## 4 Discussion
No full subjective assessment has been described where medical history and lifestyle details are considered to aid in treatment decisions. The papers identified in this review do not describe the plethora of tests which are used to both diagnose and prescribe effective non-surgical treatments for PTTD; additionally, they do not describe how this is/should be followed up to determine the success or failure of said treatment. The research also does not describe how to assess for treatment failure, or what to do if treatment fails; for example, they do not address a bridge between non-surgical and surgical treatments. Gait examination was not found to be presented as a method used for clinical examination of PTTD in the literature search; however, a recent study interviewing podiatrists demonstrated that this is used as a part of their assessment approaches. It also highlighted that there was a lack of continuity in the assessments used and the parameters which were assessed [36]. Many studies describe the differences between the gait of patients with PTTD compared to controls without PTTD [1; 2; 3]. However, the use of gait systems or a description of visual gait analysis for patients with PTTD has not been described in the literature. No papers describe a connection between the results of the examinations or how they connect to a detailed treatment plan. Many papers discuss the use of a classification method; therefore, one would assume that these findings would be used in combination with other assessments to guide further diagnostics. However, no papers show findings which can be used to aid in a non-surgical treatment plan, they only suggest a treatment path. This is not representative of a clinical assessment; this, in line with subjective assessments and patient histories, leads to a specific treatment plan. In addition to this, although all the classification systems describe the necessity of orthotics with some detail, there is a lack of specificity in the method of manufacture, prescription, or type of orthoses to be used. Regarding the detail provided by the classification systems, [PERSON] and [PERSON] describe the use of medial shoe wedges or orthotics [6]. [PERSON] et al. describe orthoses with medial posting and a custom brace [37]. [PERSON] describes medial rearfoot posted orthotic inserts and moulded ankle-foot orthoses [9]; finally, [PERSON] et al. provide the most detail, describing the use of an ankle stirrup brace, a medial heel-and-sole shoe wedge, a hinged ankle-foot orthosis, an orthotic arch-support, a stiff orthotic support, and a rigid ankle-foot orthosis [7]. However, the relationship between the assessments used, the classification systems, and detailed treatment plans is lacking. There is a clear lack of awareness of PTTD, leading to poor referrals and delayed treatment [28]. In addition to this, this paper has identified that there is no assessment and treatment protocol defined when a patient has arrived at the correct practitioner. Due to the progressive nature of this condition, there is a need for a standardized assessment and treatment protocol, agreed upon by expert consensus. This protocol should include all assessments used within a clinical environment to aid in decision making, and the presentation of the plethora of treatment options available to the patient. More research is needed to develop assessment tools which provide data to help with non-surgical clinical decision making for PTTD. The present study shows some strengths, one of them being that it is the first to define all the assessments described in the literature; additionally, it identifies a clear lack of evidence in support of the use of these assessments. This has clinical implications and can help to guide future clinical guidelines for assessment. However, some limitations are also present in this review. The main weakness of this systematic review is the lack of high quality and homogeneity in the included studies.