At 6 months- pain intensity decreased more in the surgical group than in the control group and more in the orthosis group than the control group. At 1 year, pain intensity decreased more in the surgical group than both the other goups. All groups thought they had improved compared with baseline. Pain reduction was statistically significant in the insole group (p<0. 05). No significant difference was found in the night splint group. Hallux valgus and intermetatarsal angles decreased however differences found were not significant.
Only a few randomised trials were identified evaluating orthotic management of Morton’s neuroma (Table 2). Saygi et al. (12) compared footwear modifications with steroid injections and found steroid injections to be better in relieving pain at 6 month follow-up however at one year follow-up no statistically significant outcomes were found. Kilmartin & Wallace (13) used supination and pronation orthoses and reported 50% pain reduction in supination group and 45% pain reduction in pronation group however the results were not statistically significant.
This clinical practice guideline on hallux valgus is based upon consensus of current clinical practice and review of the clinical literature. The guideline was developed by the Clinical Practice Guideline First Metatarsophalangeal (MTP) Joint Disorders Panel of the American College of Foot and Ankle Surgeons. (6) The pathways are illustrated in the diagram below followed by written description for each step (1-8). In clinical practice it is routine to explore orthotic therapy for the management of forefoot conditions with very little evidence to continue their use.
There are only a handful of randomised controlled trials which are summarised in the results section. The studies conducted on hallux valgus (Table 1) have different age groups and interventions thus it is difficult to make any comparisons. Torkki et al. (4), a large well conducted randomised trial found that foot orthosis use for hallux valgus is beneficial as it was better than no treatment. Most studies do not provide sufficient information on the materials or manufacturing technique used to construct the orthoses used in the trails. Tehraninasr et al.
(11) and Postema et al. (14) are the few that do. In Tehraninasr et al. ‘s study a 3 month follow-up period was not long enough to note any structural changes in the angulations as well as long-term pain reduction so a longer study period would have given the ability to make stronger assumptions in the effect of the orthosis and night splint. Saygi et al. (12), a comparison study looking at steroid injections and shoe modifications have such a short follow-up making the results only preliminary. Once again a longer follow-up would have provided more valuable results.
The Kilmartin & Wallace (13) study in their comparative study of supination and pronation orthosis could not provide any evidence to support the usefulness of one orthosis over the other. All studies covered different therapeutic approaches to the conditions. An overall conclusion regarding the effectiveness of foot orthoses cannot be drawn and the studies cannot be compared with one another. The review was conducted to evaluate the effectiveness of orthotic management of forefoot deformities. There appears to be a distinct lack of quality research for these common conditions.
The research is scarce and there are only a handful randomised controlled trials. The studies also examine different areas and no comparison of data is possible. In hallux valgus, conservative measures may be used initially to reduce the symptomatology associated with this deformity however, surgical repair is often used more commonly to correct the deformity. Large well designed clinical trials are required to confirm the validity of existing smaller trials. Until then, orthotic management of forefoot deformities can only be base on clinical experience.