Foot Problems in Older People Assessment and Management

Retrocalcaneal conditions 199 Several clinical tests can assist in the diagnosis of bilisation or removable walking casts to discourage TPD. Visual observation will reveal signs of pes planus excessive weightbearing activity. (flat foot deformity), with a lowering of the longitu- dinal arch (Fig. 10.2A). Viewed from behind, the No RCTs of these treatments have been under- affected foot may demonstrate the ‘too many toes’ taken, so their efficacy is uncertain. However, two sign, in which three or more toes can be viewed lateral case series studies have reported favourable results. to the heel as a result of abduction of the forefoot.87 Wapner & Chan110 found that 67% of patients were Patients will have difficulty rising on to their toes, and satisfied with non-operative treatment, which in most a loss of heel inversion when performing this task may cases consisted of the UCBL shoe insert. Similarly, also be evident. Manual muscle testing of the tibialis Jari et al111 reported that a non-surgical management posterior muscle strength will also reveal marked approach (consisting of NSAIDs, icing, therapeutic weakness on the affected side.84,86,100 ultrasound, strengthening exercises, UCBL shoe inserts and AFOs) was effective in 23 out of 28 Diagnostic imaging is not necessary to confirm a patients followed up for two years. diagnosis of TPD but may be worthwhile to visualise the extent of tendon damage or to quantify the extent Surgical of the deformity. Plain film radiographs are useful for assessing deformity and the severity of osteoarthritic Surgical management of TPD varies according to changes, and to exclude other possible causes.101 the stage of the condition. Stage I TPD is generally Lateral X-rays will reveal a decreased calcaneal inclina- managed with synovectomy and tendon debride- tion angle, increased calcaneal-first metatarsal angle ment/repair in conjunction with calcaneal osteotomy and a break in the cyma line (Fig. 10.2B). Anteropos- to correct the foot into a more supinated position. terior X-rays are less helpful but will reveal forefoot Stage II TPD is treated in a similar manner, with the abduction and degenerative changes in the midfoot addition of tendon transfer (either flexor digitorum joints.84,102 Ultrasound will reveal increased tendon longus112,113 or a split tibialis anterior114) to assist in diameter and evidence of echogenic areas within the the antipronation function of tibialis posterior. Surgi- tendon.103 MRI can detect discontinuity in the tendon cal management of stage III TPD generally involves but does not confer any substantial benefit over ultra- triple arthrodesis (fusion of the subtalar, calcaneocu- sound and is generally only used for presurgical boid and talonavicular joints), while stage IV often planning.104–107 requires pantalar arthrodesis (fusion of the ankle sub- talar, calcaneocuboid and talonavicular joints).86,101 TREATMENT As with conservative treatments, no controlled trials of these surgical techniques have been undertaken. Conservative However, case series studies have reported good to excellent results in 80% of patients.88,113,115 Recovery Conservative treatment of TPD involves measures may take several months and will frequently require a for pain relief, mechanical interventions to control the below-knee plaster cast.86 deforming forces on the foot, and strengthening exer- cises. Initial treatment should involve the prescription RETROCALCANEAL CONDITIONS of NSAIDs and the application of rigid adhesive taping, which has been shown to significantly control Pain in the posterior region of the heel is less common foot pronation.108 Extending tape stirrups above the than plantar heel pain, and subsequently has received ankle (so-called ‘high-Dye’ taping) may be more relatively little attention in the literature. As with effective in controlling total range of motion than plantar heel pain, retrocalcaneal pain can be consid- low-Dye taping.109 Longer-term management includes ered to be a syndrome which encompasses a variety the prescription of rigid foot orthoses and appropriate of pathological entities that often present concur- supportive footwear, strengthening exercises using rently. Although accurate prevalence data is unavail- graduated elastic exercise bands and, in severe cases, able, the most common conditions affecting the ankle–foot orthoses (AFOs).84,86,100–102 Corticosteroid posterior aspect of the heel in older people appear to injection is generally not recommended because of be Haglund’s deformity (with or without retrocalca- the increased risk of tendon rupture with prolonged neal bursitis) and Achilles tendinopathy, while less use, but may be useful if combined with cast immo-

200 DISORDERS OF THE MIDFOOT AND REARFOOT common causes include soft tissue manifestations of A arthritic conditions (such as rheumatoid nodules) and soft tissue cysts and tumours. B HAGLUND’S DEFORMITY C Definition and aetiology D b Haglund’s deformity, also known as pump bumps, winter heel, achillodynia, retrocalcaneal bursitis and a cucumber heels, was first described by Patrick Haglund in 1928.116 Haglund reported a case of a 20-year-old Figure 10.4 Angles obtained from lateral foot woman with pain located in the posterosuperior radiographs of relevance to Haglund’s deformity. aspect of the heel accompanied by a bony enlarge- A. Fowler–Philip’s angle. B. Calcaneal inclination angle. ment at the insertion of the Achilles tendon, which C. Total angle. D. Calcaneal body index (A/B). Larger he attributed to the wearing of shoes with a rigid heel values for all parameters are associated with Haglund’s counter. deformity. In 1945, Fowler & Philip117 proposed that patients with a ‘tall’ calcaneus may be predisposed to develop- with the condition exhibited a structural anomaly of ing the deformity. A summary of radiographic angles the calcaneus, in which the angle formed between the of relevance to Haglund’s deformity is shown in plantar surface of the calcaneus and the most posterior Figure 10.4. projections of the bursal surface (now known as Fowler–Philip’s angle or FPA) is increased. In such a The role of footwear is unclear. Several authors foot, there is a greater tendency for the heel to become suggest that shoes with a rigid heel counter or tight compressed against the shoe, leading to inflammation heel straps may cause irritation in those predisposed of the superficial tendo achillis or retrocalcaneal bursa, to the condition116,120,122,123 and indeed, an electro- the formation of a retrocalcaneal exostosis and sub- dynographic study by Rzonca et al124 confirmed that sequent overlying hyperkeratosis. the forces applied to the posterosuperior aspect of the heel during gait were significantly larger in those with Subsequent studies have largely supported this Haglund’s deformity than in controls. However, only view;118 however, there is some debate regarding the 13% of the 117 cases in the Mishra et al121 study wore angle at which the foot is susceptible to the develop- shoes on a regular basis, indicating that the condition ment of the deformity, and preliminary evidence that can also develop in barefooted individuals. other radiographic measurements may be more highly predictive than the FPA. Ruch119 reported on 65 sur- Clinical presentation gical cases of Haglund’s deformity and found that only seven exhibited a FPA greater than 75°. However, The classical presentation of Haglund’s deformity is the calcaneal inclination angle (CIA) ranged from that of pain and inflammation around the posterior 20–50°, suggesting that a combination of the FPA and the CIA may provide a more accurate indicator of the structural anomaly of the calcaneus responsible for the condition. Vega et al120 reviewed 20 cases and suggested that the summation of the FPA and CIA (referred to as the ‘total angle’) ranges from 85° to 97° in people with Haglund’s deformity, compared to a normal range of 64–89°. More recently, a large study by Mishra et al121 of 117 cases and 72 controls indicated that the CIA was more strongly correlated with Haglund’s deformity than the FPA. The authors also proposed a new measurement, the calcaneal body index (the ratio between the maximum height of the posterior and anterior body of the calcaneus) as a possible aetiological factor, suggesting that people

Retrocalcaneal conditions 201 retrocalcaneal bursae. A recent case-control study indicated that retrocalcaneal bursae larger than 1 mm anteroposteriorly, 11 mm transversely, or 7 mm dor- soplantarly can be considered abnormal.128 Foot posture assessment and gait analysis may be useful, as several authors have suggested that excessive rearfoot motion may lead to friction between the prominence and the heel counter of the shoe. In particular, compensation for an inverted rearfoot deformity has often been implicated in the develop- ment of Haglund’s deformity.129 Figure 10.5 Haglund’s deformity. (Courtesy of Karl Conservative treatment Landorf, La Trobe University.) Conservative management of Haglund’s deformity heel, accompanied by superficial bursitis and an involves removing the potential cause (by exchanging osseous and soft tissue prominence in the region of or modifying footwear), pain management (such as the Achilles tendon insertion (Fig. 10.5). There may NSAIDs or corticosteroid injection), pressure redis- be evidence of direct abrasion from the upper edge tribution (via the use of apertured pads or silicone of the shoe heel counter. In older people, the condi- shields) and techniques to alleviate tension at the tion is frequently associated with an overlying region Achilles tendon insertion (such as heel lifts, foot of hyperkeratosis, which may become ulcerated. Pain orthoses and gastrocnemius stretching).120,129–131 Cor- may be elicited by direct pressure on the posterior ticosteroid injection needs to be carefully performed prominence or by dorsiflexing the ankle. to ensure that the injection is directed into the inflamed bursa and not into the tendon itself, because Assessment and diagnosis of the risk of rupture. A single injection of cortisone mixed with local anaesthetic has been reported to be A provisional diagnosis of Haglund’s deformity can clinically effective.129 However, no rigorous studies be reached from thorough history taking, clinical have been undertaken to assess the efficacy of these observation and physical examination. Detailed assess- techniques and it has been suggested that conserva- ment of footwear (both indoor and outdoor) is essen- tive management of Haglund’s deformity is only tial, not only to determine its possible contribution effective in very mild cases120,122,132 and is associated to the presenting complaint but also to assess the with a high recurrence rate.131,132 suitability of the shoes for modification and/or accommodation of offloading devices. Systemic con- Surgical treatment ditions that may manifest as soft tissue masses in the posterior region of the heel, such as rheumatoid Surgical management of Haglund’s deformity involves arthritic nodules and tophaceous gout deposits, first removal of the retrocalcaneal prominence via bursec- need to be ruled out.125 tomy, exostectomy, calcaneal osteotomy or, most fre- quently, a combination of these methods.122 Several Lateral weightbearing X-rays are very useful to rule different incisional approaches have been described out other conditions (such as soft tissue and osseous (Fig. 10.6). The direct posterior approach allows tumours41), to determine the magnitude of the pos- direct access to the superficial bursa and is technically terior exostosis and to evaluate the contribution of quite simple to perform. However, to remove the calcaneal morphology to the development of the con- exostosis, the Achilles tendon must be excised and dition. Ultrasound is not necessary to confirm a diag- reattached, which may lead to weakening or rupture nosis but may reveal signs of Achilles tendinopathy, of the tendon postoperatively. The longitudinal linear bursitis and ossification of the insertion of the Achilles incision avoids this potential problem; however, this tendon.126,127 Similarly, MRI is rarely used but may approach does not allow for ease of access to the assist in differentiating between normal and abnormal superficial bursa. A modification of this approach, the lazy-L incision, improves access to the superficial

202 DISORDERS OF THE MIDFOOT AND REARFOOT AB C A B Figure 10.6 Incisional approaches for surgical correction C of Haglund’s deformity. A. Direct posterior incision. B. Longitudinal linear incision lateral to the Achilles tendon. C. Lazy-L incision lateral to the Achilles tendon. bursa and leads to less skin contracture postopera- D tively.120 Finally, an endoscopic technique has also been recently described, which involves a small medial Figure 10.7 Surgical procedure for Haglund’s deformity. or lateral incision guided by fluoroscopy.132 A. Dorsolateral exostosis to be removed. B. Dorsolateral exostosis and bursa are resected and bone smoothed In most cases, a simple ostectomy is performed, with a rongeur. C. Dorsal wedge osteotomy performed. which involves removing the offending portion of D. Osteotomy site fixed with cancellous bone screws. bone and smoothing the edges with a rasp or rongeur. However, in severe cases (particularly those with a reported a worsening of symptoms. Furthermore, the large exostosis and/or a large calcaneal inclination rehabilitation period was an average of 6 months and angle) a wedge osteotomy may be considered. This few patients reported that they would be willing to approach, first described by Zadek in 1939,133 involves undergo a similar procedure again. Better long-term removing a dorsal wedge of bone from the calcaneus results were reported by Brunner et al139 in 36 patients and closing the incision with cancellous bone screws followed up for 4 years; however, the recovery time (Fig. 10.7). This technique requires a longer period ranged from 6 months to 2 years. On the basis of of cast immobilisation following surgery131 and may these findings, it is generally recommended that all therefore not be appropriate for older patients. Com- conservative approaches be tried before considering plications associated with both techniques include surgical intervention and that, when considering recurrence due to inadequate bone resection, Achilles surgery, patients need to be advised of the potentially tendon weakening and/or rupture, scar formation prolonged period of recovery. and subsequent nerve entrapment and, in the case of osteotomy, non-union and pseudoarthrosis.122 ACHILLES TENDINOPATHY Definition and aetiology Although highly favourable outcomes have been reported in case series studies of Haglund’s deformity Achilles tendinopathy is one of the most common surgery with small samples and/or a short duration overuse injuries in athletes and can be defined as the of follow-up,132,134–136 longer-term follow-up studies symptomatic overuse, degeneration and failed repair have seriously questioned the efficacy of surgical inter- of the Achilles tendon.140 While early reports consid- vention.137,138 Taylor137 followed up 42 patients who ered the condition to be inflammatory (hence the had undergone closing wedge calcaneal osteotomy over a 6–7-year period and found that 46% were dis- satisfied following the procedure. The most common reasons for dissatisfaction were residual prominence (51%), widening of the scar (48%) and altered sensa- tion (38%). Similarly, a 4–5-year follow-up of 49 patients by Schneider et al138 reported complete reso- lution of symptoms in 34 patients; however, seven

Retrocalcaneal conditions 203 term Achilles tendinitis), it is now recognised that the Irrespective of the underlying cause, histological pathological process is far more complex and that examinations of affected tendons have revealed chronic tendinopathy does not involve inflammatory several characteristic changes, including irregular cells.141 Although most commonly observed in young arrangement of collagen fibres, increased vascularity and middle-aged athletes, Achilles tendinopathy and evidence of delayed healing.163,164 In addition to may also occur in physically active142,143 or sedentary these changes, ruptured tendons also exhibit inflam- older individuals.144 As outlined in Chapter 2, there matory lesions and the presence of granulation are several age-related changes in the physiology of tissue.165 tendon tissue, including increased collagen crosslink- ing,145 decreases in water content146 and increased Assessment and diagnosis in lipid content.147 These changes may predispose to tendinopathy in physically active older people, as a Most of the information required to diagnose Achilles recent study of young and older athletes indicated tendinopathy can be obtained from a thorough patient that Achilles tendon problems were more common in history and physical examination. The primary pre- the older group (20% versus 5% of all injuries).148 Age senting complaint is pain 2–6 cm proximal to the is also recognised as a strong negative predictor insertion of the tendon, which is exacerbated by phys- of outcome in surgical repair of Achilles tendon ical activity and relieved by rest. The tendon may be disorders.149,150 diffusely swollen and palpable nodules may be present when the ankle is dorsiflexed and plantarflexed.166 The aetiology and pathophysiology of Achilles ten- Retrocalcaneal bursitis or Haglund’s deformity may dinopathy is poorly understood. Several risk factors also be present. Patients who have sustained an acute have been identified, including obesity,151 sudden rupture of the tendon will typically report a sudden increases in the duration and intensity of weightbear- onset of pain accompanied by an audible snap at the ing activity152 and decreased ankle dorsiflexion range time of injury and will be unable to bear weight on of motion (leading to an increase in strain on the the affected limb. Patients with chronic ruptures, tendon).153 Broadly speaking, three theories have however, may report only minor or no trauma and been put forward in relation to the pathophysiology often recall difficulty climbing stairs as the initial of Achilles tendinopathy.154 The mechanical theory symptom.167 suggests that repeated loading of the tendon causes gradual fatigue and subsequent microscopic degen- Achilles tendinopathy may be differentiated from eration. The vascular theory suggests that the cause rupture by conducting either of two simple tests. The of tendon degeneration is a reduction in blood supply calf-squeeze test, also known as the Thompson test, in the inherently hypovascular midportion of the was first described by Simmonds in 1957168 and tendon.155 However, the inverse has also been pro- involves squeezing the fleshy part of the calf while the posed, i.e. that exercise-induced hyperthermia may be patient is lying prone. If the Achilles tendon is intact, detrimental to tendons.156 Finally, a neural theory has this test will result in plantarflexion of the ankle joint, recently been proposed in response to the observa- whereas in the presence of a ruptured tendon no ankle tion of glutamate (a neurotransmitter) in damaged movement will be elicited. The knee flexion test tendons157 and the reported association between involves the patient flexing the knee to 90° while lying Achilles tendinopathy and sciatica.158 prone. In the presence of an Achilles tendon rupture, the foot will drop into a neutral or dorsiflexed Several medications have also been implicated in position.169 degeneration and rupture of the Achilles tendon, par- ticularly corticosteroids159 but also fluoroquinolone Diagnostic imaging is not necessary for routine antibiotics151,160 and statins.161 The role of medica- clinical diagnosis but is considered useful for presurgi- tions in predisposition to Achilles disorders is of par- cal planning.170 Plain film X-ray is not widely used in ticular importance in older people. A recent study of the diagnosis of tendinopathy but may be useful in 1367 cases and 50 000 controls indicated that, in cases of insertional tendinopathy where bony spurs people over 60 years of age, the use of quinolone are suspected. Ultrasound imaging of abnormal Achil- antibiotics significantly increased the likelihood of les tendons will reveal tendon enlargement and experiencing an Achilles tendon rupture and that this hypoechoic regions;171 however, false-positive find- risk was further increased in those who were also ings are common in mild to moderate cases172 and taking corticosteroids.162 differentiating between tendon degeneration and

204 DISORDERS OF THE MIDFOOT AND REARFOOT partial rupture is difficult.173 MRI will typically reveal The effectiveness of orthomechanical therapies (such tendon and paratenon thickening, peritendinous fluid as heel lifts and foot orthoses) has not been examined accumulation and oedema of Karger’s fat pad.174 As in detail; however, a randomised controlled trial of with ultrasound, however, there is considerable heel lifts did not provide any substantial clinical benefit overlap between the appearance of normal and abnor- when added to a treatment regimen of stretching, mal tendons. Neither the use of ultrasound nor MRI strengthening and ultrasound.181 has been shown to predict clinical outcomes of surgi- cal intervention. The most recent Cochrane review of nine ran- domised trials involving 697 patients concluded that, Conservative treatment while there was weak evidence for the use of nonste- roidal anti-inflammatory medications in alleviating Several conservative treatments have been trialled symptoms in acute tendinopathy, there is currently in the management of Achilles tendinopathy, includ- insufficient evidence to guide conservative treatment ing anti-inflammatory medications, calf stretching, of chronic Achilles tendinopathy.182 Despite this lack massage, therapeutic ultrasound, laser, cryotherapy, of evidence, the long term prognosis of conservative corticosteroid injections, strengthening exercises, heel management appears to be quite good. An 8-year lifts and foot orthoses.140,166,170,175 However, because follow-up of 83 patients managed with various con- of the limited understanding of the underlying cause servative approaches indicated that the vast majority of the condition, treatment is largely empirical and (94%) were asymptomatic or reported only mild pain varies considerably among clinicians.140,166 Further- when exercising.183 more, few of these techniques have been evaluated in randomised controlled trials and no trials have specifi- Surgical treatment cally been undertaken in older people. Surgical intervention for Achilles tendinopathy is only Initial conservative management of Achilles indicated when conservative methods have failed. tendinopathy involves pain relief, via the use of anti- Although various surgical techniques have been inflammatory medications, cryotherapy and/or corti- described, most involve debridement of degenerated costeroid injections. Anti-inflammatory medications tendon tissue, removal of adhesions between the are likely to only be of benefit in the acute phase, as tendon and paratenon and, in the case of intratendi- chronic degenerative tendinopathy is not an inflam- nous lesions, longitudinal incision and excision of matory condition. Indeed, a randomised trial found granulation tissue. Partial ruptures may require sutur- that piroxicam offered no benefits over a placebo ing or grafting.166 Clinical success rates of between medication in 70 patients with chronic Achilles ten- 75% and 100% have been reported in retrospective dinopathy.176 The use of corticosteroids is somewhat studies; however, few have used objective outcome controversial, as there is some evidence that periten- measures.184 Complications, such as residual strength dinous injection of cortisone delays tendon healing177 deficits and delayed healing, have been reported in and several cases of spontaneous rupture following approximately 10% of cases.183 corticosteroid injection have been reported.178 More recently, techniques designed to sclerose small blood Acute ruptures of the Achilles tendon generally vessels within the tendon (by the use of polidocanol179 require open operative repair with suturing or tendon or electrocoagulation180) have been trialled with some grafting techniques, followed by cast immobilisation success; however, larger studies with longer-term for 4–8 weeks.185 Although some authors suggest that follow-up are now required. older patients are best managed non-operatively, using cast immobilisation or functional bracing,167 Longer-term conservative management of Achilles good results with flexor hallucis longus transfer have tendinopathy is aimed at restoring the normal func- been reported in five patients aged 52–71 years of tion of the musculotendinous unit to prevent recur- age.186 The recent Cochrane review of 14 trials involv- rence. Strengthening the triceps surae muscle group ing 891 patients indicated that surgical management using eccentric loading exercises has been shown to of acute ruptures was associated with a lower risk of be effective in managing Achilles tendinopathy in ath- re-rupture; however, those treated non-operatively letic populations;140,175 however, whether this approach experienced fewer complications and required shorter is safe and effective in older people remains unclear. periods in hospital.187

Osteoarthritis of the midfoot and rearfoot 205 OSTEOARTHRITIS OF THE erative changes were evident in the subtalar joint in MIDFOOT AND REARFOOT 67% of cases and the transverse tarsal joint (i.e. talo- navicular and calcaneocuboid joints combined) in PREVALENCE AND RISK FACTORS 50% of cases.196 Osteoarthritis is the most common form of arthritis Although several risk factors for osteoarthritis in and is the leading cause of disability in developed other joints have been identified (such as increased countries. The prevalence of osteoarthritis increases age, family history, obesity and occupation197), little significantly with age. Approximately 28% of people is known about risk factors for primary foot osteoar- aged over 65 years report symptomatic osteoarthritis, thritis. The observation that foot osteoarthritis fre- with prevalence increasing to 37% in people aged quently coexists with osteoarthritis in the hands and over 85 years.188 Older people with osteoarthritis are knees suggests that a systemic aetiology with genetic more likely to have difficulties with activities of daily predisposition may be responsible.195 There is also living,189 reduced quality of life190 and increased risk preliminary evidence that this hereditary predisposi- of falls191 compared to those without the condition. tion may be related to anatomical variations in articu- The most commonly affected joints are the hips, lar facet configuration. An anatomical study of 191 knees and lumbar spine, and in Australia it has been osteological specimens by Drayer-Verhagen198 found estimated that 19 000 hip and 20 000 knee replace- that calcanei with a large, continuous anterior facet ments are performed for osteoarthritis each year.188 were more likely to demonstrate arthritic lipping, suggesting that the increased range of motion associ- In contrast to the wealth of literature pertaining to ated with this articular configuration may cause the hip and knee osteoarthritis, relatively little is known joint to be less stable,199 thereby predisposing to about osteoarthritis affecting the foot in older people. the development of subtalar joint osteoarthritis In the US, the 1991 National Health Interview Survey (Fig. 10.8). included a podiatry supplement and found that approximately 6% of respondents over 65 years of age Secondary osteoarthritis affecting the subtalar joint reported ‘arthritis of the toes’,192 while a recent postal and midfoot joints is a relatively common complica- survey of 5689 people over 65 years of age in the tion of ankle joint fusion. In one study, 33% of patients Netherlands reported that 8% of subjects reported who had undergone ankle arthrodesis developed sub- ‘foot osteoarthritis’.193 The prevalence of radiographi- talar joint osteoarthritis after an average of 7 years of cally confirmed osteoarthritis in the midfoot and rear- follow-up.200 The underlying mechanism appears to foot is largely unknown, as the two largest radiographic be an increase in joint contact pressures during the prevalence studies that included foot joints primarily propulsive phase of gait, as a recent cadaver study focused on the metatarsophalangeal joints.194,195 revealed that talonavicular and calcaneocuboid pres- However, a study of 50 cadavers (average age at death sures were significantly increased following ankle of 76 years) indicated that moderate to severe degen- arthrodesis when the ankle joint was placed between 0° and 20° of dorsiflexion.201 ABCD Figure 10.8 Variations in the anterior articular configuration of the calcaneus. A. Two separate anterior facets. B. Continuous figure-eight facet. C. Long continuous facet. D. Medial facet only.

206 DISORDERS OF THE MIDFOOT AND REARFOOT CLINICAL PRESENTATION A Osteoarthritis affecting the midfoot and rearfoot gen- erally presents as a vague, insidious pain in the midfoot region that is exacerbated by long periods of weight- bearing activity. Overt signs of inflammation are gen- erally absent; however, there may be mild swelling around the affected joint or joints. Palpation of the affected area may reveal the presence of large osteo- phytes at the margins of the joint, and pain may be elicited in response to moving the joint through its full range of motion. Plain film X-rays will reveal the characteristic features of osteoarthritis, including joint space narrowing, formation of osteophytes, subchon- dral sclerosis and bony cysts. Typical examples are shown in Figure 10.9. A recently published atlas of osteoarthritis affecting the foot is a useful guide for grading the severity of arthritic changes.202 CONSERVATIVE TREATMENT B Conservative management of foot osteoarthritis is similar to that of osteoarthritis in other weightbearing joints and includes the use of analgesics for pain relief and mechanical therapies to reduce the compressive load on the affected joint. Although no rigorous studies have been undertaken, foot orthoses may be effective in patients with osteoarthritis related to flat foot deformity (such as those with tibialis posterior dysfunction). There is preliminary evidence that cast orthoses may be more effective in managing symp- toms associated with foot osteoarthritis than non- steroidal anti-inflammatory medications.203 In this retrospective study, the degree of pain relief reported by 64 patients (average age 63 years) who had received various treatments for foot osteoarthritis were evalu- ated. All of those who were prescribed foot orthoses reported significant reductions in pain, and their pain relief was maintained for a longer period of time than those who were taking NSAIDs. Although there are several limitations with this type of study design, it is worth noting that foot orthoses reduce subtalar joint pronation204 and foot pain205 in patients with rheuma- toid arthritis, so it is possible that they may have similar effects in people with osteoarthritis. Figure 10.9 Radiographic appearance of osteoarthritis. A. First cuneometatarsal joint. B. Navicular–cuneiform joint. C. Talonavicular joint. C

Less common midfoot and rearfoot disorders 207 In patients with more advanced degenerative osteoarthritis of the subtalar and ankle joints, ankle– foot orthoses may be effective.206 Several studies in patients with subtalar207 and ankle208 osteoarthritis have confirmed that various designs of ankle–foot orthoses are effective in reducing rearfoot motion and may therefore relieve compression in the midfoot and rearfoot. Ankle–foot orthoses are discussed in more detail in Chapter 11. SURGICAL TREATMENT A Surgical management of rearfoot and midfoot osteo- B arthritis in older people generally involves fusion of Figure 10.10A, B Pes cavus (highly arched foot). (A the affected joint or joints.209 Traditionally, most cases Courtesy of Josh Burns, University of Sydney.) were treated with triple arthrodesis (fusion of the ankle, subtalar and transverse tarsal joints); however, more recently, single joint fusions are undertaken in an attempt to preserve as much motion as possi- ble210,211 and arthroscopic debridement has also been used as an interim approach before considering arthrodesis.212 Although no controlled trials have been undertaken, several case series studies indicate that arthrodesis is an effective treatment for advanced osteoarthritis and that most patients are satisfied with the results.213–215 However, foot function is markedly altered following surgery and many patients will exhibit gait changes associated with their reduced range of motion. In particular, many patients report difficulties walking on irregular surfaces following arthrodesis210,216 and, as stated previously, up to one- third may develop secondary osteoarthritis in adjacent joints. Furthermore, in most surgical studies a large number of patients report some degree of residual pain and require adjunctive conservative treatments such as footwear modifications and orthoses. LESS COMMON MIDFOOT Figure 10.11 Typical plantar pressure output of a AND REARFOOT DISORDERS patient with pes cavus. PAINFUL PES CAVUS development of plantar forefoot and heel pain. Because of the trend towards a lowering of the medial The term pes cavus describes a foot with an abnor- arch with advancing age,218 pes cavus is not a common mally high medial arch (Fig. 10.10) and therefore presentation in older people. The Feet First study refers to a structural anomaly rather than a discrete of 784 Americans aged over 65 years reported a 5% clinical condition. Not all people with highly arched prevalence of pes cavus, compared to a 19% preva- feet develop symptoms. However, the features com- lence of pes planus (flat feet).2 The aetiology of pes monly associated with pes cavus, such as restricted joint range of motion and loss of shock absorption, are associated with elevated pressures in the forefoot and heel (Fig. 10.11),217 which may contribute to the

208 DISORDERS OF THE MIDFOOT AND REARFOOT cavus is not well understood but many cases are ses to control excessive foot pronation.224,225 Surgical thought to be neurogenic in origin, the most common management of tarsal tunnel syndrome includes neuromuscular cause being Charcot–Marie–Tooth decompression of the nerve by flexor retinaculum disease.219 release and, if necessary, neuroma excision. Reported outcomes from case series studies are only moderate, Management of pes cavus in older people is based with 17–43% of patients reporting dissatisfaction with on addressing the presenting symptoms and associ- the result.229–231 ated complaints (such as plantar lesions) using conservative techniques, rather than ‘correcting’ the SINUS TARSI SYNDROME structural anomaly itself. A recent randomised trial indicated that customised foot orthoses are effective The sinus tarsi is a conical cavity that acts as a bound- in redistributing pressures away from the forefoot and ary between the anterosuperior surface of the calca- heel, thereby reducing symptoms associated with neus and the inferior aspect of the neck of the talus, painful pes cavus.220 Inadequate shock attenuation and contains a fat plug, joint capsule, neurovascular associated with pes cavus may also be addressed by elements and five ligaments. In 1958, O’Connor232 the provision of footwear with ethyl vinyl acetate described a condition characterised by persistent midsoles221,222 or by the addition of a shock-absorbing lateral ankle pain following an inversion sprain, which cushioned heel shoe modification (Ch. 12). was attributed to scarring of the ligaments within the sinus tarsi. Since this initial report, several authors TARSAL TUNNEL SYNDROME have described a similar syndrome, which has been variously attributed to synovitis, entrapment of the First described in 1960,223 tarsal tunnel syndrome superficial peroneal nerve, ganglia, ligament damage is an uncommon entrapment neuropathy caused by and tarsal coalition.233–235 compression of the posterior tibial nerve (or its branches) beneath the flexor retinaculum. The condi- The classical clinical presentation of sinus tarsi syn- tion is characterised by anaesthesia, paraesthesia and drome is that of persistent lateral ankle pain and insta- burning pain in the medial malleolar region that radi- bility in patients with a history of recurrent ankle ates along the course of the calcaneal, medial plantar sprains; however, the condition may occur in the or lateral plantar nerves. Tarsal tunnel syndrome may absence of previous trauma.233,235 Of particular inter- develop secondary to direct trauma of the posterior est in older patients, cases of sinus tarsi syndrome tibial nerve, the development of space-occupying associated with gout affecting the subtalar joint have lesions such as ganglia, rapid weight gain or inflam- been reported.236 Pain can be elicited on direct palpa- matory conditions such as rheumatoid arthritis.224,225 tion and by supinating the subtalar joint. Plain film X-ray is rarely helpful in reaching a diagnosis and, The diagnosis of tarsal tunnel syndrome is based although MRI may reveal ligament tears and signs on patient history and physical examination. Symp- of fibrosis, whether these observations are highly toms are generally exacerbated by prolonged periods characteristic of the condition is yet to be fully of weightbearing activity and can be elicited by pro- determined.236 nating the foot and dorsiflexing the toes or by direct percussion of the nerve (referred to as a positive As with tarsal tunnel syndrome, treatment of sinus Tinel’s sign226). Electrophysical studies are considered tarsi syndrome is largely empirical. No trials of con- to be the gold standard diagnostic test for tarsal servative treatments have been undertaken, with only tunnel syndrome and will reveal reduced sensory a single case study reporting good results with the use nerve conduction velocity and increased latency of of foot orthoses.237 A recent case series of 13 patients motor nerves compared to the unaffected side.227 who underwent resection of the deep peroneal nerve Magnetic resonance imaging is not commonly used reported highly favourable results, with 10 patients but may be useful for identifying space-occupying reporting complete pain relief after 6 months.238 lesions exerting pressure on the neurovascular bundle.228 SUMMARY Treatment of tarsal tunnel syndrome is largely A wide range of pathological conditions may manifest empirical, as few rigorous intervention studies have as pain in the rearfoot in older people and it is clear been undertaken. Conservative treatment options include NSAIDs, corticosteroid injection and ortho-

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216 DISORDERS OF THE MIDFOOT AND REARFOOT patients with ankle osteoarthritis. Archives of 224. Radin EL. Tarsal tunnel syndrome. Clinical Ortho- Physical Medicine and Rehabilitation 2006; 87: paedics and Related Research 1983; 181: 710–716. 167–170. 209. Donatto KC. Arthritis and arthrodesis of the hind- foot. Clinical Orthopaedics and Related Research 225. Cimino WR. Tarsal tunnel syndrome: review of the 1998; 349: 81–92. literature. Foot and Ankle International 1990; 11: 210. Fogel GR, Katoh Y, Rand JA et al. Talo-navicular 47–52. arthrodesis for isolated arthrosis. Foot and Ankle 1982; 3: 105–113. 226. Tinel J. Le signe du fourmillement dans les lesions 211. Mann RA, Baumgarten M. Subtalar fusion for iso- des nerfs peripheriques. Presse Medicale 1915; 23: lated subtalar disorders. Preliminary report. Clinical 388–389. Orthopaedics and Related Research 1988; 226: 260–265. 227. Mondelli M, Giannini F, Reale F. Clinical and elec- 212. Cheng JC, Ferkel RD. The role of arthroscopy in trophysiological findings and follow-up in tarsal ankle and subtalar degenerative joint disease. Clini- tunnel syndrome. Electroencephalography and Clin- cal Orthopaedics and Related Research 1998; 349: ical Neurophysiology 1998; 109: 418–425. 65–72. 213. Graves SC, Mann RA, Graves KO. Triple arthrodesis 228. Zeiss J, Ebrahim N, Rusin J. Magnetic resonance in older adults. Results after long-term follow-up. imaging in the diagnosis of tarsal tunnel syndrome. Journal of Bone and Joint Surgery 1993; 75A: Case report. Clinical Imaging 1990; 14: 123– 355–362. 126. 214. Huang PJ, Chen SK, Chen YW et al. Subtalar arthrodesis for subtalar arthritis. Kaohsiung Journal 229. Pfeiffer WH, Cracchiolo A. Clinical results after of Medical Sciences 1997; 13: 677–681. tarsal tunnel decompression. Journal of Bone and 215. Glanzmann MC, Sanhueza-Hernandez R. Arthro- Joint Surgery 1994; 76A: 1222–1230. scopic subtalar arthrodesis for symptomatic osteoar- thritis of the hindfoot: a prospective study of 41 cases. 230. Turan I, Rivero-Melian C, Guntner P et al. Tarsal Foot and Ankle International 2007; 28: 2–7. tunnel syndrome. Outcome of surgery in longstand- 216. Johansson JE, Harrison J, Greenwood FAH. Sub- ing cases. Clinical Orthopaedics and Related Research talar arthrodesis for adult traumatic arthritis. Foot 1997; 343: 151–156. and Ankle 1982; 2: 294–298. 217. Burns J, Crosbie J, Hunt A et al. The effect of 231. Jerosch J, Schunck J, Khoja A. Results of surgical pes cavus on foot pain and plantar pressure. Clinical treatment of tarsal tunnel syndrome. Foot and Ankle Biomechanics 2005; 20: 877–882. Surgery 2006; 4: 205–208. 218. Scott G, Menz HB, Newcombe L. Age-related dif- ferences in foot structure and function. Gait and 232. O’Connor D. Sinus tarsi syndrome: a clinical entity. Posture 2007; 26: 68–75. Journal of Bone and Joint Surgery 1958; 40A: 219. Brewerton D, Sandifer P, Sweetnam D. Idiopathic 720. pes cavus: an investigation into its aetiology. British Medical Journal 1963; 2: 659–661. 233. Bernstein RH, Bartolomei FJ, McCarthy DJ. 220. Burns J, Crosbie J, Ouvrier R et al. Effective orthotic Sinus tarsi syndrome: anatomical, clinical, and therapy for the painful cavus foot. Journal of the surgical considerations. Journal of the American American Podiatric Medical Association 2006; 96: Podiatric Medical Association 1985; 75: 475– 205–211. 480. 221. Light LH, McLellan GE, Klenerman L. Skeletal transients on heel strike in normal walking with dif- 234. Frey C, Feder KS, DiGiovanni C. Arthroscopic eval- ferent footwear. Journal of Biomechanics 1980; 13: uation of the subtalar joint: does sinus tarsi syn- 477–480. drome exist? Foot and Ankle International 1999; 20: 222. Lafortune MA, Hennig EM. Cushioning properties 185–191. of footwear during walking: accelerometer and force platform measurements. Clinical Biomechanics 235. Pisani G, Pisani PC, Parino E. Sinus tarsi syndrome 1992; 7: 181–184. and subtalar joint instability. Clinics in Podiatric 223. Thompson WAL, Kopell HP. Peripheral entrapment Medicine and Surgery 2005; 22: 63–77. neuropathies of the lower extremity. New England Journal of Medicine 1960; 252–256. 236. Lektrakul N, Chung CB, Lai YM et al. Tarsal sinus: Arthrographic, MR imaging, MR arthrographic, and pathologic findings in cadavers and retrospective study data in patients with sinus tarsi syndrome. Radiology 2001; 219: 802–810. 237. Shear MS, Baitch SP, Shear DB. Sinus tarsi syndrome: the importance of biomechanically- based evaluation and treatment. Archives of Physical Medicine and Rehabilitation 1993; 74: 777–781. 238. Dellon AL, Barrett SL. Sinus tarsi denervation: clini- cal results. Journal of the American Podiatric Medical Association 2005; 95: 108–113.

Orthotic therapy CHAPTER 11 CHAPTER CONTENTS Orthotic therapy plays a major role in the conservative management of foot disorders in older people.1,2 In Chairside orthoses 218 the UK National Health Service, it has been estimated Horseshoe pad 218 that £38 million is spent on orthoses each year, with Crescent pad 218 foot orthoses accounting for 75% of a district hospi- Toe prop 219 tal’s total appliances budget.3 Orthotic devices range Interdigital wedge 219 from simple adhesive pads that can be manufactured Saddle pad 220 during a routine consultation through to more Foam sleeves 220 complex techniques involving the construction of Plantar cover 220 custom-moulded insoles derived from plaster casts of Plantar metatarsal pad 220 the patient’s feet. Metatarsal shaft pad 221 Valgus pad 222 The basic principles of orthotic therapy are to Plantar calcaneal pad 222 reduce the magnitude of pressure applied to painful Retrocalcaneal pad 222 regions of the foot, to realign structures within the Silicone orthodigita 222 foot to correct any existing deformity, and to control motion of joints in the foot, either by restricting Non-cast insoles 222 excessive motion or by facilitating joints with limited motion.4–6 Although these underlying principles are Prefabricated orthoses 223 223 generally agreed upon, there are several opposing Silicone and other viscoelastic devices theories pertaining to the biomechanical function of Hallux valgus splints 224 the foot, which give rise to a plethora of alternative Contoured insoles 224 orthotic prescription protocols to achieve these objec- tives. It is beyond the scope of this chapter to discuss Cast orthoses 225 these issues in detail. Therefore, it is recommended that the reader refer to several recent reviews on the Ankle–foot orthoses 226 topic7–9 and supplement the information contained in this chapter with textbooks specifically focused on Foot orthoses and knee osteoarthritis 227 foot orthoses, such as Foot Orthoses and Other Forms of Conservative Footcare4 and Clinical Biomechanics of Foot orthoses as a balance aid 228 the Lower Extremities.10 Summary 229 The classification and nomenclature of foot ortho- References 229 ses is also a somewhat vexed issue, as no widely agreed upon system has yet been adopted. For the purpose of this chapter, the following classifications are used:

218 ORTHOTIC THERAPY ■ Chairside orthoses: padding techniques that can be Various types of foam can also be used. As a general manufactured during a routine consultation from rule, semicompressed felt is more effective in pressure widely available materials such as felt, foam and redistribution, whereas foam is more effective in shock silicone putty absorption and tends to last longer. Chairside ortho- ses can be directly adhered to the foot and secured ■ Non-cast insoles: orthoses placed inside the shoe with tape, fixed inside the shoe or made into replace- that do not require a cast to be taken of the able devices. These devices will invariably become less patient’s foot effective over time, as a result of material compression and/or loss of adhesion, and will therefore need to ■ Prefabricated orthoses: mass-produced commer- be replaced regularly. In most cases, chairside devices cially available devices that can be purchased from are designed to provide short-term symptomatic relief orthotic laboratories, medical suppliers or and, if effective, to help guide the selection and con- pharmacists struction of more permanent devices. The following section briefly describes some of the more commonly ■ Cast orthoses: devices manufactured from soft or used chairside orthoses and their clinical applications. rigid materials using a plaster replica of the patient’s Additional variants of these basic pad designs can be foot found in Paddings and Strappings of the Foot12 and Practical Orthotics for Chiropodists.13 ■ Ankle–foot orthoses: prefabricated or customised devices that extend above the ankle joint. HORSESHOE PAD Orthotic prescription and manufacture for older As the name suggests, the horseshoe pad (Fig. 11.1A) people is essentially the same as for younger people; is a U-shaped pad with two arms that extend onto the however, several factors require additional consider- dorsum of the proximal phalanges of the toes. This ation. Firstly, given the high prevalence of ill-fitting pad is used to deflect pressure away from dorsal lesions footwear in older people,11 particular care needs to be on the proximal interphalangeal joints of hammer taken to ensure that the patient’s footwear is appro- toes or claw toes, and is generally constructed from priate for orthotic therapy, particularly with regard to 7 mm compressed felt. The horseshoe pad is particu- the depth of the toebox. Secondly, the mobility of larly effective at redistributing pressure away from a older patients should be evaluated to ascertain their single lesion (in the example provided, the third toe) ability to reach their feet, as orthoses fitted directly to where the adjacent toes are neutrally aligned. For the foot will need to be removed and replaced before multiple lesions on adjacent toes, the crescent pad is and after bathing and sleeping. Finally, it is essential generally used. to assess an older person’s skin integrity prior to pre- scribing orthoses and, where there is some risk of skin CRESCENT PAD damage, orthoses should be covered with a soft and compliant material and carefully checked for rough or The crescent pad (Fig. 11.1B), also referred to as a sharp edges on a regular basis. U-pad, is used to deflect pressure away from dorsal lesions affecting one or more of the proximal inter- The following chapter briefly outlines the use of phalangeal joints. Depending on the severity of the each of these types of orthosis in the management of lesser toe deformity, 5 or 7 mm felt can be used to foot disorders in older people. The broader applica- ‘fill in’ the space between the dorsal aspect of the tions of foot orthoses in this age-group, such as the metatarsal heads and the proximal interphalangeal role of orthoses in the management of knee osteoar- joints. For optimum results, the distal edge of the pad thritis and in improving balance, are also discussed. should closely follow the shape of the dorsal promi- nences and be bevelled on the inferior surface to CHAIRSIDE ORTHOSES improve the fit of the device. The term chairside orthoses refers to simple devices Both the horseshoe and crescent pads can be that can be quickly and easily manufactured during a directly adhered to the foot; however, for longer-term routine patient consultation. The most common results, replaceable devices can be constructed by material used for these devices is adhesive semicom- pressed felt, which is available in several thicknesses (most commonly 2 mm, 5 mm, 7 mm and 10 mm).

AB Chairside orthoses 219 CD placing the non-adhesive side to the foot, looping elastic strap around the toes and affixing the strap to EF the dorsal adhesive side, and covering the dorsal surface of the pad with tape (Fig. 11.2). Figure 11.1 Padding techniques for the toes. A. Horseshoe pad. B. Crescent pad. C. Toe prop. TOE PROP D. Interdigital wedge. E. Saddle pad. F. Toe sleeve. The toe prop, also referred to as a buttress appliance or crest pad (Fig. 11.1C), has several variations and functions.14 The aim of the basic plantar toe prop is to fill in the space between the plantar metatarsal heads and the apices of the toes, thereby redistribut- ing load from plantar apical lesions, particularly in the presence of rigid claw toes. However, if the claw toe deformity is flexible, the distal edge of the pad can be extended further distally to assist in dorsiflexing the distal interphalangeal joint, thereby straightening the toes.15 A further variation (referred to as a dorsoplan- tar prop) involves the addition of a dorsal prop con- nected to the plantar prop by elastic strapping, which is thought to assist in straightening the toes by the shoe exerting a plantarly directed force on the dorsal pad while the plantar pad exerts a dorsally directed force, thereby plantarflexing the metatarsophalangeal joints and dorsiflexing the proximal and distal inter- phalangeal joints simultaneously. INTERDIGITAL WEDGE The interdigital wedge or dumbbell pad (Fig. 11.1D) is used to assist in the separation of adjacent toes and is most commonly used in the short-term manage- ment of interdigital corns (both heloma dura and heloma molle). This pad is also used in the conserva- tive management of onychocryptosis, as a means of ABC Figure 11.2 Manufacture of a replaceable horseshoe pad. A. Determining the size and shape of the pad. B. Straps adhered to dorsal adhesive surface of pad. C. Dorsal surface of pad covered with tape.

220 ORTHOTIC THERAPY alleviating pressure from adjacent nail sulci.16 As the PLANTAR COVER name suggests, the pad is cut into a dumbbell shape from compressed felt, placed between the toes and The plantar cover, or plantar pad, extends from the adhered directly to the dorsal and plantar surfaces of styloid process of the fifth metatarsal to the distal the foot. It is important to ensure that the thickness aspect of the metatarsal heads and covers the entire of the plantar aspect of the pad is reduced so as not plantar metatarsal area (Fig. 11.3A).17 It can be man- to interfere with normal weightbearing. An alternative ufactured from foam or felt of various thickness approach is to simply adhere a piece of felt to the depending on the space available in the shoe. The medial or lateral aspect of the proximal phalanx; distal edge of the pad is bevelled to improve comfort however, such devices tend to break down more and adhesion. The plantar cover is used to cushion quickly and, because of interdigital maceration, are the metatarsal heads and is particularly useful in older difficult to get to adhere for long periods of time. people with atrophy of the plantar soft tissues. The Interdigital wedges may also be manufactured from pad can be directly adhered to the plantar surface of silicone and, because of their close moulding to the the foot, adhered to the inner sole of the shoe or space between the toes, tend to be more effective and made into a replaceable device by looping elastic last longer than felt pads (see later section on silicone strapping around the middle three toes, adhering the devices). strap to the plantarly directed adhesive surface, and covering the plantar surface of the pad with tape. SADDLE PAD The plantar cover can be modified to redistribute The saddle pad, also known as a tendon pad (Fig. pressure from individual metatarsal heads by the addi- 11.1E), is designed to alleviate dorsal pressure from tion of a ‘U’ (for the second, third or fourth meta- footwear in the presence of prominent long extensor tarsal heads) or a ‘wing’ (for the first and/or fifth tendons. As the name suggests, the pad is directly metatarsal heads), as shown in Figure 11.3B and C. adhered to the dorsum of the foot like a saddle, with Such pads are used to reduce loading on metatarsal a plantar groove cut into the pad to accommodate the heads affected by keratotic lesions and insufficiency tendon. In patients with several prominent extensor fractures and have also been demonstrated to assist in tendons (such as those with multiple clawtoes, ham- the healing of plantar neuropathic ulcers in people mertoes or retracted toes associated with pes cavus with diabetes.18,19 The relative efficacy of ‘U’d plantar foot deformity), the saddle pad can be extended covers compared to other devices for offloading the across the entire dorsal aspect of the foot (with mul- metatarsal heads, however, is unclear. A recent study tiple grooves for each tendon) and bevelled to ensure using an in-shoe pressure analysis system indicated close apposition with the dorsal aspects of the meta- that a plantar metatarsal pad (discussed below) was tarsal shafts. more effective in reducing pressures.20 FOAM SLEEVES PLANTAR METATARSAL PAD Prefabricated tubefoam has several uses. The simplest The plantar metatarsal pad, also referred to as a meta- application of tubefoam is the construction of basic tarsal pad, has several variants. The most commonly toe sleeves (Fig. 11.1F) for cushioning dorsal lesions, described pad covers the shafts of the second, third used with or without additional felt crescents. Larger and fourth metatarsals and follows the distal curve of diameter tubefoam can also be used in management the respective metatarsal heads (Fig. 11.3D).12,13 The of painful hallux valgus (by constructing a toe sleeve pad is thought to have several functions: with a longer medial flange to place over the inflamed medial exostosis), or as removable alternative to the ■ To redistribute load from the metatarsal heads to saddle pad, by placing the sleeve over one of the toes the shafts and extending a flange over the dorsum of the foot. Care needs to be taken; however, that the diameter ■ To redistribute load to the first and fifth metatarsal of tubefoam selected is sufficient to prevent constric- heads tion of blood flow to the digits, particularly in older people with peripheral vascular disease. ■ To straighten the central three toes. Clinical indications for the use of this pad include keratotic lesions under the central metatarsal heads, flexible hammertoe deformity, interdigital neuroma and predislocation syndrome. Variants of the plantar

Chairside orthoses 221 ABCD E FGH Figure 11.3 Plantar padding techniques. A. Plantar cover. B. ‘U’d plantar cover. C. Winged plantar cover. D. Plantar metatarsal pad. E. Metatarsal shaft pad. F. Extended shaft pad. G. Valgus pad. H. Plantar calcaneal pad. metatarsal pad include the metatarsal dome, which pressure systems is ideal for this purpose. However, does not extend as far distally, a winged version that in the absence of such systems, some insight can be has a medial flange extending under the first metatar- gained from subjective responses from the patient, as sal shaft (to deflect pressure away from the first meta- two studies have indicated that reported pain relief is tarsal head) and smaller metatarsal pads, sometimes significantly correlated with the degree of pressure referred to as teardrop pads, which are placed proxi- reduction.22,24 mal to individual metatarsal heads. METATARSAL SHAFT PAD The optimum placement of the plantar metatarsal pad to reduce pressures under the metatarsal heads is The metatarsal shaft pad, also known as an under unclear, as several studies have been undertaken with pad,12 covers the plantar surface of one or more meta- variable results. Six studies have found that a pad tarsals (Fig. 11.3E). The aim of this pad is to elevate placed proximal to the metatarsal heads significantly the metatarsal relative to adjacent metatarsals, and is reduces metatarsal head pressures (by up to 60%),21–26 thought to be of particular benefit in the management two studies found no significant reduction in pres- of intermetatarsal neuroma (in the case of a neuroma sures with proximally placed pads27,28 and one study29 in the third–fourth intermetatarsal space, the pad is found that placing a pad 5 mm distal to the metatarsal placed under the fourth and fifth metatarsal heads).30 heads reduced pressure more effectively than placing Multiple shaft pads can also be placed to ‘rebalance’ it 5 mm proximal to the metatarsal head. These vari- pressure distribution across the plantar surface. Such able findings are likely to reflect differences in plantar devices, sometimes referred to as a forefoot imbalance pressure measurement protocols and participant char- pads31 or parallel strip padding,12 are considered to be acteristics; however, it also likely that the optimum of benefit in the management of plantar lesions caused location of plantar metatarsal pads requires some by highly prominent (‘depressed’) central metatarsal degree of trial and error. The clinical use of plantar

222 ORTHOTIC THERAPY heads, as may develop in conduction with lesser toe older people, as they contain the lateral expansion of deformity in the rheumatoid foot. In this case, two the heel on weightbearing, thereby improving shock pads are applied to the first and fifth metatarsal attenuation by maintaining the vertical thickness of shafts. the heel pad.37 The manufacture of felt or foam chair- side devices for the heel has been largely supplanted A variation of the shaft pad is the extended shaft by the availability of prefabricated heel pads manufac- pad (also known as Morton’s extension), which is tured from viscoelastic materials (see below). placed under the first metatarsal but extends distally to completely cover the first metatarsophalangeal RETROCALCANEAL PAD joint (Fig. 11.3F). This pad was originally designed to compensate for the so-called Morton’s foot type, The retrocalcaneal pad, also known as a posterior heel characterised by an excessively short first metatarsal pad,12 is a circular pad placed on the posterior aspect with subsequent overloading of the second metatarsal of the heel to reduce friction from footwear in patients head.32 However, it is now recognised that such a foot with retrocalcaneal bursitis or Haglund’s deformity. type is far less common than originally thought and Depending on the size of the bony prominence, an is not frequently associated with pathology.33 Never- aperture may also be cut into the pad. As with plantar theless, this pad is useful for redistributing pressure calcaneal pads, the availability of prefabricated, adhe- away from the first interphalangeal joint in people sive viscoelastic materials has largely replaced the tra- with limited motion at the first metatarsophalangeal ditional felt or foam pads, as they are more effective joint (such as people with hallux limitus/rigidus or at reducing friction and tend to last much longer. limited joint mobility associated with diabetes). VALGUS PAD SILICONE ORTHODIGITA The valgus pad, also known as a scaphoid pad or long The availability of medical grade silicone putties, arch pad, fills in the medial longitudinal arch region originally developed for dental casting applications, of the foot (Fig. 11.3G). The aim of this pad is to has enabled the manufacture of long-lasting, wash- support the medial arch13 and it has been shown that, able, customised orthoses within the time constraints when valgus pads are worn, plantar pressures increase of a routine clinical consultation.15,38 Commercially under the lateral border of the foot, which may indi- available two-part systems consisting of the silicone cate a lateral shift in the centre of pressure associated putty and a catalyst (such as Otoform K® and Podia- with a reduction in foot pronation.34 Valgus pads are form®) can be used to manufacture a wide range of particularly useful as an adjunct in the management devices, including toe props,39 interdigital wedges40 of forefoot ulceration in diabetic patients by ‘filling and bunion shields41 (Fig. 11.4). Silicone orthoses are in’ the space between the heel and the forefoot, and particularly useful for reducing pressures under the are often used in conjunction with plantar forefoot apices of the toes. A recent study of 14 patients with padding.35 A recent study of 30 diabetic patients by diabetes indicated that custom-moulded silicone toe Guldemond et al36 reported that the addition of a props reduced digital plantar pressures by 30% and, valgus pad to a contoured foot bed with a metatarsal when used in conjunction with keratotic lesion dome increased the degree of forefoot pressure reduc- debridement, pressures were reduced by 54%.42 In tion by up to 25%. addition to reducing toe pressures, there is some evi- dence that flexible lesser toe deformities can be gradu- PLANTAR CALCANEAL PAD ally ‘corrected’ using serial toe props, with each new device shaped to provide slightly more correction The plantar calcaneal pad, or heel pad, is placed over than the previous one.15 the weightbearing surface area of the heel (Fig. 11.3H) and is used to reduce loading of the heel in NON-CAST INSOLES patients with plantar heel pain syndrome (including plantar calcaneal bursitis and calcaneal stress frac- As the name suggests, non-cast insoles are customised tures). The efficacy of plantar calcaneal pads has not orthotic devices that do not require a cast to be taken been examined in detail; however, there is some sug- of the patient’s foot. Traditionally, these devices were gestion that rigid heel cups may be more effective in

Prefabricated orthoses 223 recording the location of key anatomical features of the foot (particularly the metatarsal heads and the location of plantar lesions). The pad design is then marked on to the cardboard template, and constructed from the appropriate materials (generally open cell black rubber). The pad is then adhered to a compressed cardboard base and covered with a soft material such as chamois. The addition of simple wedges to non-cast insoles in an attempt to support forefoot deformities (e.g. fore- foot varus and valgus) and to control foot pronation has also been suggested.43 However, while such an approach may be a useful temporary measure to ascer- tain the potential effectiveness of a more ‘functional’ foot orthosis, it has recently been shown that such A devices have relatively minor effects on foot kinetics44 and kinematics,45 possibly because of the lack of medial longitudinal arch support. To a large extent, the wide availability and low cost of prefabricated orthoses has made the traditional manufacture of non-cast insoles redundant. In con- temporary clinical practice, many foot specialists will simply modify a prefabricated orthosis by adhering appropriate padding designs to the orthosis shell itself. This approach provides the additional benefits of customised forefoot padding designs to the con- toured arch and heel cup of the prefabricated orthosis, and is much less time-consuming. B PREFABRICATED ORTHOSES Figure 11.4 Silicone devices. A. Toe prop. B. Interdigital wedges. SILICONE AND OTHER VISCOELASTIC DEVICES manufactured by affixing various types of rubber or foam pads (using similar designs to the chairside A wide range of silicone appliances are now commer- devices previously discussed) to a flat insole made cially available from medical suppliers and pharmacists from compressed cardboard, cork, leather or a com- (Fig. 11.5). To some extent, these devices are replac- bination of all three materials. The main advantages ing the chairside manufacture of felt and foam pads of non-cast insoles over chairside devices is that they for minor foot complaints.46 Although over-the- do not have to be affixed directly to the foot and, counter silicone appliances are considerably more because of the much greater resilience of the materials expensive than chairside devices, the viscoelastic prop- used, they have a much longer lifespan. The main erties of the silicone make them very comfortable and disadvantage of non-cast insoles is that the insole base surprisingly long-lasting. Some silicone devices are is constructed to match the shape and size of the last also impregnated with mineral oil, which may have of the shoe and, as such, cannot always be transferred additional effect of hydrating keratotic lesions. The from one pair of shoes to another. key disadvantage of these appliances is that they are difficult to customise. The technique involves obtaining an accurate tracing of the insole of the patient’s shoe by trimming Few studies have been undertaken to assess the a piece of cardboard and fitting it inside the shoe, then efficacy of prefabricated silicone appliances. Claisse et al47 have shown that a commercially available silicone toe prop significantly reduces pressures under the

224 ORTHOTIC THERAPY Figure 11.5 Prefabricated silicone orthoses. From right: heel pad, metatarsal pad, interdigital wedge, toe covers, bunion shield. apices of the second and third toes and under the Figure 11.6 Hallux valgus splint. third and fourth metatarsal heads. Caselli et al48 com- pared a full length silicone insole (Viscoped®) versus the hallux abductus angle and intermetatarsal angle a simple insole made from Poron® in 35 patients with had reduced in half the group 2–6 years later. In plantar keratotic lesions and reported no significant contrast, Juriansz50 compared a hallux valgus night differences between the groups in relation to pain splint to no treatment in 28 people ranging in age reduction. Finally, Kelly & Winson49 compared the from 10 to 77 years and found no improvement in efficacy of a full-length silicone insole with extra soft clinically determined degree of deformity. silicone inserts under the metatarsal heads (Viscoped®) versus a Plastazote® customisable insert system Clearly, further research is required to fully ascer- (Langer Blueline®) in 33 patients with lesser metatar- tain the effectiveness of splints in the management of salgia, and found that the Langer device provided hallux valgus in older people; however, it is likely that greater pressure reduction and pain relief. Although splints would only be effective in milder forms of the further research needs to be undertaken to more thor- condition where no significant bony remodelling has oughly assess the efficacy of silicone devices, the latter taken place. Furthermore, the acceptability of night two studies highlight that the use of more high-tech splints in older patients is uncertain. Given that sleep materials does not necessarily produce better out- disturbances are common in older people52 and that comes, and that customisation may be beneficial in high levels of dissatisfaction have been reported with certain cases. plantar fasciitis night splints because of sleeping diffi- culties,53 it is likely that hallux valgus night splints HALLUX VALGUS SPLINTS would be poorly tolerated in many older people. The use of splints to realign the hallux in people with CONTOURED INSOLES hallux valgus deformity has been described by several authors,50,51 and a range of splints are now commer- A plethora of prefabricated foot orthoses have become cially available (Fig. 11.6). These devices are worn available in recent years, not only from medical sup- when sleeping and are designed to hold the hallux in pliers and pharmacists but also from custom orthotic a rectus position in an attempt to reduce the contrac- laboratories. These devices are manufactured from a ture of soft tissues pulling the hallux in an abducted position. Only two studies have been undertaken to assess the efficacy of this approach. Groiso51 con- ducted a case series study of 56 children and adoles- cents with juvenile hallux valgus who received thermoplastic splints and exercises, and reported that

Cast orthoses 225 Figure 11.7 A selection of commercially available prefabricated orthosis to use is by no means a scien- prefabricated orthoses. tific process; rather, such choices are made on the basis of availability, cost and individual clinician Figure 11.8 Modular prefabricated orthoses. preference. As stated previously, the wide availability of con- toured prefabricated orthoses has largely replaced the manufacture of non-cast insoles. However, prefabri- cated orthoses appear to have had less impact on the prescription and manufacture of cast orthoses. Indeed, a recent survey of prescribing habits of podiatrists in Australia and New Zealand indicated that the most frequently prescribed orthosis was a cast orthosis (72% of participants compared to only 12% for prefabri- cated orthoses).55 One of the fundamental research questions that needs to be addressed in relation to prefabricated foot orthoses is whether they are as effective as the more time-consuming (and expensive) cast orthoses. A recent audit of 139 patients in the UK suggested that prefabricated orthoses provided similar levels of patient satisfaction to cast devices.3 However, the only condition for which high-quality comparisons have been undertaken is heel pain. A recent randomised controlled trial by Landorf et al56 found that, although both cast and prefabricated orthoses reduced plantar heel pain to a similar degree at 3 months, no significant differences between the groups were noted at 12 months. This paper also included a meta-analysis of their results combined with those of the earlier studies,57–59 which indicated no significant benefit of cast orthoses over prefabri- cated orthoses. These findings suggest that prefabri- cated orthoses may have similar efficacy to customised orthoses, at far less cost, for the management of heel pain. wide range of materials (including polypropylene, CAST ORTHOSES polyethylene, ethyl vinyl acetate and carbon fibre) and can vary considerably in relation to length (three- Cast orthoses, also referred to as functional orthoses, quarters or full length), arch height, flexibility, weight, are devices manufactured from an impression of the longevity and cost (Fig. 11.7). Some prefabricated patient’s foot. Most commonly, cast orthoses are con- orthoses are heat-mouldable, whereas others are avail- structed from rigid thermoplastics that are heat- able in modular form, with a range of additions moulded over a positive plaster cast, with the aim of (including frontal plane wedges, metatarsal pads, etc) providing a precise fit of the device to the plantar that can be used to customise the device (Fig. 11.8). contours of the foot (Fig. 11.9). By modifying both Whether structural variations in prefabricated ortho- the positive cast and the orthotic shell itself, the clini- ses have a significant influence on foot function or cian can theoretically modify a wide range of aspects clinical outcomes has not been explored in detail; of the weightbearing function of the foot. More however, preliminary studies indicate that differences recently, alternative impression techniques (such as exist between devices in relation to the position optical scanning) and manufacturing methods (using adopted by the foot in static stance.54 Selecting which CAD-CAM technology) have become available,

226 ORTHOTIC THERAPY A orthoses is more an art than a science and the out- comes of orthotic therapy may to some extent be B influenced by clinical expertise and experience. Figure 11.9 Customised orthoses. A. Plaster modifications. B. Finished device. Nevertheless, several studies have shown that cast orthoses do indeed modify selected aspects of foot although these systems are yet to have a widespread function (including plantar pressure distribution, impact on traditional manufacturing practices.60 joint kinematics and muscle activity)8,66 and ran- domised controlled trials have reported significant Because of our relatively limited understanding of improvements in pain and function in people with the biomechanical function of the foot and the wide rheumatoid arthritis,67 heel pain56 and painful pes range of modifications that can be made to the shape cavus.68 There is also some preliminary evidence that of an orthosis, there is currently no consensus as to cast orthoses may be more effective in managing how cast orthoses should be prescribed and manufac- symptoms associated with foot osteoarthritis than tured.7 Indeed, there is virtually no agreement as to nonsteroidal anti-inflammatory medications.69 how the foot should be assessed, how the cast should Although these findings are generally positive, as be taken (i.e. prone or supine neutral plaster casting, stated previously there is a need for further studies to partially weightbearing foam box casting or optical fully ascertain the benefits of cast orthoses over pre- scanning), the materials that should be used or the fabricated orthoses. indications for orthotic shell variations (plantar fascial grooves, heel posts, cut-outs, apertures, etc).61–65 Sub- As stated in the introduction, it is beyond the scope sequently, in clinical practice, prescription of cast of this chapter to discuss the details of prescription and manufacture of cast orthoses. Therefore, the reader is referred to specialists texts such as The Func- tional Foot Orthosis,70 Foot Orthoses and Other Forms of Conservative Footcare4 and Clinical Biomechanics of the Lower Extremities,10 as the approaches outlined in these texts are equally applicable to older people. However, it is worth mentioning that many clinicians are somewhat reluctant to prescribe cast orthoses for older people, on the assumption that they may not be able to tolerate rigid materials. While it is certainly true that older people with severe circulatory disor- ders and poor skin integrity may not be ideal candi- dates for rigid foot orthoses because of the risk of skin damage, there is no evidence that older people in general have any greater difficulty adjusting to cast orthoses than their younger counterparts. Indeed, because of age-related arch lowering and the increased prevalence of foot deformity associated with advanc- ing age,71 it could be argued that older people have a greater need for accurate customisation, as they may have difficulty finding a prefabricated device to match the contour of their foot. ANKLE–FOOT ORTHOSES Ankle–foot orthoses (AFOs) are widely used in the management of conditions resulting in weakness of the ankle dorsiflexors (such as poliomyelitis, cerebral palsy and cerebrovascular accident) in an attempt to prevent foot drop during the swing phase of gait.72,73

Foot orthoses and knee osteoarthritis 227 Figure 11.10 Ankle–foot orthoses. Left: Leaf spring motion was achieved with the AFO; however, this ankle–foot orthosis. right: Articulated ankle–foot device also resulted in the adoption of a less propul- orthosis. sive gait pattern. On the basis of this observation, the authors suggested that the HFO-R and HFO-A may Conventional AFOs consisting of a simple metal provide the best balance between motion restriction caliper attached to bespoke footwear have been largely and allowing sufficient propulsion for normal gait. replaced by thermoplastic AFOs manufactured from Subsequent studies in patients with subtalar83 and plaster casts. Although more difficult to manufacture, ankle84 osteoarthritis confirmed that both the HFO-R thermoplastic AFOs provide more precise control of and HFO-A were effective in reducing rearfoot the ankle and are aesthetically more pleasing to the motion on a range of surfaces; however, the HFO-R patient (Fig. 11.10). Several studies have demon- provided optimum results. strated that AFOs produce significant improvements in temporospatial gait parameters, energy efficiency Although no studies have directly evaluated the and lower limb muscle activity in hemiparetic biomechanical effects of AFOs in patients with tibialis patients74–77 and are generally well tolerated.78 posterior dysfunction, two case series investigations have reported favourable results with AFOs or a com- More recently, several types of AFO have been bination of AFOs and other conservative treatments. recommended for use in the conservative manage- Chao et al81 reported significant improvements in pain ment of degenerative osteoarthritis of the subtalar and and function in 49 patients treated with AFOs or foot ankle joints79 and tibialis posterior dysfunction.80,81 orthoses over an average 15-month period. Similarly, The underlying premise of this approach is that exces- in 47 patients with early stage tibialis posterior dys- sive motion of the rearfoot complex is responsible for function, Alvarez et al85 reported that 83% of patients the symptoms associated with these conditions and improved following a treatment regimen of calf that conventional foot orthoses are inadequate for stretching and strengthening and foot orthoses or controlling the pronatory motion in severe flat foot AFOs. deformity. Gait analysis studies indicate that AFOs do indeed alter the motion of the rearfoot complex; FOOT ORTHOSES AND however, different AFOs designs have different effects. KNEE OSTEOARTHRITIS Kitaoka et al82 compared a rigid thermoplastic AFO, a rigid hindfoot orthosis (HFO-R: similar to the AFO Osteoarthritis of the knee is one of the most common but trimmed to extend only as far distally as the chronic musculoskeletal disorders associated with weightbearing surface of the heel and as proximal as ageing, affecting approximately 20–40% of people the mid-calf region) and an articulated hindfoot older than 65 years.86 Although all three compart- orthosis (HFO-A: similar to the AFO but trimmed to ments of the knee may be affected, medial compart- the mid-calf region and with the addition of a sagittal ment involvement is the most common, because of plane hinge). The greatest reduction in rearfoot the large compressive forces generated when walking.87 It has previously been demonstrated that contact forces within the knee when walking are considerably greater in the medial compartment than in the lateral compartment and that varus alignment of the knee joint is strongly associated with progression of medial compartment osteoarthritis.88 In response to these findings, several studies have been undertaken to investigate the efficacy of differ- ent forms of lateral wedging as a conservative treat- ment for medial compartment knee osteoarthritis, based on the hypothesis that decreasing the varus moment at the knee may alleviate compressive forces in the medial compartment.89–92 The first study by Sasaki & Yasuda89 found that patients wearing a later- ally wedged insole (manufactured from either sponge

228 ORTHOTIC THERAPY rubber or leather) in conjunction with taking non- Theoretically, placing textured insoles under the foot steroidal anti-inflammatory drugs (NSAIDs) reported may provide additional tactile sensory input that can greater reductions in pain than patients prescribed be used by the brain to compensate for deficits in NSAIDs alone. Subsequent uncontrolled studies have other systems contributing to balance. reported similar findings. Wolfe & Brueckmann90 reported that 82% of patients with medial knee osteo- While a number of studies have indicated that arthritis reported decreased pain while wearing a different types of foot orthosis may improve lateral heel wedge, Tohyama et al91 found that lateral balance,103–106 the mechanisms that may be responsi- heel wedges reduced knee pain in patients with early ble for this have only recently been investigated. medial compartment osteoarthritis, Keating et al92 Hosoda et al107 compared responses to platform per- reported that 32 out of 85 patients with medial knee turbation in healthy subjects when wearing two types osteoarthritis reported ‘excellent’ improvement in of footwear (flat, leather-soled sandals and ‘health pain scores while wearing a lateral heel wedge, and sandals’ containing an insole with numerous small Rubin & Menz93 reported significant reductions in raised projections), and reported shorter reflex laten- knee pain in 30 osteoarthritis patients using laterally cies when the health sandals were worn. Similarly, wedged custom foot orthoses. The only randomised Waddington & Adams108 evaluated the effect of tex- comparisons so far undertaken reported that a later- tured rubber insoles (7 mm deep nodules at a density ally wedged insole combined with subtalar joint strap- of 4/cm2) on the ability of healthy young subjects to ping was more effective in reducing knee pain than a detect ankle inversion, and found that inserting an wedge placed in a sock-type ankle support.94,95 More insole into the shoe provided similar movement detec- recently, the first randomised controlled trial reported tion to the barefoot condition. The authors concluded that, while no symptomatic or functional improve- that textured insoles may be able to compensate for ment was noted in subjects prescribed laterally wedged the loss of sensitivity produced by wearing soft-soled cork and rubber insoles, they required less NSAIDs footwear, presumably by enhancing sensory feedback. for pain management than the control group.96,97 Maki et al109 measured responses to platform pertur- bation in young and older people with and without a Although these preliminary results are promising, specially designed plastic tube attached to the perim- recent systematic reviews have concluded that there is eter of the sole of the foot. This ‘plantar facilitation’ currently insufficient high-quality evidence to support reduced the incidence of multiple stepping responses the long-term use of laterally wedged orthoses98,99 as, when the platform was displaced in the anteroposte- despite some evidence of temporary pain relief, such rior direction, suggesting that the enhanced sensory devices do not appear to alter the normal course of input provided by the insoles during the initial protec- knee osteoarthritis or have any impact on radiological tive step response was used by the brain to stabilise severity. Nevertheless, there may be some value in posture, rendering an additional step unnecessary. trying wedged insoles for short-term pain relief in More recently, Priplata et al110 demonstrated signifi- older people who are considering knee replacement cant reductions in sway variables when older people surgery. stood on randomly vibrating insoles and suggested that the introduction of tactile ‘noise’ could amelio- FOOT ORTHOSES AS A BALANCE AID rate age-related impairments in balance control. Sensory receptors on the sole of the foot play an AFOs may also have positive effects on balance in important role in maintaining balance by providing older people with peripheral neuropathy. Richardson the brain with information about foot position and et al111 have recently demonstrated significant improve- changes in plantar pressure distribution. This is evi- ments in temporospatial gait regularity when older denced by numerous studies that have demonstrated people with peripheral neuropathy walked on an balance deficits in subjects with sensory neuropa- irregular surface while wearing semi-rigid AFOs. This thy.100,101 In response to these observations, there finding is consistent with previous laboratory studies, have been several studies undertaken recently to which indicated that tactile information derived from determine whether the sensory role of plantar mecha- a stimulus above the ankle is used by the brain to noreceptors can be harnessed to develop novel inter- control posture and may be able to at least partially ventions to improve balance in older people.102 compensate for loss of plantar sensation.112,113 Although these results provide interesting insights into the role of peripheral sensory input on stabilisa-

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232 ORTHOTIC THERAPY 79. Bono CM, Berberian WS. Orthotic devices. Degen- 93. Rubin R, Menz HB. Use of laterally wedged custom erative disorders of the foot and ankle. Foot and foot orthoses to reduce pain associated with medial Ankle Clinics 2001; 6: 329–340. knee osteoarthritis. A preliminary investigation. Journal of the American Podiatric Medical Associa- 80. Steb HS, Marzano R. Conservative management of tion 2005; 95: 347–352. posterior tibial tendon dysfunction, subtalar joint complex and pes planus deformity. Clinics in Podi- 94. Toda Y, Segal N, Kato A et al. Effect of a novel atric Medicine and Surgery 1999; 16: 439–451. insole on the subtalar joint of patients with medial compartment osteoarthritis of the knee. Journal of 81. Chao W, Wapner KL, Lee TH et al. Nonoperative Rheumatology 2001; 28: 2705–2710. management of posterior tibial tendon dysfunction. Foot and Ankle International 1996; 17: 736– 95. Toda Y, Segal N. Usefulness of an insole with sub- 741. talar strapping for analgesia in patients with medial compartment osteoarthritis of the knee. Arthritis 82. Kitaoka HB, Crevoisier XM, Harbst K et al. The and Rheumatism 2002; 47: 468–473. effect of custom-made braces for the ankle and hind- foot on ankle and foot kinematics and ground reac- 96. Maillefert JF, Hudry C, Baron G et al. Laterally tion forces. Archives of Physical Medicine and elevated wedged insoles in the treatment of medial Rehabilitation 2006; 87: 130–135. knee osteoarthritis: a prospective randomized con- trolled study. Osteoarthritis and Cartilage 2001; 9: 83. Huang Y-C, Harbst K, Kotajarvi B et al. Effects of 738–745. ankle–foot orthoses on ankle and foot kinematics in patients with subtalar osteoarthritis. Archives of 97. Pham T, Maillefert JF, Hudry C et al. Laterally ele- Physical Medicine and Rehabilitation 2006; 87: vated wedged insoles in the treatment of medial knee 1131–1136. osteoarthritis. A two-year prospective randomized controlled study. Osteoarthritis and Cartilage 2004; 84. Huang Y-C, Harbst K, Kotajarvi B et al. Effects of 12: 46–55. ankle–foot orthoses on ankle and foot kinematics in patients with ankle osteoarthritis. Archives of Physi- 98. Brouwer RW, Jakma TSC, Verhagen AP et al. Braces cal Medicine and Rehabilitation 2006; 87: and orthoses for treating osteoarthritis of the knee. 710–716. Cochrane Database of Systematic Reviews 2005; 1: CD004020. 85. Alvarez RG, Marini A, Schmitt C et al. Sage I and II posterior tibial tendon dysfunction treated by a 99. Reilly KA, Barker KL, Shamley D. A systematic structured nonoperative management protocol: an review of lateral wedge orthotics – how useful are orthosis and exercise program. Foot and Ankle they in the management of medial compartment International 2006; 27: 2–8. osteoarthritis? The Knee 2006; 13: 177–183. 86. Felson DT. The epidemiology of knee osteoarthritis: 100. Simoneau GG, Ulbrecht JS, Derr JA et al. Postural results from the Framingham Osteoarthritis Study. instability in patients with diabetic sensory neuropa- Seminars in Arthritis and Rheumatism 1990; 20: thy. Diabetes Care 1994; 17: 1411–1421. 42–50. 101. Boucher P, Teasdale N, Courtemanche R et al. Pos- 87. Morrison JB. The mechanics of the knee joint in tural stability in diabetic polyneuropathy. Diabetes relation to normal walking. Journal of Biomechanics Care 1995; 18: 638–645. 1970; 3: 51–61. 102. Hijmans JM, Geertzen JHB, Dijkstra PU et al. A 88. Sharma L, Song J, Felson DT et al. The role of knee systematic review of the effects of shoes and other alignment in disease progression and functional ankle or foot appliances on balance in older people decline in knee osteoarthritis. Journal of the Ameri- and people with peripheral nervous system disorders. can Medical Association 2001; 286: 188–195. Gait and Posture 2007; 25: 316–323. 89. Sasaki T, Yasuda K. Clinical evaluation of the treat- 103. Orteza LC, Vogelbach WD, Denegar CR. The ment of osteoarthritis knees using a newly designed effects of molded and unmolded orthotics on balance wedged insole. Clinical Orthopaedics and Related and pain while jogging following inversion ankle Research 1987; 221: 181–187. sprain. Journal of Athletic Training 1992; 27: 80–84. 90. Wolfe SA, Brueckmann FR. Conservative treatment of genovalgus and varum with medial/lateral heel 104. Guskiewicz K, Perrin D. Effect of orthotics on pos- wedges. Indiana Medicine 1991; 84: 614–615. tural sway following inversion ankle sprain. Journal of Orthopaedic and Sports Physical Therapy 1996; 91. Tohyama H, Yasuda K, Keneda K. Treatment of 23: 326–331. osteoarthritis of the knee with heel wedges. Interna- tional Orthopaedics 1991; 15: 31–33. 105. Stude DE, Brink DK. Effects of nine holes of simu- lated golf and orthotic intervention on balance and 92. Keating EM, Faris PM, Ritter MA et al. The use of proprioception in experienced golfers. Journal of lateral heel and sole wedges in the treatment of Manipulative and Physiological Therapeutics 1997; medial osteoarthritis of the knee. Orthopedic Review 20: 590–601. 1993; 22: 921–924.

References 233 106. Rome K, Brown CL. Randomized clinical trial into 110. Priplata AA, Niemi JB, Harry JD et al. Vibrating the impact of rigid foot orthoses on balance param- insoles and balance control in elderly people. The eters in excessively pronated feet. Clinical Rehabilita- Lancet 2003; 362: 1123–1124. tion 2004; 18: 624–630. 111. Richardson JK, Thies SB, DeMott TK et al. 107. Hosoda M, Yoshimaru O, Takayanagi K et al. The Interventions improve gait regularity in patients effects of various footwear types and materials, and with peripheral neuropathy while walking on an of fixing of the ankles by footwear, on upright irregular surface under low light. Journal of the posture control. Journal of Physical Therapy Science American Geriatrics Society 2004; 52: 510– 1997; 9: 47–51. 515. 108. Waddington G, Adams R. Textured insole effects on 112. Rogers MW, Wardman DL, Lord SR et al. Tactile ankle movement discrimination while wearing ath- sensory input improves stability during standing in letic shoes. Physical Therapy in Sport 2000; 1: normal subjects and those with lower limb sensory 119–128. loss. Experimental Brain Research 2001; 126: 514–522. 109. Maki BE, Perry SD, Norrie RG et al. Effect of facili- tation of sensation from plantar foot–surface bound- 113. Menz HB, Lord SR, Fitzpatrick RC. A tactile stimu- aries on postural stabilization in young and older lus applied to the leg improves postural stability in adults. Journal of Gerontology 1999; 54A: M281– young, old and neuropathic subjects. Neuroscience 287. Letters 2006; 406: 23–26.

Footwear considerations CHAPTER 12 CHAPTER CONTENTS Footwear plays an important role in protecting the foot from extremes of temperature, moisture and Shoe-wearing habits of older people 235 mechanical trauma. However, since the development and widespread popularity of fashion footwear in the Detrimental effects of footwear 236 1600s, the functional aspect of footwear has largely been supplanted by the requirements of fashion. In Footwear modifications 237 both men and women of all ages, shoe selection is Shock-absorbing cushioned heel 237 primarily based on aesthetic considerations, many of Thomas heel 237 which are incompatible with the optimal function of Rocker sole 238 the foot and ankle.1 In older people, inappropriate Heel and sole raises 238 footwear often causes (or at least contributes to) foot Shoe stretching and balloon patching 239 pain and deformity and therefore it is essential that foot care specialists have a sound understanding of Specialist footwear 239 the effects of footwear on the older foot. The follow- ing chapter discusses the shoe-wearing habits of older Footwear, balance and falls 240 242 people, the relationship between footwear and foot Heel height 241 problems, and the use of footwear modification and Midsole cushioning 241 prescription footwear as a therapeutic modality. Slip resistance of footwear outersoles Because of the high rate of accidental falls and frac- Heel collar height 243 tures in older people, the effect of shoe design on Midsole flaring 243 balance is also discussed. Finally, issues related to Method of fixation 244 compliance with footwear recommendations are reviewed. Advising older people about footwear 244 SHOE-WEARING HABITS OF Summary 245 OLDER PEOPLE References 246 It has long been recognised that many older people wear inappropriate footwear (Fig. 12.1).2 A house- hold survey of people aged over 80 years conducted in the UK found that most wore slippers all day, irrespective of whether or not they were housebound.3 Similarly, a survey of indoor shoe-wearing habits of

236 FOOTWEAR CONSIDERATIONS their adult life. Finally, it has been suggested that commercially available footwear simply does not ade- quately cater for the dimensions of the older foot. A recent study of 668 older people in Germany found that most older people have feet that are broader than currently available casual footwear,10 which goes some way to explaining the large number of older people who report difficulty in purchasing comfortable shoes. DETRIMENTAL EFFECTS OF FOOTWEAR Figure 12.1 Inappropriate footwear worn by older It has long been suspected that the deformation of people. (Courtesy of Lesley Newcombe, La Trobe the foot caused by shoes is a major contributing factor University.) to foot problems such as hallux valgus (bunions), lesser toe deformity, corns and calluses.11–14 Indirect 128 older people in Australia indicated that more evidence for the detrimental effects of footwear can than half spent less than $30 Australian dollars on be derived from reports of very low prevalence of foot their indoor footwear (most commonly slippers), problems in populations that have never worn replaced them infrequently, and often wore their shoes,15–17 and the marked increase in the number of indoor shoes for outdoor activities.4 More recently, a surgical procedures performed for hallux valgus in survey of subacute aged care hospital patients reported Japan following the adoption of Westernised footwear that only 14% wore ‘safe’ footwear, with the most in preference to the traditional sandal.18 A US survey commonly observed detrimental features being a lack of 356 women aged between 20 and 60 years revealed of fastening (86%), slippery soles (86%) and an exces- that 88% wore shoes that were narrower than their sively flexible heel counter (77%).5 feet, and those with the greatest disparity between foot width and shoe width were more likely to suffer By far the most commonly encountered problem from foot pain.19 with footwear in older people is the wearing of shoes that are too small. Burns et al6 compared the length Two recent studies have evaluated the association and width of the feet and shoes of 65 people aged between footwear fitting characteristics and foot between 64 and 93 years attending a rehabilitation problems in older people. Burns et al6 compared the ward and reported that 72% wore shoes of an incor- length and width of the feet and shoes of 65 people rect size. Menz & Morris7 assessed length, width and aged between 64 and 93 years attending a rehabilita- total area of feet and footwear in 176 older people tion ward and reported that the wearing of shoes of and reported that 81% wore indoor shoes narrower incorrect length was significantly associated with the than their feet and 78% wore outdoor shoes narrower presence of foot ulceration and foot pain, which the than their feet. Finally, a study of 440 veterans affairs authors attributed to excessive friction generated patients in the USA reported that only 26% were from the foot sliding inside the shoe. More recently, found to be wearing appropriately sized shoes.8 a study of 176 people aged over 65 years demon- strated that most participants wore shoes narrower Several factors may be responsible for the high than their feet, with women wearing shoes that were prevalence of ill-fitting footwear in older people. shorter, narrower and with a reduced total area com- Firstly, fashion exerts a powerful influence over foot- pared to their feet than men. Wearing shoes substan- wear selection, particularly in women, and it is clear tially narrower than the foot was associated with corns that many people are willing to endure foot pain and on the toes, hallux valgus deformity and foot pain, deformity in order to conform to societal expectations whereas wearing shoes shorter than the foot was asso- of footwear aesthetics.9 Secondly, few older people ciated with lesser toe deformity.7 regularly have their feet measured,4 as most assume that their shoe size remains constant throughout Ill-fitting footwear is of particular concern for older people with diabetic peripheral neuropathy because of the risk of ulceration, infection and amputation.

Footwear modifications 237 Although ulceration and amputation are caused by a ment, and changing footwear may, in and of itself, range of factors, poorly fitting footwear is thought lead to the resolution of many foot complaints. Strate- to be a contributing factor in approximately 50% of gies for advising patients to change their footwear are cases.20 Indeed, a recent study of 256 veterans with discussed later in this chapter. diabetes indicated that those with foot ulceration were five times more likely to have poorly fitting FOOTWEAR MODIFICATIONS footwear.8 Footwear modification (pedorthics) is a useful conser- In addition to incorrectly fitting footwear, the vative management strategy for older people with foot wearing of shoes with elevated heels is thought to problems. The aim of footwear modification is to contribute to the development of foot problems reduce shock and shear, to relieve excessive pressure by increasing the pressure borne by the metatarsal from sensitive or painful areas, to accommodate, heads21–24 and by interfering with the normal function correct and support deformities, and to control or of the first metatarsophalangeal joint25,26 during gait. limit painful motion of joints.29 This may be achieved Only two studies have been undertaken to explore by changing the geometry of the sole to influence this relationship in older people. Dawson et al27 inter- weightbearing patterns and by modifying the shape viewed 127 women aged 50–70 years regarding the of the upper to accommodate bony deformities. These highest heels they had worn for various activities approaches are particularly useful in the management across 10-year age bands (20s to 50s), and found that of diabetic foot ulcers30,31 and chronic arthritic condi- the wearing of lower heels for some activities was tions such as rheumatoid arthritis,32,33 and following associated with an increased likelihood of having foot surgical fusion of the tarsal joints.34 The following arthritis, pain and hallux valgus. This counterintuitive section briefly discusses the most common footwear result may have been due to recall bias, in that women modifications used in the management of foot prob- with foot problems may have been more likely to lems in older people. underestimate past heel height use. Furthermore, establishing an association between current foot prob- SHOCK-ABSORBING CUSHIONED HEEL lems and history of wearing high heels is difficult, as most women in this age group have been exposed to As the name suggests, shock-absorbing cushioned this type of footwear.28 More recently, Menz & heels (SACHs) are a modification of the plantar aspect Morris7 reported that wearing shoes with heel eleva- of the shoe heel to enhance shock attenuation. This tion greater than 25 mm was associated with hallux can be achieved by simply removing a wedge-shaped valgus and plantar calluses in older women. piece of the heel and replacing it with a more com- pressible material (Fig. 12.2). SACHs are indicated in Healthcare costs associated with footwear-related the management of heel pain in older people with foot problems in older people are considerable. atrophic heel pads, or as an attempt to increase lower Assuming that inappropriate footwear is responsible limb shock attenuation in patients with age-related or for, or at least contributes to, 75% of foot problems surgically induced limited joint range of motion (such requiring surgical treatment, Coughlin & Thomp- as patients who have undergone triple arthrodesis). son13 have estimated that, in the USA in 1991, No studies have directly evaluated the biomechanical 209 000 bunionectomies, 210 000 hammer toe effects of SACHs, although several authors have dem- corrections, 119 000 bunionette repairs and 66 500 onstrated that shoes with softer soles reduce both the neuroma resections were performed, at a cost of magnitude and velocity of accelerations transmitted approximately US$3 billion. Although the 75% figure through the lower limb at heel strike.35,36 is probably an overestimate, these figures do not include the costs of conservative management of foot- THOMAS HEEL wear-related foot problems, so the true figure is likely to be much higher. The Thomas heel, also referred to as an S-heel, is a shoe modification in which the distal edge of the heel Taken together, these studies generally support the is extended on the medial side to a point correspond- widespread view that the use of inappropriate foot- ing to the navicular tuberosity (Fig. 12.3).37 The aim wear is highly prevalent in older people and is associ- ated with the development of foot problems. As such, advising older patients regarding more suitable foot- wear is an essential component of clinical manage-

238 FOOTWEAR CONSIDERATIONS Figure 12.2 Shock-absorbing cushioned heel. Black Rearfoot rocker Forefoot rocker section indicates softer material inserted into sole. Figure 12.4 Rocker sole modification. Lateral rheumatoid arthritis and the restriction of foot motion in people with osteoarthritis or those who have under- Medial gone surgical fusion of one or more tarsal joints. Figure 12.3 Thomas heel modification. Broadly speaking, there are three types of rocker soles: rearfoot rockers, forefoot rockers and combined of this addition is to provide additional support to the rockers (Fig. 12.4); however, the size and placement medial arch in patients with flat foot deformity. A of the fulcrum can be modified according to individ- variant of the Thomas heel, referred to as the Thomas ual patient needs. wedge, is a wedge of material placed within the medial border of the heel in an attempt to more directly limit Several studies have shown that the addition of a eversion of the subtalar joint. In contemporary clinical rocker sole reduces forefoot plantar pressures by practice, Thomas heels are rarely used in isolation but between 30% and 65%.40–47 The optimum location of they may have some value in enhancing the effect of the rocker sole for reducing metatarsal head pressures foot orthoses in overweight patients.38 has been demonstrated to be 55–60% of shoe length, while for reducing toe pressures it is 65% of shoe Few studies have been undertaken to assess the length.42 However, individual responses to rocker biomechanical or clinical effects of the Thomas heel soles can be highly variable41 and in some cases a in detail; however, a small study by Arlen & Carville37 rocker sole may increase pressure under the foot.41 For demonstrated that the frontal plane alignment of this reason, it has been suggested that, where possible, the calcaneus does shift in the direction of inversion some form of plantar pressure measurement should when standing in shoes that have undergone this be used when prescribing rocker soles.41,42 modification. Using an in-shoe plantar pressure system, Xu et al39 demonstrated that the addition of In addition to reducing forefoot pressures, rocker a Thomas heel redirected the centre of pressure later- sole shoes have several other effects on gait, including ally, with a concomitant decrease in the magnitude of an increase in cadence,48,49 a decrease in step length,48 pressures under the medial forefoot. The application reduced sagittal plane forefoot motion50 and increased of a reverse Thomas heel (a modification in which the ankle plantarflexion, hip extension and knee flexion.49 distal edge is extended to the lateral side of the foot) While many of these alterations can be considered to had the opposite effect. be beneficial if the aim of treatment is to restrict motion within the foot, changes in pelvic motion ROCKER SOLE observed with rocker soles have been suggested to be indicative of lateral instability,51 so some caution is The underlying concept of the rocker sole, also known required when prescribing rocker soles for older as a rocker bottom sole, is to limit motion at joints in people with balance problems. the foot by providing a rigid convex platform over which the body pivots from heel strike to toe off. HEEL AND SOLE RAISES Rocker soles have two main indications: the reduction of forefoot plantar pressure in people with diabetes or The addition of material to the heel and/or sole of the shoe has several clinical indications in the management of foot problems in older people. Firstly, heel and sole raises are frequently employed in the management of limb length discrepancy, in an attempt to level the pelvis and improve the symmetry of the gait pattern. The most common cause of limb length discrepancy in older people is hip replacement

Specialist footwear 239 surgery. A postoperative analysis of 150 total hip Figure 12.5 Shoe modification for limb length replacement procedures by Williamson & Reckling52 discrepancy incorporating a heel lift, sole lift and indicated that 144 resulted in limb lengthening on forefoot rocker. (Courtesy of Karl Landorf, La Trobe the operated side, with an average lengthening of University.) 16 mm. Of those who experienced limb lengthening, almost one-third required heel lifts to address post- the shoe.56 For both devices, it is essential that the operative symptoms. Secondly, shoe raises may have upper be prepared with stretching fluid (available a role in the rehabilitation of hemiparesis, in an from footwear retailers) and that the shoe be stretched attempt to facilitate weight shifting towards the gradually. It is also important to recognise that, while affected limb. Two recent studies have shown that the leather responds very well to stretching, other upper addition of a full-length sole raise (up to 1 cm in materials do not and may simply split when stretch is thickness) to the unaffected limb resulted in improved applied. weightbearing symmetry53 and postural control54 in stroke patients. Thirdly, heel lifts are commonly used Balloon patching refers to modifying the upper of in the management of retrocalcaneal problems in the shoe by cutting out a portion of the upper corre- people with limited ankle dorsiflexion. Lee et al55 have sponding to a bony prominence or lesion and replac- shown that there is a progressive decrease in gastroc- ing it with a pocket of softer material. Although nemius muscle activity as the heel is raised, which may balloon patching can be quite effective in reducing have the effect of reducing strain in the Achilles pressure from dorsal lesions, considerable care needs tendon when walking. to be taken to ensure that the stitching required to hold the patch in place does not create additional The amount of raise required to obtain optimum areas of pressure. Furthermore, to achieve an aestheti- function is highly variable and requires some degree cally acceptable result, it is essential to accurately of trial and error. Where large raises are indicated, it match the colour and texture of the upper material is advisable to start with a smaller raise than required being replaced. and to gradually increase it over a period of several weeks or months. This is particularly important for SPECIALIST FOOTWEAR older people with balance problems. As a general rule, the heel can be raised to a maximum of 12 mm before Specialist footwear, also referred to as medical grade a sole raise is also required, as otherwise the ankle is footwear, can be broadly categorised under two main placed in a plantarflexed position and forefoot loading headings: stock or bespoke. Stock footwear is a mass- increases (Fig. 12.5). Furthermore, if a large, full- produced, off-the-shelf product targeted at the ortho- length sole raise is required, it is advisable to incor- paedic market and generally consists of shoes with porate a rocker sole to overcome problems associated extra depth and extra width fittings in a range of styles with the increased stiffness of the sole, and to hollow and colours. Stock footwear is generally more expen- out a section of the sole to reduce the total weight of sive than regular footwear. This type of shoe is ideal the shoe.56 SHOE STRETCHING AND BALLOON PATCHING Modifying the upper of the shoe to accommodate foot deformities and lesions is quite an old technique but one that can be of great benefit in older people who are unable or unwilling to change their footwear. Several shoe stretching devices are commercially avail- able. Traditional shoe stretchers are designed to increase the overall volume of the shoe and consist of a last that can be expanded (by width or length) by the adjustment of springs or screws (Fig. 12.6). Ball- and-ring stretchers are simple tools in which the ball portion is placed inside the shoe in the location of the lesion or prominence, and the ring on the outside of

240 FOOTWEAR CONSIDERATIONS A Figure 12.6 Shoe stretching device. for older people with mild to moderate foot deformi- B ties (such as lesser toe deformities and mild hallux Figure 12.7 Bespoke footwear. A. Shoes and insoles for valgus) and can be enhanced by the addition of pre- patient with congenital foot deformity. (Courtesy of Karl fabricated or custom orthoses. Bespoke footwear is Landorf, La Trobe University.) B. Boot for patient custom-made for the individual and involves con- following ankle fracture. structing a last from the patient’s foot, using either foam box, plaster or optical scanning techniques. This more effective in reducing foot pain than retail foot- type of shoe is generally used in older people with wear;59,60 however, compliance is generally poor. In severe foot deformity, such as those with rheumatoid one recent study of 80 patients,60 10 refused the spe- arthritis, plantar neuropathic ulceration, foot and cialist footwear outright and only 36 completed the ankle trauma or partial amputation (Fig. 12.7). Because trial. These studies indicate that, while specialist foot- of the additional labour involved in assessment and wear may be effective in those who use it, consider- manufacture, bespoke footwear is considerably more ably more work needs to be done to make the footwear expensive than regular or stock footwear.38 acceptable to patients. Issues relating to acceptability of footwear are discussed later in the chapter. Protocols for the provision of specialist footwear vary considerably across health services and between FOOTWEAR, BALANCE AND FALLS countries, and tend to change quite regularly in response to amendments in health financing policies. Falls in older people are a major public health problem. Readers are therefore advised to consult the most up- One in three people aged over 65 years of age fall to-date guidelines in their region. Nevertheless, within any given year,61–64 and this rate increases to several studies have been undertaken that have impli- 50% in people aged 85 years and above.65 Several cations for specialist footwear prescription irrespective studies have assessed footwear in older people who of the how footwear is funded. A systematic review57 have fallen and have implicated a wide range of shoe of nine trials of specialist footwear in preventing reul- features that may have been responsible, such as ceration in people with diabetes concluded that there was some evidence of a protective benefit over regular footwear, particularly in people with severe foot deformity or partial amputation. However, compli- ance with diabetic footwear is known to be highly variable. In one study, only 22% of patients wore their specialist footwear on a regular basis.58 A similar pattern emerges in studies of specialist footwear in people with rheumatoid arthritis. Two trials have indicated that specialist stock footwear is

Footwear, balance and falls 241 narrow heels, slippery soles, inadequate fixation, be responsible for instability and falling in older poorly fitting shoes and soft heel counters.66–70 Stron- people.2,79–83 High heels are thought to contribute to ger evidence comes from case-control or cohort instability by affecting the position of the centre of studies, in which the footwear of fallers is compared mass and by altering the position of the foot when to non-fallers. Five such studies have recently been walking.84,85 Three recent reports have highlighted the undertaken, with varying results. Kerse et al71 assessed detrimental impact of high heels on balance. Brecht et footwear in 606 older people in residential care, and al86 reported that balance performance on a moving found that wearing slippers rather than shoes increased platform was significantly worse in a heeled cowboy the risk of fractures during the 12-month follow-up boot than in a tennis shoe, and suggested that heel period. Keegan et al72 examined risk factors for various elevation may make the wearer more susceptible to fall-related fractures in people aged over 45 years and falling backwards. Lord & Bashford87 have also found found that medium–high-heeled shoes and shoes with that balance ability in older women is detrimentally a narrow heel significantly increased the likelihood of affected by high heels. In this study, older women’s all types of fracture, while slip-on shoes and sandals balance was tested when subjects were barefoot, in increased the risk of foot fractures as a result of a fall. their own shoes and in high-heeled shoes (heel height A study of 4281 people aged over 66 years by Larsen 6 cm). The worst balance performances occurred et al73 found that those who had fallen in the last 24 when women wore high-heeled shoes. Arnadottir & hours were four times more likely to have been Mercer88 found that performance on several balance wearing socks or slippers without a sole. A nested tests was impaired in elderly women when wearing case-control study of 654 people aged over 65 years dress shoes (mean heel height 5 cm) compared to by Koepsell et al74 found that going barefoot or barefoot or when wearing walking shoes (mean heel wearing stockings was associated with a tenfold height 1 cm). In contrast to these findings, Linde- increased risk of falling, with athletic shoes being mann et al89 found no differences in balance when 26 associated with the lowest risk. Further evaluation of older women wore shoes with a range of heel heights. footwear characteristics from this study found that The highest heel used in this study was 4 cm, suggest- increased heel height was associated with increased ing that there may be a critical height at which heel risk of falling, whereas greater sole contact area was elevation becomes problematic for balance. associated with decreased risk.75 Finally, a prospective study by Menz et al76 found that, while there were no Further research needs to be undertaken to ascer- differences in footwear characteristics between older tain the optimum heel elevation for women’s shoes, people who did and did not sustain a fall when out- as many older women report that they feel safer in a doors, those who fell while indoors were more likely slight heel, and heel elevation may have some benefi- to be barefoot or wearing socks. cial effects in older people with Parkinson’s disease to facilitate forward propulsion.90 Habitual wearers of On the basis of these findings, it is difficult to rec- high-heeled shoes may have experienced some changes ommend one style of shoe over another to prevent to the extensibility of posterior soft tissue structures falls. However, a number of features of shoe design (e.g. calf muscle tightening), which may contribute have been implicated as having an impact on balance, to greater comfort and possibly safety while wearing including heel height, the cushioning properties of these shoes. However, it would appear that heel eleva- the midsole, the slip resistance of the outersole, the tion greater than 6 cm is potentially detrimental to method of fixation, the height of the heel collar and balance and should therefore be avoided. midsole geometry.77 The following section outlines the available evidence pertaining to the effect of each MIDSOLE CUSHIONING of these features on balance and is based on a recent update of the literature published in the textbook The use of expanded polymer foam materials in the Falls in Older People: Risk Factors and Strategies for construction of footwear midsoles enhances the level Prevention.78 of comfort the shoe can provide to the wearer and is therefore commonly recommended as a beneficial HEEL HEIGHT feature in footwear for older people.91,92 However, research undertaken by Robbins and colleagues sug- Several authors have suggested that the changes gests that the use of thick, soft materials in footwear in function produced by high-heeled footwear may midsoles leads to instability, as the midsole material

242 FOOTWEAR CONSIDERATIONS induces a state of ‘sensory insulation’, reducing tured, slip-resistant sole may prevent slip-related sensory input to the central nervous system regarding accidents.2,79–83 Such a recommendation may not be foot position.93 appropriate in all situations, however, as a number of cases have been reported in which falls are attributed To test this hypothesis, Robbins and colleagues to excessive slip-resistance of the shoe when walking (among others) have conducted a number of studies on a pavement or performing a household task.69,99 that have evaluated balance ability when older people Despite these observations, it would appear that falls wear footwear that varies according to the thickness related to excessive slip-resistance are far less common and softness of the midsole material. The Robbins et than those resulting from inadequate slip-resistance. al studies have found that shoes with thick, soft mid- soles have a detrimental effect on the ability of older Gait analysis studies have revealed that slipping is people to maintain balance when walking on a beam,93 most likely to occur when the heel first strikes the to detect the position of their ankle joint when stand- ground;97,100,101 therefore, the geometry and texture ing on different surface inclinations94 and to detect of the heel section of a shoe may play an important the position of their foot when walking.95 The detri- role in preventing slipping accidents. Menz & Lord102 mental influence of thick soles was further supported have recently shown that casual shoes vary consider- by Sekizawa et al,96 who evaluated foot position sense ably in their slip-resistance properties. Using a spe- when subjects stood on a sloped surface and found cially-designed force plate apparatus, two types of that subjects underestimated the position of their foot shoe were tested: lace-up Oxford-style shoes and in dorsiflexion when wearing shoes with thick soles women’s fashion shoes. The Oxford shoes were modi- (5 cm at heel, 3 cm at forefoot). The suggestion that fied to produce four different heel configurations; the soft shoes may have detrimental effects on balance has unmodified Oxford shoe had a flat heel with no flaring been supported by investigations by Finlay,2 who or sole texture, the second shoe was modified by reported an association between wearing soft slippers flaring the heel laterally by 30°, the third shoe was and falls, and Frey & Kubasak,67 who found that a modified by grinding a 10° bevel into the rear section large number of older people who fell were wearing of the heel and the fourth shoe had a ‘non-slip’ tex- cushioned running shoes at the time. It would there- tured material stuck to the sole. The women’s fashion fore appear that the proposed interaction between shoes were modified to produce a narrow heel and a sensory feedback and stability is plausible and that soft broad heel, and each of these shoes was tested with soles may contribute to falls. It may therefore be and without a ‘non-slip’ textured material applied to prudent to advise against the wearing of shoes with the sole. All shoes were tested on dry and wet bath- very soft soles unless there is a specific therapeutic room tiles, concrete, vinyl flooring material and terra need for extra cushioning. cotta. Testing revealed that the Oxford shoes offered greater slip resistance than the women’s fashion shoes. SLIP RESISTANCE OF The addition of a textured sole material had no effect FOOTWEAR OUTERSOLES on slip resistance on wet surfaces and broadening the heel of women’s shoes offered little additional benefit. Accidental falls caused by slipping are a common The most slip-resistant shoe was the Oxford shoe with concern in older people, particularly in countries the 10° heel bevel, which is consistent with previous where snow- and ice-covered pavements are impli- reports in the occupational safety literature. A bevel cated in a large number of injuries to older people is thought to improve slip resistance by increasing the during winter months.97,98 Unfortunately, while a surface area of the plantar aspect of the sole at heel number of investigations have attributed falls in older contact.103 people to slipping or tripping on unstable surfaces such as cracked paths, bathroom tiles or snow, few Although heel modification has been found to be studies in the gerontology or rehabilitation literature of benefit under experimental conditions, it remains have focused on the role of the outersole of the shoe to be seen whether such footwear modifications can in these accidents. help prevent slipping in older people. However, a recent study indicates that a specially-designed foot- Nevertheless, a number of authors have suggested wear addition may prevent slipping in older people that older people should be advised to avoid shoes walking on icy surfaces. The device (the YakTrax® with slippery soles – the assumption being that a tex- Walker) is an injection-moulded thermoplastic elasto-

Footwear, balance and falls 243 The use of high heel collars as a means of improv- ing stability in older people warrants further investiga- tion, as both peripheral sensory loss106 and ankle muscle weakness107 have been found to contribute to falling. Given that ankle support has been found to improve mechanical stability and ankle position sense in younger people,108,109 shoes with high collars may be able to compensate for age-associated declines in sensory and motor function of the foot and ankle. However, such shoes must not be too restrictive, as a certain amount of foot flexibility is required to adapt to uneven terrain when walking.110,111 Figure 12.8 The Yaktrax® Walker device for preventing MIDSOLE FLARING slips in icy conditions. (Courtesy of Genesis Marketing Partners.) The term midsole flare refers to the difference between the width of the midsole at the level of the upper and mer wrapped in a mesh of metal coils that is strapped its width at the level of the outersole. A number of on to the sole of the shoe (Fig. 12.8). In a randomised authors have suggested that a large midsole flare is of controlled trial of 109 older people, McKiernan104 benefit in older people as it provides a broader base reported that those who wore the device during the of support, thereby enhancing the stability of the winter months had significantly fewer slips and fewer shoe.2,79–81,91 No studies have directly evaluated the injurious falls than those who wore their regular effect of midsole flaring on balance ability, although footwear. associations between narrow heels and falls,75 and narrow heels and fall-related fractures72 have been HEEL COLLAR HEIGHT recently reported. The association with fractures sug- gests that, if a fall does occur, the loss of balance when Stability around the heel is widely regarded as a desir- wearing narrow heels may result in greater sideways able feature when recommending footwear for unsta- impact. ble older people.2,80,81,91,92 Lord et al105 assessed the balance ability of older women when barefoot and in Theoretically, midsole flaring should improve shoes with standard collar height (Oxford-style shoe) mechanical stability by increasing the surface contact and a raised collar height (eight-laced ‘Doc Marten’ area of the shoe–ground interface.112,113 However, boot). The results revealed that subjects performed studies have also found that large midsole flares may better in the high-collared shoe, presumably because make the foot pronate more during gait114,115 and the high heel collar provides greater ankle stability there is also the possibility that a large midsole flare and increased proprioceptive feedback compared to may make the wearer susceptible to tripping by con- standard footwear. tacting the contralateral limb during the swing phase of gait. Whether these proposed detrimental effects of midsole flaring have significant ramifications for stability in older people is uncertain. Therefore, no absolute recommendations can yet be developed regarding the benefits or otherwise of midsole flaring in footwear for older people. However, given that recent work suggests that impaired lateral stability is associated with falls116 and that people who wear shoes with narrow heels are more likely to fall75 and suffer fractures,72 any attempt to improve the control of lateral movements of the centre of mass may be beneficial.

244 FOOTWEAR CONSIDERATIONS METHOD OF FIXATION terial, textured soles to improve traction, laces to provide adequate fixation and possibly the addition The method used to attach the shoe to the foot may of ankle support by the use of a high heel collar. also play a role in falls risk. It is a common clinical observation that many elderly people wear shoes However, one of the more frustrating aspects of with inadequate fixation, such as slippers, moccasins managing foot problems in older people is that it is and soft, canvas slip-on shoes.2,3 These types of shoe often difficult to convince patients to change their promote a shuffling gait pattern and may become footwear. Compliance with use of therapeutic separated from the foot when walking, thereby acting footwear has been shown to be low in people with as an external tripping hazard. In a recent study of 95 diabetes58 and rheumatoid arthritis,60 and a recent older people who had been admitted to hospital survey of emergency department physicians indicated following a fall-related hip fracture, Sherrington & that compliance with footwear recommendations to Menz70 found that those who suffered a trip were prevent falls was poor, because of ‘stubbornness and three times more likely to be wearing shoes without vanity’.118 Similarly, the American podiatrist Bill Rossi laces, zips or Velcro® fastening.70 Two of the subjects considers advising patients to change their footwear who suffered a trip and were wearing these types of to be ‘an exercise in eternal futility’.119 Nevertheless, shoe specifically blamed their footwear for the fall: many aspects of behavioural change required to one reported that her slipper ‘got stuck’, causing her improve health are difficult to achieve (e.g. weight to lose balance, while another stated that her mocca- loss, exercise, smoking cessation) and it would be sin ‘slipped off’ her foot, causing her to trip over it. negligent to ignore these issues simply because they The association recently reported between the wearing are difficult. of slip-on shoes and fall-related foot fracture adds further weight to this suggested mechanism.72 When providing footwear advice to older patients, Although it is difficult to confirm that the shoes were it is worth considering the underlying concepts of the responsible for the fall, it would seem prudent to Health Belief Model.120 This model suggests that a recommend that older people wear shoes that are patient’s decision to carry out a particular health- firmly fitted to their feet. protective behaviour (such as changing footwear) is influenced by how vulnerable they perceive them- ADVISING OLDER PEOPLE selves to be to the particular health problem, how ABOUT FOOTWEAR serious they perceive the particular health condition to be, the benefits that they perceive the health pro- The concept of the ‘ideal’ shoe is somewhat nebulous, tective behaviour will produce and what barriers there as what is ideal for one individual may be totally inap- are to carrying out the behaviour. For example, a falls propriate for another. Furthermore, the functional prevention study of 652 older people indicated that requirements of footwear vary considerably according many were unaware of the risks of inappropriate shoes to environmental and physical demands, e.g. indoor that and the main barriers to wearing more ‘sturdy’ versus outdoor shoes, walking shoes versus running shoes were difficulty putting them on, expense and shoes, etc. Nevertheless, there are some general prin- concern about their appearance.121 Considering how ciples that apply to most individuals and situations such factors differentially affect individual patients and form the basis of footwear recommendations for may assist in the development of more effective strate- older people.117 The most fundamental requirement gies to enhance compliance with footwear is that the shoe should fit properly, in order to reduce recommendations. the risk of tissue damage and the development of keratotic lesions. The shoe should also be stable, par- The provision of clear written material is an essen- ticularly in older people with underlying balance tial part of this process. The Footwear Suitability problems. Based on the literature pertaining to the Scale,122 originally designed for use in people with effect of shoe features on balance, it can be concluded diabetes, is a useful clinical tool that can also be that older people should wear shoes with thin, flat, administered to non-diabetic patients. The scale broad, bevelled heels constructed from a firm ma- consists of eight questions for patients to complete regarding the suitability of their footwear (Table 12.1). With regard to footwear and falls, Lord et al78 have developed a simple poster of what constitutes a safe and unsafe shoe, based on evidence from the lit- erature (Fig. 12.9). Both tools are simple and quick

Summary 245 Table 12.1 Footwear Suitability Scale Question Reason Tick box 1 Is the heel of your shoe less than As the height of your heel increases, the pressure under the ᮀ 2.5 cm (1 in)? ball of your foot becomes greater. Increased pressure can lead to callus and ulceration 2 Does the shoe have laces, buckles If you wear slip-on shoes with no restraining mechanism, your ᮀ or elastic to hold it onto your toes must curl up to hold the shoes on. This can cause the foot? tops of your toes to rub on your shoes, leading to corns and calluses. Secondly, the muscles in your feet do not function as they should to help you walk. Instead, they are being used less efficiently to hold your shoes on 3 Do you have 1 cm (approximately This is the best guide for the length of the shoe, as different ᮀ thumb nail length) of space manufacturers create shoes that are different sizes. Your toes between your longest toe and the should not touch the end of the shoe as this is likely to end of your shoe when standing? cause injury to the toes and place pressure on the toenails 4 Do your shoes have a well padded Shoes should have a supportive, but cushioned sole to absorb ᮀ sole? any shock and reduce pressure under the feet 5 Are your shoes made from A warm, moist environment can harbour organisms, such as ᮀ material that breathes? those that cause fungal infections 6 Do your shoes protect your feet The main function of footwear is protection from the ᮀ from injury? environment. Ensure your shoes are able to prevent entry of foreign objects that can injure the foot. If you have diabetes, a closed toe is essential to prevent injury to the foot 7 Are your shoes the same shape as Many shoes have pointed toes and cause friction over the ᮀ your feet? tops of the toes, which can lead to corns, callus and ulceration. If you can see the outline of your toes imprinted on your shoes, then the shoe is probably the wrong shape for your foot 9 Is the heel counter of your shoe Hold the sides of the heel of your shoe between the thumb ᮀ firm? and forefinger and try to push them together. If the heel compresses, it is too soft to give your foot support. The heel counter provides much of the support to the shoe and must be firm to press If you have not put a tick in every box, your footwear is probably not protecting and supporting your foot as it should to use and are useful in initiating a rational discussion contribute to the development of foot problems and regarding footwear issues with older patients. increase the risk of falls. Footwear modification is a useful conservative management strategy for a wide SUMMARY range of foot problems and can enhance the effects of other treatments. Finally, the role of footwear Footwear is a major consideration in the care of older advice should not be overlooked, as changing foot- people, as ill-fitting or inappropriate footwear may wear may, in and of itself, lead to the resolution of many foot complaints.

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