The association between body composition and foot structure and function: a systematic review

The aim of this systematic review was to investigate the relationship between body composition and foot structure and function. Six electronic databases (Ovid MEDLINE, Ovid EMBASE, Ovid AMED, CINAHL, Scopus and The Cochrane Library) and reference lists from relevant papers were searched on 2 September 2013. Sixteen papers that reported on the association between body composition and foot structure and function met our inclusion criteria and were reviewed. The evidence indicates that obesity is strongly associated with planus (low‐arched) foot posture, pronated dynamic foot function and increased plantar pressures when walking. However, there is limited evidence to support an association between other body composition measures, such as fat mass, with foot structure or function.     

Prevention of foot ulcers in the at‐risk patient with diabetes: a systematic review

Prevention of foot ulcers in patients with diabetes is important to help reduce the substantial burden on both patient and health resources. A comprehensive analysis of reported interventions is needed to better inform healthcare professionals about effective prevention. The aim of this systematic review is to investigate the effectiveness of interventions to help prevent both first and recurrent foot ulcers in persons with diabetes who are at risk for this complication. We searched the available medical scientific literature in PubMed, EMBASE, CINAHL, and the Cochrane databases for original research studies on preventative interventions. We screened trial registries for additional studies not found in our search and unpublished trials. Two independent reviewers assessed data from controlled studies for methodological quality, and extracted and presented this in evidence and risk of bias tables. From the 13,490 records screened, 35 controlled studies and 46 non‐controlled studies were included. Few controlled studies, which were of generally low to moderate quality, were identified on the prevention of a first foot ulcer. For the prevention of recurrent plantar foot ulcers, there is benefit for the use of daily foot skin temperature measurements, and for therapeutic footwear with demonstrated plantar pressure relief, provided it is consistently worn by the patient. For prevention of ulcer recurrence, there is some evidence for providing integrated foot care, and no evidence for a single session of education.Surgical interventions have been shown effective in selected patients, but the evidence base is small. Foot‐related exercises do not appear to prevent a first foot ulcer. A small increase in the level of weight‐bearing daily activities does not seem to increase the risk for foot ulceration. The evidence base to support the use of specific self‐management and footwear interventions for the prevention of recurrent plantar foot ulcers is quite strong. The evidence is weak for the use of other, sometimes widely applied, interventions, and is practically non‐existent for the prevention of a first foot ulcer and non‐plantar foot ulcer.     

Psychological variables associated with foot function and foot pain in patients with plantar heel pain

It is widely accepted that psychological variables are associated with self-reported pain and self-reported physical function in patients with musculoskeletal pain. However, the relationship between psychological variables and foot pain and foot function has not been evaluated in people with plantar heel pain. Eighty-four participants with plantar heel pain completed the Depression, Anxiety and Stress Scale short version (DASS-21) and Foot Health Status Questionnaire. Using a hierarchical regression analysis, a baseline model with age, sex and BMI explained 10 % of the variability in foot function. The addition of depression and stress in separate models explained an additional 7.3 % and 8.1 % of foot function scores, respectively. In the respective models, depression was a significant predictor (β?=??0.28; p?=?0.009) as was stress (β?=??0.29; p?=?0.006). Females drove the effect between stress and foot function (β?=??0.50; p?=?0.001) and depression and foot function (β?=??0.53; p?<?0.001). In regression models for foot pain, depression, anxiety and stress did not contribute significantly to pain scores. When the data was stratified by sex, stress (β?=??0.36; p?=?0.024) and depression (β?=??0.41; p?=?0.013) were significantly associated with foot pain in females but not in males. For participants with plantar heel pain, stress and depression scores were significantly associated with foot function but not foot pain. When the data was stratified by sex, stress and depression were significant predictors of foot pain and function in females.     

Psychosocial variables and presence,severity and prognosis of plantar heel pain: A systematic review of cross‐sectional and prognostic associations

Objective

Plantar heel pain (PHP) is often disabling, and persistent symptoms are common. Psychosocial variables are known to affect pain and disability but the association of these factors with PHP has yet to be established. The purpose of the present systematic review was to determine if psychosocial variables are associated with the presence, severity and prognosis of PHP.

Methods

A systematic review of the literature and qualitative synthesis was carried out. Electronic searches of MEDLINE, CINAHL, SPORTDiscus, PsycINFO and EMBASE were undertaken from the inception of the respective databases up to November 2017. Any study design incorporating measurements of psychosocial variables with participants with plantar heel pain were included. The quality of included articles was appraised using the Newcastle Ottawa Scale.

Results

Five articles from four studies were included in the review, with a total of 422 participants. Moderate‐level evidence suggested a clinically unimportant association with the incidence of PHP and depression, anxiety and stress, and limited evidence suggested a clinically unimportant association with job dissatisfaction. Moderate‐level evidence suggested that there may also be an association between depression, anxiety, stress and catastrophization and PHP pain, and between depression, anxiety, stress, catastrophization and kinesiophobia and PHP function. We also found moderate‐level evidence that a psychological disorder may be associated with a poorer outcome to shockwave therapy.

Conclusion

In light of this review, the association of psychosocial variables and plantar heel pain cannot be ruled out. Given recommendations to adopt an individualized and stratified approach to other musculoskeletal conditions, clinicians should remain vigilant to their presence.     

Positive power Doppler signal in plantar fasciitis

The plantar fascia is a multilayered band of fibrous tissue that support and maintain the longitudinal arch of the foot. We report a 34-old obese woman with heel pain for the past 3 years. On physical examination, she presented painful plantar fascia throughout extension of the foot. In addition, a soft painful, mobile nodule was also palpated in the medial aspect of her left heel. An US examination of her left foot showed an increased thickness of her plantar fascia with reduced echogenity, the presence of an effusion and a positive power Doppler signal. Positive US Doppler signal may be helpful in evaluating patients with plantar fasciitis and is suggestive of the presence of active microcirculation.     

Differences in foot sensitivity and plantar pressure between young adults and elderly

ObjectiveThe understanding of foot sensitivity and plantar pressure contributes to the design of insoles, shoes, as well as to guide therapeutic interventions. Here we investigate differences in plantar pressure and foot sensitivity between young adults and community-dwelling elderly.MethodsThirty-eight participants (19 young adults and 19 elderly) underwent clinical assessment of foot sensitivity and upright standing with eyes open and closed for measurement of plantar pressure in each foot. Data were compared between feet, groups, and visual conditions.ResultsFoot sensitivity was lower in the elderly and, in contrast to young adults, differed between the foot regions (loss of sensitivity was primarily seen at the heel). Elderly shift plantar pressure to more distal foot zones, namely towards midfoot and forefoot. Asymmetries in foot sensitivity and plantar pressure were not observed. Visual condition did not influence plantar pressure distribution.ConclusionsThe forward shift in plantar pressure (away from the insensitive heel) constitutes a strategy of elderly to maintain balance.     

Foot Pain,Plantar Pressures,and Falls in Older People: A Prospective Study

OBJECTIVES: To determine whether foot pain and plantar pressure are associated with falls in community‐dwelling older adults. DESIGN: Community‐based cohort study with 12‐month prospective falls follow‐up. SETTING: Sydney and Illawarra statistical regions of New South Wales, Australia. PARTICIPANTS: Randomly recruited, community‐dwelling adults (158 men and 154 women) aged 60 and older. MEASUREMENTS: Manchester Foot Pain and Disability Index to establish baseline foot pain and dynamic plantar pressures. Participants were then classified as fallers (n=107) or nonfallers (n=196) based on their falls incidence over the following 12 months. RESULTS: Fallers had a significantly higher prevalence of foot pain than nonfallers (57.9% vs 42.1%; chi‐square=4.0; P=.04). Fallers also generated a significantly higher peak pressure and pressure‐time integral under the foot than non‐fallers. In addition, individuals with foot pain had a significantly higher peak pressure and pressure‐time integral under the foot than those without foot pain. CONCLUSION: High plantar pressures generated during gait may contribute to foot pain and risk of falls. Providing interventions to older people with foot pain and high plantar pressures may play a role in reducing their falls risk.     

Plantar sensitivity, foot loading and walking pain in rheumatoid arthritis

OBJECTIVE: The aim of the present study was to investigate the tactile sensitivity of the plantar surface in rheumatoid feet and its relationship to walking pain and plantar foot loading characteristics. METHODS: In 25 patients with rheumatoid arthritis (RA) and 21 healthy controls, Semmes-Weinstein monofilaments were used to assess tactile sensitivity in six foot regions. Walking pain was examined clinically. Pedography was used to analyse foot loading parameters during barefoot walking. RESULTS: In RA patients, plantar sensitivity was significantly decreased under all foot regions examined compared with the control group (P<0.05). A loss of protective sensation was found in a total of 10 regions in seven patients but not in the control group. In the RA patients, foot loading was reduced in the hindfoot (P<0.05) but was slightly increased in the forefoot (not significant). Average walking pain was 3.8 +/- 2.1 on a scale from 0 to 10 but did not correlate with the sensitivity levels. CONCLUSION: In patients with RA, no direct relationship between pain intensity and plantar foot loading was found. The decreased tactile sensitivity may be indicative of a disturbed sensation for high plantar pressures. Therefore, pedography can be useful as an additional tool in the detection of excessive forefoot loading before complications are manifested.     

Spontaneous regression of herniated lumbar intervertebral disc

The aim of this report is to describe the very rare condition, spontaneous regression of herniated lumbar intervertebral disc, and the results of clinical follow‐up and imaging modalities. A 53‐year‐old housewife presented with a 1‐month history of low back and right leg pain. She had severe pain in her right leg radiating from the buttock to the heel and weakness of the right foot plantar flexion (rated 4/5 by manual motor testing), and straight‐leg raising test was positive at 45° on the right side. Magnetic resonance imaging (MRI) revealed a large para‐median extruded intervertebral disc at the L5–S1 level. She was followed up with medical treatments and physiotherapy and rehabilitation intervention. Follow‐up MRI after 18 months since initial presentation revealed that extruded intervertebral disc material was completely resolved. In conclusion, the regression of the disc correlated with clinical improvement and was illustrated in follow‐up magnetic resonance imaging. The exact mechanism underlying this condition is still unclear. As in our case, extruded lumbar intervertebral disc herniations may spontaneously regress and non‐surgical conservative treatments may be appropriate.     

Achilles tendon and plantar fascia in recently diagnosed type II diabetes: role of body mass index

Previous research has shown that plantar fascia and Achilles tendon thickness is increased in diabetes. The aims of present study were to assess whether tendon changes can occur in the early stages of the disease and to evaluate the extent of the influence of body mass index (BMI). The study population included 51 recent-onset type II diabetic subjects, who were free from diabetic complications, divided according to BMI into three groups (normal weight, overweight, and obese). Eighteen non-diabetic, normal-weight subjects served as controls. Plantar fascia and Achilles tendon thickness was measured by means of sonography. The groups were well balanced for age and sex. In all the diabetic subjects, plantar fascia and Achilles tendon thickness was increased compared to the controls (p < 0.001, p = 0.01, p = 0.003, respectively). A significant relationship was found between plantar fascia thickness and BMI values (r = 0.749, p < 0.0001), while the correlation between BMI and Achilles tendon was weaker (r = 0.399, p = 0.004). This study shows that plantar fascia and Achilles tendon thickness is increased in the early stages of type II diabetes and that BMI is related more to plantar fascia than Achilles tendon thickness. Further longitudinal studies are needed to evaluate whether these early changes can overload the metatarsal heads and increase the stress transmitted to plantar soft tissues, thus representing an additional risk factor for foot ulcer development.     

Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2019 update)

The International Working Group on the Diabetic Foot (IWGDF) has published evidence‐based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the use of offloading interventions to promote the healing of foot ulcers in people with diabetes and updates the previous IWGDF guideline. We followed the GRADE methodology to devise clinical questions and critically important outcomes in the PICO format, to conduct a systematic review of the medical‐scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. For healing a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes, we recommend that a nonremovable knee‐high offloading device is the first choice of offloading treatment. A removable knee‐high and removable ankle‐high offloading device are to be considered as the second‐ and third‐choice offloading treatment, respectively, if contraindications or patient intolerance to nonremovable offloading exist. Appropriately, fitting footwear combined with felted foam can be considered as the fourth‐choice offloading treatment. If non‐surgical offloading fails, we recommend to consider surgical offloading interventions for healing metatarsal head and digital ulcers. We have added new recommendations for the use of offloading treatment for healing ulcers that are complicated with infection or ischaemia and for healing plantar heel ulcers. Offloading is arguably the most important of multiple interventions needed to heal a neuropathic plantar foot ulcer in a person with diabetes. Following these recommendations will help health care professionals and teams provide better care for diabetic patients who have a foot ulcer and are at risk for infection, hospitalization, and amputation.     

Foot musculoskeletal disorders, pain, and foot-related functional limitation in older persons

OBJECTIVES: To examine whether common musculoskeletal disorders of feet are associated with pain and foot-related functional limitation. DESIGN: A cross-sectional study using stratified random sampling. Setting: A residential community. PARTICIPANTS: Ethnically diverse sample of elderly persons (n=784). MEASUREMENTS: Foot disorders (hallux valgus/bunion, pes planus (flat foot), pes cavus (high arch), hammertoe, mallet toe, claw toe, overlapping toes, bunionette, and plantar fasciitis), foot pain, the foot health functional status (FHFS, range 0-100, 100=no problems) scale, and walk time score (range 0-4, 4=fastest). RESULTS: Most commonly assessed musculoskeletal disorders, including hallux valgus and toe deformities, were not associated with pain or function limitation. Plantar fasciitis and, to a lesser extent, pes cavus were associated with worse FHFS scores; foot pain partially explained this association. Neither foot disorders nor foot pain were significantly associated with slower walk times. CONCLUSION: Many foot disorders had little relationship with foot pain or function and may not require clinical attention when asymptomatic. Risk factors and preventive and therapeutic interventions for plantar fasciitis require further longitudinal investigation.     

Plantar pressure differences between obese and non-obese adults: a biomechanical analysis.

OBJECTIVE: To investigate plantar pressure differences between obese and non-obese adults during standing and walking protocols using a pressure distribution platform. SUBJECTS: Thirty-five males (age 42.4+/-10.8 y; 67-179 kg) and 35 females (age 40.0+/-12.6 y; 46-150 kg) divided into obese (body mass index (BMI) 38.75+/-5.97 kg/m2) and non-obese (BMI 24.28+/-3.00 kg/m2) sub-groups, respectively. MEASUREMENTS: Data collection was performed with a capacitive pressure distribution platform with a resolution of 2 sensors/cm2 (Emed F01, Novel GmbH, München). The measurement protocol included half and full body weight standing on the left, right and both feet, respectively, and walking across the platform, striking with the right foot. Pressures were evaluated for eight anatomical sites under the feet. RESULTS: For both men and women, the mean pressure values of the obese were higher under all anatomical landmarks during half body weight standing. Significant increases in pressure were found under the heel, mid-foot and metatarsal heads II and IV for men and III and IV for women. Foot width during standing was also significantly increased in obese subjects. For walking, significantly higher peak pressures were also found in both obese males and females. CONCLUSION: Compared to a non-obese group, obese subjects showed increased forefoot width and higher plantar pressures during standing and walking. The greatest effect of body weight on higher peak pressures in the obese was found under the longitudinal arch of the foot and under the metatarsal heads. The higher pressures for obese women compared to obese men during static weight bearing (standing) may be the result of reduced strength of the ligaments of the foot.     

A systematic review of treatments for the painful heel.

OBJECTIVE: To establish the efficacy for treatments of pain on the plantar aspect of the heel. METHODS: Systematic review of the published and unpublished literature. Electronic search of Medline, BIDS and the Cochrane database of clinical trials. An assessment of the quality of the reporting was made of studies included in the review. Main outcome measure: patients' pain scores. Study selection: randomized controlled trials, published or unpublished, that evaluated treatments used for plantar heel pain. Foreign language papers were excluded. RESULTS: Eleven randomized controlled trials were included in the review. These evaluated some of the most frequently described treatments (steroid injections and orthoses) and some experimental therapies (extracorporeal shock wave therapy and directed electrons). The methodological assessment scores of the published trials were low; small sample sizes and failure to conceal the treatment allocation from study participants prevents more definitive statements about the efficacy of treatments. In 10 of the included trials, patients in both the intervention and control arms reported improved pain scores at the final outcome measure. CONCLUSIONS: Although much has been written about the treatment of plantar heel pain, the few randomized controlled trials involve small populations of patients and do not provide robust scientific evidence of treatment efficacy.     

Randomized trial of custom orthoses and footwear on foot pain and plantar pressure in diabetic peripheral arterial disease

Aim Custom‐made foot orthoses reduce plantar pressure, ulceration and amputation in patients with diabetes mellitus. There is limited evidence of their effect on foot pain. In a randomized, single‐blind, sham‐controlled trial, the efficacy of custom orthoses on foot pain and plantar pressure in diabetic patients with peripheral arterial disease was investigated. Methods Sixty‐one participants were randomly assigned to either custom foot orthoses (n = 30) or sham insoles (n = 31). Both groups also received standardized walking footwear. Outcomes included foot pain and function, mean pressure, toe‐brachial index, average daily steps, disability, comfort, quality of life, adherence and adverse events. A multivariate predictive model was constructed to explore factors contributing to pain relief during the trial. Results At 8 weeks, 95% of participants provided follow‐up data, adherence was high and there were few adverse events. Foot pain and function scores significantly improved at 8 weeks with both custom orthoses and the sham, but there was no significant difference between groups. Custom orthoses reduced pressure significantly more than the sham. There were no significant differences between groups for toe‐brachial index, daily steps, disability, comfort or quality of life. Regression modelling identified inappropriate pre‐trial footwear as the strongest predictor of foot pain relief during the trial. Conclusions Custom foot orthoses significantly reduced plantar pressure compared with the sham, but there were no significant differences between groups for pain or function. The high‐quality walking footwear provided to both groups may explain this finding. Footwear should have greater emphasis as the clinical intervention.     

The enigma of increased non-cancer mortality after weight loss in healthy men who are overweight or obese

Abstract. Nilsson PM, Nilsson J‐A, Hedblad B, Berglund G, Lindgärde F. (University Hospital, Malmö, Sweden). The enigma of increased non‐cancer mortality after weight loss in healthy men who are overweight or obese. J Intern Med 2002; 252: 70?78. Objective. To study effects on non‐cancer mortality of observational weight loss in middle‐aged men stratified for body mass index (BMI), taking a wide range of possible confounders into account. Design. Prospective, population based study. Setting. Male population of Malmö, Sweden. Participants. In all 5722 men were screened twice with a mean time interval of 6 years in Malmö, southern Sweden. They were classified according to BMI category at baseline (<21, 22?25, overweight: 26?30, and obesity: 30+ kg m^?2) and weight change category until second screening (weight stable men defined as having a baseline BMI ± 0.1 kg m^?2 year^?1 at follow‐up re‐screening). Main outcome measures. Non‐cancer mortality calculated from national registers during 16 years of follow‐up after the second screening. Data from the first year of follow‐up were excluded to avoid bias by mortality caused by subclinical disease at re‐screening. Results. The relative risk (RR; 95% CI) for non‐cancer mortality during follow‐up was higher in men with decreasing BMI in all subgroups: RR 2.64 (1.46?4.71, baseline BMI <21 kg m^?2), 1.39 (0.98?1.95, baseline BMI 22?25 kg m^?2), and 1.71 (1.18?2.47, baseline BMI 26+ kg m^?2), using BMI‐stable men as reference group. Correspondingly, the non‐cancer mortality was also higher in men with increasing BMI, but only in the obese group (baseline BMI 26+ kg m^?2) with RR 1.86 (1.31?2.65). In a subanalysis, nonsmoking obese (30+ kg m^?2) men with decreased BMI had an increased non‐cancer mortality compared with BMI‐stable obese men (Fischer's test: P=0.001). The mortality risk for nonsmoking overweight men who increased their BMI compared with BMI‐stable men was also significant (P=0.006), but not in corresponding obese men (P=0.094). Conclusions. Weight loss in self‐reported healthy but overweight middle‐aged men, without serious disease, is associated with an increased non‐cancer mortality, which seems even more pronounced in obese, nonsmoking men, as compared with corresponding but weight‐stable men. The explanation for these observational findings is still enigmatic but could hypothetically be because of premature ageing effects causing so‐called weight loss of involution.     

Determinants of plantar pressures in the diabetic foot

The aim of this study was to determine, by the use of regression analysis, the factors that are associated with the increased plantar pressure in the diabetic foot. In-shoe plantar pressure measurements using the Novel Pedar were carried out on 50 subjects with diabetes. Variables measured were age, body weight, duration of diabetes, a number of selected structural radiographic angles, soft tissue thickness, plantarflexion, and dorsiflexion strength at the ankle and first metatarsophalangeal joint, Neuropathy Symptom Score, and the Michigan Neuropathy Disability Score. Stepwise regression modelling indicates that 28% of the variability in hallux peak pressure could be explained by the first metatarsophalangeal joint range of motion and the Michigan Neuropathy Disability Score (P=.0004). The Michigan Neuropathy Disability Score explained 17% of the peak pressure under the first metatarsal head (P=.002). None of the measured variables could explain any of the variation in peak pressure plantar to the lateral forefoot. Thirty-two percent (32%) of the variability in peak pressure under the heel was explained by the Michigan Neuropathy Disability Score and age (P<.0001). Very little of the variation in the pressure time integrals could be explained by the measured variables except for 10.3% of the variation in the pressure time integral for the heel being explained by body weight. This study has shown that neuropathy-related variables play an important role in the plantar pressure under the diabetic foot. The range of motion of the first metatarsophalangeal joint is also important in determining pressures under the hallux.     

The role of foot pressure measurement in the prediction and prevention of diabetic foot ulceration—A comprehensive review

The predominant risk factor of diabetic foot ulcers (DFU), peripheral neuropathy, results in loss of protective sensation and is associated with abnormally high plantar pressures. DFU prevention strategies strive to reduce these high plantar pressures. Nevertheless, several constraints should be acknowledged regarding the research supporting the link between plantar pressure and DFUs, which may explain the low prediction ability reported in prospective studies. The majority of studies assess vertical, rather than shear, barefoot plantar pressure in laboratory‐based environments, rather than during daily activity. Few studies investigated previous DFU location‐specific pressure. Previous studies focus predominantly on walking, although studies monitoring activity suggest that more time is spent on other weight‐bearing activities, where a lower “peak” plantar pressure might be applied over a longer duration. Although further research is needed, this may indicate that an expression of cumulative pressure applied over time could be a more relevant parameter than peak pressure. Studies indicated that providing pressure feedback might reduce plantar pressures, with an emerging potential use of smart technology, however, further research is required. Further pressure analyses, across all weight‐bearing activities, referring to location‐specific pressures are required to improve our understanding of pressures resulting in DFUs and improve effectiveness of interventions.     

Foot pain: Is current or past shoewear a factor?

Objective

Foot pain is common, yet few studies have examined the condition in relationship to shoewear. In this cross‐sectional study of men and women from the population‐based Framingham Study, the association between foot pain and type of shoewear was examined.

Methods

Data were collected on 3,378 members of the Framingham Study who completed the foot examination in 2002–2008. Foot pain (both generalized and at specific locations) was measured by the response to the question “On most days, do you have pain, aching or stiffness in either foot?” Shoewear was recorded for the present time and 5 past age categories, by the subject's choice of the appropriate shoe from a list. The responses were categorized into 3 groups (good, average, or poor shoes). Sex‐specific multivariate logistic regression models were used to examine the effect of shoewear (average shoes were the referent group) on generalized and location‐specific foot pain, adjusting for age and weight.

Results

In women, compared with average shoes, those who wore good shoes in the past were 67% less likely to report hindfoot pain (P = 0.02), after adjusting for age and weight. In men, there was no association between foot pain, at any location, and shoewear, possibly due to the fact that <2% wore bad shoe types, making it difficult to see any relationship.

Conclusion

Even after taking age and weight into account, past shoewear use in women remained associated with hindfoot pain. Future studies should address specific support and structural features of shoewear.