A systematic review of outcome tools used to measure lower leg conditions. Reliability and Validity of 6 Measures of Pain, Function, and Disability for Ankle Arthroplasty and Arthrodesis Psychometric Comparison of the PROMIS Physical Function CAT With the FAAM and FFI for Measuring Patient-Reported Outcomes Impact of comorbidities on the measurement of health in patients with ankle osteoarthritis. Evaluation of the foot and ankle outcome score in patients with osteoarthritis of the ankle. Are current foot- and ankle outcome measures appropriate for the evaluation of treatment for osteoarthritis of the ankle?: Evaluation of ceiling effects in foot- and ankle outcome measures. Validation of the Turkish version of the foot and ankle outcome score Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle fractures. Responsiveness and Validity of the SF-36, Ankle Osteoarthritis Scale, AOFAS Ankle Hindfoot Score, and Foot Function Index in End Stage Ankle Arthritis Responsiveness and minimally important change for the Manchester-Oxford foot questionnaire (MOXFQ) compared with AOFAS and SF-36 assessments following surgery for hallux valgus. The effect of different shoes on functional mobility and energy expenditure in post-stroke hemiplegic patients using ankle–foot orthosis Comparison of Plantar Fasciitis Injected With Platelet-Rich Plasma vs Corticosteroids Protocol for evaluating the effects of a foot-ankle therapeutic exercise program on daily activity, foot-ankle functionality, and biomechanics in people with diabetic polyneuropathy: a randomized controlled trial Infectious and Healing Complications after Elective Orthopaedic Foot and Ankle Surgery during Tumor Necrosis Factor-Alpha Inhibition Therapy Foot and ankle strength, range of motion, posture, and deformity are associated with balance and functional ability in older adults. Outcome after Unstable Ankle Fracture: Effect of Syndesmotic Stabilization Limited Open Repair of Achilles Tendon Ruptures: A Technique with a New Instrument and Findings of a Prospective Multicenter Study Effects of strengthening, stretching and functional training on foot function in patients with diabetic neuropathy: results of a randomized controlled trial Comparison of the Otto Bock solid ankle cushion heel foot with wooden keel to the low-cost CR-Equipements™ solid ankle cushion heel foot with polypropylene keel: A randomized prospective double-blind crossover study assessing patient satisfaction and energy expenditure Short-Term Results of Our First 49 Scandanavian Total Ankle Replacements (STAR) Impact of intermittent pneumatic foot pumps on delay to surgery following ankle fracture. Low-dose botulinum toxin with ankle taping for the treatment of spastic equinovarus foot after stroke. The effectiveness of exercise on recovery and clinical outcomes of soft tissue injuries of the leg, ankle, and foot: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.
BACKGROUND CONTEXT A variety of self-report and physical performance-based outcome measures are commonly used to assess progress and recovery in the lower leg , ankle , and foot . A requisite attribute of any outcome measure is its ability to detect change in a condition , a construct known as " responsiveness " . There is a lack of consistency in how responsiveness is defined in all outcome measures . PURPOSE The purpose of this study was to review the currently used recovery outcome measures for lower leg , ankle and foot conditions in order to determine and report recommended responsiveness values . METHODS A systematic literature search that included electronic search es of PubMed , CINAHL and SportD iscus as well extensive cross-referencing was performed in January , 2013 . Studies were included if each involved : 1 ) a prospect i ve , longitudinal study of any design ; 2 ) any condition associated with the lower leg , ankle or foot ; 3 ) a measure of responsiveness ; and 4 ) was an acceptable type of outcome measure ( eg . self-report , physical performance , or clinician report ) . The quality of the included articles was assessed by two independent authors using the responsiveness sub-component of the Consensus-based St and ards for the selection of health Measurement Instruments ( COSMIN ) . RESULTS Sixteen different studies met the inclusion criteria for this systematic review . The most commonly used outcome measures were the Foot and Ankle Ability Measure and the Lower Extremity Functional Scale . Responsiveness was calculated in a variety of methods including effect size , st and ardized response mean , minimal clinical ly important difference/ importance , minimal detectable change , and minimal important change . CONCLUSION Based on the findings of this systematic review there is a lack of consistency for reporting responsiveness among recovery measures used in the lower leg , ankle or foot studies . It is possible that the variability of conditions that involve the lower leg , ankle and foot contribute to the discrepancies found in reporting responsiveness values . Further research must be conducted in order to st and ardize reporting measures for responsiveness . LEVEL OF EVIDENCE 2a Background : Patient-reported outcome measures are increasingly used evaluating clinical care . Many measures used to assess operative hindfoot interventions vary in content , and some have not been psychometrically vali date d in this population . The purpose of this study was to compare measurement properties of  6 lower-extremity patient-reported outcome measures  , and to evaluate their reliability and validity in light of patients ’ preferences . Methods : Cross-sectional survey of 42 preoperative and 100 postoperative patients completed 6 lower-extremity outcome measures  on 2 occasions : Foot Function Index ( FFI ) , Ankle Osteoarthritis Scale ( AOS ) , patient-reported items of the  American  Orthopaedic Foot & Ankle Society Question naire ( AOFAS ) , Lower Extremity Functional Scale ( LEFS ) , Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) , and the Short Musculoskeletal Function Assessment ( SMFA ) , as well as measures of preference , and symptoms . Results : Internal consistency was good to excellent for all scales and subscales ( α = .84-.97 ; ICC [ 2,1 ] = .81-.96 ) . Correlations between scales ranged from .50 ( WOMACStiffness and FFIActivity Limitations ) to .92 ( LEFS and SMFAOverall , WOMACPain and AOSOverall , FFIOverall and AOFASOverall ) . Higher correlations occurred within instruments ( r = .97 AOSPain and AOSOverall ) and between similar subscales from different instruments ( r = .91 WOMACPain and AOSPain ) . Construct validity showed moderate to high correlations to global ratings of Pain , Stiffness , and difficulty performing Daily Activities . The highest correlations ( r > .75 ) occurred between Pain and AOSOverall ( r = .84 ) , stiffness and WOMACStiffness ( r = .81 ) , and Daily Activities and AOSDisability ( r = .87 ) . Patients rated instruments by preference . FFI , WOMAC , LEFS , and SMFA rated favorably for length . FFI , WOMAC , LEFS , and AOFAS rated high for underst and ability . FFI was rated by postoperative patients as most likely to capture change due to surgery . SMFA rated the best overall . Conclusions : Direct comparison of instruments revealed similarity between scales in construct validity and reliability . Patient preferences supported the use of these scales . Foot-specific instruments offered no clear advantage over lower-extremity instruments . Level of Evidence : Level II , prospect i ve comparative study Background : Selecting optimal patient-reported outcome ( PRO ) instruments is critical to improving the quality of health care . The purpose of this study was to compare the reliability , responsiveness , and efficiency of three PRO measures : the Foot and Ankle Ability Measure – Activity of Daily Living subscale ( FAAM_ADL ) , the Foot Function Index 5-point verbal rating scale ( FFI-5pt ) , and the PROMIS Physical Function computerized adaptive test ( PF CAT ) . Methods : Data were aggregated from 10 clinical sites in the AOFAS ’s National Orthopaedic Foot and Ankle Research ( OFAR ) Network from 311 patients who underwent elective surgery for a disorder of the foot or ankle . Patients were administered the FAAM_ADL , FFI-5pt , and PF CAT at their preoperative visit and at 6 months after surgery . Reliabilities were evaluated using a Rasch model . Responsiveness was calculated using paired sample s t test and efficiency was recorded as number of seconds to complete the instrument . Results : Similar reliabilities were found for the three instruments . Item reliabilities for FAAM_ADL , FFI-5pt , and PF CAT were all .99 . Pearson reliabilities for FAAM_ADL , FFI-5pt , and PF CAT were .95 , .93 , and .96 , respectively . On average , patients completed the FAAM_ADL in 179 seconds , the FFI-5pt in 194 seconds , and the PF CAT in 44 seconds , ( P < .001 ) . The PF CAT and FAAM_ADL showed significant improvement ( P = .01 and P = .001 , respectively ) in patients ’ physical function after treatment ; the FFI-5pt did not show improvement . Conclusions : Overall , the PF CAT performed best in terms of reliability , responsiveness , and efficiency in this broad sample of foot and ankle patients . It can be a potential replacement for the conventional PRO measures , but further validation is needed in conjunction with the PROMIS Pain instruments . Level of Evidence : Level I , prospect i ve comparative outcome study BACKGROUND Investigators seeking to underst and the impact of musculoskeletal disorders commonly use vali date d outcome instruments to assess the effect of diseases on physical function and quality of life . However , the influence of concomitant systemic or musculoskeletal comorbidities on these scores has not been widely considered in orthopaedic research . The purpose of this study was to determine how morbidity unrelated to the ankle influences the perception of physical function and pain by patients with ankle osteoarthritis . METHODS  Short Form-36 ( SF-36 ) Physical Component Summary ( PCS ) and Mental Component Summary ( MCS ) scores , Ankle Osteoarthritis Scale ( AOS ) pain scale scores ,  demographic data  , and systemic and musculoskeletal comorbidities were determined prospect ively for 195 patients with ankle osteoarthritis and ninety-five age and gender-matched controls . The effect of systemic and musculoskeletal comorbidities on each of the scores was determined . RESULTS On the average , patients with ankle osteoarthritis had a relatively normal MCS score ( 47 + /- 13 points ) and a markedly diminished PCS score ( 32 + /- 8 points ) . Both of these scores averaged 50 + /- 9 points in the control group . The AOS pain score averaged 61 + /- 23 points in the group with ankle osteoarthritis , whereas it averaged 10 + /- 15 points in the control group . We found the perception of ankle pain by patients with ankle osteoarthritis to be significantly and linearly associated with the number of other musculoskeletal problems ( not related to the foot or ankle ) . CONCLUSIONS The degree of physical impairment associated with ankle osteoarthritis , as measured with the SF-36 , is equivalent to that reported to be associated with severely disabling medical problems including end-stage kidney disease and congestive heart failure . The perception of ankle health status as measured with a vali date d , patient-oriented , anatomically specific instrument is influenced by the patients ' perception of their overall musculoskeletal comorbidity status . The authors of clinical studies using these instruments should adjust for concomitant musculoskeletal disease The foot and ankle outcome score ( FAOS ) has been evaluated for many conditions of the foot and ankle . We evaluated its construct validity in 136 patients with osteoarthritis of the ankle , its content validity in 37 patients and its responsiveness in 39 . Data were collected prospect ively from the registry of patients at our institution . All FAOS subscales were rated relevant by patients . The Pain , Activities of Daily Living , and Quality of Life subscales showed good correlation with the Physical Component score of the Short-Form-12v2 . All subscales except Symptoms were responsive to change after surgery . We concluded that the FAOS is a weak instrument for evaluating osteoarthritis of the ankle . However , some of the FAOS subscales have relative strengths that allow for its limited use while we continue to seek other satisfactory outcome instruments BACKGROUND Many PROMs used for evaluation of ankle  osteoarthritis  are not vali date d for this purpose . We hypothesize that frequently used PROMs have an early ceiling or floor effect . METHODS We prospect ively collected data from patients with ankle osteoarthritis between 2011 and 2013 . At baseline visit patients completed the Foot and Ankle Outcome Score , the Ankle Osteoarthritis Score , the American Orthopaedic Foot and Ankle Society scale , a visual analogue scale for pain and quality of life . Outcomes were analyzed for floor or ceiling effects . RESULTS 197 patients were included in the study . A floor effect was present for the AOFAS and VAS for pain in all groups . Floor and ceiling effect are absent for the FAOS outcome measure for all groups . CONCLUSIONS Physicians should be aware of floor or ceiling effects when evaluating treatment using patient reported outcome measures . The FAOS outcome measure lacks early ceiling or floor effects The objective is to develop a Turkish version of the foot and ankle outcome score ( FAOS ) and to investigate its validity and reliability . The Turkish version of FAOS was developed after the translation and back-translation . The translated version was pretested on 20 patients with rheumatoid arthritis . Then , the Turkish FAOS was administered to 55 patients having foot and ankle problems . They were also evaluated by using the four subscales of the Turkish version of AIMS 2 , and the Turkish version of SF-36 question naire to test validity . Fifty patients filled out the FAOS for second time to determine test – retest reliability . Construct validity was investigated with use of Spearman ’s rank correlation coefficient . Test – retest reliability was assessed with use of the intraclass correlation coefficient ( ICC ) and Cronbach ’s alpha score . The psychometric properties of the Turkish FAOS were generally similar to the original FAOS . The r and om ICC for the five subscales ranged from 0.70 to 0.96 . The Cronbach ’s alpha coefficient ranged from 0.79 to 0.97 . Construct validity of the FAOS was good . The Turkish FAOS correlated with the SF-36 and AIMS 2 scales . The Turkish version of FAOS was valid and reliable instrument to assess the foot and ankle related problems . However , to assess its responsiveness further studies are needed BACKGROUND To our knowledge , no study to date has compared the use of spinal and general anesthesia in patients undergoing operative fixation of an unstable ankle fracture . The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients . METHODS Between October 2000 and November 2006 , 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospect ively . Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia .  All patients were evaluated at three , six , and twelve months postoperatively with use of st and ardized , vali date d general and limb-specific outcome instruments . St and ard and multivariable analyses comparing outcomes at these intervals were performed . RESULTS Four hundred and sixty-six patients ( 93 % ) who had been followed for a minimum of one year met the inclusion criteria . Compared with the general anesthesia group , the spinal anesthesia group had a greater mean age ( p = 0.005 ) , higher classification on the American Society of Anesthesiologists system ( p = 0.03 ) , and a greater number of patients with diabetes ( p = 0.02 ) . There was no difference in sex distribution between the groups . At three months , patients who received spinal anesthesia had significantly better pain scores ( p = 0.03 ) and total scores on the American Orthopaedic Foot and Ankle Society outcome instrument ( p = 0.02 ) . At six months , patients in the spinal anesthesia group continued to have better pain scores ( p = 0.04 ) , but there was no longer a difference in total scores ( p = 0.06 ) . At twelve months , no difference was detected between the groups in terms of functional or pain scores . There was no difference in complication rates between the groups . CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia  seem to experience less pain and have better function in the early postoperative period . We recommend that , unless there is a specific contraindication , patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture Background : We examined four commonly used scores , the SF-36 , the  Ankle Osteoarthritis Scale ( AOS )  , the  American Orthopaedic Foot and Ankle Society ( AOFAS ) Ankle Hindfoot Score  , and the  Foot Function Index ( FFI )  to determine their responsiveness and validity . Methods : Patients with end stage ankle arthritis were recruited into a prospect i ve multicenter cohort study and baseline and one year outcome scores were compared . The St and ardized Response Mean and Effect Size for the AOS , AOFAS , and FFI were calculated and the three region- or disease-specific scores were compared with the SF-36 to determine their criterion validity . Results : All four scores showed acceptable responsiveness , and when using the vali date d SF-36 as the st and ard the three region or disease specific scores all showed similar criterion validity . Conclusion : All four scores are responsive and can be considered for use in this population . The objective component of the AOFAS Ankle Hindfoot Score may make it harder to perform than the other three scores which have subjective components only , and as yet its objective component has not been shown to demonstrate reliability . We recommend use of a purely subjective score such as the Ankle Osteoarthritis Scale or Foot Function Index as the region- or disease-specific score of choice in this population . As the SF-36 shows acceptable responsiveness , using it alone could also be considered . Level of Evidence : II , Prospect i ve Comparative OBJECTIVES To assess responsiveness and minimally important change ( MIC ) for the Manchester-Oxford foot question naire ( MOXFQ ) using anchor and distribution-based approaches . Responsiveness and estimates of minimal clinical ly important difference ( MCID ) and minimal detectable change are compared with those from the Short-Form 36 ( SF-36 ) and American Orthopaedic Foot & Ankle Society ( AOFAS ) measures . METHODS A prospect i ve observational study of 91 consecutive patients ( 125 foot operations ) undergoing hallux valgus surgery at an orthopaedic hospital . Pre- and 12 month post-surgery , patients completed the MOXFQ and SF-36 , and foot surgeons assessed all four AOFAS scores corresponding to four regions of the foot . Transition items were asked about perceived changes compared with before surgery . RESULTS Mean changes in all domains of each instrument were statistically significant , but foot-specific MOXFQ and AOFAS domains produced much larger effect sizes ( > 1 ) than any SF-36 domains , indicating superior responsiveness . Clear associations occurred between transition items and all MOXFQ and AOFAS scores , but with only one ( physical function ) SF-36 domain . Anchor and distribution-based approaches identified generally comparable measures of MIC , which for the MOXFQ and AOFAS domains were between 1 and 2 st and ard error of measurement . In metric terms , the MCIDs were 16 , 12 , and 24 for the MOXFQ Walking/st and ing , Pain , and Social Interaction domains , respectively . CONCLUSIONS For hallux valgus surgery , the MOXFQ is highly responsive . Performance is comparable to the AOFAS and notably better than the generic SF-36 . Study estimates of MIC for the MOXFQ are useful to inform sample -size calculations for future clinical trials Background : Ankle – foot orthoses could be utilized both with and without shoes . While several studies have shown that ankle – foot orthoses improve gait abilities in hemiplegic patients , it remains unclear whether they should be used with shoes or without . Objectives : The study purpose was to compare the effect of st and ard shoes and rocker shoes on functional mobility in post-stroke hemiplegic patients utilizing ankle – foot orthosis .  Study design : R and omized clinical study . Methods : Thirty post-stroke hemiplegic patients participated in this study r and omly assigned to two groups . Group I received st and ard shoes + ankle – foot orthosis and group II were provided with rocker shoes + ankle – foot orthosis . Their functional mobility and energy expenditure parameters including timed up and go , timed up stairs , timed down stairs , preferred walking speed , and oxygen ( O2 ) cost ( mL/kg/m ) were measured . Results : In group I , no significant changes were seen in outcome measures after wearing st and ard shoes . While in group II , O2 cost and timed up and go time significantly decreased , and preferred walking speed increased when patients wore rocker shoes . Also , there was a significant difference between rocker shoes and st and ard shoes in improvement of timed up and go , preferred walking speed , and O2 cost . Conclusion : When patients using ankle – foot orthosis wore rocker shoes , their functional mobility improved and oxygen cost diminished . Also , rocker shoes was significantly more effective than st and ard shoes in improving functional mobility parameters . Clinical relevance This study suggests that in post-stroke hemiplegic patients using ankle – foot orthosis , wearing rocker shoes can lead to much more improved functional mobility and decreased energy expenditure compared to ankle – foot orthosis only . Thus , in stroke patients , the combination of ankle – foot orthosis-rocker shoes is recommended for both rehabilitation programs and ankle – foot orthosis efficacy investigations Background : Plantar fasciitis is one of the most common causes of heel pain . This prospect i ve study compared the efficacy of local injection of corticosteroids vs platelet-rich plasma ( PRP ) in the treatment of plantar fasciitis . Methods : Patients were r and omly allocated into 2 groups of 40 each ( group A and group B ) . Patients were treated with local corticosteroid injection in group A and autologous PRP injection in group B. Clinical assessment was done prior to the injection and at 1 month , 3 months , and 6 months following the injection , which included visual analog pain scale , subjective rating using the modified Roles and Maudsley score , functional outcome score by the Foot and Ankle Outcome Instrument ( FAI ) core scale , and the American Orthopaedic Foot & Ankle Society ( AOFAS ) ankle-hindfoot scale . Radiological assessment was done by measuring the thickness of the plantar fascia using ultrasonography . The mean age , sex , and body mass index of both groups were comparable . Results : Postinjection , there was significant improvement of visual analog score , modified Roles and Maudsley score , FAI core scale , AOFAS ankle-hindfoot score , and plantar fascia thickness in both the groups . However , with the numbers available , no significant difference in improvement could be detected between the above-mentioned variables in the 2 groups . Conclusion : We found that the treatment of plantar fasciitis with steroid or PRP injection was equally effective . Level of Evidence : Level II , prospect i ve r and omized comparative series Background Diabetic polyneuropathy ( DPN ) negatively affects foot and ankle function ( strength and flexibility ) , which itself affects the daily physical activity and quality of life of patients . A physical therapy protocol aim ing to strengthen the intrinsic and extrinsic foot muscles and increase flexibility may be a promising approach to improve lower-extremity function , prevent further complications , and improve autonomy for daily living activities in these patients . Thus , the inclusion of a specific foot-related exercises focused on the main musculoskeletal impairments may have additional effects to the conventional interventions in the diabetic foot . Methods / Design A prospect i ve , parallel-group , outcome -assessor blinded , r and omized controlled trial ( RCT ) will be conducted in 77 patients with DPN who will be r and omly allocated to usual care ( control arm ) or usual care with supervised foot-ankle exercises aim ing to increase strengh and flexibility twice a week for 12 weeks and remotely supervised foot-ankle exercises for a year through a web software . Patients will be evaluated 5 times in a 1 year period regarding daily physical activity level , self-selected and fast gait speeds ( primary outcomes ) , foot ulcer incidence , ulcer risk classification , neuropathy testing , passive ankle range of motion , quality of life , foot health and functionality , foot muscle strength , plantar pressure , and foot-ankle kinematics and kinetics during gait . Discussion This study aims to assess the effect of a foot-ankle strength and flexibility program on a wide range of musculoskeletal , activity-related , biomechanical , and clinical outcomes in DPN patients . We intend to demonstrate evidence that the year-long training program is effective in increasing gait speed and daily physical activity level and in improving quality of life ; foot strength , functionality , and mobility ; and biomechanics while walking . The results will be published as soon as they are available . Trial registration This study has been registered at Clinical Trials.gov as NCT02790931 ( June 6 , 2016 ) under the name “ Effects of foot muscle strengthening in daily activity in diabetic neuropathic patients ” Background : Biologic response modifiers are assuming a larger role in the management of patients with rheumatoid arthritis . The tumor necrosis factor-alpha ( TNF-α ) inhibitors etanercept and infliximab improve patient symptoms and function . However , these agents have been associated with a risk for healing and infectious complications due to systemic blockade of TNF-α , a ubiquitous mediator required in the normal inflammatory response in tissue healing and infection surveillance . This study analyzed the risk of healing/infectious complications in patients undergoing elective foot and ankle surgery while being treated with TNF-α inhibitors etanercept and infliximab . Methods : Patients with rheumatoid arthritis undergoing elective foot and ankle surgery over a 12-month period were prospect ively followed for the development of complications in the postoperative period . All patients continued their antirheumatic medication schedule unaltered in the perioperative period . Data collected included sex , age , all medications used to treat rheumatoid arthritis , smoking history , and number of orthopaedic foot and ankle procedures performed . Patients were then stratified into two groups based on the use of immunomodulation via TNF-α inhibition ( group 1 ) versus patients who did not receive TNF-α inhibition therapy ( group 2 ) . Groups 1 and 2 were followed and compared for the development of infectious/healing complications . Results : Thirty-one patients were enrolled in the study . Group 1 ( n = 16 ) and group 2 ( n = 15 ) patients were comparable for sex distribution , number of orthopaedic procedures performed , and use of steroids , methotrexate , leflunamide , and nonsteroidal anti-inflammatory drugs . Group 1 contained six times the number of smokers in group 2 . At mean follow-up of 10.6 months ( group 1 ) and 9.7 months ( group 2 ) , healing or infectious complications were similar in both groups . However , when total complications ( healing + infection ) were analyzed , group 1 ( TNF-α inhibition , “ higher risk ” ) patients demonstrated a lower complication rate ( p = .033 ) . Conclusions : The data suggest that in patients with rheumatoid arthritis undergoing elective foot and ankle surgery , the use of TNF-α inhibition agents may be safely undertaken in the perioperative period without increasing the risk of healing or infectious complications OBJECTIVE To determine the extent to which measures of foot and ankle strength , range of motion , posture , and deformity are associated with performance in a battery of balance and functional ability tests in older adults . DESIGN Cross-sectional study of people over 65 years . SETTING Community . PARTICIPANTS Participants ( N=305 ; age range , 65 - 93y ) recruited for a r and omized trial investigating the efficacy of a podiatry intervention to prevent falls . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES Clinical measures of foot and ankle strength ( using h and -held dynamometry ) , range of motion , posture , and deformity , and a battery of balance tests ( postural sway , maximum balance range , lateral stability , coordinated stability ) and functional ability tests ( alternate step test , sit-to-st and , timed 6-m walk ) . RESULTS Most ( 67/88 ) of the correlations between the foot and ankle tests and performance on the balance and functional tests were statistically significant . Hierarchic linear regression analysis identified hallux plantar flexion strength and ankle inversion-eversion range of motion to be the most consistent significant and independent predictors of balance and functional test performance , explaining up to 25 % of the variance in the test scores . CONCLUSIONS Foot and ankle characteristics , particularly plantar flexor strength of the hallux and ankle inversion-eversion range of motion , are important determinants of balance and functional ability in older people . Further research is required to establish whether intervention programs that include strengthening and stretching exercises for the foot and ankle may achieve improvements in balance and functional ability and reduce the risk of falls in older people Objective : This study was performed to evaluate the results of operative treatment of ankle fractures in patients who required syndesmotic stabilization in addition to malleolar fracture fixation compared with patients who required malleolar fixation alone .  Design : The authors conducted a retrospective review of prospect ively collected data . Setting : Academic medical center . Patients : Between October 2000 and November 2006 , 347 patients who underwent surgical repair of an unstable ankle fracture were enrolled in a prospect i ve data base . Intervention : Patients who had an associated syndesmotic disruption requiring surgical stabilization in association with either an ankle fracture or a fracture-dislocation were identified and compared with a cohort treated during the same time period who had sustained an ankle fracture or fracture-dislocation without syndesmotic disruption . Main Outcome Measurements : All patients were followed and evaluated at 3 , 6 , and 12 months with clinical and radiographic examination as well as functional status ( Short Musculoskeletal Functional Assessment , American Orthopaedic Foot and Ankle Society ) . Patient-reported pain and postoperative complications were recorded as well . Results : Three hundred forty-seven patients met the inclusion criteria and had 1-year minimum follow up . Seventy-nine patients ( 23 % ) who had syndesmotic stabilization  were identified and compared with 268 patients ( 77 % ) who did not . No differences were found between the two groups with respect to age or American Society of Anesthesiologists status ; however , there was a greater percentage of men in the syndesmotic injury group ( P = 0.04 ) . There was a greater percentage of Type C fractures requiring  syndesmosis stabilization , whereas Type B fractures were less likely to require syndesmosis stabilization ( P = 0.001 ) At 6- and 12-month follow up , there was a clear difference in outcome based on American Orthopaedic Foot and Ankle Society and Short Musculoskeletal Functional Assessment scores ; patients who underwent syndesmotic stabilization had worse American Orthopaedic Foot and Ankle Society scores with lower function ratings ( P = 0.04 ) and worse pain ratings ( P = 0.02 ) . Short Musculoskeletal Functional Assessment scores were also worse at 12 months in patients who had syndesmotic stabilization because the dysfunction index was higher in the syndesmotic injury group ( P = 0.009 ) . Radiographically , 18 of 144 ( 13 % ) syndesmotic screws were noted to be broken on follow-up radiographs , eight of which were subsequently removed . There were no other differences in complication rates . Conclusion : Patients who required syndesmotic stabilization in addition to malleolar fracture fixation had poorer outcomes at 12 months compared with patients who required malleolar fracture fixation alone . This information is important for patient counseling to manage expectations regarding outcomes after injury Background : Controversy persists regarding the ideal surgical technique for repair of a ruptured Achilles tendon . We propose a limited open procedure with use of an instrument that provides the advantage of an open repair but avoids the soft-tissue problems with which open repair has been associated . Methods : We first performed a cadaver study in order to develop an instrument and a technique for a limited open repair and then , using this procedure in conjunction with an early functional rehabilitation protocol , we began a prospect i ve multicenter study . We are reporting on the first eighty‐seven patients consecutively treated with the new instrument and followed for an average of twenty‐six months ( range , eighteen to forty‐two months ) . All patients were assessed clinical ly and with an enhanced American Orthopaedic Foot and Ankle Society ( AOFAS ) rating score . In addition , all fifty patients who had been followed for at least twenty-four months were further evaluated with isokinetic dynamometry . Results : Four patients were lost to follow‐up and one patient died , which left eighty‐two patients for evaluation . There were no problems with wound-healing , and there were no infections . No patient noted a sensory disturbance in the sural nerve distribution . All patients returned to their previous professional or sporting activities . The mean AOFAS score was 96 points ( range , 85 to 100 points ) . Isokinetic dynamometry showed no significant difference in strength between the injured and uninjured limbs of the fifty patients who were tested . Complications occurred in three patients . Two of them were noncompliant and removed the orthosis , so that the repair was disrupted by a new injury within the first three weeks postoperatively . One patient fell twelve weeks after the surgery and sustained a rerupture . All three new injuries were repaired with an open surgical procedure . Conclusions : This new procedure allows the surgeon to precisely visualize and control the tendon ends while avoiding excessive dissection and disturbance of local vascularity and minimizing nerve and wound-healing problems . Such a technique , along with an early functional rehabilitation program , allowed us to achieve a high rate of successful results with minimal morbidity Background Foot musculoskeletal deficits are seldom addressed by preventive medicine despite their high prevalence in patients with diabetic polyneuropathy . AIM : To investigate the effects of strengthening , stretching , and functional training on foot rollover process during gait . Methods A two-arm parallel-group r and omized controlled trial with a blinded assessor was design ed . Fifty-five patients diagnosed with diabetic polyneuropathy , 45 to 65 years-old were recruited .  Exercises for foot-ankle and gait training were administered twice a week , for 12 weeks , to 26 patients assigned to the intervention group , while 29 patients assigned to control group received recommended st and ard medical care : pharmacological treatment for diabetes and foot care instructions . Both groups were assessed after 12 weeks , and the intervention group at follow-up ( 24 weeks ) . Primary outcomes involved foot rollover changes during gait , including peak pressure ( PP ) . Secondary outcomes involved time-to-peak pressure ( TPP ) and pressure – time integral ( PTI ) in six foot- areas , mean center of pressure ( COP ) velocity , ankle kinematics and kinetics in the sagittal plane , intrinsic and extrinsic muscle function , and functional tests of foot and ankle . Results Even though the intervention group primary outcome ( PP ) showed a not statistically significant change under the six foot areas , intention-to-treat comparisons yielded softening of heel strike ( delayed heel TPP , p=.03 ) , better eccentric control of forefoot contact ( decrease in ankle extensor moment , p<.01 ; increase in function of ankle dorsiflexion , p<.05 ) , earlier lateral forefoot contact with respect to medial forefoot ( TPP anticipation , p<.01 ) , and increased participation of hallux ( increased PP and PTI , p=.03 ) and toes ( increase in PTI , medium effect size ) . A slower COP mean velocity ( p=.05 ) , and an increase in overall foot and ankle function ( p<.05 ) were also observed . In most cases , the values returned to baseline after the follow-up ( p<.05 ) . Conclusions Intervention discreetly changed foot rollover towards a more physiological process , supported by improved plantar pressure distribution and better functional condition of the foot ankle complex . Continuous monitoring of the foot status and patient education are necessary , and can contribute to preserving the integrity of foot muscles and joints impaired by polyneuropathy . Trial registration Clinical Trials.gov Identifier : NCT01207284 , registered in 20th September 2010 Background : The International Committee of the Red Cross supports a worldwide program of prosthetic fitting and rehabilitation . In this context , a prosthetic foot was developed and widely distributed in least developed countries . Study design : Prospect i ve , r and omized , double-blind , controlled study . Objective : To compare patient satisfaction and energy expenditure during ambulation between a low-cost prosthetic foot design ed with a polypropylene keel ( CR-Equipements ™ solid ankle cushion heel , International Committee of the Red Cross ) to a well-recognized solid ankle cushion heel foot with a wooden keel ( solid ankle cushion heel foot , Otto Bock ) . Methods : A total of 15 participants with unilateral transtibial amputation were evaluated using the two prosthetic feet in a r and omized prospect i ve double-blind crossover study . Main outcomes were patient satisfaction question naires ( Satisfaction with Prosthesis Question naire and prosthetic foot satisfaction ) and energy expenditure ( oxygen consumption — mL/kg/min , oxygen cost — mL/kg/m , and heart rate — bpm ) . Results : There were no significant differences between the two prosthetic feet for satisfaction and energy expenditure . Conclusion : The low-cost solid ankle cushion heel foot with polypropylene keel provides comparable satisfaction and similar energy expenditure as the solid ankle cushion heel foot with wooden keel . Clinical relevance The results of this study support the application and widespread use of the CR-Equipements ™ solid ankle cushion heel foot . From a cost-effectiveness st and point , patients are well satisfied and exhibit similar outcomes at a substantially lower cost Background : Forty-seven consecutive patients treated for ankle arthritis with a Sc and inavian total ankle replacement ( STAR ) by one surgeon were investigated retrospectively . Material s and Methods : A modification of the Foot Function Index ( FFI ) , which scores pain and task difficulties , was followed prospect ively . Patients were assessed clinical ly and radiologically . Failure was defined as revision of the prosthesis or arthrodesis for any reason . Results : In 47 patients ( 16 male , 31 female ) 49 total ankle replacements were carried out between May 1999 and June 2004 . Indication for surgery was end stage arthritis for rheumatoid arthritis in 29 cases , post-traumatic arthritis in 12 , osteoarthritis in five and arthritis secondary to degenerative flatfoot in three . Mean followup time was 28 ( 12 to 67 ) months . The modified FFI ( range , 0 to 100 , a high score meaning more pain and disability ) improved significantly from 59 before to 35 after surgery . The mean postoperative Kofoed ankle score was 68 . Sixteen procedures were complicated by fractures or temporary neurological damage . At the time of followup , 45 prostheses survived , while four replacements had failed . Radiological examination at followup showed radiolucent lines , osteolysis , and malposition of the components in 31 cases . Conclusion : Our results are comparable with those reported in the literature . The clinical outcome improved significantly . Due to aseptic and septic loosening , 8.2 % of the prosthesis failed BACKGROUND Ankle fractures requiring open reduction and internal fixation ( ORIF ) are common and place considerable burden on inpatient beds . ORIF can not be performed once the associated swelling is too excessive to permit tension-free wound closure . Where ORIF can not be performed before the onset of swelling in the first 24 - 48h , patients typically require up to 7 days of inpatient bed-rest and elevation to reduce swelling to an acceptable level for ORIF . The primary aim of this study was to determine whether delay to ORIF could be reduced with the pre-operative application of an intermittent pneumatic foot pump ( IPF ) . These devices were design ed as anti-embolic adjuncts , but have also been shown to be effective in the reduction of swelling . We compared 12 patients managed with an IPF to 12 matched historical controls who were not . No previous studies have addressed this question in unselected patients requiring ankle ORIF . METHODS We performed a retrospective , controlled , before and after study of 24 patients who underwent ankle ORIF at our orthopaedic unit .  Foot pumps were applied in the Accident and Emergency Department to ankle fracture patients requiring admission , and kept in place until ORIF . Data was collected from patient case notes for all patients . Patients were matched for age , gender , American Society of Anaesthesiologists ( ASA ) Grade , and pre-injury mobility . The primary outcome measure was time to surgery . We also recorded total hospital stay , and calculated cost savings . RESULTS Patients managed with IPFs had a statistically significant 50 % reduction in time from presentation to surgery compared to those managed without ( p=0.024 ) , and had a reduced hospital stay ( p=0.116 ) . This result ed in a net saving of £ 10,480 ( £ 953 per patient ) . CONCLUSIONS We conclude that foot pumps reduce the time to surgery and total hospital stay of patients requiring ankle ORIF , and are cost effective OBJECTIVE To evaluate the efficacy of a combined treatment for spastic foot using selective injections of botulinum toxin ( BTA ) into the tibialis posterior muscle followed by ankle taping , and to compare it with current BTA treatment procedure . DESIGN Single-blind r and omized control trial . Three-month follow-up after treatment . SETTING Neurorehabilitation clinic . SUBJECTS Eighteen out patients with equinovarus foot due to severe spasticity after stroke . INTERVENTIONS ( 1 ) Injection of 190 to 320 BTA U into several calf muscles ( group A ) ; ( 2 ) injection of 100 BTA U into the tibialis posterior muscle , followed by ankle-foot taping ( group B ) . MAIN OUTCOME MEASURES Ankle range of motion ( ROM ) , Ashworth scale , gait velocity , and step length . RESULTS Average Ashworth scores decreased 1 point in both groups , but the benefit appeared of shorter duration in group B. Changes in both foot position at rest and passive ankle ROM were observed in all patients , without treatment-related differences , except for gain in passive dorsiflexion that appeared higher in group A. Gait velocity and step length showed similar increases in both groups . CONCLUSION The combination of selective injections of low BTA doses with ankle-foot taping is as effective as the injection of the current doses for the reduction of foot inversion with positive effects on gait parameters INTRODUCTION Soft tissue injuries of the leg , ankle , or foot are common and often treated by exercise . The purpose of this study was to determine the effectiveness of  exercise  for the management of soft tissue injuries of the leg , ankle , or foot . METHODS A systematic review of the literature was conducted . We search ed five data bases from 1990 to 2015 . Relevant articles were critically appraised using Scottish Intercollegiate Guidelines Network ( SIGN ) criteria . The evidence from studies with low risk of bias was synthesized using the best- evidence synthesis methodology . RESULTS We screened 7946 articles . We critically appraised ten r and omized trials and six had a low risk of bias . The evidence suggests that for recent lateral ankle sprain : 1 ) rehabilitation exercises initiated immediately post-injury are as effective as a similar program initiated one week post-injury ; and 2 ) supervised progressive exercise plus education/advice and home exercise lead to similar outcomes as education/advice and home exercise . Eccentric exercises may be more effective than an AirHeel brace but less effective than acupuncture for Achilles tendinopathy of more than two months duration . Finally , for plantar heel pain , static stretching of the calf muscles and sham ultrasound lead to similar outcomes , while static plantar fascia stretching provides short-term benefits compared to shockwave therapy . CONCLUSIONS We found little evidence to support the use of early or supervised exercise interventions for lateral ankle sprains . Eccentric exercises may provide short-term benefits over a brace for persistent Achilles tendinopathy and plantar fascia stretching provides short-term benefits for plantar heel pain
A considerable variety of outcome measurement tools are used in the foot and ankle clinical literature , with a small proportion used consistently .
The AOFAS scales continue to be used at a high rate relative to other scales that have been vali date d. Data from the present study underscore the need for a paradigm shift toward the use of consistent , valid , and reliable outcome measures for studies of foot and ankle procedures and disorders .
It is not clear which existing vali date d outcome instruments will emerge as widely used and clinical ly meaningful .
BACKGROUND In the orthopaedic literature , there is a wide range of clinical outcome measurement tools that have been used in evaluating foot and ankle procedures , disorders , and outcomes , with no broadly accepted consensus as to which tools are preferred .
The purpose of this study was to determine the frequency and distribution of the various outcome instruments used in the foot and ankle literature , and to identify trends for use of these instruments over time .