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NHMRC Early Career Research Fellow, University of Leeds & University of South Australia


Identifying, preventing and treating foot osteoarthritis

Foot pain can have a major impact on our lives. One in four people aged over 45 years suffers from foot pain, which causes trouble with balance, walking and daily activities. Foot pain is frequently painful enough to stop people walking. Once this occurs, sufferers descend on a spiral of disadvantage characterised not just by painful feet, but all the established negative sequelae of inactivity. It is therefore critical that we gain a better understanding of foot pain and take a proactive stance toward better preventive strategies, early identification of problems and targeted treatments.

One in six adults aged over 50 have foot pain due to osteoarthritis; a condition that destroys the joints of the foot. Like the suspension system in your car, the foot is usually an incredible shock absorber. With foot osteoarthritis, this suspension system becomes damaged; the joints of the foot become overloaded, causing them to break down. The enormous physical demands we place on our feet is often related to the development of foot pain and disability through the destruction of bone and cartilage that help maintain healthy joints. This suggests that, step by step, loading of the joints in the foot may contribute to the initiation and progression of foot osteoarthritis.

New research is combining medical imaging, such as MRI, with computational methods and biomechanical data from patients to precisely identify changes that may be involved in the initiation and progression of osteoarthritis. MRI is capable of visualising early changes in bone, cartilage and soft tissue structures involved in OA and is a powerful tool being used in early-stage OA research. Moreover, investigating the role of biomechanics in foot osteoarthritis is an untapped direction for developing new treatments as foot loading can be modified with conservative options, such as shoes and insoles. This offers promise to delay or arrest disease progression as an attractive alternative to pharmaceutical and surgical interventions, which carry significantly higher risks and side-effects. Restoring foot function and reducing pain through improved treatments will greatly benefit the one in six adults aged over 50 suffering from foot osteoarthritis and help cut the billions dollars spent on osteoarthritis across the globe each year.


Effect of Full-Length Carbon Fiber Insoles on Lower Limb Kinetics in Patients With Midfoot Osteoarthritis: A Pilot Study.

Abstract: We investigated the effects of full-length carbon fiber (FCF) insoles on gait, muscle activity, kinetics, and pain in patients with midfoot osteoarthritis (OA).We enrolled 13 patients with unilateral midfoot OA (mild: Visual Analog Scale [VAS] range, 1-3; moderate, VAS range, 4-7) and healthy controls. All participants were asked to walk under two conditions: with and without FCF insole. The outcome measures were ground reaction force, quantitative gait parameters, electromyography activities and pain severity (VAS).In the patients with moderate midfoot OA, significantly longer gait cycle and higher muscle activity of lower limb during loading-response phase were observed while walking without FCF insoles. In the mild midfoot OA group, there was no significant difference in VAS score (without, 2.0 ± 1.0 vs. with, 2.0 ± 0.5) with FCF insole use. However, significantly reduced VAS score (without, 5.5 ± 1.4 vs. with, 2.0 ± 0.5) and muscle activity of the tibialis anterior and increased muscle activity of gastrocnemius were observed in the moderate midfoot OA group by using an FCF insole (P < 0.05).Full-length carbon fiber insoles can improve pain in individuals with moderate midfoot OA, which might be associated with changes in the kinetics and muscle activities of the lower limb. Taken together, the results of the present study suggest that FCF insoles may be used as a helpful option for midfoot OA.

Pub.: 16 Sep '17, Pinned: 19 Mar '18

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

Abstract: 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.

Pub.: 25 Oct '11, Pinned: 16 Mar '18

A systematic review of radiographic definitions of foot osteoarthritis in population-based studies.

Abstract: To identify the methods used in population-based epidemiological studies to diagnose radiographic foot osteoarthritis (OA) and to estimate the population prevalence of radiographic foot OA.Electronic databases searched included Medline, Embase, CINAHL and Ageline (inception to May 2009). The search strategy combined search terms for radiography, OA, foot, and specific foot joints. Predetermined selection criteria were applied. Data extracted from each paper included: sample population, radiographic views taken, foot joints examined, scoring system used, definition of OA applied, reliability of radiographic scoring and prevalence of radiographic OA in the foot.Titles and abstracts of 1035 papers were reviewed and full-texts of 21 papers were obtained. Fifteen papers met inclusion criteria and a further 12 papers were included after screening references. Radiographic views were frequently not specified (NS) but a combination of antero-posterior (AP) and lateral (Lat) views was most commonly reported. The first metatarsophalangeal (MTP) joint was the most commonly examined joint (n=20, 74%). Nineteen studies (70%) used the Kellgren and Lawrence (K&L) grading system, 95% of which defined OA as K&L grade> or =2. Estimates of the prevalence of radiographic first MTP joint OA (defined as K&L> or =2) in middle-aged to older adults ranged from 6.3 to 39%. Significant statistical heterogeneity prevented pooling of prevalence estimates.There are comparatively few studies examining radiographic foot OA. Existing studies mainly focus on the first MTP joint and use the K&L grading system. Future studies are needed to quantify the prevalence of radiographic OA at the different joint complexes within the foot.

Pub.: 18 May '10, Pinned: 16 Mar '18

The clinical assessment study of the foot (CASF): study protocol for a prospective observational study of foot pain and foot osteoarthritis in the general population.

Abstract: Symptomatic osteoarthritis (OA) affects approximately 10% of adults aged over 60 years. The foot joint complex is commonly affected by OA, yet there is relatively little research into OA of the foot, compared with other frequently affected sites such as the knee and hand. Existing epidemiological studies of foot OA have focussed predominantly on the first metatarsophalangeal joint at the expense of other joints. This three-year prospective population-based observational cohort study will describe the prevalence of symptomatic radiographic foot OA, relate its occurrence to symptoms, examination findings and life-style-factors, describe the natural history of foot OA, and examine how it presents to, and is diagnosed and managed in primary care.All adults aged 50 years and over registered with four general practices in North Staffordshire, UK, will be invited to participate in a postal Health Survey questionnaire. Respondents to the questionnaire who indicate that they have experienced foot pain in the preceding twelve months will be invited to attend a research clinic for a detailed clinical assessment. This assessment will consist of: clinical interview; physical examination; digital photography of both feet and ankles; plain x-rays of both feet, ankles and hands; ultrasound examination of the plantar fascia; anthropometric measurement; and a further self-complete questionnaire. Follow-up will be undertaken in consenting participants by postal questionnaire at 18 months (clinic attenders only) and three years (clinic attenders and survey participants), and also by review of medical records.This three-year prospective epidemiological study will combine survey data, comprehensive clinical, x-ray and ultrasound assessment, and review of primary care records to identify radiographic phenotypes of foot OA in a population of community-dwelling older adults, and describe their impact on symptoms, function and clinical examination findings, and their presentation, diagnosis and management in primary care.

Pub.: 07 Sep '11, Pinned: 16 Mar '18

"Somebody to say 'come on we can sort this'": a qualitative study of primary care consultation among older adults with symptomatic foot osteoarthritis.

Abstract: To examine the experiences of primary care consultation among older adults with symptomatic foot osteoarthritis (OA).Eleven participants (6 women and 5 men) ages 56-80 years who had radiographically confirmed symptomatic foot OA and consulted a general practitioner in the last 12 months for foot pain were purposively sampled. Semistructured interviews explored the nature of the foot problem, help-seeking behaviors, and consultation experiences. Verbatim transcripts were analyzed using interpretative phenomenological analysis.The decision to consult a physician was often the outcome of a complex process influenced by quantitative and qualitative changes in symptoms, difficulty maintaining day-to-day roles and responsibilities and the effect this had on family and work colleagues, and a reluctance to present a fragile or aging self to the outside world. Self-management was commonly negotiated alongside multimorbidities. Upon seeking help, participants often believed they received limited information, they were given a brief or even cursory assessment, and that treatment was focused on the prescription of analgesic drugs.This is the first qualitative study of primary care experiences among patients with symptomatic foot OA. The experience of primary care seldom appeared to move beyond a label of arthritis and an unwelcome emphasis on pharmacologic treatment.

Pub.: 19 Jul '13, Pinned: 16 Mar '18

The association between gout and radiographic hand, knee and foot osteoarthritis: a cross-sectional study.

Abstract: Gout is the most common type of inflammatory arthritis and is largely managed in primary care. It classically affects the first metatarsophalangeal joint and distal peripheral joints, whereas the axial joints are typically spared. The reason for this particular distribution is not well understood, however, it has been suggested that osteoarthritis (OA) may be the key factor. One hypothesis is that there is an association between the disease states of gout and OA as the conditions share common risk factors. The objective of this study was to determine whether there is an association between gout and radiographic osteoarthritis (OA).A cross-sectional study was nested within three observational cohorts of people aged ≥50 years with hand, knee and foot pain. Participants with gout were identified through primary care medical records and each matched by age and gender to four individuals without gout. The presence and severity of radiographic OA were scored using validated atlases. Conditional logistic regression models were used to examine associations between gout and the presence, frequency and severity of radiographic OA at the hand, knee and foot and adjusted for BMI, diuretic use and site of joint pain.Fifty-three people with gout were compared to 211 matched subjects without gout. No statistically significant associations were observed between gout and radiographic hand, knee or foot OA. However, individuals with gout had increased odds of having nodal hand OA (aOR 1.46; 95 % CI 0.61, 3.50), ≥8 hand joints with moderate to severe OA (aOR 3.57; 95 %CI 0.62, 20.45), foot OA (aOR 2.16; 95 % CI 0.66, 7.06), ≥3 foot joints affected (aOR 4.00; 95 % CI 0.99, 16.10) and ≥1 foot joints with severe OA (aOR 1.46; 95 % CI 0.54, 3.94) but decreased odds of tibiofemoral (aOR 0.44; 95 % CI 0.15, 1.29) or patellofemoral (aOR 0.70; 95 % CI 0.22, 2.22) OA in either knee.There was no association between gout and radiographic OA, however, people with gout appeared to be more likely to have small joint OA and less likely to have large joint OA.

Pub.: 18 Apr '16, Pinned: 16 Mar '18

Predictors of response to prefabricated foot orthoses or rocker-sole footwear in individuals with first metatarsophalangeal joint osteoarthritis.

Abstract: Osteoarthritis of the first metatarsophalangeal joint (1st MTPJ OA) is a common and disabling condition commonly managed with footwear and orthotic interventions. The objective of this study was to identify factors associated with a successful treatment response in people with 1st MTPJ OA provided with prefabricated orthoses or rocker-sole footwear as part of a randomised clinical trial.People with 1st MTPJ OA (n = 88) who participated in a randomised trial were allocated to receive prefabricated foot orthoses (n = 47) or rocker-sole footwear (n = 41) and completed a baseline questionnaire including information on demographics, anthropometrics, general health, pain characteristics (including the Foot Health Status Questionnaire [FHSQ] and Foot Function Index [FFI]) and perceptions of the interventions, and a clinical assessment of foot posture, range of motion, radiographic severity and in-shoe plantar pressures. Adherence was documented using diaries. At 12 weeks, participants documented their perception of improvement on a 15-point scale. Those reporting at least moderate improvement on this scale were classified as 'responders'.There were 29 responders (62%) in the orthoses group and 16 responders (39%) in the rocker-sole group. In the orthoses group, responders had greater baseline pain severity while walking, a higher FFI difficulty score, and wore their orthoses more frequently. In the rocker-sole group, responders had a higher FFI stiffness score and greater radiographic severity. However, the accuracy of these variables in identifying responders in each group was modest (62 and 53%, respectively).The response to prefabricated orthoses or rocker-sole footwear in people with 1st MTPJ OA is related to measures of increased pain and disease severity. However, the overall classification accuracy associated with these factors is not sufficient for identifying individuals who are most likely to benefit from these interventions.Australian New Zealand Clinical Trials Registry: ACTRN12613001245785.

Pub.: 14 May '17, Pinned: 16 Mar '18

Interventions for treating osteoarthritis of the big toe joint.

Abstract: Osteoarthritis affecting of the big toe joint of the foot (hallux limitus or rigidus) is a common and painful condition. Although several treatments have been proposed, few have been adequately evaluated.To identify controlled trials evaluating interventions for osteoarthritis of the big toe joint and to determine the optimum intervention(s).Literature searches were conducted across the following electronic databases: CENTRAL; MEDLINE; EMBASE; CINAHL; and PEDro (to 14th January 2010). No language restrictions were applied.Randomised controlled trials, quasi-randomised trials, or controlled clinical trials that assessed treatment outcomes for osteoarthritis of the big toe joint. Participants of any age or gender with osteoarthritis of the big toe joint (defined either radiographically or clinically) were included.Two authors examined the list of titles and abstracts identified by the literature searches. One content area expert and one methodologist independently applied the pre-determined inclusion and exclusion criteria to the full text of identified trials. To minimise error and reduce potential bias, data were extracted independently by two content experts.Only one trial satisfactorily fulfilled the inclusion criteria and was included in this review. This trial evaluated the effectiveness of two physical therapy programs in 20 individuals with osteoarthritis of the big toe joint. Assessment outcomes included pain levels, big toe joint range of motion and plantar flexion strength of the hallux. Mean differences at four weeks follow up were 3.80 points (95% CI 2.74 to 4.86) for self reported pain, 28.30 degrees (95% CI 21.37 to 35.23) for big toe joint range of motion, and 2.80 kg (95% CI 2.13 to 3.47) for muscle strength. Although differences in outcomes between treatment and control groups were reported, the risk of bias was high. The trial failed to employ appropriate randomisation or adequate allocation concealment, used a relatively small sample and incorporated a short follow up (four weeks). No adverse reactions were reported.The reviewed trial presented a high risk of bias, which limited conclusions that could be drawn from the presented data. The inclusion of only one trial indicates the need for more robust randomised controlled trials to determine the efficacy of interventions for this condition.

Pub.: 09 Sep '10, Pinned: 16 Mar '18

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

Abstract: 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.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.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.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.

Pub.: 16 Sep '08, Pinned: 16 Mar '18

Radiographic classification of osteoarthritis in commonly affected joints of the foot.

Abstract: To develop a radiographic atlas for the classification of osteoarthritis (OA) in commonly affected joints of the foot based on observations of osteophytes and joint space narrowing, and to assess its intra- and inter-examiner reliability.Weightbearing dorso-plantar and lateral foot radiographs from people aged over 65 years were examined, and an atlas was developed incorporating characteristic OA features of five foot joints: the first metatarsophalangeal joint, the first cuneo-metatarsal joint (1(st) CMJ), the second cuneo-metatarsal (2(nd) CMJ), the navicular-first cuneiform joint and the talonavicular joint. To assess the reliability of the atlas, two examiners independently rated 50 radiographs on two separate occasions.Observations using the atlas demonstrated moderate to excellent reliability within examiners (percentage agreement from 86 to 99% and weighted kappa from 0.45 to 0.95), and, with the exception of joint space narrowing of the 2(nd) CMJ from the lateral projection, fair to excellent reliability between examiners (percentage agreement from 86 to 97% and weighted kappa from 0.32 to 0.87). Intra-class correlation coefficients for the overall foot OA score (representing the sum of observations for all joints from both feet) ranged between 0.83 and 0.89 for intra-examiner comparisons, and between 0.72 and 0.74 for inter-examiner comparisons.Radiographic features of OA in commonly affected foot joints can be documented with high levels of agreement within examiners and moderate levels of agreement between examiners. Provided single examiners or consensus gradings are used, the atlas appears to be a useful tool to assist in the standardization of foot OA assessment for epidemiological and clinical studies.

Pub.: 13 Jul '07, Pinned: 16 Mar '18

Effectiveness of intra-articular hyaluronan (Synvisc, hylan G-F 20) for the treatment of first metatarsophalangeal joint osteoarthritis: a randomised placebo-controlled trial.

Abstract: To evaluate the effectiveness of a single intra-articular injection of hylan G-F 20 (Synvisc) for symptomatic first metatarsophalangeal joint (MTPJ) osteoarthritis (OA).Participants (n = 151) with symptomatic first MTPJ OA were randomly allocated to receive up to 1 ml intra-articular injection of either hylan G-F 20 or placebo (saline). Participants and assessors were blinded. Outcomes were evaluated at 1, 3 and 6 months after injection. The primary outcome measurement was the foot pain domain of the Foot Health Status Questionnaire (FHSQ) at 3 months. Secondary outcome measurements were foot function assessed via the FHSQ, first MTPJ pain and stiffness, magnitude of symptom change, global satisfaction, health-related quality of life (assessed using the Short-Form-36 version two), first MTPJ dorsiflexion range of motion, hallux plantar flexion strength, use of pain-relieving medication or co-interventions and changes in plantar pressures.No statistically significant differences in foot pain were found between the groups at 3 months. There were few statistically significant differences in the secondary outcome measures. Overall, the incidence of adverse effects was not significantly different between groups.An intra-articular injection of hylan G-F 20 is no more effective than a placebo in reducing symptoms in people with symptomatic first MTPJ OA.Australian New Zealand Clinical Trials Registry: number ACTRN12607000654459.

Pub.: 28 Jul '11, Pinned: 16 Mar '18

Impact of first metatarsophalangeal joint osteoarthritis on health-related quality of life.

Abstract: To determine whether there are differences in the foot-specific and general health-related quality of life (HRQOL) of people with and without first metatarsophalangeal (MTP) joint osteoarthritis (OA).The foot-specific and general HRQOL of 43 participants (mean ± SD age 50.0 ± 10.8 years) with symptomatic radiographically confirmed first MTP joint OA (case group) was compared to an age-, sex-, and body mass index-matched control group. Foot-specific HRQOL was assessed using the Foot Health Status Questionnaire (FHSQ) and general HRQOL was assessed using the Short Form 36 (SF-36) questionnaire. Both questionnaires are validated instruments with 0-100-point domains.All domains of the FHSQ were significantly lower in the case group (mean ± SD foot pain 55.5 ± 22.3 versus 93.0 ± 7.8, foot function 73.8 ± 20.9 versus 96.9 ± 11.5, footwear 39.1 ± 28.7 versus 76.6 ± 27.0, and general foot health 50.2 ± 27.0 versus 89.7 ± 16.0). Further, the SF-36 physical functioning domain was significantly lower (mean ± SD 82.8 ± 14.7 versus 95.2 ± 6.3) in the case group.People with first MTP joint OA experience more foot pain, have greater difficulty performing functional weight-bearing activities, find it more difficult to obtain suitable footwear, and perceive their feet to be in a poorer state of health. Additionally, people with symptomatic first MTP joint OA have greater difficulty performing a broad range of physical tasks and activities.

Pub.: 25 May '12, Pinned: 16 Mar '18

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

Abstract: To explore demographic and clinical factors associated with radiographic severity of first metatarsophalangeal joint osteoarthritis (OA) (First MTPJ OA).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.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.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.

Pub.: 03 Dec '14, Pinned: 16 Mar '18

Effectiveness of Foot Orthoses Versus Rocker-Sole Footwear for First Metatarsophalangeal Joint Osteoarthritis: Randomized Trial.

Abstract: To compare the effectiveness of prefabricated foot orthoses to rocker-sole footwear in reducing foot pain in people with first metatarsophalangeal (MTP) joint osteoarthritis (OA).Participants (n = 102) with first MTP joint OA were randomly allocated to receive individualized, prefabricated foot orthoses or rocker-sole footwear. The primary outcome measure was the pain subscale on the Foot Health Status Questionnaire (FHSQ) at 12 weeks. Secondary outcome measures included the function, footwear, and general foot health subscales of the FHSQ; the Foot Function Index; severity of pain and stiffness at the first MTP joint; perception of global improvement; general health status; use of rescue medication and co-interventions to relieve pain; physical activity; and the frequency of self-reported adverse events.The FHSQ pain subscale scores improved in both groups, but no statistically significant difference between the groups was observed (adjusted mean difference 2.05 points, 95% confidence interval [95% CI] -3.61, 7.71; P = 0.477). However, the footwear group exhibited lower adherence (mean ± SD total hours worn 287 ± 193 versus 448 ± 234; P < 0.001), were less likely to report global improvement in symptoms (39% versus 62%; relative risk [RR] 0.63, 95% CI 0.41, 0.99; P = 0.043), and were more likely to experience adverse events (39% versus 16%; RR 2.47, 95% CI 1.12, 5.44; P = 0.024) compared to the orthoses group.Prefabricated foot orthoses and rocker-sole footwear are similarly effective at reducing foot pain in people with first MTP joint OA. However, prefabricated foot orthoses may be the intervention of choice due to greater adherence and fewer associated adverse events.

Pub.: 08 Dec '15, Pinned: 16 Mar '18

The symptomatic course of foot osteoarthritis phenotypes: an 18-month prospective analysis of community-dwelling older adults.

Abstract: Osteoarthritis (OA) is a heterogeneous disease with symptom progression at the foot unclear. This study investigated the symptomatic course of three pre-defined foot OA phenotypes over an 18-month period.The Clinical Assessment Study of the Foot (CASF) is a community-based cohort of adults aged ≥50 years in North Staffordshire, UK. Participants who reported foot pain in a postal health survey and underwent radiographic assessment were mailed an 18-month follow-up survey. Changes in descriptive and symptomatic outcomes over 18 months were compared across the three phenotypes to determine within-phenotype changes and between-phenotype differences.Of 533 participants at baseline, 478 (89.7%) responded at 18 months. All three phenotypes showed small within-phenotype improvements in mean foot pain severity (scale from 0=no pain to 10=worst pain): no or minimal foot OA (18-month 4.0; mean change -1.15 [95% CI -1.46,-0.83]), isolated first metatarsophalangeal joint (MTPJ) OA (18-month 4.1; mean change -0.60 [95% CI -1.11,-0.10]) and polyarticular foot OA (18-month 5.1; mean change -0.77 [95% CI -1.42,-0.12]). The isolated first MTPJ OA phenotype had an increased likelihood of hallux valgus in the left foot (adjusted odds ratio 2.96 [95% CI 1.23,7.12]) compared to the no or minimal foot OA phenotype.Three foot OA phenotypes showed few descriptive or symptomatic changes over 18 months. Future clinical trials should consider that people recruited with mild-to-moderate symptomatic foot OA appear likely to remain relatively stable with usual care. Longer-term follow-up using additional time-points is required to describe further the natural history of foot OA. This article is protected by copyright. All rights reserved.

Pub.: 30 Dec '17, Pinned: 16 Mar '18

Spectrum of operative treatments and clinical outcomes for atraumatic osteoarthritis of the tarsometatarsal joints.

Abstract: The purpose of this study was to identify subtypes of atraumatic osteoarthritis of the tarsometatarsal joints based on accompanying foot deformities and to determine whether concurrent procedures done for each subtype were effective.The study included 59 patients (67 feet) with atraumatic tarsometatarsal joint osteoarthritis treated with tarsometatarsal fusion. The average patient age was 60.2 years with 40.6 months followup. Patients were evaluated with radiographs, the American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Scale, the Foot Function Index, and the Short Form-36 Health Survey Questionnaire (SF-36).Four main subtypes were identified based on associated foot deformities: pes planovalgus (27), hallux valgus (11), in-situ without deformities (eight), and rockerbottom (five). Plantar-medial closing-wedge resection was used to correct rockerbottom deformity. For pes planovalgus deformity, a medial sliding calcaneal osteotomy was done. Lateral column lengthening with medial sliding calcaneal osteotomy was done for tarsometatarsal osteoarthritis with severe pes planovalgus, and triple arthrodesis was done for rigid pes planovalgus. Tarsometatarsal osteoarthritis with hallux valgus deformity was corrected with the Lapidus procedure. There were 29 complications, most commonly sesamoid pain. The pes planovalgus group showed significant radiographic improvements in four of five parameters measured. AOFAS scores improved from retrospectively assigned preoperative 34.1 points to postoperative 83.9 points. The Foot Function Index showed a high satisfaction rate (86.6%). SF-36 scores averaged 50.6 postoperatively.When feet with atraumatic tarsometatarsal osteoarthritis are classified into four main categories based on associated deformities, appropriate concurrent procedures can be done with high satisfaction and improved function scores. Pes planovalgus feet, in particular, may benefit from concurrent procedures with improved radiographic measures.

Pub.: 04 May '07, Pinned: 16 Mar '18

Plantar pressure distribution in older people with osteoarthritis of the first metatarsophalangeal joint (hallux limitus/rigidus).

Abstract: The purpose of this study was to evaluate differences in dynamic plantar pressure distribution between older people with and without radiographically confirmed osteoarthritis (OA) of the first metatarsophalangeal joint (first MPJ) of the foot. Dynamic plantar pressure recordings using the TekScan MatScan system were obtained during barefoot level walking in 40 older participants; 20 with radiographically confirmed OA of the first MPJ displaying less than 55 degrees of passive dorsiflexion, and 20 with no evidence of OA in the first MPJ displaying greater than 55 degrees of passive dorsiflexion. Group comparisons between the variables maximum force and peak pressure were made for seven different regions underneath the right foot (heel, midfoot, first MPJ, second MPJ, third to fifth MPJs, hallux, and lesser toes). Compared to the control group, participants with OA of the first MPJ exhibited 34% greater maximum force (7.9 +/- 2.5 vs. 5.9 +/- 1.7 kg, p = 0.005) and 23% higher peak pressure (1.6 +/- 0.3 vs. 1.3 +/- 0.3 kg/cm(2), p = 0.001) under the hallux. Similar results were also found under the lesser toes with 43% greater maximum force (5.0 +/- 1.9 vs. 3.5 +/- 1.4 kg; p = 0.006) and 29% higher peak pressure (0.9 +/- 0.2 vs. 0.7 +/- 0.2 kg/cm(2), p = 0.018). No significant differences were found to exist between groups for any other plantar region. These findings indicate that OA of the first MPJ is associated with significant changes in load-bearing function of the foot, which may contribute to the development of secondary pathological changes associated with the condition, such as plantar callus formation and hyperextension of the hallux interphalangeal joint.

Pub.: 18 Jul '08, Pinned: 16 Mar '18

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

Abstract: 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).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.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).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.

Pub.: 02 Dec '09, Pinned: 16 Mar '18

The effect of orthotic treatment on midfoot osteoarthritis assessed using specifically designed patient evaluation questionnaires.

Abstract: Midfoot osteoarthritis (OA) is a degenerative condition of the foot that can be treated non-operatively by the use of orthotics. This prospective study was conducted to determine the effects of custom-made semi-rigid foot orthoses (FOs) and rigid carbon fibre (CF) footplates for the treatment of midfoot OA evaluated using specifically designed questionnaires. Fifty-seven subjects diagnosed with midfoot OA were recruited through a private clinic for inclusion in the study. Subjects were required to complete pre-treatment questionnaires prior to receiving orthotic treatment. All subjects received a pair of custom-made full-length semi-rigid FOs and 36 subjects also received CF footplates that were incorporated into the soles of the shoes worn on the symptomatic feet. Subjects completed post-treatment questionnaires at six weeks, three months and six months after receiving the orthotic treatment. The results demonstrated that there were no significant differences between the results of the subjects who received CF footplates and those who did not. The results of the questionnaires demonstrated that subjects experienced significant improvements in pain, activity levels, walking ability and footwear comfort at all intervals following the orthotic treatment (p < 0.01). Subjects' satisfaction with the appearance of their footwear did not decrease with the orthotic treatment despite needing shoes to fit the FOs and CF footplates. The questionnaires also demonstrated that subjects were generally satisfied with the orthotic treatment for the management of their midfoot OA.

Pub.: 28 Oct '10, Pinned: 16 Mar '18

Midfoot arthritis: diagnosis and treatment.

Abstract: Midfoot arthritis is a challenging problem causing chronic foot pain and impeding daily activity. There is not much written about this subject in literature and is often not well known by orthopaedic surgeons. The primary aim of treatment is to afford pain relief by enhancing midfoot stability and modifying loads sustained at the inflamed joints. The initial treatment is conservative with inserts and orthoses. Surgery, more specifically midfoot arthrodesis, is the next step when conservative management fails. The arthrodesis should be limited to the symptomatic joints but it is often difficult to determine which joints cause the symptoms. With this manuscript we would like to underline the importance of a precise anatomic preoperative diagnosis, review our surgical experience and discuss the different surgical fixation possibilities in midfoot arthrodesis.Between 2006 and 2011 24 patients (26 feet) with midfoot osteoarthritis underwent selective arthrodesis after conservative management had failed. Preoperative examinations, fixation method, complications and outcome were noted.We achieved union in 25 feet. There was one delayed union and one non-union. There were no infections but 3 patients had chronic regional pain syndrome. Reoperation was required in one foot because of non-union and one for symptomatic hardware removal.Midfoot arthrodesis is an effective treatment for osteoarthritis of the joint. Identification of the affected joints is important to stipulate the extensiveness of the arthrodesis.

Pub.: 25 Oct '12, Pinned: 16 Mar '18

Foot orthoses in the treatment of symptomatic midfoot osteoarthritis using clinical and biomechanical outcomes: a randomised feasibility study.

Abstract: This randomised feasibility study aimed to examine the clinical and biomechanical effects of functional foot orthoses (FFOs) in the treatment of midfoot osteoarthritis (OA) and the feasibility of conducting a full randomised controlled trial. Participants with painful, radiographically confirmed midfoot OA were recruited and randomised to receive either FFOs or a sham control orthosis. Feasibility measures included recruitment and attrition rates, practicality of blinding and adherence rates. Clinical outcome measures were: change from baseline to 12 weeks for severity of pain (numerical rating scale), foot function (Manchester Foot Pain and Disability Index) and patient global impression of change scale. To investigate the biomechanical effect of foot orthoses, in-shoe foot kinematics and plantar pressures were evaluated at 12 weeks. Of the 119 participants screened, 37 were randomised and 33 completed the study (FFO = 18, sham = 15). Compliance with foot orthoses and blinding of the intervention was achieved in three quarters of the group. Both groups reported improvements in pain, function and global impression of change; the FFO group reporting greater improvements compared to the sham group. The biomechanical outcomes indicated the FFO group inverted the hindfoot and increased midfoot maximum plantar force compared to the sham group. The present findings suggest FFOs worn over 12 weeks may provide detectable clinical and biomechanical benefits compared to sham orthoses. This feasibility study provides useful clinical, biomechanical and statistical information for the design and implementation of a definitive randomised controlled trial to evaluate the effectiveness of FFOs in treating painful midfoot OA.

Pub.: 29 Apr '15, Pinned: 16 Mar '18

Biomechanical Effects of Prefabricated Foot Orthoses and Rocker-Sole Footwear in Individuals With First Metatarsophalangeal Joint Osteoarthritis.

Abstract: To evaluate the effects of prefabricated foot orthoses and rocker-sole footwear on spatiotemporal parameters, hip and knee kinematics, and plantar pressures in people with first metatarsophalangeal (MTP) joint osteoarthritis (OA).A total of 102 people with first MTP joint OA were randomly allocated to receive prefabricated foot orthoses or rocker-sole footwear. The immediate biomechanical effects of the interventions (compared to usual footwear) were examined using a wearable sensor motion analysis system and an in-shoe plantar pressure measurement system.Spatiotemporal/kinematic and plantar pressure data were available from 88 and 87 participants, respectively. The orthoses had minimal effect on spatiotemporal or kinematic parameters, while the rocker-sole footwear resulted in reduced cadence, percentage of the gait cycle spent in stance phase, and sagittal plane hip range of motion. The orthoses increased peak pressure under the midfoot and lesser toes. Both interventions significantly reduced peak pressure under the first MTP joint, and the rocker-sole shoes also reduced peak pressure under the second through fifth MTP joints and heel. When the effects of the orthoses and rocker-sole shoes were directly compared, there was no difference in peak pressure under the hallux, first MTP joint, or heel; however, the rocker-sole shoes exhibited lower peak pressure under the lesser toes, second through fifth MTP joints, and midfoot.Prefabricated foot orthoses and rocker-sole footwear are effective at reducing peak pressure under the first MTP joint in people with first MTP joint OA, but achieve this through different mechanisms. Further research is required to determine whether these biomechanical changes result in improvements in symptoms.

Pub.: 08 Dec '15, Pinned: 16 Mar '18

Comparability of off the shelf foot orthoses in the redistribution of forces in midfoot osteoarthritis patients.

Abstract: Midfoot osteoarthritis (OA) is more prevalent and strongly associated with pain than previously thought. Excessive mechanical loading of the midfoot structures may contribute to midfoot OA and studies suggest that functional foot orthoses (FFO) may relieve pain through improving function. This exploratory study aimed to evaluate the mechanical effect of two off-the-shelf FFOs, compared to a sham orthosis in people with midfoot OA.Thirty-three participants with radiographically confirmed symptomatic midfoot OA were randomly assigned to wear either a commercially available FFO or a sham orthosis. After wearing their assigned orthoses for 12 weeks, plantar pressure measurements were obtained under shoe-only and assigned orthoses conditions. Participants assigned to the sham, were additionally tested wearing a second type of FFO at the end of trial. Descriptive mean change (±95% confidence intervals) in plantar pressure for each orthoses condition, versus a shoe only baseline condition are presented.Compared to the shoe only conditions, both FFOs decreased hindfoot and forefoot maximum force and peak pressure, whilst increasing maximum force and contact area under the midfoot. The sham orthosis yielded plantar pressures similar to the shoe-only condition.Findings suggest that both types of off-the-shelf FFO may provide mechanical benefit, whilst the sham orthoses produced similar findings to the shoe only condition, indicating appropriate sham properties. This paper provides insight into the mechanisms of action underpinning the use of FFOs and sham orthoses, which can inform future definitive RCTs examining the effect of orthoses on midfoot OA.

Pub.: 28 Jul '16, Pinned: 16 Mar '18

High-resolution ultrasound of the midfoot: sonography is more sensitive than conventional radiography in detection of osteophytes and erosions in inflammatory and non-inflammatory joint disease.

Abstract: This study aimed to compare the diagnostic value of ultrasonography to conventional radiography in detecting osteophytes and erosions in the midfoot joints in patients suffering from inflammatory and non-inflammatory joint disease. Patients with current foot radiographs were included and stratified in two cohorts: inflammatory and non-inflammatory joint disease. The ten midfoot joints of each foot were evaluated by conventional radiography assessing the presence of osteophytes and erosions and by ultrasonography determining the presence of osteophytes, erosions, and joint effusion. Power Doppler activity was scored semi-quantitatively from 0 to 3. A total of 2445 joints in 124 patients (90 with inflammatory joint disease, 34 with non-inflammatory joint disease) were assessed. Ultrasonography detected significantly more osteophytes than conventional radiography (344; 14.1% vs. 13; 0.5%), as well as more erosions (60; 2.5% vs. 3; 0.1%). There was weak agreement between the two modalities (κ-statistic 0.029-0.035). Power Doppler ultrasonography demonstrated no significant difference in hyperperfusion comparing patients with inflammatory joint disease and non-inflammatory joint disease. Ultrasonography of the midfoot is more sensitive than conventional radiography in the detection of osteophytes and erosions in patients suffering from inflammatory and non-inflammatory joint disease. Thus, midfoot ultrasonography may be a useful tool in the diagnosis of joint diseases as rheumatoid arthritis and osteoarthritis.

Pub.: 10 May '17, Pinned: 16 Mar '18

Development and Reliability of a Preliminary Foot Osteoarthritis Magnetic Resonance Imaging Score.

Abstract: Foot osteoarthritis (OA) is very common but underinvestigated musculoskeletal condition and there is little consensus as to common magnetic resonance imaging (MRI) features. The aim of this study was to develop a preliminary foot OA MRI score (FOAMRIS) and evaluate its reliability.This preliminary semiquantitative score included the hindfoot, midfoot, and metatarsophalangeal joints. Joints were scored for joint space narrowing (JSN; 0-3), osteophytes (0-3), joint effusion/synovitis, and bone cysts (present/absent). Erosions and bone marrow lesions (BML) were scored (0-3) and BML were evaluated adjacent to entheses and at sub-tendon sites (present/absent). Additionally, tenosynovitis (0-3) and midfoot ligament pathology (present/absent) were scored. Reliability was evaluated in 15 people with foot pain and MRI-detected OA using 3.0T MRI multisequence protocols, and assessed using ICC as an overall score and per anatomical site.Intrareader agreement (ICC) was generally good to excellent across the foot in joint features (JSN 0.90, osteophytes 0.90, effusion/synovitis 0.46, cysts 0.87), bone features (BML 0.83, erosion 0.66, BML entheses 0.66, BML sub-tendon 0.60) and soft tissue features (tenosynovitis 0.83, ligaments 0.77). Interreader agreement was lower for joint features (JSN 0.43, osteophytes 0.27, effusion/synovitis 0.02, cysts 0.48), bone features (BML 0.68, erosion 0.00, BML entheses 0.34, BML sub-tendon 0.13), and soft tissue features (tenosynovitis 0.35, ligaments 0.33).This preliminary FOAMRIS demonstrated good intrareader reliability and fair interreader reliability when assessing the total feature scores. Further development is required in cohorts with a range of pathologies and to assess the psychometric measurement properties.

Pub.: 03 Jun '17, Pinned: 16 Mar '18

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

Abstract: To derive a multivariable diagnostic model for symptomatic midfoot osteoarthritis (OA).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.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.Brief clinical assessments provided only marginal information for identifying the presence of radiographic midfoot OA among community-dwelling persons with midfoot pain.

Pub.: 21 Jun '15, Pinned: 16 Mar '18

The epidemiology of symptomatic midfoot osteoarthritis in community-dwelling older adults: cross-sectional findings from the Clinical Assessment Study of the Foot.

Abstract: The foot is largely overlooked in calls for better characterisation of clinical phenotypes in osteoarthritis (OA). Yet the midfoot complex in particular has the potential to provide important insights into OA pathogenesis given its central role in lower limb load transmission and alignment. Its recent inclusion in radiographic atlases has paved the way for international studies. In this UK study, we provide the first comprehensive account of the descriptive epidemiology of symptomatic midfoot OA.Participants aged ≥50 years registered with four general practices were recruited via a mailed health survey (n = 5109 responders) and research clinic (n = 560 responders). Symptomatic midfoot OA was defined as midfoot pain in the last 4 weeks, combined with radiographic OA in one or more joints (1st and 2nd cuneometatarsal, navicular first cuneiform and talonavicular joints) graded from weight-bearing dorso-plantar and lateral radiographs using a validated atlas. Prevalence estimates, overall and stratified by age, gender, and socio-economic class, were derived using multiple imputation and weighted logistic regression. Associations between symptomatic midfoot OA and current body mass index, previous injury, history of high-heeled footwear, nodal interphalangeal joint OA and patterns of comorbidity were estimated using binary logistic regression. Healthcare use was summarised.Symptomatic midfoot OA was present in 12.0% (95 % CI: 10.9, 13.2) of the population aged over 50 years. Higher occurrence was observed in females, adults aged over 75 years, and those in intermediate/routine occupational classes. Obesity, previous foot/ankle injury, and pain in other weight-loaded joints, but not high-heeled footwear or nodal interphalangeal joint OA, were associated with increased risk of symptomatic midfoot OA. Persons with symptomatic midfoot OA were also more likely to report multiple non-musculoskeletal comorbidities, including diabetes. In the previous 12 months, the proportions consulting a general practitioner, physiotherapist or podiatrist/chiropodist about foot pain were 46.2%, 18.5% and 47.9% respectively. A total of 64.7% had used oral analgesia in the past month for foot pain (36.1% paracetamol, 31.9% mild/moderate opioids, 27.7% NSAIDs).Our study confirms that symptomatic OA frequently affects the midfoot. The patterns of associations are interpreted as being largely consistent with the role of mechanical factors in its pathogenesis.

Pub.: 15 Jul '15, Pinned: 16 Mar '18

Comparison of in vivo segmental foot motion during walking and step descent in patients with midfoot arthritis and matched asymptomatic control subjects.

Abstract: The purpose of this study was to compare in vivo segmental foot motion during walking and step descent in patients with midfoot arthritis and asymptomatic control subjects. Segmental foot motion during walking and step descent was assessed using a multi-segment foot model in 30 patients with midfoot arthritis and 20 age, gender and BMI matched controls. Peak and total range of motion (ROM), referenced to subtalar neutral, were examined for each of the following dependent variables: 1st metatarso-phalangeal (MTP1) dorsiflexion, 1st metatarsal (MT1) plantarflexion, ankle dorsiflexion, calcaneal eversion and forefoot abduction. The results showed that, compared to level walking, step descent required greater MTP1 dorsiflexion (p<0.01), MPT1 plantarflexion (p<0.01), ankle dorsiflexion (p<0.01), calcaneus eversion (p=0.03) and forefoot abduction (p=0.01), in all subjects. In addition, step descent also necessitated greater MTP1 dorsiflexion (p<0.01), ankle dorsiflexion (p<0.01) and forefoot abduction (p=0.02) excursion compared to walking. Patients with midfoot arthritis responded differently to the step task compared to control subjects in terms of MT1 and calcaneus eversion excursion. During walking, patients with midfoot arthritis showed significantly less MT1 plantarflexion excursion compared to control subjects (p=0.03). However, during step descent, both groups showed similar MT1 plantarflexion excursion. During walking, patients with midfoot arthritis showed similar calcaneus eversion excursion compared to control subjects. However, during step descent, patients with midfoot arthritis showed significantly greater calcaneus eversion excursion compared to control subjects (p=0.03). Independently or in combination, these motions may contribute to articular stress and consequently to symptoms in patients with midfoot arthritis.

Pub.: 05 May '09, Pinned: 16 Mar '18