https://www.um.edu.mt/library/oar/handle/123456789/5175 2026-08-02T14:14:19Z 2026-08-02T14:14:19Z https://www.um.edu.mt/library/oar/handle/123456789/148035 2026-07-14T09:52:57Z 2026-01-01T00:00:00Z

Title: The effectiveness of orthotic insole materials for diabetic foot offloading : a systematic review Abstract: Review objectives: 'What is the effectiveness of different orthotic insole materials for diabetic foot offloading in reducing plantar pressure and improving biomechanical and clinical outcomes in adults living with diabetic peripheral neuropathy? 'To systematically evaluate the evidence on orthotic insole materials used for diabetic foot offloading, focusing on their biomechanical effectiveness, clinical outcomes, and relevance for the development of innovative insole materials.; The following questions will be investigated:; 1. How effective are commonly used orthotic insole materials, including EVA, Plastazote, PORON, polyurethane, gel, memory foam and viscoelastic materials, in reducing plantar pressure in adults with diabetic peripheral neuropathy?; 2. What effects do orthotic insole materials have on pressure–time integral, shear stress/forces, shock absorption and plantar pressure distribution in adults with diabetic peripheral neuropathy?; 3. What clinical outcomes are associated with the use of orthotic insoles in diabetic foot management, including ulcer prevention, ulcer recurrence, comfort, adherence and patientreported outcomes?; 4. What evidence exists regarding innovative orthotic insole materials, including non-Newtonian and adaptive polymers, and what knowledge gaps remain in their development and evaluation for diabetic foot offloading?

2026-01-01T00:00:00Z Mifsud, Tiziana Chatzistergos, Panagiotis Maganaris, Constantinos Chockalingam, Nachiappan Padhiar, Nat Micallef Stafrace, Kirill Gatt, Alfred https://www.um.edu.mt/library/oar/handle/123456789/146083 2026-04-30T12:40:00Z 2023-01-01T00:00:00Z

Title: Supersonic shear wave elastography of human tendons is associated with in vivo tendon stiffness over small strains Authors: Mifsud, Tiziana; Chatzistergos, Panagiotis; Maganaris, Constantinos; Chockalingam, Nachiappan; Padhiar, Nat; Micallef Stafrace, Kirill; Gatt, Alfred Abstract: Supersonic shear wave (SW) elastography has emerged as a useful imaging modality offering researchers and clinicians a fast, non-invasive, quantitative assessment of tendon biomechanics. However, the exact relationship between SW speed and in vivo tendon stiffness is not intuitively obvious and needs to be verified. This study aimed to explore the validity of supersonic SW elastography against a gold standard method to measure the Achilles tendon’s in vivo tensile stiffness by combining conventional ultrasound imaging with dynamometry. Twelve healthy participants performed maximal voluntary isometric plantarflexion contractions (MVC) on a dynamometer with simultaneous ultrasonographic recording of the medial gastrocnemius musculotendinous junction for dynamometry-based measurement of stiffness. The tendon’s force–elongation relationship and stress–strain behaviour were assessed. Tendon stiffness at different levels of tension was calculated as the slope of the stress–strain graph. SW speed was measured at the midportion of the free tendon and tendon Young’s modulus was estimated. A correlation analysis between the two techniques revealed a statistically significant correlation for small strains (r(10) = 0.604, p =.038). SW-based assessments of in vivo tendon stiffness were not correlated to the gold standard method for strains in the tendon>10 % of the maximum strain during MVC. The absolute values of SW-based Young’s modulus estimations were approximately-three orders of magnitude lower than dynamometry-based measurements. Supersonic SW elastography should be only used to assess SW speed for the detection and study of differences between tissue regions, differences between people or groups of people or changes over time in tendon initial stiffness (i.e., stiffness for small strains).

2023-01-01T00:00:00Z Mifsud, Tiziana Gatt, Alfred Micallef‑Stafrace, Kirill Chockalingam, Nachiappan Padhiar, Nat https://www.um.edu.mt/library/oar/handle/123456789/146054 2026-04-30T07:48:20Z 2023-01-01T00:00:00Z

Title: Elastography in the assessment of the Achilles tendon : a systematic review of measurement properties Authors: Mifsud, Tiziana; Gatt, Alfred; Micallef‑Stafrace, Kirill; Chockalingam, Nachiappan; Padhiar, Nat Abstract: Background: Managing and rehabilitating Achilles tendinopathy can be difficult, and the results are often unsatisfactory. Currently, clinicians use ultrasonography to diagnose the condition and predict symptom development. However, relying on subjective qualitative findings using ultrasound images alone, which are heavily influenced by the operator, may make it difficult to identify changes within the tendon. New technologies, such as elastography, offer opportunities to quantitatively investigate the mechanical and material properties of the tendon. This review aims to evaluate and synthesise the current literature on the measurement properties of elastography, which can be used to assess tendon pathologies.; Methods: A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. CINAHL, PubMed, Cochrane, Scopus, MEDLINE Complete, and Academic Search Ultimate were searched. Studies assessing the measurement properties concerning reliability, measurement error, validity, and responsiveness of the instruments identified in healthy and patients with Achilles tendinopathy were included. Two independent reviewers assessed the methodological quality using the Consensus-based Standards for the Selection of Health Measurement Instruments methodology.; Results: Out of the 1644 articles identified, 21 were included for the qualitative analysis investigating four different modalities of elastography: axial strain elastography, shear wave elastography, continuous shear wave elastography, and 3D elastography. Axial strain elastography obtained a moderate level of evidence for both validity and reliability. Although shear wave velocity was graded as moderate to high for validity, reliability obtained a very low to moderate grading. Continuous shear wave elastography was graded as having a low level of evidence for reliability and very low for validity. Insufficient data is available to grade three-dimensional shear wave elastography. Evidence on measurement error was indeterminate so evidence could not be graded.; Conclusions: A limited number of studies explored quantitative elastography on Achilles tendinopathy as most evidence was conducted on a healthy population. Based on the identified evidence on the measurement properties of elastography, none of the different types showed superiority for its use in clinical practice. Further high-quality studies with longitudinal design are needed to investigate responsiveness.

2023-01-01T00:00:00Z Thiaspras, Loukas Formosa, Cynthia Papanas, Nikolaos Gatt, Alfred https://www.um.edu.mt/library/oar/handle/123456789/145480 2026-04-13T09:46:50Z 2026-01-01T00:00:00Z

Title: Foot orthoses for forefoot pressure reduction and the hypothesized role in calf muscle stretching : a systematic review highlighting an evidence gap Authors: Thiaspras, Loukas; Formosa, Cynthia; Papanas, Nikolaos; Gatt, Alfred Abstract: Background: Excessive forefoot plantar pressures are associated with pain, ulceration risk, and functional limitations in both healthy individuals and those with pathologies such as rheumatoid arthritis (RA). Limited ankle dorsiflexion, often related to gastrocnemius–soleus tightness, may contribute to forefoot overload. Although foot orthoses (FOs) are widely used to redistribute plantar loads, it remains unclear whether the existing evidence includes orthotic interventions designed to promote posterior chain flexibility.; Objective: To systematically evaluate the effectiveness of foot orthoses in reducing forefoot plantar pressure and pressure-time integral (PTI), and to identify whether current evidence addresses orthoses specifically intended to facilitate calf muscle stretching.; Methods: A systematic review was conducted in accordance with PRISMA 2020 guidelines. Five databases were searched up to December 2024. Inclusion criteria encompassed adult populations, studies reporting plantar pressure outcomes, and interventions involving foot orthoses. Methodological quality was assessed using RoB 2 and ROBINS-I tools. Due to substantial clinical and methodological heterogeneity, a meta-analysis was not undertaken and findings were synthesized narratively.; Results: Twelve studies involving 456 participants met the inclusion criteria. No eligible studies directly evaluated orthoses designed to stretch the triceps surae. All included studies reported reductions in peak plantar pressure (PPP) and/or pressure-time integral (PTI). Descriptively, PPP reductions were greater in healthy cohorts (unweighted mean 20.2%) compared to RA populations (14.5%), whereas PTI reductions were descriptively higher in RA participants (22.2% vs. 14.7%). Interventions incorporating metatarsal pads and soft contoured orthoses showed consistent reductions in forefoot loading across studies.; Conclusions: Foot orthoses appear to be consistently associated with reductions in forefoot plantar loading across populations, particularly in individuals with inflammatory or structural pathology. The absence of studies specifically evaluating posterior chain flexibility represents a clear evidence gap. Future research should explore whether orthotic designs combining forefoot offloading with mechanisms that may influence ankle dorsiflexion or posterior chain mechanics could have biomechanical relevance.

2026-01-01T00:00:00Z