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The measurements of subtalar joint neutral position and hindfoot range of motion have been shown to be unreliable. The first step in making these measurements is to determine the calcaneal bisection. This study examines the reliability of bisecting the calcaneus with digital linear calipers. Five trials on each of six cadavers resulted in a mean absolute angular difference of 0.60° (SD ±1.17°). These results were then compared with results from the typical visual method used clinically. Three raters each performed five trials on six cadavers. Visual bisection was more variable, with a mean absolute error of 3.61° (±3.13°). A mean error of 6° (±1°) is certainly possible when the heel is visually bisected. It was determined that the caliper bisection was a valid technique for bisection of the heel, but that clinical visual bisection was not. (J Am Podiatr Med Assoc 91(3): 121-126, 2001)
The Relationship Between Arch Height and Arch Flexibility
A Proposed Arch Flexibility Classification System for the Description of Multidimensional Foot Structure
The correlation between arch structure and injury may be related to the fact that foot structure influences foot function. Foot structure is often defined by arch height, although arch flexibility may be just as important to form a more complete description. We propose an arch flexibility classification system, analogous to arch height classification, and then use the classification system to examine the relationship between arch flexibility and arch height.
Arch height index was calculated in 1,124 incoming military cadets, of whom 1,056 had usable data. By measuring arch height during both sitting and standing, a measurement of arch flexibility could also be calculated. These values were used to create five arch flexibility categories: very stiff, stiff, neutral, flexible, and very flexible. The distribution of arch flexibility types among arch height categories was statistically compared.
The goodness of fit test showed a disproportionate number of each arch flexibility type in each of the arch height categories (P < .01). The largest proportion of cavus feet was very stiff and the smallest proportion was very flexible. Conversely, the largest proportion of planus feet was very flexible and the smallest proportion was very stiff.
The results of this research support the common belief that cavus feet tend to be very stiff and planus feet tend to be very flexible.
Foot structure is typically evaluated using static clinical and radiographic measures. To date, the literature is devoid of a correlation between rearfoot frontal plane radiographic parameters and clinical measures of alignment. In a repeated-measures study comparing radiographic and clinical rearfoot alignment in 24 healthy subjects, radiographic angular measurements were made from standard weightbearing anteroposterior, lateral, long leg calcaneal axial, and rearfoot alignment views. Clinical measurements were made using a jig and scanner to assess the malleolar valgus index and a goniometer to evaluate the resting and neutral calcaneal stance positions. There was a significant correlation between frontal plane radiographic angles (long leg calcaneal axial and rearfoot alignment views) (r = 0.814). Similarly, there was a significant correlation between clinical measures (resting calcaneal stance position and malleolar valgus index) (r = 0.714). A multivariate stepwise regression showed that resting calcaneal stance position can be accurately predicted from 3 of the 15 clinical and radiographic measurements collected: malleolar valgus index, rearfoot alignment view, and long leg calcaneal axial view (r = 0.829). In summary, a commonly used clinical measure of static rearfoot alignment, resting calcaneal stance position, was correlated closely with the malleolar valgus index and both frontal plane radiographic parameters. (J Am Podiatr Med Assoc 95(1): 26–33, 2005)
Background: Medial tibial stress syndrome is a common overuse injury in weightbearing, physically active individuals and in athletes. Most research associated with this condition is primarily based on static foot and lower-extremity measurements.
Methods: A cross-sectional design was used to assess a set of static and dynamic measurements to determine which anatomical factors (limb length, ankle dorsiflexion, first metatarsophalangeal joint extension, and arch height) and biomechanical factors (center-of-pressure excursion index, malleolar valgus index, and gait velocity) are associated with medial tibial stress syndrome.
Results: One-way analysis of variance models revealed that participants with medial tibial stress syndrome had significantly greater visual analog pain levels and slower gait velocity than noninjured controls (P = .05). No other significant differences were found between the two groups.
Conclusions: Further investigation of these and other factors can help health professionals develop better strategies for the prevention and clinical intervention of medial tibial stress syndrome. (J Am Podiatr Med Assoc 100(2): 121–132, 2010)
Clinical observations note that foot pain can be linked to contralateral pain at the knee or hip, yet we are unaware of any community-based studies that have investigated the sidedness of pain. Because clinic-based patient samples are often different from the general population, the purpose of this study was to determine whether knee or hip pain is more prevalent with contralateral foot pain than with ipsilateral foot pain in a population-based cohort.
Framingham Foot Study participants (2002–2008) with information on foot, knee, and hip pain were included in this cross-sectional analysis. Foot pain was queried as pain, aching, or stiffness on most days. Using a manikin diagram, participants indicated whether they had experienced pain, aching, or stiffness at the hip or knee and specified the side of any reported pain. Sex-specific multinomial logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals for the association of foot pain with knee and hip pain, adjusting for age and body mass index.
In the 2,181 participants, the mean ± SD age was 64 ± 9 years; 56% were women, and the mean body mass index was 28.6. For men and women, bilateral foot pain was associated with increased odds of knee pain on any side (ORs = 2–3; P < .02). Men with foot pain were more likely to have ipsilateral hip pain (ORs = 2–4; P<.03), whereas women with bilateral foot pain were more likely to have hip pain on any side (OR = 2–3; P < .02).
Bilateral foot pain was associated with increased odds of knee and hip pain in men and women. For ipsilateral foot and hip pain, men had a stronger effect compared with women.
Anthropometric status can influence gait biomechanics, but there is relatively little published research regarding foot and ankle characteristics in the obese pediatric population. We sought to compare the structural and functional characteristics of the foot and ankle complex in obese and non-obese children.
Twenty healthy children (ten obese and ten normal weight) were recruited for a cross-sectional research study. Anthropometric parameters were measured to evaluate active ankle dorsiflexion, arch height (arch height index, arch rigidity index ratio, and arch drop), foot alignment (resting calcaneal stance position and forefoot-rearfoot alignment in unloaded and loaded positions), and foot type (malleolar valgus index). Independent t tests determined significant differences between groups for all assessed parameters. Statistical significance was set at P < .0125.
Compared with non-obese participants, obese participants had significantly greater arch drop (mean ± SD: 5.10 ± 2.13 mm versus 2.90 ± 1.20 mm; P =.011) and a trend toward lower arch rigidity index ratios (mean ± SD: 0.92 ± 0.03 versus 0.95 ± 0.02; P = .013). In addition, obese participants had significantly less active ankle dorsiflexion at 90° of knee flexion versus non-obese participants (mean ± SD: 19.57 ± 5.17 versus 29.07 ± 3.06; P < .001). No significant differences existed between groups for any other anthropometric measurements.
The decreased active ankle dorsiflexion in the obese group can increase foot contact for a longer period of the stance phase of gait. Obese participants also presented with a more flexible foot when bearing weight. (J Am Podiatr Med Assoc 102(1): 5–12, 2012)
In the offset V-bunionectomy used for hallux valgus repair, both the Kalish and the Vogler variations have a long dorsal arm, but the apex is more distal in the Kalish procedure. This study investigated the effect that pin orientation and location of the osteotomy apex have on weightbearing stability. The authors studied saw bone models that were loaded to failure in an Instron 4201 materials testing machine and, in addition, designed, fabricated, and used a unique jig assembly to help minimize data variability. Statistically significant differences were found between the surgical techniques and pin orientations: the Kalish osteotomy was stronger than the Vogler procedure, and in both osteotomies, the plantarly directed Kirschner wire orientation was stronger than the dorsally directed orientation. (J Am Podiatr Med Assoc 92(2): 82-89, 2002)
Lesser Proximal Interphalangeal Joint Arthrodesis
A Retrospective Analysis of the Peg-in-Hole and End-to-End Procedures
A retrospective study was performed to compare the prevalence of complications in peg-in-hole and end-to-end arthrodesis procedures. The authors reviewed 177 second, third, and fourth proximal interphalangeal joint fusions for the correction of hammer toe deformities in 85 patients from 1988 to 1998 at the Temple University School of Podiatric Medicine. The average age of the patients was 49 years. Sixteen percent (14) of the subjects were male and 84% were (71) female. Upon follow-up, the fourth digit was generally associated with a greater number of complications for the end-to-end and peg-in-hole procedures, with the second digit being the most common site of fusion. The prevalence of complications was evaluated using contingency table analysis and expressed as a percent of total complications (27%, the end-to-end group; 17%, the peg-in-hole group). A subset of complications deemed clinically relevant was also computed. Similarly, the prevalence of clinically relevant complications for the end-to-end (10%) and the peg-in-hole (9%) procedures was not statistically significant. Therefore, this study showed no statistically significant differences in the total or clinically relevant complications between end-to-end and the peg-in-hole arthrodesis procedures. (J Am Podiatr Med Assoc 91(7): 331-336, 2001)
Peg-in-Hole, End-to-End, and V Arthrodesis
A Comparison of Digital Stabilization in Fresh Cadaveric Specimens
The proximal interphalangeal joint arthrodesis is frequently performed to correct hammer toe deformities. This study was conducted to compare the inherent stability of the three proximal interphalangeal joint arthrodeses—peg-in-hole, end-to-end, and V constructs—in the sagittal plane by means of load-to-failure testing of 30 fresh-frozen cadaveric specimens fixated with a 0.045 Kirschner wire. The peg-in-hole construct was associated with significantly higher peak loads at failure compared with the other two procedures. Furthermore, the peg-in-hole construct had significantly higher stiffness values as compared with the V procedure. This study thus provides evidence that the peg-in-hole procedure is the most biomechanically stable surgical construct for proximal interphalangeal joint fusions under sagittal plane loading. (J Am Podiatr Med Assoc 91(2): 63-67, 2001)
Background: The purposes of this study were 1) to determine the intrarater and interrater reliability of the arch height index measurement system device, 2) to establish population normative values for the arch height index in recreational runners, and 3) to compare arch height index values between the right and left feet and between genders.
Methods: Eleven subjects were used to establish intrarater and interrater reliability of the arch height index measurement system. This system was then used to measure the arch height index of 100 recreational runners.
Results: Measurements taken with the arch height index measurement system device exhibited high intrarater and interrater reliability. The mean ± SD arch height index of the recreational runners was 0.340 ± 0.030. Men had larger feet than women, but the arch height index between genders was similar.
Conclusions: The arch height index measurement system device is reliable to use between testers while simplifying the measurement procedure for recording the arch height index. The arch height index may be helpful in identifying potential structural factors that predispose individuals to lower-extremity injuries. (J Am Podiatr Med Assoc 98(2): 102–106, 2008)