Is calcaneal stiffness more sensitive to physical activity than forearm bone mineral density? A population-based study of persons aged 20 - 79 years

Vitamin D in the Foot and Ankle: A Review of the Literature

BACKGROUND

Vitamin D is an essential vitamin that targets several tissues and organs and plays an important role in calcium homeostasis. Vitamin D deficiency is common, particularly at higher latitudes, where there is reduced exposure to ultraviolet B radiation. We reviewed the role of vitamin D and its deficiency in foot and ankle pathology.

METHODS

The effects of vitamin D deficiency have been extensively studied, but only a small portion of the literature has focused on the foot and ankle. Most evidence regarding the foot and ankle consists of retrospective studies, which cannot determine whether vitamin D deficiency is, in fact, the cause of the pathologies being investigated.

RESULTS

The available evidence suggests that insufficient vitamin D levels may result in an increased incidence of foot and ankle fractures. The effects of vitamin D deficiency on fracture healing, bone marrow edema syndrome, osteochondral lesions of the talus, strength around the foot and ankle, tendon disorders, elective foot and ankle surgery, and other foot and ankle conditions are less clear.

CONCLUSIONS

Based on the available evidence, we cannot recommend routine testing or supplementation of vitamin D in patients with foot and ankle pathology. However, supplementation is cheap, safe, and may be of benefit in patients at high risk for deficiency. When vitamin D is supplemented, the evidence suggests that calcium should be co-supplemented. Further high-quality research is needed into the effect of vitamin D in the foot and ankle. Cost-benefit analyses of routine testing and supplementation of vitamin D for foot and ankle pathology are also required.

On the use of a six-level scale for physical activity

The 4-level questionnaire to assess leisure-time physical activity (PA) originally described by Saltin and Grimby has been extended to a 6 (or 7)-level questionnaire, especially for the elderly or other persons with a low level of PA, expanded to include household activities. There are currently two main versions, one used in Swedish, Danish, and Norwegian studies, and one with further modifications used in Finnish studies. In this review, predictive validity for mortality and different aspects of physical performance are demonstrated. In a study regarding concurrent validity in one of the Finnish versions, significant correlations with accelerometer-based PA variables are shown. The scale has been used in a number of studies concerning effects of different types of intervention, such as physical training and increased PA, or to describe the PA level in the studied cohort. In presenting and analyzing the data, different combinations of PA levels have been used. As there are major differences between the versions, validity studies cannot easily be transformed between them. Thus, it is suggested that a common consensus be reached with respect to details of the questionnaire.

Long-term effects of a ten-year osteoporosis intervention program in a Swedish population—A cross-sectional study

The aim of the study was to explore long-term effects seven years after the completion of a ten-year community-based osteoporosis intervention program in Vadstena, Sweden. The association between calcaneal bone mineral density and several life style factors, and the impact of risk factors for sustaining a fracture after the age of 50 were also studied. Previous participants in the intervention group, and matched subjects were invited to calcaneal bone mass measurement by a portable device including the dual X-ray and laser (DXL) technology by Calscan, and to complete a questionnaire in 2006. A total of 417 persons (63% of those invited) in the intervention (I) group, and 120 persons (47% of those invited) in the control (C) group participated. Mean age was 63 years (37–94 years). There was somewhat more knowledge of osteoporosis in the I-group (M = 18) than in the C-group (M = 17) (p < 0.05), and more use of shoe/cane spikes in elderly women in the I-group (67%) than in the C-group (40.5%). The fully adjusted model of logistic regression showed that participants with an osteoporotic DXL T-score (≤− 2.5) had a 3-fold increased risk (95%CI 1.48–6.89) of having a history of a self-reported fracture after the age of fifty compared to women with a calcaneal T-score >− 2.5. The long-term effects of a ten-year, community-based, osteoporosis intervention program on knowledge and behavior were modest seven years after its completion.

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The effect of community-based osteoporosis intervention seems modest in the long run.

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Elderly women were compliant with fall prevention advice using spikes in winter.

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An osteoporotic calcaneal T-score may imply increased risk for fracture.

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Moderate/high physical activity was positively associated with calcaneal BMD in men.

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Brisk walks in the summer were positively associated with calcaneal BMD in women.

Bone mineral decreases in the calcanei in men after arthroscopic shoulder surgery: a prospective study over 5 years

PURPOSE

It is well known that injuries and surgical procedures in the lower extremities affect bone mineral both in the injured limb and in the contralateral limb. The possible effect on bone mineral after upper extremity surgery is not well studied, and the aim of this study was to study the effect on bone mineral in the calcanei after arthroscopic shoulder surgery.

METHODS

Twenty-two men scheduled for arthroscopic shoulder surgery underwent bone mineral area (BMA) mass measurements in both calcanei using the Calscan DXL device prior to surgery and after 6, 18, 36 and 60 months. On every occasion, the Tegner activity score and EuroQoL 5-dimensions (EQ-5D) were assessed.

RESULTS

During 5 years, there was a significant decrease in the BMA in both calcanei (p = 0.003). The Tegner activity score decreased from preinjury to the operation and did not increase significantly after the operation. The EQ-5D increased significantly after the operation.

CONCLUSION

The bone mineral in the calcanei in men during the 5-year study period decreased more than the expected age-dependent decline after arthroscopic shoulder surgery. There was an increase in health-related quality of life as measured with the EQ-5D after arthroscopic Bankart reconstruction.

LEVEL OF EVIDENCE

Case-control study, Level III.

Association between alcohol consumption and bone strength in Korean adults: the Korean Genomic Rural Cohort Study

Previous studies have reported an inconsistent relationship between alcohol consumption and bone health. A growing body of research has shown that chronic alcoholism leads to osteopenia and increased incidence of skeletal fractures, but some studies have concluded that alcohol consumption may be associated with higher bone mineral density in elderly populations. However, most studies showing a significant relationship between alcohol consumption and bone status have been in Western countries; and subjects have usually been postmenopausal women. The purpose of the present study was to investigate the association of alcohol consumption with bone strength in Korean adults. Data were from the Korean Genomic Rural Cohort Study, which is an ongoing population-based study of adults aged 40 to 70 years from 5 regions. A total of 7713 participants (3368 men, 4345 women) were surveyed about their annual consumption of alcohol such as soju, beer, makkolli, wine, and whisky. Bone strength was measured by stiffness index using the calcaneal quantitative ultrasound method. Overall, the annual age-specific decrease rate in the stiffness index of women was 2.7 times higher than that of men (0.463% for women, 0.169% for men).After adjustment for eligible covariates, the association between alcohol consumption and risk of reduced bone strength showed a J-shaped curve for both men and women. Compared with nondrinkers, the relative risk of reduced bone strength was 0.52 (95% confidence interval, 0.33-0.83) in men who drank 4 to 5 cups of soju for an amount of 29.626 to 49.375 g of alcohol per day and 0.61 (95% confidence interval, 0.38-0.86) in men who drank 6 to 7 cups of soju for an amount of 49.376 to 69.125 g of alcohol per day. We found no significant relationship between alcohol consumption and bone strength in any other group of men. For women, results suggested that the risk of reduced bone strength was lower in the moderate-consumption group; but no significant relationship was found between alcohol consumption at any level and bone strength. Among Korean adults, alcohol consumption has a J-shaped relationship with risk of reduced bone strength.

The association between physical activity and osteoporotic fractures: a review of the evidence and implications for future research

PURPOSE

Physical activity helps maintain mobility, physical functioning, bone mineral density (BMD), muscle strength, balance and, therefore, may help prevent falls and fractures among the elderly. Meanwhile, it is theoretically possible that physical activity increases risk of fractures as it may increase risk of falls and has only a modest effect on BMD. This review aims to assess the potential causal association between physical activity and osteoporotic fractures from an epidemiological viewpoint.

METHODS

As the medical literature lacks direct evidence from randomized controlled trials (RCTs) with fracture end points, a meta-analysis of 13 prospective cohort studies with hip fracture end point is presented. The current evidence base regarding the link between exercise and fracture risk determinants (namely, falls, BMD, and bone quality) are also summarized.

RESULTS

Moderate-to-vigorous physical activity is associated with a hip fracture risk reduction of 45% (95% CI, 31-56%) and 38% (95% CI, 31-44%), respectively, among men and women. Risk of falling is suggested to be generally reduced among physically active people with a potential increased risk in the most active and inactive people. Positive effects of physical activity on BMD and bone quality are of a questionable magnitude for reduction of fracture risk.

CONCLUSION

The complexity of relationship between physical activity and osteoporotic fractures points out to the need for RCTs to be conducted with fractures as the primary end point.