11/11/2012. Associations of Foot Forces and Pressures to Regional Foot Pain: The Framingham Foot Study. Acknowledgements & Disclosures

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Dufour, MA IFAR & BU School of Public Health, Boston, MA Thomas J. Hagedorn, BS IFAR, Boston MA Virginia A. Casey, PhD, MPH IFAR, Boston, MA Marian T.

1 11/11/2012 Associations of Foot Forces and Pressures to Regional Foot Pain: The Jody L. Riskowski, PhD, CSCS Institute for Aging Research (IFAR), Hebrew SeniorLife Harvard Medical School Boston, MA, USA Acknowledgements & Disclosures Alyssa B. Dufour, MA IFAR & BU School of Public Health, Boston, MA Thomas J. Hagedorn, BS IFAR, Boston MA Virginia A. Casey, PhD, MPH IFAR, Boston, MA Marian T. Hannan, ScD, MPH IFAR & Harvard Medical School, Boston, MA Funding: NIH-NIAMS RO1-AR NIH-NIA T32-AG Disclosures: No relevant financial relations to disclose Evidence-Based Medicine Introduction: Gait Bruening DA, et al. Measured and estimated ground reaction forces for multi-segment foot models. J Biomech, 2010; 43 (16): Menz HB, Morris ME. Clinical determinants of plantar forces and pressures during walking in older people. Gait Posture 2006; 24 (2):

11/11/2012 Purpose: To determine effects of regional foot pain on foot biomechanics Participants: Outcomes: Foot Biomechanical Measures Framingham Original, Offspring, & Community cohorts (2002 08)

foot biomechanics 2) regional foot pain (y/n) 3) physical foot examination Exclusion criteria: amputations Covariates: gender, age, weight, body mass index (BMI) Foot masked for regions of interest

1 (two trials, one per foot) 1 Dawber, et al., 1951; 2 Feinleib, et al., 1975 1 McPoil, et al.

2 11/11/2012 Purpose: To determine effects of regional foot pain on foot biomechanics Participants: Outcomes: Foot Biomechanical Measures Framingham Original, Offspring, & Community cohorts ( ) Original cohort: started in Offspring cohort: started in Community cohort: new cohort from census-based, randomdigit dialing of adults in Framingham, MA Inclusion criteria: data on 1) foot biomechanics 2) regional foot pain (y/n) 3) physical foot examination Exclusion criteria: amputations Covariates: gender, age, weight, body mass index (BMI) Foot masked for regions of interest (Novel Automask) Data analyzed included regional pressure and loading Foot biomechanical data collected using Tekscan Matscan Participants walked barefoot at self-selected pace using two-step method 1 (two trials, one per foot) 1 Dawber, et al., 1951; 2 Feinleib, et al., McPoil, et al., 1999 Predictors: Regional Foot Pain Covariate: Structural Foot Disorders (present/absent) Participants selected location(s) of foot pain Foot pain locations collapsed to four regions: Toes (nail, toe pain) Forefoot (ball, forefoot pain) Midfoot (arch pain) Rearfoot (heel, hindfoot pain) Grouped each foot as: Toe Pain Only 2 Regions of Pain Forefoot Pain Only 3/+ Regions of Pain Midfoot Pain Only Rearfoot Pain Only No Regional Foot Pain (referent) Hallux valgus Hallux rigidus Tailor s bunion Hammer toes Overlapping toes Claw Toes 2

Data Analysis Per-foot analysis with General Estimating Equations (GEE) determined association between regional force and pressure by pain group Models adjusted by age, gender, weight, BMI, and

05 *Structural foot disorders confounders in the midfoot region Inclusion/Exclusion (N = 3197; feet N = 6380) Missing foot pain data N = 35 Inclusion/Exclusion Missing foot pain data N = 35

3 Data Analysis Per-foot analysis with General Estimating Equations (GEE) determined association between regional force and pressure by pain group Models adjusted by age, gender, weight, BMI, and structural foot disorders* Alpha set to p 0.05 *Structural foot disorders confounders in the midfoot region Inclusion/Exclusion (N = 3197; feet N = 6380) Missing foot pain data N = 35 Inclusion/Exclusion Missing foot pain data N = 35 Inclusion/Exclusion Missing foot pain data N = 35 Total Population Total Population (N = 3197; feet N = 6380) (N = 3197; feet N = 6380) Age, years 66.2 ± 10.5 Age, years 66.2 ± 10.5 Women (%) 1795 (56) Women (%) 1795 (56) BMI, kg/m ± 5.5 BMI, kg/m ± 5.5 Toe Pain (%) 669 (11) Forefoot Pain (%) 762 (12) Midfoot Pain (%) 427 (6.8) Rearfoot Pain (%) 627 (10) Structural Foot Disorder (%) 2298 (36) Data presented as mean (standard deviation) or N feet (% of population) Data presented as mean (standard deviation) or N feet (% of population) Results: Regional Maximum Forces Blue indicates lower force, red indicates higher force, white indicates similar force relative to referent Results: Regional Peak Pressures Blue indicates lower pressure, red indicates higher pressure, white indicates similar pressure relative to referent Compared to referent after adjustment (age, gender, weight, structural foot disorders) Summative: Regional pain typically not associated with greater/lesser maximum forces region of pain Conclusion: Regional pain is associated with aberrant forces 1 1 Coughlin, et al., 2000 Compared to referent after adjustment (age, gender, weight, structural foot disorders) Summative: Increased pressure at pain region not associated with regional foot pain 3

Discussion: Summary Discussion: Strengths & Limitations Midfoot pain region has higher forces at pain site Midfoot pain increased pressure under toe region Abnormal toe pressures links with foot

and risk of osteoporosis 4 Limitations of the study: Cross-sectional analysis Only one scan per foot Recorded at 40 frames/second Strengths of the study: Population-based study of adults GEE

4 Discussion: Summary Discussion: Strengths & Limitations Midfoot pain region has higher forces at pain site Midfoot pain increased pressure under toe region Abnormal toe pressures links with foot disorders 1 Midfoot force-toe pressure affect stability 2 Distal foot pain associated with greater proximal loading Rearfoot and forefoot coupling 3 Reduced rearfoot forces may affect joint loading and risk of osteoporosis 4 Limitations of the study: Cross-sectional analysis Only one scan per foot Recorded at 40 frames/second Strengths of the study: Population-based study of adults GEE statistical modeling provides to evaluate each foot 1 Coughlin, et al., 2000: 2 Menz & Morris, 2006; 3 Woodburn, et al., 2003; 4 Lau, et al., 2011 Conclusions Differences in plantar loading with region-specific pain may influence biomechanics at other joints and injury risk Future work is needed to evaluate differences in lower extremity joints (e.g., knees, hips) with region-specific foot pain Longitudinal studies of foot biomechanics and regional pain to determine causal relations Questions? Regional maximum vertical (% difference relative to referent) Feet by region(s) of foot pain Regional peak pressure (% difference relative to referent) Toe Forefoot Referent Pain Only Pain only Midfoot Rearfoot pain only pain only 2 regions of pain 3/+ regions of pain Feet (%) Age (years) 66 ± ± ± ± ± ± ± 11.1 Women (%) 2599 (53) 171 (65) 170 (75) 40 (51) 156 (58) 320 (67) 131 (72) BMI (kg/m 2 ) 28.1 ± ± ± ± ± ± ± 6.2 Low Arch (%) 868 (19) 52 (20) 48 (21) 24 (31) 64 (25) 117 (26) 47 (28) Data presented as mean (standard deviation) or N of feet (% of population) 4

5 No Total Regional Population Foot Pain (Referent) (N=6280) (N=4760) Toe Pain Only (N=262) Forefoot Midfoot Pain Only Pain Only (N=223) (N=78) Rearfoot Pain Only (N=261) Pain in Two Regions (N=473) Pain in Three or More Regions (N=223) Structural Foot Disorder (has disorder) Hallux Valgus (%) 1724 (28) 1225 (26) 100 (38.2) 79 (35) 17 (22) 62 (24) 167 (35) 74 (33) Claw Toes (%) 106 (2) 62 (1.3) 12 (4.6) 6 (2.7) 0 9 (3.5) 9 (1.9) 8 (3.6) Hammer Toes (%) 1097 (18) 772 (16) 59 (23 42 (19) 20 (26) 38 (15) 107 (23) 59 (27) Overlapping Toes (%) 377 (6) 260 (5.5) 26 (9.9) 12 (5.4) 5 (6.4) 20 (7.7) 34 (7.2) 20 (9.0) Hallux Rigidus (%) 232 (3.7) 150 (3.2) 12 (4.6) 11 (4.9) 0 3 (1.2) 37 (7.8) 19 (8.5) Pain Locations (has pain) Toe Region (%) 669 (11) 262 (100) 255 (54) 152 (68) Nails (%) 52 (0.8) 22 (8.4) 18 (3.8) 12 (5.4) Toes (%) 633 (10) 245 (94) 238 (50) 150 (67) Forefoot Region (%) 762 (12) 223 (100) 328 (69) 221 (95) Forefoot (%) 441 (7.0) 124 (56) 205 (43) 112 (50) Ball of Foot (%) 415 (6.6) 110 (49) 143 (30) 162 (73) Midfoot Region (%) 427 (6.8) 78 (100) 175 (37) 174 (78) Rearfoot Region (%) 627 (10) 261 (100) 188 (40) 178 (80) Heel (%) 346 (5.5) 120 (46) 100 (21) 126 (57) Hindfoot (%) 390 (6.2) 177 (68) 116 (25) 97 (44) Weightbearing assessment: Hallux valgus was defined as a 15 or greater abduction of the hallux from the first metatarsal determined by comparison to a laminated depiction of the angle Hammer toes were considered present if there was a contraction of the proximal interphalangeal toe joint Claw toes were defined as a contraction of both the proximal and distal interphalangeal joint Tailor s bunion was recorded when an enlargement and lateral displacement of the fifth metatarsal was observed Non-Weightbearing assessment: For plantar fasciitis, the examiner applied four pounds of force to the front edge of the heel on the underside of the foot and recorded the disorder as present if the participant reported feeling pain Hallux rigidus was considered present if the hallux was frozen or rigid during attempted passive movement by the examiner Morton s neuroma was assessed by exerting four pounds of force between toes two and three, three and four, and then all squeezing all toes simultaneously. If the participant reported pain during any part of this procedure, Morton s Neuroma was recorded as present. Data presented as N of feet (% of population) 5

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