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The Cochrane Database of Systematic... Jan 2022Paediatric flat feet are a common presentation in primary care; reported prevalence approximates 15%. A minority of flat feet can hurt and limit gait. There is no... (Review)
Review
BACKGROUND
Paediatric flat feet are a common presentation in primary care; reported prevalence approximates 15%. A minority of flat feet can hurt and limit gait. There is no optimal strategy, nor consensus, for using foot orthoses (FOs) to treat paediatric flat feet.
OBJECTIVES
To assess the benefits and harms of foot orthoses for treating paediatric flat feet.
SEARCH METHODS
We searched CENTRAL, MEDLINE, and Embase to 01 September 2021, and two clinical trials registers on 07 August 2020.
SELECTION CRITERIA
We identified all randomised controlled trials (RCTs) of FOs as an intervention for paediatric flat feet. The outcomes included in this review were pain, function, quality of life, treatment success, and adverse events. Intended comparisons were: any FOs versus sham, any FOs versus shoes, customised FOs (CFOs) versus prefabricated FOs (PFOs).
DATA COLLECTION AND ANALYSIS
We followed standard methods recommended by Cochrane.
MAIN RESULTS
We included 16 trials with 1058 children, aged 11 months to 19 years, with flexible flat feet. Distinct flat foot presentations included asymptomatic, juvenile idiopathic arthritis (JIA), symptomatic and developmental co-ordination disorder (DCD). The trial interventions were FOs, footwear, foot and rehabilitative exercises, and neuromuscular electrical stimulation (NMES). Due to heterogeneity, we did not pool the data. Most trials had potential for selection, performance, detection, and selective reporting bias. No trial blinded participants. We present the results separately for asymptomatic (healthy children) and symptomatic (children with JIA) flat feet. The certainty of evidence was very low to low, downgraded for bias, imprecision, and indirectness. Three comparisons were evaluated across trials: CFO versus shoes; PFO versus shoes; CFO versus PFO. Asymptomatic flat feet 1. CFOs versus shoes (1 trial, 106 participants): low-quality evidence showed that CFOs result in little or no difference in the proportion without pain (10-point visual analogue scale (VAS)) at one year (risk ratio (RR) 0.85, 95% confidence interval (CI) 0.67 to 1.07); absolute decrease (11.8%, 95% CI 4.7% fewer to 15.8% more); or on withdrawals due to adverse events (RR 1.05, 95% CI 0.94 to 1.19); absolute effect (3.4% more, 95% CI 4.1% fewer to 13.1% more). 2. PFOs versus shoes (1 trial, 106 participants): low to very-low quality evidence showed that PFOs result in little or no difference in the proportion without pain (10-point VAS) at one year (RR 0.94, 95% CI 0.76 to 1.16); absolute effect (4.7% fewer, 95% CI 18.9% fewer to 12.6% more); or on withdrawals due to adverse events (RR 0.99, 95% CI 0.79 to 1.23). 3. CFOs versus PFOs (1 trial, 108 participants): low-quality evidence found no difference in the proportion without pain at one year (RR 0.93, 95% CI 0.73 to 1.18); absolute effect (7.4% fewer, 95% CI 22.2% fewer to 11.1% more); or on withdrawal due to adverse events (RR 1.00, 95% CI 0.90 to 1.12). Function and quality of life (QoL) were not assessed. Symptomatic (JIA) flat feet 1. CFOs versus shoes (1 trial, 28 participants, 3-month follow-up): very low-quality evidence showed little or no difference in pain (0 to 10 scale, 0 no pain) between groups (MD -1.5, 95% CI -2.78 to -0.22). Low-quality evidence showed improvements in function with CFOs (Foot Function Index - FFI disability, 0 to 100, 0 best function; MD -18.55, 95% CI -34.42 to -2.68), child-rated QoL (PedsQL, 0 to 100, 100 best quality; MD 12.1, 95% CI -1.6 to 25.8) and parent-rated QoL (PedsQL MD 9, 95% CI -4.1 to 22.1) and little or no difference between groups in treatment success (timed walking; MD -1.33 seconds, 95% CI -2.77 to 0.11), or withdrawals due to adverse events (RR 0.58, 95% CI 0.11 to 2.94); absolute difference (9.7% fewer, 20.5 % fewer to 44.8% more). 2. PFOs versus shoes (1 trial, 25 participants, 3-month follow-up): very low-quality evidence showed little or no difference in pain between groups (MD 0.02, 95% CI -1.94 to 1.98). Low-quality evidence showed no difference between groups in function (FFI-disability MD -4.17, 95% CI -24.4 to 16.06), child-rated QoL (PedsQL MD -3.84, 95% CI -19 to 11.33), or parent-rated QoL (PedsQL MD -0.64, 95% CI -13.22 to 11.94). 3. CFOs versus PFsO (2 trials, 87 participants): low-quality evidence showed little or no difference between groups in pain (0 to scale, 0 no pain) at 3 months (MD -1.48, 95% CI -3.23 to 0.26), function (FFI-disability MD -7.28, 95% CI -15.47 to 0.92), child-rated QoL (PedsQL MD 8.6, 95% CI -3.9 to 21.2), or parent-rated QoL (PedsQL MD 2.9, 95% CI -11 to 16.8).
AUTHORS' CONCLUSIONS
Low to very low-certainty evidence shows that the effect of CFOs (high cost) or PFOs (low cost) versus shoes, and CFOs versus PFOs on pain, function and HRQoL is uncertain. This is pertinent for clinical practice, given the economic disparity between CFOs and PFOs. FOs may improve pain and function, versus shoes in children with JIA, with minimal delineation between costly CFOs and generic PFOs. This review updates that from 2010, confirming that in the absence of pain, the use of high-cost CFOs for healthy children with flexible flat feet has no supporting evidence, and draws very limited conclusions about FOs for treating paediatric flat feet. The availability of normative and prospective foot development data, dismisses most flat foot concerns, and negates continued attention to this topic. Attention should be re-directed to relevant paediatric foot conditions, which cause pain, limit function, or reduce quality of life. The agenda for researching asymptomatic flat feet in healthy children must be relegated to history, and replaced by a targeted research rationale, addressing children with indisputable foot pathology from discrete diagnoses, namely JIA, cerebral palsy, congenital talipes equino varus, trisomy 21 and Charcot Marie Tooth. Whether research resources should continue to be wasted on studying flat feet in healthy children that do not hurt, is questionable. Future updates of this review will address only relevant paediatric foot conditions.
Topics: Child; Flatfoot; Foot Orthoses; Humans; Pain; Pain Measurement; Quality of Life
PubMed: 35029841
DOI: 10.1002/14651858.CD006311.pub3 -
International Journal of Environmental... Sep 2022This study aimed to conduct a meta-analysis of randomized controlled trials to examine the effects of the short-foot exercise (SFE) compared to foot orthosis or other... (Meta-Analysis)
Meta-Analysis Review
This study aimed to conduct a meta-analysis of randomized controlled trials to examine the effects of the short-foot exercise (SFE) compared to foot orthosis or other types of interventions. Eligibility criteria involved participants with flatfoot engaging in the SFE compared to other forms of intervention or control groups without specific intervention. Relevant studies published before the end of June 2022 were identified from databases. A meta-analysis was performed by calculating the mean differences (MD) and standard MD (SMD) using the random effects model. Six trials with 201 patients (out of 609 records) that met selection criteria were reviewed. Five of the six trials implemented distinct interventions in the control group such as shoe insoles and muscle strengthening exercises, while in the remaining trial, controls received no intervention. The SFE group significantly reduced the navicular drop test (NDT) values (MD: -0.23; 95% confidence interval: -0.45 to -0.02; = 0.04) and the foot posture index (FPI-6) score (MD: -0.67; 95% confidence interval: -0.98 to -0.36; < 0.0001) when compared to the control group. The muscle hypertrophy did not differ significantly between the groups. The SFE may contribute more benefits than other intervention as it affects flatfoot individuals' foot alignment. Hence, the SFE is recommended as a beneficial dynamic support when facing flatfoot problems.
Topics: Exercise Therapy; Flatfoot; Foot; Humans; Hypertrophy; Muscles
PubMed: 36231295
DOI: 10.3390/ijerph191911994 -
Obesity Reviews : An Official Journal... Mar 2021There is evidence that a number of medical conditions and co-morbidities are associated with obesity in young children. This review explored whether there is evidence of... (Meta-Analysis)
Meta-Analysis Review
Obesity in young children and its relationship with diagnosis of asthma, vitamin D deficiency, iron deficiency, specific allergies and flat-footedness: A systematic review and meta-analysis.
There is evidence that a number of medical conditions and co-morbidities are associated with obesity in young children. This review explored whether there is evidence of associations with other conditions or co-morbidities. Observational studies of young children (mean age < 10 years) were identified using electronic searches of five databases (MEDLINE, Embase, CINAHL, AMED and SPORTDiscus). Of 27 028 studies screened, 41 (comprising 44 comparisons) met the inclusion criteria. These studies provided data on five distinct diseases/conditions: asthma (n = 16), vitamin D deficiency (n = 10), iron deficiency (n = 10), allergies (n = 4) and flat-footedness (n = 4). Thirty-two studies were appropriate for meta-analysis using random-effects models, and revealed obesity was significantly associated with having asthma (OR 1.5, 95% CI 1.3-1.7), vitamin D deficiency (OR 1.9, 95% CI 1.4-2.5) and iron deficiency (OR 2.1, 95% CI 1.4-3.2). Heterogeneity (I ) ranged from 57% to 61%. Narrative synthesis was conducted for all studies. There was no evidence of a consistent association between obesity in young children and eczema, dermatitis or rhinitis due to the low number of studies. However, there was an association with flat-footedness. These results have implications for health policy and practice and families. Further research leading to a greater understanding of the associations identified in this review is suggested.
Topics: Anemia, Iron-Deficiency; Asthma; Child; Child, Preschool; Flatfoot; Humans; Pediatric Obesity; Vitamin D Deficiency
PubMed: 32808447
DOI: 10.1111/obr.13129 -
International Journal of Environmental... Jul 2021Adult flatfoot leads to injury and decreased quality of life. The most widely applied noninvasive approaches are wearing foot orthoses or exercising. Both interventions... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Adult flatfoot leads to injury and decreased quality of life. The most widely applied noninvasive approaches are wearing foot orthoses or exercising. Both interventions raise controversy about reducing pain and neutralizing foot posture. This study investigated the impact of foot orthoses and exercise on pain and navicular drop (present for foot posture).
METHODS
Four databases were used: MEDLINE, PubMed, Web of Science, and Cochrane, from the earliest records to November 2020. Randomized controlled studies focused on adult flatfoot that evaluated the effect of exercise and foot orthoses on pain and navicular drop were extracted. We used data analysis to estimate the relative effect of heterogeneity using and publication bias using funnel plots.
RESULTS
Ten studies were identified through to November 2020. Active interventions (AIs) were exercise and exercise combined with foot orthoses; passive interventions (PIs) were foot orthoses and added stretching. Both AIs and PIs decreased pain significantly (SMD -0.94, 95% CI -1.35, -0.54 and SMD -1.4, 95% CI -1.87, -0.92). The AIs reduced pain level better than PIs. Controversially, no treatment was found to affect navicular drop.
CONCLUSION
Both exercise and foot orthoses can reduce pain but not realign foot posture. Exercise alone or combined with foot orthoses showed a better effect on adult flatfoot than only wearing foot orthoses. Active intervention was shown to have better efficacy in reducing pain than passive intervention.
Topics: Adult; Flatfoot; Foot Orthoses; Humans; Network Meta-Analysis; Pain; Quality of Life
PubMed: 34360354
DOI: 10.3390/ijerph18158063 -
JBJS Essential Surgical Techniques 2022Proximal medial gastrocnemius release (PMGR) is a technique that is performed to relieve tension in the Achilles-calcaneus-plantar system when a biomechanical overload...
UNLABELLED
Proximal medial gastrocnemius release (PMGR) is a technique that is performed to relieve tension in the Achilles-calcaneus-plantar system when a biomechanical overload is present. One of the main indications for this technique is recalcitrant plantar fasciitis. This procedure may also be useful in second-rocker metatarsalgia or midportion Achilles tendinitis. It is considered to be an easy and safe method for achieving good results.
DESCRIPTION
PMGR is performed with the patient in the prone position. A thigh tourniquet is not utilized. We prefer to use spinal anesthesia, but local anesthesia could be applied along with sedation. A posteromedial incision is made on or just below the posterior knee crease. The crural fascia is divided, and the proximal insertion of the medial gastrocnemius is identified. Performing the "hook maneuver" with a curved dissector is helpful at this step. Only the white fibers are sectioned in order to allow for a lengthening of the muscular fibers that is completed with forceful ankle dorsiflexion. After proper hemostasis has been achieved, the subcutaneous layer and skin are closed, leaving the fascia open.
ALTERNATIVES
Nonoperative treatment should be the first option, including analgesics, insoles, heel cups, calf-stretching, injections, and extracorporeal shock wave therapy. Some authors have also suggested that application of a walking cast for 3 to 6 weeks should be attempted. Once all of these treatment options have failed, operative treatment is appropriate. Historically, open plantar fasciotomy was offered to patients with recalcitrant plantar fasciitis, and this treatment continues to be a surgical option. Other procedure, like the Strayer, Vulpius, or Baumann techniques, involve the calf system and are called "gastrocnemius recession." However, these techniques act in the more distal aspect of the calf system compared with PMGR.
RATIONALE
PMGR offers patients with recalcitrant plantar fasciitis rapid recovery and good results. This procedure obviates the complications associated with plantar fasciotomy, in which the medial aspect of the proximal plantar fascia is divided to relieve the overload. A plantar fasciotomy (either open or endoscopic) risks lateral column overload or a painful flatfoot if >50% of the fascia is divided. A long recovery period following plantar fasciotomy has also been described. On the other hand, other procedures have been utilized to lengthen the Achilles-calcaneus-plantar system to an even greater extent. Techniques like the Silfverskiöld (i.e., medial and lateral proximal gastrocnemius release) or Strayer (i.e., division of the distal aspect of the gastrocnemius fascia) technique present a higher rate of complications (up to 38%), specifically nerve injuries. We consider these procedures (classified as gastrocnemius recession procedures) more properly indicated for patients with neurological diseases or with an equinus contracture. The medial gastrocnemius is the more powerful of the 2 bellies. Releasing the medial head alone offers a robust decrease in tension and is safer than approaching the lateral head of the gastrocnemius. At the same time, this technique provides a quick recovery for the patient. PMGR can also help those patients with other clinical signs related to gastrocnemius tightness, such as calf cramps and pain or repeated muscle injuries. Moreover, it can be effective in patients with second-rocker metatarsalgia or midportion Achilles tendinitis.
EXPECTED OUTCOMES
PMGR has a reported rate of satisfaction of >80%. Most patients undergoing this procedure experience substantial pain relief within the first 2 to 3 months. PMGR is an outpatient procedure with a short operative time and a rapid return to recreational and labor activities. The complication rate is low, and the most common complications are calf hematomas and delayed wound healing. The present article demonstrates a reduction in pain and good functional results. An improvement in the perception of health-related quality of life, especially in the physical and pain domains of the Short Form-36 questionnaire, was also observed.
IMPORTANT TIPS
The prone position allows for direct access to the proximal medial head of the gastrocnemius. Preferably, perform PMGR without a tourniquet in order to assure proper hemostasis. Keep the ankle joint free at the end of operating table because ankle dorsiflexion is a helpful maneuver at some stages in this procedure. Digital (index finger) dissection should be performed among the medial head of the gastrocnemius, the hamstrings, and the posterior aspect of the proximal tibia. The hook maneuver, performed with use of a blunt dissector, is helpful to identify all of the white fibers. Only white fibers should be divided. The surgeon must also make sure to cut the more anterior part of the aponeurosis that is hidden by red fibers. After cutting the white fibers, forceful ankle dorsiflexion is required to obtain full lengthening of the muscle. Proper hemostasis should be achieved to prevent formation of a calf hematoma. Advise the patient to do calf-stretches as soon as pain permits in order to prevent a contracting muscle scar.
ACRONYMS & ABBREVIATIONS
PMGR = proximal medial gastrocnemius releaseESWT = extracorporeal shock wave therapySD = standard deviation.
PubMed: 35692721
DOI: 10.2106/JBJS.ST.20.00039 -
Cureus Sep 2023Congenital vertical talus (CVT) is the presence of rigid flatfoot deformity characterized by hindfoot valgus and equinus. This foot deformity is associated with midfoot... (Review)
Review
Congenital vertical talus (CVT) is the presence of rigid flatfoot deformity characterized by hindfoot valgus and equinus. This foot deformity is associated with midfoot dorsiflexion and forefoot abduction due to a fixed dorsal dislocation of the navicular relative to the head of the talus. It is often underdiagnosed in children due to its similarity to other disorders of the foot. Misdiagnosis of CVT and subsequent failure to address it leads to significant disability and pain. While past surgical management consisted of soft tissue releases that produced varying efficacy, current management of CVT consists of serial casting and minimally invasive procedures that have yielded excellent long-term outcomes. This review provides insight into the diagnosis and treatment of CVT with the intention of highlighting the importance of promptness of intervention to prevent further disability.
PubMed: 37753062
DOI: 10.7759/cureus.45867 -
European Journal of Physical and... Jun 2023Flatfoot is a musculoskeletal problem associated with dysfunctional active and passive supporting structures of the normal foot curvature. Strengthening of the intrinsic... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Flatfoot is a musculoskeletal problem associated with dysfunctional active and passive supporting structures of the normal foot curvature. Strengthening of the intrinsic foot muscles or using shoe orthosis are recommend treatment approaches. However, investigating the effect of combining both approaches is still warranted.
AIM
To examine the effect of applying short foot exercises (SFE) combined with shoe insole versus shoe insole alone on foot pressure measures, pain, function and navicular drop in individuals with symptomatic flexible flatfoot.
DESIGN
Prospective, active control, parallel-group, assessor-blinded, randomized controlled trial and intention-to-treat analysis.
SETTING
Outpatient physical therapy clinic of a university teaching hospital.
POPULATION
Forty participants with symptomatic flexible flatfoot.
METHODS
A six-week treatment protocol of SFE (three sets of 10 repetitions a day) in addition to shoe insole (eight hours a day) (experimental group, N.=20) or shoe insole only (eight hours a day) (control group, N.=20). Clinic visits were made at baseline and every two weeks for monitoring and follow-up. The static and dynamic foot area, force and pressure measures, pain, lower extremity function, and navicular drop were assessed at baseline and postintervention.
RESULTS
Forty participants joined the study and 37 (92.5%) completed the six-week intervention period. Foot pressure, pain and function showed a significant interaction (P=0.02 - <0.001) and time (P<0.001) effects with a non-significant group effect in favor of the experimental group. Post-hoc analysis revealed that the experimental group had lesser pain (P=0.002) and better function (P=0.03) than the control group at six weeks. Navicular drop decreased equally in both groups.
CONCLUSIONS
Implementation of shoe insole and SFE for six weeks improved pain and function and altered foot pressure distribution greater than shoe insole alone in patients with symptomatic flatfoot.
CLINICAL REHABILITATION IMPACT
Wearing shoe insole is an easy, but passive, treatment approach for a flatfoot problem. This study provided evidence regarding the added benefit of SFE. It is recommended that rehabilitation practitioners implement a comprehensive treatment protocol including both shoe insole and SFE for at least six weeks to achieve better results for their flatfoot patients.
Topics: Humans; Flatfoot; Prospective Studies; Foot Orthoses; Foot; Pain
PubMed: 36988565
DOI: 10.23736/S1973-9087.23.07846-2