Medial Foot Research Articles

Effects of limb dominance on the symmetrical distribution of plantar loading during walking and running

The purpose of this study was to investigate the symmetry or asymmetry in the plantar pressure, foot axis angle and muscle mass of dominant and non-dominant legs. Sixty-eight able-bodied participants (age: 20 ± 1 years, height: 162 ± 8 cm, mass: 53 ± 7 kg, BMI: 20.63 ± 2 kg/m2) were recruited for the walking and running tests. All participants with right dominant feet, defined as the preferred leg when kicking a ball, were asked to perform four successful trials at their self-selected walking and running speeds after warm-up. FootScan force-measuring plate was utilized to collect plantar pressure and foot axis angle. The Tanita Segmental Body Composition Analyzer was used to measure the muscle mass of the lower limbs. The time-series parameters were checked using an open-source statistical parametric mapping 1d package. The result exhibited that the medial foot pressure of the dominant limb was higher than the non-dominant limb ( p < 0.05). Foot balance index range showed asymmetry in both walking and running tasks (absolute symmetry index <10%). There was no significant difference in muscle mass between the dominant and non-dominant lower limbs ( p = 0.79). The quantification of potential differences and asymmetries could provide implications for gait injury prevention and shoe design.

A Comparison of Arch Index, Foot Posture Index and Surgeon Observation for Foot Type Classification

Category:Basic Sciences/BiologicsIntroduction/Purpose:Foot morphology is a key aspect of patient evaluation. Individuals with Pes planus usually have medial foot pain; those with Pes Cavus commonly have pain over lateral foot. Foot Posture Index (FPI) is a qualitative measure that uses six specific physical exam parameters. Arch index (AI) is a quantitative measure in which the footprint is photographed and measured. Radiographs allow for visualization of the bone and used to directly measure parameters of foot morphology such as calcaneal pitch (CP). The purpose of this study was to determine the sensitivity and specificity of surgeon observation, FPI, and AI in determining foot type, with CP serving as the reference standard. Our hypothesis is that surgeon observation will be more sensitive and specific than FPI and AI for identifying foot type.Methods:Following institutional review board approval and informed consent, we examined 41 adults (82 Feet) (average age 37.8+-17.6 yrs.; range: 20 to 68 years old; 20F/21M) without history of prior foot or ankle injury. Subject evaluation included bilateral FPI exam, lateral and hindfoot standing radiographs, pedographs, and weightbearing photographs. Three authors were trained to perform standardized FPI assessments. The radiographs and photographs were presented in a randomized order to a board-certified foot and ankle orthopaedic surgeon to classify a foot as either planus, cavus or normal (Figure 1). Calcaneal pitch was measured for each foot by finding the angle between the inferior surface of the calcaneus and the supporting surface, with normal classified as 18°-32°, planus <18° and, and cavus>32°[2,3]. Arch index was calculated for each foot from pedograph, with normal classified as 0.21 to 0.28, planus < 0.21 and cavus >0.28.Results:The gold standard calcaneal pitch measurements identified 12 planus, 57 normal, and 13 cavus feet. Surgeon observation was the most sensitive for identifying planus feet and most specific for identifying cavus feet (Table 1). Arch index was the most sensitive for identifying cavus feet and most specific for identifying both planus and normal feet. FPI was most sensitive for identifying normal feet. The correlation between raw scores on the FPI and AI to CP were weak to moderate, -0.387 and -0.526, respectively (p<0.01).Conclusion:Surgeon observation is the only method that had a sensitivity over 0.50 for two different foot morphologies. FPI does not have the highest specificity for any particular foot type; however, a specificity of 0.844 and 0.971 for planus and cavus feet demonstrates that FPI is a suitable modality for evaluating pathologic morphology. Our specificity is close to a prior reported 0.932. These similarities in statistics reassure us that our methods are consistent with prior studies. Limitations of the study include small sample size and a single surgeon reviewing imaging.

Novel Hallux Valgus Cadaveric Model: Role of Ligament Damage and Tendon Pull in Recreating the Deformity

Category:Bunion; Midfoot/ForefootIntroduction/Purpose:Hallux valgus (HV) is of uncertain origin, which explains the plethora of treatment options available. In the last few years it has been shown that it is not a one plane deformity, but a multiplanar one. It is the authors belief that Hallux Valgus originates from instabilities located at medial ray joints. To be able to further understand this frequent pathology, a cadaveric model should be developed. Through specific and limited medial column ligament damage, a model was developed trying to obtain similar deformities to the ones observed in real life, i.e. first ray varus and pronation.Methods:7 fresh frozen lower leg specimens were used without evident foot and ankle pathology. Tibio-talar and talo-navicular joints were fixed. Luminous markers were attached to the medial and middle foot ray bones, including talus. A constant tibial axial load of 25 kg was used. Cyclic tibial rotation (to simulate gait phases) and 5 kg pull on the extensor and flexor hallucis tendons (EHL and FHL) were applied to every specimen. Limited and sequential medial and middle column ligamentous sectioning were performed, including the naviculocuneiform, intercuneiform, metatarsocuneiform, metatarsophalangeal medial capsule and intermetatarsal ligaments. After each ligament damage, 3D bony alignment was registered using high speed high definition infrared cameras.Results:After ligament sectioning, an increase in intermetatarsal angle was observed of 2.5 degrees (range 0.8-5) (p=0.001), with 1 degree (0-3) (p=0.02) of further increase when Hallucis tendons pull was applied. Intercuneiform angle increased 2.3 degrees (0- 6) (p=0.01), with no change with tendons pull. Regarding bone rotation, the metatarsal pronated in relation to the navicular (metatarso-navicular angle) 6.3 degrees (3-20) (p=0.015) and the cuneiform pronated in relation to the navicular (naviculo- cuneiform angle) 3.3 degrees (0.5-6) (p=0.005). At the metatarso-cuneiform joint, a non-significant rotation was identified (1 degree (p=0.39). Hallucis tendons pull did not significantly affect any rotation angle. An evident hallux valgus deformity could be created, which further deformed with hallucis tendons pull.Conclusion:After sequential medial and middle ray ligament sectioning, a progressive and simultaneous increase in medial column varus and pronation were observed. Hallucis tendons pull, increased the medial column varus, but appeared not to play a role in bone rotation. Bone rotation occurs along the medial column joints, not isolated to the tarsometatarsal joint. Progressive medial ray ligamentous sectioning was able to recreate a Hallux valgus deformity, including medial ray varus and pronation.

A rare lumbar pyogenic spondylodiscitis caused by staphylococcus caprae with initial misdiagnosis: case report and literature review

BackgroundStaphylococcus caprae (Sc) is an uncommon causative organism for human. Lumbar pyogenic spondylodiscitis (LPS) of Sc is extremely rare and only a few cases have been reported. As far as we know, there is no specific literature on the diagnosis and treatment for LPS of Sc with L5 nerve root irritation.Case presentationA 65-year-old male patient complained of chronic low back pain for 10 years, acute worsening with radiating pain to left lower extremity over a month. Physical examination revealed tenderness point on his low back, 3/5 dorsiflexor strength in his left 1st toe and decreased sensation of pin prick over the left lateral shank and medial dorsal foot. The individual was initially misdiagnosed with lumbar disc herniation (LDH) without further examination in outpatient, which was then found to be LPS of Sc with L5 nerve root irritation after admission to our hospital. Magnetic resonance images (MRI) of lumbar spine exhibited inflammation signal at L4-L5 level of the vertebral body and disc with hypointense on T1-weighted images (T1-WI) and hyperintense on T2-weighted images (T2-WI). The causative organism was confirmed by the culture of irrigation fluid obtained from L5 vertebrae by needle puncture. After systemic conservative treatment including using sensitive antimicrobial agents and immobilization, the rare infection was finally cured. The patient also showed a satisfactory recovery during the 36-month follow-up period.ConclusionsConfirming the diagnosis and identifying the causative organism as soon as possible is the key point for the treatment of LPS. LPS of Sc causing nerve root irritation is rare but curable with early diagnosis and proper therapy. The culture of irrigation fluid obtained from vertebrae by needle puncture may be an effective and sensitive attempt for potential infection of spine to identify the causative organism at early stage of the disease.

Flatfoot and associated factors among Ethiopian school children aged 11 to 15 years: A school-based study.

The Foot health of a child plays a pivotal role in their participation in play, locomotive activities, healthy lifestyle, somatic development, and weight management. The burden of flatfoot among children in Ethiopia is not known. The objective of this study was to analyze the structure of the medial foot arch using Staheli plantar arch index and investigate its associated factors among larger sample school children, aged 11-15 years in Ethiopia. A school-based cross-sectional study was conducted among children aged 11-15 years from eleven randomly selected primary schools. The sample size was determined proportionally across school strength and governmental and private schools to ensure variety within the sample. Data collection consisted of physical measurements, footprint-based measures whilst full weight-bearing, and a structured questionnaire on foot pain, footwear type, and physical activity. Data were analyzed descriptively and through uni- and multivariate logistic regression model. A total of 823 children participated. The overall prevalence of flatfoot was 17.6% with a significant difference between age, gender, type of school, BMI, and type of footwear. Being younger (OR 3.3, 95% CI 1.6-6.7), male (OR 1.6, 95% CI 1.0-2.4), experiencing foot pain (OR 1.9, 95% CI 1.0-3.5), wearing closed shoe (OR 4.4, 95% CI 1.6-11.9), overweight (OR 3.8, 95% CI 1.2-8.7), obese (OR 4.2, 95% CI 2.5-10.9), and low level of physical activity (OR 2.1, 95% CI 1.0-4.6) were significantly associated with flatfoot. Children who were overweight, obese, and also experiencing foot pain have a 2.8 (95% CI 1.62-5.94) and 4.1 (95% CI 2.85-8.31) times greater chance of having flatfoot respectively. The prevalence of flatfoot among 560 normal weight children was 17.5%. The findings of this study demonstrated that the overall prevalence and the prevalence of flatfoot among normal-weight children are almost the same. There is a definite need to develop a screening algorithm for diagnosis and treatment indication for this children's lower extremity disorder.

The effect of continuous diffusion of oxygen treatment on cytokines, perfusion, bacterial load, and healing in patients with diabetic foot ulcers

To evaluate continuous diffusion of oxygen therapy (CDO) on cytokines, perfusion, and bacterial load in diabetic foot ulcers we evaluated 23 patients for 3 weeks. Tissues biopsies were obtained at each visit to evaluate cytokines and quantitative bacterial cultures. Perfusion was measured with hyperspectral imaging and transcutaneous oxygen. We used paired T tests to compare continuous variables and independent T tests to compare healers and nonhealers. There was an increase from baseline to week 1 in TGF‐β (P = .008), TNF‐α (P = .014), VEGF (P = .008), PDGF (P = .087), and IGF‐1 (P = .058); baseline to week 2 in TGF‐β (P = .010), VEGF (P = .051), and IL‐6 (P = .031); and baseline to week 3 with TGF‐β (P = .055) and IL‐6 (P = .054). There was a significant increase in transcutaneous oxygen after 1 week of treatment on both medial and lateral foot (P = .086 and .025). Fifty‐three percent of the patients had at least a 50% wound area reduction (healers). At baseline, there were no differences in cytokines between healers and nonhealers. However, there was an increase in CXCL8 after 1 week of treatment (P = .080) and IL‐6 after 3 weeks of treatment in nonhealers (P = .099). There were no differences in quantitative cultures in healers and nonhealers.

Flatfoot or not: subjective perception of the height of the feet arch among orthopedists

Background. The visual assessment of flatfoot is the most commonly used method by pediatric orthopedists. It is necessary to confirm good consistency among specialists to justify its use as a standard.&#x0D; Aim. The aim of this study was to determine the consistency of visual assessment of flatfoot among orthopedists.&#x0D; Materials and methods. The first stage of this study included 187 primary school-aged children. The main methods used were clinical examination and computer plantography. Then, 130 images of the right foot were randomly selected in standard projections medial and posterior, which were provided to 32 orthopedists (ten of whom were experts). Specialists needed to note whether the foot presented for analysis was flat. We used the w-Kendall concordance coefficient and -Kendall correlation coefficient to determine the inter-rater reliability. After five months, the intra-rater reliability was determined, and the Cohen coefficient was calculated.&#x0D; Results. Our study demonstrated that the inter-rater reliability varied significantly depending on whether the orthopedist specialized in foot pathology. When calculating the concordance coefficient, an increase in the consistency among experts was noted after five months (0.58 and 0.76, respectively), compared with orthopedists who do not specialize in foot pathology. Although some heterogeneity was noted according to experts on the same foot, the overall correlation coefficient corresponded to a good and excellent level of consistency (0.650.84). Cohens coefficient among specialists corresponded to a good level of confidence (0.72), whereas among orthopedists who do not specialize in foot pathology, there was a low level of confidence (0.31). According to experts, the frequency of flatfoot was 24.6%, whereas according to orthopedists who do not specialize in foot pathology, it was 40.9% when they evaluated images of the same feet.&#x0D; Conclusion. Experts answers regarding which foot should be considered flat demonstrated a good and excellent level of consistency. Therefore, they can be used to determine reference values of anthropometric parameters of the medial foot arch.

Hinged multiperforator-based extended dorsalis pedis adipofascial flap for dorsal foot defects.

BackgroundAdipofascial flaps covered with a skin graft address the challenges involved in reconstructing dorsal foot defects. The purpose of this study was to describe a large adipofascial flap based on the perforators of the dorsalis pedis artery for large foot defects.MethodsTwelve patients aged 5–18 years with large soft tissue defects of the dorsal foot due to trauma were treated with an extended dorsalis pedis adipofascial flap from May 2016 to December 2018. The flap was elevated from the non-injured half of the dorsum of the foot. Its length was increased by fascial extension from the medial or lateral foot fascia to the plantar fascia to cover the defect. All perforators of the dorsalis pedis artery were preserved to increase flap viability. The dorsalis pedis artery and its branches were kept intact.ResultsThe right foot was affected in 10 patients, and the left foot in two patients. All flaps survived, providing an adequate contour and durable coverage with a thin flap. Follow-up lasted up to 2 years, and patients were satisfied with the results. They were able to wear shoes. Donor-site morbidity was negligible. Two cases each of partial skin graft loss and superficial necrosis at the tip of the donor cutaneous flap occurred and were healed by a dressing.ConclusionsThe hinged multiperforator-based extended dorsalis pedis adipofascial flap described herein is a suitable method for reconstructing dorsal foot defects, as it provides optimal functional and aesthetic outcomes with minimal donor site morbidity.

Magnetic Resonance Imaging: Marrow Edema Patterns in Chronic Foot Pain

Objectives: The objective of the study was to determine whether there are specific magnetic resonance (MR) marrow edema patterns in patients with chronic foot pain and whether the individual small bones contribute significantly to pain. Material and Methods: A total of 153 symptomatic consecutive MR studies of patients with chronic foot pain and altered bone marrow signals of the foot and ankle were included in the study. Patients were placed into subgroups based on medial, central, or lateral marrow edema patterns. All cases with a clinical history or MR features of trauma, infection, inflammatory diseases, and tumors were excluded from the study. Statistical analysis was conducted to determine whether the marrow edema in each small bone of the subgroup was significant for the contribution of pain. Results: There were 84, 41, and 28 cases (153 patients) for the medial, central, and lateral marrow edema subgroups, respectively. The medial talus and medial and lateral sesamoid bones achieved statistical significance for an association between pain and marrow edema on MR images. Of the central group, sinus tarsi was statistically significant as a contributor of pain. None of the lateral bones were statistically significant as contributors of pain. Conclusion: Abnormal bone marrow edema patterns of the foot including the ankle on MRI fall into specific patterns of the medial, central, and lateral foot. This could be attributed to altered mechanical weight-bearing axis. The normal mechanical weight-bearing axis for the purpose of this study was along the long axis of the 2nd metatarsal, akin to the underlying seen in March fractures. The medial bone marrow edema was deemed to be a result of medial deviation of the normal mechanical weight-bearing axis, resulting in the marrow edema from the abnormal stress forces. The bone marrow edema pattern along the 2nd metatarsal was considered on the basis of excessive mechanical stress forces. The marrow edema pattern along the lateral foot, 4th and 5th metatarsals, and the lateral talus, calcaneus, and cuboid, was considered as a lateral deviation of the normal axis resulting in the abnormal stress and marrow edema pattern within these bones. By defining bone marrow edema patterns, we can assist orthopedic surgeons, physiatrists, and physiotherapists to provide appropriate corrective treatment including orthotics and physiotherapy. These MR features can also provide a baseline to monitor interval improvement after the application of the corrective measures.

MRI appearance of jogger's foot.

To characterize the MRI findings present in patients with clinically proven or suspected jogger's foot. Ten years of medical charts in patients clinically suspected of having jogger's foot and who had MRI studies completed were identified utilizing a computer database search. Six study cases were identified. The MRI examinations of the study cases and an age- and gender-matched control group were reviewed in a blinded fashion by two musculoskeletal radiologists. Size and signal intensity of the medial plantar nerve were measured and characterized. The medial foot musculature was assessed for acute or chronic denervation changes. The medial plantar nerve was found to have moderately increased T2 signal compared with normal skeletal muscle in 3/6 study group cases and markedly increased T2 signal in the remaining 3/6 cases. In all control cases, the nerve was reported to have T2 signal equal or minimally higher than normal skeletal muscle. The mean total size of the medial plantar nerve was significantly larger in the study group when compared with that in the control group at all measured locations (p < 0.04). Abnormal thickness and T2 hyperintensity of the medial plantar nerve centered at the master knot of Henry are characteristic MRI findings in patients with jogger's foot when compared with control subjects. Muscular denervation changes may also be seen, most commonly in the flexor hallucis brevis muscle.

Major factors influencing rearfoot external eversion moment during barefoot walking

BackgroundExcessive rearfoot eversion motion during walking has been considered as a risk factor for lower limb chronic injuries. External moment due to ground reaction force (GRF) is the essential cause by which the rearfoot is passively everted during walking. Research questionThis study aims to identify the key factors influencing the rearfoot external eversion moments due to the GRF during walking. MethodsFrom 3-D foot coordinates and GRF data of 29 healthy participants during walking, the rearfoot external eversion moments due to the GRF and factors composing the moment (height of the ankle joint center, mediolateral GRF, mediolateral distance of the center of pressure relative to the ankle joint center in the transverse plane, vertical GRF) were computed. ResultsThe mediolateral GRF was a key factor influencing the magnitude of the rearfoot external eversion moment just after foot contact, with which pre-contact medial foot velocity was significantly correlated. During the subsequent support phase, the mediolateral distance of the center of pressure (the application point of the vertical GRF) relative to the ankle joint center was also found to be another determinant of the magnitude of the rearfoot external eversion moment. SignificanceWe succeeded in demonstrating the specific factors that most likely explain the magnitude of the rearfoot external eversion moment during initial contact and the subsequent support phase during walking. Based on the findings, specific measures to suppress the rearfoot external eversion moment could be proposed.

Differences in loading patterns between fast walking and jogging at the same speed in male adults

Fast walking and jogging are two common exercises for people to maintain health in daily life. But the differences in loading patterns of fast walking and jogging are still unclear. The purpose of this study was to compare loading patterns in fast walking and jogging at the same speed, and to identify how differences in foot mechanics influence plantar pressure distribution between the two modes of gait. Totally, 49 healthy males participated in this study. Data of pressure parameters, including maximum force (MF), peak pressure (PP), contact area (CA), force-time integral (FTI), were recorded by Pedar-X insole plantar pressure measurement system in participants’ fast walking and jogging process at 7 km/h. A Load transfer analysis method was used to quantify the plantar load transference from fast walking to jogging. The results showed that MF, PP and CA increased in metatarsal regions and midfoot regions while decreased in toes regions and heel during jogging when compared with fast walking. FTI decreased in all foot regions during jogging compared to fast walking. Under the effects of spring mechanics and the varus of rearfoot during jogging, fast walking and jogging reveal different loading patterns. Compared jogging to fast walking, load transferred as follow: 1) in transverse direction, load transferred from lateral foot to medial foot in metatarsal regions and midfoot regions, 2) in longitudinal direction, load transferred from toes to the metatarsal, and from heel to the metatarsal and midfoot. These results also provide suggestions for footwear designs.Graphical abstract

Combined Lateral Calcaneal Lengthening Osteotomy and Dynamic Soft Tissue Reconstruction of Medial Foot in Adolescent Flexible Flatfoot

Combined Lateral Calcaneal Lengthening Osteotomy and Dynamic Soft Tissue Reconstruction of Medial Foot in Adolescent Flexible Flatfoot

Outcome of corrective osteotomy of shortened medial foot column after old talar neck fracture

To investigate the effectiveness of corrective osteotomy for shortened medial foot column after old talar neck fracture. The clinical data of 10 patients with shortened medial foot column after old talar neck fracture between June 2012 and May 2017 was retrospectively analyzed. There were 7 males and 3 females with an average age of 45.8 years (mean, 21-67 years). The time from fracture to corrective osteotomy was 9-60 months (mean, 20.9 months). The preoperative visual analogue scale (VAS) score was 7.1±1.2, the American Orthopaedic Foot and Ankle Society (AOFAS) score was 48.5±12.3, and the short-form 36 health survey scale (SF-36) score was 46.7±10.5. All 10 cases received open wedge osteotomy of medial talus. Among them, 2 received subtalar fusion and Achilles tendon lengthening, 2 lateralizing calcaneal osteotomy, and 2 Achilles tendon lengthening. All incisions healed by first intention. All patients were followed up 13-72 months (mean, 38.0 months). The X-ray film showed that the angle between longitudinal axis of 1st metatarsal bone and talus increased from (-9.6±4.5) ° before operation to (1.3±2.7) ° at last follow-up ( t=16.717, P=0.000); the angle between longitudinal axis of calcaneus and tibia increased from (-12.0±7.4) ° before operation to (-1.5±4.8) ° at last follow-up ( t=5.711, P=0.000). At last follow-up, the VAS score, AOFAS score, and SF-36 score were 1.6±1.0, 88.3±5.4, and 85.4±9.2, respectively, which increased significantly when compared with the preoperative scores ( t=13.703, P=0.000; t=14.883, P=0.000; t=16.919, P=0.000). X-ray film and CT showed that the osteotomy and arthrodesis sites healed well at 2-4 months after operation. It's a proper procedure of anatomic reduction and reconstruction for patients with shortened medial foot column and good articular cartilage morphology after old talar fracture. Opening wedge osteotomy of medial talus is recommended and can obtain satisfactory clinical and radiographic results.

Fluid around the distal tibialis posterior tendon on ankle MRI: prevalence and clinical relevance.

It has been stated that the distal 1-2 cm of the tibialis posterior tendon (TPT) does not have a tendon sheath but rather a paratenon, and that any fluid seen around this segment on ankle MRI is considered to represent paratendonitis. The prevalence and clinical significance of isolated TPT paratendonitis diagnosed on ankle MRI is unknown. This study aims to correlate the presence of isolated distal segment TPT paratendonitis on ankle MRI, with the presence or absence of medial midfoot pain. A retrospective database of 195 consecutive 3 T ankle MRI studies was assessed for the presence of isolated TPT paratendonitis. Relevant clinical notes were available in 159 of these cases, and were reviewed for the absence or presence of medial midfoot pain. Of 133 patients with both ankle MRI studies and clinical notes available, 53 (33.3%) patients had isolated TPT paratendonitis based on MRI. Of these, 37 (69.8%) had reported no medial foot pain on review of clinical records, while medial foot pain was recorded in 16 cases (30.2%). The comparison of TPT paratendonitis with clinically evident medial midfoot pain showed no statistically significant association (p = 0.19). Fluid signal intensity around the distal 1-2 cm of the TPT is a relatively common finding on ankle MRI. Therefore, care should be taken when reporting ankle MRI studies not to overstate the relevance of this finding. There was no statistically significant relationship between medial midfoot pain and the presence of isolated TPT paratendonitis.

2309 Vasculitic Mononeuritis Multiplex Mimicking Bilateral Carpal Tunnel Syndrome: A Diagnostic Challenge

INTRODUCTION: Cryoglobulinemic vasculitis(CV) can have variety of presentations including palpable purpura, arthralgias, glomerulonephritis, peripheral neuropathy, lymphadenopathy, hepatosplenomegaly, and hypocomplementemia. We present a patient with bilateral hand mononeuritis multiplex secondary to hepatitis C related CV. CASE DESCRIPTION/METHODS: A 52-year-old man with untreated hepatitis C (Viral load 520388, Genotype 1b), diabetes mellitus type II, hypertension and chronic kidney disease, presented with two months of bilateral hand pain. He also complained of numbness and tingling over the palmar aspects of the medial three digits of his hands, in addition to his medial left foot. He had no rash, arthritis, fevers, or weight loss. Physical exam was significant for positive Tinel's sign bilaterally, with weakness on finger extension, flexion and decreased power of interossei. Fundoscopy demonstrated non proliferative diabetic retinopathy (NPDR).Laboratory work-up revealed negative ANA, C-ANCA, MPO/PR3, HIV and RPR. Vitamin B12 and TSH levels were normal. However, serum cryoglobulins were positive with low C3, C4 and nephrotic range proteinuria Electromyography showed non-length-dependent neuropathy, which was more suggestive of mononeuritis multiplex rather than carpal tunnel syndrome (CTS). Sural nerve biopsy was performed and revealed vasculopathic changes consistent with vasculitis. He was diagnosed with mononeuritis multiplex secondary to hepatitis C related cryoglobulinemia. Immunosuppresive treatment was withheld because the patient tested positive for latent Tuberculosis (TB). He is currently undergoing treatment for the latent TB. DISCUSSION: CV is a small-to-medium-vessel vasculitis that occurs in 10 to 15 percent of patients chronically infected with hepatitis C virus (HCV). The two competing diagnosis for our patient’s neurological symptoms were diabetic neuropathy and CV secondary to untreated Hepatitis C. NPDR favored the microvascular complications of diabetes but the rapid onset of symptoms, positive cryoglobulins in the setting of HCV infection and sural nerve biopsy helped to establish the diagnosis of CV. This case is especially unique because it’s a very rare extrahepatic manifestation of HCV infection .Management of HCV cryoglobulinemic vasculitis involves administration of immunosuppressive therapy such as rituximab and antivirals but all patients should be tested and treated for latent TB prior to treatment initiation.

Effects of Kinesio tape on supporting medial foot arch in runners with functional flatfoot: a preliminary study

ABSTRACTThis study aimed to evaluate the anti-pronation effects of Kinesio tape on flexible flatfoot during running. Nine volunteers participated in a crossover trail of two conditions: with Kinesio tape (KT) or without taping (NT). The running consisted of 9 stages of different inclines on a treadmill over 28 minutes. Navicular drop distance (NDD) was measured before and after the running. Electromyography, the relative plantar pressure, Rating of Perceived Exertion and Visual Analogue Scale were recorded at each stage. After the application of Kinesio tapes over the tibialis posterior and transverse arch, the NDD reduced significantly and the relative posterior pressure reduced during stage 8. Without taping, the NDD decreased slightly after exercise. Comparing between conditions, the tibialis anterior were more activated with Kinesio tape in stages 4 and 5. During the latter half of the running, the medial gastrocnemius and peroneus longus reduced their activity in the KT and NT conditions respectively. In conclusion, the Kinesio tapes intended to facilitate the tibialis posterior and reinforce the transverse arch can reduce NDD in individuals with flexible flatfoot immediately after application, and increase muscle activity of their tibialis anterior during the first 15 minutes of the running.

(386) Medial Foot Column Disorders (Morton's and Rothbart's): Endemic, Underdiagnosed, and Undertreated

From Sept. 2016-Sept. 2018, 214 consecutive pats underwent a complete evaluation by both an MD and a Board Certified Myofascial Trigger point Therapist at one pain clinic. Of the 214, 133 pts (62%) had a medial foot column disorder ranging form Morton's Toe (short first metatarsal or primus metatarsus elevatus) to Rothbart's Foot (incomplete unwinding of talus). The most common complaints of the 133 pts were back pain in 37 and leg, knee, or hip pain in 29. Only 14 pts had foot pain, 5 of whom also had peripheral neuropathy. The mean age of pts was 52 yrs (13-81) and the female to male ratio was 3:1. The first metatarsal deficit (FMD) was measured using Rothbart's microwedges with the foot in subtalar neutral position. Ten pts had an FMD up to 14 mm and were considered to have mild Morton's Toe deformity. The other 123 pts (92%) had an FMD > 14 mm and were diagnosed with Rothbart's Foot Structure, all of whom also had a short first metatarsal. In the latter group 3 pts had an FMD > 20mm, consistent with pre-clinical clubfoot disorder. Pts were treated with antipronation posture congtrol insoles (PCIs 3.5, 6,or 9mm depending on FMD). Arch suppports and heel lifts were added if leg length discrepancy or pes planus was present. Medial foot column disorders are extremely common and lead to callouses, bunions, neuromas, hammer toes and even knee and hip arthritis. We are unaware of any commercial shoe or orthotic that can remedy hyperpronation at the forefoot as well as can inexpensive PCIs. No pain/posture evaluation is complete without a barefoot, standing evaluation of the feet. Earlier diagnosis and treatment of these disorders is mandatory, especially in children and athletes, in order to avoid complications requiring surgical intervention.

The peroneus longus muscle and tendon: a review of its anatomy and pathology.

This article will review the anatomy and common pathologies affecting the peroneus longus muscle and tendon. The anatomy of the peroneus longus is complex and its long course can result in symptomatology referable to the lower leg, ankle, hindfoot, and plantar foot. Proximally, the peroneus longus muscle lies within the lateral compartment of the lower leg with its distal myotendinous junction arising just above the level of the ankle. The distal peroneus longus tendon has a long course and makes two sharp turns at the lateral ankle and hindfoot before inserting at the medial plantar foot. A spectrum of pathology can occur in these regions. At the lower leg, peroneus longus muscle injuries (e.g., denervation) along with retromalleolar tendon instability/subluxation will be discussed. More distally, along the lateral calcaneus and cuboid tunnel, peroneus longus tendinosis and tears, tenosynovitis, and painful os peroneum syndrome (POPS) will be covered. Pathology of the peroneus longus will be illustrated using clinical case examples along its entire length; these will help the radiologist understand and interpret common peroneus longus disorders.

Foot Morphology in Chinese Adolescents Aged Between 13 to 18 Years Varies by Gender and Age.

BackgroundWe recently reported age and gender differences in foot shape and size in Chinese school children aged between 7–12 years. This study aimed to analyze age and gender differences in foot shape and size in Chinese adolescents aged between 13–18 years.Material/MethodsThe study included 1,252 adolescent boys and 1274 adolescent girls from seven regions in China. Twelve measurements of foot shape were recorded using a video filming system. One-way analysis of variance (ANOVA) compared the changes in the measurements with age. An independent t-test was used to analyze gender-associated differences in foot size and shape.ResultsIn adolescent boys, foot length and width increased significantly at 13–14 years and heel width, arch height, and fifth metatarsal head height increased until 18 years (P<0.05). In adolescent girls, most foot measurements ceased to increase after 15 years, except for arch height. Adolescent boys showed significantly larger foot length, width, height, and girth compared with adolescent girls (P<0.05) (Cohen’s d effect size >0.8). Adolescent boys showed a significant increase in ball width and girth, and instep length and height compared with adolescent girls, who had a longer medial foot length and higher fifth metatarsal head height compared with adolescent boys (P<0.05) (Cohen’s d effect size >0.5).ConclusionsAge and gender associated differences were found in foot measurements in Chinese adolescents, aged between 13–18 years. These differences should be considered by shoe manufacturers and when making clinical decisions about normal foot development.