Biomechanical Evaluation of Custom Foot Orthoses for Hallux Valgus Deformity.

The purpose of the present study was to compare the hallux valgus deformity pressure parameters seen in standard footwear (no orthosis) versus the pressure observed in the same footwear with the addition of 3 different length orthoses. The forefoot pressure at a hallux valgus deformity was recorded with pressure sensors placed on the plantar, medial, and dorsal surface of the first metatarsal head. The participants performed walking trials without an orthosis and with orthoses of 3 different lengths. The average pressure and maximum pressure of each area was recorded for each orthosis, and comparisons were made across the groups. The plantar pressures were decreased in the full length and 3/4 length orthoses, and the dorsal pressures were increased with the use of the full-length and sulcus-length orthoses. Significant changes in medial pressure were not seen with the addition of any orthosis compared with standard footwear alone. However, a trend toward increased medial pressures was seen with the full- and sulcus-length orthoses, and the 3/4-length orthoses exhibited a trend toward decreased medial pressures. We were unable to demonstrate that the use of a custom foot orthosis significantly decreases the medial pressures on the first metatarsal head in patients with hallux valgus deformity. The 3/4-length orthosis was less likely to negatively affect the dorsal or medial pressures, which were noted to increase with the sulcus- and full-length orthoses. Our data suggest that if a clinician uses this treatment option, a 3/4-length orthosis might be a better choice than a sulcus- or full-length orthosis.

Nonoperative management of retrocalcaneal pain with AFO and stretching regimen.

BACKGROUND: Retrocalcaneal heel pain is caused by a spectrum of etiologies all resulting in the same symptom of pain at the tendon-Achilles insertion. Several studies have reported the outcomes of operative treatment, but none have reported the outcomes or success rates of nonoperative treatment. We describe a detailed treatment algorithm and report the clinical outcomes. METHODS: One hundred thirty-five patients were prescribed a treatment regimen consisting of an AFO and stretching program and were enrolled in our prospective study. One hundred three patients completed pre- and post-treatment Foot Function Indices and were included in the analysis. The effect on FFI from clinical and radiographic factors was examined. RESULTS: Of the study population, 76% had a BMI greater than 25, 80% were older than 50 years, and 75% had an exostosis on radiographs. The mean pre-treatment FFI was 48.4 and the mean post-treatment FFI was 18.6 indicating a statistically significant improvement in function of 29.8. Neither BMI nor age had a significant effect on the magnitude of improvement; though, smokers had significantly less improvement. FFI improvement in patients with an exostosis were less than those without an exostosis. Patients with an exostosis less than 1 cm had less improvement than those with an exostosis of 1 cm or more. Patients with Types I and III exostoses had significantly less improvement in FFI compared to Types II and IV. Twelve of the 103 (11.6%) were not pleased with the results of nonoperative treatment and elected to have a procedure performed. CONCLUSION: Our study is the first to report the outcome of non operatively treated retrocalcaneal heel pain and to classify retrocalcaneal exostoses. Using our treatment algorithm, we had an 88% success rate in alleviating symptoms and avoiding surgery. Our data suggests that the use of an AFO and stretching regimen may benefit patients suffering from retrocalcaneal heel pain.

Extracorporeal shock wave treatment of non- or delayed union of proximal metatarsal fractures.

BACKGROUND: Nonunion or delayed union of fractures in the proximal aspect of metatarsals 1 to 4 and Zone 2 of the fifth metatarsal were treated by high energy extracorporeal shock wave treatment (ESWT) to study the safety and efficacy of this method of treatment in a FDA study of the Ossatron device. MATERIALS AND METHODS: In a prospective single-arm, multi-center study, 34 fractures were treated in 32 patients (two subjects had two independent fractures) with ESWT. All fractures were at least 10 (range, 10 to 833) weeks after injury, with a median of 23 weeks. ESWT application was conducted using a protocol totaling 2,000 shocks for a total energy application of approximately 0.22 to 0.51 mJ/mm2 per treatment. The mean ESWT application time for each of the treatments was 24.6 +/- 16.6 minutes, and anesthesia time averaged 27.1 +/- 10.4 minutes. All subjects were followed for 1 year after treatment at intervals of 12 weeks, 6, 9, and 12 months. RESULTS: The overall success rate at the 12-week visit was 71% with low complications, significant pain improvement as well as improvement on the SF-36. The success/fail criteria was evaluated again at the 6- and 12-month followup, showing treatment success rates of 89% (23/26) and 90% (18/20), respectively. The most common adverse event was swelling in the foot, reported by five subjects (15.6%). CONCLUSION: High-energy ESWT appears to be effective and safe in patients for treatment of nonunion or a delayed healing of a proximal metatarsal, and in fifth metatarsal fractures in Zone 2.

Ipsilateral arthrodesis of the metatarsophalangeal and interphalangeal joints of the hallux.

BACKGROUND: Arthrodesis of the metatarsophalangeal joint of the hallux is frequently used for treatment of a variety of disorders. However, occasionally patients who have complex deformities or degenerative changes of the hallux require reconstruction of both the metatarsophalangeal and interphalangeal joints. There is concern that arthrodesis of both the metatarsophalangeal and ipsilateral interphalangeal joints could be problematic, interfering with the toe-off phase of gait or with shoewear. METHODS: A retrospective evaluation of seven feet in five patients who had simultaneous arthrodesis of the metatarsophalangeal and ipsilateral interphalangeal joints of the hallux was undertaken. These cases represented all the patients who had this procedure within the practice of three orthopaedic foot and ankle specialists, totaling over 50 surgeon-years of experience. The indication for surgery in all patients was moderate to severe pain with ambulation with severe fixed deformity of both the interphalangeal and metatarsophalangeal joints of the hallux. All patients had pain that limited their ambulation and interfered with their daily activities. All patients required modified shoewear to accommodate their foot deformity. The mean age of patients was 53 years. The patients were evaluated by questionnaire and radiographic examination. RESULTS: At an average of 46 months followup, all patients had resolution of their pain and were able to wear nonprescription shoes. All had limitations that interfered with full athletic activities but had no limitation of daily activities. Three patients who were employed returned to their occupations and two who were not employed were able to continue housework. CONCLUSION: Arthrodesis of the metatarsophalangeal and ipsilateral interphalangeal joints of the hallux results in painless function in patients with moderate demands.

Stage I and II posterior tibial tendon dysfunction treated by a structured nonoperative management protocol: an orthosis and exercise program.

BACKGROUND: Posterior tibial tendon dysfunction (PTTD) is a relatively common problem of middle-aged adults that usually is treated operatively. The purpose of this study was to identify strength deficits with early stage PTTD and to assess the efficacy of a focused nonoperative treatment protocol. METHODS: Forty-seven consecutive patients with stage I or II posterior tibial tendon dysfunction were treated by a structured nonoperative protocol. Criteria for inclusion were the presence of a palpable and painful posterior tibial tendon, with or without swelling and 2) movement of the tendon with passive and active nonweightbearing clinical examination. The rehabilitation protocol included the use of a short, articulated ankle foot orthosis or foot orthosis, high-repetition exercises, aggressive plantarflexion activities, and an aggressive high-repetition home exercise program that included gastrocsoleus tendon stretching. Isokinetic evaluations were done before and after therapy to compare inversion, eversion, plantarflexion, and dorsiflexion strength in the involved and uninvolved extremities. Criteria for successful rehabilitation were no more than 10% strength deficit, ability to perform 50 single-support heel rises with minimal or no pain, ability to ambulate 100 feet on the toes with minimal or no pain, and ability to tolerate 200 repetitions of the home exercises for each muscle group. RESULTS: Before therapy weakness for concentric and eccentric contractures of all muscle groups of the involved ankle was significant (p<0.001). After a median of 10 physical therapy visits over a median period of 4 months, 39 (83%) of the 47 patients had successful subjective and functional outcomes, and 42 patients (89%) were satisfied. Five patients (11%) required surgery after failure of nonoperative treatment. CONCLUSION: This study suggests that many patients with stage I and II posterior tibial tendon dysfunction can be effectively treated nonoperatively with an orthosis and structured exercises.

Plantar fasciopathy and orthotripsy: the effect of prior cortisone injection.

BACKGROUND: Corticoid steroid injection into the heel is a popular treatment method for painful heel syndromes. However, the positive results usually are short term. Extracorporeal shock wave treatment (ESW) has been shown to have a more permanent effect. We evaluated 555 patients who received ESW using the device Ossa Tron Orthotripsy (Health Tronics, Surgical Services, Marietta, GA) relative to antecedent cortisone heel injection. METHODS: Before ESW, 312 patients (56%) received one or more cortisone injections into the heel, and 243 patients (44%) had never received a cortisone injection. RESULTS: Two hundred and thirty-four patients (75%) who had antecedent injection or injections had positive outcomes after ESW. One hundred sixty-eight patients (69%) without prior heel injection had positive responses after ESW. CONCLUSION: The prior injection of cortisone did not affect the likelihood of a positive response to ESW. Similarly, the absence of prior injection of cortisone did not affect the outcome.

Electrohydraulic high-energy shock-wave treatment for chronic plantar fasciitis.

BACKGROUND: Plantar fasciitis is a common foot disorder that may be resistant to nonoperative treatment. This study evaluated the use of electrohydraulic high-energy shock waves in patients who failed to respond to a minimum of six months of antecedent nonoperative treatment. METHODS: A randomized, placebo-controlled, multiply blinded, crossover study was conducted. Phase 1 consisted of twenty patients who were nonrandomized to treatment with extracorporeal shock waves to assess the phase-2 study protocol. In phase 2, 293 patients were randomized and an additional seventy-one patients were nonrandomized. Following ankle-block anesthesia, each patient received 100 graded shocks starting at 0.12 to 0.22 mJ/mm(2), followed by 1400 shocks at 0.22 mJ/mm(2) with use of a high-energy electrohydraulic shock-wave device. Patients in the placebo group received minimal subcutaneous anesthetic injections and nontransmitted shock waves by the same protocol. Three months later, patients were given the opportunity to continue without further treatment or have an additional treatment. This allowed a patient in the active treatment arm to receive a second treatment and a patient who received the placebo to cross over to the active treatment arm. Patients were followed at least one year after the final treatment. RESULTS: Treatment was successful in seventeen of the twenty phase-1 patients at three months. This improved to nineteen (95%) of twenty patients at one year and was maintained at five years. In phase 2, three months after treatment, sixty-seven (47%) of the 144 actively treated patients had a completely successful result compared with forty-two (30%) of the 141 placebo-treated patients (p = 0.008). At one year, sixty-five of the sixty-seven actively treated, randomized patients maintained a successful result. Thirty-six (71%) of the remaining fifty-one nonrandomized patients had a successful result at three months. For all 289 patients who had one or more actual treatments, 222 (76.8%) had a good or excellent result. No patient was made worse by the procedure. CONCLUSIONS: The application of electrohydraulic high-energy shock waves to the heel is a safe and effective noninvasive method to treat chronic plantar fasciitis, lasting up to and beyond one year.

Symptom duration of plantar fasciitis and the effectiveness of Orthotripsy.

BACKGROUND: The use of surgically noninvasive application of Orthotripsy (extracorporeal shock waves) for various musculoskeletal disorders is being increasingly utilized. Because most patients have had prolonged symptoms refractory to nonoperative treatments, this study evaluated the effectiveness of electrohydraulic Orthotripsy for chronic proximal plantarfasciitis compared to the duration of symptoms prior to treatment. METHODS: Following evaluation for study inclusion (unresponsive symptoms for more than 6 months), qualified patients received Orthotripsy or placebo. The study patients were randomized per described protocol. Additional groups of nonrandomized patients also were studied. RESULTS: In both the randomized and nonrandomized patient groups, those who received Orthotripsy were slightly more likely to have a positive result (complete symptom relief or satisfactory improvement) if symptoms had been present and unresponsive to other nonoperative therapeutic attempts for less than 2 years. The same trend was evident in patients undergoing a second Orthotripsy application. In the placebo group, there was no correlation between symptom duration and outcome. However, when placebo patients crossed over to the treatment arm of the study, the same response was evident: patients with symptoms for less than 2 years were slighty more likely to have a positive therapeutic response. Interestingly, the two patients with the longest duration of symptoms (15 and 18 years) both had complete symptom relief. CONCLUSIONS: The longevity of symptoms of chronic proximal plantar fasciopathy had a minimal impact on the likelihood of a positive response to Orthotripsy.

Shockwave therapy for chronic proximal plantar fasciitis: a meta-analysis.

PURPOSE: Utilizing meta-analysis, the authors have reviewed the available literature to assess the biologic and therapeutic effects of shockwaves on patients with chronic plantar fasciitis and the credibility of these published studies. METHODS: Meta-analysis is a systematic method for statistical analysis that combines data from various independent studies, allowing the assessment of potential benefits of various treatments when conclusions based on individual studies may be difficult to evaluate. We hypothesized that extracorporeal shockwave therapy provided a reasonable nonoperative therapeutic alternative to surgical intervention in the treatment of chronic proximal plantar fasciitis. RESULTS: Eight of 20 published studies fulfilled our type A to C criteria for acceptable studies of sufficient duration (one year or more after treatment). These eight studies involved 840 patients, with success rates of as much as 88%. The other 12 studies had methodological variables or lack of appropriate follow-up data that would limit their validity, although the success rates were comparable to the A to C studies. CONCLUSIONS: This meta-analysis shows that the directed application of shockwaves to the enthesis of the plantar fascia at the inferior calcaneus is a safe and effective nonsurgical method for treating chronic, recalcitrant heel pain syndrome that has been refractory to other commonly used nonoperative therapies. The results suggest that this therapeutic procedure should be considered before any surgical intervention, and may be preferable prior to cortisone injection, which has a recognized risk of rupture of the plantar fascia and a frequent recurrence of symptoms.