Summary Report of the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society's Symposium on Targets for Osteoarthritis Research: Part 1: Epidemiology, Pathophysiology, and Current Imaging Approaches.

This first of a 2-part series of articles recounts the key points presented in a collaborative symposium sponsored jointly by the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society with the intent to survey the state of scientific knowledge related to incidence, diagnosis, pathologic mechanisms, and injection treatment options for osteoarthritis (OA) of the foot and ankle. A meeting was held virtually on December 3, 2021. A group of experts were invited to present brief synopses of the current state of knowledge and research in this area. Part 1 overviews areas of epidemiology and pathophysiology, current approaches in imaging, diagnostic and therapeutic injections, and genetics. Opportunities for future research are discussed. The OA scientific community, including funding agencies, academia, industry, and regulatory agencies, must recognize the needs of patients that suffer from arthritis of foot and ankle. The foot and ankle contain a myriad of interrelated joints and tissues that together provide a critical functionality. When this functionality is compromised by OA, significant disability results, yet the foot and ankle are generally understudied by the research community. Level of Evidence: Level V - Review Article/Expert Opinion.

Summary Report of the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society's Symposium on Targets for Osteoarthritis Research: Part 2: Treatment Options.

This second of a 2-part series of articles recounts the key points presented in a collaborative symposium sponsored jointly by the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society with the intent to survey current treatment options for osteoarthritis (OA) of the foot and ankle. A meeting was held virtually on December 10, 2021. A group of experts were invited to present brief synopses of the current state of knowledge and research in this area. Topics were chosen by meeting organizers, who then identified and invited the expert speakers. Part 2 overviews the current treatment options, including orthotics, non-joint destructive procedures, as well as arthroscopies and arthroplasties in ankles and feet. Opportunities for future research are also discussed, such as developments in surgical options for ankle and the first metatarsophalangeal joint. The OA scientific community, including funding agencies, academia, industry, and regulatory agencies, must recognize the importance to patients of addressing the foot and ankle with improved basic, translational, and clinical research. Level of Evidence: Level V, review article/expert opinion.

Pedorthic management of the diabetic foot.

BACKGROUND: Conservative pedorthic management of the diabetic foot has been shown to be an effective method to prevent ulcers, amputations, and re-amputations. This article exhibits why and how pedorthics plays such an important role via modalities such as footwear, shoe modifications, custom foot orthoses, and partial foot prostheses. OBJECTIVE: The objective of this article is to demonstrate how pedorthics has been shown to be an integral part of conservative diabetic foot care. The authors' goal was to educate the reader about the different modalities that are available for use. STUDY DESIGN: This article is based largely on review of previously published research and scholarly articles, augmented by the more than 60 years of pedorthic and orthotic clinical experience of the authors. METHODS: Approximately 60 journal articles and book chapters were reviewed by the authors. Articles were located via online resources such as PubMed as well as the authors' own libraries. RESULTS: It was repeatedly noted that pedorthic modalities such as shoes, foot orthoses, and shoe modifications may be utilized in the treatment and prevention of diabetic foot wounds and other complications. CONCLUSION: Pedorthic devices may be successfully integrated into a comprehensive treatment plan for patients with diabetes and foot ulcers. CLINICAL RELEVANCE: This information is of special interest to those who treat patients with diabetes. The article demonstrates the efficacy of pedorthic intervention through the compilation and review of relevant previously published data.

Shoes, orthoses, and prostheses for partial foot amputation and diabetic foot infection.

Amputations in patients with diabetes, while often preventable, are unfortunately a far too common outcome. The roles of the certified or licensed pedorthist, certified orthotist, and the certified prosthetist should not be undervalued in the prevention of diabetic foot complications (eg, amputations, revisions, and foot infections secondary to skin ulcerations) and in returning the patient a normal, active, and productive lifestyle in the event of an amputation. This article highlights the roles these specialists play in treating patients with partial foot amputation.

Shoe modification and the use of orthoses in the treatment of foot and ankle pathology.

Shoe modification and foot orthoses can play an important role in the nonsurgical management of foot and ankle pathology. Therapeutic footwear may be used to treat patients with diabetes, arthritis, neurologic conditions, traumatic injuries, congenital deformities, and sports-related injuries. These modalities may improve patient gait and increase the level of ambulation. They also may be used to treat acute problems such as plantar fasciitis or metatarsalgia and as preventive tools in patients with diabetic neuropathy. Shoe selection is primarily based on the condition of the patient, the foot shape and type, and the patient's daily activities. Modifications include flares, which provide stability; extended shanks to reduce bending stresses; rocker soles to rock the foot from heel strike to toe-off; and relasting, or reshaping, shoes to accommodate deformities. The four main types of custom orthoses are the accommodative, which cushions and protects the foot; the semi-rigid, which cushions and protects as well as provides support, control, and weight redistribution; the rigid, which offers arch support; and the partial foot prosthesis, which addresses partial amputations and helps protect the foot.

Biomechanics of the double rocker sole shoe: gait kinematics and kinetics.

The use of footwear with contoured soles is common in treatment and care of patients with diabetes; these rocker sole shoes are designed to alleviate loading in key areas on the plantar surface of the foot, reducing pressure in key areas and alleviating pain, and potential soft tissue damage. While investigations of pressure changes have been conducted, no quantitative study to date has addressed the three-dimensional (3D) kinematic and kinetic changes that result from using these shoes. Forty subjects were tested wearing both unmodified and double rocker sole shoes, and the resulting motion patterns were compared to assess change caused by the rocker sole. Overall walking speed remained unchanged throughout testing; slightly increased flexion (<5 degrees ) was apparent at the hip, knee, and ankle during early and mid-stance. These results demonstrate the maintenance of gait function with minimal kinematic changes when using the rocker sole shoe. Investigations of multisegmental foot motion may reveal additional information about the contour effects; analysis of contour variations may also be warranted to investigate the possibility of controlling motion based on rocker sole parameters.

Pedorthic and orthotic management of the diabetic foot.

Research as well as clinical experience has shown that pedorthic and orthotic modalities can be valuable tools in the care of the diabetic foot. The team approach is probably more beneficial to the successful treatment of the diabetic foot than nearly any other problem the physician encounters. Understanding pedorthic and orthotic principles and how to include and use the appropriate clinicians on the team can simplify the patient care process while decreasing complications such as ulcerations and amputations.

Hindfoot containment orthosis for management of bone and soft-tissue defects of the heel.

BACKGROUND: Bone, soft-tissue, and nerve deficits of the weightbearing surface of the foot are frequent sequelae from foot trauma or diabetes mellitus and present challenging treatment issues. Injury to the specialized, shock-absorbing, heel-pad tissue containing spirally arranged fat chambers is particularly difficult to manage. Appropriate footwear modifications and shoe inserts for protection of this skin are essential to the long-term management of bone and soft-tissue defects of the heel. This study evaluated the performance of a new custom total contact foot orthosis (Hindfoot Containment Orthosis, HCO) which was designed to contain the soft tissues of the heel, reduce shear forces, redistribute weightbearing load, and accommodate bone or soft-tissue deformity of the heel. METHODS: Twenty-two patients treated with HCO were retrospectively reviewed. Followup averaged 26 months. The effectiveness of the orthosis was assessed by how well the integrity of the soft tissue was maintained (e.g. the number of ulcerations since dispensing the orthosis), the number of refabrications of the orthosis that were required, and whether or not revision surgery was required. RESULTS: Ten patients had superficial ulcerations. No patient required revision surgery. A total of 62 refabrications of the orthoses in 22 patients were required over a 2-year period. Overall results were good in 17 (77%) patients, fair in four (18%), and poor in one. CONCLUSIONS: The HCO is effective for preservation of soft-tissue integrity of the heel pad after bony or soft-tissue injury. Important factors in achieving success with the HCO are patient compliance and periodic monitoring for refabrication of the orthosis to accommodate skeletal growth, change in foot size or shape, and compression or wear of insert materials.

The Therapeutic Shoe Bill: Medicare coverage for prescription footwear for diabetic patients.

This article describes the extent of coverage and the process of obtaining Medicare coverage for prescription footwear for patients with diabetes and reflects policies in effect as of April 1, 2004.

Effects of the toe-only rocker on gait kinematics and kinetics in able-bodied persons.

Rocker sole shoes are commonly prescribed to diabetic patients with insensate feet. Recent passage of the therapeutic shoe bill has drawn an increased focus on prescription of rehabilitative footwear. The purpose of this work is to investigate the dynamics of lower extremity joints (hip, knee, and ankle) with the application of a toe-only rocker sole shoe under controlled laboratory conditions. Forty (40) normal adults volunteered for gait analysis using controlled baseline and prescription toe-only rocker sole shoes. Three-dimensional motion analysis techniques were used to acquire kinematic and kinetic data using a six camera Vicon 370 motion system and two AMTI force plates. While significant changes from baseline to toe-only rocker were noted in cadence (increased) and stride length (decreased), no significant change in walking speed was observed. The most significant kinematic changes with the application of the toe-only shoe occurred at the ankle and knee in the sagittal plane during stance. The most significant kinetic effects were observed in the hip and knee during swing phase. Changes in power were noted at all joints, mostly in terminal stance. These kinematic and kinetic changes, along with previously studied effects of pressure relief at the metatarsal heads, should aid medical professionals in prescribing prophylactic footwear.

Foot orthoses in rehabilitation--what's new.

Foot orthoses have been effective in the treatment of a variety of sport-related foot conditions. Although their use is well-established in clinical practice, many of the orthoses have not been evaluated in experimental conditions. Of the clinical studies that have examined the biomechanical changes associated with their use, many do not have predictable results. The failure of some studies to find trends for a particular variable does not preclude this variable being affected by the orthoses in an individual patient; rather, it may speak to the highly subject-specific responses with orthotic use. It is important to recognize that foot orthoses cannot be considered independent of a rehabilitation protocol that includes stretching and strengthening-specific therapies, as well as a consideration of training surfaces and training regimes. Additionally, foot orthoses must be considered in concert with the foot-wear recommendation.

Effect of rocker soles on plantar pressures.

OBJECTIVE: To examine the effect of different types of rocker soles on plantar pressures. DESIGN: In-shoe plantar pressures were measured in subjects without deformity with baseline shoes and 3 types of rockers: toe-only, negative heel, and double. SETTING: Medical college. PARTICIPANTS: Forty healthy patients (20 men, 20 women) without foot deformity. INTERVENTIONS: Plantar pressures were recorded over a 2 1/2-hour test period with over 400 steps analyzed for each type of rocker sole. Peak pressures, pressure-time integral (PTI), and sensor contact duration were computed for each step. MAIN OUTCOME MEASURES: Peak plantar pressure PTI, and contact duration were compared for each rocker with a baseline shoe. RESULTS: Significant reduction (P<.01) in peak pressure and PTI were recorded across the forefoot for all 3 rockers. The reduction of pressure at the forefoot was balanced by shifting pressure to the midfoot with the negative heel and toe-only rockers. CONCLUSION: This study lends scientific credence to the prescription of rocker soles for patients who need forefoot pressure reduction, such as in diabetic neuropathy and possible ulceration.