Effectiveness of footwear and foot orthoses in reducing medial metatarsophalangeal joint pressure in women with hallux valgus.

BACKGROUND: Hallux valgus is a common condition where the subluxation of the first metatarsophalangeal joint and lateral deviation of the hallux at the interphalangeal joint creates difficulty with footwear fit. Footwear and foot orthoses are commonly prescribed nonsurgical treatments for hallux valgus. RESEARCH QUESTION: Do extra-width footwear and foot orthoses influence peak pressure at the medial aspect of the metatarsophalangeal and interphalangeal joints in women with hallux valgus? METHODS: Community-dwelling women with symptomatic hallux valgus underwent gait testing when wearing their own shoes and when wearing extra-width footwear fitted with three-quarter length, arch-contouring prefabricated foot orthoses. Peak pressure (kPa) on the medial aspect of the metatarsophalangeal and medial interphalangeal joints and on the plantar surface of the foot (hallux, lesser toes, metatarsophalangeal joint 1, metatarsophalangeal joints 2-5, midfoot and heel) were measured using the novel pedar®-X system with the pedar® pad and pedar® insole, respectively (Novel, GmbH, Munich, Germany). Paired samples t-tests were used to calculate the differences between the two conditions, and the magnitude of observed differences was calculated using Cohen's d. RESULTS: We tested 28 participants (aged 44-80 years, mean 60.7, standard deviation 10.7). Compared to their own footwear, wearing the intervention footwear and orthoses was associated with a statistically significant decrease in pressure on the medial aspect of the metatarsophalangeal joint (58.3 ± 32.8 versus 42.6 ± 32.8, p=0.026, d=0.49), increased pressure under the midfoot (70.7 ± 25.7 versus 78.7 ± 23.6, p=0.029, d=0.33) and decreased pressure underneath the heel (137.3 ± 39.0 versus 121.3 ± 34.8, p=0.019, d=0.45). SIGNIFICANCE: The intervention footwear and orthoses significantly decreased peak pressure on the medial aspect of the first metatarsophalangeal joint but had no significant effect on the interphalangeal joint. Further studies are required to determine whether these changes are associated with improvements in symptoms associated with hallux valgus.

Nonsurgical management of hallux valgus: findings of a randomised pilot and feasibility trial.

BACKGROUND: Hallux valgus is a common and disabling condition. This randomised pilot and feasibility trial aimed to determine the feasibility of conducting a parallel group randomised trial to evaluate the effectiveness of a nonsurgical intervention for reducing pain associated with hallux valgus. METHODS: Twenty-eight community-dwelling women with painful hallux valgus were randomised to receive either a multifaceted, nonsurgical intervention (footwear, foot orthoses, foot exercises, advice, and self-management) or usual care (advice and self-management alone). Outcome measures were obtained at baseline, 4, 8 and 12 weeks. The primary outcome was feasibility, evaluated according to demand (recruitment rate and conversion rate), acceptability, adherence, adverse events, and retention rate. Limited efficacy testing was conducted on secondary outcome measures including foot pain, foot muscle strength, general health-related quality of life, use of cointerventions, and participants' perception of overall treatment effect. RESULTS: Between July 8, 2021, and April 22, 2022, we recruited and tested 28 participants (aged 44 to 80 years, mean 60.7, standard deviation 10.7). This period encompassed two COVID-related stay-at-home orders (July 16 to July 27, and August 5 to October 21, 2021). The predetermined feasibility thresholds were met for retention rate, foot pain, mental health-related quality of life, and use of cointerventions, partly met for acceptability, adverse events, and muscle strength, and not met for demand (recruitment rate or conversion rate), adherence, physical health-related quality of life and perception of overall treatment effect. CONCLUSION: In its current form, a randomised trial of footwear, foot orthoses, foot exercises, advice and self-management for relieving pain associated with hallux valgus is not feasible, particularly due to the low adherence with the intervention. However, it is difficult to determine whether the trial would be feasible under different circumstances, particularly due to COVID-19 stay-at-home orders. Future trials will need to consider improving the aesthetics of the footwear and making the exercise program less burdensome. TRIAL REGISTRATION: Australian and New Zealand Clinical Trial Registry (ACTRN12621000645853).

Footwear, foot orthoses and strengthening exercises for the non-surgical management of hallux valgus: protocol for a randomised pilot and feasibility trial.

BACKGROUND: Hallux valgus is a common and disabling condition. This randomised pilot and feasibility trial aims to determine the feasibility of conducting a fully-powered parallel group randomised trial to evaluate the effectiveness of a multifaceted non-surgical intervention for reducing pain associated with hallux valgus. METHODS: Twenty-eight community-dwelling women with painful hallux valgus will be randomised to receive either a multifaceted, non-surgical intervention (footwear, foot orthoses, foot exercises, advice, and self-management) or advice and self-management alone. Outcome measures will be obtained at baseline, 4, 8 and 12 weeks. The primary outcome is feasibility, which will be evaluated according to demand, acceptability, adherence, adverse events, and retention rate. Limited efficacy testing will be conducted on secondary outcome measures including foot pain (the Manchester-Oxford Foot Questionnaire), foot muscle strength (hand-held dynamometry), general health-related quality of life (the Short Form-12), use of cointerventions, and participants' perception of overall treatment effect. Biomechanical testing will be conducted at baseline to evaluate the immediate effects of the footwear/orthotic intervention on pressure beneath the foot and on the medial aspect of the first metatarsophalangeal joint and hallux. DISCUSSION: This study will determine the feasibility of conducting a fully-powered randomised trial of footwear, foot orthoses, foot exercises, advice and self-management for relieving pain associated with hallux valgus and provide insights into potential mechanisms of effectiveness. TRIAL REGISTRATION: Australian and New Zealand Clinical Trial Registry ( ACTRN12621000645853 ).

Psychological variables associated with foot function and foot pain in patients with plantar heel pain.

It is widely accepted that psychological variables are associated with self-reported pain and self-reported physical function in patients with musculoskeletal pain. However, the relationship between psychological variables and foot pain and foot function has not been evaluated in people with plantar heel pain. Eighty-four participants with plantar heel pain completed the Depression, Anxiety and Stress Scale short version (DASS-21) and Foot Health Status Questionnaire. Using a hierarchical regression analysis, a baseline model with age, sex and BMI explained 10 % of the variability in foot function. The addition of depression and stress in separate models explained an additional 7.3 % and 8.1 % of foot function scores, respectively. In the respective models, depression was a significant predictor (ß = -0.28; p = 0.009) as was stress (ß = -0.29; p = 0.006). Females drove the effect between stress and foot function (ß = -0.50; p = 0.001) and depression and foot function (ß = -0.53; p < 0.001). In regression models for foot pain, depression, anxiety and stress did not contribute significantly to pain scores. When the data was stratified by sex, stress (ß = -0.36; p = 0.024) and depression (ß = -0.41; p = 0.013) were significantly associated with foot pain in females but not in males. For participants with plantar heel pain, stress and depression scores were significantly associated with foot function but not foot pain. When the data was stratified by sex, stress and depression were significant predictors of foot pain and function in females.

Effectiveness of trigger point dry needling for plantar heel pain: a randomized controlled trial.

BACKGROUND: Plantar heel pain can be managed with dry needling of myofascial trigger points; however, there is only poor-quality evidence supporting its use. OBJECTIVE: The purpose of this study was to evaluate the effectiveness of dry needling for plantar heel pain. DESIGN: The study was a parallel-group, participant-blinded, randomized controlled trial. SETTING: The study was conducted in a university health sciences clinic. PATIENTS: Study participants were 84 patients with plantar heel pain of at least 1 month's duration. INTERVENTION: Participants were randomly assigned to receive real or sham trigger point dry needling. The intervention consisted of 1 treatment per week for 6 weeks. Participants were followed for 12 weeks. MEASUREMENTS: Primary outcome measures included first-step pain, as measured with a visual analog scale (VAS), and foot pain, as measured with the pain subscale of the Foot Health Status Questionnaire (FHSQ). The primary end point for predicting the effectiveness of dry needling for plantar heel pain was 6 weeks. RESULTS: At the primary end point, significant effects favored real dry needling over sham dry needling for pain (adjusted mean difference: VAS first-step pain=-14.4 mm, 95% confidence interval [95% CI]=-23.5 to -5.2; FHSQ foot pain=10.0 points, 95% CI=1.0 to 19.1), although the between-group difference was lower than the minimal important difference. The number needed to treat at 6 weeks was 4 (95% CI=2 to 12). The frequency of minor transitory adverse events was significantly greater in the real dry needling group (70 real dry needling appointments [32%] compared with only 1 sham dry needling appointment [<1%]). LIMITATIONS: It was not possible to blind the therapist. CONCLUSION: Dry needling provided statistically significant reductions in plantar heel pain, but the magnitude of this effect should be considered against the frequency of minor transitory adverse events.

Hyperemia in plantar fasciitis determined by power Doppler ultrasound.

STUDY DESIGN: Cross-sectional observational study. OBJECTIVES: To investigate the presence of soft tissue hyperemia in plantar fasciitis with power Doppler ultrasound. BACKGROUND: Localized hyperemia is an established feature of tendinopathy, suggesting that neurovascular in-growth may contribute to tendon-associated pain in some patients. The presence of abnormal soft tissue vascularity can be assessed with Doppler ultrasound, and a positive finding can assist with targeted treatment plans. However, very little is known regarding the presence of hyperemia in plantar fasciitis and the ability of routine Doppler ultrasound to identify vascular in-growth in the plantar fascia near its proximal insertion. METHODS: This observational study included 30 participants with plantar fasciitis unrelated to systemic disease and 30 age- and sex-matched controls. Ultrasound examination was performed with a 13- to 5-MHz linear transducer, and power Doppler images were assessed by 2 blinded investigators. RESULTS: Hyperemia of the plantar fascia was present in 8 of 30 participants with plantar fasciitis and in 2 of 30 controls. The between-group difference for hyperemia, using a 4-point scale, was statistically significant, with participants with plantar fasciitis showing increased Doppler ultrasound signal compared to controls (Mann-Whitney U, P = .03). However, the majority of participants with plantar fasciitis with evidence of hyperemia demonstrated very mild color changes, and only 3 were found to have moderate or marked hyperemia. CONCLUSION: Mild hyperemia can occur with plantar fasciitis, but most individuals will not exhibit greater soft tissue vascularity when assessed with routine Doppler ultrasound. Clinicians treating plantar fasciitis should not consider a positive Doppler signal as essential for diagnosis of the condition but, rather, as a feature that may help to refine the treatment plan for an individual patient.

Consensus for dry needling for plantar heel pain (plantar fasciitis): a modified Delphi study.

HYPOTHESIS: Plantar heel pain (plantar fasciitis) is a common and disabling condition. A variety of treatment options are available to patients with plantar heel, however the evidence for these treatments is generally weak and the best way to manage plantar heel pain remains unclear. Trigger point dry needling is increasingly used as an adjunct therapy for musculoskeletal pain. In patients with plantar heel pain this technique is thought to improve muscle activation patterns, increase joint range of motion and alleviate pain. However, there have been no randomised controlled trials that have evaluated the effectiveness of dry needling for plantar heel pain. METHODS: In order to develop a treatment protocol to evaluate the effectiveness of dry needling for plantar heel pain we conducted a three stage modified Delphi process using a web-based survey technique. Over a series of three iterations, 30 experts (participants) worldwide indicated their level of agreement on specific issues relating to the use of dry needling for plantar heel pain including their treatment rationale, needling details and treatment regimen. Consensus for a dry needling protocol for plantar heel pain was achieved when >60% of participants (IQR ≤ 1.0 category on 5-point Likert scale) agreed the protocol was adequate. RESULTS: The response rate was 75% (n=30), 100% (n=30) and 93% (n=28) in the first, second and third rounds respectively. Round 1 helped generate a list of 10 items that were deemed important for developing a dry needling protocol for plantar heel pain. These 10 items were subsequently presented in Round 2. Of these, 5 of the 10 items met the criteria to be included in a dry needling protocol for plantar heel pain that was presented in the final round, Round 3. Items that did not meet the criteria were either removed or amended and then presented in Round 3. In the final round, 93% of participants (IQR range = 1) agreed the proposed dry needling protocol for plantar heel pain was adequate. The protocol can now be used in future research projects designed to evaluate the effectiveness of dry needling for plantar heel pain.

Effectiveness of trigger point dry needling for plantar heel pain: study protocol for a randomised controlled trial.

BACKGROUND: Plantar heel pain (plantar fasciitis) is a common and disabling condition, which has a detrimental impact on health-related quality of life. Despite the high prevalence of plantar heel pain, the optimal treatment for this disorder remains unclear. Consequently, an alternative therapy such as dry needling is increasingly being used as an adjunctive treatment by health practitioners. Only two trials have investigated the effectiveness of dry needling for plantar heel pain, however both trials were of a low methodological quality. This manuscript describes the design of a randomised controlled trial to evaluate the effectiveness of dry needling for plantar heel pain. METHODS: Eighty community-dwelling men and woman aged over 18 years with plantar heel pain (who satisfy the inclusion and exclusion criteria) will be recruited. Eligible participants with plantar heel pain will be randomised to receive either one of two interventions, (i) real dry needling or (ii) sham dry needling. The protocol (including needling details and treatment regimen) was formulated by general consensus (using the Delphi research method) using 30 experts worldwide that commonly use dry needling for plantar heel pain. Primary outcome measures will be the pain subscale of the Foot Health Status Questionnaire and "first step" pain as measured on a visual analogue scale. The secondary outcome measures will be health related quality of life (assessed using the Short Form-36 questionnaire - Version Two) and depression, anxiety and stress (assessed using the Depression, Anxiety and Stress Scale - short version). Primary outcome measures will be performed at baseline, 2, 4, 6 and 12 weeks and secondary outcome measures will be performed at baseline, 6 and 12 weeks. Data will be analysed using the intention to treat principle. CONCLUSION: This study is the first randomised controlled trial to evaluate the effectiveness of dry needling for plantar heel pain. The trial will be reported in accordance with the Consolidated Standards of Reporting Trials and the Standards for Reporting Interventions in Clinical Trials of Acupuncture guidelines. The findings from this trial will provide evidence for the effectiveness of trigger point dry needling for plantar heel pain. TRIAL REGISTRATION: Australian New Zealand 'Clinical Trials Registry'. ACTRN12610000611022.

Effectiveness of dry needling and injections of myofascial trigger points associated with plantar heel pain: a systematic review.

BACKGROUND: Plantar heel pain (plantar fasciitis) is one of the most common musculoskeletal pathologies of the foot. Plantar heel pain can be managed with dry needling and/or injection of myofascial trigger points (MTrPs) however the evidence for its effectiveness is uncertain. Therefore, we aimed to systematically review the current evidence for the effectiveness of dry needling and/or injections of MTrPs associated with plantar heel pain. METHODS: We searched specific electronic databases (MEDLINE, EMBASE, AMED, CINAHL, SPORTDiscus and AMI) in April 2010 to identify randomised and non-randomised trials. We included trials where participants diagnosed with plantar heel pain were treated with dry needling and/or injections (local anaesthetics, steroids, Botulinum toxin A and saline) alone or in combination with acupuncture. Outcome measures that focussed on pain and function were extracted from the data. Trials were assessed for quality using the Quality Index tool. RESULTS: Three quasi-experimental trials matched the inclusion criteria: two trials found a reduction in pain for the use of trigger point dry needling when combined with acupuncture and the third found a reduction in pain using 1% lidocaine injections when combined with physical therapy. However, the methodological quality of the three trials was poor, with Quality Index scores ranging form 7 to 12 out of a possible score of 27. A meta-analysis was not conducted because substantial heterogeneity was present between trials. CONCLUSIONS: There is limited evidence for the effectiveness of dry needling and/or injections of MTrPs associated with plantar heel pain. However, the poor quality and heterogeneous nature of the included studies precludes definitive conclusions being made. Importantly, this review highlights the need for future trials to use rigorous randomised controlled methodology with measures such as blinding to reduce bias. We also recommend that such trials adhere to the Standards for Reporting Interventions in Controlled Trials of Acupuncture (STRICTA) to ensure transparency.

A comparison of foot kinematics in people with normal- and flat-arched feet using the Oxford Foot Model.

Foot posture is thought to influence predisposition to overuse injuries of the lower limb. Although the mechanisms underlying this proposed relationship are unclear, it is thought that altered foot kinematics may play a role. Therefore, this study was designed to investigate differences in foot motion between people with normal- and flat-arched feet using the Oxford Foot Model (OFM). Foot posture in 19 participants was documented as normal-arched (n=10) or flat-arched (n=9) using a foot screening protocol incorporating measurements from weightbearing antero-posterior and lateral foot radiographs. Differences between the groups in triplanar motion of the tibia, rearfoot and forefoot during walking were evaluated using a three-dimensional motion analysis system incorporating a multi-segment foot model (OFM). Participants with flat-arched feet demonstrated greater peak forefoot plantar-flexion (-13.7° ± 5.6° vs -6.5° ± 3.7°; p=0.004), forefoot abduction (-12.9° ± 6.9° vs -1.8° ± 6.3°; p=0.002), and rearfoot internal rotation (10.6° ± 7.5° vs -0.2°± 9.9°; p=0.018) compared to those with normal-arched feet. Additionally, participants with flat-arched feet demonstrated decreased peak forefoot adduction (-7.0° ± 9.2° vs 5.6° ± 7.3°; p=0.004) and a trend towards increased rearfoot eversion (-5.8° ± 4.4° vs -2.5° ± 2.6°; p=0.06). These findings support the notion that flat-arched feet have altered motion associated with greater pronation during gait; factors that may increase the risk of overuse injury.