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When a deformity of the hindfoot advances to the point where it begins to affect the alignment of the ankle, it becomes a particularly challenging problem to correct. Nonoperative options are limited and should be reserved for patients who have comorbidities prohibiting surgical attention. The associated deformities must first be corrected to protect the ankle realignment procedure. The goals of treatment are to maximise flexibility and produce a painless and plantigrade foot without the need for supplementary bracing.

Background: Chronic lateral ankle instability has been associated with varus deformity of the hindfoot, hyperactivity of the peroneus longus muscle, and insufficiency of the lateral ligaments. Many operative procedures have been described to correct this problem, but instability can recur if all contributing components are not treated. The purpose of this study was to offer an approach in the diagnosis and treatment of recurrent lateral ankle instability., Methods: Eight consecutive patients (nine feet) were treated for recurrent chronic lateral ankle instability. The average age at surgery was 25 (range 8 to 37) years. All patients had prior operative procedures that failed and had persistent pain and functional instability of the ankle joint. After clinical and radiographic examination, lateralizing calcaneal osteotomy to correct the structured varus deformity and peroneus longus to peroneus brevis tendon transfer to add dynamic correction were done in all patients. A Broström ligament reconstruction was added in four feet. All patients were evaluated clinically and radiographically at an average followup of 37 months. Preoperatively and postoperatively patients were evaluated by means of the American Orthopaedic Foot and Ankle Society (AOFAS) Score., Results: All patients were satisfied with the operation. The overall AOFAS-Score improved from 57 points preoperatively to 87 points postoperatively. Hindfoot alignment was restored to a valgus position at final evaluation., Conclusions: Recurrent chronic lateral ankle instability often is associated with chronic hindfoot malalignment and leads to functional impairment and patient discomfort. Clinical examination should determine the causes of instability. Varus malalignment of the hindfoot, hyperactivity of the peroneus longus muscle, and insufficiency of the lateral ligaments should be assessed and treated in a combined operative procedure to correct structured, static and dynamic components of the instability. The preliminary results of this particular approach are encouraging.

Background: Some types of foot orthoses have been researched for their effect on lower limb electromyographic muscle activity during walking. However, foot orthoses with high levels of medial rearfoot wedging ('inverted' foot orthoses) have not been investigated., Methods: In a cross-sectional study, asymptomatic participants with a pronated foot type (n=15) were each issued with a pair of 0 degrees, 15 degrees and 30 degrees inverted custom-made foot orthoses. After four weeks of habituation to the orthoses, surface electromyography was used to measure the onset and maximum EMG amplitude of tibialis anterior, peroneus longus, medial gastrocnemius and soleus muscles using five conditions [barefoot, shoe-only, 0 degrees, 15 degrees and 30 degrees inverted foot orthoses conditions]., Findings: A statistically significant increase in tibialis anterior maximum EMG amplitude occurred using the shoe only (30% increase), 0 degrees (33% increase), 15 degrees (38% increase) and 30 degrees (30% increase) inverted orthoses conditions compared to walking barefoot (P<0.01). Peroneus longus maximum EMG amplitude increased significantly using the 15 degrees inverted orthosis condition compared to walking barefoot (21% increase, P=0.04)., Interpretation: Footwear and orthoses can significantly alter the maximum EMG amplitude of leg muscles during walking. Foot orthoses appear to increase peroneus longus EMG amplitude compared to footwear alone. However, the level of medial rearfoot posting within an orthosis does not appear to significantly alter maximum EMG amplitude. The individual responses to foot orthoses are highly variable. The changes in EMG amplitude with the use of foot orthoses and shoes may have clinical implications.

Findings from investigations of the effects of external forefoot and rearfoot posts added to foot orthoses have been inconclusive. This study was undertaken to examine the effects of rearfoot post design on the lateral-to-medial position and velocity of the center-of-pressure path. Four identical pairs of neutral-cast polypropylene orthotic shells were constructed; three pairs had a rearfoot post of specified design added. The fourth pair, the control, did not have a post added. Stance period data were broken down into four functional phases, and the statistically significant differences between the experimental conditions were calculated and analyzed. The addition of a rearfoot post to an orthotic shell affects center-of-pressure lateral-to-medial position and velocity. Although the effect of the post designs seemed to provide reasonably predictable changes in center-of-pressure position, the effect on center-of-pressure velocity was variable and inconsistent. The effect of the orthotic post was dependent on design and phase of gait. The addition of a rearfoot post and, specifically, the design of the post can probably be used to alter the center-of-pressure position and velocity.

The aim of this study was to develop and evaluate a kinematic measurement method for the foot that could be applied clinically to measure foot function including all typical foot deformities. The ankle was modelled as two anatomically based hinge joints rotating around anatomical axes estimated by the use of projection angles. For the mid- and forefoot a descriptive approach was chosen by defining angles between anatomical landmarks or reference points derived from these landmarks. The motion of 17 markers on the lower leg and foot was measured during walking gait on 10 adult participants with no known abnormalities to determine the pattern of normal foot motion, assess reliability and provide a reference against which pathological foot behaviour could be compared. Functional angles for mid- and forefoot motions were developed to improve clinical applications of the data. The combination of anatomically and technically oriented marker placement on the foot is a reliable basis for reproducible kinematic measurements and the method was shown to be viable for clinical practice.

The name Morton is associated with a foot structure characterized by a short first metatarsal in comparison with the adjacent second metatarsal. Dudley Morton is credited with recognizing a short first metatarsal as being a primary defect of the foot. Morton, an anatomist, approached his observation from an evolutionary perspective. His theory of disordered foot function was based on the premise that human alignment centered on an "axis of leverage" and around an "axis of balance." Morton concluded that the presence of a short first metatarsal was compounded when the first metatarsal segment was hypermobile. Shortness and hypermobility diminished the capacity of the first metatarsal segment to carry weight, allowed pronation during activity, and led to an overload of the central metatarsals. The term Morton Foot sprang from his teachings. The extensive writings of Morton are commonly cited even today. This study compares Morton's teachings with research published during the last 70 years, which either supports or refutes his claims.

Patellar malalignment is the most important reason for anterior knee pain. Patellar alignment is commonly determined by the measurement of the quadriceps (Q) angle. In this study, our primary aim was to investigate the Q angle difference between healthy individuals with and without joint hypermobility. The other objectives were to compare the Q angle values, which were measured in supine and upright positions, to determine hypermobility frequency among healthy males in a certain population, and to investigate the correlation between the existent skeletal deformities and Beighton score levels. Two hundred fifty-three healthy male college students were examined for hypermobility and skeletal deformities. According to the Beighton scoring system, three groups (n=20) were formed, and Q angle measurements were performed on the 60 individuals in both supine and upright positions. In the comparison of the groups, the mean Q angle values in healthy hypermobile individuals were found to be significantly higher than that of the nonhypermobile ones (p<0.05). No statistical difference was found between Q angle values in supine and upright positions (p>0.05). The frequency of joint hypermobility (Beighton score 4 or more) was found to be 29.25% in this population. No correlation was determined between existent skeletal deformities and Beighton score values (p>0.05). In conclusion, the Q angle evaluation among healthy hypermobile individuals may have a prognostic value for probable knee pathologies that may appear in the future.

Patients with a cavus or high-arched foot frequently experience foot pain, which can lead to significant limitation in function. Custom foot orthoses are widely prescribed to treat cavus foot pain. However, no clear guidelines for their construction exist, and there is limited evidence of their efficacy. In a randomized, single-blind, sham-controlled trial, the effect of custom foot orthoses on foot pain, function, quality of life, and plantar pressure loading in people with a cavus foot type was investigated. One hundred fifty-four participants with chronic musculoskeletal foot pain and bilateral cavus feet were randomly assigned to a treatment group receiving custom foot orthoses (n = 75) or to a control group receiving simple sham insoles (n = 79). At 3 months, 99% of the participants provided follow-up data using the Foot Health Status Questionnaire. Foot pain scores improved more with custom foot orthoses than with the control (difference, 8.3 points; 95% confidence interval [CI], 1.2 to 15.3 points; P = .022). Function scores also improved more with custom foot orthoses than with the control (difference, 9.5 points; 95% CI, 2.9 to 16.1 points; P = .005). Quality-of-life data favored custom foot orthoses, although differences reached statistical significance only for physical functioning (difference, 7.0 points; 95% CI, 1.9 to 12.1 points; P = .008). Plantar pressure improved considerably more with custom foot orthoses than with the control for all regions of the foot (difference, -3.0 N . s/cm(2); 95% CI, -3.7 to -2.4 N . s/cm(2); P < .001). In conclusion, custom foot orthoses are more effective than a control for the treatment of cavus foot pain and its associated limitation in function.

Objective: This study estimated the inter- and intraobserver reliability of a set of noninstrumented physical examination measures for knee pain in older adults., Study Design and Setting: Forty-five patients from primary care, and 13 patients from secondary care, were each examined by two out of a team of three physical therapists, and were reexamined by one of these observers 1 month later. The examination items were standardized and included dichotomous, ordinal and continuous variables considered relevant to a primary care context., Results: For individual dichotomous items, median interobserver and intraobserver agreement (kappa) was 0.22 (interquartile range IQR=0.12-0.35) and 0.41 (IQR=0.28-0.56) respectively. For ordinally rated variables, weighted kappa ranged from -0.08 to 0.43 for interobserver agreement, and from 0.00 to 0.79 for intraobserver agreement. The median intraclass correlation coefficient for continuous examination variables was 0.80 (range 0.68-0.89) for interobserver agreement, and 0.84 (range 0.67-0.95) for intraobserver agreement., Conclusion: For trained but nonexpert examiners, agreement was generally poor for dichotomous and ordinal examination items; however, kappa-values are liable to be depressed by the low prevalence of clinical signs in this sample. Agreement on continuous variables was notably better.

Methods for the measurement of plantar pressure are poorly defined particularly when describing sub-sections of the plantar surface of the foot in the presence of deformity. The aim of this study was to assess foot pressure measurement in healthy children, using an automatic technique of sub-area definition that has the potential for objective evaluation of treatment of foot deformity. Twelve healthy children were examined on three occasions. Plantar pressure data were collected and time synchronised with force plate and stereophotogrammetric data. The footprint was divided into five sub-sections by using the position of the markers on the foot at mid-stance projected onto the pressure footprint. Repeatability for peak pressure and peak force was assessed. Automatic sub-area definition based on marker placement was found to be reliable in healthy children. A comparison of results revealed that peak vertical force was a more consistent measure than peak pressure for each of the five sub-areas. This suggests that force may be a more appropriate measurement for outcome studies.

Objective: The aim of this study was to assess probable plantar pressure alterations in rheumatoid arthritis (RA) patients by comparison with normal subjects and to investigate the probable relation between pressure distribution under the foot and radiologic foot erosion score., Methods: Two hundred feet of 50 chronic RA patients and 50 healthy controls were evaluated. Static and dynamic pedobarographic evaluations were used to define the plantar pressure distribution. Also, the modified Larsen scoring system was used to detect the staging of erosions on feet radiograms of the RA patients., Results: Static pedobarography revealed higher pressure and contact areas in the forefoot. All dynamic pedobarographic parameters except for plantar contact area were significantly different between the RA patients and control subjects. Patients with high erosion scores had higher static forefoot and dynamic phalanx peak pressure values., Conclusion: Pedobarographic investigation can be useful to evaluate pressure distribution disorders in RA feet and may provide suitable guidelines for the design of various plantar supports.

Whereas in the past resection arthroplasty was - in analogy to hallux valgus surgery - the preferred therapy to correct lesser toe deformities, the point of view has undergone a change. Much interest is directed toward functional aspects that require reconstructive management. Whenever possible the integrity of joint play should be saved. Above all the metatarsophalangeal joint of the lesser toes is worth being preserved to prevent a severe disturbance of the biomechanics of the foot. Tendon transfers and subtle corrective osteotomies such as the Weil procedure allow restricting resection procedures to contraction deformities.

Background: Pes cavus foot deformity in neuromuscular disease is thought to be related to an imbalance of musculature around the foot and ankle. The most common cause of neurogenic pes cavus is Charcot-Marie-Tooth (CMT) disease. The aim of this investigation was to objectively quantify muscle strength and imbalance using hand-held dynamometry in patients diagnosed with CMT and pes cavus, compared to healthy controls., Methods: Muscles responsible for inversion, eversion, plantarflexion, and dorsiflexion of the foot and ankle were measured in 55 subjects (11 CMT patients with a frank pes cavus, and 44 healthy controls with normal feet) using the Nicholas hand-held dynamometer (HHD). Test-retest reliability of the HHD procedure also was determined for each of the four muscle groups in the healthy controls., Results: Test-retest reliability of the HHD procedure was excellent (ICC3,1 = 0.88 to 0.95) and the measurement error was low (SEM = 0.3 to 0.7 kg). Patients with CMT were significantly weaker than normal for all foot and ankle muscle groups tested (p < 0.001). Strength ratios of inversion-to-eversion and plantarflexion-to-dorsiflexion were significantly higher in the patients with CMT and pes cavus compared to individuals with normal foot types (p > 0.01)., Conclusions: Hand-held dynamometry is an objective and reliable instrument to measure muscle strength and imbalance in patients with CMT and a pes cavus foot deformity.

A 48-year-old woman presented to the emergency department with hematemesis and a 6-month history of unsteady gait and falls due to tripping. Because of a history of alcohol abuse, the initial diagnosis was upper gastrointestinal bleeding secondary to alcoholic gastritis or gastric ulcer, with the neuropathy likely due to alcoholism or chronic inflammatory demyelinating polyneuropathy. After further neurological examination and careful review of nerve conduction studies, however, an inherited neuropathy was suspected. Despite denial by the patient and her daughter of a family history of neuropathy, both had a pes cavus deformity with muscle atrophy and partial foot drop gait. Subsequent testing of the daughter revealed the same nerve conduction findings as the patient's. Genetic testing showed that both women had the myelin PMP22 repeat defect characteristic of Charcot-Marie-Tooth disease. Endoscopy revealed that the patient had Osler-Weber-Rendu disease, which accounted for the hematemesis.

Subtle cavus foot deformity is ubiquitous, yet it continues to be commonly missed. Simple physical examination maneuvers can provide information that allows well-planned nonoperative care and selection of operative procedures to correct the underlying cause as well as presenting pathology.

Objective: To compare electromyographic activity of the vastus medialis, vastus lateralis, and gluteus medius during functional activities in subjects with different foot types while wearing various off-the-shelf foot orthotics., Design: Experimental, controlled; 3 foot-type groups (pes planus, pes cavus, pes rectus) each tested in 4 orthotic conditions while performing 3 different exercises., Setting: Laboratory., Participants: Thirty healthy young adults, 10 with each foot type., Interventions: Four conditions: no orthotic, 7 degrees medial rearfoot post, 4 degrees lateral rearfoot post, and neutral rearfoot post., Main Outcome Measure: Surface electromyographic activity for the vastus medialis, vastus lateralis, and gluteus medius during single-leg squatting, lateral stepdown, and maximum vertical jump exercises., Results: Greater vastus medialis and gluteus medius activity was found with all 3 orthotic conditions, regardless of subject foot type, during the single-leg squat and lateral stepdown. Less vastus lateralis activity was found with the vertical jump with all orthotic conditions, again regardless of foot type., Conclusions: During slow controlled exercises such as the single-leg squat and lateral stepdown, vastus medialis and gluteus medius activity may be enhanced with an off-the-shelf orthotic, regardless of posting or foot type. These same findings do not appear to carry over to a more explosive task such as the maximal vertical jump.

Objective: To develop a self-report questionnaire for patients with degenerative disorders of the foot to evaluate the usability of their orthopaedic shoes, and to assess the reproducibility and responsiveness of the instrument., Design: Development of the Questionnaire for Usability Evaluation of orthopaedic shoes was based on a literature search, structured expert interviews and a ranking procedure. A cross-sectional study was carried out to determine the reproducibility and internal consistency of the questionnaire., Setting and Subjects: The study population comprised 15 patients with degenerative disorders of the foot, who had worn their orthopaedic shoes for at least 3 years and 15 patients with degenerative disorders of the foot, who had never worn orthopaedic shoes, but would receive them within 1 month., Results: Within the questionnaire 4 effectiveness items (pain, instability, callus, wounds), 1 efficiency item (putting on and taking off shoes) and 7 satisfaction items (pinch, slip, weight of shoes, cold feet, perspiration, maintenance, cosmetic appearance) were developed. All items in the questionnaire met the test-retest criteria. The smallest real difference ranged from 0.23 to 3.82 cm on a Visual Analogue Scale (10 cm). Cronbach's alpha's for the domains of pain and instability ranged from 0.70 to 0.92., Conclusion: The Questionnaire for Usability Evaluation should provide a good rationale to assess the usability of orthopaedic shoes and can be considered reliable.

Background: The purpose of this study was to establish the effect of simple non moulded flat based insoles on three-dimensional foot motion during normal walking. Excessive foot pronation is considered a major contributing factor to lower limb injuries. Moulded foot orthoses have been shown to decrease maximum foot eversion. Simple insoles are widely used in clinical practice as an alternative to moulded orthoses. However, there has been little research into the kinematic effects of simple insoles., Methods: All subjects had an inverted rearfoot and forefoot position when the subtalar joint was placed in neutral, which was assessed by a weight bearing goniometer. Rotations of the whole foot about three orthogonal axes relative to the shank were estimated using a five camera motion analysis system., Findings: Biplanar insoles significantly (P < 0.05) reduced maximum eversion by an average of 3.1 degrees when compared to the no insole condition. The cobra insole reduced maximum eversion by an average of 2.1 degrees when compared to the no insole condition. This difference approached statistical significance (P = 0.058)., Interpretation: Biplanar and cobra insoles had no significant effect on maximum dorsiflexion, abduction or rate of eversion, when compared to the no insole condition. These results provide some limited support for the use of simple insoles to control for excessive foot pronation during walking.

Any surgical treatment of spastic foot deformities must be preceded by an exact preoperative analysis of every aspect of the deformity and its functional consequences. The goals of surgical treatment are correction of the deformity, reestablishment of the stability of the foot and preservation of functionally important ranges of motion and muscle strength. These goals can usually be achieved only by a package of several simultaneous procedures. The foot must never be treated in isolation. Proximal joints have to be considered as well as the opposite side, because a plantigrade position of the foot is only possible when the leg is straight. Any postoperative evaluation must also take into account the proximal joints and the opposite leg in unilateral cases. The mere static evaluation of the postoperative results by reporting clinical and radiographic values should be supplemented by dynamic measurements which allow more insight into the functional results.

Objective: To study the effects of custom-made insoles on plantar pressures and load redistribution in neuropathic diabetic patients with foot deformity., Design: Cross-sectional., Background: Although custom-made insoles are commonly prescribed to diabetic patients, little quantitative data on their mechanical action exists., Methods: Regional in-shoe peak pressures and force-time integrals were measured during walking in the feet of 20 neuropathic diabetic subjects with foot deformity who wore flat or custom-made insoles. Twenty-one feet with elevated risk for ulceration at the first metatarsal head were analysed. Load redistribution resulting from custom-made insoles was assessed using a new load-transfer algorithm., Results: Custom-made insoles significantly reduced peak pressures and force-time integrals in the heel and first metatarsal head regions; pressures and integrals were significantly increased in the medial midfoot region compared with flat insoles. Custom-made insoles successfully reduced pressures in and integrals at the first metatarsal head in 7/21 feet, were moderately successful in another seven, but failed in the remaining seven. Load transfer was greatest from the lateral heel to the medial midfoot regions., Conclusions: Custom-made insoles were more effective than flat insoles in off-loading the first metatarsal head region, but with considerable variability between individuals. Most off-loading occurred in the heel (not a region typically at risk). The load transfer algorithm effectively analyses custom-made-insole action., Relevance: Because similar insole modifications apparently exert different effects in different patients, a comprehensive evaluation of custom designs using in-shoe pressure measurement should ideally be conducted before dispensing insoles to diabetic patients with neuropathy and foot deformity., (Copyright 2004 Elsevier Ltd.)

Many patients with foot and ankle deformities have concurrent deformities (osseous and soft tissue), with or without limb length discrepancies. Lower extremity deformities and limb length discrepancies typically result from trauma, congenital abnormality, avascular necrosis, previous surgery, nonunion, and malunion. Limb deformity correction requires extensive surgical experience because many considerations and factors apply to realignment. The considerations and factors regarding realignment are highlighted throughout this article.

Brachymetatarsia is abnormal anatomical shortness of the metatarsals. We describe a new diagnostic test that enables quantification of the shortening of the fourth metatarsal in brachymetatarsia. The metatarsodigital alterations most frequently related to this deformity are presented.

In our gait laboratory, the gait pattern of 18 youths with neurogenic foot deformities as a result of spina bifida or cerebral palsy was examined. The influence of technical orthopaedic devices for the foot and ankle on kinematics and kinetics of the gait and especially of the knee joint were analyzed. Kinematic data were derived from 3D-video analysis, kinetic data from force plates and pressure distribution plates. Muscle activities were measured with eight-channel EMG. The data were examined to see if there were differences when using the technical devices. All patients had already been supported externally with the different devices like orthopaedic shoes, insoles, Nancy Hilton orthoses and orthoses for the lower leg extremity. The devices restricted to the foot and the ankle joint improved the feeling of gait stability of the patients. In this investigation, the different supports had various but little effects on the kinematics and kinetics of the knee joint, depending on the type of orthoses used and the kind of handicap of the youths. Because of the great expenditure, the data obtained in this study were taken from a small number of patients. Therefore, they are individual findings and are of restricted general significance.

Several surgical treatments have been proposed to correct the deformity associated with MWD and alleviate the pain; however, no technique can be named the gold standard. TNC arthrodesis is a safe and effective technique for the treatment of the MWD and can be performed with a dorsal or medial approach;we recommend the dorsal approach. We believe that autologous bone graft provides sufficient stability and internal fixation is not needed. Treatment of MWD is not well-documented in literature; more studies are needed to determine the optimum surgical treatment for this rare disease.

The accessory navicular is a common presence in the human foot and must be included in the differential diagnosis of medial foot pain in patients who are of appropriate age. Imaging modalities aid in diagnosis of a symptomatic ossicle and guide classification and treatment. Often, a combination of studies is needed to establish an accessory navicular as the source of foot pathology. Although conservative measures always are the first line of treatment, the benefits of surgical management are well-defined in the literature. Most foot surgeons rely on resection procedures with varied handling of the PTT insertion, although newer modifications that use bony fusion techniques are being investigated. As with any musculoskeletal condition, proper diagnosis and individually-tailored treatment plans are of the utmost importance to a satisfactory outcome. With meticulous patient selection and a thorough understanding of the condition, management of the painful accessory navicular often is successful in alleviating the disability it causes.

Study Design: Counterbalanced experimental design study comparing a group of subjects with greater than or equal to 70 of forefoot varus (MFV) to a group with less than 70 of forefoot varus (LFV)., Objectives: To investigate the effect of forefoot varus on single-limb stance postural stability (PS)., Background: Impaired PS has been implicated as a potential risk factor for sustaining acute foot and ankle injuries. The identification of variables that deleteriously affect PS may be important in the prevention of future injuries., Methods and Measures: Postural stability of the MFV group (n = 20) and the LFV group (n = 12) was assessed during right and left single-limb stance and eyes-open and eyes-closed conditions. Standard deviations of the x-axis and y-axis ground reaction forces measured via a force platform were used to represent anteroposterior (AP) and mediolateral (ML) PS, respectively. The mean of 3 successful 5-second trials of each testing condition was calculated and used for subsequent data analysis using 3-way mixed-model ANOVAs with 1 between-subject and 2 within-subject factors., Results: The AP PS scores of the MFV group were significantly greater than those of the LFV group (P < .05). ML PS scores, although higher in the MFV group, were not significantly different from those of the LFV group. Both groups had significantly greater AP and ML PS scores during the eyes-closed versus the eyes-open condition (P < .05)., Conclusions: The results suggest that the presence of greater than or equal to 70 of forefoot varus may significantly impair AP PS. The decreased stability associated with increased forefoot varus may be due to decreased joint congruity and consequently an increased reliance on soft tissue structures for stability.

Hypothesis: Rheumatoid arthritis is a common disabling form of arthritis that frequently affects the hands and feet. With time, the majority of affected individuals will become disabled., Methods: Sixty-nine consecutively selected mild to moderately affected individuals with rheumatoid arthritis provided demographic data and agreed to complete the Short Musculoskeletal Function Assessment (SFMA) instrument. Focus group subjects selectively used minimally adaptive nonprescription footwear. Control subjects had similar disease expression, but did not alter their choice of footwear due to their disease., Results: Adult patients with rheumatoid arthritis demonstrate a significant negative impact on their quality of life with mild or moderate disease expression, as evidenced by poor scores in all six domains of the SFMA. Subjects who used even mildly adaptive nonprescription footwear demonstrated a statistically significant negative impact in mobility (p < .044) and functional index (p < .052) domains as compared with the control population having similar overall disease expression. Focus subjects also demonstrated a trend to less favorable scores in the arm and hand domain. Mean scores of the daily activity, emotional status, and bother index domains fared worse than population norms, but there was no statistical difference between subjects using, or not using, adaptive footwear., Conclusions: Individuals affected with mild to moderate rheumatoid arthritis are disabled as compared with the general population. There is a severe negative impact on mobility and functional capacity when the disease process begins to affect their feet.

The purpose of this study was to quantify differences in joint range of motion, foot deformity, and foot morphology among pes cavus, neutrally aligned, pes planus rigid, and pes planus flexible feet. A cohort of 1047 veterans with diabetes (contributing 2047 feet) was enrolled in a prospective study of diabetic ulcer risk factors (the Seattle Diabetic Foot Study). Significant differences between foot types were found. Pes cavus feet had an increased percentage of prominent metatarsal heads, bony prominences, and hammer/claw toes (p < .0001), as well as significantly increased amounts of hallux dorsiflexion and decreased amounts of hallux plantarflexion (p < .0001) with a total range of motion equal to the other foot types (p = .3). Neutrally aligned feet had a lower percentage of intrinsic muscle atrophy, bony prominences, and hammer/claw toes (p < .0001). Pes planus feet had an increased lateral talometatarsal angle (p < .0001) and an increased second metatarsal length. These data demonstrate structural differences between foot types in a population with diabetes.

This article reviews the most common foot deformities and pedal pathomechanical conditions that often result in pain and disability in the elderly. A description of the deformity or condition, its etiology, presenting symptoms, and various nonsurgical approaches to treatment are explored. The primary goal in all cases is to maintain or improve the patient's ability for comfortable, independent ambulation.

Aim: The operative management of cavovarus foot deformity using soft tissue and bony procedures turns out to be difficult. The present study was undertaken to evaluate an individualised operative treatment and changes in pathologic peak pressure pattern., Method: 38 patients (average age 29.6 years, follow-up 44.6 months) with 59 operated feet were examined pre- and postoperatively. The clinical assessment included a questionnaire, ankle ROM and evidence of callosities. Correction of the longitudinal arch was measured on lateral X-rays using Hibbs', calcaneal pitch and Meary's angles. Plantar peak pressures were analysed in 16 patients (21 feet) using dynamic pedobarography (EMED SF4 system)., Results: A good subjective functional and cosmetic result were achieved in 74.6 % of the feet. Walking distance, shoe wear and ankle ROM were improved. The height of longitudinal arch and calcaneal dorsiflexion decreased significantly (p = 0.001). An elevated first ray (overcorrection) was noted in 49.1 % of the cases. Postoperative plantar callosities occurred essentially under the lateral border of the foot but were improved compared to the preoperative situation. Dynamic pedobarography showed a significant postoperative (p = 0.002) decrease of loading under the lateral border, but peak pressures remained relatively high in the midfoot area. An increase of peak pressure under the great toe showed a functional improvement at push off., Conclusion: The individualised operative concept has proved to be successful and leads to satisfaction with early improvement of foot function and shoe wear. Nevertheless it is difficult to restore muscular balance and normal foot posture in progressive neuromuscular disorders. A more selective use of the Jones procedure, an additional peroneus longus to peroneus brevis tendon transfer and a dorsal wedge extension osteotomy should prevent overcorrection of the first ray. To avoid a relapsed hindfoot varus deformity, a stabilising triple arthrodesis including lateral wedge resection should be performed early in severe deformities.

As Americans above the age of 65 have become healthier and remain physically active, we are seeing an increase in lower extremity and foot problems. As life expectancy has increased in this fastest growing segment of the population, so have serious age-related problems such as injuries from falls. Periodic lower extremity evaluations and appropriate therapeutic intervention may help to prevent many of these serious and debilitating conditions and injuries. An important aspect of the treatment plan for older adults may include the use of foot orthoses and optimal shoewear.

This study was carried out to determine the effect of foot orthoses on pain, gait, and energy expenditure in patients with rheumatoid arthritis. Eighteen patients were evaluated for these parameters. Each patient was given a foot insert or shoe modification suitable for his or her foot deformity. Following 3 months of orthosis use, a significant difference was found in regards to pain (p < .05), step length and stride length (p < .05), and physiological cost index (p < .05). The results suggest that foot orthoses are an important feature in the rehabilitation of the rheumatoid foot.

A cavus deformity of the foot is easily recognizable, but appropriate neurologic assessment can help to determine the etiology. Cavovarus, the most frequent type of cavus foot, presents with an elevated medial longitudinal arch, first ray plantarflexion, and, if rigid, a fixed heel varus. Common causes include progressive motor sensory conditions, typically Charcot-Marie-Tooth disease, and nonprogressive conditions such as cerebral palsy and poliomyelitis. A calcaneocavus foot may be seen in poliomyelitis, spinal dysraphism, and peripheral neuropathy. Initially, the cavus deformity is flexible, but if left untreated, it becomes a fixed bony deformity. Physical examination should include the cavovarus block test, which assesses flexibility of the hindfoot deformity and can direct surgical treatment. Standing radiographs of the feet and spine, magnetic resonance imaging, and electrodiagnostic studies may be useful. Management goals are to obtain a plantigrade, mobile, pain-free, stable, motor-balanced foot. Surgical options include soft-tissue and plantar fascia releases for a flexible deformity, osteotomy for a fixed deformity, and tendon transfers to restore muscle balance. Triple arthrodesis has poor long-term results in patients with progressive deformity and sensory impairment.

With the advent of imaging advancements there has been renewed interest in the foot and ankle. However, many of the basic functions and biomechanical considerations of the bones, joints, and specialized tissues of the normal and dysfunctional foot and ankle remain unfamiliar to many radiologists. This article focuses on the basic biomechanics, normal alignment, and common alignment disorders of the foot and ankle that are relevant to radiologists.

On the basis of the standard measurements of 1277 long appendicular bones of the domestic sheep, a universal point scale has been elaborated. The bones examined were obtained from European, Asian and African archaeological sites dating from 4500 BC to 1500 AD. A comparative analysis of the metapodial bones of the domestic sheep from Central Europe (Poland, Germany and Hungary) has been undertaken, using this scale.

The monitoring of Charcot's arthropathy in patients with diabetes mellitus is twofold: 1) assessment of disease activity as the condition progresses from the acute to the chronic phase, and 2) identification of structural abnormalities and complications that may arise as a result of the disease. The former guides the clinician as to the duration of primary treatment, and the latter provides important information regarding the long-term prognosis and facilitates clinical decision making regarding other treatments including surgery, footwear, and orthoses. The mainstay of assessing disease activity remains thorough and regular assessment of swelling, temperature differences, and bony abnormalities. Radiographic assessment performed at baseline and periodically throughout the course of the disease will show stages of early fracture and fragmentation followed by eventual trabecular bridging, ankylosis of the affected joints, and sclerosis, heralding the chronic phase of the disease. Radiographic assessment also provides visualization of bony deformities and prominences. In addition to these assessments, changes may be further quantified by the use of infrared dermal thermography and quantitative bone scanning techniques. Careful clinical monitoring of patients is essential to optimize treatment for acute Charcot's arthropathy and improve the long-term outcome for patients presenting with this condition.

The purpose of this study was to examine the effect of first metatarsophalangeal arthrodesis on the sagittal plane orientation of the first ray and the medial longitudinal arch. Lateral weightbearing radiographs of 48 patients (54 feet) having undergone the procedure were retrospectively reviewed. Patients were separated into three groups based on their preoperative diagnosis: hallux rigidus, hallux valgus, or rheumatoid forefoot deformity. First metatarsal declination, talometatarsal, talar declination, calcaneal inclination, and talocalcaneal angles were measured on pre- and postoperative radiographs. Multivariate analysis of variance determined that there was a significant postoperative change (p < .001) in angular measurements, particularly in the first metatarsal declination, talometatarsal, and talocalcaneal angles. There was also a significant difference (p < .01) in the angular measurements between the hallux rigidus group and the other two groups. However, the amount of change from pre- to postoperatively did not vary significantly between the groups. A calculation of Pearson correlation coefficients found no significant correlation between the hallux dorsiflexion angle and changes in angular measurements. The radiographic changes found in this study support Hicks' windlass model: fixed dorsiflexion of the hallux causes plantarflexion of the first ray and an increase in the medial longitudinal arch.

The American College of Foot and Ankle Surgeons developed the Universal Evaluation Scoring System to evaluate parameters related to foot and ankle surgery. The project was developed in four sections or modules. The second of these modules, Forefoot, is presented here.

Osteotomy of the first metatarsal is a common procedure for correction of hallucal disease. Metatarsals are unique in that they are the only long bones in the human body that support load perpendicular to their longitudinal axis during standing. Thus, osteotomy of the first metatarsal may be complicated by loss of fixation, resulting in nonunion or malunion. The authors review the forces that must be resisted by the osteotomy of the first metatarsal as postoperative weight bearing is initiated, and explore the principles of osteotomy geometry and different fixation techniques to maximize stability of the final construct and to minimize the risk of displacement.

Foot problem assessments were performed on 135 community-dwelling older people in conjunction with clinical tests of balance and functional ability. Eighty-seven percent of the sample had at least one foot problem, and women had a higher prevalence than men of foot pain, hallux valgus, plantar hyperkeratosis, lesser digital deformity, and digital lesions. Postural sway did not differ between older people with and without each of these foot conditions. However, the presence of specific foot conditions impaired performance in a more challenging balance test and in some functional tests. In particular, older people with foot pain performed worse in a leaning balance test, stair ascent and descent, an alternate step-up test, and a timed six-meter walk. Furthermore, multiple regression analyses revealed that foot pain was a significant independent predictor of performance in each of these tests. These results show that the presence of foot problems, particularly foot pain, impairs balance and functional ability. As foot pain is amenable to treatment, podiatric intervention has the potential to improve mobility and independence in older people.

The purpose of this work is to characterize the three-dimensional (3-D) motion of the peritalar joint complex in vivo using magnetic resonance imaging (MRI). Each image data set utilized in this study is made of 60 longitudinal MR slices of the foot in each of eight positions from extreme pronation to extreme supination. We acquired and analyzed ten such data sets from normal subjects, seven data sets from pathological joints and two postoperative data sets. We segmented and formed the surfaces of the calcaneus, talus, cuboid and navicular from all data sets. About 30 geometrical parameters are computed for each joint in each position. The results present features of normal motion and show how normal and abnormal motion can be distinguished. They also show the consequences of surgery on the motion. This non- invasive method offers a unique tool to characterize and quantify the 3-D motion of the rearfoot in vivo from MR images.

Seventeen patients with a mean follow-up of 64.4 months following a tibialis posterior tendon transfer to regain active foot dorsiflexion were clinically examined specifically for signs of tibialis posterior tendon dysfunction. The results show that 8 patients (47%) had Grade 4 or better power of eversion but none had a clinical flatfoot on the Harris-Beath footprints. Only 6% had forefoot abduction; 17% exhibited hindfoot valgus and 82% were able to perform the single-heel rise. Tibialis posterior tendon dysfunction therefore does not appear to be an inevitable sequel of tibialis posterior tendon transfer even in the presence of a functioning peroneal muscle. Other studies have noted that a pre-existent flatfoot was often present in patients with tibialis posterior tendon dysfunction. None of the patients in this study had pre-existent flatfoot. We suggest that a predisposition, in the form of a pre-existent tendency to flatfoot may also be a factor in the pathogenesis of tibialis posterior tendon dysfunction. This may explain the long-term failure of flexor digitorum longus and flexor hallucis longus tendon transfers in the treatment for tibialis posterior tendon dysfunction when the biomechanics of the foot has not been altered.

Dynamic pedobarography (DPB) was performed in 21 patients, 9 male and 12 female with cavovarus foot deformity mostly of Charcot-Marie-Tooth origin. Age ranged from 14 to 52 years (mean 30 y). Twenty-six feet were examined pre- and postoperatively clinically, radiologically and by dynamic pedobarography with a follow-up time from 9 to 49 months (mean 22.5 mo). The EMED SF system was used for data collection during walking. Gait line, contact areas (CA), peak pressures (PP) and pressure time integral (PTI) were determined. According to the contact pattern the examined feet could be divided into three groups with antegrade, retrograde and inversion contact pattern. Data analysis showed postoperatively considerable increase in CA and decrease in PP and PTI. Clinical results such as plantar callosities and "roll over avoidance gait" did not always correlate with pedobarographic data. DPB adds a dynamic component in the diagnosis and management of cavovarus feet but certain limitations exist.

Study Design: Experimental design using 1-way analysis of variance and regression analysis to test the influence of 3 forefoot alignments on the dorsal mobility of the first ray., Objectives: To determine the effect of forefoot alignment on the magnitude of first ray dorsal mobility to an imposed load and to describe any association between forefoot alignment and age on dorsal mobility of the first ray., Background: Instability of the first ray has been implicated as a primary mechanical etiology of many foot problems. It has been proposed that a relationship exists between forefoot alignment and mobility of the first ray, with a varus aligned forefoot contributing to the development of an unstable first ray., Methods and Measures: Sixty female (n = 34) and male (n = 26) subjects aged 18-77 were assigned into valgus, neutral, and varus foot groups (20 per group) based on a clinical measurement of forefoot alignment. A load cell device measured dorsal mobility of the first ray under a standard load of 55 N. Within-day repeat measures were taken from a subsample of subjects. In addition to reliability analysis, analysis of variance and regression analyses tested the relationship between forefoot alignment, age and sex, and mobility of the first ray., Results: The forefoot valgus group demonstrated significantly less dorsal mobility of the first ray than neutral or varus groups. The varus and neutral groups were not significantly different from one another. Forefoot alignment and sex were significant linear predictors (R2 = 0.40) of first ray dorsal mobility. Age had no significant association to dorsal mobility of the first ray., Conclusion: Subjects having a valgus aligned forefoot had less dorsal excursion of the first ray than subjects having a neutral aligned forefoot. This investigation provides evidence supporting a relationship between forefoot alignment and mobility of the first ray.