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Does shoe midsole temperature affect patellofemoral and Achilles tendon kinetics during running?

by Sinclair J1*, Atkins S2,  Shore H1pdflrg

The Foot and Ankle Online Journal 9 (2): 4

The aim of the current investigation was to examine the effects cooled footwear on patellofemoral and Achilles tendon kinetics during running. Ten participants completed running trials at 4.0 m/s in two identical footwear one of which was cooled for 30 min. Lower extremity kinematics were obtained using an eight camera motion capture system and force data was obtained using a force platform. Differences between cooled and normal footwear temperatures were examined using paired samples t-tests. The results showed that peak Achilles tendon load was significantly larger in the cooled footwear (5.86 ± 1.06 B.W) in comparison to non-cooled (4.89 ± 1.04 B.W). In addition Achilles tendon loading rate was also significantly larger in the cooled footwear (48.95 ± 10.17 B.W/s) in comparison to non-cooled (42.49 ± 10.40 B.W/s). This study indicates that running in cooled footwear may place runners at increased risk from the biomechanical parameters linked to the aetiology of Achilles tendinopathy.

Key words: footwear, ankle, knee, temperature

ISSN 1941-6806
doi: 10.3827/faoj.2016.0902.0004

1 – Centre for Applied Sport and Exercise Sciences, School of Sport Tourism and Outdoors, University of Central Lancashire,
2 – School of Psychology, University of Central Lancashire.
3 – School of Health Sciences, University of Salford.
* Correspondence – jksinclair@uclan.ac.uk


Runners are known to be extremely susceptible to chronic lower extremity pathologies; 19.4-79.3 % of all runners’ will suffer from a chronic pathology over the course of one year [1]. The knee and ankle joint are the most commonly injures musculoskeletal structures and are associated with up to one-fifth of all running injuries [1]. The running shoe represents the main interface between the runners and the surface during running [2], and has thus been strongly advocated as a mechanism by which the injury rate can be mediated. One of the most important aspects of the running shoe is the mechanical dampening properties of the midsole [3]. The majority of running shoes utilize a copolymer called Ethylene-vinyl acetate as it is both durable and flexible even at low densities [3]. Ethylene-vinyl acetate like most polymers exhibits viscoelastic properties [4], and thus its mechanical properties are temperature dependant [5].

The effects of different midsole temperatures have been examined previously. Kinoshita & Bates [6] investigated the influence of different environmental temperatures on the shock absorbing characteristics of running shoe midsoles using mechanical testing. Their findings showed that with increasing temperature, peak acceleration and energy absorption decreased, and the total peak deformation of the midsole increased. Sinclair et al., [7] examined the effects of cooled footwear on the kinetics and kinematics of running in comparison to identical footwear maintained at room temperature. Their findings showed that the cooled footwear were associated with significantly increased vertical loading rate and also peak angle of eversion/ tibial internal rotation.

There has yet to be any published information concerning the effects of footwear midsole temperature on the loads experienced by the frequently injured knee and ankle joints. Therefore the aim of the current investigation was to examine the effects cooled footwear on patellofemoral and Achilles tendon kinetics during running in comparison to footwear at normal temperature.

Methods

Participants

Ten female runners took part in this study. All were injury free and provided written informed consent. The mean characteristics of the participants were: Age = 21.55 ± 2.58 years, Height = 1.67 ± 0.07 m, Mass = 61.29 ± 5.01 kg. The procedure utilized for this investigation was approved by the University of Central Lancashire, ethical committee.

Procedure

Two identical trainers (Nike Free run 5.0+; sizes 4-7 UK) were used one of which was artificially chilled (cooled) and one was maintained at room temperature (normal). The temperature of the experimental footwear was reduced by placing them inside a freezer which maintained a constant temperature of -25°C for 30 mins [7].

Kinematic data were obtained via an camera optoelectric motion capture system (Qualisys Medical AB, Goteburg, Sweden) using a capture frequency of 250 Hz. Participants completed five trials running at 4.0 m/s in both cooled and normal footwear conditions. A maximum deviation of 5 % from the predetermined velocity was allowed. The participants struck a force platform (Kistler Instruments, Model 9281CA) sampling at 1000Hz with their right (dominant) foot. Locomotion velocity was measured using timing gates (SmartSpeed Ltd UK). The stance phase of running was defined as the duration over which > 20 N vertical force was applied to the force platform [8].

To model the thigh, shank and foot segments calibrated anatomical systems technique was utilized [9]. To define the segment coordinate axes of the right; foot, shank and thigh, retroreflective markers were placed unilaterally onto 1st metatarsal, 5th metatarsal, calcaneus, medial and lateral malleoli, medial and lateral epicondyles of the femur. The centres of the ankle and knee joints were delineated as the midpoint between the malleoli and femoral epicondyle markers. The hip joint centre was taken as a point one-quarter of the distance from the ipsilateral to the contralateral greater trochanter [10]. The centres of the knee and ankle joints were taken as the midpoint between the malleoli and femoral epicondyle markers [11, 12]. Carbon fibre tracking clusters were utilized to track the shank and thigh segments, whereas the foot was tracked using the 1st metatarsal, 5th metatarsal and calcaneus markers. Static calibration trials were obtained allowing for the anatomical markers to be referenced in relation to the tracking markers/ clusters.

Data processing

Ground reaction force and kinematic data were filtered at 50 and 15 Hz respectively using a low-pass Butterworth 4th order filter using Visual 3-D (C-Motion, Rockville, MD, USA). Kinematic measures from the knee and ankle joints which were extracted for statistical analysis were 1) angle at footstrike, 2) peak angle and 3) relative range of motion (representing the angular displacement from footstrike to peak angle. Joint moments were calculated using Newton-Euler inverse-dynamics, which allowed net knee and ankle joint moments (Nm) to be calculated. The net joint moments were normalized by dividing by body mass (Nm/kg).

Patellofemoral kinetics were examined through extraction of peak knee extensor moment (KEM), patellofemoral contact force (PTCF) and patellofemoral contact pressure (PTS). PTCF was normalized by dividing the net PTCF by body weight (B.W).

PTCF during running was estimated using knee flexion angle (kfa) and KEM through the biomechanical model of Ho et al., [13]. This model has been utilized previously to resolve differences in PTCF and PTS in different footwear [14-16].

The effective moment arm of the quadriceps muscle group (QM) was calculated as a function of kfa using a nonlinear equation, based on information presented by van Eijden et al., [17]:

QM = 0.00008 kfa 3 – 0.013 kfa 2 + 0.28 kfa + 0.046

The force (N) of the quadriceps (QF) was calculated using the below formula:

QF = KEM / QM

Net PTCF (N) was estimated using the QF and a constant (C):

PTCF = QF * C

The C was described in relation to kfa using a curve fitting technique based on the nonlinear equation described by van Eijden et al., [17]:

C = (0.462 + 0.00147 * kfa 2 – 0.0000384 * kfa 2) / (1 – 0.0162 * kfa + 0.000155 * kfa 2 – 0.000000698 * kfa 3)

PTS (MPa) was calculated using the net PTCF divided by the patellofemoral contact area. The contact area was described using the Ho et al., [13] recommendations by fitting a 2nd order polynomial curve to the data of Powers et al., [18] showing patellofemoral contact areas at varying levels of kfa.

PTS = PTCF / contact area

Achilles tendon force (ATF) (B.W) was determined by dividing the plantarflexion moment (MPF) by the estimated Achilles tendon moment arm (mat). The moment arm was quantified as a function of the ankle sagittal plane angle (ak) using the procedure described by Self and Paine [19]:

ATF = MPF / mat
mat = -0.5910 + 0.08297 ak – 0.0002606 ak2

Statistical Analysis

Descriptive statistics (means and standard deviations) were obtained for each footwear temperature. Differences in patellofemoral and Achilles tendon load parameters between cooled and normal footwear conditions were examined using paired samples t-tests, with statistical significance was accepted at the P≤0.05 level [20]. In addition minimum clinically important differences (MCID) were calculated as being 2.3 * the pooled standard error. All statistical tests were conducted using SPSS v22.0 (SPSS Inc, Chicago, USA).

Results

Table 1 and figures 1-2 present the patellofemoral and Achilles tendon parameters observed as a function of footwear temperature.

Fig1

Figure 1 Knee joint kinetics and kinematics as a function of cooled footwear (a. = knee sagittal angle, b. = knee sagittal moment, c. = PTCF, d. = PTS) (black = cooled and grey = non-cooled).

Non-cooled Cooled MCID  
  Mean SD Mean SD  
Knee moment (Nm/kg) 2.72 0.51 2.70 0.46 0.32  
PTF (B.W) 3.59 0.77 3.63 0.69 0.48  
PTF load rate (B.W/s) 50.33 9.18 49.44 8.72 5.94  
Time to PTF (ms) 72.11 11.26 74.89 8.84 6.67  
PTS (Mpa) 9.34 1.91 9.35 1.71 1.20  
Ankle moment (Nm/kg) 2.33 0.49 2.80 0.49 0.33 *
ATL (B.W) 4.89 1.04 5.86 1.06 0.70 *
Time to ATL (ms) 118.78 11.60 121.17 10.86 7.46
ATL load rate (B.W/s) 42.49 10.40 48.95 10.17 6.05 *

Table 1 Patellofemoral and Achilles tendon load parameters as a function of footwear temperature.

Notes : * = significant difference

Fig2

Figure 2 Ankle joint kinetics and kinematics as a function of cooled footwear (a. = ankle sagittal angle, b. = ankle sagittal moment, c. = ATF) (black = cooled and grey = non-cooled).

Joint kinematics

No significant (P>0.05) differences in knee joint kinematics were observed. The ankle joint was shown to be significantly (t (11) = 3.62, P<0.05) more dorsiflexed at footstrike in the non-cooled footwear. In addition peak dorsiflexion was significantly (t (11) = 3.77, P<0.05) larger in the non-cooled footwear.

Patellofemoral loads

No significant (P>0.05) differences in patellofemoral loads were shown (Table 1; Figure 1).

Achilles tendon loads

Peak plantarflexion moment was significantly larger (t (11) = 3.25, P<0.05) in the cooled footwear (Table 1; Figure 2b). In addition Achilles tendon load was significantly (t (11) = 3.56, P<0.05) greater in the cooled footwear (Table 1; Figure 2c). Finally the results also confirm that Achilles tendon load rate was significantly larger (t (11) = 2.99, P<0.05) in the cooled footwear (Table 1).

Discussion

The aim of the current investigation was to investigate the effects of different footwear temperatures on the loads experienced by the patellofemoral joint and Achilles tendon. This represents the first investigation to explore the effects of footwear temperature on the specific loads experienced by the musculoskeletal structures during running. The current investigation may provide important investigation to runners regarding the effects of footwear temperature

The first key observation from the current work is that patellofemoral loads were not significantly influenced by alterations in shoe midsole temperature. Patellofemoral pain syndrome is the most common chronic pathology associated with running and is considered to be caused by excessive patellofemoral loading [13].  Therefore importantly it appears based on the findings from the current work that footwear temperature does not appear to affect runner’s susceptibility to patellofemoral disorders.   

However the findings from this investigation did show that Achilles tendon load parameters were shown to be significantly larger in the cooled footwear condition in comparison to the footwear maintained at normal temperature. This observation is in agreement with those of Kulmala et al., [15] and Sinclair, [16] who demonstrated that different midsole characteristics can influence the loads experienced by the Achilles tendon. The increases in Achilles tendon loads may have specific clinical relevance regarding the aetiology of Achilles tendon injuries as the differences exceed the magnitude denoted by the MCID. When loads of high magnitudes are applied to the tendon too frequently in sports such as running, this can lead ultimately to degradation of the tendon itself [21]. Based on these observations it appears that running in cooled footwear places runners at increased risk from Achilles tendinopathy.

It is proposed that this finding is due to the reduced midsole temperature of the cooled footwear. Sinclair et al., [7] found that cooled footwear midsoles offer reduced deformation and shock attenuating properties when compared to those at room temperature. The kinematic observations showed that the ankle position was significantly more plantarflexed in the cooled footwear throughout the stance phase when compared to the non-cooled condition.

This observation has been shown previously as an adjustment that most runners make in response to a increases in footwear or surface stiffness. Increases in ankle plantarflexion are associated with a shortening of the Achilles tendon moment arm, which leads to an increase in the load borne by the tendon itself [19].

A potential limitation of this study is that knee and ankle joint loading was estimated using a musculoskeletal modelling approach. This approach was necessary as direct measures of internal forces require invasive techniques. Nonetheless, the use of net extensor and plantarflexor moments as inputs into the calculation of patellofemoral and Achilles tendon kinetics means that antagonist forces acting in the opposing direction of the joint itself are not accounted for which may ultimately lead to an underestimation of joint loading.

In conclusion, whilst previous investigations have considered the effects of shoe midsole temperature on biomechanical parameters the effect of changing the temperature of the midsole on knee and ankle loading has not been considered. The current investigation addresses this by providing a comparison of patellofemoral and Achilles tendon kinetics when running in cooled and normal temperature footwear. Importantly the current study shows that Achilles tendon loading parameters were significantly greater when running in cooled footwear. First and foremost this study provides further insight into the biomechanical effects of reducing footwear temperature. Furthermore, the current work indicates that running in cooler footwear places runners at greater risk from chronic Achilles tendon pathologies.

References

  1. van Gent, B.R., Siem, D.D., van Middelkoop, M., van Os, T.A., Bierma-Zeinstra, S.S., & Koes, B.B. Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. B J of Sport Med 2007 41; 469-480.
  2. Shorten, M.A. (2000). Running shoe design: protection and performance pp 159-169 in Marathon Medicine (Ed. D. Tunstall Pedoe) London, Royal Society of Medicine.
  3. Brückner, K., Odenwald, S., Schwanitz, S., Heidenfelder, J., & Milani, T. Polyurethane-foam midsoles in running shoes-impact energy and damping. Proc Eng 2010 2; 2789-2793.
  4. Knauss, W.G., Emri, I., & Lu, H. (2008). Mechanics of polymers: viscoelasticity (pp. 49-96). Springer US.
  5. Dib, M.Y., Smith, J., Bernhardt, K.A., Kaufman, K.R., & Miles, K.A. Effect of environmental temperature on shock absorption properties of running shoes. Clin J of Sport Med 2005 15; 172-176.
  6. Kinoshita, H., & Bates, BT. The effect of environmental temperature on the properties of running shoes. J App Biomech 1996 12; 25-268.
  7. Sinclair, J., Naemi, R, Chockalingam, N., Taylor, P.J., & Shore, H.F. The effects of shoe temperature on the kinetics and kinematics of running, Footwear Sci 2015 7; 173-180.
  8. Sinclair, J., Edmundson, C.J., Brooks, D., & Hobbs, S.J. Evaluation of kinematic methods of identifying gait events during running. Int J Sports Sci & Eng 2011 5; 188–192.
  9. Cappozzo, A., Catani, F., Leardini, A., Benedeti, M.G., & Della, C.U. Position and orientation in space of bones during movement: Anatomical frame definition and determination. Clin Biomech 1995 10; 171-178.
  10. Sinclair, J., Taylor, P.J., Currigan, G., & Hobbs, S.J. The test-retest reliability of three different hip joint centre location techniques. Mov Sport Sci 2014; 83, 31-39.
  11. Sinclair, J., Hebron, J., & Taylor, P.J. The Test-retest Reliability of Knee Joint Center Location Techniques. J App Biomech 2015 31; 117-121.
  12. Graydon, R., Fewtrell, D., Atkins, S., & Sinclair, J. The test-retest reliability of different ankle joint center location techniques. The Foot and Ankle Online journal, 8, 1-11.
  13. Ho, K.Y., Blanchette, M.G., & Powers, C.M. The influence of heel height on patellofemoral joint kinetics during walking. Gait Posture 2012 36; 271-275.
  14. Bonacci, J., Vicenzino, B., Spratford, W., & Collins, P. (2013). Take your shoes off to reduce patellofemoral joint stress during running. Br J Sports Med. Epub ahead of print: doi:10.1136/bjsports-2013-092160.
  15. Kulmala, J.P., Avela, J., Pasanen, K., & Parkkari, J. Forefoot strikers exhibit lower running-induced knee loading than rearfoot strikers. Med Sci Sports Exerc 2013 45; 2306-2313.
  16. Sinclair, J. Effects of barefoot and barefoot inspired footwear on knee and ankle loading during running. Clin Biomech 2014 29; 395-9.
  17. van Eijden, T.M., Kouwenhoven, E., Verburg, J., & Weijs, W.A. A mathematical model of the patellofemoral joint. J Biomech 1986 19; 219–229.
  18. Powers, C.M., Lilley, J.C., & Lee, T.Q. The effects of axial and multiplane loading of the extensor mechanism on the patellofemoral joint. Clin Biomech 1998 13; 616–624.
  19. Self, B.P., & Paine, D. Ankle biomechanics during four landing techniques. Med Sci Sports Exerc 2001; 33, 1338–1344.
  20. Sinclair, J., Taylor, P. J., & Hobbs, S.J. Alpha level adjustments for multiple dependent variable analyses and their applicability–a review. Int J Sport Sci Eng 2013; 7, 17-20.
  21. Magnusson, S.P., Langberg, H., & Kjaer M. The pathogenesis of tendinopathy: balancing the response to loading. Nat Rev Rheumatol 2010; 6: 262–268.

Postoperative analgesic efficacy of dexamethasone sodium phosphate versus triamcinolone acetonide in bunionectomy: A prospective, single-blinded pilot randomized controlled trial

by Chris Olivia Ongzalima1, Wei Lin Renee Lee1, Anh Hoang1, Ming Yi Wong1, Reza Naraghi1*pdflrg

The Foot and Ankle Online Journal 9 (2): 3

Background: Corticosteroids are often administered via injection preoperatively to reduce post-operative inflammation and pain. Despite their wide anecdotal application in clinical practice, there are no current guidelines pertaining to appropriate corticosteroid selection. This study aims to investigate and compare the efficacy of dexamethasone sodium phosphate (DSP) and triamcinolone acetonide (TA) in postoperative pain management following hallux valgus surgery.
Methods: A randomized, prospective, single-blind study comparing preoperative DSP versus TA injections was conducted on 20 participants who were undergoing elective hallux valgus surgery. Postoperative pain scores (pain intensity and pain interference with daily activities) were assessed with Brief Pain Inventory Short Form (BPI-sf) questionnaire at the time of first postoperative oral analgesic consumption or 14 days after surgery if no analgesics were required. Differences in clinically significant pain scores were also assessed with prospectively defined response criteria.
Results: The difference in mean for pain intensity and pain interference were found to be significantly lower for TA group as compared to DSP group (p = 0.006 and p = 0.001) respectively. Significant difference was also observed in the proportion of participants who reported absence of postoperative pain scores between DSP and TA groups (p = 0.025 and p= 0.006) respectively. However, there were no significant differences between time to postoperative analgesia consumption and proportion of participants requiring oral analgesia (p>0.05).
Conclusions: This study provides preliminary evidence suggesting that TA is associated with lower pain scores compared to DSP. Further research is required to establish the effects of TA and DSP in managing postoperative pain following hallux valgus surgery.

Key words: Hallux valgus; Bunionectomy; Corticosteroid; Triamcinolone Acetonide; Dexamethasone Sodium Phosphate; Podiatry; Post-operative; Pain; Analgesics

ISSN 1941-6806
doi: 10.3827/faoj.2016.0902.0003

1 – School of Podiatric Medicine, Faculty of Medicine, Dentistry and Health Sciences,
The University of Western Australia, Perth, WA, Australia
* Corresponding author: Reza Naraghi  reza.naraghi@uwa.edu.au


Over the decades, pain continues to remain as one of the main postoperative adverse outcomes that cause distress to patients [1-5]. While great advances in the use of medications for postoperative pain control has been made, numerous studies have indicated continued undertreatment of pain [1-5].

A 2003 national survey conducted by Apfelbaum et al. [6] showed evidence of this ineffectiveness in pain management, where approximately 80% of patients who experienced acute pain immediately after surgery.

Of these, 86% described their pain as being moderate to severe in intensity [6]. A recent study conducted by Gan et al. [7] revealed similar findings, illustrating the lack of progress in postsurgical pain management.

Current attempts to reduce post-operative pain include the use of several agents, categorized as opioids and nonopioid analgesics [1,3,4] Amongst these, opioid analgesics are used as the conventional first-line approach to postoperative pain management [2,3]. Its use, however, has been associated with serious adverse effects such as respiratory depression, constipation, sedation and postoperative nausea and vomiting [1,8]. As such, multimodal analgesic regimens that use non-opioid analgesics to facilitate lower dosing of opioids are gradually replacing plain opioid analgesics in postoperative pain management [8]. However, serious systemic side effects associated with multimodal analgesic regimens can still occur. Hence, there is still a need for further reductions in opioid intake.

Corticosteroids are a group of hormones that elicit analgesic effects through phospholipase A2 inhibition [9]. They prevent formation of arachidonic acid and subsequent inflammatory mediators that are responsible for causing inflammation, edema and pain [9]. Its analgesic properties have been well demonstrated in the context of oropharyngeal and maxillofacial surgeries [9-11]. Their value as a therapeutic approach to postoperative pain relief for podiatric surgery is however, not well explored.
The few studies that have reported corticosteroid use in podiatric surgeries have identified dexamethasone sodium phosphate (DSP) to be a frequently administered postoperative analgesic agent [12-15]. DSP, a synthetic and soluble adrenocortical steroid, is a rapid short-acting preparation of dexamethasone that has been profoundly used in conjunction with local anaesthetics to minimize acute pain and inflammation after foot and ankle surgeries [12-15]. A study by Curda [14] demonstrated the effectiveness of DSP-bupivacaine combination over bupivacaine alone in reducing postoperative pain at 24 hours (p < 0.0001) and 4 to 7 days after surgery (p = 0.0004).

Bryant et al. [15] illustrated the opioid sparing effects of DSP by demonstrating a marked reduction in narcotics and oral analgesics intake following DSP injections, as compared to its control. Miller and Wertheimer [13], however, did not find any improvements in postoperative pain outcomes 48 – 72 hours after the use of DSP.

It is to note that the clinical trials described previously were published before year 2000. There is no recent literature which investigates the efficacy of DSP as postoperative analgesia following hallux valgus surgery. Therefore, its effectiveness in reducing pain after podiatric surgery remains debatable. A longer acting corticosteroid which provides extended and uninterrupted pain relief can greatly improve postoperative pain management. Optimal pain relief will in turn minimize patient discomfort, decrease the need for postoperative oral analgesic, facilitate early mobilization and optimize functional recovery [4].

Triamcinolone acetonide (TA), normally formulated as a crystalised suspension, is a relatively insoluble, intermediate acting adrenocortical steroid with a long duration of action [16]. Synergistic use of TA alongside mixture of bupivacaine and epinephrine has demonstrated longer pain relief, better joint mobility and significant opioid sparing effect following knee surgeries compared to the mixture itself [16-20]. The use of TA in podiatric surgery, although popular, has not been investigated.
With the above in mind, further research is required to support the use of corticosteroids in podiatric surgery and determine the most appropriate corticosteroid to alleviate postoperative pain. The aim of this research was therefore to assess and compare the postoperative analgesic efficacy of DSP and TA in participants undergoing hallux valgus surgery. The null hypothesis was that TA would exhibit the same analgesic efficacy as DSP in hallux valgus surgery.

Methods

Ethics

This study was approved by the Human Research Ethics Committee, University of Western Australia, Australia (File Reference: RA/4/1/6631).

Study design and participants

This participant-blinded randomized controlled trial compared the efficacy of DSP with TA in alleviating postoperative pain in participants undergoing hallux valgus surgery, over 14 days. As this pilot study was exploratory in nature and undertaken for feasibility, no sample size calculations were performed. We estimated that 20 participants with similar demographics would represent an adequate sample to inform future trial design and generate appropriate study hypotheses.

Recruitment

From May to December 2014, 20 healthy participants (2 males, 18 females) fulfilling the enrolment criteria and providing informed consent were recruited at the University of Western Australia Podiatric Surgery Clinic. Participants were eligible for the study if they were above 18 years old and undergoing surgical correction of hallux valgus facilitated through the University of Western Australia Podiatric Surgery Clinic. Participants were excluded from the study if they had, 1) cognitive impairment, 2) intellectual disability, 3) physical disability or mental illness, 4) allergy or hypersensitivity to any corticosteroids, 5) systemic viral and fungal infections, 6) allergy or hypersensitivity to paracetamol or codeine, 7) diabetes mellitus, 8) chronic renal failure, 9) inflammatory arthritis and any other forms of immunodeficiency, and 10) taking medications that could interact with DSP or TA at the time of study.

Randomization and blinding

Participants were randomly allocated to receive either DSP (4mg/mL) or TA (10mg/mL). Randomization allocation was prepared using simple randomization coin tossing method prior to participant recruitment. The podiatric surgeon administering the corticosteroids was blinded to the intervention allocation until the day of hallux valgus surgery. Corticosteroid allocation was revealed to the podiatric surgeon by a study investigator prior to the surgery.

The study design was only single-blind due to the difference in solubility of the two corticosteroids, which caused an inevitable color difference that could be detected by the podiatric surgeon during injection. All participants remained blinded to the intervention group assignment.

Corticosteroids

The DSP injection used was DBLTM dexamethasone sodium phosphate (Hospira Inc., Australia), a sterile solution containing 4 mg dexamethasone phosphate, 8 mg creatinine, 10 mg sodium citrate, and water for injections quantity sufficient to 1 ml. The TA used was Kenacort ® -A 10 (Aspen Pharmacare, Australia), a sterile solution containing 10 mg triamcinolone acetonide, 6.6 mg sodium chloride, 15 mg benzyl alcohol, 6.4 mg carmellose sodium, 0.4 mg polysorbate 80, and water for injections quantity sufficient to 1 ml. pH was adjusted using sodium hydroxide and hydrochloride acid for both solutions.

Protocol

The corticosteroid injection was administered to the participants pre-operatively, in combination with 5mL of 0.75% Naropeine. The amount injected was divided equally and infiltrated on the dorsal, medial, plantar and lateral aspects of the first metatarsal, in a Mayo block fashion proximal to the surgical site. The dose injected was based upon previous experiences of the podiatric surgeon and falls within the recommended dose ranges for soft tissue corticosteroid injections. The hallux valgus surgery was then performed following the standard University of Western Australia protocol for Austin bunionectomy.
After the procedure, dressings for the surgical site were applied uniformly by the same surgeon to eliminate the risk of increased postoperative pain secondary to a tighter bandage on one participant than on the other. Participants were also advised to minimize weight-bearing activities to promote healing. All participants were given postoperative oral analgesic medication, which contained the active ingredients paracetamol and codeine, as part of the University of Western Australia Podiatric Surgery Clinic’s standard postoperative care procedure. Participants were encouraged to take the oral analgesic medication when pain was perceived as intolerable. Intolerable pain was defined as pain scores greater than 3/10 on a numerical rating scale (range 0-10).

Table1

Table 1 Primary and secondary outcomes of study.

Outcome measures

The primary outcomes of this study were pain intensity, pain interference with daily activities and presence of clinically significant pain. These postoperative pain scores were assessed using the Brief Pain Inventory-Short Form (BPI-SF) questionnaire. The BPI-SF is a validated, 15-item questionnaire that rates pain over the last 24 hours and the degree to which it interferes with activities on a 0 to 10 scale [21]. In this study, pain severity was measured as worst pain in the last 24 hours (i.e. item 3 of the BPI-SF) and the pain interference score as the mean score of all seven BPI-SF items (i.e item 9A-G) assessing interference of pain with activities of daily living. All measurements were done based on recommendations by Cleeland [22]. For the purpose of pain intensity analyses, the presence of clinically significant pain was defined as a score of 4 or more on BPI-SF item 3, and for the pain interference analyses, as a mean score of 4 or more on the BPI-SF pain interference scale.

Secondary outcomes of this study include time taken to postoperative oral analgesic consumption and proportion of participants requiring postoperative oral analgesia. All secondary outcomes were recorded with a patient logbook and analyzed prospectively as per analysis plan. Primary and secondary outcomes were outlined in Table 1.
Participants were instructed to complete a baseline questionnaire covering demographic information prior to the hallux valgus surgery. The self-administered BPI-SF questionnaire was completed at the time to first postoperative oral analgesic consumption or 14 days after surgery if no postoperative oral analgesics were required. Participants were also instructed to record the date of the first oral analgesic consumed after surgery on logbook. All outcome measures were obtained 14 days after the hallux valgus surgery.

Statistical analysis

All statistical analyses were performed using International Business Machines Statistical Package for the Social Sciences Statistics software version 22.0 (SPSS Inc., Chicago, Illinois).

Demographic and outcome variables were described by using means and standard error of means for continuous variables and percentages for categorical variables by treatment group. The data were explored for normality using the Shapiro-Wilk test prior to inferential analysis.

Two-sample t tests were used to compare between-group differences for age, worst pain level and mean pain interference. Mann-Whitney U test was used to compare time to postoperative oral analgesic consumption. Lastly, Pearson’s chi-squared tests or Fisher’s exact test were used to compare gender, sides, the absence or presence of clinically significant pain and pain interference with daily activities, and proportion of participants who consumed postoperative analgesic medication within each treatment group.

The significance for all tests was set at p-value < 0.05.

Results

Demographics

Between May and December 2014, a total of 20 participants were recruited and randomly assigned to two groups: 10 participants received DSP (Group D) and the remaining 10 received TA (Group T). There were 1 male and 9 female participants in each group, with an average age of 48.2 ± 5.1years in group D and 62.1 ± 4.1 years in Group T. Age difference between group D and T was statistically significant (p = 0.048). There were no significant differences in other baseline demographics between the two treatment groups (P > 0.05) (Table 2).

Table2

Table 2 Clinical demographic details of the study groups.

Table3

Table 3 Mean (SEM) postoperative BPI-SF questionnaire score.

Table4

Table 4 Pain severity and interference with daily activities (absent vs present).

Table5

Table 5 Time (day) to postoperative analgesic medication.

Table6

Table 6 Proportion of participants who consumed postoperative analgesic medication within each treatment group.

Mean pain severity and pain interference

Participants in Group T reported significantly lesser pain level and pain interference level as compared to Group D (p = 0.006 and p = 0.001 respectively) (Table 3). In addition, the mean scores for worst pain and pain interference level observed in Group T were lower than 3, in contrast to Group D, which reported mean values of 4 and above.

Absence and presence of clinically significant pain and interference with daily activities

Greater proportions of participants in Group T reported absence of clinically significant postoperative pain and pain interference compared to Group D (p = 0.025 and p = 0.006 respectively) (Table 4).

Time to postoperative analgesic medication consumption

There were no significant differences between Group T and Group D in the number of days before consumption of analgesia (p = 0.240) (Table 5).

Proportion of participants who consumed postoperative analgesic medication within each treatment group

There were no significant differences between Group T and Group D in the proportion of participants who consumed postoperative analgesics within each treatment group (p=0.136) (Table 6).

Discussion

To our knowledge, the current study represents the first investigation aimed at exploring and comparing the postoperative analgesic efficacy of DSP and TA in hallux valgus surgery. The proposed clinical benefits of TA derived from its insoluble nature was allowing prolonged uptake of TA from its injection site [16-20,23]. As a result, TA remains in tissues for an extended period to provide sustained anti-inflammatory action [16,20,23]. Duration of action of TA is therefore longer than the soluble DSP, lasting up to 2-3 weeks, as compared to only 36-72 hours with soluble DSP. [16,19,20,23,24]
In this pilot study, TA was found to favorably affect measures of postoperative pain symptoms (patient-reported pain severity and mean pain interference with daily activities) in hallux valgus surgery compared to DSP. Notably, more than half of participants in TA group considered the pain severity and interference with daily activities to be not clinically significant. This observation is in contrast with the effects of DSP, where more than half of the participants reported clinically significant pain and pain interference with daily activities (Table 4). These results suggest that postoperative oral analgesic medication may not be required when using TA in hallux valgus surgery. On the other hand, its use may be required when using DSP.

Although the effect of TA has not been investigated in previous podiatric literatures, there are evidences that TA can substantially decrease pain scores, postoperative oral analgesic intake, and improve range of motion post-operatively following knee surgeries. Wang et al. [16] found that TA could provide significant pain relief 6 to 24 hours post-operatively (p<0.05 to p<0.01) as compared to placebo. In addition, none of the patients from TA group required rescue analgesia as compared to 53% of patients from the placebo group (p <0.001). Pang et al. [19] found significant reductions in pain (p = 0.014 at 12 hours, p = 0.031 at 18 hours and p = 0.031 at 24 hours) and better range of motion of knee (p = 0.023 at three months) post-operatively in patients receiving TA, compared to a control group without TA. Kwon et al. [17] reported lower pain intensity in TA group immediately (p= 0.021) and for up to 7 days post operatively (p>0.05) following knee arthroplasty. This finding was accompanied with earlier functional recovery (p=0.013) as compared to the control group. Therefore, our findings support the hypothesis that a longer acting corticosteroid can provide adequate, extended and uninterrupted pain relief.

Although TA achieved greater reductions of postoperative pain when compared to DSP, no significant differences were observed between DSP and TA in the time to postoperative oral analgesic consumption and proportion of participants requiring postoperative analgesia. Several possible explanations exist as to why the results were inconsistent. Even though a longer duration of action was observed in TA group compared to DSP as represented by extended time to postoperative oral analgesia, the mean difference of 3 days does not justify the theoretical duration of action of TA (14-21 days). Most participants receiving TA were seen to administer postoperative oral analgesic medications on postoperative day 0 or day 1 despite adequate analgesia (pain scores lesser than 4). One probable reason for the pre-emptive administration of oral analgesics is the fear of pain, thus the use of oral medication prophylactically as a preventative measure rather than a pain relief. Individual differences in pain sensitivity must also be considered as plausible contributing factor. Lastly, the theorized duration of action of TA might not be adequately demonstrated when injected in small quantities around the hallux.

All of the above factors can in turn correlate with the overall increase in the proportion of participants who consumed postoperative oral analgesics. The null hypothesis that TA would exhibit the same analgesic efficacy as DSP in hallux valgus surgery was therefore partially rejected.

The relationship between age and intensity of postoperative pain remains controversial. Our study showed significant difference in age group between the two treatment arms. While several studies have suggested higher postoperative pain in a younger age population [25,26], some have failed to show any correlation [27-30]. Gagliese et al. [29] had proposed that the controversy may be secondary to a series of confounding factors which indirectly affect pain intensity across age groups. Nonetheless, all of the studies mentioned above included a wide variety of surgeries under their methodologies which can contribute to multiple confounders. In addition, there is no current literature which identifies age as a predictive factor for postoperative pain following foot and ankle surgery.

On a side note, many participants reported taking other pain-relief medications during intervention period rather than the recommended oral analgesics. Upon further investigation, opioid-related side effects such as nausea, vomiting and constipation were identified to be the main reasons associated with noncompliance. While these findings did not affect study outcomes, they correlate to previous literatures which highlighted the importance of non-opioid analgesia to improve quality of postoperative recovery [1,3,8]. Therefore, future efforts require better study designs to enable a more accurate assessment and comparison of opioid sparing effect between the two corticosteroids.
The findings of this study should be interpreted in light of its limitations. Firstly, the absence of a placebo group in this study is a limitation, but withholding analgesia for a painful procedure raises ethical concerns. Secondly, the small study population limited the power and reliability to detect the mean differences between the corticosteroids. Further studies using larger sample sizes are therefore warranted.

Thirdly, as inter-participant comparison of the two corticosteroids was done in this study, individual participant tolerance to pain was a variable and pain scores might not accurately reflect the general population.  In order to increase the accuracy of the study, intra-participant comparison of the two corticosteroids should be conducted. We propose preoperative administration of different corticosteroids on each foot for patients with bilateral hallux valgus to minimize inter-participant variables. The sex ratio of the participants in this study was strongly skewed towards the female gender. Therefore, results obtained may possess certain biases towards female patients. We suggest the use of a sample size with equal sex ratio to counter this problem. Lastly, due to time constraints, we were unable to investigate for any possible long-term side effects associated with corticosteroid use. As such, we propose having a longer follow-up duration in future studies to explore into the probability of these complications.

Conclusion

This is the first randomized, prospective, single-blind pilot study investigating and comparing the postoperative analgesic efficacy of DSP versus TA in hallux valgus surgery. In this study, TA was associated with lower pain severity and pain interference scores compared to DSP, suggesting its use as a promising postoperative analgesia in relieving pain following hallux valgus surgery. However, large, adequately powered studies are needed before the effects of TA and DSP in hallux valgus surgery can be established definitively.

Abbreviations

DSP: Dexamethasone sodium phosphate; TA: Triamcinolone acetonide; BPI-SF: Brief Pain Inventory-Short Form

Acknowledgements

The authors acknowledge Professor Alan Bryant for his help in performing hallux valgus surgeries and Dr Andrew Knox for his assistance throughout the study.

References

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  2. Sinatra R. Causes and consequences of inadequate management of acute pain. Pain Med 2010 Dec; 11(12):1859-71. (PubMed)
  3. Shoar S, Esmaeili S, Safari S. Pain management after surgery: a brief review. Anesth Pain Med 2012 Jan; 1(3):184-6. (PubMed)
  4. Joshi GP, Schug SA, Kehlet H. Procedure-specific pain management and outcome strategies. Best Pract Res Clin Anaesthesiol 2014 Jun; 28(2):191-201. (http://www.ncbi.nlm.nih.gov/pubmed/24993439)
  5. Wu CL, Raja SN. Treatment of acute postoperative pain. Lancet 2011 Jun; 377(9784):2215-25. (PubMed)
  6. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Post-operative Pain Experience: Results from a National Survey Suggest Post-operative Pain Continues to Be Undermanaged. Anesth Analg 2003 Aug; 97(2):534-40. (PubMed)
  7. Gan TJ, Habib AS, Miller TE, White W, Apfelbaum JL. Incidence, patient satisfaction, and perceptions of post-surgical pain: results from a US national survey. Curr Med Res Opin 2014 Apr; 30(1):149-60. (PubMed)
  8. White PF. The Changing Role of Non-Opioid Analgesic Techniques in the Management of Post-operative Pain. Anaesth Analg 2005 Nov; 101(5):5-22. (PubMed)
  9. Buland K, Zahoor MU, Asghar A, Khan S, Zaid AY. Efficacy of Single Dose Perioperative Intravenous Steroid (Dexamethasone) for Postoperative Pain Relief in Tonsillectomy Patients. J Coll Physicians Surg Pak 2012 Jun; 22(6):349-52. (PubMed)
  10. Kim K, Brar P, Jakubowski J, Kaltman S, Lopez E. The use of corticosteroids and nonsteroidal antiinflammatory medication for the management of pain and inflammation after third molar surgery: A review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009 May; 107(5):630-40. (PubMed)
  11. Gao W, Zhang QR, Jiang L, Geng JY. Comparison of Local and Intravenous Dexamethasone for Postoperative Pain and Recovery after Tonsillectomy. Otolaryngol Head Neck Surg 2015 Mar; 152(3):530-5. (PubMed)
  12. Salerno A, Hermann R. Efficacy and Safety of Steroid Use for Post-operative Pain Relief. Update and Review of the Medical Literature. J Bone Joint Surg Am 2006 Jun; 88(6):1361-72. (PubMed)
  13. Miller SL, Wertheimer SJ. A comparison of the efficacy of injectable dexamethasone sodium phosphate versus placebo in post-operative podiatric analgesia. J Foot Ankle Surg 1998 May-June; 37(3):223-6. (PubMed)
  14. Curda GA. Post-operative analgesic effects of dexamethasone sodium phosphate in bunion surgery. J Foot Surg 1983; 22(3):187-91. (PubMed)
  15. Bryant A, Marino N, Tinley P. The efficacy of injectable dexamethasone sodium phosphate in reducing the need for post-operative pain medication following podiatric surgery. Aus J Pod Med 1999; 33:117-21.
  16. Wang JJ, Ho ST, Lee SC, Tang JJ, Liaw WJ. Intraarticular triamcinolone acetonide for pain control after arthroscopic knee surgery. Anesth Analg 1998 Nov; 87(5):1113-6. (PubMed)
  17. Kwon SK, Yang IH, Bai SJ, Han CD. Periarticular injection with corticosteroid has an additional pain management effect in total knee arthroplasty. Yonsei Med J 2014 Mar; 55(2):493-8. (PubMed)
  18. Sean VW, Chin PL, Chia SL, Yang KY, Lo NN, Yeo SJ. Single-dose periarticular steroid infiltration for pain management in total knee arthroplasty: a prospective, double-blind, randomised controlled trial. Singapore Med J 2011 Jan; 52(1):19-23. (PubMed)
  19. Pang HN, Lo NN, Yang KY, Chong HC, Yeo SJ. Peri-articular steroid injection improves the outcome after unicondylar knee replacement: a prospective, randomised controlled trial with a two-year follow-up. J Bone Joint Surg Br 2008 June; 90(6):738-44. (PubMed)
  20. Chia SK, Wernecke GC, Harris IA, Bohm MT, Chen DB, Macdessi SJ. Peri-articular Steroid Injection in Total Knee Arthroplasty: A Prospective, Double Blinded, Randomized Controlled Trial. J Arthroplasty 2013 Apr; 28(4):620-3. (PubMed)
  21. Cleeland CS. The Brief Pain Inventory User Guide. Texas: The University of Texas, MD Anderson Cancer Centre; 2009. Available from: Link
  22. Cleeland CS. Measurement and prevalence of pain in cancer. Semin Oncol Nurs 1985 May; 1(2): 87-92. (PubMed)
  23. Stephens MB, Beutler AL, O’Connor FG. Musculoskeletal Injections: A review of the Evidence. Am Fam Physician 2008 Oct; 78(8):971-6, 2008. (PubMed)
  24. Ikeuchi M, Kamimoto Y, Izumi M, Fukunaga K, Aso K, Sugimura N, et al. Effects of dexamethasone on local infiltration analgesia in total knee arthroplasty: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 2014 Jul; 22(7):1638-43. (PubMed)
  25. Gramke HF, de Rijke JM, van Kleef M, Kessels AG, Peters ML, Sommer M, et al. Predictive Factors of Postoperative Pain After Day-case Surgery. Clin J Pain 2009 Jul-Aug; 25(6):455-60. (PubMed)
  26. Sommer M, de Rijke JM, van Kleef M, Kessels AG, Peters ML, Geurts JW, et al. Predictors of acute postoperative pain after elective surgery. Clin J Pain 2010 Feb; 26(2):87-94. (PubMed)
  27. Roth ML, Tripp DA, Harrison MH, Sullivan M, Carson P. Demographic and psychosocial predictors of acute perioperative pain for total knee arthroplasty. Pain Res Manag 2007; 12(3):185-94. (PubMed)
  28. De Cosmo G, Congedo E, Lai C, Primieri P, Dottarelli A, Aceto P. Preoperative Psychologic and Demographic Predictors of Pain Perception and Tramadol Consumption Using Intravenous Patient-controlled Analgesia. Clin J Pain 2008 Jun; 24(5):399-405. (PubMed)
  29. Gagliese L, Gauthier LR, Macpherson AK, Jovellanos M, Chan VW. Correlates of Postoperative Pain and Intravenous Patient-Controlled Analgesia Use in Younger and Older Surgical Patients. Pain Med 2008 Apr; 9(3):299-314. (PubMed)
  30. Mamie C, Bernstein M, Morabia A, Klopfenstein CE, Sloutskis D, Forster A. Are there reliable predictors of postoperative pain? Acta Anaesthesiol Scand 2004 Feb; 48(2):234-42. (PubMed)

Lisfranc-like injury involving lateral tarsometatarsal joints: a case report

by Mir Tariq Altaf1*, Muhammad Haseeb2, Varun Narula3, Aakash pdflrgPandita4

The Foot and Ankle Online Journal 9 (2): 2

Lisfranc injuries or fracture-dislocation of tarsometatarsal joints are uncommon injuries. Isolated involvement of lateral tarsometatarsal joints is very rare. We present a case of plantar disruption of cuboid – fourth and fifth metatarsal joints in a 16yr old boy following a vehicular accident with injuries to head and left foot. A standing AP & lateral radiograph of left foot was suggestive of disruption of cuboid-4th/5th metatarsal joints with plantar displacement. Evidence of head injury on CT scan of head took precedence over foot injury. Patient was managed conservatively for foot injury. Patient made a reasonable recovery by conservative means only. This is an unusual case as there was an isolated lateral tarsometatarsal joint involvement. In addition, the displacement was plantar, whereas in isolated lateral Lisfranc injuries, the displacement usually is dorsal. Lisfranc-like injuries involving lateral tarsometatarsal joints are very rare. These injuries can be easily missed. Strong clinical suspicion and proper investigations are needed to diagnose these subtle injuries.

Key words: Lisfranc joint, lateral tarsometatarsal joint

ISSN 1941-6806
doi: 10.3827/faoj.2016.0902.0002

1* – DNB Orthopedics trainee, Center for Bone and Joint, Kokilaben Dhirubhai
Ambani Hospital, Four Bungalows, Andheri West, Mumbai-400053, India. mirtariqaltaf@gmail.com
2 – MS Orthopedics, Government Medical College, Bakshinagar, Jammu-180001, India.
3 – DNB Orthopedics trainee, Center for Bone and Joint, Kokilaben  Dhirubhai Ambani Hospital, Four Bungalows, Andheri West, Mumbai-400053, India.
4 – MD Pediatrics, Government Medical College, Bakshinagar, Jammu-180001, India.


The spectrum of tarsometatarsal joint injuries (Lisfranc injuries) encompasses stable sprains to clinically apparent grossly unstable deformities. It is important to recognise and treat these injuries early and aggressively for best results. There are several variations from the classic injury patterns, and we present one such variant. This case report describes a lateral tarsometatarsal disruption with neither diastasis between first & second metatarsals nor injury to first, second & third tarsometatarsal joints. Dislocations of lateral tarsometatarsal joints are rare and are almost always dorsal. To the best of our knowledge only one such case has been reported in literature before.

Case History

A 16-year-old boy had a road traffic accident sustaining injury to the head and left foot. The patient reported to our emergency department with pain and swelling of left foot (Figure 1). Lateral tarsometatarsal joints were exquisitely tender to palpation, whereas no tenderness could be elicited over the medial tarsometatarsal joints. There were no clinical signs or  symptoms of head injury. A neurosurgery consultation was sought as per our trauma protocol. Patient underwent CT scan of the head along with standing anteroposterior and lateral radiograph of left foot (Figure 2). The radiograph of the foot revealed lateral tarsometatarsal joint disruption with plantar dislocation. The patient was given a short-leg posterior slab initially along with analgesia.

Fig1

Figure 1 Clinical photo on admission.

Fig2

Figure 2 Radiographs on admission.

CT scan of the head was suggestive of depressed fracture of right frontal bone with extradural hematoma with pneumocephalus. Patient was referred to an outstation neurosurgical center for further management of the head injury. There the foot injury was neglected. Patient was cleared after 2 weeks from neurosurgery. At 2-weeks follow-up, probable nature of foot injury, diagnostic modalities available, its severity and morbidity, treatment options available and complications associated were discussed with relatives and the patient. Respecting patient’s decision, no further confirmatory investigations were undertaken and conservative treatment was continued. The posterior slab was changed into a cast. Regular follow-up radiographs were taken which revealed satisfactory recovery (Figure 3).

Fig3

Figure 3 Follow-up radiographs at 3 months.

Fig4

Figure 4 Clinical photo at last follow-up.

Discussion

‘Lisfranc joint’ refers to the medial articulation of first and second metatarsals with medial cuneiforms and ‘Lisfranc joint complex’ refers to tarsometatarsal articulations. It derives its name from Jacques Lisfranc, a French field surgeon in Napoleon’s army, who was the first to describe amputations through this joint. Fractures and dislocations of tarsometatarsal joints are frequently overlooked or misdiagnosed because of variations in the pattern of injury and clinical presentation. Road traffic accidents are the most common cause of Lisfranc fracture dislocations, while twisting injury to the foot is the most common cause for simple dislocation without fracture [1]. Clinical suspicion and radiographic evaluation is crucial in the diagnosis and treatment of this injury.

If possible at the time of presentation, weight-bearing films of the foot in anteroposterior, lateral and 30-degree medial oblique position should be obtained. Because of the possibility of spontaneous reduction in these injuries, non-weight-bearing films provide no loading of the ligaments to test their integrity [2]. In some cases, computed tomography scans and magnetic resonance imaging may be necessary to detect comminution and subtle malalignment.  Chiodo and Meyerson classified the tarsometatarsal joint injuries according to columnar theory emphasizing the motion segments of mid-foot [3]. According to this classification, metatarsals within a column function as a unit. They concluded that it is unusual for one (fourth metatarsal) to dislocate while the other (fifth metatarsal) remains in anatomic position. This was demonstrated in our patient too. Lisfranc injuries are associated with high potential for chronic disability, so precise anatomical reduction is a must either by closed or open methods [4]. The literature is divided over specific recommendations for treatment of these subtle injuries [5]. In our case, though surgical treatment would have been ideal, conservative treatment was undertaken with cast immobilization and strict non-weightbearing for 6 weeks, followed by removal of the cast and partial weight bearing with the help of a cane for another 4 weeks. Full weight bearing was allowed at 10 weeks. Return to sports and other high demanding activities was allowed at 12 weeks. Patient used to get swelling in the foot after walking a distance of more than a mile and running for one-half mile. Ipsilateral ankle range of motion was comparable to the normal side at last follow up of 9 months. Result of such treatment in our case was malunion with acceptable functional disability.

We used clinical judgement and stress radiographs only to rule out associated medial joint (lisfranc joint) involvement, although stress radiographs at best have a sensitivity of 85% but we were restrained by patient refusal for further investigations like MRI.

Our case is unique because the frequency of such injuries is very low.

Conclusion

Lisfranc-like injuries involving lateral tarsometatarsal joints are very rare. These injuries can be easily missed. There is scarcity of literature on treatment of these injuries. Further studies in future are warranted on these rare injuries. These injuries, however, don’t seem to have unacceptable results with conservative modality of treatment.

References

  1. Jeffreys T. Lisfranc`s fracture-dislocation. J Bone Joint Surg Br. Aug. 1963;45:546-51. (Pubmed)
  2. Faciszewski T, Burks R, Manaster B. Subtle injuries of Lisfranc joint. J Bone Joint Surg Am. 1990;72:1519-22. (Pubmed)
  3. Chiodo CP, Meyerson MS. Developments and advances in diagnosis and treatment of injuries to the tarsometatarsal joint. Orthop Clin North Am. 2001;32:11-20. (Pubmed)
  4. Mann R, Prieskorn D, Sobel M. Midtarsal and tarsometatarsal arthrodesis for primary degenerative osteoarthrosis or osteoarthrosis after trauma. J Bone Joint Surg Am. 1996 Sep;78:1376-85. (Pubmed)
  5. Goossens M, De Stoop N. Lisfranc fracture dislocation: etiology, radiology, and results of treatment. A review of 20 cases. Clinic Orthop Relat Res. 1983;176:154-62. (Pubmed)

Modified Scarf osteotomy for treatment of hallux valgus

by Saad R. El Ashry1, M. S. Sidhu2*, Abhay Tillu3pdflrg

The Foot and Ankle Online Journal 9 (2): 1

With over a hundred described surgical procedures for the management of hallux valgus, it is the purpose of this article to describe a new technique – the modified scarf osteotomy. This technique involves the combined use of a “closing wedge’’, with the original two individual cut features of the scarf osteotomy in the surgical correction of hallux valgus. It has been performed for 24 months, and retrospective analysis of the last 12 patients, found it to be an effective means to improve the distal metatarsal articular angle (DMAA) at mean 7°, whilst also improving functional outcome by way of the American Orthopaedic Foot and Ankle Society (AOFAS) score at mean 31.4.

Key words: Hallux valgus, DMAA, Scarf, AOFAS

ISSN 1941-6806
doi: 10.3827/faoj.2016.0902.0001

1 – Registrar, FRCS(Tr-Orth), Sandwell and West Birmingham Hospitals NHS Trust, UK
2* – Registrar, MRCS, Royal Orthopaedic Hospital Birmingham, UK, Manpreet.sidhu@doctors.org.uk
3 – Consultant, FRCS, Sandwell and West Birmingham Hospitals NHS Trust, UK


Hallux valgus is one of the most common forefoot deformities, most commonly affecting females between the ages of 20-64 [1]. Presenting with discomfort, pain and affecting patients’ day-to-day activities, it is a common cause for referral to the foot surgeon. Surgical correction of the condition comprises a variety of different procedures. The author describes a Modified Scarf Osteotomy, which has been used over the last 24 months to create a “closing wedge” within the first metatarsal, to improve both the patient’s distal metatarsal articular angle (DMAA), and American Orthopedic Foot and Ankle Society (AOFAS) score – a proven demonstrator of functional outcome [2].

The treatment of hallux valgus using a scarf osteotomy is well described in the literature, and a well understood procedure to correct the DMAA [3].  The DMAA defines the relationship of the articular surface of the distal metatarsal to the longitudinal axis of the first metatarsal.

The scarf osteotomy is a technically demanding procedure with a steep learning curve [4]. It was initially described in 1926 by Meyer who published an operative technique that included a diaphyseal Scarf-like osteotomy of the first metatarsal bone for hallux valgus correction [3,5]. While the surgical technique of an articular preserving Scarf osteotomy for forefoot management was described in detail by Barouk [6].

Nyska et al evaluated the change in position of the first metatarsal head using saw-bone models [7]. They observed that Scarf osteotomy provided less angular correction and shortening but similar lateral displacement in comparison to the basilar angular osteotomies and Ludloff osteotomy [8,9], angular correction is best brought about by rotation of the z-wing. They concluded that Scarf osteotomies are more reliable for patients with mild to moderate deformities, a short first metatarsal or an intermediate deformity with large DMAAs.

79899673

Figure 1 Exposure of the first metatarsal head.

Methods

The original z-scarf osteotomy comprises of two individual cuts – a proximal dorsal fragment, and a plantar fragment – and it is this plantar fragment, which notably comprises the metatarsal head. Two transverse cuts, around 60 degrees to the longitudinal are then performed to create a double chevron.

The author describes a method, whereby medial wedges are cut from the distal and proximal cuts of the scarf osteotomy. After the routine cuts for scarf osteotomy are performed, 2 mm of bone is then cut to form a “closing wedge” from the proximal and distal transverse cuts. This affords the benefit of simultaneous correction of a range of angles, including the DMAA, the intermetatarsal angle (IMA) and the hallux valgus angle (HVA).  

79899673

Figure 2 Z-cut and medial wedging of scarf osteotomy.

8898993

Figure 3 Medial wedging of Scarf osteotomy.

5011907283064730

Figure 4 Pre-op and post-op radiographs displayed on computer system GE CentricityTM, to highlight the DMA, IMA and, HVA respectively.

Results

Over a 6 month period, 12 patients, all female, with an average age of 52 years underwent surgery with the above mentioned modified scarf osteotomy using a closing wedge. The AOFAS score was completed pre-operatively and 6 months post procedure, at these intervals antero-posterior radiographs of the patients were also studied. The results are demonstrated in the table below.

N=12 Pre-operative Post-operative
AOFAS score (mean) 50.3 81.7
DMAA(degrees) (mean) 19.3 12.3

Table 1 Pre- and post-operative results of modified scarf osteotomy.

Discussion

Recurrent hallux valgus deformity is probably the most frequent complication of bunion surgery. Recurrence of the deformity can be associated with failure to correct the DMAA [10,11].

Different techniques have been described in the literature to correct the DMAA. A rotational scarf osteotomy is a modification of the traditional scarf osteotomy also has the advantage of decreasing troughing which is a known complication of scarf osteotomy [12]. Another technique using mini-external fixator to correct the DMAA was described by Oznur in 2006 [13].

Our technique is another modification of the traditional scarf osteotomy. All 12 patients had an improved AOFAS score, with a mean improvement of 31.4. All 12 also demonstrated an improvement in the DMAA, with a mean improvement of 7°. Of the 12 patients, none said they regretted undergoing the procedure.

This modified scarf with closing wedges as described, allows for the simultaneous correction of the DMAA, IMA and HVA. It is a simple and effective technique to reproduce, which delivers good outcomes.

References

  1. Nguyen US, Hillstrom HJ, Li W, et al. Factors associated with hallux valgus in a population-based study of older women and men: the MOBILIZE Boston Study. Osteoarthr Cartil. 2010;18(1):41-6.
  2. Thordarson D, Ebramzadeh E, Moorthy M, Lee J, Rudicel S. Correlation of hallux valgus surgical outcome with AOFAS forefoot score and radiological parameters. Foot Ankle Int. 2005;26(2):122-7.
  3. Kristen KH, Berger C, Stelzig S, Thalhammer E, Posch M, Engel A. The SCARF osteotomy for the correction of hallux valgus deformities. Foot Ankle Int. 2002;23(3):221-9.
  4. Weil LS. Scarf osteotomy for correction of hallux valgus. Historical perspective, surgical technique, and results. Foot Ankle Clin 2000; 5: 559–580
  5. Jones S, Al Hussainy HA, Ali F, Betts RP, Flowers MJ. Scarf osteotomy for hallux valgus. A prospective clinical and pedobarographic study. J Bone Joint Surg Br. 2004;86:830–6
  6. Barouk LS. Scarf osteotomy for hallux valgus correction. Local anatomy, surgical technique, and combination with other forefoot procedures. Foot Ankle Clin. 2000;5:525–58.
  7. Nyska M, Trnka HJ, Parks BG, Myerson MS. Proximal metatarsal osteotomies: a comparative geometric analysis conducted on sawbone models. Foot Ankle Int. 2002;23:938–45.
  8. Mau H. Hallux valgus. Dtsch Med Wochenschr. 1971;96:1144.
  9. Cisar J, Holz U, Jenninger W, Uhlig C. Ludloff’s osteotomy in hallux valgus surgery. Aktuelle Traumatol. 1983;13:247–9.
  10. Coughlin MJ, Carlson RE. Treatment of hallux valgus with an increased distal metatarsal articular angle: evaluation of double and triple first ray osteotomies. Foot Ankle Int. 1999;20(12):762-70.
  11. Coughlin MJ. Surgery of the Foot and Ankle. St. Louis : Mosby, c1999; 1999. pp150 – 269.
  12. Murawski CD, Egan CJ, Kennedy JG. A rotational scarf osteotomy decreases troughing when treating hallux valgus. Clin Orthop Relat Res. 2011;469(3):847-53.
  13. Oznur A. Technical Tip: mini-fixator assisted correction of DMAA in hallux valgus surgery. Foot Ankle Int. 2006;27(10):849-50.

March 2016

9 (1), 2016


Longitudinal plantar approach for excision of interdigital perineural fibroma of the foot: A case series and literature review
by George Flanagan, Ian Reilly


Comparison of the foot kinematics during weight bearing between normal foot feet and the flat feet
by Shintarou Kudo, Yasuhiko Hatanaka


Post traumatic hallux valgus – a rupture of the medial collateral ligament
by Christopher R. Hood JR, DPM, AACFAS, Jason R. Miller, DPM, FACFAS


The influence of barefoot and shod running on Triceps surae muscle strain characteristics
by Sinclair J, Cole T, Richards J


Orthopedic approach of the leprous foot
by Thiago Batista Faleiro, Gildásio de Cerqueira Daltro, Alex Guedes, Renata da Silva Schulz, Jorge Eduardo de Schoucair Jambeiro, Maria Betânia Pereira Toralles


Bilateral Charcot neuroarthropathy, a challenge for diagnosis and treatment
by Nathalie Denecker, Dimitri Aerden, Michel De Maeseneer


Bad ink: A case of a chronic ulceration of the lower extremity secondary to tattooing
by Larissa Rolim DPM, MS; Christopher Blanco DPM, FACFAS; Sara Lewis DPM


Interval measurement of the angle of calcaneal facets: A historical postmortem study
by Edward S Glaser, David C Fleming, and Norma Reece


Retrospective study of the incidence of plantar fascial rupture following cortisone injection
by Gerald T. Kuwada, DPM, NMD


Strategy for preventing practice burnout: Suicide among physicians and surgeons
by Gerald T. Kuwada, DPM, NMD


The triad of osteobiology – Rehydrating calcium phosphate with bone marrow aspirate concentrate for the treatment of bone marrow lesions
by Christopher R. Hood JR., DPM, AACFAS, Jason R. Miller, DPM, FACFAS


Foot Posture Biomechanics and MASS Theory
by Edward S Glaser and David Fleming


Interval measurement of the angle of calcaneal facets: A historical postmortem study

by Edward S Glaser1, David C Fleming2*, and Norma Reece2pdflrg

The Foot and Ankle Online Journal 9 (1): 8

Purpose:  To better understand the anatomical variation in angles that each of the three facets of the subtalar joint has with relation to the transverse, frontal and sagittal planes along the facet’s long axis.
Design:  An investigation of Calcaneo-Talo interaction.
Samples:  Calcaneal samples were obtained from the Smithsonian Institute from the Terry, Argentina, Aleutian Islands, Peru, Virginia, Seminole Indian, and Egyptian skeletal collections.
Methods:  Photographs were obtained of each calcaneus held at a 27 degree calcaneal inclination angle, angles were determined by a bisection of the facet measured against the transverse plane via a round ground protractor level. Sagittal and Frontal plane deviations were determined via ImageJ angle tool from the transverse plane photographs.
Main Outcome Measures:  We measured the angle of the bisection of each of the three facets with respect to the transverse plane, sagittal plane, and frontal plane for 162 calcanei.
Results:  The mean angulation of deviation from the transverse plane were: anterior facet 27.4°, middle facet 14.7°, and posterior facet 9.0°.  Standard deviations were 7.3°, 6.1°, and 5.0° respectively.  The mean angulation of deviation from the sagittal plane were:  anterior facet 31.42°, middle facet 34.44°, and posterior facet 44.16°.  Standard deviations were 11.88°, 7.95°, and 10.36° respectively.  The mean angulation of deviation from the frontal plane were:  anterior facet 58.58°, middle facet 55.56°, and posterior facet 45.84°. Standard deviations were 11.88°, 7.95°, and 10.36° respectively.
Conclusions:  The axis of the posterior cone shaped facet is directed toward the middle facet.  The anterior facet sits 27°±7° from the transverse.

ISSN 1941-6806
doi: 10.3827/faoj.2016.0901.0008

1 – Founder and CEO of Sole Supports, Inc.
2 – Sole Supports, Inc.
* – Correspondence: dfleming@solesupports.com


Forces being applied to the sub talar joint are influenced, as to their effect on the bones, by the angulation of the facets in all three planes by measuring two planes we can extrapolate the third. No literature was found as to calcaneal facet angles and certainly none with a large sample size. This was an investigation into foot biomechanics. In this study, we described a method for measuring calcaneal facets, using the skeletal collections at the Smithsonian museum. We further describe possible reasons for our findings.

Methods

Study Design and Samples

This Interval study included a total of 162 calcanei from the Smithsonian Institute from the following collections:  Aleutian Islands of Wislow and Kagamil, Argentina from San Zavier and San Blas, Chicama Peru, Egyptian XII Dynasty, Lewis Creek Virginia Indians, and the Terry Collection which spans 1920 to 1945.  Inclusion criteria consisted of intact Sustentaculum Tali. Intact anterior, middle, and posterior facets.  Intact portion of the calcaneus between the calcaneal tuberosity and the calcaneal tubercle.  Exclusion criteria consisted of large heel spur (>4mm).  Overall, 36 calcanei were excluded from this study.

Measurement of Facet Angles

1

Figure 1 Photograph showing the Calcaneal holding instrument and position on Calcaneal samples.

Each calcaneus was held in a position of rectus with a 27⁰ calcaneal inclination angle by a modified Hewlett Packard printer paper tray.  The tray was selected for applying equal pressure to both sides of the calcaneus simultaneously.  The paper tray was fitted with L-shaped brackets lined with 1 inch of 35 durometer EVA foam (Figure 1).  The bisection of the anterior and middle facets was determined from the most proximal articular surface point to the most distal articular surface point.  Then an imaginary line was drawn, a real line was not drawn on the bones as to preserve the Smithsonian’s samples.  The posterior facet bisection was determined from the most superior point equidistant from the lateral and medial edges of the articular surface of the cone-shaped facet to the apex of the articular portion of the facet.  The line was then measured with respect to the transverse plane using an Empire Level 36 magnetic polycast protractor.  The sagittal plane deviations were obtained via the photographs of each calcaneus (Figure 1) utilizing ImageJ’s angle tool.  Excel was then used to determine the deviation from the frontal plane using the following formula:  (90-(Sagittal deviation)=Frontal deviation). The cone shaped posterior facet protrudes from the dorsal surface of the calcaneus its axis runs posterolateral to anteromedial angulated off of the frontal plane.  The curved medial and lateral articular surfaces can be bisected by the connection of those bisection points.  This bisection, if continued medially, intersected the middle facet. (Figure 2)

2

Figure 2 Photograph showing bone markings and bisection lines of the anterior, middle, and posterior facets on calcaneal sample.

Statistical Analysis

Statistical analyses were performed using Excel 2013 for Windows (Microsoft, Redmond, VA).  Mean, standard deviation, and range for each region as well as across all 162 samples was derived for all three facets.

Results

One hundred sixty-two (n=162) calcanei were included in this study.  The mean deviation angle, standard deviation, and range were taken of each facet with respect to the three spatial planes. (Table 1)

Transverse Plane Deviation

The mean angle ± standard deviation (range) was 27.43±6.95 (9-50) for the anterior facet, 14.35±6.09 (0-30) for the middle facet, and 8.94±4.81 (0-24) for the posterior facet.  Each facet was quantified by collection.  Seventeen (n=17) calcanei from Argentina measured 24.18±5.71 (11-33) for the anterior facet, 12.71±5.13 (3-20) for the middle facet, and 8.12±3.95 (1-15) for the posterior facet.  Fifteen (n=15) calcanei from the Aleutian Islands measured 26.40±4.97 (14-33) for the anterior facet, 12.27±7.60 (0-29) for the middle facet, and 8.00±4.46 (2-16) for the posterior facet.  Twenty five (n=25) calcanei from Peru measured 30.76±5.25 (21-40) for the anterior facet, 11.12±4.46 (5-20) for the middle facet, and 8.48±4.02 (1-16) for the posterior facet.  Eleven (n=11) calcanei from Virginia measured 21.64±5.57 (13-32) for the anterior facet, 16.73±6.48 (7-28) for the middle facet, and 9.27±4.90 (0-16) for the posterior facet.  Fifty eight (n=58) calcanei from the Terry Collection measured 27.59±7.13 (9-45) for the anterior facet, 16.12±6.29 (2-30) for the middle facet, and 8.72±5.44 (0-24) for the posterior facet.  Thirty six (n=36) calcanei from Egypt measured 28.19±7.90 (14-50) for the anterior facet, 14.64±5.29 (3-27) for the middle facet, and 10.28±4.74 (1-21) for the posterior facet.

Sagittal Plane Deviation

The mean angle ± standard deviation (range) was 31.42±11.88 (1.9-66.35) for the anterior facet, 34.44±7.95 (4.75-58.93) for the middle facet, and 44.16±10.36 (18.01-74.06) for the posterior facet.  Each facet was quantified by collection.  Seventeen (n=17) calcanei from Argentina measured 29.83±16.31 (1.9-62.25) for the anterior facet, 38.15±6.29 (25.82-52.5) for the middle facet, and 34.42±8.81 (18.01-51.18) for the posterior facet.  Fifteen (n=15) calcanei from the Aleutian Islands measured 34.77±6.22 (20.33-43.53) for the anterior facet, 35.03±6.79 (19.89-43.6) for the middle facet, and 45.71±9.00 (33.78-64.9) for the posterior facet.  Twenty five (n=25) calcanei from Peru measured 26.73±9.31 (10.18-47.73) for the anterior facet, 34.70±9.93 (4.75-53.02) for the middle facet, and 47.20±7.30 (34.41-60) for the posterior facet.  Eleven (n=11) calcanei from Virginia measured 29.85±10.06 (16.62-55.44) for the anterior facet, 29.32±8.33 (14.08-42.99) for the middle facet, and 37.56±7.08 (26.5-46.07) for the posterior facet.  Fifty eight (n=58) calcanei from the Terry Collection measured 31.82±11.95 (2.7-58.39) for the anterior facet, 33.54±6.53 (12.8-45.97) for the middle facet, and 48.68±8.72 (26.3-74.06) for the posterior facet.  Thirty six (n=36) calcanei from Egypt measured 33.59±12.25 (5.79-66.35) for the anterior facet, 34.51±7.86 (16.76-58.93) for the middle facet, and 43.31±11.35 (22.18-70.2) for the posterior facet.

Frontal Plane Deviation

The mean angle ± standard deviation (range) was 58.58±11.88 (23.65-88.10) for the anterior facet, 55.56±7.95 (31.07-85.25) for the middle facet, and 45.84±10.36 (15.94-71.99) for the posterior facet.  Each facet was quantified by collection.  Seventeen (n=17) calcanei from Argentina measured 60.17±16.31 (27.75-88.1) for the anterior facet, 51.85±6.29 (37.5-64.18) for the middle facet, and 55.58±8.81 (38.82-71.99) for the posterior facet.  Fifteen (n=15) calcanei from the Aleutian Islands measured 55.23±6.22 (46.47-69.67) for the anterior facet, 54.97±6.79 (46.4-40.11) for the middle facet, and 44.29±9.00 (25.1-56.22) for the posterior facet.  Twenty five (n=25) calcanei from Peru measured 63.27±9.31 (42.27-79.82) for the anterior facet, 55.30±9.93 (36.98-85.25) for the middle facet, and 42.80±7.30 (30-55.59) for the posterior facet.  Eleven (n=11) calcanei from Virginia measured 60.15±10.06 (34.56-73.38) for the anterior facet, 60.68±8.33 (47.01-75.92) for the middle facet, and 52.44±7.08 (43.93-63.5) for the posterior facet.  Fifty eight (n=58) calcanei from the Terry Collection measured 58.18±11.95 (31.61-87.3) for the anterior facet, 56.46±6.53 (44.03-77.2) for the middle facet, and 41.32±8.72 (15.94-63.7) for the posterior facet.  Thirty six (n=36) calcanei from Egypt measured 56.41±12.25 (23.65-84.21) for the anterior facet, 55.49±7.86 (31.07-73.24) for the middle facet, and 46.69±11.35 (19.8-67.82) for the posterior facet.

It was noticed in the vast majority of cases the bisection of the posterior facet, when extended medially, passes through the middle facet.  Therefore, as the talus slides medially along the axis of the cone shaped posterior facet, the middle facet which sits on a lever of bone protruding from the medial side of the calcaneus, is loaded encouraging calcaneal eversion.

Discussion

In our study, we described a method for quantifying the angle long axis of each calcaneal facet makes with respect to the three spatial planes.  Samples are divided for different historical and geographical populations.

We showed when the calcaneus is at a twenty-seven degree of inclination, the anterior facet is 27 degrees from being parallel to the transverse plane.   When the anterior facet of the calcaneus is parallel to the transverse plane the calcaneus is inverted, and the talar head can easily rotate about the STJ axis.  This occurs, ideally, at heel strike; a condition that neither favors pronation nor supination as the force moving down the extremity runs into a perpendicular anterior articular facet.  This supinated posture provides an efficient platform for propulsion as the talus cannot rotate in the sagittal plane with relation to the calcaneus.  The head of the talus is resting on the anterior facet of the subtalar joint physically blocking sagittal plane rotation between the calcaneus and talus.  Contraction of the gastroc-soleus muscle isolates ankle rotation.  More research is necessary to see to what extent talar head transverse plane motion plays in the locking and unlocking of the foot during the stance phase of gait.

One deficit in this study is the lack of data regarding the rotational angle of each facet around the axis formed by the longitudinal bisection.  There is always some subjective decision making in determining these angles since borders of facets are not standard geometric figures.  This variable was minimized by using a relatively large sample size.

December 2015

8 (4), 2015


A case report of aneurysmal bone cyst of the lateral cuneiform bone of the foot
by Lakshya C, Vishal G, Vivek S


Tibiocalcaneal fusion using a peg-in-hole technique combined with Ilizarov external fixation method
by Edgardo R. Rodriguez DPM, Byron Hutchinson DPM, Eric G. Powell DPM, Kristin J. Thomas, DPM


Does BMI variation change the height of foot arch in healthy adults: a cross sectional study
by A. P. C Udayamali Pathirana BPT, Dr. Watson Arulsingh PT, Dr. Remya K.R PT, Joseph Oliver Raj PT


Arthroscopic first metatarsophalangeal joint fusion for hallux rigidus
by Ibrahim Turan MD, Beran Turan MD, Jan G Jakobsson MD


The influence of semi-custom orthoses on multi-segment foot kinematics in males
by Jonathan Sinclair, James Richards, Paul John Taylor, Hannah Shore

The influence of semi-custom orthoses on multi-segment foot kinematics in males

by Jonathan Sinclair*, James Richards, Paul John Taylor, Hannah Shorepdflrg

The Foot and Ankle Online Journal 8 (4): 5

The current investigation aimed to investigate the influence of semi-custom orthoses on multi-segment foot kinematics and plantar fascia strain in recreational runners. Fifteen male runners ran at 4.0 m.s-1 with and without orthotics. Multi-segment foot kinematics and plantar fascia strain were obtained using a 3D motion capture system. Differences between orthotic and no-orthotic conditions were examined using paired samples t-tests. The results showed firstly that orthoses did not significantly (p>0.05) improve plantar fascia strain. Relative transverse plane ROM rearfoot-tibia articulation was however significantly (p<0.05) reduced when wearing orthotics. This indicates that there may be some benefit from orthotic intervention. However, the mean reduction in angulation between orthotic and no-orthotic conditions was very small and thus further prospective investigations regarding the clinical efficacy of semi-custom orthoses are required.

Key words: orthotics, kinematics, plantar fascia, distance running

ISSN 1941-6806
doi: 10.3827/faoj.2015.0804.0005

Address correspondence to:
Jonathan Sinclair,
Division of Sport, Exercise and Nutritional Sciences
School of Sport Tourism and Outdoors
University of Central Lancashire,
Preston
Lancashire
PR1 2HE.
e-mail: jksinclair@uclan.ac.uk


Distance running associated with a large number of health benefits, both physical and psychological [1, 2]. However, epidemiological research has shown that chronic pathologies are a frequent complaint amongst runners [3]. As many as 80% of runners will experience a chronic injury as a consequence of their training over a one year period [4].

Foot orthoses are an extremely popular accessory for runners. It has been postulated that foot orthoses are able to attenuate the high rate of injuries in runners. As such they have received considerable research attention. The majority of research into the efficacy of foot orthoses has examined either impact loading or rearfoot eversion. Sinclair et al., [5] showed that an off the shelf orthotic significantly reduced both loading rate and tibial acceleration parameters but did not change rearfoot eversion.

Laughton et al [6] showed similarly that foot orthoses served to significantly reduce the loading rate of the ground reaction force but once again did not affect rearfoot eversion. Dixon, [7] investigated the effects of placing a commercial orthotic inside a military boot. The findings showed that the orthotic device reduced the vertical rate of loading in comparison to running without orthotic intervention, although rearfoot eversion remained unchanged.

The effects of foot orthoses on multi-segment foot kinematics have received only limited attention in biomechanical research. Only a small number of studies have investigated the effects of orthotics on multi-segment foot kinematics. Cobb et al [8] found greater rearfoot dorsiflexion during the stance phase when walking with an orthotic; they concluded that this may promote improved foot kinematics. Sinclair et al., [9] studied the influence of off the shelf orthoses on multi-segment foot kinematics and plantar fascia strain. They showed that whilst the orthotic altered the coronal and transverse plane angles of the foot segments there was no improvement in plantar fascia strain. Ferber & Benson, [10] investigated the effects of semi-custom heat mouldable orthoses on multi-segment foot kinematics and plantar fascia strain during overground walking. Their findings showed that plantar fascia strain was significantly reduced when wearing orthotics, but that no differences in multi-segment foot kinematics were evident. However this investigation only measured a limited number of discrete kinematics parameters from the foot segments. Furthermore there currently remains no information regarding the effects of custom orthoses during running.

The aim of the current investigation was therefore to examine the effects of semi-custom orthotics on 3D multi-segment foot kinematics and plantar fascia strain during the stance phase of running. This work may be helpful to runners who suffer from foot pathologies related to mal-alignment of the foot itself that may be treatable through orthotic intervention. The current investigation tests the hypothesis that orthotic intervention will serve to attenuate plantar fascia strain and reduce coronal and transverse plane motions of the foot segments.

Methods

Participants

Twelve male (age 22.1 ± 3.2 years, height 1.77 ± 0.07 meters, and body mass 73.24 ± 6.07 kg) recreational runners volunteered to take part in the current investigation. All were currently free from musculoskeletal pathology and did not have any history of prior surgery. All participants provided written informed consent and ethical approval was obtained from the University of Central Lancashire STEM ethical committee, in accordance with the principles documented in the declaration of Helsinki.

Orthoses

A commercially available orthotic (Sole, Softec response) was utilized for the current study. To mould the orthoses they were placed into a pre-heated oven (90°C) for three minutes. Following this the orthotics were then placed inside the participants shoes. Participants were asked to stand upright without moving for two minutes to allow the process of moulding the orthotics to take place.

Procedure

Participants completed five trials running at 4.0 m.s-1 ± 5% with and without orthotic intervention. The order in which participants ran in each condition was counterbalanced. Multi-segment foot kinematics were obtained at 250 Hz using an eight-camera motion analysis system (Qualisys Medical, Sweden). Participants struck an embedded force platform (Kistler 9281CA, Kistler Instruments, UK) sampling at 1000 Hz with their dominant foot. The stance phase of running was determined as the time over which >20 N of force in the axial direction was applied to the force platform.

The calibrated anatomical systems technique (CAST) was used for modelling the foot and shank segments [11]. Markers were placed on anatomical landmarks in accordance with the Leardini et al [12] foot model allowing the anatomical frames of the rearfoot, midfoot, and forefoot to be defined. Markers were also positioned on the medial and lateral femoral epicondyles to allow the anatomical frame of the tibia to be delineated and a rigid tracking cluster was also positioned onto the tibia. Participants wore the same footwear throughout (Saucony Pro Grid Guide II, Saucony, USA). Windows were cut in the experimental footwear at the calcaneus and first metatarsal locations. The pre-established guidelines for length and width outlined by Shultz & Jenkyn [13] were adhered to.

Data-processing

Data were digitized using Qualisys track manager and exported to Visual 3D (C-motion, Germantown USA). Marker trajectories were filtered at 15 Hz using a low pass zero-lag Butterworth filter. This frequency was selected based on residual analysis [14]. Cardan angles were used to calculate 3D rotations of the foot segments. Stance phase angles were computed using and XYZ cardan sequence of rotations between the rearfoot-tibia, midfoot-rearfoot, forefoot-midfoot, and forefoot-rearfoot. Discrete 3D kinematic measures which were extracted for statistical analysis were 1) angle at footstrike, 2) angle at toe-off, 3) range of motion (ROM) from footstrike to toe-off during stance, 4) peak angle during stance, and 5) relative ROM (representing the angular displacement from footstrike to peak angle). Plantar fascia strain was quantified by calculating the distance between the first metatarsal and calcaneus markers and quantified as the relative position of the markers was altered. Strain strain was calculated as the change in length during the stance phase divided by the original length [10].

Statistical analyses

Differences in multi-segment foot kinematics and plantar fascia strain were examined using paired samples t-tests with significance accepted at the p<0.05 level.

 1

Figure 1 Rearfoot-tibial kinematics as a function of orthotic and no-orthotic conditions (black = orthotic & dash = no-orthotic).

 2

Figure 2 Midfoot-rearfoot kinematics as a function of orthotic and no-orthotic conditions (black = orthotic & dash = no-orthotic).

A Shapiro-Wilk test was used to screen the data for normality, and it was confirmed that the normality assumption was not violated. Effect sizes for all statistical main effects were calculated using eta22). Statistical procedures were undertaken using SPSS v22 (IBS, SPSS Inc USA).

 3

Figure 3 Forefoot-midfoot kinematics as a function of orthotic and no-orthotic conditions (black = orthotic & dash = no-orthotic).

4

Figure 4 Forefoot-rearfoot kinematics as a function of orthotic and no-orthotic conditions (black = orthotic & dash = no-orthotic).

Results

Figures 1-4 presents the multi-segment foot kinematics obtained as a function of orthotic intervention and tables 1-4 show the discrete kinematic parameters. The results indicate that orthotic intervention significantly influenced multi-segment foot kinematics.

Rearfoot – tibial angles

In the sagittal plane relative ROM was significantly (t (11) = 2.37, p<0.05, η2 = 0.37) greater in the no-orthotic condition (Table 1; Figure 1a). In the transverse plane there was significantly (t (11) = 2.81, p<0.05, η2 = 0.42) more external rotation at footstrike in the orthotic condition. Finally, relative ROM was significantly (t (11) = 2.37, p<0.05, η2 = 0.38) greater in the no-orthotic condition (Table 1; Figure 1c).

Midfoot – rearfoot angles

In the sagittal plane relative ROM was significantly (t (11) = 2.30, p<0.05, η2 = 0.30) greater in the no-orthotic condition (Table 2; Figure 2a).

Forefoot – midfoot angles

No significant differences (p>0.05) were shown between orthotic and no-orthotic conditions.

Forefoot – rearfoot angles

No significant differences (p>0.05) were shown between orthotic and no-orthotic conditions.

Plantar fascia strain

No significant differences (p>0.05) differences in plantar fascia strain were found between orthotic (8.00 ± 4.14) and no orthotic conditions (8.70 ± 4.69).

Discussion

The aim of the current work was to examine the effects of semi-custom orthotics on 3D multi-segment foot kinematics and plantar fascia strain during the stance phase of running. To the authors knowledge this represents the first study to investigate the effects of mouldable orthoses during running.

The first important observation is that the semi-custom orthoses did not reduce the strain experienced by the plantar fascia during the stance phase of running. This opposes our hypothesis and also the findings of Ferber & Benson [10] in which significant reductions in plantar fascia strain when wearing semi-custom orthoses. This finding does however concur with the results of Sinclair et al [9] who showed that off the shelf orthoses did not reduce plantar fascia strain during running. Plantar fasciitis is considered to be caused by excessive and frequent strain imposed on the plantar fascia itself [15], therefore the current investigation supports the notion proposed by Sinclair et al [9] in that orthoses may not be effective for runners seeking to treat plantar fasciitis. More importantly it also appears based on this study that a semi-custom orthotic does not provide any additional benefits in relation to an off the shelf device, although further comparative work is required before this can be fully substantiated.

In addition, the current investigation showed that the semi-custom orthotic served to mediate reductions in transverse plane relative ROM of the midfoot-rearfoot articulation. This finding concurs with our hypothesis and also those of Sinclair et al [9] who demonstrated that foot orthoses significantly reduced coronal and transverse plane rotations of the foot segments. Excessive transverse plane articulations between the foot segments have been associated with injury aetiology [16]; therefore it appears that there may be some benefit from orthotic intervention to improve foot function during running. However, the mean reduction in angulation between orthotic and no-orthotic conditions was very small and thus further prospective investigations regarding the clinical efficacy of semi-custom orthoses are required.

A limitation of the current investigation is that plantar fascia strain was calculated using markers positioned onto the foot segment. Using this procedure assumes that plantar fascia spans from the calcaneus to the first metatarsal. This technique has been utilized in previous research to quantify and resolve differences in plantar fascia strain [10, 17] and the values obtained during the current study correspond closely with previous values. Nonetheless this clearly represents a simplified approach for which there is certain to be some degree of error [9]. Currently this represents the only non-invasive technique for the quantification of plantar fascia strain; however it is recommended that future analyses consider the efficacy of more direct methods of measuring the kinematics of the plantar fascia during gait.

In conclusion, whilst the effects of foot orthoses on the biomechanics of running have been extensively researched, the current knowledge with regards to the effects of semi-custom orthoses is limited. This study aimed to address this by providing a comprehensive investigation of 3D multi-segment foot kinematics and plantar fascia strain when wearing a semi-custom orthotic device. The findings from the current study show that semi-custom foot orthoses do not serve to influence plantar fascia strain. In addition the transverse plane relative ROM of the rearfoot-tibial articulation was shown to be significantly reduced when the orthotic was used. Given the proposed relationship between transverse plane rotations of the foot segments and the aetiology of injury, there may be some benefit from orthotic intervention to improve foot function during running. However, the mean reduction in angulation was very small and thus further prospective investigation regarding the specific clinical efficacy of semi-custom orthoses is required.

References

  1. Lee DC, Pate RR, Lavie CJ, Sui X, Church TS, Blair SN. Leisure-time running reduces all-cause and cardiovascular mortality risk. J Am Coll Cardiol 2014; 64: 472-481. Link
  2. Schnohr P, O’Keefe JH, Marott JL, Lange P, Jensen GB. Dose of jogging and long-term mortality: the Copenhagen City Heart Study. J Am Coll Cardiol 2015; 65: 411-419. Pubmed
  3. Taunton JE, Ryan MB, Clement, DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med 2002; 36: 95-101. Link
  4. van Gent R, van Middelkoop M, van Os A, Bierma-Zeinstra S, Koes B. Incidence and Determinants of Lower Extremity Running Injuries in Long Distance Runners: A Systematic Review. B J Sp Med 2007; 41: 469-480. PubMed
  5. Sinclair J, Isherwood J, Taylor PJ. Effects of foot orthoses on kinetics and tibiocalcaneal kinematics in recreational runners. FAOJ 2014; 7: 3-11. Link
  6. Laughton CA, Davis IM, Hamill J. Effect of strike pattern and orthotic intervention on tibial shock during running. J App Biomech 2003; 19: 153-168.
  7. Dixon SJ. Influence of a commercially available orthotic device on rearfoot eversion and vertical ground reaction force when running in military footwear. Mil Med 2007; 172: 446-450. PubMed
  8. Cobb SC, Tis LL, Johnson JT, Wang YT, Geil MD. Custom-molded foot-orthosis intervention and multisegment medial foot kinematics during walking. J Athl Train 2011; 46: 358-65. PubMed.
  9. Sinclair J, Isherwood J, Taylor PJ. The effects of orthotic intervention on multi-segment foot kinematics and plantar fascia strain in recreational runners. J App Biomech 2015; 31: 28-34. PubMed
  10. Ferber R, Benson B. Changes in multi-segment foot biomechanics with a heat-mouldable semi-custom foot orthotic device. JFAR 2011; 4: 1-8. PubMed.
  11. Cappozzo A, Catani F, Della Croce U, Leardini A. Position and orientation in space of bones during movement: anatomical frame definition and determination. Clin Biomech. 1995; 10: 171–178. PubMed
  12. Leardini A, Benedetti M, Berti L, Bettinelli D, Nativo R, Giannini S. Rear-foot, mid-foot and fore-foot motion during the stance phase of gait. Gait Posture 2007; 25: 453-462. PubMed
  13. Shultz R, Jenkyn T. Determining the maximum diameter for holes in the shoe without compromising shoe integrity when using a multi-segment foot model. Med Eng Phys 2012; 34: 118–122. PubMed
  14. Sinclair J, Taylor PJ, Hobbs SJ. Digital filtering of three-dimensional lower extremity kinematics: An assessment. J Hum Kin 2013; 39: 25-36. PubMed
  15. Pohl MB, Hamill J, Davis IS. Biomechanical and anatomic factors associated with a history of plantar fasciitis in female runners. Clin Journal Sport Med 2009; 19: 372-376. PubMed
  16. Sinclair J, Taylor PJ, Hebron J, Chockalingam N. Differences in multi-segment foot kinematics measured using skin and shoe mounted markers. FAOJ 2014 Link
  17. Sinclair J, Taylor PJ, Vincent H. The influence of barefoot and shod running on plantar fascia strain during the stance phase of running. FAOJ 2015 Link

Arthroscopic first metatarsophalangeal joint fusion for hallux rigidus

by Ibrahim Turan MD1, Beran Turan MD2, Jan G Jakobsson MD3*pdflrg

The Foot and Ankle Online Journal 8 (4): 4

End stage arthritis of the first metatarsophalangeal joint (MTPJ) is a forefoot complaint experienced not only in elderly but also increasingly observed in young and healthy patients. The most effective cure is an arthrodesis of the joint. Arthroscopic fusion of the first metatarsophalangeal joint is rarely described. We here present a short description of an arthroscopic MTPJ fusion technique that is easy to use; providing effective intraoperative surgery and rapid recovery.

Key words Arthrodesis, hallux rigidus, arthroscopic surgery

ISSN 1941-6806
doi: 10.3827/faoj.2015.0804.0004

Address correspondence to: Jan Jakobsson*
1. Professor Orthopaedics, Hand & Foot Surgical centre, Stockholm, Sweden
2. Orthopaedic Surgeon, Hand & Foot Surgical centre, Stockholm, Sweden
3. Professor Anaesthesia & Intensive Care, Institution for Clinical Science, Karolinska Institutet, Danderyds Hospital, Stockholm Sweden Jan.jakobsson@ki.se


There are different grades of osteoarthritis of the first metatarsophalangeal joint (MTPJ1). It commonly starts with a partial lesion of the cartilage, osteochondritis. Extirpation of the free bodies may be sufficient for symptom treatment of partial lesions. In more severe cases where the majority of the cartilage is destroyed causing intense pain and malfunction (hallux rigidus) arthrodesis is the ultimate treatment [1]. Partial resection and different prosthesis have been tested. The long-term outcome is however not optimal and classical arthrodesis, joint fusion is far more effective. Arthroscopic surgery of the MTPJ1 is a time-honored treatment. Van Dijk et al described in 1989 the successful use of arthroscopic approach for surgery of the metatarsophalangeal first joint [2]. Since then arthroscopy of the MTPJ1 has been advocated for synovitis, loose bodies, and early-grade hallux rigidus [3, 4].

Procedure

The arthroscopic arthrodesis can be performed with a foot block, regional or general anesthesia. A foot block provides not only adequate perioperative but long lasting up to 20 hours postoperative analgesia. The use of 20 ml ropivacain for block provides effective surgical anesthesia within 10 to 15 minutes and long lasting postoperative analgesia.

The patient is placed supine on the operating table with the leg in abutment to help fixate the leg and the foot is further resting on the table. There is no need for a tourniquet.

A 1.9mm size arthroscope with a 30-degree optic is used. The fluid pressure is set at 30 mmHg and an arthroscopic shaver size 2.0 mm is used for removing synovitis. Cartilage from both surfaces of the joint are removed with burr. Before starting the procedure, 5 ml lidocaine 1 mg/ml is injected into the joint for expansion and further local analgesia. The extensor tendon should be identified and marked before starting the surgery in order to avoid harm. Two ports are used, one medial and one lateral to the extensor halluces longus tendon. The optic is introduced from one side of the tendon and on the other side of the tendon the working port is introduced.

1

Figure 1 Postoperative exterior at 4 weeks.

2

Figure 2 Radiograph at postoperative week 4.

The shaver is introduced and the synovia is removed by firm shaving under continuous observation. The cartilage is drilled away from both joint surfaces with a burr. When the joint surface is reassuringly clean from synovia and the cartilage is fused by two cross-fixed 3 mm screws. The positions of the screws are verified by a plane radiograph image. A 5 to 10 degree dorsal angulation is recommended for the arthrodesis in females and a neutral position in males. Sterile strips close the ports. Patients are instructed to walk unloading the toe, putting weight on the later part of the foot for 3 weeks.

Full weight bearing is allowed after 3 weeks. Pain is commonly mild and can be managed by ordinary over the counter painkillers, combination of acetaminophen and a NSAID.

Discussion

Osteoarthritis in the MTPJ1 has become more common possibly because of more physical activity, aerobics, running, etc. Osteoarthritis was in the past most commonly seen in elderly male patients. Nowadays, we see more or less equal numbers of males and females. Also, the age profile has changed from elderly to mid aged not uncommonly active patients. We believe that the change in patient profile is associated to the increase in various physical activities providing rather extensive load on the forefoot, soccer, long distance running not uncommon on hard surfaces. A joint arthrodesis provides benefits, patients become pain free, may continue to do sports, use the foot “as usual”. The arthrodesis seems an effective and long lasting approach and may be a preferred option as compared to implantation of a prosthesis [5]. The area of the MTPJ is small and thus the forces are huge per scare cm. There is risk for further joint injury by placing a foreign material prosthesis in this metatarsophalageal joint.
We strongly recommend arthrodesis with an arthroscopic technique. The minimal invasive surgery provides less surgical trauma and speeds up the recovery and rehabilitation.

References

  1. Turan I, Lindgren U: Compression screws arthrodesis of the first metatarsophalangeal joint. Clin. Orthop Rel Res.1987; 221:292-5.
  2. van Dijk CN, Veenstra KM, Nuesch BC. Arthroscopic surgery of the metatarsophalangeal first joint. Arthroscopy. 1998; 14: 851-5.
  3. Siclari A, Piras M. Hallux metatarsophalangeal arthroscopy: indications and techniques. Foot Ankle Clin. 2015; 20:109-22.
  4. Hunt KJ. Hallux metatarsophalangeal (MTP) joint arthroscopy for hallux rigidus. Foot Ankle Int. 2015; 36:113-9.
  5. Ferguson CM, Ellington JK. Operative Technique: Interposition Arthroplasty and Biological Augmentation of Hallux Rigidus Surgery. Foot Ankle Clin. 2015; 20: 513-24.

Additional References

  1. Schmid T, A first metatarsophalangeal joint degeneration: Arthroscopic treatment. Foot Ankle Clin. 2015; 20(3):413-420.
  2. Walter R, Perera A. Open, arthroscopic, and percutaneous cheilectomy for hallux rigidus. Foot Ankle Clin. 2015; 20(3):421-43

Does BMI variation change the height of foot arch in healthy adults: a cross sectional study

by A. P. C Udayamali Pathirana BPT1, Dr. Watson Arulsingh PT2*, Dr. Remya K.R PT3, Joseph Oliver Raj PT4pdflrg

The Foot and Ankle Online Journal 8 (4): 3

Background: Many research give scatterlly distributed relationship between obesity and the medial longitudinal arch of foot. Among those studies, only two studies have stratified the samples in to underweight, normal weight, overweight and obese groups in the recent past, to explore the relationship of BMI to arch of the foot on the basis of gender variation. Yet these studies contradicted each other in their finding of associating BMI variation to foot arch height. Hence this current study was intended to explore any significance changes were found in medial arch height of foot among the stratified groups.
Design: Cross sectional observational study. For this purpose, 150 healthy adults were screened, out of which 100 were chosen and  stratified into underweight, normal weight, overweight and obese group according to Asian guideline of BMI at convenient sampling method. Brody‘s navicular drop test was used to measure height of the foot arch of each person.
Results: Spss 16 version was used for statistical analysis. One way Anova analysis was tested across four groups. The P value for left navicular drop test between groups is 0.000 < 0.005. There is significant difference between the groups for left navicular drop test compared to the right navicular drop test with changes in BMI. The P value for right navicular drop test between groups was 0.304 > 0.005.
Conclusion: It is concluded that there was no statistical significance of difference found between the groups for height of foot arch. The current study concluded, navicular drop was more in overweight group and then in obese group of right and left foot against normal weight and underweight group. But there was statistical significance of difference found within the groups for left height of foot arch.

Key words: BMI, arch of foot, navicular drop, underweight, normal weight, overweight, obese

ISSN 1941-6806
doi: 10.3827/faoj.2015.0804.0003

Address correspondence to: Watson Arulsingh*
1. Alva’s college of physiotherapy and research center, Moodbidri, 574227, D.K, India. apcudayamali@gmail.com
2*. Associate Professor, Alva’s College of Physiotherapy and research center, Moodbidri-574227 D.K
watsonarulsingh@yahoo.in.
3. Assistant Professor, Alva’s College of Physiotherapy, Moodbidri-574227, D.K. remya.unni82@gmail.com
4. Professor, Alva’s College of Physiotherapy, Moodbidri-574227, D.K. rushtojoseph@yahoo.co.in


The human foot consists of 26 bones and more than 30 articulations enabling three fundamental functions of supporting, shock absorbing and weight bearing. The arches of the foot are formed by tarsals, metatarsals, ligaments and tendons.

They help to bear the weight of the body in standing and walking, and act as shock absorbers. Types of arches are the transverse arches which run across the midfoot from outside to inside. Longitudinal arches are the lateral and medial longitudinal arches. Medial longitudinal arch is higher than lateral longitudinal arch. Medial longitudinal arch (MLA) is made up of calcaneus, talus, navicular, three cuneiforms, and the 1st, 2nd, and 3rd metatarsals. Lateral longitudinal arch is made up of calcaneus, cuboid, and 4th and 5th metatarsals [1].

Types of the foot arches are pes cavus, pes planus, and normal arch. Arch function depends on the shape of the foot, bony structure ligamentous stability, and muscular fatigue while factors like race, footwear, age, and gender are found to influence the formation of MLA [2].

There are many techniques to measure MLA. The methods are divided into two groups: indirect and direct methods. Indirect methods include ink or digital footprints which can be static (standing) or dynamic (walking) and photographic techniques. Direct methods are somatometric measurements, clinical assessment, radiographic evaluation, and ultrasonography quantification. One of the most popular and widely used clinical methods of assessing MLA is the Brody’s navicular drop test [3]. Brody’s navicular drop test is a clinically validated tool determined by Brody in 1982 [4].  It classifies the foot arch into low arch, normal, high arch, measured by navicular drop of >10mm, 6mm – 10mm, < 5mm respectively. It was intended to represent the sagittal plane displacement of the navicular tuberosity from a neutral position to a relaxed position in standing. Muller et al 1993 explored the inter rater reliability (ICC) of navicular drop test 0.78 – 0.83, Sell et al 1994 explored inter-rater reliability (ICC) 0.73 and intra-rater reliability 0.83 [5].

There are few claims across the scientific world that BMI may influence the arch configuration of foot. Research has focussed to determine whether BMI has any correlation to arch of foot. Few among them concluded that there is a direct association of BMI to medial arch index [6, 7, 8].  Arulsingh et al [10] in their study tried to determine the impact of anthropometric measurements on medial arch height in half marathon runners. They reported minimum to moderate degree of inverse correlation between anthropometric measurements and navicular height on the left side and little correlation on right side, yet their sample size was small.

Two other studies reported that males were found to have higher prevalence of flatfoot than women in the age group of 18-25 years [6,8].

Only two studies in the past have stratified samples in to underweight, normal weight, overweight and obese groups in the recent past to explore the relationship of BMI to arch of the foot on the basis of gender variation [8]. Yet these studies contradicted each other in their finding of associating BMI variation to foot arch height and have utilized foot print method to characterize foot arch type rather than using navicular height a valid method for associating with variable [11].

ASIAN guidelines for BMI classifies the individuals into underweight, normal weight, overweight, and obese, BMI< 17.50, 17.50 – 22.99, 23.00 – 27.99, > 28.00 respectively [9]. Research states that obesity lowers the medial longitudinal arch of foot. Hence this current study was intended to explore any significance changes were found in medial arch height of foot among  underweight, normal, over weight and obese groups based on ASIAN Guidelines of BMI.

METHODS

Procedure

For this study, nearly 150 healthy adults were screened from the age group of 18 to 25 years. 100 subjects fulfilled inclusion criteria and grouped into underweight (25), normal weight (25), overweight (25) and obese (25) based on ASIAN guidelines of BMI. Alva’s Institutional ethical review board approval was obtained. Patient consent form was used before including subjects for this study. Subjects who fulfilled ASIAN Guidelines were fitted in to underweight, normal, overweight and obese. Subjects presented with recent ankle sprain, fracture, or any other foot injuries, cognitively impaired subjects, deformity of foot, inflammatory disease are excluded from the study.

Brody’s navicular drop test was done on all the subjects in both weight bearing and non-weight bearing positions. For non-weight bearing, the patient was made to sit in chair with hip and knee flexed to 90 degree and foot placed flat on ground. The subtalar joint neutral position was obtained by palpation method (Figure 1). The navicular tuberosity was palpated and marked with color marker (Figure 2).  The distance from navicular tuberosity to the supporting surface is measured with metal scale (Figure 3).

image2

Figure 1 Palpation method to keep subtalar joint in neutral position.

image3

Figure 2 Marking the location of navicular tuberosity.

Participant was asked to stand with shoulder width apart in weight bearing position. Same procedure was undertaken as seated position (Figure 4). The difference of navicular drop in non-weight bearing and weight bearing was calculated for all participants with the help of vernier caliper.

image4

Figure 3 Measuring navicular height in sitting.

image5

Figure 4 Measure the distance from supporting surface to navicular tuberosity in standing.

Outcome measures

Brody’s Navicular Drop Test

Characteristic values for navicular drop are,

Normal arch = 6-10mm

Low arch     = > 10 mm

High arch    = < 5 mm

Data analysis

Spss16 version was used to analyze data. Normality of data was checked. One way Anova was used to compare navicular drop values across groups.

RESULTS

One-hundred healthy subjects were stratified into four groups according to ASIAN guidelines for BMI classification with 25 subjects in each group. Study results show that there is a significant difference of navicular drop in left foot with the BMI. Yet mean descriptive data of navicular drop test in all groups vary from one group to another regardless of right foot or left foot. The mean navicular drop values of right foot were for underweight group was 7.8±3.4, normal weight7.8 ±3.6, over weight group 8.84±3.9 and in obese group 9.5±3.7. Similarly the left foot readings of underweight group had mean navicular drop value of 8.32±3.11, normal weight group 6.4±3.0, overweight group 10.32±3.6 and obese group 9.6±2.9. The result shows that there is more navicular drop in left foot compared to right with increased BMI. On the basis of above observation, navicular drop was more in overweight group and then in obese group of right and left foot against normal weight and underweight group Table 1, 3 (see supplement, attached) show descriptive values of navicular drop test for four groups. Table 2, 4 show the p value when four groups were compared on navicular drop values. Figure 1-4 denote how navicular drop test was administered. Table 5,6 explains age, gender homogeneity across four groups. Figures 5 and 6 explain percentage of arch type across genders.

image6

Figure 5 Percentage of arch type across gender, left.

image7

Figure 6 Percentage of arch type across gender, right.

DISCUSSION

On the basis of above observation, navicular drop was more in the overweight group and then in obese group of right and left foot against normal weight and underweight group. It shows that the overweight population and obese are at a high risk of getting low arched feet. It matches the report of two other researchers stating that body weight has a direct impact on the medial arch [7,9].Yet, MCID value was not yet determined for navicular drop test to report some clinical significance between groups. This is the first study to have used ASIAN BMI guidelines in stratifying samples. Out of 100 samples, only 12 were males. Figure 5a denotes the percentage of flat foot occurrence is more in male’s left foot rather than right foot. Former studies have claimed that males have increased percentage of flat foot compared to their age matched females [6,8]. Yet none of these studies explored whether flat foot incidence are more in left foot to right foot in males. Age homogeneity was found across four groups.

Limitation of this study is that it did not take hand dominancy into account, as this study report that BMI has influence on left arch of foot. Sample size was small. Gender distribution in each group should be enhanced in future studies.

Conclusion

It is concluded that there was no statistical significance of difference found between the groups for height of foot arch. The current study concluded, navicular drop was more in overweight group and then in obese group of right and left foot against normal weight and underweight group. But there was statistical significance of difference found within the groups for left height of foot arch.

Acknowledgements: I am grateful to my parents, my teachers and friends who helped me in a different way throughout my study

REFERENCES

  1. Gray, Henry. Anatomy of the Human Body. “7j. 1918. Arches of the Foot”. Bartleby.com. ISBN 0-8121-0644-X.
  2. Rasmus G Nielsen, Michael S Rathleff, Ole H Simonsen, Henning, Langberg, Determination of normal values for navicular drop during walking: a new model correcting for foot length and gender, Journal of Foot and Ankle Research 2009, 2:12  doi:10.1186/1757-1146-2-12.
  3. R.Wozniacka, A Bac, S. Matusik R, E. Szczygie, E. Ciszek, Body weight and medial longitudinal foot arch: high arched foot, a hidden problem? Eur J Pediatr (2013) 172:683–691
  4. Evan Thomas, Navicular drop test, Physiopedia.
  5. Arzu Erden, FilizAltug, UgurCavlak, Impact of body mass index and gender on medial longitudinal arch drop in young healthy population Sport medicine journal,2013, no.34.
  6. Sneha Sameer Ganu,VrushaliPanhale, Effect of Obesity on Arch Index in Young Adults, online journal of health and allied sciences, Online J Health Allied Scs. 2012;11(4):8. Available at URL:http://www.ojhas.org/issue44/2012-4-8.html
  7. Ashwinichougala, Viditphanse, Erohitkhanna, Sudipta; Screening of body mass index and functional flatfoot in adult: an observational study; Journal of Physiotherapy and Research, Int J Physiother Res 2015, Vol 3(3):1037-41. ISSN 2321-1822; DOI:http://dx.doi.org /10.16965/ijpr.2015.133.
  8. Tejashreebhoir, Deepak b. Anap, Abhijitdiwate; Prevalence of flat foot among 18 -25 years old physiotherapy students: cross sectional study, Indian journal of basic and applied medical research; September 2014: vol.-3, Issue- 4, p. 272-278.
  9. Asian guideline for BMI by Joslin diabetes center, 2010
  10. Watson Arulsingh, Ganesh Pai, Joseph Oliver Raj, Impact of anthropometric measures on medial arch height in half marathon Runners, scholars’ research library, 2014 3 (3):37-41.
  11. 11.Piers LS, Soares MJ, Frandsen SL, O’Dea K, 2000. Indirect estimates of body composition are useful for groups but unreliable in individuals. Int. J. Obes. Relat.Metab.Disord 24;1145-1152.