First line and additional interventions

First line intervention provides the patient with guidance on self management of their condition. This advice can provide benefit at any juncture in the treatment pathway and should be reinforced as appropriate.

Orthotists should offer guidance on the following, where appropriate:
Weight loss advice / referral to weight management services

• Activity modification advice
• Sign posting to GP regarding Analgesia & Non-Steroidal Anti-Inflammatory Drugs
• PEACE and LOVE (Protect, Elevate, Avoid anti-inflammatory modalities, Compress, Educate, Load, Optimisation, Vascularisation and Exercise)
• Footwear Advice
• Exercise prescription, mobilisation and conditioning exercises

In many instances the use of orthoses combined with strengthening and conditioning regimes have been shown to improve patient outcomes and should therefore be considered in addition to the provision of an orthosis where appropriate.

Within their scope of practice and where there is a clinical justification and evidence base, Orthotists may also consider the addition of alternative treatment modalities. Depending on the presenting condition and duration of symptoms, these may include:

• Taping
• Corticosteroid injection
• Local anaesthetic injection
• Shockwave therapy
• Manipulations

Goal setting and outcome measures should be used to assess patient progress within expected and agreed time scales. Discharge should be considered when goals have been achieved or if care is being escalated. Orthotists should be aware of the escalation process within their place of work and instigate this in appropriate circumstances. This may include:

• Onward referral for further diagnostic testing where this is not available within the Orthotic service
• Onward referral for consideration of treatment from another department
• Urgent referral when Red Flag presentations are suspected

The evidence below provides some insight into the appropriateness of the preceding information; however, Orthotists should always consider the individual presentation and the evidence base for the specific presenting condition when discussing treatment options with the patient.

Weight management and MSK foot pathology

Butterworth, P.A., Landorf, K.B., Smith, S.E. and Menz, H.B., 2012. The association between body mass index and musculoskeletal foot disorders: a systematic review. Obesity reviews: an official journal of the International Association for the Study of Obesity, 13(7), p.630.
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Butterworth, P.A., Landorf, K.B., Gilleard, W., Urquhart, D.M. and Menz, H.B., 2014. The association between body composition and foot structure and function: a systematic review. Obesity reviews: an official journal of the International Association for the Study of Obesity, 15(4), p.348.
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Franceschi, F., Papalia, R., Paciotti, M., Franceschetti, E., Di Martino, A., Maffulli, N. and Denaro, V., 2014. Obesity as a risk factor for tendinopathy: a systematic review. International journal of endocrinology, 2014.
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Van Leeuwen, K.D.B., Rogers, J., Winzenberg, T. and van Middelkoop, M., 2016. Higher body mass index is associated with plantar fasciopathy/‘plantar fasciitis’: systematic review and meta-analysis of various clinical and imaging risk factors. Br J Sports Med, 50(16), pp.972-981.
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HCPC Standards of Proficiency

HCPC outline the standards of proficiency for all registered Orthotists in the UK
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Combined intervention

Houck, J., Neville, C., Tome, J. and Flemister, A., 2015. Randomized controlled trial comparing orthosis augmented by either stretching or stretching and strengthening for stage II tibialis posterior tendon dysfunction. Foot & ankle international, 36(9), pp.1006-1016.
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Huffer, D., Hing, W., Newton, R. and Clair, M., 2017. Strength training for plantar fasciitis and the intrinsic foot musculature: A systematic review. Physical Therapy in Sport, 24, pp.44-52.
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Jung, D.Y., Koh, E.K. and Kwon, O.Y., 2011. Effect of foot orthoses and short-foot exercise on the cross-sectional area of the abductor hallucis muscle in subjects with pes planus: A randomized controlled trial 1. Journal of Back and Musculoskeletal Rehabilitation, 24(4), pp.225-231.
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Kulig, K., Reischl, S.F., Pomrantz, A.B., Burnfield, J.M., Mais-Requejo, S., Thordarson, D.B. and Smith, R.W., 2009. Nonsurgical management of posterior tibial tendon dysfunction with orthoses and resistive exercise: a randomized controlled trial. Physical Therapy, 89(1), pp.26 -37.
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Smith, M., Hurn, S., Bonacci, J., Chicoine, D., Esculier, J., Collins, N. and Vicenzino, B., 2023. A systematic literature review and meta-analysis of the effect of physical interventions on the intrinsic foot muscles. Journal of Science and Medicine in Sport, 26, p.S116.
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Young, R., Nix, S., Wholohan, A., Bradhurst, R. and Reed, L., 2013. Interventions for increasing ankle joint dorsiflexion: a systematic review and meta-analysis. Journal of foot and ankle research, 6(1), p.46.
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