Foot pressure pattern, hindfoot deformities, and their associations with foot pain in individuals with advanced medial knee osteoarthritis

doi:10.1016/j.gaitpost.2017.09.041

Gait & Posture

Volume 59, January 2018, Pages 83-88

https://doi.org/10.1016/j.gaitpost.2017.09.041 Get rights and content

Highlights

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Knee osteoarthritis (OA) is a common joint disease in elderly persons.
•
Total knee arthroplasty (TKA) significantly improves knee symptoms.
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Over half of the patients with advanced knee OA had foot pain.
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Foot pain improved in one-third of them 1 year after TKA.
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Foot pain may be a compensatory method to lessen the load of OA-affected knees.

Abstract

This survey clarified foot pressure patterns and hindfoot deformities in individuals with advanced knee osteoarthritis (OA) and analyzed their associations with foot pain. Sixty-four individuals with unilateral knee OA who underwent total knee arthroplasty (TKA) were divided into the following groups: no foot pain (n = 26; men:women, 4:22; mean age, 73.7 years), foot pain resolved after TKA (12; 2:10; 75.8), and foot pain remaining after TKA (26; 4:22; 74.7). Elderly individuals without pain or deformity in either knee (54; 10:44; 74.3) were controls. Navicular height ratio of the medial longitudinal arch, leg–heel angle, and partial foot pressure as the percentage of body weight (%PFP) were calculated.%PFPs of the medial and lateral heel regions before TKA were significantly lower for the no foot pain group than for controls. One year after TKA, %PFP improved significantly. In the foot pain resolved group, before TKA, the leg–heel angle was significantly higher, and%PFPs of the medial and lateral heel regions and navicular height ratio before TKA were significantly lower than those of controls. One year after TKA, all parameters improved significantly. In the foot pain remaining group, similar abnormalities were observed before TKA; however, significant improvement was only observed for%PFP of the medial heel region 1 year after TKA. More than half of the patients with advanced knee OA had foot pain. This improved in approximately one-third, 1 year after TKA. Hindfoot deformities are probably associated with foot pain in individuals with advanced knee OA.

Introduction

Knee osteoarthritis (OA) is a common joint disease in the elderly. Individuals with advanced knee OA usually have knee pain, limited range of motion (ROM), and functional limitations [1], [2]. Total knee arthroplasty (TKA) significantly improves knee symptoms and is widely used to treat such cases. However, in clinical practice, many individuals have foot pain (FP) before TKA, and some still report FP after TKA despite knee pain improvement. FP may be a secondary or compensatory phenomenon adopted by individuals to lessen the load of the OA-affected knee [3]. Several foot deformities or disorders associated with knee OA have been reported, with flatfoot being the most common [4], [5], [6]. Arthritis of the ankle joint is another cause of knee OA-associated FP, and several individuals exhibited newly developed or progressive ankle arthritis after TKA [7]. Zhou et al. [8] recently suggested that insufficiency of the posterior tibial muscle is associated with FP in individuals with flatfoot and subtalar joint OA. However, the clinical course and frequency of FP associated with advanced knee OA remain unclear. This study investigated midfoot and hindfoot deformities in individuals with advanced knee OA and analyzed their relationships with FP.

Section snippets

Participants

Sixty-four individuals with unilateral knee OA treated at Ugo Municipal Hospital in Japan (10 men, 54 women; mean age, 74 years; range, 63–86 years) were enrolled. All individuals reported knee pain during gait and were admitted to the hospital for TKA. All examinations were performed on the day before and 1 year after TKA diagnosis. An experienced orthopedic surgeon blinded to the clinical data graded OA according to radiographs [9] using the Kellgren and Lawrence [10] scale. Individuals with

Patients

Of the 64 individuals with knee OA, 26 (40.6%) had no FP before TKA (VAS, 0) and comprised the no FP group (4 men, 22 women; mean age, 74 years; range, 63–86 years; knee extension, −4.0 ± −5.1°, knee flexion, 134.2 ± 5.0°, femorotibial angle, 181.5 ± 2.4°). Among the 38 individuals who had FP before TKA, 12 (18.2%) did not report any FP 1 year after TKA and comprised the FP resolved group (2 men, 10 women; mean age, 75.8 years; knee extension, −4.6 ± −2.6°, knee flexion, 133.8 ± 3.1°; femorotibial angle,

Discussion

Pain, problems, and deformities of the foot are not uncommon in elderly adults [18], [19], [20], [21], [22]. Despite the major focus on the structure and alignment in arthritis affecting large joints, remarkably little work has focused on the foot. Although FP associated with advanced knee OA is described in some studies [4], [23], [24], [25], its frequency was only reported by Lee and Jeong [7], who reported that 50 (35.2%) of 142 individuals had OA in the ankle before TKA. In this study, 38

Conclusions

More than half of the individuals with advanced knee OA had foot pain; however, the pain improved 1 year after TKA in approximately one-third of them. The results suggested that reversible or irreversible hindfoot deformities and low pressure of the lateral heel region are probably associated with foot pain. Therefore, careful attention should be focused on foot pain and hindfoot deformities in individuals with advanced knee OA.

Acknowledgments

None.

We certify that no party having a direct interest in the results of the research supporting this article has or will confer a benefit on us or on any organization with which we are associated.

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Partial foot pressures in these areas were expressed as the percentage of body weight (%PFP) [21]. The anteroposterior length of the COP path was measured and expressed as the percentage of the foot length (%Long; Fig. 2, A) [21]. The length of the COP path moving backward was measured and expressed as a percentage of the foot length (%Backward; Fig. 2, B).
Abnormal foot contact patterns following stroke affect functional gait; however, objective analysis targeting independent walking is lacking.
How do walking abilities and foot pressure patterns differ between post-stroke individuals who achieved independent walking and healthy controls? Secondarily, how do the abilities and patterns in post-stroke individuals change before and after achieving independent walking? Can these changes become criteria for permitting independent walking?
Twenty-eight individuals with hemiplegia and 32 controls were enrolled. Motor dysfunction score (MDScore), walking speed (WSpeed), and foot pressure patterns were measured when they were first able to walk without orthosis or physical assistance (1st assessment) and when they achieved independent walking around discharge (2nd assessment). Foot pressure patterns were measured using insole-type foot pressure-measuring system. Ratios of partial foot pressure to body weight (%PFP), ratios of anteroposterior length of center of pressure (COP; %Long), and backward moving distance of COP to the foot length (%Backward) were calculated. Parameters during the 2nd assessment were compared with those of controls and those during the 1st assessment. During the 2nd assessment, relationships among the parameters, MDScore, and WSpeed were analyzed.
During the 2nd assessment, no difference was observed in both %Long and %Backward between the non-paretic limbs and the controls. While the %Backward was higher, the %PFP of toes and %Long were lower in the paretic limb than in the controls. Although the %Backward was lower, both %PFP of toes and %Long of the paretic limb were higher in the 2nd assessment than in the 1st assessment. During the 2nd assessment, both %Long and % Backward values of the paretic limb moderately correlated with MDScore and WSpeed.
After improvement of foot pressure in toes, both an increase in anteroposterior length and a decrease in backward moving of COP path were objective signs permitting independent walking.
Calcaneal insufficiency fractures following ipsilateral total knee arthroplasty
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We speculated that when varus osteoarthritis gradually progresses, a shift in loading on the lateral side of the calcaneus and reduced load on the calcaneus due to knee pain for a long period may lead to fragility of the medial side of the calcaneus. The sudden change in varus alignment of the hind foot induced by neutral knee alignment following TKA [30,31], and increased loading on the heel due to reduced knee pain following TKA [26], subsequently results in a calcaneal IF. In our case series, a range of varus deformities on the knee alignment were observed (from 6.4° to 22.5°).
Only a few reports have described calcaneal insufficiency fractures (IFs) following total knee arthroplasty (TKA). Herein, we describe nine cases of calcaneal IFs following ipsilateral TKA. The purpose of this study was to investigate the incidence of calcaneal fractures following TKA and determine the characteristics of patients with IFs.
We retrospectively investigated cases of calcaneal IF that occurred following TKA. We collected and analyzed radiographic and magnetic resonance imaging (MRI) findings as well as patient demographic data. We compared the demographic data, bone mineral density (BMD), and preoperative hip-knee-ankle angle (HKA) between cases with a calcaneal fracture following TKA and 100 cases without a fracture following TKA.
We performed a total of 1548 knee arthroplasties at our clinic from 2011 to 2020. Nine calcaneal IFs in eight patients were diagnosed following ipsilateral TKA. All patients were women with varus knee osteoarthritis (mean age, 71.8 years). The average change in the alignment angle was 14.7° ± 5.4°. In eight cases, dysfunction was observed in the opposite lower limb. The postoperative onset of hindfoot pain started at an average of 5.6 months. In seven patients, calcaneal fractures occurred idiopathically, but in one patient, two fractures occurred after long-distance walking. No abnormal findings on a calcaneus radiograph were seen for six fractures. MRI demonstrated a definite fracture line and bone marrow edema in all patients. All patients, except one with type 2 diabetes mellitus (T2DM), had osteoporosis. Fractures healed without complications in eight patients; however, the calcaneal anterior facet fracture became displaced and caused a flat foot in one case. The calcaneal IF rate was 0.58% among all cases. Besides one case with T2DM, significant differences were observed in preoperative HKA and BMD between cases with a calcaneal fracture following TKA and those without a fracture.
A change in the load on the calcaneus due to changes in the alignment of the lower extremities after TKA may cause calcaneal IFs. Orthopedic surgeons should be aware of the possible occurrence of calcaneal IFs following TKA, especially in women with osteoporosis and severe varus knee.
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Several studies reported decreases in pressures of the hallux and lateral toe areas in several conditions including medial osteoarthritis of the knee (Saito et al., 2018) and in children with mild cerebral palsy (Chang et al., 2015). In these conditions, including in the present study, walking speed is slow (Chang et al., 2015; Saito et al., 2018). The foot pressures of hallux and lateral toes are probably related to walking speed.
The present study aimed to elucidate the effects of heel lifts on spinal alignment, walking, and foot pressure pattern in elderly individuals with spinal kyphosis.
The spinal alignment, walking speed, step length and foot pressure of 33 community-dwelling elderly individuals with spinal kyphosis (3 men, 30 women; mean age 77.3 years) were examined before and after the application of 10-mm moderately elastic heel lifts.
Spinal alignment of total inclination (mean value 6.9°vs 4.5°) and thoracic angle (43.6°vs 36.2°) were significantly lower after the application of heel lifts than before the application. The lumbar angle (7.3°vs 10.0°) was significantly higher after the application than before the application. Walking speed (0.78 vs 0.88 m/s) and step length (0.42 m vs 0.45 m) were significantly higher after the application. The partial foot pressure as a percentage of body weight of the hallux (6.7% vs 9.0%) and lateral toes (6.5% vs 9.0%) was significantly higher after the application of heel lifts than before the application. The partial foot pressure as a percentage of body weight of the heel (68.9% vs 57.5%) was significantly lower after the application than before the application.
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It has been shown that total knee arthroplasty (TKA) can correct the alignment of the lower limb, not only correcting the knee axis, but also affecting the alignment of the hindfoot. However, there is still not a significant amount of work in the literature.
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Full length articleFoot pressure pattern, hindfoot deformities, and their associations with foot pain in individuals with advanced medial knee osteoarthritis

Highlights

Abstract

Introduction

Section snippets

Participants

Patients

Discussion

Conclusions

Acknowledgments

J. Physiother.

Osteoarthr. Cartil.

Pain

Arch. Phys. Med. Rehabil.

J. Foot Ankle Surg.

Comput. Methods Programs Biomed.

Arch. Phys. Med. Rehabil.

J. Biomech.

Med. Clin. North Am.

Clin. Podiatr. Med. Surg.

J. Arthroplasty

Foot Ankle Clin.

Clin. Podiatr. Med. Surg.

Current evidence on risk factors for knee osteoarthritis in older adults: a systematic review and meta-analysis

Osteoarthr. Cartil.

The effect of knee orthoses on gait parameters in medical knee compartment osteoarthritis. A literature review

Prosthet. Orthot. Int.

Full length article
Foot pressure pattern, hindfoot deformities, and their associations with foot pain in individuals with advanced medial knee osteoarthritis