https://www.um.edu.mt/library/oar/handle/123456789/8441 2026-04-04T04:36:09Z https://www.um.edu.mt/library/oar/handle/123456789/144134 Title: An investigation into remodelling, morphological and mechanical changes in the clinical management of mid-portion achilles tendinopathy Abstract: Mid-portion Achilles tendinopathy is a chronic degenerative tendon condition characterised by pain, impaired function and structural alterations that compromise tendon integrity, affecting both sedentary and active individuals. Despite its widely reported high prevalence, the remodelling process during treatment remains poorly understood. This research investigates Achilles tendon remodelling during rehabilitation and High-Volume Image Guided Injection treatment, focusing on mechanical and morphological property changes to improve clinical management and patient outcomes. Carried out in three phases, the research first identified gaps in clinical practice and assessment modalities through various reviews and a sequential mixed methods scoping study. The findings highlighted the insufficiency of relying solely on morphological evaluation and underscored the local needs for optimised referral pathways, objective outcome measures and multidisciplinary care integration. This led to the establishment of a multidisciplinary Sports and Exercise Clinic. In phase two, the research validated both shear wave elastography and myotonometry as methods for measuring small tendon strains, the latter emerging as the more pragmatic tool. This led to the development of a standardised reliability protocol for consistent monitoring of tendon mechanical properties during treatment and rehabilitation. Phase three employed a pragmatic, assessor-blinded randomised controlled trial comparing exercise rehabilitation alone to High-Volume Image Guided Injection combined with exercise. The findings suggest that although both groups achieved comparable pain reduction, the intervention group showed an early unexpected reduction in stiffness (t=-3.09(16), p=0.007), raising questions about the injection’s immediate mechanical effect on the tendon. Furthermore, tendon bulge thickness decreased significantly in the intervention group, though this change fell short of clinical significance suggesting that morphological changes may require longer period to manifest. These findings should be interpreted in light of the small sample size, which was justified by a higher prevalence of insertional tendinopathy (67.9%) compared to mid-portion tendinopathy (20.3%) in the study population - an observation linked to shorter free tendon length, which may represent a potential anatomical risk factor for insertional tendinopathy. This research provides novel insights into tendon remodelling and is the first to objectively quantify short-term mechanical stiffness post High-Volume Image Guided Injection, highlighting a previously underexplored aspect of treatment efficacy and underscoring the need for further studies to evaluate the injection’s long term biomechanical impact. Description: Ph.D.(Melit.) 2026-01-01T00:00:00Z https://www.um.edu.mt/library/oar/handle/123456789/144132 Title: The development of a telemedicine service for core podiatry in the Maltese public service Abstract: From a technological, cultural, and social perspective, telemedicine is considered one of the significant innovations in health services. Telemedicine benefits accessibility to health care services and promotes the quality of healthcare and organizational efficiency. Nonetheless, there are significant barriers to standardizing telemedicine as well as its complete consolidation and expansion. Although a growing number of pilot projects and viability studies have been carried out in various healthcare professions, only a few telemedicine applications have been rooted in clinical practice and consolidated into medical processes. Moreover, even these were frequently dropped once the initial phase was over due to heavy regulatory laws and resistance to change from stakeholders. This PhD research study aimed to investigate the feasibility of the development of a podiatric telemedicine framework for low-risk patients in a primary care setting. This research evaluated the possibility of implementing telemedicine in core podiatry; analyse interactions that arise throughout the process of implementation in podiatric care and changes that occur in organizations, management models, culture, and healthcare services. It also reflects on significant features associated to prioritization, design, deployment, integration, and assessment tailored for core podiatry services. The evaluation of the developed podiatric telemedicine guideline ultimately concentrates on significant aspects in the successful development of telemedicine and generates recommendations to overcome difficulties that could arise. This research comprised three main studies, an initial scoping study to investigate current foot and ankle telemedicine practice guidelines, the second study adopting a modified Delphi 3 study to develop the podiatric telemedicine guideline, followed by the last phase which included healthcare provider training and a pilot study testing the podiatric telemedicine guideline in a primary care setting. Lastly, this PhD research shed light on the challenges faced and opportunities for podiatric service expansion in a primary care setting. This study developed the first evidence-based guideline for podiatry services in a primary care setting for low-risk patients. Description: Ph.D.(Melit.) 2026-01-01T00:00:00Z https://www.um.edu.mt/library/oar/handle/123456789/144131 Title: The effectiveness of an innovative Hallux Valgus sock on dysfunction of the 1st Ray and Hallux Abducto-valgus progression Abstract: Hallux Abducto Valgus (HAV) is a progressive structural deformity of the first metatarsophalangeal joint which results in the lateral deviation of the hallux, and also can lead to changes in foot biomechanics, chronic pain, decreased mobility, difficulty in footwear fitting, and diminished quality of life. With a high global prevalence, especially in older adults and females, HAV lacks a consensus on an effective form of conservative treatment, and many acute and chronic situations of HAV involved surgery as the conventional treatment. Surgery in itself can create complications and risk for the patient, therefore the justification of an effective non-invasive treatment approach is both clinically and cost effective. The aim of this PhD study was to explore, assess, and test an innovative non-invasive therapeutic device; an ergonomically designed Hallux Valgus (HV) sock with a biomechanical corrective effect to relieve symptoms and restore function. The study was undertaken in four phases. Phase I entailed a full systematic review of non-surgical treatments for HAV. The systematic review involved determining clinical effectiveness, methodological quality, and biomechanical rationale of various interventions, including orthotic devices, physical therapy, footwear modifications, and bracing methods. It also aimed to assess the long-term outcomes and potential risks associated with each treatment modality, providing a comprehensive analysis of their effectiveness in halting or reversing the progression of hallux valgus.. The review found no close similarity across studies, substantial variability in outcomes, and limited high-quality evidence showing long term effectiveness for non-surgical approaches – signifying a clinical need to develop and conduct clinical trials. Phase II focused on preliminary biomechanical evaluation of the HV sock with a series of laboratory-based pilot studies. Particularly, surface electromyography (EMG) assessed muscle activation patterns, adductor hallucis, while plantar pressure mapping evaluated changes in forefoot pressure distribution and the first ray alignment while performing dynamic tasks. The studies provided evidence of a tangible mediation by reducing medial deviation of the first metatarsal, and increasing optimal loading patterns throughout the gait with the HV sock. Phase III involved a randomized controlled clinical trial with 100 participants diagnosed with mild to moderate HAV. Participants were randomly assigned to either conservative podiatric care (control group) or conservative podiatric care plus daily use of the HV sock (intervention group) during the trial of six months. Significant outcome measures included the change in HAV angle (clinically), foot function (Foot Function Index), pain intensity (Visual Analogue Scale), and patients’ quality of life (Manchester-Oxford Foot Questionnaire). Using mixed linear model and statistical tests, clinically and statistically significant improvement was demonstrated in all outcome measures in the intervention group by using eleven months with the HV sock, including a change in HAV angle that significantly exceeded established minimal clinically important difference thresholds than control group. [...] Description: Ph.D.(Melit.) 2026-01-01T00:00:00Z https://www.um.edu.mt/library/oar/handle/123456789/129872 Title: Evaluation of footwear worn at the time of fall in a Maltese long-term elderly facility Abstract: Aim: The aim of this study was to investigate the relationship between footwear design and risk of falling in a sample of older adults living in a long-term care facility. Research Design and Method: A quantitative, post-positive study was conducted in Malta’s largest long-term care residence. This study consisted of 3 phases. Phase 1 evaluated footwear characteristics and fit worn by residents to provide an overview of the typical footwear worn in this population. A nonexperimental approach was utilised with 135 residents selected through random sampling. The most commonly worn footwear was analysed using the Footwear Assessment Form, and its fit was assessed by measuring the footwear’s length and width and comparing these to the participants’ foot measurements. Phase 2 focused on evaluating the footwear worn at the time of falls. Employing a prospective design, this phase recorded any falls sustained over a period of 9 months, resulting in 76 eligible falls. Details about each fall and the footwear worn at the time were documented using the same methodology as in Phase 1. Phase 3 aimed to evaluate the functional stability and balance of participants when wearing the footwear worn at the time of fall versus ‘adequate’ footwear as recommended by the literature. An experimental design was used, involving 41 eligible participants from Phase 2. Participants completed two clinical balance and stability tests, the Functional Reach Test (FRT) and Time Up and Go (TUG), with both sets of footwear. The goal was to determine if adequate footwear provided better balance and stability than the footwear worn at the time of fall. Results: Participants who sustained a fall were more likely to wear footwear with sub-optimal features such as heel height of more than 2.5cm and footwear having no fixation. Sandals were the most common type of footwear worn. Only 9.2% of participants who fell were wearing well-fitted footwear in terms of length and width. Participants performed significantly better in the TUG test when wearing ‘adequate’ footwear compared to the footwear worn at the time of fall. However, there was no significant difference in the FRT between the two types of footwear. Furthermore, none of the footwear characteristics were found to significantly impact the FRT and TUG test results. Conclusion: This study demonstrates that inadequate footwear increases the risk of falling among a geriatric population living in a long-term care facility. Footwear worn at the time of fall negatively affected the participants' balance during walking, as evidenced by the TUG test. However, participants’ stability over a fixed base of support, measured by the FRT test, was not affected when wearing ‘adequate’ footwear highlighting the importance of appropriate footwear for walking stability. None of the footwear characteristics significantly impacted changes in stability and balance during clinical balance tests. A plausible explanation for this, is that these tests are capable of detecting major changes between different types of footwear (e.g. adequate vs inadequate) but may not be capable of identifying subtle modifications in footwear design. Therefore, more research is required to better understand the impact of footwear on fall risk. Description: M.Sc.(Melit.) 2024-01-01T00:00:00Z