The purpose of this study was to evaluate the effect of various non-operative modalities of treatment (transcutaneous electrical nerve stimulation (TENS); neuromuscular electrical stimulation (NMES); insoles and bracing) on the pain of osteoarthritis (OA) of the knee.

We conducted a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify the therapeutic options which are commonly adopted for the management of osteoarthritis (OA) of the knee.

The outcome measurement tools used in the different studies were the visual analogue scale and The Western Ontario and McMaster Universities Arthritis Index pain index: all pain scores were converted to a 100-point scale.

A total of 30 studies met our inclusion criteria: 13 on insoles, seven on TENS, six on NMES, and four on bracing. The standardised mean difference (SMD) in pain after treatment with TENS was 1.796, which represented a significant reduction in pain. The significant overall effect estimate for NMES on pain was similar to that of TENS, with a SMD of 1.924. The overall effect estimate of insoles on pain was a SMD of 0.992. The overall effect of bracing showed a significant reduction in pain of 1.34.

Overall, all four non-operative modalities of treatment were found to have a significant effect on the reduction of pain in OA of the knee.

This study shows that non-operative physical modalities of treatment are of benefit when treating OA of the knee. However, much of the literature reviewed evaluates studies with follow-up of less than six months: future work should aim to evaluate patients with longer follow-up.

Cite this article: Bone Joint J 2016;98-B(1 Suppl A):89–94.

Summary

This study shows a significant reduction in knee adduction moment in patients with medial compartment osteoarthritis, in both the symptomatic and asymptomatic knees. Long-term follow-up studies are required to confirm the effect of treating the asymptomatic side on disease progression.

Introduction. Chronic mid body Achilles tendinopathy is a common problem. There is no consensus on treatment. The aim of this review was to assess the effectiveness of physiotherapy interventions (non surgical and non pharmacological) for this condition. Methods. A systematic review of the literature was conducted. A search of published and grey literature databases was undertaken (1999- December 2010). Two reviewers independently assessed the studies for eligibility using a strict inclusion and exclusion criteria. All eligible articles were assessed critically using the Pedro score. Data on cohort characteristics, diagnostic criteria, treatment intervention, outcome measures and results was extracted. A narrative research synthesis method was adopted. Results. 209 studies were identified. Nine publications met the review inclusion criteria. Methodological quality was adequate for all nine studies; however, blinding was a limitation for most. Interventions investigated were; Exercises (n = 2), Low level laser therapy (n = 1), Low energy shockwave treatment (SWT) (n = 3), Air cast brace (n = 2) and Insoles (n = 1). Some evidence exists for eccentric exercises in combination with SWT or Laser. However, contrary to other reviews, eccentric exercises were not found to be superior to other physiotherapy treatments. Conclusions. There is insufficient evidence to determine which method of physiotherapy is most appropriate for a chronic Achilles tendinopathy. Further well designed randomised controlled trials assessing physiotherapy interventions with specific diagnostic criteria and appropriate outcome tools are required to determine the efficacy of physiotherapy for the condition

One of the complications of hallux valgus surgery is shortening of the first metatarsal and this becomes particularly symptomatic in patients with a pre existing short metatarsal (Morton's foot or Greek foot). Initial treatment consists of appropriate insoles which incorporate not only relief of pain due to pressure metatarsalgia under the lesser metatarsal heads but also a Morton type extension under the big toe. Insoles with metatarsal relief are, however, not always well tolerated and surgery becomes necessary. The options are to shorten the lesser metatarsal heads or lengthen the previously shortened first metatarsal. Arthrodesis of the great toe metatarso-phalangeal joint can provide functional length to the first metatarsal. We have achieved good results in lengthening of the first metatarsal and believe that it is a safe option which avoids trauma to the lesser metatarso-phalangeal joints. The technique is presented and depends on whether there is a residual hallux valgus or whether the toe is well aligned. The operation should address the plane of the deformity and reverse the cause of the lengthening. Emphasis should however be placed in not getting the complication in the first instance and the incidence of the problematic short first metatarsal has significantly reduced since the decrease in popularity of the Wilson osteotomy

Introduction. Back pain is one of the most common health problems in the industrialized world. Although using insoles appears to be common clinical practice, there is no hard data to support its effectiveness in prevention of low back pain. As a part of a Cochrane review, we conducted a literature search to determine the effectiveness of shoe insoles in the prevention and treatment of non-specific back pain compared to placebo, no intervention, or other interventions.

Materials and methods. We identified relevant clinical trials by searching The Cochrane Back Group Specialized Registry, The Cochrane Central Register, MED-LINE, EMBASE and CINAHL. All retrieved abstracts were blinded and were assessed by two independent investigators who decided on their inclusion. All these were again assessed by two different independent investigators, using the eleven items reflecting internal validity recommended by the Cochrane Back Review Group. A trial was considered to be of high quality if six or more out of eleven criteria were met.

Results. Our search found a total of 324 references. 8 papers, meeting the predetermined inclusion criteria, were retrieved of which six were found suitable for final evaluation. The clinical trials described in the papers included more than 2400 patients who used insoles for 3–5 months. Two articles with 199 patients demonstrated improvement in low back pain, while three larger studies found no difference between using insoles or no using insoles.

Discussion. There is no evidence for recommending the use of insoles for prevention of back pain. Additional high quality trials must be done to determine if they are effective in the treatment of low-back pain.

Transtrochanteric curved varus osteotomy was designed to avoid some of the disadvantages of varus wedge osteotomy, such as post-operative leg-length discrepancy. In this retrospective study we investigated the leg-length discrepancy and clinical outcome after transtrochanteric curved varus osteotomy undertaken in patients with osteonecrosis of the femoral head. Between January 1993 and March 2004, this osteotomy was performed in 42 hips of 36 patients with osteonecrosis of the femoral head. There were 15 males and 21 females with a mean age at surgery of 34 years (15 to 68). The mean follow-up was 5.9 years (2.0 to 12.5). The mean pre-operative Harris hip score was 64.0 (43 to 85) points, which improved to a mean of 88.7 (58 to 100) points at final follow-up. The mean varus angulation post-operatively was 25° (12° to 38°) and the post-operative mean leg-length discrepancy was 13 mm (4 to 25). The post-operative leg-length discrepancy showed a strong correlation with varus angulation (Pearson’s correlation coefficient; r = 0.9530, p < 0.0001), which may be useful for predicting the leg-length discrepancy which can occur even after transtrochanteric curved varus osteotomy.

Background: The prevalence and incidence of low back pain in general society is high. Workers whose job involves walking long distances have even a higher tendency to suffer from low back pain.

Purpose: Our goal was to examine the effect of insoles on low back pain among workers whose job involves long-distance walking.

Methods: In this double blind prospective study we examined the effectiveness of insoles constructed in a computerized method to placebo insoles in 58 employees whose work entailed extensive walking and who suffered from low back pain. The evaluation was performed by the MILLION questionnaire.

Results: 81% of the employees preferred the real insoles in comparison to 19% of the users of the placebo insoles (p < 0.05). A substantial improvement in the LBP after the use of the true insoles was noted.. The average pain intensity before the use of the insoles was 5.46. However, after the use of the real insoles and the placebo insoles the average pain intensity decreased to 3.96 and 5.11 respectively. The difference of the average pain intensity at the start of the study and after the use of the real insoles was significant: −1.49 (p=0.0001), whereas this difference after the use of the placebo insoles was not significant: −0.31 (p=0.1189). A level 5 pain and above was reported by 77% of the subjects at the start of the study. After the use of the real insoles 37.9% of the subjects reported a similar degree of pain severity, and 50% of the subjects did so after the use of the placebo (p< 0.05).

Conclusions: LBP decreased significantly after the use of real insoles compared to placebo ones.

The neurogenic clubfoot is composed of several deformities – such as cavus and equinus, hind foot varus, supination and adduction of the forefoot – which develop due to the neurological disease leading to muscle imbalance. Whereas over-activity and spasticity occur after damage of the central nervous system, flaccid paralysis is the result of damage of the spinal motor neuron or the nerve itself. Local overload at the lateral border of the foot, poor stability and small supporting area may interfere with function and hence require treatment of the deformity. The primary aim is a functioning foot. Treatment options are conservative means or surgical procedures. Insoles are applied to correct the foot position: a lateral support forces the foot into valgus and pronation being effective only when loaded and worn in reinforced shoes. They can also be used to distribute pressure in case of local overload and sores. An individually manufactured foot orthosis provides more stability. If the forces are still overly big, the lever arm of an ankle foot orthosis is required. Surgical procedures may be carried out in addition to or instead of conservative means. Skeletal surgery should not be performed early because the neurological disease persists despite the local correction and increases the risk for recurrences. Stiffening of the foot needs to be avoided in order to preserve function. Stiffness due to cavus is reduced by a Steindler release of the plantar fascia. Equinus should not be overstressed. If necessary, it is corrected by heel cord lengthening resulting in a persistent loss of force, or by aponeurotomy maintaining force but being less efficient to gain length. To balance supination, split or complete transfer corrects the pull of hyperactive anterior or posterior tibial muscles. Lacking skeletal deformation is a prerequisite for these soft tissue procedures. Thus their presence requires bony correction alone or in addition to soft tissue surgery. The varus of the os calcis is best corrected by an original or modified Dwyer valgus osteotomy. Cavus, supination and adduction deformity can all be corrected at the midfoot. These procedures preserve mobility and hence function of the foot. Severely contracted feet, however, may need corrective fusions. Nevertheless, stiffness is badly tolerated. An alternative is application of an external fixater of the Ilizarov type to correct the skeletal deformity and followed by an additional corrective osteotomy. Botulinum toxin A paralysing a muscle for three months can be used to switch off overactive anterior or posterior tibial muscles in order to delay surgery or to prevent pull out after transfer. Application of casts to stretch overly short muscles can help to keep the deformity under control, but they need to be followed by splints in order to avoid early recurrence