Single-Leg Heel Raise Capacity is Lower, and Perceived Ankle Instability is Greater, in Dancers and Athletes With Posterior Ankle Impingement Syndrome.

OBJECTIVE: To compare clinical assessment findings between elite athletic populations with and without a clinical diagnosis of posterior ankle impingement syndrome (PAIS). DESIGN: Cross-sectional case-control study. SETTING: Elite ballet and sport. PARTICIPANTS: Ten male and female professional ballet dancers and athletes with a clinical diagnosis of PAIS and were matched for age, sex, and activity to 10 professional ballet dancers and athletes without PAIS. INDEPENDENT VARIABLES: Posterior ankle pain on body chart and a positive ankle plantarflexion pain provocation test. MAIN OUTCOME MEASURES: Single-leg heel raise (SLHR) endurance test, range of motion testing for weight-bearing ankle dorsiflexion, passive ankle plantarflexion, and first metatarsophalangeal joint dorsiflexion, and Beighton score for generalized joint hypermobility. Participants also completed the Cumberland Ankle Instability Tool (CAIT) questionnaire. RESULTS: The group with PAIS achieved significantly fewer repetitions on SLHR capacity testing ( P = 0.02) and were more symptomatic for perceived ankle instability according to CAIT scores ( P = 0.004). CONCLUSIONS: Single-leg heel raise endurance capacity was lower, and perceived ankle instability was greater in participants with PAIS. The management of this presentation in elite dancers and athletes should include the assessment and management of functional deficits.

Comparing Myofascial Pain Syndrome Treatment with Dry Needling Versus Extracorporeal Shock Wave Therapy for Plantar Fasciitis on Pain and Function of the Heel.

The aim of this study was to compare the effects of dry needling (DN) and extracorporeal shock wave therapy (ESWT) in the treatment of plantar fasciitis (PF). The study included 55 patients with PF. The patients were randomly divided into 2 groups. The DN group applied 3 sessions of DN to the myofascial trigger points in the lower limb muscles. The ESWT group applied 3 sessions of ESWT to the plantar fascia. For clinical evaluation, we used a visual analog scale (VAS) (first step, rest, activity) and Foot Function Index (FFI) (pain, disability, activity). Assessments were done baseline, post-treatment first week, and fourth week. Maximum pain-free standing time (Max PfST) and maximum pain-free walking distance (Max PfWD) were recorded at baseline and post-treatment fourth week. In this study, we found significant improvement in VAS, FFI, Max PfST, and Max PfWD in both groups (p < .01). VAS-activity baseline-forth week change was significantly superior in the DN group compared to the ESWT group (p = .023). FFI-disability baseline-fourth week change was significantly superior in the DN group compared to the ESWT group (p = .048). There was no significant difference in other treatment-related changes between the groups (p > .05). However, VAS-rest baseline-fourth week change and FFI-pain baseline-fourth week change trended towards statistical significance between groups ((p = .056), (p = .052) respectively). This study showed that DN may be a good alternative treatment for patients with PF, with effects similar to or even superior to ESWT.

Treating Heel Pain in Adults: A Randomized Controlled Trial of Hard vs Modified Soft Custom Orthotics and Heel Pads.

OBJECTIVES: This study compared the effectiveness of soft vs hard orthotics in treating heel pain and plantar fasciitis in adults. It also compared the level of function after orthotic use, cost, and number of visits for orthotics and explored whether age was a factor in orthotic effectiveness. DESIGN: Randomized controlled trial. Before randomization, patients were stratified by age (younger vs older adults) in blocks of 4 to ensure that there were an equal number of participants in each group (soft vs hard orthotics). SETTING: An orthotic clinic in a community-based hospital and a private orthotic clinic. PARTICIPANTS: The participants were adults aged 18 years or older (N=44) with heel pain and plantar fasciitis. INTERVENTION: Participants received hard or soft customized orthotics. MAIN OUTCOME MEASURES: Participants rated their pain intensity and pain interference before and after orthotic use using subscales from the Brief Pain Inventory. Function was similarly measured using the Late Life Function and Disability Instrument: Function component. Analyses of age, cost, and number of visits were also compared. RESULTS: There was a reduction in pain intensity (P=.010) and pain interference (P<.001) but no change in function over time (P=.333), and no difference between the groups who received hard vs soft orthotics. Age had no effect on orthotic effectiveness. Soft orthotics were less expensive (P<.0001) and required fewer visits for fabrication (P<.0001). CONCLUSION: Both soft and hard orthotics provided effective pain relief, but soft orthotics are less expensive.

Effects of skin moisturizer on the skin barrier dysfunction model: An evaluation of the heel via tape-stripping in healthy, young adults.

BACKGROUND: This study seeks to establish the skin barrier dysfunction model at the heel via tape-stripping (TS) by evaluating the skin moisturizing effects. MATERIALS AND METHODS: Nineteen young, female participated in the study. A sequence of TS was performed at the heel and trans-epidermal water loss (TEWL), stratum corneum (SC) hydration, and surface pH were measured. Following TS, the subjects were divided into three groups: moisturizer, emollient, and overcoat. These agents were applied daily at night, and the skin parameters were measured the next morning for a week. RESULTS: The TEWL value of TS immediately and 5 min after TS were significantly higher than what was obtained before TS, while the SC hydration after TS was significantly lower than what was obtained before TS. However, there were no significant differences in the skin parameters among the three agents on day 7 after application, with the two-way ANOVA showing no interaction among the agents and number of days. CONCLUSION: The skin barrier dysfunction model at the heel was established by TS in healthy, young adults. However, the physiological function of the skin at the heel did not change drastically and showed no differences even after continuous application for 7 days.

Treatment of acute Achilles tendon rupture - a multicentre, non-inferiority analysis.

BACKGROUND: While numerous clinical studies have compared the surgical and non-surgical treatment of acute Achilles tendon rupture (ATR), there are no studies that have performed a non-inferiority analysis between treatments. METHODS: Data from patients who were included in five randomised controlled trials from two different centres in Sweden were used. Outcomes at 1 year after ATR consisted of the patient-reported Achilles tendon Total Rupture Score (ATRS) and the functional heel-rise tests reported as the limb symmetry index (LSI). The non-inferiority statistical 10% margin was calculated as a reflection of a clinically acceptable disadvantage in ATRS and heel-rise outcome when comparing treatments. RESULTS: A total of 422 patients (350 males and 72 females) aged between 18 and 71 years, with a mean age of 40.6 (standard deviation 8.6), were included. A total of 363 (86%) patients were treated surgically. The ATRS (difference (Δ) = - 0.253 [95% confidence interval (CI); - 5.673;5.785] p = 0.36) and LSI of heel-rise height (difference = 1.43 [95% CI; - 2.43;5.59] p = 0.81), total work (difference = 0.686 [95% CI; - 4.520;6.253] p = 0.67), concentric power (difference = 2.93 [95% CI; - 6.38;11.90] p = 0.063) and repetitions (difference = - 1.30 [95% CI; - 6.32;4.13] p = 0.24) resulted in non-inferiority within a Δ - 10% margin for patients treated non-surgically. CONCLUSION: The non-surgical treatment of Achilles tendon ruptures is not inferior compared with that of surgery in terms of 1-year patient-reported and functional outcomes.

Perfusion, tissue oxygenation and peripheral temperature in the skin of heels of healthy participants exposed to pressure: a quasi-experimental study.

AIM: To evaluate the relationship between the pressure exerted on the heel of one foot resting directly on a mattress, versus that exerted on the other heel, protected by a pillow beneath the Achilles tendon area and the changes thus produced in perfusion, oxygenation and temperature in the skin of heels of healthy volunteers lying in a supine position. DESIGN: Experimental study in a pre-clinical phase, with healthy volunteer participants and intrapeople control. METHODS: The study was carried out from November 2017 - May 2018. A pressure measurement surface was placed between the participant and the constant low-pressure support surface. Doppler laser devices were used to measure local temperature and perfusion. The degree of oxygenation was determined using an infrared beam close to the pressure zone in each heel. Both feet rested immobile on the bed, in a natural position, for 2 hr. To ensure intrapeople control, in every case the left heel was raised slightly, compared with the right. RESULTS: Eighteen participants took part in this study. Analysis of the results obtained showed that capillary blood flow was significantly reduced in the heel subjected to pressure, compared with the other heel, while no significant effects on oxygen saturation or temperature were observed. The variables associated with greater oxygen saturation were capillary blood flow, local temperature and pressure exerted. Fat-free mass, fat mass and duration of exposure to pressure were all significantly associated with reduced oxygen saturation. CONCLUSIONS: In healthy participants, when the heel is subjected to constant pressure against a constant low-pressure support surface, there is a significant reduction in blood flow, compared with the heel where pressure is relieved. However, there are no significant differences in temperature or tissue oxygenation. IMPACT: Significant reductions in vascular flow were observed; however, the oxygenation and temperature of the heel tissues remained unchanged. These findings, corroborated in real patients, would advance our understanding and facilitate decision-making on measures to prevent pressure ulcers, such as repositioning or tissue protection. TRIAL REGISTRATION: The protocol is registered in ClinicalTrials.gov (NCT02736838).

Achilles tendon cross-sectional area at 12 weeks post-rupture relates to 1-year heel-rise height.

PURPOSE: Achilles tendon rupture leads to long-term plantar flexor deficits, but some patients recover functional performance better than others. Early indicators of tendon healing could be helpful in establishing patient prognosis and making individualized decisions regarding rehabilitation progression. The purpose of this study was to investigate relationships between early tendon morphology and mechanical properties to long-term heel-rise and jumping function in individuals after Achilles tendon rupture. METHODS: Individuals after Achilles tendon rupture were assessed at 4, 8, 12, 24, and 52 weeks post-injury. Tendon cross-sectional area, length, and mechanical properties were measured using ultrasound. Heel-rise and jump tests were performed at 24 and 52 weeks. Correlation and regression analysis were used to identify relationships between tendon structural variables in the first 12 weeks to functional outcomes at 52 weeks, and determine whether the addition of tendon structural characteristics at 24 weeks strengthened relationships between functional performance at 24 and 52 weeks. Functional outcomes of individuals with < 3 cm of elongation were compared to those with > 3 cm of elongation using a Mann-Whitney U test. RESULTS: Twenty-two participants [mean (SD) age = 40 (11) years, 17 male] were included. Tendon cross-sectional area at 12 weeks was the strongest predictor of heel-rise height (R2 = 0.280, p = 0.014) and work symmetry (R2 = 0.316, p = 0.008) at 52 weeks. Jumping performance at 52 weeks was not significantly related to any of the tendon structural measures in the first 12 weeks. Performance of all functional tasks at 24 weeks was positively related to performance on the same task at 52 weeks (r = 0.456-0.708, p < 0.05). The addition of tendon cross-sectional area improved the model for height LSI (R2 = 0.519, p = 0.001). Tendon elongation > 3 cm significantly reduced jumping symmetry (p < 0.05). CONCLUSION: Tendon cross-sectional area and excessive elongation related to plantar flexor performance on functional testing after Achilles tendon rupture. Once an individual is able to perform function-based testing, tendon structural measures may inform long-term prognosis. Ultrasound-based measures of tendon structure early in recovery seem to relate to later performance on functional testing. Clinically, assessing tendon structure has the potential to be used as a biomarker of tendon healing early in recovery and better predict patients at risk of negative functional outcome. LEVEL OF EVIDENCE: II.

Use of Amniotic Membrane as a Biological Dressing for the Treatment of Torpid Venous Ulcers: A Case Report.

Chronic venous disease manifested as ulcers in the lower limb is a highly prevalent pathology in our population. Antiseptics and dressings designed to improve epithelialization are often used to cure the ulcer during outpatient therapy. Despite careful management, sometimes ulcers do not respond to treatment. In this report, we discuss the antiseptic and potentially immunomodulatory effects of the amniotic membrane as a biological dressing for the treatment of venous ulcers refractory to conventional therapy.

Use of 3D-Printed Heel Support Insoles Based on Arch Lift Improves Foot Pressure Distribution in Healthy People.

BACKGROUND 3D-printed insoles are widely used. This study was conducted to test a customized three-dimensional (3D)-printed heel support insole based on arch lift and to investigate whether the pressure distribution on the sole was improved while maintaining foot function. MATERIAL AND METHODS The design was based on a 3D plantar contour scanning modeling technique. Thirty healthy male participants walked along a 10-m track under 3 self-controlled interventions. A customized 3D-printed heel support insole based on arch lift was inserted into the socks for the experimental condition A. For condition B, a customized 3D-printed heel-supporting insole was inserted into the socks, and a standardized pre-made heel-supporting insole was inserted into the socks as a control (condition C). We used the Footscan® pressure plate to measure the plantar parameters in the forefoot contact and foot flange phases in each condition. RESULTS Compared with condition B and the control condition, the peak pressure under the heel was significantly lower in condition A (P<0.05), and the peak pressure in the midfoot region was not significantly increased (P>0.05). CONCLUSIONS The biomechanical properties of the customized 3D-printed heel support are better than those of the traditional heel support insole, especially when there is a need for an additional increase in heel height. Patients do not decrease midfoot motion function while using this customized insole.

Corticosteroid injection for plantar heel pain: a systematic review and meta-analysis.

BACKGROUND: Corticosteroid injection is frequently used for plantar heel pain (plantar fasciitis), although there is limited high-quality evidence to support this treatment. Therefore, this study reviewed randomised trials to estimate the effectiveness of corticosteroid injection for plantar heel pain. METHODS: A systematic review and meta-analysis of randomised trials that compared corticosteroid injection to any comparator. Primary outcomes were pain and function, categorised as short (0 to 6 weeks), medium (7 to 12 weeks) or longer term (13 to 52 weeks). RESULTS: A total of 47 trials (2989 participants) were included. For reducing pain in the short term, corticosteroid injection was more effective than autologous blood injection (SMD -0.56; 95% CI, - 0.86 to - 0.26) and foot orthoses (SMD -0.91; 95% CI, - 1.69 to - 0.13). There were no significant findings in the medium term. In the longer term, corticosteroid injection was less effective than dry needling (SMD 1.45; 95% CI, 0.70 to 2.19) and platelet-rich plasma injection (SMD 0.61; 95% CI, 0.16 to 1.06). Notably, corticosteroid injection was found to have similar effectiveness to placebo injection for reducing pain in the short (SMD -0.98; 95% CI, - 2.06, 0.11) and medium terms (SMD -0.86; 95% CI, - 1.90 to 0.19). For improving function, corticosteroid injection was more effective than physical therapy in the short term (SMD -0.69; 95% CI, - 1.31 to - 0.07). When trials considered to have high risk of bias were excluded, there were no significant findings. CONCLUSIONS: Based on the findings of this review, corticosteroid injection is more effective than some comparators for the reduction of pain and the improvement of function in people with plantar heel pain. However, corticosteroid injection is not more effective than placebo injection for reducing pain or improving function. Further trials that are of low risk of bias will strengthen this evidence. REGISTRATION: PROSPERO registration number CRD42016053216 .

Relationship between bone turnover markers and the heel stiffness index measured by quantitative ultrasound in post-menopausal Japanese women.

Background: Osteoporosis in women is a serious health problem. The relationships between biochemical markers of bone turnover and bone mineral density (BMD) in women have been reported, but no study has examined relationships between tartrate-resistant acid phosphatase-5b (TRACP-5b) or bone-specific alkaline phosphatase (BAP) and bone mass measured by quantitative ultrasound (QUS) in Japanese post-menopausal women. Aim: To investigate the serum TRACP-5b and BAP levels and to determine their associations with the heel stiffness index measured by QUS in post-menopausal women. Subjects and methods: The subjects were 510 post-menopausal women who were invited to participate in periodic health examinations in 2011-2013 (the Unzen Study). The heel stiffness index (bone mass) was measured by QUS. Serum samples were collected and TRACP-5b and BAP levels were measured. Results: Multiple regression analysis showed that a higher log (TRACP-5b) was correlated with a lower stiffness index (p = 0.014) and log (BAP) was not correlated with stiffness index after adjusting for covariates (p = 0.136). Conclusion: Higher rates of bone resorption are associated with a lower stiffness index in Japanese post-menopausal women. These results may indicate that high bone resorption affects bone mass more than bone formation, resulting in a low bone mass.

Refining Heel Pressure Injury Risk Factors in the Hospitalized Patient.

OBJECTIVE: To replicate previous research that found four independent and significant predictors of heel pressure injuries (HPIs) in hospitalized patients using a larger and more diverse patient population. METHODS: Researchers conducted a retrospective, case-control study with a main and a validation analysis (N = 1,937). The main analysis had 1,697 patients: 323 patients who had HPIs and 1,374 who did not. The validation analysis had 240 patients: 80 patients who developed HPIs and 160 who did not. Researchers used a series of diagnosis codes to define variables associated with an HPI. Data were extracted from the New York Statewide Planning and Research Cooperative System for January 2014 to June 2015. Study authors conducted a series of forward stepwise logistic regression analyses for both samples to select the variables that were significantly and independently associated with the development of an HPI in a multivariable setting. Researchers generated a receiver operating characteristic curve using the final model to assess the regression model's ability to predict HPI development. RESULTS: Seven variables were significant and independent predictors associated with HPIs: diabetes mellitus, vascular disease, perfusion issues, impaired nutrition, age, mechanical ventilation, and surgery. The receiver operating characteristic curve demonstrated predictive accuracy of the model. CONCLUSIONS: Beyond a risk assessment scale, providers should consider other factors, such as comorbidities, which can predispose patients to HPI development.

3D printing individualized heel cup for improving the self-reported pain of plantar fasciitis.

BACKGROUND: To explore the therapeutic effect and the biomechanical mechanism of 3D printing individualized heel cup in treating of plantar heel pain. METHODS: The clinical effect was evaluated by plantar pressure analysis and pain assessment in participants. Its biomechanical mechanism of protecting the plantar heel was explored using finite element simulation. RESULTS: The individualized heel cup could support and protect the osseous structure and soft tissue of plantar heel while walking and jogging, as well as significantly reduce the self-reported pain after being worn for 4 weeks. The nylon heel cup could alter the load concentration of the heel as well as decrease the load affected on plantar fascia and calcaneus bone. It also provided an obvious support for heel pad. CONCLUSION: To summarize, the 3D printed individualized heel cup can be used as an effective method for the treatment of plantar heel pain.

Efficacy of foot orthoses for the treatment of plantar heel pain: a systematic review and meta-analysis.

BACKGROUND: Plantar heel pain (PHP) is common. Foot orthoses are often applied as treatment for PHP, even though there is little evidence to support this. OBJECTIVE: To investigate the effects of different orthoses on pain, function and self-reported recovery in patients with PHP and compare them with other conservative interventions. DESIGN: Systematic review and meta-analysis. DATA SOURCES: A systematic literature search was conducted in MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, CINAHL and Google Scholar up to January 2017. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Randomised controlled trials comparing foot orthoses with a control (defined as no intervention, sham or other type of conservative treatment) reporting on pain, function or self-reported recovery in patients with PHP. RESULTS: Twenty studies investigating eight different types of foot orthoses were included in the review. Most studies were of high quality. Pooled data from six studies showed no difference between prefabricated orthoses and sham orthoses for pain at short term (mean difference (MD) of 0.26 (95% CI -0.09 to 0.60)). No difference was found between sham orthoses and custom orthoses for pain at short term (MD 0.22 (95% CI -0.05 to 0.50)), nor was there a difference between prefabricated orthoses and custom orthoses for pain at short term (MD 0.03 (95% CI -0.15 to 0.22)). For the majority of other interventions, no significant differences were found. CONCLUSIONS: Foot orthoses are not superior for improving pain and function compared with sham or other conservative treatment in patients with PHP. PROSPERO REGISTRATION NUMBER: CRD42015029659.

Mechanisms of ACL injury in professional rugby union: a systematic video analysis of 36 cases.

BACKGROUND: The mechanisms of ACL injury in rugby are not well defined. AIM: To describe the mechanisms of ACL injury in male professional rugby players using systematic video analysis. METHODS: 36 cases from games played in top professional leagues and international matches were analysed. 5 analysts independently assessed all videos to record the estimated frame/time of initial ground contact, frame/time of ACL tear and a range of play specific variables. This included contact versus non-contact ACL injuries, injury timing, joint flexion angles and foot contact with the ground. 37 side-stepping manoeuvres from a control game were analysed to allow comparison of non-injury versus injury situations. RESULTS: 57% of ACL injuries occurred in a contact manner. 2 main scenarios were identified: (1) offensive running and (2) being tackled, indicating that the ball carrier might be at higher risk of ACL injury. The majority of non-contact ACL injuries resulted from a side-stepping manoeuvre. In most non-contact cases, initial ground contact was through heel strike. Statistical assessment of heel strike at initial ground contact versus non-heel strike cases showed a significant difference in injury versus non-injury outcomes, with heel strike associated with higher injury risk. Non-contact ACL injuries had lower median knee flexion angles and a more dorsiflexed ankle when compared with a control group (10° vs 20°, p≤0.001 and 10° vs 0°, p=0.033 respectively). CONCLUSIONS: Over half of ACL injuries in rugby in our analysis resulted from a contact mechanism. For non-contact injuries, lower knee flexion angles and heel-first ground contact in a side-stepping manoeuvre were associated with ACL injury.

Foot orthoses for plantar heel pain: a systematic review and meta-analysis.

OBJECTIVE: To investigate the effectiveness of foot orthoses for pain and function in adults with plantar heel pain. DESIGN: Systematic review and meta-analysis. The primary outcome was pain or function categorised by duration of follow-up as short (0 to 6 weeks), medium (7 to 12 weeks) or longer term (13 to 52 weeks). DATA SOURCES: Medline, CINAHL, SPORTDiscus, Embase and the Cochrane Library from inception to June 2017. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Studies must have used a randomised parallel-group design and evaluated foot orthoses for plantar heel pain. At least one outcome measure for pain or function must have been reported. RESULTS: A total of 19 trials (1660 participants) were included. In the short term, there was very low-quality evidence that foot orthoses do not reduce pain or improve function. In the medium term, there was moderate-quality evidence that foot orthoses were more effective than sham foot orthoses at reducing pain (standardised mean difference -0.27 (-0.48 to -0.06)). There was no improvement in function in the medium term. In the longer term, there was very low-quality evidence that foot orthoses do not reduce pain or improve function. A comparison of customised and prefabricated foot orthoses showed no difference at any time point. CONCLUSION: There is moderate-quality evidence that foot orthoses are effective at reducing pain in the medium term, however it is uncertain whether this is a clinically important change.

Heel Pain: Diagnosis and Management.

The differential diagnosis of heel pain is extensive, but a mechanical etiology is the most common. The specific anatomic location of the pain can help guide diagnosis. The most common diagnosis is plantar fasciitis, which leads to medial plantar heel pain, especially with the first weight-bearing steps after rest. Other causes of plantar heel pain include calcaneal stress fractures (progressively worsening pain after an increase in activity or change to a harder walking surface), nerve entrapment or neuroma (pain accompanied by burning, tingling, or numbness), heel pad syndrome (deep, bruise-like pain in the middle of the heel), and plantar warts. Achilles tendinopathy is a common cause of posterior heel pain; other tendinopathies result in pain localized to the insertion site of the affected tendon. Posterior heel pain can also be attributed to Haglund deformity (a prominence of the calcaneus that may lead to retrocalcaneal bursa inflammation) or Sever disease (calcaneal apophysitis common in children and adolescents). Medial midfoot heel pain, particularly with prolonged weight bearing, may be due to tarsal tunnel syndrome, which is caused by compression of the posterior tibial nerve. Sinus tarsi syndrome manifests as lateral midfoot heel pain and a feeling of instability, particularly with increased activity or walking on uneven surfaces.

Following the correction of varus deformity of the knee through total knee arthroplasty, significant compensatory changes occur not only at the ankle and subtalar joint, but also at the foot.

PURPOSE: This study aimed to assess radiological changes of the ankle joint, subtalar joint and foot following the correction of varus deformity of the knee with total knee arthroplasty (TKA). It was hypothesized that following the correction of varus deformity by TKA, compensatory reactions would occur at the subtalar joint in accordance with the extent of the correction. METHODS: For this prospective study, 375 knees of patients who underwent TKA between 2011 and 2012 were enrolled. The varus angle of the knee, talar tilt of the ankle joint (TT), ground-talar dome angle of the foot (GD), anterior surface angle of the distal tibia and lateral surface angle of the distal tibia, heel alignment ratio (HR), heel alignment angle (HA), and heel alignment distance (HD) were measured on radiographs obtained pre-operatively and at post-operative 6 months. RESULTS: The mean correction angle in varus deformity of the knee was 10.8 ± 4.1°. TT and GD changed significantly from 0.4 ± 1.9° and 6.5 ± 3.1° pre-operatively to 0.1 ± 1.8° and 0.2 ± 2.1°, respectively (p = 0.007, p < 0.001). No correlation was found between the preop-postop variance in mechanical axis of the lower extremity (MA) and TT, but there was a strong correlation between the preop-postop variance in MA and GD (r = 0.701). HR, HA and HD also changed significantly post-operatively, and the preop-postop variance in MA showed correlations with the preop-postop variances in HR, HA and HD (r = 0.206, - 0.348, and - 0.418). TT and the three indicators of hindfoot alignment all shifted to varus whereas GD was oriented in valgus. CONCLUSION: Following the correction of varus deformity of the knee through TKA, significant compensatory changes occurred not only at the ankle and subtalar joints, but also at the foot. The findings of this study are useful in predicting the orientation of changes in the ankle and subtalar joints and the foot following TKA, and in determining the sequence of surgery when both the ankle and knee have a problem. In other words, changes in the parts of the lower extremity below the ankle joint following the correction of varus deformity of the knee must be considered when TKA is planned and performed. Patients who have problems at the ankle, subtalar, and foot joints in addition to varus deformity of the knee are recommended to undergo knee joint correction first. LEVEL OF EVIDENCE: II.

Can an off-the-rack orthotic stiletto alter pressure and comfort scores in the forefoot, arch and heel?

The study sought to investigate whether an orthotic stiletto could modulate the pressure and comfort under the forefoot, arch and heel that stiletto wearers experience. Twenty-two women participated. We measured the peak pressure and pressure-time integral for orthotic stilettos with built-in metatarsal pad, heel cup and arch support; standard stilettos without inlays; and trainers. Comfort was recorded during 3 × 3 working days. The orthotic stiletto exhibited lower metatarsal head1 (MTH) and MTH2+3 and heel pressures than the standard stiletto (p < .01), and a long second metatarsal increased MTH2+3 pressure (p < .01). The comfort in the forefoot and heel was higher in the orthotic stiletto than in the standard one (p < .01), and comfort in the forefoot was correlated to the pressure-time integral of MTH2+3 (p = .03) and not peak pressure. Off-the-rack orthotic stilettos can notably reduce plantar pressures and improve forefoot and heel comfort during everyday use. Practitioner Summary: Off-the-rack orthotic stilettos with built-in metatarsal pad, arch support and heel caps can lower the pressure under the heel and forefoot in comparison with a standard stiletto and can improve comfort during everyday use. Having a long second metatarsal is a risk factor for increased forefoot pressure.

Patterns and associations of structural and functional cutaneous responses during loading at heel and sacral skin in aged females: A reanalysis of clinical study data.

AIM OF THE STUDY: The aim of this study was to explore possible interrelationships and cutaneous response patterns at the heel and sacral skin due to prolonged loading. MATERIALS AND METHODS: Skin stiffness, elasticity, roughness and transepidermal water loss, stratum corneum hydration, erythema, and temperature of n = 20 aged females (mean age 69.9 years) were measured before and after 90 and 150 min loading in supine position. Delta values were calculated and correlated using Spearman's rho. Strengths and directions of associations and similar patterns were subsequently identified for the heel and sacrum areas. RESULTS: At the sacral area decreased stiffness (Uf) was associated with increased TEWL and there was a positive relationship between mean roughness (Rz) and erythema. At the heel there was a positive association between TEWL and decreasing stiffness (Uf). CONCLUSIONS: Our results indicate a dynamic interaction between skin changes during loading and different physiological response patterns for sacral and heel skin. There seems to be close association between transepidermal water loss and stiffness changes during loading.