Symptomatic Limb Research Articles

The Use of Laser Therapy in the Management of Chronic Plantar Heel Pain

Purpose: To compare the efficacy of laser therapy versus conventional treatment (stretching exercises and silicone heel cups) for the short-term management of CPHP. Methods: A case-control study was carried including 18 participants with 26 symptomatic limbs with CPHP. Each participant received one of two treatments; laser therapy or conventional treatment Progress was monitored using two pain scales; VAS pain scale and the Foot Function Index where participants were asked to rate their pain at the start of the study (Time 0) and after 3 weeks (Time 1). Results: Both treatment options showed a significant reduction in pain scores (p<0.05) however, when comparing both treatment options, a significant difference (p<0.05) in mean pain score was found with the laser therapy being more effective treatment option for the short-term management of CPHP. Conclusion: Laser therapy, when compared to conventional treatment, is a better short-term treatment option for the management of CPHP. Further research in this area is warranted to ensure best patient care, to further clarify long-term efficacy and optimal treatment parameters of Laser Therapy.

Predictors of recurrence after paclitaxel drug-coated balloon use for treating femoropopliteal in-stent restenosis.

Paclitaxel drug-coated balloon (PDCB) angioplasty has been shown to be an effective treatment of in-stent restenosis (ISR) at the femoropopliteal (FP) arteries. Long-term studies, however, have shown a progressive decrease in the patency rates following PDCB. The aim of this study was to determine the predictors of stenosis recurrence after PDCB treatment of FP-ISR, and its immediate and mid-term outcomes. This prospective, non-randomized study included all chronic lower extremity ischemia patients of Rutherford class 3-6 who underwent PDCB angioplasty to treat >50% FP-ISR between June 2017 and December 2019. The primary endpoint was primary patency, defined as freedom from binary restenosis and freedom from clinically driven target lesion revascularization (CD-TLR) at 12 months. Secondary endpoints included 12-months freedom from CD-TLR and major adverse events (MAEs). A total of 73 symptomatic chronic limb ischemia patients (73 limbs including 63 with limb threatening ischemia) underwent PDCB angioplasty of FP-ISR lesions (13.7% Tosaka class I, 54.8% class II, and 31.5% class III). The mean ISR lesion length was 121.8 ± 52.7mm. Technical success was achieved in 70 (95.9%) patients. Kaplan-Meier estimate of the 12-months rates of primary patency and freedom from CD-TLR was 76.1% and 87.4%, respectively. At one year, MAEs occurred in eight patients (11.0%) including two deaths (2.7%), one major amputation (1.4%), and six (8.2%) surgical revascularizations. Multivariable analysis showed that Tosaka class III ISR (HR 4.51, CI: 1.31-15.53, p < 0.001) and reference vessel diameter (HR 0.38, 95% CI: 0.18-080, p = 0.01) were independently associated with recurrent ISR. PDCB is safe and effective treatment of FP-ISR lesions. Occlusive ISR lesions and reference vessel diameter were independently associated with recurrent ISR stenosis after PDCB treatment.

Association between the Strength of Flexor Hallucis Brevis and Abductor Hallucis and Foot Mobility in Recreational Runners

Different measurements of foot morphological characteristics can effectively predict foot muscle strength. However, it is still uncertain if structural and postural alterations leading to foot pronation could be compensated with more efficient function of the intrinsic foot muscles and how mobility and strength are associated. Additionally, the relationship between foot mobility and the strength of the intrinsic muscles that control the foot arch is still unclear. Therefore, this study aimed to investigate the morphological parameters between dominant and non-dominant feet and the relationship between the intrinsic foot muscle strength and foot mobility in recreational runners. We used a cross-sectional study design to evaluate twenty-four healthy recreational runners (minimum 15 km/week) with an average training history of 70 ± 60 months. Foot Posture Index (FPI-6), isometric intrinsic muscle strength, overall morphology, and normalized mobility of both feet were assessed. Parametric tests analyzed the unidimensional measures, and paired analysis determined differences between dominant and non-dominant sides. Pearson’s and Spearman’s correlation coefficients determined the relationships between normalized strength and the variables of interest (CI = 95%). There was no significant association between intrinsic foot muscle strength and mobility. The only difference observed was between the dominant and non-dominant foot regarding the normalized foot length and midfoot width during non-weight-bearing, with small and medium effect sizes, respectively. Neither foot morphology nor foot mobility was associated with strength from intrinsic foot muscles in healthy recreational runners. Further work should explore the relationship investigated in our study with professional athletes and runners with symptomatic lower limb injuries to potentialize training and rehabilitation protocols.

Genetic Diversity and Fungicide Sensitivity of Cytospora plurivora on Peach.

Cytospora plurivora D.P. Lawr., L.A. Holland & Trouillas has been associated with recent premature peach tree decline in South Carolina, but very little is known about the pathogen or chemical control options. Ninety-three C. plurivora isolates were collected in 2016 and 2017 from 1-year-old peach wood and symptomatic scaffold limbs, respectively, from orchards in six towns in South Carolina. Six unique genotypes were identified based on substantial ITS1-5.8S-ITS2 sequence variability and classified G1 to G6. Three of the genotypes (G2, G3, and G6) were isolated in high frequency in multiple locations of both years. In addition to the genotypic variation, multiple phenotypes were observed between and within genotype groups. Species identity was determined using additional gene loci: ACT, TUB, and EF, and isolates were found to belong to C. plurivora for all genotype groups. All tested genotypes were sensitive to thiophanate-methyl (FRAC 1) but exhibited slightly lower sensitivity to propiconazole and difenoconazole (both FRAC 3). Boscalid, fluopyram (both FRAC 7s), azoxystrobin, and pyraclostrobin (both FRAC 11s) were ineffective in vitro at inhibiting mycelial growth of C. plurivora genotypes. Field inoculation of peach and nectarine trees revealed that all genotypes developed twig cankers with differences in virulence. G1 was most virulent, and G6 was least virulent. This study provides a link between the C. plurivora genetic variability and virulence and provides fungicide sensitivity information that could be used to improve disease management practices.

Weakness of lower limb muscle in symptomatic peripheral artery disease with media sclerosis detected by ultrasound shear wave elastography.

Background: Symptomatic peripheral arterial disease (PAD) is difficult to non-invasively diagnose in the presence of calcified, media sclerotic arteries that are incompressible by blood pressure cuffs. Standard ankle-brachial index (ABI) measurements in these PAD patients are very often not helpful. Shear wave elastography (SWE) is a modern ultrasound technique to detect peripheral muscle stiffness changes i.e. muscle weakness during exercise. In a pilot study, we examined whether SWE could be a reproducible tool for diagnosing ischemic loss of muscle stiffness in patients with PAD and concomitant arterial media sclerosis. Patients and methods: N=13 consecutive patients with peripheral artery disease and media sclerosis were enrolled in the pilot study. All 13 patients were symptomatic in different stages of their PAD due to hemodynamically relevant arterial stenosis or occlusions of limb arteries as confirmed by oscillography, color-coded duplex sonography or angiography. Results: ABI measurements were invalid in all 13 patients. Mean SWE measurements of medial gastrocnemius muscles showed a significant transient muscle stiffness loss (weakness) at maximum exercise (active dorsal flexion of the foot, 103.4±25.9 kPa on the asymptomatic vs. 62.5±21.9 kPa on the symptomatic limb (p<0.001). Conclusions: SWE can reproducibly detect peripheral muscle weakness during exercise in the symptomatic leg of media sclerotic PAD patients. SWE of lower limb muscles may help to identify symptomatic PAD in patients presenting with invalid ABI measurements and unclear vascular status.

Are static foot posture and ankle dorsiflexion range of motion associated with Achilles tendinopathy? A cross-sectional study

BackgroundSubtalar hyperpronation and ankle dorsiflexion restriction have been theoretically associated with Achilles tendinopathy (AT). However, evidence to support these associations is lacking. ObjectivesTo compare foot alignment and ankle dorsiflexion range of motion (ROM) between the symptomatic and non-symptomatic limbs of individuals with unilateral AT. And to verify whether differences exist between individuals with symptomatic pronated feet and individuals with symptomatic neutral/supinated feet in terms of tendon pain, structure, and symptom severity. MethodsSixty-three participants with unilateral AT underwent a bilateral evaluation of pain during tendon palpation, symptom severity, tendon thickening, tendon neovascularization, ankle dorsiflexion ROM, and foot posture alignment [foot posture index (FPI), navicular drop, navicular drift, and longitudinal arch angle (LAA)]. Side and group comparisons were made using t-tests and correlations were evaluated using the Pearson test. ResultsThere were no differences between the symptomatic and non-symptomatic limbs regarding foot posture alignment. Specifically, non-significant negligible differences were observed between limbs regarding FPI [mean difference (MD)=-0.23; 95% confidence interval (CI)=-0.70, 0.25), navicular drop (MD=0.58 mm; 95%CI=-0.25, 1.43), navicular drift (MD=0.16 mm; 95%CI=-0.77, 1.09), and LAA (MD=0.30º; 95%CI=-1.74, 2.34). There was no difference between limbs regarding ankle dorsiflexion ROM. However, lower ankle dorsiflexion was associated with worse symptom severity (r = 0.223). Finally, no difference was observed between individuals with symptomatic pronated feet and individuals with symptomatic neutral/supinated feet in terms of tendon pain or structure. ConclusionsStatic foot alignment measures do not seem to be clinically relevant in patients with AT. Smaller ankle dorsiflexion ROM, however, was associated with greater symptom severity in this population.

Subclavian angioplasty during coronary interventions using radial approach.

In the past years, the percentage of percutaneous coronary angiography and coronary interventions using radial access had significantly increased due to its higher safety, lower risk of major bleeding, and hence lower cardiovascular mortality. Subclavian artery stenosis is one of the challenges that may be met during transradial coronary interventions, which may necessitate femoral access crossover or conversion. To evaluate the feasibility and safety of performing subclavian angioplasty via radial access during complex coronary interventions using the forearm approach. A series of patients with complex radial approach due to subclavian stenosis received subclavian angioplasty during the procedure. We included 48 patients out of 22 500 procedures performed from February 2009 to February 2020. All patients did not have alternative vascular access due to extensive peripheral arterial disease (previous history of iliac stenting or distal aortic occlusion, which makes femoral access crossover difficult; also the contralateral radial/ulnar artery was very faint or not detectable at all). Mean age was 72 (10) years and 67% of patients were males. Subclavian angioplasty was successfully done in all patients via ipsilateral radial access; 44 patients (91.7%) required subclavian stenting, and 4 patients were treated by subclavian angioplasty without stenting. Coronary angiography or intervention was perfectly achieved through the revascularized subclavian artery; coronary stenting was successfully done in 36 patients as indicated. It can be concluded that percutaneous subclavian artery angioplasty can be done safely and effectively to facilitate complex transradial coronary procedures with an acceptable immediate technical success, especially in patients without alternative vascular access. Also, we may conclude that subclavian angioplasty may be successfully performed in patients with symptomatic upper limb ischemia, via the radial approach.

A cross-sectional study on coronary artery disease diagnosis in patients with peripheral artery disease

PurposeCompared with healthy individuals, patients with peripheral artery disease (PAD) generally have a very high risk of subclinical Coronary artery disease (CAD) and cardiovascular events. To determine the correlation between CAD in PAD patients, thereby promoting the lifetime of PAD patients and reducing the serious impacts of CAD. MethodsThis clinical-based cross-sectional study comprised 100 consecutive patients in India from 2014 to 2016. In this research, PAD patients were screened for CAD by treadmill stress test and cardiac colour Doppler examination. In addition, this study performed coronary angiography followed by peripheral angiography for patients who could not perform the treadmill test. ResultsWith the statistical results, the study observed a high prevalence of CAD in PAD patients that can be detected only with angiography. Further, 30.93% of asymptomatic CAD prevalence was observed in PAD patients. The study strengthens the need for coronary angiography in all symptomatic lower limb PAD cases to detect early CAD, particularly in patients with diabetes and dyslipidemia. ConclusionThere exists a strong correlation between PAD and CAD. Hence, precise diagnosis followed by supervision of PAD patients is significant for avoiding local progression of cardiovascular risk.

Hybrid Revascularization for Extensive Iliofemoral Occlusive Disease

Total occlusion of the iliac-femoral tract can cause a variety of life-limiting symptoms ranging from mild claudication to chronic limb-threatening ischemia. Efforts should be made to revascularize the symptomatic ischemic limb. Currently there are different options in the vascular surgeon's armamentarium to achieve this. The aim of the study was to verify the feasibility and outcomes of inflow hybrid revascularizations combining femoral endarterectomy and recanalization of iliac atherosclerotic occlusion. A retrospective review was conducted of all hybrid revascularizations involving femoral endarterectomy and endovascular treatment of iliac occlusion. The operations were performed in Helsinki University Hospital between January 2013 and December 2018. First, information about patients' baseline characteristics, indications and details of surgery and technical/hemodynamic success, and complications and mortality were obtained from the vascular registry and patients records. Secondarily, a prospective assessment of mid-term patency was performed through follow-up in November 2019. Immediate technical success, 30-day mortality, complications, and patency were considered major outcomes. Hemodynamic improvement, amputation rate, and overall mortality were also assessed. One hundred sixty three iliofemoral occlusions were performed on 147 patients during the period studied. Six patients (3.6%) had infrarenal aortic occlusion, 86 (52.7%) had common iliac, and 128 (78.5%) had external iliac artery occlusion. Technical success rate was 88.3% (n=144 occlusions recanalized). Primary technical success was somewhat lower in lesions ≥ 90mm (87.1%) compared to lesions shorter than 90mm (95.7%; χ2P=0.06). Iliac stent was deployed in 141 (94.6%) cases, 51 (34.3%) of which were covered stents. Significant residual stenosis remained in 1.2% of cases. Median operative time was 4hr 34min (interquartile range 2 hr 43min) and median estimated blood loss was 743mL (interquartile range 500mL). Five patients (3.0%) developed a deep groin infection and 12 (8.1%) suffered any major cardiovascular event or stroke perioperatively. Primary patency at 30day, 6months, 1 year, and 2years was 98.7%, 98.1%, 96.6%, and 93.7%, respectively. Hemodynamic success was documented in 107 patients (73%). By the end of the follow-up, 7 iliofemoral tracts (11.1%) reoccluded, 2 limbs (1.2%) required amputation, and 50 patients (3.0%) died. Good immediate success rate and mid-term patency can be achieved by hybrid revascularization of iliofemoral occlusions. Careful patient selection is mandatory because this population often suffers from universal atherosclerosis. The involvement of the aorta represents a significant determinant of worse long-term patency, although it did not preclude technical success.

The RANGER II superficial femoral artery trial: 1-year results of the long lesion cohort

Background:The objective of the RANGER II SFA long lesion cohort analysis was to evaluate the safety and effectiveness of the Ranger drug-coated balloon (DCB) in patients with lesion lengths greater than 100 mm.Methods:Patients from the RANGER II SFA randomized controlled trial and long balloon sub-study were included in the long lesion cohort if their baseline lesion measurement was > 100 mm and if they had been treated with a RANGER DCB. Patients had symptomatic lower limb peripheral artery disease and Rutherford classification 2–4 symptomatology. The endpoints of interest included the 12-month target lesion primary patency and freedom from major adverse events (MAEs).Additional patient outcomes including changes in Rutherford classification were also evaluated.Results:A total of 129 patients met the inclusion criteria and were included in the long lesion cohort. Mean lesion length was 144.5 ± 31.7 mm. Seventy-five lesions had Peripheral Arterial Calcium Scoring System (PACSS) grades 3 (33.3%, 43/129) and 4 (24.8%, 32/129). The Kaplan–Meier estimate of the primary patency rate at 12 months was 88.0%. The rate of freedom from MAEs at 12 months was 95.1% (117/123; 95% CI: 89.7%, 98.2%); all MAEs were clinically driven target lesion revascularization (4.9%, 6/123). The 12-month mortality rate was 2.4% (3/125).Conclusions:Patients with lesions > 100 mm treated with Ranger DCBs demonstrated excellent 1-year safety and efficacy results, comparable to those of the overall RANGER II SFA randomized clinical trial. This suggests that the Ranger DCB can provide consistent results regardless of lesion length. (ClinicalTrials.gov Identifier: NCT03064126)

Clinical Impact of Intravascular Ultrasound-Guided Fluoropolymer-Based Drug-Eluting Stent Implantation for Femoropopliteal Lesions.

Treatment with a fluoropolymer-based drug-eluting stent (FP-DES has been widely applied to the contemporary femoropopliteal practice with durable outcomes. Nevertheless, the impact of intravascular ultrasound (IVUS) utilization on clinical outcomes after FP-DES implantation has not been determined. This study aimed to investigate the impact of IVUS on 1-year clinical outcomes after FP-DES) implantation for femoropopliteal lesions in patients with symptomatic peripheral artery disease. As a subanalysis of the CAPSICUM (contemporary outcomes after paclitaxel-eluting peripheral stent implantation for symptomatic lower limb ischemia with superficial femoral or proximal popliteal lesion) study, the present investigation analyzed 1,091 patients with symptomatic peripheral artery disease who underwent endovascular therapy with FP-DES for femoropopliteal lesions. One-year clinical outcomes were compared between patients treated with IVUS and those treated without IVUS after propensity score matching. The primary outcome measure was 1-year restenosis. The incidence of aneurysmal degeneration was also assessed. A total of 843 (77.2%) patients underwent IVUS-guided FP-DES implantation. After propensity score matching, the 1-year restenosis was not significantly different between the groups (11.5% [95%CI: 9.1%-14.0%] vs 15.5% [95%CI: 10.9%-20.1%]; P=0.22). The frequency of aneurysmal degeneration at 1 year was significantly higher in the IVUS group than in the non-IVUS group (19.8% [95%CI: 16.3%-23.4%] vs 7.1% [95%CI: 3.3%-11.0%]; P< 0.001). IVUS use was associated with a lower restenosis risk in patients with chronic total occlusion but not in those without (Pfor interaction=0.044). The present study revealed that 1-year restenosis risk was not significantly different between the 2groups, whereas the incidence of aneurysmal degeneration was significantly higher in the IVUS group.

Regional shear wave elastography of Achilles tendinopathy in symptomatic versus contralateral Achilles tendons.

Ultrasound often corroborates clinical diagnosis of Achilles tendinopathy (AT). Traditional measures assess macromorphological features or use qualitative grading scales, primarily focused within the free tendon. Shear wave imaging can non-invasively quantify tendon elasticity, yet it is unknown if proximal structures are affected by tendon pathology. The purpose of the study was to determine the characteristics of both traditional sonographic measures and regional shear wave speed (SWS) between limbs in patients with AT. Twenty patients with chronic AT were recruited. Traditional sonographic measures of tendon structure were measured. Regional SWS was collected in a resting ankle position along the entire length of the tendon bilaterally. SWS measures were extracted and interpolated across evenly distributed points corresponding to the free tendon (FT), soleus aponeurosis (SA), and gastrocnemius aponeurosis (GA). Comparisons were made between limbs in both traditional sonographic measures and regional SWS. Symptomatic tendons were thicker (10.2 (1.9) vs. 6.8 (1.8) mm; p < 0.001) and had more hyperemia (p = 0.001) and hypoechogenicity (p = 0.002) than the contralateral tendon. Regional SWS in the FT was lower in the symptomatic limb compared to the contralateral limb (11.53 [10.99, 12.07] vs. 10.97 [10.43, 11.51]; p = 0.03). No differences between limbs were found for the SA (p = 0.13) or GA (p = 0.99). Lower SWS was only observed in the FT in AT patients, indicating that alterations in tendon elasticity associated with AT were localized to the FT and did not involve the proximal passive tendon structures. • Baseline characteristics of a pilot sample of 20 subjects suffering from chronic Achilles tendinopathy showed differences in conventional sonographic measures of tendon thickness, qualitatively assessed hypoechogenicity, hyperemia, and quantitative measures of shear wave speed. • Regional shear wave speeds were lower in the free tendon but not in the proximal regions of the soleus or gastrocnemius aponeuroses in Achilles tendinopathy patients. • Using shear wave imaging to estimate tendon stiffness may prove beneficial for clinical validation studies to address important topics such as return to activity and the effectiveness of rehabilitation protocols.

Anatomic Factors Contributing to External Iliac Artery Endofibrosis in High-Performance Athletes

External iliac artery endofibrosis (EIAE) classically presents in cyclists with intimal thickening of the affected arteries. We investigated possible anatomical predisposing factors including psoas muscle hypertrophy, arterial tortuosity, inguinal ligament compression, and arterial kinking via a case-control comparison of symptomatic and contralateral limbs. All patients with unilateral EIAE treated surgically at our institution were reviewed. Each patient's symptomatic side was compared with their contralateral side using paired t-tests. Psoas hypertrophy was quantified by the transverse cross-sectional area (CSA) at L4, L5, and S1 vertebral levels, and inguinal ligament compression was measured as the anterior-posterior distance between the inguinal ligament and underlying bone. Tortuosity index for diseased segments and arterial kinking were measured on TeraRecon. Of 33 patients operated on for EIAE from 2004 to 2021, 27 with available imaging presented with unilateral disease, more commonly left-sided (63%). Most (96%) had external iliac involvement and 26% had ≥2 segments affected: 19% common iliac artery, 15% common femoral artery. The symptomatic limb had greater mean L5 psoas CSA (1,450mm2 vs. 1,396mm2, mean difference 54mm2, P=0.039). There were no significant differences in L4 or S1 psoas hypertrophy, tortuosity, inguinal ligament compression, or arterial kinking. 63% underwent patch angioplasty, and 85% underwent additional inguinal ligament release. 84% reported postoperative satisfaction, which was associated with a greater difference in psoas hypertrophy at L4 (P=0.022). Psoas muscle hypertrophy is most pronounced at L5 and is associated with symptomatic EIAE. Preferential hypertrophy of the affected side correlates with improved outcomes, suggesting psoas muscle hypertrophy as a marker of disease severity.

Tendon loading in runners with Achilles tendinopathy: Relations to pain, structure, and function during return-to-sport.

We aimed to (1) compare pain, tendon structure, lower limb function, and Achilles tendon loads while running between limbs in runners with Achilles tendinopathy, and (2) explore the relations of pain, tendon structure, and lower limb function to Achilles tendon loads while running. Twenty runners with Achilles tendinopathy participated in this pilot study. Pain was assessed with questionnaires, quantitative sensory testing, and functional testing. Tendon morphology and mechanical properties were evaluated with ultrasound imaging, continuous shear wave elastography, and ultrasound imaging combined with dynamometry. Lower limb function was assessed with an established test battery. Achilles tendon loads were estimated from biomechanical data acquired during running. Compared to the least symptomatic limb, the most symptomatic limb had lower scores on the Victorian Institute of Sports Assessment - Achilles questionnaire and worse pain during drop countermovement jumping, hopping, and running. Tendon thickness and cross-sectional area were greater, and Young's modulus, drop countermovement jump height, and plyometric quotient during hopping were lower on the most symptomatic limb. Side-to-side differences in drop countermovement jump height were significantly associated with side-to-side differences in Achilles tendon peak forces and average loading rates during running. Various measures of pain, structure, and function differ between limbs in runners with Achilles tendinopathy during return-to-sport. Tendon forces, however, do not differ between limbs during comfortable running. In addition to measures that differ between limbs, measures of performance during drop countermovement jumping may aid in clinical decision-making during return-to-sport because they are associated with tendon forces while running.

One-year duplex ultrasound-assessed closure outcomes of percutaneous endovenous microwave ablation for the treatment of varicose veins of the lower limbs.

This study aims to investigate the safety and efficacy of a new device using microwave technology for the endovenous ablation of the great saphenous vein (GSV) causing symptomatic lower limb varicose veins (LLVV). This prospective, single-arm, single-center, cohort study investigated the safety and effectiveness of endovenous microwave ablation for the treatment of symptomatic LLVV. Enrollment period was set between January and December 2020. Primary safety endpoint was the occurrence of procedure-related complications and primary efficacy endpoint was anatomical success defined as the duplex ultrasound (DUS)-proven GSV occlusion at 1year follow-up. Secondary endpoints included 1-year clinical success (CEAP classification improvement), repeat procedures rate due to GSV recanalization, and pain assessment at 24h post treatment. In total, 50 patients (42 female; mean age: 62 ± 12years) with 64 limbs were treated. No procedure-related complications were noted. Technical success was 95.3% (61/64 GSVs), as three cases of GSV recanalization were detected. Clinical success was 100%, as in all cases symptoms improvement by at least one grade according to CEAP classification, was achieved. Mean CEAP grade significantly improved from 3.3 ± 0.72 (median: 3) at baseline to 1.8 ± 0.85 (median: 2) at 1-year (p < 0.0001). There were no repeat procedures due to GSC recanalization. The median 24-h VAS value was 2 (mean: 1.9 ± 1.4). Endovenous microwave ablation was safe and effective for the treatment of varicose veins, achieving high 1-year GSV occlusion rates.

Relationship Between the Severity of Exercise Induced Ischaemia and the Prevalence of Exercise Induced Calf Symptoms During Treadmill Testing With Transcutaneous Oximetry

It was hypothesised that there is a linear relationship between the severity of exercise induced calf ischaemia and the prevalence of calf claudication on a treadmill until a plateau is reached. It was expected that no pain would be present in the absence of ischaemia and all severely ischaemic calves would be symptomatic. This was a retrospective analysis of a cross sectional acquired database recording. Transcutaneous oxygen pressure (TcPO2) on the chest and on each calf was used to evaluate calf ischaemia during treadmill tests with simultaneous recording of calf pain in 7 884 subjects (15 768 calves). The minimum value of calf changes from rest minus chest changes from rest (DROPm) was calculated. Regression analyses were used to determine the correlation between the proportion of exercise induced symptoms present in the calves and each unit of DROPm values. Analysis was repeated after objective determination of the cutoff point between the linear increase and the plateau. A linear relationship was found between the degree of ischaemia and the proportion of symptomatic calves for DROPm values ranging from 0 mmHg to-28 mmHg (proportion=-0.014 × DROPm+ 0.32, r= 0.961, p <.001). For DROPm values lower than-28 mmHg (severe ischaemia), on average one of three limbs remained asymptomatic. The biphasic relationship between DROPm and prevalence of symptoms persists after exclusion of patients with diabetes mellitus, exercise induced hypoxaemia, and no evidence of lower extremity arterial disease (LEAD). The relationship between exercise induced pain and ischaemia is biphasic with a linear increase in the proportion of symptomatic limbs with ischaemia severity, until a plateau is reached for the more severely ischaemic limbs. The presence of exercise related calf symptoms should not automatically be reported as indicating the presence of LEAD; and the absence of exercise induced symptoms is not proof that ischaemia does not occur during exercise.

The impact of treatment of periodic limb movements in sleep on blood pressure in patients with and without sleep apnea

Improving sleep quality in patients with obstructive sleep apnea (OSA) by positive airway pressure therapy is associated with a decrease of blood pressure (BP). It remains elusive, whether treatment of sleep disturbances due to restless legs syndrome with symptomatic periodic limb movements in sleep (PLMS) affects BP as well. The present study provides first data on this issue. Retrospective study on patients undergoing polysomnography in a German University Hospital. Inclusion criteria were first diagnosis of restless legs syndrome with PLMS (PLM index ≥ 15/h and PLM arousal index ≥ 5/h) with subsequent initiation of levodopa/benserazide or dopamine agonists. Exclusion criterion was an initiation or change of preexisting positive airway pressure therapy between baseline and follow-up. BP and Epworth sleepiness scale were assessed at two consecutive polysomnographies. After screening of 953 PLMS data sets, 114 patients (mean age 62.1 ± 12.1 years) were included. 100 patients (87.7%) were started on levodopa/benserazide, 14 patients (12.2%) on dopamine agonists. Treatment was associated with significant reductions of PLM index (81.2 ± 65.0 vs. 39.8 ± 51.2, p < 0.001) and ESS (6 [interquartile range, IQR, 3–10.5] vs. 5 [IQR 3–10], p = 0.013). Systolic BP decreased from 132.9 ± 17.1 to 128.0 ± 15.8 mmHg (p = 0.006), whereas there was no significant change of diastolic BP (76.7 ± 10.9 vs. 75.1 ± 9.2 mmHg, p = 0.15) and heart rate (71.5 ± 11.9 vs. 71.3 ± 12.7, p = 0.84). The number of antihypertensive drugs remained unchanged with a median of 2 (IQR 1–3, p = 0.27). Dopaminergic treatment of PLMS is associated with an improvement of sleep quality and a decrease of systolic BP comparable to treatment OSA.

Relationship between hip muscle strength and hip biomechanics during running in people with femoroacetabular impingement syndrome

BackgroundHip muscle weakness and altered hip biomechanics during walking are often observed in people with femoroacetabular impingement syndrome, although little is known about biomechanics during higher impact tasks. The aim of our study was to explore relationships between hip muscle strength and hip biomechanics during running in people with femoroacetabular impingement syndrome, including exploring sex as an effect-modifier of this relationship. MethodsForty-two adults with unilateral femoroacetabular impingement syndrome (20 females; age 18-50 years; alpha angle ≥60°) completed assessments of hip muscle strength and hip biomechanics during running. Strength was assessed using a hand-held dynamometer for the hip flexors, extensors, abductors, adductors, internal rotators, and external rotators. Hip biomechanics were assessed during overground running (3–3.5 m/s) using three-dimensional motion capture and a force plate. Linear models assessed the relationships between hip strength and hip biomechanics of the symptomatic limb, controlling for body mass and running velocity along with an interaction term (strength*sex). FindingsA significant negative relationship was observed between hip external rotator strength and hip frontal plane range of motion (i.e., excursion), independent of sex (estimate = −0.039, 95%CI −0.071 to −0.008, P = 0.02). Four sex-specific interactions were observed, with a significant positive relationship between hip external rotator strength and peak hip extension moment in women (estimate = −0.413, 95%CI −0.713 to −0.114, P = 0.01) but not in men. InterpretationWe found significant relationships between hip external rotator strength and stance phase running biomechanics, providing further understanding on two impaired physical measures that may inform exercise-based management strategies in femoroacetabular impingement syndrome.

Relationships between tendon structure and clinical impairments in patients with patellar tendinopathy.

The clinical relevance of altered tendon structure in patellar tendinopathy is contested since structural change persists after symptom resolution. The purpose of this study was to explore the relationships between tendon structure and clinical impairments in patellar tendinopathy. In this retrospective, secondary analysis of individuals with patellar tendinopathy (n = 41), tendon structure (thickness, cross-sectional area [CSA], shear modulus, and viscosity), symptom severity, lower extremity function (counter-movement jump [CMJ] height), and quadriceps muscle performance (knee extension force and central activation ratio [CAR]) were recorded for the symptomatic limb. Relationships among structure, symptom severity, lower extremity function, and quadriceps muscle performance were examined using sequential regression models. Adjusting for age, sex, body mass index, and pain levels, there were significant positive relationships for thickness (p < 0.001, β = 0.718) and viscosity (p = 0.006, β = 0.496) with CMJ height. There were significant negative relationships between CSA with both CMJ height (p = 0.001, β = -0.538) and CAR (p = 0.04, β = -0.517). This is the first study to demonstrate relationships between tendon structure and lower extremity function or quadriceps muscle performance in patients with patellar tendinopathy. Clinical significance: Since structural changes persist after symptom resolution, addressing these changes may assist in restoring lower extremity function and quadriceps muscle performance.

Unilateral symptomatic Achilles tendinopathy has limited effects on bilateral lower limb ground reaction force asymmetries and muscular synergy attributes when walking at natural and fast speeds

BackgroundAchilles tendinopathy (AT) may affect ground reaction force (GRF) and muscle synergy (MS) during walking due to pain, biological integrity changes in the tendon and neuroplastic adaptations. The objective of this study was to compare GRF asymmetries and MS attributes between symptomatic and asymptomatic lower limbs (LL) during walking at natural and fast speeds in adults with unilateral AT.MethodsA convenience sample consisting of twenty-eight participants walked on an instrumented treadmill at natural (1.3 m/s) and fast (1.6 m/s) speeds. Peak GRF were measured in mediolateral, anteroposterior and vertical directions. Individualized electromyography (EMG) activation profiles were time- and amplitude-normalized for three consecutive gait cycles and MS were extracted using non-negative matrix factorization algorithms. MS were characterized by the number, composition (i.e., weighting of each muscle) and temporal profiles (i.e., duration and amplitude) of the MS extracted during walking. Paired Student’s t-tests assessed peak GRF and MS muscle weighting differences between sides whereas Pearson correlation coefficients characterized the similarities of the individualized EMG and MS activation temporal profiles within sides.ResultsAT had limited effects on peak GRF asymmetries and the number, composition and temporal profiles of MS between symptomatic and asymptomatic LL while walking on a level treadmill at natural and fast speeds. In most participants, four MS with a specific set of predominantly activated muscles were extracted across natural (71 and 61%) and fast (54 and 50%) walking speeds for the symptomatic and asymptomatic side respectively. Individualized EMG activation profiles were relatively similar between sides (r = 0.970 to 0.999). As for MS attributes, relatively similar temporal activation profiles (r = 0.988 to 0.998) and muscle weightings (p < 0.05) were found between sides for all four MS and the most solicited muscles. Although the faster walking speed increased the number of merged MS for both sides, it did not significantly alter MS symmetry.ConclusionFaster walking speed increased peak GRF values but had limited effects on GRF symmetries and MS attribute differences between the LL. Corticospinal neuroplastic adaptations associated with chronic unilateral AT may explain the preserved quasi-symmetric LL motor control strategy observed during natural and fast walking among adults with chronic unilateral AT.