Threatening Fracture of Intraosseous Lipoma Treated by Internal Fixation
Case Report and Review of the Literature
Intraosseous lipomas are rare benign bone neoplasms with an incidence of less than 0.1%; origin in the calcaneus has been reported in only a few patients. First-line treatment remains conservative, but several surgical techniques have also been described. We describe a 44-year-old woman with increasing pain in her left heel for a year and a half, who noticed swelling on the lateral side of the calcaneus. The patient underwent radiography, magnetic resonance imaging, and computed tomography of her left foot, which was suspicious for an intraosseous lipoma with a threatening calcaneal fracture. We performed a surgical procedure, curettage of the tumor, spongioplastics (by autologous bone transplant and ?-tricalcium phosphate), and internal stabilization with a calcaneal plate considering the goal of immediate postoperative weightbearing. Histologic examination confirmed an intraosseous lipoma of the calcaneus. The patient's pain was relieved immediately after surgery. Internal stabilization of the calcaneus allowed the patient to immediately fully weightbear and to return to usual daily activities. Although a benign bone tumor, intraosseous lipoma can cause many complications, such as persistent pain, decreased function, or even pathologic fracture as a result of calcaneal bone weakening. Choosing an appropriate treatment is still controversial. Conservative treatment is the first option, but for patients with severe problems and threatening fracture, surgery is necessary. Internal fixation for stabilization enables immediate postoperative weightbearing and shortens recovery time.
A 30-year-old man working as a waiter presented with a progressively enlarging and symptomatic soft-tissue mass on the plantar medial aspect of his left foot. The mass was painful and disrupting ambulation, despite footwear modifications. He ultimately underwent excision of what was a determined to be a fibrolipoma, returning to his regular shoes and all activities. Plantar neoplasms, even when benign, can grow to sizes that can result in significant disability. If left untreated, particularly in individuals engaged in occupations requiring frequent standing or walking, excision of the mass will often require a more aggressive operative approach.
Varicosities as an Etiology of Tarsal Tunnel Syndrome and the Significance of Tinel’s Sign
Report of Two Cases in Young Men and a Review of the Literature
Two cases of tarsal tunnel syndrome in two young men with surgical and radiologic details are reported. The role of varicosities as a cause of tarsal tunnel syndrome and the significance of Tinel3s sign are discussed through a large review of the literature. (J Am Podiatr Med Assoc 99(2): 144–147, 2009)
There are few documented reports of arteriovenous malformations in the extremities, and even fewer specifically in the foot. Most of the documented cases in the foot present surgical treatments, and there is limited information on the nonsurgical approach. A brief review of the surgical approach to arteriovenous malformations in the foot and hand is presented first, followed by a case report of the nonsurgical treatment of an arteriovenous malformation in the foot, which was initially diagnosed incorrectly.
We sought to develop a standardized protocol for ultrasound (US) measurements of plantar fascia (PF) width and cross-sectional area (CSA), which may serve as additional outcome variables during US examinations of both healthy asymptomatic PF and in plantar fasciopathy and determine its interrater and intrarater reliability.
Ten healthy individuals (20 feet) were enrolled. Participants were assessed twice by two raters each to determine intrarater and interrater reliability. For each foot, three transverse scans of the central bundle of the PF were taken at its insertion at the medial calcaneal tubercle, identified in real time on the plantar surface of the foot, using a fine wire technique. Reliability was determined using intraclass correlation coefficients (ICC), standard errors of measurement (SEM), and limits of agreement (LOA) expressed as percentages of the mean. Reliability of PF width and CSA measurements was determined using PF width and CSA measurements from one sonogram measured once and the mean of three measurements from three sonograms each measured once.
Ultrasound measurements of PF width and CSA showed a mean of 18.6 ± 2.0 mm and 69.20 ± 13.6 mm2 respectively. Intra-reliability within both raters showed an ICC > 0.84 for width and ICC > 0.92 for CSA as well as a SEM% and LOA% < 10% for both width and CSA. Inter-rater reliability showed an ICC of 0.82 for width and 0.87 for CSA as well as a SEM% and LOA% < 10% for width and a SEM% < 10% and LOA% < 20% for CSA. Relative and absolute reliability within and between raters were higher when using the mean of three sonographs compared to one sonograph.
Using this novel technique, PF CSA and width may be determined reliably using measurements from one sonogram or the mean of three sonograms. Measurement of PF CSA and width in addition to already established thickness and echogenicity measurements provides additional information on structural properties of the PF for clinicians and researchers in healthy and pathologic PF.
Background: Tarsal tunnel syndrome (TTS) can be divided into proximal TTS and distal TTS (DTTS). Research on methods to differentiate these two syndromes is sparse. A simple test and treatment is described as an adjunct to assist with diagnosing and providing treatment for DTTS.
Methods: The suggested test and treatment is an injection of lidocaine mixed with dexamethasone administered into the abductor hallucis muscle at the site of entrapment of the distal branches of the tibial nerve. This treatment was studied with a retrospective medical record review in 44 patients with clinical suspicion of DTTS.
Results: The lidocaine injection test and treatment (LITT) was positive in 84% of patients. Of patients available for follow-up evaluation (35), 11% of those with a positive LITT test (four) had complete lasting symptom relief. One-quarter of patients with initial complete symptom relief at LITT administration (four of 16) maintained this level of symptom relief at follow-up. Thirty-seven percent of patients evaluated at follow-up (13 of 35) who had a positive response to the LITT experienced partial or complete symptom relief. No association was found between level of symptom relief maintenance and the immediate level of symptom relief (Fisher exact test = 0.751; P = .797). The results showed no difference in the distribution of immediate symptom relief by sex (Fisher exact test = 1.048; P = .653).
Conclusions: The LITT is a simple, safe, invasive method to help diagnose and treat DTTS, and it provides an additional method to assist with differentiating DTTS from proximal TTS. The study also provides additional evidence that DTTS has a myofascial etiology. The proposed mechanism of action of the LITT suggests a new paradigm in diagnosing muscle-related nerve entrapments that may lead to nonsurgical treatments or less invasive surgical interventions for DTTS.
Extracorporeal Shockwave Therapy for Interdigital Neuroma
A Randomized, Placebo-Controlled, Double-Blind Trial
Background: We sought to evaluate the safety and effectiveness of extracorporeal shockwave therapy as a therapeutic treatment for destroying Morton’s neuroma.
Methods: Twenty-five patients (25 feet) were included in the study. Indications for participation were more than 8 months of conservative care with a visual analog scale pain score of 4 or greater. The mean overall pain score on a modified visual analog scale was 6.9 preoperatively.
Results: Thirteen patients were randomized to the active group and 12 to the sham group. Two patients in the sham group were lost to follow-up. Post-treatment evaluations were performed at 1, 6, and 12 weeks by a blinded investigator (L.W.). The end point evaluation parameter was the reduction in visual analog scale score. The treatment group showed a significant difference before and after extracorporeal shockwave therapy (P < .0001). The sham group did not have a significant difference after 12 weeks (P = .1218).
Conclusions: Extracorporeal shockwave therapy is a possible alternative to surgical excision for Morton’s neuroma. (J Am Podiatr Med Assoc 99(3): 191–193, 2009)
Background: Of all of the lower-extremity injuries with multifactorial causes, heel pain represents the most frequent reason for visits to health-care professionals. Managing patients with heel pain can be very difficult. The purpose of this research was to identify key variables that can influence foot health in patients with heel pain.
Methods: A cross-sectional observational study was performed with 62 participants recruited from the Educational Welfare Unit of the University of Malaga, Malaga, Spain. Therapists, blinded for the study, acquired the anthropometric information and the Foot Posture Index, and participants completed the Foot Health Status Questionnaire.
Results: The most significant results reveal that there is a moderate relationship between clinical variables such as footwear and Foot Health Status Questionnaire commands such as Shoe (r = 0.515; P < .001). The most significant model domain was General Health (P < .001), with the highest determination coefficient (beta not standard = 34.05). The most significant predictable variable was body mass index (−0.110).
Conclusions: The variables that can help us manage clinical patients with heel pain are age, body mass index, footwear, and Foot Posture Index (left foot).
Are Three-Dimensional–Printed Foot Orthoses Able to Cover the Podiatric Physician's Needs?
Relationship Between Shore A Hardness and Infilling Density
Current management of foot pain requires foot orthoses (FOs) with various design features (eg, wedging, height) and specific mechanical properties (eg, hardness, volume). Development of additive manufacturing (three-dimensional [3-D] printing) raises the question of applying its technology to FO manufacturing. Recent studies have demonstrated the physical benefits of FO parts with specific mechanical properties, but none have investigated the relationship between honeycomb architecture (HcA) infilling density and Shore A hardness of thermoplastic polyurethane (TPU) used to make FOs, which is the aim of this study.
Sixteen different FO samples were made with a 3-D printer using TPU (97 Shore A), with HcA infilling density ranging from 10 to 40. The mean of two Shore A hardness measurements was used in regression analysis.
Interdurometer reproducibility was excellent (intraclass correlation coefficient, 0.91; 95% confidence interval [CI], 0.64–0.98; P < .001) and interprinter reproducibility was excellent/good (intraclass correlation coefficient, 0.84; 95% CI, 0.43–0.96; P < .001). Linear regression showed a positive significant relationship between Shore A hardness and HcA infilling density (R2 = 0.955; P < .001). Concordance between evaluator and durometer was 86.7%.
This study revealed a strong relationship between Shore A hardness and HcA infilling density of TPU parts produced by 3-D printing and highlighted excellent concordance. These results are clinically relevant because 3-D printing can cover Shore A hardness values ranging from 40 to 70, representing most FO production needs. These results could provide important data for 3-D manufacturing of FOs to match the population needs.
Low-Dye taping is commonly used to manage foot pathologies and pain. Precut one-piece QUICK TAPE was designed to facilitate taping. However, no study to date has demonstrated that QUICK TAPE offers similar support and off-loading as traditional taping.
This pilot study compared the performance of QUICK TAPE and low-Dye taping in 20 healthy participants (40 feet) with moderate-to-severe pes planus. Study participants completed arch height index (AHI), dynamic plantar assessment with a plantar pressure measurement system, and subjective rating in three conditions: barefoot, low-Dye, and QUICK TAPE. The order of test conditions was randomized for each participant, and the taping was applied to both feet based on a standard method. A generalized estimating equation with an identity link function was used to examine differences across test conditions while accounting for potential dependence in bilateral data.
Participants stood with a significantly greater AHI (P = .007) when either taping was applied compared with barefoot. Participants also demonstrated significantly different plantar loading when walking with both tapings versus barefoot. Both tapings yielded reduced force-time integral (FTI) in the medial and lateral forefoot and increased FTI under toes. Unlike previous studies, however, no lateralization of plantar pressure was observed with either taping. Participants ranked both tapings more supportive than barefoot. Most participants (77.8%) ranked low-Dye least comfortable, and 55.6% preferred QUICK TAPE over low-Dye.
Additional studies are needed to examine the clinical utility of QUICK TAPE in individuals with foot pathologies such as heel pain syndrome and metatarsalgia.