Consensus-based recommendations on physical activity and exercise in patients with diabetes at risk of foot ulcerations: a Delphi study.

BACKGROUND: Patients with diabetes mellitus are exposed to important complications. Currently little evidence exist on the guidelines that these patients, at some risk of foot ulceration, should follow for physical exercise. OBJECTIVES: To reach a consensus among multidisciplinary and international experts on physical activity/exercise recommendations for patients with diabetes, according to foot ulcer risk. METHODS: Using a three-round Delphi method, a panel composed of 28 multidisciplinary experts in the management of diabetic foot assessed 109 recommendations on physical activity/exercise for patients with diabetes mellitus, according to their risk of foot ulcer. Consensus was assumed when 80% of responses matched the same category (agreement/disagreement). RESULTS: Twenty-nine experts participated in the first and second rounds of consultation, and twenty-eight did so in the third, reaching final agreement on 86 of the 109 recommendations considered (78.9%). The study, thus, generated a consensus set of recommendations concerning different aspects of diabetic footcare before, during, and after exercise (e.g. when to examine the foot, how to assess it, what type of sock and insole to use, what types of exercise to perform, and when it is advisable to return to activity after an ulceration). CONCLUSION: This Delphi study generated recommendations based on the consensus of international experts on physical activity and exercise by patient with diabetes at risk of ulceration. Recommendations considered the state of the foot and the patient's history and status before physical activity and included information on intensity, duration, frequency, and progressions of physical activity/exercise, and the use of custom-made plantar orthoses, shoe prescription, and the convenience of returning to physical activity after an ulceration.

Study of Windlass Mechanism in the Lower Limb Using Inertial Sensors.

AIMS: This study aimed to quantify the degrees of movement that occur in the lower limb using a kinematic system after taking two measurements of 45° and 60° of extension at the first metatarsophalangeal joint (1st MTPJ) and to test the validity of this sensor system using radiography. METHODOLOGY: This was a quasi-experimental test-post-test study with a single intervention group (25 subjects). Four inertial sensors were placed on the proximal phalange of the first toe, dorsum of the foot, medial-lateral of the leg (level of tibia), and medial-lateral of the thigh (level of femur). The extension of the 1st MTPJ produced movements of supination in the foot and rotation at the level of leg and thigh. We studied this mechanism in three situations (relaxed, 45°, and 60°) both with the sensors and with X-rays. RESULTS: With the kinematic system, there was an increase in the range of movement in each of the variables, with a value of p < 0.05. The relationship between the kinematic system and the radiography was tested using Spearman's rho test, obtaining a correlation coefficient of 0.624 and a value of p < 0.05, and the Bland-Altman graph, with 90% of the cases within the tolerance limits. CONCLUSIONS: The extension of the 1st MTPJ generated kinematic changes associated with supination movement in the midfoot and external rotation on the tibia and femur level. Both measurement techniques were very similar in the way that they quantified the degrees of extension of the 1st MTPJ. If we extrapolate this result to the measurement technique used by the inertial sensors, we could affirm that the values recorded in the supination and external rotation movements were reliable.

An Assessment of Balance through Posturography in Healthy about Women: An Observational Study.

The incidence of falls in adults constitutes a public health problem, and the alteration in balance is the most important factor. It is necessary to evaluate this through objective tools in order to quantify alterations and prevent falls. This study aims to determine the existence of alteration of balance and the influence of age in a population of healthy women. Static posturography was performed on 49 healthy adult women with no history of falls in four different situations using the Romberg test with the NedSVE/IBV® platform. The variables studied were the body sway area and the anteroposterior and mediolateral displacements. The situation of maximum instability occurred in RGC (p = 0.001), with a significant increase in anteroposterior oscillations regarding the ML (p < 0.001), with no correlation to age. Age alone does not influence the balance in the sample studied, other factors must come together to alter it. The joint cancellation of visual and somatosensory afferents could facilitate the appearance of falls, given that it is a situation of maximum instability. Proprioceptive training is interesting as a preventive strategy for falls.

Custom-Made Foot Orthoses as Non-Specific Chronic Low Back Pain and Pronated Foot Treatment.

Excessive foot pronation has been reported as being related to chronic low back pain symptoms and risk factors in sports-specific pathologies. Compensating custom-made foot orthotics treatment has not been entirely explored as an effective therapy for chronic low back pain (CLBP). This study aims to observe the effects of custom-made foot orthoses, in subjects with foot pronation suffering from CLBP. A total of 101 patients with nonspecific CLBP and a pronated foot posture index (FPI) were studied. They were randomized in two groups: an experimental one (n = 53) used custom-made foot orthotics, and the control group (n = 48) were treated with non-biomechanical effect orthoses. The CLBP was measured using the Oswestry Disability Index (ODI) Questionnaire and a visual analogue scale (VAS), both for lower back pain. The symptoms were evaluated twice, at first when the subject was included in the study, and later, after 4 weeks of treatment. The analysis of outcomes showed a significant decrease in CLBP in the custom-made foot orthoses participants group (p < 0.001 ODI; p < 0.001 VAS). These findings suggest that controlling excessive foot pronation by using custom-made foot orthoses may significantly contribute to improving CLBP.

Longitudinal Analysis of Plantar Pressures with Wear of a Running Shoe.

Running shoes typically have a lifespan of 300-1000 km, and the plantar pressure pattern during running may change as the shoe wears. So, the aim of this study was to determine the variation of plantar pressures with shoe wear, and the runner's subjective sensation. Maximun Plantar Pressures (MMP) were measured from 33 male recreational runners at three times during a training season (beginning, 350 km, and 700 km) using the Biofoot/IBV® in-shoe system (Biofoot/IBV®, Valencia, Spain). All the runners wore the same shoes (New Balance® 738, Boston, MA, USA) during this period, and performed similar training. The zones supporting most pressure at all three study times were the medial (inner) column of the foot and the forefoot. There was a significant increase in pressure on the midfoot over the course of the training season (from 387.8 to 590 kPa, p = 0.003). The runners who felt the worst cushioning under the midfoot were those who had the highest peak pressures in that area (p = 0.002). The New Balance® 738 running shoe effectively maintains the plantar pressure pattern after 700 km of use under all the zones studied except the midfoot, probably due to material fatigue or deficits of the specific cushioning systems in that area.

Immediate and short-term radiological changes after combining static stretching and transcutaneous electrical stimulation in adults with cavus foot: A randomized controlled trial.

BACKGROUND: Cavus foot is a deformity represented by an increased and rigid medial longitudinal arch, and it is often associated with persistent pain and gait disturbances. None of the conservative conventional treatments for cavus foot have shown conclusive evidence of effectiveness, and so further is research needed to understand how to manage this condition better. This study aimed to assess the immediate and short-term radiological changes after combining static stretching and transcutaneous electrical stimulation of the plantar fascia in adults with idiopathic cavus foot. METHODS: A randomized, single-blinded clinical trial was conducted. Sixty-eight participants with idiopathic cavus foot, as determined by an internal Moreau-Costa-Bertani angle (MCBA) less than 125° in a lateral weight-bearing foot radiograph, were equally distributed into a neuromuscular stretching group (NSG) or a control group (no intervention). The NSG underwent a single session, combining transcutaneous electrical nerve stimulation with static stretching of the plantar fascia. Primary measurements of 3 angles were taken using a lateral weight-bearing foot radiograph: the internal MCBA; the calcaneal pitch angle (CPA); and the first metatarsal declination angle (FMDA). Outcomes were collected at baseline, immediately postintervention, and 1 week after intervention. RESULTS: Analysis of variance revealed a significant group effect for all angles (all, P < .05). NSG participants showed a significant increase in the internal MCBA (P = .03), and a significant decrease in the CPA (P = .01) and FMDA (P = .04) from baseline to immediately postintervention. These changes remained statistically significant 1 week after the intervention (all, P < .05). CONCLUSION: The combination of static stretching and transcutaneous electrical stimulation of the plantar fascia, compared with no treatment, achieved immediate and short-term changes in the internal MCBA, the CPA, and the FMDA, which resulted in flattening the medial longitudinal plantar arch in adults with idiopathic cavus foot.

Age Estimation Based on a Radiographic Study of the Growing Foot.

BACKGROUND: We sought to determine a predictive model of data, differentiated by sex, from a radiographic study of the skeleton of the foot as an alternative to the classic study of the hand. METHODS: The study included 2,476 digital radiographs from 816 participants aged 0 to 21 years. The radiographs were from the Radiology Diagnostic Services of the Public Health System of Extremadura (Spain) from 2007 to 2011. The method used for their analysis consisted of assigning a numerical code to each ossification center of each growing bone of the foot and subsequently subjecting the data to a multivariate, decision tree, statistical analysis. RESULTS: The decision tree study identified the bones that have a common age-dependent pattern of growth (as determined by a comparison of means test with P < .01) among individuals of the same sex. The quality of the decision tree predictions was evaluated in terms of the r 2 coefficient. These values were r2 = 0.897 for females and r2 = 0.890 for males, thus establishing the predictive goodness of the model of bone data to provide a specific estimate of the individual's age. CONCLUSIONS: The foot is a good predictor of an individual's age from birth to complete bone maturity.

Three-dimensional variations in the lower limb caused by the windlass mechanism.

BACKGROUND: The windlass mechanism was described as the effect caused by the extension of the first metatarsalphalangeal joint (1st MTPJ). Quantify the degrees of movement produced in the leg by means of the Bioval® sensor system, after performing two measurements in the 1st MTPJ, 45° extension and maximum extension. METHODS: Tests-post-test study with just one intervention group, performed in the Clinical Podiatry Area of the Faculty of Nursing, Physiotherapy and Podiatry of the University of Seville. Subjects were included as of age 20, with a value from 0° to 3° valgus, Helbing line, a value from 0° to +5° for the foot postural index, and a localisation axis for the normalised subtalar joint. Subjects with surgical operations of the first ray, fractures and surgical operations in the leg, pathologies in the first ray and rheumatic diseases were excluded. Measurement was performed with the Bioval® system by means of inserting four sensors in the bone structures involved in the windlass mechanism. RESULTS: With the 45° wedge we observed a direct correlation among the variables extension-plantar flexion 1st MTPJ and rotation of the femur. With maximal extension of the 1st MTPJ we obtained a direct relationship between the variable extension of the 1st MTPJ and the variables plantar flexion and prono-supination of the 1st metatarsal as well as with the variables tibia rotation and femur rotation. CONCLUSION: Kinematic analysis suggested that the higher the degree of extension the more movement will be generated. This reduces the level of impact the more distal the structure with respect to the 1st MTPJ, which has an impact on the entire leg. Because of the kinematic system used wasn't suitable, its impact wasn't exactly quantified.

Calcaneal Bone Mass Modification in Recreational Runners.

BACKGROUND: The calcaneus is the bone of the foot that first receives the impact of running, generating vibrations that might have a positive effect in modifying the trabecular bone mass. The objective of this study was to determine the variation in calcaneal bone density in runners during a 6-month training season, comparing it with a control sample. METHODS: Bone density of the heel was measured in 33 male recreational runners by means of a contact ultrasonic bone analyzer. Measurements were made on three occasions during a training season: at the beginning, at 350 km, and at 700 km. All of the runners wore the same model of running shoes during this period. Measurements of bone density were also made in a control sample of 62 men who did not engage in physical exercise. RESULTS: There was a significant decrease in mean calcaneal bone density over the course of the training season (from 86.1 dB/MHz to 83.2 dB/MHz; P = .006), but no significant differences with the control sample value (from 80.7 dB/MHz to 81.1 dB/MHz; P = .314). The runners' body composition changed during the study period, with lean mass increasing and fat mass decreasing. CONCLUSIONS: Distance running seems to have a negative effect on calcaneal bone mass density during the course of a 700-km training season.

A Comparison of Fourth-Year Health Sciences Students' Knowledge of Gross Lower and Upper Limb Anatomy: A Cross-Sectional Study.

OBJECTIVE: The aim of the study was to assess and compare the knowledge of fourth-year medicine, physiotherapy (PT), nursing, and podiatry students in carpal and tarsal bone anatomy. METHODS: A cross-sectional study was carried out. Based on a nonprobability convenience sampling, 177 fourth-year students (117 women and 60 men, mean age of 23.16 ± 3.82 years) from the podiatry (n = 39), nursing (n = 26), PT (n = 73), and medicine (n = 39) schools at a large Spanish university were included. Measurements were taken of their gross anatomy knowledge by means of the carpal and the tarsal bone tests. Students were asked to identify all carpal and tarsal bones in an illustration of the bony skeleton of both regions and were given a maximum of 5 minutes per test. RESULTS: Of a total of 15 bones to be labeled, the PT (11.07 ± 3.30) and podiatry (9.36 ± 2.93) students had the highest rate of correct answers compared with the medicine (6.13 ± 3.27) and nursing (4.04 ± 3.72) undergraduates. When assessing academic degrees and test scores, significant differences were observed between PT and podiatry participants vs those from the medicine and nursing schools (P < .001). CONCLUSION: Fourth-year students from the PT and podiatry programs correctly identified a higher number of carpal and tarsal bones than students from the nursing and medicine schools.

The tarsal bone test: a basic test of health sciences students' knowledge of lower limb anatomy.

OBJECTIVES: The aim of the present study was to design an easy-to-use tool, the tarsal bone test (TBT), to provide a snapshot of podiatry students' basic anatomical knowledge of the bones of the lower limb. METHODS: The study included 254 podiatry students from three different universities, 145 of them were first-year students and 109 were in their fourth and final years. The TBT was administered without prior notice to the participants and was to be completed in 5 minutes. RESULTS: The results show that 97.2% of the subjects (n = 247) correctly labelled all tarsal bones, while the other 2.8% (n = 7) incorrectly labelled at least one bone, that was either the cuboid (7 times) or the navicular (6 times). Although only one fourth-year student inaccurately identified one bone, no significant differences in the distribution of the correct and incorrect responses were found between first and fourth-year students. CONCLUSIONS: The TBT seems to be a straightforward and easy-to-apply instrument, and provides an objective view of the level of knowledge acquired at different stages of podiatry studies.

The foot posture index in men practicing three sports different in their biomechanical gestures.

BACKGROUND: The technical gestures characteristic of certain sports may lead to one type of foot being more prevalent than the others. The Foot Posture Index (FPI) has been used as a diagnostic tool for support postures in various sports, but the differences in these postures between sports of distinct gestures in their actions are far from completely understood. METHODS: The overall FPI, obtained as the sum of the scores of its six individual criteria, was determined in 90 male athletes (30 runners, 30 basketball players, and 30 handball players) in static bipedal stance and relaxed position. Analysis of variance was used to find significant differences among the three sports in the total FPI and its six criteria. RESULTS: The mean ± SD FPI was 2.9 ± 2.8 in runners, 3.9 ± 4.1 in basketball players, and -0.4 ± 6.9 in handball players, with significant differences among these groups (P = .008). Significant differences were also found in the talar head position and talonavicular prominence values between handball players and runners (P = .001 and P = .004, respectively) and between handball and basketball players (P = .002 and P = .006, respectively). CONCLUSIONS: Runners and basketball players had neutral feet, whereas handball players had supinated feet. The differences in foot posture seem to be mainly determined by two of the FPI criteria: talar head position and talonavicular prominence.

Effectiveness of neuromuscular stretching with symmetrical biphasic electric currents in the cavus foot.

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.

The effect of moderate running on foot posture index and plantar pressure distribution in male recreational runners.

BACKGROUND: Fatigue due to running has been shown to contribute to changes in plantar pressure distribution. However, little is known about changes in foot posture after running. We sought to compare the foot posture index before and after moderate exercise and to relate any changes to plantar pressure patterns. METHODS: A baropodometric evaluation was made, using the FootScan platform (RSscan International, Olen, Belgium), of 30 men who were regular runners and their foot posture was examined using the Foot Posture Index before and after a 60-min continuous run at a moderate pace (3.3 m/sec). RESULTS: Foot posture showed a tendency toward pronation after the 60-min run, gaining 2 points in the foot posture index. The total support and medial heel contact areas increased, as did pressures under the second metatarsal head and medial heel. CONCLUSIONS: Continuous running at a moderate speed (3.3 m/sec) induced changes in heel strike related to enhanced pronation posture, indicative of greater stress on that zone after physical activity. This observation may help us understand the functioning of the foot, prevent injuries, and design effective plantar orthoses in sport.