Diabetes podiatry services for Maori in Aotearoa: a step in the right direction?

Maori with diabetes are at a 65% greater risk of amputation compared to non-Maori with diabetes. Despite evidence to support the role of podiatrists in reducing diabetes-related lower limb amputations; the effectiveness of diabetes podiatry services at the community and secondary level to achieve this for Maori is largely unknown. Diabetes podiatry services need to be reorientated and be culturally applicable to Indigenous communities. Transforming diabetes podiatry services and practice may reduce Indigenous amputation rates and improve quality of life for an unserved community.

Increasing podiatry referrals for patients with inflammatory arthritis at a tertiary hospital in Singapore: A quality improvement project.

BACKGROUND: Foot disease is highly prevalent in people with inflammatory arthritis and is often under-recognized. Podiatry intervention can significantly reduce foot pain and disability, with timely access being the key factor. The aim of this study was to plan and implement a quality improvement project to identify the barriers to, and improve, uptake of podiatry services among patients with inflammatory arthritis-related foot problems seen at a tertiary hospital in Singapore. METHOD: A 6-month quality improvement program was conducted by a team of key stakeholders using quality improvement tools to identify, implement and test several interventions designed to improve uptake of podiatry services. The number of patients referred for podiatry assessment was recorded on a weekly basis by an experienced podiatrist. The criterion for appropriate referral to podiatry was those patients with current or previous foot problems such as foot pain, swelling and deformity. RESULTS: Interventions included education initiatives, revised workflow, development of national guidelines for inflammatory arthritis, local podiatry guidelines for the management of foot and ankle problems, routine use of outcome measures, and introduction of a fully integrated rheumatology-podiatry service with reduced cost package. Referral rates increased from 8% to 11%, and were sustained beyond the study period. Complete incorporation of podiatry into the rheumatology consultation as part of the multidisciplinary team package further increased referrals to achieve the target of full uptake of the podiatry service. CONCLUSION: Through a structured quality improvement program, referrals to podiatry increased and improved the uptake and acceptance of rheumatology-podiatry services.

Clinical effectiveness and cost-effectiveness of foot orthoses for people with established rheumatoid arthritis: an exploratory clinical trial.

OBJECTIVES: Foot orthoses are commonly prescribed as an intervention for people with rheumatoid arthritis (RA). Data relating to the cost-effectiveness of foot orthoses in people with RA are limited. The aim was to evaluate the clinical and cost-effectiveness of two types of foot orthoses in people with established RA. METHOD: A single-blind randomized controlled trial was undertaken to compare custom-made foot orthoses (CMFOs) and simple insoles (SIs) in 41 people with established RA. The Foot Function Index (FFI) was used to measure foot pain, disability, and functional limitation. Costs were estimated from the perspective of the UK National Health Service (NHS), societal (patient and family) perspective, and secondary care resource use in terms of the intervention and staff time. Effects were assessed in terms of health gain expressed as quality-adjusted life years (QALYs). RESULTS: At baseline, 20 participants received a CMFO and 21 participants received an SI. After 16 weeks foot pain improved in both the CMFOs (p = 0.000) and the SIs (p < 0.01). However, disability scores improved for CMFOs (p < 0.001) but not for SIs (p = 0.40). The cost-effectiveness results demonstrated no difference in cost between the arms (CMFOs: £159.10; SIs: £79.10; p = 0.35), with the CMFOs being less effective in terms of cost per QALY gain (p < 0.001). CONCLUSIONS: In people with established RA, semi-rigid customized foot orthoses can improve pain and disability scores in comparison to simple insoles. From a cost-effectiveness perspective, the customized foot orthoses were far more expensive to manufacture, with no significant cost per QALY gain.

Prevalence of foot problems in people with inflammatory arthritis in Singapore.

BACKGROUND: Foot problems are highly prevalent in people with inflammatory arthritis reported from studies in the UK, Europe and New Zealand, but there is limited evidence from Southeast Asia. The study aim was to evaluate the prevalence of foot problems in people with inflammatory arthritis in Singapore. METHODS: People with inflammatory arthritis were recruited from the rheumatology outpatient clinic of a tertiary hospital in Singapore. Disease and clinical characteristics included age, sex, disease duration, current blood tests and medications. The Leeds Foot Impact Scale was used to evaluate foot impairment/disability and the Modified Health Assessment Questionnaire was used to assess global function. RESULTS: We recruited 101 people with inflammatory arthritis, of which 50 % were female. The majority of participants were Chinese (70 %). The mean (SD) age was 52 (15) years, and the mean (SD) disease duration was 9.3 (0.3) years. The most commonly reported inflammatory arthritic conditions were rheumatoid arthritis (46), gout (31) and spondyloarthritis (15 %). The mean (SD) of the total Leeds Foot Impact Scale was 17 (13) indicating moderate to severe levels of foot impairment and activity limitation. Over 80 of participants reported foot pain during the course of their condition, and 48 % reported current foot pain. Despite the high prevalence of foot pain, only 21 participants (21 %) had been referred to a podiatrist. CONCLUSION: This is the first study to investigate the prevalence of foot problems in people with inflammatory arthritis from Singapore. The majority of the participants reported foot problems, but had not been referred to a podiatry service.

Footwear characteristics in people with inflammatory arthritis in Singapore.

BACKGROUND: Foot problems are common in people with inflammatory arthritis. Despite suitable footwear having the potential to alleviate pain, improve mobility and maintain independence, previous studies have found many people with inflammatory arthritis wearing poorly fitting and inappropriate footwear. Footwear styles and characteristics have not been reported in a Singapore inflammatory arthritis population. The objective of this study was to identify current footwear styles and characteristics of footwear worn by people with inflammatory arthritis in Singapore. METHODS: One-hundred-and-one participants with inflammatory arthritis were recruited from the rheumatology outpatient clinic of a large public hospital in Singapore. Disease and clinical characteristics were recorded. A patient-reported outcome included current foot pain. An objective footwear assessment of style, age of shoe, fit and construction was conducted. RESULTS: The majority of participants were Chinese women with a mean (SD) age was 52.0 (15.0) years old and a mean (SD) disease duration of 9.3 (0.3) years. We found 50 % of participants (n = 51) reported footwear problems. Sandals (n = 27, 26 %), flip-flops (n = 19, 19 %) and moccasin type (n = 19, 19 %) was the most common footwear choice. Evaluation of footwear characteristics found that there was a lack of motion control features. Only 32 (32 %) participants had correctly fitting footwear with regard to length, width and depth. No participant was wearing therapeutic footwear. CONCLUSION: This study provides the first insight into footwear preferences of people with inflammatory arthritis in Singapore. Use of slip-on and poorly fitting footwear was found to be common in people with inflammatory arthritis. Further research on footwear preferences in Southeast-Asian communities needs to take into account cultural habit and preference, socio-economic status, footwear options and affordability.

Incidence and characteristics of proximal femoral fractures in an Afro-Caribbean population.

BACKGROUND: Although fractures of the proximal femur (FPF) are supposedly less frequent in Black populations (studies of incidence are rare) the life expectancy in Africa is low, which could partially explain this notion. There is only one retrospective study on the incidence of FPF in the islands of the Caribbean, thus we performed an incidence study in the insular, circumscribed, 90% Afro-Caribbean population of Martinique. The goals of this study were: (1) to estimate the incidence of FPF; (2) and to prospectively describe the main characteristics. HYPOTHESIS: The incidence of fractures of the proximal femur in Martinique is lower than in Western countries. PATIENTS AND METHODS: The raw and standardized incidence ratio of FPF in relation to the world population was estimated based on data from the Medical Information System Program (Programme de médicalisation des systèmes d'information [PMSI]) for all of Martinique for a period of 4 years (January 1, 2010 to December 31, 2013). Characteristics were based on all patients over the age of 60 who presented to the Fort-de-France University Hospital (CHU) for a FPF between December 1, 2011 and April 31, 2012. Patients with light-skin phenotype, high-energy fractures and secondary fractures were excluded from the study. RESULTS: The standardized incidence ratio in relation to the world population was estimated (n=794) as 22.5/100,000 patient-years [20.6-24.4]: 22.6 and 22.4/100,000 in men and women respectively. The characteristics of eighty-seven patients (including 56 women), mean age 85.3 (±7.2) (62-100) years old were evaluated: 52 femoral neck fractures (60%) and 33 fractures of the greater trochanter (38%). The 2-month mortality rate was 21%, and 1/3 of the surviving patients could function independently. The risk of death increased in relation to the initial risk of moderate to severe dementia. DISCUSSION: The incidence of FPF in Martinique is lower than in Western countries and includes, as expected, an elderly, female population. Unlike a previous study performed in Guadeloupe, there was a majority of femoral neck fractures. A Caribbean multi-insular study is needed to confirm these results and to obtain precise data on bone density. LEVEL OF EVIDENCE: IV; descriptive prospective epidemiological study.

Effect of textured insoles on balance and gait in people with multiple sclerosis: an exploratory trial.

OBJECTIVES: To investigate the immediate effects of textured insoles on balance and gait in people with multiple sclerosis (MS), and to explore any effects after 2 weeks of wear. STUDY DESIGN: Within-session repeated-measures design with an exploratory follow-up period. SETTING: Hospital gait laboratory. PARTICIPANTS: Forty-six individuals with MS (34 females, 12 males), with a mean (SD) age of 49 (7) years, who could walk 100m unassisted or using one stick/crutch. INTERVENTION: Participants were tested wearing three types of insoles in a random order: control (smooth), Texture 1 (Algeos) or Texture 2 (Crocs™). Participants were allocated at random to wear one type of textured insoles for 2 weeks, after which they were retested. MAIN OUTCOME MEASURES: Standing balance (centre of pressure excursions and velocity) was measured with eyes open and eyes closed on a Kistler force platform. Spatio-temporal parameters of gait were measured using a GAITRite system. RESULTS: The textured insoles had no significant immediate effects on balance or gait, apart from an increase in anteroposterior sway range with eyes open for Texture 2 insoles [mean difference 4.5 (95% confidence interval 0.6 to 8.4)mm]. After 2 weeks, balance was not significantly different, but both types of textured insoles showed significant effects on spatio-temporal parameters of gait, with mean stride length increases of 3.5cm (Texture 1) and 5.3cm (Texture 2) when wearing the insoles. CONCLUSIONS: After 2 weeks of wear, there were improvements in spatio-temporal parameters of gait. However, it is unclear whether this was a placebo effect or a learning effect.

A Cochrane review of the evidence for non-surgical interventions for flexible pediatric flat feet.

The pediatric flat foot is a frequent presentation in clinical practice, a common concern to parents and continues to be debated within professional ranks. As an entity, it is confused by varied classifications, the notion of well-intended prevention and unsubstantiated, if common, treatment. The available prevalence estimates are all limited by variable sampling, assessment measures and age groups and hence result in disparate findings (0.6-77.9%). Consistently, flat foot has been found to normally reduce with age. The normal findings of flat foot versus children's age estimates that approximately 45% of preschool children, and 15% of older children (average age 10 years) have flat feet. Few flexible flat feet have been found to be symptomatic. Joint hypermobility and increased weight or obesity may increase flat foot prevalence, independently of age. Most attempts at classification of flat foot morphology include the arch, heel position and foot flexibility. Usual assessment methods are footprint measures, X-rays and visual (scaled) observations. There is no standardized framework from which to evaluate the pediatric flat foot. The pediatric flat foot is often unnecessarily treated, being ill-defined and of uncertain prognosis. Contemporary management of the pediatric flat foot is directed algorithmically within this review, according to pain, age, flexibility; considering gender, weight, and joint hypermobility. When foot orthoses are indicated, inexpensive generic appliances will usually suffice. Customised foot orthoses should be reserved for children with foot pain and arthritis, for unusual morphology, or unresponsive cases. Surgery is rarely indicated for pediatric flat foot (unless rigid) and only at the failure of thorough conservative management. The assessment of the pediatric flatfoot needs to be considered with reference to the epidemiological findings, where there is consensus that pediatric flexible flat foot reduces with age and that most children are asymptomatic. Globally, there is need for a standard by which the pediatric flat foot is assessed classified and managed. Until then, assessment should utilize the available evidence-based management model, the p-FFP Future research needs to evaluate the pediatric flat foot from representative samples, of healthy and known disease-group children prospectively, and using validated assessment instruments. The preliminary findings of the benefits of foot exercises, and discrete investigation into the effects of shoes and footwear use are also warranted.

Evaluation of static and dynamic postural stability in established rheumatoid arthritis: exploratory study.

BACKGROUND: It has been proposed that people with rheumatoid arthritis experience difficulties in postural control and activities of daily living such as walking. The aim of the study is to evaluate postural stability in rheumatoid arthritis patients. METHOD: A convenience sample of 19 rheumatoid arthritis patients (mean duration 13.1+/-9.2 years) were aged matched with a non-rheumatoid group (n=21). Postural stability was measured using a force plate for anterior-posterior and mediolateral centre of pressure excursion for 30s with eyes closed and open. Patients also performed three walks at a self-selected speed and mean temporal-spatial parameters were recorded. FINDINGS: Significant differences were observed between the groups in anterior-posterior centre of pressure excursion during the eyes open task and the eyes closed task (P<0.05). No significant differences were found in the mediolateral centre of pressure excursion during either condition (P>0.05). The rheumatoid group displayed a significantly slower mean walking velocity, double support, cadence and cycle time than the non-rheumatoid group (P<0.05). INTERPRETATION: The results from this study showed that rheumatoid arthritis patients displayed a significantly larger centre of pressure excursion in the anterior-posterior direction during quiet standing, when compared to a non-rheumatoid arthritis control group suggesting that postural control mechanisms such as ankle strategies are impeded by the rheumatoid process.

A clinical trial of specialist footwear for patients with rheumatoid arthritis.

OBJECTIVES: The structural and functional changes in the RA foot often affect the patient's gait and mobility, impacting on the patient's quality of life. Successful management of these foot pathologies and resultant problems can involve the provision of specialist therapeutic footwear. The aim of the study was to evaluate the value of a new footwear design based on patients' opinions compared with a traditional footwear design. METHOD: A total of 80 patients with RA of 5 yrs or more duration, foot deformity, difficulty in being able to obtain suitable retail footwear and self-reported foot pain were recruited. Patients were randomly assigned to either an intervention group (new design) or the control group (traditional design). Patients completed two specific health-related quality of life scales (Foot Health Status Questionnaire and the Foot Function Index) at baseline and after 12 weeks. RESULTS: Only 36 patients completed the trial. Ten refused the footwear outright and 34 withdrew from the study after the footwear was supplied, due to either non-footwear related problems or reasons related to the footwear. Both the specific health-related quality of life scales demonstrated significant improvement from baseline to week 12 with the intervention group (P < 0.05). There was no significant difference in both specific health-related quality of life scales after week 12 with the traditional group (P > 0.05). CONCLUSIONS: Improvement in pain and patient satisfaction with the new design of footwear for patients with RA over the traditional design indicates the importance of patient involvement in the design process and throughout the process of supplying and monitoring the footwear. The fact that the new-design shoe was based on patients' involvement in the design process in a previous study may be the most important factor in its success. In order to meet the clinical goals of this footwear the patients need to wear them, and to achieve this the patients' requirements need to be acknowledged.

A critical review of foot orthoses in the rheumatoid arthritic foot.

Foot orthoses are commonly prescribed by health professionals as a form of intervention for the symptomatic foot in rheumatoid arthritis. However, there is a limited evidence base to support the use of foot orthoses in this patient group. This article provides a critical review of the use of foot orthoses in the management of rheumatoid arthritic foot pathologies. A search was conducted in the Cochrane Controlled Trials Register (current issue of the Cochrane Library), Physiotherapy evidence database (PEDro), Medline, The Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Allied and Complementary Medicine (AMED) and from reference lists in journal articles. The language was restricted to English. Searching of the databases was undertaken between December 2004 and March 2005. The results indicated there is no consensus of opinion on the choice of foot orthoses used for the management of pathology in the rheumatoid foot, although there is strong evidence that foot orthoses do reduce pain and improve functional ability. The type of foot orthoses used ranged from simple cushioned insoles to custom-made rigid cast devices. Methodological issues raised included small sample size and poor use of valid and reliable outcome measures. There is limited evidence pertaining to cost-effectiveness. The results indicated a need for further investigation into the most clinically and cost-effective foot orthoses to prescribe in the management of the rheumatoid arthritic foot. This review highlights the need to identify the various types of foot orthoses that are most effective in the management of the established rheumatoid arthritic foot.

Interventions for preventing and treating stress fractures and stress reactions of bone of the lower limbs in young adults.

BACKGROUND: Stress reaction in bone, which may proceed to a fracture, is a significant problem in military recruits and in athletes, particularly long distance runners. OBJECTIVES: To evaluate the evidence from randomised controlled trials of interventions for prevention or management of lower-limb stress fractures and stress reactions of bone in active young adults. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group Specialised Register (April 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2004), MEDLINE (1966 to September week 1, 2004), EMBASE, CINAHL, Index to UK Theses, reference lists of relevant articles and contacted trialists. SELECTION CRITERIA: Any randomised or quasi-randomised trials evaluating interventions for preventing or treating lower limb stress reactions of bone or stress fractures in active young adults. DATA COLLECTION AND ANALYSIS: We independently selected trials for inclusion, assessed trial quality and extracted data. Only limited data pooling was undertaken. MAIN RESULTS: We included 16 trials. All 13 prevention trials involved military recruits undergoing training. Participants of two of the three treatment trials were military personnel. Ten prevention trials tested the effects of various foot inserts and other footwear modifications. While pooling of data was not possible, the four trials evaluating the use of "shock-absorbing" boot inserts versus control found fewer stress injuries of the bone in their intervention groups. However, the only trial showing a significant benefit lacked important information about trial design. A key issue in several trials was the acceptability, in terms of practicality and comfort, of the boot inserts. Two cluster-randomised prevention trials found no significant effect of leg muscle stretching during warm up before exercise. Pooled data from three small but very different trials testing the use of pneumatic braces in the rehabilitation of tibial stress fractures showed a significant reduction in the time to recommencing full activity (weighted mean difference -33.39 days, 95% confidence interval -44.18 to -22.59 days). These results were highly heterogeneous (I squared = 90%), which is likely to reflect the underlying differences of the trials, including differences in the control group interventions and definitions of outcomes. AUTHORS' CONCLUSIONS: The use of shock absorbing inserts in footwear probably reduces the incidence of stress fractures in military personnel. There is insufficient evidence to determine the best design of such inserts but comfort and tolerability should be considered. Rehabilitation after tibial stress fracture may be aided by the use of pneumatic bracing but more evidence is required to confirm this.

Randomized clinical trial into the impact of rigid foot orthoses on balance parameters in excessively pronated feet.

OBJECTIVE: To evaluate the effect of rigid foot orthoses on balance parameters in participants with clinically diagnosed excessively pronated feet. DESIGN: Randomized clinical trial. SETTING: University biomechanics laboratory. PARTICIPANTS: Thirty female and 20 male healthy participants (mean 23.8+/-2.2 years old) with excessively pronated feet, according to a validated foot classification system were randomly assigned to either a control or intervention group. INTERVENTIONS: Balance testing was performed using the Balance Performance Monitor with an over-the-counter rigid foot orthoses. MAIN OUTCOME MEASURES: Standing balance in the form of mean balance (measures the participants ability to stand with an even load), medial-lateral sway and anterior-posterior sway. All participants were measured while standing bipedally. RESULTS: There was no significant mean difference in balance scores between the control and intervention group at baseline. After four weeks the results demonstrated no significant differences between mean% balance (p >0.05) and anterior-posterior sway (p >0.05). However, there was a reduction with the intervention group in medial-lateral sway (p=0.02). CONCLUSION: The use of foot orthoses in the current study may have improved postural control by stabilizing the rear foot and thus maintaining balance. By the same argument, the benefits of limiting excessive foot pronation may contribute to effective control of internal rotation of the tibia and thereby reduce counter-rotatory motion at the knee and lower leg and maintain balance.

Heel pad stiffness in runners with plantar heel pain.

OBJECTIVE: To evaluate significant differences in heel pad stiffness within a cohort of runners with diagnosed plantar heel pain and to explore the clinical importance of maximum heel pad stiffness values. DESIGN: A cross-sectional design was used to quantify the heel pad stiffness of 166 runners with 33 diagnosed with plantar heel pain. BACKGROUND: Palpation is still widely used to evaluate heel pad stiffness subjectively in everyday clinical practice. However, there is limited quantifiable data pertaining to heel pad stiffness measurements in runners and those with heel pain. METHODS: A portable hand-held device measured force applied by a metal probe, and its displacement into the plantar surface of the heel pad. Non-linear modelling allowed curve coefficients b0 and b1 to be evaluated and was described by an exponential function using a non-linear regression equation. Exploratory analysis was used to describe a single-point approximation for clinical use. RESULTS: An independent t-test demonstrated a statistically significant difference between the curve coefficient b1 (p<0.05). No significant difference was found for coefficient b0 between the plantar heel pain group and the non-plantar heel pain group (p>0.05). Exploratory analysis demonstrated maximum mean stiffness of 3.22 N/mm for the non-plantar heel pain group and 2.87 N/mm for the plantar heel pain-group, an 11% mean difference. CONCLUSION: The results suggested that heel pad stiffness may be associated with plantar heel pain subjects. RELEVANCE: Heel pad stiffness measurements may give a better insight into the mechanical properties of the heel pad in subjects with plantar heel pain.

Development of a clinical instrument to measure heel pad indentation.

OBJECTIVE: To provide an accurate, reliable, non-invasive, portable instrument to measure heel pad indentation in a clinical setting. DESIGN: A novel instrument was applied to assess heel pad indentation. BACKGROUND: For the lack of quantitative biomechanical tools for in vivo assessment, palpation is used to evaluate heel pad stiffness subjectively in everyday clinical practice. Furthermore, previous studies have evaluated heel pad stiffness using non-portable instrumentation. METHODS: Cylindrical probe was attached to an electronic force gauge unit that passed through a Perspex plate for placement on heel pad. Displacement of the plate was connected to a linear variable differential transformer. A laptop PC allowed for portability and storage of data. An exponential curve described the force-displacement data. Ten healthy subjects (mean 21. 7; SD, 1.7 years) were assessed on ten separate occasions. The procedure was standardised for subject position and placement. RESULTS: Accuracy and reliability of each device component was established. An intraclass correlation (2,1) of 0.90 and 0.88 demonstrated curve coefficients b1 and b0 respectively. A paired t-test demonstrated no significant difference between the left and right foot coefficients. CONCLUSION: The results demonstrated that each system component could be measured accurately and reliable. Reproducible results were obtained over separate occasions. The study has described a method to analyse the force-displacement curve. RelevanceThe development of a hand-held device may help the clinician to assess heel pad stiffness in the clinical setting. Heel pad stiffness may be associated in the development of plantar heel pain in athletes.

Vertical ground reaction forces in patients with unilateral plantar heel pain - a pilot study.

Plantar heel pain (PHP) is a foot pathology commonly reported in both athletic and non-athletic populations. The etiology of PHP is complex and identification of risk factors associated with PHP is required to predict who is at increased risk of injury. Excessive plantar heel force and pressures are intrinsic risk factors that may play a contributing role in the development of PHP. Limited research, however, has been undertaken in terms of ground reaction forces associated with PHP. The aim of the study was to test the hypothesis that there were significant differences in the vertical ground reaction forces and loading rates at rearfoot contact between symptomatic and contra-lateral asymptomatic feet in 23 subjects diagnosed with unilateral PHP. The equipment consisted of a portable force plate using a 10-m modular walkway sampled at 200 Hz by an independent observer. Paired t-tests demonstrated no significant difference (P0.05) in the vertical ground reaction forces and loading rates between the symptomatic and contra-lateral asymptomatic feet. The results suggest that single risk factors such as vertical ground reaction force and loading rates do not contribute to PHP. The authors conclude that a model that incorporates a multi-factorial approach to risk factors may lead to a better understanding into the etiology and management of those individuals who suffer from heel pathologies.

The reliability of three techniques for measuring foot position.

The reliability of three commonly used techniques for measuring foot position--valgus index, navicular height, and arch height--was evaluated in a study involving 20 healthy subjects. The results demonstrated significant differences (P < .05) between two observers for all three techniques, although there were no significant differences between two visits for the same observer (P < .05). Secondary analysis demonstrated that navicular height yielded the highest degree of intraobserver and interobserver agreement. The results suggest that there is a wide variation in foot position in the general population, and that measurement error may result from difficulties in defining foot position, techniques used, and instrumentation.

Ultrasonic heel pad thickness measurements: a preliminary study.

The heel pad has an important role in pain-free locomotion due to its shock-attenuation function. Various diagnostic techniques are available to measure heel pad thickness. Ultrasonic measurement of the heel pad is inexpensive, involves no ionizing radiation and is portable, making it an ideal screening technique. Measurement errors may occur between different ultrasonic techniques used to measure heel pad thickness. A new standardized ultrasonic technique was performed on 15 healthy volunteers. The ultrasonic measurements were compared with the measurement obtained from a normal non-weightbearing heel pad thickness ultrasonic assessment. The results demonstrated a significant mean difference (p < 0.001) between the two techniques. The 95% confidence interval of the heel pad thickness difference indicated values between 7.68 and 9.13 mm. These results suggest that a standardized technique reduces the variability of measurement error when using weightbearing ultrasound, allowing a more reproducible diagnostic technique for assessing heel pad function, and improving patient management.

Ankle joint dorsiflexion measurement studies. A review of the literature.

A spectrum of techniques exists to measure ankle joint dorsiflexion range of motion. However, information pertaining to the objective assessment of ankle joint dorsiflexion is controversial. Different study designs make comparisons of studies difficult which leads to measurement error. These errors can be related to the examiner, the subject, or the procedure. This author reviews the sources of measurement inaccuracies within the clinical setting and describes effective interventions used to reduce measurement error.

A reliability study of the universal goniometer, fluid goniometer, and electrogoniometer for the measurement of ankle dorsiflexion.

This study investigated the reliability of three goniometers, the universal, fluid, and electro-goniometers, in the measurement of ankle dorsiflexion. Intra- and interobserver reliability were assessed using 10 healthy volunteers and five observers. A standardized ankle position was used to measure full range of active dorsiflexion. Intraobserver reliability was assessed using one observer over two successive occasions. Interobserver reliability was assessed among five observers over five separate occasions. A one-factor analysis of variance to examine intraobserver reliability demonstrated no significant difference between each of the devices on the two occasions. A multifactorial analysis of variance demonstrated significant differences among observers and again among devices (P < 0.001). Secondary analysis for interdevice reliability demonstrated significant differences among the three devices (p < 0.1). The study suggests that each device cannot be used reliably among observers or be used interchangeably, and clinical judgment based on angular changes of less than 10 degrees are invalid if rigid protocols are not followed.