An investigation into the hammer toe effects on the lower extremity mechanics and plantar fascia tension: A case for a vicious cycle and progressive damage.

Hammer toes are one of the common deformities of the forefoot that can lead to compensatory changes during walking in individuals with this condition. Predicting the adverse effects of tissue damage on the performance of other limbs is very important in the prevention of progressive damage. Finite element (FE) and musculoskeletal modeling can be helpful by allowing such effects to be studied in a way where the internal stresses in the tissue could be investigated. Hence, this study aims to investigate the effects of the hammer toe deformity on the lower extremity, especially on the plantar fascia functions. To compare the joint reactions of the hammer toe foot (HTF) and healthy foot (HF), two musculoskeletal models (MSM) of the feet of a healthy individual and that of a participant with hammer toe foot were developed based on gait analysis. A previously validated 3D finite element model which was constructed using Magnetic Resonance Imaging (MRI) of the diabetic participant with the hammer toe deformity was processed at five different events during the stance phase of gait. It was found that the hammer toe deformity makes dorsiflexion of the toes and the windlass mechanism less effective during walking. Specifically, the FE analysis results showed that plantar fascia (PF) in HTF compared to HF played a less dominant role in load bearing with both medial and lateral parts of PF loaded. Also, the results indicated that the stored elastic energy in PF was less in HTF than the HF, which can indicate a higher metabolic cost during walking. Internal stress distribution shows that the majority of ground reaction forces are transmitted through the lateral metatarsals in hammer toe foot, and the probability of fifth metatarsal fracture and also progressive deformity was subsequently increased. The MSM results showed that the joint reaction forces and moments in the hammer toe foot have deviated from normal, where the metatarsophalangeal joint reactions in the hammer toe were less than the values in the healthy foot. This can indicate a vicious cycle of foot deformity, leading to changes in body weight force transmission line, and deviation of joint reactions and plantar fascia function from normal. These in turn lead to increased internal stress concentration, which in turn lead to further foot deformities. This vicious cycle cause progressive damage and can lead to an increase in the risk of ulceration in the diabetic foot.

An investigation of the ankle contact forces in a foot with hammer toe deformity. A comparison of patient-specific approaches using finite element modeling and musculoskeletal simulation.

The internal forces and stresses in the tissue are important as they are linked to the risk of mechanical trauma and injuries. Despite their value, the internal stresses and forces cannot be directly measured in-vivo. A previously validated 3D finite element model (FEM) was constructed using Magnetic Resonance Imaging (MRI) of a person with diabetes and hammer toe deformity. The foot model simulated at five different instances during the stance phase of gait. The internal stress distribution on the talus that was obtained using the FEM simulation, was used to calculate the joint reaction force at the ankle joint. In addition, the musculoskeletal model (MSM) of the participant with hammer toe foot was developed based on the gait analysis and was used to determine the muscle forces and joint reactions. The result showed that the vertical reaction forces obtained from the FEM and MSM follow a similar trend through the stance phase of gait cycle and are significantly correlated ( R=0.99). The joint reaction forces obtained through the two methods do not differ for the first 25% of the gait cycle, while the maximum difference was ∼0.7 Body weight that was observed at 50% of the stance phase. Clinical Relevance: Finite element modeling and musculoskeletal simulation can shed light on the internal forces at the ankle in pathological conditions such as hammer toe. The similarities and differences observed in the joint reaction forces calculated from the two methods can have implications in assessing the effect of clinical interventions.

Increased exposure to loading is associated with decreased plantar soft tissue hardness in people with diabetes and neuropathy.

AIMS: Literature indicates that altered plantar loading in people with diabetes could trigger changes in plantar soft tissue biomechanics which, in turn, could affect the risk for ulceration. To stimulate more research in this area, this study uses in vivo testing to investigate the link between plantar loading and tissue hardness. METHODS: Tissue hardness and plantar pressure distribution were measured for six plantar areas in 39 people with diabetes and peripheral neuropathy. RESULTS: Spearman correlation analysis revealed that increased pressure time integral at the 1st metatarsal-head region (r = -0.354, n = 39, P = 0.027) or at the heel (r = -0.378, n = 39, P = 0.018) was associated with reduced hardness in the same regions. After accounting for confounding parameters, generalised estimating equations analysis also showed that 10% increase in pressure time integral at the heel was associated with ≈ 1 unit reduction in hardness in the same region. CONCLUSIONS: For the first time, this study reveals that people with diabetes and neuropathy who tend to load their feet more heavily also tend to have plantar soft tissues with lower hardness. The observed difference in tissue hardness is likely to affect the tissue's vulnerability to overload injury. More research will be needed to explore the implications of the observed association for the risk of ulceration.

Associations between changes in loading pattern, deformity, and internal stresses at the foot with hammer toe during walking; a finite element approach.

Over the past decade, Finite Element (FE) modelling has been used as a method to understand the internal stresses within the diabetic foot. Foot deformities such as hammer toe have been associated with increased risk of foot ulcers in diabetic patients. Hence the aim of this study is to investigate the influence of hammer toe deformity on internal stresses during walking. A 3D finite element model of the human foot was constructed based on capturing Magnetic Resonance Imaging (MRI) of a diabetic neuropathic volunteer exhibiting hammer toe. 3D gait measurements and a multi-body musculoskeletal model for the same participant were used to define muscle forces. FE simulations were run at five different instances during the stance phase of gait. Peak plantar pressure and pressure distribution results calculated from the model showed a good agreement with the experimental measurement having less than 11% errors. Maximum von Mises internal stresses in the forefoot hard tissue were observed at the 3rd and 5th metatarsals and 4th proximal phalanx. Moreover, presence of hammer toe deformity was found to shift the location of maximum internal stresses on the soft tissue to the forefoot by changing the location of centre of pressure with internal stress 1.64 times greater than plantar pressure. Hammer toe deformity also showed to reduce the involvement of the first phalanx in internal/external load-bearing during walking. The findings of this study support the association between changes in loading pattern, deformity, and internal stresses in the soft tissue that lead to foot ulceration.

Advancements in data analysis and visualisation techniques to support multiple single-subject analyses: an assessment of movement coordination and coordination variability.

Vector coding is a data analysis technique that quantifies inter-segmental coordination and coordination variability of human movement. The usual reporting of vector coding time-series data can be difficult to interpret when multiple trials are superimposed on the same figure. This study describes and presents novel data visualisations for displaying data from vector coding that supports multiple single- subject analyses. The dataset used in this study describes the lumbar-pelvis coordination in the transverse plane during a gait cycle. The data visualisation techniques presented in this study consists of the use of colour and data bars to map and profile coordination pattern and coordination variability data. The use of colour mapping provides the option to classify commonalities and differences in patterns of coordination between segment couplings and between individuals across a big dataset. Data bars display segmental dominancy data that can provide an intuitive summary on coupling angle distribution over time. The data visualisation in this study may provide further insight on how people with adolescent idiopathic scoliosis perform goal-orientated movements following an intervention, which would support clinical management strategies.

Can plantar soft tissue mechanics enhance prognosis of diabetic foot ulcer?

AIM: To investigate if the assessment of the mechanical properties of plantar soft tissue can increase the accuracy of predicting Diabetic Foot Ulceration (DFU). METHODS: 40 patients with diabetic neuropathy and no DFU were recruited. Commonly assessed clinical parameters along with plantar soft tissue stiffness and thickness were measured at baseline using ultrasound elastography technique. 7 patients developed foot ulceration during a 12months follow-up. Logistic regression was used to identify parameters that contribute to predicting the DFU incidence. The effect of using parameters related to the mechanical behaviour of plantar soft tissue on the specificity, sensitivity, prediction strength and accuracy of the predicting models for DFU was assessed. RESULTS: Patients with higher plantar soft tissue thickness and lower stiffness at the 1st Metatarsal head area showed an increased risk of DFU. Adding plantar soft tissue stiffness and thickness to the model improved its specificity (by 3%), sensitivity (by 14%), prediction accuracy (by 5%) and prognosis strength (by 1%). The model containing all predictors was able to effectively (χ2 (8, N=40)=17.55, P<0.05) distinguish between the patients with and without DFU incidence. CONCLUSION: The mechanical properties of plantar soft tissue can be used to improve the predictability of DFU in moderate/high risk patients.

Manufacturing and finite element assessment of a novel pressure reducing insole for Diabetic Neuropathic patients.

Diabetes is one of the metabolic diseases. Uncontrolled diabetes can lead to diabetic foot ulcers and if it was not treated would lead to amputation. Foot ulcers can be prevented by using suitable insoles which are made of appropriate material and geometrically designed by constituent layers. In this study, single-layer and three-layer insoles have been compared during static and dynamic loading. The selected materials were silicone gel (SG), plastazote foam (PLZ), polyfoam (PF) and ethyl vinyl acetate foam (EVA). Four single-layer and 18 combinations of three-layer insoles were selected. Materials behaviors were determined by using a uniaxial pressure test. The description of stress and strain is obtained by using the model of three dimensional nonlinear Finite Element Method (FEM). Then samples were tested by using commercially available plantar pressure measurement system. The FEM results showed that the SG and PLZ insoles are more appropriate compared to single-layer insoles. The combinations of PLZ, SG and EVA (from top to bottom) are recognized as the best between three-layer insoles. Also the best three-layer insole is more effective in promoting a favourable stress and strain distribution than single-layer insoles, especially in dynamic mode. According to simulation results, three-layer insole decreases stress concentration by 9%. Also experimental tests showed that using three-layer insole decreases plantar pressure by 63% compared to barefoot condition bare foot.

Validation of a multi-segment spinal model for kinematic analysis and a comparison of different data processing techniques.

Optoelectronic motion capture technology is a useful tool in the quantitative dynamic assessment of the spine. In a clinical setting this may help gain a further understanding of underlining musculoskeletal pathology. It is therefore important that accurate measurements are made to allow data to be comparable across various investigations. This report outlines a new multi-segment spinal model and its validation. A mechanical model consisting of an upper thoracic (UT), lower thoracic and lumbar segment was developed allowing for range of motion assessment. An electrogoniometer and torsiometer were attached to the model to provide a control measurement. The UT segment was chosen for analysis and static trials were collected at angles ranging from 2-45°. Kinematic data was captured using an optoelectronic motion capture system. Software computed angles corresponded well with the control measure. While highlighting the differences in the estimation of angles between software platforms, this study emphasizes the need for the clear description and understanding of the kinematic model used.

Three-dimensional analysis of intracycle velocity fluctuations in frontcrawl swimming.

The purpose of this study was to determine accurately the magnitude and changes of intra-cycle velocity fluctuation (Vfluc), maximum (Vmax) and minimum velocity (Vmin) of the center of mass during a maximum 200 m frontcrawl swim, and to examine whether they are associated with performance. Performance was indicated by the mean velocity (Vmean) of the stroke cycle (SC) in the swimming direction. The relative Vfluc, Vmax and Vmin were also calculated as a percentage of Vmean, while Vfluc was calculated for all three directions. Eleven male swimmers of national/international level participated in this study and their performance was recorded with four below- and two above-water-synchronized cameras. Four SCs were analyzed for the 200 m swim (one for each 50 m). Anthropometric data were calculated by the elliptical zone method. Vmean generally decreased throughout the test. Vmax and Vmin were positively correlated to performance and were significantly higher in SC1 than in the other SCs. However, the relative Vmax and Vmin values were remarkably consistent during the 200 m and not associated with performance. Despite the noteworthy magnitude of Vfluc in all directions, they were in general not correlated with performance and there were no significant changes during the test.