Management of Chronic Exertional Compartment Syndrome of the Foot: A Report of 3 Cases.

BACKGROUND: Arch pain in athletes is a common complaint with many causes. One uncommon cause of arch pain related to exercise that is often overlooked is chronic exertional compartment syndrome. This diagnosis should be considered in athletes who presents with exercise-induced foot pain. Recognition of this problem is paramount because it can significantly affect an athlete's ability to pursue further sports activities. METHODS: Three case studies are presented that underscore the importance of a comprehensive clinical evaluation. Unique historical information and findings on focused physical examination after exercise strongly suggest the diagnosis. RESULTS: Intracompartment pressure measurements before and after exercise are confirmatory. Because nonsurgical care is typically palliative, surgery involving fasciotomy to decompress involved compartments can be curative and is described in this article. CONCLUSIONS: These three cases with long-term follow-up were randomly chosen and are representative of the authors' combined experience with chronic exertional compartment syndrome of the foot.

Plate Fixation With Autogenous Calcaneal Dowel Grafting Proximal Fourth and Fifth Metatarsal Fractures: Technique and Case Series.

Metaphyseal and proximal diaphyseal fractures of the lateral column metatarsals can have problems with healing. In particular, those involving the fifth metatarsal have been associated with a high nonunion rate with nonoperative treatment. Although intramedullary screw fixation results in a high union rate, delayed healing and complications can occur. We describe an innovative technique to treat both acute and chronic injuries involving the metatarsal base from the metaphysis to the proximal diaphyseal bone of the fourth and fifth metatarsals. The surgical technique involves evacuation of sclerotic bone at the fracture site, packing the fracture site with compact cancellous bone, and plate fixation. In our preliminary results, 4 patients displayed 100% radiographic union at a mean of 4.75 (range 4 to 6) weeks with no incidence of refracture, at a mean follow-up point of 3.5 (range 1 to 5) years. The early results with our small series suggest that this technique is a useful treatment choice for metaphyseal and proximal diaphyseal fractures of the fourth and fifth metatarsals.

Clinically relevant effectiveness of focused extracorporeal shock wave therapy in the treatment of chronic plantar fasciitis: a randomized, controlled multicenter study.

BACKGROUND: The effectiveness of extracorporeal shock wave therapy in the treatment of plantar fasciitis is controversial. The objective of the present study was to test whether focused extracorporeal shock wave therapy is effective in relieving chronic heel pain diagnosed as plantar fasciitis. METHODS: Two hundred and fifty subjects were enrolled in a prospective, multicenter, double-blind, randomized, and placebo-controlled U.S. Food and Drug Administration trial. Subjects were randomized to focused extracorporeal shock wave therapy (0.25 mJ/mm(2)) or placebo intervention, with three sessions of 2000 impulses in weekly intervals. Primary outcomes were both the percentage change of heel pain on the visual analog scale composite score (pain during first steps in the morning, pain with daily activities, and pain with a force meter) and the Roles and Maudsley score at twelve weeks after the last intervention compared with the scores at baseline. RESULTS: Two hundred and forty-six patients (98.4%) were available for intention-to-treat analysis at the twelve-week follow-up. With regard to the first primary end point, the visual analog scale composite score, there was a significant difference (p = 0.0027, one-sided) in the reduction of heel pain in the extracorporeal shock wave therapy group (69.2%) compared with the placebo therapy group (34.5%). Extracorporeal shock wave therapy was also significantly superior to the placebo therapy for the Roles and Maudsley score (p = 0.0006, one-sided). Temporary pain and swelling during and after treatment were the only device-related adverse events observed. CONCLUSIONS: The results of the present study provide proof of the clinically relevant effect size of focused extracorporeal shock wave therapy without local anesthesia in the treatment of recalcitrant plantar fasciitis, with success rates between 50% and 65%. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Combined plantar plate and hammertoe repair with flexor digitorum longus tendon transfer for chronic, severe sagittal plane instability of the lesser metatarsophalangeal joints: preliminary observations.

The plantar plate provides a substantial static support for the lesser metatarsophalangeal joints. Insufficiency involving tear, attenuation, or absence of this structure can result in significant sagittal plane instability and deformity. When a plantar plate tear is established and is unresponsive to conservative treatment, plantar plate repair is indicated to address symptoms and reestablish static joint stability. The authors hypothesized that combined plantar plate and hammertoe repair with flexor digitorum longus tendon transfer provides a viable surgical option to address chronic plantar plate tears with secondary joint instability and digital deformity. The authors retrospectively evaluated a case series of 18 consecutive patients (20 feet) who underwent this combined surgical strategy as the primary procedure to address severe, chronic sagittal plane instability of the lesser metatarsophalangeal joints. Other procedures were performed concurrently in all cases to address predisposing factors and concomitant deformities. Method of evaluation included a subjective, objective, and radiologic evaluation performed at least 1 year after their surgical procedure. Two rating systems were used: the Lesser Metatarsophalangeal-Interphalangeal Scale from the American Orthopedic Foot and Ankle Society, and another designed by the authors. The average postoperative American Orthopedic Foot and Ankle Society score was 83.2/100 and the average postoperative score with the authors' rating system was 87.7/100. All patients were satisfied with their postoperative result. Study results suggest combined plantar plate and hammertoe repair with flexor digitorum longus tendon transfer to be a viable option to address severe, chronic sagittal plane instability of the internal lesser metatarsophalangeal joints. ACFAS Level of Clinical Evidence: 4.