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Pasapula C, Tadikonda P, Valentini L, Youssef H, Chaudhri S, Howell C, Hardcastle A, Shariff S. Medial arch instability/internal foot overload association with non-insertional Achilles tendinopathy and the 'Zone of Conflict Theory'. Foot (Edinb) 2024; 59:102090. [PMID: 38537500 DOI: 10.1016/j.foot.2024.102090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 03/10/2024] [Indexed: 06/17/2024]
Abstract
BACKGROUND Non insertional Achilles tendinopathy [AT] is a degenerative condition that is prevalent in runners. 30% have no preceding history and many runners do not develop AT. Overuse, pronation, and compromised blood supply are hypothesised as causal. The exact precipitant is still unknown. The link between medial arch instability and AT has not been made. The purpose of this study was to investigate the association between spring ligament (SL) laxity and first ray (FRI) instability, and the presence of (AT). METHODS Ethical approval was obtained. Patients were identified from hospital databases for unilateral AT, allowing the opposite unaffected foot to be used as an internal control. SL laxity was measured using the lateral translation score and FRI was measured using a modified digital Klauemeter. Ultrasound was used to assess the tendoachilles [TA] in affected vs unaffected legs. RESULTS 17 patients were recruited with a mean age of 55.6 and mean body mass index (BMI) of 33.3. The average symptom duration was 3.62 years. There were 12 left feet and 5 right feet. There was no statistical difference in dorsiflexion angles for the TA or the gastrocnemius. All Beighton scores < 5. Lateral translation scores, FRI scores and TA thickness was significantly greater in AT feet [p < 0.05]. More affected feet had Tibialis posterior tendon pain (TP) [p < 0.05]. CONCLUSIONS Feet with AT exhibit higher lateral translation scores and greater FRI compared to healthy feet, and combined with previous literature evidence, suggests alteration of the subtalar axis alters force moments that may lead to an intrinsic overload of the TA, when the foot enters a "zone of conflict". Medial arch instability, in particular SL laxity and FRI, may contribute to the development of non-insertional AT and treatment of this with early arch support may prevent progressive degeneration.
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Affiliation(s)
- C Pasapula
- Department of Trauma and Orthopaedics, Queen Elizabeth Hospital (QEHKL), King's Lynn PE30 4ET, UK
| | - P Tadikonda
- Department of Trauma and Orthopaedics, Queen Elizabeth Hospital (QEHKL), King's Lynn PE30 4ET, UK.
| | - L Valentini
- Department of Trauma and Orthopaedics, Queen Elizabeth Hospital (QEHKL), King's Lynn PE30 4ET, UK
| | - H Youssef
- Department of Trauma and Orthopaedics, Queen Elizabeth Hospital (QEHKL), King's Lynn PE30 4ET, UK
| | - S Chaudhri
- University of East Anglia, Norwich Research Park, Norwich NR4 7TJ, UK
| | - C Howell
- Department of Trauma and Orthopaedics, Queen Elizabeth Hospital (QEHKL), King's Lynn PE30 4ET, UK
| | - A Hardcastle
- Department of Trauma and Orthopaedics, Queen Elizabeth Hospital (QEHKL), King's Lynn PE30 4ET, UK
| | - S Shariff
- Department of Trauma and Orthopaedics, Medway Maritime Hospital, Kent ME7 5NY, UK
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Pasapula CS, Choudkhuri MR, Monzó ERG, Dhukaram V, Shariff S, Pasterse V, Richie D, Kobezda T, Solomou G, Cutts S. Review of Classification Systems for Adult Acquired Flatfoot Deformity/Progressive Collapsing Foot Deformity and the Novel Development of the Triple Classification Delinking Instability/Deformity/Reactivity and Foot Type. J Clin Med 2024; 13:942. [PMID: 38398256 PMCID: PMC10889573 DOI: 10.3390/jcm13040942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 01/24/2024] [Accepted: 01/28/2024] [Indexed: 02/25/2024] Open
Abstract
Background: Classifications of AAFD/PCFD have evolved with an increased understanding of the pathology involved. A review of classification systems helps identify deficiencies and respective contributions to the evolution in understanding the classification of AAFD/PCFD. Methods: Using multiple electronic database searches (Medline, PubMed) and Google search, original papers classifying AAFD/PCFD were identified. Nine original papers were identified that met the inclusion criteria. Results: Johnson's original classification and multiple variants provided a significant leap in understanding and communicating the pathology but remained tibialis posterior tendon-focused. Drawbacks of these classifications include the implication of causality, linearity of progression through stages, an oversimplification of stage 2 deformity, and a failure to understand that multiple tendons react, not just tibialis posterior. Later classifications, such as the PCFD classification, are deformity-centric. Early ligament laxity/instability in normal attitude feet and all stages of cavus feet can present with pain and instability with minor/no deformity. These may not be captured in deformity-based classifications. The authors developed the 'Triple Classification' (TC) understanding that primary pathology is a progressive ligament failure/laxity that presents as tendon reactivity, deformity, and painful impingement, variably manifested depending on starting foot morphology. In this classification, starting foot morphology is typed, ligament laxities are staged, and deformity is zoned. Conclusions: This review has used identified deficiencies within classification systems for AAFD/PCFD to delink ligament laxity, deformity, and foot type and develop the 'Triple classification'. Advantages of the TC may include representing foot types with no deformity, defining complex secondary instabilities, delinking foot types, tendon reactivity/ligament instability, and deformity to represent these independently in a new classification system. Level of Evidence: Level V.
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Affiliation(s)
- Chandra Seker Pasapula
- The Queen Elizabeth Hospital Kings Lynn, NHS Foundation Trust, King’s Lynn PE30 4ET, UK; (C.S.P.); (M.R.C.); (T.K.)
| | - Makhib Rashid Choudkhuri
- The Queen Elizabeth Hospital Kings Lynn, NHS Foundation Trust, King’s Lynn PE30 4ET, UK; (C.S.P.); (M.R.C.); (T.K.)
| | | | - Vivek Dhukaram
- University Hospitals Coventry & Warwickshire, Coventry CV2 2DX, UK;
| | - Sajid Shariff
- Medway Maritime Hospital, NHS Foundation Trust, Kent ME7 5NY, UK;
| | | | - Douglas Richie
- California School of Podiatric Medicine, Samuel Merritt University, Oakland, CA 94609, USA;
| | - Tamas Kobezda
- The Queen Elizabeth Hospital Kings Lynn, NHS Foundation Trust, King’s Lynn PE30 4ET, UK; (C.S.P.); (M.R.C.); (T.K.)
| | - Georgios Solomou
- School of Clinical Medicine, University of Cambridge, Cambridge CB2 2EL, UK
| | - Steven Cutts
- James Paget University Hospitals, NHS Foundation Trust, Great Yarmouth NR31 6LA, UK;
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Kim KC, Fayed A, Schmidt E, Carvalho KAMD, Lalevee M, Mansur N, de Cesar Netto C. Relationship Between Obesity and Medial Longitudinal Arch Bowing. Foot Ankle Int 2023; 44:1181-1191. [PMID: 37902194 DOI: 10.1177/10711007231199754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
BACKGROUND There have been reports about the association between obesity and the medial longitudinal arch (MLA) of foot. The purpose of this study is to investigate the change of various parameters related to the MLA according to obesity classification severity by the World Health Organization using weightbearing computed tomography (WBCT). METHODS WBCT data of the noninvolved side of patients presenting with unilateral foot and ankle problems or healthy candidates from September 2014 to October 2022 were extracted from a single referral hospital. Forty-four cases in each of 5 obesity classes were selected sequentially. Two orthopaedic surgeons measured foot and ankle offset, forefoot arch angle (FAA), hindfoot moment arm, percentage of uncoverage of the middle facet of the subtalar joint, talonavicular angle (TNA), navicular-medial cuneiform angle, medial cuneiform-first metatarsal angle, talus-first metatarsal angle (TMT1A), first tarsometatarsal subluxation (TMT1S), talonavicular coverage angle, navicular floor distance (NFD), and NFD per height. Positive values indicate plantar collapse. Intra- and interobserver reliabilities were assessed using intraclass correlation coefficients. One-way analysis of variance tests were performed for parametric data with equal variances, and Welch's test for unequal variances. Kruskal-Wallis test was performed for nonparametric data. Post hoc analysis was performed for statistically significant parameters. Correlation analysis between body mass index (BMI) and 12 parameters were performed using Pearson test. RESULTS Intraobserver and interobserver reliability were excellent, except for TMT1S. The TNA and TMT1A showed a statistically significant difference. FAA (r = -0.2), TNA (r = 0.182), TMT1A (r = 0.296), and NFD (r = -0.173) showed a statistically significant correlation with BMI. CONCLUSION In nonsymptomatic feet, we found that the talonavicular joint, as measured by the TNA, to be influenced by obesity classification. Obesity and increased BMI was associated with a negative influence on the MLA. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Ki Chun Kim
- Department of Orthopaedic Surgery, Seoul Medical Center, Seoul, South Korea
| | - Aly Fayed
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Eli Schmidt
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | - Matthieu Lalevee
- Department of Orthopedic Surgery, Rouen University Hospital, Rouen, France
| | - Nacime Mansur
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Austin IS, Norrish A, Lloyd R, Brassett C, Pasapula C. Differential contribution of lateral plantar foot ligaments to lateral column stability - A cadaver based sectioning analysis. Foot (Edinb) 2023; 56:102003. [PMID: 36966558 DOI: 10.1016/j.foot.2023.102003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 03/02/2023] [Accepted: 03/05/2023] [Indexed: 06/18/2023]
Abstract
Lateral column (LC) instability occurs in adult acquired flatfoot deformity (AAFD). Differential ligament contribution to LC stability is unknown. The primary aim was to quantify this by using cadaver sectioning of lateral plantar ligaments. We also determined the relative contribution of each ligament to dorsal translation of the metatarsal head in the sagittal plane. 17 below-knee cadaveric specimens, preserved by vascular embalming method, were dissected to expose plantar fascia, long/short plantar ligaments (L/SPL), calcaneocuboid (CC) capsule and inferior 4th/5th tarsometatarsal (TMT) capsule. Dorsal forces of 0 N, 20 N and 40 N were applied to the plantar 5th metatarsal head after sequential ligament sectioning in different orders. Pins provided linear axes on each bone, allowing relative angular bone displacements to be calculated. Photography and ImageJ processing software were then used for analysis. The LPL (and CC capsule) had the greatest contribution to metatarsal head motion (107 mm) after isolated sectioning. In the absence of other ligaments, sectioning these resulted in significantly increased hindfoot-forefoot angulation (p ≤ 0.0003). Isolated TMT capsule sectioning demonstrated significant angular displacement even when other ligaments remained intact (with intact L/SPL, p = 0.0005). CC joint instability required both LPL and capsular sectioning for significant angulation to occur, whilst TMT joint stability was largely dependent on its capsule. The relative contribution of static restraints to the lateral arch has not yet been quantified. This study provides useful information on relative ligament contribution to both CC and TMT joint stability, which may in turn improve understanding of surgical interventions used to restore arch stability.
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Affiliation(s)
| | | | | | | | - Chandra Pasapula
- Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, United Kingdom
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Chrastek D, El-Mousili M, Al-Sukaini A, Austin IS, Yanduru T, Cutts S, Pasapula C. Quantifying increased lateral column instability in Adult Acquired Flatfoot Deformity (AAFD). Foot (Edinb) 2023; 56:102036. [PMID: 37271102 DOI: 10.1016/j.foot.2023.102036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/16/2023] [Accepted: 05/06/2023] [Indexed: 06/06/2023]
Abstract
AAFD comprises ligamentous failure and tendon overload, mainly focused on the symptomatic posterior tibial tendon and the spring ligament. Increased lateral column (LC) instability arising in AAFD is not defined or quantified. This study aims to quantify the increased LC motion in unilateral symptomatic planus feet, using the contralateral unaffected asymptomatic foot as an internal control. In this case matched analysis, 15 patients with unilateral stage 2 AAFD foot and an unaffected contralateral foot were included. Lateral foot translation was measured as a guide to spring ligament competency. Medial and LC dorsal sagittal instability were assessed by direct measurement of dorsal 1st and 4th/5th metatarsal head motion and further video analysis. The mean increase in dorsal LC sagittal motion (between affected vs unaffected foot) was 5.6 mm (95% CI [4.63-6.55], p < 0.001). The mean increase in the lateral translation score was 42.8 mm (95% CI [37.48-48.03], p < 0.001). The mean increase in medial column dorsal sagittal motion was 6.8 mm (95% CI [5.7-7.8], p < 0.001). Video analysis also showed a statistically significant increase in LC dorsal sagittal motion between affected and unaffected sides (p < 0.001). This is the first study that quantifies a statistically significant increased LC dorsal motion in feet with AAFD. Understanding its pathogenesis and its link to talonavicular/spring ligament laxity improves foot assessment and may allow the development of future preventative treatment strategies.
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Affiliation(s)
- David Chrastek
- Norfolk and Norwich University Hospital, Colney Lane, Norwich, Norfolk NR4 7UY, UK.
| | - Mahmoud El-Mousili
- Queen Elizabeth Hospital King's Lynn, Gayton Road, King's Lynn, Norfolk PE30 4ET, UK
| | - Ahmad Al-Sukaini
- Norfolk and Norwich University Hospital, Colney Lane, Norwich, Norfolk NR4 7UY, UK
| | - Isabel S Austin
- University of Cambridge, The Old Schools, Cambridge CB2 1TN, UK
| | - Trisha Yanduru
- Canyon Crest Academy, 5951 Village Centre Loop Rd, San Diego, CA 92130, USA
| | - Steve Cutts
- James Paget University Hospital, Lowestoft Road, Gorleston-on-Sea, Great Yarmouth NR31 6LA, UK
| | - Chandra Pasapula
- Queen Elizabeth Hospital King's Lynn, Gayton Road, King's Lynn, Norfolk PE30 4ET, UK
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Malakoutikhah H, Madenci E, Latt LD. A computational model of force within the ligaments and tendons in progressive collapsing foot deformity. J Orthop Res 2023; 41:396-406. [PMID: 35579076 DOI: 10.1002/jor.25380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 04/17/2022] [Accepted: 05/14/2022] [Indexed: 02/04/2023]
Abstract
Progressive collapsing foot deformity results from degeneration of the ligaments and posterior tibial tendon (PTT). Our understanding of the relationship between their failures remains incomplete. We sought to improve this understanding through computational modeling of the forces in these soft tissues. The impact of PTT and ligament failures on force changes in the remaining ligaments was investigated by quantifying ligament force changes during simulated ligament and tendon cutting in a validated finite element model of the foot. The ability of the PTT to restore foot alignment was also evaluated by increasing the PTT force in a foot with attenuated ligaments and comparing the alignment angles to the intact foot. We found that failure of any one of the ligaments led to overloading the remaining ligaments, except for the plantar naviculocuneiform, first plantar tarsometatarsal, and spring ligaments, where removing one led to unloading the other two. The combined attenuation of the plantar fascia, long plantar, short plantar, and spring ligaments significantly overloaded the deltoid and talocalcaneal ligaments. Isolated PTT rupture had no effect on foot alignment but did increase the force in the deltoid and spring ligaments. Moreover, increasing the force within the PTT to 30% of body weight was effective at restoring foot alignment during quiet stance, primarily through reducing hindfoot valgus and forefoot abduction as opposed to improving arch collapse. Our findings suggest that early intervention might be used to prevent the progression of deformity. Moreover, strengthening the PTT through therapeutic exercise might improve its ability to restore foot alignment.
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Affiliation(s)
- Hamed Malakoutikhah
- Department of Aerospace and Mechanical Engineering, University of Arizona, Tucson, Arizona, USA
| | - Erdogan Madenci
- Department of Aerospace and Mechanical Engineering, University of Arizona, Tucson, Arizona, USA
| | - Leonard Daniel Latt
- Department of Orthopaedic Surgery, University of Arizona, Tucson, Arizona, USA
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Merian M, Kaim A. The Plantar Fascia Talar Head Correlation: A Radiographic Parameter With a Distinct Threshold to Validate Flatfoot Deformity and Its Corrective Surgery on Conventional Weightbearing Radiographs. Foot Ankle Int 2022; 43:414-425. [PMID: 34802299 DOI: 10.1177/10711007211052258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Corrective surgery for flexible flatfoot deformity (FD) remains controversial, and one of the main reasons for this is the lack of standardized radiographic measurements to define an FD. Previously published radiographic parameters to differentiate between a foot with and without an FD do not have a commonly accepted and distinct threshold. METHODS The plantar fascia-talar head correlation (PTC) with its defined threshold was assessed by measuring the distance between the medial border of the plantar fascia and the center of the talar head (DPT) on conventional dorsoplantar and lateral weightbearing radiographs; the authors were blinded to the clinical diagnosis of the 189 patients' first visits. Feet were sorted into groups with and without an FD based on their clinical examination. The effect of operative corrections of FD on the PTC was retrospectively evaluated on an additional 38 patients. RESULTS The sensitivity of the PTC was 0.98 (95% CI: 0.9-1) and specificity 0.96 (95% CI: 0.92-0.98), respectively, to identify an FD, consistent with the clinical examination. Thirty-five of 38 surgeries sufficiently corrected the FD and the PTC comparable to that in subjects without an FD. Three corrections with a residual FD did not adequately correct the PTC. CONCLUSION The PTC is a reliable radiographic parameter with a distinct threshold that is sensitive and specific for the differentiation of feet with and without an FD including feet with and without residual FD after corrective surgery. The PTC is applicable to monitor the needed intraoperative amount of correction using simulated weightbearing fluoroscopy. LEVEL OF EVIDENCE Level III, diagnostic.
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Affiliation(s)
- Marc Merian
- Praxis für Fuss- und Sprunggelenkschirurgie, Klinik Birshof Hirslanden AG, Münchenstein, Switzerland
| | - Achim Kaim
- Department of Radiology, Klinik Birshof Hirslanden AG, Münchenstein, Switzerland
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De Prado M, Cuervas-Mons M, De Prado V, Dalmau-Pastor M. Percutaneous plantar fasciotomy: An anatomical study about its safety and efficacy. Foot Ankle Surg 2022; 28:14-19. [PMID: 33468404 DOI: 10.1016/j.fas.2021.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 12/16/2020] [Accepted: 01/01/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Percutaneous plantar fasciotomy is one of the available options for recalcitrant cases of plantar fasciopathy, but there is a mismatch in the clinical results between different author's experience, possibly due to variability when choosing the exact cutaneous entry point. The purpose of this study is to validate the plantar approach in the surgical treatment of plantar fasciopathy, describing a safe path and cutaneous entry point to perform a percutaneous plantar fasciotomy with a 2 mm incision testing the procedure on cadavers. METHODS a unicentric cross-sectional analytical study was conducted in 12 cadaveric feet to verify the accuracy of the percutaneous fasciotomy entry point. Independent variables analysed were: extent of fasciotomy, entry point location, spur resection, and soft tissues injuries. A double evaluation was performed: an indirect evaluation under fluoroscopic vision, and a direct evaluation after anatomical dissection. RESULTS No cases of plantar cortical lesion on the calcaneus was observed. Satisfactory fasciotomy was performed in 91.7% of the cases. An optimal entry point was noticed in all cases with a mean distance to the tip of tibial malleolus of 22.5 mm (±6.9; 35.1-12.1) and a mean distance to foot midline of 7.8 mm (±1.7; 11.8-5.1). No neurological nor vascular lesions were found. In all the feet, a laceration of the plantar part of flexor digitorum brevis muscle was noted. CONCLUSION the plantar approach for percutaneous total plantar fasciotomy is a safe procedure. The current study provides an intraoperative guideline for minimising the possible risks.
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Affiliation(s)
- Mariano De Prado
- Department of Orthopaedics and Trauma Surgery, Quirónsalud Murcia Hospital, Calle Miguel Hernandez, 12. 30011 Murcia, Spain
| | - Manuel Cuervas-Mons
- Department of Orthopaedics and Trauma Surgery, 'Gregorio Marañón' University Hospital, Calle Dr Esquerdo, 46. 28007 Madrid, Spain.
| | - Virginia De Prado
- Department of Podiatry Quirónsalud Murcia Hospital, Calle Miguel Hernandez, 12. 30011 Murcia, Spain
| | - Miki Dalmau-Pastor
- Human Anatomy Unit, Department of Pathology and Experimental Therapeutics, School of Medicine, University of Barcelona, Barcelona, Spain; GRECMIP - MIFAS (Groupe de Recherche et d'Etude en Chirurgie Mini-Invasive du Pied - Minimally Invasive Foot and Ankle Society), Merignac, France; Vilamèdic Medical Center, Santa Coloma de Gramanet, Barcelona, Spain
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de Cesar Netto C, Saito GH, Roney A, Day J, Greditzer H, Sofka C, Ellis SJ, Richter M, Barg A, Lintz F, de Cesar Netto C, Burssens A, Ellis SJ, Deland J, Ellis SJ. Combined weightbearing CT and MRI assessment of flexible progressive collapsing foot deformity. Foot Ankle Surg 2021; 27:884-891. [PMID: 33358266 DOI: 10.1016/j.fas.2020.12.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/12/2020] [Accepted: 12/01/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND The objective of this study was to evaluate the correlation between Weightbearing CT (WBCT) markers of pronounced peritalar subluxation (PTS) and MRI findings of soft tissue insufficiency in patients with flexible Progressive Collapsing Foot Deformity (PCFD). We hypothesized that significant correlation would be found. METHODS Retrospective comparative study with 54 flexible PCFD patients. WBCT and MRI variables deformity severity were evaluated, including markers of pronounced PTS, as well as soft tissue degeneration. A multiple regression analysis and partition prediction models were used to evaluate the relationship between bone alignment and soft tissue injury. P-values of less than .05 were considered significant. RESULTS Degeneration of the posterior tibial tendon was significantly associated with sinus tarsi impingement (p = .04). Spring ligament degeneration correlated to subtalar joint subluxation (p = .04). Talocalcaneal interosseous ligament involvement was the only one to significantly correlate to the presence of subfibular impingement (p = .02). CONCLUSION Our results demonstrated that WBCT markers of pronounced deformity and PTS were significantly correlated to MRI involvement of the PTT and other important restraints such as the spring and talocalcaneal interosseus ligaments. LEVEL OF EVIDENCE Level III, Retrospective comparative study.
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Affiliation(s)
- Cesar de Cesar Netto
- The Hospital for Special Surgery, New York, NY, US; University of Iowa, Department of Orthopaedics and Rehabilitation, Iowa City, IA, US.
| | | | - Andrew Roney
- The Hospital for Special Surgery, New York, NY, US
| | - Jonathan Day
- The Hospital for Special Surgery, New York, NY, US
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- International Weight Bearing CT Society, Brussels, Belgium
| | | | - Alexej Barg
- The Hospital for Special Surgery, New York, NY, US
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Asghar A, Naaz S. The transverse arch in the human feet: A narrative review of its evolution, anatomy, biomechanics and clinical implications. Morphologie 2021; 106:225-234. [PMID: 34419345 DOI: 10.1016/j.morpho.2021.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 07/25/2021] [Accepted: 07/26/2021] [Indexed: 10/20/2022]
Abstract
The dominant characteristics of the human foot are its shock-absorbing capability during walking or gait cycle and its adaptation to uneven surfaces. On the stance phase of the gait, the foot has to be flexible at first for shock absorption and adapt to the terrain; whereas, during the propulsive phase, it has to be dynamically rigid to function as a lever. Foot flexibility and rigidity are mainly controlled at the subtalar and midtarsal joints by tendons and ligaments. The subtalar joint is part of the longitudinal arch, but the midtarsal joint along with the tarsometatarsal joint are components of the transverse arch. However, the existence and functional role of transverse arch in human was challenged by some authors. But recent studies have revealed that the transverse arch has a predominant role in midfoot stiffness (Venkadeshan et al., 2020, & Holowoka et al., 2017). This midfoot stiffness allows the human foot to store elastic energy at the time of heel strike, which is utilized during the push-off mechanism for propulsion, thus making bipedalism more energy-efficient. Moreover, the transverse arch allows the longitudinal arch to be flexible like a lever and, at the same time, makes the arch of the foot rigid to behave like a stiff spring lever. Understanding the role of the transverse arch is obligatory to study the biomechanics of foot injuries and Charcot or diabetic foot. Studies on diabetic foot have shown that the modulation of transverse arch biomechanics and off-loading modalities would improve outcomes in the form of wound-healing and prevention of re-ulceration.
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Affiliation(s)
- A Asghar
- Department of Anatomy, All India Institute of Medical Sciences, Patna, India.
| | - S Naaz
- Department of Anaesthesiology, All India Institute of Medical Sciences, Patna, India
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Peroneus Longus overload caused by soft tissue deficiencies associated with early adult acquired flatfoot: A finite element analysis. Clin Biomech (Bristol, Avon) 2021; 86:105383. [PMID: 33992889 DOI: 10.1016/j.clinbiomech.2021.105383] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 04/03/2021] [Accepted: 05/07/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Peroneus Longus tendinopathy has been related to overload from cavus and ankle instability. The etiology of isolated Peroneus Longus tendon synovitis has not been elucidated. Loss of foot arch integrity as a cause of isolated Peroneus Longus overload is difficult to establish using cadaver modeling. Our objective was to analyze Peroneus Longus stress changes in pathological scenarios related to flatfoot development. METHODS A three-dimensional finite element foot model which included the foot bones and main soft tissues that maintain the arch was used. Simulations were performed in midstance of gait. Tendon's maximum principal stress and von Mises were calculated in scenarios where the plantar fascia, spring ligament and the posterior tibial tendon were weakened. FINDINGS Decreasing plantar fascia stiffness thus weakening arch integrity increases Peroneus Longus stresses by over three times. Additional failure of tissues that support arch, such as the spring ligament and tibialis posterior tendon further overloads this tendon. The absence of Peroneus Longus also affects stresses in tissues that maintain the arch. Stress concentrations increase in the plantar component of the Peroneus Longus. INTERPRETATION Results offer an explanation into isolated Peroneus Longus overload synovitis. Recognition of failing medial arch structures that occur in early acquired flatfoot as a cause of Peroneus Longus overload could help in its treatment. We caution the practice of transfer of peroneus brevis to longus in surgical treatment of flatfoot as it may further overload an overloaded tendon and focus should be on restoration of arch stability to offload stresses within it.
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Pasapula C, Kiliyanpilakkil B, Khan DZ, Di Marco Barros R, Kim S, Ali AMES, Hardcastle A, Cutts S. Plantar fasciitis: Talonavicular instability/spring ligament failure as the driving force behind its histological pathogenesis. Foot (Edinb) 2021; 46:101703. [PMID: 33386208 DOI: 10.1016/j.foot.2020.101703] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 05/19/2020] [Indexed: 02/04/2023]
Abstract
The aetiology of plantar fasciitis (PF) remains uncertain and to date, it is not known if there is an association with spring ligament laxity. In this study, 28 patients with unilateral plantar fasciitis were evaluated. A digital Klaumeter was used to assess first ray for instability and lateral plane translation was used as a measure of spring ligament laxity in the affected vs unaffected foot (internal control). Retromalleolar tenderness as a sign of a reactive tibialis posterior tendon was also assessed. The mean lateral translation score for symptomatic feet was 67.2 (95% CI [63.26-71.14]), compared to asymptomatic feet mean of 33.0 (95% CI [27.35-38.65] p < 0.05). The mean TMT instability score for symptomatic feet was 11.3 (95% CI [10.29-12.3]), compared to the asymptomatic feet mean of 5.9 (95% CI [4.49-7.31] p < 0.05). 100% of symptomatic feet had a retromalleolar tenderness over the tibialis posterior compared to 14% of asymptomatic feet. This is the first study to demonstrate a statistically significant increase in spring ligament strain in feet affected with PF using internal controls. The study postulates that tensile overload at the medial plantar fascia develops secondary to spring ligament failure regardless of foot shape. Furthermore, this condition can be regarded as an early warning sign of adult acquired flat foot disorder (AAFD). Future treatments for PF should not further destabilise the medial arch. This understanding may allow development of new treatment strategies in restoring spring ligament integrity to offload the plantar fascia strain.
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Affiliation(s)
| | | | | | | | - Suewan Kim
- Queen Elizabeth Hospital, Kings Lynn, United Kingdom
| | | | | | - Steven Cutts
- James Paget Hospital, Great Yarmouth, United Kingdom
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Cen X, Xu D, Baker JS, Gu Y. Effect of additional body weight on arch index and dynamic plantar pressure distribution during walking and gait termination. PeerJ 2020; 8:e8998. [PMID: 32341901 PMCID: PMC7182029 DOI: 10.7717/peerj.8998] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 03/26/2020] [Indexed: 11/20/2022] Open
Abstract
The medial longitudinal arch is considered as an essential feature which distinguishes humans from other primates. The longitudinal arch plays a supporting and buffering role in human daily physical activities. However, bad movement patterns could lead to deformation of arch morphology, resulting in foot injuries. The authors aimed to investigate any alterations in static and dynamic arch index following different weight bearings. A further aim was to analyze any changes in plantar pressure distribution characteristics on gait during walking and stopping, Twelve males were required to complete foot morphology scans and three types of gait tests with 0%, 10%, 20% and 30% of additional body weight. The dynamic gait tests included walking, planned and unplanned gait termination. Foot morphology details and plantar pressure data were collected from subjects using the Easy-Foot-Scan and Footscan pressure platform. No significant differences were observed in static arch index when adding low levels of additional body weight (10%). There were no significant changes observed in dynamic arch index when loads were added in the range of 20% to 30%, except in unplanned gait termination. Significant maximal pressure increases were observed in the rearfoot during walking and in both the forefoot and rearfoot during planned gait termination. In addition, significant maximum pressure increases were shown in the lateral forefoot and midfoot during unplanned gait termination when weight was increased. Findings from the study indicated that excessive weight bearing could lead to a collapse of the arch structure and, therefore, increases in plantar loading. This may result in foot injuries, especially during unplanned gait termination.
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Affiliation(s)
- Xuanzhen Cen
- Faculty of Sports Science, Ningbo University, Ningbo, China
| | - Datao Xu
- Faculty of Sports Science, Ningbo University, Ningbo, China
| | - Julien S Baker
- Department of Sport and Physical Education, Hong Kong Baptist University, Hong Kong, China
| | - Yaodong Gu
- Faculty of Sports Science, Ningbo University, Ningbo, China
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De Prado M, Cuervas-Mons M, De Prado V, Golanó P, Vaquero J. Does the minimally invasive complete plantar fasciotomy result in deformity of the Plantar arch? A prospective study. Foot Ankle Surg 2020; 26:347-353. [PMID: 31113726 DOI: 10.1016/j.fas.2019.04.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 10/09/2018] [Accepted: 04/17/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Complete plantar fasciotomy has been associated with changes in foot loading, leading to medial longitudinal arch collapse. The purpose of this study is to analyse our clinical experience with percutaneous complete plantar fasciotomy and quantify the possible changes in foot loading measured by the calcaneal pitch angle. METHODS A prospective case series study with patients operated between 2005-2012 was conducted, where AOFAS, Maryland Foot Score (MFS), VAS and radiological calcaneal pitch (CP) were recorded. Postoperative data were collected, where the surgeon evaluated the presence of complications, and an independent investigator performed radiological and scale evaluations follow-up: AOFAS, MFS, VAS and Benton-Weil questionnaire. RESULTS A total of 60 patients, 62 feet, with a mean follow-up of 57 months (range 13-107) were studied. The MFS increased a mean of 21 points (p=.001), the AOFAS score a mean of 25 points (p=.001), and the VAS decreased a mean of 8.89 points (p=.001). A total of fifty-seven feet (91.9%) were pain-free at the end of follow-up. The mean CP dropped from 20.2° (range 11-34) preoperatively to 19.3° (range 11-34) at the end of follow-up (p=.05). In 25 feet (40.3%) there were no changes in the calcaneus pitch angle, in 21 feet dropped 1° (33.9%), in 11 dropped 2° (17.8%), 3 feet 3° (4.8%) and 2 feet (3.2%) 4°. Postoperative complications were noted in 4 feet (6.4%), with lateral column pain. The surgery meets the expectations of all patients. CONCLUSIONS Percutaneous total fascia release is safe and does not produce a significant drop in arch height based on the radiological finding. Lack of success after surgery may be explained by other pathologies that might appear like plantar fasciitis. Further studies with gait analysis after total plantar fascia release in patients are needed.
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Affiliation(s)
- Mariano De Prado
- Department of Orthopaedics and Trauma Surgery, Quirónsalud Murcia Hospital, Calle Miguel Hernandez, 12, 30011, Murcia, Spain
| | - Manuel Cuervas-Mons
- Department of Orthopaedics and Trauma Surgery, 'Gregorio Marañón' University Hospital, Calle Dr Esquerdo, 46, 28007, Madrid, Spain; Complutense University of Madrid, Avenida. Séneca, 2, 28040, Madrid, Spain.
| | - Virginia De Prado
- Department of Podiatry Quirónsalud Murcia Hospital, Calle Miguel Hernandez, 12, 30011, Murcia, Spain
| | - Pau Golanó
- Human Anatomy & Embriology Unit, University of Barcelona, Gran Via de les Corts Catalanes, 585, 08007, Barcelona, Spain
| | - Javier Vaquero
- Department of Orthopaedics and Trauma Surgery, 'Gregorio Marañón' University Hospital, Calle Dr Esquerdo, 46, 28007, Madrid, Spain; Complutense University of Madrid, Avenida. Séneca, 2, 28040, Madrid, Spain
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Chen TLW, Wong DWC, Wang Y, Lin J, Zhang M. Foot arch deformation and plantar fascia loading during running with rearfoot strike and forefoot strike: A dynamic finite element analysis. J Biomech 2019; 83:260-272. [DOI: 10.1016/j.jbiomech.2018.12.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 10/24/2018] [Accepted: 12/03/2018] [Indexed: 01/22/2023]
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Guo J, Liu X, Ding X, Wang L, Fan Y. Biomechanical and mechanical behavior of the plantar fascia in macro and micro structures. J Biomech 2018; 76:160-166. [PMID: 29909926 DOI: 10.1016/j.jbiomech.2018.05.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 05/16/2018] [Accepted: 05/30/2018] [Indexed: 11/18/2022]
Abstract
Plantar fascia (PF) is a heterogeneous thickness structure across plantar foot. It is important significance to investigate the biomechanical behavior of the medial, middle and lateral PF regions. To investigate the non-uniform macro/micro structures of the different PF regions, the uniaxial tensile test of PF strips were performed to assess the mechanical behavior of PF. A scanning electron microscope (SEM) was used to visualize and measure the micro morphology of PF associated with collagen fibers. A three-dimensional foot finite element (FE) model was developed to quantify the tensile behavior of the internal PF. The elastic modulus of the lateral PF component (1560 MPa) was observed, followed by the medial (701 MPa), the central (1100 MPa) and the lateral (714 MPa) portions in the central component. Elongation of the central portion (0.192) was lower than the medial (0.223) and the lateral (0.227) portions. The corresponding SEM images showed that the fibers of the central portion were more densely packed and thicker compared to the ambilateral portions in the central component. While the FE model prediction also suggested that the greater elastic modulus of the central PF portion had lower strain (0.192) versus the ambilateral portions. Therefore, the lower elongation and greater elastic modulus at the central portion of PF would probably have a high risk of PF injury. The findings showed a relation between the mechanical tension and fibrous morphology of PF. This information would have a better understanding of the PF pathophysiology diseases related to tear and injury of PF.
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Affiliation(s)
- Junchao Guo
- Beijing Key Laboratory of Rehabilitation Technical Aids for Old-Age Disability, Key Laboratory of Human Motion Analysis and Rehabilitation Technology of the Ministry of Civil Affairs, National Research Center for Rehabilitation Technical Aids, 100176 Beijing, PR China
| | - Xiaoyu Liu
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, 100191 Beijing, PR China
| | - Xili Ding
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, 100191 Beijing, PR China
| | - Lizhen Wang
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, 100191 Beijing, PR China.
| | - Yubo Fan
- Beijing Key Laboratory of Rehabilitation Technical Aids for Old-Age Disability, Key Laboratory of Human Motion Analysis and Rehabilitation Technology of the Ministry of Civil Affairs, National Research Center for Rehabilitation Technical Aids, 100176 Beijing, PR China; Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, 100191 Beijing, PR China.
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18
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Kirby KA. Sistema de reparto de cargas del arco longitudinal del pie. REVISTA ESPAÑOLA DE PODOLOGÍA 2017. [DOI: 10.1016/j.repod.2017.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Guo JC, Wang LZ, Mo ZJ, Chen W, Fan YB. Biomechanical analysis of suture locations of the distal plantar fascia in partial foot. INTERNATIONAL ORTHOPAEDICS 2015; 39:2373-80. [DOI: 10.1007/s00264-015-2889-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Accepted: 06/20/2015] [Indexed: 10/23/2022]
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Miller LE, Latt DL. Chronic Plantar Fasciitis is Mediated by Local Hemodynamics: Implications for Emerging Therapies. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2015; 7:1-5. [PMID: 25709971 PMCID: PMC4325390 DOI: 10.4103/1947-2714.150080] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Plantar fasciitis (PF) is a common, disabling condition affecting millions of patients each year. With early diagnosis and timely application of traditional nonsurgical treatments, symptoms generally resolve over time. However, despite adequate treatment, 20% of patients will experience persistent symptoms. In these patients, minimally invasive therapies that augment local hemodynamics to initiate a regenerative tissue-healing cascade have the greatest potential to resolve long-standing symptoms. We performed a narrative review based on a best evidence evaluation of manuscripts published in Medline-indexed journals to determine the mechanisms involved in soft tissue injury and healing. This evaluation also highlights emerging minimally invasive therapies that exploit these mechanisms in recalcitrant PF.
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Affiliation(s)
- Larry E Miller
- Miller Scientific Consulting, Inc., Asheville, North Carolina, United States
| | - Daniel L Latt
- Department of Orthopaedic Surgery, University of Arizona, Tucson, Arizona, United States
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Abstract
Although anatomic and functional relationship has been established between the gastrocnemius muscle, via the Achilles tendon, and the plantar fascia, the exact role of gastrocnemius tightness in foot and plantar fascia problems is not completely understood. This article summarizes past and current literature linking these 2 structures and gives a mechanical explanation based on functional models of the relationship between gastrocnemius tightness and plantar fascia. The effect of gastrocnemius tightness on the sagittal behavior of the foot is also discussed.
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22
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Merian M, Glisson RR, Nunley JA. J. Leonard Goldner Award 2010. Ligament balancing for total ankle arthroplasty: an in vitro evaluation of the elongation of the hind- and midfoot ligaments. Foot Ankle Int 2011; 32:S457-72. [PMID: 21733454 DOI: 10.3113/fai.2011.0457] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The changes in length of the hindfoot ligaments in response to alterations in ankle and subtalar joint orientation under physiologic load in eight fresh-frozen cadaver limbs were documented. RESULTS In eversion, the tibiocalcaneal (11% ± 4%, mean ± SD], calcaneofibular (6% ± 4%), posterior talofibular (7% ± 4%), posterolateral talocalcaneal (21% ± 9%), posteromedial talocalcaneal (33% ± 45%) and calcaneonavicular (bifurcate) (8% ± 7%) ligaments were elongated relative to their lengths in inversion. In inversion, the anterior capsular (talocalcaneal) (5% ± 3%) and the plantar cuboidnavicular (5% ± 6%) ligaments were elongated relative to their everted lengths. In dorsiflexion, the superficial (26% ± 8%) and deep posterior tibiotalar (30% ± 13%), calcaneofibular (8% ± 4%), tibiocalcaneal (4% ± 2%) and lateral talocalcaneal (cervical) (2% ± 1%) ligaments were elongated. In plantarflexion, the tibionavicular (26% ± 5%) and the anterior talofibular (7% ± 4%) ligaments were lengthened. No statistically significant elongation was documented in any ankle position for the anterior tibiotalar, talocalcaneal interosseous, plantar calcaneocuboid, calcaneocuboid (bifurcate), all components of the spring ligament, and the dorsal cuboidnavicular ligaments. CONCLUSION Components of the deltoid ligament complex elongated largest at the ankle joint with any hindfoot movement but inversion. Therefore, selective release of components of the deltoid ligament complex may provide a means for achieving optimal ligament balancing in total ankle arthroplasty. Specifically, release of the superficial and deep posterior tibiotalar ligament may improve range of motion in total ankle arthroplasties, whereas the release of the tibiocalcaneal ligament may correct a varus talar tilt.
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Affiliation(s)
- Marc Merian
- Regina Pasqua Hospital, Surgery, 3988 Alberts St., Regina, Saskatchewan S4S 3R1, Canada.
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23
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Mechanical behaviors of the foot after individual releases of plantar fascia and ligaments during the balanced standing. ACTA ACUST UNITED AC 2010. [DOI: 10.1007/s12204-010-1076-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Iaquinto JM, Wayne JS. Computational Model of the Lower Leg and Foot/Ankle Complex: Application to Arch Stability. J Biomech Eng 2010; 132:021009. [DOI: 10.1115/1.4000939] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The aim of this work was the design and evaluation of a computational model to predict the functional behavior of the lower leg and foot/ankle complex whereby joint behavior was dictated by three-dimensional articular contact, ligamentous constraints, muscle loading, and external perturbation. Three-dimensional bony anatomy was generated from stacked CT images after which ligament mimicking elements were attached and muscle/body loading added to recreate the experimental conditions of selected cadaveric studies. Comparisons of model predictions to results from two different experimental studies were performed for the function of the medial arch in weight bearing stance and the contributions of soft tissue structures to arch stability. Sensitivity simulations evaluated selected in situ strain and stiffness values for ligament tissue. The greatest contributor to arch stability was the plantar fascia, which provided 79.5% of the resistance to arch collapse, followed by the plantar ligaments (12.5%), and finally the spring ligament (8.0%). Strains measured after plantar fasciotomy increased in the remaining plantar ligament by ∼300% and spring ligament by ∼200%. Sensitivity tests varying both in situ strain and stiffness across reported standard deviations showed that functional trends remained the same and true to experimental data, although absolute magnitudes changed. While not measured experimentally, the model also predicted that load can increase dramatically in the remaining plantar tissues when one of such tissues is removed. Overall, computational predictions of stability and soft tissue load sharing compared well with experimental findings. The strength of this simulation approach lies in its capacity to predict biomechanical behavior of modeled structures and to capture physical parameters of interest not measurable in experimental simulations or in vivo.
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Affiliation(s)
- Joseph M. Iaquinto
- Departments of Biomedical Engineering and Orthopaedic Surgery, Orthopaedic Research Laboratory, Virginia Commonwealth University, Richmond, VA 23284
| | - Jennifer S. Wayne
- Departments of Biomedical Engineering and Orthopaedic Surgery, Orthopaedic Research Laboratory, Virginia Commonwealth University, Richmond, VA 23284
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Tao K, Ji WT, Wang DM, Wang CT, Wang X. Relative contributions of plantar fascia and ligaments on the arch static stability: a finite element study. ACTA ACUST UNITED AC 2010; 55:265-71. [DOI: 10.1515/bmt.2010.041] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Nowak MG, Carlson KJ, Patel BA. Apparent density of the primate calcaneo-cuboid joint and its association with locomotor mode, foot posture, and the “midtarsal break”. AMERICAN JOURNAL OF PHYSICAL ANTHROPOLOGY 2009; 142:180-93. [DOI: 10.1002/ajpa.21210] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Abstract
The adult acquired flatfoot is a deformity that results from the loss of dynamic and static supportive structures of the medial longitudinal arch. The severity of the deformity is dependent upon the role of ligamentous disruption on the hindfoot that can be determined by careful clinical examination. Treatment of the adult flatfoot requires an understanding of the biomechanical effects of deforming forces, tendon dysfunction, ligament disruption, and joint sublaxation.
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Affiliation(s)
- Douglas H Richie
- Department of Applied Biomechanics, California School of Podiatric Medicine at Samuel Merritt College, 370 Hawthorne Avenue, Oakland, California 94609, USA.
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DiGiovanni CW, Langer P. The role of isolated gastrocnemius and combined Achilles contractures in the flatfoot. Foot Ankle Clin 2007; 12:363-79, viii. [PMID: 17561207 DOI: 10.1016/j.fcl.2007.03.005] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In the absence of bony deformity, ankle equinus is generally the result of shortening within the gastrocnemius-soleus complex. Restriction of ankle dorsiflexion as a proxy for equinus contracture has been linked to increased mechanical strains and resultant foot and ankle pathology for a long time. This entity has many known causes, and data suggest it can manifest as either an isolated gastrocnemius or combined (Achilles) contracture. Numerous disorders of the foot and ankle have been linked with such "equinus disease", and although some of these relationships remain controversial, a reasonably convincing relationship between equinus contracture and the development of flatfoot exists. What is still perhaps most misunderstood is the temporal association between these two pathologies, and hence higher levels of evidence are needed in the future to define more precisely the interplay between flatfoot deformity and gastrocnemius-soleus tightness.
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Affiliation(s)
- Christopher W DiGiovanni
- Division of Foot and Ankle, Department of Orthopedic Surgery, Brown Medical School, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, USA.
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Wu L. Nonlinear finite element analysis for musculoskeletal biomechanics of medial and lateral plantar longitudinal arch of Virtual Chinese Human after plantar ligamentous structure failures. Clin Biomech (Bristol, Avon) 2007; 22:221-9. [PMID: 17118500 DOI: 10.1016/j.clinbiomech.2006.09.009] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2006] [Revised: 09/27/2006] [Accepted: 09/28/2006] [Indexed: 02/07/2023]
Abstract
BACKGROUND Musculoskeletal diseases of the foot such as stress fractures, tendonitis and subsequent pain are commonly associated with elevated stresses/strains of abnormal plantar arch after plantar ligamentous structure failures. The goal of this study was to develop anatomically detailed, finite element models of the medial and lateral plantar longitudinal arch, and to investigate bone and muscle stresses resulting from plantar fasciotomy and major plantar ligament injuries. METHODS Nonlinear finite element models of the second ray and the fifth ray of plantar longitudinal arches were constructed on the basis of CT and MR images of Virtual Chinese Human "female No. 1". The models assumed a balanced standing load configuration. Three different degrees of passive intrinsic muscle tensions (weak, moderate, or severe) were used in conjunction with simulations of plantar fasciotomy and major plantar ligament injury. FINDINGS Plantar fasciotomy caused von Mises stress increases in the bones and plantar ligaments while major plantar ligament injuries caused stress increases in the bones, flexor tendons, and plantar fascia. Increasing intrinsic muscle passive tensions decreased stress/strain levels in the medial and lateral arch, and adjusted abnormal tension/compression stress flows of both arches to close to the normal biomechanical states. INTERPRETATION This study shows that plantar longitudinal arches are concordant combination of bony structures, intrinsic muscles, plantar fascia and ligaments. After plantar ligamentous structure failures, intrinsic muscles have to contribute to stabilize the plantar arches. This mechanism may reduce the risk of developing stress fractures, tendonitis and pain syndrome.
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Affiliation(s)
- Lijun Wu
- Department of Biomedical Engineering, Wenzhou Medical College, Wenzhou, Zhejiang, China
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31
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Cheung JTM, Zhang M, An KN. Effect of Achilles tendon loading on plantar fascia tension in the standing foot. Clin Biomech (Bristol, Avon) 2006; 21:194-203. [PMID: 16288943 DOI: 10.1016/j.clinbiomech.2005.09.016] [Citation(s) in RCA: 143] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2005] [Revised: 09/22/2005] [Accepted: 09/28/2005] [Indexed: 02/07/2023]
Abstract
BACKGROUND The plantar fascia, which is one of the major arch-supporting structures of the human foot, sustains high tensions during weight-bearing. A positive correlation between Achilles tendon loading and plantar fascia tension has been reported. Excessive stretching and tightness of the Achilles tendon are thought to be the risk factors of plantar fasciitis but their biomechanical effects on the plantar fascia have not been fully addressed. METHODS A three-dimensional finite element model of the human foot and ankle, incorporating geometrical and material nonlinearity, was employed to investigate the loading response of the plantar fascia in the standing foot with different magnitudes of Achilles tendon loading. FINDINGS With the total ground reaction forces of one foot maintained at 350 N to represent half body weight, an increase in Achilles tendon load from (0-700 N) resulted in a general increase in total force and peak plantar pressure at the forefoot of up to about 250%. There was a lateral and anterior shift of the centre of pressure and a reduction in the arch height with an increasing Achilles tendon load as a result of the plantar flexion moment on the calcaneus. From the finite element predictions of simulated balanced standing, Achilles tendon forces of 75% of the total weight on the foot (350 N) were found to provide the closest match of the measured centre of pressure of the subject during balanced standing. Both the weight on the foot and Achilles tendon loading resulted in an increase in tension of the plantar fascia with the latter showing a two-times larger straining effect. INTERPRETATION Increasing tension on the Achilles tendon is coupled with an increasing strain on the plantar fascia. Overstretching of the Achilles tendon resulting from intense muscle contraction and passive stretching of tight Achilles tendon are plausible mechanical factors for overstraining of the plantar fascia.
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Affiliation(s)
- Jason Tak-Man Cheung
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong, China, and Biomechanics Laboratory, Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN, USA
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Abstract
BACKGROUND Plantar fasciotomy, a common operative procedure to relieve chronic heel pain, has been suggested to decrease foot arch stability. A systematic evaluation of the biomechanical consequences of partial or total plantar fascia release is essential to the understanding of the biomechanical rationale behind these operative procedures. METHODS A geometrical detailed three-dimensional (3-D) finite element (FE) model of the human foot and ankle, incorporating geometrical and contact nonlinearities, was constructed by 3-D reconstruction of MR images. Partial and complete plantar fascia releases were simulated to evaluate the corresponding biomechanical effects on load distribution of the bony, ligamentous, and encapsulated soft-tissue structures. RESULTS Partial and total plantar fascia release may decrease arch height but did not necessarily cause total collapse of the foot arch even with additional dissection of the long plantar ligament. Operative release of the plantar fascia was compromised by increased strains of the plantar ligaments and intensified stress in the midfoot and metatarsal bones. Load redistribution among the centralized metatarsal bones and focal stress relief at the calcaneal insertion were predicted with different types of fasciotomy. CONCLUSIONS The FE model suggested that plantar fascia release may provide relief of focal stress and therefore could relieve associated heel pain. However, these operative procedures may pose a risk to arch stability and clinically may produce dorsolateral midfoot pain. The initial strategy for treating plantar fasciitis should be nonoperative. If surgery is necessary, partial release of less than 40% of the fascia is recommended to minimize the effect on arch instability and maintain normal foot biomechanics.
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Affiliation(s)
- Jason Tak-Man Cheung
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Rehabilitation Engineering Centre, Hung Hom, Kowloon, Hong Kong, China
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Cheung JTM, Zhang M, An KN. Effects of plantar fascia stiffness on the biomechanical responses of the ankle-foot complex. Clin Biomech (Bristol, Avon) 2004; 19:839-46. [PMID: 15342156 DOI: 10.1016/j.clinbiomech.2004.06.002] [Citation(s) in RCA: 114] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2004] [Accepted: 06/04/2004] [Indexed: 02/07/2023]
Abstract
BACKGROUND The plantar fascia is one of the major stabilizing structures of the longitudinal arch of human foot, especially during midstance of the gait cycle. Knowledge of its functional biomechanics is important for establishing the biomechanical rationale behind different rehabilitation, orthotic and surgical treatment of plantar fasciitis. This study aims at quantifying the biomechanical responses of the ankle-foot complex with different plantar fascia stiffness. METHODS A geometrical detailed three-dimensional finite element model of the human foot and ankle, incorporating geometric and contact nonlinearities was constructed by 3D reconstruction of MR images. A sensitivity study was conducted to evaluate the effects of varying elastic modulus (0-700 MPa) of the plantar fascia on the stress/strain distribution of the bony, ligamentous and encapsulated soft tissue structures. FINDINGS The results showed that decreasing the Young's modulus of plantar fascia would increase the strains of the long and short plantar and spring ligaments significantly. With zero fascia Young's modulus to simulate the plantar fascia release, there was a shift in peak von Mises stresses from the third to the second metatarsal bones and increased stresses at the plantar ligament attachment area of the cuboid bone. Decrease in arch height and midfoot pronation were predicted but did not lead to the total collapse of foot arch. INTERPRETATION Surgical dissection of the plantar fascia may induce excessive strains or stresses in the ligamentous and bony structures. Surgical release of plantar fascia should be well-planned to minimise the effect on its structural integrity to reduce the risk of developing arch instability and subsequent painful foot syndrome.
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Affiliation(s)
- Jason Tak-Man Cheung
- Jockey Club Rehabilitation Engineering Centre, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong, PR China
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Abstract
When the foot works properly it is an amazing, adaptive, powerful aid during walking, running, jumping, and in locomotion up or down hill and over uneven ground. Dysfunction of the foot can often arise from the foot losing its normal structural support, thus altering is shape. An imbalance in the forces that tend to flatten the arch and those that support the arch can lead to loss of the medial longitudinal arch. An increase in the arch-flattening effects of the triceps surae or an increase in the weight of the body will tend to flatten the arch. Weakness of the muscular, ligamentous, or bony arch supporting structures will lead to collapse of the arch. The main factors that contribute to an acquired flat foot deformity are excessive tension in the triceps surae, obesity, PTT dysfunction, or ligamentous laxity in the spring ligament, plantar fascia, or other supporting plantar ligaments. Too little support for the arch or too much arch flattening effect will lead to collapse of the arch. Acquired flat foot most often arises from a combination of too much force flattening the arch in the face of too little support for the arch. Treatment of the adult acquired flat foot is often difficult. The clinician should remember the biomechanics of the normal arch and respond with a treatment that strengthens the supporting structures of the arch or weakens the arch-flattening effects on the arch. After osteotomies or certain hindfoot fusions, the role of the supporting muscles of the arch, in particular the PTT, play less of a role in supporting the arch. Rebalancing the forces that act on the arch can improve function and lessen the chance for further or subsequent development of deformity.
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Affiliation(s)
- Drew H Van Boerum
- Department of Orthopaedics and Sports Medicine, Harborview Medical Center, P.O. Box 359798, Seattle, WA 98104, USA
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