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