Plantar pressures and relative lesser metatarsal lengths in older people with and without forefoot pain

Forefoot pain is a common problem in older people. We determined whether plantar pressures during gait and the relative lengths of the lesser metatarsals differ between older people with and without plantar forefoot pain. Dynamic plantar pressure assessment during walking was undertaken using the Tekscan MatScan® system in 118 community‐dwelling older people (44 males and 74 females), mean age 74 (standard deviation = 5.9) years, 43 (36%) of whom reported current or previous plantar forefoot pain. The relative lengths of metatarsals 1–5 were determined from weightbearing X‐rays. Participants with current or previous plantar forefoot pain exhibited significantly (p = 0.032) greater peak plantar pressure under metatarsal heads 3–5 (1.93 ± 0.41 kg/cm² vs. 1.74 ± 0.48 kg/cm²). However, no differences were found in relative metatarsal lengths between the groups. These findings indicate that older people with forefoot pain generate higher peak plantar pressures under the lateral metatarsal heads when walking, but do not exhibit relatively longer lesser metatarsals. Other factors may be responsible for the observed pressure increase, such as reduced range of motion of the metatarsophalangeal joints and increased stiffness of plantar soft tissues. © 2012 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 31: 427–433, 2013     

Comparison of plantar pressure distribution in CAD–CAM and prefabricated foot orthoses in patients with flexible flatfeet

BackgroundsThe effect of foot orthoses on plantar pressure distribution has been proven by researchers but there are some controversies about advantages of custom-made foot orthoses to less expensive prefabricated foot orthoses.MethodsNineteen flatfeet adults between 18 and 45 participated in this study. CAD–CAM foot orthoses were made for these patients according to their foot scan. Prefabricated foot orthoses were prepared according to their foot size. Plantar pressure, force and contact area were measured using pedar^®-x in-shoe system wearing shoe alone, wearing CAD–CAM foot orthoses and wearing prefabricated foot orthoses. Repeated measures ANOVA model with post-hoc, Bonferroni comparison were used to test differences.ResultsCAD–CAM and prefabricated foot orthoses both decreased pressure and force under 2nd, 3–5 metatarsal and heel regions comparing to shoe alone condition. CAD–CAM foot orthosis increased pressure under lateral toe region in comparison to shoe alone and prefabricated foot orthosis. Both foot orthoses increased pressure and contact area in medial midfoot region comparing to shoe alone condition. Increased forces were seen at hallux and lateral toes by prefabricated foot orthoses in comparison with CAD–CAM foot orthoses and control condition, respectively.ConclusionAccording to the results, both foot orthoses could decrease the pressure under heel and metatarsal area. It seems that the special design of CAD–CAM foot orthoses could not make great differences in plantar pressure distribution in this sample. Further research is required to determine whether these results are associated with different scan systems or design software.     

Comparison between the plantar pressure effects of toe separators and insoles in patients with hallux valgus at a one-month follow-up

BackgroundVarious designs of foot orthoses for hallux valgus have been developed to reduce foot pain. The plantar pressure assessment can determine the better intervention. This study aimed to compare the effectiveness of plantar pressure distribution in patients with hallux valgus during walking with toe separator and insole.MethodPatients with hallux valgus were randomized into one of two interventions: prefabricated toe separator or customized insole. The plantar pressure distribution of the participants was measured during walking with the devices after use for one month with an in-shoe measurement system.ResultsTwenty-three participants were analyzed. After 1-month, significant peak pressures and pressure-time integral reductions were observed during walking in the middle forefoot (64.28 kPa and 28.97 kPa s, respectively) and lateral forefoot regions (54.03 kPa and 22.30 kPa s, respectively) after insole use compared with a toe separator.ConclusionsAfter one month of use, the customized insole was more effective in plantar pressure reduction than the toe separator for a hallux deformity.     

An investigation to determine the normal 1st to 5th metatarsal peak pressure and PTI ratio of the forefoot

BackgroundThe foot support has been described as that of a tripod. Biomechanical studies often report on peak pressures and pressure time integrals under specific areas of the foot. Reference needs to be made to the normal tripod distribution especially in the forefoot. In the forefoot the ratio between the 1st metatarsal and the 5th metatarsal on the medial and lateral columns of the foot respectively provide an excellent reference especially if the normal ratio is known. This study provides conclusive evidence of the 1st to 5th metatarsal ratio for peak pressures and pressure time integrals in the normal foot to be used as a reference.MethodsA group of normal healthy volunteers (n = 12) and a group of patients with unilateral end stage hallux rigidus (n = 17) were recruited. Repeated measures of 1st and 5th metatarsal peak pressures and Pressure time integrals were measured to determine reliability of measurement and to provide a reference normal ratio.ResultsIn the healthy volunteer group, the 1st/5th metatarsal ratio for PTI was very close to 1 while it was just over 1.5 for peak pressure. In patients with unilateral end stage hallux rigidus, in the normal foot the 1st/5th metatarsal ratio for PP and PTI was very close to 1. These ratios were reproduced in the operated foot following 1st MTPJ replacement.ConclusionThis study using normal healthy volunteers and patients undergoing 1st MTPJ replacement has demonstrated that the normal 1st/5th metatarsal peak pressure and pressure time integrals should be close to 1.     

Plantar pressure distribution and pain after distal osteotomy for hallux valgus: A prospective study of 22 patients with 12-month follow-up

BackgroundElevated pressure under the central forefoot region is common in hallux valgus and this is often associated with metatarsalgia.ObjectiveTo ascertain whether there was a difference in pain and plantar pressure distribution parameters after correction of the deformity by two distal metatarsal osteotomy techniques.MethodsTwenty-two patients randomly assigned to distal chevron or Lindgren first metatarsal osteotomy were evaluated prospectively with dynamic plantar pressure measurement, quality of life scores and clinical and radiographic measurements. Data were collected pre-operatively, at 6 and 12 months after surgery. Results of the combined operated group were compared with an age-matched control group.ResultsThere were no significant differences in plantar pressure distribution parameters between the two operated groups at any occasion. At 6 months peak pressure was significantly less under the lateral forefoot in the operated feet compared with the non-operated feet and significantly greater under the central forefoot than in the control group and the medial forefoot than under the non-operated feet, although the operated group had normalised after 12 months. The visual analogue scale (VAS) showed significant improvements after both surgical techniques.ConclusionBoth surgical techniques resulted in significant clinical and radiographic improvements and reduced the level of pain, although the foot pressure recordings demonstrated no biomechanical effect.     

Biomechanical consequences of adding plantar fascia release to metatarsal osteotomies: Changes in forefoot plantar pressures

Destruction of the normal metatarsal arch by a long metatarsal is often a cause for metatarsalgia. When surgery is warranted, distal oblique, or proximal dorsiflexion osteotomies of the long metatarsal bones are commonly used. The plantar fascia has anatomical connection to all metatarsal heads. There is controversial scientific evidence on the effect of plantar fascia release on forefoot biomechanics. In this cadaveric biomechanical study, we hypothesized that plantar fascia release would augment the plantar metatarsal pressure decreasing effects of two common second metatarsal osteotomy techniques. Six matched pairs of foot and ankle specimens were mounted on a pressure mat loading platform. Two randomly assigned surgery groups, which had received either distal oblique, or proximal dorsiflexion osteotomy of the second metatarsal, were evaluated before and after plantar fasciectomy. Specimens were loaded up to a ground reaction force of 400 N at varying Achilles tendon forces. Average pressures, peak pressures, and contact areas were analyzed. Supporting our hypothesis, average pressures under the second metatarsal during 600 N Achilles load were decreased by plantar fascia release following proximal osteotomy (p < 0.05). However contrary to our hypothesis, peak pressures under the second metatarsal were significantly increased by plantar fascia release following modified distal osteotomy, under multiple Achilles loading conditions (p < 0.05). Plantar fasciotomy should not be added to distal metatarsal osteotomy in the treatment of metatarsalgia. If proximal dorsiflexion osteotomy would be preferred, plantar fasciotomy should be approached cautiously not to disturb the forefoot biomechanics. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:800–804, 2017.

     

Can static foot posture measurements predict regional plantar surface area?

BackgroundThe intent of this study was to determine if the use of a single or combination of static foot posture measurements can be used to predict rearfoot, midfoot, and forefoot plantar surface area in individuals with pronated or normal foot types.MethodsTwelve foot measurements were collected on 52 individuals (mean age 25.8 years) with the change in midfoot width used to place subjects in a pronated or normal foot mobility group. Dynamic plantar contact area was collected during walking with a pressure sensor platform. The 12 measures were entered into a stepwise regression analysis to determine the optimal set of measures associated with regional plantar surface area.ResultsA two variable model was found to describe the relationship between the foot measurements and forefoot plantar contact area (r² = 0.79, p < 0.0001). A four variable model was found to describe the relationship between the foot measurements and midfoot plantar contact area (r² = 0.85, p < 0.0001) in those individuals with a 1.26 cm or greater change in midfoot width.ConclusionsThe results indicate that clinicians can use a combination of simple, reliable and time efficient foot measures to explain 79% and 85% of the plantar surface area in the forefoot and midfoot, respectively.     

Effect of the shoe on plantar foot pressures

The bare foot plantar pressures were compared to in-shoe pressure measurements in 11 normal male volunteers using the EMED system. Shoes diminished pressures and forces in most areas under the foot except the medial forefoot. The hallux showed less force, a smaller contact area and a reduced contact time. Therefore a shoe can interfere with the toe-off mechanism. There was no difference between various types of shoes with rubber and leather soles. Heavier subjects tended to put less weight on the medial forefoot.     

The relationship of the position of the metatarsal heads and peak plantar pressure

We test the premise that peak plantar pressure is located directly under the bony prominences in the forefoot region. The right foot of standing volunteers was examined in three different postures by a CT-scanner. The plantar pressure distribution was simultaneously recorded. The position of the metatarsal heads and the sesamoids could be related to the corresponding local peak plantar pressures. The metatarsal heads 1, 4, and 5 had a significantly different position than the local peak plantar pressures. The average difference in distance between the position of the metatarsal heads and the peak plantar pressure showed a significant correlation: on the medial side the head was located more distally to the local peak plantar pressure, on the lateral side more proximally. The findings suggest that normal plantar soft tissue is able to deflect a load. The observations might improve insight into the function of the normal forefoot and might direct further research on the pathological forefoot and on the design of footwear.     

The role of a total contact insole in diminishing foot pressures following partial first ray amputation in diabetic patients

BackgroundIn diabetic subjects, reulcerations following first ray amputations are particularly frequent. Treatment usually includes an in-shoe intervention to reduce plantar pressure.ObjectiveTo investigate the effects of a total contact insole on the plantar pressure reduction in patients with partial first ray amputations.Material and methodsTwenty diabetic subjects (mean age 60 years, mean body mass index 27 kg/m²) with partial first ray amputation of one foot. Plantar pressure data was recorded using Matscan system (Tekscan vers. 6.34, Boston, USA) while standing and taking a step for three conditions (shoe, shoe with total contact insole, and shoe with flat insole). Plantar pressures were determined at the five metatarsal areas, mid foot area and medial and lateral heel areas.ResultsPressures diminished significantly (P < 0.05) in tested areas using the total contact insole while standing and walking. While using the flat insole, significant pressure changes were only seen while walking (P < 0.05) (P < 0.05). A highly significant change in pressures with the total contact insoles during walking in all areas except for the M1 area (P < 0.001) as compared to that of flat insole.ConclusionThe conforming total contact insole showed significant reduction in plantar pressures in patients with first ray amputation.     

Effects of wearing foot orthosis with medial arch support on the fifth metatarsal loading and ankle inversion angle in selected basketball tasks

STUDY DESIGN: Preintervention and post-intervention, repeated-measures experimental design. OBJECTIVES: The objective was to investigate the effects of foot orthoses with medial arch support on ankle inversion angle and plantar forces and pressures on the fifth metatarsal during landing for a basketball lay-up and during the stance phase of a shuttle run. BACKGROUND: Proximal fractures of the fifth metatarsal, specifically the Jones fracture, are common in sports. Wearing foot orthoses with medial arch support could increase the ankle inversion angle and the plantar forces and pressure on the fifth metatarsal that may increase the risk for fifth metatarsal fracture, METHODS AND MEASURES: Three-dimensional (3-D) videographic, force plate, and in-shoe plantar force and pressure data were collected during landing after a basketball lay-up and during the stance phase of a shuttle run with and without foot orthoses with medial arch support for 14 male subjects. Two-way ANOVAs with repeated measures were performed to compare ankle inversion angle, maximum forces, and pressure on the fifth metatarsal head and base between conditions and between tasks. RESULTS: The maximum ankle inversion angle and maximum plantar force and pressure on the base of the fifth metatarsal during both tasks as well as the maximum plantar force and pressure on the head of the fifth metatarsal during the stance of the shuttle run were significantly increased (P< or =026) when wearing foot orthoses. No significant differences were found in the maximum vertical ground reaction forces between foot orthotic conditions. CONCLUSION: Generic use of off-the-shelf foot orthoses with medial arch support causes increased plantar forces and pressures on the fifth metatarsal and may increase the risk for proximal fracture of the fifth metatarsal. Future studies are needed to investigate this risk, acknowledging that the differences noted in our study were small in magnitude and the foot type was not measured.     

Plantar pressure distribution in normal,hallux valgus and hallux limitus feet

Selected dynamic plantar pressure measurements of 30 control, 30 hallux valgus and 30 hallux limitus subjects, using an EMED-SF system and a two-step method of data collection, were analysed for significant differences, with a one-way analysis of variance being performed with P<0.05. In comparison to normal control subjects, those with hallux valgus feet demonstrated significant medial plantar peak and mean pressures under the first, second and third metatarsal heads. In contrast, hallux limitus feet showed significantly high mean pressure under the hallux, lesser toes, third and fourth metatarsal heads, indicating a more lateral forefoot load.     

Treatment of metatarsalgia based on claw toe deformity through soft tissue release of the metatarsophalangeal joint and resection of the proximal interphalangeal joint: Evaluation based on foot kinematics and plantar pressure distribution

IntroductionThis study investigated the effect of operative claw toe correction with release of the metatarsophalangeal (MTP) joint, repositioning of the plantar fat pad and resection of the proximal interphalangeal joint on foot kinematics, plantar pressure distribution and Foot Function Index (FFI).MethodsProspective experimental study with pretest-posttest design. The plantar pressure, 3D foot kinematics and the FFI of 15 patients with symptomatic claw toes were measured three months before and 12 months after surgery. Mean pressure, peak pressure and pressure time integral per sensor and various foot angles were calculated for the pre- and posttest and compared to a control group (N = 15).ResultsClaw toe patients have increased pressure under the distal part of the metatarsal head and less pressure under the proximal part of the metatarsal heads compared to healthy controls. After surgery, there was a redistribution of pressure, resulting in a significant decrease of pressure under the distal part and an increase under the proximal part of the metatarsal head, providing a more equal plantar pressure distribution. Except for some small areas under the forefoot, heel and toes, there were no significant differences in pressure distribution between the operated feet and controls. Small, but significant differences between the pre- and postoperative condition were found for the lateral arch angle, calcaneus/malleolus supination and tibio-talar flexion. The score on the FFI improved statistically significant.DiscussionThese findings imply that the present operative procedure results in a more equal distribution of the plantar pressure under the forefoot and decrease of pain and offers successful treatment of metatarsalgia based on claw toe deformity.     

Use of the modified Stainsby procedure in correcting severe claw toe deformity in the rheumatoid foot: A retrospective review

IntroductionIn claw toe deformity, the plantar plate of the metarsophalangeal joint becomes displaced onto the dorsal aspect of the metatarsal head. The Stainsby procedure replaces the displaced plantar plate to its correct position beneath the metatarsal head.ObjectiveIn this study we assess the efficacy of a modified Stainsby procedure for the treatment of claw toe deformity.MethodsThirteen patients were operated on between 2002 and 2008. Eleven patients (13 feet) were available for review with the average follow-up period being 16 months. Clinical examination was performed and AOFAS forefoot scores were measured.ResultsAll 13 (100%) of the feet operated on had severe or moderate pain preoperatively. None had significant pain at review. Plantar callosities were reduced from 13 (100%) feet preoperatively to 1 (9%) foot postoperatively. The AOFAS forefoot score in the eleven patients improved significantly by 40.7 points from a preoperative mean of 20.1 to a mean of 50.2 at review (p < 0.001). Ten (91%) of the 11 patients were completely satisfied with the procedure, 1 patient was satisfied with some reservations.ConclusionThis study demonstrates the modified Stainsby procedure to be effective in correcting claw toe deformity in the rheumatoid patient. It relieves pain, skin callosities and improves overall forefoot function.     

第1跖跗关节骨折脱位不同内固定方式对前足足底压力变化的影响

目的 :测量第1跖跗关节骨折脱位3种内固定对前足足底压力的变化,为选择内固定提供实验参考。方法:取8具新鲜足标本,制成第1跖跗关节骨折脱位模型,依次进行3.5 mm全螺纹皮质骨螺钉,1/4管形钢板及加压骑缝钉固定。经加载600 N后,通过F-scan足底压力分析系统,测量前足足底压力的变化。结果:第1跖跗关节骨折脱位后,第1跖骨头下的峰值压力将减小,而第2跖骨头下的峰值压力将增大,差异具有统计学意义(P<0.05)。对第1跖跗关节分别采用螺钉、钢板进行固定后,第1、2跖骨头下的峰值压力都将趋于正常状态,而进行骑缝钉固定后,虽然第1、2跖骨头下的峰值压力都有所恢复,但仍与正常状态比较,差异有统计学意义(P<0.05)。结论 :当第1跖跗关节骨折脱位后,邻近跖骨头可能存在着"负荷转移"的调节机制以代偿部分足底压力;当第1跖跗关节骨折脱位采用螺钉和钢板内固定治疗后,前足足底压力都可恢复至正常状态,而若采用骑缝钉固定,则前足足底压力仍难以恢复至正常状态。     

The Linear Hallux Valgus Offset– A novel way to measure Hallux Valgus

IntroductionHallux Valgus (HV) is a complex deformity involving the first ray of the forefoot and a common cause of forefoot pain. Several radiological measurements such as Hallux Valgus Angle (HVA), First Metatarsophalangeal Angle (IMA) and Distal metatarsal articular angle (DMAA) exist to calculate the severity of HV and direct patient management. However, these are angular measurements are prone to error with variable intra- and inter-observer reliability.PurposeTo describe a new radiological linear hallux valgus offset (LHVO) to measure HV deformity.Patient and methodsWe performed a retrospective cohort study looking at Antero-posterior, weight-bearing foot radiographs of 100 consecutive patients with forefoot pain referred to our foot and ankle clinic. Demographic details, clinical indication, HVA (hallux valgus angle) and LHVO were measured for each patient and data were analyzed using the student t-test. Intraclass Correlation Coefficient (ICC) analysis was evaluated to assess the intra-class reliability between observers.ResultsThere was a female predominance of approximately 2:1, with 51.3 years (range 13–86 years). There was a statistically significant difference of LHVO between normal and hallux valgus cohorts with a p-value of 0.0001. The LHVO gave moderate intra-observer and inter-observer reliability on ICC analysis of 0.7.ConclusionThe LHVO can be an additional measure of assessing severity of hallux valgus. In contrary to the traditional angular measurements, this linear measure is easier to calculate and reproducible on plain, weight bearing radiographs. LHVO measurement has shown a moderate inter-observer reliability in the study to complement traditional radiological evaluation of hallux valgus alignment.     

正常足与外翻足的足底压力研究

目的　对正常足与外翻足的足底压力进行测量。方法　运用自行研制的足底生物力学测试系统对30 名健康人60 足,45 例外翻患者89 足进行了行走时足底压力的测试。结果　重度外翻组31 足和正常组相比,第一跖骨头下压力明显减低( P< 0.001),第二跖骨头下压力明显增加(P< 0 .05),第三、五跖骨头下压力有增高的趋势。结论　正常人前足第一跖骨头下压力最高,并向外侧递减。重度外翻足前足第一跖骨头下压力明显减低,第二跖骨头下压力明显增高     

Inter-observer and intra-observer reliability in the radiographic measurements of paediatric forefoot alignment

BackgroundFoot bones in children have more rounded shapes in radiograms than adults. Thus, the goal of this work was assessing inter- and intra-observer reliability in paediatric forefoot angle measurements.Material and methodsSix forefoot angles in 34 AP standing paediatric foot radiographs were measured by 5 researchers. A classic statistical analysis with use of IBM SPSS Statistics 25 was performed and a new method with two-way analysis of variance was applied.ResultsResults of statistical analysis revealed the properties of a subjective assessment related to specific angles. Kilmartin’s angle, calcaneus-fifth metatarsal angle and first ray angle are the most reliable; metatarsus adductus angle should be used with great caution in pediatric population. Engel’s angle is the most difficult for measuring and measurement error is the highest.ConclusionThe power of paediatric forefoot measurements is various. Several angles are reliable, while Engle’s angle is the most doubtful.     

Effects of the Lapidus Arthrodesis and Chevron Bunionectomy on Plantar Forefoot Pressures

Hallux valgus with or without first ray insufficiency has been strongly implicated as a contributing factor in lesser metatarsal overload. The principle goals of a bunionectomy are to relieve the pain, correct the deformity, and restore first metatarsophalangeal joint congruity. Until now, little evidence has been available to assess the effects of bunionectomy procedures on forefoot pressure. The primary aim of the present prospective study was to evaluate the preoperative and postoperative plantar pressures after 2 specific bunionectomies: the chevron bunionectomy and Lapidus arthrodesis. A total of 68 subjects, 34 in each group, were included for radiographic and pedographic evaluation. Both procedures demonstrated radiographic improvements in the mean intermetatarsal and hallux abductus angles. The mean hallux plantar pressure decreased significantly in both procedure groups (p < .001). However, Lapidus group exhibited an increase in the mean fifth metatarsal head plantar pressure (p = .008) and pressure under the fifth metatarsal as a percentage of the total forefoot pressure (p = .01). Furthermore, the pressure under the second metatarsal as a percentage of the total forefoot pressure decreased significantly (p = .01). This study suggests that the Lapidus arthrodesis and chevron bunionectomy both provide correction for hallux valgus deformity, but when comparing forefoot load sharing pressures, the Lapidus arthrodesis appeared to have greater influence on the load sharing distribution of forefoot pressure than did the bunionectomy employing the chevron osteotomy.