Orthotic management of common forefoot deformities: a clinical practice guideline for hallux valgus.
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Orthotic management of common forefoot deformities: a clinical practice guideline for hallux valgus. Introduction Foot problems have been known since early mankind (1) and shoes have been a part of human attire from early civilization. (2,3) Throughout the centuries, fashion has played an important role in the success of certain styles from being soft to hard, rigid high-fashion footwear. (2) These footwear constrict the width of the foot especially in the forefoot compressing the toes. Improper footwear can frequently lead to deformities of the forefoot including hallux valgus, bunionettes, and hammer toes. (2) This review will be looking at literature related to orthotic management for deformities of the forefoot. Since there are a large number of deformities of the forefoot including the toes, and research is scarce, this review will include some of the most common such as hallux valgus, Morton's neuroma and metatarsalgia. Methods The literature was reviewed to identify studies that investigated the use of foot orthoses as part of conservative treatment of forefoot deformities. The focus of this review was on randomized controlled trials as they have a strong level of evidence. Forefoot deformities including hallux valgus, Morton's neuroma and metatarsalgia will be included with a focus on hallux valgus as it is one of the most common and has been researched the most. The review will conclude with a clinical practice guidelines outline on hallux valgus.
2005 69 (71 neuromas) Quasi-randomised Steroid injection vs. shoe modifications Pain (not indicated how well it was assessed) No significant difference at 1 year Kilmartin & Wallace, 1994 (UK) 23 Randomised Supinatory insoles vs. pronatory insoles Visual analog scale (VAS) pain, McMaster Toronto arthritis patient function preference questionnaire (MACTAR) 50% pain reduction in supination group, 45% in pronation group. No statistical significance Table 3. Summary of study conducted on metatarsalgia. Reference Sample Methods Outcomes measures Results Postema et al. 1998 (The Netherlands) 42 Randomised Extra depth shoes with rockerbar Ready-made insole Pain questionnaire (0 no pain to 5 extreme pain), Pressure platform (Mikro-EMED) Pain was significantly lower for insole group. Both insole and rockerbar reduced peek pressures. Clinical Practice Guideline Hallux valgus This clinical practice guideline on hallux valgus is based upon consensus of current clinical practice and review of the clinical literature. The guideline was developed by the Clinical Practice Guideline First Metatarsophalangeal (MTP) Joint Disorders Panel of the American College of Foot and Ankle Surgeons. (6) The pathways are illustrated in the diagram below followed by written description for each step (1-8). Fig 1. Clinical practice guideline pathways for hallux valgus. Derived from Vanore et al. (6) 2003 INITIAL TREATMENT OPTIONS 5 PATIENT DIRECTED Tx NON-OPERATIVE Tx SURGERY Wider, lower heeled shoes Orthoses Bunion pad Shoe modifications Ice Patient Education NSAIDs Rx NSAIDs 6 IMPROVED NOT IMPROVED 1.
The studies also examine different areas and no comparison of data is possible. In hallux valgus, conservative measures may be used initially to reduce the symptomatology associated with this deformity however, surgical repair is often used more commonly to correct the deformity. Large well designed clinical trials are required to confirm the validity of existing smaller trials. Until then, orthotic management of forefoot deformities can only be base on clinical experience. Additional educational resources * http://www.uptodate.com/patients/content/topic.do?topicKey=~1XV1X72MODjxpF&selectedTitle=1%7E19&source=search_result#H14 UpToDate is an evidence-based, peer-reviewed information resource designed to help clinicians provide better care for their patients by providing evidence-based recommendations. It is written by physicians who are experts in their fields and continuously up-dated. Article on hallux valgus provides a great referencing list at the end for further reading. * http://www.foothyperbook.com/default.html An evidence-based resource for education in foot and ankle surgery. * http://www.epodiatry.com/foot_problems.htm A website primarily for foot health professionals with information on a range of foot problems with links to relevant databases and great resources such as information on conferences, courses and discussion forums. Resources for patients * http://www.uptodate.com/patients/content/topic.do?topicKey=~1XV1X72MODjxpF&selectedTitle=1%7E19&source=search_result#H14 UpToDate is a great resource for patients with current medical information to answer their clinical questions. * http://www.foothyperbook.com/default.html A great resource for the general population who need an explanation in simple terms and not medical language which can be hard to understand. * http://www.foothealthcare.com/html/footprobs/problem/probindex.htm A consumer foot care products provider website which also contains information on the different foot conditions with links to suitable products that may help such as bunion shields etc.
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