intervention used to treat plantar heel pain,3 however there is limited high quality evidence to support this practise. Because corticosteroid injection is frequently used for plantar heel pain, it is important that health professionals understand whether the evidence-base supports the use of this intervention. Objectives To conduct a systematic review and meta-analysis of the effectiveness of corticosteroid injection for pain and function in people with plantar heel pain. Methods Databases searched include Medline, CINAHL, SPORTDiscus, Embase and the Cochrane Library. Included studies had to be randomised trials that evaluated the effectiveness of corticosteroid injection on pain or function for plantar heel pain. The primary outcomes were pain (including ‘first step’ pain) and function, categorised as short (0 to 6 weeks), medium (7 to 12 weeks) or longer term (13 to 52 weeks). A secondary outcome was plantar fascia thickness. Mean differences or standardised mean differences and 95% confidence intervals were calculated. The Cochrane Collaboration tool for assessing risk of bias was used to assess trial quality, and the GRADE approach was used to assess the strength of evidence. Results A total of 37 trials (2200 participants) were included. In the short term, corticosteroid injection was more effective for reducing pain than autologous blood injection (SMD −0.56 [-0.86,–0.26]) and orthotic devices (SMD −1.20 [-2.30,–0.11]). There were no significant findings in the medium term. In the longer term, corticosteroid injection was less effective than platelet-rich plasma injection (SMD 0.87 [0.30, 1.45]). For function, corticosteroid injection was more effective than physical therapy in the short term only (SMD −0.69 [-1.31,–0.07]). Notably, corticosteroid injection was not more effective than placebo injection for reducing pain in the short (SMD −0.98 [-2.06, 0.11]) and medium (SMD −0.86 [-1.90, 0.19]) terms. When trials considered to have high risk of bias were excluded, there were no significant findings. Conclusions Our review found that corticosteroid injection is more effective for reducing pain than some comparators, and more effective for improving function than physical therapy in the short term. Corticosteroid injection is more effective than platelet-rich plasma injection in the longer term. Corticosteroid injection is not more effective than placebo injection for reducing pain or improving function. References [1] Hill CL, Gill TK, Menz HB, Taylor AW. Prevalence and correlates of foot pain in a population-based study: the North West Adelaide Health Study. Journal of Foot and Ankle Research2008;1(2):1–7. doi:10.1186/1757–1146–1–2 [2] Dunn JE, Link CL, Felson DT, Crincoli MG, Keysor JJ, McKinlay JB. Prevalence of foot and ankle conditions in a multiethnic community sample of older adults. American Journal of Epidemiology2004;159(5):491–498. doi:10.1093/aje/kwh071 [3] Buchbinder R. Plantar fasciitis. New England Journal of Medicine2004;350(21):2159–2166. doi:10.1056/NEJMcp032745 Disclosure of Interest None declared

Background\ud The area beneath the metatarsal heads is a common location of foot pain, which is often associated with high plantar pressures. Current plantar pressure assessment protocols focus mainly on the gross area of the forefoot with minimal attention paid to specific areas such as the metatarsal heads. The aim of this study was to develop and assess a new anatomically-based masking protocol that is clinically relevant to measure forefoot plantar pressure during shod conditions based on the anatomical positions of the metatarsal heads.\ud \ud Methods\ud Initially, we developed a masking protocol to measure forefoot plantar pressure during shod conditions based on the anatomical positions of the metatarsal heads. This new masking protocol divided the forefoot into three sub-areas (proximal, beneath, and distal to the metatarsal heads) as determined by the position of each metatarsal head. Following development of the new masking protocol, we compared the new protocol against a traditional protocol, which defines the forefoot as between 51 and 81% of the foot length. To compare the two masking protocols, we tested two experimental conditions: (i) a control condition (i.e. no metatarsal pad), and (ii) a metatarsal pad condition. We then compared plantar pressure differences between the two experimental conditions for the two masking protocols. Participants for this component of the study included 36 community dwelling older adults (mean age 75.6 years ±5.4) with a history of forefoot pain. Forefoot plantar pressure data were measured while walking using the pedar®-X in-shoe system. Peak pressure, maximum force and contact area at the time of peak pressure were determined and results were compared between the two masking protocols.\ud \ud Results\ud The traditional masking protocol showed that the metatarsal pad significantly decreased peak pressure and increased contact area in the forefoot area (i.e. within the entire mask area), but maximum force was not significantly different between the two conditions. In contrast, the newly developed anatomically-based masking protocol indicated that the metatarsal pad decreased peak plantar pressures distal to and beneath the metatarsal heads by increasing force and contact area proximal to the metatarsal heads.\ud \ud Conclusions\ud An anatomically-based masking protocol that is clinically relevant was developed to assess forefoot plantar pressure during shod conditions based on the anatomical positions of metatarsal heads. We propose that the new forefoot masking protocol will provide greater interpretability of forefoot plantar pressure data, which will aid clinicians and researchers for diagnostic, prognostic and therapeutic purposes.

The authors of this systematic review1 found that foot orthoses are not effective for plantar heel pain (when compared with sham devices) and suggest ‘that clinicians should be reserved in prescribing foot orthoses in all patients with plantar heel pain’. This finding is in contrast to a similar systematic review and meta-analysis that we recently published in the British Journal of Sports Medicine that concluded foot orthoses are effective at reducing pain in those with plantar heel pain and that ‘health practitioners may consider using foot orthoses … but the reduction in pain may not be sufficient for some people’.2 The publication of these meta-analyses in the same journal, within a short time-period may create uncertainty for health practitioners regarding the effectiveness of foot orthoses for plantar heel pain. Furthermore, there may be a loss of trust by health practitioners and members of the public in the process of conducting and reporting systematic reviews and meta-analyses, as reviews by different authors can arrive at contrasting findings. Therefore, it is important to provide context to the different conclusions reached in these meta-analyses in …

Background Adults with end-stage renal disease are at increased risk of foot ulceration and lower extremity amputation. However, the central determinants of lower limb injury and loss are incompletely understood. Methods We conducted a systematic review of non-randomized studies that quantified the major risk factors for foot ulceration and amputation in adults treated with dialysis and analysed patient populations in which risks were greatest. Random-effects meta-analysis was used to generate summary estimates. Results Thirty studies (48 566 participants) were identified. Risk factors for foot ulceration and amputation included previous foot ulceration (odds ratios, OR, 17.56 and 70.13), peripheral arterial disease (OR, 7.52 and 9.12), diabetes (OR, 3.76 and 7.48), peripheral neuropathy (OR, 3.24 and 3.36) and coronary artery disease (OR, 3.92 and 2.49). Participants with foot ulceration or amputation had experienced a longer duration of diabetes (mean difference, MD, 4.04 and 6.07 years) and had lower serum albumin levels (MD, -0.23 and -0.13 g/dL). Risk factors for foot ulceration also included retinopathy (OR, 3.03), previous amputation (OR, 15.50) and higher serum phosphorus levels (MD, 0.40 mg/dL), while risk factors for amputation also included male sex (OR, 1.50), current smoking (OR, 2.26) and higher glycated haemoglobin levels (MD, 0.75%). Conclusions Dialysis patients who have markedly higher risks of ulceration or amputation include those with previous foot ulceration or amputation, peripheral neuropathy, diabetes or macrovascular disease. The temporal relationship between these risk factors and the development of foot ulceration and/or limb loss is uncertain and requires further study. Stable estimates of the key risk factors for ulceration and amputation can inform the design of future trials investigating clinical interventions to reduce the burden of lower limb disease in the dialysis population.

ObjectivesTo evaluate the effectiveness of prefabricated foot orthoses for the prevention of lower limb overuse injuries in naval recruits.MethodsThis study was a participant-blinded and assessor-blinded, parallel-group randomised controlled trial. Three-hundred and six participants aged 17–50 years who undertook 11 weeks of initial defence training at the Royal Australian Navy Recruit School (Cerberus, Australia) were randomised to a control group (flat insoles, n=153) or an intervention group (contoured, prefabricated foot orthoses, n=153). The combined incidence of medial tibial stress syndrome, patellofemoral pain, Achilles tendinopathy and plantar fasciitis/plantar heel pain during the 11-week training period were compared using incidence rate ratios (IRR). Data were analysed using the intention-to-treat principle.ResultsSixty-seven injuries (21.9%) were recorded. The control and intervention group sustained 40 (26.1%) and 27 (17.6%) injuries, respectively (IRR 0.66, 95% CI 0.39 to 1.11, p=0.098). This corresponds to a 34% reduction in risk of developing medial tibial stress syndrome, patellofemoral pain, Achilles tendinopathy or plantar fasciitis/plantar heel for the intervention group compared with the control group. Participants in the prefabricated orthoses group were more likely to report at least one adverse event (20.3% vs 12.4%; relative risk (RR) 1.63, 95% CI 0.96 to 2.76; p=0.068; number needed to harm 13, 95% CI 6 to 253). The most common adverse events were foot blisters (n=20, 6.6%), arch pain (n=10, 3.3%) and shin pain (n=8, 2.6%).ConclusionPrefabricated foot orthoses may be beneficial for reducing the incidence of lower limb injury in naval recruits undertaking defence training.Trial registration numberAustralian New Zealand Clinical Trials Registry: ACTRN12615000024549.

Background Foot posture is a risk factor for some lower limb injuries, however the underlying mechanism is not well understood. Plantar pressure analysis is one technique to investigate the interaction between foot posture and biomechanical function of the lower limb. Research question The aim of this review was to investigate the relationship between foot posture and plantar pressure during walking. Methods A systematic database search was conducted using MEDLINE, CINAHL, SPORTDiscus and Embase to identify studies that have assessed the relationship between foot posture and plantar pressure during walking. Included studies were assessed for methodological quality. Meta-analysis was not conducted due to heterogeneity between studies. Inconsistencies included foot posture classification techniques, gait analysis protocols, selection of plantar pressure parameters and statistical analysis approaches. Results Of the 4213 citations identified for title and abstract review, sixteen studies were included and underwent quality assessment; all were of moderate methodological quality. There was some evidence that planus feet display higher peak pressure, pressure-time integral, maximum force, force-time integral and contact area predominantly in the medial arch, central forefoot and hallux, while these variables are lower in the lateral and medial forefoot. In contrast, cavus feet display higher peak pressure and pressure-time integral in the heel and lateral forefoot, while pressure-time integral, maximum force, force-time integral and contact area are lower for the midfoot and hallux. Centre of pressure was more laterally deviated in cavus feet and more medially deviated in planus feet. Overall, effect sizes were moderate, but regression models could only explain a small amount of variance in plantar pressure variables. Significance Despite these significant findings, future research would benefit from greater methodological rigour, particularly in relation to the use of valid foot posture measurement techniques, gait analysis protocols, and standardised approaches for analysis and reporting of plantar pressure variables.

Background This article describes the design of a parallel-group, participant- and assessor-blinded randomised controlled trial comparing the effectiveness of shoe-stiffening inserts versus sham shoe insert(s) for reducing pain associated with first metatarsophalangeal joint (MTPJ) osteoarthritis (OA). Methods Ninety participants with first MTPJ OA will be randomised to receive full-length shoe-stiffening insert(s) (Carbon Fibre Spring Plate, Paris Orthotics, Vancouver, BC, Canada) plus rehabilitation therapy or sham shoe insert(s) plus rehabilitation therapy. Outcome measures will be obtained at baseline, 4, 12, 24 and 52 weeks; the primary endpoint for assessing effectiveness being 12 weeks. The primary outcome measure will be the foot pain domain of the Foot Health Status Questionnaire (FHSQ). Secondary outcome measures will include the function domain of the FHSQ, severity of first MTPJ pain (using a 100-mm Visual Analogue Scale), global change in symptoms (using a 15-point Likert scale), health status (using the Short-Form-12® Version 2.0 and EuroQol (EQ-5D-5L™) questionnaires), use of rescue medication and co-interventions, 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. Economic analysis (cost-effectiveness and cost-utility) will also be performed. In addition, the kinematic effects of the interventions will be examined at 1 week using a three-dimensional motion analysis system and multisegment foot model. Discussion This study will determine whether shoe-stiffening inserts are a cost-effective intervention for relieving pain associated with first MTPJ OA. The biomechanical analysis will provide useful insights into the mechanism of action of the shoe-stiffening inserts. Trial registration Australian New Zealand Clinical Trials Registry, identifier: ACTRN12616000552482. Registered on 28 April 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1936-1) contains supplementary material, which is available to authorized users.

Video abstract During the last 300 years, a range of terms have been used to describe pain under the plantar aspect of the heel including gonorrhoeal heel, Policeman’s heel, heel spur syndrome, subcalcaneal pain, jogger’s heel, plantar fasciitis, plantar fasciopathy, plantar fasciosis and plantar heel pain. To facilitate effective communication between clinicians, improve patients’ understanding of their condition and allow for shared decision making, consistent and unambiguous terminology is required. Similar challenges with terminology have been recognised for other conditions, including groin pain experienced by athletes.1 The aim of this article is to provide a stimulus for discussion about the terminology used to describe pain under the heel and propose an appropriate term based on current knowledge. By doing so, we hope that we will set the scene for a future consensus on appropriate nomenclature for the condition of pain under the heel and its associated diagnostic criteria. Pain under the heel is typically characterised by pain located at the anteromedial aspect of the plantar heel during weight-bearing. It is usually …

Objective: To identify foot pain clusters according to pain location in a community-based sample of the general population. Methods: This study analyzed data from the North West Adelaide Health Study. Data were obtained between 2004 and 2006, using computer-assisted telephone interviewing, clinical assessment, and self-completed questionnaire. The location of foot pain was assessed using a diagram during the clinical assessment. Hierarchical cluster analysis was undertaken to identify foot pain location clusters, which were then compared in relation to demographics, comorbidities, and podiatry services utilization. Results: There were 558 participants with foot pain (mean age 54.4 years, 57.5% female). Five clusters were identified: 1 with predominantly arch and ball pain (26.8%), 1 with rearfoot pain (20.9%), 1 with heel pain (13.3%), and 2 with predominantly forefoot, toe, and nail pain (28.3% and 10.7%). Each cluster was distinct in age, sex, and comorbidity profile. Of the two clusters with predominantly forefoot, toe, and nail pain, one of them had a higher proportion of men and those classified as obese, had diabetes mellitus, and used podiatry services (30%), while the other was comprised of a higher proportion of women who were overweight and reported less use of podiatry services (17.5%). Conclusion: Five clusters of foot pain according to pain location were identified, all with distinct age, sex, and comorbidity profiles. These findings may assist in the identification of individuals at risk for developing foot pain and in the development of targeted preventive strategies and treatments. Refereed/Peer-reviewed

Plantar forefoot pain is common in older people and is related to increased peak pressures under the foot during gait. Variations in the hardness of the shoe sole may therefore influence both the magnitude of loading under the foot and the perceived comfort of the shoe in this population. The aim of this investigation was to determine the effect of varying shoe sole hardness on plantar pressures and comfort in older people with forefoot pain. In-shoe plantar pressures under the forefoot, midfoot and rearfoot were recorded from 35 older people (mean age 73.2, SD 4.5 years) with current or previous forefoot pain using the pedar-X(®) system. Participants walked at their normal comfortable speed along an 8m walkway in shoes with three different levels of sole hardness: soft (Shore A25), medium (Shore A40) and hard (Shore A58). Shoe comfort was measured on a 100mm visual analogue scale. There were statistically significant differences in peak pressure of between 5% and 23% across the forefoot, midfoot and rearfoot (p

Background Adults on dialysis are at increased risk of foot ulceration, which commonly precedes more serious lower limb complications, including amputation. Limited data exist regarding the prevalence and factors associated with foot disease in this population. Hence, this study set out to investigate factors associated with foot ulceration and amputation in a dialysis cohort. Methods This study presents a cross-sectional analysis of baseline data from a multi-center prospective cohort study. We recruited 450 adults with end-stage renal disease on dialysis from multiple satellite and home-therapy dialysis units in Melbourne, Australia from January to December 2014. Data collection consisted of a participant interview, medical record review, health-status questionnaire and non-invasive foot examination. Logistic regression analyses were conducted to evaluate associations between screened variables and study outcomes. Results Mean age was 67.5 (SD, 13.2) years, 64.7% were male, 94% were on hemodialysis, median dialysis duration was 36.9 (IQR, 16.6 to 70.1) months, and 50.2% had diabetes. There was a high prevalence of previous ulceration (21.6%) and amputation (10.2%), 10% had current foot ulceration, and 50% had neuropathy and/or peripheral arterial disease. Factors associated with foot ulceration were previous amputation (OR, 10.19), peripheral arterial disease (OR, 6.16) and serum albumin (OR, 0.87); whereas previous and/or current ulceration (OR, 167.24 and 7.49, respectively) and foot deformity (OR, 15.28) were associated with amputation. Conclusions Dialysis patients have a high burden of lower limb complications. There are markedly higher risks of foot ulceration and/or amputation in those with previous and/or current ulceration, previous amputation, peripheral arterial disease, lower serum albumin, and foot deformity. Although not a major risk factor, diabetes in men was an important effect modifier for risk of ulceration. Electronic supplementary material The online version of this article (10.1186/s12882-017-0711-6) contains supplementary material, which is available to authorized users.

Cross-sectional observational study.To investigate the presence of soft tissue hyperemia in plantar fasciitis with power Doppler ultrasound.Localized hyperemia is an established feature of tendinopathy, suggesting that neurovascular in-growth may contribute to tendon-associated pain in some patients. The presence of abnormal soft tissue vascularity can be assessed with Doppler ultrasound, and a positive finding can assist with targeted treatment plans. However, very little is known regarding the presence of hyperemia in plantar fasciitis and the ability of routine Doppler ultrasound to identify vascular in-growth in the plantar fascia near its proximal insertion.This observational study included 30 participants with plantar fasciitis unrelated to systemic disease and 30 age- and sex-matched controls. Ultrasound examination was performed with a 13- to 5-MHz linear transducer, and power Doppler images were assessed by 2 blinded investigators.Hyperemia of the plantar fascia was present in 8 of 30 participants with plantar fasciitis and in 2 of 30 controls. The between-group difference for hyperemia, using a 4-point scale, was statistically significant, with participants with plantar fasciitis showing increased Doppler ultrasound signal compared to controls (Mann-Whitney U, P = .03). However, the majority of participants with plantar fasciitis with evidence of hyperemia demonstrated very mild color changes, and only 3 were found to have moderate or marked hyperemia.Mild hyperemia can occur with plantar fasciitis, but most individuals will not exhibit greater soft tissue vascularity when assessed with routine Doppler ultrasound. Clinicians treating plantar fasciitis should not consider a positive Doppler signal as essential for diagnosis of the condition but, rather, as a feature that may help to refine the treatment plan for an individual patient.

Background: Falls are common in older people and are associated with substantial health-care costs. A recent randomized controlled trial of a multifaceted podiatric medical intervention demonstrated a 36% reduction in the fall rate over 12 months. We evaluated the acceptability of and levels of satisfaction with this intervention in the older people who participated in the trial. Methods: Participants allocated to the intervention group (which included a home-based program of foot and ankle exercises, assistance with the purchase of safe footwear when necessary, and provision of prefabricated foot orthoses) completed a structured questionnaire 6 months after they had received the intervention. The questions addressed participants’ perceptions of their balance and foot and ankle strength, the perceived difficulty of the exercise program, and the degree of satisfaction with the footwear and orthoses provided. Results: Of 153 participants, 134 (87.6%) attended the 6-month follow-up assessment and completed the questionnaire. Most participants perceived improvements in balance (62.7%) and foot and ankle strength (74.6%) after 6 months of performing the exercises, and 86.6% considered the difficulty level of the exercises to be “about right.” Most participants reported that they were somewhat or very satisfied with the footwear (92.3%) and orthoses (81.6%) provided. Conclusions: The multifaceted podiatric medical intervention used in this trial was generally perceived to be beneficial and demonstrated high levels of satisfaction among participants. Further research is now required to evaluate the feasibility of implementing the intervention in a range of clinical practice settings. (J Am Podiatr Med Assoc 103(6): 457–464, 2013)

The aim of this systematic review was to investigate the relationship between body composition and foot structure and function. Six electronic databases (Ovid MEDLINE, Ovid EMBASE, Ovid AMED, CINAHL, Scopus and The Cochrane Library) and reference lists from relevant papers were searched on 2 September 2013. Sixteen papers that reported on the association between body composition and foot structure and function met our inclusion criteria and were reviewed. The evidence indicates that obesity is strongly associated with planus (low-arched) foot posture, pronated dynamic foot function and increased plantar pressures when walking. However, there is limited evidence to support an association between other body composition measures, such as fat mass, with foot structure or function.

OBJECTIVE: Foot pain is a common complaint in adults. Increased BMI and fat mass have been linked only to foot pain prevalence. Therefore, a longitudinal study to examine the relationship between body composition and incident foot pain over 3 years was conducted. DESIGN AND METHODS: Sixty-one community dwelling participants from a previous study of musculoskeletal health, who did not have foot pain at study inception in 2008, were invited to take part in this follow-up study in 2011. Current foot pain was determined using the Manchester Foot Pain and Disability Index, and body composition was measured using dual X-ray absorptiometry at study baseline. RESULTS: Of the 51 respondents (84% response rate, 37 females and 14 males), there were 11 who developed foot pain. BMI ranged from underweight to morbidly obese (17-44 kg/m2), mean 27.0 ± 6.0 kg/m2. Incident foot pain was positively associated with both fat mass (odds ratio [OR] 1.11, 95% confidence interval [CI] 1.03-1.20) and fat-mass index (OR 1.28, 95% CI 1.04-1.57) in multivariate analysis. CONCLUSIONS: Fat mass is a predictor of incident foot pain. This study supports the notion that incident foot pain in overweight individuals is associated with fat mass rather than body mass alone.

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.

Background\ud Foot pain has been shown to be prevalent across all age groups. The presence of foot pain may reduce mobility and impact on the ability to undertake activities of daily living. The aim of this study was to determine factors that are predictive of foot pain in a community based sample of the general population.\ud \ud Methods\ud This study analysed data from the North West Adelaide Health Study, a cohort study located in the northwestern suburbs of Adelaide, South Australia. Data were obtained between 2004–2006 and 2008–2010, using a self-completed questionnaire, computer assisted telephone interviewing, and a clinical assessment. The sensitivity, specificity and positive predictive values of variables were determined and generalised linear models ascertained the variables associated with the highest relative risk of self-reporting foot pain in 2008–2010 based on the data obtained in 2004–2006.\ud \ud Results\ud The prevalence of foot pain in 2004–2006 was 14.9 % (95 % CI 13.6–16.4) and in 2008–2010, 29.9 % (95 % CI 27.5–32.5). Variables with the highest sensitivity were: female sex, ever having back pain, self-reported arthritis, body mass index (BMI) classified as obese and having foot pain in 2004–2006, while most variables demonstrated high specificity. Those with the highest risk of reporting foot pain in 2008–2010 were those with depressive symptoms, self-reported arthritis, high BMI, self-reported upper limb pain and foot pain (in general or in specific regions of the foot) in 2004–2006.\ud \ud Conclusion\ud Foot pain is common in the general population and those with the greatest risk of foot pain potentially represent a high level of chronicity and potential burden on the health system. Addressing the factors that predict foot pain, as well as the provision of targeted messages to highlight the importance of managing foot pain, may help reduce the impact on the population.

The primary aim of this systematic review was to investigate the relationship between body mass index (BMI) and foot disorders. The secondary aim was to investigate whether weight loss is effective for reducing foot pain. Five electronic databases (Ovid MEDLINE, Ovid EMBASE, Ovid AMED, CINAHL and The Cochrane Library) and reference lists from relevant papers were searched in April 2011. Twenty-five papers that reported on the association between BMI and musculoskeletal foot disorders met our inclusion criteria and were reviewed. The evidence indicates: (i) a strong association between increased BMI and non-specific foot pain; and (ii) a strong association between increased BMI and chronic plantar heel pain in a non-athletic population. The evidence is inconclusive regarding the relationship between BMI and the following specific disorders of the foot; hallux valgus, tendonitis, osteoarthritis and flat foot. With respect to our second aim, there were only two prospective cohort studies that reported a reduction in foot symptoms following weight loss surgery. In summary, increased BMI is strongly associated with non-specific foot pain in the general population and chronic plantar heel pain in a non-athletic population. However, there is currently limited evidence to support weight loss to reduce foot pain.

Hypothesis Plantar heel pain (plantar fasciitis) is a common and disabling condition. A variety of treatment options are available to patients with plantar heel, however the evidence for these treatments is generally weak and the best way to manage plantar heel pain remains unclear. Trigger point dry needling is increasingly used as an adjunct therapy for musculoskeletal pain. In patients with plantar heel pain this technique is thought to improve muscle activation patterns, increase joint range of motion and alleviate pain. However, there have been no randomised controlled trials that have evaluated the effectiveness of dry needling for plantar heel pain. Methods In order to develop a treatment protocol to evaluate the effectiveness of dry needling for plantar heel pain we conducted a three stage modified Delphi process using a web-based survey technique. Over a series of three iterations, 30 experts (participants) worldwide indicated their level of agreement on specific issues relating to the use of dry needling for plantar heel pain including their treatment rationale, needling details and treatment regimen. Consensus for a dry needling protocol for plantar heel pain was achieved when >60% of participants (IQR ≤ 1.0 category on 5-point Likert scale) agreed the protocol was adequate. Results The response rate was 75% (n=30), 100% (n=30) and 93% (n=28) in the first, second and third rounds respectively. Round 1 helped generate a list of 10 items that were deemed important for developing a dry needling protocol for plantar heel pain. These 10 items were subsequently presented in Round 2. Of these, 5 of the 10 items met the criteria to be included in a dry needling protocol for plantar heel pain that was presented in the final round, Round 3. Items that did not meet the criteria were either removed or amended and then presented in Round 3. In the final round, 93% of participants (IQR range = 1) agreed the proposed dry needling protocol for plantar heel pain was adequate. The protocol can now be used in future research projects designed to evaluate the effectiveness of dry needling for plantar heel pain.

Plantar heel pain is one of the most common musculoskeletal conditions affecting the foot and it is commonly experienced by older adults. Contoured foot orthoses and some heel inserts have been found to be effective for plantar heel pain, however the mechanism by which they achieve their effects is largely unknown. The aim of this study was to investigate the effects of foot orthoses and heel inserts on plantar pressures in older adults with plantar heel pain. Thirty-six adults aged over 65 years with plantar heel pain participated in the study. Using the in-shoe Pedar(®) system, plantar pressure data were recorded while participants walked along an 8 m walkway wearing a standardised shoe and 4 different shoe inserts. The shoe inserts consisted of a silicon heel cup, a soft foam heel pad, a heel lift and a prefabricated foot orthosis. Data were collected for the heel, midfoot and forefoot. Statistically significant attenuation of heel peak plantar pressure was provided by 3 of the 4 shoe inserts. The greatest reduction was achieved by the prefabricated foot orthosis, which provided a fivefold reduction compared to the next most effective insert. The contoured nature of the prefabricated foot orthosis allowed for an increase in midfoot contact area, resulting in a greater redistribution of force. The prefabricated foot orthosis was also the only shoe insert that did not increase forefoot pressure. The findings from this study indicate that of the shoe inserts tested, the contoured prefabricated foot orthosis is the most effective at reducing pressure under the heel in older people with heel pain.