3rd Metatarsal Heads Research Articles

Analysis of transfer lesions in patients who underwent surgery for diabetic foot ulcers located on the plantar aspect of the metatarsal heads

To analyse the risk of reulceration caused by the transfer of lesions in patients with diabetes, undergoing resection of at least one metatarsal head. A total of 119 patients with diabetes from the Diabetic Foot Unit (Complutense University, Madrid, Spain), who underwent resection of at least one metatarsal head were analysed prospectively from November 2006 to December 2011 to assess reulceration in the other metatarsal head. Seven patients were excluded for being subjected to a pan-metatarsal head resection and 11 patients dropped out. During a median follow-up period of 13.1 months (interquartile range 6.1-22.8 months), 41% of patients suffered from reulcerations. Reulceration frequency in patients operated on the 1st, 2nd, 3rd, 4th, 5th and several metatarsal heads was 9 (69%), 8 (44%), 12 (52%), 2 (25%), 6 (19%) and 4 (50%) events, respectively. The Cox regression model showed hazard ratios that were significant for the location of the metatarsal resection. The first metatarsal showed the highest risk for reulceration (hazard ratio 3.307; 1.472-7.430) and the fifth metatarsal showed the lowest risk (hazard ratio 0.339; 0.138-0.832). Reulceration is a frequent event following resection of a metatarsal head and should be regarded as an implicit complication of the intervention. The location of the resection determines the risk of reulceration, which is highest for patients operated on the first metatarsal head and lowest for patients operated on the fifth metatarsal head.

A simple surgical technique for treatment of Freiberg's disease

BackgroundOf all the osteochondrosis, Freiberg's disease is reported to be the fourth most common, exceeded by Köhler's disease, Panner's disease, and Sever's disease. This disease usually occurs in the 2nd metatarsal head and relatively in the 3rd and 4th metatarsal heads. ObjectiveThe purpose of this study was to evaluate the outcome of debridement, synovectomy, dorsal closing wedge osteotomy and pin fixation for Freiberg's disease treatment. MethodsTen female patients, mean age 18.3 years; (ranged 14–24 years) were treated by the above mentioned technique. The main presenting symptom was pain on walking or sport; affected their daily life and activities and was not improved by non-surgical treatment. The second metatarsal head was affected in all patients. Halve of patients had a history of trauma. According to Smillie's classification, four patients were type V and six patients were type IV. Mean follow-up period was 19.2 months (range 6–36 months). ResultsWere assessed by the Lesser Metatarsophalangeal-Interphalangeal (LMPI)Scale by Kitaoka et al. At the final follow up, scoring was changed from (44–76) with an average 57 to (66–100) with an average 80. There was no case of infection, avascular necrosis, arthritis or pseudoarthrosis. ConclusionWe founded that dorsiflexion osteotomy of the metatarsal head is presented as a logical procedure that is simple, reliable, not destructive, and capable of good results regardless of the stage of the disease.

Immediate Effects of Acute Postural Correction on Plantar Pressures and Gait Characteristics in an Individual with Diabetic Peripheral Neuropathy: A Case Report

Purpose: The purpose of this case report is to assess the immediate effects of acute postural changes on plantar pressure distribution and gait characteristics during comfortable walking speed in an individual with diabetic peripheral neuropathy. Case description/intervention: Subject is a 71 year old Caucasian male with a BMI of 31.3 and a medical diagnosis of Type II Diabetes given 8 years ago. The patient exhibits mild peripheral neuropathy as scored by the Michigan Neuropathy Screening Instrument (MNSI; 7/23) as well as callous formation over the 2nd and 3rd metatarsal heads. The patient performed 3 separate walking conditions at a comfortable walking speed. The 3 conditions were: (1) Normal walking (NW), (2) Forward bending walking (FBW), and (3) Upright walking (UW). Measurements were recorded and averaged from these 3 conditions. NW condition was used as a control for comparing gait characteristics and plantar pressure parameters with the other gait conditions. Results: UW may be the most mechanically efficient condition for distributing plantar pressure with increased gait speed (1.441 m/s), largest contact surface area of the foot, and increased hip range of motion; however, for this individual the increased plantar pressure in the forefoot (FF) area may contribute to the risk of ulceration. The FBW condition showed the limited medial to lateral excursion of the center of forceand lowest pressure in the FF area; therefore, FBW may be the most beneficial for this patient in decreasing the risk of ulceration in the area of greatest concern. Conclusion: Variations in gait characteristics during UW and FBW indicate that alterations in posture may serve as another method to reduce the risk of plantar ulcer formation; however, further research is needed to examine the long term effects of such an intervention.

The effect of aging on the hardness of foot sole skin: A preliminary study

BackgroundFoot problems are common in older people and altered biomechanical parameters under the foot sole has been proposed as a key risk factor for foot lesions. Therefore the aim of this study was to investigate the age-related differences in the hardness of foot sole skin. MethodsTwenty-six healthy volunteers without foot problems, aged from 26 to 65 years, were examined using shore meter. The hardness of the foot sole under the big toe (area 8), 1st metatarsal head (area 5), 3rd metatarsal head (area 6), 5th metatarsal head (area 7), mid foot (area 3, 4) and hind foot (area 1, 2) were measured. The correlation between age and hardness of foot sole was examined and comparisons were made between two age groups. ResultsFrom the result we observe statistical significant (p<0.05; p<0.01; p<0.005) differences in hardness between age groups in hind foot, metatarsal heads (1st, 3rd & 5th) and big toe. Strong positive correlations between age and hardness of the foot sole were found at the big toe (r=0.57; p<0.005), 1st metatarsal head (r=0.567; p<0.00001), 3rd metatarsal head (r=0.565; p<0.00001), 5th metatarsal head (r=0.55; p<0.00001), and heel (r=0.59; p<0.0001). ConclusionThe loss of compliance in the foot sole may be one of the factors responsible for the higher incidence of foot problems in aged people. Routine foot examination and appropriate therapeutic intervention including the use of foot orthoses and optimal hardness of foot wear insole may help to prevent the serious foot injuries.

Effect of simulated leg length discrepancy on plantar pressure distribution in diabetic patients with neuropathic foot ulceration

To study the effect of a minor degree of artificially induced leg length discrepancy (LLD) on plantar pressure distribution in diabetic patients with neuropathic foot ulceration. In-shoe plantar pressure distributions were measured on the ulcerated foot during walking using F-scan (Tekscan Inc.). To simulate minor LLD, the contralateral leg length was changed by asking patients to walk under three different conditions: wearing shoe of the same sole thickness (NLLD), walking with a bare foot (20mm long leg) and wearing a 40mm-high platform-sole shoe (20mm short leg). These three different walking conditions were compared in a randomised, single-blinded crossover design. The study included 28 diabetic patients with neuropathic foot ulcers (53.7 ± 6.8 years; 16 males, 12 female). Notably, the peak pressure and pressure time integral (PTI) were the most affected parameters. PTI significantly increased beneath total foot, mid-foot, 2nd, 3rd, 4th and 5th metatarsal heads (MTHs), and 3rd toe, when the 20mm short leg was simulated (79.4 ± 21.1; 61.5 ± 32.3; 59.9 ± 36.5; 69 ± 42.1; 70.6 ± 42.3; 63.9 ± 33.7; 40.± 33.2 kPa·s, respectively), compared with NLLD (73.7 ± 19.9; 55.524; 51.8 ± 30.1; 58.4 ± 37.6; 60.3 ± 39.5; 57.2 ± 32.3; 36.9 ± 33.3 kPa·s, respectively). The short leg of diabetic patients with neuropathic foot ulcers will be subjected to greater pressure load, primarily beneath the total foot, mid-foot and 2nd, 3rd, 4th and 5th metatarsal heads. As such, care should be taken to avoid minor LLD, as it could inadvertently develop on using offloading devices. The authors have nothing to declare.

Are diurnal changes in foot sole sensation dependent on gait activity?

The foot sole is loaded during stance and gait and plantar cutaneous mechanoreceptors sense the local stress distribution. It is not clear whether the perception thresholds of these mechanoreceptors change during the day and how they respond to walking activities. The primary aim of the present study was to investigate diurnal changes of plantar sensitivity. Furthermore, the aim was to find out whether daily changes depend on the individual level of step activity. Twenty-six healthy subjects, 17 women and 9 men, aged 28.6 ± 6.7 years participated in the study. Detection thresholds to light touch were measured in six plantar regions with Semmes–Weinstein monofilaments in the morning, noon and afternoon. Step activity was recorded with a StepWatch™ Activity Monitor and analyzed for three periods (8 a.m.–4 p.m., 8 a.m.–12 p.m., 12 p.m.–4 p.m.). The hallux, the 3rd metatarsal head and the heel showed significantly decreased detection thresholds from 8 a.m. to 4 p.m. ( p ≤ 0.05). A fair correlation between the decrease of detection threshold and the total number of steps was found for the 3rd metatarsal head and the heel ( p ≤ 0.05). Foot sole sensation appears to improve during the day and seems to be associated with the step activity. This may reflect an improving transfer of afferent information to the central nervous system during the day as well as an adaptation of receptors to gait activity.

Bilateral Foot Pain - Former Runner

HISTORY: A 26-year-old female presents for evaluation of chronic bilateral foot pain. The pain began one year ago in her left foot with no clear preceding event. She was initially evaluated at an outside hospital, and MRI revealed possible stress fracture of the 2nd and 3rd metatarsal heads versus 2nd and 3rd digit tendinopathy of the flexor hallucis longus and digitorum longus and brevis. Her left foot was placed in a CAM walker for 1-2 months, but she had no resolution of her symptoms. Over the past two months, she began having pain in her right foot. Pain was initially located on the dorsum of her left foot, but now is primarily on bilateral plantar aspects. It is made worse by walking in high heels, but improved with tennis shoes. She previously lost 20 kg with diet and running before she stopped running 2 years ago. Her menses have been normal. She denies any previous stress fracture, fracture, osteoporosis, or eating disorder. Her medical history is significant for depression and anxiety for which she takes citalopram. PHYSICAL EXAMINATION: Ht 5'10", Wt 152 lbs, BMI 22. Bilateral hindfoot valgus and pes planus. Normal foot and ankle range of motion. Tenderness to palpation on plantar aspect of 2nd - 4th metatarsals bilaterally. Squeeze test was painful but did not cause radiation, numbness, or tingling in her toes. Gait is slightly antalgic. DIFFERENTIAL DIAGNOSIS: 1. Bilateral metatarsal stress fracture 2. Freiburg's disease 3. Morton's neuroma 4. Chronic Tendinitis 5. Rheumatologic disorder 6. Hyperparathyroidism TEST AND RESULTS: Comprehensive metabolic panel, TSH, vitamin D level, and bilateral 3-view of feet normal. MRI of bilateral feet: -Marked marrow edema of left 2nd -3rd and right 5th metatarsal heads. Small to moderate amount of fluid within the right 1st intermetatarsal space. Effusion within the left 2nd MTP joint. There is large surrounding joint effusion and intraarticular heterogeneous curvilinear low signal, likely representing robust synovitis within the right 2nd and 3rd MTP joints. -Subsequent ESR, CRP, CBC, and ANA profile normal -Rheumatoid factor 90 IU/ml (positive) -Anti-CCP > 200 U/ml (positive) FINAL WORKING DIAGNOSIS: Atypical rheumatoid arthritis of forefeet TREATMENT AND OUTCOMES: Referred to rheumatologyTreated with Diclofenac and prednisone with great improvement in symptoms

The Effect of Using Trunk Control Pelvic Movement Exercise in the Sitting and Standing Positions on the Relative Impulse of Hemiplegic Patients

[Purpose] The purpose of this study was to investigate the effect of using trunk control pelvic movement (TCPM) exercises with changes in the body position on the relative impulse in hemiplegic patients. [Subjects] Thirty-seven hemiplegic patients were randomly divided into 3 groups: control group (CG, n=12), sitting exercise group (SIEG, n=12), and standing exercise group (STEG, n=13) [Methods] A F-Scan System was used to measure the relative impulse of foot pressure on the hemiplegic side during walking. [Results] After the exercise, the relative impulses of the hallux and 2nd, 3rd metatarsal heads in SIEG and STEG were significantly increased during walking. [Conclusion] These results suggest that TCPM exercise in the sitting and standing positions is effective at improving foot pressure on the hemiplegic side. In addition, propulsion during push off was increased in the standing position.

Differences in foot pressures between Caucasians and Indians

Indians are the largest single ethnic minority group in the United Kingdom and form more than one million of the current population. No studies have investigated foot pressure differences between Caucasians and Indians. The aim of our study was to investigate the in-shoe pressure differences in Caucasians and Indians using the Pedar(®)-m (Novel GmbH, Germany). The study included 12 Caucasians and 21 Indians. Peak pressure (PP), contact area (CA), contact time (CT), pressure-time integral (PTI), force-time integral (FTI), instant of peak pressure (IPP), maximum force (MaxF) and mean force (MeanF) were recorded. Caucasians had higher significant PP compared to Indians under the heel (293 kPa vs. 251 kPa; P<0.001), 1st metatarsal head (294 kPa vs. 233 kPa; P=0.01), 2nd metatarsal head (266 kPa vs. 236 kPa; P=0.03), 3rd metatarsal head (254 kPa vs. 223 kPa; P=0.04), and the 5th metatarsal head (168 kPa vs. 133 kPa; P=0.04). There was no significant difference in the contact area between the two race groups. The PTI was statistically significantly higher in Caucasians in the region of the 1st metatarsal head (79 kPas vs. 62 kPas; P=0.03) and 5th metatarsal head (58 kPas vs. 44 kPas; P=0.03). There were no significant differences among CT, FTI, IPP, MaxF and MeanF among them. The PP under the heel, 1st, 2nd, 3rd and 5th metatarsal heads and the PTI under the 1st and 5th metatarsal heads in Caucasians is higher than in Indians. There is no difference in the CA.

Foot pressure differences in men and women

Women and men are anatomically and physiologically different in a number of ways. Anthropometric studies have shown considerable differences in the foot bones of both genders. These differences could potentially mean different foot pressures in men and women. The aim of our study was to investigate any potential foot pressure differences between males and females using the Pedar-M (Novel gmbh, Germany) in-shoe foot pressure measurement system. Twenty-eight subjects (16 females and 12 males) were recruited. Peak pressure, contact area, contact time, pressure-time integral, force-time integral, instant of peak pressure, maximum force and mean force were recorded and subsequently analysed. In males, contact area was significantly larger in all regions of the foot compared with females. There were no significant between gender differences in peak pressure, contact time, pressure-time integral and instant of peak pressure. Force-time integral was significantly greater in males than females under the 1st, 3rd, and 4th metatarsal heads. Maximum force was also significantly higher in males under the heel, 1st and 3rd metatarsal heads. Mean force was greater in males under the 3rd metatarsal head. There were no peak pressure differences; however the contact area of the male foot was larger than that in females.

Form and structure of the metatarsal head arch in adults. Ultrasonographic and podometric studies

Ultrasonic measurements (n = 172) and plantar pressure investigations (n = 119) are performed on the forefeet of healthy adults, in order to constitute a correlation between shape and function of the anterior metatarsal arch. The thickness of the sole of the foot has its maximum beneath the 2nd metatarsal head and its minimum beneath the 1st and 5th ray. The highest pressure values are found at the 2nd and 3rd metatarsal head. It is concluded that despite the arch like configuration of the forefoot there is no structural arch function. The biological principle of adequate padding of pressure points results-depending on the load-in a different thickness of the soft tissues of the sole of the foot. The higher pressure under the central metatarsal heads is accompanied by thicker soft tissue pads and a more dorsal position of these rays.

PLANTAR PRESSURE REDISTRIBUTION AFTER A HIGH AND LOW UNLOAD

The plantar soft tissue is the primary means of physical interaction between a person and the ground during locomotion. Dynamic loads greater than body weight are borne across the entire plantar surface during each step. However, most testing of these tissues has concentrated on the structural properties of the heel pad. The purpose of this study was to determine the material properties of the plantar soft tissue from six locations beneath: the great toe (subhallucal), the 1st, 3rd and 5th metatarsal heads (submetatarsal), the lateral midfoot (lateral submidfoot) and the heel (subcalcaneal). We obtained specimens from these locations from 11 young, non-diabetic donors; the tissue was cut into 2 cm×2 cm blocks and the skin was removed. Stress relaxation experiments were conducted and the data were fit using the quasi-linear viscoelastic (QLV) theory. To determine tissue modulus, energy loss and the effect of test frequency, we also conducted displacement controlled triangle waves at five frequencies ranging from 0.005 to 10 Hz. The subcalcaneal tissue was found to have an increased relaxation time compared to the other areas. The subcalcaneal tissue was also found to have an increased modulus and decreased energy loss compared to the other areas. Across all areas, the modulus and energy loss increased for the 1 and 10 Hz tests compared to the other testing frequencies. This study is the first to generate material properties for all areas of the plantar soft tissue, demonstrating that the subcalcaneal tissue is different than the other plantar soft tissue areas. These data will have implications for foot computational modeling efforts and potentially for orthotic pressure reduction devices.

The compressive material properties of the plantar soft tissue

The plantar soft tissue is the primary means of physical interaction between a person and the ground during locomotion. Dynamic loads greater than body weight are borne across the entire plantar surface during each step. However, most testing of these tissues has concentrated on the structural properties of the heel pad. The purpose of this study was to determine the material properties of the plantar soft tissue from six locations beneath: the great toe (subhallucal), the 1st, 3rd and 5th metatarsal heads (submetatarsal), the lateral midfoot (lateral submidfoot) and the heel (subcalcaneal). We obtained specimens from these locations from 11 young, non-diabetic donors; the tissue was cut into 2 cm×2 cm blocks and the skin was removed. Stress relaxation experiments were conducted and the data were fit using the quasi-linear viscoelastic (QLV) theory. To determine tissue modulus, energy loss and the effect of test frequency, we also conducted displacement controlled triangle waves at five frequencies ranging from 0.005 to 10 Hz. The subcalcaneal tissue was found to have an increased relaxation time compared to the other areas. The subcalcaneal tissue was also found to have an increased modulus and decreased energy loss compared to the other areas. Across all areas, the modulus and energy loss increased for the 1 and 10 Hz tests compared to the other testing frequencies. This study is the first to generate material properties for all areas of the plantar soft tissue, demonstrating that the subcalcaneal tissue is different than the other plantar soft tissue areas. These data will have implications for foot computational modeling efforts and potentially for orthotic pressure reduction devices.

Relationship between peripheral vascular disease and high plantar pressures in diabetic neuro-ischaemic patients

It has been shown that high foot pressure in diabetic patients plays a crucial role in plantar ulcer development. The purpose of the study is to analyze the relationship between foot arterial pressures and plantar pressures in diabetic patients with both peripheral neuropathy vascular disease. We have evaluated the relationship between foot arterial pressures and plantar pressure parameters (Peak Plantar Pressure, Foot-Floor Contact and Plantar Pressure Integral) in eleven diabetic patients with both peripheral neuropathy and peripheral vascular disease. Peripheral neuropathy was defined as a tuning fork score<4/8 measured at the great toe and internal malleolus with a Tuning fork (Rydel-Seiffer 128 Hz), the absence of both patellar and ankle reflexes and with a temperature discrimination more than +5 degrees C (Thermocross). The peripheral vascular disease (PVD) was evaluated by Doppler technique. Peak Plantar Pressure (PPP) and Foot-Floor Contact (FFC) were measured by Force-Sensing Resistive (FSR 174) sensors under the 1st, 3rd and 5th metatarsal heads as well as under the heel and big toe of both feet. The Plantar Pressure Integral (PPI) was defined by the integral of the pressure over the time. We have found significant relationship between plantar pressure parameters (PPP, FFC, and PPI) under the first metatarsal heads and Doppler arterial pressures of both tibial posterior and dorsalis pedis artery. However, there was no relationship between Doppler arterial pressures and plantar pressure parameters (PPP, FFC, PPI) under 3rd and 5th metatarsal heads or under both the heel and the big toe. According to our results, the peripheral vascular disease could contribute to the elevation of plantar pressures and to the prolonged duration of foot floor contact at each step in diabetic patients with both peripheral neuropathy and peripheral vascular disease. In such patients, severe ischaemia could lead to an increased risk of foot ulceration and consecutive lower extremity amputation.

The influence of a small insert, in the footbed of a shoe, upon plantar pressure distribution

INTRODUCTION:: A recent development in plantar pressure distribution research, has been the study of the effects of sensory input on pressure distribution. It has been suggested that proprioceptive and exteroceptive information received from the plantar surface of the foot plays an important role in adapting to high pressures in shoes. Robbins and Gouw (1991) suggested that surface irregularities should be added to the insoles of running shoes to gain correct sensory input. Hayda et al. (1994) found that placing a pad proximal to the metatarsal heads produced significant reductions in forefoot plantar pressures around the first and second metatarsal heads. A development by Villeneuve (1993), 'La Posteropodle', utilized a small insert to maintain postural equilibrium, by stimulating the mechanoreceptors in the plantar surface of the foot. The aim of this study was to measure changes in plantar pressure distribution using a small circular insert. METHODS:: Ten non-pathological male subjects were tested whilst walking, after one day of wearing a pair of oxfords (hard) and running shoes (soft), containing an insert of 4 mm in height placed on a 0.8 mm EVA insole. The foot was split into five sections: (1) midfoot, (2) first metatarsal head, (3) 2nd and 3rd metatarsal heads, (4) 4th and 5th metatarsal heads, (5) the phalanges. A PEDAR system (Novel GmbH) was used to collect in-shoe plantar pressure data, with data collections at the beginning and end of a working day. Subjects were tested under two conditions: (1) the insert 5 mm proximal to the metatarsal heads, between the 2nd and 3rd heads, (2) a control, with no insert. RESULTS:: Preliminary results indicate that whilst wearing a hard shoe the insert had the effect of shifting peak pressures from the first metatarsal head, to the area of the second and third metatarsal heads. Peak pressures were found to be lower with the insert present. This has not yet been tested for significance. With the running shoe there appeared to be no significant differences between conditions with and without the insert. There were also no differences between the beginning and end of the day, for both shoe types. DISCUSSION:: From the results it appears that the insert is successful in both shifting peak pressures from the medial to the lateral forefoot, whilst reducing peak pressures simultaneously. This was only evident in the hard shoe condition however, suggesting that the footbed of the running shoe was perhaps too soft to allow the insert to influence sensory input sufficiently. These findings indicate that there may be implications for the use of small orthotics. Further study is required, however, to fully substantiate this hypothesis.

The average pressure distribution of the diabetic foot: Can it be used as a clinical diagnostic aid?

INTRODUCTION:: The aim of this study was to investigate whether averaged data obtained from pressure distribution measurements could be used to distinguish differences between diabetic feet with normal and no sensation. The calculated parameters most sensitive to any differences were established, and the potential of the averaged maximum pressure picture as a quick recognition pattern of a neuropathic diabetic foot was assessed for clinical use. METHODS:: Dynamic pressure distribution data was collected from 56 diabetics using an emed SF2 platform. The first step method was used, and only one step per subject was recorded for this set of data. Each subject completed a questionnaire which included a grading of the sensitivity to vibration on the plantar surface of the foot evaluated by a clinician. The subjects were subsequently divided into four groups depending on this sensitivity, but only data from the two groups with normal (n=16) and no sensation (n=12) were evaluated in this study. Control data were obtained from two separate sources: for adults (n=40) using an emed SF4 platform and for teenagers (n=73) using a mini-emed platform. The groupmask evaluation program from the novel-win software and the average program from the novel-ortho software were used to evaluate the data. Each dynamic pressure distribution was automatically masked using the foot recognition algorithms of the 'novel' mask, which divided the foot into ten areas: the heel, midfoot, first, second, third, fourth and fifth metatarsal heads (MTH), hallux, second toe, and remaining toes. The parameters analysed for each of these masks included: the mean peak pressure, maximum force, contact time, beginning of contact time, pressure-time integral and force-time integral. RESULTS AND DISCUSSION:: The results showed clearly that both pressure and contact time are important parameters in differentiating a neuropathic from a non-neuropathic diabetic foot. Values of the maximum force in each area of the foot showed no difference between the two groups. Owing to the small sample sizes for the two diabetic groups the 95% confidence limits were relatively large, however, clear differences existed between the two sets of data for the mean peak pressure and the mean pressure-time integral for the total foot and the forefoot. Based upon this data, peak pressure values above 56 N/cm(2) for the 1st MTH, 46 N/cm(2) for the 3rd MTH, 35 N/cm(2) for the 4th MTH and 26 N/cm(2) for the 5th MTH, and pressure-time integrals above 31 Ns/cm(2) for the 1st MTH, 21 Ns/cm(2) for the 2nd MTH, 24 Ns/cm(2) for the 3rd MTH, 19 Ns/cm(2) for the 4th MTH and 12 Ns/cm(2) for the 5th MTH would suggest the possibility of a neuropathic diabetic foot. The averaged maximum pressure distribution picture for each group showed some differences between diabetic feet with normal sensation and those with no sensation. However, owing to the small size of the groups, it was felt that the averaged pressure pictures were, at the moment, limited in their use as a quick recognition pattern for the clinician. Although further data has already been collected and will be added to the databank in the near future. CONCLUSIONS:: These data show that averaged maximum pressure pictures alone do not provide sufficient information to differentiate clearly between a non-neuropathic and a neuropathic diabetic foot. Parameters obtained from the dynamic process, in particular, the pressure-time integral, must also be taken into account. It is anticipated that this work will be continued in order to investigate differences between other dynamic processes of potential importance, such as the location and speed of the gait line. ACKNOWLEDGEMENTS:: The authors would like to thank Dr M Morlock and Dr T Tsvetkova for the control data.

Observations concerning the transverse metatarsal arch

The existence of a transverse arch of the foot has been disputed in the past. In the present study, the alignment of the metatarsal heads was investigated by ultrasonography in 100 feet of healthy volunteers. In addition, plantar pressure measurements were performed with a capacitance sensor force plate. Ultrasonographic measurements in the weightbearing position showed the 2nd to 4th metatarsal heads in a more plantar position, compared to the 1st and 5th, which confirms there is not a transverse arch in the forefoot. Plantar pressure measurements revealed the maximum pressure during one gait cycle in the mid-forefoot, at the site of the 3rd metatarsal head. Significantly lower pressures were measured under the 2nd and 4th metatarsal heads, the lowest pressures occurred under the 1st and 5th metatarsal heads. In the present study, no anatomically or functionally relevant transverse arch was found. ‘Anterior flat foot’ is not a pathological condition and does not in itself require treatment.

Effect of metatarsal head resection for diabetic foot ulcers on the dynamic plantar pressure distribution

Diabetic neuropathic ulcers are thought to arise from repetitive injury during normal walking in areas of high plantar pressures. It has been suggested that metatarsal head (MTH) resection alleviates elevated pressures at the site of the ulcer and, thus, expedites healing and prevents recurrence. We investigated the effect of MTH resection on plantar pressure distribution and ulcer healing. Sixteen diabetic patients with neuropathic plantar ulcers present for a mean of 36 ± 28 weeks undergoing MTH resection were studied. Plantar pressure distribution was measured preoperatively and postoperatively using the EMED-SF pressure sensor platform (Novel, Munich, Germany). The data showed that 68.8% of the patients had mean peak plantar pressures (MPPs) elevated (greater than 500 kilopascal (kPA)) at sites of plantar ulceration. The MPPs following MTH resection were significantly reduced irrespective of the site (p = 0.002). There was maximal MPP reduction following the resection of the 1st MTH (70%) and a lower reduction with 2nd–3rd MTH (39.9%) and 4th–5th MTH (45.8%) resections. We found no significant transfer of pressure to adjacent metatarsal heads following resection of the 1st MTH (p = 0.87), 2nd–3rd MTH (p = 0.11), and 4th-5th MTH (p = 0.75). All patients achieved complete ulcer healing within 8 ± 2 weeks after surgery. We concluded that reduction of plantar pressure is crucial for plantar ulcer healing, and we have demonstrated definitively that MTH resection leads to reduced peak plantar pressure, thus, expediting ulcer healing.

Zur Klinik und Pathogenese der Morton'schen Krankheit

From experience with 58 own cases the authors found that Morton's metatarsalgia due to a sclerosing neuroma of the plantar digital nerve is very often not recognised for many years. As this painfull affection easily can be cured, the clinical symptoms and histological findings, the diagnostic steps and treatment are described and the etiology discussed. For the excision of the plantar digital neuroma, situated generally between 3rd and 4th metatarsal head, the dorsal web-splitting approach is preferred because of better scars and immediate weigt-bearing. The operation is performed on outdoor patients. There were no complications. The results of 35 operations two or more years back show immediate and complete relief of pain in 31 cases and significant but incomplete relief in 4 cases.