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Introduction: Flat feet in children negatively affect lower limb alignment and cause adverse health-related problems. The long-term application of foot orthoses (FOs) may have the potential to improve lower limb coordination and its variability., Aim: To evaluate the effects of long-term use of arch support FOs on inter-joint coordination and coordination variability in children with flexible flat feet., Methods: Thirty boys with flexible flat feet were randomly assigned to the experimental (EG) and control groups. The EG used medial arch support FOs during daily activities over a four-month period while the control group received a flat 2-mm-thick insole for the same time period. Lower-limb coordination and variability during the 3 sub-stance phases were quantified using a vector coding technique., Results: Frontal plane ankle-hip coordination in EG during mid-stance changed to an anti-phase pattern (156.9 ° ) in the post-test compared to an in-phase (221.1 ° ) in the pre-test of EG and post-test of CG (222.7). Frontal plane knee-hip coordination in EG during loading response (LR) changed to an anti-phase pattern (116 ° ) in the post-test compared to an in-phase (35.5 ° ) in the pre-test of EG and post-test of CG (35.3). Ankle inversion/eversion-knee internal/external rotation joint coupling angle in EG changed to an in-phase pattern (59 ° ) in the post-test compared to a proximal phase (89 ° ) in the pre-test. Coupling angle variability increased in the post-test of EG for sagittal plane ankle-hip during push-off, transverse plane ankle-hip during LR and mid-stance, and transverse plane knee-hip during LR and mid-stance compared to pre-test of EG and post-test of CG., Conclusion: The long-term use of arch support FOs proved to be effective to alter lower limb coordination and coordination variability during walking in children with flexible flat feet. This new insight into coordinative function may be useful for improving corrective exercise strategies planned for children with flat feet., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflict of interest relating to the material presented in this article., (Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.)

The use of inserts and orthopedic shoe adjustment represents an essential component of the conservative therapy of degenerative diseases and deformities of the musculoskeletal system. Inserts can have supportive, bedding and corrective effects and are used in particular for complaints of the feet and ankles. The combination of diverse materials allows a high level of cushioning and supporting features and corresponding longevity to be accomplished. The production is carried out on an individual basis and if necessary computer-assisted in order to achieve an optimal fit. For severe and rigid deformities the formation of pressure ulcers can be prevented by orthopedic shoe adjustment and by the use of orthopedic tailor-made shoes.

From a subject group of pes cavus, the purpose of this study was to evaluate the biomechanical characteristics of lower limbs, based on plantar foot pressure and electromyography (EMG) activities, by the effects on two kind of custom-made insoles. Ten individuals among thirty females with a clinical diagnosis of idiopathic pes cavus (mean age (SD): 22.3 (0.08) years) were selected for the study. The plantar foot pressure data and EMG activities of four lower limb muscles were collected, when subjects walked on a treadmill, under three different experimental conditions. The plantar foot pressure data was analyzed, after the bilateral foot was divided into three areas of masks and into four sections of stance phase, to compare plantar foot pressure. The EMG activities were analyzed for integrated EMG (IEMG) value. The results show that plantar foot pressure concentrated in particular parts is decreased by custom-made insoles. In the case of EMG, all the muscle activities decreased significantly. The custom-made insoles dispersed pressure concentrated by the higher medial longitudinal arch and improved the efficient use of muscles. In particular, the extension structure in the forefoot of custom-made insoles was more efficient for pes cavus. Therefore, it could help patients to walk, by offering support to prevent the disease of pes cavus deformity, and to relieve the burden and fatigue in the lower limbs on gait.

Customised foot orthoses (FOs) featuring extrinsic rearfoot posting are commonly prescribed for individuals with a symptomatic pronated foot type. By altering the angle of the posting it is purported that a controlled dose-response effect during the stance phase of gait can be achieved, however these biomechanical changes have yet to be characterised. Customised FOs were administered to participant groups with symptomatic pronated foot types and asymptomatic normal foot types. The electromyographic (EMG) and plantar pressure effects of varying the dose were measured. Dose was varied by changing the angle of posting from 6° lateral to 10° medial in 2° steps on customised devices produced using computer aided orthoses design software. No effects due to posting level were found for EMG variables. Significant group effects were seen with customised FOs reducing above knee muscle activity in pronated foot types compared to normal foot types (biceps femoris p=0.022; vastus lateralis p<0.001; vastus medialis p=0.001). Interaction effects were seen for gastrocnemius medialis and soleus. Significant linear effects of posting level were seen for plantar pressure at the lateral rearfoot (p=0.001), midfoot (p<0.001) and lateral forefoot (p=0.002). A group effect was also seen for plantar pressure at the medial heel (p=0.009). This study provides evidence that a customised FOs can provide a dose response effect for selected plantar pressure variables, but no such effect could be identified for muscle activity. Foot type may play an important role in the effect of customised orthoses on activity of muscles above the knee., (Copyright © 2013 Elsevier B.V. All rights reserved.)

Background: Pes cavus is a structural deformity in which the increased plantar arch can lead to greater metatarsal verticality with the consequent excess of pressure under the forefoot zone (especially the metatarsal zone), causing pain and significant loss of functional capacity. We sought to determine whether neuromuscular stretching with symmetrical rectangular biphasic currents can reduce the pressure supported by this zone., Methods: This prospective, nonrandomized, longitudinal, analytical, and experimental controlled trial included 34 patients with pes cavus. Pedobarometric measurements were made using the footscan USB Gait Clinical System platform considering the toes and metatarsal heads, forefoot, midfoot, and hindfoot before and after performing stretching using a Med Tens 931 electrotherapy device. The measurements were repeated 7 days after the application., Results: With the Student t test for paired samples, we showed that there was a significant decline in metatarsal pressure (P < .001) in the zones of the first (P = .045) and third (P = .01) metatarsals and that this reduction was maintained 1 week after the plantar stretching., Conclusions: Plantar stretching with symmetrical rectangular biphasic currents is effective for the prevention and treatment of pes cavus metatarsalgia caused by excessive pressure.

Lower back pain (LBP) is a widespread, expensive, and debilitating problem in Western industrialized countries. Though LBP can be caused by acute injuries, biomechanical discrepancies have also been indicated to cause chronic LBP. A possible link between podiatrical deviations and LBP has been established in the literature; yet, no comprehensive review investigating the effects of foot and ankle deviations on low back pain has been published. The aim of this study was to assess the relevant literature concerning the effects of foot and ankle deviations on LBP. After review, it was determined that there is limited research regarding ankle and foot deviations and their connection to LBP. Reviewed studies have linked flat feet, ankle instability, sagittal plane blockage and excessive pronation to LBP. Specifically, excessive pronation has been shown to cause leg length discrepancies leading to pelvic tilts and LBP. Based on these results, ankle and foot deviations can be considered a potential cause for LBP due to the disruption of the kinetic chain from the foot to the back. Clinicians should consider the foot and ankle when addressing LBP, especially if more conventional etiologies fail to describe the condition.

Aims: Custom-made therapeutic footwear is often prescribed to patients with diabetic neuropathy, foot deformity and a healed plantar foot ulcer. Offloading these feet is important to prevent ulcer recurrence. The aim was to evaluate the offloading effect of custom-made footwear in these patients., Methods: In 171 patients with diabetic neuropathy (336 feet) with foot deformity and a recently healed plantar foot ulcer, plantar pressures walking barefoot and inside new custom-made footwear were measured. At the previous ulcer location and at locations of highest barefoot pressure attributable to the deformity, in-shoe pressures were compared with non-deformed feet. The footwear was considered effective in offloading when in-shoe peak pressure at these locations was < 200 kPa., Results: Mean in-shoe peak pressures ranged between 211 and 308 kPa in feet with forefoot deformity (vs. 191-222 kPa in non-deformed feet) and between 140 and 187 kPa in feet with midfoot deformity (vs. 112 kPa in non-deformed feet). Offloading was effective in 61% of all feet with deformity, 81% of feet with midfoot deformity, 44% of feet with forefoot deformity and 62% of previous ulcer locations. Inter-subject variability in measured in-shoe plantar pressure was large., Conclusions: Offloading in custom-made footwear is often not sufficiently achieved in high-risk diabetic feet with deformity. Highest offloading success rates were seen at known high-risk locations such as previous ulcer locations and Charcot feet, the lowest success rates in forefoot deformities. Together with the large inter-subject variability in pressure outcomes, this emphasizes the need for evidence-based prescription and evaluation procedures to assure adequate offloading., (© 2012 The Authors. Diabetic Medicine © 2012 Diabetes UK.)

Repeatability studies on 3D multi-segment foot models (3DMFMs) have mainly considered healthy participants which contrasts with the widespread application of these models to evaluate foot pathologies. The current study aimed at establishing the repeatability of the 3DMFM described by Leardini et al. in presence of foot deformities. Foot kinematics of eight adult participants were analyzed using a repeated-measures design including two therapists with different levels of experience. The inter-trial variability was higher compared to the kinematics of healthy subjects. Consideration of relative angles resulted in the lowest inter-session variability. The absolute 3D rotations between the Sha-Cal and Cal-Met seem to have the lowest variability in both therapists. A general trend towards higher σ(sess)/σ(trial) ratios was observed when the midfoot was involved. The current study indicates that not only relative 3D rotations and planar angles can be measured consistently in patients, also a number of absolute parameters can be consistently measured serving as basis for the decision making process., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Background: Chronic foot conditions have been reported to be a significant cause of impairment and disability to individuals affected. However, studies to date have particularly focussed on patient satisfaction with outcomes following surgery., Objectives: The aim of this study is to examine the impact of three common foot conditions on the levels of impairment and quality of life prior to surgery. Three conditions include Hallux Valgus (HV), Hallux Rigidus (HR) and Hammer Toe (HT)., Methods: This was a pilot cross-sectional observational study of people who were radiologically and clinically diagnosed with one of the three common foot pathologies: HV, HR and HT. Age and gender matched controls were also recruited. Self-reported quality of life was measured., Results: The SF-36 scores did not differ significantly between the groups. There was a significant difference in self reported impairment between the groups on the Global Foot and Ankle Scale indicating that the 'bilateral foot group' perceived themselves to be significantly more impaired than their counterparts in the control group., Conclusion: Patient quality of life is now recognised as one of the most important outcomes of surgery. These findings serve to highlight the level of impairment and quality of life of individuals prior to surgery., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Treating patients with custom foot orthoses for common pathologies is a rewarding experience when the proper steps are taken during foot casting and custom-orthosis prescription writing. This article describes successful methods for orthoses casting and prescription writing for custom-molded orthoses for Achilles tendonitis, pes planus, hallux limitus, plantar fasciitis/heel spurs, lateral ankle instability, metatarsalgia, and pes cavus. In addition, a summary of orthotic laboratory instructions for each pathology-designed custom orthosis is provided, which should be considered by orthotic laboratories., (Copyright © 2011 Elsevier Inc. All rights reserved.)

The nozoological structure of podiatric pathology in Novosibirsk oblast is represented mainly by the injuries of talocrural articulation (39.2% of examined patients), deformation of foot (20.7%) and degenerative lesion of foot (15.9%), fractures of heel bone (4.2%). This pathology has higher social significance. The main cause of disability is the deforming arthritis of talocrural articulation (48.5%) and subtalar articulation (20.3%). The model of specialized podiatric care was developed and approved in the functioning of Novosibirsk specialized podiatric center. The model includes outpatient, diagnostic, treatment, rehabilitation stages. The implementation of this approach permits to avoid the re-appealability to municipal medical care system and application to the specialized medical institution. This approach precipitates the period of care delivering and decreases the possibility of disabling patients due to non-effective treatment of podiatric pathology in common curative institution.

Objective: To develop a short and easy to use questionnaire to measure use and usability of custom-made orthopaedic shoes, and to investigate its reproducibility., Design: Development of the questionnaire (Monitor Orthopaedic Shoes) was based on a literature search, expert interviews, 2 expert meetings, and exploration and testing of reproducibility. The questionnaire comprises 2 parts: a pre part, measuring expectations; and a post part, measuring experiences., Patients: The pre part of the final version was completed twice by 37 first-time users before delivery of their orthopaedic shoes. The post part of the final version was completed twice by 39 first-time users who had worn their orthopaedic shoes for 2-4 months., Results: High reproducibility scores (Cohen's kappa > 0.60 or intra class correlation > 0.70) were found in all but one question of both parts of the final version of the Monitor Orthopaedic Shoes questionnaire. The smallest real difference on a visual analogue scale (100 mm) ranged from 21 to 50 mm. It took patients approximately 15 minutes to complete one part., Conclusion: Monitor Orthopaedic Shoes is a practical and reproducible questionnaire that can measure relevant aspects of use and usability of orthopaedic shoes from a patient's perspective.

Chronic venous disease is very common and widespread. Chronic Venous Insufficiency (CVI) is a condition characterized by hypertension of the venous system of the lower limbs which manifests itself through a large range of symptoms. The main cause of CVI is hypertension of the venous system of lower limbs, which in most cases is due to reflux for the incontinence of the valvar system of veins. Other causes are related to obstruction of the venous outflow, or at a reduced venous emptying due to inefficiency of the system of the veno-muscular pumps of the calf and of the foot. The purpose of this study was to evaluate if the use of a non-invasive rehabilitative mode to improve the efficiency of the veno-muscular pumps of the foot and of the calf using photoplethysmography in reflected light. Fifty (50) patients suffering from flatfoot and ped cavus, were studied doing a stabilometric and baropodometric test to evaluate the angle of the foot and the podalic angle. Patients were evaluated by examining vascular examination and venous reography in basal condition, using corrective visco-elastic insoles for the correction of dysmorphisms that we were studying. An improvement of the angle of the Right and Left axis (p<0.05) and the podalic angle (p<0.001), using the right insole both in the flatfoot and cavus foot, was shown by the podobarographic examination. A not important tendency to improvement was also shown by the use of non-specific insole in both pathologies. The vascular examination showed an improvement of 38 percent in venous emptying capacity of the foot/calf veno-muscular pump in cavus foot with the specific B insole (p<0.002). An important improvement of 24 percent, using the specific A insole (p<0.05), was documented in flatfoot. The photoplethysmography examination documented a significant improvement of the venous emptying capacity of foot-calf veno-muscular system due to the use of specific insoles for the studied dysmorphism, with an improving tendency even with the use of non-specific insoles. The hemodynamic improvement is correlated with the improvement of the analyzed biomechanical parameters: contact time, lenght of the halfstep, podalic angle and angle of the foot. The partial normalization of biomechanical parameters allows a reorganization of relationships of forces between ground and foot, as well as the improvement of the function of the subtalar joint, causing a partial recovery of the complex physiological mechanism of activation of the veno-muscular pumps of the foot and of the calf.

Background: A scientific study was conducted to evaluate the effects of non-custom-molded (over-the-counter) foot orthoses., Methods: Several parameters were examined, including foot, knee, hip, and back pain; balance; and reduction in flexible deformities, such as hammer toes and hallux valgus. Wherever possible, objective measurements were used, including measurements of shifts in center of pressure to assess balance and changes in bone position examined on radiographs. Forty-one individuals were analyzed using one of two types of prefabricated, non-custom insoles. Insoles were fit by an assistant trained to follow the fitting recommendations of the manufacturer under the direct supervision of a podiatric physician., Results: Use of these arch supports resulted in a significant reduction in some types of foot pain associated with hallux valgus (P = .04) and pain in the arch area (P = .004), knee (P = .002), and back (P = .007) by week 4. We also measured changes in foot position documented by radiography, although some changes may be attributed to parallax associated with measurement techniques. Improvement in balance was not observed to be significant when the orthoses were worn., Conclusions: Using both subjective and objective measures, we found that these over-the-counter foot orthoses were effective in bringing about changes in foot shape and concomitant relief of certain specific painful conditions. This study indicates that there is a scientific basis for attempting to relieve pain with orthoses.

Unlabelled: The general consensus regarding the postoperative management of patients who have undergone first metatarsophalangeal joint arthrodesis is to maintain non-weight bearing for 4 to 6 weeks. However, a number of studies indicate that immediate postoperative weight bearing does not result in a higher rate of nonunion. A retrospective case series investigation was performed to evaluate the fusion rate of first metatarsophalangeal joint arthrodesis using various forms of pin and wire fixation, and a postoperative protocol that involved immediate weight bearing with a padded surgical shoe. The impetus behind allowing immediate postoperative weight bearing stems from the desire to avoid difficult non-weight-bearing forms of ambulation in patients at risk for falling, and to enhance postoperative rehabilitation in patients at risk for other joint maladies, as in those suffering with rheumatoid and other polyarticular forms of arthritis. A total of 22 fusions (20 patients) were reviewed. Nonunion developed in 2 feet (9.1%), and a delayed union occurred in 1 additional foot (4.55%), for a total complication rate of 13.64% (3/22 cases) and a fusion rate of 86.36%. The remaining patients demonstrated radiographic consolidation of the arthrodesis. A crude rough comparison to previously published reports, wherein weight bearing was initiated anywhere from immediately to up to 2 weeks postoperative, showed that the rate of fusion observed in the patients described in this report was similar. This study demonstrated that immediate ambulation following first metatarsophalangeal joint fusion with wire fixation was safe and effective., Level of Clinical Evidence: 4.

Background: People with pes cavus frequently suffer foot pain, which can lead to significant disability. Despite anecdotal reports, rigorous scientific investigation of this condition and how best to manage it is lacking., Objectives: To assess the effects of interventions for the prevention and treatment of pes cavus., Search Strategy: We searched the Cochrane Neuromuscular Disease Group Trials Register (April 2007), MEDLINE (January 1966 to April 2007), EMBASE (January 1980 to April 2007), CINAHL (January 1982 to April 2007), AMED (January 1985 to April 2007), all EBM Reviews (January 1991 to April 2007), SPORTdiscuss (January 1830 to April 2007) and reference lists of articles. We also contacted known experts in the field to identify additional published or unpublished data., Selection Criteria: We included all randomised and quasi-randomised controlled trials of interventions for the treatment of pes cavus. We also included trials aimed at preventing or correcting the cavus foot deformity., Data Collection and Analysis: Two authors independently selected papers, assessed trial quality and extracted data., Main Results: Only one trial (custom-made foot orthoses) fully met the inclusion criteria. Two additional cross-over trials (off-the-shelf foot orthoses and footwear) were also included. Both studies assessed secondary biomechanical outcomes less than three-months after randomisation. Data used in the three studies could not be pooled due to heterogeneity of diagnostic groups and outcome measures. The one trial that fully met the inclusion criteria investigated the treatment of cavus foot pain in 154 adults over a three month period. The trial showed a significant reduction in the level of foot pain, measured using the validated 100-point Foot Health Status Questionnaire, with custom-made foot orthoses versus sham orthoses (WMD 10.90; 95% CI 3.21 to 18.59). Furthermore, a significant improvement in foot function measured with the same questionnaire was reported with custom-made foot orthoses (WMD 11.00; 95% CI 3.35 to 18.65). There was also an increase in physical functioning of the Medical Outcomes Short Form - 36 (WMD 9.50; 95% CI 4.07 to 14.93). There was no difference in reported adverse events following the allocation of custom-made (9%) or sham foot orthoses (15%) (RR 0.61; 95% CI 0.26 to 1.48)., Authors' Conclusions: In one randomised controlled trial, custom-made foot orthoses were significantly more beneficial than sham orthoses for treating chronic musculoskeletal foot pain associated with pes cavus in a variety of clinical populations. There is no evidence for any other type of intervention for the treatment or prevention of foot pain in people with a cavus foot type.

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.

Inserts are orthopedic aids in the treatment of foot disorders that result from changes of the static or dynamic situation. Provision of appropriate orthopedic devices can relieve the pain caused by forefoot deformities either in lieu of surgical intervention or in rare cases also following surgical treatment to improve the symptoms of residual pain.Available materials provide support, padding, and cushioning. Inserts are custom-made to measure and/or based on a plaster impression. Determining the indication, prescribing the inlay, and checking the orthosis are the tasks of the physician. One treatment option for relieving the pain of forefoot deformities consists in conservative therapy with an insert combining features of padding and support as well as adjusting a ready-made shoe. The shoe and inlay should constitute a functional unit since often the optimal effect is only achieved with a combination of insert and orthopedic adjustment of the ready-made shoe.

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.

Background: The purpose of this study was to determine the interrater reliability of visual rating of forefoot frontal plane deformities among clinicians with different training., Methods: Thirty individuals (16 men and 14 women) between the ages of 22 and 52 years of age participated in the study. None of the patients had a history of congenital deformity, pain, or trauma in the lower extremities during the 6 months before the study. Three clinicians of different educational backgrounds and experience visually evaluated each of the patients and rated forefoot alignment. None of the clinicians knew the rating assigned by either of the other two clinicians., Results: The results of this study showed that two of the clinical raters agreed 61.7% of the time, but neither of them agreed with the third clinician more than 15% of the time., Conclusion: This study indicates that the commonplace method of visually rating forefoot frontal plane deformities is unreliable and of questionable clinical value.

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.)

Retrocalcaneal bursitis in athletes is frequently misdiagnosed. Results of conservative treatment are not very promising. This investigation evaluates the results of 39 consecutive cases in 38 patients surgically treated due to chronic retrokalkaneal bursitis in a sport specific population. Preoperative MRI and ultrasound investigation showed corresponding lesions (focal degeneration, partial rupture) of the anterior Achilles tendon. This is possibly the result of a previously undescribed impingement lesion produced by the Haglund's bone and the chronically inflamed retrocalcaneal bursa. During operation this lesion was additionally addressed in 85% of the cases. Follow up was done after 32 months. Success rate was 54%. VISA-A Score at follow up was 80.6 points. Training and competition activities were started at 16 weeks and 9 months respectively. Unsatisfying results were analysed. In two cases Haglund's bone resection was incomplete and had to be removed in a reoperation. Additionally one deep wound infection had to be revised. Due to the distal Achilles tendon fiber extensions around the medial and lateral calcaneal bone, an unintended Achilles tendon lesion, induced by the edge of the osteotome seems to be possible. Two calcanear stress fractures complicated the postoperative rehabilitation.

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.

Background and Purpose: Dynamic ankle-foot orthoses (DAFOs) are often recommended for children with spastic diplegia in order to facilitate better function. The aim of the present study was to explore how the parents of children with diplegic cerebral palsy experience the use of DAFOs., Method: A qualitative interview study with a broad research question: 'How do you perceive that DAFOs influence your child?' The parents of 15 children, aged 4-18 years, who all had spastic diplegia and wore DAFOs were interviewed., Results: Content analysis resulted in the following categories: 'Physical effects'; 'New functions and activities'; 'The orthosis as a part of the treatment'; 'Opportunity for independence and play'; and 'Problems with DAFOs'. According to the parents, DAFOs appeared to contribute to the (mechanical) changes in posture affecting the muscular system. They meant that when wearing DAFOs the foot and ankle are more stable. This in turn enables postural control and alignment, contributing to functional activities under more favourable physiological conditions. The psychosocial effects were regarded by parents as being just as important as the physical effects., Conclusion: In clinical practice, DAFOs may (according to parents) be regarded as a suitable complement to other treatments in children with diplegic cerebral palsy.

This exploratory study attempted to estimate the severity of health complaints and disabilities in patients supplied with foot orthoses for degenerative foot disorders in the Netherlands. Information on the severity and the distribution of the complaints in these patients is important to acquire insight in the problems which these patients experience, and moreover is essential for further research, especially for evaluating effects of patients undergoing foot orthosis treatment. Patients with degenerative foot disorders aged 18 years and over were recruited from nine orthopaedic workshops over a period of three months in 2000. One hundred and twenty-two (122) patients were included in the study. Two approaches were used to obtain data. Firstly, shoe technicians and orthotists inspected patients' feet and legs and interviewed them at their initial visit. Data on gender, age, height, weight, existing and prescribed orthotic devices were recorded on a report form. Secondly, patients were asked to fill in a questionnaire assessing type, location, frequency, intensity and duration of health complaints, and disability. Data indicate that females with degenerative foot disorders and foot orthoses are twice as common as men. Patients supplied with foot orthoses are twice as often overweight compared to subjects in the general population. Besides frequent and protracted pain there are also fatigue complaints, particularly in the feet and lower leg. Duration and frequency of the complaints suggest that these patients suffer from a chronic pain syndrome. In addition, the results indicate that the functional level of these patients is below that of the general population, in particular regarding physical activities.

The objectives of this study were to quantitatively determine the effects of subtalar arthrodesis on the planovalgus foot using three-dimensional (3-D) gait analysis and plantar pressure measurements. Twelve children and adolescents with planovalgus foot deformity secondary to spastic cerebral palsy participated in this outcome study. The pediatric population were evaluated preoperatively and following subtalar fusion. Seventeen feet were operated for the correction of the planovalgus foot deformity. A Holter-type microprocessor-based portable in-shoe data acquisition system was used in this study to collect the multistep dynamic plantar pressure history, while a five-camera Vicon-based gait analysis system was used to track the lower extremity joint kinematics. The results obtained from the plantar pressure measurement showed significant increases in mean peak vertical plantar pressures postoperatively at the lateral midfoot and lateral metatarsal heads. Mean contact durations and mean pressure-time integrals were also significantly increased at these plantar locations following foot surgery. This redistribution in pressure metrics suggests the formation of new lateral plantar weight bearing areas. The 3-D gait analysis system, using standardized lower extremity measurements, was unable to reveal any significant changes in joint kinematics, particularly at the foot and ankle where the surgery was performed. This suggests the need for a more refined system to track the complex motion of the pediatric foot and ankle during gait.

Neuropathy may bring about changes in form and function of the foot, which may lead to ulceration and progressive deformity. These manifestations often require specially adapted footwear. A comprehensive concept of the medical, functional, and technical requirements for this type of footwear is still lacking to date. In this article, We present an algorithm that should facilitate prescription and manufacture of adequate shoes. This algorithm attempts to establish a link between the requirements from a medical and functional point of view and the technical possibilities of orthopedic shoe technology.

The gait cycle involves a closely linked interplay among the joints of the lower extremity, notably the complex joints of the foot and ankle. The goals of bracing and orthoses in the management of neuromuscular foot and ankle problems are to prevent further deformity, passively correct deformity, and modulate motor tone. Tone-reducing AFO, in effect, improves the position of the lower extremity and facilitates the pathologic gait. The type of deformity present and its natural history by virtue of the pathologic origin must be considered when embarking on a conservative nonoperative course. Associated issues and thought processes are elaborated in the article. The biomaterials of which the orthotic brace is constructed, the design considerations, and expected goals of an orthosis must be appropriate to accommodate the pathomechanical forces encountered in the face of the cutaneous insensitivity. It is evident from the multiple facets of rehabilitative care that a team of professionals, including the orthopedist, physical therapist, and orthotist, along with involved health care workers, must be in communication and agreement to manage the challenges of these patients successfully.

Emed-system is used for assessment of pressure distribution under the foot at standing and walking since 1985. The method is non-invasive, useful in diagnosing and monitoring of treatment for foot disorders both in children and adults. It may be utilized in orthopedics, traumatology, rehabilitation, rheumathology and diabetology.

The bone structure of the foot, knee and hip and their principle deformities are presented. With this in mind, the orthopedic shoe and its modifications are discussed as an extremely important element in correcting deformities that cause walking alterations, pain, etc.... How the shoes are made, the basic characteristics they should possess, which shoes are appropriate for which age, and problems the wrong shoe type can provoke are also discussed.

Pediatric splinting and bracing techniques may be effectively used in the treatment of lower extremity rotational deformities. Early diagnosis coupled with the timely implementation of these techniques allows the practitioner to enhance normal development of the pediatric patient's lower extremities.

We added hydrotherapy to 50 patients with spinal muscular atrophy (SMA) who were being treated with individual conventional physiotherapy. Hydrotherapy performed at an approximate temperature of 30 degrees Celsius, twice a week, for thirty minutes in children and forty-five minutes in adults during a 2-year period. The outcome derived from this combined modality of treatment was rated according to physiotherapeutic evaluations, the MMT (Manual Muscular Test), and the Barthel Ladder. Patients were reevaluated at 2-month intervals. After two years of ongoing treatment, we were able to observe that the deformities in hip, knee and foot were progressive in all SMA Type II patients, and in some Type III. Muscle strength stabilized in most SMA Type III patients, and improved in some. MMT was not done in SMA Type II. In all patients we were able to detect an improvement in the Barthel Ladder scale. This study suggests that a measurable improvement in the quality of daily living may be obtained in patients with SMA Types II and III subjected to conventional physiotherapy when associated with hydrotherapy.

A general understanding of the cause and natural history of rotational and angular malalignment of the lower extremity allows accurate differentiation between pathologic and physiologic conditions. One can then educate the involved and often concerned family and proceed with observational management of physiologic conditions as spontaneous improvement of alignment can be expected. Aside from treatment for resistant metatarsus adductus, other forms of treatment, such as special shoes, casts, or braces, are rarely beneficial and have no proven efficacy. Persistent deformity beyond skeletal maturity is unusual and rarely causes significant functional disability. In rare cases of severe residual deformity, operative correction is the only effective treatment.

Hereditary motor and sensory neuropathy (HMSN) is one of the most frequently inherited causes of peripheral neurological disability. To date, the classification has been based on clinical, histological and genetic grounds. Due to increased genetic knowledge at the molecular level in recent years, diagnosis of the different subtypes has been considerably improved and their relationship clarified. We describe three generations of a family with HMSN IA (Charcot-Marie-Tooth disease IA = CMT 1A) with a genetic defect mapped to chromosome 17 and show the importance of genetic testing. Even in benign and clinically non-manifested causes of the disease, an early and non-invasive diagnosis should be made by genetic testing to identify affected persons; thus, nerve biopsy can be abandoned. Operations of pes cavus, which are not indicated and are often complicated by delayed healing, may be avoided. Instead, patients should undergo early physiotherapy and be counselled about their professional careers and family planning.

Custom orthopedic shoes represent the ultimate combination of function and aesthetics. Incorporating biomechanics and craftsmanship, shoes can redistribute weight, restrict joint motion, facilitate ambulation, and decrease the probability of neuropathic ulceration. Despite these advantages, many podiatrists know little about shoe therapy and consequently underuse it. This article describes the various types of therapeutic shoe modalities available and presents a systematic method of their application. Some of the latest developments in technology and health care reform also are revealed.

One of the most common pediatric abnormalities treated by podiatrists is an angle-of-gait disturbance. Prior to the initiation of treatment, it is imperative that the practitioner determines both the cause and extent of the problem. At this point, the practitioner will be able to determine what the most appropriate treatment should be. In-toe and out-toe gait plates provide an effective manner of altering a developing youngster's angle-of-gait problems and are capable of allowing the child to function and develop in a more normal fashion.

In conclusion, a functional orthosis may be used to effectively treat most, but not all, abnormalities of the lower extremity that cause abnormal function of the foot. Abnormalities that are resistant to treatment with functional orthoses are compensated talipes equinus, excessive verticality of the oblique axis of the midtarsal joint, forefoot adductus that exceeds 15 degrees of adductus, Charcot's disease, congenital shortage of the iliopsoas muscle, and certain neurologic diseases that exhibit transient muscle spasm or paralysis, resulting in abnormal forces acting upon the foot that vary with time. Unfortunately, laboratories that claim to fabricate functional orthoses may turn out products that vary from nondescript arch supports to orthoses that only partially control function of the foot. The author hopes the practitioner who reads this article will be better able to evaluate whether his or her laboratory is providing his or her patient with a functional orthosis when one is ordered.

Background and Purpose: The purpose of this study was to determine the effects of different orthotic posting methods on controlling abnormal foot pronation during ambulation., Subjects: Twenty-two individuals with forefoot varus deformities of at least 8 degrees (13 women, aged 21-40 years, and 9 men, aged 20-50 years) participated in the study. The female subjects had an average height and weight of 162.6 cm (64 in) and 55.3 kg (122 lb), and the male subjects had an average height and weight of 175.3 cm (69 in) and 80.7 kg (178 lb)., Methods: The subjects were examined with a computerized video motion analysis system. A control trial consisted of walking at 4.0 km/h in running shoes. Experimental trials included walking at 4.0 km/h in running shoes with unposted orthotic shells and with orthotic shells posted in the forefoot, the rear foot, and both forefoot and rear foot., Results: Maximal calf-to-calcaneus and calcaneus-to-vertical angles were decreased more by orthoses posted in both the forefoot and the rear foot than by orthoses posted only in the forefoot. No difference in maximal calf-to-calcaneus and calcaneus-to-vertical angles were found with combined forefoot and rear-foot posting compared with posting in the rear foot alone. The maximal calf-to-calcaneus angle was decreased by orthoses posted in any of the three methods and by the orthotic shell alone when compared with shoes alone. The maximal calcaneus-to-vertical angle was decreased by orthoses posted in any of the three methods, but not by the orthotic shell alone when compared with shoes alone., Conclusion and Discussion: Clinicians should consider combined posting or rear-foot posting alone when maximal control of rear-foot frontal-plane pronation is desired, though forefoot posting alone and the orthotic shell also provide control of rear-foot frontal-plane pronation.

There is presented the experience of treatment of 81 patients with equinus-cavus-varus deformation of 102 feet of different etiology by means of closed application of Volkov-Oganesyan-Povarov's hinged-distraction apparatus to restore the form and function of foot and talocrural articulation. For impartial assessment of the outcomes of treatment there has been developed and applied the scheme of multimark grading system of clinico-functional state of feet. The grade of the foot form and function restoration is appraised by 15 indices in comparison with the same in normal state. The sum of marks equals to 100 in case of optimum outcome. In accordance with the developed scheme there have been appraised 54 feet with the sum of marks obtained from 45 to 91 and their statistic reliability. The proposed scheme allows to make an impartial assessment of the outcomes of treatment of the equinus-cavus-varus deformation of feet and can be applied in practical institutions.

A trial has been conducted to produce the uppers for orthopaedic shoes using an existing commercial computer-aided design system. The aims of the trial were to confirm that a CAD system developed for the volume shoe trade (Shoemaster from Clarks Shoes) could be used for the upper design of orthopaedic shoes and to assess the contribution of professional shoe design on cosmesis and acceptability of these shoes. A small number of adult diabetic patients and children with foot deformities were selected, all of who had previously been prescribed and issued with special shoes. The existing lasts for these patients were digitised, and new styles developed on the CAD system over a 3D image of the last. Pattern pieces were cut automatically and the uppers closed. Lasting was done as normal at the two collaborating orthopaedic companies and the shoes supplied to the patients. The CAD system proved successful in coping with orthopaedic last shapes and shoe requirements. Professional design produced fashionable and cosmetically-pleasing styles within the constraints imposed by the underlying medical conditions.

The technique and results of extraarticular subtalar arthrodesis using the dowel method during the 10-year period between 1976 and 1986 were reviewed retrospectively. Fifty feet in 30 children underwent extraarticular subtalar arthrodesis for valgus deformity for diagnoses including meningomyelocele, idiopathic flatfoot, and cerebral palsy. The aims of the procedure were to correct the deformity, obtain a solid arthrodesis, and improve ambulation by reducing bracing requirements and eliminating pain. Results were excellent in 28 cases (56%), satisfactory in 15 (30%), and unsatisfactory in seven (14%). Intraoperative positioning error and simultaneous perineal tendon lengthening in children with cerebral palsy were the major sources of unsatisfactory results.

The podiatrist specializing in biomechanical therapy must begin with a solid foundation of standardized definitions in order to discuss theories of mechanical foot treatment as they have been presented and developed over the past century. Equally important, is the building of a working knowledge and familiarity with the wide variety of available materials and their diverse properties. In addition, in order to arrive at an accurate biomechanical diagnosis, the clinician must evaluate the patient from static, dynamic, and radiographic perspectives. One must also keep current in regard to various technological advances in casting and fabrication of orthotic devices, as well as in new developments in biomechanical theory and associated therapy. It also must be kept in mind that functional foot orthoses are not 100 per cent efficient, therefore, their shape, fabrication, and composition should all be devised and prescribed with specific goals for total body mechanics.

The methods presented for replacement of broken orthoses have proved very effective (Fig. 9). In more than 5 years of employing such duplication techniques, we have found patient satisfaction in the product to be commensurate with that for their originally prescribed devices. The techniques presented are not the only methods by which orthoses can be duplicated. We recognize that the clinician should refabricate the same orthosis only when the cause of breakage has been determined to be material fatigue or stress. Should the patient's weight, foot structure, or activities have changed, new orthoses should be fabricated with those factors in mind.