Effect of foot orthoses vs sham insoles on first metatarsophalangeal joint osteoarthritis symptoms: a randomized controlled trial.

OBJECTIVES: To compare contoured foot orthoses to sham flat insoles for first MTP joint OA walking pain. DESIGN: This was a participant- and assessor-blinded, sham-controlled, multi-centre randomized clinical trial set in community-based private practices. Eighty-eight adults aged ≥45 years with symptomatic radiographic first MTP joint OA were randomized to receive contoured foot orthoses (n = 47) or sham flat insoles (n = 41), worn at all times when wearing shoes for 12 weeks. Primary outcome was change in first MTP joint walking pain (11-point numerical rating scale (NRS), 0-10) over 12 weeks. Secondary outcomes included additional first MTP joint and foot pain measures, physical function, quality of life and physical activity. Separate linear regression models for primary and secondary outcomes on treatment group were fit, adjusting for the outcome at baseline and podiatrist. Other measures included adverse events. RESULTS: 88 participants were randomized and 87 (99%) completed the 12-week primary outcome. There was no evidence foot orthoses were superior to sham insoles for reducing pain (mean difference -0.3 NRS units (95% CI -1.2 to 0.6), p = 0.53). Similarly, foot orthoses were not superior to sham on any secondary outcomes. Sensitivity analyses yielded similar results. Adverse events were generally minor and transient. CONCLUSION: Contoured foot orthoses are no more effective than flat sham insoles for the clinical management of first MTP joint OA. Given the dearth of evidence on treatments for first MTP joint OA, further research is needed to identify effective management approaches for this common and debilitating condition.

International Foot and Ankle Osteoarthritis Consortium review and research agenda for diagnosis, epidemiology, burden, outcome assessment and treatment.

OBJECTIVE: To summarise the available evidence relating to the diagnosis, epidemiology, burden, outcome assessment and treatment of foot and ankle osteoarthritis (OA) and to develop an agenda to guide future research. METHOD: Members of the International Foot and Ankle Osteoarthritis Consortium compiled a narrative summary of the literature which formed the basis of an interactive discussion at the Osteoarthritis Research Society International World Congress in 2021, during which a list of 24 research agenda items were generated. Following the meeting, delegates were asked to rank the research agenda items on a 0 to 100 visual analogue rating scale (0 = not at all important to 100 = extremely important). Items scoring a mean of 70 or above were selected for inclusion. RESULTS: Of the 45 delegates who attended the meeting, 31 contributed to the agenda item scoring. Nineteen research agenda items met the required threshold: three related to diagnosis, four to epidemiology, four to burden, three to outcome assessment and five to treatment. CONCLUSIONS: Key knowledge gaps related to foot and ankle OA were identified, and a comprehensive agenda to guide future research planning was developed. Implementation of this agenda will assist in improving the understanding and clinical management of this common and disabling, yet relatively overlooked condition.

Shoe-stiffening inserts for first metatarsophalangeal joint osteoarthritis: a randomised trial.

OBJECTIVE: To evaluate the efficacy of carbon-fibre shoe-stiffening inserts in individuals with first metatarsophalangeal joint osteoarthritis. DESIGN: This was a randomised, sham-controlled, participant- and assessor-blinded trial. One hundred participants with first metatarsophalangeal joint osteoarthritis received rehabilitation therapy and were randomised to receive either carbon fibre shoe-stiffening inserts (n = 49) or sham inserts (n = 51). The primary outcome measure was the Foot Health Status Questionnaire (FHSQ) pain domain assessed at 12 weeks. RESULTS: All 100 randomised participants (mean age 57.5 (SD 10.3) years; 55 (55%) women) were included in the analysis of the primary outcome. At the 12 week primary endpoint, there were 13 drop-outs (7 in the sham insert group and 6 in the shoe-stiffening insert group), giving completion rates of 86 and 88%, respectively. Both groups demonstrated improvements in the FHSQ pain domain score at each follow-up period, and there was a significant between-group difference in favour of the shoe-stiffening insert group (adjusted mean difference of 6.66 points, 95% CI 0.65 to 12.67, P = 0.030). There were no between-group differences for the secondary outcomes, although global improvement was more common in the shoe-stiffening insert group compared to the sham insert group (61 vs 34%, RR 1.73, 95% CI 1.05 to 2.88, P = 0.033; number needed to treat 4, 95% CI 2 to 16). CONCLUSION: Carbon-fibre shoe-stiffening inserts were more effective at reducing foot pain than sham inserts at 12 weeks. These results support the use of shoe-stiffening inserts for the management of this condition, although due to the uncertainty around the effect on the primary outcome, some individuals may not experience a clinically worthwhile improvement.

Characteristics of general practitioner referrals to podiatrists in Australia, 2000-2016.

OBJECTIVE: The aim of the study was to describe patterns of referral to podiatrists by general practitioners (GPs) in Australia. STUDY DESIGN: This is a continuous cross-sectional study of Australian general practice activity. METHODS: We analysed data from the Bettering the Evaluation and Care of Health program, collected from April 2000 to March 2016 inclusive. Data were summarised using descriptive statistics with 95% confidence intervals around point estimates. Multivariate logistic regression was used to identify GP and patient characteristics independently associated with referral. RESULTS: The data set included 1,568,100 encounters, including 5,912 podiatry referrals. Referrals increased from 7.0 to 39.5 per 1000 population over the evaluation period. In multivariate analyses, female GPs were more likely than male GPs to refer, and GPs aged ≥55 years were less likely to refer. Patients referred to podiatrists were more likely to be aged ≥85 years, be Indigenous, be from an English-speaking background and have previously been seen at the practice. The problem generating the highest number of referrals was diabetes. After the introduction of Medicare funding, referred patients were more likely to be women, be aged >45 years, have a healthcare card, be socio-economically disadvantaged and have previously been seen at the practice. CONCLUSIONS: GP referral to podiatrists in Australia increased markedly after the introduction of Medicare funding and appears to be targeted to those with the greatest need. Further research is required to determine whether this policy has improved outcomes and is cost-effective.

Foot structure and lower limb function in individuals with midfoot osteoarthritis: a systematic review.

OBJECTIVE: To determine how foot structure and lower limb function differ between individuals with and without midfoot osteoarthritis (OA). DESIGN: Electronic databases were searched from inception until May 2020. To be eligible, studies needed to (1) include participants with radiographically confirmed midfoot OA, with or without midfoot symptoms, (2) include a control group of participants without radiographic midfoot OA or without midfoot symptoms, and (3) report outcomes of foot structure, alignment, range of motion or any measures of lower limb function during walking. Screening and data extraction were performed by two independent assessors, with disagreements resolved by a third independent assessor. The methodological quality of included studies was assessed using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. RESULTS: A total of 1,550 records were screened by title and abstract and 11 met the inclusion criteria. Quantitative synthesis indicated that individuals who had midfoot OA had a more pronated foot posture, greater first ray mobility, less range of motion in the subtalar joint and first metatarsophalangeal joints, longer central metatarsals and increased peak plantar pressures, pressure time integrals and contact times in the heel and midfoot during walking. Meta-analysis could not be performed as the data were not sufficiently homogenous. CONCLUSIONS: There are several differences in foot structure and lower limb function between individuals with and without midfoot OA. Future research with more consistent case definitions and detailed biomechanical models would further our understanding of potential mechanisms underlying the development of midfoot OA.

Midfoot osteoarthritis: potential phenotypes and their associations with demographic, symptomatic and clinical characteristics.

OBJECTIVE: To investigate the demographic, symptomatic, clinical and structural foot characteristics associated with potential phenotypes of midfoot osteoarthritis (OA). DESIGN: Cross-sectional study of 533 community-dwelling adults aged ≥50 years with foot pain in the past year. Health questionnaires and clinical assessments of symptoms, foot structure and function were undertaken. Potential midfoot OA phenotypes were defined by the pattern of radiographic joint involvement affecting either the medial midfoot (talonavicular, navicular-1st cuneiform, or cuneiform-1st metatarsal joint), central midfoot (2nd cuneiform-metatarsal joint), or both medial and central midfoot joints. Multivariable regression models with generalised estimating equations were used to investigate the associations between patterns of midfoot joint involvement and symptomatic, clinical and structural characteristics compared to those with no or minimal midfoot OA. RESULTS: Of 879 eligible feet, 168 had medial midfoot OA, 103 central midfoot OA, 76 both medial and central midfoot OA and 532 no/minimal OA. Having both medial and central midfoot OA was associated with higher pain scores, dorsally-located midfoot pain (OR 2.54, 95%CI 1.45, 4.45), hallux valgus (OR 1.76, 95%CI 1.02, 3.05), flatter foot posture (ß 0.44, 95%CI 0.12, 0.77), lower medial arch height (ß 0.02, 95%CI 0.01, 0.03) and less subtalar inversion and 1st MTPJ dorsiflexion. Isolated medial midfoot OA and central midfoot OA had few distinguishing clinical characteristics. CONCLUSIONS: Distinct phenotypes of midfoot OA appear challenging to identify, with substantial overlap in symptoms and clinical characteristics. Phenotypic differences in symptoms, foot posture and function were apparent in this study only when both the medial and central midfoot were involved.

Risk factors for lower limb injuries during initial naval training: a prospective study.

INTRODUCTION: This study aimed to identify risk factors associated with the development of common lower limb injuries during initial defence training in naval recruits who were enrolled in a randomised trial. METHODS: Three-hundred and six naval recruits were randomly allocated flat insoles (n=153) or foot orthoses (n=153) while undertaking 11 weeks of initial training. Participant characteristics (including anthropometrics, general health, physical activity, fitness and foot characteristics) were collected at the baseline assessment and injuries were documented prospectively. Injury was defined as the combined incidence of participants with medial tibial stress syndrome, patellofemoral pain, Achilles tendinopathy and plantar fasciitis/plantar heel pain throughout the 11 weeks of training. A discriminant function analysis was used to explore the ability of baseline measures to predict injury. RESULTS: Overall, 67 (21.9%) participants developed an injury. Discriminant function analysis revealed that participants who sustained an injury were slightly younger (mean 21.4±SD 4.1 vs 22.5±5.0 years) and were less likely to be allocated to the foot orthosis group (40% vs 53%) compared with those who remained uninjured. The accuracy of these baseline variables to predict injury was moderate (78.1%). CONCLUSIONS: Lower limb injury was not accurately predicted from health questionnaires, fitness results and clinical assessments in naval recruits undertaking initial defence training. However, although not reaching statistical significance, the use of foot orthoses may be protective against common lower limb injuries. TRIAL REGISTRATION NUMBER: ACTRN12615000024549; Post-results.

Longitudinal association between foot and ankle symptoms and worsening of symptomatic radiographic knee osteoarthritis: data from the osteoarthritis initiative.

OBJECTIVE: To assess whether foot and/or ankle symptoms are associated with an increased risk of worsening of knee pain and radiographic change in people with knee osteoarthritis (OA). METHODS: The presence and laterality of foot/ankle symptoms were recorded at baseline in 1368 participants from the Osteoarthritis Initiative (OAI) with symptomatic radiographic knee OA. Knee pain severity (measured using the Western Ontario and McMaster Universities Osteoarthritis Index pain subscale) and minimum medial tibiofemoral joint space (minJSW) width measured on X-ray were assessed yearly over the subsequent 4 years. Associations between foot/ankle symptoms and worsening of (1) knee pain, and (2) both knee pain and minJSW (i.e., symptomatic radiographic knee OA) were assessed using logistic regression. RESULTS: Foot/ankle symptoms in either foot/ankle significantly increased the odds of knee pain worsening (adjusted OR 1.54, 95% CI 1.25 to 1.91). Laterality analysis showed ipsilateral (adjusted OR 1.50, 95% CI 1.07 to 2.10), contralateral (adjusted OR 1.44, 95% CI 1.02 to 2.06) and bilateral foot/ankle symptoms (adjusted OR 1.61, 95% CI 1.22 to 2.13) were all associated with knee pain worsening in the follow up period. There was no association between foot/ankle symptoms and worsening of symptomatic radiographic knee OA. CONCLUSION: The presence of foot/ankle symptoms in people with symptomatic radiographic knee OA was associated with increased risk of knee pain worsening, but not worsening of symptomatic radiographic knee OA, over the subsequent 4 years. Future studies should investigate whether treatment of foot/ankle symptoms reduces the risk of knee pain worsening in people with knee OA.

The relationship between foot and ankle symptoms and risk of developing knee osteoarthritis: data from the osteoarthritis initiative.

OBJECTIVE: To investigate whether foot and/or ankle symptoms increase the risk of developing (1) knee symptoms and (2) symptomatic radiographic knee osteoarthritis (OA). DESIGN: 1020 Osteoarthritis Initiative (OAI) participants who were at-risk of knee OA, but were without knee symptoms or radiographic knee OA, were investigated. Participants indicated the presence and laterality of foot/ankle symptoms at baseline. The main outcome was development of knee symptoms (pain, aching or stiffness in and around the knee on most days of the month for at least 1 month in the past year). A secondary outcome was development of symptomatic radiographic knee OA (symptoms plus Kellgren and Lawrence [KL] grade ≥2), over the subsequent 4 years. Associations between foot/ankle symptoms and study outcomes were assessed by logistic regression models. RESULTS: Foot/ankle symptoms in either or both feet significantly increased the odds of developing knee symptoms (adjusted odds ratio (OR) 1.55, 95% confidence interval (CI) 1.10 to 2.19), and developing symptomatic radiographic knee OA (adjusted OR 3.28, 95% CI 1.69 to 6.37). Based on laterality, contralateral foot/ankle symptoms were associated with developing both knee symptoms (adjusted OR 1.68, 95% CI 1.05 to 2.68) and symptomatic radiographic knee OA (adjusted OR 3.08, 95% CI 1.06 to 8.98), whilst bilateral foot/ankle symptoms were associated with developing symptomatic radiographic knee OA (adjusted OR 4.02, 95% CI 1.76 to 9.17). CONCLUSION: In individuals at-risk of knee OA, the presence of contralateral foot/ankle symptoms in particular increases risk of developing both knee symptoms and symptomatic radiographic knee OA.

Running retraining to treat lower limb injuries: a mixed-methods study of current evidence synthesised with expert opinion.

IMPORTANCE: Running-related injuries are highly prevalent. OBJECTIVE: Synthesise published evidence with international expert opinion on the use of running retraining when treating lower limb injuries. DESIGN: Mixed methods. METHODS: A systematic review of clinical and biomechanical findings related to running retraining interventions were synthesised and combined with semistructured interviews with 16 international experts covering clinical reasoning related to the implementation of running retraining. RESULTS: Limited evidence supports the effectiveness of transition from rearfoot to forefoot or midfoot strike and increase step rate or altering proximal mechanics in individuals with anterior exertional lower leg pain; and visual and verbal feedback to reduce hip adduction in females with patellofemoral pain. Despite the paucity of clinical evidence, experts recommended running retraining for: iliotibial band syndrome; plantar fasciopathy (fasciitis); Achilles, patellar, proximal hamstring and gluteal tendinopathy; calf pain; and medial tibial stress syndrome. Tailoring approaches to each injury and individual was recommended to optimise outcomes. Substantial evidence exists for the immediate biomechanical effects of running retraining interventions (46 studies), including evaluation of step rate and strike pattern manipulation, strategies to alter proximal kinematics and cues to reduce impact loading variables. SUMMARY AND RELEVANCE: Our synthesis of published evidence related to clinical outcomes and biomechanical effects with expert opinion indicates running retraining warrants consideration in the treatment of lower limb injuries in clinical practice.

Clinical diagnosis of symptomatic midfoot osteoarthritis: cross-sectional findings from the Clinical Assessment Study of the Foot.

OBJECTIVE: To derive a multivariable diagnostic model for symptomatic midfoot osteoarthritis (OA). METHODS: Information on potential risk factors and clinical manifestations of symptomatic midfoot OA was collected using a health survey and standardised clinical examination of a population-based sample of 274 adults aged ≥50 years with midfoot pain. Following univariable analysis, random intercept multi-level logistic regression modelling that accounted for clustered data was used to identify the presence of midfoot OA independently scored on plain radiographs (dorso-plantar and lateral views), and defined as a score of ≥2 for osteophytes or joint space narrowing in at least one of four joints (first and second cuneometatarsal, navicular-first cuneiform and talonavicular joints). Model performance was summarised using the calibration slope and area under the curve (AUC). Internal validation and sensitivity analyses explored model over-fitting and certain assumptions. RESULTS: Compared to persons with midfoot pain only, symptomatic midfoot OA was associated with measures of static foot posture and range-of-motion at subtalar and ankle joints. Arch Index was the only retained clinical variable in a model containing age, gender and body mass index. The final model was poorly calibrated (calibration slope, 0.64, 95% CI: 0.39, 0.89) and discrimination was fair-to-poor (AUC, 0.64, 95% CI: 0.58, 0.70). Final model sensitivity and specificity were 29.9% (95% CI: 22.7, 38.0) and 87.5% (95% CI: 82.9, 91.3), respectively. Bootstrapping revealed the model to be over-optimistic and performance was not improved using continuous predictors. CONCLUSIONS: Brief clinical assessments provided only marginal information for identifying the presence of radiographic midfoot OA among community-dwelling persons with midfoot pain.

Demographic and clinical factors associated with radiographic severity of first metatarsophalangeal joint osteoarthritis: cross-sectional findings from the Clinical Assessment Study of the Foot.

OBJECTIVE: To explore demographic and clinical factors associated with radiographic severity of first metatarsophalangeal joint osteoarthritis (OA) (First MTPJ OA). DESIGN: Adults aged ≥50 years registered with four general practices were mailed a Health Survey. Responders reporting foot pain within the last 12 months were invited to undergo a clinical assessment and weight-bearing dorso-plantar and lateral radiographs of both feet. Radiographic first MTPJ OA in the most severely affected foot was graded into four categories using a validated atlas. Differences in selected demographic and clinical factors were explored across the four radiographic severity subgroups using analysis of variance (ANOVA) and ordinal regression. RESULTS: Clinical and radiographic data were available from 517 participants, categorised as having no (n = 105), mild (n = 228), moderate (n = 122) or severe (n = 62) first MTPJ OA. Increased radiographic severity was associated with older age and lower educational attainment. After adjusting for age, increased radiographic first MTPJ OA severity was significantly associated with an increased prevalence of dorsal hallux and first MTPJ pain, hallux valgus, first interphalangeal joint (IPJ) hyperextension, keratotic lesions on the dorsal aspect of the hallux and first MTPJ, decreased first MTPJ dorsiflexion, ankle/subtalar joint eversion and ankle joint dorsiflexion range of motion, and a trend towards a more pronated foot posture. CONCLUSIONS: This cross-sectional study has identified several dose-response associations between radiographic severity of first MTPJ OA and a range of demographic and clinical factors. These findings highlight the progressive nature of first MTPJ OA and provide insights into the spectrum of presentation of the condition in clinical practice.

Development of a diagnostic rule for identifying radiographic osteoarthritis in people with first metatarsophalangeal joint pain.

OBJECTIVE: To develop a diagnostic rule for the identification of radiographic osteoarthritis (OA) of the first metatarsophalangeal joint (MTPJ) in people with first MTPJ pain. DESIGN: Symptoms and clinical observations were documented in 181 people with first MTPJ pain, and the presence of OA was confirmed using plain film radiography. Diagnostic test statistics were calculated to assess the ability of symptoms and clinical observations to identify radiographic OA. Multivariate logistic regression was used to develop two diagnostic models: a statistically optimal model and a simplified clinical model. RESULTS: Multivariate logistic regression identified pain duration greater than 25 months, the presence of a dorsal exostosis, hard-end feel, crepitus and less than 64° of first MTPJ dorsiflexion to be significantly associated with radiographic OA. The statistically optimal model and clinical model performed similarly, with the areas under the receiver operating characteristics curves being 0.87 (95% confidence interval [CI] 0.81-0.93) and 0.87 (95% CI 0.80-0.93), respectively, and the percentage of cases correctly classified being 86.2 and 85.6, respectively. A cut-off score of ≥3 using the clinical model resulted in a sensitivity of 88%, specificity of 71%, accuracy of 84%, positive likelihood ratio of 3.07 and negative likelihood ratio of 0.17. CONCLUSIONS: In people with first MTPJ pain, a model consisting of five clinical observations can accurately identify the presence or absence of radiographic OA. The application of this diagnostic rule may assist clinical decision making and potentially reduce the need for referral for radiographs.

The immediate effects of foot orthoses on functional performance in individuals with patellofemoral pain syndrome.

OBJECTIVE: Patellofemoral pain syndrome (PFPS) often results in reduced functional performance. There is growing evidence for the use of foot orthoses to treat this multifactorial condition. In this study, the immediate effects of foot orthoses on functional performance and the association of foot posture and footwear with improvements in function were evaluated. METHODS: Fifty-two individuals with PFPS (18-35 years) were prescribed prefabricated foot orthoses (Vasyli Pro; Vasyli International, Labrador, Australia). Functional outcome measures evaluated included the change in (1) pain and (2) ease of a single-leg squat on a five-point Likert scale, and change in the number of (3) pain-free step downs and (4) single-leg rises from sitting. The association of foot posture using the Foot Posture Index, navicular drop and calcaneal angle relative to subtalar joint neutral; and the footwear motion control properties scale score with improved function were evaluated using Spearman's ρ statistics. RESULTS: Prefabricated foot orthoses produced significant improvements (p<0.05) for all functional outcome measures. A more pronated foot type and poorer footwear motion control properties were found to be associated with reduced pain during the single-leg squat and improvements in the number of pain-free single-leg rises from sitting when wearing foot orthoses. In addition, a more pronated foot type was also found to be associated with improved ease of completing a single-leg squat when wearing foot orthoses. CONCLUSION: Prefabricated foot orthoses provide immediate improvements in functional performance, and these improvements are associated with a more pronated foot type and poorer footwear motion control properties.

Greater peak rearfoot eversion predicts foot orthoses efficacy in individuals with patellofemoral pain syndrome.

OBJECTIVE: There is growing evidence for the provision of foot orthoses when treating individuals with patellofemoral pain syndrome (PFPS), and prescription is frequently based on the assessment of foot posture/function. However, evaluation of the link between abnormal foot posture/function and foot orthoses outcomes has previously been limited to static alignment measures and has produced inconsistent findings. In this study, the ability of baseline foot kinematics associated with pronation to predict marked improvement 12 weeks following foot orthoses prescription in individuals with PFPS was evaluated. METHODS: 26 individuals with PFPS were issued with prefabricated foot orthoses, and patient-reported level of improvement was documented at 12 weeks. Potential predictors of marked improvement at 12 weeks were measured during walking at baseline and included forefoot dorsiflexion and abduction, and rearfoot eversion. RESULTS: Of the 25 participants who completed the study, seven (28%) reported marked improvement with the foot orthoses after 12 weeks. Discriminant function analysis revealed a greater peak rearfoot eversion to be the only significant independent predictor of marked improvement. CONCLUSION: These findings provide preliminary evidence that greater peak rearfoot eversion is predictive of marked improvement 12 weeks following prefabricated foot orthoses prescription in individuals with PFPS. Therefore, foot orthoses may be most effective in the subgroup of people with PFPS and increased dynamic foot pronation.

Foot structure and function in older people with radiographic osteoarthritis of the medial midfoot.

OBJECTIVE: To investigate whether foot structure and dynamic foot function differ between older people with and without radiographically confirmed osteoarthritis (OA) of the talo-navicular joint (TNJ) and navicular-first cuneiform joint (N1(st)CJ). METHOD: Dorso-plantar and lateral weighbearing foot radiographs (right feet) were obtained from 205 older people aged 61-94 years, and the presence of OA in the TNJ and N1(st)CJ was determined using a standardized atlas. Foot structure was assessed using a clinical measure (the arch index [AI]) and two radiographic measures (calcaneal inclination angle [CIA] and calcaneal-first metatarsal angle [C1MA]). Dynamic plantar pressure assessment during walking was undertaken using the Tekscan MatScan system. RESULTS: Thirty-five participants exhibited radiographic OA in the TNJ and N1(st)CJ. There were no significant differences between the groups in relation to age, sex, weight or walking velocity. Compared to those without OA in these joints, those with OA had significantly flatter feet, as evidenced by larger AI (0.26+/-0.05 vs 0.25+/-0.05, P=0.02), smaller CIA (18.5+/-6.3 vs 21.3+/-5.4 degrees, P<0.01) and larger C1MA (137.0+/-9.3 vs 132.4+/-8.0 degrees, P<0.01), and exhibited significantly higher maximum forces in the midfoot (15.2+/-7.3 vs 11.2+/-7.0 kg, P<0.01; 36% increase). CONCLUSION: Older people with radiographic OA of the TNJ and N1(st)CJ exhibit flatter feet and increased loading of the plantar midfoot when walking. Excessive loading of the midfoot may predispose to OA by increasing dorsal compressive forces, although prospective studies are required to confirm whether this relationship is causal.

Radiographic evaluation of foot osteoarthritis: sensitivity of radiographic variables and relationship to symptoms.

OBJECTIVES: To evaluate a radiographic atlas for grading foot osteoarthritis (OA) in relation to the relative sensitivity of different radiographic and views and features, and to examine the relationship between radiographic OA and foot symptoms. METHODS: Weightbearing dorso-plantar (DP) and lateral foot radiographs were obtained from 197 people (126 women and 71 men) aged 62-94 years (mean age 75.9, standard deviation [SD] 6.6). The prevalence of OA in five joints (the first metatarsophalangeal joint [1st MPJ], the first cuneo-metatarsal joint [1st CMJ], the second cuneo-metatarsal joint [2nd CMJ], the navicular-first cuneiform joint [N1st CJ] and the talo-navicular joint [TNJ]) was then determined using both views in combination (as recommended in the atlas), or by using either view in isolation. Associations between radiographic OA in individual foot joints and symptoms were then explored. RESULTS: Joint-specific prevalence of OA using both DP and lateral views was 1st MPJ (42.4%), 1st CMJ (22.6%), 2nd CMJ (60.2%), N1st CJ (39.1%) and TNJ (32.7%). Using only the DP view detected almost all cases of 1st MPJ OA (94.6%), however, the sensitivity was lower for the other joints (31.0-60.7%). Using only the lateral view detected almost all cases of OA (83.8 to 86.9%), with the exception of the 1st MPJ and 1st CMJ (50.9% and 60.7%, respectively). Using either osteophytes (OP) alone or joint space narrowing (JSN) alone showed low sensitivity for all joints (14.3-63.0%), with the exception of OP alone in the DP view for the 1st MPJ and JSN in the lateral view for the 2nd CMJ (83.8% and 84.0%, respectively). Radiographic OA in individual foot joints and the total number of joints affected were both moderately associated with foot symptoms. CONCLUSION: Epidemiological and clinical studies should incorporate observation of both OP and JSN from both DP and lateral views to determine the presence of OA in the foot, as the number of cases detected is reduced if only one radiographic feature or view is used. Radiographic foot OA is common in older people and is moderately associated with foot symptoms.

Factors associated with prevalent and incident foot pain: data from the Tasmanian Older Adult Cohort Study.

OBJECTIVES: To describe factors associated with prevalent and incident foot pain in a population-based cohort of older adults (n = 1092). STUDY DESIGN: Longitudinal observational study. MAIN OUTCOME MEASURES: Prevalent foot pain, incident foot pain after 5 years. METHODS: Potential correlates included demographic factors, anthropometry, leg strength, metabolic factors, steps per day (using pedometer), pain at 6 other sites, and psychological wellbeing. Data were analysed using log binomial models. RESULTS: Participants were aged 50-80 years (mean 63 years), 49% male, mean body mass index (BMI) 27.8 ± 4.7 at baseline. The prevalence of foot pain at baseline was 38% and the incidence of new pain over 5 years was 20%. BMI, pain at other sites (neck, hands, knees, pain at three or more sites), and poorer psychological wellbeing were independently associated with baseline foot pain. Baseline BMI and pain in the neck, hands, and knees were independently associated with incident foot pain; but change in weight or BMI, total number of painful joints and psychological wellbeing were not. Self-reported diabetes and cigarette smoking were not associated with prevalent or incident foot pain. CONCLUSIONS: This study demonstrates that greater body weight and joint pain at multiple sites were consistently associated with prevalent foot pain and predict incident foot pain. Addressing excess body mass and taking a global approach to the treatment of pain may reduce the prevalence and incidence of foot pain in older adults.

Factors associated with chronic plantar heel pain: a systematic review.

Chronic plantar heel pain (CPHP) is one of the most common soft tissue disorders of the foot, yet its aetiology is poorly understood. The purpose of this systematic review was to examine the association between CPHP and the various aetiological factors reported in the literature. Seven electronic databases and the reference lists of key articles were searched in August 2005. The resulting list of articles was assessed by two independent reviewers according to pre-determined selection criteria and a final list of articles for review was created. The methodological quality of the included articles was assessed and the evidence presented in each of the articles was descriptively analysed. From the 16 included articles, body mass index in a non-athletic population and the presence of calcaneal spur were the two factors found to have an association with CPHP. Increased weight in a non athletic population, increased age, decreased ankle dorsiflexion, decreased first metatarsophalangeal joint extension and prolonged standing all demonstrated some evidence of an association with CPHP. Evidence for static foot posture and dynamic foot motion was inconclusive and height, weight and BMI in an athletic population were not associated with CPHP. The findings of this review should be used to guide the focus of prospective cohort studies, the results of which would ultimately provide a list of risk factors for CPHP. Such a list is essential in the development of new and improved preventative and treatment strategies for CPHP.

The contribution of foot problems to mobility impairment and falls in community-dwelling older people.

OBJECTIVES: To investigate the relationship between foot problems, balance, and functional ability in community-dwelling older people and to determine whether older people with a history of multiple falls exhibit greater foot impairment than those who have not fallen or who have fallen once only. DESIGN: A cross-sectional, retrospective study. SETTING: Falls and Balance Laboratory, Royal North Shore Hospital, Sydney, Australia. PARTICIPANTS: One hundred thirty-five community-dwelling men and women age 75 to 93 (mean age +/- standard deviation, 79.8 +/- 4.1). MEASURES: Foot problem score; postural sway; coordinated stability; stair ascent and descent; an alternate stepping test; timed 6-meter walk; and tests of vision, sensation, strength, and reaction time. RESULTS: Eighty-seven percent of the sample had at least one foot problem. Women had a significantly higher foot problem score than did men. The foot problem score was significantly associated with performance on the coordinated stability test, stair ascent and descent, alternate stepping test, and timed 6-meter walk. Multiple regression analyses revealed that the foot problem score was a significant independent predictor of performance in the coordinated stability test, stair ascent and descent, and the alternate stepping test. Subjects with a history of multiple falls had a significantly higher foot problem score than did those who had not fallen or who had fallen once only, but the prevalence of individual foot conditions or the presence of foot pain did not differ between these groups. CONCLUSIONS: Foot problems are common in older people and are associated with impaired balance and performance in functional tests. Furthermore, older people with a history of multiple falls have greater foot impairment than non- or once-only fallers. These findings provide further evidence that foot problems are a falls risk factor and suggest that the cumulative effect of multiple foot problems is more important in increasing falls risk than the presence or absence of individual foot conditions.