Coexistence of plantar calcaneal spurs and plantar fascial thickening in individuals with plantar heel pain.

Objectives: To examine associations between plantar calcaneal spurs, plantar fascia thickening and plantar heel pain (PHP), and to determine whether tenderness on palpation of the heel differentiates between these presentations. Methods: Adults aged ⩾50 years registered with four general practices were mailed a Health Survey. Responders reporting foot pain within the last 12 months underwent a detailed clinical assessment. PHP in the past month was documented using a foot manikin. Plantar calcaneal spurs were identified from weight-bearing lateral radiographs and plantar fascia thickening (defined as >4 mm) from ultrasound. Tenderness on palpation of the plantar fascia insertion was documented. Associations between these factors and PHP were explored using generalized estimating equations. Results: Clinical and radiographic data were available from 530 participants (296 women, mean [s.d.] age 64.9 [8.4] years), 117 (22.1%) of whom reported PHP. Plantar calcaneal spurs and plantar fascia thickening were identified in 281 (26.5%) and 501 (47.3%) feet, respectively, but frequently coexisted (n = 217, 20.4%). Isolated plantar calcaneal spurs were rare (n = 64, 6.0%). Participants with PHP were more likely to have a combination of these features compared with those without PHP (odds ratio 2.16, 95% CI 1.24, 3.77, P = 0.007). Tenderness on palpation of the heel was not associated with plantar calcaneal spurs or plantar fascia thickening, either in isolation or in combination, in those with PHP. Conclusion: Plantar calcaneal spurs and plantar fascial thickening are associated with PHP, but frequently coexist. Tenderness on palpation of the heel does not appear to differentiate between clinical presentations of PHP.

Exercise for lower limb osteoarthritis: systematic review incorporating trial sequential analysis and network meta-analysis.

STUDY QUESTION: Which types of exercise intervention are most effective in relieving pain and improving function in people with lower limb osteoarthritis? SUMMARY ANSWER: As of 2002 sufficient evidence had accumulated to show significant benefit of exercise over no exercise. An approach combining exercises to increase strength, flexibility, and aerobic capacity is most likely to be effective for relieving pain and improving function. WHAT IS KNOWN AND WHAT THIS PAPER ADDS: Current international guidelines recommend therapeutic exercise (land or water based) as "core" and effective management of osteoarthritis. Evidence from this first network meta-analysis, largely based on studies in knee osteoarthritis, indicates that an intervention combining strengthening exercises with flexibility and aerobic exercise is most likely to improve outcomes of pain and function. Further trials of exercise versus no exercise are unlikely to overturn this positive result.

Incidence and Progression of Hallux Valgus: A Prospective Cohort Study.

OBJECTIVE: Hallux valgus is a common and disabling condition. The objective of the present study was to identify factors associated with hallux valgus incidence and progression. METHODS: Participants were from a population-based prospective cohort study, the Clinical Assessment Study of the Foot. All adults ages ≥50 years who were registered at 4 general practices in North Staffordshire, UK, were invited to take part in a postal survey at baseline and at 7-year follow-up, which included health questionnaires and self-assessment of hallux valgus using line drawings. RESULTS: Complete baseline and follow-up data were available for 1,482 participants (739 women and 743 men, mean ± SD age 62.9 ± 8.1 years), of whom 450 (30.4%) had hallux valgus in at least 1 foot at baseline. Incident hallux valgus was identified in 207 (20.1%) participants (349 [15.4%] feet) and was associated with baseline age, poorer physical health, foot pain, and wearing shoes with a very narrow toe-box shape between the ages of 20 and 29 years. Hallux valgus progression was identified in 497 (33.6%) participants (719 [24.3%] feet) but was not associated with any baseline factors. CONCLUSION: Incident hallux valgus develops in 1 in 5 adults ages ≥50 years over a 7-year period and is related to age, poorer physical health, foot pain, and previous use of constrictive footwear. Progression occurs in 1 in 3 adults. These findings suggest that changes in first metatarsophalangeal joint alignment may still occur beyond the age of 50 years.

Identification of Radiographic Foot Osteoarthritis: Sensitivity of Views and Features Using the La Trobe Radiographic Atlas.

OBJECTIVE: To compare the sensitivity of alternative case finding approaches for the identification of foot osteoarthritis (OA) based on the La Trobe radiographic atlas. METHODS: This was a cross-sectional study of 533 adults age ≥50 years with foot pain in the past year. Weightbearing dorsoplantar (DP) and lateral radiographs were taken of both feet. The La Trobe radiographic atlas was used to document the presence of osteophytes (OPs) and joint space narrowing (JSN). The prevalence of OA in each joint was documented using both views and features in combination (as recommended in the original atlas), and by using a single view (DP or lateral only) and a single feature (OP or JSN only). RESULTS: Compared to the recommended case definition based on OPs and JSN using both views, a DP-only view identified between 15% and 77% of OA cases, while a lateral-only view identified between 28% and 97% of OA cases. Compared to the recommended case definition of using both features, using only OPs identified between 46% and 94% of OA cases, while using only JSN identified between 19% and 76% of OA cases. CONCLUSION: Applying the La Trobe radiographic atlas but using only 1 radiograph view (DP or lateral) or 1 feature (OP or JSN) in isolation misses a substantial number of OA cases, and the sensitivity of these approaches varies considerably between different foot joints. These findings indicate that, where possible, the atlas should be administered according to the original description to avoid under-ascertainment of radiographic foot OA.

Impairment-targeted exercises for older adults with knee pain: protocol for a proof-of-principle study.

BACKGROUND: Exercise therapy for knee pain and osteoarthritis remains a key element of conservative treatment, recommended in clinical guidelines. Yet systematic reviews point to only modest benefits from exercise interventions.One reason for this might be that clinical trials tend to use a one-size-fits-all approach to exercise, effectively disregarding the details of their participants' clinical presentations. This uncontrolled before-after study (TargET-Knee-Pain) aims to test the principle that exercises targeted at the specific physical impairments of older adults with knee pain may be able to significantly improve those impairments. It is a first step towards testing the effectiveness of this more individually-tailored approach. METHODS/DESIGN: We aim to recruit 60 participants from an existing observational cohort of community-dwelling older adults with knee pain. Participants will all have at least one of the three physical impairments of weak quadriceps, a reduced range of knee flexion and poor standing balance. Each participant will be asked to undertake a programme of exercises, targeted at their particular combination and degree of impairment(s), over the course of twelve weeks. The exercises will be taught and progressed by an experienced physiotherapist, with reference to a "menu" of agreed exercises for each of the impairments, over the course of six fortnightly home visits, alternating with six fortnightly telephone calls. Primary outcome measures will be isometric quadriceps strength, knee flexion range of motion, timed single-leg standing balance and the "Four Balance Test Scale" at 12 weeks. Key secondary outcome measures will be self-reported levels of pain, stiffness and difficulties with day-to-day functional tasks (WOMAC). Outcome measures will be taken at three time-points (baseline, six weeks and twelve weeks) by a study nurse blinded to the exercise status of the participants. DISCUSSION: This study (TargET-Knee-Pain) is the first step towards exploring whether an impairment-targeted approach to exercise prescription for older adults with knee pain may have sufficient efficacy to warrant further testing. If warranted, future randomised clinical trials may compare this approach with more traditional one-size-fits-all exercise approaches. TRIAL REGISTRATION: Current Controlled Trials ISRCTN61638364.

The search for stable prognostic models in multiple imputed data sets.

BACKGROUND: In prognostic studies model instability and missing data can be troubling factors. Proposed methods for handling these situations are bootstrapping (B) and Multiple imputation (MI). The authors examined the influence of these methods on model composition. METHODS: Models were constructed using a cohort of 587 patients consulting between January 2001 and January 2003 with a shoulder problem in general practice in the Netherlands (the Dutch Shoulder Study). Outcome measures were persistent shoulder disability and persistent shoulder pain. Potential predictors included socio-demographic variables, characteristics of the pain problem, physical activity and psychosocial factors. Model composition and performance (calibration and discrimination) were assessed for models using a complete case analysis, MI, bootstrapping or both MI and bootstrapping. RESULTS: Results showed that model composition varied between models as a result of how missing data was handled and that bootstrapping provided additional information on the stability of the selected prognostic model. CONCLUSION: In prognostic modeling missing data needs to be handled by MI and bootstrap model selection is advised in order to provide information on model stability.

Associations Between Calcaneal Enthesophytes and Osteoarthritis of the Hands and Feet.

OBJECTIVE: To examine associations between calcaneal enthesophytes and osteoarthritis (OA) in the hands and feet, and to provide insights into the role of biomechanical and systemic processes in the development of OA. METHODS: Adults ages ≥50 years who were registered with 4 general practices were mailed a Health Survey. Responders reporting foot pain within the last 12 months underwent a detailed assessment, including hand and foot radiographs. Calcaneal enthesophytes (plantar and posterior) and OA features (osteophytes and joint space narrowing) were documented. Associations between enthesophytes and hand and foot OA (including OA phenotypes and OA features at individual joints) were explored using generalized estimating equations, adjusting for age, sex, and body mass index. RESULTS: Data were available from 532 participants (298 women, mean ± SD age 64.9 ± 8.4 years). Calcaneal enthesophytes were not associated with hand OA phenotypes or OA at individual hand joints. In contrast, plantar calcaneal enthesophytes were positively associated with polyarticular foot OA (odds ratio [OR] 1.80 [95% confidence interval (95% CI) 1.02-3.17]). When individual foot joints were examined, posterior enthesophytes were associated with talonavicular joint OA (OR 1.58 [95% CI 1.02-2.44]) and plantar enthesophytes were associated with first metatarsophalangeal joint OA (OR 0.67 [95% CI 0.49-0.98]) and navicular-cuneiform joint OA (OR 2.30 [95% CI 1.40-3.79]). Patterns of association were similar for osteophytes and joint space narrowing. CONCLUSION: Calcaneal enthesophytes are associated with foot OA but not hand OA. The pattern of association is indicative of a local, biomechanical rather than systemic bone-forming process.

Predictors of pain interference and potential gain from intervention in community dwelling adults with joint pain: A prospective cohort study.

INTRODUCTION: There is little research on identifying modifiable risk factors that predict future interference of pain with daily activity in people with joint pain, and the estimation of the corresponding population attributable risk (PAR). The present study therefore investigated modifiable predictors of pain interference and estimated maximum potential gain from intervention in adults with joint pain. METHODS: A population-based cohort aged ≥50 years was recruited from eight general practices in North Staffordshire, UK. Participants (n = 1878) had joint pain at baseline lasting ≥3 months and indicated no pain interference. Adjusted associations of self-reported, potentially modifiable prognostic factors (body mass index, anxiety/depressive symptoms, widespread pain, inadequate joint pain control, physical inactivity, sleep problems, smoking and alcohol intake) with onset of pain interference 3 years later were estimated via Poisson regression, and corresponding PAR estimates were obtained. RESULTS: Inadequate joint-specific pain control, insomnia and infrequent walking were found to be independently significantly associated with the onset of pain interference after 3 years, with associated PARs of 6.3% (95% confidence interval -0.3, 12.4), 7.6% (-0.4, 15.0) and 8.0% (0.1, 15.2), respectively, with only the PAR for infrequent walking deemed statistically significant. The PAR associated with insomnia, infrequent walking and inadequate control of joint pain simultaneously was 20.3% (8.6, 30.4). CONCLUSIONS: There is potential to reduce moderately the onset of pain interference from joint pain in the over-50s if clinical and public health interventions targeted pain management and insomnia, and promoted an active lifestyle. However, most of the onset of significant pain interference in the over-50s, would not be prevented, even assuming that these factors could be eliminated.

Self-Reported Sleep Duration and Quality and Cardiovascular Disease and Mortality: A Dose-Response Meta-Analysis.

Background There is growing evidence that sleep duration and quality may be associated with cardiovascular harm and mortality. Methods and Results We conducted a systematic review, meta-analysis, and spline analysis of prospective cohort studies that evaluate the association between sleep duration and quality and cardiovascular outcomes. We searched MEDLINE and EMBASE for these studies and extracted data from identified studies. We utilized linear and nonlinear dose-response meta-analysis models and used DerSimonian-Laird random-effects meta-analysis models of risk ratios, with inverse variance weighting, and the I2 statistic to quantify heterogeneity. Seventy-four studies including 3 340 684 participants with 242 240 deaths among 2 564 029 participants who reported death events were reviewed. Findings were broadly similar across both linear and nonlinear dose-response models in 30 studies with >1 000 000 participants, and we report results from the linear model. Self-reported duration of sleep >8 hours was associated with a moderate increased risk of all-cause mortality, with risk ratio , 1.14 (1.05-1.25) for 9 hours, risk ratio, 1.30 (1.19-1.42) for 10 hours, and risk ratio, 1.47 (1.33-1.64) for 11 hours. No significant difference was identified for periods of self-reported sleep <7 hours, whereas similar patterns were observed for stroke and cardiovascular disease mortality. Subjective poor sleep quality was associated with coronary heart disease (risk ratio , 1.44; 95% confidence interval, 1.09-1.90), but no difference in mortality and other outcomes. Conclusions Divergence from the recommended 7 to 8 hours of sleep is associated with a higher risk of mortality and cardiovascular events. Longer duration of sleep may be more associated with adverse outcomes compared with shorter sleep durations.

Epidemiology of Shoe Wearing Patterns Over Time in Older Women: Associations With Foot Pain and Hallux Valgus.

BACKGROUND: Foot problems are prevalent in older women and are thought to be associated with footwear. This study examined women's shoe wearing patterns over time and evaluated associations between footwear characteristics and foot pain and hallux valgus. METHODS: Women aged 50-89 years (n = 2,627) completed a survey that included drawings of four toe-box shapes and four heel heights. For each life decade, participants indicated which footwear style they wore most of the time. Foot pain in the past 12 months and hallux valgus were documented by self-report. Logistic regression examined associations between heel height, toe-box shape, foot pain and hallux valgus. RESULTS: Wearing shoes with a high heel and very narrow toe box between the ages of 20 and 29 was common, but decreased to less than 10% by the age of 40. Compared with women who had worn shoes with a very wide toe box, the likelihood of hallux valgus increased in those who had worn shoes with a wide (odds ratio [OR] 1.96, 95% CI 1.03-3.71), narrow (2.39, 1.29-4.42) and very narrow (2.70, 1.46-5.00) toe box between the ages of 20 and 29 and those who wore shoes with a very narrow toe box (1.93, 1.10-3.39) between the ages of 30 and 39. CONCLUSIONS: Women wear shoes with a lower heel and broader toe box as they age. Wearing constrictive footwear between the ages of 20 and 39 may be critical for developing hallux valgus in later life.

Exercise for lower limb osteoarthritis: systematic review incorporating trial sequential analysis and network meta-analysis.

OBJECTIVE: To determine whether there is sufficient evidence to conclude that exercise interventions are more effective than no exercise control and to compare the effectiveness of different exercise interventions in relieving pain and improving function in patients with lower limb osteoarthritis. DATA SOURCES: Nine electronic databases searched from inception to March 2012. STUDY SELECTION: Randomised controlled trials comparing exercise interventions with each other or with no exercise control for adults with knee or hip osteoarthritis. DATA EXTRACTION: Two reviewers evaluated eligibility and methodological quality. Main outcomes extracted were pain intensity and limitation of function. Trial sequential analysis was used to investigate reliability and conclusiveness of available evidence for exercise interventions. Bayesian network meta-analysis was used to combine both direct (within trial) and indirect (between trial) evidence on treatment effectiveness. RESULTS: 60 trials (44 knee, two hip, 14 mixed) covering 12 exercise interventions and with 8218 patients met inclusion criteria. Sequential analysis showed that as of 2002 sufficient evidence had been accrued to show significant benefit of exercise interventions over no exercise control. For pain relief, strengthening, flexibility plus strengthening, flexibility plus strengthening plus aerobic, aquatic strengthening, and aquatic strengthening plus flexibility, exercises were significantly more effective than no exercise control. A combined intervention of strengthening, flexibility, and aerobic exercise was also significantly more effective than no exercise control for improving limitation in function (standardised mean difference -0.63, 95% credible interval -1.16 to -0.10). CONCLUSIONS: As of 2002 sufficient evidence had accumulated to show significant benefit of exercise over no exercise in patients with osteoarthritis, and further trials are unlikely to overturn this result. An approach combining exercises to increase strength, flexibility, and aerobic capacity is likely to be most effective in the management of lower limb osteoarthritis. The evidence is largely from trials in patients with knee osteoarthritis. PROTOCOL REGISTRATION: PROSPERO (www.crd.york.ac.uk/prospero/) No CRD42012002267.

The population prevalence of foot and ankle pain in middle and old age: a systematic review.

A systematic review and meta-analysis of population-based epidemiological studies was undertaken to determine the prevalence of foot and ankle pain in middle and old age. Searches were conducted in the following electronic databases from inception to October 2010: PubMed, EMBASE, AMED, CINAHL, Cochrane, PEDro, and SportDiscus. Full-text English language articles were included if they used population sample frames, cross-sectional design or analysis, and reported prevalence estimates for foot and/or ankle pain in adults aged 45 years and over. Thirty-four articles from 31 studies involving 75,505 participants provided 529 prevalence estimates based on different case definitions and population strata. Random-effects meta-analyses of studies with comparable case definitions provided pooled prevalence estimates, for frequent foot pain of 24% (95% confidence interval 22-25%; n=3; I(2)=46%) and for frequent ankle pain of 15% (95% confidence interval 13-16%; n=2; I(2)=0). Small sample sizes and low response rates in some studies, together with heterogeneous case definitions, limit confident conclusions on the distribution, subtypes, and impact of foot/ankle pain. Narrative synthesis of evidence from existing studies suggested preponderance in females, an age-related increase in prevalence in women but not men, that the toes/forefoot were the most common anatomical sites of pain, and that moderate disability in an aspect of daily life was reported by two-thirds of cases. This review provides estimates of the community burden of foot and ankle pain in middle and old age. By outlining the scale of this clinical problem, these findings can be used to inform health care planning and provision.