Foot Pain and Disability in Women with Rheumatoid Arthritis, Ehlers-Danlos Syndrome and Systemic Lupus Erythematosus: Relationship with Quality of Life.

The aim of this work was to investigate the relationship foot pain and foot disability have with HRQoL in groups of women with RA, SLE and EDS, in comparison with a control group. A cross-sectional study was carried out with females with one of these conditions and a control group. The SF-12 questionnaire was used to collect data about quality of life. The type of foot was classified according to the footprint and the foot posture index. A total of 156 patients and 47 controls participated in the study (N = 203). Neither pain nor foot posture were different between groups. The physical and mental components of SF-12 were worse in rheumatoid arthritis and Ehlers-Danlos syndrome patients, and the physical component was worse in systemic lupus erythematosus patients, compared to controls. A significant difference was also observed in the mental component between systemic lupus erythematosus and Ehlers-Danlos syndrome patients, the latter having the lowest values among the groups. We can conclude that women with rheumatoid arthritis, Ehlers-Danlos syndrome, systemic lupus erythematosus and foot pain perceive a worse quality of life. There are no significant changes in foot posture. Pain and health-related quality of life are independent of foot posture.

Age related changes in the Q angle of non-professional football players.

Background: Football practice involves a great muscular demand, leading to the development of the lower limbs that, on occasions, can cause deviations from the normal anthropometric values. The quadriceps angle (Q angle) is a value often taken as a reference for the alignment of the lower limbs. Objective: To observe the changes of the Q angle in young football players, because of muscular effort, analyzing the differences between four groups of different ages and to determine whether the playing position might influence these variations. Methods: A cross sectional study was carried out with 104 male subjects divided into four groups according to age: under 8 years-old, 8-17 years-old, 17-21 years-old and over 21 years-old. A photograph was taken in standing position and the Q angle was plotted with KINOVEA® software. As for the reliability of the measurements, intraclass intra and interobserver coefficient were 0.958 and 0.860 respectively. The study was conducted in mid-season. Results: Q angle value is greater in those under 8 years of age and decreases gradually and significantly (p < 0.005) until 17-21 years of age, where it stabilizes at values of 5.73° ± 2.78 for right Q angle and 5.88° ± 2.55 for left Q angle. Two way ANOVA demonstrated a significant group*position interaction for goalkeepers with a medium effect size in both angles (p < 0.001) with a medium effect (η2 Right Q angle = 0.31; η2 Left Q angle = 0.37). The values remain unchanged in subjects over 21 years of age (p > 0.005), except for goalkeepers, who suffered a difference in the evolution of the angle within their age category (p < 0.005) and with a high effect size with the other positions (value > 0.8) except forward (value < 0.5). Conclusion: This study determines that the Q angle in football players decreases with growth, reaching values below 15° at the end of development. Playing positions only influence players over the age of 21, and the Q-angle of goalkeepers is greater than that of other players.

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.

Effectiveness of custom-made functional foot orthoses versus flat cushioning insoles on pain in patients with systemic lupus erythematosus.

OBJECTIVE: To determine the effect of foot orthoses on pain, disability and foot functionality in patients with Systemic Lupus Erythematosus. DESIGN: Randomized clinical trial. SETTING: University Podiatric Clinical Area. SUBJECTS: Patients with systemic lupus erythematosus. INTERVENTIONS: Patients were randomly assigned to either group A, which received custom-made functional foot orthoses, or group B, which received flat cushioning insoles, for three months. MAIN MEASURES: The primary outcome was foot pain, measured by 11-point numeric pain rating scale. Foot functionality and foot-related disability were evaluated using the foot function index, the Manchester foot pain and disability, at the beginning and at days 90. RESULTS: Sixty-six participants (age 47.3 ± 11.9 years) suffering from foot pain, received either the custom-made foot orthoses (N = 33) or the flat cushioning insoles (N = 33). For the analysis of the data, only participants who had finished the follow-up period (90 days) were included. None statistically significant difference between groups were found. In group A, all variables showed statistically significant differences when comparing the initial and final measurements. Pain showed 6.8 ± 1.6 and 4.2 ± 2.9 in group A, at baseline and at 90 days, respectively, group B showed 6.5 ± 1.5 and 4.7 ± 3.0 at baseline and at 90 days, respectively. CONCLUSION: Both groups showed a reduction in foot pain. This study suggests that not only controlling the foot function, but providing cushioning to the foot, may have positive effects to manage foot pain in patients with systemic lupus erythematosus.

Use of Plantar Pressure Sensors to Take Weight-Bearing Foot Casts.

Techniques of taking casts mainly rely not on the objectivity of the procedure, but on the experience and skill of the technician. The aim of this study was to demonstrate the efficiency of a technique of taking standing foot casts controlled via pressure sensors. In this way, we mean to objectivize the degree of correction. The study was carried out through 150 procedures on 50 feet of 29 patients. The value of the "Heel Symmetry Index" was calculated on three casts in three different situations of the same foot: A first cast in which the subject did not control the position of his/her foot; a second cast where manipulations corrected the foot's pronator position; and a third cast with pressure sensors placed in the subject's heel. This enabled the control and quantification of the pressure during the manipulation when taking the cast. The comparison of the "Heel Symmetry Index" in the different groups showed significant p-values of 0.05. Conclusion: The technique of taking casts controlled by pressure sensors achieved more equilibrated casts with a better symmetry index of the heel's outline.

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.

Effectiveness of custom-made foot orthoses in patients with systemic lupus erythaematosus: protocol for a randomised controlled trial.

INTRODUCTION: Systemic lupus erythaematosus (SLE) is a chronic autoimmune disease of heterogeneous involvement. The disease may affect feet with a high prevalence of symptoms such as, for example, pain, forefoot and rearfoot deformities, and biomechanics dysfunctions. Custom-made foot orthoses (CMFO) have been previously reported to be effective in patients with other rheumatic diseases. However, as far as the authors know, there exist no studies about their effectiveness in SLE. This study aims at determining the effect of CMFO versus placebo flat cushioning insoles on pain, foot functionality, fatigue and quality of life in patients with SLE. METHODS AND ANALYSIS: A randomised controlled trial would compare the effects of (1) CMFO and group B, which received a placebo, flat cushioning insoles, for 3 months. The main outcome measures are foot pain, foot functionality and foot-related disability. The secondary outcome measures are fatigue and quality of life. ETHICS AND DISSEMINATION: The study has been approved by the Portal de Ética de la Investigación Biomédica de Andalucía ethical committee 1494-N-19. The results will be disseminated regardless of the magnitude or direction of effect. TRIAL REGISTARTION NUMBER: Clinicaltrials.gov identifier NCT04098055.

Fatigue in Children with Pronated Feet After Aerobic Exercises.

BACKGROUND: Sports have a strong influence on current society. Foot posture has been postulated to be a risk factor for overuse injuries; however, the link between foot posture and injuries is unclear. This study aimed to determine whether children with pronated feet become more fatigued after participating in sports tests than those with normal feet. METHODS: One hundred five children aged 10 to 12 years (mean ± SD age, 10.46 ± 0.78 years) participated in the sports tests, which were aerobic-type resistance exercises with six stations at which each child remained for 30 sec. The posture of the foot was evaluated via the Foot Posture Index and the plantar footprint via the arch index and the Clarke angle before and after aerobic-type resistance exercises. Perceived tiredness was evaluated with the Pictorial Children's Effort Rating Table (PCERT) and whether there was pain during or after physical activity. RESULTS: The variables used to measure foot posture and the plantar arch changed more in the pronated feet, suggesting that the feet undergo more pronation after physical exercise. The neutral feet obtained a mean ± SD PCERT score of 5.46 ± 1.89 and the pronated feet a score of 7.60 ± 1.92. CONCLUSIONS: Children with pronated feet showed more fatigue and foot pain during and/or after physical exercise than those with neutral feet. Foot type could be responsible for the lack of enthusiasm of children toward undertaking healthy activities, and this problem might be solved via appropriate orthopedic treatment.

Analysis and Assessment through Mechanical Static Compression Tests of Damping Capacity in a Series of Orthosis Plantar Materials Used as Supports.

High plantar pressure is the cause of multiple types of foot injuries and one of the main reasons for patient visits in podiatry and traumatology. Therefore, there is a need to acquire specific tools to address such injuries. The aim of this study was to determine the absorption capacity of selected materials applied as plantar supports and their response to pressure. The study had a cross-sectional design. A total of 21 materials were chosen and different material families were assessed, including ethylene-vinyl acetate, polyurethane foams, and polyethylene foams. Static compression tests were performed to analyze each material. The system is ideally suited for lower-force applications, small components, biomedical applications, and lower-strength materials. Damping was determined using mathematical calculations performed on the study data. It was found that materials with a low Shore A, or soft materials, exhibited worse absorption capacity than harder materials. Ethyl-vinyl acetates had good absorption capacity, polyurethane foams had a poor absorption capacity, and soft materials provided better adaption to impact. The results suggested that damping is not determined by the hardness of the material, and materials within the same family exhibit different damping capabilities.

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.

Comparative Study Between the Different Techniques of Molding and the Morphology of the Foot in Weightbearing.

BACKGROUND: Taking a mold of the foot is an important advance for podiatric medicine and an indispensable procedure for the individualization of orthopedic treatments. We sought to determine which method of measuring molds (plaster cast in weightbearing and nonweightbearing and phenolic foam in weightbearing) reproduces with more reliability the expansion of the foot in weightbearing by comparing the widths of the forefoot and hindfoot in the different methods and in barefoot weightbearing. METHODS: In 54 patients, we studied the differences in width between the forefoot and hindfoot in barefoot weightbearing compared with in the different mold obtainment techniques. A descriptive, observational, and transversal study was performed in which foot molds were obtained with the different techniques, without corrective maneuvers, followed by scanning of each as well as barefoot weightbearing. RESULTS: Significant differences among the techniques were shown, with phenolic foam being more similar to barefoot weightbearing in forefoot and hindfoot width. CONCLUSIONS: The method that reproduces the expansion of the foot in weightbearing with more reliability is phenolic foam. The forefoot width is superior in barefoot weightbearing versus the three foot casts studied. The hindfoot width is superior in the foot cast with plaster in weightbearing compared with barefoot weightbearing and the other two foot casts.

Ankle sprain as a work-related accident: status of proprioception after 2 weeks.

PURPOSE: This study aims at verifying whether proprioception is abnormal or not, two weeks after a grade 1 and 2 ankle sprain in the scope of work-related accident. METHODS: A descriptive, observation and transversal study was designed to compare speed, movement and oscilation of centre of pressure in employees of companies signed up to a mutual company. Participants' healthy feet comprised the control group, and feet that had undergone an ankle sprain due to a work-related accident comprised the cases group. The following stability tests were undertaken to both the healthy and injuried feet using a force plate: Monopodal Romberg test with eyes open, Monopodal Romberg test with eyes open on a 30 mm thick foam rubber, Monopodal Romberg test with eyes closed, and Romberg test as monopodal support with eyes closed on a 30 mm thick foam rubber. A multiple logistic regression analysis was performed. From the results of this regression model the COR curve test was performed. RESULTS: 71.7% accuracy in the predictions was attained. The equation was as follows: Condition (injured or healthy) = 0.052⋅% RGC AP Movement - 0.81⋅MREO AP Movement. The variable MREO antero-posterior movement was used in the COR curve methodology. The area under the curve was greater than 0.65 and at a 95% confidence interval the 0.75 value was included, which in our case was the injured subject condition. Values for sensitivity, specificity, positive predictive value and negative predictive value were 0.667, 0.633, 64.5%, and 65.5%, respectively. CONCLUSION: The participants in this study showed a diminished capacity for postural control in an ankle two weeks after an ankle sprain.

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.

Metatarsal pain and plantar hyperkeratosis in the forefeet of female professional flamenco dancers.

OBJECTIVES: The objectives of this study were to determine the frequency of metatarsal pain and of hyperkeratosis on the plantar forefoot in female professional flamenco dancers, and to determine whether there is a relationship between the two disorders. METHOD: Forty-four female professional flamenco dancers, with a minimum activity of 25 hrs/wk, participated in this cross-sectional study. The presence or absence of metatarsal pain while dancing was recorded, and plantar pressures were measured on a pressure platform, both barefoot and shod with the usual dance shoe. The heel height of the dance shoe was also measured. RESULTS: Of the dancers, 80.7% experienced metatarsal pain while dancing, and 84.1% presented with plantar hyperkeratosis. Plantar hyperkeratosis coincided with the presence of metatarsal pain in 67.04% of the feet studied. The maximum load point in the feet when the dancers were barefoot was located 59.5% in the rearfoot and 40.5% in the forefoot; when dancers wore their specific flamenco dancing shoes, it was located 52.4% in the rearfoot and 47.6% in the forefoot. CONCLUSIONS: Metatarsal pain and plantar hyperkeratosis in the forefoot are common foot disorders in female flamenco dancing. The incidence of the maximum load point being located in the forefoot, and the difference between the results of the tests while shod or barefoot, are both too low to support the idea that the raised heels of flamenco shoes are a major contributing factor for these injuries. Therefore, these disorders may be caused by chronic repetitive trauma suffered during the practice of footwork dancing.

Normal values of metatarsal parabola arch in male and female feet.

There is not any method to measure metatarsal protrusion in the whole metatarsal. The aim of this research is to know the normal metatarsal parabola in male and female feet. The system of measurement devised by Hardy and Clapham to evaluate the protrusion between metatarsals I and II was adapted to study the whole metatarsal parabola and applied to the five metatarsals of 169 normal feet, 72 female feet and 97 male feet. Authors measured all metatarsal protrusion relative to metatarsal II. The results obtained show a female metatarsal protrusion relative to metatarsal II of +1.27% for metatarsal I, -3.36% for metatarsal III, -8.34% for metatarsal IV, and -15.54% for metatarsal V. Data obtained for male metatarsal parabola were +0.5% for metatarsal I, -3.77 for metatarsal III, -9.57 for metatarsal IV, and -17.05 for metatarsal V. Differences between both metatarsal parabola were significant.

Hallux abductus interphalangeus in normal feet, early-stage hallux limitus, and hallux valgus.

BACKGROUND: Excessive deviation of the distal phalanx in abduction frequently occurs in advanced stages of hallux rigidus but not in hallux valgus. Therefore, theoretically there should be no significant differences in the hallux interphalangeal angle (HIPA) between individuals with normal feet, those with hallux valgus, and those with mild hallux limitus. The objective of the present study was thus to determine if significant differences in HIPA exist in the early stages of hallux valgus or hallux limitus deformities. METHODS: The hallux interphalangeal angle was measured in three groups of participants: a control group with normal feet (45 participants), a hallux valgus group (49 participants), and a hallux limitus group (48 participants). Both of the pathologies were at an early stage. A dorsoplantar radiograph under weightbearing conditions was taken for each individual, and measurements (HIPA and hallux abductus angle [HAA]) were taken using AutoCAD (Autodesk Inc, San Rafael, California) software. Intergroup comparisons of HIPA, and correlations between HIPA, HAA, and hallux dorsiflexion were calculated. RESULTS: The comparisons revealed no significant differences in the values of HIPA between any of the groups (15.2 ± 5.9 degrees in the control group, 15.5 ± 3.9 degrees in the hallux valgus group, and 16.15 ± 4.3 in the hallux limitus group; P  =  0.634). The Pearson correlation coefficients in particular showed no correlation between hallux dorsiflexion, HAA, and HIPA. CONCLUSIONS: For the study participants, there were similar deviations of the distal phalanx of the hallux with respect to the proximal phalanx in normal feet and in feet with the early stages of the hallux limitus and hallux valgus deformities.

Angular position of the cleat according to torsional parameters of the cyclist's lower limb.

OBJECTIVE: The aim of this work was to study the relationship of torsional and rotational parameters of the lower limb with a specific angular position of the cleat to establish whether these variables affect the adjustment of the cleat. DESIGN: Correlational study. SETTING: Motion analysis laboratory. PARTICIPANTS: Thirty-seven male cyclists of high performance. INTERVENTIONS: The variables studied of the cyclist's lower limb were hip rotation (internal and external), tibial torsion angle, Q angle, and forefoot adductus angle. MAIN OUTCOME MEASURES: The cleat angle was measured through a photograph of the sole and with an Rx of this using the software AutoCAD 2008. The variables were photograph angle (photograph), the variable denominated cleat-tarsus minor angle, and a variable denominated cleat-second metatarsal angle (Rx). Analysis included the intraclass correlation coefficient for the reliability of the measurements, Student's t test performed on the dependent variables to compare side, and the multiple linear regression models were calculated using the software SPSS 15.0 for Windows. RESULTS: The Student's t test performed on the dependent variables to compare side showed no significant differences (P = 0.209 for the photograph angle, P = 0.735 for the cleat-tarsus minor angle, and P = 0.801 for the cleat-second metatarsal angle). Values of R and R2 for the photograph angle model were 0.303 and 0.092 (P = 0.08), the cleat/tarsus minor angle model were 0.683 and 0.466 (P < 0.001), and the cleat/second metatarsal angle model were 0.618 and 0.382, respectively (P < 0.001). CONCLUSIONS: The equation given by the model was cleat-tarsus minor angle = 75.094 - (0.521 × forefoot adductus angle) + (0.116 × outward rotation of the hips) + (0.220 × Q angle).

Comparison of plantar pressures and contact area between normal and cavus foot.

BACKGROUND: In pes cavus, the medial longitudinal arch elevation reduces the contact surface area and consequently increases the corresponding plantar pressure measurements. This poor distribution of loads may produce associated pathology and pain in this or other areas of the body. Normal reference values need to be established in order to determine which patterns are prone to pathology. OBJECTIVES: To compare the plantar pressures and weight-bearing surface in a population with pes cavus to a population with neutral feet. METHOD: The sample comprised 68 adults, 34 with pes cavus and 34 with neutral feet. The Footscan USB Gait Clinical System(®) was used as a platform to measure the total contact area and plantar pressure under the forefoot, midfoot, hindfoot, each metatarsal head, and the overall metatarsal area. A statistical analysis of the data was performed using Student's t-test for independent samples. RESULTS: The pes cavus subjects showed a significant reduction in their weight-bearing area [neutral feet: 165.04 ( ± 20.68) cm(2); pes cavus: 118.26 ( ± 30.31) cm(2); p < 0.001] and significantly increased pressures under all zones of the forefoot except the fifth metatarsal [metatarsal pressure: in neutral feet 503,797 ( ± 9.32) kPa; in pes cavus 656.12 ( ± 22.39) kPa; p < 0.001]. CONCLUSIONS: Compared to neutral feet, pes cavus feet show a reduction in total contact surface and the load under the first toe. A significant increase is present in the load under the metatarsal areas, but the relative distribution of this load is similar in both groups.

Tratamiento físico y ortopodológico en pie plano rígido / Physical and orthopodologic therapy in stiff flat foot

El caso clínico que presentamos a continuación trata de un paciente adolescente al cual diagnosticamos de pie plano rígido en fase de contractura muscular. Planteamos un tratamiento integrado combinando la podología física mediante la realización de movilizaciones articulares, estiramientos musculares y cinesiterapia activa; junto con la ortopodología aplicando un tratamiento evolutivo mediante soportes plantares personalizados (AU)