Adolescent Perspectives on Participating in a Feasibility Trial Investigating Shoe Inserts for Patellofemoral Pain

Background Patellofemoral pain (PFP) affects one-quarter of adolescents, yet there are few evidence-informed recommendations to treat PFP in this population. HAPPi Kneecaps! is a randomised, controlled, participant- and assessor-blind, parallel-group feasibility trial of shoe inserts for adolescents with PFP. The aim of this qualitative study was to explore adolescents’ perspectives of participating in HAPPi Kneecaps!. Methods All 36 adolescents with PFP from the HAPPi Kneecaps! study were invited to participate in semi-structured interviews. We used a descriptive qualitative methodology underpinned by a relativist framework to investigate adolescents’ perspectives on participating in the trial. Inductive thematic analysis was used to examine patterns regarding how each adolescent experienced the HAPPi Kneecaps! study within their social, cultural, and historical contexts. Results 14 out of 36 HAPPi Kneecaps! participants provided consent and participated in interviews (12 females; mean [SD] age 14.9 [2.4] years). Overall, most adolescents responded positively when discussing their experience, such as improvements in their knee pain and satisfaction with how the study was run. Major themes emerging from the analysis and feedback were: (1) shoe inserts require little effort to use; (2) shoe inserts improve symptoms and function; (3) participation in the trial could be made easier; (4) warm weather matters; and (5) life happens. Conclusion Adolescents with PFP who participated in the HAPPi Kneecaps! study found that shoe inserts were easy to wear. Most adolescents experienced an improvement in their symptoms and enhanced participation in sport and exercise. Adolescents with PFP prefer an option for warmer climates (e.g. flip flops or sandals), access to online logbooks, and clinicians who are easily accessible. Trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12619000957190. Date registered: 8/07/2019.

Conservative Treatment for Primary Metatarsalgia

Metatarsalgia is one of the most common causes of forefoot pain, and it is characterized by pain in the front part of the foot under the head of the metatarsal bones. Primary metatarsalgia is idiopathic, but it has been suggested to be related to forefoot plantar compression. Because of the various causes of metatarsalgia, there is the need to thoroughly consider the etiology of metatarsalgia to find novel, effective, and conservative treatments for metatarsalgia to avoid surgical treatment. Pressure reduction or redistribution can be achieved using toe exercise, flat shoe inserts, metatarsal pads, custom-molded inserts, and rockerbars. There was no need for one treatment. If toe function was poor, toe exercises were recommended. If dorsiflexion of the ankle joint was limited, the Achilles tendon was stretched. If the pain was localized to the plantar aspect of the 2nd MTP, a decompression insole was applied. If the pain was limited to the plantar aspect of the 2nd MTP, a decompression insole was worn. If swelling occurred, anti-inflammatory drugs were indicated to reduce inflammation. The combination of the two was appropriate for this condition. Toe exercises can improve balance and are worth trying. An in-depth understanding of the various etiologies of metatarsal and toe deformities is essential for successful treatment.

Choosing the target wisely: partial tibial nerve transfer to extensor digitorum motor branches with simultaneous posterior tibial tendon transfer. Could this be a way to improve functional outcome and gait biomechanics?

OBJECTIVEThe objective of this study was clinical assessment of the reduction of pathological motor phenomena with the recovery of long toe extensors, and evaluation of functional outcome with simultaneous nerve and tendon transfer in cases of common peroneal nerve (CPN) injuries.METHODSSeven male patients (mean age 26.4 years) received a partial tibial nerve transfer to the extensor hallucis longus muscle (MEHL) and extensor digitorum longus muscle (MEDL) motor branches, after a mean of 2.7 months following a traction-type injury to the CPN. Tibialis posterior muscle (MTP) tendon transfer through the interosseous route was performed on the same day. The follow-up period included a clinical neurological examination, a modified Stanmore System questionnaire (MSSQ), electromyographic examination of the interference pattern, and a video-based analysis of the gait biomechanics in the 3rd and 12th months. Video analysis of the gait investigated the presence or reduction of “stair-climbing maneuver” (SCM), foot slap (FS), and foot stability during the gait cycle.RESULTSThe average range of active dorsiflexion in the 3rd month was 0.85°. SCM accompanied walking in 6 patients (86%). FS accompanied walking in 3 patients (43%) and 3 patients (43%) avoided FS by planting the entire foot on the ground. All patients required orthopedic support (shoe inserts) to compensate for mediolateral foot instability. The average MSSQ score was 80.4 points. The average duration for the effective recovery of function (≥ 4 points on the Medical Research Council grading system) of long toe extensors was 11.2 months. The average range of active dorsiflexion in the 12th month increased to 4.4°. A reduction of FS was observed in 5 patients (71%). Excessive foot eversion was reduced in 4 patients (57%). Another 3 patients (43%) required no specific orthopedic shoe inserts. Reduction of pathological motor phenomena with recovery of the long toe extensors resulted in an increase of functional outcome. The average MSSQ score after 12 months was 92.4 points.CONCLUSIONSPartial tibial nerve transfer to the motor branches of the extensor hallucis longus and the long toe extensors along with the simultaneous tibialis posterior tendon transfer produce the reduction of FS and bring mediolateral stability to the foot, i.e., improved gait biomechanics. The reduction of pathological motor phenomena at the time of recovery of the long toe extensors is reflected in an increase in patients’ functional perception of the injured lower extremity during daily walking.

The FOOTPATH study: protocol for a multicentre, participant- and assessor-blind, parallel group randomised clinical trial of foot orthoses for patellofemoral osteoarthritis

IntroductionPatellofemoral (PF) osteoarthritis (OA) is a common and burdensome subgroup of knee OA, with very little evidence for effective treatments. Prefabricated foot orthoses are an affordable and accessible intervention that have been shown to reduce PF pain in younger adults. Similarities between PF pain and PFOA, as well as our pilot work, suggest that foot orthoses may also be an effective intervention for PFOA. The primary objective of this study is to compare the 3 month efficacy of prefabricated foot orthoses and flat shoe inserts in people with PFOA, on knee pain severity.Methods and analysisThe FOOTPATH Study (FOot OrThoses for PAtellofemoral osteoarTHritis) is a multicentre, randomised, participant- and assessor-blinded superiority trial with two parallel groups, a 3 month observation period (pre-randomisation) and 12 month follow-up. 160 participants with a clinical diagnosis of PFOA will be recruited from three sites in Australia, and randomised to one of two groups (prefabricated foot orthoses or flat shoe inserts). The primary outcome is worst knee pain severity during a self-nominated aggravating activity in the previous week (100 mm visual analogue scale) at 3 months, with a secondary endpoint at 12 months. Secondary outcomes include global rating of change, symptoms, function, health-related quality of life, kinesiophobia, self-efficacy and use of co-interventions for knee pain. Blinded, intention-to-treat analyses of primary and secondary patient-reported outcomes will be performed, as well as economic analyses.Ethics and disseminationEthical approval has been granted by La Trobe University’s Human Ethics Committee and The University of Queensland’s Medical Research Ethics Committee. Study outcomes will be disseminated via peer-reviewed journals, conference presentations targeting a range of healthcare disciplines and an open access website with clinician resources.Trial registration numberANZCTRN12617000385347; Pre-results.