The CurePPaC Study - Analysing Non-surgical Treatment Strategies to Cure Pes Planovalgus Associated Complaints

Foot Injuries Clinical Trial

Official title:

The CurePPaC Study - Analysing Non-surgical Treatment Strategies to Cure Pes Planovalgus Associated Complaints

Clinical Trial Details — Status: Terminated

Administrative data

• NCT number: NCT01839669
• Other study ID #: 140928
• Status: Terminated
• Phase: N/A
• First received: April 17, 2013
• Last updated: October 25, 2017
• Start date: July 2013
• Est. completion date: October 25, 2017

Study information

• Verified date: October 2017
• Source: Bern University of Applied Sciences
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

Pes planovalgus, also called flat foot, is a common foot deformity characterized by a flattening of the foot's longitudinal arch and is accompanied by a dysfunction of the posterior tibial tendon ("posterior tibial tendon dysfunction" or "PTTD"). Early stages of this pathology are thought to be treated with non-surgical therapy options like foot orthoses (relief of tendon stress by mechanical unloading of the arch), strengthening exercises or basic physiotherapeutic measures. Recent literature clearly states the urgent need for high quality studies to evaluate the proposed non-surgical treatments (Bowring 2009, 2010). There is only one high quality study available that shows benefits of orthoses therapy and exercise (Kulig 2009). No study to date evaluated functional changes pre-post in dynamic movement pattern like gait or stair climbing. The widespread use of several non-surgical treatment strategies lead to extensive financial expenses of the health care system. An optimized therapeutic strategy could eventually lead to more efficient health care investments. The presented proposal addresses this latest knowledge and aims to analyse non-surgical treatment strategies to Cure Pes Planovalgus associated Complaints (CurePPaC) in the CurePPaC Study.

Description:

Introduction: Pes planovalgus or flatfoot-associated complaints are frequent symptoms, which are thought to be caused by the foot deformity itself. Concurrently, the multifactorial weakness of the M. tibialis posterior and its tendon (trauma, systemic disease, chronic tendon degeneration by overuse) can lead to a flattening of the medial longitudinal arch of the foot. Affected patients suffer from functional impairment and pain. Less severe cases are eligible for non-surgical treatment. Foot orthoses are considered to be the first line approach. Furthermore strengthening of the arch and ankle stabilizing muscles are thought to contribute to an active compensation of the deformity. There is only limited evidence concerning the numerous therapy approaches since high quality studies are missing. One excellent report (Kulig et al. 2009) shows clear benefits by the use of foot orthoses and eccentric strengthening exercises. Beside the fact that evidence-based guidelines for therapy have yet to be developed, no data is available showing functional benefits that accompany the therapy process. This would give further insight into mechanisms behind non-surgical management strategies and how patients benefit functionally from therapy. Purpose: The purpose of this randomized longitudinal intervention study is the evaluation of the therapeutic benefit of three different non-surgical treatment regimens (foot orthoses only FOO, foot orthoses and eccentric exercise FOE, foot orthoses sham treatment FOS) in patients with Pes planovalgus and accompanying complaints. Furthermore the analysis of possible functional changes in gait mechanics (kinematic and kinetic view) and neuromuscular control (electromyographic analysis) will contribute to a superior understanding of functional changes that accompany non-operative management. The purpose of the study is to optimize non-surgical management in patients suffering from Pes planovalgus associated pain leading to an efficient use of health care system's financial resources. Methods: 60 patients with Pes planovalgus associated complaints (clinical diagnosis with plain weight bearing radiographs), M. tibialis posterior dysfunction) are included in the study. Functional impairment is evaluated pre and post intervention by the Foot-Function-Index (FFI, German version). Anthropometric data recording is followed by preparation of subject's foot anatomical landmarks with retroreflective markers and superficially detectable muscles of the ankle joint complex are prepared with surface electromyography (SEMG) electrodes. The 3D kinematic data allows inter alia the calculation of segmental angels of the lower extremity and measurement of navicular drop. The neuromuscular activity is analysed in the time (on-off pattern) and amplitude domain (gait cycle specific phases). Procedure: Potential participants are recruited via the Outpatient Clinic of the Department of Orthopaedic Surgery of the Inselspital, University Hospital, Bern. After initial screening, subjects are randomized to one of three intervention groups (foot orthoses only FOO, foot orthoses and eccentric exercise FOE, foot orthoses sham treatment FOS). FOO-subjects wear custom-made foot orthoses only. FOE-subjects wear individually accustomed foot orthoses and they will perform a combined monitored and home training program to progressively strengthen the M. tibialis posterior and accompanying ankle stabilizing muscles with eccentric exercises. FOS-subjects wear custom-made sham foot orthoses without the functional elements of the treatment orthoses (longitudinal arch support, ankle stabilizer, bowl-shaped heel for rearfoot stability). Subjects are measured pre and post intervention (12 weeks). Measurements include the primary outcome measure Foot-Function-Index (FFI, German version: total score) followed by basic anthropometric measures. Subject preparation allows then the measurement of 10 trials on a walkway and on stairs with embedded force plates in barefoot condition. An average step cycle out of 10 trials is calculated and biomechanical outcome measures are extracted. A re-test allows the calculation of intervention effects by one-factor ANOVA (group: treatment FOO vs. FOE vs. FOS) for repeated measures.

Recruitment information / eligibility

• Status: Terminated
• Enrollment: 7
• Est. completion date: October 25, 2017
• Est. primary completion date: October 25, 2017
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years to 60 Years

Eligibility

Inclusion Criteria:

• Age: 18-60

• Current complaint of foot and ankle pain that lasted for 3 months or more

• Flexible Pes planovalgus deformity in the clinical assessment

• Posterior tibial tendon dysfunction (PTTD) of stage I and II (Johnson & Strom 1989)

• Pes planovalgus foot deformity with longitudinal arch flattening verified by radiograph (Younger 2005): Lateral view: lateral talo-first metatarsal angle ? 0° (break of axis): angle >10° according to Younger (2005); 60Anteroposterior view: anteroposterior talo-first metatarsal angle ? 0° (break of axis): angle >10° according to Younger (2005)

• "too-many toes"-sign from rear frontal view with an abducted forefoot (Johnson & Strom 1989, Kulig 2009b)

• Eligibility for non-surgical treatment

• No indication / not yet an indication for surgical treatment of foot deformity

Exclusion Criteria:

• Rigid foot deformity

• Posterior tibial tendon dysfunction (PTTD) of stage III and IV according to Johnson & Strom 1989 (=>rigid foot deformity)

• Cardio-, neuro-, or peripheral vascular pathology, musculoskeletal pathology, acute infection or alcohol addiction limiting participation in study protocol

• Acute use of local or systemic analgesics

• Acute physical therapy, training therapy or physiotherapy

• Acute overuse or traumatic injury to the lower leg (excluding Pes planovalgus associated pathology)

• Prior surgery to the lower limb

Related Conditions & MeSH terms

• Flatfoot
• Foot Injuries
• Posterior Tibial Tendon Dysfunction

Intervention

Device:
• Foot Orthoses Only
patients wear foot orthoses as a treatment condition - no further therapy

Procedure:
• Foot Orthoses and Eccentric Exercise
patients wear foot orthoses and they perform an additional home-based eccentric training program for the M. tibialis posterior

Device:
• Sham Foot Orthoses
patient wear sham foot orthoses (control condition)

Locations

Country	Name	City	State
Switzerland	Inselspital, University Hospital Bern	Bern
Switzerland	Klinik Sonnenhof Bern	Bern
Switzerland	Salem Spital Bern	Bern
Switzerland	Salem-Spital Orthopädische Klinik Bern	Bern
Switzerland	Spital Netz Bern Ziegler	Bern
Switzerland	spital STS AG	Thun

Sponsors (3)

Lead Sponsor	Collaborator
Bern University of Applied Sciences	Swiss National Science Foundation, University Hospital Inselspital, Berne

Country where clinical trial is conducted

Switzerland, 

References & Publications (6)

Blasimann A, Eichelberger P, Brülhart Y, El-Masri I, Flückiger G, Frauchiger L, Huber M, Weber M, Krause FG, Baur H. Non-surgical treatment of pain associated with posterior tibial tendon dysfunction: study protocol for a randomised clinical trial. J Foot Ankle Res. 2015 Aug 14;8:37. doi: 10.1186/s13047-015-0095-4. eCollection 2015. — View Citation

Bowring B, Chockalingam N. A clinical guideline for the conservative management of tibialis posterior tendon dysfunction. Foot (Edinb). 2009 Dec;19(4):211-7. doi: 10.1016/j.foot.2009.08.001. Epub 2009 Sep 18. — View Citation

Bowring B, Chockalingam N. Conservative treatment of tibialis posterior tendon dysfunction--a review. Foot (Edinb). 2010 Mar;20(1):18-26. doi: 10.1016/j.foot.2009.11.001. Epub 2009 Dec 24. Review. — View Citation

Johnson KA, Strom DE. Tibialis posterior tendon dysfunction. Clin Orthop Relat Res. 1989 Feb;(239):196-206. — View Citation

Kulig K, Reischl SF, Pomrantz AB, Burnfield JM, Mais-Requejo S, Thordarson DB, Smith RW. Nonsurgical management of posterior tibial tendon dysfunction with orthoses and resistive exercise: a randomized controlled trial. Phys Ther. 2009 Jan;89(1):26-37. doi: 10.2522/ptj.20070242. Epub 2008 Nov 20. — View Citation

Younger AS, Sawatzky B, Dryden P. Radiographic assessment of adult flatfoot. Foot Ankle Int. 2005 Oct;26(10):820-5. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Other	Pain Disability Index	additional analysis of change from baseline to week 4, and analysis of change from baseline to week 8	change from baseline (pre intervention) to week 12 (post intervention)
Other	Visual Analogue Scale	assessing pain pre- and post biomechanical testing / change from baseline to week 12	change from baseline (pre intervention) to week 12 (post intervention)
Other	kinematic data from 3d movement analysis	regarding distance: navicular drop; regarding angular data (angle at initial contact, max. manifestation during stance, range): foot progression angle, forefoot to rearfoot dorsiflexion, forefoot to rearfoot adduction, forefoot to rearfoot supination, ankle dorsiflexion, ankle adduction, ankle eversion, knee flexion, knee adduction, knee internal rotation, hip flexion, hip adduction, hip internal rotation	change from baseline (pre intervention) to week 12 (post intervention)
Other	neuromuscular activity	EMG of M. tibialis anterior, M. peroneus longus, M. gastrocnemius lateralis/medialis, M. soleus: onset of activation, time of maximum activation, total time of activation, normalized amplitude in preactivation, normalized amplitude in weight acceptance, normalized amplitude in mid-stance, normalized amplitude in push-off	change from baseline (pre intervention) to week 12 (post intervention)
Primary	Foot Function Index - total score	additional analysis of change from baseline to week 4, and analysis of change from baseline to week 8	change from baseline (pre intervention) to week 12 (post intervention)
Secondary	Foot Function Index - subcategory pain	additional analysis of change from baseline to week 4, and analysis of change from baseline to week 8	change from baseline (pre intervention) to week 12 (post intervention)
Secondary	Foot Function Index - subcategory disability	additional analysis of change from baseline to week 4, and analysis of change from baseline to week 8	change from baseline (pre intervention) to week 12 (post intervention)
Secondary	Foot Function Index - subcategory activity limitation	additional analysis of change from baseline to week 4, and analysis of change from baseline to week 8	change from baseline (pre intervention) to week 12 (post intervention)

External Links

•   project description in the database of the Swiss National Science Foundation