Characteristic 3D foot motion patterns during gait of patients with Charcot-Marie-Tooth identified by cluster analysis.

BACKGROUND: CMT is a clinically and genetically heterogenous disease with varying degrees of progression. Different foot deformities, gait and movement patterns are observed. In order to achieve an improved, targeted treatment strategy, the participants are divided into characteristic groups using a mathematical cluster analysis based on the data from the three-dimensional foot kinematics during walking. METHODS: Outpatients from age 5-64 years (N = 33 participants, 62 feet) with a proven CMT type 1 (N = 16, 31 feet) or CMT without any further type assignment (N = 17, 31 feet) were retrospectively analyzed. After a standard clinical examination, participants underwent 3D gait analysis using the Oxford Foot Model. To classify the movement patterns, a k-means cluster analysis was calculated based on the principal component analysis (PCA) of the foot kinematics data. Gait parameters, clinical parameters and X-ray data were statistically tested. RESULTS: The cluster analysis divided the gait data of the participants into two groups. Cluster 1 (N = 21 participants, 34 feet) showed increased dorsiflexion of the hindfoot and increased plantarflexion of the forefoot with cavus position in the sagittal plane, a hindfoot inversion and forefoot pronation with hindfoot varus in the frontal plane and in the transversal plane a forefoot adduction. Cluster 2 (N = 17 participants, 28 feet) deviated significantly from the norm mainly in the frontal plane and were characterized by a strong eversion of the hindfoot with a supination in the forefoot. DISCUSSION: Based on the findings, the resultant clusters can be interpreted as cavovarus feet (cluster 1) and pes valgus (cluster 2). The most reliable variables in the 3D gait analysis to classify CMT feet with regard to significance are the ones in the frontal plane. This subdivision of participants goes hand in hand with the various necessary guidelines for orthopedic treatment.

Clinical, Radiographic and Gait Parameters Associated with Medial Arch Pain in the Flexible Pediatric Flatfoot.

Pain in the flexible flatfoot is a common complaint, if present it is important to find its exact location and causes Therefore, the study aimed to find differences between children with and without medial arch pain and relate them to the reduction of pain following surgical treatment. Children with idiopathic flexible flatfeet were retrospectively included in the study. All children underwent a clinical, radiographic, and gait examination. The feet were subdivided into 2 groups: asymptomatic and those with medial arch pain. Factors associated with medial arch pain were identified via t test. Significant radiological and gait parameters were correlated to the change in medial arch pain score following surgery. Included were 322 feet belonging to 177 children, with the mean age of 11.8 (SD = 2.2) years. The pain was perceived in 52% of the feet, of these, 74% in the medial arch. In the group with pain, 31 feet received a gait analysis following surgery. The radiological parameters, talus-1 and -2 metatarsal angles and the gait parameter, calcaneal lateral shift during walking showed a significant difference (p ≤ .004) between the no pain and pain groups and were associated (R2 ≥0.14, p ≤ .04) with the reduction in pain following surgery. The increased talus-1 and -2 metatarsal angles and the calcaneal lateral shift may cause increased tension on the soft-tissues along the medial side of the foot and may produce pain. Therapies aiming at improving the medial arch pain should be directed to normalize the talus-1 or -2 metatarsal angles and the calcaneal lateral shift.

Treatment of spastic varus/ equinovarus foot with split-tendon transfers in cerebral palsy: How does it affect the hindfoot motion?

INTRODUCTION: The flexible spastic varus foot in cerebral palsy is commonly corrected by split-tendon transfer of tibialis anterior or tibialis posterior. These tendon transfers are said to preserve hindfoot motion, which is until now not been proven. Therefore, the aim of the study was to show the hindfoot motion following split-tendon transfer in comparison to a midtarsal arthrodesis. MATERIALS AND METHODS: A retrospective study was done on patients with flexible spastic varus foot in cerebral palsy who underwent a combined split-tendon transfer of tibialis anterior and posterior. Patients with a rigid foot deformity underwent a midfoot arthrodesis. These children and normal children served as controls. An instrumented gait analysis was done in all patients before and at follow-up. A statistical analysis was done using 2-factor ANOVA with repeated measures on time. RESULTS: Thirteen children underwent a combined split-tendon transfers of tibialis anterior and posterior muscles and 14 children midtarsal arthrodesis. The mean follow-up was 2.4 (SD=0.8) years for flexible varus foot and 1.9 (SD=0.7) years for rigid foot deformity. The preoperative hindfoot range of motion in eversion-inversion was 54% and 49% of TD controls in flexible varus foot and rigid foot deformity respectively. At follow-up, it reduced further to 45% and 42% of TD controls in the respective groups. CONCLUSION: Both flexible and rigid hindfoot deformity reduced the hindfoot motion. However following surgery, the hindfoot motion reduced further and was identical in both groups independent of the type of surgery. This indicates a tenodesis-effect of split-tendon transfers on the hindfoot.

Prefabricated ankle-foot orthoses for children with cerebral palsy to overcome spastic drop-foot: does orthotic ankle stiffness matter?

BACKGROUND: Spastic drop-foot is a common problem in children with cerebral palsy that may lead to tripping and falling. To improve ankle dorsiflexion in swing phase, prefabricated carbon-composite ankle-foot orthoses are commonly prescribed; by increasing ankle stiffness, these orthoses may also improve knee extension in stance. OBJECTIVES: To compare the effect of a stiff vs. flexible prefabricated ankle-foot orthosis on sagittal plane ankle and knee kinematics and kinetics during walking. STUDY DESIGN: Cross-sectional, repeated-measures, interventional study. METHODS: Twenty-seven children and adolescents with cerebral palsy who had drop-foot in swing were included. Gait analysis was conducted under four conditions: barefoot, shod, with a stiff, and with a flexible orthosis. Participants were divided into two groups including children and adolescents who have a flexed knee during stance (KF, N = 12) and without flexed knee during stance (KE, N = 15). RESULTS: Ankle dorsiflexion in swing phase was significantly improved compared with the shod condition by 6.3 degrees (SD = 3.3 degrees) only in the KE group when using the flexible orthosis. For the stiff orthosis, knee extension in stance was significantly increased by 2.4 degrees (SD = 3.3 degrees) in the KE group compared with the shod condition. No significant improvements were observed for the KF group. Further analysis indicated that only seven patients in the KF group with weak ankle plantarflexors improved knee extension while using the stiff orthosis. CONCLUSIONS: Our results suggested that in the KE group, the flexible orthosis was best suited for patients with drop-foot without a knee extension deficit. The stiff orthosis was not suitable in this group as it caused a hyperextended knee without improving dorsiflexion in swing phase. Therefore, stiffness should be considered when prefabricated orthoses are prescribed.

The Ability to Run in Young People with Cerebral Palsy before and after Single Event Multi-Level Surgery.

The objective of the study is to identify and evaluate possible factors that influence the ability to run before and after single event multi-level surgery (SEMLS). Young patients (6-25 years) with spastic cerebral palsy (GMFCSI-II) were retrospectively included. Type and number of surgical procedures, time for recovery and 3D gait analysis variables were analyzed with respect to the ability to run. In total, 98 patients (38 females; 60 males) who received SEMLS (12 years, SD 3.4) were included and compared to a control group of 71 conservatively treated patients. Of 60 runners pre-surgery, 17 (28%) lost the ability, while gained in 8 of 38 (21%) non-runners. The number of surgical procedures was a significant predictor and those who lost their ability to run had significantly more (mean = 5.9, SD = 1.7), compared to the patients who gained the ability (mean = 3.5, SD = 0.9). Further, pre-surgical function (e.g., gait speed) was significantly different (p < 0.001). Pre-surgical function and the number of surgical procedures seem to play an important role for the gain or loss of the ability to run after surgery. Caution is warranted in patients with lower pre-surgical function and the ability to run, as they seem at a higher risk to lose the ability.

[Correction of complex defomities around the Knee Joint]. / Komplexe Achskorrekturen um das Kniegelenk.

Complex deformities around the knee joint are usually severe and have several aetiologies. They can be present in one or more planes, with variations in severity between planes. The occurrence and progression of the deformity can be influenced by local and systemic factors. Several types of osteotomies and fixation methods are available to correct these complex deformities. The selection of the osteotomy used to correct a deformity depends on the type of deformity, its severity and its aetiology. Therefore, precise planning taking into consideration the above factors is necessary to achieve the goal.

Dynamic stability in cerebral palsy during walking and running: Predictors and regulation strategies.

BACKGROUND: The postural control in cerebral palsy (CP) is often deficient and manifests in a variety of impairments. Consequently, maintaining balance and controlling posture is impeded and results in an increased cost of locomotion and higher risk of falls. The margin of stability is an established measure to quantify dynamic stability during gait. It can be facilitated to analyze impaired control mechanisms, but it is unknown if and how people with CP manage to control the margin of stability during a more demanding motor task, such as running. RESEARCH QUESTION: How do people with cerebral palsy regulate dynamic stability during walking and running? METHODS: Children and adolescents with bilateral cerebral palsy (N = 117; 50 female, 67 male; age 11.0 ± 3.2) were retrospectively included. All underwent instrumented 3D gait analysis, walking and running barefoot at a self-selected gait speed. People with CP were compared to a control group of N = 25 typically developed (TD). Repeated measures ANOVAs were computed to analyze group differences and multiple linear regressions to identify predictors for the medio-lateral margin of stability. RESULTS: The medio-lateral margin of stability was significantly higher in the CP group and was statistically unchanged during running. Different adaptions when running were particularly observed in the lateral trunk lean and step width, which remained high in CP, whereas the TD increased the trunk lean and reduced their step width. Step width was the main predictor for the medio-lateral margin of stability in both gait conditions. SIGNIFICANCE: Young people with cerebral palsy manage to maintain their medio-lateral margin of stability during walking and running, however, with significantly higher safety margins compared to typically developed. This conservative strategy may reflect an adaption to motor and postural control impairments.

Effects of idiopathic flatfoot deformity on knee adduction moments during walking.

INTRODUCTION: Flatfoot deformity is commonly characterized by a subtalar valgus, a low medial longitudinal arch, and abduction of the forefoot. Although flatfoot deformity has been associated with lower first (KAM1) and second (KAM2) peak knee adduction moments during walking, the biomechanical connection remains unknown. RESEARCH QUESTION: We hypothesized that hindfoot eversion, lateral calcaneal shift correlate with KAM1 and forefoot abduction and arch height with KAM2, due to the lateralization of the ground reaction force vector resulting from shifted heel and forefoot in flatfoot deformity. METHODS: Gait data from 103 children with flatfoot deformity who underwent three-dimensional gait analysis with the Oxford Foot Model were retrospectively included. Children with knee varus/valgus, in- and out-toeing were excluded. Fifteen healthy children with a rectus foot type were also collected from the database. Lateral calcaneal shift was defined as the distance between the projection of the ankle joint center onto the calcaneal axis and the midpoint of the calcaneal axis formed by the medial and lateral calcaneal markers. A subgroup of children with idiopathic flatfoot deformity that had received corrective surgery was also identified. Statistical analysis included Pearson's correlations and independent and paired t-tests (α < .05). RESULTS: When compared to a norm cohort, flatfooted children had significant lower KAM1 and KAM2 (t-test, P < .001). Lateral calcaneal shift correlated with KAM1 and KAM2 (r = 0.42, p < .001 and r = 0.32, P < .001, respectively). Arch height correlated with KAM2 (r = 0.23, p = 0.017). KAM1 and KAM2 normalized after surgery and the change in KAM1 correlated with the change in lateral calcaneal shift for children who underwent corrective surgery. SIGNIFICANCE: Lateral calcaneal shift explains the reduction of KAM1 by lateralization of the point of force application in flatfooted children. It is recommended to consider the lateral calcaneal shift when investigating KAM in gait analysis research.

Is shortening of Tibialis Anterior in addition to calf muscle lengthening required to improve the active dorsal extension of the ankle joint in patients with Cerebral Palsy?

INTRODUCTION: Shortening of the tibialis anterior tendon (TATS) has been shown to improve the ankle dorsiflexion in swing following the calf muscle lengthening procedure (CMLP) in patients with cerebral palsy (CP). Others have reported the similar improvements following CMLP but without TATS. However there are no studies comparing both procedures. Therefore the purpose of the study was to compare the ankle dorsiflexion in swing and foot position in the sagittal plane during gait following TATS and CMLP to that of CMLP alone. MATERIALS AND METHODS: A retrospective study was carried out in CP patients who presented with fixed equinus deformity. They were grouped into unilateral CP and bilateral CP. Depending on the procedures, each group was again subdivided into subgroup CMLP only and subgroup CMLP and TATS (CMLPTATS). All patients were subjected to pre and postoperative clinical and gait analysis. RESULTS: 44 feet in 44 patients were included in the study. Of these, 24 feet (24 patients) belonged to unilateral and 20 feet (20 patients) to bilateral CP group. The mean age of the patients at surgery was 11.5 years (6.0 - 29.0) in the unilateral CP group and 10.5 years (5.0-34.0) in the bilateral CP group. In the unilateral CP group, 12 feet belonged to subgroup CMLP and 12 to subgroup CMLPTATS with a mean equinus contracture of 7.5° in both subgroups. In bilateral CP group, 11 feet belonged to subgroup CMLP with a mean equinus contracture of 5° and 9 to subgroup CMLPTATS, with a mean equinus contracture of 10°. The subgroups did not vary significantly in the demographics, anthropometry, kinematics and kinetics of ankle joint preoperatively. The mean follow up time was 19.7 months. The surgery produced significant changes in both groups and subgroups. However, none of the relevant gait parameters were significantly different between groups and subgroups. SIGNIFICANCE: Adding TATS to CMLP, compared to CMLP alone did not improve ankle dorsiflexion in swing and the foot position more than CMLP alone.

Compensatory mechanisms in children with idiopathic lower extremity internal rotational malalignment during walking and running.

BACKGROUND: Noticeable in-toeing gait is present in most children with internal rotational malalignment and often a reason to consult an orthopedic specialist. The risk of tripping may be higher for these patients. RESEARCH QUESTION: The aim of this study was to determine compensatory mechanisms adopted by children with internal rotational deformities to avoid tripping and falling during walking and running. METHODS: Sixty-nine patients between 5-18 years with idiopathic internal rotational malalignment were retrospectively included and subdivided into three groups: 18 patients with internal tibial torsion (ITT), 25 patients with internal femoral torsion (ITF) and 26 patients with both (ITB). Twenty-two typically developing age-matched children (TD) were analyzed for comparison. Three-dimensional gait data were evaluated. ANOVA's on two factors, group (ITT, ITF, ITB, TD) and movement (walking, running) with post-hoc t-tests were used to identify significant differences between groups. RESULTS: All groups had significantly greater step width than TD during walking (P ≤ .002) and all torsional groups had significantly greater step width during running (P ≤ .001). Similarly, all torsional groups showed greater peak ankle dorsiflexion in swing during running than TD (P ≤ .006). Only the ITT group showed significantly greater external hip rotation than TD. When compared to TD, the ITF and ITB group had a significantly lower hip abduction moment in stance during running, but not for walking (P ≤ .032). SIGNIFICANCE: Compensatory mechanisms in children with internal rotational deformities were mostly dependent on the location of rotational malalignment. All children with internal rotational malalignment had greater ankle dorsiflexion and greater step width during running. Especially in active patients, this greater ankle dorsiflexion during running may result in overuse of the ankle dorsiflexor muscles, while greater step width may have beneficial effects in normalizing knee adduction moments.

Does an overcorrected clubfoot caused by surgery or by the Ponseti method behave differently?

BACKGROUND: Overcorrection is a recognized problem following surgical treatment of congenital clubfoot. Recently this complication has also been mentioned following Ponseti treatment. RESEARCH QUESTION: Do overcorrected clubfeet (OCCF) caused by surgery behave differently from those caused by Ponseti treatment in terms of segmental motion of the feet and show differences in the severity of deformity on X-rays? METHODS: Children between 7 and 12 years with OCCF were included in this study. Depending on the aetiology causing them, the feet were divided into 2 groups (Ponseti and peritalar release surgery). 25 typically developing children served as controls. All subjects were subjected to clinical and radiological examination and 3-Dimensional gait analysis using the Oxford Foot Model. RESULTS: Thirty-two children with OCCF, of these 18 feet in the surgical and 14 feet in the Ponseti group, were included in the study. No radiological differences were seen in the flatfoot parameters between OCCF groups except in the calcaneal inclination angle that was more pathological in the Ponseti group. The clinical ankle plantar flexion was significantly reduced in the surgical group. During walking the range motion of the hindfoot in the frontal plane was significantly reduced in surgically treated feet compared to the Ponseti group. The other parameters did not show any significant difference between groups. SIGNIFICANCE: The overcorrected clubfeet following surgery and Ponseti showed similar appearance and showed no significant differences in 11/12 radiological parameters. The segmental motion of the feet showed no significant differences between groups except the in the range of motion of the subtalar eversion. A considerable subtalar joint motion was present even in the surgical group. These findings might help plan the treatment of these feet.

Excessive Lateral Trunk Lean in Patients With Cerebral Palsy: Is It Based on a Kinematic Compensatory Mechanism?

Introduction: Excessive lateral trunk lean is a commonly observed gait deviation in children with cerebral palsy (CP), with implications for energy expenditure and the development of back pain. While the trunk lean toward the stance leg is widely interpreted as a compensatory strategy to unload the hip, in CP the relation to hip abductor muscle strength is only weak. Therefore, other mechanisms may play a role in the prevalence of excessive trunk lean in CP, or it could be a primary motor function deficit. Research Question: Is the excessive lateral trunk lean in patients with CP part of an underlying biomechanical mechanism? Materials and Methods: Patients with bilateral CP (N = 255; age 13.6 ± 6.6 years) were retrospectively included and divided into a group with (n = 174) and without (n = 81) excessive lateral trunk lean. Ten lower-extremity joint angle waveforms were analyzed using a principal component analysis (PCA) to identify patterns of correlated deviations from average angle waveforms. Binary logistic regressions were performed to determine the discriminative capacity of the identified patterns. Results: The PCA identified correlated kinematic patterns, with lower-order patterns showing more common gait pathologies, such as torsional malalignments and crouch gait pattern. Within five patterns, significant (p < 0.0025) group differences were identified. Interestingly, the trunk lean was not always distinctive in these patterns and despite the significant differences their effect sizes were small. The logistic regression was unable to reliably classify patients based on their trunk lean patterns. Discussion: The current study identified multiple trunk lean-related patterns, however, excessive trunk lean was not attributable to a distinctive CP related gait pathology or to a specific compensatory strategy. Overall, the results do not support the hypothesis that excessive trunk lean is part of a biomechanical mechanism. Therefore, it seems more likely that excessive lateral trunk lean is based on other disease specific dysfunctions, influenced by the severity of the disease.

Management of Severe Equinovalgus in Patients With Cerebral Palsy by Naviculectomy in Combination With Midfoot Arthrodesis.

BACKGROUND: Equinovalgus deformity is the second most common deformity in cerebral palsy and may be flexible or rigid. Several operative methods from joint sparing to arthrodesis have been described with varying success rates. The aim of this study was to investigate the effectiveness of naviculectomy in combination with midfoot arthrodesis (talo-cuneiform and calcaneocuboid arthrodesis) in the correction of a rigid equinovalgus foot deformity in cerebral palsy. METHODS: Forty-eight rigid equinovalgus feet were operated upon in 30 patients from 2008 to 2013. Of these, 44 feet in 26 patients with cerebral palsy (Gross Motor Function Classification System III, IV, or V) with follow-up of more than 2 years were included in the study. The mean age at surgery was 18.1 years. The outcomes were measured objectively using radiographic angles and subjectively using 5 questions to be answered by the caregiver. The feet were then graded into excellent, good, fair, and poor. The mean follow-up was 5.0 ± 1.7 years. RESULTS: Excellent to good results were obtained in 81% of the feet. Both objective and subjective outcomes improved significantly postoperatively ( P < .001). Three feet in 2 patients were graded as poor and underwent a revision operation for pain and recurrence. CONCLUSIONS: Naviculectomy in combination with midfoot arthrodesis enabled a good 3-dimensional correction of the forefoot. However, the procedure did not necessarily correct the fixed subtalar joint deformity. Several additional bony and soft-tissue procedures were necessary to achieve a complete correction in these difficult feet. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Effect of lower limb malalignment in the frontal plane on transverse plane mechanics during gait in young individuals with varus knee alignment.

BACKGROUND: Varus knee alignment has been identified as a risk factor for the progression of medial knee osteoarthritis (OA). This study tested the hypothesis that not only frontal plane kinematics and kinetics but also transverse plane lower extremity mechanics during gait are affected by varus malalignment of the knee. METHODS: Eighteen, otherwise healthy children and adolescents with varus malalignment of the knee were studied to examine the association between static varus malalignment and functional gait parameters. Kinematic data were collected using a Vicon motion capture system (Vicon Motion Systems, Oxford, UK). Two AMTI force plates (Advanced Mechanical Technology, Inc., Watertown, MA, USA) were used to collect kinetic data. RESULTS: The results indicated that changes in transverse plane mechanics occur concomitantly with changes in knee malalignment in the frontal plane. A mechanical consequence of varus knee malalignment is obviously an increased endorotation of the foot (internal foot placement) and an increased internal knee rotation (tibia rotation) during stance phase. The linear correlation between the maximum external knee adduction moment in terminal stance and the internal knee rotation in terminal stance (r=0.823, p<0.001) shows that this transverse plane gait mechanics is directly in conjunction with intrinsic compressive load on the medial compartment during gait. CONCLUSIONS: Understanding factors that influence dynamic knee joint loading in healthy, varus malaligned knees may help us to identify risk factors that lead to OA. Thus, three-dimensional gait analysis could be used for clinical prognoses regarding the onset or progression of medial knee OA.

Pathological trunk motion during walking in children with amyoplasia: is it caused by muscular weakness or joint contractures?

The aim was to investigate the causes for pathological trunk movements during gait in children with Amyoplasia. Eighteen children with Amyoplasia were compared with 18 typically developed children. Three-dimensional motions of pelvis, thorax and spine during gait were analyzed. Excessive trunk movements were defined as being above 4 standard deviations of those of typically developed children. Clinical examination of active strength and passive range of motion of the hip, knee and ankle joints were correlated to the parameter that showed the greatest prevalence of pathological trunk motion. The greatest prevalence of 56% was seen for thorax obliquity range during walking. The spine angles showed the lowest deviations from typically developed children. Significant correlations (p<0.001) between thorax obliquity range and clinical parameters were found for passive hip extension, hip flexion, hip abduction and active hip extension, hip flexion and ankle dorsiflexion strength. The highest correlation coefficients were found for passive hip flexion and active hip flexion strength of rho=-0.73 and rho=-0.69 respectively. Excessive thorax obliquity during gait in children with Amyoplasia could be mainly caused by reduced strength and mobility of the hip. Therefore both mobility and strength of the hip are equally important and should be increased in the therapy to improve gait in children with Amyoplasia.

Predictors of pelvic retraction in children with cerebral palsy derived from gait parameters and clinical testing.

Excessive pelvic rotation in the transverse plane is common in patients with cerebral palsy. Knowing the underlying reasons is important for clinical decision making, since changes in pelvic retraction might have an effect on internally rotated gait. We hypothesized that the contralateral leg contributes considerably to pelvic rotation on the retracted side. Therefore the aim of this study is to calculate predictors for pelvic retraction using both, parameters from the retracted and from the contralateral protracted side. Thirty-two children with diplegia and 18 children with hemiplegia were examined by three-dimensional gait analysis followed by a clinical examination protocol. Stepwise multilinear regression of the response value mean pelvic retraction during stance phase was performed on 10 potential predictors of dynamic gait data and 10 corresponding predictors of clinical data of the retracted and the contralateral protracted side. Gait analysis revealed ankle push-off energy on the protracted side as the best predictors in hemiplegic patients explaining 59% of the variance in pelvic retraction. In diplegic patients external hip rotation of the protracted side was most accurate in predicting pelvic retraction (27%). Best clinical predictors for hemiplegic patients were ankle dorsiflexion on the retracted side (46%) and for diplegic patients it was the knee extension strength on the protracted side together with hip rotation on the retracted side (36%). In hemiplegic patients ankle push-off energy of the contralateral side is a significant compensation mechanism that might cause increased pelvic retraction to compensate for the weakness of the involved side. In diplegic patients prediction of pelvic retraction was only moderate and requires further investigation.

An unusual cause of acute carpal tunnel syndrome.

Acute carpal tunnel syndrome following anticoagulation is uncommon. We describe a case in which the diagnosis was missed on three previous presentations by several clinicians. Although the presentation is typical, lack of awareness of this complication, inability to notice subtle signs and failure to do INR may lead to missing the diagnosis.

Can peripheral nerve blocks contribute to heel ulcers following total knee replacement?

Peripheral nerve blocks are widely used for postoperative analgesia following total knee replacement. We would like to present three cases of heel ulcers encountered following a peripheral nerve block for knee replacement surgery. Postoperative heel ulcers have resulted in delayed rehabilitation in all three patients. Attention needs to be given to the pressure points in the foot after the nerve blocks. Awareness of this uncommon complication is necessary to prevent its occurrence.