Dishan Singh

Fortnightly review: Plantar fasciitis

Plantar fasciitis is the most common cause of inferior heel pain (fig 1). Its aetiology is poorly understood by many, which has led to a confusion in terminology.1 It is said to affect patients between the ages of 8 and 80, but is most common in middle aged women and younger, predominantly male, runners.2 Fig 1 Causes of inferior heel pain The role of the doctor in the management of plantar fasciitis is to make an appropriate diagnosis and to allow enough time for the condition to run its course, with the aid of supportive measures. If treatment is begun soon after the onset of symptoms, most patients can be cured within six weeks.3 This article is based largely on our experience and recent concepts that have changed our management of inferior heel pain. Reviews written by experts have been supplemented by selected original articles cited in Medline between 1976 and 1995 and published in high quality journals. We used the following keywords for the Medline search: plantar fasciitis, inferior heel pain, heel spur, calcaneodynia. The plantar fascia is a strong band of white glistening fibres which has an important function in maintaining the medial longitudinal arch: spontaneous rupture or surgical division of the plantar fascia will lead to a flat foot.4 5 The plantar fascia arises predominantly from the medial calcaneal tuberosity on the undersurface of the calcaneus, and its main structure fans out to be inserted through several slips into the plantar plates of the metatarso-phalangeal joints, the bases of the proximal phalanges of the toes and the flexor tendon sheaths. Just after heel strike during the first half of the stance phase of the gait cycle, the tibia turns inward and the foot pronates to allow flattening of the foot. This stretches the plantar fascia. …

Partial Achilles Tendon Ruptures Associated with Fluoroquinolone Antibiotics: A Case Report and Literature Review

Fluoroquinolone antibiotics (such as ciprofloxacin, pefloxacin, ofloxacin, norfloxacin, temafloxacin, etc.) have recently been implicated in the etiology of Achilles tendinitis and subsequent tendon rupture. We report on a patient with bilateral partial Achilles tendon ruptures associated with ciprofloxacin therapy and present a review of the current literature on this increasingly recognized complication. Treatment with fluoroquinolones should be discontinued at the first sign of tendon inflammation so as to reduce the risk of subsequent rupture. Magnetic resonance imaging is useful in distinguishing between Achilles tendinitis and partial tendon rupture.

The peroneus quartus muscle: ANATOMY AND CLINICAL RELEVANCE

Whilst a few studies have associated various symptoms with the presence of a peroneus quartus muscle in the peroneal compartment of the leg, little is known of the clinical relevance of this muscle. We dissected 102 cadaver legs and reviewed the magnetic resonance images of 80 patients with symptoms from the ankle. The peroneus quartus, with a number of different attachments, was present in 6.6% of the legs. It most commonly arose from the peroneus brevis muscle and inserted into the retrotrochlear eminence of the calcaneum. Associated pathology included a longitudinal tear in the tendon of peroneus brevis, possible peroneal tendon subluxation or dislocation, and a prominent retrotrochlear eminence. On the MR scans its presence was associated with pain and weakness of the ankle. Orthopaedic surgeons and radiologists should be aware of the possible presence of the peroneus quartus muscle, not only because of possible associated pathology, but also for its potential use for surgical reconstruction.

Tibialis posterior dysfunction: a common and treatable cause of adult acquired flatfoot

Adults with an acquired flatfoot deformity may present not with foot deformity but almost uniformly with medial foot pain and decreased function of the affected foot (for a list of causes of an acquired flatfoot deformity in adults, see box 1).1 Patients whose acquired flatfoot is associated with a more generalised medical problem tend to receive their diagnosis and are referred appropriately. However, in patients whose “adult acquired flatfoot deformity” is a result of damage to the structures supporting the medial longitudinal arch, the diagnosis is often not made early.2 These patients are often otherwise healthier and tend to be relatively more affected by the loss of function resulting from an acquired flatfoot deformity. The most common cause of an acquired flatfoot deformity in an otherwise healthy adult is dysfunction of the tibialis posterior tendon, and this review provides an outline to its diagnosis and treatment. We seached PubMed for publications by using the keywords “flatfoot” and “tibialis posterior dysfunction”. ### Tibialis posterior dysfunction: a common condition Tibialis posterior dysfunction is well recognised by orthopaedic surgeons specialising in foot and ankle surgery and by podiatrists. However, greater general awareness of this condition is required,2 as most patients presenting to a general practitioner receive a diagnosis of ankle sprain or arthritis. By the time most patients present to a specialist foot and ankle clinic they have had the condition for several years and have consulted numerous doctors.3 Even general orthopaedic surgeons and physiotherapists often miss the diagnosis.3 However, tibialis posterior dysfunction need not remain a “specialist diagnosis” as it is usually diagnosed without any investigations, from a history and physical examination.2 Many patients benefit from relatively simple treatment, such as orthotic devices.4 Population based studies to identify the prevalence of tibialis posterior dysfunction are under way. In elderly people the condition …

Tibialis Posterior Tendon Dysfunction: A Primary of Secondary Problem?

Seventeen patients with a mean follow-up of 64.4 months following a tibialis posterior tendon transfer to regain active foot dorsiflexion were clinically examined specifically for signs of tibialis posterior tendon dysfunction. The results show that 8 patients (47 %) had Grade 4 or better power of eversion but none had a clinical flatfoot on the Harris-Beath footprints. Only 6 % had forefoot abduction; 17 % exhibited hindfoot valgus and 82 % were able to perform the single-heel rise. Tibialis posterior tendon dysfunction therefore does not appear to be an inevitable sequel of tibialis posterior tendon transfer even in the presence of a functioning peroneal muscle. Other studies have noted that a pre-existent flatfoot was often present in patients with tibialis posterior tendon dysfunction. None of the patients in this study had pre-existent flatfoot. We suggest that a predisposition, in the form of a pre-existent tendency to flatfoot may also be a factor in the pathogenesis of tibialis posterior tendon dysfunction. This may explain the long-term failure of flexor digitorum longus and flexor hallucis longus tendon transfers in the treatment for tibialis posterior tendon dysfunction when the biomechanics of the foot has not been altered.

The prevalence of symptomatic posterior tibialis tendon dysfunction in women over the age of 40 in England

BACKGROUND To investigate the prevalence of posterior tibial tendon dysfunction (PTTD) in women over the age of 40. METHODS A validated survey was posted to a random sample of 1000 women (over 40 years) from a GP group practice in Hertfordshire, England. Survey positive women were telephoned and when indicated, a detailed examination was performed. RESULTS There were 582 usable responses. The majority indicated they had minor forefoot or no problems. Telephone contact was made with 116 women and of those 79 required examination. The diagnosis of symptomatic flatfeet was made in 9 patients, 7 patients had stage I PTTD, 12 patients had stage II PTTD and 9 patients had an adult acquired flatfoot deformity. CONCLUSIONS This is the first report of the prevalence of stage I and II PTTD in women (over 40 years). The prevalence is 3.3% and all patients were undiagnosed despite characteristic and prolonged symptoms.

Electron spin resonance spectroscopic demonstration of the generation of reactive oxygen species by diseased human synovial tissue following ex vivo hypoxia-reoxygenation.

OBJECTIVE--To apply an electron spin resonance (ESR) spectroscopic technique as a means of determining the oxidising capacity of reactive oxygen species produced during hypoxia and reoxygenation of diseased human synovial tissue. METHODS--Twenty four specimens of fresh synovial tissue were obtained from patients undergoing primary total knee joint replacement and graded according to the degree of inflammation present. Tissue samples were subjected to an ex vivo hypoxia-reoxygenation cycle in the presence of the nitroso based spin trap, 3,5-dibromo-4-nitrosobenzene sulphonate. The degree of oxidation of the spin trap to a stable free radical was determined and followed with time. Control samples were subjected to hypoxia only. RESULTS--The results indicate that the oxidising capacity of reactive oxygen species produced by human synovial tissue varies with the degree of inflammation present. Only the more inflamed specimens, from both rheumatoid arthritis and osteoarthritis patients, demonstrated increased production of reactive oxygen species when subjected to a hypoxia-reoxygenation cycle. This change was reduced by both competitive and non-competitive inhibitors of the endothelial based enzyme xanthine oxidase. The relative concentration of reactive oxygen species generated by the synovial tissue samples correlated with the mean capillary density of the specimens. CONCLUSION--This study supports the hypothesis of movement induced hypoxicreperfusion injury of the chronically inflamed joint by demonstrating the generation of reactive oxygen species within inflamed human synovium following an ex vivo hypoxia-reoxygenation cycle. Evidence is presented that the microvascular endothelial based enzyme xanthine oxidase is the predominant source of ESR detectable oxidising species in inflamed synovial specimens exposed to hypoxia-reoxygenation.

A method for evaluating the results of tendon transfers for foot drop.

A system for assessing the results of tibialis posterior tendon transfers in the treatment of foot drop secondary to nerve palsy is proposed. There are seven sections to this scoring system: pain, need for orthosis, ability to wear normal shoes, activity level, muscle power of ankle dorsiflexion, degree of active ankle dorsiflexion, and foot posture. The total score is 100. The results are classified as excellent for scores between 85 and 100, good between 70 and 84, fair between 55 and 69, and poor for scores below 55. The results of 18 patients (mean followup, 64.6 months) who had a tibialis posterior tendon transfer were assessed using this method. Four patients (22.2%) had an excellent result, seven (38.8%) had a good result, two (11.1%) had a fair result, and five (27.7%) had a poor result. The average score was 67.2, suggesting an overall fair result for this operation. In nine patients, there was correlation between the outcome when assessed with this method and with patient rating. In two patients, the outcomes were better when assessed with this method than with patient rating, whereas the reverse was true in seven other patients. Thus, this system may provide a more objective and critical evaluation of tibialis posterior transfers for foot drop.

Levels of evidence in foot and ankle surgery literature: progress from 2000 to 2010?

BACKGROUND The focus on evidence-based medicine has led to calls for increased levels of evidence in surgical journals. The purpose of the present study was to review the levels of evidence in articles published in the foot and ankle literature and to assess changes in the level of evidence over a decade. METHODS All of the articles in the literature from the years 2000, 2005, and 2010 in Foot & Ankle International and Foot and Ankle Surgery, as well as all foot and ankle articles from The Journal of Bone and Joint Surgery (JBJS, American [A] and British [B] Volumes) were analyzed. Animal, cadaver, and basic science articles; editorials; surveys; special topics; letters to the editor; and correspondence were excluded. Articles were ranked by a five-point level-of-evidence scale, according to guidelines from the Centre for Evidence-Based Medicine. RESULTS A total of 720 articles from forty-three different countries were analyzed. The kappa value for interobserver reliability showed very good agreement between the reviewers for types of evidence (κ = 0.816 [p < 0.01]) and excellent agreement for levels of evidence (κ = 0.869 [p < 0.01]). Between 2000 and 2010, the percentage of high levels of evidence (Levels I and II) increased (5.2% to 10.3%) and low levels of evidence (Levels III, IV, and V) decreased (94.8% to 89.7%). The most frequent type of study was therapeutic. The JBJS-A produced the highest proportion of high levels of evidence. CONCLUSION There has been a trend toward higher levels of evidence in foot and ankle surgery literature over a decade, but the differences did not reach significance.

Nils Silfverskiöld (1888-1957) and gastrocnemius contracture.

Nils Silfverskiöld was an orthopaedic surgeon, Swedish aristocrat, bon vivant, Olympic gymnast, left wing intellectual and anti-Nazi who described that the force required to dorsiflex the ankle in spastic equinus contracture decreased with knee flexion in isolated gastrocnemius contracture. He advocated detaching the origins of the gastrocnemii from the femur and reattaching them to the tibia. The Silfverskiöld knee flexion test has now also been adapted to distinguish between isolated gastrocnemius contracture and combined shortening of the gastrocnemius-soleus complex in non-spastic contracture by measuring the range of ankle dorsiflexion with the knee flexed and the knee straight.