In Vivo Forces in the Plantar Fascia During the Stance Phase of Gait
Sequential Release of the Plantar Fascia
Plantar fasciotomies have become commonplace in podiatric and orthopedic medicine for the treatment of plantar fasciitis. However, several complications have been associated with plantar fascial release. It has been speculated that the cause of these complications is excessive release of the plantar fascia. The aim of this project was to determine whether the amount of fascia released, from medial to lateral, causes a significant increase in force in the remaining fascia. A dynamic loading system was developed that allowed a cadaveric specimen to replicate the stance phase of gait. The system was capable of applying appropriate muscle forces to the extrinsic tendons on the foot and replicating the in vivo timing of the muscle activity while applying force to the tibia and fibula from heel strike to toe-off. As the plantar fascia was sequentially released from medial to lateral, from intact to 33% released to 66% released, the real-time force and the duration of force in the remaining fascia increased significantly, and the force was shifted later in propulsion. In addition, the subtalar joint was unable to resupinate as the amount of fascia release increased, indicating a direct relationship between the medial band of the plantar fascia and resupination of the subtalar joint during late midstance and propulsion. (J Am Podiatr Med Assoc 93(6): 429-442, 2003)
Literature examining the incidence of foot diseases in rock climbing is limited to traumatic injuries. We examined a large sample of climbers, assessed the chronic diseases of the foot, and correlated them with foot morphology, shoe type, and type of climbing practiced.
Between May 1 and September 30, 2009, 144 climbers (mean age, 31.7 years) were examined to analyze the effect of rock climbing on the various foot diseases found at the time of the evaluation.
Eighty-six percent of the climbers were affected by a pathologic condition. Nail disease was found in 65.3% of patients, followed by recurrent ankle sprains (27.8%), retrocalcaneal bursitis (19.4%), Achilles tendinitis (12.5%), metatarsalgia (12.5%), and plantar fasciitis (5.6%). Male sex, the use of high-type shoes, the high degree of climbing difficulty, and the competitive level were often related to the onset of foot diseases. Climbing shoes are usually smaller than common footwear. This “shoe-size reduction” averaged 2.3 sizes, forcing the foot into a supinated and cavus posture that favors lateral instability. The posterior edge of the shoe aperture produces increased pressure on the heel, with retrocalcaneal bursitis.
Overuse foot diseases related to rock climbing are particularly frequent and debilitating. Detailed knowledge of these diseases and their predisposing factors may help us implement effective preventive or therapeutic measures, including changes in the type of climbing, correction of body weight, degree of difficulty, footwear, orthoses, and measures that maximize the support of the foot to the ground. (J Am Podiatr Med Assoc 103(2): 113–120, 2013)
Closely related pathologic disorders sometimes manifest with the same symptoms, making for a complex differential diagnosis. This is the situation in plantar fasciitis (PF) and myofascial pain syndrome (MPS) with myofascial trigger points (MTPs) in the sole of the foot. This research assessed the analgesic effect on plantar pain of combination therapy with interferential current stimulation therapy (ICST), treating MTPs in the great toe adductor muscle and the short flexor muscles of the toes in patients whose diagnosis was compatible with PF or MPS.
This study included 22 feet of 17 patients with a diagnosis compatible with PF or MPS with MTP. Participants received combination therapy with ICST for 15 sessions, and the decrease in pain was measured with an algometer and the visual analog scale. Both measurements were taken before and after every fifth session. The pressure pain threshold (PPT) results obtained with the Student t test and the pain intensity perception (PIP) results obtained with the Wilcoxon signed rank test were analyzed by comparing the measurements taken before the treatment and after the fifth, tenth, and 15th sessions.
The decrease in PIP was significant after the fifth, tenth, and 15th sessions (P < .001). The increase in PPT was also significant after the fifth (P = .010), tenth (P = .023), and 15th (P = .001) sessions (P < .05).
The suggested combination therapy of ultrasound with ICST is clinically significant for reducing plantar pain after 15 treatment sessions, with a 6.5-point reduction in mean PIP and a 4.6-point increase in PPT.
We investigated the role of first metatarsal head shape in the etiology of hallux valgus. By pedobarographic analysis, we evaluated whether first metatarsal head shape causes an alteration in plantar pressure values that would result in metatarsalgia.
Referrals to our clinic for metatarsalgia, plantar fasciitis, and calcaneal spur were scanned retrospectively. Patients with severe hallux valgus, pes planus, gastrocnemius stiffness, generalized joint laxity, neuromuscular disease, or a history of lower-extremity orthopedic surgery were excluded. Sixty-two patients with plantar pressure assessment and radiographic evaluation were included. These patients were invited for reassessment after 10 years. Feet were divided into three groups by metatarsal head shape: round, square, and chevron. On anteroposterior radiographs, the hallux valgus and intermetatarsal angles, relative first metatarsal length, lateral sesamoid subluxation, and presence of bipartite sesamoid were noted. Plantar pressure was assessed with pedobarography.
Feet with round-shaped first metatarsal heads had a statistically significantly greater progression in hallux valgus angle than the other shapes. Plantar pressures under the first, second and third, and fourth and fifth metatarsals increased with time. This can explain the mechanism of transfer metatarsalgia and painful callosities under the first metatarsal in hallux valgus. There was no correlation between hallux valgus angle, relative metatarsal length, and lateral sesamoid subluxation.
We found a strong relation between round-shaped first metatarsal head and hallux valgus angle progression. No patients had a risk factor responsible for hallux valgus. In other words, this study gives approximately 10-year natural history results in nearly normal feet.
Micronized Dehydrated Human Amnion/Chorion Membrane Injection in the Treatment of Chronic Achilles Tendinitis
A Large Retrospective Case Series
Human amniotic membrane contains growth factors and cytokines that promote epithelial cell migration and proliferation, stimulate metabolic processes that lead to collagen synthesis, and attract fibroblasts, while also reducing pain and inflammation. Randomized studies have shown effectiveness of micronized dehydrated human amnion/chorion membrane (mdHACM) allograft injection in treatment of plantar fasciitis. We present our experience and short-term outcomes with using mdHACM injection as a treatment for Achilles tendinopathy.
Retrospective case series of patients with Achilles tendinopathy treated with mdHACM by a single physician. Participants had at least two follow-up visits within 45 days of mdHACM injection. Outcomes examined included change in reported level of pain during the 45-day observation period and treatment-associated adverse events.
Follow-up data were available for 32 mdHACM-treated patients. At treatment initiation, 97% of patients reported severe (66%) or moderate (31%) pain. At the first follow-up visit (mean ± SD of 8.1 ± 2.7 days postinjection), 27 patients (84%) reported improvement in pain levels, although 37% of patients continued to report severe (6%) or moderate (31%) pain. At the second follow-up visit (mean ± SD of 23.1 ± 6.2 days postinjection), no patients reported severe pain and one reported moderate pain. Within 45 days of mdHACM injection, complete symptom resolution was reported by 66% of treated patients (n = 21), with the remaining 34% (n = 11) reporting symptom improvement but not complete resolution. Two patients reported calf or quadricep pain or tightness after injection.
In our experience, mdHACM injection reduced or eliminated pain in all 32 patients with follow-up data.
Orthotic management is helpful in the treatment of most orthopedic conditions involving the rearfoot, including plantar fasciitis, Achilles tendon disorders, posterior tibial tendon dysfunction, flatfoot, ankle sprains, and problems associated with diabetes, arthritis, and equinus disorders. A review of the effectiveness of orthoses in the treatment of these conditions is presented here. An in-depth analysis of the orthotic management of plantar fasciitis and a critical review of foot orthoses for the pronated foot are presented. Also discussed are the rationale and effectiveness of the tension night splint in the treatment of plantar fasciitis, orthotic devices for the different stages of posterior tibial tendon dysfunction, and the various categories of orthoses for off-loading the diabetic foot. The modern ankle brace, the effectiveness of prefabricated versus prescription foot orthoses, and recent developments in the ankle-foot orthosis are also reviewed.
The efficacy of the transverse plantar incisional approach for the treatment of recalcitrant heel spur syndrome or plantar fasciitis was investigated by evaluating cases of this procedure performed by the authors from 1991 to 1998. Patient records were reviewed for conservative treatment rendered prior to surgical intervention as well as for the perioperative course of the patient. All patients were asked to complete questionnaires regarding their heel spur syndrome or plantar fasciitis and their opinion of both the conservative and the surgical treatments received.
Background: Ankle joint dorsiflexion range of motion is essential to normal gait. Ankle equinus has been implicated in a number of foot and ankle pathologies included Achilles tendonitis, plantar fasciitis, ankle injury, forefoot pain, and foot ulceration. Reliable measurement of ankle joint dorsiflexion range of motion, both clinically and in a research setting, is important.
Methods: The primary aim of this study was to investigate the intertester reliability of an innovative device for measuring ankle joint dorsiflexion range of motion. A total of 31 (n = 31) participants volunteered to take part in this study. A paired t-test was performed to assess for systematic differences between the mean measures of each rater. Intertester reliability was evaluated using the intraclass correlation coefficient (ICC) and their 95% confidence intervals.
Results: A paired t-test demonstrated that the mean ankle joint dorsiflexion range of motion did not significantly differ between raters. The ankle joint ROM mean for rater 1 was 4.65 SD (3.71) and rater 2 was 4.67 SD (3.91). Intertester reliability for the use of the Dorsi-Meter was excellent and demonstrated a very narrow range of error. The ICC (95%CI) was 0.991 (0.980 to 0.995) the SEM (in degrees) was 0.07, the MDC95, in degrees was 0.19 and 95% LOA, degrees was –1.49 to 1.46.
Conclusions: We found the intertester reliability of the Dorsi-Meter to demonstrate higher levels of intertester reliability compared to previous studies investigating other devices. We reported the MDC values to provide an estimate of the smallest amount of change in the ankle joint dorsiflexion range of motion that must be achieved to reflect a true change, outside the error of the test. The Dorsi-Meter has been established as an appropriate reliable device to measure ankle joint dorsiflexion for clinicians and researchers with very small minimal detectable change and limits of agreement.
The authors present a case of atypical heel pain masquerading as plantar fasciitis. The patient was subsequently diagnosed with hyperparathyroidism-induced stress fracture of the calcaneus. The clinical entity of hyperparathyroidism and its manifestations in the skeletal system are presented, as well as a review of stress fractures and pertinent imaging studies.
The deep fascia of the foot lies beneath the subcutaneous tissue and surrounds the intrinsic foot muscles. Depending on its location, the composition of the deep fascia varies. In some areas it is thin, while in other areas it is greatly thickened to form retinacula and the plantar aponeurosis. Selected clinical considerations that relate to the deep fascia of the foot are described. These include the following: plantar fasciitis, infection, compartment syndrome, calcaneal fracture, and neuroma.