Evaluation of in-shoe plantar pressure and shear during walking for diabetic foot ulcer prevention.

OBJECTIVE: To investigate reliability and changes of in-shoe plantar pressure and shear during walking at three cadences with two insole designs. This was a precursor to the investigation of plantar loading in people with diabetes for potential foot ulcer prevention. METHOD: A sensorised insole system, capable of measuring plantar pressure and shear at the heel, fifth metatarsal head (5MH), first metatarsal head (1MH) and hallux, was tested with ten healthy participants during level walking. Reliability was evaluated, using intra-class correlation coefficient (ICC), while varying the cadences and insole types. Percentage changes in pressure and shear relative to values obtained at self-selected cadence with a flat insole design were investigated. RESULTS: Mean±standard deviation of maximum pressure, medial-lateral and anterior-posterior shear of up to 380±24kPa, 46±2kPa and -71±4kPa, respectively, were measured. The ICC in ranges of 0.762-0.973, 0.758-0.987 and 0.800-0.980 were obtained for pressure, anterior-posterior and medial-lateral shear, respectively. Opposite anterior-posterior shear directions between 5MH and 1MH (stretching), and between 1MH and hallux (pinching) were observed for some participants. Increasing cadence increased pressure and anterior-posterior shear (by up to +77%) but reduced medial-lateral shear at the heel and hallux (by up to -34%). Slower cadence increased anterior-posterior shear (+114%) but decreased medial-lateral shear (-46%) at the hallux. The use of a flexible contoured insole resulted in pressure reduction at the heel and 5MH but an increase in anterior-posterior shear at the heel (+69%) and hallux (+75%). CONCLUSION: The insole system demonstrated good reliability and is comparable to reported pressure-only systems. Pressure measurements were sensitive to changes in cadence and insole designs in ways that were consistent with the literature. However, our plantar shear showed localised shear changes with cadences and insoles for the first time, as well as stretching and pinching effects on plantar tissue. This opens new possibilities to investigate plantar tissue viability, loading characteristics and orthotic designs aimed towards foot ulcer prevention.

A Wearable Insole System to Measure Plantar Pressure and Shear for People with Diabetes.

Pressure coupled with shear stresses are the critical external factors for diabetic foot ulceration assessment and prevention. To date, a wearable system capable of measuring in-shoe multi-directional stresses for out-of-lab analysis has been elusive. The lack of an insole system capable of measuring plantar pressure and shear hinders the development of an effective foot ulcer prevention solution that could be potentially used in a daily living environment. This study reports the development of a first-of-its-kind sensorised insole system and its evaluation in laboratory settings and on human participants, indicating its potential as a wearable technology to be used in real-world applications. Laboratory evaluation revealed that the linearity error and accuracy error of the sensorised insole system were up to 3% and 5%, respectively. When evaluated on a healthy participant, change in footwear resulted in approximately 20%, 75% and 82% change in pressure, medial-lateral and anterior-posterior shear stress, respectively. When evaluated on diabetic participants, no notable difference in peak plantar pressure, as a result of wearing the sensorised insole, was measured. The preliminary results showed that the performance of the sensorised insole system is comparable to previously reported research devices. The system has adequate sensitivity to assist footwear assessment relevant to foot ulcer prevention and is safe to use for people with diabetes. The reported insole system presents the potential to help assess diabetic foot ulceration risk in a daily living environment underpinned by wearable pressure and shear sensing technologies.

Conservative Treatment for Acute Ankle Sprain: A Systematic Review.

The aim was to identify conservative treatments available for acute ankle sprain and to evaluate their effectiveness with respect to pain relief and short-term recovery of functional capacity. A systematic review of the relevant literature was conducted via a data search of the PROSPERO, PubMed, Scopus, CINAHL, PyscINFO and SPORTDiscus databases, from inception until December 2019, focusing on randomised control trial studies. Two of the authors independently assessed the quality of each study located and extracted the relevant data. The quality of each paper was assessed using the Cochrane risk of bias tool included in RevMan 5. In all, 20 studies met the inclusion criteria. In terms of absence of bias, only nine papers were classed as "high quality". Studies (75%) were of low quality in terms of the blinding of participants and personnel and uncertainty in blinding of outcome assessment and all presented one or more other forms of bias. Despite the generally low quality of the studies considered, it can be concluded that conservative treatment for acute ankle sprain normally achieves pain relief and rapidly improved functionality. Research based on higher-quality study designs and procedures would enable more definitive conclusions to be drawn.

Systematic review of the psychometric properties of patient-reported outcome measures for rheumatoid arthritis in the foot and ankle.

OBJECTIVE: To identify self-reported outcome measures specific to the foot and ankle in patients with rheumatoid arthritis and to investigate the methodological quality and psychometric properties of these measures. METHOD: A systematic review focusing on patients with rheumatoid arthritis. SETTING: The search was conducted in the PubMed, SCOPUS, CINAHL, PEDro and Google Scholar databases, based on the following inclusion criteria: population (with rheumatoid arthritis) > 18 years; psychometric or clinimetric validation studies of patient-reported outcomes specific to the foot and ankle, in different languages, with no time limit. Two of the present authors independently assessed the quality of the studies located and extracted the relevant data. Terwee's criteria and the COSMIN checklist were employed to ensure adequate methodological quality. RESULTS: Of the initial 431 studies considered, 14 met the inclusion criteria, representing 7,793 patients (56.8 years). These instruments were grouped into three dimensions (pain, perceived health status and quality of life and disability). The time to complete any of the PROMs varies around 15 minutes. PROMs criterias with the worst scores by COSMIN, 92.85% and 85.71% were criterion validity, measurement error, internal consistency and responsiveness. 28.57% of PROMs were compared with the measurement properties. CONCLUSION: the Self-Reported Foot and Ankle Score achieved the highest number of positive criteria (according to Terwee and COSMIN), and is currently the most appropriate for patients with Rheumatoid arthritis.

Evaluation of orthotic insoles for people with diabetes who are at-risk of first ulceration.

OBJECTIVE: This study focussed on pressure relieving orthotic insoles designed for retail footwear and people with diabetes and at risk of first forefoot ulceration. The aim was to investigate whether the pressure relieving effects of a customised metatarsal bar and forefoot cushioning are sensitive to bar location and shape, and material choice. RESEARCH DESIGN AND METHODS: Patient-specific foot shape was used to design an orthotic insole, with metatarsal bar location and shape customised according to plantar pressure data. Changes in forefoot plantar pressure were investigated when 60 people with diabetes and neuropathy walked in nine variants of the orthotic insole. These comprised three variations in proximal/distal location of the customised metatarsal bar and three different metatarsal head offloading materials. RESULTS & CONCLUSIONS: The most frequent reductions in pressure occurred when the anterior edge of the metatarsal bar was placed at 77% of the peak pressure values, and its effects were independent of the choice of EVA or Poron offloading material. In the flat insole, 61% of participants had one or more metatarsal head areas with pressure above the 200 KPa, reducing to 58% when adopting generic orthotic design rules and 51% when using the best orthotic insole of the nine tested. Our results confirm that plantar pressure relief is sensitive to orthotic insole design decisions and individual patient feet.

Contributions of foot muscles and plantar fascia morphology to foot posture.

BACKGROUND: The plantar foot muscles and plantar fascia differ between different foot postures. However, how each individual plantar structure contribute to foot posture has not been explored. The purpose of this study was to investigate the associations between static foot posture and morphology of plantar foot muscles and plantar fascia and thus the contributions of these structures to static foot posture. METHODS: A total of 111 participants were recruited, 43 were classified as having pes planus and 68 as having normal foot posture using Foot Posture Index assessment tool. Images from the flexor digitorum longus (FDL), flexor hallucis longus (FHL), peroneus longus and brevis (PER), flexor hallucis brevis (FHB), flexor digitorum brevis (FDB) and abductor hallucis (AbH) muscles, and the calcaneal (PF1), middle (PF2) and metatarsal (PF3) regions of the plantar fascia were obtained using a Venue 40 ultrasound system with a 5-13 MHz transducer. RESULTS: In order of decreasing contribution, PF3 > FHB > FHL > PER > FDB were all associated with FPI and able to explain 69% of the change in FPI scores. PF3 was the highest contributor explaining 52% of increases in FPI score. Decreased thickness was associated with increased FPI score. Smaller cross sectional area (CSA) in FHB and PER muscles explained 20% and 8% of increase in FPI score. Larger CSA of FDB and FHL muscles explained 4% and 14% increase in FPI score respectively. CONCLUSION: The medial plantar structures and the plantar fascia appear to be the major contributors to static foot posture. Elucidating the individual contribution of multiple muscles of the foot could provide insight about their role in the foot posture.

Morphology of the Toe Flexor Muscles in Older Adults With Toe Deformities.

OBJECTIVE: It has been suggested that atrophied or weak toe flexor muscles are associated with the formation of toe deformities, but there is little evidence to support this theory. This study aimed to determine whether the size of the toe flexor muscles differed in older adults with and without toe deformities. METHODS: Forty-four older adults (>60 years) were recruited for the study. Each participant had their feet assessed for the presence of hallux valgus or lesser toe deformities. Intrinsic and extrinsic toe flexor muscles were imaged with an ultrasound system using a standardized protocol. Assessor-blinded measurements of muscle thickness and cross-sectional area were taken using Image J software. RESULTS: Participants with lesser toe deformities (n = 20) were found to have significantly smaller quadratus plantae (P = 0.003), flexor digitorum brevis (P = 0.013), abductor hallucis (P = 0.004), and flexor hallucis brevis (P = 0.005) muscles than the participants without any toe deformities (n = 19). Female participants with hallux valgus (n = 10) were found to have significantly smaller abductor hallucis (P = 0.048) and flexor hallucis brevis (P = 0.013) muscles than the female participants without any toe deformities (n = 10; P < 0.05). CONCLUSION: This is the first study to use ultrasound to investigate the size of the toe flexor muscles in older adults with hallux valgus and lesser toe deformities compared to otherwise healthy older adults. The sizes of the abductor hallucis and flexor hallucis brevis muscles were decreased in participants with hallux valgus, whereas the quadratus plantae, flexor digitorum brevis, abductor hallucis, and flexor hallucis brevis muscles were smaller in the participants with lesser toe deformities.

Optimisation of rocker sole footwear for prevention of first plantar ulcer: comparison of group-optimised and individually-selected footwear designs.

BACKGROUND: Appropriate footwear for individuals with diabetes but no ulceration history could reduce the risk of first ulceration. However, individuals who deem themselves at low risk are unlikely to seek out bespoke footwear which is personalised. Therefore, our primary aim was to investigate whether group-optimised footwear designs, which could be prefabricated and delivered in a retail setting, could achieve appropriate pressure reduction, or whether footwear selection must be on a patient-by-patient basis. A second aim was to compare responses to footwear design between healthy participants and people with diabetes in order to understand the transferability of previous footwear research, performed in healthy populations. METHODS: Plantar pressures were recorded from 102 individuals with diabetes, considered at low risk of ulceration. This cohort included 17 individuals with peripheral neuropathy. We also collected data from 66 healthy controls. Each participant walked in 8 rocker shoe designs (4 apex positions × 2 rocker angles). ANOVA analysis was then used to understand the effect of two design features and descriptive statistics used to identify the group-optimised design. Using 200 kPa as a target, this group-optimised design was then compared to the design identified as the best for each participant (using plantar pressure data). RESULTS: Peak plantar pressure increased significantly as apex position was moved distally and rocker angle reduced (p < 0.001). The group-optimised design incorporated an apex at 52% of shoe length, a 20° rocker angle and an apex angle of 95°. With this design 71-81% of peak pressures were below the 200 kPa threshold, both in the full cohort of individuals with diabetes and also in the neuropathic subgroup. Importantly, only small increases (<5%) in this proportion were observed when participants wore footwear which was individually selected. In terms of optimised footwear designs, healthy participants demonstrated the same response as participants with diabetes, despite having lower plantar pressures. CONCLUSIONS: This is the first study demonstrating that a group-optimised, generic rocker shoe might perform almost as well as footwear selected on a patient by patient basis in a low risk patient group. This work provides a starting point for clinical evaluation of generic versus personalised pressure reducing footwear.

Challenging the foundations of the clinical model of foot function: further evidence that the root model assessments fail to appropriately classify foot function.

BACKGROUND: The Root model of normal and abnormal foot function remains the basis for clinical foot orthotic practice globally. Our aim was to investigate the relationship between foot deformities and kinematic compensations that are the foundations of the model. METHODS: A convenience sample of 140 were screened and 100 symptom free participants aged 18-45 years were invited to participate. The static biomechanical assessment described by the Root model was used to identify five foot deformities. A 6 segment foot model was used to measure foot kinematics during gait. Statistical tests compared foot kinematics between feet with and without foot deformities and correlated the degree of deformity with any compensatory motions. RESULTS: None of the deformities proposed by the Root model were associated with distinct differences in foot kinematics during gait when compared to those without deformities or each other. Static and dynamic parameters were not correlated. CONCLUSIONS: Taken as part of a wider body of evidence, the results of this study have profound implications for clinical foot health practice. We believe that the assessment protocol advocated by the Root model is no longer a suitable basis for professional practice. We recommend that clinicians stop using sub-talar neutral position during clinical assessments and stop assessing the non-weight bearing range of ankle dorsiflexion, first ray position and forefoot alignments and movement as a means of defining the associated foot deformities. The results question the relevance of the Root assessments in the prescription of foot orthoses.

A narrative review of musculoskeletal problems of the lower extremity and back associated with the interface between occupational tasks, feet, footwear and flooring.

At least 50% of workers are exposed to the risk of musculoskeletal disorders (MSD) due to spending prolonged hours standing at work. There is a lack of information regarding issues with the feet, solutions to the problem, and links between MSD, feet, footwear and flooring. The present article provides a narrative review of the research in this area, based on 31 papers. Workers who stand for large proportions of the working day had a level of MSD considerably greater than a normal population. Muscle co-activation, blood pooling, muscle fatigue and individual characteristics are all associated with MSD. Altering flooring provided mixed results, while footwear appeared to have the potential to affect MSD, although the dearth of literature limited the conclusions that could be drawn. Despite their inextricable link, literature regarding the relationship between occupational tasks, MSD, footwear and flooring remains limited and future studies will benefit from rigorously designed protocols.

Estimating the material properties of heel pad sub-layers using inverse Finite Element Analysis.

Detailed information about the biomechanical behaviour of plantar heel pad tissue contributes to our understanding of load transfer when the foot impacts the ground. The objective of this work was to obtain the hyperelastic and viscoelastic material properties of heel pad sub-layers (skin, micro-chamber and macro-chamber layers) in-vivo. An anatomically detailed 3D Finite Element model of the human heel was used to derive the sub-layer material properties. A combined ultrasound imaging and motorised platform system was used to compress heel pad and to create input data for the Finite Element model. The force-strain responses of the heel pad and its sub-layers under slow compression (5mm/s) and rapid loading-hold-unloading cycles (225mm/s), were measured and hyperelastic and viscoelastic properties of the three heel pad sub-layers were estimated by the model. The loaded (under ∼315N) thickness of the heel pad was measured from MR images and used for hyperelastic model validation. The capability of the model to predict peak plantar pressure was used for further validation. Experimental responses of the heel pad under different dynamic loading scenarios (loading-hold-unloading cycles at 141mm/s and sinusoidal loading with maximum velocity of 300mm/s) were used to validate the viscoelastic model. Good agreement was achieved between the predicted and experimental results for both hyperelastic (<6.4% unloaded thickness, 4.4% maximum peak plantar pressure) and viscoelastic (Root Mean Square errors for loading and unloading periods <14.7%, 5.8% maximum force) simulations. This paper provides the first definition of material properties for heel pad sub-layers by using in-vivo experimental force-strain data and an anatomically detailed 3D Finite Element model of the heel.

Effects of Age on Strength and Morphology of Toe Flexor Muscles.

Study Design Descriptive, cross-sectional. Background Age-related muscle atrophy is common in lower-limb muscles. We therefore speculated that foot muscles may also diminish with age. However, there is a paucity of literature characterizing foot muscle strength and morphology, and any relationship between these 2, in older people. Objective To compare the strength and size of the toe flexor muscles of older adults relative to their younger counterparts. Methods Seventeen young adults with a normal foot type were matched by sex and body mass index to 17 older adults with a normal foot type, from an available sample of 41 younger (18 to 50 years of age) and 44 older (60 or more years of age) adults. Among the matched groups (n = 34), muscle thickness and cross-sectional area for 5 intrinsic and 2 extrinsic toe flexor muscles were obtained using ultrasound. Toe strength was assessed using a pressure platform. Differences in toe flexor strength and muscle size between the young and older matched groups were determined using analysis of covariance (controlling for height). Correlations between strength and size of the toe flexor muscles of the pooled group (n = 34) were also calculated. Results Toe strength and the thickness and cross-sectional area of most foot muscles were significantly reduced in the older adults (P<.05). Hallux and toe flexor strength values were strongly correlated with the size of the intrinsic toe flexor muscles. Conclusion The smaller foot muscles appear to be affected by sarcopenia in older adults. This could contribute to reduced toe flexion force production and may affect the ability of older people to walk safely. Interventions aimed at reversing foot muscle atrophy in older people require further investigation. J Orthop Sports Phys Ther 2016;46(12):1065-1070. Epub 29 Oct 2016. doi:10.2519/jospt.2016.6597.

The evaluation of three treatments for plantar callus: a three-armed randomised, comparative trial using biophysical outcome measures.

BACKGROUND: Callus is one of the most common foot skin complaints experienced by people of all ages. These painful and unsightly lesions often result in disability. The 'gold standard' of treatment is scalpel debridement by a trained specialist; however, people also seek over-the-counter remedies. There is a lack of clinical evidence for the efficacy of such products, which makes selection by patients and practitioners difficult. METHODS: This randomised, three-armed, parallel, comparative trial aimed to test the efficacy of two home treatments for plantar callus using novel, objective outcome measures (skin hydration using the capacitance method; elasticity using negative pressure application; and surface texture using imaging). Additional outcome measures were: size of callus, quality of life (Foot Health Status Questionnaire) and self-reported participant satisfaction and compliance. The results were compared to a podiatry treatment. Participants were randomly allocated to one of three groups: potassium hydroxide (KOH, 40 %); trichloroacetic acid (TCA); and podiatry treatment. Participants were followed for 3 weeks after their initial intervention appointment (days 7, 14 and 21). The primary outcomes were the change from baseline in callus hydration, elasticity, texture, and size at each of the three time points. The secondary outcomes where: change in quality of life 21 days after treatment; resolution of calluses via visual inspection; and participant compliance and perception. RESULTS: Forty-six participants (61 ft) with plantar calluses were recruited. The podiatry treatment showed immediate and significant changes in all objective outcomes, associated foot pain and function (p <0.01). Lesser changes in skin quality and perceived pain and functional benefits occurred with TCA and KOH over 21 days. CONCLUSIONS: This is the first study where objective outcome measures have been used to measure changes in the nature of skin in response to callus treatments. We found significant differences in plantar callus in response to podiatry and two home treatments. The podiatry treatment showed immediate and significant changes in skin and associated foot pain and function. Lesser, but sometimes comparable, changes in skin and perceived pain and functional benefits occurred with TCA and KOH over 21 days. TRIAL REGISTRATION: ISRCTN14751843 : date of registration: 30 April 2015.

Are clinical measures of foot posture and mobility associated with foot kinematics when walking?

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

An action research approach to facilitating the adoption of a foot health assessment tool in India.

BACKGROUND: India has a diabetes population that is growing and alongside this, the incidence of limb threatening foot problems is increasing. Foot health care provision does not yet meet this demand. In one locality in India, clinicians had an unstructured approach to foot health assessments resulting in poor adoption of evidence based guidelines from the West and a persistence of serious foot complications. There was the perception that existing assessment tools did not take into account the local cultural, organizational and professional needs and there was a lack of ownership of any potential solution to the problem. Therefore, the aim of this work was to facilitate the ownership and development of a foot health assessment tool for use in the Indian context. In order to achieve this an action research approach was chosen. METHODS: Participants were facilitated through the action and implementation phases of the action research cycle by the researchers. The action phase included generating a list of potential items for inclusion in the tool from a review of the literature to provide an evidence based foundation for the foot health assessment tool. A modified Delphi method was used to further refine the contents of the tool. Members of the Delphi Panel (n = 8) were experts in their field of medicine and experts in delivering health care within services in India. RESULTS: The outcome of the study was the adoption of a locally developed foot health assessment tool (Salford Indian Foot Health Assessment Tool, SIFT). It contains thirteen sections, which reflect the risk factors identified for assessing foot health agreed by the participants to fit the Indian context. The SIFT is supported with evidence based guidelines from the West and a training program was delivered by the researchers in order to support its implementation into clinical practice. CONCLUSION: An action research approach has facilitated the development and implementation of a locally created and owned foot health assessment tool. This in turn has resulted in the integration of evidence-based guidelines from the West with consideration to local cultural, organizational and professional needs and ultimately the needs of their patients. Further work is underway evaluating the outcomes of the SIFT in practice.

Foot posture and function have only minor effects on knee function during barefoot walking in healthy individuals.

BACKGROUND: Foot posture has been postulated as a risk factor for overuse injuries of the knee, however the link between foot posture and knee joint function is unclear. The aims of this study were to: (i) compare knee adduction moment and knee joint rotations between normal, planus and cavus foot posture groups, and (ii) to determine the relationship between rearfoot and midfoot joint rotations and knee adduction moment magnitude. METHODS: Rotation of the knee, rearfoot and midfoot was evaluated in 97 healthy adults that were classified as normal (n=37), cavus (n=30) or planus (n=30) for the Foot Posture Index, Arch Index and normalised navicular height. One way analyses of variance were used to compare tri-planar knee joint rotation, knee adduction moment peak variables and knee adduction angular impulse between foot posture groups. Pearson's correlation coefficient was used to investigate the association between rearfoot and midfoot joint rotation during initial contact phase and the magnitude of 1st knee adduction moment peak. FINDINGS: The planus group displayed significantly greater external rotation angle at heel contact compared to both normal and cavus groups. The planus groups also displayed greater extension at heel contact and sagittal plane flexion range of motion during propulsion and early swing compared to the cavus group. Otherwise, differences between groups were characterised by small effect sizes. There was no association between rearfoot or midfoot joint rotations and knee adduction moment. INTERPRETATION: These findings suggest that in healthy individuals, foot posture and foot joint rotations do not substantially influence knee joint rotations and knee adduction moment while walking at a comfortable pace.

Foot posture is associated with kinematics of the foot during gait: A comparison of normal, planus and cavus feet.

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

Movement of the human foot in 100 pain free individuals aged 18-45: implications for understanding normal foot function.

BACKGROUND: Understanding motion in the normal healthy foot is a prerequisite for understanding the effects of pathology and thereafter setting targets for interventions. Quality foot kinematic data from healthy feet will also assist the development of high quality and research based clinical models of foot biomechanics. To address gaps in the current literature we aimed to describe 3D foot kinematics using a 5 segment foot model in a population of 100 pain free individuals. METHODS: Kinematics of the leg, calcaneus, midfoot, medial and lateral forefoot and hallux were measured in 100 self reported healthy and pain free individuals during walking. Descriptive statistics were used to characterise foot movements. Contributions from different foot segments to the total motion in each plane were also derived to explore functional roles of different parts of the foot. RESULTS: Foot segments demonstrated greatest motion in the sagittal plane, but large ranges of movement in all planes. All foot segments demonstrated movement throughout gait, though least motion was observed between the midfoot and calcaneus. There was inconsistent evidence of movement coupling between joints. There were clear differences in motion data compared to foot segment models reported in the literature. CONCLUSIONS: The data reveal the foot is a multiarticular structure, movements are complex, show incomplete evidence of coupling, and vary person to person. The data provide a useful reference data set against which future experimental data can be compared and may provide the basis for conceptual models of foot function based on data rather than anecdotal observations.

The assessment and management of diabetes related lower limb problems in India-an action research approach to integrating best practice.

BACKGROUND: In this article the authors explore the current issues and barriers related to achieving successful outcomes to diabetic foot complications in India. This was achieved by engaging clinicians in taking ownership of the problems and facilitating them in the identification of solutions to action change in clinical practice. METHODS: This was accomplished through facilitating participants in this study via a process of problem identification and planning, the first phases of an action research cycle approach. The methods of data collection were focus groups, observations and individual conversations. The data were analysed using a thematic framework. RESULTS: Based on the practitioner's experiences and opinions, key themes were identified. These themes had the potential to inform the changes needed in clinical practice, to overcome barriers and embed ownership of the solutions. Five themes were identified highlighting: concerns over a fragmented service; local recognition of need; lack of standardised care pathways; lack of structured assessment and an absence of annual foot screening. Combined, the issues identified were thought to be important in preventing timely assessment and management of foot problems. CONCLUSION: It was unanimously agreed that a formalised process of foot assessment should be developed and implemented as part of the subsequent phases of the action research process, which the authors intended to take forward and report in a further paper. The aim of which is to guide triage, education, care pathways, audit and evaluation of outcomes. Facilitation of the clinicians in developing a program and screening tool to implement and teach these skills to others could be an important step in reducing the number of high-risk cases that are often resulting in the amputation of limbs.

Ultrasound evaluation of foot muscles and plantar fascia in pes planus.

BACKGROUND: Multiple intrinsic and extrinsic soft tissue structures that apply forces and support the medial longitudinal arch have been implicated in pes planus. These structures have common functions but their interaction in pes planus is not fully understood. The aim of this study was to compare the cross-sectional area (CSA) and thickness of the intrinsic and extrinsic foot muscles and plantar fascia thickness between normal and pes planus feet. METHODS: Forty-nine adults with a normal foot posture and 49 individuals with pes planus feet were recruited from a university population. Images of the flexor digitorum longus (FDL), flexor hallucis longus (FHL), peroneus longus and brevis (PER), flexor hallucis brevis (FHB), flexor digitorum brevis (FDB) and abductor hallucis (AbH) muscles and the plantar fascia were obtained using a Venue 40 ultrasound system with a 5-13 MHz transducer. RESULTS: The CSA and thickness of AbH, FHB and PER muscles were significantly smaller (AbH -12.8% and -6.8%, FHB -8.9% and -7.6%, PER -14.7% and -10%), whilst FDL (28.3% and 15.2%) and FHL (24% and 9.8%) were significantly larger in the pes planus group. The middle (-10.6%) and anterior (-21.7%) portions of the plantar fascia were thinner in pes planus group. CONCLUSION: Greater CSA and thickness of the extrinsic muscles might reflect compensatory activity to support the MLA if the intrinsic foot muscle function has been compromised by altered foot structure. A thinner plantar fascia suggests reduced load bearing, and regional variations in structure and function in feet with pes planus.