Elsevier

Clinical Biomechanics

Volume 59, November 2018, Pages 117-129
Clinical Biomechanics

Review
Effect of foot orthosis design on lower limb joint kinematics and kinetics during walking in flexible pes planovalgus: A systematic review and meta-analysis

https://doi.org/10.1016/j.clinbiomech.2018.09.018Get rights and content

Highlights

  • Medial postings a suitable intervention for excessive foot pronation

  • Anti-pronator components are necessary for a positive biomechanical effect.

  • Arch support alone is not effective to control excessive pronation.

  • Evidences for benefits of foot orthosis on gait features for flat feet remain weak.

  • Studies of higher quality are required to facilitate flat feet clinical management.

Abstract

Background

Foot orthoses are commonly used for the management of excessive foot pronation in people with pes planovalgus. However, results are inconsistent due to variability in orthosis geometrical designs. This systematic review with meta-analysis aimed to classify and investigate the effects of foot orthoses, based on their design, in terms of lower limb kinematics and kinetics in people with pes planovalgus.

Methods

Electronic databases were searched up until August 2017. Peer-reviewed journal studies including adult participants with flexible pes planovalgus and reporting kinematics and kinetics effects of foot orthoses during walking were included and classified based on the orthosis design. Eleven studies were retained and assessed according to methodological (mean 76.1%; range [63.2%–84.2%] - high) and biomechanical (mean 71.6%; range [44.4%–100%] - moderate) qualities. Meta-analysis was performed by calculating the effect size, using standardized mean differences, between control and orthotics conditions.

Findings

Meta-analysis revealed less rearfoot eversion with the use of foot orthoses including medial forefoot or both forefoot and rearfoot posting. However, no significant effect of foot orthoses with arch support and neutral rearfoot posting to control excessive foot pronation were found. In terms of kinetics, none of the foot orthoses showed effects.

Interpretation

Using medial posting is the most effective foot orthotic feature to reduce the peak rearfoot eversion and to control excessive foot pronation. Nevertheless, heterogeneity between study protocols contributes to the low evidences of foot orthoses effects on kinematics and kinetics during walking in people with pes planovalgus.

Introduction

Foot pronation is a natural and essential motion of the foot allowing for a greater ground contact surface during the stance phase of a gait cycle, thus resulting in a better shock absorption (Horwood and Chockalingam, 2017; Lafortune et al., 1994). Throughout this phenomenon, the medial longitudinal arch plays a key role as it provides elasticity and shock absorbing properties. Flexible pes planovalgus (also known as flexible “flat foot”) is a common condition in which the medial longitudinal arch totally or partially collapses in the weight-bearing stance, resulting in excessive foot pronation (Shibuya et al., 2010). In the United States, flexible pes planovalgus has been reported to affect 19% of the adult population (Dunn et al., 2004). Based on physical examination, this condition is accompanied with rearfoot eversion and forefoot abduction relative to rearfoot (Lee et al., 2005). As a consequence, flexible pes planovalgus interferes with the normal foot function. Previous studies revealed significant differences in kinematics and kinetics of adults with flexible pes planovalgus during walking compared to individuals with a normal foot posture. Mostly, studies have reported higher peak and range of motion (RoM) of rearfoot eversion (Ledoux and Hillstrom, 2002; Levinger et al., 2010; Root, 1977; Tome et al., 2006) as well as a higher ankle invertor moment (Hunt and Smith, 2004). Although pes planovalgus alters foot motion, not all flat feet are symptomatic. However, this foot posture may contribute to pain and injury development. Indeed, a higher prevalence of foot, knee and low back pain (Kosashvili et al., 2008; Menz et al., 2013) as well as an increased risk of overuse injuries such as tissue stress injuries, medial tibial stress syndrome or stress fracture (Kaufman et al., 1999; Nawoczenski et al., 1998; Neal et al., 2014) have been reported. Therefore, the clinical management of people with flexible pes planovalgus relies on the control of excessive foot pronation. Typically, this control is obtained using foot orthoses (FOs).

FOs represent one of the most common medical devices prescribed to alter lower extremity movement, especially to control excessive foot pronation, and to reduce pain for pes planovalgus. In a recent study, Banwell et al. (2015) highlighted that 50% of the people with symptomatic pes planovalgus were treated using FOs. Clinically, the use of FOs has been related to positive impacts on lower limb and back pain (Castro-Mendez et al., 2013; Eng and Pierrynowski, 1993; Zammit and Payne, 2007). With regard to kinematics and kinetics during walking, the effect of FOs is not clearly established yet. While some studies reported significantly reduced rearfoot eversion (Johanson et al., 1994; Telfer et al., 2013), others found no difference using FOs (Hurd et al., 2010; Zifchock and Davis, 2008). Similarly with kinetics, Telfer et al. (2013) reported a decrease in rearfoot eversion moment using FOs, whereas Bishop et al. (2016) found no difference. The inconsistency in these results may be explained by the diversity of the geometrical design of FOs used across these studies (Banwell et al., 2015). Such different effect of FOs on controlling foot pronation, especially in the frontal plane, was associated to different designs by Johanson et al. (1994). Furthermore, the variability in the eligibility criteria of the participants as well as the variability in the protocols (e.g. walking speed, shoe type, foot model, etc.) used for the kinematic assessment may explain conflicting findings. The variability among studies regarding the beneficial effect of FOs makes treatment of people with pes planovalgus uncertain. To this end, a meta-analysis could provide evidence of changes on a parameter as an effect of FO design and give guidelines for health practitioners.

In 2011, a systematic review and meta-analysis about people with excessive foot pronation showed that FOs, especially custom-made ones, were globally effective in reducing rearfoot eversion and therefore control excessive foot pronation in the frontal plane (Cheung et al., 2011). However, another recent (2014) systematic review assessed the effectiveness of FOs on kinematics and kinetics in adults with pes planovalgus, and revealed low evidence level on the proficiency of FOs to improve the rearfoot kinematics and kinetics (Banwell et al., 2014). To our knowledge, no review has yet evaluated how the geometrical design of FO could affect gait features of people with this foot condition. Therefore, the aim of this systematic review and meta-analysis is to determine the impact of the FO geometrical design on lower extremity kinematics and kinetics during walking for adult participants with pes planovalgus. Moreover, this study will provide more insights for FO design and prescription.

Section snippets

Information sources, search strategy

This systematic review and meta-analysis was reported using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines (Moher et al., 2009). The following electronic literature databases were searched from their original available dates to August 2017: MEDLINE, Scopus, PubMed, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL). Three main groups of keywords covering all MeSH terms and keywords related to “foot orthosis”, “design and geometrical

Study selection

The initial search identified 4635 papers of which 4579 were excluded by removing duplicates and screening title and abstract (Fig.1). From 56 papers reviewed by full-text, 18 were excluded as they considered the effect of FOs on activities other than walking, and 15 were excluded for not assessing lower limb kinematics or kinetics. Finally, 11 studies that provided clear details on the geometrical design of the FOs used were included. Studies were then categorized into five subgroups based on

Discussion

The purpose of this study was to determine the effect of the geometrical design of FOs on lower limb kinematics and kinetics parameters for people with pes planovalgus during walking. Our main finding was that FOs medially posted at the forefoot, and both at the rearfoot and forefoot, control excessive foot pronation by reducing rearfoot eversion by 2°. This kinematic change has previously been assumed to be associated with clinical improvements as it contributes to alleviate tissue stress (

Conclusion

FOs including a medial forefoot posting or both a medial forefoot and a rearfoot posting reduce the peak rearfoot eversion and therefore are effective to control excessive foot pronation. However, except this finding, there is low evidence of beneficial effects of FOs on kinematics and kinetics during walking in people with pes planovalgus. The low evidence is likely due to heterogeneity between studies in the methods used to investigate their effect. In addition, the magnitude of effect on

Declarations of interest

None.

Acknowledgments

This work was supported by the TransMedTech Institute and conducted partially thanks to the financial support of Canada First Research Excellence Fund.

References (76)

  • W.R. Ledoux et al.

    The distributed plantar vertical force of neutrally aligned and pes planus feet

    Gait Posture

    (2002)
  • M.S. Lee et al.

    Diagnosis and treatment of adult flatfoot

    J. Foot Ankle Surg.

    (2005)
  • P. Levinger et al.

    A comparison of foot kinematics in people with normal-and flat-arched feet using the Oxford foot model

    Gait Posture

    (2010)
  • C. MacLean et al.

    Influence of a custom foot orthotic intervention on lower extremity dynamics in healthy runners

    Clin. Biomech.

    (2006)
  • J.C. Menant et al.

    Effects of walking surfaces and footwear on temporo-spatial gait parameters in young and older people

    Gait Posture

    (2009)
  • C.E. Milner et al.

    Reliability and minimal detectable difference in multisegment foot kinematics during shod walking and running

    Gait Posture

    (2016)
  • C. Morio et al.

    The influence of footwear on foot motion during walking and running

    J. Biomech.

    (2009)
  • A. Mündermann et al.

    Foot orthotics affect lower extremity kinematics and kinetics during running

    Clin. Biomech.

    (2003)
  • C. Nester et al.

    Effect of foot orthoses on the kinematics and kinetics of normal walking gait

    Gait Posture

    (2003)
  • C. Pothrat et al.

    One- and multi-segment foot models lead to opposite results on ankle joint kinematics during gait: implications for clinical assessment

    Clin. Biomech.

    (2015)
  • A.O. Radzimski et al.

    Effect of footwear on the external knee adduction moment—a systematic review

    Knee

    (2012)
  • F. Riva et al.

    Gait variability and stability measures: minimum number of strides and within-session reliability

    Comput. Biol. Med.

    (2014)
  • N. Shibuya et al.

    Characteristics of adult flatfoot in the United States

    J. Foot Ankle Surg.

    (2010)
  • R. Shultz et al.

    Differences in neutral foot positions when measured barefoot compared to in shoes with varying stiffnesses

    Med. Eng. Phys.

    (2011)
  • A. Stacoff et al.

    Biomechanical effects of foot orthoses during walking

    Foot

    (2007)
  • G. Stoquart et al.

    Effect of speed on kinematic, kinetic, electromyographic and energetic reference values during treadmill walking

    Neurophysiol. Clin.

    (2008)
  • S. Telfer et al.

    Dose-response effects of customised foot orthoses on lower limb kinematics and kinetics in pronated foot type

    J. Biomech.

    (2013)
  • M.H. Yamashita

    Evaluation and selection of shoe wear and orthoses for the runner

    Phys. Med. Rehabil. Clin. N. Am.

    (2005)
  • R.A. Zifchock et al.

    A comparison of semi-custom and custom foot orthotic devices in high- and low-arched individuals during walking

    Clin. Biomech.

    (2008)
  • G. Aminian et al.

    The effect of prefabricated and proprioceptive foot orthoses on plantar pressure distribution in patients with flexible flatfoot during walking

    Prosthetics Orthot. Int.

    (2013)
  • J.B. Arnold et al.

    Quantifying foot kinematics inside athletic footwear: a review

    Footwear Sci.

    (2013)
  • H.A. Banwell et al.

    Foot orthoses for adults with flexible pes planus: a systematic review

    J. Foot Ankle Res.

    (2014)
  • H. Bateni

    Changes of postural steadiness following use of prefabricated orthotic insoles

    J. Appl. Biomech.

    (2013)
  • C. Bishop et al.

    Effects of taping and orthoses on foot biomechanics in adults with flat-arched feet

    Med. Sci. Sports Exerc.

    (2016)
  • G.P. Brown et al.

    The effect of two types of foot orthoses on rearfoot mechanics

    J. Orthop. Sports Phys. Ther.

    (1995)
  • A. Castro-Mendez et al.

    The short-term effect of custom-made foot orthoses in subjects with excessive foot pronation and lower back pain: a randomized, double-blinded, clinical trial

    Prosthetics Orthot. Int.

    (2013)
  • R.T. Cheung et al.

    Efficacies of different external controls for excessive foot pronation: a meta-analysis

    Brit. J. Sport. Med.

    (2011)
  • S.C. Cobb et al.

    Custom-molded foot-orthosis intervention and multisegment medial foot kinematics during walking

    J. Athl. Train.

    (2011)
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