Thesis (M.Sc.(Sports Medicine))--University of the Witwatersrand, Faculty of Health Sciences, 2014. / Within the context of sports medicine, biomechanical corrective custom foot orthoses are utilised as a treatment intervention to correct pathological gait disorders. In order to manufacture such corrective devices a replicate model of the patients’ foot needs to be obtained. This study aimed to assess both the inter-rater reliability and the intra-rater repeatability of a semi weight bearing foot modelling technique employing a three dimensional white light surface foot scanner. The sample cohort included twenty healthy male and female subjects with ages ranging from 18-70 years. Six qualified Podiatrists were utilised as raters to perform the foot placements on the white light scanner. All raters and participants were given a ten minute training session to familiarise them with the equipment and scanning procedure. The subjects’ left foot was marked and raters positioned and scanned the left foot three times. Digital foot parameter measurements of medial arch height, forefoot width, foot length and rearfoot width were recorded and analysed. The results from this study showed high inter-rater reliability with intraclass correlation coefficients ranging from 0.997 to 1.00 with the specified foot parameter measurements. Intra-rater repeatability of the same specified foot parameter measurements demonstrated good repeatability with Pearson coefficients of correlation values ranging from 0.973 to 0.997. The assessment of the reliability of computerised digital white light scanning as an integral first step in the manufacture of custom foot orthoses has a direct effect on Podiatric practice and the outcomes of patient treatments with this therapeutic modality.

The development of prescription methods and evaluation of biomechanical performance of bespoke orthoses has been a source of research for the last 40 years. What started as anecdotal and experience–led knowledge has evolved into a more quantifiable paradigm utilising state of the art technologies commonly found in other high-precision industries. The manufacturing challenges associated with such customised products have been driven by the requirement to produce small (often one-off) batches, bespoke for the end user. The introduction of precise scanning equipment and CAD/CAM systems to the podiatry community is enabling the accurate and repeatable manufacture of orthoses that were previously predominantly hand crafted and shaped. Although these traditional production methods are still in use today, the advantages that scanning and CAD/CAM provide mean they are rapidly being adopted. Today, CNC machining and additive manufacture provide state of the art manufacturing methods for bespoke insoles prescribed and modelled in a CAD environment. However, the limitations of both these manufacturing methods relate to the materials that can be processed, which becomes problematic when manufacturing soft or semi-rigid orthoses. Hence an opportunity exists to develop a new and innovative method for processing foamed polymer materials that are typically vacuum formed today. This research explores the prescription and analysis methods attributed to insole design for sporting applications using specific sports shoes. The insole designs encompass material selection to deliver a product that provides control and function whilst also providing a degree of impact attenuation, recognising the dynamic and high-impact nature of the sportsspecific movements. Consideration is also given to the types of activities that function with the device. This research analyses characteristic plantar pressures experienced whilst undertaking sports-specific movements to aid in the prescription of bespoke insoles for the chosen sport. A design methodology encompassing state of the art scanning technologies and anthropometric measurements provides a repeatable and accurate means to produce the required geometry for a bespoke sport and symptom-specific insole. The research also presents the concept of cryogenic machining, a novel manufacturing method for the CNC machining of foamed polymers. The materials are cooled with the use of a liquid cryogen to below their glass transition temperature at which point relative motion at a molecular level is significantly reduced, providing a rigid and machineable form. This, along with a bespoke cryogenic facility encompassing a vertical 3 axis CNC machining centre, a pressurised liquid nitrogen dewar connected to a bespoke-designed fixture by a vacuum jacketed pipe, enables the dual-sided machining of an amorphous material, something which is not possible with conventional processes. The major contributions of this work are the design methodology to prescribe a sport and symptom-specific insole using state of the art scanning and CAM methods, the design and manufacture of a fixture to facilitate the dual-sided machining of a customised insole and the subsequent testing of the designs in a laboratory environment. In addition the research utilises motion analysis, force plate data and pressure measurement to explore the effects of the insoles on the kinetics, kinematics and peak plantar pressures at discrete anatomical regions during sport-specific manoeuvres.

Background: Diabetic peripheral neuropathy (DPN) is diagnosed clinically as a loss of sensation in the feet and affects over 2 million people in the UK. One of the functional effects of DPN is a decrease in standing stability giving rise to a risk of falls. In an attempt to stabilise in the mediolateral direction, people with DPN frequently walk with a wider base of support and stand with a larger stance width. This is often seen in the elderly and is not always beneficial for stability contributing to falls risk. Standing balance requires the integration of sensory information from somatosensory, vestibular and visual systems. Alterations in distal sensory input may result in a re-weighting of the effectiveness of remaining sensations in mediating a stabilising postural response; termed sensory re-weighting. Alterations in posture such as adopting a wider stance width and wearing Ankle Foot Orthoses (AFOs) may also affect sensory input as well as altering the mechanics of the ankle and hip joints. The impact of distal sensory loss on the sensory control of balance in people with DPN compared to the healthy population is unknown. Moreover, it is not known whether standing balance or the sensory control of balance is affected by the adoption of an increased stance width and wearing (AFOs) that restrict mediolateral ankle motion. A better understanding of the mechanisms underlying balance dysfunction in diabetic peripheral neuropathy and how it might be manipulated could inform the development of future interventions to improve balance. Aim: To explore the effects of ankle foot orthoses and stance width on standing balance and the sensory control of mediolateral balance in people with DPN and healthy controls. Objectives: To assess how mediolateral postural stability and the sensory control of balance is affected by (a) AFO use and alterations in stance width in healthy participants (study 1) (b) acute distal sensory loss in healthy participants (study 2) (c) chronic sensory loss in people with DPN and how this in turn is modulated by AFO use and alterations in stance width (study 3). Methods: Postural stability and the response to selective muscle vibration that stimulates muscle spindle afferents was measured by 3D motion analysis. Study 1 investigated the effects of stance width and AFOs on postural sway and the response to selective hip proprioception stimulation induced by vibration of the hip abductors in healthy participants. Study 2 investigated the effect of an acute reduction of somatosensory information induced by cooling in healthy participants on the response to ankle evertor and hip abductor vibration. This provided a model of the acute effects of sensory loss. Study 3 compared healthy people with people with chronic DPN. It investigated the impact on stance stability and whether there was a change in the postural response (gain) to ankle evertor and hip abductor vibration. It further explored the effect of altering the stance width and wearing an AFO on stability and the postural response to hip abductor vibration. Results: Study 1: In healthy controls postural sway was significantly reduced when wearing an ankle foot orthoses and when standing at wider stance widths. Whilst this was also seen during balance perturbation, trunk motion increased at larger stance widths. This could be the result of the AFO restricting ankle motion and affecting the interpretation of the hip vibratory input by the postural control system. Study 2: Experimental reduction in distal sensation by cooling resulted in a reduction in postural responses to ankle evertor muscle vibration. Conversely postural responses at the level of the hip, to proximal (hip) muscle vibration, significantly increased. Study 3: Baseline sway velocity was higher in people with DPN compared to healthy controls. Postural strategies were modified in the DPN group, with increased motion at more proximal segments of the shoulder and head. In both groups, AFO and stance width significantly reduced baseline sway velocity, and the size of postural responses (translations) to hip abductor muscle vibration. Conclusion: Alterations in stance width and the use of AFOs can affect postural sway and the response to selective proprioceptive stimulation. Whilst acute reductions in distal sensory loss are associated with sensory re-weighting of distal and proximal proprioceptive information this is not seen in people with chronic DPN, possibly resulting from long term adaptive changes in the multi-sensory control of balance. Novel differences were found in postural strategies between healthy and DPN groups. The increase in head and trunk motion in people with DPN may have a negative impact on visual acuity and therefore a risk factor for falls. In people with diabetic peripheral neuropathy AFOs and increased stance width led to a reduction in postural response size and postural sway. The effect of AFO on sway velocity was more pronounced in those with DPN at smaller stance widths. Clinically this suggests that an AFO could be used in those with diabetic peripheral neuropathy to slow down the velocity of sway and increase stability.

Ankle foot orthoses (AFOs) are used to improve walking in some lower extremity conditions but AFOs restrict ankle motion resulting in a trade-off in ankle and hip mechanics. While the use of AFOs have been well documented, there still remain gaps in the literature. The first study compared the differences in sagittal plane ankle and hip kinematics and kinetics across three conditions at two speeds in healthy individuals while the second study compared frontal plane kinetics at the hip and knee and vertical ground reaction forces between two conditions at two speeds in healthy individuals. This was studied by collecting and analyzing three-dimensional joint kinematics and ground reaction forces from twelve healthy adults. Participants walked in three conditions (shod; i.e. athletic shoes only and two reduced push-off conditions using solid ankle foot orthoses (SAFOs); i.e. unilateral brace and bilateral brace conditions) and at two speeds (1.25m/s and 1.5m/s). In the first study, generalized linear models with general estimating equations were used to compare ankle and hip angles, moments and power for the braced and unbraced sides separately in all three conditions. In the second study, frontal plane kinetics and vertical ground reaction forces in the unbraced limb in the unilateral brace condition were compared to the same side during shod walking using paired sample t-tests. From our first study we found that the reduced push-off from the use of SAFOs results in decreased peak plantarflexion angles and power generation at the ankle and increased peak flexion angles, and first and second peak power generation at the hip in the braced limbs in both unilateral (p≤0.05) and bilateral (p≤0.05) brace conditions at both speeds. On the unbraced side in the unilateral brace condition, there were decreased peak power generation at the ankle at 1.25m/s and increased peak extension moments, first and second peak power generation at the hip compared to the shod condition (p<0.05) at both speeds. In the comparison between the unilateral and bilateral brace conditions, the changes in ankle and hip mechanics were similar to the changes between the shod condition and the bilateral brace condition on the unbraced side; in addition, participants also had higher peak extension moments in the unilateral brace condition compared to the bilateral brace condition (p<0.05). On the braced side, participants had lower peak plantarflexion moments at the ankle and lower peak flexion angles at the hip when walking with bilateral SAFOs, compared to walking with unilateral SAFOs (p<0.05). In the second study, we found that peak internal knee and hip abduction moments were 3% and 4% higher, respectively, in the unbraced limb in the unilateral brace condition at 1.25m/s (p≤0.041) compared to the same side in the shod condition. Peak vertical ground reaction force was 3% higher in the unbraced limb in the unilateral brace condition at both speeds (p=0.002). Findings indicate that walking with unilateral ankle foot orthoses presents an increased risk of developing secondary conditions.

Children with cerebral palsy (CP) have a higher than normal O2 uptake (VO2) during walking. While various interventions are used to improve locomotion, little is known about their effect on the metabolic and cardiopulmonary cost of walking. We therefore assessed the effects of one popular intervention, hinged ankle foot orthoses (AFO), on cardiopulmonary and metabolic variables during 2 min of steady state treadmill walking at three speeds: 3 kph, comfortable walking speed (CWS) and fast walking speed (FWS). We also assessed the effect of these braces on comfortable and maximum ground walking speed and on gross motor abilities using the Gross Motor Function Measure. Ten children with spastic diplegic CP (9.01 years ± 2.10) who habitually used hinged AFO participated. Not all children could walk at all speeds on the treadmill however, and some cardiopulmonary and metabolic data on three children were missing due to equipment failure. We performed an ANOVA on data for children who walked at 3 kph and CWS (n=8 for heart rate (HR); n=9 for pulmonary ventilation and metabolic variables) and a t-test on data at FWS (n=9 for HR, n=8 for pulmonary ventilation and metabolic variables). When children wore AFO, absolute VO2 was reduced by 4.6% at 3 kph and by 4.1% at FWS, and absolute VO2 per metre walked by 4.6% and 4.4% at the same speeds, respectively. Adjusting VO2 for body mass, or for resting VO2 or calculating energy expenditure in kJ, revealed the same pattern. Pulmonary ventilation was lower with AFO on by 7.17%, but only at 3 kph. AFO did not affect gross motor abilities. Nor did it affect HR, or the respiratory exchange ratio at any speed, nor any physiologic variable at CWS. We suggest the lower O2 cost may reflect an increase in stability and a corresponding decrease in coactivation of lower limb antagonistic muscles. / Thesis / Master of Science (MSc)

Individuals with various lower-limb neuromuscular and musculoskeletal impairments are often prescribed passive-dynamic ankle-foot orthoses (PD-AFOs) to compensate for impaired ankle muscle weakness. Several studies have demonstrated the beneficial effects of PD-AFOs on pathological gait, but few studies have examined the influence of the AFO stiffness characteristics on gait performance. One challenge to performing such studies is the difficulty of manufacturing custom AFOs with a wide range of controlled stiffness levels. However, selective laser sintering (SLS) is a well-suited additive manufacturing technique for generating subject-specific PD-AFOs of varied stiffness. Therefore, the overall goal of this study was to use SLS manufactured PD-AFOs to identify the relationships between AFO stiffness and gait performance in patients with various lower-limb neuromuscular and musculoskeletal impairments. Six subjects with unilateral impairments were enrolled in this study. For each subject, one subject-specific PD-AFO equivalent to the subject’s clinically prescribed carbon fiber PD-AFO (nominal), one 20% more compliant and one 20% more stiff were manufactured using SLS. Three-dimensional kinematic and kinetic data were collected from each subject while ambulating with each PD-AFO at two different speeds to allow a comprehensive biomechanical analysis to assess the influence of PD-AFO stiffness on gait performance. The results showed that in the compliant AFO condition, the AFO limb vertical ground reaction force (GRF) impulse during loading and the non-AFO limb medial GRF impulse during push-off decreased. In addition, the AFO limb braking GRF impulse during loading and the non-AFO limb braking GRF impulse in early single-limb stance decreased. Furthermore, in the compliant AFO condition, negative knee work during early single-limb stance increased while positive hip work in early swing decreased in the AFO limb. Overall, as AFO stiffness decreased, the AFO limb contributed less to body support and braking. In addition, a decreased medial GRF impulse coupled with an increased vertical GRF impulse during non-AFO single-limb stance suggests that walking stability may be compromised as AFO stiffness decreases. Thus, a tradeoff may exist between preserving stability and increasing net propulsion, which should be considered when assessing the mobility needs of individuals prescribed PD-AFOs as a result of various neuromuscular and musculoskeletal impairments. / text

Orientador: Manoel Barros Bertolo / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-24T00:50:53Z (GMT). No. of bitstreams: 1 Bernardes_CynaraFerreira_M.pdf: 2007451 bytes, checksum: e391b0c846a262e5780f400dd970089f (MD5) Previous issue date: 2013 / Resumo: Objetivos: Avaliar a eficácia do uso das palmilhas em pacientes com Artrite Reumatóide (AR) na redução da dor, melhora da função e redução da média dos picos de pressão plantar. Material e Métodos: Vinte e sete pacientes com AR e dor nos pés foram avaliados em relação à dor, presença de deformidade e calosidades, incapacidade (Heath Assessment Questionnaire - HAQ-DI) e atividade de doença (Clinical Disease Activity Index - CDAI). Palmilhas foram prescritas de acordo com a necessidade de cada sujeito com objetivo de suporte articular e redução de dor. Os pacientes foram submetidos à avaliação pelo Foot Function Index (FFI) e podobarometria (Sistema F-SCAN) com a avaliação da média dos picos de pressão plantar em consulta inicial e após duas semanas de intervenção. Resultados: Houve redução do FFI após a intervenção em todas sub escalas. Os escores iniciais mais elevados do FFI total e suas subescalas de incapacidade (FFI-inc) e limitação da atividade (FFI-la) foram significativamente relacionados aos maiores escores do CDAI e HAQ-DI (p < 0.05). A melhora do FFI foi independente da idade dos sujeitos, tempo de doença, CDAI e HAQ-DI. Não houve redução significativa na média dos picos de pressão plantar após a intervenção, mesmo quando foram avaliados separadamente os pacientes com dor predominante em ante pé e retro pé. As palmilhas foram usadas em média 7,08 horas por dia. Efeitos adversos menores foram observados em sete pacientes, nenhum resultando em interrupção do tratamento. Conclusão: Foi observado redução de dor e incapacidade em indivíduos com AR após o uso de palmilhas, sem redução significativa das médias dos picos de pressão plantar. Os benefícios do uso das órteses em pés reumatóides podem ser multifatoriais, não somente relacionado à melhor distribuição da pressão plantar, mas à melhor acomodação do pé e aumento do estímulo proprioceptivo / Abstract: Objective: To evaluate the efficacy of insoles in Rheumatoid Arthritis (AR) patients reducing pain, improving function and reducing the mean peak plantar pressure. Methods: Twenty-seven rheumatoid patients with foot pain were evaluated regarding foot deformity, disability (Health Assessment Questionnaire - HAQ-DI) and disease activity (Clinical Disease Activity Index - CDAI). Foot orthosis were prescribed according to each patient's needs aiming to provide a better joint support and to reduce pain. The Foot Function Index (FFI) and the mean peak plantar pressure (FSCAN system) were evaluated at baseline and after two weeks of intervention. Results: FFI values decreased in all subscales after intervention. Higher initial disability and activity limitation FFI subscales and FFI total scores were significantly related to higher CDAI and to higher HAQ-DI scores (p < 0.05). FFI improvement was independent from age, disease duration, CDAI and HAQ-DI. No significant reduction in the mean peak plantar pressure was noted, even if evaluating separately the patients with pain mainly on the forefoot or on the hindfoot. Orthosis were worn 7.08 hours-day on average. Minor adverse effects were noted in seven patients, none of them resulting in treatment interruption. Conclusion: Foot orthosis reduces patient's referred foot pain and foot disability with no significant reduction in the mean peak plantar pressure. The benefits of foot orthosis in RA may be multifactorial, not only related to plantar pressure distribution, but also to a better foot accommodation and increased proprioceptive stimulus / Mestrado / Clinica Medica / Mestra em Clínica Médica

Thesis (MScPhysio)--Stellenbosch University, 2012 / ENGLISH ABSTRACT: SYSTEMATIC REVIEW ABSTRACT - BACKGROUND: Ankle Foot Orthoses (AFOs) are considered as the most suitable lower limb orthosis to correct gait deficits related to ankle instability. AFOs are recommended to minimize gait deviations and to correct drop foot or equinus foot in hemiplegic patients. OBJECTIVES - To identify the effectiveness of different ankle orthoses and/or supports on the temporal, spatial, kinetic and kinematic gait parameters. To critically appraise the methodological quality of the included studies and to provide a description of the studies with a view to identify opportunities to improve future research quality. METHODS - Search strategy A comprehensive search was conducted between March and October 2010, and updated in August 2011. Thirteen computerized bibliographic databases were individually searched, namely PubMed Central, Cohrane Library, CINAHL, OT Seeker, SPORTDiscus, PsyARTICLE, PEDro, Proquest, Biomed Central, Science Direct, Clinicaltrials.gov, Web of Science, and Ingenta Connect. All databases were searched since their inception. The following key terms were used: stroke, hemipleg*, assistive device*, ankle foot orthos*, AFO, (splint*), taping, and strapping. A secondary search (pearling) was conducted by screening the reference lists of all eligible full text studies. The authors of the unpublished studies were conducted to minimize publication bias. Selection criteria The following selection criteria applied: all relevant randomized and non-randomized controlled trails published in English; participants were post-stroke patients older than eighteen years; interventions included any type of ankle foot orthosis (AFO), ankle taping or strapping and ankle foot splint without any additional intervention and the comparison/control groups were limited to walking without support, either barefoot or walking with shoes only. Studies were excluded when the outcome measures did not focus on at least one of the following: temporal spatial gait parameters, kinetic gait parameters or kinematic gait parameters. Data collection and analysis Two reviewers independently selected trials for inclusion and assessed methodological quality. The data was extracted by the primary reviewer and validated by a second reviewer. In event of disagreement, a third reviewer was asked to re-evaluate until consensus could be reached. Homogenous data were statistically summarized in sub-group meta-analysis using Revman© Review Manager Software. The results of heterogeneous data were summarized in a narrative form. MAIN RESULTS - The search yielded 11134 initial hits. Sixteen studies met the inclusion/exclusion criteria. The studies investigated the immediate effect of various types of AFOs on a broad range of temporal spatial gait parameters mainly gait speed, cadence, stride and step length. Only two studies reported on the kinetic and six on various kinematic gait parameters. The meta-analysis yielded significant improvement in gait speed (0.06 m/s; 95% CI 0.04, 0.08. p < 00001), walking cadence (5.41; 95% CI 3.79, 7.03. p < 00001), stride length (6.67; 95% CI 3.29, 10.06. p < 00001) and step length (2.66; 95% CI 1.59, 3.72. p < 0.00001). CONCLUSION - AFOs are effective to improve mobility, gait speed, cadence, stride and step length for post-stroke patients and may have a positive impact on the daily function of post-stroke patients. . The long term benefit or adverse effects of AFOs are still inconclusive. The effectiveness of AFOs on the kinetic and the frontal- or transverse- plane joint kinematics is largely unresolved. There is insufficient evidence to either support or refute the effectiveness of taping/strapping and splinting of the ankle on hemiplegic gait. EXPERIMENTAL STUDY ABSTRACT - BACKGROUND: Temporal, spatial and affected ankle kinematic gait parameters of adults with hemiplegia are significantly different from the normal able-bodied population. Enabling hemiplegic patients to walk is a major goal of rehabilitation programs. Taping of the plegic ankle could be utilized by therapists as external support of the ankle to improve foot position and placement during gait rehabilitation. OBJECTIVE - The purpose of the study was to describe the immediate effect of neutral ankle taping on temporal spatial gait parameters and ankle joint kinematics of the affected ankle in ambulant adult hemiplegic patients. METHODS - A clinical trial using a crossover randomized testing order was conducted on a convenient sample of ten ambulant hemiplegic patients at the Physiotherapy and Motion Analysis Clinic, Faculty of Health Sciences, Stellenbosch University, Tygerberg, Cape Town, South Africa. The affected ankle joint was taped in a neutral talocrural dorsiflexion/ plantarflexion and neutral hindfoot inversion/ eversion position using rigid adhesive tape (5 cm). The gait parameters were analysed according to the Plug-In Gait Model using a motion analysis system (Vicon Nexus 1.1.7; Vicon Motion System Limited, Oxford, UK). The analyses were repeated six times for each testing condition and the average values were used for further analysis. The data were analyzed using Least Square Means tests and post hoc Fisher (Least Significant Difference) LSD multiple comparison tests to determine the significant differences at 95% confidence level. RESULTS - The main results of the study indicate that taping of the affected ankle joint in a neutral position does not significantly improve (p>0.5) temporal spatial gait parameters and ankle joint kinematics in ambulant adult hemiplegic patients. The following positive trends were however found and need to be further explored in larger homogeneous study samples: ankle taping of ambulant adult hemiplegic patients has limited benefits on selected temporal parameters as ankle taping could potentially improve cadence. Ankle taping could decrease plantarflexion of the plegic leg at initial contact. CONCLUSIONS - A systematic review revealed no conclusive evidence either to support or refute the beneficial effects of ankle taping on gait parameters of ambulant adult hemiplegic patients. Ankle taping of ambulant adult hemiplegic patients has potential clinical benefits on temporal, spatial and affected ankle kinematics, gait cadence and affected leg swing and stance duration.

Anterior knee pain (AKP) is a common, chronic lower limb musculoskeletal overuse condition that represents substantial morbidity to those affected, and has a significant impact on the health care industry. Health practitioners frequently prescribe foot orthoses in the management of AKP as an alternative or adjunct to multimodal physiotherapy. The primary aim of this thesis was to investigate the clinical efficacy of foot orthoses in AKP, utilising high-quality research methodologies. The two systematic reviews conducted have identified a significant gap in the literature regarding evidence from randomised clinical trials (RCTs) for foot orthoses in AKP and other lower limb overuse conditions. While the best evidence for AKP management was for multimodal physiotherapy, there was insufficient evidence to support or refute the use of foot orthoses in the treatment of lower limb overuse conditions, including AKP. Meta-analysis provided evidence to support the use of foot orthoses in the prevention of the first incidence of lower limb overuse conditions. An interesting finding was evidence from pooled and individual study data of no difference between custom and prefabricated foot orthoses in both treatment and prevention of lower limb overuse conditions, inferring that either type of orthosis may be utilised. Both systematic reviews highlighted substantial methodological flaws of the included studies, and recommended that future studies include larger participant numbers, longer participant follow-up, more consistent use of reliable and valid outcome measures and reporting of outcome data, and utilisation of the CONSORT guidelines in the design and reporting of RCTs. A 12-month prospective RCT investigated the short- and long-term clinical efficacy of prefabricated foot orthoses in the treatment of 179 participants with AKP. Foot orthoses were more effective than flat shoe inserts in the short term, implying that their contoured form has some therapeutic effect. Foot orthoses were not significantly different to multimodal physiotherapy over 12 months, nor was there any benefit in adding foot orthoses to physiotherapy. Considering that all groups experienced clinically meaningful long-term improvements in pain and function, clinicians may prescribe foot orthoses for AKP to hasten recovery. Findings of post-hoc analyses to develop a clinical prediction rule indicate that those of older age and shorter height, who have a lower severity of AKP and a more mobile midfoot, are more than twice as likely to experience a successful outcome with foot orthoses. As a secondary aim, this thesis has provided a more comprehensive profile of AKP as a condition. Baseline data from the RCT participants confirms previous reports of higher rates of AKP in females, and a tendency towards bilaterality and chronicity. This AKP sample did not differ from asymptomatic individuals in terms of body mass index, physical activity level, general and mental health, and foot posture, although they tended to have a more mobile foot under load. These characteristics tend to be homogenous across a number of published RCTs, indicating that the findings of the RCT described above are likely to be generalisable to the broader population with AKP. An additional finding in this group was that those with AKP of long duration, higher pain levels, lower functional levels, and an overall lower score on a specific measure of AKP have a poorer prognosis over 12 months, irrespective of their age, gender or morphometry. These findings suggest that, in order to improve prognosis and the chance of a successful outcome, the primary goals of intervention should be to reduce the severity and duration of AKP, through the use of early intervention with foot orthoses, multimodal physiotherapy, or a combination of the two.

Les gonalgies et les aponévrosites plantaires représentent la majorité des motifs de consultations d’un cabinet de podologie. Les patients souffrant de ces pathologies ressentent des douleurs au niveau du genou ou du pied qui peuvent être invalidantes. Bien que le port d’orthèses plantaires représente un traitement conservateur efficace, la prescription de ce traitement repose sur une connaissance empirique des effets de ce dernier. Le but de ce travail était donc d’étudier les effets des semelles orthopédiques à dominante biomécanique (modifiant la posture) ou proprioceptive (stimulant les capteurs de la sole plantaire) sur les modifications de la stratégie neurale chez les patients souffrant de ces pathologies et de déterminer quels pouvaient être les liens avec la diminution de la douleur ressentie. Pour cela, nous avons procédé à une évaluation de la douleur, un examen de la marche, un examen stabilométrique et des enregistrements électrophysiologiques (réflexes mesurés au repos et lors d’une contraction musculaire volontaire). L’évolution de ces différents paramètres a été mesurée après trois, six et neuf semaines de port d'orthèses plantaires. Les résultats obtenus ont été comparés à ceux recueillis chez des patients témoins indemnes de toute pathologie.Même si les résultats obtenus lors de ces études ne sont pas aussi concluants que nous l’aurions souhaité et que de nombreuses questions restent encore en suspend, ce travail a permis toutefois d’ouvrir au domaine de la podologie un champ de recherche jusque-là peu ou pas exploré. / Knee pain and plantar fasciitis represent most of the reasons for consultation of a podiatrist. Patients with these pathologies experience knee or foot pain that can be disabling. Although the use of foot orthoses is an effective conservative treatment, its prescription is based on an empirical knowledge of its effects. The aim of this study was to investigate the effects of foot orthoses based on biomechanical (modifying the posture) or proprioceptive (stimulating sensors of the plantar sole) principles on neural strategy changes in suffering patients and to determine the links with the decrease in perceived pain. For this, we performed a pain assessment, walking and stabilometric examination and electrophysiological recordings (reflexes measured at rest and during voluntary muscle contraction). The evolution of these different parameters was measured after three, six and nine weeks of wearing foot orthoses. The results obtained were compared with those obtained in control patients free from any pathology.Although the results of these studies are not as conclusive as we would have liked and many questions remain unresolved, this work has opened up to the podiatry a field of research until then little or not explored.