When Should Manual Therapy & Foot Orthoses be Added to the ... · baropodometry. • Results:’Signiﬁcantchange’in’anterior’ ... – Newell (Phys Sports Med 1981) • Described

When Should Manual Therapy & Foot Orthoses be Added to the

Physical Therapy Plan of Care?

Paul Mintkin, PT, DPT, OCS, FAAOMPT Thomas McPoil, PT, PhD, FAPTA

University of Colorado Denver

12/3/12

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Current Evidence to Support Manual Therapy for Foot & Ankle Disorders

Paul Mintken PT, DPT, OCS, FAAOMPT Associate Professor

University of Colorado School of Medicine Department of Physical Therapy

Email: [email protected]

Objectives

•  Review the current best evidence for manual therapy for foot and ankle disorders

•  Describe common conditions that may benefit from manual therapy

•  Identify patients that may respond to manual therapy for the foot and ankle

Introduc>on

•  Substan>al evidence suppor>ng manual therapy for other regions.

•  Ankle/Foot: Is the evidence there? •  Should this informa>on change your clinical prac>ce?

•  Considera>on of regional interdependence.

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Menz HB, The Foot, 1998

… there are considerable limitations in the manual therapy paradigm and a great deal of further research is required before the technique’s scientific credibility

can be established…

…in its current form the practice of foot and ankle manipulation must be viewed as a non-standard or

alternative therapy…

Effec%veness of manual therapies: the UK evidence report

Bronfort et al. Chiroprac)c & Osteopathy 2010

Ankle Sprains

•  23,000 ankle injuries daily in the US •  10-‐15% of all sports related injuries •  Lateral ankle sprain most common •  Intrinsic Risk factors (de Noronha 2006):

– History of ankle injuries – Decreased DF ROM – Postural sway

Kerhoffs et al. Cochrane Database Syst Rev .2009

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Manual Therapy in the Management of Ankle Sprains

•  Is it safe? •  Does it lead to improved outcomes? •  What techniques are commonly u>lized? •  When during the course of injury can I apply these techniques?

•  Is there a sub-‐group who respond to MT?

Green et al, Physical Therapy, 2001

Design: RCT Population: N=38, acute sprain (< 72 hrs) Outcomes: DF ROM, 3 gait parameters Intervention: RICE vs RICE + mob (< 14 days)

Results: RICE + Mob group ↑ DF Within session ↑ in stride speed &

length

Limitations: Use of ROM as main outcome No objective measurement of pain or function No exercise, balance training included

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O’Brien & Vicenzino, Manual Therapy, 1998

•  Design: Single subject design (BABC, ABAC) •  Population: N=2; 1st acute inversion sprain •  Intervention: MWM & taping •  Outcomes:

•  Pain (VAS) & AROM (inversion, WB DF) •  Function: VAS (“no function” to “full function”) •  Kaikkonen Scale (functional performance test)

•  Results: •  Pain, Inv ROM, function (performance test) –

greater rate of improvement during rx periods Kaikkonen et al. A performance test protocol and scoring scale for the

evaluation of ankle injuries. AJSM 1994; 22: 462-469.

Collins et al, Manual Therapy, 2004

Design: Double-blind, RCT Population: N=16 subjects, sub-acute (Gr II, subjects own controls) Outcomes: DF ROM, pain (pressure, thermal) Interventions:

Mobilization-with-movement (MWM) Placebo MWM Relaxed stance – 5”

Results: MWM ↑ DF ROM (within session) Limitation:

Immediate outcomes only No functional outcomes assessed

cm

Vicenzino et al. JOSPT 2006

•  N= 16, chronic ankle sprain. •  Within subjects design. •  3 condi>ons: ▲  WB MWM ❍ NWB MWM ♢ Control

•  Outcomes: –  Inc WB DF ROM –  Posterior talar glide ROM.

PEDro Score = 7/10

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Reid et al. Physiotherapy Canada 2007

•  N = 23 – Ankle sprains within last 2 years, limited DF.

•  Randomized cross over design. •  Sham vs. WB MWM •  Outcome: WB DF ROM •  Change in DF following

– MWM: .63 cm –  Sham: .18 cm

PEDro Score = 7/10

Eisenhart et al, JAOA, 2003

Design: RCT Population: N=55, acute sprains (<24 hrs), in ED Outcomes: Edema, AROM, Pain (immed, 7 days) Intervention:

•  Control – RICE, analgesics, crutches •  Experimental - Addition of manual rx

Results: •  Post-treatment – sig change in pain & edema with manual rx •  1 Wk – All improved in all measures •  Significant between group difference in ROM

Limitations: •  No blinding, no assessment of function/disability, reliability of

ROM measurements

Pellow and BranGngham, JMPT, 2001

Design: RCT Population: N=36, Gr I-II, sub-acute & chronic

Outcomes: Pain, ROM, function (baseline, 4 wk, 2 mo)

Intervention: < 8 sessions, 4 wks Group 1: Placebo US (5 min) Group 2: “Adjustment” (mortise separation)

Results: Grp 2 - improved pain, ROM, function Limitations

•  Assessor not blinded to group •  No ITT •  No exercise or balance training •  Re-injury = exclusion •  (5 dropped)

VAS - Pain

McGill Pain Questionnaire

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Anderson et al. ACO 2003

•  N = 52 subjects with h/o inversion ankle sprain. –  Subjects not currently repor>ng pain and injury occurring > 6 months previously.

•  Treatment group: TCJ Distrac>on Thrust. •  Control: No interven>on. •  Outcome: Immediate change DF ROM

–  No difference between groups. –  Subjects in thrust group who experienced a cavita>on had the largest increase in DF ROM.

Lopez-‐Rodrıguez et al. JMPT 2007

•  N= 52 field hockey players with GD II Ankle sprains

•  Group 1: TC Thrust manipula>on and posterior talar glide manipula>on

•  Group 2: Placebo (setup, no manip) •  Outcome: WB load distribu>on using baropodometry.

•  Results: Significant change in anterior and posterior load distribu>on in foot in MT group compared to placebo.

Kohne et al. J Amer Chiro Assoc. 2007

•  RCT •  N = 30 pa>ents with recurrent GDI-‐II ankle sprains.

•  Group 1: 6 sessions distrac>on thrust manipula>on over 4 weeks.

•  Group 2: same manip 1x •  Outcome: increased ankle DF and joint posi>on sense Group 1 at 5 weeks.

PEDro Score = 3/10

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Cosby et al JMMT 2011

•  17 pa>ents (9 Tx, 8 control) with acute lateral ankle sprain

•  Examined effects of single bout of Grade III AP TC joint mob –  Self-‐reported func>on –  Dorsiflexion ROM

–  Posterior talar transla>on •  Both groups had improved

dorsiflexion ROM and func>on •  Significant improvements in

pain in Rx group

Grindstaff et al J Electromyogr Kines 2011

Immediate effects of >b-‐fib manipula>on on lower extremity H-‐reflex measurements in individuals with chronic ankle instability (CAI) •  43 subjects randomized to

–  Prox >bfib manip –  Distal >bfib manip –  Control

•  Measured max H-‐reflex and max M-‐wave measurements (H/M ra>o) in peroneus longus and soleus

•  Distal >bfib group had significant increase (P < .05) in soleus H/M ra>o

•  Distal >bfib manip acutely increases soleus muscle ac>va>on

Beazell et al JOSPT 2012 Immediate effects of >b-‐fib manipula>on on ankle ROM and func>on in individuals with chronic ankle instability (CAI) •  43 subjects randomized to

–  Prox >bfib manip –  Distal >bfib manip –  Control

•  Measured dorsiflexion ROM, single-‐limb stance balance, the step-‐down test, and the FAAM sports subscale.

•  No significant differences between groups across >me.

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Hoch et al J Orthop Res 2012

•  Prospec>ve Cohort study of 12 pa>ents with CAI •  Examined effect of a 2-‐week AP ankle joint

mobiliza>on on –  Weight-‐bearing dorsiflexion ROM –  Dynamic balance –  Self-‐reported func>on (FAAM)

•  Outcomes assessed –  1 week before Rx (baseline) –  Prior to first Rx (pre-‐interven>on) –  24–48 h following the final Rx (post-‐interven>on) –  1 week later (1-‐week follow-‐up)

•  Results: –  Dorsiflexion ROM, balance, and the FAAM improved significantly (p < 0.05 for all)

Predic>ng Short-‐Term Response to Thrust and Nonthrust Manipula>on and Exercise

in Pa>ents Post Inversion Ankle Sprain JOSPT 2009

•  N = 85 •  Prospec>ve Cohort Single Arm Trial •  Standardized examina>on •  Standardized Interven>on up to 2 visits •  Inclusion criteria:

–  GD I-‐II inversion ankle sprains, ages 16-‐60, at least 3/10 on NPRS.

•  Exclusion criteria: –  GD III sprain, +OAR, Red Flags, prior ankle/foot surgery, fractures.

•  Success = at least +5 on GROC.

Manual Therapy Interven>ons

Whitman et al. JOSPT 2009

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Exercise Interven>on

•  Achilles WB & NWB stretch 3 x 30 sec. 2 x/day. •  Ankle ‘Alphabet’ 2x/day. •  Self mobiliza>on TC & ST 3 x 30 reps. •  Maintain ac>vity as tolerated •  Ice and eleva>on Whitman et al.

JOSPT 2009

CPR for Manual Therapy for Ankle Sprains Whitman et al JOSPT 2009

Pre-test Probability of Success

75%

> 3 factors present: •  Symptoms worse when standing •  Symptoms worse in the evening •  Navicular drop > 5 mm •  Distal tibiofibular joint

hypomobility

95%

Post-test Probability of Success +LR = 5.9

Fitzgerald KC Physical Therapy June 2010

•  “We should really ques>on whether a CPR is needed is when we start with a pretest or pretreatment probability of success that is already presy high. For example, there are 2 studies on the development of a CPR for treatment selec>on that reported pretreatment probabili>es of success on the order of 61% (Mintken et al 2010) and 75% (Whitman et al 2009).

•  I would argue that the pre-‐treatment probabili>es of success alone would induce me to try these treatment approaches without even considering use of the CPR derived in these studies. If you give me a treatment approach where the probability of success is likely to be greater than 60% and the probability of doing harm is low, I would not need a CPR to guide my decision to try the treatment approach.”

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Inversion Sprain Management: Role of Manual PT

•  No evidence of harm with ankle & foot manipulation •  Not a replacement for more conventional PT (van Os 2005,

Kerkoffs 2005, Zoch 2003) , but growing supportive evidence

•  Consider an adjunct based on individual response

•  More research is needed •  Assessors blind to treatment group •  Include pain, function, disability •  Comparison or control group •  Include exercise in the treatment program

Manual Therapy for Ankle Sprains Clinical Decision Making

•  Precau>ons & Red Flags •  Acute: avoid increased pain •  Severe, GD III Sprain •  Fracture & syndesmo>c injury •  Screen for associated injuries

•  Perform a lower quarter screen, especially if chronic •  Assess func>onal comparable sign •  Address Common Mobility Impairments •  MT & Exercise (including propriocep>on) •  Reassess func>onal comparable sign

Plantar Heel Pain

•  10% life>me prevalence. •  Most common foot condi>on treated by HCP’s.

•  Risk Factors – Decreased DF ROM*. –  BMI >30. –  Standing for a large part of the day.

•  <80% have resolu>on of symptoms within 12 months.

APTA Orthopaedic ICF Guidelines Heel Pain

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Young et al, JOSPT, 2004

•  4 cases with sub-acute to chronic plantar heel pain, sx duration 6 – 52 wks

•  Rx: 2-7 visits: –  All 4: Stretching & impairment based

manual therapy –  2 pts: custom orthoses –  1 pt: additional strengthening

•  Outcome: –  NPRS with agg activities 5.8/10 to 0/10 –  Return to normal ADLs

Evidence Based Management Plantar Heel Pain Guidelines

•  Orthoses: A – No difference custom vs. OTC

•  Stretching: B – Calf and plantar fascia

•  Iontophoresis: B •  Taping: C

– Calcaneal or Low Dye •  Manual Therapy: E

– Based on case series evidence. McPoil et al. Heel pain--plantar fasciitis: clinical practice guildelines. JOSPT. 2008;38(4):A1-A18.

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Is manual therapy and exercise more effective than a traditional approach in

the management of heel pain?

•  60 subjects with heel pain •  (18-60 yrs, LEFS ≤ 60 points)

•  RCT, 2 groups, 6 visits over 4 weeks: •  EPAX: traditional approach exercise

and modalities •  MPEX: manual therapy and exercise

•  Outcomes: •  LEFS (MCID = 9) •  FAAM (MCID = 8) •  NPRS •  GRC

LEFS FAAM NPRS

Discussion

•  MTEX superior to EPAX •  Differences in func>on surpassed MCID •  2 clinics from 2 countries •  90% FU at 6-‐months •  NNT = 4 for successful outcome MTEX group at 4 wks and 6mo

•  Future research: –  > 6 visits lead to more improvement? – How would MTEX +/-‐ Ortho>cs or night splint compare?

– Neurodynamic interven>ons.

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Conclusion-‐ Heel Pain

McPoil et al, Heel Pain-Plantar Fasciitis: Clinical Practice Guidelines, JOSPT ‘08 •  Strong Evidence – orthotics (short term) •  Moderate Evidence – calf muscle/plantar fascia stretching, ionto, night splints •  Weak or Theoretical Evidence – manual therapy, low-Dye taping

–  Published prior to Cleland article on heel pain

Role of Manual PT Interventions •  Part of a comprehensive program to address lower quarter impairments •  Manual therapy + exercise > electrophysiologic agents + exercise

Cuboid syndrome

•  Pain plantar region of cuboid •  Mechanism: forceful contrac>on of the peroneus longus with plantar subluxa>on.

•  Prevalence: – Dancers 17% of foot/ankle injuries – Athletes 4% of foot injuries –  Lateral ankle sprains 7%

Adams & Madden Current Sports Medicine Reports 2009

Mooney & Maffey-‐Ward JOSPT 1994

Diagnosis

•  Pain during gait with reduced push-‐off.

•  Localized pain and tenderness.

•  Pain with passive physiological and accessory mo>on tes>ng.

•  Evidence on radiograph or CT?

Adams & Madden Current Sports Medicine Reports 2009

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Cuboid Subluxa>on •  Several case series:

–  Newell (Phys Sports Med 1981) •  Described original manipulation as the

"Black Snake Heel Whip." –  Marshal & Hamilton (Am J Sports Med 1999)

•  N=3, ballet dancers •  Rx with manipulation, returned to dancing

and no recurrence long-term –  Mooney& Maffey-Ward (JOSPT 1994)

•  N=2, both s/p sprain in past •  Successfully treated with manip

Hallux rigidus/limitus •  Degenera>ve arthrosis 1st MTP •  2nd most common great toe disorder.

•  Effects 1/45 over age 50. •  Most common injury to great toe in athletes.

•  RCT’s for conserva>ve management lacking.

•  2 case reports using manual Rx: –  Bran>ngham &Wood, J Chiro Medicine 2002

–  Shamus et al, JOSPT, 2004

Bran>ngham & Wood 2002

Shamus et al, JOSPT, 2004

Design: RCT Population: N=20, functional hallux limitus Outcomes: First MPJ extension, FHL strength, pain •  Intervention: TIW x 4 wk

–  Group 1: Traditional PT (gastroc/HS stretching, US 8”, whirlpool 15”, MTP passive ROM, mob to MTJ, marble pick up, seated PWB MTP ext, e-stim 15”)

–  Group 2: Traditional PT + sesamoid mob, FHL strengthening, gait training

–  Results: Group 2 – sig better all outcomes •  Limitations: Low sample size, non-blinded

assessor

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Bran>ngham &Wood J Chiro Medicine 2002

•  Case report of professional tennis player with hallux rigidus.

•  Authors describe manipula>ve techniques to restore mo>on without irrita>ng joint. Non-‐thrust trac>on

Trac>on thrust 1st MTP

Hallux Valgus

•  Affects 1% of adults in the US. •  Incidence increased with age

–  3% 15-‐30 years –  9% 31-‐60 years –  16% > 60 years

•  Female to Male ra>o -‐ 2:1 to 4:1

Hallux Valgus Bran>ngham et al. Clin Chiro 2007

•  Pilot RCT, n= 60 with HV •  6 visits TIW x 2 weeks •  Group A: progressive manipula>ve therapy and ice.

•  Group B: detuned ac>on poten>al.

•  Outcomes: MT group with significant decrease in pain and improved FFI compared to control at 1 week follow up.

PEDro Score = 3/10

Non thrust trac>on

Thrust and non-‐thrust trac>on with adduc>on

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Morton’s Neuroma Govender et al. J Am Chiro Assoc, 2007

•  N = 40 pa>ents with morton’s neuroma

•  Treatment biw x 3 weeks. •  Group 1: manual therapy •  Group 2: detuned US •  Both groups advised to avoid >ght footwear.

•  Outcomes 6 weeks: –  Significant decreased pain in MT group –  No difference in FFI.

PEDro Score = 5/10

Bran>ngham et al. Manipula>ve Therapy for Lower Extremity Condi>ons: Update of a

Literature Review. JMPT. 35(2); 2012: 127–166 Review of literature from March 2008 to May 2011. •  Inclusion criteria required LE diagnosis and MT with or without other care Results •  48 clinical trials were assessed for quality.

Menz HB, The Foot, 1998

“…foot and ankle manipulation must be viewed as a non-standard or alternative therapy…”

Do we have enough evidence now to refute this statement?

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Summary: Manual Therapy for Ankle & Foot Disorders

•  Poor-‐Moderate quality evidence for the use of MT

•  MT should complement other evidence based interven>ons.

•  Considera>on of Regional Interdependence

•  If there is impaired joint mobility, assess, treat and reassess!

•  As Tim Flynn says “Move It and Move On!”

Questions? Email: [email protected]

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Current Evidence to Support the Use of Foot

Orthoses Thomas McPoil, PT, PhD, FAPTA

School of Physical Therapy

Why Prescribe Foot Orthoses? •  Re-distribute the pressures acting on the

plantar surface of foot –  Hyposensitive foot (diabetes, peripheral neuropathy) –  Hypersensitivity

•  Primary & Secondary Metatarsalgia, Morton’s Toe, Interdigital Neuroma, Sesamoiditis

•  Increase the contact surface area –  Pes cavus or Rigid Pes Planus

•  Motion Control –  Plantar Fasciitis, General Arch Pain, Posterior Tibial

Tendonitis, Medial Tibial Stress Syndrome, Anterior Knee Pain

Foot Orthoses •  Types of Foot Orthoses that have been

proposed for MOTION CONTROL • Cobra Pad, Functional Foot Orthosis (usually

with intrinsic or extrinsic posting), Blake Inverted, MASS device, Kirby Heel Skive, Off-the-Shelf or Pre-Fabricated, Prescription, Custom, Proprioceptive, Accommodative

– Material density used in construction • Soft, Hard, Semi-Rigid, or Rigid

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Foot Orthoses •  Types of Foot Orthoses that have been

proposed for MOTION CONTROL • Cobra Pad, Functional Foot Orthosis (usually

with intrinsic or extrinsic posting), Blake Inverted, MASS device, Kirby Heel Skive, Off-the-Shelf or Pre-Fabricated, Prescription, Custom, Proprioceptive, Accommodative

– Material density used in construction • Soft, Hard, Semi-Rigid, or Rigid

Types of Foot Orthoses that have been proposed for MOTION CONTROL

•  Functional Foot Orthosis (“classic podiatric device”) –  Device developed by Root, Orien,

& Weed –  Usually prescribed with 4 to 6o

RF medial post with required FF posting

–  Posting could be •  Intrinsic – added to cast

impression •  Extrinsic – added to bottom of

orthoses

The Wedging or “Posting” of the Orthoses to “Balance” the Intrinsic Deformity

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Functional Foot Orthoses •  Basis for this theory is:

Functional Foot Orthoses

•  How did Podiatry prevent the “functional foot orthoses” from becoming an arch support?

•  ARCH FILL –  The medial longitudinal arch

region on model of patient’s foot is reduced or “filled in” by adding 1/4” to 1/2” of plaster

Superior View

Foot Casting to “Capture” the Intrinsic Deformity

Neutral Position Slipper Cast

Modifications to Positive Mold

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Important Issues Related to the Design and Prescription

•  The ARCH “FILL IN”

Medial View

Superior View

Effect of Arch Fill

Positioned in SJNP Positioned in RSP

Types of Foot Orthoses that have been proposed for MOTION CONTROL

•  Blake inverted orthotic –  First described by R. Blake in

1986 •  Blake JAPMA 1986 76:275-276

–  Designed to provide “greater” control of abnormal foot pronation

–  Usually has a 15o to 25o of medial posting in RF & FF

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BLAKE INVERTED DEVICE

•  Williams, et al; Med Sci Sport Exer, 2003 –  Assessed 3-D kinematics and kinetics of rearfoot and knee –  11 subjects tested

–  Control, Standard Orthotic (4o RF post), Inverted Orthotic (15 -25o posted) –  Initially fitted with standard orthotic with partial or limited relief of symptoms –  All subjects able to return to pain-free running with use of Inverted Devices

–  RESULTS •  No differences among orthotics for peak eversion control

–  Control = 7.49o Standard = 9.1o & Inverted = 8.7o

•  Ferber, et al; J Biomech, 2005 –  Assessed effect on rearfoot & leg coupling using same subjects –  RESULTS

•  No differences among orthotics in rearfoot – tibial coupling patterns •  Concluded symptom relief with inverted orthotics likely due to other factors

Theories for Using Foot Orthoses for Motion Control

•  The “biomechanical” paradigm is the classic reason for use of FOs based on the hypotheses “that abnormal or excessive foot pronation is a major contributor to lower limb injuries”

•  In addition to “biomechanical” paradigm, two other paradigms proposed for using FOs for overuse injuries – Shock Attenuation – Neurosensory

Theories for Using Foot Orthoses for Motion Control

•  Shock Attenuation – FOs act as cushioning interface between ground-shoe

& the foot

•  Neurosensory – FOs act to provide or modulate afferent input

through the plantar surface of the foot

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Systematic Reviews on Effectiveness

of Foot Orthoses •  Mills, et al: Br J Sports Med, 2009

–  Included studies focused on mechanism of action, not efficacy from 1971 to 2008

–  20 papers met inclusion criteria (initial eval on 206 papers) •  30 different orthoses designs •  Described kinematic and kinetic variables

–  Reported on effectiveness for •  Motion Control •  Shock Attenuation •  Neurosensory

Systematic Reviews on Effectiveness of

Foot Orthoses •  Mills, et al: Br J Sports Med, 2009

–  Because of so many foot orthoses descriptions, developed the following FO classifications:

•  Posted Non-Molded –  FOs fabricated with NO specific contouring to patient’s foot

but with posting •  Non-Posted Molded

– Custom-made or contoured to the patient but with NO posting •  Posted & Molded

– Custom-made or contoured with posting •  Molded or Non-Molded with relief points

– Custom-made or contoured with modifications to relieve painful plantar regions


•  In example – The classic podiatric “functional

foot orthoses” would be classified as a Posted & Molded orthoses using a modified 3-D model of the patients foot

“MODIFIED” because of the arch fill

Superior

View

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•  In example – The “soft foot orthotics” described by Eng &

Pierrynowski (Phys Ther 1993) - caused short-term pain relief in AKP patients – was flat piece of Spenco insole material with rubber medial wedges – it would classified as Posted-Non-Molded orthoses



•  Results - MOTION CONTROL –  Posted-Molded and Posted Non-Molded orthoses have a

significant effect on decreasing rearfoot eversion •  Maximum reduction was 2.3o

•  Is 2o considered to be adequate for “motion control”? – How much of 2o is skin movement?

Example Illustrating Amount of “Motion Control” Provided

•  Data from Davis, et al: JAPMA, 98:394, 2008

Walking

Running

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•  RESULTS – SHOCK ATTENUATION

•  Molded orthoses either custom or pre-fabricated with or without posting, were most effective at attenuating loading rate & vertical impact forces

– Material density does not influence the biomechanical or shock attenuation role of the orthoses



•  RESULTS – NEUROSENSORY

•  Effect of orthoses design on the neurosensory system was inconclusive

•  Primary reason for this is highly variable response with lower leg EMG activity

Systematic Reviews on Effectiveness of Foot Orthoses

•  Collins et al: Foot & Ankle Int 28:396, 2007 –  Assessed clinical efficacy for using foot orthoses for LE

overuse conditions •  Possibly relevant papers identified n = 3,194

–  Excluded n = 2865 •  Retrived 327 papers for detailed evaluation

–  Excluded n = 305 (did not meet inclusion criteria) •  RCTs included in review = 22

–  Concluded Evidence to Support •  Use of foot orthoses to prevent 1st LE overuse incident

–  Difficult to support or refute use if already have overuse condition •  NO difference between CUSTOM & Pre-FABRICATED orthoses

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•  Hawke et al: Cochrane Database Syst Rev: 2008 Jul 16: CD006801

–  Assessed effectiveness of custom foot orthoses for foot pain •  11 RCTs included in review

–  5 trials – plantar fasciitis; 3 trials – Adult RA; 1 trail – Pes Cavus, HAV, Juvenile Idiopathic Arthritis (JIA)

–  Concluded •  Custom orthoses were effective for painful pes cavus; RF

pain in RA; foot pain in JIA •  Non-custom foot orthoses appear just as effective for JIA,

plantar fasciitis, or MTP joint pain in RA


•  Hossain, et al: Cochrane Database Syst Rev: 2011 Jan 19:CD008402 –  Assessed use of foot orthoses for patellofemoral pain in

adults •  2 RCTs with 210 participants included in review

–  CONCLUDED •  Contoured foot orthoses compared to flat orthoses caused

greater reduction in knee pain at 6 weeks, but not at 1 year F/U •  While foot orthoses may provide short-term knee pain relief,

the benefit may be marginal

Recommendations for Foot Orthoses used of MOTION CONTROL based on

Best Available Evidence

•  Posted-Molded orthoses would provide optimal biomechanical & shock attenuation effect

•  Material density of orthoses should be based on patient preference/comfort –  Mills et al: Clin Biomech 27:202, 2012

•  Pre-fabricated or Custom Foot Orthoses will provide a similar outcome – Most cost effective device can be used!

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SINCE Posting is Required for Optimal Motion Control

•  What is best method to determine amount of posting? – Podiatric Method

•  Palpation of subtalar joint neutral position has poor inter-rater reliability

•  Measurement techniques used in the “biomechanical” examination have poor inter-reliability

– Multiple clinicians cannot compare findings

– Treatment Direction Test •  Meier et al: Res Sports Med 2008; 48:36-42

Treatment Direction Test •  Highly successful in determining if patient is a

candidate for foot orthoses •  Vicenzino et al: Gait & Posture, 1997 •  Hadley et al: JAPMA, 1999 •  Vicenzino et al: JOSPT, 2000 •  Vicenzino: Manual Therapy, 2004

•  Meier et al assessed if TDT was successful – Could change in resting standing foot posture

created by taping be used to determine amount of orthotic posting

•  Posting is added in millimeters - NOT degrees

TDT CASE SERIES •  Meier et al: Research In Sports Med, 2008

– 7 high school athletes – 5 sports represented

•  Football, volleyball, X-country, soccer, basketball – All subjects had symptoms at least 2 weeks – Conditions included in case series

•  Medial tibial stress syndrome, anterior knee pain, arch pain, ITB syndrome

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Meier et al •  If athlete reported improvement in symptoms

after 3 days - then provided orthotics & followed for 1 month – VAS for pain – FAAM sports subscale

•  Orthotic posting based on change in Dorsal Arch Ht

Method used to Assess Dorsal Arch Height Change 2o to Tape

•  Step 1 –  Create template having

patient march-in-place

•  Step 2 –  On template, determine 50%

total foot length

•  Step 3 –  Assess dorsal arch hgt in

relaxed standing at 50% foot length point

Method used to Assess Dorsal Arch Height Change 2o to Tape

•  Step 4 –  Tape patient to provide

pronation control •  Step 5

–  Reassess dorsal arch hgt •  Best if done at end of workout

or after walking on treadmill to allow for tape stretching

•  Step 6 –  Orthotic posting based on

change in dorsal arch hgt created by tape

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Meier et al Change in DAH & Posting for LEFT Foot

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

Subj 1 Subj 2 Subj 3 Subj 4 Subj 5 Subj 6 Subj 7(in

cen

tim

ete

rs)

Chg in DAH

Posting

Change in DAH & Posting for RIGHT Foot

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

Subj 1 Subj 2 Subj 3 Subj 4 Subj 5 Subj 6 Subj 7

(in

cen

tim

ete

rs)

Chg in DAH

Posting

•  Maximum Amount of Posting = 3 mm

•  Orthotic Densities selected –  4 Blue –  2 Red –  1 Green

•  Posting applied to medial fore & rear of orthoses

Meier et al

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t


Percent Change in VAS Pain Scores

Day 3-PAIN

WK 2-PAIN

WK 4-PAIN

Meier et al Change Scores for FAAM Sports Subscale

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Day 3-FAAM

WK 2-FAAM

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Clinically Significant

Improvement

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Functional Posting Determined by Taping

•  Provides the clinician with – Function-based scheme to determine if

controlling foot pronation will decrease pain and symptoms while performing the provoking physical activity or sport;

– Amount of change in foot posture required by the foot orthoses to maintain or further improve pain reduction and function improvement

Systematic Reviews Assessing Effectiveness of Tape

•  Cheung et al: Br J Sports Med 45:743, 2011 – 29 studies selected for Review & Meta-Analysis

•  Assessed effectiveness of FO, Footwear, & Tape •  13 foot orthoses; 10 motion control footwear, 10 taping

– RESULTS •  Taping most effective (mean pronation reduction = 2.64o)

–  Low-Dye taping (mean change = 1.50o) –  Taping techniques ABOVE the ankle (mean change = 4.62o)

•  Motion Control Footwear (mean pronation reduction = 2.52o) •  Foot Orthoses (mean pronation reduction = 2.24o)

Foot Orthoses: Clinical Evidence •  For Plantar Fasciitis, current research indicates

– Pre-fabricated or custom foot orthoses can provide short-term (3 months) pain and function improvement.

•  Type of orthotic (custom vs. pre-fab) makes no differences in degree of pain or function improvement

– NO evidence to support use of orthotic for long-term ( >1 yr) pain or function improvement

•  Pfeffer et al. Foot Ankle Int 20:214, 1999 •  Martin et al, JAPMA 91:55, 2001 •  Landorf et al, Arch Intern Med 166:1305, 2006 •  Baldassin et al, Arch Phys Med Rehab 90:701, 2009

1

The Use of the FOOT POSTURE INDEX

for the Classification of Foot Posture

Paul Mintkin, PT, DPT, OCS, FAAOMPT Thomas McPoil, PT, PhD, FAPTA

University of Colorado Denver

Foot Posture Index (FPI) Redmond, 2005

•  FPI is a clinical tool designed to allow clinician to quantify observed foot posture –  Supinated, pronated, or normal position

•  The clinician attaches a score to 6 different observations of foot posture –  Pronation postures - positive score –  Normal postures - zero –  Supinated postures - negative score

•  The aggregate score gives an estimate of overall foot posture

FPI – Calcaneal Frontal Plane Position

Score -2 -1 0 +1 +2 > 5o inverted Between vertical &

5o inverted Vertical Between vertical

& 5o everted > 5o everted

2

Foot Posture Index •  Final FPI score is whole number between -12 & +12 •  RELIABILITY

–  Intra-rater is Good, Inter-rater is Moderate to Good •  Cornwall et al; JAPMA, 2008 •  Barton et al: JOSPT, 2010 •  Evans et al: JFAR, 2012

•  “Original” Classification of FPI (Redmond 2005) –  Normal = 0 to +5 –  Pronated = +6 to +9; Highly Pronated > +10 –  Supinated = -1 to -4; Highly Supinated > -5

Foot Posture Index •  Redmond et al; JFAR 1:6, 2008

–  Developed normative values based on 1007 healthy feet & 641 patients with defined pathologies

•  Various musculoskeletal symptoms; diabetic neuropathy; neurologic & idiopathic pes cavus

–  Results •  Slightly pronated foot posture in RSP is typical (FPI raw score = +4) •  No differences between males & females •  No relationship between FPI & BMI

Pathological Potentially Abnormal

Normal Range Potentially Abnormal

Pathological

< -2 SD -2 SD -1 SD Mean +1 SD + 2 SD > +2 SD

FPI Raw Score < -3 -3 +1 +4 +7 +10 > +10

Foot Posture Index •  Teyhen et al: JOSPT

41:100, 2011 –  Assessed the FPI on

1000 healthy individuals (right foot only)

–  To determine normal distribution of FPI values

•  Used original & modified REDMOND critieria

•  Used +/- 1.5 SD

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Foot Posture Index •  Reilly et al: Physiotherapy 95:164, 2009

–  Assessed foot posture using the FPI and ankle joint ROM in 60 individuals

•  20 with medial compartment knee OA; 20 healthy controls –  RESULTS

•  Patients with medial compartment knee OA had pronated feet – Median FPI score of 7.0 – Healthy subjects had median FPI of 1.0

•  Levinger et al: JFAR 3:29, 2010 –  32 individuals with medial compartment knee OA had

greater FPI in comparisons to healthy controls

Foot Posture Index •  Redmond et al: Clin Biomech 21:89, 2006

–  Assessed relationship of FPI to static & dynamic foot posture •  15 healthy subjects assessed using 3D motion analysis

–  Correlation Results •  FPI vs. static standing posture: r = .80; r2 = .64 •  FPI vs. foot posture at midstance: r = .64; r2 = .41

•  Chuter VH: J Foot & Ankle Res 3:9, 2010 –  Assessed relationship of FPI to MAX RF eversion in 40 subjects

•  20 normal & 20 pronated foot types using 3D motion analysis –  Correlation Results

•  FPI score & Max RF Ever (All subjects): r = .92; r2 = .84. •  Pronated foot type (FPI = +6 to +9) & Max RF Ever: r = .81; r2 = .65.

Relationship of FPI to Foot Mobility

•  Cornwall & McPoil, JFAR, 4:4, 2011 –  Assess static foot posture

& mobility in 203 healthy subjects

•  Subjects with high FPI values had greater foot mobility

•  Subjects with low FPI values had less foot mobility

4

Foot Posture Index (FPI) •  The 6 clinical criteria assessed:

– Talar head palpation – Supra & infra lateral malleolar curvature – Calcaneal frontal plane position – Prominence in region of talonavicular joint – Height & congruence of the medial longitudinal

arch – Abduction/adduction of the forefoot on rearfoot

Foot Posture Index •  Before assessing patient:

– Patient instructed to march-in-place for several steps – then stop & place their feet in a comfortable stance position

– Patient is asked to relax their feet, place equal weight on their feet, & look straight ahead with arms at sides.

–  Important that patient NOT move while assessment occurring!

FPI – Talar Head Palpation

•  Requires palpation of the Talar Head

PRONATION

SUPINATION

5

FPI – Talar Head Palpation

Score -2 -1 0 +1 +2 Lat not Med Lat / min Med Equal Med /min Lat Med not Lat

FPI – Supra & Infra Lateral Malleolar Curvature

Score -2 -1 0 +1 +2 Curve below straight or convex

Curve below concave – but more shallow than curve above

Curves equal above & below

Curve below more concave than curve above

Curve below markedly more concave than curve above

FPI – Calcaneal Frontal Plane Position

Score -2 -1 0 +1 +2 > 5o inverted Between vertical &

5o inverted Vertical Between vertical

& 5o everted > 5o everted

6

FPI – Bulging in region of talonavicular joint

Score -2 -1 0 +1 +2 Area markedly concave

Area slightly, but definitely concave

Area flat

Area bulging slightly

Area bulging markedly

FPI – Height & Congruence of Medial Longitudinal Arch

Score -2 -1 0 +1 +2 High arch & angled posteriorly

Moderate high arch & slightly posterior

Normal arch normal

Arch lowered & some flattening of middle part

Arch very low with severe flattening in middle

FPI – Abduction/adduction of forefoot on rearfoot

Score -2 -1 0 +1 +2 NO Lat toes visible – Med toes very visible

Med toes more visible than Lat

Med & Lat toes equally visible

Lat toes more visible than Med

NO Med toes visible – Lat toes very visible

When Should Manual Therapy & Foot Orthoses be Added to the ... · baropodometry. • Results:’Signiﬁcantchange’in’anterior’ ... – Newell (Phys Sports Med 1981) • Described

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