Effects of dry needling and stretching exercise versus stretching exercise only on pain intensity, function, and sonographic characteristics of plantar fascia in the subjects with plantar fasciitis: a parallel single-blinded randomized controlled trial.

OBJECTIVES: Plantar fasciitis is a common problem in the foot region which has negative considerable impact on foot function. METHODS: In this parallel blinded randomized controlled trial, a total of thirty-seven subjects with plantar fasciitis (forty feet) were enrolled randomly to either the control group (stretching exercise) or the experimental group (stretching exercise plus dry needling). All interventions lasted six weeks and both groups were followed for two weeks. Primary outcomes were first step pain, pain, and activity daily function subscales of the FAOS questionnaire and secondary outcomes were plantar fascia thickness, and echogenicity. RESULTS: The mixed model ANOVAs showed significant group × time interactions for all primary outcomes. In both groups, first step pain and both subscales of the FAOS questionnaire were improved compared to baseline measurements. There were considerable differences between the two groups and the experimental group experienced more improvements in primary outcomes compared to the control group. For secondary outcomes, plantar fascia thickness at insertion significantly decreased, and the echogenicity in the two regions significantly increased in the experimental group compared to the control group. CONCLUSION: These results suggest that the combination of dry needling and stretching exercises can be an effective conservative treatment for plantar fasciitis subjects.

Iliopsoas muscle thickness and pelvic alignment in pronated and normal foot postures.

It is hypothesized that the subtalar hyperpronation may provoke the development of a biomechanical chain of events in lower extremity alignment. Several studies have shown that pelvic alignment may alter in the presence of immediate foot hyperpronation induced by external forces. It is unknown whether these alterations are presented in chronic foot hyperpronation or not. It is also unknown if these potential postural changes could affect iliopsoas muscle size. Therefore, it appears necessary to carry out thorough research in this study. Twenty nine females with pronated foot posture and twenty seven females with normal foot posture participated in this study. The iliopsoas muscle was measured using ultrasound imaging (USI). Pelvic angle (PA) was measured using reflective markers and digital photography. Intrarater reliability of USI for the iliopsoas muscle thickness was also measured. The results indicated that the iliopsoas muscle thickness and the PA were not different in individuals with pronated foot compared to the normal foot group. However, a good intrarater reliability of USI was found for measuring the iliopsoas muscle thickness.

Ultrasonography Comparison of the Plantar Fascia and Tibialis Anterior in People With and Without Lateral Ankle Sprain: A Case-Control Study.

OBJECTIVE: The purpose of the present study was to evaluate the thickness of the plantar fascia (PF) at the insertion of the calcaneus and the midfoot and forefoot fascial locations, in addition to the thickness of the tibialis anterior, by ultrasound imaging in individuals with and without lateral ankle sprain (LAS). METHODS: A sample of 44 participants was recruited and divided in 2 groups: 22 feet with a prior diagnosis of grade 1 or 2 LAS (case group) and 22 feet without this condition (healthy group). The thickness and cross-sectional area were evaluated by ultrasound imaging in both groups. RESULTS: Ultrasound measurements of the PF at the calcaneus, midfoot, and forefoot showed statistically significant differences (P < .05), with a decrease in thickness in the LAS group relative to the healthy group. For the thickness and cross-sectional area of the tibialis anterior, no significant differences (P < .05) were observed between groups. CONCLUSION: The thickness of the PF at the calcaneus, midfoot, and forefoot is reduced in individuals with LAS relative to the healthy group.

Calcium Sulfate/Calcium Phosphate Bone Void Filler in the Treatment of Bilateral Adolescent Unicameral Calcaneal Bone Cysts: 36-Month Follow-Up.

A 36-month follow-up of the management of bilateral adolescent unicameral bone cysts in a high school gymnast treated with a calcium sulfate/calcium phosphate (CSCP) bone void filler (BVF) is presented. The more developed left calcaneal cyst was managed with a traditional, open approach consisting of allogenic bone graft, CSCP BVF mixed with platelet-rich plasma. The less developed right calcaneal cyst was managed with a less used approach, a percutaneous bone cortex incision with only the CSCP BVF. The rationale for the selection between the open and percutaneous approaches, long-term BVF incorporation, and positive patient outcome allowing a quick return to athletics are presented.

An extravascular fluid transport system based on structural framework of fibrous connective tissues in human body.

OBJECTIVE: Interstitial fluid in extracellular matrices may not be totally fixed but partially flow through long-distance oriented fibrous connective tissues via physical mechanisms. We hypothesized there is a long-distance interstitial fluid transport network beyond vascular circulations. MATERIALS AND METHODS: We first used 20 volunteers to determine hypodermic entrant points to visualize long-distance extravascular pathway by MRI. We then investigated the extravascular pathways initiating from the point of thumb in cadavers by chest compressor. The distributions and structures of long-distance pathways from extremity ending to associated visceral structures were identified. RESULTS: Using fluorescent tracer, the pathways from right thumb to right atrium wall near chest were visualized in seven of 10 subjects. The cutaneous pathways were found in dermic, hypodermic and fascial tissues of hand and forearm. The perivascular pathways were along the veins of arm, axillary sheath, superior vena cava and into the superficial tissues on right atrium. Histological and micro-CT data showed these pathways were neither blood nor lymphatic vessels but long-distance oriented fibrous matrices, which contained the longitudinally assembled micro-scale fibres consistently from thumb to superficial tissues on right atrium. CONCLUSIONS: These data revealed the structural framework of the fibrous extracellular matrices in oriented fibrous connective tissues was of the long-distance assembled fibres throughout human body. Along fibres, interstitial fluid can systemically transport by certain driving-transfer mechanisms beyond vascular circulations.

Toe Flexor Muscle Strength and Morphological Characteristics of the Foot in Judo Athletes.

Whether practicing in judo influences the muscle strength and morphological characteristics of the foot is unknown. The purpose of this study was to determine the toe flexor muscle strength and morphological characteristics of the foot in judo athletes. Judo athletes (JUDO, men=24) and age-, gender- and body mass-matched physically active healthy subjects (CON, men=24) were recruited, and their toe flexor strength and morphological characteristics of the foot were compared. The maximum isometric toe flexor strength and foot intrinsic muscle thicknesses were measured using a toe grip dynamometer and a B-mode ultrasound, respectively. Foot arch height was assessed as the distance between the navicular tuberosity of the foot and the floor in the sitting and standing positions. JUDO showed a significantly lower foot arch height and smaller foot arch index than CON, whereas foot length and muscle thickness did not significantly differ between groups. The toe flexor strength relative to total muscle thickness was significantly larger in JUDO than CON. The foot arch dynamics was significantly larger in JUDO than CON. This study suggests that exercise training specific to judo may affect the force-generating capacity, morphological structure and arch function of the foot.

Surgical Considerations for Vitamin D Deficiency in Foot and Ankle Surgery.

Vitamin D deficiency affects nearly one-sixth of the world's population and is common in patients undergoing foot and ankle surgery. Vitamin D is critical for calcium homeostasis and plays an important role in the maintenance of bone health. Patients undergoing foot and ankle procedures can be evaluated preoperatively with vitamin D level testing, and deficiencies can be addressed with either preoperative or postoperative supplementation. Current data suggest that patients with adequate vitamin D levels may have better outcomes, but the details are not yet clear. Vitamin D supplementation is well tolerated with rare side effects.

Immediate effects of ultrasound-guided percutaneous neuromodulation versus physical exercise on performance of the flexor hallucis longus muscle in professional dancers: a randomised clinical trial.

BACKGROUND: Ultrasound-guided percutaneous neuromodulation (US-guided PNM) is a minimally invasive intervention. This technique consists of the application of percutaneous electrical stimulation (PES) through an acupuncture needle-like electrode that is placed in close proximity to the nerve or motor point of the target muscle under ultrasound guidance. OBJECTIVE: To examine the immediate effects of a stretching exercise, an eccentric exercise and US-guided PNM on the performance of the flexor hallucis longus (FHL) muscle in young dancers. METHODS: Randomised clinical trial. A total of 45 dancers were divided into three groups: Stretching group, Eccentric group and PNM group. The following performance parameters were assessed: range of motion (ROM) of the first metatarsophalangeal joint, balance test and unilateral heel raise fatigue test. RESULTS: There were no differences between these groups in baseline measurements; at the end of the study, mean balance and endurance values were only significantly higher for the PNM group compared to the Stretching (p = 0.007 and p < 0.001, respectively) and Eccentric groups (p = 0.003 and p < 0.001, respectively). The effect sizes were large for the balance (d = 0.8) and endurance (d = 1.83) tests in the PNM group. Both the Stretching and Eccentric groups exhibited improvements in ROM compared to their baseline values (p = 0.009 and p = 0.004, respectively), whereas there was no significant temporal improvement noted for the PNM group. The effect sizes with respect to ROM values were moderate for stretching (d = 0.6) and eccentric (d = 0.7) exercises. CONCLUSION: An isolated PES intervention provides a greater immediate increase in balance and muscular strength than an active stretching and eccentric exercise of the FHL muscle in young ballet dancers.

Non-Weight-Bearing and Weight-Bearing Ultrasonography of Select Foot Muscles in Young, Asymptomatic Participants: A Descriptive and Reliability Study.

OBJECTIVE: The primary aim of this study was to determine the reliability of diagnostic ultrasound imaging for select intrinsic foot muscles using both non-weight-bearing and weight-bearing postures. Our secondary aim was to describe the change in muscle cross-sectional area (CSA) and dorsoplantar thickness when bearing weight. METHODS: An ultrasound examination was performed with a linear ultrasound transducer operating between 9 and 12 MHz. Long-axis and short-axis ultrasound images of the abductor hallucis, flexor digitorum brevis, and quadratus plantae were obtained in both the non-weight-bearing and weight-bearing postures. Two examiners independently collected ultrasound images to allow for interexaminer and intraexaminer reliability calculation. The change in muscle CSA and dorsoplantar thickness when bearing weight was also studied. RESULTS: There were 26 participants (17 female) with a mean age of 25.5 ± 3.8 years and a mean body mass index of 28.0 ± 7.8 kg/m2. Inter-examiner reliability was excellent when measuring the muscles in short axis (intraclass correlation coefficient >0.75) and fair to good in long axis (intraclass correlation coefficient >0.4). Intraexaminer reliability was excellent for the abductor hallucis and flexor digitorum brevis and ranged from fair to good to excellent for the quadratus plantae. Bearing weight did not reduce interexaminer or intraexaminer reliability. All muscles exhibited a significant increase in CSA when bearing weight. CONCLUSIONS: This is the first report to describe weight-bearing diagnostic ultrasound of the intrinsic foot muscles. Ultrasound imaging is reliable when imaging these muscles bearing weight. Furthermore, muscle CSA increases in the weight-bearing posture.

Prospective Randomized Controlled Trial of Hindfoot and Ankle Fusions Treated With rhPDGF-BB in Combination With a ß-TCP-Collagen Matrix.

BACKGROUND: Ankle and hindfoot arthrodesis is often supplemented with autograft to promote bony union. Autograft harvest can lead to increased perioperative morbidity. Purified recombinant human platelet-derived growth factor BB homodimer (rhPDGF-BB) has stimulated bone formation in mandibular defects and hindfoot fusion. This randomized controlled trial evaluated the efficacy and safety of rhPDGF-BB combined with an injectable, osteoconductive beta-tricalcium phosphate (ß-TCP)-collagen matrix versus autograft in ankle and hindfoot fusions. METHODS: Seventy-five patients requiring ankle or hindfoot fusion were randomized 5:1 for rhPDGF-BB/ß-TCP-collagen (treatment, n = 63) or autograft (control, n = 12). Prospective analysis included 142 autograft control subjects from another clinical trial with identical study protocols. Standardized operative and postoperative protocols were used. Patients underwent standard internal fixation augmented with autograft or 0.3 mg/mL rhPDGF-BB/ß-TCP-collagen. Radiologic, clinical, and quality-of-life outcomes were assessed over 52 weeks. Primary outcome was joint fusion (50% or more osseous bridging on computed tomography) at 24 weeks. Secondary outcomes included radiographs, clinical healing status, visual analog scale pain score, American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale score, Foot Function Index score, and Short Form-12 score. Noninferiority P values were calculated. RESULTS: Complete fusion of all involved joints at 24 weeks as indicated by computed tomography was achieved in 53 of 63 (84%) rhPDGF-BB/ß-TCP-collagen-treated patients and 100 of 154 (65%) autograft-treated patients (P < .001). Mean time to fusion was 14.3 ± 8.9 weeks for rhPDGF-BB/ß-TCP-collagen patients versus 19.7 ± 11.5 weeks for autograft patients (P < .01). Clinical success at 52 weeks was achieved in 57 of 63 (91%) rhPDGF-BB/ß-TCP-collagen patients and 120 of 154 (78%) autograft patients (P < .001). Safety-related outcomes were equivalent. Autograft controls had 2 bone graft harvest infections. CONCLUSIONS: Application of rhPDGF-BB/ß-TCP-collagen was a safe, effective alternative to autograft for ankle and hindfoot fusions, eliminating the pain and morbidity associated with autograft harvesting. LEVEL OF EVIDENCE: Level I, prospective randomized study.

Melorheostosis: segmental osteopoikilosis or a separate entity?

PURPOSE: Melorheostosis is a progressive hyperostotic bone disease that commonly affects the appendicular skeleton. Melorheostosis has a significant degree of overlap with other hyperostosis conditions including osteopoikilosis and likely represent varying degrees of a clinical spectrum. METHODS: This is a report of 2 patients with melorheostosis who presented with different clinical presentations and involvement of different anatomic locations. RESULTS: One of the patients presented with foot size asymmetry along with intermittent foot pain and limping. This patient also had irregular nonblanching yellow plaque-like lesion on the forehead. The second patient presented with abnormal gait but no pain. Radiographs demonstrated endosteal hyperostosis, which were consistent with a mixed picture of melorheostosis and osteopoikilois. Genetic testing of the LEMD3 gene from a blood sample was negative in both cases. CONCLUSIONS: The diagnosis of melorheostosis can be made based on the clinical and radiographic features and can be challenging to differentiate from other hyperostosis conditions. LEVEL OF EVIDENCE: Level V.

Use of high-resolution ultrasound to measure changes in plantar fascia thickness resulting from tissue creep in runners and walkers.

OBJECTIVE: This study sought to use high-resolution ultrasound to measure changes in plantar fascia thickness as a result of tissue creep generated by walking and running. METHODS: Independent samples of participants were obtained. Thirty-six walkers and 25 runners walked on a treadmill for 10 minutes or ran for 30 minutes, respectively. Standardized measures of the thickness of the plantar fascia were obtained in both groups using high-resolution ultrasound. RESULTS: The mean thickness of the plantar fascia was measured immediately before and after participation. The mean plantar fascia thickness was decreased by 0.06 ± 0.33 mm SD after running and 0.03 ± 0.22 mm SD after walking. The difference between groups was not significant. CONCLUSION: Although the parameters of this study did not produce significant changes in the plantar fascia thickness, a slightly higher change in the mean thickness of the plantar fascia in the running group deserves further investigation.

[Footwear according to the "business dress code", and the health condition of women's feet--computer-assisted holistic evaluation]. / Obuwie zgodne z "business dress code" a kondycja zdrowotna stóp kobiet--komputerowo wspomagana ocena holistyczna.

BACKGROUND: According to the verdict of the Supreme Court in 2005, an employer may dismiss an employee if their conduct (including dress) exposes the employer to losses or threatens his interests. The aim of the study was a holistic assessment of the pleiotropic effects of high-heeled pointed shoes on the health condition of women's feet, wearing them at work, in accordance with the existing rules of the "business dress code". MATERIALS AND METHODS: A holistic multidisciplinary analysis was performed. It takes into account: 1) women employees of banks and other large corporations (82 persons); 2) 2D FEM computer model developed by the authors of foot deformed by pointed high-heeled shoes; 3) web site found after entering the code "business dress code". RESULTS: Over 60% of women in the office wore high-heeled shoes. The following has been found among people walking to work in high heels: 1) reduction in the quality of life in about 70% of cases, through periodic occurrence of pain and reduction of functional capacity of the feet; 2) increase in the pressure on the plantar side of the forefoot at least twice; 3) the continued effects the forces deforming the forefoot. CONCLUSIONS: 1. An evolutionary change of "dress code" shoes is necessary in order to lead to a reduction in non-physiological overload of feet and the consequence of their disability. 2. These changes are particularly urgent in patients with so-called "sensitive foot".

Spinal cord stimulation for recurrent painful neuromas of the foot.

The authors report the case of a patient affected by recurrent neuromas of the interdigital nerves of the left foot that appeared after surgery for Morton's disease. Implantation of spinal cord stimulation (SCS) system was performed after three unsuccessful surgical revisions, which demonstrated the presence of multiple neuromas growing at endings of the stumps of the nerves and fasciculi. The patient developed chronic neuropathic pain localized within the third metatarsal region of the left foot. Conservative treatments failed and autonomous gait became impossible. SCS immediately abolished pain and the patient was able to perform her normal daily activities within 1 month. At our knowledge, this is the first report in literature of SCS successfully employed for recurrent and refractory pain due to Morton's neuroma.

Early findings of small-animal MRI and small-animal computed tomography correlate with histological changes in a rat model of rheumatoid arthritis.

With the use of a commonly utilized animal model of rheumatoid arthritis, the central goal of this work was to determine how well the small-animal imaging tools, small-animal MRI (microMRI) and small-animal X-ray computed tomography (microCT), can detect very early histological changes that occur immediately after induction of the disease. Arthritis was induced in rats by injecting complete Freund's adjuvant into the tail. Right hind paws of living rats were evaluated with 4.7 T microMRI with T1-weighted spin echo and inversion recovery sequences. Paw specimens were also evaluated with microCT and by histological examination (n = 29). MicroMR images were scored for the presence of joint effusion, soft tissue swelling, bone marrow changes, and bone erosions. MicroCT measured bone mineral density (BMD). Histology scores were obtained from representative slides from the same rats. The correlation between BMD, MRI and histology was analyzed using linear regression analysis and analysis of covariance. MRI abnormalities were detected on day 5 after induction as joint effusion and soft tissue swelling, followed by bone marrow changes on day 6 and bone erosion on day 8. BMD measured by microCT decreased, the decrease becoming significant on day 7 (P < 0.019). Soft tissue swelling, joint effusion, and bone erosion scores on microMRI correlated with histology (r2 approximately 0.7). Bone marrow changes were seen more clearly with microMRI than by histological examination. Bone loss could be detected earlier by microCT than on histological sections. In conclusion, microMRI and microCT can be used to evaluate early disease changes within 1 week of induction in the adjuvant-induced arthritis model, and have the ability to detect certain manifestations of disease earlier than histological analysis. The use of small-animal imaging techniques potentially allows earlier diagnosis, improved subject stratification, earlier drug implementation, and therefore improved drug trials in animal models of rheumatoid arthritis.

[Infection with Aeromonas hydrophila after use of leeches (Hirudo medicinalis) in a free microvascular osteo-(myo-)cutaneous flap--suggestions for successful management]. / Aeromonas hydrophila-Infektion nach Therapie mit Hirudo medicinalis bei venöser Stauung nach freiem mikrovaskulären osteo-(myo-)kutanen Gewebetransfer--Empfehlungen zur erfolgreichen Therapie.

Medical leeches (Hirudo medicinalis) are an important therapeutic option in the treatment of venous congestion of flaps. In a case report an infection with Aeromonas hydrophila of a free microvascular osteo-(myo)-cutaneous flap after leech application for venous congestion is described and the current literature reviewed. Infection associated with leech therapy is a documented complication of leech application, with reported incidences ranging from 2.4 to 20 %. In some cases an infection of the wound developed with Aeromonas hydrophila, a Gram-negative rod that lives symbiotically in the intestines of the leech. Because of the risk of graft loss, early diagnosis and immediate initiation of an empirical intravenous antibiotic therapy with Piperacillin/Tacobactam or a third or fourth generation cephalosporins are essential even before results for sensitivity testing are received. An alternative is a short-term preemptive therapy with Cotrimoxazol or Ciprofloxacin during leech application.

[Regional circulation in gunshot wounds of the ankle joint and foot]. / Regionarnoe krovoobrashchenie pri ognestrel'nykh raneniiakh golenostopnogo sustava i stopy.

Problems of treatment of battle injuries of the ankle joint and foot are discussed. These injuries are characterized with severe disturbances of regional circulation and microcirculation causing hypoxia and metabolic disorders both in soft tissues and in bones. Digital substraction angiography (DSA) was used in 7 wounded (7.53%) of all patients with battle injuries of the foot and ankle joint. Combined treatment including surgery, drugs, physical and exercise therapy, hyperbaric oxygenation was used in all the patients. Prolonged intraarterial infusion of drugs was carried out in 4 of 7 patients. It is concluded that early evaluation of regional circulation permits to clarify expediency of applied combined treatment. Injury of three arteries is the indication for amputation, but even one functioning artery enables use of combined therapy with intraarterial infusion for extremity salvage.

Diagnosis, characterisation and evaluation of treatment response of frostbite using pertechnetate scintigraphy: a prospective study.

No large prospective study is available on use of a radionuclide method to assess frostbite and its response to conservative treatment. Recently, a large retrospective study using two-phase bone scintigraphy suggested that non-uptake (or low uptake) in frostbite lesions in the blood pool or bone phase had a strong correlation with the subsequent need for amputation. In the present study, we performed early blood pool scintigraphy with technetium-99m pertechnetate in 20 patients (10-180 days after frostbite injury; 71 clinical lesions) referred for a topical treatment protocol for mild to moderately severe frostbite, and in 22 asymptomatic controls. The aims of the study were to define the "normal" microcirculation of the hands and feet, to characterise the appearances of frostbite lesions on scintigraphy and correlate these with the clinical presentation, and to evaluate the usefulness of scintigraphy for assessing the treatment response. Six patients were "fresh", 12 had been undergoing conservative treatment (topical homeopathic) for several weeks and two had permanent fibrotic hand phalanges. Nine patients on treatment underwent serial scintigraphy a total of 22 times. Eleven patients were imaged only once, including the two with permanent fixed defects. Three distinct physiological microcirculation patterns were evident in control hands or feet: right- or left-handedness (seven subjects), subclinical inflammatory foci correlating with callosity or pressure points (36 lesions) and distinctly increased pooling of radiotracer at the thenar or hypothenar region (eight subjects). In frostbite patients, 128 lesions (48 inflammatory, 80 ischaemic) were seen on the scan. This number included all 71 lesions identified clinically, the rest being subclinical. Subclinical frostbite lesion as an entity has not been described previously. Microvasculature of normal muscle groups (in the hands, elbow or feet) was shown on scintigraphy to improve after topical treatment. The treatment resulted in improved or normalised perfusion scan in 25 of 45 ischaemic segments with matching clinical improvement, and reduction or normalisation of uptake in inflammatory lesions (n=30). The data confirm the vasodilator and anti-inflammatory action of the topical preparation, and the sensitivity of the radionuclide method in monitoring treatment response. In contrast to the previous findings that non-uptake on a scan performed 2 or more weeks after exposure correlates with the need for amputation, none of the 80 ischaemic lesions in our series required amputation while 60% showed improvement or normalisation in microvascular blood flow even though they were 10-180 days old. Our findings suggest that moderate to severe frostbite lesion can be classified as having infarcted, ischaemic or hibernating (viable) tissue, similar to the classification employed when using myocardial scintigraphy. Absence of uptake even after the initial 10 days does not necessarily indicate infarction and the need for amputation as many such lesions retain potential for vasodilation and recovery.