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- Author or Editor: James S. Wrobel x
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Recognizing the Prevalence of Changing Adult Foot Size
An Opportunity to Prevent Diabetic Foot Ulcers?
Ill-fitting shoes may precipitate up to half of all diabetes-related amputations and are often cited as a leading cause of diabetic foot ulcers (DFU), with those patients being 5 to 10 times more likely to present wearing improperly fitting shoes. Among patients with prior DFU, those who self-select their shoe wear are at a three-fold risk for reulceration at 3 years versus those patients wearing prescribed shoes. Properly designed and fitted shoes should then address much of this problem, but evidence supporting the benefit of therapeutic shoe programs is inconclusive. The current study, performed in a male veteran population, is the first such effort to examine the prevalence and extent of change in foot length affecting individuals following skeletal maturity. Nearly half of all participants in our study experienced a ≥1 shoe size change in foot length during adulthood. We suggest that these often unrecognized changes may explain the broad use of improperly sized shoe wear, and its associated sequelae such as DFU and amputation. Regular clinical assessment of shoe fit in at-risk populations is therefore also strongly recommended as part of a comprehensive amputation prevention program.
Background: This literature review was undertaken to evaluate the reliability and validity of the orthopedic, neurologic, and vascular examination of the foot and ankle.
Methods: We searched PubMed—the US National Library of Medicine’s database of biomedical citations—and abstracts for relevant publications from 1966 to 2006. We also searched the bibliographies of the retrieved articles. We identified 35 articles to review. For discussion purposes, we used reliability interpretation guidelines proposed by others. For the κ statistic that calculates reliability for dichotomous (eg, yes or no) measures, reliability was defined as moderate (0.4–0.6), substantial (0.6–0.8), and outstanding (> 0.8). For the intraclass correlation coefficient that calculates reliability for continuous (eg, degrees of motion) measures, reliability was defined as good (> 0.75), moderate (0.5–0.75), and poor (< 0.5).
Results: Intraclass correlations, based on the various examinations performed, varied widely. The range was from 0.08 to 0.98, depending on the examination performed. Concurrent and predictive validity ranged from poor to good.
Conclusions: Although hundreds of articles exist describing various methods of lower-extremity assessment, few rigorously assess the measurement properties. This information can be used both by the discerning clinician in the art of clinical examination and by the scientist in the measurement properties of reproducibility and validity. (J Am Podiatr Med Assoc 98(3): 197–206, 2008)
Dynamic Footprint Measurement Collection Technique and Intrarater Reliability
Ink Mat, Paper Pedography, and Electronic Pedography
Background:
Identifying the variability of footprint measurement collection techniques and the reliability of footprint measurements would assist with appropriate clinical foot posture appraisal. We sought to identify relationships between these measures in a healthy population.
Methods:
On 30 healthy participants, midgait dynamic footprint measurements were collected using an ink mat, paper pedography, and electronic pedography. The footprints were then digitized, and the following footprint indices were calculated with photo digital planimetry software: footprint index, arch index, truncated arch index, Chippaux-Smirak Index, and Staheli Index. Differences between techniques were identified with repeated-measures analysis of variance with post hoc test of Scheffe. In addition, to assess practical similarities between the different methods, intraclass correlation coefficients (ICCs) were calculated. To assess intrarater reliability, footprint indices were calculated twice on 10 randomly selected ink mat footprint measurements, and the ICC was calculated.
Results:
Dynamic footprint measurements collected with an ink mat significantly differed from those collected with paper pedography (ICC, 0.85–0.96) and electronic pedography (ICC, 0.29–0.79), regardless of the practical similarities noted with ICC values (P = .00). Intrarater reliability for dynamic ink mat footprint measurements was high for the footprint index, arch index, truncated arch index, Chippaux-Smirak Index, and Staheli Index (ICC, 0.74–0.99).
Conclusions:
Footprint measurements collected with various techniques demonstrate differences. Interchangeable use of exact values without adjustment is not advised. Intrarater reliability of a single method (ink mat) was found to be high. (J Am Podiatr Med Assoc 102(2): 130–138, 2012)
Bizarre Parosteal Osteochondromatous Proliferation
A Novel Case Report of Recurrence in the Toe
Bizarre parosteal osteochondromatous proliferation (BPOP) is an uncommon reactive mesenchymal lesion mainly affecting the small bones of the hands and feet. They frequently occur in young adults. It is important to understand and differentiate BPOP from other lesions, especially because of its atypical microscopic features and tendency to recur. We present a case of a recurrent lesion involving the toe and discuss management options. To our knowledge, our current case report is the first in the literature to report a recurring BPOP lesion of the toe.
Association of Footprint Measurements with Plantar Kinetics
A Linear Regression Model
Background
The use of foot measurements to classify morphology and interpret foot function remains one of the focal concepts of lower-extremity biomechanics. However, only 27% to 55% of midfoot variance in foot pressures has been determined in the most comprehensive models. We investigated whether dynamic walking footprint measurements are associated with inter-individual foot loading variability.
Methods
Thirty individuals (15 men and 15 women; mean ± SD age, 27.17 ± 2.21 years) walked at a self-selected speed over an electronic pedography platform using the midgait technique. Kinetic variables (contact time, peak pressure, pressure-time integral, and force-time integral) were collected for six masked regions. Footprints were digitized for area and linear boundaries using digital photo planimetry software. Six footprint measurements were determined: contact area, footprint index, arch index, truncated arch index, Chippaux-Smirak index, and Staheli index. Linear regression analysis with a Bonferroni adjustment was performed to determine the association between the footprint measurements and each of the kinetic variables.
Results
The findings demonstrate that a relationship exists between increased midfoot contact and increased kinetic values in respective locations. Many of these variables produced large effect sizes while describing 38% to 71% of the common variance of select plantar kinetic variables in the medial midfoot region. In addition, larger footprints were associated with larger kinetic values at the medial heel region and both masked forefoot regions.
Conclusions
Dynamic footprint measurements are associated with dynamic plantar loading kinetics, with emphasis on the midfoot region.
Background: This pilot study examined the effect of custom and prefabricated foot orthoses on self-selected walking speed, walking speed variability, and dynamic balance in the mediolateral direction.
Methods: The gait of four healthy participants was analyzed with a body-worn sensor system across a distance of at least 30 m outside of the gait laboratory. Participants walked at their habitual speed in four conditions: barefoot, regular shoes, prefabricated foot orthoses, and custom foot orthoses.
Results: In the custom foot orthoses condition, gait speed was improved on average 13.5% over the barefoot condition and 9.8% over the regular shoe condition. The mediolateral range of motion of center of mass was reduced 55% and 56% compared with the shoes alone and prefabricated foot orthoses conditions, respectively. This may suggest better gait efficiency and lower energy cost with custom foot orthoses. This tendency remained after normalizing center of mass by gait speed, suggesting that irrespective of gait speed, custom foot orthoses improve center of mass motion in the mediolateral direction compared with other footwear conditions. Gait intercycle variability, measured by intercycle coefficient of variation of gait speed, was decreased on average by 25% and 19% compared with the barefoot and shoes-alone conditions, respectively. The decrease in gait unsteadiness after wearing custom foot orthoses may suggest improved proprioception from the increased contact area of custom foot orthoses versus the barefoot condition.
Conclusions: These findings may open new avenues for objective assessment of the impact of prescribed footwear on dynamic balance and spatiotemporal parameters of gait and assess gait adaptation after use of custom foot orthoses. (J Am Podiatr Med Assoc 100(4): 242–250, 2010)
Clinicians have traditionally assessed range of motion of the first metatarsophalangeal and ankle joints in a static position. It is unclear, however, if these measurements accurately reflect functional sagittal plane limitations of these joints during gait. For 50 patients (100 feet), we assessed available dorsiflexion at the first metatarsophalangeal and ankle joints, as well as the presence of pinch callus. We then compared these findings with 11 functional gait parameters, as measured using a pressure sensor system. After adjusting for age, weight, smoking status, glycosylated hemoglobin, and insensitivity to monofilament, we found that patients with pinch callus demonstrated statistically significant compensatory gait patterns in 7 of 11 measures. Hallux limitus and equinus patients demonstrated six and three statistically significant associations, respectively. Pinch callus seems to be as predictive of functional gait alterations as static first metatarsophalangeal joint and ankle dorsiflexion. (J Am Podiatr Med Assoc 94(6): 535–541, 2004)
Elevated plantar pressures are an important predictor of diabetic foot ulceration. The objective of this study was to determine which clinical examination variables predict high plantar pressures in diabetic feet. In a cross-sectional study of 152 male veterans with diabetes mellitus, data were collected on demographics, comorbid conditions, disease severity, neuropathy status, vascular disease, and orthopedic and gait examinations. Univariate predictors included height, weight, body surface area, body weight per square inch of foot surface area, bunion deformity, hammer toe, Romberg’s sign, insensitivity to monofilament, absent joint position sense, decreased ankle dorsiflexion, and fat pad atrophy. Variables that remained significantly associated with high plantar pressures (≥4 kg/cm2) in multivariate analysis included height, body weight per square inch of foot surface area, Romberg’s sign, and insensitivity to monofilament. These results may be useful in identifying patients who would benefit from interventions designed to decrease plantar foot pressures. (J Am Podiatr Med Assoc 93(5): 367-372, 2003)
Gait Changes with the Use of Heelys
A Case Study
Heelys shoes are a novel athletic shoe with a concealed wheel. They have been popular among youths since their introduction in 2000. This case study serves as a first look into the biomechanical implications of Heelys shoes on gait. Pressure readings of the forefoot, midfoot, and rearfoot during ambulation in regular athletic-shoe walking, Heelys without the wheel walking, Heelys with the wheel walking, and Heelys skating with the wheel were recorded on a single subject using the Pedar X System. A visual gait analysis was also performed on the subject. The resulting data show increased forefoot and rearfoot pressure while walking with the Heelys with the wheel. The visual gait analysis showed a diminished heel strike and a more rapid forefoot loading. These results demonstrate that Heelys do in fact affect the biomechanics of gait. (J Am Podiatr Med Assoc 99(3): 247–250, 2009)
Background: We sought to examine the economic value of specialized lower-extremity medical care by podiatric physicians in the treatment of diabetic foot ulcers by evaluating cost outcomes for patients with diabetic foot ulcer who did and did not receive care from a podiatric physician in the year before the onset of a foot ulcer.
Methods: We analyzed the economic value among commercially insured patients and Medicare-eligible patients with employer-sponsored supplemental medical benefits using the MarketScan Databases. The analysis consisted of two parts. In part I, we examined cost or savings per patient associated with care by podiatric physicians using propensity score matching and regression techniques; in part II, we extrapolated cost or savings to populations.
Results: Matched and regression-adjusted results indicated that patients who visited a podiatric physician had $13,474 lower costs in commercial plans and $3,624 lower costs in Medicare plans during 2-year follow-up (P < .01 for both). A positive net present value of increasing the share of patients at risk for diabetic foot ulcer by 1% was found, with a range of $1.2 to $17.7 million for employer-sponsored plans and $1.0 to $12.7 million for Medicare plans.
Conclusions: These findings suggest that podiatric medical care can reduce the disease and economic burdens of diabetes. (J Am Podiatr Med Assoc 101(2): 93–115, 2011)
