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Due to the exponential increase in the quantity and quality of podiatric medicine–related research during the past decade, podiatric physicians are inundated with an insurmountable volume of research relevant to clinical practice. Systematic reviews can refine this literature by using explicit, rigorous, and reproducible methods to identify, critically appraise, and synthesize the best evidence from all clinical trials to answer clearly defined clinical questions. The Cochrane Collaboration is an international not-for-profit organization created to improve the user-friendliness and accessibility of medical literature mainly through preparing and maintaining systematic reviews of health-care interventions. The Cochrane Library currently contains more than 50 podiatric medicine–relevant systematic reviews summarizing and synthesizing evidence from many hundreds of randomized controlled trials evaluating interventions for foot problems. Although more than 60 countries worldwide have open online access to The Cochrane Library, in the United States, only the state of Wyoming has free access to full-text reviews. In an era demanding an evidence-based approach for every clinical intervention, high-quality systematic reviews streamline podiatric medical literature by reducing the time, cost, and training necessary to establish a solid evidence base for practice. (J Am Podiatr Med Assoc 99(3): 260–266, 2009)

Summary Objectives To evaluate a radiographic atlas for grading foot osteoarthritis (OA) in relation to the relative sensitivity of different radiographic and views and features, and to examine the relationship between radiographic OA and foot symptoms. Methods Weightbearing dorso-plantar (DP) and lateral foot radiographs were obtained from 197 people (126 women and 71 men) aged 62–94 years (mean age 75.9, standard deviation [SD] 6.6). The prevalence of OA in five joints (the first metatarsophalangeal joint [1st MPJ], the first cuneo-metatarsal joint [1st CMJ], the second cuneo-metatarsal joint [2nd CMJ], the navicular-first cuneiform joint [N1st CJ] and the talo-navicular joint [TNJ]) was then determined using both views in combination (as recommended in the atlas), or by using either view in isolation. Associations between radiographic OA in individual foot joints and symptoms were then explored. Results Joint-specific prevalence of OA using both DP and lateral views was 1st MPJ (42.4%), 1st CMJ (22.6%), 2nd CMJ (60.2%), N1st CJ (39.1%) and TNJ (32.7%). Using only the DP view detected almost all cases of 1st MPJ OA (94.6%), however, the sensitivity was lower for the other joints (31.0–60.7%). Using only the lateral view detected almost all cases of OA (83.8 to 86.9%), with the exception of the 1st MPJ and 1st CMJ (50.9% and 60.7%, respectively). Using either osteophytes (OP) alone or joint space narrowing (JSN) alone showed low sensitivity for all joints (14.3–63.0%), with the exception of OP alone in the DP view for the 1st MPJ and JSN in the lateral view for the 2nd CMJ (83.8% and 84.0%, respectively). Radiographic OA in individual foot joints and the total number of joints affected were both moderately associated with foot symptoms. Conclusion Epidemiological and clinical studies should incorporate observation of both OP and JSN from both DP and lateral views to determine the presence of OA in the foot, as the number of cases detected is reduced if only one radiographic feature or view is used. Radiographic foot OA is common in older people and is moderately associated with foot symptoms.

The purpose of this study was to evaluate differences in dynamic plantar pressure distribution between older people with and without radiographically confirmed osteoarthritis (OA) of the first metatarsophalangeal joint (first MPJ) of the foot. Dynamic plantar pressure recordings using the TekScan MatScan system were obtained during barefoot level walking in 40 older participants; 20 with radiographically confirmed OA of the first MPJ displaying less than 55 degrees of passive dorsiflexion, and 20 with no evidence of OA in the first MPJ displaying greater than 55 degrees of passive dorsiflexion. Group comparisons between the variables maximum force and peak pressure were made for seven different regions underneath the right foot (heel, midfoot, first MPJ, second MPJ, third to fifth MPJs, hallux, and lesser toes). Compared to the control group, participants with OA of the first MPJ exhibited 34% greater maximum force (7.9 +/- 2.5 vs. 5.9 +/- 1.7 kg, p = 0.005) and 23% higher peak pressure (1.6 +/- 0.3 vs. 1.3 +/- 0.3 kg/cm(2), p = 0.001) under the hallux. Similar results were also found under the lesser toes with 43% greater maximum force (5.0 +/- 1.9 vs. 3.5 +/- 1.4 kg; p = 0.006) and 29% higher peak pressure (0.9 +/- 0.2 vs. 0.7 +/- 0.2 kg/cm(2), p = 0.018). No significant differences were found to exist between groups for any other plantar region. These findings indicate that OA of the first MPJ is associated with significant changes in load-bearing function of the foot, which may contribute to the development of secondary pathological changes associated with the condition, such as plantar callus formation and hyperextension of the hallux interphalangeal joint.

Background There is a common misperception that a statistically significant result in clinical research equates to a meaningful or worthwhile outcome for patients. However, not all statistically significant findings are considered important by patients. Objective This research project aimed to calculate the minimal important difference for commonly used outcome measures in research related to the feet. Methods Data from 175 participants from two trials that evaluated conservative interventions for plantar fasciitis were used to determine minimal important differences for the following outcome measures: the Foot Health Status Questionnaire, the original Foot Function Index and a Visual Analogue Scale used to measure pain. The mean change in the outcome measure was compared to a simple global question of improvement. The amount of change in the outcome measure that related to "a little change" in the global improvement question represented the minimal important difference. Results For the Foot Health Status Questionnaire the following minimal important differences were found: 14 for pain, 7 for function and 9 for general foot health. Similar results were found for the Foot Function Index: 12 for pain, 7 for disability and 7 for Total Foot Function Index. The minimal important difference for the Visual Analogue Scale was 9mm. Conclusion Our findings can be used to help interpret results from clinical trials that have used these outcome measures to evaluate the effectiveness of interventions, particular for the treatment of plantar fasciitis. Researchers can also utilise these minimal important differences to assist in prospective sample size calculations for clinical trials, although caution is required for trials on disorders other than plantar fasciitis.

Plantar heel pain, also known as plantar fasciitis, causes soreness or tenderness of the sole of the foot under the heel, which sometimes extends into the medial arch. Pain associated with the condition may cause substantial disability and poor health-related quality of life. The prevalence and prognosis are unclear, but the symptoms seem to resolve over time in most people.We conducted a systematic overview, aiming to answer the following clinical questions: What are the effects of conservative treatments for plantar heel pain? What are the effects of non-conservative treatments for plantar heel pain? We searched: Medline, Embase, The Cochrane Library and other important databases up to November 2013 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review).At this update, searching of electronic databases retrieved 162 studies. After deduplication and removal of conference abstracts, 84 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 39 studies and the further review of 45 full articles. Of the 45 full articles evaluated, five systematic reviews and nine RCTs were included at this update. We performed a GRADE evaluation for 30 PICO combinations.In this systematic overview, we categorised the efficacy for 12 interventions based on information relating to the effectiveness and safety of corticosteroid injection alone (both short-term and longer-term effects), corticosteroid injections plus local anaesthetic injection (both short-term and longer-term effects), customised foot orthoses, extracorporeal shock wave therapy, heel pads and cups, local anaesthetic injection alone, night splints, stretching exercises, surgery, and taping.

Background There is uncertainty as to which foot posture measures are the most valid in terms of predicting kinematics of the foot. The aim of this study was to investigate the associations of clinical measures of static foot posture and mobility with foot kinematics during barefoot walking. Method Foot posture and mobility were measured in 97 healthy adults (46 males, 51 females; mean age 24.4 ± 6.2 years). Foot posture was assessed using the 6-item Foot Posture Index (FPI), Arch Index (AI), Normalised Navicular Height (NNHt) and Normalised Dorsal Arch Height (DAH). Foot mobility was evaluated using the Foot Mobility Magnitude (FMM) measure. Following this, a five-segment foot model was used to measure tri-planar motion of the rearfoot, midfoot, medial forefoot, lateral forefoot and hallux. Peak and range of motion variables during load acceptance and midstance/propulsion phases of gait were extracted for all relative segment to segment motion calculations. Hierarchical regression analyses were conducted, adjusting for potential confounding variables. Results The degree of variance in peak and range of motion kinematic variables that was independently explained by foot posture measures was as follows: FPI 5 to 22 %, NNHt 6 to 20 %, AI 7 to 13 %, DAH 6 to 8 %, and FMM 8 %. The FPI was retained as a significant predictor across the most number of kinematic variables. However, the amount of variance explained by the FPI for individual kinematic variables did not exceed other measures. Overall, static foot posture measures were more strongly associated with kinematic variables than foot mobility measures and explained more variation in peak variables compared to range of motion variables. Conclusions Foot posture measures can explain only a small amount of variation in foot kinematics. Static foot posture measures, and in particular the FPI, were more strongly associated with foot kinematics compared with foot mobility measures. These findings suggest that foot kinematics cannot be accurately inferred from clinical observations of foot posture alone. Electronic supplementary material The online version of this article (doi:10.1186/s13047-015-0122-5) contains supplementary material, which is available to authorized users.

Process Initially, two systematic reviews were undertaken to assess: (i) the relationship between body mass index with musculoskeletal foot disorders, and (ii) the relationship between body composition and foot structure and function. Following this, we undertook a longitudinal and cross-sectional study of fat mass and foot pain to determine any association. Finally, a cross-sectional study of foot posture, range of motion and plantar pressure characteristics in obese and non-obese individuals was undertaken.

Foot orthoses are frequently used for the prevention of lower limb overuse injuries but evidence for their effectiveness is limited. The primary aim of this study is to determine if prefabricated foot orthoses reduce the incidence of lower limb overuse injuries in naval recruits undertaking 11 weeks of basic training. This study is a participant and assessor blinded, parallel-group, randomised controlled trial. The trial will recruit participants undertaking 11 weeks of basic training at the Royal Australian Navy Recruit School, Cerberus, Victoria, Australia. Participants will be randomised to a control group (flat insole) or an intervention group (prefabricated foot orthosis). Over the 11 weeks of basic training, participants will document the presence and location of pain in weekly self-report diaries. The end-point for each participant will be the completion of 11 weeks of basic training. The primary outcome measure will be the combined incidence of four lower limb injuries (medial tibial stress syndrome, patellofemoral pain, Achilles tendinopathy, and plantar fasciitis/plantar heel pain) which are common among defence members. Secondary outcome measures include: (i) overall incidence of lower limb pain, (ii) severity of lower limb pain, (iii) time to injury, (iv) time to drop-out due to injury, (v) adverse events, (vi) number of lost training days, (vii) shoe comfort, and (viii) general health status. Data will be analysed using the intention-to-treat principle. This randomised controlled trial will evaluate the effectiveness of prefabricated foot orthoses for the prevention of common lower limb overuse injuries in naval recruits. Australian New Zealand Clinical Trials Registry: ACTRN12615000024549 .

BackgroundRandomized trials must be of high methodological quality to yield credible, actionable findings. The main aim of this project was to evaluate whether there has been an improvement in the methodological quality of randomized trials published in the Journal of the American Podiatric Medical Association (JAPMA).MethodsRandomized trials published in JAPMA during a 15-year period (January 1999 to December 2013) were evaluated. The methodological quality of randomized trials was evaluated using the PEDro scale (scores range from 0 to 10, with 0 being lowest quality). Linear regression was used to assess changes in methodological quality over time.ResultsA total of 1,143 articles were published in JAPMA between January 1999 and December 2013. Of these, 44 articles were reports of randomized trials. Although the number of randomized trials published each year increased, there was only minimal improvement in their methodological quality (mean rate of improvement = 0.01 points per year). The methodological quality of the trials studied was typically moderate, with a mean ± SD PEDro score of 5.1 ± 1.5. Although there were a few high-quality randomized trials published in the journal, most (84.1%) scored between 3 and 6.ConclusionsAlthough there has been an increase in the number of randomized trials published in JAPMA, there is substantial opportunity for improvement in the methodological quality of trials published in the journal. Researchers seeking to publish reports of randomized trials should seek to meet current best-practice standards in the conduct and reporting of their trials.

Background Digital nerve blocks are widely used prior to minor surgery to the digits but the injections are associated with some degree of unwanted pain and anxiety. Methods to reduce the pain associated with injection, such as cryotherapy, are therefore worthwhile. However, cryotherapy (e.g. ice) applied prior to digital injections has received little scientific evaluation. Objective This study aimed to assess whether there was any change in pain associated with an injection into the hallux, if the site of injection was first refrigerated using ice. Method Twenty participants each received two injections of lignocaine into the hallux (one each on the medial and lateral sides) as a standard digital nerve block. Prior to each injection, participants were randomized to receive either no-ice or a six-minute application of ice over the injection site. The primary outcomes were needle-stick pain and infiltration pain measured on a visual analogue pain scale. Results The application of ice significantly reduced needle-stick pain, with the median scores for the no-ice and ice injections being 57 and 16mm, respectively ( P P =0.204). Nevertheless, 16 out of 20 participants preferred ice prior to the injection. Only four indicated no preference and none indicated a preference for no-ice. Conclusion Icing the digit prior to injection is an effective and inexpensive method to reduce the discomfort of a local anaesthetic injection.

A systematic review.To determine the strength of evidence of the effect of low-Dye taping on lower limb kinematic, kinetic, and electromyographic variables.Low-Dye taping is a foot-taping technique that aims to limit foot pronation and is commonly used to treat a number of foot disorders.Systematic review of randomized or quasi-randomized trials examining the effect of low-Dye taping compared with no taping on kinematic, kinetic, and electromyographic variables. Trials were identified by searching CINAHL, EMBASE, MEDLINE, SPORTDiscus, and CENTRAL, and by recursive checking of bibliographies. Data were extracted from published trials and from mail contact with authors for further information as necessary. Meta-analyses were planned for all outcomes using the generic inverse variance method. Sensitivity analyses were planned by pooling data from nonrandomized trials. Statistical heterogeneity was assessed using the quantity I2.Six trials met inclusion criteria and, of these, 5 trials reported sufficient data on kinematic and kinetic variables to be included in the analysis. Results from the 5 randomized trials were considered robust when pooled with data from 7 nonrandomized trials in a sensitivity analysis. When compared to no taping, low-Dye taping increased navicular height immediately after application (weighted mean difference [WMD], 5.90 mm; 95% confidence interval [CI], 0.41 to 11.39; P = .04) and had no effect on navicular height post exercise (WMD, 4.70 mm; 95% CI, -0.61 to 10.01; P = .08), maximum rearfoot eversion while walking (WMD, -0.59 degrees; 95% CI, -2.53 to 1.35; P = .55), and total rearfoot range of motion while walking (WMD, 2.3 degrees; 95% CI, -0.64 to 5.24; P = .13).Low-Dye taping provides a small change in navicular height post application, although it is unclear whether this change is clinically important. There was high heterogeneity between some trials examining other variables, indicating that more research is needed to confirm the results of previous trials.

Variations in foot posture are associated with the development of some lower limb injuries. However, the mechanisms underlying this relationship are unclear. The objective of this study was to compare foot kinematics between normal, pes cavus and pes planus foot posture groups using a multi-segment foot model. Ninety-seven healthy adults, aged 18-47 were classified as either normal (n=37), pes cavus (n=30) or pes planus (n=30) based on normative data for the Foot Posture Index, Arch Index and normalised navicular height. A five segment foot model was used to measure tri-planar motion of the rearfoot, midfoot, medial forefoot, lateral forefoot and hallux during barefoot walking at a self-selected speed. Angle at heel contact, peak angle, time to peak angle and range of motion was measured for each segment. One way ANOVAs with post hoc analyses of mean differences were used to compare foot posture groups. The pes cavus group demonstrated a distinctive pattern of motion compared to the normal and pes planus foot posture groups. Effect sizes of significant mean differences were large and comparable to similar studies. Three key differences in overall foot function were observed between the groups: (i) altered frontal and transverse plane angles of the rearfoot in the pes cavus foot; (ii) less midfoot motion in the pes cavus foot during initial contact and midstance; and (iii) reduced midfoot frontal plane ROM in the pes planus foot during pre-swing. These findings indicate that foot posture does influence motion of the foot.

Clinicians often use foot orthoses to manage the symptoms of plantar fasciitis. Although there has been considerable research evaluating the effectiveness of orthoses for this condition, there is still a lack of scientific evidence that is of suitable quality to fully inform clinical practice. Randomized controlled trials are recognized as the “gold standard” when evaluating the effectiveness of treatments. We discuss why randomized controlled trials are so important, the features of a well-conducted randomized controlled trial, and some of the problems that arise when trial design is not sound. We then evaluate the available evidence for the use of foot orthoses, with particular focus on published randomized controlled trials. From the evidence to date, it seems that foot orthoses do have a role in the management of plantar fasciitis and that prefabricated orthoses are a worthwhile initial management strategy. At this time, however, it is not possible to recommend either prefabricated or customized orthoses as being better, and it cannot be inferred that customized orthoses are more effective over time and therefore have a cost advantage. Additional good-quality randomized controlled trials are needed to answer these questions. (J Am Podiatr Med Assoc 94(6): 542–549, 2004)

Some clinicians may feel dissociated from, and intimidated by the ever-increasing emphasis on research. However, with an understanding of some of the basic principles and key terms, research can feel less daunting. It is the aim of this article, the second in a series of three focusing on understanding research, to introduce clinicians to the different approaches to research, to improve understanding of what the approaches mean, and to highlight when a particular approach may be appropriate. Furthermore, the article will provide an explanation of some of the common terms used within clinical research. This should aid the clinician in applying good, simple, scientific principles to evaluating clinical research evidence. (J Am Podiatr Med Assoc 92(3): 159-169, 2002)

Background Foot orthoses are commonly used for symptomatic flexible pes planus in adults. However, there are no clinical guidelines for the prescription of customised foot orthoses that are specific to this population. The aim of this study was to investigate prescription habits of Australian podiatrists for customised foot orthoses for symptomatic flexible pes planus in adults and to develop consensus-based practice recommendations for the prescription of these foot orthoses. Methods A four round Delphi survey was undertaken with 24 podiatric experts to establish current use and rationale for individual prescription variables of customised foot orthoses for symptomatic flexible pes planus in adults. Round one determined prescription use (consensus) and rounds two, three and four determined the rationale for use (agreement) of prescription variables across the rearfoot, midfoot, forefoot, as well as accommodation and materials used. For consensus and agreement to be accepted, 70% of the respondents were required to use or agree on the rationale for use of individual prescription variables. Results Consensus was reached in round one for two variables, choice of shell material (polyolefin) and when to prescribe a forefoot post balanced to perpendicular. In rounds two, three and four, agreement was reached for 52 statements related to the rationale for use of individual prescription variables, including when to prescribe: an inverted cast pour [heel in an inverted position], an inverted rearfoot post, a medial heel (Kirby) skive, minimal/maximum arch fill, a medial flange, a forefoot post and common orthotic accommodations. Conclusion This study found consensus or agreement for the use of several prescription variables for customised foot orthoses for symptomatic flexible pes planus in adults. The findings were used to develop the Foot orthosis Prescription Recommendations for symptOmatic flexible Pes planus in adults (FootPROP) proforma, to guide clinicians and researchers in the prescription of customised foot orthoses for this population. Electronic supplementary material The online version of this article (doi:10.1186/s13047-014-0049-2) contains supplementary material, which is available to authorized users.

Aim To evaluate the effectiveness of customised foot orthoses in chronic mid-portion Achilles tendinopathy. Methods This was a participant-blinded, parallel-group randomised controlled trial at a single centre (La Trobe University, Melbourne, Australia). One hundred and forty participants aged 18–55 years with mid-portion Achilles tendinopathy were randomised to receive eccentric calf muscle exercises with either customised foot orthoses (intervention group) or sham foot orthoses (control group). Allocation to intervention was concealed. The Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire was completed at baseline, then at 1, 3, 6 and 12 months, with 3 months being the primary end point. Differences between groups were analysed using intention to treat with analysis of covariance. Results After randomisation into the customised foot orthoses group (n=67) or sham foot orthoses group (n=73), there was 70.7% follow-up of participants at 3 months. There were no significant differences between groups at any time point. At 3 months, the mean (SD) VISA-A score was 82.1 (16.3) and 79.2 (20.0) points for the customised and sham foot orthosis groups, respectively (adjusted mean difference (95% CI)=2.6 (−2.9 to 8.0), p=0.353). There were no clinically meaningful differences between groups in any of the secondary outcome measures. Conclusions Customised foot orthoses, prescribed according to the protocol in this study, are no more effective than sham foot orthoses for reducing symptoms and improving function in people with mid-portion Achilles tendinopathy undergoing an eccentric calf muscle exercise programme. Trial Registration Number Australian New Zealand Clinical Trials Registry: number ACTRN12609000829213.

Background Offloading is key to preventing or healing plantar neuropathic foot ulcers in diabetes. Total contact casts or walkers rendered irremovable are recommended in guidelines as first-line options for offloading, however the use of such devices has been found to be low. This study aimed to investigate offloading practices for diabetes-related plantar neuropathic ulcers. Methods An online survey of closed and open-ended questions was administered via SurveyMonkey®. Forty-one podiatrists experienced in high-risk foot practice, from 21 high-risk foot services around Australia, were approached to participate. Results The response rate was 88%. Participants reported using 21 modalities or combinations of modalities, for offloading this ulcer type. The most frequently used modalities under the forefoot and hallux were felt padding, followed by removable casts or walkers, then non-removable casts or walkers. Participants indicated that many factors were considered when selecting offloading modality, including: compliance, risk of adverse effects, psycho-social factors, restrictions on activities of daily living, work needs and features of the wound. The majority of participants (83%) considered non-removable casts or walkers to be the gold-standard for offloading this ulcer type, however they reported numerous, particularly patient-related, barriers to their use. Conclusions Selecting offloading for the management of foot ulceration is complex. Felt padding, not the gold-standard non-removable cast or walker, was reported as the most commonly selected modality for offloading plantar neuropathic ulceration. However, further evaluation of felt padding in high quality clinical trials is required to ascertain its effectiveness for ulcer healing.

Background Plantar heel pain can be managed with dry needling of myofascial trigger points; however, there is only poor-quality evidence supporting its use. Objective The purpose of this study was to evaluate the effectiveness of dry needling for plantar heel pain. Design The study was a parallel-group, participant-blinded, randomized controlled trial. Setting The study was conducted in a university health sciences clinic. Patients Study participants were 84 patients with plantar heel pain of at least 1 month's duration. Intervention Participants were randomly assigned to receive real or sham trigger point dry needling. The intervention consisted of 1 treatment per week for 6 weeks. Participants were followed for 12 weeks. Measurements Primary outcome measures included first-step pain, as measured with a visual analog scale (VAS), and foot pain, as measured with the pain subscale of the Foot Health Status Questionnaire (FHSQ). The primary end point for predicting the effectiveness of dry needling for plantar heel pain was 6 weeks. Results At the primary end point, significant effects favored real dry needling over sham dry needling for pain (adjusted mean difference: VAS first-step pain=−14.4 mm, 95% confidence interval [95% CI]=−23.5 to −5.2; FHSQ foot pain=10.0 points, 95% CI=1.0 to 19.1), although the between-group difference was lower than the minimal important difference. The number needed to treat at 6 weeks was 4 (95% CI=2 to 12). The frequency of minor transitory adverse events was significantly greater in the real dry needling group (70 real dry needling appointments [32%] compared with only 1 sham dry needling appointment [ Limitations It was not possible to blind the therapist. Conclusion Dry needling provided statistically significant reductions in plantar heel pain, but the magnitude of this effect should be considered against the frequency of minor transitory adverse events.

Background Plantar forefoot pain is commonly experienced by older people and it is often treated with forefoot pads to offload the painful area. However, studies have found inconsistent effects for different forefoot pads on plantar pressure reduction, and optimum forefoot pad placement is still not clear. The aim of this study was to compare the effects of different forefoot pads on plantar pressure under the forefoot in older people with forefoot pain. Methods Thirty-seven adults (31 females, 6 males) with a mean age of 73.5 (SD 4.8) participated. Forefoot plantar pressure data were recorded using the pedar®-X in-shoe system while participants walked along an 8 m walkway. Five conditions were tested in a standardised shoe: (i) no padding (the control), (ii) a metatarsal dome positioned 10 mm proximal to the metatarsal heads, (iii) a metatarsal dome positioned 5 mm distal to the metatarsal heads, (iv) a metatarsal bar, and (v) a plantar cover. Results Compared to the shoe-only control condition, each of the forefoot pads significantly reduced forefoot peak pressure and maximum force. The metatarsal dome positioned 5 mm distal to the metatarsal heads and the plantar cover were most effective for reducing peak pressure (17%, p p Conclusions These findings indicate that forefoot pads are effective for reducing forefoot pressures in older people with forefoot pain, and that the position of the pad relative to the metatarsal heads may be more important than the shape of the pad.

This research project investigated the orthotic prescription habits of podiatric physicians in Australia and New Zealand. A 23-item questionnaire was distributed to all members of the Australian Podiatry Association and the New Zealand Society of Podiatrists. When asked what type of foot orthoses they prescribe most often, 72% of respondents reported functional foot orthoses; the next most common response was prefabricated orthoses (12%). A typical prescription for functional foot orthoses consisted of a modified Root style orthosis, balanced to the neutral calcaneal stance position, with the shell made from polypropylene and an ethyl vinyl acetate (EVA) rearfoot post applied. The majority of podiatric physicians surveyed used a commercial orthotic laboratory to fabricate their orthoses. However, New Zealand respondents were three times more likely to prescribe prefabricated foot orthoses, and males were twice as likely as females to manufacture the orthoses themselves rather than use a commercial orthotic laboratory. (J Am Podiatr Med Assoc 91(4): 174-183, 2001)

Obesity is a world-wide health problem and is strongly associated with musculoskeletal disorders of the lower limb. The aim of this study was to evaluate plantar loading patterns in obese and non-obese individuals, while accounting for the contribution of foot structure, range of motion and walking speed. Sixty-eight participants (mean±SD age, 52.6±8.0 years), including 47 females (69%), underwent assessments of body mass index, foot pain and foot structure. Plantar pressures were also obtained, using a floor-mounted resistive sensor mat system. Multiple regression analysis was used to determine which variables were most strongly associated with plantar loading patterns. Obese individuals exhibited flatter feet, reduced inversion-eversion range of motion, and higher peak plantar pressures when walking. After accounting for foot structure and walking speed, bodyweight was found to be significantly associated with elevated loading of the foot, particularly the forefoot and midfoot. These findings suggest that obesity increases the stresses applied to the foot directly, via increased bodyweight, and indirectly, via alterations to foot structure, which may partly explain the link between obesity and the development of foot pain. Clinicians dealing with foot problems should consider the effect of increased bodyweight on plantar loading in obese patients.

Health research published in journals provides an ever-increasing number of studies and trials that espouse the benefits of all sorts of interventions. But how do consumers of research, for example the readers of Journal of Foot and Ankle Research (JFAR), know whether to believe the findings of research articles that they read? Clearly, health journals have an unambiguous responsibility to support good quality research that provides believable findings. Equally, they also have a responsibility to filter out poor quality research that provides findings that are not believable. JFAR steadfastly supports good quality research and the editorial team (with the assistance of the peer-reviewers) work conscientiously to publish only those studies that are of the highest quality; that is, studies with believable findings. While this is not always easy, and the goal posts that define quality of research are constantly being repositioned, the editors strive to bring the readers of JFAR the best foot and ankle research. Unfortunately, not all studies use perfect methods, so if a study does have limitations and is published, then the editors are careful to ensure that the authors clearly acknowledge the limitations in their articles, affording readers an insight into the pitfalls of the study. To assist the editors in this task, there is a burgeoning array of guidelines and recommendations for the conduct and reporting of different study designs. For example, there are the CONsolidated Standards Of Reporting Trials (CONSORT) Statement [1] and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement [2]. Each guideline has been developed to ensure that important aspects of a trial or review are reported by the authors. To assist in this process, there is a checklist for each item in the guideline, which covers key aspects of a study (e.g. blinding, sample size determination and statistical analysis) that authors should report to ensure that they have included essential pieces of information, which ultimately makes the study’s findings more believable. That is, it prevents authors from deceiving the reader, by concealing that they did not do something they should have, or equally bad, done something that they should not have. As an added bonus to readers of such articles, if guidelines like CONSORT and PRISMA are followed they invariably make an article less ambiguous and much easier to understand what has occurred in the study. The developers of such guidelines are experts, with most having decades of highly active experience researching and practicing these study designs. They are also generous individuals that have provided the guidelines in consumer friendly packages that are freely available. Potential users of these guidelines can easily access them through the well-developed CONSORT [3] and PRISMA [4] websites. Further to the guidelines mentioned above, there are many others for different study designs, for example; the Guidelines for Reporting Reliability and Agreement Studies (GRRAS) [5] and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement [6,7]. Authors are recommended to consult these where appropriate and an excellent resource when writing manuscripts is that of the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) Network [8], which is a virtual one-stop shop for guidelines that are relevant to publishing in health science journals. The EQUATOR Network includes guidelines for both quantitative and qualitative research. JFAR, as a BioMed central journal, adheres to these guidelines and authors of studies that use these study designs are obliged to include such checklists upon submission of their article. Few foot and ankle journals ensure this or even worse, do not even recommend this. However, JFAR is setting the benchmark in this area because the editors believe that it leads to the highest possible quality research articles for its readers, and consequently the most believable findings will be presented in JFAR. Furthermore, if clinical trials – where participants receive an intervention that is evaluated – are considered in more detail, JFAR also demands that authors must register their trial with a recognised clinical trial registry. Ideally, clinical trials should be registered prior to recruitment. Up to now, JFAR has accepted clinical trials that have been registered with a recognised clinical trial registry after the first participant has been recruited. However, from now on, JFAR will only accept clinical trials that are registered prior to recruitment. Why is this important? To begin with, it means that all clinical trials can be tracked and the results of clinical trials are less likely to be not published, which occurs more frequently in ‘non-significant trials’ (where no difference is detected between interventions). However, an equally important reason is that it prevents investigators changing their protocol or analysis in light of their findings if they unwisely assess the results prior to the completion of the trial, or once they have evaluated the results but before publication (often referred to as over-analysing the data or “cherry-picking” the results, which results in bias). By default, this means that investigators have to commit to their protocol and analysis, thus keeping them honest, which again leads to more believable findings. There are many recognised clinical trial registries and a list of recommended registries can be found on the International Committee of Medical Journal Editors website (http://www.icmje.org/publishing_j.html). With all of this information in mind, two key points need to be considered. Firstly, consumers of articles that are published in JFAR should be assured that they are reading articles that present findings from high quality research. Secondly, potential authors of research manuscripts being submitted to JFAR need to adhere to the standards set by the journal; that is, they must read the guidelines for authors and carefully follow them when preparing their manuscripts. The journal’s guidelines are clear (http://www.jfootankleres.com/authors/instructions/research) and it is now, more than ever, not acceptable for authors to plead ignorance. As the impact of JFAR continues to increase, the editors are receiving more and more manuscripts to be considered for publication. This allows the editors more freedom to choose only the best quality research articles. If a manuscript is poorly written at the outset – for example, it has not adhered to the journal’s guidelines – then it has a much greater chance of rejection. Currently, JFAR rejects over 40% of the manuscripts submitted to it, and this figure is rising as the journal becomes more popular. For the best health journals in the world, such as New England Journal of Medicine and Lancet, this figure is about 95%. This means that they only publish the highest quality research. While there are exceptions, this research will generally be the most believable and will have the most impact. In conclusion, the editors of JFAR work hard to ensure that they provide a vehicle for the best quality foot and ankle research. While a small number of mistakes will undoubtedly be made and errors detected only after publication, readers can be assured that JFAR is trying to set the highest standards possible to foster a culture of believable research. We trust that readers of the journal can appreciate that such standards lead to better, more believable information for them. Some may view this as being elitist or exclusive, but if this is the price for believable research findings then that is a label the editors are prepared to wear. Conducting good research is not easy, and clear evidence can sometimes take years to compile (take the evidence for the ill-effects of tobacco smoking as a perfect example). Journals that follow an easy formula, where there are few checks and balances, ultimately provide a ‘fast food’ approach to health information – it may look fabulous and satiate ones appetite for knowledge easily, but it is not good for anyone in the long term. Professional journals have a responsibility to ensure that statements made in manuscripts can be supported by the study findings (i.e. good-quality evidence). This responsibility should not be viewed as being elitist or exclusive and in no way suppresses freedom of expression. Indeed, the fundamental premise of scientific publication is the reporting of empirically verifiable facts, which means believable information.

This paper reviews the literature relating to foot orthoses, in particular foot orthoses that attempt to alter biomechanical function. Whilst few well-controlled studies have been performed, the findings from the available literature are generally positive. The authors provide an overview of this literature and then summarise the findings. The literature is categorised into six research outcome areas: (i) patient satisfaction, (ii) pain and deformity, (iii) plantar pressures, (iv) position and motion, (v) muscle activity, and (vi) oxygen consumption. In addition, the difficulties associated with researching foot orthoses are discussed.

This paper is designed to be a guide to the classification and treatment of fifth metatarsal fractures. Types of fifth metatarsal fracture include: avulsion fracture of the tuberosity, proximal diaphyseal (Jones) fracture, proximal diaphyseal stress fracture, diaphyseal (shaft) fracture, and fractures of the neck and head. Diagnosis of these fractures can be made with a sound anatomical knowledge, identification of the mechanism of injury and previous symptoms, as well as appropriate X-ray examination. Confusion with diagnosis may occur due to the similarity of the proximal fractures on X-ray and the presence of normal variants around the base of the metatarsal. Treatment of fifth metatarsal fractures is usually conservative unless the fracture is a proximal diaphyseal fracture. Proximal diaphyseal fractures (Jones and stress) require long periods of nonweightbearing immobilization or internal fixation as they are prone to delayed union. Delayed union may occur due to the mechanics of the fifth metatarsal and the poor blood supply to the proximal diaphysis. To avoid unsatisfactory long-term results, clinicians must be aware of the different types of fifth metatarsal fracture, in particular the proximal diaphyseal fractures.

Variations in foot posture, such as pes planus (low-arched foot) or pes cavus (high-arched foot), are thought to be an intrinsic risk factor for injury due to altered motion of the lower extremity. Hence, the aim of this systematic review was to investigate the relationship between foot posture and lower limb kinematics during walking. A systematic database search of MEDLINE, CINAHL, SPORTDiscus, Embase and Inspec was undertaken in March 2012. Two independent reviewers applied predetermined inclusion criteria to selected articles for review and selected articles were assessed for quality. Articles were then grouped into two broad categories: (i) those comparing mean kinematic parameters between different foot postures, and (ii) those examining associations between foot posture and kinematics using correlation analysis. A final selection of 12 articles was reviewed. Meta-analysis was not conducted due to heterogeneity between studies. Selected articles primarily focused on comparing planus and normal foot postures. Five articles compared kinematic parameters between different foot postures - there was some evidence for increased motion in planus feet, but this was limited by small effect sizes. Seven articles investigated associations between foot posture and kinematics - there was evidence that increasing planus foot posture was positively associated with increased frontal plane motion of the rearfoot. The body of literature provides some evidence of a relationship between pes planus and increased lower limb motion during gait, however this was not conclusive due to heterogeneity between studies and small effect sizes.

"“When you can measure what you are speaking about, and express it in numbers, you know something about it; but when you cannot measure it, when you cannot express it in numbers, your knowledge is of a meagre and unsatisfactory kind”" Lord Kelvin, 1883 [1]. Science is all about quantification. It is therefore somewhat ironic that the mechanism by which science is disseminated – academic publishing – has yet to develop an acceptable way of measuring itself. Several fundamental issues regarding the scholarly publishing enterprise remain largely unresolved, such as how journal performance should be assessed, how journals should be compared and ranked, and how the impact of individual manuscripts should be evaluated. These issues are of relevance not only to journal editors and publishers, but also to librarians, who need to decide which journals to purchase, to researchers, who need to decide which journals to select for submission to, and to clinicians, who need to decide which journals they should read. By far the most widely used measure of journal performance is the Impact Factor, first developed by Eugene Garfield in 1955 as a means of selecting which journals to include in the Science Citations Index[2-4]. The Impact Factor represents the average number of citations received per paper published in that journal during the two preceding years. For example, the Impact Factor of a journal in 2011 is calculated as follows: A = the number of times articles published in 2009 and 2010 were cited by indexed journals during 2011. B = the total number of "citable items" published by that journal in 2009 and 2010. ("citable items" include articles, reviews or proceedings and excludes editorials and letters). 2011 Impact Factor = A/B. Due largely to its simplicity, the Impact Factor has been widely adopted as a measure of journal “prestige”, and many researchers consider the Impact Factor when selecting a journal to which to submit their work. Impact Factors have also been used to assess the output of researchers seeking academic promotion [5] and to guide research resource allocation [6], although these broader applications of the Impact Factor in isolation are not recommended by Thomson Reuters, the company that owns the Impact Factor and publishes journal rankings through the Journal Citation Reports database [7]. Several valid criticisms have been made of the Impact Factor. These criticisms relate primarily to: (i) the questionable assumption that citation rates are a valid measure of research impact or quality, (ii) the entirely arbitrary (and for some disciplines, very short) window of two years in which citations to a manuscript “count” toward the Impact Factor calculation, (iii) the skewed distribution of manuscript citations within a journal (i.e. very highly cited papers make a disproportionate contribution to a journal’s Impact Factor), and (iv) limitations in the coverage of journals in the Thomson ISI database, which has an English-language and US bias [8-11]. There is also evidence of editors intentionally manipulating journal content to achieve a higher Impact Factor by instructing authors to cite more papers within the journal, and by publishing review papers and commentaries with high levels of self-citation [12-14]. Despite these significant limitations, it would appear that the Impact Factor will continue to play a role in journal rankings until a more appropriate metric takes its place, therefore it would be disingenuous of the editorial team at JFAR to suggest that the publication of our first Impact Factor is not of considerable interest to us. JFAR was formally accepted for tracking by Thomson ISI on November 18, 2011, and our first Impact Factor was therefore calculated from 2009–2011 data. In 2009–2010, JFAR published 66 manuscripts, which attracted 88 citations in 2011. Therefore, our first Impact Factor is 88/66 = 1.333. In other words, on average, each manuscript published in JFAR in 2009–2010 attracted an average of 1.333 citations in 2011. The obvious question that arises from this is whether 1.333 is a “good” Impact Factor, however the answer to this question depends largely on the frame of reference. Our journal is clearly not going to give the New England Journal of Medicine (Impact Factor = 53.298) a run for its money. However, relative to our competitors, JFAR’s Impact Factor compares extremely well. Of the 14 English-language journals specifically focused on foot and ankle research, only five are tracked by Thomson ISI (see Table 1), and JFAR’s Impact Factor is the highest in this group of journals. In a broader context, JFAR is listed under Thomson ISI’s Orthopaedics category, and is ranked 32nd out of the 63 journals in this discipline. Table 1 2011 Impact Factors of English language foot-specific journals Although the Impact Factor is the most well-known journal performance metric, an alternative, freely accessible journal ranking known as the SCImago Journal Rank has recently been developed by the technology company SCImago Lab [15]. The SCImago Journal Rank uses Elsevier’s more extensive SCOPUS database rather than Thomson ISI’s Web of Science, and uses a more complex algorithm similar to Google’s PageRank which accounts for both the number of citations received by a journal and the importance or prestige of the journals where the citations came from. The SCImago Journal Rank shares many of the limitations of the Impact Factor, however its developers argue that it is a more accurate reflection of a journal’s prestige due to: (i) the broader journal coverage of the SCOPUS database, (ii) a wider citation “window” of three years, (iii) a correction factor to prevent excessive self-citation (the proportion of self-citations is restricted to 33% of the total), and (iv) consideration of the “quality” of citations [16]. Of the 14 English-language journals specifically focused on foot and ankle research, ten are tracked by SCOPUS and therefore have a SCImago Journal Rank (see Table 2). Since 2009 when SCOPUS tracking commenced, JFAR’s SCImago Journal Rank has consistently been the highest in this group of journals (see Figure 1), and it is currently ranked 29th out of the 143 journals listed in the Orthopaedics and Sports Medicine category [17]. Table 2 2011 SCImago Journal Rankings of English-language foot-specific journals Figure 1 SCImago Journal Rankings of English language foot-specific journals, 1999–2011. Notwithstanding our concerns regarding the validity of both the Impact Factor and SCImago Journal Rank as measures of journal prestige, the editors of JFAR are very satisfied with the journal’s initial rankings, particularly given that we only commenced publication in July 2008. The publication of our Impact Factor and SCImago Journal Rank will undoubtedly influence the journal selection process of researchers in our discipline, so it is likely that the overall number of submissions to JFAR will increase in future years. However, rather than agonising over ubiquitous yet flawed journal performance metrics, we will continue to make editorial decisions based on the relevance and scientific quality of individual manuscripts, keeping in mind the (frequently cited) words of Nobel prize winning biologist Sydney Brenner: “Before we develop a pseudoscience of citation analysis, we should remind ourselves that what matters absolutely is the scientific content of a paper and that nothing will substitute for either knowing it or reading it” [18].

The chevron and scarf osteotomies are commonly used for the surgical management of hallux valgus (HV). However, there is debate as to whether one osteotomy provides more 1-2 intermetatarsal (1-2 IMA) correction than the other. The objective of this systematic review and meta-analysis was to compare the effectiveness of 3 types of first metatarsal osteotomy for reducing the 1-2 IMA in HV correction: the chevron osteotomy, the long plantar arm (modified) chevron osteotomy, and the scarf osteotomy. A systematic search for eligible studies was performed of the following databases: Medline, Embase (Ovid), CINAHL (EBSCO Host), and The Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials. Only English-language studies previous to May 2010 were included in the review. Additional hand and electronic content searches of relevant foot and orthopaedic journals were performed. Criteria for inclusion in this analysis included systematic reviews of randomized controlled trials, prospective and retrospective cohort studies, and case-control studies, as well as case-series studies involving the chevron, scarf, or long plantar arm chevron osteotomy of >20 participants with a minimum of 80% follow-up. Quality of evidence of the included studies was assessed with the Grading of Recommendations Assessment, Development and Evaluation system. All pooled analyses were based on a fixed effects model. There was a total of 1351 participants who underwent either a chevron (n = 1028), scarf (n = 300), or long plantar arm chevron osteotomy (n = 23). Only one study for the long plantar arm chevron group fitted the eligibility criteria for this review; however, it was not amenable to meta-analysis. The chevron osteotomy was associated with a mean reduction of 1-2 IMA from preoperative to postoperative of 5.33° (95% confidence interval, 5.12 to 5.54, p < .001), and the scarf osteotomy was associated with a mean reduction of 6.21° (95% confidence interval, 5.70 to 6.72, p < .001). There was a statistically significant 0.88° increase in the correction of the 1-2 IMA in favor of the scarf osteotomy compared with the chevron osteotomy. The studies included in this review were of very low- to low-quality evidence. Our findings indicate that the scarf osteotomy provides greater correction of the 1-2 IMA when used for HV correction. However, only a weak recommendation in favor of the scarf osteotomy can be made based on the low quality of evidence of the studies included in this analysis.

Background Despite emerging evidence that foot problems and inappropriate footwear increase the risk of falls, there is little evidence as to whether foot-related intervention strategies can be successfully implemented. The aim of this study was to evaluate adherence rates, barriers to adherence, and the predictors of adherence to a multifaceted podiatry intervention for the prevention of falls in older people. Methods The intervention group (n = 153, mean age 74.2 years) of a randomised trial that investigated the effectiveness of a multifaceted podiatry intervention to prevent falls was assessed for adherence to the three components of the intervention: (i) foot orthoses, (ii) footwear advice and footwear cost subsidy, and (iii) a home-based foot and ankle exercise program. Adherence to each component and the barriers to adherence were documented, and separate discriminant function analyses were undertaken to identify factors that were significantly and independently associated with adherence to the three intervention components. Results Adherence to the three components of the intervention was as follows: foot orthoses (69%), footwear (54%) and home-based exercise (72%). Discriminant function analyses identified that being younger was the best predictor of orthoses use, higher physical health status and lower fear of falling were independent predictors of footwear adherence, and higher physical health status was the best predictor of exercise adherence. The predictive accuracy of these models was only modest, with 62 to 71% of participants correctly classified. Conclusions Adherence to a multifaceted podiatry intervention in this trial ranged from 54 to 72%. People with better physical health, less fear of falling and a younger age exhibited greater adherence, suggesting that strategies need to be developed to enhance adherence in frailer older people who are most at risk of falling. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12608000065392.

ObjectivesTo evaluate the effectiveness of a single intra-articular injection of hylan G-F 20 (Synvisc) for symptomatic first metatarsophalangeal joint (MTPJ) osteoarthritis (OA).MethodsParticipants (n = 151) with symptomatic first MTPJ OA were randomly allocated to receive up to 1 ml intra-articular injection of either hylan G-F 20 or placebo (saline). Participants and assessors were blinded. Outcomes were evaluated at 1, 3 and 6 months after injection. The primary outcome measurement was the foot pain domain of the Foot Health Status Questionnaire (FHSQ) at 3 months. Secondary outcome measurements were foot function assessed via the FHSQ, first MTPJ pain and stiffness, magnitude of symptom change, global satisfaction, health-related quality of life (assessed using the Short-Form-36 version two), first MTPJ dorsiflexion range of motion, hallux plantar flexion strength, use of pain-relieving medication or co-interventions and changes in plantar pressures.ResultsNo statistically significant differences in foot pain were found between the groups at 3 months. There were few statistically significant differences in the secondary outcome measures. Overall, the incidence of adverse effects was not significantly different between groups.ConclusionsAn intra-articular injection of hylan G-F 20 is no more effective than a placebo in reducing symptoms in people with symptomatic first MTPJ OA.Australian New Zealand Clinical Trials Registry: number ACTRN12607000654459.

Objective To determine the effectiveness of a multifaceted podiatry intervention in preventing falls in community dwelling older people with disabling foot pain. Design Parallel group randomised controlled trial. Setting University health sciences clinic in Melbourne, Australia. Participants 305 community dwelling men and women (mean age 74 (SD 6) years) with disabling foot pain and an increased risk of falling. 153 were allocated to a multifaceted podiatry intervention and 152 to routine podiatry care, with 12 months’ follow-up. Interventions Multifaceted podiatry intervention consisting of foot orthoses, advice on footwear, subsidy for footwear ($A100 voucher; £65; €74), a home based programme of foot and ankle exercises, a falls prevention education booklet, and routine podiatry care for 12 months. The control group received routine podiatry care for 12 months. Main outcome measures Proportion of fallers and multiple fallers, falling rate, and injuries resulting from falls during follow-up. Results Overall, 264 falls occurred during the study. 296 participants returned all 12 calendars: 147 (96%) in the intervention group and 149 (98%) in the control group. Adherence was good, with 52% of the participants completing 75% or more of the requested three exercise sessions weekly, and 55% of those issued orthoses reporting wearing them most of the time. Participants in the intervention group (n=153) experienced 36% fewer falls than participants in the control group (incidence rate ratio 0.64, 95% confidence interval 0.45 to 0.91, P=0.01). The proportion of fallers and multiple fallers did not differ significantly between the groups (relative risk 0.85, 0.66 to 1.08, P=0.19 and 0.63, 0.38 to 1.04, P=0.07). One fracture occurred in the intervention group and seven in the control group (0.14, 0.02 to 1.15, P=0.07). Significant improvements in the intervention group compared with the control group were found for the domains of strength (ankle eversion), range of motion (ankle dorsiflexion and inversion/eversion), and balance (postural sway on the floor when barefoot and maximum balance range wearing shoes). Conclusions A multifaceted podiatry intervention reduced the rate of falls in community dwelling older people with disabling foot pain. The components of the intervention are inexpensive and relatively simple to implement, suggesting that the programme could be incorporated into routine podiatry practice or multidisciplinary falls prevention clinics. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12608000065392.

There was a significant reduction in falls rate in the intervention group compared to the control group (incidence rate ratio=0.64, 95% CI 0.45 to 0.91, p=0.01) but no significant differences between the groups in the proportion of fallers/ multiple fallers. There were also significant improvements in secondary outcome measures of the SF-12 physical subscale, the MFPDI function subscale, and several measures of foot and ankle strength and ROM, balance and functional ability in the intervention group compared to the control group. Conclusions In older people with foot pain and an elevated risk of falling, a multifaceted podiatry intervention reduces the rate of falls by 36% and improves several aspects of foot and ankle strength, ROM, balance and functional ability suggesting that podiatry has av aluable role to play in preventing falls in older people.

Background Off-loading of plantar pressure is a key intervention strategy to prevent the formation of or to heal existing neuropathic plantar ulcers in diabetes. Walking casts (e.g. total contact cast) that reduce plantar pressures are currently considered the gold-standard for treating such neuropathic ulcers. However, alternative methods for off-loading that are as effective, but cheaper and easier to use are continually being sought. The aim of this study was to evaluate the effectiveness of the DH Pressure- Relief™ Shoe in off-loading high pressure areas in the neuropathic foot in diabetes. Methods A 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 shoe, and the DH shoe. The primary outcome was peak plantar pressure measured using the PedarX ® mobile in-shoe system between the 3 footwear conditions.

Background Chronic plantar heel pain (CPHP) is a generalised term used to describe a range of undifferentiated conditions affecting the plantar heel. Plantar fasciitis is reported as the most common cause and the terms are frequently used interchangeably in the literature. Diagnostic imaging has been used by many researchers and practitioners to investigate the involvement of specific anatomical structures in CPHP. These observations help to explain the underlying pathology of the disorder, and are of benefit in forming an accurate diagnosis and targeted treatment plan. The purpose of this systematic review was to investigate the diagnostic imaging features associated with CPHP, and evaluate study findings by meta-analysis where appropriate. Methods Bibliographic databases including Medline, Embase, CINAHL, SportDiscus and The Cochrane Library were searched electronically on March 25, 2009. Eligible articles were required to report imaging findings in participants with CPHP unrelated to inflammatory arthritis, and to compare these findings with a control group. Methodological quality was evaluated by use of the Quality Index as described by Downs and Black. Meta-analysis of study data was conducted where appropriate. Results Plantar fascia thickness as measured by ultrasonography was the most widely reported imaging feature. Meta-analysis revealed that the plantar fascia of CPHP participants was 2.16 mm thicker than control participants (95% CI = 1.60 to 2.71 mm, P < 0.001) and that CPHP participants were more likely to have plantar fascia thickness values greater than 4.0 mm (OR = 105.11, 95% CI = 3.09 to 3577.28, P = 0.01). CPHP participants were also more likely to show radiographic evidence of subcalcaneal spur than control participants (OR = 8.52, 95% CI = 4.08 to 17.77, P < 0.001). Conclusion This systematic review has identified 23 studies investigating the diagnostic imaging appearance of the plantar fascia and inferior calcaneum in people with CPHP. Analysis of these studies found that people with CPHP are likely to have a thickened plantar fascia with associated fluid collection, and that thickness values >4.0 mm are diagnostic of plantar fasciitis. Additionally, subcalcaneal spur formation is strongly associated with pain beneath the heel.

Background The severity of hallux valgus is easily appreciated by its clinical appearance, however x-ray measurements are also frequently used to evaluate the condition, particularly if surgery is being considered. There have been few large studies that have assessed the validity of these x-ray observations across a wide spectrum of the deformity. In addition, no studies have specifically focused on older people where the progression of the disorder has largely ceased. Therefore, this study aimed to explore relationships between relevant x-ray observations with respect to hallux valgus severity in older people. Methods This study utilised 402 x-rays of 201 participants (74 men and 127 women) aged 65 to 94 years. All participants were graded using the Manchester Scale - a simple, validated system to grade the severity of hallux valgus - prior to radiographic assessment. A total of 19 hallux valgus-related x-ray observations were performed on each set of x-rays. These measurements were then correlated with the Manchester Scale scores. Results Strong, positive correlations were identified between the severity of hallux valgus and the hallux abductus angle, the proximal articular set angle, the sesamoid position and congruency of the first metatarsophalangeal joint. As hallux valgus severity increased, so did the frequency of radiographic osteoarthritis of the first metatarsophalangeal joint and a round first metatarsal head. A strong linear relationship between increased relative length of the first metatarsal and increased severity of hallux valgus was also observed. Conclusions Strong associations are evident between the clinical appearance of hallux valgus and a number of hallux valgus-related x-ray observations indicative of structural deformity and joint degeneration. As it is unlikely that metatarsal length increases as a result of hallux valgus deformity, increased length of the first metatarsal relative to the second metatarsal may be a contributing factor to the development and/or progression of hallux valgus.

Foot problems are highly prevalent in older people. To treat such problems in this age-group prefabricated ('off-the-shelf') foot orthoses are frequently prescribed. However, such devices are susceptible to material compression and deformation, which may reduce their effectiveness over time. Therefore, the aim of this study was to compare the pressure-redistributing properties of new prefabricated orthoses to orthoses worn for at least 12 months. Thirty-one adults (10 males, 21 females) aged over 65 years (mean 75.4, SD 5.2) participated. Plantar pressure data were collected under the rearfoot, midfoot and forefoot using the Pedar(®) in-shoe system while participants walked along an 8m walkway wearing shoes only, new orthoses and old orthoses (orthoses were full length, dual-density prefabricated Formthotic™ devices). Compared to the shoe-only condition, both the new and old orthoses produced significant reductions in peak pressure and maximum force in the rearfoot with corresponding increases in force and contact area in the midfoot. Compared to the new orthoses, the old orthoses exhibited small but significant increases in peak pressure in the rearfoot (6%, p=0.001) and maximum force in the rearfoot (5%, p

Background Plantar heel pain (plantar fasciitis) is a common and disabling condition, which has a detrimental impact on health-related quality of life. Despite the high prevalence of plantar heel pain, the optimal treatment for this disorder remains unclear. Consequently, an alternative therapy such as dry needling is increasingly being used as an adjunctive treatment by health practitioners. Only two trials have investigated the effectiveness of dry needling for plantar heel pain, however both trials were of a low methodological quality. This manuscript describes the design of a randomised controlled trial to evaluate the effectiveness of dry needling for plantar heel pain. Methods Eighty community-dwelling men and woman aged over 18 years with plantar heel pain (who satisfy the inclusion and exclusion criteria) will be recruited. Eligible participants with plantar heel pain will be randomised to receive either one of two interventions, (i) real dry needling or (ii) sham dry needling. The protocol (including needling details and treatment regimen) was formulated by general consensus (using the Delphi research method) using 30 experts worldwide that commonly use dry needling for plantar heel pain. Primary outcome measures will be the pain subscale of the Foot Health Status Questionnaire and "first step" pain as measured on a visual analogue scale. The secondary outcome measures will be health related quality of life (assessed using the Short Form-36 questionnaire - Version Two) and depression, anxiety and stress (assessed using the Depression, Anxiety and Stress Scale - short version). Primary outcome measures will be performed at baseline, 2, 4, 6 and 12 weeks and secondary outcome measures will be performed at baseline, 6 and 12 weeks. Data will be analysed using the intention to treat principle. Conclusion This study is the first randomised controlled trial to evaluate the effectiveness of dry needling for plantar heel pain. The trial will be reported in accordance with the Consolidated Standards of Reporting Trials and the Standards for Reporting Interventions in Clinical Trials of Acupuncture guidelines. The findings from this trial will provide evidence for the effectiveness of trigger point dry needling for plantar heel pain. Trial registration Australian New Zealand 'Clinical Trials Registry'. ACTRN12610000611022.

The authors regret that an error was made in the calculation of effect sizes (standardised mean difference – Cohen’s d) that are presented in Table 5 and Fig. 2. Consequently, the magnitude of these results were classified and interpreted as small in the abstract, discussion and conclusion sections. Using the classification scale outlined in the methods section, the corrected effect sizes are classified as large, except for three results that are classified as moderate. These corrected findings, therefore, indicate moderate to large changes in the mean difference relative to the variability in the data and may increase the likelihood that such kinematic effects are clinically meaningful. Amendments have been made to Table 5 and Fig. 2, as well as where we make reference to them in the abstract, discussion and conclusion sections of the manuscript. The amendments are outlined below in the order that they appear in the original article. In the second last sentence of the abstract, the interpretation of effect sizes was amended, the sentence now reads as follows: Five article compared kinematics parameters between different foot postures – there was some evidence for increased motion in planus feet with large effect sizes. Seven articles investigated associations between foot posture and kinematics – there was evidence that increasing planus foot posture was positively associated with increased frontal plane motion of the rearfoot. In the final two sentences of the third paragraph within the subsection of the Discussion titled: ‘4.1. Quality assessment and effect size’, the interpretation of effect sizes was amended. The sentences now read as follows: As illustrated in Table 5 and Fig. 2, all effect sizes were large, except for three that were classified as moderate. Effect sizes of this magnitude indicate moderate to large changes in the mean difference relative to the variability in the data and may increase the likelihood that such kinematic effects are clinically meaningful. In the third sentence of the conclusion, the reference to effect sizes in the interpretation of the quality of evidence has been removed. The sentence now reads as follows: However, the quality of evidence is poor due to methodological issues with the included studies. The authors sincerely apologise for any inconvenience caused by this error.

Recent events in the USA and UK have raised questions about the appropriate definition and application of the terms 'foot' and 'surgeon'. In this editorial, we explore these issues and clarify our use of these terms in the journal. © 2010 Menz et al; licensee BioMed Central Ltd.

Purpose: To examine the reliability of an intra-operative evaluation tool for assessing the location, depth and surface area of cartilage degeneration of the first metatarsophalangeal joint (1st MPJ) in hallux valgus. The tool consists of diagrams of four regions of the 1st MPJ (see Figure 1), divided into 13 zones (see Figure 2) upon which cartilage lesions are sketched during surgery and an estimate of the depth of each lesion is documented.

Background Osteoarthritis affecting of the big toe joint of the foot (hallux limitus or rigidus) is a common and painful condition. Although several treatments have been proposed, few have been adequately evaluated. Objectives To identify controlled trials evaluating interventions for osteoarthritis of the big toe joint and to determine the optimum intervention(s). Search methods Literature searches were conducted across the following electronic databases: CENTRAL; MEDLINE; EMBASE; CINAHL; and PEDro (to 14th January 2010). No language restrictions were applied. Selection criteria Randomised controlled trials, quasi-randomised trials, or controlled clinical trials that assessed treatment outcomes for osteoarthritis of the big toe joint. Participants of any age or gender with osteoarthritis of the big toe joint (defined either radiographically or clinically) were included. Data collection and analysis Two authors examined the list of titles and abstracts identified by the literature searches. One content area expert and one methodologist independently applied the pre-determined inclusion and exclusion criteria to the full text of identified trials. To minimise error and reduce potential bias, data were extracted independently by two content experts. Main results Only one trial satisfactorily fulfilled the inclusion criteria and was included in this review. This trial evaluated the effectiveness of two physical therapy programs in 20 individuals with osteoarthritis of the big toe joint. Assessment outcomes included pain levels, big toe joint range of motion and plantar flexion strength of the hallux. Mean differences at four weeks follow up were 3.80 points (95% CI 2.74 to 4.86) for self reported pain, 28.30 ° (95% CI 21.37 to 35.23) for big toe joint range of motion, and 2.80 kg (95% CI 2.13 to 3.47) for muscle strength. Although differences in outcomes between treatment and control groups were reported, the risk of bias was high. The trial failed to employ appropriate randomisation or adequate allocation concealment, used a relatively small sample and incorporated a short follow up (four weeks). No adverse reactions were reported. Authors' conclusions The reviewed trial presented a high risk of bias, which limited conclusions that could be drawn from the presented data. The inclusion of only one trial indicates the need for more robust randomised controlled trials to determine the efficacy of interventions for this condition.

Background Plantar heel pain (plantar fasciitis) is one of the most common musculoskeletal pathologies of the foot. Plantar heel pain can be managed with dry needling and/or injection of myofascial trigger points (MTrPs) however the evidence for its effectiveness is uncertain. Therefore, we aimed to systematically review the current evidence for the effectiveness of dry needling and/or injections of MTrPs associated with plantar heel pain. Methods We searched specific electronic databases (MEDLINE, EMBASE, AMED, CINAHL, SPORTDiscus and AMI) in April 2010 to identify randomised and non-randomised trials. We included trials where participants diagnosed with plantar heel pain were treated with dry needling and/or injections (local anaesthetics, steroids, Botulinum toxin A and saline) alone or in combination with acupuncture. Outcome measures that focussed on pain and function were extracted from the data. Trials were assessed for quality using the Quality Index tool. Results Three quasi-experimental trials matched the inclusion criteria: two trials found a reduction in pain for the use of trigger point dry needling when combined with acupuncture and the third found a reduction in pain using 1% lidocaine injections when combined with physical therapy. However, the methodological quality of the three trials was poor, with Quality Index scores ranging form 7 to 12 out of a possible score of 27. A meta-analysis was not conducted because substantial heterogeneity was present between trials. Conclusions There is limited evidence for the effectiveness of dry needling and/or injections of MTrPs associated with plantar heel pain. However, the poor quality and heterogeneous nature of the included studies precludes definitive conclusions being made. Importantly, this review highlights the need for future trials to use rigorous randomised controlled methodology with measures such as blinding to reduce bias. We also recommend that such trials adhere to the Standards for Reporting Interventions in Controlled Trials of Acupuncture (STRICTA) to ensure transparency.

Background Plantar fasciitis is the most commonly reported cause of chronic pain beneath the heel. Management of this condition commonly involves the use of corticosteroid injection in cases where less invasive treatments have failed. However, despite widespread use, only two randomised trials have tested the effect of this treatment in comparison to placebo. These trials currently offer the best available evidence by which to guide clinical practice, though both were limited by methodological issues such as insufficient statistical power. Therefore, the aim of this randomised trial is to compare the effect of ultrasound-guided corticosteroid injection versus placebo for treatment of plantar fasciitis. Methods The trial will be conducted at the La Trobe University Podiatry Clinic and will recruit 80 community-dwelling participants. Diagnostic ultrasound will be used to diagnose plantar fasciitis and participants will be required to meet a range of selection criteria. Participants will be randomly allocated to one of two treatment arms: (i) ultrasound-guided injection of the plantar fascia with 1 mL of 4 mg/mL dexamethasone sodium phosphate (experimental group), or (ii) ultrasound-guided injection of the plantar fascia with 1 mL normal saline (control group). Blinding will be applied to participants and the investigator performing procedures, measuring outcomes and analysing data. Primary outcomes will be pain measured by the Foot Health Status Questionnaire and plantar fascia thickness measured by ultrasound at 4, 8 and 12 weeks. All data analyses will be conducted on an intention-to-treat basis. Conclusion This will be a randomised trial investigating the effect of dexamethasone injection on pre-specified treatment outcomes in people with plantar fasciitis. Within the parameters of this protocol, the trial findings will be used to make evidence-based recommendations regarding the use of corticosteroid injection for treatment of this condition. Trial Registration Australian New Zealand Clinical Trials Registry. ACTRN12610000239066.

Background The Visual Analogue Scale (VAS) and the Foot Health Status Questionnaire (FHSQ) are two commonly used outcome measures for evaluating foot health. This study aimed to calculate the Minimal Important Difference (MID) of the VAS and the FHSQ. Methods 184 participants with plantar heel pain were recruited from the general public to take part in two randomised trials (92 participants in each trial) that studied the effectiveness of two conservative interventions for plantar heel pain. Data from these participants were used to calculate the MIDs of the VAS and the FHSQ. An anchor-based method was used to calculate the MIDs. Two distinct types of pain were investigated for the VAS: average pain and first-step pain. All four domains of the FHSQ were investigated: foot pain, foot function, footwear and general foot health. Results The MID for the VAS using the anchor-based approach was -8 mm (95% CI: -12 to -4) for average pain and -19 mm (95% CI: -25 to -13) for first-step pain on the 100 mm VAS. The MID for the FHSQ was 13 points (95% CI: 6 to 19) for pain and 7 points (95% CI: 1 to 13) for function. The MID for the footwear domain of the FHSQ was -2 points (95% CI: -8 to 4) and 0 points (95% CI: -7 to 6) for the general foot health domain of the FHSQ. Conclusion The results of this study provide additional evidence for MID values of the VAS and the FHSQ for plantar heel pain. This is important for clinicians and researchers as it provides a greater understanding of how much improvement is required by a patient before a minimal, worthwhile change is experienced. The calculated MIDs will also assist researchers with prospective sample size calculations.