Last update: August 28, 2015

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August 2015

 Ned Tijdschr Geneeskd. 2015

Dutch-language patient-reported outcome measures for foot and ankle injuries; a systematic review

Weel H, Zwiers R, Sierevelt IN, Haverkamp D, van Dijk CN, Kerkhoffs GM.


OBJECTIVE: To investigate which valid and reliable patient-reported outcome measures (PROMs) are available for foot and ankle disorders in the Dutch population, and which of these is the most suitable for uniform use.
DESIGN: Systematic review.
METHOD: PubMed, Embase and Google Scholar were systematically searched for relevant articles; subsequently two researchers screened first the title and the abstract, and then the full article within a selection of these articles. Studies that described a validation process for foot- and ankle-PROMs in a Dutch population were included. Data on measurement characteristics and translation procedure were extracted, and methodological quality of the studies was assessed using the COSMIN checklist. ('COSMIN' stands for 'Consensus-based standards for the selection of health status measurement instruments'.)
RESULTS: Two general foot- and ankle-PROMs in the Dutch language were validated: the Foot and Ankle Outcome Score (FAOS) and the Foot and Ankle Ability Measurement (FAAM); two foot-PROMs: the Manchester Foot Pain and Disability Index (MFPDI) and the 5-point Foot Function Index (FFI-5pt) were also validated. There were also two disorder-specific PROMs available in Dutch: the Victorian Institute of Sports Assessment-Achilles (VISA-A) for Achilles tendinopathies and the Foot Impact Scale for Rheumatoid Arthritis (FIS-RA) for rheumatoid arthritis patients.
CONCLUSION: The FAOS and the FFI-5pt showed the strongest evidence for having good measurement characteristics. Currently, we regard the FAOS as the most appropriate foot- and ankle-PROM for general foot and ankle problems. Further studies of higher methodological quality are, however, required to draw firmer conclusions.


Knee Surg Sports Traumatol Arthrosc. 2015 Aug


Non-steroidal anti-inflammatory drugs (NSAIDs) for treating acute ankle sprains in adults: benefits outweigh adverse events.

van den Bekerom MP, Sjer A, Somford MP, Bulstra GH, Struijs PA, Kerkhoffs GM.


PURPOSE: In the recent clinical guideline for acute lateral ankle sprain, the current best evidence for diagnosis, treatment and prevention strategies was evaluated. Key findings for treatment included the use of ice and compression in the initial phase of treatment, in combination with rest and elevation. A short period of taking non-steroidal anti-inflammatory drugs (NSAIDs) may facilitate a rapid decrease in pain and swelling can also be helpful in the acute phase. The objective was to assess the effectiveness and safety of oral and topical NSAID in the treatment for acute ankle sprains.
METHODS: Randomised controlled trials comparing oral or topic NSAID treatment with placebo or each other were included. Primary outcome measures were pain at rest or at mobilisation and adverse events. Trials were assessed using the Cochrane risk of bias tool.
RESULTS: Twenty-eight studies were included, and 22 were available for meta-analysis. Superior results were reported for oral NSAIDs when compared with placebo, concerning pain on weight bearing on short term, pain at rest on the short term, and less swelling on short- and intermediate term. For topical NSAIDs, superior results compared with placebo were found for pain at rest (short term), persistent pain (intermediate term), pain on weight bearing (short- and intermediate term) and for swelling (short and intermediate term). No trials were included comparing oral with topic NSAIDs, so conclusions regarding this comparison are not realistic.
CONCLUSIONS: The current evidence is limited due to the low number of studies, lack of methodological quality of the included studies as well as the small sample size of the included studies. Nevertheless, the findings from this review support the use of NSAIDs for the initial treatment for acute ankle sprains.
LEVEL OF EVIDENCE: Meta-analysis of RCTs, Level I.


Injury. 2015 Jul 26.

Guesstimation of posterior malleolar fractures on lateral plain radiographs.

Meijer DT, Doornberg JN, Sierevelt IN, Mallee WH, van Dijk CN, Kerkhoffs GM, Stufkens SA; Ankle Platform Study Collaborative - Science of Variation Group; Ankle Platform Study Collaborative - Science of Variation Group.

BACKGROUND: Accurate assessment of articular involvement of the posterior malleolar fracture fragments in ankle fractures is essential, as this is the leading argument for internal fixation. The purpose of this study is to assess diagnostic accuracy of measurements on plain lateral radiographs.
METHODS: Quantification of three-dimensional computed tomography (Q-3D-CT) was used as a reference standard for true articular involvement (mm2) of posterior malleolar fractures. One-hundred Orthopaedic Trauma surgeons were willing to review 31 trimalleolar ankle fractures to estimate size of posterior malleolus and answer: (1) what is the involved articular surface of the posterior malleolar fracture as a percentage of the tibial plafond? and (2) would you fix the posterior malleolus?
RESULTS: The average posterior malleolar fragment involved 13.5% (SD 10.8) of the tibial plafond articular surface, as quantified using Q-3D-CT. The average involvement of articular surface of the posterior malleolar fragment, as estimated by 100 observers on plain radiographs was 24.4% (SD 10.0). The factor 1.8 overestimation of articular involvement was statistically significant (p<0.001). Diagnostic accuracy of measurements on plain lateral radiographs was 22%. Interobserver agreement (ICC) was 0.61. Agreement on operative fixation, showed an ICC of 0.54 (Haraguchi type I=0.76, Haraguchi type II=0.40, Haraguchi type III=0.25).
CONCLUSIONS: Diagnostic accuracy of measurements on plain lateral radiographs to assess articular involvement of posterior malleolar fractures is poor. There is a tendency to misjudge posteromedial involvement (Haraguchi type II).


J Foot Ankle Surg. 2015 Jul 25

Posterior Ankle Impingement in Two Athletic Twin Brothers, Could Genetics Play a Role?

Bech NH, de Leeuw PA, Haverkamp D


Pain posteriorly in the ankle can be caused by bony impingement of the posterolateral process of the talus. This process impinges between the tibia and calcaneus during deep forced plantar flexion. If this occurs it is called posterior ankle impingement syndrome. We report the case of 2 athletic monozygotic twin brothers with bony impingement posteriorly in the left ankle. Treatment consisted of ankle arthroscopy in both patients during which the symptomatic process was easily removed. At 3 months after surgery, both patients were completely free of pain, and 1 of the brothers had already returned to sports. The posterior ankle impingement syndrome is not a rare syndrome, but it has not been described in siblings thus far. That these 2 patients are monozygotic twin brothers suggests that genetics could play a role in the development of skeletal deformities that can result in posterior ankle impingement syndrome.

BMJ Clin Evid. 2015 Jul

Ankle sprain: the effects of non-steroidal anti-inflammatory drugs.

Struijs PA, Kerkhoffs GM.


Injury of the lateral ligament complex of the ankle joint occurs in about one in 10,000 people per day, accounting for a quarter of all sports injuries.
METHODS AND OUTCOMES: We conducted a systematic overview, aiming to answer the following clinical question: What are the effects of non-steroidal anti-inflammatory drugs (NSAIDs) in the treatment of acute ankle sprains? We searched: Medline, Embase, The Cochrane Library, and other important databases up to April 2014 (Clinical Evidence overviews are updated periodically; please check our website for the most up-to-date version of this overview).
RESULTS: At this update, searching of electronic databases retrieved 158 studies. After deduplication and removal of conference abstracts, 97 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 48 studies and the further review of 49 full publications. Of the 49 full articles evaluated, one systematic review and four RCTs were added. We performed a GRADE evaluation for four PICO combinations.
CONCLUSIONS: In this systematic overview, we categorised the efficacy for three interventions, based on information relating to the effectiveness and safety of oral NSAIDs versus placebo, oral versus topical NSAIDs, selective COX-2 inhibitors versus other NSAIDs, and topical NSAIDs versus placebo.



July 2015


Foot Ankle Int. 2015 Jul 9.

Hind- and Midfoot Motion After Ankle Arthrodesis

van der Plaat LW, van Engelen SJ, Wajer QE, Hendrickx RP, Doets KH, Houdijk H, van Dijk CN.


After ankle arthrodesis (AA), compensatory increased range of motion in adjacent joints might lead to increased osteoarthritis. Evaluation of patient-reported outcomes after AA with validated questionnaires is rare. Likewise, reliable radiographic analysis of the position of the AA, expected to influence the range of motion of the hind- and midfoot, is lacking. Therefore, the current study was performed.
Seventeen patients with unilateral AA were included. Sagittal hind- and midfoot range of motion was measured radiographically. The position of the AA in the sagittal and coronal planes and osteoarthritis of adjacent joints were also evaluated radiographically. Measurements were compared to the contralateral side. Patient-reported outcomes via validated questionnaires were compared to a control group (n = 18).
Average follow-up was 3.5 years. Mean combined hind- and midfoot sagittal range of motion after AA equaled that of the contralateral side (20.8 vs 21.0 degrees; P = .93). The tibiotalar angle after AA equaled that of the contralateral side (107 vs 107 degrees; P = .86). The talus was translated posteriorly after AA (T-T ratio 0.45 vs 0.34; P < .001). Low intraclass correlation coefficients (ICC) precluded reliable evaluation of the coronal position of the hindfoot (ICC, 0.07 and -0.34) and osteoarthritis in adjacent joints (ICC range, 0-0.54). SF-36 physical health scores after AA are lower as compared with those of controls (50 vs 56; P = .01). Scores on the Foot and Ankle Outcome Score and Ankle Osteoarthritis Scale were also significantly lower. Patient satisfaction with AA was high (average visual analog scale score, 83).
No increased sagittal range of motion in the hind- and midfoot after AA was found at 3.5 years of follow-up as compared with the contralateral side. Tibiotalar angles were equal. The talus was translated posteriorly. The hindfoot alignment view was not suitable to analyze the position of the hindfoot. Low ICC of the Kellgren and Lawrence scale precluded evaluation of osteoarthritis of adjacent joints. Patients scored lower than controls on self-reported outcome questionnaires but were satisfied with the result of AA.


The 15th Amsterdam Foot & Ankle Course took place on the 17th and 18th of June 2015. There were 76 participants coming from all continents. The average score for the lectures, interactive computer courses, live surgery and of course the hands-on time in the cadaver lab sessions was 4,47(out of 5)!


Quotes of participants:
"Very balanced course, interesting interactive lectures, useful life surgery and instructive hands-on cadaver time. Even the social program is really good. Thanks for everything professor van Dijk!"

"Great course! Professor van Dijk is an excellent teacher and a good man. Keep on going!"

"Learning to do a good arthroscopy from the man himself. His tips and tricks makes me a better surgeon in only two days. I thoroughly enjoyed it!"


Next year course dates are 22th and 23th of June 2016.




The first Advanced Amsterdam Foot & Ankle Course took place on the 17th and 18th of June 2105. The 34 enthusiastic participants reward the course with an average score of 4,5!(out of 5).


Quotes of participants:
"A few years ago I went to the beginner course which was very wonderful and I learned a lot. During the advanced course we had more cadaver time to practice difficult procedures with very helpful course instructions from professor van Dijk!"

"It was really an honor to participate in the first advanced foot and ankle course. Great course and great faculty!"

"I did my first FHL-transfer!!! Wow what a course!"


Next year course dates are 23th and 24th of June 2016.



June 2015


 Knee Surg Sports Traumatol Arthrosc. 2015 Jun 5.

Randomized comparison of tape versus semi-rigid and versus lace-up ankle support in the treatment of acute lateral ankle ligament injury.

van den Bekerom MP, van Kimmenade R, Sierevelt IN, Eggink K, Kerkhoffs GM, van Dijk CN, Raven EE.


Functional treatment is the optimal non-surgical treatment for acute lateral ankle ligament injury (ALALI) in favour of immobilization treatment. There is no single most effective functional treatment (tape, semi-rigid brace or lace-up brace) based on currently available randomized trials.
This study is designed as a randomized controlled trial to evaluate the difference in functional outcome after treatment with tape versus semi-rigid versus lace-up ankle support (brace) for grades II and III ALALIs. The Karlsson score and the FAOS were evaluated at 6-month follow-up.
One hundred and ninety-three patients (52 % males) were randomized, 66 patients were treated with tape, 58 patients with a semi-rigid brace and 62 patients with a lace-up brace. There were no significant differences in any baseline characteristics between the three groups. Mean age of the patients was 37.3 years (35.1-39.5; SD 15.3). Ninety-five males (49 %) were included. One hundred and sixty-one (59 + 50 + 52) patients completed the study through final follow-up; 32 % lost at follow-up. In two patients treated with tape support, the treatment was changed to a semi-rigid brace because of dermatomal blisters. Except for the difference in Foot and Ankle Outcome Score sport between the lace-up and the semi-rigid brace, there are no differences in any of the outcomes after 6-month follow-up.
The most important finding of current study was that there is no difference in outcome 6 months after treatment with tape, semi-rigid brace and a lace-up brace.

May 2015

J Pediatr Orthop. 2015 May 6.

Treatment of Calcaneal Apophysitis: Wait and See Versus Orthotic Device Versus Physical Therapy: A Pragmatic Therapeutic Randomized Clinical Trial.

Wiegerinck JI, Zwiers R, Sierevelt IN, van Weert HC, van Dijk CN, Struijs PA.


Calcaneal apophysitis is a frequent cause of heel pain in children and is known to have a significant negative effect on the quality of life in affected children. The most effective treatment is currently unknown. The purpose of this study is to evaluate 3 frequently used conventional treatment modalities for calcaneal apophysitis.
Three treatment modalities were evaluated and compared in a prospective randomized single-blind setting: a pragmatic wait and see protocol versus a heel raise inlay (ViscoHeel; Bauerfeind) versus an eccentric exercise regime under physiotherapeutic supervision. Treatment duration was 10 weeks.
age between 8 and 15 years old, at least 4 weeks of heel pain complaints due to calcaneal apophysitis based, with a minimal Faces Pain Scale-Revised of 3 points. Primary exclusion criteria included other causes of heel pain and previous similar treatment. Primary outcome was Faces Pain Scale-Revised at 3 months. Secondary outcomes included patient satisfaction and Oxford Ankle and Foot Questionnaire (OAFQ). Points of measure were at baseline, 6 weeks, and 3 months. Analysis was performed according to the intention-to-treat principles.
A total of 101 subjects were included. Three subjects were lost to follow-up. At 6 weeks, the heel raise subjects were more satisfied compared with both other groups (P<0.01); the heel raise group improved significantly compared with the wait and see group for OAFQ Children (P<0.01); the physical therapy group showed significant improvement compared with the wait and see group for OAFQ Parents (P<0.01). Each treatment modality showed significant improvement of all outcome measures during follow-up (P<0.005). No clinical relevant differences were found between the respective treatment modalities at final follow-up.
Treatment with wait and see, a heel raise inlay, or physical therapy each resulted in a clinical relevant and statistical significant reduction of heel pain due to calcaneal apophysitis. No significant difference in heel pain reduction was found between individual treatment regimes. Calcaneal apophysitis is effectively treated by the evaluated regimes. Physicians should deliberate with patients and parents regarding the preferred treatment.

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