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Gait plates

Gait plates are a specialised orthotic modification used to influence the angle of gait and can be a useful tool in managing in‑toe gait in children when applied to the right patient and integrated into a broader treatment plan. This essay will outline the biomechanics and causes of in‑toe gait, the design and mechanism of gait plates, the evidence for their effectiveness, clinical indications and limitations, and practical considerations for their use in paediatric practice.

In‑toe gait in children

In‑toe gait (or pigeon‑toeing) describes a walking pattern in which the feet point medially relative to the line of progression. It is common in early childhood and is most frequently associated with three main anatomical contributors: metatarsus adductus, internal tibial torsion, and increased femoral anteversion.

In many toddlers, mild in‑toeing is considered a normal variant of development and often improves spontaneously as rotational alignment normalises with growth. However, persistent or severe in‑toe gait can be associated with frequent tripping, reduced participation in play or sport, pain, and cosmetic or psychosocial concerns for the child and family. For these children, intervention may be warranted, beginning with careful assessment to determine the primary level of rotational deformity (foot, tibia, or femur) and to exclude neuromuscular or structural pathology.

Gait plate design and mechanism

A gait plate is an orthotic design feature that modifies the distal contour and line of flexion of the device to alter the child’s angle of gait. Unlike traditional functional orthoses that typically terminate just proximal to the metatarsal heads, gait plates extend distally beyond the metatarsophalangeal joints asymmetrically to influence how the shoe flexes and how the foot operates within the shoe.

For in‑toe gait, the gait plate is commonly extended laterally so that the distal edge finishes under or past the lateral toes, shifting the effective flexion line and making it easier and more comfortable for the foot to externally rotate during propulsion. The device is thought to act via a combination of mechanical constraint and proprioceptive feedback: as the child attempts to toe‑in, contact with the orthosis and shoe encourages a subtle out‑toe position that gradually becomes the preferred pattern while the device is worn.

Gait plates can be fabricated as modifications to custom orthoses or as stand‑alone flat plates sourced from rigid materials such as polypropylene or carbon fibre, then posted or contoured as required. They are typically used inside everyday footwear, including school shoes and runners, provided there is sufficient depth and width to accommodate the extended forefoot section.

Evidence for effectiveness

The literature on gait plates is relatively limited but suggests that they can produce a measurable improvement in the angle of gait and reduce functional problems such as tripping in children with in‑toe gait. Early work by Schuster in the 1960s reported improvements of around 15° in angle of gait with gait plate use in children with rotational gait abnormalities. Subsequent studies have shown more modest but statistically significant reductions in in‑toeing, along with decreased tripping and high levels of parental satisfaction.

A more recent study of children with in‑toe gait due to increased femoral anteversion found that a gait plate insole worn in ordinary shoes increased the angle of gait by approximately 11.1° compared with barefoot walking and by around 7° compared with shoes alone. The same study reported changes in centre of pressure displacement in the anterior–posterior direction, indicating a subtle alteration in gait mechanics rather than a purely cosmetic change. Importantly, these improvements occurred immediately when the device was worn, which supports the view that gait plates primarily modify gait while in situ rather than permanently correcting underlying torsional deformities.

Clinical reports from podiatry practices indicate that gait plates can noticeably reduce tripping and improve the appearance of gait in children with more severe in‑toeing, with many parents reporting that children adapt quickly and find the devices comfortable. However, there is limited high‑quality long‑term data on whether these devices influence structural rotational alignment over time, so they should be viewed as functional aids rather than definitive corrective tools.

Indications, limitations, and clinical decision‑making

Gait plates are most appropriately indicated in children who have persistent in‑toe gait beyond the expected age of spontaneous resolution, particularly when it is associated with frequent tripping, pain, or psychosocial distress. They can be especially useful when the in‑toe gait is functionally significant but surgery would be disproportionate or inappropriate given the child’s age and overall function.

Before prescribing a gait plate, practitioners should identify the primary source of in‑toeing, as some causes are less responsive to conservative approaches. For example, tibial torsion is often reported not to respond meaningfully to splints, footwear modifications, or physical therapy alone; surgical derotation may be considered only in older children with severe functional limitations. In contrast, in‑toe gait related to increased femoral anteversion has shown measurable improvement in angle of gait when a gait plate insole is used, suggesting that in these cases the device can be an effective adjunct to monitoring and exercise.

A key limitation is that gait plates are generally effective only while worn; they do not necessarily resolve the underlying torsional deformity. Clinicians should therefore avoid over‑promising structural correction and instead frame the goal as improving function, reducing tripping, and enhancing the cosmetic appearance of gait during use. Additionally, the extended distal profile may limit footwear options, and careful shoe selection is essential to avoid pressure on the toes or poor fit.

Practical application in a paediatric treatment plan

In practice, gait plates should be prescribed as part of a comprehensive management plan for the child with in‑toe gait rather than as a stand‑alone cure. This plan typically begins with a detailed history and physical examination, including assessment of rotational profiles (foot progression angle, thigh–foot angle, hip rotation range), neuromuscular status, and any associated pain or functional limitations.

When gait plates are selected, custom devices are often designed from a cast or scan to incorporate both standard orthotic features (such as rearfoot posting or arch support) and the specific gait plate extension tailored to the child’s pattern of in‑toeing. The child and family are counselled on a gradual wear‑in schedule to allow adaptation and to monitor for pressure areas or discomfort, with follow‑up reviews to assess changes in gait and function over time.

Adjunctive therapies frequently include stretching and strengthening programs targeted at identified deficits, such as hip external rotator strengthening or calf and hamstring stretching, as well as postural and balance work. Many clinicians also incorporate gait retraining strategies, using verbal cues, visual feedback, and sometimes video to help the child internalise a straighter foot progression pattern. In this context, the gait plate can be seen as a facilitative device that reinforces the desired movement pattern with each step, complementing active rehabilitation efforts.

Ultimately, gait plates represent a useful tool in the paediatric podiatrist’s repertoire for managing symptomatic or functionally significant in‑toe gait, offering a non‑invasive means to improve gait appearance and reduce tripping while a child continues to grow and develop. Used judiciously and with clear expectations, they can play an important role in supporting both physical function and the child’s confidence during everyday activities.

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How to do a gait analysis

Conducting a gait analysis involves structured observation, measurement, and interpretation of how a person walks, from initial history through to clinical decision-making. A systematic, repeatable approach improves diagnostic accuracy and links what you see to underlying pathology and treatment options.

1. Preparation and history

Begin by clarifying why you are assessing gait and which functional tasks are problematic for the patient. A concise, targeted history will frame what you expect to see and what you need to measure.

Key elements of history include:

  • Presenting complaint: pain location, onset, aggravating and easing factors, and whether symptoms appear during walking, running, or specific terrains.
  • Functional impact: falls, near-falls, reduced walking distance, difficulty with stairs, or changes in walking speed reported by the patient or family.
  • Medical background: neurological disease, musculoskeletal conditions, diabetes, previous surgery, and medications that may affect balance or muscle performance.
  • Footwear and orthoses: usual shoes, recent changes, wear patterns, and use of aids such as insoles, braces, or prosthetics.

A brief physical examination should follow, including range of motion, manual muscle testing, neurology and skin checks, because gait deviations often reflect deficits identified in this exam. This baseline informs both safety (for example, whether a walking aid is required) and interpretation of later observations.

2. Environment and basic setup

Gait analysis requires a safe, consistent environment so that deviations reflect the patient rather than the setting. A flat, well-lit walkway or a treadmill set at zero incline is typically used, with enough distance for the patient to achieve steady-state gait.

Important setup considerations:

  • Surfaces and distance: provide a straight path that allows several strides at the individual’s natural pace, avoiding sharp turns within the observation zone.
  • Footwear choice: observe both in usual footwear and, where safe, barefoot, as shoes can mask or modify foot and ankle mechanics.
  • Recording: video from sagittal, frontal, and posterior views allows slow-motion review and side-to-side comparison.
  • Warm-up: allow the patient to walk for a short period to reach a self-selected, comfortable speed before formal recording begins.

Ensuring consistency in speed and conditions across sessions is crucial for comparing gait over time or after interventions. In more advanced settings, instrumented walkways or motion capture systems extend this basic setup, but the underlying principles remain the same.p

3. Observational gait analysis

Observational gait analysis starts broad and becomes progressively more focused, moving from overall pattern to specific joint behaviour. Viewing the patient from the front, side, and rear helps you build a three-dimensional mental model of their movement.

From a global perspective, assess:

  • Symmetry and smoothness: look for regular, rhythmic steps with minimal abrupt changes and similar movements on both sides.
  • Posture and alignment: note trunk lean, pelvic tilt, head position, and the width of the base of gait.
  • Use of aids and compensations: observe how the patient manages canes, walkers, and whether they use arm swing or trunk strategies to compensate for weakness or pain.

Then consider specific temporal–spatial features that describe how the person uses time and space while walking. Clinically important parameters include walking speed, cadence, step length, step time, step width, and the proportions of single and double support. Even in a purely visual exam, you can estimate whether these parameters are reduced, increased, or asymmetric, which provides a quantitative framework for your impressions.

4. Joint-by-joint observation

Once you understand the overall pattern, refine your analysis by looking joint-by-joint through the gait cycle. The gait cycle can be divided broadly into stance (foot in contact with the ground) and swing (foot off the ground), each with characteristic movements.

Key elements to observe include:

  • Hip: monitor flexion and extension ranges, pelvic drop or hike, and any circumduction used to clear the limb. Reduced extension can shorten step length, whereas excessive flexion or adduction may signal weakness or contracture.
  • Knee: evaluate heel strike, knee flexion in loading response, and extension in mid-stance, plus swing-phase flexion needed for foot clearance. Stiff-knee gait or excessive flexion may result from pain, spasticity, or joint restriction.
  • Ankle and foot: note heel-first contact, progression through mid-stance, timing and quality of heel rise, and forefoot loading. Watch for excessive pronation or supination, foot slap, toe drag, or lack of push-off, all of which can represent neuromuscular or structural pathology.j

Relate each deviation to potential mechanical causes: for example, reduced plantarflexor strength can limit push-off and slow walking speed, while ankle dorsiflexor weakness may cause foot drop and compensatory hip hiking. Understanding these links guides both further assessment and targeted intervention.

5. Quantitative and advanced measures

When available, instrumented systems add objective metrics to support observational findings and monitor change over time. Common tools include pressure platforms, force plates, motion capture systems, and instrumented treadmills or walkways.

These systems measure:

  • Spatiotemporal parameters: precise values for walking velocity, cadence, step length, step width, and stance–swing timing, often with variability indices that relate to fall risk.
  • Kinematics: joint angles across the gait cycle, typically in three planes, which help distinguish between pattern and cause when multiple deviations coexist
  • Kinetics and plantar loading: ground reaction forces and centre of pressure paths, which reveal how load travels through the foot and lower limb.

Standardised protocols for marker placement, data collection, and processing are essential to ensure reproducible, clinically meaningful results. These data complement, rather than replace, skilled clinical observation and should always be interpreted in the context of the individual patient.

6. Interpretation, documentation, and clinical use

The final stage of gait analysis is to synthesise your observations and measurements into a coherent explanation that informs management. This involves linking gait deviations to underlying impairments and then to specific, modifiable treatment targets.

Effective interpretation includes:

  • Identifying primary versus compensatory deviations, for example distinguishing a true hip abductor weakness from a trunk lean used to reduce joint load.
  • Prioritising clinically significant issues such as instability, fall risk, or joint overload that may accelerate degenerative change.
  • Documenting findings in a structured manner, often by combining narrative description with key spatiotemporal values and, where appropriate, video stills or diagrams.

Gait analysis findings feed directly into plans for strengthening, stretching, orthotic or footwear prescription, assistive devices, surgical referral, or gait retraining. By following a systematic, reproducible method from history to interpretation, clinicians can use gait analysis as a powerful tool for both diagnosis and ongoing evaluation of therapeutic outcomes.

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Ganglion cysts of the foot

Ganglion cysts of the foot are benign, jelly‑filled lesions that arise from a joint capsule, tendon sheath, or fascia, and treatment ranges from simple observation to complex reconstructive surgery depending on symptoms, anatomy, and recurrence risk. In the foot specifically, the goals of management are to relieve pain, reduce shoe pressure, preserve function, and minimise recurrence while avoiding unnecessary operative morbidity.f

Indications for treatment

Many foot ganglia are incidental findings and require no active intervention. Up to half of ganglion cysts may resolve spontaneously, so a conservative approach is often appropriate when the lesion is painless and does not interfere with footwear or gait.

Intervention is generally considered when one or more of the following are present:

  • Local pain or aching exacerbated by weight‑bearing or pressure from shoes
  • Problems with footwear fit, recurrent shoe rubbing, or focal skin irritation and callus over the cyst.
  • Neurological symptoms such as tingling, numbness, or weakness from nerve compression.
  • Rapid growth, diagnostic uncertainty, or cosmetic concern in selected patients.

Before definitive treatment, careful clinical assessment and, where necessary, imaging (ultrasound or MRI) help confirm that the lesion is cystic, define its pedicle and origin, and exclude solid or vascular pathology.

Non‑surgical management

Non‑surgical strategies aim to offload the cyst and control symptoms without altering local anatomy. These are first‑line for most symptomatic foot ganglia, especially in patients with comorbidities, minimal pain, or high surgical risk.

Observation and education

Close monitoring (“watchful waiting”) is appropriate when the ganglion is small, minimally symptomatic, and not compromising footwear. Patients are counselled regarding the benign nature of the lesion, potential for spontaneous resolution, and signs that should prompt reassessment (increasing pain, neurological symptoms, rapid enlargement).

Footwear modification and padding

Because dorsal and lateral foot ganglia are frequently irritated by shoe uppers and seams, modifying footwear can markedly reduce symptoms. Practical measures include:

  • Selecting shoes with a roomy, high toe box and soft uppers to minimise pressure over the cyst.
  • Choosing styles with adjustable lacing or straps, allowing local accommodation.
  • Using local padding (e.g. felt, silicone, or foam) inside the shoe to create a pressure‑relief cavity over the lesion.

These modifications mirror broader orthopaedic principles where therapeutic footwear reduces dorsal prominence irritation at the forefoot, and can be readily adapted for ganglia over the midfoot or ankle.

Foot orthoses and biomechanical measures

Although orthoses do not directly reduce cyst volume, they may redistribute plantar pressures and alter joint loading, potentially reducing mechanical stimuli that perpetuate ganglion formation or symptoms.

  • Custom or prefabricated insoles can offload a joint or tendon sheath associated with the cyst, particularly in midfoot or tarsometatarsal ganglia.
  • Stiff or extended shank inserts limit motion through painful joints, analogous to their role in managing first MTP joint pathology, and can be helpful if joint irritation coexists.

In practice, orthotic therapy is often combined with footwear modification and activity advice to optimise symptom relief.

Aspiration with or without injection

Needle aspiration involves puncturing the cyst and evacuating its viscous contents, sometimes followed by corticosteroid injection. It is usually performed under local anaesthesia in an outpatient setting and can provide rapid symptom relief, particularly for tense, superficial cysts that interfere with shoes.

However, recurrence after aspiration is common. General ganglion literature reports recurrence rates of approximately 60–95% after aspiration alone, reflecting persistence of the cyst wall and pedicle. Foot and ankle–specific guidance notes recurrence rates up to about 63% following aspiration, and repeat aspiration may be considered if initial benefit is short‑lived.

Corticosteroid injection after aspiration may reduce inflammation and transiently decrease recurrence, but evidence is mixed and many cysts still return. Potential complications include local skin depigmentation, fat atrophy, infection, and iatrogenic tendon or nerve injury, which must be weighed against the minimally invasive nature of the procedure.

Surgical treatment

Surgery is reserved for cases where non‑surgical measures fail, symptoms are significant, or there is diagnostic uncertainty. In the foot, particular attention is paid to preserving skin integrity, neurovascular structures, and tendon function due to limited soft‑tissue envelopes and high mechanical demand.

Open excision

Open excision remains the most common operative technique for symptomatic or recurrent ganglion cysts. The key technical principle is not just to remove the cyst sac but also to identify and excise the pedicle and any degenerative joint capsule or tendon sheath from which it arises, to reduce recurrence. Meticulous dissection and protection of nearby nerves and tendons are critical, especially for dorsal midfoot ganglia where extensor tendons and neurovascular bundles are closely related.

Across anatomical sites, reported recurrence rates after open excision vary widely from about 1% to 50%, reflecting differences in technique, follow‑up, and case selection. Large series have demonstrated recurrence rates around 3.8–20% for open excision, with surgeon experience associated with lower recurrence. For the foot, recurrence after surgical excision has been reported as high as 43% in some series, underscoring the technical challenges of complete pedicle removal in a constrained anatomical space.

Post‑operatively, patients typically require a short period of immobilisation or activity modification, followed by gradual return to weight‑bearing in appropriate footwear. Most can resume normal activities within several weeks, although local tenderness, scar sensitivity, and transient stiffness are not uncommon.

Arthroscopic and endoscopic techniques

Arthroscopic or endoscopic resection is more established in wrist ganglia but has also been described for certain ankle and foot ganglia, particularly those arising from the talonavicular or subtalar joints. Recurrence rates for arthroscopic resections in the general ganglion literature are reported around 8.5–30%, with some studies showing rates similar to open excision and others suggesting potential advantages.

Potential benefits in the foot include smaller incisions, less soft‑tissue disruption, and improved visualisation of intra‑articular origins; however, these techniques require specialised expertise and may not be suitable for all cyst locations. Long‑term comparative data specific to the foot and ankle remain limited.

Reconstructive approaches for complex or recurrent lesions

For recurrent or structurally complex foot ganglia—particularly those involving tendons—more extensive reconstructive strategies have been reported. One such approach involves excision of the cyst along with the affected segment of a degenerated tendon, followed by tendon reconstruction or allograft replacement to restore function. These procedures highlight the principle that, in recalcitrant cases, the underlying degenerative substrate (joint capsule or tendon) may need to be addressed rather than the cyst alone

Because recurrence can remain substantial even after surgery, pre‑operative counselling should emphasise realistic expectations, including the possibility of persistent or recurrent swelling, scar symptoms, and the rare need for revision surgery.

Choosing an appropriate management plan

Selecting the optimal treatment for a foot ganglion requires individualised assessment of symptom severity, anatomical location, underlying biomechanics, patient comorbidities, and expectations. For a low‑demand patient with a small, mildly symptomatic dorsal midfoot ganglion, a reasonable plan might be footwear modification, local padding, and observation, reserving aspiration or surgery for progression. Conversely, for an active patient whose midfoot ganglion repeatedly interferes with running footwear and has recurred after aspiration, open excision with careful pedicle identification and, if necessary, orthotic modification post‑operatively may be justified.

Across this spectrum, podiatric management focuses not only on the cyst itself but also on optimising shoe fit, managing associated deformities or overload, and monitoring for recurrence over time, ensuring that treatment of foot ganglia remains both symptom‑directed and function‑oriented.

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The Foot Tapping Test

The Foot Tapping Test is a simple, timed motor task used to quantify lower limb bradykinesia and related motor dysfunction in people with Parkinson’s disease (PD). It provides an objective, repeatable measure that complements standard clinical scales and can help in diagnosis, monitoring progression, and evaluating treatment response.

Background and Rationale

Bradykinesia, defined as slowness and decrement of voluntary movement, is a cardinal motor feature of Parkinson’s disease and is required for its clinical diagnosis. While finger tapping is widely used to assess upper-limb bradykinesia, lower-limb assessment is equally important because gait disturbance, freezing of gait, and falls are major causes of morbidity in PD. The Foot Tapping Test (FTT) was developed as a quick way to quantify the speed and consistency of repetitive dorsiflexion, which relies on intact central motor control and is sensitive to basal ganglia dysfunction. Research indicates that reduced foot tapping rates are seen in PD and correlate with mobility impairment and other disease outcome measures.

Test Procedure

In its traditional clinical form, the Foot Tapping Test is performed with the patient seated in a chair, hips and knees flexed approximately to 90 degrees and both feet flat on the floor. The patient is asked to keep the heel of the tested foot in contact with the ground while rapidly tapping the forefoot up and down for a fixed interval, most commonly 10 seconds. The examiner counts the number of taps and observes qualitative features such as amplitude, rhythm, hesitations, and fatigue-related decrement during the trial. Some protocols test each foot separately, repeating the trial several times and averaging the counts to improve reliability, whereas others allow testing with shoes on or use a simple mechanical or electronic counter to register taps more precisely.

More instrumented variants have been developed for research, including force platforms, foot switches, and gyroscope-based sensors attached to the foot or embedded in insoles to capture tap frequency, amplitude, and variability with high temporal resolution. In the broader Parkinson’s motor exam, heel or foot tapping is often embedded in standardized assessment batteries such as the motor section of the Unified Parkinson’s Disease Rating Scale (UPDRS) or MDS-UPDRS as part of the evaluation of bradykinesia and lower-limb function.

What the Test Measures and How It Relates to Parkinson’s Disease

The primary quantitative output of the Foot Tapping Test is tap rate, usually expressed as the number of taps in 10 seconds. This rate reflects the patient’s ability to rapidly activate and deactivate the ankle dorsiflexors, a process that depends on both corticospinal pathways and basal ganglia circuits that are impaired in PD. In individuals with Parkinson’s disease, tap rate is typically reduced compared with healthy controls, and taps may become progressively slower and smaller in amplitude, demonstrating bradykinesia and “sequence effect” (decrement over time). Studies have shown that foot tapping measures correlate with established PD outcome metrics and can be sensitive to changes in dopaminergic medication, suggesting value as an objective outcome measure in clinical trials.

Beyond simple rate, qualitative aspects of performance are clinically informative. Patients with PD may show irregular rhythm, pauses or blocks suggestive of freezing, and difficulty initiating tapping on command. Comparison between sides can help identify asymmetry, which is characteristic in early Parkinson’s disease. Because reduced tap speed is also associated with aging and other upper motor neuron disorders, interpretation must occur in the context of age-related reference values and the broader neurologic examination.

Reliability, Validity, and Clinical Utility

The Foot Tapping Test has been reported to exhibit high test–retest, day-to-day, and inter-rater reliability, indicating that it is stable over time and consistent between examiners when standardized protocols are used. Research in PD suggests that alternate foot tapping measures may be at least as reliable as finger tapping and may correlate more strongly with existing PD outcome measures than repetitive foot tapping alone. These findings support its validity as a measure of lower-limb bradykinesia and a potential marker of treatment response in PD drug trials.

Clinically, the FTT offers several advantages. It is quick, requires minimal equipment, and can be performed even in patients who cannot safely ambulate, providing a way to quantify leg motor function when gait tests are not feasible. Because tap speed has been linked to gait speed and overall mobility, periodic testing may help identify patients at risk for mobility decline, falls, and functional impairment. The test can also be repeated over time to document progression of motor symptoms or improvement following interventions such as medication adjustments, deep brain stimulation, or physiotherapy.

Technological Innovations and Future Directions

Recent work has extended the concept of the Foot Tapping Test using wearable and in-shoe sensor technology for remote monitoring of Parkinson’s disease. One approach uses smart shoe insoles that measure toe or forefoot tapping and stream data to a smartphone application, which can then analyze tapping frequency, amplitude, and other temporal features to estimate fall risk and track symptom progression. These systems aim to overcome limitations of in-clinic observation, such as the brief sampling window, variability due to patient anxiety, and travel burden for individuals with mobility issues.

Such digital implementations may allow more frequent, ecologically valid sampling of motor function in the home environment, providing clinicians with richer datasets to guide treatment decisions and personalize therapy. As sensor technology and analytics improve, the Foot Tapping Test and related paradigms are likely to be integrated into broader digital biomarker platforms that combine upper- and lower-limb tasks to give a comprehensive picture of motor status in Parkinson’s disease. For now, the Foot Tapping Test remains a practical, low-cost tool that complements established clinical scales by offering an objective, quantifiable measure of lower-limb bradykinesia in everyday clinical practice.

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Fluoroquinolones and tendon injury

Fluoroquinolones are widely used broad‑spectrum antibiotics, but their association with tendinopathy and tendon rupture has become a major safety concern, particularly in weightbearing tendons such as the Achilles. This essay outlines the epidemiology, pathophysiology, clinical presentation, risk factors, and management of fluoroquinolone‑associated tendon injury, with particular attention to implications for lower‑limb practice.

Overview and epidemiology

Fluoroquinolones (FQs) such as ciprofloxacin, levofloxacin, and ofloxacin achieve excellent oral bioavailability and tissue penetration, and have therefore been heavily prescribed for urinary, respiratory, and gastrointestinal infections. Despite their efficacy, post‑marketing surveillance and observational studies have consistently linked these agents to tendinopathy and tendon rupture, prompting regulatory warnings in multiple countries.

Large database studies suggest that the absolute risk of tendon rupture with FQs is low but clinically meaningful. In a cohort of over 740,000 fluoroquinolone‑exposed patients, the excess risk attributable to current FQ use was estimated at about 3.7 additional tendon ruptures per 10,000 person‑years for any tendon rupture and 2.9 per 10,000 person‑years specifically for Achilles rupture. Another UK primary‑care database study reported an incidence of any tendon rupture of 5.9 per 10,000 person‑years, with Achilles tendon rupture at 1.9 per 10,000 person‑years, and found that FQ exposure increased the relative risk compared with a non‑FQ antibiotic comparator.

Relative risk estimates vary but generally demonstrate a 1.5–5‑fold increase in tendon rupture with current fluoroquinolone exposure, with higher estimates for Achilles tendon injuries. One nested case–control analysis reported odds ratios of 1.6 for any tendon rupture, 2.7 for Achilles rupture, and 1.5 for biceps rupture with current FQ use compared with non‑exposed patients. These data underpin the current view that, while population‑level risk is modest, the consequences for affected individuals can be severe and long‑lasting, especially in active or older adults.

Pathophysiology and mechanisms

The precise mechanism by which fluoroquinolones damage tendon tissue is not fully elucidated, but several converging pathways have been identified in experimental and translational studies. Tendons depend on a highly organised collagenous extracellular matrix maintained by tenocytes and other resident cells; disturbance of this balance predisposes to micro‑damage, degeneration, and, ultimately, mechanical failure.

In vitro and animal studies demonstrate that fluoroquinolones can impair fibroblast and tenocyte function by reducing collagen synthesis and up‑regulating matrix degradation. Ciprofloxacin, for example, has been shown to decrease type I collagen production and increase activity of matrix‑degrading enzymes, shifting the tendon milieu toward net catabolism. FQs also appear to increase apoptosis in human tenocytes, reducing the viable cell population needed for ongoing repair and homeostasis.

Another proposed mechanism relates to the chelating properties of fluoroquinolones, which bind divalent cations such as magnesium. This may disrupt cell–matrix interactions and interfere with integrin‑mediated signalling that is essential for mechanotransduction and collagen organisation. Histopathological studies of affected tendons have described hyaline and mucoid degeneration, chondroid metaplasia of tenocytes, altered mucopolysaccharide content, and disorganisation of collagen fibres, findings consistent with a degenerative tendinopathy rather than pure inflammatory process.

Vascular factors may further contribute. The Achilles tendon already has relatively poor blood supply, particularly in its mid‑portion, and this perfusion appears to decline with age. Reports of narrowed vasculature and paratendinous changes in FQ‑associated tendinopathy suggest that impaired blood flow and local ischaemia could exacerbate drug‑mediated matrix damage, helping explain the predilection for the Achilles in older patients. Together, changes in gene expression, cell survival, extracellular matrix composition, and microvascular supply create a vulnerable tendon prone to symptomatic tendinopathy and rupture under normal or modest mechanical loading.

Clinical features and risk factors

Fluoroquinolone‑associated tendon injury typically presents as an acute or subacute onset of pain, swelling, and stiffness in a tendon region within days to weeks of drug exposure, although onset can be delayed. The Achilles tendon is most commonly involved, accounting for nearly 90% of reported cases, but other sites such as the biceps brachii, supraspinatus, triceps, extensor pollicis longus, and various hand and shoulder tendons have also been described. Symptoms may be unilateral or bilateral and often include focal tenderness, impaired function, and difficulty with tasks that load the tendon (e.g., push‑off in gait or climbing stairs).

Several risk factors substantially amplify the likelihood of tendon injury in the setting of fluoroquinolone therapy. Advancing age is consistently associated with higher risk; epidemiological analyses show greater absolute risk in older adults, reflecting age‑related changes in tendon vascularity and matrix quality. Concomitant systemic corticosteroid therapy is a particularly potent enhancer, with studies indicating a materially increased risk of Achilles tendon rupture when FQs and steroids are used together compared with FQs alone. Other reported risk factors include chronic kidney disease and renal transplantation (with reduced drug clearance and higher tissue exposure), diabetes, and pre‑existing tendon disorders, as well as high levels of physical activity or sudden changes in loading.

From a podiatric perspective, a typical clinical scenario might involve an older patient treated with levofloxacin for pneumonia while on oral prednisolone for chronic obstructive pulmonary disease, presenting one to two weeks later with sudden posterior heel pain and difficulty weightbearing. If not recognised promptly and the antibiotic continued, this tendinopathy can progress to partial or complete rupture, often during relatively low‑demand activities such as walking.

Diagnosis and management

Diagnosis of fluoroquinolone‑associated tendinopathy is primarily clinical, based on a compatible symptom pattern, localisation to a tendon, and a history of recent or current FQ use in the absence of alternative causes. Ultrasound and MRI are not mandatory but can be valuable for confirming tendon involvement, characterising partial tears, and excluding other pathology, particularly for deep or less accessible tendons. Typical ultrasound features include tendon thickening, hypoechoic areas, and increased neovascularity on Doppler imaging, mirroring changes seen in non‑drug‑induced tendinopathy.

Once suspected, immediate cessation of the fluoroquinolone is recommended, even if the antibiotic course is incomplete, and an alternative non‑FQ agent should be selected whenever feasible. Early management centres on rest and load reduction for the affected tendon, often using heel lifts, counterforce bracing, walking aids, or short periods of immobilisation for Achilles involvement to reduce tensile stress. In Achilles cases, guidelines describe protecting the tendon for several weeks to months, with progressive re‑loading guided by pain and function.

Physical therapy plays a major role in rehabilitation once acute pain has settled. Protocols based on principles of connective tissue remodelling and eccentric loading, such as Alfredson’s heel‑drop programme, have been successfully adapted for FQ‑induced Achilles tendinopathy. Case reports describe meaningful improvements in pain and functional scores over 3–11 months with structured physiotherapy, sometimes combined with adjunctive modalities such as extracorporeal shockwave therapy when rest alone failed. Most cases of tendinosis recover over several weeks and typically within two months after discontinuation of the drug, although some patients experience more prolonged symptoms.

When tendon rupture occurs, management parallels that of non‑drug‑related ruptures and may be operative or non‑operative depending on patient factors, tendon involved, and local expertise. Early orthopaedic or sports medicine referral is appropriate, as delayed recognition can compromise outcomes. Importantly, individuals who have experienced fluoroquinolone‑associated tendon injury should generally avoid future exposure to this drug class, and prescribers should carefully evaluate the risk–benefit ratio before initiating FQs in patients with recognised risk factors.

Overall, fluoroquinolones exemplify the tension between antimicrobial efficacy and musculoskeletal safety. For clinicians working with the lower limb, recognising early tendon symptoms in patients recently treated with these agents, particularly older adults and those on corticosteroids, is critical to preventing progression from reversible tendinopathy to disabling rupture.

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How to Care for Your Feet

Our feet are the foundation of our bodies, carrying us through every step of life. Despite their importance, foot health is often overlooked until pain or injury occurs. Proper foot care is essential for maintaining mobility, preventing long-term complications, and supporting overall wellness.

The Importance of Foot Health

The average adult takes between 5,000 and 10,000 steps per day, placing significant stress on the feet. Each step exerts a force approximately one and a half times the body’s weight. Over time, that pressure can lead to strain, calluses, and joint misalignments if not managed properly. The feet also reflect broader health issues — systemic diseases like diabetes, arthritis, and circulatory disorders often manifest early signs in the lower limbs. Thus, caring for the feet is not merely about comfort or aesthetics; it is a form of preventative healthcare that supports the whole body.

Daily Foot Hygiene

Good foot hygiene is the cornerstone of foot health. Daily washing with warm water and mild soap helps remove sweat, bacteria, and dirt that can accumulate over the course of the day. It is important to dry the feet thoroughly, especially between the toes, where moisture can create an environment conducive to fungal infections such as athlete’s foot.

Moisturizing is equally vital. A suitable foot cream or lotion applied after drying prevents cracks and dryness, particularly on the heels. However, moisturizing between the toes should be avoided to reduce fungal growth risk. For individuals prone to excessive sweating or odour, antifungal sprays or drying powders can help keep the feet fresh. Regular inspection of the feet — ideally once per day — allows early detection of blisters, cuts, or abnormal changes that could indicate infection or poor circulation.

Proper Nail and Skin Care

Toenail maintenance prevents painful conditions such as ingrown toenails and infections. Nails should be trimmed straight across rather than rounded, following the natural contour of the toe. Cutting them too short can cause irritation or allow the nail edge to grow into the skin. For people with thickened nails or deformities, using a nail file or emery board can help smooth sharp edges.

The skin of the feet needs attention as well. Calluses and corns often develop on high-pressure areas due to friction or tight footwear. These should never be cut off or shaved with sharp instruments at home, as doing so can lead to injury or infection. Instead, gently filing thickened areas with a pumice stone after bathing and keeping the skin moisturized helps manage them safely. If a corn or callus becomes painful, a podiatrist can remove it professionally and assess underlying biomechanical causes.

Choosing the Right Footwear

Footwear plays a decisive role in long-term foot health. Shoes that fit properly and provide adequate support can prevent a multitude of problems, from bunions and hammertoes to plantar fasciitis and back pain. Comfort should never be sacrificed for style — ill-fitting shoes compress the toes, alter gait patterns, and contribute to chronic discomfort.

A well-fitted shoe should have enough room in the toe box to wiggle the toes freely, secure support around the heel without slipping, and cushioning appropriate to the activity. For athletic activities, sport-specific shoes that align with the shape of the foot and the type of movement involved are essential. Wearing high heels or narrow dress shoes for extended periods can strain the forefoot and contribute to deformities such as bunions or neuromas. Alternating between different shoe types and avoiding worn-out footwear can also reduce repetitive strain.

Socks are another important but often neglected element of footwear choice. Natural, breathable materials like cotton or moisture-wicking synthetics help regulate temperature and reduce friction. For people with diabetes or poor circulation, seamless, non-restrictive socks help avoid pressure spots and ulcers.

Foot Biomechanics and Exercise

Beyond hygiene and footwear, maintaining strong and flexible feet is essential for proper biomechanics and balance. The muscles and tendons of the feet support the arches and assist with shock absorption. Weakness or stiffness in these structures can contribute to pain and inefficiency in walking or running.

Simple exercises — such as toe curls, heel raises, and arch stretches — can enhance range of motion and muscular control. Rolling the sole of the foot over a tennis ball or frozen water bottle can relieve plantar tension and improve circulation. Yoga poses that strengthen the lower legs and improve proprioception, like tree pose or downward dog, also support healthy biomechanics.

Maintaining a healthy body weight further relieves excessive pressure on the feet. Each kilogram of extra weight increases the load on foot joints, accelerating wear and tear. Thus, foot care is inseparable from general fitness and weight management.

Preventing and Managing Common Foot Problems

Several common conditions can compromise foot health, many of which are preventable with good care practices. Athlete’s foot, a fungal infection that causes itching and peeling between the toes, can be avoided by keeping feet dry, changing socks regularly, and wearing breathable shoes. Plantar fasciitis, marked by heel pain from inflammation of the plantar fascia, responds to rest, stretching, supportive footwear, and sometimes orthotic inserts to redistribute pressure.

Corns, bunions, and hammertoes typically result from mechanical stress and ill-fitting shoes. Addressing these early with supportive devices like orthoses or toe spacers can prevent progression. Diabetic foot complications require special vigilance — neuropathy and vascular problems can make minor injuries dangerous, leading to ulcers or infections. Daily inspection, moisture control, protective footwear, and regular podiatric check-ups are critical for diabetic individuals.

Another often overlooked issue is poor circulation, which can cause cold or discoloured feet. Regular movement, leg elevation, and avoiding prolonged sitting or crossing the legs can improve blood flow.

Professional Foot Care and When to Seek Help

While self-care covers most daily needs, professional foot assessment is invaluable. Podiatrists can identify structural abnormalities, gait issues, and early signs of systemic disease that may not be visible to the untrained eye. Custom orthotics may be prescribed to correct imbalances in foot function and prevent overuse injuries. For individuals with chronic foot pain, deformities, or recurrent infections, ongoing podiatric management is essential.

Regular check-ups are especially important for at-risk populations, including athletes, older adults, and those with diabetes or arthritis. Early professional intervention can prevent minor issues from developing into major, debilitating conditions.

The Holistic View of Foot Care

Caring for the feet should be seen as part of a holistic approach to health. The feet are intricately connected to posture, movement, and systemic circulation. Problems in the feet can ripple through the body, causing pain in the knees, hips, or lower back. Conversely, good foot care enhances stability, mobility, and comfort, enabling an active lifestyle that benefits cardiovascular and mental well-being alike.

Integrating regular stretching, mindful walking, and proper footwear into one’s routine fosters long-term resilience. Just as dental hygiene prevents cavities and heart health begins with diet and exercise, consistent attention to foot health preserves independence and quality of life.

The feet are remarkable structures — resilient yet sensitive, stable yet adaptable. They deserve daily care, thoughtful footwear choices, and periodic professional attention. Through consistent hygiene, balanced biomechanics, and informed prevention, we can avoid many of the ailments that commonly affect our feet and maintain the mobility that defines our freedom. In essence, foot care is self-care; it is the science of maintaining the body’s foundation so the rest of life can move comfortably forward.

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Use of Foot Orthotics

Foot orthotics are widely used medical devices designed to support, align, and improve the function of the foot and lower limb. They play an important role in managing pain, optimising biomechanics, and preventing injury across a range of patient populations, from high‑performance athletes to people with chronic disease.

Definition and Types of Foot Orthotics

Foot orthotics (or foot orthoses) are external devices placed inside footwear to modify the mechanical function of the foot and lower limb. They are typically used to support arches, redistribute plantar pressures, and influence joint motion throughout the kinetic chain.

Broadly, orthotics are classified as:

  • Prefabricated (off‑the‑shelf) devices, manufactured to generic foot shapes and conditions.
  • Custom‑made devices, fabricated from a 3D representation of an individual’s foot (plaster, foam, or digital scan) and prescribed after a biomechanical assessment.

They can also be described by function: accommodative orthoses, made from softer materials to cushion and relieve pressure; and functional orthoses, often more rigid or semi‑rigid, aimed at controlling motion, particularly excessive pronation or supination. This basic taxonomy underpins clinical decision‑making when matching device type to pathology and patient goals.

Biomechanical Rationale and Mechanisms of Action

The use of foot orthotics rests on the principle that altering foot–ground interaction can change forces and motion throughout the lower limb. Orthoses can redistribute plantar pressure away from painful or high‑risk areas, such as metatarsal heads or the medial heel, by increasing contact area and supporting the longitudinal and transverse arches.

By contouring to the plantar surface and incorporating posting or wedging, orthotics can influence rearfoot and forefoot position in stance and gait. Controlling excessive pronation, for example, can reduce internal tibial rotation and downstream stresses at the knee and hip, while improving alignment may lessen compensatory muscle activity and fatigue. In addition, materials with shock‑absorbing properties attenuate impact forces during walking and running, which can reduce repetitive loading on bones, joints, and soft tissues.

Clinical Indications and Therapeutic Benefits

Foot orthotics are prescribed for a wide range of musculoskeletal and systemic conditions affecting the feet and lower limbs. Common indications include plantar fasciitis, posterior tibial tendon dysfunction, metatarsalgia, and mechanical heel pain, where orthoses help offload symptomatic tissues and support strained structures. They are also used in patients with flat feet or high arches to improve stability, distribute pressure more evenly, and reduce localised discomfort.

Beyond local foot pathology, orthoses may assist in managing shin splints, patellofemoral pain, and some presentations of knee, hip, or lower back pain when these are driven or exacerbated by abnormal foot mechanics. In people with diabetes or peripheral neuropathy, accommodative orthotics and total‑contact insoles are integral to ulcer prevention strategies because they reduce peak plantar pressures and shear in high‑risk areas. In the athletic population, orthotics are employed both as a treatment and as a preventive measure, with evidence suggesting reductions in overuse injuries and stress fractures in certain sporting cohorts.

Role in Performance, Function, and Quality of Life

Although their primary purpose is therapeutic, foot orthotics can also contribute to improved functional performance. By optimising alignment and enhancing stability, they may facilitate more efficient gait and running mechanics, allowing improved propulsion and reduced perceived exertion in some individuals. Enhanced shock absorption and pressure distribution can translate to greater comfort during prolonged standing, walking, or sport, which indirectly supports performance by delaying fatigue.

Importantly, orthotics can have a substantial impact on quality of life. For people whose activity is limited by chronic foot or lower limb pain, an effective orthotic prescription can restore the capacity to work, exercise, and participate in daily tasks. In older adults, improved stability and balance from appropriate footwear and orthoses may reduce fall risk and increase confidence in mobility. These functional gains underscore the broader health value of orthotic therapy beyond local symptom relief.

Limitations, Risks, and Considerations in Prescription

Despite their benefits, foot orthotics are not a universal solution and must be prescribed judiciously. Poorly indicated or poorly fitted devices can provoke new symptoms, such as pressure lesions, altered gait patterns, or pain elsewhere in the kinetic chain. Patients may also experience an adaptation period with transient discomfort as tissues adjust to altered loading.

Cost is a relevant limitation, especially for custom devices, and can affect adherence. Moreover, orthotics should rarely be used in isolation. Best‑practice management typically integrates them with footwear modification, targeted exercise therapy, load management, and, when appropriate, weight management or workplace changes. Long‑term or repeated use without periodic review may be problematic, as materials wear, patient biomechanics change, and underlying conditions evolve. Regular reassessment helps determine whether the device is still necessary, needs modification, or can be weaned.

Conclusion

The use of foot orthotics represents a key conservative intervention in contemporary lower‑limb care. By modifying foot function and load distribution, orthoses can relieve pain, prevent injury, and support better movement across diverse patient groups. Their effectiveness, however, depends on careful assessment, appropriate device selection, and integration into a broader, evidence‑based treatment plan that considers the whole person rather than the foot in isolation

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Friar’s balsam

Friar’s balsam, or compound benzoin tincture, is a traditional resin‑based preparation that has persisted into modern practice as a niche but useful topical agent for selected foot conditions. In podiatry it is used far less as a “panacea” than in the past, but remains relevant as both an adhesive enhancer for padding and dressings and as a mild antiseptic and protectant for superficial lesions and fissures.

Composition and pharmacological actions

Friar’s balsam is a solution of benzoin resin in ethanol, with additional balsamic resins such as storax, Tolu balsam and aloe, giving it characteristic antiseptic, astringent and film‑forming properties. The alcohol vehicle facilitates rapid evaporation, leaving a thin resinous film that adheres to the stratum corneum and increases surface tack.

The benzoin and related resins contain esters and free cinnamic and benzoic acids, compounds long associated with weak antimicrobial and antiseptic effects. When applied to intact or minimally disrupted skin, the evaporating alcohol has a transient drying, cleansing effect, while the residual film acts as a protectant, reducing minor friction and contamination over small wounds, fissures or chapped skin. However, these same resins are also well‑recognised contact allergens, which places practical limits on widespread use.

Historical and modern indications

Historically Friar’s balsam was promoted as a near‑universal topical remedy for “wounds of all kinds, bruises, and all skin disorders”, and even taken internally for problems as diverse as worms, haemorrhoids and “cardiac disease”. Contemporary regulatory indications are far narrower, with the product listed in Australia, for example, as an antiseptic for minor cuts and abrasions and as a symptomatic treatment for common colds when inhaled as steam.

For foot care, modern over‑the‑counter descriptions emphasise its use as an antiseptic protectant for minor cuts and abrasions, chapped skin, small skin fissures and bedsores, and to relieve itch associated with chilblains and mild eczematous conditions. In practice this translates to typical podiatric scenarios such as superficial heel fissures, minor interdigital splits, small periungual cracks and low‑grade excoriations where a light, protective barrier is useful but heavy occlusion is undesirable.​

Role as an adhesive enhancer in foot care

Within podiatry and sports medicine, Friar’s balsam is now best known for its role as an adhesive enhancer under taping and padding on the foot. When applied sparingly to clean, dry, intact skin and allowed to dry for 30–60 seconds, compound benzoin tincture markedly increases the bond strength of adhesive tapes, dressings, felt and foam padding, particularly in high‑friction, high‑sweat environments such as the plantar forefoot and heel.

This property is especially valuable in:

  • Management of friction blisters: ensuring that prophylactic tapes and hydrocolloid dressings remain adherent on macerated or sweaty skin during running, hiking or field sports.
  • Off‑loading corns and calluses: helping semi‑compressed felt or foam pads remain in situ over bony prominences like metatarsal heads or toe dorsum for longer between changes.
  • Securing post‑operative or post‑debridement dressings: improving adherence around toes and plantar surfaces where conforming dressings tend to lift.blister-prevention+1​

However, the very stickiness that makes Friar’s balsam useful can also raise local friction if used over too large an area: exposed resin can attract sock fibres and grit as the foot perspires, increasing the coefficient of friction and, paradoxically, the risk of blisters. Clinically, this necessitates highly targeted application limited to the footprint of the intended tape or pad, with any exposed areas dusted with powder or covered to prevent unwanted traction.

Use for fissures, chapping and minor lesions

Product information from several manufacturers highlights Friar’s balsam as a topical protectant for “chapped skin and lips, cracked nipples, small skin fissures and bedsores”, with additional claims of relieving itching in chilblains, eczema and urticaria. Transposing these indications to the foot, potential uses include:

  • Small, superficial heel fissures or peri‑fissure skin where a light film may reduce further splitting and contamination once bleeding has ceased.
  • Mild periungual cracks or interdigital fissures secondary to irritant dermatitis or cold exposure, if the surrounding skin is otherwise intact.
  • Low‑grade chilblain itch on toes, as an adjunct to standard warmth and vascular‑protective measures, noting that the evidence is experiential rather than trial‑based.

Nevertheless, the alcohol base will sting intensely on open blisters, abrasions or actively exuding eczema. Best practice is therefore to restrict application to intact or nearly healed skin around a lesion, and to rely on more conventional emollients, barrier creams and appropriate dressings for substantive fissures, ulcers or dermatitis.

Risks, contraindications and patient selection

The major clinical limitation in using Friar’s balsam on the feet is the risk of dermatitis. Allergic contact dermatitis to the balsamic resins (benzoin, storax, Tolu balsam) is well documented and considered the most important adverse effect, often presenting with delayed pruritic, eczematous eruptions 24–72 hours after exposure. Once sensitised, patients are likely to exhibit cross‑reactivity with other fragrance mixtures and Balsam of Peru, creating persistent difficulties with many cosmetics and topical products.biomedicus​

Irritant contact dermatitis is also possible, driven by the high alcohol content and resin load, and typically presents as immediate burning and erythema at the site of application, particularly on already compromised skin. Product information also notes that frequent or widespread application can cause skin dryness and cracking, an undesirable effect on already vulnerable plantar skin.file2.

Other safety considerations include:

  • Avoidance on broken or significantly inflamed skin, given stinging, potential irritancy and theoretical risk of increased systemic absorption.
  • Caution in atopic patients or those with known fragrance or Balsam of Peru allergy, where the sensitisation risk is high.
  • Avoidance of use as an inhalant in individuals with asthma or significant respiratory disease, due to the potential for bronchospasm.

In podiatric settings, patch‑testing a small area before wider use may be prudent in patients with complex dermatological histories, and practitioners should counsel patients to discontinue use and seek review if any rash, intense itching or blistering develops.

Place of Friar’s balsam in contemporary podiatry

In modern evidence‑based foot care, Friar’s balsam occupies a modest, adjunctive role rather than a central therapeutic position. Its primary contemporary value lies in:

  • Enhancing the adherence and durability of tapes, dressings and off‑loading pads in challenging high‑moisture, high‑friction environments such as athletic or occupational feet.
  • Providing mild antiseptic and protective film effects for minor, superficial lesions and fissures, when used judiciously on nearly intact skin.

Balanced against this are the relatively high rates of irritant and allergic contact dermatitis and the availability of alternative adhesive enhancers and barrier products (such as colourless skin‑prep wipes) that may offer similar benefits with less mess and potentially lower allergenicity. For the podiatric clinician, Friar’s balsam is therefore best considered a specialised tool: useful in selected patients and specific foot‑care scenarios, but always deployed with restraint, targeted application and awareness of its sensitising potential.

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Freiberg disease

Freiberg disease, also called Freiberg infraction, is an osteonecrosis of a lesser metatarsal head that most commonly affects the second metatarsal in adolescent or young adult females, causing forefoot pain and stiffness at the metatarsophalangeal (MTP) joint. It represents a spectrum from subtle subchondral collapse to advanced arthrosis and deformity, with early stages often responding well to conservative off‑loading and later stages sometimes requiring joint‑preserving or joint‑sacrificing surgery.pmc.ncbi.nlm.nih+3​

Definition and epidemiology

Freiberg disease is defined as a localized osteonecrosis/osteochondrosis of a lesser metatarsal head, characterized by collapse, fragmentation, and subsequent deformity of the articular surface. Pathologically it is a form of osteonecrosis rather than classic inflammatory arthritis, and it most frequently involves the second metatarsal head, with the third less often affected and the fourth or fifth rarely involved.

Epidemiologically, Freiberg disease predominates in females and typically presents in adolescence or early adulthood, although later presentations occur in both sexes. The female preponderance is often attributed to both biomechanical factors (a relatively long second metatarsal and forefoot loading patterns) and footwear factors such as high‑heeled or narrow toe box shoes that increase pressure under the lesser metatarsal heads.

Etiology and pathophysiology

The precise cause is multifactorial, with several overlapping theories. A traumatic theory proposes that repetitive microtrauma to the metatarsal head—seen in running, dancing, jumping sports, or high‑heel use—produces cumulative injury to the subchondral bone plate and vascular supply, leading to collapse. A vascular theory emphasises disruption or insufficiency of intraosseous blood flow to the metatarsal head, predisposing to osteonecrosis in structurally vulnerable metatarsals such as a long second ray.wikipedia+4​

Biomechanical and systemic contributors also appear relevant. Altered forefoot loading from cavus or planus foot types, hallux valgus with transfer loading, or iatrogenic overload after first ray surgery can increase stress on the second metatarsal head. Systemic factors such as collagen disorders, endocrine abnormalities, or vascular compromise are occasionally reported, although strong causal links remain less clear.

Clinical presentation and staging

Clinically, patients usually report insidious forefoot pain localised to the affected lesser MTP joint, worsened by weight‑bearing, particularly push‑off and activities that load the forefoot. Swelling, joint tenderness dorsally over the metatarsal head, and difficulty with high‑heeled or fashion shoes are typical, and patients may develop a limp or lateralised gait to avoid painful loading. Stiffness and reduced range of motion at the affected MTP joint, plantar callus under the involved metatarsal, and sometimes mechanical catching or locking can also occur as the articular surface fragments.

Radiographically, Freiberg disease classically demonstrates flattening and sclerosis of the metatarsal head with varying degrees of fragmentation and joint space irregularity. MRI is useful in early disease, showing bone marrow oedema and subchondral changes in the metatarsal head before plain radiographs become diagnostic, which helps prompt off‑loading at a reversible stage. The Smillie classification describes five stages, from subchondral fissuring (stage 1) through dorsal collapse, fragmentation, and deformity (stages 2–4) to end‑stage arthrosis with a flattened, deformed head and secondary degenerative change (stage 5).

Management strategies

Treatment aims to relieve pain, preserve or restore joint congruity, and maintain functional gait, with strategies tailored to stage, symptoms, and patient demands. In early Smillie stages (1–3), nonoperative management is the mainstay, focusing on reducing load through the diseased metatarsal head so that bone remodelling and revascularisation can occur. Common measures include activity modification, temporary immobilisation or casting in more acute cases, metatarsal pads or bars, stiff‑soled or rocker‑soled footwear, and custom orthoses designed to off‑load the affected ray while redistributing pressure to adjacent metatarsals and the midfoot.

When conservative measures fail or in more advanced stages (typically Smillie 3–5), surgery is considered, balancing joint preservation against pain relief and long‑term function. Joint‑preserving options include dorsal closing‑wedge osteotomy of the metatarsal head to rotate a relatively preserved plantar cartilage segment dorsally into the weight‑bearing zone, osteochondral autologous transplantation (OAT) of cylindrical plugs from the knee to reconstruct the joint surface, and microfracture or drilling procedures for smaller focal lesions. For end‑stage deformity, interposition arthroplasty using soft‑tissue spacers, implant arthroplasty, or resection/shortening arthroplasty of the metatarsal head can relieve pain and restore shoe wear, though at the expense of some power at push‑off and with careful consideration of transfer metatarsalgia risk.

Prognosis and clinical implications

Prognosis is generally favourable when Freiberg disease is recognised early and appropriately off‑loaded, with many patients in early stages achieving pain relief and radiographic remodelling without surgery. Later‑stage disease can still be managed effectively, but may leave residual stiffness or mild deformity even with well‑executed reconstructive procedures, and return to high‑impact sport may be limited depending on the extent of osteonecrosis and the technique used.

From a clinical standpoint, Freiberg disease is an important differential diagnosis for chronic lesser MTP joint pain in adolescents and young adults, particularly active females or those with a long second metatarsal and a history of high‑heel or forefoot‑loading activities. Early detection using targeted imaging, meticulous assessment of forefoot biomechanics, and timely implementation of footwear and orthotic strategies can reduce progression to advanced collapse, while contemporary surgical algorithms—including dorsal osteotomy, OAT, and interposition arthroplasty—offer structured options for those who remain symptomatic despite conservative care.

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    Forensic podiatry

    Forensic podiatry is a specialist branch of forensic science in which podiatric knowledge about foot anatomy, biomechanics, and footwear is used to examine foot-related evidence for legal purposes, usually to help identify or exclude individuals in criminal and civil cases. It sits at the intersection of clinical podiatry and forensic practice, translating routine podiatric understanding of the functioning foot into evidential analysis of footprints, gait patterns, footwear, and foot-related records

    Definition and Scope

    Forensic podiatry has been formally defined as “the application of sound and researched podiatry knowledge and experience in forensic investigations, to show the association of an individual with a scene of crime, or to answer any other legal question concerned with the foot or footwear that requires knowledge of the functioning foot.” This definition emphasises that the discipline is evidence‑based and focused on answering specific questions raised within legal investigations rather than providing general clinical care.

    The scope of forensic podiatry is broad, but consistently centres on the relationship between a person’s feet, their gait, their footwear, and the physical traces or images these generate in real‑world environments. Practitioners routinely engage with both physical artefacts such as shoes and footprints, and documentary material such as podiatry records or imaging studies, integrating them into a coherent evidential picture.

    Core Areas of Practice

    Most contemporary descriptions group forensic podiatry practice into three or four core domains: bare footprint analysis, gait analysis from video, footwear examination, and podiatric record comparison.

    • Bare footprint analysis involves the examination of static and dynamic footprints, assessing size, shape, pressure distribution, and individualising features such as deformities, callus patterns, scars, or missing toes to associate or dissociate a footprint with a particular person.
    • Gait analysis uses captured images, often CCTV, to evaluate how a person walks, looking at cadence, step length, joint angles, asymmetries, and habitual compensations, and comparing these with suspects’ observed gaits under controlled conditions
    • Footwear examination focuses on internal and external wear patterns, fit, deformation, insole impressions, and dimensional features to determine whether a shoe is consistent with being worn by a specific individual and how its wear reflects underlying foot function or pathology.
    • Podiatric record comparison is used particularly in human identification, where features of feet recovered in post‑mortem examination are compared with ante‑mortem podiatry notes, radiographs, and other clinical records to support or refute identification hypotheses.

    Role in Criminal and Civil Investigations

    In criminal investigations, forensic podiatrists contribute primarily to questions of identification and reconstruction. When barefoot impressions, shod prints, or relevant CCTV footage are recovered from a scene, the podiatrist may be asked whether they are consistent with a particular suspect, or what they reveal about the unknown individual’s stature, foot morphology, pathology, or gait characteristics.

    Their analyses can also assist with crime scene reconstruction by interpreting the sequence, direction, and qualitative features of footprints to infer aspects of movement such as speed, turning, limping, or falls. Beyond criminal work, forensic podiatrists may be instructed in civil litigation, for example to evaluate whether footwear wear patterns support or undermine claimed mobility limitations, or to comment on the functional implications of shoe fit and design in alleged injury cases.

    Methods, Evidence and Limitations

    Forensic podiatry emphasises systematic, documented methodology, often borrowing and adapting approaches from broader forensic science. Examination typically involves high‑quality imaging, measurement, and detailed description, combined with comparison against exemplar footprints, gait recordings, or footwear from known individuals under controlled conditions. Maintaining an unbroken chain of custody and clear, reproducible procedures is central, because the results must withstand scrutiny in court.

    At the same time, the discipline recognises important limitations: pedal evidence is often partial, distorted by substrate and environmental factors, and influenced by variability in gait and footwear use. Consequently, conclusions are usually expressed in terms of degrees of association or consistency rather than absolute identification, and there is ongoing debate in the legal literature about the evidential weight and validation of some forensic podiatry techniques.

    Training, Professional Standards and Future Directions

    Forensic podiatry is generally practised by clinicians who first qualify in podiatry and then undertake additional education and supervised experience in forensic science, evidence law, and discipline‑specific methods. Professional bodies and specialist advisory groups have published role and scope documents, outlining competencies such as understanding musculoskeletal function, recognising pathological and developmental foot features, and applying these to the analysis of footprints, gait, and footwear within a forensic framework.

    The field continues to evolve, with work underway to strengthen the scientific basis for methods through validation studies, reliability testing, and clearer reporting standards. As digital surveillance, wearable sensors, and high‑resolution imaging become more widespread, forensic podiatry is likely to engage increasingly with large datasets of gait and plantar pressure information, potentially enhancing both the discriminative power and the accountability of this emerging forensic science sub‑discipline.